妇产科诊疗常规及技术操作规程

PAGEPAGE2XXXXX院妇产科诊疗常规及技术操作规程XXXXXXXX院二〇一七年一月修订目录第一章产科疾病············································11、产前检查············································12、正常分娩·············································23、难产处理················································7（1）产力异常···············································7〔附〕子宫收缩环··········································7（2)骨产道异常·············································11（3）胎位及胎儿异常········································10①枕后位(枕横位)········································10②颜面位·················································11③臀位···················································11④横位···················································12⑤巨大胎儿·············································13⑥无脑儿················································13⑦脑积水·················································144、妊娠病理···············································15(1）妊娠高血压综合征······································15(2)过期妊娠··············································18（3）双胎··················································19（4)胎儿宫内发育迟缓(IUGR)································20（5）死胎··················································22（6)羊水过少··············································22（7)羊水过多··············································23(8）前置胎盘··············································24（9)胎盘早期剥离··········································26（10)早产·················································27（11)前次剖宫产············································28(12)疤痕子宫·············································295、妊娠合并症·············································29(1）妊娠合并贫血··········································29（2）妊娠合并心脏病········································31（3）妊娠合并心律失常······································33（4)围产期心肌病··········································34(J)妊娠合并卵巢肿瘤·······································34（6）妊娠合并甲状腺功能亢进································35(7）妊娠合并糖尿病········································36(8)妊娠合并慢性肾炎······································37(9)妊娠合并急性肾盂肾炎·······························38（11)妊娠合并病毒性肝炎····································40（12)妊娠合并急腹症·······································41①妊娠合并急性阑尾炎····································41②妊娠合并消化性溃疡急性穿孔·····························41③妊娠合并胆囊炎及胆石症·································42④妊娠合并肠梗阻······································42⑤妊娠合并急性胰腺炎·····································42⑥妊娠合并卵巢囊肿蒂扭转·································43⑦妊娠期急腹症手术应注意的问 