Huong Dan Quoc Gia CSSKSS 2009

B Y T
---o0o---

HNG DN QUC GIA
v cc dch v chm sc
sc khe sinh sn
(Ban hnh km theo Quyt nh s 4620/Q-BYT ngy 25/11/2009
ca B trng B Y t)

H Ni, 2009
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MC LC

Cc t vit tt........................................................................................................................................ vii
Li gii thiu ......................................................................................................................................... ix
Cch s dng "Hng dn quc gia v cc dch v chm sc sc khe sinh sn" ..................................... xi
PHN 1 NHNG QUI NH CHUNG .................................................................................................... 1
Mi quan h tng h gia ngi cung cp dch v v cng ng ............................................................ 3
T vn trong chm sc sc kho sinh sn ................................................................................................ 5
Truyn mu v cc dch thay th trong sn ph khoa............................................................................... 8
S dng khng sinh trong sn khoa ....................................................................................................... 11
Cc nguyn tc v khun trong dch v chm sc sc khe sinh sn ...................................................... 13
Qui trnh v khun dng c trong dch v chm sc sc khe sinh sn ................................................... 15
Thuc thit yu chm sc sc khe sinh sn ti tuyn x........................................................................ 17
Trang b thit yu v sc khe sinh sn cho mt trmy t x ................................................................. 20
C s chm sc sc khe sinh sn ti tuyn x ...................................................................................... 23
Bo hnh i vi ph n ....................................................................................................................... 26
Sng lc v p ng ca nhn vin y t i vi bo hnh ph n............................................................ 28
T vn cho ph n b bo hnh ............................................................................................................. 30
T vn, chm sc trc khi c thai ........................................................................................................ 32
PHN 2. LM M AN TON................................................................................................................ 35
A. CHM SC TRC ................................................................................................................... 37
T vn cho ph n c thai ..................................................................................................................... 39
Chn on trc sinh ............................................................................................................................ 41
Hng dn chi tit chm sc trc sinh ................................................................................................. 42
Qun l thai .......................................................................................................................................... 48
B. CHM SC TRONG KHI ........................................................................................................... 51
T vn cho sn ph trong chuyn d v ngay sau .............................................................................. 53
Cc yu t tin lng mt cuc chuyn d ............................................................................................. 55
Chn on chuyn d ............................................................................................................................ 57
Theo di chuyn d thng............................................................................................................... 59
Theo di lin tc cn co t cung v nhp timthai ................................................................................... 63
Biu chuyn d................................................................................................................................. 66
thng ngi chm....................................................................................................................... 69
X tr tch cc giai on 3 ca chuyn d .............................................................................................. 72
C. CHM SC SAU ......................................................................................................................... 75
Lmrn tr s sinh ............................................................................................................................... 77
Kimtra rau .......................................................................................................................................... 78
Ct v khu tng sinh mn .................................................................................................................... 80
Chm sc b m v tr s sinh ngy u sau ..................................................................................... 82
Chm sc b m v tr s sinh tun u sau ...................................................................................... 85
Chm sc b m v tr s sinh 6 tun u sau ................................................................................... 88
D. CC BT THNG TRONG THAI NGHN, CHUYN D V SINH ................................. 91
Thai nghn c nguy c cao .................................................................................................................... 93
Chy mu trong na u thai k ............................................................................................................ 97
Chy mu trong na cui thai k v trong chuyn d ........................................................................... 102
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Chy mu sau ................................................................................................................................. 105
Chong sn khoa ................................................................................................................................. 109
Tng huyt p, tin sn git v sn git ................................................................................................ 112
Sinh i .............................................................................................................................................. 115
Ngi bt thng .................................................................................................................................. 116
Da non v non .......................................................................................................................... 119
Thai qu ngy sinh .............................................................................................................................. 121
V i non ............................................................................................................................................ 122
Sa dy rn ........................................................................................................................................... 123
Thai cht trong t cung ........................................................................................................................ 125
Nhim HIV khi c thai ........................................................................................................................ 126
X tr ph phi cp trong chuyn d .................................................................................................... 128
Chuyn d nh tr .............................................................................................................................. 129
Theo di cuc vi sn ph c so m t cung .............................................................................. 130
Suy thai cp ........................................................................................................................................ 131
S dng oxytocin ................................................................................................................................ 132
S dng thuc gimco t cung trong chuyn d ................................................................................. 134
St sau ............................................................................................................................................ 135
Pht hin cc du hiu nguy him, x tr v chuyn tuyn cc cp cu sn khoa .................................. 140
ti nh v x tr ri ............................................................................................................... 146
E. CC TH THUT V PHU THUT ........................................................................................... 151
Cc phng php v cmtrong sn khoa ............................................................................................. 153
Cc phng php gy chuyn d.......................................................................................................... 160
K thut bmi ................................................................................................................................... 163
Nghimphp lt ngi chm................................................................................................................. 165
u trong ngi mng ...................................................................................................................... 167
Xoay thai trong ................................................................................................................................... 169
X tr thai th hai trong sinh i .......................................................................................................... 171
Forceps ............................................................................................................................................... 173
Gic ko .............................................................................................................................................. 175
Bc rau nhn to ................................................................................................................................. 177
Kimsot t cung ............................................................................................................................... 179
Phu thut ly thai ............................................................................................................................... 180
Phu thut thai ngoi t cung ............................................................................................................... 182
K thut h tr sinh sn ....................................................................................................................... 183
G. PHN KHC .................................................................................................................................... 185
Chc d ti cng sau v m ti cng sau.............................................................................................. 187
Tui mn kinh ..................................................................................................................................... 189
Khmph khoa ................................................................................................................................... 192
Khmv ............................................................................................................................................. 194
Cc bnh lnh tnh tuyn v................................................................................................................. 195
Cc tn thng lnh tnh c t cung..................................................................................................... 197
U x t cung ....................................................................................................................................... 199
Nang bung trng ............................................................................................................................... 200
Tn thng tin ung th c t cung ..................................................................................................... 202
Ung th xm ln c t cung ................................................................................................................. 204
Ung th v .......................................................................................................................................... 206
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PHN 3. CHM SC S SINH ...........................................................................................................209
Giao tip v h tr tinh thn i vi gia nh tr bnh ......................................................................... 211
Chuyn vin an ton cho tr s sinh..................................................................................................... 213
Cho tr ra vin .................................................................................................................................... 215
Phi hp chuyn ngnh sn khoa v nhi khoa trong chm sc tr s sinh ............................................. 216
Nguyn tc s dng khng sinh cho tr s sinh .................................................................................... 218
Thuc thit yu trong chm sc tr s sinh ti cc tuyn ...................................................................... 219
Trang thit b thit yu cho chm sc s sinh ti cc tuyn y t ........................................................... 220
Chm sc tr s sinh non/nh cn ................................................................................................... 221
Chm sc tr bng phng php Cng-gu-ru ....................................................................................... 222
D tt s sinh cn can thip sm.......................................................................................................... 224
T vn nui con bng sa m .............................................................................................................. 225
H thn nhit tr s sinh ................................................................................................................... 227
Ri lon nc in gii ....................................................................................................................... 228
Vng da tng bilirubin t do ................................................................................................................ 229
Suy h hp s sinh .............................................................................................................................. 230
Vimphi ........................................................................................................................................... 231
Th p lc dng lin tc (CPAP)....................................................................................................... 232
Xut huyt tr s sinh....................................................................................................................... 233
Nhimkhun huyt s sinh ................................................................................................................. 234
Nhimkhun mt ................................................................................................................................ 236
Nhimkhun rn ................................................................................................................................ 238
Tr sinh ra t m b vim gan B, lao, lu, giang mai, HIV .................................................................... 240
Hi chng co git ................................................................................................................................ 243
Cp cu sc sa .................................................................................................................................. 244
Hi sc s sinh ngay sau ................................................................................................................ 245
Truyn mu ........................................................................................................................................ 247
t catheter tnh mch rn .................................................................................................................. 249
Nui dng tr s sinh bng ng tnh mch ..................................................................................... 250
Thay mu tr s sinh ........................................................................................................................ 251
Ly mu ng mch ............................................................................................................................ 252
Ly mu gt chn................................................................................................................................ 253
t ni kh qun ................................................................................................................................. 254
Chc ht v t ng dn lu mng phi ............................................................................................... 255
K thut t ng thng d dy cho tr s sinh ...................................................................................... 256
K thut chiu n iu tr vng da ..................................................................................................... 257
Chc d tu sng ................................................................................................................................ 258
H ng huyt s sinh ....................................................................................................................... 259
PHN 4. K HOCH HA GIA NH...............................................................................................261
T vn k hoch ha gia nh .............................................................................................................. 263
Dng c trnh thai trong t cung ......................................................................................................... 266
Bao cao su .......................................................................................................................................... 274
Vin thuc trnh thai kt hp .............................................................................................................. 276
Vin thuc trnh thai ch c Progestin ................................................................................................. 281
Thuc timtrnh thai .......................................................................................................................... 286
Thuc cy trnh thai............................................................................................................................ 291
Trit sn nambng phng php tht v ct ng dn tinh .................................................................... 297
Trit sn n bng phng php tht v ct vi t cung ......................................................................... 300
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Bin php trnh thai khn cp .............................................................................................................. 304
Cc bin php trnh thai truyn thng (t nhin) .................................................................................. 307
Bin php trnh thai cho b v kinh ..................................................................................................... 309
Tiu chun phng th thut.................................................................................................................. 311
PHN 5. NHIM KHUN NG SINH SN V NHIM KHUN LY TRUYN QUA NG
TNH DC ............................................................................................................................................. 313
Hng dn chung ................................................................................................................................ 315
Hi chng tit dch m o .................................................................................................................. 322
Hi chng tit dch niu o namgii ............................................................................................... 325
Si mo g sinh dc ............................................................................................................................ 328
Hi chng au bng di .................................................................................................................... 331
Hi chng lot sinh dc ....................................................................................................................... 334
Hi chng sng hch bn .................................................................................................................... 338
Danh mc thuc iu tr nhimkhun ng sinh sn/nhimkhun ly truyn qua ng tnh dc....... 341
PHN 6. SC KHE SINH SN V THNH NIN V THANH NIN .......................................... 345
Hng dn chung ................................................................................................................................ 347
Nhng c imgii phu, tmsinh l trong thi k v thnh nin....................................................... 348
K nng sng lin quan n sc khe sinh sn/sc khe tnh dc ca v thnh nin v thanh nin
Tnh dc an ton v lnh mnh ............................................................................................................ 353
T vn v sc khe sinh sn v thnh nin v thanh nin ...................................................................... 355
Kinh nguyt v xut tinh v thnh nin .............................................................................................. 357
Thm khm sc khe sinh sn cho v thnh nin v thanh nin ............................................................. 361
Cc bin php trnh thai cho v thnh nin v thanh nin ...................................................................... 364
Mang thai v thnh nin .................................................................................................................... 366
V thnh nin v thanh nin vi vn bo hnh .................................................................................. 369
Dch v sc khe thn thin vi v thnh nin v thanh nin ................................................................. 372
PHN 7. PH THAI AN TON .......................................................................................................... 377
Hng dn chung ................................................................................................................................ 379
T vn v ph thai ............................................................................................................................... 380
Ph thai bng phng php ht chn khng ......................................................................................... 384
Ph thai bng thuc n ht tun th 9 ................................................................................................. 387
Ph thai bng thuc t tun 13 n ht tun 22 .................................................................................... 390
Ph thai bng phng php nong v gp t tun 13 n ht tun 18 ..................................................... 393
X l dng c ht thai chnn khng bng tay ....................................................................................... 396
PHN 8. NAM HC............................................................................................................................. 399
Mn dc namgii ............................................................................................................................... 401
Suy sinh dc nam................................................................................................................................ 404
V sinh nam ........................................................................................................................................ 406
Ri lon cng dng ......................................................................................................................... 409
Xut tinh sm...................................................................................................................................... 412
Xut tinh ra mu .................................................................................................................................. 414
L i lch thp ................................................................................................................................... 417
X cng vt hang ................................................................................................................................ 419
Tinh hon n th cao ........................................................................................................................... 421
Gin tnh mch tinh ............................................................................................................................. 423
Tnh dc ng gii .............................................................................................................................. 425
Cc ri lon bit ha gii tnh sinh dc ................................................................................................ 427
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PHN PH LC....................................................................................................................................431
Quyt nh S 17/2005/Q-BYT ngy 01/7/2005 ca B trng B Y t v vic ban hnh danh mc
thuc thit yu Vit Nam ln th V ..................................................................................................... 433
Quyt nh s 120/2008/Q-TTg ngy 29/8/2008 ca Th tng chnh ph v vic quy nh iu kin xc
nh ngi b phi nhimvi HIV, b nhimHIV do tai nn ri ro ngh nghip ................................... 449
Quyt nh s 4361/Q-BYT ngy 07/11/2007 ca B trng B Y t v vic ban hnh Quy trnh chm
sc v iu tr d phng ly truyn HIV t m sang con ...................................................................... 455
Quyt nh s 06/2007/Q-BYT ngy 19/01/2007 ca B trng B Y t v vic ban hnh Quy ch
truyn mu .......................................................................................................................................... 481
Quyt nh s 12/2005/Q-BYT ngy 28/03/2005 ca B trng B Y t v vic ban hnh Quy nh
chuyn mn trong cng tc xt nghim HIV bo man ton truyn mu ..................................... 508
Danh sch cc c nhn v t chc tham gia qu trnh xy dng v cp nht Hng dn quc gia v cc
dch v chm sc sc khe sinh sn ..................................................................................................... 511

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CC T VIT TT
BMTE B m tr em
BPTT Bin php trnh thai.
BVSKBMTE Bo v sc kho b m tr em.
CSSK Chm sc sc kho.
DCTC Dng c t cung
v, IU n v
HIV/AIDS Virus gy suy gim min dch ngi/hi chng suy gim min
dch mc phi.
KHHG K hoch ho gia nh.
LTQTD Ly truyn qua ng tnh dc.
NKSS Nhim khun ng sinh sn.
NKLTQTD Nhim khun ly truyn qua ng tnh dc.
SKSS Sc kho sinh sn.
SKTD Sc kho tnh dc.
VTN V thnh nin.
VTN/TN V thnh nin/thanh nin.

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LI GII THIU

Hi ngh quc t v Dn s v Pht trin hp ti Cair nm 1994, vi s tham d ca
trn 180 nc trn th gii trong c Vit Nam, nht tr vi cch tip cn ton din v
chm sc sc khe sinh sn (SKSS). Sau hi ngh Vit Nam thc hin cam kt ca mnh
thng qua mt lot cc bin php nhm nng cao cht lng v a dng ha cc loi hnh
dch v chm sc SKSS p ng nhu cu chm sc SKSS ca nhn dn, h thp t l t
vong m v t vong tr em.
Trong qu trnh thc hin cc dch v chm sc SKSS, vic chun ha cc hot ng
chuyn mn l vn cn c c bit ch trng nhm nng cao cht lng dch v chm
sc SKSS v hn ch ti a nhng sai st c th xy ra. Cun "Hng dn chun quc gia
v cc dch v chm sc SKSS" c B Y t ban hnh ln th nht nm 2002 bc
u a cng tc chm sc SKSS cho nhn dn i vo nn np, hn ch sai st v p ng
c phn ln yu cu quan trng trn.
Hng dn Chun quc gia v cc dch v chm sc SKSS nm 2002 c p dng
cho tt c cc c s y t bao gm c y t nh nc v t nhn c bit l tuyn y t c s,
l c s php l cho vic thc hin dch v chm sc SKSS, l cm nang hng dn cho
cn b y t trong qu trnh cung cp dch v v cng l c s xy dng cc ti liu o
to cho cn b y t, cng tc gim st, cng tc nh gi cht lng dch v chm sc
SKSS ti cc c s y t.
Tuy nhin, sau 5 nm thc hin Hng dn chun quc gia v cc dch v chm sc
SKSS, nhiu tin b khoa hc k thut trong lnh vc chm sc sc khe b m, tr em
c trin khai p dng v nhiu quy nh trong Hng dn chun quc gia khng cn
ph hp vi thc t cn c b sung, sa i. Chnh v vy B Y t ch trng r sot, b
sung v cp nht Hng dn quc gia v cc dch v chm sc SKSS thay th cho
Hng dn chun trc y.
Ti liu Hng dn quc gia v cc dch v chm sc SKSS c bin son vi s
tham gia ca cc ng ch lnh o v chuyn vin cc V, Cc ca B Y t, cc Vin,
Bnh vin u ngnh v Sn Ph khoa, Nhi khoa v Da liu, ca cc chuyn gia trong v
ngoi nc vi s h tr c v ti chnh v k thut ca Vn phng Qu Dn s Lin hip
quc (UNFPA), Qu Nhi ng Lin hip quc (UNICEF), T chc Y t th gii (WHO),
IPAS, Pathfinder International, Qu Ford foundation, T chc Cu tr nhi ng M
(SCUS). Trong qu trnh son tho, ti liu nhn c nhiu kin ng gp qu bu
cu cc cn b y t a phng ca cc t chc trong nc v quc t hot ng trong lnh
vc chm sc SKSS ti Vit Nam.
y l ln th hai B Y t xy dng v ban hnh "Hng dn quc gia v cc dch v
chm sc SKSS", mc d rt c gng nhng cng khng th trnh khi nhng thiu st
v mt ni dung v in n. B Y t rt mong nhn c nhng kin ng gp qu bu
ti liu c hon thin hn trong nhng ln xut bn sau.
Xin trn trng cm n!
H ni ngy .... thng .... nm 2009
Th trng B Y t

Ts.Trn Ch Lim
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CCH S DNG
"HNG DN QUC GIA V CC DCH V
CHM SC SC KHE SINH SN"
1. Gii thiu tm tt v qu trnh xy dng
gp phn thc hin thng li "Chin lc quc gia v chm sc sc khe sinh sn
giai on 2001 - 2010", mt trong nhng bin php quan trng l nng cao cht lng v
a dng ha cc loi hnh dch v chm sc SKSS nhm p ng nhu cu ngy cng tng
ca nhn dn. Hng dn Chun quc gia v cc dch v chm sc SKSS nm 2002 p
ng c mt phn quan trng i hi cp bch nu trn.
Tuy nhin, sau 5 nm thc hin Hng dn chun quc gia v cc dch v chm sc
SKSS, nhiu tin b khoa hc k thut trong lnh vc chm sc sc khe b m, tr em
c trin khai p dng v nhiu quy nh trong Hng dn chun quc gia khng cn
ph hp vi thc t cn c b sung, sa i. Chnh v vy B Y t ch trng r sot, b
sung, cp nht ban hnh Hng dn quc gia v cc dch v chm sc SKSS mi.
Mc ch ca ti liu nhm:
- Chun ha cc dch v chm sc SKSS: vi vic ban hnh cc qui trnh v hng dn
chun v cc dch v chm sc SKSS, ti liu ny khng nhng l c s cho vic thc hin
cc dch v chm sc SKSS, m cn cung cp, cp nht cho cn b y t nhng qui nh v
hng dn c bn gip cho vic tra cu trong qu trnh cung cp dch v qua nhm
nng cao cht lng v a dng ha dch v chm sc SKSS.
- Cung cp c s xy dng cc ti liu o to trong lnh vc chm sc SKSS: sau
khi Hng dn ra i, cc ti liu phc v cho vic o to k c o to mi v o to li
thuc lnh vc chm sc SKSS s c bin son, chnh l v b sung.
- Cung cp c s xy dng cc cng c phc v cng tc gim st v nh gi cc
c s v cn b cung cp dch v chm sc SKSS: hng dn ny s l ti liu xy
dng cc tiu chun nh gi cht lng cung cp dch v cng nh xy dng cc bng
kim qui trnh k thut, hng dn chm sc gip cng tc theo di, gim st.
Hng dn quc gia v cc dch v chm sc SKSS 2009 c son tho cng phu vi
s tham gia ca cc chuyn gia trong nc v s h tr k thut ca cc chuyn gia quc t
thng qua cc hi tho, tho lun nhm. Hng dn quc gia 2009 cng qua cc ln th
nghim ti mt s tnh c 3 min Bc, Trung v Nam. Trong qu trnh xy dng, Hng
dn quc gia cng c gi xin kin ca cc t chc quc t ang hot ng trong lnh
vc chm sc SKSS ti Vit Nam. Tt c cc kin ng gp ca cc t chc v c nhn
trong v ngoi nc u c nhm son tho cn nhc k lng trong qu trnh bin
son v sa cha cho ph hp vi iu kin thc tin ca Vit Nam.
2. Hng dn s dng
Ti liu bao gm 8 phn da theo 8 ni dung u tin lin quan n chm sc SKSS:
Phn I: Nhng hng dn chung
Phn ny bao gm nhng ch c lin quan n ton b cc ni dung ca cun sch
th d: t vn trong chm sc SKSS, cc qui nh v trang thit b v c s cung cp dch
v chm sc SKSS ti tuyn x, cc nguyn tc c bn trong truyn mu, truyn dch,
nguyn tc v qui trnh v khun, s dng khng sinh trong sn ph khoa, ...
Phn II: Chm sc s sinh
xii |
Phn ny l cc ch v chm sc s sinh, bao gm c giao tip, h tr, thuc, trang
thit b v cc k thut lin quan
Phn III: Lm m an ton
Phn ny bao gm ton b cc ch thuc lnh vc lm m an ton c trnh by
theo th t t chm sc trc , chm sc trong khi , chm sc sau v cc bt
thng trong thai nghn v chuyn d, cc th thut, phu thut v mt s vn v ph
khoa.
Phn IV: K hoch ha gia nh
Phn ny gii thiu cc bin php trnh thai hin i v truyn thng v ang c
s dng ti Vit Nam.
Phn V: Nhim khun ng sinh sn v bnh ly truyn qua ng tnh dc
Phn ny trnh by nhng hi chng hoc nhng bnh thng gp ng sinh sn
trong bao gm c cc bnh ly truyn qua ng tnh dc.
Phn VI: Sc khe sinh sn v thnh nin
Phn ny ch yu cp n cc vn bt thng v SKSS thng gp v thnh
nin v cc hng dn khi thm khm cng nh tip xc vi v thnh nin.
Phn VII: Ph thai an ton
Phn ny trnh by cc phng php ph thai hin ang p dng ti Vit Nam.
Phn VIII: Nam hc
Phn ny gm mt s ch v sc khe sinh sn cho nam gii

Trong cc ni dung t phn II n phn VIII, cc hng dn chung v cc vn t
vn chuyn bit ca tng phn c a ln u, ring cc vn lin quan n t vn c
th cho tng ch c lng ghp vo trong tng ch tin p dng khi cung cp
dch v.
Cc ni dung lin quan n ni dung Lm m an ton, K hoch ha gia nh v Ph
thai an ton c B Y t ban hnh trong cun "Qui trnh k thut bnh vin" v nhng
ni dung v HIV/AIDS lin quan n lnh vc chm sc SKSS c B Y t ban hnh
nhng nm trc nu khng ph hp vi Hng dn quc gia v chm sc SKSS 2009 th
phi thc hin theo Hng dn quc gia.
Cc ni dung trong ti liu ny ch a ra nhng bc tin hnh c bn, nhng nguyn
tc chung cn tun th gip cho cn b cung cp dch v trong qu trnh thc hin khng
b st cc bc trnh cc sai st c th xy ra. c bit trong tng ch ca ti liu
u ch trng n hng dn x tr theo tuyn da trn Quy nh ca B Y t v nhim v
k thut trong lnh vc chm sc SKSS ti cc c s y t. Phn hng dn c th cho tng
thao tc k thut theo Hng dn quc gia (tr mt s phn chuyn khoa su nh Nam
hc, cc phng php v cm trong sn khoa) s c cp mt cch c th trong gio
trnh o to.
Ban son tho
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PHN 1
NHNG QUI NH CHUNG
2 |

3 |
MI QUAN H TNG H
GIA NGI CUNG CP DCH V V CNG NG

Tuyn p dng.
Tt c cc tuyn.
Ngi thc hin.
Cn b cung cp dch v.

1. Mi quan h gia y t nh nc v cng ng.
1.1. Ti tuyn x.
Ngi cung cp dch v:
- Thng xuyn lm vic vi cng ng ci thin SKSS.
- Gii thch c nhng nguyn nhn gy nh hng n SKSS cho mi ngi trong
cng ng.
- Xc nh c nhng vic cn thit m ngi cung cp dch v phi lm h tr
cng ng. C k hoch nh k tip xc vi cng ng (i xung thn, bn, xm).
- To iu kin thun li, chia s vi cng ng v vn h gp phi, t k hoch
tm ra bin php gii quyt.
- Cng lm vic vi cng ng gii quyt cc vn ny sinh.
- Khi giao tip vi cng ng, phi nhn bit nhng ngi ch cht trong cng ng,
gip h bit v vai tr v chc nng ca h cng nh nhng kh khn v hn ch h
gp phi.
1.2. T tuyn huyn tr ln.
Ngi cung cp dch v:
- Phi cho n nim n vi ngi bnh, ngi nh ca ngi bnh v ngi cung cp
dch v t tuyn di n.
- Phi ng vin, cm n ngi cung cp dch v tuyn di chuyn ngi bnh ln
tuyn trn.
- a ra nhng hng dn lm sng, gi thch hp v kn o cng c v duy tr s
tn nhim ca cng ng i vi tuyn di.
- Cn gp g v trao i vi ngi cung cp dch v tuyn di tng uy tn ca h
vi cng ng. C k hoch nh k i xung cc c s tuyn di gim st h tr.
- Tn trng v m bo tnh ring t ca ngi bnh, to iu kin thoi mi cho h v
gia nh ngi bnh.
2. Mi quan h gia y t t nhn v cng ng.
- Cc c s y t t nhn cung cp cc dch v cho cng ng tun theo qui nh v
chuyn mn, nghip v, c s vt cht.
- Gii thch c vn ca ngi bnh, t vn cho h ti c s y t ph hp khi tin
lng bnh vt qu kh nng ca mnh.
- Tn trng v bo m tnh ring t ca ngi bnh, cn chia s thng tin vi ngi
bnh trong qu trnh cung cp dch v.
4 |
3. Mi quan h gia cc tuyn ca y t nh nc.
Ngi bnh (v ngi nh) t tuyn di thng c chuyn ln tuyn trn, ni c
sn cc iu kin can thip phu thut v chm sc s sinh.
3.1. Thc hin.
Tuyn di:
- Khi chuyn ngi bnh ln tuyn trn cn c cc dng c, vt dng cn thit.
- Cung cp thng tin v ngi bnh nh tn, tui, a ch, bnh n, tin s sn khoa,
nguyn nhn chuyn tuyn v l do khc, cch iu tr tin hnh v kt qu.
Tuyn trn:
- ng vin v cm n n lc ca tuyn di trong vic chuyn ngi bnh ti c s y
t.
- Phn hi: sau khi x tr cc trng hp t tuyn di chuyn ln, cn b y t tuyn
trn cn thng bo cho tuyn di v kt qu x tr v iu tr nu c th c.
Tuyn ngang nhau
- Chia s, gip , hp tc.
3.2. Gim st h tr v o to thng xuyn.
- Tuyn trn thc hin gim st h tr cho tuyn di nhm tng cng nng lc v ci
thin cht lng dch v.
- Tng cng vic ch o tuyn ca tuyn trn i vi tuyn di.
- Thc hin o to li, cm tay ch vic cho tuyn di.
4. Mi quan h gia y t nh nc v y t t nhn.
- Cc c s y t nh nc v y t t nhn u l nhng ni cung cp dch v chm sc
SKSS theo qui nh ca B Y t.
- Nhn vin y t ca y t nh nc v t nhn c mi quan h bnh ng vi nhau trn
mi phng din.
- Hot ng ca y t nh nc v t nhn gn b cht ch vi nhau, gip , h tr ln
nhau cung cp dch v c cht lng cao.
- C s y t t nhn cn lin h vi cc c s y t nh nc nhn c s hp tc, h
tr, gip khi cn thit v ngc li.
- Vic o to li, cp nht cn thc hin c vi y t nh nc v t nhn.
5. Mi quan h gia ngi cung cp dch v vi nhng nhm khch hng c
bit.
- Nhm khch hng nhim bnh LTQTD v HIV/AIDS.
- Nhm khch hng v thnh nin.
- Nhm khch hng b bo hnh.
* Lu : Ngi cung cp dch v cn ch n vai tr ca nam gii v gia nh trong
chm sc SKSS.
| 5
T VN TRONG CHM SC SC KHO SINH SN
Tuyn p dng.
Tt c cc tuyn.
Ngi thc hin.
Cn b cung cp dch v.

T vn trong chm sc SKSS l qu trnh giao tip hai chiu gia nhn vin y t v
khch hng theo yu cu ca h. y l mt phn quan trng khng th thiu trong dch v
chm sc SKSS.
Tt c cn b, nhn vin y t lm dch v chm sc SKSS u phi t vn cho khch
hng. Trng hp khch hng cn t vn chuyn su mt vn no s c gii thiu
n cc chuyn gia trong tng lnh vc.
1. Nhng nguyn tc chung v t vn trong dch v chm sc SKSS.
- T vn v chm sc SKSS phi da trn nhu cu, mong mun ca khch hng.
- T vn cn da trn s tin cy, tn trng ln nhau, nhm gip khch hng c hiu bit
ng, bit cch x tr v quyt nh cc vn v SKSS ca bn thn.
- Cn b y t chuyn trch t vn phi c kin thc chuyn mn tt v chm sc SKSS,
phi gii quyt c cc vn nguy c v kh nng d b mc nhim khun ng
sinh sn ca khch hng.
- Phi c hiu bit v qui trnh v c k nng t vn v SKSS.
- Mi cuc t vn c th c mc ch, ni dung, phng php c th khc nhau nhng
u c chung cc k nng, yu cu v cc bc t vn.
2. Nhng yu cu ca mt cuc t vn c cht lng.
2.1. Tn trng khch hng.
- Cn b t vn phi m bo gi b mt, khng tit l thng tin v khch hng nu cha
c khch hng ng .
- Tn trng khch hng, bt k h l ai v h c vng mc g. Chp nhn m khng
phn xt.
- Phi kin tr lng nghe hiu r nhu cu v mong mun ca khch hng.
- t mnh vo hon cnh ca khch hng hiu h ngh g, mun g v lm th no
gip h.
- Mun t vn c hiu qu cn xy dng mi quan h thoi mi, tin cy, ci m, tn tr
ng gia cn b t vn v khch hng.
2.2. Cung cp thng tin chnh xc v r rng.
- Cn cung cp nhng thng tin chnh xc m khch hng mun bit, cn bit, bao gm
c nhng yu t khng thun li v nguy c.
- S dng ngn ng d hiu, trnh dng thut ng chuyn mn. Khuyn khch khch
hng hi li, sau gii thch r hoc hn ln sau tr li.
- Trc khi kt thc t vn cn hi li xem khch hng hiu ng cha, cn g cha
r. Nhc li hoc tm tt nhng g khch hng cn bit hoc cn lm. Hn gp li nu
cn.
6 |
3. Cc k nng t vn c bn.
3. 1. K nng tip n.
- Cho hi khch hng v t gii thiu nhm to s thn mt.
- Tip xc c bng i thoi ln c ch (vui v, chm ch, sn lng).
3.2. K nng lng nghe.
- Kin tr lng nghe hiu r nguyn nhn ca cc vn , cc lo lng v mong mun
ca khch hng.
- Ch lng nghe lm cho khch hng cm thy vn ca h c nhn bit, tn trng
v thng cm, nh gim c s cng thng, bt an.
- Chp nhn mi iu khch hng ni, khng bc b hoc ph phn m cn tm hiu s
lo u ca khch hng.
- Kin tr nu khch hng c thc mc, do d, khc lc hoc bc tc.
3.3. K nng giao tip.
- Theo di cu chuyn ca khch hng bng cc iu b ph hp nh tip xc bng nh
mt, gt u...
- Cn b t vn cn quan st phn ng ca khch hng. C gng tm hiu l do gy nn
thi ca khch hng i vi vn ca mnh (nh lng tng, lo lng, tc gin, tuyt
vng...).
- K cho khch hng nghe mt vi trng hp thc t to c hi cho khch hng ni.
- Cn b t vn phi c k nng s dng cc phng tin thng tin, gio dc truyn
thng.
3.4. K nng gii quyt vn .
- Cn phi xc nh bn cht ca vn .
- Xc nh cc nguy c hoc hnh vi khng ng, khuyn khch khch hng nhn nhn
li nhng quan nim, t duy ca mnh v tm cch thay i nu cn thit.
- Tch cc tm kim cc gii php khc nhau, trong mi gii php khng ch nu u
im thun li m cn phi ni r cc iu khng thun li, thm ch c nhng ri ro,
bin chng khch hng suy ngh, la chn.
- Gip khch hng xem xt tng gii php v quyt nh p dng gii php ph hp
nht, nhng khng p t khch hng phi theo kin ca mnh.
- m bo vi khch rng h lun c h tr khi tm v thc hin gii php.
- i khi cn b t vn cn gip khch hng c c nhng k nng mi nh k nng
trao i v tnh dc an ton.
Cc lu c bit khi t vn cho khch hng tr tui
- T vn cho khch hng tr tui c th mt nhiu thi gian hn.
- Ngi tr tui phi cm thy tin tng rng nhng iu ring t v b mt ca h c
tn trng.
- Hy nhy cm vi kh nng c bo hnh tnh dc hoc p dm. Quan h vi nhng bn
tnh nhiu tui hn, nhiu kh nng l do p dm v nguy c nhim bnh
LTQTD/HIV cao hn.
- Bo m chc chn ngi tr tui hiu c s pht trin tnh dc bnh thng v hin
tng c thai xy ra nh th no.
| 7
- Bo m chc chn ngi tr tui c th ni khng i vi quan h tnh dc khng
an ton.
- Tho lun cc vn lin quan n dng ma ty, ru v tnh dc khng an ton.
- S tham gia ca cc ng ng vin c th l hu ch.
- Hy tm hiu xem ngi v thnh nin c tin mua thuc cn cho iu tr bnh
LTQTD v c th iu tr liu khng. Nhng ngi tr tui c bit hay ngng
hoc gin on liu trnh iu tr khi h thy tc dng ph.
- m bo cc ln khm li c sp xp thi im thun li cho cc khch hng tr.
4. Cc bc ca qu trnh t vn.
4.1. Gp g.
- Cn b t vn cho hi thn thin, nhit tnh, mi khch hng ngi...
- T gii thiu v mnh.
- Tr chuyn to s thoi mi, tin cy.
4.2. Gi hi.
- Gi hi nhu cu, mong mun, l do khch hng cn t vn. Tm hiu nhng nhu cu v
SKSS hin ti v sp ti ca khch hng.
- Gi hi cc thng tin c lin quan n cc vn cn c t vn (gia nh, iu kin
sng, bnh s, nhng lo lng v hiu bit ca khch...).
- Nn s dng cu hi m, ch lng nghe, quan st.
4.3. Gii thiu.
- Cn b t vn phi cung cp nhng thng tin chnh xc, ph hp v cn thit cho
khch (c mt tch cc v tiu cc, c cc yu t thun li v khng thun li).
- S dng cc phng tin thng tin, gio dc truyn thng ph hp.
- Cn b t vn khng c p t i vi khch.
4.4. Gip .
- Cn b t vn phi gip khch hng hiu c thc cht vn ca h gip h la
chn quyt nh ph hp.
- Hng dn c th gip khch hng bit phi lm g t gii quyt vn ca mnh.
4.5. Gii thch.
- Gii thch nhng g khch hng cn thc mc hoc hiu cha ng.
- Cung cp ti liu hng dn c lin quan n vn ca h.
4.6. Gp li.
Hn khch hng quay tr li theo di kt qu hoc gii thiu tuyn trn t vn,
iu tr tip nu cn thit.
Trong 6 bc trn, tr bc 1 v 6 l bc u v cui ca bui t vn, cn li cc
bc khc phi thc hnh xen k nhau, khng phi theo th t ht bc ny mi chuyn
sang bc khc. Trong 4 bc vic gi hi l quan trng nht. C gi hi tt mi bit
c khch hng suy ngh, hnh ng th no gii thiu, gip v gii thch thit thc
nht i vi h.
5. a im t vn.
- Cn kn o, bo m tnh ring t.
- Cn c tranh nh, thng tin, ch dn, ti liu hng dn lin quan n SKSS.
8 |
TRUYN MU V CC DCH
THAY TH TRONG SN PH KHOA

Tuyn p dng.
Truyn mu: t tuyn huyn tr ln.
Truyn dch: t tuyn x tr ln.
Ngi thc hin.
Truyn mu:
Ngi ch nh: bc s (thng qua hi chn).
Ngi theo di: bc s, n h sinh, y s, iu dng vin.
Truyn dch:
Ngi ch nh: bc s (i vi x khng c bc s: n h sinh, y s).
Ngi theo di: bc s, n h sinh, y s, iu dng vin.

1. Truyn dch.
Truyn dch thay th l liu php iu tr u tay trong trng hp gim th tch tun
hon. N c th cu sng ngi bnh v to ra khong thi gian khng ch chy mu v
ch i ly mu truyn nu cn thit.
1.1. Ch nh.
- Khi lng dch trong c th mt i do qu trnh phu thut hoc trong chuyn d hoc
bnh tt.
- duy tr huyt p trong khi ch i truyn mu.
1.2. Dch thay th.
- Nc mui ng trng 0,9% v Ringer lactat l dung dch c dng thay th mu
iu tr gim th tch tun hon.
- Trong trng hp khng c 2 loi trn c th dng glucose 5 % thay th.
1.3. Kim tra dch truyn.
- Phi kim tra chai dch hoc ti ng c nguyn vn khng.
- Kim tra xem cn hn s dng khng.
- Kim tra dung dch c trong khng.
1.4. Theo di.
- Trc khi truyn, phi kim tra: mch, huyt p, nhit , nhp th, lng nc tiu.
- Trong khi truyn: theo di mch, huyt p 15 pht/ln, lng nc tiu v theo di
nhng phn ng c th xy ra (st rt run, chong).
- Trong trng hp mt mu nng, truyn dung dch mui ng trng hoc Ringer
lactat 1 lt trong 20 pht nng huyt p.
- Sau khi truyn: theo di tip t nht 1 gi.
| 9
2. Truyn mu.
2.1. Qui nh.
- T tuyn huyn tr ln.
- C bc s ch nh.
2.2. Ch nh.
- Mt mu nhiu trong sn ph khoa.
- Thiu mu nng, c bit c thai trong 3 thng cui (nn truyn hng cu lng nu c).
2.3. Nguyn tc c bn ca truyn mu.
- Nguyn tc quan trng nht l ch truyn mu v sn phm mu cho ngi bnh khi
mt mu nhiu nhanh chng bi ph lng mu mt.
- C gng ch truyn nhng thnh phn m ngi bnh cn (hng cu, bch cu, tiu
cu....) nu c.
- Ni no c ngn hng mu th s dng mu ca ngn hng. Ni no khng c ngn
hng mu th phi tun th nguyn tc sng lc mu theo qui nh ca quc gia nh
sau:
Tt c cc ngun mu cho phi sng lc:
HIV-1; HIV-2.
Vim gan B, vim gan C.
Giang mai, st rt.
- i vi cn b y t:
Ch truyn mu khi cn thit iu tr.
Truyn mu theo ng hng dn chung ca quc gia.
Nu sn ph mt mu nhiu cn truyn dch v cho th oxygen trong khi ch
truyn mu.
Cn b y t phi hiu bit nhng nguy c do truyn mu c th xy ra.
Phi theo di truyn mu pht hin sm nhng phn ng c th xy ra.
2.4. Nguy c ca truyn mu.
Trc khi ch nh truyn mu hoc sn phm mu cho ngi ph n, phi cn nhc k
nguy c c th xy ra:
- Nguy c trc mt: chong, rt run, ni mn, ph phi cp
- Nguy c lu di c th lm ly truyn cc tc nhn gy bnh nh: HIV, vim gan B,
vim gan C, giang mai, st rt cho ngi nhn mu.
2. 5. Qui trnh truyn mu.
2.5.1. Chun b.
- o mch, nhit , huyt p, nhp th.
Xc nh lng mu cn phi b. Kim tra hn s dng ca mu
Th phn ng cho ti ging.
n nh lu lng truyn (s git truyn mi pht).
- Trong khi truyn: theo di ton trng cht ch, theo di bin i mu da v thn nhit,
o huyt p v mch 15 pht/ln.
- Sau khi truyn xong: theo di t nht 2 gi.
10 |
- Ghi li thi gian bt u truyn, thi gian hon tt vic truyn, th tch mu truyn
v cc dch truyn thay th khc.
2.5.2. Nhng phn ng c th xy ra khi truyn mu v x l.
Khi truyn mu, nu c phn ng nh da, nga hoc chong phn v, phi ngng
truyn ngay, gi tnh mch bng cch truyn dch nh dung dch nc mui ng trng
hoc Ringer lactat ng thi tm ngi h tr.
- Nu phn ng nh: promethazin 10 mg (ung).
- Nu chong phn v:
t ngi bnh u thp, th oxygen, ht m ri
Adrenalin pha long 1 % (0,1 ml trong 10 ml dung dch nc mui ng trng
hoc Ringer lactat) tim tnh mch chm.
Promethazin 10 mg (tim tnh mch).
Depersolon 30 - 90 mg (1 - 3 ng) hoc hydrocortison 100 mg x 5 l tim tnh
mch chm hoc truyn nh git. Tim nhc li khi c ch nh.
- Nu c kh th do co tht ph qun: cho aminophylin 250 mg pha trong 10 ml nc
mui ng trng hoc Ringer lactat tim tnh mch chm.
- Theo di chc nng tim, thn, phi.
- Chuyn ngay ln tuyn trn khi cn thit.
- Kim tra li mu mu ngay sau khi phn ng xy ra.
- Nu nghi ng chong nhim khun do n v mu b nhim khun phi ngng truyn
ngay v cy mu trong chai.

| 11
S DNG KHNG SINH TRONG SN KHOA

Tuyn p dng.
Tt c cc tuyn.
Ngi thc hin.
Bc s (i vi x khng c bc s: n h sinh, y s).

Nhim khun trong thi k thai nghn hoc sau c th do nhiu loi vi sinh vt phi
hp, bao gm vi khun k kh, i kh. S dng khng sinh da trn vic theo di sn ph.
Nu khng c p ng trn lm sng th cn lm khng sinh la chn khng sinh
thch hp. Ngoi ra, cy mu nu nghi ng nhim khun huyt. Trng hp nhim khun
ng tit niu xy ra sau sy thai hoc sau cn s dng khng sinh ph rng. Trng
hp sy thai khng an ton hoc ri cn tim phng un vn.

1. Khng sinh d phng.
Trong lnh vc sn khoa, c nhiu th thut c coi l t c nguy c nhim khun.
Vic s dng khng sinh ch mang tnh cht phng nga v gi l s dng khng sinh d
phng.
- Khi thc hin mt s phu thut hoc th thut sn khoa (nh phu thut ly thai, bc
rau bng tay) mc ch l d phng nhim khun lc lm th thut. Trong trng
hp b nhim khun hoc chn on nhim khun th dng khng sinh iu tr
nh thng thng.
Cch dng: cho khng sinh d phng 30 pht ng tnh mch trc khi bt u phu
thut hoc th thut khng sinh i vo cc m ca c th khi bt u phu thut
hoc th thut.
- Trong trng hp phu thut ly thai, mt liu khng sinh d phng cn c cho ngay
sau khi cp dy rn. Nu phu thut ko di trn 6 gi hoc mt mu nhiu (c
khong trn 1000 ml) phi cho liu th hai duy tr nng khng sinh trong mu.
2. iu tr.
Ba nhm khng sinh c th c s dng trong thi gian mang thai khng hn ch vi
qui tc v liu lng thng thng: beta lactamin, macrolid, polypeptid.
2.1. Tuyn x.
- Da theo thuc thit yu kt hp iu tr.
- Nu cho khng sinh sau 2 ngy khng th chuyn tuyn trn.
2.2. Tuyn huyn.
iu tr cc bnh nhim khun ban u thng dng phi hp cc loi khng sinh theo
cch sau:
- Dng khng sinh nhm cephalosporin phi hp vi nhm macrolid.
- Trong trng hp nghi ng nhim vi khun k kh, phi hp vi metronidazol (cn
nhc, thn trng s dng thuc ny trong qu I ca thai k).

12 |
3. Chng ch nh.
- Tetracyclin: v nguy c gy c cho gan ca m v nh hng ti pht trin xng v
lm hng men rng ca thai nhi.
- Cloramphenicol: v c nguy c suy tu i vi thai.
- Aminoglycosid: v gy ng c cho thn kinh thnh gic v thn ca thai.
- Sulfamid: gy qui thai 3 thng u, gy vng da tan huyt nng tr s sinh nu dng
3 thng cui thi k thai nghn .
- Quinolon: nh hng n u sn khp ca thai.
- Metronidazol: do tc dng khng acid folic v gy qui thai trong 3 thng u. Nu s
dng th kt hp vi s dng cc loi vitamin.

| 13
CC NGUYN TC V KHUN
TRONG DCH V CHM SC SC KHE SINH SN

Tuyn p dng.
Tt c cc tuyn.
Ngi thc hin.
Cn b cung cp dch v.

1. Mi trng sch cc phng k thut.
- Trong c s y t, phng k thut phi c u tin ni sch s, kh ro, xa cc ni d
ly nhim nh nh bp, nh v sinh cng cng, khoa ly...
- Phng k thut phi c nn v tng khng thm nc c th ra bng nc v x
phng, c h thng kn dn nc thi.
- Phng k thut khng dng qut trn, c qut bn hoc iu ha nhit . Cc ca s
phi lp knh, cao hn sn nh 1,5 m, nu khng c ca knh phi c li hoc mn
trnh rui mui bay vo phng.
- Nhng lc khng lm k thut, phng phi ng ca kn khng ai c ra vo. Tuyt
i khng lm vic khc trong phng k thut.
- Sau mi ca th thut phi thay tm lt bn th thut, lau chi sch s tm tri bn ri
mi s dng tip.
- Phng phu thut: mi vt trong phng phi lun sch, tin hnh lau chi thng
xuyn.
2. Khch hng (ngi s dng cc dch v chm sc SKSS).
2.1. Trc khi lm th thut, phu thut.
- Trc khi lm th thut v phu thut, khch hng tm ra, thay qun o sch.
- i tiu hoc lm rng bng quang.
- Cn b y t kim tra li mt ln na trc khi phu thut xem vng sp lm th thut
c tn thng xc, mn, nht, gh, c nhim khun khng. Nu c th nn hon
cuc phu thut tr trng hp cp cu.
- Vng sp phu thut (bng, bu...) phi c ra sch, bi thuc st khun da, nim
mc nh iod hu c 10 %.
2.2. Sau khi lm th thut, phu thut.
- Sau khi phu thut, khch hng phi mc qun o sch, phi c gi vt m sch v
kh, nu tm phi trnh lm t vt m.
- Nu bng vt m kh, sch khng c mu, th khng nn thay bng hng ngy. Ti
ngy ct ch (5 - 7 ngy) s va ct ch va thay bng.
3. Ngi cung cp dch v (cn b y t).
- Giy dp ca cn b y t phi ngoi phng k thut (i dp guc ca phng k
thut). M phi kn khng l tc ra ngoi, khu trang phi che kn mi. Nhn vin y
t ang c bnh nhim khun khng c phc v trong phng k thut. Thay o phu
thut, gng, khu trang sau mi ca phu thut.
14 |
- Phu thut vin, ngi tr th phi: ct ngn mng tay, tho nhn, vng tay, i m,
eo khu trang v khun. Ra tay theo ng qui trnh ri mc o chong.
Ch : Ra tay l mt bc quan trng nht trong chng nhim khun khi thc hin cc
dch v chm sc SKSS.
- Nguyn tc s dng gng tay:
Cc dch v chm sc SKSS u cn s dng gng tay.
Hu ht gng v khun hin nay s dng mt ln. Gng dng li (cng phi qua cc
thao tc v khun) ch cn dng lau ra dng c hoc v sinh c th cho ngi
bnh.
Trc khi mang gng phi ra tay sch (thng qui hay phu thut), lau kh tay
bng khn sch (nu ra tay thng quy) hay khn v khun (nu ra tay phu
thut).
Khi mang gng v khun ( phu thut, ...), d tay ra sch vn khng
c ngn tay chm vo mt ngoi (mt s dng ca gng), thc hin nguyn
tc tay chm tay, gng chm gng.
4. Cc dng c, phng tin s dng trong th thut, phu thut.
- Cc thit b nh bn phu thut, bn ,... phi c lm sch sau mi ln lm th thut
bng cch ra, lau sch mu, dch sau lau li bng khn vi dung dch st khun
(dung dch clorin 0,5 %, glutaraldehyd 2 %), cui cng lau li bng nc sch; hng
tun phi ra bng x phng v nc sch ri tip tc cc bc tip theo; bn ph khoa
cc bnh vin (do s lng khm nhiu) phi c lm sch hng ngy theo cch .
Thay khn tri sau mi ln th thut.
- Cc dng c bng kim loi, cao su, nha, vi, thu tinh... phi c tit khun theo qui
trnh v khun i vi tng loi dng c.
- Cc phng tin trnh thai nh dng c t cung, thuc, que cy trnh thai c bo
qun trong bao b v khun do nh sn xut thc hin. Khi pht hin bao b rch, thng
th khng c s dng.

| 15
QUI TRNH V KHUN DNG C
TRONG DCH V CHM SC SC KHE SINH SN

Tuyn p dng.
Tt c cc tuyn.
Ngi thc hin.
Cn b cung cp dch v.

1. Qui trnh v khun dng c.
1.1. Kh nhim dng c.
- Kh nhim l bc u tin trong qui trnh v khun.
- Thit b: 1 x nha c quai xch vi chiu cao trn 35 cm v mt gi nha c quai hi
nh hn lt vo x.
- Dung dch ha cht kh nhim: dung dch clorin 0,5 % hoc glutaraldehyd 2 %.
Dung dch ny s thay sau mi bui lm vic.
- Dng c sau khi lm th thut, phu thut phi cho ngay vo x, ngp ht trong dung
dch kh nhim, ngm trong 10 pht. Sau em ra ra.
1.2. Lm sch dng c.
- Thit b: mt chu nha, vi nc sch, x phng, bn chi.
- Trong khi ra, ngi ra dng c cn i gng cao su v eo khu trang, eo knh, i
ng v mc tp d trnh ly nhim. Dng bn chi v x phng nh sch dng c
cho ht mu v t chc c th bm li trn dng c.
- C sch cc ni d bm bn nh rng, khe k ca dng c. Sau ra sch x phng
v lau kh bng khn sch. C ra di vi nc chy hiu qu hn c ra trong chu
nc.
- Yu cu: mu m v cc m bm vo dng c nh rau thai, m, c... khng cn dnh
li trn dng c.
1.3. Kh khun mc cao.
C hai cch:
- Kh khun bng luc dng c.
- Kh khun bng ha cht.
1.3.1. Luc dng c.
- Thit b: hp luc dng c bng kim loi c np y kn, ln cha dng c, di
hp c h thng bp in hoc s dng mt bp ring (in, ga hoc du).
- Yu cu: dng c ra sch cho vo hp luc, nc sch vo hp sao cho ngp
cc dng c. Khi nc si, duy tr trong 20 pht, vt dng c dng ngay khng c
lu.
1.3.2. Kh khun mc cao bng ha cht.
Ngm dng c vo dung dch kh khun (glutaraldehyd 2 % hoc dung dch clorin 0,5
%) trong 20 pht sau trng sch bng nc un si ngui.
16 |
1.4. Tit khun.
1.4.1. Hp t p lc cao.
- Phng php ny dng cho tt c cc loi dng c y t tr nha (bm v ng ht
thai, catheter...). vi v cao su phi hp ring, v nhit , p sut, thi gian hp
hai loi khc nhau.
- Thit b: ni hp t p lc cc loi.
- Yu cu: khi nhit ln ti 121
o
C (p lc 1,2 kg/cm
2
) i vi dng c ng gi phi
duy tr nhit nh vy trong 30 pht. i vi dng c khng ng gi ch cn duy tr
20 pht.
1.4.2. Sy kh.
- Phng php ny ch dng cho cc dng c y t bng kim loi.
- Thit b l t sy kh.
- Yu cu:
Nu nhit 170
o
C phi duy tr 60 pht.
Nu nhit 160
o
C phi duy tr 120 pht.
Ghi ch: Cch kim tra dng c sy, hp t nhit cn thit hay cha bng cch sau:
Trc khi hp, sy, dn mt giy bo hiu an ton (trng) vo hp hay gi .
Sau khi hp hoc sy xong nu giy bo hiu i mu (en) l dng c hp
sy t yu cu v nhit .
Dng c sau khi sy, hp phi dn nhn ghi r ngy v tn ngi hp sy vo np
hp v gi .
1.4.3. Tit khun bng ha cht.
- Ngm trong dung dch ha cht (glutaraldehyd 2 %, khng c dng dung dch clorin
5 %) trong 10 gi cc dng c bng nha nh ng thng (sonde), ng ht thai... Dng
c vt ra phi ra bng nc tit khun, trong hp kim loi tit khun, np c dn
nhn, ghi ngy v tn ngi tit khun.
- i vi nhng dng c khng cn tit khun th ch ngm trong 20 pht kh khun
mc cao.
2. Bo qun dng c v khun.
- Ni bo qun dng c v khun phi sch s, kh ro, c ca ng kn.
- C gi, k v t ng dng c, c s sch ghi chp tn dng c, ngy x l v khun,
ngy nhp, xut dng c (ch nguyn tc nhp trc xut trc).
- Khng ln dng c tit khun vi dng c cha tit khun.
- Thi gian bo qun:
Khng bo qun nhng dng c tit khun m khng ng gi (loi ny cn phi
dng ngay sau khi tit khun).
Dng c kh khun cao ch c s dng trong vng 3 ngy. Ring dng c
luc ch dng trong vng 24 gi.
Nhng dng c tit khun c ng gi hoc t trong hp tit khun, c bo
qun mt tun, sau mt tun nu cha dng cn phi hp sy li.
Nhng hp dng c m ra dng, nu dng c bn trong cha dng ht th sau 24
gi phi a i sy hp li.
Khi vn chuyn dng c tit khun t ni bo qun n phng th thut, phu
thut, phi che y trnh nhim bn.
| 17
THUC THIT YU CHM SC SC KHE SINH SN
TI TUYN X

I. QUAN NIM V THUC THIT YU:
1. Thuc thit yu l:
- Nhng thuc p ng nhu cu chm sc sc kho ca i a s nhn dn.
- c m bo bng Chnh sch thuc quc gia, gn lin nghin cu, sn xut, phn
phi thuc vi nhu cu thc t chm sc sc kho ca nhn dn.
- Lun sn c bt c lc no vi cht lng m bo, s lng cn thit, di dng
bo ch ph hp, an ton, gi c hp l.
2. Nguyn tc la chn thuc thit yu:
- m bo c hiu qu, hp l, an ton,
- Phi sn c vi s lng y , c dng bo ch ph hp vi iu kin bo qun,
cung ng, s dng,
- Ph hp vi m hnh bnh tt, phng tin k thut, trnh cn b chuyn mn ca
tuyn s dng,
- a s l n cht, nu l a cht phi chng minh c s kt hp c hiu qu hn
khi dng tng thnh phn ring r v tc dng cng nh an ton. Nu c hai hay
nhiu thuc tng t nhau phi la chn trn c s nh gi y v hiu lc, an
ton, cht lng, gi c, kh nng cung ng.
- Gi c hp l.
II. DANH MC THUC THIT YU CHM SC SKSS
Theo Quyt nh s 17/2005/Q-BYT ca B Trng B Y t v ban hnh danh mc
thuc thit yu Vit Nam ln V
1. Thuc gim au, tin m.
1.1. Khng cha Opi
- Ibuprofen 200, 400 mg ung.
- Paracetamol 100 mg, 500 mg ung.
- Lidocain 1 %, 2 % tim.
- Diazepam 5 mg/ml ng 2 ml tim (ni khng c bc s, cho php
n h sinh, y s s dng trong
trng hp cp cu).
1.2. C Opi
- Morphin 10 mg/ml tim bp.
2. Thuc khng sinh.
- Ampicillin 250 mg, 500 mg ung.
- Erythromycin 250 mg ung.
- Doxycyclin 100 mg ung.
- Co-trimoxazol 480 mg ung.
- Metronidazol 250 mg, 500 mg ung, t m o.
18 |
- Clotrimazol 500 mg t m o.
- Nystatin 100.000 v t m o.
- Benzyl penicillin 1.200.000 v, 2.400.000 v tim.
- Benzyl penicillin procain 1.000.000 v, 3.000.000 v tim.
- Cloramphenicol 1 g tim.
- Gentamycin 80 mg/ml tim.
3. Thuc h huyt p
Tuyn c s khng c nhim v iu tr cao huyt p, nhng nu c tin sn git nng
cn chuyn vin th ngoi vic cho thuc an thn (diazepam) cng nn kt hp cho thuc
h huyt p.
- Aldomet (methyldopa) vin 250 mg ung.
- Nifedipin vin nang 10 mg (phng thch chm).
4. Thuc st khun v kh khun
- Clorhexidin (digluconat) 5 % (dung dch) dng ngoi.
- Cn 70 : dng ngoi.
- Cn iod 2,5 % dng ngoi.
- Nc oxy gi (dung dch 3 %) dng ngoi.
- Povidon iod 10 % dng ngoi.
5. Thuc chng co tht
- Salbutamol 2 mg ung.
- Nifedipin vin 10 mg ngm di li.
- Papaverin vin 40 mg ung
6. Thuc co bp t cung
- Ergometrin 0,2 mg/ml tim bp.
- Oxytocin 5 v/ml tim bp, tnh mch.
7. Thuc an thn
- Diazepam 5 mg (vin) ung.
5 mg/ml tim (ni khng c bc s, cho
php n h sinh, y s ch nh).
8. Nhm Vitamin v cht khang
- Vitamin A vin, 5000 v ung, vin bc ng.
- Vitamin B1 25 mg/ml ng tim.
10 mg vin ung.
- Vitamin C 100 mg ng tim.
100 mg vin ung.
- Vitamin K
1
1 mg/ml, 10 mg/ml ng tim (km bm tim 1 ml).
- Vin st acid folic mi vin 60 mg st v 0,5 mg acid folic.
9. Nhm thuc trnh thai
Tuyn c s cn c t nht 3 loi thuc trnh thai:
- Vin trnh thai kt hp nn c 2 loi, v d: Rigevidon, Ideal.
- Vin trnh thai ch c progestin: Exluton.
- Thuc tim trnh thai DMPA 150 mg.
| 19
10. Cc nhm thuc khc
10.1. Dch truyn
Khng th thiu khi c h huyt p, chy mu, kit sc do chuyn d ko di, suy thai.
- Glucose 5 %, 20 % dung dch, tim truyn.
- Natri clorid 0,9% dung dch, tim truyn.
- Ringer lactat dung dch, tim truyn.
10.2. Thuc st rt (vng c st rt)
- Artemisinin 250 mg ung.
- Cloroquin 150 mg ung.
- Mefloquin 250 mg ung.
10.3. Cc loi khc
- Magnesi sulfat 15 %, ng 10 ml
- Calci gluconat 100 mg/10 ml, ng tim
III. MT S THUC CN THIT KHC TRONG CHM SC SKSS TI
TUYN X
1. Thuc st khun v kh khun
- Clorine 0,5 % (dung dch) kh nhim, kh khun mc cao.
- Clorhexidin 2 % kh nhim, kh khun mc cao v tit khun.
hoc Presept vin 1,25 g hoc 2,5 g
2. Thuc chng co tht
- Spasmaverin 40 mg ung.
- Spasfon 40 mg, 80 mg ung, tim.
3 Thuc co bp t cung
- Misoprostol 200 mcg ngm di li, t hu mn
sau hoc t di li.
IV. BO QUN THUC THIT YU
1. Phi c t thuc chuyn dng
Mt s thuc cn bo qun lnh hoc cn trnh nh sng trc tip, cn c t ng ring.
2. Phi c danh mc thuc
3. Mi loi thuc
- ng phi c hp ng, nhn theo ng qui ch.
- Vin phi c l, c nhn theo ng qui ch.
- ng ni qui nh.
4. i chiu hng ngy
C s trong danh mc phi khp vi s thuc hin c trong t cng vi s thuc
dng trong ngy.

20 |
TRANG B THIT YU V SC KHE SINH SN
CHO MT TRM Y T X

B khm thai : 01
B : 03
B ct khu tng sinh mn : 01
B kim tra c t cung : 01
B hi sc s sinh : 01
B t v tho dng c t cung : 01
B khm ph khoa : 03
B bm ht thai chn khng bng tay 1 van : 01
Cc dng c khc

1. B khm thai.
- ng h c kim giy ( bt mch nghe tim thai).
- Cn (ngi ln) c thc o chiu cao c th.
- Huyt p k. ng nghe tim phi.
- ng nghe tim thai.
- Test th thai.
- Phng tin th protein niu (que th hoc ng nghim, n cn).
- Phng tin th huyt sc t, hematocrit, test th HIV, vim gan B v giang mai nu
c iu kin.
- Thc dy (o chiu cao t cung, vng bng).
2. B .
- Kp thng c mu : 02
- Ko thng : 01
- Hp ng kim loi c np kn : 01
- Kp di st khun : 02
3. B ct khu tng sinh mn.
- Ko ct tng sinh mn (1 u t) : 01
- Ko ct ch : 01
- Van m o : 02
- Kp phu tch (c mu) : 01
- Kp kim : 01
- Kim trn ( khu c, nim mc) : 01
- Kim 3 cnh ( khu da) : 01
- Ch khu (catgut, lanh, vicryl)
| 21
4. B kim tra c t cung.
- Van m o : 02
- Kp hnh tim 28cm : 02
- Kp phu tch : 01
- Kp kim : 01
- Kim trn : 01
- Ch khu (catgut)
5. B hi sc s sinh.
- ng ht nht : 01
- My ht (p chn hoc chy in) : 01
- Dy ni ng ht nht vi my ht : 01
- u ni ng ht vi dy ht : 01
- Phng tin si m (ti thiu l 1 bng n 150W) : 01
- Mt n, bp bng oxygen
- Bnh oxygen
6. B t v tho dng c t cung.
- Van m o (hoc m vt) : 01
- Kp c t cung : 01
- Kp thng (dng khi tho DCTC) : 01
- Thc o bung t cung : 01
- Ko : 01
7. B khm ph khoa.
- M vt : 03 (to, va, nh)
- Hp ng (c np y kn) : 01
- VIA test (test pht hin tn thng nghi ng
c t cung bng mt thng lugol v acid acetic) : 01
8. B ht thai chn khng bng tay 1 van.
- Van m o : 01
- Kp c t cung : 01
- ng ht s 4 : 01
- ng ht s 5 : 01
- ng ht s 6 : 01
- Bm ht thai 1 van : 01
22 |
9. Vt t tiu hao.
- Bng bng, gc.
- Gng tay.
- Sng vi hoc giy lt ln.
- Khn nilon.
10. Cc dng c khc.
- T thuc.
- Bn .
- Bn dch v.
- Bn khm ph khoa.
- Bn dng c.
- Ging nm (c cc mn).
- Ni luc (in).
- T sy kh.
- Ni hp t.
- Hp nha c np ( kh khun bng ha cht).
- Nilon.
- Hp khn tri.
- Bn lm rn v hi sc s sinh.
- Cn s sinh.
- Chu tm tr em.
- Bm tim nha 1 ml, 5 ml, 10 ml.
- n g hoc cc n thay th.
- Cc truyn, dy truyn, kim lun.
- Mt n, bp bng cho ngi ln.
- X nha, gi nha dng kh nhim.
- Hp cng ng dng c sc nhn.
- Knh bo h.
- Gng, ng.

Ghi ch: C th trang b mt hp ring cc kp di st khun dng chung cho tt c
cc th thut.

| 23
C S CHM SC SC KHE SINH SN
TI TUYN X
Cn c cc phng nh sau
- Phng khm thai v t vn
- Phng + th thut
- Phng khm ph khoa
- Phng nm ca sn ph
C s c iu kin c th b tr 6 phng:
- Phng khm thai.
- Phng khm ph khoa.
- Phng th thut.
- Phng .
(Cc phng trn u phi c ni ra tay).
- Phng nm ca sn ph.
- Phng truyn thng t vn.

Cc phng trn cn c bin tn phng. C s cn c bng thng bo cc dch v m c
s cung cp v bng 10 quyn khch hng.
1. Phng khm thai.
1.1. Tiu chun.
- Phng c chc nng khm thai v qun l thai nghn.
- C s khng iu kin b tr phng ring th:
Khm thai: c th lm phng khm chung, trn mt ging c nhn.
Qun l thai nghn: c th phng truyn thng.
1.2. Trang b.
- khm thai: b khm thai, xem bi Trang thit b thit yu cho tuyn x
- qun l thai nghn:
Phiu thm thai.
S khm thai.
Bng theo di v qun l thai nghn.
Hp phiu hn.
2. Phng khm ph khoa.
2.1. Phng khm.
- Phi l mt phng ring, khng chung vi phng .
- Din tch ti thiu 9 m
2
.
- Mt bn khm ph khoa c bc ln xung, c ch gc chn.
- Mt bn lm vic tip n, ghi chp, lu gi s sch.
- Mt bn con dng c khm.
- Mt n soi.
- C ni treo qun o ca khch hng.
24 |
2.2. Dng c khm.
- t nht cn c 3 b dng c khm v gng tay v khun.
- Nhng phng tin khc:
Bng ming nh, tm nc kh khun lau m o, c t cung.
Acid acetic 3 % phn bit tn thng c t cung vi vim.
Lugol 3 % pht hin tn thng nghi ng c t cung.
Betadin st khun khi cn.
3. Phng th thut.
(xem phnK hoch ha gia nh)
4. Phng .
4.1. Tiu chun ti thiu.
- Din tch trn 16 m
2
.
- Trn sch, tng p gch men, ti thiu cao 1,6 m.
- Ca bo m chng bi, chng rui mui, chng gi.
- Nn lt gch men khng thm, thot nc.
- C n in, dy mc gn gng, an ton v in.
- C khu ra tay thun tin cho vic nhng khng lm t nn phng .
- Xa ni nhim.
- C h thng kn dn nc thi.
- Khng s dng phng khm ph khoa.
4.2. Trang b ti thiu.
- Mt bn sch.
- Mt t thuc v dng c (c theo qui nh).
- Mt bn dng c , ct khu tng sinh mn.
- Gc hi sc s sinh gm mt bn lm rn v b dng c hi sc s sinh.
- Mt n chiu khu tng sinh mn, .
- C phng tin m cho b, ti thiu l bng n 150 W.
- Cc hp: gc ming, ch, bng, gc di, vi tri hp v cn hn dng.
- C guc dp ring.
5. Phng nm ca sn ph (ch , sau , sau ht thai).
- S ging c tnh theo nhu cu v hot ng SKSS ca c s, trnh phi nm ghp
nhng cng trnh ging khng s dng.
- Bung phi sch, khng c mng nhn, khng tng bn (cn nh k qut vi).
- Ging sch, c cc mn - ngi mi n c thay chiu (hoc vi tri ging) sch.
- V tr thun tin cho ngi trc theo di.
- C ca s v ca ra vo m bo kn gi trong ma ng, thong mt trong ma h v
c th ng yn v ban m.
- C nc sch, bung tm, bung v sinh thun tin.
| 25
6. Phng hoc gc truyn thng - t vn.
6.1. Phng truyn thng t vn.
- Nn c phng ring v tr thun tin.
- C bn gh cn c th lm t vn nhm.
- Qut dn v sinh hng ngy, lun sn sng n khch hng.
- m bo kn o, c s m cng khi t vn.
- C s khng iu kin th b tr mt gc ca phng khm chung.
6.2. Trang b.
- T gp (v ni dung s t vn).
- p phch (treo ngay ngn, khng rch, khng mc).
- Sch lt.
- M hnh.
- Hin vt (cc bin php trnh thai nh dng c t cung, cc v thuc ung trnh thai,
bao cao su...).
7. V sinh v x l cht thi.
7.1. V sinh mi trng.
- C tng bao, hoc hng ro, khng bi rm, h nc ng, khi thng cng rnh.
- C thng rc ni i li, ng ngi ngi ch.
7.2. V sinh cc phng lm vic v ni ch, ni iu tr ca ngi bnh.
- Phng thong, sch s, gn gng.
- Trt t trong bung bnh.
- t thng rc v phn loi rc theo quy nh.
- Thuc, dng c, h s c t ring.
7.3. V sinh ni ra tay, tm git v ngun nc.
- Lau ra thng xuyn, trnh ng nc.
- Thng ra tay c np y, c kim tra v ra thng xuyn.
- Cc cng trnh v vt liu gy nhim hay gy c (bung tm, bung v sinh, h rc,
cc ti cha ha cht dit khun, my phun thuc dit cn trng...) khng c gn
ngun nc hoc ni cha nc.
- Ging nc c chu vi bo v phi trn 10 m, sn ging c ng knh t nht 3 m.
7.4. Thu gom v x l rc thi.
- H x sch s, khng c rui. Phn c thu gom v khng c s dng lm phn
bn. Tt nht s dng h x t hoi.
- Phn bit cc loi rc thng thng (khng phi rc y t), rc hu c (l cy, rau,
qu), thu gom chung trong cng ng hoc gom trm t hng tun.
- Rc y t (bng, bng, mu, dch...) khng gom vo rc thng thng, t h rc hoc
l t n gin.
- Bm tim, kim tim thu gom vo hp an ton v a i hu.

26 |
BO HNH I VI PH N

1. nh ngha.
Bo hnh i vi ph n l bt c hnh ng bo lc no trn c s gii gy ra, hoc
c th gy ra tn hi cho ph n v mt th cht, tnh dc hoc v tm l hay kinh t, bao
gm c vic e do thc hin nhng hnh ng , p buc hay c tnh tc ot mt cch
ty tin s t do, d xy ra ni cng cng hay i sng ring t.
Bo hnh i vi ph n vi phm nghim trng nhng quyn con ngi c bn nht v
mang mu sc bt bnh ng gii r rt. y cng l nguyn nhn gy t vong v suy gim
sc khe cho ph n tui sinh sn.
2. Nhn din cc biu hin bo hnh.
- Bo hnh tm l: ln t kin, mng chi, xc phm nhn phm, bi nh danh d, uy
tn, lng nhc, c lp, e do b ri, hnh h con ci (nht l con ring ca v) nhm
lm cho ngi ph n au kh.
- Bo hnh th cht: tt tai, tm tc, tt, m, , bp c, giam hm hay nht, tt acid,
dng hung kh gy thng tn cho ngi ph n, thm ch gy cht ngi.
- Bo hnh v sinh sn v tnh dc: b ngc i trong khi mang thai, cng bc tnh
dc; khng cho s dng bin php trnh thai, p buc v phi sinh bng c con trai,
xi gic v i vo con ng lm gi im hay m nhn k v mc ch t li.
- Bo hnh v kinh t: khng cho v kim vic lm, buc v phi l thuc v kinh t,
chim ot tin v ti sn ring ca v.
3. Hu qu bo hnh i vi sc khe ph n.
Cc hu qu c th bao gm:
3.1. Hu qu gy t vong: git ngi, t t, t vong m.
3.2. Hu qu th cht: thng tt, tn tt vnh vin, sc khe yu nhng hnh vi sc
khe tiu cc: ht thuc, lm dng ru, ma ty v xut hin cc bnh mn tnh.
3.3. Hu qu n sc khe sinh sn: c thai khng mong mun, cc bnh vim nhim
ng sinh sn, HIV, ri lon kinh nguyt, no thai khng an ton, bin chng do no
thai, sy thai, tr s sinh thiu cn, vim nhim tiu khung, ri lon chc nng tnh
dc.
3.4. Hu qu n sc khe tinh thn: stress sau chn thng, trm cm, lo hi, trng thi
hong lon, ri lon v n ung, ri lon tiu ha.
3.5. Cc hu qu khc:
- V kinh t-x hi: gy tn km cho ngn sch y t - x hi ca quc gia, nh hng
n thu nhp ca tng gia nh (cha tr thng tch, gim nng sut lao ng, con ci
khng c chm sc chu o, cn tr c hi c hc hnh v c vic lm ca ph
n...).
- i vi tr em: tr em trong nhng gia nh thng xuyn phi chng kin cnh b m
xung t sau ny cng rt c th tr thnh nhng k v phu, lp li nhng hnh vi nh
cha m hoc c nhng vn v hnh vi nh lo s, trm cm, stress sau chn thng.
Tr em cng c nguy c b cht oan do hnh vi bo hnh t cha m chng.
- Tip cn vi ru, ma ty: t xoa du khi c nhng vn gy hong lon, gip h
i ph vi nhng ngh dn vt, nhng k c lin quan n s c gy chn thng.
| 27
Ru v ma ty c th l mt gii php tc thi, c hiu qu nhanh nhng li c th
dn n nhng vn nghim trng hn, mt kh nng kim sot bn thn.
4. Mt s gi thuyt v nguyn nhn.
Khng c nguyn nhn duy nht cho mi hnh thi bo hnh. Bo hnh i vi ph n
l vn rt phc tp do nhiu nguyn nhn khc nhau, theo cc nh tm l c th c vai
tr ca yu t sinh hc thn kinh, yu t nhn cch (ni tm), yu t x hi v nhng tnh
hung tc ng n i sng gia nh.
- thc gia trng, trng nam khinh n, c ngun gc t nhng nh hng ca t tng
phong kin c bit nh kin gii (nam gii t coi mnh v tr cao hn v, c quyn
bt v phi phc tng).
- S tuyn truyn, gio dc v can thip cha mnh ca cng ng ngn chn t
nn bo hnh i vi ph n.
- S thiu hiu bit ca ngi dn v php lut lin quan n mi quan h bt bnh ng
gii gia nam v n cn hn ch, s yu ui, cam chu, t hiu bit v ph thuc kinh
t ca chnh ph n nui dng thm s i x bt bnh ng ca s n ng c t
tng gia trng.
5. Vai tr ca cn b y t.
- Vn bo hnh ph n l vn ln v phc tp, khng d c gii php, ngnh y t
khng th n c gii quyt nhng vi thi nhy cm v nhng n lc th c th
gp phn lm gim bo hnh ph n.
- Cn b y t cn nhn thc rng bo hnh ph n do chng/bn tnh c tc ng xu
trc tip n nhiu vn sc khe quan trng nh lm m an ton, KHHG v phng
trnh cc bnh LTQTD, HIV/AIDS.
- Cung cp thng tin v bo hnh ph n cn bt u ngay t phng ch ca ngi bnh.
Trng by nhng pan, p phch vi nhng thng ip phng chng bo hnh ph n
v gii thiu cc a ch gip ph n b bo hnh.
- Ngi cn b y t c s c vai tr rt ln trong vic pht hin du hiu ca bo hnh
khi ph n n c s y t khm bnh hoc n do nhng l do khc. Cn b y t c th
l nhng ngi u tin tip xc vi ph n b tn thng do bo hnh, cung cp thng
tin v h tr ph n b bo hnh. Do h phi c o to v k nng tip xc v
ghi chp h s, bnh n, s sch chuyn bit cho nhng khch hng ny.
- Nhng nh qun l y t cng c th gip cng ng hiu r hn v bo hnh ph n v
h thc c l nguyn nhn quan trng gy ra tnh trng suy yu v hu hoi sc
khe ph n, cung cp thng tin cho cc c quan truyn thng i chng, ra nhng
hng dn c th nng cao kh nng nhn bit v x tr nhng trng hp bo hnh
hay lm dng ph n.

28 |
SNG LC V P NG CA NHN VIN Y T
I VI BO HNH PH N
Tuyn p dng.
Tt c cc tuyn.
Ngi thc hin.
Cn b cung cp dch v.

1. Nguyn tc khi sng lc ph n b bo hnh.
- Thc hin sng lc vi tt c khch hng n n nhn dch v: bt k mt ph n no
n c s y t nhn dch v SKSS cng c th l nn nhn ca bo hnh v trong rt
nhiu trng hp kh c th bit c ai l nn nhn. V th, tt c khch hng n
nhn dch v SKSS cn c sng lc, pht hin bo hnh ngay t phng khm.
- m bo b mt thng tin ca khch hng. Ch hi khi khng c mt ngi khc, ngoi
khch hng v nhn vin y t.
- Sau khi khm nu cn hi thm nhng cu hi lin quan n bo hnh ch khch hng
khi mc y qun o h cm thy c tn trng.
- Hi khch hng vi mt thi khng phn xt v ng cm. Ty tng khch hng m
t cu hi trc tip hay gin tip. Cn b y t cn tht kin nhn, t nh v gip ph n
ni ra c nhng m c l bc quan trng chng t nn bo hnh.
- Nu ngi khm l nam gii, th cn c mt ca mt nhn vin y t n khc khi khm
khch hnh b bo hnh.
2. Qui trnh sng lc.
2.1. Hi v quan st khch hng xem h c b xm phm v mt th cht, tm l v tnh
dc khng.
- khch hng khng cm thy t ngt, nn gii thch v sao li cn hi nhng cu
hi ny. V d: Bo hnh i vi ph n l vn lin quan n sc khe, v th
chng ti hi tt c khch hng n v vn ny c th gip h.
- V d cu hi sng lc bo hnh do chng/bn tnh: c rt nhiu ph n n c
s y t ca chng ti tng b ngi thn trong gia nh nh chng/bn tnh nh
p, chi mng hoc b cng p phi quan h tnh dc? iu c xy ra vi ch
khng?
- V d cu hi sng lc v cng p tnh dc, hip dm: C bao gi ch b ngi thn
hoc thm ch ngi l bt phi quan h tnh dc m ch khng mun khng?
2.2. Khm thc th: theo ng qui trnh khm cha bnh. Lu cc du hiu c th lin
quan n bo hnh.
2.2.1. Cc du hiu thc th.
- i li hoc ngi kh khn.
- Tn thng mt, nhng vt bm tm, chy mu, bng hoc rch da khng c l do.
- Qun o hoc qun o lt rch nt, dnh mu.
- au bng.
- Suy dinh dng.
| 29
2.2.2. Cc du hiu tn thng lin quan n SKSS.
- Ri lon chc nng tnh dc, lnh cm.
- B bnh ph khoa, sy thai, au vng tiu khung mn tnh.
- Tn thng b phn sinh dc n.
- Khng s dng bin php trnh thai no mc d khng mun c thai.
- Ht thai nhiu ln.
- Mc cc bnh LTQTD, nhim HIV/AIDS.
- Vt thng trong qu trnh mang thai: vt thng bng.
- i, tiu tin khng t ch.
- Nhim khun tit niu ti pht.
2.2.3. Cc du hiu tnh cm v hnh vi.
- C biu hin ri lon tinh thn sau bo hnh.
- Thiu lng t tin, s hi, bn chn, xu h, trm cm, xa lnh mi ngi.
- Mc cm phm ti, khng dm biu l s tc gin.
- Mt ng, n khng ngon.
- Bin h hay ni nh i v hnh vi ca chng.
- Toan tnh t t.
3. X tr.
3.1 X tr khi pht hin khch hng b bo hnh.
- Hi ton b tin s v bo hnh v ghi chp vo h s ca bnh vin.
- iu tr y t:
m bo nhng thng tn thc th ca khch hng u c iu tr chu o hoc
chuyn khch hng ti cc khoa khc trong cng c s nu cn, hoc chuyn ln
tuyn trn.
Trong trng hp ngi bnh b hm hip, cung cp thuc trnh thai khn cp khi
s vic xy ra cng sm cng tt (xem bi Cc bin php trnh thai khn cp);
cung cp xt nghim thai hoc chuyn ln tuyn trn.
Nu khch hng c thai ngoi mun: cn t vn v to iu kin cho khch hng
n c s y t cung cp dch v ph thai nu h mun.
- T vn, cung cp thng tin nng cao nhn thc v bo hnh ph n v quyn c
chm sc bo v: nhn mnh s an ton ca khch hng v con ci h.
- Gii thiu khch hng b bo hnh n cc c s gip khc ngoi y t (t vn,
chuyn gia tm l, cng an, ta n, chnh quyn, hi ph n...).
- Hn khm li.
3.2 Nu khch hng khng tit l v bo hnh nhng nhn vin y t nghi ng, hoc
khch hng tr li tng b bo hnh nhng hin ti khng b.
- Chia s vi khch hng v ni cho h bit bo hnh ph n c th s xy ra vi h.
- Cung cp nhng thng tin v bo hnh ph n.
- Gii thiu vi khch hng c s y t sn sng gip nn nhn b bo hnh.
- thi v hnh vi ca ngi n ng a khch hng n, pht hin nhng biu
hin ng ng.
- Ghi chp nghi ng ny vo h s bnh vin c th theo di sau ny.
- Gii thiu khch hng b bo hnh n cc c s gip khc ngoi y t (t vn, cng
an, ta n, chnh quyn, hi ph n...).
30 |
T VN CHO PH N B BO HNH

Tuyn p dng.
Tt c cc tuyn.
Ngi thc hin.
Cn b y t v cn b t vn.

1. Mc ch.
- Xc nh mc an ton ca khch hng, ca con ci h v tho lun k hoch an
ton.
- Xc nh cc nguy c lin quan n SKSS, SKTD v gip khch hng phng cc nguy
c ny.
- Gip khch hng nhn bit c h ang l nn nhn ca bo hnh v bit c bo
hnh l hnh vi khng chp nhn c.
- Gip khch hng chia s, gii to cm xc, ng vin, an i khch hng, gip khch
hng t tin v c th t ra quyt nh.
- Cung cp cho khch hng cc a ch h tr trong v ngoi h thng y t v gip khch
hng lin h vi cc c quan h tr nu cn.
2. Cc bc t vn.
Tun th cc nguyn tc, k nng v cc bc ca bi T vn sc khe sinh sn. Ch
trng cc ni dung c th lin quan n bo hnh trong tng bc t vn nh sau:
- Gp g:
Ni vi khch hng vic khch hng cho cn b y t bit mnh ang b bo hnh l
mt vic rt tt v iu s gip cn b y t h tr khch hng hiu qu hn.
Lm r vi khch hng cuc t vn c th khng lm gim bo hnh ngay c
nhng s gip khch hng gim thiu nguy c lin quan n SKSS, SKTD ca
khch hng, gip m bo an ton cho khch hng v con ci h. c bit qua cuc
t vn ny, nhn vin y t c th gip khch hng kt ni n cc h tr trong v
ngoi y t khc khi vic h tr nm ngoi kh nng ca c s.
Khng nh vi khch hng v tnh b mt thng tin ca cuc t vn cng nh
quyn ca khch hng khng phi tr li tt c cc cu hi. Khch hng c th
dng cuc t vn nu mun.
- Gi hi:
Hi tin s ca khch hng (tn, tui, hon cnh gia nh, mc b bo hnh, hnh
thc bo hnh...). Cn tm hiu hin trng b bo hnh ca khch hng tt c cc
kha cnh nh th xc, tinh thn, tnh dc v kinh t.
nh gi nguy c b mang thai ngoi mun v mc bnh LTQTD bao gm c
HIV.
Tm hiu nguy c v an ton tnh mng ca bn thn khch hng v con ci sau
cuc thm khm ny.
Tm hiu nguy c khch hng b gy kh khn trong vic thc hin chm sc v
iu tr trong ln thm khm ny.
| 31
- Gii thiu: ty tng trng hp c th m vic cung cp thng tin c th khc nhau.
Cc thng tin c bn cn cung cp l:
Khi nim bo hnh, thi vi bo hnh v quyn ca ph n.
Nguy c v bnh LTQTD\HIV v nguy c mang thai ngoi mun.
Cc nguy c khc v SKSS v SKTD do bo hnh gy ra.
Thng tin v cc bin php tnh dc an ton, cc cch thc gip m bo an ton
tnh mng cho khch hng v con ci.
Thng tin v cc a ch h tr.
- Gip : cng khch hng lp k hoch c th cho tng vn sau:
An ton tnh dc.
An ton ca bn thn khch hng v con ci trong trng hp nguy cp.
Chm sc cc vn lin quan n ni chung v c th l SKSS v SKTD do bo
hnh gy ra.
Gim nguy c b bo hnh.
Tho lun chi tit vi khch hng v cc vic cn lm trong tng k hoch, thi gian
thc hin, phng php, phng tin.
- Gii thch:
Tm hiu cc kh khn khch hng c th gp phi khi thc hin cc k hoch
trn.
Cung cp cc thng tin cn thit nh thng tin v cc c nhn v t chc c th h
tr khch hng, thng tin v ni mua hoc nhn bao cao su...
Cung cp cc k nng cn thit nh k nng s dng bao cao su, k nng thng
thuyt, k nng kim ch cm xc, k nng th gin...
Gip khch hng kt ni vi cc c nhn v n v h tr trong v ngoi c s y t.
- Gp li: hn khch hng thi gian gp li. Ni khch hng c th lin h bt c khi no
khch hng cm thy cn. Cho khch hng a ch lin h trong trng hp khn cp.
3. Cc im nn lm khi t vn cho ph n b bo hnh.
- m bo tnh ring t, kn o, tn dng mi thi im m cn b t vn c th tip
xc ring vi khch hng (v d: ti phng khm, khi a khch hng i lm xt
nghim...).
- Lng nghe tch cc, lm cho khch hng cm thy tin tng hn v sn sng th l.
- Gip khch hng mnh m hn: lun khen ngi v cho khch hng bit c nhiu ngi
cng gp hon cnh nh vy. Tm cc im khch hng lm tt v khen khch hng.
- Cung cp cc ti liu tuyn truyn khch hng tm hiu thm sau bui t vn.
- khch hng t quyt nh, ngi t vn ch a ra cc la chn ch khng quyt
nh thay cho khch hng.
- Cn chun b sn khn giy trong phng t vn v khch hng c th khc.
4. Cc im cn trnh khi t vn
- Khng nn t vn cho ngi b bo hnh khi c mt ngi khc (v d nh ngi nh,
ngi bnh khc) tr khi khch hng yu cu v c th gy nguy him cho h.
- Khng phn xt ngi ph n, khng h c cm gic c li v xu h.
- Khng nn quyt nh thay khch hng, nhng cn gip khch hng ngh ra cc gii
php ph hp v khch hng t quyt nh.
32 |
T VN, CHM SC TRC KHI C THAI

Tuyn p dng.
Tt c cc tuyn.
Ngi thc hin.
Cn b cung cp dch v.

Sc khe trong thi gian mang thai ph thuc rt nhiu vo giai on chun b trc
. Ngi ph n trc khi c thai 1- 2 nm nn c t vn trc khi c thai v vic
khm trc khi c thai gip pht hin nhng nguy c nh hng xu ti thai k. Qua t
vn, ngi ph n s quyt nh c mang thai hay khng v thi im c thai thch hp.

1. T vn.
1.1. Mc ch ca t vn trc khi c thai.
Gio dc sc khe v t vn trc khi c thai nhm thay i hnh vi, khuyn khch
thc y nhng vic cn lm cho ph n trong la tui sinh chun b sc khe tt
trc khi mang thai.
1.2. Nhng ni dung cn t vn.
- T vn trc khi c thai phi tin hnh trc khi ngi ph n mun c thai di s
tr gip ca cc xt nghim cn lm sng nhm xc nh:
Cc yu t di truyn do t bin nhim sc th hoc t bin n gen, di truyn a
yu t c th gy sy thai, thai cht lu v cc d tt bm sinh c bit cc cp v
chng ln tui hoc qu tr tui, nhng ngi tip xc vi mi trng ha cht c
hi, nhim cht c da cam, s dng dc phm (cc thuc an thn, chng co git,
chng st rt...), m b nhim virus, vi khun, k sinh trng.....
Khng tng hp min dch gia m v con: yu t Rh, nhm mu ABO...
Nu c vn bt thng th chuyn n c s chuyn khoa
- Khuyn khch vic ch ng i khm sc khe pht hin cc bnh mn tnh tim n
nhm iu tr bnh kp thi (bnh tim mch, tng huyt p, thiu mu, tiu ng, vim
gan, vim thn, lao, ng kinh, ri lon tm thn, bt thng v cu trc hoc chc
nng c quan sinh dc....).
- Cn t vn vi khch nhng yu t nguy c c bit lin quan ti cc tai bin sn khoa
c tim nng ti pht, nhim Chlamydia, rubella, v vic s dng thuc trong qu kh,
thi quen hng ngy, ngh nghip, mi trng sng v lm vic, ngi thn trong gia
nh, cc nhim khun LTQTD, c bit nhim lu, giang mai, herpes sinh dc, HIV,
vim gan B.....
- Tuyn truyn dinh dng l yu t quan trng nht cho sc khe ngi ph n v s
pht trin ca bo thai. Nhng ph n thiu dinh dng c nguy c con nh cn v
ngi m s khng an ton trong khi mang thai v trong khi .
- Vn ng ung b sung st v acid folic d phng thiu mu. Vi acid folic l mt
dng folat tng hp c th lm gim nguy c d tt bm sinh ng thn kinh ca thai nhi.
- Tuyn truyn s dng mui iod trong cc ba n hng ngy.
| 33
- Lm cho ph n trc khi c thai hiu c vic cn thit ty giun t 6 thng n 1
nm 1 ln v thc hin v sinh c nhn (ra tay x phng), v sinh mi trng nhm
gim kh nng ti nhim giun tr li.
- Vn ng khng ung ru, khng ht/nghin thuc l, thuc lo (k c tip xc vi
khi thuc l) nh hng n con, nhng cht ny c th nh hng n kh nng sinh
sn ca nam gii...
- Gio dc truyn thng v tnh dc an ton v p dng cc bin php phng trnh ly
nhim cc bnh LTQTD v HIV.
- Hng dn cc bin php trnh thai khi 2 v chng cha mun c con.
- Tng cng s hiu bit v:
Hu qu ca ph thai c bit l ph thai khng an ton (nht l vi v thnh nin).
Hu qu ca cc bnh NKSS v bnh LTQTD.
2. Ni dung chm sc sc khe trc khi c thai.
- Bo m dinh dng y cho ph n trc khi c thai. Thc hin ch n hp l,
a dng, 4 nhm thc phm (m, m, ng, vitamin v mui khong) nhm t
ch s khi c th (BMI) bnh thng t 18,5 - 24 hoc c cn nng t nht l trn 40
kg.
- Ung b sung vin st v acid folic 400 mcg hng ngy t nht trong 3 thng trc khi
c thai v vin a vi cht phng chng thiu mu do thiu st v thiu vi cht.
- S dng mui iod, bt canh iod hng ngy.
- Ty giun bng albendazol.
- Tim vaccin phng un vn cho ph n t 15 n 35 tui.
- Nn tim phng cm, rubella cho ph n trc khi c thai t nht 3 thng.
- Thc hin ch lao ng v ngh ngi hp l, trnh tip xc vi cc cht c hi.
- Khm ni khoa nh k hng nm v iu tr cc bnh huyt p, tim mch v cc bnh
kinh nin (nh bnh tiu ng v mt s bnh khc), pht hin cc yu t c th nh
hng n kh nng mang thai v sinh con khe mnh.
- Khm ph khoa nh k 6 thng v iu tr thch hp cc bnh ph khoa, vim nhim
ng sinh sn v LTQTD.
- Ngi ph n c trang b kin thc lm m v chm sc con.
- Khi ngi ph n mun c thai c th hng dn xc nh thi gian c kh nng th
thai cao nht theo chu k kinh nguyt, lp th biu din nhit c th, ch n
tit cht nhy m o. Ngi chng nn mc nhng qun o rng ri khng b cht
hoc khng b nng sn xut tinh trng ca tinh hon c bnh thng.

34 |
35 |

PHN 2
LM M AN TON

36 |
| 37

A
CHM SC TRC

38 |
| 39
T VN CHO PH N C THAI
Tuyn p dng.
Tt c cc tuyn.
Ngi thc hin.
Cn b cung cp dch v.

