友善生產實證醫學

楊誠嘉 財團法人天主教聖保祿修女會醫院 婦產部

生產常規

• • • • • • • • • 剃薙 灌腸 持續性胎心音監測 生產時的禁食 待產姿勢 生產姿勢 會陰切開術〈常規性 v.s.選擇性〉 即刻新生兒照護 止痛藥物 vs 持續性支持

當前生產常規的迷思 • • • • 生產與生病 產婦與病人 有沒有區別？ 目前的生產常規是爲了多數正常生產而設 計還是爲少數異常個案而設計？ 目前的生產常規是爲了照護人員方便而設 計還是爲母嬰利益而設計？ 目前的生產常規除了生理照顧是否有考慮 到心理照顧？

剃薙 • • 舊有的觀點 – 減少會陰傷口感染率 – 加速及方便會陰傷口縫合 實證醫學觀點 – 會陰傷口感染率並未減少，反而可能製造更多 傷口 – 置產婦於窘境，增加不適感 – 陰毛新生時容易造成產婦不適與搔癢感 – 增加照顧人員感染風險

參考文獻

• World Health Organization.

Care in Normal Birth: A Practical Guide.

Report of a Technical Working Group. Geneva: WHO , 1996.

• Johnston RA, Sidall RS. Is the usual method of preparing patients for delivery beneficial or necessary?

Am J Obstet Gynecol

1922;4:645 –50.

• Kantor HI, Rember R, Tabio P, Buchanon R. Value of shaving the pudendal –perineal area in delivery preparation.

Obstet Gynecol

1965;25:509 –12.

• Basevi V, Lavender T. Routine perineal shaving on admission in labour.

Cochrane Database Syst Rev

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• Kovavisarach E, Jirasettasiri P. Randomised controlled trial of perineal shaving versus hair cutting in parturients on admission in labor.

J Med Assoc Thai

2005;88:1167 –71.

灌腸 • • 舊有的觀點 – 減少會陰傷口感染及新生兒感染 – 刺激子宮收縮，加速胎頭下降 實證醫學觀點 – 減少會陰傷口感染及新生兒感染效果有限 – 無法加速產程 – 增加產婦不適 – 增加照顧人員工作負擔 – 增加醫療費用成本

參考文獻

• World Health Organization.

Care in Normal Birth: A Practical Guide.

Report of a Technical Working Group. Geneva: WHO , 1996.

• Romney ML, Gordon H. Is your enema really necessary?

Br Med J

1981;282:1269 –71.

• • Rutgers S. Hot, high and horrible. Should routine enemas still be given to women in labour?

Cent Afr J Med

1993; 39:117 –20.

Reveiz L, Gaitán HG, Cuervo LG. Enemas during labour.

Database

Syst Rev. 2007 .

Cochrane

• Tzeng YL, Shih YJ, Teng YK, Chiu CY, Huang MY. Enema prior to labor: a controversial routine in Taiwan .

J Nurs Res

2005;13:263 –70.

• Cuervo LG, Bernal MD, Mendoza N. Effects of high volume saline enemas

vs.

no enemas during labour —the N-MA Randomised Controlled Trial [ISRCTN 43153145].

BMC Pregnancy Childbirth

2006;6:8.

持續性胎心音監測

• • 舊有的觀點 – – 減少新生兒週產期死亡率 減少新生兒未來神經發展缺陷〈如腦性麻痺〉 實證醫學觀點 – 新生兒因為缺氧所造成的死亡率只有降低一些〈未達統計上 明顯差異〉，新生兒總週產期死亡率並未降低 – – 新生兒癲癇發生率降低但無助於長期神經發展預後 出生時APGAR score，NICU住院率，腦性麻痺發生率無明顯 差異 – 持續性胎心音監測適用於高危險妊娠，對於低風險正常生產 它並不能比間斷性胎心音監測提供更多好處，反而可能增加 剖腹產率，增加產鉗及真空吸引器使用率

參考文獻《一》

• Yeh SY, Diaz F, Paul RH. Ten-year experience of intrapartum fetal monitoring in Los Angeles County/University of Southern California Medical Center. 496 –500.

Am J Obstet Gynecol

1982;143: • Ingemarsson E, Ingemarsson I, Svenningsen NW. Impact of routine fetal monitoring during labor on fetal outcome with long-term follow-up.

