1、1现代分娩管理10/24/20222现代分娩管理10/24/20223现代分娩管理10/24/2022剖宫产率剖宫产率Hamilton BE,Martin JA,Ventura SJ.Births:Preliminary data for 2010.National vital statistics reports;vol 60 no 2.National Center for Health Statistics.2011.4现代分娩管理10/24/2022Clark,S.,et al.Maternal death in the 21st century:causes,prevention,a
2、nd relationship to cesarean delivery.Am J Obstet Gynecol 2008;199:36.e1-36.e5.5现代分娩管理10/24/2022Washington S,et al.Birth,2012 6现代分娩管理10/24/2022避免第一胎剖宫产避免第一胎剖宫产7现代分娩管理10/24/2022初次剖宫产的主要适应症初次剖宫产的主要适应症先露异常多胎高血压综合征巨大儿产妇需求8现代分娩管理10/24/2022典型的正常分娩:First stage Second stageFriedman EA.Primigravid labor.Obste
3、t Gynecol 1955 9现代分娩管理10/24/202210现代分娩管理10/24/2022Friedman et al.Am J Obstet Gynecol,1954Friedman et al.Am J Obstet Gynecol,195511现代分娩管理10/24/2022Friedman et al.Am J Obstet Gynecol,1954Friedman et al.Am J Obstet Gynecol,195512现代分娩管理10/24/2022潜伏期潜伏期活跃期活跃期均数8.6 hrs3.0 cm/hr95%ile20.6 hrs1.2 cm/hrFried
4、man et al.Am J Obstet Gynecol,1954Friedman et al.Am J Obstet Gynecol,195513现代分娩管理10/24/2022某种程度上14现代分娩管理10/24/2022Zhang et al.Reassessing the labor curve in nulliparous women.Am J Obstet Gynecol 2002Cervical Dilation(cm)Zhang:1162 位初产妇，位初产妇，with term？头位？头位,单胎，自然分娩单胎，自然分娩(1992-1996)15现代分娩管理10/24/2022
5、16现代分娩管理10/24/2022Friedman EA.Primigravid labor.Obstet Gynecol 1955Zhang et al.Reassessing the labor curve in nulliparous women.Am J Obstet Gynecol 2002Friedman(n=500)Zhang(n=1162)数据收集1950s1992-1996出生体重 2500-4000gm85%100%引产4%0%硬膜外麻醉8%48%加大催产素剂量9%50%低位钳夹/负压吸引51%13%Friedman vs.Zhang17现代分娩管理10/24/2022Z
6、hang et al.Obstet&Gynecol,201018现代分娩管理10/24/2022Zhang et al.Obstet&Gynecol,201019现代分娩管理10/24/2022Friedman,1954Zhang,2010中位数最小值5%中位数最小值 5%初产3.0cm/hour1.2cm/hour1.9cm/hour0.4cm/hourFriedman et al.Am J Obstet Gynecol 1954Zhang et al.Obstet&Gynecol,201020现代分娩管理10/24/2022Nullips,Hrs(cum%)Multips,Hrs(cum%
7、)cmSpontaneousInducedSpontaneousInduced013.8(0.3)14.5(4)-(0.1)16.0(2)110.0(2)9.4(10)-(1)11.7(6)26.8(3)5.6(15)-(3)8.6(9)34.0(7)4.3(23)6.9(6)5.5(16)44.0(17)4.0(40)2.7(14)3.4(29)53.5(28)3.2(53)4.0(19)2.4(44)62.9(38)2.8(63)3.6(31)2.5(54)72.8(46)2.2(69)2.8(39)2.6(63)83.0(56)2.6(75)2.8(53)2.9(71)92.2(65)2
8、.3(81)2.8(69)1.7(83)2nd stg3.8(100)3.5(100)2.9(100)2.8(100)Zhang et al.Am J Obstet Gynecol 201021现代分娩管理10/24/202222现代分娩管理10/24/202223现代分娩管理10/24/202224现代分娩管理10/24/202225现代分娩管理10/24/202226现代分娩管理10/24/202227现代分娩管理10/24/202228现代分娩管理10/24/202229现代分娩管理10/24/202230现代分娩管理10/24/2022 First stage Second stage
9、Friedman EA.Primigravid labor.Obstet Gynecol 1955 ACOG Practice bulletin.Dystocia and augmentation of labor.No 49;Obstet Gynecol 2003n第二产程第二产程n 初产：初产：2 hoursn 经产经产:1 hour31现代分娩管理10/24/2022Friedman EA.Primigravid labor.Obstet Gynecol 1955Zhang et al.Reassessing the labor curve in nulliparous women.Am
10、 J Obstet Gynecol 2002Friedman(n=500)Zhang(n=1162)数据收集1950s1992-1996出生体重 2500-4000gm85%100%引产4%0%硬膜外麻醉8%48%加大催产素剂量9%50%低位钳夹/负压吸引51%13%Friedman vs.Zhang32现代分娩管理10/24/202233现代分娩管理10/24/202234现代分娩管理10/24/2022正常的第二产程是什么样的正常的第二产程是什么样的?当前定义当前定义初产初产:未经硬膜外镇痛，未经硬膜外镇痛，2 h 经硬膜外镇痛，经硬膜外镇痛，3 h多产多产:未经硬膜外镇痛，未经硬膜外镇痛
11、，1 h 经硬膜外镇痛，经硬膜外镇痛，2 hACOG Practice bulletin.Dystocia and augmentation of labor.No 49;Obstet Gynecol 200335现代分娩管理10/24/2022Zhang et al.Does epidural prolong labor&increase risk of cesarean delivery.Am J Obstet Gynecol 2001Kilpatrick et al.Characteristics of normal labor.Obstet Gynecol 198936现代分娩管理10