T vn cho ph n c thai l qu trnh giao tip, trao i hai chiu, gip h xc nh
c nhng iu cn thit v bo v thai nghn, t quyt nh nhng hnh ng thch
hp nht c li cho sc khe m v con.
1. Nhng ni dung t vn trong mi trng hp.
- S cn thit ca vic khm thai nh k.
- Dinh dng ca thai ph trong khi c thai.
- Lao ng, lm vic trong khi c thai.
- V sinh thn th trong khi c thai.
- Cc sinh hot khc trong i sng khi c thai k c quan h tnh dc.
- Nhn bit nhng du hiu nguy him thng gp khi c thai kp thi i khm.
- Chun b sn sng cho cuc sinh sp ti.
- Nui con bng sa m (tham kho bi T vn nui con bng sa m)
- Bin php trnh thai sau khi sinh.
- HIV/AIDS v cc NKLTQTD khc.
- T vn v vai tr v trch nhim ca chng v cc thnh vin khc trong gia nh.
2. Nhng ni dung t vn cc trng hp c th.
Ngoi cc ni dung trn, cn ch :
2.1. C thai ln u.
T vn y v dinh dng (thng c tm l s n nhiu, con to), v li ch ca
khm thai sm, khm nh k theo hn, d kin ngy , chun b y cho m v con
khi , d kin ni , ngi v c ngi nh chm sc, chun b cho vic nui con
bng sa m, t vn v sinh hot tnh dc.
2.2. t 4 ln tr ln.
- T vn v dinh dng, nguy c ngi bt thng, chuyn d ko di, chy mu trong
giai on s rau v d b t cung.
- T vn v li ch ca khm thai nh k pht hin nguy c v chuyn tuyn.
2.3. Vi thai ngoi mun.
Nu mun nh ch (ph thai) th khi no l thch hp, nu thai pht trin phi c
trch nhim y ca gia nh.
2.4. Vi thai ngoi gi th.
Cho thai ph bit cc bin php c th la chn. Nu quyt nh khng nh ch thai
nghn, t vn v trch nhim lm m khi sinh con.
40 |
2.5. Cc trng hp him mun, c thai qu sm (di 18 tui), con so ln tui (trn 35
tui) sy lin tip, tin s d dng, thai cht lu, kh, c so m c t cung.
Nn t vn v s cn thit ca vic khm thai nhiu ln v u n hn cc trng hp
bnh thng khc v ni r vn cn chuyn tuyn.
2.6. Vi ngi tht nghip, ngho i, m ch.
Cn bn bin php gip c th m bo dinh dng khi c thai v cc chi ph
khi sinh .
2.7. Vi nhng ngi vng su, vng xa.
Phi t vn k v vic chun b y phng tin, khi cn chuyn tuyn (hoc n
bnh vin sm trc ngy d nh ).
2.8. nhng ni c tp tc ti nh.
T vn v li ch ca vic ti c s y t, nu thai ph cha ng , t vn nn mi
cn b y t c o to v n ti nh.
2.9. T vn k hoch ha gia nh v nui con bng sa m.
Nu c iu kin cng nn tin hnh t khi cn mang thai.
2.10. Nhng trng hp bo hnh vi thai ph.
Cn t vn cho gia nh nht l vi ngi chng v nhim v bo v b m v tr em.
Xem thm bi T vn cho ph n b bo hnh
2.11. i vi nhng b m chch ht ma ty.
T vn v cc nguy c c th xy ra i vi em b, gii thiu ni c th chm sc
tuyn trn, hng dn cch phng trnh hoc hn ch nguy c v bin chng. T vn xt
nghim HIV cho mi b m nu c th.
2.12. i vi trng hp nghi HIV (+)
- Xem bi Nhim HIV khi c thai v Qui trnh phng chng ly nhim HIV t m
sang con
- T vn v chuyn tuyn trn.
2.13. Trng hp b hip dm.
- ng vin ngi ph n v tho lun vn ph thai.
- T vn v gim nguy c v an ton cho ph n, xem thm bi T vn v bo hnh
ph n.
- Sn sng iu tr d phng cc bnh LTQTD.
3. Nhng vic cn lm.
- Thi vui v thn mt, thng cm.
- Nm vng ni dung t vn, thng tin chnh xc.
- Kin tr gii thch.
4. Nhng vic cn trnh.
- Ph phn, g p, ch trch.
- Dng li khuyn qu chung chung.
- a qu nhiu thng tin hoc a cc thng tin khng ph hp vi trnh thai ph.
| 41
CHN ON TRC SINH

Tuyn p dng.
T tuyn huyn tr ln.
Ngi thc hin.
Bc s chuyn khoa sn c o to v chn on trc sinh.

Chn on trc sinh nhm pht hin sm nht cc bt thng ca thai trong t cung.
Nhm yu t nguy c:
M c tui t 35 tr ln.
Tin s c con b d tt bm sinh bt thng.
Gia nh c con bt thng.
Tin s tip xc vi cc ha cht c hi, thuc gy d dng thai, tia x....
1. Tuyn x v c s tng ng.
- T vn cho cc ph n, cc cp v chng c nguy c cao thai b bt thng chuyn ln
tuyn trn khm.
- Nn thc hin t vn ny v chuyn i khm tuyn trn t khi cha c thai.
2. Tuyn huyn.
- Sng lc cc bt thng ca thai bng siu m (lc tui thai khong 11 - 13 tun, 18 -
22 tun v 28 - 32 tun).
- T vn gi tuyn trn nu siu m c du hiu khng bnh thng.
3. Tuyn tnh v trn tuyn tnh.
- Thc hin cc thm d c th c (siu m, ha sinh, chc ht nc i, sinh thit gai
rau, nhim sc ) nhm xc nh chn on bt thng ca thai.
4. X tr.
- Tuyn x.
T vn, chuyn tuyn trn.
- Tuyn huyn.
Siu m sng lc.
- Tuyn tnh tr ln.
Thnh lp hi ng chuyn gia a chuyn ngnh (sn khoa, chn on hnh nh, nhi
khoa, ngoi khoa, thy thuc ca cc phng xt nghim) hi chn quyt nh
thi x tr i vi tng trng hp c th.
Bc s sn khoa gii thch cn k, t vn cho ngi bnh v thn nhn ngi bnh
v nhng kin v quyt nh ca hi ng trong mi trng hp, ngi bnh
v gia nh la chn
Nu c ch nh nh ch thai nghn, ngi bnh phi k giy chp thun. Nu thai
trn 22 tun nn lm cho thai cht trong t cung trc khi nh ch thai nghn
cho nhn vin y t v gia nh gim bt sang chn tinh thn.
T vn v ln c thai tip theo.
42 |
HNG DN CHI TIT CHM SC TRC SINH

Tuyn p dng.
Tt c cc tuyn.
Ngi thc hin.
Cn b cung cp dch v.

1. Phn hi.
1.1. Bn thn.
- H v tn.
- Tui.
- Ngh nghip, iu kin lao ng: t th lm vic ngi hay ng, ch ngh ngi, c
tip xc c hi khng.
- a ch (ghi theo a ch h khu ch vng su, xa).
- Dn tc (ch dn tc thiu s).
- Trnh hc vn.
- iu kin sng, kinh t (ch hon cnh i ngho...).
1.2. Sc khe.
1.2.1. Hin ti.
Hin mc bnh g, nu c, mc bnh t bao gi, din bin th no, iu tr g, kt
qu iu tr, c nh hng g n sc khe, ang dng thuc g.
1.2.2. Tin s bnh.
Mc nhng bnh g? Lu nhng bnh phi nm vin, phi phu thut, phi truyn
mu, cc tai nn, d ng, nghin ru, thuc l, ma ty, cc bnh tiu ng, tim
mch, tm thn, ni tit, bnh v mu, gan, thn.
1.2.3. Tin s sn khoa (PARA).
- c thai bao nhiu ln, ghi theo 4 s:
S th nht l s ln thng.
S th hai l s ln non.
S th ba l s ln sy thai hoc ph thai.
S th t l s con hin sng.
V d: 2012: thng 2 ln, khng non, 1 ln sy hoc ph thai, hin 2 con sng.
- Vi tng ln c thai:
Tui thai khi kt thc ( bit non hay thng).
Ni : bnh vin, trm x, ti nh, ri.
Thi gian chuyn d.
Cch : thng, kh (forceps, gic ko, phu thut ly thai ...).
Cc bt thng:
Khi mang thai: ra mu, tin sn git.
Khi : ngi bt thng, kh, thai d dng
Sau : bng huyt, nhim khun.
| 43
Cn nng con khi .
Gii tnh con.
Tnh trng con khi ra: khc ngay, ngt, cht ...
1.2.4. Hi v tin s ph khoa.
C iu tr v sinh, iu tr ni tit, c cc bnh NKSS, bnh LTQTD, t c t
cung (t nhit, t in, laser, p lnh) cc khi u ph khoa, sa sinh dc, cc phu thut
ph khoa...
1.2.5. Hi v cc bin php trnh thai dng.
- Loi BPTT.
- Thi gian s dng ca tng bin php.
- L do ngng s dng.
- BPTT dng ngay trc ln c thai ny (nu c dng, ti sao mang thai).
1.2.6. Hi v ln c thai ny.
- Chu k kinh nguyt c u khng v ngy u ca k kinh cui.
- Cc triu chng nghn.
- Ngy thai my.
- St bng (xut hin 1 thng trc , do ngi thai xung thp).
- Cc du hiu bt thng nh au bng, ra mu, dch tit m o tng.
- Mt mi, u oi, au u, n km ngon (du hiu thiu mu).
- Nhc u, hoa mt, au thng v, nn ma (du hiu tin sn git).
1.3. Gia nh.
- Sc khe, tui b m, anh ch, cn sng hay cht. Nu cht, cho bit l do.
- C ai mc bnh ni khoa: tng huyt p, i tho ng, tim mch, gan, thn, lao
- C ai mc bnh nhim khun: lao, bnh LTQTD, HIV/AIDS, st rt,
- Cc tnh trng bnh l khc: sinh i, con d dng, d ng...
- Hi sng lc bo hnh ph n, nu pht hin, x l cc bc theo hng dn trong
bi Sng lc v p ng ca nhn vin y t i vi bo hnh ph n
1.4. Tin s hn nhn.
- Ly chng nm bao nhiu tui.
- H tn, tui, ngh nghip, sc khe, bnh tt ca chng.
1.5. D tnh ngy sinh theo ngy u ca k kinh cui.
- Tnh ng 40 tun k t ngy u ca k kinh cui.
- Theo dng lch, ly ngy u ca k kinh cui cng 7, thng cui cng 9 (hoc tr 3
nu tng s ln hn 12).
Th d: Ngy u ca k kinh cui 15/9/2007.
Ngy d kin 22/6/2008.
- Nu c bng quay tnh ngy d kin th cng tin.
- Nu khng nh ngy u ca k kinh cui th c th da trn kt qu siu m (tt nht
l trong 3 thng u ca thai k) xc nh tui thai.
- Nu sn ph khng nh ngy dng lch, ch nh ngy m lch th cn b y t da vo
lch m chuyn ngy m sang ngy dng.
44 |
- Trong trng hp bm tinh trng vo t cung th ngy u ca k kinh cui c tnh
l trc ngy bm 14 ngy. D tnh ngy sinh c tnh nh cch trn.
2. Khm ton thn.
- o chiu cao c th (ln khm thai u).
- Cn nng (cho mi ln khm thai).
- Khm da, nim mc, nh gi c ph hoc thiu mu hay khng (cho mi ln khm
thai).
- o huyt p (cho mi ln khm thai).
- Khm tim phi (cho mi ln khm thai).
- Khm v.
- Khm cc b phn khc khi c du hiu bt thng.
3. Khm sn khoa.
3.1. Ba thng u.
- Nn trn mu xem thy y t cung cha.
- Xem c vt so phu thut bng di.
- t m vt xem c t cung c vim khng nu nghi ng vim nhim ng sinh dc.
- Ch thm m o nu cc du hiu c thai cha r, cn xc nh thm.
- C iu kin nn lm siu m ln 1 (khi thai khong 11 - 13 tun): xc nh tui thai.
3.2. Ba thng gia.
- o chiu cao t cung.
- Nghe tim thai khi y t cung n rn (tt nht l bng my nghe tim thai nu c).
- C ng thai, s lng thai, tnh trng i.
- C iu kin nn lm siu m ln 2 (khi thai khong 20 - 24 tun).
- Nu nghi ng c vim nhim ng sinh dc nn quan st m o, c t cung qua t
m vt.
3.3. Ba thng cui.
- Tt nht nn khm thai mi thng mt ln.
- o chiu cao t cung/vng bng.
- Nn ngi th (t thai 36 tun tui).
- Nghe tim thai.
- nh gi xung ca u (trong vng 1 thng trc d kin ).
- C ng thai, s lng thai, tnh trng i.
- C iu kin nn lm siu m ln 3 khi tui thai 30 - 32 tun.
- Khi nm ngh, ng nn nm nghing v tt hn l nghing bn tri, hai chn k gi hi
cao nu c ph chn do ng.
- Nu nghi ng c vim nhim ng sinh dc cn c quan st m o, c t cung
qua t m vt.
* Lu : khi lm siu m nhn vin y t khng c cho thai ph bit gii tnh thai nhi
| 45
4. Cc xt nghim cn thit.
4.1. Th protein nc tiu.
- Ly nc tiu bui sng, gia dng.
- Dng que th protein (so vi gam mu mu) hoc dng phng php t.
- Th nc tiu cn lm cho mi thai ph vo mi ln thm thai.
- Nu c sn que th, nn hng dn thai ph t lm.
4.2. Th huyt sc t.
- Th huyt sc t bng giy th.
- Ti tuyn huyn, x c trang b phi th thm hematocrit.
4.3. Cc xt nghim khc.
- Nu c thiu mu th xt nghim phn xem c giun khng.
- Th HIV, giang mai v vim gan (xem Qui trnh phng chng ly nhim HIV t m
sang con).
- Xt nghim kh h (nu cn).
5. Tim phng un vn.
- Vi ngi cha tim phng un vn ln no: tim mi u khi pht hin thai nghn bt
k thng no; tip theo tim mi th hai sau mi tim u t nht mt thng v phi
cch thi gian d kin t nht 1 thng.
- Vi nhng ngi tim 2 mi, nu:
Ln tim trc trc < 5 nm: tim 1 mi.
Ln tim trc trc > 5 nm: tim 2 mi.
- Vi ngi tim ba mi hoc bn mi, cn tim nhc li mt mi.
- Vi ngi tim nm mi phng un vn theo ng lch, nu mi tim cui cng
cch 10 nm tr ln th nn tim thm mt mi nhc li.
6. Cung cp thuc thit yu.
- Thuc st rt (vng st rt lu hnh) theo phc qui nh ca ngnh st rt.
- Vin st/folic:
Ung ngy 1 vin trong sut thi gian c thai n ht 6 tun sau . Ti thiu ung
trc 90 ngy.
Nu thai ph c biu hin thiu mu r, c th tng t liu d phng ln liu iu
tr 2 - 3 vin/ngy.
Vic cung cp vin st/acid folic cn c thc hin ngay t ln khm thai u.
Kim tra vic s dng v cung cp tip trong cc ln khm thai sau.
7. Gio dc sc khe.
7.1. Dinh dng.
Ch n khi c thai.
- Lng tng t nht 1/4 (tng s ba n v s lng cm, thc n trong mi ba).
- Tng cht: m bo cho s pht trin ca m v con (tht, c, tm, sa, trng, u lc,
vng, du n, rau qu ti).
- Khng nn n mn, nn thay i mn ngon ming.
46 |
- Khng ht thuc l, ung ru.
- Khng ung thuc nu khng c ch nh ca thy thuc.
- Trnh to bn bng ch n hp l, khng nn dng thuc chng to bn.
7.2. Ch lm vic khi c thai.
- Lm theo kh nng, xen k ngh ngi nhng khng qu nng nhc, trnh lm ban m
(nht l t thng th by).
- Khng lm vic vo thng cui m bo sc khe cho m v con tng cn.
- Khng mang vc nng trn u, trn vai.
- Khng kit sc.
- Khng lm vic di nc hoc trn cao.
- Khng tip xc vi cc yu t c hi.
- Trnh i xa, trnh xc xe hay va chm mnh.
- Quan h tnh dc thn trng.
7.3. V sinh khi c thai.
- Nh phi thong kh sch s, trnh m, nng, khi.
- Mc qun o rng v thong.
- Tm ra thng xuyn, gi sch v v b phn sinh dc hng ngy.
- Duy tr cuc sng thoi mi, trnh cng thng.
- Ng t nht 8 gi mi ngy. Ch trng ng tra.
- Trnh bm ra trong m o.
8. Ghi chp s v phiu khm thai, phiu hn.
- Ghi s khm thai: nu l ln u ghi tt c cc mc trong 26 ct ca s khm. Nu
l ln khm sau ghi tt c nhng mc hi v khm (mt s mc nh tn, tui, tin
s... khng cn ghi li).
- Ghi vo phiu Theo di sc khe b m v s sinh ti nh (phn theo di, khm thai)
hoc vo phiu khm thai thng thng ang s dng cc c s khm bnh.
- Trong phn ghi phiu khm, ngoi tnh hnh thai ph v cc s liu thm khm o c
c, nht thit phi ghi li kt qu nh gi v ln khm thai , cc du hiu quan
trng thai ph cn t theo di, tn thuc v liu dng, cch dng (nu c) v thi gian
hn ti khm.
- Ti x, nu dng Phiu theo di sc khe b m v s sinh ti nh th phi ghi li
trn phiu th hai lu trm v phiu lu ny vo ngn (hp, hay ti) lun chuyn
phiu khm vo ng c thng qui nh ca ln khm sau. Nu ch c phiu khm
thai a cho thai ph lu gi th vit thm phiu hn cho thai ph v t phiu ny vo
ca thng hn n khm tip.
- trm y t x, ghi phiu con tm ngay t ln khm u tin gn ln bng Qun l
thai. Trong nhng ln khm sau nu pht hin thai nghn c nguy c th nh du
thm vo phiu .
9. Kt lun - dn d.
- Thng bo cho thai ph bit kt qu ca ln khm thai c bnh thng hay khng, tnh
trng m v thai pht trin th no, cn lu nhng im g trong thi gian t sau khi
khm n ln khm tip theo.
| 47
- x, khi khm pht hin nhng du hiu bt thng, cn gii thch v hng dn chu
o cho thai ph i khm hi chn tuyn trn.
- Cung cp thuc thit yu v hng dn cch dng (nu cn thit).
- Dn d.
9.1. Vi thai ba thng u.
- Hn tim phng un vn.
- Hn thm ln 2 sau.
- Thng bo c s y t gn nh nht nu cn th ti.
9.2. Vi thai ba thng gia.
- Hn thm ln sau.
- Hn tim phng un vn (nu cha tim ).
9.3. Vi thai ba thng cui.
- Hn thm tip (nu c yu cu).
- D kin ngy sinh, ni sinh..
- Hng dn chun b cc phng tin cho m v con khi (k c ngi h tr v cho
mu nu cn thit).
- Hng dn cc du hiu bo ng cn thm li ngay nh au bng, ra huyt v ph n.
- Hng dn cch nm, cch th khi chuyn d v rn .
- Hng dn cho con b ngay sau khi v chm sc tr s sinh.
Trc khi kt thc cuc khm, nn hi mt s iu kt lun v dn d quan trng
thai ph nhc li xem h c hiu v nh ng hay khng.

Ch : iu tr HIV/AIDS v bnh LTQTD
Xem Qui trnh phng chng ly nhim HIV t m sang con v phn Nhim khun
ng sinh sn v bnh ly truyn qua ng tnh dc

48 |
QUN L THAI
Tuyn p dng.
Tuyn x.
Ngi thc hin.
N h sinh hoc y s ph trch cng tc chm sc SKSS ti trm y t x.
T chc h tr.
Mng li y t thn bn v cc on th qun chng ti x.

Qun l thai l cc bin php gip cn b y t x nm chc s ngi c thai trong tng
thn xm, trong ai c thai bnh thng, ai c nguy c cao, vic khm thai ca thai ph
th no; hng thng s c bao nhiu ngi ti trm hoc phi tuyn trn; theo di,
chm sc b m khi sinh v sau cho ti ht thi k hu sn.
Qun l thai l mt trong nhng cng vic quan trng nht gp phn bo v SKSS cho
mi gia nh, gim t l t vong b m ca y t tuyn x, phng.
Bn cng c dng thc hnh cng tc qun l thai l:
- S khm thai.
- Phiu theo di sc khe b m ti nh hoc phiu khm thai.
- Bng Qun l thai sn (hay bng con tm).
- Hp (hay ti) lun chuyn phiu hn.

1. S khm thai.
- S khm thai l s ghi tn, tui, a ch v cc d kin pht hin c trong mi ln
khm thai cho thai ph. S khm thai cng ng thi l s ng k thai nghn khi
ngi ph n c khm thai ln u.
- S khm thai gip cn b y t nm bt c din bin qu trnh thai nghn v tnh hnh
c th ca mi ln khm trong sut qu trnh mang thai ca thai ph.
- S khm thai theo mu ca B Y t hin nay c tt c 26 ct dc.
- Trong ln khm u tin (ln ng k) hu ht cc ct phi c ghi y (tr trng
hp cha c du hiu hay triu chng no , v d: b cao t cung, tim thai).
- S th t (ct dc s 1) trong s khm thai l s ngi khm (trong tng thng hay tnh
t u nm ty qui nh ca mi a phng).
- Sau ln khm u tin, cho mi thai ph, dnh ra 3 - 5 dng (hoc nhiu hn ty c s)
ghi cc d kin cho cc ln khm sau. Nh vy ln khm sau khng phi ghi li cc
mc tn, tui, tin s (v ghi t ln khm u) v ch ghi nhng tnh hnh, s liu
thu nhn c khi khm thai mi ln .
- m s dng ngang s bit c s ln khm thai ca mi thai ph.
- S khm thai phi c ghi chp y , trung thc, gi gn sch s, m bo b mt
i vi khch hng.
2. Phiu theo di sc khe b m ti nh hoc phiu khm thai.
2.1. Phiu theo di sc khe b m ti nh (TDSKBMTN): l mt quyn s tng hp
nhiu chi tit cn b y t tt c cc tuyn theo di v ghi chp ti mi ln ngi ph
n c thm khm (k c khm thai v sinh ), trong c cc phn chnh nh sau:
| 49
- Phn bn thn: Ghi nhng yu t chnh v bn thn nh: h v tn, ngy sinh, a ch,
s ng k
- Phn tin s sn khoa: ghi cc tin s sn khoa chnh vi cc trng ghi ch "khng"
v cc c mu ghi ch "c". Khi ng k ghi phiu ny cho ngi ph n, nu loi
tin s no khng c th ghi hoc nh du vo trng (khng) nu c th ghi hoc
nh du vo c mu (c).
- Phn chm sc thai nghn hin ti: ghi cc d kin v tng ln khm thai (c 3
hoc 5 ct dc dnh cho 3 - 5 ln khm trong sut qu trnh thai nghn). Mi d kin
pht hin khi khm thai nu bnh thng th ghi vo trng; nu bt thng ghi vo
c mu.
Thai ph no trong tin s sn khoa v trong phn chm sc thai nghn c t mt du
hiu hay tnh trng c ghi c mu tr ln th thai ph thuc nhm thai nghn
c nguy c cao, cn c theo di v quan tm c bit, nu cn phi gi i khm hi
chn tuyn trn v x khng c trnh tai bin c th xy ra.
Tip theo, phiu TDSKBMTN cn c phn theo di cc din bin chuyn d, vic sinh
, tnh trng s sinh v din bin ca sn ph trong 6 tun hu sn.
Sau phn ny phiu TDSKBMTN cn phn "k hoch ha gia nh sau " v"Li
khuyn ca cn b y t".
Nh vy ti nhng ni ang x dng phiu TDSKBMTN th phiu ny chnh l phiu
cn b y t ghi mi ln khm thai ti phn "Chm sc thai nghn hin ti".

Cch s dng:
- Phiu c lp cho ph n t tui 15 n 49. Sau 49 tui, phiu khng c s dng
na.
- Khi c thai, phiu ny s l phiu theo di khm thai nh k theo hn ca cn b y t.
- Phiu s c lp hai bn ghi ging ht nhau cho mi ph n; mt phiu trao cho thai
ph gi bit ngy hn khm ln sau hoc i khm bt k lc no v bt k c
s y t no khc; phiu cn li lu ti trm (khi cha c thai th lu cc trong t
h s phn loi theo thn xm; khi c thai th lu phiu ny trong hp (hay ti) lun
chuyn phiu hn).
2.2. Phiu khm thai.
nhng ni cha thc hin c vic lp phiu TDSKBMTN th dng "phiu khm
thai" trong c phn ghi tn tui, tin s v cc ct ghi cc d kin thm khm v dn
d thai ph mi ln khm thai. Mu phiu ny c th khng ging nhau ty tng a
phng thit k in mu nhng ni chung u c nhng mc cn thit c th theo di,
nh gi qu trnh thai nghn.
Phiu TDSKBMTN hay phiu khm thai u c tc dng ghi li nhng d kin pht
hin khi khm thai, nhc nh thai ph n khm li ln sau ng hn v nhng li dn d
hoc hng dn v dinh dng, ngh ngi hay dng thuc
3. Bng qun l thai sn.
Bng qun l thai sn l mt bng ln treo tng c gn mu ba nh ghi cc thng tin
v thai ph vo thng d kin ca thai ph . Mu ba ny thng gi l "con tm".
- Bng c 13 ct dc, trong ct u tin l tn thn (xm), 12 ct sau l cc thng ghi
t thng 1 n thng 12.
50 |
- Cc ngang dnh cho mi thn (xm) mt . X c nhiu thn th s ngang phi
nhiu s thn trong x.
- Phn cui ca bng qun l thai sn l cc "Sau ". Sau khi sn ph th con
tm ghi cc thng tin v sn ph c g ra chuyn xung y theo di, chm sc
sau .
Mi "con tm" c ghi su thng tin chnh l: h v tn, tui, PARA, s ng k thai,
ngy kinh cui cng, ngy sinh d kin. Thng dng tm mu xanh cho trng hp thai
ph cha sinh ln no (thai con so); tm mu vng cho thai ph s sinh ln 2 v tm mu
cho thai ph s sinh t ln 3 tr ln. Ngoi ra nu l trng hp thai nghn c nguy c
cao th nh mt du hoa th gc mu ba.
- Tm s c gn (hay dn) vo mt nm trong thng d kin sinh ca thai ph, ph
hp vi c v tr thn (xm) ca thai ph ang c tr.
- Bng qun l thai sn gip cho cn b y t x bit c:
S sn ph d kin s sinh mi thng (v c s c nguy c cao trong thai nghn).
Trn c s ch ng c k hoch chun b chu o cho vic sinh ca nhn
dn trong x (nht l vo nhng thng c th xy ra thin tai, bo lt).
Tnh hnh thc hin KHHG ca ton x (thng qua s tm mu xanh, vng, ).
Pht hin kp thi s sn ph c thai qu hn, hoc sinh ni khc (khi n
ht thng m "con tm" vn cn nm ti ch cha c lt ra chuyn xung di).
Nm chc s lng sn ph c k hoch thm c m v con ti nh.
4. Hp (hay ti) lun chuyn phiu hn.
- Hp (hay ti) lun chuyn phiu hn l cng c gip cn b y t x bit thai ph c
c khm thai nh k theo ng hn ca trm hay khng.
- Cng c l mt hp bng g hay bng giy c 12 ngn, tng ng 12 thng, nh s
t 1 n 12. Khng c hp th thay bng ti nilon, bn ngoi ti ghi tn thng.
- Thai ph n khm vo thng no th tm phiu TDSKBMTN ca thai ph trong
ngn (ti) ca thng . Sau khi khm xong, hn ngy n khm ln sau vo thng no
th phiu lu vo ngn (ti) ca thng .
- Trng hp n ht thng m trong ngn (ti) vn cn li phiu c ngha l ngi c
hn theo phiu khng n khm v cn b y t phi tm hiu nguyn nhn.
- Trng hp khng c phiu TDSKBMTN th vit vo phiu hn vo cc ngn (ti)
.

51 |

B
CHM SC TRONG KHI

52 |
| 53
T VN CHO SN PH TRONG CHUYN D
V NGAY SAU
Tuyn p dng.
Tt c cc tuyn.
Ngi thc hin.
Cn b cung cp dch v.

1. Nguyn tc chung v t vn trong chuyn d.
- ng vin sn ph bt lo u.
- Lng nghe nhng iu khin bn thn sn ph v gia nh lo lng.
- Thng cm v tn trng nhng truyn thng vn ha v tn gio ca sn ph.
- Ni cho sn ph v gia nh bit nhng iu c th xy ra, gip cho sn ph hiu v
tnh trng ca sn ph v cch x tr lm gim s lo u v gip h chun b trc
cho nhng tnh hung c th xy ra.
- Gii thch cho sn ph v gia nh v nhng tai bin c th gp khi chuyn d.
2. T vn trc khi sinh.
- Thng tin cho sn ph v cuc bnh thng hay kh.
- Gip , ng vin sn ph gim bt lo lng.
- Hng dn sn ph bit cch th u, th su (khi khng c cn co), th nhanh, mnh
kt hp xoa vng xng cng - ct (khi au do cn co), cch nn hi, rn v cch
thi ra khi khng c rn na...
- ni c th, khuyn khch ngi thn hoc bn b chm sc sn ph, c bit v tinh
thn.
3. T vn ngay sau khi sinh.
- Cung cp thng tin v cuc v tnh trng s sinh, h tr tnh cm cho sn ph nht
l nhng trng hp c vn bt thng. Cho sn ph tip xc vi con mi sinh cng
sm cng tt.
- Tn trng lng tin truyn thng, phong tc tp qun, gip nhng g sn ph v gia
nh cn. Tuy nhin cng cn gii thch cho sn ph v gia nh hiu nhng vic lm
khng c li cho m v con nh khng cho b b ngay sau sinh, vt b sa non, cho b
ung mt ong hay nc cam tho... nu nh sn ph thc hin.
- T vn cho sn ph v gia nh v theo di v chm sc sau sinh cho c m v con.
- T vn cho con b ngay sau v cch nui con bng sa m (tham kho bi T vn
nui con bng sa m - phn Chm sc s sinh)
- Gii thch mi vn gip h gim ni lo u, bn khon.
- Lng nghe, hiu cn k v tn trng ni xc ng ca sn ph.
4. T vn cho cc trng hp c bit.
4.1. Sn ph gp bin chng.
- Phi gii thch cho sn ph v gia nh bit cc din bin c th gp phi trc mt v
v sau.
- Phi c chng trnh chm sc thm hi.
54 |
4.2. Sn ph trong tnh trng nguy kch.
- Phi bnh tnh, iu tr tch cc mi thi im.
- Nu ci cht khng th trnh c, cn an i v chia s vi gia nh. Gii thch cho gia
nh bit l do cht v tr li nhng cu hi thc mc.
- To iu kin cho gia nh chn ct nu c th.
4.3. Tr s sinh cht.
- Nu cht trong t cung: phi gii thch cho sn ph v gia nh bit nguyn nhn c th
dn n ci cht ca tr.
- An i sn ph v gia nh h chp nhn s mt mt.
- Cho php b m v gia nh cnh b cht h nhn a con nu h yu cu.
- Khng nn b m c con va cht nm chung phng vi b m c con khe mnh.
- Nu phi tin hnh cc th thut trn a tr (nh trong trng hp chc s), khng
ngi m nhn thy (nu b m v gia nh vn mun nhn mt con th cn dng chn
bc, che cc phn tn thng, lau sch mu, dch bm trn da ri mi a ra).
- Trao i gia b m b v cn b y t nhm tm kim cc bin php d phng trong
tng lai.
4.4. Tr s sinh d dng.
- Ch cho b m thy cc d dng ca chu nu c yu cu.
- Trong trng hp chu b b d dng qu nhiu th qun chu trong chn cho m
nhn thy chu trc v sau mi ni r d dng.
- Khng bt b m kim tra d dng.
- Tho lun vi b m v trng hp d dng v tr li cc cu hi.
- Khuyn khch gia nh tip xc v chm sc b. Nu b m cha mun th khng p
buc, nn t vn thuyt phc n khi h chp nhn.
4.5. Suy sp tm l sau .
- Cn ng vin v gip v tm l, c bit khi con cht hoc d dng, gii tnh ca
con khng ph hp vi nguyn vng.
- Lng nghe tm t ca sn ph m khng phn xt v cn gip sn ph t tin hn vi
vai tr lm m. ng vin ngi chng gip v. Khuyn khch h ni chuyn vi
cc sn ph khc c h tr thm.
- Nu tn thng tm l nng cn cho thuc an thn, gim au hoc chuyn tuyn trn.
4.6. Sn ph nhim HIV/AIDS v bnh LTQTD.
Xem bi Nhim HIV khi c thai phn Lm m an ton v Qui trnh chm sc v
iu tr d phng ly truyn HIV t m sang con - phn Ph lc
| 55
CC YU T TIN LNG MT CUC CHUYN D

Tuyn p dng.
Tt c cc tuyn.
Ngi thc hin.
Bc s chuyn khoa sn, n h sinh, hoc cn b y t c b tc v sn khoa.

Yu cu tt c ngi cung cp dch v t tuyn x tr ln phi tin lng mt cuc
chuyn d, pht hin khi hi bnh, thm khm v trong qua trnh theo di, gip cho ngi
thy thuc nh gi d on v mt cuc . Cc yu t tin lng v mt cuc chuyn d
c trnh by sau y c th ch lin quan n tuyn x hoc tuyn huyn hoc tuyn tnh.
Chnh v vy ty theo cc du hiu c pht hin m cc tuyn s thc hin theo nhim
v v chc nng ca mnh.
1. Cc yu t tin lng mt cuc chuyn d.
y l nhng du hiu, nhng triu chng th hin trong qu trnh mang thai v qu
trnh theo di chuyn d, cn phi khm xt tht k lng tin lng v c phng n
x tr ngay ti tuyn x hoc chuyn ln tuyn trn. Cng cn ni thm rng cc yu t tin
lng cuc p dng cho tt c cc tuyn c s s sn khoa.
1.1. Ton trng v sc khe ca ngi m.
- Ngi m hon ton khe mnh, tm l thoi mi hoc b chi phi bi l do sc khe,
gia nh v x hi.
- Ngi m mc cc bnh c trc hoc trong khi mang thai. Ty theo tng loi bnh
m tin lng cuc s c theo di thng hoc bng forceps hoc phu
thut ly thai. V d nh ngi m b bnh tim th phi bng forceps nu khng km
theo cc nguyn nhn kh khc; cng b mc bnh tim nhng suy tim th phu
thut ly thai l hp l.
- Mt s yu t khc c lin quan ti ngi m nh con so tui di 18 hoc trn 35,
con r tui trn 40. qu dy hoc qu nhiu (khong cch gia 2 ln di 3 nm,
trn 4 ln).
1.2. S tng ng gia thai nhi vi khung chu v phn mm ca ngi m.
Nu c s tng xng gia thai nhi v khung chu cuc s c theo di qua
ng m o. Khung chu hp, khung chu mo, khung chu lch, tng sinh mn cng,
cc khi u tin o bao gm khi u t cung, khung chu v trong m o... l nhng
yu t gy kh. Ty theo tng loi khung chu m tin lng cuc khc nhau, chng
hn nh khung chu hp ton din m thai c trng lng bnh thng th phu thut ly
thai. Khung chu mo m thai nhi l ngi chm th phi lm nghim php lt ngi chm v
tin lng cuc ph thuc vo kt qu ca nghim php lt ngi chm... Cc khi u tin
o th ty thuc vo kch thc v v tr khi u m cuc s phi phu thut ly thai hay
khng...
1.3. Ngi, th, kiu th v mt s yu t c lin quan ti thai nhi v phn ph ca thai.
tin lng mt cuc , yu t ngi, th, kiu th ca thai nhi trong bung t cung
cng gp phn ng k. Nhng ngi thai c th c qua ng m o nh ngi
chm, ngi mt cm trc, ngi mng; nhng ngi bt buc phi phu thut ly thai nh
56 |
ngi vai, ngi mt cm sau, ngi trn hoc ngi thp trc c nh. Ngay c nhng ngi
c th theo di ng m o th kiu th sau c tin lng khng tt bng ngi c kiu
th trc.
- Thai qu ngy sinh hoc cha n ngy sinh.
- a thai.
- Con him, tin s v sinh, phi p dng cc k thut h tr sinh sn
- Thai d dng.
- Rau tin o.
- Sa dy rn.
Nhng yu t trn y u gp phn vo tin lng mt cuc , ty thuc vo tng
yu t m thi x tr c khc nhau.
1.4. Cc yu t ng trong chuyn d.
Khi theo di mt cuc chuyn d, c 5 du hiu bt buc cn theo di sau y:
- Cn co t cung: l ng lc chnh ca cuc chuyn d. Nu cn co t cung nhp
nhng, u n v ph hp vi xa, m ca c t cung l tin lng tt. Nu cn co
khng ng b, qu mau hoc qu mnh, qu yu l tin lng khng tt cho cuc
chuyn d.
- Xa m c t cung: nhp nhng, ph hp vi cn co t cung l tin lng tt. Ngc
li, nu c t cung dy, cng, ph n, m chm hoc khng m thm l tin lng xu.
V vy cn nm vng cc giai on ca cuc chuyn d c tin lng cho cuc
chuyn d.
- lt ca ngi thai: u lun lun chm v, ngi thai khng tin trin, u khng ci,
c hin tng chng khp s hoc khng lt s c tin lng xu. Ngc li, nu di
tc dng ca cn co t cung, ngi thai s t cao lng tin n chc, cht ri lt qua
khung chu ca ngi m l tin lng tt cho cuc chuyn d.
- u i: Nu u i dt, biu hin s bnh chnh ca thai nhi v khung chu l tt. u
i phng, mng i dy, i v non hoc i v sm, u i hnh qu l (trong thai cht
lu) c th l tin lng khng tt cho cuc chuyn d.
- Tim thai: nhp tim thai u, dao ng bnh thng c tin lng tt. Theo di nhp tim
thai bng my (monitor sn khoa). Cc bin i nhp tim thai theo cn co t cung nh
nhp phng, DIP I; DIP II; DIP bin i u l cc du hiu cn theo di cht ch trong
cuc chuyn d pht hin thai suy.
1.5. Cc tai bin c th xy ra trong cuc chuyn d.
- Chy mu (rau tin o, rau bong non, v t cung).
- Da v t cung, v t cung.
- Sa dy rn, sa tay.
- Tc mch i.
2. Kt lun.
- Tin lng mt cuc chuyn d cho chnh xc l iu kh nhng li l iu m ngi
thy thuc sn khoa no cng phi thc hin trnh cc tai bin c th xy ra cho m
v con. S dng biu chuyn d l cn thit trong qu trnh theo di chuyn d
nhm pht hin sm nhng chuyn d bt thng.
| 57
CHN ON CHUYN D

Tuyn p dng.
Tt c cc tuyn.
Ngi thc hin.

Chuyn d l mt lot hin tng din ra ngi c thai trong giai on cui lm cho
thai v bnh rau c a ra khi bung t cung qua ng m o. Chn on chuyn d
khng chnh xc c th dn n s lo lng hoc can thip khng cn thit.

1. Triu chng chuyn d.
- au bng tng cn do co bp t cung tng dn, nu tn s t 3 cn trong 10 pht, mi
cn ko di trn 20 giy th chuyn d l chc chn.
- Sn ph thy ra dch nhy c mu (nha chui) m o.
- C t cung xa ht hoc gn ht v nu m t 2 cm tr ln th chc chn.
- Thnh lp u i.
2. Khm chn on chuyn d.
2.1. Hi.
- Tin s: c nhn, gia nh, tin s sn ph khoa.
- Tnh hnh k thai ny:
Kinh cui cng.
Din bin qu trnh thai nghn. Kt qu cc ln khm thai.
Du hiu chuyn d: tnh cht ca au bng, ra nhy hng...
2.2. Khm ton thn.
- o chiu cao, cn nng, m mch, o huyt p, o thn nhit, nghe tim phi, khm
ph, da - nim mc, quan st ton b (th trng, cao, ln, tht...). c bit ch ngi
con so hay con r nhng ln trc con b, kh
2.2.3. Khm sn khoa.
- Quan st bng to hay nh, t th t cung.
- o chiu cao t cung, vng bng.
- S nn bng xem ngi th.
- Nghe tim thai.
- o cn co t cung.
- o v nh gi khung chu ngoi
- Thm m o nh gi tnh trng:
Ngi, th, kiu th v mc tin trin ca ngi thai.
Tnh trng u i ( thnh lp cha, phng hay dt).

58 |
Chuyn d tht Chuyn d gi
Cn co t cung Tin trin tng dn theo qu trnh
chuyn d: u n, mi lc mt
mnh ln, di ra v mau hn.
Cn co gy au.
Cn co t cung tht thng, khng
u, khng tng ln r rt v tn
s v cng .
Cn co khng gy au.
Xa m c t
cung
C t cung bin i, m rng dn
theo qu trnh chuyn d.
C t cung hu nh khng tin
trin sau mt thi gian theo di.
u i thnh lp. Cha thnh lp

Ch :
- C th xc nh thm chuyn d bng monitor sn khoa.
- Hn ch khm m o trong qu trnh chuyn d.
3. X tr.
- Nu chuyn d: cho sn ph nhp vin, theo di chuyn d cho n khi (xem bi
Theo di chuyn d thng).
- Nu cha r chuyn d:
Cho v nh nu thai nghn bnh thng.
Nm theo di hoc chuyn tuyn trn nu thai nghn c nguy c cao.
Nu i v m cha chuyn d tuyn x chuyn tuyn trn, tuyn huyn v tuyn
tnh cho ch huy, cho khng sinh chng nhim khun khi i v trn 6 gi.
Nu sn ph xa tin s kh, cn b chuyn khoa cha xc nh chuyn d tht:
Cho nm lu theo di thm, phng khi chuyn d c nguy c cho m v thai.

| 59
THEO DI CHUYN D THNG
Tuyn p dng.
Tt c cc tuyn.
Ngi thc hin.
Bc s chuyn khoa sn, n h sinh,hoc cn b y t c b tc v sn khoa.

1. Cc nguyn tc chm sc trong khi chuyn d.
- Tt nht b m phi c theo di chuyn d ti c s y t. Ngi n h sinh cn gii
thch nhng ch li ca vic ti c s y t c chm sc chu o. Trong trng
hp khng th n c c s y t, nn mi cn b c o to v n ti
nh.
- Phi theo di chuyn d bng biu chuyn d mt cch ton din, c h thng, phi
thnh tho cc thao tc chuyn mn, phi bit ghi v phn tch c mt biu
chuyn d, pht hin cc yu t bt thng trong chuyn d, kp thi x tr (thuc,
th thut, phu thut hay chuyn tuyn) m bo an ton cho m v con.
- Nu sn ph c quyt nh ti c s y t x, ngi n h sinh cn phi chun b
nhng dng c ti thiu cn thit v m bo v khun cng vi nhng dng c
chm sc s sinh ngay sau . Nu sn ph ti nh phi chun b nc sch v s
dng gi sch (hoc b dng c c hp v khun trong ti cp cu).
- Khi , rau, kim tra rau, lm rn s sinh phi thao tc ng qui trnh. Mt s
trng hp phi bc rau nhn to, kim sot t cung, khu tng sinh mn cng phi
thao tc ng qui trnh v m bo v khun mi hy vng gp phn h t l nm tai
bin sn khoa.
- Tn tnh, kin nhn v t m l nhng c tnh cn thit ca ngi chm sc chuyn d.
- Trong khi theo di qu trnh chuyn d, cn b y t cn ng vin, h tr v tinh thn
gip cho sn ph gim bt lo lng.
- Khuyn khch sn ph i li, khng nn nm mt ch.
- Hng dn cch th khi khng c cn co v khi c cn co t cung.
- Khuyn khch sn ph i tiu 2 gi/ln.
2. Theo di trong qu trnh chuyn d.
2.1. Vi cuc chuyn d bnh thng.
2.1.1. Theo di ton thn.
- Mch
Trong chuyn d bt mch 4 gi/ln, ngay sau phi m mch, ghi li trong h
s ri sau c 15 pht/ln trong gi u, 30 pht/ln trong gi th hai v 1
gi/ln trong 4 gi tip theo.
Bnh thng mch 70 - 80 ln/pht, mch nhanh 100 ln/pht hoc chm 60
ln/pht, tuyn x phi hi sc ri chuyn tuyn gn nht. Cc tuyn trn phi
khm, tm nguyn nhn x tr.
- Huyt p
o huyt p: trong chuyn d 4 gi/ln, ngay sau phi o huyt p ghi li
trong h s, sau 1 gi/ln trong 2 gi u; phi o huyt p thng xuyn khi c
chy mu hoc mch nhanh.
60 |
tuyn x, phi chuyn t uyn khi :
Huyt p ti a trn 140 mmHg hoc huyt p ti thiu trn 90 mmHg hoc c
hai. Cho thuc h p trc khi chuyn (tham kho phn x tr trong bi Tng
huyt p, tin sn git v sn git).
Huyt p tt thp di 90/60 mmHg phi hi sc v chuyn tuyn, nu tt qu
thp phi hi sc v gi tuyn trn xung h tr (xem bi Chong sn khoa).
Tuyn trn phi c x tr kp thi khi huyt p cao hoc chong.
- Thn nhit
o thn nhit 4 gi/ln.
Bnh thng 37
o
C. Khi nhit 38
o
C, nu tuyn x, gim nhit bng cc
phng tin n gin (v d chm mt...), chuyn tuyn khi x tr khng kt qu.
Cho sn ph ung nc.
Quan st din bin ton th trng: nu b m mt l, kit sc, vt v, kh th cn c
x tr thch hp v chuyn tuyn (i vi tuyn x) v x tr tch cc ty theo
nguyn nhn (i vi cc tuyn trn).
2.1.2. Theo di cn co t cung.
- Theo di di mt cn co v khong cch gia 2 cn co.
- Trong pha tim tng o 1 gi/ln trong 10 pht, pha tch cc 30 pht/ln trong 10 pht.
- Vi tuyn x, cn co t cung qu ngn (< 20 giy), qu di (>60 giy) hoc ri lon
(tn s < 2 hoc > 4) u phi chuyn tuyn (xem bi S dng thuc gim co). Vi
cc tuyn trn, phi tm nguyn nhn gy ri lon cn co c thi x tr thch hp.
2.1.3. Theo di nhp tim thai.
- Nghe tim thai t nht 1 gi/ln pha tim tng, 30 pht/ln pha tch cc. Nghe tim
thai trc v sau v i hay khi bm i.
- Thi im nghe tim thai l sau khi ht cn co t cung. n giai on rn nghe tim
thai sau mi cn rn.
- m nhp tim thai trong 1 pht, nhn xt nhp tim thai c u hay khng?
- Nhp tim thai trung bnh t 120 - 160 ln/pht. Nu nhp tim thai trn 160 ln/pht
hoc di 120 ln/pht hoc khng u, tuyn x phi hi sc v chuyn tuyn (xem
bi Thai suy). Ti cc tuyn trn phi tm nguyn nhn x tr.
2.1.4. Theo di tnh trng i.
- Nhn xt tnh trng i mi ln thm m o (4 gi/ln) v khi i v.
- Bnh thng u i dt, nc i c th trong hay trng c.
- Nu nc i mu xanh, mu hoc nu en, hi, a i, thiu i x u phi chuyn
tuyn. tuyn trn tm nguyn nhn x tr thch hp.
- Nu i v non, i v sm trn 6 gi cha , x cho khng sinh ri chuyn tuyn.
cc tuyn trn cn tm nguyn nhn x tr.
2.1.5. Theo di mc xa m c t cung.
- Thm m o 4 gi/ln, khi i v v khi quyt nh cho sn ph rn. Trng hp cuc
chuyn d tin trin nhanh, c th thm m o nh gi c t cung, lt ca ngi.
Cn hn ch thm m o trnh nhim khun.
- Pha tim tng ko di 8 gi (t khi c t cung xa n m 3 cm).
- Pha tch cc ko di ti a 7 gi (t khi c t cung m 3 cm n 10 cm).
- Bnh thng c t cung mm, mng, khng ph n. ng biu din c t cung trn
biu chuyn d lun bn tri ng bo ng.
| 61
- Nu c t cung khng tin trin, ph n, ng biu din c t cung chuyn sang bn
phi ng bo ng hoc c t cung m ht m u khng lt, tuyn x phi chuyn
ngay ln tuyn trn, ni c iu kin phu thut.
2.1.6. Theo di mc tin trin ca ngi thai
- Phi nh gi mc tin trin ca u thai nhi bng cch nn ngoi thnh bng v
thm m o. C 4 mc: u cao lng, u chc, u cht v u lt. Khi u lt, c
3 mc: lt cao, lt trung bnh v lt thp.
- Ghi lt vo biu chuyn d. Pht hin sm chuyn d nh tr.
- Nu ngi thai khng tin trin, tuyn x phi chuyn tuyn c iu kin phu thut.
2.1.7. Theo di khi thai s
(xem bi thng ngi chm)
2.1.8. Theo di khi s rau
(xem bi X tr tch cc giai on 3 ca chuyn d v bi Kim tra rau).

Tm tt cc yu t cn theo di

Yu t Pha tim tng Pha tch cc
Mch 4 gi/ln 4 gi/ln
Huyt p 4 gi/ln 4 gi/ln
Nhit 4 gi/ln 4 gi/ln
Tim thai 1 gi/ln 30 pht/ln
Cn co t cung 1 gi/ln 30 pht/ln
Tnh trng i 4 gi/ln 2 gi/ln
lt ca ngi (nn ngoi) 1 gi/ln 30 pht/ln
Chng khp (qua thm trong) 4 gi/ln 2 gi/ln
m c t cung (qua thm trong) 4 gi/ln 2 gi/ln

2.2. Vi cuc chuyn d c du hiu bt thng.
- V nguyn tc khng c theo di chuyn d v ti tuyn x.
- Ngi h sinh ti cc tuyn trn trong trng hp ny phi theo di theo y lnh ca
thy thuc. V d khi sn ph chuyn d b st cao th sau khi dng cc bin php h
nhit bao nhiu pht sau phi o li nhit ; hoc khi sn ph chuyn d vi tnh trng
tng huyt p th ngoi vic theo y lnh dng thuc h p, ngi h sinh phi theo di
huyt p theo y lnh ca thy thuc (khng th c 4 gi/ln nh ni phn trn). Cc
du hiu bt thng khc trong chuyn d (nh nhp tim thai, cn co t cung, m
ca c t cung) cng tng t nh vy.
- Khi theo di chuyn d, trong v sau mi ln thm khm, ngi h sinh phi ni cho
sn ph bit tnh hnh cuc chuyn d lc h yn tm.
3. Ch nh chuyn tuyn (i vi x, phng v huyn khng c phu thut).
- Mch: trn 100 ln/pht, di 60 ln/pht.
62 |
- Huyt p: huyt p tm thu trn 140 mmHg hoc di 90 mmHg. Huyt p tm trng
trn 90 mmHg hoc di 60 mmHg.
- Nhit : 38
o
C tr ln.
- Ton trng: rt mt mi, kh th, da xanh, nim mc nht.
- C du hiu suy thai: nc i c ln phn su hoc mu, nhp tim thai nhanh (trn 160
ln/pht), chm (di 120 ln/pht) hoc khng u (lc nhanh lc chm).
- Cc du hiu nhim khun i.
- C cn co bt thng: qu di (trn 1 pht), qu ngn (di 20 giy), qu mau (trn 5
cn trong 10 pht) c lin quan n tin trin chm ca c t cung.
- Bt tng xng gia khung chu v u thai nhi: u khng lt, c hin tng chng
khp s t 2 tr ln.
- Chuyn d tin trin chm: pha tim tng ko di (trn 8 gi); pha tch cc tr tr (m
di 1cm/gi).
- Cc bnh ton thn nng.
- Sn git, tin sn git.
- Chy mu trong khi chuyn d.
- Ngi thai bt thng, nhiu thai, a i, thiu i v thai qu ngy sinh.

| 63
THEO DI LIN TC CN CO T CUNG
V NHP TIM THAI

Tuyn p dng.
Cc c s chm sc sn khoa c monitor sn khoa.
Ngi thc hin.
Bc s chuyn khoa sn hoc bc s c b tc v sn khoa; n h sinh c o to.

1. Mc ch.
- Pht hin thai suy trong qu trnh c thai v trong chuyn d.
- Pht hin cn co t cung bt thng v s p ng ca tim thai vi cn co t cung.
2. Phng php theo di lin tc nhp tim thai tng ng vi cn co t cung
trong chuyn d.
2.1. Ch nh.
- Nu c iu kin nn p dng cho tt c sn ph.
- p dng cho cc trng hp thai nghn c nguy c cao nh:
Sn ph b bnh l nh hng n thai.
Sn ph c tin s sn khoa nng n.
Sn ph ln tui.
C du hiu nghi ng thai suy hoc thai km pht trin trong t cung.
Chuyn d: i v non, i v sm, ri lon cn co t cung, chuyn d ko di, t
cung c so m c.
2.2. Chun b.
- Phng tin: monitor sn khoa ghi cn co t cung v nhp tim thai.
- Sn ph: c gii thch v mc ch theo di thai bng my v cch thc tin hnh.
2.3. Cc bc tin hnh.
- t u d ghi cn co t cung v nhp tim thai.
- Ghi biu nhp tim thai v cn co t cung.
- Ghi nhng thng tin cn thit v sn ph trn bng giy ghi ca my.
2.4. Phn tch kt qu.
- Nhp tim thai: tn s, ng tim thai c bn, dao ng.
- S thay i ca tim thai khi c cn co t cung.
- Cn co t cung: tn s, bin ca cn co v trng lc c bn ca t cung.

3. Theo di lin tc nhp tim thai trc chuyn d.
- Nhm mc ch nh gi tnh trng thiu oxygen gy suy thai, cn gi l cc th
nghim theo di thai.
64 |
- C hai loi th nghim chnh:
Test khng kch: theo di nhp tim thai n thun, khng cn to nn cn co t
cung.
Test kch: theo di nhp tim thai tng ng vi cn co t cung hay l th nghim
chu ng ca thai i vi cn co t cung to nn do oxytocin (test oxytocin) hoc
do kch thch nm v.
3.1. Theo di lin tc nhp tim thai khng s dng oxytocin.
3.1.1. Ch nh.
- Tt c ph n c thai, c bit l thai nghn nguy c cao.
3.1.2. Thi gian th nghim.
- Trong khong t 20 n 30 pht nu xut hin 3 - 4 ln nhp tim thai p ng r, tng
ng vi thai vn ng c th kt lun l thai bnh thng.
3.1.3. Phn tch kt qu.
- Th nghim c p ng: tim thai tng ln khong 15 nhp/pht trong thi im thai c
ng. ng tim thai c bn dao ng bnh thng.
- Th nghim khng p ng: nhp tim thai khng thay i hoc tng di 15 nhp trong
thi im thai c ng hoc nhp tim thai c bn v dao ng ca tim thai khng bnh
thng (< 5 nhp/pht). Nu th nghim khng p ng th thai nhi c th b e da,
khi cn c nhng nh gi tip theo (test c kch hoc cc ch s sinh hc ca
thai nhi hoc can thip ly thai ra).
Test c cho l bnh l khi nhp tim thai chm km theo ng nhp tim thai c bn
bt thng
3.2. Theo di lin tc nhp tim thai c s dng oxytocin.
3.2.1. Ch nh.
- Ch p dng nhng c s c iu kin, phng tin.
- Thai nghn c nguy c cao cn nh gi tnh trng thai khi test khng kch khng
p ng.
3.2.2. Chng ch nh tuyt i.
- T cung c so m c, rau tin o, r i.
3.2.3. Chng ch nh tng i.
- a i, tin s non, a thai.
3.2.4. Thi im lm th nghim.
- Ch lm khi tui thai sau 34 tun.
3.2.5. Cc bc tin hnh.
- Chun b ngi thc hin, dng c v thai ph, cc bc tin hnh nh theo di lin
tc nhp tim thai tng ng vi cn co t cung trong chuyn d.
- Theo di nhp tim thai c s dng oxytocin.
- Pha 5 v oxytocin trong dung dch glucose 5 % truyn nh git tnh mch liu ban u
5 git/pht, sau 10 - 15 pht tng dn liu cho n khi t c 3 cn co t cung trong
10 pht, ghi li nhp tim thai v cn co t cung trong thi gian t 30 - 40 pht.
3.2.6. nh gi kt qu
- Kt qu m tnh khi nhp tim thai khng thay i v tn s v cng .
- Kt qu dng tnh khi xut hin nhp tim thai chm mun thng xuyn.
| 65
- Kt qu nghi ng khi thnh thang mi xut hin nhp tim thai chm mun, phi lm li
th nghim trong vng 24 gi.
- Tng kch thch: nhp tim thai chm mun xy ra do cn co qu mau, mi cn co cch
nhau di 2 pht hoc cn co ko di trn 60 giy, trng lc c bn ca t cung tng.
- Khng t yu cu khi ng biu din nhp tim thai khng r rng, kh phn tch.
3.3. Th nghim kch thch u v:
Ging nh th nghim dng oxytocin nhng oxytocin c thay th bng kch thch
hai nm v.
4. Theo di v x tr tai bin.
4.1 Theo di:
- Dn thai ph khng c ng nhiu v c th lm thay i v tr ca u d gy nhiu
trn giy ghi.
- Nu thy nhp tim thai b nhiu, cn kim tra li v tr t u d v bng chun c nh
u d c kt qu r rng.
- Xem kt qu ghi trn giy 10 pht/ln, nu xut hin nhp tim thai hay cn co t cung
bt thng cn khm li ngay c thi x tr kp thi.
4.2 X tr.
- Do t th nm nga, thai ph c th b chong (mch nhanh, huyt p h, v m hi,
mt mi) v thai c th b suy do t th nm nga ca m biu hin bng nhp tim thai
chm, ko di c khi ti vi pht. Cn phi thay i ngay t th nm ca sn ph
(nghing tri) v cho m th oxygen, nu nhp tim thai khng c ci thin phi tm
cch ly thai ra nhanh nht.

66 |
BIU CHUYN D

Tuyn p dng.
Tt c cc tuyn.
Ngi thc hin.

1. Ch nh.
- Tt c cc trng hp chuyn d c tin lng c theo ng m o (k c
trng hp c so m c t cung hoc ngi mng c ch nh cho ng m
o) u c theo di chuyn d trn biu .
- Khi sn ph c theo di bng biu chuyn d th t lc tr i ngi theo
di chuyn d khng phi ghi tnh hnh din bin ca h trong phiu theo di ca bnh
n sn khoa, tr cc din bin c bit khng c ch ghi trong biu mi phi ghi
trong bnh n. V d sn ph t nhin ra mu t, b ngt xu, co git...
2. Loi tr.
- Phu thut ly thai ch ng.
- Nhng trng hp cp cu sn khoa cn x tr ngay khi cha chuyn d (do bnh l
m hoc thai) hoc cn kt thc ngay cuc chuyn d (da v t cung, chy mu, thai
suy cp...).
- Nhng trng hp n c s y t c t cung m ht, tin lng cuc s din ra
trong t pht.
3. Thi im bt u ghi biu chuyn d.
- Ch bt u ghi biu chuyn d khi sn ph c chuyn d thc s (thi im ny
c th khc vi thi im sn ph vo vin). Thi im bt u ghi trn phn th
tc ca biu phi ghi ng theo gi v pht trong ngy nhng khi theo di trn biu
th gi u tin theo di c lm trn s.
4. Ni dung cn ghi trn biu chuyn d.
4.1. Tin ca chuyn d.
- m c t cung.
- xung v lt ca ngi thai.
- Cn co t cung.
4.2. Tnh trng ca thai.
- Nhp tim thai (m trong 1 pht).
- Nc i: mu sc, s lng.
- S chng khp (un khun) ca u thai nhi.
4.3. Tnh trng ca sn ph.
- Mch, huyt p.
- Nhit .
| 67
- Nc tiu: protein
- Cc thuc c s dng.
- Lng dch c b sung cho m.
5. Cch ghi cc k hiu trn biu chuyn d.
5.1. Cc k hiu dng ghi trn biu chuyn d.
- Biu chuyn d bt u c ghi khi sn ph c chuyn d thc s.
- K hiu ghi m c t cung c ghi bng du X, ni cc im ghi trong cc ln
thm khm sau bng mt ng lin vch.
- K hiu ghi lt ca ngi thai c ghi bng du O, ni cc im vi nhau bng
ng chm (khng lin vch).
- Cc k hiu v nhp tim thai, mch, huyt p ca sn ph ging nh cch ghi thng
thng (chm ghi nhp tim thai, mch m v mi tn hai u nhn ghi 2 s o huyt
p).
- Cc k hiu khc nh tnh trng i, chng khp, cn co t cung... theo hng dn
ca ti liu o to hoc trn biu .
5.2. Pha tim tng.
- C t cung di 3 cm v xa cha ht.
- Khi c t cung m > 3 cm th phi chuyn k hiu ghi m lc sang pha tch cc,
nm trn ng bo ng, tng ng vi mc ch m ca c t cung lc . Cng
vi s chuyn v tr ghi k hiu v c t cung, phi chuyn ghi gi trong ngy n
thch hp vi tnh trng c t cung lc v tt c cc k hiu ghi nhn v mi din
bin khc cng phi chuyn theo.
5.3. Pha tch cc.
- C t cung m t 3 - 10 cm v xa hon ton.
- C t cung m t 3 cm tr ln th phi bt u ghi m c t cung pha tch cc,
trn ng bo ng v ghi gi bt u ghi biu vo thi gian tng ng. Cc k
hiu khc ca cuc chuyn d cng ghi theo v tr ghi v m c t cung ghi lc
ban u.
6. c v x tr.
6.1. Ti tuyn x, phng
- Pha tim tng: thng thng khng ko di qu 8 gi. Nu ko di trn 8 gi, tuyn x
cn chuyn tuyn trn nh gi v x tr.
- Pha tch cc: ng m c t cung phi bn tri ca ng bo ng (m trn 1
cm/gi). Nu ng m c t cung chuyn sang bn phi ng bo ng (m di
1cm/gi) th tuyn x phi chuyn ln tuyn trn.
6.2. Ti cc tuyn trn.
- Phi tm nguyn nhn kh x tr.
68 |
9
8
7
6
5
4
3
2
1
180
170
160
150
130
120
140
110
100
Nhp
t im
t hai
Tnh tr ng i
chng kh p
Thi gian
Thn nhit C
Prtin niu
o
180
170
160
150
130
120
140
110
100
70
80
90
60
M ch
v
Huyt
p
T
h
u
n
g
5
1
2
4
3
S
n

c
o

T
C
T
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1
0

p
h
t
<20 giy
>40 giy
20-40 giy

C
T
C

(
c
m
)
(
X
)
Tin trin
ca u
(O)
Ngy/gi bt u ghi biu ............................................................. i v .......... gi
H v t n: ...............................................................PARA ....................... S nhp vin ...................
Biu chuyn d
n
g

b
n
g

n
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h
n
h

n
g

Pha t imtng Pha Tch cc
0
1 2 20 19 18 17 16 15 14 13 12 11 10 9 8 7 6 5 4 3 21 24 23 22 Gi
10
| 69
THNG NGI CHM

Tuyn p dng.
Tt c cc tuyn.
Ngi thc hin.
Bc s, n h sinh, y s sn nhi, c thn bn c o to v .

1. nh ngha.
thng ngi chm kiu chm v l th thut tc ng vo th s thai gip
cuc c an ton theo ng m o, khng cn can thip (tr trng hp ct tng
sinh mn).
2. Ch nh.
Thai ngi chm, u lt thp, thp th m h v chun b s.
3. Chng ch nh.
- Thai khng c kh nng c theo ng di.
- Ngi chm cha lt.
4. Chun b.
4.1. Phng tin.
- B dng c v b khn v khun.
- B dng c ct, khu tng sinh mn.
- Khn, bng, bng, gc hp, ch khu, kim khu.
- Dng c ht nht v hi sc s sinh (my ht, ng nha)
- Thng i.
4.2. Sn ph.
- c ng vin, hng dn cch th, cch rn v th gin ngoi cn rn.
- c hng dn i i tin hoc tht tho phn lc mi bt u chuyn d v tiu tin
khi sp . Nu c cu bng quang m khng t i c th thng tiu.
- Ra vng sinh dc ngoi bng nc chn.
- St khun rng vng sinh dc v bn, i, tri khn v khun.
4.3. T th sn ph.
- Nm nga trn bn , nng ging ln c t th na nm na ngi, u cao, hai
tay nm vo hai thnh bn , hai i giang rng, mng st mp bn, hai cng chn gc
trn hai cc chng gi chn.
5. Cc bc tin hnh.
5.1. Nguyn tc.
- Ngi phi tn trng nguyn tc v khun trong khi , phi kin nhn ch
i, hng dn sn ph rn khi c t cung m ht v c cn co t cung, khng c
nong c t cung v m o, khng c y bng sn ph.
70 |
- th lt, xung v xoay khng can thip, ch theo di cn co t cung, tim thai, xa
m c t cung, lt, khi c t cung m ht u lt thp mi cho sn ph rn.
- Thi gian rn ti a ngi con so l 60 pht, ngi con r l 30 pht. Nu qu thi
gian ny cn can thip ly thai ra bng forceps hoc bng gic ko.
- Trong thi gian sn ph rn vn phi theo di tim thai thng xuyn, sau mi cn
rn.
5.2. K thut ngi chm kiu chm v.
5.2.1. Ngi ch bt tay vo khi c cc iu kin sau:
- C t cung m ht.
- i v (cha v th bm i).
- Ngi thai lt v thp th m mn lm tng sinh mn cng gin, hu mn loe rng.
- Hng dn cho sn ph ch rn khi c cm gic mt rn cng vi s xut hin ca cn
co t cung.
5.2.2. Cc thao tc hu ht lm trong cn rn ca sn ph v cn phi:
- Nh nhng.
- Gip cho thai s t t.
- Kin nhn ng vin sn ph, khng thc p, gic gi, st rut.
- Nh l ch khng phi ko thai.
5.2.3. Cc thao tc gm c.
u
- Gip u ci tt: n nh nhng vo vng chm trong mi cn co t cung.
- Nu cn th ct tng sinh mn v tr 5 gi hoc 7 gi, vo lc tng sinh mn gin
cng.
- Khi h chm t di khp v: sn ph ngng rn, mt tay gi tng sinh mn, mt tay
y vo vng trn ngc ln trn, gip u nga dn, mt, mi, ming, cm s ln lt
s ra ngoi.
- Ch ht dch hoc lau ming thai nhi khi nc i c phn su.
vai
- Quan st xem u thai c xu hng quay v bn no th gip cho chm quay v bn
(chm tri - ngang hoc chm phi - ngang), kim tra dy rn nu qun c: g hoc ct
(khi cht khng g c).
- Hai bn tay m u thai nhi hai bn nh thi dng, ko thai xung theo trc rn -
ct vai trc s trc. Khi b di c delta t di khp v th mt tay gi u (c
nm gia khe hai ngn ci v tr) tay kia gi tng sinh mn, nhc thai ln pha trn v
cho s vai sau. th ny d rch tng sinh mn, v vy phi gi tng sinh mn tt v
cho vai s t t.
thn, mng v chi
- Khi s xong hai vai, b tay gi tng sinh mn thn thai nhi s v khi thn ra
ngoi th bt ly hai bn chn, tim bp 10 v oxytocin khi chc chn khng cn thai
no trong t cung (xemX tr tch cc giai on 3 ca chuyn d).
- Gi thai t th ngang, u hi thp (hoc thai nm nghing trn phn bn
c ko ra hoc cho nm sp trn bng m) ri tin hnh cp ct rn. Nu ngi
chnh cn b gi thai th ng tc cp ct rn do ngi ph thc hin.
| 71
- Chuyn thai ra bn hi sc, giao cho ngi ph chm sc, lm rn, nh gi ch s
Apgar pht th 1 v th 5.
6. K thut kiu chm cng.
Cch theo di c bn ging nh ngi chm v ch khc mt s im sau:
- Khi u v ngi chm s kiu chm cng mt thai nga ln pha xng mu ngi
m nn phi gip u ci bng cch dng u ngn tay n vo u thai t di ln.
- Khi h chm ca thai ra n mp sau m h th cho u thai nga dn ra sau l cc
phn trn, mt, mi, cm.
- Khi u s hon ton ch cho u t quay v pha no s gip thai quay hn sang
bn (tri hoc phi ngang).
- Tip tc vai v cc phn khc ca thai nh vi ngi chm chm v
Ch :
- Ngi chm s chm cng thng din bin lu, s kh hn v d gy sang chn cho
m v vy cn ct rng tng sinh mn trc khi u thai nhi.
- Thai nhi s chm cng cng d b ngt v th cng phi hi sc thai tht tt.
7. Theo di v x l tai bin.
7.1. Theo di.
- Sau mi cn rn, ngi ph li nghe nhp tim thai, bo li cho ngi chnh,
nhm pht hin suy thai c thi x l thch hp.
- Lun quan st bng sn ph pht hin kp thi du hiu da v.
- H bn nm ngang khi thai s ra ngoi.
- Sau khi , ngi chnh phi quan st sn ph kp thi pht hin chy mu,
vt rch v nh gi mc co hi t cung chun b x tr tch cc giai on 3 ca
chuyn d.
- Ghi li tnh hnh din bin cuc vo h s.
7.2. X tr.
- Ngay sau khi s thai, rau bong d dang gy bng huyt cn bc rau nhn to v kim
sot t cung ngay.
- Nu rch m h, m o, tng sinh mn (hoc ct ch ng): khu li sau khi s rau
v kim tra bnh rau.
- Nu b bng huyt do t cung phi tp trung cp cu bng cc bin php lm ngng
chy mu v bi ph lng mu mt.
- Thai ngt: phi hi sc thai.

72 |
X TR TCH CC GIAI ON 3 CA CHUYN D

Tuyn p dng.
Mi trng hp ng di ti c s y t t trung ng n x v cc trng hp
ti nh c nhn vin y t h tr.
Ngi thc hin.
Bc s, n h sinh/y s sn nhi, c thn bn c o to v v x tr tch
cc giai on 3 ca chuyn d.

X tr tch cc giai on 3 ca chuyn d l cc thao tc ch ng ca ngi tc
ng giai on sau khi s thai gip rau bong v s ra ngoi nhanh hn, nhm phng
nga chy mu sau .

1. Ch nh.
Cho mi trng hp ng di, khi thai va mi s ra ngoi v chc chn khng
cn thai no trong t cung.
2. Cch thc tin hnh.
2.1. T vn.
Gii thch cng vic s tin hnh ly rau sau khi thai ra ngoi cho sn ph yn tm
v hp tc vi nhn vin y t.
2.2. Phng tin, dng c.
Ngoi cc dng c, thuc men, vi v cc vt liu v khun cn thit cho v
kim tra rau, cn c thm oxytocin 10 v, chun b trong bm tim sn trn bn dng c
.
2.3. Qui trnh thc hin.
- Bc 1: Nn t cung ngay sau khi thai s ra ngoi chc chn trong t cung
khng cn thai no na.
- Bc 2: Tim bp oxytocin vo mt trc i cho sn ph 10 v oxytocin chun b
trc.
- Bc 3: Cp v ct dy rn gn st m h b m khi ko dy rn d dng hn
(khng nn vi vng ct rn ngay).
- Bc 4: Ko dy rn c kim sot.
Kim tra s co hi ca t cung: mt tay gi cng dy rn ch i t cung co li,
tay cn li t trn bng sn ph nh gi t cung co tt.
rau: mt tay ngi t trn bng sn ph, pha trn xng mu, n nh vo
mt trc on di t cung, y nh ln pha xng c trnh t cung b ko xung
di khi ko dy rn. Tay kia gi kp dy rn, ko dy rn nh nhng v lin tc
dc theo ng , ko nh vy trong vng 2 - 3 pht, nu rau khng s trong giai
on ny, dng li 5 pht ri ko li.
Mng rau: h thp bnh rau xung li dng sc nng ca bnh rau ko mng ra.
Cng c th dng hai bn tay bnh rau v xoay nh mng rau ra ht.
| 73
Xoa nn t cung: sau khi rau s, xoa ngay y t cung qua thnh bng n khi t
cung co tt.
- Kim tra rau: khi chc chn t cung co tt v khng thy chy mu mi tin hnh
kim tra bnh rau, mng rau, dy rn nh thng l (xem qui trnh Kim tra rau).
- Theo di sn ph sau : xoa y t cung 15 pht/ln trong vng 2 gi u cho n
khi chc chn t cung co hi tt.
2.4. Kh khn v cch x tr:
- Ko dy rn nhng bnh rau khng bong v khng xung dn trong t cung: khng
c ko git, khng c ko mnh, ch i mt lt ri tip tc ko li. Nu vn
khng kt qu, ch cho rau bong t nhin ri ra. Nu rau vn khng bong:
Tuyn x:
Nu chy mu: bc rau nhn to ti ch.
Nu khng chy mu: chuyn tuyn trn.
Tuyn huyn tr ln c th t 1 - 4 vin misoprostol (200 - 800 mcg) ngm di
li, sau 15 pht nu rau khng bong tin hnh bc rau nhn to.
- Trng hp dy rn b t trong khi ko: thc hin bc rau nhn to (tuyn x cng
chuyn bnh vin).
- Sau khi x tr tch cc giai on 3 chuyn d m vn chy mu, tham kho bi Chy
mu sau .
74 |

75 |

C
CHM SC SAU

76 |

| 77
LM RN TR S SINH

Tuyn p dng.
Tt c cc tuyn.
Ngi thc hin.
Cn b y t cung cp dch v.

Lm rn l buc hoc kp dy rn v ct ngn sau khi cp, ct dy rn trong lc .

1. Chun b.
- B lm rn.
- Khn v khun, bng, gc v khun, cn 70
o
.
- Bn lm rn c nh sng v m.
- Kp rn, ch lanh v khun.
2. Cc bc tin hnh.
- Dng mt tm gc che quanh chn rn, st khun dy rn bng cn 70
o
.
- Buc rn bng ch lanh v khun. C th dng kp rn nha v khun cp rn thay cho
buc ch.
- Ct b phn dy rn cn li trn nt buc.
- St khun mt ct.
- Ct phn ch buc rn cn tha.
- Khng bng kn rn. rn kh v sch. C th ph mt lp gc mng v khun trong
ngy u tin.
3.1.Theo di.
- Chy mu rn.
3.2. X tr.
- Chy mu rn: buc li.
- Chy mu chn rn: khu cm mu.
- Nhim khun rn: tham kho bi Nhim khun rn.

78 |
KIM TRA RAU

Tuyn p dng.
Tt c cc tuyn.
Ngi thc hin.
Cn b y t cung cp dch v.

1. nh ngha.
Kim tra rau l thao tc quan st cc mt mi, mt mng ca bnh rau, cc mng rau,
dy rn c bnh thng khng v c st rau, st mng khng.
2. Ch nh.
Kim tra rau phng st rau, st mng phi c thc hin cho tt c cc cuc
ng di.
3. Chun b.
- Mt khay to, phng hoc mt chu ng rau khi rau ra.
- Gng cao su cho ngi kim tra rau, bng, gc cn cho vic lau thm mu khi kim tra.
4. Cc bc tin hnh.
4.1. Kim tra mng rau.
- Quan st mng rau v nh gi xem hay thiu.
- Quan st v tr l rch i .
- Vi bnh rau sinh i cn bc tch phn mng nh gi 1 hay 2 bnh rau.
- Quan st v tr bm ca dy rn: bm trung tm, bm cnh hay bm mng.
- Quan st cc mch mu t chn dy rn i ra n tn b mp bnh rau pht hin mi
rau ph.
4.2. Kim tra bnh rau: ln lt kim tra cc phn sau.
- Quan st k cc mi rau t trung tm ra xung quanh xem c mi no b khuyt khng
- nh gi cht lng bnh rau: c cc nhi mu, cc lng ng calci, tnh trng rau
c b x ha hay khng.
4.3. Kim tra dy rn.
- Tm xem c b tht nt (nt tht).
- Quan st mt ct ca dy rn, kim tra cc mch mu rn.
- o di dy rn, o 2 pha (pha bm vo bnh rau v pha bm vo rn s sinh).
- Kt thc phn kim tra, thng bo kt qu cho sn ph bit v gii thch nhng iu
cn thit nu c nhng bt thng cn phi x tr tip.
- Gip sn ph ng khn v sinh v mc vy, o.
5.1. Theo di.
- Ngay khi kim tra rau, phi m mch v o huyt p, ghi h s.
| 79
- Trc khi chuyn sn ph v bung hu sn cng phi theo di v ghi li trong h s
tnh trng mch, huyt p, mc chy mu, co hi t cung v ton trng.
5.2. X tr:
5.2.1. Trng hp sau khi rau ra b bng huyt.
- Kim sot t cung ri cho thuc co t cung v khng sinh v hi sc (nu cn) ti tt c
cc tuyn.
5.2.2. Trng hp st rau hoc st nhiu mng rau (trn 1/3 mng b st).
- Nu khng bng huyt:
Ti tuyn x, phng: chuyn sn ph ln tuyn trn.
Ti cc tuyn trn: kim sot t cung ly rau v mng b st ri tim thuc co t
cung v khng sinh.
- Nu c bng huyt: tin hnh hi sc, cm mu c hc, kim sot t cung, tim thuc
co t cung v dng khng sinh d phng nhim khun.

80 |
CT V KHU TNG SINH MN

Tuyn p dng.
Tt c cc tuyn.
Ngi thc hin.
Bc s chuyn khoa ph sn, n h sinh, y s sn nhi c o to v v ct khu
tng sinh mn.

1. Ch nh.
1.1. Ngi m.
- m h hp, tng sinh mn ngn v rn.
- m h v tng sinh mn ph n.
1.2. Thai nhi.
- Thai to.
- Thai non yu, thiu thng, thai suy.
- Cc ngi thai c kh khn khi s.
1.3. Th thut ng di (nu cn).
2. Chun b.
2.1. Phng tin.
- B ct, khu tng sinh mn.
- Thuc gy t, phng tin st khun
2.2. Sn ph.
T vn cho sn ph.
3. Cc bc tin hnh.
3.1. Nguyn tc.
Ct khi m h, tng sinh mn phng cng trong lc c cn co t cung v sn ph
ang rn.
3.2. K thut.
- Gy t vng m h tng sinh mn thi im gia 2 cn rn.
- Ct v tr 7 gi, chch 45
o
so vi ng trc m h, di 4 - 5 cm ty mc cn thit.
- Thng ch ct mt bn l , rt hn hu trong nhng thai to, s kh c th ct c hai
bn.
- Dng ko thng, u t, li di v sc.
- Khu phc hi:
Khu sau khi s rau v kim tra rau.
St khun m h, tng sinh mn.
t mt bc to vo m o, khu theo cc lp gii phu, m bo khu ht nh vt
ct, khng khong trng ng hm
| 81
4.1. Theo di.
- Gi vt khu sch v kh. Ct ch vo ngy th 5 nu khu da bng ch khng tiu.
- Nu vt khu khng lin do nhim khun phi x tr ti ch, khng khu li ngay.
4.2. X tr.
- Chy mu do c khong trng gia cc lp khu: khu li cho cc lp lin v p vo
nhau.
- Nhim khun: ct ch tng sinh mn cch qung, ra sch, khng sinh ti ch v ton
thn.
82 |
CHM SC B M V TR S SINH
NGY U SAU
Tuyn p dng.
Tt c cc tuyn.
Ngi thc hin.
Tt c cn b y t v y t thn bn/c thn bn trc tip chm sc cho b m v s
sinh khi .

1. Theo di - chm sc trong 2 gi u.

Cho m Cho con
- Sn ph vn nm phng .

- Nu m v con u bnh thng,
ngay lc ny c th cho con nm
cnh m v hng dn b m cch
cho con b.

Theo di:
Th trng, mch, huyt p, co hi
t cung, ra mu ti cc thi im
15 pht, 30 pht, 45 pht, 60 pht,
90 pht v 120 pht.
- Bo m tr th c bnh thng: ngay khi tr
ra, hi nghing u tr di dt d chy ra ngoi.
Nu c biu hin ngt, phi x tr cp cu ngay..
- Gi m: nhit phng t 26
o
C - 28
o
C, khng c
gi la. Lun tr nm vi m, tt nht l t tr
tip xc da k da trn ngc m. Mc m, i m.
Khng tm cho tr trc 6 gi sau .
- Cho b m ngay trong vng 1 gi u sau .
Khng cho bt c thc n, nc ung no khc.
- Thc hin chm sc thng qui: khm ton thn,
chm sc rn, mt, tim vitamin K1, tim vaccin
vim gan B v BCG.

Theo di:
- Ngay khi ra: ch s Apgar pht th 1, th 5 v
th 10.
- Ton trng: th, mu sc da, thn nhit, tiu ha: 15
- 20 pht trong 2 gi u.

Lu : khi theo di/chm sc m v con phi m bo v sinh mc ti a:
- Ra tay nc sch v x phng trc v sau mi ln chm sc.
- Dng c chm sc phi v khun, khng dng chung cho cc sn ph hoc tr s sinh
khc.
- T, o, khn, dng cho m v con phi kh, sch.

| 83
Mt s tnh hung bt thng c th xy ra v cch x tr
Cho m Cho con
Pht hin X tr Pht hin X tr
Mch nhanh trn 90
ln/pht.
Kim tra ngay
HA, cu an ton,
ra mu.
Kh th, ngng
th, tm ti, c
mm nho.
Hi sc th - hi
sc tim - chuyn
tuyn.
HA h (ti a < 90 mmHg). X tr chong sn
khoa.
Tr b lnh hoc
phng lnh.
m, cho tr nm
tip xc da k da
vi m, si m
vi phng tin
sn c.
Tng HA (ti a > 140,
hoc tng 30 mmHg; ti
thiu > 90 hoc tng 15
mmHg so vi trc.
X tr tin sn
git.
Chy mu rn. Lm rn li.
T cung mm, cao trn rn. X tr t cung.
Chy mu trn 250 ml v
vn tip tc ra.
X tr bng huyt
sau .

Rch m o, tng sinh
mn.
Sp xp khu
li.

Khi mu t. Theo di quyt
nh x tr hoc
chuyn tuyn
(nu x).

2. Theo di t gi th ba n ht ngy u.
Cho m Cho con
- a m v con v phng, theo di cc ni
dung nh trn 1 gi/ln.
- M c bng v sinh sch, thm.
- Gip m n ung v ng yn.
- Cho m vn ng sm sau 6 gi.
- Hng dn m cho con b sm v ng cch.
- Hng dn m cch chm sc con, theo di
chy mu rn.
- Hng dn m v gia nh (b) bit chm sc
v pht hin cc du hiu bt thng.
- Yu cu gi ngay nhn vin y t khi m chy
mu nhiu, au bng tng, nhc u, chng
mt, hoa mt.
Theo di t gi th 7:
Ton trng, co hi t cung (rn - trn),
bng v sinh (kim tra lng mu mt)
Theo di tr 1 gi/1 ln:
- Lun con nm cnh m, ch gi
m cho tr
- Cho b m hon ton
- Hng dn b m nhn bit cc du
hiu bt thng cn gi ngay nhn vin
y t: tr b b, khng th, tm ti, chy
mu rn.

Theo di t gi th 7:
Theo di tr 6 gi/ln
Ton trng: th (c kh th?), mu
sc da (c tm ti? c vng khng? s c
lnh khng?), rn (c chy mu?), tiu
ha, b m: c b m c khng?
a phn su cha?).
84 |
Mt s tnh hung bt thng c th xy ra v cch x tr
Cho m
Pht hin X tr
- T cung mm, cao qu rn.
- Bng v sinh thm t mu sau 1
gi.
- Xoa bp t cung, n y ly mu cc.
- Tim thuc co t cung (10 v oxytocin).
- Kim tra, x tr theo bi Chy mu sau .

Cho con
Pht hin X tr
Cha b m hoc kh khn khi cho
con b.
Hng dn b m cch cho con b

Tr lnh hoc phng lnh.

- m cho tr: cho tr nm tip xc da k da vi
m, mc thm o, p thm chn
- Lm m phng.
Kh th, tm ti X tr cp cu (xem bi X tr suy h hp).
Chy mu rn. Lm li rn. Nu vn chy mu, khng tm c
nguyn nhn, mi hi chn hoc chuyn tuyn trn
Khng c phn su. Kim tra hu mn: nu pht hin khng hu mn,
mi hi chn ngoi khoa hoc chuyn tuyn
Khng i Kim tra xem tr c c b khng? Nu khng
tm thy nguyn nhn, mi hi chn hoc chuyn
tuyn
Vng da iu tr ngay hoc chuyn tuyn

| 85
CHM SC B M V TR S SINH TUN U SAU
(khi thm b m v s sinh ti h gia nh hoc ti trm y t x)

Tuyn p dng.
Tuyn x v thn bn.
Ngi thc hin.
Cn b y t v y t thn bn/c thn bn trc tip chm sc cho b m v s sinh
sau .

1. Hi.
V m V con
- Sc khe chung, gic ng, n ung.
- St.
- i, tiu tin. C r nc tiu hoc sn phn.
- au bng, sn dch.
- Tnh trng v: cng, au, tit sa, c sa cho con.
- Trng thi tinh thn ca b m.
- Nhc u hoa mt.
- au tng sinh mn.
- Ung thuc: vin st, vitamin A.
- Cc vn khc (trong phiu theo di sc khe b m ti
nh).
- B m?
- Ton trng
- Ng.
- i tiu tin.

2. Khm.
Cho m Cho con
- Quan st tnh trng tinh thn: vui v,
phn khi, bun b, trm cm.
- Cc ch s sinh tn: mch, huyt p,
thn nhit, da xanh, ph n.
- Nn bng kim tra t cung: co hi,
au, mt (mm, rn).
- Kim tra tng sinh mn: kh, lin hay
sng, au, nhim khun.
- Kim tra v: bu v, nm v, s tit
sa, lng sa.
- Ton trng.
- Th.
- Thn nhit.
- Da: c vng khng, c sn, mn khng?
- Rn: c t/sng/c m?
- B m .

86 |
3. Hng dn chm sc.
Cho m Cho con
- V sinh hng ngy: ra vng sinh dc t
nht 3 ln/ngy; lau ngi thay sch,
sau 2 - 3 ngy tm nhanh bng nc
m.
- Chm sc v: cho con b hon ton sa
m, khng cho bt c thc n, nc
ung khc; nu tc tia sa cn x l sm
(day, vt, ht, i khm) phng nga
vim v, p xe v.
- X tr au do co bp t cung: nu au
nh: khng cn x tr. Nu au nhiu:
chm nng, cho ung paracetamol.
- Vt khu tng sinh mn (nu c): ra
sch m h sau i, tiu tin v thm
kh. Ct ch nu 5 ngy sau .
- Ch n ung v sinh hot: n
lng, cht, khng king v l. Ng
8 gi/ngy, tn trng gic ng tra. Mc
sch s, rng ri.
- Ch vn ng: sau 6 gi c th
ngi dy, ngy hm sau i li, vn ng
nh nhng.
- T vn v gip gii quyt vn tm l
(nu c).
- T vn v KHHG, v nui con bng
sa m.
- Hn n thm hoc hn sn ph n
khm ti trm vo 6 tun sau .
- Hng ngy: nm chung vi m trong
phng m. Ng mn. Khng t tr nm
sp, trn nn lnh, cng. Khng cho tip
xc vi ngi ang c bnh, khng cho
gn sc vt, khng trong mi trng
khi, bi, khi thuc.
- Nui con bng sa m: cho b m hon
ton, b c ngy/m, t nht 8 ln/ngy.
Nu m c kh khn khi cho b, hng
dn cch cho con b ng.
- Chm sc mt: ra tay sch bng x
phng trc/sau khi chm sc. Dng
khn sch, m lau mt hng ngy.
Khng nh bt c thuc g vo mt tr.
- Chm sc rn: rn kh v sch.
Khng bng kn hoc p bt c th g
ln rn. C th ph mt lp gc mng v
khun. Hn ch s vo rn v vng
quanh rn.
- V sinh thn th v chm sc da: lau
ra hng ngy, khng nht thit phi tm
hng ngy. Tm bng nc m,sch
trong phng m, kn gi. Thay vi
nh m, o, t lt hng ngy v mi khi
tr bi tit.
- Hn ngy tim phng v ghi nhn xt
vo phiu.
- Hn n thm b .

4. Mt s tnh hung bt thng c th xy ra v cch x tr.
Cho m Cho con
T cung: co
chm, mm,
n au, c th
km theo st,
sn dch hi.
X tr St sau . Mu sc da: xanh ti, vng da
m tng dn .
Chuyn
tuyn c
kh nng
iu tr.

Sn dch: c
m, mi hi.
X tr St sau . Th bt thng: nhp th
nhanh hoc chm:( 60 hoc <
40 ln/pht, co rt lng ngc
nng.

| 87
Cho m Cho con
R, r nc
tiu, sn
phn.
Gi tuyn trn khm v
iu tr.
Thn nhit: st cao ( 38,5
o
C)
hoc h thn nhit (<36,5
o
C).
Chuyn
tuyn c
kh nng
iu tr.

Tng sinh
mn: sng,
ph n, au,
, r nc
vng
Khng sinh, chm sc v
sinh hng ngy, ct ch
(khi cn), ra vt
thng. Nu tn thng
rng chuyn tuyn.
Tiu ha:
- B km, b b.
- Nn lin tc.
- Chng bng.
- Khng a/khng i sau 24
gi.

V:
Nm v lm,
nt, sng, au
hoc c kh
khn khi cho
con b.
Vt sa ra cho tr n
bng tha. (tham kho
bi T vn nui con
bng sa m)
Chuyn
tuyn c
kh nng
iu tr.

Cc du hiu
nguy him:
- St cao.
- Mch nhanh.
- Tng HA.
- Da rt xanh.
- Ph n.
- Co git
Chuyn khm, iu tr
tuyn trn sau khi s cu
(ty trng hp: truyn
dch, khng sinh, tim
thuc co t cung, thuc
chng co git).
Cc du hiu nguy him khc:
- Ng li b kh nh thc.
- Co git.
- Mt ty , c m.
- Vim ty lan rng quanh rn
hoc rn c m.
- Chy mu bt c ni no trn
c th.

88 |
CHM SC B M V TR S SINH 6 TUN U SAU

Tuyn p dng.
Tuyn x v thn bn.
Ngi thc hin.
Tt c cn b y t v y t thn bn/c thn bn trc tip chm sc cho b m v s
sinh sau .

1. Hi.
V m V con
Tnh hnh chung:
- n ung, ng, ngh ngi, lao ng.
- Tiu ha, tit niu.
- Dch m o
- Cho con b: c sa khng, s ln
b/ngy.
- Ung vin st, vitamin A.
- C kinh tr li cha.
- Cc nhu cu v KHHG
- Nhng ni lo lng, thc mc lin quan
n sc khe m v con.
Nhng bt thng:
- St.
- au bng di.
- Tm hiu v h tr nhng vn b
m lo lng.
- B m.
- Ton trng.
- Ng.
- i tiu tin.
- tim phng cc loi vaccin no.
- Tm hiu v h tr cc vn b m lo
lng.

2. Khm.
Cho m Cho con
- Quan st ton thn v trng thi tinh
thn.
- o mch, huyt p, thn nhit, cn
nng.
- Khm v v tm hiu cc vn lin
quan n cho con b.
- Khm nn bng.
- Kim tra tng sinh mn.
- t m vt kim tra nu nghi c vim
sinh dc.
- Cn tr.
- Khm ton thn: tim, phi, bng.
- Khm mt.
- Khm tai, mi, hng.
- Khm da.
- Khm rn.
| 89
3. Hng dn b m t chm sc mnh v chm sc con
Cho m Cho con
- Sau mi ln i, tiu tin
phi ra v lau kh m h.
- C th tm hng ngy bng
nc sch v m.
- Mc sch s v rng ri.
- n ung no, cht c
sc khe v sa nui
con.
- Cho con b m hon ton.
- Sau 1 tun c th lm
vic nh, trnh lao ng
nng, ko di.
- Nn tp th dc gip c th
chng phc hi, trnh to
bn, gip n ngon ming.
- Nn trnh quan h tnh dc
trong vng 6 tun v d
sang chn, nhim khun.
Ging nh phn chm sc tr trong vng 1 tun sau :
- Chm sc chung hng ngy.
- Cho con b m hon ton.
- Chm sc mt.
- Chm sc rn: rn rng t khong 7 n 10 ngy sau
, lin so khong 15 ngy.
- V sinh thn th v chm sc da cho tr.
- Hng dn b m nhng du hiu nguy him cn a
tr i khm.
nh gi s pht trin ca tr:
- Kim tra cn nng v theo di tng cn trn biu
tng trng.
- Pht hin sm cc vn v thnh gic, th gic.
- Nu tr non/nh cn, c cc vn v dinh dng,
bnh tt, sinh ra t b m c HIV(+) cn c hng
dn theo di, chm sc c bit.
X tr v hng dn b m x tr mt s vn thng
thng:
- Nhim khun ti ch.
- C kh khn khi cho con b.
- Nhc nh b m lch tim vaccin phng bnh cho tr.
4. Mt s tnh hung c th xy ra v cch x tr.
Cho m Cho con
Tt c u
bnh thng.
- Tho lun thc hin
KHHG.
- Ghi phiu theo di.
Tt c u bnh
thng
- Hng dn v sinh, cho
b, gic ng, theo di tng
trng, tim chng.
- Ghi phiu theo di.
Thiu mu. iu tr thiu mu. Tr khng tng
cn.
- nh gi ba b.
- Chuyn tuyn trn
khm.
Nhim khun. iu tr nhim khun. Nu c bt thng.
(xem Chm sc
b m v tr s
sinh trong vng 1
tun sau )
Chuyn tuyn.
Cng v, nt
nm v.
nh gi ba b, cho
li khuyn ph hp.

Bnh l nng. Chuyn tuyn.
90 |

91 |

D
CC BT THNG
TRONG THAI NGHN, CHUYN D
V SINH

92 |

| 93
THAI NGHN C NGUY C CAO

Tuyn p dng.
Tt c cc tuyn (theo phn tuyn k thut).
Ngi thc hin.
Bc s chuyn khoa sn, n h sinh, y s sn nhi.

Thai nghn c nguy c cao l tnh trng thai nghn khng c li cho m, thai v s
sinh.

