Shoulder Dystocia

肩难产
  • 文章类型: Journal Article
    背景:围产期窒息是新生儿发病和死亡的主要原因之一。在中度和重度窒息病例中,随后可能出现一种称为缺氧缺血性脑病(HIE)和相关的永久性神经系统疾病.由于窒息的多因素病因,这可能很难预防,但是在足月新生儿中,治疗冷却可用于预防或减少永久性脑损伤。这项研究的目的是评估中度和重度HIE的不同产前和分娩相关危险因素的重要性以及治疗性低温的需要。
    方法:我们在2013-2017年期间在赫尔辛基大学地区医院进行了一项回顾性配对病例对照研究。包括患有中度或重度HIE和需要治疗性低温的新生儿。使用ICD代码P91.00,P91.01和P91.02从医院数据库中识别出它们。对于每个需要治疗性低温的新生儿,按性别选择连续的单胎新生儿,胎儿表现,分娩医院,选择分娩方式作为对照。计算产科和分娩危险因素与HIE发展之间的赔率比(OR)。
    结果:88例具有匹配对照的病例在研究期间符合纳入标准。病例和对照组的母婴特征相似,但吸烟在病例中更为常见(aOR1.46,CI1.14-1.64,p=0.003)。先兆子痫的发病率,糖尿病和宫内生长受限组相等.引产(aOR3.08,CI1.18-8.05,p=0.02)和产科紧急情况(aOR3.51,CI1.28-9.60,p=0.015)在病例组中更为常见。在第二产程或分娩镇痛的持续时间中未发现差异。
    结论:吸烟,引产和任何产科急诊,尤其是肩难产,增加HIE的风险和治疗性低温的需要。引产的决定需要仔细权衡,因为产妇吸烟和产科急症很难由临床医生控制。
    BACKGROUND: Peripartum asphyxia is one of the main causes of neonatal morbidity and mortality. In moderate and severe cases of asphyxia, a condition called hypoxic-ischemic encephalopathy (HIE) and associated permanent neurological morbidities may follow. Due to the multifactorial etiology of asphyxia, it may be difficult prevent, but in term neonates, therapeutic cooling can be used to prevent or reduce permanent brain damage. The aim of this study was to assess the significance of different antenatal and delivery related risk factors for moderate and severe HIE and the need for therapeutic hypothermia.
    METHODS: We conducted a retrospective matched case-control study in Helsinki University area hospitals during 2013-2017. Newborn singletons with moderate or severe HIE and the need for therapeutic hypothermia were included. They were identified from the hospital database using ICD-codes P91.00, P91.01 and P91.02. For every newborn with the need for therapeutic hypothermia the consecutive term singleton newborn matched by gender, fetal presentation, delivery hospital, and the mode of delivery was selected as a control. Odds ratios (OR) between obstetric and delivery risk factors and the development of HIE were calculated.
    RESULTS: Eighty-eight cases with matched controls met the inclusion criteria during the study period. Maternal and infant characteristics among cases and controls were similar, but smoking was more common among cases (aOR 1.46, CI 1.14-1.64, p = 0.003). The incidence of preeclampsia, diabetes and intrauterine growth restriction in groups was equal. Induction of labour (aOR 3.08, CI 1.18-8.05, p = 0.02) and obstetric emergencies (aOR 3.51, CI 1.28-9.60, p = 0.015) were more common in the case group. No difference was detected in the duration of the second stage of labour or the delivery analgesia.
    CONCLUSIONS: Smoking, induction of labour and any obstetric emergency, especially shoulder dystocia, increase the risk for HIE and need for therapeutic hypothermia. The decisions upon induction of labour need to be carefully weighed, since maternal smoking and obstetric emergencies can hardly be controlled by the clinician.
