降低剖宫产率临床措施探讨

目的探讨降低剖宫产率的临床措施和效果。方法回顾性分析1999年1月至2004年12月广东省东莞市凤岗医院1816例剖宫产及181例围生儿死亡的临床资料。结果6年间剖官产率分别为10．72％、12．05％、13．61％、17．38％、18．63％、16．44％，围生儿死亡率分别为140．75／万、148．22／万、164．63／万、148．49／万、140．91／万、151．46／万，6年间剖宫产指征一直以难产为第1位、社会因素为最后1位。结论只要严格掌握剖宫产指征。剖宫产率是可以控制的，围生儿死亡率也可以稳定在正常范围内。     

宫腔填塞纱条治疗剖宫产术中大出血68例分析

产后出血一直是产科最严重的并发症,目前仍是产妇死亡的主要原因之一。剖宫产时术中出血量明显多于阴道分娩,我院采用纱条填塞宫腔治疗剖宫产术中大出血６８例,取得满意效果,现分析报告如下。１　临床资料１－１　一般资料　自１９９１年１月至１９９７年１２月７年间我院共行剖宫产术７５４９例,平均年龄２５－４岁（２２～３６岁）;初产妇７５３０例,经产妇１９例;平均孕周３７周（３２～４２周）。其中古典式５例,腹膜外术式１２例,余７５３２例均为子宫下段剖宫产术,手术均采用连续硬膜外麻醉,术中常规使用预防性宫缩剂,在…     

42年孕产妇死亡原因变化分析

回顾性分析我院１９４９～１９９０年间孕产妇死亡原因及其变化，结果：４２年孕产妇总死亡率为１５０．２２／１０万，将４２年分４个阶段（１９４９～１９６０年，１９６１～１９７０年，１９７１～１９８０年，１９８１～１９９０年），死亡差从第一阶段的３６５．３１／１０万下降至第四阶段的４３．６７／１０万，第四阶段与以上阶段死亡率相比，差异有显著性（Ｐ＜０．０１）。死于直接产科原因的构成比在一、第二、第三阶段分     

不同年代产后出血346例临床特点分析

目的 通过对我院产后出血的病例进行回顾性分析，比较不同年代产后出血病例特点的变化。方法 对1993～1995年、2002-2004年共346例产后出血病例分为前后3年两组进行回顾性对比分析，包括年龄、孕周、产次、分娩方式、产后出血原因、分娩前后血红蛋白（HB）和血球压积（HCV）变化等指标。结果 2002年-2004年产后出血发生率较1993年～1995年明显上升。后3年产妇年龄较前3年增加。剖宫产分别占两组产后出血病例的49．04％和51．24％。宫缩乏力仍然是导致产后出血的第一位原因（51．9％vs58．7％），胎盘因素有显著上升（14．1％VS20．7％）。产后出血产妇分娩前后血红蛋白下降值和血球压积下降值后3年明显低于前3年（P〈0．05）。6年间因产后出血行子宫切除7例，其中5例为胎盘因素。结论 宫缩乏力仍是产后出血的首要原因，胎盘因素导致的产后出血近年来有所增加，成为产后出血的第二位原因，并成为导致子宫切除的严重产后出血的主要原因。     

羟乙基淀粉200／0．5氯化钠注射液对剖宫产术腰麻血压的影响

目的：探讨羟乙基淀粉200／0．5氯化钠注射液对剖宫产术腰麻血压的影响。方法：选择2012年1月至2012年12月在我中心行剖宫产手术的产妇400例，随机分为A、B两组，每组200例。麻醉前30分钟静脉10ml／kg输注羟乙基淀粉200／0．5氯化钠和复方乳酸钠，然后实施腰麻。于输注前（T1）、预输注完毕时（T2）、腰麻注药后5min（T3）：10min（T4）、20min（T5）记录血压、术中产妇恶心呕吐次数及出血量、麻黄碱的使用次数。结果：两组产妇SBP在T3-T5都有所下降。但B组较A组更显著（P〈0．05）。结论：腰麻前输注羟乙基淀粉200／0．5氯化钠较复方乳酸钠更有效防治腰麻剖宫产术低血压的发生。     

