妇产科学教学课件：7 dystocia 异常分娩

1DYSTOCIA

异常分娩2ReferenceWilliam’sObstetrics22thHighRiskPregnancy3thCurrentObstetrics&GynecologyDiagnosis&Treatment9th3DefinitionDystocialiterallymeansdifficultlaboranditischaracterizedbyabnormallyslowprogressoflaborItistheconsequenceoffourdistinctabnormalitiesthatmayexistsinglyorcombination4顺产难产顺产分娩四因素异常分娩四因素不相适应处理得当处理不当5EffectofDystociaonMother

ProlongedlaborPostpartumHemorrhagePuerperalInfectionPostpartumUrineRetentionGenitalTractFistulaUterusProlapseRuptureofuterus6EffectofDystociaonFetusAsphyxiaBirthTrauma:bone、nerve、cranialPerinatalMorbidity&Mortility↑7AbnormalofthePowers(uterinecontractilityandmaternalexpulsiveeffort)

—产力AbnormalitiesofthePassage(birthcanal)

—产道AbnormalitiesofthePassenger(fetus)

—胎儿Psychologicalfactor

—心理

Categoriesofdystocia8A．POWERConsistMyometrialcontractionsContractionsofabdominalwall&diaphragmaContractionsoflevatoranimuscleAssessmentAmplitudeDurationRepetitionTone9CharacterofPower*

ForceofLabor*Contractionandretraction*

Effacementofcervixanddilatation*Rhythmicity,Polarity,Symmetry10UterinedysfunctioninertiaHyper-contractilityHypotonicprimarysecondaryHypertonicConcordantPrecipitatedeliveryPathologicretractionringMis-matchTetaniccontractionConstrictionring产力异常11Abnormalitiesofthepowers12Abnormalitiesofthepowers

-----uterineinertia1.EtiologyofuterineinertiaCephalopelvicdisproportionorFetalmalpositionAbnormalofuterinemuscleImbalanceofendocrinesystemAdministrationofanalgesiaPsychical-factorsOthers：fatigue，etc13Abnormalitiesofthepowers

-----uterineinertia2.Clinicalfindings---FailuretoprogressLackofprogressivecervicaldilatation

Prolongedlatentphase（潜伏期延长）

Prolongedactivephase（活跃期延长）

Protractedactivephase（活跃期停滞）

Prolongedsecondphase（第二产程延长）

Protractedsecondphase（第二产程停滞）LackoffetaldecentProlongeddescent（胎头下降延缓）

Protracteddescent（胎头下降停滞）

Prolongedlabor（滞产）14Abnormalitiesofthepowers

-----uterineinertia3.diagnosisPalpation:

strength

duration

frequencyTocodynamometerVaginalexamination151617

产程曲线延长

潜伏期延长(8h)

活跃期延长(4h)第二产程延长(2h)

规律宫缩--宫口宫口3cm—开全第二产程达1h

开3cm胎头下降无进展

进入活跃期后宫口不再扩张达2小时

活跃期停滞

第二产程停滞18Abnormalitiesofthepowers

-----uterineinertia4.Effectonmaternalandfetusmaternalfatigue

acidosisinfectionpostpartumhemorrhagecesareansectionrate

fetusbirthinjurydistressprolapseofumbilicalcordstillbirth19Abnormalitiesofthepowers

-----uterineinertia5.management

Hypotonicgeneralmanagementphysicalmethods：amniotomydrugs：oxitocin、diazepinec-sectionHypertonicsedative：pethidinec-section20Abnormalitiesofthepowers

-----hypercontractility1.ClinicalfindingsanddiagnosisPrecipitatedeliveryConstrictionringofuterusTetaniccontractionofuterus21Abnormalitiesofthepowers

-----hypercontractility2.EffectonmaternalandfetusPrecipitatedeliverySoftbirthcanaltraumaRuptureofuterusFetaldistressFetaldeathStillbirth22Abnormalitiesofthepowers

-----hypercontractility3.managementProphylaxisTocolytictherapiesForcepC-section23B.PASSAGESBonypelvisSofttissue:cervix,lowersegment,pelvicfloor

24AssessmentofPelvicInletPlane入口平面Midplane中骨盆平面Outletplane出口平面25

骨盆入口平面各径线１.前后径(conjugatevera)11cm2.横径(transversediameter)13cm3.斜

径(obliquediameters)12.75cm26

interspinaldiameter,IS(髂棘间径)23~26cm27

intercristaldiameter,IC髂嵴间径25~28cm28

diagonalconjugate,DC骶耻内径≮18cm12.5-13cm18-20cm≮11.5cmexternalconjugate，EC骶耻外径29

中骨盆平面各径线3010cm

interspinousdiameter坐骨棘间径可容6指31骨盆出口各径线(斜面观)1.出口横径约9cm2.出口前矢状径6cm3.出口后矢状径8.5cm328.5~9cm90度11.5cmtransverseoutlet,TO出口横径阴道检查测量出口面前后径Angleofpubicarch33DC+后矢状径>15cmDC+后矢状径<15cmDC8.5-9cm34TypesofPelvicGynecoid（女型）Android（男型）Platypelloid（扁平型）Anthropoid（类人猿型）35正常骨盆入口呈心型出口呈漏斗型funnelshapedpelvis47.3%5.8%36.6%10.9%Flat(platypelloid)anthropoid前后径狭窄

