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正常分娩與異常分娩張斌zhangbinyuan@Threeelements(3P)PowersPassagesPassenger----Foranormaldeliverytotakeplace,eachofthesethreefactorsmustfulfilitsownrole,andinteractefficientlywiththeothertwofactors.ThestagesoflabourFirststage:fullcervicaldilatationSecondstage:deliveryofthebabyThirdstage:deliveryoftheplacentaandmembranes.CardinalmovementsinlabourFetalheaddescentandincreasedflexionInternalrotationExtentionRestitutionExternalrotationPartogramAcompositechartincludesthepatient’sidentificationandhelpstopictoriallypresenttheprogressinlabourNormalLabourConductoftheSecondStageDorsalposition(lithotomyposition)EpisiotomyGuardstheperineumAssisttheflexionandextensionNormalLabourConductoftheThirdstageWhenthebulkoftheplacentaisdelivered,itmayhelptotwistthemembranes-amanoeuvrethatwillstrengthenthetrailingmembranesandgentlyaidtheirseparationfromtheloweruterinesegment.ShoulderDystociaExaggeratedlithotomypositionGenerousepisiotomySuprapubicpressureBreakoneclavicleCasesA29yearoldprimigravidpatientisadmittedtothelabourwardat01.00hours.Sheisatterm,havinghadanuncomplicatedpregnancy,andgivesahistoryofshowandregularpainfulcontraction-likepainoccurring3:10min.Justasshewasadmitted,spontaneousruptureofmembranesoccurred.Onabdominalexaminationsheisfoundtohaveauterinefundalheightcompatiblewithterm;thefetushasalongitudinallieandcephalicpresentation.Onvaginalexaminationthecervixisfoundtobe4cmdilated,fullyeffacedwiththevertexatO-2station,atthepatient’srequst,epiduralanesthesiaisadministeredforanalgesia.Some4hlater,at05.00hours,sheisre-examinedtoassessprogressinlabour.Two-tothree-fifthsofthheadarepalpableabdominally.Onvaginalexaminationthecervixisfoundtobe5-6cmdilated,fullyeffacedwiththefetalheadat0-1station.TheCTGissatisfactoryandtheepiduralanalgesiaremainseffective.Afurther2hlater,at07.00hours,sheisreassessedbythemidwifeandfoundtobe6cmdilatedbutotherwisethefindingshavenotchangedfromthepreviousassessment.Question1Youareaskedtomakeanassessmentofthesituation.Whatdoyouconsidertobethedifferentialdiagnosisforherslowprogressinlabourandhowwouldyoumanagethis? Youexaminethepatientandfindthatthepresentingpartisthevertexintheleftoccipitoanteriorposition;thecervixis6cmdilatedandthevertexis1cmabovetheischialspines.Youprescribeintravenousoxytocin.Twohourslater,youassessher.Shehasuterinecontractions3:10minandtwo-tothree-fifthsofthefetalheadarepalpableabdominally.Thecervixis6-7cmdilated,thevertexremainsat0-1stationandirreducibleoverlap

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