摘要
妊娠晚期孕妇预警评分表的研制
目的：
本研究旨在研制适合护士使用的妊娠晚期孕妇预警评分表。将预警评分表应用于临床，验证其实用性及有效性，为妊娠晚期孕妇的分类救治提供客观量化依据。
方法：
1. 在查阅文献法、半结构访谈法的基础上，采用专家函询法（Delphi method）构建妊娠晚期孕妇预警评分表指标框架，用文献法和专家会议法确定指标分级、赋分，采用层次分析法计算各指标权重，并进行 85 例预试验对评分表的指标进行删选，最终形成妊娠晚期孕妇预警评分表。
2. 采用便利抽样的方法选取某所三级甲等医院 2017 年 7 月到 2017 年 10 月收治的 370 名妊娠晚期潜在危重孕妇，由经过培训的护士或助产士采用研制的妊娠晚期孕妇预警评分表对其进行病情评估。数据录入�用 Excel 2010 软件，用评估结果检验评分表的信效度。
3. 采用便利抽样法选取某三甲综合医院产科 2017 年 11 月到 2017 年 12 月收治的妊娠晚期潜在危重孕妇 100 例为研究对象，绘制受试者工作特征曲线( receiveroperatingcharacteristic curve，ROC)对评分表进行敏感性、特异性分析，并确定最佳阈值。
结果：
1.两轮专家函询问卷的有效回收率分别为 97.78%和 95.45%（＞70%）；专家权威程度分别为 0.927 和 0.936（＞0.70）；专家意见协调系数分别为 0.158 和 0.297，第二轮专家咨询后指标变异系数范围为 0.07-0.20。5 项一级指标及权重分别为：一般情况（0.1384）、症状（0.0954）、体征（0.1831）、检查（0.3409）、和检验（0.2422）。
最终形成 5 项一级指标，24 项二级指标的妊娠晚期孕妇预警评分表。
2.将预警评分表应用于 370 名妊娠晚期潜在危重孕妇的评估结果显示：评分表总体的克朗巴赫α系数、分半 Spearman-Brown 系数、Theta 系数（θ）及 Omega 系数（ω）分别为 0.537，0.540，0.760 和 0.638，评定者间信度为 0.978。效度方面，各指标的内容效度指数（I-CVI）范围为 0.8-1.0，评分表总体的内容效度指数（S-CVI）为 0.975；探索性因子分析结果显示：共提取出 8 个公因子，累积贡献率达 56.562％，各指标因子载荷为 0.335-0.915。
3.预警评分表的 ROC 曲线下面积为 0.869，95%置信区间(0.793-0.945)，最佳阈值为 10.317，此时预警评分表的敏感性、特异性、约登指数分别为 0.82、0.88、0.70。
结论：
专家函询的积极系数、权威程度及协调系数等结果证明，本次专家咨询具有较高的可信度。预警评分表的各指标具有良好的权重系数，且经过实测验证评分表具有较好的信度及效度，对妊娠晚期危重孕妇有较高的敏感性和特异性，构建的预警评分表可以全面反应孕晚期孕妇的健康状况，为孕晚期孕妇的病情评估提供依据，有助于识别危重孕妇。
关键词：妊娠晚期；预警评分；德尔菲法；研制.
Abstract
Objective:
The purpose of this study was to develop an early warning scale for pregnant womenin the third trimester of pregnancy, which was suitable for nurses, and applied it to clinicalpractice to verify its practicability and effectiveness, and to provide an objective andquantitative basis for the classification and treatment of pregnant women in the thirdtrimester of pregnancy.
Methods：
1.Based on the literature review and semi-structured interviews, the Delphi methodwas used to construct an indicator framework for early pregnancy scores in the thirdtrimester of pregnancy. The index classification and scoring were determined using theliterature method and the expert meeting method. The analytic hierarchy process was used.
Calculate the weight of each index, and perform 85 pre-experiments to delete the index ofthe score table, and finally form the early warning score for pregnant women during thethird trimester.
2.A convenient sampling method was used to select 370 pregnant women who wereadmitted to a Grade 3A hospital from July 2017 to October 2017. The trained nurses ormidwives used the developed early warning scale for pregnant women to evaluate theircondition. The data were recorded in the software Excel 2010 and the reliability andvalidity of the scale were tested with the evaluation results.
