「產兒科護理學-妊娠期婦女的護理」分娩期常見生理現象與胎心變異Common Physiological Phenomena and Fetal Heart Rate Variability during Labor

分娩過程中的常見現象與胎兒狀況
During labor, several physical changes occur in both the mother and the fetus.

產婦的外觀變化
The mother may experience:

臉色潮紅、陰道出血增加： 當胎兒下降，產道受到擠壓時，產婦臉色會變得紅潤，且陰道出血量會增加。這都是正常的生理現象。

A flushed face due to increased blood flow.Increased vaginal bleeding as the baby descends and puts pressure on the birth canal.

宮縮時的用力： 宮縮時，產婦會感到強烈的宮縮感並產生向下用力的衝動，這是身體的自然反應，有助於胎兒順利娩出。

Strong contractions and an urge to push as the body prepares to deliver the baby.

胎位與胎心音

胎兒在子宮中的位置稱為胎位。不同的胎位，胎心音的聽診位置也會有所不同。常見的胎位有：

The position of the baby in the uterus, known as the fetal position, affects where the fetal heartbeat is best heard. Common fetal positions and corresponding fetal heart tone locations are:

左枕前位（LOA）： 胎兒的枕骨（頭部）朝向母親的骨盆左側前方，胎背朝向母親的左上方。胎心音在母親的左上方（靠近背部）聽得最清楚。

In a left occipitoanterior (LOA) position, the baby's head (occiput) is positioned towards the mother's left anterior pelvis. The fetal back faces the mother's left upper quadrant. The fetal heart tone is best heard on the mother's upper left side, closer to her back.

右枕前位（ROA）： 胎兒的枕骨朝向母親的骨盆右側前方，胎背朝向母親的右上方。胎心音在母親的右上方聽得最清楚。

In a right occipitoanterior (ROA) position, the baby's head (occiput) is positioned towards the mother's right anterior pelvis. The fetal back faces the mother's right upper quadrant. The fetal heart tone is best heard on the mother's upper right side.

左枕後位（LOP）： 胎兒的枕骨朝向母親的骨盆左側後方，胎背朝向母親的左下方。胎心音在母親的左下方聽得最清楚。

In a left occipitoposterior (LOP) position, the baby's head (occiput) is positioned towards the mother's left posterior pelvis. The fetal back faces the mother's left lower quadrant. The fetal heart tone is best heard on the mother's lower left side.

右枕後位（ROP）： 胎兒的枕骨朝向母親的骨盆右側後方，胎背朝向母親的右下方。胎心音在母親的右下方聽得最清楚。

In a right occipitoposterior (ROP) position, the baby's head (occiput) is positioned towards the mother's right posterior pelvis. The fetal back faces the mother's right lower quadrant. The fetal heart tone is best heard on the mother's lower right side.

產程分期與呼吸方式
Stages of Labor and Breathing Techniques

產程分為三個階段，每個階段的呼吸方式有所不同：

Labor is divided into three stages:   

第一產程： 子宮頸逐漸開大。

First Stage: This stage begins with regular contractions and ends when the cervix is fully dilated.    

呼吸方式： 吹蠟燭呼吸法、開聲門用力、緩慢哈氣呼吸等，有助於放鬆身體、減緩疼痛。

Breathing techniques: Techniques such as blowing like blowing out a candle, making vocal sounds, and slow, deep breathing can help relax the body and manage pain during contractions.  

第二產程： 胎兒娩出。

Second Stage: The main objective is to push the baby out through the birth canal.   

呼吸方式： 配合宮縮進行屏氣用力，將胎兒推出產道。但要注意用力方式，避免過度用力造成產道撕裂。

Breathing techniques: Bearing down with contractions is essential during this stage. However, it's important to avoid pushing too hard or for too long, as this can increase the risk of tearing.

第三產程： 胎盤娩出。

Third Stage: This stage begins after the baby is born and ends with the delivery of the placenta.   

呼吸方式： 一般呼吸即可，保持放鬆。

Breathing techniques: Normal breathing is sufficient during this stage.

胎心率變化
Fetal Heart Rate Changes

早期減速Early decelerations

胎心率在宮縮時暫時減慢，這是正常的生理現象，表示胎兒對宮縮的反應。

 A temporary decrease in fetal heart rate that occurs with contractions is a normal finding and indicates that the fetus is tolerating labor.   

