Factors associated with vaginal birth after previous cesarean section in Brazilian women.

OBJECTIVE: To identify factors associated with a vaginal second delivery in women who had one previous cesarean section. METHODS: A nested case-control study was carried out as a secondary data analysis of an original retrospective, population-based cohort study of women who delivered their first child during 1985 in the city of Campinas, S?o Paulo, Brazil, and who were interviewed 10 years later in 1995. The study population consisted of 1352 women who had their first delivery by cesarean section and who had also had at least one subsequent delivery. The group of cases (150 women, around 11% of the sample) consisted of women who had a vaginal second delivery, and the control group was made up of 1202 women who had a cesarean section at second delivery. For each possible associated factor we calculated the odds ratio and 95% confidence interval. For ordered categorical variables the c2 test for trend was used. Unconditional multivariate regression analysis was used to estimate the adjusted odds ratio for each associated factor. RESULTS: The factors significantly associated with vaginal delivery were monthly family income below 5-fold the Brazilian minimum monthly wage, reliance on the Brazilian national health system for healthcare, low maternal age, and first cesarean section indicated because of fetal breech or transverse presentation, or twin pregnancy. Among those women who also had a cesarean section at their second delivery, only 11% had undergone a trial of labor. CONCLUSIONS: The main determining factors for a vaginal second delivery in women with a previous cesarean section were unfavorable social and economic factors.     

Obstetric delivery and risk of neonatal mortality in Goiânia in 2000, Brazil

OBJECTIVE: To determine factors associated to vaginal delivery and increased neonatal mortality in cohort studies of newborns. METHODS: A retrospective cohort study was carried out using linkage data from the Information System on Live Births and Mortality Data System database, which included all newborns in Goiania for the year 2000. A stratified analysis of delivery routes and maternity hospitals by risk factors of neonatal mortality was conducted through the calculation of relative risk at a 5% significance level. Statistical analyses were carried out using the Chi-square test at a 5% significance level. RESULTS: Vaginal deliveries were more commonly seen than cesarean sections in situations where there was an increased risk of neonatal mortality. Public hospitals, where vaginal deliveries predominated, were sought by the majority of those pregnant women with an increased risk of neonatal mortality. Private hospitals, not affiliated to the public-funded Brazilian Healthcare System (SUS) and where the incidence of cesarean section was as high as 84.9%, opted for vaginal delivery in situations of greater risk, such as extreme prematurity and very-low-birth-weight infants. CONCLUSIONS: The association between vaginal delivery and increase neonatal mortality resulted from a selection bias due to the distribution of pregnant women in the hospital network. In addition, this selection bias also resulted from an almost universal preference for cesarean sections in low-risk pregnancies as opposed to vaginal delivery for pregnancies with an increased risk of neonatal mortality.     

妊娠妇女产前的分娩认知和态度与其分娩方式的相关性研究

目的：分析妊娠妇女产前对分娩安全性的认知和态度等因素对其分娩方式选择的影响。方法采用自行设计的问卷对在某妇幼保健院住院待产的妊娠妇女进行现场调查。待产妇分娩后,根据其分娩方式将参与调查的产妇分为剖宫产组和阴道分娩组,再进行统计分析,比较两组妊娠妇女对分娩认知和态度之间的差异。结果多因素 Logistic 回归分析结果显示,具有本科及以上文化程度妊娠妇女(OR ：3?22,95％CI ：1?52~6?79)、产前倾向于剖宫产或无明显倾向的妊娠妇女(OR ：9?54,95％CI ：4?09~22?25)、认为剖宫产更安全的妊娠妇女(OR ：3?73,95％CI ：1?65~8?41)最后采用剖宫产分娩的可能性显著升高。结论产妇产前对分娩的认知和对不同分娩方式的选择意向会影响产妇最终分娩方式的选择。     