题 快递公司问题件快递公司问题件货款处理关于圆的周长面积重点题型关于解方程组的题及答案关于南海问题 ···························436、产科手术·············································44(1）剖宫产···············································44（2)会阴切开缝合术········································46（3)产钳术··································47（4)胎头吸引术…………………………………………。（5)外倒转术··············································50(6)臀位助产术············································51（7)臀位牵引术·····································51(8)宫颈探查术············································52(9)人工剥离胎盘术········································52(10）清宫术···············································53(11)子宫腔纱布条填塞术···································53(12）引产术·············································537、分娩期并发症··········································56（1)先兆子宫破裂···································56(2)子宫破裂············································56(3)产后出血（PPH)·····································57(4)胎膜早破············································60(5）脐带先露及脐带脱垂····································61（6)胎儿宫内窘迫································61（7）羊水栓塞········································628、产后疾病·········································63（1）晚期产后出血······································63（2)产褥感染·········································61（3）产后尿储留·····································66（4）乳胀与乳头毅裂·······································669、产科危重病人抢救（MICU）······························67（1)心跳骤停、心肺复苏··································67(2)产科抢救············································68(3)呼吸衰竭抢救·········································69(4)产科休克抢救········································69（5）水、电解质平衡及酸碱平衡紊乱诊断与处理·················71(6）急性子宫内翻症···································78第二章妇科疾病········································801、外阴病变·······································80(1）外阴痰痒症········································80（2）硬化性萎缩性苔鲜····································80（3）增生性营养障碍·······································81（4)前庭大腺炎·································81(5）外阴溃疡··········································81（6)外阴创伤·······································822、女性生殖器炎症·······································82(1)滴虫性阴道炎···································82(2)霉菌性阴道炎·······································