阴道助产对剖宫产术后阴道分娩母婴结局的影响

doi:10.3877/cma.j.issn.2095-3259.2020.03.011

目的

探讨阴道助产对于剖宫产术后再次妊娠阴道分娩母婴结局的影响。

方法

回顾性分析2014年1月1日至2018年12月31日广东省妇幼保健院收治的剖宫产术后再次妊娠阴道分娩的567例产妇的临床资料，将成功阴道分娩者纳入顺产组475例，将阴道分娩过程中接受助产手术者纳入助产组92例(产钳助产59例、胎头吸引助产33例)，比较两组母婴结局和并发症情况，以及不同助产方式母婴结局和并发症情况。

结果

(1)助产组高龄产妇29例(31.52%)，顺产组89例(18.74%)，两组相比差异有统计学意义(χ²＝7.64，P<0.001)；助产组住院时间(2.80±0.73)d，顺产组(2.04±0.24)d，差异有统计学意义(t＝-18.13，P<0.001)。(2)助产组产后出血量(316.16±483.67)ml，产后出血率5.43%，顺产组产后出血量(201.38±144.43)ml，产后出血率1.26%，差异有统计学意义(t＝-4.29，P<0.001; χ²＝7.05，P＝0.008)；两组其他分娩并发症及新生儿并发症发生率均无统计学差异(P>0.05)。(3)两种助产方式之间相比，产钳组出胎时间(10.36±1.75)min，胎吸引产组出胎时间(12.12±2.36)min，差异有统计学意义(t＝-4.09，P<0.001)。产钳组住院时间为(2.95±0.71)d，胎吸引产组为(2.55±0.71)d，差异有统计学意义(t＝2.63，P＝0.010)；两种助产方式分娩并发症及新生儿并发症发生率无统计学差异(P>0.05)。

结论

阴道助产可能会增加剖宫产术后再次妊娠阴道试产产妇产后出血的风险，但未增加新生儿并发症的发生风险，产程中应根据母胎情况选择恰当的助产方式。

关键词: 剖宫产术后阴道分娩, 阴道助产术, 子宫破裂, 产钳助产术, 胎头吸引术

Objective

To investigate the effect of Operative Vaginal Delivery on women with one previous low transverse cesarean.

Methods

This a retrospective study. The clinical data of patients underwent a VBAC(vaginal birth after cesarean section, VBAC) were collected who were admitted to Department of Obstetrics of our hospital from January1, 2014 to December 31, 2018. The patients successfully underwent VBAC were included in the vaginal delivery group, patients who underwent forceps-assisted delivery or vacuum-assisted delivery were included in operative vaginal delivery group. The results and complications of the different groups were compared.

Results

(1)567 patients were enrolled. 475 in vaginal delivery group.92 in operative vaginal delivery group, including 59 forceps-assisted vaginal delivery (62.58%), and 33 vacuum-assisted vaginal delivery (37.42%). (2)There were 29 (31.52%) advanced maternal age cases in operative vaginal delivery group and 89 cases (18.74%) in vaginal delivery group. The difference between the two groups was statistically significant (χ²=7.64, P<0.001); The mean hospitalization time of patients in operative vaginal delivery group was 2.80±0.73 d, and that in vaginal delivery group was 2.04±0.24 d, the difference was statistically significant (t=-18.13, P<0.001). (3) The average amount and incidence of postpartum hemorrhage in operative vaginal delivery group was 316.16±483.67 ml and 5.43%, and that in vaginal delivery group was 201.38±144.43 ml and 1.26%, the differences were statistically significant (t=-4.29, P<0.001; χ²=7.05, P=0.008). there were no statistical difference in the incidence of other delivery complications and neonatal complications between the two groups. (4) Analysis between forceps-assisted group and vacuum-assisted group showed that the determine-to-delivery time interval was shorter in forceps-assisted group(10.36±1.75 min vs 12.12±2.36 min, t=-4.09, P<0.001), but the average hospitalization time was longer(2.95±0.71 d vs 2.55±0.71 d, t=2.63, P=0.010). There were no significant difference in other delivery complications and neonatal complications between the two groups.

