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。     

Induction of labor with prostaglandin E2 vaginal tablets in parous and grandmultiparous patients with previous cesarean section.

OBJECTIVES: To compare the outcome of induction of labor with prostaglandin E2 vaginal tablets between lower parity (parity 1-5) and grandmultiparous (parity >5) patients with a history of one previous lower segment cesarean section. METHODS: A prospective study of 113 patients conducted at King Faisal Military Hospital, Khamis Mushayt, Saudi Arabia during a 5-year period spanning January 1995 to December 1999. RESULTS: There were no statistically significant differences in the two groups regarding mean maternal age, dose of prostaglandin used, gestation at delivery, mean birth weight, P>0.05. Syntocinon augmentation was used in 16 (21.9%) of the lower parity patients compared with 8 (20.0%) in the grandmultiparas but this was not statistically significant, (P=0.677). However, there was a statistically significant difference in the cesarean section rate between the two groups, P=0.019. Although no cases of uterine hyperstimulation were recorded, there was one rupture of the uterus in each of the two groups of patients; 1.36% and 2.5%, respectively, but this was not statistically significant, P=1.000. CONCLUSIONS: The complications of induction of labor with prostaglandin E2 vaginal tablets in grandmultiparous patients with previous cesarean section were similar to those with lower parity but the cesarean section rate was significantly higher. However, larger studies are needed for validation.     

Mode of delivery after one cesarean section.

OBJECTIVES: To investigate labor patterns and mode of delivery of aginal births after cesarean (VBAC) versus unsuccessful trial of labor after cesarean (TOLAC) in a South African district hospital, and the influence of the indication for the primary cesarean section (C-section) on the subsequent mode of delivery. METHODS: Retrospective audit of the partogram of 202 VBAC and 382 repeat C-section. There were 108 elective repeat cesarean deliveries (ERCD) and 274 emergency repeat C-sections after unsuccessful TOLAC. The indication of the primary C-section was known in 127: 43 (33.9%) VBAC and 84 (66.1%) repeat C-sections. RESULTS: The indication for the primary C-section in terms of recurrent/non-recurrent did not affect the subsequent mode of delivery (chi(2)=3.5; P=0.06; OR 0.49, 95% CI 0.23-1.04). The indication of the primary C-section in terms of dysfunctional/non-dysfunctional labor did not reoccur in the same parturients (chi(2)=0.01; P=0.91; OR 0.94, 95% CI 0.35-2.55). CONCLUSION: Dysfunctional labor accounted for most primary and repeat emergency C-sections, but not as a recurrent condition in the same parturients.     

10年间剖宫产率及指征变化与围生儿死亡率的关系

目的：探讨剖宫产率及剖宫产指征变迁对围生儿死亡率的影响。方法：对10年间剖宫产病例资料进行回顾性分析。结果：1992－1996年剖宫产率为36．50％，显著低于1997－2001年的47．78％，两者比较，差异有极显著性（P＜0．01）。在剖宫产指征中，妊娠并发（合并）症始终处于第1位，社会因素上升为第2位，难产为第3位，胎儿窘迫为第4位。围生儿死亡率1992－1996年为17．88‰，1997-2001年为22．23‰，两者比较，差异无显著性（P＞0．05）。结论：剖宫产率升高在一定范围内降低了围生儿死亡率，但随着剖宫产率的进一步升高，围生儿死亡率并未随之下降。因此，应合理掌握剖宫产指征，降低剖宫产率。     

剖宫产术后再次妊娠阴道分娩的安全性及影响因素分析

目的探讨剖宫产术后再次妊娠阴道分娩的安全性及其影响因素。 方法回顾性分析2017年1月至2018年10月在佛山市妇幼保健院住院分娩的剖宫产术后再次妊娠阴道试产孕妇的临床资料。按照是否成功经阴道分娩分成剖宫产后阴道分娩(vaginal birth after cesarean section, VBAC)组和剖宫产后阴道试产(trial of labor after cesarean,TOLAC)失败组,比较VBAC组和TOLAC失败组患者的妊娠结局,采用多因素Logistic回归分析方法分析VBAC的影响因素。 结果(1)2017年1月至2018年10月共纳入TOLAC研究的孕妇共323例,其中VBAC率为80.2%(259/323),TOLAC失败率为19.8%(64/323);子宫破裂发生率为0.62%(2/323),均为TOLAC失败组;两组患者均无子宫切除。(2)VBAC组和TOLAC失败组比较,VBAC组头盆评分(7.77±1.15)分,高于TOLAC失败组(7.16±0.70)分,(t＝4.891,P<0.001);TOLAC失败组产前阴道出血率6.3%(4/64),高于VBAC组1.2%(3/259),P＝0.033;两组的Bishop评分、羊水指数、羊水最深均没有统计学差异(P>0.05)。(3)TOLAC失败组产后出血≥500 ml的比例为51.6%(33/64),高于VBAC组的2.8%(7/259),( χ²＝105.500,P<0.001);TOLAC失败组子宫破裂率3.2%(2/64),高于VBAC组(0/259),( χ²＝8.144,P＝0.017);但两组间产后出血≥1000 ml的比例、输血率没有统计学差异(P>0.05)。(4)VBAC组的分娩孕周、新生儿出生体重、身长、头围和胸围均低于TOLAC失败组,1 min Apgar评分高于TOLAC失败组且具有统计学意义(P<0.05)。(5)多因素分析显示,孕妇的头盆评分(OR＝0.610, 95%CI：0.420～0.887,P＝0.010)、新生儿出生体重3500～3999 g(OR＝4.783, 95%CI：1.431～15.989,P＝0.011)和新生儿出生体重≥4000 g(OR＝16.042, 95%CI：1.306～196.983,P＝0.030)是VBAC的独立影响因素。 结论在严格的纳入排除标准、系统的产前评估和严密的产程管理下,TOLAC是安全可行的,VBAC成功率也较高。多因素分析显示,头盆评分和胎儿出生体重是VBAC的独立影响因素。     