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  • 文章类型: Journal Article
    背景:患有妊娠糖尿病(DIP)的澳大利亚原住民和托雷斯海峡岛民妇女更有可能出现高于目标范围的血糖水平,因此,他们的婴儿胎儿过度生长的风险更高。肩难产,定义为在需要产科操作的头部出生后胎儿肩自然出生失败,是与DIP和胎儿大小密切相关的产科急诊。这项研究的目的是调查DIP母亲所生的原住民婴儿的肩难产的流行病学。
    方法:按原住民身份分层,比较了有和没有DIP的妇女并发肩难产的出生特征,并描述了肩难产的发生率和时间趋势。比较了DIP女性对旨在预防肩难产的指南的依从性。使用逻辑回归估计来计算与DIP相关的肩难产的人口归因分数(PAF),并估计出生体重>3kg的DIP母亲所生的婴儿的肩难产概率。
    结果:患有DIP的母亲所生的土著婴儿阴道分娩的肩难产率是非土著婴儿的两倍(6.3%vs3.2%,p<0.001),随着时间的推移没有改善。妊娠合并肩难产的糖尿病土著母亲更有可能有肩难产史(13.1%vs6.3%,p=0.032)。在糖尿病和出生体重>4.5kg的孕妇中,指南推荐的选择性剖腹产率在土著妇女中更低(28.6%vs43.1%,p=0.004)。PAFs表明,土著妇女中13.4%(95%CI:9.7%-16.9%)的肩难产病例(非土著妇女中为2.7%(95%CI:2.1%-3.4%))归因于DIP。出生体重>3kg时,患有DIP的土著母亲所生的婴儿的肩难产概率更高。
    结论:患有DIP的土著母亲患肩难产的风险更高,出生体重与肩难产之间的关联更强。许多病例反复出现。在临床实践中和咨询妇女时应考虑这些因素。
    BACKGROUND: Australian Aboriginal and Torres Strait Islander women with diabetes in pregnancy (DIP) are more likely to have glycaemic levels above the target range, and their babies are thus at higher risk of excessive fetal growth. Shoulder dystocia, defined by failure of spontaneous birth of fetal shoulder after birth of the head requiring obstetric maneuvers, is an obstetric emergency that is strongly associated with DIP and fetal size. The aim of this study was to investigate the epidemiology of shoulder dystocia in Aboriginal babies born to mothers with DIP.
    METHODS: Stratifying by Aboriginal status, characteristics of births complicated by shoulder dystocia in women with and without DIP were compared and incidence and time-trends of shoulder dystocia were described. Compliance with guidelines aiming at preventing shoulder dystocia in women with DIP were compared. Post-logistic regression estimation was used to calculate the population attributable fractions (PAFs) for shoulder dystocia associated with DIP and to estimate probabilities of shoulder dystocia in babies born to mothers with DIP at birthweights > 3 kg.
    RESULTS: Rates of shoulder dystocia from vaginal births in Aboriginal babies born to mothers with DIP were double that of their non-Aboriginal counterparts (6.3% vs 3.2%, p < 0.001), with no improvement over time. Aboriginal mothers with diabetes whose pregnancies were complicated by shoulder dystocia were more likely to have a history of shoulder dystocia (13.1% vs 6.3%, p = 0.032). Rates of guideline-recommended elective caesarean section in pregnancies with diabetes and birthweight > 4.5 kg were lower in the Aboriginal women (28.6% vs 43.1%, p = 0.004). PAFs indicated that 13.4% (95% CI: 9.7%-16.9%) of shoulder dystocia cases in Aboriginal (2.7% (95% CI: 2.1%-3.4%) in non-Aboriginal) women were attributable to DIP. Probability of shoulder dystocia among babies born to Aboriginal mothers with DIP was higher at birthweights > 3 kg.
    CONCLUSIONS: Aboriginal mothers with DIP had a higher risk of shoulder dystocia and a stronger association between birthweight and shoulder dystocia. Many cases were recurrent. These factors should be considered in clinical practice and when counselling women.
