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1、2019RCO（肩难产指南level 3level 3RCOG Green-top Guideline No. 422of 18 Royal College of Obstetricians andGynaecologistslevel 3RCOG Green-top Guideline No. 423of 18 Royal College of Obstetricians and GynaecologistsRCOG Green-top Guideline No. 424of 18 Royal College of Obstetricians and GynaecologistsRCOG G
2、reen-top Guideline No. 425of 18 Royal College of Obstetricians and GynaecologistsRCOG Green-top Guideline No. 426of 18 Royal College of Obstetricians and GynaecologistsRCOG Green-top Guideline No. 427of 18 Royal College of Obstetricians and GynaecologistsRCOG Green-top Guideline No. 428of 18 Royal C
3、ollege of Obstetricians and GynaecologistsSimilarly, symphysiotomy has been suggested as a potentially useful procedure, both inthedeveloping 74,75and developed world.76However, there is a high incidence of seriousmaternalmorbidity and poor neonatal outcome.77Serious consideration should be given to
4、 thesefacts,particularly where practitioners are not trained in the technique.Other techniques, including the use of a posterior axillary sling, have been recently reportedbutthere are few data available.78,79Evidence level 46.4What is the optimal management of the woman and baby after shoulder dyst
5、ocia?Birth attendants should be alert to the possibility of postpartum haemorrhage and severe perinealtears.Evidencelevel 2+andEvidence level 3There is significant maternal morbidity associated with shoulder dystocia,particularly postpartumhaemorrhage (11%) and third and fourth degree perineal tears
6、(3.8%).11Other reportedcomplications include vaginal lacerations,80cervical tears, bladder rupture,uterine rupture,symphyseal separation, sacroiliac joint dislocation and lateral femoral cutaneousneuropathy.81,82The baby should be examined for injury by a neonatal clinician.BPI is one of the most im
7、portantcomplications of shoulder dystocia, complicating 2.3% to 16% of suchdeliveries. 7,11,13,14Other reported fetal injuries associated with shoulder dystocia include fractures of thehumerusand clavicle, pneumothoraces and hypoxic brain damage.15,83,84An explanation of the delivery should be given
8、 to the parents (see section 9).Evidence level 37. Risk management7.1Training7.1.1What are the recommendations for training?All maternity staff should participate in shoulder dystocia training at least annually. Grade DEvidence level 4The fifth CESDI report recommended that aawareness and training f
9、or all birthattendantshigh level ofshould be observed.50Annualskill drills, including shoulder dystocia, are recommendedjointly by boththe Royal College of Midwives and the RCOG85and are one of the requirements inthe Clinical Negligence Scheme for Trusts (CNST) maternity standards.86Where training h
10、as been associated with improvements in neonatal outcome, all staffreceivedannual training.14One study looked at retention of skill for up to one year following training using simulation. Ifstaffhad the ability to manage a severe shoulder dystocia immediately following training, the abilitytodeliver
11、 tended to be maintained at one year.877.1.2What is the evidence for the effectiveness of shoulder dystocia training?Practical shoulder dystocia training has been shown to improve knowledge,88confidence 89andmanagement of simulated shoulder dystocia.90 93Training has also been shown to improve theac
12、tor-their care during simulated shoulder dystocia.94Evidence level 3Evidence level 2-Evidence level 1-RCOG Green-top Guideline No. 429of 18 Royal College of Obstetricians and GynaecologistsRCOG Green-top Guideline No. 4210of 18 Royal College of Obstetricians and Gynaecologistspatientsperception ofma
13、noeuvres performed, their timing and sequence maternal perineal and vaginalexaminationestimated blood lossstaff in attendance and the time they arrived general condition of the baby (Apgar score) umbilicalcord blood acid-base measurementsneonatal assessment of the baby.104,106It is particularly impo
14、rtant to document the position of the fetal head at delivery as thisfacilitatesidentification of the anterior and posterior shoulder during the delivery.8.Suggested audit topicsincident reporting of shoulder dystocia (CNST standard)critical analysis of manoeuvres used in the management of shoulder d
