正常分娩循證護(hù)理PPT課件

1、正常分娩循證護(hù)理助產(chǎn)士節(jié)-5-5 世界需要助產(chǎn)士現(xiàn)在比以前更甚教學(xué)目標(biāo)1、明確正常分娩護(hù)理原則2、找出工作中可能存在的不合理措施3、制定可行的、可操作性的、具體的實(shí)施計(jì)劃調(diào)查表觀看電影請(qǐng)找出電影中你認(rèn)為不恰當(dāng)?shù)淖o(hù)理措施內(nèi)容提要正常分娩的定義正常分娩的特征正常分娩的服務(wù)原則循證護(hù)理自然的生理性分娩（natural physiological birth）自然的生理性分娩自然是來(lái)自天然而非來(lái)自人工。在自發(fā)性宮縮開始后，沒(méi)有人工干預(yù)，胎兒經(jīng)陰道自然娩出者，稱為自然的生理性分娩，簡(jiǎn)稱自然分娩。促進(jìn)自然的生理性分娩是助產(chǎn)人員的基本工作目標(biāo)。正常分娩（Normal labor）WHO分娩指導(dǎo)中正常分娩（N

2、ormal labor）的定義為，低危產(chǎn)婦，胎兒?jiǎn)翁?、頭位，在37孕周和42孕周之間自然的發(fā)動(dòng)宮縮，胎兒經(jīng)陰道自然娩出，產(chǎn)后母親與胎兒情況均良好。產(chǎn)科分娩有專家建議將正常分娩，應(yīng)用了干涉措施，如促宮頸成熟、引產(chǎn)、縮宮素應(yīng)用、人工破膜等后，經(jīng)陰道自然娩出的分娩，歸為產(chǎn)科分娩，以與自然的未加干涉措施的分娩相區(qū)分。應(yīng)努力促進(jìn)自然的產(chǎn)程，盡可能減少不必要的干涉措施 the best outcomes, the least interventions正常分娩的特征自然生理本能-分娩的最基本特征分娩是自然的生理過(guò)程，而不是疾病正常分娩的基本服務(wù)原則being with rather than doing

3、to and can provide continuous care正常分娩第一原則：產(chǎn)婦是正常分娩的主動(dòng)者！觀察、關(guān)愛(ài)、支持正常分娩循證護(hù)理問(wèn)題1、產(chǎn)程的起點(diǎn)：一個(gè)從來(lái)都不準(zhǔn)確的概念潛伏期延長(zhǎng)：一個(gè)從來(lái)都是錯(cuò)誤的診斷活躍期起點(diǎn)：？為什么是3CM？活躍期延長(zhǎng)：時(shí)間延長(zhǎng)？母兒情況異常？睡， 忍痛， 慢臨盆耐心等待自然的宮縮正常分娩最重要的一步 人為早產(chǎn)的教訓(xùn)有多少因素在妨礙正常生理性分娩的節(jié)律？入院-肛診胎監(jiān) 輸液交接班什么時(shí)候入院 低危產(chǎn)婦的臨產(chǎn)診斷評(píng)估晚入院，活躍期入院，一個(gè)重要的管理措施）臨產(chǎn)的評(píng)估-一個(gè)漫長(zhǎng)的等待臨產(chǎn)與假臨產(chǎn)，需要助產(chǎn)專業(yè)人員的耐心指導(dǎo)（案例-漫長(zhǎng)的等待）2.Mobili

4、ty and Posture in Labour產(chǎn)床？一個(gè)可怕的難產(chǎn)工具Laboring women must have the freedom to move around, change position,and work with gravity, along with enjoying physical space, privacy, and even a sense of connection to the earth.倡議產(chǎn)房?jī)?nèi)至少有一把產(chǎn)婦專用的坐椅-不管什么材質(zhì)、便宜或昂貴的-產(chǎn)婦能坐的地方產(chǎn)婦能進(jìn)食-飲水機(jī)3. 第二產(chǎn)程 directed, or coached pushin

5、g, a practice that persists without any supporting scientific evidence！用力！不用力什么時(shí)間用力（被動(dòng)的下降期、主動(dòng)期）第二產(chǎn)程延長(zhǎng)（-有爭(zhēng)議的問(wèn)題）4. Care of the Perineumepisiotomy be restricted to fetal indications onlystudies do not show that the pelvic floor is injured by vaginal birth. Antenatal pelvic floor exercises are heartily

6、recommended.WHO 分娩指導(dǎo)原則對(duì)產(chǎn)婦及胎兒有害需要禁止的措施1.Routine episiotomy is associated with poor healing, and longer hospital stays. Episiotomies should only be done where clinically required. 常規(guī)的會(huì)陰切開術(shù)帶來(lái)愈合不良、住院時(shí)間延長(zhǎng)等。只有在有醫(yī)學(xué)指征時(shí)才能應(yīng)用會(huì)陰切開。http:/www.liv.ac.uk/選擇性（限制應(yīng)用）會(huì)陰切開術(shù)結(jié)果分析No increase in incidence of major outcomes

