剖宫产后再次阴道分娩

随着医疗水平的提高和社会各方面的因素,剖宫产率呈现逐年增高的趋势,剖宫产后再次妊娠的分娩方式,尚存争议。本文综合分析剖宫产后再次妊娠阴道分娩(vaginal birth after cesarean,VBAC)的发展趋势、病例选择及相关处理方法,以进一步降低剖宫产率,提高产科质量。     

Vaginal birth after cesarean section in rural Tanzania.

Eighty-seven of 134 women with a history of previous cesarean section in two rural hospitals in Tanzania had a vaginal delivery after a trial of labor. The incidence of scar-rupture was high: in 9 of 134 cases (6.7%). Maternal death, however, did not occur. It is concluded that a trial of labor is justified, and that the risk of scar-rupture should be balanced with the risk of repeat operations.     

Vaginal birth after cesarean section: management debate

Obstetric performance of 1847 women with previous cesarean section (CS) during the years 1983 and 1984 were studied. Vaginal birth after cesarean section (VBAC) was attempted in 94% of females with one previous CS, 4% in those with two previous CS, and one among the 70 patients with three or more previous CS. VBAC was achieved in 51% of those with one previous CS. It was successful in 60% of parturients with CS for non-recurrent causes, 36% of CS for cephalopelvic disproportion (CPD) and in 64% of those with a prior vaginal delivery. Uterine scar dehiscence was found in 0.9% of all patients with a previous CS. A failed attempt with Ventouse to achieve VBAC caused maximum maternal and perinatal morbidity.     

Vaginal birth after cesarean section: X-ray pelvimetry at term is informative

OBJECTIVE: To examine whether X-ray pelvimetry data to evaluate the likelihood of vaginal birth after previous cesarean section. DESIGN: Retrospective study. SETTING: University hospital. POPULATION: Patients with a previous cesarean delivery who underwent X-ray pelvimetry and gave birth at gestational age 37 weeks during a seven-year period. METHODS: 1190 patients with a scarred uterus were compared with 15,189 patients without a scarred uterus. In the scarred uterus group, 760 patients with a transverse pelvic diameter > or =12 cm were compared with 430 patients with a transverse pelvic diameter <12 cm. MAIN OUTCOME MEASURES: The obstetrical outcomes were spontaneous or induced labor, and mode of delivery. The maternal morbidity outcomes were hemorrhage requiring transfusion of packed red cells, uterine rupture, bladder injury, and hysterectomy due to hemorrhage. The neonatal morbidity outcomes were the 5-min Apgar score, transfer to intensive care, and intubation. RESULTS: Patients with a scarred uterus had a significantly higher rate of cesarean section (35.5%) than those with no prior cesarean section (9%). Among patients with a scarred uterus who were selected for vaginal delivery, 81% delivered vaginally when the transverse diameter (TD) of the pelvic inlet was greater than 12 cm, 68% when the TD was between 11.5 and 12 cm, and 58% when the TD was less than 11.5 cm. Maternal morbidity was significantly higher in the patients with a scarred uterus. The neonatal results were comparable in the different groups. CONCLUSION: X-ray pelvimetry tailors the information given to each patient about the likelihood of having a vaginal delivery. It can also be used to optimize the selection of patients allowed to enter labor.     

Vaginal birth after cesarean section in grand multiparous women

Objective. To determine the rate, delivery outcome and safety of attempted vaginal birth after cesarean section (VBAC) in grand multiparous women (para 6 or more). Methods. This is a retrospective case-control study, performed at King Abdulaziz university hospital, the charts of 405 grand multiparous women with previous caesarean section were reviewed to determine rate and delivery outcome of attempted VBAC. The outcome of 217 VBAC in grand multiparous women was compared to the outcome of 217 VBAC in multiparous women (para 2–5) during the same period. Results. The rate of VBAC in grand multiparous women was 53.6%. One hundred-seventy five (80.7%) grand multiparous women were delivered vaginally compared to 170 (78.3%) in multiparous women, this was not statistically significant difference. Sixteen (7.4%) grand multiparous women need labor augmentation with oxytocin, while 34 (16%) in multiparous women, this was statistically significant difference (P value 0.005). The labor duration was 6.4±3.5 h in grand multiparous women compared to 9.0±4.3 h in multiparous women, and was also statistically significant difference (P value 0.001). The fetal weight, Apgar scores, postpartum hemorrhage, fever and number of hospital days in the two groups, were not statistically significant differences. In the control multiparous women there was one uterine rupture, two uterine dehiscence, and one stillbirth due to placental abruption. Conclusion. VBAC in grand multiparous women is common practice, safe and efficacious. High parity in association with vaginal deliveries is good prognostic factor and also can predict successful VBAC outcome. However, further studies are needed to confirm our findings.     

Vaginal birth after cesarean section. Experience in a community-based practice

The option of vaginal birth after a previous cesarean section (VBAC) is widely recognized as a safe procedure for mother and infant as well as a means of reducing the cesarean section rate. Nevertheless, it remains underutilized in community, non-level III hospitals, where most births occur. Over a 30-month period, all patients presenting to a community-based practice who met the criteria for VBAC as outlined by the American College of Obstetricians and Gynecologists were offered this option. Of 72 candidates, 66 chose a trial of labor; only 4 failed to deliver vaginally. No complications were noted in any of the women or infants. This study demonstrated that in a community setting, VBACs are safe and can yield a high success rate.     

Vaginal birth after cesarean section in rural Zaire. Changing concepts.

