⾻骨盤位分娩の管理理
第66回⽇日本産科婦⼈人科学会学術講演会専攻医教育プログラム
筑波⼤大学医学医療療系  総合周産期医学   　⼩小畠真奈奈
平成26年年4⽉月17⽇日

本⽇日お話しする内容
1. ⾻骨盤位分娩に関する臨臨床試験
2. ⾻骨盤位の分娩管理理⽅方針決定に関わる要素
3. ⾻骨盤位経腟分娩の管理理

1. ⾻骨盤位分娩に関する臨臨床試験¤ ⾻骨盤位経腟分娩は前世紀の遺物か？
2000年年

2004年年

2006年年

症例例の選択予定帝切切率率率 　50%→80%
Term Breech Trial

2009年年

技術の継承

2years after Term Breech Trial

ACOG Committee Opinion No.265  　 ACOG Committee Opinion No. 340  　PREMODA study
SOGC Clinical Practice Guideline 　Term Breech Trial
Hannah ME, et al., Lancet, 2000Articlesp 26カ国  121施設 2183⼈人

Planned caesarean section versus planned vagin
breech presentation at term: a randomised multp 予定帝切切群の児の短期予後が、予定経腟群よりも明らかに良良い⼀一⽅方で、⺟母体の短期予後は両群で有意差が認められなかった  Mary E Hannah, Walter J Hannah, Sheila A Hewson, Ellen D Hodnett, Saroj Saigal, Andrew
Trial Collaborative Group*Summary

ArticlesBackground For 3–4% of pregnancies, the fetus will be inARTICLES
the breech presentation at term. For most of these women,
the approach to delivery is controversial. We did arandomised trial to compare a policy of planned caesarean
section with a policy of planned vaginal birth for selected
breech-presentation pregnancies.

Planned caesarean section versus planned
vaginalbirth2088for
Methods At 121 centres
in 26 countries,
women witha singleton fetus in a frank or complete breech
breech presentation at term: a randomised
trial
presentation weremulticentre
randomly assigned planned
caesarean

section or planned vaginal birth. Women having a vaginal
breech delivery had an experienced clinician at the birth.
Mothers and infants were followed-up to 6 weeks postpartum. The primary outcomes were perinatal mortality,neonatalor serious
neonatalmorbidity;
andMary E Hannah, Walter J Hannah, Sheila A Hewson, Ellen D Hodnett,
Sarojmortality,Saigal, Andrew
R Willan,for theTerm Breechmaternal mortality or serious maternal morbidity. Analysis
Trial Collaborative Group*
was by intention to treat.

SummaryBackground For 3–4% of pregnancies, the fetus will be in
the breech presentation at term. For most of these women,
the approach to delivery is controversial. We did arandomised trial to compare a policy of planned caesarean
section with a policy of planned vaginal birth for selected
breech-presentation pregnancies.
Methods At 121 centres in 26 countries, 2088 women witha singleton fetus in a frank or complete breech
presentation were randomly assigned planned caesarean
section or planned vaginal birth. Women having a vaginal
breech delivery had an experienced clinician at the birth.
Mothers and infants were followed-up to 6 weeks post
partum. The primary outcomes were perinatal mortality,
neonatal mortality, or serious neonatal morbidity; andmaternal mortality or serious maternal morbidity. Analysis
was by intention to treat.
Findings Data were received for 2083 women. Of the 1041
women assigned planned caesarean section, 941 (90·4%)
were delivered by caesarean section. Of the 1042 womenassigned planned vaginal birth, 591 (56·7%) deliveredvaginally. Perinatal mortality, neonatal mortality, or serious
neonatal morbidity was significantly lower for the planned
caesarean section group than for the planned vaginal birthFindings Data were received for 2083 women. Of the 1041

