Cohen Wayne R, Friedman Emanuel A
Department of Obstetrics and Gynecology, University of Arizona College of Medicine, Tucson, AZ.
Department of Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School, Boston, MA.
Am J Obstet Gynecol. 2015 Jun;212(6):753.e1-3. doi: 10.1016/j.ajog.2015.04.012. Epub 2015 Apr 17.
In a recent review we expressed concerns about new guidelines for the assessment and management of labor recommended jointly by the American Congress of Obstetricians and Gynecologists (ACOG) and the Society for Maternal-Fetal Medicine (SMFM). These guidelines are based heavily on a new concept of how cervical dilatation and fetal descent progress, derived from the work of Zhang et al. In their Viewpoint article they have addressed, but not allayed, the concerns we described in our review. We assert that the dilatation curve promulgated by Zhang et al cannot be reconciled with direct clinical observation. Even if they were correct, however, it still does not follow that the ACOG/SMFM guidelines should recommend replacing the coherent system of identifying and managing labor aberrations described by Friedman. That system is grounded in well-established clinical principles based on decades of use and the objectively documented association of some labor abnormalities with poor fetal and maternal outcomes. Recommendations for new clinical management protocols should require the demonstration of superior outcomes through extensive, preferably prospective, assessment. Using untested guidelines for the management of labor may adversely affect women and children. Even if those guidelines were to reduce the currently excessive cesarean delivery rate, the price of that benefit is likely to be a trade-off in harm to parturients and their offspring. The nature and degree of that harm needs to be documented before considering adoption of the guidelines.
在最近的一篇综述中，我们对美国妇产科医师学会（ACOG）和母胎医学协会（SMFM）联合推荐的产程评估与管理新指南表达了担忧。这些指南很大程度上基于张等人的研究得出的关于宫颈扩张和胎儿下降进展的新概念。在他们的观点文章中，他们回应了我们在综述中描述的担忧，但并未消除这些担忧。我们断言，张等人公布的扩张曲线与直接的临床观察结果不一致。然而，即便他们是正确的，也不能由此得出ACOG/SMFM指南就应该推荐取代弗里德曼所描述的用于识别和管理产程异常的连贯体系。该体系基于数十年来广泛应用且有客观记录表明某些产程异常与不良母婴结局相关的成熟临床原则。新临床管理方案的推荐应该通过广泛的、最好是前瞻性的评估来证明其能带来更好的结局。使用未经检验的产程管理指南可能会对妇女和儿童产生不利影响。即便这些指南能降低当前过高的剖宫产率，这种益处的代价很可能是对产妇及其后代造成伤害的权衡。在考虑采用这些指南之前，需要记录这种伤害的性质和程度。
