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中华妇幼临床医学杂志(电子版)

Chinese Journal of Obstetrics & Gynecology and Pediatrics(Electronic Edition) ›› 2020, Vol. 16 ›› Issue (03): 278 -287. doi: 10.3877/cma.j.issn.1673-5250.2020.03.005

Special Issue: ；

Original Article

Analysis of influencing factors and pregnancy outcomes of trial of labor after cesarean section

Zhenyu Chen1, Jingli Sun1,†(), Xiaoming Chen1, Wan Zhong1, Jiaxi Jin1   

  1. 1. Department of Obstetrics and Gynecology, Heping Branch of General Hospital of Northern War Zone, Shenyang 110003, Liaoning Province, China
  • Received:2019-11-12 Revised:2020-01-09 Published:2020-06-01
  • Corresponding author: Jingli Sun
  • About author:
    Corresponding author: Sun Jingli, Email:
  • Supported by:
    Natural Science Foundation of Liaoning Province(20180551133)
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Objective

To explore pregnancy outcomes of trial of labor after cesarean section (TOLAC) and influencing factors of vaginal birth after cesarean section (VBAC).

Methods

A total of 193 pregnant women with one prior cesarean section and TOLAC in Heping Branch of General Hospital of Northern War Zone from January 2015 to June 2019 were selected as research subjects. All subjects were divided into successful TOLAC group (n=122, by VBAC) and failed TOLAC group (n=71, by repeated cesarean section after failure of TOLAC) according to the final delivery mode. According to the time of accepting TOLAC, successful TOLAC group were further divided into pre-implementing subgroup (n=25, before implement of TOLAC from January 2015 to December 2016) and post-implementing subgroup (n=97, after implement of TOLAC from January 2017 to June 2019). The clinical data such as interval time between this delivery and last cesarean delivery, Bishop score of cervix at admission, spontaneous onset of labor, birth weight of neonate, etc. were reviewed retrospectively. Univariate analysis was conducted on influencing factors of VBAC by independent-samples t test, chi-square test and Mann-Whitney U test. Then, combined with the existing research results, clinical experiences and univariate analysis results, 9 possible influencing factors of VBAC were analyzed by multivariate unconditional logistic regression analysis. The pregnant outcomes between successful TOLAC group and failed TOLAC group, between pre-implementing subgroup and post-implementing subgroup were compared by independent-samples t test and chi-square test. The study was approved by the institutional research ethics committee of Heping Branch of General Hospital of Northern War Zone (Approval No. 202H2019PJ039). There were no significant differences on maternal age, constituent ratio of education levels, gravidity and parity between successful TOLAC group and failed TOLAC group (P>0.05).

Results

①From January 2015 to June 2019, the TOLAC rate in our hospital was 5.01% (193/3 851) and the VBAC rate was 63.21% (122/193). After initiatively implementing TOLAC from January 2017, the rate of VBAC increased from 47.17% (25/53, during January 2015 to December 2016) to 69.29% (97/140, during January 2017 to June 2019), and the difference was statistically significant (χ2=8.086, P=0.004). ②Gestational weight gain, body mass index (BMI) before delivery, gestational age at delivery, interval time between this delivery and last cesarean delivery, rate of macrosomia and birth weight of neonate in VBAC group all were lower or shorter than those in failed TOLAC group, while Bishop score of cervix at admission, rate of spontaneous labor, and rate of preterm delivery in VBAC group were higher than those in failed TOLAC group, and all the differences between two groups for the above indicators were statistically significant (P<0.05). ③Multivariate unconditional logistic regression analysis of 9 possible influencing factors of VBAC showed that Bishop score of cervix at admission >6 scores (OR=2.806, 95%CI: 1.290-6.105, P=0.009), spontaneous labor (OR=2.650, 95%CI: 1.137-6.175, P=0.024), and birth weight of neonate <3 750 g (OR=2.928, 95%CI: 1.193-7.185, P=0.019) were independent influencing factors of VBAC. While the others all were not independent influencing factors of VBAC. ④Postpartum hemorrhage (PPH) volume and rate of PPH in VBAC group were higher than those in failed TOLAC group, while hospital stays after delivery and hospitalization expenses in VBAC group were lower than those in failed TOLAC group, and all the differences were statistically significant (t=12.991, P<0.001; χ2=4.555, P=0.033; t=-11.487, P<0.001; t=-14.774, P<0.001). No maternal and newborn deaths occurred in the 193 cases of TOLAC. ⑤Among pregnant women in successful TOLAC group, gestational weight gain, BMI before delivery, gestational age at delivery, birth weight of the neonate, rates of using oxytocin during labor, analgesia and operative vaginal delivery, and duration of first stage labor, duration of total labor, and hospital stays after delivery in pre-implementing subgroup all were lower or less or shorter than those in post-implementing subgroup, while Bishop score of cervix at admission, rates of spontaneous labor, preterm and neonatal intensive care unit (NICU) admission were higher than those in post-implementing subgroup, and all the differences were statistically significant (P<0.05).