Introduction
women assigned planned caesarean section, 941 (90·4%)About
3–4% of by
allcaesarean
pregnancies
reachOfterm
with awomenfetus inwere delivered
section.
the 10421
thebreech presentation.
publishedassignedplanned vaginalData
birth,from591previously(56·7%) delivered
cohorthave shown
general,vaginally.studies
Perinatal mortality,
neonatal that,mortality,inor serious
neonatal caesarean
morbidity wassection
significantly
lower forthan
the plannedplannedis betterplannedcaesarean
sectiongroup
thanthatfor theplannedasvaginal
birth atvaginalbirth
for thefetus
presents
a breech
2,3 (17 of 1039 [1·6%] vs 52 of 1039 [5·0%]; relative
group
term.
These studies are potentially biased, however,
risk
0·33
[95%CI0·19–0·56];
p<0·0001).
There
were
nobecause women were not allocated to the different
differences
betweenatgroups
in terms
of maternalmodes
of delivery
random.
Other
concernsmortality
are thator studies
serious maternal
morbidity(41 of1041 [3·9%]thatvs 33
ofthemight haveincluded
pregnancies
would
1042 [3·2%]; 1·24 [0·79–1·95]; p=0·35).
not currently be considered for a trial of labour(eg,footlingbreech
presentation[withthefeet
entering
Interpretation Planned caesarean section is better thanthebirth vaginal
canal aheadof anyotherfetus
part inof thethebreechbody]),plannedbirth forthe term
andthat clinicians
undertaking
vaginalbreechpresentation;
serious maternal
complications
are similardeliveriesmay
not have been experienced in the
between thegroups.
technique. Two randomised controlled trials and a
Cochranemeta-analysisof these trials have not foundLancet 2000;
356: 1375–83
plannedcaesarean
section to be associated with
See Commentary
page 1368
substantial benefits for the fetus, but both trials had very
4–6smallsample sizes.
*Members listed at end of paper
There is ofa Obstetrics
general andconsensus
thatSunnybrookplannedandcaesarean
Department
Gynaecology,
sectionbetterthanplanned
MDCM, for the
Women’sisCollege
HealthSciences
Centre vaginal(M Hannahbirth); Maternal
InfantReproductive
Health ResearchW HannahdeliveryofMDthefetus intheandbreechpresentation
at term ifUnit,
Centre for Researchin Women’s
Health,(M isHannah,
thepresentation
is footling,if thefetus
compromised,, E large
Hodnettor
PhDhas, A WillanPhD) and Facultyof Nursing that
Hewsonif SthefetusBAisa congenitalabnormality(E Hodnett), University of Toronto, Toronto; and Departments ofcould cause a mechanical problem at vaginal delivery, orPaediatrics (S Saigal MD) and Clinical Epidemiology and
if Biostatistics
a clinician (Aexperiencedin vaginal breech delivery is not
Willan, M Hannah), McMaster University, Hamilton,
7Introduction

About 3–4% of all pregnan
the breech presentation.1 D
cohort studies haveplanned caesarean secti
vaginal birth for the fetu
term.2,3 These studies arebecause women were nmodes of delivery at rand
the studies might have inc
not currently be consid(eg, footling breech presethe birth canal ahead ofand that clinicians udeliveries may not hav
technique. Two random
Cochrane meta-analysis oplanned caesarean sectsubstantial benefits for thesmall sample sizes.4–6
There is a general consection is better than pdelivery of the fetus in thethe presentation is footlin
if the fetus is large or has
could cause a mechanicalif a clinician experienced iavailable.7 However, for mbest approach by which toclinicians believe a policy
best because of the res
whereas others remain
evidence from randomised
outcome is improved withsection. We undertook
determine whether planne
than planned vaginal bir
breech presentation at tecentres that could assure w
delivery that an experienc
at the birth.

Methods

Patients
Women were eligible for t
live fetus in a frank or coterm (!37 weeks’ gestatio
was defined as hips flexe
breech was defined as hipTerm Breech Trial の2年年後Whyte H, et al., Am J Obstet Gynecol, 2004p 予定帝切切は2歳の時点での児の死亡や神経発達遅延のリスク減少にはつながらなかった。
Hannah ME, et al., Am J Obstet Gynecol, 2004p 2年年後の⺟母体予後のアンケート調査では、予定帝切切と予定経腟でほぼ同じであった。
Su M, et al., BJOG, 2004p 予定帝切切は予定経腟よりも分娩中の問題による周産期予後のリスクを減少させる

