剖宫产后再次妊娠的分娩方式探讨

目的 :探讨剖宫产后再次妊娠的最佳分娩方式。方法 :对 15 6例剖宫产后再次妊娠孕妇的分娩方式进行回顾性分析。结果 :88例孕妇阴道试产 ,试产成功率者 88 6 %。选择再次剖宫产 6 8例。结论 :剖宫产史作为再次妊娠剖宫产的指征是不合理的 ,如无剖宫产指征 ,应给予试产 ,因为阴道分娩可减少再次开腹手术给患者带来的各种危险和并发症 ,减少患者手术痛苦和经济负担。     

Terbutaline Tocolysis Prior to Cesarean Section for Fetal Distress

Two hypotheses are examined: l) side effects of terbutaline tocolysis are limited to maternal tachycardia and 2) terbutaline tocolysis at the diagnosis of fetal distress will facilitate intrauterine resuscitation while preparation for cesarean delivery is underway. This is a 10-year chart review of terbutaline tocolysis as part of the management of acute fetal distress prior to cesarean delivery. All charts were reviewed for side effects of terbutaline use. During the final 27 months, efficacy of terbutaline resuscitation was studied by comparing the scalp-pH-to-cord-pH difference of individual fetuses in the terbutaline group with those where terbutaline was not used. The mean maternal pulse after terbutaline was 113 ± 20 (SD) beats per minute (bpm). A pulse of ≥140 bpm occurred in 11.7% of the terbutaline group (n = 368). A pulse of ≥140 bpm was more common (51.0%) when preoperative vagolytic medication (n = 119) was also administered. A pulse of ≥140 bpm occurred in 1.9% of the control group (n = 215). Mean arterial pressure was not changed by terbutaline, even in the presence of preeclampsia. Of those in the terbutaline group with a scalp pH value <7.25, there were significantly fewer low, 5-min Apgar scores; fewer fetuses demonstrating a fall in pH between the paired scalp and cord values; and a greater mean pH increase than in the respective control group. Of strong clinical pertinence is that the fetuses with the lowest scalp pH had the greatest increase in pH value. Our study supports the safety and efficacy of intrauterine resuscitation by terbutaline tocolysis.     

Updating Care of Cesarean Section Patients

At a time when prepared childbirth and the participation of both parents in labor and delivery is being stressed, nurses need to reexamine the impact of a cesarean section on the family. Nurses need to he active in modifying those experiences of a cesarean section family that may he in direct conflict with their expectations: loss of participation in delivery, separation of the couple during delivery, diminution of the father's role, and prolonged isolation of the infant front the parents after delivery. Nursing cure of these patients should be maternity-oriented rather than surgery-oriented.     

Laparoendoscopic Single-Site Surgery With Hysterectomy in Patients With Prior Cesarean Section: Comparison of Surgical Outcomes With Bladder Dissection Techniques

Study ObjectiveThe aim of this study was to compare operative outcomes from 300 patients who underwent laparoendoscopic single-site surgery (LESS) with hysterectomy (H) according to previous cesarean section and to describe the bladder dissection technique in detail.DesignRetrospective cohort study (Canadian task classification II-2).SettingA university hospital, research hospital, and a tertiary care center.PatientsIn total, 300 LESS-H procedures were performed for benign gynecologic disease, cervical disease, and endometrial disease at Samsung Medical Center in Seoul, Korea, between May 2008 and February 2012. Patients were categorized into 2 groups according to previous cesarean history: the previous cesarean section group (n = 98) and the no history of previous cesarean section group (n = 202).InterventionLESS-H with vaginal or lateral approach for bladder dissection.Measurements and Main ResultsBaseline demographics and clinical characteristics, except for age, were generally the same between the 2 groups. The operative outcomes including operative time, uterine weight, estimated blood loss, hemoglobin change, hospital stay, and transfusion rate were not different between the 2 groups. Adhesiolysis was required more in the previous cesarean section group (p = .002). LESS failure requiring additional trocars occurred more often in the previous cesarean section group (p = .041), but the rates of conversion to laparotomy were not different (p = .327). The overall surgical complication rate except transfusion was 2.67% in this study. Two cases of urologic problems with ureter injury or bladder injury were reported in the previous cesarean section group. In the no previous cesarean section group, there were 2 urologic problems.ConclusionLESS-H is a feasible procedure with a lateral approach or vaginal approach for bladder dissection, even in patients with previous cesarean section.     

