产程中改变产妇体位矫正胎方位的探讨

目的：探讨产程中改变产妇体位以矫正胎方位的临床效果。方法：选择先兆临产至潜伏期经Ｂ超检查判断为枕后位的初产妇２４０例，随机分为两组，各１２０例。研究组在产程中指导产妇取侧俯卧位，利用胎儿重力、羊水浮力、子宫间歇收缩的合力作用，使胎头在下降时逐渐从枕后位转至枕前位娩出，并与对照组比较。结果：研究组１０６例（８８．３％）胎儿从枕后位转到枕前位经阴道娩出。剖宫产１４例（１１．７％）。对照组经阴道娩出仅２０例（１６．７％），剖宫产１００例（８３．３％）。两组比较，差异有非常显著性（Ｐ＜０．００１）。研究组第一产程平均时间３０２．６分钟，第二产程平均５９．８分钟。对照组第一产程平均４８３．７分钟，第二产程平均１５６．７分钟。两组比较，差异有极显著性（Ｐ＜０．０１）。结论：在产程中指导产妇取侧俯卧位矫正胎头枕后位是降低难产发生率的有效方法。     

高龄初产妇的妊娠与分娩

报告了１９９０年１月～１９９１年１２月收住院的８１例高龄初产妇的妊娠与分娩方式，并与同期年轻初产妇做了比较。结果表明高龄组妊娠期合并症、并发症和分娩期并发症均明显高于年轻组（Ｐ＜０．０５，Ｐ＜０．００１，Ｐ＜０．０５）；妊高征和剖宫产率明显高于年轻组（Ｐ＜０．０１，Ｐ＜０．００１）。作者认为应重视对高龄初产妇的监护，及早发现潜在难产因素，合理掌握剖宫产指征，以期获得良好的分娩结果。     

计划分娩中应用催产素与头位难产关系的探讨

为探讨催产素计划分娩对头位分娩的影响以及与头位难产的关系，对我院５年来头位分娩中应用催产素计划分娩（催产素组）与产程自然进展（对照组）两组头位难产发生率、最终分娩方式进行对照分析。结果表明：催产秦组３０９０例，发生头位难产５６２例，头位难产发生率１８．２％；对照组２９８２例，发生头位难产３７１例，头位难产发生率１２．４％。催产素组头位难产发生率、会阴侧切胎头吸引器助产率、剖宫产率均明显高于对照组（Ｐ＜０．００５）。资料表明：在计划分娩中，催产素用量越大、持续时间越长、次数越多头位难产发生率越高。     

宫缩图对识别头位难产的价值

对６０例单胎、头先露，正式临产需手术助产分娩的初产妇及６０例单胎，头先露，正式临床经阴道自然分娩的初产妇的宫缩图进行分析。结果表明：研究组宫缩图的类型平行型及多交叉型多于对照组（Ｐ〈０．０５），对照组宫缩图的类型单交叉型显著多于研究组（Ｐ〈０．０５），研究组宫缩图第一交叉出现至胎儿娩出时间及至产程图交叉的时间均明显长于对照组（Ｐ〈０．０５）；研究组第一交叉出现时宫颈口扩张明显小于对照组（Ｐ〈０．０     

前脑动脉血流阻抗指数用于缺血缺氧性脑病的诊断

不得以连续波多普勒血流分析仪对１８２例正常新生儿（正常组）及６７例高危新生儿（异常组），分别进行了５３４次和２３０次前脑动脉血流阻抗指数（ＲＩ）测定。结果：正常组前脑动脉ＲＩ值分布范围为０．６２±０．０９（ｓ），其与日龄呈显著正相关（ｒ＝０．７２，Ｐ＜０．０５）；正常前脑动脉血流速度频谱图为规则图形。此外，在高危新生儿中，ＲＩ异常的标化发生率在有缺血缺氧性脑病（ＨＩＥ）病理基础的高危儿（甲组）中明显高于正常组（Ｐ＜０．００１），无ＨＩＥ病理基础的高危儿（乙组）则与正常组间差异无显著性（Ｐ＞０．０５）；同时，甲组的ＲＩ异常的标化发生率也明显高于乙组（Ｐ＜０．００１）。特别在９例有严重ＨＩＥ并发症者中，前脑动脉不规则血流图的标化发生率显著高于其他高危儿（Ｐ＜０．００１）。提示：从新生儿预后方面看，前脑动脉ＲＩ极度异常，尤其是有不规则血流图出现时，ＨＩＥ的严重并发症发生率及新生儿死亡率均急剧增高（Ｐ＜０．００１）。因此，前脑动脉ＲＩ异常提示有新生儿ＨＩＥ存在，特别当有不规则血流图出现时，新生儿预后多不良。     

