Durnwald Celeste, Mercer Brian
Department of Obstetrics and Gynecology, MetroHealth Medical Center, Case Western Reserve University School of Medicine, 2500 MetroHealth Drive, Cleveland, OH 44109-1989, USA.
J Matern Fetal Neonatal Med. 2004 Jun;15(6):388-93. doi: 10.1080/14767050410001724290.
To identify predictors of successful trial of labor in women after one low transverse Cesarean delivery and no prior deliveries, and to assess perinatal morbidity associated with a failed vaginal birth after Cesarean delivery (VBAC).
Retrospective chart review of women with one low transverse Cesarean delivery in their first pregnancy who delivered their next pregnancy at our institution. Clinical characteristics and intrapartum data were reviewed to identify predictors of successful VBAC. Perinatal outcomes were reviewed to assess morbidity associated with VBAC attempt and failed VBAC.
Of 768 women studied, 522 (68%) attempted VBAC and 344 (66%) of these were successful. Uterine rupture occurred in 0.8% of the VBAC group. On initial examination, women with cervical dilation >1 cm, effacement > 50% and station lower than -1 were more likely to deliver vaginally. Women with successful VBAC had more spontaneous labor (85.2 vs. 76.4%, p=0.02) and less oxytocin use (49.7 vs. 70.8%, p < 0.0001). There were no differences in outcomes between failed and successful VBAC, except more frequent 1-min Apgar scores < 5 (10.1 vs. 4.1%, p=0.01) and increased endometritis (9.6 vs. 2%, p=0.0002) with failed VBAC. Compared with elective repeat Cesarean delivery, VBAC attempt was associated with amnionitis (5.9 vs. 0%, p < 0.0001) and low 1- and 5-min Apgar scores (6.1 vs. 2.4%, p=0.03 and 2.3 vs. 0%, p=0.01, respectively), but not endometritis, admission to a neonatal intensive care unit (NICU), ventilation, intraventricular hemorrhage (IVH) or seizures. Failed VBAC had more amnionitis (7.3 vs. 0%, p < 0.0001), postpartum fever (11.2 vs. 2.4%, p=0.0003) and endometritis (9.6 vs. 2.0, p=0.0007) than elective repeat Cesarean delivery and was associated with low 1- and 5-min Apgar scores (10.1 vs 2.4%, p < 0.001 and 2.8 vs. 0%, p=0.01, respectively), but not NICU admission, ventilation, IVH or seizures.
Favorable initial pelvic examination, spontaneous labor and a lack of oxytocin use are associated with successful VBAC in women with a single prior low transverse Cesarean delivery and no prior vaginal deliveries. While attempted VBAC and failed VBAC have more maternal infectious morbidity and lower Apgar scores, infant outcomes are similar to those of elective repeat Cesarean delivery.
确定首次行低位横切口剖宫产且无既往分娩史的女性经阴道分娩成功的预测因素，并评估剖宫产术后阴道分娩失败（VBAC失败）相关的围产期发病率。
对在我院首次妊娠行低位横切口剖宫产且下次妊娠在我院分娩的女性进行回顾性病历审查。回顾临床特征和产时数据以确定经阴道分娩成功的预测因素。回顾围产期结局以评估VBAC尝试和VBAC失败相关的发病率。
在研究的768名女性中，522名（68%）尝试VBAC，其中344名（66%）成功。VBAC组子宫破裂发生率为0.8%。初次检查时，宫颈扩张>1cm、宫颈消退>50%且胎头位置低于-1的女性更有可能经阴道分娩。经阴道分娩成功的女性自发宫缩更多（85.2%对76.4%，p=0.02）且缩宫素使用更少（49.7%对70.8%，p<0.0001）。VBAC失败和成功的结局之间没有差异，只是VBAC失败时1分钟Apgar评分<5更常见（10.1%对4.1%，p=0.01），且子宫内膜炎增加（9.6%对2%，p=0.0002）。与择期再次剖宫产相比，VBAC尝试与绒毛膜羊膜炎（5.9%对0%，p<0.0001）及1分钟和5分钟Apgar评分低相关（分别为6.1%对2.4%，p=0.03和2.3%对0%，p=0.01），但与子宫内膜炎、入住新生儿重症监护病房（NICU）、机械通气、脑室内出血（IVH）或惊厥无关。VBAC失败比择期再次剖宫产有更多的绒毛膜羊膜炎（7.3%对0%，p<0.0001）、产后发热（11.2%对2.4%，p=0.0003）和子宫内膜炎（9.6%对2.0%，p=0.0007），并与1分钟和5分钟Apgar评分低相关（分别为10.1%对2.4%，p<0.001和2.8%对0%，p=0.01），但与入住NICU、机械通气、IVH或惊厥无关。
良好的初次骨盆检查、自发宫缩和未使用缩宫素与首次行低位横切口剖宫产且无既往阴道分娩史的女性VBAC成功相关。虽然尝试VBAC和VBAC失败有更多的母体感染性发病率和更低的Apgar评分，但婴儿结局与择期再次剖宫产相似。
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