肩难产15例回顾性分析

目的:分析肩难产的危险因素,探讨早期预测、识别和处理方法。方法:回顾性分析2000年01月至2010年01月10年间的肩难产病例,并随机抽取同期阴道分娩病例作为对照,比较两组孕妇的产前、产时指标,分娩并发症及新生儿径线、新生儿并发症的区别。结论:巨大儿发生肩难产的比例最高,但根据高危因素仍很难预测肩难产。正确处理肩难产是降低围生儿并发症的重要措施。     

肩难产紧急处理16例分析

目的分析肩难产发生特点，降低相关母儿并发症。 方法回顾性分析2013年1月至2018年12月陆军军医大学第一附属医院产科收治的紧急发生肩难产病例16例的临床资料，分析指标包括肩难产高危因素、诊断、助娩方式及母儿结局。 结果6年内经阴道分娩共16 252例，肩难产16例，发生率0.1%。高危因素分布为巨大儿3例，妊娠期糖尿病4例，器械助产5例，4例患者无高危因素。7例肩难产确诊表现为胎头娩出后胎肩嵌顿，9例表现为胎头娩出胎肩嵌顿并合并有"乌龟征"的临床表现。16例肩难产病例运用3～5种经阴道最终娩出。母儿结局：产后出血1例，会阴侧切11例，软产道损伤9例，无严重会阴裂伤；14例新生儿健康状况良好，1例新生儿3月龄时发现眼睑下垂，1例失访。 结论肩难产仍是无法预测的产科急症，需要正确判断肩难产的发生，掌握肩难产救治流程，快速施救，从而降低母儿并发症。     

54例肩难产的回顾性分析

目的:了解肩难产的母婴并发症及预防、处理方法;方法:对1998年1月～2010年12月在我院阴道助娩的肩难产病例54例进行回顾性分析,评价肩难产的处理方法、母婴并发症,总结肩难产的预防方法.结果:12年间分娩总数为8508例,发生肩难产54例,其中巨大儿50例,锁骨骨折4例,臂丛神经麻痹7例,轻度新生儿窒息15例,重度新生儿窒息9例;产妇会阴Ⅱ°裂伤17例,Ⅲ°裂伤5例;产后出血16例;结论:肩难产是产科少见的并发症,巨大儿发生肩难产的比例最高.及时发现和正确处理肩难产是降低母婴并发症的主要措施。     

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45例临床分析

目的:探讨肩难产发生的高危因素和母婴并发症及处理方法。方法:回顾性分析四川省安县妇幼保健院2000年10月至2010年10月45例肩难产的临床资料,根据肩难产时母婴并发症的发生率与新生儿体重、助产手法及娩肩时间的关系进行分组,并进行分析。结果:①肩难产发生的高危因素主要有巨大儿(62.2%),子宫收缩乏力(15.6%),妊娠期糖尿病(11.1%)。②肩难产母婴并发症主要有:母体会阴裂伤(17例,37.8%),产后出血(7例,15.6%),新生儿窒息(29例,64.4%)。巨大儿组的母婴并发症发生率高于正常体重儿组(P<0.05);母亲并发症发生率与助产手法及娩肩时间无明显关系(P>0.05),而新生儿并发症发生率随助产手法种类的增加及娩肩时间的增加而增加(P<0.05)。③助产手法:采用屈大腿法成功分娩10例(22.2%),屈大腿法+压前肩法成功16例(35.6%),屈大腿法+压前肩法+旋肩法成功12例(26.7%),屈大腿法+压前肩法+旋肩法+牵后臂法成功7例(15.6%)。结论:巨大儿是肩难产发生的首要高危因素。母体会阴裂伤、产后出血及新生儿窒息是肩难产的常见并发症,母亲并发症主要与胎儿体重有关,新生儿并...     

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：     

肩难产的预防和处理

肩难产是难以完全预测的高危产科急症,发生率0.2%～3.0%。可引起严重母儿并发症,以新生儿臂丛神经损伤最为常见（4%～40%）,产科从业人员应该注意肩难产发生的危险因素并在任何一次分娩时均需要警惕其发生。一旦发生需要立刻采取正确的处理。了解其高危因素并制定针对性预防措施,熟练掌握正确的处理技术以有效降低严重并发症的发生率。     

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     

Shoulder dystocia: Risk factors,predictability, and preventability

Shoulder dystocia remains an unpredictable obstetric emergency, striking fear in the hearts of obstetricians both novice and experienced. While outcomes that lead to permanent injury are rare, almost all obstetricians with enough years of practice have participated in a birth with a severe shoulder dystocia and are at least aware of cases that have resulted in significant neurologic injury or even neonatal death. This is despite many years of research trying to understand the risk factors associated with it, all in an attempt primarily to characterize when the risk is high enough to avoid vaginal delivery altogether and prevent a shoulder dystocia, whose attendant morbidities are estimated to be at a rate as high as 16–48%. The study of shoulder dystocia remains challenging due to its generally retrospective nature, as well as dependence on proper identification and documentation. As a result, the prediction of shoulder dystocia remains elusive, and the cost of trying to prevent one by performing a cesarean delivery remains high. While ultimately it is the injury that is the key concern, rather than the shoulder dystocia itself, it is in the presence of an identified shoulder dystocia that occurrence of injury is most common.     

