3%的婴儿出生在臀位,仍然是交付它们的首选方式仍然存在争议。这项系统评价的目的是根据婴儿足月处于臀位时的预期分娩方式评估母亲和孩子的安全性。
人群(P)是孕妇,有一个臀位小孩,从孕周34+0。干预措施(I)是剖宫产分娩的意向,比较(C)为阴道分娩意向.结果(O)是围产期死亡率,围产期发病率,孕产妇死亡率,孕产妇发病率,交付方式的转换,和母亲的经验。进行了系统的文献检索。我们纳入了随机试验,在1990年至2021年10月期间,以英语或北欧语言撰写的超过500名女性/组的队列研究和超过15,000名女性的病例系列。使用GRADE方法评估证据的确定性,并将数据汇总在荟萃分析中。PROSPERO注册号:CRD42020209546。
纳入了32篇文章(530604名女性)。证据的确定性是中等或低,因为研究设计大多是回顾性队列研究。唯一的随机试验显示计划剖宫产降低了围产期死亡率的风险,风险比(RR)0.27(95%置信区间[CI]0.08-0.97,2078名女性,证据确定性低),排除死产。队列研究的荟萃分析得出了类似的估计,RR0.36(95%CI0.25-0.51,21项研究,388714名妇女,证据的确定性低)。我们还发现,在一项随机对照试验中,代表围产期发病率0-28天的结局风险降低:5分钟Apgar评分小于7:RR0.27(95%CI0.12-0.58,2033名妇女,证据的适度确定性),在荟萃分析中:RR0.1(95%CI0.14-0.26,18项研究,217024名女性,证据的中等确定性);5分钟时APGAR评分小于4分:RR0.39(95%CI0.19-0.81,五项研究,44498名女性,证据确定性低);pH值小于7.0:RR0.23(95%CI0.12-0.43,四项研究,13440名妇女,证据的确定性低)。除了计划剖宫产组的尿失禁风险降低外,各组母亲的结局相似:RR0.62(95%CI0.41-0.93,一项研究,1940年妇女,证据的确定性低)。从计划阴道分娩到紧急剖宫产的转换率为16%至51%(中位数为41.8%,10研究,50763名妇女,证据的适度确定性)。
与预期的阴道分娩相比,预期的剖宫产可以降低围产期死亡率和围产期以及一些产妇发病率的风险。不确定产妇死亡率是否有任何差异。从预期的阴道分娩到紧急剖宫产的转化率很高。
Three per cent of all infants are born in breech presentation, still the preferred way to deliver them remains controversial. The objective of this systematic
review was to assess the safety for the mother and child depending on intended mode of delivery when the baby is in breech position at term.
The population (P) was pregnant women with a child in breech presentation, from gestational week 34+0 . The intervention (I) was the intention to deliver by cesarean section, the comparison (C) was the intention to deliver vaginally. Outcomes (O) were perinatal mortality, perinatal morbidity, maternal mortality, maternal morbidity, conversion of delivery mode, and the mother\'s experience. Systematic literature searches were performed. We included randomized trials, cohort studies with more than 500 women/group and case series for more than 15 000 women published between 1990 and October 2021, written in English or the Nordic languages. The certainty of evidence was assessed using the GRADE approach and data were pooled in meta-analyses. PROSPERO registration number: CRD42020209546.
Thirty-two articles were included (with 530 604 women). The certainty of evidence was moderate or low because the study designs were mostly retrospective cohort studies. The only randomized trial showed reduced risk of perinatal mortality for planned cesarean section, risk ratio (RR) 0.27 (95% confidence interval [CI] 0.08-0.97, 2078 women, low certainty of evidence), stillbirths excluded. A meta-analysis of cohort studies resulted in a similar estimate, RR 0.36 (95% CI 0.25-0.51, 21 studies, 388 714 women, low certainty of evidence). We also found reduced risk for outcomes representing perinatal morbidity 0-28 days: 5-min Apgar score less than 7 in one randomized controlled trial: RR 0.27 (95% CI 0.12-0.58, 2033 women, moderate certainty of evidence), and in a meta-analysis: RR 0.1 (95% CI 0.14-0.26, 18 studies, 217 024 women, moderate certainty of evidence); APGAR score less than 4 at 5 min: RR 0.39 (95% CI 0.19-0.81, five studies, 44 498 women, low certainty of evidence); and pH less than 7.0: RR 0.23 (95% CI 0.12-0.43, four studies, 13 440 women, low certainty of evidence). Outcomes for the mother were similar in the groups except for reduced risk for experience of urinary incontinence in the group of planned cesarean section: RR 0.62 (95% CI 0.41-0.93, one study, 1940 women, low certainty of evidence). The conversion rate from planned vaginal delivery to emergency cesarean section ranged from 16% to 51% (median 41.8%, 10 studies, 50 763 women, moderate certainty of evidence).
Intended cesarean section may reduce the risk of perinatal mortality and perinatal as well as some maternal morbidity compared with intended vaginal delivery. It is uncertain whether there is any difference in maternal mortality. The conversion rate from intended vaginal delivery to emergency cesarean section is high.