83(3)老年性阴道炎··········································83(4)非特异性阴道炎·······································83(5）子宫颈炎·········································84①急性子宫颈炎·······································84②慢性子宫颈炎································84（6)子宫内膜炎········································85（7）盆腔炎···········································86①急性盆腔炎············································86②慢性盆腔炎及亚急性盆腔炎·······························863、早、中期妊娠疾病····································87（1）流产··············································87①先兆流产············································87②难免流产·············································88③不全流产···········································88④完全流产············································88⑤过期流产··········································88⑥习惯性流产···········································89(2）妊娠剧吐··········································89（3）异位妊娠··········································894、妇科肿瘤············································90(l）外阴癌·········································90(2)子宫颈癌·············································91(3)子宫肌瘤··········································93（4)子宫内膜癌·········································94(5)卵巢肿瘤············································95（6）滋养细胞肿瘤········································96②、侵蚀性葡萄胎和绒毛膜癌····························975、内分泌疾病·······································98（1）功能性子宫出血病·····································98①无排卵型功能性子宫出血···························99②有排卵型功能性子宫出血·····················100（2）经前期紧张综合症·······························100（3）子宫内膜异位症······································101(4)子宫腺肌病·····································1016、损伤性疾病·········································102（1）尿瘩···········································102(2)直肠阴道痰·································102（3）子宫脱垂········································103(4)陈旧性会阴m度撕裂···································1037、女性生殖器官畸形·································104(1）处女膜闭锁································104(2)先天性无阴道···································104（3）阴道横隔···········································105（4)阴道纵隔或斜隔·····································105（5）子宫发育异常······························105第三章生殖健康科及 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生育疾病························1061、计划生育手术常规······················106(1）宫内节育器放置常规.。。