🤱 产科与新生儿 · 第6课，共6课 · 6 min
产程的各个阶段以及护士在每个阶段的职责
Stages of Labor and What the Nurse Does in Each
⏱️ “我宫口开多少了”是每位产妇都会问的问题。“她处于哪个产程阶段、我现在的工作是什么”是考试问你的问题。
⏱️ 'How dilated am I?' is the question every laboring client asks. 'What stage is she in and what is my job right now?' is the question the exam asks you.
💡 核心要点
第一产程至 10 cm（潜伏期、活跃期、过渡期），第二产程至胎儿娩出，第三产程娩出胎盘，第四产程恢复，第一小时每 15 分钟检查一次宫底。
First stage to 10 cm (latent, active, transition), second stage to birth, third stage the placenta, fourth stage recovery with fundal checks every 15 minutes for the first hour.
🧠 为什么重要
真性临产：规律宫缩随活动增强、宫颈发生变化，疼痛从背部开始并移向前方；假性临产的宫缩不规律，走动可缓解，且不引起宫颈变化。第一产程从临产开始到宫颈完全扩张（10 cm）：潜伏期（0 至约 5 或 6 cm）是宣教和鼓励下床活动的时间；活跃期宫缩更强、扩张更快，需监测宫缩、胎心率和母亲生命体征；过渡期（8 至 10 cm）最为剧烈，伴有恶心、颤抖、易怒和想用力的冲动，在宫颈完全扩张前必须忍住这种冲动。第二产程从宫颈完全扩张到胎儿娩出：支持产妇随宫缩用力，每次宫缩后监测胎心率，并为分娩做准备。第三产程是胎盘娩出，在约 30 分钟内完成，伴有剥离征象（血液涌出、脐带延长、子宫呈球形）；婴儿出生后（或胎盘娩出后，按机构规程）立即给予预防性 oxytocin 以防止出血。第四产程是恢复的最初 1 至 4 小时，第一小时每 15 分钟检查一次生命体征和宫底。舒适措施和硬膜外麻醉：置管前给予液体推注，监测母亲低血压（用侧卧、补液和 ephedrine 治疗）和胎儿心动过缓，并检查膀胱，因为患者感觉不到膀胱充盈。
TRUE labor: regular contractions that intensify with activity, cervical change, and pain starting in the back and moving to the front; FALSE labor contractions are irregular, ease with walking and cause no cervical change. FIRST STAGE runs from the onset of labor to full dilation (10 cm): the LATENT phase (0 to about 5 or 6 cm) is the time for teaching and encouraging ambulation; the ACTIVE phase brings stronger contractions and faster dilation, with monitoring of contractions, fetal heart rate and maternal vital signs; TRANSITION (8 to 10 cm) is the most intense, with nausea, shaking, irritability and an urge to push that must be resisted until full dilation. SECOND STAGE runs from full dilation to birth: support pushing with contractions, monitor the fetal heart rate after each contraction, and prepare for delivery. THIRD STAGE is the delivery of the placenta, within about 30 minutes, with signs of separation (a gush of blood, lengthening cord, globular uterus); prophylactic oxytocin is given right after the baby is born (or after the placenta delivers, per facility protocol) to prevent hemorrhage. FOURTH STAGE is the first 1 to 4 hours of recovery, with vital signs and fundal checks every 15 minutes for the first hour. Comfort measures and epidurals: a fluid bolus before placement, monitor for maternal hypotension (treat with side-lying, fluids and ephedrine) and fetal bradycardia, and bladder checks because the client cannot feel fullness.
🏥 真实场景
🧊 一名处于过渡期的患者说她再也坚持不下去了，想在 8 cm 时用力。护士指导她在宫缩时吹气，安慰她这个阶段是最短的，并让她不要在尚未打开的宫颈上用力。二十分钟后她宫口开全，用力变得富有成效而不是有害。
🧊 A client in transition says she cannot do this anymore and wants to push at 8 cm. The nurse coaches her to blow through contractions, reassures her that this phase is the shortest, and keeps her from pushing on a cervix that is not yet open. Twenty minutes later she is complete, and pushing becomes productive instead of harmful.
