瘢痕子宫再次妊娠阴道分娩的临床探讨

瘢痕子宫是指剖宫产或肌间型肌瘤剥除后的子宫。瘢痕子宫再次分娩，若前次剖宫产绝对指征(如骨盆狭窄等)不存在时可考虑阴道试产及阴道自然分娩，并非均需再次剖宫产。通过对选择进行阴道试产成功(106例)与失败(23例)的瘢痕子宫妊娠的分析，希望对产科临床工作有所裨益。     

瘢痕子宫患者再次妊娠分娩方式的选择与母婴结局分析

目的比较瘢痕子宫患者再次妊娠不同分娩方式对产妇及新生儿的影响,分析自然分娩的风险及注意事项。方法回顾性分析中国人民解放军海军总医院2010年6月至2015年6月收治的瘢痕子宫再次妊娠孕妇436例的资料,根据分娩方式的不同分为瘢痕子宫阴道分娩组172例、瘢痕子宫剖宫产组264例,比较两种分娩方式对产妇及新生儿的影响,按1:1比例选择同期非瘢痕子宫阴道分娩172例及非瘢痕子宫剖宫产产妇264例,分析瘢痕与非瘢痕子宫阴道分娩、瘢痕与非瘢痕子宫剖宫产对产妇及新生儿结局的影响。结果 (1)436例瘢痕子宫产妇,208例行阴道试产,172例试产成功行阴道分娩,成功率为78.6%,228例患者行剖宫产分娩;(2)瘢痕子宫剖宫产组产后24 h出血量、产后发热、新生儿窒息、住院时间明显多于瘢痕子宫阴道分娩组(P0.05);(3)瘢痕子宫阴道分娩组潜伏期、活跃期、总产程、产时出血量、新生儿Apgar评分、新生儿窒息发生率与非瘢痕子宫阴道分娩组差异无统计学意义(P0.05);(4)瘢痕子宫剖宫产组手术时间、住院时间、产后出血量、新生儿窒息、切口愈合不良、产褥感染、盆腹腔粘连发生率明显高于非瘢痕子宫剖宫产组(P0.05)。结论瘢痕子宫剖宫产会明显增加母婴并发症,临床应尽量避免瘢痕子宫无指征剖宫产,排除禁忌证的情况下,鼓励阴道试产,加强产程管理,提高产科质量。     

182例瘢痕子宫再次妊娠分娩试产的结果分析

目的探讨瘢痕子宫再次妊娠分娩方式的选择。方法回顾2008年12月1日至2010年11月30日在新疆墨玉县人民医院产科瘢痕子宫再次妊娠分娩采用阴道试产的182例患者的临床资料并进行分析。结果瘢痕子宫再次妊娠共209例,其中182例进行了阴道试产,试产率为87.08%,成功阴道分娩130例(71.43%);失败52例(28.57%),其中子宫破裂6例(3.30%)。结论瘢痕子宫再次妊娠分娩,除有明确再次剖宫产指征者均应在严密监护下给予阴道试产机会,避免不必要的再次剖宫产。     

瘢痕子宫再次妊娠分娩时机和分娩方式选择的影响因素分析

目的：探讨瘢痕子宫再次妊娠分娩时机和分娩方式选择的影响因素。方法：选取2015年1月-2017年12月于深圳市龙华区人民医院妇产科待产并选择阴道试产的瘢痕子宫再次妊娠孕妇228例为研究对象,根据最终分娩方式分为再次剖宫产组（121例）及阴道分娩组（107例）,收集并比较2组孕妇的临床资料。结果：228例孕妇中,107例顺利完成阴道分娩,成功率为46.93%,且所有孕妇均无子宫破裂发生;单因素分析发现,2组孕妇在年龄、文化程度、产前体质量指数（BMI）、距离上次剖宫产时间、阴道分娩史、定期产前检查、使用催产素、瘢痕厚度、现孕周、新生儿体质量等因素间差异有统计学意义（P＜0.05）;多因素分析发现,年龄、产前BMI、距离上次剖宫产时间、阴道分娩史、定期产前检查、瘢痕厚度、新生儿体质量是分娩方式选择的影响因素。结论：瘢痕子宫再次妊娠阴道分娩较为安全,对于35岁以下、BMI＜30 kg/m2、距离上次剖宫产时间超过2年、瘢痕厚度≥3 mm、预计新生儿体质量＜2 500 g且行定期产前检查的瘢痕子宫再次妊娠孕妇可选择阴道分娩。     