2（2)宫内节育器取出常规。。。16(3)输卵管结扎术常规...41（4）负压吸宫术常规...59（5）钳刮术常规...65（6）米非司酮配伍前列腺素终止早期妊娠常规.。。72（7）依沙吖啶羊膜腔内注射中期妊娠引产常规。。.82（8）水囊引产常规.。.88（9）经腹剖宫取胎术·································1142、复杂计划生育并发症处理常规····························116(1)终止妊娠并发症····································116（2）腹式输卵管结扎术并发症·····························1203、输卵管吻合术(再通术)······························1224、清宫术········································1235、宫注术·····································1246、女性不孕症·········································1257、高泌乳素血症及闭经泌乳综合征························1278、多囊卵巢综合征··································1299、闭经········································13110、淋病·······································13411、尖锐湿疵·····································135第四章妇产科常用诊疗技术操作规程························1371、内窥镜检查·······························137（1）腹腔镜·········································137①检查性腹腔镜···································137②手术性腹腔镜····································138（2）宫腔镜检查······························139（3)阴道镜检查··································1412、宫颈刮片细胞学检查·································1423、宫颈活检·········································1434、宫颈粘液检查·····································1435、取内膜术····························1446、诊断性刮宫·······································1447、后弯隆穿刺术·······································1458、子宫输卵管造影术···························1469、宫颈息肉摘除术·······························14710、激光治疗································148第一章产科疾病产前检查一、就诊范围及复诊时间1。初诊预约：于孕三个月内开始立孕妇联系卡.2。约定孕妇定期参加孕妇学校听课，学习孕期保健、临产分娩、母乳喂养及产后保健等知识。3。预约复诊时间:孕20周前检查2-3次,孕20—28周,每4周复查1次，孕28—36周每2周复查1次，孕36周开始每周复查1次，有异常情况随时来院检查，如:身体不适，腹胀,腹痛，阴道流血、流水，头昏头痛，水肿，高血压等。二、初诊内容（一)病史采集1一般情况:姓名、年龄、职业、籍贯、家庭地址、丈夫姓名及工作单位。2.现病史:孕早期反应、自觉胎动时间、饮食、大小便情况、有否头昏、眼花、腰酸、阴道流血、孕期内服药物及病毒感染史、有否内科疾病及其治疗情况。3月经史:初潮年龄、月经周期情况、末次月经日期及推算预产期.4婚产史：结婚年龄，是否近亲结婚，有无早产、难产、死胎、死产史,既往分娩、有无产前、产后出血史，感染等病史，新生儿体重及健康情况，如系剖宫产需了解手术指征、手术方式、子宫切口位置、术前、术后有无感染史、及伤口愈合情况。5.家族史:有无高血压、精神病、内分泌及遗传病史等。6过去史:有无肝炎、肾炎、高血压等病史，有无手术及药物过敏史等。（二)体检1一般情况:注意孕妇体态、步态、发育、营养状况、皮肤巩膜有无黄染、身高、体重、血压等。2。全体情况：包括头颅、五官、颈、胸、心肺、乳房发育大小、乳头有否凹陷、腹部、肝、脾、脊柱四胶等情况。描绘妊娠图。3产科检查及骨盆外测量:包括产科腹部四步手法检查、宫底高度、胎位、胎先露及是否人盆、测量宫高、腹围、听胎心音、必要时作阴查,了解阴道有无炎症、畸形、肿瘤，取阴道分泌物查滴虫、霉茵、淋菌等,孕37周以后门诊不做阴查。（三）化验检查1。血常规、血型.2尿常规、尿糖。3孕妇年龄30岁以上需作宫颈刮片防癌检查（37周后不做）。4。肝功能+HAA。5血巨细胞病毒、风疹病毒、弓形体、淋病、梅毒、艾滋病等检查。6。阴道分泌物常规检查。(四)特殊检查1.纠正贫血：红细胞〈3.0X10’2/L，血色素〈100g/L予补血药物治疗。血色素<80g/L应进一步查明贫血原因，积极治疗贫血。