不同分娩方式对低危孕产妇分娩结局及卫生经济学指标的影响

目的探讨不同分娩方式对低危孕产妇分娩结局及卫生经济学指标的影响。方法对2002年9月至2007年4月北京协和医院分娩的3751例孕37-41周^＋6的低危孕产妇的资料进行回顾性分析,按分娩的干预方式不同分为3组：择期引产组（包括药物及手术引产）501例、择期剖宫产组1634例和自然临产组1616例,分别对3组孕产妇的一般情况及住院费用以及分娩结局（产后出血、产褥病率、尿潴留、输血情况、切口愈合情况、产时副损伤）、新生儿Apgar评分情况等进行统计比较。结果（1）一般情况分析：自然临产组孕产妇住院天数（4．8d）与择期引产组（6．3d）及择期剖宫产组（6．3d）比较,差异有统计学意义（P〈0．01）;择期剖宫产组孕产妇住院费用（3472元）明显高于择期引产组（3201元）及自然临产组（2293元）,分别比较,差异有统计学意义（P〈0．01）,尤其是择期引产组中的剖宫产患者住院费用明显高于择期剖宫产组及自然临产组中的剖宫产患者,分别比较,差异均有统计学意义（P〈0．01）。（2）产时及产后并发症总发生率：孕产妇产时及产后并发症总发生率分别是择期引产组为12．4％、择期剖宫产组为0．9％,自然临产组为6．8％。（3）产后出血（≥500ml）发生率：择期引产组、择期剖宫产组和自然临产组分别为3．0％（15／501）、0．6％（9／1634）和1．2％（19／1616）,3组分别比较,差异有统计学意义（P〈0．01）。（4）尿潴留发生率：择期引产组、择期剖宫产组和自然临产组分别为4．6％（23／501）、0和3．3％（54／1616）,择期剖宫产组尿潴留发生率低于择期引产组与自然临产组（P〈0．01）,择期引产组与自然临产组比较,差异无统计学意义（P〉0．01）。（5）有无分娩中或产后输血：择期引产组、择期剖宫产组和自然临产组率孕产妇有输血者分别为2．0％（10／501）、0．1％（1／1634）和0．4％（6／1616）,3组分别比较,差异有统计学意义（P〈0．01）。（6）产时副损伤：择期引产组、择期剖宫产组和自然临产组产时副损伤发生率分别为0．6％（3／501）、0和0．4％（7／1616）,3组分别比较,择期剖宫产组低于其他两组（P〈0．01）,择期引产组与自然临产组比较,差异无统计学意义（P〉0．01）。（7）切口延期愈合：择期引产组、择期剖宫产组和自然临产组分别为0．8％（4／501）、0和0．2％（4／1616）,3组分别比较,差异有统计学意义（P〈0．01）。（8）产褥病率：3组间相互比较,差别无统计学意义（P〉0．01）。（9）新生儿窒息发生率：择期引产组、择期剖宫产组和自然临产组分别为1．2％（6／501）、0．1％（1／1634）和1．0％（17／1616）,择期剖宫产组与其他两组分别比较,差异均有统计学意义（P〈0．01）,择期引产组与自然临产组比较,差异无统计学意义（P〉0．01）。结论择期引产会增加孕产妇产后出血、分娩中或产后输血的机会,且没有降低产妇尿潴留、新生儿窒息的发生率;择期剖宫产是相对安全的分娩方式,对孕产妇分娩并发症的发生没有不良影响,但会明显增加住院费用。     