Term Breech Trial の問題点
Glezerman M., Am J Obstet Gynecol, 2006p 多施設共同研究：国・施設による周産期医療療レベルの差
p RCT: 除外基準と振り分けは適切切であったかp 周産期死亡の原因は分娩様式に関連しているかp 予定帝切切群 1039例例中 17例例p 予定経腟群  1039例例中 52例例

p Peer reviewは適切切に⾏行行われたかACOG Committee Opinion
No. 265, Obstet & Gynecol, 2001p 満期単胎⾻骨盤位の予定経腟分娩は、もはや妥当とはいえない
No. 340, Obstet & Gynecol, 2006p 満期単胎⾻骨盤位の分娩様式は、熟練した医師の判断に委ねられるべきである 　 　 　 　 　 　 　 　 　 　 　 　 　 　 　 　 　 　 　 　 　 　 　 　 　ACOG Committee
Committee on
Obstetric PracticeOpinionNumber 340, July 2006

This document reflects emerging
clinical and scientific advances asof the date issued and is subject tochange. The information should
not be construed as dictating anexclusive course of treatment orprocedure to be followed.
Copyright © July 2006
by the American College of(Replaces No. 265, December 2001)

Mode of Term Singleton Breech
Delivery
ABSTRACT: In light of recent studies that further clarify the long-term risksof vaginal breech delivery, the American College of Obstetricians andGynecologists recommends that the decision regarding mode of delivery
should depend on the experience of the health care provider. Cesarean delivery will be the preferred mode for most physicians because of the diminishing expertise in vaginal breech delivery. Planned vaginal delivery of a termPREMODA study
Goffinet F, et al., Obstet & Gynecol, 2006p フランスとベルギーにおける観察研究p 厳密な基準によって症例例を選択することにより、満期の⾻骨盤位経腟分
娩は安全な選択肢となるAmerican Journal of Obstetrics and Gynecology (2006) 194, 1002–11

www.ajog.org

Is planned vaginal delivery for breech presentation
at term still an option? Results of an observational
prospective survey in France and Belgium
François Goffinet, MD, PhD,a,b Marion Carayol, Midwife,a Jean-Michel Foidart, MD,PhD,c Sophie Alexander, MD, PhD,d Serge Uzan, MD,e Damien Subtil, MD, PhD,fGérard Bréart, MD,a,e for the PREMODA Study Group
INSERM U149, Epidemiological Research Unit on Perinatal Health and Women’s Health, Universite´ Pierre et Marie
Curie Paris VI, Hôpital Tenona; Universite´ Paris-Descartes Paris 5, Faculte´ de me´decine, Service de gyne´cologie etobste´trique de Port-Royal, Hôpital Cochin Saint-Vincent-de-Paul, Assistance Publique-Hôpitaux de Paris,b France;
Department of Obstetrics and Gynaecology, La Citadelle Hospital,c Lie`ge, Belgium; School of Public Health School,dBruxelles, Belgium; Department of Obstetrics and Gynaecology, Tenon Hospital, Assistance Publique-Hôpitaux deParis, Universite´ Pierre et Marie Curie Paris VI,e France; Department of Obstetrics and Gynaecology, Jeanne deFlandre Hospital,f Lille Cedex, France
Received for publication June 30, 2005; revised September 30, 2005; accepted October 27, 2005

KEY WORDS
Breech presentation
Mode of delivery

Objective: A large trial published in 2000 concluded that planned vaginal delivery of term breech
births is associated with high neonatal risks. Because the obstetric practices in that study differedfrom those in countries where planned vaginal delivery is still common, we conducted an ob-SOGCのガイドライン 20091.

⾻骨盤位経腟分娩は選択的帝切切よりも周産期死亡率率率と新⽣生児短期予後不不良良のリスクが⾼高い

2.

近代的な施設において慎重に症例例を選択して管理理すれば、選択的帝切切と同様の安全性が得られる。

3.

満期の単胎⾻骨盤位は、症例例を選べば経腟分娩は妥当な選択である。

4.

慎重に症例例を選択して管理理すれば、⾻骨盤位の周産期死亡率率率は1000出⽣生に約2⼈人、重篤な新⽣生児短期予後不不良良は2%である。

5.

