有研究对硬膜外使用高浓度和低浓度局麻药的对比研究做了一项荟萃分析( Sultan eta.2013)，结果显示硬膜外使用低浓度局麻药(低浓度定义：≤0.1%布比卡因或者≤0.17%罗哌卡因)和高浓度局麻药相比，前者减少阴道分娩助产率、运动阻滞、尿储留、第二产程时间。但在剖宫产率、疼痛评分、恶心呕吐发生率、低血压、胎心异常、5分钟 Apgar评分和新生儿复苏率间无差异。研究发现，分娩过程中，产妇硬膜外或蛛网膜下腔加入常规剂量的芬太尼或舒芬太尼，在产后24h内对新生儿无显著影响( Wang et al.2014)与芬太尼混合使用，布比卡因及罗哌卡因都相对有和安全。另外，布比卡因与芬太尼联合镇痛(BUP-FEN)可以缩短第二产程，而罗哌卡因与芬太尼联合镇痛(ROPI-FEN)能够显著降低运动阻滞的发生率( Li et al,2015)。随着新型局麻药物的不断出现，硬膜外镇痛的阻滞效果明显提高，而循环不稳定发生率又明显低于蛛网膜下腔镇痛。某些药物，如新斯的明，以前报道不能用于硬膜外的药物，现在开始得到应用。椎管内应用新斯的明，能够显著减少局麻药的用量，且不伴有严重的不良母婴结局( Cossu et al,2015)。硬膜外镇痛是目前临床上使用最广泛的方法，尤其对于潜伏期分娩镇痛更为适用。在第一产程潜伏期使用低浓度局部麻醉药和或联合使用阿片类药物可提供T1~L1节段的感觉阻滞。硬膜外镇痛可以在无运动阻滞情况下有效缓解疼痛、降低母体儿茶酚胺水平，还可以在必要时快速达到急诊剖宫产所需要的麻醉深度。国外给药方法中有时会加入1:20万的肾上腺素以加强局麻药的镇痛效果，但因其引起的并发症较多已逐渐不再使用，但是在美国一直使用含有1/20万肾上腺素的1.5%的利多卡因3ml作试验剂量。( Mhyre et al.,2013)研究表明硬膜外腔注射氢吗啡酮100μg可以减少膜外使用布比卡因的剂量，需要进一步研究论证，国内也研究表明部分产妇使用布托啡诺替代舒芬太尼可增加其夜间待产时睡眠质量，但受限于样本量较少。
1.3.优势与不足
近年来，病人自控硬膜外镇痛(PatientControlled Epidural Analgesia,PCEA)作为一项安全有效的技术，能够提供有效的分娩镇痛效果以及较好的患者满意度，而在临床上得到广泛的使用。它可以减少局麻药的使用总量，减少运动阻滞和低血压等副作用。它还可以减少医务人员的工作量，并且产妇可自主给药，使用药趋于个体化、合理化，用最小的剂量达到最佳的镇痛效果，同时给很多产妇自我拥有治疗权利的感觉。最近有研究( Genc Moralar,2013)表明产妇PCA与持续硬膜外用药相比，前者局麻药的用量明显减少，且运动阻滞发生率低，第一产程镇痛效果更好，因此PCEA成为更流行的产科分娩镇痛方式。同时有研究发现规律间断脉冲式注药方式对产妇的镇痛效果明显优于持续注药方式，这是由于规律间断脉冲式注药方式速度较快，压力较大，可以使药物在硬膜外腔分布更加广泛，分布更加均匀( Wong et al,2006)。PIEB技术应用,可减少药物用量，镇痛效果更加完善，对母婴安全可靠，提高了产妇满意度。是一种更科学，合理的方法。