7、(e.g., severe vaginal or perineal trauma nor in pain, dyspareunia or urinary incontinence) 不增加會(huì)陰裂傷、排尿困難，尿失禁（會(huì)陰松馳表現(xiàn)） Incidence of 3rd degree tear reduced (1.2% with episiotomy, 0.4% without)會(huì)陰三度裂傷在常規(guī)會(huì)陰切開者為1.2% ，在選擇性應(yīng)用中為0.4% (Carroli and Belizan 2000.Eason et al 2000; WHO 1999.)對(duì)產(chǎn)婦及胎兒有害需要禁止的措施2.Routin

8、e enemas. They are uncomfortable, make a mess, and are of no benefit. Enemas should be used only if requested. 常規(guī)的灌腸。對(duì)產(chǎn)婦及胎兒有害需要禁止的措施3.Perineal shaving. This is degrading and of no demonstrable benefit. 剃除陰毛。沒(méi)有益處，使產(chǎn)婦感到不舒適。4.Withholding oral fluids. This is uncomfortable and unjustified. 分娩過(guò)程中限制喝水。這使產(chǎn)

9、婦不舒適并沒(méi)有證據(jù)。對(duì)產(chǎn)婦及胎兒有害需要禁止的措施5.Routine artificial rupture of the membranes (AROM). Painful, and of no value unless progress in labor is abnormal. 常規(guī)人工破膜。帶來(lái)疼痛，對(duì)正常分娩無(wú)益。6.Supine position for delivery. Affects blood flow in the uterus and interferes with progress of second stage of labor. 仰臥位分娩。這減少子宮血流供給并妨礙

10、第二產(chǎn)程進(jìn) 展不恰當(dāng)應(yīng)當(dāng)避免的措施7.Routinely moving laboring woman to a different room at onset of second stage在第二產(chǎn)程常規(guī)的搬動(dòng)產(chǎn)婦到另一房間（產(chǎn)房）8.Encouraging woman to push when full dilation or nearly full dilation of cervix has been diagnosed, before woman feels urge to bear down 在產(chǎn)婦還不想用力時(shí)就指導(dǎo)產(chǎn)婦屏氣用力有利應(yīng)提倡的措施1.Companionship prov

11、ided by a family member or lay carer during labour. This improves maternal satisfaction, shortens labour and improves breastfeeding. It also reduces the need for pain relief and assisted delivery. 由家庭成員或?qū)I(yè)人員提供陪伴分娩。這增加產(chǎn)婦滿意度，縮短產(chǎn)程并增加母乳喂養(yǎng)成功率。減輕分娩時(shí)疼痛，并減少助產(chǎn)手術(shù)。有利應(yīng)提倡的措施2.Being mobile during labour. This sho

12、rtens labour and reduces the need for pain relief and assisted deliveries. 產(chǎn)婦在產(chǎn)程中可自由活動(dòng)?？煽s短產(chǎn)程，減輕疼痛，減少助產(chǎn)手術(shù)。有利應(yīng)提倡的措施3.Routine antibiotics for preterm, prelabour rupture of membranes. They improve maternal and neonatal outcomes早產(chǎn)兒常規(guī)應(yīng)用抗菌素。. 4.Keeping the umbilical cord clean at delivery. Poor hygiene is

13、associated with neonatal tetanus and sepsis. 無(wú)菌斷臍有利應(yīng)提倡的措施應(yīng)用一次性無(wú)菌用物或重復(fù)消毒用品手套，隔離衣，鞋，圍裙，眼鏡（防水，防血）洗 手Wash womans perineum with soap and water and keep it clean用肥皂和清水清洗會(huì)陰部保持清潔Ensure that surface on which newborn is delivered is kept clean 保持新生兒娩出后在潔凈的地方High-level disinfect instruments, gauze and ties for

14、 cutting cord嚴(yán)格無(wú)菌斷臍WHO 2006版1、較充分的依據(jù)支持晚斷臍（等待臍帶搏動(dòng)停止后，60-90秒（一個(gè)平均的臍帶搏動(dòng)停止的參數(shù)，不是一個(gè)嚴(yán)格的時(shí)間限制?。?、水中待產(chǎn)：是有循證依據(jù) 水中分娩：依據(jù)不足，可以采用3、臍帶護(hù)理：無(wú)菌斷臍，DRY AND CLEAN清潔干燥，不包扎，不用消毒劑，（不剪?。▽ｍ?xiàng)推廣項(xiàng)目）案例分析4CM常規(guī)人工破膜平臥？2小時(shí)后檢查？（宮口評(píng)估標(biāo)準(zhǔn)、宮縮時(shí)？間歇時(shí)？一個(gè)人？多個(gè)人？）無(wú)痛分娩（宣傳）輸液持續(xù)靜脈留置？會(huì)陰側(cè)切產(chǎn)后常規(guī)探查宮腔？產(chǎn)后常規(guī)縮宮素？產(chǎn)后斷臍時(shí)間？總結(jié)有益的措施Have a skilled attendant present 專業(yè)人員Use partograph 應(yīng)用產(chǎn)程圖Use specific criteria to diagnose active labor 正確的判斷活躍期（3CM？4CM？一個(gè)點(diǎn)？一段時(shí)間？WHO 新版產(chǎn)程圖）-臨產(chǎn)診斷評(píng)估Restrict use of unnecessary interventions 限制不必要的措施（如會(huì)陰切開）Support womans choice for position during