今日の臨床サポート

分娩遷延

著者: 徳永昭輝 とくなが女性クリニック

監修: 金山尚裕 静岡医療科学専門大学校

著者校正/監修レビュー済:2020/10/01
参考ガイドライン:
  1. 日本産科婦人科学会日本産婦人科医会:産婦人科診療ガイドライン産科編2020
患者向け説明資料

概要・推奨   

  1. 分娩第1期(潜伏期)で分娩進行が遅延している場合は、母体・胎児の状態を観察しながら基本的には待機的管理を行う(推奨レベルC)。
  1. 人工破膜は、内診で児頭の固定を確認後に行う(推奨レベルB)。
  1. 陣痛促進剤による陣痛促進を行う場合には、「産婦人科診療ガイドライン産科編2020」のCQ415-1、415-2 および415-3を順守する(推奨レベルA)。
薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
徳永昭輝 : 未申告[2021年]
監修:金山尚裕 : 特に申告事項無し[2021年]

改訂のポイント:
  1. 分娩第1期潜伏期が遷延しているかどうかの判断は難しいことが多く、産婦人科診療ガイドライン産科編2020に基づき確認を行った。 

病態・疫学・診察

疾患情報(疫学・病態)  
  1. 分娩の遷延は、分娩第1期では全分娩の3~4%、分娩第2期では全分娩の約8%といわれている[1]
  1. 分娩が遷延している場合には、母児の安全のために原因を早期に発見することが求められる。
  1. 分娩第1期の遷延は潜伏期が遷延した偽分娩のことも少なくない。分娩が始まっていないと考えられる場合には帰宅させることもある。
  1. 一般に、有効陣痛は子宮の頸管が3~4cm以上開大(活動期:active phase)すると発来し、頸管開大と児頭の骨盤腔への下降が始まる。
  1. 分娩の遷延とは、陣痛周期が10分以内になった時点から、初産婦では30時間、経産婦では15時間経過しても児娩出に至らない場合である[2]
  1. 一般的にわが国の産科施設では、Friedmanによる分娩進行図(Friedman曲線;分娩開始から時間経過と子宮口開大度と児頭下降度の標準的な関係をグラフにしたもの <図表>)を分娩進行の評価としてきた[3][4]
 
分娩第1期;潜伏期における対応
  1. 最近では、平均的な分娩進行はFriedman曲線で予測される時間より長い経過を辿るとの報告も見られ[5][6]、分娩の進行状態から性急な帝王切開を避けるとのACOG/SMFMコンセンサスも公表されている[7]
  1. パルトグラム(分娩経過図)とFriedman曲線を比較することで分娩経過の異常の有無を判断できるが、分娩経過には個人差があり、分娩第1期潜伏期(latent phase)が遷延しているか否かを判断することが難しい場合も多い。
  1. 潜伏期では、母児の健康に異常を認めなければ、遷延していても病的意義は少ないと判断し、定期的な母体のバイタル測定や胎児心拍モニタリングを行いつつ、基本的には待機的な管理とする[7]。ACOG/SMFMコンセンサスでは、子宮頸管開大6cm未満までを潜伏期と考え、ゆっくりであっても分娩の進行を認めれば、待機的な管理を行うとしている[7]。また、水分摂取・食事摂取・睡眠が可能であれば,母体の休養・精神的サポートに努める[8]
  1. 医療介入:
  1. 潜伏期が遷延し母体が疲労することもあるため、子宮収縮薬を使用して積極的に分娩進行を促進することもある。
  1. 子宮内感染が示唆されるなどの迅速な対応が求められる産婦では、子宮収縮薬の使用や急速遂娩を検討する。
  1. 医療従事者による産婦の精神的サポートは、産痛の緩和や子宮収縮薬による陣痛促進剤使用率の減少、帝王切開や吸引・鉗子分娩率の減少に寄与するとともに、児のApgarスコア5分値が上るなど経腟分娩を完遂するうえできわめて有効である[8]
  1. 助産師などによる産婦の精神的サポートは分娩の予後がよくなると報告されている。
 
陣痛による痛みのために水分摂取・食事摂取・睡眠異常が見られる潜伏期における対応
  1. 分娩予後に悪影響を及ぼす可能性がある。脱水による血栓症発症の予防に努める。
  1. 脱水・エネルギー不足が微弱陣痛の原因となるか否かについての十分なエビデンスはないが、水分摂取は遷延分娩回避に重要であると考えられている[9]
  1. この時点で、帝王切開の予測は困難であるが、帝王切開の可能性について考慮し、経口水分摂取を進めるか輸液をするか考慮した選択が求められる。
 
