Grisaru-Granovsky Sorina, Bas-Lando Maayan, Drukker Lior, Haouzi Fred, Farkash Rivka, Samueloff Arnon, Ioscovich Alexander
Department of Obstetrics and Gynecology, Shaare Zedek Medical Center, affiliated with the Hebrew University Hadassah School of Medicine, Jerusalem, Israel.
Department of Obstetric Anesthesia, Shaare Zedek Medical Center, affiliated with the Hebrew University Hadassah School of Medicine, Jerusalem, Israel.
J Perinat Med. 2018 Apr 25;46(3):261-269. doi: 10.1515/jpm-2016-0382.
Epidural analgesia has been considered a risk factor for labor dystocia at trial of labor after cesarean (TOLAC) and uterine rupture. We evaluated the association between exposure to epidural during TOLAC and mode of delivery and maternal-neonatal outcomes.
A single center retrospective study of women that consented to TOLAC within a strict protocol between 2006 and 2013. Epidural "users" were compared to "non-users". Primary outcome was the mode of delivery: repeat in-labor cesarean or vaginal birth after cesarean (VBAC). Secondary outcomes were maternal/neonatal morbidities. Univariate/multivariate analyses for associations between epidural and mode of delivery were adjusted for significant covariates/mediators.
Of a total of 105,471 births registered, 9464 (9.0%) were eligible for TOLAC; 7149 (75.5%) women consented to TOLAC, among which 4081 (57.1%) had epidural analgesia. The in labor cesarean rate was significantly lower for the epidural "users" 8.7% vs. "non-users" 11.8%, P<0.0001, with a parallel increased rate of instrumental delivery. Uterine rupture rates were comparable: 0.4% and 0.29%, respectively (P=0.31). The adjusted multivariate model showed that epidural "users" were more likely to experience a VBAC, odds ratio (OR) 4.58 [3.67; 5.70]; P<0.0001 with a similar rate of adverse maternal-neonatal outcomes.
Epidural analgesia at TOLAC may emerge as a safe and significant adjunct for VBAC.
硬膜外镇痛被认为是剖宫产术后阴道试产（TOLAC）时发生产程延长和子宫破裂的一个危险因素。我们评估了TOLAC期间使用硬膜外镇痛与分娩方式及母婴结局之间的关联。
对2006年至2013年间按照严格方案同意进行TOLAC的女性进行单中心回顾性研究。将硬膜外“使用者”与“非使用者”进行比较。主要结局是分娩方式：再次剖宫产或剖宫产术后阴道分娩（VBAC）。次要结局是母婴发病率。对硬膜外镇痛与分娩方式之间的关联进行单因素/多因素分析，并对显著的协变量/中介因素进行校正。
在总共登记的105471例分娩中，9464例（9.0%）符合TOLAC条件；7149例（75.5%）女性同意进行TOLAC，其中4081例（57.1%）使用了硬膜外镇痛。硬膜外“使用者”的产时剖宫产率显著较低，分别为8.7%和“非使用者”的11.8%，P<0.0001，器械助产率相应增加。子宫破裂率相当：分别为0.4%和0.29%（P=0.31）。校正后的多因素模型显示，硬膜外“使用者”更有可能经历VBAC，优势比（OR）为4.58 [3.67；5.70]；P<0.0001，母婴不良结局发生率相似。
TOLAC时的硬膜外镇痛可能成为VBAC一种安全且重要的辅助手段。
