指南速递 | SOGC临床实践指南 NO.382 剖宫产术后再次妊娠阴道试产（一）

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译者：汪文雁 陈琼 张茜 田迪雅 厦门大学附属成功医院（解放军陆军第七十三集团军医院）

审校：郑剑兰 厦门大学附属成功医院（解放军陆军第七十三集团军医院）

本修订的临床实践指南由作者编写，并通过了产科临床实践数据库和指南管理及监督委员会的审核，同时经加拿大妇产科医师协会（SOGC）理事会批准。

本临床实践指南取代发表于2005年2月的原版本(NO.155)。

关键词

剖宫产术后再次妊娠阴道分娩；阴道试产；子宫破裂；引产；缩宫素；前列腺素；米索前列醇。

实践中的变化

1、对于没有禁忌证且剖宫产术后再次妊娠阴道分娩(VBAC)可能性大的孕产妇，建议剖宫产术后再次妊娠阴道试产（TOLAC）。

2、分娩间隔小于18个月的孕产妇，TOLAC会增加子宫破裂的风险。

3、为了减少母婴的发病率和死亡率，一旦怀疑子宫破裂需立即剖腹手术，所以，紧急剖宫产的最短时间是不够的。

关键点

1、建议对无临产和阴道分娩禁忌证、有阴道分娩史和/或自然临产的孕产妇进行剖宫产术后再次妊娠阴道试产（TOLAC）。

2、选择性重复剖宫产（ERCS）的孕产妇死亡率的相对风险较高，TOLAC子宫破裂的相对风险较高，但这两种结局的绝对风险均较低；

3、TOLAC发生子宫破裂概率是0.47%；

4、必须告知计划TOLAC的孕产妇，其围产儿死亡的相对风险比ERCS高，但绝对风险较低。

5、在计划TOLAC时，持续胎心监护和可立即剖腹手术是必不可少的。

本文显示了在发布之日出现的临床和科学的进展，可能会发生变化。这些内容不应被解释为强行规定的应遵循的治疗过程或程序，地方机构可以要求修改这些意见，如果进行修改，则应做好记录，未经出版者的事先书面许可，不得以任何形式复制上述内容。

所有人都有权利和责任与医疗保健工作者合作，就其护理作出明智的决定。为了促进知情选择，应向孕产妇提供基于证据的、文化上适合其需要的信息和支持。

本指南是用将孕产妇安排在护理中心的情况下编写的。也就是说，SOGC致力于尊重所有人的权利，包括变性人、非二元性别者和双性人，都可以适用本指南。我们鼓励医疗保健工作者与孕产妇进行有礼貌的对话，将其性别认同作为提供安全和适当护理的关键部分。应了解每位孕产妇及其家属的价值观、信仰和个人需要，并尊重孕产妇选择的护理和治疗方案的最后决定。

摘要

目的：为剖宫产术后再次妊娠阴道试产提供循证指导。

结果：母胎的发病率和死亡率与剖宫产术后再次妊娠阴道分娩和重复剖宫产相关。

证据：使用关键词“剖宫产术后再次妊娠阴道分娩”搜索MEDLINE数据库中1995年1月1日至2017年10月31日发表的文章，使用加拿大定期健康检查工作组报告中概述的证据标准来评估描述得出的证据质量。

结果：这些指南由加拿大临床实践产科委员会和妇产科学会理事会批准。

建议

1、在没有禁忌证的情况下，经适当讨论和记录母婴风险和益处后，应向所有既往一次子宫下端横切口剖宫产的孕产妇提供剖宫产术后再次妊娠阴道试产，并将讨论记录在案(II-2B)。

2、建议无分娩禁忌、有过顺产史和/或已自然临产的妇女行剖宫产术后再次妊娠阴道试产，因为她们是优秀候选人，且有较高的剖宫产术后再次妊娠阴道分娩率 (II-2B)。

3、如果孕产妇有影响剖宫产术后再次妊娠阴道分娩成功的消极因素，可以在剖宫产术后再次妊娠进行阴道试产，但应告知他们，剖宫产术后再次妊娠阴道分娩的成功率较低，同时并发症和重复剖宫产的风险增加(II-2A)。

4、应告知孕产妇，择期性重复剖宫产的产妇死亡的相对风险较高，剖宫产术后再次妊娠阴道试产的子宫破裂和复合严重并发症的风险较高，但这些结局的绝对风险较低(II-2B)。

5、既往一次子宫下段横切口剖宫产者应被告知，剖宫产术后再次妊娠阴道试产发生子宫破裂的风险为0.47% (II-2A)。

6、应告知孕产妇，在选择性重复剖宫产和剖宫产术后再次妊娠阴道试产中，大多数的其他母体并发症的发生率无显著差异(II-2B)。

7、引产不是剖宫产术后再次妊娠阴道试产的禁忌证(II-2A)。

8、应告知孕产妇，引产与剖宫产术后再次妊娠阴道分娩率较低和子宫破裂的风险增加有关，应在适当咨询后谨慎使用。妊娠40周以上的孕产妇引产后发生子宫破裂的风险似乎最高(II-2A)。

