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Anesth Pain Med 2010; 5: 7~11 임상연구 무통분만시경막외제통및미추블록이분만 2 기에미치는영향 차의과학대학교마취통증의학교실 정성희ㆍ권경석ㆍ이병상ㆍ김민성ㆍ김현혜ㆍ김병국ㆍ고동균 Effect of lumbar epidural and caudal analgesia on the second stage of labor Key Words: Caudal block, Epidural analgesia, Labor pain. Sung Hee Chung, Kyoung Seok Kweon, Byung Sang Lee, Min Sung Kim, Hyun Hye Kim, Byeong Kuk Kim, and Tong Kyun Ko Department of Anesthesiology and Pain Medicine, CHA Medical Center, CHA University, Gumi, Korea 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. (Anesth Pain Med 2010; 5: 7 11) Received: November 2, 2009. Revised: November 19, 2009. Accepted: December 1, 2009. Corresponding author: Kyoung Seok Kweon, M.D., Department of Anesthesiology and Pain Medicine, CHA Medical Center, CHA University, Hyeonggok 1-dong, Gumi 730-728, Korea. Tel: 82-54-450-9683, Fax: 82-54-450-9989, E-mail: kwonks486@naver.com 서론경막외제통이분만과정에미치는영향은여전히논란의여지가있는문제이지만국소마취제나아편양제제의혼합물을사용하여최근에는경막외제통이분만진행이나제왕절개술의빈도에영향이없다는보고로인해분만시경막외제통이널리이용되고있다 [1]. 그러나, 자궁수축감소에의한분만 1기와 2기의연장을감소시키기위해국소마취제의농도를감소시켜서시행하는것이분만 2기의통증감소효과를떨어뜨리고더욱이기계적분만의빈도를감소시킨다는이유로분만 2기에경막외제통을중단시키는방법을시행함으로써분만 2기의제통은간과되고있다. 분만 2기에경막외제통을중단하는방법은분만의결과나기계적분만의빈도와관련이없으며오히려분만 2기의통증의증가를초래한다고보고하고있다 [2,3]. 이러한결과에도불구하고여전히산모와태아의안전을위해분만 2기에경막외제통을꺼려하는경우가많으며감소된국소마취제의농도에의한경막외제통은분만 2기의제통에부족한점이있다. 분만시통증조절을위한미추블록은 1942년처음으로보고되었고이후지속적미추블록으로효과적인분만 2기의제통을제공하였으나지속적경막외제통이시도되면서혼합된경막외미추블록으로시행되다가경막외제통의쉬운방법과우수한제통으로점차분만시제통에서사라지게되었다 [4,5]. 미추블록이실패율이높고감염의위험성및우발적인태아내주입의가능성과중추신경독성의증상빈도가높으므로 [6,7] 잘시행되지않고있으나분만 1기를연장시키지않으면서일회주입으로분만 2기에효과적인제통을제공할수있다 [8,9]. 이에저자들은분만 2기의통증이 S2-S4 분절과관련되어있는사실에기인하여 43명의경산부를대상으로미추블 7

8 Anesth Pain Med Vol. 5, No. 1, 2010 록을시행하여미추블록이분만 2기의연장이나통증의정도, 기계적분만의빈도와관련이있는지를비교관찰하였다. 대상및방법 2008년 9월부터 2009년 8월까지자연분만을위해본원에내원한산모들중미국마취과학회신체상태분류 1, 2등급에해당하는경산부를대상으로하였다. 시술에대해충분히설명을한후동의를구하였으며, 제대주수 36주이상이면서태아두부체위, oxytocin 점적주입을사용한경우로전자간증, 자간증, 다태아, 태아기형, 자궁내태아발육지연, 아두골반불균형, 노령산모는제외하였다. 이산모들중무통을원하지않는산모 (N 군 ) 와무통을원하는산모중무작위로경막외제통만시행한군 (E 군 ) 과경막외제통및미추블록을시행한군 (E-C 군 ) 으로분류하였다. E 군과 E-C 군의산모들은자궁경부가 3 5 cm 개대시제 2 3 또는 3 4 요추에저항소실법을이용하여두부방향으로 3 cm 정도경막외카테터를거치한뒤 2% lidocaine 3 ml를주입하여지주막하나혈관내주입이아님을확인하였다. 