경막외 무통 분만이 산모와 신생아에게 미치는 영향

박옥선,한상숙 대한임상건강증진학회 2008 Korean Journal of Health Promotion Vol.8 No.2

Background Owing to development of the obstetrical anesthesia, the epidural analgesia has been widely operated, relieving mothers of their delivery pain much, but the controversies surrounding safety of the epidural analgesia still remain. In such a circumstance, this study aimed to examine the effects of epidural analgesia on mothers and their newborns during progresses of labor. Methods The researchers sampled 243 expectant mothers hospitalized at a women's special hospital for the normal vaginal delivery and thus, classified them into the epidural anesthesia group (n=143, 90 primiparas and 53 multiparas) and the nonanesthesia group (n=100, 52 primiparas and 48 multiparas) and thereby, comparatively t-tested the effects of epidural analgesia on mothers and their newborns by progress of labor. Results The primary and secondary progress of labor was significantly longer only in the epidural anesthesia primipara group, compared with the non-anesthesia group. Both epidural anesthesia primipara group and multipara group used the oxytocin significantly more frequently than their counterpart non-anesthesia groups. Both epidural anesthesia primipara group and multipara group mothers' satisfaction with delivery methods did not significantly between two groups. The Apgar score measured 1 minute and 5 minutes after delivery of newborns was significantly lower in the epidural anesthesia groups regardless of whether they were primiparas or multiparas. Newborns' meconium color was related with the epidural analgesia only for primiparas. Conclusions As a result of this study, it was found that the epidural analgesia had more effects on primiparas' progresses of labor and their newborns' meconium than multiparas', and that it had effects on newborns' Apgar scores for both primipara and multipara groups. Hence, it is deemed required of nurses to positively manage the progresses of labor for mothers' and their newborns' safety when the epidural analgesia is applied. (Korean J Health Promot Dis Prev 2008 ; 8(2):88-95) Key words Epidural, Analgesia, Labor, Mothers, Newborns 연구배경 산과마취의 발달로 경막외 무통분만이 널리 시행되면서 분만통증은 많이 완화되었지만 아직도 무통분만의 안전성에 대한 논 란이 많다. 따라서 본 연구에서는 경막외 무통분만이 분만과정의 산모와 신생아에게 미치는 영향을 파악하기 위함이다. 방 법 정상 질식 분만을 위하여 여성전문병원에 입원한 산모 243명을 대상으로 경막외 마취군 143명(초산부 90명, 경산부 53명)과 비마취군 100명(초산부 52명, 경산부 48명)을 대상으로 분만 진행과정의 산모와 신생아에게 미치는 영향을 t-test로 분석 비교 하였다. 결 과 분만 제 1기(F=11.40, p=.001)와 2기(F=21.14, p<0.001) 기간은 초산부에서만 경막외 마취군이 비마취군 보다 유의하게 길었다. oxytocin의 사용빈도는 초산부(χ2=9.80, p=.002)와 경산부((χ2=22.9, p<0.001) 모두 경막외 마취군이 비마취군 보다 유의하게 높 았다. 분만 만족도는 초산부와 경산부 모두 경막외 마취군과 비마취군 간에 유의한 차이가 없었다. 신생아의 출생 후 1분 Apgar 점수는 초산부(t=-8.37, p<0.001)와 경산부(t=-7.91, p<0.001) 모두 경막외 마취군이 비마취군 보다 유의하게 낮았고, 5분 Apgar 점수도 초산부(t=-10.37, p<0.001)와 경산부(t=-10.69, p<0.001) 모두 경막외 마취군이 비마취군 보다 유의하게 낮았다. 신생아의 태변착색정도는 초산부에서만 경막외 무통분만 여부와 관련성이 있었다(χ2=9.71, p=.021). 결 론 본 연구결과 경막외 무통분만은 경산모보다 초산모 집단에서 분만과정과 신생아의 태변착색에 영향을 미치고, 신생아의 Apgar 점수는 초산모과 경산모 집단 모두에서 영향을 미치고 있음이 확인되었다. 따라서 경막외 무통분만 시행 시 산모와 신생아의 안녕을 위해 적극적인 분만 관리방법이 요구됨을 시사한다.

