产程的观察与处理PPT课件

妇产科护理nursingofgynecologyandobstetreics,正常分娩NormalLabor董丽媛DongLiyuan,1,.,1.假临产即不规则的宫缩。FalseLaborirregularuterinecontraction2.胎儿下降感因胎先露入盆即衔接所致。Feelingoffetaldescendingduetoengagementoffetalpresentation,whichisalsoknownasjointing.3.见红分娩前2448h，阴道排出血性分泌物。Bloodysecretioncanbeseen2448hbeforedelivery.,先兆临产Threateneddelivery,2,.,1.规律性宫缩的出现。30秒以上/56分左右Irregularuterinecontraction:30secondsorlonger/56minutes2.宫颈管的消失。Cervicalcanalsdisappear3.宫口的扩张。Dilatationofcervicalorifice4.胎先露的下降。Descendingoffetalpresentation,临产诊断DiagnosisBeforeDelivery,3,.,一、评估病史evaluationofmedicalhistory1.确认产前检查资料Confirmthedataofprenatalphysicalexamination.2.了解此次妊娠史Gettheinformationofthispregnancy.3.了解骨盆大小、胎先露、胎方位及胎心等。Gettheinformationofthesizeofpelvic,fetalpresentation,fetalposition,andfetalheartrate,etc.4.过去妊娠史Pregnancyhistory5.一般健康状况及家族史Generalhealthconditionandfamilyhistoryofpregnancy,临产妇入院评Evaluationofadmissionforparturients,4,.,二.入院后身体评估physicalevaluation观察：生命体征Observation：vitalsigns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。gettingtheinformationof:1.uterinecontraction,dilatationofcervix,descendingoffetalpresentetion,ruptureoffetalmemberanes2.fetalheartrate,fetalposition,thewayofpresentation正确评估:产妇对疼痛的耐受性。evaluation:toleranceofpain,临产妇入院评Evaluationofadmissionforparturients,5,.,总产程：规律宫缩-胎儿胎盘娩出Theoverallprocess:fromuterinecontractiontodeliveryoffetusandtheplacenta第一产程（宫颈扩张期）；从规则宫缩到宫口开全。Thefirststageofdelivery(dilatationofcervix):fromirregularcontractiontocompletedilatationofcervicalorifece.初产妇一般需要1112h；经产妇约需68h。generally1112hforprimparaand68hformultipara第二产程（胎儿娩出期）：从宫口开全到胎儿娩出。Thesecondstageofdelivery(deliveryoffetus):fromcompletedilatationofcervicalorificetodeliveryoffetus.初产妇一般需要12h，经产妇只需数分钟，多则1h。generally12hforprimparaandseveralminutes,1hatmostformultipara,第三产程（胎盘娩出期）；从胎儿娩出到胎盘娩出。Thethirdstageofdelivery(deliveryofplacenta):fromdeliveryoffetustodeliveryofplacenta.约需515min，一般不超过30min。generally515min,nolongerthan30min,产程的分期StagesofDelivery,6,.,总产程：规律宫缩-胎儿胎盘娩出Theoverallprocess:fromuterinecontractiontodeliveryoffetusandtheplacenta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：1112h12h515min,primpara经产妇：68h几分钟或1h不超过30minmultiparaseveralminutesto1hlessthan30min,产程的分期StagesofDelivery,Thefirststageofdelivery,Thesecondstageofdelivery,Thethirdstageofdelivery,Dilatationofcervicalorifice,Stageofdeliveryoffetus,Stageofdeliveryofplacenta,Regularuterinecontraction,Completedilatationofcervicalorifice,Deliveryoffetus,Deliveryofplacenta,7,.,一、临床表现clinicalmanifestations1.规律宫缩regularuterinecontraction2.宫口扩张dialtionofcervix3.胎头下降descendingoffetalhead4.胎膜破裂ruptureoffetalmemberane5.疼痛pain,第一产程的观察与处理Observationandtreatmentofthefirststageofdelivery,8,.,（一）规律宫缩regularuterinecontraction持续时间（短长）/间歇时间（长短）duration:shortshortintermittence:longshort,第一产程的观察Observationofthefirststageofdelivery,9,.,（二）宫口扩张胎头下降dilataionofcervixanddescendingoffetalhead潜伏期-规律宫缩宫口扩张3cm，历时8小时，16小时为延长Latentphase:regularuterinecontraction,3cmofdilatationofcervix,8hduration,16h:prolongeddelivery活跃期-宫口扩张3cm10cm，历时4h，8小时为延长activephase:3cm10cmofdilatationofcervix,4hduration,8h:prolongeddelivery以坐骨棘为判断胎先露下降的标志Ischialspineistheindicationofdetermingfetalpresentation.,第一产程的观察Observationofthefirststageofdelivery,10,.,（三）胎膜破裂多发生在宫口近开全时。