두군모두에서경막외로 0.1875% ropivacaine 과 0.0004% fentanyl의혼합용액 12 ml를부하용량으로주입한뒤, 0.09375% ropivacaine과 0.0002% fentanyl 혼합용액을자가통증조절기 (Automed R 3200, Ace medical Co, Korea) 를이용하여지속주입은시간당 10 ml, 일시주사는 3 ml, 잠금시간은 20분으로설정하였다. E-C 군의산모들은경막외제통을위에서처럼시행한후같은좌측이나우측와위자세에서천골열공을확인하고 23 G 6 cm 바늘을사용하여미추천자한뒤주사기를흡인하여혈액이역류하는지를확인후에혈액이역류하지않으면 2% lidocaine 3 ml를시험용량으로주고지주막하척수강내약물주입의증거가없으면 0.1875% ropivacaine 8 ml를천골강내에투여하였다. 약물투여전두군모두에서산모의혈압감소를예방하기위해 5% 포도당식염수 300 500 ml를미리정주하였다. 경막외제통과미추블록전산모의혈압과심박수, 태아 의상태가안정되어있는지확인하였고, 약물을주입한후산모의혈압과심박수를 5분마다측정하였다. 태아감시장치를이용하여태아의심박동수를지속적으로감시하였으며, E 군과 E-C 군사이에제통의효과정도와산모의만족도, 운동마비의정도를비교하였고기계적분만의발생과제왕절개로전환을조사하였다. N 군, E 군, E-C 군의세군사이에분만 2기의시간을비교하였고, 모든관찰결과는평균 ± 표준편차와백분율로표시하였다. 제통의효과정도는경막외제통을시행하기전, 경막외제통및미추블록을시행한후 30분, 자궁경부가열린후태아만출전에시각아날로그척도 (Visual Analogue Scale, VAS) 로측정하였고, 산모의만족도는분만직후에산모를면담하여 11 points numeric digital scale(0 = 전혀만족할수없음, 10 = 완전한만족감 ) 로평가하였으며운동마비정도는 modified Bromage score[10](table 1) 을사용하여평가하였다. 통계적검증을위해서 SAS R Enterprise Guide 제 4 판을이용하였고, Student t-test와일변수분산분석 (one-way analysis of variance) 으로비교하였다. 모든경우에서 P < 0.05일때를통계적으로유의한것으로판별하였다. 결 43명의경산모중에서무통분만을시행하지않는 N 군은 14명, 경막외제통만시행한 E 군은 15명, 경막외제통과미추블록을시행한 E-C 군은 14명이었고, 세군의평균연령, 체중, 신장, 임신주수는통계적으로유의한차이를보이지않았다 (Table 2). Table 1. Modified Bromage Score[10] 1 Complete block (unable to move feet or knees) 2 Almost complete block (able to move feet only) 3 Partial block (just able to move knees) 4 Detectable weakness of hip flexion (between scores 3 and 5) 5 No detectable weakness of hip flexion while supine (full flexion of knees) 6 Able to perform partial knee bend 과 Table 2. Demographic Data N group (n = 14) E group (n = 15) E-C group (n = 14) Age (yr) 31.5 ± 3.6 31.5 ± 2.7 30.9 ± 1.7 Height (cm) 160.4 ± 4.9 161.1 ± 4.5 163.1 ± 4.3 Weight (kg) 65.8 ± 7.3 68.3 ± 11.8 71.8 ± 7.7 Gestational age (days) 278.3 ± 4.7 275.5 ± 9.0 279.9 ± 9.0 Values are mean ± SD. There were no significant differences among the groups.

