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新生儿产伤

Author
Tiffany M McKee-Garrett, MD
Section Editors
Leonard E Weisman, MD
William Phillips, MD
Marc C Patterson, MD, FRACP
Deputy Editor
Melanie S Kim, MD
Translators
王亚娟, 主任医师，副教授

引言

产伤是指由出生时的不良事件所导致的新生儿身体结构或功能的损伤。随着产科护理及产前诊断水平的不断发展，产伤的总体发生率已有所下降。据报道，单胎头位阴道分娩和剖宫产的新生儿产伤的发生率分别约为2%和1.1%[1,2]。损伤可能发生在临产时、分娩时或分娩后，尤其是需要在产房进行复苏的新生儿更可能发生产伤。

产伤的范围广泛，轻则为轻微的自限性损伤(如，撕裂伤或瘀斑)，重则为可能导致新生儿严重并发症或死亡的损伤(即，脊髓损伤)。

与出生时创伤及具体产伤相关的危险因素将总结在此。

危险因素

以下增加产伤风险的因素可由于胎儿因素(如，胎儿大小和胎先露)、母亲因素(如，母亲身材及是否存在骨盆异常)或分娩过程中使用产科器械。

  • 巨大儿–当胎儿体重超过4000g时，产伤的发生率与胎儿大小呈正比。一项研究显示，出生体重为4000-4499g、4500-4999g和大于5000g的新生儿的产伤发生率分别为正常新生儿的2倍、3倍和4.5倍[3]。另一项研究发现，出生体重大于4500g的婴儿的胎儿损伤发生率为7.7%[4]。

    巨大儿的诊断及其对肩难产的影响将单独详细讨论。 (参见“巨大儿”和“肩难产：危险因素及相应高危妊娠时的计划分娩”，关于‘疑似高出生体重的妊娠’一节)
  • 母亲肥胖–母亲肥胖[定义为体质指数(body mass index, BMI)大于40kg/m2]与产伤风险增加相关。这可能是因为肥胖的母亲在分娩过程中需要更大程度地使用器械，和/或这些母亲分娩大于胎龄儿并出现肩难产的风险增加[5]。 (参见“Obesity in pregnancy: Complications and maternal management”和“肥胖女性的剖宫产”)
  • 胎先露异常–非头先露的胎位(尤其是臀先露)在经阴道分娩时产伤风险增加。剖宫产分娩可降低臀先露婴儿经阴道分娩相关的并发症发病率，这部分内容将单独讨论。 (参见“臀先露概述”和“臀先露的胎儿娩出”)
  • 阴道助产–阴道助产是指临床医生使用产钳或负压设备协助母亲娩出胎儿的分娩方式。将助产工具置于胎头，然后临床医生通过牵引力向外拉出胎儿，通常在子宫收缩同时母亲向下用力时外拉。与非阴道助产相比，产钳和胎头吸引术均可使产伤发生率增加(表 1)。相继使用负压吸引和产钳比单独使用任何一种所致的产伤风险更大(表 2)。阴道助产所引起的新生儿并发症将会单独详细讨论。 (参见“Operative vaginal delivery”)
  • 剖宫产–与阴道分娩相比，经剖宫产娩出的新生儿发生产伤的风险通常更低。一项关于卫生保健成本和利用率项目全国住院患者样本(Health Care Cost and Utilization Project Nationwide Inpatient Sample)的分析证实了上述结果，研究显示，与阴道分娩相比，剖宫产发生所有产伤的可能性均降低(调整OR 0.55，95%CI 0.53-0.58)[6]。然而，当该分析使用由AHRQPSI(Agency for Healthcare Research and Quality Patient Safety Indicator)制定的产伤定义时，剖宫产会使产伤的风险增加(校正OR 1.65，95%CI 1.51-1.81)。AHRQPSI定义的产伤不包括锁骨骨折或臂丛神经和头皮损伤，而这些损伤更常见于阴道分娩。这些结果表明，根据产伤类型的不同，剖宫产和阴道分娩所致的产伤风险也有所差异。
  • 其他因素–一项研究报道称，男婴和初产妇所生婴儿发生头颈部损伤的概率增加[7]。此外，母亲身材矮小和骨盆异常会使产伤风险增加。 (参见“肩难产：危险因素及相应高危妊娠时的计划分娩”，关于‘骨盆测量和胎儿生物学测量’一节)

                          

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Literature review current through: 2017-06 . | This topic last updated: 2017-05-09.
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