Epidemiology Branch, the Biostatistics and Bioinformatics Branch, and Glotech, Inc, Division of Intramural Population Health Research, and the Pregnancy and Perinatology Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland; the Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Thomas Jefferson University, Philadelphia, Pennsylvania; and the Division of Education & Research, Department of Obstetrics and Gynecology, Christiana Care Health System, Newark, Delaware.
Obstet Gynecol. 2014 Jul;124(1):57-67. doi: 10.1097/AOG.0000000000000278.
To assess neonatal and maternal outcomes when the second stage of labor was prolonged according to American College of Obstetricians and Gynecologists guidelines.
Electronic medical record data from a retrospective cohort (2002-2008) from 12 U.S. clinical centers (19 hospitals), including 43,810 nulliparous and 59,605 multiparous singleton deliveries at 36 weeks of gestation or greater, vertex presentation, who reached 10-cm cervical dilation were analyzed. Prolonged second stage was defined as: nulliparous women with epidural greater than 3 hours and without greater than 2 hours and multiparous women with epidural greater than 2 hours and without greater than 1 hour. Maternal and neonatal outcomes were compared and adjusted odds ratios calculated controlling for maternal race, body mass index, insurance, and region.
Prolonged second stage occurred in 9.9% and 13.9% of nulliparous and 3.1% and 5.9% of multiparous women with and without an epidural, respectively. Vaginal delivery rates with prolonged second stage compared with within guidelines were 79.9% compared with 97.9% and 87.0% compared with 99.4% for nulliparous women with and without epidural, respectively, and 88.7% compared with 99.7% and 96.2% compared with 99.9% for multiparous women with and without epidural, respectively (P<.001 for all comparisons). Prolonged second stage was associated with increased chorioamnionitis and third-degree or fourth-degree perineal lacerations. Neonatal morbidity with prolonged second stage included sepsis in nulliparous women (with epidural: 2.6% compared with 1.2% [adjusted odds ratio (OR) 2.08, 95% confidence interval (CI) 1.60-2.70]; without epidural: 1.8% compared with 1.1% [adjusted OR 2.34, 95% CI 1.28-4.27]); asphyxia in nulliparous women with epidural (0.3% compared with 0.1% [adjusted OR 2.39, 95% CI 1.22-4.66]) and perinatal mortality without epidural (0.18% compared with 0.04% for nulliparous women [adjusted OR 5.92, 95% CI 1.43-24.51]); and 0.21% compared with 0.03% for multiparous women (adjusted OR 6.34, 95% CI 1.32-30.34). However, among the offspring of women with epidurals whose second stage was prolonged (3,533 nulliparous and 1,348 multiparous women), there were no cases of hypoxic-ischemic encephalopathy or perinatal death.
Benefits of increased vaginal delivery should be weighed against potential small increases in maternal and neonatal risks with prolonged second stage.
: II.
根据美国妇产科医师学会的指南，评估第二产程延长时的母婴结局。
对来自美国 12 个临床中心（19 家医院）的回顾性队列的电子病历数据（2002-2008 年）进行分析，包括 43810 名初产妇和 59605 名经产妇，均为单胎妊娠，孕周 36 周或以上，头位，宫颈扩张达 10cm。第二产程延长定义为：硬膜外麻醉的初产妇产程大于 3 小时且无大于 2 小时，经产妇产程大于 2 小时且无大于 1 小时。比较了产妇和新生儿的结局，并在控制了产妇种族、体重指数、保险和地区等因素后计算了调整后的优势比。
第二产程延长在硬膜外麻醉的初产妇和经产妇中分别占 9.9%和 13.9%和 3.1%和 5.9%，无硬膜外麻醉。与指南内相比，第二产程延长的阴道分娩率分别为 79.9%和 97.9%和 87.0%和 99.4%，初产妇和经产妇的无硬膜外麻醉率分别为 88.7%和 99.7%和 96.2%和 99.9%（所有比较均<.001）。第二产程延长与绒毛膜羊膜炎和三度或四度会阴裂伤有关。第二产程延长的新生儿并发症包括初产妇的败血症（硬膜外麻醉：2.6%比 1.2%[调整优势比（OR）2.08，95%置信区间（CI）1.60-2.70]；无硬膜外麻醉：1.8%比 1.1%[调整 OR 2.34，95% CI 1.28-4.27]）、初产妇硬膜外麻醉的窒息（0.3%比 0.1%[调整 OR 2.39，95% CI 1.22-4.66]）和无硬膜外麻醉的围产儿死亡率（0.18%比 0.04%）。初产妇（调整 OR 5.92，95% CI 1.43-24.51）和经产妇（0.21%比 0.03%）（调整 OR 6.34，95% CI 1.32-30.34）。然而，在接受硬膜外麻醉且第二产程延长的产妇的婴儿中（3533 名初产妇和 1348 名经产妇），没有发生缺氧缺血性脑病或围产儿死亡。
在增加阴道分娩的益处与第二产程延长可能带来的母婴风险增加之间，应权衡利弊。
Ⅱ级。