정성희외 6 인 : 무통분만시미추블록의영향 9 Table 3. Clinical Characteristics of Labor and Effect of Analgesia N group (n = 14) E group (n = 15) E-C group (n = 14) Duration First stage (min) 110 ± 52.5 131 ± 61 Second stage (min) 25.0 ± 12.3 21.7 ± 3.9 22.9 ± 8.2 VAS First stage 78.6 ± 6.6 10 ± 9.3* 12.1 ± 7.0* Second stage 84.3 ± 7.6 28 ± 6.8* 23.6 ± 13.9* Motor Block (score) 4 ± 0 3.9 ± 0.4 Satisfaction (scale) 3.8 ± 0.41 3.9 ± 0.4 Values are mean ± SD. VAS: Visual Analogue Scale. N: no analgesia, E: epidural analgesia, E-C: epidural and caudal analgesia. *: P < 0.05 compared with N group. : P < 0.05 compared with first stage. Fig. 1. Duration of Second Stage depending on Type of Analgesia. Values are expressed as mean ± SD. N: no analgesia, E: epidural analgesia, E-C: epidural and caudal analgesia. E 군과 E-C 군사이에는분만 1기의기간, 운동마비정도, 만족도에서통계적으로유의한차이를보이지않았다 (Table 3). 세군모두에서기계적분만이나제왕절개로의전환은없었고, 산모의저혈압이나태아의서맥이발생한경우는없었다. 분만 2기의기간은 N 군, E 군, E-C 군의세군사이에서통계적으로유의한차이를보이지않았다 (Fig. 1). 분만 1기와분만 2기의 VAS에서는 N 군과 E 군, N 군과 E-C 군사이에는통계적으로유의한차이를보였으나 (P < 0.05)(Fig. 2), E 군과 E-C 군사이에는유의한차이가없었다 (Fig. 2). E 군에서분만 1기의 VAS가분만 2기의 VAS 보다통계적으로유의하게낮았고 (P < 0.05)(Fig. 2, Table 3), E-C 군에서도분만 1기의 VAS가분만 2기의 VAS 보다유의하게낮았다 (P < 0.05)(Fig. 2, Table 3). 무통분만을하지않은군에서오심이 2명, 경막외제통만시행한군에서오심 1명, 가려움증이 1명발생하였고, 경막외제통과미추블록을시행한군에서오심이 3명, 가 Fig. 2. VAS depending on the Type of Analgesia and the Stage of Labor. Results are expressed as median (filled circle) with 1 st and 3 rd quartiles(boxes) and 10 th and 90 th percentiles (vertical line). N: no analgesia, E: epidural analgesia, E-C: epidural and caudal analgesia. 0: before active phase of labor, 1: first stage of labor, 2: second stage of labor. *: P < 0.05 compared with N group. : P < 0.05 compared with first stage. 려움증이 2명발생하였으며오심, 가려움증의세군간의발생빈도에서통계학적유의성은없었다. 고 무통분만을위한경막외제통은과도한감각차단이나운동차단없이우수한진통을제공하여야하며, 전신독성이나부작용이최소이어야하고정상질식분만의기회가많도록하는것이이상적이다 [11]. 최근까지도경막외나척수강내에시행하는제통이분만과정과자궁의활동에주는영향은논란의여지가많으나낮은농도의국소마취제사용과아편양제제의혼합사용으로분만의연장이나이로인한제왕절개율증가, 기계적분만의빈도증가등을감소 찰