横径狭窄transverselycontractedpelvisgynecoidandroid36女性骨盆gynecoid入口面横椭圆近似圆形骶坐切迹正常大小耻弓角宽大骨盆深度正常37男性骨盆android入口呈三角形

骶切迹狭窄骶骨下段前倾耻弓角狭小骨盆深38扁型骨盆platypelloid

入口横的扁圆形骶坐切迹稍狭窄耻弓角宽大 骨盆浅39猿型骨盆anthropoid(transverselycontractedpelvis)入口面呈长椭圆形 骶坐切迹宽大耻弓角中等 骨盆深40AbnormalityofBonyPelvicContractedpelvicinletSimpleflatpelvis单纯扁平骨盆

Rachiticflatpelvis佝偻病性扁平骨盆Contractedofmidplane&outletFunnelshapedpelvis漏斗骨盆

Transverselycontractedpelvis横径狭窄骨盆GenerallycontractedpelvisMalformationpelvisOsteomalacicpelvis骨软化症骨盆

Obliquelycontractedpelvis偏斜骨盆41

ContractedpelvicinletI--borderline（EC18cm）II--relatively（EC16.5~17.5cm）III–absolutely（EC≤16cm）单纯扁平骨盆佝偻病性扁平骨盆42Contractedpelvicmidplane&outletI--borderline（坐骨棘间径10cm,TO7.5cm）II--relatively（坐骨棘间径10cm,TO6.0~7.0cm）III–absolutely（坐骨棘间径10cm,TO≤5.5cm）漏斗骨盆（男型）横径狭窄骨盆（类人猿型）43各径线均小于2cm均小骨盆Generallycontractedpelvis44骨软化症骨盆偏斜骨盆Malformationpelvis45DiagnosisHistoryPhysicalexaminationPelvimetry骨盆测量

externalpelvimetryinternalpelvimetrydiagonalconjugate12.5~13cmbiischialdiameter10cmincisuraischiadica5~6cm46NotesAbsolutecephalopelvicdisproportionisraretoday.Obstetricianspaygreatattentiontraditionallyto“engagement”.Clinical&x-raypelvimetryhavepoorpredictivevalue.MRI&CT,coupledwithultrasoundfetalbiometrymaybeusedtoimprovediagnosis.Shortcomingsofpelvimetry,andthecomplexmechanismoflaborthatreliesonflexion,rotation,andevenpelviccompliance,meansthatclinicianshavetofallbackon“tryitandsee”.47CephalopelvicDisproportion入盆耻骨联合平面胎头同一平面低于高于可以可疑不可以跨耻征(-)(+)(±)48跨耻征检查阴性阳性49EffectsonmaternalandfetusMaternal:prolongedlaborprocess,abnormalfetalposition,ruptureofuterus,fistulaofgenitaltract,etc.Fetus:prolapseofcord,distressoffetus,stillbirth,trauma,etc.50ManagementAbsoluteContractedPelvis→CSRelativeContractedPelvis→assessment→try→CS，ifanycomplicationhappened51PerineumVulva：scar,edema,etc.Vaginal：septum,cyst,tumor,etc.Cervix：conglutination,edema,scar,cancer,myoma,etc.Uterus:malformation,Scar.Pelvic:Myoma,tumor.AbnormalofSoftTissue52C.PassengerMalposition(vertexmalposition)occiputposterior枕后位

occiputtransverse枕横位

sincipitalpresentation胎头高直位

anteriorasynelitism前不均倾位Malpresentationbrowpresentation额先露

facepresentation面先露

breechpresentation臀先露

compoundpresantation复合先露Abnormalfetallietransverseorobliquelie（shoulderpresentation）53CauseofAbnormalFetalPositionPresentation--Flexion/DeflexionPosition–RotationAbnormalPelvisUterineDysfunctionOthers：myoma，placentaprevia，etc。54★★胎头的姿态及其通过骨盆的径线

俯屈(枕先露)不俯屈不仰伸(前顶先露)

仰伸(额先露)极度仰伸(面先露)5556DiagnosisofAbnormalFetalPositionProtractedorprolongedlaborprogressAbdominalexaminationPelvicexaminationUltrasonography57PersistentOcciput

Posterior/TransversePosition582.SincipitalPresentation593.AnteriorAsynelitism604.FacePresentation颏前位可自娩，颏后位不能自然娩出615.BreechPresentationCompletebreechpresentationFrankbreechpresentationIncompletebreechpresentation62臀位分娩机转636.ShoulderPresentation64忽略性肩先露657.CompoundPresentation668.ShoulderDystosiaFetalmacrosomialargeforgestationalage(LGA)≥4000g

6768FetalMalformation69D.PsychologicalFactor对阴道分娩充满信心→有利于顺利分娩对分娩充满恐惧、丧失信心→体内儿茶酚胺释放→宫缩乏力、血压升高、胎儿窘迫产时镇痛:提倡非药物镇痛→Doulas70ActiveManagementCorrectdiagnosisoflaborUseofapartogramFetalanduterinemonitoringAppropriateinterventionAuditingofoutcomes71Partogram产程图MaternalSignsFetalSignsProgressofLabor72LatentphaseActivephaseIIIstage产程图partogram73A潜伏期延长prolongedlatentphaseB活跃期延长

prolong