嘉義長庚紀念醫院
婦產科
教學與工作規範
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催生(Induction)
引產病人之選擇:
懷孕引起之高血壓(Pregnancy induced hypertention) 早期破水(Premature rupture of membranes) 絨毛羊膜炎(Chorioamnionitis) 經由生化或生理評估,懷疑胎兒有危險者 (例如胎兒生長遲滯、過期妊娠、同種免疫isoimmunization) 母體內科問題(例如糖尿病、腎臟病、慢性阻塞性肺部疾病) 胎兒死亡 地域問題(離醫院太遠,擔心急產) 過期妊娠
禁忌項目: 胎盤或血管前置(Placenta or vasa previa) 胎位不正 臍帶先露(Cord presentation) 先前做過縱向子宮切開(Classical incision) 生殖器官感染活性期庖疹 骨盆腔不正常結構 侵犯性子宮頸癌
Bishop scores:(評估子宮頸之狀況)
常用方式: Prostaglandin E PG E Prostin E PGE
Oxytocin (Piton-S):
Medical induction or augmentation of labor。促進子宮收縮,預防產後出血等。 Piton-S
ò
Piton-S run
ò
Piton-S run
ò
Piton-S run
ò
Piton-S run
ò
Piton-S run
ò
Piton-S run
ò
Piton-S run
ò
Piton-S run
ò
Piton-S run
ò
Piton-S run
ò
Piton-S run
調整子宮收縮素之劑量直到每
Amniotomy 人工破水可安全且有效地引產或促進產程,人工破水之所以會引起宮縮,是由於產生了前列腺素,而內因性的子宮收縮素可能沒有此項作用。
產婦有不錯之子宮頸(Bishop
score大於等於 在人工破水之前需先確定胎頭已經在好的子宮頸位置,人工破水之後應立即記錄胎心音,產程通常會很快開始,此時可給予適當劑量之子宮收縮素。
待產過程 Labor course: 影響生產之
& Arrest disorder:
Type of delivery: I. Vaginal delivery: NSD (including Vacuum & forceps delivery):
Stage of labor:
H
H
H
H
n Episiotomy: · Local anesthesia with xylocaine · Median vs medial lateral n Perineal laceration:
è
Repair with
Patient prepare: ò 協助病人移至待產台並放好腳架(Lithotomy position)
ò
以無菌方式戴上手套並抽取 ò 將產械放置妥當(大毛巾、小彎盆及其內物品放至warmer處) ò 穿上無菌手術衣 ò 手拿羊水收集器(DeLee trap)準備吸出嬰兒口鼻內之羊水,尤其有meconium時。(需注意放入嬰兒嘴內時要先折住DeLee,以免壓力過大傷到mucosa) ò 若有機會隨時準備delivery。Delivery procedure:參見下圖。 ò 協助會陰縫合。(縫合方式見附圖) ò 術後協助搬運病人,並完成接生記錄單及藥單。
II. Cesarean section: 常見之indications:
Malpresentation Chorioamnionitis Multiple Pregnancy CPD Previous myomectomy Placenta previa
Arrest of descent
Patient prepare: ê 協助病人移至手術台上。 ê 麻醉前及麻醉後用Doppler聽胎心音。(聽胎兒之背部,large part) ê 通常會讓病人左側躺,以避免子宮壓到inferior vena cava,減少venous reture。 ê 用soap清洗手術部位,然後用無菌單擦拭乾淨。 ê 刷手上刀。 ê 手術步驟:(實際操作及講解) ê 術後協助搬運病人,並完成接生記錄單、藥單及檢驗單。
C/S types: H Intraperitoneal low segment transverse (LST) C/S H Extraperitoneal low segment transverse C/S H Others: Classical C/S, lower segment vertical incision, invert T incision, Porro’s (cesarean) hysterectomy, combined with myomectomy, cystectomy or oophorectomy, ATS
Cesarean section operative Procedures: The woman was brought to the operating room. After oSpinal oEpidural oGeneral anesthesia, the patient was put in supine position. The abdomen was prepared with soap and better iodine and draped as usual. A o pfannestial incision o median longitudinal incision was made. The abdominal wall was opened layer by layer. o After the peritoneum was opened, two pads were put into the peritoneal cavity to push the intestine upward. A third blade was put in the caudal aspect to expose the lower segment of the uterus.----------------------------(Intraperitoneal type) o By dissecting through the space of Retzius and then along one side and beneath the bladder to reach the lower uterine segment.----------(Extraperitoneal type) A transverse incision of the
lower segment of the uterus was made. A baby was delivered smoothly.
