A Retrospective Study Of Scar Uterus Vaginal Delivery Success Factors And Outcomes

In the 1980’s, China cesarean delivery rate lower than 5%. Cesarean delivery rate was gradually rising since the mid 80’s in China. The latest statistics literature is pointed out that China cesarean section rate has reached 54% in 2014. With the rising rate of cesarean delivery, it brought a lot of scar uterus to secondary pregnancy complications: pelvic adhesion, scar pregnancy, placenta previa, dangerous placenta previa (placenta implantation), incomplete uterine rupture and so on. With the further understanding of cesarean section, people saw recent and future complications of cesarean section, recognized vaginal trial delivery again, to return natural childbirth, in order to reduce the rate of cesarean delivery. In the past, some previous studies showed that uterine rupture rate is much higher occurred in scar uterus vaginal deliver, cesarean delivery is the only choose for uterine scar pregnancy again. But with related researches for the re-pregnant woman after cesarean birth, people became to know vaginal delivery can be chose by pregnant women previously received cesarean section. Because of the changing of the national family planning policy, the family which only has one child can be allow to have another one, the fertility rate will increase again, the number of uterine scar pregnant women will be riser and riser. For the high tension in China medical relations, the cesarean delivery rate staying at a high level, the women pregnant again after cesarean section how to choose the delivery method, how to reduce the risks of surgery again become the obstetric clinical face common problems.With the progress of medicine, the deepening of the research, the United Sates took the lead to said that the pregnant women after cesarean section by under strict conditions controlled, can choose the vaginal trial production. The American VBAC (Vaginal Birth After Cesarean) success rate is 6.6% in 1985 to 28.3% in 1996. In 2010, ACOG (the American College of Obstetricians and Gynecologists) made the pregnancy again after vaginal delivery cesarean section guideline. But some literatures showed VBAC failure increased incidence of adverse outcome of uterine rupture、asphyxia neonatorum, vaginal trial production failure in surgical injury、postpartum hemorrhage increased、an increased risk even hysterectomy. Due to the doctor-patient relationship tense in China, pregnant women are unwilling to bear the scar uterus vaginal trial production in the risk of uterine rupture, fetal distress and postpartum hemorrhage; the increasing medical disputes, the obstetrician should tell the maternal on admission to the details about the advantages and disadvantages of vaginal trial production, Scar uterus pregnant women inadequate understanding of vaginal trial production, lack of confidence, many pregnant women concerns complications then refused to vaginal trial production. At present our country still has no expert consensus or guide line about TOLAC (trial of labor after cesarean section), it still did not have scar uterus vaginal delivery prognosis for large sample survey statistics, there is no applicable risk assessment or prediction formula in our country for TOLAC, a pregnancy pregnant women still choose cesarean section again after cesarean section as the main mode of delivery, becoming an important factor in the increasing cesarean delivery rate. This study is retrospectively analyzed to our country about maternal and neonatal outcomes of TOLAC, further discuss the safety and complication of VBAC, provide the basis for scar uterus pregnant women for choosing childbirth way, provides guidance for clinical obstetrician to reduce the corresponding complications Caused by the blind vaginal trial production or cesarean section, and to improve the success rate of vaginal birth after cesarean.Chapter 1 The Retrospective Analysis Of Scar Uterus Vaginal Delivery Success Factors And ComplicationsPart 1 Scar Uterus Vaginal Delivery Success Factors Retrospective Analyzed[Objectives] Collected 1637 cases of TOLAC for retrospectively study, explore the uterine scar pregnancy again choose vaginal delivery success factors, to provide the basis for scar uterus pregnant women for choosing childbirth way, provide guidance for clinical obstetrician.[Methods]1 DateCollection:Selection on January in 2009 to December in 2013 from the Nan fang hospital、Guangzhou Medical school third affiliated hospital、Shenzhen baoan district maternity and child care hospital、No.3 Dongguan people’s hospital、No.8 Dongguan people’s hospital scar uterus vaginal delivery 1637 cases of pregnant women, including VBAC group 1039 cases, the average birth gestational age is 38.56±2.31 week. Selection cesarean section after VBAC failure 598 cases as control group, the average birth gestational age is 38.55±1.36 week. Subject inclusion criteria:The time distance from previous pregnancy cesarean delivery operation time has reached two years or more, only a history of cesarean section; Cesarean section incision using lower uterine transverse incision, without puerperal infection; uterine scar healing well by B ultrasonic examination, without uterine rupture before; spontaneous labor; singleton and cephalic presentation; without internal medicine and surgery complications.2 ContentComparison between VBAC group and cesarean section after VBAC failure group associated factors, to find out VBAC success factors.3 Statistical analysisUse statistical software SPSS 19.0 for statistics analysis and drawing, use one-way analysis of variance for VBAC, applied Binary Logistic regression analysis screening to predict VBAC significant influencing factors.