黃健　丁巖　程明軍

(復(fù)旦大學(xué)附屬婦產(chǎn)科醫(yī)院婦科，上?！?00011)

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·論著·

健康教育及盆底肌訓(xùn)練對(duì)產(chǎn)后盆底功能障礙的影響

黃健丁巖程明軍

(復(fù)旦大學(xué)附屬婦產(chǎn)科醫(yī)院婦科，上海200011)

摘要目的：探討健康教育和盆底肌訓(xùn)練對(duì)產(chǎn)后盆底功能障礙的防治效果。方法： 選擇復(fù)旦大學(xué)附屬婦產(chǎn)科醫(yī)院2015年1月—3月產(chǎn)后42 d來(lái)復(fù)診的足月單胎初產(chǎn)婦312例，根據(jù)孕期及產(chǎn)褥期是否接受健康教育及盆底肌訓(xùn)練分為訓(xùn)練組和對(duì)照組，訓(xùn)練組64例，對(duì)照組248例。測(cè)定盆底肌肌力，進(jìn)行盆腔器官脫垂定量(pelvic organ prolapse quantitation，POP-Q)評(píng)分和尿墊試驗(yàn)及性生活質(zhì)量問(wèn)卷調(diào)查等，產(chǎn)后6個(gè)月復(fù)查。結(jié)果： 訓(xùn)練組產(chǎn)后6個(gè)月盆底肌肌力、盆腔臟器脫垂發(fā)生率、性生活質(zhì)量與對(duì)照組比較差異均有統(tǒng)計(jì)學(xué)意義(P<0.05)，兩組尿墊試驗(yàn)陽(yáng)性率差異無(wú)統(tǒng)計(jì)學(xué)意義；產(chǎn)后42 d各項(xiàng)檢測(cè)結(jié)果差異均無(wú)統(tǒng)計(jì)學(xué)意義。結(jié)論： 孕期及產(chǎn)褥期開展健康教育及盆底肌訓(xùn)練有助于防治產(chǎn)后盆底功能障礙的發(fā)生。

關(guān)鍵詞盆底功能障礙；健康教育；盆底肌訓(xùn)練

Effect of Health Education and Pelvic Muscle Training on Postpartum Pelvic Floor Dysfunction

HUANGJianDINGYanCHENGMingjun

DepartmentofGynecology,ObstetricsandGynecologyHospitalofFudanUniversity,Shanghai200011,China

AbstractObjective： To investigate the preventive and therapeutic effect of health education and pelvic muscle training on postpartum pelvic floor dysfunction. Methods： A total of 312 full-term single-fetus primiparas, who came to Obstetrics and Gynecology Hospital of Fudan University for further consultation 42 days after delivery, were enrolled from Jan. 2015 to Mar. 2015. And they were divided into exercise group and control group according to whether they had received health education and pelvic floor muscle exercise during pregnancy and puerperium.There were 64 cases in exercise group and 248 cases in control group. The pelvic floor muscle strength testing, pelvic organ prolapse quantitation(POP-Q) score, urine pad test, and questionnaire of sexual life quality were conducted. And they were conducted again six months after delivery. Results： Six months after delivery, the pelvic floor muscle strength, occurrence rate of pelvic organ prolapse and sexual quality of life in exercise group were all significantly better than those in control group (P<0.05),however there was no significant difference regarding the positive rate of urine pad test.There was no significant difference regarding all those measures 42 days after delivery. Conclusions： Health education and pelvic muscle training is conducive to prevent and treat postpartum pelvic floor dysfunction.