The placenta was removed manually. Then the uterus was closed by two
layers sutures with
The abdomen wall was closed
layer by layer. The skin was approximated with
o
唐氏症母血篩檢
& 經由母血內一些因懷孕而產生之物質(AFP, b-hCG, free b-hCG etc),配合妊娠週數、母親年齡及體重,而計算出唐氏症之危險機率。
篩檢週數: 目前長庚醫院使用之檢驗方式為:ABBA (a-fetoprotein, free b–hCG, maternal body weight, gestational age & maternal age) 產前母體血清篩檢報告:
結果 free b–hCG (游離型貝他人類絨毛膜性腺激素): ----MoM (中位值倍數) (----ng/ml) AFP (甲型胎兒蛋白) : ----MoM (中位值倍數) (----ng/ml) 本胎兒患有唐氏症之危險機率為: 本胎兒患有神經管缺損之危險機率為: 說明:
1.
2.
母血篩檢可找出 3. 此種抽血檢驗是一種篩檢方法,並非最後確定診斷方法。
4.
中國人患有神經管缺損之危險機率為 P.S. 除看危險機率外,仍須看APF及free b–hCG之MoM值,決定是否進一步檢查。
胎兒監視(Fetal monitoring) Fetal monitoring: Fetal heart rate, variability, uterine contraction strength, duration & interval. Running rate:
FHR deceleration: n Early deceleration: fetal head compression. n Variable deceleration: cord compression n Late decelearation: placenta dysfunction n Acute fetal distress Nonstress test (NST): Determination of fetal heart rate (FHR) accelerations in response to fetal movement in a defined period of time.
Reactive: two
or more FHR accelerations of at least
Nonreactive: no
acceptable FHR accelerations over a
Oxytocin challenge test (OCT), contraction stress test (CST): Three completed
contractions of at least
ð Negative: no late decelerations
ð
Positive: late decelerations following
>
è
Suspicious: intermittent late or variable decelerations with
<
Hyperstimulation:
FHR decelerations associated with excessive uterine activity.
(frequency >
every
è
Unsatisfactory: fewer than
安胎(Tocolysis) 新生兒死亡中仍以早產者佔大多數,因此應讓胎兒儘量留在子宮內至足月。 需安胎之情況: 1. 早期宮縮(Preterm labor, PTL)。 2. 早期破水(Premature rupture of membrane, PROM)。 3. 子宮異常。 4. 子宮過度漲大,如羊水過多(Polyhydramnios),多胞妊娠。 5. 產前出血(Antepartum hemorrhage, APH),如胎盤早期剝離,前置胎盤。 6. 母親疾患,如妊娠高血壓(PIH),妊娠糖尿病(GDM)等。
一般住院安胎醫囑: ò Admitted to the service of Dr. ò Check vital sign as DR/Ward routine ò On diet ò Check CBC/DC, U/A, CRP
ò
Set IV with D ò Bed rest (with hip elevated when PROM)
ò
On fetal monitor & check FHB q ò Ultrasonography
安胎第一線藥物為Ritodrine,但須注意其禁忌症,其用法為:
ò
Ritodrine
ò
Ritodrine á
ò
Ritodrine á
ò
Ritodrine á
ò
Ritodrine á
ò
Ritodrine á
若仍有規則宮縮則考慮加上第二線藥物MgSO
ò
MgSO
ò
MgSO
ò
MgSO
ò
MgSO
ò
Check DTR, RR & I/O q
ò
Prepare Ca gluconat
其他安胎常用之方法尚有: 1. Hydration
2.
Indomethacin (Inteban)
3. Nifedipine
&
為促進胎兒肺部成熟,於 &
Ritodrine (b-mimetic):
MgSO
Inteban:
Ritodrine由IV form改成口服方法:
ò
Ritodrine run
ò
DC IV form Ritodrine & keep Ritodrine
ò
Ritodrine change to
ò
Ritodrine change to
Contraindications of tocolytic agents: ð Ritodrine: Heart disease, Hyperthyroidism, Hypertension, DM.
ð
MgSO Can not be used with Barbiturate, Narcotics, Hypnotic drugs.
Can not be used when Resp rate
<
ð Nifedipine: Hypersensativity
Steroid administration: Dexan
Contractions for the steroid administration 1. PROM 2. Multiple gestation
3.