分娩第1期の活動期(Active phase)における分娩進行が遷延した場合の医療介入:
  1. 分娩経過の異常と判断する場合には、分娩の3要素(陣痛-微弱陣痛、産道の異常-児頭骨盤不均衡(CPD)、頚管熟化不全、娩出物の異常-胎位・回旋胎勢の異常、巨大児など)などからその原因を総合的に判断する必要がある。
  1. ~どの時点で子宮収縮薬を開始するかといった統一見解はない~
  1. ①活動期以降の陣痛の回数が10分間に3回未満となった時点[8]で使用する、②2時間で子宮口開大1cm/時間以下、2時間分娩進行が無かったら[10]使用する、といった意見がある。
  1. 子宮収縮薬による陣痛促進時には、「産婦人科診療ガイドライン産科編2020」のCQ415-1、415-2及び415-3を遵守する。
  1. 【順守すべき留意点[11]
  1. 文書による説明と同意を得る(CQ415-1)
  1. 子宮収縮薬2剤を同時使用しない(CQ415-1、表2)
  1. 開始投与速度、増量法、ならびに最高投与速度に関して例外を設けない(CQ415-1、表3、4)
  1. 母体の血圧と脈拍数を適宜(原則2時間ごと)評価する(CQ415-2)
  1. 原則として投与開始まえから分娩監視装置を装着し、子宮収縮・胎児心拍数を連続的に記録する(CQ415-2)。
  1. トイレ歩行時など医師が必要と認めた時には、一時的に分娩監視装置を外すことは可能である(CQ410)。
  1. 「産婦人科診療ガイドライン産科編2017」[12]では、微弱陣痛が原因と考えられる遷延分娩への対応について解説している。
  1. 医療介入(人工破膜、陣痛促進、産科手術:吸引分娩、鉗子分娩、帝王切開)をする場合、母児の状態並びに産婦人科医の技術や経験を基に判断すべきである。
問診・診察のポイント  
問診:
  1. 陣痛が規則的になった時期(陣痛周期が10分以内)を確認する。

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文献 

著者: E A Friedman
雑誌名: Bull N Y Acad Med. 1972 Jul;48(6):842-58.
Abstract/Text
PMID 4504890  Bull N Y Acad Med. 1972 Jul;48(6):842-58.
著者: Jun Zhang, Helain J Landy, D Ware Branch, Ronald Burkman, Shoshana Haberman, Kimberly D Gregory, Christos G Hatjis, Mildred M Ramirez, Jennifer L Bailit, Victor H Gonzalez-Quintero, Judith U Hibbard, Matthew K Hoffman, Michelle Kominiarek, Lee A Learman, Paul Van Veldhuisen, James Troendle, Uma M Reddy, Consortium on Safe Labor
雑誌名: Obstet Gynecol. 2010 Dec;116(6):1281-7. doi: 10.1097/AOG.0b013e3181fdef6e.
Abstract/Text OBJECTIVE: To use contemporary labor data to examine the labor patterns in a large, modern obstetric population in the United States.
METHODS: Data were from the Consortium on Safe Labor, a multicenter retrospective study that abstracted detailed labor and delivery information from electronic medical records in 19 hospitals across the United States. A total of 62,415 parturients were selected who had a singleton term gestation, spontaneous onset of labor, vertex presentation, vaginal delivery, and a normal perinatal outcome. A repeated-measures analysis was used to construct average labor curves by parity. An interval-censored regression was used to estimate duration of labor, stratified by cervical dilation at admission and centimeter by centimeter.
RESULTS: Labor may take more than 6 hours to progress from 4 to 5 cm and more than 3 hours to progress from 5 to 6 cm of dilation. Nulliparous and multiparous women appeared to progress at a similar pace before 6 cm. However, after 6 cm, labor accelerated much faster in multiparous than in nulliparous women. The 95 percentiles of the second stage of labor in nulliparous women with and without epidural analgesia were 3.6 and 2.8 hours, respectively. A partogram for nulliparous women is proposed.
CONCLUSION: In a large, contemporary population, the rate of cervical dilation accelerated after 6 cm, and progress from 4 cm to 6 cm was far slower than previously described. Allowing labor to continue for a longer period before 6 cm of cervical dilation may reduce the rate of intrapartum and subsequent repeat cesarean deliveries in the United States.

PMID 21099592  Obstet Gynecol. 2010 Dec;116(6):1281-7. doi: 10.1097/AO・・・
著者: Ritsuko Suzuki, Shigeko Horiuchi, Hiroshi Ohtsu
雑誌名: Am J Obstet Gynecol. 2010 Sep;203(3):226.e1-6. doi: 10.1016/j.ajog.2010.04.014. Epub 2010 May 21.
Abstract/Text OBJECTIVE: We sought to compare Japanese nulliparous labor progression with Friedman's classic 1955 curve and Zhang's 2002 curve.
STUDY DESIGN: We developed a labor curve using retrospective record reviews of 2369 Japanese nulliparas, at term, spontaneous labor onset and singleton vertex deliveries of normal birth weight infants.
RESULTS: The new Japanese Suzuki-Horiuchi labor curve with slower cervical dilation in the active phase was like Zhang's and differed from Friedman's curve. Labor length was approximately 5 hours occurring between 4-10 cm compared with Friedman's 2.5 hours and Zhang's 5.5 hours. Even at 10-cm dilation, labor lasted >2 hours at the 95th percentile of time interval.
CONCLUSION: Similar to Zhang's curve, the Suzuki-Horiuchi curve was smooth and more gradually sloped than Friedman's curve. Appraise "arrested or protracted labor" with these slower labor curves in mind using Friedman's curve cautiously.

