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指南速递 | 2020 RCOG指南:阴道助产(No.26)

2020-12-17 15:14 来源: 中国妇产科网 作者: 中国妇产科网 浏览量: 895

图片译者:黄启涛 (南方医科大学南方医院)

审校:郑剑兰 (厦门大学附属成功医院、陆军第73集团军医院)

阴道助产的准备工作

阴道助产可以避免吗?

Encourage women to have continuous support during labour asthis can reduce the need for assisted vaginal birth.  A

鼓励妇女在分娩期间获得持续的支持,以减少对阴道助产的需求。A

Inform women that epidural analgesia may increase the need forassisted vaginal birth although this isless likely with newer analgesic techniques. [New 2020]  A

告知妇女硬膜外镇痛可能增加阴道助产的需求,尽管使用较新的镇痛技术则可能性较小。[New2020]    A

Inform women that administering epidural analgesia in thelatent phase of labour compared to the active phase oflabour does not increase the risk of assisted vaginal birth. [New 2020]  A

告知妇女,在潜伏期与活跃期采取硬膜外镇痛不会增加阴道助产的风险。[New2020]    A

Encourage women not using epidural analgesia to adopt uprightor lateral positions in the second stage oflabour as this reduces the need for assisted vaginal birth.  A

鼓励未实施硬膜外镇痛的妇女在第二产程中采用直立或侧卧位,因为这会减少对阴道助产的需求。    A

Encourage women using epidural analgesia to adopt lying downlateral positions rather than upright positionsin the second stage of labour as this increases the rate of spontaneous vaginal birth. [New 2020]  A

鼓励采取硬膜外镇痛的妇女在第二产程中采用侧卧位而不是直立位,因为这会增加自然阴道分娩的几率。[New2020]    A

Recommend delayed pushing for 1–2 hours in nulliparous womenwith epidural analgesia as this may reduce theneed for rotational and midpelvic assisted vaginal birth.  B

建议硬膜外镇痛的初产妇延迟1-2小时用力,因为这可以减少中骨盆平面阴道助产和旋转胎头的需要。    B

Do not routinely discontinue epidural analgesia during pushingas this increases the woman’s pain with no evidence of a reduction in the incidence of assisted vaginalbirth. [New 2020]  A

不要在用力过程中常规停用硬膜外镇痛,因为这会增加妇女的疼痛,而且也没有证据表明能使阴道助产的发生率降低。[New2020]    A

There is insufficient evidence to recommend any particularregional analgesia technique in terms of reducingthe incidence of assisted vaginal birth. [New  2020]  A

没有足够的证据建议采取特定的局部镇痛技术可以减少阴道助产的发生率。[New2020]    A

There is insufficient evidence to recommend routine oxytocinaugmentation for women with epidural analgesiaas a strategy to reduce the incidence of assisted vaginal birth. [New 2020]  A

没有足够证据建议对硬膜外镇痛的妇女常规使用缩宫素可减少阴道助产的发生率。[New2020]    A

There is insufficient evidence to recommend routineprophylactic manual rotation of fetal malposition in thesecond stage of labour to reduce the risk of assisted vaginal birth. [New 2020]  B

没有足够证据建议在第二产程常规手法旋转胎方位可以减少阴道助产的风险。[New2020]    B

如何评价阴道助产?

Use a standard classification system for assisted vaginal birthto promote safe clinical practice, effectivecommunication between health professionals and audit of outcomes.  D

对阴道助产使用标准分类系统,以促进临床实践的安全性,以及卫生专业人员之间的有效沟通和结果审核。    D

何时推荐/禁止阴道助产?

