S DNG BIU CHUYN D

B MN PH SN

Mc tiu hc tp
Sau khi hc xong bi ny, hc vin c kh nng:

1/ Ghi ng cc din bin ca cuc chuyn d trong qu trnh theo di sn ph bng biu chuyn d (BCD). 2/ Pht hin c cc du hiu bt thng biu hin nguy c i vi m v con khi theo di sn ph trn BCD. 3/ Nu c cch s tr cho mt s nguy c xut hin khi theo di trn BCD (ch yu dnh cho cc bc s iu tr).

M t cu trc mt BCD
1/ Phn th tc
2/ Phn ghi chp v tnh trng thai nhi (NTT, tnh trng i, chng khp).
3/ Phn theo di tin trin ca cuc chyn d (biu m CTC, Tin trin ca ngi thai, cn co TC). 4/ Phn ghi thuc dng. 5/ Phn ghi tnh trng ton thn sn ph (Mch, HA, T0, Prtin niu).

Ch nh v thi im bt u ghi BCD

Thi im bt u ghi BCD: Ch bt u ghi BCD khi sn ph chuyn d tht s. Ch nh s dng BCD: Cc trng hp chuyn d c kh nng ng m o (k c cc trng hp gy chuyn d nhn to v so m c TC c ch nh cho ng di). Khng ghi BCD: Nhng trng hp khng c kh nng ng di (SP chuyn d trong tnh trng cp cu nh: do v TC, rau tin o chy mu, rau bong non, sn git... cn MLT, hoc nhng trng hp c ch nh MLT theo chng trnh nh khung chu hp, vt m c TC nhiu ln, RT trung tm chn on xc nh...

Ghi v phn tch, nh gi din bin ca chuyn d trn Biu

+ + Phn th tc Ghi NTT ( ) v nh gi Ghi tnh trng i v nh gi: i cha v: i dt (D), i phng (P). i v: ghi theo mu sc nc i: T: nc i trong hoc bnh thng; X: nc i xanh phn xu; M: i c mu. Ghi chng khp v nh gi: Khng chng khp: (0) khi khe gia 2 xng nh hi cch xa nhau. Chng khp 1: (+) khi 2 xng nh st nhau khng c khe h. Chng khp 2: (++) khi b xng nh bt u trm ln nhau. Chng khp 3: (+++) khi 2 xng nh trm ln nhau nhiu.

+ + + +

Ghi v phn tch nh gi DIN BIN TRN BCD (TIP) + + + + + + + + + Ghi m CTC (x) v nh gi: Bt u ghi khi chuyn d (CD) cn pha tim tng. Bt u ghi khi CD pha tch cc. Bt u ghi CD pha tim tng sau chuyn sang pha tch cc. Cch ghi mc tin trin ca ngi thai (o) v nh gi: Cao: nm ngn ca c bn tay trn xng mu chm c u thai, s 5. Chc: 4 ngn tay, s 4. Cht: 3 ngn tay, s 3. Lt cao: 2 ngn tay, s 2. Lt va: 1 ngn tay, s 1. Lt thp: khng ngn no chm c u thai, s 0

Ghi v phn tch nh gi DIN BIN TRN BCD (TIP) Cch ghi CCTC v nh gi: + Ghi theo tn s cn co trong 10 pht (mi vung biu th mt CCTC). + ng khung, trng khi mi CCTC di 20 giy. + ng khung chm chm bn trong khi mi CCTC t 20 n 40 giy. + ng khung gch cho khi mi cn co trn 40 giy. Ghi mch ( ) v HA ( ) ca sn ph. Ghi thn nhit: theo nhit giai bch phn (0C) bng ch s. Ghi prtin niu: (-), (), (+), (++) hoc (+++). Ghi nhng s kin din ra trong qu trnh theo di: Ti thi im no dng mi tn nh du thi im . Ghi thm ch di, v d: "v i", "bm i", "cho rn ", "", "SP vt v", "ra mu"...