Conclusions

Operative vaginal delivery may increase the risk of postpartum hemorrhage, but did not increase the risk of neonatal complications. Appropriate way of instrumental-assisted delivery should be selected according to the situation of mother and fetus.

Key words: Vaginal birth after cesarean section, Instrumental-assisted delivery, Operative vaginal delivery, Uterine rupture, Forceps-assisted delivery, Vacuum-assisted delivery

表1 助产组与顺产组基本情况对比

组别	例数	年龄[例(%)]		阴道分娩史[例(%)]	分娩间隔(±s，岁)	子宫下段横切口[例(%)]	住院时间(±s，d)	BMI(±s，kg/m²)	孕周(±s，周)
组别	例数	19～34岁	≥35岁	阴道分娩史[例(%)]	分娩间隔(±s，岁)	子宫下段横切口[例(%)]	住院时间(±s，d)	BMI(±s，kg/m²)	孕周(±s，周)
助产组	92	63(68.48)	29(31.52)	2(2.17)	4.55±2.03	79(85.87)	2.80±0.73	22.64±2.63	38.75±0.99
顺产组	475	386(81.26)	89(18.74)	23(4.84)	4.87±2.47	416(87.58)	2.04±0.24	22.98±2.45	38.84±0.94
统计值		χ²＝7.64		χ²＝1.30	t＝-1.17	χ²＝0.20	t＝-18.13	t＝-1.15	t＝0.87
P值		0.006		0.254	0.244	0.652	<0.001	0.250	0.383

表1 助产组与顺产组基本情况对比

组别	例数	年龄[例(%)]		阴道分娩史[例(%)]	分娩间隔(±s，岁)	子宫下段横切口[例(%)]	住院时间(±s，d)	BMI(±s，kg/m²)	孕周(±s，周)
组别	例数	19～34岁	≥35岁	阴道分娩史[例(%)]	分娩间隔(±s，岁)	子宫下段横切口[例(%)]	住院时间(±s，d)	BMI(±s，kg/m²)	孕周(±s，周)
助产组	92	63(68.48)	29(31.52)	2(2.17)	4.55±2.03	79(85.87)	2.80±0.73	22.64±2.63	38.75±0.99
顺产组	475	386(81.26)	89(18.74)	23(4.84)	4.87±2.47	416(87.58)	2.04±0.24	22.98±2.45	38.84±0.94
统计值		χ²＝7.64		χ²＝1.30	t＝-1.17	χ²＝0.20	t＝-18.13	t＝-1.15	t＝0.87
P值		0.006		0.254	0.244	0.652	<0.001	0.250	0.383

表2 助产组与顺产组分娩并发症情况对比

组别	例数	产妇分娩并发症[例(%)]				第二产程延长[例(%)]	产后出血量(±s，ml)
组别	例数	产后出血	Ⅲ度裂伤	子宫破裂	肩难产	第二产程延长[例(%)]	产后出血量(±s，ml)
助产组	92	5(5.43)	2(2.17)	1(1.09)	1(1.09)	19(20.65)	316.16±483.67
顺产组	475	6(1.26)	3(0.63)	1(0.21)	3(0.63)	11(2.32)	201.38±144.43
检验值		χ²＝7.05	χ²＝2.10	χ²＝1.68	χ²＝0.23	χ²＝88.41	t＝-4.29
P值		0.008	0.148	0.194	0.633	<0.001	<0.001