对新生儿窒息新法复苏实施强化培训效果的评价

目的 探讨理论与操作相结合的强化培训模式对落实新法窒息复苏规范操作、提高复苏质量、降低新生儿窒息发生率和病死率的影响。方法 采用理论与实践相结合、技术骨干“一对一”、“手把手”操作指导的培训模式进行窒息复苏方法培训，比较强化培训前后市、镇（区）医院ABCD复苏的规范操作、复苏用药及治疗转归情况。结果 （1）培训前新生儿窒息发生率为2．67％，培训后第1年窒息发生率为2．21％，比培训前明显下降，差异有统计学意义（χ^2=12．581，P〈0．01）；培训后第2、3年窒息发生率分别为2．44％和2．45％，虽比培训前下降，但差异无统计学意义。培训前规范复苏为51．3％，培训后第1年提高至75．7％，第2、3年分别降至62．7％和51．6％，差异均有统计学意义（P均〈0．01）；（2）培训前复苏中用药的患儿占63．8％，培训后第1、2和3年分别降至45．0％、50．0％和49．2％，差异有统计学意义（P〈0．01）；（3）市、镇（区）医院经初步复苏后需要继续复苏者分别为89．9％和85．7％，规范复苏分别为83．7％和48．6％，使用一种或多种药物复苏分别为42．2％和79．2％，其中不合理用药分别为15．3％和39．4％，差异均有统计学意义（P均〈0．01）；（4）培训前新生儿窒息病死率为9．05％，培训后降至5．08％，差异有统计学意义（P〈0．05）。市、镇（区）医院培训后治疗转归情况好于培训前，差异有统计学意义（P均〈0．05）。结论 在行政干预下，采用理论与实践相结合的重点培训模式可明显提高新生儿窒息复苏培训效果。但复苏技术仍存在误区和不规范操作，镇（区）医院仍是复训的重点，复训间隔时间不能超过两年。     

孕41周妊娠结局及引产利弊分析

目的通过对孕41周妊娠结局的分析，了解延期妊娠对胎儿及新生儿的影响；孕41周后引产的利弊。方法采用回顾性研究，对2002年7月至2004年12月足月无合并症初产妇资料进行分析，共计2903例，其中461例为延期妊娠（41～41舶周）。结果延期妊娠组剖宫产率为48.81％，胎儿窘迫发生率为43．38％。明显高于其它孕周组（P〈0．01），新生儿窒息发生率为1．08％，高于孕周38周组，低于其它组。但无统计学意义（P〉0．05）。延期妊娠引产组剖官产率为52．28％，自然临产组为28．36％，引产组明显高于自然临产组（P〈0．01），胎儿窘迫和新生儿窒息发生率分别为42．89％和1．02％，34．33％和1．49％，均无统计学意义（P〉0．05）。引产组宫颈Bishop评分低于5分者，剖宫产率为65．6％，高于自然临产组和评分6分及以上组（P〈0．05），与评分5分相比无统计学意义（P〉0．05）。孕41～41^＋3周分娩者与孕41^＋4～41^＋6周分娩者结局无明显差别。结论妊娠满41周后胎儿有官内缺氧的危险，应适时终止。宫颈条件不成熟者引产。难产危险性增加。刚满41周宫颈条件不成熟、又无迫切原因需要立即终止妊娠者，可严密观察下等待2～3d至41^＋4周再引产是可行的。     

孕母子(癎)前期、子(癎)对新生儿脑损伤及神经发育的影响

目的 研究孕母妊娠期合并子痫前期、子痫对新生儿脑损伤及远期神经发育的影响。方法 通过临床观察和动态颅脑影像学检查，观察子痫前期、子痫母亲所生265例新生儿脑损伤的情况，并对神经系统发育情况进行随访。结果 新生儿脑损伤发生率为63．0％。损伤类型主要是脑室旁白质损伤和缺氧缺血性脑病。母亲子痫前期、子痫的病情越重新生儿重度脑损伤的发生率越高，早发型重度子痫前期孕母的新生儿重度脑损伤的发生率（38．5％）明显高于晚发型（19．4％）（P〈0．05）。214例随访患儿中有56．1％出现了神经发育异常：严重神经发育异常发生率为3．3％；轻度神经发育异常发生率为17．3％；一过性神经发育异常发生率为35．5％。母亲子痫前期、子痫的病情越重小儿神经发育异常的发生率越高，重度脑损伤小儿神经发育异常的发生率（93．5％）明显高于轻度脑损伤者（66．7％）（χ^2=82．5，P〈0．01）。小儿神经发育异常的危险因素是孕母重度子痂前期（OR=4．37，95％CI1．67～8．35）和新生儿期重度脑损伤（OR=9．66，95％CI3．73～21．16）。结论 母亲子痫前期、子痫程度越重，其新生儿脑损伤和生长过程中神经发育异常发生率越高，早发型重度子痫前期孕母的新生儿重度脑损伤的发生率高于晚发型，重度子痫前期和重度脑损伤是小儿神经发育异常的危险因素。因此，对于子痫和子痫前期孕母所生新生儿要加强监测，早诊断、早干预以改善预后。     