Shoulder dystocia: Simulation and a team-centered protocol

Shoulder dystocia is an obstetric emergency that has been reported to occur in 0.2–3% of all vaginal deliveries. Several characteristics of shoulder dystocia make it a particular challenge to manage effectively. It is relatively infrequent, the diagnosis cannot be made according to a single objective criterion that can be recognized to exist by all members of the care team who are present, it is unpredictable, and there is the need for coordinated actions of all members of the health care team who have come together on the day of the delivery and may not have worked together before or specifically during a shoulder dystocia. In general, there is evidence from different medical disciplines that checklists/protocols and simulation may be used to enhance team performance. There is also some evidence, albeit limited, that such techniques may be used to improve shoulder dystocia outcomes.     

Shoulder dystocia and the next delivery: Outcomes and management

Objective. To evaluate delivery mode management decisions and the rate of shoulder dystocia recurrence for women with a prior delivery complicated by shoulder dystocia.

Study design. We used a computerized perinatal database and ICD-9 codes to identify all vaginal deliveries complicated by shoulder dystocia from 1996 to 2001. Subsequent deliveries over the next three years were identified and reviewed for relevant clinical, obstetric, and delivery outcomes. Management including use of labor induction, labor augmentation, operative vaginal delivery, and delivery mode (elective cesarean section (CS) vs. trial of labor (TOL)) were reviewed. The recurrence rate of shoulder dystocia was calculated and the characteristics of these cases further described.

Results. Over the initial 5-year study, there were 25 995 vaginal deliveries, 205 shoulder dystocia cases (0.8%), 36 (17.5%) with neonatal injury. Of the 205 initial shoulder dystocia cases, 39 patients had 48 subsequent deliveries at our institution (a subsequent delivery rate of 23% at our institution, significantly less than the overall population (42%, p < 0.001)). Complete data were available for 47 deliveries. Four women had elective CS without labor (one due to prior shoulder dystocia), 43 (91.5%) had a TOL, and 42 (88%) achieved vaginal delivery. Recurrent shoulder dystocia complicated 9.5% (4/42) of deliveries; one case included neonatal brachial plexus injury that resolved prior to hospital discharge. Of the four recurrent shoulder dystocia cases, none were complicated by maternal diabetes, macrosomia, prolonged second stage of labor, or underwent an operative vaginal delivery. No statistically significant univariate differences were seen between the recurrence group and the no-shoulder dystocia vaginal delivery group; however birth weight and nulliparity at initial shoulder dystocia pregnancy jointly demonstrated a relationship of recurrence (p = 0.048).

Conclusion. In TOL cases that result in a vaginal delivery, the rate of recurrence of shoulder dystocia is high—approximately 10 times higher than the rate for the general population. Often the only identifiable risk factor is the prior history itself, which may influence delivery management in subsequent pregnancies. Birth weight and nulliparity at initial shoulder dystocia pregnancy may influence clinical decision-making in cases of prior shoulder dystocia.     

Shoulder dystocia: Management and documentation

Shoulder dystocia is an obstetric emergency that occurs when the fetal shoulders become impacted at the pelvic inlet. Management is based on performing maneuvers to alleviate this impaction. A number of protocols and training mnemonics have been developed to assist in managing shoulder dystocia when it occurs. This article reviews the evidence regarding the performance, timing, and sequence of these maneuvers; reviews the mechanism of fetal injury in relation to shoulder dystocia; and discusses issues concerning documentation of the care provided during this obstetric emergency.     

Shoulder dystocia in a Jamaican cohort

Objective

To assess the risk factors for shoulder dystocia in Jamaica.

Methods

A retrospective cohort analysis of all cases of shoulder dystocia, and birth weight-matched controls identified from January 1, 2000 to December 31, 2004. Multiple factors were analyzed individually and in combination to identify risk factors.

Results

The incidence of shoulder dystocia was 0.83%. Nulliparity, a first stage of labor greater than 7 hours, a second stage lasting more than 1 hour, and use of oxytocin augmentation were found to be statistically significant factors with unadjusted odds ratios (95% confidence interval) of 1.78 (0.86-3.34), 1.89 (0.91-3.94), 2.78 (0.24-31.47), and 1.56 (0.77-3.15), respectively. The incidence of shoulder dystocia decreased as parity increased when adjusted for age.

Conclusion

Individual risk factors for shoulder dystocia remain obscure. The nulliparous pelvis, when controlled for neonatal weight, was associated with a statistically increased risk of shoulder dystocia; this risk decreased with increasing parity.     

Antenatal and intrapartum prediction of shoulder dystocia

Objectives

To (1) develop algorithms to calculate the risk of shoulder dystocia at individual deliveries; (2) evaluate screening for shoulder dystocia.

Study design

Retrospective analysis of 40284 consecutive term cephalic singleton pregnancies using a ‘train and test’ method. Four models were derived using logistic regression and tested (birthweight alone; birthweight and other independent antenatal variables; birthweight and all independent antenatal and intrapartum variables; and all independent variables excluding birthweight).

Results

Shoulder dystocia occurred in 240 deliveries (0.6%). Birthweight was the most important risk factor although 98 cases (41%) occurred in babies weighing <4.0 kg. Birthweight and maternal height were the only independent antenatal variables; for intrapartum use, only these and instrumental delivery were independent. The antenatal model could calculate an individual's risk; the intrapartum model could also calculate the risk if an instrumental delivery were undertaken. Both showed 0.7% women to have a risk of shoulder dystocia of >10%. Although the antenatal model had high predictability (area under curve 0.89), it was no better than birthweight alone and had a sensitivity of 52.4%. Where birthweight was excluded, prediction of shoulder dystocia was poor.

Conclusion

Antepartum and labour calculation of the risk of shoulder dystocia is possible. Whilst greatly hindered by the inaccuracy of estimating weight, it allows due weight to be given to factors which may already be influencing clinical practice. However, shoulder dystocia cannot be predicted with sufficient accuracy to allow universal screening.