瘢痕子宫再次妊娠不同分娩方式近远期并发症比较

目的:探讨瘢痕子宫再次妊娠不同分娩方式的近远期并发症。方法:选择2002年2月至2017年12月苏州大学附属第一医院妇产科收治的瘢痕子宫孕妇2617例,其中择期再次剖宫产2246例(ERCD组),阴道试产成功334例(VBAC组),阴道试产失败转急诊剖宫产37例(TOLAC失败组)。对3组患者的妊娠结局及产后近远期并发症进行比较分析。结果:3组患者中,TOLAC失败组剖宫产患者并发症发生率最高(18. 92%),其次是ERCD组患者(6. 99%),而VBAC组患者并发症发生率最低(3. 29%)。VBAC组出现输血、产后发热和尿潴留的比例明显低于ERCD组(分别为0 vs 1. 65%、1. 20%vs 4. 14%、0. 30%vs 2. 98%,P <0. 05);发生子宫破裂、输血、尿潴留、肠梗阻的比例低于TOLAC失败组(分别为0 vs 10. 81%、0 vs 8. 11%、0. 30%vs 5. 41%、0 vs 5. 41%,P <0. 05); TOLAC失败组发生子宫破裂、输血、肠梗阻的比例显著高于ERCD组(分别为10. 81%vs 0. 31%、8....     

Difficult Deliveries in Cesarean Section

Cesarean section rate has been on the rise. It is commonly perceived as a simple and safe alternative to difficult vaginal birth. However, there are situations during C section where delivery of fetus may be difficult. This can cause maternal and fetal complications. To avoid such mishaps, anticipation of potential difficulties and planning in advance can be fruitful. This amounts to mobilization of a good team of anesthetist, assistant and skilled neonatologist. Proper technical skills are needed not only to use the equipment but to deal with such situations for safe delivery of the fetus. The training in technical skills can be imparted through drill protocols under C section skills. This way, one should try and accomplish safe atraumatic fetal delivery.     

Trial of Labour in Patients with a Prior Caesarean Section and an Intervening Vaginal Delivery

202 patients having had one vaginal delivery after a prior Caesarean section between 1980 and 1984 were followed-up to December, 1986; 77 of them came again for delivery during this time. Four elective Caesarean sections and 103 trials of labour were carried out in this patient group. Of these, 88 (85.4%) ended in vaginal delivery. There was no fetal loss, nor any significant maternal or fetal morbidity; in particular there was no uterine rupture or scar dehiscence. It is concluded that the prognosis for vaginal delivery is good once a successful trial of scar has occurred, so long as the labour is carefully monitored and a repeat Caesarean section performed when indicated.     

腹主动脉球囊阻断在凶险性前置胎盘患者剖宫产术中的应用

随着剖宫产率的升高,凶险性前置胎盘的发生率也逐年升高,分娩时可发生难以控制的大出血,且子宫切除率高,临床处理困难,严重威胁孕产妇的生命。其发病原因主要与剖宫产术后瘢痕形成过程中子宫蜕膜发育与滋养细胞侵袭之间的失调有关。如何有效地控制产时产后出血、保留患者的子宫是抢救凶险性前置胎盘成功的关键。近年来国内外医师探索在剖宫产过程中联合腹主动脉球囊阻断技术来控制术中出血风险,降低子宫切除率。虽然腹主动脉球囊阻断技术操作简单易行,止血效果明显,可使手术视野清晰,但是其同时也存在多种影响因素和手术相关并发症,其价值及风险仍在逐步认识阶段。现就腹主动脉球囊阻断技术的发展过程、其应用于凶险性前置胎盘的优势及弊端进行综述。     

Perioperative Outcomes of Total Vaginal Hysterectomy in Women with Prior Cesarean Delivery

Study ObjectiveTo compare the incidence of perioperative complications of total vaginal hysterectomy (TVH) in women with and without a prior cesarean section (CS).DesignRetrospective cohort.SettingTertiary care academic institution.PatientsA total of 742 women who underwent TVH over a 5-year period.InterventionsTVH.Measurements and Main ResultsPrior CS did not increase the overall rate of Clavien-Dindo grades 2 to 3 complications (p =.20). The incidence of cystotomy (2.2% CS vs 1.1% no CS, p =.29), ureteral injury (1.1% vs 0.2%, p =.23), proctotomy (1.1% vs 0.2%, p =.23), postoperative bleeding (1.1% vs 0.6%, p =.47), or reoperation (0.0% vs 0.3%, p = 1.00) was not increased from having a prior CS. Prior CS increased blood transfusion (5.6% vs 0.6%, p <.05) but did not increase conversion to laparotomy (2.2% vs 0.6%, p =.15), length of hospitalization (11.2% vs 14.1% discharge on the same day, 66.3% vs 63.6% discharge on postoperative day 1, and 22.5% vs 22.4% discharge on or after postoperative day 2, p =.76), or 30-day readmission rates (1.1% vs 3.5%, p =.34).ConclusionIn patients who underwent TVH, a prior CS increased postoperative blood transfusion but did not increase the risk for overall perioperative complications.     

