【作者】 王丽娟；

【导师】 李根霞；

【作者基本信息】 郑州大学 ， 妇产科学（专业学位）， 2022， 硕士

【摘要】 背景产科急危重症是围产期孕产妇死亡的最主要原因,在非高危孕妇中发生风险约为15%,这些紧急情况是无法预料的,一旦发生则进展迅速。情景模拟教学对产科医师、助产士和麻醉医师等多学科的人员进行的培训,目前国际上统一称之为:产科急症多学科模拟培训。在国际上迅速推广,在国内国家级、省级、市级产科相关专业会议及继续教育项目中产科危重症救治情景模拟培训有了广泛的推广,但鲜有多中心,尤其是市级、县级医疗机构的培训前后效果对比研究。目的本研究采用多中心的队列研究法,探讨运用产科急症多学科团队情境模拟培训在市级及县级医疗机构对母婴结局的影响。研究对象及方法1.研究对象:在2018-11-01至2020-12-30之间,来自六家医院(三家市级医疗机构、三家县级医疗机构)的接受培训的产科多学科团队160名医护人员,(分别属于产科、产房、麻醉科、新生儿科等多学科)和在培训前后半年的孕妇和新生儿。培训前作为对照组,培训后作为试验组,统计分析相关母婴临床结局,并评价培训前后的教学效果。2.研究方法:于2018-11-01至2020-12-30之间,对包括助产、产科、新生儿科、麻醉科等科室在内的产科多学科团队分别进行两次培训,培训的项目有产后大出血、羊水栓塞、阴道助产、臀位分娩、肩难产、新生儿复苏。统计2次培训后相关母婴临床结局指标:培训前后理论成绩及操作成绩、孕产妇死亡率、产后出血率、阴道助产率、剖宫产率、会阴侧切率、和新生儿窒息率。统计学方法采用SPSS 25.0软件进行数据处理。计量资料采用?X±s表示,6组样本均数的比较,若资料符合正态分布且方差齐,采用单因素方差分析;非正态分布资料以中位数(最小值,最大值)表示。计数资料采用频数及率进行描述,组间差异比较采用χ~2检验或校正χ~2检验。结果1培训效果评估1.1满意度调查对课程内容非常赞同的受培训人员的达86%,对组建的专业培训小组的教学方式、授课水平非常满意的占71%,对场景的布置满意达60%,认为经过这样的培训后能够收获更多的新知识和技能的人员占79%,认为通过这样的培训有着显著的临床实用性可以在临床大力推广的医务人员占96%,认为对提高临床多科室团队协作能力的有96%。1.2培训前后理论及操作成绩受培训人员训练前的平均理论考试成绩为70.21±9.86,训练后为85.07±8.40,训练后笔试成绩较训练前提高了14.86±1.46,差异有统计学意义(P<0.05)。培训后,操作、判断、求助和团队合作的协调性得到显着改善,差异具有统计学意义(P<0.05)。2母婴情况2.1一般情况本研究共纳入产妇33533人(培训前16398例,培训后17135例),新生儿33748人(培训前16451例,培训后17297例)。产妇平均年龄29.32±4.51岁,平均孕周39.12±2.45周,平均孕次1.87±1.12次,平均产次1.45±0.85次。新生儿出生平均体重3402.75±526.74g。2.2母儿结局在培训后的6家医疗机构中,培训前后均未发生孕产妇死亡;剖宫产率由46.65%下降到44.38%,会阴侧切率由34.25%下降到26.74%,阴道助产率由4.58%升高到6.35%,差异有统计学意义(P<0.05);其中市级医疗机构中,剖宫产率由51.48%下降到48.67%,会阴侧切率由35.08%下降到20.91%,阴道助产率由3.55%升高到6.72%,差异有统计学意义(P<0.05);县级医院的剖宫产率由41.49%下降到39.81%,有统计学差异(P<0.05),会阴侧切率、阴道助产率明显变化无统计学差异。结论在市级和县级医疗机构进行产科急症的多学科情景模拟教学,利用各种情景模拟再现产科危急情况,可以提高市级、县级医疗机构医务人员的急救能力和综合素质,团队合作能力,提升产科质量和改善剖宫产率、阴道助产率、产后出血率。更多还原

