Pregnancy and childbirth are normal physiological processes of human reproduction, and most women can naturally give birth to healthy babies. Cesarean section is an important means to solve dystocia, deal with serious pregnancy complications and save the lives of mother and baby.
In recent years, with the development of perinatal medicine, the conditions of operation, anesthesia technology and drug treatment have been gradually improved, and the safety of cesarean section has been continuously improved. At the same time, the cesarean section rate has been increasing all over the world.
Twenty-one medical institutions were randomly selected from Beijing, Yunnan and Zhejiang to participate in the World Health Organization (WHO) Global Survey on Pregnancy and Perinatal Care (2007-2008), and the survey results were published in The Lancet magazine in February 2010.
The average cesarean section rate in the three continents (Asia, Latin America and Africa) participating in this survey is 25.7%, of which Asia is 27.3%, while China is 46.5%, ranking first among the 24 countries participating in the survey.
The report also pointed out that in China, the cesarean section rate with non-medical indications accounts for 11.7% of all cesarean sections, ranking first among the sampling countries; In Viet Nam, which ranks next to China, the cesarean section rate is 35.6%, but the cesarean section rate without medical indications is only 1%.
The cesarean section rate in China has far exceeded the WHO standard of reducing the cesarean section rate to below 15%. The rapid increase of cesarean section rate and the decrease of natural delivery rate have brought heavy economic burden to society and families, and also wasted great health resources.
1. Present situation of natural childbirth in China
In the 1950s and 1970s, the natural delivery rate in China was around 95%. Since then, with the progress of medical technology and the improvement of material living standards, the natural delivery rate has been declining, and the cesarean section rate has been increasing year by year. After the 1980s, it quickly rose to 30% ~ 40%, and almost reached 40% ~ 60% in the 1990s.
In the 21st century, cesarean section has become more common. The cesarean section rate in most domestic urban hospitals is above 40% ~ 60%, and a few may be higher. The wide application of cesarean section has not reduced the perinatal mortality. Compared with natural delivery, the relative risk of maternal death has risen, which has a greater impact on the follow-up of maternal and perinatal children and increases the consumption of health resources, which has become another serious public health problem in China.
Zhu Xuanbo and others found that the cesarean section rate was 37.6% from 1993 to 2010 in the study of cesarean section rate of singleton primiparous women and pregnant women in some areas of China. Pregnant women require 10.0% cesarean section.
The rate of cesarean section in southern cities increased from 29.4% to 58.7%, in southern rural areas from 18.2% to 58.3%, and in northern rural areas from 4.3% to 49.5%. Among them, the rate of cesarean section required by pregnant women in southern cities increased from 0.6% to 21.3%, up 34 times; From 0.6% to 24.4% in southern rural areas, it has increased by 40 times;
The rural areas in the north increased by 44 times from 0.6% to 27.3%. Pregnant women’s request for cesarean section accounts for the main part of cesarean section.
In 2006, the National Institutes of Health,NIH) and the American College of Obstetricians and Gynecologists (ACOG) put forward the definition and principles for the cesarean section required by the mother of this singleton pregnancy without clinical complications.
It is defined as Cesar can delivery on cesarean section (CDMR) requested by the mother. The principle of handling CDMR is that the decision should be individualized and ethical, and CDMR should not be performed unless there is evidence of fetal lung maturity before 39 weeks of pregnancy.
At the same time, delivery institutions should provide effective pain management for all delivery women, and pain should not be the reason for choosing CDMR. Mothers who need to have multiple children do not advocate CDMR.
Therefore, clinicians in China should refer to the suggestions of NIH and ACOG, fully inform pregnant women of the advantages and disadvantages of CDMR, and avoid improper timing of elective cesarean section without clear indications, so as to reduce the increasing cesarean section rate.
At present, China is at the peak of fertility, and it is estimated that the peak will continue until 2015 before it will gradually stabilize. Nowadays, most young expectant mothers are only children, and fear of pain and convenience has become an important reason for them to choose cesarean section during delivery.
Superior living and working conditions weaken people’s tolerance for pain. For today’s healthy young women, there is nothing more painful than having to endure pain for more than ten hours when giving birth. The fear of "pain" urges them to choose cesarean section during delivery.
In addition, compared with natural delivery, cesarean section does not need a "long" wait, and "one knife" can solve the problem. For the above reasons, the number of pregnant women who choose cesarean section, especially primiparas, is increasing.
ACOG and SMFM jointly issued the first obstetrical care consensus No.1 & mdash; Safely avoid the first cesarean section.
It is suggested that doctors weigh the short-term and long-term advantages and disadvantages of cesarean section and vaginal delivery, and avoid the abuse of cesarean section safely and effectively, especially the first cesarean section. The common causes of the first cesarean section were analyzed by consensus, and the results were as follows: abnormal labor process, abnormal fetal heart rate monitoring, abnormal fetal position, multiple pregnancies and suspected macrosomia.
