Kielland's产钳运用技巧拾遗

Ｋｉｅｌｌａｎｄ＇ｓ产钳有近百年的历史。它能在第二产程母婴安全受到威胁时,方便、快捷地娩出胎儿。Ｋｉｅｌｌａｎｄ＇ｓ产钳结构特点,王历等已作详细介绍［１］。一、Ｋｉｅｌｌａｎｄ＇ｓ钳具有独特的优势上钳时无需上推胎头或改变胎头的位置;握头牢靠,能适应胎头的大小及纠正胎头不均倾;兼备旋转和牵引的双重功能,且一次完成;牵引可在盆轴上施力,用力小;不增加母婴的损伤。二、Ｋｉｅｌｌａｎｄ＇ｓ钳操作技巧拾遗１．迂回法上钳［１－３］。是把前叶沿侧盆壁插入,然后用手法把它绕过胎儿的面部,送到耻骨联合后方,术者在…     

Kielland‘s产钳助产150例分析

持续性枕横位是常见的头位难产，临床上常用的助产方法有徒手转胎头、负压吸引器及Ｋｉｅｌａｎｄ＇ｓ产钳旋转胎头。我院自１９９１年２月至１９９８年４月，应用Ｋｉｅｌａｎｄ＇ｓ产钳对持续性枕横位１５０例（ＫＦ组）行助产术，并与同期１３０例手转胎头后Ｓｉｍｐｓ...     

单手置产钳术的操作及体会

产钳手术的置钳法有双手及单手法两种。作者经多年临床实践,认为单手置产钳术能及时解决难产,减少母儿损伤,达到“稳、准、快”的目的。现将单手置产钳的优越性、操作方法及体会介绍如下。一、从产钳手术的目的分析:产钳术是解决单胎头位分娩第二期延长的难产(因继发宫缩无力或头盆轻度不称),加速娩出胎儿,减少骨盆对胎头造成的挤压性创伤,因此必须选择简而易行比较安全的置钳法。双手法须两手交换固定胎头与置钳,不仅手术时间较长,且不易置准。     

Kiclland's产钳单手迂回置钳法的临床应用

1 操作方法 1.1 术前准备:产妇取膀胱截石位,常规消毒外阴、导尿及铺无菌巾,阴道检查确定胎方位、先露高低,宫口是否开全,是否破膜,有无明显头盆不称,决定能否施术,可施术者做阴部神经阻滞麻醉后行会阴侧切术。 1.2 操作步骤:①将无菌石蜡油涂于两叶钳匙上,以右枕横位产钳为例,左手以执笔式握左钳柄,钳叶垂直向下,将右手四指置胎头与阴道后壁间,右手掌向上,将左叶产钳沿右手掌伸向指掌与胎头之间,缓慢地沿着胎头弯度向深向上,钳柄向下向中轻推钳叶滑行至耻骨联合后方,置于胎儿的前顶部,在滑行中不应     

再谈持续性枕后位北大核心CSCD

持续性枕后位发病率为5％～12％,易出现母儿并发症。体格检查联合超声检查可提高其诊断准确率。临产前、第一产程中大部分枕后位可自行转为枕前位分娩。第二产程若出现持续性枕后位,应预防性徒手旋转胎方位;若出现胎心监护异常或第二产程延长,需立即旋转胎头、器械助产或剖宫产终止妊娠。     

会阴按摩预防产时会阴损伤

据1998年英国统计,85％的妇女首次阴道分娩时会有会阴损伤,其中2/3需要缝合。这种损伤对产妇的生理、心理及社会健康都会有近期及远期影响,如性交痛、尿失禁、大便失禁,以及会阴持续性疼痛等。产次、胎儿大小、胎先露及胎方位都与会阴损伤有关,而臀位、枕后位、侧切术及产钳术更直接增加会阴损伤。其它如种族、年龄、营养状况、产前训     