12、/24/2022n初产妇的第二产程初产妇的第二产程Zhang J et al.Reassessing labor curve in nulliparous women.Am J Obstet Gynecol 2002 StationTime(minutes)1%ile Median 95%ile+1 to +2 1 16 176+2 to +3 1 7 3837现代分娩管理10/24/202238现代分娩管理10/24/202239现代分娩管理10/24/2022中位数95%ile初产，无硬膜外麻醉初产，无硬膜外麻醉 50 min201 min初产，硬膜外麻醉初产，硬膜外麻醉126 min33
13、9 min初产，无硬膜外麻醉初产，无硬膜外麻醉14 min 84 min经产，硬膜外麻醉经产，硬膜外麻醉40 min262 min结果结果:第二产程第二产程p=4 Cheng et al.How long is too long.Am J Obstet Gynecol 2004%初产妇初产妇第二产程结果第二产程结果n15,759 初产妇第二产程分娩情况初产妇第二产程分娩情况 n第二产程时间与分娩模式第二产程时间与分娩模式Spontaneous VDOperative VDCesarean42现代分娩管理10/24/2022Cheng et al.How long is too long.Am
14、J Obstet Gynecol 2004第二产程延长的结果第二产程延长的结果子宫肌内膜炎绒毛膜羊膜炎撕裂伤产后出血剖宫产辅助阴道分娩胎粪43现代分娩管理10/24/2022Cheng et al.How long is too long.Am J Obstet Gynecol 20044h以后的结果以后的结果44现代分娩管理10/24/2022%p0.001 for allMyers et al.Maternal&neonatal outcomes in patient with a prolonged 2nd stage.Obstet Gynecol 200345现代分娩管理10/24/2
15、022Allen et al.Maternal and Perinatal outcomes with increasing duration of 2nd stage.Obstet Gynecol 2009延延长长不延不延长长局部麻醉 Yes No15%2%85%98%加速产程 Yes No23%5%77%95%分娩方式 SVD OpVD Cesarean35%43%22%89%10%1%46现代分娩管理10/24/2022Allen et al.Maternal and Perinatal outcomes with increasing duration of 2nd stage.Obs
16、tet Gynecol 2009初产5 hr产后 出血6.0%1.301.531.591.75输血0.5%0.890.620.530.64OB？创伤0.2%1.451.842.072.18子宫肌内膜炎 2.3%1.301.631.511.49Referent:2nd stage 2 hrs(baseline rate);aOR by 2nd stage duration compared to referent47现代分娩管理10/24/2022Allen et al.Maternal and Perinatal outcomes with increasing duration of 2nd
17、 stage.Obstet Gynecol 2009初产5 hr5min Apgar71.01%1.331.361.041.12Major trauma0.13%1.280.610.871.21败血症0.35%0.891.130.881.00NICU 5.31%1.241.641.681.46Referent:2nd stage 3 hours2nd stage 0-3 hours孕妇临产孕妇临产 辅助阴道分娩自然分娩 辅助阴道分娩继续待产剖宫产剖宫产 Cheng YW,et al.JMFMNM,201149现代分娩管理10/24/20222nd stage 3 hours2nd stage
18、0-3 hours孕妇临产孕妇临产 辅助阴道分娩自然分娩辅助阴道分娩继续待产Cheng YW,et al.JMFMNM,201150现代分娩管理10/24/2022Cheng YW,et al.JMFMNM,201151现代分娩管理10/24/202252现代分娩管理10/24/202253现代分娩管理10/24/2022Fraser WD et al.AJOG,2000;182:1165-7254现代分娩管理10/24/2022Fraseret al.Multicentered,RTC of delayed pushing for nulliparas in the second stage
19、 with continuous epidural analgesia.Am J Obstet Gynecol 2002延延迟发动迟发动(n=926)早期早期发动发动(n=936)有效率有效率 95%CI第二产程时间(min)187min(86-314)123min(49-248)-手术分娩 Mid-骨盆 procedures Low-骨盆 procedure 剖宫产17.8%9.3%3.5%5.0%22.5%13.0%3.8%5.7%0.79 0.66-0.950.72 0.55-0.930.93 0.58-1.490.88 0.60-1.293rd/4th degree 撕裂伤 9.3%9
20、.5%NSEBL500ml17.6%16.8%NS55现代分娩管理10/24/2022Fraseret al.Multicentered,RTC of delayed pushing for nulliparas in the second stage with continuous epidural analgesia.Am J Obstet Gynecol 2002延延迟发动迟发动(n=926)早期早期发动发动(n=936)P-value5-min Apgar82.8%3.1%NS需要辅助通气 6.9%6.3%NS非正常脐带 pH4.5%1.8%0.0556现代分娩管理10/24/2022
21、相相对风险对风险95%CI自发阴道分娩1.081.01 1.15手术阴道分娩0.770.77 0.85剖宫产0.800.57 1.12发动持续时间-0.19-0.27 -0.12会阴撕裂伤0.880.72 1.07外阴切开术0.970.88 1.06Broncato et al.A meta-analysis of passive descent versus immediate pushing in nulliparous women with epidural analgesia in the 2nd stage of labor.J Obstet Gynecol Neonatal Nurs 200857现代分娩管理10/24/202258现代分娩管理10/24/202259现代分娩管理10/24/2022Thank You 60现代分娩管理10/24/2022
