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提高剖宫产术后再次妊娠阴道试产率*
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发布人：yaot　发布时间：2023/3/7 17:01:34　 浏览次数：1675次
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——王丽娟 饶珈铭 陈宝珊 郭惠筱 李燕金 张卓玲 冯锦屏 卢德梅

【摘要】目的提高剖宫产术后再次妊娠阴道试产（TOLAC）率。方法开展问题解决型品管圈活动：通过现状调查与原因解析，确定问题真因为宣教形式单一、缺乏专科咨询通道、担心并发症、缺乏TOLAC孕妇评估体系、缺乏TOLAC管理平台、没有阴道分娩经验；提出多项改进措施并实施，包括建立多维度宣传模式、提供优质的TOLAC母婴安全保障服务、优化全孕期TOLAC管理模式、构建“4+1”联动TOLAC互联网+体系等。结果TOLAC率由活动前的8.33%提高到活动后的13.71%，达成了活动目标。结论开展品管圈活动可以持续改进TOLAC管理，提高TOLAC率，促进自然分娩，并确保母婴安全。
【关键词】品管圈；问题解决型品管圈；剖宫产术；再次妊娠；阴道试产
中图分类号：R719.8；R714.1；R197.323 文献标识码：B
To Improve the Rate of Trial of Labor after Cesarean/WANG Lijuan,RAO Jiaming,CHEN Baoshan,et al.//Chinese Health Quality Management，2023,30(2):75-80
Abstract Objective?/b>To improve the rate of trial of labor after cesarean (TOLAC) in patients.Methods The problem-solving quality control circle activities were carried out. Through the status investigation and cause analysis, it was determined that the problem was caused by "single form of education", "lack of specialist consultation channel", "worry about complications", "lack of TOLAC pregnant women evaluation system", "lack of TOLAC management platform" and "lack of vaginal delivery experience". A number of improvement measures were put forward and implemented, including "establishing a multi-dimensional publicity mode", "providing high-quality TOLAC maternal and child safety protection services", "optimizing TOLAC management mode during the whole pregnancy", and "building a "4+1" connected TOLAC Internet + system". Results TOLAC rate increased from 8.33% before the activity to 13.71% after the activity, achieving the activity goal.Conclusion Carrying out quality control circle activities can continuously improve TOLAC management, increase TOLAC rate, promote natural delivery, and ensure the safety of mother and child.
Key words Quality Control Circle; Problem Solving Quality Control Circle; Cesarean Section; Second Pregnancy; Vaginal Trial Labor
Firstauthor's address Foshan Maternity & Child Healthcare Hospital, Foshan,Guangdong,528000,China
1主题选定

圈员结合临床实际广泛提出问题，并采用权重法结合“5-3-1”评价法从重要性、迫切性、圈能力、上级重视程度4个维度进行评价，选出得分最高的“提高剖宫产术后再次妊娠阴道试产率”为本期活动主题。经QC-Story判定，本期活动主题为问题解决型。
名词定义：（1）剖宫产术（Cesarean Section，CS），指经腹切开子宫取出胎儿及其附属物的手术，常分为子宫下段剖宫产术、子宫体部剖宫产术、腹膜外剖宫产术。（2）剖宫产术后再次妊娠阴道试产（Trial of Labor after Cesarean，TOLAC）［1］，按成功与否可分为试产成功和试产失败。（3）剖宫产术后阴道分娩（Vaginal Birth after Cesarean Section，VBAC），指有剖宫产史的产妇进行阴道试产并且成功经阴道分娩［2］。
衡量指标：TOLAC率=符合TOLAC条件且有试产意愿的产妇例数/符合TOLAC条件的产妇例数×100%［3］。
纳入标准：（1）产妇年龄为18岁～40岁，理解并接受试产失败和紧急剖宫产的风险；（2）仅有1次剖宫产史，切口无延裂，如期恢复，无晚期产后出血；（3）胎儿为头位，不存在前次剖宫产指征，未出现新的剖宫产指征；（4）两次分娩间隔时间≥18个月［4］；（5）B超估计胎儿体重不足4 000 g［5］；（6）B超检查子宫前壁下段肌层连续、均匀，无缺损、瘢痕黏连及憩室形成。
选题背景：世界卫生组织认为，理想的剖宫产率应为10%～15%［6］。据报道［7］，2018年我国整体剖宫产率为36.7%，随着全面二孩政策的实施，剖宫产术后再次妊娠孕妇数量不断攀升。因此，探讨剖宫产术后再次妊娠孕妇分娩方式十分重要。子宫受损时，在修复过程中可形成瘢痕，称为瘢痕子宫。因剖宫产术造成的瘢痕子宫，又称剖宫产术后瘢痕子宫(Scarred Uterus after Cesarean Section，SUAC)［8］。SUCA再次妊娠存在子宫破裂［9］、胎盘植入［10］、羊水栓塞、下肢静脉血栓栓塞［11］、产后出血、脏器损害［12］等风险。近年来，TOLAC相关临床问题引起了各界广泛重视。目前，多国指南［1-3］均认为，对于绝大多数仅有一次子宫下段横切口剖宫产术产妇而言，再次妊娠经阴道试产是安全、可靠的。


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