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剖宫产后四大酷刑之二：术后早日下地走

发布日期：2024-08-04 12:07:45编辑：网络收集

在选择分娩方式的时候，很多人会比较纠结，顺产有“四大担心”：一怕宫缩痛，二怕顺转剖，三怕会阴侧切，四怕阴道松弛；剖宫产有“四大酷刑”：压肚子排恶露，术后早日下地走，拔了尿管上厕所，手术之后排浊气。

伸头是一刀，缩头也是一刀，你总得要选择一种分娩方式。

其实顺产并没有你想象的那么可怕，剖宫产也不会像你想的那么爽气，从妇产科医生的角度，我们还是首选推荐顺产的，如果真的是选择了剖宫产，所谓的“四大酷刑”也没那么残酷，上次和大家聊了压肚子排恶露，这次接下来继续聊剖宫产后四大酷刑之二：术后早日下地走。

剖宫产术后大家不肯下地走主要是怕伤口痛，怕宫缩痛，怕伤口裂开，怕引流管导尿管不方便，怕没力气头晕眼花摔倒。

剖宫产术后当医生查房让你早下地的时候，你妈可能会说：医生啊，我们家子涵身体比较弱，刚做完手术中气不足，就让她多静养休息两天吧。

其实这种观念是不对的，老是躺在床上不下地非但无助于身体的恢复，反而会有各种的坏处。为了让大家愿意很快下地走，医生们还是很花心思的，做了很多的临床研究，制订了相应的临床指南，来增加你的信心，解决你的担心。

鼓励所有手术后患者早点下地走的做法被称为“快速康复外科”， ERAS （enhanced recovery after surgery），它指的是指采用一系列有循证医学证据支持的围手术期处理优化措施，以有效降低手术患者机体应激反应, 达到快速康复的目的。

具体的做法是：术后早期下地活动，尽早恢复经口饮水和进食，通过这些做法可以减少和外科手术相关的可能并发症，例如疼痛、切口感染、切口裂开、腹膜炎、腹腔脓肿、下肢静脉血栓、粘连性肠梗阻等。

下床活动应循序渐进，不要勉强，要在本人可耐受范围之内，要注意防止低血糖、体位性低血压，在下床活动时要观察有无头晕、气促、心悸、出冷汗等不适，如发生上述情况，应暂停活动。随着术后时间的延长, 每天每次的活动形式要变化，活动量也要逐渐增加，直至基本恢复到术前状态。

快速康复外科（ERAS）在产科的应用被称为“剖宫产快速康复”（Enhanced Recovery After Cesarean delivery, ERAC)， ERAC与外科的ERAS有很多相同点，但也有不同。

剖宫产的产妇通常较为年轻，较少需要术前优化、术后并发症少，但是她需要自己照顾新生儿，有强大的快速康复的动力。

美国的产科麻醉及围产医学协会（The Society for Obstetric Anesthesia and Perinatology，SOAP）将ERAC的推荐意见从麻醉的角度做了一个总结，共列出了三大类关于择期剖宫产的推荐意见。

术前ERAC推荐

1.术前禁饮禁食的优化

麻醉前禁食固体食物8小时，禁饮清亮液体2小时，术前2小时可饮用无渣高碳水化合物饮料。

2.术前患者宣教

3.母乳喂养的准备和宣教

4.术前优化血红蛋白

妊娠期贫血是产后多种并发症的重要预测因素，纠正产前贫血有利于减少输血，改善认知功能，避免产后抑郁，因此需对孕妇常规进行贫血筛查，并对贫血者补充铁剂治疗。

术中ERAC推荐

1.预防腰麻后低血压

低血压是剖宫产腰麻后常见的不良反应，可能对母体和胎儿造成不良影响，应尽可能维持血压在基础值水平。

2.维持正常体温

术中低体温对母亲和新生儿都可能带来各种，建议采取多种有效的保暖措施，改善产妇体感舒适度，降低低体温相关并发症的发生率。

3.缩宫素的合理应用

输注低剂量缩宫素有助于预防产后出血，减少不良反应的发生。

4.预防性使用抗生素

5.预防术中和术后恶心呕吐（IONV＆PONV）

6.启动多模式镇痛

除了椎管内阿片类药物之外，应在术中（比如胎儿娩出后）就开始非阿片药物镇痛。

7.早期母婴接触

母婴间皮肤与皮肤的接触有利于母乳喂养，并对新生儿过渡到宫外生活带来很多生理益处。条件允许时，在手术室内就应尽早实现母亲和婴儿的皮肤接触。

8.优化静脉输液，避免过多补液

9.延迟脐带结扎（DCC）

对活力好的足月儿和早产儿，DCC时间至少为30～60秒。

术后ERAC推荐

1.早期进食

剖宫产术后早期进食可以促进肠道蠕动，有利于肠道功能的恢复，促进母乳喂养，缩短住院时间。剖宫产术后60min内就可以饮水，只要能耐受，术后4h即可恢复规律饮食。

2.早期下床活动

只有当运动功能足够恢复了才考虑下床活动，例如术后8h内可以考虑逐步从坐在床边过渡到坐在椅子上，24h内只要能耐受就尽可能步行1~2次。

在下床活动前必须去除妨碍早期活动的一些障碍，例如静脉输液、导尿管、明显的疼痛、过度镇静、眩晕、PONV以及椎管内阻滞消退缓慢等。

3.增加休息时间

尽量减少探视者和医务人员对产妇休息的打扰，产妇疲劳可能对认知功能、抑郁、情绪、母婴接触等都有负面影响。

4.早期拔除导尿管

在产后6-12h可以考虑拔除导尿管，这会利于产妇早期下床活动，缩短住院时间，降低尿路感染发生率。

5.采取相应措施预防下肢静脉血栓

6.简化早期出院流程

7.纠正贫血

对术中出血或术前贫血的产妇在产后1-2d进行实验室检查，纠正贫血。

8.母乳喂养的支持

产后1h是启动母乳喂养的黄金1h，母婴间皮肤与皮肤的接触应一直持续至第一次母乳喂养（吮吸乳汁的动作）完成，即使准备人工喂养，母婴接触也至少持续1h。

9.多模式镇痛

可联合多种不同作用机制的药物达到优化术后疼痛管理的目的，并减少不良反应和阿片类药物的使用量。

10.控制血糖

11.促进肠道功能恢复

尽量减少阿片类药物应用以及早期活动都可以促进术后胃肠道功能恢复，此外，咀嚼口香糖也是一个简单而有效的促进胃肠道功能恢复的方法。

所以，在医生和护士的指导与帮助之下，你完全可以在剖宫产术后早下地活动，不用再去有更多的担心了，但令人遗憾的是，并不是所有的医院和医生都会很积极的支持与落实ERAC。

在选择分娩医院的时候，除了要考虑硬件环境和服务以外，很重要的是要看医生们对这些哪怕是很简单的临床行为的专业态度和专业能力，所以你可以问一下你的产检医生，她们对ERAC的态度，以及她们有没有鼓励和支持ERAC的具体措施和做法，这些事貌似简单，但很重要，管理要在现场，魔鬼会在细节。

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