胎心监护仪文档

胎心监护仪文档 F6系列胎儿母婴监护仪 第二人民医院妇产科 胎儿母婴监护仪用于产前检查，监护临产和分娩中孕妇死亡各项生理参数。可以连续观察胎心率，并且可同时测出宫缩压力和胎动次数。我科自2013年10月起，把胎儿母婴监护仪用于产程连续监测，即产妇进入活跃期宫口扩张3cm以上，给予胎儿监护仪监护直至胎儿娩出，简称全产程监护。此项工作开展以来，在降低新生儿窒息，减轻医护人员的工作量，提高产科质量方面效果显著。现报道如下。 1 临床资料 1.1 对象 产妇50名。年龄25,30岁，孕周38,41周，系统进行产前检查，无高危因素的产妇。 1.2 方法 产妇宫口大于3cm，给予电子胎心监护。以两条较宽的弹性皮带，将宫缩探头固定于母亲腹部胎心音最清晰处。监测器接受讯号后，屏幕可显示胎心率及宫缩压力。 2 护理 2.1 监护前护理 2.1.1 评估 仔细阅读病史，了解产前检查的情况及产妇的一般情况，如:年龄、孕产次、异常孕产史、家族史、既往史等。给予常规的产前检查，根据宫口扩张、子宫收缩的情况判断是否进入第一产程活跃期。 2.1.2 物品准备 检查胎儿母婴监护仪性能的完好性，放入描纸，准备好透明凝胶(用于增加胎心音的传导)，两条宽的弹性皮带。 2.1.3 产妇准备 嘱其排空膀胱，解开腰带，半卧位，可适当改变体位。 2.2 心理护理 由于职业关系，对医护人员司空见惯的监护仪，对产妇来说却十分陌生。如果不加解释，就在产妇腹部捆上有电线的接头，会引起产妇惊恐不安，或躁动，或拒绝使用.因此在使用前，应运用通俗易懂，准确精练的语言，向产妇及其家属介绍胎心监护仪的有关知识、监护方法及其优点。尤其需要强调胎儿监护仪对胎儿和母亲无任何创伤，使产妇有良好的心态和积极的态度来配合监护。 coupling Centre shall be checked, the second poured concrete strength of more than 70%. In the process of reaming or boring, apart from the special provisions in factory, does not allow any work that may affect the coupling Centre, such as irrigation, to cylinder connections to flood the condenser pipes and so on. Well boring, hinge bolt hole flange with coupling of vertical, not oblique. Mounting bolts should be added lubricants, typing gently with a small hammer, not too loose or too tight, packed the bolts with the corresponding seal screw hole should be marked. 6.4.5.4.2 coupling reamed and pairings is close to the diameter of bolt bearing good hinge holes, dressed with a good two coupling bolts before you can move the rotor, boring-reaming hole in turn. Coupling bolts must be tight coupling is symmetrical diameter, in boring, reaming, two bolts out. Well boring, hinge bolt hole flange with coupling of vertical, not oblique. Due to the coupling bolts in accordance with hinge holes corresponding to the diameter of the screw holes one by one after processing, processing back bolt installation location cannot be changed, so according to bolt after the actual weight difference of nut and lock washer to match. General requirements for coupling two symmetrical diameter bolt, nut and lock washer's total weight difference should not be greater than 10 g and knocks stamped mark. (See Figure 18) The coupling bolts apply lubricant, and then gently with copper home, not too loose or too tight. Bolt Assembly is finished, symmetrical tightening all bolts to 30%, 50%, 70%, 100% force, and check the coupling flutter and before connecting the circle gradually changes its value should be less than 0.02mm. Tightening torque of the coupling bolts shall comply with the technical requirements manufacturers drawings, with a dynamometric wrench or log tension tools. Three wheel rotor swing test coupling connections should be checked: taking leave, 2.3 监护观察及护理 正常胎心率为120,160次/min，如果超出正常范围，结合与子宫收缩的关系，可分为增速，早期减速，晚期减速，变异减速。在监护过程中，护士应该密切注意胎心变化，如有异常，立即汇报医师，并且积极配合医师，改善胎儿宫内缺氧状况。 2.3.1 改变产妇体位 产程中，产妇可采用左侧卧位，或膝胸卧位，此体位可以解除对脐带的压迫，改善脐带的血流，增加子宫胎盘的灌流量。 2.3.2 氧气的吸入 双鼻腔导管给氧法，每分钟3L，增加母体血液氧分压，使氧气易进入胎儿循环，改善胎儿缺氧。 2.3.3 减弱宫缩 停用催产素，或者给予宫缩减缓药物，如硫酸镁等。 2.3.4 纠酸补液 遵医嘱用药，纠正胎儿酸中毒。 2.3.5 协助医师迅速结束分娩。 3 讨论 3.1 优点 3.1.1 提高出生人口质量 随着产程的进展，宫缩逐渐增强，潜在的胎儿缺氧也逐渐暴露，产时缺氧可造成胎儿死亡，或造成胎儿永久性中枢神经损害。使用产时连续性电子胎心监护，可以尽早发现胎儿缺氧，尽早采取相关医护措施，改善缺氧状况，减少出生婴儿窒息率，达到优生优育的目的。 3.1.2 缓解产妇紧张心理 让产妇及家属连续听到腹中宝宝的心跳声，使产妇安心、放心，并且可以使其产生强烈责任感，更好的配合医疗护理。 