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  • 文章类型: Journal Article
    目的:通过使用磁共振成像(MRI)评估胎儿体重(EFW)作为二线确认成像来模拟Boulvain试验的结果。
    方法:来自Boulvain试验和PREMACRO(预测MACROsomia)研究的数据用于模拟1000名患者的试验。Boulvain的试验将引产(IOL)与疑似巨大儿的期待管理进行了比较,而PREMACRO研究比较了超声-EFW(US-EFW)和MRI-EFW在预测出生体重方面的表现。主要结果是明显的肩难产(SD)的发生率。剖腹产(CD),高胆红素血症(HB),选择妊娠<39周(WG)的IOL作为次要结局。对Boulvain试验进行了亚组分析,以估计两个研究组的真阳性和假阳性组的主要和次要结局的发生率。灵敏度,特异性,阳性和阴性预测值(PPV,NPV)用于通过MRI-EFW预测36个WG的巨大儿,并为每个结果构建决策树。
    结果:在PREMACRO试验中US-EFW预测巨大儿的PPV为56.3%。MRI-EFW作为预测工具优于US-EFW,导致假阳性病例的诱导率较低。使用MRI-EFW作为二线测试重复Boulvain的试验将导致类似的SD率(相对风险[RR]:0.36),CD(RR:0.84),和新生儿HB(RR:2.6),就像最初的审判一样。增加MRI-EFW的敏感性和特异性导致SD的相对风险与Boulvain的试验相似,但随着IOL<39WG的发生率降低,改善CD的RR有利于IOL。我们发现US-EFW和MRI-EFW的IOL率与SD发生率呈负相关,虽然IOL的总体发生率,CD,根据MRI得出的胎儿体重估计值,新生儿HB会更低。
    结论:MRI-EFW诊断巨大儿的准确性优于US-EFW可能导致IOL的发生率较低,而不会损害干预措施的相对优势,但未能证明使用MRI-EFW作为二线测试来证明复制原始试验的显着益处。
    OBJECTIVE: To simulate the outcomes of Boulvain\'s trial by using magnetic resonance imaging (MRI) for estimated fetal weight (EFW) as a second-line confirmatory imaging.
    METHODS: Data derived from the Boulvain\'s trial and the study PREMACRO (PREdict MACROsomia) were used to simulate a 1000-patient trial. Boulvain\'s trial compared induction of labor (IOL) to expectant management in suspected macrosomia, whereas PREMACRO study compared the performance of ultrasound-EFW (US-EFW) and MRI-EFW in the prediction of birthweight. The primary outcome was the incidence of significant shoulder dystocia (SD). Cesarean delivery (CD), hyperbilirubinemia (HB), and IOL at < 39 weeks of gestation (WG) were selected as secondary outcomes. A subgroup analysis of the Boulvain\'s trial was performed to estimate the incidence of the primary and secondary outcomes in the true positive and false positive groups for the two study arms. Sensitivity, specificity, positive and negative predictive values (PPV, NPV) for the prediction of macrosomia by MRI-EFW at 36 WG were calculated, and a decision tree was constructed for each outcome.
    RESULTS: The PPV of US-EFW for the prediction of macrosomia in the PREMACRO trial was 56.3 %. MRI-EFW was superior to US-EFW as a predictive tool resulting in lower rates of induction for false-positive cases. Repeating Boulvain\'s trial using MRI-EFW as a second-line test would result in similar rates of SD (relative risk [RR]:0.36), CD (RR:0.84), and neonatal HB (RR:2.6), as in the original trial. Increasing the sensitivity and specificity of MRI-EFW resulted in a similar relative risk for SD as in Boulvain\'s trial, but with reduced rates of IOL < 39 WG, and improved the RR of CD in favor of IOL. We found an inverse relationship between IOL rate and incidence of SD for both US-EFW and MRI-EFW, although overall rates of IOL, CD, and neonatal HB would be lower with MRI-derived estimates of fetal weight.
    CONCLUSIONS: The superior accuracy of MRI-EFW over US-EFW for the diagnosis of macrosomia could result in lower rates of IOL without compromising the relative advantages of the intervention but fails to demonstrate a significant benefit to justify a replication of the original trial using MRI-EFW as a second-line test.
