总产程超过24小时产妇的高危因素及母婴结局分析

Risk Factors and Maternal and Neonatal Outcomes of Pregnant Women with Total Labor over 24 Hours

背景规范的产程管理对保障母婴安全非常重要。随着新产程模式的发布,现已不再强调滞产的概念,在新产程模式下,要求尽量减少产程干预,因此总产程>24 h的产妇数量较前增多。目的分析总产程>24 h产妇的高危因素及母婴结局,探讨在新产程模式下的产程管理。方法本研究为回顾性研究,收集2022年在南京医科大学第一附属医院产科产检并分娩的产妇临床资料,选择总产程延长的单胎、头位初产妇40例为观察组(总产程>24 h),同期住院分娩的产程正常的单胎、头位初产妇95例为对照组(总产程≤24 h),比较两组产妇的年龄、BMI、分娩孕周、妊娠期糖尿病、妊娠期高血压、新生儿体质量、产程情况、镇痛分娩率、分娩干预率。采用多因素Logistic回归分析探讨产妇总产程>24 h的高危因素。比较两组母婴结局情况:是否有产时发热、羊水污染、会阴侧切、阴道助产、宫颈裂伤、产后出血、人工剥离胎盘等,是否有胎儿窘迫、新生儿窒息及是否转新生儿重症监护病房(NICU)。结果两组产妇年龄、BMI、分娩孕周、妊娠期高血压、妊娠期糖尿病、新生儿体质量比较,差异均无统计学意义(P>0.05)。观察组产妇第一产程、第二产程、总产程时长均长于对照组,分娩镇痛率及分娩干预率均高于对照组(P<0.05);但多因素Logistic回归分析显示,分娩镇痛及分娩干预均不是导致总产程>24 h的影响因素(P>0.05)。两组产妇产后出血、人工剥离胎盘及新生儿窒息发生率比较,差异无统计学意义(P>0.05);观察组产妇产时发热、羊水污染、会阴侧切、阴道助产、宫颈裂伤及胎儿窘迫、新生儿转NICU发生率均高于对照组(P<0.05);两组均未发生新生儿窒息。结论由于产程的延长,总产程>24 h的产妇分娩过程中的分娩镇痛率及分娩干预率显著提高。总产程>24 h不会导致产妇产后出血、人工剥离胎盘及新生儿窒息发生率的升高,但会增加产妇产时发热、羊水污染、会阴侧切、阴道助产、宫颈裂伤及胎儿窘迫、新生儿转NICU的发生率。妇产科医生应重视总产程延长导致的母婴不良结局,个体化管理产程。

Background It is of great importance to standardize labor management for ensuring maternal and neonatal safety.Since the publication of the new stage of labor,the definition of prolonged labor has not been emphasized and it is recommended to minimize interventions during labor,therefore,the number of pregnant women with labor over 24 h is increased compared to the previous.Objective To analyze the risk factors and maternal and neonatal outcomes of pregnant women with labor over 24 h and discuss the labor management under the new stage of labor.Methods The clinical data of pregnant women received maternity examination and delivered at Department of Obstetrics,the First Affiliated Hospital with Nanjing Medical University from January to December 2022 were collected in the retrospective study.A total of 40 single birth pregnant women with normal fetal position and prolonged total labor(more than 24 h)were selected as the observational group,and 95 single birth pregnant women with normal fetal position and normal total labor(less than 24 h)were selected as the control group.The age,BMI,gestational age of delivery,gestational diabetes,gestational hypertension,neonatal body mass,labor condition,analgesic delivery rate and delivery intervention rate of the two groups were compared.Multivariate Logistic regression analysis was used to explore the risk factors for total labor over 24 h.The maternal and neonatal outcomes including intrapartum fever,amniotic fluid contamination,mediolateral episiotomy,vaginal instrumental delivery,cervical laceration,postpartum hemorrhage,manual removal of placenta,fetal distress,neonatal asphyxia and referral to neonatal intensive care unit(NICU)were compared to screen the risk factors and analyse the maternal and neonatal outcomes of pregnant women with labor over 24 h.Results There were no significant differences in age,BMI,gestational age of delivery,gestational hypertension,gestational diabetes mellitus and neonate body mass between the two groups(P>0.05).The first stage of labor,second stage of labor and total labor were longer and the rates of labor analgesia and labor intervention were higher in the observational group than the control group(P<0.05).Multivariate Logistic regression analysis showed that labor analgesia and intervention were not risk factor for total labor over 24 h(P>0.05).There were no significant differences in the incidence of postpartum hemorrhage,vaginal instrumental delivery and fetal distress between the two groups(P>0.05);the incidence of intrapartum fever,amniotic fluid contamination,mediolateral episiotomy,vaginal instrumental delivery,cervical laceration and referral to NICU in the observational group was higher than the control group(P<0.05);no neonatal asphyxia occurred in both groups.Conclusion The rates of labor analgesia and labor intervention were significantly increased in pregnant women with total labor over 24 h due to prolonged labor.Although prolonged labor does not increase the incidence of postpartum hemorrhage,manual removal of placenta and neonatal asphyxia,it increases the incidence of intrapartum fever,amniotic fluid contamination,mediolateral episiotomy,vaginal instrumental delivery,cervical laceration and fetal distress.Obstetricians and gynecologists should pay attention to the adverse maternal and neonatal outcomes caused by prolonged labor and individualized management of labor.