第八章 异常分娩妇女的护理 Nursing care during abnormal childbirth

1. 第八章 异常分娩妇女的护理Nursing care during abnormal childbirth

2. Review • 影响分娩的四个因素：4Ps • Labor and birth are affected by powers, passageway, passenger, psychological responses. • Abnormal labor/ dystocia: If there are one or more abnormal factors, maladaptation may occur. • This chapter focuses on dysfunction of powers, abnormalities of the passengers and passages.

3. 第一节 产力异常产妇的护理 • 产力包括： • 子宫收缩的特点： • 子宫收缩异常: 子宫收缩乏力&子宫收缩过强 • powers: uterine contraction & maternal pushing • Uterine contraction’s characteristics: rhythmicity, symmetry, polarity, brachystasis Abnormal uterine contraction: hypotonic (<25mmHg) & hypertonic uterine activities

4. 一、分类： 1、产力异常：主要指子宫收缩力异常。如果子宫收缩失去正常的节律性、极性或对称性，强度及频率有改变，都称为子宫收缩异常。 2、分类： 宫缩乏力{ 子宫收缩力 异常 宫缩过强{ { 原发性 继发性 协调性 不协调性 { 协调性 不协调性 强直性子宫 收缩 子宫痉挛性 狭窄环 {

5. 病因 Etiology • 头盆不称 cephalopelvic disproportion, CPD • 子宫因素 uterine factors • 精神因素 psychological factors • 内分泌失调 endocrine disturbance • 药物影响 side effects of medication • 其他 others：fatigue, bladder/rectum fullness, weakness

6. 子宫收缩乏力 • 协调性子宫收缩乏力 特征：正常节律性、对称性和极性，宫缩＜2次/10min，分原发性和继发性 • 不协调性子宫收缩乏力 特征：初产妇，自子宫一处或多处。节律不协调，间歇期子宫壁不松弛，极性消失或倒置。不能使宫口扩张和胎先露下降，属无效宫缩，持续疼痛，胎位不清，胎心不规则

7. 产程异常 • 潜伏期延长:>16h • 活跃期延长:>8h • 活跃期停滞 • 第二产程延长 初产妇 >2h, 经产妇>1h • 第二产程停滞 • 胎头下降延缓 初产妇 <1cm/h,经产妇<2cm/h • 胎头下降停滞 • 滞产：>24h

8. 正常与异常产程图对比

9. Nursing assessment • Health history • Present status: • Prolonged latent phase:>16h, average 8h • Prolonged active phase: >8h, average 4h, primipara<1.2cm/h,multipara<1.5cm/h • Protracted active phase: cervix no more dialatation > 2h • Prolonged second stage: primipara >2h, multipara>1h • Protracted second stage: no progress >1h • Prolonged descent: primipara <1cm/h, multipara <2cm/h • Protracted descent: fetal head doesn’t descend >1h • Prolonged labor: >24 h

10. 对母儿的影响 • 对产妇的影响：effects on laboring women 1.enengy exhausted；2. soft birth canal injury；3.postpartum hemorrhea;4.infection • 对胎儿、新生儿的影响：effects on fetus and neonate 1. fetal injury； 2. fetal distress

11. Nursing diagnosis • Fatigue • Anxiety • Fear • Risk for infection • Potential complication

12. Treatment • 协调性子宫收缩乏力 • 不协调性子宫收缩乏力

13. intervention • Observation: uterine contraction, FHR, labor progress, pain level, V/S • General care: help & comfort client, nutrition • Co-op treatment: medication administration • Psychology support: • Health education: rest, high calorie, fluid, etc early ambulation, perineum care, prevent infection

14. 子宫收缩过强产妇的护理 • 病因/ Etiology of hypertonic uterine contraction 1.急产Precipitate delivery， especially multipara, labor process <3h 2. 缩宫素oxytocin使用不当、用量过大、或对其敏感 3.产妇精神过度紧张、极度疲劳、粗暴的宫腔内操作

