Reynolds J L
Department of Family Medicine, University of Western Ontario, London.
CMAJ. 1995 Aug 1;153(3):275-82.
To determine the effectiveness of a continuous quality improvement (CQI) program in reducing episiotomy rates.
Before-and-after study; CQI methods were used to examine the process of care during labour and birth.
Identification of care factors that would increase the probability of episiotomy. Implementation of initiatives that would change the process of care to minimize the probability of episiotomy. Educational strategies included promotion of better understanding of what constitutes an appropriate episiotomy rate and ways to reduce maternal exhaustion and true fetal distress as well as manoeuvres to protect the perineum during birth.
Low-risk family practice obstetrics service in a tertiary care hospital in southwestern Ontario.
All 102 family physicians at the study hospital who provided intrapartum care in the year before and the year during which the CQI program was implemented and the women for whom the care was provided (approximately 1,400 per year).
Episiotomy rates (overall, among primiparous and multiparous women, and among individual family physicians) and rates of perineal tear, perineal infection and postpartum readmission.
Although the planned reduction in the episiotomy rate was not achieved during the study period, the overall rate decreased significantly from 44.5% to 33.3% (p < 0.001). Among the primiparous women the rate decreased from 57.6% to 46.2% (p < 0.001) and among the multiparous women from 34.3% to 23.6% (p < 0.001). The reduced episiotomy rate among the primiparous women was associated with a significant decrease in the rate of third- and fourth-degree perineal tears and a significant increase in the number of women giving birth with an intact perineum or a minor (first-degree) tear. These benefits were not seen among the multiparous women, whose decreased episiotomy rate was associated with a significant increase in the number of women experiencing a second-degree perineal tear. During the intervention period, there was no increase in the rates of vaginal trauma or postpartum bleeding, infection or readmission because of complications related to perineal trauma. The episiotomy rates for most physicians decreased significantly during the intervention period.
The CQI model may be useful in modifying clinical practices such as episiotomy because it focuses on understanding the process of care and the environment in which care is provided, both of which may have a major impact on physician behaviour. Further study is needed to ascertain the sustainability of the effects of this approach and which components of the model had the greatest effect.
确定持续质量改进（CQI）项目在降低会阴切开术发生率方面的有效性。
前后对照研究；采用CQI方法检查分娩过程中的护理流程。
识别会增加会阴切开术可能性的护理因素。实施旨在改变护理流程以尽量降低会阴切开术可能性的举措。教育策略包括促进更好地理解何为适当的会阴切开术发生率，以及减少产妇疲惫和真正胎儿窘迫的方法，还有在分娩时保护会阴的手法。
安大略省西南部一家三级护理医院的低风险家庭医疗产科服务部门。
研究医院所有102名在CQI项目实施前一年及实施期间提供产时护理的家庭医生，以及接受护理的女性（每年约1400名）。
会阴切开术发生率（总体、初产妇和经产妇中的发生率，以及个体家庭医生的发生率）以及会阴撕裂、会阴感染和产后再入院率。
尽管在研究期间未实现会阴切开术发生率的预期降低，但总体发生率从44.5%显著降至33.3%（p<0.001）。初产妇中的发生率从57.6%降至46.2%（p<0.001），经产妇中的发生率从34.3%降至23.6%（p<0.001）。初产妇会阴切开术发生率的降低与三度和四度会阴撕裂发生率的显著降低以及会阴完整或轻度（一度）撕裂分娩的女性数量的显著增加相关。经产妇中未观察到这些益处，其会阴切开术发生率的降低与二度会阴撕裂女性数量的显著增加相关。在干预期间，阴道创伤、产后出血、感染或因会阴创伤相关并发症导致的再入院率没有增加。大多数医生的会阴切开术发生率在干预期间显著降低。
CQI模式可能有助于改变会阴切开术等临床实践，因为它侧重于理解护理流程以及提供护理的环境，这两者都可能对医生行为产生重大影响。需要进一步研究以确定这种方法效果的可持续性以及该模式的哪些组成部分效果最大。