不同分娩方式对低危孕产妇分娩结局及卫生经济学指标的影响

目的探讨不同分娩方式对低危孕产妇分娩结局及卫生经济学指标的影响。方法对2002年9月至2007年4月北京协和医院分娩的3751例孕37-41周^＋6的低危孕产妇的资料进行回顾性分析,按分娩的干预方式不同分为3组：择期引产组（包括药物及手术引产）501例、择期剖宫产组1634例和自然临产组1616例,分别对3组孕产妇的一般情况及住院费用以及分娩结局（产后出血、产褥病率、尿潴留、输血情况、切口愈合情况、产时副损伤）、新生儿Apgar评分情况等进行统计比较。结果（1）一般情况分析：自然临产组孕产妇住院天数（4．8d）与择期引产组（6．3d）及择期剖宫产组（6．3d）比较,差异有统计学意义（P〈0．01）;择期剖宫产组孕产妇住院费用（3472元）明显高于择期引产组（3201元）及自然临产组（2293元）,分别比较,差异有统计学意义（P〈0．01）,尤其是择期引产组中的剖宫产患者住院费用明显高于择期剖宫产组及自然临产组中的剖宫产患者,分别比较,差异均有统计学意义（P〈0．01）。（2）产时及产后并发症总发生率：孕产妇产时及产后并发症总发生率分别是择期引产组为12．4％、择期剖宫产组为0．9％,自然临产组为6．8％。（3）产后出血（≥500ml）发生率：择期引产组、择期剖宫产组和自然临产组分别为3．0％（15／501）、0．6％（9／1634）和1．2％（19／1616）,3组分别比较,差异有统计学意义（P〈0．01）。（4）尿潴留发生率：择期引产组、择期剖宫产组和自然临产组分别为4．6％（23／501）、0和3．3％（54／1616）,择期剖宫产组尿潴留发生率低于择期引产组与自然临产组（P〈0．01）,择期引产组与自然临产组比较,差异无统计学意义（P〉0．01）。（5）有无分娩中或产后输血：择期引产组、择期剖宫产组和自然临产组率孕产妇有输血者分别为2．0％（10／501）、0．1％（1／1634）和0．4％（6／1616）,3组分别比较,差异有统计学意义（P〈0．01）。（6）产时副损伤：择期引产组、择期剖宫产组和自然临产组产时副损伤发生率分别为0．6％（3／501）、0和0．4％（7／1616）,3组分别比较,择期剖宫产组低于其他两组（P〈0．01）,择期引产组与自然临产组比较,差异无统计学意义（P〉0．01）。（7）切口延期愈合：择期引产组、择期剖宫产组和自然临产组分别为0．8％（4／501）、0和0．2％（4／1616）,3组分别比较,差异有统计学意义（P〈0．01）。（8）产褥病率：3组间相互比较,差别无统计学意义（P〉0．01）。（9）新生儿窒息发生率：择期引产组、择期剖宫产组和自然临产组分别为1．2％（6／501）、0．1％（1／1634）和1．0％（17／1616）,择期剖宫产组与其他两组分别比较,差异均有统计学意义（P〈0．01）,择期引产组与自然临产组比较,差异无统计学意义（P〉0．01）。结论择期引产会增加孕产妇产后出血、分娩中或产后输血的机会,且没有降低产妇尿潴留、新生儿窒息的发生率;择期剖宫产是相对安全的分娩方式,对孕产妇分娩并发症的发生没有不良影响,但会明显增加住院费用。     

应用B—lynch缝合术处理剖宫产术时出血56例临床分析

剖宫产术是产科最常见的手术．是解决难产与产科并发症的主要手段。国内报道剖宫产后子宫切除率为0．45％～0．61％。切除子宫使年轻妇女丧失生育功能，给产妇身心带来严重创伤。因此。迅速采取有效的措施控制出血是广大医务工作者面临的问题。我院自2002年以来采用捆绑式（B—lynch）缝合术救治56例剖宫产术时大出血患者，避免了子宫切除，现报道如下。     

胎膜早破剖宫产儿咽吸出物及羊水细菌培养结果分析

本文随机选择５４例以剖宫产结束分娩的胎膜早破产妇作为研究对象。剖宫产术中取单水及新生儿咽部分泌物做细菌培养，发现５４例胎膜早破者羊水中细菌培养阳性率为４６．３０％（２５／５４），新生儿咽部细菌培养阳性率为３１．４８％（１７／５４），均明显高于未破膜者（Ｐ＜０．０１）；进一步分析发现，破膜距胎儿娩出时间大于４８小时者，羊水及新生儿咽部带菌率明显升高（Ｐ＜０．０１）；产程中阴道检查超过３次者，羊水中及新生儿咽部带菌率明显升高（Ｐ＜０．０１）。作者认为：破膜时间超过１２小时未临产者应引产，超过４８小时未临产者，估计胎儿可存活应手术结束分娩。     

