Bingham P, Lilford R J
Obstet Gynecol. 1987 Jun;69(6):965-78.
In this study, the concepts of decision theory have been applied to a clinical obstetric controversy--the management of the selected mature breech presentation. We have reviewed in detail the literature published since 1974 and estimated the probabilities of various outcomes after different treatment strategies. We conclude that a policy of selected vaginal delivery will result in four perinatal deaths for every 1000 patients delivered. A similar probability of neurologic handicap, at least until discharge from hospital, can also be attributed to this method of delivery. These unfavorable outcomes were reported less frequently in more recent reports covering the years since 1974. In these cases, the probability of fetal death due to a trial of vaginal delivery is approximately two in 1000. Cesarean section rates have risen, however, and 18-40% of trials of labor for breech presentation now result in "emergency" cesarean section. Decision analysis has demonstrated that a policy of elective cesarean section for all cases would not necessarily increase maternal mortality and morbidity. Thus the greater dangers of emergency compared with nonelective surgery may abolish the advantages of attempting a vaginal delivery. Depending on the relative dangers of elective and emergency cesarean section, planned delivery becomes the safer option when 16-30% of trials of vaginal breech delivery are unsuccessful. The strength and limitations of this probabilistic approach to the breech presentation are discussed in detail.
在本研究中，决策理论的概念已应用于临床产科的一个争议问题——选定的足月臀位分娩的处理。我们详细回顾了自1974年以来发表的文献，并估计了不同治疗策略后各种结果的概率。我们得出结论，选定的阴道分娩策略将导致每1000例分娩中有4例围产期死亡。至少在出院前，这种分娩方式也会导致类似概率的神经功能障碍。在涵盖1974年以来各年份的近期报告中，这些不良结果的报告频率较低。在这些情况下，因试产阴道分娩导致胎儿死亡的概率约为千分之二。然而，剖宫产率有所上升，目前臀位分娩试产中有18% - 40%会导致“急诊”剖宫产。决策分析表明，对所有病例采用选择性剖宫产策略不一定会增加孕产妇的死亡率和发病率。因此，与非选择性手术相比，急诊手术的更大风险可能会抵消试产阴道分娩的优势。根据选择性剖宫产和急诊剖宫产的相对风险，当16% - 30%的臀位阴道分娩试产失败时，计划性分娩成为更安全的选择。本文详细讨论了这种针对臀位分娩的概率性方法的优势和局限性。
