Biswas Arijit
Department of Obstetrics and Gynaecology, National University Hospital, National University of Singapore, Singapore.
Curr Opin Obstet Gynecol. 2003 Apr;15(2):123-9. doi: 10.1097/00001703-200304000-00007.
The management of cesarean sections causes much controversy among healthcare providers, patients, and insurers. A trial of vaginal birth after previous cesarean is reported to be a safe and practical method to reduce the rate of cesarean sections. The popularity of vaginal birth after previous cesarean has increased over the past two decades, but rates have recently started to decline again. This review will evaluate recent literature that might be responsible for this reversal in trend.
Earlier studies on previous cesarean section pregnancies focused primarily on the success rate of vaginal birth after previous cesarean, which is reported to be 60-80%. Recent large, retrospective, population-based cohort studies examined the maternal and neonatal safety of trial of labour compared with elective repeat cesarean delivery, and confirmed that the risks of uterine rupture and neonatal mortality were significantly increased after trial of labour, particularly when induced with prostaglandins. However, the absolute risk of adverse events remains small. The maternal and neonatal morbidity risk increases when vaginal birth after previous cesarean attempts fails, which emphasizes the importance of careful case selection.
Recent studies highlighted the risks of attempted vaginal birth after previous cesareans, especially when trials fail, but have not addressed the long-term risks of an elective repeat cesarean delivery. The assessment of treatment risks by observational studies is subject to bias, because the different treatment groups may not be comparable at the outset. In the absence of better data, the counselling of such women must currently be based on this evidence.
剖宫产的管理在医疗服务提供者、患者和保险公司之间引发了诸多争议。据报道，既往剖宫产史后试产是一种安全且实用的降低剖宫产率的方法。在过去二十年里，既往剖宫产史后阴道分娩的受欢迎程度有所上升，但最近这一比例又开始下降。本综述将评估可能导致这一趋势逆转的近期文献。
早期关于既往剖宫产史妊娠的研究主要关注既往剖宫产史后阴道分娩的成功率，据报道成功率为60%-80%。近期大型、基于人群的回顾性队列研究比较了试产与择期再次剖宫产对产妇和新生儿安全性的影响，证实试产后子宫破裂和新生儿死亡风险显著增加，尤其是使用前列腺素引产时。然而，不良事件的绝对风险仍然较小。既往剖宫产史后试产失败时，产妇和新生儿发病风险会增加，这凸显了谨慎选择病例的重要性。
近期研究强调了既往剖宫产史后试产的风险，尤其是试产失败时，但尚未涉及择期再次剖宫产的长期风险。观察性研究对治疗风险的评估存在偏差，因为不同治疗组在开始时可能不具有可比性。在缺乏更好数据的情况下，目前对此类女性的咨询必须基于这一证据。