무통 분만 시 경막외 제통 및 미추 블록이 분만 2기에 미치는 영향

정성희,권경석,이병상,김민성,김현혜,김병국,고동균 대한마취통증의학회 2010 Anesthesia and pain medicine Vol.5 No.1

Background: Epidural analgesia is the most effective way of providing pain relief during labor. However, its effect on the second stage of labor is controversial. This study examined the effect of epidural analgesia combined with caudal analgesia on the second stage of labor. Methods: Forty three multiparous women were divided into three groups, non-epidural group, epidural group and epidural with caudal group. Epidural analgesia was maintained with patient-controlled epidural analgesia (0.09375% ropivacaine with 0.0002% fentanyl)in both the epidural and epidural with caudal groups. The epidural with caudal group was injected with 0.09375% ropivacaine into the caudal epidural space after inserting the lumbar epidural catheter. The assessments made throughout labor included the visual analogue score (VAS), patient’s satisfaction, motor block and duration of the second stage. Results: There were no significant differences in the patient’s satisfaction, VAS and motor block between the epidural group and epidural with caudal group. There were no significant differences in the duration of the second stage between the non-epidural,epidural and epidural with caudal groups. No cesarean or instrumental deliveries were performed. Conclusions: Epidural with caudal analgesia offers no additional benefit during the second stage of labor. However, it carries no added risk on the maternal outcome.

Programmed intermittent epidural bolus as compared to continuous epidural infusion for the maintenance of labor analgesia: a prospective randomized singleblinded controlled trial

Christina W. Fidkowski,Sonalee Shah,Mohamed-Rida Alsaden 대한마취통증의학회 2019 Korean Journal of Anesthesiology Vol.72 No.5

Background: Programmed intermittent epidural bolus (PIEB) techniques are a new area of interest for maintaining labor analgesia due to the potential to decrease motor block and improve labor analgesia. This study compares continuous epidural infusion (CEI) to 2 PIEB regimens for labor analgesia. Methods: One hundred fifty patients undergoing scheduled induction of labor at term gestation having epidural labor analgesia were randomized to receive an epidural analgesia regimen of bupivacaine 0.125% with fentanyl 2 μg/ml at either PIEB 5 ml every 30 min (Group 5q30), PIEB 10 ml every 60 min (Group 10q60), or 10 ml/h continuous infusion (Group continuous epidural infusion [CEI]). The primary outcome is the pain scores throughout labor. Secondary outcomes include degree of motor block, dermatomal sensory levels, the number of physician-administered boluses, and patient satisfaction. Results: While the average pain scores throughout labor did not differ significantly between groups, fewer patients in group 10q60 received physician-administered boluses for breakthrough pain (34.9% in 10q60 vs. 61.0% in 5q30 and 61.9% in CEI, P = 0.022). Dermatomal sensory levels, degree of motor block, and patient satisfaction did not differ significantly between groups. Conclusions: Our study suggests that high volume PIEB regimens for labor analgesia decrease breakthrough pain and physician-administered boluses.

