[[alternative]]Application of Perineal Warm Packs on Perineal Outcomes and Labor Pain in the Second Stage of Labor

[[abstract]]研究背景 減少產痛是產科照護中的重要問題，文獻指出第二產程給予會陰熱敷可以減輕產婦產後的會陰疼痛程度、會陰撕裂傷、降低發生尿失禁機率且改善孕產婦的生產滿意度。研究目的 探討第二產程會陰熱敷介入措施對產婦會陰撕裂傷、疼痛程度、舒適程度及生產滿意度之成效。研究方法 本研究採類實驗性研究，以連續方便取樣於民國105年5月至106年2月在北部某區域教學醫院收案，將符合收案條件之個案進行收案，並依照個案意願分派至實驗組及控制組分別為47位，實驗組於第二產程開始時執行前測，由研究者或產房護理人員評估會陰疼痛、舒適情形，教導及執行第一次會陰熱敷，並於熱敷後立即、熱敷完成後30分鐘、熱敷完成後60分鐘及產後24小時，評估會陰疼痛緩解、舒適情形；於產後24小時評估會陰撕裂傷程度、會陰疼痛程度、生產滿意度及舒適程度；控制組之產婦只接受一般待產照護常規。採結構式問卷收集資料，研究工具包含人口學及產科學資料、視覺類比量表（疼痛及舒適）、生產滿意度量表及會陰傷口評分量表。以SPSS 20.0統計軟體進行資料整理與分析，包含描述性統計、獨立樣本t檢定、卡方檢定及廣義估計方程式等推論性統計。研究結果 本研究共計94位個案參與，實驗組比控制組有較少的縫合線數量（t=3.51, p﹤.05）、較短的縫合時間（t=4.25, p﹤.01）、較低的會陰傷口評估(REEDA） 分數（t=6.31, p﹤.01）及較低的會陰裂傷程度（t=3.32, p﹤.05）。會陰疼痛程度兩組在子宮頸全開時（t=2.02, p﹤.05） 、熱敷後立即(t=4.17, p﹤.01）、熱敷後30分鐘（t=10.08, p﹤.01）、熱敷後60分鐘(t=16.86, p﹤.01）及產後24小時（t=5.42, p﹤.01） 有顯著差異。會陰舒適程度兩組在子宮頸全開時（t=-0.75, p= .46） 沒有顯著差異，另外在熱敷後立即（t=-6.31, p﹤.01）、熱敷後30分鐘（t=-16.96, p﹤.01）、熱敷後60分鐘（t=-27.34, p﹤.01）及產後24小時(t=-6.56, p﹤.01） 則有顯著差異。實驗組較控制組有較高的生產滿意度（t=-4.46, p﹤.05）。 本研究結果發現經由會陰熱敷介入措施呈現「組別與時間」的交互作用，實驗組的會陰疼痛程度分數比控制組來的低而且隨著時間分數逐漸下降，控制組的疼痛程度則隨著時間增加而增加。另外，實驗組的會陰舒適程度分數比控制組高而且隨著時間分數逐漸上升，尤其在子宮頸全開後的60分鐘分數最高，反之，控制組的會陰舒適程度分數則是隨著時間舒適分數逐漸下降。結論與應用 年齡、教育程度、第二產程時間、總用力時間、懷孕週數及新生兒頭圍對於會陰疼痛及舒適程度均無影響，會陰裂傷程度為影響會陰疼痛程度的主要關鍵因素，即會陰裂傷程度越嚴重，會陰疼痛程度也越厲害，舒適程度也就越少，本研究結果在第二產程經由會陰熱敷介入措施，可以明顯減少產婦會陰裂傷的嚴重程度，且減少會陰疼痛及增加舒適度，並且縫線用的數量較少，所需縫合的時間較短。會陰熱敷是一個低成本且非侵入性的預防措施，而且參與人員並不需要受特別的訓練，期望透過本研究提供產科人員在協助產婦於臨床照護使用熱敷技巧，以減少會陰撕裂傷程度和會陰疼痛程度、增加會陰舒適程度及提升生產滿意度，希望讓目前以醫療為主的生產環境中，讓產婦能多一種選擇非藥物減痛的方式，增加自主權，協助正向的看待生產過程，有一個美好的生產經驗。[[abstract]]Background Reducing pain during labor and delivery is an important issue in maternity care. Studies have indicated that applying a hot compress to the perineum during the second stage of labor may effectively reduce postpartum perineal pain, perineal laceration severity, and urinary incontinence and thus improve the birth satisfaction of new mothers. Purpose The present study explores the effect of applying a hot compress to the perineum during the second stage of labor on perineal laceration severity, postpartum perineal pain, and patient-perceived comfort and birth satisfaction. Methods This quasi-experimental study used continuous convenience sampling to recruit qualified cases from a regional research hospital in northern Taiwan between May 2016 and February 2017. Forty-seven cases were assigned based on stated preference to the intervention group and to the control group, respectively, with 94 cases in total. The intervention group completed the pretest at the start of the second stage of labor, with the researcher or a maternity nurse first assessing patient perineal pain and physical comfort and then administering the initial hot compress application to the perineal region. The control group received standard maternity care only. Changes in perineal pain and physical comfort were then assessed and recorded at the following intervals: immediately after, 30-minutes after, and 60-minutes after the application and at 24-hours postpartum. Perineal laceration severity and birth satisfaction were also assessed and recorded at 24-hours postpartum. A structured questionnaire that included a demographic and obstetrics datasheet, visual analogue scales for pain and comfort, a childbirth satisfaction scale, and a perineal wound assessment scale was used to