Influence of intraspinal anesthesia and analgesia on early postpartum pelvic floor functions of primiparae with vaginal delivery

doi:10.3877/cma.j.issn.1673-5250.2022.04.015

Objective

To explore influence of intraspinal anesthesia and analgesia on early postpartum pelvic floor functions of primiparae with vaginal delivery.

Methods

A total of 242 primiparae with vaginal delivery who received pelvic floor function examination at 42 d after delivery in Yantai Yuhuangding Hospital from March 2020 to June 2021 were selected as research subjects by propensity score matching method. According to whether they were delivered under intraspinal anesthesia and analgesia or not, they were divided into study group (n=121, with intraspinal anesthesia and analgesia) and control group (n=121, without anesthesia and analgesia measure). Results of transperineal pelvic floor three-dimensional ultrasonography and pelvic floor surface electromyography (sEMG), and incidences of bladder prolapse, uterine prolapse, stress urinary incontinence (SUI) and postpartum urinary retention (PUR) between two groups were compared by independent-samples t test, Mann-Whitney U test and chi-square test. The procedure followed in this study was in line with the requirements of the Helsinki Declaration of the World Medical Association revised in 2013. There were no significant differences in general clinical data such as height and weight, body mass index (BMI), age, and gestational age at delivery, and duration of the second stage of labor, and fetal birth weight between two groups (P>0.05).

Results

①The incidence of PUR was 13.2% (16/121) in study group, which was significantly higher than that of 5.8% (7/121) in control group (χ²=3.892, P=0.049). There were no statistical significances in composition ratios of different degrees of early postpartum bladder prolapse, uterine prolapse and incidence of SUI between two groups (P>0.05). ②There were no significant differences between two groups of primiparae in incidences of unclosed of internal urethra meatus during the maximum Valsalva maneuver and incomplete anal sphincter, vertical distances of the lowest point of posterior bladder wall, the lowest point of cervical external aperture, and the lower border of rectum ampulla to inferior border of pubic symphysis, area of levator hiatus and mobility of bladder neck (P>0.05) by transperineal pelvic floor three-dimensional ultrasonography. ③There were no significant differences between two groups in average value of pelvic floor muscle electromyography in pre-resting stage, maximum value of pelvic floor muscle electromyography in fast contraction stage, and average values of pelvic floor muscle electromyography in tense contraction stage, endurance contraction stage and post-resting stage (P>0.05) by pelvic floor sEMG detection.

Conclusions

Intraspinal anesthesia and analgesia could increase risk of early postpartum PUR in primipara with vaginal delivery, but it does not increase risk of bladder prolapse, uterine prolapse, SUI, and pelvic floor muscle injury.

Key words: Analgesia, obstetrical, Intraspinal labor anesthesia and analgesia, Postpartum period, Pelvic floor function, Urinary retention, Urinary incontinence, stress, Primipara

图1 1例研究组经阴道分娩初产妇(34岁)产后42 d超声检查盆底正中矢状切面超声图像示意图注：B为膀胱，U为尿道，Cx为宫颈。PR为肛提肌，PS为耻骨联合，RA为直肠壶腹，AC为肛管

表1 2组经阴道分娩初产妇一般临床资料比较

组别	例数	身高[cm，M(Q₁, Q₃)]	分娩时体重(kg，±s)	分娩时BMI[kg/m²，M(Q₁, Q₃)]	分娩年龄[岁，M(Q₁, Q₃)]	分娩孕龄[周，M(Q₁, Q₃)]	第二产程时间[min，M(Q₁, Q₃)]	新生儿出生体重[g，M(Q₁, Q₃)]
研究组	121	164(160，168)	73.1±9.0	26.9(24.6，28.8)	29(28，31)	40(39^＋2，40^＋4)	34.0(23.5，55.0)	3 300(3 050，3 550)
对照组	121	165(161，168)	73.3±9.1	26.6(24.8，29.1)	29(27，32)	39^＋5(39，40^＋2)	36.0(19.0，52.5)	3 400(3 050，3 600)
统计量		Z＝－1.001	t＝－0.113	Z＝－0.560	Z＝－0.253	Z＝－1.907	Z＝－0.237	Z＝－1.301
P值		0.317	0.910	0.575	0.801	0.057	0.813	0.193

表1 2组经阴道分娩初产妇一般临床资料比较

组别	例数	身高[cm，M(Q₁, Q₃)]	分娩时体重(kg，±s)	分娩时BMI[kg/m²，M(Q₁, Q₃)]	分娩年龄[岁，M(Q₁, Q₃)]	分娩孕龄[周，M(Q₁, Q₃)]	第二产程时间[min，M(Q₁, Q₃)]	新生儿出生体重[g，M(Q₁, Q₃)]
研究组	121	164(160，168)	73.1±9.0	26.9(24.6，28.8)	29(28，31)	40(39^＋2，40^＋4)	34.0(23.5，55.0)	3 300(3 050，3 550)
对照组	121	165(161，168)	73.3±9.1	26.6(24.8，29.1)	29(27，32)	39^＋5(39，40^＋2)	36.0(19.0，52.5)	3 400(3 050，3 600)
统计量		Z＝－1.001	t＝－0.113	Z＝－0.560	Z＝－0.253	Z＝－1.907	Z＝－0.237	Z＝－1.301
P值		0.317	0.910	0.575	0.801	0.057	0.813	0.193

