不同分娩方式对低危孕产妇分娩结局及卫生经济学指标的影响

Clinical analysis of maternal and neonatal outcomes in uncomplicated term nulliparous after different routes of delivery

目的探讨不同分娩方式对低危孕产妇分娩结局及卫生经济学指标的影响。方法对2002年9月至2007年4月北京协和医院分娩的3751例孕37～41周^(+6)的低危孕产妇的资料进行回顾性分析,按分娩的干预方式不同分为3组:择期引产组(包括药物及手术引产)501例、择期剖宫产组1634例和自然临产组1616例,分别对3组孕产妇的一般情况及住院费用以及分娩结局(产后出血、产褥病率、尿潴留、输血情况、切口愈合情况、产时副损伤)、新生儿 Apgar 评分情况等进行统计比较。结果 (1)一般情况分析:自然临产组孕产妇住院天数(4.8 d)与择期引产组(6.3 d)及择期剖宫产组(6.3 d)比较,差异有统计学意义(P<0.01);择期剖宫产组孕产妇住院费用(3472元)明显高于择期引产组(3201元)及自然临产组(2293元),分别比较,差异有统计学意义(P<0.01),尤其是择期引产组中的剖宫产患者住院费用明显高于择期剖宫产组及自然临产组中的剖宫产患者,分别比较,差异均有统计学意义(P<0.01)。(2)产时及产后并发症总发生率:孕产妇产时及产后并发症总发生率分别是择期引产组为12.4%、择期剖宫产组为0.9%,自然临产组为6.8%。(3)产后出血(≥500 ml)发生率:择期引产组、择期剖宫产组和自然临产组分别为3.0%(15/501)、0.6%(9/1634)和1.2%(19/1616),3组分别比较,差异有统计学意义(P<0.01)。(4)尿潴留发生率:择期引产组、择期剖宫产组和自然临产组分别为4.6%(23/501)、0和3.3%(54/1616),择期剖宫产组尿潴留发生率低于择期引产组与自然临产组(P<0.01),择期引产组与自然临产组比较,差异无统计学意义(P>0.01)。(5)有无分娩中或产后输血:择期引产组、择期剖宫产组和自然临产组率孕产妇有输血者分别为2.0%(10/501)、0.1%(1/1634)和0.4%(6/1616),3组分别比较,差异有统计学意义(P<0.01)。(6)产时副损伤:择期引产组、择期剖宫产组和自然临产组产时副损伤发生率分别为0.6%(3/501)、0和0.4%(7/1616),3组分别比较,择期剖宫产组低于其他两组(P<0.01),择期引产组与自然临产组比较,差异无统计学意义(P>0.01)。(7)切口延期愈合:择期引产组、择期剖宫产组和自然临产组分别为0.8%(4/501)、0和0.2%(4/1616),3组分别比较,差异有统计学意义(P<0.01)。(8)产褥病率:3组间相互比较,差别无统计学意义(P>0.01)。(9)新生儿窒息发生率:择期引产组、择期剖宫产组和自然临产组分别为1.2%(6/501)、0.1%(1/1634)和1.0%(17/1616),择期剖宫产组与其他两组分别比较,差异均有统计学意义(P<0.01),择期引产组与自然临产组比较,差异无统计学意义(P>0.01)。结论择期引产会增加孕产妇产后出血、分娩中或产后输血的机会,且没有降低产妇尿潴留、新生儿窒息的发生率;择期剖宫产是相对安全的分娩方式,对孕产妇分娩并发症的发生没有不良影响,但会明显增加住院费用。

Objective To compare maternal and neonatal outcomes after induction, elective cesarean section and spontaneous onset of labor in uncomplicated term nulliparous women. Methods A total of 3751 uncomplicated term nullipara who delivered in Peking Union Medical College Hospital from Sept 2002 to April 2007 were retrospectively analyzed. They were divided into three groups： the induction group, the elective cesarean section group, and the spontaneous onset of labor group. Their general conditions （such as age, weeks of pregnancy, hospital days and cost）, postpartum complications （such as postpartum hemorrhage, puerperal morbidity, urinary retention, blood transfusion, delayed healing, and trauma）, and Apgar score were compared by statistic methods. Results （ 1 ） Among 3751 women, 501 （ 13.3% ） of them underwent induction（ the induction group）, 1634 （43.6%）delivered by cesarean section（ cesarean section group）, the other 1616 （43. 1% ） women underwent spontaneous onset of labor（ the spontaneous onset of labor group）. （2） Results of general conditions： the spontaneous onset of labor group had the shortest hospital days, which was longer in the induction group, and the longest in the selective cesarean section group（ P 〈0. 01 ）. The selective cesarean section group had the most cost during hospitalization, which was less in the induction group, and least in the spontaneous onset of labor group （P 〈 0. 01 ）. Women who undergwent emergent cesarean section after induction spent more money on hospitalization than those who were in the selective cesarean section group and the spontaneous onset of labor group （ P 〈 0. 01 ）. （ 3 ） Puerperal complications： （1） postpartum hemorrhage： the incidence of postpartum hemorrhage was 3.0% （15/501）in the induction group, 0. 6% （9/1634） in the selective cesarean section group and was 1.2% （19/1616） in the spontaneous onset of labor group（ P 〈 0. 01 ）. （2）Urinary retention： the incidence of urinary retention was 4. 6% （23/501） in the induction group, 0 in the selective cesarean section group, and 3.3% （54/1616） in the spontaneous onset of labor group. So the rate of urinary retention was lower in the cesarean section group than in the other two groups （ P 〈 0. 01 ） . （3）Blood transfusion ： the incidence of blood transfusion in delivery was 2. 0% （ 10/501 ） in the induction group, 0. 1% （ 1/1634 ） in the selective cesarean section group, and 0. 4% （6/1616） in the spontaneous onset of labor group （ P 〈 0. 01 ）. （4） Trauma： the incidence of trauma in delivery was 0. 6% （3/501） in the induction group, 0 in the selective cesarean section group, and 0. 4% （7/1616） in the spontaneous onset of labor group. So the rate of trauma was lower in the cesarean section group than in the other two groups（ P 〈0. 01 ） . （5）Delayed healing： the incidence of delayed healing of incision was 0. 8% （4/501） in the induction group, 0 in the selective cesarean section group, and 0. 2% （4/1616） in the spontaneous onset of labor group （ P 〈 0. 01 ）. （6） Puerperal morbidity： there was no difference in puerperal morbidity among the three groups （P 〈 0. 01 ）. （7） Neonatal asphyxia： the incidence of neonatal asphyxia was 1.2% （6/501） in the induction group, 0. 1% （1/1634） in the selective cesarean section group, and 1.0% （17/1616） in the spontaneous onset of labor group. The rate of neonatal asphyxia was lower in the cesarean section group than in the other two groups （P 〈0. 01 ） . Conclusions Induction may increase incidences of postpartum hemorrhage and blood transfusion, yet, it does not decrease the incidence of urinary retention and neonatal asphyxia. Generally, selective cesarean section is safer than induction and spontaneous onset of labor, but it costs most.