陰道分娩於第二產程延遲或立即用力對產婦及胎兒的影響:隨機對照試驗之統合分析Comparison of the maternal and fetal outcomes between delayed and immediate pushing in second stage of vaginal delivery: Systematic review and Meta-analysis of randomized controlled trials

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2019-08-31 已刊登
新刊登 綜 整 預防/治療/介入類型

作  者

斯莉婷* 周寶鈺 林步鴻


A 類:實證健康照護綜整




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


  • 婦女健康 Women’s Health


第二產程 自然分娩 延遲用力 立即用力


Second stage of labor Immediate Pushing vaginal delivery delayed pushing






第二產程為子宮頸完全擴張至胎兒出生為止,子宮收縮在此階段強度最強。待產時過早用力、不恰當的用力或姿勢,可能導致子宮破裂、會陰疼痛及嚴重撕裂傷等併發症。然而,待產使用減痛分娩藥物,部分婦女在子宮頸口全開時無法正確施力,在子宮頸口全開之後即開始用力,可能讓母親在漫長的待產過程中感到疲憊。因此,部分產科照護者會在子宮頸口全開、胎頭下降、且有不自主用力感時,才開始引導產婦用力,以保留體力將胎兒娩出。第二產程對母嬰而言具有潛在的風險,因此,在適當時機教導產婦正確用力的方式非常重要。本研究目的為探討陰道分娩婦女於第二產程子宮頸全開時即開始引導產婦用力 (立即用力)、或子宮頸全開、胎頭下降接近陰道口且有不自主用力感時 (延遲用力) 再開始引導產婦用力,對產婦及胎兒的影響。
以系統性文獻回顧,使用”Labor Stage, Second”, “Delayed Pushing”, “Immediate Pushing”, 第二產程、自然產、延遲用力、立即用力等中、英文關鍵字,搜尋Cochrane Library、EMBASE、PubMed、華藝線上圖書館等資料庫,未設定語言限制,搜尋時間至2019年7月止。共找到2,318篇文獻,經刪除重複文獻,並檢視所有文章主題與摘要後,最後共納入10篇符合主題之隨機對照試驗進行分析。
納入文獻以考科藍偏差風險評估工具 (Cochrane's Risk of Bias tool) 進行品質評估,由兩位受過實證護理訓練的研究者 (斯、周),獨立評讀每篇文章,完成後進行交叉核對,當看法不一致時,則邀請第三位審查者 (林) 討論以達共識。納入文獻中,在分派隱匿方面、參與者和研究人員隱匿方面,偏差呈現「不清楚」。萃取數據以Review Manager 5.3 (The Nordic Cochrane Centre, Copenhagen, Denmark, 2014) 軟體進行統合分析。 本研究共納入10篇隨機對照試驗,共3,525位待產婦,統合分析結果如下:(一) 母親結果指標方面:相較於立即用力,延遲用力可以縮短用力時間25分鐘 (95% 信賴區間 [confidence interval, CI]:-37.2至-13.5)。另外,產婦之產後疲憊分數也較立即用力組低0.7分 (95% CI -1.1至-0.3)。(二) 新生兒結果指標方面:新生兒出生後第一分鐘阿帕嘉計分 (Apgar score),延遲用力比立即用力增加0.19分 (95% CI 0.10 至0.27)。
產婦在子宮頸全開、等待胎頭下降之用力衝動感來臨時再開始用力 (延遲用力),可以縮短用力時間並減輕產後疲憊程度,且不影響新生兒出生之阿帕嘉計分。因此,我們建議在待產期間,產科健康照護者在適當的時間開始引導正確用力,讓產婦有更充裕的時間休息、保留體力將胎兒娩出。


Ask an answerable question (PICO):
According to the current definition, the second stage of labor starts from complete dilatation of the cervix until the delivery of the fetus. At this stage, the force of uterine contraction is considered to be the strongest. After the cervix has been fully dilated, the caregiver/nurse will provide guidance to the mother regarding the push technique for delivering the fetus. However, complications, such as uterine rupture, post-partum perineum tenderness and severe laceration, may occur in the premature push of the second stage with inadequate technique or posture. When the patient received analgesic medications during labor for minimizing pain, or other fetal/maternal causes leading to prolong labor, some patient may not be able to push correctly after dilatation of the cervix. Severe tiredness and fatigue may be experienced during such long period of labor, especially in those who started immediate push right after full dilatation. Therefore, some obstetrician chose to start guiding the patient push only when the cervix is fully dilated, decent of fetal head, and involuntary exertion sensation in order to decreased the side effect from painless medications and save energy. Since the second stage of labor poses potential risks to both mother and fetus, it is especially critical to teach the patient the optimal time and correct way to start push. The purpose of this study was to investigate the maternal and fetal outcome in the puerpera who started to push when the second stage is reached (immediate pushing) comparing with push under the circumstance of fully dilated cervix, presenting part reach near introitus and involuntary exertion sensation (delayed pushing).
The Method and Analysis of Literature Review:
The search of literatures was conducted from Cochrane Library, EMBASE, PubMed, and Airiti Library (Chinese database) using the key words of “Labor stage, second”, “Delayed pushing”, “immediate pushing”, second stage, vaginal delivery, delay push, immediate push, without language restriction up to July, 2019. A total of 2,318 articles were retrieved. After deleting the duplicated articles, the title and abstracts of remaining study were reviewed based on the inclusion and exclusion criteria. In the end, there were 15 randomized controlled trials included in this study.
Critical Appraisal:
The included literatures were evaluated using Cochrane’s risk of bias tool for quality assessment by two independent reviewers (LT Szu, PU Zhou) and crosscheck after completion. In case of a discrepancy in opinion, a third person (PH Lin) served as a mediator, and a consensus was reached by discussion. In our review, distribution concealment and blinding of participants and personnel were given “unclear”. The extracted data was integrated and analyzed using Review Manager 5.3 (The Nordic Cochrane Centre, Copenhagen, Denmark, 2014) software. There are 10 randomized controlled studies included in this review with total 3,525 participates. The results are the following: (1) Maternal outcomes: comparing immediate pushing, delayed pushing could decrease total pushing time for 25 minutes (95% confidence interval [confidence] Interval, CI]: -37.2 to -13.5). In addition, maternal postpartum fatigue score was 0.7 points lower than the immediate pushing group (95% CI -1.1 to -0.3). (2) Neonatal outcome (Apgar score at 1 minute), has shown a higher score (0.19 points) in delayed pushing group than immediate pushing group (95% CI 0.10 to 0.27).
Conclusions and Recommendations:
It has been shown that the optimal time for push at the second stage is when the cervix is fully dilated, presenting part is near introitus, and experience involuntary exertion sensation (delayed pushing). This pushing strategy can decrease the total pushing time and decrease tiredness after the delivery without having negative impact on fetal health condition and Apgar score. Therefore, we recommend the caregiver instructs the pushing time at optimal moment, which allows the patient having more resting time and saving more energy during the labor