表2 2组经阴道分娩初产妇产后早期不同类型PFD发生情况比较[例数(%)]

组别	例数	膀胱脱垂			子宫脱垂			SUI	PUR
组别	例数	中、重度	轻度	无	中、重度	轻度	无	SUI	PUR
研究组	121	76(62.8)	40(33.1)	5(4.1)	19(15.7)	52(43.0)	50(41.3)	27(22.3)	16(13.2)
对照组	121	69(57.0)	47(38.8)	5(4.1)	20(16.5)	37(30.6)	64(52.9)	25(20.7)	7(5.8)
χ²值		0.901			4.273			0.098	3.892
P值		0.637			0.118			0.754	0.049

表2 2组经阴道分娩初产妇产后早期不同类型PFD发生情况比较[例数(%)]

组别	例数	膀胱脱垂			子宫脱垂			SUI	PUR
组别	例数	中、重度	轻度	无	中、重度	轻度	无	SUI	PUR
研究组	121	76(62.8)	40(33.1)	5(4.1)	19(15.7)	52(43.0)	50(41.3)	27(22.3)	16(13.2)
对照组	121	69(57.0)	47(38.8)	5(4.1)	20(16.5)	37(30.6)	64(52.9)	25(20.7)	7(5.8)
χ²值		0.901			4.273			0.098	3.892
P值		0.637			0.118			0.754	0.049

表3 2组经阴道分娩初产妇最大Valsalva动作时盆底三维超声检查指标比较

组别	例数	尿道内口打开[例数(%)]	肛门括约肌不完整[例数(%)]	距耻骨联合下缘的垂直距离(mm，±s)^a			肛提肌裂孔面积(cm²，±s)	膀胱颈移动度(mm，±s)
组别	例数	尿道内口打开[例数(%)]	肛门括约肌不完整[例数(%)]	膀胱后壁最低点	宫颈外口最低点	直肠壶腹部下缘	肛提肌裂孔面积(cm²，±s)	膀胱颈移动度(mm，±s)
研究组	121	57(47.1)	120(99.2)	－11.8±6.3	－4.7±6.1	－19.4±4.3	28.3±5.8	39.0±7.5
对照组	121	64(52.9)	116(95.9)	－11.1±6.7	－4.4±7.4	－18.9±4.0	27.6±5.5	38.5±7.0
统计量		χ²＝0.066	χ²＝1.538	t＝－0.888	t＝－0.383	t＝－0.850	t＝0.980	t＝0.489
P值		0.797	0.215	0.375	0.702	0.396	0.328	0.625

表3 2组经阴道分娩初产妇最大Valsalva动作时盆底三维超声检查指标比较

组别	例数	尿道内口打开[例数(%)]	肛门括约肌不完整[例数(%)]	距耻骨联合下缘的垂直距离(mm，±s)^a			肛提肌裂孔面积(cm²，±s)	膀胱颈移动度(mm，±s)
组别	例数	尿道内口打开[例数(%)]	肛门括约肌不完整[例数(%)]	膀胱后壁最低点	宫颈外口最低点	直肠壶腹部下缘	肛提肌裂孔面积(cm²，±s)	膀胱颈移动度(mm，±s)
研究组	121	57(47.1)	120(99.2)	－11.8±6.3	－4.7±6.1	－19.4±4.3	28.3±5.8	39.0±7.5
对照组	121	64(52.9)	116(95.9)	－11.1±6.7	－4.4±7.4	－18.9±4.0	27.6±5.5	38.5±7.0
统计量		χ²＝0.066	χ²＝1.538	t＝－0.888	t＝－0.383	t＝－0.850	t＝0.980	t＝0.489
P值		0.797	0.215	0.375	0.702	0.396	0.328	0.625

图2 1例对照组经阴道分娩初产妇(33岁)与1例研究组初产妇(32岁)产后42 d盆底三维超声检查声像图(图2A：对照组初产妇最大Valsalva动作时肛提肌完整图像；图2B：研究组初产妇静息状态时左侧肛提肌断裂图像)

表4 2组经阴道分娩初产妇盆底sEMG检测结果比较(μV，±s)

组别	例数	前静息阶段盆底肌肌电平均值	快速收缩阶段盆底肌肌电最大值	紧张收缩阶段盆底肌肌电平均值	耐力收缩阶段盆底肌肌电平均值	后静息阶段盆底肌肌电平均值
研究组	121	4.5±2.8	32.6±14.4	24.3±10.7	23.0±10.4	4.6±2.8
对照组	121	4.3±2.8	30.2±14.3	23.1±9.9	21.6±9.6	4.6±3.0
t值		0.514	1.272	0.912	1.080	0.025
P值		0.608	0.205	0.363	0.281	0.980

表4 2组经阴道分娩初产妇盆底sEMG检测结果比较(μV，±s)

组别	例数	前静息阶段盆底肌肌电平均值	快速收缩阶段盆底肌肌电最大值	紧张收缩阶段盆底肌肌电平均值	耐力收缩阶段盆底肌肌电平均值	后静息阶段盆底肌肌电平均值
研究组	121	4.5±2.8	32.6±14.4	24.3±10.7	23.0±10.4	4.6±2.8
对照组	121	4.3±2.8	30.2±14.3	23.1±9.9	21.6±9.6	4.6±3.0
t值		0.514	1.272	0.912	1.080	0.025
P值		0.608	0.205	0.363	0.281	0.980

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