| 摘要: | 目的：待產過程中發生急性胎心窘迫是產房最危急之事件，其救治時間更是分秒必爭，因此，本研究希望藉由醫院現有相關數據找出急性胎心窘迫救治中胎心窘迫至胎兒娩出時間鏈( Distress-to-Delivery Time, DDT) 的關鍵時間點，並探討影響罹患急性胎心窘迫施行緊急剖腹產之胎兒救治預後相關因素。
方法：本研究採回溯性方式之病歷資料研究，收案對象為2000年1月1日起至2008年4月30日在待產中發生急性胎心窘迫，需要施行剖腹生產者共349位產婦。依照產婦背景、胎兒救出後健康狀況、緊急剖腹生產、胎心窘迫時間鏈及醫院背景等作描述性及雙變項分析，並用Kaplan-Meier方法找出胎心窘迫緊急剖腹產之黃金時間。最後以羅吉斯迴歸分析探討影響急性胎心窘迫胎兒救治之相關因素。
結果：本研究349位樣本發生胎心窘迫置胎兒出生時間距DDT (Distress-to-Delivery Time)平均時間為60.8分鐘，醫師決策至胎兒出生時間距DDI (Decision to Delivery Interval)平均時間為49.2分鐘。依Kaplan-Meier分析出發生胎心窘迫時，DDT的參考黃金時間為56分鐘，而DDI的參考黃金時間為48分鐘。本研究中對胎兒救出後健康狀況影響之顯著正相關因素為懷孕週數、產婦送到開刀房至麻醉開始時之間距；顯著負相關因素為產檢胎兒生長遲滯情形、麻醉方式、胎便染色情形、發生胎心窘迫至產婦到開刀房之時間距、醫師決策到產婦到開刀房之時間距、發生胎心窘迫至胎兒出生時間距以及醫師決策至胎兒出生時間距。
結論：多段時間距皆與胎兒健康狀況有顯著相關，若能掌握救治相關時間應能提高胎兒救治率。國外相關數據顯示，DDI超過75分鐘胎兒健康狀況顯著趨於不佳，本篇研究的DDI平均為49.2分鐘，顯見台灣地區產房醫療品質應在可容許的範圍，若能將救治時間縮短為35分鐘，則能將胎兒救活率之比例提高至75%。
Objectives: Severe acute fetal distress (SAFD) is the most urgent event for the pregnant women in the delivery room, and the correct timing is most essential for the proper treatment. In this study, we approximated the critical time point (Distress-to-Delivery Time, DDT) between the finding of SAFD and the time of emergency delivery by screening the clinical data of patients with SAFD and investigated the prognostic factors for the patients, who received the emergency cesarean delivery (ECD).
Methods: This is a retrospective study collecting data of 349 patients, who had SAFD during pre-delivery and received Cesarean sections for the emergency delivery. The study period is from January 1, 2000 to April 30, 2008. A description and binominal analysis were performed according to maternity background, ECD, DDT, health condition of neonates, and Hospital facilities. The golden time for the proper ECD was approximated using Kaplan-Meier plot, and the prognostic factors for neonates were estimated by logistic regression.
Results: Calculated from 349 patients, the average DDT was 60.8 minutes, and the Decision to Delivery Interval (DDI), the time between obstetrician’s decisions to the incision, was 49.2 minutes. Using Kaplan-Meier plot, the reference golden time for DDT was approximated to 56 minutes, and that for DDI was 48 minutes. The health condition of neonates was positively correlated with (1) gestation weeks and (2) intervals between the mothers arrived at operation room and the initiation of anesthesia. However, it was negatively correlated with (1) intra-uterine growth retardation of fetus during prenatal examination, (2) method of general anesthesia, (3) the presence of meconium stain, (4) intervals between discovery of SAFD and the mothers arriving at operation room, (5) intervals between decision and the mothers arriving at operation room, (6) intervals between discovery of SAFD and the baby delivery time, and (7) intervals between decision and the baby delivery time.
Conclusions: The study results showed that health conditions of the neonates were significantly correlated with the timing of treatment. The multiple time points and their durations of DDT of this study could, therefore, affect the fetal survival. The previous other countries’ reports showed that when DDI was over 75 minutes, health conditions of the neonates would certainly turn worse. Our results showed that in Taiwan the average DDI is 49.2 minutes, and the time intervals are permissible for quality of obstetric care. If the DDI could be shortened to 35 minutes, survival rate of fetal care should be able to increase to 75%. |
