Outcome of subsequent pregnancy three years after previous operative delivery in the second stage of labour: cohort study
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《英国医生杂志》
1 St Michael's Hospital, Bristol BS2 8EG, 2 Maternal and Child Health Sciences, University of Dundee, Ninewells Hospital and Medical School, Dundee DD1 9SY
Correspondence to: D J Murphy d.j.murphy@dundee.ac.uk
Abstract
Rising rates of caesarean section have been recorded across the developed world.1 The management of the first time mother with a singleton cephalic pregnancy at term seems to account for much of the increase in rates of caesarean section and, perhaps more importantly, much of the variation between individual obstetricians, delivery units, regions, and countries.1 2 A consensus group of the American College of Obstetricians and Gynecologists has suggested that to control rates of caesarean section there should be further training in instrumental vaginal delivery.2 Many obstetricians are concerned, however, about the potential for neonatal trauma and maternal pelvic floor morbidity after instrumental delivery,3-5 leading to a sharp fall in the number of obstetricians prepared to offer mid-cavity or rotational instrumental vaginal delivery.6 Delivery by caesarean section is associated with important potential consequences, including subfertility,7-9 uterine rupture,10 and placenta previa.11 Obstetricians need to consider the overall reproductive outcome for an individual woman and not just the outcome of the index pregnancy in isolation.
High rates of spontaneous vaginal delivery can be achieved after a previous instrumental vaginal delivery; in one study more than 75% of women achieved a spontaneous vaginal delivery, having heavier babies in the second pregnancy and with very low overall rates of birth trauma or asphyxia.12 Similar rates of vaginal delivery are not seen after a previous caesarean section, largely because fewer women are aiming for vaginal delivery in these circumstances.1 Evidence is also growing that maternal choice is being limited, with some North American maternity units declining access to vaginal birth after caesarean section.13 We have previously reported that 4% of women in a UK population needed a trial of instrumental delivery in theatre or a caesarean section at full dilatation, suggesting that difficult operative deliveries in the second stage of labour are at least as common as breech presentation at term.14 We found an excess of early maternal morbidity and admission to the neonatal intensive care unit after caesarean section and an excess of neonatal trauma after instrumental vaginal delivery. These results suggest the need for a balance between the risks of different types of morbidity when managing delay in the second stage of labour. When we surveyed women one year after their initial delivery, those who had experienced an instrumental vaginal delivery were significantly more likely to report a preference for vaginal delivery in a subsequent pregnancy.15 We have now surveyed our original cohort of women at three years after the initial operative delivery to evaluate their reproductive outcome and mode of delivery in subsequent pregnancies.
Methods
Two hundred and eighty three women from the original cohort of 393 (72%) returned the postal questionnaire sent three years after their previous operative delivery. The demographic, obstetric and neonatal characteristics of the respondents were similar to the profile of the original cohort, suggesting that the available study sample at follow up was representative of the original cohort (table 1). We did not have consent to establish the pregnancy outcome of the non-respondents.
Table 1 Maternal and neonatal characteristics in relation to instrumental vaginal delivery and caesarean section. Values are numbers (percentages) unless stated otherwise
Women were less likely to report difficulty conceiving (adjusted odds ratio 0.33 (95% confidence interval 0.12 to 0.98)) and were more likely to have achieved a further pregnancy (2.09 (1.10 to 4.28)) after an instrumental vaginal delivery than after a caesarean section (table 2). The interval between trying for a pregnancy and conception ranged from four to 24 months. A total of 140 women (49%) had achieved a further pregnancy at three year follow up, representing 73% (140/192) of those who had planned or were going to consider a further pregnancy. We found no significant differences for ectopic pregnancy, miscarriage, and preterm birth between the caesarean section group and the vaginal delivery group. No woman reported a termination of pregnancy. Of the 91 women who had not planned to have a further pregnancy, almost half (42/91) stated that they "could not go through childbirth again," with no significant difference in this response between the women in the instrumental vaginal delivery group and those in the caesarean section group (table 3).
