目的 探讨孕产妇首次剖宫术后再次妊娠经阴道试产(trial of labor after previous cesarean delivery,TOLAC)引起子宫破裂的重要因素及预防。方法 选取2015-10至2017-10剖宫产术后再次妊娠,在孕30周首次筛查符合阴道试产条件的,无试产绝对禁忌证者共412例,分析样本的分娩方式及导致子宫破裂重要因素。结果 经过回顾性分析得出,共有215例进行了TOLAC,试产阴道分娩(vaginal birth after cesarean,VBAC)成功率为72.56%(156/215),剖宫产率为27.44%(59/215),完全子宫破裂发生率仅为0.47%(1/215)。根据试产结局将样本分为两组,阴道分娩组及再次剖宫产组,其中阴道分娩组的产后出血量明显低于再次剖宫产组(P<0.01);对13例发生子宫破裂的孕产妇样本数据进行比对,探究共同特征,得出胎心及宫缩异常等指标是共性因素。结论 TOLAC绝对危险性很小,产妇年龄、巨大儿及瘢痕厚度等均不是绝对禁忌证,但在做最后决策时,必须考虑本文推断出的共性因素,即胎心和宫缩情况,以提高TOLAC的成功率,降低子宫破裂发生率。
Objective To investigate the main causes and ways of prevention of uterine rupture caused by re-pregnancy after cesarean section.Methods A total of 412 cases of patients without absolute contraindications were selected for the first screening of pregnancy after cesarean section between October 2015 and October 2017.Results After a retrospective analysis of the samples, it was found that 215 cases implemented TOLAC (trial of labor after previous cesarean delivery).The rate of successful vaginal trial production was 72.56 %(156/215)in the 215 pregnancies,the rate of cesarean section was 27.44%(59/215),and the incidence of complete uterine rupture was only 0.47 % (1/215 ). According to the outcomes of trial of labor, these patients were divided into two groups: the second-time cesarean group and the vaginal delivery group. The bleeding volume in the second-time cesarean group was significantly larger than that of the vaginal delivery group,so there was statistically significant difference (P<0.01).After we compared these results with the sample data of 13 pregnant women with uterine rupture, we found that the common characteristics included such indexes as abnormalities of the fetal heart and uterine contraction.Conclusions The risk of TOLAC is very small.The age of pregnant women, macrosomia and scar thickness are not absolute contraindications, but in clinical practice, it is necessary to take into account the fetal heart and uterine contraction so as to improve the success rate of TOLAC and reduce the occurrence of uterine rupture.
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