教學(xué)查房（產(chǎn)后出血）

教學(xué)查房產(chǎn)后出血TeachingroundsPostpartumhemorrhage目錄CATALOGUE01病歷資料

Medicalrecords02概述Overview03病因及發(fā)病機(jī)制Etiologyandpathogenesis04臨床表現(xiàn)Clinicalpresentation05對母兒的影響

Impactonmotherandchild06處理原則

PrinciplesofProcessing07護(hù)理

Nursing08健康宣教

Healtheducation01病例資料MedicalrecordsPART現(xiàn)病史：患者歐萍，38歲，已婚，孕37+2周，因胎兒宮內(nèi)發(fā)育受限收住產(chǎn)科。G2P2（孕2產(chǎn)2），有剖宮產(chǎn)史，此次因“疤痕子宮”行剖宮產(chǎn)術(shù)。術(shù)中出現(xiàn)胎盤娩出后子宮收縮差、滲血明顯的情況，經(jīng)處理后子宮收縮好轉(zhuǎn)，出血停止。生命體征：T:36.4℃，：P:110次/分，R：20次/分，BP：140/80mmHgSPO2:96%。Presentillnesshistory:PatientOuPing,38yearsold,married,37+2weekspregnant.Shewasadmittedtotheobstetricsdepartmentduetofetalintrauterinegrowthrestriction.G2P2(twopregnanciesandtwodeliveries).Shehasahistoryofcesareansection.Thistime,cesareansectionwasperformeddueto"scarreduterus".Duringtheoperation,aftertheplacentawasdelivered,theuterinecontractionwaspoorandtherewasobviousoozingofblood.Aftertreatment,theuterinecontractionimprovedandthebleedingstopped.Bodytemperature:T:36.4°C,pulse:110beats/min,respiration:20beats/min,bloodpressure:140/80mmHgSPO296%.病歷資料Medicalrecords術(shù)中液體入量：晶體液2800m1，膠體液1000m1，輸紅細(xì)胞800m1，血漿600m1；出量：出血1600mI,尿量60m1。因患者為高危孕產(chǎn)婦，術(shù)中失血量大，循環(huán)不穩(wěn)，以“產(chǎn)后大出血、剖宮產(chǎn)術(shù)后”收入我科加強(qiáng)監(jiān)護(hù)治療。輔助檢查：入室血?dú)夥治鍪荆簆H7.309，p02130mmHg，pCO233.6mmHg，ABE-8.5mmol/L，K+3.5mmo1/L，Na+142mmo1/L,Ca2+1.08mmo1/L,C1-116mmol/LGlu8.0mmol/L,Lac2.5mmol/L,tHb111g/L。

Intraoperativefluidintake:crystalloids2800m1,colloids1000m1,redbloodcelltransfusions800m1,plasma600m1;Output:bleeding1600mI,urinevolume60m1。Becausethepatientwasahigh-riskpregnantwoman,withalargeamountofintraoperativebloodlossandunstablecirculation,shewasadmittedtoourdepartmentforintensivemonitoringandtreatmentwith"postpartumhemorrhageandpost-cesareansection".

Auxiliaryexamination:in-roombloodgasanalysisshows:pH7.309，p02130mmHg，pCO233.6mmHg，ABE-8.5mmol/L，K+3.5mmo1/L，Na+142mmo1/L,Ca2+1.08mmo1/L,C1-116mmol/LGlu8.0mmol/L,Lac2.5mmol/L,tHb111g/L。

手術(shù)經(jīng)過Surgery輸血記錄術(shù)中特向輸血科電請A型R陽性懸浮紅細(xì)胞4U，冰凍血漿600m1，實(shí)發(fā)A型Rh陽性懸浮紅細(xì)胞紙，冰凍血漿600m1。開始輸冰凍血漿時間:2024-08-31

12:55；輸血15分鐘后，患者T36.80，HR98bpm，BP130/80mmHg(血管活性藥物泵入中),氧飽97-99%(呼吸機(jī)輔助呼吸），輸冰凍血漿結(jié)束時間:2024-08-31