2、产前筛查：地贫、唐氏综合征、神经管缺陷.3、糖耐量筛查。三、复诊1.测量体重、血压，如体重一周内增加超过500g，血压升高〉4/2kpa或达17/12kpa时应作尿蛋白检查.2.测量宫高、腹围,检查胎位,胎先露及先露衔接情况，听胎心音，数胎心率，估计胎儿大小,检查下肢有否浮肿，填写妊娠图,注意有无胎儿宫内生长迟缓或胎儿过大.四、高危门诊孕妇有以下情况，可到高危门诊随访和检查，进行系统监护，针对各种不同病因进行治疗。1.某些影响孕妇健康及胎儿发育的疾病.如:原发性高血压，心脏病,糖尿病，甲亢，慢性肾炎，肺结核等产科、内科、外科各种疾病合并妊娠.2.过去不良分娩史。如：习惯性流产、早产、死胎、死产、产伤、新生儿死亡.3。本次妊娠有异常。如：宫颈闭锁不全，生殖道畸形（双子宫、双阴道、阴道纵、横隔等)，中、重度妊高征，前置胎盘，胎盘早剥，阴道流血,重度贫血，羊水过多或过少，双胎母儿血型不合等。4。估计分娩有异常。如:孕妇身高<150cm,体重<45kg或>85kg，胸廓、脊柱、骨盆畸形，头盆不称,狭窄骨盆，胎位异常(臀、横位)，剖宫产史等。5。切盼儿、不孕症治疗后受孕，高龄初产，胎儿宫内生长迟缓等。正常分娩一、人室检查(一)仔细查阅门诊病历及各种检查需注意以下几点1。结婚年龄，生育年龄，孕产次.如:是否高龄初产或不孕症治疗后受孕，有否习惯性流产史；有无不良分娩史,如:死胎、死产、新生儿死亡；有否手术产史，如:产钳、胎吸和剖宫产术，并要注明上次手术时间、指征、手术情况、手术后情况;有无伤口感染等。2.初诊的各项检查 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、基础血压、血和尿常规、肝功能、骨盆外测量情况、复查每次产前检查情况,包括：先露、胎心、血压、体重、浮肿、宫高、B超、胎心监护及其它辅助检查的结果。3.在以往妊娠分娩中有否异常，如：人流引产及与妊娠有关并发症，有否软产道及骨产道方面异常情况。4。此次妊娠有无并发症。如为妊高征应注意发生孕周、程度、用药情况，如为内科疾患应注意发病性质、程度、用药及现在状况。（二）收人院指征1。近临产的初、经产妇.2.确诊或可疑胎膜早破者。3.有剖宫产史或子宫疤痕、初产头浮者应提前两周(38W）住院待产。4。胎位异常:如臀位、横位需提前两周(38w)人院待产。5。超过预产期7天须人院准备分娩.6.羊水过少，羊水过多,监护有异常或胎心快慢不均者住院待产.7.有妊娠合并症需人院治疗。8.有内、外科疾病者需人院治疗。9.有产前出血者无论何孕周均需住院治疗.10。外院转来的危重病人。11.先兆早产，晚期先兆流产(孕12一28W）均收住院安胎治疗。(三)填写产科病历如为正常入院待产产妇，应填写产科表格或病历，每个空格均要填完整，可由助产士代医生填写：如为高危产妇住院待产，需写产科住院病历，由医生按病历规范书写，并要求写首次病情记录。1.病史记录内容（1）孕产次，停经周数，因何来院,说明症状的发生和持续时间。(2)重点扼要记录孕期概况，有无用药、药量、用法、用药时孕周。(3)描写月经史、周期、末次月经、计算预产期及婚姻情况。（4）已有宫缩者,写明何时开始,何时转紧，宫缩性质、强度。（5）询问三天内有无性交、盆浴史，如胎膜早破要询问有无诱因，记录破膜时间。（6）按系统询问过去史，特别是心、肺、肝、肾、高血压等疾患,如有疾患需问清发病时间,治疗情况，愈后以及最后发病日期与妊娠关系。2。全身及产科检查(1)一般情况，注意孕妇体态、营养、发育情况、皮肤、巩膜有无黄染,身长、体重、血压、脉搏、呼吸等情况。(2)全身检查:头颅五官、颈、胸、心肺、腹部、肝、脾。及脊柱四肢等。(3)产科检查时需注意：胎先露、入盆否、胎心率、宫底高度、腹围、估计胎儿体重，如腹围过大，需作B超检查，除外羊水过多、巨大儿、胎儿畸形，如腹围过小、需除外胎儿宫内发育迟缓、羊水过少,并要核实月经史,特别是末次月经,如未做过产前检查,应作骨盆测量，如疑门诊测量有异常须复测一次.（4)肛查：如已临产者需作肛门指诊，了解宫颈情况，确定先露及先露高低，胎膜情况，如疑胎膜早破,肛查时轻推胎头看有否羊水流出。二、产程观察及处理分娩过程:从规律宫缩开始到胎儿、胎盘娩出为止.临床分为三个产程：（一)第一产程:从规律宫缩开始到子宫颈口开全。初产妇约需11-12小时，经产妇约需6—8小时.1.观察产程:描绘产程图，记录产程经过，临产后每2-4小时作一次肛查，了解宫颈口扩张及先露下降情况。（1）潜伏期：从规律宫缩开始至宫颈口扩张3cm，约需8小时，最大期限为16小时,>16小时为潜伏期延长。（2)活跃期:从宫颈口扩张3cm至宫颈口开全，最大期限为8小时，>8小时为活跃期延长。宫颈口扩张乖进展2小时为活跃期停滞。2.温肥皂水灌肠:适于初产妇宫口〈4cm，经产妇宫口<2cm者.但胎膜早破，阴道流血，胎位异常，有剖宫产史，心脏病及中、重度妊高征者不宜灌肠。3.人工破膜:初产妇宫颈口扩张至2—3cm，行人工破膜，以了解羊水性状及加速产程进展。破膜后即听胎心音.但先露高浮、胎位异常者不宜行人工破膜。4.听胎心音：第一产程每30分钟听一次胎心音并记录。5。测体温、呼吸、脉搏、血压，每4—6小时一次.有合并症时加强监护.6鼓励产妇饮食和休息。(1）饮食：给予富有营养、易消化的高热量半流食。不能进食者可静脉补充水分、电解质、葡萄糖和维生素。(2)休息:初产妇宫颈口扩张至3-4cm，可予静脉推注安定l0mg，让产妇休息,并减轻产妇焦虑、恐惧心理。(二)第二产程:从宫颈口开全到胎儿娩出,初产妇约需1-2小时，经产妇一般数分钟即可完成，但亦有长达1小时者。