Gherman Robert B, Chauhan Suneet, Ouzounian Joseph G, Lerner Henry, Gonik Bernard, Goodwin T Murphy
Division of Maternal/Fetal Medicine, Department of Obstetrics and Gynecology, Prince George's Hospital Center, Cheverly, MD, USA.
Am J Obstet Gynecol. 2006 Sep;195(3):657-72. doi: 10.1016/j.ajog.2005.09.007. Epub 2006 Apr 21.
Much of our understanding and knowledge of shoulder dystocia has been blurred by inconsistent and scientific studies that are of limited scientific quality. In an evidence-based format, we sought to answer the following questions: (1) Is shoulder dystocia predictable? (2) Can shoulder dystocia be prevented? (3) When shoulder dystocia does occur, what maneuvers should be performed? and (4) What are the sequelae of shoulder dystocia?
Electronic databases, including PUBMED and the Cochrane Database, were searched using the key word "shoulder dystocia." We also performed a manual review of articles included in the bibliographies of these selected articles to further define articles for review. Only those articles published in the English language were eligible for inclusion.
There is a significantly increased risk of shoulder dystocia as birth weight linearly increases. From a prospective point of view, however, prepregnancy and antepartum risk factors have exceedingly poor predictive value for the prediction of shoulder dystocia. Late pregnancy ultrasound likewise displays low sensitivity, decreasing accuracy with increasing birth weight, and an overall tendency to overestimate the birth weight. Induction of labor for suspected fetal macrosomia has not been shown to alter the incidence of shoulder dystocia among nondiabetic patients. The concept of prophylactic cesarean delivery as a means to prevent shoulder dystocia and therefore avoid brachial plexus injury has not been supported by either clinical or theoretic data. Although many maneuvers have been described for the successful alleviation of shoulder dystocia, there have been no randomized controlled trials or laboratory experiments that have directly compared these techniques. Despite the introduction of ancillary obstetric maneuvers, such as McRoberts maneuver and a generalized trend towards the avoidance of fundal pressure, it has been shown that the rate of shoulder-dystocia associated brachial plexus palsy has not decreased. The simple occurrence of a shoulder dystocia event before any iatrogenic intervention may be associated with brachial plexus injury.
For many years, long-standing opinions based solely on empiric reasoning have dictated our understanding of the detailed aspects of shoulder dystocia prevention and management. Despite its infrequent occurrence, all healthcare providers attending pregnancies must be prepared to handle vaginal deliveries complicated by shoulder dystocia.
许多关于肩难产的理解和认识因质量有限、缺乏一致性的科学研究而变得模糊不清。我们以循证医学的形式，试图回答以下问题：（1）肩难产可预测吗？（2）肩难产能预防吗？（3）当肩难产发生时，应采取哪些手法？（4）肩难产的后遗症有哪些？
使用关键词“肩难产”检索包括PUBMED和Cochrane数据库在内的电子数据库。我们还对手动检索这些所选文章参考文献中包含的文章进行了回顾，以进一步确定纳入综述的文章。仅纳入以英文发表的文章。
随着出生体重呈线性增加，肩难产的风险显著增加。然而，从前瞻性角度来看，孕前和产前风险因素对肩难产的预测价值极低。孕晚期超声同样显示敏感性较低，随着出生体重增加准确性下降，且总体上有高估出生体重的倾向。对于疑似巨大儿引产，未显示能改变非糖尿病患者肩难产的发生率。预防性剖宫产作为预防肩难产从而避免臂丛神经损伤的手段这一概念，未得到临床或理论数据的支持。尽管已描述了许多成功缓解肩难产的手法，但尚无直接比较这些技术的随机对照试验或实验室实验。尽管引入了诸如麦罗伯茨手法等辅助产科手法以及普遍避免宫底加压的趋势，但已表明与肩难产相关的臂丛神经麻痹发生率并未降低。在任何医源性干预之前单纯发生肩难产事件可能与臂丛神经损伤有关。
多年来，仅基于经验推理的长期观点主导了我们对肩难产预防和管理细节的理解。尽管其发生率较低，但所有参与妊娠护理的医疗服务提供者都必须做好处理并发肩难产的阴道分娩的准备。
