| Background:Labor pain is one of the strongest pain experiences that female can ever suffer,only second to burn pain. Severe pains in delivery may give rise to a series of side effects on maternal and neonates. Nowdays, most gravidas would like to choose cesarean section(CS) to terminate pregnancy due to in-tolerance to labor pain.Thus, more and more CS without operation indications increases the mortality of maternal and neonates,the medical cost and the morbility of postoperative complications of maternal and neonates.With the continuous improvement of quality of life, the improve of medical services requirements and the development of perinatology, the demend of labor analgesia of puerperae becomes higher and higher. At present, when compared with intravenous labor analgesia, epidural analgesia definitely is the gold standard, but due to various reasons, there are still many women can't block intra-spinal canal labor analgesia. Encountered this situation, intravenous labor analgesia is a viable option.Objective:To compare the efficacy of intravenous labor analgesia with remifentanil and remifentanil/oxycodone and its influence on maternal and neonatal.Materials and Methods:1. Research object(1) Research sourcesAll the 90 participants were selected from maternal and child health care of Zhengzhou from January 2014 to December 2015. All the participants were maternal fetal full-term primipara of single. Obtained labor analgesia written informed consent,in strict according with implement and exclusion criteria, the puerpera were randomly assigned in hydrochloric acid Refentanyl group (R group), hydrochloric acid, combined fentanyl oxycodone hydrochloride group (Q) and the control group (group C) combined spinal epidural anesthesia. There was no any interventions and restrictions in the process of implementation.The puerperal was randomly assigned to labor wards.(2) Inclusion criteria? Single fetal head first-time mothers to full term.? Age of 21-40 years.? BMI?32.? Weight 55-85kg.? The gestation age 37-40 weeks.? The ASA rating of 1-2 levels.? Preoperative routine blood test, liver and kidney function, coagulation function in the normal range.? No obstetric diseases such as hypertension, diabetes during pregnancy.? No allergy to refentanyl and oxycodone hydrochloride and opioids addiction..? No spinal canal anesthesia contraindications such as spinal deformity, the puncture point infection.(11) Obtainned informed consent,signed anesthesia and analgesia delivery informed consent.(12) Approved by the zhengzhou city health care of women and children's academic and ethical committee.(3) Exclusion Criteria and Eliminated citeria.? Abnormal labor, intrapartum complication or abnormal cardiopulmonary function.? A history of mental illness.? Suspected of fetus congenital deformity.? A history of opioids addiction.? The patients or their family members uncooperate.? Quited up for other reasons.(4) Study group assignation90 single full-term pregnant women were initially enrolled into this study strictly according to the inclusion and exclusion creteria. The 90 participants were randomed into hydrochloric acid Refentanyl group (R group,n=30), oxycodone hydrochloride group (Q group,n=30) and combined spinal epidural anesthesia group (group C,n=30) via random number table, with double blinded observation.2. Memods of anesthesiaAll the three group puerperae would be allowed to enter in labor ward when they entered into the first active labor (uterine cervix mouth up to 3 cm).Then a dedicated intravenous cannula was inserted at left upper limb peripheral vein, inputting acetic acid Ringer solution at regular rate. Oxygen inhalation was conducted through nasal catheter with a constant flow rate 2L/min. Intraoperative monitoring included a three-lead ECQheart rate (HR), mean arterial pressure (MAP), and measurements of oxygen saturation by pulse oximetry(SpO2).R group:hydrochloric acid refentanyl 1 mg was diluted in 20 ug/ml by 0.9%sodium chloride 50 ml, and the researchers setted the background dosage from 0.01 to 0.05 ug/kg/min, a bolus of 0.4 ug/kg, locking time for 5 min. Q group:oxycodone hydrochloride 10 mg concentration was presented at 1 mg/ml diluted in 0.9%sodium chloride 9 ml.The first dose was 2 to 10 mg through slowly intravenous dripping within 1 to 2 minutes.The participants received the same dose after 3-4 h. Intravenous analgesia pump infusion solution: hydrochloric acid refentanyl 1 mg concentration was diluted in 20 ug/ml by 0.9% sodium chloride 50 ml, and the researchers setted the background dose from 0.01 to 0.05 ug/kg/min, a bolus of 0.4 ug/kg, lock time for 5 min. Group C:The labour women were told to take left side and bend knees to the chest.All the needed drugs were well prepared before researchers conducted single combined spinal epidural anesthesia.Regular disinfection liquid spread towels and extract preparation need, line of waist hard joint anesthesia, core-needle clearance, We choose L3-L4 as the puncture point and then administered 2 ml of 1%lidocaine into the puncture point as local infiltration anaesthesia. Locate at the middle of the epidural needle puncture, continuously inserted in with normal saline untiled the constantly pressure suddenly disappeared, which was meaned that the epidural anaesthesia needles have been worn out yellow ligament into the epidural space.And then we continued to puncture with 25G spinal needle to wear out arachnoid while clear cerebrospinal fluid flowed out smoothly.After that we injected citrate sufentanil 5 ug into subarachnoid, and then pulled out the needle at once.and then liened epidural catheter 3 cm towards the head.Finally,we pulled out epidural needle, connected the syringe, fixed catheter and ensured that there was no blood and cerebrospinal fluidwhen withdrawed. After connected to the disposable infusion microcomputer controlled analgesia pump and continued to administered the mixture of 0.08% ropivacaineand 0.45 ug/ml citrate sufentanil,controlling by patients.Then we helped the maternal to maintain at supine position and leaned the bed to the left at 15 degree, or let them to take their comfortable position.3.measurements(1) The general informationRecorded age?gestational age?height?weight,?ASA status,?injection time,? analgesic start and end time?connection analgesic pump time of gravidas of each group.