1。严密监测胎心及观察羊水性状:每5-10分钟听一次胎心或用胎儿监护仪监测胎心，若胎心异常，立即查找原因，及时处理，尽快结束分娩.2.指导产妇屏气，并常规吸氧：当第二产程已达1。5小时胎儿尚未娩出时,应行阴道检查寻找原因,采取措施结束分娩。3。接产:常规消毒外阴，铺巾，接生者消毒手臂，穿手术衣。戴消毒手套。注意保护会阴，必要时行会阴侧切术。4。会阴侧切手术适应症(1）会阴水肿,会阴过紧，缺乏弹性，耻骨弓过低，胎儿过大:（2）阴道手术助产。（3)胎1L窘迫，以加速胎儿娩出.（4）早产、避免胎头受压过久。(5)产妇因病情需要缩短第二产程者。(三）第三产程：从胎儿娩出到胎盘娩出,约需5-15分钟，不超过30分钟。1.新生儿处理:及时清理呼吸道，处理脐带，新生儿评分。2。协助胎盘娩出:正确处理胎盘娩出，以减少产后出血，确定胎盘已完全剥离，宫缩时左手扶宫底，右手牵拉脐带，当胎盘分娩至阴道口时，接产者双手捧胎盘向一个方向旋转，并缓慢向外牵拉，协助胎膜完整剥离娩出。3.检查胎盘、胎膜是否完整，有无异常。4.检查软产道有无裂伤,有裂伤及时缝合修补。5.预防产后出血:胎儿娩出后，静脉推注催产素10—20单位加50葡萄糖20m1。以促使胎盘快速剥离，减少出血。胎儿娩出后30分钟，或胎儿娩出不到30分钟但有活动性出血应立即行徒手剥离胎盘。6。产后在产房休息室观察2小时，观察产妇血压、脉搏、子宫收缩及阴道出血量。7。实行产后半小时内新生儿与母亲进行皮肤接触，并开始吸吮母亲乳头,即是皮肤接触、早吸吮、早开奶。三、异常产程处理常规(一）产妇人室待产,正式临产后由助产士描绘产程图。1.潜伏期开始，画出宫口扩张及胎头下降的曲线,潜伏期超过8小时为进展缓慢，超过16小时为延长.处理:为了避免滞产，我们应从潜伏期开始进行处理，因此,如潜伏期超过6—8小时，应寻找原因，病人较疲劳者应给予肌注杜冷丁，让病人休息,同时可静脉滴注能量合剂，脂肪乳等补充产妇热能以利解除疲劳恢复体力，促进产程进展.见图1图1潜伏期有延长倾向或延长者的处理原则:正常(<15h)潜伏期宫颈扩张活跃期有延长倾向(>8h）或已延长（>15h)给镇静剂(杜冷丁100mg)有进展给能量脂肪乳等改善病人情况无进展（无头盆不称)有进展给催产素有进展2h无进展4h头盆不称无进展（无头盆不称,宫口开>2cm）人工破膜无进展剖宫产宫颈性难产剖宫产2。活跃期从宫口扩张3cm至宫口开全这段时间,这时每小时宫口扩张>lcm.活跃期宫颈扩张迟缓:宫颈扩张 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刺激宫缩.四、对于不协调宫缩，常用杜冷丁加东蓑若碱使产妇充分休息后可控制不协调宫缩。五、子宫收缩过强，可酌情给杜冷丁肌注、硫酸镁静脉滴注抑制宫缩。〔附〕子宫收缩环因子宫壁某部肌肉呈痉挛性不协调收缩所形成的环状狭窄，称子宫痉挛性狭窄环。〔诊断要点〕一、多在精神过度紧张，或阴道操作过多,局部受强刺激的情况下发生。二、可出现于子宫的任何部位，但在子宫上下段交界处、宫颈外口、及胎体的较小部位如胎颈、腰处多见。三、环的位置不随宫缩而上升。〔防治〕一、立即停止产科操作，减少不必要的刺激并给镇静解痉剂，如杜冷丁和东厦若碱肌注。二、给予子宫肌肉松弛药物:如1：1000盐酸肾上腺素0.3m1皮下注射；或阿托品0.5-lmg肌肉注射；或25%硫酸镁loml溶于20m]葡萄糖液内，5—10分钟内静脉缓慢推注.三、如子宫颈口已开全，可经阴道分娩者,则在深度乙醚麻醉下行产钳术结束分娩。如胎儿已死亡，则行碎胎术。四、伴胎儿窘迫而又短期内不能阴道分娩者，可行剖宫产术,术时宜作子宫纵形切口，切断收缩环以利胎儿娩出。骨产道异常骨盆的大小形态是固定的,胎儿通过时必须与之相适应,否则可导致难产，因此骨盆大小对分娩能否顺利进展具有重要意义.〔狭窄骨盆的基本类型〕一、均小骨盆:骨盆外测量的各径线均较正常值小2cm以上,但仍保持女性型骨盆的形态.多见于身材矮小、体型相称的妇女。二、扁平骨盆:单纯扁平骨盆的前后径比正常缩短，测量骼耻外径在18cm以下，而其他径线则保持正常。三、漏斗型骨盆:骨盆人口各径线正常，因骨盆壁渐向内倾斜，使中骨盆及出口均有明显狭窄，坐骨结节间径小于8cm，耻骨弓角小于90度，骨盆腔呈漏斗型。此类骨盆常有男性骨盆的特点，骨质较厚，盆腔较深。四、畸形骨盆:骨盆外形失去正常形态及对称性。其原因很多，所引起的畸形也不一致。〔诊断要点〕一、详细追问病史1。根据过去分娩史中有无难产史、难产原因,新生儿体重及出生后的情况，进行判断此次是否能经阴道分娩.2。询问过去史时，应特别注意幼时有无影响骨盆变形的疾病(如拘楼病、结核、小儿麻痹症等）及外伤史。二、一般检查1.注意孕妇的一般发育状况,包括身长及体重，身长150cm以下者，往往有均小骨盆，注意站立及行走的体态。2。注意有无跋足和脊柱后凸，菱形窝是否对称，以及关节的活动度等。3。注意腹部形状，有无悬垂腹。三、腹部检查法估计胎儿大小及头盆关系。方法为产妇排尿后仰卧,两腿伸直，检查者用一手于耻骨联合上方向盆腔方向推压胎头，如胎头低于耻骨联合平面，表示胎头可以人盆，无头盆不称，称胎头跨耻征阴性;如胎头与耻骨联合在同一平面，表示可疑头盆不称，称胎头跨耻征可疑阳性；如胎头高于耻骨联合平面,表示头盆不称,称胎头跨耻征阳性。四、胎位检查因骨盆狭窄影响胎头衔接，常产生不正常的胎位.五、骨盆检查1.外测量:其径线及测量方法见产前检查。2内测量:包括阴道检查，测量骸耻内径等。3。