9、计划剖宫产术后再次妊娠阴道试产的孕产妇可使用Foley导管促宫颈成熟(II-2B)。

10、不禁止剖宫产术后再次妊娠阴道试产的孕产妇使用催产素引产或催生。然而，使用催产素与子宫破裂的风险增加有关，应在适当咨询后谨慎使用(II-2B)。

11、用前列腺素E2（地诺前列酮）进行药物引产与子宫破裂的风险增加有关，所以，经过适当的咨询，不推荐在剖宫产术后再次妊娠阴道试产中使用(II-2B)。

12、前列腺素E1(米索前列醇)与子宫破裂的高风险有关，不宜用于足月的剖宫产术后再次妊娠阴道试产(II-2A)。

13、两次剖宫产史和一次剖宫史的孕产妇有相似的阴道分娩概率，但剖宫产一次以上的孕产妇在剖宫产术后再次妊娠阴道试产中应被告知子宫破裂的风险较高(II-2B)。

14、关于两次以上剖宫产的孕产妇结局的研究报告有限（I）。

15、臀位的妇女进行剖宫产术后再次妊娠阴道试产并不是绝对禁忌证，然而，应告知她们，此前没有足够评估剖宫产术后再次妊娠臀位阴道试产风险的经验(III-B)。

16、多胎妊娠不是剖宫产术后再次妊娠阴道试产的禁忌证(II-2B)。

17、分娩间隔小于18个月的瘢痕子宫孕产妇应被告知剖宫产术后再次妊娠阴道试产将增加子宫破裂的风险(II-2A)。

18、尽管子宫下段厚度与子宫破裂有一定的关系，但剖宫产术后再次妊娠阴道试产安不安全的绝对界限并不存在，因此，这个时候，我们不能光凭子宫下段的超声测量就告知孕产妇是否能阴道试产(II-2B)。

19、古典式剖宫产或T型子宫切口的孕产妇不适合剖宫产术后再次妊娠阴道试产(II-2A)。

20、既往子宫肌层单层缝合的子宫下段剖宫产的妇女，如希望尝试剖宫产术后再次妊娠阴道试产，应意识到子宫破裂的风险可能增加(II-2A)。

21、应尽一切努力得到既往剖宫产的手术记录，以确定子宫切口的类型。在瘢痕未知的情况下，有关以前分娩情况的信息有助于确定下段横切口的可能性。如果下段横切口的可能性高，可行剖宫产术后再次妊娠阴道试产(II-2B)。

22、计划剖宫产术后再次妊娠阴道试产的孕产妇应被告知，与选择性重复剖宫产相比，剖宫产术后再次妊娠阴道试产的围产儿死亡率和严重发病率的相对风险较高，但绝对风险较低(II-2B)。

23、应告知孕产妇，随着剖宫产的增加，前置胎盘和胎盘植入的风险增加(II-2A)。

24、剖宫产术后再次妊娠阴道试产和选择性重复剖宫产的风险和益处的适当讨论及知情同意书，应作为剖宫产术孕产妇护理计划的一部分。(III-A)。

25、剖宫产术后再次妊娠阴道试产或选择性重复剖宫产的孕产妇的意愿都应明确，既往子宫瘢痕的资料应清楚标记在产前记录中(III-A)。

26、整个小组都应知道在分娩单元中有一名孕产妇接受剖宫产术后再次妊娠阴道试产(III-A)。

27、对剖宫产术后再次妊娠阴道试产的孕产妇进行连续的胎儿心电监测是必要的，因为胎心率描记的变化是子宫破裂存在的关键指标之一(II-2A)。

28、怀疑子宫破裂需立即剖宫产终止妊娠，以降低母婴的发病率和死亡率(III-B)。

29、为了改善子宫破裂情况下的母婴结局，剖宫产术后再次妊娠阴道试产的孕产妇应在有资源立即剖宫产的医院进行(III-B)。

30、孕产妇及其医疗卫生保健工作者必须了解选择分娩地点的产科、麻醉科、儿科和手术室工作人员的可用性(III-A)。

背景/介绍

加拿大剖宫产分娩儿的比例持续上升。2015-2016年医院分娩的剖宫产率是27.9%，而1995-1996年为17.6%[1]。加拿大35岁及以上妇女的初次剖宫产率继续显著高于年轻人（23.6%对17.8%）[2]。加拿大剖宫产的主要指征是瘢痕子宫，占所有剖宫产的30%以上。