1. Pht hin cc yu t nguy c.
C th phn chia cc yu t nguy c thnh 5 nhm chnh sau y:
1.1. Nhm nguy c c lin quan ti c a ca thai ph.
- Tui ca thai ph:
Di 16 tui: d b kh, non, t l t vong chu sinh cao.
Trn 35 tui: d b kh, nguy c ri lon nhim sc th, s sinh d dng, t vong
chu sinh cao.
- Th trng ca thai ph: qu bo (trn 70 kg) hoc qu gy (di 40 kg) cng l mt
trong nhng yu t nguy c cho m trong cuc .
- Nhng bt thng v gii phu ca ng sinh dc nh t cung i, t cung hai sng,
vch ngn t cung d gy non.
1.2. Nhm nguy c lin quan ti bnh tt ca m c t trc.
- Tng huyt p: nguy c t vong m v thai (sn git).
- Bnh thn: nguy c cao huyt p mn dn ti sn git, tin sn git.
- Tiu ng: gy thai to v d t vong.
- Bnh tim: c bit l bnh tim c bin chng gy t vong cao.
- Bnh ni tit: Basedow, tiu ng d gy bin chng cho m v cho thai nhi.
- Ri lon h min dch, bnh to keo.
- Bnh c tnh ca m: ung th v, c t cung, bung trng
- Bnh thiu mu: suy tu, hng cu li lim.
- Bnh nhim khun cp hoc mn tnh: lao phi, thng hn
- Bnh LTQTD: chlamydia trachomatis, herpes sinh dc, HPV, lu, giang mai, HIV.
- Bnh do virus: vim gan virus, rubella.
- Bnh do k sinh trng: st rt cn, trichomonas m o.
- Bnh no: vim no, ng kinh, tm thn...
- Nhim khun niu - sinh dc: t cu, Coli, Proteus.
- Bnh di truyn c tnh cht gia nh nh: chy mu, tiu ng, sinh i, a thai
- Bnh ngoi khoa: gy xng chu, bnh tr, to hnh bng quang do chn thng
94 |
1.3.Nhm bnh v cc yu t bt thng pht sinh trong k thai ny.
Chng hn nh bnh st rt, bnh thiu mu, tin sn git do thai nghn, ngi bt
thng, thai to (thng lin quan n bnh tiu ng).
1.4. Nhm c tin s sn khoa nng n:
- Sy thai lin tip nhiu ln: thng do bt thng ca hai v chng, thiu nng ni tit,
bt thng t cung.
- Thai cht lu: cn pht hin nguyn nhn. V d: u x t cung, bnh ton thn nh tng
huyt p, bnh thn..
- Tin s non, con di 2500 g gy nguy c cho s sinh.
- Hot ng ca ni tit sinh dc km d gy sy thai, non
- Bt ng nhm mu ABO gy nguy c cho thai.
- Tin s sn git d b sn git nhng ln c thai sau.
- Tr d dng bm sinh, bt thng th nhim sc th d b d dng cc ln sau.
- Tin s b nh ch thai nghn th ln c thai ny cng d b nguy c . Chng hn
nh tin s nh ch thai nghn do tin sn git nng th thai ln ny cng d b nh
vy.
- Tin s phu thut ly thai d c nguy c phu thut li hoc tin s forceps, gic
ko d b can thip li ln c thai ny.
- Cc ln qu gn hoc qu xa nhau.
1.5. Nhm nguy c cao c lin quan ti yu t x hi.
Lin quan ti nhm ny, phi k n cc yu t nh cnh ngho i, trnh vn ha
thp, xa c s y t, giao thng vn ti khng thun tin. Tt c nhng yu t trn u l
nhng nguy c cao cho thai k ca mt ph n.
2. Khm thc th pht hin thai nghn c nguy c cao.
2.1.Khm ton trng.
- Chiu cao sn ph di 145 cm th kh.
- Khm cn nng: tng 20 % trng lng khi c thai l bnh thng.
- Huyt p.
- Da, nim mc, khm v, khm tim mch, khm phi, khm mt, khm ngoi khoa
(vo, g).
2.2. Khm chuyn khoa.
Khung chu, t cung (chiu cao t cung, t th, u x), m o (sa sinh dc), c t cung
(rch, vim, t th..), tng sinh mn (ngn, di, so c..), phn ph (u..).
2.3. Chm sc v nh gi sut qu trnh thai nghn.
2.3.1. Khm thai nh k.
Lm cc bc 3.1 v 3.2 v cc xt nghim cn nhc cng sn ph c nn tip
tc thai nghn hay khng.
2.3.2. Nhng vn cn nh gi duy tr thai nghn.
- Tnh trng sc khe ca m tt, m bo cho mt qu trnh thai nghn.
- Nhng thay i sinh l ph hp, khng nh hng ti sc khe ngi m v tim,
mch, huyt p..
| 95
- Chiu cao t cung ph hp tui thai.
- Khng c thai nghn bt thng: cha trng, thai ngoi t cung...
- Thai my na sau ca thai k, tim thai nghe u r.
- Nu c rau tin o: khng ra mu hoc ra mu t.
- Tin sn git: khng nng ln, c th duy tr nu p ng vi iu tr.
- Nu c nhim khun: iu tr tch cc cho thai ph khi trc khi chuyn d v khng
li nguy c cho m v con.
- D kin ngy chnh xc, trnh thai gi thng.
2.3.3. Nhng yu t c th gy bin chng trong chuyn d.
Cn bit nhng yu t sau y tin lng thai nghn c nguy c cao trong chuyn
d.
Chuyn d d thng, non hay gi thng bin chng u c th xy ra khi:
- Bnh ca m c tng ln trong : tng huyt p, hn m gan, lao phi
- a i, thiu i, i v non, v sm, nhim khun i
- Ngi thai bt thng: ngi trn, ngi vai
- Ri lon cn co t cung: cng tnh, khng u...
- Bt thng v dy rn: ngn, qun c, sa dy rn...
- Suy thai.
- C t cung khng tin trin.
- M rn yu, chuyn d ko di.
- Ch nh sn khoa khng ng v forceps, v s dng oxytocin.
- Cho s sinh: thot v c honh (bm sinh), ngt, xp phi, chy mu phi, non thng
nh cn < 2500 g.
3. Cc xt nghim thm d cn lm sng.
3.1. Xt nghim thng qui: nhm mu, cng thc mu, nc tiu
3.2. T cc du hiu lm sng s c quyt nh xt nghim cn lm sng nh gi
nguy c:
- Siu m: thai sng, cht, d dng, s lng thai, lng nc i
- Th nhim sc: cho ph n > 35 tui, tin s con b bnh Down hoc ri lon th
nhim sc khc.
- Theo di nhp tim thai (ng nghe tim thai, monitor sn khoa).
- Test gy cn co t cung xc nh tim thai bnh thng hay bt thng.
- nh gi ch s Bishop chn cch cho ph hp.
- Theo di nhng hot ng sinh hc ca thai qua siu m (thai th, c ng..)
- Chn on X quang: t dng.
4. nh gi thai trong chuyn d.
Cn nh gi nguy c thai nhi trong chuyn d da vo cc im sau:
- Tn s tim thai.
- Nhp tim thai.
- Tim thai v cn co t cung (DIP I, DIP II, DIP bin i...).
- Phn su, i.
96 |
- nh gi nguy c cho m trong chuyn d: c trc nh tin sn git, hen ph qun,
tng huyt p, bnh tim... trong chuyn d s nng ln nh sn git, suy tim, ph phi
cp
5. Chm sc thai nghn c nguy c.
V nguyn tc, tuyn x khi pht hin thai nghn c nguy c cao th phi chuyn ln
tuyn huyn. Tuyn huyn ty tng trng hp v ty theo kh nng chuyn mn v trang
thit b ca mnh m quyt nh gi thai ph li tuyn ca mnh iu tr hoc gi ln
tuyn tnh. Cn tn trng nguyn tc sau:
- Khng xy ra tai bin ri mi nh ch thai nghn.
- nh ch thai nghn cu m khi cn thit.
- Tch cc iu tr thai suy v s sinh ngt.
5.1. Bin php chung.
- Qun l thai nghn sm xc nh cc yu t nguy c.
- Loi b thai nghn khng mong mun bng bin php sn khoa thch hp.
- Thc hin chm sc v nh gi mc thai nghn nguy c vi phng chm cu m
l chnh, c gng bo tn thai.
5.2. Bin php ring.
- iu tr ni khoa cc bnh ni khoa ca sn ph: tim, phi
- iu tr ngoi khoa: ct b u x, khu vng c t cung...
- Cai nghin thuc l, ma ty...
- Ngh ngi ti ging.
- Thuc gim co, corticoid gip cho phi thai trng thnh.
- nh ch thai nghn cu m.

| 97
CHY MU TRONG NA U THAI K
Tuyn p dng.
Ngi thc hin.
Bc s, n h sinh, y s sn nhi theo qui nh ca tng tuyn (xem chi tit trong bi).

1. Bnh cnh thng gp.
- Da sy thai, sy thai.
- Thai ngoi t cung.
- Cha trng.
2. X tr chung.
- nh gi nhanh th trng chung, cc du hiu sinh tn: mch, huyt p, nhp th. Nghe
tim phi.
- Nu c du hiu chong hoc chy mu nhiu phi x tr ngay.
- T vn, gii thch r cch x tr ty theo tnh hung c th.
3. X tr c th.
3.1. Da sy thai, sy thai.
- Sy thai l trng hp thai v rau b tng ra khi bung t cung trc 22 tun (k t
ngy u ca k kinh cui).
3.1.1. Da sy thai.
Triu chng
- C chm kinh v tnh trng nghn.
- Ra mu m o ti.
- Tc bng di hoc au m vng h v.
- C t cung cn di, ng kn.
- Kch thc thn t cung to tng ng vi tui thai.
- Xt nghim hCG bng que th nhanh dng tnh.
- Siu m thy hnh nh ti i hoc c thai, m vang thai v tim thai trong bung t
cung.
X tr
Tuyn x:
- Nm ngh, n nh, chng to bn.
- T vn cho ngi bnh v gia nh nhng tin trin c th xy ra.
- Nu sau khi ngh ngi, cc triu chng khng phi chuyn ln tuyn trn.
- Thuc gim co: spasmaverin 40 mg ung 02 vin x 2 ln/ngy.
Tuyn huyn:
- iu tr nh tuyn x.
- C gng tm nguyn nhn iu tr, nu sy thai lin tip chuyn tuyn tnh.
- Nu khng mun gi thai th chm dt thai nghn.
98 |
3.1.2. ang sy thai.
Triu chng
- au bng nhiu tng cn vng h v.
- Mu ra ngy cng nhiu, c khi chong.
- Thm m o: c t cung xa, m, c th thy rau, thai hoc c t cung hnh con
quay v l trong v phn trn c t cung gin rng phnh to do khi thai xung
on di.
X tr
Tuyn x:
- Nu rau v thai thp th c t cung th dng 2 ngn tay hoc kp hnh tim ly thai
ra ri chuyn tuyn trn. Cho oxytocin 5 v x 1 ng tim bp trc khi chuyn v mt
ng ergometrin 0,2 mg tim bp nu bng huyt nng.
- Nu c chong truyn dch trong khi chuyn tuyn hoc ch tuyn trn xung x tr.
Tuyn huyn
- Nong c t cung nu cn ri gp bc thai ra v ht.
- Nu c chong: truyn dung dch mn ng trng 0,9% hoc Ringer lactat
- Cho oxytocin 5 v x 1 ng hoc/v ergometrin 0,2 mg tim bp trc khi ht. C th
cho thm oxytocin nu cn chy mu.
- Cho khng sinh.
3.1.3. Sy thai hon ton.
Triu chng
- Thng gp khi sy thai trong 6 tun u.
- Sau khi au bng, ra mu, thai ra c bc sau mu ra t dn.
- Khm c t cung ng, t cung nh hn tui thai.
X tr
Tuyn x
- Cho ung khng sinh (nu c nguy c nhim khun).
- Nu ngi bnh n khm li v nhng triu chng bt thng nh: au bng, ra mu,
st th chuyn tuyn.
Tuyn huyn:
- Siu m: nu bung t cung sch khng cn ht.
3.1.4. Sy thai khng hon ton: st rau.
Triu chng
- Sau khi thai sy, ra mu ko di.
- Cn au bng.
- C t cung m v t cung cn to.
X tr
Tuyn x
- T vn, cho khng sinh v chuyn tuyn trn.
Tuyn huyn
- Cho khng sinh.
- Nu siu m thy trong bung t cung cn nhiu m vang bt thng th cn cho
misoprostol (c 3 - 4 gi cho ung 200 mcg, ti a ch cho 3 ln).
| 99
- Ngy hm sau siu m li nu khng ci thin th ht bung t cung.
- Cho oxytocin 5 v x 1 ng tim bp trc khi ht.
- Nu khng c siu m, tin hnh ht sch bung t cung i vi tt c cc trng hp.
3.1.5. Sy thai nhim khun.
Triu chng
- Thng i sau mt ph thai khng an ton (khng bo m v khun) hoc sy thai st
rau.
- T cung mm, n au.
- C t cung m.
- St, mt mi kh chu, tim p nhanh.
- Ra mu ko di v hi, c khi c m.
X tr
Tuyn x
- T vn.
- Phi cho khng sinh gentamycin 80 mg x 01 ng (tim bp) hoc amoxicillin 500 mg x
2 vin (ung) v chuyn tuyn trn ngay.
Tuyn huyn
- Cho khng sinh liu cao, phi hp nh tuyn x v metronidazol 500 mg tnh mch.
- Nu mu chy nhiu, tin hnh hi sc v ht ngay. Nu mu ra t, dng khng sinh 4 -
6 gi sau ht rau cn st li trong t cung. Cho oxytocin 5 v x 1 ng tim bp
trc khi ht.
- Trong trng hp chy mu v nhim khun nng th phi chuyn tuyn tnh ngay v
c th c ch nh ct t cung .
- T vn cho ngi bnh v gia nh nhng bin chng v tai bin nguy him c th xy
ra cho ngi bnh. V vy, phi tun th nhng ch nh iu tr ca y, bc s.
3.1.6. Sy thai cht.
Sy thai cht l tnh trng thai cht tui thai di 22 tun thng lu li trong t
cung. Trong nhng thng u cc triu chng ging nh trng hp sy thai.
Triu chng
- C triu chng c thai sau ra mu m o, ht nghn, v c th tit sa non, khng
thy thai my, tim thai khng c.
- C t cung ng kn, c mu en, t cung nh hn tui thai.
- Xt nghim hCG m tnh (nu thai cht lu). Siu m ti i mo m, khng c tim
thai.
X tr
Tuyn x
- T vn v chuyn tuyn trn v x tr c th chy mu v nhim khun nng.
Tuyn huyn
- Siu m xc nh chn on.
- Xt nghim mu: cng thc mu, nhm mu v sinh si huyt.
- Thai di 12 tun
Cho misoprostol 200 mcg x 1 vin, 4 gi/ln.
Ht thai.
100 |
Khng sinh sau th thut.
Theo di du hiu sinh tn, chy mu.
- Nu kch thc t cung tng ng thai trn 12 tun chuyn tuyn tnh x tr.
Tuyn tnh
- Xt nghim mu: cng thc mu, nhm mu, cc yu t ng mu.
- iu chnh li tnh trng ri lon ng mu nu c.
- Thai trn 12 tun: ngm di li misoprostol ti a 200 mcg mi ln, c 6 gi/ln, ti
a 4 ln. Nu khng c kt qu s dng li thuc vi cng liu lng sau 48 ting. Nu
vn khng c kt qu, chuyn tuyn trung ng.
- Kim sot bung t cung sau khi thai ra nu cn.
- Cn ch theo di chy mu sau khi thai ra.
Ch :
- Ngi bnh c so m c t cung: chng ch nh dng misoprostol. C th truyn
oxytocin tnh mch gy sy thai.
3.2. Thai ngoi t cung.
Triu chng
- C chm kinh hoc ri lon kinh nguyt, c th c triu chng nghn.
- au m vng bng di v au v bn vi t cung c trng lm t, thnh thang c
cn au nhi.
- Rong huyt: mu ra t mt ko di m o vi c im mu en, ln cn (nh b
cph) v r rch ra trong nhiu ngy.
- Thn t cung hi to hn bnh thng, cnh t cung c khi n, ranh gii khng r, n
au, c t cung ng kn. Khi chm ngn tay vo c t cung th au tng ln.
- Xt nghim hCG dng tnh. Nu lm siu m s khng thy hnh nh ti i hoc cc
m vang thai trong bung t cung m c th thy nhng m vang bt thng mt bn
vi t cung.
- Nu thai ngoi t cung v: ngi bnh c cn au d di, t ngt, c chong do
mt mu, bng chng nh, c phn ng thnh bng v cm ng phc mc, g c
vng thp. C t cung ng c t mu theo tay, cc ti cng y, c bit ti cng sau
phng v n ngn tay vo ngi bnh rt au, t cung di ng nh bi trong nc.
X tr
Tuyn x
- Khi nghi ng thai ngoi t cung phi t vn v gi ngay ln tuyn trn.
- Th ngp mu bng phi hi sc chng chong v chuyn i bng phng tin nhanh
nht n ni c kh nng phu thut gn nht, hoc mi kp phu thut v hi sc
tuyn trn xung x tr. Nu di chuyn phi c cn b y t i h tng v c thuc hi
sc em theo.
Tuyn huyn v tuyn tnh
- Chn on xc nh thai ngoi t cung th cha v:
Phu thut (phu thut bng hay ni soi): ct hay bo tn vi t cung.
iu tr ni khoa nu c ch nh v c iu kin theo di.
- Thai ngoi t cung th v:
Hi sc chng chong.
Phu thut ct vi t cung, ly ht mu long v cc mu trong bng.
C th truyn mu hon hi nu c iu kin.
| 101
3.3. Cha trng.
Cha trng l bnh ca rau trong gai rau thai ha thnh cc ti mng nc.
Triu chng
- Mt kinh nh nhng thai nghn khc.
- Tnh trng nghn nng hn bnh thng.
- Ra mu m o t mt, mu en, dai dng nhiu ngy, ban m mu thng ra nhiu
hn.
- T cung to nhanh hn tui thai, mm, khng nn thy cc phn thai nhi, khng nghe
thy tim thai.
- C th c ph, huyt p cao, protein niu.
- Th hCG tng cao.
- Siu m c hnh nh tuyt ri.
X tr
Tuyn x:
- T vn v chuyn ngay ln tuyn trn ngay c khi ang chy mu.
- Cn phi nhc nh ngi bnh i thm khm y , ng nh k tuyn trn v
khng nn c thai trong vng 1 nm.
Tuyn huyn:
- Xc nh chn on, chuyn tuyn tnh ngay c x tr sm.
- Ch no ht trng khi ang sy v sau chuyn ngi bnh v bnh phm ln tuyn
tnh.
Tuyn tnh:
- Ht thai trng (2 ln cch nhau 2 n 3 ngy, nu cn).
- Theo di bin chng ung th nguyn bo nui v chuyn tuyn nu khng c kh nng
iu tr.
- Ct t cung c khi nu l cha trng, ln tui v con.

102 |
CHY MU TRONG NA CUI THAI K
V TRONG CHUYN D
Tuyn p dng.
Ngi thc hin.
Bc s chuyn khoa sn hoc bc s c b tc v sn khoa; n h sinh, y s sn nhi
(xem chi tit trong bi).

1. Rau tin o.
L rau bm on di t cung lan ti hoc che lp l trong c t cung.
1.1. Triu chng.
- Chy mu t ngt, khng km au bng, mu ra ti, kt thc t ngt cng nh
khi xut hin, khong cch gia cc t ngn li, lng mu ra cng v sau cng nhiu
hn. Khi chuyn d chy mu nguy him n tnh mng.
- Ton thn: thiu mu, c th chong.
- Khm: ngi cao hoc ngi bt thng.
- Tim thai: bnh thng, c th suy thai nu m b chong.
- Cn phn bit chy mu do tn thng c t cung nh polip, vim c t cung, si
mo g m o v c t cung, gin tnh mch m h, ung th c t cung cn phi t
van hoc m vt quan st (ch nh lm phng phu thut).
- Khng thm khm m o bng tay.
1.2. X tr.
Tuyn x
- Khi ngh n rau tin o: chuyn tuyn.
- Nu chuyn d: cho thuc gim co nifedipin 10 mg ngm di li v tim bp 10 mg
morphin gim au, ri chuyn tuyn trn ngay.
Mu ra nhiu km theo chong, cn s b chng chong bng truyn dch (nc
mui sinh l hoc Ringer lactat) cho thuc gim co t cung ri chuyn ln tuyn c
trung tm phu thut ngay hoc mi tuyn trn xung h tr.
Khi chuyn tuyn c nhn vin y t i cng.
- Chn on xc nh bng siu m.
- Khi cha chuyn d:
Nu thai c 36 tun tr ln v rau tin o trung tm th phu thut ch ng.
Nu thai cn qu non thng v chy mu t hay ngng chy mu th iu tr ch i
ti bnh vin cho thai ln hn.
Nu chy mu nhiu th phu thut ly thai ngay bt k tui thai, kt hp vi hi
sc.
- Khi chuyn d:
Nu l rau tin o trung tm hoc bn trung tm phi phu thut ly thai ngay kt
hp vi hi sc (truyn dch, truyn mu).
| 103
Nu l rau bm thp, rau bm mp, ra mu nhiu th c ch nh phu thut ly thai.
Nu chy mu t th bm i, x rng mng i v theo di ng m o.
- Trong khi phu thut ly thai:
Nu rau bm mt trc: rch da ng gia di rn, s on di t cung xc
nh vng khng c rau bm rch ly thai.
Nu khng tm c vng khng c rau bm: rch ngang on di qua bnh rau
ly thai.
Nu rau bm mt sau: rch da ng ngang, rch on di t cung ly thai.
Nu sau khi ly rau c chy mu v tr rau bm:
Khu cc mi ch X cm mu.
Pha long 5 v oxytocin x 04 ng trong 1 lt dch (nc mui sinh l hay dung
dch Ringer lactat) truyn tnh mch 60 git/pht.
Nu vn chy mu:
con: ct t cung ht phn b chy mu
Trng hp cn bo tn t cung: tht ng mch t cung, tht ng mch h v,
tht ng mch dy chng t cung bung trng. Nu vn chy mu: ct t cung
ht phn b chy mu.
Kt hp vi hi sc chng chong.
2. Rau bong non.
L rau bm v tr bnh thng nhng bong sm trc khi s thai do bnh l hoc
chn thng.
2.1. Triu chng.
Th nh:
- Ton trng bnh thng, chy mu t.
- Khng c suy thai.
- Thng ch chn on c khi lm siu m
Th trung bnh:
- C hi chng tin sn git.
- T cung co cng nhiu.
- Tim thai nhanh hay chm.
- Ra mu m o lng va, long.
- C th c chong nh.
Th nng:
- Sn ph au d di, tim thai khng nghe thy.
- C hi chng tin sn git nng.
- Tnh trng chong nng.
- Ra mu m o thm en, long khng ng.
- Trng lc c t cung tng, t cung cng nh g v t cung tng chiu cao.
- C t cung cng, i cng phng, nc i c th c mu.
2.2. X tr.
Tuyn x.
- T vn v chuyn tuyn c iu kin phu thut v hi sc, c nhn vin y t cng i.
- Nu c chong phi hi sc trc v trong khi chuyn tuyn.
104 |
Tuyn huyn v tuyn tnh.
- Hi sc chng chong (nn truyn mu ti) v phu thut ly thai.
- Nu tnh trng nng (mt mu nng r rng hay tim n) phi chuyn ln tuyn tnh
hoc mi tuyn tnh n h tr hi sc v phu thut ly thai cng sm cng tt.
- phng ri lon ng mu bng cch b th tch mu lu thng bng truyn dch.
3. Da v t cung.
3.1. Triu chng.
- Sn ph au nhiu do cn co t cung mnh v mau.
- Vng Bandl ln cao, t cung c hnh qu bu nm.
- Thai suy: tim thai nhanh, chm hoc khng u.
- Thm m o: ngi bt thng, ngi cao hoc cha lt.
3.2. X tr.
Tuyn x.
- Thng tiu.
- Truyn dch vi nc mui sinh l hoc Ringer lactat.
- Cho thuc gim co t cung: nifedipin 10 mg x 1 vin ngm di li, morphin 10 mg x
1 ng (tim bp) gim au.
- T vn, gi i tuyn trn ngay v c nhn vin y t i km.
- Cho thuc gim co t cung: nifedipin 10 mg x 1 vin ngm di li, hoc morphin 10
mg x 1 ng (tim bp) gim au.
- Nu iu kin ng di th lm forceps.
- Nu cha iu kin th phu thut ly thai.
4. V t cung.
4.1. Triu chng.
- Trc khi v t cung c du hiu da v t cung tr trng hp c so phu thut c
t cung. Thai ph ang au d di, sau mt cn au chi t ngt th ht au v c th
chong.
- Cn co t cung khng cn.
- Tim thai mt.
- Bng mo m v khng cn du hiu da v.
- Bng chng, nn au.
- S thy phn thai ngay di da bng.
- C th ra mu m o.
- Thm m o khng xc nh ngi thai.
- Thng c du hiu chong.
4.2. X tr.
Tuyn x.
- Hi sc chng chong, t vn v chuyn ngay n tuyn c kh nng phu thut, c
nhn vin y t i km.
- Nu tnh trng nng phi mi tuyn trn n h tr.
- Hi sc chng chong v phu thut cp cu, x tr vt rch t cung (bo tn hoc ct
t cung bn phn hoc ton phn).
| 105
CHY MU SAU

Tuyn p dng.
Ngi thc hin.
Chy mu m o qu 500 ml sau c gi l chy mu sau . Chy mu sau l
bin chng thng gp nht v l nguyn nhn t vong m hng u.

1. Bnh cnh thng gp.
- t cung.
- Chn thng ng sinh dc (c bit l v t cung).
- Bt thng v bong rau, s rau.
- Ri lon ng mu.
2. X tr chung.
- Huy ng tt c mi ngi cp cu.
- Khn trng nh gi th trng chung ca sn ph (cc du hiu sinh tn: mch, huyt
p, nhp th, nhit ).
- Nu nghi ng c chong hoc bt u c chong phi x tr ngay theo phc x tr
chong.
- nh gi tnh trng mt mu.
- Thng tiu.
- Xoa bp t cung v thc hin cc bin php cm mu c hc khc cm mu.
- Tim bp 10 v oxytocin.
- Thit lp ng truyn tnh mch, cho dch chy vi tc nhanh.
- Gi tuyn trn hoc chuyn tuyn trn nu th trng cho php.
3. Triu chng v x tr.
3.1. t cung.
3.1.1. Triu chng.
- Chy mu ngay sau khi s rau l triu chng ph bin nht.
- T cung gin to, mm nho, co hi km hoc khng co hi, khng c khi an ton.
- C th dn n chong nu khng x tr kp thi.
3.1.2 X tr.
Tuyn x
- Dng cc bin php c hc cm mu: xoa bp t cung, chn ng mch ch bng,
chn t cung qua thnh bng, p ngoi t cung bng hai tay hoc p trong v ngoi t
cung.
- Thng tiu.
106 |
- Kim sot t cung ly ht rau st v mu cc ri tim bp oxytocin 5 - 10 v, c th
tim nhc li 2 ln. Nu t cung khng co, tim ergometrin 0,2 mg x 1 ng vo bp
hoc misoprostol 200 mcg x 1 - 4 vin ngm di li.
- Truyn dch chng chong.
- Cho khng sinh ton thn.
- Nu khng cm c mu th t vn v nhanh chng chuyn ln tuyn trn hoc mi
tuyn trn h tr. Khi chuyn nht thit phi c nhn vin y t i km theo di v
hi sc ng thi xoa bp t cung lin tc.
- X tr nh tuyn x.
- Phi x tr kp thi trnh tnh trng chy mu ko di dn ti ri lon ng mu.
- Nu x tr nh trn nhng khng c kt qu th phi phu thut ct t cung bn phn
(nu con) hoc nu c iu kin v kinh nghim th s dng mi khu B-Lynch
hoc tht ng mch h v, ng mch t cung trc khi ct t cung.
- Kt hp va phu thut va hi sc, truyn mu.
- Cho khng sinh ton thn.
3.2. Chn thng ng sinh dc (rch m h, m o, rch tng sinh mn, rch c t
cung, v t cung v mu t ng sinh dc).
3.2.1. Triu chng.
- T cung co hi tt nhng mu vn chy ra ngoi m h, mu ti chy r r hay
thnh dng lin tc.
- Khm thy vt rch v mu t ng sinh dc.
3.2.2. X tr.
Tuyn x.
- X tr theo nguyn tc tin hnh song song cm mu v hi sc.
- Khu li tng sinh mn nu rch 1, 2.
- Nu rch tng sinh mn 3, rch m h, m o, c t cung, vn tip tc chy mu,
hoc mu t phi chuyn tuyn trn hoc mi tuyn trn xung x tr. Khi chuyn
tuyn phi cm mu tm thi bng cp mch ni chy mu hoc chn cht trong m
o.
- Cho khng sinh.
- Cm mu, hi sc chng chong.
- Khu phc hi cc vt rch bng ch t tiu mi ri ( c t cung, ti cng, m h, m
o) v khu nhiu lp ch rch tng sinh mn.
- Vi v t cung: xem bi Chy mu trong na cui thi k thai nghn v trong khi
chuyn d.
- Ty theo v tr, kch thc v s tin trin ca khi mu t c thi x tr thch
hp.
3.3. Bt thng v bong rau v s rau.
3.3.1. St rau, st mng
Triu chng
- Chy mu thng xut hin sau khi s rau.
| 107
- T cung c th co hi km.
- Ra mu r r, lng mu ra c th t hoc nhiu, mu ti ln mu cc.
- C th pht hin sm st rau bng cch kim tra rau v mng rau.
- Nu pht hin mun, khng kp thi, mt mu nhiu c du hiu chong.
X tr.
Tuyn x.
- Truyn dch tnh mch ngay.
- Cho thuc gim au (morphin10 mg x 1ng tim bp) v tin hnh kim sot t cung.
- Tim bp 5 - 10 v oxytocin hoc/v ergometrin 0,2 mg.
- Dng khng sinh ton thn.
- Theo di mch, huyt p, chy mu v co hi t cung.
- Nu c chong phi hi sc, t vn ri chuyn ln tuyn trn hoc mi tuyn trn h
tr. Khi chuyn tuyn phi c nhn vin y t i km.
- Hi sc truyn mu nu thiu mu cp.
- Tip tc theo di mch, huyt p, chy mu v co hi t cung.
- Nu cn ra mu cho thm thuc oxytocin tim bp hoc truyn tnh mch.
- Kim sot t cung li nu cn.
3.3.2 Rau khng bong.
Triu chng.
- Rau khng bong trong vng 30 pht sau khi s thai hoc dng bin php x tr tch cc
giai on 3 ca chuyn d khng kt qu.
- Rau bm cht v khng chy mu.
- Rau ci rng lc bn phn th sau khi thai s 30 pht rau khng bong hon ton,
chy mu nhiu hay t ty theo din rau bong rng hay hp.
- Rau ci rng lc ton phn: t gp, khng chy mu.
Ch : Thng c pht hin trong qu trnh bc rau nhn to.
X tr.
Tuyn x.
- Nu chy mu, tin hnh bc rau v kim sot t cung, tim bp oxytocin 10 v, xoa
bp t cung, hi sc chng chong, cho khng sinh. Nu khng bc c hoc vn
chy mu th phi chuyn tuyn trn ngay hoc mi tuyn trn h tr.
- Nu rau khng bong th khng c bc rau, chuyn ln tuyn trn ngay.
- Bc rau nhn to v kim sot t cung. Tim thuc co bp t cung.
- Rau ci rng lc bn phn chy mu hoc rau ci rng lc ton phn phi ct t
cung.
- Nu chy mu nhiu cn phi hi sc chng chong, truyn mu v phu thut.
- Cho khng sinh.
3.4. Ri lon ng mu.
C th tin pht do cc bnh v mu nhng thng l th pht do chy mu nhiu, mt
sinh si huyt (ng mu ni qun ri rc). ng mu ni qun ri rc c th kt hp vi
108 |
tin sn git nng, thai cht trong t cung v rau bong non th n. Tt c cc tnh trng
bnh l ny c th dn n tiu sinh si huyt.
Tuyn x.
- T vn v chuyn tuyn trn.
- iu tr ni khoa bng mu ti l chnh v iu tr nguyn nhn.
- Nu tnh trng nng tuyn huyn chuyn tuyn tnh hoc mi tuyn tnh n h tr.
4. D phng.
- m bo cng tc qun l thai nghn tt, pht hin sm cc nguy c cao chuyn ln
tuyn trn.
- X tr tch cc giai on 3 ca chuyn d.
- Khng xy ra chuyn d ko di.
- ng k thut, nh nhng trnh gy chn thng ng sinh dc. Khi c tn
thng ng sinh dc cn pht hin sm v x tr kp thi.
- Theo di st sn ph 6 gi u sau , c bit l trong 2 gi u pht hin sm cc
trng hp chy mu.

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CHONG SN KHOA

Tuyn p dng.
Ngi thc hin.
Cn b y t tham gia cung cp dch v.

Trong thc hnh lm sng, chong sn khoa l mt tnh trng cp cu c th nh hng
n tnh mng ca sn ph cn c pht hin sm v x tr kp thi.
1. nh ngha.
Chong l mt tnh trng suy sp tun hon do nhiu nguyn nhn khc nhau, lm
gim hoc ngng cung cp mu, oxygen n nui dng cc c quan c bit l cc c
quan quan trng nh tim, phi, no. y l tnh trng nguy him i hi nhn vin y t
phi c thi x tr kp thi v tch cc mi c kh nng cu sng ngi bnh.
Trong sn khoa chong thng gp l chong do mt mu (bng huyt sau , sy
thai...) hoc do nhim khun (nhim khun hu sn, ph thai nhim khun...).
2. Biu hin lm sng.
- Mch nhanh nh (mch thng nhanh >110 ln/pht), c khi khng u, mch ngoi
bin khng bt c.
- Huyt p tt < 90/60 mmHg.
- Da xanh ti (quanh mi, mi mt v lng bn tay).
- V m hi.
- Tay chn lnh do co mch ngoi vi.
- Nhp th nhanh nng (nhp th thng trn 30 ln/pht).
- L m, vt v hoc hn m.
- Thiu niu hoc v niu.
- Ty tng nguyn nhn gy chong m c biu hin lm sng khc nhau.
3. X tr.
3.1 X tr ban u.
ng trc mt trng hp chong, x tr tch cc ban u l rt quan trng nhm cu
ngi bnh qua cn nguy kch.
- Ku gi mi ngi n gip , cng cp cu ngi bnh.
- Kim tra cc du hiu sinh tn: mch huyt p, nhp th, nhit .
- m bo thng thang ng th bng cch cho ngi bnh nm t th u nga thp
(hoc quay v mt bn nu nh ngi bnh nn).
- Ht m di nu ngi bnh tit nhiu m di v cho ngi bnh th oxygen qua mi
vi tc 6 - 8 lt/pht. Ti tuyn x nu khng c bnh oxygen c th cho ngi bnh
th oxygen qua ti ng oxygen, tt nht nn cho oxygen i qua mt bnh cha nc
m bo m.
- B khi lng tun hon bng truyn tnh mch tc nhanh cc dung dch ng
trng (Ringer lactat), khng nn dng cc dung dch ng bi ph li khi lng
110 |
tun hon. Trong trng hp nguy cp cn lp nhiu ng truyn cng mt lc. Tc
truyn c th ti 1 lt dch trong 15 - 20 pht, trong gi u tin phi truyn c 2
lt dch. C gng bi ph dch vi tc nhanh nu nh chong do chy mu v khi
lng dch b vo gp 2 - 3 ln khi lng mu mt.
- Trong trng hp mt mu (do bng huyt) cn phi truyn mu cho ngi bnh. Vic
quyt nh truyn mu hay khng ch yu da vo lm sng v xt nghim hemoglobin
<50 g/lt. Nn tin hnh th mu ti ging bnh.
- Kim tra thng xuyn cc du hiu sinh tn 15 pht/ln.
- Trong trng hp bng huyt phi bng mi cch cm mu ngay lp tc.
- Xt nghim cng thc mu, chc nng gan thn, tnh trng ng mu...
- Trong trng hp chong do nhim khun cn cy mu, cy sn dch tm nguyn nhn
gy bnh sau dng ngay khng sinh ph rng v kt hp khng sinh, khi c
khng sinh th dng thuc theo khng sinh .
3.2. Xc nh v x tr nguyn nhn gy chong.
Sau khi iu tr ban u ngi bnh n nh th tin hnh xc nh nguyn nhn gy
chong.
3.2.1. Chong do mt mu.
- Xc nh nguyn nhn chy mu v x tr cm mu ngay lp tc: c th chy mu do
sy thai, sy thai trng hoc do thai ngoi t cung v. Cng c th chy mu trong
nhng thng cui thi k thai nghn hay trong chuyn d nh rau tin o, rau bong
non, v t cung, sang chn ng sinh dc sau hay t cung gy bng huyt.
Trong cc trng hp ny phi nhanh chng hoc bng thuc hoc bng th thut hay
phu thut cm mu.
- Truyn mu cng sm cng tt b p li khi lng tun hon mt.
Tuyn x.
- Gi tuyn trn c gip , huy ng tt c nhn vin sn c tp trung chng
chong cho ngi bnh.
- T vn cho gia nh v chuyn tuyn trn, c nhn vin y t i km.
- Truyn dch, thng tiu trong khi ch tuyn trn v trn ng chuyn tuyn.
Tuyn huyn.
- Bi ph th tch mu mt bng truyn mu (nu c iu kin) hoc dch thay th
nh Ringer lactat, huyt thanh mn 0,9%.
- Cho th oxygen.
- Tr tim mch: dopamin truyn tnh mch (ng 50 mg, liu khi u l < 5
mcg/kg/pht, tng dn liu lng c th ti 20 mcg/kg/pht).
- Chng ri lon ng mu bng tim fibrinogen tnh mch (l 1 - 3 g).
- iu tr nguyn nhn gy chy mu.
- Nu tnh trng nng chuyn tuyn tnh hoc mi tuyn tnh h tr.
3.2.2. Chong do nhim khun v nhim c.
Triu chng.
- Mt mi, l m, chn tay lnh, vt v.
- St cao, rt run.
- Mch nhanh nh, huyt p h, kt hoc dao ng.
- Th nhanh, su.
- Da xanh, vng. C nhng mng hay nt xut huyt da.
- Nc tiu t.
| 111
Tuyn x.
Tim bp khng sinh ampicilin 1 g v gentamycin 160 mg, hi sc v chuyn tuyn
trn.
Tuyn huyn.
- Th oxygen, truyn dch.
- Tr tim.
- Khng sinh liu cao phi hp v theo khng sinh .
- Corticoid.
- X tr nguyn nhn nhim khun: dn lu m, loi b nhim khun (ct t cung).
- Nu tnh trng nng chuyn tuyn tnh hoc mi tuyn tnh h tr.
3.3. nh gi li.
Sau khi iu tr tch cc trong vng khong 30 pht cn nh gi li xem ngi
bnh c p ng vi iu tr khng, cc du hiu cn nh gi l:
- Mch huyt p c n nh khng (mch dn chm li, huyt p tng ln).
- Tnh trng tri gic ca ngi bnh ci thin ln (ngi bnh tnh to li hoc bt l
ln).
- Lng nc tiu ci thin (lng nc tiu > 30 ml/gi). Theo di lng dch vo v
dch ra.
- Nu tnh trng ngi bnh ci thin th tip tc iu tr duy tr, nng huyt p v cn
bng lng nc vo v ra, ng thi iu tr nguyn nhn gy chong.
- Nu tnh trng ngi bnh khng ci thin th phi tip tc iu tr tch cc, tip tc
truyn dch.
- Tip tc theo di truyn dch.
- Lm cc xt nghim cn thit tin lng v chn on nguyn nhn.
- Ty theo nguyn nhn m lc s tin hnh x tr theo nguyn nhn, v d chong do
nhim khun hu sn th phi phu thut ct t cung. Chong do chy mu phi
phu thut tht ng mch t cung, h v hoc ct t cung ty tng hon cnh c
th.

112 |
TNG HUYT P, TIN SN GIT V SN GIT

Tuyn p dng.
Ngi thc hin.

nh ngha tng huyt p.
- Khi huyt p tm trng trn 90 mmHg hoc huyt p tm thu trn 140 mmHg i vi
ngi khng bit s o huyt p bnh thng ca mnh;
- Khi huyt p tm trng tng 15 mmHg hoc huyt p tm thu tng trn 30 mmHg so
vi huyt p bnh thng trc khi c thai.
Thai nghn gy tng huyt p c th gp.
- Tng huyt p khng km theo protein niu hoc ph.
- Tin sn git nh.
- Tin sn git nng.
- Sn git.
1. Triu chng v chn on.
Triu chng Chn on
Huyt p tm trng 90 mmHg hoc cao hn, trc
20 tun tui thai.
Tng huyt p mn tnh trc khi
c thai.
- Huyt p tm trng 90 - 110 mmHg o 2 ln cch
nhau 4 gi, sau 20 tun tui thai.
- Khng c protein niu.
Thai nghn gy tng huyt p.
- Huyt p tm trng 90 - 110 mmHg, o 2 ln
cch nhau 4 gi, sau 20 tun tui thai.
- Protein niu c th ti ++.
- Khng c triu chng khc.
Tin sn git nh.

- Huyt p tm trng 110 mmHg tr ln sau 20
tun tui thai v protein niu +++ hoc hn.
- Ngoi ra c th c cc du hiu sau:
- Tng phn x.
- au u tng, chng mt.
- Nhn m, hoa mt.
- Thiu niu (di 400 ml/24 gi).
- au vng thng v.
- Ph phi.
- Xt nghim ha sinh: ure, SGOT, SGPT, acid uric,
bilirubin l cc cht tng cao trong mu, trong khi
tiu cu v protid huyt thanh ton phn li gim
Tin sn git nng.
Ba triu chng gm: tan mu vi
th (biu hin bng bilirubin
tng), cc enzym ca gan tng
(SGOT v SGPT tng cao t 70
v/l tr ln) v s lng tiu cu
gim di 100000/mm
3
mu s
to nn hi chng HELLP.

- C cn git vi 4 giai on in hnh: xm nhim,
git cng, git gin cch v hn m.
- Km theo mt s du hiu tin sn git nng.
Sn git.
| 113
Chn on phn bit tng huyt p mn tnh
trc khi c thai v tng huyt p do thai nghn

Cc du hiu Tng huyt p mn tnh
trc khi c thai
Tng huyt p do thai
Thi gian xut hin Trc 20 tun ca thai k T tun th 20 ca thai k
Acid uric C th tng Ch tng cao trong tin sn git
Protein niu C th xut hin Xut hin sau 20 tun thai k
2. X tr.
2.1. Thai nghn gy tng huyt p.
2.1.1. Tuyn x.
- T vn cho thai ph v gia nh v ch n ung, sinh hot, ngh ngi.
- Theo di huyt p, protein niu, tnh trng thai hng tun. Nu khng gim, chuyn
tuyn trn v gii thch cho ngi nh bit nguy c tin sn git, sn git c th xy ra.
2.1.2. Tuyn huyn v tuyn tnh.
- Nu huyt p gim ti mc bnh thng th cho nm ngh ngi ti ging, cho php v
nh v hn khm li.
- Nu huyt p n nh theo di tip cho n khi chuyn d.
- Nu huyt p ngy cng tng cao, iu tr nh tin sn git.
2.2. Tin sn git, sn git.
2.2.1. Tuyn x.
Chuyn tuyn trn.
- Trng hp tin sn git nng: trc khi chuyn tim tim bp chm magnesi sulfat
15% 4 g (nu c), thng tiu.
- Trng hp sn git: trc khi chuyn tim diazepam 10 mg x 1 ng kim sot cn
git, sau tim bp magnesi sulfat 15 % 4 g (nu c). Phng cn li, ht phi m
di. m, ht m di, th oxygen (nu c).
2.2.2. Tuyn huyn.
Tin sn git nh:
- Nu cc du hiu khng nng ln hoc tr li bnh thng: theo di mi tun 2 ln
(huyt p, s lng nc tiu, protein niu, tnh trng thai) n khi thng.
- Nu huyt p tm trng trn 100 mmHg, ung aldomet 250 mg x 2 vin x 2 ln/ngy.
Nhng ngy sau 250 mg/ln x 4 ln.
- T vn cho sn ph v gia nh v s nguy him ca tin sn git nng v sn git, v
ch n.
- Nu c t cung m th bm i cho , ch l cn da vo con s huyt p m cho
thng hay bng forceps nu iu kin. Ch phu thut ly thai nu km theo cc
l do sn khoa khc nh: ngi bt thng, rau tin o
- Nu c t cung cha xa th tip tc theo di thai nghn.

114 |
Tin sn git nng:
- ngi bnh nm nghing tri, m.
- Cho thuc chng co git: magnesi sulfat 15 % liu khi u 2 - 4 g tim tnh mch tht
chm vi tc 1 gam/pht hoc pha long trong dung dch glucose truyn tnh mch.
Sau c 1 gi tim bp su 1 g/ln. Phi theo di phn x gn xng hng ngy,
phng dng qu liu magnesi sulfat (phn x gn xng gim).
- Cho hydralazin 5 mg tim tnh mch chm cho n khi huyt p gim xung cn 100
mmHg, c th tim bp nhc li nu cn thit. Nu khng c hydralazin th dng
nifedipin 10 mg ngm di li.
- Trong trng hp tin sn git nng iu tr ni khoa nhng khng kt qu: cn
chm dt thai k bo m sc khe cho m v cu thai nhi nu c th.
- Trong trng hp khng iu kin hoc iu tr tch cc trong 24 gi m tnh
trng khng thuyn gim hoc nng ln: chuyn tuyn tnh.

iu tr sn git.
Tuyn x v huyn: sau khi s cu ban u, chuyn sn ph ln tuyn tnh.
Tuyn tnh:
- t sn ph nm nghing, ngng ming phng cn phi li, ht phi m di, cho
ngi bnh th oxygen.
- Cho thuc chng co git duy tr 24 gi hoc sau cn git cui cng.
- Tip tc cho thuc h huyt p cho n khi huyt p tm trng gim.
- Theo di lng nc tiu.
- Nu chuyn d: forceps khi iu kin, nu khng iu kin th phu thut ly
thai.
- Nu cha chuyn d:
Ngi bnh n nh:
tui thai 28 - 34 tun, iu tr corticoid (hoc cho betamethason 12 mg, tim
bp 2 liu cch nhau 24 gi hoc cho dexamethason 6 mg/ln, tim bp 4 ln,
cch nhau 12 gi), tip tc theo di trong 24 gi ri nh ch thai nghn. Nu
thai nhi khng c kh nng sng th nh ch thai nghn cng sm cng tt ngay
khi tnh trng sn ph cho php.
Tui thai trn 34 tun nh ch thai nghn cng sm cng tt.
Ngi bnh khng n nh: phu thut ly thai sau khi ct cn git
2.3. Tng huyt p mn tnh trong khi c thai.
Tuyn x.
- Chuyn tuyn trn.
Tuyn huyn tr ln.
- ng vin sn ph ngh ngi, theo di lng nc tiu hng ngy.
- Nu huyt p tm trng 100 mmHg hoc hn, huyt p tm thu 160 mmHg hoc hn
cho thuc h huyt p ri chuyn tuyn trn nu ti tuyn huyn hoc tnh khng c
kh nng iu tr.
- Nu khng c bin chng theo di ch .
- C du hiu suy thai (tim thai di 120 hoc trn 160 ln/pht) x tr nh suy thai.

| 115
SINH I

Tuyn p dng.
Tuyn huyn tr ln.
Ngi thc hin.
Bc s chuyn khoa sn hoc bc s c b tc v sn khoa.

1. Chn on.
- T cung to hn so vi tui thai.
- Nn thy 3 hoc nhiu hn 3 cc (1 hoc 2 u, 1 hoc 2 mng).
- Nghe thy 2 tim thai 2 v tr khc nhau (cch nhau 10 cm) vi tn s khc nhau.
- Thm m o c th xc nh c ngi th ca thai th nht.
- C th da vo siu m xc nh chc chn.
- Chn on phn bit vi: thai to, a i, c thai v khi u trong bng.

2. X tr.
2.1. Tuyn x.
- T vn, chuyn tuyn trn.
2.2. Tuyn huyn.
- Phn ln thai i c th ng di c v trng lng thng khng to.
- Nn gy t ngoi mng cng nu c iu kin sn sng gim au khi phi ni xoay
thai th hai.
- Nu thai th nht l ngi mng th nn phu thut ly thai.
- thai th nht ging nh cho mt thai.
- Nguy c c th xy ra cho thai th hai sau khi thai th nht: t cung co li lm rau
bong v c th gp ngi bt thng.
- Ngay sau khi thai th nht cn kim tra ngi ca thai th hai: nu l ngi u th
bm i c nh ngi. Nu l ngi vai th ni xoay thai v i ko thai.
- C th dng oxytocin truyn tnh mch 5 v trong 500 ml dung dch glucose 5 % nu
cn co t cung yu hoc sau khi thai th nht s 15 pht khng c cn co t cung (ch
dng sau khi xc nh thai th hai l ngi chm hoc ngi mng).
- Ch phng chy mu v sau d b t cung.
- Ni xoay thai th hai: xem bi Xoay thai trong

116 |
NGI BT THNG
Tuyn p dng.
Tuyn huyn tr ln.
Ngi thc hin.

1. Ngi mt.
- L ngi u nga ti a, mt thai nhi trnh din trc eo trn.
- Ngi mt c chn on xc nh trong qu trnh theo di cuc chuyn d bng
thm m o.
1.1. Chn on.
- Ngi u, nn ngoi, c du hiu nht ru nu l kiu cm sau, nu l kiu cm trc s
thy cm c hnh mng nga. Khng bao gi thy thp sau hoc thp trc khi thm
trong.
- Chn on xc nh bng thm m o, tm c mc ca ngi l mm cm, vic chn
on xc nh s d hn khi c t cung m, nhng phi cn thn khi thm khm
khng lm v i.
- Cn chn on phn bit vi ngi trn, ngi mng.
1.2. X tr.
Tuyn x
Tuyn huyn
- Cuc ngi mt din ra lu v kh khn hn ngi chm.
- Ch c ngi mt cm trc c th ng m o. Nu ng m o c th c h
tr bng forceps, tuyt i khng c dng gic ko
- Ngi mt cm sau t quay c v cm trc cng c th ng m o.
- Phu thut ly thai cho nhng trng hp ngi mt cm sau hoc cm trc c kt hp
thm cc yu t kh khc.
2. Ngi trn v ngi thp trc.
L ngi trung gian gia ngi mt v chm, u khng ci hn m cng khng nga
hn, trn hoc thp trc ca thai trnh din trc eo trn.
2.1. Chn on.
- Lc bt u chuyn d l mt ngi u cao lng.
- Chn on xc nh da vo vic thm m o khi c t cung m c t 3 cm tr ln,
i v v ngi c nh cht.
- S thy gc mi, 2 h mt, trn v thp trc (ngi trn) hoc thy thp trc chnh
gia tiu khung (ngi thp trc).
- Khng bao gi s thy thp sau v mm cm.
- Cn chn on phn bit vi ngi mt v ngi chm.
| 117
2.2. X tr.
Tuyn x.
Theo di st cc cuc chuyn d pht hin sm, nu nghi ng ngi trn hoc thp
trc cn t vn v chuyn tuyn trn.
Tuyn huyn tr ln.
Phu thut ly thai khi c chn on xc nh.
3. Ngi mng.
- L mt loi ngi dc, u thai nm pha y t cung, mng trnh din trc eo trn.
- L mt ngi kh do u l phn quan trng nht to nht v rn nht li ra sau
cng, nguy c mc u hu c th lm cho thai cht hoc sang chn do ly u hu kh
khn.
3.1. Chn on.
- Ngi dc, u y t cung.
- Thm m o s thy xng cng, l hu mn v hai mng thai nhi, mt hoc hai bn
chn cng vi mng.
- Chn on phn bit vi: ngi mt, ngi vai, ngi u sa chi.
3.2. X tr.
Tuyn x.
- T vn, thai t 36 tun chuyn tuyn trn theo di v x tr.
- Nu c chuyn d phi chuyn ngay ln tuyn trn sau khi cho thuc gim co.
Tuyn huyn tr ln.
Cn xem xt cc yu t tin lng cho cuc ngi mng (xem bi Cc yu t tin
lng cuc ).
- Phu thut ly thai cho nhng ngi mng khi c kt hp vi bt k mt yu t nguy c
no.
- ng di khi c nhng iu kin thun li.
4. Ngi vai.
- Trong ngi vai thai khng nm theo trc ca t cung m nm ngang hoc chch, trc
ca thai khng trng vi trc ca t cung.
- Mc ca ngi l mm vai, ngi vai khng c c ch nn hu ht cc trng hp u
phi phu thut ly thai. Ch lm ni xoay thai cho thai th 2 trong song thai.
4.1. Chn on
- T cung b ngang, nn thy u mng sn hoc h chu, chiu cao t cung thp
hn so vi tui thai, thm m o thy tiu khung rng, i rt phng. Khi c chuyn d
nu i v, c t cung m c th s thy mm vai hoc tay thai nhi trong m o.
- C th dng siu m chn on.
- Chn on phn bit vi ngi mng.
4.2. X tr.
Tuyn x.
- T vn, thai t 36 tun chuyn tuyn trn theo di v x tr.
- Nu c chuyn d phi chuyn ngay ln tuyn trn sau khi cho thuc gim co.
118 |
Tuyn huyn tr ln.
- Phu thut ly thai khi c chuyn d .
- Ni xoay thai cho thai th hai ngi vai trong trng hp sinh i, iu kin ni
xoay.

| 119
DA NON V NON

Tuyn p dng.
Ngi thc hin.

1. Da non.
1.1. Chn on.
- Tui thai t ht 22 n ht 37 tun.
- C cn co t cung gy au.
- C t cung ng.
- C th c ra mu hay cht nhy mu hng.
- Siu m o chiu di c t cung.
1.2. X tr.
Tuyn x.
- Nm ngh tuyt i cho ti khi ht cn co.
- T vn.
- Cho: salbutamol vin 2 mg, ngm 2 vin n 4 vin/ngy (chia u).
- Khng : chuyn tuyn trn.
Tuyn huyn.
- Nm ngh tuyt i.
- T vn.
- Hoc truyn tnh mch salbutamol: pha 5 mg vo 500 ml dung dch glucose 5 %, t
thai ph nm nghing tri, truyn vi tc XX git/pht (tc 10 mcg/pht). Nu cn
co khng c th tng liu dn ln, ti a c th ti 45 git/pht (trn 20 mcg/pht).
Khng truyn salbutamol khi c d ng thuc, bnh tim nng, chy mu nhiu, nhim
khun i.
- Cho: salbutamol vin 2 mg, ngm 2 vin n 4 vin/ngy nu cn co t cung nh hay
tip theo sau khi truyn tnh mch.
- Dng corticoid: ch nh dng cho tui thai t 28 n ht 34 tun, ch dng mt t.
Hiu qu xut hin sau khi bt u dng thuc 24 gi.
Hoc cho betamethason 12 mg, tim bp 2 liu cch nhau 24 gi.
Hoc cho dexamethason 6 mg/ln, tim bp 4 ln, cch nhau 12 gi.
Tuyn tnh.
- Nm ngh tuyt i.
- T vn.
- Cho thuc ct cn co t cung:
Nifedipin: nn dng trong trng hp tiu ng, chy mu trong rau tin o, a
thai:
120 |
Liu tn cng: nifedipin 10 mg, ngm di li. Nu cn cn co, c 20 pht
ngm 1 vin, tng liu khng qu 4 vin.
Liu duy tr: sau vin cui ca liu tn cng 3 gi, dng nifedipin tc dng
chm 20 mg, ung 1 vin, c 6 gi n 8 gi mt ln.
Nu nifedipin tht bi, sau liu cui 2 gi c th dng salbutamol
Phi theo di huyt p sau khi dng nifedipin 15 pht.
Chng ch nh dng khi huyt p thp (<90/50 mmHg)
Hoc salbutamol (nh trn).
- Cho corticoid nu trc cha c dng.
(Lu : Khng iu tr do non cho thai t 36 tun tr ln).
2. non.
2.1. Chn on.
- Tui thai t ht tun 22 n trc khi ht 37 tun.
- C t cung xa, c khi m.
- Cn co t cung u n, gy au.
- C dch nhy mu hng.
2.2. X tr.
Cn m bo cho tr t b chn thng nht trong .
Tuyn x:
- T vn, chuyn tuyn trn cng sm cng tt. Ch thc hin khi khng th
chuyn i c.
- Trng hp x:
Chm sc tr: xem phc chm sc tr non thng, nh cn.
Chm sc m: theo di chy mu, kim sot t cung nu rau thiu, t vn, chuyn
tuyn nu cn.
Tuyn huyn:
- Chuyn ln tuyn tnh nu thai qu non (di 32 tun).
- Ngh ngi hon ton.
- Cho corticoid nu cha c dng.
- T vn.
- C gng lm chm cuc trong 24 gi sau khi tim corticodid bng cch cho
nifedipin hay salbutamol.
- Ch cuc tin trin bnh thng (ch kim sot t cung khi c ch nh, khng kim
sot t cung hng lot).
- Thng bo cho bc s nhi khoa.
- Chun b phng tin hi sc, chm sc s sinh thiu thng.
Tuyn tnh:
- Dng nifedipin hay salbutamol lm chm cuc .
- Dng corticoid nu trc cha c dng.
- X tr nh tuyn huyn.
| 121
THAI QU NGY SINH

Tuyn thc hin.
Ngi thc hin.

1. Chn on v nh gi.
- Thai qu ngy sinh l thai trong bng m qu 287 ngy (qu 41 tun) tnh t ngy
u ca k kinh cui cng.
- Thc hin xc nh tui thai bng siu m nu c iu kin trong vng 20 tun u tin
ca thai k.
- Phi cho nm vin theo di cc thai nghn t sau 41 tun (287 ngy) tr ln pht
hin sm suy thai.
- V bnh rau thoi ha nn thai d b suy, ngt, t vong do thiu dinh dng.
- Thai qu ngy sinh thng to nn d gy tai bin khi .
2. X tr.
2.1. Tuyn x.
Nu nghi ng qu ngy sinh (thai trn 287 ngy tr i), chuyn tuyn ngay sau khi t
vn.
2.2. Tuyn huyn v tuyn tnh.
2.2.1. Chn on.
- Da vo tui thai (tnh t ngy u ca k kinh cui, c gi tr nu vng kinh bnh
thng).
- Da vo siu m xc nh tui thai i vi thai trc 20 tun nu ngy u k kinh
cui khng xc nh hoc kinh khng u.
2.2.2. X tr.
- Theo di ch s nc i bng siu m (thiu i l mt du hiu ca suy tun hon rau -
thai v thai thiu oxygen) v bng soi i (nc i ln phn su thng gp thai qu
ngy sinh).Theo di tnh trng thai nhi bng test khng kch (non stress test) 2 - 3
ngy/ln. Nu test khng p ng th phi lm test c kch (stress tess) (v nm v,
truyn oxytocin), hoc gy chuyn d (xem Cc phng php gy chuyn d). Nu
test khng kch hoc test kch bnh l th phi phu thut ly thai.
- Nu c t cung khng thun li (ch s Bishop di 5) th lm mm c t cung bng
misoprostol 50 mcg ngm di li, c 4 - 6 gi/ln, ngy khng qu 3 liu.
- Nu c t cung thun li (ch s Bishop > 5) th gy chuyn d bng bm i v truyn
oxytocin tnh mch.
- Tr qu ngy sinh cn c chm sc: m, thng ng h hp, cho vitamin K
1
v
theo di s pht trin ca tr.
122 |
V I NON

Tuyn thc hin.
Ngi thc hin.

V i non l v i khi cha c chuyn d.
1. Chn on.
- Cha c du hiu chuyn d.
- Nc i ra t nhin.
2. X tr.
2.1. Tuyn x
- T vn.
- Khng sinh.
- Chuyn tuyn trn.
2.2. Tuyn huyn
- Theo di thn nhit.
- ng kh sch, theo di lng nc i ra.
- nh gi tui thai c thi x tr.
- Siu m nh gi tnh trng thai, nc i, v tr bnh rau.
- Cho khng sinh, corticoid v chuyn tuyn trn nu thai non thng (di 34 tun tui).
Nu c cn co th cho thuc gim co nifedipin ngm di li 10 mg trc khi chuyn
- Nu tui thai 35 tun tr ln v tip tc ra nc i sau 24 gi th gy chuyn d (xem
Cc phng php gy chuyn d).
- Nu nc i khng ra na, khng st: siu m li xc nh ch s nc i l bnh
thng. Tip tc cho khng sinh d phng 7 ngy v cho php sn ph v nh, hn
khm li sau 1 tun
2.3. Tuyn tnh.
- Tui thai trn 34 tun: iu tr ging tuyn huyn
- Tui thai t 34 tun tr xung: iu tr gi thai bng khng sinh d phng v cc thuc
gim co v cho corticoid
- Nu c du hiu nhim khun i, nh ch thai bt k tui thai no.
- Sau 34 tun, gy chuyn d nu tip tc ra nc i.
| 123
SA DY RN

Tuyn thc hin.
Ngi thc hin.

1. Chn on.
Sa dy rn trong bc i: khm m o thy dy rn nm bn hoc di ngi thai
nhng vn trong bc i.
- Nu i v th thy dy rn sa trong m o, c khi ra ngoi m h.
- Hay gp ngi bt thng.
2. X tr chung.
2.1. Sa dy rn trong bc i.
Tuyn x.
- T vn cho sn ph khng rn.
- t sn ph nm theo t th u gi - ngc.
- Dng thuc gim co t cung, nh nifedipin 10 mg ung, hoc salbutamol vin 2 mg x 2
vin.
- Chuyn tuyn trn (t th sn ph mng cao).
Tuyn huyn.
- Phu thut ly thai.
- Nu thai cht, c iu kin: ly thai ng di.
2.2. Sa dy rn khi v i.
Tuyn x.
- Xc nh xem dy rn cn p khng (kp dy rn gia 2 ngn tay) v nghe tim thai.
- Nu thai cn sng:
Cho sn ph nm t th u thp v nh gi tin trin ca cuc chuyn d v tnh
trng thai nhi.
Nu iu kin nhanh: cho .
Nu khng iu kin ng di: chuyn tuyn.
Dng thuc gim co t cung, nh nifedipin 10 mg ung hoc salbutamol vin 2 mg
x 2 vin trc khi chuyn tuyn.
Cho 2 ngn tay vo trong m o y ngi thai ln cao, trnh chn p vo dy rn
hoc bm 500 ml huyt thanh vo bng quang, kp ng thng.
T vn v vic khng nn rn v nhng din bin xu c th xy ra i vi thai.
Nu dy rn sa ra ngoi m h, bc dy rn nh nhng bng khn m, m.
- Nu thai cht: gii thch cho thai ph v thn nhn ri chuyn tuyn trn. Ch gi li
c s nu l ngi u v cuc sp kt thc.
124 |
Tuyn huyn.
- Xc nh xem dy rn cn p khng, nghe tim thai. Nu c siu m th dng siu m
chn on xc nh tim thai (nu cn).
- Nu thai cn sng:
ng di nu iu kin.
Phu thut ly thai ngay nu khng iu kin ng di.
- Nu thai cht, khng cn tnh cht cp cu, theo di ng di nu khng c
cc nguyn nhn kh khc.

| 125
THAI CHT TRONG T CUNG

Tuyn thc hin.
Ngi thc hin.

Thai cht trong t cung l thai cht khi tui thai t 22 tun tr ln cho n trc khi
chuyn d.

1. Chn on.
- T cung c th nh hn tui thai.
- Khng nghe thy tim thai.
- Siu m: khng thy hot ng tim thai, c th thy du hiu chng xng s, thai
khng c ng.

2. X tr.
2.1. Tuyn x.
- T vn, chuyn tuyn.
2.2. Tuyn huyn v tnh.
- Xt nghim cc yu t ng mu.
- Nu sinh si huyt di 2 g, sn ph c bnh ni khoa khc: tuyn huyn chuyn tuyn
tnh
- Gy chuyn d bng thuc misoprostol 100 mcg, c 4 - 6 gi/ln, ngm di li hoc
t m o. Nu thai ra khng hon ton sau chy mu nhiu th phi dng th thut
ht, no ly ra. Nu cn dng thm oxytocin.
- H tr tinh thn cho sn ph.

126 |
NHIM HIV KHI C THAI

Tuyn thc hin.
Ngi thc hin.
Bc s chuyn khoa sn hoc bc s c b tc v sn khoa; n h sinh, y s sn nhi.

1. Chn on nhim HIV.
- Mu huyt thanh c coi l dng tnh vi HIV khi dng tnh c 3 ln xt nghim
bng 3 loi sinh phm vi cc nguyn l v khng nguyn khc nhau (phng cch
III).
- Ch nhng phng xt nghim t tiu chun c B Y t cho php mi c quyn
thng bo kt qu xt nghim HIV dng tnh.
2. X tr.
T vn vic ly truyn HIV t m sang con thai ph quyt nh gi thai hay ph thai.
- Thai di 22 tun: t vn v ph thai hoc gi thai.
- Thai t 22 tun: qun l v iu tr.
- Nu xin ph thai.
Ty tui thai tin hnh ph thai (xem phn Ph thai an ton).
T vn v cc bin php trnh thai sau khi ph thai.
Sau ph thai, chuyn thai ph v Trung tm Phng chng AIDS qun l v iu
tr theo m s.
- Nu mun gi thai.
Qun l thai nghn.
T vn v nguy c ly truyn cho con v kh nng phng bnh.
Khi chuyn d nn phu thut ly thai.
Phc AZT + nevirapin cho m.
AZT ung 300 mg x 2 ln/ngy t tun thai th 28.
Khi chuyn d AZT 600 mg v nevirapin 200 mg.
Phc s dng nevirapin.
Khi bt u chuyn d hoc trc khi phu thut ly thai 4 gi cho ung
nevirapin 200 mg.
Phc 3 thuc
AZT/d4T + 3TC + NFV/SQV/r hng ngy cho n khi .
Liu dng: (zidovudin) +nevirapin (NVP)
AZT(zidovudin) 300 mg ung x 2 ln/ngy hoc d4T 30 mg cho ngi m nng
di 60 kg v 40 mg nu ngi m nng trn 60 kg, ung 2 ln/ngy.
3TC 150 mg ung 2 ln/ngy.
Nelfinavir 1250 mg (nh hng ti gen) ung x 2 ln/ngy hoc
saquinavir/ritonavir 1000 mg/100 mg x 2 ln/ngy.
Cho s sinh AZT hay nevirapin.
AZT sir 2 mg/kg, 6 gi mt ln, bt u 8 - 10 gi sau sinh, ko di 6 tun.
Nevirapin sir 2 mg/kg/ln ung trong vng 72 gi sau sinh.
| 127
T vn v vic khng cho b sa m trnh ly truyn bnh v t vn v cch dng
cc sn phm thay th sa m (tham kho bi T vn nui con bng sa m v
Qui trnh chm sc v iu tr d phng ly truyn HIV t m sang con ca B Y
t).
Qun l m v con v tip tc iu tr bnh cho m bng thuc chng retrovirus v
d phng cc bnh nhim khun c hi.
128 |
X TR PH PHI CP TRONG CHUYN D

Tuyn p dng.
Tuyn huyn tr ln.
Ngi thc hin.
Bc s chuyn khoa sn hoc bc s gy m hi sc.

1. X tr chung.
- Theo di cc du hiu sinh tn: mch, huyt p, nhp th, nghe tim phi.
- Cho nm u cao.
- Ht m ri lm thng ng h hp.
- Th oxygen.
- T vn cho gia nh bit tnh trng nng ca bnh, nguy c cho m v cho con.
- Tuyn x phi tim di da 10 mg morphin v chuyn ln tuyn huyn ngay, c nhn
vin y t i km, cho ngi bnh th oxygen (nu c), t th u cao khi chuyn.
2. X tr c hiu.
2.1. Ph phi cp huyt ng.
- Cho thai ph ngi thng, chn thng.
- Garo ba chi lun chuyn.
- t ni kh qun ht m ri, th oxygen 60 % vi dung lng 8 - 12 lt/pht.
- Tim tnh mch:
Thuc li tiu (thuc c la chn thng l lasix 20 mg x 4 ng). Khi cn thit
c th tng liu, ty thuc vo lng nc tiu v tnh trng kh th ca ngi
bnh.
Tr tim: v d nh cedilanit 0,4 mg x 1 - 2 ng.
Tim di da 10 mg morphin.
Nu cn th phi trch mu tnh mch. Khuyn co nn trch 300 ml mu.
- X tr sn khoa:
Phu thut ly thai khi ht cn ph phi cp.
Forceps khi iu kin.
2.2. Ph phi cp do tn thng.
- t ni kh qun th my, h hp h tr, th oxygen.
- Dopamin truyn tnh mch.
- Truyn huyt tng.
- Khng sinh liu cao.
- Methyl prednisolon: 30 mg tim tnh mch, cch 4 gi/ln
- C th phu thut ly thai khi c ch nh.
| 129
CHUYN D NH TR

Tuyn thc hin.
Tuyn huyn tr ln.
Ngi thc hin.

Chuyn d nh tr bao gm chuyn d ko di v chuyn d tc nghn.

1. Cc du hiu ca chuyn d nh tr.
- Pha tim tng b ko di qu 8 gi, pha tch cc ko di qu 7 gi.
- Khm thy lt ca ngi khng tin trin.
- Xut hin tnh trng chng khp s, c bu huyt thanh.
- ng m c t cung ct sang bn phi ng bo ng trn biu chuyn d
- C t cung ngng tin trin lun l du hiu ca chuyn d nh tr.
- Suy thai, cn co t cung mau (trn 5 cn trong 10 pht), c vng Bandl.
Ch : Khng phi trng hp chuyn d nh tr no cng c cc du hiu trn.

2. Nguyn nhn gy chuyn d nh tr.
- Do m:
Bt tng xng u - chu, tin s m c bnh gy bin dng khung chu (bi lit,
lao, chn thng).
Ri lon cn co t cung: cn co tha yu, cn co mau mnh, cn co khng ng
b.
C khi u tiu khung (u x t cung, u nang bung trng v u tiu khung).
- Do thai:
Cc ngi bt thng (trn, mt, mng, vai).
Thai to (c t 3500 g tr ln).
Thai bt thng (no ng thu, bng cc).
- Nguyn nhn khc.
Dy rn ngn.

3. X tr.
- Tuyn x: chuyn tuyn trn.
- Tuyn huyn tr ln: x tr theo nguyn nhn.
ng m o (forceps hoc gic ko) khi iu kin.
Dng thuc iu chnh cn co yu khi chuyn d ko di.
Phu thut ly thai khi c ch nh.
Hu thai nu c ch nh.

130 |
THEO DI CUC
VI SN PH C SO M T CUNG

Tuyn p dng.
Tuyn huyn c phu thut tr ln.
Ngi thc hin.

Cc so m do bc u x, u c t cung, m thn t cung ly thai trc y, hoc so v
t cung c v so ghp t cung i th phi ch nh phu thut ly thai ch ng t tun
th 38 trnh v t cung do nt so c.
Nhng sn ph c so m t cung, ln ny nu mun ng di phi c bc s
c kinh nghim theo di v t vn c s c phu thut. Sn ph s c t vn v kh
nng c hay phi phu thut v nguy c cao cho c m v con.

1. Cc so t cung.
Bao gm so phu thut ly thai c, phu thut bc nhn x, phu thut ct gc t cung
do thai ngoi t cung, phu thut khu cc chn thng c t cung do v, tai nn, thng
t cung v phu thut ghp t cung i.
2. Tuyn x v c s tng ng.
C nhim v theo di, qun l thai nghn, t vn v nguy c ban u v chuyn sn
ph ln tuyn trn qun l thai trc ba thng cui ca thai k.
3. Tuyn huyn.
- Vi ngi chm theo di v t vn v nguy c, tin lng.
- Khng c gy bng thuc.
- Nu chuyn d tin trin thun li: cho bng forceps v kim sot t cung sau .
- Nu cuc chuyn d tin trin bt thng th phu thut ly thai.
4. Tuyn tnh.
- Nu chuyn d tin trin thun li: ty theo kinh nghim v kh nng ca thy thuc c
th cho thng, gic ko hoc forceps v c th khng cn kim sot t cung sau .
- Nu cuc chuyn d tin trin bt thng th phu thut ly thai.

| 131
SUY THAI CP

Tuyn p dng.
Tt c cc tuyn.
Ngi thc hin.
Bc s chuyn khoa sn, bc s c b tc v sn khoa.

1. Cc du hiu ca thai suy.
1.1. Nhp tim thai.
- Nhp tim thai khng u, hoc nhanh trn 160 ln/pht hoc chm di 120 ln/pht
(m bng ng nghe tim thai, m c 1 pht, m trc v ngay sau cn co t cung)
khi nghe tim thai cc ln khc nhau.
- Bng monitor sn khoa (xem bi Theo di cn co t cung).
1.2. Nc i.
- C ln phn su (khi v i thy mu nc i xanh hoc vng bn).
- Thiu i (trn siu m hoc khi bm i)
2. X tr.
2.1. Tuyn x.
Khi thy suy thai cp v cn co mau th cho thuc gim co t cung, gii thch cho gia
nh v chuyn tuyn ngay n c s phu thut gn nht.
2.2. Tuyn huyn tr ln (c kh nng phu thut).
- Hi sc thai:
Cho th oxygen 6 lt/pht.
Nm nghing tri.
Gim cn co nu c ch nh vi salbutamol (xem bi Thuc gim co t cung
trong chuyn d).
Nu ang truyn oxytocin th ngng truyn.
Ch : Khng dng salbutamol nu c chy mu m o.
- nh gi li tnh trng thai nhi, nu tnh trng suy thai khng ci thin:
iu kin th ly thai bng forceps.
Khng iu kin th phu thut ly thai.
132 |
S DNG OXYTOCIN

Tuyn p dng.
Tuyn huyn c kh nng phu thut tr ln.
(ring tuyn x ch s dng trong x tr tch cc giai on 3 ca chuyn d v sau ).
Ngi thc hin.
Bc s, n h sinh, y s.

Thuc oxytocin l thuc gy co bp t cung c v tn s v cng .

1. Ch nh.
- X tr tch cc giai on ba trong chuyn d, sau khi s thai phng chy mu sau
.
- iu tr chy mu sau .
- S dng oxytocin gy cn co t cung trong trng hp gy chuyn d hoc
chuyn d nhng cn co tha, yu. Ch nh ny p dng ni c phu thut vi ch
nh r rng ca bc s.
2. Chng ch nh.
- Bt tng xng u - chu.
- Ngi khng c ch nh ng m o.
- Rau tin o.
- Rau bong non.
- Suy thai cp v mn tnh.
- Khng c phng phu thut, bc s v phng tin phu thut.
3. Cch dng.
- x tr tch cc giai on 3 ca chuyn d (xem bi X tr tch cc giai on 3 ca
chuyn d).
- phng v iu tr bng huyt do t cung (Tham kho bi Chy mu sau ).
- Trong trng hp chuyn d nu cn co t cung tha v yu hoc do i v sm m cn
co khng cho cuc chuyn d tch cc. Cch thc hin nh sau:
Dung dch glucose 5 % x 500 ml pha vi oxytocin 5 v (1 ng), nh git tnh mch
vi tc sau:
Ban u l 5 git/pht, sau theo di cn co t cung (cng , khong cch
cc cn co) m iu chnh tc git hp l (10, 20, 30, 40 git) sao cho t
c 3 cn co trong 10 pht. Nu cn co t cung qu mnh (c trn 5 cn co
trong 10 pht v mi cn co ko di trn 1 pht), ngng truyn oxytocin v xin
ch nh ca bc s trc khi bt u gim liu.
Bm tim in c iu khin tc truyn l cch s dng tt nht.

| 133
Theo di:
Bc s phi trc tip chm sc sn ph lin tc khng c ri xa theo di
ton trng v cn co t cung.
Phi ghi trn biu chuyn d. Ch tng thm oxytocin nu chuyn d tin
trin chm.
Khm ngoi: c 15 pht/ln u n theo di cn co t cung, nhp tim thai,
lt ca ngi.
Nu c du hiu suy thai phi ngng truyn oxytocin. Sau khi ngng truyn
oxytocin 15 pht khng c kt qu, phi phu thut ly thai ngay hoc forceps
nu iu kin.

134 |
S DNG THUC GIM CO T CUNG
TRONG CHUYN D

Tuyn p dng.
Tt c cc tuyn.
Ngi thc hin.
(NHS/YSSN i vi nhng x khng c bc s, trong trng hp cp cu)

1. Thuc s dng.
Dng mt trong cc thuc sau.
- Alverin (spasmaverin) 40 mg (vin ung) hoc ng 40 mg tim bp hoc tnh mch 1 -
2 ng.
- Salbutamol vin 2 mg, ng 0,5 mg tim bp. Chng ch nh trong trng hp chy
mu nhiu.
- Nitroglycerin 1 mg ngm di li.
- Nifedipin 10 mg ngm di li (xem bi Da non). Nifedipin an ton hn so vi
cc thuc gim co khc.
2. Ch nh.
- Cn co t cung qu mnh hoc qu mau gy suy thai.
- Rau tin o c chy mu.
- Da v t cung.
- Do non (thai trc 34 tun).
3. Cch dng.
3.1. Tuyn x.
Trc khi chuyn ln tuyn trn cc sn ph c ch nh dng thuc gim co:
- Nifedipin.
- Salbutamol vin 2 mg ung (khng c dng loi tim).
- Spasmaverin
3.2. Tuyn huyn.
iu tr nh tuyn x, sau s dng thuc da theo nh gi tnh trng thc t ca
sn ph. C th s dng nitroglycerin.

| 135
ST SAU
Tuyn p dng.
Ngi thc hin.

1. nh ngha.
St sau l st t trn 24 gi sau khi sinh vi thn nhit t 38
o
C tr ln. y l triu
chng do nhiu nguyn nhn khc nhau vi mc nng nh khc nhau.
2. Cc nguyn nhn.
2.1. Bnh ni ngoi khoa.
- Nhim khun vt m .
- Vim bng quang.
- Vim b thn cp.
- St rt.
- Vim phi, lao phi.
- Thng hn, vim gan
2.2. Nhim khun hu sn.
- Nhim khun m h, m o, tng sinh mn.
- Vim ni mc t cung, vim ton b t cung, vim t cung phn ph, vim phc mc
tiu khung, vim phc mc ton b, nhim khun huyt.
2.3. St sau do cc bnh v v.
Cng v, vim v, p xe v.
3. Cc du hiu v x tr.
3.1. Nhim khun vt m.
- Du hiu chnh: vt m sng, c dch tit l mu hay m, ty quanh vt khu.
- X tr: ct ch cch qung, dn lu cho thot dch, khng sinh, ra vt m bng dung
dch st khun v thay bng ti thiu ngy 2 ln.
3.2. St sau do cc bnh v v.
3.2.1. Cng v:
- Du hiu chnh: v sng au c hai bn, xut hin mun 3 - 5 ngy sau .
- X tr:
Nu ngi m cho con b, khuyn khch tng s ln cho con b.
Vt sa bng tay hoc bng bm ht.
Gim au tc: chm lnh, xoa sau lng, lm t u v cho con d bt v. Sau
khi cho b: chm lnh, bng nng hai bu v khng qu cht.
Thuc: paracetamol 500 mg x 2 - 4 vin/ngy.
136 |
Nu ngi m khng cho b: trnh kch thch u v, chm lnh, bng cht v,
paracetamol 500 mg x 2 - 4 vin/ngy; parlodel 2,5 mg x 2 vin trong 5 ngy (
ct sa).
3.2.2. Vim v
- Du hiu chnh: v cng, au, , u v thng nt n, thng b mt bn.
- X tr:
Khng sinh:
Amoxicillin 500 mg ung 1 vin x 4 ln/ngy, 10 ngy hoc
Erythromycin 250 mg ung 1vin x 4 ln/ngy, 10 ngy.
Khuyn khch ngi m tip tc cho b thng xuyn. Bi parafin nu c nt u
v.
Bng nng v khng qu cht.
Chm lnh v sau khi cho b.
Paracetamol 500 mg (khi cn).
L liu php.
3.3. p xe v.
- Du hiu chnh: v cng to, sng , c ch n mm, chc d c m.
- X tr:
Tuyn x chuyn tuyn trn.
Dn lu m v iu tr khng sinh.
Nn gy m (ketamin).
Rch theo ng nan hoa (trnh gy thng tn cho ng dn sa).
Cho ngn tay i gng v khun vo ph cc vch ngn trong p xe, nn m.
Nht gc vo p xe dn lu m (rt sau 24 gi v thay th bng 1 gc chn
khc nh hn).
iu tr khng sinh (sau khi trch p xe).
Cloxacillin 500 mg ung 1 vin x 4 ln/ngy, trong 10 ngy hoc
Erythromycin 500 mg ung 1 vin x 4 ln/ngy, trong 10 ngy.
Tip tc cho b: nu bn v p xe cn chy mu, m th cho b bn lnh v vt b
sa v bn au. Sau 48 gi li cho b c hai bn.
Bng v.
Chm lnh.
Paracetamol 500 mg x 2 - 4 vin/ngy.
4. St do nhim khun hu sn.
4.1. Nhim khun tng sinh mn, m h, m o, c t cung.
Triu chng
- Vt rch hoc ch khu sng ty, , au i khi c m
- T cung co hi tt, sn dch c th hi hoc rt hi.
- C th st nh 38C - 38,5C
X tr
- Khm m o loi tr st gc.
- V sinh ti ch v khng sinh.
- Nu sau khi dng khng sinh, vt khu vn sng, , r nc vng th ct ch ngt
qung.
| 137
- Nu ton b vt khu nhim khun, bung ht ch th phi ra vt thng cho n khi
hon ton khng c m, nc vng, m di da hi phc tr li mi c khu li tng
sinh mn (x phi chuyn tuyn).
4.2. Vim ni mc t cung.
Thng do kim sot t cung, nhim khun i, chuyn d ko di hoc i khi c th
do st rau. Vim ni mc t cung khng iu tr s dn n cc bin chng trm trng hn
nh vim t cung ton b, vim phc mc, nhim khun huyt
Triu chng.
- Mt mi, lo lng.
- Ngi m st 38
o
C - 39
o
C t 2 ngy sau khi .
- T cung co hi chm, mm, n au.
- Sn dch hi, i khi c ln m.
iu tr.
Tuyn x.
- H st bng p khn m v cho ung nc.
- Cho thuc co hi t cung (oxytocin 5 v x 1 - 2 ng/ngy, tim bp).
- Dng khng sinh thch hp c th tim hoc ung trong 7 ngy.
- Nu sau 24 gi khng h st th phi chuyn tuyn.
Tuyn huyn.
- Ti huyn x tr nh x v iu chnh khng sinh ty tnh trng bnh
- Nu b sn dch: nong c t cung cho dch thot ra ngoi.
- Nu st rau: ht hoc no ly rau sau khi cho khng sinh.
- Sau iu tr cc triu chng gim, cho khng sinh tip n 5 - 7 ngy ri v xut vin.
- Nu cc triu chng khng gim chuyn tuyn tnh.
4.3. Vim t cung ton b.
Triu chng.
- y l hnh thi lm sng tin trin nng ln ca vim ni mc t cung, sn dch rt hi
thi, mu nu en.
- T cung to, mm, n rt au, di ng t cung au, i khi n gy ting ku lo xo nh
c hi, c bit c th c ra huyt vo khong ngy th 8 - 10.
X tr.
iu tr cn s dng khng sinh liu cao v phi hp nhiu loi.
4.4. Vim t cung v phn ph.
- X tr ti tuyn tnh.
- T t cung, tnh trng nhim khun c th lan rng sang cc c quan ph cn nh dy
chng rng, vi t cung, bung trng
Triu chng.
- Xut hin mun ngy th 8 - 10 sau .
- St cao ko di km theo au bng di.
- T cung to, co hi chm, n au.
- Bn cnh t cung thy xut hin mt khi cng, au, b khng r rt.

138 |
iu tr.
- Khng sinh phi hp, liu cao.
- Nu khi vim tin trin thnh ti m nm thp st ti cng th rch ti cng dn
lu m qua m o.
- Tin trin c th khi dn nu iu tr hu hiu v kp thi.
- C th gy bin chng vim phc mc hay ti m v vo bng quang, m o, trc
trng.
4.5. Vim phc mc tiu khung.
T t cung v cc c quan ph cn, nhim khun c th lan sang phc mc vng tiu
khung.
Triu chng.
- C th xut hin sm khong 3 ngy sau hoc chm hn khong ngy th 7 - 10 sau
mt thi k nhim khun t cung hay m h, m o.
- St cao 39C - 40C, c th rt run.
- au nhiu vng bng di, n bng c phn ng vng ny.
- Khm m o thy t cung cn to, di ng km, au, ti cng sau y, ph n.
- Trng hp ti m nm ti cng sau, kch thch trc trng gy hi chng gi l.
iu tr.
Ni khoa vi khng sinh liu cao. Nu c bc m ti cng th chuyn vin dn lu
qua ng m o. Phu thut bng dn lu khi c bin chng vim phc mc ton b.
4.6. Vim phc mc ton b.
Triu chng:
- Ton thn mt mi, st cao, gy st cn, hc hc, mch nhanh, kh th, nn.
- Bng chng, au.
- Phn ng thnh bng.
- Cm ng phc mc
- Thm ti cng rt au.
iu tr.
- Dng khng sinh liu cao, kt hp.
- Nng th trng.
- Vim phc mc ton b phi ct t cung dn lu bng. y l ni pht sinh ra m.
4.7. Nhim khun huyt.
- Do th thut hoc dng c khng v khun.
- Do iu tr cc tnh trng nhim khun khng ng cch, dng khng sinh, khng
liu lng, khng thi gian.
- C th do can thip phu thut qu sm khi cha bao vy c nhim khun khu tr
ti b phn sinh dc bng khng sinh, to iu kin cho vi khun lan trn vo mu.
Triu chng v chn on.
- Thng l st cao, rt run nhiu ln trong ngy. C nhng th bn cp, khng st cao
nhng st ko di.
- Ton trng suy nhc, c th i n chong, h huyt p, m man.
- Cy mu chn on xc nh (tuyn trn).
| 139
- cc trng hp nng, ngoi nhim khun u tin cn c nhng nhim khun th
pht nh thn, gan, phi, no...
X tr.
- Khng sinh liu cao, kt hp, ng tnh mch.
- Truyn dch, iu chnh cn bng nc in gii.
- Gii quyt nhim khun nguyn pht: ct t cung (a s trng hp ct t cung bn
phn li hai phn ph, sn ph cn tr v thng th hai phn ph hu nh khng b
hoi t sau khi ct t cung bn phn).
- Tin lng rt xu. Vn chnh l phng bnh.
5. Vim tc tnh mch.
- L bnh him gp nc ta. Thng xut hin vo ngy th 18 sau vi cc triu
lm sng sau y: st cao, au ti ni vim tc tnh mch, ngi bnh khng i li
c nu vim tc cc tnh mch chi di. Nu vim tc cc tnh mch trong bng
th ngi bnh au bng, nht l vim tc tnh mch mc treo, bnh c th biu hin
cc tnh mch phi, no.vi cc triu chng au cc c quan ny, i khi b
lit.
- Xt nghim thy tng sinh si huyt, c th chp tnh mch thy cc gy tc
(thrombus).
iu tr.
- Dng khng sinh ton thn.
- Thuc chng ng nh heparin.
- C nh chi c vim tc tnh mch.
- Nu cc gy tc to c th tin hnh phu thut ly b.

140 |
PHT HIN CC DU HIU NGUY HIM, X TR
V CHUYN TUYN CC CP CU SN KHOA

Tuyn p dng.
Ngi thc hin.
Cn b cung cp dch v.

Chuyn tuyn cc cp cu sn khoa l cng vic phi thc hin ca cc tuyn di (x
v huyn) v cng cn cn l vic ca tuyn trn khi cn chi vin, chuyn ch ngi bnh
t cc tuyn di v bnh vin.

1. Thi cn c ca nhn vin y t trc mt cp cu sn khoa ti tt c cc
tuyn.
- Bnh tnh.
- Khn trng.
- Tch cc.
2. Nhng du hiu nguy him cn pht hin ngay.
2.1. Ti b my h hp.
- Tm ti.
- Kh th.
- Bnh cnh thng gp: thiu mu nng, suy tim, hen, vim phi, ph phi cp.
2.2. Ti b my tun hon.
- Da lnh, m t.
- Mch: nhanh, nh.
- Huyt p: tt thp hay tng cao.
- Bnh cnh thng gp: chong (chy mu, nhim khun), tng huyt p, tin sn git
nng...
2.3. Chy mu m o.
- Chy mu t m h, m o v t cung.
- Tnh trng t cung.
- Cc vt rch, mu t.
- Tnh trng bng quang.
- Bnh cnh thng gp: sy thai, thai trng, thai ngoi t cung, rau tin o, rau bong
non, v t cung, t cung, rch (chn thng) ng sinh dc, mu t ng sinh
dc, st rau, ln t cung, ri lon ng mu.
2.4. Hn m hoc/v co git.
Bnh cnh thng gp: sn git, st rt, ng kinh, un vn, vim no - mng no.
| 141
2.5. St cao.
- Bnh cnh thng gp: sy thai nhim khun, st rau, nhim khun i, nhim khun
hu sn, cc nhim khun ton thn khc: vim no - mng no, thng hn, vim
phi, st rt, vim phc mc, nhim khun v.
2.6. au bng d di.
- Bnh cnh thng gp: u bung trng xon, vim rut tha, si tit niu, vim thn -
b thn, thai ngoi t cung v, do sy v sy, chuyn d , nhim khun i, rau bong
non, do v t cung, cc bnh ngoi khoa khc bng.
3. X tr ban u.
Bnh cnh cp cu Ti tuyn x Ti tuyn huyn Ti tuyn tnh
3.1. Chy mu:
3.1.1. Hng x tr
chung:
- Tp trung nhn vin s cu.
- T vn, cho ngi bnh v gia nh.
- Nu c chong: truyn ngay natri clorid 0,9% v/hoc Ringer lactat.
- ng thi x tr nguyn nhn chy mu.
- Theo di st cc du hiu sinh tn
3.1.2. Chy mu na
u thai k:
- ang sy (sy thng
cng nh sy trng).

- Khng c x tr ti
x.

- Tin hnh ht, no
sch bung t cung.

X tr nh tuyn
huyn.

- Sy khng hon ton
(khng trn, st rau).

- Hi sc chng chong
(nu cn).
- Timbp oxytocin hoc
ergometrin hoc cho
misoprostol 400 - 600
mcg ngm di li hoc
t m o
- Sau th thut: thuc
co t cung, khng
sinh (nu cn thit).

X tr nh tuyn
huyn.

- Nu sn ph chy
mu nhiu nguy him
n tnh mng.

- Chuyn tuyn.
- Timthuc co t cung
(trng hp thy khi
thai thp th c th dng
kp hnh timgp ra ri
chuyn).
ng thi tin hnh
hi sc chng chong
v ht bung t cung
X tr nh tuyn
huyn.

- Thai ngoi t cung
cha v.

- Chuyn tuyn.

-Nu chn on xc
nh: phu thut ct
b khi thai

- Nu chn on
xc nh: phu thut
m hoc phu thut
ni soi. C th bo
tn vi t cung
bng iu tr ni
khoa hoc ngoi
khoa.
- Thai ngoi t cung v - Chuyn tuyn kt hp
hi sc, hoc mi tuyn
trn chi vin.
- Phu thut cp cu
kt hp hi sc,
truyn mu hon hi
(nu c th).
Phu thut cp cu,
hi sc, truyn mu
v truyn mu hon
hi nu c th
142 |
-Thai trng. - Cha sy: chuyn
tuyn.
- ang sy: hi sc v
chuyn tuyn (gi tuyn
trn h tr).
- Cha sy: chuyn
tuyn.
- ang sy: hi sc,
ht bung t cung,
chuyn tuyn km
theo bnh phm.
- Cha sy + ang
sy: hi sc, ht
bung t cung.
3.1.3. Chy mu na
sau thai k hoc khi
chuyn d:
- Nu ngh n rau tin
o:

- Khng thm khm m
o.
- C th cho thuc gim
co nu c cn co t cung.
- Chuyn tuyn.

- Xc nh chn on
bng siu m, khng
thm m o.
- Vo vin theo di
v phu thut cp cu
ph thuc tnh trng
chy mu, ty loi
rau tin o v ty
tui thai.

- Nh vi tuyn
huyn.
- Theo di vi thai
non thng (truyn
mu nu cn) v
iu tr d phng
nu non.
- Rau bong non:

- Chuyn tuyn ngay kt
hp hi sc nu c
chong hoc mi tuyn
trn chi vin.

- Phng nga v
chng chong tch
cc.
- Cho ng di
hay phu thut cp
cu ty tnh hung c
th.
- Nh vi tuyn
huyn. Tng cng
hi sc chng
chong v truyn
mu (nu cn).

- Do v t cung:

- Thng tiu.
- Gim au v gimco.
- Chuyn tuyn khn cp.
- Ly thai ng di
bng forceps nu
iu kin hoc phu
thut ly thai ngay.
- Nh vi tuyn
huyn.

- V t cung:

- Tp trung hi sc chng
chong.
- Chuyn khn cp n
c s phu thut hoc xin
chi vin ca tuyn trn.

- Hi sc chng
chong kt hp phu
thut cp cu, ct t
cung bn phn.

- Nh vi tuyn
huyn nhng c th
t vn bo tn
t cung (khu vt
rch) nu c th.
- Truyn mu khi
cn.
- Chy mu sau : - Cmmu ngay bng
cc bin php c hc.
- ng thi truyn dch
hi sc chng chong.
- Cho 10 v oxytocin
v/hoc 1000 mg
misoprostol t m o.
- Tmmi cch chuyn
tuyn sm.
- X tr bc u nh
x.
- Tmnguyn nhn
gii quyt k c phu
thut ct t cung nu
cn.
- Truyn mu nu c
th
- X tr ging nh
tuyn huyn.
- Sn sng truyn
mu khi cn thit.
- C th p dng
cc phu thut bo
tn (tht ng mch
t cung, h v...)
| 143
3.2. Hn m hoc/v
co git:
3.2.1. Tin sn git
nng:

- Timbp diazepam 10
mg.
- Thng tiu.
- Thuc h p.
- Theo di st cc du
hiu tinh thn v lng
nc tiu.
- Chuyn tuyn.

- X tr nh tuyn x.
- C th cho thuc h
p nu cn.
- Theo di cht ch
tnh trng tmthn v
nc tiu.
- Chuyn tuyn.

