Department of Obstetrics and Gynecology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan (Yano, Sayama, Iriyama, Ariyoshi, Akiba, Ichinose, Toshimitsu, Seyama, Kumasawa, Nagamatsu, and Osuga).
Department of Obstetrics and Gynecology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan (Yano, Sayama, Iriyama, Ariyoshi, Akiba, Ichinose, Toshimitsu, Seyama, Kumasawa, Nagamatsu, and Osuga).
Am J Obstet Gynecol MFM. 2024 Aug;6(8):101403. doi: 10.1016/j.ajogmf.2024.101403. Epub 2024 Jun 15.
It is clinically challenging to determine when to intervene in the prolonged second stage. Although individualized prediction of spontaneous vaginal delivery is crucial to avoid maternal and neonatal complications associated with operative deliveries, the approach has not been fully established.
We aimed to evaluate the predictability of spontaneous vaginal delivery using the difference in angle of progression between pushing and rest, delta angle of progression, to establish a novel method to predict spontaneous vaginal delivery during the prolonged second stage in nulliparous women with epidural anesthesia.
We retrospectively analyzed deliveries of nulliparous women with epidural anesthesia between September 2018 and October 2023. Women were included if their delta angle of progression during the second stage was available. Operative deliveries were defined as the cases that required forceps, vacuum, and cesarean deliveries due to labor arrest. Women requiring operative deliveries due to fetal and maternal concerns, or women with fetal occiput posterior presentation were excluded. The second stage was stratified into the prolonged second stage, the period after 3 hours in the second stage, and the normal second stage, the period from the beginning until the third hour of the second stage. The association of the delta angle of the progression measured during each stage with spontaneous vaginal delivery and operative deliveries was investigated. Furthermore, the predictability of spontaneous vaginal delivery was evaluated by combining the delta and rest angle of progression.
A total of 129 women were eligible for analysis. The delta angle of progression measured during the prolonged second stage and normal second stage were significantly larger in women who achieved spontaneous vaginal delivery compared to operative deliveries (p<.001 and p<.05, respectively). During the prolonged second stage, a cutoff of 18.8 derived from the receiver operative characteristic curves in the context of the delta angle of progression predicted the possibility of spontaneous vaginal delivery (sensitivity, 81.8%; specificity, 60.0%; AUC, 0.76). Combining the rest angle of progression (>140) and delta angle of progression (>18.8) also provided quantitative prediction of spontaneous vaginal delivery (sensitivity, 86.7%; specificity, 70.0%; AUC, 0.80).
The delta angle of progression alone or in combination with the rest angle of progression can be used to predict spontaneous vaginal delivery in the second stage in nulliparous women with epidural anesthesia. Quantitative analysis of the effect of pushing using the delta angle of progression provides an objective guide to assist with an assessment of labor dystocia in the prolonged second stage on an individualized basis, which may optimize labor management in the prolonged second stage by reducing neonatal and maternal complications related to unnecessary operative deliveries and prolonged second stage of labor.
确定何时干预第二产程延长具有临床挑战性。虽然个体化预测自然分娩对避免与手术分娩相关的母婴并发症至关重要，但该方法尚未完全建立。
我们旨在评估产程中用力与休息时进展角度差（delta 角）预测自然分娩的能力，以建立一种新的方法来预测硬膜外麻醉下初产妇第二产程延长时的自然分娩。
我们回顾性分析了 2018 年 9 月至 2023 年 10 月间接受硬膜外麻醉分娩的初产妇。如果 delta 角在第二产程中可用，则纳入研究。手术分娩定义为因产程停滞而需要产钳、真空和剖宫产的病例。因胎儿和母亲的担忧而需要手术分娩的妇女，或胎儿枕后位的妇女被排除在外。第二产程分为第二产程延长、第二产程 3 小时后，以及第二产程正常，即从第二产程开始到第 3 小时。研究了在每个阶段测量的 delta 角与自然分娩和手术分娩的关系。此外，还通过结合 delta 角和休息角的进展来评估自然分娩的预测能力。
共有 129 名妇女符合分析条件。与手术分娩相比，delta 角在第二产程延长和第二产程正常时明显更大（p<.001 和 p<.05）。在第二产程延长时，来自 delta 角进展的受试者工作特征曲线的截断值为 18.8 可预测自然分娩的可能性（敏感性为 81.8%，特异性为 60.0%，AUC 为 0.76）。在第二产程延长时，将 delta 角（>18.8）和休息角（>140）结合起来也可以对自然分娩进行定量预测（敏感性为 86.7%，特异性为 70.0%，AUC 为 0.80）。
delta 角单独或与休息角联合应用，可用于预测硬膜外麻醉下初产妇第二产程中的自然分娩。通过 delta 角对用力效果的定量分析，可以为基于个体的第二产程延长时的分娩困难评估提供客观指导，从而通过减少与不必要的手术分娩和第二产程延长相关的新生儿和产妇并发症，优化第二产程的分娩管理。