무통분만

이해진,전진영 대한의사협회 2010 대한의사협회지 Vol.53 No.1

We discuss recent advances in the administration of labor analgesia aimed at a more effective birthing experience for parturient women. Patient-controlled epidural analgesia (PCEA) is the most effective method of labor pain relief in medical practice. It also provides more consistent and predictable labor analgesia. When a parturient women has a contraindication to epidural analgesia, systemic analgesia techniques are provided as a guide to effective analgesia. PCEA of “low-dose” or “light mixtures” of local anesthetics and lipophilic opioids has allowed anesthesiologists to provide reasonable pain relief for most parturient women while decreasing the total dose of local anesthetics and opioids, thus minimizing the side effects of each agent. Fentanyl analgesia utilizing patient -controlled intravenous analgesia (PCIA), may provide effective self-titrated pain relief, although they are not as effective as the epidural method. Recently, remifentanil was suggested as the opioid of choice for labor analgesia. Potential advantages of remifentanil include better titration of analgesia and neonatal outcome. However,all systemic opioids rapidly cross the placenta. These drugs may cause neonatal respiratory and neurobehavioral depression. In order to reduce the incidence of breakthrough pain, more research on computer-integrated patient-controlled analgesia technology may be necessary. The study of a new local anesthetic drug that has less motor blockade and cardiotoxicity than ropivacaine is desirable, while PCEA is the most effective form of labor analgesia currently available. If epidural analgesia is contraindicated, PCI remifentanil bolus alone may be a suitable systemic analgesia for labor pain.

The effects of epidural labor analgesia on the progress of labor: a retrospective study

유정희,소윤미,황정원,도상환,김종수 대한마취통증의학회 2009 Anesthesia and pain medicine Vol.4 No.2

Background: Epidural analgesia provides effective pain control during labor. However, its influence on the course of delivery is controversial. The aim of this study was to assess the effect of epidural analgesia on the course of delivery and the perinatal outcome and to examine the changes of the cesarean delivery rates that are associated with epidural analgesia. Methods: Among 1,200 parturients who delivered in our hospital from 2003 to 2005, we obtained the demographic and obstetric data for 240 primiparous deliveries (120 women in the epidural group [group E] and 120 women in the nonepidural group [group N]). The duration of the active phase and the second and third stages of labor, the perinatal outcome and the incidence of emergency cesarean delivery were analyzed. Results: The duration of the second stage of labor was longer in group E (41 ± 23 min in group N vs. 49 ± 28 min in group E, P = 0.02). The incidences of cesarean delivery were similar between the two groups [15 (12.5%) in group N vs. 18 (15%) in group E, P = 0.6]. The incidences of fetal distress during the active phase of labor did not differ in both groups (48% vs. 41%, respectively, P = 0.4). The neonatal outcomes, including the birth weight, fetal heart rate deceleration or bradycardia during labor and the Apgar score, were similar between the two groups. Conclusions: We conclude that epidural labor analgesia does not seem to be associated with an increased incidence of cesarean delivery. In addition, epidural labor analgesia seems to have no adverse effect on the perinatal outcomes of primiparous women.