连续蛛网膜下腔镇痛(CSA)，和单次注药前部分操作一样，脑脊液流出通畅后使用28G导管通过22G穿刺针置入蛛网膜下腔1~2cm，退腰麻针稳定导管，退针时转动穿刺针同时插入导管，可以避免导管打折等问题。置管成功后，牢固固定导管，通过导管注入腰麻镇痛药物进行分娩镇痛。主要的难题及争议是蛛网膜下腔穿刺针及导管的选择。蛛网膜下腔安全穿刺针的选择是CSA技术在临床应用受限制重要原因( Palmer,2010)。首次尝试解决穿刺针问题的是 Touly(1944)，使用4F的输尿管导管，通过15G的穿刺针置入到蛛网膜下腔。然而，当时临床常用的15G穿刺针，在硬脊膜上形成的破口，不可避免的出现了穿刺后头痛( Post Dural Puncture Headache,PDPH)。Hurley及 Lambert(1990)成功将32G“微管”通过26G的穿刺针置入蛛网膜下腔。CSA技术的应用从此逐渐增多，且市场上出现可以穿过22G或更细穿刺针的28-32G导管。这些细穿刺针及导管承诺能够降低PDPH发生率，从而使CSA技术得到广泛应用。然而，接下来的许多研究，揭露了使用微管给予局麻药时，药物在脑脊液中分布不均带来的一系列并发症，包括可发生永久性的神经损伤。因此，曾被美国食品药物管理局( United States Food and Drug Administration,FDA)一度禁用。后经报道分析这主要是由于导管的内径过小，严重限制了局麻药注射时的流速，低流速导致了局麻药的层流，使得部分神经根暴露在高浓度局麻药下，造成神经损伤，其主要原因为麻醉药浓度过高。而后FDA撤回允许使用24G或更小穿刺针的决定。
近来，经FDA允许的一项安全性研究显示，将产妇采用28G导管蛛网膜下腔持续输注舒芬太尼及布比卡因混合液，与连续硬膜外分娩镇痛进行比较(Arkoosh et al,2008）。研究发现，导管相关的神经损伤的风险小于1%；与CEA组产妇相比，镇痛启动后，CSA组产妇在第一产程的疼痛评分相对较低，且运动阻滞发生率也较低，但瘙痒评分更高。总之，CSA组产妇具有更高的满意度，两组间产科及新生儿结局无显著差异。
腰硬联合镇痛综合了蛛网膜下腔镇痛和硬膜外镇痛的双重优点，副作用少。项Meta分析比较了CSEA与CSA镇痛后产妇的镇痛起效时间，提示CSEA起效时间快(2～5 min Vs 10～15min)( Simmons etal,2007)。另外，腰麻用药量显著低于硬膜外，能够显著降低产妇全身药物中毒的风险。由于CSEA产妇的循环吸收的腰麻药物较少，所以母婴血浆药物浓度均低于CSA组。
CSEA技术的另一个优势是，可以通过鞘内单次给予脂溶性的阿片类药物，在分娩早期达到完善的镇痛效果，同时减少运动阻滞的发生及低血压的风险( Campbell et al.1995)。CSEA技术尤其适用于渴望自由行走的产妇，同时它还能有效降低硬膜外镇痛的失败率(如无效硬膜外导管)( Norris,0; Pan et al,2004)
然而，CSEA技术也伴随一些不良反应。其中，PDPH是硬脊膜穿破后最常见的不良反应；当使用直径较小的穿刺针时，可以一定程度上降低PDPH的发生率( Simmons et al,2007)。可能发生的更为严重的一个问题是，硬脊膜穿破可能是产后椎管内感染的重要危险因素，虽然发生率低，但是严重威胁产妇的生命安全( Collis& t Harries,205aer2006)。其次，鞘内注射阿片类药物，导致瘙痒的发生率，比CSA的产妇显著升高( (Simmons,2007)。同时，CSEA的另一个缺陷是，在镇痛开始后1～2h,我们无法确认硬膜外导管的位置是否恰当。因此，CSEA技术并不是分镇痛的最佳选择，因为作用确切的硬膜外导管是分娩镇痛成功的重要因素。
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