降低剖宫产率

近年来剖宫产率迅猛上升,如何将其控制在适当水平已经成为产科医生共共同关注的问题。本文综述宫产的四个主要手术指征：难产;剖宫产后再次妊娠;臀位妊娠;胎儿窘迫。通过各种积极处理,减少具有相对剖宫产指征的剖宫产数,从而降低总剖宫产率。     

提高阴道分娩安全性有效降低剖宫产率

<正>剖宫产术是处理妊娠并发症和合并症、解决难产和围生儿宫内窒息的重要手段,在降低孕产妇和围生儿死亡率方面起到重要作用。20世纪70年代开始,胎儿电子监护和超声影像学的应用,围生医学的兴起,进一步扩大了剖宫产的指征,至80年代,剖宫产率上升到10%～15%。这一     

影响剖宫产率及剖宫产指征变化的因素分析

剖宫产是处理高危妊娠和异常分娩,挽救孕产妇和围生儿生命的有效手段,合理选择剖宫产指征,可降低高危孕妇和围生儿的病死率,近年来,剖宫产率有逐年上升的趋势。现对剖宫产率升高的具体原因进行分析,以合理掌握剖宫产指征。1资料与方法1.1研究对象2000年1月至2004年12月在两院产     

剖宫产率增高原因的探讨

目的 分析20年剖宫产率和指征变化,探讨剖宫产率升高原因。方法 抽样选择1980年～1999年20年我院剖宫产病例1579例,比较剖宫产率和手术指征变化。结果 80年代剖宫产率平均23.79％,90年代平均达41.15％,两者差异有显著性(P<0.01)。在剖宫产指证中,头盆不称、妊娠并发症逐渐下降,而胎儿宫内窘迫、高龄初产、巨大儿、社会因素逐渐上升。结论 提高医务人员对剖宫产的认识,加强孕产期保健及管理,改变产时服务模式,正确掌握剖宫产指征,有望控制剖宫产率。     

心理干预与降低剖宫产率的探讨

目的:探讨实施心理干预,对降低剖宫产率的影响。方法:将280例孕产妇随机分为观察组和对照组,每组各140例。观察组在孕期及产程中进行心理干预,对照组按产程常规处理。结果:观察组剖宫产率明显低于对照组(P<0.01),观察组产妇出血量明显低于对照组(P<0.05)。结论:孕产期对孕产妇实施心理干预,可降低剖宫产率,减少产后出血量。     

影响剖宫产率与剖宫产指征的因素分析

目的：剖析近年来剖宫产率居高不下的主要影响因素，为制定降低剖宫产率的具体措施提供资料。方法：对1989年至2001年间吉林大学第二医院产科住院产妇的足月分娩病例进行回顾性分析。结果：①剖宫产率呈逐年上升趋势，而产钳率呈逐年下降趋势；②剖宫产占难产分娩的比例逐年增高，同期产钳助产占难产分娩的比例逐年下降；③2000年以前居于前四位的剖宫产手术指征是：相对头盆不称、胎儿窘迫、臀位、胎膜早破；1999年起珍贵儿指征已出现，2000年及2001年已跃居第二位；④2000年与2001年脐带绕颈作为剖宫产指征居于第五位和第六位；⑤因单因素指征行剖宫产的比例逐年增加，而因多因素指征行剖宫产的比例逐年下降。结论：现今，剖宫产手术指征已远远超过单纯医学指征的范围，来自孕产妇及医生的主观意愿影响着对分娩方式的合理选择。     

剖宫产率及剖宫产指征14年变化研究

目的：探讨剖宫产率及剖宫产指征的变化和对围生儿病死率的影响。方法：选择14年间剖宫产病例820例，分析剖宫产率及剖宫产指征变化、各项相关数据和围生儿病死率的关系。结果：①剖宫产率逐年上升；②在剖宫产指征变化中，难产因素、胎儿窘迫持续在第1、2位，社会因素占第3位，并显示逐年升高；③围生儿病死率逐年趋于稳定。结论：剖宫产率升高，在一定范围内降低了围生儿病死率，但剖宫产率升高到20以上时，围生儿病死率并不随之下降。     

剖宫产术后阴道试产的新探讨

本文综述了９０年代以来许多国家有关剖宫产术后阴道分娩的研究进展。     

剖宫产率增高因素分析

近年来剖官产率逐年上升，国内外医学界对此高度关注。医学研究已确认，剖宫产与自然分娩相比较，对孕妇和孩子健康都不利。现就剖宫产增加的原因，结合我科工作情况进行分析，以便在保证母要平安的前提下，合理掌握剖宫产指征，降低剖宫产率。     

科学分析管理剖宫产指征、降低剖宫产率

目的：分析江苏省扬州市妇幼保健院2009年1月—2012年12月剖宫产率及剖宫产指征构成比及其变化情况,探讨降低剖宫产率的有效方法。方法：成立高危妊娠评估专家组,每例剖宫产者均需由专家组审批、核查;坚持每周一次例会制度,回顾性分析每周的剖宫产指征;正确对待经济利益,增加分娩镇痛项目及其他服务。结果：4年间不同剖宫产指征构成比及顺位有所改变,其中社会因素从2009年的第2位降至2012年的第9位;剖宫产率逐年下降,从68.0%降至46.5%。结论：剖宫产率过高是多因素共同作用的结果,通过采取科学、综合、集体管理和行政干预等方法能有效降低剖宫产率。     