Operators should be aware that no indication is absolute andthat clinical judgment is required in all situations.  D

操作者应意识到没有绝对的指征,在任何情况下都需要临床判断。    D

Suspected fetal bleeding disorders or a predisposition tofracture are relative contraindications to assisted vaginal birth. [New 2020]  √

怀疑胎儿出血性疾病或有骨折倾向是阴道助产的相对禁忌症。[New2020]    √

Blood borne viral infections in the woman are not an absolutecontraindication to assisted vaginal birth. [New2020]  D

妇女血源性病毒感染并不是阴道助产的绝对禁忌症。[New2020]    D

The use of a vacuum is not contraindicated following a fetalblood sampling procedure or application of afetal scalp electrode. [New 2020]   B

胎儿血液采样或胎儿头皮电极后,不禁止使用胎头吸引术。[New2020]    B

Operators should be aware that there is a higher risk ofsubgaleal haemorrhage and scalp trauma with vacuumextraction compared with forceps at preterm gestational ages. Vacuum birthshould be avoided below 32 weeks of gestation and should be used with cautionbetween 32+0and 36+0weeks of gestation. [New 2020]  C

操作者应意识到,早产时胎头吸引比产钳导致帽状腱膜下出血和头皮损伤的风险更大。妊娠32周之前避免使用胎头吸引术,妊娠32+0周至36+0周之间应谨慎使用。[New2020]    C

阴道助产顺利的必备条件?

Safe assisted vaginal birth requires a careful assessment ofthe clinical situation, clear communication withthe woman and healthcare personnel, and expertise in the chosen procedure.   D

安全的阴道助产需要对临床状况仔细评估、医疗保健人员与妇女进行清楚的沟通,并具备所选方法的专业知识。    D

超声能否用于阴道助产前的评估?

Ultrasound assessment of the fetal head position prior toassisted vaginal birth is recommended where uncertainty exists followingclinical examination. [New 2020]  A

如果临床检查存在不确定性,推荐阴道助产前对胎头位置进行超声评估。[New2020]    A

There is insufficient evidence to recommend the routine use ofabdominal or perineal ultrasound forassessment of the station, flexion and descent of the fetal head in the second stage of labour. [New 2020]  C

没有足够证据建议常规使用腹部或会阴超声来评估第二产程胎头的位置、俯屈和下降程度。[New2020]    C

阴道助产前的知情同意

Women should be informed about assisted vaginal birth in theantenatal period, especially during their firstpregnancy. If they indicate specific restrictions or preferences then thisshould be explored with an experienced obstetrician, ideally inadvance of labour.  √

妇女在产前,特别是第一次怀孕期间,应了解阴道助产的情况。如果她们指出了特定的限制或偏好,应在分娩前与经验丰富的产科医生探讨。 √

For birth room procedures verbal consent should be obtainedprior to assisted vaginal birth and the discussionshould be documented in the notes.  √

在产房进行阴道助产前应征得口头同意,讨论应记录在相应文件中。 √

When midpelvic orrotational birth is indicated, therisks and benefits of assisted vaginal birth should be compared with the risks and benefits of second stage caesareanbirth for the given circumstances andskills of the operator. Written consent should be obtained for a trial of assisted vaginal birth in an operating theatre. [New2020]    √

当有中骨盆平面或需旋转胎头指征时,应根据操作者的特定情况和技能,将阴道助产的利弊与第二产程剖宫产的利弊进行比较。在手术室进行阴道助产应获得书面同意。[New2020]    √

实施阴道助产

阴道助产的手术人员

Assisted vaginal birth should be performed by, or in thepresence of, an operator who has the knowledge, skillsand experience necessary to assess the woman, complete the procedure and manageany complications that arise.  D

阴道助产应由具备必要知识、技能和经验的操作者在场或进行操作,并及时处理出现的并发症。D

Advise obstetric trainees to achieve expertise in spontaneousvaginal birth prior to commencing training inassisted vaginal birth.  √

建议产科实习生开始阴道助产相关培训之前,应先掌握好自然阴道分娩的专业知识。 √

Ensure obstetric trainees receive appropriate training invacuum and forceps birth, including theoreticalknowledge, simulation training and clinical training under direct supervision.[New 2020]  √

确保产科实习生接受适当的胎头吸引与产钳助产技术的培训,包括理论知识、模拟训练,并在导师指导下进行临床操练。[New2020]    √

Competency should be demonstrated before conductingunsupervised births. [New 2020]  √

在执行无人督导的分娩前,应证明其操作技能过关。[New2020]    √

Complex assisted vaginal births should only be performed byexperienced operators or under the directsupervision of an experienced operator.  D

复杂的阴道助产只能由经验丰富的操作者进行,或在其直接督导下完成。D

阴道助产的督导人员

An experienced operator, competent at midpelvic births, should be present from the outset to supervise allattempts at rotational or midpelvic assisted vaginal birth.  D

一个能够胜任中骨盆平面助产的经验丰富的操作者,应该从一开始就在场督导旋转胎头或中骨盆平面阴道助产的所有尝试。D

何处进行阴道助产?

