Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX (Drs Mendez-Figueroa, Blackwell, and Chauhan).
Department of Obstetrics and Gynecology, Christiana Care, Newark, DE (Dr Hoffman).
Am J Obstet Gynecol MFM. 2021 Jul;3(4):100359. doi: 10.1016/j.ajogmf.2021.100359. Epub 2021 Mar 20.
Although the neonatal morbidity associated with shoulder dystocia are well known, the maternal morbidity caused by this obstetrical emergency is infrequently reported.
This study aimed to assess the composite adverse maternal and neonatal outcomes among vaginal deliveries (at 34 weeks or later) with and without shoulder dystocia.
This is a secondary analysis of the Consortium of Safe Labor, an observational obstetrical cohort of all vaginal deliveries occurring at 19 hospitals (from 2002-2008) and for which data on the occurrence of shoulder dystocia were available. The composite adverse maternal outcome included third- or fourth-degree perineal laceration, postpartum hemorrhage (>500 cc blood loss for a vaginal delivery and >1000 cc blood loss for cesarean delivery), blood transfusion, chorioamnionitis, endometritis, thromboembolism, admission to intensive care unit, or maternal death. The composite adverse neonatal outcome included an Apgar score of <7 at 5 minutes, a birth injury, neonatal seizure, hypoxic ischemic encephalopathy, or neonatal death. A multivariable Poisson regression was used to estimate the adjusted relative risks with 95% confidence intervals. The area under the receiver operating characteristic curve was constructed to determine if clinical factors would identify shoulder dystocia.
Of the 228,438 women in the overall cohort, 130,008 (59.6%) met the inclusion criteria, and among them, shoulder dystocia was documented in 2159 (1.7%) cases. The rate of composite maternal morbidity was significantly higher among deliveries with shoulder dystocia (14.7%) than without (8.6%; adjusted relative risk, 1.71; 95% confidence interval, 1.64-2.01). The most common maternal morbidity with shoulder dystocia was a third- or fourth-degree laceration (adjusted relative risk, 2.82; 95% confidence interval, 2.39-3.31). The risk of composite neonatal morbidity with shoulder dystocia (12.2%) was also significantly higher than without shoulder dystocia (2.4%) (adjusted relative risk, 5.18; 95% confidence interval, 4.60-5.84). The most common neonatal morbidity was birth injury (adjusted relative risk, 5.39; 95% confidence interval, 4.71-6.17). The area under the curve for maternal characteristics to identify shoulder dystocia was 0.66 and it was 0.67 for intrapartum factors.
Although shoulder dystocia is unpredictable, the associated morbidity affects both mothers and newborns. The focus should be on concurrently averting the composite morbidity for the maternal-neonatal dyad with shoulder dystocia.
肩难产相关的新生儿发病率众所周知，但这种产科急症引起的产妇发病率却鲜有报道。
本研究旨在评估伴有和不伴有肩难产的阴道分娩（34 周或以上）的产妇-新生儿复合不良结局。
这是安全分娩联合会的二次分析，这是一个观察性的产科队列，纳入了 19 家医院（2002-2008 年）的所有阴道分娩，并可获得肩难产发生的数据。复合不良产妇结局包括三度或四度会阴裂伤、产后出血（阴道分娩出血量＞500 毫升，剖宫产出血量＞1000 毫升）、输血、绒毛膜羊膜炎、子宫内膜炎、血栓栓塞、入住重症监护病房或产妇死亡。复合不良新生儿结局包括 5 分钟时 Apgar 评分＜7 分、出生损伤、新生儿癫痫发作、缺氧缺血性脑病或新生儿死亡。采用多变量泊松回归估计调整后的相对风险及其 95%置信区间。构建受试者工作特征曲线，以确定临床因素是否能识别肩难产。
在整个队列的 228438 名女性中，有 130008 名（59.6%）符合纳入标准，其中 2159 名（1.7%）有肩难产记录。肩难产组产妇发病率明显高于无肩难产组（14.7%比 8.6%；调整后的相对风险，1.71；95%置信区间，1.64-2.01）。肩难产最常见的产妇发病率是三度或四度裂伤（调整后的相对风险，2.82；95%置信区间，2.39-3.31）。有肩难产的新生儿复合发病率（12.2%）也明显高于无肩难产（2.4%）（调整后的相对风险，5.18；95%置信区间，4.60-5.84）。最常见的新生儿发病率是出生损伤（调整后的相对风险，5.39；95%置信区间，4.71-6.17）。识别肩难产的产妇特征的曲线下面积为 0.66，产时因素的曲线下面积为 0.67。
尽管肩难产是不可预测的，但相关的发病率会同时影响产妇和新生儿。重点应放在同时避免肩难产产妇-新生儿对的复合发病率。
