减少娩儿失血的五缓慢步骤(精).doc

13頁的第13頁
English first, simplified Chinese later 先英語, 后簡體漢字
Steps in lowering blood loss
There are 5 steps.
First is to deliver the head and body of the baby in stages, meaning to reduce the uterine volume in stages. That is, using as much time as necessary to remove the amniotic fluid, and using more time than you normally use to delivery the fetal head. The rationale is to give the upper segment a short rest during volume reduction, enabling it to make strong contraction and retraction to close the injured blood vessels.
Second is to repair the uterine incision as quickly as possible. Normally the anterior wall of the uterine lower segment has no opening. What the lower segment needs is to repair the uterine incision quickly.
The slow steps of this operation technique is to imitate the lengthy labour process of a vaginal delivery. When a patient is in labour, 1. the amniotic fluid takes several hours to leave the uterus, 2. the fetal head takes several hours to descend to the vulva, 3. descent of the fetal head from the cervix through the vulva takes almost an hour or more, 4.when the fetal head has come through the vulva, allow 10 or more seconds for the air passages to be cleared before delivering the rest of the baby, 5.let the placenta wait for the obvious signal that it has been separated and descended to the top of the vagina before pushing it out. This usually means a wait of several minutes after the second stage.
Obviously, if these 5 stages of action are transplanted to a cesarean delivery, first is to make a small uterine incision at the right place, and to take 20-90 seconds to remove all of the amniotic fluid, second is to use 4 fingers or a Murless extractor slowly to lift up the head to the incision level, then, together using 30 or more second to pull up the upper uterine flap, third is give 20 or more seconds to lift the head out of the incisions without lacerating the incision, and allowing the incisions squeeze out fluids in the air passages, fourth is take more than 10 seconds to deliver the body, allowing time for the assistant to clear the air passages, fifth is to wait for the edge of the placenta making its appearance before removing the placenta. By carrying out the above 5, blood loss can come down to less than 300ml.
And if the high uterine incision of this technique is used, blood loss will be much less.
High lower segment incision can reduce bleeding while closing the uterine incision
Pick up in small steps the peritoneum covering the lower segment from middle part of the lower segment towards the upper segment. As the toothed pickup forceps approaches the upper segment, it finds the peritoneum can only be barely picked up. And, the spot where the peritoneum cannot be picked up, is the border of the serosa. The level 3 cm caudal to the serosa is the level of the high incision. A high incision should not be made <2cm from the serosa. This is because the needle holes on the left side of the suture like usually oozes blood. This necessitates several stitches to stop.
In the case of shoulder presentation, the lower segment appears as an inverted standing triangle, with emptiness inside. Only a toothed pickup can locate the correct level of the high incision.

The surgeon incises lightly the lower segment at midline 3cm caudal to the serosal border, pushes away the peritoneal edges, then the superficial and then the deeper layer until the amniotic membranes are exposed, punctures the membranes, suctions out all of the amniotic fluid. He then makes two short uptilt ends, and extends the two ends towards the roots of the round ligaments. He then proceeds to use 4 fingers or a Murless retractor to deliver the fetal head.

How to deliver a large fetal head with little blood loss and no laceration
First make the high uterine incision, then use the Murless extractor to lift up and lift out the head slowly from the existing occipital position. The first assistant helps resuscitation of the new born, the surgeon cuts the umbilical cord, and apply clamps to stop bleeding on the incision edges when necessary.

減少娩兒失血的五緩慢步驟
7頁內容: (一) 模仿經陰分娩步驟達成失血少
(二) “緩慢” 操作減少失血
(三) 但是, “緩慢” 操作只適用于高位水平宮切口
(四) 娩巨大兒, 如何保持高位宮切口完整及失血少

取法 “經陰分娩” 的兩個步驟調整之至適用於剖宮產
傳統足月剖宮產失血多於經陰分娩, 均因沒有取法經陰產時失血少的步驟。 本產術摸清經陰分娩有兩個步驟值得模仿,遂將該兩步驟作適當調整, 移用于剖宮產、達成實現經陰分娩失血少的效果。 下述是調整好的兩個經陰分娩步驟。
(一)經陰分娩是通過產時分時段削減宮腔容積, 調整好的步驟應用于本剖宮產的是 “用足夠時間吸干羊水、用超過您願意用的時間娩胎頭”。
(二)經陰分娩的子宮宮下段是沒有缺口的, 應用于本剖宮產時的調整是娩兒后立馬手取胎盤及急速修復宮切口哄騙子宮其宮下段無缺口。

