论文标题：Reasons for previous Cesarean deliveries impact a woman’s independent decision of delivery mode and the success of trial of labor after Cesarean

期刊：BMC Pregnancy and Childbirth

作者：Kaname Uno, Michinori Mayama et al.

发表时间：2020/03/24

DOI：10.1186/s12884-020-2833-2

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最近发表在开放获取期刊《BMC妊娠与生育》（BMC Pregnancy and Childbirth）上的一项研究表明，有剖腹产史但尝试自然分娩的方式，其成功率可能在90%以上。如果医生在不同的分娩方式上提供关于风险和收益的详细信息，有剖腹产史的准妈妈选择自然分娩而非再次剖腹产的几率会升高。

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研究的作者、日本丰田纪念医院宇野枢博士说：“目前全球的剖腹产率都在升高，有近一半的剖腹产决定是建立在是否有既往剖腹产史的基础上的。曾经剖腹产但仍尝试自然分娩的过程被简称做TOLAC（trial of labour after Cesarean），这个过程被认为是一个安全的选择，但大部分符合条件的女性依然会选择再次剖腹产。”

研究者分析了2005年4月至2017年8月间1086名孕妇的数据，这些孕妇都至少曾有过一次剖腹产经历。在这些孕妇中，有735人符合TOLAC的指征。医院向她们详细解释了TOLAC和再次剖腹产分别有什么风险和益处，希望每位准妈妈能将两种分娩方式都考虑在内，并要求她们在孕34周时做出决定。

宇野博士说：“过去经历过剖腹产再进行顺产的一个潜在风险就是子宫破裂，破裂可能会沿上次剖腹产留下的已愈合刀口发生。但是剖腹产本身也有出血、感染和其他并发症的风险。成功完成TOLAC可以减少出血与感染的风险，并提高未来孕产过程的成功率。”

在735名准妈妈中，471名（64.1%）选择了TOLAC，264名（35.9%）选择再次剖腹产。在选择TOLAC的471名女性中，430名（91.3%）成功完成了阴道自然分娩，41名（8.7%）被认为“TOLAC失败”，因为并发症无法进行自然分娩而通过再次剖腹产生产。在这些女性中，有3位（0.6%）发生了子宫破裂，但没有母亲或新生儿死亡。胎膜早破、提前宫缩以及妊娠超过40周都是TOLAC失败的重要危险因素。在该研究中，过去有过自然分娩史的女性中96.4%都成功完成了TOLAC。这些结果证实了过去一些研究的结论，即剖宫产后自然分娩是可以替代重复剖宫产的安全选择。

宇野博士说：“有剖腹产史并选择自然分娩可能会延长妊娠时间，降低儿童潜在健康并发症的发生风险。研究结果表明，应鼓励健康专业人士与准妈妈持续探讨两种分娩方式的风险与益处，让她们在充分知情下做出自己的选择。”

作者提醒，由于研究中各组的规模直接取决于准妈妈们的选择，研究结果可能会受到个人偏见、过往经验和地区差异的影响，因此可能无法推及广泛人群。另外由于只有三名女性发生了子宫破裂，需要进一步的调研来评估子宫破裂这种潜在并发症。

摘要：

Background

Cesarean delivery rates are increasing globally with almost half of them occurring due to a previous Cesarean delivery. A trial of labor after Cesarean (TOLAC) is considered a safe procedure, but most eligible women instead undergo Cesarean before 39 weeks of gestation. Lack of education about TOLAC is often associated with increased repeat Cesarean. To reveal the safety and feasibility of TOLAC, we conducted this observational, prospective study with women’s independent decisions. We aimed to clarify the relationship between their chosen mode of delivery and the reason for their previous Cesarean. Additionally, we have tried to identify maternal and obstetric factors associated with failed TOLAC to improve its success rate.

Methods

This was a prospective, observational study of 1086 pregnant women with at least one previous Cesarean delivery. Of these, 735 women met our TOLAC criteria (Table 1), and then, could choose TOLAC or repeat Cesarean after receiving detailed explanations regarding the risks and benefits of both procedures. The primary outcomes were the number of successful TOLAC procedures and 5-min Apgar scores < 7 for the trial of labor after Cesarean group and elective Cesarean group. We collected the maternal and neonatal data including the reasons of previous Cesarean.

Results

In total, 64.1% of women chose TOLAC. The success rate was 91.3%. The uterine rupture rate was 0.6%. There were no significant differences in the rate of Apgar scores at 5 min < 7 between both groups. Histories of experience of labor in previous Cesarean delivery were observed in 30 and 50% of women who chose TOLAC and repeat Cesarean, respectively (p < 0.05). Factors related to failed TOLAC included ≥40 weeks of gestation (odds: 5.47, 95% CI: 2.55–11.70) and prelabor rupture of membranes (PROM) (odds: 4.47, 95% CI: 2.07–9.63).

Conclusions

TOLAC is a favorable delivery option for both mothers and neonates when women meet criteria and choose after receiving detailed explanations. Women who experience PROM or ≥ 40 weeks of gestation, their modes of delivery should be reconsulted.

（来源：科学网）