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楊誠嘉

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

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楊誠嘉

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  1. 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

  2. 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

  3. 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？

  4. 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

  5. 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 Gynecol1922;4:645–50. • Kantor HI, Rember R, Tabio P, Buchanon R. Value of shaving the pudendal–perineal area in delivery preparation. Obstet Gynecol1965;25:509–12. • Basevi V, Lavender T. Routine perineal shaving on admission in labour. Cochrane Database Syst Rev 2001;(1): CD001236. • 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.

  6. 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

  7. 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 J1981;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. Cochrane DatabaseSyst Rev. 2007. • 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.

  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

  9. 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. Am J Obstet Gynecol1982;143: 496–500. • Ingemarsson E, Ingemarsson I, Svenningsen NW. Impact of routine fetal monitoring during labor on fetal outcome with long-term follow-up. Am J Obstet Gynecol1981;141: 29–38. • 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 Med1986;315:615–9. • 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 Gynecol1995;85:149–55.

  10. 參考文獻《二》 • American College of Obstetricians and Gynecologists. ACOG Practice Bulletin No. 70. Intrapartum fetal heart rate monitoring. Obstet Gynecol2005;106:1453–61. • Thacker SB, Stroup D, Chang M. Continuous electronic heart rate monitoring for fetal assessment during labor.Cochrane Database Syst Rev 2001;(2):CD000063. • National Institutes of Health. Antenatal diagnosis. NIH Consensus Statement 1979;2:11–5. • 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.

  11. 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

  12. 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 Anaesthesia 54 (4) , 329–334 doi:10.1046/j.1365-2044. • 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

  13. 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

  14. 參考文獻《一》 • Atwood , R. J. ( 1976 ). Parturitional posture and related birth behavior .Acta Obstetricia et Gynecologica Scandinavica Supplement ,57 , 5 . • Engelmann , G. J. ( 1977 ). Labor among primitive peoples . Reprint of 1882 edition . New York : AMS Press . • Johnson , N. , Johnson , V. A. , & Gupta , J. K. ( 1991 ). Maternal positions during labor . Obstetric and Gynecological Survey, 46 , 428 - 434 . • Fenwick , L. , & Simkin , P . ( 1987 ). Maternal positioning to prevent or alleviate dystocia in labor . Clinical Obstetrics and Gynecology, 30 , 83 - 89 .

  15. 參考文獻《二》 • Lawrence A, Lewis L, Hofmeyr GJ, Dowswell T, Styles C. Maternal positions and mobility during first stage labour. Cochrane DatabaseSysRev. 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 . Birth , 30 , 130 – 132

  16. 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 生產時背部直立，雖然可能增加出血量，但可以提供以下優點 • 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

  17. 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. Cochrane Database of Systematic Reviews .2007 Issue4.Art.No:CD002006 • Nasir A, Child birth in squatting position. J Pak Med Assoc. 2007 Jan;57(1):19-22. • 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. • Brément S, Delivery in lateral position. Randomized clinical trial comparing the maternal positions in lateral position and dorsal position for the second stage of labour. Gynecol Obstet Fertil. 2007 Jul-Aug;35(7-8):637-44. Epub 2007 Jun 15.

  18. 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 , 6 , 7 . • Collis , R. E. , Harding , S. A. , & Morgan , B. M. ( 1999 ). Effect of maternal ambulation on labour with low-dose combined spinal-epidural analgesia . Anaesthesia , 54 ( 6 ), 535 - 539 . • 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, 104 , 567 - 571 . • Fenwick , L. , & Simkin , P . ( 1987 ). Maternal positioning to prevent or alleviate dystocia in labor . Clinical Obstetrics and Gynecology, 30 , 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 , 13 ( 2 ), 30 - 34

  19. 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

  20. 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 Surv1983;38:322–38. • Weber AM, Meyn L. Episiotomy use in the United States, 1979–1997. Obstet Gynecol2002;100:1177–82. • Scott JR. Episiotomy and vaginal trauma. Obstet Gynecol Clin North Am2005;32:307–21. • Woolley RJ. Benefits and risks of episiotomy: a review of the English-language literature since 1980. Obstet Gynecol Surv1995;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 2004;156:1–198. • Bansal RK, Winoma MT, Ecker JL. Is there a benefit to episiotomy at spontaneous vaginal delivery? A natural experiment. Am J Obstet Gynecol1996;175:897–901.

  21. 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 Am1999;26:305–25. • Angioli R, Gomez-Marin O, Cantuaria G. Severe perineal lacerations during vaginal delivery: the University of Miami experience. Am J Obstet Gynecol2000;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 Gynecol2006;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.

  22. 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

  23. 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, 92 , 320 - 326 . • Keirse , M. J. , Enkin , M. , Crowther , C. , Neilson , J. , Hodnett , E. ,Hofmeyr , J. , et al . ( 2000 ). A guide to effective care in pregnancy and childbirth ( 3rd ed .). New York : Oxford University Press, Inc . • Kennell , J. , & McGrath , S . ( 2005 ). Starting the process of motherinfant bonding . Acta Paediatrica, 94 , 775 - 777 . • 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, 286 ,460 – 463

  24. 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 infantsCochrane Database of Systematic Reviews 2007 Issue 3 (Status: Updated) • Sari Goldstein Ferber and Imad R. Makhoul, The Effect of Skin-to-Skin Contact (Kangaroo Care) Shortly After Birth on the Neurobehavioral Responses of the Term Newborn: A randomized, Controlled TrialPediatrics2004;113;858-865 • Marshall Klaus, Mother and Infant: Early Emotional Ties,Pediatrics1998;102:1244–1246 • Nadia Bruschweiler Stern, Early Emotional Care for Mothers and Infants,Pediatrics1998;102:1278 –1281

  25. 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

  26. 參考文獻 • Albers , L. L. ( 2005 ). Overtreatment of normal childbirth in U.S. hospitals . Birth, 32 , 67 - 68 . • Hodnett ED, Gates S, Hofmeyr GJ, Sakala C, Weston J. Continuous support for women during childbirth. Cochrane Database of SystematicReviews .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 . Journal of Nursing Scholarship , 38 , 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 . Lifelines , 10 , 58 - 65

  27. 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

  28. 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]

  29. 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]

  30. 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[Good quality] • Ingestion of liquids/ nutrition[Fair quality] • Intravenous fluids[Poor quality] • Ambulation (walking)[Good quality] • Water immersion [Good quality] • Partogram [Fair quality] • Second stage • Pushing using a “closed” glottis[Good quality]

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

  32. 醫療化生產 V.S. 友善生產 科技 V.S.環保

  33. 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 V.S. 友善生產

  34. 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 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 醫療化生產 V.S. 友善生產

  35. 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

  36. 謝謝聆聽

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