Table 2 Fertility and pregnancy outcome at three years in relation to mode of delivery at index pregnancy. Values are numbers (percentages) unless stated otherwise
Table 3 Reasons given for voluntary infertility in relation to mode of delivery at index pregnancy. Values are numbers (percentages) unless stated otherwise
Women were more likely to aim for a vaginal delivery if they had had a previous instrumental vaginal delivery than if they had had a previous caesarean section (table 4). This association was reported at one year after the index pregnancy (8.15 (3.07 to 21.67)) and persisted when the women were planning delivery in the subsequent pregnancy (15.55 (5.25 to 46.04)). Women were more likely to have a vaginal delivery if they had had a previous instrumental vaginal delivery (9.50 (3.48 to 25.97)), although there was a high rate of vaginal delivery in women who had had a previous caesarean section but were aiming for a vaginal delivery subsequently (17/18 (94%)). In three of the 42 (7%) women who had had an instrumental vaginal delivery previously and who subsequently delivered vaginally, the subsequent delivery was an instrumental vaginal delivery (all ventouse). In eight of the 17 (47%) women who had had a previous caesarean section and who subsequently delivered vaginally, the subsequent delivery was an instrumental vaginal delivery (seven ventouse, one forceps). Six women had given birth twice since the initial delivery, four after an initial instrumental delivery and two after a caesarean section; all six women delivered vaginally for the second birth.
Table 4 Mode of delivery for subsequent pregnancy in relation to mode of delivery at index pregnancy in women who achieved term pregnancy. Values are numbers (percentages) unless stated otherwise
Discussion
Thomas J, Paranjothy S, Royal College of Obstetricians and Gynaecologists Clinical Effectiveness Support Unit. National sentinel caesarean section audit report. London: RCOG Press, 2001.
American College of Obstetricians and Gynecologists. Evaluation of cesarean delivery. Washington, DC: ACOG, 2000.
Towner D, Castro MA, Eby-Wilkens E, Gilbert WM. Effect of mode of delivery in nulliparous women on neonatal intracranial injury. N Engl J Med 1999;341: 1709-14.
Donnelly V, Fynes M, Campbell D, Johnson H, O'Connell PR, O'Herlihy C. Obstetric events leading to anal sphincter damage. Obstet Gynecol 1998;92: 955-61.
MacLennan AH, Taylor AW, Wilson DH, Wilson D. The prevalence of pelvic floor disorders and their relationship to gender, age, parity and mode of delivery. Br J Obstet Gynaecol 2000;107: 1460-70.
Bofill JA, Rust OA, Perry KG, Roberts WE, Martin RW, Morrison JC. Operative vaginal delivery: a survey of fellows of ACOG. Obstet Gynecol 1996;88: 1007-10.
Hall MH, Campbell DM, Fraser C, Lemon J. Mode of delivery and future fertility. Br J Obstet Gynaecol 1989;96: 1297-303.
Jolly J, Walker J, Bhabra K. Subsequent obstetric performance related to primary mode of delivery. Br J Obstet Gynaecol 1999;106: 227-32.
Murphy DJ, Stirrat GM, Heron J, ALSPAC Study Team. The relationship between caesarean section and subfertility in a population-based sample of 14,541 pregnancies. Hum Reprod 2002:17: 1914-7.
Lydon-Rochelle M, Holt VL, Easterling TR, Martin DP. Risk of uterine rupture during labor among women with a prior caesarean delivery. N Engl J Med 2001;345: 54-5.
Gilliam M, Rosenberg D, Davis F. The likelihood of placenta previa with greater number of cesarean deliveries and higher parity. Obstet Gynecol 2002;99: 976-80.
Kadar N, Romero R. Prognosis for future childbearing after mid-cavity instrumental deliveries in primigravidas. Obstet Gynecol 1983;62: 166-70.
Maternity Center Association. Listening to mothers: report of the first national US survey of women's childbearing experiences. New York: MCA, 2002.