(2) Assessment of the function of circulatory and respiratoryUse the PHLIPS (IntelliVueMX600, Germany) multifunctional monitor to monitor and record changes of DBP (Diastolic blood pressure, DBP)?SBP (Systolic blood pressure, SBP)?RR (respiratory rate, RR)?Heart rate (Heart rate, HR)?MAP (Mean arteril pressure, MAP),?SpO2 (saturation of pulse oximetry, SpO2) at the time of preoperative (T0)?5 min (T1)?10 min (T2)?30 min (T3) after medication,and palace mouth open full-time (T4) and fetal childbirth (T5)(3) Assessment of apgar scoreRecord Apgar score at the time of 1 min and 5 min after birth.(4) Labor timeRecord the first, second and third maternal labor time of each gravidas.(5) Assessment of analgesic effectUse Visual Analogue Scale (Visual Analogue Scale/Score, VAS)pain intensity as the standard to assess the intensity of labour pain from 0 to 10 score.0 score means no pain; Below 3 scores:mild pain that patients can endure; Four to six scores:patients can't stand the pain and cannot sleep well; and need clinical treatment; 7-10 scores:patients have gradually intense pain, and difficult to endure.(6) Sedation scoresAdopt Ramsay rating:1 point:Be unquiet and agitated; Two points:be queit and cooperate; Three points:be lethargy, but can follow instructions; 4 points:sleep, but can be waked up; Five points:lags in response; Six points:deep sleep state, cannot be waked up.2-4 points satisfied calm; 5-6 points:excessive calm.(7) Monitoring cardiac and contractionsAfter gravidas entered into the active phase of delivery,we continuously monitored fetal heart rate (FHR) using fetal heart monitor (PHILIPS Avalon FM20) and recored at an interval of 15-30 min, cooperated with abdominal palpation and auscultated to know maternal uterine contractions and the status of maternal intrauterine fetus.(8) Neonatal umbilical cord blood and blood gas analysisAfter fetal childbirth,obstetricians clamped fetus umbilical cord with two hemostatic forceps to extract umbilical arterial blood using a 2 ml syringe with anticoagulant, and then inspected immediately.(9) Assessment and process of adverse effectsObserve and record intraoperative blood pressure, heart rate, nausea, vomiting, lethargy, itchy skin, and the rate of respiratory depression of the patients.The situation of uterine contration and fetal heart rate of each gravid was monitored by midwives throughout the delivery.After giving birth to the newborn,we conducted Apgar 1 min and 5 min scores for neonates.If the gravida was observed abnormal fetal heart rate which need to suffer cesarean section,then give up the experiment by themself.4.Statistics analysisAll the observation data recorded in EXCEL.2015 management. Statistical analyses were completed using Statistical Package for the Social Sciences Inc. (SPSS version 17.0). Descriptive statistics were used to characterize the data. Quantitative data was statistical descriptived by mean ± standard deviation (x ±s). Comparison between groups using Kolmogorov Smirnov(K-S) was used to explore the relationship between groups.Levene was used to explore normality test and the homofeneity of variance.One way ANOVA was used if the data accorded with Normal distribution and the homofeneity of variance, while other data was explored by chi-square test if not. A p value< 0.05 was considered statistically significant.Results:1. Cmpared with pre-dose, there was no significant statistically difference in MAP, HR, RR, SPO2 after drug taking (P> 0.05).2. The VAS scores were significantly decreased (P< 0.05) in three groups after anesthesia, and all patients were well analgesia and without frown/moving position when uterine contractions under the guidance of the midwife,and were satisfied with analgesia. But the VAS scores in C and Q group of each time after dosing were below R group, the difference was statistically significant (P< 0.05). Ramsay score:Q group were basicly quiet and cooperated at 2 scores.There are 5 cases presenting (3 points) sleepiness but can follow instructions.No deep sleep that cantnot be waked up. Compared with R and C group, there was significant statistically difference (P< 0.05) which shown in table 2. There were 5 case in R group found itching, but spontaneously cured.There was no side effects such as nausea and vomiting in three groups of mothers.3 There was no statistically significant difference between three groups in 1 min and 5 min Apgar score and arterial blood gas analysis (P> 0.05).Conclusions:The analgesic effect of intravenous analgesia childbirth is not better than that of the spinal canal block labor analgesia; Intravenous analgesia childbirth oxycodone hydrochloride in compound hydrochloric acid, the analgesic effect of fentany labor analgesia is better than simply using hydrochloric acid fentany labor analgesia Hydrochloric acid refentany combined with oxycodone hydrochloride intravenous for labor has satisfied analgesia effect and has no increased advers effects in maternal and neonatal, which can be used as an alternative and complementary method for labor analgesia intra-spinal canal. |
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