Conclusions

The safety of TOLAC and rate of VBAC can be improved by taking corresponding measures and standardized management. Favorable cervix, spontaneous onset of labor, birth weight of neonate <3 750 g are independent influencing factors of VBAC.

Key words: Vaginal birth after cesarean, Cesarean section, repeat, Trial of labor after cesarean section, Pregnancy outcome, Cervical ripening, Influencing factors, Puerpera
表1 本院2015年1月至2019年6月接受TOLAC及VBAC产妇情况与VBAC率等比较
年份(年) 分娩产妇总数 有剖宫产术分娩史产妇[例数(%)]b TOLAC[例数(%)]c VBAC[例数(%)]d VBAC率(%)e VBAC降低总剖宫产术分娩率(%)f
2015 4 832 577(11.94) 15(2.60) 6(1.04) 40.00 0.12
2016 8 585 934(10.88) 38(4.07) 19(2.03) 50.00 0.22
2017 7 399 990(13.38) 47(4.75) 28(2.83) 59.57 0.38
2018 6 922 871(12.58) 56(6.42) 39(4.48) 69.64 0.56
2019 a 3 950 479(12.13) 37(7.72) 30(6.26) 81.08 0.76
合计 31 688 3 851(12.15) 193(5.01) 122(3.17) 63.21 0.39
表2 TOLAC成功组与TOLAC失败组产妇一般临床资料比较
组别 例数 年龄(岁，±s) 学历[例数(%)] 孕次(次，±s) 产次(次，±s)
大专及以上 高中及以下
TOLAC成功组 122 32.7±4.1 85(69.7) 37(30.3) 2.7±0.8 1.05±0.22
TOLAC失败组 71 33.1±3.7 52(73.2) 19(26.8) 2.8±0.9 1.03±0.17
检验值 t＝－0.644 χ2＝0.277 t＝－1.488 t＝0.703
P值 0.520 0.598 0.138 0.483
表3 TOLAC成功组与TOLAC失败组VBAC影响因素的单因素分析
组别 例数 孕前BMI(kg/m2，±s) 孕期体重增加值(kg，±s) 分娩前BMI(kg/m2，±s) 阴道分娩史[例数(%)] 本次妊娠距前次剖宫产术分娩间隔时间[月，M(P25～P75)] 入院时宫颈评分[分，M(P25～P75)] 子宫前壁下段肌层厚度(cm，±s) 妊娠期高血压疾病[例数(%)]
TOLAC成功组 122 22.0±3.2 13.4±5.2 27.0±3.2 5(4.1) 56.5(36.0～84.0) 6.0(4.0～7.0) 0.21±0.06 7(5.7)
TOLAC失败组 71 22.6±3.2 15.6±5.8 28.4±3.0 2(2.8) 72.0(40.0～108.0) 3.0(2.0～4.0) 0.20±0.05 1(1.4)
检验值 t＝－1.250 t＝－2.785 t＝－2.910 χ2＝0.004 a Z＝－2.205 Z＝－7.101 t＝1.475 χ2＝1.168 a
P值 0.213 0.006 0.004 0.950 0.027 <0.001 0.142 0.280
组别 例数 妊娠期糖尿病[例数(%)] 胎膜早破[例数(%)] 自然临产[例数(%)] 分娩孕龄(周，±s) 早产[例数(%)] 巨大儿[例数(%)] 新生儿出生体重(g，±s)
TOLAC成功组 122 9(7.4) 33(27.0) 108(88.5) 38.5±1.8 16(13.1) 2(1.6) 3 219±463