Theo di v iu tr
ton din i vi
tin sn git nng
v sn git cho c
m v thai bng tt
c cc bin php ni
khoa, sn khoa v
ngoi khoa khi c
ch nh.
3.2.2. Sn git:

- Timbp 10 mg
diazepam.
- Magnesi sulfat 15 %, 20
ml bp.
- Phng cn phi li,
nga ht phi mri,
phng ng.
- Cho thuc h p nu cn
- Theo di st cc du
hiu tinh thn v lng
nc tiu
- Chuyn tuyn.
- Nu l tin sn git
nng v sn git, sau
khi tmn nh
chuyn tuyn tnh.
- Chuyn tuyn.
3.2.3.Cc bnh khc:

- Timdiazepam10 mg
bp.
- Chuyn tuyn
- Hi chn xc nh
bnh ri chuyn iu
tr khoa thch hp.
- X tr nh vi
tuyn huyn.
3.3. St cao:
3.3.1. Khi c thai:

- Chuyn tuyn.
- C th h nhit.
- Trc khi chuyn c th
dng khng sinh nu nghi
st nhimkhun.

- Nhp vin theo di,
chn on nguyn
nhn st v iu tr
theo nguyn nhn
xc nh.

- Nh vi tuyn
huyn.

3.3.2. Sau sy hoc :

Nu di 39
o
C c th
theo di, iu tr ti x:
- H nhit bng thuc v
chmmt.
- Khng sinh v thuc co
t cung nu c chy mu.
- Chuyn tuyn: nu iu
tr sau 3 ngy khng ht
st hoc st trn 39
o
C.

Cho mi trng hp
st:
- Nhp vin theo di,
chn on nguyn
nhn v iu tr theo
nguyn nhn xc
nh.
- C th ht, no
bung t cung nu st
rau, sau khi iu
tr khng sinh 24 gi.
- Chuyn tuyn tnh
nu l vimphc mc
ton th hoc/v
nhimkhun huyt.
- Nh vi tuyn
huyn.
- Theo di, iu tr
mi nhimkhun k
c vimphc mc
ton b hoc/v
nhimkhun huyt
bng cc phng
php ni khoa v
ngoi khoa.

144 |
3.3.3. Do cc bnh ni,
ngoi khoa khc:
- Chuyn tuyn. - Ty theo nguyn
nhn a v theo di
v iu tr ti cc
khoa ph hp.
- Nh vi tuyn
huyn.

3.4. au bng d di:
- Khng c timbt c
thuc gim au no.
- Nu kmtheo chong
cn hi sc, chng
chong.
- Chuyn tuyn hoc mi
tuyn trn chi vin.
- Cho nhp vin theo
di, chn on xc
nh nguyn nhn v
x tr ty theo nguyn
nhn .
- Nu c chong: va
hi sc chng chong
va x tr nguyn
nhn.
- Nh vi tuyn
huyn.
4. Chuyn tuyn.
4.1. Nhn lc.
- Mi c s y t phi c ngi thng trc cp cu lin tc.
- Phn cng c th ngi trc thng tr ti nh c th gi chi vin vo gi ngh, ban
m.
- Ti x, nn lp i cp cu da vo cng ng.
- Khi chuyn tuyn c nhn vin y t h tng vi ti thuc cp cu, bnh hoc bng
oxygen, dng c sch i km.
4.2. Phng tin vn chuyn.
- Mi c s y t phi lun c sn ti cp cu v cc phng tin vn chuyn.
- Ti x, hp ng c th vi nhng ngi li xe m, ch xe t, ch thuyn b gn c
s y t c th huy ng bt c lc no cn chuyn ngi bnh cp cu.
- Xe t cp cu ca bnh vin huyn v tnh lun t th sn sng cp cu. Khng
c dng xe cp cu vo vic khc. Li xe c ch trc lin tc nh nhn vin y t.
4.3. V phng tin thng tin lin lc.
Tt c cc c s y t t x tr ln cn c in thoi v danh b ca c s y t tuyn trn
lin lc xin chi vin, xin kin ch o iu tr.
4.4. Chm sc ngi bnh khi vn chuyn:
- Gi m ngi bnh nhng khng qu nhiu chn, nht l khi st cao hoc c tnh
trng chong.
- t ngi bnh t th thch hp:
Na nm na ngi (t th Fowler) cho cc ca kh th, bnh tim.
u thp, chn cao, nghing mt bn cho cc ca c chong (nu thai nhi cn trong
bng m th nn cho nm nghing tri).
u thp, k cao mng (t th u gi - ngc) cho nhng trng hp sa dy rn.
Nu sn ph b bng huyt do t cung, cn ra mu th ngi h tng ngi bn
cnh lin tc xoa bp t cung; khi cn, p t cung bng hai tay qua thnh bng,
hoc buc cht bng di bng mt bng vi thun.
| 145
- Khi cn thit vn phi tip tc truyn dch, cho th oxygen, tim thuc hi sc, thuc
co t cung... trn ng di chuyn.
4.5. H s ngi bnh mang theo khi chuyn tuyn.
Cn ghi cc thng tin ti thiu sau y:
- Tn, tui, a ch.
- L do chuyn tuyn.
- Tin s sn khoa.
- Thi gian n c s cp cu u tin.
- Tnh trng ban u ca ngi bnh: cc triu chng ch yu ni bt nht khi n c s
cp cu.
- Cc bin php x tr v thuc dng trc khi chuyn tuyn v trong khi vn
chuyn.

146 |
TI NH V X TR RI

Tuyn p dng.
Tt c cc tuyn, c bietj l tuyn x v thn bn.
Ngi thc hin.
Mi cn b y t nht l cc cn b lm dch v chm sc SKSS k c cc c thn
bn hoc nhn vin y t thn bn c o to.

1. ti nh.
ti nh l iu khng khuyn khch nc ta. Tuy nhin, mt s vng, min
ni xa xi ho lnh, ng bo vn cn tp qun sinh ti nh, t t hoc mi b m
n nh . Trong trng hp nu sn ph c ngi c o to v chm
sc th c th gim nhiu tai bin nguy him cho sn ph.
1.1. Chun b.
- Ni : phi sch s, an ton, khng b lnh, cn m bo tnh ring t, kn o.
- C sn gi sch hoc ti lu ng ca trm y t x.
- C cc dng cn thit ra tay, ng bnh rau, hng nc i v mu, qun o, t
lt cho s sinh, khn sch lau b
1.2. Cng vic cn lm trc khi bt tay vo .
- Nu sn ph cha ngay: khuyn sn ph i i tin, tiu tin. Nu c th th tm
nhanh. Thn mt tr chuyn, ng vin an i sn ph khi chm sc.
- Gip sn ph nm trn ging ng t th .
- Ra sch vng sinh dc v bn, i, hu mn.
- Tri tm nilon sch di lng v mng.
- Ngi ct ngn mng tay v ra tay sch vi x phng (c ngi nh sn
phgip dng go di).
- i gng v khun (trong ti sch).
1.3. Cc iu kin cn v bt tay vo .
- u thai thp th bn ngoi m h.
- i v (hoc nu mng i cn trm pha trc u thai th phi bm i).
- Khi c cn co t cung sn ph mt rn v khi rn, tng sinh mn gin di, l hu mn
loe rng, mt gn ht vt nhn chung quanh.
1.4. Cc bc thc hin thai ra nh sau.
- ng vin sn ph rn khe, di hi, ng k thut.
- Thi gian ngh (ngoi cn co), ngi nghe li nhp tim thai, khuyn sn ph ht
su, th ra t t, u n. Gip sn ph lau m hi, cho ung nc, chuyn tr vi h
trong lc ch cn rn tip.
- Trong mi cn rn , gi tng sinh mn vt nh cho u ci tt hn.
- Khi chm ra nhiu hn th lm thao tc nga u dn ln s mt v u. Gi tng
sinh mn trnh b rch.
| 147
- u thai t quay sang th chm ngang (tri hoc phi).
- Kim tra xem c dy rn qun c khng. Nu c khi phn vai phi g dy rn qun
c .
- Lm thao tc ko thai xung pha chn vai trc.
- Lm thao tc nng, ko thai ln pha trn s vai sau. Gi tng sinh mn khng b
rch.
- thn v chi di ca thai khi thai s hn ra ngoi, gi thai nm ngang ri t sp ln
bng m cp ct (hoc buc) dy rn khi dy rn ht p.
1.5. Chm sc s sinh ngay sau .
1.5.1. Nu c dng c cp, ct rn bng ko sau khi s thai.
- Cp kp th nht vo dy rn cch bng s sinh mt on khong 20 cm.
- Vut dy rn t v tr kp th nht v pha ngi m ri cp kp th hai cch kp th
nht khong 2 cm.
- Dng ko ct dy rn gia 2 kp .
- a tr ra ni lm rn bng cc dng c c trong ti sch.
1.5.2. Ct rn v lm rn ngay sau bng dng c c trong ti sch.
- t b nm trn bng m (c lt khn sch v c ngi nh gi b).
- t mt ming gc ln bng b, st vi chn cung rn.
- Dng bng thm cn 70
o
bi t chn rn ln cao khong 5 - 6 cm. Khng cn ri
xung da bng tr.
- Dng si ch th nht buc cht nt u tin cch chn rn khong 2 cm.
- Cng buc nh th nt th hai pha ngoi nt buc th nht 1 cm (cch chn rn
khong 3 cm).
- Buc nt th ba cch nt th hai 1 cm.
- Nng dy rn ln bng si ch mi buc ri dng li dao bo ct t dy rn gia
nt buc th hai v th ba.
- Khi ct xong, dng ming gc trn bng b bp vo cung rn xem c r mu
khng. Nu mu cn r ra cn buc thm mt nt ch na gia 2 nt ch c trn
cung rn.
- Cm si ch nng cung rn bi cn st khun t mt ct ca n tr xung n chn
rn.
- Thay ming gc mi trn bng b. t u cung rn vo gia ming gc, ct ch tha
v h rn.
- Kim tra b xem c d tt khng (ch n hu mn) ri mc o, qun t cho b.
- Giao b cho m b v vn ng m cho b ngay.
1.6. rau v kim tra rau.
Thng sau khi lm rn cho b xong th rau cng c th bong. Vic rau v kim
tra rau ty thuc vo phng php x tr no c sn thc hin:
1.6.1. Nu c thuc oxytocin: tim vo bp i 10 v ngay khi thai ra ngoi th c th
rau nh sau (theo cch x tr tch cc giai on 3 ca chuyn d):
u tin t tay ln bng sn ph xem t cung co li tt cha. Nu co cha tt th
phi xoa bp bn ngoi cho n khi t cung co cht thnh qu cu an ton mi lm bc
tip theo.
148 |
- Mt tay xe ra t trn bng di sn ph ngn ci mt bn, 4 ngn cn li bn
i din, hi y t cung ln pha rn v chn gi n ti ch trong khi tay cn li cm
gi dy rau ko t t vi lc tng dn theo hng lc u xung pha di, sau ko
ngang v cui cng hng ln trn cho bnh rau ra t t.
- Khi bnh rau sp ra ngoi th h thp dy rn xung cho bnh rau ri, ko theo mng
rau ra lun.
- Trng hp mng rau khng tut ra th hai bn tay cm bnh rau xon li nhiu vng
mng s ra dn.
- Trc khi kim tra rau cn nn bng di nh gi co hi t cung v quan st m h
xem c b chy mu khng.
1.6.2. Trng hp khng c oxytocin: mun rau phi lm nghim php bong rau
bit rau bong mi c bng cch:
t tay ln bng di sn ph, n nh xung vng trn xng mu y vo on
di t cung (thn t cung s b y ln trn).
- Nu thy dy rn khng b ko theo ln trn (c khi cn di thm ra ngoi m h) th
chng t rau bong v c th thc hin vic rau. Nu dy rn cn b ko theo ln
khi n trn xng mu th phi ch ti khi no rau bong mi c .
- Cch nh sau: mt tay cm dy rn nng ln cao, tay kia t ln bng, pha y t
cung, y theo hng rn - mu vi lc tng dn y bnh rau ra.
- Cch mng rau cng lm nh phn trn m t.
1.7. Kim tra rau.
- t bnh rau trn mt ci khay hay chu.
- Cm dy rn nng bnh rau ln, vut nh mng rau xung.
- Quan st l rch ca mng: nu l rch trn, u th mng , nu l rch nham nh th
c th st mt t mng.
- Quan st cc mch mu trn mt mng ca bnh rau pht hin bnh hoc mi rau
ph.
- t bnh rau xung khay cho mt mi ca n nga ln, gt mu cc ra ngoi quan
st cc mi rau. Mt mi rau nhn, mn, mu thm. Nu trn mt mi c vng no
b khuyt th phn rau ni khuyt ang cn st li trong t cung.
1.8. Chm sc sn ph sau khi .
- Kim tra xem t cung c co tt khng, c vt rch no ng sinh dc khng. Hi
cm gic sn ph, quan st da, nim mc v bt mch nh gi tnh trng ton thn sau
sinh.
- Ra li vng sinh dc, lau kh v gip ng kh (khn v sinh), mc o qun cho sn
ph.
- Thu dn dng c , v sinh ni .
- Cho sn ph n nh, nng hp khu v (cho, sa, ph, m).
- Vn ng cho con b sm ngay sau (cn c tc dng ngn nga chy mu sau ).
- Trong vng hai gi sau , c 15 pht li bt mch v nn bng nh gi co hi t
cung, quan st khn v sinh nh gi lng mu. Nu t cung mm th phi xoa nn
cho co li v mi cn b y t x n x tr tip.
| 149
2. X tr ri.
ri l tnh trng khng c d kin trc, xy ra ngoi mun ca mi ngi
nhng ni khng ph hp vi vic sinh nh: ti ni ang lm vic (cng s, nh my,
cnh ng) hoc trn ng, trn tu xe (i lm hay i n c s y t).
X tr ri c thc hin khn cp, ngay ti ch v ty theo tnh hung c th ca
sn ph lc
Trc ht phi nhanh chng gii phng thai nhi khi qun hoc vy o ca sn ph, sau
:
2.1. Nu c sn ti sch.
X ngay bao gi s dng cc vt liu c sn trong :
- Tri tm nilon ngay ni b m ri, t chu b nm vo , m b bng bt c th
g c th c c b m v ngi x tr (khn, o, giy bo).
- Ly cc si ch buc rn trong gi ny buc cht dy rn v tr cng xa da bng b
cng tt.
- Khng c ct dy rn.
- Chuyn b cho m m st vo ngi hn ch b nhim lnh.
- Tm mi cch chuyn hai m con v trm y t gn nht c chm sc tip.
- Ti c s iu tr, m s c ly rau, theo di v x tr chy mu, nhim khun; con
s c lm rn li, c hai s c tim huyt thanh chng un vn.
2.2. Nu khng c sn gi sch.
- Ngay lp tc m chu b bng mi vi c sn ti ch.
- Tm mt si dy nh, mm, bt c l dy g (dy rt, dy x t vt o hay khn mi
xoa, dy buc ) buc cht dy rn, cng xa ni bm ca n bng b cng tt.
- Khng c ct dy rn.
- Trao b cho m m p v tm mi cch chuyn ngay v c s y t gn nht x tr
cho m, cho con nh phn trn.

150 |

151 |

E
CC TH THUT V PHU THUT

152 |
| 153
CC PHNG PHP V CM TRONG SN KHOA

Tuyn p dng.
Xem chi tit trong bi.
Ngi thc hin.
Xem chi tit trong bi.

1. Cc phng php v cm trong cc th thut sn khoa.
1.1. Gy t ti ch.
1.1.1. Ch nh.
Ct, khu tng sinh mn.
1.1.2. K thut.
- Tim 5 ml lidocain 1 % vo vng tng sinh mn ni nh ct (v tr 5 hoc 7 gi) bng
kim s 22 g di 5 cm.
- Trnh tim thuc t vo mch mu bng cch va y kim t t vo su v va ht
xem c ra mu khng. Khi kim gy t vo su t v tr cn gy t th va rt kim t
t va bm thuc.
- Ch 2 - 4 pht thuc t c tc dng th tin hnh ct tng sinh mn. Nn ct trong
cn rn ca sn ph.
- Nu tim nhm thuc t vo mch mu c th gy co git thm ch gy t vong. X tr:
chng co git bng tim tnh mch thiopental hoc benzodiazepin, h hp nhn to.
1.1.3. Tuyn p dng v ngi thc hin:
- C s y t chm sc sn khoa t tuyn x tr ln
- Ngi thc hin l cc bc s gy m hi sc, bc s sn khoa, n h sinh gy m.
1.2. Gy t quanh c t cung.
1.2.1. Ch nh.
Khi nong c t cung ht hoc no thai.
1.2.2. K thut.
- t 2 van m o, st khun m o v c t cung bng betadin.
- Dng km Pozzi 2 rng cp c t cung ko nh ra ngoi, nghing sang tng bn phi,
tri nhn thy ch bm ca biu m c t cung vo m o, y l ni s gy t.
- Dng kim 22 g, di 3,5 cm, lp vo bm tim 20 ml.
- Thuc s dng: lidocain 0,5 %.
- Tim t ln lt vo cc im 5 - 7 - 11 - 1 gi, mi im tim 2 ml dung dch lidocain
ngay di biu m, khng su qu 3 mm.
- n gin hn c th ch tim hai im 5 v 7 gi, mi im 10 ml lidocain l gy
t dy chng rng hai bn.
- Trc khi bm thuc phi ht th xem kim c chc vo mch mu khng. Nu ht ra
mu phi rt kim ngay, chc ch khc.
- Sau khi gy t xong, ch 2 pht v cp th vo c t cung, nu ngi bnh cn au ch
thm 2 pht na ri th li, ht au mi tin hnh th thut.
154 |
1.2.3. Tuyn p dng:
C th p dng tuyn x, tuyn huyn, tuyn tnh.
1.3. Gy t ty sng.
1.3.1. Ch nh.
V cm cho cc th thut ng di: ko, gp v ct thai.
1.3.2. Chng ch nh.
- Sn ph t chi.
- C bnh l bm sinh hoc mc phi v ng mu.
- ang iu tr thuc chng ng.
- Nhim khun ton thn hoc ti ch gy t.
- Tng p lc ni s.
- Chy mu nhiu, gim khi lng tun hon.
- Cc bnh tim nng.
- D ng thuc t.
1.3.3. Chun b gy t.
- Chun b thuc v cc phng tin cn thit.
- Sn ph nm nghing tri.
- t 1 ng truyn tnh mch kim 20 G.
- Truyn 10 ml/kg cn nng dung dch Ringer lactat hoc natri clorid ng trng trc
khi gy t.
- Ephedrin 20 - 40 mg truyn tnh mch ty theo mc huyt p.
- Tagamet 200 mg si ung khi c ch nh gy t lm th thut.
- Monitor theo di: in tim, huyt p, bo ha oxygen mao mch.
- Th oxygen 3 - 4 lt/pht.
1.3.4. K thut.
- T th ngi bnh: nm nghing tri hoc ngi.
- St khun vng nh chc bng betadin v cn 70 .
- V tr chc kim: L2 - L3 hoc L3 - L4.
- Kim gy t: nn dng loi nh hn hoc bng 27G l tt nht.
- Thuc t: bupivacain 0,5 % t trng cao.
- Liu: dng 3 - 5 mg bupivacain 0,5 % phi hp thuc h morphin l fentanyl 30 mcg
hoc morphin 100 mcg
- Sau gy t 3 - 5 pht c th lm th thut c.
- Nn s dng ephedrin d phng ngay sau gy t, liu ti a c th 60 mg, khi huyt p
h nhiu v ko di c th truyn adrenalin.
- Phi theo di st: mch, huyt p, bo ha oxygen sau gy t cho n lc lm th thut
xong v khi nm ti phng hi tnh.
- Tht bi phi chuyn gy m ton thn lm th thut.
- Thc hin t tuyn huyn tr ln.
- K thut ny phi do bc s gy m thc hin.
| 155
1.4. Gy m tnh mch bng propofol 1 %
- Rt tt cho cc th thut no ht thai.
- K thut gy m tnh mch ny phi do bc s gy m thc hin.
- Ngi bnh nhn n t nht 6 gi trc khi lm th thut.
- T th ngi bnh: nm nghing u sang mt bn.
- K thut:
Tim primperan 10 mg tnh mch.
Tim zantac 50 mg tnh mch.
Tim fentanyl 50 mcg tnh mch.
Sau khi tim cc thuc trn 10 pht, khi chun b sn sng lm th thut:
Tim fentanyl 50 mcg tnh mch.
Tim propofol 1 % liu 1,5 - 2 mg/kg.
- Liu lng thuc duy tr ty theo thi gian th thut, nu ko di th nn duy tr bng
bm tim in hoc tim ngt qung 3 ml/ln (30 mg).
- Cn theo di khi lm th thut v sau th thut:
Nhp th: ngi bnh thng th chm, c khi ngng th, phi c phng tin
h tr h hp khi cn.
Nn: nu nn cn h u thp v ht dch nn, trnh tro ngc vo phi.
Mch.
Huyt p: nu h huyt p th truyn dch nhanh.
1.4. Tuyn p dng v ngi thc hin
- Do bc s gy m thc hin.
2. Cc phng php gim au trong chuyn d .
- C 2 phng php: gy t ngoi mng cng v gy t ty sng liu thp.
- Chng ch nh ca 2 phng php ny ging nh chng ch nh ca gy t quanh ty
sng thng thng.
2.1. Phng php gy t ngoi mng cng.
2.1.1. Chun b ngi bnh:gii thch, ng vin, gip ngi bnh an tm.
2.1.2. Chun b phng tin:
- Cc phng tin gy m ton thn v thuc gy m.
- B kim gy t ngoi mng cng (hp ng sn).
- Cc loi thuc t, thuc phi hp vi thuc t, thuc an thn, thuc tr tim mch,
oxytocin, dch truyn.
2.1.3. K thut:
- t mt ng truyn tnh mch ngoi vi kim 22 g.
- Thi im chc kim: ngoi cn co t cung.
- T th kim: u vt song song dc thn.
- Test khi chc: dch hoc thuc t 3 - 5 ml.
- Lun catheter su 2 - 3 cm trong khoang ngoi mng cng.
156 |
- Liu thuc t: liu ban u ca bupivacain 0,125 % hoc ropivacain 0,125 % tnh theo
cng thc:
S ml =[chiu cao (cm) - 100] x 0,2.
Liu duy tr: thng bng 1/2 n 2/3 liu ban u, duy tr bng bm tim in nhng
vi nng thuc thp hn (bupivacain 0,0625 % hoc ropivacain 0,0625 %).
- Thuc kt hp:
Liu khi u: fentanyl 1 mcg/kg hoc sufentanil 7,5 mcg hoc morphin 4 mg.
Liu duy tr: fentanyl 10 - 20 mcg/gi hoc sufentanil 1 - 5 mcg/gi.
Trong giai on s thai hoc lm th thut nu au c th b sung thm thuc t. Trong
qu trnh chuyn d nn truyn oxytocin duy tr cn co t cung v phi theo di lin tc
qu trnh chuyn d v huyt ng.
- Tuyn tnh tr ln
2.2. Phng php gy t ty sng liu thp.
- Tin hnh gy t ty sng khi c t cung m trn 4 cm v tin lng ngi bnh c th
c ng di.
- Thuc s dng: bupivacain (Marcain) 1,5 - 2 mg phi hp vi fentanyl 25 mcg hoc
morphin 100 mcg.
- C hai phng php ny u cho kt qu, gim au tt, khng lit vn ng, huyt
ng ca m n nh, tim thai tt. Nhng cn truyn thm oxytocin liu thp 5 v pha
trong 500 ml nh git 10 - 15 git/pht ty theo cn co t cung.
- Phng php ny thc hin tuyn tnh tr ln v phi do bc s gy m thc hin.
3. Cc phng php gy m, gy t trong phu thut ly thai v cp cu sn
khoa.
3.1.Gy m ni kh qun.
3.1.1. Ch nh.
Phu thut ly thai, phu thut ct t cung do chy mu khi c chng ch nh ca gy
t vng.
3.1.2. K thut.
- Chun b ngi bnh:
Nm nghing tri 10 - 15 .
t mt ng truyn tnh mch ngoi vi kim 20 g, truyn dch Ringer lactat hoc
huyt thanh mn ng trng.
Th oxygen 100 % 3 - 5 pht trc khi khi m.
t my theo di: mch, huyt p, bo ha oxygen mao mch.
ng vin gip ngi bnh an tm.
- Chun b phng tin:
Cc thuc m v thuc hi sc.
My gy m, my ht, dng c t ni kh qun.
- Tin m: phi cho cc thuc phng nn v tro ngc.
Primperan 10 mg tim tnh mch.
Cimetidin hoc ranitidin tim tnh mch 1 ng hoc ung 1 vin dng si.
| 157
Citrat natri 0,3 m ung 30 ml.
Pethidin 50 mg v dimedrol 20 mg pha long trong 10 ml v tim tnh mch chm
chia 2 ln cch 10 - 15 pht trc khi khi m.
Hoc fentanyl 1 mcg/kg tim tnh mch chm.
- Khi m: tim tnh mch.
Thiopental 4,5 - 5 mg/kg.
Succinylcholin 1 mg/kg.
t ni kh qun ng s 7 sau khi tim thuc gin c kh cc 45 - 60 giy, bm bng
chn ca ni kh qun v ni vi my th.
Ch : Khi ngi bnh bt u mt thc th tin hnh th thut Sellick.
- Duy tr m:
Thuc m bc hi: halothan <0,5 % hoc dng N
2
0 vi t l oxygen/N
2
O l 50/50
Thuc gin c khng kh cc c dng mt trong cc thuc sau y: atracurium,
vecuronium, rocuronium
Sau cp rn.
Oxytocin 5 - 10 v tim tnh mch chm, sau pha 10 v trong 500 ml Ringer
lactat truyn tnh mch.
Fentanyl 1,5 - 2 mcg/kg tim tnh mch.
Tim thm 1/2 liu thiopental ban u hoc duy tr bng N
2
O.
Tim khng sinh d phng.
- Thot m:
Cho ngi bnh th li, nu th tt chuyn phng hi tnh.
Nu cn thit c th cho gii gin c bng neostigmin 0,5 mg +atropin 0,25 mg
tim tnh mch chm.
Rt ni kh qun khi ngi bnh tnh, c th l c th m mt h mm v t nng
u theo yu cu ca thy thuc.
n ung tr li sau 24 gi.
Ngoi thiopental c th dng cc thuc m khc nh:
Propofol 2,5 mg/kg
Ketamin 2 mg/kg trong hen ph qun v chy mu (cn thm benzodiazepin
chng o gic).
Etomidat 0,2 - 0,3 mg/kg trong bnh tim, tng huyt p, tin sn git.
3.1.3. Tuyn p dng v ngi thc hin.
3.2. Gy t vng phu thut ly thai (gy t ngoi mng cng v gy t ty sng).
3.2.1 Chng ch nh.
- Sn ph t chi.
- C bnh l bm sinh hoc mc phi v ng mu.
- ang iu tr thuc chng ng.
- Nhim khun ton thn hoc ti ch gy t.
- Suy thai cp (c th lm c khi bc s gy m c kinh nghim).
- Tng p lc ni s.
- Chy mu nhiu, gim khi lng tun hon.
158 |
- Cc bnh tim nng.
- D ng thuc t.
3.2.2.Chun b gy t:
- Chun b thuc v cc phng tin gy t, gy m ton thn.
- Sn ph nm nghing tri.
- t 1 ng truyn tnh mch kim 20 g.
- Truyn 10 - 15 ml/kg cn nng dung dch Ringer lactat hoc natri clorid ng trng
trc khi gy t.
- Ephedrin 20 - 40 mg truyn tnh mch ty theo mc huyt p.
- Tagamet 200 mg si ung khi c ch nh phu thut.
- Monitor theo di: in tim, huyt p, bo ha oxygen mao mch.
- Th oxygen 3 - 4 lt/pht.
3.2.3.K thut gy t ngoi mng cng.
- St khun rng bng betadin v cn 70 vng nh chc.
- Gy t ti ch bng lidocain 1 - 2 %.
- Liu test lidocain 5 ml +adrenalin 1/200000 sau 5 pht.
- Lun catheter vo khoang ngoi mng cng su 2 - 3 cm, rt kim, c nh, bm thuc
t tng liu 5 ml vi tng liu 20 ml.
Thuc t:
Lidocain 2 % n thun hoc
Lidocain 15 ml +bupivacain 0,5 % 5 ml hoc
Lidocain 15 ml +bupivacain 0,5 % 5 ml +fentanyl 50 - 70 mcg (c th thm 4 mg
morphin).
- Sau cp rn:
Oxytocin 5 - 10 v tim tnh mch chm sau 10 v trong 500 ml truyn tnh
mch.
Tim khng sinh d phng.
- Phng php ny c thc hin tuyn tnh tr ln v phi do bc s gy m thc
hin.
3.2.4. K thut gy t ty sng.
- St khun vng nh chc bng betadin v cn 70 .
- Kim gy t: nn dng loi nh hn hoc bng 27G l tt nht.
- Thuc t: bupivacain 0,5 % t trng cao.
- Liu: ty theo chiu cao ca sn ph v ty theo c kt hp vi cc thuc khc hay
khng. Nu dng bupivacain n thun liu: 0,06 x chiu cao (cm). Nu dng phi hp
vi cc thuc h morphin, liu 0,05 x chiu cao (cm). Cc thuc phi hp h morphin
l: fentanyl 30 mcg hoc morphin 100 mcg.
- Sau gy t 3 - 5 pht c th phu thut c.
| 159
- Nn s dng ephedrin d phng ngay sau gy t, liu ti a c th 60 mg, khi huyt p
h nhiu v ko di c th truyn adrenalin.
- Phi theo di st: mch, huyt p, bo ha oxygen sau gy t cho n lc phu thut
xong v khi nm ti phng hi tnh.
- Tht bi phi chuyn gy m ton thn phu thut.
- K thut ny c th p dng tuyn huyn tr ln v phi do bc s gy m thc hin.
160 |
CC PHNG PHP GY CHUYN D

Tuyn p dng.
T huyn c kh nng phu thut tr ln.
Ngi thc hin.
Bc s chuyn khoa hoc c b tc v sn khoa.

Gy chuyn d hoc khi pht chuyn d l s tc ng ca thy thuc lm cho cuc
chuyn d bt u khng phi cuc chuyn d t nhin chm dt thai k.
1. Ch nh.
- i v nhng cha chuyn d, mng i v nhng cha c cn co t cung hoc cn
co yu, cn i.
- Thai qu ngy sinh.
- Bnh l ca m nh: tng huyt p, tin sn git, ung th cn nh ch thai nghn, bnh
tim nhng cha suy tim m i b v non, bnh cht to keo.
- Nhim khun i.
- Thai c d tt bm sinh nng c ch nh nh ch thai nghn.
- Thai cht lu trong t cung.
- Thai chm pht trin trong t cung.
2. Chng ch nh.
- Test khng kch v kch c biu hin bnh l.
- Bt tng xng thai - khung chu.
- Ngi bt thng khng c ch nh ng di.
- Rau tin o.
- So m c trn t cung.
- Sa dy rn (thai sng).
- Herpes sinh dc.
- Cc bnh l mn tnh nghim trng ca m nh suy tim, tin sn git nng, sn git...
c th ch nh phu thut ly thai.
3. nh gi trc khi gy chuyn d.
3.1. V pha m.
- nh gi li khung chu.
- nh gi c t cung (qua ch s Bishop).
- Xem li cc nguy c cng nh cc li ch ca gy chuyn d.
3.2. V pha thai.
- Xc nh tui thai.
- c lng cn nng thai nhi.
- Xc nh ngi thai.

| 161
Bng ch s Bishop
im

nh gi
0 im 1 im 2 im 3 im
m c t cung (cm) 0 1 - 2 3 - 4 5 - 6
xa c t cung (%) 0 - 30 40 - 50 60 - 70 80
lt ca thai -3 -2 -1 - 0 +1 - +2
Mt c t cung Cng Va Mm
Hng c t cung Sau Trung gian trc

Nu ch s Bishop < 5 th lm chn mui c t cung bng prostaglandin trc khi
gy chuyn d.
Nu ch s Bishop 5 th gy chuyn d bng mt trong cc phng php di
y.

4. Cc phng php gy chuyn d.
4.1. Bc tch mng i.
- Khm m o, a ngn tay vo gia mng i v c t cung, u ngn tay phi p st
c t cung tch mng i ra khi thnh c t cung v on di t cung.
4.2. Bm i.
- Bm i ch thc hin c khi c t cung m, bng cch dng 1 kim chc d di
hoc 1 cnh Kocher gy thng mng i, sau dng ngn tay x rng mng i. C
th bm i n thun hoc kt hp vi truyn oxytocin.
- nh gi s lng v mu sc dch i.
- Theo di nhp tim thai trc v ngay sau khi bm i.
4.3. Bng Foley.
- a mt thng Foley qua l trong c t cung. Bm 10 ml huyt thanh mn 0,9% lm
phng bng cao su to p lc gip cho c t cung xa v m. Khi c t cung m c
3 cm, thng s t tut ra ngoi v cuc chuyn d c khi pht. C th kt hp vi
truyn tnh mch oxytocin nu cn.
4.4. Prostaglandin (ch c tin hnh ti c s c phu thut.)
- Prostaglandin gip c t cung chn mui v mm.
- Thuc thng c dng hin nay l misoprostol.
- t vo ti cng sau m o vi liu 50 mcg, c 3 gi/ln, ti a l 6 liu hoc 25 mcg
c 3 gi/ln, ti a 8 liu hoc bng ng ung 50 mcg c 4 gi/ln.
4.5. Bm i kt hp vi truyn oxytocin (ch c tin hnh ti c s c phu thut.)
4.5.1. Cc bc tin hnh.
- Cho 5 v oxytocin pha vo 500 ml dung dch glucose 5 %, truyn nh git tnh mch
chm, liu lng lc u 5 - 8 git/pht cho n khi xut hin cn co t cung.
- Bm i, x rng mng i.
162 |
- Theo di v iu chnh s git t c s cn co ph hp vi s tin trin ca
chuyn d.
- Ngoi ra, ty tnh hnh ca cuc ch huy nu cn co mau cho oxytocin chy chm
hoc c th phi hp vi nhng thuc gim co c tc dng lm mm c t cung.
- Cuc ch huy c coi l c kt qu khi cn co u n, tim thai tt, ngi lt v c
t cung m ht, c th cho ng di v ly ra mt thai nhi khe mnh.
Lu : i vi nhng thuc c th km hm trung tm h hp ca thai nhi, ch nn dng
khi c t cung m 5 - 6 cm, thai c kh nng lt v s trong mt thi gian ngn.
4.5.2. Theo di v x tr tai bin.
Theo di: tim thai, cn co t cung, m c t cung, lt ca ngi c thi x
tr kp thi.
- Nu thai suy, phi ngng ch huy, phu thut cu thai.
- Nu cn co t cung qu tha, nh, tng s git truyn. Nu qu mnh, mau th gim
lu lng truyn v c th s dng gim co t cung.
- Nu cuc ch huy ko di qu 6 gi m khng tin trin tt th phi phu thut ly
thai.
- Tai bin c th gp l thai suy hoc t vong do theo di khng tt, can thip mun.
- C th v t cung do truyn oxytocin gy cn co mau, mnh: phi phu thut cu
m v con.

| 163
K THUT BM I

Tuyn p dng.
Ngi thc hin.

Bm i l mt th thut c lm trong qu trnh chuyn d , khi c t cung xa
m, mc ch lm v mng i ch ng nc i thot ra ngoi.

1. Ch nh.
- Mng i dy, c t cung khng tin trin.
- Gy ch huy hay lm nghim php lt ngi chm hoc thai th hai trong sinh
i.
- Rau bm bn, bm mp chy mu.
- Bm i cho nc i chy ra t t trong trng hp a i.
- Bm i khi c t cung m ht.
- Mt s bnh l ca ngi m cn bm i rt ngn chuyn d, nh bnh tim, tin sn
git nng khi c t cung m t 4 cm tr ln.
2. Chng ch nh.
- Cha chuyn d thc s.
- Sa dy rn trong bc i.
- C t cung cha m ht trong ngi mng, ngi mt, ngi vai.
3. Chun b.
- Phng tin: mt kim di 15 - 20 cm u t c nng hoc 1 cnh ca kp Kocher c
rng.
- Sn ph: nm trn bn , t th sn khoa, th u, khng rn.
4. Cc bc tin hnh.
- Ra sch m h bng nc v khun.
- eo gng v khun.
- Trc khi bm i, kim tra li xem c sa dy rn trong bc i khng.
- Trong ngi u, u i dt th nn bm trong cn co t cung, u i phng bm ngoi
cn co.
- i vi ngi mng, nn bm i ngoi cn co t cung ch khi c t cung m ht, cho
nc i chy ra t t ri mi x rng mng i.
- i vi ngi vai (thai th 2) khi c ch nh v iu kin ni xoay thai th chc
u i, a c c bn tay vo bung t cung v nm ly chn thai nhi lm ni xoay.
V vy, sau khi chc i v x mng i, phi a ngay c bn tay vo bung t cung,
va tm chn thai nhi va ngn khng cho nc i chy t ra ngoi.
164 |
- Nu bm i trong rau tin o bm thp, bm mp, sau khi chc u i, x rng mng
i song song vi b bnh rau, trnh x vo bnh rau gy chy mu.
- Nu bm i trong a i cn sn ph nm u thp, mng hi cao. Dng phng
php tia i, ngha l dng kim chc mt l nh, chc ngoi cn co t cung, cho
nc i chy t t, khi nc i chy gn ht mi x rng mng i. Trong trng hp
ny nu nc i chy o ra ngoi, d gy bong rau v sa dy rn hoc ngi c th
tr thnh bt thng.
- Sau khi bm i phi kim tra li xem c sa dy rn hay khng v ngi thai c thay i
g khng c hng x l kp thi. Sau cng nghe li tim thai, ri nhn nh mu sc
v lng nc i.
- Nu sau khi bm i b sa dy rn, phi cho sn ph nm t th u gi - ngc (u
thp, mng cao), dng 2 ngn tay y ngi thai ln trnh vo dy rn (xem bi Sa
dy rn) v phu thut ly thai ngay. Nu chy mu sau bm i hay nc i bt
thng (c mu hoc ln phn su) phi tm nguyn nhn x l kp thi.

| 165
NGHIM PHP LT NGI CHM

Tuyn p dng.
Tuyn huyn c kh nng phu thut ly thai tr ln.
Ngi thc hin.
Bc s chuyn khoa sn hoc bc s c o to phu thut ly thai, ngi theo di
l n h sinh.

Nghim php lt ngi chm l phng php nh gi cuc khi khung chu gii hn,
trng lng thai nhi bnh thng hoc khi khung chu bnh thng nhng thai nhi li kh
to, nhm a n quyt nh l thai nhi c th c qua ng m o hay phi phu
thut ly thai.
1. Ch nh.
- Khung chu gii hn, thai bnh thng.
- Khung chu bnh thng, thai to.
- Khung chu hp, thai nh.
2. iu kin.
- Phi l ngi chm.
- C chuyn d tht s.
C t cung xa ht v m 3 cm tr ln.
Cn co t cung tt. Nu cn co khng tt phi tng co bng oxytocin, nh git tnh
mch.
- Phi theo di cn thn pht hin kp thi nhng bin chng xy ra trong khi lm
nghim php lt nh sa dy rn, thai suy, cn co t cung dn dp, da v t cung.
3. Chng ch nh.
- Khung chu hp hon ton hoc hp eo gia v eo di.
- Thai suy.
- Cc ngi khng phi l ngi chm.
- C so m c t cung.
4. Chun b.
- Mt kim di 15 cm hoc mt cnh ca km Kocher bm i.
- Thuc tng v gim cn co t cung, dch truyn.
- Biu chuyn d, nu c iu kin theo di thm bng monitor sn khoa.
5. Cc bc tin hnh.
Bc 1: Sn ph nm t th sn khoa.
Bc 2: Khm sn khoa, tnh trng tim thai, cn co t cung, ngi thai, khung chu.
Bc 3: Dng kim bm i khi c cn co t cung v x rng mng i cho ngi t vo c
t cung. Nu ngi thai cn cao phi phng sa dy rn.
Bc 4: Ghi r gi bt u bm i v din bin ca cn co.
166 |
Bc 5: Theo di cn co t cung, tim thai. Tnh trng c t cung, ngi thai c khm li
sau mt gi v sau hai gi lm nghim php lt nh gi s tin trin
Bc 6: Nu cn co t cung tng nhiu (trn 3 cn co trn 10 pht), gim s git oxytocin.
Nu trng lc tng phi ngng truyn oxytocin, nu t cung vn tng trng lc th dng
cc thuc gim co.
Ch : Thi gian ch i ti a l 6 gi.
Trong thi gian lm nghim php, nn cho khng sinh.
6.1. Phu thut cp cu ly thai ngay trong cc trng hp.
- Cn co t cung dn dp, lin tc d ngng oxytocin v cho thuc gim co.
- Thai suy.
- Sa dy rn.
- Sau 2 gi lm nghim php, c t cung khng m thm hoc rn hn hoc ph n; ngi
thai vn cao, khng lt v bt u c bu huyt thanh.
6.2. Theo di thm chuyn d.
Nu sau 2 gi lm nghim php lt ngi chm m c t cung m thm t 2 cm tr ln,
tim thai vn u n, ngi thai xung su hn trong tiu khung, c th quyt nh cho theo
di thm; khi c t cung m ht u lt thp, c th cho sn ph thng hay ly thai
bng forceps, gic ko.

| 167
U TRONG NGI MNG

Tuyn p dng.
T tuyn huyn tr ln.
Ngi thc hin.
Bc s chuyn khoa sn.

u hu trong ngi mng l th thut can thip gip u thai nhi ci tt hn v
s d dng.
1. Ch nh.
Tt c cc trng hp ngi mng u phi can thip gip u s.
2. Chun b.
- Phng tin.
B cp ct rn s sinh.
B hi sc cp cu.
- Sn ph: c hng dn th u, khng ku, khng rn.
3. Cc bc tin hnh.
Bt k ngi mng no khi chuyn d cng cn c to lp mt ng truyn tnh
mch vi glucose 5 %.
C 3 th thut ly u trong ngi mng.
3.1. n u ci qua thnh bng.
- Dng trong tt c cc trng hp u trong ngi mng.
- Ngi ph dng mt bn tay p sp ln thnh bng trn khp mu ca ngi m, n
cho u ci tt trc v trong khi ngi chnh lm th thut. Th thut ny h tr
vi th thut Bracht.
3.2. Th thut Bracht
- Dng trong trng hp con r, tng sinh mn mm, u thai nh.
- Quay thai cho u ng t th chm v.
- Dng hai ngn tay t vo c thai nhi, ko cho u xung thp hn h chm t vo
b di khp v.
- Bn tay kia nm ly hai chn thai nhi nhc ln cao v lt nh ln pha trn, cho lng
thai nhi ng vo bng m.
- ng tc lm u thai nhi ci tt v cm, mm, mi, mt v trn s qua tng sinh
mn s ra ngoi.
- Khi b tay t c ra ly tng sinh mn.
- Trong th thut ny, hai tay ca phu thut vin phi nm vo 2 i ca thai lm
thao tc cho u nga v s khi phu thut vin hng cho lng thai v pha bng m.
n khi u thai sp s th dng mt bn tay nm gi 2 bn chn ca thai cn tay kia
ko nh vo dy rn bt b cng v gip 2 tay ca thai s d dng.
168 |
3.3. Th thut Mauriceau.
- Dng trong trng hp con so, tng sinh mn rn, u thai to hoc u khng to nhng
b nga, quay cho u thai nhi t th chm v.
- Phi hp hai tay: thai nhi ci ln cnh tay phi, hai chn dui hai bn cnh tay,
lun ngn tr v ngn gia ca tay phi vo mm thai nhi v n vo cung li ri ko
vo hm di gip u ci thm. Cng lc dng ngn tr v ngn gia ca bn
tay tri n vo vng chm ri t hai ngn tay vo gy thai nhi ko cho u ci
xung.
- Hai tay phi hp cho u thai nhi va ci thm va xung thp.
- Khi h chm n b di khp v th hai tay phi hp hng thn thai nhi ra trc
lt nga ln bng m.
- Cm, mm, mi, trn s dn dn s ra ngoi m h.

Ngoi ra c th dng forceps ly u hu nu thy thuc c kinh nghim
- Nu u b nga hay khng quay v chm v th thi gian ko u thai nhi qu lu lm
thai nhi b ngt hay b sang chn s no.
- Tng sinh mn c th b rch rng khi u thai s, nn ct ni tng sinh mn trc
thai s d dng.

| 169
XOAY THAI TRONG

Tuyn thc hin.
Tuyn huyn tr ln.
Ngi thc hin.
Bc s chuyn khoa sn.

Xoay thai trong l th thut dng tay a vo bung t cung chuyn thai nhi t ngi
ngang thnh ngi mng v ko thai ra ngoi.

1. Ch nh.
- Ngi ngang, thai nh tin lng kh c kh nng sng.
- Ngi ngang thai cui cng trong a thai.
2. iu kin xoay thai trong.
- C t cung m ht.
- Cn i.
- Khng c bt tng xng u - chu.
- Thai khng suy.
3. Chng ch nh.
- Con so.
- Khi khng iu kin xoay thai.
4. Chun b.
4.1. Cc phng tin.
- Thuc gim co: nifedipin ngm di li, dolosal 0,10 g.
- Thuc st khun.
- Thuc gin c.
- Thuc gy m tnh mch hoc ngoi mng cng.
- Oxygen.
4.2. Sn ph: c gii thch hiu r cc bc tin hnh th thut v nm thoi mi trn
bn.
5. Cc bc tin hnh.
- Thng i trc khi xoay.
- Ngi lm th thut ra tay, mc o, eo gng nh trong cuc phu thut.
- Gim au, tin m.
- Kim tra k xc nh c t th thai nhi trong t cung.
- Kim tra li xem cc iu kin xoay thai c y hay khng: cn co tha, cn
nhiu nc i, ngi cao lng, c t cung m ht, khung chu rng, thai nh.
170 |
- Cn phn bit tay vi chn thai khi ko nhm.
- Cho tay thun vo t cung tm chn thai nhi.
- Ko c hai chn xung cng mt lc l tt nht. Nu kh qu phi ko mt chn th ko
chn trc ca thai. Nu ko phi chn sau th quay cho chn sau thnh chn trc.
Ko t t thai ra ngoi m h.
- Bc rau v kim sot t cung ngay sau khi thai s xem c v t cung hay khng
kp x tr. y l th thut bt buc sau khi xoay thai trong.
- Kim tra c t cung, m o, tng sinh mn xem c rch khng.
- C th v t cung khi xoay thai, ko chn xung thp, gy chong, chy mu: phu
thut ngay khu hay ct t cung cm mu.
- Nhim khun c th xy ra sau khi xoay thai trong: cho khng sinh.

| 171
X TR THAI TH HAI TRONG SINH I

Tuyn p dng.
T tuyn huyn tr ln v nhng ni bt buc phi x tr (khng chn on c t
trc)
Ngi thc hin.
Bc s chuyn khoa sn, ni khng c bc s chuyn khoa th n h sinh c thc hin
(tr trng hp xoay thai trong).

Trong thai sinh i sau khi thai th nht s, thng c bin c xy ra vi thai th hai.
C th lm thai th hai quay trong t cung, cn co t cung li tha, m li mt mi v
gng sc thai th nht. V th, cn phi bit x l bo m an ton cho m v cho
thai.

1. Chun b.
1.1. Cn b chuyn khoa: ngi xong thai th nht th giao s sinh cho ngi ph
chun b cho thai th hai.
1.2. Phng tin.
- Hai hp .
- Hai b dng c hi sc s sinh.
- khn v gng v khun.
- Thuc co hi t cung: oxytocin, ergometrin.
2. Cc bc tin hnh.
- thai th nht nh bnh thng cp cht dy rn c 2 u pha con v pha m,
giao tr cho ngi ph chm sc.
- Nu sn ph ang c truyn dch oxytocin tnh mch (trng hp ch huy) th cho
dch chy nhanh hn.
- Cho tay vo m o kim tra ngay ngi, th, kiu th ca thai th hai. Nu ngi u th
ch i c cn co t cung ri bm i v nh thng l.
- Ngi bt thng (ngi vai, ngi trn, thai nh) th phi bm i ngay v ni xoay thai
thnh ngi mng. Sau ngi mng nh thng hoc i ko thai ngay.
- Tim bp 10 v oxytocin ri x tr tch cc giai on 3 ly rau, nu chy mu bc
rau nhn to v kim sot t cung ngay.
- Kim tra bnh rau bit xem c st rau khng v xc nh sinh i mt non hay
hai non.
3.1.Theo di.
- Ngay sau khi thai th nht phng thai th hai l ngi bt thng.
- Chy mu sau do t cung.
172 |
3.2. X tr.
- Nu bung i th hai b v t ngt, thai tr thnh ngi vai, t cung bp cht vo thai:
phi phu thut ly thai.
- Sau b t cung chy mu: phu thut ct t cung cp cu nu cc phng php
cm mu thng thng khng kt qu.
- Nu nghi ng st rau: phi kim sot t cung ngay.

| 173
FORCEPS

Tuyn p dng.
C s y t t huyn tr ln.
Ngi thc hin.

Lm forceps l th thut dng km kp cp vo u thai nhi ko ra ngoi m h.

1. Ch nh.
1.1. V pha m.
- M mt, rn khng s.
- M c chng ch nh cho rn: bnh l ni khoa (tim, phi, thn, thn kinh), t cung c
so m c, tin sn git nng, sn git...
- Tng sinh mn rn, khng gin n.
1.2. V pha thai.
- Thai suy.
- Forceps u hu trong ngi mng.
2. iu kin.
- u lt thp.
- C t cung m ht.
- i v hoc phi bm i trc khi lm.
3. Chun b.
3.1. Cn b chuyn khoa: y s, bc s chuyn khoa ph sn
- Khm li ton thn, t vn cho ngi m v gia nh.
- Ra tay, mc o, i m, eo khu trang, eo gng c tit khun nh lm phu
thut.
3.2. Phng tin.
- B forceps, b dng c v b khu tng sinh mn, b kim tra c t cung.
- Cc phng tin hi sc s sinh.
3.3. Sn ph.
- t sn ph t th sn khoa, m rng hai i.
- ng vin sn ph nm yn, th u, khng rn.
- St khun rng vng m h, tng sinh mn.
- Thng i.
- Tri khn v khun nh phu thut ng di.
- Nu m c ch nh forceps v bnh tim, tng huyt p, tin sn git th phi iu
tr ni khoa thch hp trc khi lm th thut.
174 |
- Nn gim au bng gy t ti ch hoc gy t ngoi mng cng hoc gy t ty sng.
- Ch rn khi hai bu nh ra khi m h nu khng phi trng hp ch nh v
khng c cho sn ph rn.
- Theo di mch, huyt p, chy mu.
4. Cc bc tin hnh.
Xc nh ngi, th, kiu th, lt v iu kin lm forceps.
Th 1: t hai cnh forceps.
- Cnh t trc l cnh di. Thng l cnh tri, sau khi t giao cho ngi ph
gi.
- t tip cnh th hai, i xng khp vi cnh th nht. Nu cnh th hai khng
khp c vi cnh th nht cn t li.
Th 2: Khp cnh v ko.
- Khp hai cnh vi nhau.
- Ko t t theo c ch bng sc ca cng tay, tt nht trong cn co phi hp vi sc
rn ca ngi m, tr trng hp c chng ch nh rn.
- Ct tng sinh mn gia hai cnh forceps.
Th 3: Tho cnh forceps.
- Khi ng knh ln nht ca u thai nhi (lng nh) qua m h th ngng ko
tho cnh. Cnh t sau ly ra trc, cnh t trc ly ra sau.
- thai nhi nh thng.
- rau nh thng l bng phng php x tr tch cc giai on 3 ca chuyn d.
- Kim tra tn thng c t cung m o v tng sinh mn.
- Khu tng sinh mn v cc vt rch.
5. X tr tai bin.
- Rch m h, m o, c t cung: khu li.
- Nu nghi ng c tn thng t cung v on di: kim sot t cung xc nh
v phu thut ngay.
- Nu forceps do t cung c so m c: nn kim sot t cung.
- Khm s sinh ngay pht hin v x tr cc tai bin c th c (lit dy thn kinh, sang
chn no, chy mu mng no...).

| 175
GIC KO
Tuyn p dng.
C s y t t tuyn huyn tr ln.
Ngi thc hin.

Gic ko sn khoa l mt th thut sn khoa dng dng c to lc ht chn khng tc
ng ln u thai (ngi chm) ko thai ra ngoi.

1. Ch nh.
- Giai on hai ko di.
- Nghi ng suy thai (nc i c phn su).
- T cung c so m c (t tuyn tnh tr ln).
2. iu kin.
- Thai sng.
- Ngi chm.
- C t cung m ht.
- u lt thp.
- i v hay bm i.
3. Chng ch nh.
- M c bnh ni khoa khng c php rn (thay th bng forceps).
- Cc ngi khng phi ngi chm.
- Thai non thng.
- u c bu huyt thanh to.
- u cha lt thp.
- Suy thai.
4. Chun b.
4.1. Phng tin.
- My ht bm in hay bm tay, cc chp gic ko c to nh khc nhau, mt tay cm
ko, dy xch v cc ng cao su.
- B v ct khu tng sinh mn.
- Khn v khun.
4.2. Sn ph.
- T vn cho sn ph v gia nh.
5. Cc bc tin hnh.
- Ngi lm th thut ra tay, mc o, i m, eo gng v khun.
- St khun vng m h, tng sinh mn.
- Thng i.
176 |
- Kim tra li kiu th v lt ca ngi.
- Chp gic ko thch hp vi m ca c t cung. Thng khi c t cung m ht,
dng chp s 5 - 6.
- Cm nghing chp cho vo m o, t vo ngi thai. t chp vo vng chm khng
chm ln thp sau.
- To p lc m bng cch bm ti 0,2 kg/cm
2
, kim tra li chp gic ko ti ni bm.
- Nu ht phi phn mm hoc chp b knh th tho hi v t li.
Tng p lc ht n 0,7 - 0,8 kg/cm
2
th bt u ko khi c cn co t cung v phi
hp vi sc rn ca sn ph. Dy ko lun lun thng gc vi din chp, ko bng
sc ca cng tay. Ct tng sinh mn nu cn.
Khi h chm t vo khp v th ko ln cho u s. Sau tho hi t t, b chp
ra ngoi, cho sn ph rn tip mt hi, u thai nhi s s ra m h, nh bnh
thng.
Ch .
Thi gian bm ht hi cng nh lc x hi phi ko di 1 - 2 pht.
Theo di tin trin ca ngi sau mi cn co. Tng sinh mn phi gin sau ln ko
th 2.
Khng c ko lu qu 10 pht hoc qu 4 cn co.
Nu trong lc ang ko, gic ko b trt, ch t li chp mt ln na v khng
qu 1 ln.
- Rch thnh m o, c t cung: khu cm mu.
- Khm k thai nhi pht hin cc sang chn x tr.

| 177
BC RAU NHN TO

Tuyn p dng.
Tt c cc tuyn.
Ngi thc hin.
Bc s sn khoa hoc bc s c b tc v sn khoa; n h sinh, y s sn nhi.

Bc rau nhn to l th thut a tay vo bung t cung ly rau ra sau khi thai s.
1. Ch nh.
- Nu x tr giai on 3 ca chuyn d tht bi th phi bc rau (t tuyn huyn tr ln)
- Chy mu trong thi k s rau khi rau cn trong t cung (c thc hin x tr ln).
- Nhng trng hp cn kim tra s ton vn ca bung t cung sau khi s thai.
Ch : Sn ph ang chong, phi hi sc ri mi bc rau nhn to.
2. Chun b.
2.1. Cn b chuyn khoa.
Th thut vin ra tay n khuu, mc o, i gng v khun.
2.2. Phng tin.
- Thuc gim au s dng mt trong cc loi sau y:
Dolosal 0,10 g, hoc
Fentanyl 1 %, tim tnh mch chm 50 mcg (ni c bc s), hoc
Diazepam 5 mg/ml, tim tnh mch chm (ni c bc s).
- Thuc tr tim, hi sc dng khi cn.
2.3. Sn ph.
- c t vn trc khi lm th thut.
- Thng i, st khun tng sinh mn, m o, tri khn v khun.
- Gim au.
3. Cc bc tin hnh.
- Khng sinh d phng ung hoc tim.
- a tay vo t cung ln theo dy rn ti vng rau bm, dng b trong ca bn tay tch
bnh rau khi thnh t cung. Nu bn tay khng a c vo bung t cung, th thut
vin nn ch mt lt, cho thuc gim co (2 mg glycerol trinitrat di li) ri dng tay
nong t t vo bung t cung.
- Tay trn bng c nh y t cung.
- Khi rau bong ht th tay trong t cung y bnh rau ra ngoi.
- Sau khi bc rau nhn to phi kim sot bung t cung ngay.
- Thuc co t cung: oxytocin 5 v, tim bp hoc tim tnh mch hoc/v
Ergometrin 0,2 mg, tim bp hoc.
Misoprostol 200 mcg ngm di li 1 - 2 vin hoc t hu mn 3 - 4 vin.
178 |
- Nu khng bc c bnh rau v rau bm cht hoc rau ci rng lc th khng c
c sc bc, phi chuyn phu thut ct t cung.
4.1. Theo di.
- Mch, huyt p, ton trng v phn ng ca sn ph.
- Co hi t cung v lng mu chy t t cung ra.
4.2. X tr.
- Chong do au hoc do mt mu (tham kho bi Chong sn khoa).
- Gi cho t cung co tt (tham kho bi Chy mu sau )
- Nu t cung vn khng co d dng thuc co t cung cn kim sot t cung li
ly ht mu cc v rau st.
- Nu mu tip tc chy trong khi t cung co tt phi kim tra tn thng c t cung
v m o.
- Cn cho khng sinh iu tr nu nghi ng c nhim khun.

| 179
KIM SOT T CUNG

Tuyn p dng.
Tt c cc tuyn.
Ngi thc hin.
Bc s sn khoa hoc bc s c b tc v sn khoa; n h sinh, y s sn nhi.

Kim sot t cung l th thut tin hnh sau khi rau s hoc ngay sau khi bc rau
nhn to kim tra xem c st rau hoc st mng v s ton vn ca t cung.
1. Ch nh.
- Chy mu sau khi s rau (c lm tuyn x).
- St rau, st mng.
- Kim tra s ton vn ca t cung.
- T cung c so m c.
Ch : Sn ph ang chong, phi hi sc sau mi kim sot t cung.
2. Chun b.
Ngi lm th thut phi ra tay phu thut, i m, eo gng, mc o v khun.
Phng tin
Tham kho bi Bc rau nhn to.
Sn ph
Tham kho bi Bc rau nhn to.
3. Cc bc tin hnh.
- a tay vo bung t cung ti tn y t cung, ri kim tra ln lt: y t cung, mt
trc, mt sau, hai b v hai sng t cung bng cc u ngn tay. Mt tay t trn
bng c nh t cung. Nu thy cc mnh rau v cc mng rau th vt nh nhng,
ng thi kim tra xem t cung c b rn nt khng. Kim tra xong mi rt tay ra,
trnh a tay ra nhiu ln.
- Sau khi kim sot nu t cung co hi khng tt th tay trong bung t cung nng y t
cung ln st thnh bng, dng tay bn ngoi xoa bp t cung ti khi t cung co cht th
mi rt tay ra.
- Thuc: tham kho bi Bc rau nhn to.
(Tham kho bi Bc rau nhn to).

180 |
PHU THUT LY THAI

Tuyn p dng.
Tuyn huyn c iu kin phu thut tr ln.
Ngi thc hin.
Bc s chuyn khoa sn, bc s c b tc v sn khoa.

Phu thut ly thai l phu thut nhm ly thai ra khi t cung sau khi m bng v m
t cung.

1. Chun b.
1.1. Sn ph.
- c gii thch y l do phu thut ly thai, k giy cam oan phu thut.
- Thng i, st khun thnh bng, tri khn v khun sau khi c gim au.
1.2. Kp phu thut.
- Phu thut vin, ngi gy t ty sng cng cc tr th v dng c vin thc hin ra
tay ngoi khoa, mc o, khu trang, i gng v khun.
1. 3. Gim au.
- Gim au vng (gy t ty sng hay gy t ngoi mng cng) l u tin. C th gy m
ni kh qun khi gim au vng c chng ch nh.
- Khng khuyn co gy t ti ch hay gy m tnh mch.
2. K thut phu thut ly thai.
- M bng: m bng theo ng ngang trn v hay ng trng gia di rn.
- M phc mc on di t cung theo ng cong lm quay ln trn. Bc tch v y
phc mc pha bng quang xung di.
- M t cung ngay gia (lu trnh chm vo phn thai ngay di). M rng vt
rch t cung sang hai bn. ng m t cung song song vi ng m phc mc on
di.
- Ly thai: ly u thai nu l ngi u, ly chn thai hay mng thai nu l cc ngi cn
li.
- Kp dy rn, tim 1 liu khng sinh d phng.
- Tim tnh mch chm 10 v oxytocin. Ly rau bng cch ko dy rn v n y t
cung qua thnh bng. Lm sch bung t cung. Nong c t cung nu cn.
- Khu phc hi lp c t cung bng ch tiu s 1. C th bng mi ri hay khu vt c
kha hay khng c kha. Mi khu ly ton b chiu dy lp c t cung. Khng nn
khu c lp ni mc t cung. Thng thng khu mt lp l . Nu cn th khu vt
lp th hai cm mu v che ph lp khu th nht.
- Ph phc mc on di t cung hay lp phc mc l thnh khi c nguy c nhim
khun.
- ng bng theo tng lp.
| 181
3. Sn sc sau phu thut.
3.1. Theo di sau phu thut.
- Mch, huyt p, ton trng, bi tit nc tiu.
- Co hi t cung, lng mu chy t t cung ra.
- Vt m thnh bng.
- Trung tin.
3.2. Chm sc.
- Cho thuc gim au sau phu thut.
- Cho sn ph ung, n sm (ung, thc n lng khi cha trung tin, n bnh thng khi
c trung tin).
- Vn ng sm.
- Cho con b sm.
- Khng sinh iu tr (nu cn).

182 |
PHU THUT THAI NGOI T CUNG
Tuyn p dng.
Tuyn huyn c iu kin phu thut tr ln.
Ngi thc hin.
1. Chun b.
1.1. V cm.
Nn gy m ni kh qun.
1.2. Phng tin, dng c.
- B phu thut (phu thut m hoc ni soi).
- Cc loi dch truyn thay th mu v thuc hi sc.
- Dng c truyn mu hon hi v mu cng nhm.
1.3. Sn ph.
- c t vn v l do phi phu thut v nguy c c th xy ra, k cam oan phu
thut. Nu ngi bnh chong nng c ngi nh k thay.
- V sinh vng bng, thng tiu, st khun vng phu thut.
- Tin m, hi sc tch cc nu chong.
1.4. Kp phu thut.
- Bc s ngoi khoa hoc chuyn khoa sn.
- Bc s gy m hi sc v kp phc v phu thut.
- Ra tay, i m i gng v khun.
2. K thut.
- M bng (ht mu nu thai ngoi t cung v (truyn mu hon hi nu c th).
- Cch thc phu thut:
Cha vi t cung:
Ct vi st t cung.
Bo tn vi t cung (nu khi thai cha v): m b t do ca vi t cung, ly
khi thai, cm mu.
Nu cha gc t cung hoc k t cung: ct gc t cung.
Cha bung trng: ly khi thai khu cm mu.
Cha trong bng: ly khi thai, li bnh rau.
Cha ng c t cung: ct t cung hon ton (nu pht hin sm c th iu tr ni
khoa.)
- ng bng.
3. Chm sc hu phu.
- Trong 3 gi u phi theo di mch, huyt p, nhit , nhp th (ch s sinh tn) ti
phng hi sc.
- Dng khng sinh liu d phng hay iu tr ty tnh trng ngi bnh.
4. Bin chng.
- Nhim khun: iu tr khng sinh tch cc.
- Nu chy mu sau phu thut, hi chn phu thut ngay.
| 183
K THUT H TR SINH SN
Tuyn p dng.
Tnh/thnh ph, trung ng.
Ngi thc hin.
Cn b y t c o to, c chng ch v lnh vc h tr sinh sn.

1. iu kin cn thit thc hin k thut h tr sinh sn.
- Phi c cc xt nghim, thm d c bn v v sinh.
- Chn on c nguyn nhn v sinh.
- Phi c bn cam kt ca ngi bnh.
- C trang thit b.
- C s y t thc hin k thut th tinh trong ng nghim phi c B Y t thm nh
v cp giy php.
2. Ch nh.
2.1.Bm tinh trng vo bung t cung (IUI), ch p dng khi vi t cung thng.
- Bt thng v phng tinh.
- Do c t cung.
- Tinh trng t, yu.
- C khng th khng tinh trng.
- V sinh khng r nguyn nhn.
- Ri lon phng non, bung trng a nang.
- Lc ni mc t cung th nh v va.
- Bm tinh trng ca ngi cho.
2.2.Th tinh trong ng nghim (IVF), bm tinh trng vo bo tng non (ICSI), ly
tinh trng mo tinh (PESA) dnh cho nhng trng hp:
- Tc hai vi t cung.
- Do tinh trng.
- Tc ng dn tinh.
- IUI nhiu ln khng kt qu.
- V sinh khng r nguyn nhn.
3. Chng ch nh.
- C s y t cha iu kin thc hin k thut h tr sinh sn.
- Ngi ph n b bnh khng c php mang thai.
4. Cc phc p dng trong th tinh trong ng nghim.
Cc ngn, ngn, di v cc di. Chn phc ph thuc vo:
- Tui.
- Tin s kch thch bung trng
- Trng lng c th.
184 |
- Siu m nang s cp.
- Xt nghim ni tit ngy 2 hoc ngy 3 ca chu k kinh.
5. Cc tai bin c th xy ra.
- Qu kch bung trng.
- Chy mu trong.
- Nhim khun.
- Thai ngoi t cung.
- Cha a thai
6. nh gi kt qu.
- C thai.
- a thai, nu c ch nh gim thiu th thc hin khi thai c 7 tun.
7. Mt s k thut c php thc hin.
Xin non, xin tinh trng, xin phi.
- N b suy bung trng: xin non.
- Nam khng c tinh trng: xin tinh trng.
- Do c hai: xin phi.
- Phi c bn cam kt ca ngi nhn v ngi hin. Nhng c hai bn u khng c
bit v khng c tip xc vi nhau.
8. Mang thai h
- Lut php Vit Nam cm.

| 185

G
PHN KHC

186 |
| 187
CHC D TI CNG SAU V M TI CNG SAU

Tuyn p dng.
Tuyn huyn c kh nng phu thut tr ln.
Ngi thc hin.
Bc s chuyn khoa sn.

1. Chc d ti cng sau.
L mt th thut nhm xc nh ti cng Douglas c dch, mu hay m.
1.1. Ch nh.
- Nghi thai ngoi t cung v.
- Ly dch bng lm xt nghim.
- Nghi c p xe phn ph hoc p xe Douglas.
1.2. Chun b.
- Ngi bnh:
T vn: cho ngi bnh bit cc bc tin hnh.
ng vin, h tr tinh thn, v sinh c quan sinh dc ngoi v i tiu tin.
- Dng c:
B khm ph khoa.
Cc dung dch st khun.
Lidocain, nc ct.
Bm tim 10 - 20 ml, kim chc d ty sng.
- Nhn lc: nn c ngi ph cho ngi lm th thut.
1.3.K thut tin hnh.
- Ngi bnh nm theo t th ph khoa.
- St khun rng vng m h.
- t m vt (c th dng van m o) tip tc st khun phn trong m o v ti cng
sau.
- Dng km Pozzi kp mp sau c t cung, ko nh theo hng ra ngoi v ln trn, bc
l ti cng sau m o.
- Lp kim vo bm tim.
- Chc nhanh kim vo ti cng sau di mp sau c t cung (thng khng cn phi
gy t)
- Ko nng bm tim t t ht dch ti cng Douglas. Nu:
Ht ra c mu en long, khng ng, c th l chy mu trong do thai ngoi t
cung.
Ht ra c mu nhng bn ngoi mt lc th ng, c th chc vo mch
mu. Nu cn c th chc li ln na theo hng khc.
Ht ra dch vng, trong v khng phi mu. C th l thai ngoi t cung cha v
hoc vim t cung.
188 |
- Nu ht ra m, th lu kim li ti ch, tin hnh m ti cng dn lu m v gi xt
nghim.
2. M ti cng sau.
M ti cng sau m o l phu thut rch nim mc m o vo phc mc lm cho m
o thng vi bng.
2.1. Ch nh.
- Dn lu ti m phn ph hoc p xe Douglas.
2.2. Chun b
- Ngi bnh:
ng vin, h tr tinh thn, v sinh khu vc c quan sinh dc ngoi v i tiu tin.
Tht tho phn
Khm hai tay phi hp xc nh khi m: v tr, kch thc. C th lm siu m
xc nh cc tnh cht ca khi m.
- Dng c:
B khm ph khoa.
Cc dung dch st khun (betadin), kp Kelly to, kp Allis, ko, dao phu thut,
gc, gc di, ng dn lu bng nha c ng knh t 1 - 1,5 cm.
Bm tim 10 - 20 ml, kim chc d ty sng, lidocain, nc ct.
- Nhn lc: cn c hai ngi.
2.3. K thut tin hnh.
- Ngi bnh nm theo t th ph khoa.
- St khun rng m h, tri khn phu thut.
- t van m o, tip tc st khun phn trong ca m o v ch ti cng sau.
- Dng km Pozzi kp vo mp sau ca c t cung ko nh ra ngoi v ln trn, bc l
ti cng sau ca m o.
- Gy t ti ch vi lidocain ti v tr chc, c trng hp phi gy m ton thn.
- Chc kim vo ti cng sau pha di mp sau c t cung, nh nhng a kim vo
m, va a vo su va ht. Khi ht c m th gi nguyn v tr kim lm mc
rch.
- Dng kp Allis kp vo nim mc ca m o (vo vng nh rch) to mt np gp
dc trc - sau.
- Dng ko hay dao phu thut ct hay rch st vo b trn ca kim.
- Dng ko u t khp kn a vo l rch, v rt ra t th m. u mi ko s
lm cho l rch rng hn, m chy ra. C th dng u ngn tay ph v nhng ngc
ngch ca p xe, ng thi n t cung qua thnh bng m chy ra ngoi.
- a ng dn lu qua vt rch, c nh vo pha ngoi ca thnh m o.
- Rt ng dn lu khi khng cn m chy ra.

| 189
TUI MN KINH
Tuyn p dng.
Ngi thc hin.
Cn b cung cp dch v.

1. Khi nim.
Mn kinh l hin tng sinh l bnh thng ca ngi ph n xy ra khi nng
estrogen gim. Tui mn kinh bao gm thi k trc, trong v sau mn kinh.
- Tui trung bnh t 48 - 52 tui.
- Kinh nguyt bt u thay i, thng biu hin kinh t v tha nhng cng c khi kinh
nhiu, kinh mau do khng c progesteron nn nim mc t cung tng sn.
2. Chn on.
Mn kinh c chn on ch yu da trn lm sng, khi mt ph n t trc vn c
kinh u mi thng li t nhin ngng, khng c kinh trong 12 chu k lin tip.
Khi mt ph n cn tr (di 40 tui m v kinh lin tip 12 thng) hoc mt ph n
b ct t cung m c mt s cc triu chng c nng ca mn kinh, mun chn on l
mn kinh cn lm cc xt nghim nh lng ni tit bung trng v tuyn yn, nu:
o FSH 40 mIU/ml.
o Estradiol thp, khong di 50 pg/l.
th c th xem ngi ph n y mn kinh.
Mn kinh thng l t nhin, nhng cng c th do phu thut ct b hai bung trng
v bnh l, do x tr.
3. Triu chng c nng thng gp khi mn kinh.
3.1. Ri lon kinh nguyt.
- Ri lon kinh nguyt thng gp nht l rong huyt. Nguyn nhn gy rong huyt
thng l do khng phng non.
- Ni mc dy ln c th tin n hin tng tng sn ni mc t cung. Mt s trng
hp tng sn ni mc t cung c th tin trin thnh ung th ni mc t cung.
3.2. Ri lon vn mch.
Cn bc nng mt.
- Thng xy ra t ngt, t nhin cm thy bc nng mt, c, ngc.
- Cn bc nng xy ra chng vi pht, c th ngn hn, ch vi giy, nhng thng km
theo triu chng v m hi. Thng cc cn bc nng hay xy ra vo ban m hoc
trong khi c stress
- Triu chng ny thng ko di 6 thng n vi nm, c th 2 - 3 nm nhng cng c
ngi n 5 nm.
V m hi.
- C th km theo cn bc nng mt hay xy ra n l.
- V m hi cng thng xy ra vo ban m nn gy mt ng, kh chu.
190 |
3.3. Triu chng thn kinh tm l.
- Hi hp, mt mi, kh chu.
- Mt ng, gim cm gic khi quan h tnh dc hay lo lng, cu gt, trm cm.
- au nhc xng khp, c th xut hin cn au nhc na u (migrain).
3.4. Triu chng tit niu - sinh dc.
- m o kh teo, giao hp au, d b vim, nhim khun, khm m o thy nim mc
mng, kh, nht nht.
- Cc dy chng gi t cung v cc c quan vng chu mt tnh n hi v sc cng nn
d a n sa sinh dc.
- T cung v c t cung teo nh. Ni mc t cung mng, khng cn c hin tng phn
bo hay ch tit, rt t mch mu.
- Nim mc ng tit niu cng teo mng, d nhim khun tit niu, sn tiu hay i
dt, tiu khng t ch.
4. Mt s bnh l thng gp khi mn kinh.
4.1. Long xng.
- Dn n d gy xng c tay, c xng i, cng lng, au lng.
Nhiu yu t lm tng nguy c long xng v gy xng cho ph n tui mn kinh nh:
- Tui cao, ngi nh b, gy g.
- Yu t di truyn rt quan trng.
- Ung nhiu thuc corticoid trong thi gian di.
- Ch dinh dng thiu calci, vitamin D3.
- Ru, thuc l, t vn ng, thiu estrogen.
d phng long xng tui mn kinh, cn:
- C ch dinh dng v b sung calci t khi cn tr, nht l trong lc c thai v
cho con b t c mt xng ti a vo khong tui 25 n tui 30.
- Khng ung ru, ht thuc, khng ung nhiu c ph, khng s dng cc loi
corticoid thng xuyn.
- Thng xuyn tp th dc, lao ng chn tay.
- Ph n mn kinh c nng estrogen thp, cn xem xt b sung ni tit.
- T khong 50 tui tr ln, mt xng gim nhiu. Do , i vi ngi c mt
trong nhng yu t nguy c cao, cn o mt xng mi nm.
4.2. iu tr long xng: cn iu tr ko di, 2 - 3 nm.
Cn c ch dinh dng hp l, tp th dc v lao ng chn tay nh nhng mi
ngy, cung cp y calci cho c th. i vi ph n mn kinh, lng calci cn thit mi
ngy khong 1200 - 1500 mg.
4.3. Bnh tim mch.
Mt s yu t lm tng nguy c bnh tim mch:
- Bo ph, cholesterol trong mu cao, tng huyt p, tiu ng, ht thuc l.
- t vn ng.
- Thn kinh thng xuyn cng thng.
- C tin s gia nh.
| 191
- Ung thuc vin trnh thai liu cao trn 10 nm.
- Thiu ht estrogen do mn kinh.
4.4. Bnh Alzheimer.
- L mt qu trnh thoi ha t bo thn kinh, lm gim chc nng no b.
- Khong 40 % ngi trn 80 tui mc bnh ny.
- Sau tui 70, t l mc bnh ca ph n gp 3 ln nam gii.
- Ngi mc bnh Alzheimer phi sng l thuc vo ngi khc.
4.5. Mt s ung th thng gp nh ung th c t cung, ung th nim mc t cung,
ung th v.
Cn i khm nh k pht hin sm cc ung th trn (xem bi Ung th c t cung,
ung th v).
5. Chn on.
- mt ph n t 45 - 52 tui ang hnh kinh, t nhin khng c kinh 12 thng lin
tip, c mt s triu chng c nng ca mn kinh, c th ngh n hi chng mn kinh.
- Nu ngi ph n di 40 tui khng cn hin tng kinh nguyt na, c th cho lm
xt nghim nh lng FSH v estradiol. Nu FSH > 40 mIU/ml v/hoc estradiol <50
pg/l c th chn on mn kinh.
Hi tin s: bn thn, gia nh: v long xng, tim mch, cc bnh ung th.
5.1. Xt nghim
- Cholesterol ton phn, triglycerid, HDL, LDL, lipoprotein.
- Chc nng gan, thn, in tim.
- Chp v.
- Sng lc ung th c t cung, ni mc t cung bng t bo m o - c t cung, soi c
t cung, no sinh thit nim mc t cung, o mt xng.
5.2. iu tr: ni tit v t vn cho ngi bnh.
Nguyn tc s dng ni tit.
Liu thp nht c hiu qu.
- Thi gian s dng ty thuc vo th trng v yu cu tng ngi.
- Phi hp estrogen/progestogen nu cn t cung.
Chng ch nh s dng tit.
- C ung th hay nghi ng ung th.
- C thai hay nghi ng c thai.
- C khi u lin quan n ni tit.
- b vim tc tnh mch hay ng mch.
- ang b xut huyt m o bt thng cha chn on c nguyn nhn.
T vn v ch dinh dng, sinh hot, mi trng sng trong gia nh v ngoi x hi.

192 |
KHM PH KHOA

Tuyn p dng.
Tt c cc tuyn.
Ngi thc hin.
Cn b cung cp dch v.

Khm ph khoa l th thut c thc hin trong nhiu dch v chm sc sc khe
sinh sn, c bit trc khi cung cp cc dch v k hoch ha gia nh, chn on v iu
tr cc bnh ph khoa ni chung v NKSS/ LTQTD ni ring. Khm ph khoa bao gm
cc bc chnh: chun b, khm bng v bn, khm b phn sinh dc ngoi, khm m o
bng m vt v khm m o phi hp vi nn bng (khm bng hai tay), trong hai th
cui cng ch c thc hin nu c th tip cn c bng ng m o, nu khng th
c th thay th bng khm trc trng phi hp vi nn bng.
1. Chun b.
- T vn trc khi khm.
- Chun b khch hng:
Hng dn khch hng i tiu v v sinh b phn sinh dc
Hng dn khch hng b qun v gip ln bn khm.
- Chun b dng c: bn khm hoc ging, n chiu sng, m vt, km kp bng, bng
v khun, que ly bnh phm, ng nghim, lam knh, cc dung dch nc mui sinh l,
acetic 3 %, Lugol v du bi trn.
- Chun b cn b y t: mc o chong, i m
- Hi v tin s v l do n khm:
L do n khm.
Hi v ngh nghip chng/khch hng.
Tin s sn ph khoa.
Tin s bnh tt chung.
- Ra tay thng qui.
2. Khm.
2.1. Khm vng bng di v vng bn.
- Hng dn khch hng nm t th sn khoa.
- Bc l ton b vng bng.
- Nhn bng: pht hin so phu thut, dch c chng, tun hon bng h.
- Dng mt trong ca bn tay n nh nhng cc vng ca bng, xc nh xem c khi u
khng. Nu c cn xc nh v tr, kch thc, mt , di ng, au.
- Nu c au bng, cn xc nh im au, phn ng thnh bng.
- Nu c vt lot vng bn, i gng mi hay gng c kh khun mc cao c hai
tay trc khi khm. S nn c hai bn xc nh hch, khi u hay sng.

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2.2. Khm b phn sinh dc ngoi.
- Hng dn khch hng gt chn ln gi gt chn, tri sng.
- iu chnh nh sng chiu thng vo vng b phn sinh dc.
- i gng sch vo c hai tay.
- t tay vo mt trong i ngi bnh trc khi chm vo bt k ch no ca b phn
sinh dc.
- Kim tra vng mu, m vt v vng tng sinh mn.
- Khm hai mi ln, mi nh, m vt, l niu o, l m o (m mn) v cc tuyn tit
dch. Nu nghi c vim nhim th cho xt nghim cht dch.
- Hng dn ngi bnh rn mnh trong khi vn m m mn kim tra xem c sa
thnh trc hay sau ca m o khng.
- Nhn k vng tng sinh mn, kim tra xem c so, tn thng, vim nhim hay c try
trt trn da khng.
2.3. Khm bng m vt.
- Gii thch cho khch hng s dng m vt khm.
- a m vt vo su trong m o, m m vt. Quan st cc thnh m o.
- Quan st c t cung, l c t cung pht hin tn thng.
- Ly bnh phm t bo c t cung bng que bt Ayre, pht ln lam knh xt nghim
sng lc ung th c t cung (nu sn c xt nghim).
- Nu c t cung d chy mu hay c nhiu cht nhy, ly mt mu nhum gram v
xt nghim lu cu v Chlamydia (nu sn c xt nghim).
- Tho m vt v ngm vo dung dch clorin 0,5 % kh nhim.
2.4. Khm m o phi hp nn bng (khm bng hai tay).
- Khm c t cung, t cung v hai phn ph bng hai tay xc nh v tr, mt , kch
thc, t th, hnh dng, cc ti cng m o.
- Nu c khi u, cn xc nh:
V tr.
Hnh dng.
Kch thc.
Mt .
au.
Lin quan vi t cung.
2.5. Khm trc trng phi hp nn bng.
Th ny ch thc hin nu khng tip cn c bng ng m o hoc bnh cnh c
th i hi phi nh gi thm bng khm trc trng (nh khm ung th ph khoa).
- Khm di, kch thc, hnh dng ca c t cung. Xc nh v tr, mt ca c t
cung.
- Khm ti cng Douglas.
- Xc nh, nh gi mt dy chng ngang c t cung.
2.6. Hon thnh khm ph khoa.
- Thng bo kt qu khm cho khch hng v tho lun vi h v kt qu khm.
- Ghi chp h s.
- Hn ti khm.
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KHM V

Tuyn p dng.
Tt c cc tuyn.
Ngi thc hin.
Bc s chuyn khoa ph sn, bc s c b tc v ph sn; n h sinh, y s sn nhi
c o to.

Khm v c thc hin trong nhiu dch v chm sc SKSS. Khm v kt hp t vn
hng dn t khm v gip pht hin cc bnh l tuyn v v pht hin sm ung th v.

1. Chun b.
1.1. Khch hng.
- Tip n.
- Hi l do n khm.
- Gii thch v cc bc khm.
- Khai thc bnh s, tin s.
1.2. Dng c.
Gng tay sch.
2. Khm v.
- Khm hai t th: ngi v nm.
- Quan st cc nm v v ton b v pht hin cc bt thng.
- Nn tuyn v hai bn theo nguyn tc xon c t ngoi vo trong bt u t phn trn
ngoi, s dng k thut xon c.
- Nn nh nm v xem c tit dch khng.
- Hng dn khch hng ngi dy v gi hai tay ngang vai. Khm v bng cch n nh
dc theo b ngoi ca c ngc v dn a tay ln n nch. Kim tra xem c sng
hch hay au trong nch hoc vng h trn xng n.
- Sau khi khm xong, khch hng mc o, gii thch mi s bt thng, nhng iu
cn lm thm; nu kt qu khm l bnh thng, thng bo cho h l mi th u bnh
thng v hn khm ln sau.
3. Hng dn t khm v.
- Gii thch vi khch hng l do cn phi t khm v thng xuyn rt quan trng.
- Thi gian khm tt nht l ngay sau khi sch kinh.
- Hng dn cc bc ca t khm v trn m hnh.

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CC BNH LNH TNH TUYN V

Tuyn p dng.
Tt c cc tuyn.
Ngi thc hin.
Bc s chuyn khoa ph sn v bc s c b tc v ph sn.

Cc bnh lnh tnh ca v c phn chia theo cc nhm: au v, u x tuyn v, u nang
tuyn v, tit dch v, p xe v, ri lon tit sa, u v lnh tnh.
i vi tuyn x ch khm pht hin v chuyn tuyn trn, iu tr p dng t tuyn
huyn tr ln.
Cc bnh lnh tnh tuyn v thng c triu chng au v. C th au theo chu k hoc
khng theo chu k, ngi bnh thng c cm gic nng, cng v trong tun trc khi
hnh kinh v mt i sau khi thy kinh, c coi l au v c chu k. au v khng theo
chu k c th kt hp vi gin ng tuyn, c pht hin qua chp v.

1. Hoi t m m.
- Thng gp sau chn thng, hoc tn thng do sinh thit, c th gp khi cng, co
ko nm v. Phi sinh thit loi tr ung th v.
- iu tr: phi chch ly khi hoi t, c th kt hp vi cc thuc ni tit nh danazol:
200 mg x 2 vin/ngy, tamoxifen 100 mg x 2 vin/ngy, m progestogel bi v t ngy
12 n ngy 25 ca chu k kinh.
2. U x tuyn v.
- L khi u c v bc, c th gp mt hoc hai bn v. Thng l khi u cng, di ng
v c kch thc to nh khc nhau.
- iu tr: bc khi u.
3. U philoid: l loi u tuyn x vi lp m pht trin nhanh, d ti pht.
- iu tr ct khi u, v khi u to d ti pht nn ct b v.
4. X nang tuyn v.
L khi u khu tr hoc lan ta, mt mm, gp ph n trong tui sinh hoc
tin mn kinh.
- Nguyn nhn do mt cn bng ni tit.
- Chn on: s thy cc khi mm xut hin vo na sau ca chu k kinh, c th c
hai bn v, chc t bo loi tr ung th.
- iu tr: vitamin E 400 v/ngy.
5. Bnh nang tuyn v.
Thng gp ph n tui 35 - 50, rt him gp ph n tr <25 tui. Nang thng l
nhng khi ring r, di ng, mt cng. Chc ht dch nang c mu vng chanh hoc
nu. Nu dch ht ra l mu th phi sinh thit sau ht dch loi tr ung th, sau chc ht
nu nang ti pht th phi ht li v iu tr phu thut bc nang.
196 |
6. Cc bnh c tit dch nm v.
Tit dch nm v ngoi thi k nui con b c th do cc nguyn nhn sau:
Gin hoc x nang ng tuyn.
Tng tit sa kt hp vi v kinh, v sinh.
Papilloma ng tuyn.
Ung th v.
- Khm lm sng cn lu : mu sc dch tit (trong, ln mu, hoc c mu khc) c km
theo khi u, c nhiu tia hay mt tia, dch ra lin tc hay tng t, ra t nhin hay vt,
dch ra c lin quan vi k kinh, c ung thuc trnh thai hay ung estrogen
- X tr ty theo tn thng
7. Vim tuyn v v p xe v.
- Tham kho bi St sau .
8. V bt thng: c th gp nhng trng hp v teo, v km pht trin hoc ph i
tuyn v, cn phu thut to hnh.

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CC TN THNG LNH TNH C T CUNG

Tuyn p dng.
Tt c cc tuyn.
Ngi thc hin.
Bc s chuyn khoa ph sn, bc s c b tc v ph sn.

Vim nhim ng sinh dc di l bnh hay gp ph n trong tui sinh trong
vim m o, c t cung chim t l cao. Triu chng thng gp l ra kh h lm cho
ngi bnh kh chu phi i khm.

1. Vim c t cung.
Nguyn nhn: thng do lu cu, xon khun giang mai, vi khun gy bnh h cam,
Chlamydia trachomatis, herpes simplex virus, HPV (human papilloma virus), trichomonas.
1.1. Vim c t cung cp.
- Triu chng: ra kh h nh m mu xanh vng, c bt hay gp vim do trng roi
(trichomonas) km theo nga, rt, bi dung dch Lugol s thy mu nu sm, trn nn
nu c nhiu chm trng hay trng (hnh nh m sao) kh h trng bt, nga thng
vim do nm candida albican; kh h c mu xm gp trong vim do Chlamydia
trachomatis.
- X tr: theo nguyn nhn gy bnh.
Vim do trichomonas: metronidazol 2 g mt liu duy nht ung hoc 500 mg x 2
ln/ngy x 7 ngy kt hp t m o chng vim.
Vim do nm: fluconazol 150 mg x 1vin ung liu duy nht, kt hp t thuc ti
ch nh nystatin 1000 v x 10 ngy.
Vim do tp khun: metronidazol 500 mg x 2 vin/ngy x 7 ngy.
Vim do do Chlamydia: ung azithromycin 1 g, liu duy nht.
Vim do HPV: t in lm bc hi tn thng.
Vim do lu cu: xem bi Hi chng tit dch m o.
1.2 Vim c t cung mn tnh.
- Triu chng: ra kh h, thng kt hp vi l tuyn c t cung.
- X tr: t thuc chng vim nhim (nu cn).
2. L tuyn c t cung.
- L tn thng do vim lu ngy, mt biu m lt tng, mt ngoi c t cung b ph
hu, lp biu m tuyn ln ra ngoi.
- Khm qua m vt: thy vng biu m lt khng nhn bng m s s mu c lp kh
h c bao ph, bi acid acetic 3 % cc cht nhy ng li khi soi c t cung thy hnh
nh chm nho, bi Lugol khng bt mu (m tnh).
- X tr: t dit tuyn nu din l tuyn rng trn 0,5 cm bng t in hoc p lnh.
Nu c vim km theo th t thuc chng vim trc khi x tr.

198 |
3.Cc ti to lnh tnh c t cung.
- Nang Naboth: mu vng nht ni g ln, trn mt c cc mch mu trong nang cha
dch nhy do biu m lt ph ln ming tuyn nhng tuyn vn ch tit.
- Ca tuyn: l cc tuyn sau iu tr biu m lt bao quanh mt ming tuyn.
- o tuyn: l biu m lt bao quanh mt s tuyn.
- y l nhng ti to lnh tnh nhng trong qu trnh ti to biu m lt vn vn c th
c nhng ti to bt thng nn vn cn phi theo di.
- X tr: t thuc chng vim, t hoc chc ht nang Naboth.
4. Polip c t cung.
- L cc tht c cung mc ln t ng c t cung (c th t thn hoc t on eo t cung
th ra ngoi)
- X tr xon polip nu c th xon c, phi thm d chn polip nu chn polip mc
ln t bung t cung th phi soi bung t cung ct polip.
5. Lc ni mc t cung: l nhng nt mu xanh tm hay en sm, nh n c ri rc
quanh c t cung
X tr: t lc ni mc.
6. U x c t cung: thng l u li ra, chc, i khi che lp c t cung hoc lm xa c
t cung.
X tr: ct u x c t cung.

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U X T CUNG
Tuyn p dng.
Tuyn huyn tr ln (tuyn x: gi ngi bnh ln tuyn trn iu tr).
Ngi thc hin.
Bc s chuyn khoa ph sn hoc bc s c b tc v sn ph khoa.

U x t cung hay u x c t cung l khi u lnh tnh t cung, thng gp ph n
trong tui sinh t 30 - 50 tui.
1. Phn loi.
1.1. U x di phc mc.
C th c cung hay khng, thng pht trin v pha bng, h chu, hoc gia hai
l ca dy chng rng gy chn p vo niu qun, hay nhm vi u bung trng.
1.2. U k.
L khi u pht trin t phn gia ca c t cung, lm bin dng bung t cung.
1.3. U di nim mc.
L khi u x c di nim mc. i khi c cung gi l polip bung t cung.
2. Triu chng.
Thng pht hin khi i khm v l do: ri lon kinh nguyt, v sinh, chm c thai, ra
mu m o.
2.1. Triu chng c nng.
- Ra mu t bung t cung l triu chng chnh (nht l cc u x di nim mc) th
hin di dng cng kinh, rong kinh.
- Ton thn thng b thiu mu.
- au vng h v hoc h chu, au kiu nng bng, tc bng.
- Ra dch trong, long.
2.2. Triu chng thc th.
- Nn bng: thy khi u vng h v.
- t m vt: c th thy polip c cung nm ngoi c t cung.
- Thm m o kt hp nn bng thy t cung to, chc, c khi thy nhng khi li trn
mt t cung. Di ng c t cung th khi u di ng theo.
3. Chn on.
- Siu m thy hnh nh khi u t cung.
4. X tr.
- Ty theo kch thc khi u nu nh cha gy triu chng rong kinh, rong huyt th
khng cn iu tr theo di khm nh k hoc iu tr ni khoa.
- Nu khi u to km theo c triu chng rong kinh rong huyt th phu thut, ty theo
ngi bnh tr hay gi m quyt nh bo tn t cung hay ct t cung.
200 |
NANG BUNG TRNG

Tuyn p dng.
Tuyn huyn tr ln (tuyn x: gi ngi bnh ln tuyn trn iu tr).
Ngi thc hin.
Cc bc s chuyn khoa ph sn hoc c b tc v ph sn.

Nang bung trng l nhng u c v bc ngoi, bn trong c cha dch gp trong mi
la tui. C hai loi nang c nng v nang thc th.

