Division of Maternal Fetal Medicine, Ospedale Cristo Re, Università di Roma Tor Vergata, Rome, Italy.
Department of Obstetrics and Gynecology, The First I.M. Sechenov Moscow State Medical University, Moscow, Russia.
Acta Obstet Gynecol Scand. 2021 Nov;100(11):1941-1948. doi: 10.1111/aogs.14236. Epub 2021 Aug 8.
The objective was to report the role of intrapartum ultrasound examination in affecting maternal and perinatal outcome in women undergoing instrumental vaginal delivery.
MEDLINE, Embase, CINAHL, Google Scholar and ClinicalTrial.gov databases were searched. Inclusion criteria were randomized controlled trials comparing ultrasound assessment of fetal head position vs routine standard care (digital examination) before instrumental vaginal delivery (either vacuum or forceps). The primary outcome was failed instrumental delivery extraction followed by cesarean section. Secondary outcomes were postpartum hemorrhage, 3rd or 4th degree perineal lacerations, episiotomy, prolonged hospital stay, Apgar score<7 at 5 min, umbilical artery pH <7.0 and base excess greater than -12 mEq, admission to neonatal intensive care unit (NICU), shoulder dystocia, birth trauma, a composite score of adverse maternal and neonatal outcome and incorrect diagnosis of fetal head position. Risk of bias was assessed using the Revised Cochrane risk-of-bias tool for randomized trials (RoB-2). The quality of evidence and strength of recommendations were assessed using the Grading of Recommendations Assessment Development and Evaluation (GRADE) methodology. Head-to-head meta-analyses using a random-effect model were used to analyze the data and results are reported as relative risk with their 95% confidence intervals.
Five studies were included (1463 women). There was no difference in the maternal, pregnancy or labor characteristics between the two groups. An ultrasound assessment prior to instrumental vaginal delivery did not affect the cesarean section rate compared with standard care (p = 0.805). Likewise, the risk of composite adverse maternal outcome (p = 0.428), perineal lacerations (p = 0.800), postpartum hemorrhage (p = 0.303), shoulder dystocia (p = 0.862) and prolonged stay in hospital (p = 0.059) were not different between the two groups. Composite adverse neonatal outcome was not different between the women undergoing and those not undergoing ultrasound assessment prior to instrumental delivery (p = 0.400). Likewise, there was no increased risk with abnormal Apgar score (p = 0.882), umbilical artery pH < 7.2 (p = 0.713), base excess greater than -12 (p = 0.742), admission to NICU (p = 0.879) or birth trauma (p = 0.968). The risk of having an incorrect diagnosis of fetal head position was lower when ultrasound was performed before instrumental delivery, with a relative risk of 0.16 (95% confidence interval 0.1-0.3; I :77%, p < 0.001).
Although ultrasound examination was associated with a lower rate of incorrect diagnoses of fetal head position and station, this did not translate to any improvement of maternal or neonatal outcomes.
目的在于报告产时超声检查在影响行器械助产分娩的产妇和围产儿结局方面的作用。
检索了 MEDLINE、Embase、CINAHL、Google Scholar 和 ClinicalTrial.gov 数据库。纳入标准为比较超声评估胎儿头部位置与器械助产分娩前常规标准护理（阴道检查）的随机对照试验。主要结局为器械助产分娩失败后行剖宫产。次要结局为产后出血、3 度或 4 度会阴裂伤、会阴切开术、延长住院时间、5 分钟时 Apgar 评分<7、脐动脉 pH<7.0 和碱剩余大于-12mEq、收入新生儿重症监护病房（NICU）、肩难产、分娩创伤、产妇和新生儿不良结局综合评分以及胎儿头部位置的错误诊断。使用修订后的 Cochrane 随机试验偏倚风险工具（RoB-2）评估偏倚风险。使用 Grading of Recommendations Assessment Development and Evaluation（GRADE）方法评估证据质量和推荐强度。使用随机效应模型对头对头的荟萃分析来分析数据，结果以相对风险及其 95%置信区间表示。
纳入了 5 项研究（1463 名女性）。两组间产妇、妊娠或分娩特征无差异。与标准护理相比，器械助产分娩前进行超声评估并未影响剖宫产率（p=0.805）。同样，复合不良产妇结局（p=0.428）、会阴裂伤（p=0.800）、产后出血（p=0.303）、肩难产（p=0.862）和延长住院时间（p=0.059）的风险在两组间无差异。行或不行器械助产分娩前超声评估的产妇中，复合不良新生儿结局无差异（p=0.400）。同样，异常 Apgar 评分（p=0.882）、脐动脉 pH<7.2（p=0.713）、碱剩余大于-12（p=0.742）、收入 NICU（p=0.879）或分娩创伤（p=0.968）的风险无增加。与标准护理相比，器械助产分娩前进行超声检查时，胎儿头部位置和方位不正确的诊断风险较低，相对风险为 0.16（95%置信区间 0.1-0.3；I²：77%，p<0.001）。
尽管超声检查与较低的胎儿头部位置和胎方位不正确诊断率相关，但这并未转化为任何产妇或新生儿结局的改善。
