检索历史 清除

目的：探讨剖宫产术后再次妊娠阴道试产的可行性及安全性。方法回顾性分析2011年1月—2015年12月广东省5家地市级医院（包括广州医科大学第三附属医院、广东省惠州市第一妇幼保健院、广东省云浮市中心医院、广东省肇庆市高要区人民医院和广东省惠州市中心医院）住院分娩孕妇的资料，比较剖宫产术后瘢痕子宫再次妊娠孕妇与非瘢痕子宫孕妇的分娩方式、产时出血、新生儿结局等情况，探讨剖宫产术后再次妊娠阴道试产的可行性和安全性。结果（1）阴道试产情况：2011年1月—2015年12月间广东省5家地市级医院的分娩总数95600例，其中剖宫产术后再次妊娠孕妇13824例，包括行选择性再次剖宫产术12027例、阴道试产1797例，阴道试产率为13.00%（1797/13824）。阴道试产的1797例孕妇中，试产成功经阴道分娩1308例，试产成功率为72.79%（1308/1797）。近5年（2011—2015年）来，剖宫产术后再次妊娠孕妇的比例逐年增高，分别为10.71%、13.28%、14.45%、15.54%、16.98%；其中阴道试产孕妇的比例也逐年增高，分别为11.85%、12.25%、13.49%、13.82%、12.93%。（2）阴道试产失败中转行剖宫产术的手术指征：剖宫产术后再次妊娠孕妇阴道试产失败中转行剖宫产术489例（27.21%，489/1797），其中因社会因素要求行剖宫产术68例（13.91%，68/489），与非瘢痕子宫孕妇（7.18%，206/2869）相比，差异有统计学意义（χ2=27.356， P=0.000）；产程中医师诊断为子宫破裂（包括先兆子宫破裂、子宫不全破裂或子宫破裂）者58例（11.86%，58/489），与非瘢痕子宫孕妇（1.43%，41/2869）相比，差异也有统计学意义（χ2=1578.223，P=0.000）。（3）试产成功阴道分娩孕妇的产程经过及母儿结局：剖宫产术后再次妊娠试产成功阴道分娩孕妇，其子宫破裂的发生率明显高于非瘢痕子宫孕妇[分别为0.74%（9/1211）、0.01%（2/31200）；χ2>2000，P=0.000]；产后出血的发生率也明显高于非瘢痕子宫孕妇[分别为6.94%（84/1211）、3.05%（951/31200）；χ2=16.328，P=0.000]；而试产成功阴道分娩孕妇的产程时限以及新生儿重度窒息的发生率、新生儿出生体质量分别与非瘢痕子宫孕妇比较，差异均无统计学意义（P>0.05）。结论近5年来，剖宫产术后再次妊娠孕妇及阴道试产孕妇的比例均逐年增高，但试产成功阴道分娩率总体较低。剖宫产术后再次妊娠阴道试产是安全可行的，但风险也比较高，加强产程监护及分娩室内可进行紧急剖宫产术是安全阴道试产的重要保障。

Objective To study the feasibility and safety of trial of labor after cesarean section (TOLAC). Methods Retrospective analysis of five medical center of Guangdong province from January 2011 to December 2015 hospitalized delivery information, compare the same scar TOLAC (research group) with the scar pregnancy (control group) pregnancy outcomes, to study the feasibility and safety of TOLAC. Results (1)During 2011-2015, total delivery 95 600 cases in five medical center, 13 824 cases of thme with uterine scar pregnancy, including 12 027 cases elective repeat cesarean section and 1 797 cases (13.00%, 1 797/13 824) with scar uterus vaginal trial of labor. Among 1 308 cases of vaginal delivery,the success for trial of labor rate was 72.79% (1 308/1 797). From 2011 to 2015, there were increased rate of pregnancy after cesarean section, which were respectively 10.71%, 13.28%, 14.45%, 15.54%and 16.98%. The will of vaginal birth were rising and the rate were respectively 11.85%, 12.25%, 13.49%, 13.82%and 12.93%. (2) There were 489(27.21%,489/1 797) cases of scar uterus maternal emergency cesarean section in the trial of labor, reason for“social factors”require for cesarean delivery have 68 cases, the percentage was 13.91% (68/489), compared with control group (7.18%, 206/2 869), the difference was statistically significant difference (χ2=27.356,P=0.000). Doctors diagnosed as“aura uterine rupture”in the labor was 11.86% (58/489), compared with that in control group (1.43%, 41/2 869), the differences were statistically significant difference (χ2=1 578.223,P=0.000). (3) The incidence of uterine rupture of the research group(0.74%,9/1 211)was significantly higher than that of control group (0.01%,2/31 200;χ2>2 000,P=0.000). The incidence of postpartum hemorrhage in research group was 6.94% (84/1 211), compared with that in the control group (3.05%, 951/31 200), there was statistically significant difference (χ2=16.328,P=0.000). While, there were no statistical significancefor the labor time limit,birth rate of severe asphyxia and neonatal birth weight average differences between two groups (P>0.05). Conclusions The rate of pregnancy after cesarean section is increasing year by year, and the will of vaginal birth is increasing, while it still are generally low. TOLAC is safe and feasible, but also significantly higher risk, strictly labor monitoring and can proceed fast cesarean delivery in delivery room is an important guarantee of safe delivery.