15. Nursing assessment • Health history: • Present status 1. 协调性子宫收缩过强 Labor<3h,uterine firm, contraction duration long, latent phase short, affect fetal circulation →distress →fracture, trauma, infection 2. 不协调性子宫收缩过强 （1）强直性子宫收缩: tetanic uterine contraction, persistent abdominal pain （2）子宫痉挛性狭窄环constriction ring 3.心理社会状况

16. Nursing diagnosis • Pain r/t hypertonic uterine contraction • Fear r/t pain and concerning about her/fetal safety • Risk for injury r/t injury to maternal soft tissue of birth canal & neonate • Potential complication: uterus rupture

17. treatment • 急产precipitate delivery: 减缓分娩速度，尽快做好接生准备，防止母子创伤 • 强直性子宫收缩: 抑制宫缩，or 剖宫产 • 子宫痉挛性狭窄环：镇静解痉，or 剖宫产

18. Nursing intervention • Psychological care: instruct deep breathing exercises & relaxation technique, massage abdomen, distract her attention, relieve her pain • observation • Cooperative treatment：stop oxytoncin缩宫素, may IV push MgSO4硫酸镁, or epinephrine 肾上腺素IV drip, prepare for c-section delivery; for constriction ring, use sedatives first • Prevent injury: no push, no breath held, give VitK1, tetanus toxids • Health education

19. 第二节 产道异常产妇的护理abnormal birth canal • 骨产道异常分类： 1. 骨盆入口平面狭窄（contracted pelvic inlet), 单纯扁平骨盆（simple flat pelvis）， 佝偻病性扁平骨盆（rachitic flat pelvis) ,入口平面前后径<10cm 2. 中骨盆及出口平面狭窄: 漏斗骨盆 funnel shaped pelvis, 横径狭窄骨盆 transversely contracted pelvis, 坐骨棘 < 10cm, 坐骨结节间径<8cm 3. 骨盆三个平面均狭窄generally contracted pelvis 4. 畸形骨盆: 骨软化症骨盆 osteomalacic pelvis， 偏斜骨盆 obliquely contracted pelvis

20. Nursing assessment • 健康史: 佝偻病rachitis、脊髓灰质炎poliomyelitis、脊柱和髋关节结核tuberculosis以及外伤史,经产妇有无难产史以及新生儿产伤

21. Physical assessment • 骨盆入口平面狭窄 1）于临产前胎头不能入盆，胎头高浮，尖腹或悬垂腹 2）胎位异常：臀先露、肩先露 3）跨耻征检查+/- 4）骨盆测量：骶耻外径<18cm, 对角径<11.5 • 中骨盆及外出口平面狭窄,入盆，但无法内旋转，形成持续性枕横位或枕后位，第二产程缓慢或停滞。坐骨棘间径<10cm, 耻骨弓角度<90o • 均小骨盆：孕妇< 145cm • 畸形骨盆：跛行、脊椎偏斜、米氏菱形区不对称

22. 对母子的影响 • 对产妇的影响： 1. 胎膜早破 2. 生殖器官瘘fistula 3. 子宫破裂 4. 感染

23. 对母子的影响 • 对胎儿及新生儿的影响 • 羊膜早破造成脐带脱垂、胎儿窘迫fetal distress、新生儿窒息neonatal asphyxia • 产程长造成胎头受压，新生儿颅内出血intracranial hemorrhage; • 手术助产（operative delivery），易造成新生儿产伤和感染

24. 软产道异常 • 软产道包括： • 外阴异常 1.外阴坚韧、外阴瘢痕 2.外阴水肿edema • 阴道异常 1.阴道横隔、纵膈2.阴道瘢痕性狭窄3.阴道肿瘤tumor • 宫颈异常 1. 宫颈坚韧、水肿、外口粘合 2.宫颈瘢痕、肌瘤、子宫颈癌