双胎一胎死亡后另一胎儿的预后

双胎中一胎发生宫内死亡,对另一胎会产生怎样的影响,一直是临床工作者所关心的问题。我们对此类病例进行回顾性分析,并对部分存活儿做了远期随访,结果如下。一、临床资料我院１９８７～１９９７年间共有双胎产妇１３８例,其中因一胎死亡后入院或在院内发生一胎死亡者共１９例,发生率为１３．７％。一胎儿发生死亡的孕周为２４～３９周,平均（３４±４．５８）周。双胎类型中因性别不同肯定为双卵双胎者４例;单绒毛膜单卵双胎８例;另７例为双绒毛膜双羊膜双胎。１．另一围产儿情况：１９例病人中的另一儿有４例随后亦发生宫内死胎（…     

妊娠期子宫肌瘤剔除术86例Meta分析

目的 探讨妊娠期子宫肌瘤剔除术的手术指征、并发症、妊娠结局以及影响手术成功的因素。方法 检索Pubmed（1989年1月～2004年4月）有关妊娠期行子宫肌瘤剔除术文献资料，对文献质量进行评价并提取相关信息．总结妊娠期行子宫肌瘤剔除术者的肌瘤特点、手术指征、并发症、妊娠结局等。结果 妊娠期行子宫肌瘤剔除术的86例中绝大部分在孕中期进行（12～26周），主要手术指征为腹痛（64％，35／55）和肌瘤过大或生长过快（20％．11／55）．术中无出血过多、子宫切除的并发症，术后自然流产4例．活产率达92％．分娩方式以剖宫产为主，占75％（53／71）。结论 在严格掌握适应证的基础上，妊娠期仍可安全地行子宫肌瘤剔除术。     

Changes in the rate of tubal ligation done after cesarean section.

OBJECTIVE: We studied tubal ligations done after cesarean section in a Spanish hospital during a 20-year period, in order to analyze changes in patient characteristics and indications for cesarean delivery. STUDY DESIGN: We reviewed the clinical records, for the period from 1978 to 1997, of 1996 cases of cesarean section followed by tubal ligation in 108776 births in which the fetus weighed 1000 g or more. RESULTS: During the 20-year period of study, the proportion of cesarean sections relative to vaginal deliveries increased, as did the frequency of cesarean section followed by tubal ligation relative to cesarean and vaginal deliveries. The proportion of women who underwent tubal ligation after a second cesarean section decreased from 60% during 1978-1982 to 5.6% during 1993-1997. The most frequent maternal pathology associated with gestation was previous cesarean section (60.5%), although 50% of the women had no underlying pathology. CONCLUSIONS: In our setting, the rate of cesarean section followed by tubal ligation has been increasing steadily since the early 1980s. The proportion of women who requested tubal sterilization and who had only one living child, or who had had a previous cesarean birth, also increased.     

235例妊娠合并心脏病围产期的处理

分析了１９７８年至１９９１年妊娠合并心脏病２３５例的临床资料，结果表明患病率为１％，产妇病死率１７‰，心脏病孕产妇病死率占非产科原因死亡的第一位。围产儿病死率为５９．６‰。本组剖宫产率为３６．１％，其中心功能Ⅲ、Ⅳ级者１５例，占６．４％。认为改善母婴预后的关键在于良好的孕产妇系统管理及高危妊娠的临护，积极防治贫血、妊高征、产程延长及各种并发症，适时终止妊娠可获良好的妊娠结局。     