[Results]1 One-way analysis of variance in VBAC, compare with VBAC group and cesarean section after VBAC failure group:the two groups of age、prenatal BMI、 delivery gestational age、the last time of cesarean section、a history of vaginal delivery、admission when preview of labor, cervical dilatation was statistically significant (P< 0.05). But previous cesarean section indications、scar thickness、 previous birth weight of newborn babies、the neonatal birth weight has no statistical significance (P>0.05)2 VBAC success factors by Binary Logistic analysis:uterine scar pregnancy again pregnant women age、prenatal BMI、a history of vaginal delivery、gestational age、 the last time of cesarean section、admission when preview of labo、cervical dilatation has statistical significance (P< 0.05). Pregnant women age (OR= 1.039,95% CL: 1.051-1.137), prenatal BMI (OR=1.093,95% CL:1.051-1.137), a history of vaginal delivery (OR=2.322,95% CL:1.607-3.355), gestational age (OR=0.420, 95% CL:0.255-0.692), the last time of cesarean section (OR=1.,060,95% CL: 1.003-1.121), admission when preview of labor (OR=1.453,95% CL:1.007-2.097), cervical dilatation (OR=0.714,95% CL:0.629-0.810)[Conclusion]1. The pregnant women, year< 35, prenatal BMI< 30, delivery before 40 weeks, the last time of cesarean section in 2-10 years, has a history of vaginal delivery, admission when preview of labor, the cervix expansion>6cm is conducive to successful for VBAC.2. Scar thickness、previous cesarean section indications、previous birth weight of newborn babies、the neonatal birth weight has no influence for VBAC success.3. A history of vaginal delivery is the most important factor for VBAC.Part 2 Scar Uterus Vaginal Delivery Complications Retrospective Analyzed[Objectives] Collected 1637 cases of TOLAC for retrospectively study, explore the mother and fetal outcomes of the uterine scar pregnant women, such as:postpartum hemorrhage, uterine rupture, asphyxia neonatorum, to find out risk factors of complications.[Methods]1 Date:details as Part 1 list.2 ContentComparison between VBAC group and cesarean section after VBAC failure group on the incidence rate of postpartum hemorrhage, uterine rupture, asphyxia neonatorum, to find out risk factors of complications.3 Statistical analysisUse statistical software SPSS 19.0 for statistics analysis and drawing, count data to describe the percentage (%), the comparison of two samples rate use Person X2 test or Fisher’s exact test, P< 0.05 indicated significant difference. Use one-way analysis of variance for screening VBAC risk factors of complications.[Results]1. In the last five years in Nan fang hospital、uangzhou Medical School third affiliated hospital、Shenzhen baoan district maternity and child care hospitalsNo.3 Dongguan people’s hospital、No.8 Dongguan people’s hospital TOLAC pregnant women occurred postpartum hemorrhage is totally 72 people, including 25 in VBAC group, the rate is 2.41%,47 in cesarean section after VBAC failure group, the rate is 7.86%. Uterine rupture occurred is 14 people in all, including 3 in VBAC group, the rate is 0.29%,11 in cesarean section after VBAC failure group, the rat is 1.84%. asphyxia neonatorum is 28 people, including 23 in VBAC group, the rate is 2.21%,5 in cesarean section after VBAC failure group, the rate is 0.84%, P values are less than 0.05, the difference was statistically significant.2. One-way analysis of variance in postpartum hemorrhage:compare with postpartum hemorrhage group and the without postpartum hemorrhage group:The neonatal birth weight>3.5Kg have statistical significance (P< 0.05). The two groups of age, prenatal BMI, delivery gestational age% scar thickness、the last time of cesarean section、previous cesarean section indicatio、n a history of vaginal delivery、whether emergency admission、cervical dilatation、previous birth weight of newborn babies、 the first labor time、the second labor time、the third labor time and the total labor time has no statistical significance (P> 0.05).3. One-way analysis of variance in uterine rupture:compare with uterine rupture group and with no uterine rupture group:whether emergency admission have statistical significance (P< 0.05). The two groups of age、prenatal BMI、delivery gestational age、scar thickness、the last time of cesarean section、previous cesarean section indication、a history of vaginal delivery、cervical dilatation、previous birth weight of newborn babies、the neonatal birth weight has no statistical significance (P>0.05).4. One-way analysis of variance in asphyxia neonatorum:compare with asphyxia neonatorum group and the without asphyxia neonatorum group:the pregnant women age、prenatal BMI>30、the neonatal birth weight>3.5 have statistical significance (P < 0.05). The two groups of delivery gestational age、the last time of cesarean section、 a history of vaginal delivery、emergency admission、cervical dilatation、the first labor time、the second labor time has no statistical significance (P>0.05).