Less than
羊膜外引產(Extraovular (Extra-amniotic) induction) Indication: 妊娠
作法: ò 病人排空膀胱後,採lithotomy姿勢,外陰部予以清潔消毒,並鋪無菌罩單。 ò 用鴨嘴(speculum)撐開陰道並予以Aq. B-I徹底消毒。
ò
將
ò
將 ò 拉緊Foley並以布膠固定於大腿內側。
ò
之後每
ò
之後用 ò 胎兒掉出後視出血情況進產房清胎盤(一般在一小時後),必要時需超音波指引。 ò 整個待產過程可給予抗生素、Demeral、Novamine。
羊膜穿刺 (Amniocentesis) Indication: Chromosome study Fetal lung maturity R/O chorioamnionitis (culture & gram stain) Releasing polyhydramnios
Procedure: ê 先以超音波找出最適宜下針處(羊水最多,並避開胎盤)。
ê
將Jelly擦掉,用Alc
B-I及 ê 將超音波探頭裝入消毒過之塑膠袋內。(不一定要用adaptor)
ê
Sona guide下,以
(Chromosome
study
附錄: 產前遺傳診斷適應症(衛生署) 1. 高齡產婦。 2. 本胎次有生育先天缺陷兒之可能者:?神經管缺陷?染色體異常(超音波或母血篩檢)?代謝異常?地中海型貧血。 3. 曾生育過先天缺陷兒者:?神經管缺陷?染色體異常?代謝異常?地中海型貧血或水胎。 4. 本人或配偶有遺傳疾病者:?性聯遺傳?染色體異常?代謝異常?地中海型貧血帶因 5. 家族中有遺傳疾病者:?性聯遺傳?染色體異常?代謝異常 6. 重複性流產。 7. 其他。
新生兒急救(Neonatal Resuscitation) Apgar Score:
Initial stabililzation: 1. Enviroment: Warm & Dry 2. Positioning: Sniffing Position
3.
Suction:
4. Tactile stimulation
Resuscitation:
Oxygen administration-
Ventilation-
Endotracheal Tube Size and Depth Of Insertion:
Neonatal Resuscitation Supplies and Equipment 1. Suction equipment Bulb syringe
Suction catheter
Wall suction set at low continuous suction (
Meconium aspirator if available or
2. Bag and Mask equipment
Face masks: premature and newborn size(cushioned rims) Oxygen with flow meter and tubing Oral airways: newborn and premature sizes
3. Intubation Equipment
Laryngoscope with straight blades: No
Extra bulbs and batteries for laryngoscope
Endotracheal tubes: Stylet
4. Medications
Epinephrine
Naloxone
Volume expanders (one or more of these) Normal saline Ringer’s lactate
Albumin
O-negative blood
Sodium bicarbonate
Detrose
Sterile water
5. Miscellaneous Radiant warmer Adhesive tape
Syringes:
Needles:
Intravenous catheters:
Alcohol and betadine sponges Benzoline spray Umbillical tape
Umbillical catheters:
Warm blankets and towels Cord clamps
早期破水 (Premature rupture of membrane)
Admission routine: ò Endocervical swab for group B streptococcus, aerobic and anaerobic culture. ò Tocolysis as preterm labor protocol, if indicated. ò Transvaginal sonography for exclusion of forelying cord and measurement on diameter of cervical canal. (without contact with exocervix) ò Sonography fetal assessment
Amniotic fluid index (adequate AFI
³
Routine fetal biometry, estimated fetal weight, fetal monography, fetal biophysical activity Umbilical cord Doppler wave form study. (S/D ratio, PI, RI) ò Ultrasound guided amniocentesis Amniotic fluid for Gram staining and culture
L/S ratio, PG, Lamellar body. (
>
ò Expectant management Confined to bed rest CRP st and qwk
CBC/DC st & qW Weekly ultrasound for amniotic fluid index
Ultrasound fetal assessment every
NST bid ò Repeated amniocentesis indicated when
increased white count over
significant increased CRP maternal fever, tender lower abdomen, foul discharge. Persistent fetal tachycardia.
妊娠與高血壓(Hypertensive Disorder of Pregnancy) 定義及分類: Pre-eclampsia (pregnancy
induced hypertension; toxemia):
大於 Triad: proteinuria, edema, hypertension
Hypertension: Diastolic pressure
>
Systolic pressure
>
Proteinuria:
Edema: general accumulation of
fluid.休息
Table: Criteria for severe pre-eclampsia
收縮血壓
>
(休息後測量,至少兩次間隔
Protein uria
>
少尿 (Oligouria
<
Cerebral or visual disturbance 上腹痛 (epigastric pain) 肺水腫或Cyanosis 不明原因肝功能受損 (impaired liver function) 血小板減少 (thrombocytopenia) Eclampsia: Pre-eclampsia plus the development of generalized tonic-clonic seizure not caused by neurological disorders.
Chronic hypertension: Persistent hypertension of
at least
Persistent hypertension
beyond
Superimposed pre-eclampsia or eclampsia: Development of pre-eclampsia or eclampsia in woman with chronic hypertensive vascular or renal disease.
Transient hypertension: Development of isolated hypertension later in pregnancy or early in the puerperium.