Bi tp tnh hung s 1:
(Son t tnh hung 1, ti liu HV tr. 105)

(BCD ca cuc chuyn d bnh thng) Tnh hung:

B A. 26 tui, chuyn d sinh con ln u, PARA 0010, bt u ghi BCD hi 5 gi sng: Tnh trng m bnh thng: Mch 70 l/pht, HA 110/70 mmHg, To 36,8oC; prtin niu (-). V thai nhi: Ngi chm, NTT 140 l/pht. i cn, u i dt. chng khp (0), u chc; CTC m 2 cm; CCTC 3/10 pht, mi cn 25 giy.

Tnh hung (tip): n 9 gi: M bnh thng nh lc trc. NTT 135 l/pht. i v t nhin, nc i trong, u cht, chng khp (0), CTC m 5 cm, CCTC 4/10 pht, mi cn 40 giy. n 13 gi: M bnh thng nh trc. NTT 150 l/pht. u lt trung bnh, chng khp (+), CTC m ht. CCTC 5/10 pht, mi cn 45 giy. SP mt rn v c hng dn cho rn . 13 gi 20 pht: B A. sinh ng m o mt gi 2900 gam, Apgar sau 1 pht 9/10. Cu hi: Nhng du hiu no trn BCD ca b A. cho bit cuc chuyn d din bin bnh thng c th sinh c ng di?

p n bi tp tnh hung s 1: BCD cho thy:

Khng c yu t bt thng v pha m (mch, HA, To, ton trng) v thai (NTT, tnh trng i, chng khp). Khng c yu t bt thng trong tin trnh chuyn d, c th l: + Cn co TC u v tng dn v khong cch v di mi cn. + CTC tin trin bnh thng, trong pha tch cc m trn 1cm/gi th hin bng ng biu din CTC hng ln trn v lun bn tri ng bo ng. + Ngi thai tin trin tt: ng biu din tin trin ca u hng i xung dn trong qu trnh CD.

Bi tp tnh hung s 2
(Son t bi tp tnh hung 2 ti liu HV tr. 105-106)

Chuyn d c cn co c iu chnh bng Oxytocin

Tnh hung: B B. 28 tui, chuyn d sinh ln 2 ti trm x x. PARA 1001. BCD ghi lc 6 gi: Ton trng: Mch 80, HA 120/70. To 36,9oC. Prtin niu (-). NTT 140 l/pht. u i dt. u cao, chng khp (0). CTC 2 cm. CCTC 2/10 pht, mi cn 20 giy. 10 gi (sau 4 ting theo di trm), cc din bin ca cuc CD vn nh trc, CTC m 4 cm, u thai chc. CCTC vn tn s 2 nhng thi gian co di 20 giy mi cn. B B. vn c theo di tip ti y t x. n 12 gi, ton trng m v thai vn nh trc, CTC khng m thm. u vn chc. CCTC 2/10 pht, mi cn vn di 20 giy. ng biu din CTC chuyn sang bn phi ng bo ng nn b B. v gia nh c CBYT gii thch v cho chuyn ln BV huyn.

Tnh hung (tip): Ti BV huyn: theo di tip n 13 gi, i v t nhin, nc i trong. Tnh trng m v con khng c g khc trc, CTC khng m thm, CCTC gim ch cn di 2/10 pht v mi cn di 20 giy. Lc ny BS cho truyn oxytocin (5 n v trong 500 ml huyt thanh) vi tc ban u l 10 git/pht v c 30 pht theo di, li tng 10 git/pht cho n 30 git/pht CCTC t tn s 3/10 pht, mi cn 25-30 giy th duy tr mc truyn nh git . n 16 gi, cuc CD tin trin hn: CCTC tn s 3/10 pht, mi cn 35 - 40 giy. CTC m c 6cm. u lt cao. n 18 gi, CTC m ht. u lt trung bnh. Chng khp (+). CCTC tn s 4/10 pht, mi cn trn 40 giy. Ton trng m v thai bnh thng. SP tip tc c truyn oxytocin, cho rn . n 18 gi 30, CCTC tn s 5/10 pht. u thai thp th. B B. sinh ng m o lc 18 gi 35 mt trai 3000 gam, Apgar sau 1 pht 9/10. Oxytocin c truyn ht chai vo lc rau s sau hn 1 gi.

