肩难产14例临床分析

肩难产是一种不常见的分娩并发症。由于其常在儿头娩出后意外发生，常使接产者措手不及，操作不当可致严重后果，如发生新生儿臂丛神经损伤、肱骨骨折、锁骨骨折等，新生儿重度窒息率达14．3‰，围生儿病死率22．9‰。因此，早期预测、识别和正确处理肩难产是非常重要的。我院4年间共发生14例。现将有关资料进行分析如下。     

肩难产发生的危险因素和临床特征的多中心分析

目的 探讨肩难产发生的危险因素和临床特征.方法 收集2008年1月至2013年9月,广州医科大学附属第三医院等5家医院住院的足月妊娠、单胎、头位并经阴道分娩的产妇共44 580例,其中发生肩难产116例(肩难产组),其余未发生肩难产者为对照组.对两组产妇的临床资料进行回顾性分析,包括年龄、身高、孕前体质指数(BMI)、孕期体质量增重值、孕周、孕次、产次、宫高、腹围、既往肩难产病史、分娩巨大儿、妊娠期糖尿病、糖尿病合并妊娠、过期妊娠及产程情况.结果 (1)44 580例产妇中发生肩难产116例,发生率为0.260％(116/44 580).肩难产组产妇年龄、孕前BMI、孕期体质量增重值明显高于对照组,两组比较,差异均有统计学意义(P＜0.01);两组产妇身高、孕周、孕产次、宫高及腹围分别比较,差异均无统计学意义(P＞0.05).(2)肩难产组产妇有肩难产病史(11.21％,13/116)、分娩巨大儿(13.79％,16/116)、糖尿病合并妊娠(7.76％,9/116)、过期妊娠(10.34％,12/116)、最大加速期延长(8.62％,10/116)及第二产程延长(7.76％,9/116)的发生率,分别与对照组[分别为(1.43％,636/44 464)、(1.48％,658/44 464)、(0.57％,252/44 464)、(1.15％,513/44 464)、(0.72％,322/44 464)、(0.65％,289/44 464)]比较,差异均有统计学意义(P＜0.05).(3)logistic回归分析显示,产妇年龄＞35岁(OR=1.116,95％CI为1.022～2.445)、孕前BMI＞27 kg/m2(OR=1.893,95％ CI为1.358～2.228)、孕期体质量增重值(＞20 kg)(OR=2.031,95％CI为1.749～ 3.231)、肩难产病史(OR=2.138,95％ CI为1.564～ 3.853)、分娩巨大儿(OR=3.276,95％CI为2.315～ 4.638)、糖尿病合并妊娠(OR=3.261,95％CI为2.237～ 4.943)、过期妊娠(OR=1.473,95％CI为1.003～ 2.721)、最大加速期延长(OR=2.022,95％CI为1.681～ 3.732)及第二产程延长(OR=1.943,95％CI为1.285～ 3.215),以上各项P值均＜0.05,是肩难产发生的危险因素.结论 高龄孕产妇(年龄＞35岁)、孕前BMI＞27 kg/m2、孕期体质量增重＞20 kg、肩难产病史、分娩巨大儿、糖尿病合并妊娠、过期妊娠、最大加速期延长及第二产程延长是肩难产发生的危险因素及临床特征.     

肩难产预测及临床处理

肩难产是分娩时突然发生的产科急症,可导致母婴严重危害。尽管肩难产的发病危险因素已被了解,但目前仍缺乏统一标准来预测其发生可能性,因此熟练掌握肩难产的处理方法,可减少肩难产导致的母婴严重并发症,改善母儿结局。     

肩难产的临床处理及预测

肩难产是一种不常见的分娩并发症。国外报道其发生率为 0 .15 %～ 0 .3% [1 ] ,国内报道为 0 .15 % [2 ] 。由于其常在儿头娩出后意外发生 ,常使接产者措手不及 ,往往因经验不足 ,操作不当而致严重后果 ,如新生儿臂丛神经损伤、肱骨骨折、锁骨骨折等 ,新生儿重度窒息率达 1.43% ,围产儿死亡率2 2 .9‰ [3 ]。母亲可发生软组织损伤、产后出血、感染等。近年 ,随着产前检查等措施的改进 ,剖宫产率的增加及废除高、中位产钳等导致围产儿残疾的因素减少 ,肩难产的发生率并由此导致的医疗纠纷逐渐增加。因此 ,早期预测、识别和正确处理肩难产是非…     