Non-rotational low-pelvic and lift out assisted vaginal birthshave a low probability of failure and most procedurescan be conducted safely in a birth room. [New 2020]  C

不需旋转胎头的骨盆出口平面和上抬手柄的阴道助产的失败概率很低,因此大都可在产房安全进行。[New2020]    C

Assisted vaginal births that have a higher risk of failureshould be considered a trial and be attempted in aplace where immediate recourse to caesarean birth can be undertaken.  C

具有较高失败风险的阴道助产应视为一种试验收,并需在可立即剖宫产的场所进行。C

阴道助产的器械

The operator should choose the instrument most appropriate tothe clinical circumstances and their level ofskill.  √

操作者应根据临床情况和自身技术水平选择最合适的器械。 √

Operators should be aware that forceps and vacuum extractionare associated with different benefits and risks;failure to complete the birth with a single instrument is more likely with vacuum extraction, but maternal perineal trauma is morelikely with forceps. [New 2020]  A

操作者应意识到,产钳和胎吸助产各有利弊,单纯使用胎头吸引术可能无法完成分娩,而产钳助产造成母亲会阴裂伤的可能性更大。[New2020]    A

Operators should be aware that soft cup vacuum extractorshave a higher rate of failure but a lower incidence of neonatal scalp trauma.[New 2020]  A

操作者应注意,柔软罩杯的胎头吸引器失败率较高,但新生儿头皮损伤的发生率较低。[New2020]    A

Rotational births should be performed by experienced operators;the choice of instrument depending on theclinical circumstances and expertise of the individual. The options include Kielland’s rotational forceps, manual rotationfollowed by direct traction forceps or vacuum, and rotational vacuum extraction.  C

旋转胎头分娩应由经验丰富的操作者进行,根据临床情况和专业知识选择合适器械,包括Kielland旋转产钳、手动旋转直接牵引式产钳、胎头吸引器、旋转胎头吸引器。  C

何时中止胎头吸引术?其后续处理如何?

Discontinue vacuum-assisted birth where there is no evidence ofprogressive descent with moderate traction during each pull of a correctly applied instrument by anexperienced operator. [New 2020]  √

经验丰富的操作者在每次宫缩时使用合适的胎头吸引器适度牵引力而先露没有进行性下降,应停止胎头吸引术。[New2020]    √

Complete vacuum-assisted birth in the majority of cases with amaximum of three pulls to bring the fetalhead on to the perineum. Three additional gentle pulls can be used to ease the head out of the perineum. [New 2020]  √

大多数情况下胎头吸引最多可牵拉三次,使胎头靠近会阴,另外三次缓慢轻柔牵拉使胎头娩出会阴。[New2020]    √

If there is minimal descent with the first two pulls of avacuum, the operator should consider whether theapplication is suboptimal, the fetal position has been incorrectly diagnosed or there is cephalopelvic disproportion. Less experiencedoperators should stop and seek a second opinion. Experienced operators should re-evaluate the clinical findings andeither change approach ordiscontinue the procedure. [New 2020]  √

如果在前两次胎吸先露几乎不下降,操作者应考虑使用胎头吸引器是否不太合适,胎儿位置是否判断错误,是否存在头盆不称。经验不足的操作者应停下来征求别人的意见, 经验丰富的操作者需重新评估临床情况,或更改阴道助产方法或停止阴道助产。[New2020]    √

Discontinue vacuum-assisted birth if there have been two ‘pop-offs’ of the instrument. Less experienced operators should seek senior support after one ‘pop-off’ to ensure the woman has the best chance of a successful assisted vaginal birth. [New 2020]  √

若牵引时吸引器滑脱两次,应停止胎头吸引。经验不足的操作者应在吸引器滑脱一次马上寻求上级的帮助,以确保妇女最高的阴道助产的成功机率。[New2020]    √

The rapid negative pressure application for vacuum-assistedbirth is recommended as it reduces the duration of theprocedure with no difference in maternal and neonatal outcomes. [New 2020]  √

