再谈头位阴道助产术

头先露的阴道助产术包括产钳助产术和胎头负压吸引术。在第二产程中判断胎头位置及胎方位是阴道助产成功的关键。胎头最低位置于坐骨棘2 cm以下,胎方位为枕前位者,助产风险相对小。产科医生要严格把握阴道助产的手术指征,并与患者充分沟通。临床医生的判断能力,培训经历以及临床经验是助产成功的重要因素。     

产钳助产术与胎头吸引助产术的评估

在分娩过程中 ,采用适当的阴道助产方法 ,对于降低剖宫产率 ,保证母婴健康是安全而有效的手段。阴道助产的方法主要有两种 ,一种是产钳助产术 ,另一种是胎头吸引助产术。这两种助产方法所需条件基本相同 ,但又有各自的优缺点 ,怎样选择正确的助产方法 ,达到使产妇经阴道安全分娩 ,减少新生儿损伤的目的 ,是产科医生的必备技能。1　产钳助产术　　产钳是为牵引出胎儿而设计的 ,产钳助产术开始于 17世纪 ,在 2 0世纪初抗生素问世以前 ,剖宫产术的危险性较大 ,产钳助产术解决了部分难产 ,但高、中位的产钳也造成了较多的胎儿及母体的损伤。现在…     

产钳助产术108例临床分析

为正确评价产钳助产术（ｏｂｓｔｅｔｒｉｃａｌｆｏｒｃｅｐｓａｉｄｄｅｌｉｖｅｒｙ，ＯＦＡＤ）在产科中的应用价值，现将我院５年来施行ＯＦＡＤ的资料分析如下。１临床资料１９９０年２月至１９９５年１月在我院共有１５８４例产妇分娩，其中初产妇９０例，经产妇１...     

Kielland产钳“改良牵引法”用于持续性枕横位低位产钳助产术的研究

目的:探讨改进Kielland产钳助产操作牵引方法。方法:随机选取符合纳入标准的Kielland产钳助产275例,其中145例牵引方法采用"改良牵引法"(研究组),130例牵引方法采用"王历牵引法"(对照组)。比较两组的母婴并发症发生情况。结果:两组产钳助产成功率均为100%。研究组的阴道壁裂伤、产后出血发生率低于对照组,差异有统计学意义(P﹤0.05);两组的宫颈裂伤发生率比较,差异无统计学意义(P0.05)。对照组中有3例会阴Ⅲ度裂伤。研究组的面部皮肤损伤发生率明显低于对照组,差异有统计学意义(P﹤0.01);两组的窒息率比较,差异无统计学意义(P0.05),但对照组有1例新生儿颅内出血导致新生儿重度窒息。结论:Kielland产钳"改良牵引法"可减少产钳助产术后的母婴损伤。     

阴道助产术应注意的问题

正确选用阴道助产方法,有益于降低剖宫产率,并保证母婴健康。在阴道助产指征明确和条件具备情况下,选用胎头吸引助产术或产钳助产术应结合各种情况考虑。低位或出口产钳以及胎吸助产是解决第二产程宫缩乏力、因疾病需缩短第二产程的良好手段,手术时间短,产后恢复好。     

产钳助产术

一、要开展产钳术产钳助产术为历经改进完善能熟练应用的解决难产的重要手段。近年多数需用产钳术解决的难产已为剖宫产及胎吸术合理取代,但在不少特定情况下仍以应用产钳术最为有利。正确评价和合理使用产钳术,不但要懂产钳术,也要结合剖宫产术与胎吸术的利弊综合衡量...     

产钳助娩后5h,呼吸困难伴休克

病例摘要：患者，29岁，主因“产后5h，阴道出血增多，血压降低4h”于2004年12月20日21：05急诊由基层医院转入我院。患者2004年12月20日因39“周自然临产入住外院。入院当日4：30arn出现规律宫缩，产程进展顺利，宫口开全后，予缩宫素2．5U 5％GS500ml静点，因第二产程延长行胎头吸引术未成功改行产钳助产，     

10年间阴道助产术的临床应用回顾性分析

目的:分析2007~2016年10年期间四川省妇幼保健院分娩产妇中的阴道手术助产率、剖宫产率以及母婴结局的变化,探索提高阴道助产技术,降低剖宫产率的方法和途径。方法:回顾性分析2007~2016年分娩的51199例产妇病历资料,比较经过全面阴道助产培训后的5年(2012~2016年)与全面培训前的5年(2007~2011年)全院的分娩情况及近期母婴预后,并分析培训后5年分娩产妇的阴道助产率、剖宫产率、新生儿窒息率的变化趋势。结果:(1)培训前的5年,分娩产妇的阴道手术助产率是1.11%,剖宫产率是58.52%,Ⅲ度以上会阴裂伤率是0.56%,新生儿窒息率是5.88%。而培训后的最近5年,分娩产妇的阴道助产率是3.16%,剖宫产率是46.42%,Ⅲ度以上会阴裂伤率是0.23%,新生儿窒息率是3.21%。培训前后两个阶段的指标比较,差异均有统计学意义(P0.05)。(2)经过培训后近五年我院分娩产妇的阴道助产率逐年上升,而剖宫产率则逐年下降,新生儿窒息率和产妇的会阴损伤率也逐年下降。结论:通过对我院产科医护人员进行阴道助产模拟培训和临床实践培训,可以提高阴道助产技术的临床应用,降低剖宫产率,并改善母婴结局,阴道助产模拟培训模式值得推广运用。     

