摘要目的 观察生物节律对产妇分娩疼痛、硬膜外分娩镇痛及最终分娩方式的影响. 方法 采用回顾性队列研究方法,将2010年1月1日至2012年12月31日北京大学第一医院3 571例拟行阴道分娩的头位、单胎、足月,且接受硬膜外分娩镇痛的初产妇纳入本研究.根据镇痛开始时间将产妇分为4个时间段组,分别为上午组(7:01 ～13:00) 955例、下午组(13:01～19:00)1 159例、晚上组(19:01～1:00) 763例和凌晨组(1:01～7:00) 694例.采用数字评定量表(numeric rating scale,NRS)对4组产妇硬膜外分娩镇痛前后的疼痛情况进行评估,并比较4组产妇的分娩方式、不良事件发生率和新生儿结局.采用单因素方差分析、LSD法、x2检验或Fisher确切概率法、Bonferroni法、一般线性模型和Logistic回归进行统计学分析. 结果 (1)上午组、下午组、晚上组及凌晨组镇痛前NRS疼痛评分分别为(8.6±1.1)、(8.8±1.0)、(8.9±1.0)和(8.7±1.0)分,一般线性模型校正后,NRS疼痛评分分别为(8.6±0.0)、(8.8±0.0)、(8.9±0.0)和(8.7±0.0)分.单因素分析及多因素分析均显示,下午组与上午组比较,差异有统计学意义(P＜0.0l),晚上组与上午组、凌晨组比较,差异均有统计学意义(P值均＜0.05).(2)镇痛10和30 min后上午组、下午组、晚上组及凌晨组NRS疼痛评分分别为(4.3±1.0)和(1.8±0.9)分、(4.8±1.0)和(2.1±0.9)分、(4.9±1.1)和(2.2±1.0)分、(4.4±1.1)和(1.8±1.0)分,下午组、晚上组与上午组、凌晨组比较,差异均有统计学意义(P值均＜0.01或0.05);镇痛达标(NRS疼痛评分≤3分)比例分别为19.7％(188/955)和97.4％(930/955)、11.6％(13 4/1159)和96.0％(1 113/1 159)、11.3％(84/743)和95.2％(707/743)、18.7％(130/694)和96.5％(670/694),下午组、晚上组与上午组、凌晨组比较,差异均有统计学意义(P值均＜0.01或0.05).(3)4组产妇最终分娩方式、不良事件发生率和新生儿结局比较,差异无统计学意义. 结论 下午和晚上2个时间段接受硬膜外分娩镇痛的产妇镇痛前疼痛程度更重,镇痛1 0和30 min后的效果和镇痛达标率更差,但分娩方式、新生儿结局、分娩镇痛期间不良事件发生率未受影响.

abstractsObjective To investigate the influence of biological rhythm on labor pain,epidural analgesia and delivery mode in parturients.Methods In this retrospective cohort study,3 571 Chinese nulliparas with term singleton cephalic pregnancy who were preparing to deliver vaginally and receive epidural analgesia,were included.Parturients were divided into four groups according to the beginning time of analgesia,i.e.,morning group (7:01 to 13:00,n=955),afternoon group (13:01 to 19:00,n=1 159),evening group (19:01 to 1:00,n=763),and night group (1:00 to 7:00,n=694).Pain scores were assessed using a numeric rating scale (NRS) before and after epidural analgesia.Delivery mode,incidence of adverse events and neonatal outcomes were also compared among the four groups with monovariance analysis,LSD,Chi-square test or Fisher's exact test,Bonferroni,General Linear Model (GLM) and Logistic regression analysis.Results (1) The NRS pain scores of morning,afternoon,evening and night groups before analgesia were 8.6± 1.0,8.8± 1.0,8.9± 1.0 and 8.7± 1.0,respectively.After adjusted by GLM,the NRS pain scores of the four groups were 8.6±0.0,8.8 ± 0.0,8.9±0.0 and 8.7±0.0,respectively.Univariate and multivariable analyses showed that pain scores before analgesia were higher in afternoon group than in morning group (P＜0.01),and they were significantly higher in evening group than in morning and night groups (all P＜0.05).(2) At 10 and 30 minutes after epidural analgesia,the NRS pain scores of the four groups were 4.3± 1.0 and 1.8±0.9,4.8± 1.0 and 2.1 ±0.9,4.9± 1.1 and 2.2± 1.0,and 4.4± l.l and 1.8± 1.0,respectively,which were also significantly higher in afternoon and evening groups than in morning and night groups (all P ＜ 0.01 or 0.05) ; and the proportions of analgesia satisfaction (NRS pain score ≤ 3) were 19.7％ (188/955) vs 97.4％ (930/955),11.6％ (134/1 159) vs96.0％ (1 113/1 159),11.3％ (84/743) vs95.2％ (707/743),18.7％ (130/694) vs 95.6％ (670/694),respectively,which were significantly lower in afternoon and evening groups than in morning and night groups (all P＜0.01 or 0.05).(3) Delivery mode,incidence of adverse events and neonatal outcomes were similar among the four groups.Conclusions More severe labor pain before analgesia occur in parturients who receive epidural analgesia in the afternoon and at night,and less efficient analgesia and a lower rate of satisfaction are observed at 10 and 30 minutes after analgesia.However,delivery mode,neonatal outcomes and incidence of adverse events are not influenced by biological rhythm.