基于单病种限价的自然分娩临床路径研究

目的探讨单病种限价条件下自然分娩的最佳住院临床路径。方法以北京市自然分娩单病种结算人均次1 900元为标准,选取236例自然分娩住院费用数据资料,运用CHISS统计软件包进行统计处理。结果住院床日对住院费用影响最大,住院4日为明显的住院费用超标节点。结论自然分娩临床路径规划以住院3天～4天为宜。     

Client satisfaction and transfers across care levels of women with uncomplicated pregnancies at the onset of labor

Objectiveto compare the client satisfaction of women with uncomplicated pregnancies at the onset of labor who were transferred across care levels during childbirth and women who were not transferred across care levels in the Dutch perinatal healthcare system, and–if there are differences–to identify the variables that may explain them.Methodsthe research entailed a population-based study of women with uncomplicated pregnancies at the onset of labor living in the catchment area of a Dutch Neonatal Intensive Care Unit (NICU) in the eastern part of the Netherlands who gave birth between April 2014 and September 2014. Respondents completed a validated questionnaire (n = 842; mean age 30.7 years). Client satisfaction, measured on a 10-point scale, was assessed within 12 weeks after childbirth.Findingsof the 842 respondents, 277 women experienced a transfer of care during childbirth, and 565 women were not transferred. The client satisfaction of women who were transferred across care levels (mean 8.04; SD 1.4) was significantly lower (p<0.001) than that of women who were not transferred across care levels (mean 8.78; SD 0.9). Seven variables together explained 93.2% of the difference in client satisfaction. Explanatory pregnancy and childbirth variables were perceived health problems for the mother and medical interventions during childbirth. Explanatory clients’ experiences with the care process variables were respect, prompt attention, quality of basic amenities, social consideration, and choice and continuity.Conclusionwomen were highly satisfied with the care they received, although transfers across care levels during childbirth were associated with substantially lower client satisfaction. The differences in client satisfaction between transferred and non-transferred women can largely be explained by pregnancy and childbirth characteristics, and by clients’ experiences with the care process.     

Healthcare professionals’ attitudes,knowledge and self-efficacy levels regarding the use of self-hypnosis in childbirth: A prospective questionnaire survey

Objectiveto examine healthcare professionals' attitudes, knowledge and levels of self-efficacy regarding the use of self-hypnosis in childbirth.Designa prospective survey.Settingtwo large maternity units in London, England.Participantshealthcare professionals (n=129) involved in the care of childbearing women (anaesthetists, midwives and obstetricians).Methodsonline questionnaire assessing healthcare professionals' experience, knowledge, attitudes and self-efficacy relating to self-hypnosis in childbirth.Main outcome measuresattitude, self-efficacy and knowledge.Findingsover half of the participants surveyed (56%) reported they had minimal or no knowledge of hypnosis. Higher levels of knowledge were associated with higher levels of self-efficacy (p<0.001) and also with more positive attitudes (p<.001). Midwives reported significantly higher levels of knowledge, more positive attitudes (7.25, 95% CI: 4.60–9.89) and higher levels of self-efficacy (3.48, 95% CI: 1.46–5.51) than doctors. Midwives also reported more exposure to/experience of hypnosis than doctors, and more exposure was significantly associated with higher levels of self-efficacy (midwives p<.001; doctors p=.001). Professionals who would plan to use self-hypnosis in their own or partners' births had significantly higher self-efficacy scores (p<.001).Key conclusionsif healthcare professionals are to effectively support women using self-hypnosis in childbirth, they need to be confident in their ability to facilitate this method. Previous research has established that self-efficacy is a strong indicator of performance.Implications for practiceProfessionals with more knowledge of self-hypnosis are also more confident in supporting women using this technique in childbirth. Multi-disciplinary staff training which aims to increase knowledge, and which includes exposure to hypnosis in labour, may be beneficial in assisting staff to support women choosing to use self-hypnosis in labour.     

Pregnancy with a pinhole introitus: A report of two cases and a review of the literature

Abstract

Objectives As over 125 million women worldwide have undergone female genital mutilation (FGM), 170,000 of whom are estimated to live in the UK alone, obstetricians and gynaecologists need to be aware of the grades and consequences of this devastating condition. Women with type III FGM, even when they are unable to have penetrative intercourse, can conceive, and obstetricians should be aware of this to ensure optimal care of these patients. To determine the most appropriate surgical approach, deinfibulation in pregnancy should follow some basic principles which take into account the psychological needs of women as well as the extent of scarring.

Cases We present two cases of women who had never engaged in penetrative intercourse and therefore presented with no knowledge that they were pregnant. They underwent antenatal deinfibulation and subsequent management based on individual request.

Conclusions Management in pregnancy can pose particular problems and should be individualised. In all childbearing women with FGM, even where intercourse has not been possible, pregnancy should be considered. Clinicians should be aware of the types of FGM and management should be undertaken by a designated clinician with appropriate expertise. Pregnant women who have undergone FGM should be examined to identify the requirement for antenatal surgical correction.