3.1.3 提高工作质量，降低工作强度 医护人员不必定时听胎心，只要观察屏幕显示的胎心数字及宫缩压力来进行工作，既准确又节省人力。 3.1.4 提高助产士的业务知识水平 由于电子胎儿监护仪专科性较强，使用频率高，监测结果与胎儿有密切关系，这就迫使每个助产士都必须具备使用监护仪和判断监护结果的知识和能力，以便在发生异常情况时能尽早处理或通知医师，提高护理专业的自主性。 3. 缺点 固定带引起的不适 由于弹性皮带，产妇不能随心所欲的活动，只能适当变换体位，加上皮带对腹部的压力，均能使产妇产生一些不适感。 coupling Centre shall be checked, the second poured concrete strength of more than 70%. In the process of reaming or boring, apart from the special provisions in factory, does not allow any work that may affect the coupling Centre, such as irrigation, to cylinder connections to flood the condenser pipes and so on. Well boring, hinge bolt hole flange with coupling of vertical, not oblique. Mounting bolts should be added lubricants, typing gently with a small hammer, not too loose or too tight, packed the bolts with the corresponding seal screw hole should be marked. 6.4.5.4.2 coupling reamed and pairings is close to the diameter of bolt bearing good hinge holes, dressed with a good two coupling bolts before you can move the rotor, boring-reaming hole in turn. Coupling bolts must be tight coupling is symmetrical diameter, in boring, reaming, two bolts out. Well boring, hinge bolt hole flange with coupling of vertical, not oblique. Due to the coupling bolts in accordance with hinge holes corresponding to the diameter of the screw holes one by one after processing, processing back bolt installation location cannot be changed, so according to bolt after the actual weight difference of nut and lock washer to match. General requirements for coupling two symmetrical diameter bolt, nut and lock washer's total weight difference should not be greater than 10 g and knocks stamped mark. (See Figure 18) The coupling bolts apply lubricant, and then gently with copper home, not too loose or too tight. Bolt Assembly is finished, symmetrical tightening all bolts to 30%, 50%, 70%, 100% force, and check the coupling flutter and before connecting the circle gradually changes its value should be less than 0.02mm. Tightening torque of the coupling bolts shall comply with the technical requirements manufacturers drawings, with a dynamometric wrench or log tension tools. Three wheel rotor swing test coupling connections should be checked: taking leave, 、 产时连续性电子胎心监护的应用价值 郸城县第二人民医院 【摘要】目的探讨胎心电子监护在孕妇产时连续性应用的价值。方法 选择500例产妇在产时进行连续性胎心电子监护，分析胎心电子监护对处理产程、分娩方式的影响。结果 选择NST反应型者共500例进行产时连续性监护，其中顺产375例，产钳助产16例，手术产109例;Apgar评分7分以上480例，7分以下20例;其中3例进入产程后出现胎心音异常，羊水?度污染行剖宫产，评分在4分以下。胎心基线变异明显减弱或消失、重度变异减速、延长减速及晚期减速者发生羊水粪染、脐带缠绕及新生儿窒息比例明显高于其他胎心监护图形异常者。结论 产时对产妇进行胎心连续性监护有效指导产程处理，早期发现胎儿窘迫，决定分娩方式，降低新生儿窒息率，对优生优育意义重大。 【关键词】 妊娠;连续性监护;胎心电子监护仪 胎心监护仪以走纸或数字式的形式对胎心率进行监测，可以连续观察胎心率，并且可同时测出宫缩压力。我院自2001年起，把胎儿监护仪用于产程连续监测，即产妇进入活跃期宫口扩张3cm以上，给予胎儿监护仪监护直至胎儿娩出，简称全产程监护，此项工作开展以来，在降低新生儿窒息，减轻医护人员的工作量，提高产科质量方面效果显著。现报告如下。 1 临床资料 1.1 一般资料 各取2009年1-6月及2010年1-6月产妇500例。年龄25,30岁，孕周38,41周，各系统进行产前检查，无高危因素。 1.2 方法 宫口大于3cm，给予电子胎心监护。以两条较宽的弹性皮带，将宫缩探头固定于母亲腹部胎心音最清晰处。监测器接受讯号后，屏幕可显示胎心率及宫缩压力。 coupling Centre shall be checked, the second poured concrete strength of more than 70%. In the process of reaming or boring, apart from the special provisions in factory, does not allow any work that may affect the coupling Centre, such as irrigation, to cylinder connections to flood the condenser pipes and so on. Well boring, hinge bolt hole flange with coupling of vertical, not oblique. Mounting bolts should be added lubricants, typing gently with a small hammer, not too loose or too tight, packed the bolts with the corresponding seal screw hole should be marked. 