新⽣生児の短期予後が重篤であっても、⻑⾧長期的な神経学的予後は、どの分娩様式を予定したかによる差はない。
International Journal of Gynecology and Obstetrics, 2009

2. 分娩管理理⽅方針決定に関する要素
a. ⾻骨盤位の基礎知識識
b. 分娩管理理⽅方針
c. 試験⾻骨盤位経腟分娩の必要条件

a. ⾻骨盤位の基礎知識識¤ ⾻骨盤位の頻度度¤ 妊娠28週 　 　 　 　25%
¤ 妊娠36週以降降 　 　2-3%¤ ⾻骨盤位の要因¤ ⺟母体（狭⾻骨盤、⼦子宮奇形） 　¤ ⽺羊⽔水・胎盤¤ 胎児（先天異異常）¤ ⾻骨盤位の種類¤ 単臀位 　Frank 　 　複臀位 　Complete¤ Incomplete 　（膝位 　Keeling 　 　⾜足位 　Footling）

b. 分娩管理理⽅方針¤ 外回転¤ 選択的帝王切切開¤ 経腟分娩

c. 試験経腟分娩の必要条件¤ 膝位、⾜足位でないこと¤ 2500g以上であること¤ 37週以降降であること¤ ⺟母体⾻骨盤が充分な⼤大きさがあること¤ Hyperextension of the neckがないこと¤ ⽂文書による妊婦の同意が得られていること

3. ⾻骨盤位経腟分娩の管理理
a. 陣痛室・分娩室でb. ⾻骨盤位分娩の三種の神器
c. ⾻骨盤位経腟分娩の分娩⼿手技

a. 陣痛室・分娩室で¤ ⾻骨盤位分娩に習熟した医師が管理理する¤ 分娩進⾏行行が順調であることを適宜評価する¤ 胎児⼼心拍数陣痛モニタリングを⾏行行う¤ 破⽔水時はすぐに内診し、臍帯脱出がないことを確認する¤ 分娩第⼆二期は⼿手術室に近接した部屋で管理理する¤ 分娩時には新⽣生児蘇⽣生に習熟した医師が⽴立立ち会うb. ⾻骨盤位分娩の三種の神器¤ ⽀支脚器¤ タオル¤ 後続児頭鉗⼦子c. ⾻骨盤位経腟分娩の分娩⼿手技¤ ⾃自然経腟分娩¤ 臍輪輪までは⾃自然娩出を待つ¤ Bracht⼿手技¤ 部分的な⾻骨盤位牽出術¤ 肩甲娩出法：横8字法、古典的上肢解出¤ 後続児頭娩出法：Veit-Smellie法、後続児頭鉗⼦子¤ ⾻骨盤位牽出術¤ 全牽出術は可能な限り回避し、帝王切切開を選択する

CQ402 　⾻骨盤位の取り扱いは？
産婦⼈人科診療療ガイドライン産科編2011
1.

外回転術を施⾏行行する場合は、以下のすべての条件を満たす症例例とする。
(C)
1. 緊急帝王切切開が可能である
2. 帝王切切開既往がない
3. 児が成熟している2.

膝位、⾜足位、低出⽣生体重児、早産、児頭⾻骨盤不不均衡のいずれかまたはそれを疑わせる場合には帝王切切開を⾏行行う。(C)3.

以下2点を共に満たす場合には、2以外の⾻骨盤位に対して、経腟分娩も（が）選択できる。(C)1. ⾻骨盤位牽出術への充分な技術を有する医療療スタッフが常駐すること
2. 経腟分娩と帝王切切開双⽅方の危険と利利益とを妊婦に充分説明すること

4.

分娩様式選択に際しては、⽂文書による同意を取る。(A)まとめ¤ 慎重に分娩⽅方針を選択した場合、⾻骨盤位の経腟分娩は、帝王切切開分娩を予定する場合と同等に安全である可能性がある。
¤ ⾻骨盤位経腟分娩の管理理は、選択肢の⼀一つとしてその技術を継承するとともに検証していかなくてはならない。