瘢痕子宫再次妊娠分娩时机和分娩方式选择的影响因素分析

目的:探讨瘢痕子宫再次妊娠分娩时机和分娩方式选择的影响因素。方法:选取2015年1月—2017年12月于深圳市龙华区人民医院妇产科待产并选择阴道试产的瘢痕子宫再次妊娠孕妇228例为研究对象,根据最终分娩方式分为再次剖宫产组(121例)及阴道分娩组(107例),收集并比较2组孕妇的临床资料。结果:228例孕妇中,107例顺利完成阴道分娩,成功率为46.93%,且所有孕妇均无子宫破裂发生;单因素分析发现,2组孕妇在年龄、文化程度、产前体质量指数(BMI)、距离上次剖宫产时间、阴道分娩史、定期产前检查、使用催产素、瘢痕厚度、现孕周、新生儿体质量等因素间差异有统计学意义(P0.05);多因素分析发现,年龄、产前BMI、距离上次剖宫产时间、阴道分娩史、定期产前检查、瘢痕厚度、新生儿体质量是分娩方式选择的影响因素。结论:瘢痕子宫再次妊娠阴道分娩较为安全,对于35岁以下、BMI30 kg/m~2、距离上次剖宫产时间超过2年、瘢痕厚度≥3 mm、预计新生儿体质量2 500 g且行定期产前检查的瘢痕子宫再次妊娠孕妇可选择阴道分娩。     

瘢痕子宫再次妊娠分娩方式及效果

目的：分析瘢痕子宫再次妊娠分娩方式选择及效果。方法：收集2011年1月至2013年12月间在我院分娩的43例剖宫产后瘢痕子宫再次妊娠产妇临床资料,对其进行恢复性分析总结。结果：43例产妇中13例行择期剖宫产,30例产妇行阴道试产,其中13例产妇经阴道分娩成功,阴道试产失败17例患者行剖宫产;行剖宫产的产妇出血量明显高于阴道分娩组（P〈0．05）,两种分娩方式的新生儿Apgar评分及产程时间无明显差异（P〉0．05）。结论：临床中对于瘢痕子宫再次妊娠患者应把握好阴道分娩指征,倡导行阴道试产,以最大限度地减少不必要的剖宫产。     

瘢痕子宫再次分娩115例临床分析

近年来随着剖宫产手术指征的放宽，剖宫产率有所上升，但围产儿死亡率并未明显下降，而产妇手术死亡率及并发症均明显高于阴道分娩者，而反复剖宫产率增加是剖宫产率增加的一个原因。首次剖宫产后经阴道分娩(VBAC)已成为妇产科学界试图降低剖宫产率的焦点问题。本文对我院近5年剖宫产后瘢痕子宫再次分娩115例进行回顾性分析，以探讨如何正确处理瘢痕子宫再次妊娠分娩的问题。     

剖宫产术后瘢痕子宫再次妊娠分娩方式探讨

目的:剖宫产术后瘢痕子宫再次妊娠分娩方式探讨。方法:对我院从2006年1月至2010年12月的剖宫产后瘢痕子宫再次妊娠的孕妇分娩方式、分娩结局及母婴并发症进行分析。将其中再次剖宫产的83例与同期随机抽取首次剖宫产的83例进行对比,将剖宫产后阴道试产成功的48例与同期随机抽取非瘢痕子宫试产成功的48例也进行比较。结果:146例中有63例选择了阴道试产,48例试产成功。剖宫产后阴道试产成功组产程出血、产程时间、新生儿并发症差异无统计学意义P>0.05;再次剖宫产组与首次剖宫产组的产程出血、产程时间及腹腔粘连情况相比差异有统计学意义P<0.05;剖宫产组与阴道分娩组相比产程出血差异有统计学意义P<0.05。结论:剖宫产术后再妊娠分娩不是剖宫产的绝对指征,符合试产条件者,在严密监护下阴道试产也是安全的。     