Pregnancy outcome after induction of labor in women with previous cesarean section

Objective: As conflicting data exist concerning the safety of induction of labor (IoL) in women with previous single lower segment cesarean section (CS), we aimed to assess pregnancy outcome following IoL in such patient population.

Methods: All singleton pregnancies with previous single CS which underwent IoL during 2008–2012 were included (study group). Their pregnancy outcome was compared to those pregnancies with previous single CS that admitted with spontaneous onset of labor (control group).

Results: Overall, 1898 pregnancies were eligible, of them, 259 underwent IoL, and 1639 were admitted with spontaneous onset of labor. Parity, gestational age at delivery and birthweight were similar. Women in the study group were more likely to undergo CS mainly due to labor dystocia (8.1 versus 3.7%, p?<?0.01). The rate of CS due to non-reassuring fetal heart rate was similar. No difference was found in the rate of uterine rupture/dehiscence. Short-term neonatal outcome was similar between the groups. On multivariable logistic regression analysis, IoL was not independently associated with uterine rupture (OR 1.33, 95% C.I 0.46–3.84, p?=?0.59).

Conclusion: Our data suggest that IoL in women with one previous low segment CS neither increases the risk of uterine rupture nor adversely affects immediate neonatal outcome.     

Association and risk factors between induction of labor and cesarean section

Abstract

Objective: To determine risk factors and to quantify the risk of cesarean section (CS) associated with labor induction.

Method: A prospective controlled study of women admitted for labor induction with PGE2 in a single tertiary medical center. Outcome was compared with women who presented with spontaneous onset of delivery.

Results: The induction group were characterized by a higher body mass index (BMI), lower Bishop score and a higher cervical length at presentation compared with controls. Labor induction with PGE2 was associated with increased risk of CS (14.8% versus 4.5%, p?=?0.02). This association persists after adjustment for potential confounders including Bishop score at presentation (OR?=?2.9, 95% CI 1.03–11.8). The risk of CS was especially high for nulliparous (24.4% versus 5.1%, p?=?0.02), overweight (21.2% versus 3.7%, p?=?0.047), induction at <40 weeks of gestation (22.2% versus 2.2%, p?=?0.004), in Bishop score <4 (18.2% versus 4.5%, p?=?0.03), cervical length >25?mm (19.2% versus 4.5%, p?=?0.005), or intact membranes (25.0% versus 4.5%, p?=?0.02) at presentation.

Conclusions: Labor induction with PGE2 is associated with increased risk of CS. These data should be taken into consideration when deciding on labor induction, especially in the absence of clear medical indication.     

Re-laparotomy after cesarean section

OBJECTIVE: To assess the rate, indications, and outcome of re-laparotomy after cesarean section in the early postoperative period. DESIGN: A retrospective observational study during a 121-month period. SETTING: A tertiary care university center. POPULATION: A cohort of 3380 women who underwent cesarean section out of 18,609 parturients. MAIN OUTCOME MEASURES: Incidence of re-laparotomy after cesarean section in the early postoperative period. RESULTS: The incidence of re-laparotomy after cesarean section was 0.53% (18/3380). Of these 18 women, 12 (66%) were operated for hemorrhage, 3 (17%) for eventration, and 3 (17%) for formation of intra-abdominal abscess. Hysterectomy was required in one case (5.5%). We had no maternal mortalities. CONCLUSION: Although the incidence of re-laparotomy after cesarean in the early postoperative period is low and the outcome is favorable, several measures must be undertaken to reduce the need for re-laparotomy.     

Myomectomy during cesarean section.