지속적인 경막외 제통이 분만 진행에 미치는 영향

김상태 충북대학교 의과대학 충북대학교 의학연구소 1998 忠北醫大學術誌 Vol.8 No.2

연구 목적 : 경막외 제통은 분만통을 감소시키고 카테콜아민의 분비를 줄여서 자궁으로 공급되는 혈류량을 잘 유지시키고 산모의 과환기와 저환기를 막아주어 태아로의 산소 공급을 원활히 해주는 장점이 있다. 그러나 분만과정의 지연을 초래하고 기계적 분만으로의 이행 빈도를 증가시킨다는 논란이 있어서 경막외 제통이 분만과정 및 태아에 미치는 영향을 알아보고자 본 연구를 시행하였다. 대상 및 방법 : 정상 질식 분만을 위하여 본원에 입원한 산모 116명을 대상으로 경막외 제통을 받은 군과 받지 않은 군으로, 초산부와 경산부로 나누어 연구를 실시하였다. 결과 : 초산부의 경우 경막외 제통을 실시한 군에서 분만 1기의 활동기 기간, 분만 2기 기간이 연장되었으며 경산부는 활동기의 연장은 없었고 분만 2기의 기간만 유의하게 연장되었다. Oxytocin 사용 빈도는 모든 산모에서 경막외 제통을 시행한 환자에서 유의하게 높았으며, 기계적 분만으로 이행하는 빈도는 경막외 제통의 시행 유무와는 상관 관계가 없었다. 신생아의 1분 및 5분 Apgar score도 작았지만 모두 7점 이상을 유지하였고, 신생아의 pH를 포함한 모든 제대 정맥혈 가스분석소견은 두군간에 유의한 차이가 없었다. 경막외 제통을 실시한 시각이 잠복기 흑은 활동기인가에 따라서 조사한 결과 1분 Apgar score만 활동기에 실시한 군에서 높은 점수를 기록했을 뿐 다른 지표와는 유의한 상관 관계가 없었다(P〈0.05). 결론 : 따라서 본 연구결과는 경막외 제통을 실시하면 분만 2기의 기간은 길어지지만 기계적 분만의 빈도도 증가하지 않고 태아에 미치는 영향은 없으며 경막외 제통 실시 시작은 활동기 또는 잠복기라도 일정이상의 자궁경부의 개대가 있으면 빨리 시작하는 것이 좋을 것으로 생각한다. Purpose : Epidural analgesia can reduce the labor pain and have a benefit of sustaining normal uterine blood flow from reducing the catecholamine secretion and good oxygen supply to fetus from preventing maternal hyperventilation and hypoventilation. But some controversies are exist on epidural analgesia, such as labor prolongation and increased frequency of instrumental delivery after epidural analgesia. The purpose of this study was to evaluate the effect of epidural analgesia on the labor progress. Materials and Method : One hundred and sixteen pregnant women were divided into 4 groups : nulliparous women received epidural analgesia and not received group, mulltiparous women received epidural analgesia and not received group. Result : On nulliparous women, the duration of the active phase and 2nd stage was significantly prolonged on epidural group. On multiparous women, the duration of the 2nd stage was significantly prolonged on epidural group, but active phase was not. Also the incidence of oxytocin-used was increased on epidural group. But the incidence of instrumental delivery was not increased on epidural group regardless of parity. Apgar score was lower than nonepidural group, but higher than 7 score at 1, 5 min. All parameters of umbilical venous blood gas analysis were not significantly different between groups(p<0.05). Conclusion : From the result of this study, I conclude that epidural analgesia can prolong the duration of the 2nd stage, but not increase the frequency of instrumental delivery. And fetal adverse effect of epidural analgesia was minimal.

Clinical Research Article : A survey on informed consent process for epidural analgesia in Labor pain in Korea

( Nan Ju Lee ),( Ji Yeon Sim ),( Mi Soon Lee ),( Won Sik Ahn ),( Sun Sook Han ),( Hwa Mi Lee ) 대한마취과학회 2010 Korean Journal of Anesthesiology Vol.59 No.1

Background: There is a legal obligation to explain the procedure and use of epidural analgesia in labor primarily due to the possibility of potential risks and associated complications. The present study details on the survey carried out to ascertain the current status of obtaining informed consent (IC) for explaining the epidural analgesia in labor. Methods: The present study is based on a survey through a telephone questionnaire that covered all the hospitals in Korea where the anesthesiologists` belonged to and are registered with Korean Society of Anesthesiologists. The questionnaire included questions pertaining to administration of epidural analgesia to a parturient, information on different steps of obtaining an IC, whether patient status was evaluated, when the consent was obtained, and the reasons behind, if the consent had not being given. Results: A total of 1,434 respondents took part in the survey, with a response rate of 97% (1,434/1,467). One hundred seventy-four hospitals had conducted epidural analgesia on the parturient. The overall rate of obtaining IC for epidural analgesia during labor was 85%, of which only 13% was conducted by anesthesiologists. The rate of evaluating preoperative patient status was 74%, of which 45% was conducted by anesthesiologists. Almost all of the consent was obtained prior to the procedure. Conclusions: The rate of obtaining IC for epidural analgesia in labor is relatively high (85%) in Korea. However, it is necessary to discuss the content of the consent and the procedure followed for obtaining IC during the rapid progress of labor. (Korean J Anesthesiol 2010; 59: 34-38)