瘢痕子宫与非瘢痕子宫经阴道分娩的临床分析

目的探讨剖宫产术后瘢痕子宫再次妊娠经阴道分娩方式的可行性,从而降低再次剖宫产率。方法选取我院2013年5月~2015年4月收治的瘢痕子宫再次妊娠经阴道分娩患者93例为Ⅰ组,同期选取非瘢痕子宫分娩产妇104例为Ⅱ组。结果Ⅰ组成功率为77.4%,分娩过程中未出现子宫破裂等严重并发症,产后出血量、总产程、新生儿评分与Ⅱ组比较,差异无统计学意义(P0.05)。两组在阴道试产过程中改为剖宫产的分别为21例和11例,差异有统计学意义(P0.05)。结论对具有剖宫产手术史的产妇在选取分娩方式时,在具备阴道试产适应症的情况下,阴道分娩是安全可靠的推荐方式。     

剖宫产术后瘢痕子宫再次妊娠93例分娩方式探讨

目的:探讨剖宫产术后瘢痕子宫再次妊娠分娩方式的选择.方法:回顾性分析2007年1月1日至2011年10月31日我院收治的剖宫产术后瘢痕子宫再次足月妊娠93例的临床资料,分析瘢痕子宫足月分娩方式的选择.结果:93例孕妇中有38例行阴道试产,试产率为40.86％,试产成功率84.21％ (32/38),再次剖宫产率65.59％(61/93),子宫破裂发生率1.08％(1/93).阴道分娩组的产后24小时出血量及新生儿体重明显低于剖宫产组,差异有统计学意义(P＜0.05);两组孕妇在年龄、孕周、新生儿窒息发生率、产褥病率方面相比较,差异无统计学意义(P＞0.05).结论:对符合阴道分娩条件的剖宫产术后瘢痕子宫再次妊娠孕妇给予阴道试产机会是可行的.     

二次腹膜外剖宫产术临床研究

目的 探讨二次腹膜外剖宫产术及预防并发症的可行性。方法 将前次腹膜外剖宫产再次行腹膜外剖宫产的100例（腹膜外组），与同期再次腹膜内剖宫产的100例（腹膜内组）的手术时间、出血量、术后病率等进行比较。结果 手术时间：腹膜外组平均45min，其中28例兼行输卵管结扎术，腹膜内组平均6min，其中36例兼行输卵管结扎术（P〈0．05）；出血量：腹膜外组平均141ml，腹膜内组平均235ml（P〈0．05）；术后病率：腹膜外组2％，腹膜内组24％（P〈0．01）。结论 再次腹膜外剖宫产优于再次腹膜内术式。     

上海市20年剖宫产产妇死亡原因分析

目的 了解剖宫产产妇死亡原因及剖宫产潜在危险性，以降低剖宫产产妇死亡率。方法 对上海市１９７８～１９９７年间剖宫产产妇死亡病例资料进行回顾性分析。结果 （１）１９７８～１９８７年的剖宫产率为１５．５５％（２５８１５８／１６５９８９２），显著低于１９８８～１９９７年的２９．３９％（３６５３７６／１２４３３３７），两者比较，差异有极显著性（Ｐ〈０．０１）。（２）２０年间产妇死亡４３０例，其中剖宫产产妇     

Excessive use of cesarean section for the second twin?

