背景:剖宫产是产妇发病率的主要来源,重复剖宫产占剖宫产的40%,但是最近关于剖宫产后分娩和剖宫产后阴道分娩的试验数据有限。
目的:本研究旨在报告全国剖宫产后分娩率和剖宫产后阴道分娩率,并研究人口统计学和临床特征对这些率的影响。
方法:这是一项基于人群的队列研究,使用美国出生数据文件。研究样本仅限于4,135,247个非异常单例,妊娠37至42周的头端分娩,既往有剖宫产史,2010年至2019年在医院分娩。分娩率按既往剖宫产次数(1、2或≥3次)分组。每年计算剖宫产后分娩(先前剖宫产分娩中的分娩)和剖宫产后阴道分娩(剖宫产后分娩中的阴道分娩)率的试验。根据以前的阴道分娩史进一步分组。交货年份,先前剖宫产的数量,既往剖宫产史,年龄,种族和民族,母亲教育,肥胖,糖尿病,高血压,产前护理不足,医疗补助付款人,采用多因素logistic回归分析,对剖宫产后分娩和剖宫产后阴道分娩的试验进行胎龄检查。SAS软件(版本9.4)用于所有分析。
结果:剖宫产后产程试验从2010年的14.4%增加到2019年的19.6%(P<.001)。在先前剖宫产分娩的所有类别中都可以看到这种趋势。此外,剖宫产后阴道分娩率从2010年的68.5%上升至2019年的74.3%.剖宫产后分娩和剖宫产后阴道分娩的试产率最高,有1次剖宫产和阴道分娩史的分娩率最高(28.9%和79.7%,分别)和具有≥3次剖宫产史和无阴道分娩史的最低(4.5%和46.9%,分别)。与剖宫产后分娩和剖宫产后阴道分娩试验相关的因素相似,但是几个因素有不同的影响方向,例如非白人种族和种族,这与剖宫产后试产的可能性较高有关,但剖宫产后阴道分娩成功的可能性较低。
结论:80%以上有既往剖宫产史的患者通过重复计划剖宫产分娩。随着剖宫产后阴道分娩率的增加,在剖宫产后尝试分娩的人中,重点应放在安全增加剖宫产后分娩的试验上。
BACKGROUND: Cesarean delivery is a major source of maternal morbidity, and repeat cesarean delivery accounts for 40% of cesarean delivery, but recent data on the trial of labor after cesarean and vaginal birth after cesarean are limited.
OBJECTIVE: This study aimed to report the national rates of trial of labor after cesarean and vaginal birth after cesarean by number of previous cesarean deliveries and examine the effect of demographic and clinical characteristics on these rates.
METHODS: This was a population-based cohort study using the US natality data files. The study sample was restricted to 4,135,247 nonanomalous singleton, cephalic deliveries between 37 and 42 weeks of gestation, with a history of previous cesarean delivery and delivered in a hospital between 2010 and 2019. Deliveries were grouped by number of previous cesarean deliveries (1, 2, or ≥3). The trial of labor after cesarean (deliveries with labor among deliveries with previous cesarean delivery) and vaginal birth after cesarean (vaginal deliveries among trial of labor after cesarean) rates were computed for each year. The rates were further subgrouped by history of previous vaginal delivery. Year of delivery, number of previous cesarean deliveries, history of previous cesarean delivery, age, race and ethnicity, maternal education, obesity, diabetes mellitus, hypertension, inadequate prenatal care, Medicaid payer, and gestational age were examined concerning the trial of labor after cesarean and vaginal birth after cesarean using multiple logistic regression. SAS software (version 9.4) was used for all analyses.
RESULTS: The trial of labor after cesarean rates increased from 14.4% in 2010 to 19.6% in 2019 (P<.001). This trend was seen in all categories of number of previous cesarean deliveries. Moreover, vaginal birth after cesarean rates increased from 68.5% in 2010 to 74.3% in 2019. The trial of labor after cesarean and vaginal birth after cesarean rates were the highest for deliveries with a history of both 1 previous cesarean delivery and a vaginal delivery (28.9% and 79.7%, respectively) and the lowest for those with a history of ≥3 previous cesarean deliveries and no history of vaginal delivery (4.5% and 46.9%, respectively). Factors associated with the trial of labor after cesarean and vaginal birth after cesarean rates are similar, but several factors have different directions of effect, such as non-White race and ethnicity, which is associated with a higher likelihood of trial of labor after cesarean but a lower likelihood of successful vaginal birth after cesarean.
CONCLUSIONS: More than 80% of patients with a history of previous cesarean delivery deliver by repeat scheduled cesarean delivery. With vaginal birth after cesarean rates increasing among those who attempt a trial of labor after cesarean, emphasis should be put on safely increasing the trial of labor after cesarean rates.