分娩镇痛概述课件

,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,分娩镇痛,有关分娩镇痛的争议,ALWAYS,controversial !,“Birth is a natural process”,Women should suffer!,Concerns for mothers safety,Concerns for baby,Concerns for effects on labor,相关历史,圣经故事：伊甸园,原罪（,Original Sin,）,God,punished Eve: “In sorrow thou shalt bring forth children.” Genesis 3:16,Formed the basis of,1800 years of opposition,to pain relief in labor.,1591,年,Lady Euframe MacAlyane of Edinburgh, Scotland:,was Burned,at the Stake because asking for labor analgesia,分娩镇痛的历史,The modern era of childbirth analgesia began in 1847 when Dr J Y Simpson administered ether to a woman in childbirth, and later in the same year, chloroform,Queen Victoria was given chloroform by John Snow (1853) for the birth of her 8,th,child,Prince Leopold,and this did much to popularize the use of pain relief in labor,Chloroform a la reine,The inhalation lasted fifty-three minutes. The chloroform was given on a handkerchief in fifteen minim doses; the Queen expressed herself as greatly relieved by the administration,Chloroform a la reine,Dr Snow gave me the blessed chloroform and the effect was soothing, quieting and delightful beyond measure,分娩镇痛的历史,1855,年,：,Religious acceptance,Archbishop of Canterburys daughter received chloroform for labor pains. He refused to criticize,1860-1940 : Dark ages of obstetric anesthesia,August Bier, Virginia Apgar,1900: Oskar Kreis , used spinal anesthesia for childbirth for the first time,分娩镇痛的历史,1933 : John Cleland pain pathways,1943 : Hingson Continuous caudal,1949 : Flowers - Continuous lumbar epidural,产科麻醉的黑暗时代在西方终于结束了！,产科麻醉的黑暗时代在天朝仍然持续中,分娩疼痛到底有多严重？,A comparison of pain scores obtained through the McGill Pain Questionnaire. Scores were collected from women in labor, patients in a general hospital clinic, and patients in the emergency department after accidents involving traumatic injury. Note the modest difference in pain scores between nulliparous women with and without prepared childbirth training.,PRI,Pain rating index, which represents the sum of the rank values of all the words chosen from 20 sets of pain descriptors. (Modified from Melzack R. The myth of painless childbirth The John J. Bonica Lecture. Pain 1984; 19:321-37.),Figure 1 (facing page). Sources of Pain during Labor and Maternal Physiological Responses. The pain of labor, caused by uterine contractions and cervical dilatation, is transmitted through visceral afferent (sympathetic) nerves entering the spinal cord from T10 through L1. Later in labor, perineal stretching transmits painful stimuli through the pudendal nerve and sacral nerves S2 through S4. Cortical responses to,pain and anxiety during labor are complex and may be influenced by the mother,s expectations for her childbirth experience, her preparation (through education), the presence of emotional support, her age, and other factors. The perception of pain is increased by fear and anxiety. Coping behaviors may include verbalization and the need to move into various positions. She may be