In view of the above reasons, the consensus puts forward a series of intervention measures, including redefining abnormal labor process and reducing unnecessary intervention in labor process; To provide non-medical support during labor and improve the recognition ability of fetal heart monitoring;
Carry out the application of external gluteal inversion; Reasonable nutrition guidance during pregnancy to prevent macrosomia; It is suggested that cesarean section should not be used as far as possible in twin pregnancy with the first fetus as the head position. The suggestions put forward by this consensus have a guiding role in reducing the delivery rate of first cesarean section in China.
At present, with the liberalization of the second child policy, not only will there be a group of pregnant women who will have two children for the first time in the future, but also a group who will be pregnant again after cesarean section. In the past, most countries preferred elective cesarean section for those pregnant women with a history of cesarean section (CS). In 1999, Lu Lini reported 1174 cases of cesarean section, of which 137 cases were cesarean section again, accounting for 11.6%, while in 2003, the rate of cesarean section again in the United States was as high as 89.4%.
Therefore, it is widely discussed in the industry that the second cesarean section will obviously increase the bleeding during maternity and postpartum, the rate of blood transfusion, infection, bladder and intestinal injury and the incidence of deep venous thrombosis. At the same time, pelvic adhesion caused by previous surgery also increases the difficulty of surgery. Newborns are also prone to transient dyspnea.
Therefore, since 1996, the United States began to encourage pregnant women with a history of CS to choose vaginal delivery (VBAC) when they are pregnant again. ACOG began to advocate VBAC in 1999. However, after nearly ten years’ efforts, there are still many difficulties to be solved, especially the possibility of uterine rupture and the risk of maternal and fetal failure in trial delivery.
In 2005, the Society of Obstetricians and Gynaecologists of Canada (SOGC) published the second edition of Clinical Guidelines for Vaginal Delivery after Cesarean Section, which reviewed the contraindications of trial of labor, TOL) after Cesarean Section and its impact on pregnant women and fetus, and made an evidence-based assessment of the safety of VBAC.
It is believed that obstetricians should discuss the risks and benefits of VBAC with pregnant women who are willing to accept TOL. If the previous cesarean section was a transverse incision of the lower uterus and there was no contraindication to VBAC, the pregnant women should be advised to take TOL.
In order to ensure the safety and effectiveness of VBAC, the parturient should go to the hospital where emergency cesarean section can be carried out. During the labor process, we should closely monitor whether there is any abnormality between the mother and the baby, and deal with it in time if there is any abnormality. It is safe and reliable to use oxytocin to induce labor.
When the parturient is willing to accept induced labor and knows its risks, it is feasible to induce labor for the parturient with clear indications. Prostaglandin E2 and prostaglandin E1 are not recommended for induced labor during TOL. If the cervical maturity is low during TOL, Foley catheter can be used to soften the cervix. Although the success rate is not high, it will not increase the risk of uterine rupture.
At present, many large-scale case series studies have confirmed that VBAC is relatively safe. The domestic and foreign literature reports that the success rate of vaginal trial delivery after cesarean section is 60% ~ 80%, and the uterine rupture rate of patients with transverse incision of lower uterine segment after previous cesarean section is only 0.1% ~ 1.5%.
Therefore, vaginal delivery after cesarean section can effectively reduce the incidence of uterine rupture, improve the success rate of vaginal delivery, and also play a positive role in reducing postpartum maternal and child complications.
In the mid-1950s, Friedman established the standard of normal delivery progress and delivery curve by evaluating the labor process data of 500 primiparas admitted to Sloane Hospital in new york, and the delivery curve was called Friedman’s labor process diagram or labor process standard.
This standard has been used to evaluate and manage the delivery process of lying-in women and played a certain role. However, in the practice of obstetrics and anesthesia, it is found that with the development of human society, the natural process of childbirth has changed because of the delay of marriage and childbearing age, the increase of pregnant women’s body weight and the increase of fetal body weight. Managing the labor process according to Friedman’s labor process standard has greatly increased obstetric interventions such as artificial rupture of membranes, widespread use of oxytocin and abuse of instrumental midwifery.
In recent years, some evidence-based medicine research results reflecting the changes of natural labor process have been published one after another. The unanimous conclusion is that Friedman labor chart is no longer suitable for today’s obstetric clinic, and it is recommended to abandon it.
The National Institute of Child Health and Human Development (NICHD), the American Maternal and Fetal Medical Association (SMFM) and ACOG jointly recommended the use of new labor progress standards to manage the labor process. In 2014, experts from the Obstetrics and Gynecology Branch of the Chinese Medical Association also put forward a new standard of labor process and an expert consensus on its handling, advocating the popularization and use of new standards of normal labor process and abnormal labor process in China’s obstetric clinical work, and further observing and summing up experience in the implementation, so that this new standard of labor process can play a role in reducing unnecessary labor process intervention, reducing cesarean section rate and ensuring maternal delivery safety.
