剖宫产率及指征变化临床分析

目的总结我院8年来剖宫产率及指征的变化。方法回顾性分析我院8年间剖宫产病例的临床资料。结果(1)剖宫产率逐年升高，1996～1999年为20．2％，2002～2003年上升至38．30％，明显高于WHO提出的目标。(2)1996～1999年，剖宫产指征以胎儿宫内窘迫为第1位，难产为第2位；近2年来，社会精神因素跃为首位，胎儿宫内窘迫次之。结论剖宫产率上升的主要原因是无医学指征剖宫产术增加所致，与医患双方有关，降低手术率的关键是要提高人口综合素质，减少社会因素和精神因素导致的剖宫产，并严格掌握手术指征。     

25年初产妇剖宫产率及适应证的变化分析

目的 从初产妇剖宫产率和适应证的变化中,探讨剖宫产率升高的原因.方法 抽样选择1970～1995年25年初产妇剖宫产病例562例,比较及分析其剖宫产率及适应证的变化.结果 初产妇剖宫产率自80年代逐年上升.在剖宫产适应证中,难产因素比例逐年下降,胎儿因素比例逐年上升;新生儿出生体重的增加和产妇年龄的增大也是影响初产妇剖宫产率增高的原因.结论 初产妇增多并不是引起剖宫产率增高的主要原因.应加强孕产期保健,鼓励产妇阴道分娩,严格掌握剖宫产指征.     

1971年至2003年我国剖宫产率变化趋势及社会人口学影响因素的研究

目的从人群角度出发了解近32年来我国育龄妇女实际的剖宫产率变化情况及其社会人口学影响因素。方法采用分层、二阶段的与规模(育龄妇女人数)成正比的PPS抽样方法获得调查对象，由调查员入户对7307名育龄妇女进行面对面的问卷调查。资料录入使用EPIDATA2．1软件，采用双录入法，数据分析使用SPSS11．5版。结果随着时间推移，调查对象剖宫产率不断提高由1971至1980年的0．9％增高到2001至2002年的20．2％，发展速度越来越快，而且妇女主动要求进行的剖宫产比例不断增加，由1971至1985年的19．3％增加到2001至2002年的49．7％。多因素分析显示年龄小于30岁、具有高中及以上文化程度、非农业脑力劳动及未就业、东部地区、产前检查次数9次及以上、进行了B超检查等特点的妇女剖宫产的可能性大。结论近几十年来我国剖宫产率不断上升，尤其是上世纪九十年代以后增加迅速。出现这种情况，一方面是因为围产科学理念的进展和科学技术发展的因素使得符合医学指征的剖宫产增加。另一方面是因为医疗机构和某些人口社会学因素使得非医学指征的剖宫产比例迅速增加，从而导致孕妇主动要求剖宫产的比例越来越高。     

近15年剖宫产率及剖宫产指征变化的临床分析

目的总结近15年剖宫产率及剖宫产指征的变化。方法回顾性分析我院近15年来剖宫产孕妇的临床资料。结果（1）剖宫产率逐年升高，1992年为12．1％，2006年上升至38．6％，明显高于WHO提出的目标；（2）1992—2003年，剖宫产指征以难产为第一位，而2004年以后，社会因素跃为首位。结论剖宫产率上升的主要原因是无医学指征剖宫产术增加所致，与医患双方有关，降低剖宫产率的关键是减少社会因素所致剖宫产，严格掌握手术指征。     

剖宫产率及指征2006例分析

目的探讨剖宫产率及指征的变化。方法对2001年1月-2004年12月间的2006例剖宫产资料进行回顾性分析。结果4年间剖宫产率从36．93％上升至44．90％。社会因素、胎儿宫内窘迫、胎位不正是前三位的主要手术指征。结论社会因素是剖宫产率升高的重要原因，提高产科质量，加强孕产期保健及孕期健康教育，严格掌握剖宫产指征，开展无痛分娩，将有助于降低剖宫产率。     

21年初产妇剖宫产率及适应证的变化分析

目的 从初产妇剖宫产率和适应证的变化中，探讨剖宫产率升高的原因。方法 抽样选择1984-2004年21年初产妇剖宫产病例671例，比较及分析其剖宫产率及适应证的变化。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4位的剖宫产手术指征是：相对头盆不称、胎儿窘迫、胎位异常、胎膜早破；1999年起珍贵儿指征已出现，2004年已跃居第2位；④新生儿出生体重的增加和产妇年龄的增大也是影响初产妇剖宫产率增高的原因。结论 初产妇增多并不是引起剖宫产率增高的主要原因。应加强孕产期保健，鼓励产妇阴道分娩，严格掌握剖宫产指征。     