表2 助产组与顺产组分娩并发症情况对比

组别	例数	产妇分娩并发症[例(%)]				第二产程延长[例(%)]	产后出血量(±s，ml)
组别	例数	产后出血	Ⅲ度裂伤	子宫破裂	肩难产	第二产程延长[例(%)]	产后出血量(±s，ml)
助产组	92	5(5.43)	2(2.17)	1(1.09)	1(1.09)	19(20.65)	316.16±483.67
顺产组	475	6(1.26)	3(0.63)	1(0.21)	3(0.63)	11(2.32)	201.38±144.43
检验值		χ²＝7.05	χ²＝2.10	χ²＝1.68	χ²＝0.23	χ²＝88.41	t＝-4.29
P值		0.008	0.148	0.194	0.633	<0.001	<0.001

表3 助产组与顺产组新生儿并发症情况对比

组别	例数	1 min Apgar评分[例(%)]		新生儿体重(±s，g)	新生儿发热[例(%)]
组别	例数	4～7分	8～10分	新生儿体重(±s，g)	新生儿发热[例(%)]
助产组	92	3(3.26)	89(96.74)	3264±347	1(1.09)
顺产组	475	5(1.05)	470(98.95)	3201±349	2(0.42)
统计值		χ²＝2.70		t＝-1.63	χ²＝0.65
P值		0.100		0.104	0.420

表3 助产组与顺产组新生儿并发症情况对比

组别	例数	1 min Apgar评分[例(%)]		新生儿体重(±s，g)	新生儿发热[例(%)]
组别	例数	4～7分	8～10分	新生儿体重(±s，g)	新生儿发热[例(%)]
助产组	92	3(3.26)	89(96.74)	3264±347	1(1.09)
顺产组	475	5(1.05)	470(98.95)	3201±349	2(0.42)
统计值		χ²＝2.70		t＝-1.63	χ²＝0.65
P值		0.100		0.104	0.420

表4 产钳组与胎吸引产组基本情况对比

组别	例数	年龄[例(%)]		BMI(±s，kg/m²)	分娩间隔(±s，年)	子宫下段横切口[例(%)]	住院时间(±s，d)	孕周(±s，周)
组别	例数	19～34岁	≥35岁	BMI(±s，kg/m²)	分娩间隔(±s，年)	子宫下段横切口[例(%)]	住院时间(±s，d)	孕周(±s，周)
产钳组	59	42(71.19)	17(28.81)	22.73±2.53	4.44±1.45	51(86.44)	2.95±0.71	38.83±1.04
胎吸引产组	33	21(63.64)	12(36.36)	22.48±2.83	4.76±2.81	28(84.85)	2.55±0.71	38.61±0.90
检验值		χ²＝0.56		t＝0.432	t＝-0.72	χ²＝0.04	t＝2.63	t＝1.04
P值		0.455		0.667	0.477	0.833	0.010	0.300

表4 产钳组与胎吸引产组基本情况对比

组别	例数	年龄[例(%)]		BMI(±s，kg/m²)	分娩间隔(±s，年)	子宫下段横切口[例(%)]	住院时间(±s，d)	孕周(±s，周)
组别	例数	19～34岁	≥35岁	BMI(±s，kg/m²)	分娩间隔(±s，年)	子宫下段横切口[例(%)]	住院时间(±s，d)	孕周(±s，周)
产钳组	59	42(71.19)	17(28.81)	22.73±2.53	4.44±1.45	51(86.44)	2.95±0.71	38.83±1.04
胎吸引产组	33	21(63.64)	12(36.36)	22.48±2.83	4.76±2.81	28(84.85)	2.55±0.71	38.61±0.90
检验值		χ²＝0.56		t＝0.432	t＝-0.72	χ²＝0.04	t＝2.63	t＝1.04
P值		0.455		0.667	0.477	0.833	0.010	0.300

表5 产钳组与胎吸引产组分娩并发症情况对比[例(%)]

组别	例数	助产原因[例(%)]			产后出血[例(%)]	产后出血量(±s，ml)
组别	例数	产妇因素	产程延长	胎窘	产后出血[例(%)]	产后出血量(±s，ml)
产钳组	59	8(13.56)	12 (20.34)	39(66.10)	3(5.08)	340.76±588.55
胎吸引产组	33	7(21.21)	7(21.21)	19(57.58)	2(6.06)	272.18±185.26
统计值		χ²＝0.91	χ²＝0.01	χ²＝0.66	χ²＝0.04	t＝0.65
P值		0.341	0.921	0.416	0.843	0.517