B超对胎头变形能力的研究

我们于1988年11月至1989年5月,对自然发动宫缩经阴道分娩的新生儿80例,测定其产前及产后的双顶径(BPD)和头围(HC),观察胎头的变形能力,并以同期儿头未经受压以剖宫产结束分娩的新生儿78例作对照观察,现报道如下.1 资料与方法1.1 病例构成:孕39～41~( 6)周、单胎、无合并症和并发症的正常孕妇80例,平均年龄为26.4±2.8岁,初产妇77例,经产妇3例,枕前位62例,枕后位13例,枕横位5例,新生儿平均体重3388.1±3.2g,分娩方式:顺产77例,产钳3例。1.2 仪器与方法:(1)我们使用的仪器是日本Aloka-SSD 280型线     

Kjelland氏产钳迂回上钳法的临床应用(附359例分析)

目前产科分娩量大,而且几乎都是初产妇,因此手术产的发生率上升。剖宫产术虽能解决不少难产,但产钳术仍有广阔的使用前途。在枕横位或枕后位时,Kjelland 氏产钳(简称吉兰产钳)有其独特的优点。本文通过我们的临床实践,介绍一下吉兰氏产钳的迂回上钳法.并通过临床资料阐述此方法的优点。资料和方法一、产钳操作的步骤吉兰氏产钳有三种上钳的方法:①古典上钳法:这种方法由于有在宫腔内转钳的步骤,蕴藏着很大的危险,早已不用。②迂回上钳法:即上前叶产钳是从胎儿面额部滑向颞部。③直插上钳法:使用机会不多。现以右枕横位为例介绍迂回上钳法:(一)准备:孕妇取膀胱截石位,两大腿尽量外旋。臀部要突出于床边2～3 cm,排空膀胱,阴道检查以确定胎头位置。作阴部神经阻滞麻醉,然后作会阴切开。术者先将涂过润滑油的合好的整把产钳     

手转胎头术纠正枕位异常的临床评价

手转胎头术(manual rotation of fetal head)是经阴道徒手旋转胎头纠正异常枕位的无损害性干预手术。成功的手转胎头术为经阴道分娩创造了条件,是降低剖宫产率的手段之一。我们对我院近20年来手转胎头纠正枕先露异常535例临床资料进行回顾性分析。 资料与方法 1.临床资料:采用回顾性资料分析方法对1980年1月～1999年12月在我院分娩行手转胎头术的535例资料进行了分析,1980～1985年徒手转胎头术223例,占同期分娩总数的6.73％;1986～1990年手转胎头术174例,占同期分娩总数的6.48％;而在1991～1995年和1996～1999年,手转胎头术均下降,分别为96例和49例,占同期分娩总数的5.35％和3.19％。535例枕位异常的产妇中持续性枕横位     

活跃期枕后位胎儿脊柱位置与分娩结局的关系

目的 探讨产程中活跃期枕后位胎儿脊柱位置与分娩结局的关系. 方法 本研究为回顾性研究.2008年5月1日至2011年10月31日在解放军第四五八医院分娩的足月单胎妊娠初产妇,其胎儿体重＜4000 g,均为头先露、枕后位,共288例.在试产过程中宫口扩张4～5 cm并已破膜时,征得孕妇及家属同意,行B超检查胎头及脊柱位置,并动态观察至分娩结束.采用独立样本t检验和x 2检验对分娩结局进行分析. 结果 288例中,胎儿脊前位202例,脊后位86例.脊前位组新生儿窒息发生率低于脊后位组[1.5％(3/202)与8.1％(7/86),x2=7.97,P＜0.01].脊后位组86例分娩中胎儿均为持续性枕后位,其中4例以枕后位经阴道分娩(包括产钳助产2例).脊前位组和脊后位组产程中不同宫口扩张程度时因持续性枕后位行剖宫产终止妊娠的比例差异有统计学意义[宫口扩张6 cm:4.0％ (8/202)与36.0％(31/86),x2=53.04;7 cm:3.5％(7/202)与18.6％(16/86),x2=18.81;8 cm:1.5％(3/202)与10.5％(9/86),x2=12.18;9 cm:0.5％(1/202)与5.8％(5/86),x2=8.63;开全:1.5％(3/202)与15.1％(13/86),x2=21.36;开全1h:0.5％(1/202)与9.3％(8/86),x2=15.45;P均＜0.01].徒手旋转胎位均在宫口扩张5～6 cm时进行.脊后位组2例徒手旋转胎位均未成功.脊前位组202例中,155例未行手旋转胎位而在继续试产中胎头转为枕前位经阴道分娩,12例经徒手旋转胎位至枕前位经阴道分娩,余35例均行剖宫产终止妊娠,其中23例手术指征为持续性枕后位. 结论 产程中活跃期枕后位胎儿脊柱位置与分娩结局有密切关系,活跃期及时了解枕后位胎儿脊柱位置,可帮助医师及时采取合理分娩方式,以降低母婴并发症,提高产科质量.     