motivated to have a certain type of birthing experience, and these opinions will influence her judgment about pain management and other choices during labor and delivery. Maternal physiological responses to labor pain may influence maternal and fetal well-being and the progress of labor. Hyperventilation may induce hypocarbia. An increased metabolic rate increases oxygen consumption. Increases in cardiac output and vascular resistance may increase maternal blood pressure. Pain, stress, and anxiety cause release of stress hormones such as cortisol and,-endorphins. The sympathetic nervous system response to pain results in a marked increase in circulating catecholamines, such as norepinephrine and epinephrine, that can adversely affect uterine activity and uteroplacental blood flow. Effective analgesia attenuates or eliminates these responses.,分娩疼痛、应激反应和激素改变,激素释放,交感神经：儿茶酚胺,肾上腺髓质：胰高血糖素；糖异生；脂肪分解,垂体后叶：,ADH,垂体前叶,ACTH,：皮质醇和醛固酮,内啡肽,TSH,：甲状腺激素,生长激素；催乳激素,应激反应对血压和子宫血流的影响,分娩疼痛引起的生理、心理改变,分娩疼痛到底有好处吗？,相信大家是一定有自己的判断的！,了解一些小知识吧,一、产程和产程图,第一产程：初产妇,11 - 12h,，经产妇,6 - 8h,潜伏期：,8 - 16h,，超过,20h,为异常,活跃期：,4 - 8h,三个阶段：加速期，最大加速期和减速期,第二产程,：初产妇,1 - 2h,，经产妇, 1h,第三产程,：,5 15min,，,3h,，经产妇, 2h,张氏曲线和当代数据,潜伏期至活跃期的转折点,6 cm,第一产程比历史数据更长,使用硬膜外镇痛后第二产程的第,95,百分位时间增加了,0.8h,（初产妇）和,0.7h,（经产妇）,新的产程参考时间表,二、分娩时的疼痛来自于那里？,镇痛技术,胸段硬膜外,蛛网膜下腔,椎旁阻滞,腹下神经丛阻滞,阴部神经阻滞,宫颈旁阻滞,骶管阻滞,产程和分娩疼痛,第一产程：内脏痛，,T,10,- L,1,；第一产程晚期（宫颈扩张至,7 10 cm,）和整个第二产程，除了内脏痛还加上了体感痛，,S,2-4,分娩疼痛的来源,当宫颈扩张,2-3 cm,时候，疼痛的严重程度明显增强，此时分娩镇痛的需求明显增加了,分娩疼痛的来源：小结,第一产程：以内脏痛为主,宫体收缩，宫颈和子宫下段扩张,钝性痛，难以精确定位,由,C,纤维传导（慢传导）至,T,10, L,1,第二产程：以体感痛为主,盆底、阴道和会阴部的扩张和骨盆韧带牵拉,疼痛尖锐而严重，容易定位,由,A,纤维传导至,S,2, 4,分娩镇痛：有哪些方法？,非药物方法,精神分析法：心理助产法，导乐分娩,经皮神经电刺激（,TENS,）,针刺疗法,水治疗法,经皮水注射法,药物方法,Pharmacological,Systemic,Medications,Inhalational,Regional Blocks,椎管内分娩镇痛,椎管内镇痛的优点,镇痛效果最有效且最少镇静作用,阻滞深度和阻滞时间可按需调节,降低母体儿茶酚胺的浓度,改善子宫胎盘的血流,低剂量局麻药：不影响子宫的活动度,低剂量阿片类：无新生儿抑制作用,Regional Analgesia - Neonatal Effects,Uterine perfusion maintained,FHR changes,baseline variability,periodic decelerations (due to, maternal catechols?),Apgar scores, acid-base status - unaffected,Neurobehavioral effects absent,LA toxicity -,extremely,rare,Profound hypotension,- possible fetal compromise,椎管内镇痛尤其适合以下情况,Hypertensive disorders,Cardiac disease,Asthma,Diabetes,Prolonged labor/ Oxytocin augmentation,Prematurity,Multiple gestation,Vaginal breech delivery,椎管内镇痛的指征,椎管内镇痛的目的：,缓解分娩疼痛,和放置硬膜外导管便于需要时,转换为硬膜外麻醉,缓解分娩疼痛,美国妇产科医师学院和,ASA,一致同意：母亲要求，且除外禁忌证就是椎管内分娩镇痛的充分和必要条件（指征）,准备行剖宫产术的试产产妇,双胞胎；子痫前期；经历过剖宫产术的产妇；肥胖产妇；,BMI 40,或,OSAS,产妇；可能有困难气道的产妇等；既往有产后出血（,PPH,）病史,实施椎管内分娩镇痛前的准备,实施前评估,关注妊娠史，麻醉史和普通病史。有目的的进行体格检查，包括生命体征、气道评估、心血管、呼吸和背部检查,实验室检查,健康产妇无需特殊的检查,特殊的产妇需要检查血小板计数或凝血功能,获得产妇或其家属的知情同意,建立外周静脉（,18 G,）,椎管内镇痛的方法,硬膜外分娩镇痛,蛛网膜下腔分娩镇痛,腰,-,硬联合（,CSE,）分娩镇痛,椎管内镇痛选择药物的目的,Minimize motor block, preserve the ability to push, and maintain maternal satisfaction,Avoid maternal hypotension,Minimize placental transfer of drugs to the fetus,Reduce the risks of LA systemic toxicity (LAST) for unrecognized intravascular catheters and of high or total spinal for unrecognized intrathecal catheters,感谢关注,欢迎讨论,