Spain Janine E, Frey Heather A, Tuuli Methodius G, Colvin Ryan, Macones George A, Cahill Alison G
Department of Obstetrics and Gynecology, Washington University in St. Louis School of Medicine, St. Louis, MO.
Department of Obstetrics and Gynecology, Washington University in St. Louis School of Medicine, St. Louis, MO.
Am J Obstet Gynecol. 2015 Mar;212(3):353.e1-5. doi: 10.1016/j.ajog.2014.10.001. Epub 2014 Oct 5.
We sought to examine neonatal morbidity associated with different maneuvers used among term patients who experience a shoulder dystocia.
We conducted a retrospective cohort study of all women who experienced a clinically diagnosed shoulder dystocia at term requiring obstetric maneuvers at a single tertiary care hospital from 2005 through 2008. We excluded women with major fetal anomaly, intrauterine death, multiple gestation, and preterm. Women exposed to Rubin maneuver, Wood's screw maneuver, or delivery of the posterior arm were compared to women delivered by McRoberts/suprapubic pressure only, which served as the reference group. The primary outcome was a composite morbidity of neonatal injury (defined as clavicular or humeral fracture or brachial plexus injury) and neonatal depression (defined as Apgar <7 at 5 minutes, arterial cord pH <7.1, continuous positive airway pressure use, intubation, or respiratory distress). Logistic regression was used to adjust for nulliparity and duration of shoulder dystocia, defined as time from delivery of fetal head to delivery of shoulders.
Among the 231 women who met inclusion criteria, 135 were delivered by McRoberts/suprapubic pressure alone (57.9%), 83 women were exposed to Rubin maneuver, 53 women were exposed to Wood's screw, and 36 women were exposed to delivery of posterior arm. Individual maneuvers were not associated with composite morbidity, neonatal injury, or neonatal depression after adjusting for nulliparity and duration of shoulder dystocia.
We found no association between shoulder dystocia maneuvers and neonatal morbidity after adjusting for duration, a surrogate for severity. Our results demonstrate that clinicians should utilize the maneuver most likely to result in successful delivery.
我们试图研究足月儿发生肩难产时采用不同手法与新生儿发病率之间的关系。
我们对2005年至2008年在一家三级医疗中心因临床诊断为足月儿肩难产而需要产科手法操作的所有女性进行了一项回顾性队列研究。我们排除了有严重胎儿畸形、宫内死亡、多胎妊娠和早产的女性。将采用鲁宾手法、伍德螺旋手法或娩出后臂的女性与仅采用麦罗伯茨手法/耻骨上加压的女性进行比较，后者作为参照组。主要结局是新生儿损伤（定义为锁骨或肱骨骨折或臂丛神经损伤）和新生儿窒息（定义为5分钟时阿氏评分<7、脐动脉血pH<7.1、使用持续气道正压通气、插管或呼吸窘迫）的综合发病率。采用逻辑回归分析对初产情况和肩难产持续时间（定义为从胎头娩出到胎肩娩出的时间）进行校正。
在符合纳入标准的231名女性中，135名仅通过麦罗伯茨手法/耻骨上加压分娩（57.9%），83名女性采用了鲁宾手法，53名女性采用了伍德螺旋手法，36名女性娩出了后臂。在校正初产情况和肩难产持续时间后，单独的手法操作与综合发病率、新生儿损伤或新生儿窒息均无关联。
在校正作为严重程度替代指标的持续时间后，我们发现肩难产手法与新生儿发病率之间无关联。我们的结果表明，临床医生应采用最有可能成功分娩的手法。