Copyright 2010 Mosby, Inc. All rights reserved.
PMID 20494329  Am J Obstet Gynecol. 2010 Sep;203(3):226.e1-6. doi: 10.・・・
著者: American College of Obstetricians and Gynecologists (College), Society for Maternal-Fetal Medicine, Aaron B Caughey, Alison G Cahill, Jeanne-Marie Guise, Dwight J Rouse
雑誌名: Am J Obstet Gynecol. 2014 Mar;210(3):179-93. doi: 10.1016/j.ajog.2014.01.026.
Abstract/Text In 2011, 1 in 3 women who gave birth in the United States did so by cesarean delivery. Cesarean birth can be lifesaving for the fetus, the mother, or both in certain cases. However, the rapid increase in cesarean birth rates from 1996 through 2011 without clear evidence of concomitant decreases in maternal or neonatal morbidity or mortality raises significant concern that cesarean delivery is overused. Variation in the rates of nulliparous, term, singleton, vertex cesarean births also indicates that clinical practice patterns affect the number of cesarean births performed. The most common indications for primary cesarean delivery include, in order of frequency, labor dystocia, abnormal or indeterminate (formerly, nonreassuring) fetal heart rate tracing, fetal malpresentation, multiple gestation, and suspected fetal macrosomia. Safe reduction of the rate of primary cesarean deliveries will require different approaches for each of these, as well as other, indications. For example, it may be necessary to revisit the definition of labor dystocia because recent data show that contemporary labor progresses at a rate substantially slower than what was historically taught. Additionally, improved and standardized fetal heart rate interpretation and management may have an effect. Increasing women's access to nonmedical interventions during labor, such as continuous labor and delivery support, also has been shown to reduce cesarean birth rates. External cephalic version for breech presentation and a trial of labor for women with twin gestations when the first twin is in cephalic presentation are other of several examples of interventions that can contribute to the safe lowering of the primary cesarean delivery rate.