6.4.5.4.2 coupling reamed and pairings is close to the diameter of bolt bearing good hinge holes, dressed with a good two coupling bolts before you can move the rotor, boring-reaming hole in turn. Coupling bolts must be tight coupling is symmetrical diameter, in boring, reaming, two bolts out. Well boring, hinge bolt hole flange with coupling of vertical, not oblique. Due to the coupling bolts in accordance with hinge holes corresponding to the diameter of the screw holes one by one after processing, processing back bolt installation location cannot be changed, so according to bolt after the actual weight difference of nut and lock washer to match. General requirements for coupling two symmetrical diameter bolt, nut and lock washer's total weight difference should not be greater than 10 g and knocks stamped mark. (See Figure 18) The coupling bolts apply lubricant, and then gently with copper home, not too loose or too tight. Bolt Assembly is finished, symmetrical tightening all bolts to 30%, 50%, 70%, 100% force, and check the coupling flutter and before connecting the circle gradually changes its value should be less than 0.02mm. Tightening torque of the coupling bolts shall comply with the technical requirements manufacturers drawings, with a dynamometric wrench or log tension tools. Three wheel rotor swing test coupling connections should be checked: taking leave, 1.3 胎心宫缩图(CTG)的识别 本组异常胎心宫缩图按《高危妊娠的处理》中的分类标准进行分类，其中包括基线率异常、基线变异异常和胎心率各类减速，有些混合型异常图形则按各种异常图形所占的比例或是否重要而归类。如频发早减(ED)合并偶发晚减(LD)则归为ED类，心动过速或过缓合并重度可变减(VD)则归VD类[1] 。 1.4 出现异常CTG需进一步了解胎儿下列情况 (1)羊水量及羊水性状:B超测羊水指数，B超羊水指数<8，分娩时羊水量<300ml为羊水过少。未破膜者须上推胎头，让羊水流出观察其性状及量。以上两项操作需慎防脐带脱垂。(2)脐带:B超检测有无脐带脱垂、脐带缠绕肢体，对已破膜、宫口已开大2cm时，需行阴道检查，除外脐带脱垂。(3)宫缩情况:是否因宫缩过频过强而引起胎心变化。如正在用缩宫素点滴，则应立即停止使用。 2 结果 2.1 异常CTG与产程各期的关系 500例中，出现异常图形191例，占38.2%。潜伏期监护192例中，异常图形44例，占22.92%，进入活跃期监护136例中，异常图形63例，占46.32%，进入第二产程监护172例中，异常图形84例，占48.84%。随着产程的进展异常CTG呈增加趋势，潜伏期有44例占22.9%，活跃期及第二产程异常CTG呈明显增加趋势，分别为46.32%和48.84%。在各类胎心减速中VD和LD随产程进展而呈增加趋势，并较多出现于活跃期及第二产程。 2.2 异常CTG与Apgar评分 新生儿中度窒息(4,7分)有20例，其中胎心加速9例，过缓4例，基线变异度跳跃5例，减少2例，胎心率变异其中ED 1例，VD 2例，LD 1例。新生儿重度窒息3例，其中晚减2例，可变减1例。 3 讨论 脐动脉流经胎盘血窦内与母体血液进行物质交换，而后经过脐静脉回到胎儿体内，当脐带受到压迫或牵拉刺激时均易影响脐带血流，所以任何影响母胎间供给的因素均可引起胎心变化。如胎盘功能不良、脐带异常、宫缩异常等，均可影响胎心出现异常监护图形[2] 。 近几年各种杂志报道早期减速多发生于第一产程，因胎头进入骨盆受压，颅内压一时性增高，大脑血流量减少，交感神经被抑制，副交感神经兴奋引起心率减慢。另外，脐带受压脐血流受阻，胎儿血压上升，刺激压力感受器反射性引起心率减慢[3]。变化减速是产时最常见的图形，往往是脐带受压胎儿血氧分压下降，二氧化碳分压上升，血液中化学成分改变coupling Centre shall be checked, the second poured concrete strength of more than 70%. In the process of reaming or boring, apart from the special provisions in factory, does not allow any work that may affect the coupling Centre, such as irrigation, to cylinder connections to flood the condenser pipes and so on. Well boring, hinge bolt hole flange with coupling of vertical, not oblique. Mounting bolts should be added lubricants, typing gently with a small hammer, not too loose or too tight, packed the bolts with the corresponding seal screw hole should be marked. 