Management: F Lab assessment: CBC/DC Platelet qwk, Mg, Ca,
Na, K, C Renal function: BUN, Cr, CCr qwk Liver function: GOT, GPT, Alk-P qwk Coagulation profile: PT, APTT qwk DIC profile if abnormal PT, APTT or platelet U/A,
Anticonvulsant medication: Magnesium sulfate (MgSO
Regimen:
*
急救盤:Calcium gluconate; tongue depressor; Valium. (Oxygen and endo-tracheal tube)
注意項目:DTR
q
Table: Magnesium toxicity
feelinf of warmth, flushing
somnolence
slurred speech
muscular paralysis
respiratory difficulty
cardiac arrest
*使用sedative (Valium and chlormethiazole) or antihypertensives無特別預防痙攣之作用。
Antihypertensive therapy: Hydralazine hydrochloride (Apresoline):
vasodilator;
Methyldopa (Aldomet):
central a-agonist;
Labetalol (Trandate):
a/b
blocker;
Management flow chart: Nifedipine (Adalat): Ca
blocker,
BP
>
胎兒監視 · Non-stress test (NST): · Biophysical profile:
Score
<
· Umbillical artery Doppler flow study: S/D ratio, RI, PI · Amniocentesis for lung maturity: PG, L/S ratio, lamellar body
糖尿病與妊娠(Diabetes and Pregnancy)
※糖尿病母親胎兒之先天異常
心臟血管系統 Transposition of great vessels (Cardiovascular) Ventricular septal defect Atrial septal defect Hypoplastic left ventricle Situs inversus Anomalies of aorta
中樞神經系統 Anencephaly (Central nervous system) Encephalocele Menigomyelocele Holoprosencephaly Microcephaly
骨骼系統 Caudal regression syndrome (Skeletal) Spinal bifida
泌尿生殖系 Abscent kidney (Potter syndrome) (Genitourinary) Polycystic kidneys Double ureter
腸胃系統 Tracheoesophageal fistula (Gastrointestinal) Bowel atresia Imperforate anus
Classification of diabetes during pregnancy
Type of maternal diabetes Type I Ketoacidosis Type II obesity; hypertension Metabolic control and timing Early pregnancy birth defects & spontaneous abortion Late pregnancy hyperinsulinemia, overgrowth, stillbirth, Polyththemia, RDS Maternal vascular complications Retinopathy worsening during pregnancy Nephropathy edema, hypertension, IUGR Atherosclerosis maternal death
Gestational Diabetes Fetal risk hyperinsulinemia and macrosomia ? stillbirth Maternal risk hypertensive disorder of pregnancy Diabetes following pregnancy Metabolic control
Fasting glucose
<
Fasting glucose
>
妊娠與糖尿病-
A
Any Any
None A-
B Over
C
D Before
F Any Any Nephropathy Insulin R Any Any Proliferative retinopathy Insulin H Any Any Heart disease Insulin
妊娠與糖尿病-
Class Fasting Plasma Glucose Postprandial Plasma Glucose
A-
A-
週數: 對象:肥胖者、有糖尿病(家族)史者、產檢有尿糖者等。(理論上應每位孕婦皆做)。
作法:不用禁食、服用
*
NDDG*
Carpenter
O’Sullivan
WHO
妊娠期間血糖控制目標(Rigid Control)
早餐前
午餐、晚餐、睡前點心前
飯後
£
凌晨
Insulin regimens for diabetic women during pregnancy
Regimen
Regimen
Regimen
or long
Regimen
or long
Regimen
胰島素劑量從妊娠早期每公斤理想體重
早餐前RI: NPH
=
晚餐前RI: NPH
=
Work-up and management during hospitalization for pregnant diabetes:
1.
SMA
2. EKG
3.
U/A & U/C;
4. Consultation for Ophthalmologist, Dietian, social worker and diabetologist.
5.
DM diet
6.
Blood sugar monitoring: AC & PC
7. Adjust insulin requirement
Fetal well-being surveillance 1. Baseline ultrasound examination
2.
Daily fetal movement (DFMR) since
3. NST 4. Biophysical profile 5. Doppler ultrasound examination
Tocolytic agents for pregnant diabetics 1. Magnesium sulfate 2. Prostaglandin synthase inhibitor 3. b-mimetic (last resort)
4.
if ritodrine used, add KC
Management for pregnant diabetics admitted in labor floor
ò Assessment of fetal lung maturity Ultrasound evaluation for good control diabetics Amniocentesis: lung maturity profile (PG, L/S ratio) ò On continuous fetal monitoring ò May on diet prior to active labor
ò
Monitor blood sugar q
ò
Prepare IV fluid: N/S
ò NPO when in active labor
ò
If blood sugar
>
ò
IV fluid: N/S
increase RI at
ò
If blood sugar ranging between
switch IV fluid to D
ò
If blood sugar
<
switch IV fluid D
ò
When in active phase of labor (cervical dilatation over
switch IV fluid to D
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