 Cu hi 1/bi tp tnh hung 2:

Din bin cuc chuyn d ca b B. c g bt thng? p n 1:

B B. chuyn d ban u pha tim tng l bnh thng. Sang pha tch cc, CCTC yu v tha nn tin trnh chuyn d chm li, c nguy c gy chuyn d ko di
Cu hi 2/bi tp tnh hung 2: Thi x tr ca CBYT x nh th no? p n 2: trm x x, khi c du hiu chuyn d bt thng (ng biu din CTC lch sang bn phi ng bo ng) CBYT gii thch vi b B. v gia nh chuyn ln BV l ng v kp thi.

 Cu hi 3/bi tp tnh hung 2:

Thi x tr ca BV huyn nh th no? p n 3: Ti BV huyn, sau khi tip nhn SP, theo di st trong vng mt gi xc nh chc chn l do cn tr tin trnh chuyn d v khi xc nh ng cho truyn nh git TM oxytocin tng cng CCTC gip cuc chuyn d tin trin tt hn. Ch nh thn trng, ng v kp thi. Cu hi 4/bi tp tnh hung 2: C nn ct truyn Oxytocin ngay sau khi s thai hay khng? V sao? p n 4: Nn dch truyn tip tc sau khi s rau cho n khi TC co tt, khng c nguy c chy mu lc y mi ct truyn. Cch lm ca BV i vi b B. l ng.

Bi tp tnh hung s 3 (Son theo bi tp tnh hung 3 ti liu HV tr.106)

Chuyn d ko di
B C. 36 tui, PARA 1101, n BV huyn lc 10 gi, chuyn d ln 3, pha tch cc, i cha v, c theo di chuyn d bng biu v y l BDCD ni ln din bin cuc ca b C.
Cu hi 1/bi tp 3: Hy c cc kt qu ghi trn BCD ca b C. t khi bt u ghi n khi kt thc?

p n 1/bi tp 3
B C. bt u c ghi BCD lc 10 gi: Lc ny: SP c Mch 80 l/pht, HA 110/70 mmHg. To 37oC. Prtin niu (-). NTT 140 l/pht, i dt. u thai cao. CTC m 4 cm. CCTC 2/10 pht, mi cn < 20 giy. n 14 gi: NTT 140 l/pht. i v t nhin, nc trong, u vn cao. CTC vn 4 cm. CCTC tha, yu (1/10 pht mi cn < 20 giy). 18 gi: NTT 130 l/pht. u vn cao. CTC 6 cm. CCTC mi t tn s 2, mi cn 20 giy. 21 gi: CTC vn 6 cm. NTT lc ny gim ch cn 110 l/pht, khng u. Khm thy nc i c phn xu, u thai chc. CCTC tn s 3/10, mi cn vn ch 20 giy. B C. c cho nm nghing tri, cho th xy v theo di st NTT. 5 pht sau NTT ch cn 90 l/pht. Chn on lc ny l suy thai do chuyn d ko di v ch nh m cp cu. 21 gi 20 pht m ly ra mt gi 2800 gam, ngt tm, Apgar sau 1pht 6/10 phi hi sc tch cc sau 5 pht Apgar ln c 9/10 v khc to.