3.The convenience sampling method was used to select 100 pregnant women whowere admitted from November 2017 to December 2017 in obstetrics department of ageneral hospital for the study of potential critical pregnant women in the third trimester ofpregnancy. The receiver operating characteristic curve (ROC curve) was drawn to analyzethe sensitivity and specificity of the scoring table and to determine the best threshold.
Results:
1. The effective recovery rate of the two rounds of expert letter inquiry volume was97.78% and 95.45% (>70%) respectively; the authority of experts was 0.927 and 0.936(>0.70) respectively; the coordination coefficient of expert opinion was 0.158 and 0.297,respectively. After the round of expert consultation, the index coefficient of variationranged from 0.07 to 0.20. The five primary indicators and weights were: general condition(0.1384), symptom (0.0954), physical sign (0.1831), check (0.3409), and test (0.2422). Inthe end, five first-level indicators and 24 second-level indicators of early pregnancywarning scores for pregnant women were formed.
2. Applying the early warning scale to the evaluation of 370 pregnant women withpotential critical pregnancy in the third trimester of pregnancy, the results showed that theoverall Cronbach.
3.The area under the ROC curve of the Early Warning Scale was 0.869 with a 95%confidence interval (0.793-0.945).the best threshold is 10.317.At this time, the sensitivity,specificity and Yorden index of the early warning scoring scale were 0.82 ,0. 88, 0. 70.
Conclusion:
The positive coefficient, the degree of authority and the coordination coefficient of theexpert letter prove that the expert consultation has a high credibility, and the indexes of theearly warning scoring table have good weight coefficient. The reliability and validity of thescale were verified by actual test, and it had high sensitivity and specificity for critically illpregnant women during late pregnancy. The early warning scale could reflect the healthstatus of the pregnant women in the third trimester. To provide the basis for the evaluationof the condition of pregnant women in the third trimester, and help to identify the criticalpregnant women.
Key words:late pregnancy; early warning score; Delphi method; Development.
目 录
1 引 言
1.1 问题的提出与研究意义
1.1.1 问题的提出
从 2013 年到 2015 年，我国的计划生育政策从“单独二孩”到“全面开放二孩”，发生了很大的变化。全面两孩政策实施后，累积生育需求释放，高龄孕产妇比例增高，而高龄孕产妇存在生育能力下降、围产期并发症增加、病理妊娠凸显等问题。2017年世界卫生组织发布的《2017 年世界卫生统计报告》中指出，我国 2015 年上半年孕产妇死亡率约为 14/10 万。而据国家卫计委统计 2016 年上半年我国孕产妇死亡率高达 18.3/10 万，比 2015 年同期增长 30.6%。由此看出随着我国计划生育政策的调整，孕产妇的死亡率有所反弹，危重孕产妇管理救治面临新的挑战。
2016 年 10 月 25 日，我国国务院提出的《“健康中国 2030”规划纲要》中明确提出要加强重点人群的健康服务，其中首要指出要提高妇幼健康水平，提升孕产妇急危重症救治能力，并将孕产妇死亡率作为主要健康指标。2017 年 7 月国家卫生计生委在《关于加强母婴安全保障工作的通知》中指出必须要全面开展妊娠风险筛查与评估，以保障母婴安康，保障全面两孩政策的实施。随后国家卫生计生委制定了《孕产妇妊娠风险评估与管理工作规范》。在新形势下，这些政策的出台为本课题提供了研究背景。护士作为妊娠风险评估的主要参与者和执行者，能够及时判断孕产妇的病情变化，迅速实施相关救治尤为重要。
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1.2 国内外相关研究综述
1.3 研究方法
1.4 数据来源与处理
1.5 论文的创新点
2 妊娠晚期孕妇预警评分表的编制
2.1 德尔菲法构建预警评分表指标框架
2.2 预警评分表指标分级赋分
2.3 预警评分表指标权重设置
2.4 小样本预试验修订预警评分表
3 妊娠晚期孕妇预警评分表的信效度检验
3.1 研究目的
3.2 研究对象
3.3 研究方法
3.4 研究结果
4 妊娠晚期孕妇预警评分表的敏感性和特异性分析
4.1 研究目的
4.2 研究对象与方法
4.3 研究结果与分析
5 讨论与结论
5.1 讨论
5.2 结论
5.3 研究不足与展望
参考文献