初产妇剖宫产指征回顾

剖宫产目前是产科工作者处理难产的常用手术，随着医学技术的发展，剖宫产的相对安全性迎合了社会对优生优育的要求，因而致剖宫产率提高。有资料显示：国内有些城市剖宫产率高达45％左右，但新生儿窒息率无明显下降。我院2000年1月-2003年12月住院分娩数2743例，其中初产妇1286例，剖宫产424例，初产妇剖宫产率为33．0％，占同期剖宫产的67．8％(424／625)，与汕头大学第二附属医院初产妇剖宫产率(66．3％)接近，本文就424例初产妇剖官产的指征讲行回顾件总结。     

7年剖宫产率及指征变化临床分析

目的：总结我院7年来剖宫产率的变化,分析剖宫产率升高的原因及对策。方法：采用回顾性分析的方法,对我院2005年1月至2011年12月住院分娩的5483例剖宫产病例进行临床分析。结果：①剖宫产率呈逐年上升趋势。②剖宫产各因素所占的比例发生了变化,社会因素,羊水过少,巨大儿剖宫产率上升。结论：加强孕产妇围产期保健和监护,进一步提高产科医师及助产师的技术水平,注重产程观察,防治产科并发症,提高产科质量,正确掌握剖宫产指征。在一定程度上可降低剖宫产率。     

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。     

剖宫产手术指征把握对提高分娩质量相关性探讨

目的：探讨正确把握剖宫产手术指征对提高分娩质量的相关性。方法：本次研究选取2003年、2004年我院产科分娩资料,探讨剖宫产率及产科质量变化,并分析二者相关性。结果：对比两年产科质量,新生儿窒息率、产后出血率、剖宫产率无明显变化（P〉0．05）。对比剖宫产指征,社会因素在两年中均居第一,其次均为疤痕子宫,与2003年比较,2004年胎盘比例有所下降,胎儿窘迫比例上升,均有统计学差异（P〈0．05）,其它指征比较无明显变化（P〉0．05）。结论：我国剖宫产率居较高水平,易引发多种远期并发症,需加大健康宣教,降低因社会因素等引发的剖宫产率,并做好各项指征的把握,以全面提高产科分娩质量。     

2002—2010年剖宫产率升高的影响因素分析

目的探讨近年来剖宫产率升高的影响因素及其弊端。方法对解放军总医院妇产科2002年1月至2010年12月分娩的12522例孕妇的临床资料进行回顾性分析,比较不同时期剖宫产率和剖宫产手术指征的变化。结果从2002年至2005年剖宫产率由44.50%（514/1155）升至66.02%（746/1130）,2008年（64.97%,1059/1630）至2010年（64.06%,1251/1953）剖宫产率仍保持较高水平,剖宫产率总体呈升高趋势。阴道分娩助产率从2002年的3.29%（38/1155）下降至2010年的0.05%（1/1953）,两者比较,差异有统计学意义（P〈0.05）。2006—2010年剖宫产指征中,社会因素、妊娠合并症并发症和胎儿窘迫位于前3位。瘢痕子宫作为剖宫产指征所占比例从2006年的3.57%（26/729）升高至2010年的6.95%（87/1251）;多胎妊娠作为剖宫产指征从2006年的2.33%（17/729）升高至2010年的3.52%（44/1251）。结论剖宫产率升高原因多种,其中社会因素、妊娠期合并症并发症和胎儿窘迫是重要的影响因素,严格掌握剖宫产指征是降低剖宫产率的关键。     

Delivery after previous cesarean section. Experience with 173 patients]

We have taken into consideration the obstetric outcome in 173 women, with prior cesarean section, who were delivered in our hospital between june 1988 and january 1991. This group of patients represented 5.3% of our obstetric population. Overall 64 patients (37%) achieved vaginal delivery and 109 (63%) underwent an iterative cesarean section. Considering the 76 patients (44%) admitted to trial of labour, 64 (84.2%) achieved vaginal delivery and 12 (15.8%) were delivered with iterative cesarean section. No maternal or neonatal complications occurred, even though the silent dehiscence of the uterine scar, found during cesarean section, seems to occur four times (12%) more frequently than that reported in recent literature. It follows that vaginal delivery after prior cesarean section is, in our experience, lacking in risks, and we think that such management may be widely adopted. In 1986 iterative cesarean section represented 35% of cesarean section indications, in 1990 this rate was reduced to 23.7% by the introduction of a policy to allow women to undergo trial of labour.     

