摘要目的 探讨肩难产的综合预防措施.方法 计算机检索2014年5月以前的PubMed数据库、美国EBSCO数据库、荷兰医学文摘数据库、Cochrane图书馆数据库,以“shoulder dystocia and prevention”为主题词检索英文文献.对检索到的文献进行质量评价,文献研究类型仅限于随机对照临床试验(RCT)研究;研究对象为经阴道分娩产妇,干预措施包括孕期管理、预防性引产、预防性剖宫产术,预防性肩难产处理.纳入的文献采用RevMan 5.1软件进行荟萃分析,以肩难产发生率作为终点指标.结果 共有16篇英文文献纳入荟萃分析,发表时间为1993-2009年.(1)对妊娠期糖尿病(GDM)孕妇的孕期干预:有2篇文献比较了GDM孕妇的孕期干预(干预组)与不干预(不干预组)对肩难产发生率的影响,结果显示,干预组肩难产发生率显著低于不干预组(OR=0.40,95％ CI为0.21～0.75,P=0.004).(2)对GDM孕妇的孕期严格干预:5篇文献比较了GDM孕妇的孕期严格干预(饮食控制+胰岛素应用;严格干预组)与不严格干预(单纯饮食控制等;不严格干预组)对肩难产发生率的影响,结果显示,严格干预组肩难产发生率显著低于不严格干预组(OR=0.29,95％CI为0.11～ 0.73,P=0.009).(3)非糖尿病孕妇可疑巨大儿者引产:有4篇文献比较了非糖尿病孕妇可疑巨大儿者提前引产(提前引产组)对肩难产发生的影响,结果显示,提前引产组肩难产发生率与对照组比较,差异无统计学意义(OR=0.85,95％CI为0.41～ 1.75,P=0.660).(4)GDM孕妇引产:有2篇文献比较了GDM孕妇提前引产(孕38～ 39周;提前引产组)对肩难产发生的影响,结果显示,提前引产组肩难产发生率与对照组比较,差异有统计学意义(OR=0.18,95％CI为0.03～ 0.97,P=0.050);只与对照组中孕40周以后分娩者比较,提前引产组肩难产发生率显著低于对照组(OR=0.13,95％ CI为0.02～ 0.75,P=0.020).(5)GDM孕妇可疑巨大儿者提前终止妊娠:仅有1篇文献比较了GDM孕妇中可疑巨大儿者提前终止妊娠(提前终止妊娠)对肩难产发生率的影响,结果显示,提前终止妊娠组的肩难产发生率与对照组比较,差异有统计学意义(OR=0.34,95％CI为0.12～ 0.99,P=0.050).(6)产时预防性干预(产时干预组)对肩难产发生率的影响:有2篇文献比较了产时胎头娩出后行预防性干预对肩难产发生率的影响,结果显示,产时干预组肩难产发生率与对照组比较,差异无统计学意义(OR=0.44,95％CI为0.16～ 1.18,P=0.100).结论 对有肩难产高危因素的孕妇适当进行临床措施的干预,可明显降低肩难产的发生率.

abstractsObjective To investigate the composite prevention strategy for shoulder dystocia.Methods The published articles of randomized controlled trial (RCT)of comparison about the prevention of shoulder dystocia were searched in PubMed,EMBASE,EBSCO databases and Cochrane Library,and these studies were screened under inclusion and exclusion criteria.The quality of included studies were evaluated.And the Meta-analysis using statistic software RevMan 5.1 was completed.Results Totally 16 articles,all English published with no one Chinese article being searched out,were included in this analysis,published from 1993 to 2009.(1)To the gestational diabetes mellitus (GDM)patients,reviewed from 2 articles,it was found that the incidence of shoulder dystocia was reduced significantly by prenatal intervention versus usual care (OR=0.40,95％ CI:0.21-0.75,P=0.004).(2)To the GDM patients with intensive prenatal intervention,reviewed form 5 articles,it was found that the incidence of shoulder dystocia was reduced significantly by intensive intervention (diet control combined with insulin if necessary)versus less intensive intervention (only diet control),OR=0.29 (95 ％ CI:0.11-0.73,P=0.009).(3) To the non-GDM patients with suspected macrosomia,reviewed from 4 articles,it was found that the incidence of shoulder dystocia was not reduced by early artificial induction of parturition (OR=0.85,95 ％ CI:0.41-1.75,P=0.660).(4)To the GDM patients,reviewed form 2 articles,it was found that the incidence of shoulder dystocia was reduced marginal significantly by artificial induction of parturition in 38-39 gestational weeks compared with all spontaneous parturition patients (OR=0.18,95 ％ CI:0.03-0.97,P=0.050) and significantly reduced when compared with those spontaneous parturition patients after 40 gestational weeks (OR=0.13,95 ％ CI:0.02-0.75,P=0.020).(5)To the GDM patients with suspected macrosomia,reviewed from only one article,it was found that the incidence of shoulder dystoeia was reduced marginal significantly by early artificial induction of parturition (OR=0.34,95 ％ CI:0.12-0.99,P=0.050).(6)Reviewed from 2 articles,it was found that the incidence of shoulder dystocia was not significantly reduced by the intrapartum prophylactic maneuvers (OR=0.44,95％ CI:0.16-1.18,P=0.100).Conclusion Some varieties of intervention for the high risk patients could reduced the occurrence of shoulder dystocia.