摘要
目的：众所周知，产后疼痛治疗方法存在很大差异，并受到非临床因素的影响。我们旨在研究有助于临床医生评估和处理产后疼痛的因素，包括阿片类药物的作用：我们对在一家大型三级医疗中心提供产后护理的产科临床医生进行了一项定性研究（2021 年 11 月至 2022 年 6 月）。妇产科主治医师、实习医师和高级医师（APP）使用半结构化访谈指南完成了深度访谈。我们采用了有目的的抽样方法，以确保每种临床医生类型的样本都具有代表性。参与者被问及影响产后疼痛管理的因素。采用恒定比较法对数据进行分析：在 46 名参与者中，48% 是主治医生，32% 是实习医生，20% 是 APP。分析显示了与产后评估和管理相关的三个关键主题：影响因素（影响实践的知识或经验）、客观发现和咨询的作用（表 1）。虽然临床医生称指南和患者满意度是主要的影响因素，但也有几位医生分享了两者之间可能产生的内在冲突。客观研究结果，特别是疼痛对患者实现功能目标的影响，也影响了临床医生的决策。与此相反，许多与会者表示数字疼痛量表作为客观指标的作用有限。此外，与会者还强调了咨询在共同决策和提供预期指导中的作用。最后，临床医生对阿片类药物在疼痛治疗中的作用有不同的看法，但许多人谈到了阿片类药物作为二线治疗的价值以及阿片类药物流行对处方实践的影响：结论：影响临床医生评估和处理产后疼痛的因素偶尔会发生冲突。此外，数字疼痛量表等客观测量方法也有很大的局限性。Objective: Postpartum pain management practices have significant variation and are known to be influenced by non-clinical factors. We aimed to examine factors which contribute to clinicians' assessment and management of postpartum pain, including the role of opioids.
Study design: We conducted a qualitative study of obstetric clinicians providing postpartum care at a single, large, tertiary care center (11/2021-6/2022). Attending and trainee OB/GYN physicians and advance practice providers (APPs) completed in-depth interviews using a semi-structured interview guide. Purposive sampling was employed to ensure a representative sample of each clinician type was included. Participants were asked about factors that influence postpartum pain management. Data were analyzed using the constant comparative method.
Results: Of 46 participants, 48% were attending physicians, 32% trainee physicians, and 20% APPs. Analysis demonstrated three key themes related to postpartum assessment and management: influencing factors (knowledge or experiences that influence practice), objective findings, and the role of counseling (Table 1). While clinicians reported guidelines and patient satisfaction as major influencing factors, several also shared the inherent conflict that may arise between them. Objective findings, specifically the impact of pain on patients achieving functional goals, also influenced clinician decision making. Conversely, many participants reported the limited utility of the numeric pain scale as an objective metric. Additionally, the role of counseling in shared decision-making and providing anticipatory guidance was emphasized. Finally, clinicians had a range of opinions on the role of opioids in pain management, but many spoke to the value of opioids as second-line treatment and the impact of the opioid epidemic on prescribing practices.
Conclusion: The factors that influence clinicians' assessment and management of postpartum pain are occasionally in conflict. Furthermore, objective measures, such as the numeric pain scale, have significant limitations.
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