早产、胎膜破裂、胎儿窘迫与女性护理-母婴护理

NursingCareforWomenwithPretermLabor,PrematureRuptureofMembranes,andFetalDistress徐丽华上海交通大学护理学院LearningObjectivesDefinethekeyterms:pretermlabor,prematureruptureofmembranes,fetaldistressUnderstandthedifferenceinpertermbirthandlowbirthweightIdentifyrisksfactorsofpertermlaborUnderstandthecurrentinterventiontotreatpretermlaborDiscussthenursingcareforwomenexperiencedpertermlabor,pertermruptureofmembranes,andfetaldistressPertemLaborDefination:Cervicalchangeanduterinecontractionsoccurringbetween20weeksan37weeksofpregnancyPertermbirthlead75%oftheperinatalmortalityPertermbirthalsoisthesecondleadingdeathofinfantsintheUSA,nexttoCHD.(ComerfordFreda,2000)PertermLaborand

LowBirthWeightPertermLabor:<37weeksofgestationalageLowbirthweight:weightattimeofbirthislessthanorequalto2500grams.Intrauterinegrowthretadation:IUGRRiskFactorsofPretermLaborDemographicRisks:youngmother,lowsocioeconomicstatus,unmarried,lowlevelofeducationMedicalrisk:historyofpretermbirth,multipleabortions,uterineanomalies,lowpregnancyweight,DM,Hypertention，multiplegestation,infection,incompetentcervix,UTI,bleeding,placentapreviaorabruptioplancenta,anemia,fetalanomaliesBehavioralandEnvironmentalRiskforPretermLaborDiethylstilbestrol(DES)ExposureSmokingPoorNutritionAlcoholorothersubstanceuse,expeciallycocaineLateornoprenatalcareStress,uterineirritability,longworkinghours,inabillitytorestRiskFactorsforPertermLaborBacterialVaginosis40%increasedriskSyphilisandgonorrhea50%increasedriskAsymptomaticbacteriuria50%increasedriskSymptomsofPretermLabor

20-37weeksofgestationalagePelvicpressurefeelslikethebabyispushingdownLow,dullbackacheMenstrual-likecrampsChangeorincreaseinvaginaldischargeUterinecontractions(hardness),every10minutesormoreoftenwithorwithoutpainIntestinalcrampingwithorwithoutdiarrheaSupressionofUterine

ActivityTocolyticsTherapy：Ritodrine（Yutopar）Terbutaline

MagnesiumSulfate

IndomethacinContraindicationstoTocolysisMaternalfactor：SeverePIHoreclampsiaActivevaginalbleedingsIntrauterineinfectionCardiacdistressMedicalorobstericconditionthatcontraindicatescontinuationofpregnancyContraindicationstoTocolysisFetalFactors:Estimatedgestationalage>37weeksDilationof>4cmEstimatedweightofbirth>2500gramsFetalDemiseLethalfetalanomalyChorioamnionitisAcuteFetalDistressChronicIUGRNursingDiagnossifor

PertermLaborKnowledgedeficitrelatedto-recognitionofpretermsymptomsRiskformaternalorfetalinjuryrelatedto–pretermlaborandbirthAnxietyrelatedto–pertermbirthandfamilyconsequencesImpairedmobilityrelatedtoprescribedbedrestAnitipatorygrievingrelatedto–pretermlaborandbirthNursingcareforwomenwithtocolytictherapyPositiononLfsideforbetterplacentaperfusionAssessbloodpressure,pulse(not>120/min),andrespiratoryrateAssesssignsofpulmonaryedema(chestpain,shortnessofbreath,crackles,rhonchi)Assessurinaryoutputq1h,monitorforketonuriaLimitfluidintaketo2500-3000ml/dayProvidepsychosocialsupportandreleaseanxietyMonitorelectrolyte,bloodglucoselevelPromotingFetalLungMaturityAntenatalglucocorticoidtherapy:betamethasone,dexamethasoneAction:stimulatesfetallungmaturationbypromotingreleaseofenzymesthatinduceproductionandorreleaseoflungsurfactantNursingconsideration:Assesssignsofinfection,pulmonaryedema,bloodglucselevel,lungsound,takes24hoursfordrugtoeffective,nottogivewomen>35weeksofpregnancy.HealthTeachingfor

pertemlaborpreventionWhenpertermlaboroccur:Liedownonyourleftsidefor1hourDrink2-3glassessofwaterorjuicePalaateforcontractionsIfnocontraction,assumelightactivity,ifsysmpotmcomeback,needtonotifyhealthcareprofessionals.LifestylemodificationSigsnofPertermLoborUterinecontractionsevery5minutesorlessVaginalbleedingOdorousvaginaldischargeFluidleakingfromthevaginaPrematureRuptureofMembrance(PROM)