 Cu hi 2/bi tp 3: L do gy suy thai i vi trng hp chuyn d ca b C.? p n 2/bi tp 3: Do cuc chuyn d ko di v CCTC yu v tha trong nhiu gi. Cu hi 3/bi tp 3: Cn phi x tr th no trc v vo thi im no l thch hp nht? p n 3/bi tp 3: ng l phi cnh gic vi tnh trng CCTC ca b C. ngay khi bt u ghi BCD. Sau 4 ting (14 gi) l lc phi xc nh chn on v nu cho tng co ngay bng nh git TM oxytocin th c th gip cuc chuyn d tin trin tt ln, cuc c th khng cn phi m.

Bi tp tnh hung s 4 (Son t bi tp tnh hung 4, ti liu HV tr. 107)

Chuyn d tc nghn
B D. ln 4. PARA 3002, c trm x x chuyn ln BV huyn vi chn on thai to, i v lc 6 gi v chuyn d. Vo vin lc 7 gi v c ghi BCD ngay. Da trn BCD ca b D. ghi c: Cu hi 1/bi tp 4: Trnh by din bin cuc chuyn d ca b D. t khi ghi BCD n khi kt thc cuc ?

p n 1/bi tp 4: Cuc chuyn d ca b D. din bin nh sau: Lc 7 gi: Mch 80 l/pht. HA 120/70 mmHg. To 36,8. Protein niu (-). NTT 140 l/pht. Ngi chm, i v, nc i trong, u chc chng khp (0). CTC m 2cm. CCTC 3/10 pht, mi cn 20-40 giy. 10 gi: NTT vn 140 l/pht. Nc i trong, u cht, chng khp (+). CTC m 4 cm. CCTC 3/10 pht, mi cn vn 20-40 giy. Ton thn b D. nh trc. 14 gi: NTT 130 l/pht. Nc i trong, u vn cht v chng khp vn (+). CTC m 6 cm (chuyn sang bn phi ng bo ng). CCTC tn s 4/10 pht mi cn trn 40 giy. Ton thn: Mch 90 l/pht, HA 120/80 mmHg. To 37. 16 gi: NTT 120 l/pht. Nc i c mu xanh nht. u vn cht, chng khp (++). CTC vn ch 6 cm. CCTC tn s 5/10 pht. B D. c m ly thai lc 16 gi 25, ly ra mt trai 4.200 g, Apgar sau 1 pht 8/10.

 Cu hi 2/bi tp 4:
Phn tch cc du hiu bt thng xut hin trong khi theo di trn biu v cho chn on khi s tr? p n 2/bi tp 4: - Trong cuc CD ca b D. pha tim tng khng c vn g c bit ngoi tnh trng i v sm. Sang pha tch cc, ng lc ca cuc chuyn d l CCTC din bin tng u, mi lc mnh hn, di hn nhng kt qu ca cn co khng t: CTC m chm, mi gi khng c 1 cm (ng biu din CTC lch sang phi ng bo ng) trong khi u thai khng tin trin ( mc cht) v li c hin tng chng khp mi lc mt tng. Bnh cnh c th chn on "chuyn d tc nghn" do thai to. - X tr m ly thai trong trng hp ny l ng.

 Cu hi 3/bi tp 4:

nh gi s theo di v s tr ca BV huyn c y v kp thi khng?

p n 3/bi tp 4: Vic theo di chuyn d v s tr ca BV huyn i vi b D. c s thn trng, hp l v kp thi.

Bi tp tnh hung s 5
(Son theo bi tp tnh hung 5, ti liu HV tr. 107)
Hy pht hin nhng im ghi chp sai trn BCD ca b Trnh Kim L: thai ln th 2, ln u sy, ghi BCD t lc 7gi 15 ngy 20/7, i v 1 gi. (mi HV c pht mt BCD ca b L) p n bi tp 5: Nhng im ghi chp sai trong BCD ca b L l: - PARA khng ng (phi l 0010) - Khng ghi S nhp vin - Khng chuyn cc k hiu v m CTC, tin trin ca u thai, NTT, ton trng m v cc d kin khc sang pha tch cc (lc 21 gi) t mi ghi tip. - Thi gian phi l 0 gi 20 pht ngy 21/