妊娠合并糖代谢异常孕妇的妊娠结局分析

目的 探讨妊娠合并糖代谢异常孕妇的发生率变化趋势及经规范治疗后的不同类型糖代谢异常的母、儿结局。方法 1995年1月至2004年12月,在北京大学第一医院妇产科分娩的妊娠合并糖代谢异常患者共1490例,按照糖代谢异常情况分为糖尿病合并妊娠79例（DM组）,妊娠期糖尿病777例（GDM组,其中A1型355例,A2型316例,分型不明106例）,妊娠期糖耐量异常634例（GIGT组）。采用回顾性分析的方法对3组的母、儿结局进行分析,并对糖代谢异常孕妇的发生率进行统计。同期分娩的19013例糖代谢正常孕妇作为对照组。结果 （1）妊娠合并糖代谢异常的总发生率为7．3％,呈逐年上升的趋势。第一阶段即1995年1月至1999年12月,发生率呈缓慢增长,平均为4．3％（376／8739）;第二阶段即2000年1月至2001年12月,发生率呈快速增长趋势,平均为10．8％（445／4133）;第三阶段为2002年1月至2004年12月,基本稳定于8．9％（678／7640）。（2）3组糖代谢异常孕妇总的巨大胎儿、子痫前期、早产的发生率分别为12．1％（180／1490）、9．5％（141／1490）和9．4％（140／1490）,均明显高于对照组孕妇（P〈0．01）。3组糖代谢异常孕妇子痫前期、早产、宫内感染、羊水过多、酮症的发生率相互比较,差异有统计学意义（P〈0．05）,而3组的巨大儿发生率比较,差异无统计学意义（P〉0．05）。（3）3组糖代谢异常孕妇围产儿总死亡率为1．19％（18／1513）,其中,DM组为4．93％（4／81）,显著高于GDM组的1．14％（9／787）和GIGT组的0．78％（5／645）（P〈0．05）。而且,DM组新生儿窒息、低血糖及转诊的发生率均高于GDM组和GIGT组（P〈0．01）。（4）3组1505例新生儿中仅有0．6％（9／1505）发生呼吸窘迫综合征（RDS）,均发生于早产儿。结论 （1）妊娠合并糖代谢异常的发生率逐年上升,应重视提高对孕期糖尿病的筛查、诊断和处理。（2）经过孕期规范化管理,巨大儿、子痫前期和早产仍是糖代谢异常孕妇最常见的并发症,DM孕妇的母、儿合并症显著高于GDM和GIGT孕妇,今后应进一步加强该类型糖尿病孕妇管理。（3）新生儿RDS已不再是新生儿的主要合并症。     

胎心监护无负荷试验中变化减速波形的临床分析

目的 探讨胎心监护无负荷试验（NST）中变化减速（VD）发生的影响因素及围生儿结局。方法 回顾性分析山东省立医院2001年2月至2005年2月5120例NST中出现VD的283例监护图形,比较不同图形影响因素的发生率和围生儿结局。结果 NST中VD的发生率5.53%（283/5120）。单纯VD中影响因素发生率56.49%（87/154）,不典型VD中影响因素发生率94.57%（122/129）,差异具有显著性意义（χ^2=52.7,P〈0.01）。在分娩的283例新生儿中,1分钟Apgar评分〉7分者252例,≤7分者31例,其中单纯VD组新生儿窒息率2.59%（4/154）,而不典型VD组新生儿窒息率20.92%（27/129）,差异具有显著性意义（χ^2=24.2,P〈0.01）;单纯VD组剖宫产率（21.43%,33/154）低于不典型VD组（55.04%,71/129）,差异具有显著性意义（χ^2=34.1,P〈0.01）。结论 NST中变化减速的发生与多种因素有关,脐带异常最常见,不典型VD较典型者影响因素更明确,新生儿窒息的发生率更高,不典型VD较单纯VD更容易发生胎儿宫内窘迫。     

