陰道分娩產婦在第二產程使用自然用力法是否能減輕會陰撕裂傷程度Vaginal delivery maternal use of spontaneous pushing method in the second stage of labor can reduce the degree of perineal laceration

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2020-10-21 已刊登
新刊登 綜 整 預防/治療/介入類型

作  者

張淑雲* 傅美玲 古雪貞

實證知識類別

A 類:實證健康照護綜整

PICO

治療/預防性問題

治療/介入措施

婦產科與婦女健康 Obstetrics, Gynecology and Women's Health

科別

  • 婦女健康 Women’s Health

中文關鍵詞

第二產程 自然用力法 會陰撕裂傷

英文關鍵詞

second stage of labor spontaneous pushing perineal laceration

機構名稱

台灣基督長老教會馬偕醫療財團法人馬偕紀念醫院

申請單位

馬偕紀念醫院護理部

中文摘要

形成臨床提問:
陰道分娩產婦於第二產程時常使用閉氣用力方式,閉氣用力會使胎頭快速且強烈的下降,易造成產婦會陰、子宮頸及泌尿道的損傷,增加使用器械輔助生產的比率,易造成新生兒的損傷、更會增加產婦的疲憊感。有研究指出採用自然用力法可以減緩胎兒下降的速度,使產婦的會陰部肌肉慢慢延展,減少陰道壁、子宮頸韌帶和結締組織的壓力。因此,期望經由文獻的搜尋及分析,產生有利證據,提供臨床醫護人員照護上的參考。
文獻搜尋的方法與分析:
以實證PICO的方式進行資料收集,關鍵字為第二產程產婦(Labor Stage, Second)、自然用力法(spontaneous pushing;bearing down pushing)、閉氣用力法(Valsalva maneuver;breath-holding pushing;directed pushing)、會陰傷口、會陰撕裂傷(perineal laceration;perineal wound),將關鍵字依布林邏輯以OR連集及以AND交集,並應用切截字進行文獻搜尋。搜尋Cochrane library、PubMed、CINAHL、臺灣期刊論文索引系統及華藝線上圖書館等資料庫,並適當調整搜尋設定,共獲得47篇相關文獻,排除重複、標題及摘要與主題不符,最後選擇與主題符合的2篇隨機實驗研究進行評讀。
文獻的品質評讀:
評讀工具使用Critical Appraisal Skill Programme(CASP),進行有效性(validity)、重要性(importance)及應用性(practicability)等進行文獻評析。依Oxford Centre for Evidence- Based Medicine 2011 Levels of Evidence的臨床研究證據等級,評析文章皆屬於 Level 2。
結論與建議:
評析結果兩篇文獻皆顯示陰道分娩產婦於第二產程時,使用自然用力法或閉氣用力法造成會陰部撕裂傷方面無顯著差異,讓產婦能依著自己身體的感覺使用自然用力法,緩緩吐氣或發出聲音,不僅能放鬆會陰部肌肉,降低產時的疲憊感受,使其在待產及生產的過程中獲得更多的掌控權,進而提升其滿意度。

英文摘要

Ask an answerable question (PICO):
Valsalva maneuver is a common method used by vaginal-delivery women in the second stage of labor. However, Valsalva maneuver will wear out the maternity, cause both maternal and neonatal damage, and even increase the rate of device-assisted delivery; meanwhile, it also results in rapid and intense descending of the fetal head which raises the damage level of perineum, cervix and urinary tract. The review of this article indicates that using spontaneous pushing is able to slow down the descending of fetal head and allows perineal muscles to slowly extend, which further reduced the pressure on the anterior vaginal wall, the supporting cervical ligament and connective tissues. Therefore, through looking into this article, we expect to provide a caring principle for clinical staff and professions.
The Method and Analysis of Literature Review:
This article is demonstrated in EBM ,setting “Second Labor Stage”,” Spontaneous pushing” , “bearing down pushing”, “Valsalva maneuver”, “breath-holding pushing”, “directed pushing”, “perineal laceration”,”perineal wound” as keywords in PICO; Under Brin logics, the keywords were included in the Union of OR and the Intersection of AND, and using cut-off words for searching. Searching in databases such as Cochrane library, PubMed, CINAHL, Taiwan journal article index system and Huayi online library while adjusting the searching settings, 47 related documents were included. After excluding duplication, un-related titles and abstracts, two randomized experimental studies that met the subject were reviewed.
Critical Appraisal:
According to the clinical research evidence level of "Oxford Centre for Evidence- Based Medicine 2011 Levels of Evidence", the Critical Appraisal Skill Programme (CASP) was used as a reviewing tool to pull out article reviews on three aspects: validity, importance, and practicability. The reviewed articles are all rated as Level 2.
Conclusions and Recommendations:
After article reviewing and evaluation, both documents revealed that there was no significant difference in perineal laceration between Spontaneous pushing and Valsalva maneuver in the second stage of labor, however, the former allows maternity to exhale or let out sound depending on her own feeling, not only does this relax the perineal muscles, reduce maternal exhaustion, but allow more maternal control in delivery process, and by doing so, it improves their satisfaction, reduces postpartum urinary incontinence rate effectively and furthermore, improves the quality of life.