10 Anesth Pain Med Vol. 5, No. 1, 2010 시킴으로써이상적인무통분만에보다근접하게되었다. 그러나, 분만 1기의후반과 2기의천골부위제통을위해서는추가적인용량이요구되어짐에도 [12] 여러센터에서경막외제통이골반저부가이완되면서태아두부의회전이늦어지고반사에의한밀기와자궁활동이감소되어기계적분만의빈도가증가할 [13,14] 것이라는이유로분만 2 기의제통은소극적으로이루어지고있다 [2,15}. 이에저자들은회음부부위제통을위해일시적미추블록을시행하였고분만 2기에미치는영향에대해알아보기위해분만 1기와 2기가길지않은경산부를대상으로하였으며우발적인태아내주입을예방하고산모의편의를위해경막외제통과동시에미추블록을시행하였다. Schaupp와 Durfee는 [9] 분만 1기의후반에시행하는안장차단마취와일회주입의미추블록이분만 2기의제통에만족할만한효과를보인다고하였다. 또한, 카테터를이용한지속적미추블록은분만 1기에도제통의효과가있고산도를이완시킴으로써조직손상을감소시키며수술적조작을용이하게하고산모와태아에게부작용없이분만 2기가연장된다하더라도제통을가능하게할수있다고보고하였다. Meehan은 [8] 미추블록을시행하였을때작용발현시간이 10 20분걸리고작용지속시간은 bupivacaine의경우 2 시간내지 2시간반정도지속되며 epinephrine을첨가하였을경우그이상도가능하다고하였다. 본연구에서 bupivacaine과작용지속시간이비슷한 ropivacaine을사용하였고분만 1 기의평균시간이약 2시간정도이며분만 2기의평균시간이약 20분정도이므로미추마취의효과가분만 2기까지지속되었을것이라예상하였다. 그러나, 본연구결과에서 E 군과 E C군사이에분만 2기 VAS의차이가통계학적으로유의하지않은것으로나타났고산모들의만족도또한통계학적으로유의한차이를보이지않은것으로보아미추블록이분만 2기의제통에영향이없거나블록의효과가사라졌을가능성도배제할수없다. 미추블록이분만 2기의제통에효과적인것을증명하지는못하였으나 Boutros 등의 [16] 연구에서분만시경막외제통을시행하고적당한제통을유지하기위해추가적인경막외주입을하여도시간에지남에따라 VAS가증가하는결과를얻은것과같이본연구에서도 E 군과 E C군모두에서분만 1기보다분만 2기에서통계적으로유의하게 VAS가증가했다는것은분만 2기의제통에경막외제통외에추가적인제통방법이필요함을보여준다. Ropivacaine은 bupivacaine에비해운동마비의발생정도가약하면서제통의효과나만족도에있어서 bupivacaine과비슷하고추가용량의필요도차이가없다고알려져있다 [17,18]. 이에저자들은 ropivacaine을사용하였고, 추가적으로미추블록을시행하여도경막외제통시운동마비의 정도는통계학적으로의미있는차이를보이지않은것으로보아낮은농도의국소마취제 8 ml의미추블록용량은운동마비의정도를증가시키지않는것으로생각된다. Cibils와 Spackman은 [19] 산모의미추블록이분만 1기의연장에는관련이없으나분만 2기를연장시킨다고보고하였고, Schiessl 등은 [20] 분만 2기의연장에영향을주는요소중가장중요한것이경막외제통이라하였다. 초산부나경산부모두에서경막외제통이제왕절개율을증가시키지는않으나기계적분만의빈도를증가시키며 [21] 경산부에서는분만 2기가평균 19분정도이고경막외제통에의해평균 20 30분정도연장된다고하였다 [22]. 이와같은보고들과상반된결과로본연구에서는경막외제통이경산부의분만 2기를연장시키지않았고기계적분만의빈도도증가시키지않았다. 이러한결과는경막외제통이분만 2기의연장을초래할수있다하더라도분만 2기의분만개조자의도움에의한산모의즉각적인밀기가분만 2기의연장을감소시킬수있는것으로해석할수있다 [23,24]. 이에따라분만 2기가연장되지않으면서기계적분만의경우나제왕절개로의전환의경우도없었을것이라생각된다. 본연구에서경막외제통과함께시행된미추블록이분만 2기의제통이나산모의만족도, 운동마비의정도, 분만 2기의연장에는경막외제통만시행한경우와통계학적으로유의한차이를보이지는않으므로미추블록의필요성에대해의문을가지게된다. 이러한결과를나타낸것은미추블록을분만 1기초반에시행함으로인해블록의효과가분만 2기까지지속되지않았을가능성이있다고사료되며분만 1기후반이나 2기초기에미추블록을시행하는연구가더필요하다고생각된다. 본연구의다른제한점으로미추블록이운동마비의정도를증가시키지는않으나분만 1기에회음부위에감각차단효과는있을것이라생각되고내진시의불편함을비교하거나미추블록을분만 1기후반에시행하여회음부절개시에불편함이경막외제통만시행한경우와차이가있는가에대한비교를하지못한것이다. 또한, 미추블록이감염증가율이높은단점때문에미추블록만을시행하여경막외제통을시행한경우와비교하지못하였다. 본연구에서미추블록에대한효과를입증하지못하였으나과거미추블록이무통분만에이용된문헌들을살펴보면경막외제통이널리이용되기전에미추강을통한분만시제통이부적절한자궁활동이나일차적경부난산, 자간증, 조산아분만, 심폐합병증등을가진산모들에서적용할수있는제통방법으로알려져있었다 [8]. 이후사례들에서네쌍둥이를임신한두산모가과도한전만증과등의부종으로인해경막외제통을할수없을때미추강을통한제통으로성공적으로자연분만한예가있었다 [25].