The making of a medical tradition: vaginal birth after cesarean

By 1982, both the National Institutes of Health (NIH) and the American College of Obstetricians and Gynecologists had recommended that hospitals adopt policies favoring vaginal birth after cesarean (VBAC). Yet VBAC has since made only small inroads against repeat cesarean section and is primarily popular among progressive obstetricians and middle-class women wanting to experience natural childbirth and to avoid surgery. This study was undertaken to learn why, in hospitals permitting and ostensibly encouraging VBAC, some obstetrical patients choose 'trial of labor' for vaginal delivery, and others choose elective repeat cesarean section. Interviews with 100 women showed that the choice of a delivery method was largely influenced by the respondents' interactions with physicians, their reconstructions of the meanings of the previous cesarean section, and their personal ideologies about reproduction and motherhood. Ethnic minority women exhibited a greater preference for elective repeat cesarean than did white women. Caution is nevertheless urged in overinterpreting the significance of patient ethnicity for the continued popularity of elective repeat cesarean surgery.     

自我效能和生育意愿与孕中期妇女剖宫产意愿的相关性研究

目的:探讨阴道分娩自我效能、生育意愿及其他已知因素对上海市某区孕中期初产妇剖宫产意愿的影响。方法:对2010年12月～2011年5月到上海市某区仅有的2所接产医院建立大卡(初次产检)的482名孕中期初产妇进行问卷调查,调查内容包括自我效能、生育意愿、个人基本情况、对分娩方式的认知和分娩意愿等。结果:孕中期初产妇剖宫产意愿比例达12.1%。三个多因素Logistic回归模型的对比发现,阴道分娩自我效能和一胎意愿是剖宫产意愿的两个独立的相关因素。孕妇阴道分娩自我效能得分每增加1分,阴道分娩意愿可能性增至1.198倍(P<0.01);打算只生1个孩子的孕妇剖宫产意愿是不打算或未考虑过者的2.143倍(P<0.05)。此外,年龄大、有生育保险、对分娩方式有错误认知的孕妇更倾向于有剖宫产意愿。结论:卫生保健服务提供者应努力帮助孕妇提高阴道分娩的自我效能。建议可进一步研究计划生育政策与剖宫产意愿及行为的关系。     

联合干预措施对降低孕产妇剖宫产率的临床观察

目的探讨孕期对孕妇进行健康教育,个体化营养指导,产时实施自控硬膜外镇痛分娩同时导乐陪产多方面联合干预措施,对降低孕产妇剖宫产率的疗效观察。方法将2010年10月至2011年9月在中山市博爱医院门诊进行产前检查无高危因素的孕妇,自愿就诊营养门诊、参加孕妇学校、健康教育系列活动,并实施自控硬膜外镇痛分娩的孕妇2160例作为观察组,同时以同期仅进行常规围产期保健检查的孕妇1320例作为对照组。比较指标变化,检验干预结果。结果观察组:阴道产1933例,剖宫产227例(10.51%);对照组:阴道产1085例,剖宫产235例(17.80%)。采取联合干预措施后剖宫产率显著下降(P<0.05)。死产率、新生儿窒息率、阴道助产率差异无统计学意义(P>0.05)。结论通过联合干预措施合理降低剖宫产率效果显著。     

Factors influencing the practice of vaginal birth after cesarean section.

OBJECTIVES. Vaginal birth after cesarean has been recommended for most women with previous cesarean sections for the past 10 years. This practice, however, has not yet been generalized because high variations can still be observed among countries, hospitals, and physicians. METHODS. A case-control study involving 635 case patients and 2593 control patients was carried out to determine which characteristics of the physician, the patient, or the hospital were important in the adoption of this practice. RESULTS. The results of the multiple stepwise logistic regression analysis indicate a higher likelihood that women will experience vaginal birth after cesarean if their physicians had cesarean rates under 20%, had less than 5% of their patients considered at risk, and were younger than 54 years old. Vaginal birth after cesarean was also favored by hospitals characterized by a high degree of neonatal and obstetrical specialization, and a patient population with a low level of education. CONCLUSIONS. This policy is still in the developmental stage, as evidenced by the great variability between hospitals and physicians in rates of vaginal birth after cesarean. Further efforts are required for this policy to become the norm.     

Cesarean sections: who wants them and under what circumstances?