Observations on vaginal delivery in women with previous cesarean section

BACKGROUND: The significant increase in cesarean sections both before (52.73%) and during labour (89.82%) observed in the 1990s compared to the period 1970-1980 prompted the authors to review the cases of women admitted to Department B of the Gynecology and Obstetrics Clinic at the University of Turin and to study the number of women with previous cesarean sections undergoing labour. The aim of this study was to throw light on this complex question and to reduce the incidence of surgical births wherever possible. METHODS: Two groups of pregnant women with previous cesarean sections were studied in Department B of the Gynecology and Obstetrics Clinic at the University of Turin: one group included women undergoing cesarean sections between 1990-1998, and the other included women undergoing cesarean sections between 1970-1980. The authors analysed the indications for repeat cesarean section and the percentage of vaginal births. RESULTS: The results show that during 1970-1980 the percentage of vaginal births was 24.34% (259 vaginal births out of 1593 patients), whereas between 1990-1998 the percentage of vaginal births fell to 10.18% (51 vaginal births out of 1060 patients). CONCLUSIONS: The high percentage of repeat cesarean sections found in the 1990s is not only due to strictly medical reasons, but also to ethical and political motives, and above all the maternal desire not to undergo natural labour.     

Reversing the upward trend in the cesarean section rate

The incidence of the main indications for cesarean sections in the last 20 years was analysed. Starting in 1981, we changed our attitude to cesarean sections and gradually initiated various means of decreasing our overall cesarean section rate. As a result, our increasing section rate was reversed in two phases: first by halting the upward trend, plateauing around 12%, followed by a 20% decrease to 9.7% in 1985. The change was in both the primary section rate and the repeat rate. The major decrease was in breech indication (1.2% vs. 2.8%), as a result of more external cephalic versions and fewer elective sections for this indication. By allowing more trials of labor after a prior cesarean section, combined with the reduction in the primary cesarean sections, a decrease in the repeat cesarean sections was noted (2.6% vs. 3.7%). By preventing the self-perpetuation of repeat sections, a reduction in multiple repeat sections is expected in the future. The intrapartum fetal mortality rate was not affected by the decreasing cesarean section rate. A further decrease in our cesarean section rate is expected in the future.     

Ways of delivery after cesarean section]

OBJECTIVE: To analyse deliveries after a previous cesarean section. STUDY DESIGN: The way of birth of 262 patients between 1993-1995 in the Ist Department of Obstetrics and Gynaecology of Warsaw University Hospital was analysed. Material was divided into two groups: an elective cesarean section operation was performed on 117 women, while 145 women underwent a trial of labour. RESULTS: The most common indications for an elective cesarean section were fetal distress and maternal diseases. A trial of vaginal delivery was successful in 55.2%. The repeated operation was performed on 44.8% of women. The most frequent indication for a cesarean section during a trial of labour was failure to progress. CONCLUSIONS: Women after a previous cesarean section, who underwent a trial of labour delivered vaginally in 55.2%-30.5% of all the patients in the analysed material. The indications for the repeated operation were the same as for the first one in 27% of the cases.     

Extremely preterm cesarean delivery: a clinical study

OBJECTIVES: To describe indications for cesarean section for extremely preterm delivery, peri- and postoperative complications and perinatal outcome. DESIGN: A case-referent study with clinical follow-up. SETTING: A tertiary perinatal center. POPULATION: All deliveries at gestational age <28 weeks at Ume? University Hospital in 1997-2003. For preterm cesarean section referents were women with elective first-time term cesarean section. METHODS: Indications for cesarean section delivery were assessed. Peri- and postoperative complications, asphyxia, and infant survival at discharge were described. RESULTS: The cesarean section rate was 75%, in one third the operation was considered as difficult. Indications for extremely preterm abdominal delivery were severe disease during pregnancy and delivery complications. Six out of ten cesarean sections were performed on fetal indication. Nonisthmic incision was performed in 20% of cases. No major postoperative complications and few minor postoperative complications were noted. Irrespective of mode of delivery, few of the infants had severe asphyxia. CONCLUSION: In balancing the risks of complications related to the surgical procedure against the purported benefits of the infant, this study adds support to the argument to deliver even extremely preterm infants by cesarean section.     