“緩慢” 操作有利患者
剖宮產期間五個時段逐步減縮宮腔容積至零, 每一個時段僅削減宮腔一部分容積, 每一個時段都要緩慢地完成, 緩慢完成使到宮體尚未進行下一個操作之前獲得短暫歇息, 因而達成實現吸干羊水娩頭娩兒身娩盤后(即縫合宮切口后)、宮體強勢收縮、縮復及結扎受傷血管。
本剖宮產術的緩慢操作是模擬經陰分娩步驟的五個漫長的時段, 例如: 經陰分娩時(一)破羊膜流出羊水的時間是需要數小時的, (二)胎頭需要經過數小時下降至接近陰戶外口, (三)娩胎頭的第二產程, 時間是一小時或超過一小時, (四)胎頭娩出陰戶后, 使用適當時間吸出兒口鼻積液后纔娩兒身也就說明娩兒身是等待抽出腔液后纔完成, 娩兒身絕對不是一兩秒鐘完成的,(五)娩胎盤也要等待宮體擠壓胎盤至陰道頂然后動手的, 亦即是說娩兒后等待3數分腫然后進行的。
可見, 假如模擬和調整好的經陰分娩五個時段步驟和搬它們到剖宮產術: (一)提供小U形宮切口及20s~90s時間吸淨前后羊水, (二)右手4手指緩緩地插進宮下段宮腔, 4s~6s緩慢地張開切口至雙頂徑值, 和以>30s時間上提胎頭至宮切口水平, 助手同時以>10s時間向母臍上拉切口上緣中部, (三)給予>20s或按情況更長時間娩胎頭出宮腹兩切口, 為的是給予切口充裕時間擴大而不致裂傷, 及讓宮腹兩切口擠壓兒面、口、鼻, (四)邊提供>10s娩出兒身、助手邊吸口鼻, (五)等待胎盤邊緣出現宮切口或其外纔開始娩胎盤, 上述五時段做法就能避免娩盤后假象宮縮乏力出現致失血≧450ml, 實踐體驗, 失血量減少至<300ml。
但是, 如果術者採用本產術的高位宮切口, 失血量更少。

實施宮下段高位切口取得失血少
用有齒鑷子尋找 和打開宮下段高位U切口的橫向切口水平 (見左圖右圖、中圖顯示宮切口癒合口由肌肉組成), 橫向裁開漿膜界線下

3cm宮下段中部臟腹膜、表肌層≦4cm, 隨即用剪刀或刀柄頭推開其下的肌層直達胎膜、破膜、插入吸頭、一助邊手指上提宮腹兩切口上緣或按壓封閉直腸旁側溝入口、二助邊用負壓吸管吸干前后羊水, 再在短橫切口的兩端往上裁開長<2cm的豎臂, 插入4手指至胎頭之下、向宮底上提之直至顱頂平切口水平, 讓兒耳頭髮或皮膚暴露枕位置(見上頁右照片) 。