1. Nang c nng.
L nhng nang nh cha dch, c th gp bt k tui no nhng hay gp tui dy
th v mn kinh. Thng l nhng nang nh, trn lm sng kh pht hin, nhng nu nang
c kch thc t 5 - 6 cm th c th s thy. Nang thng bin mt sau vi vng kinh, nu
nang tn ti trn 60 ngy vi kinh nguyt bnh thng th c th l nang thc th.
1.1. Nang bc non.
Kch thc nang thng t 3 - 8 cm hoc ln hn, do nang De Graff khng v vo ngy
phng non.
- Triu chng: khng r rng, i khi biu hin ra mu hoc au bng do xon nang
hoc thay i chu k kinh nguyt di, hoc ngn, c triu chng ging thai ngoi t
cung v (nu nang v).
- Chn on phn bit vi: vim vi t cung, lc ni mc t cung, nang hong th, khi
u khc.
- X tr: ty thuc vo loi nang, kch thc v triu chng.
i vi nang nh.
- Gp la tui sinh , nang thng t nhin mt i.
- Khi ung thuc trnh thai trong thi gian 3 thng c th ngn cn s pht trin ca
nang.
- Nu ng knh nang > 5 cm cn phn bit vi nang thc th hoc thai ngoi t cung
hoc lc ni mc t cung.
- Phu thut: c ch nh khi thy u nang tn ti trn 3 thng hoc sau khi iu tr bng
thuc trnh thai 3 thng khng mt hoc c du hiu xon hoc v nang.
1.2. Nang hong th:
Hay gp hai bn bung trng, dch trong nang c mu vng rm. Loi nang thng
gp trong cha trng, ung th nguyn bo nui hoc qu mn trong kch thch phng non
ngi bnh v sinh.
- X tr: nang thng bin mt sau iu tr nh no trng, iu tr ung th nguyn bo
nui.
- Phu thut ch t ra khi c du hiu xon nang hoc v nang (t tuyn huyn tr ln).
2. Nang bung trng thc th.
L nang lnh tnh, tuy nhin vn c kh nng c tnh
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2.1. Nang nc.
V mng, cha dch trong, kch thc thng to, i khi chan ht bng, thng l
nang lnh tnh, nu c nh d c tnh.
- Triu chng:
Gp mi la tui, hay c pht hin tui 20 - 30.
Khm tiu khung thy khi u, hoc siu m thy khi u.
- X tr:
Phu thut ct b nang. Trong khi phu thut nn ct lnh chn on loi tr ung
th. Vi tuyn huyn gi khi u ln tuyn trn lm gii phu bnh.
2.2. U nang nhy.
- Thng gp tui t 30 - 50.
- U nang nhy v mng v nhn gm nhiu thu cha dch nhy c, kch thc thng
to nht trong cc u bung trng v c th dnh vo cc tng xung quanh.
- Chn on: ngi bnh thng c cm gic nng tiu khung, khm tiu khung thy
khi u to bit lp vi t cung, mt cng khng au, t cung thng b y lch sang
mt bn h chu.
- X tr: nh vi nang nc.
2.2. Nang b.
- Cn gi l u qui (teratoma), trong cha cc m nh rng, tc, b u. Nang b thng
lnh tnh nhng cng c th tr thnh c tnh, hay c pht hin la tui 20 - 30
tui v c th c hai bn bung trng.
- Triu chng: khm lm sng v siu m thy khi u.
- X tr: ging vi nang nc bung trng.
3. Tin trin v bin chng.
3.1. Xon nang.
3.2. V nang.
3.3. Nhim khun nang v chn p tiu khung.
3.4. C thai km nang bung trng.
- c chn on qua khm thai nh k hoc qua siu m.
- C th gp bt k loi nang no nhng hay gp l nang hong th hay nang b, t khi
gp nang c tnh. Nu xon nang phi phu thut cp cu, nu khng xon th phu
thut vo qu II ca thai k hoc sau khi .
- U bung trng c th tr thnh khi u tin o trong khi chuyn d hoc c th b xon
sau khi . (tham kho thm bi Cc yu t tin lng mt cuc chuyn d v
Chuyn d nh tr)

202 |
TN THNG TIN UNG TH C T CUNG

Tuyn p dng.
Ngi thc hin.
Bc s chuyn khoa ph sn hoc bc s c o to v ph sn.

Ung th c t cung l bnh c tnh thng gp nht ng sinh dc n, ng th hai
sau ung th v.
Tui thng gp l 45 nhng c th gp mi la tui, ngay c khi mang thai. 95 %
ung th giai on sm c th cha khi.
Qu trnh sinh bnh hc thng di v tri qua nhng giai on ca khi u trong biu
m, tip sau l ung th xm ln. Qu trnh ny bin i trong nhiu nm nhng khng
phi tt c cc ung th xm ln u tri qua nhng giai on ny.

Tn thng tin ung th.
nh ngha: tn thng tin ung th cn gi l lon sn, ch s ri lon pht trin biu
m c t cung mt vng bt thng m trong mt phn biu m lt c thay th
bng nhng t bo bt thng. V mt t bo hc, lon sn thng c phn thnh cc
mc nh, trung bnh v nng.
Lon sn nh (LSIL, CIN1), lon sn trung bnh (HSIL, CIN2) v lon sn nng
(HSIL, CIN3) thng tin trin thnh ung th trong biu m.
Lon sn nh (LSIL, CIN1) c t l t thai trin cao, trn phin ch cha t t
bo lon sn nh phn ln l t bo nng.
Lon sn trung bnh (HSIL, CIN2) s lng t bo lon sn v mc bt thng
ca nguyn sinh cht v nhn gia tng. T bo lon sn xut pht t lp trn v lp
gia ca biu m lt bnh thng hoc biu m lt d sn, c th biu hin sng
ha.
Lon sn nng (HSIL, CIN3) cn gi l ung th trong biu m (CIS): l cc lon
sn c cc t bo bt thng lp su ca biu m lt.
c im ca t bo lon sn trn tiu bn l s phn b t bo ch yu n c, i
khi thnh mng c nhn ln r rt, t l nhn trn nguyn sinh cht tng mnh, nguyn
sinh cht mn.
Ung th trong biu m c cc t bo lon sn cha xm ln qua mng y.

1. Nhng yu t nguy c.
- Nhim HPV (human papilloma virus) typ 16, 18.
- Hot ng tnh dc sm di 16 tui.
- C nhiu bn tnh.
- Mc cc bnh LTQTD.
- Sinh sm.
- iu kin v sinh km.
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2. Chn on.
Tn thng tin ung th thng khng c triu chng lm sng i khi ngi bnh n
khm v ra kh h hoc v mt l do khc. chn on da vo t bo m o - c t
cung, soi c t cung, sinh thit.
Tuyn x.
- Bi acid acetic ln c t cung (test VIA: visual inspection with acetic acid) nu thy
tn thng trng ni r l test dng tnh th chuyn tuyn trn.
- Bi Lugol ln c t cung (test VILI: visual inspection with LugolIodine) c mu vng
ngh l test dng tnh th chuyn tuyn.
Tuyn huyn.
- Lm t bo m o - c t cung: biu m lt khng bnh thng t lon sn nh n
nng.
- Soi c t cung:
Tt c cc ngi bnh c t bo bt thng u phi soi c t cung.
C th thy tn thng vt trng, lt , chm y hoc mt tn thng hy hoi,
vng bin i gia biu m lt v biu m tr.
- Sinh thit c t cung:
Trn c s soi c t cung, bm sinh thit chn on xc nh.
y l phng php duy nht chn on xc nh v c quyt nh iu tr. Nu
soi c t cung thy tn thng trong ng c t cung th phi no nim mc ng c
t cung gi xt nghim m bnh hc.
3. iu tr.
- i vi cc tn thng tin ung th, phi c iu tr ngay sau khi chn on.
- Phng php iu tr c th l p lnh, t in, t bng laser, khot chp, ct ct c
t cung ty theo tn thng.
- i vi ngi ln tui vi tn thng CIN3 th nn ct t cung hon ton v hai phn
ph.
- D phng:
Khm sng lc t bo m o - c t cung nh k hng nm pht hin sm tn
thng tin ung th.
Tim vaccin phng HPV cho tr em gi t 10 tui n 26 tui (nu cha quan h
tnh dc).
204 |
UNG TH XM LN C T CUNG
Tuyn p dng.
Tuyn tnh tr ln.
Ngi thc hin.
Bc s chuyn khoa ph sn hoc bc s chuyn khoa ung th.

Ung th c t cung l bnh c tnh thng gp nht ng sinh dc n, ng th hai
sau ung th v.

1. Triu chng lm sng.
- Ung th c t cung xm ln giai on sm (hoc giai on Ib) thng khng c triu
chng, ch c pht hin bnh qua sng lc t bo hc.
- giai on mun gy xut huyt gia k kinh hoc sau giao hp, ra kh h hi ln
mu.
- Khi khi u ln v hoi t hoc di cn ti thnh chu, cc c quan khc ca vng
chu nh bng quang, niu qun, trc trng th cc triu chng nng hn c th gy
chn p v au vng tht lng, hoc au thn kinh ta, i ra mu.
- Ung th c t cung c chia ra 4 giai on:
I. Ung th khu tr c t cung, khng c triu chng.
II. Ung th lan ra khi c t cung nhng cha ti thnh chu hng, lan ti
thnh m o nhng cha ti 1/3 di.
III. Ung th lan ti thnh chu hng hoc ti 1/3 di m o.
IV. Di cn ti bng quang, trc trng v cc c quan xa.
2. Khm lm sng.
- Tnh trng ton thn, da nim mc c thiu mu.
- C hch bn, chn c th ph.
3. Khm ph khoa.
- t m vt: nh nhng trnh sang chn c t cung, nhn hnh dng v kch thc c t
cung.
- Khm bng tay qua m o, c t cung:
Xc nh li kch thc c t cung v khi u.
nh gi s xm ln ca khi u vo ti cng, dy chng rng 2 bn, m o, thnh
chu hng.
- Khm qua ng trc trng nh gi khi u xm ln vo bng quang, trc trng.
4. Cc xt nghim.
- Lm t bo m o - c t cung.
- Soi c t cung: rt c ch trong vic xc nh v tr tn thng bm sinh thit. Ch
vng ranh gii gia biu m lt v biu m tr.
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- Sinh thit: bt k mt tn thng nghi ng no cng cn phi sinh thit: vng Lugol
m tnh, m lot, n si, tn thng mao mch. C khi phi khot chp hoc no ng
c t cung. y l phng php tt nht chn on.
- X quang:
Chp phi.
Chp ct lp (CT scanner) pht hin cc chui hch cnh ng mch ch b
m ung th xm nhim.
Chp thn nh gi s tin trin ca ung th gy tc nghn ng tit niu.
- Chn on phn bit:
Ra mu: u nguyn bo nui, lao c t cung, polip c t cung.
Ra kh h: phn bit vi l tuyn c t cung, si mo g, lot do cc bnh
LTQTD.
5. iu tr: ty thuc vo giai on.
Tuyn tnh: iu tr giai on IA bngphu thut ct t cung hon ton.
Tuyn trung ng:
Giai on IA: nh tuyn tnh.
Giai on IB-IIA: phu thut kt hp x tr hu phu.
Giai on IIB: x tr tin phu + phu thut + x tr hu phu.
Giai on III-IV: x tr n thun.

206 |
UNG TH V
Tuyn p dng.
Tuyn tnh tr ln.
Ngi thc hin.
Bc s chuyn khoa ph sn hoc bc s chuyn khoa ung th.

Ung th v l bnh hay gp nht trong ung th ph n, ng th hai sau ung th c
t cung v l bnh gy t vong cao nht. Nu pht hin giai on sm s em li hiu
qu cao.
1. Khm lm sng.
Hi tin s.
- Hi k v tin s gia nh.
- Nu c xut hin khi u v: hi v thi gian, v tr xut hin, triu chng au v, au
c thay i theo chu k kinh nguyt khng? Khi u c gy kh chu khng v ung th
v t khi gy au. C dch tit nm v khng? Nu c, hi mu sc, lng v ngun
gc dch tit mt hay hai bn v? v nhng du hiu lin quan n u tuyn yn.
2. Thm khm.
2.1. Khm thc th bao gm: quan st, s nn v v hch bch huyt vng nch, hch
thng n, hch h n.
- Ngi bnh ng thng hoc nm t 2 tay di u. Nhn hnh dng v, s cn i,
thay i da (ban , sn da cam, co ko khi u, lot). Nm v tt hay lch hng.
- Dng 3 ngn tay gia m v vo thnh ngc vi nhng di ng hnh trn nh vi
nhng lc n khc nhau, nng m v ln gia 2 bn tay.
- S nn: hch thng n, hch h n, hch nch. Khm 4 vng ca v: 1/4 v trn
trong, trn ngoi (thng gp nht), di trong, di ngoi bng 2 tay, mi tay 3 ngn,
n qung v v nm v pht hin dch tit bt thng.
- Xc nh kch thc khi u, hnh dng, mt , v tr, di ng.
- Dch tit: 1 bn hay 2 bn, s lng ng dn c lin quan, mu sc, mt , lm t bo
hc.
- Dy chng Cooper b co ko, da dy.
2.2. Cc phng php thm d.
2.2.1. Chp v.
- Ch nh:
Mng rn v khng r nguyn nhn.
V c nhiu khi ln nhn.
V tit dch.
Kim tra v bn i din khi v bn kia b ung th, d khng s thy hch nch.
Khm sng lc ung th v.
- Tiu chun chn on chnh:
Ranh gii khi u khng r rng.
Tng cn quang.
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Calci ha.
Thng tn c cu trc hnh sao trn phim tng ng v mt m hc vi ung
th ng hay ung th tiu thy pht trin kiu si v trong ung th tiu qun.
Nu c tn thng ny cn lm gii phu bnh.
Calci ha ng: c th gp calci ha dng ht khng ng u, th, biu hin s
tng sinh ca ni ng hoc ung th trong ng calci ha dng khun l du hiu
c th v ng tin cy ca tn sinh ng. Thng biu hin ung th t bit ha.
2.2.2. Siu m.
- Siu m pht hin nhng khi u v. Trong ung th s thy khi u ranh gii khng r,
m, m vang khng ng nht, ng sa gin khng u v thy hch bch huyt b
xm nhim.
- Siu m gip chn on phn bit u lnh hay ung th v. Tn thng l nang th khng
cn thit phi phu thut m ch cn ht dch l .
2.2.3. Chc ht.
- Chc ht bng kim nh chn on v iu tr.
- Chc ht t bo bng kim nh vi p lc m ln c th dng ly t bo t mt khi
u v c gip chn on c khi u lnh tnh hay c tnh, tng kh nng chn on
chnh xc v quyt nh thi gian sinh thit. Chc ht bng kim nh l mt th thut
thc hin ti phng khm ht dch hay lm t bo. y l phng php cho gi tr
chn on cao, n gin d thc hin.
- Ch nh:
Nang tuyn v.
Khi u c lnh tnh ph n tr.
Khi u nghi ng ung th.
Hch nch.
- K thut chc: dng kim nh, st trng da, c nh khi u gia 2 ngn tay n xung
pha c ngc, dng ng tim 20 ml, kim s 20 g.
- Thi gian chc: ngy 3 - 10 ca chu k kinh loi tr nh hng ca ni tit i vi
ph n tr v thi k tin mn kinh. Nu l nang tuyn s ht ra dch, nu dch l mu
hoc dch ti pht sau ht 3 - 4 tun, hoc nu vn s thy khi sau ht th phi sinh
thit.
2.2.4. Sinh thit v.
- L phng php n gin thun tin d lm v mang li li ch cao, l tiu chun vng
chn on xc nh. Quyt nh sinh thit v sau khi khm lm sng, chp v, t
bo ung th.
- Ch nh sinh thit: khi u tn ti lu.
- Khi chn on ung th v th nn sinh thit v bn i din nu c du hiu kh
nghi khi chp.
- K thut: gy t ti ch hoc gy m ton thn.
- ng rch ngang qua u ly nhng tn thng khng nn ni khi ch thy qua chp
v. Dng k thut nh khu trc khi phu thut bng kim hay tim cht mu ni r.
- Ly ton b khi u gi gii phu bnh.
208 |
3. Chn on.
3.1. Chn on xc nh.
- Giai on sm c th s thy khi u cng hoc mt mng cng, b r, chp v c hnh
nh bt thng.
- Giai on mun: c th thy da hoc nm v b co ko, s thy hch nch, v to v ,
ph hoc au khi u dnh vo da v c ngc.
- Giai on cui: c tn thng lot, c hch thng n ph cnh tay c th di cn vo
phi, xng, gan no v cc tng khc.

Phn chia giai on lm sng:
- Giai on I: kch thc khi u < 2 cm, khng s thy hch, cha c di cn xa
- Giai on II: kch thc khi u < 5 cm, hch nch di ng
- Giai on III: kch thc khi u > 5 cm hoc c bt k kch thc no nhng xm
ln vo da hoc c ngc, di cn hch thng n, nhng cha di cn xa
- Giai on IV: di cn xa
3.2. Chn on phn bit.
Cn loi tr cc bnh vim v: vim v khng c hiu, vim cp hay mn, p xe
ngi cho con b v cc u lnh.
- Thy tuyn v c th to ln trc khi hnh kinh v nh li sau khi sch kinh.
- Nhn x tuyn v.
- Papilloma ni ng.
- Chm nm v ging bnh Paget.
4. Hnh thi lm sng ca ung th v.
4.1. Carcinoma Paget.
- Tn thng thng thm nhim ni ng, l loi ung th rt bit ha, biu m nm v
b thm nhim nhng t thay i nm v, khi u khng s thy.
- Triu chng ban u thng nga, ty u v, c th c vt trt hoc lot da.
- chn on: bm sinh thit. D nhm vi vim da, eczema nn c iu tr nh
vim da do vi khun do dn n pht hin mun.
4.2. Ung th v vim.
y l hnh thi c tnh nht ca ung th v.
- Lm sng: v au, to, sng , khng s r khi u v tn thng thm nhim lan rng.
- Chn on: bm sinh thit thy ung th xm nhim vo bch mch di da.
- Nu nghi ng ung th th phi cho khng sinh khong 2 tun v sinh thit chn
on, di cn thng sm v rng.
5. X tr.
- Tuyn x v huyn: khm pht hin khi u v, chuyn tuyn.
- Tuyn tnh: khi chn on chc chn l ung th v th chuyn tuyn trung ng
iu tr.

209 |

PHN 3
CHM SC S SINH
210 |
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GIAO TIP V H TR TINH THN
I VI GIA NH TR BNH
Tuyn p dng.
Tt c cc tuyn.
Ngi thc hin.
Cn b cung cp dch v.

1. Giao tip vi ngi nh tr bnh.
1.1. Nguyn tc chung.
- Phong cch chng chc, thi quan tm, thn thin to nim tin cho gia nh tr bnh.
- Tn trng, thng cm vi nhng ni lo lng ca gia nh.
- Lng nghe v khuyn khch ngi nh hi hoc t kin.
- Ch quan tm n b m k c khi khng c b m i theo. Cn hi v tnh trng b
m thu thp thng tin lin quan n tr v biu l s quan tm ca mnh.
1.2. Cc vic cn lm khi tip xc vi ngi nh tr bnh.
- Tip nhn tr ngay v nh gi nhanh xem tr c trong tnh trng cp cu khng.
Nu c, phi x tr ngay; nu khng, tin hnh x tr tr theo qui trnh ca bnh vin.
- Hi bnh: lun c thi tn trng v cm thng vi ngi nh khi hi bnh. Lng
nghe nhng kin ca gia nh, khuyn khch h hi v by t thi quan tm ca
mnh. Cch hi bnh cn kho lo, trnh lm tn thng gia nh.
- Khm bnh: khm bnh phi ton din, t m, chu o. Ch ng tc khm phi nh
nhng.
- Thng bo v bnh tt v k hoch iu tr cho tr: dng ngn t r rng, chnh xc khi
thng bo cho gia nh v tnh trng, tin trin v k hoch iu tr cho tr.
- Gii thch v nhng vn lin quan n qui ch bnh vin: ph bin cc hng dn,
ni qui bnh vin. Bo m quyn dn ch cho ngi nh ngi bnh. i vi nhng
trng hp cn lm th thut, m t thi..., gii thch cho ngi nh bit cc qui nh
hin hnh.
2. H tr tinh thn cho gia nh tr trong cc trng hp bnh nng.
Cc hng dn sau y p dng cc c s y t c iu tr tr b bnh nng.
2.1. i vi tt c gia nh c tr b bnh nng.
- ng vin an i gia nh.
Khng c trch gia nh ngi bnh nu h a tr n qu mun hoc khng
quan tm n tnh trng bnh ca tr.
Biu hin s quan tm, tn trng i vi tr v gia nh:
Khuyn khch v cho php b m vi tr. Nu b m khng th vi tr th
khuyn khch b m n thm tr cng nhiu cng tt. C gng c ging nm
cho c b m v tr.
Khuyn khch b m cng tc trong vic chm sc tr.
Khuyn khch, ng vin, h tr b m cho con b. Trng hp khng th cho
con b c, hng dn, gip b m vt sa v dng tha, cc cho tr n.
212 |
- Thm tr.
Ch nhng ngi thn trong gia nh vo thm v hng dn h tun th cc qui
nh ca bnh vin.
Nhng ngi nh ang b st, c du hiu b bnh cp tnh, bnh truyn nhim (nh
nhim khun ng h hp, thu u..) khng c vo thm tr.
Khi thm tr cn phi:
Ra sch tay.
Mc qun o, i dp ca bnh vin.
Ch thm ngi nh ca mnh, khng tip xc vi cc tr khc trong bung
bnh.
2.2. Gia nh c tr b khuyt tt bm sinh.
Cn b y t cn c thi thng cm, tinh t trong khi gii thch v tnh trng d tt
cho ngi nh.
- Nu tr b d dng nng th cn nhc vic cho b m gp tr. Nu bt buc phi cho
m gp tr, tm cch che bt sao cho b m khng nhn thy ht nhng d dng ny khi
ln u gp tr.
- Ln u tip xc vi tr, khng nn b m mt mnh m cn c thm mt ngi na
gim bt s lo s cho b m.
- Hng dn v bo m cha/m tr bit cch chm sc tr.
- T vn v tin lng bnh ca tr v gii thiu n cc c s iu tr tip tc.
2.3. Gia nh c tr ang hp hi hoc mt.
- Tr ang hp hi:
Cho php ngi nh vo thm tr, ngay c khi ang c gng cp cu cho tr, nu
thy ph hp.
Gii thch tnh trng bnh ca tr.
Nu bit chc chn tr khng th qua khi cn an i, ng vin gia nh ngi
bnh v thng bo cho gia nh bit l khng th cu sng tr.
- Khi tr t vong:
Sau khi tr mt, mc qun o, chia s vi gia nh ngi bnh v cho php gia
nh gp mt, nu h mun.
Tn trng cc tp tc a phng: gi vt k nim, chn ct... nhng phi ng
theo qui nh a phng v bo m ng cc qui trnh y t.
Hon thnh mi th tc, giy t theo qui nh xc nhn t vong ca tr. Ghi chp
y cc thng tin lin quan v lu h s tr t vong.
a giy chng t cho gia nh v hng dn chm sc b m sau sinh.
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CHUYN VIN AN TON CHO TR S SINH

Tuyn p dng.
Tt c cc tuyn.
Ngi thc hin.
Cn b cung cp dch v.

1. Chuyn tr t tuyn x.
- Ty iu kin ti cc trm y t, s dng cc phng tin vn chuyn thch hp sn c
vi nguyn tc l m bo an ton cho tr trong sut qu trnh chuyn. Cn c bit
ch :
Gi m cho tr: tt nht l t tr tip xc da k da vi m hoc ngi i cng
trong sut qu trnh chuyn.
C gng c nhn vin y t i km v c cc trang thit b, thuc thit yu cho cp
cu trn ng chuyn.
- Nu c iu kin, lin h vi tuyn trn yu cu h tr n ngi bnh hoc hng dn
v h tr x tr ty thuc vo tnh trng ngi bnh.
- Trc khi chuyn:
Vit giy chuyn vin bao gm cc thng tin v tnh trng bnh ca tr, cc chm
sc/x tr lm; cc vn lin quan n cuc v tnh trng b m.
Trng hp nghi ng hoc xc nh nhim khun nng: tim bp (mng) cho tr
1 liu khng sinh: gentamicin 2,5 mg/kg v penicilin 50.000 v/kg (ch phi pha
long gentamicin trc khi dng vi nng 10 mg/ml).
2. Chuyn t tuyn huyn, tnh v trung ng.
2.1. Lin h, trao i vi tuyn chuyn n.
- Lin lc bng in thoi trc khi chuyn.
- Cc thng tin cn trao i: tnh trng bnh tt, cc thuc iu tr, tham kho kin
chuyn mn, phng tin chuyn v c tnh thi gian n.
2.2. Chun b cn b, phng tin v trang thit b cho chuyn vin.
- Cn b: cn b chuyn mn i km bit chm sc s sinh c bn, cp cu ngng tim,
ngng th.
- Phng tin vn chuyn: xe cu thng phi c n sng c th theo di, chm
sc ngi bnh trn ng chuyn, trong xe phi bo m v sinh sch s. Li xe phi
thng trc lin tc.
- Dng c v thuc cn mang theo: bo m c , v khun v s dng c.
214 |

Cc loi dng c cn thit Cc loi thuc thit yu
- Bng, mt n dng cho tr s sinh.
- Bnh/ti oxygen dng trong qu trnh chuyn.
- ng thng, b dy ni th oxygen, ng thng d dy, ht
dch; bm tim.
- B t ni kh qun, ng ni kh qun cc c 2,5; 3; 3,5.
- ng nghe; nhit k, my ht m/nht.
- Dng c/thit b m.
- Dng c o bo ha oxygen qua da, nu c iu kin.
- Dch truyn: glucose 10
%; natri clorid 0,9%; natri
bicarbonat 4,2 %.
- Phenobacbital.
- Adrenalin 1.
- Khng sinh (gentamicin,
penicilin).

2.3. Chun b chuyn vin.
- Bo m l gii thch k cho gia nh l do phi chuyn vin v c gia nh ng
. Nn chuyn m i cng tr.
- Tnh trng ngi bnh tng i n nh, c th duy tr c cc chc nng sng trn
ng chuyn.
- Trng hp nghi ng hoc xc nh nhim khun nng: tim bp (mng) cho tr 1
liu khng sinh: gentamicin 2,5 mg/kg v penicilin 50.000 v/kg (ch phi pha long
gentamicin trc khi dng vi nng 10 mg/ml).
- Nu tr mt nc nng: bi ph nc v in gii.
- Vit giy chuyn vin.
2.4. Chm sc v theo di trn ng chuyn vin.
- Bo m gi m cho tr trc v trong khi chuyn, khuyn khch tr tip xc da k
da vi m/ngi nh.
- Bo m cho n v dch truyn:
Nu tr b c, khuyn khch b m cho tr b.
Nu tr khng th b c, vt sa cho tr n bng tha hoc qua ng thng hoc
nui dng tnh mch nu cn b i km c kh nng thc hin.
- Theo di: din bin bnh v cc du hiu sinh tn.
- X tr cc tnh hung: nu tr c cc vn nghim trng (ngng th/tim hoc co git)
th cn dng xe x tr. Khng nn i nhanh n tuyn chuyn vin m khng x tr.
2.5. n c s chuyn vin: bn giao ngi bnh, cc h s lin quan, cc din bin v x
tr trn ng chuyn vin.

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CHO TR RA VIN

Tuyn p dng.
Tt c cc tuyn.
Ngi thc hin.
Bc s iu tr trong cc c s y t l ngi quyt nh cho tr ra vin v cn tun th
cc tiu ch sau.

1. Thi im ra vin.
1.1. Cc tiu chun v chuyn mn c th cho tr bnh ra vin:
- Bnh l chnh n nh, khng c vn g khc cn phi iu tr ti c s y t.
- Thn nhit ca tr bnh thng v duy tr trong khong 36,5
o
C - 37,4
o
C.
- Tr b tt. Nu tr khng c ch nh b m, phi hng dn b m kin thc v thc
hnh nui con bng cc phng php cho n thay th.
- Tr c chiu hng tng cn.
1.2. Nu v hon cnh c bit, gia nh mun xut vin sm hn so vi d nh ca thy
thuc, cn hng dn b m cch tip tc iu tr ti nh (nn c cam kt t b m xin ra
vin sm v thc hin ng cc hng dn ca thy thuc), khuyn khch b m a tr
khm li sau 1 - 2 ngy, lin h vi nhn vin y t a phng ngh tip tc theo di tr.
2. Cc th tc cn lm khi cho ngi bnh ra vin.
2.1. Khm tr trc khi ra vin: bo m chc chn l bnh chnh n nh, cc tiu
chun cho tr xut vin.
2.2. Thng bo cho gia nh bit v quyt nh ra vin:
- Tr c y cc iu kin cn thit ra vin.
- Gii thch cc qui nh v th tc ra vin cho b m hiu v tr li cc cu hi ca b
m.
- Trng hp c bit phi gii quyt ra vin theo yu cu ca gia nh, cn thng qua
kin lnh o v phi c ch k ca gia nh vo bnh n.
3. Hng dn cho b m/ngi nh khi cho tr ra vin.
- Cp thuc hoc k n, hng dn cch s dng hon thnh t iu tr ti nh v
hn khm li.
- Hng dn cho b m cch chm sc, theo di tr ti nh. c bit lu i vi cc b
m c vn kh khn (v nui con bng sa m, b bnh nng, HIV(+), c con ln
u, tui v thnh nin hoc b m c thn...).
- Kim tra v hng dn lch tim chng ln tip theo.
4. Hon tt cc th tc hnh chnh.
- Vit giy ra vin gm y cc thng tin v chn on, hng dn theo di v khm
li.
- Hon thnh h s ra vin.
216 |
PHI HP CHUYN NGNH SN KHOA V NHI KHOA
TRONG CHM SC TR S SINH

Tuyn p dng.
Tt c cc tuyn.
Ngi thc hin.
Cn b cung cp dch v.

1. Ti tuyn x.
1.1. Chm sc trc v trong thi gian mang thai.
Cn b thc hin l bc s, n h sinh, y s sn nhi hoc iu dng sn nhi ang lm
vic ti trm y t x chu trch nhim theo di sc khe cho ph n la tui sinh . Ni
dung thc hin:
- Gio dc gii tnh, tnh dc an ton v cung cp cc kin thc chun b lm m cho tr
gi tui v thnh nin.
- T vn v thc hin cc dch v KHHG.
- T vn, chm sc trong thi gian mang thai (theo cc ni dung trong phn chm sc b
m trong thi gian mang thai).
- Qun l thai nghn.
- Nhn bit thai c nguy c chuyn tuyn ng ch nh.
1.2. Chm sc ti cuc .
Cn b thc hin l bc s, n h sinh, y s sn nhi ti trm y t x. Cn b phi
c o to v k nng, kin thc c bn v chm sc sn khoa v s sinh thit yu, thc
hin cc nhim v:
- Cung cp dch v an ton cho cc trng hp thng v nhn bit, x tr
(hoc chuyn vin) kp thi cc bin chng cho c b m v tr.
- Chm sc m: bo m sch, s dng biu chuyn d nhn bit v x tr c
cc bt thng trong chuyn d v cc bin chng sau sinh.
- Chm sc con: thc hin cc chm sc thit yu cho tr sm ngay sau sinh, trong ngy
u v tun u sau sinh.
1.3. Chm sc sau sinh.
- Ti trm y t: ni dung chm sc b m sau c hng dn phn Chm sc b
m. Khi theo di sc khe b m, cn b y t phi ng thi thc hin cc chm sc s
sinh thit yu v theo di tr trong nhng ngy u sau sinh. Khm ton thn cho c
m v con trc khi cho v nh.
- Theo di ti nh: t nht 1 ln trong vng tun u sau cho c m v con. Cc ni
dung khm tr s sinh cng bao gm cc vn nh theo di c s y t v b m,
tnh trng rn, da, pht hin cc tnh trng bnh l. Cn ch pht hin sm vng da
bnh l, kim tra tnh trng tim chng, tng cn v pht trin ca tr.
| 217
2. Ti tuyn huyn.
Cn b thc hin l bc s, n h sinh, iu dng trong khoa sn v khoa nhi c
o to v chm sc sn khoa, chm sc s sinh thit yu v hi sc s sinh. Ni dung
thc hin gm:
- Thc hin tt c cc ni dung nh trm y t x v:
- Trong phng phi c bn hi sc s sinh.
- Khi tr s sinh c vn v sc khe cn chuyn sang iu tr khoa Nhi. Khi chuyn
phi cung cp y cc thng tin v cuc , tin s sn khoa v cc din bin bnh
ca tr v cc x tr lm.
- Cc trng hp tin lng kh cn hi chn, mi bc s lm nhi tham gia cuc
c th x tr kp thi cc vn c th xy ra i vi tr.
- Nu phi chuyn ln tuyn trn, thc hin ng tt c cc bc chm sc chuyn vin
an ton.
3. Ti tuyn tnh: phi hp Sn - Nhi cn thc hin ton din c v t chc, nhn lc v
ni dung
3.1. T chc.
- C ni hi sc s sinh trong phng /phng m v c trang b y trang thit b,
dng c cn thit.
- Cn b tr khoa Sn v khoa Nhi gn nhau.
- C n v s sinh trong khoa Nhi, c phng hi sc cp cu s sinh vi trang thit
b cn thit cho cc hi sc s sinh c bn v ton din. Phi bo m cc tiu chun v
v sinh v phng chng nhim khun.
3.2. Nhn lc.
- Bc s, n h sinh khoa Sn phi thc hin thnh tho cp cu, hi sc tr ngt, chm
sc thit yu tr s sinh trong ngy u, tun u sau sinh.
- Bc s, iu dng khoa Nhi phi c o to v chm sc v cp cu s sinh.
- Cc bc s, iu dng trong n v s sinh cn c o to su v chuyn khoa s sinh.
3.3. Ni dung thc hin.
- Cc b m mang thai c nguy c cn c hi chn gia cc bc s sn v nhi tin
lng cuc v c hng x tr ph hp cho c m v con.
- Phi hp theo di b m mang thai c nguy c v tr s sinh ti cuc :
Chm sc tr s sinh bnh l: khi tr s sinh ti khoa Sn c vn v sc khe
cn c hi chn vi bc s Nhi v chn on, chm sc, iu tr, t vn. Nu qu
kh nng chm sc ti khoa Sn chuyn tr sang khoa Nhi iu tr. Khi chuyn tr
phi cung cp y thng tin v m, cuc v tr. Cn c s chia s trch nhim
khi c bt c vn g xy ra i vi tr.
Tr s sinh bnh khi chuyn sang khoa Nhi cn c b tr nm cng vi m nu
c iu kin v bnh khng qu nng.
Nu b m cn phi tip tc iu tr, theo di, cn b Sn cn n khoa Nhi thm
khm v chm sc cho b m.
- Nhng ni c iu kin thc hin sng lc trc sinh, sng lc s sinh: cc cn b
khoa Sn v khoa Nhi hp tc tin hnh cc hot ng:
Truyn thng cung cp kin thc cho cng ng.
T vn di truyn, bnh tt.
T chc mng li, thc hin sng lc trc sinh v s sinh trn din rng.

218 |
NGUYN TC S DNG KHNG SINH CHO TR S SINH

Tuyn p dng.
Tt c cc tuyn.
Ngi thc hin.
Cn b cung cp dch v.

1. Cc nguyn tc s dng khng sinh.
- Ch s dng khng sinh khi c bng chng nhim khun hoc c nguy c nhim khun
cao.
- Nhng trng hp nhim khun nng nn dng khng sinh dit khun ng tnh
mch v phi hp.
- Thn trng khi dng nhng khng sinh c c tnh i vi gan v thn (nh
cloramphenicol, aminoglicosid, quinolon)
- Khng trn ln cc khng sinh khc nhau khi dng.
2. Cc khng sinh s dng theo tuyn.
- Tuyn x:
Khuyn khch s dng khng sinh ng ung.
Trng hp phi dng khng sinh ng tim th dng ng tim bp, khuyn
khch tim mng.
Tun th nguyn tc tim an ton.
- Tuyn huyn:
Nh tuyn x.
S dng khng sinh ng tnh mch, phi hp trong nhng trng hp nhim
khun nng.
Chuyn tuyn khi vt qu kh nng iu tr hoc tnh trng khng ci thin sau 2
ngy iu tr.
- Tuyn tnh v tuyn trung ng:
Lm cc xt nghim tm nguyn nhn nhim khun.
La chn khng sinh theo khng sinh .
Sau 72 gi iu tr, nu tnh trng bnh khng ci thin th phi thay i khng
sinh.
Dng s dng khng sinh ngay khi khng cn thit.
| 219
THUC THIT YU TRONG CHM SC TR S SINH TI
CC TUYN

1. Tuyn x.
- Dch truyn: glucose 10 %, natri clorid 0,9%.
- Khng sinh: benzyl penicilin, ampicilin, gentamycin.
- Thuc cp cu: adrenalin 1/1000.
- Dung dch st khun da/chm sc rn: tm gentian 0,5 %, cn 70
0
hoc povidon iod
2,5%.
- M tetracyclin 1 % nh mt.
- Argyrol 1 %.
- Vitamin K
1
.
- Vaccin: BCG, vim gan B.
- Dung dch kh khun dng c: clorhexidin, glutaraldehyd, hexaniose, cloramin.
2. Tuyn huyn.
Gm cc thuc nh tuyn x v b sung thm cc thuc sau:
- Dch truyn cc loi: glucose 5 %, natri bicarbonat 4,2 %, 1,4 %.
- Khng sinh: cefotaxim, ceftriaxon, cloxacilin, amikacin, nystatin.
- Thuc chng co git: phenobarbital.
- Cafein citrat 7%, theophylin.
- Dung dch st khun tay: st khun tay nhanh clorhexidin 4 %.
3. Tuyn tnh.
Gm cc thuc nh tuyn huyn v b sung thm cc thuc sau:
- Dch truyn: dung dch acid amin 10 %, lipofundin 20 %, natri clorid u trng, calci
clorid 10 %, kali clorid 10 % v mu.
- Thuc cp cu tim mch: dopamin, dobutamin.
- Morphin, fentanyl, naloxon.
- Heparin, lidocain.
- Khng sinh: ciprofloxacin.

220 |
TRANG THIT B THIT YU
CHO CHM SC S SINH TI CC TUYN Y T
1. Tuyn x.
- Bn lm rn v hi sc s sinh.
- n si m.
- Cn tr s sinh v thc o chiu di.
- Nhit k.
- H thng th oxygen: bnh oxygen, bng bp s sinh v mt n cc c.
- My ht v ng ht.
- Bm kim tim v dy truyn dch, kim bm cho tr em.
- Kim ly thuc s 18.
- Bng dnh, bng cun.
- ng thng d dy, ng thng hu mn.
- Gng tay v trng.
- Bn ra tay c nc v x phng, khn lau tay.
- Bn chi, x phng.
2. Tuyn huyn.
Cc trang b nh tuyn x v:
- ng ht m s 6 - 8, gng sch.
- H thng th oxygen: b trn oxygen - kh tri.
- Kim lun tnh mch, kim bm.
- B t ni kh qun s sinh.
- ng ni kh qun s sinh cc c.
- n chiu vng da.
- CPAP.
- My o bo ha oxygen qua da.
- B chc d ty sng.
- My o ng huyt ti ging.
- Ging si m, lng p.
- Ging cho b m thc hin chm sc tr bng phng php Kangaroo.
- vi sch dng cho s sinh.
- Xe cp cu vn chuyn tr bnh: c y cc trang thit b cp cu cn thit.
3. Tuyn tnh.
Cc trang b huyn v:
- X quang chp ti ging.
- Nu c iu kin, trang b: my siu m tim mu, no ti ging v u d thch hp.
- My ht chn khng.
- Catheter rn s 3,5 - 5F.
- Chc 3, 4.
- B truyn mu.
- B thay mu.
- My bm tim t ng, dy ni bm tim.
- Catheter tnh mch trung tm, b dng c o p lc tnh mch trung tm.
- B chc d v m mng phi.
- My th, my monitor.
- My o kh mu.
- My iu ha nhit 2 chiu.
| 221
CHM SC TR S SINH NON/NH CN
Tuyn p dng.
Tt c cc tuyn.
Ngi thc hin.
Cn b cung cp dch v.

1. Tuyn x.
- Xc nh tui thai, cn nng, chiu di v chm sc thit yu sau sinh.
- Chm sc tr trn 2000 g khng c suy h hp, b c.
- Hng dn b m gi m cho tr bng phng php Kangaroo, nui con bng sa m,
phng chng nhim khun.
- Tim bp vitamin K
1
: 1 mg ngay sau ; 0,5 mg i vi tr c cn nng < 1500 g.
- Tim chng theo qui nh: BCG v vim gan B.
- Pht hin d tt, du hiu nguy him chuyn tr ln tuyn trn.
2. Tuyn huyn
Thc hin cc chm sc, iu tr nh tuyn x v:
- Chm sc tr t 1500 g tr ln, khng suy h hp nng v c th b m hoc nui
dng qua ng tiu ha.
- Theo di v iu tr cc nguy c thng gp ca tr non: ch vng da (chiu n),
nhim khun (iu tr khng sinh), suy h hp (s dng CPAP).
- Ch tm sot bnh l vng mc tr s sinh thiu thng.
- Chuyn tuyn nu pht hin cc d tt bm sinh ngoi kh nng iu tr v cc trng
hp suy h hp nng, cc bnh nhim khun khng p ng vi iu tr.
- Theo di s pht trin v tinh thn v th cht ca tr sau khi ra vin.
3. Tuyn tnh, trung ng.
Thc hin cc chm sc, iu tr nh tuyn huyn v:
- Chm sc tr di 1500 g.
- Chm sc iu tr suy h hp nng vi chuyn mn v k thut cao: CPAP, my th,
chng toan mu, surfactan.
- Nui dng tnh mch.
- S dng lng p.
- iu tr cc bnh km theo khc.
- Pht hin v iu tr sm cc bin chng (bnh vng mc, khim thnh, bnh phi mn
tnh).
4. Tiu chun xut vin vi tr non.
- Tr hng ho, b tt.
- Tng cn 15 - 20 g/kg thn trng mi ngy trong 3 ngy lin tc v c cn nng khi ra
vin t nht l 1800 g.
- Nhit n nh bnh thng.
- Khng c cn ngng th nng.
- Cc du hiu khc bnh thng.
- M v ngi nui dng c hng dn v chm sc tr.
- Hn khm li mi thng 1 ln trong nm u.
222 |
CHM SC TR BNG PHNG PHP CNG-GU-RU
(Kangaroo Mother Care)
Tuyn p dng.
Tt c cc tuyn.
Ngi thc hin
Cn b cung cp dch v.

1. Chm sc tr bng phng php Cng-gu-ru ti tuyn x.
Bc s, n h sinh hoc iu dng khuyn khch v hng dn b m:
- Thc hin tip xc da - k - da vi m ngay t nhng pht u sau khi lt lng m.
- H tr ngi m cho tr b trong vng 1 gi u sau khi tr trn ngc, tip xc da
- k - da vi m.
- Nu phi chuyn tuyn, c gng tr tip xc da - k - da vi m hoc vi cc thnh
vin khc trong gia nh trn ng chuyn.
2. Ti tuyn huyn tr ln.
Bc s, n h sinh hoc iu dng khoa Sn v khoa Nhi thc hin phng php
Cng-gu-ru cn phi c o to v k nng t vn v phng php thc hin chm sc
ny. Ti khoa phng cn b tr mt hoc vi phng ring cho hot ng ny.
2.1. Tiu chun chn tr thc hin phng php Cng-gu-ru.
- Tr non hoc nh cn khng c du hiu bnh l hoc vt qua giai on bnh l
nng.
- Khng phi nui dng bng ng tnh mch na.
- C p ng tt vi cc kch thch.
2.2. Yu cu i vi ngi m tham gia thc hin phng php Cng-gu-ru.
- T nguyn, hp tc thc hin phng php Cng-gu-ru theo hng dn.
- Sc khe tt.
- Dnh ton b thi gian thc hin phng php Cng-gu-ru.
- Thc hin v sinh tt.
- C thm mt ngi nh thch hp, t nguyn, nhit tnh thc hin phng php
Kangaroo c th thay th ngi m khi cn.
2.3. Ni dung thc hin phng php Cng-gu-ru.
- Hng dn t tr v gi tr v tr Cng-gu-ru.
- Hng dn nui con bng sa m khi ang thc hin phng php Cng-gu-ru.
- Hng dn cch chm sc, v sinh v theo di cho tr hng ngy, cc du hiu nguy
him c th xy ra i vi tr v cch x tr kp thi.
- Kch thch v xoa bp cho tr.
- H tr b m: hng dn cch vn ng, th gin c th v gii ta nhng ni lo lng,
s hi...
2.4. Tiu chun ra vin.
- i vi tr:
Tr khng c biu hin bnh l.
| 223
Tr b m c.
Tr tng cn: 15 - 20 g/kg thn trng mi ngy v trong t nht 3 ngy lin tip.
- i vi b m:
Thnh tho cch thc hin tip xc da - k - da tip tc cho tr ti nh.
Bit cch iu chnh theo nhu cu ca tr nh tng thi gian tip xc da - k - da
nu tr lnh tay, chn hoc nhit mi trng thp v ban m.
Bit cch chm sc, theo di ti nh v nhn bit cc du hiu nguy him a tr
n khm kp thi.
Bit ni khm chm sc sc khe nh k, thi gian khm li v ni dung khm.
- Hng dn khi ra vin: cp t ri, hng dn thc hin phng php Cng-gu-ru ngoi
tr v hn khm li.
3. Thc hin phng php Cng-gu-ru cho tr phi chuyn vin.
- Nu tr c ch nh chuyn vin: gii thch, ng vin v gip ngi m hoc ngi
i cng vi tr, m bo cho tr vn c chm sc tip xc da - k - da trn ng
chuyn.
- tr v tr Cng-gu-ru khi thc hin cc chm sc khc trn ng vn chuyn (th
oxygen, cho n sa m qua ng thng hoc nh git...).
224 |
D TT S SINH CN CAN THIP SM
Tuyn p dng.
Tt c cc tuyn.
Ngi thc hin.
Cn b cung cp dch v.

1. Tuyn x.
- Pht hin cc d tt cn can thip ngay nh: khng hu mn, thot v rn, khe h thnh
bng, teo thc qun, hi chng tc rut.
- Vn chuyn an ton ln tuyn trn ni c kh nng phu thut.
- Lu : khi chuyn tr b thot v rn v khe h thnh bng cn m bo khi thot v
c p huyt thanh m lin tc v v khun.
2. Tuyn huyn.
Nh tuyn x v:
- Pht hin c mt s d tt bng khm lm sng, chp X quang v siu m nu c.
- Chuyn tuyn an ton phu thut.
3. Tuyn tnh, trung ng.
Nh tuyn huyn v:
- X tr cc loi d tt bm sinh cn can thip sm.
- Lm cc xt nghim c bn v mt s xt nghim thm d xc nh chn on.
- Can thip phu thut sm
4. Nhng im cn lu khi chm sc tr b d tt.
- Nhng d tt teo tc rut phi nhn n hon ton v t ng thng d dy dn lu.
- D tt teo thc qun: nhn n hon ton, t tr nm u cao, ht m ri lin tc.
- Thot v honh: tuyt i khng bp bng qua mt n, nu cn h tr h hp phi t
ni kh qun.
- Nhng d tt v xng khp cn ch c nh tt khi vn chuyn.

| 225
T VN NUI CON BNG SA M
Tuyn p dng.
Tt c cc tuyn.
Ngi thc hin.
Cn b cung cp dch v.

1. Khi mang thai.
- Gii thch li ch ca b m.
- Hi kinh nghim nui con bng sa m.
- Gii thch tm quan trng ca vic chm sc v v nm v, xin php khm.
- To nim tin l tt c b m u c th nui con bng sa m.
2. Ngay sau .
- Cho con nm cnh m:
Gip b m cho con b sm trong vng 1 gi u sau .
M d chm sc,theo di con.
Tr t khc hn.
Thi gian b m c lu hn.
- T vn v li ch ca vic cho b sm:
Li ch ca sa non.
Sa v sm hn.
Tr tng cn tt hn.
t b cng tc sa.
Khng vt b sa non, cn cho con b c sa non.
- Hng dn b m cho con b ng:
Tr ngm bt v ng (mir ntr ngm bt mi di hng ra ngoi, li chm
quanh bu v, m chm trn, qung v cn li pha trn nhiu hn pha di)
T th cho b ng (u v thn tr trn cng mt ng thng, mt tr i din
vi v v mi tr i din vi nm v, thn tr st vi m, ton b ngi tr)
Tr b c hiu qu (mt chm, su, thnh thang dng li ri b tip. C th nhn
hoc nghe thy ting tr nut).
- Pht hin cc trng hp c kh khn khi cho b m hng dn chi tit.
- Cch gi gn ngun sa m:
Ung nhiu nc.
n cht v tng ba.
Ngh ngi , ng 8 gi/ngy hoc hn.
Gii thch v nhng thc n v nhng yu t c nh hng n s lng, cht
lng sa (k c cc thuc).
S dng bt k thuc g u phi c kin ca thy thuc.
3. Cho con b trong nhng ngy u.
- Gii thch nhng thay i v v trong nhng ngy u.
226 |
- Khng hn ch s ln cho tr b, cho b theo nhu cu, t nht l 8 ln/ngy, c ngy v
m.
- B ht sa mt bn v mi chuyn sang bn kia.
- Khng dt v khi b cha mun thi b.
- Ch cho b sa m, khng cho tr n hay ung bt c thc n, nc ung no khc.
- Nu v cng au hoc tr kh bt v giai on u: hng dn b m vt sa v gii
thch cho b m yn tm l vn ny s c gii quyt, tr s b li c bnh
thng.
4. Cho tr non thng, nh cn b m.
- Nhn mnh tm quan trng ca vic nui con bng sa m.
- Gip b m yn tm l c th nui con bng sa m.
- Khuyn khch b m vt sa t ngy u.
- gip sa chy tt, nhc ngi m vt t sa trc lc cho b bt v.
- Nu tr khng b c, cn vt sa, cho n bng tha v cc sch, tt nht l luc cc
dng c trc khi cho tr n.
- Gii thch cho b m l tr s ln dn v b tt hn.
5. Cho tr sinh i b.
- Gip b m yn tm l vi 2 bu v, b m c th nui c 2 con.
- C th cho c 2 tr b cng mt lc hoc 1 tr b trc, 1 tr b sau.
- Nu c 2 tr cng b:
t 1 gi bn di hai tay b m (t th ngi).
t mi tr bn di 1 cnh tay
- Nu 1 tr yu hn, cn lu cho tr ny b , c th vt gip sa khi tr b.
- ng vin b m kin tr. Tr sinh i thng l non thng, thp cn, cn nhiu thi
gian mi thch nghi c vi vic b m.
- Hng dn b m v gia nh v nhu cu n ung trong trng hp sinh i.

| 227
H THN NHIT TR S SINH
Tuyn p dng.
Tt c cc tuyn.
Ngi thc hin.
Cn b cung cp dch v.

1. Tuyn x.
- Nhn bit tr c nguy c h thn nhit: nh cn, non, nhim khun nng, tr sinh ra
vo ma lnh.
- Pht hin kp thi du hiu h thn nhit: s bn tay, bn chn lnh.
- o thn nhit t nht 1 ln trong ngy u sau . Nhng tr c nguy c cn kim tra
thn nhit thng xuyn hn.
- X tr:
Hng dn b m gi m cho tr bng phng php Cng-gu-ru hoc qun thm t,
mc thm qun o, i m v p chn m cho tr hoc hng dn cc phng
php m khc.
Khuyn khch b m cho tr b sm, nhiu ln, nu tr khng th b th vt sa v
cho n qua tha.
Nu thn nhit sau 1 gi khng tr v bnh thng hoc km theo bt c du hiu
nguy him no khc cn chuyn ln tuyn trn.
Chuyn tuyn an ton
2. Tuyn huyn.
Nh tuyn x v:
- Khm lm sng, lm xt nghim ng mu, cc xt nghim c bn chn on v
iu tr theo nguyn nhn.
- Trng hp h thn nhit nng:
S dng cc phng tin m khc sn c (lng p).
iu tr cc ri lon km theo.
Chuyn tuyn khi vt qu kh nng iu tr hoc tnh trng khng ci thin sau 2
ngy iu tr.
3. Tuyn tnh.
Nh tuyn huyn v:
- Lm thm cc xt nghim xc nh nguyn nhn: cy mu v cc dch khc.
- iu tr nguyn nhn (nhim khun nng).

228 |
RI LON NC IN GII
Tuyn p dng.
Tt c cc tuyn.
Ngi thc hin.
Cn b cung cp dch v.

1. Tuyn x.
- Pht hin:
Cc du hiu mt nc: nn, b t, tiu chy nhiu ln, i tiu t, st cn, thp lm,
mt trng.
Du hiu tha nc c gi bi tng cn, ph.
Du hiu nguy him: ri lon tri gic, co git, suy h hp.
- X tr:
Tip tc cho tr b m.
Chuyn tuyn an ton.
2. Tuyn huyn.
- Phn loi mc mt nc: mt nc nng, c mt nc.
- Xt nghim c bn: cng thc mu.
- X tr:
Theo tnh trng mt nc v ri lon in gii.
Pht hin v x tr bnh km theo.
Chuyn tuyn an ton, nu qa kh nng iu tr.
3. Tuyn tnh.
Nh tuyn huyn v:
- Chn on nguyn nhn ri lon nc in gii.
- Lm thm cc xt nghim:
Cy mu, tng phn tch nc tiu.
in gii mu, creatinin mu, ure mu, kh mu (nu c th).
X quang bng, siu m bng nu c nghi ng d tt bm sinh ng tiu ha.
- X tr:
Tip tc iu chnh ri lon nc in gii v iu tr nguyn nhn.
iu tr h tr.

| 229
VNG DA TNG BILIRUBIN T DO
Tuyn p dng.
Tt c cc tuyn.
Ngi thc hin.
Cn b cung cp dch v.

1. c im vng da sinh l. 2. c im vng da bnh l.
Thng gp ngy th 3 - 5 sau , trong
tun u sau .
Vng da xut hin trc 24 gi sau .
- Tr thng: bilirubin mu tng cao vo
ngy th 3 (khong t 6 - 8 mg/dl tng
ng 100 - 120 mol/l, khng vt
qu 12 mg/dl hoc 150 mol/l), sau
gim dn.
- Tr non tng chm hn, khong vo
ngy th 5 v lng bilirubin mu cng
cao hn 12 mg/dl, cao nht c th ln ti
15 mg/dl (tng ng 200 mol/l), sau
gim dn.
Bilirubin trong mu tng nhanh trn 0,5
mg/dl/gi (8,5 mol/l/gi).
Vng da km theo cc du hiu khc (li b,
nn, n km, nhit khng n nh, ngng
th)
Vng da ko di trn 8 ngy tr thng
v >15 ngy i vi tr non.
3. Tuyn x: pht hin vng da bnh l v chuyn tuyn ngay
4. Tuyn huyn.
- Pht hin vng da bnh l.
- nh gi mc vng da trn lm sng da vo phn vng vng da ca Krammer hoc
nh lng bilirubin mu, nhm mu (nu c).
- Chiu n.
- Chuyn tuyn khi:
Chiu n tht bi (bilirubin tip tc tng > 8,5 mol/l/gi).
C nguy c cao nh: tan mu do bt ng nhm mu m con, ngt, nhit khng
n nh, li b, nhim khun, toan chuyn ha hoc albumin mu <30 g/l.
Bilirubin mu cao ti ngng phi thay mu.
5. Tuyn tnh.
Nh tuyn huyn v:
- Lm xt nghim c bn xc nh nguyn nhn vng da.
- Thay mu khi c ch nh ( nhng c s c iu kin).
- iu tr nguyn nhn.
230 |
SUY H HP S SINH
Tuyn p dng.
Tt c cc tuyn.
Ngi thc hin.
Cn b cung cp dch v.

Suy h hp l hi chng thng gp nht tr s sinh, c bit l tr s sinh thiu
thng, c th gy t vong nhanh nu khng chn on v x tr kp thi.

1. Tuyn x.
- Pht hin nhng tr c nguy c suy h hp: non, kh, m ...
- Pht hin kp thi du hiu suy h hp: c mt trong cc du hiu sau:
Th nhanh (t 60 ln/pht tr ln).
Co ko lng ngc nng.
Th kh kh, th rt hoc th rn.
- X tr ban u trc khi chuyn tuyn:
Thng thong ng th.
Th oxygen.
Cp cu ngng th.
Tim bp su (tim mng) khng sinh: ampicillin v gentamycin.
Chuyn tuyn an ton.
2. Tuyn huyn.
- Khm lm sng, nh gi mc suy h hp v lm cc xt nghim c bn (cng thc
mu, X quang tim phi), xc nh chn on v iu tr suy h hp.
- iu tr cc trng hp suy h hp 1 v 2.
- Sau 2 ngy iu tr khng ci thin hoc qu kh nng iu tr th chuyn tuyn.
3. Tuyn tnh.
Nh tuyn huyn v:
- Xt nghim xc nh nguyn nhn suy h hp: kh mu, cy dch ni kh qun.
- X tr:
Ty mc suy h hp quyt nh phng php h tr h hp.
iu tr suy h hp theo nguyn nhn.
Khng sinh: iu tr theo khng sinh . Khi cha c khng sinh th dng khng
sinh ph rng phi hp. Thi gian iu tr 7 - 10 ngy.
iu tr cc ri lon hoc bin chng km theo.
Chm sc h tr.
Chuyn iu tr theo chuyn khoa khi cn.

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VIM PHI
Tuyn p dng.
Tt c cc tuyn.
Ngi thc hin.
Cn b cung cp dch v.

1. Tuyn x.
- Pht hin nhng tr c nguy c b vim phi.
- Xc nh cc du hiu nghi ng vim phi: nhp th trn 60 ln/pht, rt lm lng ngc
nng, tm ti.
- X tr: ng thi
Tim mt liu khng sinh phi hp ampiciclin v gentamycin, tim bp su (tim
mng).
Chuyn vin an ton.
2. Tuyn huyn.
- Chn on xc nh vim phi da vo lm sng v mt s xt nghim c bn: cng
thc mu, X quang tim phi.
- X tr:
Cho th oxygen qua ng thng 0,5 - 1 lt/pht.
iu tr khng sinh phi hp ph rng trong 7 ngy v chm sc h tr khc.
Sau 2 ngy iu tr khng ci thin chuyn ln tuyn trn.
3. Tuyn tnh.
- Lm nh tuyn huyn v
- Lm thm xt nghim chn on nguyn nhn: kh mu (nu c), cy mu v cy
dch ht kh qun.
- X tr:
+ iu tr theo nguyn nhn.
+ H tr h hp: th CPAP qua mi.
+ Phi hp khng sinh ph rng trc khi c kt qu xt nghim v iu chnh khng
sinh thch hp theo kt qu khng sinh hoc chuyn khng sinh nu sau 2 ngy
iu tr khng ci thin.
+ iu tr cc bin chng v ri lon i km.
+ Theo di pht hin sm cc di chng.

232 |
TH P LC DNG LIN TC (CPAP)
Tuyn p dng.
Bnh vin huyn, bnh vin tnh v cc bnh vin trung ng.
Ngi thc hin.
Bc s.

1. Ch nh.
- Tr non c biu hin suy h hp, vn c nhp t th, tn s 60 - 70 ln/pht hoc c
cn ngng th ngn < 20 giy.
- Tr suy h hp th oxygen qua liu vi nng oxygen >30 % nhng khng ci
thin.
- Sau khi ngng th my.
- Co ko c h hp nhiu sau khi rt ni kh qun.
- C du hiu suy h hp: silverman >5 im, bo ha oxygen qua da (SpO2) <90%.
2. Chng ch nh:
- D tt ng h hp trn (st mi h hm ch, teo l mi sau, teo thc qun c d kh -
thc qun, thot v honh...).
- Ngng th ko di (>20 giy).
- p lc CO
2
mu ng mch (PaCO
2
) >60 mmHg, pH <7,25.
3. Tiu chun ngng cho th CPAP.
- Tr khng cn biu hin suy h hp trn lm sng, th u, hng ho, khng co ko c
h hp.
- Chp X quang phi: phi n tt (nu c iu kin kim tra X quang).
- Th CPAP vi p lc 5 cm nc, nng O
2
kh th vo (FiO
2
) <30 % m vn duy tr
SpO
2
92 %.
- Khi th CPAP tht bi (yu cu FiO
2
>60 % v p lc > 7 cm nc m khng hiu
qu) th chuyn th my hoc chuyn tuyn an ton (nu khng c my th).
4. K thut tin hnh: thc hin ng qui trnh k thut.
Lu :
- Bo m h thng th kn.
- Bo m v khun.
- Theo di, phng cc bin chng (trn kh mng phi, xut huyt ni s, nhim
khun ti ch).
| 233
XUT HUYT TR S SINH
Tuyn p dng.
Tt c cc tuyn.
Ngi thc hin.
Cn b cung cp dch v.

1. Tuyn x.
- Pht hin tr c nguy c xut huyt: ngt, kh, non thng.
- Nhn bit cc du hiu xut huyt da, rn, ng tiu ha v bt k mt du hiu
nguy him no.
- X tr:
Cm mu: chy mu rn, chy mu ch tim (bng p).
Tim bp 1 mg vitamin K
1
.
Chuyn tuyn an ton.
2. Tuyn huyn.
- Khm lm sng nh gi mc xut huyt.
- Lm cc xt nghim c bn chn on nguyn nhn: thi gian mu chy, thi gian
mu ng, cng thc mu (tiu cu)...
- X tr:
Nh tuyn x.
Truyn dch, truyn mu (ty mc mt mu).
Thng ng th, cung cp oxygen.
iu tr cc ri lon km theo (nu c).
Chuyn tuyn an ton khi vt qu kh nng iu tr.
3. Tuyn tnh.
- X tr nh tuyn huyn.
- Lm thm cc xt nghim: ng mu ton b v mt s cc xt nghim khc chn
on nguyn nhn (chn on hnh nh).
- X tr:
iu tr theo nguyn nhn.
iu tr cc ri lon km theo.
Chm sc h tr.
234 |
NHIM KHUN HUYT S SINH
Tuyn p dng.
Tt c cc tuyn.
Ngi thc hin.
Cn b cung cp dch v.

1. Tuyn x.
Chn on da vo bnh s v lm sng:
- Hi tin s b m, pht hin cc yu t nguy c nhim khun cho con.
- Xc nh cc du hiu nghi ng nhim khun huyt:
Ri lon thn nhit.
Biu hin thn kinh: li b hay kch thch, co git, run ry, c th hn m, ri lon
trng lc c, thp phng
Triu chng h hp: tm ti, th rn, th nhanh, co ko lng ngc nng, c cn
ngng th.
Triu chng tun hon: da xanh, tm, ni vn tm, da lnh, v m hi, nhp tim
nhanh, lon nhp.
Triu chng ngoi da: vng da sm, da xanh tm, ni ban, xut huyt, c nt phng
m, ph cng b.
Gan lch to.
Triu chng tiu ha: b km, nn, tiu chy, bng chng, km tiu.
- X tr: nu c mt hay nhiu triu chng nh trn, phi chuyn tuyn ngay. Trc khi
chuyn cn:
Khng sinh: tim bp (mng) ampicillin phi hp vi gentamycin, mt liu trc
khi chuyn tuyn.
Chuyn an ton ln tuyn trn.
2. Tuyn huyn.
- Chn on da vo bnh s, lm sng nh tuyn x v lm thm cc xt nghim c
bn: cng thc mu, X quang phi, soi cy vi khun.
- X tr:
iu tr ngay bng khng sinh ph rng, c th phi hp 2 n 3 loi khng sinh
ty theo bnh cnh trong thi gian 10 - 14 ngy.
Nu sau 48 gi khng ci thin v lm sng v cn lm sng cn hi chn
chuyn tuyn trn.
3. Tuyn tnh.
Thc hin nh tuyn huyn v:
- Chn on sm da vo lm sng, cc xt nghim c bn v cc xt nghim chuyn
su chn on nguyn nhn.
- X tr cp cu nu c (ri lon thn nhit, ri lon h hp, tun hon, co git)
- Phi hp khng sinh ph rng trc khi c kt qu xt nghim, nu sau 48 gi m bnh
cnh khng ci thin th nn hi chn i khng sinh v iu chnh khng sinh thch
hp theo kt qu khng sinh .
| 235
- Ch pht hin iu tr ngay cc bin chng v cc ri lon i km nh: ng mu
ni qun lan ta, ri lon ng mu, vim mng no m, co git, ri lon h hp - tun
hon, ri lon nc in gii, thng bng toan kim, ri lon chuyn ha
- Dinh dng v chm sc h tr.
- Theo di pht hin sm cc di chng x tr nu c.

236 |
NHIM KHUN MT
Tuyn p dng.
Tt c cc tuyn.
Ngi thc hin.
Cn b cung cp dch v.

1. Ti tuyn x.
1.1. Hi v khm lm sng phn loi l nhim khun ti ch hay lan rng.
- Nhim khun ti ch, nu:
Chy m mt t.
Mt khng sng .
- Nhim khun mt lan rng, nu:
Chy m mt nhiu.
Mt sng , lan rng.
C th c cc biu hin nhim khun ton thn.
1.2. X tr:
- Nhim khun ti ch:
iu tr ti ch, khng cn dng khng sinh ton thn.
Hng dn b m chm sc ti nh.
Hn khm li sau 2 ngy. Khm li ngay nu bnh khng hoc c cc du hiu
nguy him ton thn.
- Nhim khun lan rng:
Chuyn ln tuyn trn.
Cho 1 liu khng sinh tim bp trc khi chuyn.
2. Tuyn huyn, tnh.
- Hi v khm lm sng nh tuyn x.
- Lm xt nghim xc nh chn on nguyn nhn.
- Khm xc nh b m c b nhim khun ng sinh dc khng.
- X tr:
Nhim khun ti ch: iu tr v x tr nh tuyn x v chuyn v iu tr ti x
hoc hng dn b m iu tr ti nh (hn khm li theo hn, hng dn khm li
ngay khi khng hoc c du hiu nguy him ton thn).
Nhim khun nng: iu tr theo nguyn nhn:
Vim kt mc do t cu vng:
Tra m tetracyclin ln mt vim 4 ln/ngy trong 5 ngy.
Khng cn dng khng sinh ton thn.
Vim kt mc do lu cu:
Tim bp ceftriaxon 50 mg/kg, mt liu duy nht.
V sinh mt hng ngy.
| 237
Gii thiu, hi chn chuyn khoa da liu iu tr lu cu cho b m v ng
b/ngi tnh nu h cha c iu tr.
Vim kt mc do Chlamydia:
Cho ung erythromycin 75 mg/kg/ngy trong 14 ngy.
V sinh mt.
Nh thuc m tetracyclin 1 % cho n khi mt khng cn sng, , ht d, m.
Nu khng xc nh c nguyn nhn hoc khng lm khng sinh c,
iu tr nh sau:
Nu tr di 7 ngy tui, cha c iu tr khng sinh ton thn th iu tr
nh vim kt mc do lu cu.
Nu tr t 7 ngy tui tr ln v c iu tr khng sinh ton thn khng
kt qa hoc tr di 7 ngy tui, tnh trng bnh khng ci thin sau 48 gi
iu tr th iu tr nh vim kt mc do Chlamydia.
- Chm sc ton din:
Cn tun th cht ch cc nguyn tc phng chng nhim khun i vi s sinh
nhm hn ch ly nhim t tr ny sang tr khc.
C gng bo m cho tr nm vi m v nui con bng sa m hon ton.
- Gii thiu, hi chn chuyn khoa da liu iu tr cho b m v ng b/ngi tnh
nu h cha c iu tr.
238 |
NHIM KHUN RN
Tuyn p dng.
Tt c cc tuyn.
Ngi thc hin.
Cn b cung cp dch v.

1. Tuyn x.
1.1. Hi v khm lm sng phn loi l nhim khun ti ch hay lan rng.
1.2. Khm, phn loi.
- Nhim khun rn ti ch:
Rn t, sng, .
Vng quanh rn sng, lan rng di 1 cm.
- Nhim khun rn nng:
Rn sng, hoc chy m, c mi hi.
Vng quanh rn sng, lan rng xung quanh trn 1cm.
Chng bng.
1.3. X tr.
- Nhim khun rn ti ch:
iu tr ti ch, khng cn dng khng sinh ton thn:
Ra sch tay.
Ra sch rn v nh nhng thm kh.
Bi tm gentian 0,5 % ln vng rn nhim khun 4 ln/ngy cho n khi ht
m.
Ra sch tay sau khi chm sc rn.
Hng dn b m chm sc ti nh.
Hn khm li sau 2 ngy. Khm li ngay nu bnh khng hoc c cc du hiu
nguy him ton thn.
- Nhim khun rn nng: chuyn ln tuyn trn. Tim bp 1 liu khng sinh trc khi
chuyn.
2. Tuyn huyn, tnh.
- Hi v khm lm sng nh tuyn x.
- Chn on v xc nh nguyn nhn.
- X tr cc bin chng hoc cc bnh km theo.
- Lm cc xt nghim: cy dch hoc m rn, cng thc mu, cy mu nu c nghi ng
nhim khun huyt.
- X tr:
Nhim khun ti ch: iu tr nh tuyn x.
Nhim khun rn nng:
Nu nhim khun rn do nhim khun bnh vin, x tr theo hng dn v
nhim khun bnh vin.
iu tr nh nhim khun huyt.
| 239
iu tr cc bin chng hoc cc bnh km theo nu c.
Sau khi ngng khng sinh th theo di tr trong 24 gi, nu ht nhim khun
rn, tr b tt, khng cn du hiu cn nm vin th cho tr ra vin v hng
dn b m chm sc, theo di ti nh.
Nu c kt qa khng sinh , iu tr theo khng sinh .
Chm sc rn ti ch.
- Chm sc ton din: lun tun th cht ch nguyn tc phng chng nhim khun
trong chm sc tr trnh ly nhim t tr ny sang tr khc. Bo m tr c b m
hon ton v c gng b tr tr nm cng vi m.

240 |
TR SINH RA T M B VIM GAN B,
LAO, LU, GIANG MAI , HIV

Tuyn p dng.
Tt c cc tuyn.
Ngi thc hin.
Cn b cung cp dch v.

1. M b vim gan B.
1.1. Tuyn x.
- Nu pht hin m b vim gan B trong giai on mang thai th nn khuyn m
tuyn trn vic x tr sau c y hn.
- Nu ti trm y t:
Tim phng vaccin vim gan B cho con ngay trong vng 24 gi sau v globulin
min dch, nu c. Nu khng c iu kin, chuyn tr ln tuyn trn.
Vn cho tr b m tr khi m ang trong giai on vim gan B cp.
- Tim bp (i) cho tr vaccin vim gan B 0,5 ml, liu u tin trong vng 12 gi sau
sinh, tt nht l tim ngay sau sinh, cng sm cng tt.
- Nu c globulin min dch khng virus vim gan B, tim bp 0,5 ml (i bn kia) trong
vng 24 gi, chm nht l 48 gi.
2. M b bnh lao.
Nguyn tc chung:
- Nu b m iu tr y hay ang iu tr ng theo phc c 2 thng th
khng cn iu tr cho tr.
- Nu b m ang b lao phi tin trin v c iu tr trc khi sinh cha 2 thng
hoc mi pht hin lao th:
2.1. Tuyn x.
- Vn cho tr b sa m.
- Khng c tim vaccin BCG cho tr sau sinh.
- Chuyn tuyn trn hoc bo chng trnh phng chng bnh lao iu tr.
2.2. Tuyn huyn, tnh.
Thc hin nh tuyn x v:
- Cho tr ung d phng isoniazid 5 mg/kg/ngy, 1 ln/ngy, trong 6 thng.
- Khi tr c 6 tun tui th nh gi li cn nng v cho tr chp X quang phi.
- Nu tr khng tng cn hoc c du hiu gi lao tin trin th iu tr thuc khng lao
theo ng phc cho tr n 6 thng tui.
- Nu tr tng cn tt, xt nghim lao m tnh th ch cho tr isoniazid d phng trong 6
thng.
- Ch tim vaccin BCG cho tr sau khi tr hon thnh iu tr 2 tun.
- Khuyn m tip tc iu tr bnh lao n khi n nh.
| 241
3. M b giang mai.
3.1. Tuyn x.
- Pht hin cc trng hp b m b giang mai qua qu trnh qun l thai nghn, kim tra
xem m c iu tr y cha. Nu cha th khuyn m ti tuyn trn iu
tr cho tr sau sinh.
- Pht hin cc triu chng ca giang mai bm sinh chuyn tuyn trn (c cc nt ,
cc m xm, phng hay tut da lng bn tay bn chn km gan lch to, vng da,
thiu mu, nhim khun nng). Nu c, chuyn tuyn trn c m v con.
- Nu b m iu tr y (2,4 triu v penicilin) t nht 30 ngy trc sinh th
khng cn iu tr cho tr.
- Nu b m cha iu tr giang mai, iu tr cha y hoc khng bit chc chn qu
trnh iu tr ca mnh th tim bp procain benzylpenicillin (hoc bezathin benzyl-
pennicillin) cho tr nh sau:
Nu tr khng c triu chng: tim bp procain benzyl penicillin 50.000 v/kg
(hoc benzathin benzyl - pennicilin) liu duy nht cho tr.
Nu tr c triu chng: tim bp procain benzyl penicilin 50.000 v/kg, 1 ln/ngy
trong 10 ngy cho tr. Hoc benzyl penicilin 50.000 v/kg, 12 gi/ln trong 7 ngy
u v 8 gi/ln cho 3 ngy sau .
Hn tr n khm li sau 4 tun kim tra sc khe, s pht trin v triu chng
giang mai.
4. M b bnh lu.
4.1. Tuyn x.
- Chn on:
Da vo tin s bnh lu ca m.
Khm tr xc nh xem tr c b nhim lu cu khng. Ch triu chng vim
mt c m vng c cng nh c th c bnh cnh nhim khun ton thn do lu
cu.
- X tr:
Nu nhim khun nh: dng 1 liu ceftriazon duy nht 25 - 50 mg/kg tim bp hay
tnh mch (nu c) hoc chuyn ngay ln tuyn trn.
Nu tr c triu chng nhim khun ton thn nng: chuyn tuyn trn. Cho tim 1
liu khng sinh nh trn trc khi chuyn.
4.2. Tuyn huyn.
- Chn on nh tuyn x v:
Soi, cy tm song cu lu Gram (-).
Xc nh xem tr ch b vim mt hay cn b nhim khun huyt, vim khp hay
km vim mng no.
- X tr:
Nu m b bnh lu cha c iu tr n nh th tim d phng cho tr 1 liu duy
nht ceftriazon 25 - 50 mg/kg, tim bp (tng liu khng qu 125 mg)
Nu tr ch b vim mt th ch cn dng 1 liu ceftriazon duy nht 25 - 50 mg/kg,
tim bp hay tnh mch (khng cn thit phi dng khng sinh nh mt).
242 |
Nu tr c triu chng nhim khun ton thn nng hoc iu tr 2 ngy khng :
chuyn tuyn trn, cho tim 1 liu khng sinh nh trn trc khi chuyn.
4.3. Tuyn tnh:
X tr nh tuyn huyn v:
- Chn on sm mc nhim khun do lu cu da vo lm sng v cc xt nghim
(vi khun, sinh ha).
- X tr:
Chn on v iu tr nh tuyn huyn nu ch b lu mt.
Nu tr b nhim khun huyt, vim khp hay b vim mng no do lu cu th
dng ceftriazon 25 - 50 mg/kg, tim bp hay tnh mch, mi ngy mt ln t 10 -
14 ngy. Hoc: cefotaxim liu 50 mg/kg/ngy (chia 2 ln) trong 7 ngy hoc 10 -
14 ngy nu c vim mng no.
5. M b nhim HIV.
5.1. Tuyn x.
- Thc hin cc nhim v theo Qui trnh chm sc v iu tr d phng ly truyn HIV
t m sang con ti tuyn x.
- Qun l v theo di gim st iu tr d phng, chuyn tuyn khi nghi ng tr c nhim
khun.
- H tr, theo di tun th iu tr cho m v con sau sinh (dng thuc v dinh dng
cho tr).
- Tr vn c th c tim chng theo lch nhng trnh cc loi vaccin sng (BCG,
sabin).
5.2. Tuyn huyn.
- Chn on xc nh da vo h s bnh n v thng tin t khoa sn hay tuyn di vi
kt qu xt nghim lm ti cc c s c B Y t cng nhn. Vic chn on v x
tr phi tun theo qui nh v hng dn chung.
- X tr: chm sc tr ngay sau sinh vi nguyn tc v khun, chng ly nhim cho.
Kim tra xem b m c dng thuc iu tr d phng ly truyn HIV t m
sang con cha.
iu tr cho tr theo phc hng dn quc gia:
Nu b m c iu tr zidovudin (AZT) 4 tun trc khi sinh th tip tc
iu tr AZT cho tr trong 6 tun sau sinh (ung 2 mg/kg, 6 gi/ln).
Nu b m c iu tr mt liu nevirapin trong khi sinh, tr cha c 3
ngy tui th cho tr ung ngay nevirapin 2 mg/kg/ngy.
Theo di cho tr trong 10 ngy kim tra tnh trng dinh dng v tng
trng.
Dinh dng: t vn dinh dng theo khuyn ngh ca B Y t.
Nu khng th iu tr thuc khng virus th t vn k vi gia nh chuyn tr
n tuyn thch hp.
5.3. Tuyn tnh.
- Chn on v x tr nh trn.
- Lm cc xt nghim kim tra theo ng qui nh.
- Ch t vn v hng dn cho gia nh sau xut vin.
- C k hoch theo di (hoc chuyn h s sang Trung tm phng chng HIV/AIDS)
theo di v sc khe v xt nghim nh k cho tr sau ny.
| 243
HI CHNG CO GIT
Tuyn p dng.
Tt c cc tuyn.
Ngi thc hin.
Cn b cung cp dch v.

1. Tuyn x.
- Xc nh cn git da vo cc biu hin lm sng.
- X tr cp cu: phi bo m h hp - tun hon v ct cn git:
Thng ng th, h tr h hp, th oxygen nu cn.
Ct cn git: phenobarbital: 15 - 20 mg/kg, tim bp. Nu sau 30 pht m cn git
c th lp li ln 2 vi liu 10 mg/kg hoc phenobarbital ung (gardenal) 10 - 20
mg/kg.
- Chuyn vin an ton ln tuyn trn. Cho mt liu khng sinh tim bp trc khi
chuyn.
2. Tuyn huyn.
- Xc nh mt s nguyn nhn thng gp:
Ri lon in gii v chuyn ha: h ng huyt, h calci...
Hi chng mng no.
Cc xt nghim c bn: cng thc mu, in gii , ng huyt, chc d ty
sng
- X tr: ct cn git v iu tr theo nguyn nhn, cho th oxygen (nu cn), chm sc
h tr khc.
- Chuyn vin an ton ln tuyn trn khi vt qu kh nng iu tr.
3. Tuyn tnh.
Nh tuyn huyn v:
- Lm cc xt nghim chn on nguyn nhn.
- Lm mt s xt nghim thm d khc (nu cn): siu m, in no , chp ct lp
no
- iu tr nguyn nhn.
- Chm sc h tr.
- T vn v theo di tr sau khi ra vin.
244 |
CP CU SC SA
Tuyn p dng.
Tt c cc tuyn.
Ngi thc hin
Cn b cung cp dch v.

1. Tuyn x.
- Hng dn cc b m pht hin v s cu sc sa kp thi theo qui trnh k thut:
t tr nm sp trn tay hoc i ca bn, u thp hn thn.
V lng: dng bn tay phi v 5 ci vo lng tr khong gia 2 xng b vai.
Nu cn tc nghn, lt nga tr tin hnh n ngc:
Lt tr nm nga, dng 2 ngn tay (tr v gia) n 5 ci vo v tr di im ct
ca ng ni 2 nm v v ng gia c mt khat ngn tay.
Nu cn tc nghn: quan st vng hng v mi tr, nu c sa th ht sch.
Nu cn thit, c th lp li trnh t nh trn.
Trong khi cp cu nh trn phi quan st nh gi tr. Nu ngng tim, ngng th
th tin hnh hi sc ngng tim, ngng th (xem bi Cp cu ngng th, ngng
tim).
- Chuyn tuyn khi tr th c.
2. Tuyn huyn.
Tin hnh cc cp cu ban u nh tuyn x v
- X tr cc bin chng km theo.
- Chuyn tuyn khi vt qu kh nng iu tr hoc tnh trng tr khng ci thin sau 2
ngy iu tr.
3. Tuyn tnh v trung ng.
Nh tuyn huyn.
- H tr h hp khi cn.
- iu tr cc triu chng nng km theo khc.

| 245
HI SC S SINH NGAY SAU
Tuyn p dng.
Tt c cc tuyn.
Ngi thc hin.
Cn b cung cp dch v.

1. Cc bc hi sc sau sinh thc hin tt c cc tuyn.
- Trong 30 giy u tin:
nh gi nhanh v xc nh xem tr c cn hi sc khng bng ch s Apgar.
m v tin hnh hi sc ngay nu tr khng khc, khng th hoc tm ti: t tr
nm, u hi nga, khn trng tin hnh ht dch hu hng v mi sau thng
ng h hp, kch thch th v t mt n bp bng, cung cp oxygen (nu cn).
- 30 giy tip theo:
Nu tr hng li, th tt th chm sc thng qui v theo di st.
Nu tr vn khng th th nhanh chng kim tra li mt n, chnh li t th u tr
v tip tc bp bng .
- nh gi tr sau 1 pht:
Nu sau tr t th c: tip tc theo di st.
Nu tr vn khng th: kim tra nhp tim:
Nu nhp tim > 60 ln/pht: bp bng 40 ln/pht, cung cp oxygen (nu c)
ngng bp bng khi nhp th > 30 ln/pht.
Nu nhp tim < 60 ln/pht th gi h tr v tin hnh n tim 120 ln/pht, ng
thi bp bng oxygen 40 ln/pht. Ngng n tim khi nhp tim > 100 ln/pht.
- Nu hi sc tch cc 20 pht m khng c kt qu th ngng hi sc.
Ch :
- Phi lun bo m gi m cho tr trong qu trnh hi sc.
- Chn mt n thch hp vi cn nng ca tr.
2. T tuyn huyn, tnh tr ln.
- Nn t ni kh qun bp bng gip th ngay nu:
Tr b thot v honh bm sinh.
Tr ht i ln phn su.
Tr ngt nng (Apgar <3).
Hi sc qua mt n tht bi.
Tr cn dng thuc qua ng ni kh qun (adrenalin, narcan).
Tr cn phi hi sc ko di.
- S dng cc thuc cn thit (nu c ch nh):
Adrenalin 1/1000:
Ch nh: khi nhp tim <60 ln/pht sau 30 giy bp bng oxygen.
Liu lng: 0,1 mg/ln nu tim tnh mch v 0,3 mg/ln nu bm qua ni kh
qun. C th lp li nu cha hiu qu.

246 |
Natri bicarbonat 4,2 %:
Ch nh: khi tr b toan chuyn ha
Liu: 1 - 2 mEq/kg tim tnh mch (2 - 4 ml/kg).
Glucose 10 %: 3 - 5 ml/kg tim tnh mch.
Naloxon (Narcan):
Ch nh: nu tr b c ch h hp do s dng morphin hay dn xut ca morphin
trong vng 2 gi trc sinh.
Liu lng: 0,1 mg/kg tim tnh mch hoc bm qua ni kh qun.
- Sau khi hi sc cn phi xc nh nguyn nhn gy ngt v chuyn vo khoa s sinh
hoc chuyn ln tuyn trn tip tc iu tr (nu cn).

| 247
TRUYN MU
Tuyn p dng.
Bnh vin tuyn huyn, tnh, trung ng.
Ngi thc hin.
Bc s v iu dng vin.

1. Ch nh.
- Chong do mt mu cp hoc chy mu nhiu.
- Thiu mu v c du hiu suy h hp:
Hematocrit <40 % nu tr phi th my.
Hematocrit <35 % nu tr phi th oxygen nng >30 %.
Hematocrit <30 % nu tr phi th th oxygen nng 30 %.
Tr khng suy h hp:
Hematocrit <25 % nu tr non.
Hematocrit <20 % nu tr thng.
- C du hiu suy h hp, suy tun hon: truyn mu khi hematocrit:
<40 % nu tr vn suy h hp mc ang d th my.
<35 % nu cn cung cp oxygen vi FiO
2
>30 %.
C cn ngng th v chm nhp tim.
<30 % nu cn cung cp oxygen vi FiO
2
30 %.
- Tr di 4 tun tui khng c suy h hp: truyn mu khi hematocrit <30 % v
C cn ngng th ti pht v chm nhp tim hoc khng tng cn.
Cn phu thut hoc hu phu.
- i vi tr non: trn 4 tun tui khng c suy h hp: truyn mu khi hematocrit <
25 % v
C cn ngng th ti pht v chm nhp tim hoc khng tng cn.
Cn phu thut hoc hu phu.
- Trong trng hp phi thay mu iu tr vng da nng hoc thay mu mt phn.
- Trong mt s trng hp nhim khun nng.
- Trong nhng trng hp c ri lon v ng cm mu.
- Chong do mt mu cp hoc chy mu nhiu v lin tc.
2. Chng ch nh: mu khng ph hp
3. Tin hnh.
- Theo ng qui trnh k thut:
Thit lp ng truyn tnh mch, bo m tnh mch v kim tim to truyn
mu.
Kim tra xem dng ng nhm mu cho tr cha, th phn ng cho.
Kim tra cht lng ca ti mu truyn.
Kim tra tnh trng bnh nhn trc khi truyn (ghi nhp th, nhp tim, thn nhit).
Lp ti mu vo dy truyn mu.
S lng truyn trung bnh 20 ml/kg.

248 |
Theo di cht ch 5 pht/ln cho tr trong 15 pht u.
Tip theo di t nht 1 gi/ln trong sut qu trnh truyn.
Sau khi truyn xong phi theo di 4 gi/ln.
Thi gian truyn cho mi ti mu khng qu 4 gi.
Ghi vo phiu truyn cc thng s:
Thi gian bt u v kt thc truyn.
Lng v loi mu truyn.
- Cc din bin c bit trong khi truyn.
- Bo m nguyn tc v khun.
- Chm sc v theo di cht ch trong sut qu trnh truyn mu pht hin nhng tai
bin v x tr kp thi.
- Mt s tai bin c th gp:
Chong phn v.
Nhim khun do mu truyn hoc thao tc khng v khun.
Phn ng tan mu nng do bt ng nhm mu.
Truyn qu nhanh hoc qu nhiu gy qu ti: biu hin suy tim hoc ph phi.

| 249
T CATHETER TNH MCH RN
Tuyn p dng.
Bnh vin tuyn huyn tr ln.
Ngi thc hin.
Bc s c hun luyn v hi sc s sinh.

1. Ch nh.
- Hi sc s sinh cn truyn tnh mch, ly mu xt nghim cp cu m khng ly c
tnh mch ngoi vi.
- Thay mu.
- o p lc tnh mch trung tm.
Ch : Ch tin hnh th thut khi rn cha rng hoc mi rng 1 - 2 ngy.
2. Chng ch nh.
- Nhim khun rn.
- Cc d tt vng rn.
- Vim phc mc (chng ch nh tng i).
- Phu thut vng rn.
3. Nguyn tc tin hnh.
o di ng catheter cn a vo.
Xc nh thnh tnh mch.
Nh nhng lun catheter vo.
Lp bm tim vo u ng thng, kim tra xem catheter thng cha.
C nh catheter.
- Bo m nguyn tc v khun.
- Pht hin nhng tai bin v x tr kp thi.

250 |
NUI DNG TR S SINH BNG NG TNH MCH

Tuyn p dng.
Tuyn tnh hoc cc trung tm c hi sc cp cu, iu tr s sinh.
Ngi thc hin.
Bc s c hun luyn v nui dng tr s sinh bng ng tnh mch
1. Ch nh.
- non thng m khng nui dng c bng ng tiu ha, khng m bo nhu
cu c bn.
- Khng nui c bng ng tiu ha:
R kh thc qun.
Suy h hp v nhim khun qu nng.
Trc v sau phu thut ng tiu ha.
Vim rut hoi t.
Nn nhiu (khng dung np thc n).
- Trc khi tin hnh cn nh gi tr bnh (tui thai, cn nng, tnh trng bnh) v xc
nh nui tnh mch mt phn hay ton phn.
- m bo nhu cu dch, nng lng, cc cht protid, glucid, lipid, vitamin, cc in
gii v phn chia u dch trong 24 gi .
- Thit lp ng truyn thc hin truyn cc dch chun b qua ng tnh mch.
- Theo di lm sng v lm cc xt nghim cn thit (in gii , ng huyt...)
3. Tai bin v x tr.
- Sng phng, chy mu, nhim khun ni tim truyn: cn tm ngng truyn x tr,
thit lp ng truyn khc.
- Nu c ri lon ng huyt: cn phi nh lng ng huyt 6 gi/ln.
- Ri lon nc v in gii: phi kim tra in gii t 1 n 3 ngy/ln iu chnh
cng nh cn theo di cn nng tr hng ngy nh gi thm tnh trng ri lon nc.

| 251
THAY MU TR S SINH
Tuyn p dng.
Bnh vin tuyn tnh v tuyn trung ng c kh nng v iu kin thc hin.
Ngi thc hin.
Bc s.
1. Ch nh.
- Nng bilirubin gin tip trong mu tng cao c ch nh thay mu.
- Nhim khun nng khng p ng vi iu tr.
- a hng cu (hematocrit >70 %), c triu chng suy h hp do c c mu.
2. Chng ch nh.
- Vng da tng bilirubin trc tip.
- ang c biu hin chong nng, suy h hp nng.
- Bo m tr sn sng cho truyn mu.
- Chun b y cc dng c.
- Thc hin ng k thut, nh nhng, khng bm, rt mu nhanh.
- Theo di st ngi bnh trong khi thay mu, mu sc da, nhit , nhp th, nhp tim
- Chn nhm mu ph hp (h Rh, ABO) vi nhm mu m v con.
- S lng mu thay: 150 - 200 mg/kg cn nng.
- Mu thay l mu c bo qun khng qu 72 gi.
- m bo v khun tuyt i.
- m bo ng qui trnh k thut:
St khun rn v vng da xung quanh rn.
T t a ng thng vo tnh mch rn cho n khi mu tro ra. Ni ng thng vi
chc 3.
Rt mu ra lm xt nghim cn thit (rt bao nhiu mu, bm tr li bng s lng
mu rt ra).
Bm mu v rt mu phi lm t t, mi ln ch 5 - 20 ml ty theo cn nng ca
tr. Tc thay mu trung bnh: 70 - 80 ml/kg/gi.
- Sau khi thay mu: xt nghim li bilirubin, cy mu.
- Tip tc chiu n sau khi thay mu v theo di bilirubin.
- Trong trng hp nghi c nhim khun, sau khi thay mu cn phi dng khng sinh.
- Kim tra, theo di cc xt nghim cn thit.
4. Theo di v x tr cc tai bin.
- Chy mu rn.
- Nhim khun.
- Tc mch do kh.
- H thn nhit.
- Chong do bm mu nhanh c bit l tr non.

252 |
LY MU NG MCH

Tuyn p dng.
Ngi thc hin
Bc s v iu dng vin.

1. Ch nh.
- Ly mu xt nghim kh mu.
- Ly mu xt nghim khi khng ly c mu tnh mch.
2. Chng ch nh.
- Thn trng trong nhng trng hp c ri lon ng - cm mu.
3. Tin hnh.
Chun b dng c cn thit.
Tun th cc nguyn tc chng nhim khun.
Xc nh ng mch cn ly: thng ly ng mch quay, ng mch thi dng
hoc mt s ng mch nng vng u.
Ra tay, eo gng.
St khun vng da c ng mch cn ly mu.
Lun kim vo da theo gc 15 , mt vt ca kim quay ln trn.
C th dng kim gn bm tim hoc kim khng c bm tim ly mu.
Ch ly lng mu cn thit.
Sau khi ly mu xong: rt kim, dng bng v khun n mnh ch ly mu cm
mu.
- Pht hin nhng tai bin v x tr kp thi:
Nhim khun ti ch hoc ton thn: chm sc ti ch hoc dng khng sinh ton
thn, nu cn.
Chy mu ko di ti ch cm mu: cm mu tch cc, nu chy mu khng cm
phi truyn mu.

| 253
LY MU GT CHN

Tuyn p dng.
Ngi thc hin.
Bc s v iu dng vin.

1. Ch nh: Khi cn ly mt lng mu nh lm xt nghim ng mu, kh mu, cc
xt nghim sng lc...
2. Tin hnh:
Chun b y dng c: ch cc dng c quan trng nh kim chuyn dng
lancet hoc kim 24, ng thy tinh mao mch
Tun th cc nguyn tc v khun.
Ra tay, i gng.
St trng vng gt chn.
Gp bn chn ng t th.
Dng kim chm vo gt v tr pha trong hoc pha ngoi gt chn.
Ch khng chm vo gan chn gy nguy him.
Bp nh gt chn mu ra.
Ly mu vo ng lm xt nghim.
Sau khi ly xong mu phi n ch ly mu trong vi pht cm mu.
- Pht hin nhng tai bin v x tr kp thi.
Nhim khun ti ch ly mu.
Vt chm qu su, chy mu ko di.

