Department of Obstetrics and Gynecology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA (Drs Adewale and Varotsis).
Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA (Drs Iyer and Berghella).
Am J Obstet Gynecol MFM. 2023 Dec;5(12):101186. doi: 10.1016/j.ajogmf.2023.101186. Epub 2023 Oct 12.
There are over 145 million births worldwide, with over 30 million cesarean deliveries yearly. There are limited data comparing the perinatal and maternal outcomes between planned cesarean delivery and planned vaginal delivery. This study aimed to evaluate perinatal and maternal morbidity and mortality by meta-analysis of randomized controlled trials that randomly assigned patients to either planned cesarean delivery or planned vaginal delivery.
Scopus, PubMed, CINAHL, Cochrane Library, and the World Health Organization clinical trial databases were searched from inception through August 2022.
Randomized controlled trials that compared planned cesarean delivery with planned vaginal delivery at any gestational age and for any delivery indication were included.
Two authors independently extracted data. PRISMA guidelines were used for data extraction and quality assessment. The primary outcome was perinatal mortality. The summary measures were reported as relative risks or as mean differences with 95% confidence intervals. Pooled odds ratios and 95% confidence intervals were calculated using Mantel-Haenszel random-effects models for outcomes.
In 15 primary randomized controlled trials, 3265 patients were randomized to planned cesarean delivery and 3353 to planned vaginal delivery. The incidence of perinatal deaths was not different (1.3% vs 1.3%; relative risk, 0.71; 95% confidence interval, 0.33-1.52). Planned cesarean delivery was associated with lower neonatal incidences of low umbilical artery pH (0.3% vs 2.4%; relative risk, 0.18; 95% confidence interval, 0.05-0.67), birth trauma (0.3% vs 0.7%; relative risk, 0.46; 95% confidence interval, 0.22-0.96), tube feeding requirement (2.5% vs 7.1%; relative risk, 0.36; 95% confidence interval, 0.19-0.66), and hypotonia (0.4% vs 3.5%; relative risk, 0.11; 95% confidence interval, 0.03-0.47), compared to planned vaginal delivery. Chorioamnionitis was less frequent in the planned cesarean delivery group (0.3% vs 1.0%; relative risk, 0.27; 95% confidence interval, 0.08-0.98). Wound infection was more common in the planned cesarean delivery group (1.9% vs 1.1%; relative risk, 1.61; 95% confidence interval, 1.04-2.52). Lower rates were observed in the planned cesarean delivery group for urinary incontinence at both ≤3 months (8.7% vs 12.2%; relative risk, 0.71; 95% confidence interval, 0.59-0.85) and 1 to 2 years (16.9% vs 22%; relative risk, 0.77; 95% confidence interval, 0.67-0.88) and for a painful perineum at 2 years (4% vs 6.2%; relative risk, 0.64; 95% confidence interval, 0.47-0.87) compared to planned vaginal delivery. Among singleton pregnancies, planned cesarean delivery was associated with a lower rate of perinatal death (0.69% vs 1.81%; relative risk, 0.45; 95% confident interval, 0.21-0.93).
Planned cesarean delivery and planned vaginal delivery were associated with similar rates of perinatal and maternal mortality in this meta-analysis of randomized controlled trials. Planned cesarean delivery was associated with significant decreases in adverse neonatal outcomes such as low umbilical artery pH, birth trauma, tube feeding requirement, and hypotonia, and significant decreases in chorioamnionitis, urinary incontinence, and painful perineum. Planned vaginal delivery was associated with significant decreases in need for general anesthesia and wound infection. Further randomized trials are needed to assess the risks and benefits of planned cesarean delivery vs planned vaginal delivery in lower-risk patients and in the general population.
全球每年有超过 1.45 亿次分娩，其中有超过 3000 万次剖宫产。比较计划性剖宫产与计划性阴道分娩的围产儿和产妇结局的相关数据有限。本研究旨在通过对随机对照试验进行荟萃分析来评估围产儿和产妇发病率和死亡率，这些试验随机分配患者接受计划性剖宫产或计划性阴道分娩。
从成立到 2022 年 8 月，在 Scopus、PubMed、CINAHL、Cochrane 图书馆和世界卫生组织临床试验数据库中进行了检索。
纳入比较任何孕龄和任何分娩指征下计划性剖宫产与计划性阴道分娩的随机对照试验。
两名作者独立提取数据。使用 PRISMA 指南进行数据提取和质量评估。主要结局是围产儿死亡率。总结措施以相对风险或均值差及 95%置信区间报告。使用 Mantel-Haenszel 随机效应模型计算结局的汇总优势比和 95%置信区间。
在 15 项主要的随机对照试验中，3265 名患者被随机分配至计划性剖宫产组，3353 名患者被随机分配至计划性阴道分娩组。围产儿死亡的发生率没有差异（1.3%比 1.3%；相对风险，0.71；95%置信区间，0.33-1.52）。与计划性阴道分娩相比，计划性剖宫产与新生儿脐动脉 pH 值较低（0.3%比 2.4%；相对风险，0.18；95%置信区间，0.05-0.67）、分娩创伤（0.3%比 0.7%；相对风险，0.46；95%置信区间，0.22-0.96）、需要管饲喂养（2.5%比 7.1%；相对风险，0.36；95%置信区间，0.19-0.66）和低张力（0.4%比 3.5%；相对风险，0.11；95%置信区间，0.03-0.47）的发生率较低，且绒毛膜羊膜炎的发生率也较低（0.3%比 1.0%；相对风险，0.27；95%置信区间，0.08-0.98）。计划性剖宫产组的伤口感染更常见（1.9%比 1.1%；相对风险，1.61；95%置信区间，1.04-2.52）。在≤3 个月（8.7%比 12.2%；相对风险，0.71；95%置信区间，0.59-0.85）和 1-2 年（16.9%比 22%；相对风险，0.77；95%置信区间，0.67-0.88）时，计划性剖宫产组尿失禁的发生率较低，并且 2 年后会阴部疼痛的发生率也较低（4%比 6.2%；相对风险，0.64；95%置信区间，0.47-0.87）。与计划性阴道分娩相比，在单胎妊娠中，计划性剖宫产与较低的围产儿死亡率相关（0.69%比 1.81%；相对风险，0.45；95%置信区间，0.21-0.93）。
在这项随机对照试验的荟萃分析中，计划性剖宫产与计划性阴道分娩与相似的围产儿和产妇死亡率相关。与计划性阴道分娩相比，计划性剖宫产与新生儿脐动脉 pH 值较低、分娩创伤、管饲喂养需求和低张力等不良新生儿结局的发生率显著降低，与绒毛膜羊膜炎、尿失禁和会阴部疼痛的发生率显著降低有关。与计划性阴道分娩相比，计划性剖宫产需要全身麻醉和伤口感染的发生率显著降低。需要进一步的随机试验来评估在低风险患者和一般人群中计划性剖宫产与计划性阴道分娩的风险和益处。
