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Vaginal Birth After Previous CesareanDelivery
Trial of labor after previous cesarean delivery (TOLAC) provides women who desire a vaginal delivery with thepossibility of achieving that goal––a vaginal birth after cesarean delivery (VBAC)?. In addition to fulfilling a patient’spreference for vaginal delivery, at an individual level VBAC is associated with decreased maternal morbidity and adecreased risk of complications in future pregnancies. At a population level, VBAC also is associated with a decreasein the overall cesarean delivery rate (1, 2). Although TOLAC is appropriate for many women with a history of acesarean delivery, several factors increase the likelihood of a failed trial of labor, which compared with VBAC, isassociated with increased maternal and perinatal morbidity (3–5). Assessment of individual risks and the likelihood ofVBAC is, therefore, important in determining who are appropriate candidates for TOLAC. The purpose of this docu-ment is to review the risks and benefits of TOLAC in various clinical situations and provide practical guidelines formanaging and counseling patients who will give birth after a previous cesarean delivery.
Background
Between 1970 and 2007, the cesarean delivery rate inthe United States increased dramatically from 5% tomore than 31% (6, 7). This increase was a result ofseveral changes in the practice environment, includingthe introduction of electronic fetal monitoring and thedecrease in use of vaginal breech deliveries and forcepsdeliveries (8–10). The increase in cesarean delivery rateswas partly perpetuated by the dictum “once a cesareanalways a cesarean” (11). In the 1970s, however, somebegan to reconsider this paradigm, and accumulated datahave since supported TOLAC as a reasonable approachin selected pregnancies (4, 5, 12–14).
This change in approach and recommendationsfavoring TOLAC was reflected in increased VBAC rates(VBAC per 100 women with a prior cesarean delivery)from just more than 5% in 1985 to 28.3% by 1996.The overall cesarean delivery rate decreased to approxi-mately 20% by 1996 (15). Yet, as the number of womenpursuing TOLAC increased, so did the number of re-ports of uterine rupture and other complications duringTOLAC (16–18). In part, these reports, and the profes-sional liability pressures they engendered, have resultedin a reversal of VBAC and cesarean delivery trends. By2006, the VBAC rate had decreased to 8.5% and thetotal cesarean delivery rate had increased to 31.1% (15,19, 20). In some hospitals, TOLAC is no longer offered.
完整下載 2010ACOG臨床指南:剖宮產(chǎn)后經(jīng)陰道分娩
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