二胎政策下的瘢痕子宫再次妊娠后阴道试产的安全性

 目的 探讨单次子宫下段横切口剖宫产术后再次妊娠后阴道试产的安全性及妊娠结局。方法 回顾性分析2016年1月1日至2018年5月31日复旦大学附属妇产科医院产检及分娩的单次子宫下段横切口剖宫产术后再次妊娠、符合我院剖宫产后再次妊娠阴道试产（trail of labor after cesarean section，TOLAC）纳入标准、分娩孕周 ≥ 28周的810例孕妇的临床资料。其中270例为期间所有TOLAC病例（TOLAC组），其余540例为随机选择的同期无TOLAC禁忌证但选择重复剖宫产分娩的病例（elective repeated cesarean section，ERCS组）。比较两组不同分娩方式的妊娠结局。结果 TOLAC组自然临产者占89.3%。TOLAC组孕妇年龄（33.0±4.2）岁、孕前体重指数（21.1±2.4）、分娩前体重指数（26.2±3.3）、产后出血量250 （80~1 500） mL、新生儿体重（3 267±482）g、住院天数4 （1~18）天，均小于ERCS组（P<0.05）。TOLAC组子宫破裂率1.9% （5/270）、膀胱损伤率0.4%（1/270），产后出血 ≥ 1 000 mL的发生率、输血治疗率均为1.1%（3/270），新生儿 1 min Apgar评分 ≤ 7分发生率1.5% （4/270）、新生儿缺血缺氧性脑病的发生率0.4%（1/270），入住新生儿重症监护室率为4.4%（12/270）。与ERCS组比较，上述指标差异无统计学意义。结论 在严格选择TOLAC人群、加强产前产时管理、可即刻提供紧急救治的医疗机构里，对于大多数单次子宫下段横切口剖宫产后再次妊娠孕妇，阴道试产是可选择的安全可行的分娩方式。

Safety of trail of labor after cesarean section under the two-child policy

Objective To investigate the safety and outcomes of vaginal delivery in gravidas with single subuterine transection cesarean section. Methods Eight hundred and ten gravidas who underwent antenatal care and delived in our hospital from January 1,2016 to May 31,2018,with single subuterine cross-section cesarean section and delivery gestational age ≥ 28 weeks were enrolled in this retrospective study.Among those subjects,270 who underwent trail of labor after cesarean were grouped into trail of labor after cesarean section (TOLAC) group,the other 540 accepting repeated cesarean section,who were randomly selected during the same period,were grouped into the elective repeated cesarean section (ERCS) group.The outcome of the two deliver modes were compared. Results The incidence of spontaneous vaginal labor was 89.3% in the TOLAC group.The age[(33.0±4.2) years],body mass index before pregnancy (21.1±2.4) and delivery (26.2±3.3),postpartum hemorrhage[250 (80-1 500) mL],neonatal birth weight[(3 267±482) g] and hospital stay[4 (1-18) days] in the TOLAC group were less than those in ERCS group (P<0.05).In the TOLAC group,the incidence rates of maternal uterine rupture and bladder injury were 1.9% (5/270) and 0.4% (1/270),respectively.The incidence rates of postpartum hemorrhage greater than 1 000 mL and maternal blood transfusion were all 1.1% (3/270).The 1 minute Apgar score ≤ 7 was 1.5% (4/270),neonatal hypoxic ischemic encephalopathy was 0.4% (1/270),and admission to neonatal intensive care unit was 4.4% (12/270).These parameters were not statistically different from those in ERCS group. Conclusions Under strict selection of TOLAC population and strengthened labor management,for the majority of women who are pregnant after cesarean section with single subuterine transection,vaginal labor is a safe and feasible way of delivery mode,in the medical facility that can provide immediate emergency care.