變異性減速Variability Decelerations

減速的發生時間、深度和恢復時間都變化不定。與子宮收縮的關係不固定，有時可能發生在子宮收縮前、中或後。通常表示臍帶受壓，導致胎兒暫時性缺氧。

Variability decelerations are characterized by inconsistent changes in the timing, depth, and recovery of fetal heart rate decelerations. These decelerations do not have a fixed relationship with uterine contractions and can occur before, during, or after a contraction. They typically indicate umbilical cord compression, leading to temporary fetal hypoxia.

假設胎兒監測器得知，胎兒心跳 100 次／分，持續 80 秒，其型態與宮縮沒有一定關係，此胎心率型態為變異性減速

Analyzing the Scenario: Fetal Heart Rate of 100 bpm for 80 seconds

If fetal monitoring shows a fetal heart rate of 100 beats per minute for 80 seconds with no consistent pattern related to uterine contractions, while initially classified as variability decelerations, this interpretation is incorrect.

胎兒心跳低於正常範圍 (120-160 次/分)，這本身就表示胎兒可能存在問題，需要進一步評估。

Low heart rate: A fetal heart rate below the normal range of 120-160 beats per minute itself suggests potential fetal distress and requires further evaluation.

持續時間過長： 80 秒的減速時間過長，遠超過正常變異性減速的持續時間。

Prolonged deceleration: A deceleration lasting 80 seconds is significantly longer than typical variability decelerations.

雖然變異性減速與宮縮的關係不固定，但通常會與宮縮有一定的關聯。

Lack of consistent relationship with contractions: Although variability decelerations do not have a fixed relationship with contractions, they usually show some correlation.

下列情況易導致待產婦女發生子宮內翻Conditions Leading to Uterine Inversion

子宮內翻是分娩期的併發症，子宮內翻發生在胎盤娩出階段，屬於分娩過程中可能出現的異常情況。

Uterine inversion is an obstetric emergency that occurs when the uterus turns inside out, often during the third stage of labor after the delivery of the placenta.

①娩出胎盤時過度牽引臍帶，會導致胎盤過快剝離，子宮底向上收縮，而子宮頸卻仍呈開的狀態。這時，子宮內膜層就像襪子被翻過來一樣，從子宮頸翻入陰道內，形成子宮內翻。過度牽引臍帶會增加子宮內翻、產後出血、子宮破裂等嚴重併發症的風險。

Excessive traction on the umbilical cord: When the umbilical cord is pulled too forcefully during the delivery of the placenta, it can cause the placenta to separate prematurely. This can lead to the uterus contracting upwards while the cervix remains open, causing the uterus to invert. Excessive traction on the umbilical cord increases the risk of uterine inversion, postpartum hemorrhage, and uterine rupture.

②過早注射 Methergin， Methergin是一種子宮收縮劑，適當的使用可以幫助子宮收縮，減少產後出血。如果在胎盤尚未完全娩出前就過早注射，反而可能導致子宮收縮不協調，增加子宮內翻的風險。但這不是最常見的原因。

Premature administration of Methergin: Methergin is a medication that stimulates uterine contractions to help control postpartum bleeding. If administered too early, before the placenta is completely delivered, it can cause the uterus to contract unevenly and increase the risk of inversion. However, this is not the most common cause.

③在子宮底施加壓力（fundal pressure），在胎盤娩出前，在子宮底施加壓力，確實可能增加子宮內翻的風險。但如果是在胎盤完全娩出後，適當的子宮底按摩可以幫助子宮收縮，減少產後出血。 

Fundal pressure: Applying pressure to the fundus (top of the uterus) before the placenta is delivered can increase the risk of uterine inversion. However, after the placenta is delivered, gentle fundal massage can help the uterus contract and reduce the risk of bleeding.

④胎盤早期剝離，是指胎盤在胎兒娩出前就從子宮壁剝離。雖然這也會導致產後出血，但並非直接導致子宮內翻的原因。

Placental abruption: Placental abruption is a condition where the placenta prematurely separates from the wall of the uterus. While this can lead to postpartum hemorrhage, it is not a direct cause of uterine inversion.

子宮內翻是一種產科急症，需要立即處理。產科醫師在處理胎盤娩出時，應注意避免過度牽引臍帶，並在胎盤完全娩出後，再進行適當的子宮按摩，以降低子宮內翻的風險。

Uterine inversion is a medical emergency that requires immediate treatment. To prevent uterine inversion, healthcare providers should avoid excessive traction on the umbilical cord during the third stage of labor. Once the placenta is delivered, gentle fundal massage can help to prevent uterine inversion and reduce the risk of postpartum hemorrhage.