13:55;開始輸懸浮紅細(xì)胞時間:13:05，輸懸浮紅細(xì)胞結(jié)束時間:2024-08-3115:25:輸血結(jié)束時的效果評價:2024-08-31血細(xì)胞分析:血紅蛋曲109g/L,纖溶檢測(D2+FDP-ATI):D-一聚體4.7ug/m1(DDU),纖維蛋白原2.46g/L.陰道少量出血，盆腔引流管無明顯引流液流出，臨床評估輸血治療有效，動態(tài)監(jiān)測血常規(guī)凝血、引流液及陰道出血情況，必要時再次申請血液制品輸注。整個輸血過程患者無發(fā)熱思寒，寒戰(zhàn)、醬油色尿等不良反應(yīng)。Duringtheoperation,thebloodtransfusiondepartmentspeciallyrequested4UoftypeARpositivesuspensionredbloodcellswith600m1offrozenplasma,and600m1offrozenplasmafromtheactualtypeARhpositivesuspensionredbloodcellpaper.Timeofstartoffrozenplasmatransfusion:2024-08-3112:55;15minutesafterbloodtransfusion,thepatientT36.80,HR98bpm,BP130/80mmHg(vasoactivedrugpumping),oxygensatiety97-99%(ventilator-assistedbreathing,endtimeoffrozenplasmatransfusion:2024-08-3113:55;Timeofstartofsuspensionredbloodcelltransfusion:13:05,endtimeofsuspensionredbloodcelltransfusion:2024-08-3115:25:Evaluationoftheeffectattheendofbloodtransfusion:2024-08-31Bloodcellanalysis:bloodredeggkoji109g/L,fibrinolysisdetection(D2+FDP-ATI):D-monomer4.7ug/m1(DDU),fibrinogen2.46g/L.Minorvaginalbleeding,noobviousdrainagefluidoutflowfromthepelvicdrainagetube,clinicalevaluationoftheeffectivenessofbloodtransfusiontreatment,dynamicmonitoringofbloodroutinecoagulation,drainagefluidandvaginalbleeding,andre-applicationforbloodproducttransfusionifnecessary.Duringthewholebloodtransfusionprocess,thepatienthadnoadversereactionssuchasfever,chills,chills,andsoysauce-coloredurine.02產(chǎn)后大出血概述OverviewofpostpartumhaemorrhagePART產(chǎn)后出血［1］是指胎兒娩出后24小時內(nèi)，陰道分娩產(chǎn)婦出血量≥500ml剖宮產(chǎn)術(shù)分娩產(chǎn)婦出血量≥1000ml，或者失血后伴有低血容量的癥狀或體征。Postpartumhemorrhagereferstovaginaldeliverywithamaternalbleedingvolumeof≥500mLwithin24hoursofdelivery,andamaternalbleedingvolumeof≥1000mLduringcesareansectiondelivery,orbloodlossaccompaniedbysymptomsorsignsofhypovolemia.定義definition定義與發(fā)病率Definitionandincidence定義與發(fā)病率Definitionandincidence發(fā)病率morbidity產(chǎn)后出血(postpartumhemorrhage,PPH)是分娩期嚴(yán)重的并發(fā)癥，是孕產(chǎn)婦死亡四大原因之首，在全世界占孕產(chǎn)婦死亡的1/4［2-3］。每年全球約有150000名產(chǎn)婦死于產(chǎn)后出血。2021年我國陰道分娩PPH率為3.26%［4］。我國的孕產(chǎn)婦死亡率在逐年下降，平均每年下降約5.3%［5］。在產(chǎn)科出血所致的孕產(chǎn)婦死亡中，由產(chǎn)后出血所致者超過半數(shù)［6］。Postpartumhemorrhageisaseriouscomplicationduringchildbirthandthefirstofthefourleadingcausesofmaternaldeath,accountingforone-quarterofmaternaldeathsworldwide.Approximately150,000womendiefrompostpartumhaemorrhageeachyear.In2021,thePPHrateofvaginalbirthinChinawas3.26%.Thematernalmortalityrateinourcountryisdecreasingyearbyyear,withanaverageannualdeclineofabout5.3%。Postpartumhemorrhageaccountsformorethanhalfofmaternaldeathsduetoobstetrichaemorrhage.1.宮縮乏力性出血Uterineatonybleeding由于產(chǎn)程過長、子宮過度膨脹等因素導(dǎo)致子宮收縮乏力。Uterinecontractionisweakduetofactorssuchasprolongedlaborandexcessiveuterinedistension.2.胎盤因素出血Bleedingfromplacentalfactors包括胎盤滯留、胎盤植入、胎盤部分殘留等。