Am J Obstet Gynecol

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• Leveno KJ, Cunningham FG, Nelson S, Roark M, Williams ML, Guzick D, et al. A prospective comparison of selective and universal electronic fetal monitoring in 34,995 pregnancies.

N Engl J Med

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• Vintzileos AM, Nochimson DJ, Guzman ER, Knuppel RA, Lake M, Schifrin BS. Intrapartum electronic fetal heart rate monitoring versus intermittent auscultation: a meta-analysis.

Obstet Gynecol

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參考文獻《二》

• American College of Obstetricians and Gynecologists. ACOG Practice Bulletin No. 70. Intrapartum fetal heart rate monitoring.

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• Thacker SB, Stroup D, Chang M. Continuous electronic heart rate monitoring for fetal assessment during labor .

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• • National Institutes of Health. Antenatal diagnosis.

NIH Consensus Statement

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• American College of Obstetricians and Gynecologists.

Intrapartum Fetal Heart Rate Monitoring

. ACOG Technical Bulletin No. 132. Washington, DC: ACOG , 1989.

Royal College of Obstetricians and Gynaecologists.

The Use of Electronic Fetal Monitoring.

Evidence-based Clinical Guideline No. 8. London: RCOG, 2001.

生產時的禁食

• • 舊有的觀點 – – – 假設須緊急剖腹生產，麻醉比較安全 可以減少產婦嘔吐症狀 可以用點滴補充水分及營養，對母親及胎兒反而比較 安全 實證醫學觀點 – 全身麻醉才較有風險，而且液體食物只須禁食2小時， 固體食物只須禁食6小時 – 禁食產婦反而較多嘔吐症狀，只是嘔吐量較少而已 – 禁食並未提供更多好處，容許產婦依其生理需求進食， 並未明顯增加風險 – 生產時使用點滴注射的好處仍未被確定，不建議常規 使用

參考文獻

     Jan-Philipp Breuer, Ingrid Correns, Claudia Spies. Preoperative Fasting in Labour Anasthesiol Intensivmed Notfallmed Schmerzther 2007; 42: 192-198 O'Sullivan G , Scrutton M . NPO during labor. Is there any scientific validation?Anesthesiol Clin North America. 2003 Mar;21(1):87-98 Sleutel M , Golden SS . Fasting in labor: relic or requirement. J Obstet Gynecol Neonatal Nurs. 1999 Sep-Oct;28(5):507-12. M. J. L Scrutton, G. A Metcalfe, C Lowy, P. T Seed, G O'Sullivan (1999) Eating in labour. A randomised controlled trial assessing the risks and benefits 2044.

Anaesthesia 54 (4) , 329–334 doi:10.1046/j.1365 Hubertina C.J. Scheepers, Marion C.J. Thans, Pieter A. de Jong, Gerard G.M. Essed, Saskia Le Cessie, Humphrey H.H. Kanhai (2002) A double-blind, randomised, placebo controlled study on the influence of carbohydrate solution intake during labour BJOG : An International Journal of Obstetrics and Gynaecology 109 (2) , 178–181 doi:10.1111/j.1471-0528.2002

待產姿勢

• • 舊有的觀點 – 產婦比較怕累，喜歡躺著，也比較舒服 – 產婦應視為病患，如果讓產婦下來走動，會增加危險，也增 加照護困難度 實證醫學觀點 – 待產過程中，允許產婦可以自由活動或變換姿勢，有助於減 輕疼痛；產婦若這一胎可以自由活動或變換姿勢，幾乎都希 望下一胎也可以如此 – – 讓產婦下來走動，對產婦或胎兒並無壞處 待產過程中，允許產婦可以自由活動或變換姿勢，並不影響 產程進行 – 產婦除非是高危險群或有禁忌症，應被允許自由活動或變換 姿勢

參考文獻《一》

• Atwood , R. J. ( 1976 ). Parturitional posture and related birth behavior .

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• Engelmann , G. J. ( 1977 ).

Labor among primitive peoples

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• Johnson , N. , Johnson , V. A. , & Gupta , J. K. ( 1991 ). Maternal positions during labor .

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參考文獻《二》

• Lawrence A, Lewis L, Hofmeyr GJ, Dowswell T, Styles C. Maternal positions and mobility during first stage labour.

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Sys Rev. 2009 Apr 15;(2):CD003934 .

• Hands and knees posture in late pregnancy or labour for fetal malposition (lateral or posterior

). Cochrane Database Syst Rev. 2007 Oct 17;(4):CD001063

• Steven L. Bloom (1998) Lack of effect of walking on labor and delivery

N Engl J Med 1998;339:76-9.