胎膜早破Definition:Ruptureoftheamnioticsacandleakageofamnioticfluidbeginningatleast1hoursbeforetheonsetoflaboratanygestationalage.PROM-IncidencePretermprematureruptureofthemembranes(PPROM):itismembranesrupturebefore37weeksofgestation25%ofallcasesofpretermlaborInfectionprecedesPPROMComplainsofsuddengushoffluidfromthevaginaorslowleakoffluidfromthevagina.PPROM-InfectionInfectionistheserioussideeffectofPPROMChorioamnionitis:intraamnioticinfectionofthechorionandamnionthatcanharmthefetusandnewbornIncidenceofPPROMandPretermBirth3-30%ofwomenwithPPROMwillhavepoistiveamnioticfluidcultureMayleadtosepesis,congenitalpneumonia,meningitisofthenewbornduetointrauterineinfectioncasuedbyRPROM

FetalSurviallance-

countingfetalmovementTeachingforfetalmovementskickcount:ChooseatimeofdayforquietmomentStartingatcertaintimeandcountthebaby’smovementuntilreach10.Ifnotcount10in12hours,needtoseephysician.Orcount4movementsaftereachmeals,shouldhave4movementin1hour,ifbyendof2hours,stilllessthan4movement,needtoseephysician.BiophysicalProfilesforFetusFetalbreathingmovementsGrossbodymovementFetaltoneReactivefetalheartrateQualitativeamnioicfluidvolumeScore:normal8-10;equivocal6;abnormal<4Manning,1995AmnioticFluidIndexMeasurementTodetermine:Normalvalue5-19cm.Oligohydramnios-amnioticfluidpacketoffluidintwoperpendicularplanesis<5cmPolyhyramnios-amnitoicfluidpacketfluidintwoperpendicularplanesis>20cm,withfetalfloating,freemovmentoflimbsNursingcareforwomenwithPPROMFetussurvillance:countfetalmovementatleastBID,10fetalmovementsina12-hoursperiod.UnderstandthevolumeofamnioticfluidremainedintheamnioticsackSignsofstressonFetalmonitorStrickpreventionofinfectionduetoamnioticsacisrupturedandbacterialmayentertheuterustoinfectfetus.RelievepsychologicalstressduetoprolongedbedrestandpossibilityofprematurebirthDischargeCriteriaforWomenwithPPROMDocumentedPPROM>72hrCervicaldilaiton3cmNosignofchorioamnionitis/pyelonephritisNosignorsymptomsofpretermlaborClinetwillingnesstocomplywithstrictpelvicrestNobreechortransversepresentation(chancesofproplapsecord)HealthTeachingforwomenwithPPROMTaketemperatureQ4hwhenawake,Reportifmorethan380CRemainonmodifiedbedrestInsertnothinginthevaginaNosexualactivity,NotubbathsAssessforuterinecontraction&fetalmovementWatchforfoul-smellingvaginaldischargeWipefronttobackafterurinatingorhavingabowelmovementTakeantibioticsifperscribedFetalDistressMaternal

RiskFactorsPregnancyInducedHypertensionCaridacDiseasesHyperemesisgravidarumSTI,vagnialinfectionPertermlaborDM,Anemia,SubstanceabusePlacentaprevia,abruptioProlongedlaborordifficultybirthAbnormalfetalpresentationTraumaticlabororbirthComplicationduringlabor-

fetaldistressIntrauterinepressure>75mmHgContraction>90secondsContractionoccurring2minorlessapartFetalbradycardia,tachycardia,ordecreasedvariablityIrregularFHRMeconium-stainedamnioticfluidArrestinprogressofthelaborMaternalfevelFoul-smellingvaginaldischargeVaginalBleedingProlapseofcordduringlaborFetalbradycardiaMembranesrupturedCordliesbelowthepresentationpartofthefetusNeedtodoemergencydeliveryNursingInterventionforProlapsedCordPositionchange,trendelenburgormodifiedsimspositionSteriletowelwrapthecordOxygen8-10L/minIVfluidMonitoringFHRDonotplacecordbackintocervixPrepareemergencybirth(vagniaalorcesarean)UltrasonographyinThirdTrimesterforAssessing

FetusG