A comparison of obstetric maneuvers for the acute management of shoulder dystocia.
A comparison of obstetric maneuvers for the acute management of shoulder dystocia.
复制标题
肩难产急性处理产科操作的比较。
DOI：
10.1097/aog.0b013e318244b405
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发表时间：
2012
影响因子：
7.2
通讯作者：
Wendy C Wilcox
中科院分区：
文献类型：
--
作者：
Timothy C. Clapper;S. Gross;Wendy C Wilcox
致编辑：我们发现霍夫曼等人的结论存在问题。1尽管其被适当标记为III级证据，但该研究可能会给那些寻求最佳实践的人留下这样的印象，即出于安全性考虑，应更早考虑肩关节后部操作。可以根据操作和损伤隔离数据，但对患者-提供者情况的了解很少;因此，无法确定因果关系。提交人不知道这些伤害是如何发生的。臂丛神经和胸锁乳突肌的伸展（如海龟征所示）可能会随着收缩而发生。此外，提供者可能没有正确地执行操作，旋转胎儿的头部而不是身体。在提供者旋转的相反方向上施加耻骨上压力限制了旋转动作的效用，并可能对胎儿造成伤害。肩难产可能发生在胎儿不能完全旋转作为恢复过程的一部分。完成旋转过程可以是生理上可行的考虑。此外，将手插入足够远以递送手臂可能不是一种选择。我们建议读者参考Leung等人的研究，2其中后肩关节的分娩与骨折风险增加有关。他们的研究是在一个具有共同方案的中心进行的，该方案将减少霍夫曼等人1认为是其研究局限性的实践变异性。任何操作都可能对胎儿造成伤害。我们的职责应该是通过提供适当的培训来预防这种伤害，包括促进团队合作和遵守协议的逼真模拟培训，这仍然需要选择以及正确应用的演习组合。
To the Editor: We find issue with the conclusions made by Hoffman et al.1 Although it is appropriately tagged as Level III evidence, the study may leave the impression, for those seeking out best practices, that posterior shoulder maneuver should be considered earlier for safety considerations. Isolating the data according to maneuvers and injury can be accomplished but tells us very little about the patient–provider situation; therefore, causation cannot be established. The authors do not know how the injuries occurred. Stretching of the brachial plexus and sternocleidomastoid muscle, as indicated by the turtle sign, can occur with contractions. Also, the providers may not be performing the maneuvers correctly, rotating the head of the fetus rather than the body. Suprapubic pressure applied in the opposite direction of the provider’s rotation limits the utility of a rotational maneuver and potentially may cause injury to the fetus. Shoulder dystocia can occur when the fetus fails to rotate completely as part of the restitution process. Completing the rotation process can be a viable consideration physiologically. Additionally, inserting the hand far enough to deliver the arm may not be an option. We respectfully would refer readers to the work by Leung et al,2 in which delivery of the posterior shoulder was associated with an increased risk of fracture. Their study was performed in a center with a common protocol that would diminish the variability of practice acknowledged by Hoffman et al1 as a limitation of their study. Any maneuver potentially can cause injury to the fetus. Our charge should be the prevention of such injuries by providing appropriate training, including realistic simulation training that promotes teamwork and adheres to protocols, which still call for choice as well as a combination of correctly applied maneuvers.