📌 要点总结
- 真性临产会改变宫颈；假性临产不会True labor changes the cervix; false labor does not
- 过渡期：8 至 10 cm，剧烈，宫口开全前不要用力Transition: 8 to 10 cm, intense, no pushing until complete
- 硬膜外麻醉后：注意母亲血压和膀胱After an epidural: watch maternal blood pressure and bladder
📖 本课术语
Oxytocin: 诱导或加强分娩并在产后收缩子宫的IV激素；通过输液泵滴定并持续监测胎心，出现10分钟内超过五次宫缩或晚期减速时，停止输注、将患者侧卧、给予氧气并通知医务人员。
Terbutaline: 松弛子宫以短暂延迟早产的β激动剂；注射使用超过48到72小时（以及任何口服使用）带有母体心脏死亡的黑框警告，因此母体脉搏超过120时停药，并报告胸痛。
Betamethasone（产前类固醇） (Betamethasone (antenatal steroids)): 给予两剂IM，每剂12 mg，间隔24小时，适用于预计在24到34周分娩的妇女，以成熟胎肺并减少呼吸窘迫、脑出血和肠道损伤；监测母亲的血糖和感染征象。
✅ 自我测试
一名宫口开 8 cm 的产妇正在颤抖、恶心，并说她必须用力。护士的最佳回应是什么？A laboring client at 8 cm is shaking, nauseated and says she has to push. What is the nurse's best response?
- 指导她在宫缩时用呼吸撑过去，直到宫颈完全扩张Coach her to breathe through contractions until she is fully dilated
- 告诉她这不是真性临产Tell her she is not in real labor
- 离开去通知医生Leave to notify the provider
- 鼓励她随每次宫缩用力Encourage pushing with each contraction
答案: A · 指导她在宫缩时用呼吸撑过去，直到宫颈完全扩张
过渡期会带来过早想用力的冲动；在 10 cm 前用力可导致宫颈水肿和损伤。
Transition brings a premature urge to push; pushing before 10 cm can cause cervical edema and injury.
哪项发现可区分真性临产与假性临产？Which finding distinguishes true labor from false labor?
- 患者走动时宫缩停止Contractions that stop when the client walks around
- 宫颈扩张和消退的进行性变化Progressive cervical dilation and effacement
- 不规律且强度不一的宫缩Irregular contractions that vary in intensity
- 主要位于下腹部和腹股沟的不适Discomfort felt mainly in the lower abdomen and groin
答案: B · 宫颈扩张和消退的进行性变化
宫颈变化是真性临产的决定性特征，无论宫缩感觉如何。主要位于下腹部和腹股沟的不适是假性临产的典型表现；真性临产疼痛通常从下背部开始并绕向前方。
Cervical change is the defining feature of true labor regardless of how the contractions feel. Discomfort felt mainly in the lower abdomen and groin is typical of false labor; true labor pain usually starts in the lower back and wraps around to the front.
硬膜外置管十五分钟后，患者的血压从 124/78 降至 88/50。护士首先应该做什么？Fifteen minutes after an epidural is placed, the client's blood pressure drops from 124/78 to 88/50. What should the nurse do first?
- 让患者取高 Fowler 体位并将双腿垂下Place the client in a high Fowler's position with her legs dangling
- 停止胎儿监护以减少焦虑Stop the fetal monitor to reduce anxiety
- 准备手术室进行立即剖宫产Prepare the operating room for an immediate cesarean delivery
- 让患者侧卧并加快 IV 输液速度Turn the client to her side and increase the IV fluid rate
答案: D · 让患者侧卧并加快 IV 输液速度
硬膜外相关的低血压用侧卧位和液体推注治疗；若持续存在则给予 ephedrine。高 Fowler 体位并将双腿垂下会使血液淤积在下半身并减少静脉回流，从而加重低血压而不是纠正它。
Epidural-related hypotension is treated with lateral positioning and a fluid bolus; ephedrine is given if it persists. High Fowler's with the legs dangling pools blood in the lower body and reduces venous return, worsening the hypotension instead of correcting it.
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