产程的观察与处理课件.pptx

妇产科护理nursing of gynecology and obstetreics,正常分娩 Normal Labor,1.假临产 即不规则的宫缩。 False Labor irregular uterine contraction2.胎儿下降感 因胎先露入盆即衔接所致。 Feeling of fetal descending due to engagement of fetal presentation, which is also known as jointing. 3.见红 分娩前2448h，阴道排出血性分泌物。 Bloody secretion can be seen 2448 h before delivery.,先兆临产Threatened delivery,1.规律性宫缩的出现。30秒以上/ 56分左右 Irregular uterine contraction: 30 seconds or longer/ 56 minutes2.宫颈管的消失。Cervical canals disappear3.宫口的扩张。 Dilatation of cervical orifice4.胎先露的下降。 Descending of fetal presentation,临产诊断Diagnosis Before Delivery,一、评估病史 evaluation of medical history 1.确认产前检查资料 Confirm the data of prenatal physical examination. 2.了解此次妊娠史 Get the information of this pregnancy. 3.了解骨盆大小、胎先露、胎方位及胎心等。 Get the information of the size of pelvic, fetal presentation, fetal position, and fetal heart rate, etc. 4.过去妊娠史 Pregnancy history 5.一般健康状况及家族史 General health condition and family history of pregnancy,临产妇入院评Evaluation of admission for parturients,二.入院后身体评估 physical evaluation 观察：生命体征 Observation：vital signs 了解: 1.宫缩强度、宫口扩张、胎先露下降、破膜与否 2. 胎心率、胎方位、胎产式。 getting the information of: 1.uterine contraction, dilatation of cervix, descending of fetal presentetion, rupture of fetal memberanes 2. fetal heart rate, fetal position, the way of presentation 正确评估:产妇对疼痛的耐受性。 evaluation: tolerance of pain,临产妇入院评Evaluation of admission for parturients,总产程：规律宫缩-胎儿胎盘娩出The overall process: from uterine contraction to delivery of fetus and the placenta 第一产程（宫颈扩张期）；从规则宫缩到宫口开全。The first stage of delivery (dilatation of cervix): from irregular contraction to complete dilatation of cervical orifece. 初产妇一般需要1112h；经产妇约需68h。 generally 1112h for primpara and 68h for multipara第二产程（胎儿娩出期）：从宫口开全到胎儿娩出。The second stage of delivery (delivery of fetus): from complete dilatation of cervical orifice to delivery of fetus. 初产妇一般需要12h，经产妇只需数分钟，多则1h。 generally 12h for primpara and several minutes, 1 h at most for multipara,第三产程（胎盘娩出期）；从胎儿娩出到胎盘娩出。The third stage of delivery (delivery of placenta): from delivery of fetus to delivery of placenta. 约需515min，一般不超过30min。 generally 515min, no longer than 30min,产程的分期 Stages of Delivery,总产程：规律宫缩-胎儿胎盘娩出The overall process: from uterine contraction to delivery of fetus and the placenta 第一产程 第二产程 第三产程 规律宫缩-宫口开全-胎儿娩出-胎盘娩出 宫口扩张期 胎儿娩出期 胎盘娩出期 初产妇： 1112h 12h 515min, primpara 经产妇： 68h 几分钟或1h 不超过30minmultipara several minutes to 1h less than 30min,产程的分期 Stages of Delivery,The first stage of delivery,The second stage of delivery,The third stage of delivery,Dilatation of cervical orifice,Stage of delivery of fetus,Stage of delivery of placenta,Regular uterine contraction,Complete dilatation of cervical orifice,Delivery of fetus,Delivery of placenta,一、临床表现 clinical manifestations 1.规律宫缩 regular uterine contraction 2.宫口扩张 dialtion of cervix 3.胎头下降 descending of fetal head 4.胎膜破裂 rupture of fetal memberane 5.疼痛 pain,第一产程的观察与处理Observation and treatment of the first stage of delivery,（一）规律宫缩 regular uterine contraction 持续时间（短长）/ 间歇时间（长短） duration : short short intermittence: long short,第一产程的观察Observation of the first stage of delivery,（二）宫口扩张 胎头下降 dilataion of cervix and descending of fetal head 潜伏期-规律宫缩宫口扩张3cm，历时8小时，16小时为延长 Latent phase: regular uterine contraction, 3cm of dilatation of cervix, 8h duration, 16h:prolonged delivery 活跃期-宫口扩张3cm10cm，历时4h， 8小时为延长 active phase: 3cm10cm of dilatation of cervix, 4h duration, 8h:prolonged delivery 以坐骨棘为判断胎先露下降的标志 Ischial spine is the indication of determing fetal presentation.,第一产程的观察Observation of the first stage of delivery,（三）胎膜破裂 多发生在宫口近开全时。 Rupture of fetal memberane occurs at approximate complete dilatation of cervix 1.记录破膜时间 Record the time of memberane rupture. 2.观察羊水性状,颜色和流出量 Observe the character, colour and the amount of the amniotic fluid. 