| 摘要: | 疲憊是孕產期婦女常見的不適症狀，亦是干擾產婦身心復原及角色執行的重要因素。雖已有研究探討孕產婦的疲憊，但現有研究多以自然產產婦為對象且侷限於懷孕期或產後階段，鮮少有以剖腹產產婦為主並長期追蹤其疲憊變化的研究。根據統計，國內有高達三分之一的婦女以剖腹方式生產，因此如何減輕或預防剖腹產產婦的疲憊及其不良影響，是產科臨床照護範疇極其重要的一環。基於此，本研究旨在描述剖腹產產婦孕產期疲憊之型態及其發展趨勢，探討影響不同疲憊型態之生理、心理、情境因素，並瞭解不同疲憊型態對剖腹生產產婦的影響。採前瞻、縱貫性設計（prospective, longitudinal design），以問卷調查法，在自然的情境下，於第三孕期、產後第一天、第五天及一個月，系統性的收集產婦與疲憊相關的資料，共完整收集139位剖腹產產婦資料。將所收集之資料以semiparameteric mixture model 區辨出不同型態疲憊之成長曲線，以邏輯式迴歸模式(logistic regression model)分析成長曲線型態與生理、心理、情境變項的關係，並依資料的類型，採Chi-square及t-test 檢定不同疲憊型態對婦女產後母性角色執行效能及功能性狀態的影響。
研究結果顯示，剖腹產婦女存在了二種不同的疲憊型態，且以中度持續型疲憊程度居多。二種剖腹產疲憊型態至產褥期結束（術後三十天）時；中度持續型疲憊組（N＝116；81.6％）產婦仍維持中度疲憊；而高度持續型疲憊組（N＝23；18.4％）產婦至產褥期結束其疲憊強度仍非常高。此結果顯示高疲憊組者，其疲憊程度易持續維持在高點不易下降。本研究亦發現，剖腹手術後一天無論高、中度持續型疲憊組之疲憊程度均達到最強，因此建議護理人員應重視此關鍵時刻，在產後二十四小時內協助產後婦女獲得充分休息恢復能量，提供減輕疲憊的介入措施，以協助產後婦女度過容易出現高疲憊的產後第一天。
此外，本研究結果亦顯示焦慮與疼痛是二種不同剖腹產疲憊型態之預測因子。研究結果顯示，若剖腹產產婦在第三孕期有高焦慮或高疼痛者，孕產期也會容易產生高疲憊。因此及早處理焦慮及疼痛將有助於減輕孕產期疲憊，本研究結果可作為未來擬定減輕剖腹產婦女疲憊介入性措施性研究之依據。至於不同剖腹產疲憊型態對產後的影響方面，二種剖腹產疲憊型態確會影響婦女產後調適甚至影響術後第一天哺餵母乳及施行母嬰同室意願。尤其高度持續型疲憊對婦女產後調適的影響較中度持續型疲憊更大。因而護理人員宜盡可能及早預防或處理具高度持續型疲憊風險者，以免影響剖腹產婦女產後身心調適與母職角色的執行。
整體而言，本研究藉長時間系統性的收集資料，以及適當的分析策略，針對採剖腹產婦女孕產期疲憊問題進行實徵性的探討，研究結果有助於確認處理剖腹產疲憊的關鍵時間點及必須優先處理的高危險群，更可釐清剖腹產疲憊在孕產過程的本質和特徵。不僅有利於深化理論的基礎，更有助於臨床護理人員在實際照顧產婦時，掌握關鍵時刻，提供適時照護，以更有效的處理剖腹產產婦的疲憊問題。研究結果除有助於護理科學知識之建構外，更可作提升周產期臨床實務之照護品質。
Fatigue is common symptom in pregnant women, and it also may interfere the ability of women in adjusting maternal recovery and in undertaking the maternal role after birth. Though the factors and causes of fatigue relevant to pregnant have been investigated in previous studies, most studies only chose the women of vaginal delivery as their participant, and focused on the period of pregnancy and postpartum. There are few studies to investigate the pattern of distinct fatigue trajectory longitudinally among the cesarean women.
According to the statistical data, nearly one-third of the pregnant women in Taiwan would choose cesarean; therefore, either to alleviate or to prevent fatigue and their adverse effect of women who delivered via cesarean section plays an important role in maternity nursing care. This research aimed to describe the fatigue trajectory of cesarean women throughout the childbearing period, and the development trends to explore the influence of the physiological, psychological, situational factors on different exhaustion types, and understand the impact of different fatigue patterns on cesarean women. Prospective, longitudinal design, the survey method were adopted in this research to collect available related data during the third trimester, the first day, the fifth day and one month of postpartum respectively. 139 cases were collected in a medical center in central Taiwan. The data would be analyzed by Semiparameteric Mixture Model to identify different growth curves under different patterns. Logistic Regression Model was used to identify the relation between growth curves and the physiological, psychological, situational factors. Chi-square and t-test were used to examine the influence of distinct childbirth-related fatigue patterns toward maternal performance and childbirth outcome.
The results showed that the cesarean women suffered from two patterns of fatigue, and mostly were in moderate persistent fatigue levels. The maternal with moderate persistent fatigue remained moderate fatigue (N = 116; 81.6%), and those with high persistent fatigue still remained high status (N = 23; 18.4%) in the end of the puerperium (30 days). The results indicated that people with highly persistent fatigue often remained in the high point. The study also found that the fatigue levels reached the highest the day after cesarean section no matter in high or moderate persistent fatigue groups. Therefore, we suggest that nurses should pay more attention to this critical moment to help postpartum women get enough rest to recovery in the twenty-four hours after postpartum and to provide some intervention measures to help get over the first day of high fatigue in postpartum women.
In addition, the study also showed that the anxiety and pain were two predictors of different cesarean fatigue patterns. The results showed that the cesarean women with high anxiety or pain in the third trimester would be prone to high fatigue during the pregnancy and childbirth. Early treatment of anxiety and pain would help reduce maternal fatigue. Furthermore, the results of this study can be used as reference to the intervention which reducing the fatigue of cesarean women in the future. As for the impact of the different cesarean fatigue patterns on postpartum, the different cesarean fatigue patterns did affect women's postpartum adjustment, the breastfeeding in the first day and the will of rooming-in. In particular, the influence on postpartum adaptation was much larger in the high persistent fatigue group than in moderate persistent fatigue group. Nurses should be as soon as possible to prevent or deal with those people who with high persistent fatigue risk for reducing the effect on the postpartum physical and mental adjustment and the role of motherhood among the cesarean women.
Overall, the study was an empirical research about the cesarean women’s fatigue during pregnancy and childbirth by collecting long-term data and using appropriate analysis strategies. The results can help us to confirm the critical period of dealing with the cesarean fatigue in time and know the priority; moreover, they can clarify the nature and characteristics of cesarean fatigue in the process of pregnancy and childbirth. Not only be conducive to deepen the theoretical basis, but to help clinical nurses provide timely care while taking care of maternal women and deal with the fatigue problem of cesarean women effectively. Besides contributing to the construction of nursing scientific knowledge, the research results can also be used as reference to enhance the quality of maternal care. |
