Cornthwaite Katie, Draycott Tim, Bahl Rachna, Hotton Emily, Winter Cathy, Lenguerrand Erik
Women's Health Department, North Bristol NHS Trust, UK; Translational Health Sciences, University of Bristol, UK.
Women's Health Department, North Bristol NHS Trust, UK.
Eur J Obstet Gynecol Reprod Biol. 2021 Jun;261:85-91. doi: 10.1016/j.ejogrb.2021.04.021. Epub 2021 Apr 21.
To investigate risk factors, management and outcomes of impacted fetal head (IFH) at caesarean section (CS).
This is a retrospective cohort study of all women with singleton, cephalic pregnancies who had an emergency CS during one-year (2016) at North Bristol NHS Trust, UK (n = 838). The incidence of caesarean section at full dilatation (CSFD) and IFH were calculated using the annual birth rate. To identify risk factors for IFH, maternal, perinatal and intrapartum characteristics were compared according to the presence or absence of IFH, and separately for first- and second-stage CS. Techniques employed to disimpact the fetal head were described. Univariable and multivariable comparisons of maternal and perinatal outcomes were made between cases with and without an IFH. Characteristics and outcomes were compared using modified Poisson regression.
CSFD accounted for 2.1 % of all births. IFH complicated 1.5 % of all births (11.3 % of emergency CS), with 55.8 % occurring prior to full cervical dilatation. Increased rates of IFH at CS were associated with: oxytocin augmentation (RR = 2.47 [1.61-3.80]), full cervical dilatation (RR = 4.24 [2.96-6.07], mid/low station (RR = 4.14 [2.72-6.32]), moulding (RR = 4.39 [2.55-7.54]) and caput (RR = 6.60 [3.09-14.10]). Junior operators documented IFH more than consultants (RR = 9.61 [1.35-68.2]). The strategies recorded for managing IFH included: tocolysis, reverse breech extraction and vaginal push up (33.7 %, 14.7 % and 11.6 % cases respectively) with two or more techniques used in 21.1 % cases. IFH at CS was independently associated with an increased risk of uterine extensions (RR = 3.09 [1.96-4.87]) and a composite adverse perinatal outcome (RR = 1.66 [1.21-2.28]).
IFH is a common and heterogeneous complication associated with increased complications for both mother and baby, independent of those of CSFD. Obstetricians must remain vigilant to the possibility of IFH at all emergency CS, particularly those at full cervical dilatation or with evidence of obstructed labour. There is an urgent need for a standardised management algorithm and training in evidence-based disimpaction techniques.
探讨剖宫产术中胎头嵌顿（IFH）的危险因素、处理方法及结局。
这是一项回顾性队列研究，研究对象为英国北布里斯托尔国民保健服务信托基金在2016年进行急诊剖宫产的所有单胎头位妊娠妇女（n = 838）。使用年出生率计算宫口开全时剖宫产（CSFD）和IFH的发生率。为确定IFH的危险因素，根据是否存在IFH比较产妇、围产期和产时特征，并分别对第一阶段和第二阶段剖宫产进行比较。描述了用于解除胎头嵌顿的技术。对有IFH和无IFH的病例进行产妇和围产期结局的单变量和多变量比较。使用修正泊松回归比较特征和结局。
CSFD占所有分娩的2.1%。IFH在所有分娩中占1.5%（急诊剖宫产的11.3%），其中55.8%发生在宫颈未开全之前。剖宫产时IFH发生率增加与以下因素相关：缩宫素加强宫缩（RR = 2.47 [1.61 - 3.80]）、宫颈开全（RR = 4.24 [2.96 - 6.07]）、中低位（RR = 4.14 [2.72 - 6.32]）、颅骨重叠（RR = 4.39 [2.55 - 7.54]）和头皮水肿（RR = 6.60 [3.09 - 14.10]）。初级手术医生记录IFH的情况多于顾问医生（RR = 9.61 [1.35 - 68.2]）。记录的处理IFH的策略包括：宫缩抑制剂、倒转臀牵引术和阴道上推（分别占病例的33.7%、14.7%和11.6%），21.1%的病例使用了两种或更多技术。剖宫产时IFH与子宫破裂风险增加（RR = 3.09 [1.96 - 4.87]）和围产期综合不良结局（RR = 1.66 [1.21 - 2.28]）独立相关。
IFH是一种常见且异质性的并发症，与母婴并发症增加相关，与CSFD无关。产科医生在所有急诊剖宫产时，尤其是宫颈开全或有产程梗阻证据的剖宫产时，必须对IFH的可能性保持警惕。迫切需要标准化的处理算法和基于证据的解除嵌顿技术培训。