Includingplacentalretention,placentaaccreta,partialplacentalremnant,etc.產(chǎn)后出血的“４Ｔ”原因［7］："4T"causesofpostpartumhemorrhage3.軟產(chǎn)道裂傷出血Bleedingfromalacerationofthesoftbirthcanal由于胎兒過大、急產(chǎn)等因素導(dǎo)致會陰、陰道、宮頸等軟產(chǎn)道裂傷。Lacerationoftheperineum,vagina,cervixandothersoftbirthcanalsduetofactorssuchasfetalsizeandprematurebirth.4.凝血功能障礙性出血Coagulopathicbleeding由于血液疾病、肝功能異常等因素導(dǎo)致凝血功能障礙。Coagulationdysfunctionduetofactorssuchasblooddisorders,abnormalliverfunction,etc.目前只能通過針對這“４Ｔ”的高危因素予以篩查、評估，對高、中、低風(fēng)險做出分層管理。03病因及發(fā)病機(jī)制EtiologyandpathogenesisPART病因及發(fā)生機(jī)制EtiologyandpathogenesisPPH病因復(fù)雜，常見有子宮收縮乏力、胎盤因素、軟產(chǎn)道損傷和凝血功能障礙等。它們之間可互為因果，亦可相互影響。子宮收縮乏力性PPH約占PPH的70%,是PPH的最主要病因［8］。TheetiologyofPPHiscomplex,andthecommononesincludeuterineatony,placentalfactors,softbirthcanalinjury,andcoagulationdysfunction.Theycancauseandeffecteachother,andtheycanalsoinfluenceeachother.UterineatonyPPHaccountsforapproximately70%ofPPHandistheleadingcauseofPPH.1.子宮收縮乏力Uterinecontractionisweak（1）全身因素Systemicfactors產(chǎn)婦精神緊張,體質(zhì)虛弱,合并全身性疾病等。Maternalnervousness,physicalweakness,combinedwithsystemicdiseases,etc.（2）產(chǎn)科因素Obstetricfactors見于產(chǎn)程延長,前置胎盤、胎盤早剝、妊娠期高血壓疾病等妊娠并發(fā)癥。Itisseeninprolongedlabor,placentaprevia,placentalabruption,hypertensivedisordersduringpregnancy,andotherpregnancycomplications.(3)子宮因素Uterinefactors子宮肌纖維過度伸展,如雙胎妊娠、羊水過多、巨大胎兒，子宮壁損傷,如子宮瘢痕、多產(chǎn)、感染、刮宮過度;子宮病變,如子宮發(fā)育不良、乏力畸形或子宮肌瘤。Hyperextensionofuterinemusclefibers,suchastwinpregnancy,polyhydramnios,fetalmacrosomia,uterinewallinjury,suchasuterinescarring,proparity,infection,excessivecurettage;Uterinepathologiessuchasuterinedysplasia,fatiguemalformations,oruterinefibroids.(4)藥物因素Pharmacologicalfactors臨產(chǎn)后過多使用鎮(zhèn)靜劑、麻醉劑或?qū)m縮抑制劑。Excessiveuseofsedatives,anesthetics,ortocolyticsafterlabor.通常胎盤在胎兒娩出后15min內(nèi)娩出，若超過30min胎盤仍不排出，稱胎盤滯留。胎盤未完全剝離或剝離后未及時排出，影響子宮收縮，導(dǎo)致大出血。Usually,theplacentaisdeliveredwithin15minutesafterthefetusisdelivered,andiftheplacentaisnotdischargedafter30minutes,itiscalledplacentalretention.Theplacentaisnotcompletelyabruptorisnotdischargedintimeafterablation,whichaffectsuterinecontractionsandleadstoheavybleeding.（1）胎盤滯留Placentalretention胎盤絨毛在其附著部位與子宮肌層緊密連接，導(dǎo)致胎盤剝離困難，引起大出血。Theplacentalvilliaretightlyconnectedtothemyometriumatthesiteoftheirattachment,makingitdifficultfortheplacentatodetachandcausingmassivebleeding.（2）胎盤植入Placentaaccreta（3）胎盤殘留Residualplacenta2.胎盤因素Placentalfactors胎盤小葉、副胎盤或部分胎膜殘留于宮腔內(nèi)，可影響子宮收縮而出血。Placentallobules,paraplacenta,orpartofthefetalmembranesremainintheuterinecavity,whichcanaffectuterinecontractionsandcausebleeding.分娩過程中可能導(dǎo)致會陰、陰道、宮頸等部位的損傷，引起出血。Duringchildbirth,itcanleadtodamagetotheperineum,vagina,cervixandotherareas,causingbleeding.3.軟產(chǎn)道損傷Injurytothesoftbirthcanal4.凝血功能障礙Coagulationdysfunction