建议在胎吸助产中快速使用负压,以缩短助产时长,且不增加母婴不良结局。[New2020]    √

The use of sequential instruments is associated with anincreased risk of trauma to the infant. However, the operator needs to balance the risks of a caesarean birthfollowing failed vacuum extraction with therisks of forceps birth following failed vacuum extraction.  B

虽然连续使用助产器械会导致胎儿损伤的风险,但操作者需要衡量胎头吸引失败后改用剖宫产或产钳助产带来的风险。 B

Obstetricians should be aware of the increased neonatalmorbidity following failed vacuum-assisted birth and/or sequential use of instruments, and should inform theneonatologist when this occurs to ensureappropriate care of the baby.  √

产科医生应意识到胎头吸引助产失败和/或连续使用助产器械可能导致新生儿发病率升高,并应在发生这种情况时通知新生儿科医生,以确保新生儿得到适当的护理。  √

Obstetricians should be aware of the increased risk ofobstetric anal sphincter injury (OASI) followingsequential use of instruments. [New 2020]  C

产科医生应意识到连续使用助产器械后,产妇肛门括约肌损伤(OASI)的风险增加。[New2020]    C

何时中止产钳助产?其后续处理如何?

Discontinue attempted forceps birth where the forceps cannot beapplied easily, the handles do notapproximate easily or if there is alack of progressive descent with moderate traction. [New 2020]  B

若产钳不好使用,手柄不易扣合,或适度牵引力先露无进行性下降,则应停止产钳助产。[New2020]    B

Discontinue rotational forceps birth if rotation is not easilyachieved with gentle pressure. [New 2020]  B

如果在轻柔的压力不易旋转,则停止产钳旋转胎头。[New2020]    B

Discontinue attempted forceps birth if birth is not imminentfollowing three pulls of a correctly applied instrumentby an experienced operator. [New 2020]  B

如果有经验的操作者在正确使用器械反复三次牵拉胎儿无法立即娩出,应停止产钳助产。[New2020]    B

If there is minimal descent with the first one or two pulls ofthe forceps, the operator should consider whetherthe application is suboptimal, the position has been incorrectly diagnosed or there is cephalopelvic disproportion. Less experiencedoperators should stop and seek a second opinion. Experienced operators should re-evaluate the clinical findings andeither change approach ordiscontinue the procedure. [New 2020]  √

如果一次或两次产钳牵拉后先露几乎不下降,操作者应考虑产钳是否不太合适,胎儿位置是否判断错误,是否存在头盆不称。经验不足的操作者应停下来征求别人的意见,,经验丰富的操作者需重新评估临床情况,或更改阴道助产方法或停止阴道助产。 [New2020]    √

Obstetricians should be aware of the potential neonatalmorbidity following a failed attempt at forceps birth and should inform theneonatologist when this occurs to ensure appropriate management of the baby. [New 2020]  √

产科医生应意识到产钳助产失败可能导致新生儿的发病率升高,并应在发生这种情况时通知新生儿科医生,以确保新生儿得到适当的护理。 [New2020]    √

Obstetricians should be aware of the increased risk of fetal head impaction at caesarean birth following a failedattempt at birth via forceps and should be prepared to disimpact the fetal head using recognised manoeuvres. [New 2020]  √

产科医生应意识到产钳助产失败后剖宫产胎儿头部受到撞击的风险会增加,并应准备好使用确认的方法减少胎头受损。[New2020]  √

会阴切开术在预防产妇盆底疾病中的作用?

Mediolateral episiotomy should be discussed with the woman aspart of the preparation for assisted vaginalbirth. [New 2020]  √

作为阴道助产准备的一部分,应与妇女讨论会阴侧切开术。[New2020]    √

In the absence of robust evidence to support either routine orrestrictive use of episiotomy at assisted vaginalbirth, the decision should be tailored to the circumstances at the time and the preferences of the woman. The evidence to support use ofmediolateral episiotomy at assisted vaginal birth interms of preventing OASI is stronger for nulliparous women and for birth via forceps. [New 2020]  B

在无有力证据支持阴道助产常规或限制性会阴切开术的情况下,应根据当时临床情况和妇女的意愿作决定。证据支持初产妇和产钳助产者进行会阴侧切开术可以更有效地预防产科肛门括约肌损伤(OASI)。[New2020]    B

When performing a mediolateral episiotomy the cut should be ata 60 degree angle initiated when the head isdistending the perineum. [New 2020]  B

当进行会阴侧切开术,切口应在胎头扩张会阴时以60度角开始。[New2020]    B

阴道助产的产后护理

可否使用预防性抗生素?