6.4.5.4.2 coupling reamed and pairings is close to the diameter of bolt bearing good hinge holes, dressed with a good two coupling bolts before you can move the rotor, boring-reaming hole in turn. Coupling bolts must be tight coupling is symmetrical diameter, in boring, reaming, two bolts out. Well boring, hinge bolt hole flange with coupling of vertical, not oblique. Due to the coupling bolts in accordance with hinge holes corresponding to the diameter of the screw holes one by one after processing, processing back bolt installation location cannot be changed, so according to bolt after the actual weight difference of nut and lock washer to match. General requirements for coupling two symmetrical diameter bolt, nut and lock washer's total weight difference should not be greater than 10 g and knocks stamped mark. (See Figure 18) The coupling bolts apply lubricant, and then gently with copper home, not too loose or too tight. Bolt Assembly is finished, symmetrical tightening all bolts to 30%, 50%, 70%, 100% force, and check the coupling flutter and before connecting the circle gradually changes its value should be less than 0.02mm. Tightening torque of the coupling bolts shall comply with the technical requirements manufacturers drawings, with a dynamometric wrench or log tension tools. Three wheel rotor swing test coupling connections should be checked: taking leave, 刺激颈动脉及大动脉的化学感受器，使交感神经兴奋，血管收缩，胎儿血压升高又刺激颈动脉窦、主动脉弓的压力感受器引起迷走神经兴奋，胎心下降。因脐带受压程度不同下降也有轻重之分[1] 。Krebs等提出不典型变化减速均提示胎儿缺氧。我院将此图形归于重度可变减速类。当胎儿缺氧加重达一定程度心肌活动受到抑制，心率减慢这种减速等发生在子宫收缩力达到一定程度后，经过上述反射于宫缩高峰后出现，形成晚期减速。胎儿中枢神经系统受到缺氧的抑制变异就会减少或消失，说明胎儿酸中毒处在危急时刻[3] 。 产时胎心监护的临床意义:宫缩时，绒毛间已减少的血流又遭到间歇性的关闭，导致胎儿发生一系列的生理改变:(1)早期缺氧刺激儿茶酚胺分泌，兴奋了交感神经，使FHR过速;随着缺氧的加深，激活了化学感受器和压力感受器，使迷走神经活性增强，交感神经活性降低，使FHR过缓。(2)缺氧严重时引起心律失常及心跳过缓，出现LD及FHR过缓。此外，过期妊娠胎盘功能降低、羊水量减少，使脐带失去羊水的缓冲保护作用，宫缩时易受压。胎儿血压改变、压力感受器受刺激使迷走神经兴奋，图像上LTV振幅呈跳跃型长期不改变，连续出现ED(早期减速)以及具特征性的“V”、“U”、“W”型的VD出现、周期性加速幅度过大等。单一异常图形即使LD出现，其与Apgar低分的相关性也不及异常图像组合重要。各种类型的减速性胎心变化应引起足够的重视。胎儿缺氧早期，常表现为胎心率代偿性加速，而当缺氧严重时，胎心率则变缓，阎桂香[2]等经过对死胎死产患者产前胎心监护结果进行回顾性分析发现，31例死胎死产者中表现为各种减速性胎心变化者有26例，占83.87%，9例表现为胎心基线搏动减少，但无1例表现为加速性胎心变化，也说明减速性胎心变化对胎儿威胁最大，宜及早处理，应放宽剖宫产指征。 从我院资料分析得出，产程中出现异常的CTG对预测胎儿缺氧有着不可估量的意义。潜伏期若LD、VD、ED基线率变异异常等都可能预示着胎儿缺氧因素的存在，各类减速是判断胎儿宫内安危的重要指标之一。在潜伏期由于宫缩20,40s/4,5min，对胎儿的影响相对小一些。在活跃期及第二产程由于宫缩增强40,50s/1,2min，胎头下降受盆底肌肉组织的挤压对胎儿的影响相对大一些。所以异常CTG呈增多倾向，多由于脐带因素引起，脐带过短、脐带缠绕使母胎间血氧交换受阻而致胎儿缺氧，其次原因为羊水污染、羊水过少也是胎儿缺氧而致胎儿窘迫的征象。所以在孕末期要加强羊水监测[4]。在潜伏期若出现异常CTG宜尽早结束分娩，以剖宫产为宜。在第二产程若出现异常CTG应立即结束分娩，以胎吸或产钳助娩，并积极做好抢救婴儿的准备工作，要采取ABCDE复苏[5]。从本文资料可看出异常CTG对胎儿缺氧的原因也有指导意义，VD预示着有脐带因素存在，LD预示着胎盘功能不良，如再加上合并有变异度上的变化说明胎儿缺氧严重，要积极地处理。总而言之，为了减少围产儿的死亡率及病残率，对每个产妇都应常规地进行胎心监护。但CTG也有假阳性率，单凭异常CTG就手术分娩难免会增加手术产率。据向梅[3]等介绍用脉冲血氧定量计测量，胎儿血氧饱和度可直接反映胎儿安危，较目前胎儿监护图更可靠，就目前情况看，无论异常CTG为何种类型，于产程中任何时间都应严肃对待。 coupling Centre shall be checked, the second poured concrete strength of more than 70%. In the process of reaming or boring, apart from the special provisions in factory, does not allow any work that may affect the coupling Centre, such as irrigation, to cylinder connections to flood the condenser pipes and so on. Well boring, hinge bolt hole flange with coupling of vertical, not oblique. Mounting bolts should be added lubricants, typing gently with a small hammer, not too loose or too tight, packed the bolts with the corresponding seal screw hole should be marked. 