臀位阴道分娩

臀先露是最常见的胎位异常,阴道分娩风险高。产科医生和助产士应对臀先露的产妇进行充分评估及沟通,选择适宜的病例阴道分娩,同时加强产时监护,以确保臀位阴道分娩的母婴安全。本文围绕臀先露的病因、臀位阴道分娩的适应证、禁忌证、注意事项及可能的风险进行阐述。     

阴道手术产

阴道手术产是指助产者运用产钳或胎头吸引器使胎儿经阴道分娩,由于产科医生经验和能力的缺乏而使经阴道助产手术分娩的数量下降。文章就阴道手术产的指征、手术技巧、并发症以及手术方式的选择等进行讨论。     

Kjelland's forceps in the new millennium. Maternal and neonatal outcomes of attempted rotational forceps delivery

Background:  The use of Kjelland's forceps is now uncommon, and published maternal and neonatal outcome data are from deliveries conducted more than a decade ago. The role of Kjelland's rotational delivery in the 'modern era' of high caesarean section rates is unclear.
Aims:  To compare the results of attempted Kjelland's forceps rotational delivery with other methods of instrumental delivery in a tertiary hospital.
Methods:  Retrospective review of all instrumental deliveries for singleton pregnancies 34 or more weeks gestation in a four-year birth cohort, with reference to adverse maternal and neonatal outcomes.
Results:  The outcomes of 1067 attempted instrumental deliveries were analysed. Kjelland's forceps were successful in 95% of attempts. Kjelland's forceps deliveries had a rate of adverse maternal outcomes indistinguishable from non-rotational ventouse, and lower than all other forms of instrumental delivery. Kjelland's forceps also had a lower rate of adverse neonatal outcomes than all other forms of instrumental delivery.
Conclusions:  Prudent use of Kjelland's forceps by experienced operators is associated with a very low rate of adverse maternal and neonatal outcomes. Training in this important obstetric skill should be reconsidered urgently, before it is lost forever.     

Maternal and neonatal outcome after failed ventouse delivery: Comparison of forceps versus cesarean section

Objectives.?To compare the immediate maternal and neonatal morbidity in women delivered by forceps or cesarean section after failed ventouse delivery.

Methods.?Case notes of 400 consecutive successful ventouse deliveries compared with 342 failed ventouse deliveries, where delivery was subsequently achieved with either forceps (N = 247) or cesarean section (N = 95), which took place between October 1999 and May 2003, were reviewed.

Results.?Failed ventouse delivery was associated with an increased chance for fetal malposition (OR 3.7, 95% CI 2.6 – 5.3) and postpartum hemorrhage (OR 3.5, 95% CI 1.8 – 6.8). Compared to forceps after failed ventouse, cesarean section was associated with a higher prevalence of postpartum hemorrhage (OR 7.8, 95% CI 3.6 – 16.9) and fewer third degree perineal tears (p < 0.05). There were no significant differences between cesarean section and forceps delivery after failed ventouse for neonatal morbidity.

Conclusions.?Failure of ventouse delivery is 3 – 4 times more likely with a fetal malposition and is associated with an increased risk of postpartum hemorrhage. While cesarean section increases the postpartum hemorrhage rate, forceps delivery is associated with increased likelihood of third degree perineal tears. The neonatal morbidity was comparable regardless of whether forceps or cesarean was used after failed ventouse.     

Soft forceps.

OBJECTIVE: The risk of maternal and fetal trauma and, chiefly, the fear of law suits, have contributed to a significant decline in rates of forceps-assisted deliveries and an increase in rates of cesarean sections, especially in the United States. Our experience with gas-sterilized forceps blades covered with a soft rubber coating--the "soft" forceps--is described. METHOD: Ninety-six women who required a forceps-assisted delivery for standard indications were randomly allocated to 2 groups. There were 51 women in the regular forceps group and 45 women in the soft forceps group. Low forceps delivery with a Simpson instrument was used in all cases. The groups were compared for fetal injury. RESULTS: The rates of severe facial abrasion and minimal marking were 4.1% and 61%, respectively, in the regular forceps group and 1.9% and 34% in the soft forceps group. CONCLUSION: The soft forceps may reduce the rates of neonatal facial abrasion and skin bruises. The forceps should be further perfected, as well as vacuum extractors; they should both continue to be part of the obstetrician's armamentarium.     