Disclosing doubtful indications for emergency cesarean sections in rural hospitals in Tanzania: a retrospective criterion-based audit

Objective. To investigate in depth to what extent indications for emergency cesarean sections followed evidence-based audit criteria for realistic best practice. Design. A quality assurance analysis based on a retrospective criterion-based audit. Setting. Two rural hospitals in Tanzania. Population. From 2009, 400 cesarean section instances were investigated. Of these, 303 were emergency cesarean sections and therefore included. Methods. Documented indications for and management preceding the emergency cesarean sections were compared with the audit criteria. Main outcome measures. Prevalence of suboptimal care. Results. Of the emergency sections, 26% appeared to be decided based on inappropriate indications, and in an additional 38%, the indications were unclear. Prolonged labor was the leading indication; in 36% of these, labor progressed timely and/or the membranes were still intact. In 26%, previous cesarean section was the indication, half of these with one previous section only. Fetal distress was an indication in 14%, but for 84% of these the fetal heart rate was either reassuring or not documented. For nine women, section was decided upon because of intrauterine fetal death; none had a trial of forceps/vacuum extraction or destructive surgery. Conclusion. A considerable number of the audited emergency cesarean sections were performed on doubtful indications. In the light of the rising trend in global cesarean section rates, there seems to be a need to ensure quality of management preceding cesarean sections. This is particularly called for in rural sub-Saharan Africa where cesarean rates are still low and health risks of emergency surgery not negligible.     

A critical appraisal of cesarean section rates at teaching hospitals in India.

OBJECTIVES: To obtain an estimate of cesarean section rates and examine the indications and consequences at teaching hospitals in India. METHODS: Information was obtained on total number of normal and cesarean deliveries during 1993-1994 and 1998-1999 from 30 medical colleges/teaching hospitals. In addition, prospective data were recorded for a period of 2 months on 7017 consecutive cesarean sections on indications for cesarean delivery, associated complications and mortality. RESULTS: The overall rate of cesarean section increased from 21.8% in 1993-1994 to 25.4% in 1998-1999. Among the 7,017 cesarean section cases, 42.4% were primigravidas, 31% had come from rural areas, 20.8% were referred including 8% with history of interference, 66% were booked cases, period of gestation was less than 37 weeks in 21.7% and in 18% the surgery was elective. Major indications for cesarean section included dystocia (37.5%), fetal distress with or without meconium aspiration (33.4%), repeat section (29.0%), malpresentation (14.5%) and PIH (12.5%). Maternal and perinatal mortality was 299/100,000 and 493/1,000 deliveries, respectively, and is high in spite of the increase in the cesarean section rates. CONCLUSIONS: There is need for standardized collection of information on all aspects of childbirth to ascertain the incidence and indications of cesarean section nationally so that comparison and improvements of care can take place.     

Reducing cesarean sections at a teaching hospital

A department-wide effort to reduce the cesarean section rate at the University Medical Center of Jacksonville (Florida) began in 1987. University Medical Center, a teaching hospital with approximately 4500 annual deliveries, serves an almost exclusively indigent obstetric population. Overall, the cesarean section rate declined from 28 per 100 deliveries in 1986 to 11 per 100 in 1989. Decreasing the number of repeat cesarean sections played an important role in reducing total cesarean deliveries. In 1986 32% of women with prior cesarean sections underwent a trial of labor. By 1989 this proportion had increased to 84%. In 1986 65% of women undergoing a trial of labor were delivered vaginally. By 1989 this proportion had increased to 83%. For these reasons the proportion of patients who had repeat cesarean sections dropped from 8% in 1986 to 3% in 1989. Changing approaches to the evaluation and management of dystocia and fetal distress also helped to lower the overall cesarean section rate. In 1986 cesarean sections for at least one of these two indications accounted for 14% of all deliveries. By 1989 this percentage had dropped to 4%. Because selective criteria for vaginal delivery of fetuses in breech presentation were maintained, incremental increased rates of vaginal breech delivery had only a minimal impact on lower overall cesarean section rates. The reduction in the number of cesarean sections was accomplished without compromising neonatal outcomes. In fact, during this 4-year period neonatal mortality rates actually decreased; neonatal morbidity rates remained stable. Our experience suggests that cesarean section rates can be substantially reduced without compromising the newborn.     

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.