Department of Obstetrics and Gynecology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland.
THL Finnish Institute for Health and Welfare, Department of Knowledge Brokers, Helsinki, Finland.
Acta Obstet Gynecol Scand. 2024 Oct;103(10):1965-1974. doi: 10.1111/aogs.14780. Epub 2024 Jan 26.
Shoulder dystocia is a severe obstetric emergency that can cause substantial neonatal and maternal complications. This study aims to assess the performed obstetric maneuvers and their frequency, success, and association with maternal and neonatal complication rates.
The study population was collected among all deliveries in the Hospital District of Helsinki and Uusimaa between 2006 and 2015 (n = 181 352) by searching for ICD-10 codes for shoulder dystocia, brachial plexus injury and clavicle fracture. Shoulder dystocia cases (n = 537) were identified by reviewing the medical records. Shoulder dystocia cases treated with one or two maneuvers were compared with those treated with at least three. Medical records of a matched control group constituting of 566 parturients without any of the forementioned ICD-10 codes were also scrutinized.
Using the four most common obstetric maneuvers (McRoberts maneuver, suprapubic pressure, rotational maneuvers, the delivery of the posterior arm) significantly increased during the study period with individual success rates of 61.0%, 71.9%, 68.1% and 84.8%, respectively. Concurrently, the rate of brachial plexus injury and combined neonatal morbidity significantly declined from 50% to 24.2% (p = 0.02) and from 91.4% to 48.5% (p < 0.001). Approximately 75% of shoulder dystocia cases treated with maneuvers were resolved by the McRoberts maneuver and/or suprapubic pressure, but each of the four most performed maneuvers significantly increased the cumulative success rate individually and statistically (p < 0.001). The rates of brachial plexus injury and combined neonatal morbidity were at their highest (52.9% and 97.8%) when none of the maneuvers were performed and at their lowest when two maneuvers were performed (43.0% and 65.4%). The increasing number (≥3) of maneuvers did not affect the combined maternal or neonatal morbidity or brachial plexus injury but increased the risk for third- or fourth-degree lacerations (odds ratio 2.91, 95% confidence interval 1.17 to 7.24).
The increased use of obstetric maneuvers during the study period was associated with decreasing rates of neonatal complications; conversely, the lack of obstetric maneuvers was associated with the highest rate of neonatal complications. These emphasize the importance of education, maneuver training and urgently performing shoulder dystocia maneuvers according to the international protocol guidelines.
肩难产是一种严重的产科急症，可导致新生儿和产妇严重并发症。本研究旨在评估所实施的产科手法及其频率、成功率，并探讨其与产妇和新生儿并发症发生率的关系。
通过搜索 ICD-10 编码肩难产、臂丛神经损伤和锁骨骨折，从 2006 年至 2015 年在赫尔辛基和乌西玛地区医院区的所有分娩中收集研究人群（n=181352）。通过审查病历识别肩难产病例（n=537）。对接受一种或两种手法治疗的肩难产病例与接受至少三种手法治疗的病例进行比较。还仔细检查了一个由 566 名没有任何上述 ICD-10 编码的产妇组成的匹配对照组的医疗记录。
在研究期间，最常用的四种产科手法（McRoberts 手法、耻骨上施压、旋转手法、后臂娩出）的使用显著增加，其单独成功率分别为 61.0%、71.9%、68.1%和 84.8%。同时，臂丛神经损伤和新生儿合并发病率的发生率从 50%降至 24.2%（p=0.02）和从 91.4%降至 48.5%（p<0.001）。大约 75%接受手法治疗的肩难产病例通过 McRoberts 手法和/或耻骨上施压得到解决，但四种最常使用的手法均单独且统计学上显著增加了累积成功率（p<0.001）。当不进行任何手法时，臂丛神经损伤和新生儿合并发病率最高（52.9%和 97.8%），而当进行两种手法时最低（43.0%和 65.4%）。手法的数量（≥3）增加不会影响产妇或新生儿合并发病率或臂丛神经损伤，但会增加第三或第四度裂伤的风险（比值比 2.91，95%置信区间 1.17 至 7.24）。
在研究期间，产科手法的使用增加与新生儿并发症发生率降低相关；相反，缺乏产科手法与新生儿并发症发生率最高相关。这强调了根据国际协议指南进行教育、手法训练和紧急进行肩难产手法的重要性。
