非巨大儿肩难产发生的高危因素及其临床预测
비거대인견난산발생적고위인소급기림상예측
Risk factors and clinical prediction of shoulder dystocia in non-macrosomia
  • 万方数据
    中华妇产科杂志 중화부산과잡지
    CHINESE JOUNAL OF OBSTETRICS AND GYNECOLOGY
    2015年 1期 17-21 ,共5页

    栗娜%李秋玲%常靓%刘彩霞

    률나%리추령%상정%류채하

    难产%肩%产伤%臂丛神经病%危险因素 難產%肩%產傷%臂叢神經病%危險因素
    난산%견%산상%비총신경병%위험인소
    Dystocia%Shoulder%Birth injuries%Brachial plexus neuropathies%Risk factors
    目的 探讨非巨大儿肩难产发生的高危因素、临床预测及分娩过程中的处理.方法 2009年1月2013年12月间于中国医科大学附属盛京医院经阴道分娩的产妇中发生肩难产11例,同期经阴道分娩产妇7 811例,肩难产发生率为0.14％(11/7 811);其中,巨大儿肩难产1例,非巨大儿肩难产10例(肩难产组).随机抽取每例非巨大儿肩难产病例发生前后1周内经阴道分娩的10例产妇为对照组.分析巨大儿及非巨大儿肩难产的发生趋势及其高危因素,比较两组产妇的宫高、腹围、体质指数(BMI)增长、胎儿双顶径、股骨长、各产程时间、新生儿出生体质量、头围、胸围及Apgar评分.结果 (1)7 811例产妇中共分娩巨大儿213例,巨大儿发生率为2.73％(213/7 811),其中发生巨大儿肩难产1例(0.46％,1/213);非巨大儿肩难产10例(0.13％,10/7 598).(2)2009-2013年的5年间,巨大儿发生率分别为2.32％(24/1 034)、3.61％(42/1 164)、2.60％ (46/1 772)、3.01％(62/2 060)、2.19％(39/1 781),分别比较,差异均无统计学意义(P＞0.05);10例非巨大儿肩难产在5年间的发生比例分别为0.10％(1/1 034)、0.26％(3/1 164)、0.11％(2/1 772)、0.10％(2/2 060)、0.11％(2/1 781),分别比较,差异均无统计学意义(P＞0.05).(3)肩难产组10例产妇中,胎膜早破5例(5/10)、高龄4例(4/10)、经产妇3例(3/10)、妊娠期糖尿病3例(3/10)、第一产程枕后位3例(3/10)、第二产程延长3例(3/10)、常规侧切分娩6例(6/10);对照组产妇中,发生胎膜早破3例(3/10)、高龄1例(1/10)、经产妇2例(2/10)、妊娠期糖尿病3例(3/10)、第二产程时间延长1例(1/10)、常规侧切分娩7例(7/10).(4)两组产妇宫高、BMI、胎儿双顶径、股骨长及第一产程时间分别比较,差异均无统计学意义(P＞0.05).肩难产组及对照组产妇BMI增长[(6.8±3.1)及(4.8±1.4)kg/m2]、第二产程时间[(86±65)及(38±28) min]及腹围[(108±8)及(101±7)cm]分别比较,差异均有统计学意义(P＜0.05).(5)肩难产组及对照组新生儿胸围[(34.0±1.6)及(32.2±1.9) cm]及胸围/头围比值(0.99±0.03及0.97±0.03)比较,差异均有统计学意义(P＜0.05).肩难产组新生儿1分钟Apgar评分[(7.4±2.8)分]明显低于对照组[(10.0±0.0)分],两组比较,差异有统计学意义(P＜0.01).肩难产组新生儿锁骨骨折3例,新生儿发生臂丛神经损伤4例,其余3例无明显副损伤.结论 临床预测非巨大儿肩难产的发生难度较大,通过产前超声测量胎儿头围、胸围及胸围/头围比值可能评估其发生风险;发生非巨大儿肩难产的高危因素为合并胎膜早破、第一产程胎位异常及第二产程延长.
    목적 탐토비거대인견난산발생적고위인소、림상예측급분면과정중적처리.방법 2009년1월2013년12월간우중국의과대학부속성경의원경음도분면적산부중발생견난산11례,동기경음도분면산부7 811례,견난산발생솔위0.14％(11/7 811);기중,거대인견난산1례,비거대인견난산10례(견난산조).수궤추취매례비거대인견난산병례발생전후1주내경음도분면적10례산부위대조조.분석거대인급비거대인견난산적발생추세급기고위인소,비교량조산부적궁고、복위、체질지수(BMI)증장、태인쌍정경、고골장、각산정시간、신생인출생체질량、두위、흉위급Apgar평분.결과 (1)7 811례산부중공분면거대인213례,거대인발생솔위2.73％(213/7 811),기중발생거대인견난산1례(0.46％,1/213);비거대인견난산10례(0.13％,10/7 598).(2)2009-2013년적5년간,거대인발생솔분별위2.32％(24/1 034)、3.61％(42/1 164)、2.60％ (46/1 772)、3.01％(62/2 060)、2.19％(39/1 781),분별비교,차이균무통계학의의(P＞0.05);10례비거대인견난산재5년간적발생비례분별위0.10％(1/1 034)、0.26％(3/1 164)、0.11％(2/1 772)、0.10％(2/2 060)、0.11％(2/1 781),분별비교,차이균무통계학의의(P＞0.05).(3)견난산조10례산부중,태막조파5례(5/10)、고령4례(4/10)、경산부3례(3/10)、임신기당뇨병3례(3/10)、제일산정침후위3례(3/10)、제이산정연장3례(3/10)、상규측절분면6례(6/10);대조조산부중,발생태막조파3례(3/10)、고령1례(1/10)、경산부2례(2/10)、임신기당뇨병3례(3/10)、제이산정시간연장1례(1/10)、상규측절분면7례(7/10).(4)량조산부궁고、BMI、태인쌍정경、고골장급제일산정시간분별비교,차이균무통계학의의(P＞0.05).견난산조급대조조산부BMI증장[(6.8±3.1)급(4.8±1.4)kg/m2]、제이산정시간[(86±65)급(38±28) min]급복위[(108±8)급(101±7)cm]분별비교,차이균유통계학의의(P＜0.05).(5)견난산조급대조조신생인흉위[(34.0±1.6)급(32.2±1.9) cm]급흉위/두위비치(0.99±0.03급0.97±0.03)비교,차이균유통계학의의(P＜0.05).견난산조신생인1분종Apgar평분[(7.4±2.8)분]명현저우대조조[(10.0±0.0)분],량조비교,차이유통계학의의(P＜0.01).견난산조신생인쇄골골절3례,신생인발생비총신경손상4례,기여3례무명현부손상.결론 림상예측비거대인견난산적발생난도교대,통과산전초성측량태인두위、흉위급흉위/두위비치가능평고기발생풍험;발생비거대인견난산적고위인소위합병태막조파、제일산정태위이상급제이산정연장.