TOLAC失败组 71 8(11.3) 20(28.2) 41(57.7) 39.2±1.4 3(4.2) 9(12.7) 3 480±462
检验值 χ2＝0.846 χ2＝0.028 χ2＝24.156 t＝－3.002 χ2＝3.996 χ2＝8.222 a t＝－3.770
P值 0.358 0.867 <0.001 0.003 <0.001 0.004 <0.001
表4 VBAC影响因素的多因素非条件logistic回归分析的变量含义及赋值情况
自变量/因变量 变量名 赋值情况
是否为VBAC y y＝0表示非VBAC，y＝1表示VBAC
早产 x1 x1＝0表示足月产，x1＝1表示早产
入院时宫颈评分 x2 x2＝0表示入院时宫颈评分≤6分，x2＝1表示入院时宫颈评分>6分
是否为自然临产 x3 x3＝0表示引产，x3＝1表示自然临产
新生儿出生体重 x4 x4＝0表示新生儿出生体重≥3 750 g，x4＝1表示新生儿出生体重<3 750 g
是否分娩巨大儿 x5 x5＝0表示非巨大儿，x5＝1表示巨大儿
分娩孕龄 x6 x6表示实际分娩孕龄
孕期体重增加值 x7 x7表示孕期体重增加值
分娩前BMI x8 x8表示分娩前BMI
本次妊娠距前次剖宫产术分娩间隔时间 x9 x9表示本次妊娠距前次剖宫产术分娩间隔时间
表5 VBAC影响因素的多因素非条件logistic回归分析
影响因素 B SE Wald值 P值 OR值 OR值95%CI
早产 0.760 0.945 0.647 0.421 2.138 0.336～13.624
入院时宫颈评分>6分 1.032 0.397 6.771 0.009 2.806 1.290～6.105
自然临产 0.974 0.432 5.096 0.024 2.650 1.137～6.175
新生儿出生体重<3 750 g 1.074 0.458 5.501 0.019 2.928 1.193～7.185
巨大儿 －2.218 1.102 3.695 0.055 0.120 0.014～1.042
分娩孕龄 －0.002 0.162 0.002 0.991 0.998 0.726～1.372
孕期体重增加值 －0.016 0.033 0.217 0.641 0.985 0.922～1.051
分娩前BMI －0.082 0.059 1.952 0.162 0.921 0.820～1.034
本次妊娠距前次剖宫产术分娩间隔时间 －0.564 0.354 2.538 0.111 1.758 0.878～3.519
表6 TOLAC成功组与TOLAC失败组母婴妊娠结局比较
组别 例数 新生儿窒息[例数(%)] 新生儿胎粪吸入综合征[例数(%)] 新生儿Apgar评分(分，±s) 新生儿转入NICU[例数(%)] 羊水性状[例数(%)]
清亮 粪染
TOLAC成功组 122 1(0.8) 1(0.8) 9.9±0.6 13(10.7) 102(83.6) 20(16.4)
TOLAC失败组 71 0(0) 0(0) 10.0±0.0 4(5.6) 60(84.5) 11(15.5)
检验值 — — t＝－1.301 χ2＝1.409 χ2＝0.027
P值 0.444 0.444 0.196 0.235 0.869
组别 例数 PPH量(mL，±s) PPH[例数(%)] 输血[例数(%)] 产褥期疾病[例数(%)] 产后住院时间(d，±s) 总住院费用(元，±s)
TOLAC成功组 122 429.0±101.7 17(13.9) 1(0.8) 0(0) 2.7±0.6 7 330±2 074
TOLAC失败组 71 280.3±94.9 3(4.2) 0(0) 1(1.4) 3.8±0.6 12 232±2 527
检验值 t＝12.991 χ2＝4.555 — — t＝－11.487 t＝－14.774
P值 <0.001 0.033 0.444 0.368 <0.001 <0.001
表7 TOLAC成功组中，开展前亚组与开展后亚组VBAC产妇临床资料比较
