硬脊膜外減痛分娩對婦女及新生兒健康的影響

研究背景:生產陣痛可能造成孕產婦心理衝擊，增加慢性疼痛、產後憂鬱風險；然而已廣泛使用的硬脊膜外減痛分娩，卻可能對生產歷程造成影響。過去文獻對硬脊膜外減痛分娩和產後憂鬱關係的研究結果並不一致，在產後不同時間點的結果也有差異，而且鮮少探討和全身性、局部慢性疼痛之關係。研究目的:本研究目的在於探討硬脊膜外減痛分娩對婦女陰道生產結果、疼痛與產後憂鬱的影響，以及對新生兒健康的影響。研究方法:本研究設計包含橫斷式及縱貫式觀察性研究。於台灣北部某醫學中心收案，共258位單胞胎、頭位、陰道產之初產婦納入研究。研究工具包含「流行病學研究中心憂鬱量表」、「簡易麥克吉爾疼痛量表」及「個案基本資料問卷」，收集生產至產後共七個時間點的疼痛資料及產後五個時間點的憂鬱分數。以IBM SPSS Statistics 25.0分析所得資料，以描述性統計敘述有無使用硬脊膜外減痛分娩兩組婦女之基本屬性、生產結果、疼痛及產後憂鬱分布，以Chi-square test、Student's' t Test、Multiple linear regression、Multiple logistic regression分析硬脊膜外減痛分娩對生產結果、生產疼痛的影響；以Generalized estimating equation (GEE)分析使用硬脊膜外減痛分娩對產後第一年憂鬱的影響。研究結果:共納入258位陰道產婦女，包括無硬脊膜外減痛113人(43.8%)、有硬脊膜外減痛145人(56.2%)。依據使用硬脊膜外減痛分娩與否進行差異性分析，結果顯示和無硬脊膜外減痛婦女相比，有硬脊膜外減痛分娩婦女之懷孕週數顯著較大(p<0.01)、新生兒出生體重顯著較重(p<0.01)、催生(p=0.03)及器械輔助生產比率顯著較高(p<0.01)、第一產程(p<0.01)和第二產程時間(p<0.01)顯著較長。控制干擾因素後，多元線性迴歸分析結果指出，硬脊膜外減痛分娩會顯著延長陰道生產婦女的第一產程時間(p<0.01)，但並未影響第二產程時間(p=0.06)。多元羅吉斯回歸分析結果指出，有硬脊膜外減痛分娩者接受器械輔助生產的風險較高(OR=2.34，95% CI=1.32- 4.15)，但新生兒健康指標如新生兒第一分鐘、第五分鐘阿帕嘉計分和新生兒入住單位皆無顯著差異。另外，相較無硬脊膜外減痛組，生產時硬脊膜外減痛組的整體嚴重疼痛比率顯著較低(p=0.04)，但控制干擾因素後，確認硬脊膜外減痛分娩不是生產時整體嚴重疼痛的影響因素。於產後一年內有憂鬱症狀的比率，無硬脊膜外減痛組婦女為22.8–40.6%，有硬脊膜外減痛組婦女為18.6–32.8%。GEE分析結果顯示，硬脊膜外減痛分娩不是陰道分娩婦女產後第一年憂鬱的獨立影響因素；但對生產時具有整體嚴重疼痛的婦女，使用硬脊膜外減痛分娩可降低其產後第一年有憂鬱傾向的風險(OR=0.29，95% CI=0.09 – 0.96)。結論:本研究結果指出，硬脊膜外減痛分娩會延長陰道生產婦女的第一產程時間、增加器械輔助生產風險，但可降低生產時具嚴重整體疼痛的婦女在產後第一年有產後憂鬱之風險。建議未來在硬脊膜外減痛分娩婦女的臨床照護上，應有計畫地促進產程進展、運用具實驗證據之待產輔助工具和頻繁變換姿勢，以促進產程進展、減少相關風險。針對陰道分娩婦女，不論生產時或產後，應落實疼痛評估，及早預防、控制嚴重疼痛，以預防後續衍生慢性疼痛和產後憂鬱。