정성희외 6 인 : 무통분만시미추블록의영향 11 이에따르면미추강을통한제통이자궁내조작을용이하게하였고, 적당한제통을제공하였으며, 자발적인만출노력을방해하지않는다고하였다. 또한, 척추만곡증이나다른척추수술을받고 Harrington rods를지니고있는산모들의경우에는경막외제통이불가능할수있다. 이런경우미추강을통한제통이경막외제통을대체할수있는효과적인방법이될수있다고하였다 [26,27]. 기계적분만이불가피한난산의산모들의경우통증감소를위해미추블록을권장하는경우도있다 [28]. 결론적으로, 경막외자가통증과동시에시행된일회의미추블록은경막외자가통증만을사용한산모와비교해, 분만 2기의연장, 기계적분만이나운동마비의정도를증가시키지도않지만, 분만 2기제통이나만족도를개선시키지도못한다. 향후미추블록의효용성여부를알기위해서는경막외자가통증과시간을달리한미추블록이분만 2기제통효과에미치는영향을평가하는것이다. 또한평가방법으로는내진이나회음부절개시불편함도포함되어야할것이다. 참고문헌 1. Segal S, Su M, Gilbert P. The effect of a rapid change in availability of epidural analgesia on the cesarean delivery rate: A meta-analysis. Am J Obstet Gynecol 2000; 183: 974-8. 2. Torvaldsen S, Roberts CL, Bell JC, Raynes-Greenow CH. Discontinuation of epidural analgesia late in labour for reducing the adverse delivery outcomes associated with epidural analgesia. Cochrane Database Syst Rev 2004; (4): CD004457. 3. Patterson DA, Winslow M, Matus CD. Spontaneous vaginal delivery. Am Fam Physician 2008; 78: 336-41. 4. Chadwick HS. Obstetric anesthesia - then and now. Minerva Anestesiol 2005; 71: 517-20. 5. Marmer MJ, Cadranel JL, Krohn L. Lidocaine-norepinephrine anesthesia in obstetrics; xylocaine and levelophed combination in caudal block. Obstet Gynecol 1956; 7: 315-8. 6. Paech MJ, Godkin R, Webster S. Complications of obstetric epidural analgesia and anaesthesia: a prospective analysis of 10,995 cases. Int J Obstet Anesth 1998; 7: 5-11. 7. Sinclair JC, Fox HA, Lentz JF, Fuld GL, Murphy J. Intoxication of the fetus by a local anesthetic. A newly recognized complication of maternal caudal anesthesia. N Engl J Med 1965; 273: 1173-7. 8. Meehan FP. Continuous caudal analgesia in obstetrics. Proc R Soc Med 1969; 62: 185-6. 9. Schaupp KL, Jr., Durfee RB. Saddle block and caudal block analgesia for the control of pain in labor. Calif Med 1949; 70: 211-5. 10. Breen TW, Shapiro T, Glass B, Foster-Payne D, Oriol NE. Epidural anesthesia for labor in an ambulatory patient. Anesth Analg 1993; 77: 919-24. 11. Yang WC, Lee BH, Lee EM, Chung MH, Won RS. Conventional Intermittent "Top-up" Injections of 0.25% Bupivacaine/Fentanyl vs 0.125% Bupivacaine/Fentanyl during Labor. Korean J Anesthesiol 1998; 35: 467-72. 12. Yarnell RW, Ewing DA, Tierney E, Smith MH. Sacralization of epidural block with repeated doses of 0.25% bupivacaine during labor. Reg Anesth 1990; 15: 275-9. 13. Bates RG, Helm CW, Duncan A, Edmonds DK. Uterine activity in the second stage of labour and the effect of epidural analgesia. Br J Obstet Gynaecol 1985; 92: 1246-50. 