產科手術
(黃醫師)
Forceps >600 kinds, (Fetal-medicine Committee, ACOG; American College of Obstetricians and Gynaecologists鑒定)
Chamberlain 17th century 最早
4 parts: Blade, shank, lock, handle
Cephalic curve, pelvic curve
English lock: Simpson (鏤空), Tucker-Mc Lane (solid) forceps
Sliding lock: Kielland
Indication: Elective outlet forceps (DeLee 1920)
常見併發症neonatal jaundice
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Prerequisites for forceps delivery
- Emptying of bladder
- Engagement
- Vertex presentation or MA in face presentation. (MP need Cesarean)
- the vertex presentation: the occiput is the leading part
- MA: Mento-Anterior
- Position
- Full dilatation of cervix (effacement)
- ROM; rupture of membrane
- No CPD
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Local anesthesia: pudendal nerve
Epidural anesthesia (EA): Meperidine
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VED; Vacuum Extraction Delivery
1840 Simpson
放在small fontanelle，不要在large fontanelle, frontal
0-100 cm-Hg, 一般用50-60.
1954 Malmstrom, artificial
caput (chignon=bun)
Complications:
- Scalp laceration
- Subgaleal hematoma
- Cephalohematoma: periosteum, not cross midline
- ICH
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Breech delivery: 3-4% of singleton
- Full Breech: frank: spontaneous dropout
- Incomplete Breech: footling: pop out
Mainly preterm baby
Elective Cesarean
原則：不介入、晚介入
常用Piper forcep
常用Piper forcep
Complications: fractures
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Version
Week 32 以上的胎位才有意義
Internal podalic version: 抓腳，不要抓手，避免paralyzed arms
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Vernix
Caseosa至少要等出生後的6-24小時處理才會比較妥當。
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CD; Cesarean Delivery(不要寫C/S, C-S，不專業)
德文Kaiserschnitt; 拉丁文Caedere 切開的意思, 本身就是切開的意思，所以不用再加上section
Lapratomy+ hysterotomy
(abdominal pregnancy, uterine rupture只有lapratomy不能叫做CD)
Taiwan ~40%
美帝 ~32.9%
台大總院 ~30%
Indication:
- Previous CD (Repeat CD)
- Dystocia- CPD; Cephalopelvic Disproportion
- Malpresentation 胎位不正
- Fetal distress
- CDMR (Cesarean delivery on maternal request) 婦女權美帝保險有給付
- Maternal Eisenmenger syndrome, RV failure (NTUH 用ECMO生過)
- Previous uterine surgery
- Preeclampsia
- Major bleeding
- Poliomyelitis, lame induced non circle bony pelvis (骨盆不對稱或變形)
- Short stature < 150 cm
- Hydrocephalus
- Meningocele (超音波發現就直接CD，避免浪費時間)
- Soft Parts Dystocia, including the vulva, perineum, vagina, cervix, uterus, adnexa, rectum and bladder.
NPO for 8 hours
- EA or GA
- SA，血壓掉打麻黃素
- Ketamine 叫intern打, 加上muscle suppression
- Local (以前appemdititis也是打local)
現在主流low segment transverse uterine incision
with abdominal longitudinal incision
1912 Kronig 1926 Kerr 發明
Low segment血管較少(主要是uterine a. 橫的分支)
Upper segment 很多肌肉，血管很多
Pfannenstiel bikini cut 很費時
Vertical uterine incision (1912Kronig)可能會往下裂開，很難trace
現在也會放一些tissue barrier，減少adhesion
現在縫內兩層，外層自然adhesion，減少手術時間
1882 Max Sanger提出要縫合
轉為傳統術式的indication:
- Low segment adhesion with bladder, myoma, invasive cervical carcinoma
- Large fetus with transverse lie (too big to take out)
- Placenta previa with anterior implantation
- Very small fetus in breech
1916 Cragin, "Once a Cesarean, always a Cesarean."
(classical vertical)
1978 UT的Merrill
& Gibbs提倡VBAC; vaginal
birth after Cesarean (transverse)
成功率不高
- 1980 17%
- 1988 25%
- 2007 8.5%
VBAC risk: 0.1% Uterine rupture (1999 Leveno)
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古代沒有abx，會做extraperitoneal CD (ECS)
- 1907 Frank
- 1909 Latzko
- 1940 Waters
減少peritonitis
但是很容易adhesion
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Cesarean hysterectomy (1876 Porro's OP.)(CD + subtotal hysrectomy)
Indication:
- Intrauterine infection
- POP; Pelvic Organ Prolapse
- Uterine scar
- Hypotonic uterus with PPH; Postpartum Hemorrhage 院外轉來很多，可以先給radiologist做UAE看看
- Major vessel laceration
- Large myoma
- Cervix cancer
- Placenta creta (accreta, incerta, or percreta)
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PMR; Perinatal mortality rate(No. of
death under age 1) / (1000 live births)
NMR;
neonatal = (No. of deaths under 4 wks & >GA 28 weeks) / (1000 live births)
Neonatal death = Deaths under 4 wks (28 days, roughly 1 mo.)