Brazil has extremely high cesarean rates. Among related factors, it has been suggested that a "culture of cesarean childbirth" (or a preference for this type of delivery) exists among Brazilian women. Our study investigates this notion. Data were collected from September 1998 to March 1999 in two maternity hospitals in Rio de Janeiro Interviews were conducted and hospital records analyzed for a random representative sample of 909 women who had just given birth (454 vaginal deliveries and 455 cesareans). In the interviews, when asked if they had wanted to have a cesarean, 75.5% replied in the negative, thus indicating that these women cannot be considered as adhering to a "culture of cesarean sections" The main complaints against cesareans were: slower and more difficult recovery (39.2%) and greater pain and suffering (26.8%). However, 17% of the sample had at some point requested a cesarean, 75% of whom during labor. Analysis revealed that the request for a cesarean section is directly proportional to time between admission to the hospital and delivery. This suggests that (in addition to being the usual means of access to tubal ligation) the actual circumstances of birthing are important factors in Brazilian women s requests for cesarean sections.     

双氯芬酸钾用于预防放置宫内节育器疼痛的临床研究

目的:观察双氯芬酸钾用于预防放置宫内节育器(IUD)所致疼痛的效果。方法:随机选取经剖宫产分娩后和阴道分娩后的两组妇女各100例,两组分别放置宫铜200IUD和TCu380IUD:剖宫产分娩后放置宫铜200IUD的妇女49例(观察组24例,对照组25例),放置TCu380IUD的妇女51例(观察组26例,对照组25例)。阴道分娩后放置宫铜200IUD的妇女50例(观察组和对照组各25例),放置TCu380IUD的妇女50例(观察组和对照组各25例)。观察双氯芬酸钾在置器术中、术后30min、术后6h、术后当晚睡前及术后第3日晚睡前预防疼痛的效果及服药的副反应等。结果:阴道分娩后置器的妇女,观察组和对照组在术中、术后30min、术后6h、术后当晚睡前及术后第3日晚睡前的疼痛分级差异均无统计学意义(P>0.05)。剖宫产分娩后放置宫铜200IUD的妇女,观察组和对照组比较,在术中及术后第3日晚睡前疼痛分级差异有统计学意义(P<0.05);放置TCu380IUD的妇女,观察组和对照组术后30min的疼痛分级差异有统计学意义(P<0.05)。结论:双氯芬酸钾用于预防剖宫产分娩后放置IUD所致疼痛有一定的效果,但未发现其能预防阴道分娩后放置IUD所致的疼痛。     

中国部分医疗保健机构剖宫产术使用状况调查

目的:描述2002年中国医疗保健机构剖宫产术的使用情况。方法:对中国31个省/自治区/直辖市中部分医疗保健机构进行问卷调查,对调查结果进行描述性分析。结果:①在被调查的887家医疗保健机构中有70.1%开展了剖宫产,在普通乡卫生院开展率也达到了41.0%;②被调查的医疗保健机构中产妇接受剖宫产的比例平均达到38.0%;③被调查的医疗保健机构的剖宫产费用是阴道产的2～4倍。结论:目前剖宫产在我国得到广泛开展,但是在其使用中还存在很多问题,需要引起各方重视。     

非必须剖宫产与产妇的分娩知识、态度和行为(KAP)的关系——1∶2病例对照研究

目的: 探讨产妇的分娩知识、态度、行为与非必须剖宫产的关系, 为预防和控制剖宫产率提供科学依据和综合性干预措施。方法: 采用回顾性研究方法, 以 2002年 10月 6日~12月 10日在武汉市 4家医院分娩的 855例产妇作为研究对象,从中筛选出单胎分娩的非必须剖宫产产妇, 根据配比条件与单胎阴道产产妇进行 1∶2配比。结果: 孕次和产前体重在两组产妇之间差异具有显著性意义 (P<0 05)。影响非必须剖宫产的因素包括: 怀孕期间已决定分娩方式、认为剖宫产可以保护会阴、产妇要求剖宫产、医生要求产妇剖宫产。结论: 亟需对孕妇进行有关分娩知识的健康教育, 改变她们的分娩态度, 促使她们正确选择分娩方式。     