14. Mayberry LJ, Wood SH, Strange LB, Lee L, Heisler DR, Neilson- Smith K. Managing second-stage labor. AWHONN Lifelines 1999; 3: 28-34. 15. Kang YI, Kim MH, Kim SY, Bang EC, Lee HS, Cho KS, et al. Effect of Continuous Epidural Analgesia on the Progress of Labor. Korean J Anesthesiol 2000; 39: 183-8. 16. Boutros A, Blary S, Bronchard R, Bonnet F. Comparison of intermittent epidural bolus, continuous epidural infusion and patient controlled-epidural analgesia during labor. Int J Obstet Anesth 1999; 8: 236-41. 17. Halpern SH, Carvalho B. Patient-controlled epidural analgesia for labor. Anesth Analg 2009; 108: 921-8. 18. Sah N, Vallejo M, Phelps A, Finegold H, Mandell G, Ramanathan S. Efficacy of ropivacaine, bupivacaine, and levobupivacaine for labor epidural analgesia. J Clin Anesth 2007; 19: 214-7. 19. Cibils LA, Spackman TJ. Caudal analgesia in first-stage labor: effect on uterine activity and the cardiovascular system. Am J Obstet Gynecol 1962; 84: 1042-50. 20. Schiessl B, Janni W, Jundt K, Rammel G, Peschers U, Kainer F. Obstetrical parameters influencing the duration of the second stage of labor. Eur J Obstet Gynecol Reprod Biol 2005; 118: 17-20. 21. Anim-Somuah M, Smyth R, Howell C. Epidural versus non-epidural or no analgesia in labour. Cochrane Database Syst Rev 2005; (4): CD000331. 22. Zhang J, Yancey MK, Klebanoff MA, Schwarz J, Schweitzer D. Does epidural analgesia prolong labor and increase risk of cesarean delivery? A natural experiment. Am J Obstet Gynecol 2001; 185: 128-34. 23. Brancato RM, Church S, Stone PW. A meta-analysis of passive descent versus immediate pushing in nulliparous women with epidural analgesia in the second stage of labor. J Obstet Gynecol Neonatal Nurs 2008; 37: 4-12. 24. Plunkett BA, Lin A, Wong CA, Grobman WA, Peaceman AM. Management of the second stage of labor in nulliparas with continuous epidural analgesia. Obstet Gynecol 2003; 102: 109-14. 25. Abouleish E. Caudal analgesia for quadruplet delivery. Anesth Analg 1976; 55: 61-6. 26. Moeller-Bertram T, Kuczkowski KM, Ahadian F. Labor analgesia in a parturient with prior Harrington rod instrumentation: is caudal epidural an option? Ann Fr Anesth Reanim 2004; 23: 925-6. 27. Sudunagunta S, Eckersall SJ, Gowrie-Mohan S. Continuous caudal analgesia in labour for a patient with Harrington rods. Int J Obstet Anesth 1998; 7: 128-30. 28. Dennerstein G. Caudal analgesia by the obstetrician. Aust N Z J Obstet Gynaecol 1990; 30: 203-5.