椎管内镇痛与阴道分娩术后新生儿并发症发病率的关系：一项回顾性横断面研究

在接受阴道分娩术的产妇中，高达84%的人都接受了椎管内镇痛。然而，在接受阴道分娩术的妇女中，椎管内镇痛与新生儿并发症发病率之间的关系知之甚少。作者假设在接受阴道分娩术的妇女中，椎管内镇痛与降低新生儿并发症发病率有关。

利用美国出生证明数据，这项研究纳入了2017年接受阴道分娩手术(产钳或真空泵辅助分娩)的单胎孕妇。作者研究了椎管内镇痛与新生儿并发症发病率的关系，新生儿并发症的定义如下：5min时的Apgar评分小于7分，立即辅助通气，辅助通气大于6h，新生儿重症监护病房入院，新生儿在分娩后24小时内转院，以及新生儿癫痫或严重的神经功能障碍。作者在分析中考虑到了社会人口和产科因素作为潜在的混杂因素。

研究队列包括106 845名接受阴道分娩术的产妇，其中92 518人(86.6%)接受了椎管内镇痛。椎管内镇痛组新生儿并发症发病率高于非椎管内组(分别为10 409 /92 518例(11.3%)和1 271/14 327例(8.9%)，P<0.001)。未调整前的相对危险度为1.27(95%CI，1.20~1.34；P<0.001)，用多因素模型考虑混杂因素后，调整后的相对危险度为1.19(95%CI，1.12~1.26；P<0.001)。在事后分析中，排除新生儿重症监护病房入院和新生儿转院的综合结果后，椎管内镇痛对新生儿并发症发病率的影响没有统计学意义(调整后的相对危险度为1.07；95%CI为1.00~1.16；P=0.054)。

在这项以人群为基础的横断面研究中，未观察到椎管内镇痛对减少阴道分娩出的新生儿并发症具有优势。指征混淆可以解释观察到的椎管内镇痛和新生儿并发症发病率之间的联系，然而这个数据集并不是为了评估这些考虑因素而设计的。

Association between Neuraxial Labor Analgesia and Neonatal Morbidity after Operative Vaginal Delivery

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A Retrospective Cross-sectional Study

ABSTRACT

Background:

Up to 84% of women who undergo operative vaginal delivery receive neuraxial analgesia. However, little is known about the association between neuraxial analgesia and neonatal morbidity in women who undergo operative vaginal delivery. The authors hypothesized that neuraxial analgesia is associated with a reduced risk of neonatal morbidity among women undergoing operative vaginal delivery.

Methods:

Using United States birth certificate data, the study identified women with singleton pregnancies who underwent operative vaginal (forceps- or vacuum-assisted delivery) in 2017. The authors examined the relationships between neuraxial labor analgesia and neonatal morbidity, the latter defined by any of the following: 5-min Apgar score less than 7, immediate assisted ventilation, assisted ventilation greater than 6 h, neonatal intensive care unit admission, neonatal transfer to a different facility within 24 h of delivery, and neonatal seizure or serious neurologic dysfunction. The authors accounted for sociodemographic and obstetric factors as potential confounders in their analysis.

Results:

The study cohort comprised 106,845 women who underwent operative vaginal delivery, of whom 92,518 (86.6%) received neuraxial analgesia. The proportion of neonates with morbidity was higher in the neuraxial analgesia group than the nonneuraxial group (10,409 of 92,518 [11.3%] vs. 1,271 of 14,327 [8.9%], respectively; P < 0.001). The unadjusted relative risk was 1.27 (95% CI, 1.20 to 1.34; P < 0.001); after accounting for confounders using a multivariable model, the adjusted relative risk was 1.19 (95% CI, 1.12 to 1.26; P < 0.001). In a post hoc analysis, after excluding neonatal intensive care unit admission and neonatal transfer from the composite outcome, the effect of neuraxial analgesia on neonatal morbidity was not statistically significant (adjusted relative risk, 1.07; 95% CI, 1.00 to 1.16; P = 0.054).

Conclusions:

In this population-based cross-sectional study, a neonatal benefit of neuraxial analgesia for operative vaginal delivery was not observed. Confounding by indication may explain the observed association between neuraxial analgesia and neonatal morbidity, however this dataset was not designed to evaluate such considerations

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