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肩难产的产时诊断、处理和结局

Author
John F Rodis, MD
Section Editor
Charles J Lockwood, MD, MHCM
Deputy Editor
Vanessa A Barss, MD, FACOG
Translators
高岩, 主任医师

引言

分娩胎儿头部时及分娩胎儿头部后阴道分娩可发生肩难产，除了轻柔地牵引之外，还需要额外的产科操作手法以娩出胎儿肩部。肩难产在所有分娩中的发生率为0.2%-3%，是一种产科急症[1,2]。由于大多数肩难产都是在无危险因素的情况下发生，仅极少数肩难产可被预测及预防。因此产科医生必须有准备能立刻识别肩难产，并能采取有序的操作步骤及时将胎儿娩出。处理肩难产的目标是预防胎儿窒息和永久性Erb's麻痹或死亡，同时避免物理性损伤(如骨折、母体创伤)，但如果是为了预防孩子的永久性损伤，物理性损伤是可以接受的。

本文将总结肩难产的产时诊断和处理。肩难产的危险因素和对可能肩难产妊娠的处理将单独讨论。 (参见“肩难产：危险因素及相应高危妊娠时的计划分娩”)

病理生理学

胎儿双肩径(胎肩最外部分之间的距离)通常以后肩先于前肩的斜角进入骨盆，随着胎头的外旋在骨盆出口转为前-后位。前肩随后可在耻骨联合下方滑过娩出(图 1)。如果在下降过程中胎儿双肩保持前后位或同时下降而非依次下降进入骨盆入口，那么前肩可能嵌顿于耻骨联合后方；后肩可被骶岬阻挡。前梗阻较后梗阻常见。如果胎头继续下降，而前或后肩持续嵌顿，则可能出现臂丛神经拉伸，并导致神经损伤。

出生时诊断的损伤可能是源于产前的损害、与临产和嵌顿肩部自身相关的创伤或由助产人员娩出胎儿的尝试所造成。脐带受压，绷紧的绕颈脐带压迫胎儿颈部血管，或这些因素的联合作用可能会引起酸血症[3]。

诊断

肩难产是一种主观的临床诊断。当胎头娩出后由于胎肩在骨盆入口嵌顿产生的反向牵引力导致胎头退回会阴部(即乌龟征)时，应怀疑肩难产。若常规向下轻柔牵引胎头仍无法完成前肩的娩出，可作出肩难产的诊断。

                        

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Literature review current through: 2017-06 . | This topic last updated: 2017-06-22.
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