高龄初产妇妊高征孕妇脐血清中过氧化脂质及超氧化物歧化酶水平的变化

总结１９９４年５月～１９９６年４月高龄初产妇妊高征患者４０例，并以正常高龄初产妇５５例作为对照组，测定孕晚期孕妇及脐血清中ＬＰＯ及ＳＯＤ含量的变化。高龄初产妇妊高征孕妇血清ＬＰＯ水平比对照组明显升高（Ｐ＜０．００１），血清ＳＯＤ水平明显降低（Ｐ＜０．００１），并随病情的加重，血清ＬＰＯ水平升高及血清ＳＯＤ水平降低更为显著，但两组脐血清ＬＰＯ及ＳＯＤ水平比较，则无明显统计学差别（Ｐ＞０．１及＞０．０５）。妊高征组ＩＵＧＲ明显高于对照组（Ｐ＜０．００５）。提示妊高征的发病与ＩＵＧＲ的发生与孕妇血中高水平的ＬＰＯ有关。     

三种引产方法的前瞻性比较研究

目的：前瞻性研究米索前列醇（Ｍｉｓｏ）、低位水囊（ＬＰＷＢ）及小剂量催产素（ＯＸ）静脉滴注３种引产方法的有效性及对母、婴的影响。方法：将１２４例单胎、头位、、宫颈Ｂｉｓｈｏｐ评分＜５分、足月妊娠初产妇随机分为３组：Ｍｉｓｏ组４１例，ＬＰＷＢ组４３例，ＯＸ组４０例；３种方法引产后，如宫颈Ｂｉｓｈｏｐ评分≥７分，则行人工破膜术。结果：ＬＰＷＢ组及Ｍｉｓｏ组较ＯＸ组、宫颈Bｉｓｈｏｐ评分＜５分显著提高（Ｐ＜０．００１，P＜０．０１），引产到临产时间明显缩短（Ｐ＜０．００１，Ｐ＜０．０５），但３组间母、婴并发症差异无显著性。结论：对宫颈不成熟孕妇采用ＬＰＷＢ及Ｍｉｓｏ引产安全、有效、经济，可靠，ＯＸ静脉滴注引产不宜作为首选引产方法     

硫酸普拉酮钠用于中期妊娠引产的疗效观察

对５０例利凡诺引产的中期妊娠妇女应用硫酶普拉酮钠（硫酸去氢表雄酮，ＤＨＡＳ）促宫颈成熟（用药组），并与同期５０例单纯利凡诺引产的中期妊娠妇女（对照组）进行比较。结果表明：用药组５０例宫颈Ｂｉｓｈｏｐ评分均有升高，显效率为８６％；总有效率为９８％；与对照组比较差异有显著性（分别为Ｐ＜０．００１及Ｐ＜０．０１）；用药组平均引产时间比对照组缩短１３．４小时，差异有显著性（Ｐ＜０．０１）。     