任何原因的凝血功能異常均可導(dǎo)致產(chǎn)后出血。常見于:產(chǎn)科并發(fā)癥、全身凝血功能障礙性疾病。Coagulationabnormalitiesofanycausecanleadtopostpartumhemorrhage.Commonin:obstetriccomplications,systemiccoagulopathy.04臨床表現(xiàn)ClinicalpresentationPART生命體征測量Vitalsignmeasurement生命體征定義與重要性VitalSignsDefinitionandImportance生命體征定義Definitionofvitalsigns生命體征是用來判斷病人的病情輕重和危害程度的指針，主要包括體溫、脈搏、呼吸和血壓。Vitalsignsareindicatorsusedtojudgetheseverityanddegreeofharmofapatient'scondition,mainlyincludingbodytemperature,pulse,respiration,andbloodpressure.重要性importance生命體征的檢測對于及時發(fā)現(xiàn)患者病情變化、評估治療效果以及預(yù)測疾病發(fā)展趨勢具有重要意義，是醫(yī)療護(hù)理工作中不可或缺的一部分。Thedetectionofvitalsignsisofgreatsignificancefortimelydetectionofchangesinpatients'conditions,evaluationoftreatmenteffects,andpredictionofdiseasedevelopmenttrends,andisanindispensablepartofmedicalcare.?？埔曨l1.子宮收縮乏力Uterineatony