3.立即听胎心 Listen to the fetal heart.（四）疼痛 宫缩会给每个产妇带来不同程度的疼痛 Uterine contractions bring about pain in various degrees. （五）勤听胎心 Listen to the fetal heart frequently.,第一产程的观察Observation of the first stage of delivery,1.饮食：鼓励产妇少量多餐，补充足够水分。 Diet: frequent meals in small amount, have enough water 2.活动: 胎膜未破、宫缩不强者鼓励在室内适当活动 Activities: no fetal memberane rupture, less intense uterine contraction proper inner activities 休息: 初产妇宫口大于5cm,经产妇宫口扩张3cm 左侧卧位。 Rests: The cervical orifice of a primipara is approximately 5cm.That of a multipara is approximately 3cm.Take left lateral position.,第一产程的健康指导Health guidance of the first stage of delivery,3.清洁：协助产妇沐浴、更衣，给予外阴备皮 Cleanliness: help the maternity patient with bath, changing clothes. Have preoperative preserved skin done.4.排尿:鼓励产妇24排尿次 Urination: 1 time every 245.灌肠：初产妇宫口扩张 5cm，经产妇 3cm Clysis The cervical dilatation of a primipara is 5cm. The cervical dilatation of a multipara is 3cm.,第一产程的健康指导Health guidance of the first stage of delivery,第二产程的临床表现Clinical manifestation of the second stage of delivery,宫缩加强排便感屏气strengthening uterine contraction desire to defecate breath holding 会阴膨隆变薄,肛门松弛perineum bulging, anal relaxation 胎头拨露胎头着冠胎头娩出fetal head invisible on vulval gapping crowning delivery of fetal head胎体娩出后羊水涌出deliverying head of fetus amniotic fluid,1.宫缩增强 strengthening uterine contraction 宫口开全（10cm）后，宫缩进一步增强，持续时间约 1min或以上，间歇时间12min。 10min after dilatation of uterine oriice, the uterine contraction strengthens further. The duration is approximately 1min or more. The intermittence time is 12min.,第二产程的临床表现Clinical manifestation of the second stage of delivery,2.胎儿下降与娩出 fetal descending and delivering 拨露-胎头于宫缩时显露于阴道口，宫缩间歇时又缩回于阴道内。 Head visible on vulval gapping: The fetal head reveals at the vaginal outlet during uterine contraction and retracts during the intermittence time. 着冠-经过几次拨露，胎头外露部分不断增大，直至胎头双顶径越过 骨盆出口横径，在宫缩间歇时也不再缩回。 Crowning: After several times of the process mentioned above, revealing part of the fetal head continuously enlarges. It will not retract during the intermittence time until the fetal biparietal diameter is ?over the transverse diameter of the pelvic outlet.,第二产程的临床表现Clinical manifestation of the second stage of delivery,3.疼痛与排便感 会阴痛，向大腿内侧放射。 pain and desire to defecate The perineum pain radiates to the medial surface of the thigh.,第二产程的临床表现Clinical manifestation of the second stage of delivery,1.宫口开全时间 the time of dilatation of uterine orifice 2.宫缩、胎心、羊水 uterine contraction, fetal heart rate, amniotic fluid 3.有无排便感 having desire to defecate or not 4.观察胎头拨露 observation of head visible on vulval gapping 5.会阴条件 perineal conditions 6.是否需行会阴切开术 having perineoctomy,第二产程中评估的内容Evaluation of the second stage of delivery,一、密切监测胎心 carefully fetal heart monitoring 每510min听胎心1次 ausculate fetal heart every 510min二、指导产妇屏气用力 give directions of breath holding,第二产程的观察与处理Observation and management of the 2nd stage of delivery,（1）产妇准备：会阴冲洗 （2）接生人员准备：按外科刷手法,三. 做好接产准备 preparation for delivery 初产妇宫口开全,经产妇宫口扩张3cm时准备 Do the preparations when: primipara:complete dilatation of uterine orifice multipara:3cm of dilatation of uterine orifice,第二产程的观察与处理Observation and management of the second stage of delivery,Maternity patient: perineum washMidwife: ?,四.接产要领-保护会阴的同时，协助胎头俯屈，让胎头以最小径线在宫缩间歇期缓慢通过阴道口。还必须正确娩出胎肩，同时保护好会阴。Attention: protect the perineum while assisting the fetal head flexion, in order to let the fetal head slowly pass the vaginal outlet in minimal diameter. Deliver the fetal shoulder correctly while protecting the perineum.,第二产程的观察与处理Observation and management of the second stage of delivery,五.保护会阴的时机： the occasion of protecting the perineum 阴唇后联合紧张时- 胎儿双肩娩出 tension of the posterior commisure of labia delivery of fetal shoulders,第二产程的观察与处理Observation and management of the second stage of delivery,（二）胎剥离与娩出 separation of placenta and delivery,（一）宫缩再现 recurrence of uterine contraction,第三产程的临床表现Clinical manifestations of the third stage of delivery,1.