Copyright © 2014. Published by Mosby, Inc.
PMID 24565430  Am J Obstet Gynecol. 2014 Mar;210(3):179-93. doi: 10.10・・・
著者: American College of Obstetrics and Gynecology Committee on Practice Bulletins-Obstetrics
雑誌名: Obstet Gynecol. 2003 Dec;102(6):1445-54.
Abstract/Text
PMID 14662243  Obstet Gynecol. 2003 Dec;102(6):1445-54.
著者: Feroza Dawood, Therese Dowswell, Siobhan Quenby
雑誌名: Cochrane Database Syst Rev. 2013 Jun 18;(6):CD007715. doi: 10.1002/14651858.CD007715.pub2. Epub 2013 Jun 18.
Abstract/Text BACKGROUND: Several factors may influence the progression of normal labour. It has been postulated that the routine administration of intravenous fluids to keep women adequately hydrated during labour may reduce the period of contraction and relaxation of the uterine muscle, and may ultimately reduce the duration of the labour. It has also been suggested that intravenous fluids may reduce caesarean sections (CS) for prolonged labour. However, the routine administration of intravenous fluids to labouring women has not been adequately elucidated although it is a widely-adopted policy, and there is no consensus on the type or volume of fluids that are required, or indeed, whether intravenous fluids are at all necessary. Women may be able to adequately hydrate themselves if they were allowed oral fluids during labour.Furthermore, excessive volumes of intravenous fluids may pose risks to both the mother and her newborn and different fluids are associated with different risks.
OBJECTIVES: To evaluate whether the routine administration of intravenous fluids to low-risk nulliparous labouring women reduces the duration of labour and to evaluate the safety of intravenous fluids on maternal and neonatal health.
SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (13 February 2013).
SELECTION CRITERIA: Randomised controlled trials of intravenous fluid administration to spontaneously labouring low-risk nulliparous women.
DATA COLLECTION AND ANALYSIS: The review authors independently assessed trials for inclusion, trial quality and extracted data.
MAIN RESULTS: We included nine randomised trials with 1781 women. Three trials had more than two treatment arms and were included in more than one comparison.Two trials compared women randomised to receive up to 250 mL/hour of Ringer's lactate solution as well as oral intake versus oral intake only. For women delivering vaginally, there was a reduction in the duration of labour in the Ringer's lactate group (mean difference (MD) -28.86 minutes, 95% confidence interval (CI) -47.41 to -10.30). There was no statistical reduction in the number of CS in the Ringer's lactate group (risk ratio (RR), 0.73 95% CI 0.49 to 1.08).Three trials compared women who received 125 mL/hour versus 250 mL/hour of intravenous fluids with free oral fluids in both groups. Women receiving a greater hourly volume of intravenous fluids (250 mL) had shorter labours than those receiving 125 mL (MD 23.87 minutes, 95% CI 3.72 to 44.02, 256 women). There was no statistically significant reduction in the number of CS in the 250 mL intravenous fluid group (average RR 1.00, 95% CI 0.54 to1.87, three studies, 334 women). In one study the number of assisted vaginal deliveries was lower in the group receiving 125 mL/hour (RR 0.47, 95% CI 0.27 to 0.81).Four trials compared rates of intravenous fluids in women where oral intake was restricted (125 mL/hour versus 250 mL/hour). There was a reduction in the duration of labour in women who received the higher infusion rate (MD 105.61 minutes, 95% CI 53.19 to 158.02); P < 0.0001, however, findings must be interpreted with caution as there was high heterogeneity amongst trials (I(2) = 53%). There was a significant reduction in CS in women receiving the higher rate of intravenous fluid infusion (RR 1.56, 95% CI 1.10 to 2.21; P = 0.01). There was no difference identified in the assisted delivery rate (RR 0.78, 95% CI 0.44 to 1.40). There was no clear difference between groups in the number of babies admitted to the NICU (RR 0.48, 95% CI 0.07 to 3.17).Two trials compared normal saline versus 5% dextrose. Only one reported the mean duration of labour, and there was no strong evidence of a difference between groups (MD -12.00, 95% CI -30.09 to 6.09). A trial reporting the median suggested that the duration was reduced in the dextrose group. There was no significant difference in CS or assisted deliveries (RR 0.77, 95% CI 0.41 to 1.43, two studies, 284 women) and (RR 0.59, 95% CI 0.21 to 1.63, one study, 93 women) respectively. Only one trial reported on maternal hyponatraemia (serum sodium levels < 135 mmol/L ). For neonatal complications, there was no difference in the admission to NICU) or in low Apgar scores, however 33.3% of babies developed hyponatraemia in the dextrose group compared to 13.3 % in the normal saline group (RR 0.40, 95% CI 0.17 to 0.93) (P = 0.03). One trial reported a higher incidence of neonatal hyperbilirubinaemia in the dextrose group of babies. There was no difference in neonatal hypoglycaemic episodes between groups.
AUTHORS' CONCLUSIONS: Although the administration of intravenous fluids compared with oral intake alone demonstrated a reduction in the duration of labour, this finding emerged from only two trials. The findings of other trials suggest that if a policy of no oral intake is applied, then the duration of labour in nulliparous women may be shortened by the administration of intravenous fluids at a rate of 250 mL/hour rather than 125 mL/hour. However, it may be possible for women to simply increase their oral intake rather than being attached to a drip and we have to consider whether it is justifiable to persist with a policy of 'nil by mouth'. One trial raised concerns about the safety of dextrose and this needs further exploration.None of the trials reported on the evaluation of maternal views of being attached to a drip during their entire labour. Furthermore, there was no objective assessment of dehydration. The evidence from this review does not provide robust evidence to recommend routine administration of intravenous fluids. Interpreting the results from trials was hampered by the low number of trials contributing data and by variation between trials. In trials where oral fluids were not restricted there was considerable variation in the amount of oral fluid consumed by women in different arms of the same trial, and between different trials. In addition, results from trials were not consistent and risk of bias varied. Some important research questions were addressed by single trials only, and important outcomes relating to maternal and infant morbidity were frequently not reported.