（最常見）(mostcommon)

臨床表現(xiàn)：多發(fā)生在產(chǎn)后2小時內(nèi)，陰道出血多，色暗紅，可出現(xiàn)失血性休克；檢查腹部時往往感到子宮輪廓不清，松軟如袋狀，摸不到宮底或?qū)m底升高。治療原則：使用宮縮素、按摩子宮（為常用有效的方法）、宮腔內(nèi)填塞紗布條或結(jié)扎血管Clinicalpresentation:

Itmostlyoccurswithin2hoursaftergivingbirth,withalotofvaginalbleeding,darkredcolor,andhemorrhagicshockmayoccur;

Examinationoftheabdomenoftenshowsthattheuterusisuncontoured,softasapouch,andthefunduscannotbefeltoriselevated.

PrinciplesofTreatment:

Useoftotocin,massageoftheuterus(whichisacommonandeffectivemethod),tamponadeoftheuterinecavity,orligationofbloodvessels2.胎盤因素Placentalfactors

臨床表現(xiàn)：胎盤娩出后檢查胎盤、胎膜，發(fā)現(xiàn)胎盤母體面有缺損或胎膜有缺損而邊緣有斷裂的血管。大量血液自宮腔流出。治療原則：及時將胎盤取出，并做好必要的刮宮準(zhǔn)備Clinicalpresentation:Aftertheplacentaisdelivered,theplacentaandfetalmembranesareexamined,andtheplacentaisfoundtobedefectiveinthematernaldignityLesionsordefectsinfetalmembraneswithrupturedbloodvesselsonthesides.Alargeamountofbloodflowsfromtheuterinecavity.PrinciplesofTreatment:Removetheplacentaintimeandprepareforthenecessarycurettage3.軟產(chǎn)道裂傷Softbirthcanallaceration

臨床表現(xiàn)：胎兒娩出后立即發(fā)生陰道流血，血液鮮紅，能自凝；陰道壁血腫的產(chǎn)婦會有尿頻或肛門墜脹感，且有排尿疼痛；檢查子宮收縮良好，宮頸有裂傷，個別可裂至子宮下段。陰道裂傷多在陰道壁、后壁和會陰部。治療原則：在嚴(yán)格無菌操作下修復(fù)縫合。Clinicalpresentation:Vaginalbleedingoccursimmediatelyafterdeliveryofthefetus,thebloodisbrightredandcanself-coagulate;Womenwithhematomainthevaginalwallmayhavefrequenturinationoranaldistensionandpainfulurination;Checkthattheuterusiswellcontracted,andthecervixiscleft,andinsomecasesitcanbeclefttotheloweruterus.Vaginallacerationsaremorecommoninthevaginalwall,posteriorwall,andperineum.PrinciplesofTreatment:Repairsuturesunderstrictasepticprocedures.4.凝血功能障礙Coagulopathy