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  • 文章类型: Randomized Controlled Trial
    这项研究分析了使用虚拟现实(VR)训练方式处理肩难产(SD)的改良产科高级生命支持(ALSO)算法(HELP-RER)的依从性。次要结果是培训后诊断至分娩时间的改善,人类技能因素(HuFSHI),和感知任务负载指数(TLX)。前瞻性,病例控制,单盲,1:1随机交叉研究。向参与者显示了SD管理的360°VR视频。对照组从理论上进行了简要介绍。两组在基线和基于人体模型的训练后都进行了HuFSHI和HELP-RER评分评估。然后施用TLX问卷。经过12周的冲洗阶段,我们进行了交叉,和小组交换。在第一次培训期间,两组之间的结果相似。然而,交叉后,对照组的HELP-RER评分明显较高[7vs.6.5;(p=0.01)],诊断至分娩时间较短[85.5vs.99s;(p=0.02)],和TLX得分[57vs.68;(p=0.04)]。在多元线性回归分析中,VR训练与HELP-RER评分的提高独立相关(p=0.003)。两组之间的HuFSHI评分相当。我们的数据证明了对护理人员进行SD管理的VR模拟训练的可行性。考虑到常见高保真训练的缺点,基于VR的模拟提供了新的视角。
    This study analyzed the adherence to the modified Advanced Life Support in Obstetrics (ALSO) algorithm (HELP-RER) for handling shoulder dystocia (SD) using a virtual reality (VR) training modality. Secondary outcomes were improvements in the post-training diagnosis-to-delivery time, human skills factors (HuFSHI), and perceived task-load index (TLX). Prospective, case-control, single-blind, 1:1 randomized crossover study. Participants were shown a 360° VR video of SD management. The control group was briefed theoretically. Both groups underwent HuFSHI and HELP-RER score assessments at baseline and after the manikin-based training. The TLX questionnaire was then administered. After a washout phase of 12 weeks, we performed a crossover, and groups were switched. There were similar outcomes between groups during the first training session. However, after crossover, the control group yielded significantly higher HELP-RER scores [7 vs. 6.5; (p = 0.01)], with lower diagnosis-to-delivery-time [85.5 vs. 99 s; (p = 0.02)], and TLX scores [57 vs. 68; (p = 0.04)]. In the multivariable linear regression analysis, VR training was independently associated with improved HELP-RER scores (p = 0.003). The HuFSHI scores were comparable between groups. Our data demonstrated the feasibility of a VR simulation training of SD management for caregivers. Considering the drawbacks of common high-fidelity trainings, VR-based simulations offer new perspectives.
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  • 文章类型: Journal Article
    OBJECTIVE: Large-for-gestational-age (LGA) is associated with several adverse maternal and neonatal outcomes. Although many studies have found that early induction of labor (eIOL) in LGA reduces the incidence of shoulder dystocia (SD), no current guidelines recommend this particular strategy, due to concerns about increased rates of cesarean delivery (CD) and neonatal complications. The purpose of this study was to assess whether the timing of IOL in LGA fetuses affects maternal and neonatal outcomes in a single center; and to combine these results with the evidence reported in the literature.
    METHODS: This study comprised two parts. The first was a retrospective cohort study that included: consecutive patients with singleton pregnancy, an estimated fetal weight (EFW) ≥90th percentile on ultrasound (US) between 35+0 and 39+0 weeks of gestation (WG), who were eligible for normal vaginal delivery. The second part was a systematic review of literature and meta-analysis that included the results of the first part as well as all previously reported studies that have compared IOL to expectant management in patients with LGA. The perinatal outcomes were CD, operative vaginal delivery (OVD), SD, brachial plexus palsy, anal sphincter injury, postpartum hemorrhage (PPH), APGAR score, umbilical arterial pH, neonatal intensive care unit (NICU) admission, use of continuous positive airway pressure (CPAP), intracranial hemorrhage (ICH), phototherapy, and bone fracture.
    RESULTS: Retrospective cohort: of the 547 patients, 329 (60.1%) were induced and 218 (39.9%) entered spontaneous labor. Following covariate balancing, CD was significantly higher in the IOL group in comparison to the spontaneous labor group. This difference only became apparent beyond 40WG (hazard ratio: 1.9, p=0.030). The difference between both groups for shoulder dystocia was not statistically significant. Systematic review and metanalysis: 17 studies were included in addition to our own results giving a total sample size of 111,300 participants. When IOL was performed <40+0WG, the risk for SD was significantly lower in the IOL group (OR: 0.64, 95%CI: 0.42-0.98, I2 =19%). There was no significant difference in CD rate between IOL and expectant management after pooling the results of these 17 studies. However, when removing the studies in which IOL was done exclusively before 40+0WG, the risk for CD in the remaining studies (IOL not exclusively <40+0WG) was significantly higher in the IOL group (odds ratio [OR]: 1.46, 95% confidence interval [95%CI]: 1.02-2.09, I2 =56%). There were no statistically significant differences between IOL and expectant management for the remaining perinatal outcomes. Nulliparity, history of CD, and low Bishop score but not methods of induction were independent risk factors for intrapartum CD in patients who were induced for LGA.
    CONCLUSIONS: Timing of IOL in patients with suspected macrosomia significantly impacts perinatal adverse outcomes. IOL has no impact on rates of SD but does increase CD when considered irrespective of gestational age, but it may decrease the risk of SD without increasing the risk of other adverse maternal outcomes, in particular cesarean section when performed before 40+0 WG. (GRADE: Low/Very low). This article is protected by copyright. All rights reserved.