Modern techniques to optimize neuraxial labor analgesia

Jalal A. Nanji,Brendan Carvalho 대한마취통증의학회 2018 Anesthesia and pain medicine Vol.13 No.3

Neuraxial analgesia is the gold standard method for pain relief in labor. Several techniques can optimize both the initiation and maintenance of neuraxial labor analgesia. Initiation techniques such as combined spinal-epidural or dural puncture epidural may offer some advantages over standard epidural insertion. The use of ultrasound to assist with landmarking and optimizing block placement improves neuraxial success, and is particularly useful in certain patient populations. Maintaining labor analgesia with a regimen that includes background programmed intermittent boluses with a patientcontrolled epidural analgesia component affords the best combination of pain relief and avoidance of undesired effects. These techniques are most effective when dilute local anesthetics with lipophilic opioids are utilized.

무통분만을 위한 경막외 진통에서 Fentanyl의 용량에 따른 0.2% Ropivacaine의 작용발현시간과 작용지속시간

방은치,신지현,이현숙,강용인,조경숙,김수연 대한마취통증의학회 2010 Anesthesia and pain medicine Vol.5 No.3

Background:The purpose of this study was to identify the effect of fentanyl dose on the onset and duration of 0.2% ropivacaine. Methods:Sixty-one nulliparous women with singleton vertex pregnancy who requested epidural labor analgesia were enrolled.Patients were administered randomly 0, 50, 100μg of fentanyl with 10 ml of 0.2% ropivacaine (Group F0, F50 and F100, respectively).VAS pain scores were recorded 0, 5, 10, 15 min after epidural injection, after which they were recorded every 15 min.The onset and duration of analgesia were measured.Side effects such as, pruritus, motor blockade, and hypotension were recorded.Satisfaction scores, type of delivery, and neonatal outcomes were recorded. Results:The onset of analgesia was at 8.5 ± 3.4 min in Group F100, compared with 13.7 ± 7.2 min in Group F0 and 13.6 ± 5.3 min in Group F50 (P = 0.009).The duration of analgesia was 122.6 ± 20 min in Group F100, compared with 72.3 ± 21.2 min in Group F0 and 97.8 ± 22.4 min in Group F50 (P = 0.000).There were significant differences in VAS pain scores and satisfaction scores among the three groups. There were no differences in the incidences of maternal side effects and operative delivery or neonatal outcomes. Conclusion:Fentanyl 100μg was the most appropriate dose when combined with 0.2% ropivacaine due to the rapid onset and long duration of epidural labor analgesia.

Confirmation of Epidural Catheter Placement in a Pregnant Woman by using an Electrical Stimulating Epidural Catheter with Conductive Guidewire: A Case Report

( Jung Eun Kim ),( Sung Wook Kang ),( Chung Hun Lee ),( Min Ki Lee ),( Sang Sik Choi ),( Keon Sik Kim ),( Sung Wook Park ),( Hee Yong Kang ) 경희대학교 경희의료원 2017 慶熙醫學 Vol.32 No.1

Although epidural analgesia during labor can effectively attenuate labor and delivery pain, the technique can be difficult for anesthesiologists to perform. Loss of resistance (LOR) technique to determine the epidural space is the most widely used method for epidural catheter placement. However, it is difficult to identify LOR in parturient women due to obesity and edema. We present a case of successful administration of epidural analgesia using an electrical stimulating catheter that allowed us to confirm the epidural space in pregnant women. A 30-years-old woman with a gestation of 39 weeks and 6 days was admitted for painless childbirth. For pain control, we tried epidural analgesia and applied electrical stimulation to confirm epidural placement of the catheter. The authors could confirm the epidural space correctly using an electrical stimulating catheter in pregnant women. LOR technique with electrical nerve stimulation can increase the success rate of epidural analgesia during labor.