減痛分娩產婦待產期間導尿方式與生產結果之相關性探討

Abstract

研究背景：單次導尿與留置導尿管是面對施打減痛分娩後發生產中尿液滯留問題時，使尿液排出膀胱的常見方式，然而現階段的研究尚無法確定施打減痛分娩產婦於待產過程中使用不同導尿方式之優劣，現有的研究也並未納入足夠且完整的控制變項，同時也並沒有針對將待產過程中放置的留置導尿管留存至產後移除的研究，因此本研究將討論施打減痛分娩產婦使用不同導尿方式對於產婦生產過程及產後併發症的影響。 研究目的：（1）了解北部某醫學中心內產婦施打硬脊膜外麻醉後尿液滯留的發生狀況；（2）探討施打硬脊膜外麻醉後不同的導尿方式下，產婦的生產過程（第二產程時長、生產方式）是否會受到影響；（3）探討施打硬脊膜外麻醉後不同的導尿方式下，產婦的產後併發症（產後尿液滯留、產後泌尿道感染）發生狀況是否會受到影響。 研究方法：本研究採相關性回溯性世代研究設計，回溯北部某醫學中心產房內自2022年12月1日至2024年7月31日之病歷，納入預計陰道生產而入院待產或催生、18歲以上、先露部位為胎兒頭部、施打減痛分娩且施打後無法自主解尿的足月單胎初產婦或經產婦，依採行的導尿方式將產婦分為「單次導尿」、「留置導尿管」、及「單次導尿及留置導尿管」三個組別，並在收集基本資料、生產資料、減痛分娩資料、及導尿相關資料後，進行第二產程時長、生產方式、產後尿液滯留、產後泌尿道感染的迴歸模型分析。 研究結果：本研究發現收案期間所有產婦中，發生產中尿液滯留的比例為78.9%，最終共納入836名符合收案條件的產婦。生產過程部分，線性迴歸模型顯示，三種導尿方式與第二產程時長無顯著相關（p > 0.05）；生產方式的羅吉斯迴歸模型顯示，行單次導尿及留置導尿管的產婦。其剖腹產的勝算比是採行單次導尿產婦的3.55倍（OR = 3.55，p = 0.012）。產後併發症部分，產後尿液滯留的羅吉斯迴歸模型顯示，採行單次導尿及留置導尿管的陰道生產產婦，其發生產後尿液滯留的勝算比是採行單次導尿的0.24倍（OR = 0.24，p = 0.008），而留置導尿管組別的產後尿液滯留發生人數為0人；產後泌尿道感染的卜瓦松迴歸模型顯示，三種導尿方式與產後泌尿道感染無顯著相關（p > 0.05）。 結論：待產過程中選擇單次導尿、留置導尿管、或單次導尿及留置導尿管，對於施打減痛分娩後發生產中尿液滯留的產婦來說，導尿方式與生產過程及產後併發症並沒有顯著負面的相關性，以不傷害產婦的角度出發，單次導尿與留置導尿管皆是臨床上可選擇的措施，臨床上也可由醫療人員向產婦解釋後共同討論決定，依照產婦意願或其他因素決定導尿方式。另外，不同導尿方式與施打減痛分娩且發生產中尿液滯留的產婦的第二產程時長沒有顯著相關性，放置留置導尿管且放置至產後移除可以減少其陰道生產產後尿液滯留的發生，同時，待產期間留置導尿管的放置不會顯著增加產後泌尿道感染風險，因此施打減痛分娩後發生產中尿液滯留的產婦需要導尿時，可考慮採取留置導尿管方式。

Background: Intermittent catheterization and indwelling urinary catheterization are commonly employed to manage intrapartum urinary retention following epidural analgesia. However, existing literature has yet to establish the comparative advantages or disadvantages of these catheterization methods during labor. In addition, current studies are limited by insufficient adjustment for confounding variables and a lack of investigation into the outcomes of continued indwelling catheterization from labor to the postpartum period. This study aims to examine the impact of different catheterization methods on labor outcomes and postpartum complications among women receiving epidural analgesia. Objectives: This study aims to: (1) determine the incidence of urinary retention following epidural analgesia in a medical center in northern Taiwan; (2) evaluate the association between different catheterization methods and labor outcomes, including the duration of the second stage of labor and mode of delivery; (3) assess the association between catheterization methods and postpartum complications, including postpartum urinary retention and postpartum urinary tract infections. Methods: A retrospective cohort design was employed. Medical records were reviewed from the delivery room of a medical center in northern Taiwan, covering the period from December 1, 2022, to July 31, 2024. Eligible participants included women aged 18 years or older with term singleton pregnancies, cephalic presentation, admitted for spontaneous labor or induction, who received epidural analgesia and subsequently experienced an inability to void spontaneously. Participants were categorized into three groups based on the catheterization method utilized: (1) intermittent catheterization, (2) indwelling catheterization, and (3) a combination of both. Data on demographic characteristics, labor details, epidural analgesia, and catheterization practices were collected. Regression analyses were conducted to evaluate the associations between catheterization methods and outcomes including second-stage labor duration, mode of delivery, postpartum urinary retention, and urinary tract infections. Results: Among all women who received epidural analgesia during the study period, the incidence of intrapartum urinary retention was 78.9%. A total of 836 women met the inclusion criteria. Linear regression analysis revealed no statistically significant association between catheterization method and the duration of the second stage of labor (p > 0.05). Logistic regression indicated that women who underwent both intermittent and indwelling catheterization had significantly higher odds of cesarean delivery compared to those who received intermittent catheterization alone (OR = 3.55, p = 0.012). Regarding postpartum complications, logistic regression demonstrated that among women who delivered vaginally, those who received both intermittent and indwelling catheterization had significantly lower odds of postpartum urinary retention compared to the intermittent group (OR = 0.24, p = 0.008). Notably, no cases of postpartum urinary retention were observed in the indwelling catheterization-only group. Poisson regression analysis showed no significant association between catheterization method and the incidence of postpartum urinary tract infection (p > 0.05). Conclusion: Among parturients who developed intrapartum urinary retention following epidural analgesia, the choice of catheterization method—intermittent, indwelling, or a combination of intermittent and indwelling—did not exert a significantly negative impact on labor outcomes or postpartum complications. Both intermittent and indwelling catheterization can be considered clinically appropriate options. Clinically, healthcare providers may explain the available catheterization options to the parturient. The choice of catheterization method can then be determined based on the patient’s preference or other relevant clinical factors. Moreover, the findings indicate that the duration of the second stage of labor is not significantly associated with the catheterization method. Retaining an indwelling catheter until the postpartum period may reduce the risk of postpartum urinary retention among women undergoing vaginal delivery, and indwelling urinary catheterization does not appear to significantly increase the risk of postpartum urinary tract infection. Therefore, in cases of intrapartum urinary retention following epidural analgesia, indwelling catheterization may be a suitable management strategy.