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  • 文章类型: Journal Article
    背景:肩难产是一种罕见的产科并发症,复发的风险对于规划未来的分娩很重要。
    方法:我们的研究目的是评估肩难产复发的发生率和危险因素,并确定在随后的阴道分娩中有高复发风险的妇女。研究设计是一项全国性的基于注册的研究,包括2007-2017年期间丹麦医学出生登记处和国家患者登记处的数据。纳入了头部表现为单胎胎儿的未产妇女,以分析指数和随后分娩的危险因素。
    结果:在研究期间,据报道,肩难产6002例,阴道分娩妇女的总发生率为1.2%。在222225名阴道分娩的未产妇女中,肩难产复杂2209例(1.0%)分娩。在索引分娩中,有1106例(50.1%)的肩难产妇女随后出生,其中837例(77.8%)阴道分娩。据报道,与没有肩难产史的女性相比,肩难产复发60例(7.2%),风险增加了6倍(风险比[RR]5.70,95%置信区间[CI]:4.41至7.38;校正RR3.06,95%CI:2.03至4.68)。低产妇身高是肩难产复发的重要危险因素。在随后的交付中,复发的重要危险因素是出生体重>4000g,从指数到后续分娩的胎儿体重差异超过250克,用催产素刺激和手术阴道分娩。在肩难产后的后续妊娠中,接受计划剖宫产的女性(n=176)的特征是年龄更高,随后妊娠中糖尿病患病率更高.此外,他们更经常经历手术阴道分娩,严重的会阴撕裂,和严重的新生儿并发症在指数分娩。
    结论:阴道分娩的未分娩妇女的肩难产发生率为1.0%,其中约50%的人随后分娩,其中78%的人随后阴道分娩,复发风险为7.2%。复发的重要危险因素是产妇身高较低,从指数到随后的分娩和手术阴道分娩,出生体重增加≥250g。
    BACKGROUND: Shoulder dystocia is a rare obstetric complication, and the risk of recurrence is important for planning future deliveries.
    METHODS: The objectives of our study were to estimate the incidence and risk factors for recurrence of shoulder dystocia and to identify women at high risk of recurrence in a subsequent vaginal delivery. The study design was a nationwide register-based study including data from the Danish Medical Birth Registry and National Patient Register in the period 2007-2017. Nulliparous women with a singleton fetus in cephalic presentation were included for analysis of risk factors in index and subsequent delivery.
    RESULTS: During the study period, 6002 cases of shoulder dystocia were reported with an overall incidence among women with vaginal delivery of 1.2%. Among 222 225 nulliparous women with vaginal births, shoulder dystocia complicated 2209 (1.0%) deliveries. A subsequent birth was registered in 1106 (50.1%) of the women with shoulder dystocia in index delivery of which 837 (77.8%) delivered vaginally. Recurrence of shoulder dystocia was reported in 60 (7.2%) with a six-fold increased risk compared with women without a prior history of shoulder dystocia (risk ratio [RR] 5.70, 95% confidence interval [CI]: 4.41 to 7.38; adjusted RR 3.06, 95% CI: 2.03 to 4.68). Low maternal height was a significant risk factor for recurrence of shoulder dystocia. In the subsequent delivery, significant risk factors for recurrence were birthweight >4000 g, positive fetal weight difference exceeding 250 g from index to subsequent delivery, stimulation with oxytocin and operative vaginal delivery. In the subsequent pregnancy following shoulder dystocia, women who underwent a planned cesarean (n = 176) were characterized by more advanced age and a higher prevalence of diabetes in the subsequent pregnancy. Furthermore, they had more often experienced operative vaginal delivery, severe perineal lacerations, and severe neonatal complications at the index delivery.
    CONCLUSIONS: The incidence of shoulder dystocia among nulliparous women with vaginal delivery was 1.0% with a 7.2% risk of recurrence in a population where about 50% had a subsequent birth and of these 78% had subsequent vaginal delivery. Important risk factors for recurrence were low maternal height, increase of birthweight ≥250 g from index to subsequent delivery and operative vaginal delivery.
