Knight Hannah E, van der Meulen Jan H, Gurol-Urganci Ipek, Smith Gordon C, Kiran Amit, Thornton Steve, Richmond David, Cameron Alan, Cromwell David A
Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom.
Lindsay Stewart Centre for Audit and Clinical Informatics, Royal College of Obstetricians and Gynaecologists, London, United Kingdom.
PLoS Med. 2016 Apr 19;13(4):e1002000. doi: 10.1371/journal.pmed.1002000. eCollection 2016 Apr.
Concerns have been raised that a lack of senior obstetricians ("consultants") on the labour ward outside normal hours may lead to worse outcomes among babies born during periods of reduced cover.
We carried out a multicentre cohort study using data from 19 obstetric units in the United Kingdom between 1 April 2012 and 31 March 2013 to examine whether rates of obstetric intervention and outcome change "out-of-hours," i.e., when consultants are not providing dedicated, on-site labour ward cover. At the 19 hospitals, obstetric rotas ranged from 51 to 106 h of on-site labour ward cover per week. There were 87,501 singleton live births during the year, and 55.8% occurred out-of-hours. Women who delivered out-of-hours had slightly lower rates of intrapartum caesarean section (CS) (12.7% versus 13.4%, adjusted odds ratio [OR] 0.94; 95% confidence interval [CI] 0.90 to 0.98) and instrumental delivery (15.6% versus 17.0%, adj. OR 0.92; 95% CI 0.89 to 0.96) than women who delivered at times of on-site labour ward cover. There was some evidence that the severe perineal tear rate was reduced in out-of-hours vaginal deliveries (3.3% versus 3.6%, adj. OR 0.92; 95% CI 0.85 to 1.00). There was no evidence of a statistically significant difference between out-of-hours and "in-hours" deliveries in the rate of babies with a low Apgar score at 5 min (1.33% versus 1.25%, adjusted OR 1.07; 95% CI 0.95 to 1.21) or low cord pH (0.94% versus 0.82%; adjusted OR 1.12; 95% CI 0.96 to 1.31). Key study limitations include the potential for bias by indication, the reliance upon an organisational measure of consultant presence, and a non-random sample of maternity units.
There was no difference in the rate of maternal and neonatal morbidity according to the presence of consultants on the labour ward, with the possible exception of a reduced rate of severe perineal tears in out-of-hours vaginal deliveries. Fewer women had operative deliveries out-of-hours. Taken together, the available evidence provides some reassurance that the current organisation of maternity care in the UK allows for good planning and risk management. However there is a need for more robust evidence on the quality of care afforded by different models of labour ward staffing.
有人担心，非工作时间产房缺少资深产科医生（“会诊医生”）可能会导致在人员配备减少期间出生的婴儿出现更糟的结局。
我们进行了一项多中心队列研究，使用2012年4月1日至2013年3月31日期间英国19个产科单位的数据，以检验产科干预率和结局在“非工作时间”（即会诊医生未提供专门的现场产房护理时）是否会发生变化。在这19家医院，产科值班表的现场产房护理时间每周从51小时到106小时不等。该年有87,501例单胎活产，其中55.8%发生在非工作时间。与在现场产房护理期间分娩的女性相比，在非工作时间分娩的女性产时剖宫产（CS）率略低（12.7%对13.4%，调整优势比[OR]0.94；95%置信区间[CI]0.90至0.98）以及器械助产率略低（15.6%对17.0%，调整OR 0.92；95%CI 0.89至0.96）。有一些证据表明，非工作时间阴道分娩的严重会阴撕裂率有所降低（3.3%对3.6%，调整OR 0.92；95%CI 0.85至1.00）。没有证据表明非工作时间分娩与“工作时间”分娩在5分钟时阿氏评分低的婴儿比例（1.33%对1.25%，调整OR 1.07；95%CI 0.95至1.21）或脐带血pH值低的比例（0.94%对0.82%；调整OR 1.12；95%CI 0.96至1.31）上存在统计学显著差异。主要研究局限性包括可能存在指征偏倚、依赖会诊医生在场的组织性衡量指标以及产科单位的非随机样本。
根据产房会诊医生的在场情况，母婴发病率没有差异，非工作时间阴道分娩的严重会阴撕裂率可能降低除外。非工作时间进行手术分娩的女性较少。总体而言，现有证据提供了一些保证，即英国目前的产科护理组织能够进行良好的规划和风险管理。然而，需要有更有力的证据来证明不同产房人员配备模式所提供的护理质量。