手转胎头适宜时机的临床观察

目的:探讨头位难产时,选择适宜时机进行手转胎头,以加速产程进展,提高自然分娩率。方法:选择2009年1月至2010年12月共192例单胎头位,持续性枕横位、枕后位,无严重并发症及合并症的产妇,分为观察组96例,对产妇选择适宜时机(宫口开大6～10cm,胎先露在坐骨棘平或坐骨棘下1～2cm)进行手转胎头;对照A组53例,对产妇选择宫口开大<6cm,胎先露在坐骨棘上进行手转胎头;对照B组43例,选择宫口开全后,胎先露在坐骨棘下≥2cm进行手转胎头。结果:观察组手转胎头成功率明显高于对照组(P<0.01);观察组阴道分娩率显著高于对照组,剖宫产率显著低于对照组(P<0.01);产程进展时间、分娩方式、产后出血、新生儿1分钟阿普加评分等与对照组比较差异有高度统计学意义(P<0.01);新生儿窒息率明显降低。结论:手转胎头是处理头位难产的重要方法,选择适宜的时机进行手转胎头,使难产变为顺产,可缩短产程,提高自然分娩率,有效降低阴道助产及剖宫产率,减少母婴并发症。     

Kielland-Barton-Laufe (K.B.L.) Forceps with Luikart Modification in the Management of Transverse and Posterior Positions of the Fetal Head

Disadvantages of Kielland and Barton forceps are described. A trial of K.B.L. forceps was undertaken in transverse and posterior positions of the fetal head. It was concluded that these forceps are easier to apply than Kielland forceps. Rotation of the head is easier, and they are the equal of Kiellands as tractors, with the advantage of causing less marking of the fetal head than either Kielland or Barton forceps.     

More on the Kielland forceps

A study of 103 deliveries with Kielland forceps has been presented. Mother's age, parity, presentation, height of the head, anaesthesia, weight of the child, failures, puerperium, indications, injuries to the mother, conditions of the child, maternal and children mortality are discussed. Kielland instrument still maintains its position as a usefull specialized forceps for deep transverse arrest and also for obliqually placed fetal head.     

Use of intrathecal analgesia in a rural hospital Case studies

A woman's experience of unrelenting back pain with a fetus in an occipitoposterior position and the escalating interventions culminating in a cesarean birth is every midwife's nightmare. Intrathecal analgesia is a relatively simple and rapid method to provide maternal relaxation and relief from severe back labor. This article describes the use of intrathecal opioid analgesia in labor complicated by failure to progress in first-stage labor due to persistent occipitoposterior position of the fetus. Intrathecal analgesia has the advantage of being inexpensive and providing rapid onset of adequate pain relief for the first stage of labor. It does not cause motor blockade, so it allows the mother to be mobile and feel the urge to push. Consequently, there is no associated risk of an increased need for forceps or vacuum-assisted delivery. The authors note a decreased incidence of operative delivery for fetal occipitoposterior position with the use of intrathecal narcotics.     