【Abstract】 BackgroundAcute and critical obstetric illness is the most important cause of perinatal maternal death,with a risk of about 15%in non-high-risk pregnant women.These emergencies are unexpected and progress rapidly once occur.Situationsimulation teaching for obstetricians,midwives,anesthesiologists and other mult-idisciplinary personnel training,the international is widely known as:obstetric emergency multidisciplinary simulation training.It has been rapidly promoted internationally,and in the domestic national,provincial and municipal obstetrics related professional conferences and continuing education projects,the obstetric critical illness treatment scenario simulation training has been widely promote-d;However,there are few multi-center studies,especially in the municipal and county medical institutions before and after training.PurposeThis study used a multicenter cohort study to explore the impact of mater-nal and infant outcomes using obstetric emergency and multidisciplinary team situational simulation training in municipal and county medical institutions.Study subjects and methods1.Study subjects:Between 2018-11-01 and 2020-12-30,a trained obstetric multidisciplinary team of 160 medical staff from six hospitals(three municipal medical institutions and three county-level medical institutions),including obstetricians,midwives,anesthesiologists,and neonatologists.Acting as the control group before the training and as the trial group after the training,the relevant maternal and infant clinical outcomes were statistically analyzed,and the teaching effect before and after the training was evaluated.2.Methods:Between 2018-11-01 and 2020-12-12-30,the multidisciplinary teams,including obstetrics,midwifery,anesthesiology,and neonatology departments,were trained twice.The training programs include postpartum hemorrhage,amniotic fluid embolism,vaginal midwifery,breech delivery,shoulder dystocia,and neonatal resuscitation.Statistics of relevant maternal and infant clinical outcomes after two training:theoretical and operational results before and after training,maternal mortality rate,postpartum bleeding rate,vaginal delivery rate,cesarean section rate,perineal incision rate,and neonatal asphyxia rate.Statistical methodsData processing was performed using the SPSS 25.0 software.Measurement data used X±s。Comparison of the sample mean in the 6 groups,if the data meet the normal distribution and have equal variance,the one-way analysis of variance is used;Non-normally distributed data are expressed as the median(minimum,maximum)。Counting data were described by frequency and rate,and differences between groups were compared byχ~2 test or correctedχ~2 test.Results1 Evaluation of training effectiveness1.1 Satisfaction survey86%of the trainees agree with the course content,71%are satisfied with the teaching methods and teaching level of the professional training team,60%are satisfied with the scene layout,79%think the training can gain more new knowledge and skills,96%think the training has significant clinical utility can be promoted clinically,and 96%have great help to improve the teamwork ability of clinical multiple departments.1.2 Theoretical and operational results before and after trainingThe average theoretical test score of the trainees before the training was 70.21±9.86 and after the training was 85.07±8.40.The written test score after the training was14.86±1.46 higher than that before the training,and the difference was statistically significant(P<0.05).After the training,the coordination of operation,judgment,help-seeking,operation and teamwork was significantly improved,and the difference was statistically significant(P<0.05).2 Maternal and infant situation2.1 GeneralA total of 33533 maternal women(There were 16398 cases before training and17135 cases after training)and 33748 newborns(There were 16451 cases before training and 17297 cases after training)were included in this study.The mean maternal age was 29.32±4.51 years,the mean gestational week was 39.12±2.45 weeks,the mean pregnancy was 1.87±1.12,and the average birth was 1.45±0.85.The average neonatal birth weight was 3402.75±526.74g.2.2 Maternal and child outcomesAmong the six medical institutions after the training,before and after the training,there were no maternal deaths in the six hospitals;The rate of cesarean section decreased from 46.65%to 44.38%,the perineal lateral shear rate decreased from 34.25%to 26.74%,the vaginal midwifery rate increased from 4.58%to 6.35%,the difference was statistically significant(P<0.05);Among municipal medical institutions,the cesarean section rate decreased from 51.48%to 48.67%,the perineal resection rate decreased from 35.08%to 20.91%,and the vaginal midwifery rate increased from 3.55%to 6.72%,the difference was statistically significant(P<0.05);The cesarean section rate in county-level hospitals decreased from 41.49%to 39.81%,with statistical differences(P<0.05),but there was no significant difference in the perineal resection rate and vaginal midwifery rate.Conclusion:In municipal and county medical institutions for obstetric emergency multidisciplinary scenario simulation teaching,the use of various situation simulation obstetric critical situation,can improve the municipal and county medical institutions medical aid ability and comprehensive quality,teamwork ability,improve obstetric quality and improve cesarean delivery rate,vaginal midwifery rate,postpartum bleeding rate.更多还原