Uterine Rupture Following One Successful Vaginal Birth After Caesarean Section: A Case Report

A 30-year-old, G3 P2 woman presented in spontaneous labour. Her first pregnancy had ended in a Caesarean section for failure to progress. Her second pregnancy had ended in a successful vaginal birth after Caesarean section (VBAC) after labour was augmented with oxytocin. During her third pregnancy, she presented in early labour and went on to a spontaneous complete rupture of her uterus which necessitated a Caesarean hysterectomy.     

Are Women’s and Obstetricians,Views on Mode of Delivery Following a Previous Cesarean Section Really OCEANS Apart?

Purpose

Most women with one previous cesarean section (CS) are suitable for either a vaginal birth after CS (VBAC) or an elective repeat CS. Previously, nurse-led prenatal education and support groups have failed to have an impact on the mode of delivery, which women opted for after one CS. A novel one-stop obstetrician-led cesarean education and antenatal sessions (OCEANS) has been developed to inform and empower women in their decision-making following one previous CS. The objective of our study was to evaluate how OCEANS influences the mode of delivery for women who have previously had one CS.

Study Design

Two-hundred and sixty-six women who had a single previous lower segment CS were invited to attend OCEANS, which is a 1-h discussion group of women between 5 and 15 in number, facilitated by an experienced obstetrician. Data were collected prospectively on women who were invited to attend OCEANS over a 12-month period commencing on the 1st January 2012.

Results

188 (71 %) attended the group, while 20 (8 %) canceled their appointment and 58 (22 %) did not keep their appointment. Those who attended OCEANS were 38 % more likely to opt for a VBAC than those who did not attend. There was no difference in the rates of successful vaginal delivery between women who attended OCEANS and those who did not (56 vs. 61 %, p = 0.55).

Conclusions

While nurse-led prenatal education and support groups have no impact on mode of delivery after one CS, a dedicated obstetrician-led clinic increases the rate of those opting for VBAC by 38 %. Such clinics may be a useful tool helping in empowering women in their decision-making and reduce the rate of CSs.     

Once a cesarean always a cesarean? A computer-assisted decision analysis

Objective A previous decision analysis models for two strategic choices for trial of labor or repeated cesarean after prior cesarean concluded that the degree of wish for an additional future pregnancy appeared to be a major determinant for choice between the two strategic options. We had extended the analysis model to stillbirth and hypoxic-ischemic encephalopathy in addition to placental complications while updating most of the outcomes in the decision tree. Study design A model was formulated using a decision tree based on reported probabilities for various outcomes and estimated utilities. The question asked was should trial of labor or repeated cesarean be performed after a prior cesarean, with a varying desire for an additional pregnancy. The highest expected outcome determines the preference of our model. Results Our model favors repeated elective cesarean (0.9947) over trial of labor (0.9917) after a previous cesarean and is the preferred approach. This approach was preferable irrespective of the probability of additional pregnancy. Conclusion In contrary to previous models, when taking into account the occurrence of a live infant birth, birth of an infant with hypoxic-ischemic encephalopathy stillbirth, neonatal death, abnormal placental implantation, hysterectomy and maternal death the preferred approach for women with previous cesarean is an elective repeated cesarean rather than trial of vaginal delivery.     

Repeat cesarean section and primary elective cesarean section: recently trained obstetrician-gynecologist practice patterns and opinions

OBJECTIVE: This study was undertaken to determine opinions of obstetrician-gynecologists regarding vaginal birth after cesarean (VBAC) section and elective cesarean section. STUDY DESIGN: A questionnaire was administered to obstetrician-gynecologists attending 2 review courses. RESULTS: Of 500 obstetrician-gynecologists, 304 completed the survey for a response rate of 61%. Most (92%) counseled VBAC candidates differently, and 84% quoted differential VBAC completion rates on the basis of the indication for prior cesarean section. Uterine rupture was virtually always discussed (99%). Pelvic floor risks were infrequently discussed with urinary incontinence, pelvic organ prolapse, and fecal incontinence discussed by less than one third of obstetricians (30%, 28%, and 25%, respectively). Fifty-nine percent of physicians would perform a primary elective cesarean section, and 67% would perform a primary elective cesarean section specifically to prevent pelvic floor disorders. CONCLUSION: Two thirds of recent graduates are willing to perform an elective cesarean section to prevent pelvic floor injury. Most offer VBAC; however, less than a third include risk of pelvic floor injury in their informed consent discussions.     

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....     

