协和医学杂志

2013, v.4(02) 169-173

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肩难产高危因素、产程特点及并发症
Risk Factors,Labor Characteristics,and Outcomes of Shoulder Dystocia

宋英娜;刘俊涛;杨剑秋;边旭明;李雷;
SONG Ying-na,LIU Jun-tao,YANG Jian-qiu,BIAN Xu-ming,LI Lei Department of Obstetrics and Gynecology,Peking Union Medical College Hospital,Chinese Academy of Medical Sciences & Peking Union Medical College,Beijing 100730,China

摘要(Abstract):

目的探讨肩难产发生的高危因素、产程特点及其对母婴结局的影响。方法选择北京协和医院1993年至2012年间的81例肩难产患者作为病例组,同期随机选取的足月、单胎、头位、阴道分娩者共6299例为对照组,回顾性分析肩难产发生的高危因素及其对母婴结局的影响。结果肩难产的发生率为0.47%(81/17287)。分娩时孕周大于40周及合并糖尿病者肩难产的发生率明显增加(P均<0.001)。肩难产组产程中出现宫缩乏力、胎心监护异常、羊水Ⅲ度污染的比例明显高于对照组(P均<0.001)。肩难产组中有更多的患者采取了助产及会阴切开(P均<0.001)。肩难产组的新生儿体重明显大于对照组(P=0.004),新生儿锁骨骨折、臂丛神经损伤、新生儿窒息及会阴Ⅱ度以上裂伤的比例高于对照组(P均<0.001)。多因素Logistic回归分析显示巨大儿、宫缩乏力、合并糖尿病、采用助产、孕周大于40周为导致肩难产的独立危险因素(P均<0.001)。结论巨大儿、合并糖尿病、孕周大于40周是肩难产发生的高危因素,产程中出现继发性宫缩乏力、采用助产时要高度警惕肩难产发生的可能。母婴并发症与是否使用助产及新生儿出生体重有关。
Objective To investigate the risk factors,labor characteristics,and perinatal outcomes of shoulder dystocia (SD) . Methods The clinical data of 81 SD cases who were admitted to Peking Union Medical College from January 1993 to December 2012 were retrospectively analyzed. Meanwhile,6299 cases of term vaginal deliveries of singleton offspring in cephalic presentation during the same period were enrolled as the control group. The risk factors of SD and its influence on the maternal and neonatal outcomes were retrospectively analyzed. Results The incidence of SD during this period was 0. 47% (81/17 287) . The incidence of SD significantly increased in fetuses with gestational age of greater than 40 weeks and in mothers with diabetes mellitus (both P <0. 001) . The SD group had significantly higher rates of uterine inertia (54. 3%) ,abnormal fetal heart rate (27. 2%) ,and meconium stained amniotic fluid (22. 2%) than in the control group (all P < 0. 001) . More patients in the SD group received assisted deliveries (24. 7%) and episiotomy (93. 8%) (both P < 0. 001) . Newborns delivered after SD had significantly higher rates of asphyxia (19. 8%) ,clavicular fracture (18. 5%) and brachial plexus injury (6. 2%) (all P <0. 001) . Their body weight was also significantly higher (P =0. 004) . Multivariable analysis showed the independent risk factors for SD included macrosomia (OR = 12. 7; 95% CI: 7. 6-21. 4) ,uterine inertia (OR = 12. 1; 95% CI : 7. 3-20. 1) ,diabetes mellitus (OR =8. 4; 95% CI: 5. 0-14. 8) ,assisted deliveries (OR = 6. 6; 95% CI: 3. 5-12. 4) and deliveries after due date (OR =2. 6; 95% CI: 1. 6-4. 3) (all P < 0. 001) . Conclusions Macrosomia,deliveries after due date,and diabetes mellitus are risk factors of SD. SD should be suspected when secondary uterine inertia exists or assisted delivery is applied. The maternal and neonatal complications are closely related with fetal weight and assisted deliveries.

关键词(KeyWords): 肩难产;高危因素;并发症
shoulder dystocia; high risk factors; complication

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作者(Author): 宋英娜;刘俊涛;杨剑秋;边旭明;李雷;
SONG Ying-na,LIU Jun-tao,YANG Jian-qiu,BIAN Xu-ming,LI Lei Department of Obstetrics and Gynecology,Peking Union Medical College Hospital,Chinese Academy of Medical Sciences & Peking Union Medical College,Beijing 100730,China

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