Many pregnant women in China choose cesarean section because they are unwilling to endure the pain of natural delivery. However, the development of painless delivery in China is still in its infancy, and there is still a big gap with developed countries in Europe and America. In developed countries, the labor analgesia rate is over 80%, and the cesarean section rate is less than 20%, while the labor analgesia rate in China is less than 1%, but the cesarean section rate is 50%.
Increasing the rate of labor analgesia can effectively reduce pregnant women’s fear of labor pain and help reduce cesarean section by at least 5%, or even more.
The situation that the natural delivery rate is continuously low and the cesarean section rate remains high in China has attracted the attention of the state. In 2011, China Maternal and Child Health Association launched the project of "promoting natural delivery and ensuring the well-being of mother and baby", and adopted a series of measures at the national level to "cool down" cesarean section.
The overall goal of the five-year project is to create a social environment and concept to promote natural childbirth, popularize appropriate midwifery techniques and standardized health education contents and methods to promote natural childbirth, reduce unnecessary cesarean section and maternal and infant mortality, and establish an incentive mechanism to promote natural childbirth through the establishment of training centers, the formation of missionary teams, the cultivation of technical backbones, and the improvement of safeguard measures.
Popularize appropriate techniques and measures to promote natural delivery and improve medical staff’s cognition and handling ability of maternal and infant complications; Standardize the health education guidance to promote natural childbirth; Raise public awareness of promoting natural childbirth; Effective use of maternal and child health care technical service resources, reduce non-medical indications of cesarean section, improve and protect the health of women and children.
In 2010, the Health Department of Sichuan Province also vigorously advocated natural delivery and reduced the cesarean section rate, and included the reduction of cesarean section rate in the target assessment of hospitals, requiring all hospitals in the province to reduce the cesarean section rate by 5 percentage points on the original basis. It is believed that under the control of the government, the high cesarean section rate in China can be curbed.
2. Prospect of natural childbirth in China
With the harm of cesarean section to parturient and newborn being paid attention to by the state and obstetricians, and the increase of measures to promote natural delivery, such as labor analgesia, doula companionship, the improvement of midwifery technology, the reduction of episiotomy rate of natural delivery, the increase of breech inversion, and the liberalization of national second child policy, prenatal health education and publicity for pregnant women, diet control during pregnancy, strengthening exercise, reducing the first cesarean section, and advocating VBAC.
The current cesarean section rate has been declining year by year in recent years, and the mode of intrapartum service has also changed from the mode of intervention to the mode of giving priority to the safety and health of mother and baby, and advocated providing humanized and individualized services to pregnant women in physiology, psychology and environment.
Continuous physical, psychological and emotional support to the parturient during the delivery process makes the parturient feel comfortable and safe, and can cooperate with the medical staff to spend the delivery process safely and happily, thus achieving the purpose of promoting natural delivery.
Organized by the Women’s Health Branch of the Chinese Preventive Medicine Association, the women who gave birth in 9 medical and health institutions such as Beijing Maternity Hospital from November 2000 to June 2001 were taken as the research objects, and the influence of accompanying delivery on the labor process, maternal and infant outcome and maternal psychology, the feasibility of appropriate delivery technology and the influence of changing the health care model during delivery on pregnancy outcome were studied by using the control research method. The results showed that vaginal delivery accounted for 85.5% in the accompanying group, which was significantly higher than that in the control group (66.0%). Cesarean section accounted for 8.1% in the labor group, which was significantly lower than that in the control group (28.6%).
The emergency labor rate, postpartum hemorrhage rate and neonatal asphyxia rate in the accompanying labor group were also significantly lower than those in the control group. Compared with the control group, the degree of mental stress, worry and fear in the accompanying group was significantly reduced, while those who relaxed and cooperated with the labor process were significantly higher than the control group. It shows that the appropriate delivery service mode can increase the natural delivery rate, reduce the cesarean section rate and improve the prognosis of mother and baby.
The application of new labor chart is strongly advocated in the world and China, which can reduce unnecessary labor intervention, reduce cesarean section rate and ensure the delivery safety of pregnant women.
At present, China’s cesarean section rate is as high as 46.2%, ranking first in the world, which brings heavy economic burden to the country, society and families and wastes great health resources. Therefore, it is the responsibility and obligation of contemporary medical workers to improve the natural delivery rate and reduce the cesarean section rate.
It is possible to promote vaginal delivery and reduce the cesarean section rate to less than 30% on the premise of the safety of mother and baby through pre-pregnancy health care, pregnancy education and obstetric clinic, but the WHO’s proposal of less than 15% is unrealistic in China.
Because WHO put forward this standard around 1985, the present situation has changed a lot compared with that time. And the basis for WHO to propose this goal comes from countries with a majority of multiparas.
At present, the delivery in our country is mainly primiparas, and even multiparas, about 50% people have a history of cesarean section. It is a challenge for China to improve the natural delivery rate and reduce the cesarean section rate. We have a long way to go to truly attach importance to maternal and child health.