Murphy DJ, Liebling RE, Verity L, Swingler R, Patel R. Cohort study of the early maternal and neonatal morbidity associated with operative delivery in the second stage of labour. Lancet 2001;358: 1203-7.
Murphy DJ, Liebling RE. Cohort study of maternal views on future mode of delivery following operative delivery in the second stage of labor. Am J Obstet Gynecol 2003;188: 542-8.
Patel RR, Liebling RE, Murphy DJ. Effect of operative delivery in the second stage of labor on breastfeeding success. Birth (in press).
Smith GC, Pell JP, Cameron AD, Dobbie R. Risk of perinatal death associated with labor after previous cesarean delivery in uncomplicated term pregnancies. JAMA 2002;287: 2684-90.
Hemminki E. Impact of cesarean sections on future pregnancy: a review of cohort studies. Paediatr Perinat Epidemiol 1996;10: 366-79.
Czarnocka J, Slade P. Prevalence and predictors of post-traumatic stress symptoms following childbirth. Br J Clin Psychol 2000;39: 35-51.
Creedy DK, Shochnet IM, Horsfall J. Childbirth and the development of acute trauma symptoms: incidence and contributing factors. Birth 2000;27: 104-11.
Wijma K, Soderquist J, Wijma B. Post-traumatic stress disorder after childbirth: a cross sectional study. J Anxiety Disord 1997;11: 587-97.
Murphy DJ, Pope C, Frost J, Liebling RE. Women's views on the impact of operative delivery in the second stage of labour—qualitative study. BMJ 2003;327: 1132-5.
Morrell CJ, Spilby H, Stewart P, Walters S, Morgan A. Costs and effectiveness of community postnatal support workers: randomised controlled trial. BMJ 2000;321: 593-7.
Small R, Lumley J, Donohue L, Potter A, Waldenstrom U. Randomised controlled trial of midwife led debriefing to reduce maternal depression after operative childbirth. BMJ 2000;321: 1043-7.
Lavender T, Walkinshaw SA. Can midwives reduce postpartum psychological morbidity? A randomised trial. Birth 1998;25: 215-21.(Rachna Bahl, specialist r)
Correspondence to: D J Murphy d.j.murphy@dundee.ac.uk
Abstract
Rising rates of caesarean section have been recorded across the developed world.1 The management of the first time mother with a singleton cephalic pregnancy at term seems to account for much of the increase in rates of caesarean section and, perhaps more importantly, much of the variation between individual obstetricians, delivery units, regions, and countries.1 2 A consensus group of the American College of Obstetricians and Gynecologists has suggested that to control rates of caesarean section there should be further training in instrumental vaginal delivery.2 Many obstetricians are concerned, however, about the potential for neonatal trauma and maternal pelvic floor morbidity after instrumental delivery,3-5 leading to a sharp fall in the number of obstetricians prepared to offer mid-cavity or rotational instrumental vaginal delivery.6 Delivery by caesarean section is associated with important potential consequences, including subfertility,7-9 uterine rupture,10 and placenta previa.11 Obstetricians need to consider the overall reproductive outcome for an individual woman and not just the outcome of the index pregnancy in isolation.
High rates of spontaneous vaginal delivery can be achieved after a previous instrumental vaginal delivery; in one study more than 75% of women achieved a spontaneous vaginal delivery, having heavier babies in the second pregnancy and with very low overall rates of birth trauma or asphyxia.12 Similar rates of vaginal delivery are not seen after a previous caesarean section, largely because fewer women are aiming for vaginal delivery in these circumstances.1 Evidence is also growing that maternal choice is being limited, with some North American maternity units declining access to vaginal birth after caesarean section.13 We have previously reported that 4% of women in a UK population needed a trial of instrumental delivery in theatre or a caesarean section at full dilatation, suggesting that difficult operative deliveries in the second stage of labour are at least as common as breech presentation at term.14 We found an excess of early maternal morbidity and admission to the neonatal intensive care unit after caesarean section and an excess of neonatal trauma after instrumental vaginal delivery. These results suggest the need for a balance between the risks of different types of morbidity when managing delay in the second stage of labour. When we surveyed women one year after their initial delivery, those who had experienced an instrumental vaginal delivery were significantly more likely to report a preference for vaginal delivery in a subsequent pregnancy.15 We have now surveyed our original cohort of women at three years after the initial operative delivery to evaluate their reproductive outcome and mode of delivery in subsequent pregnancies.