影响剖宫产术后再次妊娠阴道分娩成功因素分析

目的分析影响剖宫产术后再次妊娠孕妇阴道分娩成功的因素。方法回顾性分析遂宁市中医院产科2015年10月至2016年10月426例剖宫产后再次妊娠孕妇分娩试产的临床资料,统计试产结果并对影响因素进行单因素和多因素相关性分析。结果 426例孕妇中,阴道试产成功271例,阴道自然/助产分娩,且无子宫破裂;失败155例,试产期间出现剖宫产指征而改行剖宫产。对影响因素进行统计分析,成功组产后出血率3.32%,子宫破裂率1.10%,失败组产后出血率7.10%,子宫破裂率1.29%,产后出血率差异明显(P0.05),而子宫破裂率、新生儿窒息人数比较差异无统计学意义;经单因素分析,两组孕妇产前体质量指数(body mass index,BMI)、孕妇年龄、子宫下段厚度、有阴道分娩史等比较差异有统计学意义(P0.05),而在瘢痕厚度、孕周、入院宫口扩张、距前次剖宫产手术时间、新生儿重量等方面比较差异无统计学意义(P0.05);经多因素分析,孕妇产前BMI、孕妇年龄、子宫下段厚度、有阴道分娩史、是否临产入院均对剖宫产后再次妊娠阴道试产有统计学意义(P0.05),其中有阴道分娩史OR值最高,是影响试产成功的重要因素。结论孕妇产前BMI30 kg/m~2,年龄30岁,子宫下段厚度4 mm,上次术后无发热,临产入院者,有阴道分娩史经历者比较适合阴道试产。     

剖宫产再孕阴道分娩临床指标选择及影响因素分析

目的:探讨剖宫产再孕阴道分娩的临床指标选择及成功分娩影响因素。方法:回顾性收集本院剖宫产后再孕产妇临床资料共157例,其中阴道分娩成功76例,剖宫产分娩81例。对比分析两组孕妇相关指标差异,使用logistic回归进行多因素分析。结果:子宫下段瘢痕厚度、距离上次剖宫产时间在两组间有差异(P0.05),阴道分娩组子宫下段瘢痕厚度(3.4mm±0.5mm)高于剖宫产组(3.1mm±1.0mm);产时出血量、新生儿Apgar得分、产后并发症发生率与剖宫产组未见统计学差异(P0.05);再分娩间隔时间(OR=4.40)、子宫下段瘢痕厚度(OR=1.86)是剖宫产再孕阴道分娩成功的影响因素。结论:间隔时间≥2年、子宫下段瘢痕厚度3mm是剖宫产再孕阴道分娩的安全因素。对剖宫产再孕的分娩方式应视产时情况而定,条件允许情况下可以采取经阴道方式进行试分娩。     

武汉市剖宫产流行特征及其影响因素研究

目的 :初步掌握目前武汉市剖宫产在部分医院的流行特征 ,分析高剖宫产比的影响因素。方法 :对 2 0 0 2年 10月 6日～ 12月 10日在武汉市 4家医院分娩的 85 5例产妇进行回顾性分析。结果 :(1)剖宫产占 47 60 % ,阴道产占 5 0 88% ,阴道助产占 1 5 2 %。 (2 )剖宫产指征构成比居首位的是社会因素 (2 5 83 % )。 (3 )非必须剖宫产 165例 ,占分娩例数的 19 3 0 %。(4 )产妇选择剖宫产分娩考虑的首要因素是为了孩子健康 ,占 5 9 95 % ,其次是考虑只生一胎 ,占 45 45 %。假设无任何剖宫产指征、有无痛分娩或由信任的人陪伴 ,绝大部分产妇愿意选择阴道分娩。结论 :此次所调查医院的总体剖宫产率较高 ,其中非必须剖宫产比例较高是其重要原因。产妇及其丈夫不正确的分娩知识、态度和行为与产科医生不正确的态度和行为是非必须剖宫产的重要危险因素。     