PMID 23780639  Cochrane Database Syst Rev. 2013 Jun 18;(6):CD007715. d・・・
著者: Shu-Qin Wei, Zhong-Cheng Luo, Hairong Xu, William D Fraser
雑誌名: Obstet Gynecol. 2009 Sep;114(3):641-9. doi: 10.1097/AOG.0b013e3181b11cb8.
Abstract/Text OBJECTIVE: To estimate the effects of early augmentation with oxytocin for slow progress of labor on the delivery method and on indicators of maternal and neonatal morbidity.
DATA SOURCES: We conducted electronic database searches of PubMed, MEDLINE, EMBASE, and the Cochrane Library for articles published through February 2009 using the keywords "oxytocin," "augmentation," "active management of labor," "cesarean section," and "labor." Primary authors were contacted directly if the data sought were unavailable.
METHODS OF STUDY SELECTION: We included randomized controlled trials comparing early oxytocin augmentation with a more conservative approach to care in labor. We included only those studies in which membrane management was similar in the two groups. Early oxytocin augmentation was defined as immediate oxytocin administration when dystocia was identified. Data were extracted by two authors independently and evaluated for potential sources of bias. Relative risk (RR) and 95% confidence interval (CI) were calculated using fixed and random effects models.
TABULATION, INTEGRATION, AND RESULTS: Nine trials with 1,983 women met the inclusion criteria. Early oxytocin was associated with an increase in the probability of spontaneous vaginal delivery (RR 1.09, 95% CI 1.03-1.17). For every 20 patients treated with early oxytocin augmentation, one additional spontaneous vaginal delivery is expected. Although the point estimate for the effect on cesarean delivery (RR 0.87, 95% CI 0.71-1.06) and on operative vaginal delivery (RR 0.84, 95% CI 0.70-1.00) showed modest protective effects, the CIs for both estimates included the null effect. A decrease in antibiotic use (RR 0.45, 95% CI 0.21-0.99) was observed with early intervention. Early oxytocin was associated with an increased risk of hyperstimulation (RR 2.90, 95% CI 1.21-6.94) without evidence of adverse neonatal effects. Women in the early oxytocin group reported higher levels of pain and discomfort in labor.
CONCLUSION: Early oxytocin for augmentation in labor is associated with an increase in spontaneous vaginal delivery.

PMID 19701046  Obstet Gynecol. 2009 Sep;114(3):641-9. doi: 10.1097/AOG・・・
著者: Karin B Nelson
雑誌名: Clin Obstet Gynecol. 2008 Dec;51(4):749-62. doi: 10.1097/GRF.0b013e318187087c.
Abstract/Text Causative factors in cerebral palsy (CP) vary to some degree according to gestational age group and clinical CP subtype. Such catastrophes of birth as placental abruption, cord prolapse, and uterine rupture sharply heighten risk of CP. These conditions are fortunately uncommon, and are sometimes not survived; individually and collectively they account for only a small proportion of CP. Among other factors associated with increased risk of CP are prematurity, intrauterine exposure to infection or maternal fever in labor, ischemic stroke, congenital malformations, atypical intrauterine growth (restricted or excessive for gestational age), and complications of multiple gestations. Although any 1 factor, if severe, may be sufficient to cause CP, more often it is the presence of multiple risk factors that overwhelms defense mechanisms and leads to CP. The contribution of genetic vulnerabilities that interact with environmental stressors is an emerging aspect of our understanding of causative factors in CP.

PMID 18981800  Clin Obstet Gynecol. 2008 Dec;51(4):749-62. doi: 10.109・・・
著者: Y W Wu, J M Colford
雑誌名: JAMA. 2000 Sep 20;284(11):1417-24.
Abstract/Text CONTEXT: Chorioamnionitis has been implicated in the pathogenesis of cerebral palsy, but most studies have not reported a significant association. Cystic periventricular leukomalacia (cPVL) is believed to be a precursor of cerebral palsy in preterm infants.
OBJECTIVES: To determine whether chorioamnionitis is associated with cerebral palsy or cPVL and to examine factors that may explain differences in study results.
DATA SOURCES: Searches of MEDLINE (1966-1999), Index Medicus (1960-1965), Doctoral Dissertation Abstracts On-Line (1861-1999), bibliographies, and online conference proceedings (1999) were performed for English-language studies with titles or abstracts that discussed prenatal risk factors for cerebral palsy or cPVL.
STUDY SELECTION: Of 229 initially identified publications, meta-analyses were performed on studies that addressed the association between clinical (n = 19) or histologic (n = 7) chorioamnionitis and cerebral palsy or cPVL in both preterm and full-term infants. Inclusion criteria were: presence of appropriate exposure and outcome measures, case-control or cohort study design, and provision of sufficient data to calculate relative risks (RRs) or odds ratios with 95% confidence intervals (CIs). Studies evaluating risk of cerebral palsy following maternal fever, urinary tract infection, or other maternal infection were collected, but not included in the meta-analysis.
DATA EXTRACTION: Information from individual studies was abstracted using standardized forms by 2 independent observers blinded to authors' names, journal titles, and funding sources.
DATA SYNTHESIS: Using a random effects model, clinical chorioamnionitis was significantly associated with both cerebral palsy (RR, 1.9; 95% CI, 1.4-2.5) and cPVL (RR, 3.0; 95% CI, 2.2-4.0) in preterm infants. The RR of histologic chorioamnionitis and cerebral palsy was 1.6 (95% CI, 0.9-2.7) in preterm infants, and histologic chorioamnionitis was significantly associated with cPVL (RR, 2.1; 95% CI, 1.5-2.9). Among full-term infants, a positive association was found between clinical chorioamnionitis and cerebral palsy (RR, 4.7; 95% CI, 1.3-16.2). Factors explaining differences in study results included varying definitions of clinical chorioamnionitis, extent of blinding in determining exposure status, and whether individual studies adjusted for potential confounders.
CONCLUSION: Our meta-analysis indicates that chorioamnionitis is a risk factor for both cerebral palsy and cPVL. JAMA. 2000;284:1417-1424.