254 |
T NI KH QUN
Tuyn p dng.
Ngi thc hin.
Bc s, iu dng vin v n h sinh c o to

1. Ch nh.
- Hi sc h hp v tun hon.
- Suy h hp nng, cn th my hoc bp bng qua ng ni kh qun.
- Thot v honh cn c h tr h hp.
- Un vn cn h tr h hp.
2. Chun b.
- Kim tra cc dng c cn thit: bo m y v ph hp vi tui s sinh.
- Gii thch cho ngi nh v s cn thit lm th thut.
- Thc hin ng qui trnh, k thut v lu t th ng khi t ni kh qun. Lun cn
c thm 1 ngi ph.
Tun th y cc nguyn tc v khun.
Chun b bnh nhn: bo m thng ng h hp, tim cn p.
Chun b y dng c: li n soi, ng ni kh qun, my ht, bng, ng nghe.
Chn li n, ng ni kh qun ph hp vi tr.
t tr nm nga, k gi mng di vai u hi nga ra sau.
Tay tri cm cn n, a li n vo ming tr nng li tr ln.
Nng cn n theo hng ln trn v ra trc, khi nhn thy dy thanh m, dng tay
phi a ng ni kh qun vo qua thanh mn.
Dng tay tri rt nng ni kh qun.
Lp u ng ni kh qun vo bng v bp bng. Dng ng nghe kim tra xem ng
ni kh qun vo ng v tr cha? c su qu khng?
Nu ng ni kh qun vo ng v tr, nh du v c nh li.
- Theo di nh gi tr: k thut t tt khi nghe r ro ph nang u 2 phi, lng ngc
ln xung u theo nhp bng. u ng ni kh qun nm v tr trn ng ba kh qun
1 cm. Tr hng ho, bo ha oxygen ci thin tt.
4. Theo di v x tr.
- a ng nhm vo thc qun: rt ng ra, bp bng cho tr kh ln ri t li.
- Tut ng ni kh qun: t li v c nh. Cc thao tc phi lm nhanh chng.
- Tc ng ni kh qun: ht lm thng hoc t li ng ni kh qun.

| 255
CHC HT V T NG DN LU MNG PHI

Tuyn p dng:
Ngi thc hin
Bc s c o to

1. Ch nh :
- Trn kh hoc trn dch mng phi gy kh th do chn p
- t dn lu mng phi trong trng hp trn kh hoc trn dch gy chn p ko di
- iu tr: dn lu kh v dch trong cc trng hp
+ Trn kh mng phi gy kh th, chn p v d kh ph mc
+ Trn dch (mu, m, dng chp)
+ Dn lu sau m lng ngc
2. Nguyn tc tin hnh th thut:
- Gii thch cho ngi nh tr bnh s cn thit phi lm th thut v cc tai bin c th
xy ra trong qu trnh tin hnh
- Trc khi lm th thut cho tr cn c xc nh v tr v mc , trn kh hoc trn
dch mng phi bng X quang. Bo m v khun tuyt i.
- Bo m h thng dn lu kn.
- Thc hin ng quy trnh k thut:
+ Thc hin v khun theo ng quy trnh.
+ V tr chc d: lin sn 2-3 ng gia xng n pha trn trn kh; lin sn 5-
6 ng nch gia pha bn trn dch
+ Lp bm tim vi chc ba v kim chc d
+ Chc kim thng gc vo v tr c xc nh: khoang lin sn 2-3, ng gia
xng n, b trn ca xng sn di: i vi chc ht kh; khoang lin sn 5-
6, ng nch gia, b trn ca xng sn di vo khoang mng phi: i vi
chc ht dch.
+ Rt kh hoc dch qua bm tim
+ Rt kim v p cht ch chc d vi giy
+ t 1 ming bng gc v khun ln vng chc d, bng dnh
+ Theo di tnh trng mch huyt p, h hp ca tr sau chc d
- Nu cn t ng dn lu th phi khu c nh ng v bng li bng bng v khun
3. Theo di v cch x tr
- Chc chm vo t chc phi: cn rt ra nng hn v theo di tip tc.
- Chy mu: bng p v theo di mc xut huyt x tr.
- Trn kh di da: c th xy ra nhng thng t gp, kh s t rt.
- Theo di: tnh trng mch, huyt p, h hp ca tr trong v sau chc d.
- Theo di h thng dn lu, khi tr bnh n nh kim tra li bng Xquang.

256 |
K THUT T NG THNG D DY CHO TR S SINH
Tuyn p dng.
Ngi thc hin.
Bc s v iu dng.

1. Ch nh.
- Nui dng qua ng thng d dy v ly dch lm xt nghim.
- Dn lu dch v kh t d dy trong cc trng hp: bng chng, vim rut hoi t...
- D tt bm sinh ng tiu ha (teo, tc...)
2. Tin hnh.
Nguyn tc tin hnh:
- Gii thch cho ngi nh tr trc khi tin hnh.
- Bo m v khun.
Ra tay sch, eo gng tay.
c lng di ng cn thit: Gi ng v tr nh khi c a vo trong c
th (tc l t ming hoc l mi n vnh tai di v sau xung n bng, ngay
pha di mi c; v dng bt hoc bng dnh nh du trn ng.
Hi gp c ca tr v nh nhng a ng vo bn trong ming tr hoc qua 1 bn
mi n on ng nh du theo nhp nut ca tr.
- Khi cho n qua ng thng, cn ht dch d dy trc khi cho n nh gi lng dch
ng.
- C nh ng thng bng bng dnh.
- Trng hp dng ng thng dn lu dch d dy th cht thi chy vo ti sch v
c nh ng thng bng bng dnh.
3. Theo di v cch x tr.
- Tm ti ngng th trong khi t ng thng d dy do ng thng i lc vo kh qun. X
tr: rt ngay ng thng d dy ra. Hi sc tim phi khi cn thit.
- Try xc nim mc thc qun gy chy mu.
- Gy sc sa, vim phi ht do cho n qua ng thng d dy khi ng thng d dy nm
sai v tr.
- Thi gian lu ng thng: thay ng thng mun nht l sau 48 gi.

| 257
K THUT CHIU N IU TR VNG DA

Tuyn p dng.
Ngi thc hin.
Bc s v iu dng vin.

1. Ch nh: Nng bilirubin trong mu vt qu mc bnh thng theo ngy tui, cn
nng v mc vng da hoc da vo tiu chun trong bng Krammer.
2. Chng ch nh: Khi vng da tng bilirubin trc tip.
- Cn chiu n sm c bit tr non.
Thc hin ng qui trnh k thut.Tr cn phi c nm trn ch qun mt kh
mng da ca tr tip xc vi nh sng cng nhiu cng tt. Thay i t th 2
gi/ln. Bo m thn nhit cho tr.
Che mt v b phn sinh dc khi chiu n.
Bi ph lng nc mt khi chiu n. Khuyn khch dng sa m.
Kim tra bilirubin mu 12 - 24 gi/ln v da vo kt qu xt nghim bilirubin gin
tip, ton phn c ch nh tip tc iu tr bng phng php chiu n na hay
khng.
Ngng chiu n khi: vng da gim r, bilirubin tr v bnh thng.
Chuyn thay mu nu chiu n khng hiu qu, bilirubin tng cao.
4. Chm sc v theo di.
- Theo di cn nng, m bo nng lng nui dng tr ty theo ngy tui v cn nng.
- Theo di tnh trng da, triu chng thn kinh trn lm sng.
- Theo di ng huyt, bilirubin mu v in gii kp thi iu chnh.

258 |
CHC D TU SNG

Tuyn p dng.
Ngi thc hin.
Bc s.

1. Ch nh.
- Chc d xc nh cc bnh vim mng no, xut huyt no - mng no.
- nh gi p ng trong iu tr vim mng no nhim khun.
2. Chng ch nh.
- Suy h hp cha c h hp vin tr.
- Nhim khun ti v tr chc d.
- Thot v mng no tu ti v tr chc d.
- Kim tra chc nng sng ca tr trc khi tin hnh.
- Tin hnh th thut khi tr khng b kch thch.
- Tun th theo qui trnh v khun.
- m bo gi m cho tr trong qu trnh lm th thut.
- Thc hin ng qui trnh k thut:
Ngi ph gi tr nm nghing, quay mt v pha ngi ph, lng thng ng vi
mt bn, hi un lng tr sao cho cc khe t lng gin rng.
Ngi lm th thut xc nh v tr chc: khe lin t sng tht lng 4 - 5.
St khun.
Chc vo khe lin t.
Sau khi ly dch, lp thng nng v rt kim.
Bng p bng gc v khun.
4. Theo di v cch x tr.
- Chc chm mu: dng th thut, chc li sau 24 gi.
- Nhim khun ti ch: chm sc v trnh chc kim tra dch no ty ti cc v tr
cc ln chc sau.
- t tr nm ti phng trong vng 5 pht.
- Theo di tnh trng tim mch, h hp, ton trng trong 10 pht trc khi a tr v vi
m.
- Ch pht hin cc bin chng nh: suy h hp, suy tun hon, nhim khun, t mu
ni chc d... x tr kp thi.

259 |
H NG HUYT S SINH
Tuyn p dng.
Tt c cc tuyn.
Ngi thc hin.
Bc s, n h sinh, y s sn nhi v iu dng.

1. Tuyn x.
- Pht hin ch yu da vo bnh s v cc triu chng lm sng:
Tin s: tr c m b bnh i ng, tr b khng sa.
Lm sng: li b, gim trng lc c, run git chi, co git, b yu, t vn ng, c th
b ngng th, h thn nhit, hn m.
- X tr:
S cu, ct cn git, nu c co git (xem bi X tr co git).
Cho b m, nu khng b c th vt sa v cho n bng tha.
Chuyn vin an ton ln tuyn trn nu tr khng b c hoc c du hiu lm
sng nng ln. Ch cho tr n v gi m khi chuyn.
2. Tuyn huyn.
- Chn on: nh tuyn x v:
Xc nh mc h ng huyt (test nhanh, xt nghim mu).
Xc nh nguyn nhn v cc bnh km theo iu tr.
- X tr:
Ty mc h ng huyt m x tr: cho n qua thng d dy, tim hoc truyn
tnh mch glucose. X tr cc ri lon km theo.
Nu iu tr m ng huyt vn thp sau 2 ln th hoc c du hiu bnh nng
hn th chuyn ln tuyn trn.
3. Tuyn tnh:
X tr nh tuyn huyn v:
- Chn on xc nh, tm cc nguyn nhn cng nh pht hin cc ri lon km theo (co
git, ngng th, h thn nhit)
- X tr theo mc h ng huyt theo lu sau:
- iu tr nguyn nhn v iu chnh cc ri lon i km (co git, ngng th...)
- Theo di sau xut vin.

o ng huyt
> 45 mg/dl
- Cho b sm
- Th ng huyt 12
gi/ln n khi n
nh (2 ln lin tip >
45 mg% )

< 25 mg/dl:
- TimTM glucose 10% 2ml/kg
- Truyn TM glucose 6-8 mg/kg/pht
- Cho n smhoc bm sa qua ng
thng d dy
- Theo di test nhanh 3 gi/ln n khi
n nh (2 ln lin tip >45 mg%)
25 45 mg/dl
- Cho b sm hoc bm qua
ng thng d dy.
- Th test nhanh dextrostix
3 gi/ln n khi n nh
(2 ln lin tip >45 mg%

260 |

261 |

PHN 4
K HOCH HA GIA NH

262 |

| 263
T VN K HOCH HA GIA NH
Tuyn p dng.
Tt c cc tuyn.
Ngi thc hin.
Cn b cung cp dch v.

T vn K hoch ha gia nh (KHHG) c chung cc k nng v cc bc nh trong
t vn chm sc SKSS (xem bi T vn v chm sc SKSS). Bi ny ch nu nhng
im ring bit cho t vn trong KHHG. Trong qu trnh t vn, khi trnh by v cc
bin php trnh thai (BPTT) c th nn s dng ti liu B tranh lt t vn KHHG. Khi
t vn cho ngi HIV(+) nn s dng ti liu B tranh lt t vn KHHG cho ngi
HIV(+).
T vn gip khch hng t la chn mt BPTT thch hp trong mt giai on sinh sn
nht nh. Ni dung t vn p ng nhu cu ca khch hng ch khng xut pht t
mun ch quan ca ngi t vn. Cn lu l tr bao cao su, cc bin php KHHG khc
khng c tc dng phng cc NKLTQTD.
1. Vai tr ca t vn KHHG.
- Gip khch hng chn ng mt BPTT v s dng ng bin php chn.
- Gip tng t l tip tc s dng v hn ch b cuc.
- Gip tng t l s dng BPTT.
- Gp phn tng cng sc khe v gim chi ph chng trnh KHHG.
- Hiu r v thc hnh tnh dc an ton s gp phn gim nguy c mang thai ngoi
mun v NKLTQTD.
2. Mi quyn c bn ca khch hng
- Quyn c thng tin.
- Quyn c tip cn dch v v thng tin.
- Quyn t do la chn BPTT v t chi hoc chm dt BPTT.
- Quyn c nhn dch v an ton.
- Quyn c m bo b mt.
- Quyn c m bo kn o.
- Quyn c thoi mi khi tip nhn dch v.
- Quyn c tn trng.
- Quyn c tip tc nhn dch v.
- Quyn c by t kin.
3. Cc phm cht cn thit ca cn b t vn KHHG.
3.1. Tn trng khch hng.
- Tn trng khch hng d cho khch hng l ngi nh th no.
- Lng nghe nhu cu v kin ca khch hng.
3.2. Thng cm v thu hiu i vi khch hng.
- Tm hiu tm t, mong mun v thu hiu nhu cu ca khch hng.
- Cn tip khch hng ni ring bit, yn tnh, m bo tnh ring t, b mt.

264 |
3.3. Thnh tht vi khch hng.
- Cn ni s tht v cc BPTT, bao gm c thun li v khng thun li, tc dng ph,
nguy c c th c ca bin php .
- Khng t chi cung cp thng tin cho khch hng. Nu thng tin ngi t vn cha
nm vng th hn tr li sau.
3.4. Thng tin r rng, c trng tm cho khch hng.
- S dng cu t ngn, gn, d hiu, hn ch dng t chuyn mn.
- S dng phng tin h tr: tranh nh, m hnh, hin vt v khuyn khch khch hng
quan st trc tip.
- Tm hiu phn hi ca khch hng.
- Tm tt, nhn mnh cc im quan trng v nu c th mi khch hng nhc li trc
khi kt thc t vn.
4. Su bc t vn KHHG.
4.1. Gp g.
- Cho hi, mi ngi, t thi thn mt v bnh ng, to lng tin cho khch hng.
- T gii thiu v bn thn.
4.2. Gi hi.
- Hi cc thng tin lin quan n hon cnh, sc khe, nhu cu trnh thai v bo v kp.
Khai thc kin thc v hnh vi hin ti ca khch hng v cc BPTT.
- Ch lng nghe, khng st rut, trnh ni nhiu.
- Pht hin nhng nhn thc sai lch ca khch hng.
- Hi thng tin v bo hnh ph n, c bit vi khch hng khng s dng BPTT mc
d khng mun c thai
4.3. Gii thiu.
- Gii thiu v bo v kp.
- Gii thiu cc BPTT hin c c s v th trng.
- Cung cp y thng tin v c u im v nhc im; cc tc dng ph v tai bin
c th gp ca BPTT. Bn v nhu cu trnh thai v nhu cu phng NKLTQTD.
- Tp trung vo vn khch hng quan tm, gii thch khi khch hng hiu sai.
4.4. Gip .
- Gip cho khch hng t la chn BPTT ph hp nht.
- Khng p t theo kin ch quan ca mnh.
- Nu khch hng chn BPTT khng ph hp v chng ch nh th gp cho khch
hng tm BPTT khc.
4.5. Gii thch.
- Khi khch hng chp nhn mt BPTT, gii thch y hn v cch s dng.
- Ch dn qu trnh thc hin v cc th tc tin hnh (vi cc BPTT lm sng nh
dng c t cung, trit sn).
- Gii thch nhng nguyn nhn c th a n tht bi v cch phng trnh.
- Ni r nhng du hiu ca tc dng ph v cch x tr ti nh.
- Nu cho khch hng bit nhng du hiu cnh bo v cch x tr.

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- Ni r mc phc hi ca BPTT.
- Gii thch ti sao cn c kim tra nh k v khuyn thc hin y .
- Gii thch mt cch tha ng nhng hiu bit sai lch ca khch hng.
- Sau khi gii thch, hi li khch hng c phn hi.
4.6. (Hn) Gp li.
- Trc khi cho tm bit, dn d khch hng, hn khm kim tra nh k v khi c cc
du hiu bt thng c th quay tr li bt k lc no.
- Cung cp ti liu truyn thng.
Ch : Tr bc v 6, cc bc cn li cn p dng linh hot, xen k v b sung cho nhau.

266 |
DNG C TRNH THAI TRONG T CUNG

Tuyn p dng.
Tt c cc tuyn.
Ngi thc hin.
Cn b y t lm dch v KHHG c o to.

Dng c trnh thai trong t cung (DCTC) l mt BPTT tm thi v hiu qu. DCTC
hin c 2 loi: (i) DCTC cha ng (TCu-380A v MLCu-375) c lm t mt thn
plastic vi cc vng ng hoc dy ng, v (ii) DCTC gii phng levonorgestrel c mt
thn ch T bng polyethylen cha 52 mg levonorgestrel, gii phng 20 g hot cht/ngy.
DCTC TCu-380A c tc dng trong 10 nm v DCTC gii phng levonorgestrel c tc
dng ti a 5 nm. Khch hng nhim HIV hay c bn tnh nhim HIV c th s dng
DCTC nhng cn lu l BPTT ny khng gip ngn nga NKLTQTD v HIV/AIDS.

1. Ch nh.
- Ph n trong tui sinh , mun p dng mt BPTT tm thi, di hn, hiu qu cao
v khng c chng ch nh.
- Trnh thai khn cp (ch i vi DCTC cha ng).
2. Chng ch nh.
2.1. Chng ch nh tuyt i (nguy c i vi sc khe qu cao, nn khng c s
dng DCTC):
- C thai.
- Nhim khun hu sn.
- Ngay sau sy thai nhim khun.
- Ra mu m o cha c chn on nguyn nhn.
- Bnh nguyn bo nui c tnh hoc c tnh trng hCG vn gia tng.
- Ung th c t cung, ung th nim mc t cung.
- ang b ung th v (ch i vi DCTC gii phng levonorgestrel).
- U x t cung hoc cc d dng khc lm bin dng bung t cung.
- ang vim tiu khung.
- ang vim m c t cung hoc nhim Chlamydia, lu cu.
- Lao vng chu.
2.2. Chng ch nh tng i (nguy c tim n cao hn so vi li ch thu nhn, nhng
c th p dng nu khng c BPTT khc):
- Trong vng 48 gi sau sinh (ch i vi DCTC gii phng levonorgestrel).
- Trong thi gian t 48 gi n 4 tun u sau sinh (k c sinh bng phu thut).
- ang b bnh lupus ban h thng v c khng th khng phospholipid (ch i vi
DCTC gii phng levonorgestrel) hoc c gim tiu cu trm trng
- Bnh nguyn bo nui lnh tnh c tnh trng tnh trng hCG gim dn.

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- tng b ung th v v khng c biu hin ti pht trong 5 nm tr li (ch vi
DCTC gii phng levonorgestrel), hoc b ung th bung trng.
- C nguy c b NKLTQTD cao.
- Bnh AIDS c tnh trng lm sng khng n nh.
- ang b thuyn tc mch (ch chng ch nh vi DCTC gii phng levonorgestrel).
- ang hoc b thiu mu c tim, chng au na u nng (ch chng ch nh vi
tip tc s dng DCTC gii phng levonorgestrel), hoc ang b x gan mt b c
gim chc nng gan trm trng, hoc u gan (ch vi DCTC gii phng levonorgestrel).
- ang s dng mt s thuc khng virus thuc nhm c ch sao chp ngc nucleotid
(NRTIs) hoc khng nucleotid (NNRTIs) hoc nhm c ch men protease Ritonavir-
booster.
3. Qui trnh thc hin.
3.1.T vn v cung cp thng tin v DCTC.
- Tm hiu nhu cu ca khch hng v DCTC.
- Gii thiu cc loi DCTC hin c v hng dn c th v loi DCTC khch hng s
dng.
- Trn m hnh hay hnh v, gii thch cho khch hng v tr DCTC nm trong t cung v
cch t.
- Hiu qu, thun li v bt li ca DCTC. Ch l BPTT ny khng c tc dng phng
trnh NKLTQTD. Hin ti cha c bng chng v mi lin quan gia s dng DCTC
v kh nng v sinh.
- Gii thiu nhng tc dng ngoi thng gp nh c th ra mu m o hoc au
nng bng (DCTC cha ng), thiu kinh hoc i khi v kinh (DCTC gii phng
levonorgestrel). Gii thiu cc thuc gim au nhm khng vim khng c steroid
x tr tnh trng au bng hoc cng kinh lin quan n DCTC.
- Cho khch hng bit hn dng ca DCTC n tho khi ht hn. Hng dn khch
hng t theo di DCTC, cch s dng thuc c cp sau khi t DCTC. Dn d
khch hng n khm kim tra li sau mt thng, khm nh k hng nm v nhng
trng hp cn i khm li ngay khi c du hiu bt thng. Khch hng c quyn
ngh tho b dng mt BPTT khc nu h khng mun tip tc mang DCTC. t
mt s cu hi v nhng iu c bn t vn cho khch hng h tr li. m bo
s b mt, ring t ca khch hng.
- i vi DCTC gii phng levonorgestrel cn gii thch r v cc c im nh ra mu,
v kinh sau t, ra mu gia k, ra mu thm git hoc au nh vng chu c th gp
trong nhng tun u.
3.2. Thm khm nh gi trc khi p dng bin php.
- Hi k tin s pht hin chng ch nh (dng bng kim).
- Thm khm loi tr c thai, ra mu khng r nguyn nhn. Trong hon cnh xt
nghim nc tiu th thai khng sn c, c th nh gi l khng c thai" nu
khch hng khng c du hiu c thai v tha mn mt trong nhng tiu chun sau:
Khng giao hp k t ln c kinh bnh thng ngay trc .
v ang s dng mt BPTT tin cy mt cch lin tc v ng phng php.
Trong 7 ngy u sau k kinh bnh thng (hoc trong vng 12 ngy nu khch
hng mun s dng DCTC).
Trong 4 tun u sau sinh v khng cho con b.

268 |
Trong 7 ngy u sau no, ht, sy thai.
ang cho b m hon ton (hoc gn nh hon ton), v kinh v trong 6 thng u
sau sinh.
3.3. Thi im t DCTC.
3.3.1. Khch hng cha s dng BPTT.
* DCTC cha ng
- Bt k lc no trong vng 12 ngy t ngy u ca k kinh.
- bt c thi im no nu bit chc l khng c thai. Khng cn s dng BPTT h tr
no khc.
- V kinh: bt k thi im no nu c th khng nh khng c thai.
- Sau sinh (k c sau phu thut ly thai) v cho con b:
Sau sinh 4 tun tr i, v kinh: bt k lc no, nu bit chc l khng c thai.
Sau sinh 4 tun tr i, c kinh tr li: nh trng hp hnh kinh bnh thng.
- Sau ph thai (3 thng u v 3 thng gia): ngay sau khi ph thai, ngoi tr nhim
khun sau ph thai.
* DCTC gii phng levonorgestrel
- Trong vng 7 ngy u k t ngy hnh kinh u tin.
- bt c thi im no nu bit chc l khng c thai. Nu qu 7 ngy t khi bt
u hnh kinh cn trnh giao hp hoc s dng thm BPTT h tr trong 7 ngy k tip.
- V kinh: bt k thi im no nu c th khng nh khng c thai, cn trnh giao hp
hoc s dng thm BPTT h tr trong 7 ngy k tip.
- Sau sinh (k c sau phu thut ly thai) v cho con b:
Sau sinh 4 tun tr i, v kinh: bt k lc no, nu chc chn khng c thai.
Sau sinh 4 tun tr i, c kinh tr li: nh trng hp kinh nguyt bnh thng.
Khng t DCTC cho sn ph c nhim khun hu sn hay trong vng 4 tun u
sau sinh.
- Sau sinh (k c sau phu thut ly thai), khng cho con b:
Sau sinh 4 tun tr i, v kinh: bt k lc no, nu chc chn khng c thai.
Sau sinh 4 tun tr i, c kinh tr li: nh trng hp kinh nguyt bnh thng.
- Sau ph thai (3 thng u v 3 thng gia): ngay sau khi ph thai, ngoi tr nhim
khun sau ph thai.
3.3.2. Khch hng ang s dng BPTT khc.
- Ngay lp tc, nu chc chn khng c thai.
- i vi DCTC gii phng levonorgestrel:
Trong vng 7 ngy u k t ngy hnh kinh u tin: khng cn s dng BPTT h
tr.
Qu 7 ngy k t ngy hnh kinh u tin: cn trnh giao hp hoc s dng thm
BPTT h tr trong 7 ngy k tip.
Nu chuyn i t thuc tim: cho n thi im hn tim mi tip theo, khng cn
s dng BPTT h tr.
3.3.3. Trnh thai khn cp.
- DCTC cha ng: trong vng 5 ngy sau cuc giao hp khng c bo v, nu c
tnh c ngy phng non c th t mun hn 5 ngy sau giao hp khng bo v

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nhng khng qu 5 ngy k t ngy phng non. DCTC cha ng khng c s
dng trnh thai khn cp cho trng hp b hip dm v c nguy c NKLTQTD cao.
- DCTC gii phng levonorgestrel khng c khuyn co s dng cho trnh thai khn
cp.
- Nu bit chc ngy phng non, t DCTC trnh thai khn cp c th c thc
hin trong vng 5 ngy sau phng non, tc c th tr hn 5 ngy sau giao hp khng
c bo v.
3.4. Th thut t DCTC.
3.4.1. i vi tt c cc loi DCTC.
- DCTC c a vo ng t ngay trc khi t.
- Cn m bo v khun v tun th nhng qui nh ca Phng nga chun khi thc hin
th thut. m bo k thut khng chm. Cn thay gng mi sau khi chun b
DCTC.
3.4.2. t DCTC loi TCu 380-A
* Chun b t
- Kim tra dng c v bao ng DCTC (thi hn s dng, bao cn nguyn vn).
- Cho khch hng i tiu.
- Khch hng nm trn bn theo t th ph khoa.
- Gii thch cho khch hng cc th thut chun b tin hnh.
- Khm trong xc nh t th, th tch t cung v phn ph.
- Thay gng v khun.
- St khun b phn sinh dc ngoi (kp st khun 1).
- Tri khn v khun.
- T th thy thuc: ngi trn gh, khong gia 2 i ca khch hng. Nu c ngi ph
th ngi ph ngi bn tri thy thuc (i gng v khun tay cm van hoc dng c).
* Cc thao tc t DCTC
- Bc l c t cung.
M m o bng van.
St khun c t cung v ti cng m o bng Betadin (kp st khun 2).
Cp c t cung bng kp Pozzi v ko nh xung.
- o bung t cung.
a thc o vo t cung theo hng ca n trong tiu khung, khng chm vo m
h v thnh m o.
Xc nh su bung t cung.
- Lp DCTC vo ng t
Lp DCTC trong bao.
iu chnh nc hm trn ng t ng hng v ng su bung t cung.
- a DCTC vo trong t cung
Cm ng t ng t th, ng hng, tay kia cm kp Pozzi ko c t cung v
pha m mn ri nh nhng a ng t (c DCTC) qua c t cung vo trong n
khi nc hm chm vo l ngoi CTC.
Gi nguyn cn y, ko ng t xung gii phng cnh ngang ch T.
Gi nguyn ng t, rt cn y ra ngoi.

270 |
y nh ng t ln m bo b phn hm ti st c t cung.
Rt ng t.
Ct dy DCTC li t 2 - 3 cm v gp vo ti cng sau m o.
- Tho dng c
Tho kp Pozzi.
Kim tra chy mu v cm mu nu cn.
Tho van hay m vt.
- Thng bo cho khch hng bit cng vic xong.
3.4.3. t DCTC loi Multiload
* Chun b t
- Nh cch chun b t TCu 380-A.
* Cc thao tc t DCTC
- Bc l c t cung (nh vi TCu 380-A).
- o bung t cung (nh vi TCu 380-A).
- a DCTC vo trong t cung
M bao b, t nc hm ng hng v su bung t cung.
Mt tay cm kp Pozzi ko c t cung v pha m mn, tay kia gi ng t (c
DCTC) ng hng (theo nc hm), y DCTC vo qua c t cung theo ng t
th t cung cho ti khi chm y.
Rt ng t ra ngoi.
Ct ui DCTC li 3 cm, gp vo ti cng sau m o.
3.4.4. t DCTC gii phng levonorgestrel.
* Chun b t
- Khch hng c t vn r v k vo giy cam kt.
- Khm ph khoa, nh gi v tr v kch thc t cung, loi tr thai nghn, vim c t
cung v cc chng ch nh khc.
- Dng khng sinh d phng nu c ch nh.
- p dng k thut v khun.
- Dng thuc gim au nu cn thit.
- V sinh m o v c t cung bng dung dch st khun.
- Gy t cnh c t cung nu cn thit.
- Kp mp trc c t cung bng km Pozzi v ko thng ng c t cung so vi bung t
cung.
- o lng t cung. Nu cm gic ng c t cung hp cn nong c t cung. Bung t
cung cn c kch thc t 6 n 9 cm. Bung t cung su di 6 cm c th lm tng
nguy c tt DCTC, chy mu, au, thng t cung v c thai.
* Cc thao tc t DCTC
- M ti cha b dng c, ko dy DCTC ra qu cn t. y pt tng cn t ln v tr
ti a (st vi DCTC) v chnh v tr 2 cnh ca DCTC nm ngang.
- Nm hai dy v ko sao cho dng c lt vo trong ng ca cn t, u 2 cnh nm
l trn cng ca ng t. C nh 2 si dy vo kp cui pt tng v chnh kha nh
du v tr ng vi kch thc bung t cung o.
- Nm chc cn t v tr xa nht. Kp c t cung bng km Pozzi v ko nh ng c
t cung thng so vi bung t cung. Nh nhng y cn t qua ng c t cung vo

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bung t cung cho n khi kha nh du cch l ngoi c t cung 1,5 - 2 cm. Ch
khng y cn t qu mnh.
- Gi cn t v ko t t pt tng cho n khi u tn cng ca pt tng ra n g nh
du trn cn t..
- y nh nhng cn t vo bung t cung cho n khi kha nh du chm vo c t
cung.
- Gi chc cn t v nh nhng ko pt tng ra ht ngoi cn t.
- Rt cn t ra khi bung t cung. Ct ngn dy DCTC, li bn ngoi t cung 2 -
3cm.
3.5. Tho DCTC.
3.5.1. Ch nh tho DCTC.
- V l do y t:
C thai (nu thy dy DCTC mi c tho).
Ra nhiu mu.
au bng di nhiu.
Nhim khun t cung hoc tiu khung.
Pht hin tn thng c tnh hoc nghi ng c tnh t cung, c t cung.
DCTC b tt thp.
mn kinh (sau khi mt kinh 12 thng tr ln)
DCTC ht hn (10 nm vi TCu 380-A, 5 nm vi Multiload): sau khi tho c
th t ngay DCTC khc (nu khch hng mun)
- V l do c nhn:
Mun c thai tr li.
Mun dng mt BPTT khc.
Thy khng cn dng BPTT no na.
3.5.2. Cch tho DCTC.
- C ba loi DCTC TCu 380-A, Multiload v gii phng levonorgestrel u c dy nn
ch cn dng kp cp vo c 2 dy, nh nhng ko ra l c.
- Trong tr nhn thy dDCTC kh th chuyn ln tuyn trn.
4. Nhng vn kh khn khi s dng, v cch x tr.
DCTC khng cha ni tit t.
4.1. Ra mu nhiu hoc ko di (> 8 ngy hoc gp i lng mu kinh bnh thng).
- Gii thch cho khch hng hin tng ra mu nhiu hoc ko di thng gp trong 3 - 6
thng u v s ci thin dn.
- Nu iu tr, c th ch nh:
Cc thuc khng vim khng c steroid (khng dng aspirin), hoc
Acid tranexamic.
- Nu nghi ng bnh l: cn loi tr cc NKSS/NKLTQTD khc, nu c bnh cn
phi iu tr hoc chuyn tuyn.
Nu ra mu nhiu n mc e da n sc khe: tho DCTC v hng dn chn
BPTT khc.
B sung st v khuyn co cc thc n giu st.

272 |
4.2. Ra mu m o bt thng.
- Tip tc s dng DCTC, cn kho st nguyn nhn vi x tr l iu tr hoc chuyn
tuyn.
4.3. au h v.
- Hi bnh, khm pht hin nguyn nhn, x tr. Chuyn tuyn nu c mt trong cc
vn sau:
Mt kinh, tr kinh hoc khng nh c thai
Mi sinh hoc sy thai
au, cng vng bng khi khm
Ra mu m o
S c khi vng chu
- Nu khng c bt k du hiu no trn y, chn on vim vng chu nu c t nht
mt trong cc du hiu sau:
Thn nhit > 38
0
C.
Kh h bt thng.
au khi di ng c t cung.
Khi n vng phn ph.
Bn tnh gn y c tit dch niu o hoc c iu tr lu.
- iu tr hoc chuyn tuyn ngay iu tr.
- Nu khch hng mun tho DCTC: dng khng sinh v tho.
- Theo di: nu khng ci thin sau 2 - 3 ngy iu tr hoc hnh thnh p xe, cn chuyn
n bnh vin. Tho DCTC.
- Khm v iu tr cho bn tnh.,
4.4. ang b NKLTQTD hoc b trong vng 3 thng gn y hoc vim m c t cung
- Tho DCTC.
- Chn on v iu tr NKLTQTD hoc chuyn tuyn.
- Khm v iu tr bn tnh.
4.5. C thai.
- Loi tr thai ngoi t cung.
- Mang thai 3 thng u (< 13 tun), thy dy DCTC.
Gii thch rng nn tho DCTC trnh nguy c nhim khun, sy thai v non.
ng tc tho vng cng c nguy c thp gy sy thai.
Nu khch hng ng , tho DCTC hoc chuyn tuyn tho. Cn khm li ngay
nu ra mu nhiu, au bng, ra dch m o hoc st.
- Nu khng thy dy DCTC v/hoc thai > 3 thng.
Cn siu m nh gi xem liu DCTC c cn nm ng v tr khng.
Gii thch rng c nguy c nhim khun nng, nu khng mun mang thai c th
x tr theo qui nh v chm dt thai k vi mc ch iu tr.
Nu mun hoc bt buc tip tc mang thai, gii thch v nguy c nhim khun v
sy thai. Cn theo di thai nghn cht v khm li ngay nu ra mu nhiu, au
bng, ra dch m o hoc st.
4.6. Bn tnh phn nn v dy DCTC.
- Gii thch cho khch hng v bn tnh (nu c th) rng cm gic l bnh thng.

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- M t cc la chn v x tr:
Ct ngn on dy, hoc
Tho DCTC.
Ch : Hn khm li sau 3 n 6 tun v khm li ngay nu gp kh khn hay nhng vn
nu phn 4.
5. i vi khch hng HIV(+).
- Khch hng HIV(+) hoc AIDS vi tnh trng lm sng n nh c th s dng DCTC.
Khng cn ly DCTC ra nu khch hng tin trin thnh AIDS, tuy nhin nhng ngi
ny cn theo di cc du hin ca tnh trng vim vng chu.
- Yu cu khch hng s dng bao cao su km theo. Khi s dng ng cch, thng
xuyn, bao cao su gip ngn nga ly nhim HIV v cc NKLTQTD.

274 |
BAO CAO SU

Tuyn p dng.
Tt c cc tuyn.
Ngi thc hin.
Cn b cung cp dch v.

Bao cao su l mt BPTT tm thi, hiu qu, an ton v r tin. Bao cao su l BPTT c tc
dng bo v kp: va c tc dng trnh thai va gip phng NKLTQTD v HIV/AIDS.
Khch hng nhim HIV hoc c bn tnh nhim HIV nn s dng bao cao su trnh thai
v phng NKLTQTD/HIV. Bao cao su c hai loi: loi s dng cho nam v loi s dng
cho n.
1. Ch nh.
- Dng cho tt c cc trng hp mun trnh thai.
- C tc dng bo v kp va trnh thai va phng HIV/AIDS v NKLTQTD.
- L BPTT h tr (v d: nhng ngy u sau tht ng dn tinh, qun ung thuc trnh
thai).
2. Chng ch nh.
D ng vi latex (i vi loi bao cao su c latex) hoc cc thnh phn c trong bao
cao su.
3.1. T vn.
- Lng nghe v tm hiu nhu cu trnh thai ca khch hng.
- Ch : cho khch hng xem bao cao su v hng dn cch s dng.
- Nu r hiu qu, thun li v khng thun li ca bin php.
- Bao cao su l BPTT hiu qu nu s dng ng cch v l bin php duy nht c tc
dng bo v kp va trnh thai va phng NKLTQTD/HIV/AIDS. Tuy nhin, cc vt
lot sinh dc hay si mo g c th ly truyn do tip xc nhng phn khng c
che ph bng bao cao su.
- S dng bao cao su kt hp vi cc BPTT khc lm gia tng hiu qu trnh thai, cao
hn ch dng bao cao su.
- Nu khch hng p dng bin php king giao hp, khuyn khch hng nn chun b
sn bao cao su nu quyt nh quan h tnh dc Lun c sn bao cao su dng khi
cn.
- Nu bao cao su b rch, thng hoc tut khi giao hp cn p dng BPTT khn cp. Nu
phi hp bao cao su vi thuc dit tinh trng th hiu qu trnh thai s cao hn. Khng
dng bt c loi cht bi trn no thuc loi tan trong du hoc gc du (nh du n,
du tr em, m, b, vaselin...) khi dng loi bao cao su c latex.

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3.2. Thm khm nh gi trc khi p dng: khng cn.
3.3. Thi im thc hin.
- Khch hng cha s dng BPTT: bt k lc no.
- Khch hng ang s dng BPTT (chuyn i): bt k lc no.
3.4. Cch s dng v bo qun.
- Kim tra trc v tnh trng nguyn vn ca bao cao su v hn dng.
- Mi ln giao hp u phi s dng bao cao su mi.
- i vi bao cao su nam: lng bao cao su vo dng vt ang cng trc khi giao hp, gi
cho vnh cun ca bao nm pha ngoi. Tho cun vnh bao ln ti gc dng vt, khng
cn ko cng. Sau khi xut tinh, rt dng vt ra lc cn cng, gi cht vnh bao cao su
gc dng vt trong khi rt dng vt ra bao khi b tut v tinh dch khng tro ra ngoi.
Ch s dng mi bao cao su 1 ln.
- i vi bao cao su n: t bao vo trong m o trc khi giao hp. Cm ly vng
trn nh bp mo a nghing vo trong m o, vng trn ny s bung ra che c t
cung. Vng trn to nm ngoi v ph kn cc mi ln v vng tin nh. Bao cao su n
c th t trc vi gi nhng cn tho sm sau khi giao hp xong trc khi ngi dy
hay ng dy trnh khng cho tinh dch tro ra ngoi.
- Bo qun bao cao su: ni thong mt v trnh nh sng.
4.1. Nu bao cao su b rch.
- Ra dng vt v m h bng nc sch hoc thuc dit tinh trng (nu c).
- Cn p dng BPTT khn cp.
4.2. Nu c nga hoc ni ban ti b phn sinh dc.
- Khm li khch hng v bn tnh, tm kim du hiu nhim khun.
- Nu khng c nhim khun m d ng vi latex: trong trng hp nh c th khuyn
khch hng i loi bao cao su khc hoc c th gip khch hng la chn BPTT
khc nu khch hng khng c nguy c NKLTQTD.
- Khch hng c nguy c NKLTQTD k c HIV/AIDS, cn t vn k v cch s dng
ng v tc dng bo v kp ca bao cao su khuyn khch khch hng tip tc s
dng bao cao su.
4.3. Nam gii khng duy tr c cng khi mang hoc s dng bao cao su.
- Thng do bi ri, cha quen s dng: cn hng dn khch hng v bn tnh hiu r,
gip nhau si ri, cha quen
- C thnhaung bao cao su c cht bi trn hoc s dng nc/cht bi trn bn ngoi
bao. S dng thm mt t nc hoc cht bi trn tan trong nc c th lm tng cm
gic v duy tr cng.
5. i vi khch hng HIV (+)
Khch hng HIV(+) hoc AIDS hoc ang iu tr thuc khng virus nn s dng bao
cao su, c th kt hp vi BPTT khc. Khi s dng ng cch, thng xuyn, bao cao su
gip ngn nga ly nhim HIV v cc bnh LTQTD.

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VIN THUC TRNH THAI KT HP

Tuyn p dng.
Tt c cc tuyn.
Ngi thc hin.
Cn b cung cp dch v.

Vin thuc trnh thai kt hp l BPTT tm thi, cha 2 loi ni tit l estrogen v
progestin. S dng vin thuc trnh thai kt hp i hi khch hng phi ung thuc u
n. Khch hng nhim HIV hay c bn tnh nhim HIV c th s dng vin thuc trnh
thai kt hp nhng cn lu l BPTT ny khng gip ngn nga NKLTQTD v
HIV/AIDS.

1. Ch nh.
Ph n mun s dng mt BPTT tm thi c hiu qu cao.
2. Chng ch nh.
2.1. Chng ch nh tuyt i.
- C thai hoc nghi ng c thai.
- ang cho con b trong vng 6 tun sau sinh.
- Ln tui ( 35 tui) v ht thuc thng xuyn 15 iu/ngy.
- C nhiu nguy c b bnh mch vnh (ln tui, ht thuc l, i tho ng v tng
huyt p)
- Tng huyt p nng (HA tm thu 160 mmHg, HA tm trng 100 mmHg).
- hoc ang b bnh l tim mch v ng mu nh (i) bnh l mch mu, hoc (ii)
thuyn tc tnh mch su, hoc (iii) thuyn tc phi, hoc (iv) bnh l ng mu, hoc
(v) bnh thiu mu c tim, hoc (vi) bnh l van tim phc tp, hoc (vii) tai bin mch
mu no, hoc (viii) c a huyt khi di truyn.
- Sp phu thut i hi nm trn 1 tun.
- au na u (migrain).
- ang b ung th v.
- i tho ng c bin chng (thn, thn kinh, vng mc, mch mu).
- ang b lupus ban h thng v c khng th khng phospholipid (hoc khng lm
xt nghim).
- ang b bnh gan nng c suy gim chc nng gan trm trng nh (i) vim gan cp
ang din tin, hoc (ii) x gan mt b, hoc (iii) u gan (ngoi tr trng hp tng sinh
lnh tnh dng nt - benign focal nodular hyperplasia).
2.2 Chng ch nh tng i.
- ang cho con b sau sinh t 6 tun n 6 thng hoc khng cho con b trong vng 4
tun sau sinh.
- Ln tui ( 35 tui) v ht thuc < 15 iu/ngy.

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- hoc ang b cao huyt p trung bnh (HA tm thu 140 - 159 mmHg, HA tm
trng 90 - 99 mmHg).
- hoc ang b tng lipid mu hoc tng cholesterol do ung thuc trnh thai.
- tng b ung th v v khng c biu hin ti pht trong vng 5 nm tr li.
- Si mt ang iu tr ni khoa hoc x gan cn b
- ang s dng mt s loi thuc nh rifampicin/rifabutin, thuc khng virus nhm c
ch protease Ritonavir-booster (Ritonavir-booster protease inhibitor) v mt s thuc
chng co git nh phenytoin, carbamazepin, barbiturat, primidon, topiramat,
oxcarbazepin hoc lamotrigin.
3.1 T vn.
Lng nghe v tm hiu nhu cu ca khch hng v vin thuc trnh thai kt hp. Nu r
hiu qu, nhng thun li v khng thun li khi s dng thuc. Cn lu khch hng l
bin php ny khng c tc dng phng NKSS hoc gim nguy c vim tiu khung c
triu chng. Khng c tc dng phng trnh NKLTQTD.
Cho khch hng xem v thuc v hng dn cch s dng trn v thuc. Ch cho khch
hng nhng vin thuc nhc (v 28 vin) v bo cho khch hng thi im s ra kinh. Cho
khch hng bit cc tc dng ph, nh bun nn, ra mu t, au u, cng ngc, tng cn
v nhng kh khn c th gp.
Nhc khch hng cch theo di trong khi s dng thuc:
Khch hng c th quay li khm v t vn bt k lc no nu c vn .
Trong 3 thng u ung thuc phi n c s y t khm, o huyt p, cn nng.
Hn n khm li hng nm.
3.2 Thm khm nh gi trc khi p dng BPTT.
Hi k tin s v khm lm sng pht hin chng ch nh (s dng bng kim).
Thm khm loi tr c thai. Trong hon cnh xt nghim nc tiu th thai
khng sn c, c th nh gi l khng c thai" da vo nhng du hiu lm sng (xem
phn 3b, Dng c t cung).
3.3 Thi im thc hin.
3.3.1. Khch hng hin ang khng s dng BPTT s bt u ung thuc.
- Trong vng 5 ngy u tin ca chu k kinh (k c nhng trng hp sau sinh c
kinh li) hoc trong vng 7 ngy sau no/ht/sy thai.
- bt c thi im no nu bit chc l khng c thai. Cn phi s dng thm BPTT h
tr (nh trnh giao hp hoc s dng bao cao su) trong 7 ngy k tip nu: (i) bt
u sau 5 ngy u ca chu k kinh, hoc (ii) khng c kinh, hoc (iii) bt u t tun
th 4 sau sinh nu khng cho con b v cha c kinh tr li.
3.3.2. Khch hng ang s dng BPTT ni tit s bt u ung thuc.
- Ngay lp tc nu ang s dng lin tc v ng cch hoc nu bit chc l khng c
thai hoc thi im lp li mi tim.
3.3.3. Khch hng ang s dng BPTT khng ni tit s bt u ung thuc
- Trong vng 5 ngy u tin ca chu k kinh. Nhng khch hng ang s dng DCTC
c th c ly DCTC thi im ny.

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- bt c thi im no nu bit chc l khng c thai. Nu bt u ung thuc sau c
kinh hn 5 ngy, khch hng cn phi s dng thm BPTT h tr trong 7 ngy k tip.
Nhng khch hng ang s dng DCTC c th c ly DCTC chu k kinh sau.
3.4 Cch s dng.
- Ung mi ngy 1 vin, nn vo gi nht nh d nh, theo chiu mi tn trn v
thuc (v thuc nn dn ngy trnh qun).
- Khi ht v thuc, phi ung vin u tin ca v tip theo vo ngy hm sau d ang
cn kinh (vi v 28 vin) hoc ngh 7 ngy ri dng tip v sau, d ang cn kinh (vi
v 21 vin).
4. Nhng vn kh khn xy ra khi ung thuc v cch x tr.
4.1 Qun ung thuc.
Qun ung thuc s lm tng nguy c tht bi, c bit nu qun ung thuc trong
tun l u hoc tun l th ba ca thng. Cch x tr nh sau:
4.1.1. Qun ung vin thuc c ni tit (tc t tun 1 n tun 3).
- Nu qun 1 hoc 2 vin (i vi loi thuc c nng estrogen 30 - 35 mcg) hoc
qun 1 vin (i vi loi thuc c nng estrogen 20 mcg) hoc bt u v thuc
chm t 1 - 2 ngy: khch hng cn ung mt vin ngay khi nh ra v tip tc ung
mi ngy mt vin nh thng l.
- Nu qun t 3 vin tr ln (i vi loi thuc c nng estrogen 30 - 35 mcg) hoc
qun t 2 vin tr ln (i vi loi thuc c nng estrogen 20 mcg) hoc bt u
v thuc chm t 3 ngy tr ln, khch hng cn ung ngay mt vin thuc ngay khi
nh ra v tip tc ung thuc nh thng l. Khch hng cn thm BPTT h tr trong
7 ngy k tip.
Nu xy ra tun l th nht (bt u v thuc) v c giao hp khng bo v trong
vng 5 ngy va qua, khch hng cn s dng thm BPTT khn cp.
Nu xy ra tun l th ba, khch hng cn ung tip nhng vin thuc c ni tit,
b cc vin thuc nhc v tip tc ngay vo v thuc mi.
4.1.2. Qun ung vin thuc nhc (t vin th 22 n vin th 28).
- B vin thuc qun, ung tip vin thuc k.
4.2 Nn trong vng 2 gi sau ung thuc.
- Ung li mt vin thuc khc.
4.3 Nn nhiu v tiu chy sau ung thuc.
- Nu xy ra trong vng 24 gi, khch hng cn tip tc ung thuc theo ng lch.
- Nu xy ra lin tc t 2 ngy tr ln, khch hng s thc hin ging nh trng hp
qun ung thuc.
4.4 Ri lon kinh nguyt.
4.4.1. Kinh nguyt khng u.
- Trn an khch hng rng nhiu ph n s dng thuc trnh thai cng c tnh trng kinh
nguyt khng u, tnh trng ny s gim v ht sau vi thng s dng thuc
- Hi khch hng cc nguyn nhn c th gy ra tnh trng ny, bao gm: (i) qun thuc,
(ii) ung thuc vo nhng thi im khc nhau mi ngy, (iii) nn hoc tiu chy, hoc
(iv) bt u ung thuc chng co git hoc rifampicin

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- X tr tnh trng ri lon kinh nguyt:
Yu cu khch hng ung thuc mi ngy v vo thi im tng t nhau
Hng dn cch x tr khi qun thuc (k c khi b nn hoc tiu chy)
K n:
Ibuprofen 800 mg (hoc cc thuc khng vim khng steroid khc), ung sau
khi n, 3 ln/ngy trong 5 ngy (bt u khi c ri lon kinh nguyt)
ngh khch hng ung loi thuc trnh thai khc t nht trong 3 thng nu khch
hng ung thuc nga thai nhiu thng v tnh trng ri lon kinh nguyt khng
ht sau khi ung thuc khng vim
4.4.2. Mt kinh.
- Trn an khch hng rng nhiu ph n s dng thuc trnh thai cng b mt kinh
- Hi khch hng xem c ung thuc u mi ngy khng? Nu c ung u th khuyn
khch hng tip tc ung thuc; nu khng chc chn ung thuc u th nn th thai.
- Hi xem khch hng c b khng ung 7 vin thuc nhc (v 28 vin) hoc khng ch
7 ngy sau khi ung xong v thuc (v 21 vin) khng? Nu c th gii thch nguyn
nhn khng c kinh v khuyn khch hng tip tc ung.
- Hi xem khch hng c qun ung thuc hoc bt u ung v thuc mi tr khng?
Nu c th x tr nh phn Qun thuc.
4.4.3. Ra mu hoc qu nhiu (t gp i bnh thng tr ln) hoc ko di (t 8 ngy tr
ln).
Khm ton din tm nguyn nhn. Trong qu trnh khm bnh khch hng vn c
th tip tc s dng thuc trnh thai.
4.5 Khc.
4.5.1. Nhc u.
- C th k n mt trong cc loi thuc gim au nh aspirin, ibuprofen hoc
paracetamol
- Khm ton din nu tnh trng nhc u khng gim hoc trm trng hn
- Khuyn khch hng s dng BPTT khc hoc chuyn sang loi thuc trnh thai khng
c estrogen nu khch hng bt u b nhc na u (migrain) hoc tnh trng nhc
na u tr nn trm trng hn.
4.5.2. Bun nn hoc chng mt.
- Khuyn khch hng ung thuc trc khi ng hoc ung thuc trong khi n.
4.5.3. Cng ngc.
- Khuyn khch hng th chng ngc bng khn lnh hoc m.
paracetamol
4.5.4. Mn.
- ngh khch hng ung loi thuc trnh thai khc t nht trong 3 thng nu khch
hng ung thuc nga thai nhiu thng v tnh trng mn vn khng gim hoc gia
tng.
4.5.5 Khch hng bt u s dng cc thuc nga co git hoc rifampicin (cc thuc ny
c th lm gim tc dng ca thuc nga thai).
- Nu khch hng s dng thuc nga co git hoc rifampicin ko di: cn chuyn sang
BPTT khc.

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- Nu khch hng s dng thuc nga co git hoc rifampicin trong thi gian ngn: c
th tip tc s dng thuc trnh thai km vi cc BPTT h tr.
4.5.6. Khch hng phi nm bt ng mt thi gian (t vi tun tr ln).
- Nhc khch hng bo cho bc s phu thut (nu phi phu thut) l mnh ang ung
thuc trnh thai.
- Yu cu khch hng ngng thuc trnh thai v s dng cc bin php trnh thai h tr
khc trong thi gian ny.
- Bt u s dng li thuc trnh thai 2 tun sau khi khch hng i li c.
4.5.7. Xut hin cc du hiu ca bnh l ni khoa (nh bnh tim, gan, tng huyt p hoc
tc mch)
- Yu cu khch hng ngng thuc trnh thai v s dng cc BPTT h tr khc trong
thi gian chn on bnh.
4.5.8. Nghi ng c thai.
- Xc nh tnh trng thai.
- Yu cu khch hng ngng thuc trnh thai nu chc chn c thai. Khng c bng
chng v nguy c ln thai khi s dng thuc trnh thai trong lc mang thai.
- Khch hng HIV(+) hoc AIDS hoc ang iu tr thuc khng virus c th s dng
vin thuc trnh thai kt hp.
- Yu cu khch hng s dng bao cao su km theo khi s dng vin thuc trnh thai kt
hp. Khi s dng ng cch, thng xuyn, bao cao su gip ngn nga ly nhim HIV
v cc NKLTQTD.

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VIN THUC TRNH THAI CH C PROGESTIN

Tuyn p dng.
Tt c cc tuyn.
Ngi thc hin.
Cn b cung cp dch v.

Vin thuc trnh thai ch c progestin l BPTT tm thi, cha mt lng nh
progestin, khng c estrogen. S dng vin thuc trnh thai ch c progestin i hi khch
hng phi ung thuc u n v ng gi. Khch hng nhim HIV hay c bn tnh nhim
HIV c th s dng vin thuc ch c progestin nhng cn lu l BPTT ny khng gip
ngn nga NKLTQTD v HIV/AIDS.

1. Ch nh.
Ph n mun s dng mt BPTT tm thi c hiu qu, c bit thch hp cho ph n
ang cho con b hoc c chng ch nh thuc trnh thai kt hp.
2. Chng ch nh.
- C thai.
- ang b ung th v.
2.2. Chng ch nh tng i.
- ang b thuyn tc tnh mch su/thuyn tc phi.
xt nghim) hoc c gim tiu cu trm trng.
- X gan mt b c suy gim chc nng gan trm trng, hoc u gan (ngoi tr trng
hp tng sinh lnh tnh dng nt - benign focal nodular hyperplasia).
- ang s dng mt s loi thuc nh rifampicin/rifabutin, thuc khng virus nhm c
ch protease Ritonavir-booster (Ritonavir-booster protease inhibitor) v mt s thuc
chng co git nh phenytoin, carbamazepin, barbiturat, primidon, topiramat,
oxcarbazepin.
- Khng tip tc s dng nu khch hng:
hoc ang b tai bin mch mu no hoc thiu mu c tim
au na u c km m mt
3.1. T vn.
- Lng nghe v tm hiu nhu cu ca khch hng v vin thuc trnh thai ch c
progestin. BPTT ny thch hp cho nhng khch hng ang cho con b hoc khng th
s dng thuc vin trnh thai kt hp. Nu r hiu qu, nhng thun li v khng thun

282 |
li khi s dng thuc. Cn lu khch hng l bin php ny khng c tc dng phng
trnh NKTQTD. Ngoi ra, vin thuc ch c progestin thng hay gy ri lon kinh
nguyt hn (c bit i vi ph n khng cho con b).
- Cho khch hng xem v thuc v hng dn cch s dng trn v thuc. Cho khch
hng bit cc tc dng ph nh: v kinh, ra mu bt thng, mt mi v nhng kh
khn c th gp. Ch rng nhng khch hng khng th ung thuc ng gi nn
c t vn chn BPTT khc.
- Nhc khch hng cch theo di trong khi s dng thuc:
Khch hng c th quay li khm v t vn bt k lc no nu c vn .
Trong 3 thng u ung thuc phi n c s y t khm, o huyt p, cn nng.
Hn n khm li hng nm.
3.2. Thm khm nh gi trc khi p dng BPTT.
- Hi k tin s v khm lm sng pht hin chng ch nh (s dng bng kim).
- Thm khm loi tr c thai. Trong hon cnh xt nghim nc tiu th thai
khng sn c, c th nh gi l khng c thai" da vo nhng du hiu lm sng
(xem phn 3b, Dng c t cung).
3.3.1. Khch hng cha s dng BPTT s bt u ung thuc.
- C th bt u ngay khi c sa (thng 48 gi sau sinh).
- Trong vng 5 ngy u tin ca chu k kinh (k c nhng trng hp sau sinh c
kinh li) hoc trong vng 4 tun u sau sinh hoc trong vng 7 ngy sau ph thai.
- bt c thi im no nu bit chc l khng c thai. Cn phi s dng thm BPTT h
tr (nh trnh giao hp hoc s dng bao cao su) trong 2 ngy k tip nu: (i) bt
u sau 5 ngy u ca chu k kinh, hoc (ii) khng c kinh (k c bt u t tun th
4 sau sinh v khng cho con b).
3.3.2. Khch hng ang s dng BPTT ni tit s bt u ung thuc.
thai hoc thi im lp li mi tim.
3.3.3. Khch hng ang s dng BPTT khng ni tit s bt u ung thuc.
- Trong vng 5 ngy u tin ca chu k kinh. Nhng khch hng ang s dng DCTC
c th c ly DCTC thi im ny.
- bt c thi im no nu bit chc l khng c thai. Nu bt u ung thuc sau c
kinh >5 ngy, khch hng cn phi s dng thm BPTT h tr trong 2 ngy k tip.
Nhng khch hng ang s dng DCTC c th c ly DCTC chu k kinh sau.
3.4. Cch s dng.
- Ung mi ngy 1 vin, phi ung vo mt gi nht nh, theo chiu mi tn trn v
thuc. Ung thuc tr 3 gi tr ln phi c x tr nh qun thuc.
- Dng v k tip ngay sau khi ht v u, khng ngng gia hai v.
4. Nhng vn kh khn xy ra khi ung thuc v cch x tr.
4.1. Qun ung thuc (mt vin hoc nhiu hn) hoc ung tr 3 gi tr ln.
4.1.1. Khch hng c kinh (k c ang cho con b).
- Ung mt vin ngay khi nh v tip tc ung mi ngy mt vin nh thng l.

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- Cn thm BPTT h tr trong 2 ngy tip theo. C th cn nhc s dng thm BPTT
khn cp nu c nguy c cao.
4.1.2. Khch hng cha c kinh v ang cho con b.
- Ung mt vin ngay khi nh ra v tip tc ung mi ngy mt vin nh thng l.
- Cn thm BPTT h tr trong 2 ngy, nu sau 6 thng hu sn.
4.2. Nn trong vng 2 gi sau ung thuc.
- Ung li mt vin thuc khc.
4.3. Nn nhiu v tiu chy sau ung thuc.
- Nu xy ra trong vng 24 gi, khch hng cn tip tc ung thuc theo ng lch.
- Nu xy ra lin tc t 2 ngy tr ln, khch hng s thc hin ging nh trng hp
qun ung thuc.
4.4.1. V kinh.
- Nu khch hng ang cho con b: trn an khch hng rng nhiu ph n ang cho con
b s dng thuc trnh thai cng b mt kinh v iu ny khng nguy him.
- Th thai nu khch hng khng chc chn ung thuc u.
4.4.2. Kinh nguyt khng u hoc ra mu thm git.
- Trn an khch hng rng nhiu ph n s dng thuc trnh thai cng b tnh trng kinh
nguyt khng u, tnh trng ny s gim v ht sau vi thng s dng thuc. c bit
l bn thn nhiu ph n ang cho con b cng c kinh nguyt khng u.
- Hi khch hng cc nguyn nhn c th gy ra tnh trng kinh nguyt khng u bao
gm: (i) nn hoc tiu chy, hoc (ii) bt u ung thuc chng co git hoc
rifampicin.
Hng dn cch ung thuc ng (k c khi b nn hoc tiu chy).
K n: ibuprofen (hoc cc thuc khng vim khng steroid khc).
ngh khch hng ung loi thuc trnh thai khc t nht trong 3 thng nu khch
hng ung thuc nga thai nhiu thng v tnh trng ri lon kinh nguyt khng
ht sau khi ung thuc khng vim.
- Nu tnh trng ri lon kinh nguyt xut hin sau vi thng c kinh bnh thng hoc
sau mt thi gian v kinh hoc tip tc khng ht hoc nghi ng c nguyn nhn bnh
l khc: cn khm ton din tm nguyn nhn.
ln).
- Trn an khch hng rng tnh trng ny i khi cng xy ra nhiu ph n s dng
thuc trnh thai, tnh trng ny s gim v ht sau vi thng s dng thuc.
- C th x tr ban u nh nhng khch hng b kinh nguyt khng u sau ung thuc
- Nu tnh trng ra mu nhiu xut hin sau vi thng c kinh bnh thng hoc sau mt
thi gian v kinh, hoc tip tc khng ht, hoc nghi ng c nguyn nhn bnh l khc:
cn khm ton din tm nguyn nhn. Trong qu trnh khm khch hng vn c th
tip tc s dng thuc trnh thai.

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4.5. Khc.
4.5.1. Nhc u.
- C th k toa mt trong cc loi thuc gim au nh aspirin, ibuprofen hoc
paracetamol
- Khm ton din nu tnh trng nhc u khng gim hoc trm trng hn.
- Khuyn khch hng ngng thuc v s dng BPTT khng c ni tit nu khch hng
bt u b nhc na u (migrain) c km m mt. Trng hp khch hng nhc na
u khng km m mt th vn c th tip tc s dng thuc trnh thai ch cha
progestogen nu mun.
4.5.2. Cng ngc.
- Nu khch hng ang cho con b:
Nu c tnh trng cng sa v tc ng dn sa (thng v cng, au v c nhng
du hiu ca vim nh: sng, nng, ...):
Tip tc cho b b.
Xoa bp bu v trc v trong khi cho b b.
Chm m hoc lnh.
Thay i cc t th cho b khc nhau.
Cho b b ng cch.
Nn b mt t sa trc khi cho b.
S dng khng sinh nu c tnh trng nhim trng.
Nu c nt nm v:
C th tip tc cho b b.
Nh vi git sa vo nm v trc khi cho b b; dng ngn tay ngt sa sau
khi cho b xong trc khi ko b khi bu v.
Khng v qu cng, nn sa nu v cng v b cha b.
- Nu khch hng khng cho con b:
Khuyn khch hng th chm ngc bng khn lnh hoc m.
C th k n mt trong cc loi thuc gim au nh aspirin, ibuprofen hoc
paracetamol
4.5.3. au nng bng di.
Cn loi tr nang, khi u bung trng, vim rut tha, vim vng chu hoc thai ngoi
t cung.
- Thai ngoi t cung: iu tr hoc chuyn tuyn.
- Nang c nng bung trng: gii thch nang thng t bin mt, nu c th khm li sau
3 tun.
- au do cc nguyn nhn khc: khng cn ngng thuc.
4.5.4. Bun nn hoc chng mt.
- Khuyn khch hng ung thuc trc khi ng hoc ung trong khi n
4.5.5. Khch hng bt u s dng cc thuc nga co git hoc rifampicin (cc thuc ny
BPTT khc.

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4.5.6. Xut hin cc du hiu ca bnh l ni khoa (nh nghi tc mch su chn hoc
phi hoc ung th v).
- Yu cu khch hng ngng thuc trnh thai v s dng cc BPTT h tr khc trong
thi gian chn on bnh.
vin thuc trnh thai ch c progestin.
- Yu cu khch hng s dng bao cao su km theo khi s dng vin thuc trnh thai ch
c progestin. Khi s dng ng cch, thng xuyn, bao cao su gip ngn nga ly
nhim HIV v cc NKLTQTD.
- T vn cho khch hng HIV(+) phng thc nui con ph hp nht:
Ch khng cho b m khi (v ch khi) c y iu kin s dng sa thay th,
c th l y iu kin kinh t, sn phm lun sn c v c cung ng thun
tin.
Nu khng th c iu kin s dng sa thay th, khch hng HIV(+) c th
cho con b m hon ton trong 6 thng u. Cho con b xen k (gia b m v cc
loi sa khc) c th lm tng nguy c ly nhim HIV. Cn rt ngn thi gian cai
sa khi chuyn tip t b m hon ton sang n dm.
C th gim ti a kh nng ly nhim HIV bng cch vt sa m v un si trc
khi cho b n bng tha.
- Cn t vn cho khch hng HIV(+) v ch dinh dng v v sinh. Cc tnh trng
nhim khun nh: vim tuyn v, p xe v nt nm v u lm gia tng nguy c ly
nhim.

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THUC TIM TRNH THAI
Tuyn p dng.
Tt c cc tuyn.
Ngi thc hin.
Cn b cung cp dch v c o to.

Thuc tim trnh thai l BPTT tm thi, cha ni tit progestin. Thuc tim trnh thai
hin c hai loi: (i) DMPA (depot medroxygenprogesteron acetat) liu 150 mg, c tc dng
trnh thai 3 thng, v (ii) NET-EN (norethisteron enantat) liu 200 mg, c tc dng trnh
thai 2 thng. Khch hng nhim HIV hay c bn tnh nhim HIV c th s dng thuc tim
trnh thai nhng cn lu l BPTT ny khng gip ngn nga NKLTQTD v
HIV/AIDS.
1. Ch nh.
Ph n trong tui sinh sn mun dng mt BPTT tm thi v c hi phc.
2. Chng ch nh.
- C thai.
- ang b ung th v.
- C nhiu nguy c b bnh mch vnh (nh ln tui, ht thuc l, tiu ng v tng
huyt p).
- Tng huyt p (HA tm thu 160 mmHg hoc HA tm trng 100 mmHg) hoc c
bnh l mch mu.
- ang b thuyn tc tnh mch su, thuyn tc phi hoc tng hoc ang b tai bin
mch mu no hoc thiu mu c tim.
xt nghim) hoc c gim tiu cu trm trng.
- Ra mu m o bt thng cha c chn on nguyn nhn.
- Tiu ng c bin chng (thn, thn kinh, vng mc, mch mu) hoc trn 20 nm.
- X gan mt b c suy gim chc nng gan trm trng hoc u gan (ngoi tr trng hp
tng sinh lnh tnh dng nt - benign focal nodular hyperplasia)
- Khng tip tc s dng nu khch hng au na u c km m mt.
3.1. T vn.
- Tm hiu nhu cu ca khch hng v thuc tim trnh thai.
- Hiu qu, u, nhc im ca thuc tim trnh thai. Khng nn s dng cho nhng
ngi c nh c thai trong 1 nm ti. Thuc khng c tc dng phng trnh cc
bnh LTQTD.

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- Khch hng c th n khm li bt c lc no.
- Hn ngy v ni tim ln sau.
- Hi k tin s pht hin chng ch nh (dng bng kim)
nghim nc tiu th thai khng sn c, c th nh gi l khng c thai" da vo
nhng du hiu lm sng (xem phn 3b, Dng c t cung).
- C th bt u ngay khi c sa (thng 48 gi sau sinh).
- Trong vng 7 ngy u k t ngy hnh kinh u tin (bao gm c nhng ngi c
kinh li sau 6 tun hu sn) hoc bt c lc no trong vng 21 ngy hu sn (v khng
cho con b) hoc ngay sau ph thai, sy thai.
- bt c thi im no nu bit chc l khng c thai. C th cn s dng BPTT h tr
trong 7 ngy k tip nu: (i) qu 7 ngy t khi bt u hnh kinh, hoc (ii) v kinh,
hoc (iii) 6 tun sau sinh v cha c kinh, hoc (iv) t 21 ngy sau sinh tr i v cha
c kinh. Trong nhng trng hp ny, cn th thai trc khi cho khch hng mi tim
tip theo.
3.3.2. Khch hng ang s dng BPTT ni tit s c tim thuc.
thai hoc vo thi im lp li mi tim cho nhng khch hng ang s dng thuc
tim.
3.3.3. Khch hng ang s dng BPTT khng ni tit (khng phi DCTC) s c tim
thuc.
thai. Nu qu 7 ngy t khi bt u hnh kinh cn trnh giao hp hoc s dng thm
3.3.4. Khch hng ang s dng DCTC (k c DCTC gii phng levonorgestrel) s c
tim thuc.
- Trong vng 7 ngy u tin ca vng kinh, c th ly DCTC thi im ny.
- Bt k lc no nu bit chc l khng c thai.
Nu qu 7 ngy t khi bt u hnh kinh v c giao hp: cn ly DCTC vo
chu k sau.
Nu qu 7 ngy t khi bt u hnh kinh v khng giao hp: cn trnh giao hp
hoc s dng thm BPTT h tr trong 7 ngy k tip. Nu DCTC chnh l bin
php h tr: cn ly DCTC vo chu k sau.
- Nu v kinh hoc ra mu bt thng: xem hng dn dnh cho ph n v kinh.
3.3.5. Cc mi tim ln sau.
- Khong cch gia hai ln tim: 3 thng vi DMPA v 2 thng vi NET-EN.
- Nu mi tim ln sau c thc hin tr hn hn chch (xem phn 4.1 Chm ngy
tim).
- Chuyn i gia thuc tim trnh thai v NET-EN
Khng khuyn co chuyn i gia thuc tim trnh thai v NET-EN.
Nu nht thit phi chuyn i cn tim vo thi im mi tim lp li.

288 |
- Nu cn tim lp li m loi thuc v thi im tim ln trc khng r:
C th tim nu bit chc l khng c thai, cn trnh giao hp hoc s dng thm
BPTT h tr trong 7 ngy k tip, k c xem xt s dng BPTT khn cp.
3.4. K thut tim
- St khun vng tim (c delta b vai hoc mng) bng cn, c pha iod cng tt.
- Dng bm kim tim mt ln.
- Kim tra thuc c cn hn, lc u l thuc trc khi ht thuc ra bm tim.
- Cn m bo v khun v tun th nhng qui nh ca Phng nga chun khi thc hin
th thut.
- Tim su, y bm tim t t cho thuc vo ht bo m 150 mg thuc tim
trnh thai c a vo c th.
- Sau khi rt kim khng xoa vng tim trnh thuc lan ta sm v nhanh.
3.5. Theo di sau tim.
- Vim nhim ti ch, au, vng tim.
- p xe.
4.1. Chm ngy tim.
- Nu khch hng tr hn thi hn tim trong vng trong vng 2 tun (i vi NET-EN)
v trong vng 4 tun (i vi DMPA): vn c th tim thuc m khng cn s dng
BPTT h tr.
- Nu khch hng tr hn thi hn tim sau hn 2 tun (i vi NET-EN) v sau 4 tun
(i vi DMPA): vn c th tim thuc nhng cn trnh giao hp hoc s dng thm
BPTT h tr trong 7 ngy k tip, k c cn nhc s dng BPTT khn cp, nu:
Khch hng khng giao hp trong vng hai tun tnh t ngy ng l phi c
tim mi lp li, hoc
Khch hng s dng BPTT h tr hoc BPTT khn cp mi ln giao hp
khng c bo v trong vng hai tun tnh t ngy ng l phi c tim mi lp
li, hoc
Khch hng cho con b hon ton hoc gn nh hon ton v va sinh trong vng 6
thng
- Nu khch hng tr hn thi hn tim sau hn 2 tun (i vi NET-EN) v sau 4 tun
(i vi DMPA) v khng tha nhng iu kin trn: vn c th tim thuc nu bit
chc l khng c thai. Cn trnh giao hp hoc s dng thm BPTT h tr trong 7
ngy k tip, k c cn nhc s dng BPTT khn cp v phi th thai trc khi chch
lp li mi thuc ln sau.
- Cn tho lun vi khch hng v l do tr hn tim v bn gii php thch hp. Nhc
nh thi hn tim v tho lun thm cc BPTT h tr hoc gi BPTT khc trong
trng hp khch hng khng th n ng hn.
4.2.1 V kinh.
- Gii thch rng v kinh l bnh thng khi dng thuc tim trnh thai.
- Nu khch hng khng chp nhn v kinh: c th hng dn s dng BPTT khc.

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4.2.2. Ra mu thm git hoc kinh nguyt khng u.
- Trn an khch hng rng nhiu ph n s dng thuc trnh thai b kinh nguyt khng
u, tnh trng ny s gim v ht sau vi thng s dng thuc.
K n: acid mefenamic hoc valdecoxid trong nm ngy,
l khc: cn khm ton din tm nguyn nhn. Nu b vim vng chu hoc
NKLTQTD: c th tip tc s dng thuc cy trong thi gian iu tr bnh.
ln).
- y l tnh trng him gp, nhng cn c ch c bit. Cn trn an khch hng
rng tnh trng ny i khi cng xy ra nhiu ph n s dng thuc tim trnh thai;
tnh trng ny s gim v ht sau vi thng s dng thuc.
- C th x tr ban u nh nhng khch hng b kinh nguyt khng u hoc s dng
50 mcg ethinyl estradiol trong mt chu k.
- Nu tnh trng ra mu nhiu lm nh hng n sc khe: tho lun vi khch hng
chn BPTT khc.
- Khuyn khch hng ung vin st hoc n cc thc phm giu cht st.
thi gian v kinh hoc tip tc khng ht hoc nghi ng c nguyn nhn bnh l khc:
cn khm ton din tm nguyn nhn.
4.2.4 Ra mu m o bt thng.
- Khm ton din tm nguyn nhn.
- C th ngng s dng thuc tim nhm gip chn on thun tin hn, trong thi gian
ny khch hng c th s dng BPTT khc (khng nn l DCTC hoc que cy).
- Nu nguyn nhn ra mu l vim vng chu hoc NKLTQTD th khch hng vn c
th vn tip tc s dng thuc tim trong thi gian iu tr bnh.
4.3. Khc.
4.3.1Nhc u.
paracetamol
- Ngng thuc tim nu khch hng b nhc u km m mt.
4.3.2 Xut hin cc du hiu ca bnh l ni khoa (nh tc mch su chn hoc phi,
thiu mu c tim hoc t qu hoc ung th v).
- Ngng thuc tim v yu cu khch hng s dng cc BPTT h tr khc trong thi
gian chn on bnh.
4.3.3 Nghi ng c thai.

290 |
thuc tim trnh thai.
- Yu cu khch hng s dng bao cao su km theo. Khi s dng ng cch, thng

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THUC CY TRNH THAI
Tuyn p dng.
Tuyn huyn tr ln.
Ngi thc hin.

Thuc cy trnh thai l BPTT tm thi c cha progestin. Hin nay thuc cy trnh
thai c hai loi: (i) Norplant: gm 6 nang mm, v bng cht do sinh hc, mi nang cha
36 mg levonorgestrel, v (ii) Implanon: ch c mt nang, cha 68 mg etonogestrel.
Norplant c tc dng ko di 5 nm (hoc n 7 nm vi nhng ph n c trng lng
di 70 kg ti thi im t v trong qu trnh s dng) v Implanon c tc dng 3 nm.
Khch hng nhim HIV hay c bn tnh nhim HIV c th s dng thuc cy trnh thai
nhng cn lu l BPTT ny khng gip ngn nga NKLTQTD v HIV/AIDS.

1. Ch nh.
Ph n mun s dng mt BPTT di hn v c hi phc.
2. Chng ch nh.
- C thai.
- ang b ung th v.
- ang b thuyn tc tnh mch su, thuyn tc phi.
xt nghim).
- Ra mu m o bt thng cha c chn on nguyn nhn.
- X gan mt b c suy gim chc nng gan trm trng, hoc u gan (ngoi tr trng
hp tng sinh lnh tnh dng nt - benign focal nodular hyperplasia).
- Khng tip tc s dng nu khch hng:
tng hoc ang b tai bin mch mu no hoc thiu mu c tim
au na u c km m mt
3.1. T vn.
- Lng nghe v tm hiu nhu cu ca khch hng v thuc cy trnh thai.
- Hiu qu, u, nhc im (c th kh ly ra). Bin php khng c tc dng phng
trnh NKLTQTD v HIV/AIDS.
- Cho khch hng bit cc tc dng ph c th gp, c bit l ra mu bt thng.
- Khch hng c th n khm li bt c lc no khi c vn hoc mun tho que cy
trnh thai.

292 |
- Khng phi l BPTT vnh vin, Norplant c tc dng trong 5 - 7 nm, Implanon c tc
dng trong 3 nm.
- Hi k tin s pht hin chng ch nh (dng bng kim).
nghim nc tiu th thai khng sn c, c th nh gi l khng c thai" da vo
nhng du hiu lm sng (xem phn 3b, Dng c t cung).
- Ngay khi ang c kinh hoc trong 7 ngy u (hoc trong vng 5 ngy u i vi
Implanon) ca vng kinh.
- bt c thi im no nu bit chc l khng c thai. Nu qu 7 ngy (hoc nu
qu 5 ngy i vi Implanon) t khi bt u hnh kinh cn trnh giao hp hoc s
dng thm BPTT h tr trong 7 ngy k tip.
- V kinh: bt k thi im no nu c th khng nh khng c thai, cn trnh giao hp
hoc s dng thm BPTT h tr trong 7 ngy k tip.
- Sau sinh v cho con b hon ton hoc gn nh hon ton:
Trong vng 6 tun sau sinh v ang cho con b: ch s dng thuc cy mt khi
khng cn BPTT no khc.
T 6 tun n 6 thng, v kinh: bt k lc no,
Nu c kinh li sau 6 tun: nh trng hp hnh kinh bnh thng.
- Sau sinh khng cho b hon ton.
Trong vng 6 tun sau sinh: ch s dng mt khi khng cn BPTT no khc.
Sau 6 tun:
nu cha c kinh li: bt k lc no nu chc chn l khng c thai, khch hng
cn s dng BPTT h tr trong 7 ngy k tip.
nu c kinh li: nh trng hp hnh kinh bnh thng.
- Sau sinh, khng cho con b:
Di 21 ngy: bt k lc no.
T 21 ngy tr i v cha c kinh: bt k thi im no nu c th khng nh
khng c thai, cn trnh giao hp hoc s dng thm BPTT h tr trong 7 ngy k
tip.
Nu c kinh li bnh thng: nh trng hp hnh kinh bnh thng.
- Ngay sau ph thai hoc sy thai:
Trong vng 7 ngy sau ph thai, sy thai: c th cy thuc ngay lp tc.
Sau 7 ngy: bt k thi im no nu c th khng nh khng c thai, cn trnh
giao hp hoc s dng thm BPTT h tr trong 7 ngy k tip.
- Sau s dng thuc trnh thai khn cp: s dng thuc cy trong vng 7 ngy u ca
k kinh k tip (vo trong vng 5 ngy i vi Implanon) hoc trong bt k thi im
no nu chc chn l khng c thai. Cung cp cc BPT h tr hoc thuc trnh thai
trong thi gian ch cy thuc.
- Ngay sau khi ly thuc cy nu mun cy tip.

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3.3.2. Khch hng ang s dng BPTT ni tit s c cy thuc.
thai, vo thi im lp li mi tim.
3.3.3. Khch hng ang s dng BPTT khng ni tit (khng phi DCTC) s c cy
thuc:
thai. Nu qu 7 ngy t khi bt u hnh kinh cn trnh giao hp hoc s dng thm
3.3.4. Khch hng ang s dng DCTC (k c DCTC gii phng levonorgestrel) s c
cy thuc:
- Trong vng 7 ngy u tin ca vng kinh, c th ly DCTC thi im ny.
- Bt k lc no nu bit chc l khng c thai:
Nu qu 7 ngy t khi bt u hnh kinh v c giao hp: cn ly DCTC vo
chu k sau.
Nu qu 7 ngy t khi bt u hnh kinh v khng giao hp: cn trnh giao hp
hoc s dng thm BPTT h tr trong 7 ngy k tip. Nu DCTC chnh l bin
php h tr: cn ly DCTC vo chu k sau.
- Nu v kinh hoc ra mu khng theo chu k: xem hng dn dnh cho ph n v kinh.
3.4. K thut cy.
Cn m bo v khun v tun th nhng qui nh ca Phng nga chun khi thc
hin th thut.
3.4.1. Norplant:
- St khun da vng nh cy thng mt trong cnh tay khng thun.
- Tri vi c l vng nh cy.
- Gy t di da vng cy, mi nan qut 1 ml lidocain 1 %.
- Rch da 2 mm.
- a ng t vo di da qua ng rch.
- t tng nang Norplant t bn ny sang bn kia, mi nang thy ni l m di da sao
cho cc nang xp hnh nan qut, gia hai nang to gc 15
o
, 2 nang ngoi cng to gc
75
o
. u ngoi ca nang cy cch ch rch da 5 mm khi tt ra. Cy nng di da,
tng cng 6 nang hnh nan qut.
- t xong khng day, dng bng dnh bng li.
3.4.2. Implanon:
- St khun da vng nh cy: thng khong gia mt trong cnh tay khng thun.
- Tri vi c l vng nh cy.
- Gy t vng nh cy bng lidocain 1 % dc ng cy.
- Ly ng cy v khun ra khi bao b.
- Kim tra bng mt thng xem nang cy c trong kim khng.
- t nang cy bng cch m kim ngay di da v va y va dng u kim nng mt
da ln.
- Gi nguyn pt tng ti ch v ko ng cy, nang thuc cy s nm li trong cnh tay.
Cy nng di da.
- Kim tra nang thuc c cy.
- Bng p bng gc v khun.

294 |
3.5. K thut tho (p dng chung cho Norplant v Implanon)
- St khun.
- Tri vi.
- Gy t.
- Rch da 2 mm nh khi cy.
- Dng tay nn cho u nang l ra ch rch.
- Dng 1 kp nh kp u nang cy, ko nh ra.
- Sau khi tho ht, st khun, bng li.
4.1.1 V kinh.
- Gii thch rng v kinh l bnh thng khi dng thuc cy trnh thai.
- Nu khch hng khng chp nhn v kinh: tho hoc chuyn n c s c th tho, v
hng dn s dng BPTT khc
4.1.2. Ra mu thm git hoc kinh nguyt khng u.
- Trn an khch hng rng nhiu ph n s dng thuc trnh thai b kinh nguyt khng
u; tnh trng ny s gim v ht sau vi thng s dng thuc.
K n:
Ibuprofen (hoc cc thuc khng vim khng steroid khc),
Thuc trnh thai kt hp (progestin: levonorgestrel) hoc ethinyl estradiol trong
21 ngy nu khng c chng ch nh estrogen.
l khc: cn khm ton din tm nguyn nhn. Nu b vim vng chu hoc
NKLTQTD: c th tip tc s dng thuc cy trong thi gian iu tr bnh.
ln).
- y l tnh trng him gp, nhng cn c ch c bit. Cn trn an khch hng
rng tnh trng ny i khi cng xy ra nhiu ph n s dng que cy trnh thai; tnh
trng ny s gim v ht sau vi thng s dng thuc.
- C th x tr ban u nh nhng khch hng b kinh nguyt khng u. Thuc trnh
thai kt hp vi liu 50 mcg ethinyl estradiol c th hiu qu hn loi liu thp.
- Khuyn khch hng ung vin st hoc n cc thc phm giu cht st.
thi gian v kinh hoc tip tc khng ht hoc nghi ng c nguyn nhn bnh l khc:
cn khm ton din tm nguyn nhn. Trong qu trnh khm, khch hng vn c th
tip tc s dng thuc trnh thai.
4.2. au h v.
Cn loi tr nang v khi u bung trng, vim rut tha, vim vng chu, thai ngoi t
cung hoc u gan v.
- Thai ngoi t cung: iu tr hoc chuyn tuyn, tho thuc cy.

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- Nang c nng bung trng: gii thch nang thng t bin mt, nu c th khm li sau
3 tun.
- au do cc nguyn nhn khc: khng cn tho thuc cy.
4.3. Ti v tr cy.
4.3.1. au sau khi cy.
- Hng dn cho khch hng.
m bo bng p khng qu cht.
Thay bng p mi.
Trnh mnh vo vng cy trong vi ngy v trnh p vo nu sng au.
- Ch nh aspirin hoc cc thuc khng vim khng steroid.
4.3.2. Nhim khun v tr cy (au, nng, ) hoc p xe (c m).
- Vim.
Khng tho que cy.
Ra sch vng cy bng thuc st khun hoc nc x phng.
Ch nh khng sinh cho 7 ngy v yu cu khch hng quay li sau 1 tun. Nu
khng , tho que cy hoc chuyn tuyn.
- p xe.
Ra sch vng vim bng thuc st khun, rch da v tho m
Nu nhim khun da nhiu: ch nh khng sinh ung trong 10 ngy .
iu tr vt thng.
Tho que cy hoc chuyn tuyn tho (nu tnh trng khng n nh).
4.4. Khc.
4.4.1. Nhc u.
paracetamol
- Tho que cy v khuyn khch hng s dng BPTT khng c ni tit nu khch hng
bt u b nhc na u (migrain) c km m mt hoc b nng ln sau khi cy, c
bit i km nhn m, mt th gic thang qua, mt n om m hoc thy cc ng
dc dc, ri lon ngn ng hoc vn ng. Trng hp nhc na u khng km m
mt vn c th tip tc s dng que cy nu mun.
- Chuyn tuyn iu tr bnh tng ng.
4.4.2. Cng ngc.
- Khuyn khch hng th chm ngc bng khn lnh hoc m.
paracetamol
4.4.3. Khch hng bt u s dng cc thuc nga co git hoc rifampicin (cc thuc ny
BPTT khc.

296 |
4.4.4. Xut hin cc du hiu ca bnh l ni khoa (nh tc mch su chn hoc phi,
thiu mu c tim hoc t qu hoc ung th v)
- Tho que cy hoc chuyn tuyn tho v yu cu khch hng s dng cc BPTT h
tr khc trong thi gian chn on bnh.
thuc cy trnh thai.
- Yu cu khch hng s dng kt hp vi bao cao su. Khi s dng ng cch v thng

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TRIT SN NAM BNG PHNG PHP THT
V CT NG DN TINH
Tuyn p dng.
T tuyn huyn (bao gm c i KHHG lu ng ca huyn) tr ln.
Ngi thc hin.
Cn b y t c o to v trit sn nam.

Trit sn nam bng phng php tht v ct ng dn tinh l BPTT vnh vin dnh cho
nam gii bng cch lm gin on ng dn tinh dn n khng c tinh trng trong mi ln
xut tinh. y l bin php thc hin mt ln c tc dng trnh thai sut i v th khch
hng cn c t vn k trc khi quyt nh thc hin. y l mt th thut ngoi khoa
n gin v an ton. Hiu qu trnh thai rt cao (trn 99,5 %) v trit sn nam khng c
nh hng n sc khe v sinh hot tnh dc. Trit sn nam khng phng trnh c cc
NKLTQTD v HIV/AIDS.
1. Ch nh.
Nam gii c s con mong mun, khe mnh, t nguyn dng mt BPTT vnh
vin v khng hi phc sau khi c t vn y .
2. Chng ch nh (khng c chng ch nh tuyt i).
2.1. Cn THN TRNG (c th thc hin bnh thng khi c thm nhng chun b cn
thit) nu khch hng c mt trong nhng du hiu sau.
- Tin cn chn thng bu hoc bu sng to do gin tnh mch vng thng tinh, tinh
hon lc ch 1 bn.
- Bnh l ni khoa nh tiu ng, trm cm hoc tr tui.
2.2. HON th thut nu khch hng c mt trong nhng du hiu sau.
- NKLTQTD cp hoc vim (sng, au) u dng vt, ng dn tinh hoc tinh hon
hoc nhim khun tinh hon.
- Nhim khun ton thn hoc b bnh ph chn voi.
2.3. Cn c CHUN B C BIT (nh phu thut vin c kinh nghim hoc phng
tin gy m ni kh qun hoc nhng phng tin hi sc cn thit) nu khch hng c
mt trong nhng du hiu sau: thot v bn, c AIDS hoc ri lon ng mu.
3.1. T vn.
- Lng nghe v tm hiu nhu cu ca khch hng v trit sn nam.
- Hiu qu, u im, nhc im ca trit sn nam (nhn mnh y l BPTT khng phc
hi, nn khng thch hp cho i tng cn tr cha c con). Bin php ny khng c
tc dng phng trnh NKLTQTD, HIV/AIDS.
- Gii thch qui trnh trit sn nam.
- K n tnh nguyn xin trit sn.

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3.2. Thm khm trc khi thc hin th thut.
- Tm hiu k xem khch hng c ng ch nh khng.
- Hi k tin s bnh tt ni ngoi khoa, khm ton thn v b phn (tim, phi, bng).
c bit ch khm vng sinh dc ngoi (bu, tinh hon, mo tinh).
- Xt nghim thng khng cn thit tr khi hi tin s v thm khm lm sng pht
hin nhng vn cn thm d thm. Nhng xt nghim c th lm l: hemoglobin
v/hay hematocrit, phn tch nc tiu tm glucose v protein.
- Khuyn khch hng v sinh sch s vng sinh dc v vng i trn trc phu thut;
mc qun lt sch.
Bt k thi gian no thun tin.
3.4. Thc hin trit sn nam.
3.4.1.Chun b tin hnh th thut.
- Lm sch vng phu thut: ct bt lng mu, ra sch vng sinh dc bng dung dch st
khun.
- Khch hng mc qun o sch, nm nga thoi mi trn bn phu thut. Tri khn phu
thut c l h vng bu.
- Phu thut vin v tr th ra tay, mc o, i gng nh qui trnh phu thut.
- Nhit phng phu thut phi m, khng qu lnh.
3.4.2. Gim au trong trit sn nam.
- Nu khch hng qu lo lng, cho ung 5 mg diazepam 30 pht trc th thut.
- Gy t ti ch bng lidocain 1 % (loi khng c adrenalin). Liu ti a khng qu 4,5
mg/kg trng lng c th.
3.4.3. K thut trit sn nam khng dng dao.
Cn m bo v khun v tun th nhng qui nh ca Phng nga chun khi thc hin
th thut.
- Tht ng dn tinh bn phi.
Dng k thut 3 ngn tay xc nh v c nh ng dn tinh.
t kp m ng dn tinh qua da bu.
Chc km phu tch qua da.
Bc l v nng cao ng dn tinh.
Bu vo ng dn tinh bng kp vng trn.
Bc tch cn tinh.
Tht v ct on ng dn tinh.
Buc hai u bng ch khng tiu hay chromic catgut.
t 1 cn cch ly u xa ca ng dn tinh.
- Tht ng dn tinh bn tri: k thut tng t
Lu :
Khng cn khu da bu, ch cn bng l m da bu.
Phi cm mu k trong sut qu trnh lm th thut.
3.4.4. Theo di v hng dn khch hng ngay sau phu thut.
- khch hng ngh ngi thoi mi trong vi gi u, khng cn nm vin.
- Khch hng c th v nh sau khi ngh ngi ti ch mt vi gi.

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- Ung khng sinh 5 ngy.
- Gim au bng paracetamol.
- Hng dn khch hng t chm sc.
Khch hng c th c cm gic tc nng bu nhng khng au (nn mc qun lt
cht trong vi ngy u gip c cm gic thoi mi).
C th dng ti nh cha nc p ln vng chung quanh bu gim sng au.
Trnh lao ng nng trong 1 - 2 ngy u.
Lun gi vt m sch v kh. C th tm sau 24 gi nhng trnh lm t vt m.
Sau 3 ngy c th ra vt m bng x phng.
Sau 1 tun c th sinh hot tnh dc bnh thng nhng vn c th c thai.
Hng dn khch hng trnh giao hp hoc dng bao cao su hoc BPTT c hiu
qu khc trong vng 12 tun sau trit sn nam.
- Khch hng cn n khm li ngay nu c nhng du hiu nh: st, chy mu, c m
vt m, sng au vt m khng gim.
4. Tai bin v bin chng.
Bao gm chy mu trong lc phu thut v sau phu thut, phn ng thuc t, sng
au, t mu sau phu thut, nhim khun v tr hn c th gp vim mo tinh v u ht tinh
trng. Vic pht hin sm v iu tr thch hp l rt cn thit. Ngoi ra c th gp au ko
di (2 %), thng khng qu 1 nm hoc c th hi tic sau trit sn.
BPTT trit sn nam. Cn c nhng chun b c bit khi thc hin cho khch hng c
AIDS.
- Yu cu khch hng s dng bao cao su km theo. Khi s dng ng cch v thng

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TRIT SN N BNG PHNG PHP THT
V CT VI T CUNG
Tuyn p dng.
T tuyn huyn (bao gm c i KHHG lu ng ca huyn) tr ln.
Ngi thc hin.
Cn b y t c o to v trit sn n.

Trit sn n bng phng php tht v ct vi t cung l mt phu thut lm gin on
vi t cung, khng cho tinh trng gp non thc hin th tinh. Trit sn n l bin php
trnh thai vnh vin, hiu qu trnh thai rt cao (trn 99%) v khng nh hng n sc
khe, quan h tnh dc. Trit sn n khng phng trnh c NKLTQTD, HIV/AIDS.
1. Ch nh.
- Ph n ang tui sinh c s con mong mun, cc con khe mnh, t
nguyn dng mt BPTT vnh vin v khng hi phc sau khi c t vn y .
- Ph n b cc bnh c chng ch nh c thai.
2. Chng ch nh: (khng c chng ch nh tuyt i).
2.1. Cn THN TRNG (c th thc hin bnh thng khi c thm nhng chun b cn
thit) nu khch hng c mt trong nhng c im sau.
- Bnh l sn khoa (tin s hoc hin ti) nh: tin s vim vng chu t ln mang thai
trc, ung th v, u x t cung hoc tin s phu thut vng chu hoc bng di.
- Bnh l tim mch nh: tng huyt p (140/90 - 159/99 mmHg), tin s t qu hoc
bnh tim khng bin chng.
- Bnh mn tnh nh ng kinh, tiu ng cha c bin chng, nhc gip, x gan cn
b, u gan hoc nhim schistosomiasis gan, thiu mu thiu st mc va
(hemoglobin 7 - 10 g/dl), bnh hng cu hnh lim, thalassemia, bnh thn, thot v
honh, suy dinh dng nng, bo ph, trm cm hoc cn tr.
2.2. HON thc hin nu khch hng c mt trong nhng c im sau.
- C thai hoc trong thi gian 7 - 42 ngy hu sn.
- Hu sn ca thai k b tin sn git nng hoc sn git.
- Bin chng sau sinh, sau no trm trng nh: nhim khun, xut huyt hoc chn
thng hoc cn mu bung t cung nhiu hoc ra huyt m o bt thng gi
bnh l ni khoa.
- Vim vng chu hoc vim m c t cung hoc vim c t cung do Chlamydia hoc
lu cu.
- Ung th vng chu hoc bnh t bo nui c tnh.
- Bnh l ti mt c triu chng hoc vim gan siu vi cp.
- Thiu mu thiu st trm trng (hemoglobin < 7 g/dl).
- Bnh phi nh: vim phi, vim ph qun.
- Nhim khun ton thn hoc nhim khun da bng.
- Khch hng chun b phu thut do nguyn nhn cp cu hoc do nhim khun.