15、ystocianeonatal teamcalled at diagnosis of shoulder dystocia documentation of the event (see above)performance ofcord blood gas analysismonitoring neonatal injury (BPI bony fractures) following shoulder dystocia staff attendance atannual trainingdiscussion of events with parents.9. SupportAn informa
16、tion leaflet for parentsA difficult birth: what is shoulderdystocia?produced by the RCOG isavailable online(http:/www.rcog.org.uk/womens-health/clinical-guidance/difficult-birth-what- shoulder-dystocia).The Erbs Palsy Group (www.erbspalsygroup.co.uk) provides an excellent support networkfor children
17、 andfamilies affected by BPI.References1.Resnick R. Management of shoulder dystocia girdle. Clin ObstetGynecol 1980;23:559-64.2. Spong CY, Beall M, Rodrigues D, Ross MG. An objectivedefinition of shoulder dystocia: prolonged head-to-bodydelivery intervalsan d/or the use of an ciliary obstetricma neu
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69、gree of forces applied during simulation of shoulderdystocia. Am J Obstet Gynecol2019;197:156.e1-6.99. Deering SH, Weeks L, Benedetti T . Evaluation of force appliedduring deliveries complicated by shoulder dystocia usingsimulation. Am J Obstet Gynecol2019;204:234.e1-5.100. Kelly J, Guise J-M, Oster
70、weil P, Li H. 211: Determining the valueof force-feedback simulation training for shoulder dystocia. Am J Obstet Gynecol2019;199(Suppl A):S70.101. Vanderhoeven J, Marshall N, Segel S, Li H, Osterweil P, Guise J-M.201: Evaluating in-situ simulation and team training onresponse to shoulder dystocia. A
71、m JObstet Gynecol2019;199(Suppl A):S67.102. The4kg and overenquiries. In: Confidential Enquiries intoStillbirths and Deaths in Infancy. Sixth Annual Report. London: Maternal and Child HealthResearch Consortium;1999. p35-47.103. Deering S, Poggi S, Hodor J, Macedonia C, Satin AJ. Evaluation ofresiden
72、ts delivery notes after a simulated shoulder dystocia.Obstet Gynecol 2019;104:667-70.104. National Health Service Litigation Authority: Summary ofsubstandard care in cases in brachial plexus injury. NHSLA J2019;2 suppl:ix-xi105. Acker DB. A shoulder dystocia intervention form. ObstetGy necol 1991;78
73、:150-1.106. Crofts JF, Bartlett C, Ellis D, Fox R, Draycott TJ. Documentationof simulated shoulder dystocia: accurate and complete? BJOG 2019;115:1303-8.107. Royal College of Midwives. Clinical risk management Paper 2:Shoulder dystocia. RCM Midwives J 2000;3.RCOG Green-top Guideline No. 4213of 18Roy
74、al College of Obstetricians and GynaecologistsAPPENDIX1Figure 1. The McRoberts manoeuvre (from the SaFE study)Figure 2Suprapubic pressure (from SaFE study)Figure 3 Delivery of the posterior arm (from the SaFE study)RCOG Green-top Guideline No. 4214of 18 Royal College of Obstetricians and Gynaecologi
75、stsAPPENDIX2RCOG Green-top Guideline No. 4215of 18Royal College of Obstetricians and GynaecologistsRCOG Green-top Guideline No. 4216of 18 Royal College of Obstetricians and GynaecologistsAPPENDIX 4Clinical guidelines aresystematically developed statements which assistclinicians and women in makingde
76、cisions about appropriate treatment for specific conditions.Each guideline is systematically developedusing a standardised methodology. Exact details ofthis process can be found in Clinical Governance Advice No.1: Development of RCOG Green-topGuidelines (available on the RCOG website athttp:/www.rco
77、g.org.uk/guidelines). Theserecommendations are not intended to dictate an exclusivecourse of management or treatment.They must be evaluated with reference to individual patient needs,resources and limitationsunique to the institution and variations in local populations. It is hoped that thisprocess
78、of localownership will help to incorporate these guidelines into routine practice. Attention isdrawn toareas of clinical uncertainty where further research might be indicated.The evidence used in this guideline was graded using the scheme below and therecommendationsformulated in a similar fashion with a standardised grading scheme.RCOG Green-top Guideline No. 4217of 18Royal College of Obstetricians and GynaecologistsRCOG Green-top Guideline No. 4218of 18Royal College of Obstetricians and Gynaecologists