A single prophylactic dose of intravenous amoxicillin andclavulanic acid should be recommendedfollowing assisted vaginal birth as it significantly reduces confirmed orsuspected maternal infection compared to placebo. [New 2020]  A

阴道助产后应推荐静脉注射单剂量的阿莫西林和克拉维酸,因与安慰剂相比,可以显著减少母亲确诊或疑似感染。[New2020]    A

Good standards of hygiene and aseptic techniques arerecommended.  √

建议采用良好的卫生标准和无菌技术。 √

血栓预防的必要性

Reassess women after assisted vaginal birth for venousthromboembolism risk and the need for thromboprophylaxis.  D

在阴道助产后重新评估产妇出现静脉血栓栓塞的风险,和预防血栓形成的必要性。D

产后止痛药

In the absence of contraindications, women should be offeredregular nonsteroidal anti- inflammatory drugs(NSAIDs) and paracetamol routinely.  A

在没有禁忌症的情况下,应定期规律地给妇女提供非甾体抗炎药(NSAIDs)和扑热息痛。  A

产后的膀胱护理

Women should be educated about the risk of urinary retention sothat they are aware of the importance ofbladder emptying in the postpartum period. [New 2020]  √

妇女应接受尿潴留风险相关的教育,使她们认识到产后排空膀胱的重要性。 [New 2020] √

The timing and volume of the first void urine should bemonitored and documented. [New 2020]  C

应监测并记录第一次排空尿液的时间和尿量。 [New 2020]  C

A post void residual should be measured if urinary retention issuspected.  √

若怀疑尿潴留,应测量排尿后的残余尿量。    √

Recommend that women who have received regional analgesia for atrial of assisted vaginal birth in theatrehave an indwelling catheter in situ after the birth to prevent covert urinary retention. This should beremoved according to the local protocol. [New 2020]  √

建议在手术室接受区域麻醉阴道助产的产妇,产后原位留置导尿管,以预防隐性尿潴留。后根据个人的情况拔除尿管。  [New 2020] √

Offer women physiotherapy-directed strategies to reduce therisk of urinary incontinence at 3 months.  B

为妇女提供物理治疗指导策略,以降低产后3个月尿失禁的风险。  B

如何降低产后心理疾病的发病率?

Shared decision making, good communication, and positivecontinuous support during labour and birth have thepotential to reduce psychological morbidity following birth. [New 2020]  √

共同的决策、良好的沟通和分娩期间积极持续支持有可能降低产后心理疾病的发病率。   [New 2020] √

Review women before hospital discharge to discuss theindication for assisted vaginal birth, management of anycomplications and advice for future births. Best practice is where the woman is reviewed by the obstetrician who performed theprocedure.  √

出院前告知妇女阴道助产的适应症及并发症的处理以及对未来分娩的建议。最佳做法是由实施该操作的产科医生对该妇女进行复查。    √

Offer advice and support to women who have had a traumaticbirth and wish to talk about their experience.The effect on the birth partner should also be considered. [New 2020]  √

为经历过痛苦分娩并希望讨论她们经历的妇女提供建议和支持,还应考虑对分娩伴侣的影响。  [New 2020] √

Do not offer single session, high-intensity psychologicalinterventions with an explicit focus on ‘reliving’ thetrauma. [New 2020]  √

不要提供单一疗程、高强度的心理干预,特别是“创伤再现”的干预手法。   √

Offer women with persistent post-traumatic stress disorder(PTSD) symptoms at 1 month referral to skilledprofessionals as per the NICE guidance on PTSD. [New 2020]  D

根据英国国家卫生和临床技术优化研究所(NICE)的创伤后应激障碍(PTSD)治疗指导,对于PTSD症状持续1个月的妇女应转诊给专业的医护人员。 [New 2020]  D

妇女再次妊娠前应被告知的信息?