• Simkin , P . ( 2003 ). Maternal positions and pelvis revisited .

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生產姿勢

• • 舊有的觀點 – 產婦平躺，比較好用力，比較不會疲勞 – 產婦平躺，醫師比較方便接生，比較安全 實證醫學觀點 點 生產時背部直立，雖然可能增加出血量，但可以提供以下優 – 子宮脊椎相對角度比較能有效用力產出胎兒 – – – – – – – 利用重力加速胎頭下降 增加骨盆內口及外口寬度 增強子宮收縮強度 減少下腔靜派壓迫，增加血液回流，較少胎心音異常 縮短第二產程 減少使用產鉗或真空吸引，減少會陰切開 減輕疼痛

參考文獻《一》

• • • • Bodner-Adler B , Women's position during labour: influence on maternal and neonatal outcome.

Wien Klin Wochenschr. 2003 Oct 31;115(19-20):720-3.

• Position for women during second stage of labour.

Cochrane Database Syst Rev. 2004;(1):CD002006.

• • Gupta JK, Hofmeyr GJ, Smyth R. Position in the second stage of labour for women without epidural anaesthesia.

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of Systematic Reviews .2007 Issue4.Art.No:CD002006 Nasir A

,

Child birth in squatting position

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Roberts J , Best practices in second stage labor care: maternal bearing down and positioning.

J Midwifery Womens Health. 2007 May-Jun;52(3):238-45.

Downe S , A prospective randomised trial on the effect of position in the passive second stage of labour on birth outcome in nulliparous women using epidural analgesia.

Midwifery. 2004 Jun;20(2):157-68.

Br é ment S , Delivery in lateral position. Randomized clinical trial comparing the maternal positions in lateral position and dorsal position for the second stage of labour

2007 Jun 15. . Gynecol Obstet Fertil . 2007 Jul-Aug;35(7-8):637-44. Epub

參考文獻《二》

• Caldeyro-Barcia , R . ( 1979 ). The influence of maternal position on time of spontaneous rupture of membranes, progress of labor, and fetal head compression .

Birth and the Family Journal

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• Collis , R. E. , Harding , S. A. , & Morgan , B. M. ( 1999 ). Effect of maternal ambulation on labour with low-dose combined spinal epidural analgesia .

Anaesthesia

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• DeJong , P. R. , Johanson , R. B. , Baxen , P. , Adrians , V. D. , van der Westhuisen , S. , & Jones , P. W. ( 1997 ). Randomized trial comparing the upright and supine positions for the second stage of labour .

British Journal of Obstetrics and Gynaecology

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, 567 571 .

• Fenwick , L. , & Simkin , P . ( 1987 ). Maternal positioning to prevent or alleviate dystocia in labor .

Clinical Obstetrics and Gynecology

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, 83 - 89 .

• Keen , R. , DiFranco , J. , Amis , D. , & Albers , L . ( 2004 ). #5: Non supine(e.g., upright or side-lying positions for birth .)

Journal of Perinatal Education

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會陰切開術〈常規性 v.s.選擇性

〉 • • 舊有的觀點 – – 減少骨盆腔及會陰鬆弛，減少尿失禁及大便失禁 減少新生兒出生時缺氧窘迫，減少新生兒顱內出血， 減少新生兒腦性麻痺 – 傷口不規則，不好縫合，不容易瘉合，傷口較痛 實證醫學觀點 – 無證據支持可以減少骨盆腔及會陰鬆弛，尿失禁及大 便失禁，新生兒出生時缺氧窘迫，新生兒顱內出血， 新生兒腦性麻痺 – – – 減少前側會陰裂傷，但增加會陰三或四度裂傷發生率， 傷口併發症及疼痛增加 常規性會陰切開並未提供更多好處，選擇性會陰切開 應是較佳方法

參考文獻《一

》 • Thacker SB, Banta HD. Benefits and risks of episiotomy: aninterpretative review of the English language literature,1860 –1980.

Obstet Gynecol Surv

1983;38:322 –38.

• Weber AM, Meyn L. Episiotomy use in the United States, 1979 –1997.

Obstet Gynecol

2002;100:1177 –82.

• Scott JR. Episiotomy and vaginal trauma.

Obstet Gynecol Clin North Am

2005;32:307 –21.

