住院医师管理阴道非头位第二胎儿分娩后的新生儿发病率。

Neonatal Morbidity After Management of Vaginal Noncephalic Second-Twin Delivery by Residents.

机构信息

Assistance Publique-Hôpitaux de Paris, Hôpital Robert Debré, Service de Gynécologie Obstétrique, Université Paris Diderot, INSERM, U1153, Epidemiology and Biostatistics Sorbonne Paris Cité Research Center, Obstetrical, Perinatal and Pediatric Epidemiology Team, Maternité Notre Dame de Bon Secours, Groupe Hospitalier Saint-Joseph, and Université René Descartes, Paris, CHRU de Lille, Maternité Jeanne de Flandre, and Université de Lille 2, Lille, Assistance Publique-Hôpitaux de Paris, Hôpital Trousseau, Service de Gynécologie Obstétrique, and Université Pierre et Marie Curie, Paris, Centre Hospitalier Intercommunal de Poissy, Service de Gynécologie Obstétrique, Poissy, Université de Versailles Saint-Quentin-en-Yvelines, Versailles, CHU de Strasbourg, Hôpital Hautepierre, and Université de Strasbourg, Strasbourg, Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre, Service de Gynécologie Obstétrique, and; Université Paris Sud, Le Kremlin Bicêtre, CHU de Bordeaux, Service de Gynécologie Obstétrique, and Université de Bordeaux, Bordeaux, CHU de Toulouse, Service de Gynécologie Obstétrique, and Université Toulouse III Paul Sabatier, Toulouse, CHU de Nantes, Service de Gynécologie Obstétrique, CIC Mère enfant, INRA, UMR 1280 Physiologie des adaptations nutritionnelles; Université de Nantes, Nantes, and Assistance Publique-Hôpitaux de Paris, Maternité Port-Royal, and DHU risques et grossesse, Paris, France.

出版信息

Obstet Gynecol. 2018 Dec;132(6):1377-1385. doi: 10.1097/AOG.0000000000002955.

DOI:10.1097/AOG.0000000000002955

PMID:30399103

Abstract

OBJECTIVE

To assess neonatal mortality and morbidity according to whether a resident or senior obstetrician initially managed vaginal delivery of noncephalic second twins.

METHODS

The JUmeaux MODe d'Accouchement study was a national, prospective, population-based, cohort study of twin deliveries in 176 maternity units in France, where active management of second-twin delivery is recommended. The primary outcome of our study was a composite of neonatal mortality and morbidity. Neonatal outcomes of noncephalic second twins born at or after 32 weeks of gestation after vaginal delivery of the first twin were compared according to the initial managing practitioner-supervised resident or senior obstetrician. Deliveries performed by a senior obstetrician after failure by a resident were classified as resident deliveries. Deliveries in maternity units without residents were excluded. We used multilevel multivariable Poisson regression models and propensity score matching to control for indication bias and potential confounders, including the maternity unit status. We performed subgroup analyses according to gestational age at delivery, before or after 37 weeks of gestation, and to the noncephalic second twin presentation, breech or transverse.

RESULTS

Among 1,376 noncephalic second-twin deliveries, 545 (39.6%) were initially managed by a resident and 831 (60.4%) by a senior obstetrician. Residents failed to deliver the second twin in 125 (22.9%) women. Composite neonatal mortality and morbidity did not differ between the resident and senior groups (13/545 [2.4%] vs 29/831 [3.5%]; adjusted relative risk 0.78, 95% CI 0.35-1.74). Subgroup analyses were consistent with the overall analysis.

CONCLUSION

Supervised resident and senior staff management of noncephalic second-twin vaginal delivery is associated with similar neonatal morbidity and mortality, which supports continued training of residents in such deliveries.

摘要

目的

评估根据是否由住院医生或资深产科医生最初管理非头位第二胎阴道分娩，新生儿的死亡率和发病率。

方法

JUmeaux MODe d'Accouchement 研究是一项全国性、前瞻性、基于人群的法国 176 个产科单位的双胎分娩队列研究，该研究中建议积极管理第二胎分娩。我们研究的主要结局是新生儿死亡率和发病率的复合指标。比较了第一胎经阴道分娩后，32 周及以上胎龄的非头位第二胎的新生儿结局，根据初始管理医生 - 监督住院医生或资深产科医生的不同进行分组。如果住院医生失败，由资深产科医生进行的分娩被归类为住院医生分娩。没有住院医生的产科单位的分娩被排除在外。我们使用多水平多变量泊松回归模型和倾向评分匹配来控制适应证偏倚和潜在混杂因素，包括产科单位的状态。我们根据分娩时的孕龄（37 周之前或之后）和非头位第二胎的先露部位（臀位或横位）进行亚组分析。

结果

在 1376 例非头位第二胎分娩中，545 例（39.6%）最初由住院医生管理，831 例（60.4%）由资深产科医生管理。在 125 例（22.9%）女性中，住院医生未能娩出第二胎。居民组和高级组的复合新生儿死亡率和发病率无差异（545 例中有 13 例[2.4%] vs. 831 例中有 29 例[3.5%]；调整后的相对风险 0.78，95%CI 0.35-1.74）。亚组分析与总体分析一致。