Uterine contractility in women whose fetus is delivered in the occipitoposterior position

OBJECTIVE: Most fetuses in the occipitoposterior position rotate spontaneously after striking the pelvic floor. The increased prevalence of prolonged labor, operative delivery, and oxytocin augmentation in women with an occipitoposterior fetal position seems consistent with decreased uterine contractility. We sought to test the hypothesis that women with a persistent occipitoposterior fetal position have inadequate intrauterine pressure. STUDY DESIGN: Intrauterine pressure was measured prospectively electronically in 94 women whose labor pain was controlled by patient-requested epidural analgesia. Eleven women (12%) were delivered as a persistent occipitoposterior fetal position. In a nested case-control study, these women were compared with 22 women who were delivered as an occipitoanterior fetal position who were matched for age, parity, gestational age, cervical examination at study enrollment, and body mass index. The intrauterine pressure measurements were initiated during the first stage of labor and continued throughout the entire labor process. Women were encouraged in the second stage of labor, after a period of recording baseline contractility, to push using a standardized Valsalva maneuver once the vertex reached the +2 station. The area under the intrauterine pressure curve (integral) was used to estimate uterine contractility and expulsive performances. RESULTS: Five women (45%) in the occipitoposterior group required operative delivery. The average duration of the second stage of labor in the occipitoposterior group was 91.4 +/- 23.2 minutes compared with 51.7 +/- 6.6 minutes in the occipitoanterior fetal position (P =.04). Ninety percent of women in the occipitoposterior group required oxytocin, compared with 59% of the women in the occipitoanterior group (P =.11). There were no differences in uterine contractility between occipitoposterior and occipitoanterior groups during either the first stage of labor (integral mean +/- SEM: occipitoposterior [1685.3 +/- 194.6 mm Hg. s] vs occipitoanterior fetal position [1700.8 +/- 128.9 mm Hg. s, P =.98]) or second stages of labor (occipitoposterior [1952.6 +/- 186.5 mm Hg. s] vs occipitoanterior fetal position [1740.8 +/- 104.3 mm Hg. s, P =.46]). Further, there were no significant differences in pushing performances between the occipitoposterior and occipitoanterior groups (Valsalva maneuver: occipitoposterior 2864.9 +/- 328.8 mm Hg. s] vs occipitoanterior [2898.6 +/- 222.2 mm Hg. s, P =.90]). CONCLUSION: Women who were delivered as a persistent occipitoposterior fetal position do not have lower intrauterine pressure levels immediately before or during the second stage of labor.     

USE OF INTRATHECAL ANALGESIA IN A RURAL HOSPITAL: Case Studies

A woman's experience of unrelenting back pain with a fetus in an occipitoposterior position and the escalating interventions culminating in a cesarean birth is every midwife's nightmare. Intrathecal analgesia is a relatively simple and rapid method to provide maternal relaxation and relief from severe back labor. This article describes the use of intrathecal opioid analgesia in labor complicated by failure to progress in first-stage labor due to persistent occipitoposterior position of the fetus. Intrathecal analgesia has the advantage of being inexpensive and providing rapid onset of adequate pain relief for the first stage of labor. It does not cause motor blockade, so it allows the mother to be mobile and feel the urge to push. Consequently, there is no associated risk of an increased need for forceps or vacuum-assisted delivery. The authors note a decreased incidence of operative delivery for fetal occipitoposterior position with the use of intrathecal narcotics.     

Randomized Controlled Trial of Hands‐and‐Knees Positioning for Occipitoposterior Position in Labor

ABSTRACT: Background: Hands‐and‐knees positioning during labor has been recommended on the theory that gravity and buoyancy may promote fetal head rotation to the anterior position and reduce persistent back pain. A Cochrane review found insufficient evidence to support the effectiveness of this intervention during labor. The purpose of this study was to evaluate the effect of maternal hands‐and‐knees positioning on fetal head rotation from occipitoposterior to occipitoanterior position, persistent back pain, and other perinatal outcomes. Methods: Thirteen labor units in university‐affiliated hospitals participated in this multicenter randomized, controlled trial. Study participants were 147 women laboring with a fetus at ≥37 weeks’ gestation and confirmed by ultrasound to be in occipitoposterior position. Seventy women were randomized to the intervention group (hands‐and‐knees positioning for at least 30 minutes over a 1‐hour period during labor) and 77 to the control group (no hands‐and‐knees positioning). The primary outcome was occipitoanterior position determined by ultrasound following the 1‐hour study period and the secondary outcome was persistent back pain. Other outcomes included operative delivery, fetal head position at delivery, perineal trauma, Apgar scores, length of labor, and women's views with respect to positioning. Results: Women randomized to the intervention group had significant reductions in persistent back pain. Eleven women (16%) allocated to use hands‐and‐knees positioning had fetal heads in occipitoanterior position following the 1‐hour study period compared with 5 (7%) in the control group (relative risk 2.4; 95% CI 0.88–6.62; number needed to treat 11). Trends toward benefit for the intervention group were seen for several other outcomes, including operative delivery, fetal head position at delivery, 1‐minute Apgar scores, and time to delivery. Conclusions: Maternal hands‐and‐knees positioning during labor with a fetus in occipitoposterior position reduces persistent back pain and is acceptable to laboring women. Given this evidence, hands‐and‐knees positioning should be offered to women laboring with a fetus in occipitoposterior position in the first stage of labor to reduce persistent back pain. Although this study demonstrates trends toward improved birth outcomes, further trials are needed to determine if hands‐and‐knees positioning promotes fetal head rotation to occipitoanterior and reduces operative delivery. (BIRTH 32:4 December 2005)     