PMID 10989405  JAMA. 2000 Sep 20;284(11):1417-24.
著者: G Kendall, D Peebles
雑誌名: Early Hum Dev. 2005 Jan;81(1):27-34. doi: 10.1016/j.earlhumdev.2004.10.012. Epub 2004 Nov 19.
Abstract/Text The fetal brain is protected from the effects of acute hypoxia by a range of haemodynamic and metabolic compensations. Hypoxia alone is therefore an unusual cause of perinatal brain injury in either preterm or term infants. More recently, materno-fetal infection has been implicated as a causative factor in cases of cerebral palsy associated with preterm and term birth. This paper explores the concept that exposure to infection, and in particular pro-inflammatory cytokines, may reduce the threshold at which hypoxia becomes neurotoxic, so making the brain much more vulnerable to even mild hypoxic insults. The hypothesis is supported by an increasing body of evidence from animal studies that also demonstrate the importance of duration between exposure to infection and subsequent hypoxia. There are a number of clinical and research implications that centre around the role of antibiotics, mode and timing of delivery, maternal cooling during labour and the role of immune-modulating drugs.

PMID 15707712  Early Hum Dev. 2005 Jan;81(1):27-34. doi: 10.1016/j.ear・・・
著者: Rebecca M D Smyth, Carolyn Markham, Therese Dowswell
雑誌名: Cochrane Database Syst Rev. 2013 Jun 18;(6):CD006167. doi: 10.1002/14651858.CD006167.pub4. Epub 2013 Jun 18.
Abstract/Text BACKGROUND: Intentional artificial rupture of the amniotic membranes during labour, sometimes called amniotomy or 'breaking of the waters', is one of the most commonly performed procedures in modern obstetric and midwifery practice. The primary aim of amniotomy is to speed up contractions and, therefore, shorten the length of labour. However, there are concerns regarding unintended adverse effects on the woman and baby.
OBJECTIVES: To determine the effectiveness and safety of amniotomy alone for routinely shortening all labours that start spontaneously.
SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 April 2013).
SELECTION CRITERIA: Randomised controlled trials comparing amniotomy alone versus intention to preserve the membranes. We excluded quasi-randomised trials.
DATA COLLECTION AND ANALYSIS: Two review authors assessed identified studies for inclusion, assessed risk of bias and extracted data. Primary analysis was by intention-to-treat.
MAIN RESULTS: We have included 15 studies in this updated review, involving 5583 women. Amniotomy alone versus intention to preserve the membranes (no amniotomy) for spontaneous labour There was no clear statistically significant difference between women in the amniotomy and control groups in length of the first stage of labour (mean difference (MD) -20.43 minutes, 95% confidence interval (CI) -95.93 to 55.06), caesarean section (risk ratio (RR) 1.27, 95% CI 0.99 to 1.63), maternal satisfaction with childbirth experience (MD -1.10, 95% CI -7.15 to 4.95) or Apgar score less than seven at five minutes (RR 0.53, 95% CI 0.28 to 1.00). There was no consistency between trials regarding the timing of amniotomy during labour in terms of cervical dilatation. Amniotomy alone versus intention to preserve the membranes (no amniotomy) for spontaneous labours that have become prolonged There was no clear statistically significant difference between women in the amniotomy and control group in caesarean section (RR 0.95, 95% CI 0.15 to 6.08), maternal satisfaction with childbirth experience (MD 22.00, 95% CI 2.74 to 41.26) or Apgar score less than seven at five minutes (RR 2.86, 95% CI 0.12 to 66.11).
AUTHORS' CONCLUSIONS: On the basis of the findings of this review, we cannot recommend that amniotomy should be introduced routinely as part of standard labour management and care. We recommend that the evidence presented in this review should be made available to women offered an amniotomy and may be useful as a foundation for discussion and any resulting decisions made between women and their caregivers.