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  • 文章类型: Journal Article
    背景:肩难产是一种相对罕见但严重的分娩相关紧急情况。
    目的:通过高保真模拟训练,探索肩难产管理技能的提高和保留。
    方法:SAFE(模拟高保真)研究是一项前瞻性队列研究,利用高保真分娩模拟器。注册助产士和最后一年的助产士学生被邀请参加为期一天的研讨会,每6个月一次。有一个30分钟的初步评估,30分钟的理论和实践培训,和30分钟的训练后评估肩难产管理。比较了预定结果的训练前和训练后的值。在每个研讨会上,我们评估了成功的模拟分娩的比例,管理肩难产的动作表现,头对身体的出生时间,胎头牵引力,沟通的质量,对出生时间的感知,和自我报告的信心水平。
    结果:基线研讨会招募了101名参与者,这些参与者显示成功模拟分娩的比例显着增加(8.9%vs93.1%),演习得分增加了两倍到三倍,通信,训练后的信心。那些培训前能力和信心水平较低的人在基线培训后的改善程度最大。保留了一些动作,6个月的沟通技巧和信心。随着时间的推移,胎头牵引力没有减少。那些在初次培训之前精通的人保留了下来,并在6个月的随访中表现最佳。
    结论:SAFE研究发现,在6个月后保留的初始高保真模拟训练后,技能和信心有了显着改善。
    BACKGROUND: Shoulder dystocia is a relatively uncommon but serious childbirth-related emergency.
    OBJECTIVE: To explore the improvement and retention of skills in shoulder dystocia management through high-fidelity simulation training.
    METHODS: The SAFE (SimulAtion high-FidElity) study was a prospective cohort study that utilised a high-fidelity birth simulator. Registered midwives and final year midwifery students were invited to participate in a one-day workshop at 6-monthly intervals. There was a 30-minute initial assessment, a 30-minute theoretical and hands-on training, and a 30-minute post-training assessment on shoulder dystocia management. Pre-training and post-training values for the predetermined outcomes were compared. In each workshop we assessed the proportion of successful simulated births, the performance of manoeuvres to manage shoulder dystocia, the head-to-body birth time, the fetal head traction force, the quality of communication, the perception of time-to-birth, and the self-reported confidence levels.
    RESULTS: The baseline workshop recruited 101 participants that demonstrated a significant increase in the proportion of successful simulated births (8.9% vs 93.1%), and a two-fold to three-fold increase in the score of manoeuvres, communication, and confidence after training. Those with low pre-training levels of competency and confidence improved the most post-training at baseline. There was a retention of manoeuvres, communication skills and confidence at 6 months. There was no reduction in fetal head traction force over time. Those being proficient before initial training retained and performed best at the 6-month follow-up.
    CONCLUSIONS: The SAFE study found a significant improvement in skills and confidence after the initial high-fidelity simulation training that were retained after 6 months.
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  • 文章类型: Journal Article
    背景:肩难产是一种严重的产科急症,可引起严重的新生儿和产妇并发症。这项研究旨在评估所进行的产科操作及其频率,成功,以及与产妇和新生儿并发症发生率的关系。
    方法:通过搜索肩难产的ICD-10代码,在2006年至2015年赫尔辛基和Uusimaa医院区的所有分娩中收集了研究人群(n=181352),臂丛神经损伤和锁骨骨折。通过回顾病历确定了肩难产病例(n=537)。将一次或两次手术治疗的肩难产病例与至少三次治疗的病例进行比较。还仔细检查了由566名产妇组成的匹配对照组的医疗记录,其中没有任何上述ICD-10代码。
    结果:使用四种最常见的产科动作(麦克罗伯茨动作,耻骨上压力,旋转机动,后臂的分娩)在研究期间显着增加,个体成功率为61.0%,71.9%,68.1%和84.8%,分别。同时,臂丛神经损伤和新生儿综合发病率从50%下降到24.2%(p=0.02),从91.4%下降到48.5%(p<0.001)。大约75%的手术治疗肩难产病例通过McRoberts手术和/或耻骨上压力解决。但4次最常用的动作均显著增加了累积成功率(P<0.001).不进行任何操作时,臂丛神经损伤和新生儿综合发病率最高(52.9%和97.8%),进行两次操作时最低(43.0%和65.4%)。动作次数的增加(≥3)不会影响孕产妇或新生儿的合并发病率或臂丛神经损伤,但会增加三度或四度撕裂的风险(比值比2.91,95%置信区间1.17至7.24)。
    结论:在研究期间,产科操作的使用增加与新生儿并发症的发生率降低有关;相反,缺乏产科操作与新生儿并发症发生率最高相关.这些强调了教育的重要性,根据国际协议指南进行机动训练和紧急进行肩难产操作。
    BACKGROUND: Shoulder dystocia is a severe obstetric emergency that can cause substantial neonatal and maternal complications. This study aims to assess the performed obstetric maneuvers and their frequency, success, and association with maternal and neonatal complication rates.