米索前列醇用于足月妊娠引产的临床观察

目的：探讨米索前列醇用于足月妊娠引产的安全性及效果。方法：将６０例有引产指征的孕足月单胎头位、无宫缩的初产妇，随机分成两组，研究组（３０例）用米索前列醇５０μｇ阴道用药，每３小时１次至正式临产；对照组（３０例）用蓖麻油鸡蛋餐口服。结果：两组引产总有效率无显著差异，研究组引产时间显著少于对照组（Ｐ＜０．０５），研究组需静脉滴注催产素人数为１０．０％，显著少于对照组的４０．０％，（Ｐ＜０．０５），用药６小时后研究组宫颈评分提高５．５分，对照组提高３．１分，评分结果比较，差异有显著性（Ｐ＜０．０５），研究组子宫收缩过频的发生率为１６．７％，对照组为３．０％。结论：阴道放置米索前列醇用于足月妊娠引产能促宫颈成熟及发动子宫收缩，是安全、有效的引产方法     

米索前列醇在足月妊娠引产中的应用

目的：探讨米索前列醇用于足月妊娠引产的可行性及对母儿的安全性。方法：对８４例足月妊娠单胎头位初产妇，用米索前列醇口服０．１ｍｇ每小时一次，直至胎儿娩出，进行引产（米索组）。以５０例同样条件的孕妇，用催产素引产（催产素组）为对照。结果：米索组及对照组引产成功及有效率分别为９７．６％和８０．０％，Ｐ＜０．０１，有显著性差异。两组１２小时分娩成功率分别为７３．８％与４６．０％，Ｐ＜０．０１，有显著性差异。两组失败率分别为２．４％和２０．０％，Ｐ＜０．０１，有显著性差异。结论：米索前列醇口服用于足月妊娠引产疗效显著、安全、方便，有推广价值     

持续性枕横位及枕后位的产程特点及围产儿预后

目的：探讨持续性枕横位及枕后位的产程特点及围产儿预后。方法：采用回顾性资料分析方法，对１９９５年１１月至１９９６年７月在我院分娩的持续性枕横位及枕后位孕妇的临床资料进行分析。并与同期枕位正常的９０例（对照组）孕妇进行比较。结果：枕位异常者，胎儿体重过大、宫缩乏力的比例明显增加，产程各期时间均明显延长，胎先露下降速度明显减慢，各产程异常发生率明显增加，手术产率明显增加。枕横位总手术产率为８２．８１％，枕后位为９２．３１％，胎儿宫内缺氧、新生儿窒息率明显增加。结论：持续性枕横位及枕后位是难产的主要原因之一，若处理不当，围产儿预后欠佳。     

Is abnormal labor associated with shoulder dystocia in nulliparous women?

OBJECTIVE: This study was undertaken to examine the relationship between labor abnormalities and shoulder dystocia in nulliparous women. STUDY DESIGN: Nulliparous women whose delivery was complicated by shoulder dystocia were studied and compared with a control group selected based on the best possible match for race, labor type (spontaneous or induced), and birth weight. The duration of first and second stage of labor, as well as the rates of labor progress, were calculated and compared between groups. RESULTS: During this 4-year study period, there were 8010 nulliparous singleton deliveries of which 65 (0.8%) were complicated by shoulder dystocia. Compared with controls, there was no difference in the rate of cervical dilation in the active phase of the first stage of labor. In the shoulder dystocia group, more patients had a second stage of labor greater than 2 hours (22% vs 3%; P <.05) and had operative vaginal deliveries (26% vs 1.5%; P <.001). In shoulder dystocia cases with birth weight greater than 4000 g, 33% had a second stage of labor greater than 2 hours. CONCLUSION: In our population, the combination of fetal macrosomia, second stage of labor longer than 2 hours and the use of operative vaginal delivery were associated with shoulder dystocia in nulliparous women.     