Postdischarge Surveillance After Cesarean Section

Background: Cesarean section is a major surgical procedure with a relatively short hospital stay. A significant rate of surgical site infection after this procedure is missed by standard inpatient surveillance. This study aimed to evaluate a method of postdischarge surveillance and compare results with the incidence of infection before discharge. Method: A postdischarge survey was sent on day 30 to 277 women who had delivered by cesarean section during the 12‐month study period. A follow‐up telephone interview was conducted if the questionnaire had not been returned within 2 weeks, if a diagnosis of infection could not be clearly determined from the participant's responses, or to confirm the diagnosis of infection. If follow‐up was not completed, a chart audit was undertaken. Results: A total response rate of 89 percent (247/277) was obtained, and 28 women with a surgical site infection were identified from the survey. Telephone follow‐up and chart review of patients with possible infection and of nonresponders identified 32 percent more postdischarge infections (14/42). The overall infection rate was 17 percent compared with 2.8 percent at discharge. Conclusions: Postdischarge surveillance is necessary to determine accurate surgical site infection rates after cesarean section, increase awareness of caregivers about infection control problems, and indicate the need for appropriate follow‐up care. Women undergoing a cesarean delivery should be informed of the risk of postdischarge infection and educated about the signs and symptoms of infection.     

剖宫产后再次妊娠的阴道分娩

近年来剖宫产率在我国不断升高,有些城市已从20年前的9%上升到45%.造成剖宫产率升高的原因很多,例如惧怕分娩、胎儿电子监护的广泛使用、对臀位产缺乏训练和经验、阴道手术产的减少以及再次剖宫产的增多等.减少过高的剖宫产率的办法之一就是剖宫产史孕妇经阴道试产.     

Trial of Labor and Vaginal Delivery Rates in Women with a Prior Cesarean

ObjectiveTo evaluate evidence on trial of labor (TOL) and vaginal delivery rates in women with a prior cesarean and to understand the characteristics of women offered a trial of labor.Data SourcesMEDLINE, DARE, and Cochrane databases were searched for articles evaluating mode of delivery for women with a prior cesarean delivery published between 1980 and September 2009.Study SelectionStudies were included if they involved human participants, were in English, conducted in the United States or in developed countries, and if they were rated fair or good base on U.S. Preventive Services Task Force (USPSTF) criteria.Data Extraction and SynthesisThe search yielded 3,134 abstracts: 69 full‐text papers on TOL and vaginal birth after cesarean (VBAC) rates and 10 on predictors of TOL. The TOL rate in U.S. studies was 58% (95% CI [52, 65]) compared with 64% (95% CI [59, 70]) in non U.S. studies. The TOL rate in the U.S. was 62% (95% CI [57, 66]) for studies completed prior to 1996 and dropped to 44% (95% CI [34, 53]) in studies launched after 1996, p = .016. In U.S. studies, 74% (95% CI [72, 76]) of women who had a TOL delivered vaginally. Women who had a prior vaginal birth or delivered at a large teaching hospital were more likely to be offered a TOL.ConclusionsAlthough the TOL rate has dropped since 1996, the rate of vaginal delivery after a TOL has remained constant. Efforts to increase rates of TOL will depend on patients understanding the risks and benefits of both options. Maternity providers are well positioned to provide key education and counseling when patients are not informed of their options.     

Sonographic Prediction of Scar Dehiscence in Women with Previous Cesarean Section

Purpose

To estimate the risk of uterine dehiscence/rupture in women with previous cesarean section (CS) by comparing the thickness of lower uterine segment (LUS) and myometrium with trans-abdominal (TAS) and trans-vaginal sonography (TVS).

Method

In this case-control study, in 100 pregnant women posted for elective CS (with or without previous CS; group 1 and group 2 respectively), the thickness of LUS and myometrium was measured sonographically (TAS and TVS). Intra-operatively, LUS was graded (grades I–IV), and its thickness was measured with calipers. The primary outcome of the study was correlation between echographic measurements (TAS and TVS) and features of LUS (grades I–IV) at the time of CS. Secondary outcomes were correlation between myometrial thickness, number of previous CS, and inter-delivery interval with LUS (grades I–IV).

Results

Sonographic measurements of LUS and myometrium were significantly different between the two groups (both TAS and TVS p value = 0.000 each). However, the number of previous CS (p = 0.440) and inter-delivery interval (p = 0.062) had no statistically significant correlation with thickness of LUS.

Conclusions

Sonographic evaluation of LUS scar and myometrial thickness (both with TAS and TVS) is a safe, reliable, and non-invasive method for predicting the risk of scar dehiscence/rupture. Specific guidelines for TOLAC, after sonographic assessment of women with previous CS, are need of the hour.Keyword: Transabdominal ultrasonography, Transvaginal ultrasonography, Cesarean section, Pregnancy, Cesarean scar