产程的观察与处理-课件

妇产科护理

nursingofgynecologyandobstetreics正常分娩NormalLabor妇产科护理

nursingofgynecologyan11.假临产即不规则的宫缩。

FalseLabor

–irregularuterinecontraction2.胎儿下降感因胎先露入盆即衔接所致。

Feelingoffetaldescendingduetoengagementoffetalpresentation,whichisalsoknownasjointing.3.见红分娩前24～48h，阴道排出血性分泌物。

Bloodysecretioncanbeseen24～48hbeforedelivery.先兆临产Threateneddelivery1.假临产即不规则的宫缩。先兆临产21.规律性宫缩的出现。30秒以上/5～6分左右

Irregularuterinecontraction:30secondsorlonger/5～6minutes2.宫颈管的消失。Cervicalcanalsdisappear3.宫口的扩张。Dilatationofcervicalorifice4.胎先露的下降。Descendingoffetalpresentation临产诊断DiagnosisBeforeDelivery1.规律性宫缩的出现。30秒以上/5～6分左右临产诊断3

一、评估病史evaluationofmedicalhistory

1.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

Pregnancyhistory

5.一般健康状况及家族史

Generalhealthconditionandfamilyhistoryofpregnancy临产妇入院评Evaluationofadmissionforparturients一、评估病史evaluationofmedical4二.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二.入院后身体评估physicalevaluation临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11～12h；经产妇约需6～8h。

generally11～12hforprimpara

and

6～8hformultipara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1～2h，经产妇只需数分钟，多则1h

。

generally1～2hforprimparaandseveralminutes,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5～15min，一般不超过30min

。

generally5～15min,nolongerthan30min产程的分期StagesofDelivery总产程：规律宫缩---胎儿胎盘娩出产程的分期Stage6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：11～12h1～2h5～15min,primpara

经产妇：6～8h几分钟或1h不超过30minmultiparaseveralminutesto1hlessthan30min产程的分期StagesofDeliveryThefirststageofdeliveryThesecondstageofdeliveryThethirdstageofdeliveryDilatationofcervicalorificeStageofdeliveryoffetusStageofdeliveryofplacentaRegularuterinecontractionCompletedilatationofcervicalorificeDeliveryoffetusDeliveryofplacenta总产程：规律宫缩---胎儿胎盘娩出产程的分期Stage7

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

ruptureoffetalmemberane

5.疼痛pain

第一产程的观察与处理Observationandtreatmentofthefirststageofdelivery一、临床表现clinicalmanifestatio8

（一）规律宫缩regularuterinecontraction

持续时间（短→长）/间歇时间（长→短）

duration:short→shortintermittence:long→short第一产程的观察Observationofthefirststageofdelivery（一）规律宫缩regularuterinecont9（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3cm～10cm，历时4h，﹥8小时为延长

activephase:3cm～10cmofdilatationofcervix,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（二）宫口扩张胎头下降第一产程的观察10（三）胎膜破裂

多发生在宫口近开全时。

Ruptureoffetalmemberaneoccursatapproximatecompletedilatationofcervix

1.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（三）胎膜破裂多发生在宫口近开全时。第一产程的观察111.饮食：鼓励产妇少量多餐，补充足够水分。

Diet:frequentmealsinsmallamount,haveenoughwater

2.活动:胎膜未破、宫缩不强者鼓励在室内适当活动

Activities:nofetalmemberanerupture,lessintenseuterinecontraction→properinneractivities

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Healthguidanceofthefirststageofdelivery1.饮食：鼓励产妇少量多餐，补充足够水分。第一产程的健康指导123.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2～4ｈ排尿１次

Urination:1timeevery2～4ｈ5.灌肠：初产妇宫口扩张＜5cm，经产妇＜3cm

Clysis

←Thecervicaldilatationofaprimiparais

＜5cm.Thecervicaldilatationofamultiparais

＜3cm.第一产程的健康指导Healthguidanceofthefirststageofdelivery3.清洁：协助产妇沐浴、更衣，给予外阴备皮第一产程的健康指导13第二产程的临床表现Clinicalmanifestationofthesecondstageofdelivery宫缩加强→排便感→屏气→strengtheninguterinecontraction→desiretodefecate→breathholding→会阴膨隆变薄,肛门松弛→perineumbulging,analrelaxation→胎头拨露→胎头着冠→胎头娩出→fetalheadinvisibleonvulvalgapping→crowning→deliveryoffetalhead胎体娩出→后羊水涌出deliveryingheadoffetus→amnioticfluid第二产程的临床表现宫缩加强→排便感→屏气→141.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1～2min。