OBJECTIVE: To evaluate the outcome of myomectomy during cesarean section and to compare it with a control group. MATERIALS AND METHODS: Using a retrospective case-control design; 40 patients who underwent myomectomy at time of cesarean delivery were compared with the control group consisted of 80 patients with myomas who underwent cesarean delivery alone. RESULTS: The mean size of fibroids removed was 8.1+/-4.7 cm (range, 3-25 cm). In control group it was 5.7+/-2.7 cm (range, 2-14 cm). The incidence of hemorrhage in the study group was 12.5% as compared with 11.3% in the control group (p>0.05). There was also no significant differences in the incidence of postoperative fewer and frequency of blood transfusion between myomectomy and control groups (p>0.05). CONCLUSION: Myomectomy during cesarean section is not always a hazardous procedure and it can be performed without significant complications by experienced obstetricians.     

饱胃急诊剖宫产患者行腰硬联合麻醉的危险因素分析

目的分析饱胃患者急诊剖宫产行腰硬联合麻醉(CSEA)的危险因素。 方法选择2010年1月至2012年1月在广州医学院第三附属医院在CSEA下行ASA Ⅰ～Ⅱ级剖宫产手术的220例患者病例进行研究,其中饱胃急诊剖宫产136例为饱胃组,择期剖宫产84例为对照组。两组患者均采用CSEA。对饱胃组患者术中恶心、呕吐的相关因素进行偏相关分析,然后剔除两组术中使用卡前列素氨丁三醇注射液的病例后,再对术中不良事件和新生儿出生情况参数进行比较。 结果饱胃组患者中,与恶心存在偏相关关系的因素是术中使用卡前列素氨丁三醇注射液(r＝0.440)和术中发生低血压(r＝0.274);与呕吐存在偏相关关系的因素是术中使用卡前列素氨丁三醇注射液(r＝0.646)。饱胃组与对照组在剔除使用卡前列素氨丁三醇注射液的病例后比较,对照组术中低血压的发生率高于饱胃组( χ²＝20.455,P<0.05),两组其余指标的差异无统计学意义(P>0.05)。 结论术中使用卡前列素氨丁三醇注射液与低血压是饱胃患者在CSEA下行急诊剖宫产麻醉的危险因素。     

三种剖宫产术式比较

目的 探讨三种剖宫产术式的优缺点,寻找安全性大、优越性强的手术方式。方法 对１９３例足月妊娠具有手术指征的产妇随机分三组,分别采用新式、腹膜外及子宫下段剖宫产术,对手术时间、术后病率及病人子宫与腹壁切口Ｂ超检查情况进行了对比观察。结果 手术时间：新式与子宫下段剖宫产相比,手术时间有明显差异（Ｐ〈０．０５）,新式与腹膜外剖宫产相比,手术时间有差异（Ｐ〈０．０５）,腹膜外与子宫下段剖宫产手术时间相比,     

3475例剖宫产指征分析

目的 探讨１９９７年初至１９９８年末剖宫产指征的掌握情况。方法 对３４７５例剖宫产病例进行回顾性分析。结果 剖宫产率为４５．２％。主要指征依次为：妊娠并发症（３６．６％）、胎儿窘迫（２２．６％）、妊娠合并症（１３．５％）、巨大儿（１０．２％）、珍贵儿（９．８％）、臀位（９．８％）、高龄初产（９．１％）,其中巨大儿的诊断符合率６２．３％、５６％（１３．５％）、巨大儿（１０．２％）、珍贵儿（９．８％）     

Women's opinions and experiences with induction of labor and cesarean delivery on request in south eastern Nigeria

Objective

To assess the opinions and experiences of women regarding induction of labor and cesarean delivery on request in south eastern Nigeria.

Method

Women were interviewed using questionnaires on their awareness of their right to request labor induction and/or a cesarean delivery, and of their experience and opinion of the procedures.

Results

Of the 15.1% of the respondents who knew they could request a cesarean delivery, 2.4% had requested one; and of the 56.3% who knew they could request labor induction, 6.9% had requested one. Only 5.3% and 11.3% of the respondents who would chose the former or the latter procedure, respectively, said that they would insist on receiving it. Fear of their physicians' negative attitude regarding the procedures, and/or abandonment of care, ranked highest among their reasons for not insisting.

Conclusion

In south eastern Nigeria few women are aware of their right to a cesarean delivery on request and the rate of refusal to perform such deliveries is high among physicians; more women are aware of their right to receive induction of labor on request and the acceptance rate is higher among physicians; and most women are unwilling to insist that their physician respect their choice.     

Urbanization and the likelihood of a cesarean section

Objective

This study examines the association between the likelihood of cesarean section (CS) and the degree of urbanization in Taiwan, exploring possible explanations for the difference.