剖宫产术后再次妊娠阴道试产的研究进展

随着生育政策的转变,剖宫产术后再次妊娠孕妇逐渐增多.如何选择分娩方式引起了产科学界的广泛思考与讨论.既往此类孕妇推荐选择性重复剖宫产术作为终止方式,虽可规避子宫破裂风险,但其造成的母体二次损伤及较高的产后出血风险仍不可忽视.近年逐渐推广的剖宫产术后再次妊娠阴道试产及分娩在母儿预后方面展现出更高的价值.通过转变围生保健模...     

Obstetric outcomes in women with two prior cesarean deliveries: is vaginal birth after cesarean delivery a viable option?

OBJECTIVE: This study was undertaken to compare clinical outcomes in women with 1 versus 2 prior cesarean deliveries who attempt vaginal birth after cesarean delivery (VBAC) and also to compare clinical outcomes of women with 2 prior cesarean deliveries who attempt VBAC or opt for a repeat cesarean delivery. STUDY DESIGN: We performed a secondary analysis of a retrospective cohort study, in which the medical records of more than 25,000 women with a prior cesarean delivery from 16 community and tertiary care hospitals were reviewed by trained nurse abstractors. Information on demographics, obstetric history, medical and social history, and the outcomes of the index pregnancy was obtained. Comparisons of obstetric outcomes were made between women with 1 versus 2 prior cesarean deliveries, and also between women with 2 prior cesarean deliveries who opt for VBAC attempt versus elective repeat cesarean delivery. Both bivariate and multivariate techniques were used for these comparisons. RESULTS: The records of 20,175 women with one previous cesarean section and 3,970 with 2 prior cesarean sections were reviewed. The rate of VBAC success was similar in women with a single prior cesarean delivery (75.5%) compared with those with 2 prior cesarean deliveries (74.6%), though the odds of major morbidity were higher in those with 2 prior cesarean deliveries (adjusted odd ratio[OR] = 1.61 95% CI 1.11-2.33). Among women with 2 prior cesarean deliveries, those who opt for a VBAC attempt had higher odds of major complications compared with those who opt for elective repeat cesarean delivery (adjusted OR = 2.26, 95% CI 1.17-4.37). CONCLUSION: The likelihood of major complications is higher with a VBAC attempt in women with 2 prior cesarean deliveries compared with those with a single prior cesarean delivery. In women with 2 prior cesarean deliveries, while major complications are increased in those who attempt VBAC relative to elective repeat cesarean delivery, the absolute risk of major complications remains low.     

Preferred and actual delivery mode after a cesarean in London, UK

OBJECTIVE: To determine the delivery mode preferred by pregnant women with 1 previous cesarean delivery and to investigate the relationship between preferred and actual mode of delivery. METHOD: We reviewed the records of 215 women who were delivered in a London hospital with a history of 1 cesarean delivery. Women who planned an elective repeat cesarean section (ERCS) were compared with those who planned a vaginal birth after cesarean (VBAC). RESULTS: Although 55.3% chose VBAC overall, only 37.8% of those who chose it were delivered by it, whereas 94.8% of those who chose ERCS were delivered by ERCS. Nonwhite women were more likely to choose VBAC than white women (odds ratio, 3.5; 95% confidence interval, 1.9-6.1) but less likely to be deliver by it (odds ratio, 0.31; 95% confidence interval, 0.14-0.68). CONCLUSION: In this study, VBAC was the method of delivery preferred by most women. Nonwhite women were more likely to choose VBAC over ERCS but less likely to be delivered by VBAC.     

Cervical dilatation at the time of cesarean section may affect the success of a subsequent vaginal delivery

Objective.?To evaluate the effect of labor progress prior to cesarean delivery on the outcome of vaginal birth after cesarean delivery (VBAC).

Methods. The medical records of women attempting VBAC between January 2000 and February 2008 were reviewed. All women had only one previous cesarean and underwent spontaneous labor.

Results.?Among 1148 enrolled women, 956 (83.3%) achieved a successful VBAC. Birth weight, previous indication for cesarean delivery and oxytocin augmentation were significantly associated with VBAC outcome. By multivariate analysis, a cervical dilatation ≥8 cm at previous cesarean was independently predictive of successful VBAC in women with a previous cesarean for non-recurrent indications (p = 0.046), yielding a VBAC success rate of 93.1%, whereas the extent of cervical dilatation at the previous cesarean did not affect the outcome of subsequent delivery in women with a previous cesarean for recurrent indications.

Conclusions.?Women with cesarean for non-recurrent indications who achieved a cervical dilatation ≥8 cm may be the best candidates for VBAC, with the greatest likelihood of a successful VBAC. Labor progress at previous cesarean can serve as a valuable indicator for VBAC outcome in women with a previous cesarean for non-recurrent indications, and therefore should be discussed as part of preconception counseling.     

Vaginal Birth After Caesarean Section: Clinical and Legal Perspectives

Vaginal birth after Caesarean section (VBAC) is currently the preferred method of delivery for pregnant women who have undergone I previous low transverse Caesarean section. This common practice warrants some reconsideration in light of recent clinical data on the risks associated with VBAC, and it is incumbent upon clinicians to ensure that women under their care are fully aware of these risks. Indeed, in some circumstances, an attempt at VBAC may be perceived by the courts to represent a negligent standard of care.