如何減少失血的娩兒法或娩巨大兒大胎頭取得失血少與不裂傷宮切口
這就是即四手指提頭至宮切口水平叫停、轉用單葉產鉗緩慢地從容地以原枕位或枕前位娩胎頭, 一助復蘇新生兒、主術者同步剪臍帶、隨即鉗夾切口下緣出血點及按情術前給抗生素。
示範病例
1994年筆者受郎景和教授邀請到北京協和醫院作剖宮產示範手術, 孕产妇是东北人, 其腹形已清楚顯示胎儿体重>4 Kg, 以及腹壁脂肪層特別厚。 由于麻醉师习惯施行硬膜外麻醉, 而筆者习惯在全麻下娩胎儿, 麻醉師特別破例施行全麻, 可惜術中腹直肌很绷緊, 儿頭也已入盆還未到中盆。 在這逆境下, 筆者提醒自己按 “3缓慢” 綜合步驟進行操作, 即 “緩慢” 地上提胎头出子宫切口才是今天避免裂傷切口和減少失血的上策。 于是, 首先切开一個 “胎頭大小都能通用的” 腹壁切口, 即脂肪層切口超級大, 一邊緩緩地切開高位子宫切口至差不多接近7cm~8cm寬度, 一邊吸淨前后羊水, 然后向宮底方向上提胎头 (不是 “撬起” 胎頭) 至高位切口水平為止() 在宫切口水平停下来的原因是, 高位宫切口水平在耻骨联合上缘之上, 耻骨联合可作娩胎头时的槓桿支点。
, 四手指上提的力度以抵擋住胎頭不會下移為度, 然后靜待后續宮縮的發生, 由于手指擋住了胎頭下降的通道, 胎枕只有緩緩地仰伸, 并推壓子宫切口上缘, 使之逐漸擴大, 時經差不多60s (拖延時間的意義是: 一廂情願地逐漸解壓、激活宮縮與縮復力, 增加娩盤后子宮縮復力與減少失血), 胎頭就通過了子宮切口, 進入子宮体与下腹壁之間的空間, 繼之胎頭便娩出了腹壁切口。 術中宮腔失血小, 高位切口无裂伤。 新生儿重4.3 Kg, Apgar評分10 分, 遺憾的是當時忘記查問新生儿的枕额周邊值尺碼。 但是, 如此巨大的胎儿能在沒有任何按壓宮底及用力牽拉腹壁切口上緣兩側緣等的外力輔助情况下, 能自然完成各机轉動作而順利娩出且得滿分, 足以證明筆者之創意的鮮明效益。
联想到胎頭從宮切口娩出的全部過程, 酷似產時子宮破裂——子宫颈口未开全, 或者骨产道狭窄。 雖有足夠強的子宫收缩力, 因为無法通過产道, 胎儿只好經由子宮下段前壁的破口鑽出至腹腔內。
上述病例成功的關键在于：①提前提供一個 “胎頭大小都能通過的” 脂肪層及肌腱層切口, 即本著下腹壁低位橫切口。 ②吸淨前后羊水, 便利子宮体在降低容積的情況下啟動宮縮, 并充分发挥收縮力下推胎頭。③ 膀胱尿瀦留過多過久會使到膀胱排尿乏力, 巨大兒作產期過長也使到第三產程產后宮縮乏力, 兩者都需要一些時間讓肌肉逐漸恢復功能。 是次手術過程通過分開數段時間 (吸干前后羊水、擴大切口、娩頭) 緩慢地使宮腔逐漸地減少容積, 激活了一鼓作氣的宮縮及持續的縮復力。 ④4手指擋住胎頭前往陰道的去路, 引領胎枕改道向前及緩慢的仰伸, 得以擴大子宮切口上緣, 从而娩出子宮切口。 此處有一個重要問題, 那就是, 如果延伸宮切口下缘就成为裂伤子宫切口两端的因素。
可以得到的結論是, 不論胎儿是否巨大, 使胎頭先行娩出至子宫切口外, 然后再娩頭出腹壁切口, 永遠有利母嬰无害子宮。 也可以说, 不讓胎頭在同一時間內通過宮、腹兩切口是 “弃车保帅” ( “车” 指同一時間娩头出两切口, “帅” 指不致裂伤子宫切口) 的手段, 其有利之处在于胎頭首先通過子宮切口, 可以立馬擺脫了胎儿缺氧的危险和产道感染因素的蔓延。 同時, 又由于胎頭已娩出至子宮切口之外, 撬胎頭的步驟也再不需要了, 也再不存在實施雙葉產鉗及手轉胎頭致裂伤子宮切口的危險, 因操作不是在子宮下段內。 极少情况下如發現腹壁切口狹窄, 只在子宮腔外實施雙葉產鉗, 数秒钟之內便會將胎頭娩出腹壁切口。
上述的一切是本著剖宮產術的縮影。 抓住它的神韻, 可以在行施手術時增加對母嬰的好處。
請注意, 筆者說娩頭過程需要差不多60s, 目的是强调必须緩慢地娩胎頭出宫切口的實質, 不過, 90%以上胎頭枕额周邊值≧34cm~≦36cm的娩出, 都不需要等待如此漫長的時間。 另外, 前面所说的高位切口术中失血小、无裂伤, 但是, 倘若娩出儿頭過急, 切口裂伤和失血過多仍難免, 而且后續修補和清理操作所需的時間會更長。 何況裂傷的范圍大小難卜。 胎儿体重≧3.7 Kg的, 枕額周徑≧36cm的胎頭肯定需要依赖緩慢娩头减少失血量和切口裂伤。 按上述過去筆者在香港特區行行施剖宮產的孕產妇群, 如例行緩慢地娩头, 每例都成功减少失血量和切口裂伤, 結论是, 不論胎頭大小都需要缓慢娩出。
还有, 成功上提胎頭需要依賴一个重要因素, 那就是, 身高160cm手术者娩头时必須站在一块踏板上, 創造一個環境, 增加自身高度, 让手指与手掌成直角, 而手掌和上下手臂形成一直线, 當身軀側彎向手術台台頭時, 身軀就帶動手臂手指上提胎頭。