影响产程图临床应用的相关因素分析

产程图作为描述产程进展的标准化图形,自提出以来,不断发展演变,其目的是更好地帮助医务人员识别产程中出现的问题,并根据临床管理方案采取干预措施,降低母婴不良结局的发生。但产程图是复杂多变的,理论上的最佳实践干预措施与临床实际操作存在差距。通过对产程图临床应用的研究进展进行回顾并综述,探讨产程图自身因素、医务人员专业技能、孕妇、社会环境、组织背景、经济和政治背景等因素对产程图在临床中有效应用的影响。医务人员应准确识别这些影响因素,正确评估产程图在产科中的地位,并依赖新兴技术将产程图进行改善和优化,从而使产程图得到更好的应用并服务于临床工作。     

产程研究进展

全球剖宫产率的逐年升高已经引起产科学界的热切关注及担忧,产程延长或停滞是临产后剖宫产的指征。产程正常与否的准确判断对降低剖宫产率至关重要。临床上常应用产程图动态反映产程进展。本文从产程图、产程时限及产程干预三方面进行阐述,简述产程图的出现、进展及国内外产程时限的研究变化,综合临床上采用的产程干预措施,以展望设计适应我国妊娠妇女的产程图并制定相应的产程标准,减少产程干预、降低剖宫产率。     

分娩机制头盆适应性的分析与思考

分娩机制的核心是头盆适应性,训练产房工作者将产程图数据解读为胎头与骨盆各平面适应性画面,是产程管理的重要理念。推荐应用不涵盖潜伏期的WHO改良产程图管理产程,结合产程图研究进展,根据胎头与骨盆各平面之间的适应性确定产程处理原则。产程以观察和评价为主,避免过多人为干预,在加强胎儿、产妇对分娩耐受性监护的基础上,适时评价头盆适应性,把握待产或试产程度,及时识别和判断难产,决定是否以更积极的分娩措施促进分娩,包括促进产程措施、阴道助产或剖宫产结束分娩。对活跃期前期和无头盆不称的第二产程后期,在观察胎儿、母亲对进一步分娩耐受性的基础上,应给予比既往更长时间的试产机会。     

产程时限的现代观

<正>产程处理是现代产程管理中重要的环节,而正确的产程处理、有效识别早期难产因素、减少产时干预、降低剖宫产率,从而保障母婴安全与产程时限的判断密切相关。六十余年来,国内外对产程时限的划分均达成了共识,并作为处理产程的标准。但随着当今分娩人群的变化、产程干预的实施以及临床研究方法的改进和完善,既往一直沿用的产程时限受到了众多学者的质疑。     

产时Ⅱ类胎心监护的流程管理

Ⅱ类胎心监护是产程中常见的胎心监护图形，其形式多样，正确识别和评估Ⅱ类胎心监护，并根据具体临床情况进行针对性干预，可降低不良妊娠结局的发生。文章根据产时胎心监护三级评估系统，介绍产时Ⅱ类胎心监护的处理流程，并对不同类型Ⅱ类胎心监护的病因及干预措施进行了阐述，以指导临床实践。     

欠发达地区基层医院产后出血的多中心临床干预性研究

目的:分析影响产后出血的临床相关因素,评价临床干预效果。方法:选取6个基层医院为研究点,进行前瞻性研究,先进行流行病学调查;培训推广预防技术,进行临床干预;最后比较干预前后产后出血情况,评价效果。结果:影响产后出血的相关因素有产程处理,新生儿出生体重,第3产程与第4产程干预;干预前后产后出血量,产后出血率比较差异均有统计学意义。结论:孕期合理营养,正确处理产程,第3产程与第4产程干预,推广产后出血预防技术,推广称重法估计失血量,建立三级联动机制,非血源地建立预警方案等,有利于防治产后出血。     

