Severe maternal and neonatal morbidity after attempted operative vaginal delivery
Severe maternal and neonatal morbidity after attempted operative vaginal delivery
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DOI：
10.1016/j.ajogmf.2021.100339
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发表时间：
2021-03-29
影响因子：
6.3
通讯作者：
Lyell, Deirdre J.
中科院分区：
文献类型：
--
作者：
Panelli, Danielle M.;Leonard, Stephanie A.;Lyell, Deirdre J.
背景技术背景：手术阴道分娩是减少初次剖宫产的关键工具，但手术阴道分娩率下降和对提供者技能的担忧需要清楚地了解风险。这些风险是不明确的，因为大多数研究比较了手术阴道分娩的结果与自然阴道分娩的结果，而不是在第二产程剖宫产的结果，这通常是现实的选择。目的：本研究的目的是比较成功经阴道手术分娩的第二产程延长患者的分娩方式对严重孕产妇和新生儿发病率的影响，研究设计：我们使用基于人群的数据库来评估2007年至2012年期间加州第二产程延长患者的未经产、足月、单胎、头端活产。出生证明和国际疾病分类，第九次修订，临床修改编码诊断和程序用于确定暴露，结果和人口统计学。暴露是有任何手术阴道分娩尝试的患者与无手术阴道分娩尝试的剖宫产患者的分娩方式。结果是严重的孕产妇发病率和严重的意外新生儿发病率，使用既定的指数定义。预计第二产程延长的代码将仅代表一部分真正的手术阴道分娩候选人，进行了二次分析，消除了这一限制，以探索更大队列中不成功分娩的粒度结局。采用多变量逻辑回归分析比较经测量混杂因素校正的分娩方式的结局。敏感性分析排除了联合真空产钳辅助分娩和出生体重>4000 g的患者。共纳入9239例第二产程延长后的分娩，其中6851例经阴道手术分娩成功率为74.1%，2087例（22.6%）为剖宫产分娩，未行阴道分娩。在成功的手术阴道分娩中，6195例（90.4%）是真空辅助，656例（10.6%）是产钳辅助。在指定手术阴道分娩类型的手术阴道分娩失败中，83例（47.4%）为真空辅助，38例（21.7%）为产钳辅助，54例（30.9%）为真空-产钳联合辅助。值得注意的是，我们发现的所有54例真空产钳辅助阴道分娩尝试均失败。手术阴道分娩失败的患者的结局与手术阴道分娩成功的患者不同，例如合并症的发生率较高，联合手术阴道分娩的使用，以及出生体重>4000 g。成功的手术阴道分娩与降低严重的产妇发病率相关（校正比值比，0.55; 95%置信区间，0.39-0.78），而没有严重的意外新生儿发病率的差异（校正比值比，0.99; 95%置信区间，0.78-1.26）。相比之下，阴道手术分娩失败与严重产妇发病率（校正比值比，2.14; 95%置信区间，1.20-3.82）和严重意外新生儿发病率（校正比值比，1.78; 95%置信区间，1.09-2.86）增加相关。此外，结果是相似的二次分析260,585例不成功的labor.CONCLUSION：在这个大队列的未经产，长期，单胎，头产，成功的手术阴道分娩与45%的严重产妇发病率降低没有严重的意外新生儿发病率相比，剖宫产后延长第二产程。手术阴道分娩很少失败，与严重的孕产妇发病率增加214%和严重的意外新生儿发病率增加78%相关;此外，联合手术阴道分娩是主要贡献者，因为所有联合手术阴道分娩失败。通过改善患者选择、提高提供者技能和讨论联合手术阴道分娩等手段优化手术阴道分娩成功率，可以减少孕产妇和新生儿并发症。
BACKGROUND: Operative vaginal delivery is a critical tool in reducing primary cesarean delivery, but declining operative vaginal delivery rates and concerns about provider skill necessitate a clear understanding of risks. These risks are ambiguous because most studies compare outcomes of operative vaginal delivery with that of spontaneous vaginal delivery rather than outcomes of cesarean delivery in the second stage of labor, which is usually the realistic alternative.OBJECTIVE: This study aimed to compare severe maternal and neonatal morbidity by mode of delivery of patients with a prolonged second stage of labor who had a successful operative vaginal delivery, a cesarean delivery after failed operative vaginal delivery, or a cesarean delivery without an operative vaginal delivery attempt.STUDY DESIGN: We used a population-based database to evaluate nulliparous, term, singleton, vertex live births in California between 2007 and 2012 of patients with prolonged second stage of labor. Birth certificates and the International Classification of Diseases, Ninth Revision, Clinical Modification coded diagnoses and procedures were used for ascertainment of exposure, outcome, and demographics. Exposure was mode of delivery of patients who had any operative vaginal delivery attempt vs cesarean delivery without operative vaginal delivery attempt. The outcomes were severe maternal morbidity and severe unexpected newborn morbidity, defined using established indices. Anticipating that the code for prolonged second stage of labor would represent only a fraction of true operative vaginal delivery candidates, a secondary analysis was conducted removing this restriction to explore granular outcomes in a larger cohort with unsuccessful labor. Multivariable logistic regression was used to compare outcomes by mode of delivery adjusted for measured confounders. Sensitivity analyses were done excluding patients with combined vacuum-forceps-assisted delivery and birthweight of >4000 g.RESULTS: A total of 9239 births after prolonged second stage of labor were included, where 6851 (74.1%) were successful operative vaginal deliveries, 301 (3.3%) were failed operative vaginal deliveries, and 2087 (22.6%) were cesarean deliveries without operative vaginal delivery attempts. Of successful operative vaginal deliveries, 6195 (90.4%) were vacuum assisted and 656 (10.6%) were forceps-assisted. Of failed operative vaginal deliveries where operative vaginal delivery type was specified, 83 (47.4%) were vacuum assisted, 38 (21.7%) were forceps-assisted, and 54 (30.9%) were combined vacuum-forceps-assisted. Of note, all 54 combined vacuum-forceps-assisted operative vaginal delivery attempts that we identified failed. The outcomes of patients with failed operative vaginal delivery differed from those with successful operative vaginal delivery, such as higher rates of comorbidities, use of combined operative vaginal delivery, and birthweight of >4000 g. Successful operative vaginal delivery was associated with reduced severe maternal morbidity (adjusted odds ratio, 0.55; 95% confidence interval, 0.39-0.78) without a difference in severe unexpected neonatal morbidity (adjusted odds ratio, 0.99; 95% confidence interval, 0.78-1.26). In contrast, failed operative vaginal delivery was associated with increased severe maternal morbidity (adjusted odds ratio, 2.14; 95% confidence interval, 1.20-3.82) and severe unexpected neonatal morbidity (adjusted odds ratio, 1.78; 95% confidence interval, 1.09-2.86). In addition, findings were similar in the secondary analysis of 260,585 patients with unsuccessful labor.CONCLUSION: In this large cohort of nulliparous, term, singleton, vertex births, successful operative vaginal delivery was associated with a 45% reduction in severe maternal morbidity without differences in severe unexpected neonatal morbidity compared with cesarean delivery after prolonged second stage of labor. Operative vaginal delivery infrequently failed and was associated with a 214% increase in severe maternal morbidity and a 78% increase in severe unexpected neonatal morbidity; furthermore, combined operative vaginal deliveries were major contributors to this, as all combined operative vaginal deliveries failed. Optimization of operative vaginal delivery success rates through means such as improved patient selection, enhanced provider skill, and discussions against combined operative vaginal delivery could reduce maternal and neonatal complications.