One-blade rotation of a persistent posterior vertex

Fifteen women in labor at term with no evidence of protraction or arrest disorder successfully underwent a single-blade rotation of the fetus from occipitoposterior to occipitoanterior position. There were no failures, no fetal injuries, and no significant maternal trauma. This method of forceps rotation appears to be a safe alternative to current methods of managing occipitoposterior positions.     

Mediolateral episiotomy reduces the risk for anal sphincter injury during operative vaginal delivery

Objective  To determine the risk factors for anal sphincter injuries during operative vaginal delivery.
Setting and design  A population-based observational study.
Population  All 21 254 women delivered with vacuum extraction and 7478 women delivered with forceps, derived from the previously validated Dutch National Obstetric Database from the years 1994 to 1995.
Methods  Anal sphincter injury was defined as any injury, partial or complete, of the anal sphincters. Risk factors were determined with multivariate logistic regression analysis.
Main outcome measures  Individual obstetric factors, e.g. fetal birthweights, duration of second stage, etc.
Results  Anal sphincter injury occurred in 3.0% of vacuum extractions and in 4.7% of forceps deliveries. Primiparity, occipitoposterior position and fetal birthweight were associated with an increased risk for anal sphincter injury in both types of operative vaginal delivery, whereas duration of second stage was associated with an increased risk only in vacuum extractions. Mediolateral episiotomy protected significantly for anal sphincter damage in both vacuum extraction (OR 0.11, 95% CI 0.09–0.13) and forceps delivery (OR 0.08, 95% CI 0.07–0.11). The number of mediolateral episiotomies needed to prevent one sphincter injury in vacuum extractions was 12, whereas 5 mediolateral episiotomies could prevent one sphincter injury in forceps deliveries.
Conclusions  Primiparity and occipitoposterior presentation are strong risk factors for the occurrence of anal sphincter injury during operative vaginal delivery. The highly significant protective effect of mediolateral episiotomies in both types of operative vaginal delivery warrants the conclusions that this type of episiotomy should be used routinely during these interventions to protect the anal sphincters.     

Intrapartum ultrasonographic depiction of fetal malpositioning and mild parietal bone compression in association with large lower segment uterine leiomyoma

With normal flexion of the fetal head prior to and during early normal labor, the fetal biparietal diameter becomes engaged in (and subsequently traverses) the anterior posterior aspect of the pelvic inlet. Thus, the biparietal diameter (characterized sonographically by depiction of the falx cerebri, thalami, and cavum septum pellucidum) will be obtainable upon transverse suprapubic placement of the ultrasound transducer during the first stage of labor. Deflexion, or extension, of the fetal head may be demonstrated sonographically at the level of the cervical spine. Recently, during intrapartum ultrasonographic assessment of a nulliparous patient with a known, large, lower-segment, uterine fibroid, exhibiting poor progress of labor, the fetal biparietal diameter was documented upon midsagittal suprapubic placement of the transducer. In addition, mild compression of the distal parietal fetal bone was demonstrated and considered consistent with compression by the leiomyoma. Following abdominal delivery, due to fetal distress and arrest of descent, significant deflexion of the fetal head (not suspected by intrapartum cervical examinations) and mild parietal bone depression, consistent with the ultrasonographic examination, were noted.