Impact of pushing timing on occult injury of levator ani: secondary analysis of a randomized trial.
Impact of pushing timing on occult injury of levator ani: secondary analysis of a randomized trial.
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推动时间对左旋ANI神秘损伤的影响：随机试验的次要分析。
DOI：
10.1016/j.ajog.2022.02.020
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发表时间：
2022-05
影响因子：
9.8
通讯作者：
中科院分区：
文献类型：
--
作者：
提肛肌系统脱离的证据更多见于盆底疾病的患者。有人认为，胎儿在推进前被动下降可用于减少手术中的阴道分娩和提肛肌损伤。这项计划分析的目的是确定立即或延迟推是否与未分娩的妇女在第一次分娩后肛提肌系统损伤的比例增加有关。第二阶段研究的优化管理为多中心随机试验。有足月妊娠和神经轴向镇痛的未分娩妇女在完全宫颈扩张时被随机分配为立即推或延迟推1小时。一部分受试者同意接受纵向客观盆底评估：1)产后(最初)；2)6周(PP1)；3)6个月(PP2)经会阴三维超声检查。在所有受试者完成所有访问后，以掩蔽方式评估保存的三维超声体积。结果是左侧或右侧的提肛肌受到“隐匿性”损伤，定义为利用提肌尿路间隙测量，提肛肌与其起始处的连接处扩大。两组间的测量和比例通过研究访问进行比较，对于分类变量采用χ2检验或FISHER精确检验，对于连续变量采用t检验或Mann-Whitney U检验。在2414名随机受试者中，941名(39.0%)参与了盆底评估，其中452名参与了即时推进组，489名参与了延迟推推组。我们对67%、83%和77%的盆底评估参与者在最初、产后1和产后2次就诊时分别进行了超声检查。两组的人口统计和劳动特征具有可比性；94%是非西班牙裔，50%是黑人参与者。初诊时77例(13.6%)患者出现提肛肌损伤，PP1时99例(13.1%)，PP2时72例(10.6%)。与延迟推进组相比，立即推进组与延迟推进组在损伤方面没有差异。当提肛肌损伤的阈值(敏感度)被调整为不那么保守的措施时，这些发现没有改变。在接受神经轴向镇痛的足月未产妇中，在第二产程立即或延迟推入产程的妇女之间，隐性提肛肌损伤的发生率没有差别。需要进一步的研究努力来了解盆底疾病的发展和潜在的预防。在接受神经轴向镇痛的产后初产妇中，随机推推与立即推推的产妇在提肛肌损伤方面没有差异。
Evidence of detachment of the levator ani muscle system is seen more frequently in patients with pelvic floor disorders. It has been suggested that passive descent of the fetus prior to pushing could be used to decrease operative vaginal delivery and levator ani muscle injury. The objective of this planned analysis was to determine whether immediate or delayed pushing was associated with an increased proportion of injury to the levator ani muscle system after a first delivery among nulliparous women. The Optimizing Management of the Second Stage study was a multicenter randomized trial. Nulliparous women with term pregnancies and neuraxial analgesia were randomly assigned at complete cervical dilation to either immediate pushing or delayed pushing for 1 hour. A subset of participants consented to longitudinal objective pelvic floor assessments: 1) during postpartum stay (initial); 2) at 6 weeks (PP1); and 3) at 6 months (PP2) with transperineal 3-Dimensional ultrasound. Following the completion of all visits by all subjects, saved 3-Dimensional ultrasound volumes were assessed in a masked fashion. The outcome was “occult” levator ani muscle injury on the right or left, defined as a widening of the attachment of the levator ani to its origin utilizing the Levator Urethra Gap measurement. Measurements and proportions were compared between the two groups by study visit using the χ2 test or Fisher exact test for categorical variables and the t test or Mann-Whitney U test for continuous variables as appropriate. 941 (39.0%) of 2414 randomized participants participated in the pelvic floor assessments; 452 in the immediate pushing and 489 in the delayed pushing groups. We obtained sonograms on 67%, 83%, and 77% of the pelvic floor assessment participants at the initial, post-partum 1 and post-partum-2 visits, respectively. Demographic and labor characteristics were comparable between the 2 groups; 94% were non-Hispanic and 50% were Black participants. Levator ani muscle injury was noted in 77 (13.6%) participants at the initial visit, 99 (13.1%) at PP1, and 72 (10.6%) at PP2. There were no differences in injury between those in the immediate pushing compared to the delayed pushing groups. These findings did not change when the threshold (sensitivity) of levator ani muscle injury was adjusted to a less conservative measure. Among nulliparous women at term with neuraxial analgesia, the rates of occult levator ani muscle injury were not different between women undergoing immediate or delayed pushing in the second stage of labor. Further research efforts are needed to understand the development of and potential prevention of subsequent pelvic floor disorders. In postpartum primiparas who received neuraxial analgesia, there was no difference in levator ani muscle injury between those randomized to delayed versus immediate pushing.
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DOI：
10.1111/j.1471-0528.2008.01751.x
发表时间：
2008-07-01
影响因子：
5.8
作者：
Dietz, H. P.;Simpson, J. M.
通讯作者：
Simpson, J. M.
影响因子：
1.8
作者：
Dietz, Hans Peter;Bernardo, Maria Jose;Shek, Ka Lai
通讯作者：
Shek, Ka Lai
影响因子：
1.8
作者：
Vila Pouca MCP;Parente MPL;Natal Jorge RM;DeLancey JOL;Ashton-Miller JA
通讯作者：
Ashton-Miller JA
影响因子：
7.2
作者：
Dietz, HP;Lanzarone, F
通讯作者：
Lanzarone, F
影响因子：
9.8
作者：
Heilbrun ME;Nygaard IE;Lockhart ME;Richter HE;Brown MB;Kenton KS;Rahn DD;Thomas JV;Weidner AC;Nager CW;Delancey JO
通讯作者：
Delancey JO