新产程标准下产程中转剖宫产影响因素研究进展

随着我国新产程标准的实施,阴道分娩率增加,首次剖宫产率降低,但以胎儿窘迫、产程中发热为指征的产程中转剖宫产增加,产程中转剖宫产导致母儿并发症的风险增加。阴道分娩是一个复杂的生理过程,在影响分娩的各个因素中,孕妇年龄、身高、体质量指数、孕周、引产方式、胎膜早破和分娩镇痛等都是预测产程中转剖宫产的有价值的指标,单一某因素的异常不一定会导致产程中转剖宫产,但多种影响因素叠加时,产妇虽无剖宫产指征,产程中发生中转剖宫产的概率明显增加。因此,在产程中识别和关注中转剖宫产的高危因素,把握剖宫产的手术指征和手术时机十分重要。现对新产程标准下产程中转剖宫产的影响因素进行综述,以期为构建产程中转剖宫产的风险预测模型提供方向。     

产程时限研究进展及适宜的产程干预时机选择

六十余年来,国内外对产程时限的划分达成了共识,Friedman提出的产程曲线成为了全球大部分产科工作者进行产程管理的标准。但随着当今分娩人群的变化、产程中缩宫素使用、人工破膜、分娩镇痛等产程干预措施的实施以及临床研究方法的改进和完善,既往一直沿用的产程时限受到了众多学者的质疑并逐渐呈现出不适应当代分娩人群的趋势。因此,重新评估既有的并建立新的正常产程时限标准,对指导产程处理、减少不必要的产科干预具有重要意义。我国新产程标准的出台,更推进了相关产科干预措施实施的必要性探讨。回顾国内外不同学者对产程时限的研究,就低危产妇入院时机选择、缩宫素使用时机、人工破膜及分娩镇痛实施时机等方面进行综述,以期对新产程标准下产科干预时机有所认识。     

人工破膜的历史与现状

人工破膜是一项古老的产科技术,距今已有百年历史,作为一项诱发或促进产程的干预措施在临床中广泛应用。近年来随着新产程理论的提出,妇产科医生和助产士对于人工破膜的应用有了新的理解。本文从人工破膜的历史、现状以及目前存在的热点争议问题进行探讨。     

产程管理和干预措施

随着分娩人群特点和产程干预的明显变化,传统产程图是否还适用于现代产科人群变得很有争议。近年来,张军等的一系列产程研究结果得到很多研究的支持,在这些研究的基础上,国内外也发布了相关指南和共识,但张军等的研究是当时美国产科实践的一项回顾性研究,结果是否适合中国人群尚有待临床验证。在产程标准观点已经逐步发生改变,而中国产程研究尚未得出结论前,如何进行产程管理和干预成为临床医生最关注的问题之一。     

The timing of interventions during labour: descriptive results of a longitudinal study

Objective

to describe the timing and frequency of interventions during labour, and in addition to compare the timings of the interventions against the partogram action lines.

Design

longitudinal prospective and retrospective cohort study.

Setting

47 hospitals in Lower Saxony, Germany.

Participants

3963 births of nulliparae and multiparae with singletons in vertex presentation giving birth between April and October 2005. The participation rate for the prospectively recruited sample (n=1169) was 4.7%.

Measurements

time intervals until intrapartal interventions were calculated by Kaplan–Meiers estimation. Outcome variables were duration of labour and mode of birth.

Findings

multiparae had slightly longer median time intervals between the onset of labour and the beginning of care by the midwife than nulliparae. With regard to the intervals between the onset of labour and the occurrence of interventions, multiparae had shorter median durations than nulliparae in respect of amniotomy, oxytocin augmentation and neuraxial analgesia. By three hours after onset of labour 8.4% of nulliparae had received oxytocin augmentation, 10.7% neuraxial analgesia and 8.9% an amniotomy. Of multiparae, 9.1% had received oxytocin augmentation but only 5.6% neuraxial analgesia; 20.0% had had an amniotomy. The median time interval before the initiation of water immersion and massage was between three and four hours; that before the initiation of vertical positioning was 1.8 hours.

Key conclusions and implications for practice

current German practice without the use of partogram action lines reveals that early interventions were performed before the partogram action lines were met. Interventions applying midwifery care techniques such as vertical positioning preceded more invasive medical interventions during the process of childbirth.     