Chinese Abstract

摘要

目的 全世界1.25亿妇女经受了女性生殖器切割(FGM),经估计,其中有170000名妇女生活在英国,妇产科医生需意识到这种破坏性疾病的分级和带来的后果。FGM, 型的妇女即使不能进行插入式性交仍可受孕,妇产科医生应当了解这一情况以为此类患者提供最佳的治疗。为了确认最佳的手术方式,妊娠期的去锁阴术应当遵循一些基本原则,其中应考虑到女性的心理需要以及疤痕的范围。

病例 我们所报告的两例病例中的妇女没有进行过插入式性交,因此并未意识到自己已怀孕。基于两名妇女的个人需求,为她们实施了产前去锁阴术和术后管理.

结论 妊娠期管理可造成特定的问题并应当个体化。所有的育龄期FGM妇女,即使不能进行插入式性交,也应当考虑到怀孕的可能性。临床医生应当了解FGM的分型,也应由指定的具有专业知识的医师对FGM 进行处理。经受过FGM的妊娠妇女应接受检查以明确产前外科矫治的需要。

关键词

分娩;股间性交;去锁阴术;女性割礼;FGM;股性交;妊娠;手术终止妊娠     

‘My pain was stronger than my happiness’: Experiences of caesarean births from Lebanon

Objective

the rising trends in caesarean section have been partially attributed to women's requests. Many studies in developed and very few in developing countries have attempted to understand this phenomenon. This qualitative study explores experiences of women having caesarean section on demand in a middle-income country with a private health-care system.

Design

an inductive qualitative design, using face-to-face semi-structured interviews.

Setting

women were identified and recruited through a perinatal database and selected obstetricians' clinics in the Greater Beirut area in Lebanon.

Participants

a purposive sample of women who had a caesarean childbirth within the four months preceding the interview, were visited for an interview at home using a semi-structured interview guide. Thematic content analysis was conducted on a sub-sample of 22 women who requested a caesarean birth.

Findings

lack of information about caesarean sections fosters women's fear from labour pain and acts as the main impetus for women to consider caesareans as the pain free alternative. Findings reveal health-care providers' role in reinforcing beliefs about caesarean sections being the way for pain free deliveries by overestimating the safety of the procedure and disregarding postpartum health issues.

Key conclusion and implications for practice

caesarean birth is presented to women as a safe option for ‘pain free’ childbirth. This needs to be considered within the cultural context of understanding safety and pain as well as the dynamics of power in maternity care. Health-care professionals need to explore these dimensions and promote women's informed choice as well as encouraging the normality of birth.     

National survey of how acupuncture education is organised for Swedish midwives

Objective

in Sweden, acupuncture education is required before midwives can use the method in clinical practice. Courses in acupuncture are usually organised by private individuals or companies, and each health facility decides on the adequacy of the educational package. Therefore, there is no overall standard or quality control for free-standing courses of acupuncture education for midwives. The aim of this study was to survey the education given to Swedish midwives in the use of acupuncture treatment in the obstetric area.

Design

a postal survey using a structured questionnaire.

Setting

organisers of acupuncture education.

Participants

18 acupuncture instructors.

Measurements and findings

acupuncture courses were usually organised outside universities and colleges. The courses were similar in terms of extent and content, and were mainly based on a Western medical approach. The recommended indications were extensive despite a lack of scientific evidence. The most common instructor profile was a midwife without any academic degree.

Key conclusions and implications for practice

courses differed considerably in the extent to which they were research based. Continuing professional education for midwives should be given at the same academic level, at least, as basic midwifery education.     

A randomised controlled multicentre trial of women’s and men’s satisfaction with two models of antenatal education

Objective

to study women’s and men’s satisfaction with two models of antenatal education: natural childbirth preparation with psychoprophylaxis, and standard antenatal education including preparation for childbirth and parenthood but no psychoprophylaxis.

Design

randomised controlled multicentre trial.

Setting

15 antenatal clinics in Sweden between January 2006 and May 2007.

Participants

1087 nulliparous women and 1064 of their partners.

Interventions

both models had four two-hour sessions during pregnancy and one session post partum. The natural model was manual-based and focused on childbirth preparation, including psychoprophylaxis. In the standard care model, the group leader was free to choose her teaching approach, with an equal amount of time allocated to preparation for childbirth and for parenthood.

Measures

women’s and men’s evaluation of antenatal education at three months post partum. The proportion of women and men in each model that expressed satisfaction with the education were compared using χ² test.

Findings

more women and men in the natural groups were satisfied with the education compared with the standard care groups: women 76% versus 68% (p=0.03) and men 73% versus 65% (p=0.03). The figures were similar for satisfaction with the childbirth preparation component: 78% and 62% in women (p<0.001), and 79% and 67% in men (p<0.001) in the natural and standard care groups, respectively. Fewer participants were satisfied with the parenthood preparation component, but the proportions were higher in the standard care groups: women 37% versus 32% (p<0.001) and men 23% versus 20% (p<0.001).

Conclusion and implications for practice

a structured manual-based model of antenatal education which focuses on childbirth preparation with psychoprophylaxis may better meet expectant parents’ expectations than standard antenatal education in Sweden.