「會陰切開術」的產科醫學論述形成與轉變－關於自然產的醫學知識與典範轉移

Abstract

本研究企圖分析國內外婦產科界對於會陰切開術（Episiotomy）的論述演變，透過了解國外會陰切開術相關實證研究的辨證與技術規範的形成過程，進一步分析台灣婦產科學界，在自然產典範知識、態度與技術上的差異。 會陰切開術在本研究作為自然產醫學典範的研究標的。透過歷史比較、科技與社會研究以及女性主義的觀點，運用典範以及創新的擴散理論，分析關於自然產會陰切開術「醫療介入」的論述，國外資料包括Medline、PsyLIT、SSI文獻資料庫中相關文獻、不同版本的威廉氏產科學；國內則以醫學界內部通訊、醫學生共同筆記、報紙期刊相關內容分析國內的論述。再加上德國的田野觀察與台北一區域醫院的產房變革的個案研究。 研究發現，此自然產醫學典範在國外曾歷經轉移的過程，以會陰切開術為例，曾在醫療化的生產概念底下，發展了一套醫學論述，但在經過質疑和實證研究的過程，最後形成醫界內部規範。其翻轉原因受到不同專業、團體與實證科學發展的影響，醫學對於自然產重新詮釋；對於台灣高會陰切開術的現象，除了生產技術醫療化專科化，生產環境機構化的醫療因素，作為行動主體的婦女，才逐步進入這個自然產運動的領域。 醫學典範一如科學典範，可以被挑戰。各國的自然產與會陰切開術情形不同，會陰切開術與生產醫療化、機構化的程度相關。國內自然產與技術掌握於婦產科醫師，低科技相關技術並未如高科技，受到醫界的重視，原因自然產的醫學典範並未受到來自醫界內部與婦女界外部的挑戰，而受到個別經驗、信念與體系因素的交互影響。而醫療論述轉變期間除了不同專業力量的角逐，也有婦女健康運動關於自然產的涉入。 未來婦女健康政策關於人性化生產，除了評估生產時母嬰親善醫院、應鼓勵本土的生產經驗研究、與生產資訊的公開。除了生產的過程外，產前與產後的社會與醫療支持體系，也是婦女生育健康的議題。如此，婦女生產環境中，才有親善支持條件的可能性。

OBJECTIVES. This research is tried to analyze the medical discourses of formation and transformation about episiotomy in the obstetrics practice inside and outside Taiwan. And episiotomy is regarded as an important indicator of the paradigm of natural childbirth and it can be compared in the different social contexts. MATERIAL AND METHODS. Archives Analysis and field study were used to examine the medical discourses about episiotomy. Different electronic databases such as Medline, PsyLIT, SSI , ProQuest were searched by the keyword “ episiotomy”. Different editions of Williams Obstetrics, and the influential announcement or practical guidelines among the important organizations were also inspected. In the context inside Taiwan, lecture notes, textbooks, communications in the obstetrics community, newspapers and public journals were analyzed. Besides, Field studies in Germany and one Taipei regional hospital were described. RESULTS. The medical discourses about episiotomy were constructed under different points of view. The formation about the benefits of episiotomy was established in 1930s. Then the pathological assumptions put the natural childbirth into more medical intervention and episiotomy was gradually accepted in different societies. But it was transformed in 1990s. The reasons come from the results of the women’s health, natural childbirth movement, professional competitions, and the evidence based researches. Compared the overseas conditions, it seems that most Taiwanese obstetricians are not affected by the latest transformation due to obstetrics dominance, mostly institutionalized childbirth, and the newly childbirth movement involvement. The “High Tech” values among physicians make them ignore the importance of restricted use of episiotomy , which is a ”Low Tech” but “High Art” procedure. CONCLUSIONS. From the history of the formation and transformation about episiotomy, we know that the medical Paradigm of childbirth can be challenged. The obstetrical practice in Taiwan needs further scientific, psychosocial assessments and aggressive attentions towards women’s health.