臨床表現(xiàn)：孕前或妊娠期已有全身性出血傾向。胎盤剝離或產(chǎn)道有損傷時，出現(xiàn)凝血功能障礙，血不凝、不易止血。產(chǎn)后出血失血嚴(yán)重，休克時間長，可引起希恩綜合征。治療原則：針對不同病因、疾病種類進(jìn)行治療。Clinicalpresentation:pre-pregnancyorpre-existingsystemicbleedingtendency.Whentheplacentaisabruptorthebirthcanalisdamaged,coagulationdysfunctionoccurs,andtheblooddoesnotcoagulateandisnoteasytostopbleeding.Postpartumhemorrhageissevere,bloodlossissevere,andshockisprolonged,whichcancauseSheehansyndrome.PrinciplesofTreatment:Treatmentisprovidedfordifferentcausesandtypesofdiseases.5.陰道流血Vaginalbleeding主要表現(xiàn)為胎兒或胎盤娩出后陰道流血及出現(xiàn)失血性休克等相應(yīng)癥狀。胎盤娩出后間歇性陰道流血較多,色暗紅,子宮軟,輪廓不清,應(yīng)考慮子宮收縮乏力或胎盤、胎膜殘留。胎兒娩出后陰道持續(xù)性流血,色鮮紅,首先考慮軟產(chǎn)道裂傷。陰道持續(xù)流血且血液不凝,或伴身體其他部位出血,有明顯誘因,應(yīng)考慮凝血功能障礙出血。陰道流血不多而失血征象明顯,伴陰道壁疼痛或肛門墜脹感,應(yīng)考慮陰道壁血腫。Itismainlymanifestedbyvaginalbleedingafterdeliveryofthefetusorplacentaandhemorrhagicshockandothercorrespondingsymptoms.Afterdeliveryoftheplacenta,intermittentvaginalbleedingisabundant,darkred,uterinesoft,andthecontourisnotclear,anduterinecontractionorresidualplacentaandfetalmembranesshouldbeconsidered.Persistentvaginalbleedingthatisbrightredafterdeliveryofthefetusisfirstconsideredforalacerationofthesoftbirthcanal.Coagulopathybleedingshouldbeconsideredifthereisanobviouscauseofpersistentvaginalbleedingthatdoesnotcoagulate,orifbleedingfromotherpartsofthebodyispresent.Vaginalwallhematomashouldbeconsideredifvaginalbleedingissmallandthereareobvioussignsofbloodloss,accompaniedbyvaginalwallpainoranaldistention.6.低血壓癥狀產(chǎn)后患者出現(xiàn)頭暈、面色蒼白，若產(chǎn)婦出現(xiàn)煩躁、皮膚濕冷、脈搏細(xì)速、脈壓縮小時，已處于休克早期。Postpartumpatientshavedizzinessandpaleness,andifthemotherisirritable,theskinisclammyandcold,thepulseisthinandthepulseiscompressed,itisalreadyintheearlystageofshock.7.輔助檢查INVESTIGATIONS實(shí)驗(yàn)室檢查Laboratorytests包括血常規(guī)、凝血功能、肝腎功能等，以評估產(chǎn)婦的整體狀況。Includingbloodroutine,coagulationfunction,liverandkidneyfunction,etc.,toevaluatetheoverallconditionofthemother.05對母兒的影響ImpactonmotherandchildPART(1)失血性貧血Hemorrhagicanemia產(chǎn)后大出血導(dǎo)致大量血液流失，引起貧血，嚴(yán)重時可能導(dǎo)致休克。Postpartumhemorrhagecausesalargeamountofbloodtobelost,causinganemiaand,inseverecases,shock.(2)凝血功能障礙Coagulopathy大量失血可能導(dǎo)致凝血因子減少，從而引發(fā)凝血功能障礙Heavybloodlossmayleadtoadecreaseinclottingfactors,whichcanleadtocoagulationdysfunction.Pooruterinerejuvenation。(3)子宮復(fù)舊不良Pooruterinerejuvenation由于大出血，子宮可能無法有效收縮，導(dǎo)致子宮復(fù)舊不良。Duetoheavybleeding,theuterusmaynotbeabletocontracteffectively,resultinginpooruterinerejuvenation.1.對產(chǎn)婦的生理影響Physiologicaleffectsonthemother1.對產(chǎn)婦的生理影響Physiologicaleffectsonthemother(3)席漢綜合征Sheehansyndrome產(chǎn)后出血可造成垂體缺血壞死，出現(xiàn)不能泌乳、閉經(jīng)和第二性征減退、甲狀腺功能減退和腎上腺皮質(zhì)功能不足等臨床表現(xiàn)。Postpartumhemorrhagecancausepituitaryavascularnecrosis,andclinicalmanifestationssuchasinabilitytolactate,amenorrhea,hyposexuality,hypothyroidism,andadrenalinsufficiencymayoccur.(4)子宮切除Hysterectomy當(dāng)產(chǎn)后出血量大于2000ml時，切除子宮是治療的有效措施之一。但會導(dǎo)致將來不育以及相關(guān)術(shù)后并發(fā)癥等風(fēng)險。Whentheamountofpostpartumbleedingisgreaterthan2000ml,removaloftheuterusisoneoftheeffectivemeasuresfortreatment.However,itcanleadtoriskssuchasfutureinfertilityandrelatedpostoperativecomplications.產(chǎn)后大出血可能導(dǎo)致產(chǎn)婦出現(xiàn)焦慮和恐懼情緒，擔(dān)心自身健康和生命安全。Postpartumhemorrhagemaycauseanxietyandfearformothers,fearingfortheirhealthandsafety.(1)焦慮和恐懼Anxietyandfear大出血可能導(dǎo)致產(chǎn)婦出現(xiàn)情緒波動，如情緒低落、易怒等，嚴(yán)重時可能導(dǎo)致產(chǎn)后抑郁。Heavybleedingmaycausemoodswings,suchasdepressedmood,irritability,etc.,andinseverecases,itmayleadtopostpartumdepression.(2)情緒波動Moodswings由于焦慮和身體不適，產(chǎn)婦可能出現(xiàn)失眠和記憶力減退等問題。Duetoanxietyandphysicaldiscomfort,womenmayexperienceproblemssuchasinsomniaandmemoryloss.(3)失眠和記憶力減退Insomniaandmemoryloss2.對產(chǎn)婦的心理影響Psychologicaleffectsonmothers導(dǎo)致新生兒缺血缺氧，進(jìn)而影響腦部發(fā)育。Thisleadstoischemiaandhypoxiainnewborns,whichinturnaffectsbraindevelopment.(1)缺血缺氧性腦病Ischemic-hypoxicencephalopathy導(dǎo)致新生兒低血糖。Causesneonatalhypoglycemia(2)低血糖hypoglycemia導(dǎo)致母體感染，從而增加新生兒感染和早產(chǎn)的風(fēng)險。Causesmaternalinfection,whichincreasestheriskofinfectionandpretermbirthinnewborns.(3)感染和早產(chǎn)Infectionandpretermbirth3.對新生兒的影響Effectsonnewborns產(chǎn)后出血發(fā)生后，產(chǎn)婦循環(huán)血量減少，母乳分泌時間延后，乳量減少。Aftertheoccurrenceofpostpartumhemorrhage,theamountofcirculatingbloodinthemotherdecreases,thetimeofbreastmilksecretionisdelayed,andthemilkvolumedecreases.(4)母乳缺乏Lackofbreastmilk06處理原則PrinciplesofProcessingPART處理原則