组别 例数 年龄(岁，±s) 学历[例数(%)] 孕次(次，±s) 产次(次，±s) 孕前BMI(kg/m2，±s) 孕期体重增加值(kg，±s) 分娩前BMI(kg/m2，±s)
大专及以上 高中及以下
开展前亚组 25 32.1±3.9 15(60.0) 10(40.0) 2.6±0.8 1.1±0.3 21.6±4.0 10.9±4.9 25.8±3.7
开展后亚组 97 32.9±4.1 70(72.2) 27(27.8) 2.7±0.8 1.0±0.2 22.1±3.0 14.0±5.1 27.4±3.0
检验值 t＝－0.860 χ2＝1.392 t＝－0.107 t＝0.795 t＝－0.622 t＝－2.765 t＝－2.178
P值 0.391 0.238 0.915 0.428 0.535 0.007 0.031
组别 例数 阴道分娩史[例数(%)] 本次妊娠距前次剖宫产术分娩间隔时间[月，M(P25～P75)] 入院时宫颈评分[分，M(P25～P75)] 胎膜早破[例数(%)] 妊娠期高血压疾病[例数(%)] 妊娠期糖尿病[例数(%)] 子宫前壁下段肌层厚度(cm，±s) 自然临产[例数(%)]
开展前亚组 25 2(8.0) 56.0(36.0～72.0) 7.0(5.5～10.0) 6(24.0) 1(4.0) 2(8.0) 0.23±0.06 25(100.0)
开展后亚组 97 3(3.1) 60.0(37.0～84.0) 6.0(4.0～7.0) 27(27.8) 6(6.2) 7(7.2) 0.22±0.06 83(85.6)
检验值 — Z＝－0.914 Z＝3.100 χ2＝0.148 — — 0.756 —
P值 0.271 0.361 0.002 0.700 0.999 0.999 0.452 0.043
表8 TOLAC成功组中，开展前亚组与开展后亚组VBAC产妇的母婴结局比较
组别 例数a 分娩孕龄(周，±s) 早产[例数(%)] 新生儿出生体重(g，±s) 羊水粪染[例数(%)] 新生儿Apgar评分(分，±s) 新生儿转入NICU[例数(%)] 产程中使用缩宫素[例数(%)]
开展前亚组 25 37.8±2.1 7(28.0) 3 036±538 1(4.0) 9.96±0.20 5(20.0) 0(0)
开展后亚组 97 38.6±1.7 9(9.3) 3 267±432 19(19.6) 9.93±0.62 8(8.2) 22(22.7)
检验值 t＝－2.112 χ2＝6.114 t＝－2.260 χ2＝3.524 t＝0.257 χ2＝4.855 —
P值 0.037 0.013 0.026 0.072 0.798 0.028 0.007
组别 例数a 分娩镇痛[例数(%)] 阴道助产[例数(%)] 会阴侧切[例数(%)] 产程时间(min，±s)
第一 第二 第三 总产程
开展前亚组 25 3(12.0) 0(0) 21(84.0) 279.6±117.3 48.0±41.3 8.6±3.4 336.2±127.9
开展后亚组 97 37(38.1) 14(14.4) 88(90.7) 376.9±164.3 57.3±46.7 8.3±3.7 442.5±176.5
检验值 χ2＝6.165 — χ2＝0.943 t＝－2.780 t＝－0.913 t＝0.422 t＝－2.823
P值 0.013 0.043 0.331 0.006 0.363 0.674 0.006
组别 例数a PPH量(mL，±s) PPH[例数(%)] 输血[例数(%)] 子宫破裂[例数(%)] 产后住院时间(d，±s)
开展前亚组 25 399.6±70.7 3(12.0) 0(0) 0(0) 2.4±0.5
开展后亚组 97 404.6±115.9 14(14.4) 1(1.0) 1(1.0) 2.8±0.7
检验值 t＝－0.207 χ2＝0.098 － － t＝－2.993
P值 0.836 0.754 0.999 0.999 0.003
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