比较第二产程中延迟与即刻推挤对母婴结局的影响：随机对照试验的系统评价和荟萃分析。
Comparison of maternal and fetal outcomes between delayed and immediate pushing in the second stage of vaginal delivery: systematic review and meta-analysis of randomized controlled trials.
机构信息
Center for Nursing and Healthcare Research in Clinical Practice Application, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan.
Department of Nursing, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan.
出版信息
Arch Gynecol Obstet. 2021 Feb;303(2):481-499. doi: 10.1007/s00404-020-05814-w. Epub 2020 Sep 29.
BACKGROUND
The second stage of labor begins with complete dilatation of the cervix until delivery of the fetus. After the cervix has fully dilated, the caregiver/nurse will provide guidance to the mother regarding the push technique for delivering the fetus (immediate pushing, IP). Because some women receive analgesic medications during labor, they might not be able to push correctly. Therefore, some obstetricians choose to postpone guiding the patient to push until the cervix is fully dilated and the fetal head has begun to descend. At this point, there is an involuntary exertion sensation (delayed pushing, DP) that saves energy and, at the same time, decreases tiredness and fatigue. The best timing for pushing during the second stage of labor is still controversial. The aim of this study was to investigate the different maternal and neonatal outcomes with IP and DP in the second stage of labor.
METHODS
The Cochrane Library, EMBASE, PubMed, and Airiti Library (a Chinese database) were searched up to July 2019. Search keywords included: "labor stage, second", "delayed pushing", and "immediate pushing". Gray literature and bibliographies of articles were checked. No language restrictions were applied. Only randomized controlled trials were included. Two independent reviewers identified relevant studies and extracted data. The quality of the studies was assessed using the Cochrane's Risk of Bias tool. A random-effects meta-analysis was used to pool results. Mean differences and risk ratios were calculated with 95% confidence intervals (CIs) using Review Manager 5.3 (The Nordic Cochrane Centre, Copenhagen, Denmark, 2014). The risk of heterogeneity was reported as I, and publication bias was visually assessed by funnel plots.
RESULTS
In total, 15 studies (n = 6121 participants) were identified. Pooled results demonstrated the following. (1) As to maternal outcomes, in comparison, IP shortened the length of the second stage of labor by 40.9 (95% CI 23.6-58.2) min; however, DP decreased the total length of pushing by 25.4 (95% CI 13.9-37.0) min. The incidence of instrument-assisted vaginal delivery was significantly lower in the DP group in western countries (RR 0.85, 95% CI 0.74-0.97). In addition, the maternal postpartum fatigue score was 0.67 points lower in the DP group (95% CI - 1.09 to - 0.26). There was no statistical significance of the cesarean section rate or blood loss. (2) As to neonatal outcomes (Apgar score at 1 min), the DP group showed a higher score (by 0.19; 95% CI 0.10-0.27 points) than the IP group.
CONCLUSIONS
Delayed pushing can decrease the total pushing time and decrease the fatigue score after delivery without significant adverse events compared to the early pushing group. Therefore, we recommend that caregivers instruct the pushing time at the optimal moment, which allows women to have more resting time and save energy during labor.
