护理硕士论文：全程陪伴式导乐分娩对分娩结局的影响

摘 要

　　目的

　　通过对某三甲医院收治孕产妇的分娩过程进行护理干预，调查在产科服务中引入全程陪伴式导乐分娩（Doula on whole process-accompanied delivery）这一方式对产妇产程进展、疼痛感受、心理状态、分娩结局、产后抑郁、护理满意度等方面的影响，并针对其中的相关因素进行分析。探讨全程陪伴式导乐在分娩全程的应用效果与意义，为提高自然分娩率、优化分娩模式提供参考依据。

　　方法以某三甲医院妇产科 2016 年 7 月至 2018 年 7 月期间收治的孕产妇 1831 例为研究对象，通过自制问卷、产程记录、产后回访等方式进行调查和资料收集，根据其自愿选择进行分组，其中知情同意且按全程陪伴式导乐干预流程处理的归为干预组；未进行导乐干预常规分娩流程处理的归为非干预组。比较两组产妇的分娩过程、分娩结局、产后心理等方面有何差异。所收集记录数据和资料按分组进行对比分析，SPSS 22.0 及 SAS 9.1 统计学软件进行分析，采用 n 或%反映计数资料，计数资料比较用χ检验，等级资料比较用行平均得分差检验。

　　结果

　　1. 分娩态度：分娩前干预组有 221 人（39.25%）对分娩从不感到害怕，有316 人（56.13%）对分娩轻度紧张、但尚未恐惧，有 15 人（2.67%）感觉即将分娩已造成了一定的烦扰，有 11 人（1.95%）感到十分担心、已影响到自身健康；非干预组有 988 人（77.92%）对分娩从不感到害怕、有 244 人（19.24%）对分娩轻度紧张、但尚未恐惧，有 25 人（1.97%）感觉即将分娩已造成了一定的烦扰，有 11 人（0.87%）感到十分担心、已影响到自身健康。

　　2. 心理状态：产后 48h 测评，干预组中度焦虑人数由 125 人（22.20%）降至 116 人（20.61%），重度焦虑人数由 22 人（3.91%）降至 13 人（2.31%）；非干预组中度焦虑人数由 318 人（25.08%）降至 299 人（23.58%），重度焦虑人数由 84 人（6.62%）升至 91 人（7.18%）。

　　3. 分娩疼痛：干预组评分为优（0～2 分）的有 155 例（27.53%），评分为差（>8 分）的有 39 例（6.93%）；非干预组有 373 例（29.42%）评分为优（0～2 分）、118 例（9.31%）评分为差（>8 分）。

　　4. 分娩结局：干预组有 81 例（14.39%）最终转为剖宫产，其中中转剖 35例（6.21%），计划外干预 46 例（8.17%），非干预组共有 253 例（19.95%）最终转为剖宫产，其中中转剖 146 例（11.51%），计划外干预 107 例（8.44%）。

　　5. 干预组产妇产后出血例数 28 例少于非干预组 85 例、新生儿 Apgar 评分不满 10 分者 32 例少于非干预组 113 例。干预组尿潴留发生例数 11 例少于非干预组 48 例。

　　6. 产后抑郁：干预组评分等于或低于 9 分者 289 例（51.33%），非干预组为 565 例（25.2%）；干预组评分等于或高于 13 分者可进行综合干预的产妇有61 例（10.83%），非干预组为 245 例（13.38%）。

　　结论

　　1. 干预组的孕产妇在临产前对分娩的紧张、恐惧程度要明显低于非干预组，良好的心态对促进自然分娩、保证产程顺利进行有积极作用。

　　2. 在整个产程的不同阶段，应用不同的方式（合理体位、导乐球、音乐、导乐仪等）对产妇进行全程陪伴式的干预，能够影响产妇的分娩过程：表现在缓解产妇分娩焦虑、提高自然分娩率、减少产后并发症、减轻产后抑郁等方面。

　　这与导乐师在产妇分娩时给予的全程陪伴、对产妇心理生理感受的高度关注以及科学、有效的干预和疏导等有关。

　　3. 全程陪伴式导乐分娩有效改善了产妇的分娩感受、促进了产妇的分娩舒适度，这对提高自然分娩率、降低剖宫产率、促进产妇良好预后、保证母婴健康等有积极作用，对提升产科服务质量有临床指导意义。

　　关键词: 全程陪伴；导乐；分娩

　　Abstract

　　Objectives

　　Through nursing intervention in the delivery process of pregnant womenadmitted to a third class hospital, the authors investigated the effect of (Doula onwhole process-accompanied delivery) on the progress, pain and psychological state ofdelivery. The effects of childbirth outcome, postpartum depression and nursingsatisfaction were analyzed. To explore the effect and significance of the application ofDoula in the whole course of labor, to provide reference for improving the rate ofnatural delivery and optimizing the mode of delivery.

　　MethodsFrom July 2016 to July 2018, 1831 cases of pregnant and lying-in womenadmitted to gynecology and obstetrics department from July 2016 to July 2018 wereselected for investigation and data collection through self-made questionnaires,records of labor process and postpartum visits, and were grouped according to theirvoluntary choices. Informed consent and according to the whole process ofaccompanying Doula intervention process were classified as the intervention group;Those without Doula intervention were classified as non-intervention group. Thedifferences of delivery process, delivery outcome and postpartum psychologybetween the two groups were compared. Recorded data and data collected forcomparative analysis by group, SPSS 22.0 and SAS 9 .1 Statistical software was usedto analyze, n or% reflection counting data, count data comparison usingResults.