    METHODS: The study population was collected among all deliveries in the Hospital District of Helsinki and Uusimaa between 2006 and 2015 (n = 181 352) by searching for ICD-10 codes for shoulder dystocia, brachial plexus injury and clavicle fracture. Shoulder dystocia cases (n = 537) were identified by reviewing the medical records. Shoulder dystocia cases treated with one or two maneuvers were compared with those treated with at least three. Medical records of a matched control group constituting of 566 parturients without any of the forementioned ICD-10 codes were also scrutinized.
    RESULTS: Using the four most common obstetric maneuvers (McRoberts maneuver, suprapubic pressure, rotational maneuvers, the delivery of the posterior arm) significantly increased during the study period with individual success rates of 61.0%, 71.9%, 68.1% and 84.8%, respectively. Concurrently, the rate of brachial plexus injury and combined neonatal morbidity significantly declined from 50% to 24.2% (p = 0.02) and from 91.4% to 48.5% (p < 0.001). Approximately 75% of shoulder dystocia cases treated with maneuvers were resolved by the McRoberts maneuver and/or suprapubic pressure, but each of the four most performed maneuvers significantly increased the cumulative success rate individually and statistically (p < 0.001). The rates of brachial plexus injury and combined neonatal morbidity were at their highest (52.9% and 97.8%) when none of the maneuvers were performed and at their lowest when two maneuvers were performed (43.0% and 65.4%). The increasing number (≥3) of maneuvers did not affect the combined maternal or neonatal morbidity or brachial plexus injury but increased the risk for third- or fourth-degree lacerations (odds ratio 2.91, 95% confidence interval 1.17 to 7.24).
    CONCLUSIONS: The increased use of obstetric maneuvers during the study period was associated with decreasing rates of neonatal complications; conversely, the lack of obstetric maneuvers was associated with the highest rate of neonatal complications. These emphasize the importance of education, maneuver training and urgently performing shoulder dystocia maneuvers according to the international protocol guidelines.
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  • 文章类型: Journal Article
    背景:先前的研究已将肩难产的病史确定为肩难产的重要危险因素,但是对肩难产严重程度的研究很少。尚不清楚肩难产是否会在世代之间传递。我们旨在通过严重程度评估同一女性以及母亲和父亲两代人之间的肩难产复发风险。我们还评估了肩难产后第二次分娩和计划剖宫产的可能性。
    方法:这是一项基于人群的队列研究,使用挪威医学出生登记处的数据。为了研究同一个母亲的复发,我们确定了1091067对第一和第二,第二和第三,第三和第四出生在同一个母亲。为了研究代际复发,我们在824323对母子对和614663对父子对中确定了作为新生儿和母亲或父亲的个体.我们使用贝叶斯对数二项多水平回归计算95%可信区间的相对风险(RR)。
    结果:在同一女性的后续分娩中,在调整可能的混杂因素后,未调整的复发RR分别为7.05(95%可信区间6.39-7.79)和2.99(2.71-3.31),包括目前的出生体重。暴露或结果为严重肩难产的RRs较高。严重的肩难产作为暴露和结果,未调整和调整后的RR分别为20.42(14.25-29.26)和6.29(4.41-8.99),分别。重度和轻度肩难产的妇女和没有肩难产的妇女的后续分娩率分别为71.1、68.9和69.0%,分别。然而,无肩难产者在后续分娩中计划剖宫产率,轻度和重度分别为1.3%,5.2%和16.0%,分别。在母方,未调整的代际复发RR在父方为2.82(2.25-3.54)和1.41(1.05-1.90)。相应的调整后汇率为1.90(1.51-2.40)和1.19(0.88-1.61),分别。
    结论:我们发现肩难产的复发风险很大,尤其严重,随后在同一个女人的分娩中。母亲的代际复发风险高于父亲。有肩难产史的妇女更经常计划剖宫产。
    BACKGROUND: Previous studies have established a history of shoulder dystocia as an important risk factor for shoulder dystocia, but studies on shoulder dystocia by severity are scarce. It is unknown if shoulder dystocia tends to be passed on between generations. We aimed to assess the recurrence risk of shoulder dystocia by severity in the same woman and between generations on both the maternal and paternal side. We also assessed the likelihood of a second delivery and planned cesarean section after shoulder dystocia.