妊娠急性脂肪肝的临床诊断及治疗方法

目的 探讨妊娠急性脂肪肝的临床诊断及治疗方法。方法 对上海市公共卫生临床中心1988年1月至2007年7月收治的36例妊娠急性脂肪肝患者的临床资料进行回顾性分析。结果 （1）临床表现：36例妊娠急性脂肪肝患者均发生于妊娠晚期,有明显的临床症状（以恶心、呕吐为主）和实验室检查特征（36例患者全部出现白细胞计数、肝酶及血清总胆红素水平升高,全部出现凝血酶原时间延长及血清白蛋白水平降低）。肝脏B超的阳性检出率为57％（17／30）,肝脏CT的阳性检出率为73％（16／22）,肝脏CT的阳性检出率高于B超（P〈0．05）。（2）分娩方式：阴道分娩12例,其中产后出血发生率为42％（5／12）,孕产妇死亡率为50％（6／12）,围产儿死亡率为50％（6／12）,新生儿窒息发生率为58％（7／12）;剖宫产分娩24例,其中产后出血发生率为42％（10／24）,孕产妇死亡率为8％（2／24）,围产儿死亡率为13％（3／24）,新生儿窒息发生率为38％（9／24）。（3）剖宫产终止妊娠加内科综合支持治疗能明显降低产后出血发生率、孕产妇死亡率、围产儿死亡率、新生儿窒息发生率。剖宫产分娩的孕产妇死亡率及围产儿死亡率与阴道分娩比较,差异有统计学意义（P〈0．05）,剖官产分娩的产后出血发生率及新生儿窒息发生率与阴道分娩比较,差异无统计学意义（P〉0．05）。（4）全部死亡病例均是从发病至接受正规治疗时间超过7d的患者。结论 结合临床症状、实验窀检查特征、肝脏B超、CT检查等,力争在发病1周内明确诊断;立即剖宫产术终止妊娠、积极内科综合支持疗法是改善母儿预后的关键。     

妊娠合并甲状腺功能亢进症患者抗甲状腺药物治疗后对其新生儿先天畸形的影响

目的探讨妊娠合并甲状腺功能亢进症（甲亢）患者抗甲状腺药物（ATDs）治疗对其新生儿先天畸形的影响。方法采用回顾性分析方法对1983年1月1日-2003年12月31日在北京协和医院分娩的100例妊娠合并甲亢患者及其101例新生儿的临床资料进行研究。根据妊娠合并甲亢患者的甲状腺功能（甲功）状态及服用ATDs的情况对其新生儿先天畸形发生率、影响因素进行分析。结果（1）妊娠合并甲亢患者分娩的101例新生儿中,合并先天畸形7例,新生儿先天畸形发生率为6．9％,显著高于同期出生的新生儿先天畸形发生率的0．9％（212／22765）。其相对危险性为同期出生新生儿的7．9倍（P〈0．01）。（2）101例新生儿中,其母孕早期合并甲功亢进52例,新生儿先天畸形5例,先天畸形发生率为9．6％（5／52）;其母孕早期甲功正常49例,新生儿先天畸形2例,先天畸形发生率为4．1％（2／49）,两者新生儿先天畸形发生率比较,差异无统计学意义（P〉0．05）。（3）其母孕早期服用甲巯咪唑的12例新生儿中,合并新生儿先天畸形5例,先天畸形发生率为41．7％;其母孕早期服用丙基硫氧嘧啶的28例新生儿中,合并新生儿先天畸形1例,先天畸形发生率为3．6％;其母孕早期未服用ATDs的61例新生儿中,合并新生儿先天畸形1例,先天畸形发生率为1．6％。3者之间新生儿先天畸形发生率比较,差异有统计学意义（P〈0．01）。其中服用甲巯咪唑患者的新生儿先天畸形发生率显著高于服用丙基硫氧嘧啶者（P〈0．01）和未用药者（P〈0．01）。妊娠合并甲亢孕早期服用甲巯咪唑患者新生儿发生先天畸形的危险性,为服用丙基硫氧嘧啶患者的19．3倍;为未服用ATDs患者的42．9倍。对数线性模型分析显示,妊娠合并甲亢患者孕早期服用不同种类的ATDs,对新生儿先天畸形的形成存在显著的差异（P=0．0003）。结论妊娠合并甲亢患者其新生儿发生先天畸形的危险性增加。妊娠合并甲亢患者孕早期服用甲巯咪唑可能是导致新生儿先天畸形的主要因素之一。因此,妊娠合并甲亢患者应避免选用甲巯咪唑,以减少发生新生儿先天畸形的危险性。     