Intrapartum risk factors for permanent brachial plexus injury

OBJECTIVE: The purpose of this study was to compare maternal, neonatal, and second stage of labor characteristics in shoulder dystocia deliveries that result in permanent brachial plexus injury with shoulder dystocia deliveries that result in no injury. STUDY DESIGN: Our cases were culled from a database of deliveries that resulted in permanent brachial plexus injuries and matched to control cases that were taken from a database of consecutive shoulder dystocia deliveries from one hospital. Deliveries that resulted in injury were excluded from the control cases; those cases with no recorded shoulder dystocia were excluded from the cases. Matching was for birth weight (+/-250 g), parity, and diabetic status. Rates of precipitous and prolonged second stage, operative delivery, neonatal depression, and average number of shoulder dystocia maneuvers used were compared between the two groups with chi(2) test, Fisher exact test, and the Student t test; a probability value of <.05 was considered significant. RESULTS: There were 80 matched patients, of which 26 patients were nulliparous and 11 patients were diabetic. Mothers of the uninjured group were younger than those of the injured group (23.7+/-6.2 years vs 27.4+/-5.1 years, P<.001). The injured group had a significantly higher rate of 5-minute Apgar scores of <7 (13.9% vs 3.8%, P=.04). Differences in maternal weight, body mass index, height, race, gestational age, average number of maneuvers, head-to-body delivery interval, operative delivery rate, prolonged second stage rate, precipitous second stage rate, and sex were not significant between groups. The rates of precipitous second stage for both groups (28.0% injured and 35.0% uninjured) were more than triple the rates of prolonged second stage (9.5% injured and 11.3% uninjured). CONCLUSION: No characteristic of second-stage of labor predicts permanent brachial plexus injury. Precipitous second stage is the most prevalent labor abnormality that is associated with shoulder dystocia.     

McRoberts法联合上推宫颈对孕妇活跃期停滞的作用

目的探讨McRoberts法联合上推宫颈操作对活跃期产程停滞的作用。方法将2003年1月至2012年12月北京积水潭医院妇产科住院分娩的胎膜已破、因活跃期停滞而行阴道检查的足月单胎头位初产妇221例以随机数字法分为两组,采用McRoberts法行阴道检查及上推宫颈者为研究组(109例);采用膀胱截石位行相同操作者为对照组(112例)。观察两组孕妇阴道操作后1h宫颈扩张及胎先露下降情况及其分娩方式。结果研究组上推宫颈操作后宫颈扩张速度中位数为4cm/h,胎先露下降速度中位数为4cm/h,对照组分别为2cm/h和2cm/h,两组比较,差异均有统计学意义(P<0.001)。研究组自然分娩79例(72.5%),阴道助产6例(5.5%),对照组分别为60例(53.6%)和22例(19.6%),两组比较,差异均有统计学意义(P<0.05)。研究组剖宫产24例(22.0%),对照组30例(26.8%),两组比较,差异无统计学意义(P>0.05);但研究组手术分娩(剖宫产+产钳助产)30例(27.5%),对照组52例(46.4%),两组比较,差异有统计学意义(P<0.05)。研究组产后出血率(8.3%,9/109)明显低于对照组(20.5%,23/112;P<0.05)。结论 McRoberts法联合上推宫颈通过改变骨盆倾斜度,纠正胎头入盆姿势不良,达到缩短活跃期时间,降低手术分娩率和减少产后出血的作用。     

胎轴与头位难产关系的研究

根据体表标志，设计胎轴尺，以此测量异常胎轴并对此进行分度。结果：妊娠晚期的５１２例中，胎轴异常者１０８例，占２１．１％，其中重度为５１．８％；分娩期的４８３例中，胎轴异常８８例，均为重度，占１８．２％。８８例又随机分为两组：对照组３０例，研究组５８例，研究组行手法矫正。结果：研究组胎头下降加速，产程缩短，持续性枕后或枕横位发生率及手术产率降低，产后出血量减少。与对照组比较，差异有显著性。提示：妊娠晚期及产时，胎轴异常对分娩过程有一定影响，及时发现和矫正，对减少产力消耗和降低难产发生率有一定临床意义。     

