Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA (Berghella).
Women & Infants Hospital of Rhode Island, Brown University, Providence, RI (Adewale and Rouse).
Am J Obstet Gynecol MFM. 2024 Nov;6(11):101501. doi: 10.1016/j.ajogmf.2024.101501. Epub 2024 Sep 21.
With approximately 145 million births occurring worldwide each year-over 30 million by cesarean delivery (CD), the need for evaluation of maternal and perinatal outcomes in different delivery scenarios is more pressing than ever. Recently, in a meta-analysis of the available randomized controlled trials, planned CD was associated with significantly decreased rates of low umbilical artery pH, and neonatal complications such as birth trauma, tube feeding, and hypotonia when compared to planned vaginal delivery (VD). Among singleton pregnancies, planned CD was associated with a significantly lower rate of perinatal death. For mothers, planned CD was associated with significantly less chorioamnionitis, more wound infection, and less urinary incontinence at 1 to 2 years. Conversely, planned VD has been associated with benefits such as a lower incidence of wound infection and quicker postpartum recovery compared to planned CD. Nonetheless, several risk factors for CD are increasing-such as older maternal age, obesity, diabetes, excessive gestational weight gain, and birth weight-while maternal pelvises are getting smaller. Concerns about the potential long-term risks of multiple cesarean deliveries, such as placenta accreta spectrum disorders, highlight the need for a balanced evaluation of both delivery modes. However, the total fertility rate is decreasing in the US and around the world, with many people wanting two or fewer babies, which decreases future risk of placenta accreta incurred by multiple cesarean deliveries in these individuals. Furthermore, one in four obstetricians-gynecologists has undergone a CD on maternal request for their nulliparous, singleton, term, vertex (NSTV) pregnancy, and CD rates less than about 19% have been associated with higher perinatal and maternal mortality. Thus, we propose that it is imperative that we prioritize conducting randomized trials to compare planned cesarean to planned VD for NSTV pregnancies. Such trials would need to include 8000 or more individuals; they would ideally follow each participant to the end of their reproductive life and study perinatal and maternal outcomes, including nonbiologic outcomes such as patient satisfaction, postpartum depression, breastfeeding rates, mother-infant bonding, post-traumatic stress, and cost-effectiveness. The time for such a trial is now, as it holds the potential to inform and improve obstetrical care practices globally. El resumen está disponible en Español al final del artículo.
每年全球大约有 1.45 亿婴儿出生，其中超过 3000 万是通过剖宫产分娩（CD），因此评估不同分娩情况下的母婴围生期结局比以往任何时候都更加紧迫。最近，在一项对现有随机对照试验的荟萃分析中，与计划性阴道分娩（VD）相比，计划性 CD 与脐动脉 pH 值降低以及新生儿并发症（如出生创伤、管饲喂养和低张力）的发生率显著降低相关。在单胎妊娠中，计划性 CD 与围产儿死亡率显著降低相关。对于母亲，计划性 CD 与绒毛膜羊膜炎发生率显著降低、伤口感染更多、1 至 2 年内尿失禁更少相关。相反，与计划性 CD 相比，计划性 VD 与较低的伤口感染发生率和更快的产后恢复相关。尽管如此，剖宫产的几个危险因素正在增加，例如母亲年龄较大、肥胖、糖尿病、过度妊娠体重增加和出生体重，而母亲的骨盆却越来越小。人们对多次剖宫产可能带来的长期风险（如胎盘植入谱系疾病）的担忧，凸显了对两种分娩方式进行平衡评估的必要性。然而，美国和世界各地的总生育率正在下降，许多人希望生育两个或更少的孩子，这降低了这些人因多次剖宫产而导致胎盘植入的风险。此外，四分之一的妇产科医生为他们的初产妇、单胎、足月、头位（NSTV）妊娠的母亲请求行剖宫产，且剖宫产率低于 19%与较高的围生期和孕产妇死亡率相关。因此，我们认为，当务之急是优先进行比较 NSTV 妊娠计划性 CD 与计划性 VD 的随机试验。此类试验需要纳入 8000 名以上的个体；最好能跟踪每位参与者直至其生殖生命结束，并研究围生期和母婴结局，包括非生物学结局，如患者满意度、产后抑郁、母乳喂养率、母婴联系、创伤后应激和成本效益。现在是进行此类试验的时候了，因为它有可能为全球的产科护理实践提供信息并加以改善。