• Woolley RJ. Benefits and risks of episiotomy: a review of the English-language literature since 1980.

Obstet Gynecol Surv

1995;50:806 –35.

• • Kozak LJ, Owings MF, Hall MJ. National Hospital Discharge Survey: 2001 annual summary with detailed diagnosis and procedure data.

Vital Health Stat

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Bansal RK, Winoma MT, Ecker JL. Is there a benefit to episiotomy at spontaneous vaginal delivery? A natural experiment.

Am J Obstet Gynecol

1996;175:897 –901.

參考文獻《二》

• Myers-Helfgott MG, Helfgott AW. Routine use of episiotomy in modern obstetrics: should it be performed?

Obstet Gynecol Clin North Am

1999;26:305 –25.

• Angioli R, Gomez-Marin O, Cantuaria G. Severe perineal lacerations during vaginal delivery: the University of Miami experience.

Am J Obstet Gynecol

2000;182:1083 –5.

• Carroli G, Belizan J. Episiotomy for vaginal birth.

Cochrane Database Syst Rev

2000;(2):CD000081.

• Hartmann K, Viswanathan M, Palmieri R, Gartlehner G, Thorp J Jr, Lohr KN. Outcomes of routine episiotomy: a systematic review.

JAMA

2005;293:2141 –8.

• American College of Obstetricians and Gynecologists. ACOG Practice Bulletin No. 71. Episiotomy.

Obstet Gynecol

2006;107:957 – 62.

• Labrecque M, Baillargeon L, Dallaire M. Association between median episiotomy and severe perineal lacerations in primiparous women.

Can Med Assoc J

1997;156:797 –802.

即刻新生兒照護

• • 舊有的觀點 – 所有新生兒均須即刻接受醫療照護如：抽吸口腔，斷 臍，臍帶護理，測量體重身長，沐浴，Vit K1注射， 點眼藥等，保溫箱內觀察一段時間，確保新生兒正常 穩定後才能讓父母接觸 實證醫學觀點 – 出生後新生兒與母親的即刻肌膚接觸以及後續的親子 同室有助於新生兒度過剛出生時的關鍵生理適應期， 幫助親子依附關係的建立以及協助母乳哺育成功

參考文獻《一》

• Bystrova , K. , Widstom , A. M. , Matthiesen , A. S. , Ransjo Arvidson ,A. B. , Welles-Nystrom , B. , & Wassberg , C . ( 2003 ). Skin-to-skin contact may reduce negative consequences of “ the stress of being born ” : A study on temperature in newborn infants, subjected to different ward routines in St. Petersburg .

Acta Paediatrica

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• Keirse , M. J. , Enkin , M. , Crowther , C. , Neilson , J. , Hodnett , E. ,Hofmeyr , J. , et al . ( 2000 ).

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( 3rd ed .). New York : Oxford University Press, Inc .

• Kennell , J. , & McGrath , S . ( 2005 ). Starting the process of motherinfant bonding .

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• Klaus , M. H. , Jerauld , R. , Kreger , N. , McAlpine , W. , Steffa , M. K. , & Kennell , J . ( 1972 ). Maternal attachment: Importance of the first post-partum days .

New England Journal of Medicine

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參考文獻《二

》 • Klaus , M. H. , & Kennell , J. H. ( 1982 ).

Parent-infant bonding

( 2nd ed .). St. Louis, MO : C.V. Mosby .

• ER Moore, GC Anderson, N Bergman, Early skin-to-skin contact for mothers and their healthy newborn infants

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Pediatrics

2004;113;858-865 • Marshall Klaus, Mother and Infant: Early Emotional Ties,

Pediatrics

1998;102:1244 –1246 • Nadia Bruschweiler Stern, Early Emotional Care for Mothers and Infants,

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1998;102:1278 –1281

止痛藥物 vs 持續性的支持

• • 舊有的觀點 – 支持並不能減緩產婦疼痛，對生產過程與結果的影響不如醫療措 施重要 – 訓練陪產醫護人員擁有執行醫療措施的專業知識與技術比學會支 持技巧重要 – 提供實質藥物減痛勝於心理支持 實證醫學觀點 – – – 持續性的支持可以 – 減少如剖腹產，產鉗或真空吸引等醫療介入性措施的使用，產程 較少使用止痛藥物或無痛分娩 – 使產婦較能投入整個生產的適應過程，較能掌控自己的生理及心 理反應，合作性較高 使產婦有較高滿意度的生產經驗，也有較高的哺乳率 使產婦對自己的新生兒有更高的評價 使產婦產後較少焦慮表現 有較低的憂鬱評分 有較高的自信 產婦生產時接受的照顧方式可能影響產婦之後照顧新生兒的方式

參考文獻

• Albers , L. L. ( 2005 ). Overtreatment of normal childbirth in U.S. hospitals .