Methods
Two hundred and eighty three women from the original cohort of 393 (72%) returned the postal questionnaire sent three years after their previous operative delivery. The demographic, obstetric and neonatal characteristics of the respondents were similar to the profile of the original cohort, suggesting that the available study sample at follow up was representative of the original cohort (table 1). We did not have consent to establish the pregnancy outcome of the non-respondents.
Table 1 Maternal and neonatal characteristics in relation to instrumental vaginal delivery and caesarean section. Values are numbers (percentages) unless stated otherwise
Women were less likely to report difficulty conceiving (adjusted odds ratio 0.33 (95% confidence interval 0.12 to 0.98)) and were more likely to have achieved a further pregnancy (2.09 (1.10 to 4.28)) after an instrumental vaginal delivery than after a caesarean section (table 2). The interval between trying for a pregnancy and conception ranged from four to 24 months. A total of 140 women (49%) had achieved a further pregnancy at three year follow up, representing 73% (140/192) of those who had planned or were going to consider a further pregnancy. We found no significant differences for ectopic pregnancy, miscarriage, and preterm birth between the caesarean section group and the vaginal delivery group. No woman reported a termination of pregnancy. Of the 91 women who had not planned to have a further pregnancy, almost half (42/91) stated that they "could not go through childbirth again," with no significant difference in this response between the women in the instrumental vaginal delivery group and those in the caesarean section group (table 3).
Table 2 Fertility and pregnancy outcome at three years in relation to mode of delivery at index pregnancy. Values are numbers (percentages) unless stated otherwise
Table 3 Reasons given for voluntary infertility in relation to mode of delivery at index pregnancy. Values are numbers (percentages) unless stated otherwise
Women were more likely to aim for a vaginal delivery if they had had a previous instrumental vaginal delivery than if they had had a previous caesarean section (table 4). This association was reported at one year after the index pregnancy (8.15 (3.07 to 21.67)) and persisted when the women were planning delivery in the subsequent pregnancy (15.55 (5.25 to 46.04)). Women were more likely to have a vaginal delivery if they had had a previous instrumental vaginal delivery (9.50 (3.48 to 25.97)), although there was a high rate of vaginal delivery in women who had had a previous caesarean section but were aiming for a vaginal delivery subsequently (17/18 (94%)). In three of the 42 (7%) women who had had an instrumental vaginal delivery previously and who subsequently delivered vaginally, the subsequent delivery was an instrumental vaginal delivery (all ventouse). In eight of the 17 (47%) women who had had a previous caesarean section and who subsequently delivered vaginally, the subsequent delivery was an instrumental vaginal delivery (seven ventouse, one forceps). Six women had given birth twice since the initial delivery, four after an initial instrumental delivery and two after a caesarean section; all six women delivered vaginally for the second birth.
Table 4 Mode of delivery for subsequent pregnancy in relation to mode of delivery at index pregnancy in women who achieved term pregnancy. Values are numbers (percentages) unless stated otherwise
Discussion
Thomas J, Paranjothy S, Royal College of Obstetricians and Gynaecologists Clinical Effectiveness Support Unit. National sentinel caesarean section audit report. London: RCOG Press, 2001.
American College of Obstetricians and Gynecologists. Evaluation of cesarean delivery. Washington, DC: ACOG, 2000.
Towner D, Castro MA, Eby-Wilkens E, Gilbert WM. Effect of mode of delivery in nulliparous women on neonatal intracranial injury. N Engl J Med 1999;341: 1709-14.