表5 产钳组与胎吸引产组分娩并发症情况对比[例(%)]

组别	例数	助产原因[例(%)]			产后出血[例(%)]	产后出血量(±s，ml)
组别	例数	产妇因素	产程延长	胎窘	产后出血[例(%)]	产后出血量(±s，ml)
产钳组	59	8(13.56)	12 (20.34)	39(66.10)	3(5.08)	340.76±588.55
胎吸引产组	33	7(21.21)	7(21.21)	19(57.58)	2(6.06)	272.18±185.26
统计值		χ²＝0.91	χ²＝0.01	χ²＝0.66	χ²＝0.04	t＝0.65
P值		0.341	0.921	0.416	0.843	0.517

表6 产钳组和胎吸引产组新生儿并发症情况对比

组别	例数	胎儿娩出时间(±s，min)	1min Apgar评分[例(%)]		新生儿体重(±s，g)
组别	例数	胎儿娩出时间(±s，min)	4～7分	8～10分	新生儿体重(±s，g)
产钳组	59	10.36±1.75	1(1.69)	58(98.31)	3289±348
胎吸引产组	33	12.12±2.36	2(6.06)	31(93.94)	3222±347
统计值		t＝-4.09	χ²＝1.28		t＝0.89
P值		<0.001	0.258		0.377

表6 产钳组和胎吸引产组新生儿并发症情况对比

组别	例数	胎儿娩出时间(±s，min)	1min Apgar评分[例(%)]		新生儿体重(±s，g)
组别	例数	胎儿娩出时间(±s，min)	4～7分	8～10分	新生儿体重(±s，g)
产钳组	59	10.36±1.75	1(1.69)	58(98.31)	3289±348
胎吸引产组	33	12.12±2.36	2(6.06)	31(93.94)	3222±347
统计值		t＝-4.09	χ²＝1.28		t＝0.89
P值		<0.001	0.258		0.377