A 10-year population-based study of uterine rupture

OBJECTIVE: To review the incidence, associated factors, methods of diagnosis, and maternal and perinatal morbidity and mortality associated with uterine rupture in one Canadian province. METHODS: Using a perinatal database, all cases of uterine rupture in the province of Nova Scotia for the 10-year period 1988-1997 were identified and the maternal and perinatal mortality and morbidity reviewed in detail. RESULTS: Over the 10 years, there were 114,933 deliveries with 39 cases of uterine rupture: 18 complete and 21 incomplete (dehiscence). Thirty-six women had a previous cesarean delivery: 33 low transverse, two classic, one low vertical. Of the 114,933 deliveries, 11,585 (10%) were in women with a previous cesarean delivery. Uterine rupture in those undergoing a trial for vaginal delivery (4516) was complete rupture in 2.4 per 1000 and dehiscence in 2.4 per 1000. There were no maternal deaths, and maternal morbidity was low in patients with dehiscence. In comparison, 44% of those with complete uterine rupture received blood transfusion (odds ratio 7.60, 95% confidence interval 1.14, 82.14, P =.025). Two perinatal deaths were attributable to complete uterine rupture, one after previous cesarean delivery. Compared with dehiscence, infants born after uterine rupture had significantly lower 5-minute Apgar scores (P <.001) and asphyxia, needing ventilation for more than 1 minute (P <.01). CONCLUSION: In 92% of cases, uterine rupture was associated with previous cesarean delivery. Uterine dehiscence was associated with minimal maternal and perinatal morbidity. In contrast, complete uterine rupture was associated with significantly more maternal blood transfusion and neonatal asphyxia.     

Management trend and safety of vaginal delivery for term breech fetuses in a tertiary care hospital of Karachi, Pakistan.

AIM: To investigate the safety of vaginal delivery for term breech fetuses in a tertiary-care hospital of Pakistan. METHODS: We reviewed the medical records of all live singleton breech deliveries at or beyond 37 weeks of gestation, at the Aga Khan University Hospital, Karachi, from January 1988 to December 1995. RESULTS: Rate of cesarean section increased from 48% (1988) to 74% (1995). Out of 287 subjects, 158 underwent elective cesarean section while 129 received a trial of labor, 77% of which delivered vaginally. There was no neonatal or maternal death. Compared to babies delivered by emergency or elective cesarean section, those delivered vaginally had significantly more neonatal intensive-care unit admissions (none and 5% versus 13%) and higher rates of birth trauma (none and 0.6% versus 7%). However, there was no significant difference in the Apgar score at 5 minutes and the risk of maternal complications by delivery mode. CONCLUSION: Allowing trial of labor to carefully selected mothers can result in vaginal delivery in 77% of the cases. However, the risk of trauma and neonatal intensive-care unit admissions, among vaginal births may favor the decision of elective cesarean section, unless rigorous pre-delivery assessment and conduct of delivery by adequately trained obstetricians is performed.     

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.     

Maternal deaths after elective cesarean section for breech presentation in the Netherlands

BACKGROUND AND METHODS: The cesarean section rate for term singleton breech babies in the Netherlands rose from 57 to 81% after the Term Breech Trial in 2000. The Dutch Maternal Mortality Committee registered and evaluated maternal mortality due to elective cesarean section for breech. RESULTS: Four maternal deaths after elective cesarean section for breech presentation, from 2000 to 2002 inclusive, were registered, 7% of total direct maternal mortality in that period. Two women died due to massive pulmonary embolism, both were obese, and thromboprophylaxis was not adjusted to their weight. The other two women died from sepsis, one had not receive perioperative prophylactic antibiotics. The case fatality rate for elective cesarean section for breech presentation was 0.47/1,000 operations. No death after emergency cesarean section for breech presentation was registered at the committee. CONCLUSIONS: Elective cesarean section does not guarantee the improved outcome of the child, but may increase risks for the mother, compared to vaginal delivery.     

Mode of delivery for breech presentation in grandmultiparous women.

OBJECTIVES: To compare maternal and neonatal outcomes of planned vaginal delivery vs. elective cesarean delivery for breech presentation at term. METHODS: Retrospective study of term breech deliveries from January 1997 through December 2000. A group of 128 women for whom vaginal delivery was planned was compared with a group of 122 women who had an elective cesarean delivery with regard to neonatal mortality and morbidity (birth trauma, birth asphyxia, hyperbilirubinemia, and duration of stay in the neonatal intensive care unit) and maternal morbidity (infections, hemorrhage, hysterectomy, deep venous thrombosis, and pulmonary embolism). RESULTS: There was no difference in neonatal mortality and morbidity between the two groups (13.0% vs. 9.4%). There were fewer maternal complications in the planned vaginal group than in the elective cesarean group (5.5% vs. 18%; P<0.01). In the planned vaginal delivery group 70% of multiparas and 85% of grandmultiparas were delivered vaginally compared with 50% of nulliparas. CONCLUSIONS: In breech presentations at term vaginal delivery can be achieved in 85% of grandmultiparas without significant neonatal morbidity. Elective cesarean section is associated with increased maternal morbidity compared with planned vaginal delivery.     

