剖宫产后再次妊娠自然临产分娩方式的探讨

Mode of Delivery for Pregnancy after Prior Cesarean when Spontaneous Labor

目的:探讨剖宫产后再次妊娠孕妇自然临产分娩方式的选择。方法:回顾性研究2015年1月-2016年4月在苏州母子医疗保健中心入院分娩且曾有1次剖宫产史的孕妇共230例。所有孕妇均为足月单胎,头位,自然临产,根据孕妇意愿分为阴道试产(trial of labor after cesarean,TOLAC)组(98例)和拒绝TOLAC组(132例),TOLAC组根据最终分娩方式分为TOLAC成功组(87例)和TOLAC失败组(11例)。对孕妇的产程管理根据现有规范进行。比较3组的一般人口学特征、前次剖宫产相关因素、母婴结局和社会经济效益。结果:TOLAC成功率为88.78%(87/98),11例因产时胎心异常或产程停滞中转剖宫产终止妊娠。3组体质量指数(BMI)比较,差异有统计学意义,且TOLAC失败组高于TOLAC成功组和拒绝TOLAC组(均P<0.05);其他人口学特征及前次剖宫产相关因素比较,差异均无统计学意义。TOLAC组子宫破裂率与拒绝TOLAC组比较,差异无统计学意义(2.04%vs.1.52%,χ~2=0.091,P=0.767)。3组产时出血量比较差异有统计学意义,且TOLAC成功组明显低于TOLAC失败组和拒绝TOLAC组(均P<0.05);3组输血率比较差异有统计学意义,TOLAC成功组输血率明显低于TOLAC失败组,差异有统计学意义(P<0.05);TOLAC失败组与拒绝TOLAC组在产时出血量和输血率方面差异无统计学意义(P分别为0.434和0.092);3组间新生儿入新生儿重症监护病房(NICU)率差异无统计学意义(P=0.23)。3组均未发生子宫切除和母儿死亡等严重并发症。结论:对于前次剖宫产后再次妊娠的孕妇,只要进行充分评估,在合理的监管模式下,TOLAC是一种合理安全的分娩方式,尤其当这些孕妇临产后,阴道分娩可能是比急诊剖宫产更为安全可靠的分娩方式。

Objective：To discuss the mode of delivery for the pregnant women after prior cesarean when spontaneous labor. Methods：A retrospective study was conducted, which included 230 pregnant women attending Suzhou Municipal Hospital from Jan. 2015 to Apr. 2016. All women had a previous cesarean and a singleton pregnancy with cephalic presentation,also spontaneous labor when admitted. The cases were divided into two groups according to the women ′ s preferences, trial of labor after cesarean（TOLAC） group and refused TOLAC group. The TOLAC group were further divided into successful TOLAC and failed TOLAC groups. The demographic characteristics, relevant factors about prior cesarean, pregnancy outcomes and socioeconomic performance were evaluated. Results：In all 230 pregnant women, 98 women eligible for TOLAC. TOLAC led to vaginal birth in 87 women（88.78%）, 11 women failed due to fetal distress or a non-progress of labor. The BMI in failed TOLAC group was significantly higher than the other two groups（both P 〈0.05）. In total, 2 women who eligible for TOLAC [2.04%（2/98）]and 2 women refused TOLAC [1.52%（2/132）] had uterus scar rupture, there was no significant difference in two groups（χ~2=0.091,P=0.767）. The mean intrapartum blood loss in successful TOLAC group was significantly lower than the other two groups（both P 〈0.05）; when failed TOLAC group compared with refused TOLAC group, there was no significant difference（ P=0.434）. The proportion who required bold transfusion in successful TOLAC group was significantly lower than failed TOLAC group（ P 〈0. 05）, however there were no significant differences in the proportion in failed TOLAC group and refused TOLAC group（P=0.092）. The proportion of neonates who had to be admitted to intensive care did not differ significantly by mode of delivery.Conclusions：Based on sufficient evaluate, under strict supervision and administration, TOLAC is a reasonable option,particularly when spontaneous onset of labor. Vaginal birth will be much safer and more reliable than emergency cesarean.