生產決策輔助工具於剖腹產後婦女之陰道分娩

Birth Choice Decision Aids in Women Planning Vaginal Birth after Cesarean Delivery

"剖腹產後陰道分娩（vaginal birth after cesarean, VBAC）對於曾有先前剖腹產的婦女而言，是一種安全且合理的選擇。台灣每年有超過1／3的婦女剖腹產，但VBAC比率歷年都不到0.5％。醫病共享決策（shared decision making, SDM）則是進行VBAC諮詢的最佳選擇，但在台灣卻仍未被期待運用。本研究旨在探討計畫剖腹產後陰道分娩婦女之生產共享決策過程。採質性研究，立意取樣於北台灣北部的一家地區醫院，招募曾經有過一次剖腹產的懷孕婦女。婦女於妊娠14－24週婦產科產檢時會收到生產決策輔助手冊，並帶回家與家人討論生產方式。在此期間，會提供至少兩次的線上諮詢。37－38週回診時，婦女會與產科醫師共同決定生產方式選擇。產後一個月邀請婦女進行一對一深度線上訪談，資料分析採不斷的比較分析技術。合計有29名婦女參與SDM，生產決策輔助工具介入後，有11位婦女計畫採VBAC生產，產後一個月共有八位婦女接受訪談。資料經歸納婦女的決策過程為：（1）確定生產方式偏好：比較生產方式優缺點、考量過去經驗、醫師專業分析；（2）嘗試剖腹產後陰道分娩：VBAC成功率評估、子宮破裂風險評估；（3）煎熬陰道分娩的不確定性：產程的進展性、醫療處置的可行性；（4）堅持或放棄VBAC選擇：醫生不一致的態度、重要他人的不支持。儘管SDM理想的健康照護模式，但在台灣仍存在許多困難。孕期應致力於於文化的轉變，改變婦女和產科醫生對生產期待的決策關係。在醫學培訓中，應加強醫師有效及人性化的溝通技巧，並發展生動互動式電腦決策輔助工具，以增加產科醫師與婦女及家庭共同參與決策的意願。"

Vaginal Birth after Cesarean (VBAC) is a safe and reasonable option for women who have undergone a C-section. More than one-third of childbirth in Taiwan undergo C-sections each year, but the VBAC rate has been less than 0.5% over the past years. Shared Decision Making (SDM) is the best choice for VBAC consultation, but it is still not expected to be used in Taiwan. This study aimed to explore the application of birth choice decision aids in the process of SDM in women planning vaginal birth after cesarean. A qualitative approach was conducted. Using purposing sampling, women who have had one previous caesarean section were recruited in a regional hospital in northern Taiwan. Women received a birth choice decision aids at 14-24-week's gestation in routine antenatal examination, and brought it home to discuss with their family and made a birth option at 37-38 week's gestation. During this period, at least two online consultations was provided. One month after birth, women planning to attempt VBAC were invited to participate in a one-on-one in-depth online interview. Continuous comparative analysis techniques were used for the data analysis. A total of 29 women participated in the SDM. After the intervention of birth choice decision aids, 11 women planned VBAC. One month after birth, a total of eight women participated in the interviews. Women's decision-making process regarding mode of birth included: (1) Confirmation of birth mode preference: comparison between the advantages and disadvantages regarding mode of birth, consideration of previous experience, the professional analysis of obstetricians; (2) Attempt on VBAC: an evaluation of the success rate of VBAC, an evaluation of the risk of uterine rupture; (3) Uncertainty of suffering from vaginal birth: the progress of labor, feasibility of medication intervention; (4) Insistence or abandonment of VBAC: inconsistent attitude of the obstetricians, unsupported from significant others. Although SDM is an ideal healthcare model, it is still difficult to implement in Taiwan. Pregnant women should devote themselves to cultural changes and change the decision-making relationship between women and obstetricians regarding their birth expectations. In medical training, the obstetricians' effective and humanized communication skills should be strengthened, and vivid and interactive computer decision-making aids should be developed to increase the willingness of obstetricians, women and their families to participate in SDM.