肩难产的体会

肩难产属于产科急诊，必须迅速及时作出处理，否则影响母婴健康。肩难产的定义是娩出胎头至娩出胎体的间隔时间超过60秒或胎头娩出后需用辅助方法完成分娩者。2002年6月至11月我科发生了3例肩难产，因处理及时迅速，母婴均不造成不良后果，现将体会报告如下：     

肩难产的预测、处理和预防

肩难产在现代临床产科虽较少见，但由于胎肩不能及时娩出及过度牵拉胎头而导致新生儿窒息、缺血缺氧性脑病、臂丛神经损伤等并发症，严重时可致胎儿死亡，是产科最严重的危险因素之一。因此，对肩难产的全面认识有利于提高产科质量，降低母婴发病率和死亡率。本文就肩难产的预测、处理和预防研究概况综述如下。     

肩难产的诊治

肩难产属产科急诊 ,必须迅速处理 ,否则 ,母婴均会有不良结局。1　肩难产的定义既往肩难产的定义是胎头娩出后胎儿前肩嵌顿于耻骨联合上方 ,用常规助产手法不能娩出胎儿双肩称为肩难产。但如果处理恰当 ,用手法协助胎肩顺利娩出 ,许多助产士和临床医生也不诊断其为肩难产 ,也未做检查了解胎肩是否嵌顿于耻骨联合上方。 1986年Ｒｅｓｎｉｋ[1] 作了更具体的描述 ,认为胎头娩出后除向下牵引和会阴切开之外 ,还需其它手法娩出胎肩者称为肩难产。 1995年Ｓｐｏｎｇ[2 ] 对 2 5 0例无选择的阴道分娩 ,计算从胎头娩出到娩出胎肩的时间及胎体娩出的…     

肩难产的预测、预防和处理

在现代产科临床实践中肩难产位于所有危险因素的首位 [1 ] ,因此对肩难产的全面认识有利于提高产科质量 ,降低母婴病率。现对肩难产的发生、处理及预测预防作一综述。一、定义及发生率肩难产传统的定义为胎头娩出后胎儿前肩嵌顿于耻骨联合上方 ,用常规助产手法不能娩出胎儿双肩     

肩难产综合预防措施的荟萃分析

目的 探讨肩难产的综合预防措施.方法 计算机检索2014年5月以前的PubMed数据库、美国EBSCO数据库、荷兰医学文摘数据库、Cochrane图书馆数据库,以“shoulder dystocia and prevention”为主题词检索英文文献.对检索到的文献进行质量评价,文献研究类型仅限于随机对照临床试验(RCT)研究;研究对象为经阴道分娩产妇,干预措施包括孕期管理、预防性引产、预防性剖宫产术,预防性肩难产处理.纳入的文献采用RevMan 5.1软件进行荟萃分析,以肩难产发生率作为终点指标.结果 共有16篇英文文献纳入荟萃分析,发表时间为1993-2009年.(1)对妊娠期糖尿病(GDM)孕妇的孕期干预:有2篇文献比较了GDM孕妇的孕期干预(干预组)与不干预(不干预组)对肩难产发生率的影响,结果显示,干预组肩难产发生率显著低于不干预组(OR=0.40,95％ CI为0.21～0.75,P=0.004).(2)对GDM孕妇的孕期严格干预:5篇文献比较了GDM孕妇的孕期严格干预(饮食控制+胰岛素应用;严格干预组)与不严格干预(单纯饮食控制等;不严格干预组)对肩难产发生率的影响,结果显示,严格干预组肩难产发生率显著低于不严格干预组(OR=0.29,95％CI为0.11～ 0.73,P=0.009).(3)非糖尿病孕妇可疑巨大儿者引产:有4篇文献比较了非糖尿病孕妇可疑巨大儿者提前引产(提前引产组)对肩难产发生的影响,结果显示,提前引产组肩难产发生率与对照组比较,差异无统计学意义(OR=0.85,95％CI为0.41～ 1.75,P=0.660).(4)GDM孕妇引产:有2篇文献比较了GDM孕妇提前引产(孕38～ 39周;提前引产组)对肩难产发生的影响,结果显示,提前引产组肩难产发生率与对照组比较,差异有统计学意义(OR=0.18,95％CI为0.03～ 0.97,P=0.050);只与对照组中孕40周以后分娩者比较,提前引产组肩难产发生率显著低于对照组(OR=0.13,95％ CI为0.02～ 0.75,P=0.020).(5)GDM孕妇可疑巨大儿者提前终止妊娠:仅有1篇文献比较了GDM孕妇中可疑巨大儿者提前终止妊娠(提前终止妊娠)对肩难产发生率的影响,结果显示,提前终止妊娠组的肩难产发生率与对照组比较,差异有统计学意义(OR=0.34,95％CI为0.12～ 0.99,P=0.050).(6)产时预防性干预(产时干预组)对肩难产发生率的影响:有2篇文献比较了产时胎头娩出后行预防性干预对肩难产发生率的影响,结果显示,产时干预组肩难产发生率与对照组比较,差异无统计学意义(OR=0.44,95％CI为0.16～ 1.18,P=0.100).结论 对有肩难产高危因素的孕妇适当进行临床措施的干预,可明显降低肩难产的发生率.     

