妇产科诊疗常规及技术操作规程.doc

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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············································1
1、产前检查············································1
2、正常分娩·············································2
3、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········································10
①枕后位(枕横位) ········································10
②颜面位·················································11
③臀位···················································11
④横位···················································12
⑤巨大胎儿·············································13
⑥无脑儿················································13
⑦脑积水·················································14
4、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·············································29
5、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·······································41
①妊娠合并急性阑尾炎····································41
②妊娠合并消化性溃疡急性穿孔·····························41
③妊娠合并胆囊炎及胆石症·································42
④妊娠合并肠梗阻······································42
⑤妊娠合并急性胰腺炎·····································42
⑥妊娠合并卵巢囊肿蒂扭转·································43
⑦妊娠期急腹症手术应注意的问题···························43
6、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·············································53
7、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········································62
8、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·······································66
9、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········································80
1、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·······································82
2、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·········································84
①急性子宫颈炎·······································84
②慢性子宫颈炎································84
(6)子宫内膜炎········································85
(7)盆腔炎···········································86
①急性盆腔炎············································86
②慢性盆腔炎及亚急性盆腔炎·······························86
3、早、中期妊娠疾病····································87
(1)流产··············································87
①先兆流产············································87
②难免流产·············································88
③不全流产···········································88
④完全流产············································88
⑤过期流产··········································88
⑥习惯性流产···········································89
(2)妊娠剧吐··········································89
(3)异位妊娠··········································89
4、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········································96
②、侵蚀性葡萄胎和绒毛膜癌····························97
5、内分泌疾病·······································98
(1)功能性子宫出血病·····································98
①无排卵型功能性子宫出血···························99
②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·····································101
6、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···································103
7、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计划生育疾病························106
1、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·································114
2、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·····························120
3、输卵管吻合术(再通术)······························122
4、清宫术········································123
5、宫注术·····································124
6、女性不孕症·········································125
7、高泌乳素血症及闭经泌乳综合征························127
8、多囊卵巢综合征··································129
9、闭经········································131
10、淋病·······································134
11、尖锐湿疵·····································135
第四章妇产科常用诊疗技术操作规程························137
1、内窥镜检查·······························137
(1)腹腔镜·········································137
①检查性腹腔镜···································137
②手术性腹腔镜····································138
(2)宫腔镜检查······························139
(3)阴道镜检查··································141
2、宫颈刮片细胞学检查·································142
3、宫颈活检·········································143
4、宫颈粘液检查·····································143
5、取内膜术····························144
6、诊断性刮宫·······································144
7、后弯隆穿刺术·······································145
8、子宫输卵管造影术···························146
9、宫颈息肉摘除术·······························147
10、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. 0 X 10'2 /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.初诊的各项检查记录、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（>15 h)

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<lcm/h。
活跃期宫颈扩张停滞:2小时宫口无扩张，停滞在原来水平。
活跃期虽历时较短，但十分重要，绝大多数难产都在此期表现出来，因此一旦发现活跃期延长，应积极寻找原因，具体处理:
(1)阴查，行人工破膜，了解羊水情况，了解宫颈是否水肿，儿头回转情况，骨盆情况，如发现严重胎头位置异常，如高直后位，前不均倾位，颊后位，额位，面先露，应及时以剖宫产结束分娩。
(2)如经阴查无明显头盆不称，无胎头位置异常，无胎儿宫内窘迫者，可予1%催产素静脉点滴，如宫口开大在6cm以内，产妇疲劳可静注安定10mg及静滴能量合剂、脂肪乳以补充热能，加速产程。
(3)如经上述处理试产2-4小时，产程无进展或进展缓慢，宫口扩张<0. 5cm小，应停止试产改剖宫产。(7cm以前)
(4)如第一产程早期进展较快(7cm以前)，但到了末期进展缓慢或停滞，宫颈扩张尚在一定水，儿头无下降或下降不明显，应及时作阴查，了解中骨盆及骨盆出口有无狭窄，并注意宫颈及儿头情况，如有头盆不称，枕后位、宫颈明显水肿，儿头颅骨重叠及产瘤形成等应以剖宫产结束分娩。如阴查无明显异常，仅为宫缩乏力，应予点滴催产素加强宫缩，解除产妇疲劳，如经处理仍无效，儿头下降停滞2h以上或二程超2h胎头仍在0十z以上者，因阴道助产母婴损伤较大，应及时施行剖宫产。见图2:
图2活跃期宫颈扩张迟缓或停滞的处理原则

宫颈扩张活跃期 正常（<8h） 胎儿娩出期
延缓(<1cm/h)
或阻滞(2h无扩张)

人工破膜 有进展
安定或654-2iv

无进展 无头盆不称 催产素 有进展
无胎位不正
头盆不称
或胎位异常
剖宫产

难产处理
产力异常
〔定义〕
子宫收缩乏力，宫缩失去节律性、极性或子宫收缩过强，统称为子宫收缩力异常或产力异常。
〔诊断要点〕
一、引起子宫收缩力异常的常见原因，包括精神过分紧张、疲劳、子宫发育不良、子宫肌纤维过度伸展或子宫畸形、不适当地应用大量镇静剂或刺激子宫收缩的药物、以及胎先露不能紧贴子宫颈部缺乏局部刺激等。
二、临床上分为三大类
1.子宫收缩乏力，指子宫收缩仍有正常的极性，对称性和节律性，但收缩力弱，间隔时间长，持续时间短，以致子宫颈口扩张缓慢，产程延长，尤其是第二产程过分延长时，胎头受压迫过久，可使膀胧局部组织缺血、坏死，严重者可引起生殖道痰，同时也会使胎儿颅内出血。
2.不协调子宫收缩，指子宫收缩失去正常的对称性和极性，阵缩间歇时宫壁不完全放松，子宫腔内压力始终较高，不易促使宫口扩张和胎儿先露部下降，造成胎儿子宫内缺氧，窒息，产妇肠胀气、尿储留等。
3.子宫收缩过强，指子宫收缩的节律性正常，但收缩力过强、过频。在产道与胎儿之间阻力小的情况下，过强宫缩可使分娩在很短时间内结束，总产程不足三小时者称为急产;在产道与胎儿之间有轻度头盆不称时，宫缩过强尚可能经阴道分娩，但如有明显头盆不称，过强宫缩又未及时发现，可致子宫破裂，危及母婴生命。
〔防治〕
一、产前作好宣教工作，解除恐惧和紧张，临产后进行安慰及鼓励进食，注意排空大小便。
二、如产妇精神疲乏，休息不好时，可边静脉滴注补液，边加用镇静剂包括杜冷丁和东蓑若碱联合应用，并注意纠正水、电解质平衡。
三、经适当休息后仍感宫缩乏力者，在除外头盆不称情况下，给子宫收缩剂刺激宫缩。常用催75-素2.5--5。