Darmstadt Gary L, Yakoob Mohammad Yawar, Haws Rachel A, Menezes Esme V, Soomro Tanya, Bhutta Zulfiqar A
Department of International Health, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.
BMC Pregnancy Childbirth. 2009 May 7;9 Suppl 1(Suppl 1):S6. doi: 10.1186/1471-2393-9-S1-S6.
Approximately one million stillbirths occur annually during labour; most of these stillbirths occur in low and middle-income countries and are associated with absent, inadequate, or delayed obstetric care. The low proportion of intrapartum stillbirths in high-income countries suggests that intrapartum stillbirths are largely preventable with quality intrapartum care, including prompt recognition and management of intrapartum complications. The evidence for impact of intrapartum interventions on stillbirth and perinatal mortality outcomes has not yet been systematically examined.
We undertook a systematic review of the published literature, searching PubMed and the Cochrane Library, of trials and reviews (N = 230) that reported stillbirth or perinatal mortality outcomes for eight interventions delivered during labour. Where eligible randomised controlled trials had been published after the most recent Cochrane review on any given intervention, we incorporated these new trial findings into a new meta-analysis with the Cochrane included studies.
We found a paucity of studies reporting statistically significant evidence of impact on perinatal mortality, especially on stillbirths. Available evidence suggests that operative delivery, especially Caesarean section, contributes to decreased stillbirth rates. Induction of labour rather than expectant management in post-term pregnancies showed strong evidence of impact, though there was not enough evidence to suggest superior safety for the fetus of any given drug or drugs for induction of labour. Planned Caesarean section for term breech presentation has been shown in a large randomised trial to reduce stillbirths, but the feasibility and consequences of implementing this intervention routinely in low-/middle-income countries add caveats to recommending its use. Magnesium sulphate for pre-eclampsia and eclampsia is effective in preventing eclamptic seizures, but studies have not demonstrated impact on perinatal mortality. There was limited evidence of impact for maternal hyperoxygenation, and concerns remain about maternal safety. Transcervical amnioinfusion for meconium staining appears promising for low/middle income-country application according to the findings of many small studies, but a large randomised trial of the intervention had no significant impact on perinatal mortality, suggesting that further studies are needed.
Although the global appeal to prioritise access to emergency obstetric care, especially vacuum extraction and Caesarean section, rests largely on observational and population-based data, these interventions are clearly life-saving in many cases of fetal compromise. Safe, comprehensive essential and emergency obstetric care is particularly needed, and can make the greatest impact on stillbirth rates, in low-resource settings. Other advanced interventions such as amnioinfusion and hyperoxygenation may reduce perinatal mortality, but concerns about safety and effectiveness require further study before they can be routinely included in programs.
每年约有100万死产发生在分娩过程中；这些死产大多发生在低收入和中等收入国家，且与产科护理缺失、不足或延迟有关。高收入国家分娩期死产比例较低，这表明通过高质量的分娩期护理（包括及时识别和处理分娩期并发症），分娩期死产在很大程度上是可以预防的。关于分娩期干预措施对死产和围产期死亡率影响的证据尚未得到系统研究。
我们对已发表的文献进行了系统综述，检索了PubMed和Cochrane图书馆，查找报告了分娩期间实施的八项干预措施的死产或围产期死亡率结果的试验和综述（N = 230）。对于任何给定干预措施，若在最近一次Cochrane综述之后发表了符合条件的随机对照试验，我们将这些新的试验结果纳入与Cochrane纳入研究的新的荟萃分析中。
我们发现很少有研究报告对围产期死亡率，尤其是死产有统计学显著影响的证据。现有证据表明，手术分娩，尤其是剖宫产，有助于降低死产率。晚期妊娠引产而非期待管理显示出有显著影响的有力证据，不过没有足够证据表明任何一种引产药物对胎儿有更高的安全性。一项大型随机试验表明，足月臀位计划性剖宫产可降低死产率，但在低收入/中等收入国家常规实施该干预措施的可行性和后果为其应用推荐增添了限制条件。硫酸镁用于子痫前期和子痫可有效预防子痫发作，但研究未证明其对围产期死亡率有影响。关于产妇高氧治疗有影响的证据有限，且对产妇安全性仍存在担忧。根据许多小型研究的结果，经宫颈羊膜腔灌注治疗胎粪污染在低收入/中等收入国家应用似乎很有前景，但一项该干预措施的大型随机试验对围产期死亡率无显著影响，这表明还需要进一步研究。
尽管全球呼吁优先提供紧急产科护理，尤其是真空吸引术和剖宫产，这在很大程度上基于观察性和基于人群的数据，但这些干预措施在许多胎儿窘迫病例中显然能挽救生命。在资源匮乏地区，尤其需要安全、全面的基本和紧急产科护理，这对降低死产率可能产生最大影响。其他先进干预措施，如羊膜腔灌注和高氧治疗，可能会降低围产期死亡率，但在它们能够常规纳入项目之前，对其安全性和有效性的担忧需要进一步研究。