未足月胎膜早破449例临床分析

目的探讨未足月胎膜早破（preterm premature rupture of membranes,pPROM）的发病规律,分析pPROM患者不同孕周对分娩方式及围产儿结局的影响。方法对2003年1月至2007年12月间郑州大学第三附属医院的449例pPROM患者的临床资料进行回顾性分析。结果胎膜早破的发生率为14．3％,而pPROM发生率为3．3％;pPROM相关因素的构成比中,流产、引产史最高41．0％,其次为不明原因23．8％o、多胎10．4％及感染史9．8％;在分娩的437例pPROM患者中,孕32-34^＋6周组的剖宫产率高于孕28-31^＋6周组和孕35-36^＋6周组（P=0．001）;而孕28-31^＋6周组与孕35-36^＋6周组比较,无统计学意义（P=0．78）;490例围生儿中,孕32-34^＋6周组不同分娩方式对围生儿结局比较,无统计学意义（P〉0．0166）,孕28～31^＋6周组、孕32-34^＋6周组的转PICU率、新生儿窒息率及低体重儿率均高于孕35-36^＋6周组,差异有统计学意义（P=0．001）。结论流产、引产史、感染及不明原因是pPROM发生的主要影响因素;剖宫产并不是降低围生儿不良结局的最佳分娩方式;围生儿结局与孕周密切相关。     

舒芬太尼复合罗哌卡因联合分娩镇痛对产程及阴道助产率影响的研究

目的探讨舒芬太尼复合罗哌卡因联合分娩镇痛对产程及阴道助产率的影响。方法选择足月阴道分娩初产妇486例,分为分娩镇痛组362例和非无痛分娩组（对照组）124例,观察镇痛效果、镇痛药物不良反应、第一产程、第二产程时间,缩宫素使用、产钳助产、胎儿窘迫、新生儿窒息及产后出血等发生情况。结果舒芬太尼复合罗哌卡因分娩镇痛效果显著（P〈0．01）;镇痛组第一产程活跃期和第二产程时间略长于对照组,但两组比较差异无统计学意义（P〉0．05）;缩宫素的使用、产钳助产、胎儿窘迫、新生儿窒息及产后出血量两组比较,差异无统计学意义（P〉0．05）。镇痛组主要的不良反应为皮肤瘙痒,与对照组比较,差异有统计学意义（11．6％ vs 2．4%,P〈0．05）;但呕吐及运动阻滞的不良反应两组间差异无统计学意义（P〉0．05）;结论舒芬太尼复合罗哌卡因用于分娩镇痛效果好,略延长产程,但并不增加助产率。     

Amnioinfusion in term labor with low amniotic fluid due to rupture of membranes: a new indication