    METHODS: This was a population-based cohort study, using data from the Medical Birth Registry of Norway. To study recurrence in the same mother, we identified 1 091 067 pairs of first and second, second and third, and third and fourth births in the same mother. To study intergenerational recurrence, we identified an individual both as a newborn and as a mother or father in 824 323 mother-offspring pairs and 614 663 father-offspring pairs. We used Bayesian log-binomial multilevel regression to calculate relative risks (RR) with 95% credible intervals.
    RESULTS: In subsequent deliveries in the same woman the unadjusted RR of recurrence was 7.05 (95% credible interval 6.39-7.79) and 2.99 (2.71-3.31) after adjusting for possible confounders, including current birthweight. The RRs were higher with severe shoulder dystocia as exposure or outcome. With severe shoulder dystocia as both exposure and outcome, unadjusted and adjusted RR was 20.42 (14.25-29.26) and 6.29 (4.41-8.99), respectively. Women with severe and mild shoulder dystocia and those without had subsequent delivery rates of 71.1, 68.9 and 69.0%, respectively. However, the rates of planned cesarean section in subsequent deliveries for those without shoulder dystocia, mild and severe were 1.3, 5.2 and 16.0%, respectively. On the maternal side the unadjusted inter-generational RR of recurrence was 2.82 (2.25-3.54) and 1.41 (1.05-1.90) on the paternal side. Corresponding adjusted RRs were 1.90 (1.51-2.40) and 1.19 (0.88-1.61), respectively.
    CONCLUSIONS: We found a strong recurrence risk of shoulder dystocia, especially severe, in subsequent deliveries in the same woman. The inter-generational recurrence risk was higher on the maternal than paternal side. Women with a history of shoulder dystocia had more often planned cesarean section.
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  • 文章类型: Journal Article
    这项计算研究的目的是研究以新生儿为中心的临床分娩手法对肩难产期间臂丛神经(BP)的影响。肩难产期间,新生儿的前肩阻塞在产妇骨盆的耻骨联合后面,新生儿头部分娩后。这是通过一系列临床输送操作来管理的。这项研究的目的是模拟这些分娩操作,并研究其对新生儿BP应变的影响。使用母亲骨盆和第90百分位新生儿的MADYMO模型,模拟分娩动作和位置,包括单独的产妇骨盆截石术位置,使用各种耻骨上压力(SPPs)进行输送,处于倾斜位置的新生儿,以及在后臂输送操作期间。在这些独立模拟的情景中报告了所得的BP应变(%)以及所需的母体分娩力。单独的截石位作为基线。每次连续的操作都报告了所需的输送力的降低,并导致新生儿BP劳损。随着施加的SPP力的增加,所需的产妇分娩力和新生儿BP应变降低。在斜位观察到分娩力和新生儿血压应变进一步下降。在后臂分娩过程中报告的最低分娩力和新生儿血压紧张。在这项研究中,从改进的计算模型中获得的数据增强了我们对复杂的分娩情况(例如肩难产)中临床操作对新生儿BP应变的影响的理解。
    The purpose of this computational study was to investigate the effects of neonate-focused clinical delivery maneuvers on brachial plexus (BP) during shoulder dystocia. During shoulder dystocia, the anterior shoulder of the neonate is obstructed behind the symphysis pubis of the maternal pelvis, postdelivery of the neonate\'s head. This is managed by a series of clinical delivery maneuvers. The goal of this study was to simulate these delivery maneuvers and study their effects on neonatal BP strain. Using madymo models of a maternal pelvis and a 90th-percentile neonate, various delivery maneuvers and positions were simulated including the lithotomy position alone of the maternal pelvis, delivery with the application of various suprapubic pressures (SPPs), neonate in an oblique position, and during posterior arm delivery maneuver. The resulting BP strain (%) along with the required maternal delivery force was reported in these independently simulated scenarios. The lithotomy position alone served as the baseline. Each of the successive maneuvers reported a decrease in the required delivery force and resulting neonatal BP strain. As the applied SPP force increased (three scenarios simulated), the required maternal delivery force and neonatal BP strain decreased. A further decrease in both delivery force and neonatal BP strain was observed in the oblique position, with the lowest delivery force and neonatal BP strain reported during the posterior arm delivery maneuver. Data obtained from the improved computational models in this study enhance our understanding of the effects of clinical maneuvers on neonatal BP strain during complicated birthing scenarios such as shoulder dystocia.
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