Ruptureoffetalmemberaneoccursatapproximatecompletedilatationofcervix1.记录破膜时间Recordthetimeofmemberanerupture.2.观察羊水性状,颜色和流出量Observethecharacter,colourandtheamountoftheamnioticfluid.3.立即听胎心Listentothefetalheart.（四）疼痛宫缩会给每个产妇带来不同程度的疼痛Uterinecontractionsbringaboutpaininvariousdegrees.（五）勤听胎心Listentothefetalheartfrequently.,第一产程的观察Observationofthefirststageofdelivery,11,.,1.饮食：鼓励产妇少量多餐，补充足够水分。Diet:frequentmealsinsmallamount,haveenoughwater2.活动:胎膜未破、宫缩不强者鼓励在室内适当活动Activities:nofetalmemberanerupture,lessintenseuterinecontractionproperinneractivities休息:初产妇宫口大于5cm,经产妇宫口扩张3cm左侧卧位。Rests:Thecervicalorificeofaprimiparaisapproximately5cm.Thatofamultiparaisapproximately3cm.Takeleftlateralposition.,第一产程的健康指导Healthguidanceofthefirststageofdelivery,12,.,3.清洁：协助产妇沐浴、更衣，给予外阴备皮Cleanliness:helpthematernitypatientwithbath,changingclothes.Havepreoperativepreservedskindone.4.排尿:鼓励产妇24排尿次Urination:1timeevery245.灌肠：初产妇宫口扩张5cm，经产妇3cmClysisThecervicaldilatationofaprimiparais5cm.Thecervicaldilatationofamultiparais3cm.,第一产程的健康指导Healthguidanceofthefirststageofdelivery,13,.,第二产程的临床表现Clinicalmanifestationofthesecondstageofdelivery,宫缩加强排便感屏气strengtheninguterinecontractiondesiretodefecatebreathholding会阴膨隆变薄,肛门松弛perineumbulging,analrelaxation胎头拨露胎头着冠胎头娩出fetalheadinvisibleonvulvalgappingcrowningdeliveryoffetalhead胎体娩出后羊水涌出deliveryingheadoffetusamnioticfluid,14,.,1.宫缩增强strengtheninguterinecontraction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。10minafterdilatationofuterineoriice,theuterinecontractionstrengthensfurther.Thedurationisapproximately1minormore.Theintermittencetimeis12min.,第二产程的临床表现Clinicalmanifestationofthesecondstageofdelivery,15,.,2.胎儿下降与娩出fetaldescendinganddelivering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。Headvisibleonvulvalgapping:Thefetalheadrevealsatthevaginaloutletduringuterinecontractionandretractsduringtheintermittencetime.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:Afterseveraltimesoftheprocessmentionedabove,revealingpartofthefetalheadcontinuouslyenlarges.Itwillnotretractduringtheintermittencetimeuntilthefetalbiparietaldiameteris?overthetransversediameterofthepelvicoutlet.,第二产程的临床表现Clinicalmanifestationofthesecondstageofdelivery,16,.,3.疼痛与排便感会阴痛，向大腿内侧放射。painanddesiretodefecateTheperineumpainradiatestothemedialsurfaceofthethigh.,第二产程的临床表现Clinicalmanifestationofthesecondstageofdelivery,17,.,1.宫口开全时间thetimeofdilatationofuterineorifice2.宫缩、胎心、羊水uterinecontraction,fetalheartrate,amnioticfluid3.有无排便感havingdesiretodefecateornot4.观察胎头拨露observationofheadvisibleonvulvalgapping5.会阴条件perinealconditions6.