助产士门诊干预对首次剖宫产再次妊娠孕妇分娩结局的影响研究

目的探讨助产士门诊干预对首次剖宫产后再次妊娠孕妇分娩结局的影响。方法收集2016年1~11月广州市花都区妇幼保健院首次剖宫产后再次妊娠的孕妇123例作为研究对象,按照随机数字表法将其分成两组。对照组61例接受常规产检门诊宣教和参加瘢痕子宫阴道分娩专家门诊,研究组62例在对照组的基础上实施助产士门诊干预,比较两组孕妇分娩方式、产后出血量、3个产程及总产程时间、新生儿出生体重与出院前母乳喂养率。结果研究组顺产率、新生儿出生体重、产后出血量、第二产程时间、出院前母乳喂养率均优于对照组(P0.05);研究组第一产程、第三产程和总产程时间与对照组比较,差异无统计学意义(P0.05)。结论实施助产士门诊干预能提高首次剖宫产后再次妊娠孕妇的顺产率、出院前母乳喂养率,改善母婴分娩结局,值得临床推广。     

Cesarean section and operative vaginal delivery in low-risk primiparous women, Western Australia.

OBJECTIVES. A major component of the increasing trend in cesarean sections in Western Australia is the rise in emergency cesarean sections in primiparous women. The aim of this study was to identify independent risk factors (particularly those known early in pregnancy) associated with operative delivery in low-risk primiparous women. METHODS. Retrospective multivariate logistic regression analyses of antenatal and perinatal data were conducted for all low-risk primiparous women entering labor spontaneously and giving birth in Western Australia in 1987 (n = 3641). RESULTS. Of the subjects, 58% had a spontaneous vaginal delivery, 8% had an emergency cesarean section, and 34% had an operative vaginal delivery. The significant independent risk factors for emergency cesarean section were older maternal age, shorter maternal height, heavier infant birthweight, and long labor. The risk factors for operative vaginal delivery were older maternal age, shorter maternal height, heavier infant birthweight, epidural anesthesia, labor/delivery complications, male infant, private patient status, and being married. CONCLUSIONS. This multivariate analysis confirms known risk factors for operative delivery in low-risk primiparous women and suggests that it may be possible to predict the likelihood of operative delivery for an individual woman by using knowledge of maternal age and height and assessment of infant birthweight.     

不同分娩方式对围绝经期女性盆底功能影响的研究

目的:探讨不同分娩方式对围绝经期妇女盆底功能的影响。方法:随机选择2005年9月～2009年9月该院妇保科就诊的围绝经期妇女77例,其中初产为剖宫产者36例、阴道顺产者41例,采用盆底肌力检测法、阴道检查法对盆底肌力及有无阴道萎缩进行评价并对比研究。结果:剖宫产组盆底肌力≤3分者达77.8%(28/36),≥4分者占22.2%(8/36);阴道分娩组≤3分者达78.0%(32/41),≥4分者占22.0%(9/41),差异无统计学意义(P0.05)。而阴道萎缩率剖宫产组为38.9%(14/36),阴道分娩组17.1%(7/41),差异有统计学意义(P0.05)。结论:两种分娩方式对围绝经期女性盆底肌力影响不明显,但阴道分娩者阴道萎缩的发生率低于剖宫产组,提示阴道分娩对围绝经期女性的阴道萎缩有一定保护作用。     

Choice of a childbirth method after cesarean

Concern about the rising cesarean-section rate and the high percentage of elective repeat cesareans led to an exploratory, retrospective examination of women's decision-making about a childbirth method after cesarean. Fifty women who had delivered by a repeat cesarean (RC) or vaginal birth after cesarean (VBAC) participated in a telephone interview. Three questions were addressed: (1) who made the decision for a birth method; (2) what factors were associated with the choice of method; and (3) was the choice of method associated with the actual method of delivery? The majority of women (90%) perceived that they were the primary decision-maker for a birth method, and choice of birth method was positively associated with actual method of delivery. The major reason for VBAC choice was to experience a vaginal birth, whereas the primary reason for RC choice was to avoid an unsuccessful labor. Other factors associated with choice of a birth method were: sources of information and support, beliefs, previous cesarean experience and locus of control. These findings have important implications for enhancing women's health-care decision-making, as well as for reducing the rate of repeat-cesarean deliveries.