BACKGROUND: In Sweden, the frequency of cesarean section of the second twin after vaginal birth of the first twin has increased in recent years. METHODS: To investigate the indications for second twin cesarean sections, all twin deliveries at Huddinge University Hospital from 1995 to 1997 were reviewed retrospectively. The rates of cesarean section for the second twin were compared with figures from the whole country, based on the Swedish medical birth register. RESULTS: Thirty-one percent of all twin deliveries had a spontaneous onset and spontaneous vaginal delivery. The total twin cesarean section rate, including cesarean section for the second twin, was 45% at Huddinge University Hospital in 1995-1997 and 44% in Sweden in 1995. Cesarean section for the second twin after vaginal delivery of the first twin occurred in 11%. On review, 2/3 of the cesarean sections for the second twin were considered potentially avoidable. CONCLUSION: In normal twin pregnancies with vertex/nonvertex presentation, the favorable fetal outcome and also the maternal risks associated with cesarean section support vaginal delivery as the recommended delivery route. Extraction or version of a second nonvertex twin should be attempted before cesarean section for this twin is performed.     

Is term breech presentation in primigravida an absolute indication for cesarean section?

Excessive perinatal loss is associated with breech presentation, this loss being accounted for by prematurity, congenital anomalies and birth trauma. In the endeavor to exert an effect on two of these problems, cesarean section has been resorted to increasingly. We have compared two management regimes of primigravida term breech presentation corresponding to two 4-yr periods. During the first period every case was evaluated carefully and, if no other pathology was found, a trial vaginal delivery was allowed. During the second period all the cases were delivered by elective cesarean section. Of the 108 cases of the first period, 46 delivered vaginally and 62 underwent cesarean section. 119 cases were scheduled for abdominal delivery during the second period. Immediate infant outcome for each group was determined by the 1 and 5 min Apgar scores. Analysis of 5 min Apgar scores demonstrated no significant differences in immediate outcome between infants delivered vaginally and by cesarean section. Fetal morbidity related to birth trauma was higher in the vaginal delivery group but there were no perinatal deaths. Maternal morbidity was observed only in the cesarean section groups. This study suggests that properly selected primigravid term breech infants could be delivered vaginally without increased perinatal mortality and with immediate outcomes comparable to those found with cesarean section.     

Management and outcome of vertex-breech and vertex-vertex presentation in twin gestation: a comparative study

A comparative study of twin pregnancies with vertex-breech and vertex-vertex presentation was undertaken to evaluate the effect of mode of delivery on perinatal outcome. During the years 1978-1984 there were 89 cases of vertex-breech deliveries at our institution and a control group of 89 cases of vertex-vertex presentation were chosen. The cesarean section rate was 11.2% for both twins in vertex-breech, and 20.2% for the first twin and 23.6% for the second in vertex-vertex presentation. The primary indications for cesarean section were not related to the type of presentation. The perinatal mortality was 22.4/1000 in the study group and 89.8/1000 in the control population. There were no statistically significant differences in 5-min Apgar scores and perinatal morbidity between the two types of presentation. We found that the high perinatal morbidity and mortality of both twins is related to prematurity and intrauterine growth retardation and not associated with the type of presentation of the second twin. Therefore, routine cesarean section for vertex-breech presentation is not necessarily indicated.     

Pelvic floor morbidity at 3 years after instrumental delivery and cesarean delivery in the second stage of labor and the impact of a subsequent delivery

OBJECTIVE: To compare pelvic floor symptoms at three years following instrumental delivery and cesarean section in the second stage of labor and to assess the impact of a subsequent delivery. STUDY DESIGN: We conducted a prospective cohort study of 393 women with term, singleton, cephalic pregnancies who required instrumental vaginal delivery in theatre or cesarean section at full dilatation between February 1999 and February 2000. 283 women (72%) returned postal questionnaires at three years. RESULTS: Urinary incontinence at three years post delivery was greater in the instrumental delivery group as compared to the cesarean section group (10.5% vs 2.0%), OR 5.37 (95% CI, 1.7, 27.9). There were no significant differences in ano-rectal or sexual symptoms between the two groups. Pelvic floor symptoms were similar for women delivered by cesarean section after a failed trial of instrumental delivery compared to immediate cesarean section. A subsequent delivery did not increase the risk of pelvic floor symptoms at three years in either group. CONCLUSION: An increased risk of urinary incontinence persists up to three years following instrumental vaginal delivery compared to cesarean section in the second stage of labor. However, pelvic floor symptoms are not exacerbated by a subsequent delivery.     

Complications associated with cesarean section in the second stage of labor.