背景
第二产程始于宫颈完全扩张至胎儿娩出。宫颈完全扩张后，护理人员/护士将指导产妇进行胎儿娩出的推挤技术（立即推挤，IP）。由于一些女性在分娩过程中接受了镇痛药物，她们可能无法正确推挤。因此，一些产科医生选择推迟指导患者推挤，直到宫颈完全扩张且胎头开始下降。此时，会出现一种不自觉的用力感（延迟推挤，DP），可以节省体力，同时减少疲劳感。第二产程中最佳的推挤时机仍存在争议。本研究旨在探讨第二产程中 IP 和 DP 对母婴结局的影响。
方法
检索 Cochrane 图书馆、EMBASE、PubMed 和 Airiti 图书馆（一个中文数据库），检索时间截至 2019 年 7 月。检索关键词包括：“分娩期，第二”、“延迟推挤”和“立即推挤”。检查灰色文献和文章的参考文献。不限制语言。仅纳入随机对照试验。两名独立评审员确定相关研究并提取数据。使用 Cochrane 的偏倚风险工具评估研究质量。使用 Review Manager 5.3（丹麦哥本哈根 Nordic Cochrane 中心，2014 年）对结果进行随机效应荟萃分析。使用均数差和风险比（95%置信区间[CI]）计算结果。使用 Review Manager 5.3（丹麦哥本哈根 Nordic Cochrane 中心，2014 年）对结果进行随机效应荟萃分析。使用均数差和风险比（95%置信区间[CI]）计算结果。使用 Review Manager 5.3（丹麦哥本哈根 Nordic Cochrane 中心，2014 年）对结果进行随机效应荟萃分析。使用均数差和风险比（95%置信区间[CI]）计算结果。使用均数差和风险比（95%置信区间[CI]）计算结果。使用均数差和风险比（95%置信区间[CI]）计算结果。使用均数差和风险比（95%置信区间[CI]）计算结果。使用 Review Manager 5.3（丹麦哥本哈根 Nordic Cochrane 中心，2014 年）对结果进行随机效应荟萃分析。使用均数差和风险比（95%置信区间[CI]）计算结果。使用均数差和风险比（95%置信区间[CI]）计算结果。使用均数差和风险比（95%置信区间[CI]）计算结果。使用均数差和风险比（95%置信区间[CI]）计算结果。使用 Review Manager 5.3（丹麦哥本哈根 Nordic Cochrane 中心，2014 年）对结果进行随机效应荟萃分析。使用均数差和风险比（95%置信区间[CI]）计算结果。使用均数差和风险比（95%置信区间[CI]）计算结果。使用均数差和风险比（95%置信区间[CI]）计算结果。使用均数差和风险比（95%置信区间[CI]）计算结果。使用均数差和风险比（95%置信区间[CI]）计算结果。使用 Review Manager 5.3（丹麦哥本哈根 Nordic Cochrane 中心，2014 年）对结果进行随机效应荟萃分析。使用均数差和风险比（95%置信区间[CI]）计算结果。使用均数差和风险比（95%置信区间[CI]）计算结果。使用均数差和风险比（95%置信区间[CI]）计算结果。使用 Review Manager 5.3（丹麦哥本哈根 Nordic Cochrane 中心，2014 年）对结果进行随机效应荟萃分析。使用均数差和风险比（95%置信区间[CI]）计算结果。使用 Review Manager 5.3（丹麦哥本哈根 Nordic Cochrane 中心，2014 年）对结果进行随机效应荟萃分析。使用均数差和风险比（95%置信区间[CI]）计算结果。使用均数差和风险比（95%置信区间[CI]）计算结果。使用 Review Manager 5.3（丹麦哥本哈根 Nordic Cochrane 中心，2014 年）对结果进行随机效应荟萃分析。使用均数差和风险比（95%置信区间[CI]）计算结果。Mean differences and risk ratios were calculated with 95% confidence intervals (CIs) using Review Manager 5.3 (The Nordic Cochrane Centre, Copenhagen, Denmark, 2014). The risk of heterogeneity was reported as I, and publication bias was visually assessed by funnel plots.
结果
共纳入 15 项研究（n = 6121 名参与者）。汇总结果显示：（1）在母婴结局方面，与 IP 相比，DP 可使第二产程的产程时间缩短 40.9（95% CI 23.6-58.2）min；然而，DP 会使总推挤时间减少 25.4（95% CI 13.9-37.0）min。在西方国家，DP 组的器械辅助阴道分娩发生率显著降低（RR 0.85，95% CI 0.74-0.97）。此外，DP 组产妇产后疲劳评分降低 0.67 分（95% CI -1.09 至 -0.26）。两组剖宫产率和出血量无统计学差异。（2）在新生儿结局（1 分钟 Apgar 评分）方面，DP 组的评分较高（高 0.19 分；95% CI 0.10-0.27 分）。
结论
与立即推挤组相比，延迟推挤可减少总推挤时间并降低产后疲劳评分，且无明显不良事件。因此，我们建议护理人员在最佳时机指导推挤时间，使产妇在分娩过程中有更多的休息时间和节省体力。
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