会阴切开的发生率及影响因素分析

张旱梅; 周利华; 马红; 程玉婷

doi:10.16766/j.cnki.issn.1674-4152.002638

会阴切开的发生率及影响因素分析

doi: 10.16766/j.cnki.issn.1674-4152.002638

1.
安徽医科大学第一附属医院妇产科，安徽合肥 230088
2.
安徽医科大学护理学院，安徽合肥 230088

基金项目:

安徽省省级教学质量工程项目 2019kfkc041

安徽省省级示范基层教研室项目 2020-215

详细信息

通讯作者:
周利华, E-mail: 531879548@qq.com

中图分类号: R714.3 R719
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出版历程
- 收稿日期: 2022-02-12
- 网络出版日期: 2022-11-29

Incidence and influencing factors of perineotomy

1.
Department of Obstetrics and Gynecology, the First Affiliated Hospital of Anhui Medical University, Hefei, Anhui 230088, China

摘要

摘要: 目的调查分析阴道分娩会阴切开现状，为提高助产质量，减少会阴切开提供干预方向。方法采用便利抽样法, 横断面调查安徽医科大学第一附属医院高新院区2019年1月1日—12月31日阴道分娩产妇年龄、产次、产程、孕周、妊娠合并症或/和并发症、会阴切开及切开指征等临床资料，统计分析其会阴切开率及影响因素。结果纳入阴道分娩产妇1 992例中700例行会阴切开术，年平均会阴切开率为35.14%。最常见的切开指征是会阴条件差(356例，50.86%)、胎心异常(190例，27.14%)和羊水Ⅲ度污染(75例，10.71%)。单因素分析显示孕妇年龄(Z=4.586，P＜0.001)、文化程度(Z=2.414，P=0.016)、助产士工作年限(Z=2.398，P=0.016)、产次(Z=14.307，P＜0.001)、第二产程时间(χ²=300.016，P＜0.001)、孕周(Z=3.104，P=0.002)、有无妊娠合并症或并发症(χ²=60.435，P＜0.001)及瘢痕子宫(χ²=6.591，P=0.010)是会阴切开的影响因素。基于单因素分析结果进行多因素logistic回归分析，结果显示孕妇年龄＞35岁、助产士工作年限＞10年、第二产程时间＞120 min以及瘢痕子宫是会阴切开的独立危险因素(均P＜0.05)。结论目前会阴切开率仍较高，需要进一步加强对助产士的培训。可通过提高助产士对产妇会阴条件、产程和母儿情况的综合评估水平以提高助产质量，降低会阴切开率，改善产妇产后生活质量。
- 阴道分娩 /
- 会阴切开 /
- 影响因素
Abstract: Objective To investigate and analyse the situation of episiotomy in vaginal delivery to provide intervention direction for improving the quality of midwifery and reducing the rate of episiotomy. Methods The convenience sampling method was used to conduct a cross-sectional survey of vaginal delivery patients in the Gaoxin Branch of the First Affiliated Hospital of Anhui Medical University from January 1 to December 31, 2019, including their age, times of delivery, course of delivery, gestational weeks, pregnancy complications or/and complications, perineum incision and its indications. The perineum incision rate and its influencing factors were statistically analyzed. Results A total of 1 992 cases of vaginal delivery were included, of which 700 cases underwent episiotomy. The annual average rate of episiotomy was 35.14%. The top three indications for perineotomy were poor perineal condition (356 cases, 50.86%), abnormal foetal heart rate (190 cases, 27.14%) and amniotic fluid Ⅲ degree contamination (75 cases, 10.71%). Univariate analysis showed that age (Z=4.586, P < 0.001), education level(Z=2.414, P=0.016) of pregnant women, working years of midwives (Z=2.398, P=0.016), parity (Z=14.307, P < 0.001), the second stage of labour time (χ²=300.016, P < 0.001), gestational weeks (Z=3.104, P=0.002), with or without pregnancy complications or complications (χ²=60.435, P < 0.001) and scar uterus (χ²=6.591, P=0.010) were the influencing factors of episiotomy. Multivariate logistic regression analysis based on the results of univariate analysis showed that the age of pregnant women >35 years, midwife working experience >10 years, the second stage of labour time >120 minutes and scar uterus were independent risk factors of episiotomy (all P < 0.05). Conclusion At present, the rate of episiotomy remains high, and the training of midwives needs to be further strengthened. This work can be used to enhance the quality of midwifery, reduce the rate of episiotomy and improve the quality of postpartum life by improving the midwife ' s comprehensive assessment of perineal conditions, labour process and maternal and foetal conditions.
- Vaginal delivery /
- Perineal incision /
- Influencing factors