10minafterdilatationofuterineoriice,theuterinecontractionstrengthensfurther.Thedurationisapproximately1minormore.Theintermittencetimeis1～2min.

第二产程的临床表现Clinicalmanifestationofthesecondstageofdelivery1.宫缩增强strengtheninguterine152.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。

Headvisibleonvulval

gapping: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Clinicalmanifestationofthesecondstageofdelivery2.胎儿下降与娩出fetaldescendingand163.疼痛与排便感

会阴痛，向大腿内侧放射。

painanddesiretodefecate

Theperineumpainradiatestothemedialsurfaceofthethigh.第二产程的临床表现Clinicalmanifestationofthesecondstageofdelivery3.疼痛与排便感会阴痛，向大腿内侧放射。第二产程的临床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Evaluationofthesecondstageofdelivery1.宫口开全时间thetimeofdilatati18一、密切监测胎心

carefullyfetalheartmonitoring

每5～10min听胎心1次

ausculatefetalheartevery5～10min二、指导产妇屏气用力

givedirectionsofbreathholding第二产程的观察与处理Observationandmanagementofthe2ndstageofdelivery一、密切监测胎心第二产程的观察与处理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:complete

dilatationofuterineorificemultipara:3cmofdilatationofuterineorifice第二产程的观察与处理ObservationandmanagementofthesecondstageofdeliveryMaternitypatient:perineumwashMidwife:?（1）产妇准备：会阴冲洗三.做好接产准备prepara20四.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四.接产要领---保护会阴的同时，协助胎头俯屈，让胎头以最小21五.保护会阴的时机：

theoccasionofprotectingtheperineum

阴唇后联合紧张时-----胎儿双肩娩出

tensionoftheposteriorcommisureoflabia→deliveryoffetalshoulders第二产程的观察与处理Observationandmanagementofthesecondstageofdelivery五.保护会阴的时机：第二产程的观察与处理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（二）胎剥离与娩出（一）宫缩再现第三产程的231.胎盘剥离征象：signsofplacentalseparation①宫体变硬由球形变为狭长形，宫底升高达脐上

Thebodyoftheuterushardensandtransformfromsphericaltolongandnarrow.②阴道少量出血

Asmallamountofvaginalbleeding③阴道口外露的脐带自行下降延长

Descendingandprolongingoftheumbilicalcordoutofthevaginaoutlet④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Clinicalmanifestationsofthethirdstageofdelivery1.胎盘剥离征象：signsofplacentals242.胎盘娩出方式：typesofplacentaldelivery

①胎儿面娩出式Schultzmechanism②母体面娩出式

Duncanmechanism第三产程的临床表现Clinicalmanifestationsofthethirdstageofdelivery第三产程的临床表现251.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managementformaternitypatientsduringthethirdstageofdeliveryAssistingdeliveryofplacentalmemberanes1.正确助娩胎盘---必在胎盘剥离后进行第三产程---产妇的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managementformaternitypatientsduringthethirdstageofdelivery2.检查胎盘胎膜：第三产程---产妇的处理27第三产程---产妇的处理managementformaternitypatientsduringthethirdstageofdelivery2.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.第三产程---产妇的处理2.检查胎盘胎膜：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20UIntramuscularlyinject20Uoxytocinassoonasfetalshouldersaredelivered.第三产程---产妇的处理managementformaternitypatientsduringthethirdstageofdelivery3.检查软产道：checkthesoftbirth295.产后2h产妇留在产房内观察

Observationinthedeliveryroom2hafterdelivery

注意生命体征、vitalsigns

子宫收缩情况、宫底高度、conditionsofuterinecontractionandtheheightofut