A Randomized Controlled Trial of a Bedside Partogram in the Active Management of Primiparous Labour

ObjectiveThe partogram is a pictorial representation of the progress of labour, used in an effort to enhance early recognition of dystocia and help avoid Caesarean section (CS). The objective of this study was to evaluate the effect of partogram use on the CS and obstetric intervention rates.MethodsWe conducted a randomized controlled trial of use of the partogram in 1932 primiparous women with uncomplicated pregnancies at term. Patients were randomly assigned to one of two groups: the standard group, who had the progress of labour charted in written notes, or the partogram group, whose progress in labour was recorded using a bedside graphical partogram as well as in written notes. Outcomes were stratified according to whether labour was spontaneous or induced and whether membranes were initially intact or ruptured. The primary outcome was the rate of CS; secondary outcome measures were rates of obstetric intervention for dystocia.ResultsThere was no significant difference between the groups in rates of CS (partogram 24%, standard notes 25%), rates of other interventions, amniotomy, oxytocin use, or the mean cervical dilatation in labour.ConclusionIn this study, the use of a partogram without a mandatory management of labour protocol had no effect on rates of CS or other intrapartum interventions in healthy primiparous women at term.     

Use of the partogram in a private hospital in South Africa

Objectiveto explore and describe the use of the partogram in private hospitals in South Africa.Designan explanatory mixed method design. In-depth interviews were conducted with the midwives and midwife specialists to explicate the significance of the initial quantitative questionnaires.Settinga private maternity hospital in Gauteng Province, South Africa.Participants11 midwives and 3 advanced midwives working in the labour unit of the private maternity hospital.Findingsalthough all the midwives and midwife specialists knew the purpose of the partogram, where to find the recommendations on the use of the partogram and the signs of true labour, not all were sure when the partogram had to be completed and who is accountable for plotting the findings. Fetal heart rate monitoring during the active phase of labour remains a concern.Key conclusionthe findings revealed that the midwives understood the importance of the partogram but are not using it within the parameters for which it was intended. The obstetricians intervened during labour with no or little use of the partogram.Implications for practicethe study identified the knowledge strengths and deficits of midwives working in a private hospital on partogram use that would benefit from training interventions and professional development. Evidence suggests a culture where the partogram is not central to care as obstetricians are not using the partogram. The purpose of the partogram in the private sector needs to be reviewed.     

The impact of delivery suite guidelines on intrapartum care in 'standard primigravida'

OBJECTIVE: To compare intrapartum interventions and outcomes in low-risk primiparous women and identify factors which may contribute to the variations between different maternity units. DESIGN: Prospective observational study. PARTICIPANTS: Ten maternity units in England. METHODS: Participating units provided data on 11 clinical indicators for all 'standard primigravidae' delivered between January and December 2000 and provided information on written delivery suite policies operational during July 2000. RESULTS: There was a significant inter-unit variation in the use of intrapartum foetal blood sampling, use of syntocinon for augmentation of labour, mode of delivery, type of perineal damage, postpartum haemorrhage, low Apgar score and admission to SCBU. Units with guidelines for intrapartum foetal heart monitoring had higher rate of normal vaginal deliveries (odds ratio (OR): 1.34; 99% confidence interval (CI): 1.05-1.70) and lower rate of Caesarean section for foetal distress (OR: 0.57; 99% CI: 0.34-0.96). Units with partogram guidelines also had lower rates of Caesarean section for foetal distress (OR: 0.49; 99% CI: 0.30-0.81). Units with guidelines on the management of episiotomy had higher episiotomy rates (OR: 1.54; 99% CI: 1.15-2.06) while units with guidelines on the involvement of neonatal staff recorded less babies with Apgar score <7 at 5 min (OR: 0.37; 99% CI: 0.17-0.76). CONCLUSIONS: Written delivery suite guidelines have significant impact on the type of intrapartum care and outcome of pregnancy in low-risk women. Their availability suggests more active role of interested clinicians in the provision of intrapartum care. There is an urgent need to identify other factors that influence quality and quantity of clinical input into the care of low-risk pregnant women.     

Perinatal mortality in rural Tanzania

Summary. Prolonged labour was the most frequent cause of perinatal death in a rural hospital in the south western highlands of Tanzania. After the introduction of an obstetric policy aiming to prevent pro longed labour by making use of the guidelines of the partogram, perinatal mortality was reduced from 71 to 39 per 1000 births. Baird's clinico-pathological classification is still considered a useful instrument for the discovery of avoidable factors in perinatal deaths. The concept of the partogram should be an integral part of the training of medical auxiliaries in the field of maternal and child health (MCH).     