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表 1 会阴切开产妇会阴切开指征统计[例(%)]

Table 1. Statistics of indications of perineotomy in parturient women [cases (%)]

项目	会阴切开
会阴条件(包括会阴炎症、水肿、会阴体过短、弹性差等)	356(50.86)
胎心异常(胎心慢、胎心快、早期减速或变异减速)	190(27.14)
羊水Ⅲ度污染	75(10.71)
胎儿窘迫	23(3.29)
阴道手术助产	72(10.28)
早产	35(5.00)
产妇缺乏配合	2(0.29)
其他	47(6.71)
注：部分产妇会阴切开指征登记同时有2个或以上，因此表中总数相加>700例。

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表 2 2组产妇一般人口学资料比较[例(%)]

Table 2. Comparison of general demographic data between two groups of parturients [cases (%)]

组别	例数	年龄(岁)				文化程度			家庭所在地
组别	例数	≤24	25~30	31~35	＞35	初中及以下	高中	大学及以上	城镇	农村
非会阴切开组	1 292	98(7.59)	862(66.72)	287(22.21)	45(3.48)	110(8.51)	75(5.81)	1 107(85.68)	682(52.79)	610(47.21)
会阴切开组	700	70(10.00)	513(73.29)	105(15.00)	12(1.71)	48(6.86)	30(4.28)	622(88.86)	349(49.86)	351(50.14)
统计量		4.586^a				2.414^a			1.560^b
P值		＜0.001				0.016			0.212
注：^a为Z值，^b为χ²值。

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表 3 2组产妇会阴切开影响因素的单因素分析[例(%)]

Table 3. Univariate analysis of influencing factors of parturient perineotomy in 2 groups [cases (%)]

项目	非会阴切开组(n=1 292)	会阴切开组(n=700)	统计量	P值
助产士工作年限(年)			2.398^a	0.016
1~3	550(42.57)	245(35.00)
4~6	263(20.36)	158(22.57)
7~10	357(27.63)	223(31.86)
＞10	122(9.44)	74(10.57)
产次			14.307^a	< 0.001
第1次	811(62.77)	646(92.29)
第2次	463(35.84)	51(7.29)
第3次	18(1.39)	3(0.42)
新生儿体重(g)			1.217^a	0.224
≤2 500	47(3.64)	29(4.14)
2 501~3 000	299(23.14)	135(19.29)
3 001~3 500	606(46.90)	342(48.86)
3 501~4 000	301(23.30)	175(25.00)
＞4 000	39(3.02)	19(2.71)
第二产程时间(min)			300.016^b	< 0.001
≤30	583(45.12)	202(28.86)
31~60	330(25.54)	204(29.14)
61~120	162(12.54)	191(27.29)
＞120	23(1.78)	89(12.71)
无明确时限	194(15.02)	14(2.00)
孕周(周)			3.104^a	0.002
28~31⁺⁶	13(1.01)	4(0.57)
32~34⁺⁶	8(0.62)	12(1.71)
35~36⁺⁶	33(2.55)	31(4.43)
37~39⁺⁶	764(59.13)	329(47.00)
40~42	474(36.69)	324(46.29)
并发症和/或合并症			60.435^b	< 0.001
无	560(43.34)	180(25.71)
有	732(56.66)	520(74.29)
妊娠期糖尿病	181(14.01)	90(12.86)	0.513^b	0.474
妊娠期高血压疾病	53(4.10)	41(5.86)	3.110^b	0.078
胎膜早破	302(23.37)	163(23.29)	0.002^b	0.964
妊娠合并心脏疾病	4(0.31)	2(0.29)	0.112^b	0.737
妊娠合并肝内胆汁淤积症	5(0.39)	1(0.14)	0.272^b	0.602
胎儿宫内发育迟缓	5(0.39)	1(0.14)	0.272^b	0.602
瘢痕子宫	5(0.39)	10(1.43)	6.591^b	0.010
妊娠合并甲减	68(5.26)	39(5.57)	0.085^b	0.771
妊娠合并子宫肌瘤	11(0.85)	8(1.14)	0.408^b	0.523
妊娠合并乙肝	45(3.48)	28(4.00)	0.344^b	0.558
妊娠合并梅毒	3(0.23)	2(0.29)	0.058^b	0.809
妊娠合并贫血	43(3.33)	26(3.71)	0.202^b	0.653
羊水过少	42(3.25)	30(4.29)	1.396^b	0.237
前置或低置胎盘	2(0.15)	2(0.29)	0.010^b	0.921
帆状或球拍状胎盘	10(0.77)	2(0.29)	1.084^b	0.298
脐带绕颈	86(6.66)	56(8.00)	1.238^b	0.266
其他合并症或并发症	104(8.05)	99(14.14)	18.418^b	1.773
注：^a为Z值，^b为χ²值。(1)第二产程无明确时限是指产程进展过快，未观察到明确宫口开全时间。(2)因部分产妇同时合并2种或2种以上合并症或并发症，所以表中总数相加>1 992例。