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 Hodnett ED, Gates S, Hofmeyr GJ, Sakala C, Weston J. Continuous support for women during childbirth. Cochrane Database of Systematic Reviews . 2011, Issue 2. Art.No:CD003766 • Wolman WL.

Social Support During Childbirth. Psychological and Physiological Outcomes.

Johannesburg, South Africa: University of Witwatersrand; 1991. Thesis • Sauls , D. J. ( 2006 ). Dimensions of professional labor support for intrapartum practice .

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, 36 – 41 • Adams , E. , Besuner , P. , Bianchi , A. , Lowe , N. , Ravin , C. , Reed , M. , et al . ( 2006 ). Labor support: Exploring its role in modern and high-tech birthing practices .

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Evidenced-based recommendations for labor and delivery

American Journal of Obstetrics & Gynecology Reviews ,

NOVEMBER 2008

Vincenzo Berghella, MD; Jason K. Baxter, MD, MSCP; Suneet P. Chauhan, MD

A: strongly recommends that clinicians provide [the service] to eligible patients.

• First stage

– Support person (doula) [Good quality]

– Training of birth assistants in developing country

[Good quality]

• Second stage

– Upright position [Good quality] – Perineal massage from 34 wks on [Good quality]

B: recommends that clinicians provide [this service] to eligible patients

.

• First stage

– Delayed admission [fair quality]

– Active management of labor

[Good quality]

• Second stage

– Delayed pushing [Good quality]

– Perineal massage during second stage

[Good quality]

– Warm packs

[Good quality]

C: makes no recommendation for or against routine provision of [the service].

• • First stage – Midwife vs conventional care [Good quality] – Fetal admissions tests: Fetal heart rate tracing – Ingestion of liquids/ nutrition [Fair quality] – – Intravenous fluids [Poor quality] Ambulation (walking) [Good quality] – Water immersion [Good quality] – Partogram [Fair quality] [Good quality] Second stage – Pushing using a “closed” glottis [Good quality]

D: recommends against routinely providing [the service] to asymptomatic patients

.

• First stage – Radiographic pelvimetry [Good] – Home-like births [Good] – Fetal admissions tests: Amniotic fluid volume [Good] – Enemas [Fair] – Perineal shaving [Fair] – Chlorhexidine vaginal irrigation – Routine early AROM – Meperidine for abnormal progression of labor • Second stage – Prophylactic oxygen – Prophylactic tocolysis – “Hands on” method – Fundal pressure – Episiotomy

醫療化生產 V.S. 友善生產 科技 V.S.環保

醫療化生產 V.S. 友善生產 • High-Tech – 儀器代替人力 – 人員訓練相對簡單， 素質要求不高 – minimal requirement & 標準化照顧 – 視生產為一個高風險 過程 – 視產婦與新生兒為兩 個不同服務對象 • High-touch – 人力密集事業 – 人員訓練相對困難， 且講究素質 – High quality & 個 別化照顧 – 視生產為人生一個重 要生命經驗 – 視產婦與新生兒為一 體

醫療化生產

• High-Tech – 在醫療安全原則下， 先考慮照護人員之需 求 – 多數產婦是沒有能力 克服產痛，他們需要 被協助 – 以外在醫療方法快速 減輕產婦疼痛 – 以藥物或醫療處置滿 足產婦生理需求為治 療原則

V.S. 友善生產

• High-touch – 在醫療安全原則下， 先考慮照護對象之需 求 – 多數產婦是有能力可 以克服產痛，他們需 要被引導 – 以非醫療方法啟發產 婦內在減痛機制 – 以非藥物或支持措施 滿足產婦心理需求為 治療原則

結語 • • • • 生產, 不是生病, 不要把產婦當病患, 不 要把生產當做一般疾病來治療 生產是自然的, 是健康的, 是正常的生理 現象 讓生產充滿尊嚴與能量 溫和(人性化)生產既不是捨棄科技, 也不 全然仰賴科技, 而是依實證醫學平衡運用 科技

謝謝聆聽