OBJECTIVE: The null hypothesis was that the use of intrapartum amnioinfusion to induce term labor because of premature rupture of membranes when labor was complicated by low amniotic fluid volume due to vaginal loss would not improve fetal heart rate patterns, decrease the incidence of operative delivery, or improve neonatal acid-base status. STUDY DESIGN: 200 term pregnancies with low amniotic fluid due to vaginal loss were randomly chosen to receive intrapartum amnioinfusion or standard obstetric care without amnioinfusion. Fetal heart rate pattern, method of delivery and neonatal acid-base status were compared with Student's t test, chi-squared analysis, Mann-Whitney U- or Fisher's exact test. RESULTS: When amnioinfusion was used, the fetuses had lower rates of variable (74 vs. 91%, P<0.01) or late (26 vs. 58%, P<0.001) decelerations. Spontaneous deliveries were more frequent (77 vs. 59%, P<0.01) and cesarean sections less frequent (3 vs. 10%, P<0.05). Mean umbilical arterial (7.24+/-0.07 vs. 7.21+/-0.08, P<0.01) and venous (7.31+/-0.06 vs. 7.28+/-0.08, P<0.01) pH were significantly higher in newborns with amnioinfusion, and babies in this group had lower rates of neonatal acidemia of arterial (22 vs. 36%, P<0.005) or venous (13 vs. 26%, P<0.005) origin. CONCLUSIONS: Amnioinfusion improved fetal heart rate pattern, lowered the incidence of operative delivery, and improved neonatal acid-base status in term labor complicated by low amniotic fluid due to vaginal loss.     

早产主要因素及对早产儿的影响(附285例临床分析)

目的：探讨早产主要因素及对早产儿的影响。方法：回顾性分析285例早产的主要高危因素，将其分为阴式分娩组和剖宫产组，对不同原因所致早产儿的预后作分析比较。结果：胎膜早破、多胎妊娠及妊高征是引起早产的主要因素；胎龄小死亡率明显增高，特别是胎龄＜32周者；剖宫产组和阴式分娩组中早产儿的存活率及发病率（尤其是颅内出血）有显著性差异（P＜0．05）。结论：早产是新生儿发病和死亡的主要原因，窒息及颅内出血是早产儿死亡的主要原因，早产不是剖宫产的禁忌证。     

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     

B超诊断羊水过少120例临床分析

目的分析B超诊断足月妊娠孕妇羊水过少对围产结局的影响。方法应用B超羊水最大深度法估测羊水量,并测定脐动脉收缩期最大血流速度(S)和舒张末期血流速度(D)的比值(S/D值),同时测定24 h尿雌三醇与肌酐的比值,比较分析120例B超诊断羊过少(观察组)和120例B超诊断羊水正常的足月妊娠妇女(对照组)B超测量羊水量与实际过少的符合率、分娩情况及新生儿预后。结果AFD在1.0～1.2 cm时,与实际羊水过少符合率为100％;1.3～2.0cm时为80％;2.1～3.0 cm时为58％;观察组择期剖宫产和急诊剖宫产率均显著高于对照组(P<0.01);阴道分娩的成功率明显低于对照组(P<0.01);胎儿宫内窘迫与羊水轻度混浊的发生率明显高于对照组(P<0.01);新生儿轻度窒息发生率明显高于对照组(P<0.01);重度窒息率两组间差异无显著(P>0.05)。结论加强对羊水过少的产前及产时监护,对重度羊水过少者不予试产,对试产的孕妇产程中出现异常及时行急诊剖宫产而不过度试产。对于羊水过少,同时又合并其它高危因素者,应禁止试产,以剖宫产结束妊娠。     

阴道分娩新生儿窒息的预防

新生儿窒息是阴道分娩过程中常见的急危重症，也是引起新生儿不良结局的重要原因。应在围产期对母体及胎儿情况进行充分评估，明确高危因素，严密观察产程进展，正确判读胎心监护图形，及时给予必要的产科干预，从而降低新生儿窒息的发生率，降低新生儿重症监护病房住院率，改善母儿结局。     

Uterine rupture and risk factors for caesarean delivery following induced labour in women with one previous lower segment caesarean section