Study design

The database used in this study was the Taiwan 2004 National Health Insurance Research Database. A total of 200,207 singleton deliveries fulfilled our criteria and were included in our study. The urbanization level of cities/towns where parturients resided at the time of delivery was stratified into seven categories. A multilevel logistic regression model was applied to examine the relative likelihood of CS by urbanization level after adjusting for parturient, physician and hospital characteristics.

Results

There was an upward trend in the CS rate with advancing urbanization level; the CS rates for urbanization level 1 (most urbanized) through 7 (least urbanized) were 33.7, 32.3, 30.4, 30.2 29.7, 29.5, and 28.6%, respectively. Compared with participants living at the highest urbanization level, the adjusted odds of a CS were 0.91 (95% CI = 0.85–0.98, p = 0.014), 0.84 (95% CI = 0.78–0.91, p < 0.001), 0.83 (95% CI = 0.68–0.88, p < 0.001), 0.79 (95% CI = 0.72–0.86, p < 0.001), and 0.70 (95% CI = 0.62–0.80, p < 0.001) times, respectively, for those living in cities/towns ranked from the third highest to the lowest levels of urbanization.

Conclusions

We conclude that higher urbanization levels were associated with higher odds of CS. Highly urbanized communities could therefore be targeted for policy intervention aimed at reducing the unnecessary CS rate.     

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.     

Differences in outcomes between cesarean section in the second versus the first stages of labor

Objective: We aimed to compare maternal morbidity and mortality of cesarean sections (CS) in the second versus first stage of labor.

Study design: Retrospective study of all CS at a single, university-affiliated medical center, between January 2010 and December 2014. Eligibility was limited to term, singleton pregnancies with cephalic presentation. Maternal outcomes of second-stage CS were compared to those of first-stage CS. The primary outcome was defined as estimated blood loss >1000?ml.

Results: Overall, 1004 women met the inclusion criteria, of which 290 (29%) had a second-stage CS and 714 (71%) had a first-stage CS. Women in the second-stage CS group had a higher nulliparity and hypertensive disorders rates and a lower rate of previous CS. Second-stage CS was associated with more than double the rate of estimated blood loss >1000?ml (9.7% versus 3.8%, p<.001), and more prone to unintentional uterine incision extension, uterine atony, hemoglobin decrease >2?g/l and antibiotic treatment for suspected endometritis. In a multivariable logistic regression model, second-stage CS was found to be independently associated with unintentional uterine incision extension (OR 6.8, 95% CI 4.1–11.2), uterine atony (OR 3.3, 95% CI 1.4–8.0) and antibiotic treatment for suspected endometritis (OR 2.6, 95% CI 1.4–5.1), but not with excessive blood loss (OR 1.5, 95% CI 0.8–2.8). Additionally, failed assisted vaginal delivery prior to second-stage CS was not associated with a higher rate of complications.

Conclusion: Second-stage CS is associated with higher rates of adverse maternal outcomes, mainly unintentional uterine incision extension, uterine atony, and suspected endometritis.     

剖宫产社会性因素分析

目的 分析社会性因素剖官产的相关因素及对母婴的影响。方法 采用回顾性分析的方法对1993年1月至1999年10月间517例行剖宫产的资料进行分析。结果 社会性因素行剖宫产者93例(17.99％)。其中知识分子59例(63.44％);因医务人员亲属或朋友33例(35.48％);未临产或潜伏期里剖宫产者75例(80.65％)。产后3日内乳汁分泌量少于经阴道分娩者82例(88.17％),剖宫产后并发大出血11例(11.83％),切口感染4例,术中出现呼吸骤停抢救1例,发生新生儿窒息5例(其中重度窒息2例) (5.38％);新生儿肺炎2例(2.15％)。结论 剖宫产社会性因素包括现代观念、医患方因素等。开展无痛阴道分娩,降低社会性因素剖宫产率。     

A predictive model for cesarean section in low risk pregnancies.

OBJECTIVE: A small number of women with low risk pregnancies undergo cesarean section. A model that can predict this risk and therefore identify these women will be of help in several hospitals where personnel and resources are limited. METHODS: The study consisted of 2 parts. All charts of women with low risk singleton pregnancies admitted to labor room over a 5-month period were analyzed. Adjusted odds ratios were calculated to find out relative importance of each risk factor and likelihood ratios were obtained. These were prospectively applied to 1010 consecutive low risk women and the post test probability calculated. Finally the actual incidence of cesarean section was compared with posttest probability derived from predictors. RESULTS: A combination of maternal age >24 years, primiparity and height <150 cm or a combination of any 2 of the 3 variables is significantly associated with increased cesarean section rate. Individually, primiparity, height <150 cm or age >24 years also significantly increased the chances of cesarean section. CONCLUSIONS: A predictive model consisting of maternal age, parity and height can be used to identify low risk pregnant women who are likely to require cesarean section.