[非巨大儿肩难产的危险因素及临床预测]

Li Na, Li Qiuling, Chang Liang, Liu Caixia

Department of Obstetrics and Gynecology, Shengjing Hospital, China Medical University, Shenyang 110004, China.

Department of Obstetrics and Gynecology, Shengjing Hospital, China Medical University, Shenyang 110004, China. Email:

Zhonghua Fu Chan Ke Za Zhi. 2015 Jan;50(1):17-21.

OBJECTIVE

To investigate the risk factors, clinical prediction and intrapartum management of shoulder dystocia in non-macrosomia.

METHODS

Totally 7 811 cases of vaginal delivery were retrospectively reviewed from Juanary 2009 to December 2013 in Shengjing Hospital. Shoulder dystocia was found in 11 cases (0.14% , 11/7 811), including 1 case of macrosomia and 10 cases of non-macrosomia (shoulder dystocia group). Each non-macrosomia shoulder dystocia case was matched with 10 cases of normal delivery in the same week, which were selected randomly as the control group. The tendency and risk factors of shoulder dystocia in macrosomia and non-macrosomia were analyzed, and the following data between the two groups were compared, including the height of uterus fundus, abdominal circumference of the pregnant woman, the increasing of body mass index (BMI), fetal biparietal diameter (BPD), fetal femur length (FL), duration of every stage of labor, birth weight of the newborn, head circumference and chest circumference of the newborn, Apgar score.

RESULTS

(1) There were 213 macrosomias among the 7 811 vaginal deliveries, with the incidence of 2.73% (213/7 811). Only 1 shoulder dystocia was macrosomia (0.46%, 1/213); while the other 10 cases were non-macrosomia ( 0.13%, 10/7 598). (2) From 2009 to 2013, the macrosomia happened by 24 cases (2.32%, 24/1 034), 42 cases (3.61%, 42/1 164), 46 cases (2.60%, 46/1 772), 62 cases (3.01%, 62/2 060), 39 cases (2.19%, 39/1781), respectively. The incidence of macrosomia had no significant difference among these 5 years (P > 0.05). The shoulder dystosia occurrence without macrosia in these 5 years were 1 case ( 0.10% , 1/1 034), 3 cases (0.26%, 3/1 164), 2 cases ( 0.11%, 2/1 172), 2 cases (0.10%, 2/2 060), 2 cases ( 0.11%, 1/1 781), respectively. The incidence of shoulder dystocia without macrosomia had no significant difference among these 5 years (P > 0.05). (3) In the should dystocia group, 5 cases were complicated with premature rupture of membrane (5/10), 4 cases were mother≥ 35 years old (4/10), 3 cases were multipara(3/10), 3 cases had gestational diabetes mellitus(3/10), 3 cases were occiput posterior during the first stage of labor (3/10), 3 cases had prolonged second stage of labor (3/10) and 6 cases had routine lateral incision (6/10). In the control group, 3 cases were complicated with premature rupture of membrane(3/10); 1 case was mother≥35 years old (1/10); 2 cases were multipara(2/10), 3 cases had gestational diabetes mellitus (3/10), 1 case had prolonged second stage (1/10) and 7 cases had routine lateral incision (7/10). (4) There were no significant difference in the height of uterus fundus, BMI, BPD, FL, and duration of the first stage of labor between the shoulder dystocia group and the control group (P > 0.05). Compared with the control group, the increasing of BMI [(6.8±3.1) vs (4.8±1.4) kg/m(2)], the time of the second stage of labor[(86±65) vs (38±28) minutes ] and abdominal circumference[(108±8) vs (101±7) cm] were significantly higher in the shoulder dystosia group (P < 0.05). (5) There were significant difference in the chest circumference of the newborn [(34.0±1.6) vs (32.2±1.9) cm ] and the ratio of chest circumference to head circumference of the newborn [(0.99±0.03) vs (0.97±0.03) ] between the two groups (P < 0.05). The 1-minute Apgar score of the newborn (7.4±2.8) was significantly lower than the control group (10.0±0.0) (P < 0.01). Clavicular fracture occurred in 3 newborns and brachial plexus injury occurred in 4 newborns in the shoulder dystosia group.

CONCLUSION

It is difficult to predict shoulder dystocia in non-macrosomia. Shoulder dystocia of non-macrosomia could be predicted by measurement of the head circumference, chest circumference, the ratio of chest circumference to head circumference by using prenatal ultrasound. The risk factors may complicated with premature rupture of membrane, abnormal occiput position during the first stage of labor and prolonged second stage of labor.

目的

探讨非巨大儿肩难产的危险因素、临床预测及产时处理。

方法

回顾性分析2009年1月至2013年12月在盛京医院分娩的7811例阴道分娩病例。其中发生肩难产11例（0.14%，11/7811），包括巨大儿1例，非巨大儿10例（肩难产组）。每例非巨大儿肩难产病例随机匹配同期10例正常分娩病例作为对照组。分析巨大儿与非巨大儿肩难产的发生趋势及危险因素，并比较两组孕妇宫高、腹围、体重指数（BMI）增加值、胎儿双顶径（BPD）、股骨长（FL）、各产程时间、新生儿出生体重、头围、胸围及Apgar评分。

结果

（1）7811例阴道分娩中巨大儿213例，发生率2.73%（213/7811）。巨大儿中仅1例发生肩难产（0.46%，1/213）；其余10例为非巨大儿（0.13%，10/7598）。（2）2009至2013年，每年巨大儿发生例数分别为24例（2.32%，24/1034）、42例（3.61%，42/1164）、46例（2.60%，46/1772）、62例（3.01%，62/2060）、39例（2.19%，39/1781），5年巨大儿发生率差异无统计学意义（P>0.05）。5年非巨大儿发生肩难产例数分别为1例（0.10%，1/1034）、3例（0.26%，3/1164）、2例（0.11%，2/1172）、2例（0.10%，2/2060）、2例（0.11%，1/1781），5年非巨大儿肩难产发生率差异无统计学意义（P>0.05）。（3）肩难产组中，胎膜早破5例（5/10），产妇年龄≥35岁4例（4/10），经产妇3例（3/10），妊娠期糖尿病3例（3/10），第一产程枕后位3例（3/10），第二产程延长3例（3/10），常规侧切6例（6/10）。对照组中，胎膜早破3例（3/10）；产妇年龄≥35岁1例（1/10）；经产妇2例（2/10），妊娠期糖尿病3例（3/10），第二产程延长1例（1/10），常规侧切7例（7/10）。（4）肩难产组与对照组孕妇宫高、BMI、BPD、FL及第一产程时间差异无统计学意义（P>0.05）。与对照组比较，肩难产组BMI增加值[（6.8±3.1）vs（4.8±1.4）kg/m²]、第二产程时间[（86±65）vs（38±28）分钟]及腹围[（108±8）vs（101±7）cm]明显增加（P<0.05）。（5）两组新生儿胸围[（34.0±1.6）vs（32.2±1.9）cm]及胸围与头围比值[（0.99±0.03）vs（0.97±0.03）]差异有统计学意义（P<0.05）。肩难产组新生儿1分钟Apgar评分（7.4±2.8）明显低于对照组（10.0±0.0）（P<0.01）。肩难产组有3例新生儿发生锁骨骨折，4例发生臂丛神经损伤。