Objective: To determine the outcome of induction of labor, specifically incidence of uterine rupture and reliable predictors of repeat caesarean delivery, in women undergoing induction of labor after previous caesarean section. Methods: A review of obstetric and perinatal records of 167 women who had their labor induced after one transverse lower uterine incision performed at previous caesarean delivery in a referral tertiary hospital in Nigeria between January 2006 and December 2009. Results: The incidence of uterine rupture was 2.4%. Independent risk factors for repeat caesarean delivery were absence of prior vaginal delivery (OR 3.7; 95% CI 1.9–7.1), duration of latent phase >2?h (OR 4.3; 95% CI 1.7–11.2), postdated pregnancy (OR 2.2; 95% CI 1.1–4.0) and previous caesarean for non-recurrent indication (OR 2.1; 95% CI 1.1–4.0). Conclusion: Choice of appropriate delivery option for this cohort of women based on the identified risk factors is essential to minimize the incidence of failed vaginal birth and its associated adverse maternal and neonatal outcome.     

Obstetric and neonatal outcome of babies weighing more than 4.5 kg: an analysis by parity

OBJECTIVES: To analyse by parity the obstetric and neonatal outcome of babies delivered weighing more than 4.5 kg. METHODS: All deliveries resulting in a baby weighing more than 4.5 kg, in the 5 years from 1991 to 1995, were identified using a computerised database. The following variables confined to singleton, cephalic pregnancies were recorded: mode of delivery, duration of labour, incidence of shoulder dystocia and admission to the neonatal centre. Outcome measures in primigravidae and multigravidae were compared using the Epi Info package (WHO, Version 6.0b January 1997). RESULTS: There were 32,834 deliveries over the study period and 828 (2.5%) weighed more than 4.5 kg. Birthweight more than 4.5 kg occurred in 1.6% (n=198) of primigravidae and 3.1% (n=630) of multigravidae (P<0.05). Primigravidae had a higher risk of prolonged labour (27.7% vs. 4.9%), operative vaginal delivery (32% vs.9%) and emergency caesarean section (24.2% vs. 5.7%) compared to multigravidae. When delivering a macrosomic baby, primigravidae had a higher incidence of prolonged labour (27% vs. 7.9%), operative vaginal delivery (32% vs.25%) and emergency caesarean section (24.2% vs. 5.7%) compared to normal weight babies. The incidence of shoulder dystocia and elective caesarean section were similar in both primigravidae and multigravidae. CONCLUSIONS: Macrosomic infants have an increased incidence of prolonged labour, operative vaginal delivery and emergency caesarean section compared with normal weight babies and these complications are more pronounced in primigravidae compared to multigravidae. Shoulder dystocia occurs with equal frequency in primigravidae and multigravidae. The poor antenatal predictability of macrosomia, the high rate of vaginal delivery and the low incidence of shoulder dystocia would not support the use of elective caesarean section for delivery of the macrosomic infant either in primigravidae or multigravidae.     

Short-term maternal and neonatal outcomes by mode of delivery. A case-controlled study

OBJECTIVE: Side-by-side comparisons of short-term maternal and neonatal outcomes for spontaneous vaginal delivery, instrumental vaginal delivery, planned caesarean section and caesarean section during labor in patients matched for clinical condition, age, and week of gestation are lacking. This case-controlled study was undertaken to evaluate short-term maternal and neonatal complications in a healthy population at term by mode of delivery. STUDY DESIGN: Four groups of healthy women, with antenatally normal singleton pregnancies at term, who underwent instrumental vaginal delivery (no. 201), spontaneous delivery (no. 402), planned caesarean section without labor (no. 402) and caesarean section in labor (no. 402) have been retrospectively selected. Outcome measures were maternal and neonatal short-term complications. Odds ratios (OR) and 95% confidence intervals (CI) were calculated. RESULTS: Maternal complications were mostly associated with forceps-assisted and vacuum-assisted instrumental deliveries (OR: 6.9; 95% CI: 2.9-16.4 and OR 3.0; 95% CI 1.1-8.8, respectively, versus spontaneous deliveries). No significant differences in overall complications were observed between spontaneous vaginal deliveries and caesarean sections, whether planned or in labor. By comparison with caesarean sections in labor, instrumental deliveries significantly increased the risk of complications (OR: 3.2; 95% CI: 1.6-6.5). Neonatal complications were also mostly correlated with forceps-assisted and vacuum-assisted instrumental deliveries (OR: 3.5; 95% CI: 1.9-6.7 and OR 3.8; 95% CI 2.0-7.4, respectively, versus spontaneous deliveries). By comparison with caesarean sections in labor, instrumental vaginal deliveries significantly increased the risk of complications (OR: 4.2; 95% CI: 2.4-7.4). CONCLUSIONS: In healthy women with antenatally normal singleton pregnancies at term, instrumental deliveries are associated with the highest rate of short-term maternal and neonatal complications.     

