产后出血：先按摩，再用药

🧠 为什么重要

产后出血是指失血量达到 1,000 mL 或更多，或任何伴有低血容量征象的失血；子宫收缩乏力是最常见的原因，尤其是在产程过长、胎儿过大、双胎、使用 oxytocin 或膀胱充盈之后。宫底在分娩后应坚实、位于中线，并在脐部或脐部附近（约高于脐部 1 cm，至 12 小时时），随后每天下降约 1 cm（一指宽）。宫底柔软时先进行宫底按摩，一只手支撑子宫下段；宫底偏向一侧通常意味着膀胱充盈，因此让患者排尿或进行导尿。药物：先用 oxytocin，然后是 methylergonovine（高血压禁用）、carboprost（哮喘禁用）和 misoprostol。宫底坚实但仍持续鲜红色出血，提示裂伤或残留碎片，需要医生处理。评估恶露：恶露 rubra（红色，第 1 至 3 天）、serosa（粉褐色，第 4 至 10 天）、alba（黄白色，持续至约 6 周）；15 分钟内浸透一张卫生巾、大血块或恶臭都应报告。BUBBLE-HE 评估包括乳房、子宫、膀胱、肠道、恶露、会阴切开或会阴、痔疮和腿部（检查单侧肿胀、发热或压痛；Homans 征不可靠），以及情绪。产后忧郁（最初 2 周内的流泪情绪）是正常的；产后抑郁持续超过 2 周并损害功能；产后精神病伴有幻觉或伤害婴儿的想法，是急症。每位未致敏的 Rh 阴性孕妇在妊娠 28 周时接受 Rh 免疫球蛋白，如果婴儿为 Rh 阳性，分娩后 72 小时内再接受一次。

POSTPARTUM HEMORRHAGE is blood loss of 1,000 mL or more, or any loss with signs of hypovolemia; UTERINE ATONY is the most common cause, especially after a long labor, a large baby, twins, oxytocin use or a full bladder. The fundus should be FIRM, MIDLINE and at or near the umbilicus right after birth (about 1 cm above it by 12 hours), then descend about 1 cm (one fingerbreadth) a day. A BOGGY fundus gets FUNDAL MASSAGE first, with one hand supporting the lower uterus; a fundus deviated to the side usually means a FULL BLADDER, so have the client void or catheterize. Medications: OXYTOCIN first, then METHYLERGONOVINE (contraindicated in hypertension), CARBOPROST (contraindicated in asthma) and MISOPROSTOL. A firm fundus with continued bright red bleeding suggests a LACERATION or retained fragments, which need the provider. Assess LOCHIA: rubra (red, days 1 to 3), serosa (pink-brown, days 4 to 10), alba (white-yellow, to about 6 weeks); saturating a pad in 15 minutes, large clots or a foul odor are reported. The BUBBLE-HE assessment covers breasts, uterus, bladder, bowels, lochia, episiotomy or perineum, hemorrhoids and legs (check for unilateral swelling, warmth or tenderness; Homans' sign is unreliable), and emotions. BABY BLUES (tearfulness in the first 2 weeks) are normal; POSTPARTUM DEPRESSION lasts beyond 2 weeks and impairs function; POSTPARTUM PSYCHOSIS, with hallucinations or thoughts of harming the infant, is an emergency. Every unsensitized Rh-NEGATIVE pregnant client receives Rh immune globulin at 28 weeks, and again within 72 hours after birth if the baby is Rh-positive.

🏥 真实场景

👐 产程过长的两小时后，宫底柔软并向右偏移。护士按摩直至宫底变坚实，然后协助患者去洗手间；排出 700 mL 尿液后，宫底回到中线，出血减慢。按医嘱输注 oxytocin。顺序是手、膀胱、药物。考试会把药物放在第一位、打电话放在第二位；作为第一步，两者都是错的。

👐 Two hours after a long labor the fundus is boggy and displaced to the right. The nurse massages until it firms, then helps the client to the bathroom; 700 mL of urine later, the fundus returns to midline and the bleeding slows. Oxytocin runs as ordered. The sequence was hands, bladder, drug. The exam will offer the drug first and the phone call second; both are wrong as the first step.

📌 要点总结

• 宫底坚实、位于中线、每天下降 1 cm；柔软意味着按摩Fundus firm, midline, descending 1 cm a day; boggy means massage
• 宫底偏移意味着膀胱充盈Displaced fundus means a full bladder
• 先用 oxytocin；高血压时不用 methylergonovine；哮喘时不用 carboprost；72 小时内给予 Rh 免疫球蛋白Oxytocin first; methylergonovine not with hypertension; carboprost not with asthma; Rh immune globulin within 72 hours

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