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.%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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