欣普贝生用于足月胎膜早破低宫颈评分引产的效果观察

目的:探讨欣普贝生(地诺前列酮栓)在足月胎膜早破初产孕妇中应用的安全性及有效性。方法:100例足月胎膜早破单胎孕妇,破膜2h后未临产,宫颈条件未成熟(宫颈Bishop评分≤4分),孕妇知情同意后欣普贝生组入组50例,催产素组50例。比较两组的分娩方式及母儿结局情况。结果:与催产素组比较,欣普贝生组8h、12h促宫颈成熟总有效率明显增加(92.0%vs 64.5%,P0.01;95.9%vs 79.2%,P0.05)。欣普贝生组阴道分娩率明显升高(86.0%vs 60.0%,P0.01),且欣普贝生组用药12h、24h内阴道分娩率亦显著提高(42.0%vs 8.0%,P0.001;64.0%vs 34.0%,P0.01)。欣普贝生组用药至临产、用药至阴道分娩时间明显短于催产素组[(7.4±1.0)h vs(14.2±2.0)h,P0.01;(15.4±1.4)h vs(21.4±1.6)h,P0.01]。欣普贝生组引产失败率、绒毛膜羊膜炎发生率显著降低(2.0%vs 16.0%,P0.05;0 vs 12.0%,P0.05);两组急产、胎儿宫内窘迫、相对性头盆不称发生率无明显统计学差异;两组均无产后出血、新生儿窒息。结论:足月胎膜早破且宫颈条件未成熟的初产孕妇,应用欣普贝生促宫颈成熟安全、有效,且效果优于直接催产素引产,但用药期间应加强母儿监护。     

Does epidural analgesia prolong labor and increase risk of cesarean delivery? A natural experiment

OBJECTIVE: More than 50% of pregnant women in the United States are using epidural analgesia for labor pain. However, whether epidural analgesia prolongs labor and increases the risk of cesarean delivery remains controversial. STUDY DESIGN: We examined this question in a community-based, tertiary military medical center where the rate of continuous epidural analgesia in labor increased from 1% to 84% in a 1-year period while other conditions remained unchanged-a natural experiment. We systematically selected 507 and 581 singleton, nulliparous, term pregnancies with spontaneous onset of labor and vertex presentation from the respective times before and after the times that epidural analgesia was available on request during labor. We compared duration of labor, rate of cesarean delivery, instrumental delivery, and oxytocin use between these two groups. RESULTS: Despite a rapid and dramatic increase in epidural analgesia during labor (from 1% to 84% in 1 year), rates of cesarean delivery overall and for dystocia remained the same (for overall cesarean delivery: adjusted relative risk, 0.8; 95% confidence interval, 0.6-1.2; for dystocia: adjusted relative risk, 1.0; 95% confidence interval, 0.7-1.6). Overall instrumental delivery did not increase (adjusted relative risk, 1.0; 95% confidence interval, 0.8-1.4), nor did the duration of the first stage and the active phase of labor (multivariate analysis; P >.1). However, the second stage of labor was significantly longer by about 25 minutes (P <.001). CONCLUSION: Epidural analgesia during labor does not increase the risk of cesarean delivery, nor does it necessarily increase oxytocin use or instrumental delivery caused by dystocia. The duration of the active phase of labor appears unchanged, but the second stage of labor is likely prolonged. (Am J Obstet Gynecol 2001;185:128-34).     

蛛网膜下腔-硬膜外联合阻滞麻醉用于分娩镇痛206例分析

目的　探讨分娩镇痛的效果及对产程、母婴状况的影响。方法　采用蛛网膜下腔 -硬膜外联合阻滞(CSEA)用于分娩镇痛的产妇 2 0 6例作为观察组 ,将未采用任何分娩镇痛药物而进入产程的产妇 2 0 6例作为对照组 ,分别观察产程时间、分娩方式、产后出血、胎儿窘迫及新生儿窒息情况。结果　两组产程活跃期比较 ,有极显著性差异 (P <0 0 1) ;两组分娩方式比较有显著性差异 (P <0 0 5 ) ;两组胎儿窘迫、新生儿窒息及产后出血发生率比较 ,无显著性差异 (P >0 0 5 )。结论　CSEA用于分娩镇痛 ,疼痛阻滞完善 ,加速了产程活跃期及第二产程的进展 ,降低了剖宫产及阴道难产率 ,对母婴均无不良影响