    Objective To investigate the risk factors,clinical prediction and intrapartum management of shoulder dystocia in non-macrosomia.Methods Totally 7 811 cases of vaginal delivery were retrospectively reviewed from Juanary 2009 to December 2013 in Shengjing Hospital.Shoulder dystocia was found in 11 cases (0.14％,11/7 811),including 1 case of macrosomia and l0 cases of non-macrosomia (shoulder dystocia group).Each non-macrosomia shoulder dystocia case was matched with 10 cases of normal delivery in the same week,which were selected randomly as the control group.The tendency and risk factors of shoulder dystocia in macrosomia and non-macrosomia were analyzed,and the following data between the two groups were compared,including the height of uterus fundus,abdominal circumference of the pregnant woman,the increasing of body mass index(BMI),fetal biparietal diameter (BPD),fetal femur length (FL),duration of every stage of labor,birth weight of the newborn,head circumference and chest circumference of the newborn,Apgar score.Results (1) There were 213 macrosomias among the 7 811 vaginal deliveries,with the incidence of 2.73％ (213/7 811).Only 1 shoulder dystocia was macrosomia (0.46％,1/213); while the other 10 cases were non-macrosomia (0.13％,10/7 598).(2) From 2009 to 2013,the macrosomia happened by 24 cases (2.32％,24/1 034),42 cases (3.61％,42/1 164),46 cases (2.60％,46/1 772),62 cases (3.01％,62/2 060),39 cases (2.19％,39/1781),respectively.The incidence of macrosomia had no significant difference among these 5 years (P＞0.05).The shoulder dystosia occurrence without macrosia in these 5 years were 1 case (0.10％,1/1 034),3 cases (0.26％,3/1 164),2 eases (0.11％,2/1 172),2 cases (0.10％,2/2 060),2 cases (0.11％,1/1 781),respectively.The incidence of shoulder dystocia without macrosomia had no significant difference among these 5 years (P＞0.05).(3) In the should dystocia group,5 cases were complicated with premature rupture of membrane (5/10),4 cases were mother≥ 35 years old (4/10),3 cases were multipara(3/10),3 cases had gestational diabetes mellitus(3/10),3 cases were occiput posterior during the first stage of labor(3/10),3 cases had prolonged second stage of labor (3/10) and 6 cases had routine lateral incision (6/10).In the control group,3 cases were complicated with premature rupture of membrane(3/10); 1 case was mother≥35 years old (1/10); 2 cases were multipara(2/10),3 cases had gestational diabetes mellitus (3/10),1 case had prolonged second stage (1/10) and 7 cases had routine lateral incision (7/10).(4) There were no significant difference in the height of uterus fundus,BMI,BPD,FL,and duration of the first stage of labor between the shoulder dystocia group and the control group (P＞0.05).Compared with the control group,the increasing of BMI [(6.8±3.1) vs (4.8± 1.4) kg/m2],the time of the second stage of labor[(86±65) vs (38±28) minutes] and abdominal circumference[(108±8) vs (101±7) cm] were significantly higher in the shoulder dystosia group (P＜0.05).(5)There were significant difference in the chest circumference of the newborn [(34.0±1.6) vs (32.2±1.9) cm] and the ratio of chest circumference to head circumference of the newborn [(0.99±0.03) vs (0.97±0.03)] between the two groups(P＜0.05).The 1-minute Apgar score of the newborn (7.4±2.8) was significantly lower than the control group (10.0±0.0) (P＜0.01).Clavicular fracture occurred in 3 newborns and brachial plexus injury occurred in 4 newborns in the shoulder dystosia group.Conclusion It is difficult to predict shoulder dystocia in non-macrosomia.Shoulder dystocia of non-macrosomia could be predicted by measurement of the head circumference,chest circumference,the ratio of chest circunfference to head circumference by using prenatal ultrasound.The risk factors may complicated with premature rupture of membrane,abnormal occiput position during the first stage of labor and prolonged second stage of labor.
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