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2.3. Cn c CHUN B C BIT (nh: phu thut vin c kinh nghim hoc phng
tin gy m ni kh qun hoc nhng phng tin hi sc cn thit), nu khch hng c
mt trong nhng c im sau.
- AIDS hoc t cung b c nh do phu thut trc hoc do nhim khun hoc c
chn on lc ni mc t cung hoc thot v rn hoc thnh bng hoc v, thng t
cung sau sinh, sau ph thai.
- Nhiu tnh trng c th lm gia tng nguy c t qu nh ln tui km ht thuc nhiu,
huyt p, tiu ng hoc hin ti tng huyt p trm trng ( 160/100 mmHg) hoc
tiu ng c bin chng hoc bnh van tim nng c bin chng.
- Bnh l ni khoa nh x gan mt b, cng gip, ri lon ng mu, bnh phi mn
tnh hoc lao vng chu.
3.1. T vn.
- Lng nghe v tm hiu nhu cu ca khch hng v trit sn n. Lu nhng trng
hp quyt nh trit sn trong nhng thi im b sang chn tm l nh sau sinh hay
sau h thai
- Hiu qu, u, nhc im ca trit sn n (nhn mnh y l BPTT khng hi phc).
- Bin php khng nh hng n sc khe, gii tnh v sinh hot tnh dc.
- Sau trit sn kinh nguyt thng khng thay i (tr nhng trng hp ang s dng
DCTC hay trnh thai bng ni tit th c th thay i tm thi trong mt khong thi
gian sau khi ngng s dng cc phng php ny).
- Bin php khng c tc dng phng trnh NKLTQTD, HIV/AIDS.
- Gii thch qui trnh trit sn n.
- K n tnh nguyn xin trit sn.
3.2. Thm khm trc th thut.
- Hi tin s: ngoi hi tin s ni, ngoi khoa cn lu :
Tnh trng p dng BPTT hin ti nu c.
Ngy u k kinh cui cng.
Tin s bnh l vng chu.
Tin s sn khoa.
Nhng phu thut vng chu trc .
- Thm khm thc th:
Cn nng, mch, nhit , huyt p.
Khm tim, phi.
Khm bng.
nh gi tnh trng dinh dng.
Trc khi thc hin trit sn n thi im khng c thai: phu thut vin cn
thm khm vng chu xc nh kch thc t cung, tnh cht di ng v v tr
ca t cung loi tr nhng trng hp vim vng chu v khi u vng chu.
Trc khi thc hin trit sn n sau sinh v sau ph thai: phu thut vin cn thm
khm k loi tr nhng bin chng sau sinh v sau ph thai.
- Xt nghim:
Hemoglobin v/hoc hematocrit.
C th thc hin thm nhng xt nghim khc ty theo kt qu hi tin s v thm
khm lm sng.

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- Khi khng c thai.
- Sau : thi im tt nht l trong vng 7 ngy u hoc tr hon n thi im sau 6
tun sau .
- Sau ph thai: trong vng 7 ngy u.
- Kt hp trit sn khi phu thut bng di v mt l do khc (phu thut ly thai, phu
thut u nang bung trng) v c yu cu ca khch hng.
3.4. Chun b tin hnh th thut.
- Thng tiu hoc cho khch hng i tiu trc khi ln bn phu thut.
- khch hng nm t th ph khoa hoc t th nm nga ty theo phu thut vin
dng cn nng t cung hay khng.
- Nu dng cn nng t cung th t cn trc khi phu thut.
- Phu thut vin thng ng bn tri, ngi ph m ng i din.
- Bn dng c trong tm tay ca ngi ph m.
- Mt ngi gy m hi sc chuyn theo di khch hng.
- Mt ngi phc v bn ngoi.
3.5. Gim au trong trit sn n.
- Pethidin (bit dc: Dolargan, Dolosal) 25 - 50 mg hoc diazepam 10 mg tim bp 30 -
60 pht trc khi phu thut hoc cho ung 5 mg nu khch hng qu lo lng.
- Ty iu kin, trang thit b v kinh nghim, c th p dng 1 trong 3 k thut sau:
Gy t ti ch bng lidocain 1 %. Liu ti a khng qu 4,5 mg/kg trng lng c
th (ph n 50 kg, liu ti a l 25 ml lidocain 1 %).
Ch nh gy m ni kh qun cho nhng ngi khng th thc hin th thut bng
gy t ti ch (thng p dng cho nhng trng hp bo ph, vt m c dnh, bnh
nhn tm thn).
Gy t ngoi mng cng t khi p dng.
Hai phng php sau ch c dng trong bnh vin.
3.6. K thut trit sn n.
Cn m bo v khun v tun th nhng qui nh ca Phng nga chun khi thc
hin th thut.
3.6.1. ng vo.
- ng m bng nh (minilap): rch ngang hay rch dc thnh bng. Nu rch dc th
khi im t ch cao nht, c th nng y t cung bng cn nng. Chiu di ng
rch di 5 cm. Trit sn sau c th rch cong theo np di ca rn. Chng ch
nh ng m bng nh trong trng hp c so m c hay ngi qu bo.
- ng m bng ln khi thc hin cc phu thut khc v kt hp trit sn.
3.6.2. K thut lm tc vi t cung.
- Tm v xc nh hai vi t cung i t sng t cung ra ti tn loa vi t cung.
- Dng kp rng chut nng phn eo ca vi t cung hnh thnh quai vi.
- Dng ch catgut tht di quai mt on.
- Ct quai vi trn ch buc.
- Thc hin k thut tng t cho vi t cung bn i din.
- Sau khi kim tra gc, ng bng theo tng lp c th khng cn khu phc mc
thnh bng.

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3.7. Theo di sau trit sn.
- Ngay sau trit sn theo di cc du hiu sinh tn (ton trng, mch, huyt p, nhp th
trong 6 gi u sau th thut).
- C th cho khch hng v nh khi n nh (thng thng l trong ngy). Nhng du
hiu chng t khch hng n nh l:
Du hiu Romberg (khch hng ng vng khi nhm 2 mt v a thng hai tay ra
pha trc).
Khch hng tnh to, t mc qun o c.
- Ung khng sinh 5 ngy.
- Gim au bng paracetamol.
- Hng dn khch hng chm sc vt m ngay sau trit sn
Gi vt m kh, sch. C th tm sau 24 gi, khi tm trnh khng lm t vt m.
Trnh ng chm vt m.
Ct ch vt m vo ngy th 6 ti nh hay trm y t x (nu khu bng ch khng
tiu).
Trnh lm vic nng v trnh giao hp 1 tun.
- Nhng du hiu bo ng: nu c mt trong cc du hiu sau cn bo ngay cho cn b
y t hoc trc tip ti c s y t khm:
St.
au bng khng gim hoc tng.
Chy mu, m vt m.
Sng vng m.
- Tr kinh, nghi ng c thai.
4. Tai bin v bin chng.
- Chy mu bng.
- Nhim trng vng chu, vim phc mc.
- Hnh thnh khi mu t.
- Chy mu v nhim trng vt m.
- Him gp: tn thng t cung, rut, bng quang.
- Trng hp tht bi sau trit sn c th gp thai ngoi t cung.
BPTT trit sn n. Cn c nhng chun b c bit khi thc hin cho khch hng
AIDS.
- Yu cu s dng bao cao su khi giao hp. Khi s dng ng cch v thng xuyn,
bao cao su gip ngn nga ly nhim HIV v cc NKLTQTD.

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BIN PHP TRNH THAI KHN CP
Tuyn p dng
Tt c cc tuyn
Ngi thc hin:
Cn b cung cp dch v.

Bin php trnh thai khn cp c s dng sau khi giao hp khng c bo v, gm
c: ung thuc vin trnh thai v t dng c t cung. Thuc trnh thai khn cp c hiu
qu cng cao nu s dng cng sm. Khch hng nhim HIV hay c bn tnh nhim HIV
c th s dng cc BPTT khn cp nhng cn lu l BPTT ny khng gip ngn nga
NKLQTD v HIV/AIDS.

1. Ch nh.
Ph n sau giao hp khng c bo v hoc s dng BPTT tht bi, nh rch bao cao
su, qun ung thuc, tim thuc mun... hoc b hip dm.
2. Chng ch nh.
2.1. Vin thuc trnh thai.
C thai.
2.2. Dng c t cung.
Xem bi Dng c t cung.
3. Quy trnh thc hin
3.1. T vn.
- Lng nghe v tm hiu nhu cu ca khch hng v cc BPTT khn cp. T vn r v
hiu qu, nhng thun li v khng thun li khi s dng cc BPTT khn cp. Cn lu
khch hng l bin php ny khng c hiu qu cao, khng c tc dng phng trnh
NKLTQTD v nn s dng mt BPTT tin cy khc nu c quan h tnh dc thng
xuyn. Ngoi ra, BPTT khn cp cn c s dng cng sm cng tt, v hiu qu
cng gim nu s dng cng mun.
- Cho khch hng xem vin thuc v hng dn cch s dng. Cho khch hng bit cc
tc dng ph v nhng kh khn c th gp nh ra mu m o hoc bun nn, nn.
- T vn cho khch hng v s dng DCTC trnh thai khn cp.
- Nhc khch hng kim tra tnh trng c thai nu chm kinh sau s dng BPTT khn
cp.
3.2. Thm khm nh gi trc khi p dng BPTT.
- Hi k tin s v khm lm sng pht hin chng ch nh (s dng bng kim).
- Thm khm loi tr c thai. Trong hon cnh xt nghim nc tiu th thai
khng sn c, c th nh gi l khng c thai" da vo nhng du hiu lm sng
(xem phn 3b, Dng c t cung).

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3.3. Thi im thc hin
- Khch hng s s dng BPTT khn cp (ung thuc hoc t DCTC) cng sm cng
tt trong vng 5 ngy (120 gi) sau giao hp khng c bo v. Hiu qu trnh thai
khn cp gim dn mi ngy.
- Nu bit chc ngy rng trng, t DCTC trnh thai khn cp c th c thc hin
trong vng 5 ngy sau rng trng, tc c th tr hn 5 ngy sau giao hp khng c
bo v.
3.4. Cch s dng:
- Vin thuc trnh thai:
Vin thuc trnh thai khn cp ch cha progestin (Postinor, Excapel)
Loi mt vin: cha 1,5 mg levonorgestrel hoc 3 mg norgestrel: ung mt vin
(liu duy nht)
Loi 02 vin: mi vin cha 0,75 mg levonorgestrel. Ung hai ln, mi ln mt
vin cch nhau 12 gi hoc ung mt ln c 02 vin
Vin thuc trnh thai kt hp (Ideal, Choice, New Choice) nu khng c vin
thuc trnh thai khn cp)
Ung 2 ln cch nhau 12 gi; mi ln 4 vin (mi vin cha 30 mcg ethinyl
estradiol v 0,15 mg hoc 0,125 mg lenovorgestrel) m bo t nht mi ln 0,1
mg ethinyl estradiol v 0,5 mg levonorgestrel (hoc 1 mg norgestrel hoc 2 mg
noresthisteron)
- DCTC (xem bi DCTC trnh thai): y l la chn thch hp cho nhng khch hng
mun tip tc s dng DCTC trnh thai
4. S dng cc BPTT sau s dng BPTT khn cp
4.1 Vin thuc trnh thai kt hp, vin thuc trnh thai khn cp ch c progestin
- Bt u ngay sau ngy ung thuc trnh thai khn cp, khng cn ch n k kinh sau
- S dng tip theo v thuc ang s dng (nu khch hng ang s dng) hoc bt u
v thuc mi (nu khch hng cha s dng BPTT ny trc )
- S dng BPTT h tr trong vng 7 ngy k tip sau ung thuc
4.2 Thuc tim trnh thai
- Bt u ngay trong ngy ung thuc trnh thai khn cp, hoc c th bt u trong
vng 7 ngy sau khi c kinh li (nu khch hng yu cu).
- S dng BPTT h tr trong vng 7 ngy k tip sau tim thuc
- Nhc khch hng ti khm nu c du hiu nghi ng c thai
4.3 Thuc cy
- Bt u ngay sau khch hng c kinh li
- Cung cp cc BPTT h tr hoc thuc trnh thai ung bt u t ngay sau ngy ung
thuc trnh thai khn cp, trong thi gian ch i n thi im cy thuc
4.4 t DCTC
- Tip tc s dng DCTC nu khch hng s dng DCTC trnh thai khn cp hoc
- Bt u ngay trong ngy khch hng ung thuc trnh thai khn cp
4.5 Bao cao su, mng ngn m o, phng php xut tinh ngoi m o
Ngay lp tc

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4.5 BPTT tnh ngy kinh
Bt u ngay sau khi khch hng c kinh li
5. Nhng vn kh khn khi s dng trnh thai khn cp, v cch x tr
4.1. Nn trong vng 2 gi sau ung thuc
- Ung li liu thuc trnh thai khn cp cng sm cng tt.
- C th s dng thuc chng nn trc khi ung liu lp li cho nhng khch hng
ung vin thuc trnh thai kt hp, hoc liu lp li c th c t ng m o nu
khch hng vn tip tc nn nhiu,
- Ch l phc s dng thuc trnh thai khn cp ch c levonorgestrel trnh thai
khn cp t gy bun nn v nn hn so vi vin thuc kt hp v khng khuyn co
phi s dng thuc chng nn mt cch thng qui trc khi ung thuc trnh thai
khn cp.
- Tc dng ph bao gm ra huyt m o bt thng, bun nn, nn, cng ngc, nhc
u v chng mt.
4.2. Chm kinh
- Cn th thai hoc ti khm ti c s y t nu chm kinh.
- Khng c bng chng v nguy c ln thai khi s dng thuc trnh thai khn cp v
mang thai.
4.3. Ra mu thm git
Trn an khch hng y khng phi du hiu bt thng, v s t ht khng cn iu
tr.
5. i vi khch hng HIV(+):
Khch hng HIV(+) hoc AIDS hoc ang iu tr thuc khng virus c th s dng
BPTT khn cp.

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CC BIN PHP TRNH THAI TRUYN THNG
(T NHIN)
Tuyn p dng.
Tt c cc tuyn.
Ngi thc hin.
Cn b cung cp dch v.

BPTT truyn thng (t nhin) l nhng BPTT khng cn dng dng c, thuc hay th
thut no ngn cn th tinh. y l nhng BPTT tm thi v t hiu qu bao gm: (i)
bin php tnh theo vng kinh, (ii) bin php xut tinh ngoi m o. Cc BPTT truyn
thng khng nn khuyn co cho khch hng s c nguy c cao khi mang thai. Khch hng
c nhim HIV hay bn tnh c nhim HIV cn cn nhc khi s dng BPTT truyn thng v
BPTT ny khng gip ngn nga NKLTQTD v HIV/AIDS.
1. Ch nh.
Tt c khch hng cha mun sinh con u c th p dng.
2. Chng ch nh tng i (khng c chng ch nh tuyt i).
- Ph n cho con b trong vng 6 tun sau sinh. Cn ch i cho n khi khch hng c
t nht 3 chu k kinh u.
- Chu k kinh khng u hoc ra mu m o bt thng, bao gm c thi k mi dy
th v thi k tin mn kinh (i vi bin php tnh theo vng kinh).
- Thn trng khi khch hng ang s dng nhng loi thuc c th lm chm phng
non, v d nh thuc an thn (tr benzodiazepin), thuc chng trm cm, s dng
khng sinh ko di hoc s dng thuc khng vim khng steroid ko di.
3. Hng dn thc hin cc bin php.
3.1. T vn.
- Lng nghe v tm hiu nhu cu trnh thai ca khch hng. Khng khuyn khch khch
hng s dng BPTT t nhin nu nh h c kh nng s dng mt BPTT khc hiu
qu hn.
- Cn nu r hiu qu, u, nhc im ca BPTT t nhin, c bit l nhng kh khn v
d nh hiu qu thp v kh p dng khi vng kinh khng u hoc hai bn khng hp
tc. Bin php ny khng c tc dng phng trnh NKLTQTD.
- Cn lu khch hng l do hiu qu ca cc BPTT t nhin khng cao nn cn s
dng phi hp cc BPTT vi nhau hoc phi hp vi cc BPTT h tr nng cao
hiu qu. Cung cp thng tin v cc BPTT khn cp d phng khi p dng BPTT t
nhin tht bi.
- Trnh by c im ca tng BPTT t nhin.
BPTT theo vng kinh.
Giai on t an ton (trc phng non) hiu qu trnh thai khng cao do c th
c hin tng phng non sm v tinh trng c th sng c qu lu.
Hiu qu thp i vi ph n c vng kinh khng u.
Ch nn giao hp t do vo khong mt tun trc k kinh sau.

308 |
BPTT xut tinh ngoi m o.
y l BPTT t hiu qu, khng thch hp cho nhng khch hng xut tinh sm
hoc khng nhn bit c thi im xut tinh.
3.2. Hng dn thc hin.
3.2.1. BPTT tnh theo vng kinh.
- Cn c vo s ngy mi vng kinh ca khch hng, hng dn khch hng tnh c
ngy d kin s c kinh ln sau:
+ * +
1 7 12 16 26
+ * +
1 9 14 18 28
+ * +
1 11 16 20 30
+ * +
1 11 16 20 32
Giai on "t an ton" . KHNG AN TON . "an ton"

Ghi ch: * ngy d kin phng non.
+......+ nhng ngy c kh nng th thai.
- T ngy d kin c kinh li li 14 ngy l ngy c th phng non trong vng kinh.
- Trong vng 5 ngy trc v 4 ngy sau khi phng non l nhng ngy khng an ton,
cn king giao hp hoc nu giao hp th cn dng BPTT h tr.
3.2.2. BPTT bng cch xut tinh ngoi m o.
- Khi cm thy sp xut tinh th rt dng vt ra, phng tinh ngoi m o.
- Khng tinh dch r ra khi dng vt cn trong m o v khng tinh dch
phng ra ngoi ri tr li m o.
cc BPTT truyn thng. Cn ch rng nhng BPTT truyn thng ny khng gip
ngn nga ly truyn HIV v khng c hiu qu trnh thai cao.
- Yu cu khch hng s dng bao cao su km theo khi s dng cc BPTT truyn thng.
Khi s dng ng cch v thng xuyn, bao cao su gip ngn nga ly nhim HIV v
cc NKLTQTD.

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BIN PHP TRNH THAI CHO B V KINH

Tuyn p dng.
Tt c cc tuyn.
Ngi thc hin.
Cn b cung cp dch v.

Bin php cho b v kinh l mt BPTT tm thi da vo vic cho b m hon ton sau
sinh khi cha c kinh tr li v con di 6 thng tui. Bin php cho b v kinh l BPTT
hiu qu khng cao, khng nn khuyn co cho nhng khch hng s c nguy c cao khi
mang thai. Bin php cho b v kinh khng nn s dng cho nhng khch hng nhim
HIV hoc c bn tnh nhim HIV v khng gip ngn nga NKLTQTD, HIV/AIDS.
1. Ch nh.
Ph n cho con b hon ton, cha c kinh tr li v con di 6 thng tui.
2. Chng ch nh.
- M ang s dng nhng loi thuc chng ch nh cho con b nh: cc loi thuc
chng ng, chng chuyn ha, bromocriptin, corticosteroid liu cao, cyclosporin,
ergotamin, lithium, thuc trm cm v thuc c ng v phng x.
- Nhng tnh trng ca b nh hng n vic cho b nh: b c d tt vng ming, hu -
hng, b non thng hoc nh so vi tui thai cn chm sc c bit, b b mt s tnh
trng ri lon chuyn ha.
M nhim HIV.
3.1. T vn.
- Lng nghe v tm hiu nhu cu trnh thai ca khch hng. Nu r hiu qu, thun li,
khng thun li ca bin php cho b v kinh. BPTT ny khng nn s dng cho
khch hng nhim HIV v khng c tc dng phng trnh NKLTQTD, HIV/AIDS.
- Cn dn khch hng quay tr li hng dn p dng BPTT hiu qu khc nu: (i)
bt u cho n b sung hoc (ii) c kinh tr li hoc (iii) con trn 6 thng.
- Hn gp li khch hng t nht 1 ln trong vng 3 thng v hi nhng thng tin lin
quan n:
C kinh tr li.
Tr n nhng thc n khc ngoi sa m.
Nhng kh khn trong vic cho b c hng dn gip .
S dng thuc trong thi k cho con b.
Mi b nhng bnh nhim khun nh vim gan do virus (vng da, vng mt), HIV
mi c pht hin...
Tho lun v thi im bt u BPTT khc.

310 |
Bt u ngay sau khi sinh.
3.3. Qui trnh thc hin.
- Cho b b sau sinh cng sm cng tt.
- Cho b ng cch.
- Cho b b bt k lc no b i, k c ngy v m. Cho b 8 - 10 ln/ngy, ban ngy
khng c cch qu 4 gi, ban m khng cch qu 6 gi gia 2 ln b.
- Cn duy tr cho b m ngay c khi m hoc b m.
- Ngoi vic b sa m, tr khng n ung thm mt th g khc.
3.4. Chuyn BPTT khc.
Cn chuyn ngay sang mt BPTT hiu qu khc nu c mt trong nhng du hiu sau:
- C kinh tr li (khng tnh ra mu trong 6 tun u sau sinh).
- M khng cho b hon ton hoc b c cho n/ung b sung.
- Tr hn 6 thng tui.
- Khng mun p dng bin php cho b - v kinh.
- Khch hng HIV(+) hoc AIDS hoc ang iu tr thuc khng virus KHNG NN s
dng BPTT cho b - v kinh.
- T vn cho khch hng HIV(+) phng thc nui con ph hp nht:
Ch khng cho b m khi (v ch khi) c y iu kin s dng sa thay th,
c th v iu kin kinh t y , kh nng cung ng sn phm thun tin v lun
sn c.
Nu khng th c iu kin s dng sa thay th, khch hng HIV(+) c th
cho con b m hon ton trong 6 thng u i. Trong trng hp ny (cho con b
m hon ton trong 6 thng u), c th s dng BPTT cho b - v kinh nhng cn
yu cu khch hng s dng bao cao su km theo. Khi s dng ng cch v
thng xuyn, bao cao su gip ngn nga ly nhim HIV v cc NKLTQTD. Cho
con b xen k (gia b m v cc loi sa khc) c th lm tng nguy c ly nhim
HIV. Cn rt ngn thi gian cai sa khi chuyn tip t b m hon ton sang n
dm.
C th gim ti a kh nng ly nhim HIV bng cch vt sa m v un si trc
khi cho b n bng tha.
- Cn t vn cho khch hng HIV(+) v ch dinh dng v v sinh. Cc tnh trng
nhim khun nh: vim tuyn v, p xe v nt nm v u lm gia tng nguy c ly
nhim.

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TIU CHUN PHNG TH THUT

Phng th thut s dng t DCTC, ph thai v cc th thut khc, cn t cc tiu
chun sau:
1. C s h tng.
1.1. V tr.
- ni thong mt, c nh sng.
- Xa cng trnh v sinh, xa ni gy nhim.
1.2. Din tch v cu trc.
- Din tch t 10 m n 16 m.
- Ca s c ca chp, ca knh m chng bi, li chn cn trng.
- Tng p gch men cao ti thiu 1,6 m.
- Trn qut vi hoc sn trng.
- Nn khng thm nc c dc v l thot nc.
- Khng treo qut trn, nn c qut thng gi.
- C h thng in, n, cm thch hp.
- Ni ra tay c nc sch, nc chn v thun tin cho cn b k thut ng ra tay.
2. Nhn vin.
Cc cn b lm cng tc chm sc SKSS c o to v cung cp dch v KHHG,
bao gm: t DCTC, ht thai v t vn.
- N h sinh.
- Y s sn nhi.
- Bc s chuyn khoa sn.
- Bc s, y s a khoa c tp hun v c cp giy chng nhn ca kha o to v
k hoch ha gia nh, t DCTC, ht thai v t vn.
- K thut vin.
3. Dng c, phng tin.
- Bn lm th thut: sch, khng han r, c m.
- Bn dng c: khng han r, c bnh xe.
- n khm.
- 2 gh.
- C n soi kim tra m rau.
- C thuc gim au, thuc v cm, thuc t (lidocain), hp thuc chng chong.
- Cc dng c cn thit, s lng lm cc th thut t DCTC v ht thai c
v khun.
4. Hu cn.
4.1. Cc trang thit b.
- Ni hp t.
- Ni luc in.
- T sy kh.
- Hp nha c np chuyn dng kh khun cao v tit khun bng ha cht.

312 |
4.2. Cc phng tin khc thc hin khng ch nhim khun.
- Cc loi x ng dng c ngm cloramin trong phng th thut.
- Dung dch st khun, kh khun, tit khun (dung dch iodin 2 % - 3 %, cloramin
0,5%, glutaraldehyd).
- Cc loi x chu, gng tay di, tp d, x phng, bn chi phc v ra dng c.
- Trang b knh eo, tp d cho cn b lm k thut, c guc dp sch trong phng
th thut.
- Vi nha tri bn 50 x 50 cm, sng vi 80 x 80 cm thay sau mi trng hp th
thut.
- C qun o cng tc ring.
4.3.Thuc thit yu (theo qui nh ca B Y t).
4.4. Phng tin trnh thai.
Bao cao su, cc loi thuc trnh thai, dng c t cung...
4.5. Cc loi s sch.
- Theo di khch hng.
- Cp pht phng tin trnh thai.
- S theo di s dng BPTT cho khch hng.
5. Ni t vn.
- C ni t vn m bo c tnh ring t, tt nht l b tr phng t vn ring.
- C s theo di t vn v ti liu dng cho t vn.
6. C ni x l cht thi y t theo qui nh.

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PHN 5
NHIM KHUN NG SINH SN
V NHIM KHUN LY TRUYN
QUA NG TNH DC

314 |

| 315
HNG DN CHUNG

Tuyn p dng.
Tt c cc tuyn.
Ngi thc hin.
Bc s, y s, n h sinh c o to v nhim khun ng sinh sn.

Nhim khun ng sinh sn (NKSS) l mt thut ng rng bao gm cc nhim
khun ly truyn qua ng tnh dc (NKLTQTD) v cc nhim khun ng sinh sn
khc khng ly truyn qua ng tnh dc. a s cc trng hp NKLTQTD u li
hu qu v mt sc khe nng n hn so vi NKSS. Cc NKSS gy ra bi cc vi sinh
vt thng c mt ti ng sinh sn hoc do cc vi sinh vt t bn ngoi vo thng qua
hot ng tnh dc hoc qua cc th thut y t. Khng phi tt c cc nhim khun ly
truyn qua ng tnh dc u l cc nhim khun ng sinh sn v cng khng phi tt
c cc nhim khun ng sinh sn u c th ly truyn qua ng tnh dc.
NKLTQTD ni n cch thc ly truyn trong khi NKSS li cp n v tr ni
cc nhim khun tin trin.

1. Nhim khun ng sinh sn gm ba loi:
(1) Cc nhim khun ly truyn qua ng tnh dc (NKLTQTD) nh nhim
Chlamydia, bnh lu, trng roi sinh dc, bnh giang mai, bnh h cam, herpes sinh
dc, si mo g sinh dc v nhim HIV...
(2) Nhim khun ni sinh do tng sinh qu mc cc vi sinh vt c trong m o ca
ph n nh vim m o do vi khun v vim m h - m o do nm men.
(3) Nhim khun y sinh l cc nhim khun do th thut y t khng v khun.

Cc nhim khun trn c th d phng hoc c th cha khi c.

NKLTQTD/NKSS l mt trong cc cn nguyn quan trng nht gy bnh tt v t
vong cho b m v tr em trong thi k chu sinh. Cc nhim khun ny c th a n
vim tiu khung, v sinh, cha ngoi t cung, ung th c t cung, sy thai, tr thiu
cn, m la, nhim khun tr s sinh, vim phi v tr n tr em... Ngoi ra, mt s
NKSS cn lm tng nguy c nhim HIV.

CC LOI NKLTQTD/NKSS

Ngun gc Cch ly truyn V d hay gp
Nhim
khun ly
truyn qua
ng tnh
dc.
Cc bn tnh b
NKLTQTD.
Quan h tnh dc vi ngi
b nhim bnh.
Lu,
Chlamydia,
giang mai, h
cam, trng roi,
herpes sinh
dc, si mo
g sinh dc,
HIV...

316 |

Ngun gc Cch ly truyn V d hay gp
Nhim
khun ni
sinh.
Vi sinh vt thng c m
o.
Thng khng ly t ngi
ny sang ngi khc,
nhng s pht trin qu
mc c th gy nn triu
chng bnh.

Nhim nm
men, vim m
o do vi
khun.
Nhim
khun y
sinh.
T bn trong hay bn ngoi
c th:
Ni sinh (vi sinh vt c
trong m o).
NKLTQTD (c t cung
hay m o).
Nhim t bn ngoi .
Cc th thut y t, sau khi
khm bnh, cc can thip
trong thi k mang thai,
sinh , thi k hu sn,
KHHG v khm ph
khoa... Nhim khun c th
c y qua c t cung
ln ng sinh dc trn v
gy nn cc nhim khun
nghim trng t cung,
vi t cung v cc c quan
khc trong tiu khung.
t DCTC, kim tim hoc
dng c khi thm khm m
h, m o, thm d t
cung c th gy nhim
khun nu vic kim sot
nhim khun km.
Bnh vim
tiu khung sau
ht thai hoc
sau cc th
thut i qua c
t cung. Cc
bin chng
nhim khun
sau thai k v
giai on hu
sn.

Cc NKLTQTD c c nam v n. Khi ngi bnh mc NKLTQTD cn phi iu
tr cho c bn tnh ca h phng ti nhim cho ngi bnh, phng ly nhim cho
bn tnh ca bn tnh ca h (mt ngi c th c nhiu bn tnh). Cc nhim khun ni
sinh nh vim m o do vi khun v vim m h - m o do nm ph n khng ly
truyn qua ng tnh dc cho nn khng cn thit iu tr cho bn tnh ca h.
Qun l cc NKSS i hi nhn vin y t phi c k nng v s hp tc tt ca ngi
bnh. Nhn vin y t phi m bo cc chun mc v o c ngh nghip v nghip v,
tn trng ngi bnh, m bo s b mt. Phng khm phi m bo ring t v sch s
cung ng cht lng tt vic khm cha cc NKSS v cc NKLTQTD. i vi ngi
bnh n, vic khm bnh bao gm c khm m o bng m vt v khun nhn trc tip
c t cung v thnh m o. Vic phng bnh l mt phn ch yu i vi qun l cc
NKLTQTD. T vn cho hnh vi tnh dc an ton bao gm quan h mt v mt chng s
dng bao cao su thng xuyn, ng cch v khm cha bnh cho bn tnh.
Ti liu hng dn ny c rt t thng tin v chn on v iu tr theo cn nguyn do
vic hn ch ca cc phng tin xt nghim h tr tuyn c s. Do vy, cch tip cn
theo hi chng c a ra p dng cho cc tuyn y t c s v cc n v y t khng c
xt nghim h tr. Vic khuyn co s dng khng sinh c th thay i theo kt qu gim
st khng sinh hng nm. Cc nhn vin y t cn cp nht thng tin u n.

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Cc hi chng NKLTQTD/NKSS thng thng

Hi chng NKLTQTD/
NKSS
Tc nhn gy bnh Loi tc
nhn gy
bnh
LTQ
TD
C cha
c/
Khng
Lot sinh
dc
Giang mai Treponema pallidum Vi khun C C
H cam Haemophilus
ducreyi
Vi khun C C
Herpes Herpes simplex virus
(HSV-2)
Virus C Khng
Bnh u ht bch
huyt hoa liu
(hay cn gi l bnh
ht soi)
(Lymphogranuloma
Venereum - LGV)
Chlamydia
trachomatis
Vi khun C C
U ht bn
(Granuloma
Inguinale)
(donovanosis)
Klebsiella
granulomatis
Vi khun C C
Tit dch
niu o v
m o
Nhim nm men Candida albicans Nm Khng C
Vim m o do vi
khun
Gardnerella
vaginalis v mt s
vi khun k kh khc
Vi khun Khng C
Trng roi m o Trichomonas
vaginalis
n bo C C
Lu Neisseria
gonorrhoeae
Vi khun C C
Chlamydia Chlamydia
trachomatis
Vi khun C C
Cc hi
chng khc
Si mo g sinh dc Virus gy u nh
ngi (Human
Papilloma Virus -
HPV)
Virus C Khng

2. NKLTQTD/NKSS chim mt t l kh ln trong tng s bnh tt trn ton th
gii ch yu l: lu, Chlamydia, giang mai v trng roi. ph n, cc NKSS khng ly
truyn qua ng tnh dc thm ch cn hay gp hn. lm gim gnh nng ca
NKSS, cn phi c n lc t cc c s y t v cng ng. Phng bnh v qun l c hiu
qu cc ca bnh do cc nhn vin y t m nhim s lm gim gnh nng ca
NKLTQTD/NKSS bng nhiu cch. iu tr hiu qu lm gim s ly truyn
NKLTQTD/NKSS trong cng ng v cc th thut an ton, ph hp ti cc phng
khm s lm gim cc nhim khun y sinh. Gio dc v tip cn cng ng l cn thit
thc y vic phng nga cc nhim khun v s dng cc dch v y t, do lm gim s
ly truyn bnh trong cng ng.

318 |
20 ni dung lm gim NKLTQTD/NKSS
1 Nng cao nhn thc v NKLTQTD/NKSS v hu qu ca chng l v sinh, sy
thai, t vong ca sn ph v HIV/AIDS
2 Chun b phng khm sao cho mi ngi cm thy thoi mi khi n khm v
NKLTQTD/NKSS.
3 Nng cao cht lng cc loi dch v. Tm cch li ko nam gii tham gia phng
nga NKLTQTD v m bo rng ngi tr tui bit n cc loi dch v ny v
cm thy thoi mi khi s dng chng. Tip cn cc qun th d b tn thng l
mt trong nhng phng cch tt nht kim sot s ly truyn ca NKLTQTD
trong cng ng.
4 Cung cp bao cao su (BCS), khuyn khch s dng BCS v t vn gim s bn
tnh hoc tr hon cc hot ng tnh dc lm gim nguy c b li NKLTQTD.
5 Thc hin cc th thut i qua c t cung an ton ngn chn cc nhim khun y sinh.
6 Ph bin cho ph n cc vic n gin h c th lm phng nga cc nhim
khun ni sinh.
7 Xem xt nguy c mc NKLTQTD/NKSS ca tng ngi bnh a ra
phng php phng nga hoc iu tr thch hp.
8 T vn v phng nga NKLTQTD/NKSS v hi v cc triu chng
NKLTQTD/NKSS mi ln khm v k hoch ha gia nh hoc khm thai. Tm
kim cc du hiu ca NKLTQTD/NKSS mi khi khm bnh v cc nguyn
nhn khc.
9 Sng lc giang mai v tm c hi sng lc cc NKLTQTD/NKSS khc.
10 Khng khng nh mt ngi b mc NKLTQTD khi m vic chn on l cha
chc chn.
11 Gio dc cho mi khch hng v phng nga NKLTQTD/NKSS.
12 Gio dc ngi bnh mc NKLTQTD/NKSS h tun th iu tr v khuyn
bn tnh i iu tr.
13 Hc cch t vn h tr khch hng thay i hnh vi.
14 Khuyn khch v hng dn s dng BCS phng nga NKLTQTD/NKSS v
trnh thai.
15 Khuyn khch i khm thai sm. T vn v phng nga NKLTQTD/NKSS
mang thai an ton hn.
16 Sng lc giang mai tt c cc ph n mang thai t nht mt ln trong mi thai k
v m bo ph n c phn ng dng tnh (v bn tnh ca h) c iu tr.
17 i vi nhng ph n b cng hip, ngh bin php trnh thai khn cp, iu tr
NKLTQTD v nu c th th iu tr d phng sau phi nhim HIV.
18 Qun l hiu qu cc NKLTQTD/NKSS c triu chng bng cch s dng s
hi chng hoc nu c iu kin th chn on theo cn nguyn da vo cc xt
nghim.
19 iu tr cho bn tnh khi mt NKSS c th c cn nguyn t ly truyn qua ng
tnh dc nhng cng phi t vn cn thn cho ngi bnh v bn tnh ca h khi
bn khng chc chn.
20 iu tr cc nhim khun ng sinh dc trn, c bit l cc nhim khun sau khi
ph thai hoc sinh con mt cch tch cc bo v cuc sng v kh nng sinh sn
cho ngi ph n.

| 319
3. Hng dn c th.
3.1. Khai thc tin s v bnh s.
Cc thng tin sau cn c khai thc:
- Triu chng hin ti.
- Thi gian xut hin triu chng bnh v thi gian bnh tn ti.
- Tin s kinh nguyt v thai nghn.
- c ln no ra kh h hoc b bnh tng t, bnh NKLTQTD cha? Nu c l
my ln?
- Ln giao hp cui cng.
- Lin quan gia triu chng v giao hp: gy au hoc lm triu chng nng ln.
- c v, chng hay bn tnh thng xuyn cha? S bn tnh v cc loi bn tnh (v
gii, ngh nghip...).
- V, chng hoc bn tnh c triu chng, c chn on hoc c nguy c vim nhim
ng sinh dc khng?
- Thuc, cc bin php iu tr v ang s dng.
- Tin s d ng thuc.
- Tin s hoc hin ang nghin, chch ma ty, xm tr.
3.2. Khm lm sng.
3.2.1. Nguyn tc v iu kin.
- Ni khm nh sng, kn o, yn tnh, m, m bo b mt v tm l tt cho
khch hng.
- Ngi thy thuc m bo tc phong ngh nghip, tn trng ngi bnh v phong tc
tp qun ca h. Nu ngi bnh l n, thy thuc nn cng gii vi ngi bnh. Nu
thy thuc l nam, cn c tr th l n.
- i gng tay v khun khi khm bnh.
- Chun b dng c v khun: m vt, kp, gng tay, dng c ly bnh phm, lam knh,
bng, cn...
- Ngi bnh ng (nam) hoc nm trn bn (n), bc l ton b vng sinh dc.
3.2.2. Khm bnh.
Khm khch hng n.
- Khm ton b da v nim mc pht hin nhng thng tn bnh l. Ch cc phn
hay xut hin tn thng l ming, nch, bn, hu mn v lng bn tay, bn chn.
- Khm b phn sinh dc ngoi:
T th: ngi bnh nm t th ph khoa, ch bc l vng sinh dc.
Khm mi ln, mi b v vng hu mn, niu o, m vt. Pht hin cc tn
thng: sn, vt lot, si, tn thng gh, hch bn, rn mu v trng rn.
Dch m o: mu sc, mi, c im dch (dch nhiu hay t, trong hay c, vng,
xanh, c m, c bt, c dnh vo thnh m o khng, ln mu khng).
- Khm trong:
t m vt: t m vt v khun vo trong m o, m m vt v nh v c t cung
vo gia hai cnh m vt. Kim tra k c t cung v cc thnh m o.
nh gi tnh cht kh h (mu, s lng, mi). nh gi dch trong ng c t
cung: dch trong, dch m hoc m c ln mu.

320 |
Pht hin cc tn thng lot, ht hoc si trong c t cung v thnh m o.
Khm bng hai tay: a hai ngn tay vo m o, n ln xem niu o c m hoc
dch chy ra khng, tay kia nn nh bng di xem c khi cng hoc au vng
bng khng, khi y c t cung v di ng t cung c au, c nhy cm khng?
Nu c th l cc du hiu ca vim tiu khung.
- Khm hu mn v vng quanh hu mn.
Khm khch hng nam.
- T th: ngi bnh ng.
- Khm ton b da v nim mc pht hin nhng thng tn bnh l. Ch cc phn
hay xut hin tn thng l ming, nch, bn, hu mn v lng bn tay, bn chn.
- Khm dng vt, ming so, ln bao qui u v vut dc niu o xem c dch chy ra
khng (xem xt mu sc dch, s lng dch v cc tnh cht khc ca dch).
- Khm bu, kim tra tinh hon, mo tinh hon v mt , kch thc, cc thng tn
khc.
- Khm hu mn v vng quanh hu mn.
4. nh gi nguy c vim c t cung v cc NKLTQTD khc (bao gm c
HIV).
Mt ngi c nguy c b NKLTQTD cao hn nu ngi c t nht mt trong
nhng yu t sau y:
- Bn tnh c nhng triu chng ca NKLTQTD (tit dch niu o), hoc
- C hnh vi tnh dc khng an ton, hoc
- C quan h tnh dc hoc bn tnh c quan h tnh dc vi nhm ngi c hnh vi tnh
dc nguy c cao (mi dm, ma ty...), hoc
- C 2 trong 3 yu t sau y:
Thanh nin tui 20, cha lp gia nh v c quan h tnh dc khng an ton.
C trn mt bn tnh hoc bn tnh c quan h tnh dc khng an ton vi nhiu bn
tnh khc.
Mi thay i bn tnh trong vng 3 thng gn y.
5. Cc trng hp cn lm xt nghim HIV.
- Tt c ngi bnh mc bnh NKLTQTD u cn c t vn v ngh xt nghim
t nguyn HIV.
- c bit ch n cc ngi bnh mc bnh giang mai c triu chng, herpes sinh
dc, si mo g tnh trng nng hoc lan to, h cam, nm candida hu hng v cc
bnh NKLTQTD khc khng p ng vi iu tr thng thng; cc trng hp bnh
c biu hin lm sng nng v hay ti pht.
6. T vn v phng v iu tr bnh hiu qu.
6.1. Thng tin v t vn v NKLTQTD.
Thng tin v t vn v hnh vi tnh dc an ton cn c p dng vi mi trng hp
nht l mc cc NKLTQTD. Cc vn chnh cn t vn l:
- Cc hu qu ca NKLTQTD i vi nam v n, c bit l trong trng hp khng
c iu tr ng v y .
- Nhn mnh tm quan trng ca iu tr sm v tun th iu tr liu, thm ch khi
triu chng bnh ht vn cn tip tc cho ht tr liu, n khm li theo lch hn.

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- Kh nng ly truyn cho bn tnh.
- Xc nh v iu tr bn tnh, k c khi h khng c triu chng bnh.
- i vi v thnh nin cn thng tin cho h v nguy c mc v bin chng ca cc bnh
ly truyn qua ng tnh dc, t vn v thc hin tnh dc an ton, nu mc bnh cn
i khm v iu tr sm.
- Tnh dc an ton v s dng bao cao su ng cch v thng xuyn trnh mc cc
bnh ly truyn qua ng tnh dc v HIV, ng thi phng trnh c thai ngoi
mun.
- Nguy c ly nhim cc NKLTQTD khc v HIV, t vn h t nguyn xt nghim
HIV. Thng tin v a im t vn v xt nghim HIV.
6.2. S dng bao cao su thc hin tnh dc an ton.
Bao cao su l phng tin hiu qu nht phng nga nhim khun qua ng tnh
dc v HIV/AIDS. Mi ngi mc NKLTQTD cn c cn b y t khuyn khch v
hng dn s dng bao cao su ng cch bo m tnh dc an ton, ng thi phng
trnh c thai ngoi mun.
6.3. Thng bo bn tnh.
- i vi cc NKLTQTD, cn b y t phi khuyn khch ngi bnh t nguyn thng
bo bn tnh. Cn b y t cn gii thch hu qu ca NKLTQTD nu bn tnh khng
c iu tr.
- iu tr cho bn tnh ca ngi bnh da trn hi chng bnh ca ngi bnh.

322 |
HI CHNG TIT DCH M O

Tuyn p dng.
Tt c cc tuyn.
Ngi thc hin.
Cn b cung cp dch v c o to v nhim khun ng sinh sn.

Hi chng tit dch m o (kh h) dng cho qun l bnh vim m o.
Hi chng tit dch m o l mt hi chng lm sng thng gp m ngi bnh than
phin l c dch m o (kh h) v km theo mt s triu chng khc nh nga, au rt
vng sinh dc, i kh, au khi giao hp...v nu khng iu tr c th gy bin chng nh
vim tiu khung, v sinh, thai ngoi t cung, nht l i vi lu v Chlamydia. Mi trng
hp vim m h, vim m o, vim m h - m o v vim c t cung u a n tit
dch m o.
- Cn nguyn thng gp ca vim m h, m o v c t cung:
Nm men candida gy vim m h - m o.
Trng roi m o gy vim m o.
Vi khun gy vim m o do vi khun.
Lu cu khun gy vim ng c t cung v niu o.
Chlamydia trachomatis gy vim ng c t cung v niu o.
Cc du hiu v triu chng ca tit dch m o bnh l (kh h): s lng t hoc
nhiu, long hoc c, mu trong, c hoc mu vng, mi hi hoc khng hi. Ngoi ra
cn c cc triu chng khc i km:
- Nga vng m h, m o (c bit do nm men candida).
- Cm gic bng rt vng m h, m o (c bit do nm men candida).
- Vim n m h.
- au khi giao hp.
- C th km theo i kh.
2. Khai thc tin s v bnh s
- Xem hng dn chung.
- nh gi nguy c vim ng c t cung.
Mt ngi c nguy c b vim ng c t cung (thng do lu cu khun v Chlamydia)
cao hn nu ngi c mt trong nhng yu t sau y:
Bn tnh c nhng triu chng ca NKLTQTD, hoc
C hnh vi tnh dc khng an ton, hoc
C quan h tnh dc hoc bn tnh c quan h tnh dc vi nhm ngi c hnh vi
tnh dc nguy c cao (mi dm, ma ty ...), hoc
C 2 trong 3 yu t sau y
Thanh nin tui 20, cha lp gia nh v c quan h tnh dc.
C trn mt bn tnh hoc bn tnh c quan h tnh dc vi nhiu bn tnh khc.
C bn tnh mi trong vng 3 thng gn y.

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3. Khm lm sng.
- Xem Hng dn chung
- Vim ng c t cung hay vim c t cung m nhy khi khm hoc khi soi c t cung:
biu hin vim c t cung km theo ph n, . Khi chm vo c t cung d chy mu
v c m nhy trong ng c t cung khi a tm bng vo trong ng c t cung. Tc
nhn gy vim ng c t cung l lu cu v Chlamydia trachomatis. Xt nghim dch
m nhy c >30 bch cu/vi trng vi phng i 1000 ln.
- Vim m o thng thng do 3 tc nhn gy nn l vim m h - m o do nm men
candida, vim m o do trng roi v vim m o do vi khun.
4. Xt nghim h tr.
- Th pH m o.
- Soi ti tm trng roi m o v nm men candida.
- Nhum Gram tm lu cu khun, t bo clue.
- Xt nghim nhanh Sniff (th nghim mi c n vi KOH 10 %) xc nh vim m
o do vi khun.
5. Chn on.
- Vim ng c t cung do lu v Chlamydia: trong ng c t cung c dch nhy m hoc
m c mu. C th km theo vim tuyn Bartholin, Skne.
- Vim m o: c kh h m o vi tnh cht:
Do candida: kh h c, mu trng nh vng sa dnh vo thnh m o, c vt
trt, s lng nhiu hoc va, thng km theo nga v cm gic bng rt m h -
m o.
Do trng roi m o: kh h mu xanh, long, c bt, s lng nhiu, mi hi, c
th gy vim c t cung nng (c t cung nh qu du). Chn on xc nh bng
soi ti dch m o c trng roi di ng.
Do vi khun: mu xm trng, ng nht, dnh u vo thnh m o, s lng t,
mi hi. Test Sniff dng tnh.
6. iu tr.
- Nu xc nh c nguyn nhn th iu tr nguyn nhn, nu khng th iu tr theo
hi chng.
- i vi mi trng hp tit dch m o, cn b y t cn xc nh v iu tr cho (cc)
bn tnh, tr trng hp vim m o do nm hoc vi khun.
6.1. Phc iu tr vim ng c t cung.
iu tr ng thi lu v Chlamydia trachomatis theo 1 trong 4 phc sau:
- Cefixim 200 mg, ung 2 vin, liu duy nht + doxycyclin 100 mg, ung 1 vin, ngy 2
ln, trong 7 ngy, hoc
- Ceftriaxon 250 mg, tim bp, liu duy nht + doxycyclin 100 mg, ung 1 vin, ngy 2
- Spectinomycin 2 g, tim bp, liu duy nht + doxycyclin 100 mg, ung 1 vin, ngy 2
- Cefotaxim 1 g, tim bp, liu duy nht + doxycyclin 100 mg, ung 1 vin, ngy 2 ln,
trong 7 ngy.

324 |
Ch :
C th thay doxycyclin bng tetracyclin 500 mg, ung 1 vin, ngy 4 ln, trong 7 ngy.
- Ph n c thai v cho con b khng c dng doxycyclin v tetracyclin. Thuc c
thay th s bng mt trong cc phc sau:
Azithromycin 1 g, ung liu duy nht, hoc
Erythromycin base 500 mg, ung 1 vin, ngy 4 ln, trong 7 ngy, hoc
Amoxicillin 500 mg, ung 1 vin, ngy 3 ln, trong 7 ngy.
- iu tr cho bn tnh d h khng c triu chng lu v Chlamydia vi liu tng t.
6.2. Phc iu tr vim m o
iu tr ng thi vim m o do trng roi, vim m o do vi khun v vim m o
do nm candida.
6.2.1. iu tr vim m o do trng roi v vi khun:
Dng mt trong cc phc sau y:
- Metronidazol 2 g hoc tinidazol 2 g ung liu duy nht, hoc
- Metronidazol 500 mg ung 2 ln/ngy x 7 ngy.
Vi vim m o do trng roi, iu tr cho bn tnh vi liu tng t.
6.2.2. iu tr vim m o do nm candida
Dng mt trong cc phc sau y:
- Nystatin vin t m o 100.000 n v, 1vin/ngy trong 14 ngy, hoc
- Miconazole hoc Clotrimazole vin t m o 200mg, 1 vin/ngy trong 3 ngy, hoc
- Clotrimazole 500mg, vin t m o, t 1 liu duy nht, hoc
- Itraconazole (Sporal) 100mg ung 2 vin/ngy trong 3 ngy, hoc
- Fluconazole 150mg ung 1 vin duy nht.
Ch :
- Khng cn iu tr cho bn tnh. Tuy nhin, cc trng hp bn tnh c vim qui u
v bao da qui u do nm vn cn iu tr.
6.2.3 Chuyn tuyn khi
- Khng c sn cc thuc trn y.
- Cc triu chng khng gim sau mt t iu tr.
- Nu nghi c vim tiu khung th phi iu tr ti tuyn huyn tr ln.
7. Thng tin v t vn
Mi trng hp mc hi chng tit dch m o u cn c thng tin v t vn v
hnh vi tnh dc an ton. Cc vn chnh cn t vn cho ngi mc hi chng tit dch
m o, c bit i vi cc trng hp c chn on xc nh hoc c kh nng b lu,
nhim Chlamydia v trng roi m o l:
- Cc hu qu ca bnh c th l nhim khun ngc dng, thai ngoi t cung, v sinh...
- Tun th phc iu tr d triu chng ht, n khm li theo lch hn.
- King quan h tnh dc cho n khi kt thc iu tr.
- Tnh dc an ton v s dng bao cao su ng cch v thng xuyn.
- iu tr bn tnh.
- Nguy c ly nhim HIV. Thng tin v a im t vn v xt nghim HIV.
- Nu triu chng bnh nng ln, khng gim hoc xut hin au bng di, au khi
giao hp cn phi n khm li.

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HI CHNG TIT DCH NIU O NAM GII

Tuyn p dng.
Tt c cc tuyn.
Ngi thc hin.
Cn b cung cp dch v c o to v nhim khun ng sinh sn.

Hi chng tit dch niu o gm c dch/m chy t l niu o nam gii km theo
cc triu chng khc nh i but, i kh. Nu khng iu tr kp thi c th ly cho bn
tnh v li bin chng nh vim mo tinh hon, hp niu o, v sinh.
Hi chng tit dch niu o dng cho qun l vim niu o nam gii. y l nhim
khun ly truyn qua ng tnh dc thng gp nht nam gii.
Cn nguyn chnh gy hi chng tit dch niu o l lu cu khun v Chlamydia
trachomatis. Nu qun l theo hi chng, iu tr cho ngi bnh b tit dch niu o cn
phi iu tr c hai tc nhn ny.

- Ra m hoc dch nhy l niu o.
- i but.
- i rt.
- i kh.
- Cm gic nga rm rt dc theo niu o.
Ngoi cc triu chng trn, cn c th c cc du hiu km theo:
- Vim kt mc, vim hu hng (lu).
- Sng, au bu.
2. Khai thc tin s v bnh s.
Xem Hng dn chung. Ngoi ra cn khai thc thm mt s thng tin sau:
- Bnh bt u t ngt hay t t? Thi gian bnh?
- Cc triu chng xut hin rm r, cp tnh hay t t kn o?
- Dch niu o t hay nhiu, tnh cht dch?
3. Khm lm sng.
Cch khm xem hng dn chung. Ngoi ra, cn khm pht hin cc du hiu ca bnh
lu, Chlamydia v nhng bnh vim nhim ng sinh dc khc:
- S lng dch nhiu hay t. Nu khng nhn thy dch, cn phi vut dc dng vt nh
nhng t gc n l niu o
- Tnh cht dch: trong hay c, c m, c nhy khng?
- Tinh hon v mo tinh c sng au hay khng?
- Khm xem c au khp, au hng, vim kt mc khng?
- C cc hi chng nhim khun ng sinh dc khc nh: lot sinh dc, si mo g,
hch bn khng?

326 |
4. Xt nghim h tr.
Nhum Gram tm song cu Gram (-) hnh ht c ph trong v ngoi t bo bch cu a
nhn v m s lng bch cu trong dch niu o.
5. Chn on.
5.1. Vim niu o do lu.
- Khi bnh cp tnh, rm r, i but, i rt km theo chy m ming so, do
ngi bnh thng i khm ngay.
- Thi gian bnh ngn, khong 2 - 6 ngy.
- Dch niu o l m vng c hoc vng xanh, s lng nhiu.
- Xt nghim: nhum Gram thy song cu khun Gram (-) nm trong v ngoi t bo
bch cu a nhn.
5.2. Vim niu o khng do lu.
- Thi gian bnh lu hn, khong 1 - 5 tun.
- Triu chng km rm r, ngi bnh thng khng c i but, s lng dch niu o
t, thng l dch trong.
- Xt nghim: khng thy song cu khun Gram (-) c trn 5 bch cu/vi trng vi
phng i 1000 ln.
6. iu tr.
- Nu xc nh c nguyn nhn th iu tr nguyn nhn, nu khng th iu tr theo
hi chng.
- i vi mi trng hp tit dch niu o, cn b y t cn xc nh v iu tr cho
(cc) bn tnh.
- iu tr vim niu o do lu ng thi phi iu tr vim niu o do Chlamydia.
6.1. Phc iu tr vim niu o do lu.
- Dng mt trong cc loi thuc sau kt hp vi mt trong cc loi thuc iu tr vim
niu o khng do lu:
Cefixim 200 mg, ung 2 vin, liu duy nht + doxycyclin 100 mg, ung 1 vin,
ngy 2 ln, trong 7 ngy, hoc
Ceftriaxon 250 mg, tim bp, liu duy nht + doxycyclin 100 mg, ung 1 vin,
Spectinomycin 2 g, tim bp, liu duy nht + doxycyclin 100 mg, ung 1 vin,
Cefotaxim 1 g, tim bp, liu duy nht + doxycyclin 100 mg, ung 1 vin, ngy 2
ln, trong 7 ngy.
6.2. Phc iu tr vim niu o khng do lu
- Dng mt trong 3 thuc sau:
Doxycyclin 100 mg, ung 1 vin, ngy 2 ln, trong 7 ngy.
Tetracyclin 500 mg, ung 1 vin, ngy 4 ln, trong 7 ngy.
Azithromycin 1 g, ung liu duy nht.
Ch :
- iu tr cho bn tnh vi liu tng t.

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- Khng dng doxycyclin, tetracyclin cho ph n c thai v b m cho con b. Thay th
bng mt trong cc thuc sau:
Erythromycin stearat 500 mg, ung 1 vin, ngy 4 ln, trong 14 ngy
Amoxicillin 500 mg, ung 1 vin, ngy 3 ln, trong 14 ngy
- Ngi bnh c khuyn n khm li nu cc triu chng vn cn sau khi iu tr
7 ngy
6.3. Chuyn tuyn khi.
- C bin chng vim mo tinh hon l bin chng t gp ca vim niu o khng c
iu tr. Triu chng thng bt u mt cch t ngt, sng v au mt bn tinh hon
(chn on phn bit vi xon tinh hon - mt cp cu ngoi khoa cn c loi tr).
7. Thng tin v t vn.
Mi trng hp mc hi chng tit dch niu o u cn c gio dc v t vn v
hnh vi tnh dc an ton. Cn b y t cn tun th cc nguyn tc v t vn trong cun
chun mc ny. Cc vn chnh cn t vn cho ngi mc hi chng tit dch niu o
l:
- Hu qu ca bnh khi khng c iu tr ng v y , cn nhn mnh nguy c ly
nhim v gy vim tiu khung, thai ngoi t cung, v sinh bn tnh, gy vim kt
mc mt tr s sinh c th dn n m la, vim phi tr s sinh...
- Tun th ch nh iu tr ca thy thuc, n khm li theo lch hn.
- Tnh dc an ton, khuyn khch v hng dn s dng bao cao su ng cch, thng
xuyn.
- Thng bo v iu tr bn tnh.
- C ti trn 50 % cc trng hp nhim khun khng triu chng vn c th ly bnh
cho bn tnh v c th tin trin gy cc bin chng cho chnh h.
- Nguy c ly nhim cc bnh LTQTD khc v HIV, t vn trc khi xt nghim HIV.
- a im t vn v xt nghim HIV.

328 |
SI MO G SINH DC

Tuyn p dng.
Tuyn huyn tr ln.
Ngi thc hin.
Bc s, y s c o to v nhim khun ng sinh sn.

Si mo g sinh dc l mt bnh ly truyn qua ng tnh dc kh ph bin, c nam
v n.
Bnh gy nn do virus gy u nh ngi (Human papilloma virus-HPV). Hin nay c
khong trn 150 tp HPV, trong gy bnh si mo g l tp 6, 11 khng c kh nng gy
ung th. t nht 13 trong tng s tp HPV c kh nng gy ra lon sn, ung th c t cung,
hu mn, dng vt, vm hng, ming, c bit cc cc trng hp nhim HPV tp 16,
18 (khong 70 % - 80 %).

Biu hin bnh l cc u nh mu hng ti, mm, c chn hoc c cung, khng au
v d chy mu khi ng chm vo, thng khng c du hiu ch quan. C th thy tn
thng dng phng, kh pht hin. n, si mo g hay thy m vt, mi nh, quanh l
niu o, tng sinh mn, cng c th gp si mo g c t cung, hu mn. nam gii,
si mo g thng gp rnh qui u, qui u, bao da v thn dng vt, c khi thy
ming so, hu mn.
XemHng dn chung.
3. Khm lm sng.
XemHng dn chung. Ngoi ra cn ch khm:
- Nam gii: khm t m ton b vng sinh dc ngoi - hu mn pht hin tn thng
si mo g qui u, bao da, rnh dng vt, trong ming so v hu mn.
- N gii: khm t m ton b vng sinh dc ngoi - hu mn. t m vt pht hin
tn thng trong c t cung v thnh m o.
- Ch pht hin cc bnh l ly truyn ng tnh dc khc.
4. Chn on.
- Tn thng si mo g rt c hiu, do vy chn on ch yu da vo triu chng
lm sng.
- Ngi bnh n b si mo g c t cung cn phi lm xt nghim phin c t cung
nh k hng nm hoc cc xt nghim khc pht hin sm lon sn, ung th.
5. iu tr.
- Si mo g l bnh hin nay cha c thuc iu tr c hiu, do vy ngi bnh c th
mang bnh sut i tnh trng c biu hin triu chng hoc khng c triu chng.
Cc phng thc iu tr sau y ch c tc dng lm gim triu chng hoc loi tr
thng tn m khng dit c HPV.

| 329
- Cc trng hp si mo g u phi iu tr tuyn huyn tr ln.
- i vi mi trng hp si mo g, cn b y t cn xc nh v iu tr cho (cc) bn
tnh.
5.1. Si mo g vng sinh dc ngoi v hu mn.
- Acid trichloracetic 80 % - 90 % chm vo nt si 1 ln/ngy, hoc
- Podophyllin 10 % - 25 % bi 1 ln/ngy hoc 2 - 3 ln/tun vo nt si.
- t lnh bng nit lng hoc t in, laser, hoc
- Phu thut ct b hoc no.
5.2. Si mo g trong m o.
- t lnh bng nit lng, t in, laser, hoc
- Podophyllin 10 % - 25 % bi 1 ln/ngy hoc 2 - 3 ln/tun, hoc
- Phu thut ct b.
Ch : Khi bi podophyllin vo cc si mo g m o cn phi thuc kh ri mi rt
m vt ra. Vng nim mc lnh xung quanh thng tn phi bi vaselin hoc m khng
sinh trnh thuc lan ra vng khng b bnh.
5.3. Si mo g c t cung.
- t lnh bng nit lng, hoc
- t in, laser.
5.4. Si mo g ming so.
- Ct, no, hoc
- t lnh, t nhit, hoc
- Acid trichloracetic 80 % - 90 % chm, hoc
- t in, laser.
5.5. Si mo g hu mn.
- t in, laser, hoc
- t lnh, t nhit, hoc
- Phu thut ct b, hoc
- Podophyllin 10 % - 25 % bi 1 - 2 ln/tun vo nt si. Vng da nim mc lnh xung
quanh thng tn phi bi vaselin hoc m khng sinh trnh thuc lan ra vng
khng b bnh.
5.6. Si mo g ph n c thai.
- Phu thut ct b, hoc
- t lnh bng nit lng
- t bng laser CO
2

Ch :
- Khng s dng podophyllin cho ph n c thai, ph n cho con b v khng bi c
t cung.
6. Thng tin v t vn.
Hin nay khng c thuc dit virus si mo g, do vy ngi bnh s mang mm bnh
ny sut i c th c biu hin triu chng lm sng hoc khng c triu chng.

330 |
- Nguy c ly nhim cng cao nu c nhiu bn tnh, quan h ming - sinh dc, hu mn
- sinh dc.
- Khong 50 % cc trng hp si mo g s ti pht trong vng 6 thng sau iu tr.
- Si mo g sinh dc c nguy c dn n ung th sinh dc, nht l ung th c t cung. Ngi
bnh n cn c t vn xt nghim phin c t cung nh k hng nm v cc xt
nghim khc pht hin sm cc lon sn, ung th.
- C nguy c ly cho bn tnh nn bn tnh cn c thng bo n khm, iu tr v t
vn v si mo g c th khng c triu chng.
- Nhng trng hp c chn on si mo g cn c t vn xt nghim HIV, c
bit l cc trng hp si rng.
- Ph n c thai b si mo g khng c iu tr th c nguy c gy u nh thanh qun
tr s sinh.
- Tnh dc an ton v hng dn s dng bao cao su.

| 331
HI CHNG AU BNG DI

Tuyn p dng.
Tt c cc tuyn.
Ngi thc hin.

Hi chng au bng di c cc triu chng tit dch m o, au, chy mu khi giao
hp v st. Hi chng au bng di bao gm c NKSS v NKLTQTD. Tt c cc ph
n c hot ng tnh dc b au bng di cn phi c nh gi cn thn tm cc du
hiu vim tiu khung. au bng di do lu cu, Chlamydia c nguy c dn n v sinh.
Tuy nhin, au bng di c th do mt s bnh cp cu ngoi khoa v sn ph khoa, do
vy cn c khm xt cn thn c chn on v ch nh iu tr ng.
Tnh cht au.
- au c th l cp tnh hoc mn tnh.
- au cp tnh: cn loi tr cc cp cu ngoi khoa hoc sn ph khoa nh: vim rut
tha, nang bung trng xon, thai ngoi t cung, lc ni mc t cung v...
- au mn tnh: khng theo chu k, thng c lin quan n vim tiu khung, vim phn
ph.
Nguyn nhn gy au bng di lin quan n vim tiu khung.
- Lu cu khun.
- Chlamydia trachomatis.
- Vi khun k kh, vi khun Gram m v lin cu.

- au bng di, lin tc hoc gin on, nh hoc nng.
- au, chy mu khi giao hp.
- Tit dch m o.
- C th st hoc thn nhit vn bnh thng.
- Tuy nhin, cc du hiu lm sng ca vim tiu khung thay i v c th khng r
rng.
- Xem hng dn chung.
- Ch n chu k kinh nguyt, bin php trnh thai ang s dng, thai nghn.
3. Khm lm sng.
- Xem hng dn chung.
- c bit ch khi khm
Tit dch m/nhy m o v c t cung.
Khm hai tay xc nh kch thc t cung, au khi di ng ca c t cung v
cc tnh trng ca cc phn ph, c mu ra tay khng?

332 |
Xc nh xem c mt hoc hai vi t cung sng to hay cng, c khi au nhy cm
h chu, c phn ng thnh bng hoc au nhy cm thnh bng khng.
4. Xt nghim h tr (i vi tuyn qun/huyn).
- Cng thc mu, tc lng mu.
- Nhum Gram dch c t cung v m o.
- Siu m.
- Test thai nghn.
5. Chn on.
- Trc ht cn chn on phn bit vi cc cp cu ngoi khoa v sn khoa nh:
Vim rut tha cp tnh.
Tc rut.
U nang bung trng xon.
Thai ngoi t cung...
Nhim khun ng tit niu.
Cc nguyn nhn khc.
- Chn on vim tiu khung da vo cc triu chng sau:
C th st.
Tit dch nhiu, dch nhy m m o v c t cung khi khm.
au khi di ng c t cung v khi giao hp.
au c hai bn, au nhiu hn mt bn.
au bng di v bn cnh t cung.
Khi sng dnh vo t cung.
Mu lng hoc/v s lng bch cu tng.
Ngi bnh cn c xt nghim pht hin cc NKLTQTD khc v pht hin
nguyn nhn bnh nu c iu kin xt nghim h tr.
6. iu tr
- Nu xc nh c nguyn nhn th iu tr nguyn nhn.
- i vi mi trng hp au bng di, cn b y t cn xc nh v iu tr cho (cc)
bn tnh, cn c bit ch khi nghi ng nguyn nhn lu hoc Chlamydia.
- Nu khng xc nh c nguyn nhn th iu tr ng thi ton b cc nguyn nhn
gy vim, phi hp 3 phc sau y:
6.1. Phc iu tr lu.
Dng mt trong cc thuc sau:
- Ceftriaxon 250 mg , tim bp liu duy nht, hoc
- Spectinomycin 2 g , tim bp liu duy nht, hoc
- Cefotaxim 1 g tim bp liu duy nht, hoc
- Cefixim 200 mg x 2 vin, ung liu duy nht.
6.2. Phc iu tr Chlamydia.
Dng mt trong cc thuc sau:
- Doxycyclin 100 mg, ung 1 vin, 2 ln/ngy, trong 14 ngy, hoc
- Tetracyclin 500 mg, ung 1 vin, 4 ln/ngy, trong 14 ngy, hoc
- Azithromycin 1 g, ung 1 ln/tun, trong 2 tun.

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Ch : Khng dng doxycyclin cho ph n c thai, ang cho con b, thay th bng mt
trong cc thuc sau
Erythromycin stearat 500 mg, ung 1 vin, 4 ln/ngy, trong 14 ngy.
Amoxicillin 500 mg, ung 1 vin, 3 ln/ngy, trong 14 ngy.
6.3. Phc iu tr vim nhim do vi khun k kh.
- Metronidazol 500 mg, ung 1 vin, 2 ln/ngy, trong 14 ngy.
Ch :
Khng dng metronidazol cho ph n c thai ba thng u m thay th bng
amoxicillin 500 mg, ung 1 vin, 3 ln/ngy, trong14 ngy.
Khng ung ru trong thi gian iu tr cho ti sau khi ht thuc 24 gi.
- Cc triu chng khng gim sau 3 ngy iu tr.
- Nghi ng au bng do nguyn nhn ngoi khoa.
- Ngi bnh c chm kinh, mi , sy thai, ngi bnh c km theo chy mu m o.
7. Thng tin v t vn.
- Tun th nghim ngt phc iu tr cho d triu chng bnh c gim sau mt vi
ngy iu tr v n khm li theo lch hn, cn phi n khm ngay nu triu chng
khng thuyn gim hoc nng hn.
- Cc hu qu ca bnh khi khng c iu tr ng v y , c bit ch nguy c
thai ngoi t cung v v sinh.
- Cn b y t cn khuyn khch ngi bnh thng bo bn tnh v iu tr bn tnh, c
bit i vi nhng trng hp nghi ng lu hoc nhim Chlamydia trachomatis.
- Tnh dc an ton v hng dn s dng bao cao su. Ngi bnh cn c khuyn
khch v hng dn s dng bao cao su phng nga ti nhim bnh cng nh ly
nhim cc bnh LTQTD khc v ly nhim HIV/AIDS.

334 |
HI CHNG LOT SINH DC

Tuyn p dng.
Tt c cc tuyn.
Ngi thc hin.

Hi chng lot sinh dc dng cho qun l bnh c nam v n.
Hi chng lot sinh dc l tnh trng c cc vt lot vng sinh dc, hu mn gy nn
bi cc tc nhn nhim khun ly truyn qua ng tnh dc.
M hnh bnh lot sinh dc thay i theo cc khu vc khc nhau trn th gii trong
herpes sinh dc, giang mai v h cam l nhng bnh hay gy ra lot.
Tc nhn gy lot sinh dc thng gp:
Xon khun giang mai gy bnh giang mai.
Trc khun h cam gy bnh h cam.
Virus herpes (Herpes Simplex Virus-HSV) c 2 loi HSV-1 v HSV-2, nhng
herpes sinh dc ch yu do HSV-2 gy ra.

- C mt hay nhiu vt lot vng sinh dc - hu mn, mi, li, hng c th au
hoc khng au.
- Hch to, hch bn mt bn hoc hai bn di ng hoc khng, au hoc khng au,
mng m ri v gy lot hoc khng.
- Ton trng: bnh thng hoc c st nh, mt mi.
XemHng dn chung.
3. Khm lm sng.
- Khm b phn sinh dc: xem Hng dn chung (phn khm), ngoi ra lu thm:
- Khm (cc) vt lot:
+ S lng, v tr.
+ Kch thc, hnh dng.
+ c im: cng, mm; y sch hoc c m; b trn u hay nham nh, au hay
khng au, b mt vt lot phng hay g gh, c hay ti pht khng.
- Khm hch: to hay nh, c nh hay di ng, mt bn hay hai bn, au hay khng au,
c sng khng, c mng m khng, c v m khng.
- Khm tm cc thng tn trn da: sn, sn m, o ban, cn khm k lng bn tay, bn
chn tm tn thng giang mai.
- Khm nim mc vng hu mn, ming, hng, mi tm cc thng tn nim mc v
bn nim mc ca bnh giang mai, herpes.
- Cc triu chng khc: rng tc, au khp, mt mi.

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4. Xt nghim h tr.
Phn ng huyt thanh chn on giang mai (RPR, VDRL, TPHA)
5. Chn on.
- Vt lot do giang mai (hay sng giang mai thi k I): l vt trt nng, hnh trn hoc
bu dc, ranh gii r rng, khng c b, y phng, thm nhim cng, khng nga,
khng au, khng iu tr cng s t khi sau 6 - 8 tun, thng c mt vt. Km theo
vim hch vng ln cn, thng l hch bn mt bn, di ng, khng au, khng mng
m.
- Vt lot do h cam: thng nhiu vt lot do t ly nhim (kissing ulcers). Vt lot c
y lm chm, nhiu m, b nham nh, rt au, hch bn to mt bn. Sau mt vi tun
hch v m, to thnh p xe hoc l d.
- Vt lot do herpes: thng bt u bng m mn nc nh nh ht tm, ht u xanh,
cm li thnh m nh chm nho, sau dp v to thnh cc vt trt nng, mm, b
c nhiu cung km theo cm gic rt hoc nga, vt trt t khi, nhng rt hay ti pht.
C th sng hch mt bn hoc hai bn bn, au, khng lm m.
- Nu c vt lot, nhng khng phi giang mai, h cam hoc herpes th chuyn tuyn
trn chn on.
Ch :
Cc vt lot c th khng in hnh nh m t trn y.
Hin nay nhiu khu vc trn th gii, herpes sinh dc l cn nguyn hay gp nht
gy vt lot sinh dc. nhng ni c nhiu ngi nhim HIV, t l lot sinh dc do
herpes dng nh ngy cng tng ln.
Cc vt lot do herpes (v cc lot do NKQTD ni chung) nhng ngi bnh
HIV(+) c th khng in hnh v din bin dai dng.
6. iu tr.
- i vi mi trng hp lot sinh dc do cc cn nguyn trn, cn b y t cn xc nh
v iu tr cho (cc) bn tnh.
- Nu xc nh c nguyn nhn th iu tr nguyn nhn.
- Nu vt lot khng xc nh c l giang mai hay h cam th iu tr ng thi giang
mai v h cam.
- iu tr lot sinh dc ngi HIV(-) v (+) nh nhau.
- Hng dn chm sc c bn cho tn thng (gi sch v kh).
- Khuyn ngi bnh khm li sau 7 ngy nu thng tn khng lnh hn hoc sm hn
nu tnh trng lm sng tr nn xu i.
- Phc chi tit xin xem thm trong bng Danh mc thuc iu tr NKSS/
NKLTQTD.
6.1. Phc iu tr giang mai I.
Dng mt trong cc thuc sau y.
- Benzathin penicilin G 2,4 triu v, tim bp liu duy nht, hoc
- Procain penicilin G 1,2 triu v, tim bp 1 ln/ngy, trong 10 ngy lin tip
- Trng hp d ng hoc khng c penicilin, c th dng doxycyclin 100 mg, ung 1
vin, 2 ln/ngy, trong 15 ngy.
Ch : khng dng doxycyclin cho ph n c thai v cho con b, tr di 7 tui. Thay
bng erythromycin base 500 mg, ung 1 vin, 4 ln/ngy, trong 15 ngy.

336 |
6.2. Phc iu tr h cam.
Dng mt trong cc thuc sau y:
- Ceftriaxon 250 mg, tim bp liu duy nht, hoc
- Spectinomycin 2 g, tim bp liu duy nht, hoc
- Azithromycin 1 g, ung liu duy nht, hoc
- Erythromycin base 500 mg, ung 1 vin, 4 ln/ngy, trong 7 ngy, hoc
- Ciprofloxacin 500 mg, ung 1 vin, 2 ln/ngy, trong 3 ngy.
Ch : Khng dng ciprofloxacin cho ph n c thai, ph n cho con b v ngi di 18
tui.
6.3. Phc iu tr Herpes sinh dc
- Dng mt trong cc thuc sau y:
Acyclovir 400 mg, ung 1 vin, 3 ln/ngy, trong 7 ngy (nu mc ln u), trong 5
ngy (vi trng hp ti pht).
Acyclovir 200 mg, ung 1 vin, 5 ln/ngy, trong 7 ngy (nu mc ln u), trong 5
Famcyclovir 250 mg, ung 1 vin, 3 ln/ngy, trong 7 ngy (nu mc ln u),
trong 5 ngy (vi trng hp ti pht), hoc
Valacyclovir 1 g, ung 1 vin, 2 ln/ngy, trong 7 ngy (nu mc ln u), trong 5
Ch : Mc d khng c thuc iu tr c hiu cho HSV nhng iu tr bng cc thuc
khng virus nh acyclovir c th rt ngn thi gian b bnh, gim cc t ti pht v gim
nguy c ly truyn bnh. Do cn iu tr ngay cng sm cng tt cho trng hp mi
mc herpes s pht.
- Herpes ti pht t 6 ln tr ln trong mt nm.
- Trng hp bnh giang mai v h cam khng p ng vi iu tr hoc bnh herpes
sinh dc c biu hin lm sng nng v lan to nn ngh n kh nng ngi bnh b
suy gim min dch do nhim HIV.
- Trng hp thai ph sp sinh b herpes s pht cn chuyn tuyn trn v nguy c gy
bin chng cho thai nhi cao. C th cho iu tr trc 4 gi hoc trong 4 gi trc khi
v i v nn phu thut ly thai trnh ly cho con.
7. Thng tin v t vn
Ngoi nhng thng tin v t vn chung (xem Hng dn chung), cn ch nhng
im sau y:
- Cn tun th y phc iu tr, c bit i vi bnh giang mai v h cam
phng cc bin chng ca bnh v ct t ngun ly.
- Khm li theo lch hn.
- Lot sinh dc to iu kin cho HIV ly truyn d hn cc NKLTQTD/NKSS khc.
H cam, herpes sinh dc v giang mai hay gp nhng ni t l lu hnh HIV cao v
vic phng chng cc bnh ny l thnh phn rt quan trng ca phng chng HIV.

| 337
- Nhim HIV c th lm thay i hnh th lm sng ca lot sinh dc lm cho chn on
bnh chng kh hn. Do cn nhn mnh s cn thit phi iu tr sm, c bit
nhng ngi nhim HIV.
- Ngoi nguy c nhim HIV, herpes sinh dc cn nguy c ly nhim cao cho thai nhi,
c bit giai on chuyn d .
- Hin nay cha c thuc iu tr c hiu i vi herpes sinh dc, ngi bnh phi
mang bnh sut i v rt hay ti pht. Nu ti pht t 6 ln tr ln trong mt nm cn
gi tuyn trn iu tr. Ngi b herpes sinh dc d dng lm ly nhim cho bn tnh
cho nn vic t vn phng ly nhm l rt cn thit.
- Bnh giang mai c th ly truyn t m sang thai qua bnh rau gy: sy thai, thai cht
lu, giang mai bm sinh ...
- Tnh dc an ton v hng dn s dng bao cao su ng cch v thng xuyn. Cn
ch i vi cc vt lot do herpes sinh dc, bao cao su khng c tc dng bo v nu
khng che ph ht cc vt lot.
- Thng bo v iu tr bn tnh.

338 |
HI CHNG SNG HCH BN

Tuyn p dng.
Tt c cc tuyn.
Ngi thc hin.

Hi chng sng hch bn c th gp c nam v n.
Hi chng sng hch bn l vim ca cc hch lympho vng bn, c th au v c
th c m. Khi cc hch ny v ra, chng ging cc vt lot vng bn.
Cc nguyn nhn thng gp:
- Xon khun giang mai gy bnh giang mai.
- Trc khun h cam gy bnh h cam.
- Chlamydia trachomatis tp L1, L2, L3, gy bnh ht xoi hay bnh u ht bch huyt
hoa liu (lymphogranuloma venereum - LGV hay bnh Nicolas-Favre).
- U ht bn hay bnh Donovan do klebsiella granulomatis hay cn gi l calymmato
bacterium granulomatis (him gp Vit Nam).

- Hch bn to mt hoc c hai bn.
- Cc vt lot, mn nc, sn nh vng hu mn, sinh dc trc hoc km theo.
- Cc biu hin khc da hoc nim mc: sn, sn m, o ban c bit ch thng
tn lng bn tay v bn chn.
- St hoc khng st.
Xem Hng dn chung, ngoi ra khai thc thm:
- Cc nguyn nhn ca sng hch bn do cc vt thng, vt try xc da gy nhim
khun cp tnh chn, bn chn cng bn.
- C au hch khng? C l r, chy m?
3. Khm lm sng.
3.1. Khm cc du hiu vim hch.
- Hch sng mt bn hay hai bn bn.
- au, khng au? Vim hch cp hay mn tnh?
- S lng: nhiu hoc t, kch thc: to hoc nh.
- Tnh cht: mm hay chc, di ng hay khng di ng, tch ri hay hnh thnh khi
dnh lin da v m bn di. C l r?
3.2. Khm pht hin cc vt lot, sn nh, mng nim mc.
- Thng nim mc sinh dc, hu mn, ming, mi.

| 339
- Phn ln cc trng hp h cam, vt lot sinh dc thng nhn thy, nhng vt lot
trong m o ph n c th b b st.
3.3. Khm pht hin cc du hiu khc da/nim mc.
Cc du hiu thng gp l sn, mn m, sn m, o ban, mng nim mc da ton
thn, lng bn tay, bn chn hoc nim mc ming, mi, sinh dc v hu mn.
4. Chn on.
4.1. Vim hch do giang mai.
Nu giang mai giai on I: thng hch to, di ng, khu tr ph bin l mt bn
bn, trong chm hch c mt hch to hn hn gi l "hch cha".
Nu giang mai giai on II: hch lan trn hai bn bn v nhiu ni khc: nch, c,
di hm. Km cc biu hin khc: o ban, sn, mng nim mc, rng tc, c th c st...
4.2. Vim hch do h cam.
Xut hin sau 2 tun khi c vt lot h cam. Thng ch c mt hch vim mt bn
bn. Hch , nng, sng, au. Hch v m (nh mu s c la), to thnh vt lot lu lnh
c b nham nh.
4.3. Vim hch do u ht bch huyt hoa liu (LGV hay bnh Nicolas-Favre).
Vim hch xut hin vi ngy, vi tun sau khi c mn nc, sn nh hoc vt lot.
Vim hch thng mt bn (ph bin l bn). Cc hch vim thng to thnh mt
khi, khng di ng, mm dn v chy m ra ngoi thnh nhiu l d hoc ng hm
thng nhau ging nh "gng sen". Tin trin lu c th km vim hu mn, trc trng,
i khi cht hp hu mn, l r quanh hu mn.
Nu sng hch bn, nhng khng phi cc trng hp trn th tm nguyn nhn khc.
5. Xt nghim h tr.
Phn ng huyt thanh chn on giang mai (RPR hoc VDRL, TPHA).
6. iu tr.
- i vi mi trng hp sng hch bn nghi ng do bnh ly truyn qua ng tnh
dc, cn b y t cn xc nh v iu tr cho (cc) bn tnh.
- Nu chn on c cn nguyn gy bnh th iu tr theo cn nguyn, nu khng th
phi hp phc iu tr giang mai v h cam.
- Cc hch to, mm, bng nhng cn c chc ht qua vng da lnh. Vic chch rch v
dn lu cc hch ny c th lm chm qu trnh lnh vt thng v khng nn c gng
thc hin.
6.1. Giang mai.
Dng mt trong cc thuc sau.
- Benzathin penicilin G 2,4 triu v, tim bp liu duy nht (mi bn mng 1,2 triu v),
hoc
- Procain penicilin G 1,2 triu v, tim bp 1 ln/ngy, trong 10 ngy lin tip, hoc
- Nu ngi bnh d ng vi penicilin thay bng doxycyclin 100 mg, ung 1 vin, 2
ln/ngy, trong 14 ngy lin tip.
Ch : Khng dng doxycyclin cho ph n c thai v cho b. Thay bng erythromycin 500
mg, ung 1 vin, 4 ln/ngy, trong 14 ngy lin tip.

340 |
6.2. H cam.
Dng mt trong cc thuc sau
- Azithromycin 1 g, ung liu duy nht, hoc
- Ceftriaxon 250 mg, tim bp liu duy nht, hoc
- Ciprofloxacin 500 mg, ung 1 vin, 2 ln/ngy, trong 3 ngy, hoc
- Erythromycin base 500 mg, ung 1 vin, 4 ln/ngy, trong 7 ngy.
Ch : Khng dng ciprofloxacin cho ph n c thai, ph n cho con b v ngi di 18
tui.
6.3. U ht bch huyt hoa liu
Dng mt trong cc thuc sau
- Doxycyclin 100 mg, ung 1 vin, 2 ln/ngy, trong 14 ngy, hoc
- Erythromycin base 500 mg, ung 1 vin, 4 ln/ngy, trong 14 ngy, hoc
- Tetracyclin 500 mg, ung 1 vin, 4 ln/ngy, trong 14 ngy.
Ch : Khng dng doxycyclin v tetracyclin cho ph n c thai v cho con b.
- Nghi ng sng hch bn do cc nguyn nhn khc khng phi giang mai, h cam v u
ht bch huyt hoa liu.
7. Thng tin v t vn.
- Cc hu qu ca bnh khi khng c iu tr ng.
- Tun th phc iu tr, n khm li theo lch hn.
- Cn b y t cn khuyn khch ngi bnh thng bo bn tnh v iu tr bn tnh.
- Tnh dc an ton v hng dn s dng bao cao su. Ngi bnh cn c khuyn
khch v hng dn s dng bao cao su phng nga ly nhim HIV/AIDS v cc
NKTQTD.
- T vn v xt nghim HIV, c bit i vi bnh giang mai v h cam v hai bnh ny
c nguy c ly nhim HIV cao hn.

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DANH MC THUC IU TR
NHIM KHUN NG SINH SN/NHIM KHUN LY
TRUYN QUA NG TNH DC

Chn on Phc 1 Phc 2 Phc 3 Ghi ch
1. Chlamydia
ng sinh
sn.
Azithromycin 1 g,
ung liu duy
nht.
Doxycyclin
100 mg, ung 2
ln/ngy, trong 7
ngy.
Erythromycin
base 500 mg,
ung 4 ln/ngy,
trong 7 ngy.

2. Chlamydia
ng sinh
sn khi thai
nghn.
Azithromycin 1 g,
ung liu duy
nht.
Amoxicillin 500
mg, ung 3
ln/ngy, trong 7
ngy.
Erythromycin
base 500 mg,
ung 4 ln/ngy,
trong 7 ngy.

3. Chlamydia
vimkt mc
s sinh.
Erythromycin
base hoc
ethylsuccinat 50
mg/kg, chia 4
ln/ngy, trong 14
ngy.
Trimethoprim40
mg v
sulfamethoxazol
200 mg, ung 2
ln/ngy, trong 14
ngy.
Khng c.
4. Herpes s
pht.
Acyclovir 400
mg, ung 3
ln/ngy, trong 7
ngy.
Acyclovir 200 mg
ung 5 ln/ngy,
trong 7 ngy.
Famciclovir 250
mg, ung 3 ln/
ngy, trong 7
ngy.
iu tr ngay cng
sm cng tt, nu
tn thng cha
lnh thi gian iu
tr c th ko di
n 10 ngy.
5. Herpes ti
pht.
Acyclovir 400
mg, ung 3
ln/ngy, trong 5
ngy.
Acyclovir 200 mg,
ung 5 ln/ngy
trong 5 ngy.
Famciclovir 125
mg, ung 2
ln/ngy, trong 5
ngy.
iu tr ngay khi
c triu chng ti
pht.
6. Herpes khi
thai nghn.
Acyclovir 400
mg, ung 3
ln/ngy, trong 5
ngy.
Acyclovir 200 mg,
ung 5 ln/ngy,
trong 5 ngy.
Khng c. Cn nhc phu
thut ly thai nu
nh xut hin
herpes thi gian
gn khi sinh.
7. S sinh mc
hoc nghi mc
herpes khi
sinh.
Acyclovir 10
mg/kg, timtnh
mch 3 ln/ngy,
trong 21 ngy
nu tn thng
lan rng hoc
nghi vimno.

Acyclovir 10
mg/kg, timtnh
mch 3 ln/ngy
trong 14 ngy nu
ch tn thng khu
tr da v nim
mc.
Khng c. Nu tr tip xc
vi herpes khi
sinh cn theo di
st.

342 |
8. Herpes
ngi nhim
HIV.
Acyclovir 400
mg, ung 3 - 5
ln/ngy, n khi
khi.
Famciclovir 500
mg, ung 2
ln/ngy n khi
khi.
Khng c.
9. Gh v rn
mu.
DEP, bi 1
ln/ngy, trong 10
ngy.
Permethrin 1 % bi
1 ln/ngy, tm sau
bi 24 gi
Khng c. DEP khng dng
cho ph n c
thai v cho con
b. DEP bi vo
b phn sinh dc
s gy nng rt.
10. Giang mai
sm (bao gm
giang mai I v
giang mai II
s pht).
Benzathin
penicilin G 2,4
triu v, timbp
liu duy nht.
Procain penicilin G
1,2 triu v, tim
bp 1 ln/ngy,
trong 10 ngy lin
tip.
Doxycyclin 100
mg, ung 2
ln/ngy, trong 14
ngy.

11. Giang mai
mun (trn 2
nm).
Benzathin
penicilin G 2,4
triu v, timbp
mi tun, trong 3
- 4 tun lin tc.
Procain penicilin G
1,2 triu v, tim
bp 1 ln/ngy,
trong 20 ngy lin
tc.
Doxycyclin
100 mg, ung 2
ln/ngy, trong 30
ngy.

12. Giang mai
sm ph n
c thai
Benzathin
penicilin G 2,4
triu v, timbp
liu duy nht.
Procain penicilin G
1,2 triu v, tim
bp 1 ln/ngy,
trong 10 ngy lin
tc.
Khng c.
13. Giang mai
mun ph
n c thai.
Benzathin
penicilin G 2,4
triu v, timbp,
mi tun, trong 3
- 4 tun lin tc..
Procain penicilin G
1,2 triu v, tim
bp 1 ln/ngy,
trong 20 ngy lin
tc.
Erythromycin 500
mg, ung 4
ln/ngy, trong 30
ngy.
Erythromycin c
t l tht bi cao.
14. Giang mai
bm sinh sm
(di 2 tui).
Benzylpenicilin
100.000 - 150.000
v/kg/ngy, tim
tnh mch 2
ln/ngy, trong 7
ngy v 3 ln/ngy,
trong 3 ngy tip
theo.
Procain penicilin G
50.000 v/kg, tim
bp 1 ln/ngy,
trong 10 ngy lin
tc.
Khng c.
15. H cam. Azithromycin 1 g,
ung liu duy
nht.
Ceftriaxon 250 mg,
timbp liu duy
nht.
Ciprofloxacin 500
mg, ung 2
ln/ngy, trong 3
ngy.
Vi bo co v
vic trc khun
h cam khng li
ciprofloxacin v
erythromycin.

| 343
16. Lu khng
bin chng.
Ceftriaxon 250
mg, timbp, liu
duy nht.
Cefixim400 mg,
ung liu duy nht.
Spectinomycin 2
g, timbp liu
duy nht.
40 % vi khun
lu khng vi
quinolon.
17. Lu khi
thai nghn.
Ceftriaxon 250
mg, timbp, liu
duy nht.
Cefixim400 mg,
ung liu duy nht.
Spectinomycin 2
g, timbp liu
duy nht.

18. Lu h
thng.
Ceftriaxon 1
g/ngy, timbp,
trong 7 ngy.
Spectinomycin 2 g,
timbp 2
ln/ngy, trong 7
ngy.
Cefixim400 mg,
ung 2 ln/ngy,
trong 7 ngy.

Vimni mc
tim, iu tr n 6
tun.
19. Vimkt
mc do lu.
Ceftriaxon 1 g,
timbp liu duy
nht.
Lu : Tr s
sinh 50 mg/kg,
timbp khng
qu 125 mg trong
24 gi.
Spectinomycin 2 g,
timbp liu duy
nht.
Azithromycin 2 g,
ung liu duy
nht.
Phi hp vi lm
sch mt bng
nc mui sinh
l lin tc trong 5
ngy.
20. Nm
candida.
Nystatin
100.000v,
t m o, 1
vin/ngy, trong
14 ngy.
Itraconazol 100 mg,
ung 2 ln/ngy,
trong 3 ngy.
Fluconazol
150mg, ung liu
duy nht.

21. Nm
candida khi
thai nghn.
Clotrimazol 100
mg, t m o
trong 7 ngy.
Miconazol 100 mg,
t m o trong 7
ngy.
Nystatin 100.000
v, t m o 1
vin/ngy, trong
14 ngy.

22. Si mo
g sinh dc
chung.
Acid
trichloroacetic 80
% - 90 %.
t in hoc t
lnh.
Podophyllin 10 %
- 25 %.
Podophyllin hp
th, c tnh. Bi
m khng sinh
vo vng da,
nimmc xung
quanh si mo
g.
23. Si mo
g sinh dc
khi thai
nghn.
Acid
trichloroacetic 80
% - 90 %.
t lnh. t in hoc
laser CO
2.

Thng tn
thng si mo
g pht trin
nhanh trong thi
k mang thai.
Xem xt phu
thut ly thai.

344 |
24. Trng roi
m o.
Metronidazol 500
mg, ung 2
ln/ngy, ung
trong 7 ngy.
Metronidazol 2 g,
ung liu duy nht.
Tinidazol 2 g,
ung liu duy
nht.
Khng ung
ru, khng dng
cho ph n c
thai trong 3 thng
u khi iu tr
bng
metronidazol.
25. Trng roi
m o ph
n c thai.
Metronidazol 250
mg ung 3
ln/ngy, trong 7
ngy.
Metronidazol gel
0,75 % bi m o,
2 ln/ngy, trong 5
ngy.
Clindamycin 300
mg, ung 2
ln/ngy, trong 7
ngy.
Ch dng thuc
sau 3 thng u
ca thai k hoc
thay bng bi gel
metronidazol.
26. Vimm
o do vi
khun.
Metronidazol 500
mg ung 2
ln/ngy, trong 7
ngy.
Kem clindamycin 3
% bi m o khi
i ng, trong 7
ngy.
Tinidazol 2 g,
ung liu duy
nht.
Khng ung
ru, khng dng
cho ph n c
thai trong 3 thng
u khi iu tr
bng
metronidazol.
27. U ht bch
huyt hoa liu
(ht xoi).
Doxycyclin 100
mg ung 2
ln/ngy, trong 14
ngy.
Erythromycin base
500 mg, ung 4
ln/ngy, trong 14
ngy.
Tetracyclin 500
mg/ngy, trong 14
ngy.

Doxycyclin v
tetracyclin khng
dng cho ph n
c thai v b m
cho con b.