PMID 23780653  Cochrane Database Syst Rev. 2013 Jun 18;(6):CD006167. d・・・
著者: Heather C Brown, Shantini Paranjothy, Therese Dowswell, Jane Thomas
雑誌名: Cochrane Database Syst Rev. 2013 Sep 16;(9):CD004907. doi: 10.1002/14651858.CD004907.pub3. Epub 2013 Sep 16.
Abstract/Text BACKGROUND: Approximately 15% of women have caesarean sections (CS) and while the rate varies, the number is increasing in many countries. This is of concern because higher CS rates do not confer additional health gain but may adversely affect maternal health and have implications for future pregnancies. Active management of labour has been proposed as a means of reducing CS rates. This refers to a package of care including strict diagnosis of labour, routine amniotomy, oxytocin for slow progress and one-to-one support in labour.
OBJECTIVES: To determine whether active management of labour reduces CS rates in low-risk women and improves satisfaction.
SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (16 April 2013).
SELECTION CRITERIA: Randomised controlled trials comparing low-risk women receiving a predefined package of care (active management) with women receiving routine (variable) care. Trials where slow progress had been diagnosed before entry into the trial were excluded.
DATA COLLECTION AND ANALYSIS: At least two review authors extracted data. We assessed included studies for risk of bias.
MAIN RESULTS: We included seven trials, with a total of 5390 women. The quality of studies was mixed. The CS rate was slightly lower in the active management group compared with the group that received routine care, but this difference did not reach statistical significance (RR 0.88, 95% CI 0.77 to 1.01). However, in one study there was a large number of post-randomisation exclusions. On excluding this study, CS rates in the active management group were statistically significantly lower than in the routine care group (RR 0.77 95% CI 0.63 to 0.94). More women in the active management group had labours lasting less than 12 hours, but there was wide variation in length of labour within and between trials. There were no differences between groups in use of analgesia, rates of assisted vaginal deliveries or maternal or neonatal complications. Only one trial examined maternal satisfaction; the majority of women (over 75%) in both groups were very satisfied with care.
AUTHORS' CONCLUSIONS: Active management is associated with small reductions in the CS rate, but it is highly prescriptive and interventional. It is possible that some components of the active management package are more effective than others. Further work is required to determine the acceptability of active management to women in labour.

PMID 24043476  Cochrane Database Syst Rev. 2013 Sep 16;(9):CD004907. d・・・
著者: Suneet P Chauhan, William A Grobman, Robert A Gherman, Vidya B Chauhan, Gene Chang, Everett F Magann, Nancy W Hendrix
雑誌名: Am J Obstet Gynecol. 2005 Aug;193(2):332-46. doi: 10.1016/j.ajog.2004.12.020.
Abstract/Text OBJECTIVE: To review the prevalence of and our ability to identify macrosomic (birthweight >4000 g) fetuses. Additionally, based on the current evidence, propose an algorithm for treatment of suspected macrosomia.
STUDY DESIGN: A review.
RESULTS: According to the National Vital Statistics, in the United States, the prevalence of newborns weighing at least 4000 g has decreased by 10% in seven years (10.2% in 1996 and 9.2% in 2002) and 19% for newborns with weights >5000 g (0.16% and 0.13%, respectively). Bayesian calculations indicates that the posttest probability of detecting a macrosomic fetus in an uncomplicated pregnancy is variable, ranging from 15% to 79% with sonographic estimates of birth weight, and 40 to 52% with clinical estimates. Among diabetic patients the post-test probability of identifying a newborn weighing >4000 g clinically and sonographically is over 60%. Among uncomplicated pregnancies, there is sufficient evidence that suspected macrosomia is not an indication for induction or for primary cesarean delivery. For pregnancies complicated by diabetes, with a prior cesarean delivery or shoulder dystocia, delivery of a macrosomic fetus increases the rate of complications, but there is insufficient evidence about the threshold of estimated fetal weight that should prompt cesarean delivery.
CONCLUSION: Due to the inaccuracies, among uncomplicated pregnancies suspicion of macrosomia is not an indication for induction or for primary cesarean delivery.

PMID 16098852  Am J Obstet Gynecol. 2005 Aug;193(2):332-46. doi: 10.10・・・
著者: Shu-Qin Wei, Zhong-Cheng Luo, Hui-Ping Qi, Hairong Xu, William D Fraser
雑誌名: Am J Obstet Gynecol. 2010 Oct;203(4):296-304. doi: 10.1016/j.ajog.2010.03.007. Epub 2010 May 8.
Abstract/Text The objective of this systematic review was to estimate the efficacy and safety of high-dose vs low-dose oxytocin for labor augmentation on the risk of cesarean section and on indicators of maternal and neonatal morbidity. We searched PubMed, MEDLINE, EMBASE, and the Cochrane Library for randomized clinical trials published until January 2010. Ten randomized clinical trials, including 5423 women, met the inclusion criteria. High-dose oxytocin was associated with a moderate decrease in the risk of cesarean section (relative risk [RR], 0.85; 95% confidence interval [CI], 0.75-0.97), a small increase in spontaneous vaginal delivery (RR, 1.07; 95% CI, 1.02-1.12), and a decrease in labor duration (mean difference: -1.54 hours, 95% CI, -2.44 to -0.64). While hyperstimulation was increased with high-dose oxytocin (RR, 1.91; 95% CI, 1.49-2.45), there was no evidence of an increase in maternal or neonatal morbidity. We conclude that high-dose oxytocin for labor augmentation is associated with a decrease in cesarean section and shortened labor.