胎盘剥离征象： signs of placental separation宫体变硬由球形变为狭长形，宫底升高达脐上 The body of the uterus hardens and transform from spherical to long and narrow.阴道少量出血 A small amount of vaginal bleeding阴道口外露的脐带自行下降延长 Descending and prolonging of the umbilical cord out of the vagina outlet接生者用左手掌尺侧缘轻压产妇耻骨联合上方将宫体向上推，而外露的脐带不再回缩 The midwife slightly presses the upper margin of pubic bone with the medial border of the hand, in order to push the body of uterus upward. The umbilical cord out of the vaginal outlet will not retract.,第三产程的临床表现Clinical manifestations of the third stage of delivery,2.胎盘娩出方式：types of placental delivery 胎儿面娩出式 Schultz mechanism 母体面娩出式 Duncan mechanism,第三产程的临床表现Clinical manifestations of the third stage of delivery,1.正确助娩胎盘-必在胎盘剥离后进行 Correctly assist the placental delivery definitely after the separation of placenta.,第三产程-产妇的处理management for maternity patients during the third stage of delivery,Assisting delivery of placental memberanes,2.检查胎盘胎膜： check the placenta and fetal memberane 将胎盘铺平，先检查母体面，检查胎盘小叶有无缺损，然后将胎盘提起，检查胎膜是否完整，再仔细检查胎儿两边缘有无血管断裂，即能及时发现副胎盘。若有副胎盘，部分胎盘残留或大块胎盘残留时，则产后出血或感染的机会增多。 Spread the placenta and check its maternal surface and the defective lobules. Lift the placenta to seriously check the completeness of the memberane and the blood vessel breaking at two borders of the fetus. Accessory placenta can be seen during the check.The possibility of postpartum hemorrhage and inflammation increases due to the accessory placenta and the remnants of the placenta.,第三产程-产妇的处理management for maternity patients during the third stage of delivery,第三产程-产妇的处理management for maternity patients during the third stage of delivery,2.检查胎盘胎膜： check the placenta and fetal memberane 检查胎盘母体面时，若发现有凝血块压迫胎盘部位，则表明母体表面有缺损。对胎膜的检查应注意观察其颜色及坚实度，是否存在胎粪污染或感染征象。观察并测量脐带长度。脐带过短，即不足30cm 的情况下，在临产及产程中易出现牵引，导致脐带脱出，破裂或子宫倒置。脐带过长易出现脱垂，缠绕胎儿或缠绕成脐带真结。 The blood clot compressing the placenta indicates the impairment of the maternal surface. Check the color and firmness of the placental memberane seriously to determine whether having signs of meconium staining and inflammation. Observe and measure the length of the umbilical cord. The short cord, less than 30cm, easily causes pulling before delivery and during the delivery stages, which will result in prolapse and rupture cord or diversion of uterus. The long cord easily causes prolapse, winding the fetus or knotting.,3.检查软产道：check the soft birth canal 4.预防产后出血: prevent postpartum hemorrhage 胎儿双肩娩出后, 立即给产妇肌内注射缩宫素20U Intramuscularly inject 20U oxytocin as soon as fetal shoulders are delivered.,第三产程-产妇的处理management for maternity patients during the third stage of delivery,5.产后2h产妇留在产房内观察 Observation in the delivery room 2h after delivery 注意生命体征、vital signs 子宫收缩情况、宫底高度、conditions of uterine contraction and the height of uterine fundus 阴道流血量 volume of colporrhagia 膀胱充盈程度，发现异常及时处理。Filling of bladder Any abnormal conditions should be treated immediately.,第三产程-产妇的处理management for maternity patients during the third stage of delivery,三 .正确处理新生儿，预防新生儿窒息 Correct treatment of neonatus and prevention of neonatal apnea,1.清理呼吸道：clean the respiratory tract 2.新生儿Apgar评分：neonatal Apgar score 满分为10分，The maximal score is 10. 810分为正常； 810 normal 47分为轻度窒息 47 mild neonatal apnea 03分为重度窒息 03 severe neonatal apnea,3.处理脐带：气门芯、棉线结扎法、脐带夹等。 Treatment of umbilical cord: valve, cotton thread ligation, umbilical cord clamps,etc.,4.一般护理 general nursing,第三产程的观察与处理Observation and management of the third stage of delivery,Apgar 评分 Apgar Score,第三产程的观察与处理Observation and management of the third stage of delivery,第三产程的观察与处理Observation and management of the third stage of delivery,Apgar评分 Apgar score,