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表 4 变量赋值表

Table 4. Variable assignment table

变量	赋值方法
年龄	≤24岁=0；25~30岁=1；31~35岁=2；＞35岁=3
文化程度	初中及以下=0；高中=1；大学及以上=2
助产士工作年限	1~3年=0；4~6年=1；7~10年=2；＞10年=3
产次	第1次=0；第2次=1；第3次=2
第二产程时间	≤30 min=0；31~60 min=1；61~120 min=2；＞120 min=3；无明确时限=4
孕周	28~31⁺⁶周=0；32~34⁺⁶周=1；35~36⁺⁶周=2；37~39⁺⁶周=3；40~42周=4
瘢痕子宫	否=0；是=1
会阴切开	否=0；是=1

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表 5 会阴切开影响因素的多因素logistic回归分析

Table 5. Multivariate logistic regression analysis of influencing factors of perineotomy

变量	B	SE	Wald χ²	P值	OR值	95% CI
年龄
25~30岁	0.619	0.400	2.395	0.122	1.856	0.848~4.063
31~35岁	0.623	0.362	2.965	0.085	1.864	0.918~3.786
＞35岁	0.830	0.365	5.173	0.023	2.294	1.122~4.692
文化程度
高中	0.210	0.149	1.981	0.159	1.233	0.921~1.651
大学及以上	-0.017	0.215	0.007	0.935	0.983	0.644~1.499
助产士工作年限
4~6年	0.119	0.171	0.483	0.487	1.126	0.806~1.574
7~10年	0.202	0.181	1.240	0.265	1.223	0.858~1.745
＞10年	0.342	0.155	4.883	0.027	1.408	1.039~1.906
产次
第2次	0.654	0.518	1.595	0.207	1.923	0.697~5.305
第3次	0.515	0.514	1.007	0.316	1.674	0.612~4.583
第二产程时间
31~60 min	0.226	0.182	1.547	0.214	1.253	0.878~1.789
61~120 min	0.158	0.171	0.854	0.355	1.171	0.838~1.638
＞120 min	0.354	0.156	5.171	0.023	1.425	1.050~1.933
无明确时限	-1.638	0.277	34.977	＜0.001	0.194	0.113~0.334
孕周
32~34⁺⁶周	-0.509	0.602	0.715	0.398	0.601	0.185~1.957
35~36⁺⁶周	-0.983	0.574	2.930	0.087	0.374	0.121~1.153
37~39⁺⁶周	0.376	0.262	2.062	0.151	1.457	0.872~2.436
40~42周	-0.142	0.099	2.064	0.151	0.867	0.714~1.053
瘢痕子宫	-1.637	0.669	5.990	0.014	0.195	0.052~0.722

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参考文献(21)