是否需行会阴切开术havingperineoctomy,第二产程中评估的内容Evaluationofthesecondstageofdelivery,18,.,一、密切监测胎心carefullyfetalheartmonitoring每510min听胎心1次ausculatefetalheartevery510min二、指导产妇屏气用力givedirectionsofbreathholding,第二产程的观察与处理Observationandmanagementofthe2ndstageofdelivery,19,.,（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preparationfordelivery初产妇宫口开全,经产妇宫口扩张3cm时准备Dothepreparationswhen:primipara:completedilatationofuterineorificemultipara:3cmofdilatationofuterineorifice,第二产程的观察与处理Observationandmanagementofthesecondstageofdelivery,Maternitypatient:perineumwashMidwife:?,20,.,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:protecttheperineumwhileassistingthefetalheadflexion,inordertoletthefetalheadslowlypassthevaginaloutletinminimaldiameter.Deliverthefetalshouldercorrectlywhileprotectingtheperineum.,第二产程的观察与处理Observationandmanagementofthesecondstageofdelivery,21,.,五.保护会阴的时机：theoccasionofprotectingtheperineum阴唇后联合紧张时-胎儿双肩娩出tensionoftheposteriorcommisureoflabiadeliveryoffetalshoulders,第二产程的观察与处理Observationandmanagementofthesecondstageofdelivery,22,.,（二）胎剥离与娩出separationofplacentaanddelivery,（一）宫缩再现recurrenceofuterinecontraction,第三产程的临床表现Clinicalmanifestationsofthethirdstageofdelivery,23,.,1.胎盘剥离征象：signsofplacentalseparation宫体变硬由球形变为狭长形，宫底升高达脐上Thebodyoftheuterushardensandtransformfromsphericaltolongandnarrow.阴道少量出血Asmallamountofvaginalbleeding阴道口外露的脐带自行下降延长Descendingandprolongingoftheumbilicalcordoutofthevaginaoutlet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Themidwifeslightlypressestheuppermarginofpubicbonewiththemedialborderofthehand,inordertopushthebodyofuterusupward.Theumbilicalcordoutofthevaginaloutletwillnotretract.,第三产程的临床表现Clinicalmanifestationsofthethirdstageofdelivery,24,.,2.胎盘娩出方式：typesofplacentaldelivery胎儿面娩出式Schultzmechanism母体面娩出式Duncanmechanism,第三产程的临床表现Clinicalmanifestationsofthethirdstageofdelivery,25,.,1.正确助娩胎盘-必在胎盘剥离后进行Correctlyassisttheplacentaldeliverydefinitelyaftertheseparationofplacenta.,第三产程-产妇的处理managementformaternitypatientsduringthethirdstageofdelivery,Assistingdeliveryofplacentalmemberanes,26,.,2.检查胎盘胎膜：checktheplacentaandfetalmemberane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。Spreadtheplacentaandcheckitsmaternalsurfaceandthedefectivelobules.Lifttheplacentatoseriouslycheckthecompletenessofthememberaneandthebloodvesselbreakingattwobordersofthefetus.Accessoryplacentacanbeseenduringthecheck.Thepossibilityofpostpartumhemorrhageandinflammationincreasesduetotheaccessoryplacentaandtheremnantsoftheplacenta.,第三产程-产妇的处理managementformaternitypatientsduringthethirdstageofdelivery,27,.,第三产程-产妇的处理managementformaternitypatientsduringthethirdstageofdelivery,2.检查胎盘胎膜：checktheplacentaandfetalmemberane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。Thebloodclotcompressingtheplacentaindicatestheimpairmentofthematernalsurface.Checkthecolorandfirmnessoftheplacentalmemberaneseriouslytodeterminewhetherhavingsignsofmeconiumstainingandinflammation.Observeandmeasurethelengthoftheumbilicalcord.Theshortcord,lessthan30cm,easilycausespullingbeforedeliveryandduringthedeliverystages,whichwillresultinprolapseandrupturecordordiversionofuterus.Thelongcordeasilycausesprolapse,windingthefetusorknotting.,28,.,3.检查软产道：checkthesoftbirthcanal4.预防产后出血:preventpostpartumhemorrhage胎儿双肩娩出后,立即给产妇肌内注射缩宫素20UIntramuscularlyinject20Uoxytocinassoonas