25. 第三节 胎儿异常 abnormal fetus • 胎儿异常包括胎位异常malposition和胎儿发育异常fetal malformation • 持续性枕后位persistent occiput posterior position、枕横位persistent occiput transverse position

26. 病因Etiology • 骨盆狭窄 • 胎头俯屈不良 • 宫缩乏力、产程中尿潴留、前置胎盘及宫颈肌瘤

27. 对母子的影响 • 胎位异常及过早用腹压体力消耗导致继发性宫缩乏力、产程延长，需阴道助产 • 软产道损失soft tissue injury、产后出血postpartum hemorrhage、感染infection • 胎头受压长，极度塑型molding，胎儿窘迫fetal distress，新生儿窒息neonate asphyxia、颅内出血intracranial hemorrhage

28. Nursing intervention • Daily care：nutrition& rest，take the opposite position of the fetal back to lay down • Observation during the labor: FHR, • Cooperative tx: administering oxytocin or antibiotics, preparing for c-section and take care of newborns

29. 臀先露产妇的护理 • Breech presentation： 最常见的异常胎位 • Etiology: 1. 胎儿在宫腔内活动范围过大，如羊水过多、经产妇腹壁松弛以及早产儿羊水相对偏多 2. 胎儿在宫腔内活动范围受限：羊水过少、子宫畸形、胎儿畸形 3. 胎头衔接受阻，如骨盆狭窄、前置胎盘

30. 分类 • 单臀先露或腿直臀先露 frank breech presentation：双髋关节屈曲，双膝关节伸直，以臀部为先露 • 完全臀先露或混合臀先露 /complete breech presentation:双髋关节及双膝关节均屈曲，先露为臀和双足 • 不完全臀先露/incomplete breech presentation: 单足或双足、单膝或双膝为先露。较少见

31. Nursing assessment • Health history: fetal lie, pelvis’ measurement, plancenta previa, uterine malformation, polyhydramnios, oligoamnios • Present physical status • Woman can self feel round and firm fetal head under ribs • Ob check show round and firm part in fundus ,FHT is above the umbilicus • Vaginal/anal check find soft and irregular part • Uterine contraction is hypotonic & labor progress is slow

32. Maternal & fetal Effects • Effects on mother: b/c breech small, irregular, can’t closely attach cervix, →hypotonic contraction, prolonged labor process, postpartum hemorrhage, infection, cervical injury • Effects on infant: b/c breech irregular, pressure is unbalanced, → premature membrane rupture, prolapse of umbilical cord, fetal distress, intracranial hemorrhage, brachia plexus injury, fracture

33. Nursing intervention • 矫正异常胎位correct abnormal fetal position：若30周后仍为臀先露者 • 胸膝卧位knee-chest position: • 激光照射laser exposure或艾灸moxibustion至阴穴 • 外倒转术abdominal version ：32-34wks,under ultrasound monitor, dangerous

34. Nursing care during labor • General care: nutrition, rest, no anal check, no enema, prevent premature rupture of membrane • Observation: uterine contraction, FHR, labor process, if membrane rupture, lift bottom up • Cooperative tx: administering oxytocin & antibiotics If cervix not completely opened, use aseptic towel to push fetal foot or bottom back and call doctor; if umbilicus shows, delivery within 2-3mins.

35. 胎儿发育异常 • 巨大胎儿 macrosomia: >4000g • 胎儿畸形 fetal malformation 1. 脑积水 hydrocephalus 2. 无脑儿 anencephalus

36. 第四节 过度焦虑与恐惧 • Anxiety is a negative psychological reaction • Anxiety in labor and plasma epinephrine肾上腺素 were related to FHR pattern in active labor • Duration of labor was related to plasma epinephrine and norepinephrine levels in multiparas肾上腺素分泌增加，引起心跳加快、心排出量增加、BP↑。同时去甲肾上腺素↑，引起血管收缩，血供减少，胎儿缺氧 • Longer labors were associated with higher catecholamines儿茶酚胺, which r/t measures of anxiety • Anxiety →extreme pain