Klein M C, Kaczorowski J, Robbins J M, Gauthier R J, Jorgensen S H, Joshi A K
British Columbia's Women's Hospital and Health Centre Society, Vancouver.
CMAJ. 1995 Sep 15;153(6):769-79.
To evaluate whether physicians' beliefs concerning episiotomy are related to their use of procedures and to differential outcomes in childbirth.
Post-hoc cohort analysis of physicians and patients involved in a randomized controlled trial of episiotomy.
Two tertiary care hospitals and one community hospital in Montreal.
Of the 703 women at low risk of medical or obstetric problems enrolled in the trial we studied 447 women (226 primiparous and 221 multiparous) attended by 43 physicians. Subjects attended by residents or nurses were excluded.
intact perineum v. perineal trauma, length of labour, procedures used (instrumental delivery, oxytocin augmentation of labour, cesarean section and episiotomy), position for birth, rate of and reasons for not assigning women to a study arm, postpartum perineal pain and satisfaction with the birth experience, physicians: beliefs concerning episiotomy.
Women attended by physicians who viewed episiotomy very unfavorably were more likely than women attended by the other physicians to have an intact perineum (23% v. 11% to 13%, p < 0.05) and to experience less perineal trauma. The first stage of labour was 2.3 to 3.5 hours shorter for women attended by physicians who viewed episiotomy favourably than for women attended by physicians who viewed episiotomy very unfavorably (p < 0.05 to < 0.01), and the former physicians were more likely to use oxytocin augmentation of labour. Physicians who viewed episiotomy more favourably failed more often than those who viewed the procedure very unfavourably to assign patients to a study arm late in labour (odds ratio [OR] 1.88, p < 0.05), both overall and because they felt that "fetal distress" or cesarean section necessitated exclusion of the subject. They used the lithotomy position for birth more often (OR 3.94 to 4.55, p < 0.001), had difficulty limiting episiotomy in the restricted-use arm of the trial and diagnosed fetal distress and perineal inadequacy more often than the comparison groups. The patients of physicians who viewed episiotomy very favourably experienced more perineal pain (p < 0.01), and of those who viewed episiotomy favourably and very favourably experienced less satisfaction with the birth experience (p < 0.01) than the patients of physicians who viewed the procedure very unfavourably.
Physicians with favourably views of episiotomy were more likely to use techniques to expedite labour, and their patients were more likely to have perineal trauma and to be less satisfied with the birth experience. This evidence that physician beliefs can influence patient outcomes has both clinical and research implications.
评估医生对会阴切开术的看法是否与他们的手术操作及分娩中的不同结局相关。
对参与会阴切开术随机对照试验的医生和患者进行事后队列分析。
蒙特利尔的两家三级护理医院和一家社区医院。
在该试验中登记的703名医疗或产科问题低风险女性中，我们研究了由43名医生照料的447名女性（226名单胎初产妇和221名经产妇）。由住院医生或护士照料的受试者被排除。
会阴完整与会阴创伤、产程长度、使用的手术操作（器械助产、缩宫素引产、剖宫产和会阴切开术）、分娩体位、未将会阴切开术分配到研究组的女性比例及原因、产后会阴疼痛和对分娩经历的满意度，医生：对会阴切开术的看法。
与由其他医生照料的女性相比，由对会阴切开术持非常负面看法的医生照料的女性更有可能会阴完整（23%对11%至13%，p<0.05）且会阴创伤更少。与由对会阴切开术持非常负面看法的医生照料的女性相比，由对会阴切开术持正面看法的医生照料的女性第一产程缩短2.3至3.5小时（p<0.05至<0.01），且前者更有可能使用缩宫素引产。与对会阴切开术持非常负面看法的医生相比，对会阴切开术持更正面看法的医生在产程后期将患者分配到研究组失败的情况更常见（优势比[OR]1.88，p<0.05），总体如此，且因为他们认为“胎儿窘迫”或剖宫产需要将受试者排除。他们更常采用截石位分娩（OR 3.94至4.55，p<0.001），在试验的限制使用组中难以限制会阴切开术的使用，且比对照组更常诊断胎儿窘迫和会阴条件不佳。与由对会阴切开术持非常负面看法的医生照料的患者相比，由对会阴切开术持非常正面看法的医生照料的患者会阴疼痛更多（p<0.01），且由对会阴切开术持正面和非常正面看法的医生照料的患者对分娩经历的满意度更低（p<0.01）。
对会阴切开术持正面看法的医生更有可能使用加速产程的技术，且他们的患者更有可能出现会阴创伤且对分娩经历的满意度更低。这一医生看法可影响患者结局的证据具有临床和研究意义。
