Department of Obstetrics, Gynecology & Reproductive Sciences, Yale School of Medicine, New Haven, CT.
Stamford Hospital, Stamford, CT.
Am J Obstet Gynecol MFM. 2019 May;1(2):165-172. doi: 10.1016/j.ajogmf.2019.05.002. Epub 2019 May 10.
Evaluating trends in indications may identify targets to safely reduce the primary cesarean delivery rate.
The purpose of this study was to examine physician-documented indications for cesarean delivery to identify specific factors that contribute to a decreasing cesarean delivery rate.
We analyzed rates of primary and repeat cesarean deliveries, which included indications for the procedure, among 22,265 live births at an academic tertiary center from 2009-2013. Time trends for each indication were modeled to estimate the absolute and cumulative annualized relative risk of cesarean delivery by indication over time and the relative contribution of each indication to the overall decrease in primary cesarean delivery rate.
From 2009-2013, the cesarean delivery rate decreased from 36.5-31.4%; 74% of the decrease was attributable to a decrease in primary cesarean deliveries, which decreased from 21.7-17.6%. Among documented indications for primary cesarean delivery, labor arrest, abnormal or indeterminate fetal heart rate, and preeclampsia decreased significantly over time (P<.001), whereas malpresentation, multiple gestation, maternal-fetal, macrosomia, and other obstetric and elective/maternal requests did not change (P>.05). Labor arrest was responsible for the largest proportion of the decrease in the primary cesarean delivery rate (44%), followed by abnormal or indeterminate fetal heart rate (23%) and preeclampsia (13%).
Primary cesarean births accounted for 74% of the decreasing cesarean delivery rate. Reductions in the diagnosis of labor arrest and abnormal fetal heart rate led to a decreased cesarean delivery rate at a major academic institution. Contemporaneous changes in definitions of labor arrest and approaches to fetal monitoring that were adopted at our institution may have considerable effect on the cesarean delivery rate.
评估指征的变化趋势可能会发现安全降低初次剖宫产率的目标。
本研究旨在检查医生记录的剖宫产指征，以确定导致剖宫产率下降的具体因素。
我们分析了 2009 年至 2013 年在一家学术性三级中心的 22265 例活产的初次和再次剖宫产率，包括手术指征。对每种指征的时间趋势进行建模，以估计每种指征随时间推移的剖宫产绝对和累积年化相对风险，以及每种指征对总体初次剖宫产率下降的相对贡献。
2009 年至 2013 年，剖宫产率从 36.5%降至 31.4%；74%的下降归因于初次剖宫产的减少，从 21.7%降至 17.6%。在初次剖宫产的记录指征中，产程停滞、异常或不确定的胎心监护和子痫前期的发生率随着时间的推移显著下降（P<.001），而胎位不正、多胎妊娠、母婴、巨大儿和其他产科及择期/母亲要求的发生率没有变化（P>.05）。产程停滞是导致初次剖宫产率下降的最大因素（44%），其次是异常或不确定的胎心监护（23%）和子痫前期（13%）。
初次剖宫产占剖宫产率下降的 74%。诊断产程停滞和胎心监护异常的减少导致了一家主要学术机构剖宫产率的下降。我们机构采用的产程停滞和胎儿监测定义的同期变化可能对剖宫产率产生重大影响。