評估醫療水準
C.f. Parity >GA 20 weeks
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自然分娩及接生案例討論 (江醫師)
1.藍單
2.產程圖（cervical
curve跟胎位）,胎兒心音圖及子宮收縮圖
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NSD; Normal Spontaneous Delivery
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3P 必要條件
- Power
- Passenger
- Passage
- ------------
SO-B line
Suboccipital-Bregma 9.8cm
Deflexion:
- SO-F (frontal) 11cm
- SO-M (mentol) 12.5cm
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產程圖(Partogram)(超重要)
Labor分幾個stage？
- Stage1：開始真正產痛到子宮頸全開，又分latent phase平均8.6hrs(cervix 0~3cm)，active phase平均4.9hrs (acceleration(3~4cm)、phase of maximum slope(4~9cm)、deceleration(9~10cm))如圖所示。
- Stage2：子宮頸全開到胎兒娩出，會有bear down sensation（便意感），一般在初產婦為50minutes，經產婦為20 minutes。
- Stage3：胎兒娩出至胎盤娩出，約半小時以內。
- Stage4：胎盤娩出後一小時內。
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Latency phase (8hr), <1cm/hr
Active phase (各2hr),
>1cm/hr
Acceleration
Maximum (通常達到7-8cm,進入deceleration)
deceleration
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- Inter-ischial line 0 cm
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Engagement
Station 0 cm
Cervical dilatation ~7-8cm
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Full
- Cervical dilatation 10 cm
- Station +2 cm
初產婦
Latency 最多等20hr
Active phase最多各等3hr
所以first stage最多等29hr
Second stage最多等2hr
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prolonged
latent phase
- primipara: True labor後>20hrs未進入active phase
- multipara: True labor後>14hrs未進入active phase
充足水份與休息即可，Oxytocin*加強宮縮緊急狀況應
CS
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Protraction
disorder (產程遲滯)
觀察、休息
如有 CPD 則 C/S
protracted
active phase dilatation—最常見
- primipara: 子宮頸擴張<1.2cm/hr
- multipara: 子宮頸擴張<1.5cm/hr
protracted
descent
- primipara: 子宮頸全開後，胎頭下降 <1cm/hr
- multipara: 子宮頸全開後，胎頭下降 <2cm/hr
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下降停滯(Arrest of descent) station < 0cm
- primipara: 在active phase，胎頭>1hr沒有下降
- multipara: 在active phase，胎頭>1hr沒有下降
胎頭無法下降(Failure of descent) station < 2cm
- primipara: 在deceleration phase或stage2胎頭沒下降
- multipara: 在deceleration phase或stage2胎頭沒下降
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Med86 林思宏醫師 OBGYN Clerkship & Internship Survival Guide Version 4.0 p114
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Modified Bishop score
Cervical length replace effacement
- 0 for >3 cm,
- 1 for >2 cm,
- 2 for >1 cm,
- 3 for >0 cm.
Bishop Score (依照判讀順序)
- Station
- Effacement
- Position
- Consistency
- Dilatation
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Parameter
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Score
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|
|
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Description
|
|
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0
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1
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2
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3
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Fetal station
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−3
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−2
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−1, 0
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+1, +2
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Fetal
station describes the position of the fetus' head in relation to the distance
from the ischial spines,
which are approximately 3-4 centimetres inside the vagina and are not usually
felt. Health professionals visualise where these spines are and use them as a
reference point. Negative numbers indicate that the head is further inside
than the ischial spines and positive numbers show that the head is below the
level of the ischial spines.
|
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0-30%
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40-50%
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60-70%
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80+%
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Effacement
translates to how 'thin' the cervix is. The cervix is normally approximately
three centimetres long, as it prepares for labour and labour continues the
cervix will efface till it is 'fully effaced' (paper thin).
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|
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Position
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Posterior
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Middle
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Anterior
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–
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The
position of the cervix changes with menstrual cycles and also tends to become
more anterior (nearer the opening of the vagina) as labour becomes closer.
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Consistency
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Firm
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Medium
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Soft
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–
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In primigravid women the
cervix is typically tougher and resistant to stretching, much like a balloon
that has not been previously inflated (it feels like the bottom of a chin).
With subsequent vaginal deliveries the cervix becomes less rigid and allows
for easier dilation at term.
|
|
Closed
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1–2 cm
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3–4 cm
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5+cm
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Dilation is
a measure of how open the cervical os is (the hole). It is usually the most
important indicator of progression through the first stage of labour.
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