指南发布后，会阴侧切术使用下降了

纽约哥伦比亚大学的Alexander M. Friedman医生及其同事们分析了美国保险索赔数据库中2006年至2012年间510家医院共2,261,070例住院阴道分娩患者的数据显示，会阴侧切使用率从2006年的17.3%下降至2012年的11.6%。共有325,193例患者在这7年的时间接受了侧切术，该项分析结果发表在2015年1月13日的《美国医学会杂志》（JAMA）上（JAMA 2015;313:197-9）。

该项研究分析中所采用的样本不包括肩难产、胎儿宫内窘迫或胎儿心率异常的情况，因为这些并发症是可以考虑进行会阴侧切术的。

侧切术使用率的下降是在指南建议减少其广泛使用后产生的。 2006年，美国妇产科医师学会建议取消会阴切开术的常规操作，并在2008年的全国质量论坛会议上发表文章阐述限制常规会阴侧切术对于患者安全的重要性，并指出其可增加疼痛、撕裂伤以及手术相关肛门失禁的风险。

研究发现，会阴侧切术使用率在各医院之间差异较大。在50家使用频率较高的医院中比例高达34.1%，在50家使用频率最少的医院中比例为2.5%。

作者认为这种差异化似乎是由于一些非医疗因素导致的，例如，白人女性（15.7%）会阴侧切率几乎是黑人女性（7.9%）的2倍。同样，有商业保险的女性与只参与公共医疗补助的女性相比更可能接受会阴侧切术。

Friedman医生及其同事在文章中写道，“还需要进一步的策略加强坚持循证医学的建议”。

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By: MARY ANN MOON, Ob.Gyn. News Digital Network

VITALS

Key clinical point: The use of episiotomy dropped from an average of 17.3% to 11.6% between 2006 and 2012.

Major finding: Among 2.2 million women hospitalized for a vaginal delivery from 2006-2012, a total of 325,193 had an episiotomy.

Data source: A cohort study of women who underwent vaginal delivery at 510 U.S. hospitals from 2006-2012.

Disclosures: The study authors reported having no financial disclosures.

The rate of episiotomy use declined from 17.3% to 11.6% from 2006 to 2012, according to claims data from 510 U.S. hospitals.

The drop in the procedure’s frequency follows guidance advising against its widespread use. In 2006, the American Congress of Obstetricians and Gynecologists recommended against routine episiotomy, and in 2008 the National Quality Forum stated that limiting routine episiotomy was important to patient safety, noting the increased risks of pain, laceration, and anal incontinence associated with the procedure.

Dr. Alexander M. Friedman and his colleagues at Columbia University in New York, analyzed claims in an insurance database that included 2,261,070 women hospitalized for a vaginal delivery from 2006 to 2012. The sample did not include cases of shoulder dystocia, fetal distress, or fetal heart rate abnormalities, since these complications can be considered indications for episiotomy. A total of 325,193 of these women had an episiotomy during the 7-year period, according to the analysis published in JAMA on Jan. 13 (JAMA 2015;313:197-9).

The rate of episiotomy use varied widely among hospitals. It was 34.1% among the approximately 50 hospitals that used the procedure the most often, compared with 2.5% in the 50 hospitals that used the procedure the least.

The variation appears to be due to nonmedical factors, the authors wrote. For instance, the rate of episiotomy was nearly twice as high among white women (15.7%) as among black women (7.9%). Similarly, women with commercial insurance were more likely to undergo the procedure than those with Medicaid insurance.

“Further strategies are needed to enhance adherence to evidence-based recommendations,” Dr. Friedman and his colleagues wrote.