Copyright © 2010 Mosby, Inc. All rights reserved.
PMID 20451894  Am J Obstet Gynecol. 2010 Oct;203(4):296-304. doi: 10.1・・・
著者: Jun Zhang, D Ware Branch, Mildred M Ramirez, S Katherine Laughon, Uma Reddy, Mathew Hoffman, Jennifer Bailit, Michelle Kominiarek, Zhen Chen, Judith U Hibbard
雑誌名: Obstet Gynecol. 2011 Aug;118(2 Pt 1):249-56. doi: 10.1097/AOG.0b013e3182220192.
Abstract/Text OBJECTIVE: To examine the effects and safety of high-dose (compared with low-dose) oxytocin regimen for labor augmentation on perinatal outcomes.
METHODS: Data from the Consortium on Safe Labor were used. A total of 15,054 women from six hospitals were eligible for the analysis. Women were grouped based on their oxytocin starting dose and incremental dosing of 1, 2, and 4 milliunits/min. Duration of labor and a number of maternal and neonatal outcomes were compared among these three groups stratified by parity. Multivariable logistic regression and generalized linear mixed model were used to adjust for potential confounders.
RESULTS: Oxytocin regimen did not affect the rate of cesarean delivery or other perinatal outcomes. Compared with 1 milliunit/min, the regimens starting with 2 milliunits/min and 4 milliunits/min reduced the duration of first stage by 0.8 hours (95% confidence interval 0.5-1.1) and 1.3 hours (1.0-1.7), respectively, in nulliparous women. No effect was observed on the second stage of labor. Similar patterns were observed in multiparous women. High-dose regimen was associated with a reduced risk of meconium stain, chorioamnionitis, and newborn fever in multiparous women.
CONCLUSION: High-dose oxytocin regimen (starting dose at 4 milliunits/min and increment of 4 millliunits/min) is associated with a shorter duration of first-stage of labor for all parities without increasing the cesarean delivery rate or adversely affecting perinatal outcomes.
LEVEL OF EVIDENCE: II.

PMID 21775839  Obstet Gynecol. 2011 Aug;118(2 Pt 1):249-56. doi: 10.10・・・
著者: P Bret, J Chazal, P Janny, B Renaud, M Tommasi, J J Lemaire, M Bret, A Jouvet
雑誌名: Neurochirurgie. 1990;36 Suppl 1:1-159.
Abstract/Text The aim of this study is to sum up our current knowledge on the so-called "normal pressure hydrocephalus" syndrome, revisited by the authors as the "adult chronic hydrocephalus" syndrome (A.C.H.). It is based upon 1) a review of the literature dealing with the subject (518 references) and 2) an original series of 243 cases summarizing a 10 year experience of 2 french neurosurgical teams (Lyon: 123 cases, Clermont-Ferrand: 120 cases). Part I is devoted to the review of pathologic and pathophysiologic data. Both autopsy and microscopic findings clearly show 2 categories of anomalies in the brains of patients showing this condition: "non specific" lesions may be either causative (leptomeningeal thickening, villositar sclerosis) or secondary to hydrocephalus (ependymal wall disruption, sub-ependymal "edema"). Conversely, "specific lesions" are either degenerative (Alzheimer-type) or ischemic in origin. They seem unrelated to hydrocephalus, but may play a role in the ventricular enlargement by favoring changes in brain elastic properties. Data available from brain biopsies (13 cases) have confirmed the high incidence of such "specific lesions" of the parenchyma. Following the Hakim's initial hypothesis, several mechanisms have been proposed to explain the progressive ventricular dilation despite a fall in C.S.F. pressure. Experimental and clinical data (namely those referring to the pathogenesis of secondary A.C.H.) are reviewed. The sequence of events following acute ventricular obstruction is analysed. The ultimate state of chronic uncompensated hydrocephalus involve multiple factors among which a trans-cerebral mantle pressure gradient may play a major role. The intervention of compensatory mechanisms (reduction of C.S.F. production, establishment of alternative pathways of C.S.F. absorption) is also discussed. Part II is devoted to the presentation of the clinical material. Series of the literature including more than 20 surgical cases are briefly reviewed together with the authors' material and methods. Criteria of selection of patients, methods of clinical evaluation and of statistical analysis of results are exposed. Of the 243 patients of the present series, 225 were managed by C.S.F. shunt (V.A.: 137, V.P.:60, L.P.:28). Results were as follows (mean follow-up:31 mths +/- 28): good results (including excellent results): 128 (52.6%), fair: 52 (21.3%), poor and aggravated: 49 (20%), early deaths: 14 (5.7%), 12 of those post-operatively. The rate of surgical complications was 35% (S.D.H.: 16.8%, sepsis: 4%, seizures: 4%, shunt malfunction: 10.6%) leading to reoperation in 25.7%. Long-term survival rate was 75% (172 alive patients and 57 late deaths).(ABSTRACT TRUNCATED AT 400 WORDS)

PMID 2197567  Neurochirurgie. 1990;36 Suppl 1:1-159.

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