[1]	谢幸, 孔北华, 段涛. 妇产科学[M]. 9版. 人民卫生出版社, 2018: 98-174. XIE X, KANG B H, DUAN T. Obstetrics and gynecology[M]. 9th edition. People ' s Medical Publishing House, 2018: 98-174.
[2]	KHRESHEH R, BARCLAY L. Knowledge, attitude and experience of episiotomy practice among obstetricians and midwives in Jordan[J]. Women and Birth, 2020, 33(2): 176-181. doi: 10.1016/j.wombi.2019.03.007
[3]	朱远, 徐桂华, 刘婧岩, 等. 分娩期会阴切开影响因素的病例对照研究[J]. 解放军护理杂志, 2018, 35(4): 32-36. https://www.cnki.com.cn/Article/CJFDTOTAL-JFHL201804008.htm ZHU Y, XU G H, LIU j Y, et al. Case-control study of the influencing factors of episiotomy during in delivery period[J]. Nursing Journal of Chinese People ' s Liberation Army, 2018, 35(4): 32-36. https://www.cnki.com.cn/Article/CJFDTOTAL-JFHL201804008.htm
[4]	郭琳, 丁焱, 张铮, 等. 分娩时会阴切开决策影响因素预测模型的构建[J]. 中华护理杂志, 2019, 54(10): 1469-1474. doi: 10.3761/j.issn.0254-1769.2019.10.005 GUO L, DING Y, ZHANG Z, et al. Establishment of predictive model of midwives' decision on episiotomy during childbirth[J]. Chinese Journal of Nursing, 2019, 54(10): 1469-1474. doi: 10.3761/j.issn.0254-1769.2019.10.005
[5]	潘映红, 胡艳, 陈晓霞, 等. 会阴无保护分娩对初产妇分娩结局及产后盆底功能的影响[J]. 中国妇产科临床杂志, 2020, 21(6): 606-608. https://www.cnki.com.cn/Article/CJFDTOTAL-FKLC202006014.htm PAN Y H, HU Y, CHEN X X, et al. Effects of "hands off" techniques on delivery outcome and postpartum pelvic floor function[J]. Chinese Journal of Clinical Obstetrics and Gynecology, 2020, 21(6): 606-608. https://www.cnki.com.cn/Article/CJFDTOTAL-FKLC202006014.htm
[6]	WHO. Intrapartum care for a positive childbirth experience[M]. Geneva: World Health Organization, 2018: 150.
[7]	KADDOURA R, DEJONG J, ZURAYK H, et al. Episiotomy practice in the Middle East: A Lebanese teaching tertiary care centre experience[J]. Women Birth, 2019, 32(2): 223-228. doi: 10.1016/j.wombi.2018.07.005
[8]	王晓蕾, 张丽萍, 胡迎春, 等. 基于新产程管理模式研究初产妇第二产程延长对盆底功能损伤的影响分析[J]. 中国全科医学, 2020, 23(S1): 92-94. https://www.cnki.com.cn/Article/CJFDTOTAL-QKYX2020S1027.htm WANG X L, ZHANG L P, HU Y C, et al. Study on the effect of the second stage of labor extension on pelvic floor function injury based on the management model of new stage of labor[J]. Chinese General Practice, 2020, 23(S1): 92-94. https://www.cnki.com.cn/Article/CJFDTOTAL-QKYX2020S1027.htm
[9]	王丽惠, 沈小芳, 徐亚萍, 等. 分娩方式及分娩因素对产妇产后早期发生盆腔脏器脱垂的影响[J]. 中华全科医学, 2019, 17(9): 1530-1532. doi: 10.16766/j.cnki.issn.1674-4152.000989 WANG l H, SHEN X F, XU Y P, et al. The effect of different delivery methods on pelvic organ prolapse in early postpartum period and the correlation between obstetric delivery factors and early pelvic organ prolapse[J]. Chinese Journal of General Practice, 2019, 17(9): 1530-1532. doi: 10.16766/j.cnki.issn.1674-4152.000989
[10]	SPEKSNIJDER L, OOM D M J, VAN BAVEL J, et al. Association of levator injury and urogynecological complaints in women after their first vaginal birth with and without mediolateral episiotomy[J]. AJOG, 2019, 220(1): 93. e1-93. e9. 10.1016/j.ajog.2018.09.025. doi: 10.1016/j.ajog.2018.09.025
[11]	罗香平, 高钰琳, 王菘, 等. 助产士对疤痕子宫产妇阴道分娩行会阴切开决策影响因素的质性研究[J]. 解放军护理杂志, 2021, 38(1): 21-24. https://www.cnki.com.cn/Article/CJFDTOTAL-JFHL202101006.htm LUO X P, GAO Y L, WANG S, et al. Qualitative study on the influencing factors of Midwives' decision-making on episiotomy during vaginal birth for multiparas after cesarean[J]. Nursing Journal of Chinese People ' s Liberation Army, 2021, 38(1): 21-24. https://www.cnki.com.cn/Article/CJFDTOTAL-JFHL202101006.htm