Labor course and delivery in epidural analgesia: a case-control study.

BACKGROUND: We aimed to establish if epidural analgesia is associated with a higher incidence of operative vaginal delivery, longer duration of labor and more frequent use of oxytocin than labor without analgesia. METHODS: We analyzed a cohort of 207 women with no risk factors who delivered with epidural analgesia in the labor unit of Spedali Civili, Brescia, Italy, during 2001. Length of the first and second stage of labor, mode of delivery, neonatal cord blood pH, neonatal Apgar score and neonatal outcomes were evaluated. RESULTS: Epidural analgesia was performed on request in 6%: in this group (group A) there were 141 (68%) nulliparae and 66 (32%) pluriparae; mean ( +/- standard deviation) gestational age at delivery was 39.4 +/- 1.3 weeks (range: 34.1-41.5 weeks). In this group, 184 (89%) had vaginal delivery and 23 (11%) delivered by Cesarean section. Among controls (group B), 368 (89%) had a vaginal delivery and 46 (11%) delivered by Cesarean section; vacuum extraction was used in 18 deliveries (9%) in group A and in 13 deliveries (3%) in group B. The duration of the second stage of spontaneous labor in the nulliparae of group A was significantly longer than in group B. No statistically significant differences were found between mean umbilical artery pH values of groups A and B. CONCLUSION: Our results confirm that epidural analgesia does not affect the rate of Cesarean delivery, while increasing the use of oxytocin augmentation, the duration of the second stage of labor and the rate of instrumental vaginal delivery.     

Low concentration Ropivacaine in labor epidural analgesia. A prospective study on obstetric and neonatal outcome]

BACKGROUND: Epidural analgesia effectively alleviates labor pain. However controversy exists about the effect of epidural analgesia on labor outcome. The aim of this study is to assess the effect of a low concentration local anesthetic (ropivacaine 0.08%) in labor epidural analgesia (LEA) on labor pain relief, on the incidence of cesarean sections and instrumental vaginal deliveries, and on neonatal outcome. METHODS: In the period April 1998 - July 2000, 323 women in active labor with live, singleton and in vertex presentation fetuses at term of gestation were included in this prospective study. Women with pre-gestational and/or obstetric diseases or previous caesarean deliveries were excluded. One-hundred and five patients requiring - by written informed consent - LEA were allocated to receive standardised protocol of a low concentration local anesthetic (ropivacaine 0.08%) coadministered with opioid (sufentanil): ropivacaine group. The remaining 239 parturients who didn't require LEA were included in the control group. RESULTS: The demographic characteristics of the two groups were similar; 12 (10.4%) patients receiving LEA delivered by cesarean section, 17 (14.8%) by vacuum extractor whereas 86 (74.8%) had a spontaneous delivery. The risk of cesarean section (adjusted for age, BMI, parity, neonatal weight and gynecologist) resulted lower, even if not significantly, in the ropivacaine group (OR 0.9; 95% IC: 0.6-1.3), while a significant increased instrumental vaginal delivery rate has been reported, although little numbers reduce statistical significance. Neonatal outcome was unaffected by the use of LEA. CONCLUSIONS: The conclusion is drawn that a lower concentration of ropivacaine (0.08%) in LEA produces good labor pain relief with no detectable adverse effects on mother and neonate, and without significantly increasing cesarean section rate.