針對出血原因，迅速止血；補(bǔ)充血容量，

糾正失血性休克；防止感染

Rapidhemostasisforthecauseofbleeding;

replenishbloodvolumeandcorrecthemorrhagicshock;

Preventinfection及時補(bǔ)充血容量，預(yù)防休克。Timelybloodvolumereplacementtopreventshock.建立靜脈通道Establishintravenousaccess給予氧氣吸入，監(jiān)測血氧飽和度。Oxygeninhalationisgivenandoxygensaturationismonitored.保持呼吸道通暢Keepyourairwaysopen包括出血的量、速度和產(chǎn)婦的生命體征等Thisincludestheamountandspeedofbleedingandthemother'svitalsigns.迅速評估出血情況Rapidassessmentofbleeding迅速查找出血原因，如子宮收縮乏力、胎盤因素等Quicklylookforthecauseofbleeding,suchasuterineatony,placentalfactors,etc.查找出血原因Findthecauseofthebleeding1.處理措施Measures使用宮縮劑促進(jìn)子宮收縮，減少出血，如縮宮素、麥角新堿等。麥角新堿，0.2-0.4mg肌內(nèi)注射，有惡心嘔吐和胸痛，高血壓或心血管疾病患者禁用。Useuterotonicstopromoteuterinecontractionsandreducebleeding,suchasoxytocin,ergometrine,etc.Ergometrine,0.2-0.4mgintramuscularly,iscontraindicatedinpatientswithnausea,vomitingandchestpain,hypertensionorcardiovasculardisease.宮縮劑Uterotonics止血藥Hemostaticdrugs抗生素antibiotic對于凝血功能障礙或纖溶亢進(jìn)者，可使用止血藥Inpatientswithcoagulopathyorhyperfibrinolysis,hemostaticdrugsmaybeused.。預(yù)防性使用抗生素，降低感染風(fēng)險。Antibioticsareusedprophylacticallytoreducetheriskofinfection.2.藥物治療方案選擇Choiceofdrugregimen保守治療無效Conservativetreatmentisineffective如宮縮劑、止血藥等保守治療無效，出血持續(xù)增多，應(yīng)及時手術(shù)治療。Ifconservativetreatmentsuchasuterotonicsandhemostaticdrugsisineffective,andbleedingcontinuestoincrease,surgicaltreatmentshouldbeperformedintime.手術(shù)方式選擇Choiceofsurgicalmodality根據(jù)出血原因和病情嚴(yán)重程度，選擇適當(dāng)?shù)氖中g(shù)方式，如子宮壓縮縫合術(shù)、子宮動脈栓塞術(shù)等。Dependingonthecauseofbleedingandtheseverityofthecondition,appropriatesurgicalmethodssuchasuterinecompressionsuture,uterinearteryembolization,etc.手術(shù)時機(jī)Timingofsurgery一旦決定手術(shù)，應(yīng)盡早進(jìn)行，以減少出血和并發(fā)癥的發(fā)生Oncesurgeryisdecided,itshouldbedoneasearlyaspossibletoreducebleedingandcomplications。3.手術(shù)治療Surgicaltreatment07護(hù)理NursingPART1.護(hù)理診斷Nursingdiagnosis一、組織灌注量不足相關(guān)因素：產(chǎn)后大出血導(dǎo)致血容量減少。表現(xiàn)：血壓140/80mmHg（需警惕后續(xù)血壓下降），心率110次/分偏快，術(shù)中出血量1600ml，尿量60ml偏少，血?dú)夥治鍪続BE-8.5mmol/L提示代謝性酸中毒可能與組織灌注不足有關(guān)，tHb111g/L提示有失血情況。二、氣體交換受損風(fēng)險相關(guān)因素：術(shù)中失血量大可能影響機(jī)體氧合。表現(xiàn)：目前血氧飽和度96%，但仍需警惕因失血引起的組織缺氧導(dǎo)致氣體交換受損。1.InsufficienttissueperfusionAssociatedfactors:Volumedepletionduetopostpartumhaemorrhage.Manifestations:bloodpressureof140/80mmHg(needtobevigilantforsubsequentbloodpressuredrops),rapidheartrateof110beats/minute,intraoperativebloodlossof1600ml,urineoutputof60mlislow,bloodgasanalysisshowsABE-8.5mmol/Lsuggestsmetabolicacidosismayberelatedtotissuehypoperfusion,tHb111g/Lsuggestsbloodloss.2.RiskofdamagetogasexchangeAssociatedfactors:Largeintraoperativebloodlossmayaffectoxygenation.Presentation:Despiteacurrentoxygensaturationof96%,thereisstillaneedtobesuspiciousofimpairedgasexchangeduetotissuehypoxiaduetobloodloss.三、有感染的風(fēng)險相關(guān)因素：剖宮產(chǎn)手術(shù)創(chuàng)傷、術(shù)中失血量大致機(jī)體抵抗力下降。表現(xiàn)：目前無明顯感染征象，但高危孕產(chǎn)婦、手術(shù)及大量失血為感染的潛在危險因素。四、焦慮/恐懼相關(guān)因素：病情危重，對自身及胎兒健康擔(dān)憂。表現(xiàn)：患者可能出現(xiàn)緊張不安、情緒低落等表現(xiàn)。五、潛在并發(fā)癥：休克、DIC相關(guān)因素：產(chǎn)后大出血，循環(huán)不穩(wěn)。表現(xiàn)：需密切觀察患者生命體征、凝血功能等指標(biāo)，以早期發(fā)現(xiàn)休克、DIC的發(fā)生。1.護(hù)理診斷Nursingdiagnosis3.ThereisariskofinfectionAssociatedfactors:Traumaofcesareansectionsurgery,intraoperativebloodloss,anddecreasedbodyresistance.Presentation:Therearenoobvioussignsofinfection,buthigh-riskpregnantwomen,surgery,andmassivebloodlossarepotentialriskfactorsforinfection.4.Anxiety/FearAssociatedfactors:Criticalillness,concernaboutthehealthofthepatientandthefetus.Presentation:Patientsmaypresentwithnervousness,anxiety,anddepressedmood.5.Potentialcomplications:shock,DICAssociatedfactors:postpartumhemorrhage,circulatoryinstability.Manifestations:Vitalsigns,coagulationfunctionandotherindicatorsshouldbecloselyobservedtodetecttheoccurrenceofshockandDICearly.一、病情觀察