虽然加拿大的初次剖宫产率保持在17.8%的稳定水平，但重复剖宫产率(既往剖宫产的孕产妇接受重复剖宫产的比例)稳步上升。在2015-2016年，81%剖宫产史的孕产妇重复剖宫产，重复剖宫产的稳步上升伴随着TOLAC和VBAC的下降[2]。在加拿大 (除了魁北克), 2003年至2014年间 , 197540名 孕周>37 周、一次剖宫产史的单胎妊娠孕产妇中，TOLAC成功率仅为29.7%[3]。加拿大各地的TOLAC成功率差别很大。1998-2014间新斯科舍的TOLAC成功率为37.2%[4]，单魁北克医院1995-2003的TOLAC成功率为52%[5]，2015-2016年安大略的TOLAC成功率为28.5%至62.2%[6]。

TOLAC的孕产妇中，VBAC成功率也存在很大差异, 在加拿大的2003年至2014年间，范围从47.8%到50.8%[3]，魁北克的为65.1%[5]，新斯科舍是68.1%[4]，在安大略省，2015 - 2017年的 2和3级医院中(出生数据库)，一次剖宫产史的孕产妇VBAC成功率为69%。在加拿大，每年超过3万多名孕产妇面临这种选择，是试产阴道分娩还是ERCS。SOGC连同其他专业协会，包括英国皇家妇产科学院和美国妇产科医师协会，建议对有剖宫产史的符合阴道分娩条件的孕产妇提供TOLAC [7-9]。计划TOLAC的对象是本人和医疗保健工作者都权衡了VBAC的风险和益处的孕产妇。适合一个孕产妇的风险和益处的平衡对另一个孕产妇来说似乎是不可接受的[9]。

目的和范围

当计划剖宫产后分娩时，孕产妇本人及其医疗卫生保健工作者需充分讨论TOLAC和ERCS的风险和益处。在某些情况下，禁止TOLAC [10]，建议ERCS。但在大多数情况下，VBAC对母婴都是安全的[11-13]。本文回顾了有关TOLAC和ERCS的可用证据，并讨论这些分娩方式选择与母婴的相关风险。加拿大于1985年发表了一份关于TOLAC的共识声明，SOGC于2004年[14]及2005年[15] 分别出版临床实践指南。本文通过1995年1月1日到2018年6月31日发表的文章更新了从2005年的SOGC指南。文章是通过使用关键词“剖宫产后阴道分娩”在MEDLINE数据库检索获得的。数据受到三个重要因素的限制：一，没有TOLAC和剖宫产及ERCS的随机对照试验，二，母婴不良结局是罕见的，需大样本的研究人群来观察其显著差异，最后，孕产妇TOLAC的选择受其既往生育经历、医疗保健工作者和当地资源的严重影响，常常导致在发表报告中的选择偏见[17]。

本指南中建议的证据水平和质量是根据加拿大定期健康检查工作组描述的标准确定的（表1）[18]。

TOLAC的对象

有剖宫产史的接受正规产前护理的孕产妇应考虑TOLAC [16,19,20]，在某些情况下，禁止TOLAC [8]，建议ERCS。在许多选择合适的TOLAC的孕产妇中，母婴都可安全地实现阴道分娩[11-13]。

剖宫产后阴道试产的先决条件：

古典式或怀疑古典式剖宫产者

前次剖宫产倒置T型或子宫下段纵切口

既往子宫破裂史

既往子宫重建手术(如子宫肌瘤切除术的全厚度修补、子宫畸形修复、子宫角切除术)

孕产妇本人请求ERCS而不是TOLAC

专家简介

郑剑兰

郑剑兰，主任医师，教授，研究生导师，厦门大学附属成功医院、解放军第七十三集团军医院暨全军计划生育优生优育技术指导中心妇儿科主任，全军妇产科专业委员及产科学组秘书长，南京军区妇产科副主任委员，英国帝国理工大学母婴研究中心签约学者，全球健康中心及美国辛辛那提大学交流学者，中华医学会围产医学分会委员，中国医师协会母胎医学分会委员，中国对外交流促进会妇产科分会委员，中国妇幼保健协会高危妊娠常务委员，中国研究型医院学会孕产期母儿心脏病专业委员会常务委员，福建省围产医学分会委员、优生优育及妇幼保健协会盆底委员会常务委员、骨质疏松及骨矿盐学会委员，厦门市围产医学分会候任主任委员、妇产科副主任委员、产科质控中心副主任，SCI期刊《ANZJOG》 及《JOGR》审稿专家。

妇产科临床工作30多年，擅长妇科腔镜及产科危急重症抢救，近年来主要从事围产医学研究。主编专著2部；发表SCI及国内核心期刊论著20余篇；主持国家自然科学基金面上项目，省市及军队科研项目10项；引进Bakri产后止血球囊和CRB促宫颈成熟及引产球囊；发明Zheng子宫压迫缝合术，第一完成人获国家专利3项，并获军队和福建省、厦门市医疗成果及科技进步奖9项，享受军队一类科技人才岗位津贴，是军队334工程拔尖人才和厦门大学科技创新人才，多次荣立军队二等功及三等功。

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