The safety of trials of labor after cesarean section has yet to be established in developing countries. Centre Médical Evangélique is a referral hospital in rural northeastern Zaire. From August 1, 1989, to January 15, 1990, 33 women with previous cesarean deliveries were offered a trial of labor. Of them, 22 (67%) had successful vaginal deliveries. The indications for the previous cesarean section did not influence the outcome of the trial of labor. There was a high rate of immediate maternal morbidity but no significant long-term morbidity. The rate of uterine dehiscence was 9.1%. The perinatal death rate, 60.1/1,000, was similar to the overall rate for the institution. Trials of labor after cesarean section are a valid therapeutic option in developing countries.     

Vaginal birth after cesarean delivery.

VBAC is considered safe and is often successful in carefully selected populations of women. Women with prior CDs are given the option of elective repeat CD or a trial of labor; neither option is risk free. Less morbidity is encountered in women with successful VBACs versus those with elective repeat CD. Patients who undergo successful trials of labor experience fewer blood transfusions, fewer postpartum infections, and shorter hospital stays and generally have no increased perinatal mortality. The high CD rate begins with the high frequency of the first CD. Therefore, a concerted effort should be made to decrease primary CDs. Paul and Miller remind us of the importance of the decision to proceed with the initial CD in their statement, "once a cesarean, always a scar (p 1907)." Many patients present for prenatal care with one or more prior uterine scars. Careful and thoughtful counseling of patients with a previous CD regarding the risks and benefits of a labor trial based on the current available literature is prudent. Pitkin's editorial in Obstetrics and Gynecology in 1991 stated, "Without question, the most remarkable change in obstetric practice over the last decade involves management of the woman with a prior cesarean delivery (p 939)." Controversies regarding the management of women with scarred uteri remain. In his review of the CD controversy, Flamm leaves us with an important thought: "A woman with a prior cesarean is at increased risk regardless of her mode of birth, and eliminating VBAC will not eliminate the risks. Vigilance with respect to primary cesarean delivery is the only way to avoid this dilemma (p 315)."     

剖宫产后阴道分娩相关问题

剖宫产后再次妊娠的分娩方式始终是一个具有争议的产科问题。随着我国全面实施“二孩”政策,剖宫产后阴道分娩问题越来越受到关注。目前,多个妇产科学术机构已达成共识：计划性剖宫产后阴道分娩对于大多数一次子宫下段剖宫产史的产妇是一种安全的选择。文章就剖宫产后阴道分娩的相关循证医学证据进行讨论,并为有剖宫产后阴道试产意愿的产妇制定产前、产时管理方案。     

Vaginal birth after cesarean

Allowing a woman with a previous cesarean birth a trial of labor rather than performing an elective repeat cesarean section continues to be a controversial area in obstetrics today. In an effort to evaluate the risks associated with a trial of labor, a prospective investigation was undertaken from July 1, 1982, through June 30, 1984. During the first year of the study, patients with a known vertical scar or more than one prior cesarean birth were excluded from an attempted trial of labor. Beginning July 1, 1983, patients with two prior cesarean births were no longer excluded and were studied prospectively. During this 2-year period, 32,854 patients were delivered of their infants at the Los Angeles County/University of Southern California Medical Center. Of these patients, 2708 (8.2%) had undergone a prior cesarean birth, and 1796 women (66%) underwent a trial of labor. A total of 1465 (81%) of them achieved a vaginal delivery. Successful vaginal delivery by the number of prior cesarean sections was as follows: one, 82%; two, 72%; three, 90%. When contrasted with the group without a trial of labor, the group with a trial of labor had significantly less maternal morbidity. In a comparison of the groups with and without a trial of labor, the incidence of uterine dehiscence (1.9% versus 1.9%) and rupture (0.3% versus 0.5%) was similar. With the application of attempted vaginal delivery in our patients with a previous cesarean birth, we were able to reduce our cesarean delivery rate for this population alone by 54%. In summary, the benefits associated with a trial of labor in the patient with a prior cesarean birth far outweigh the risks. The policy of "once a cesarean section, always a cesarean section" should be abandoned.     

Vaginal birth after cesarean section: a reappraisal of risk

A three-year retrospective study was performed to assess morbidity associated with an attempted vaginal birth after cesarean section at a tertiary level military obstetric hospital. Examination of delivery records revealed a 61.16% success rate for attempted vaginal births after cesarean sections. Mean birth weights differed significantly between successful and unsuccessful vaginal births after cesarean sections. Infants with birth weights greater than 3720 gm were less likely to be vaginally delivered. Those gravidas with a successful vaginal birth after cesarean section had a significantly higher rate of perineal lacerations, as compared with other vaginal births during the study period. The scar separation rate of 1.79% was significantly higher than the 0.50% rate reported elsewhere. One patient who attempted a vaginal birth after cesarean section required a cesarean hysterectomy after scar separation occurred during labor. There were two perinatal deaths, both of which occurred at greater than 40 weeks' gestation, for a perinatal mortality rate of 8.93/1000 births. Women who consider vaginal birth after cesarean section should be counseled with regard to the increased risk of perineal trauma. Estimates of fetal weight at term should be a part of the decision-making process before vaginal birth after cesarean section is attempted.     

Vaginal birth after cesarean section versus elective repeat cesarean delivery: Weight-based outcomes

OBJECTIVE: The study was undertaken to compare infectious morbidity and trial of labor (TOL) success stratified by weight in women. STUDY DESIGN: Vaginal birth after cesarean section (VBAC) candidates were divided into groups based on prepregnancy weight: group I, 70 (<200 pounds); group II, 70 (200-300 pounds); and group III, 69 (>300 pounds). RESULTS: The TOL success rate was 81.8% in group I compared with 57.1% in group II and 13.3% in group III (P =.001). The overall infectious morbidity was significantly greater in the obese women 39% (P =.001) compared with the average women at 11.4% and the lean women at 5.7%. CONCLUSION: Infectious morbidity is increased and VBAC success is reduced in patients who weigh more than 300 pounds.