Perinatal mortality in rural Tanzania

Prolonged labour was the most frequent cause of perinatal death in a rural hospital in the south western highlands of Tanzania. After the introduction of an obstetric policy aiming to prevent prolonged labour by making use of the guidelines of the partogram, perinatal mortality was reduced from 71 to 39 per 1000 births. Baird's clinico-pathological classification is still considered a useful instrument for the discovery of avoidable factors in perinatal deaths. The concept of the partogram should be an integral part of the training of medical auxiliaries in the field of maternal and child health (MCH).     

Evidence-based strategies for implementing guidelines in obstetrics: a systematic review

OBJECTIVE: To estimate effective strategies for implementing clinical practice guidelines in obstetric care and to identify specific barriers to behavior change and facilitators in obstetrics. DATA SOURCES: The Cochrane Library, EMBASE, and MEDLINE were consulted from January 1990 to June 2005. Additional studies were identified by screening reference lists from identified studies and experts' suggestions. METHODS OF STUDY SELECTION: Studies of clinical practice guidelines implementation strategies in obstetric care and reviews of such studies were selected. Randomized controlled trials, controlled before-after studies, and interrupted time series studies were evaluated according to Effective Practice and Organization of Care criteria standards. TABULATION, INTEGRATION, AND RESULTS: Studies were reviewed by two investigators to assess the quality and the efficacy of each strategy. Discordances between the two reviewers were resolved by consensus. In obstetrics, educational strategies with medical providers are generally ineffective; educational strategies with paramedical providers, opinion leaders, qualitative improvement, and academic detailing have mixed effects; audit and feedback, reminders, and multifaceted strategies are generally effective. These findings differ from data on the efficacy of clinical practice guidelines implementation strategies in other medical specialties. Specific barriers to behavior change in obstetrics and methods to overcome these barriers could explain these differences. The proportion of effective strategies is significantly higher among the interventions that include a prospective identification of barriers to change compared with standardized interventions. CONCLUSION: Prospective identification of efficient strategies and barriers to change is necessary to achieve a better adaptation of intervention and to improve clinical practice guidelines implementation. In the field of obstetric care, multifaceted strategy based on audit and feedback and facilitated by local opinion leaders is recommended to effectively change behaviors.     

Lactate concentration in amniotic fluid: a good predictor of labor outcome

Objective

Previous publications have suggested that high levels of lactate in amniotic fluid (AF) correlate with dysfunctional labor. The aim of this study was to investigate whether lactate concentration in AF together with the partogram is a better predictor of operative intervention in dysfunctional labor than the partogram alone.

Study design

A prospective observational study was carried out of 825 laboring women. Samples of AF were collected and the lactate concentration was analyzed at the bedside during labor. The main outcome of the study was the method of delivery (operative/spontaneous vaginal) in relation to the concentration of lactate in AF. Logistic regression was used to estimate the association between lactate concentration in AF and labor outcome and to adjust for well-known risk factors for dysfunctional labor.

Results

385/825 women had an arrested labor according to the partogram, and 193 of them were delivered operatively. High lactate in AF (>10.1 mmol/l) when labor arrested was associated with an increased risk of operative intervention due to dysfunctional labor (adjusted OR, 5.4, 95% CI, 3.2-9.1). Low levels of lactate in AF (<10.1 mmol/l) were associated with an increased probability of spontaneous vaginal delivery (adjusted OR, 2.7, 95% CI, 1.7-4.8).

Conclusion

The partogram together with the concentration of lactate in AF is a better predictor of operative intervention in dysfunctional labor than the partogram alone.     

Risk management in gynaecology

Risk management has become an integral part of the practice of gynaecology. The identification and management of risk contributes to evidence-based clinical practice and produces the best outcome for the patient. A risk may affect the patient, the staff or the corporate organization resulting in harm to the health of the patients or staff, damage to the reputations of staff or the organization, and may have financial consequences. Risk management is influenced by medical sources such as the guidelines of the Royal College of Obstetricians and Gynaecologists and legal sources such as the Clinical Negligence Scheme for Trusts. Incident reporting plays an important role in the process. Hospitals and Trusts are particularly interested in damage limitation exercises. This article outlines the principles of risk management together with some examples from high risk areas of gynaecological practice.