gather data. Data were managed and analyzed on SPSS 20.0 using inferential statistics, including descriptive statistics, the independent samples t test, the chi-square test, and the GEE.Results A total of 94 participants completed the present study. The control group had fewer cases of surgical suturing (t=3.51, p<.05), a shorter average suture time (t=4.25, p<.01), a lower average REEDA scale score (t=6.31, p<.01), and lower average perineal laceration severity (t=3.32, p<.05). Significant differences between the two groups were observed in terms of level of perineal pain at pretest (full dilation; t=2.02, p<.05), immediately after the time of hot compress application (t=4.17, p<.01), 30 minutes after the time of hot compress application (t=10.08, p<.01), 60 minutes after the time of hot compress application (t=16.86, p<.01), and at 24-hours postpartum (t=5.42, p<.01). No difference was observed between the two groups in terms of perceived perineal comfort at pretest (t=-0.75, p=.46). However, significant intergroup differences for this variable were recorded at all post-application observation time points (immediately after [t=-6.31, p<.01], 30-mins after [t=-16.96, p<.01], 60-mins after [t=-27.34, p<.01], and 24-hrs after [t=-6.56, p<.01]. Finally, the experimential group had a higher average birth satisfaction scores (t=-4.46, p<.05). The findings discerned the interaction effects of both group and time. Not only did the intervention group earn lower perineal pain scores than the control group, this intergroup difference increased over time as pain scores for the former gradually decreased and those for the latter gradually increased. Additionally, the posttest intergroup difference in perineal comfort also increased over time, with scores reaching their highest at 60-minutes posttest for the intervention group and decreasing steadily over time for the control group.Conclusions and Clinical Applications Demographic and obstetrics variables, including age, education level, duration of second-stage labor, total pushing time, weeks of pregnancy, and infant head circumference, had no significant effect on either perineal pain or comfort. Degree of perineal laceration was found to have the most significant effect on perineal pain, with higher degrees of laceration associated with greater perineal pain and reduced perineal comfort. Results support that applying the perineal hot compress intervention during the second stage of labor significantly reduces perineal laceration severity and perineal pain while improving perineal comfort. Furthermore, the intervention group required fewer perineal stitches and thus less stitching time. The perineal hot compress is a low-cost, noninvasive intervention that may be performed by staffs without special training. The authors hope that the present article provides maternity-ward personnel with the basic skills necessary to perform this intervention in clinical settings in order to reduce the perineal laceration severity and perineal pain and to improve the perineal comfort and birth satisfaction of new mothers. Moreover, the authors hope to help focus greater medical community attention on this non-pharmacological method of pain control as a way to further enhance patient autonomy, promote positive perspectives on the birth process, and achieve optimal birth outcomes