Key WordsPelvic floor dysfunction；Health education；Pelvic muscle training

女性盆底功能障礙性疾病(pelvic floor dysfunction，PFD)是由于各種原因?qū)е碌呐枨慌K器位置及功能異常的一組疾病，主要包括盆底器官脫垂、壓力性尿失禁等，發(fā)生率高達(dá)19.7%[1]，嚴(yán)重影響婦女的身心健康和生活質(zhì)量。PFD的誘發(fā)因素包括妊娠、分娩損傷、長(zhǎng)期腹壓增加、肥胖、藥物等，其中妊娠和分娩是導(dǎo)致PFD的主要高危因素[2]。因此，在孕期及產(chǎn)褥期進(jìn)行早期干預(yù)治療對(duì)預(yù)防PFD的發(fā)生及提高生活質(zhì)量具有重要意義。

1資料與方法

1.1一般資料選擇復(fù)旦大學(xué)附屬婦產(chǎn)科醫(yī)院2015年1月—3月產(chǎn)后42 d來(lái)復(fù)診的初產(chǎn)婦312例，年齡25～35歲，足月單胎，經(jīng)陰道分娩，無(wú)產(chǎn)科合并癥，無(wú)泌尿生殖系統(tǒng)疾病。根據(jù)孕期及產(chǎn)褥期是否接受過(guò)健康教育及盆底肌訓(xùn)練分為訓(xùn)練組和對(duì)照組，訓(xùn)練組64例，對(duì)照組248例。訓(xùn)練組和對(duì)照組年齡、孕產(chǎn)次、孕周、新生兒出生體質(zhì)量、產(chǎn)前體質(zhì)量指數(shù)比較，差異均無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05)。

1.2方法產(chǎn)后42 d進(jìn)行盆底肌肌力測(cè)定、盆腔器官脫垂定量(pelvic organ prolapse quantitation，POP-Q)評(píng)分、尿墊試驗(yàn)及性生活質(zhì)量問(wèn)卷調(diào)查，產(chǎn)后6個(gè)月復(fù)查。

1.2.1人工法和機(jī)器法檢測(cè)盆底肌肌力(1)人工法：將中指和食指放在產(chǎn)婦陰道后穹隆并后退1.5 cm，使手指與陰道肌肉接觸，根據(jù)Ortiz標(biāo)準(zhǔn)評(píng)估盆底肌肌力(分0～5級(jí))。(2)機(jī)器法：使用法國(guó)神經(jīng)肌肉刺激治療儀(PHENIX USB4)，將壓力探頭放入陰道內(nèi)，評(píng)估盆底Ⅰ/Ⅱ類肌纖維的肌力。產(chǎn)婦盆底肌肌力的綜合評(píng)分為：80%儀器評(píng)分+20%指檢評(píng)分。

1.2.2性生活質(zhì)量問(wèn)卷調(diào)查采用盆腔器官脫垂及尿失禁性生活質(zhì)量問(wèn)卷(pelvic organ prolapse-urinary incontinence sexual questionnaire，PISQ-12)[3]調(diào)查產(chǎn)婦產(chǎn)后性生活質(zhì)量。

1.2.3盆腔臟器脫垂由同一位盆底康復(fù)師按照國(guó)際統(tǒng)一的POP-Q分度法進(jìn)行分度。

1.2.4壓力性尿失禁在產(chǎn)婦有明顯尿意、無(wú)急迫感時(shí)，讓其用最大力屏氣和咳嗽，觀察有無(wú)尿液流出，并做尿墊試驗(yàn)和尿失禁問(wèn)卷，根據(jù)結(jié)果做出壓力性尿失禁的診斷。

1.3統(tǒng)計(jì)學(xué)處理采用SPSS 13.0軟件進(jìn)行統(tǒng)計(jì)學(xué)分析，計(jì)數(shù)資料組間比較采用χ2檢驗(yàn)，計(jì)量資料組間比較采用t檢驗(yàn)。以P<0.05為差異有統(tǒng)計(jì)學(xué)意義。

2結(jié)果

2.1健康教育及盆底肌訓(xùn)練對(duì)產(chǎn)后盆底肌肌力及性生活質(zhì)量的影響訓(xùn)練組產(chǎn)后42 d盆底肌肌力、性生活質(zhì)量與對(duì)照組比較差異均無(wú)統(tǒng)計(jì)學(xué)意義，產(chǎn)后6個(gè)月盆底肌肌力、性生活質(zhì)量與對(duì)照組比較差異均有統(tǒng)計(jì)學(xué)意義(P<0.05)，見表1。

