Lembrouck C, Mottet N, Bourtembourg A, Ramanah R, Riethmuller D
Pôle mère-femme, CHRU de Besançon, 3, boulevard Fleming, 25000 Besançon, France.
Pôle mère-femme, CHRU de Besançon, 3, boulevard Fleming, 25000 Besançon, France.
J Gynecol Obstet Biol Reprod (Paris). 2016 Jun;45(6):641-51. doi: 10.1016/j.jgyn.2015.08.002. Epub 2015 Oct 1.
To determine which clinical practice changes were responsible for a decrease in cesarean rate from 19.2% in 2003 to 15.5% in 2012 at our university hospital treating high risk pregnancies, while verifying the absence of any increase in neonatal morbidity and death.
A descriptive retrospective study was undertaken at our labour ward including all patients delivering in 2003 and in 2012. Maternal, obstetrical and neonatal characteristics of the two populations were compared. Cesarean rates were analysed following : (1) Robson classification, (2) some maternal and obstetrical characteristics, and (3) indications for cesarean.
Mean age, BMI and rate of scarred uterus significantly increased in 2012. The two populations remained comparable in terms of other criteria studied. The main cause responsible for decrease in cesarean rate was breech presentations (p<0.05). Furthermore, significantly less cesareans were performed after labour induction (p=0.04). We also significantly decreased our elective cesarean rate by more than 3% without increasing cesarean sections during labour, showing a rise in successful vaginal delivery trials. The impact of in utero transfers on the global rate of cesarean is highly significant since the latter has been divided by half in 10 years in this population considered to be of high risk for cesareans.
These significant decreases reflect our experience in allowing vaginal deliveries in breech presentations, and also a better selection of patients for labour induction. Furthermore, it should be noted that increasing vaginal delivery trials in various obstetrical situations participated in this decrease. We clearly found that some indications for elective cesarean can be avoided, such as multiple pregnancies and scarred uterus, thus showing the importance of restricting the first indication for cesarean. Finally, the decrease in cesarean rate had no negative effect on neonatal outcome.
Decreasing cesarean rate is possible in a university hospital treating high risk pregnancies. It requires daily obstetrical case by case critical analysis, allowing wide acceptance of vaginal delivery trials, and continuously evaluating clinical practices.
确定在我们这家治疗高危妊娠的大学医院中，哪些临床实践的改变导致剖宫产率从2003年的19.2%降至2012年的15.5%，同时核实新生儿发病率和死亡率有无增加。
在我们的产科病房进行了一项描述性回顾性研究，纳入了2003年和2012年分娩的所有患者。比较了这两组人群的孕产妇、产科和新生儿特征。按照以下方面分析剖宫产率：（1）罗布森分类法，（2）一些孕产妇和产科特征，（3）剖宫产指征。
2012年产妇的平均年龄、体重指数和瘢痕子宫发生率显著增加。在研究的其他标准方面，这两组人群仍具有可比性。剖宫产率下降的主要原因是臀位分娩（p<0.05）。此外，引产术后进行剖宫产的比例显著降低（p=0.04）。我们还将择期剖宫产率显著降低了3%以上，同时未增加产时剖宫产率，这表明成功的阴道分娩试产有所增加。宫内转运对总体剖宫产率的影响非常显著，因为在这个被认为剖宫产高危的人群中，剖宫产率在10年内减半。
这些显著下降反映了我们在允许臀位阴道分娩方面的经验，以及对引产患者的更好选择。此外，应该指出的是，在各种产科情况下增加阴道分娩试产也促成了这一下降。我们清楚地发现，一些择期剖宫产指征是可以避免的，如多胎妊娠和瘢痕子宫，因此显示了限制首次剖宫产指征的重要性。最后，剖宫产率的下降对新生儿结局没有负面影响。
在治疗高危妊娠的大学医院降低剖宫产率是可行的。这需要每天对产科病例进行逐例批判性分析，广泛接受阴道分娩试产，并持续评估临床实践。