Inform women that there is a high probability of a spontaneousvaginal birth in subsequent labours followingassisted vaginal birth. [New 2020]  B

告知经阴道助产分娩的妇女,在其后续妊娠时自然阴道分娩的可能性很高。[New2020]    B

Individualise care for women who have sustained a third- orfourth-degree perineal tear, or who have ongoingpelvic floor morbidity.  √

为患有Ⅲ度或Ⅳ度会阴撕裂和持续存在盆底疾病的妇女提供个性化的护理。 √

阴道助产的管理问题

阴道助产的文书记录

Documentation for assisted vaginal birth should includedetailed information on the assessment,decision making and conduct of the procedure, a plan for postnatal care and sufficient information for counselling in relation tosubsequent pregnancies. Use of a standardisedproforma is recommended.  √

建议阴道助产的文书使用标准化格式记录,包括分娩方式评估、决策和实施过程的详细信息,产后护理计划以及后续妊娠咨询的足够信息。   √

Paired cord blood samples should be processed and recordedfollowing all attempts at assisted vaginal birth. [New2020]  √

在所有的阴道助产的尝试后,应处理并记录配对的脐血样本结果。 [New 2020]   √

Adverse outcomes, including unsuccessful assisted vaginalbirth, major obstetric haemorrhage, OASI, shoulderdystocia and significant neonatal complications should trigger an incidentreport as part of effective risk management processes. [New2020]  √

应记录阴道助产失败、产科大出血、产科肛门括约肌损伤(OASI)、肩难产和严重的新生儿并发症等不良结局,以作为有效的分娩风险管理流程的一触发事件报告。[New 2020]   √

如何处理母儿不良结局?

Obstetricians should ensure that the ongoing care of the woman,baby and family is paramount. [New2020]  √

最重要的是产科医生应确保对母婴及其家庭的持续护理。 [New 2020]   √

Obstetricians have a duty of candour; a professionalresponsibility to be honest with patients when things go wrong. [New 2020]  √

当事情出现差错时,产科医生应有坦诚的义务,诚实的专业职责。 [New 2020]   √

Obstetricians should contribute to adverse event reporting, confidential enquiries, and take part in regular reviews and audits. They should respondconstructively to outcomes of reviews, taking necessarysteps to address any problems and carry out further retraining where needed.[New 2020]  √

产科医生应为不良事件报告及原因调查做贡献,并参加定期的检查和审核,应对审查结果做出建设性的回复,采取必要步骤解决问题,并在需要时进行进一步的再培训。 [New 2020]   √

专家简介

郑剑兰,主任医师,教授,研究生导师

厦门大学附属成功医院、陆军第73集团军医院暨全军计划生育优生优育技术指导中心妇儿科主任,全军妇产科专业委员及产科学组秘书长,南京军区妇产科副主任委员,英国帝国理工大学母婴研究中心签约学者,全球健康中心及美国辛辛那提大学交流学者,中华医学会围产医学分会委员,中国医师协会母胎医学分会委员,中国对外交流促进会妇产科分会委员,中国妇幼保健协会高危妊娠常务委员,中国研究型医院学会孕产期母儿心脏病专业委员会常务委员,福建省围产医学分会委员、优生优育及妇幼保健协会盆底委员会常务委员、骨质疏松及骨矿盐学会委员,厦门市围产医学分会候任主任委员、妇产科副主任委员、产科质控中心副主任,SCI期刊《ANZJOG》 及《JOGR》审稿专家。

妇产科临床工作30多年,擅长妇科腔镜及产科危急重症抢救,近年来主要从事围产医学研究。主编专著2部;发表SCI及国内核心期刊论著20余篇;主持国家自然科学基金面上项目,省市及军队科研项目10项;引进Bakri产后止血球囊和CRB促宫颈成熟及引产球囊;发明Zheng子宫压迫缝合术,第一完成人获国家专利3项,并获军队和福建省、厦门市医疗成果及科技进步奖9项,享受军队一类科技人才岗位津贴,是军队334工程拔尖人才和厦门大学科技创新人才,多次荣立军队二等功及三等功。

文献来源:RCOG Green-top Guideline No. 26





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