　　1. Delivery attitude: 221 people (39.25%) in the pre-delivery intervention groupwere never afraid of delivery, 316 (56.13%) were slightly nervous about delivery, butnot yet afraid. Fifteen (2.67 per cent) felt that the imminent delivery had caused someannoyance, while 11 (1.95 per cent) were very worried and had affected their ownhealth; In the non-intervention group, 988 (77.92%) were never afraid of childbirth,244 (19.24%) were slightly nervous about delivery, but not yet frightened, and 25(1.97%) felt that the impending delivery had caused some disturbance, with 11 cases.People (0.87%) are very worried and have affected their own health.

　　2. Psychological status: the number of moderate anxiety in intervention groupdecreased from 125 (22.20%) to 116 (20.61%), and the number of severe anxietydecreased from 22 (3.91%) to 13 (2.31%) in 48 hours postpartum. In thenon-intervention group, the number of moderate anxiety decreased from 318 (25.08%)to 299 (23.58%), and the number of severe anxiety increased from 84 (6.62%) to 91(7.18%).

　　3. There were 155 cases (27.53%) with excellent score (0～2 points) and 39cases (6.93%) with poor score (> 8points) in the intervention group. In thenon-intervention group, 373 cases (29.42%) had excellent scores (0～2 points) and118 cases (9.31%) had poor scores (> 8 points).

　　4. Delivery outcome: 81 cases (14.39%) in the intervention group wereconverted to cesarean section, 35 cases (6.21%) were converted to cesarean section,46 cases (8.17%) were unplanned intervention, 253 cases (19.95%) in thenon-intervention group were finally converted to cesarean section. Among them, 146cases (11.51%) were transferred to dissection, 107 cases (8.44%) were unplannedintervention.

　　5. The number of postpartum hemorrhage in intervention group (28 cases) wasless than that in non-intervention group (85 cases), and the number of neonatal Apgarscore less than 10 cases (32 cases) was less than that in non-intervention group (113cases). The incidence of urinary retention in the intervention group was less than thatin the non-intervention group.

　　6. Postpartum depression: 289 cases (51.33%) in intervention group and 565cases (25.2%) in non-intervention group; There were 61 cases (10.83%) inintervention group and 245 cases (13.38%) in non-intervention group..

　　Conclusion

　　1. The pregnant and lying-in women in the intervention group had lower degreeof fear than that in the non-intervention group before labor, and a good state of mindplayed a positive role in promoting the natural delivery and ensuring the smooth progress of labor.

　　2. At different stages of labor, the use of different ways (reasonable posture, ball,music, instrument, etc.) in the whole period of labor can influence the deliveryprocess of the parturient: it can alleviate the anxiety of the parturient. Improve therate of natural delivery, reduce postpartum complications, reduce postpartumdepression and so on. This has something to do with the full companionship, theattention to the psychophysiological feelings of the parturient, the science, theeffective intervention and the guidance.

　　3. Doula can effectively improve the feeling of delivery and promote thecomfort of delivery, which can improve the rate of natural delivery, reduce the rate ofcesarean section, promote the good prognosis of parturient and ensure the health ofmother and child. It is of clinical significance to improve the quality of obstetricalservice.

　　Key words: Complete companionship; Doula; Delivery.

　　目录

　　1 引言

　　1.1 研究背景

　　自剖宫产技术产生以来，随着社会环境的变化和社会医学卫生技术的不断提升，有很多的孕产妇因为害怕分娩疼痛，担心顺产对身体的影响等而选择了剖宫产方式分娩。虽然这一方式可以一定程度上避免自然分娩产程中漫长的等待，也解决很多难产问题，在非常情况下对母婴的抢救效果相对显著，但一些实践表明，剖宫产方式分娩的胎儿由于没有经历产道的挤压对婴儿肺部的刺激等，后期对胎儿的肺部发育会有一定的影响。而且，剖宫产跟产妇的乳汁分泌率降低、术后子宫复旧、伤口愈合等有关，一定程度上影响了产妇的尽快恢复，不利于新生儿的健康成长。考虑到自然分娩对胎儿发育、产妇身体情况的有利作用，以及自然分娩后产妇较快恢复的优势，进一步采取有效的方式和干预方法，去帮助产妇自然分娩并有效缩减产程，对确保母婴健康安全具有重要意义。

　　近年来由于各种原因导致无指征性剖宫产率居高不下，降低剖宫产率、适应新的产时模式、降低侧切率、提高自然分娩率成为了各大医院妇产科工作中的一个极大的挑战。我国剖宫产率一直居高不下，受到了社会的广泛关注和有关部门的高度重视，这是一个非常严重的“公共卫生问题”。

　　现代社会背景下，从独生子女政策到如今的二胎政策，所见到的是每一位孩子对于每一个家庭的弥足珍贵，孕产妇及其家庭从备孕期就开始充分准备，越来越多的家庭关注到孕产妇的围产保健、产科医院的选择、产后恢复、新生儿照护及喂养等方方面面的问题。在注重人文关怀的现代医学背景下，如何创新助产医学模式从而进一步改善产妇对自然分娩的感知感受，显得更为重要。

　　全程陪伴式导乐分娩即由导乐人员（一般是由助产专业的医护人员来承担）对孕产妇进行“一对一”的陪伴并直至其分娩的全过程，在此过程中导乐师对孕产妇从生理、心理、情感等多方面予以综合全面的支持和干预，最终帮助产妇建立自然分娩的信心，鼓励产妇勇敢面对分娩这一生理现象并能积极面对。经过近几年的推广及发展，全程陪伴式导乐分娩这种体现现代产科人文关怀的医疗模式进入分娩服务领域。全程陪伴式导乐分娩是产科高端服务中的一种，作为新型的助产模式在推广后受到许多孕产妇及其家庭的关注和青睐。