X线骨盆测量:个别通过临床检查不能 决定 郑伟家庭教育讲座全集个人独资股东决定成立安全领导小组关于成立临时党支部关于注销分公司决定 的可采用X线摄片了解骨盆人口形态及骸骨的弯曲度,并测量骨盆人口和出口各平面的主要径线。六、临床表现及对分娩的影响1。胎先露未能很好入盆时，易发生胎膜早破及脐带脱垂.2。先露部下降受阻时，可致先兆子宫破裂或子宫破裂。3。胎儿颅骨可有明显重叠而致颅内出血.4.由于产程进度缓慢，产妇衰竭，手术产率高；产后出血及感染率增高;易发生胎儿窘迫导致新生儿窒息.〔处理原则〕首先须明确骨盆狭窄的类别和程度,并了解胎位，胎儿大小、胎心、宫缩强弱，宫颈口扩张程度、破膜与否,结合年龄、产次，既往分娩史综合分析判断、决定分娩方式.一、一般处理在分娩过程中，应安慰产妇,使其精神不紧张，保证营养及水份的摄人，适当的休息，仔细观察宫缩情况及胎心变化，注意是否破膜。二、骨盆人口狭窄的处理骨盆属绝对性狭窄者,应行剖宫产术，而属相对性狭窄者应予试产。试产的方法:因决定分娩因素除骨产道外，尚有产力和胎儿的因素，因此估计胎)L能否经阴道分娩，必须全面分析产道、产力、胎儿等各方面因素。首先要在临产后观察矛盾是否向有利方向转化,这个观察过程称为试产。试产是指在良好宫缩下观察一定时间内胎头能否人盆，产程是否有进展。1。试产条件:骸耻内径在l0cm以上者，除胎儿特别大或有明显的骑跨征阳性外，均应给予试产的机会。2。试产时间:试产时间长短,应根据胎头下降的情况，骨缝是否重叠，产瘤是否形成，胎膜是否已破，宫颈口扩张大小及产力强弱等情况来决定，一般在良好的宫缩下，试产时间大约在6—8小时左右。3.经破膜试产而胎头仍不能下降人盆，产程无明显进展者,则为试产失败，应行剖宫产。三、中骨盆狭窄的处理胎先露达坐骨棘水平后即停滞不进，内转受阻，胎头取持续性枕横位或枕后位。1。如果胎头双顶径已下降至坐骨棘水平或更低水平，这时子宫颈口已开全，产程已较长者，可用产钳术结束分娩.2.如果胎头双顶径在坐骨棘以上,应施行剖宫产术。四、骨盆出口狭窄的处理1.坐骨结节间径与后矢状径之和小于13。5cm时,则足月活婴不能从阴道分娩,应及早施行剖宫产术.2。对轻度的出口狭窄产妇，在胎头娩出前应作较大的会阴侧切术，以避免严重的会阴撕裂,第二产程延长时，可以使用出口产钳或胎头负压吸引术。胎位及胎儿异常枕后位（枕横位）〔定义〕胎儿枕骨位于母体骨盆的后方或侧方，而在分娩过程中不能转向前方，称持续性枕后位（枕横位）。〔诊断要点〕一、腹部检查在子宫底部可触及胎臀,胎背偏向母体的侧方或后方，母体腹壁可以触及较多胎儿肢体。胎心音在母体腹壁偏外侧听得较清楚。二、产程特点1.枕后位的先露部不能紧贴子宫颈，故常伴有宫缩乏力。2.子宫颈口扩张及胎头下降缓慢，产程延长.3.胎儿枕骨位于骨盆后方，直接压迫直肠，故子宫颈尚未开全时产妇即出现肛门下坠及排便感觉，过早使用腹压，宫颈受压过久易致水肿.4.第二产程延长。三、肛门检查、阴道检查当宫口部分开大或开全时，可发现胎头矢状缝位于骨盆的斜径，前后径(或横径)上,触及大囱门在前，小自门在后（或均在侧方），并可从胎儿耳廓、耳屏的位置及方向来确定胎头方位.〔防治〕一、第一产程应关心产妇的精神状态,饮食及休息，让产妇朝向胎背的对侧方侧卧，以利于胎头向枕前位旋转，指导产妇不要过早屏气用力，以免引起子宫颈水肿影响产程进展。二、第二产程初产妇近2小时，经产妇近1小时,应作阴道检查,如双顶径已达坐骨棘水平或以下，可试用手旋转胎头，使胎头枕部转向前方，以胎头吸引术或产钳术结束分娩。个别情况如转成枕前位确有困难,亦可转为正枕后位，行产钳助产，但枕后位娩出时需按枕后位分娩机转助产.枕后位分娩机转助产：鼻根出现在耻骨联合下缘时，以鼻根为支点,胎头向上俯屈，使大囱门、枕部从会阴前缘娩出，然后胎头仰伸，使鼻、口、颊相继由耻骨联合下娩出。枕后位娩出时因胎头径线大，应作会阴侧切术，切口宜偏大，并注意保护，谨防会阴班.撕裂。枕横位时应注意是否有不均倾的情况存在，如确定为前不均倾，以剖宫产结束分娩为宜。三、第三产程因产程延长，易并发子宫收缩乏力,应防止产后出血。四、若胎头位置高,疑有头盆不称存在,或产妇年龄较大,或切盼儿时，均可考虑剖宫产。颜面位〔定义〕由于胎头极度仰伸,胎儿枕部与胎背接触，胎儿面部最先进人骨盆人口，称面先露或颜面位。以额为指示点,根据颊部与母体骨盆的关系，分为颊左前、颊右横、颊左后、颊右前、颊左横、颊右后六种胎位。〔诊断要点〕一、腹部检查：因胎体伸直，子宫底较高。颊前位时，胎儿肢体靠近腹壁.故易触及。颊后位时于下腹部耻骨联合上方，可触及胎儿枕骨隆突与胎体间有明显的凹沟,胎心远而弱。二、肛门检查：可触到高底不平，软硬不均的面部,若肛查疑为颜面先露时，应行阴道检查确诊。三、阴道检查：当宫口已扩张时可以区分出胎儿的口、鼻、眼各部，当确定为颜面位后，以颊部的位置决定是颊前还是颊后。四、颜面位时，由于面部水肿有时与臀先露不易区别，故阴道检查时应与腹部检查相配合进行诊断。个别情况不能确诊时，可行B超或腹部X光摄片协助诊断。〔处理〕诊断明确后，不论须前或颊后位以剖宫产为宜.个别情况如胎儿很小而为颊前位,可阴道试产，如胎儿已死可行经眼眶行穿颅术阴道分娩，如胎儿有畸形，则应在宫口开全后行碎胎术。臀位〔定义〕胎儿臀部最先进入骨盆入口称臀位。臀先露时以入盆的先露，又分为混合臀先露、单臀先露、足先露。臀位以骶骨作为指示点:可分为骶左前、骶左横、骶左后、骶右前、骶右横、骶右后六种胎位。〔诊断要点〕一、腹部检查：胎体纵轴与母体纵轴一致，于子宫底部可触到圆而硬、按压时有浮球感的胎头。在耻骨联合上方可触到较软，宽而不规则的胎臀，胎心在脐部的左上方或右上方听得清楚。