Rapid Cycle Deliberate Practice Versus Traditional Simulation to Improve Resident Performance in Forceps Deliveries

This study aimed to assess the effectiveness of rapid cycle deliberate practice (RCDP) in improving obstetrics and gynaecology residents’ performance and skill retention in forceps-assisted vaginal deliveries. Thirty-three residents were randomly assigned to RCDP or traditional debriefing. Performance was evaluated using an objective structured assessment of technical skills (OSATS) tool. There were no significant differences in immediate performance scores between groups (P = 0.082). At 4–6 months, both groups demonstrated improved performance scores (traditional, P = 0.001; RCDP, P = 0.001). Seventy-six percent of residents in the RCDP group indicated “real-time” feedback was advantageous. Three residents suggested this method was less beneficial at a senior level.     

Qualitative analysis by interviews and video recordings to establish the components of a skilled rotational forceps delivery

Objective

To define the skills of a mid-cavity rotational forceps delivery to facilitate transfer of skills from expert obstetricians to trainee obstetricians.

Study design

Qualitative interviews and video analysis carried out at maternity units of two university teaching hospitals (St. Michael's Hospital, Bristol, and Ninewells Hospital, Dundee). Ten obstetricians were identified as experts in conducting operative vaginal deliveries. Semi-structured interviews were carried out to identify key technical skills. The experts were also video recorded conducting mid-cavity rotational deliveries in a simulation setting. The interviews and video recordings were transcribed verbatim and analysed using thematic coding. The anonymised data were individually coded by the three researchers and then compared for consistency of interpretation. The experts reviewed the data for respondent validation. The themes that emerged following the coding were used to formulate a taxonomy of skills.

Results

Rotational forceps were preferred by eight experts and two experts preferred manual rotation followed by direct traction forceps. The final taxonomy included detailed technical skills for Kielland rotational forceps delivery and manual rotation followed by direct traction forceps delivery.

Conclusion

This explicitly defined skills taxonomy could aid trainees’ understanding of the technique of rotational forceps delivery. This is an important potential contributor to safely reducing the rate of second-stage caesarean section.     

Consent Practices for Assisted Vaginal Births (AVB) at Two Tertiary Care Hospitals: A Retrospective Review of Physician Documentation

ObjectiveTo determine whether assisted vaginal birth (AVB) consent documentation, a surrogate for in vivo consent, aligns with Canadian practice guidelines at 2 Canadian tertiary-level obstetric centres.MethodsThis was a retrospective review of AVBs (vacuum and forceps) from July 2019 to December 2019 at 2 tertiary-level hospitals with template-based (Site 1) or dictation-based (Site 2) documentation. We extracted, from obstetric and neonatal charts, AVB type, physician and documenter types (resident/fellow/family doctor/generalist obstetrics and gynecology [OBGYN]/maternal-fetal medicine), and consent elements (present/absent) based on a predetermined checklist. Data were summarized and comparisons were made using chi-square test, Fisher exact test, and logistic regression, where appropriate.ResultsWe identified 551 AVBs (156 forceps, 395 vacuum) with most documentation completed by generalist OBGYNs or residents (333/551, 60.5%). Most vacuum-assisted deliveries documented no specific maternal (366/395, 92.7%) or neonatal (364/395, 92.2%) risks, and 107/156 (68.6%) and 106/156 (67.9%) forceps-assisted deliveries lacked specific documentation of maternal and neonatal risk, respectively. At Site 2, postpartum hemorrhage risk at vacuum-assisted deliveries was more commonly documented (6/90 [6.7%] vs. 2/395 [0.7%], P = 0.002) as was at least 1 neonatal risk and risk of obstetrical anal sphincter injury at forceps-assisted deliveries (50/133 [37.6%] vs. 0/23 [0%], P < 0.001) and (43/133 [32.3%] vs. 0/23 [0%], P = 0.001), respectively.ConclusionsOpportunity to improve AVB consent documentation exists, warranting quality improvement initiatives.     

Kielland产钳在持续性枕后位中的应用

目的 评估Ｋｉｅｌｌａｎｄ产钳对持续性枕后位进行反置上钳旋转胎头的安全性及可行性。方法 对１００例胎头双顶径已达或已过坐骨棘水平的持续性枕后位产妇,用Ｋｉｅｌｌａｎｄ产钳进行反置上钳旋转胎头产钳术。结果 成功率１００％,母体软产道损伤１７％,新生儿损伤１２％,无会阴Ⅲ度裂伤,无后穹窿,宫颈,膀胱损伤及子宫破裂,无新生儿颅内出血及死亡等严重并发症,结论 Ｋｉｅｌｌａｎｄ产钳反置上钳旋转胎头术用于双顶