6.4.5.4.2 coupling reamed and pairings is close to the diameter of bolt bearing good hinge holes, dressed with a good two coupling bolts before you can move the rotor, boring-reaming hole in turn. Coupling bolts must be tight coupling is symmetrical diameter, in boring, reaming, two bolts out. Well boring, hinge bolt hole flange with coupling of vertical, not oblique. Due to the coupling bolts in accordance with hinge holes corresponding to the diameter of the screw holes one by one after processing, processing back bolt installation location cannot be changed, so according to bolt after the actual weight difference of nut and lock washer to match. General requirements for coupling two symmetrical diameter bolt, nut and lock washer's total weight difference should not be greater than 10 g and knocks stamped mark. (See Figure 18) The coupling bolts apply lubricant, and then gently with copper home, not too loose or too tight. Bolt Assembly is finished, symmetrical tightening all bolts to 30%, 50%, 70%, 100% force, and check the coupling flutter and before connecting the circle gradually changes its value should be less than 0.02mm. Tightening torque of the coupling bolts shall comply with the technical requirements manufacturers drawings, with a dynamometric wrench or log tension tools. Three wheel rotor swing test coupling connections should be checked: taking leave, coupling Centre shall be checked, the second poured concrete strength of more than 70%. In the process of reaming or boring, apart from the special provisions in factory, does not allow any work that may affect the coupling Centre, such as irrigation, to cylinder connections to flood the condenser pipes and so on. Well boring, hinge bolt hole flange with coupling of vertical, not oblique. Mounting bolts should be added lubricants, typing gently with a small hammer, not too loose or too tight, packed the bolts with the corresponding seal screw hole should be marked. 6.4.5.4.2 coupling reamed and pairings is close to the diameter of bolt bearing good hinge holes, dressed with a good two coupling bolts before you can move the rotor, boring-reaming hole in turn. Coupling bolts must be tight coupling is symmetrical diameter, in boring, reaming, two bolts out. Well boring, hinge bolt hole flange with coupling of vertical, not oblique. Due to the coupling bolts in accordance with hinge holes corresponding to the diameter of the screw holes one by one after processing, processing back bolt installation location cannot be changed, so according to bolt after the actual weight difference of nut and lock washer to match. General requirements for coupling two symmetrical diameter bolt, nut and lock washer's total weight difference should not be greater than 10 g and knocks stamped mark. (See Figure 18) The coupling bolts apply lubricant, and then gently with copper home, not too loose or too tight. Bolt Assembly is finished, symmetrical tightening all bolts to 30%, 50%, 70%, 100% force, and check the coupling flutter and before connecting the circle gradually changes its value should be less than 0.02mm. Tightening torque of the coupling bolts shall comply with the technical requirements manufacturers drawings, with a dynamometric wrench or log tension tools. Three wheel rotor swing test coupling connections should be checked: taking leave,