肩难产发生的危险因素和临床特征的多中心分析

Multicenter analysis of risk factors and clinical characteristics of shoulder dystocia

目的 探讨肩难产发生的危险因素和临床特征.方法 收集2008年1月至2013年9月,广州医科大学附属第三医院等5家医院住院的足月妊娠、单胎、头位并经阴道分娩的产妇共44 580例,其中发生肩难产116例（肩难产组）,其余未发生肩难产者为对照组.对两组产妇的临床资料进行回顾性分析,包括年龄、身高、孕前体质指数（BMI）、孕期体质量增重值、孕周、孕次、产次、宫高、腹围、既往肩难产病史、分娩巨大儿、妊娠期糖尿病、糖尿病合并妊娠、过期妊娠及产程情况.结果 （1）44 580例产妇中发生肩难产116例,发生率为0.260％（116/44 580）.肩难产组产妇年龄、孕前BMI、孕期体质量增重值明显高于对照组,两组比较,差异均有统计学意义（P＜0.01）;两组产妇身高、孕周、孕产次、宫高及腹围分别比较,差异均无统计学意义（P＞0.05）.（2）肩难产组产妇有肩难产病史（11.21％,13/116）、分娩巨大儿（13.79％,16/116）、糖尿病合并妊娠（7.76％,9/116）、过期妊娠（10.34％,12/116）、最大加速期延长（8.62％,10/116）及第二产程延长（7.76％,9/116）的发生率,分别与对照组[分别为（1.43％,636/44 464）、（1.48％,658/44 464）、（0.57％,252/44 464）、（1.15％,513/44 464）、（0.72％,322/44 464）、（0.65％,289/44 464）]比较,差异均有统计学意义（P＜0.05）.（3）logistic回归分析显示,产妇年龄＞35岁（OR=1.116,95％CI为1.022-2.445）、孕前BMI＞27 kg/m^2（OR=1.893,95％ CI为1.358-2.228）、孕期体质量增重值（＞20 kg）（OR=2.031,95％CI为1.749- 3.231）、肩难产病史（OR=2.138,95％ CI为1.564- 3.853）、分娩巨大儿（OR=3.276,95％CI为2.315- 4.638）、糖尿病合并妊娠（OR=3.261,95％CI为2.237- 4.943）、过期妊娠（OR=1.473,95％CI为1.003- 2.721）、最大加速期延长（OR=2.022,95％CI为1.681- 3.732）及第二产程延长（OR=1.943,95％CI为1.285- 3.215）,以上各项P值均＜0.05,是肩难产发生的危险因素.结论 高龄孕产妇（年龄＞35岁）、孕前BMI＞27 kg/m2、孕期体质量增重＞20 kg、肩难产病史、分娩巨大儿、糖尿病合并妊娠、过期妊娠、最大加速期延长及第二产程延长是肩难产发生的危险因素及临床特征.

Objective To explore the risk factors and clinical characteristics of shoulder dystocia.Methods The data of 44 580 single pregnancy and full-term head delivery were colleceted in the Third Affiliated Hospital of Guangzhou Medical University,Nanfang Hospital,Shenzhen Nanshan Hospital,Peking University Shenzhen Hospital and Yue Bei People＇s Hospital from January 2008 to September 2013.Totally 116 cases of shoulder dystocia were defined as the shoulder dystocia group,and the others were in the control group.The clinical data of the two groups were analyzed retrospectively,including the maternal age,maternal height,pre-gestational body mass index,weight gain during pregnancy,gestational weeks,gravidity,parity,fundal height,fetal abdominal perimeter,shoulder dystocia medical history,macrosomia,gestational diabetes mellitus,pre-gestational diabetes mellitus,post-term pregnancy and the condition of labor stages.Results （1） The incidence of shoulder dystocia was 0.260% （116/44 580）.The maternal age,pre-gestational body mass index and weight gain during pregnancy in the shoulder dystocia group were higher than those in the control group （all P〈0.01）.While the maternal height,gestational weeks,gravidity,parity,fundal height,abdominal circumference in the two groups had no significant difference （all P〉0.05）.（2） In the shoulder dystocia group,the incidence of shoulder dystocia medical history （11.21%,13/116）,macrosomia （13.79%,16/116）,pre-gestational diabetes mellitus （7.76%,9/116）,post-term pregnancy （10.34%,12/116）,prolongation of maximum acceleration phase （8.62%,10/116） and prolongation of second labor stage （7.76%,9/116） were different from those in the control group [1.43%（636/44 464）,1.48%（658/44 464）,0.57%（252/44 464）,1.15%（513/44 464）,0.72%（322/44 464）,0.65%（289/44 464）,respectively; all P〈0.05].（3） Logistic regression analysis showed that the risk factors of shoulder dystocia were maternal age over thirty-five years （OR=1.116,95%CI：1.022-2.445）,pre-gestational body mass index more than 27 kg/m^2 （OR=1.893,95%CI：1.358-2.228）,weight gain more than 20 kg during pregnancy （OR=2.031,95%CI：1.749-3.231）,shoulder dystocia medical history （OR=2.138,95%CI：1.564-3.853）,macrosomia （OR=3.276,95% CI：2.315-4.638）,pre-gestational diabetes mellitus （OR=3.261,95% CI：2.237-4.943）,post-term pregnancy （OR=1.473,95% CI：1.003-2.721）,prolongation of the maximum acceleration phase （OR=2.022,95% Ch 1.681-3.732）,prolongation of second labor stage（OR=1.943,95% CI：1.285-3.215）.Conclusion Maternal age over thirty-five years old,pre-gestational body mass index more than 27 kg/m2,weight gain more than 20 kg during pregnancy,shoulder dystocia medical history,macrosomia,pre-gestational diabetes mellitus,post-term pregnancy,prolongation of the maximum acceleration phase,and prolongation of second labor stage are risk factors and clinical characteristics of shoulder dystocia.