Objective: To determine maternal and neonatal complications associated with cesarean section done in the second stage of labor. Method: Cohort study comparing cesarean sections done in the second stage of labor (cases) with those done for poor progress in the first stage (controls). Only singleton cephalic live pregnancies at 36 weeks or more, without previous cesarean section, were included. Result: There were 39 cases and 39 controls. Cesarean section in the second stage of labor took significantly longer (median 45 vs. 30 min; P<0.001), and was associated with more frequent postoperative pyrexia (10 vs. 2; P=0.012). There were more neonatal admissions in the case group (17 vs. 3; P<0.001). Hypoxic ischemic encephalopathy was more frequent in infants following second-stage cesarean section (8 vs. 1; P=0.013), as was subaponeurotic hemorrhage (6 vs. 0; P=0.012). Conclusion: Cesarean section in the second stage of labor is associated with significant intraoperative and neonatal morbidity.     

前置胎盘患者再次剖宫产术中发生产后出血的15例临床病例分析

目的:总结既往处理经验,结合文献复习,摸索针对前置胎盘患者施行再次剖宫产术的更好的临床路径。方法:回顾分析1999年1月至2011年12月在我院产科行再次剖宫产术中合并前置胎盘和产后出血的15例患者的临床资料。患者年龄26～43岁;既往有2次剖宫产史者2例,1次者13例;终止妊娠孕周为30～40周。15例患者中产前B超提示前置胎盘者12例,其中孕期或产前有阴道出血症状者9例。手术按常规步骤进行。结果:(1)15例患者中13例为完全性前置胎盘,胎盘主体位于前壁者8例、后壁者7例;2例为边缘性前置胎盘。胎盘完全或部分粘连者13例,其中9例存在不同程度的胎盘植入,1例胎盘部分直接侵入膀胱;(2)术中平均出血量2564ml(400～12500ml),中位出血量1100ml。11例患者术中发生休克,3例患者继发弥漫性血管内凝血(DIC)。出血后采取促宫缩剂治疗及手术方法,包括局部缝合开放的血窦,缝扎子宫动脉下行支,填塞宫纱,Blynch缝合及子宫次全切除术。2例术中同时行膀胱修补术;(3)13例患者术中止血成功,2例术后加行双侧子宫动脉栓塞术。患者预后均良好。结论:前次剖宫产史的患者如合并前置胎盘、胎盘粘连或植入,术前、术中和术后都极易并发大出血,应引起临床医生的重视。     

Management of vesico-uterine fistulae: a report of six cases

Six cases of vesico-uterine fistulae caused by cesarean section in four and pelvic trauma in two cases were treated during the past 15 years. Both the cases of vesico-uterine fistulae due to pelvic trauma and one case of vesico-uterine fistula due to cesarean section in whom the fistula was detected in the early post-operative period, could be managed successfully by suprapubic urinary diversion and control of infection. Two patients who were seen more than 1 year after the cesarean section, were cured by trans-abdominal closure of the fistula with omental interposition. One patient who reported 3 months after the cesarean section was managed by estrogen and progesterone-induced amenorrhea. The management protocol for vesico-uterine fistula should thus be individualised taking into consideration the etiology, and time interval between its occurrence and institution of treatment regimen.     

Effects of cesarean section on fertility and abortions

The impact of cesarean section on subsequent fertility and abortions was studied by comparing cohorts of women from two populations with unequal rates of cesarean section. After excluding women with strong confounding factors, all primiparae having had a cesarean section in 1973 and 1976 and matched controls were identified from the Swedish Birth Registry. The subsequent births in the next five and eight years were sought from the same registry and subsequent spontaneous abortions from the Hospital Inpatient Discharge Registry. There were fewer second children, subsequent children and twin deliveries in the cesarean section groups than in the control groups. The ratio of spontaneous abortions to births was somewhat higher in the cesarean section groups, but the difference was not statistically significant. Regardless of the different rates of cesarean section in the two populations, the 1973 and 1976 cohorts were similar. Apparently the findings were due not only to selection in the first cesarean section but possibly also to the operation itself.