1、产时电子胎儿监护产时电子胎儿监护 主要内容主要内容胎监应用的历史胎监应用的历史应用胎监来筛查产时胎儿缺氧的发展现状应用胎监来筛查产时胎儿缺氧的发展现状产时缺氧对胎儿及新生儿预后的关系产时缺氧对胎儿及新生儿预后的关系 胎心率与胎儿的生物物理活动的关系胎心率与胎儿的生物物理活动的关系产时缺氧的产时缺氧的EFM（Electronic Fetal Monitoring）胎儿监护的发展胎儿监护的发展fetal monitors today have the following features:Reliable, provided they are regularly maintained and se
2、rviced User friendly with operating manual and video/DVD FHR recording: by external Doppler ultrasound (US) with autocorrelation by fetal electrode (ECG)Twin monitoringMaternal heart rate Event markerExternal tocographyMode, date and time printoutAutomatic maternal blood pressure pulse and SaO2 faci
3、lity 胎儿心率的发育胎儿心率的发育The fetal heart is detectable by transvaginal US as early as 4 weeks after conception At this stage the mean FHR is about 100 bpm. Thereafter it progressively rises, reaching a mean of about 140-150 by 10 weeks menstrual age (8 weeks post conception), and levels off at that rate b
4、y the start of the second trimester.From 14 weeks to term there is a progressive fall in the mean baseline FHR which is unaffected by whether the fetus is Active or Quiescent This lowering of the baseline rate with gestation is a reflection of the fact that the sympathetic autonomic 胎心率变异胎心率变异胎儿氧供的来
5、源胎儿氧供的来源Fetal oxygenation is therefore dependent upon many factors in this process. Anything that disturbs this chain of oxygen transfer will potentially affect fetal oxygenation and the FHR. The key components of the chain are:Maternal blood pressure and oxygenation The integrity of the placenta, s
6、pecifically the amount of surface area for oxygen transfer The patency of the umbilical cord 胎心减速胎心减速From 26 weeks onwards decelerations of the fetal heart should be regarded as abnormal. However, fetal decelerations are a normal feature before 26 weeks 胎儿产时缺氧胎儿产时缺氧IP fetal hypoxia occurs in about 1
7、% of labours. It can lead to one of three adverse outcomes:Perinatal death (stillbirths and neonatal deaths) Cerebral palsy Hypoxic ischemic encephalopathy (HIE) 胎儿缺氧的机制与结局胎儿缺氧的机制与结局Hypoxia may present chronically or acutely.Chronic hypoxia evolves through a series of sequential changes. Acute hypox
8、ia also evolves through a different series of sequential changes. However, both routes eventually can lead to the common outcome判读胎儿电子监护图形的基本判读胎儿电子监护图形的基本要点要点 基线基线变异变异加速加速减速减速宫缩宫缩无宫缩无宫缩-NST有规律宫缩有规律宫缩 -CST -OCT胎儿电子监护的判读胎儿电子监护的判读 胎监图形的各个基本指标的概念、胎监图形的各个基本指标的概念、 客观评价标准、临床意义客观评价标准、临床意义 胎监图形的结果评价胎监图形的结果评价
9、 结果如何指导临床的处理结果如何指导临床的处理胎监的临床意义胎监的临床意义图形图形判读判读评价评价如何如何处理处理各个指标的临床意义各个指标的临床意义 胎儿不存在宫内缺氧胎儿不存在宫内缺氧胎心加速胎心加速 胎头受压胎头受压 胎儿缺氧：第一产程早期的早减胎儿缺氧：第一产程早期的早减早期减速早期减速 胎儿缺氧胎儿缺氧 无脑儿等无脑儿等晚期减速晚期减速 脐带受压脐带受压 胎儿缺氧：非典型变异减速胎儿缺氧：非典型变异减速变异减速变异减速 胎儿缺氧胎儿缺氧正弦曲线正弦曲线 胎监的三级诊断胎监的三级诊断分级分级定义定义评价评价处理处理 同时满足以下条件：同时满足以下条件： 基线基线：110-160bpm
10、基线变异基线变异：中度：中度 晚期或变异减速晚期或变异减速：无：无 早期减速早期减速：有或无：有或无 加速加速：有或无：有或无 正常正常 定期监护定期监护 胎监的三级诊断胎监的三级诊断分级分级定义定义评评价价处理处理 胎心监护未达胎心监护未达和和级标准，如级标准，如 基线：基线：胎心过缓胎心过缓但不伴但不伴变异缺失变异缺失 胎心过速胎心过速 基线变异：基线变异：微小变异微小变异 变异缺失变异缺失不伴反复出现不伴反复出现的的晚期晚期减速减速 显著变异显著变异 加速：刺激胎儿后仍缺失加速：刺激胎儿后仍缺失 周期性减速：周期性减速： 反复出现的变异减速伴微小变异或中度反复出现的变异减速伴微小变异或中
11、度变异变异 延长减速（延长减速（ 2min但但10min） 反复出现的晚期减速伴基线中度变异反复出现的晚期减速伴基线中度变异 非特异性的变异减速非特异性的变异减速 可疑可疑 需进行评估，需进行评估，持续监护和再持续监护和再评估，必要时评估，必要时行其它辅助检行其它辅助检查以确定胎儿查以确定胎儿情况及实施宫情况及实施宫内复苏内复苏 胎监的三级诊断胎监的三级诊断分级分级定义定义评评价价处理处理 满足以下条件之一：满足以下条件之一：胎心基线变异缺失胎心基线变异缺失伴下列情况之一：伴下列情况之一： 反复出现的晚期减速反复出现的晚期减速 反复出现的变异减速反复出现的变异减速 胎心过缓胎心过缓正弦曲线正弦
12、曲线 异异常常 立即评估，迅立即评估，迅速采取措施如速采取措施如吸氧、侧卧、吸氧、侧卧、停止刺激、处停止刺激、处理孕妇低血压理孕妇低血压以及宫缩过频以及宫缩过频引起的胎心改引起的胎心改变；如上述措变；如上述措施均无效，应施均无效，应立即终止妊娠立即终止妊娠 级和级胎心监护的宫内复苏方法 停用催产素停用催产素宫缩过频或过强宫缩过频或过强 阴道检查阴道检查脐带、胎头受压脐带、胎头受压 改变体位改变体位脐带受压脐带受压 血压监测、血氧血压监测、血氧母亲因素母亲因素 常用、但安全性及有效性待证实常用、但安全性及有效性待证实吸氧吸氧 宫缩抑制剂的应用宫缩抑制剂的应用宫缩频密宫缩频密 羊膜腔灌注羊膜腔灌注脐带受压脐带受压