Complications of shoulder dystocia

Complications of shoulder dystocia are divided into fetal and maternal. Fetal brachial plexus injury (BPI) is the most common fetal complication occurring in 4–40% of cases. BPI has also been reported in abdominal deliveries and in deliveries not complicated by shoulder dystocia. Fractures of the fetal humerus and clavicle occur in about 10.6% of cases of shoulder dystocia and usually heal with no sequel. Hypoxic ischemic brain injury is reported in 0.5–23% of cases of shoulder dystocia. The risk correlates with the duration of head-to-body delivery and is especially increased when the duration is >5 min. Fetal death is rare and is reported in 0.4% of cases. Maternal complications of shoulder dystocia include post-partum hemorrhage, vaginal lacerations, anal tears, and uterine rupture. The psychological stress impact of shoulder dystocia is under-recognized and deserves counseling prior to home discharge.     

Reducing the risk of shoulder dystocia and associated brachial plexus injury

Despite persisting controversy over shoulder dystocia prediction, prevention, and injury causation, the authors find considerable evidence in recent research in the field to recommend additional guidelines beyond the current American College of Obstetricians and Gynecologists and Royal College of Obstetricians and Gynecologists guidelines to improve clinical practice in managing patients at risk for experiencing shoulder dystocia. In this article, the authors offer health care providers information, practical direction, and advice on how to limit shoulder dystocia risk and, more importantly, to reduce adverse outcome risk.     

Prevention of shoulder dystocia related birth injuries: Myths and facts

Traditionally, brachial plexus damage was attributed to excessive traction applied on the fetal head at delivery. Recently, it was proposed that most injuries occur spontaneously in utero. The author has studied the mechanism of neurological birth injuries based on 338 actual cases with special attention to (1) fetal macrosomia; (2) maternal diabetes; and (3) methods of delivery. There was a high coincidence between use of traction and brachial plexus injuries. Instrumental extractions increased the risk exponentially. Erb’s palsy following cesarean section was exceedingly rare. These facts imply that spontaneous neurological injury in utero is extremely rare phenomenon. Literary reports show that shoulder dystocia and its associated injuries increased in the United States several-fold since the introduction of active management of delivery in the 1970’s. Such a dramatic change in a stable population is unlikely to be caused by incidental spontaneous events unrelated to external factors. The cited investigations indicate that brachial plexus damage typically is traction related. The traditional technique which precludes traction is the optimal method for avoiding arrest of the shoulders and its associated neurological birth injuries. Effective prevention also requires meticulous prenatal care and elective abdominal delivery of macrosomic fetuses in carefully selected cases.     