[12]	中国妇幼保健协会助产士分会. 会阴切开及会阴裂伤修复技术与材料选择指南(2019)[J]. 中国护理管理, 2019, 19(3): 453-457. https://www.cnki.com.cn/Article/CJFDTOTAL-GLHL201903041.htm Midwives Branch of Maternal and Child Health Care of China Association. Guideline of repairing techniques and material selection in episiotomy and perineal tears[J]. Chinese Nursing Management, 2019, 19(3): 453-457. https://www.cnki.com.cn/Article/CJFDTOTAL-GLHL201903041.htm
[13]	唐春燕, 文明琴. 会阴评估表在低危初产妇经产道头位分娩中的临床应用[J]. 中西医结合护理(中英文), 2016, 2(2): 63-65. https://www.cnki.com.cn/Article/CJFDTOTAL-ZXHL201602024.htm TANG C Y, WEN M Q. Application of perineal assessment scale in head position delivery of low-risk primiparas[J]. Journal of Clinical Nursing in Practice, 2016, 2(2): 63-65. https://www.cnki.com.cn/Article/CJFDTOTAL-ZXHL201602024.htm
[14]	刘幸, 万丽. 对分娩中产妇应用会阴评估量表指导会阴切开的效果观察[J]. 护理学报, 2020, 27(12): 60-64. https://www.cnki.com.cn/Article/CJFDTOTAL-NFHL202012018.htm LIU X, WAN L. Application of perineal assessment scale in perineotomy[J]. Journal of Nursing, 2020, 27(12): 60-64. https://www.cnki.com.cn/Article/CJFDTOTAL-NFHL202012018.htm
[15]	窦姗姗, 白桦, 顾晓乐, 等. 河南省助产工作现状及助产适宜技术应用情况的调查研究[J]. 中华护理杂志, 2018, 53(2): 158-161. https://www.cnki.com.cn/Article/CJFDTOTAL-ZHHL201802008.htm DOU S S, BAI H, GU X L, et al. Investigation of the present situation of midwifery and the appropriate technical application in Henan Province[J]. Chinese Journal of Nursing, 2018, 53(2): 158-161. https://www.cnki.com.cn/Article/CJFDTOTAL-ZHHL201802008.htm
[16]	BLANC-PETITJEAN P, MEUNIER G, SIBIUDE J, et al. Evaluation of a policy of restrictive episiotomy on the incidence of perineal tears among women with spontaneous vaginal delivery: A ten-year retrospective study[J]. JOGOHR, 2020, 49(8): 1-6.
[17]	BOUJENAH J, TIGAIZIN A, FERMAUT M, et al. Is episiotomy worthwhile to prevent obstetric anal sphincter injury during operative vaginal delivery in nulliparous women?[J]. EJOG, 2019, 232: 60-64. DOI: 10.1016/j.ejogrb.2018.11.014.
[18]	GONZALEZ-DÍAZ E, FERNÁNDEZ G F, ORDEN J M G, et al. Which characteristics of the episiotomy and perineum are associated with a lower risk of obstetric anal sphincter injury in instrumental deliveries[J]. EJOG, 2019, 233: 127-133. DOI: 10.1016/j.ejogrb.2018.12.019.
[19]	何菁菁, 罗碧如. 基于知识图谱的国内助产专业研究现状与发展趋势分析[J]. 护理研究, 2018, 32(2): 202-207. https://www.cnki.com.cn/Article/CJFDTOTAL-SXHZ201802012.htm HE J J, LUO B R. Analysis of research status quo and development trend of midwifery specialty in China based on knowledge mapping[J]. Chinese Nursing Research, 2018, 32(2): 202-207. https://www.cnki.com.cn/Article/CJFDTOTAL-SXHZ201802012.htm
[20]	戴嘉喜, 茅清, 陆虹, 等. 福建省13所医院助产士核心胜任力现状及影响因素研究[J]. 中华护理杂志, 2018, 53(2): 215-220. https://www.cnki.com.cn/Article/CJFDTOTAL-ZHHL201802024.htm DAI J X, MAO Q, LU H, et al. The investigation and analysis of core competency among midwives from 13 hospitals in Fujian Province[J]. Chinese Journal of Nursing, 2018, 53(2): 215-220. https://www.cnki.com.cn/Article/CJFDTOTAL-ZHHL201802024.htm
[21]	胡蕾, 姜梅, 徐鑫芬, 等. 中国助产士人力资源现状调查研究[J]. 中华护理杂志, 2020, 55(2): 192-197. https://www.cnki.com.cn/Article/CJFDTOTAL-ZHHL202002009.htm HU L, JIANG M, XU X F, et al. Investigation on the current situation of midwives human resources in China[J]. Chinese Journal of Nursing, 2020, 55(2): 192-197. https://www.cnki.com.cn/Article/CJFDTOTAL-ZHHL202002009.htm