Outcomes associated with cesarean section versus vaginal breech delivery at a university hospital.

OBJECTIVE: To determine whether vaginal breech delivery is associated with increased morbidity in term breech singletons using strict selection criteria. This study encompasses our previous studies (in 1987 and 1995) and extends our experience to 21 years. STUDY DESIGN: Retrospective cohort study from 1980 to 2001 including term, non-anomalous singleton breech deliveries selected by strict criteria. Univariable and multivariable analyses were performed for neonatal and maternal outcomes. RESULTS: Five hundred and eleven women underwent cesarean section and 214 a trial of labor. We found greater overall maternal morbidity in the cesarean section group (odds ratio (OR) 1.89, 95% confidence interval (CI)=1.34-2.65). In the vaginal delivery group, neonates were more likely to have had >1 day of mechanical ventilation (OR 10.0, 95% CI=1.56-63.9). No maternal deaths occurred and no neonatal deaths or seizures occurred. CONCLUSION: Given our findings, offering a trial of vaginal breech delivery to well-counseled strictly selected patients remains an appropriate option.     

Maternal morbidity associated with cesarean delivery without labor compared with spontaneous onset of labor at term

OBJECTIVE: To estimate the maternal morbidity associated with cesarean deliveries performed at term without labor compared with morbidity associated with spontaneous labor. METHODS: A 14-year, population-based, cohort study (1988-2001) using the Nova Scotia Atlee Perinatal Database compared maternal outcomes in nulliparous women at term undergoing spontaneous labor for planned vaginal delivery with singleton, cephalic presentation and nulliparous women delivering by cesarean without labor. RESULTS: From a total of 18,435 pregnancies, which satisfied inclusion and exclusion criteria, 721 were cesarean deliveries without labor. There were no maternal deaths or transfers for intensive care. There was no difference in wound infection, blood transfusion, or intraoperative trauma. Women undergoing cesarean deliveries without labor were more likely to have puerperal febrile morbidity (relative risk [RR] 2.2; 95% confidence interval [CI] 1.1, 4.5; P=.03), but were less likely to have early postpartum hemorrhage (RR 0.6; 95% CI 0.4, 0.9; P=.01) compared with women entering spontaneous labor. Subgroup analyses of maternal outcomes in women delivering by spontaneous and assisted vaginal delivery and cesarean delivery in labor were also performed. The highest morbidity was found in the assisted vaginal delivery and cesarean delivery in labor groups. CONCLUSION: The increased maternal morbidity in elective cesarean delivery compared with spontaneous onset of labor is limited to puerperal febrile morbidity. Maternal morbidity is increased after assisted vaginal delivery and cesarean delivery in labor compared with cesarean delivery without labor.     

妊娠合并特发性血小板减少性紫癜110例临床分析

目的：探讨妊娠合并特发性血小板减少性紫癜（idiopathic thromboeytopenic purpura,ITP）的诊断、治疗及其对母婴的影响。方法：回顾性分析1997年1月—2011年4月间住院分娩110例妊娠合并ITP患者的临床资料。结果：阴道分娩68例,剖宫产42例。其中发生产后出血3例,无死亡病例。予以单纯糖皮质激素治疗33例,糖皮质激素联合丙种球蛋白治疗25例,糖皮质激素联合丙种球蛋白治疗效果不佳或入院时血小板极低因产科因素需急诊剖宫产予以血小板悬液输注48例。除1例新生儿出生后外周血小板计数＜100×109/L外,其余均在正常水平（＞100×109/L）,无颅内出血及其他血小板减少或相关疾病。结论：妊娠合并ITP时,若处理及时得当,对母婴影响很小。糖皮质激素联合丙种球蛋白为有效的治疗方法,分娩方式由产科情况决定,若无产科指征,以阴道分娩为宜;若治疗无效或血小板水平极低,也可在血源充足时行选择性剖宫产。