產後憂鬱症（postpartum depression）

另外產後憂鬱症與產褥期密切相關，產後憂鬱症是產褥期常見的心理問題，與分娩後女性的身心變化息息相關。

Postpartum depression is closely linked to the postpartum period. It is a common mental health condition that women experience after childbirth, and is often associated with the significant physical and emotional changes that occur during this time.

有關產後憂鬱症（postpartum depression）的敘述
Here are some key points about postpartum depression:

持續支持並協助順利哺餵母乳有利於改善症狀，哺餵母乳時，身體會釋放催產素，這種荷爾蒙有助於改善情緒，增加母子連結，對產後憂鬱症有正面影響。

Benefits of breastfeeding: Consistent support and assistance with breastfeeding can help alleviate symptoms of postpartum depression. Breastfeeding triggers the release of oxytocin, a hormone that can improve mood and strengthen the bond between mother and baby.

產後低潮（baby blues）症狀常在產後 4 週出現，且症狀持續超過 2 週

Baby blues symptoms often appear within 4 weeks postpartum and last for more than 2 weeks.

可能與面臨經濟壓力與家事照顧問題有關，產後女性面臨許多新的挑戰，如照顧新生兒、經濟壓力等，這些因素都可能增加產後憂鬱症的風險。

Postpartum depression may be linked to financial stress and the demands of childcare. New mothers often face numerous challenges, such as caring for a newborn and managing financial pressures, which can increase their risk of developing postpartum depression.

可能與產後動情素、黃體素濃度在懷孕期間濃度會大幅上升，以維持懷孕，但在產後會迅速下降，這種急遽的變化可能與產後憂鬱症的發生有關。

The rapid decline in estrogen and progesterone levels after pregnancy, which were elevated to maintain the pregnancy, may contribute to the development of postpartum depression.

乳腺炎Mastitis

乳腺炎通常發生在產後初期，是產褥期常見的哺乳期併發症。乳腺炎的發生與產後泌乳功能的建立密切相關，屬於產後常見的生理現象之一。

Mastitis is a common complication of breastfeeding that often occurs in the early postpartum period. This condition is closely related to the establishment of lactation and is considered a common physiological phenomenon in the postpartum period.

乳腺炎的護理措施
Nursing Care for Mastitis

改善發紅部位的乳房引流，透過頻繁餵奶、按摩等方式，促進乳汁排出，有助於減輕乳腺阻塞，是治療乳腺炎的重要步驟。

Improving milk removal: Frequent breastfeeding and massage can help to reduce milk stasis and alleviate symptoms.

進行完整的哺乳史評估，了解哺乳的頻率、姿勢、寶寶的吸吮方式等，有助於找出導致乳腺炎的原因，並提供更針對性的治療建議。

Comprehensive breastfeeding history: A thorough assessment of breastfeeding frequency, positioning, and infant latch can help identify underlying causes of mastitis and guide targeted treatment.

給予症狀照護，包括：餵奶前服用止痛藥，或餵奶後冰敷止痛，止痛藥和冰敷可以緩解乳房的疼痛和不適，有助於產婦更舒適地進行哺乳。

Symptomatic care: Pain relievers taken before breastfeeding or ice packs applied after breastfeeding can help alleviate discomfort and facilitate continued breastfeeding.

Treatment Sequence for Mastitis

乳腺炎的治療順序：
Treatment sequence for mastitis

初期治療： 乳腺炎初期，通常建議先透過非藥物治療，如頻繁餵奶、熱敷、按摩等方式，促進乳汁排出，改善乳腺阻塞。

Initial treatment: Non-pharmacological interventions, such as frequent breastfeeding, warm compresses, and massage, are typically recommended as the first line of treatment to improve milk removal and reduce milk stasis.

藥物治療： 若非藥物治療效果不佳，且症狀持續惡化，才考慮使用抗生素。

Pharmacological treatment: Antibiotics may be prescribed if symptoms persist or worsen despite non-pharmacological interventions.

乳汁培養： 乳汁培養主要用於排除感染其他病原菌的可能，並非一發現乳腺炎就需要立即進行。

Milk culture: Milk culture is primarily used to rule out infections caused by other pathogens and is not routinely indicated for all cases of mastitis.

過度醫療： 直接進行乳汁培養和抗生素治療，可能導致濫用抗生素，增加細菌產生抗藥性的風險。

Overtreatment: The immediate use of milk cultures and antibiotics for all cases of mastitis can lead to antibiotic overuse and contribute to the development of antibiotic resistance.