密切觀察產(chǎn)婦生命體征，如血壓、心率、呼吸等，以及陰道流血量。二、液體管理

根據(jù)出血量及時補(bǔ)充血容量，糾正貧血和休克狀態(tài)。三、促進(jìn)子宮收縮

遵醫(yī)囑使用促進(jìn)子宮收縮的藥物，如縮宮素等，定時按摩子宮，促進(jìn)子宮收縮，觀察子宮硬度、輪廓及陰道出血量。四、飲食護(hù)理

術(shù)后暫禁食，待腸蠕動恢復(fù)后給予流質(zhì)飲食，逐漸過渡到半流質(zhì)和普通飲食。飲食宜清淡、易消化、富含營養(yǎng)2.護(hù)理措施Caremeasures1.Carefulobservationofmaternalvitalsigns,suchasbloodpressure,heartrate,breathing,andvaginalbleeding.2.Accordingtotheamountofbleeding,replenishbloodvolumeintimetocorrectanemiaandshock.3.Usedrugssuchasoxytocinaccordingtothedoctor'sadvice,massagetheuterusregularlytopromoteuterinecontraction,andobservethehardness,contourandvaginalbleedingoftheuterus.4.Patientscan'teatafteroperation,andeatliquiddietafterrecovery,andgraduallytransitiontosemi-liquidandordinarydiet.Dietshouldbelight,digestibleandnutritious.五、活動指導(dǎo)

術(shù)后早期協(xié)助患者翻身，鼓勵患者進(jìn)行床上活動，預(yù)防下肢靜脈血栓形成。避免劇烈運(yùn)動和重體力勞動。六、預(yù)防感染

保持會陰部清潔，預(yù)防產(chǎn)褥期感染。觀察體溫變化，若出現(xiàn)發(fā)熱等感染征象，及時報(bào)告醫(yī)生并協(xié)助處理。七、心理護(hù)理

與患者溝通了解心理狀態(tài)，給予心理支持和安慰，減輕其焦慮與恐懼2.護(hù)理措施Caremeasures5.Patientsshouldbeassistedtoturnoverearlyafteroperation,andencouragedtodobedexercisestopreventvenousthrombosisoflowerlimbs.Avoidstrenuousexerciseandheavyphysicallabor.6.Keeptheperineumcleantopreventinfection.Observethechangeofbodytemperature,reporttothedoctorintimeandassistinhandlingifthereisfever.7.Communicatewithpatientstounderstandtheirpsychologicalstate,encouragethemandrelievetheiranxietyandfear.3.護(hù)理評價Nursingevaluation1、產(chǎn)婦出血癥狀減輕或消失，生命體征正常。2、產(chǎn)婦感染得到防治，體溫正常。3、能夠積極配合完成手術(shù)，子宮收縮好轉(zhuǎn)，出血停止。4、恐懼得到緩解，能積極配合治療與護(hù)理。1.Thesymptomsofmaternalbleedingarereducedordisappeared,andthevitalsignsarenormal.2.Maternalinfectionispreventedandbodytemperatureisnormal.3.Beabletoactivelycooperatewiththecompletionoftheoperation,theuterinecontractionwillimprove,andthebleedingwillstop.4.Fearisalleviated,andyoucanactivelycooperatewithtreatmentandnursing.08健康宣教HealtheducationPART1.產(chǎn)前教育Prenataleducation孕期保健知識：告知孕婦定期產(chǎn)檢的重要性，通過產(chǎn)檢可及時發(fā)現(xiàn)如胎盤異常、妊娠期高血壓疾病等可能導(dǎo)致產(chǎn)后出血的高危因素，并采取相應(yīng)的預(yù)防措施。Healthcareknowledgeduringpregnancy:Informpregnantwomenoftheimportanceofregularprenatalcheck-ups,throughwhichhigh-riskfactorssuchasplacentalabnormalitiesandhypertensivediseasesduringpregnancycanbedetectedintime,andcorrespondingpreventivemeasurescanbetaken.鼓勵孕婦適度運(yùn)動，如散步、孕婦瑜伽等，增強(qiáng)體質(zhì)，但要避免劇烈運(yùn)動和重體力勞動，以利于順利分娩。Encouragepregnantwomentoexercisemoderately,suchaswalking,yogaforpregnantwomen,etc.,toenhancetheirphysicalfitness,butavoidstrenuousexerciseandheavyphysicallabortofacilitateasmoothdelivery.2.產(chǎn)后教育Postpartumeducation告知產(chǎn)婦及其家屬產(chǎn)后出血的主要表現(xiàn)，如陰道出血量增多、出血速度快、血液顏色鮮紅等，以及出現(xiàn)頭暈、心慌、出冷汗、呼吸急促等癥狀可能是產(chǎn)后出血的信號，應(yīng)立即通知醫(yī)護(hù)人員。Informthemotherandherfamilyofthemainmanifestationsofpostpartumhemorrhage,suchasincreasedvaginalbleeding,rapidbleeding,brightredblood,etc.,aswellasdizziness,palpitation,coldsweat,shortnessofbreathandothersymptomsmaybesignsofpostpartumhemorrhage,andshouldimmediatelynotifythemedicalstaff.3.