新产程的应用对母儿结局的影响

The impact of new labor management on maternal and neonatal outcomes

目的探究新产程应用的安全性及对母儿妊娠结局的影响。方法回顾性分析2014年10月—2015年3月在复旦大学附属妇产科医院实行旧产程管理分娩的3122例产妇(旧产程组)与2018年10月—2019年3月采取新产程标准管理产分娩的2732例产妇(新产程组)的临床资料,比较两组产妇人工干预率、中转剖宫产率及母儿并发症发生情况。结果新产程组人工破膜率、缩宫素使用率、中转剖宫率显著低于旧产程组[分别为45.53%(1244/2732)、17.64%(482/2732)、6.29%(172/2732)与52.30%(1633/3122)、22.29%(696/3122)、9.58%(299/3122),χ^(2)=26.70、19.62、18.11,P<0.001]。新产程组母体产后出血及新生儿窒息比例与旧产程相比差异无统计学意义[分别为2.56%(70/2732)、1.20%(33/2732)与2.79%(87/3122)、0.99%(31/3122),χ^(2)=0.28、0.62,P>0.05]。新产程组孕妇第一产程时限、破膜时间至胎儿娩出时间均较旧产程组显著延长[26.2(21.4~28.8) h与14.2(12.9~16.3)h,Z=18.91;31.8(26.3~33.7)与26.3(14.9~29.1)h,Z=14.13,P<0.001],但第二产程时间并无明显差异[1.3(0.5~1.9)h与1.2(0.6~1.4)h,P>0.05]。新产程组分娩镇痛率[77.3%(304/393)]及阴道检查次数[6(2~12)]显著多于旧产程组[45.0%(92/204)、4(1~9),P<0.001]。新产程中产时发热率高于旧产程组[14.39%(393/2732)与6.53%(204/3122),χ^(2)=20.57,P<0.001]。与旧产程相比,新产程中产时发热产妇的临床绒毛膜羊膜炎发病率[26.97%(106/393)与19.60%(40/204),χ^(2)=3.94,P=0.046]、产后出血发生率[10.68%(42/393)与5.39%(11/204),χ^(2)=4.43,P=0.035]显著升高,但宫腔培养阳性率[3.42%(6/186)与2.43%(3/123),χ^(2)=0.16,P=0.687]及新生儿感染发生率(17.04%(67/393)与15.68%(32/204),χ^(2)=0.18,P=0.671)无明显差异。结论新产程标准下人工干预的实施及中转剖宫产率显著降低,同时并未明显增加产后出血及新生儿窒息率。但新产程的产时发热孕妇比例率增高,且产后出血及临床绒毛膜羊膜炎发生比例增加。

Objective To investigate the safety of the application of new labor standards and its impact on maternal and neonatal pregnancy outcomes. Methods Retrospective analysis of the clinical data for 3122 maternity women(old labor group) from October 2014 to March 2015 and 2732 maternity women(new labor group in Obstetrics and Gynecology Hospital of Fudan University) from October 2018 to March 2019. The proportion of artificial intervention, transition to cesarean section,and occurrence of maternal and neonatal complications were compared between these two groups. Results The rate of the artificial interventions of AROM and labor acceleration with oxytocin and transition to cesarean section in the new labor group were 45.53%(1244/2732), 17.64%(482/2732) and 6.29%(172/2732) respectively, which were significantly lower compared with the old labor group [52.30%(1633/3122), 22.29%(696/3122) and 9.58%(299/3122), χ^(2)=26.70, 19.62, 18.11, P<0.001].The rate of maternal postpartum hemorrhage and neonatal asphyxia in the new labor group were 2.56%(70/2732) and 1.20%(33/2732), respectively, which showed no significant difference compared with the old labor [2.79%(87/3122), 0.99%(31/3122), χ^(2)=0.28, 0.62, P>0.05]. The duration at the first stage of labor(26.2(21.4–28.8) h vs 14.2(12.9–16.3) h, Z=18.91)and the time interval from membrane rupture to delivery(31.8(26.3–33.7) h vs 26.3(14.9–29.1) h, Z=14.13) were extreme significantly longer than those in the old stage of labor group(P<0.001), but there was no significant difference at the second stage of labor [1.3(0.5–1.9) h vs 1.2(0.6–1.4) h, P>0.05]. The rate of labor analgesia [77.3%(304/393) vs 45.0%(92/204)]and the frequency of vaginal examination(6 vs 4) in the new labor group were significantly higher than those of old labor group(P<0.001). However, the occurrence of maternal intrapartum fever in the new labor group was remarkably higher than that in old labor group [14.39%(393/2732) vs 6.53%(204/3122), χ^(2)=20.57, P<0.001]. Compared with the old labor group, the incidence of clinical chorioamnionitis [26.97%(106/393) vs 19.60%(40/204), χ^(2)=3.94, P=0.046] and postpartum hemorrhage [10.68%(42/393) vs 5.39%(11/204), χ^(2)=4.43, P=0.035] significantly increased in the new stage of labor, while the rate of positive intrauterine culture [3.42%(6/186) vs 2.43%(3/123), χ^(2)=0.16, P=0.687] and neonatal infection [17.04%(67/393) vs 15.68%(32/204), χ^(2)=0.18, P=0.671] were not significantly different. Conclusion The rate of artificial intervention and transition to cesarean section were significantly lower for the new labor group, and the postpartum hemorrhage and neonatal asphyxia rate were not evidently increased. However, the application of the new labor standards was associated with the higher occurrence of intrapartum fever during labor, which resulted in an increase in the incidence of postpartum hemorrhage and clinical chorioamnionitis in pregnant women with intrapartum fever.