Bailit Jennifer L, Grobman William A, Rice Madeline Murguia, Wapner Ronald J, Reddy Uma M, Varner Michael W, Thorp John M, Caritis Steve N, Iams Jay D, Saade George, Rouse Dwight J, Tolosa Jorge E
Department of Obstetrics and Gynecology, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH.
Department of Obstetrics and Gynecology, Prentice Women's Hospital, Northwestern University, Chicago, IL.
Am J Obstet Gynecol. 2016 May;214(5):638.e1-638.e10. doi: 10.1016/j.ajog.2015.11.007. Epub 2015 Nov 18.
Cesarean delivery in the second stage of labor is common, whereas the frequency of operative vaginal delivery has been declining. However, data comparing outcomes for attempted operative vaginal delivery vs cesarean in the second stage are scant. Previous studies that examine operative vaginal delivery have compared it to a baseline risk of complications from a spontaneous vaginal delivery and cesarean delivery. However, when a woman has a need for intervention in the second stage, spontaneous vaginal delivery is not an option she or the provider can choose. Thus, the appropriate clinical comparison is cesarean vs operative vaginal delivery.
Our objective was to compare outcomes by the first attempted operative delivery (vacuum, forceps vs cesarean delivery) in patients needing second-stage assistance at a fetal station of +2 or below.
We conducted secondary analysis of an observational obstetric cohort in 25 academically affiliated US hospitals over a 3-year period. A subset of ≥37 weeks, nonanomalous, vertex, singletons, with no prior vaginal delivery who reached a station of +2 or below and underwent an attempt at an operative delivery were included. Indications included for operative delivery were: failure to descend, nonreassuring fetal status, labor dystocia, or maternal exhaustion. The primary outcomes included a composite neonatal outcome (death, fracture, length of stay ≥3 days beyond mother's, low Apgar, subgaleal hemorrhage, ventilator support, hypoxic encephalopathy, brachial plexus injury, facial nerve palsy) and individual maternal outcomes (postpartum hemorrhage, third- and fourth-degree tears [severe lacerations], and postpartum infection). Outcomes were examined by the 3 attempted modes of delivery. Odds ratios (OR) were calculated for primary outcomes adjusting for confounders. Final mode of delivery was quantified.
In all, 2531 women met inclusion criteria. No difference in the neonatal composite outcome was observed between groups. Vacuum attempt was associated with the lowest frequency of maternal complications (postpartum infection 0.2% vs 0.9% forceps vs 5.3% cesarean, postpartum hemorrhage 1.4% vs 2.8% forceps vs 3.8% cesarean), except for severe lacerations (19.1% vs 33.8% forceps vs 0% cesarean). When confounders were taken into account, both forceps (OR, 0.16; 95% confidence interval, 0.05-0.49) and vacuum (OR, 0.04; 95% confidence interval, 0.01-0.17) were associated with a significantly lower odds of postpartum infection. The neonatal composite and postpartum hemorrhage were not significantly different between modes of attempted delivery. Cesarean occurred in 6.4% and 4.4% of attempted vacuum and forceps groups (P = .04).
In patients needing second-stage delivery assistance with a station of +2 or below, attempted operative vaginal delivery was associated with a lower frequency of postpartum infection, but higher frequency of severe lacerations.
第二产程剖宫产很常见，而手术阴道分娩的频率一直在下降。然而，比较第二产程中尝试手术阴道分娩与剖宫产结局的数据很少。以往研究手术阴道分娩时，是将其与自然阴道分娩和剖宫产的并发症基线风险进行比较。然而，当一名女性在第二产程需要干预时，自然阴道分娩并非她或医护人员能选择的方式。因此，合适的临床比较是剖宫产与手术阴道分娩。
我们的目的是比较在胎头位置为+2或更低时需要第二产程辅助的患者首次尝试的手术分娩（真空吸引、产钳与剖宫产）的结局。
我们对美国25家学术附属医院3年期间的一个产科观察队列进行了二次分析。纳入孕周≥37周、无畸形、头先露、单胎、既往未阴道分娩且胎头位置达到+2或更低并尝试进行手术分娩的患者。手术分娩的指征包括：胎头下降停滞、胎儿状况不佳、产程延长或产妇衰竭。主要结局包括综合新生儿结局（死亡、骨折、住院时间比母亲长≥3天、阿氏评分低、帽状腱膜下出血、呼吸机支持、缺氧性脑病、臂丛神经损伤、面神经麻痹）和个体产妇结局（产后出血、三度和四度撕裂伤[严重裂伤]以及产后感染）。通过3种尝试的分娩方式检查结局。计算调整混杂因素后的主要结局的比值比（OR）。对最终分娩方式进行量化。
共有2531名女性符合纳入标准。各组间未观察到新生儿综合结局有差异。尝试真空吸引与产妇并发症发生率最低相关（产后感染0.2%，产钳为0.9%，剖宫产为5.3%；产后出血1.4%，产钳为2.8%，剖宫产为3.8%），但严重裂伤除外（19.1%，产钳为33.8%，剖宫产为0%）。考虑混杂因素后，产钳（OR，0.16；95%置信区间，0.05 - 0.49）和真空吸引（OR，0.04；95%置信区间，0.01 - 0.17）均与产后感染的显著较低比值相关。尝试的分娩方式之间新生儿综合结局和产后出血无显著差异。剖宫产在尝试真空吸引组和产钳组中的发生率分别为6.4%和4.4%（P = 0.04）。
在胎头位置为+2或更低需要第二产程分娩辅助时，尝试手术阴道分娩与较低的产后感染发生率相关，但严重裂伤发生率较高。
