四川省自然分娩服务方式现状分析

Current status of natural childbirth services of Sichuan Province

目的了解四川省自然分娩助产服务现状,为改善助产质量提供资料。方法对四川省21个市(州)产科服务机构进行抽样问卷调查,了解其目前的临床服务方式,以世界卫生组织正常分娩实践指南为标准进行对比。结果目前临床助产服务机构在A类临床实践行为(应予鼓励和有益的方式)使用率不足50%,二甲以上医院较下级医院执行程度好。在A类方法中,"有温馨一体化产房""有分娩支持的工具分娩球步行车""有淋浴设施"在不同级别的机构中差异均有统计学意义(x^2值分别为9.666、8.337、16.132,均P<0.05),而"有饮食支持""医院提供饮食""产房有产妇专用座椅""允许家属陪伴及全程陪护"在不同级别的机构中无统计学意义(x^2值分别为1.483、3.820、2.234、1.483,均P>0.05);B类临床实践行为(应该淘汰的明显有害或无效的方法 )仍在惯性沿用达50%~100%,90%以上的医院采取仰卧位接生体位(x^2=1.105,P>0.05),大多数医院仍然沿用传统的直肠检查宫口、常规剔除阴毛、常规静脉输液等产程方法 ,各级医院间使用情况差异均无统计学意义(x^2值分别为4.1553、6.999、1.560、5.120,均P>0.05);C类是建议应谨慎使用,并需要进一步研究的方法 ,除二甲以上医院合理使用抗生素执行较合理(x^2=16.868,P<0.05),而产程中的人为干预措施高"第一产程常规早期人工破膜""第二产程宫底加腹压""产后常规使用缩宫素"等各级别医院间差异均无统计学意义(x^2值分别为5.169、3.476、6.132均P>0.05);在D类(常用的但不适当的)方法中,除外有"有温馨一体化产房"设备的医院,其它医院均是将产妇不断转移至不同的房间待产、分娩、产后观察;级别高的医院会阴侧切率,胎膜早破者常规平卧位使用率均低于级别低的医院,而临产后全程胎心监测在级别高的医院使用率高于级别低的医院,差异均有统计学意义(F=6.529;x^2值分别为13.666、37.425,均P<0.05)。结论要加强助产适宜技术培训,推广产科服务新理念,促使自然正常分娩;做好逐层培训,建立有效的机制。

Objective To investigate the current status of natural childbirth midwifery services of Sichuan Province and to provide information for improving the quality of midwifery.Methods Questionnaire survey of obstetric service institutions in 21states of Sichuan Province was conducted to understand the current services.Normal childbirth practice guidelines of the world health organization （ WHO） was taken as standard.Results The utilization rate of class A practice （ encouraged and beneficial way） in current clinical obstetric service institutions was less than 50%.The execution in second-grade class-A hospitals or above was better than lower-leveled hospitals.In class A method, there were significant differences in the different levels of institutions in the aspects of a sweet integration room, labor support tools, and shower facilities （χ^2 value was 9.666, 8.337 and 16.132, respectively, all P 〈0.05）, and there were no significant differences in the aspects of food supply, providing food and drink by hospital, delivery room with maternal special seat, and allowing family members to accompany and full escort （χ^2 value was 1.483, 3.820, 2.234 and 1.483, respectively, all P〉0.05）.Class B clinical practice （ be eliminated or obviously harmful or invalid） was still used in 50%-100% hospitals.More than 90% of the hospitals took supine position （χ^2 =1.105, P 〉0.05）, and most hospitals still used traditional rectal examination, rejecting pubic hair and intravenous transfusion.There were no significant differences among different hospitals（χ^2 value was 4.1553, 6.999, 1.560 and 5.120, respectively, all P 〉0.05 ） .Class C methods were recommended to be carefully used and needed further research.There were no significant differences in the aspects of artificial intervention measures in labor such as routine artificial rupture of fetal membrane in the first early stage of labor, increasing abdominal pressure at the bottom of the uterus, and routine use of oxytocin postpartum （χ^2 value was 5.169, 3.476 and 6.132, respectively, all P〉0.05） except that reasonable use of antibiotics in second-grade class-A hospitals （χ^2 =16.868,P〈0.05）.As for class D methods （common but inappropriate）, except for hospitals with sweet integration room equipment, the pregnant women were constantly shift to a different room for delivery and postpartum observation.The episiotomy rate and usage of horizontal position in premature rupture of membranes women were lower in high leveled hospitals than in low leveled hospitals, while the rate of fetal heart monitor in whole stage of labor was higher in high leveled hospitals than in low leveled hospitals （F=6.529,χ^2 value was 13.666 and 37.425, respectively, both P〈0.05）.Conclusion Appropriate technologies of midwifery training should be strengthened, and new ideas of obstetric service should be generalized to promote natural normal childbirth.An effective mechanism should be established to do a good job in training step by step.