Donnelly V, Fynes M, Campbell D, Johnson H, O'Connell PR, O'Herlihy C. Obstetric events leading to anal sphincter damage. Obstet Gynecol 1998;92: 955-61.
MacLennan AH, Taylor AW, Wilson DH, Wilson D. The prevalence of pelvic floor disorders and their relationship to gender, age, parity and mode of delivery. Br J Obstet Gynaecol 2000;107: 1460-70.
Bofill JA, Rust OA, Perry KG, Roberts WE, Martin RW, Morrison JC. Operative vaginal delivery: a survey of fellows of ACOG. Obstet Gynecol 1996;88: 1007-10.
Hall MH, Campbell DM, Fraser C, Lemon J. Mode of delivery and future fertility. Br J Obstet Gynaecol 1989;96: 1297-303.
Jolly J, Walker J, Bhabra K. Subsequent obstetric performance related to primary mode of delivery. Br J Obstet Gynaecol 1999;106: 227-32.
Murphy DJ, Stirrat GM, Heron J, ALSPAC Study Team. The relationship between caesarean section and subfertility in a population-based sample of 14,541 pregnancies. Hum Reprod 2002:17: 1914-7.
Lydon-Rochelle M, Holt VL, Easterling TR, Martin DP. Risk of uterine rupture during labor among women with a prior caesarean delivery. N Engl J Med 2001;345: 54-5.
Gilliam M, Rosenberg D, Davis F. The likelihood of placenta previa with greater number of cesarean deliveries and higher parity. Obstet Gynecol 2002;99: 976-80.
Kadar N, Romero R. Prognosis for future childbearing after mid-cavity instrumental deliveries in primigravidas. Obstet Gynecol 1983;62: 166-70.
Maternity Center Association. Listening to mothers: report of the first national US survey of women's childbearing experiences. New York: MCA, 2002.
Murphy DJ, Liebling RE, Verity L, Swingler R, Patel R. Cohort study of the early maternal and neonatal morbidity associated with operative delivery in the second stage of labour. Lancet 2001;358: 1203-7.
Murphy DJ, Liebling RE. Cohort study of maternal views on future mode of delivery following operative delivery in the second stage of labor. Am J Obstet Gynecol 2003;188: 542-8.
Patel RR, Liebling RE, Murphy DJ. Effect of operative delivery in the second stage of labor on breastfeeding success. Birth (in press).
Smith GC, Pell JP, Cameron AD, Dobbie R. Risk of perinatal death associated with labor after previous cesarean delivery in uncomplicated term pregnancies. JAMA 2002;287: 2684-90.
Hemminki E. Impact of cesarean sections on future pregnancy: a review of cohort studies. Paediatr Perinat Epidemiol 1996;10: 366-79.
Czarnocka J, Slade P. Prevalence and predictors of post-traumatic stress symptoms following childbirth. Br J Clin Psychol 2000;39: 35-51.
Creedy DK, Shochnet IM, Horsfall J. Childbirth and the development of acute trauma symptoms: incidence and contributing factors. Birth 2000;27: 104-11.
Wijma K, Soderquist J, Wijma B. Post-traumatic stress disorder after childbirth: a cross sectional study. J Anxiety Disord 1997;11: 587-97.
Murphy DJ, Pope C, Frost J, Liebling RE. Women's views on the impact of operative delivery in the second stage of labour—qualitative study. BMJ 2003;327: 1132-5.
Morrell CJ, Spilby H, Stewart P, Walters S, Morgan A. Costs and effectiveness of community postnatal support workers: randomised controlled trial. BMJ 2000;321: 593-7.
Small R, Lumley J, Donohue L, Potter A, Waldenstrom U. Randomised controlled trial of midwife led debriefing to reduce maternal depression after operative childbirth. BMJ 2000;321: 1043-7.
Lavender T, Walkinshaw SA. Can midwives reduce postpartum psychological morbidity? A randomised trial. Birth 1998;25: 215-21.(Rachna Bahl, specialist r)