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

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.

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

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 {

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

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

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

正常与异常产程图对比

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

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

Nursing diagnosis Fatigue Anxiety Fear Risk for infection Potential complication

Treatment 协调性子宫收缩乏力 不协调性子宫收缩乏力

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Nursing assessment Present physical status 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

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

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

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.

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

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