[Conclusion]1 the incidence of postpartum hemorrhage, uterine rupture in VBAC is lower than emergency cesarean section after VBAC failure group, but the incidence of neonatal asphyxia is higher than the VBAC failure group.2 The neonatal birth weight>3.5Kg is a risk factor of postpartum hemorrhage in TOLAC.3 This study could not find out characteristic high-risk factors to uterine rupture, newborn asphyxia of TOLAC, emergency admission is a risk fator of uterine rupture, women who pregnant over 35 years, prenatal BMI>30, the neonatal birth weight> 3.5 Kg are more prone to neonatal asphyxia.Chapter 2 The Analysis Of Scar Uterus Vaginal Delivery Rate Tendency And Vaginal Delivery Failure Reasons in Nanfang Hospital[Objectives] Analysis Nanfang hospital, southern medical university in recent five years scar uterus vaginal delivery success rate, mother and fetus outcomes, in order to understand the scar uterus vaginal delivery success rate change tendency, analyzes the reasons of emergency cesarean section after VBAC failure, for clinical doctors provide reference and scar uterus pregnant women choose childbirth way, for decreasing the rate of uterine cesarean section.[Methods]1 DateCollection:Selection on 2009 to 2013 in the Nanfang hospital TOLAC women 435 cases, among them 317 cases of VBAC, the average gestational weeks 37.47±2.94weeks; selected cesarean section after VBAC failure 118 cases as control group, the average birth gestational age 38.74±1.83 weeks, subject inclusion criteria: The time distance from previous pregnancy cesarean delivery operation time has reached two years or more, only a history of cesarean section; Cesarean section incision using lower uterine transverse incision, without puerperal infection; uterine scar healing well by B ultrasonic examination, without uterine rupture before; spontaneous labor; singleton and cephalic presentation; without internal medicine and surgery complications.2 ContentRetrospectively analyzed Nanfang hospital, during the period of five years, from January 2009 to December 2013,435 cases of cesarean section again pregnancy pregnant woman VBAC success rates and outcomes, statistics each year of VBAC success rates, the incidence of postpartum hemorrhage、uterine rupture、neonatal asphyxia complications, to show scar uterus vaginal delivery success rate and complication rates tendency. Analyzed of 118 cases of control group failure reasons.3 Statistical analysisUse statistical software SPSS 19.0 for statistics analysis and drawing, measurement data description using (mean ±standard deviation), applied the T test, count data to describe the percentage (%), the comparison of two samples rate use Person X2 test or Fisher’s exact test, the change tendency used Spearman rank correlation test, P< 0.05 indicated significant difference.[Results]1 In the past five years from 2009 to 2013 the number of TOLAC was increased year by year. In 2009, only 38 cases, but it rose to 126 cases in 2013. The success rate of vaginal delivery in 2009 was 57.89%, it rose to 80.16% in 2013. The scarred uterus pregnant women who with a history of vaginal delivery VBAC success rate is 84.62% in 2009, it rose to 93.75% in 2013. The rate of admission when preview of labor is 42.11% in 2009 to 67.48% in2013. VBAC delivery success rate with a history of vaginal deliver admission when preview of labor were positively correlated relationship, P< 0.01, the difference was statistically significant.2 In the past five years from January in 2009 to December in 2013 of the Nanfang hospital, Average annual rate of postpartum hemorrhage is 6.22%, uterine rupture rate is 1.03%, neonatal asphyxia is 5.84%. Each yesr concerns complications, uterine rupture rate, uterine rupture had no statistically significant, P>0.05. From 2009 to 2013 year, uterine rupture total for 5 people, VBAC group for 1 case,4 cases of cesarean section after VBAC failure. All for incomplete rupture of uterus. Uterine rupture of the neonatal 1 min Apgar score 5-7 points (mild asphyxia),5 min Apgar score for 9-10 points.3 Analysis the failure reason for the Nanfang hospital cesarean section after VBAC failure group in the last five years, abnormal uterine action(24.78%), Abnormal fetal position in labor (5.31%), fetal distress (34.51%), threatened uterine rupture (12.39%), CDMR factors has steadfastly refused to continue to vaginal trial production accounted for 23.01%. CDMR factors turn to cesarean section is nine in 2009 to two in 2013. CDMR rate dropped year by year.[Conclusion]1 The Nanfang hospital VBAC success rate is a rising tendency year by year in the past five years, the cesarean delivery rate deceasing for only " scar uterus " reason.2 It showed that it is not suitable for TOLAC for early hospital admission. Admission when preview of labor contribute to reduced pregnant women nervous, psychological interference factors on the labor, improving the success rate of VBAC.3 The number of TOLAC increased, the rates of postpartum hemorrhage、uterine rupture、neonatal asphyxia without significant change.4 The causes of TOLAC failure:fetal distress for the firth, followed by abnormal labor, social factors, the aura of uterine rupture, the stages of abnormal fetal position. CDMR factors transfer cesarean delivery rate gradually decline.