分娩性臂丛神经麻痹发病危险因素的探讨

目的 探讨分娩性臂丛神经麻痹(OBPP)的发病危险因素.方法 收集1997年1月至2009年12月山东省医疗事故鉴定办公室进行医疗鉴定并已诊断为OBPP的46例患者为OBPP组,按照1:3的匹配方式随机选取同医院、同时期、同性别的正常分娩138例新生儿作为对照组.采用回顾性病例对照研究的方法,对两组新生儿情况、产妇情况、分娩过程及助产士工作年限等因素进行单因素及多因素logistic回归分析.结果 (1)两组产妇骨盆外测量均在正常值范围,两组新生儿均为单胎头位并经阴道分娩.OBPP组均为单侧臂丛神经损伤,其中左侧22例,右侧24例;全臂型17例,上臂型26例,前臂型3例.两组产妇年龄、孕产次及分娩孕龄比较,差异均有统计学意义(P＜0.05).(2)OBPP组产前体质指数(BMI)、宫高、腹围分别为(29.5±2.4) kg/m2、(34.9±2.4)及(105±6) cm,对照组分别为(26.1±2.5)kg/m2、(33.7±2.2)及(99±5) cm,两组比较,差异有统计学意义(P＜0.05).OBPP组新生儿平均出生体质量[(4390±489)g]明显高于对照组[(3404±360)g],两组比较,差异有统计学意义(P＜0.01).OBPP组助产士工作年限[(5.2±2.3)年]明显低于对照组[(8.9±5.4)年],两组比较,差异有统计学意义(P＜0.01).(3)OBPP组与对照组应用器械助产率分别为28.3％及3.6％,宫缩乏力发生率分别为28.3％及6.5％,第二产程延长发生率分别为8.7％及0.7％,胎方位异常发生率分别为10.9％及2.9％.OBPP组以上各指标均高于对照组,两组比较,差异均有统计学意义(P＜0.05).(4)条件logistic回归单因素分析发现,两组产妇年龄、产前BMI、宫高、腹围、新生儿出生体质量、孕次、第二产程时间、分娩助产、胎位异常、宫缩乏力及助产士工作年限比较,差异均有统计学意义(P均＜0.05).其中,助产士工作年限为保护性因素.(5)将上述各相关指标作为变量,选择逐步回归法进行多因素logistic回归分析,选人界值均为0.10,结果显示,孕妇产前BMI和新生儿出生体质量与OBPP发生有关联(P＜0.10),OR值分别为1.733和1.004.孕妇产前BMI OR值大于新生儿出生体质量OR值,孕妇产前BMI意义大于新生儿出生体质量.结论 孕妇产前BMI是OBPP发病的最重要危险因素,其次,另一个高危因素是新生儿出生体质量.助产士工作年限较长是其保护性因素.     

Accuracy of estimated fetal weight in shoulder dystocia and neonatal birth injury

OBJECTIVE: This study was undertaken to determine whether there is any difference in the rate of error of estimated fetal weight (EFW) in cases of shoulder dystocia compared with controls. STUDY DESIGN: Women whose delivery was complicated by shoulder dystocia were studied and compared with a control group matched for parity, race, labor type (spontaneous or induced), and birth weight (BW). Accuracy (%) was defined as [(EFW-BW)/BW] x 100. The primary outcome of the study was rate of EFW underestimation error 20% or greater. RESULTS: During the 5-year study period, there were 206 cases of shoulder dystocia that met all study criteria. There was no difference in the number of patients that had EFW underestimation error 20% or greater (shoulder dystocia 9.8% vs control 12.8%; P = .38). There was also no difference in the number of patients that had EFW underestimation error 20% or greater between shoulder dystocia with and without injury (injury 8.3% vs no injury 7.1%; P = .79). CONCLUSION: EFW underestimation error in cases of shoulder dystocia is an infrequent event and does not occur more often than in deliveries without shoulder dystocia.     

Comparing McRoberts' and Rubin's maneuvers for initial management of shoulder dystocia: an objective evaluation

OBJECTIVE: This study was undertaken to objectively compare delivery traction force, fetal neck rotation, and brachial plexus elongation after 3 different initial shoulder dystocia maneuvers: McRoberts', anterior Rubin's, and posterior Rubin's. STUDY DESIGN: We developed a laboratory birthing simulator comprised of a maternal model with a 3-dimensional bony pelvis, an instrumented fetal model, a force-sensing glove, and a computer-based data acquisition system. A single operator performed 30 simulated shoulder dystocia deliveries using standard downward traction after 1 maneuver was performed. Ten deliveries simulated McRoberts' maneuver with fetal shoulders in the anteroposterior diameter. Ten deliveries involved approximately 30-degree oblique rotation of the anterior shoulder with the spine oriented anteriorly (anterior Rubin's maneuver). Ten deliveries involved approximately 30-degree rotation of the posterior shoulder to the opposite oblique pelvic diameter, with the spine oriented posteriorly (posterior Rubin's maneuver). Peak traction force, brachial plexus elongation, and neck rotation were compared between groups using analysis of variance, with P < .05 considered significant. RESULTS: Rubin's maneuvers were found to require less traction force than McRoberts': 16.2 +/- 2.1 lbs for McRoberts' compared with 8.8 +/- 2.2 lbs and 6.5 +/- 1.8 lbs for posterior and anterior Rubin's respectively (P < .0001). Brachial plexus extension was significantly lower after anterior Rubin's maneuver compared with McRoberts' or posterior Rubin's maneuvers. CONCLUSION In a laboratory model of initial maneuvers for shoulder dystocia, anterior Rubin's maneuver requires the least traction for delivery and produces the least amount of brachial plexus tension. Further study is needed to validate these results clinically.