二、肛门检查:摸不到硬而圆的胎头，而能摸到较软且形状不规则的胎臀，或摸到胎足、胎膝。三、阴道检查:如先露部位置高，肛查不清时，可行阴道检查。如子宫颈口已扩张2cm以上,且胎摸已破，可触及胎臀、外生殖器及肛门。〔辅助诊断〕超声及X线检查:少数孕妇的腹壁过厚,或胎头位置过高,嵌于肋缘下，胎位触不清,肛查也不能确诊时，可行超声检查确诊胎位,X线摄片检查不但能确诊胎位、了解有无胎头仰伸,还能除外胎儿畸形。〔处理〕一、妊娠期（一)妊娠28周前，甲羊水相对较多，胎位多不固定，发现臀位不必急于纠正,日后多数能自动转成头位。如在妊娠28—32周间仍为臀位，应矫正为头位，常用的矫正方法:1.胸膝卧位：每日2次，每次10—25分钟,一周后复查。2。艾灸至阴穴：每日1—2次，每次15分钟，一周后复查。3。如经上述方法处理无效，于妊娠34周以后，征得孕妇及其家属同意后也可行外倒转术.二、分娩期应根据产妇的年龄、胎次、骨盆大小、胎儿大小、臀位的种类及有无妊娠合并症,于足月或临产初期作出正确判断，决定分娩方式，但为了降低围产儿死亡率与病率，宜适当放松剖宫产指征。(一)剖宫产：骨盆狭窄、足位、胎儿巨大(估计体重>3500g）、高龄初产,可行剖宫产.产程中出现脐带脱垂，胎心尚好,宫口未开全，为抢救胎儿生命，亦需行剖宫产。（二）决定阴道分娩者应作如下处理1、第一产程(1)产妇应卧床，少作肛查,不灌肠,尽量避免胎膜破裂.（2）破膜后应立即听胎心，如发现胎心异常即作肛查或阴道检查,明确有无脐带脱垂.（3)随时注意宫缩、宫颈扩张及先露下降情况，宫缩乏力者，应及时纠正.（4)当宫缩时在阴道口看到胎臀及胎足时，可作阴道检查，明确宫口是否开全，即使宫口已开全，为了使阴道充分扩张,每当有宫缩时需用无菌巾以手掌堵住阴道口，以防胎臀及胎儿娩出，直至产妇向下屏气时，接生者堵在阴道口的手掌已感到相当大的冲力时，才能准备接生。（5）在“堵”的过程中，应每10—15分钟听胎心一次，并注意下腹部形态,有无先兆子宫破裂现象。(6)作好抢救新生儿窒息的一切准备。2、第二产程(1）导尿排空膀胧，初产妇应作会阴侧切术。（2)根据具体情况采用臀位助产,尽可能避免作臀位抽出术.（3)臀位分娩时，应于脐部娩出后8分钟内结束分娩。(4）胎头娩出时不应猛力牵拉，以免造成颅内出血或臂丛神经损伤。产后应检查宫颈、阴道有无撕裂，若有撕裂，应予修补.横位〔定义〕横位为胎体横卧于骨盆人口之上，先露为肩，故称肩先露.以胎儿肩脾骨为指示点,可分为肩左前、肩左后、肩右前、肩右后四种胎位。〔诊断要点〕一、腹部检查：子宫轮廓呈横椭圆形,子宫底高度较妊娠月份为低，子宫横径宽，耻骨联合上方空虚，母体腹部一侧可触到胎头，胎臀则在另一侧，胎心在脐孔两旁最清楚。二、肛门或阴道检查：胎膜未破时因先露部浮动于骨盆人口上方，肛查时不易触及先露部,如胎膜已破，子宫颈口已扩张时，阴道检查可触到肩脚骨或肩峰.如胎手已脱出于阴道口外，可用握手法鉴别是左手或右手。〔防治〕建立健全妇女保健组织,加强孕期保健及产前检查。一、妊娠期：妊娠30周后发现横位时,应及时行外倒转术纠正，并包扎腹部以固定胎位。如外倒转不成功,则应提前住院，决定分娩方式.二、分娩期:应根据年龄、胎次、孕周、胎儿大小、是否存活、骨盆有无狭窄、子宫颈扩张程度、胎膜是否破裂、子宫腔内羊水剩余量、有无子宫先兆破裂等情况，决定具体的处理方法：1.有产科指征如骨盆狭窄、前置胎盘等，则作剖宫产。2初产妇或经产妇有难产史者，也应作剖宫产.剖宫产术应于临产前或临产初期进行。3.如破膜时间已久，羊水已流尽，已有子宫先兆破裂，或子宫已破裂者，则应立即行剖宫产术。剖宫产时如发现宫腔感染严重，术时可将子宫一并切除。4.胎儿已死、无子宫先兆破裂征象者,可在宫口开全或接近开全时行断头或除脏术。5.凡经阴道手术分娩者,胎盘娩出后应常规探查宫腔、子宫下段及宫颈。如有裂伤应及时处理。6.注意子宫收缩情况,预防产后出血.巨大胎儿〔定义〕胎儿体重超过4000g者，称为巨大胎儿。〔诊断要点〕一、病史及全身状况：有巨大儿分娩史者，或有肥胖、糖尿病者，均应考虑有分娩巨大儿之可能。二、腹部检查：腹部明显膨隆，宫底高度超过相同孕周的90th％,先露部常不人盆而高浮,需与双胎、羊水过多相鉴别。三、B超检查：胎头双顶径超过相同孕周的90th，或达l0cm时，胎儿可能为巨大儿。胎儿头径大，尚需测定胸径及肩径，若胸、肩径明显大于头径者发生肩性难产的可能性甚大.〔处理〕一、孕期处理孕期发现胎儿大或既往有巨大儿产史者,应检查孕妇有无糖尿病，一经证实为糖尿病，应积极治疗，控制血糖.孕36周后应根据胎儿及胎盘功能，而决定引产或剖腹产.二、分娩中处理1。巨大儿试产应严密观察进行监护，注意防止各种并发症。由于胎头较大且硬，不易变形，不“宜试产过久，如有头盆不称且胎心好，可行剖宫产；如先露已达“十2”以下,第二产程延长时，可行会阴切开后使用胎头吸引器或产钳助产；如胎儿已死则行穿颅及碎胎术。2。阴道分娩时在助产中应特别注意肩娩出的困难，即肩难产，如处理不当，可致胎儿伤亡.当胎头娩出后应充分利用骨盆斜径，有利胎肩娩出，并应注意保护会阴和及时行会阴切开，以免会阴严重裂伤。3.巨大儿娩出后，应常规行阴道检查，以便及早发现产道损伤，并注意防治产后出血及感染。无脑儿是先天性畸形胎儿中最常见的一种，为开放性神经管缺陷畸形，常合并羊水过多,如不伴羊水过多,常为过期妊娠。〔诊断依据〕一、腹部检查：可扣及胎头较小.二、肛查或阴道检查:可扣及凹凸不平的颅顶。〔辅助诊断〕一、B型超声检查。二、X线摄片:无头盖骨的胎头可确诊。三、24小时尿E3〉6mg有诊断意义。