2.2健康教育及盆底肌訓(xùn)練對(duì)產(chǎn)后盆底臟器脫垂的影響訓(xùn)練組產(chǎn)后42 d POP-Q Ⅰ、Ⅱ度臟器脫垂率與對(duì)照組比較，差異均無(wú)統(tǒng)計(jì)學(xué)意義；訓(xùn)練組產(chǎn)后6個(gè)月POP-Q Ⅰ、Ⅱ度臟器脫垂率與對(duì)照組比較差異均有統(tǒng)計(jì)學(xué)意義(P<0.05)，見表2。

±s)

注：與對(duì)照組比較，*P<0.05

表2　2組產(chǎn)婦產(chǎn)后盆腔臟器脫垂發(fā)生率的比較 (n，%)

注：與對(duì)照組比較，*P<0.05

2.3健康教育及盆底肌訓(xùn)練對(duì)產(chǎn)后尿失禁的影響訓(xùn)練組尿墊試驗(yàn)陽(yáng)性率為4.68%(3/64)，對(duì)照組為5.24%(13/248)，差異無(wú)統(tǒng)計(jì)學(xué)意義。

3討論

妊娠和分娩可能對(duì)盆底肌肉造成不同程度的損傷，從而影響產(chǎn)后性生活質(zhì)量，引起產(chǎn)后尿失禁、盆腔器官脫垂等癥狀[4-7]，是女性PFD的主要危險(xiǎn)因素[8]。盆底肌訓(xùn)練(Kegel訓(xùn)練)指有意識(shí)地對(duì)以肛提肌為主的盆底肌肉進(jìn)行自主性收縮、加強(qiáng)控尿能力及盆底肌肉力量，是PFD最常用的非手術(shù)治療方法[9]。產(chǎn)后早期就進(jìn)行盆底肌訓(xùn)練，對(duì)提高產(chǎn)后性生活質(zhì)量，預(yù)防和治療產(chǎn)后尿失禁、盆腔器官脫垂有重要意義[10-13]。

本研究中產(chǎn)后42 d問(wèn)卷調(diào)查結(jié)果顯示，僅有20.51%(64/312)產(chǎn)婦了解孕前、產(chǎn)后盆底相關(guān)知識(shí)并進(jìn)行盆底肌訓(xùn)練，說(shuō)明孕婦學(xué)校、醫(yī)生的宣傳力度不夠或者不夠重視；訓(xùn)練組產(chǎn)婦經(jīng)過(guò)健康教育及盆底肌訓(xùn)練后，其產(chǎn)后6個(gè)月盆底肌肌力、盆底臟器脫垂及性生活質(zhì)量與對(duì)照組比較均有明顯改善(P<0.05)，與文獻(xiàn)報(bào)道相符，但在產(chǎn)后42 d時(shí)效果不明顯，說(shuō)明長(zhǎng)期的盆底肌訓(xùn)練才會(huì)有效。另外，健康教育及盆底肌訓(xùn)練對(duì)尿失禁療效不理想，可能與本研究樣本量不夠大有關(guān)。因此，如果能夠在孕期及產(chǎn)褥期盡早對(duì)孕產(chǎn)婦進(jìn)行健康教育和指導(dǎo)盆底肌訓(xùn)練，并長(zhǎng)期堅(jiān)持，則可以降低PFD的發(fā)生。

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中圖分類號(hào)R711.5

文獻(xiàn)標(biāo)志碼A

通訊作者程明軍，E-mail：chengmingjun04@163.com

基金項(xiàng)目：上海市衛(wèi)生和計(jì)劃生育委員會(huì)青年科研項(xiàng)目(編號(hào)：20124Y054)；上海市科學(xué)技術(shù)委員會(huì)西醫(yī)引導(dǎo)類項(xiàng)目(編號(hào)：124119a5501)；上海市申康醫(yī)院管理集團(tuán)新興前沿項(xiàng)目(編號(hào)：SHDC12013120)