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中华妇幼临床医学杂志(电子版) ›› 2016, Vol. 12 ›› Issue (02) : 221 -227. doi: 10.3877/cma.j.issn.1673-5250.2016.02.017

所属专题: 文献

综述

安全避免首次剖宫产
龚琳1, 刘兴会1, 张力1,*,*()   
  1. 1. 610041 成都,四川大学华西第二医院妇产科
  • 收稿日期:2015-11-10 修回日期:2016-01-10 出版日期:2016-04-01
  • 通信作者: 张力

Safe prevention of the primary cesarean delivery

Lin Gong1, Xinghui Liu1, Li Zhang1()   

  1. 1. Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
  • Received:2015-11-10 Revised:2016-01-10 Published:2016-04-01
  • Corresponding author: Li Zhang
  • About author:
    Corresponding author: Zhang Li, Email:
引用本文:

龚琳, 刘兴会, 张力. 安全避免首次剖宫产[J]. 中华妇幼临床医学杂志(电子版), 2016, 12(02): 221-227.

Lin Gong, Xinghui Liu, Li Zhang. Safe prevention of the primary cesarean delivery[J]. Chinese Journal of Obstetrics & Gynecology and Pediatrics(Electronic Edition), 2016, 12(02): 221-227.

2011年,美国剖宫产率达到33%,虽然剖宫产在特定情况下可以挽救母儿生命,但剖宫产率的快速增加并没有相应地降低围生期母儿发病率及病死率,这使过度应用剖宫产的医疗问题备受关注。笔者拟对美国妇产科联盟(ACOG)与母胎医学会(SMFM)联合发布的首个产科医疗共识进行综述。

In 2011, 33% women who gave birth in the United States did so by cesarean delivery. Although cesarean delivery can be lifesaving for both mother and fetus under specific circumstances, the rapid increase in the rate of cesarean delivery without concomitant decreases in maternal or neonatal morbidity or mortality. Those data prompt a significant concern that cesarean delivery is overused. This paper reviews the first obstetric care consensus released jointly by American Congress of Obstetricians and Gynecologists (ACOG) and Society for Maternal-Fetal Medicine (SMFM).

表1 安全避免首次剖宫产的建议及级别
建议 建议级别
第一产程  
  第一产程潜伏期延长(初产妇>20 h,经产妇>14 h)不应作为首次剖宫产指征 B
  第一产程进展延缓但有进展不应作为首次剖宫产指征 B
  宫口扩张≥6 cm可视为多数产妇进入第一产程活跃期的标志,在此之前不宜采用活跃期进展标准进行产程评价 B
  宫口扩张≥6 cm、胎膜已破裂,正常宫缩4 h或应用缩宫素>6 h仍然无进展者考虑活跃期停滞应行剖宫产 B
第二产程  
  第二产程最长时限(超过该时限应行剖宫产)尚未确定 C
  诊断第二产程停滞前,若产妇及胎儿情况允许,经产妇或初产妇分别正确使用腹压2~3 h;若产程有进展,可基于个体情况(如硬膜外镇痛、胎位不正)允许适当延长产程 B
  可由经验丰富和训练有素的产科医师实施阴道助产替代剖宫产,鼓励阴道助产技术培训 B
  当胎头下降异常时,评估胎位至关重要。发现胎位不正时,行阴道手术助产或剖宫产前应首先考虑徒手转胎位 B
引产  
  孕龄<41孕周前,决定引产应依据产妇和胎儿的医学指征。孕龄≥41孕周,应引产以降低剖宫产及围生期发病率和死亡率 A
  宫颈不成熟的孕妇,引产前应先促宫颈成熟 B
  若产妇和胎儿情况允许,延长潜伏期观察时间(可≥24 h)并在胎膜破裂后至少应用缩宫素12~18 h,可避免因潜伏期引产失败而转行剖宫产 B
胎心监护  
  重复变异减速时,羊膜腔灌注可安全降低首次剖宫产率 A
  胎心异常或不确定是否安全时,胎儿头皮刺激可用于评估胎儿体内酸碱状态,以避免不必要的首次剖宫产 C
  行剖宫产以避免潜在产伤仅限于如下情况:非糖尿病孕妇估计胎儿体重≥5 kg,糖尿病孕妇估计胎儿体重≥4.5 kg;胎儿出生体重≥5 kg的情况较为罕见,应告知产妇估计胎儿体重(尤其是在晚孕期)并不精确 C
孕妇体重增加过量  
  应告知孕妇美国IOM指南推荐的孕期体重增加建议,以避免其孕期体重增加过量 B
双胎妊娠  
  剖宫产并不能改善胎儿1为头先露的双胎妊娠的围生期结局。因此,建议头先露/头先露及头先露/非头先露双胎妊娠产妇尝试阴道试产 B
其他  
  个人、组织及政府机构应开展研究,积累证据,指导临床剖宫产决策的制定,并鼓励政策随研究进展而改变以安全降低首次剖宫产率 C
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