Amother’s intuition: successful trial of labor after Cesarean when women make an informed decision

重复剖宫产可以为母亲带来高风险,但对于有剖宫产史的妇女的劳动也可以。A新研究,,,,published inBMC怀孕和分娩在劳动力中选择低风险的妇女,并为她们提供了有关重复剖宫产和劳动的风险和利益的信息,发现超过一半的妇女选择了劳动试验,并且绝大多数这样做的人中的绝大多数人成功地避免了重复的剖宫产,几乎没有并发症。在这篇博客文章中,本研究的作者总结了实践的发现和建议。

近年来,剖宫产(CS)rate has been increasingwith the main reason being a woman’s prior CS history. Trial of labor after Cesarean (TOLAC), with the aim of achieving vaginal birth rather than repeat CS, is considered a safe and reasonable option. However, theTOLAC的速度正在降低,尤其是在日本,以及有资格使用TOLAC的大多数妇女选择选修课的重复剖宫产(ERCD),而无需收到有关TOLAC优点的详细信息。不提供TOLAC为这些妇女强调的遗产医生,即托拉克是“危险”的选择,即使risk of uterine ruptureis around 0.5% and ERCD has also a variety of complications, in contrast to successful TOLAC.

我们一直认为,患者的决定,而不是医生的决定是提高托拉克成功率的最重要的决定。因此,我们在收到TOLAC和ERCD的风险和利益的详细说明后,根据妇女的决定进行了一项前瞻性研究。Our new paperBMC怀孕和分娩显示出令人鼓舞的结果。

我们的标准

我们的TOLAC标准基于较早的研究。关于TOLAC的文件包括子宫破裂的风险,发生在约0.5%的妇女中,远高于ERCD,并具有胎儿和/或母亲死亡的风险。另一方面,ERCD的出血,感染,血栓形成和随后怀孕的并发症的风险更高。我们研究中的妇女可以在咨询这些风险后选择交付模式。

表1.本研究中TOLAC的标准

1) only one previous Cesarean delivery
2) former Cesarean delivery was a low transverse Cesarean
3) no obstetric contraindications for vaginal delivery
3) singleton pregnancy
4) vertex presentation
5)没有肌瘤的病史
6)通常,没有劳动的医学归纳
7)通知Tolac的风险

我们筛选了1,086名孕妇的资格,735个符合上述标准。其中,有64.1%的人选择了TOLAC。较早的研究还表明了相同的速度,这意味着,如果妇女获得足够的教育和支持,她们倾向于选择TOLAC作为理想的交付方式。产科医生应该理解这一事实,并且不应仅强调罕见并发症的风险。

高成功率

我们的研究有一个成功TOLAC(阴道birth) of 91.3%, similar to the vaginal birth rate of women who have no history of Cesarean, with the rate of uterine rupture being 0.6%. There were no infant deaths or long-term sequelae among all 471 TOLAC attempts. Apgar scores of <7 at 5 minutes, which is a marker of fetal asphyxia, did not significantly differ between the two groups. Women with history of vaginal birth in addition to a prior CS had a high chance of successful TOLAC (96.4%), and when labor spontaneously occurred before 40 weeks of gestation, the success rate was favorable (97.6%).

我们已经表明,TOLAC可以被认为是合理的出生手段。

We have tried to reveal the reasons for this high success rate and showed that in the successful TOLAC group, 70.5% of women had a previous CS without labor due to non-recurrent indications, including breech presentation, placenta previa, severe preeclampsia, or suspected cephalopelvic disproportion. On the other hand, over 40% of women who chose repeat ERCD had a previous CS that followed unsuccessful labor due to indications such as labor arrest disorders or non-reassuring fetal status (p<0.01). We believe these differences may have positively impacted the TOLAC success rate, partly because unsuitable candidates may have self-excluded from the TOLAC group.

与托拉克失败有关的因素

This study revealed that factors related to failed TOLAC included ≥40 weeks of gestation and prelabor rupture of membranes (PROM). After 40 weeks of gestation, success rates decreased (from 97.6% to 76.9%). Half of failed TOLAC cases experienced PROM. Until now, there have been limited studies into the impact of PROM on TOLAC. Obstetricians should be encouraged to have ongoing discussions with women about their mode of delivery after the due date or PROM, as these may be indications to change from planned TOLAC to ERCD. Ongoing discussions throughout pregnancy are important for preventing complications.

结论和建议

We have shown that TOLAC can be considered a reasonable means of birth not only for mothers but also for neonates, with over 60% of eligible women choosing TOLAC and over 90% of those achieving successful TOLAC. History of vaginal birth in addition to CS increased odds of successful TOLAC, while PROM or ≥40 weeks of gestation were risk factors for failed TOLAC. Obstetricians have to discuss the planned mode of birth throughout pregnancy in order to prevent complications.

Based on our results we would recommend that mothers who have elected ERCD choose a date of CS later than 39 weeks of gestation as some studies suggest a负面呼吸结局增加的风险在39周之前的选修课中。如果可以在计划的ERCD日期之前发生自发的劳动,则可以鼓励这些妇女尝试TOLAC而不是紧急CS,因为当工党在妊娠40周之前自发发生时,TOLAC的成功率是有利的。

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