關鍵字

硬脊膜外減痛分娩；產後憂鬱；疼痛；生產結果

並列摘要

Background:For pregnant women, labor pains may cause psychological shock and increase the risk of chronic pain and postpartum depression. Labor epidural analgesia has been widely used to relieve labor pain, but it may also affect the progress of labor. Studies have reported inconsistent results concerning the relationship between labor epidural analgesia and postpartum depression; the results have varied depending on the time point after childbirth. The relationship between labor epidural analgesia and systemic and local chronic pain has rarely been discussed. Aim:This study investigated the effects of labor epidural analgesia on the outcomes of vaginal delivery and pain and postpartum depression among mothers as well as the health outcomes of newborns. Methods:This was a secondary data analysis based on observational studies, including cross-sectional and longitudinal surveys. Two hundred fifty-eight singleton, cephalic, primiparous women were recruited from a medical center in northern Taiwan. Childbirth medical records and self-reported questionnaires were used to collect the relevant data. The questionnaire comprised the short-form McGill Pain Questionnaire (SF-MPQ), the Center for Epidemiologic Studies Depression Scale (CES-D), and questions concerning demographic characteristics and obstetric variables. SPSS 25.0 statistical software was used to analyze the data. The statistical methods employed were descriptive statistics; the chi-square test, Student’s t test, multiple linear regression, and multiple logistic regression for analyzing the effects of labor epidural analgesia on childbirth outcomes and labor pain; and a generalized estimating equation (GEE) logistic regression model for analyzing the effect of labor epidural analgesia on depression in the first year after delivery. Results:A total of 258 women who gave birth via vaginal delivery were enrolled; 145 (56.2%) who received labor epidural analgesia constituted the case group, and the control group consisted of 113 (43.8%) who did not receive such analgesia. The women who received labor epidural analgesia had been pregnant for a significantly larger number of weeks (p < 0.01) and gave birth to significantly heavier newborns (p < 0.01). These women’s rates of oxytocin use (p = 0.03) and instrumental vaginal delivery (p < 0.01) were significantly higher, and the duration of their first (p < 0.01) and second (p < 0.01) stages of labor were significantly longer than those of controls. After controlling for confounding factors, multiple linear regression confirmed that labor epidural analgesia prolonged the length of the first stage of labor (p < 0.01) but it did not affect the length of the second stage of labor (p = 0.06). Multiple logistic regression analysis confirmed that labor epidural analgesia increased the risk of instrumental vaginal delivery (odds ratio [OR] = 2.34, 95% confidence interval [CI] = 1.32–4.15). However, newborn health outcomes did not significantly differ between the groups. Women who received labor epidural analgesia had a significantly lower rate of severe overall pain during labor (p = 0.04). After controlling for confounding factors, multiple logistic regression analysis confirmed that labor epidural analgesia was not an influencing factor on severe overall pain during labor. In the first postpartum year, the rate of depression among women who did not receive labor epidural analgesia was 22.8–40.6%; by contrast, the depression rate among women who received labor epidural analgesia was 18.6–32.8%. GEE analysis confirmed that labor epidural analgesia was not an independent risk factor for depression in the first year after delivery. However, for women with severe overall pain during labor, the use of labor epidural analgesia reduced the risk of depression in the first year after delivery (OR = 0.29, 95% CI = 0.09–0.96). Conclusion:This study demonstrated that labor epidural analgesia prolongs the length of the first stage of labor and increases the risk of instrumental vaginal delivery. However, for women with severe overall pain during labor, it can reduce the risk of depression in the first year after delivery. Hence, We recommend that when caring for women who have received labor epidural analgesia, evidence-based tools such as birthing ball, peanut ball and frequent posture changes should be used to promote the progress of labor in a planned manner and reduce related obstetric risks. For women who give birth through vaginal delivery, their pain should be assessed during and after delivery to prevent and control severe pain as early as possible to forestall subsequent chronic pain and postpartum depression.