[1]	Krizman E, Grzebielski P, Antony KM, et al. Operative vaginal delivery is a safe option in women undergoing a trial of labor after prior cesarean [J]. AJP Rep, 2019, 9(2): e190-e194.
[2]	Triebwasser JE, Colvin R, Macones GA, et al. Nonreassuring Fetal Status in the Second Stage of Labor: Fetal Monitoring Features and Association with Neonatal Outcomes [J]. Am J Perinatal, 2016,33(7):665-670.
[3]	Inbar R, Mazaaki S, Kalter A, et al. Trial of labour after caesarean (TOLAC) is associated with increased risk for instrumental delivery [J]. J Obstet Gynaecol, 2017,37(1):44-47.
[4]	Wai-Hou Li, Ming-Jie Yang, Peng-Hui Wang, et al. Vaginal birth after cesarean section: 10 years of experience in a tertiary medical center in Taiwan [J]. Taiwan J Obstet Gynecol, 2016, 55(3):394-398.
[5]	Brock CO, Govindappagari S, Gyamfi-Bannerman C. Outcomes of Operative Vaginal Delivery during Trial of Labor after Cesarean Delivery [J]. Am J Perinatol, 2017, 34(8):765-773.
[6]	Polkowski M, Kuehnle E, Schippert C, et al. Neonatal and maternal short-term outcome parameters in instrument-assisted vaginal delivery compared to second-stage cesarean section in labor: A retrospective 11-year analysis [J]. Gynecol Obstet Invest, 2018,83(1):90-98.
[7]	Rottenstreich M, Rotem R, Katz B, et al. Vacuum extraction delivery at first vaginal birth folwing cesarean: maternal and neonatal outcome [J]. Arch Gynecol Obstet, 2020, 301(2):483-489.
[8]	Muraca GM, Sabr Y, Lisonkova S, et al. Morbidity and Mortality Associated With Forceps and Vacuum Delivery at Outlet, Low, and Midpelvic Station [J]. J Obstet Gynaecol Can, 2019,41(3):327-337.
[9]	中华医学会妇产科学分会产科学组. 阴道手术助产指南(2016) [J]. 中华妇产科杂志，2016, 51(8):565-567.
[10]	Friedman EA. Primigravid labor: a graphic statistical analysis [J]. Obstet Gynecol, 1955, 6:567-589.
[11]	时春艳，李博雅．新产程标准及处理的专家共识(2014)[J]．中华妇产科杂志，2014,(7).486-486.
[12]	Hamilton BE, Martin JA, Osterman MJ, et al. Births: final data for 2014. Natl Vital Stat Rep, 2015, 64(12):1-64.
[13]	周玉博，李宏田，朱丽萍，等.1993至2010年中国部分地区阴道助产分娩率变化趋势[J]．中华医学杂志，2014,94(45):3599-3602.
[14]	蒋庆源，杜晓红，李卉，等.10年间阴道助产术的临床应用回顾性分析[J]．实用妇产科杂志，2018, 34(7):527-530.
[15]	周玮，漆洪波.2019年ACOG剖宫产后阴道分娩指南解读[J]．中国实用妇科与产科杂志，2019, 35(12):1340-1343.
[16]	Caughey AB, Cahill AG, Guise J-M, et al. Safe prevention of the primary cesarean delivery [J]. Am J Obstet Gynecol，2014,210(3):179-193.
[17]	Gei AF. Prevention of the first cesarean delivery: the role of operative vaginal delivery [J]. Semin Perinatal, 2012,36(5):365-373.
[18]	Helman S, Drukker L, Fruchtman H, et al. Revisit of risk factors for major obstetric hemorrhage: insights from a large medical center [J]. Arch Gynecol Obstet，2015,292(4):819-828.
[19]	Holm C, Langhoff-Roos J, Petersen KB, et al. Severe postpartum haemorrhage and mode of delivery: a retrospective cohort study [J]. BJOG，2012,119(5):596-604.
[20]	Shmueli A, Gabbay Benziv R, Hiersch L, et al. Episiotomy-risk factors and outcomes [J]. J Matern Fetal Neonatal Med，2017,30(3):251-256.
[21]	陈炳南，王笛，张立阳，等．再次剖宫产高龄产妇产后出血危险因素分析[J]．现代妇产科进展，2020, 29(1):26-28.
[22]	Jastrow N, Demers S, Gauthier RJ, et al. Adverse obstetric outcomes in women with previous cesarean for dystocia in second stage of labor [J]. Am J Perinatol，2013,30(3):173-178.
[23]	Vachon-Marceau C, Demers S, Goyet M, et al. Labor Dystocia and the Risk of Uterine Rupture in Women with Prior Cesarean [J]. Am J Perinatol，2016,33(6):577-583.

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[8]	顾宁, 郑明明, 戴毅敏. 宫腔球囊填塞导致子宫破裂一例并文献复习[J]. 中华产科急救电子杂志, 2021, 10(04): 225-229.
[9]	韩振艳, 侯红瑛. 剖宫产子宫瘢痕缺损的评估及再次妊娠的孕期监测[J]. 中华产科急救电子杂志, 2020, 09(04): 217-221.
[10]	刘维芳, 邹丽. 瘢痕子宫再次妊娠的并发症管理[J]. 中华产科急救电子杂志, 2020, 09(02): 78-82.
[11]	李航, 马润玫. 剖宫产后阴道分娩子宫破裂早期识别与管理[J]. 中华产科急救电子杂志, 2017, 06(01): 9-13.

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The effect of operative vaginal delivery on women with previous cesarean delivery

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The effect of operative vaginal delivery on women with previous cesarean delivery