345 |

PHN 6
SC KHE SINH SN
V THNH NIN V THANH NIN
346 |

| 347
HNG DN CHUNG
V thnh nin l ngi trong tui 10 - 19, thanh nin tr l ngi trong tui 15 -
24. Khi nim v thnh nin v thanh nin (VTN/TN) dng ch ngi trong tui 10 - 24.
VTN l giai on chuyn tip t tr em thnh ngi trng thnh. VTN/TN c c im
tm sinh l c th nh thch th nghim, thch khm ph nng lc bn thn, nng ng,
sng to. Vi nhng c im ny, VTN/TN lin tc i mt vi nhng thch thc cng
nh nguy c. chinh phc thch thc ca cuc sng v phng trnh nguy c, VTN/TN
cn c p ng nhu cu c bn gm mi trng an ton, thng tin chnh xc, k nng
sng, c t vn v h tr dch v y t ph hp.
VTN/TN cn sng trong mi trng lnh mnh, trnh cng thng, lm dng v bo lc.
Mi trng ny cng gip cc em c nhng mi quan h tt p, gn gi vi gia nh,
ngi ln, bn cng trang la to c hi pht trin ti a tim nng ca mnh. VTN/TN
cn c cung cp thng tin chnh xc v ng n gip cc em hiu qu trnh pht trin
bn thn, nguy c cho sc khe, iu kin cn thit khe mnh v cc dch v sn c.
VTN/TN cn c trang b k nng sng i ph nhng i hi v thch thc ca cuc
sng. VTN/TN cn c t vn ring t gip cc em hiu v gii quyt thch thc ca
bn thn, t ra quyt nh c trch nhim. VTN/TN cn dch v y t d phng, iu tr
v nng cao sc khe mang tnh ton din bao gm cc dch v chm sc SKSS v SKTD.
Ngnh y t ng vai tr rt quan trng trong vic p ng nhu cu chm sc sc khe cho
VTN/TN.
Theo T chc Y t th gii, dch v sc khe thn thin vi VTN/TN l cc dch v
c th tip cn c v ph hp vi VTN/TN. Dch v sc khe thn thin vi VTN/TN
cn m bo cc tiu chun nh a im, gi c ph hp (c th chi tr c hoc min
ph nu cn thit), an ton, phc v theo phng cch m VTN/TN chp nhn c
nhm p ng nhu cu ca VTN/TN v khuyn khch cc em tr li c s y t khi cn
cng nh gii thiu v dch v ti bn b.
Dch v sc khe thn thin vi VTN/TN cn trin khai t tuyn c s n trung ng.
Cc c s c th trin khai cung cp thng tin gio dc truyn thng SKSS/SKTD cho
VTN: trung tm truyn thng gio dc sc khe, nh vn ha/cu lc b VTN/TN, gc
thn thin ti cng ng/trng hc, cc t im thu ht VTN/TN (khu vui chi gii tr,
qun c ph, im internet, nh sch)
Cc c s c th trin khai cung cp thng tin gio dc truyn thng v t vn v
SKSS/SKTD cho VTN/TN bao gm: cc trung tm truyn thng gio dc sc khe, cc
trung tm t vn chuyn bit v SKSS/SKTD, cc trung tm t vn chung v t vn hn
nhn gia nh, cc gc t vn, gc thn thin cho VTN/TN, cc phng t vn ca c s y
t, phng t vn c quan x nghip, cc hiu thuc.
Cc c s c th trin khai cung cp thng tin gio dc truyn thng, t vn v dch v
khm cha bnh v SKSS/SKTD cho VTN/TN: cc bnh vin a khoa tuyn trung ng,
tuyn tnh, tuyn huyn c khoa ph sn, cc bnh vin chuyn khoa ph sn, chuyn khoa
nhi, chuyn khoa da liu, cc bnh vin c chuyn khoa nam hc, cc trung tm chm sc
SKSS tnh/ thnh ph, cc trung tm y t d phng qun huyn, cc trm y t x phng,
cc c s y t t nhn c chuyn khoa ph sn, cc hi ngnh ngh, cc t chc phi chnh
ph, cc t chc t nhn hp php c lin quan n VTN/TN.

348 |
NHNG C IM GII PHU, TM SINH L TRONG
THI K V THNH NIN

Tui v thnh nin l thi k pht trin c bit - thi k xy ra ng thi hng lot
nhng bin i nhanh chng c v c th cng nh s bin i tm l v cc mi quan h
x hi. Ngi cung cp dch v cn hiu r v cc c im tm sinh l v nhng thay i
trong tui ny th mi c th tip cn, t vn v cung cp dch v c cho cc em mt
cch ph hp, thn thin v hiu qu.
La tui VTN l t 10 - 19 tui v c chia ra 3 giai on:
VTN sm: t 10 - 13 tui.
VTN gia: t 14 - 16 tui.
VTN mun: t 17 - 19 tui.
1. Nhng thay i v gii phu v sinh l trong thi k VTN.
- S pht trin c th r rt v d nhn thy nht l cc du hiu dy th. Tui dy th
cc em n thng sm hn v trong khong t 10 - 15 tui, cc em nam trong khong
t 12 - 17 tui.
- Trong giai on dy th, cc ni tit t sinh dc (estrogen v tetosteron) tng dn, c
quan sinh dc pht trin v c th chun b sn sng cho hot ng sinh sn. Biu hin
r rt cc em n l hin tng kinh nguyt v em nam l hin tng xut tinh.
Dy th cc em n:
- Pht trin nm v, qung v.
- Mc lng sinh dc: lng mu, lng nch
- T cung, m o, bung trng pht trin to ra, xng hng n ra.
- Pht trin chiu cao nhanh chng
- Xut hin kinh nguyt
- Cc tuyn b hot ng mnh, xut hin trng c
Dy th cc em nam:
- Tinh hon v dng vt to ln, da tinh hon sm mu li.
- Thanh qun m rng, v ting, yt hu l ra
- Tng trng nhanh chng v chiu cao, cc xng di pht trin, c bp vai, ngc,
cnh tay... to ra.
- Xut hin lng mu, ria mp.
- C xut tinh (thng l mng tinh hay cn gi l gic m t)
- Cc tuyn b hot ng mnh, c trng c.
2. Nhng bin i v tm l trong thi k VTN: ty theo tng giai on pht trin
ca thi k VTN m c nhng bin i v tm l khc nhau.
Thi k VTN sm:
- Bt u thc mnh khng cn l tr con, mun c c lp.
- Mun c tn trng, c i x bnh ng nh ngi ln.
- Ch trng n cc mi quan h bn b.

| 349
- Quan tm n hnh thc bn ngoi v nhng thay i ca c th.
- T m, thch khm ph, th nghim.
- Bt u pht trin t duy tru tng.
- C nhng hnh vi mang tnh th nghim, bc ng.
Thi k VTN gia:
- Tip tc quan tm nhiu hn n hnh dng c th.
- T ra c lp hn, thch t mnh quyt nh, c xu hng tch ra khi s kim sot ca
gia nh.
- Pht trin mnh c tnh, s thch c nhn.
- Chu nh hng nhiu ca bn b ng trang la.
- Quan tm n bn khc gii, d ng nhn tnh bn khc gii vi tnh yu.
- Tip tc pht trin t duy tru tng.
- Pht trin k nng phn tch, bt u nhn bit hu qu ca hnh vi.
- Bt u th thch cc qui nh, cc gii hn m gia nh hay x hi t ra.
Thi k VTN mun:
- Khng nh s c lp v to dng hnh nh bn thn tng i n nh.
- Kh nng nh gi v gii quyt vn tt hn.
- Cch suy ngh, nhn xt v ng x chn chn hn.
- nh hng ca nhm bn b gim dn, quay li ch trng mi quan h gia nh.
- Ch trng ti mi quan h ring t, tin cy gia 2 ngi hn quan h theo nhm.
- nh hng cuc sng, ngh nghip r rng hn.
- Bit phn bit tnh bn v tnh yu, cch nhn nhn tnh yu mang tnh thc t hn.
3. Nhng mong mun v quyn ca VTN/TN v sc khe/SKSS/SKTD.
- Pht trin tt v chiu cao, cn nng.
- Khng m au bnh tt.
- C kh nng trnh c ma ty, ru v cc cht gy nghin.
- Pht trin nhn cch tt, c mi ngi coi trng.
- C quyn c thng tin y , chnh xc v sc khe/SKSS/SKTD.
- C quyn tip cn cc dch v chm sc sc khe/SKSS/SKTD ph hp v c cht
lng.
- C quyn c i x bnh ng, tn trng, khng b cng bc, bo hnh.
- C quyn t quyt nh v chu trch nhim v quyt nh ca mnh trong cc vn
lin quan n sc khe/SKSS/SKTD.
- C quyn c la chn kt hn hay khng, c quan h tnh dc hay khng, khi no,
vi ai, c con hay khng trn c s c thng tin y , c gio dc v k nng
sng v ph hp vi php lut.
4. Nhng ro cn khin VTN/TN kh thc hin mong mun v quyn ca h
trong lnh vc SKSS/SKTD.
- Quan nim ca x hi i vi vic chm sc v gio dc SKSS/SKTD cho VTN/TN
cn hn ch, cha thng nht.
- Cc chnh sch, chin lc v SKSS/TD cho thanh thiu nin cn t, cha c th, cha
c nhiu chnh sch ng vin VTN/TN.

350 |
- Thiu cc c s cung cp dch v sc khe thn thin vi VTN/TN.
- Thi nh kin ca thy c gio, cha m, cng ng, c bit l ngi cung cp dch
v, i vi vic cung cp thng tin v dch v chm sc SKSS/SKTD l nhng ro cn
ln i vi VTN/TN.
- a s cc cn b cung cp dch v cn cha c hun luyn lm vic vi
VTN/TN.

| 351
K NNG SNG LIN QUAN N SC KHE SINH SN/
SC KHE TNH DC CA V THNH NIN V THANH
NIN

K nng sng l kh nng ng x ca mi c nhn trong nhng tnh hung nht
nh, l kh nng m mi c nhn c c trong vic gii quyt cc vn gp phi
v ng ph mt cch tch cc i vi nhng th thch ca cuc sng thng ngy.
K nng sng va mang tnh c nhn va mang tnh x hi. C nhn l v mi ngi t
t ra cho mnh cc gi tr, nim tin quyt nh hnh ng theo nhng mc tiu ring
m mnh t ra. Tuy nhin, nhng mc tiu phn ln li chu nh hng ca nn vn
ha, phong tc tp qun, ca nhng chun mc o c trong cng ng ni ngi sinh
sng.
K nng sng rt quan trng i vi VTN/TN, c bit trong lnh vc SKSS/SKTD.
VTN/TN thng thiu kinh nghim sng, t c rn luyn k nng sng, do khi cn
phi a ra cc quyt nh quan trng i vi SKSS/SKTD nh quan h tnh dc khi no,
vi ai, c s dng bin php bo v hay khng, lm th no ni ln quan im ca mnh
v tnh dc vi bn tnh th VTN/TN thng gp kh khn, c th a ra nhng quyt nh
sai lm lm nh hng n cuc sng v tng lai ca h.
1. Nhng k nng sng cn cho s pht trin v sc khe ca VTN/TN.
K nng xc nh gi tr.
L kh nng xc nh c tnh, nim tin, thi , chnh kin no ca mnh l quan
trng v gip mnh hnh ng theo nh hng .
K nng ra quyt nh.
L kh nng mt c nhn a ra c quyt nh cho mnh da trn c s c y
thng tin v thc c hu qu/kt qu t quyt nh ca mnh. Trong mt s tnh hung,
thng c nhiu la chn v mi ngi phi chn ra mt quyt nh ng thi phi thc
c cc kh nng, hu qu c th xy ra. Do vy, iu quan trng l mi c nhn cn d
kin c cng nhiu cng tt nhng hu qu trc khi ra quyt nh cui cng ti u
nht.
K nng kin nh.
L kh nng t nhn bit c iu mnh mun hoc khng mun, ph hp vi hon
cnh c th, ng thi gi vng c kh nng/nhn nh d c nhng iu kin khc
tc ng.
K nng t mc tiu.
L kh nng t xc nh nhng g m mi c nhn mun thc hin, mun t ti.
Mt mc tiu t ra cn phi c th hin bng nhng t ng c th. Mc tiu cn
phi tr li bng nhng cu hi sau:
Ai s thc hin? Thc hin khi no?
Thc hin ci g? Thc hin bng cch no?

352 |
K nng giao tip.
L kh nng m VTN/TN c th s dng trong giao tip hng ngy c th din t
mong mun, cm xc, suy ngh ca bn thn, ng thi hiu c quan im, thi v
mong mun ca ngi khc.
K nng giao tip l tng hp ca nhiu k nng nh: k nng lng nghe, k nng din
t, k nng t cu hi, k nng thng thuyt, k nng t chi Cc k nng ny gip
cho VTN/TN bit cch thit lp v pht trin cc mi quan h.
K nng t chi
L kh nng ni khng vi mt ngh hoc mt li mi ca ngi khc lm mt vic
m mnh khng mun lm. c bit l ngh tham gia thc hin nhng hnh vi nguy c
cho sc khe. Nhiu VTN/TN khng dm t chi v s bn b hoc bn tnh khng bng
lng. VTN/TN cn c h tr k nng t chi trnh tham gia vo nhng hnh vi nguy
c cho sc khe m vn gi c mi quan h vi bn b v bn tnh.
2. Nhng vic ngi cung cp dch v c th lm h tr k nng sng cho
VTN/TN.
Khi VTN/TN gp vn v SKSS/SKTD nh mang thai ngoi mun, c
NKLTQTD, s dng bin php trnh thai, h cn h tr v k nng sng i mt
vi vn v t a ra gii php. Trong nhng trng hp ny, vai tr ca ngi cung cp
dch v rt quan trng. S h tr ca ngi cung cp dch v v k nng sng cho
VTN/TN rt cn thit gip VTN/TN trnh nhng tn thng tm l cng nh hu qu
v sc khe.
Thng qua nhng h tr v k nng sng, ngi cung cp dch v c th gip
VTN/TN:
- i mt vi vn SKSS/SKTD ca mnh.
- Xc nh cc mc tiu c nhn trong lnh vc SKSS/SKTD.
- Xc nh cc gii php c th, s ph hp, u im, nhc im ca gii php.
- Ra quyt nh v vn SKSS/SKTD da trn c s y thng tin v c h tr
k nng.
- C kh nng thng thuyt vi bn tnh v cc vn SKSS/SKTD.
- C kh nng phng nga cc vn SKSS/SKTD trong tng lai.

| 353
TNH DC AN TON V LNH MNH

Hnh vi tnh dc bao gm tt c cc hnh vi nhm tm kim khai cm hoc sinh sn.
Hnh vi tnh dc nhm tm kim s khai cm c th din ra gia 2 bn tnh khc gii hay
cng gii, vi mt ngi hay nhiu ngi, t mnh gy khai cm (th dm) hay gy khai
cm cho nhau, m tng n chuyn tnh dc hay dng cc dng c kch thch v tm
kim khoi cm, khng n thun ch l hnh vi giao hp.
1. Tnh dc an ton.
- Tnh dc an ton l nhng hnh vi tnh dc bao gm c 2 yu t: khng c nguy c
NKLTQTD v mang thai ngoi mun.
- V phng din trnh thai, tnh dc an ton gm s dng bin php trnh thai an ton,
hiu qu v ng cch.
- V phng din phng NKLTQTD/HIV, tnh dc an ton c th chia thnh 3 nhm:
Tnh dc an ton (khng c nguy c hoc nguy c rt t): m tng tnh dc, t
mnh th dm, vut ve trn mt da lnh ln, m bn tnh, king giao hp, tnh dc
bng tay vi m o hoc vi dng vt, quan h tnh dc dng vt vi ming c
s dng bao cao su.
Tnh dc tng i an ton (nguy c trung bnh): quan h tnh dc dng vt vi
m o c s dng bao cao su, quan h tnh dc ming vi m o hoc ming vi
dng vt khng dng bao cao su.
Tnh dc khng an ton (nguy c cao): quan h tnh dc dng vt vi m o
khng s dng bao cao su, quan h tnh dc dng vt vi hu mn c hoc khng
dng bao cao su.
2. Tnh dc lnh mnh.
- Hnh vi tnh dc c coi l lnh mnh khi ph hp vi nhng c th ca tnh dc
ngi, vi chun mc o c, vn ha ca x hi hin i. Tnh dc lnh mnh phi
m bo 4 yu t: t nguyn, ng thun, c trch nhim v tn trng ln nhau.
- Mt s hnh vi tnh dc thng c x hi coi l khng lnh mnh: ngoi tnh, quan
h vi gi mi dm, xm hi tnh dc....
3. Nhng l do khin VTN/TN c hnh vi tnh dc khng an ton.
- VTN/TN d rung ng trc ngi bn khc gii, nhng xc cm yu ng pht trin
nhanh v mnh, d thay i bn tnh, khng thc c hu qu t hnh vi ca mnh.
- VTN/TN c nhu cu th nghim, mun khm ph kh nng trong quan h tnh dc, t
m v kh kim ch khi b kch thch tnh dc.
- VTN/TN d b d d v xm hi tnh dc. Mt s VTN/TN c quan h vi gi mi
dm, chch ht ma ty.
4. T vn v tnh dc an ton v lnh mnh cho VTN/TN.
4.1. Gii thch v li ch ca vic thc hnh tnh dc an ton v lnh mnh.
- VTN/TN t gic thc hnh tnh dc an ton l t bo v mnh v bo v bn tnh:
Yn tm, khng lo c thai do c khai cm hn.
An ton, t c nguy c b NKLTQTD, nht l HIV/AIDS.
Gim nguy c b ung th c t cung, gim nguy c v sinh.

354 |
- VTN/TN t gic thc hnh tnh dc lnh mnh l tn trng bn tnh, khng t bn
tnh vo tnh th kh x, khng lm thng tn bn tnh, ng thi cng khng lm tn
thng n nhng ngi xung quanh. iu ny gip bo v hnh phc bn thn v gia
nh, bo v s lnh mnh cho th h con ci, khng lm phng hi n o c, cc
chun mc vn ha ca x hi hin i.
4.2. Cc ni dung cn t vn.
- VTN/TN c th c thai v mc NKLTQTD nu khng thc hnh tnh dc an ton v
lnh mnh. VTN/TN c th c thai ngay trong ln quan h tnh dc khng c bo v
u tin. VTN/TN c th mc mt hoc nhiu NKLTQTD trong mi ln quan h tnh
dc khng an ton.
- VTN/TN cn bit nguyn tc c bn ca vic phng NKLTQTD l trnh tip xc vi
dch ca c th nhim khun (tinh dch, dch m o, mu), v trnh tip xc khng
bo v vi vng b mt c th nhim khun. Vi khun gy bnh thng xm nhp
qua nim mc m o, niu o v ming.
- VTN/TN cn hiu khi mc NKLTQTD, cn phi iu tr khng ch ring h m c
bn tnh (hay v chng), iu tr ng thuc, liu lng v nn n cc a ch tin
cy c tr gip.
- Cn khuyn khch VTN/TN li sng bit kim ch, king quan h tnh dc c xm
nhp, tp trung hc tp, lao ng, th thao. T vn cho VTN/TN cch t bo v trong
tng lai, khuyn khch VTN/TN quay tr li c s y t c t vn v tnh dc an
ton trc khi c quyt nh quan h tnh dc. Trong trng hp VTN/TN c quan
h tnh dc, cn t vn la chn bin php an ton, ng tin cy, ph hp.
- T vn v k nng sng v hng dn s dng bao cao su:
K nng ra quyt nh cn nhc quyt nh ng /khng ng quan h tnh
dc.
K nng t chi bit cch t chi quan h tnh dc.
K nng thng thuyt bit cch thuyt phc bn tnh ng s dng bao cao su
sau khi quyt nh quan h tnh dc.
K nng s dng bao cao su s dng bao cao su ng cch.
- Gii thch nhng iu VTN/TN thng hay hiu lm:
Quan h tnh dc c s dng bao cao su s lm gim khai cm, gy v sinh, gy
nhim khun, gy bt tin khi s dng.
S dng thuc dit tinh trng c t l trnh thai cao v gip trnh c
NKLTQTD.
Giao hp t th ng khng th c thai hoc nu ngi ph n nm trn trong lc
giao hp th cng khng c thai.
Sau khi xut tinh, ch cn tht ra m o bng cc dung dch nh dm, nc
chanh... th c th trnh thai.

| 355
T VN V SC KHE SINH SN V THNH NIN
V THANH NIN

T vn SKSS v thnh nin v thanh nin cn da trn nhu cu ca VTN/TN v l mt ni
dung khng th thiu c trong qu trnh cung cp dch v.

Tuyn p dng.
Tt c cc tuyn.
Ngi thc hin.

1. Nhng im cn lu khi t vn SKSS cho VTN/TN.
- Cn b t vn cn hiu nhng c im pht trin tm - sinh l ca la tui VTN/TN
m bo tnh ring t, ng cm, t nh v khng phn xt. T vn qua in thoi v
qua internet c th thc hin nhng ni c iu kin.
- Cc c s y t cn s dng nhiu loi ti liu truyn thng, qung b, cung cp thng
tin r rng, chnh xc v ph hp.
- VTN/TN thng lo s b tit l thng tin nn min cng khi chia s iu ring t v
v quan h tnh dc khi cha kt hn hin khng c x hi chp nhn. VTN/TN s
phi tha nhn c quan h tnh dc. Do , vic bo mt v hn ch chia s thng tin c
nhn rt quan trng.
- Cn b t vn cn nhiu thi gian, gii thch cn k v VTN/TN t hiu bit v c th,
SKSS/SKTD.
- Cn b t vn cn ch h tr mt s k nng sng cn thit VTN/TN c th c
thi , hnh vi ng mc v thc hnh an ton.
2. Cc bc t vn c bn.
Cc bc t vn cho VTN/TN v c bn cng ging nh 6 bc trong t vn SKSS (gp
g, gi hi, gii thiu, gip , gii thch, gp li) nhng t vn cho VTN ch din ra thun
li v c hiu qu thc s khi cn b t vn to c mi quan h tin cy, kin tr lng nghe,
bit kim ch. Bc gp g ban u ng vai tr rt quan trng bi nu VTN/TN khng c
n tng tt vi cn b t vn ngay t u th h cng s khng ci m v chia s nhng
vn h gp phi.
Trng hp cn c s tham gia ca ngi thn (gia nh, bn tnh, bn b thn, thy
gio...) phi tho lun trc vi VTN/TN.
3. Nhng k nng t vn c bn.
Cc k nng t vn cho VTN/TN v c bn cng ging nh t vn SKSS gm k nng
lng nghe, k nng giao tip, k nng khuyn khch, c bit l k nng gii quyt vn
gip VTN/TN xc nh vn v tm cch gii quyt. Tuy nhin t vn cho VTN/TN i
hi cn b t vn phi s dng cc k nng t vn mt cch thnh thc v mc yu cu
cao hn. Lng nghe VTN/TN khng ch l thu nhn c nhng g h mun ni, m cn thu

356 |
nhn c c nhng iu n cha bn trong, nhng iu m VTN/TN khng bit hoc khng
th din t.
4. Nhng ni dung cn t vn SKSS VTN/TN.
4.1. Gip VTN/TN bit cch nhn bit nhng tnh cm ca bn thn v hc cch t
kim sot:
Hng dn VTN/TN bit cch nhn bit tnh cm ca bn thn nh bun chn, tht
vng, phn n, cng thng... v bit cch t kim sot tnh cm, bit cch x tr trong tnh
hung c th.
4.2. Gip VTN/TN nhn bit nhng tri nghim trong qu kh, nhng tc ng n
hnh vi hin ti.
H tr VTN/TN by t nhng vn tri nghim tiu cc trong qu kh, nhng nh
hng n hin ti gip VTN/TN hc cc gii to, xc nh cch phng trnh v hng
x tr thch hp trong tng lai. Nu VTN/TN t chi, c th s dng nhng cch din t
khc d dng hn i vi VTN/TN nh vit ra giy hoc in thoi. i khi tri nghim
tiu cc c th khu gi li ni au khin cc em bun chn v lo lng hn
4.3. Chun b cho VTN/TN hng n nhng thay i v ra quyt nh tch cc trong
cuc sng.
- VTN/TN thng gp kh khn khi phi i mt vi nhng thay i v phi tri qua
mt thi k kh khn x l nhng h qu do s thay i gy nn. Do vy cn b t
vn cn gip cc em hc cch chun b hng n nhng thay i sp ti trong cuc
sng ca cc em. Cn b t vn cn gip cc em lp k hoch chi tit cho nhng
thay i sp ti v tho lun vi cc em v k hoch .
- VTN/TN cn c h tr nhm thay i nhn thc, thi , hnh vi v t gii quyt
vn ca h. Nhng thi v hnh vi trong lnh vc SKSS/tnh dc l khng d
dng thay i. Cn b t vn cn hng dn cho VTN/TN cc k nng sng quan trng
trong cuc sng: k nng ra quyt nh, k nng gii quyt vn , k nng t chi, k
nng thng thuyt.
5. Nhng ch cn t vn.
- c im pht trin c th, tm - sinh l tui VTN.
- Kinh nguyt bnh thng v bt thng tui VTN.
- Thai nghn v sinh tui VTN.
- Cc bin php trnh thai tui VTN.
- Tit dch m o hoc niu o tui VTN.
- Mng tinh, th dm.
- NKSS v NKLTQTD bao gm c HIV/AIDS.
- Tnh dc an ton v lnh mnh.
- Lm dng tnh dc v bo hnh tui VTN/TN.

| 357
KINH NGUYT V XUT TINH V THNH NIN

Tuyn p dng.
Tt c cc tuyn.
Ngi thc hin.

Ri lon kinh nguyt VTN n, nu khng pht hin c cc du hiu bt thng
hoc cc du hiu lin quan n thai nghn thng do nguyn nhn hot ng ca h thng
trc di i - tuyn yn - bung trng cha hon chnh.
Ri lon xut tinh VTN nam tm thi v khng pht hin du hiu bt thng qua
khm thc th thng khng cn iu tr, nhng cn h tr liu php tm l.
Nu ri lon kinh nguyt VTN n v ri lon xut tinh VTN nam nu ko di v
nh hng n sc khe v tm l, cn khm chuyn khoa.
1. Kinh nguyt VTN n.
Kinh nguyt l mt hin tng sinh l bnh thng, biu hin l chy mu ra ngoi m
o do bong nim mc t cung. Kinh nguyt c tnh cht nh k hng thng, l kt qu
ca s thay i ni tit bung trng trong c th.
tui VTN kinh nguyt c th cha u trong khong 1 - 2 nm u do hot ng ca
bung trng cha n nh.
1.1. Du hiu v triu chng lm sng.
Kinh nguyt bnh thng khi.
Tui bt u c kinh: t 11 - 18 tui.
Vng kinh t 22 - 35 ngy, trung bnh l 28 - 30 ngy.
Thi gian hnh kinh t 3 - 7 ngy.
Lng mu kinh thay 3 - 5 ln bng v sinh mi ngy.
Mu kinh mu ti, khng ng, c mi hi nng, khng tanh.
Kinh nguyt khng bnh thng cn gi l ri lon kinh nguyt.
V kinh nguyn pht: qu 18 tui cha hnh kinh.
V kinh th pht: qu 3 thng cha hnh kinh nu trc kinh rt u v qu 6
thng cha hnh kinh nu trc kinh khng u.
V kinh gi: mu kinh vn c nhng mng trinh kn hoc c t cung b dnh nn
mu kinh khng chy ra ngoi, cn gi l b kinh.
Rong kinh: hnh kinh ko di trn 7 ngy.
Kinh t: lng mu kinh ra rt t.
Kinh nhiu: lng mu kinh nhiu hn bnh thng, trn 60 ml trong c k kinh.
Kinh tha: vng kinh di trn 35 ngy.
Kinh mau: vng kinh ngn di 21 ngy.
Bng kinh: mu kinh ra rt nhiu, trn 150 ml trong thi gian mt vi ngy gy
chong vng, mt mi i khi b ngt xu.
Rong huyt: ra mu khng lin quan n k kinh.

358 |
Rong kinh: ra mu kinh ko di trn 7 ngy.
Thng kinh: au bng nhiu khi hnh kinh, c th b mt mi v nh hng sinh
hot.
Kinh sm: c kinh trc 10 tui.
1.2. X tr.
- au bng khi hnh kinh: cho thuc gim au loi khng vim khng corticoid
(paracetamol, ibuprofen, diclofenac...) hoc thuc vin trnh thai kt hp,
- Theo di nhng trng hp nh kinh tha, kinh mau, kinh t cha nh hng n sc
khe.
- V kinh: c th do ri lon dinh dng v tm l. T vn cho VTN bit ri lon dinh
dng c th nh hng xu n s pht trin chung ca c th, ng thi hng dn
VTN cch khc phc cc vn v dinh dng hay gip gii to cc vn tm l.
- Thuc vin trnh thai kt hp c th gip iu ha chu k kinh, gim au bng khi
hnh kinh.
- Rong huyt hoc ra mu bt thng c th l do nhim khun hoc bt thng c t
cung. Khm v iu tr nu c nhim khun ng sinh sn, v chuyn ln tuyn trn
lm phin m o nu cn. (xem phn NKSS/NKLTQTD).
- Cc trng hp ri lon kinh nguyt khc cn gi ln tuyn trn chn on v x tr.
1.3. T vn.
- Gii thch cho VTN hiu kinh nguyt l hin tng sinh l t nhin, gy ra do s thay
i gii phu v sinh l bnh thng ca tui dy th, khng phi l bnh m lo s. Khi
hnh kinh c th b au bng, cm gic chong vng...
- Hi li xem hiu bit ca VTN v khi nim chu k kinh nguyt, gii thch nu c
s hiu lm. c bit cn gii thch cho VTN r khi c kinh nguyt th cng s c
kh nng c thai nu c quan h tnh dc.
- Nu v thnh nin lo lng v cc chu k kinh nguyt khng u th gii thch VTN
yn tm l kinh nguyt khng u trong 1 - 2 nm khi bt u c kinh c th l bnh
thng.
- Gii thch cc trng thi tm l bt thng hay xy ra khi c kinh nh cm gic bt rt
kh chu, nhc u, lo u, mt ng, bing n...
- Hng dn c th cch gi v sinh khi c kinh nguyt, cch s dng bng v sinh.
- Gii thch v hng dn cch phng trnh thai, nu cn th cung cp cc bin php
trnh thai thch hp.
- Hng dn thc hnh tnh dc an ton, s dng bao cao su phng cc NKLTQTD
v c thai ngoi mun.
- C th mi gia nh n t vn v kinh nguyt h tr cho VTN.
2. Xut tinh VTN nam.
2.1. Du hiu v triu chng lm sng.
- Xut tinh l do c ch phn x khin cho c s co tht cc c vng chu (ch yu l c
ngi hang, c hnh hang) v niu o. Lng tinh dch cho mi ln xut tinh thng
thng vo khong 3 - 4 ml (WHO: >2 ml).
- Trong giai on dy th ca VTN nam, tinh hon bt u pht trin, sn sinh ra tinh
trng v testosteron. Do c th ln nhanh v xut hin cc c tnh sinh dc th
pht nh c bp n nang, mc ru, ging ni m m, dng vt to ra Du hiu quan

| 359
trng nht trong thi k dy th ca nam VTN chnh l ln xut tinh u tin. Thng
thng tui xut tinh ln u tin VTN nam l khong 15 - 16 tui. Xut tinh ln
u tin c th xy ra trong khi thc, khi cc em c nhng kch thch, xung ng v
tnh dc (xem phim nh, nhn thy nhng hnh nh khu gi) hoc th dm (t kch
thch b phn sinh dc) hoc xy ra trong khi ng (thng c gi l mng tinh
hoc gic m t)
- Th dm: mt trong nhng hnh vi tnh dc c th xy ra nhiu la tui, c bit
thng gp tui VTN. Th dm l vic mt ngi t kch thch mnh t c
khai cm, thng l dng tay hoc dng c kch thch b phn sinh dc. Th dm
c th gp c nam v n. Th dm nam gii c th t ti cc khai v gy phn x
xut tinh. Th dm l mt cch t gii to nhu cu tnh dc ca bn thn v l mt
trong nhng cch thc hnh tnh dc an ton. Th dm khng phi l mt bnh v
khng c hi. Tuy nhin khng nn qu lm dng th dm, ng thi cng cn bit
cch gi v sinh v trnh cc nguy c b tn thng, xy xc b phn sinh dc khi th
dm bng dng c, khng s dng chung dng c th dm cho nhiu ngi.
- Mng tinh: hin tng xut tinh trong lc ng. C th nm m thy cnh quan h tnh
dc gia nam v n, m thy ang u ym mt c gi v b kch thch cao dn ti
xut tinh. Cng c trng hp khng phi do nm m m ch n thun l hin tng
cng cng dng vt trong khi ng, kt hp vi vic gii phng tinh dch cha trong
ng ng dn tinh. Cn gip cho VTN nam khng xu h, ngng ngng hay lo lng,
m cn hiu l biu hin ca s trng thnh v chc nng sinh sn v tnh dc.
- Xut tinh sm: thng thng th hin tng xut tinh VTN nam cn cha n nhv
kh xc nh c l xut tinh bnh thng, xut tinh sm hay xut tinh mun. Tuy
nhin trong mt s trng hp, nu sau mt vi nm k t ln xut tinh u tin, VTN
nam thy thng xuyn xy ra tnh trng va cm thy b kch thch (c th l va thy
cnh nam n u ym nhau, va bt u th dm) c phn x xut tinh, thm ch
mi ch vi giy dn ti xut tinh, th l biu hin ca chng xut tinh sm.
Nguyn nhn ca hin tng xut tinh sm a s u c lin quan n nhng yu t
tm l, mt vi trng hp khc l do d tt bm sinh (cu to ti tinh, ng phng
tinh bt thng), do hu qu ca nhng phu thut (trng hp phu thut vng hu
mn t khi cn nh nh d tt khng c hu mn), do nhim khun ng sinh dc,
c bit do vi khun lao, do s dng mt s thuc ko di (nh cc loi thuc an thn,
thuc chng trm cm).
- Di tinh: tnh trng tinh dch r ra khng kim sot c v khng lin quan n cc
khai hay phn x xut tinh. Nu xy ra thng xuyn c th do cc d tt ca h thng
sinh dc hay bnh l ca cc c tht
2.2. X tr.
- T vn.
Gii thch cho VTN hiu v c ch sinh l, gii phu.
Gii thch nhng vn thng gp lin quan n xut tinh.
Gip VTN hiu v c th v cc chc nng sinh dc, hiu v cc c im cu to
v hot ng ca h thng sinh dc.
Hng dn cc thc hnh tnh dc an ton v lnh mnh.
T vn v cc bt thng trong giai on dy th v cch x tr.
T vn, hng dn VTN v nhng hnh vi c li cho sc khe v tng cng th
lc, cc bi tp th lc

360 |
- Khm thc th, lm cc xt nghim cn lm sng v iu tr trong nhng trng hp
cn thit (i vi nhng trng hp c nhng bt thng v cu to nh tinh hon lc
ch, vim tc mo tinh hon, khi u)
- Phi hp vi gia nh theo di v h tr tip theo, c bit l h tr v tm l
gip nam VTN n nh v t tin vo bn thn.

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THM KHM SC KHE SINH SN
CHO V THNH NIN V THANH NIN

Tuyn p dng.
Tt c cc tuyn.
Ngi thc hin.

Thm khm cho VTN/TN nhm 2 mc ch: gii quyt c l do m VTN n c s
y t v sng lc nhm pht hin sm cc bnh l, cc vn bt thng, b lm dng hay
c cc hnh vi nguy c.
1. Cc l do khin VTN/TN ti c s y t.
1.1. VTN/TN n.
- Pht trin khc thng v th cht v kinh nguyt.
- C thai hoc nghi ng c thai.
- Ra kh h bt thng, cc vt lot, si
- NKSS.
- B bo hnh hoc lm dng tnh dc.
- Mun c hng dn phng trnh thai v phng trnh NKLTQTD.
1.2. V thnh nin nam.
- Pht trin khc thng v th cht.
- Th dm.
- Mng tinh, di tinh, xut tinh sm.
- Tit dch niu o.
- NKLTQTD.
- Mun c hng dn phng trnh thai v phng trnh NKLTQTD.
- a bn tnh n ph thai/t vn khi mang thai ngoi mun.
1.3. Mt s vn c bn cn sng lc.
- Pht trin tm sinh l c ph hp vi la tui khng?
- Hnh vi tnh dc c an ton khng?
- C lm dng cc cht gy nghin khng ?
- C b lm dng v th cht v tnh dc khng ?.
- Tnh trng dinh dng, th lc, bnh l (nh lao phi)
2. Hi.
Da vo l do n khm ca VTN/TN m la chn nhng cu hi ph hp:
- VTN/TN n: tin s kinh nguyt (kinh nguyt ln u, chu k kinh, tnh cht kinh
nguyt v du hiu bt thng), tin s sn khoa ( sinh , c thai hoc i ph
thai), tin s ph khoa (kh h, tnh cht kh h, bnh l ph khoa).

362 |
- VTN/TN nam: xut tinh (xut tinh ln u, tnh cht cc ln xut tinh) v nhng thay
i sinh l c th.
- Nhng biu hin lin quan n hi chng NKSS.
- Tin s tnh dc v hn nhn: quan h tnh dc, s bn tnh, bin php trnh thai, tnh
trng hn nhn, xm hi tnh dc, kin thc, thi v hnh vi tnh dc.
- Tin s tm l - gia nh - x hi: thng tin v ni , gia nh v nh trng, s dng
cht gy nghin, trm cm hoc stress, bo hnh trong gia nh, tin s sc khe ca
gia nh (cha, m, anh, ch, em), quan h bn b.
3. Cc bin php lm gim cng thng khi khm thc th cho VTN.
- Gii thch ti sao vic khm thc th li cn thit.
- Gii thch nhng vic cn lm trc mi bc khm.
- m bo s kn o khi khm thc th. Cho php VTN/TN gi li qun o tr nhng
phn bt buc phi ci, che ph cc b phn c th b bc l. Khng h cc b phn
khng khm.
- Lm yn lng VTN/TN rng cc kt qu khm s c gi b mt.
- Duy tr vic giao tip gia ngi cung cp dch v v VTN/TN to dng nim tin.
Gim cng thng v lo s ca VTN/TN khi nhn thy cc dng c y t hoc nghe thy
cc ting ng gy ra do dng c bng cch gii thch v cc dng c, che ph cc
dng c y t mt cch ti a, nh nhng trong thao tc
- Lun ng vin, an i VTN/TN trong sut thi gian khm.
- Khi cn thit, cn c s ng ca cha m VTN/TN trc khi thm khm. Cn nhc
s c mt ca cha m VTN/TN trong khi thm khm v cn c kin ca VTN/TN.
- Nu c th, hy phn cng ngi khm cng gii vi VTN/TN hoc m bo c mt
ngi cng gii cng phng lc tin hnh khm, c bit nu ngi cung cp dch v
l nam gii khm cho VTN/TN n.
4. Khm thc th v thnh nin n.
4.1. Trnh t khm.
- Quan st ton thn, o chiu cao, cn nng nh gi s pht trin c th ph hp la
tui.
- Khm v (khi cn thit), quan st b phn sinh dc ngoi: m h, mi ln, mi b,
mng trinh, tnh cht kh h
- Thm khm m o ch thc hin khi c yu cu chn on v phi c s ng ca
VTN. Nu c ngi nh i cng phi c ngi nh chp thun. Nu khng ng ,
cn gii thch l do v gi c th thay bng thm trc trng.
- Nu nghi c thai, nghi ng c NKLTQTD, mng trinh khng cn nguyn vn v
c s ng ca VTN, dng m vt c nh quan st m o, c t cung v khm
m o.
4.2. Cn lm sng.
- Nghi c thai: th HCG nc tiu hoc siu m.
- Kh h: soi ti, nhum Gram.
- Thiu mu: nh lng huyt sc t.

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4.3. X tr.
- T vn, gii thch cho VTN tnh trng sc khe hin ti, cch iu tr v d phng.
- Nu c ri lon kinh nguyt, au bng kinh: xem bi "Kinh nguyt v thnh nin".
- Nu c thai: xem bi "Mang thai VTN/TN"
- Nu c tit dch, cc vt lot, si sinh dc: xem phn IV NKSS v cc bnh LTQTD.
5. Thm khm v thnh nin nam.
5.1. Trnh t khm.
- Quan st ton thn, o chiu cao, cn nng nh gi s pht trin c th ph hp la
tui.
- Thm khm b phn sinh dc ch thc hin khi c yu cu chn on v phi c s
ng ca v thnh nin.
- Khm b phn sinh dc: tinh hon, dng vt, lng mu v khm hu mn khi cn thit.
5.2. Cn lm sng.
- Xt nghim cht tit niu o v cc xt nghim khc (nu cn).
5.3. X tr.
- T vn, gii thch cho v thnh nin tnh trng sc khe hin ti ca h, cch iu tr v
d phng.
- Tit dch niu o, cc vt lot, si sinh dc: xem phn IV NKSS v cc bnh
LTQTD.
- iu tr nhim khun khi b vim bao qui u.
- Cc bt thng khc: chuyn tuyn hoc chuyn chuyn khoa thch hp.

364 |
CC BIN PHP TRNH THAI CHO V THNH NIN V
THANH NIN

Tuyn p dng.
Mi c s y t c cung cp dch v KHHG i vi cc bin php: king giao hp,
bao cao su, vin thuc trnh thai kt hp, vin thuc trnh thai ch c progestin, thuc
trnh thai khn cp, BPTT t nhin
C s y t c cung cp dch v KHHG t tuyn huyn tr ln i vi dch v dch v
t dng c t cung, thuc tim trnh thai v thuc cy trnh thai
Ngi thc hin.
Cn b cung cp dch v c o to v cc bin php trnh thai v dch v sc
khe thn thin vi VTN/TN

Hu ht cc bin php trnh thai (BPTT) u c th s dng an ton v hiu qu i
vi VTN/TN. Tuy nhin hiu qu s dng cc BPTT thng thp hn so vi ngi trng
thnh bi v VTN/TN thng hay qun, hay giu dim s ngi khc bit, thng khng
ch ng khi s dng BPTT, lo ngi v cc tc dng ph ca BPTT

1. Mt s im cn lu khi cung cp bin php trnh thai cho VTN/TN.
- Khi cung cp mt BPTT cho VTN/TN, cn cung cp thng tin v mt BPTT d phng
khc.
- Nhng tc dng ph ca cc BPTT i vi VTN/TN cn c t vn k hn.
- VTN/TN thng hay qun, khng ung thuc u n, v th cn hng dn cch thc
ung thuc khi qun.
- VTN/TN thng ngi s dng BPTT v c nim tin sai lm rng h khng th mang
thai trong ln quan h u tin.
- VTN/TN thng hiu lm v nh hng ca cc BPTT n sc khe.
- VTN/TN thng kh hoc ngi tho lun vi bn tnh v vic s dng BPTT, do vy
cn h tr h c nhng k nng sng nh k nngthng thuyt vi bn tnh la
chn v s dung BPTT ph hp v hiu qu.
2. Cc bin php trnh thai cho VTN/TN.
2.1. King giao hp (tnh dc khng xm nhp)
L thc hin cc hnh vi tnh dc m khng c s tip xc gia dng vt v m o.
Nu ch c s va chm bn ngoi gia dng vt v m h thng s khng c thai, nhng
vn c nguy c mc mt s NKLTQTD bao gm c HIV.
2.2. Bao cao su trnh thai.
- L bin php thch hp vi VTN/TN v va trnh thai an ton, hiu qu va phng
NKLTQTD . C hai loi bao cao su trnh thai dnh cho nam v n.
- VTN/TN thng s b ngi khc pht hin, VTN/TN n thng kh ch ng thuyt
phc ban tnh s dng BCS.
- Tham kho bi Bao cao su trnh thai, phn KHHG.

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2.3. Vin thuc ung trnh thai kt hp.
- L bin php trnh thai ph hp vi VTN/TN c quan h tnh dc nhng khng c
nguy c mc NKLTQTD.
- Hiu qu cao nu s dng ng, gip kinh nguyt u v gim au bng kinh, gim
mn trng c l nhng biu hin thng gp tui VTN/TN.
- Do phi ung thuc hng ngy, VTN/TN thng ngi v gia nh c th nhn thy v
thuc. Tham kho bi Vin thuc ung trnh thai kt hp, phn KHHG
2.4. Vin thuc ung trnh thai ch c progestin.
- S dng cho VTN/TN c con v ang cho con b hoc c chng ch nh s dng
thuc c estrogen.
- Tham kho bi Vin thuc ung thuc trnh thai ch c progestin, phn KHHG.
2.5. Thuc trnh thai khn cp.
- L thuc s dng sau ln quan h tnh dc khng c bo v trong vng 5 ngy, tt
nht l trong vng 72 gi (3 ngy), cng ung sm hiu qu cng cao.
- Rt ph hp cho VTN/TN c quan h tnh dc khng c bo v, l BPTT duy nht
c th s dung sau khi c quan h tnh dc.
- Tham kho bi Bin php trnh thai khn cp, phn KHHG.
2.6. Dng c trnh thai trong t cung.
- L bin php trnh thai s dng cho VTN/TN sinh con v c nhu cu trnh thai lu
di. Khng nn p dng cho VNT c nhiu bn tnh, VTN/TN c nguy c cao trong
vic mc cc bnh ly truyn qua ng tnh dc.
- Cn thc hin c s y t, ch s dng c cho VTN/TN sinh con.
- Tham kho bi Dng c trnh thai trong t cung, phn KHHG.
2.7. Thuc tim v thuc cy trnh thai.
- p dng cho VTN/TN c nhu cu trnh thai thng xuyn v lu di.
- Tham kho bi Thuc tim v thuc cy trnh thai, phn KHHG.
2.8. Bin php trnh thai t nhin (tnh vng kinh, xut tinh ngoi m o).
- Hiu qu thng khng cao, c bit la tui VTN/TN (bi v kinh nguyt ca
VTN/TN thng khng u, quan h tnh dc kh ch ng).
- Khng phng trnh c NKLTQTD.
- Tham kho bi Cc bin php trnh thai t nhin, phn KHHG.

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MANG THAI V THNH NIN
Tuyn p dng.
Tuyn huyn tr ln.
Ngi thc hin.
Bc s, n h sinh, y s sn nhi c o to v lm m an ton v ph thai an ton.

a s cc trng hp mang thai VTN l ngoi mun. V khng mong i nn vic
mang thai gy rt nhiu nh hng v xo trn ti cuc sng v sc khe ca VTN. Vic
quyt nh tip tc gi hay chm dt mang thai l mt quyt nh kh khn i vi v
thnh nin. Cn b y t cn h tr VTN cn nhc cn thn cc nguy c v sc khe, tm l
v cc yu t kinh t - x hi.

1. Cc yu t dn n mang thai VTN.
- S thiu hiu bit v chu k kinh nguyt, c ch th thai, cc bin php trnh thai
- Thiu tip cn vi cc dch v chm sc SKSS.
- Quan h tnh dc khng chun b, khng mong mun.
- Quan h tnh dc trc hn nhn, sng th trc hn nhn ngy cng tng.
2. Nhng nguy c c th gp khi mang thai tui VTN.
2.1. Nguy c khi tip tc gi thai v sinh .
- Mang thai tui VTN nh hng khng tt n sc khe, nguy c t vong m vn cn
cao so vi cc b m sinh con tui trng thnh. M d b thiu mu, tin sn git,
non, sy thai, chuyn d nh tr, bt tng xng thai khung chu. Trong lc sinh:
kh, d phi can thip bng cc th thut v phu thut (forceps, gic ko).
- T l t vong tr em sinh ra do cc b m VTN trong nm u cao hn so vi cc b
m sinh con tui trng thnh. Con ca cc b m v thnh nin thng c t l nh
cn, bnh tt v t vong cao gp nhiu ln so vi con ca cc b m tui trng thnh.
- V mt kinh t - x hi: khi c thai VTN phi gin on vic hc hnh, kh khn v
kinh t v khng kim c vic lm, dn VTN vo con ng b tc. Hnh phc gia
nh c th b rn nt, d lm vo cnh o le, nh hng n tng lai ca VTN. T l
ly d cao, d b phn bit i x. Lm m sm d b cng thng v khng hong tm l.
2.2. Nguy c khi ph thai tui VTN.
- Do mc cm, xu h nn VTN thng tm kim dch v ph thai khng an ton.
- VTN thng khng bit cc du hiu nhn bit thai nghn, nn khng tm n c s
y t sm dn n ph thai to.
- Do c th cha pht trin hon chnh, tm l li lo s nn th thut ph thai VTN
thng xy ra nhiu tai bin hn ngi trng thnh.
- Nhng nh hng tm l sau ph thai tui VTN c th rt nng n v ko di.

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3. Chn on thai v thnh nin.
3.1. Hi.
- C quan h tnh dc.
- Chm kinh, cc triu chng mang thai.
3.2. Triu chng lm sng.
- Khm v: cng, qung v sm mu, c ht nu.
- Khm m o: c t cung mm, tm; t cung to, mm.
3.3. Xt nghim.
- Th hCG nc tiu hoc siu m.
3.4. Chn on xc nh.
- Da vo hCG (+) hoc siu m c thai kt hp vi cc triu chng lm sng.
4. T vn v mang thai v thnh nin.
CBYT cn cung cp thng tin v nhng nguy c khi tip tc mang thai, sinh hoc
ph thai gip VTN t quyt nh tip tc gi thai hay chm dt thai nghn.
4.1. T vn i vi VTN quyt nh chm dt thai k.
4.1.1. T vn trc ph thai.
- Bo m dnh thi gian t vn v gii thch nhng thc mc ca VTN.
- Gii thch v thnh nin yn tm, gim lo lng cng thng.
- Gii thch qu trnh thc hin ph thai an ton.
- H tr k nng sng cho VTN, gip cc em i mt vi vn ca mnh v la chn
gii php ph hp. Nu v thnh nin cha quyt nh c, cho thm thi gian suy
ngh. Khuyn khch cc em ni chuyn vi ngi nh hoc ngi tin cy.
- Chuyn v thnh nin n c s ph thai an ton ph hp, nu dch v khng sn c.
- Trong trng hp VTN thay i quyt nh, chuyn ti cc dch v chm sc thai
nghn.
4.1.2. T vn sau ph thai.
- Hng dn v cc bin php trnh thai ngay sau ph thai.
- Cung cp bao cao su v t vn v BPTT khn cp.
- H tr v khuyn khch cc em trao i vi bn tnh v hnh vi tnh dc, v cc nguy
c v cc bin php bo v.
- phng suy sp tinh thn hoc khng hong tm l.
4.2. T vn vi VTN tip tc mang thai v sinh .
- Hng dn VTN n cc c s y t c qun l thai.
- Thai nghn VTN thng c nhiu nguy c hn ngi trng thnh, c bit khi di
16 tui. Do cn hng dn cc cch pht hin sm du hiu bt thng cng nh
phng nga nguy c c th xy ra.
- CBYT cn t vn v ch dinh dng hp l cho VTN.
- Cc im cn lu khi t vn trc sinh:
VTN mang thai v bn tnh cn phi c t vn s dng bao cao su phng
NKLTQTD.

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Cn b y t c th gip VTN xy dng k hoch sinh , xc nh ngi h tr th
cht v tinh thn trong cuc . Cn t chc v khuyn khch VTN, ngi h tr
tham gia cc lp chm sc sc khe khi mang thai.
- Cc im cn lu khi t vn trong sinh:
Khng bao gi VTN mt mnh. Gii thch nhng g ang v s xy ra gip
gim cng thng, gim au v tng kh nng chu ng. Qu trnh chuyn d nn
c mt ca ngi thn trong gia nh hoc ngi h tr cuc m VTN la
chn tham gia chm sc v h tr tinh thn cho VTN.
Khi h tr VTN trong qu trnh sinh , cn b y t cn c thi kin nhn, hiu
bit, c gii thch, thng yu v chm sc. Cn p ng cc nhu cu c bit v c
th khc nhau ca mi VTN nhm h tr chu ng v vt qua qu trnh chuyn
d.
Trong giai on chuyn d tch cc, khng VTN mt mnh. Cc cn co mnh v
nhanh c th lm cho VTN hong s. Chuyn tr vi VTN trong khi sinh lm
gim thiu s cng thng, s hi v hp tc tt hn.
- Cc im cn lu trong t vn sau sinh:
Cc b m VTN gp phi mt mu thun va l VTN va phi iu chnh vai tr
lm m. Cn b y t phi tn dng mi c hi hng dn v h tr ton b tin
trnh gn b tnh cm gia b m VTN v em b.
Nhng bun chn, trm cm thng xut hin nhiu b m sau sinh cng tr nn
nng n hn i vi VTN. Cn b y t cn tip tc theo di v c k hoch thm b
m VTN ti nh.

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V THNH NIN V THANH NIN
VI VN BO HNH
Tuyn p dng.
Tt c cc tuyn.
Ngi thc hin.

VTN/TN c th n khm ti c s y t vi l do b bo hnh hoc do hu qu ca bo
hnh. Trong trng hp pht hin c vn bo hnh, cn b y t cn cung cp cho
VTN/TN cc thng tin cn thit v dch v x hi v c quan php lut lin quan c xem
xt n mc nghim trng ca bo hnh v mong mun gii quyt ca VTN/TN b bo
hnh.
1. Cc hnh thi ca bo hnh i vi VTN/TN.
C th gp cc hnh thi khc nhau ca bo hnh nh: bo hnh v th cht, tinh thn
v tnh dc. Bn thn VTN/TN c th l nn nhn ca bo hnh v cng c th l ngi
gy ra bo hnh.
Bo hnh v th cht bao gm nhng hnh thc hnh h thn th nh nh, tt, bt tai,
bt nhn n, bt nht Bo hnh v tinh thn bao gm nhng hnh thc hnh h, uy hip
v mt tinh thn nh chi mng, lng m, lm mt th din trc mt ngi khc, xao lng
b mc, b ri, khng cng nhn Bo hnh tnh dc gm c hnh vi quy ri, lm dng,
cng p thc hin bt k hnh vi tnh dc no lm tn hi n th cht, tinh thn nh hip
dm, quy ri, s m, s dng li ni tc tu, bt buc chp hnh kho thn, bun bn tnh
dc
2. Nguyn nhn ca bo hnh.
- S thay i v tm sinh l tui VTN/TN nu khng c hng dn, h tr kp thi
c th dn n hnh vi lin quan n b bo hnh hoc i bo hnh ngi khc.
- nh hng ca thng tin khng lnh mnh.
- Hu qu ca bo hnh gia nh.
- Lm dng cc cht gy nghin.
- Phn ng tiu cc trc nhng iu xy ra trong cuc sng.
- chng t mnh vi bn b, ua i
- Bn dm/bun bn tnh dc kim tin.
3. Hu qu ca bo hnh.
- C th dn n thng tch, tn tt, t vong.
- Cc tn thng v tm l: ri lon hnh vi, trm cm, lo u, mt ng, t t...
- Ri lon chc nng tnh dc: lnh cm...
- B hc, b vic, xa lnh mi ngi.
- Tm l tr th, bt cn c th khin VTN/TN b xm hi li tr thnh k i xm hi
- Hu qu v SKSS: c thai ngoi mun, NKLTQTD/HIV/AIDS

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4. Nhng iu kin khin VTN/TN d c nguy c b bo hnh.
- Hon cnh kinh t qu kh khn.
- Sng trong gia nh c nhng yu t nh: s dng ma ty, t nn x hi (mua bn dm,
kim tin bt hp php), gia nh thng xuyn bt ha
- VTN/TN lang thang, sng xa gia nh, b b ri, m ci.
- VTN/TN b tn tt, tm thn.
- VTN/TN sng trong t, trng gio dng.
- VTN/TN ng tnh luyn i (do b k th, do mc cm).
5. Cc du hiu gip pht hin bo hnh tnh dc.
5.1. Cc du hiu thc th.
- Cc vt thm tm, chy mu, sng au, c bit c lin quan n b phn sinh dc.
- i li, ngi ng kh khn, qun o rch, bn, c dnh mu.
- Ra mu, dch m o hoc dng vt.
- au bng, au vng h v.
- Nhim khun tit niu ti din, c th i tiu tin khng t ch.
- C cc du hiu nhim bnh LTQTD: tit dch m o, tit dch niu o, vt lot,
si
- C thai.
5.2. Cc du hiu hnh vi v tinh thn.
- Ri lon tinh thn, cm gic t ti.
- Lo lng, s st, xa lnh, trn chy
- Trm cm, mc cm ti li, h thn, c biu hin da t t, t t.
- Mt ng, khng n, n khng ngon.
- Lm dng cht gy nghin.
- Ri lon v tnh dc, s hi, gh tm hnh vi tnh dc, khng c kh nng phn bit
gia cc hnh vi tnh cm v tnh dc.
- C hot ng tnh dc sm.
- C th c hnh vi xm hi, lm dng ngi khc.
6. Nhng vic ngi cung cp dch v c th lm.
6.1. i vi nhng trng hp VTN/TN b bo hnh.
- Nhn bit c bo hnh xy ra vi khch hng VTN/TN.
- Cung cp thng tin v xm hi bo hnh nhng ni c khch hng (tranh nh, t ri,
p phch phng i, t vn).
- By t thi thng cm, tn trng v ng vin.
- Hi tin s v thm khm k nh gi nguy c NKLTQTD, nguy c mang thai v
cc tn thng khc.
- iu tr hoc chuyn tuyn khi cn (bao gm c vic s dng thuc trnh thai khn cp
nu VTN/TN n b cng hip trong vng 120 gi, chuyn VTN/TN ti cc c s
chuyn khoa c t vn, xt nghim v h tr iu tr NKLTQTD/HIV).
- T vn cho VTN/TN nhng ni dung lin quan n bo hnh, h tr tm l cho h.
- m bo b mt v ring t i vi nhng thng tin ca nn nhn.

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- H tr VTN/TN tm ngi gip , tm ni an ton, tm n cc dch v x hi tr
gip.
- Ghi chp tht y , lu h s theo ng qui nh php l.
6.2. D phng v gim thiu hu qu ca bo hnh.
- Tham gia cc hot ng gio dc v d phng bo hnh ti cng ng, trng hc.
- Cung cp cc thng tin v bo hnh cho cc khch hng, c bit ch trng khch hng
VTN/TN, ngay c khi h n c s y t khng phi v vn bo hnh.
- Pht hin v ngn nga nhng du hiu, nhng biu hin c th dn ti bo hnh.
- H tr v t vn VTN/TN b xm hi gip h vt qua stress, ly li s cn bng
tm l, trnh c cm gic mun tr th, bung tri.
- m bo quyn ca VTN/TN, nhn mnh quyn bo v trnh mi hnh thc bo hnh.

372 |
DCH V SC KHE THN THIN VI V THNH NIN
V THANH NIN
Tuyn p dng.
Tt c cc tuyn.
Ngi thc hin.

VTN/TN cn mt dch v thn thin ph hp v d dng chp nhn. Cc c im
quan trng nht ca dch v sc khe thn thin vi VTN/TN gm tnh ring t, bo mt,
d tip cn, thi phc v ca cn b y t, chi ph v cc th tc hnh chnh, ph hp vi
php lut, p ng c nhu cu - mong mun ca VTN/TN. Trong trng hp thc hin
th thut, phu thut (bao gm ph thai ni khoa) i vi VTN di 18 tui, phi c n
cam kt ca b hoc m hoc ngi gim h.
1. Khi nim dch v sc khe thn thin vi VTN/TN.
C nhiu nh ngha v dch v sc khe thn thin vi VTN/TN, tuy vy v khi nim
th tng i thng nht.
Theo T chc Y t th gii, cc dch v sc khe thn thin vi VTN/TN l cc dch
v c th tip cn c v ph hp vi VTN/TN. Dch v sc khe thn thin vi
VTN/TN cn m bo cc tiu chun nh a im, gi c ph hp (c th chi tr c
hoc min ph nu cn thit), an ton, phc v theo phng cch m VTN/TN chp nhn
c nhm p ng nhu cu ca VTN/TN v khuyn khch cc em tr li c s y t khi
cn cng nh gii thiu v dch v ti bn b.
2. L do cn trin khai dch v sc khe thn thin vi VTN/TN.
- VTN/TN l nhm chim u th v s lng trong c cu dn s, l nhng ch nhn
hin ti v tng lai ca t nc. u t cho VTN/TN l u t cho tng lai.
- Vic chm sc sc khe VTN/TN s gp phn gim bnh tt v t l t vong hin ti
v tng lai, gim gnh nng bnh tt v cc chi ph y t, chi ph x hi.
- Khi cc dch v chm sc sc khe cha sn c hoc kh tip cn c VTN/TN th
chng ta l hng lot cc c hi ngn nga cc hnh vi c hi cho sc khe,
pht hin, x tr kp thi nhng hnh vi v hu qu ca nhng hnh vi ny.
3. Cc iu kin cn c ca mt dch v sc khe thn thin vi VTN/TN.
- C kh nng tip cn d dng.
- H thng cc dch v c bn, c cht lng, bn vng v lin tc
- m bo tnh ring t v tin cy.
- Cn b cung cp dch v c thi tch cc, ng h v c o to, bit cch lm
vic vi VTN/TN.
- C s tham gia ca VTN/TN trong thit k chng trnh v phn hi thng xuyn.
- C chnh sch qung b v thu ph ph hp.
- C h thng gim st nh gi thng xuyn v hiu qu

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4. Cc c im c bn ca cc dch v sc khe thn thin vi VTN/TN gm.
4.1. V c s.
- V tr thun tin i vi VTN.
- C s , bin ch dn r rng.
- Dnh din tch v m bo tnh ring t kn o.
- Gi m ca thun tin vi VTN/TN.
- Mi trng thoi mi v an ton vi VTN/TN: bi tr nh nhng v ph hp s thch
ca VTN/TN, cnh quan xung quanh khu vc dch v
4.2. V ngi cung cp dch v.
- C thi tch cc v ng h VTN/TN.
- C thi tn trng v ng cm vi VTN/TN.
- c o to chuyn bit lm vic vi VTN/TN.
- m bo tnh ring t, bo mt khi tip xc v cung cp dch v cho VTN/TN.
- c b tr v sp xp thi gian tip xc vi khch hng.
- C s cam kt cao.
- C s tham gia ca cc t vn vin ng ng (nu c th c).
4.3. V t chc cung cp dch v.
n tip v cung cp dch v:
- Gim thi gian ch i.
- Ph dch v hp l.
- C y v ng b cc dch v.
- Sn sng n tip c n v nam VTN/TN.
- Tr hon thm khm tiu khung, b phn sinh dc n khi chun b tt tm l.
- Ch trng c bit ti t vn.
- Ch trng yu t gii v bnh ng gii.
Truyn thng v qung b.
- Sn c cc ti liu c thit k ph hp vi cc nhu cu cng nh s thch ca
VTN/TN v h c th ly mang v mt cch thun tin, d dng.
- Ph bin rng ri cc c s dch v chm sc SKSS/SKTD, cc c s cung cp dch v
khm v iu tr NKLTQTD/HIV cho VTN/TN v to nim tin cho h.
Qui nh, chnh sch.
- C qui nh ring nhm phi hp cc b phn trong cng mt c s cung cp dch v
theo chui dch v to iu kin cho VTN/TN c th s dng c ti a cc dch
v.
- C cc chng trnh vn ng cng ng nhm to mi trng chnh sch v x hi
ng h cho vic chm sc SKSS/SKTD ca VTN/TN.
- C c ch lin kt v chuyn tuyn gia cc c s cung cp dch v khc nhau trong
cng mt phm vi a bn hoc cc lnh vc can thip cn thit.
- Khuyn khch s tham gia ca VTN/TN trong qu trnh thng tin, qung b, t vn v
thit k, nh gi gim st chng trnh.

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- Khuyn khch cc loi hnh hot ng khc nhau ngay ti c s cung cp dch v v ti
cng ng nh cc hot ng tho lun nhm, sinh hot cu lc b, ni chuyn chuyn

5. Cc loi dch v chm sc SKSS/SKTD thn thin vi VTN/TN.
5.1. Thng tin v t vn v SKSS v gii tnh, v k nng sng, tnh dc, tnh dc an ton,
t vn v bo hnh v xm hi tnh dc.
5.2. Cc dch v lm sng.
- Khm chm sc ng sinh sn.
- Chm sc trc, trong v sau sinh.
- Ph thai an ton v chm sc sau ph thai.
- Qun l v iu tr cc trng hp NKSS.
- Qun l v ngn nga HIV ly truyn t m sang con.
- Cung cp cc bin php trnh thai.
- Thm khm v iu tr cc vn lin quan n bo hnh v xm hi tnh dc.
5.3. Cc dch v cn lm sng: xt nghim thai, xt nghim cc bnh LTQTD, HIV, cc
xt nghim v siu m, thm d chc nng cn thit trong lnh vc SKSS/SKTD ty theo
tng c s.
5.4. Cc dch v chuyn tuyn v h tr chuyn tuyn: bao gm c cc c s truyn
thng, t vn v cung cp dch v trong cc lnh vc c lin quan nh:
- Cc c s chm sc SKSS/SKTD.
- Cc c s lm vic v HIV/AIDS: t vn, xt nghim, phng nga ly nhim HIV v
chm sc ngi c HIV, iu tr
- Cc c s t vn v iu tr cc NKSS.
- Cc c s lm vic vi nn nhn b bo hnh hoc lm dng tnh dc.
- Cc c s t vn v iu tr nhng vn v tm l, tm thn.
- Cc c s cung cp thng tin, t vn v cc dch v h tr VTN/TN trong cc lnh vc
khc nh: php lut, gii thiu vic lm, hn nhn v gia nh
6. Cc bc cn tin hnh trong qu trnh xy dng k hoch v trin khai
cung cp cc dch v sc khe thn thin vi VTN/TN.
6.1. nh gi thc trng.
- nh gi nhu cu thc t ca VTN/TN v dch v SKSS/SKTD.
- nh gi kh nng thc t ca c s d kin trin khai: v nhn lc, c s vt cht,
trang thit b, nh gi v chnh sch hin hnh c lin quan n SKSS/SKTD ca
VTN/TN.
6.2. Lp k hoch c th cho cc hot ng chun b v trin khai da trn nh gi
nhu cu thc t.
- D kin phn cng nhn s, o to.
- D tr ngn sch, cc ngun lc cn thit trin khai.
- Lp k hoch chi tit v cc hot ng cn tin hnh, ngi chu trch nhim thc hin,
thi gian, kt qu mong i v cc ch s c th
- Ln cc k hoch gim st nh gi nh k v t xut, k hoch ly kin phn hi
t VTN/TN.

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6.3. Trin khai cc hot ng chnh.
- Cc hot ng xy dng v ci to li c s vt cht, trang thit b
- Chun b v o to nhn s.
- Thng nht cc qui trnh dch v, cc th tc
- Thit lp h thng chuyn tuyn (c cung cp dch v thn thin vi VTN).
- Chun b v in n cc ti liu truyn thng gio dc.
- Cc cuc hp, hi ngh hi tho gii thiu chng trnh.
- T chc v trin khai cc hot ng tip cn, gio dc v qung b cho VTN/TN.
- Khai trng khu vc cung cp cc dch v sc khe thn thin vi VTN/TN (c th
thc hin vi nhng c s mi hoc c s no c iu kin v thy cn thit).
- Trin khai cung cp dch v thn thin VTN/TN ti c s v duy tr thng xuyn.
- Ly kin phn hi thng xuyn t khch hng VTN/TN, thu thp thng tin t
VTN/TN khng tip cn dch v tm hiu l do.
- Cc hot ng gim st v nh gi.
- Cc hot ng tham quan hc tp, trao i v chia s kinh nghim.

376 |
377 |

PHN 7
PH THAI AN TON

378 |

| 379
HNG DN CHUNG
Ph thai l ch ng s dng cc phng php khc nhau chm dt thai trong t
cung cho thai n ht 22 tun tui.

Phn ny bao gm:
- T vn v ph thai.
- Ph thai bng phng php ht chn khng (ph thai t tun th 6 n ht tun 12).
- Ph thai bng thuc n ht tun th 9 (mifepriston v misoprostol).
- Ph thai bng thuc t tun 13 n ht tun 22.
- Ph thai bng phng php nong v gp t tun 13 n ht tun 18.
- Qui trnh x l bm ht thai chn khng bng tay.

Mt s khi nim:
Ph thai bng phng php ngoi khoa.
S dng cc th thut qua c t cung chm dt thai k, bao gm ht chn khng,
nong v gp.
Ph thai bng thuc.
S dng thuc gy sy thai. i khi thut ng ph thai ni khoa cng c s
dng m t th thut ny.
Tui thai.
S ngy hoc s tun tnh t ngy u tin ca k kinh cui cng n khi nh ch thai
nghn (chu k kinh bnh thng).

Cc phng php ph thai n ht tun 12.
Phng php ngoi khoa: phng php c khuyn khch l ht chn khng.
Phng php ni khoa: Cc phng php dng thuc kt hp gia mifepriston v
misoprostol cho cc thai n ht 9 tun (63 ngy) (gii hn ny thay i ty theo
tuyn). Khi p dng phng php ph thai bng thuc cn phi c sn dch v ph
thai bng phng php ht chn khng x tr nhng trng hp tht bi.
Phng php nong v no cn c thay th bng phng php ht chn
khng.

Cc phng php ph thai t tun 13 n ht tun 22.
Ph thai bng thuc dng misoprostol n thun hay dng kt hp gia
mifepriston v misoprostol c p dng cho thai t tun 13 n ht tun 22.
Phng php nong v gp s dng bm ht chn khng v kp gp thai sau khi c
t cung c chun b bng misoprostol c p dng cho thai t tun 13 n
ht tun 18.

380 |
T VN V PH THAI

Tuyn p dng.
Tt c cc tuyn.
Ngi thc hin.
Bc s, n h sinh, y s sn nhi c o to v ph thai

T vn cho khch hng ph thai l gip khch hng t quyt nh vic ph thai v cng
cn b y t la chn phng php ph thai ph hp trn c s nm c cc thng tin v
cc phng php ph thai, qui trnh ph thai, cc tai bin, nguy c c th gp, cch t chm
sc sau th thut v cc BPTT ph hp p dng ngay sau th thut ph thai.
1. Yu cu vi cn b t vn.
1.1. V kin thc.
- Nhn thc c nhu cu v quyn ca khch hng.
- Chnh sch, php lut ca nh nc v SKSS v cc chun mc x hi.
- Nm c 6 bc thc hnh t vn.
- Kin thc chung v cc phng php ph thai: ch nh, chng ch nh, qui trnh, tai
bin v cch chm sc sau ph thai.
- Kin thc chung v cc bin php trnh thai v cc bnh ly truyn qua ng tnh
dc.
- Nhng qui nh v chuyn tuyn ph hp vi k thut ph thai c php thc hin.
1.2. V k nng t vn.
- K nng tip n.
- K nng lng nghe.
- K nng giao tip.
- K nng gii quyt vn .
2. a im t vn.
Nn c phng t vn ring, tuy nhin c th t vn bt c a im no, cn m bo:
- Ring t, kn o.
- Thoi mi.
- Yn tnh.
- Khng b gin on hoc b lm n bi cuc ni chuyn khc.
3. Qui trnh t vn.
- T vn thm khm:
Gii thch v qu trnh v mc ch thm khm.
Cc xt nghim cn lm, cc th tc hnh chnh.
Hi tin s sn ph khoa.
Hi v bo hnh.
Hi v cc bnh ly truyn qua ng tnh dc.
- T vn v quyt nh ph thai: a ra 2 la chn cho khch hng.
Tip tc mang thai v sinh con.
Ph thai.

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- Nu quyt nh cui cng l ph thai, t vn v cc phng php ph thai sn c ti c
s, gip khch hng t la chn phng php thch hp v thc hin cc th tc hnh
chnh cn thit.
- Lu vi khch hng ph thai ba thng gia.
t cu hi pht hin nhng trng hp ph thai la chn gii tnh.
Nu pht hin ph thai v la chn gii tnh, t vn cho khch hng v gia nh h
hiu rng y l iu lut php cm h thay i quyt nh.
Khng cung cp dch v ph thai nu bit chc chn ph thai v mc ch la chn
gii tnh.
3.1. T vn ph thai bng th thut.
- T vn v qu trnh th thut:
Thi gian cn thit.
Phng php gim au.
Cm gic au m khch hng phi tri qua.
Cc bc th thut.
Gii thiu ngi thc hin th thut.
Thng tin v tc dng ph v tai bin c th gp.
K cam kt t nguyn ph thai.
- T vn v cc bin php trnh thai sau th thut:
Kh nng c thai li sm, cho nn vic bt u p dng mt bin php trnh thai
ngay sau th thut l cn thit.
Gii thiu cc bin php trnh thai, gip khch hng la chn bin php trnh thai
ph hp v hng dn khch hng s dng ng.
Gii thiu cc a im c th cung cp cc bin php trnh thai.
- T vn v chm sc v theo di sau th thut:
Dng thuc theo ch nh ca bc s.
King giao hp cho ti khi ht ra mu (thng thng sau 1 tun).
T vn cch t chm sc sau th thut v ch v sinh, dinh dng v ch
sinh hot.
T theo di cc du hiu bnh thng.
Cc du hiu bt thng phi khm li ngay.
Tip tc t vn nhc li cc bin php trnh thai.
Hn khm li.
- Thi im t vn: t vn c th c tin hnh trong c 3 giai on trc, trong v sau
th thut, nhng hiu qu nht nn tin hnh vo giai on trc v sau th thut
Trc th thut: gm c 3 ni dung nu trn.
Trong th thut:
Trao i, ng vin, tng cng s hp tc trong th thut.
Nhc li mt s ni dung lin quan ti qui trnh th thut.
Sau th thut:
Nhn mnh li qu trnh t theo di chm sc sau th thut.
Nhc li cc bin php trnh thai khch chp nhn, hoc trao i vi khch
hng la chn bin php trnh thai ph hp hn.
Nhng trng hp cn c iu tr hoc chuyn tuyn.
Hn khm li.

382 |
3.2. T vn ph thai bng thuc.
- T vn v quyt nh chm dt thai nghn.
- Gii thiu cc bin php ph thai hin c ph hp vi tui thai ca khch hng.
- Gii thiu hiu qu ca ph thai bng thuc v khng nh khch hng phi chp nhn
ht thai nu ph thai bng thuc tht bi.
- Gii thiu qui trnh ph thai bng thuc: cch ung thuc v s xut hin ca cc triu
chng bnh thng sau ung thuc (ra huyt m o v au bng). Nhn mnh s cn
thit ca vic khm li theo hn.
- T vn cch t theo di v t chm sc sau dng thuc ph thai.
- Gii thiu cc tc dng ph ca thuc ph thai v cch x l.
- Nhn mnh cc triu chng cn tr li c s y t ngay.
- Cung cp thng tin lin lc khi cn lin lc trong nhng tnh hung cp cu.
- Cung cp thng tin v kh nng c thai tr li sau ph thai bng thuc.
- Gii thiu cc bin php trnh thai, gip khch hng la chn bin php trnh thai ph
hp v hng dn khch hng s dng ng.
- Cung cp bin php trnh thai hoc gii thiu a im cung cp bin php trnh thai.
- K cam kt t nguyn ph thai (di 18 tui phi c n cam kt ca b hoc m hoc
ngi gim h).
- Hn khch hng khm li: thi gian ty thuc vo phng php ph thai.
4. T vn cho cc nhm i tng c bit.
4.1. V thnh nin.
Khi t vn cho v thnh nin v ph thai, ngi cung cp dch v cn c bit ch :
- Dnh thi gian cho v thnh nin hi v a ra quyt nh.
- m bo tnh b mt.
- T vn k hn v bao cao su va trnh thai va phng cc bnh LTQTD.
- Xem chi tit phn t vn cho v thnh nin.
4.2. Nhng ph n phi chu bo hnh.
Khi t vn v ph thai cho nhng ph n b bo hnh cn c bit ch :
- Th hin s ng cm trong t vn, ng x thch hp khi khch hng s hi hoc bun
b.
- To mi quan h tt v tin cy vi khch hng.
- Gii thiu khch hng ti nhng dch v x hi hin c gip khch hng vt qua
hon cnh ca mnh.
- Cung cp dch v trnh thai sau ph thai m chnh bn thn khch hng c th ch
ng c.
- Xem thm bi T vn cho ph n b bo hnh.
- T vn cc bnh LTQTD.
4.3. Nhng ph n c HIV.
Khi t vn ph thai cho ph n b HIV/AIDS cn c bit ch :
- c tnh.
Sang chn v tm l.
Ngn ngi cha quyt nh ph thai.
B gia nh rung b, x hi k th.
- Khi t vn ch :
Chia s vi khch hng.

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Khng t ra k th, s st.
T vn v kh nng ly truyn t m sang con.
c bit l gii thiu v s dng bao cao su trnh thai v phng ly truyn cho
ngi khc.
ng vin khch hng.
T vn cho ngi nh v chm sc th cht, tinh thn v phng bnh.

384 |
PH THAI BNG PHNG PHP
HT CHN KHNG
Tuyn p dng.
- Tuyn trung ng, tnh v huyn: ph thai t tun th 6 n ht tun th 12 (i
vi khoa Chm sc SKSS huyn, do gim c S Y t quyt nh cn c vo iu
kin c s vt cht, trang thit b, nhn lc c th ca khoa).
- Tuyn x: ch ph thai n ht 7 tun (ph thai trong giai on t 36 n 49 ngy)
vi nhng trng hp mang thai bnh thng.
Ngi thc hin.
Bc s, y s sn nhi, n h sinh trung hc v cao ng c o to v ph thai bng
phng php ht chn khng.

Ph thai bng phng php ht chn khng l phng php chm dt thai nghn bng
cch dng bm ht chn khng ht thai trong t cung t tun th 6 n ht tun th 12.
1. Ch nh.
Ph thai t tun th 6 n ht tun th 12.
2. Chng ch nh.
Khng c chng ch nh tuyt i tuy nhin cn thn trng i vi trng hp ang
vim cp tnh ng sinh dc cn c iu tr hoc chuyn tuyn.
Ch : Khng c lm th thut ti tuyn x nhng trng hp sau:
U x t cung to.
Vt m t cung.
Sau di 6 thng.
D dng ng sinh dc.
Cc bnh l ni - ngoi khoa.
3. C s vt cht.
- Phng th thut: bo m tiu chun qui nh.
- Dng c:
Phng tin bo h.
o chong y t, m, khu trang.
Khn v khun.
Gng tay v khun.
Knh bo v mt.
B dng c ht chn khng:
Bm ht 1 van, bm ht 2 van, bm MVA plus, cc ng ht v du bi trn.
Hai kp st khun ngoi v trong.
Van hoc m vt.
Kp c t cung.
Nn nong.
Bm, kim tim gy t ti c t cung.
Bng gc v dung dch st khun.

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Thuc gim au, gy t, hp chng chong v thuc tng co t cung.
B dng c kim tra m.
Cc phng tin x l dng c v x l cht thi.
4. Qui trnh k thut.
4.1. Chun b khch hng.
- Ngi cung cp dch v t gii thiu vi khch hng.
- Hi tin s bnh v ni, ngoi, sn khoa. Nu c bnh ni khoa (tim mch, tng huyt
p...), d dng ng sinh dc th thc hin th thut ny tuyn c phng tin gy m
hi sc.
- Khm ton thn.
- Khm ph khoa xc nh c thai v loi tr cc trng hp cn tr hon.
- Lm test th thai.
- Siu m (nu cn).
- Tnh tui thai da vo ngy u tin ca k kinh cui cng v qua khm thc th.
- Khch hng k cam kt t nguyn ph thai (di 18 tui phi c n cam kt ca b
hoc m hoc ngi gim h).
- Thai t 9 - 12 tun nn chun b c t cung bng cch cho ngm di li 400 mcg
misoprostol 3 gi trc khi lm th thut.
4.2. T vn (xem phn t vn ph thai).
- Tho lun v quyt nh chm dt thai nghn.
- T vn v cc phng php ph thai hin c ti c s.
- Cc bc tin hnh ht thai chn khng.
- Tai bin c th xy ra khi ht thai.
- T vn v theo di sau khi ht thai.
- Cc du hiu cn khm li ngay sau khi ht thai.
- Cc du hiu hi phc sc khe v kh nng sinh sn sau ht thai.
- Thng tin v cc BPTT, hng dn chn la BPTT thch hp v s dng ng trnh
ht thai ln na.
- Cung cp BPTT hoc gii thiu a im cung cp BPTT.
4.3. Ngi thc hin th thut.
- Ra tay thng qui bng x phng di vi nc chy
- Trang phc y t: o chong, qun, m, khu trang, knh bo h.
4.4. Qui trnh k thut.
- Cho ung thuc gim au v khng sinh 30 pht trc khi lm th thut.
- Khm xc nh kch thc v t th t cung.
- Thay gng v khun.
- St khun ngoi, tri khn sch di mng.
- t van, bc l c t cung v st khun c t cung, m o.
- Kp c t cung.
- Gy t cnh c t cung.
- o bung t cung bng ng ht.

386 |
- Nong c t cung (nu cn).
- Ht thai.
- Kim tra cht ht.
- nh gi th thut hon thnh.
- C th t DCTC ngay sau khi ht thai nu m bo bung t cung sch, khng c
chng ch nh v khch hng la chn bin php ny.
- X l dng c v cht thi.
4.5. Tai bin v x tr.
- Tai bin sm: chong, chy mu, thng t cung, rch c t cung.
- Tai bin mun: nhim khun, st thai, st rau, dnh bung t cung.
- X tr:
iu tr theo phc cho tng tai bin (xem ti liu o to v ph thai).
Chuyn khch hng n tuyn iu tr thch hp.
4.6. Theo di v chm sc.
- Theo di mch, huyt p v ra mu m o t nht 30 pht sau th thut.
- K n khng sinh (nu cn thit).
- T vn sau th thut.
- Hn khm li sau 2 tun.

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PH THAI BNG THUC N HT TUN TH 9

L phng php chm dt thai k trong t cung bng cch s dng phi hp
mifepriston v misoprostol gy sy thai, cho cc thai n ht 9 tun (63 ngy).

Tuyn p dng.
Tuyn trung ng: p dng cho tui thai n ht 63 ngy.
Tuyn tnh: p dng cho tui thai n ht 56 ngy.
Tuyn huyn: p dng cho tui thai n ht 49 ngy (i vi khoa Chm sc SKSS
huyn, do gim c S Y t quyt nh cn c vo iu kin c s vt cht, trang thit b,
nhn lc c th ca khoa).
Ngi thc hin.
Bc s chuyn khoa ph sn c hun luyn v ph thai bng thuc v thnh tho k
thut ph thai bng phng php ngoi khoa.

1. Ch nh.
Thai trong t cung vi tui thai ph hp theo tuyn c php p dng.
2. Chng ch nh.
2.1. Tuyt i.
- Bnh l tuyn thng thn.
- iu tr corticoid ton thn lu ngy.
- Tng huyt p, hp van 2 l, tc mch hoc c tin s tc mch.
- Ri lon ng mu, s dng thuc chng ng.
- Thiu mu nng.
- D ng mifepriston hay misoprostol.
2.2. Tng i.
- ang cho con b.
- ang t dng c t cung (c th ly DCTC trc ph thai bng thuc).
- ang vim nhim ng sinh dc cp tnh (cn c iu tr).
3. iu kin p dng.
Khch hng c th ti c c s y t trong vng 60 pht.
4. C s vt cht.
- Ni cung cp dch v phi c nh v sinh gn phng theo di khi thc hin ph thai.
- C phng th thut v phng tin tiu chun theo qui nh thc hin can thip
khi cn.
- Phng tin dng c: cp cu, x l dng c v cht thi.
- Thuc: mifepriston, misoprostol, gim au, cp cu chng chong.

388 |
5. Qui trnh k thut.
5.1 Chun b khch hng.
- Hi tin s ni ngoi khoa, sn ph khoa, tin s d ng.
- Hi ngy u ca k kinh cui.
- Khm lm sng: khm ton thn v khm ph khoa v pht hin cc bnh LTQTD.
- Siu m chn on thai trong t cung v tui thai.
hoc m hoc ngi gim h).
5.2 T vn ph thai bng thuc (khuyn khch n h sinh c o to lm cng tc t
vn) (xem thm phn t vn ph thai).
- Gii thiu hiu qu ca ph thai bng thuc v khng nh khch hng phi chp nhn
ht thai nu ph thai bng thuc tht bi.
- Gii thiu qui trnh ph thai bng thuc: cch ung thuc v s xut hin ca cc triu
chng bnh thng sau ung thuc (ra huyt m o v au bng). Nhn mnh s cn
thit ca vic khm li theo hn.
- T vn cch t theo di v t chm sc sau dng thuc ph thai.
- Gii thiu cc tc dng ph ca thuc ph thai v cch x l.
- K n thuc gim au.
- Nhn mnh cc triu chng cn tr li c s y t ngay.
- Cung cp thng tin lin lc trong nhng tnh hung cp cu.
- Cung cp thng tin v kh nng c thai tr li sau ph thai bng thuc.
- Gii thiu cc BPTT, gip khch hng la chn BPTT ph hp v hng dn khch
hng s dng ng.
5.3 Qui trnh ph thai.
5.3.1. Thai n ht 49 ngy.
- Ung 200 mg mifepriston ti c s y t v theo di sau ung 15 pht.
- Ung hoc ngm di li 400 mcg misoprostol sau khi dng mifepriston t 36 n 48
gi, c th ung ti c s y t hay ti nh.
5.3.2. Thai t 50 n ht 63 ngy.
- Ung 200 mg mifepriston.
- Ngm di li 800 mcg misoprostol (nu khch hng nn nhiu c th t ti cng
sau) sau khi dng mifepriston t 36 n 48 gi, ti c s y t v theo di ti c s y t
t nht 3 gi.
5.4 Theo di v chm sc.
5.4.1. Theo di trong nhng gi u sau ung thuc.
- Du hiu sinh tn mi gi mt ln trong 3 gi u (nu cn).
- Tnh trng ra mu m o, au bng (c th dng thuc gim au nu cn) v cc triu
chng tc dng ph: nn, bun nn, tiu chy, st.

| 389

5.4.2. Khm li sau 2 tun.
- nh gi hiu qu iu tr.
- Sy thai hon ton: kt thc iu tr.
- St thai, st rau, thai lu: c th tip tc dng misoprostol n thun liu 400 - 600
mcg ung hay ngm di li hoc ht bung t cung.
- Thai tip tc pht trin: c th ht thai hoc tip tc ph thai bng thuc nu khch
hng mong mun.
- mu trong bung t cung: ht sch bung t cung hoc iu tr ni khoa khi khng
c nhim khun v lng mu t.
5.5 Tai bin v x tr
- Tai bin: chy mu nhiu, rong huyt ko di, nhim khun, st thai, st rau.
- X tr: theo phc cho tng tai bin (xem ti liu hun luyn).

390 |
PH THAI BNG THUC
T TUN 13 N HT TUN 22

S dng misoprostol n thun hoc s dng mifepriston kt hp vi misoprostol
ph thai t tun 13 n ht tun 22.

Tuyn p dng.
Cc bnh vin t tuyn tnh tr ln.
Ngi c php thc hin.
Bc s chuyn khoa ph sn c hun luyn v ph thai bng thuc v thnh tho k
thut ph thai bng phng php ngoi khoa.

1. Ch nh.
Thai t tun th 13 (tng ng vi chiu di u mng 52 mm) n ht tun th 22
(tng ng vi ng knh lng nh 52 mm).
2. Chng ch nh.
2.1. Tuyt i.
- Bnh l tuyn thng thn.
- iu tr corticoid ton thn lu ngy.
- Tiu ng, tng huyt p, hp van 2 l, tc mch v tin s tc mch.
- Ri lon ng mu, s dng thuc chng ng.
- Thiu mu (nng v trung bnh).
- D ng mifepriston hay misoprostol.
- C so m thn t cung.
2.2. Tng i.
- D dng sinh dc (ch c lm ti tuyn trung ng).
- C so m c on di t cung: cn cn nhc rt thn trng ng thi phi gim
liu misoprostol v tng khong cch thi gian gia cc ln dng thuc (ch c lm
ti bnh vin chuyn khoa ph sn tuyn tnh v trung ng)
3. C s vt cht.
- Phng th thut: bo m tiu chun qui nh.
- Phng tin dng c:
Phng tin cp cu.
Khay ng m thai v rau.
Dng c kim sot bung t cung.
Cc phng tin x l dng c v cht thi.
- Thuc: misoprostol v/hoc mifepriston, gim au, chng chong v thuc tng co.

| 391
4. Qui trnh k thut.
- Hi tin s bnh v ni, ngoi, sn ph khoa v cc bnh LTQTD.
- Khm ton thn.
- Khm ph khoa loi tr chng ch nh.
- Siu m xc nh tui thai.
- Xt nghim mu: cng thc mu, nhm mu, ng mu c bn hoc mu chy, mu
ng.
hay m hoc ngi gim h).
4.2. T vn (xem phn t vn ph thai).
- Cc nguy c, tai bin v bin chng c th xy ra khi ph thai.
- Cc phng php ph thai ph hp vi tui thai hin c.
- Qui trnh ph thai bng thuc.
- T theo di v chm sc sau ph thai.
- Cc du hiu cn khm li ngay.
- Kh nng c thai li sau ph thai. Cc du hiu thai nghn sm d nhn bit trnh
ph thai.
ph thai ln na.
- Tr li nhng cu hi ca khch hng v gii quyt nhng vn lo lng.
4.3. Thc hin ph thai.
4.3.1. Cc phc s dng thuc:
Phc misoprostol n thun.
- t vo ti cng sau m o 200 mcg misoprostol.
C 6 gi dng 1 vin cho thai t 18 tun tr ln (khng qu 3 ln/ngy).
C 4 gi dng 1 vin cho thai di 18 tun (khng qu 5 ln/ngy).
- Nu khng thnh cng, c th dng thm misoprostol vi liu tng t cc ngy tip
theo. Tng s ngy s dng misoprostol khng qu 3 ngy lin tc (mt t dng
thuc).
- Nu khng thnh cng sau mt t dng thuc th dng li t th hai sau mt tun.
Phc kt hp mifepriston v misoprostol.
- Ung 200 mg mifepriston.
- Sau khi dng mifepriston t 36 n 48 gi, t ti cng sau m o 200 mcg
misoprostol:
C 6 gi dng 1 vin cho thai t 18 tun tr ln (khng qu 3 ln/ngy).
C 4 gi dng 1 vin cho thai di 18 tun (khng qu 5 ln/ngy).

392 |
- Nu khng thnh cng, c th dng thm misoprostol vi liu tng t cc ngy tip
theo. Tng s ngy s dng misoprostol khng qu 3 ngy lin tc (mt t dng
thuc).
- Nu khng thnh cng sau mt t dng thuc th dng li t th hai sau mt tun.
4.3.2. Chm sc trong th thut.
- Theo di mch, huyt p, nhit , ra mu m o, au bng (cn co t cung) c 4
gi/ln, khi bt u c cn co t cung mnh c 2 gi/ln.
- Thm m o nh gi c t cung trc mi ln dng thuc.
- Cho ung thuc gim au.
- Sau khi sy thai v rau: dng thuc tng co t cung. Ch nh kim sot t cung bng
dng c (nu cn). Cho ung khng sinh trc khi kim sot t cung.
- X l thai, rau, cht thi v dng c.
- Tai bin: chy mu, rch c t cung, st rau, v t cung, chong, nhim khun.
- X tr theo phc cho tng tai bin (xem ti liu hun luyn).
- Sau khi thai ra, theo di ra mu m o, co hi t cung trong vng 4 gi.
- Ra vin sau khi ra thai t nht 2 gi.
- K n khng sinh.
- T vn sau th thut.

| 393
PH THAI BNG PHNG PHP NONG V GP
T TUN 13 N HT TUN 18

Nong v gp l phng php chm dt thai nghn bng cch s dng thuc
misoprostol chun b c t cung, sau nong c t cung v dng bm ht chn khng
kt hp vi kp gp thai ly thai ra, p dng cho tui thai t tun th 13 n ht tun
th 18.

Tuyn p dng.
Cc bnh vin tuyn trung ng v tuyn tnh.
Ngi thc hin.
Bc s chuyn khoa ph sn thnh tho k thut ph thai n ht 12 tun bng
phng php ngoi khoa v c o to k thut ph thai bng phng php nong v
gp.

1. Ch nh.
Thai t tun th 13 (tng ng vi chiu di u mng 52 mm) n ht tun th 18
(tng ng vi ng knh lng nh 40 mm).
2. Chng ch nh.
- So m c thn t cung.
- ang mc cc bnh ni khoa cp tnh.
- Tin s d ng vi misoprostol.
- Thn trng: d dng t cung, u x t cung hoc so m c on di t cung.
3.C s vt cht
- Phng k thut: bo m tiu chun qui nh.
- Phng tin dng c:
B dng c nong, gp thai: kp di st khun, kp c t cung, nong t s 8 n s
17, kp gp thai Sopher, Bierre v tha no cn.
B ht thai chn khng vi ng ht s 12 n s 16.
Khay ng m thai v rau.
Cc phng tin x l dng c v cht thi.
Phng tin cp cu.
My siu m.
- Thuc mifeprison, misoprostol, gim au, tin m, chng chong v thuc tng co t
cung.
4. Qui trnh k thut.

394 |
- Hi tin s bnh v ni, ngoi, sn ph khoa, tin s d ng v cc bnh LTQTD.
- Khm ton thn.
- Khm ph khoa loi tr chng ch nh.
- Siu m.
- Xc nh tui thai
- Xt nghim mu: cng thc mu, nhm mu, ng mu c bn hoc mu chy, mu
ng.
hoc m, ngi gim h).
4.2. T vn (xem thm phn t vn ph thai).
- Cc nguy c, tai bin v bin chng c th xy ra khi ph thai to.
- Cc phng php ph thai to.
- Cc bc ca th thut nong v gp.
- T theo di v chm sc sau ph thai
- Cc du hiu cn khm li ngay.
- Kh nng c thai li sau ph thai. Cc du hiu thai nghn sm d nhn bit trnh
ph thai to
ph thai ln na.
- Tr li nhng cu hi ca khch hng v gii quyt nhng vn lo lng.
- Cung cp BPTT v gii thiu a im cung cp BPTT.
4.3. Ngi thc hin th thut.
- Ra tay thng qui bng x phng di vi nc chy.
- Trang phc y t: o chong, qun, m, khu trang, eo knh bo h.
4.4. Cc bc tin hnh th thut.
4.4.1. Chun b c t cung:
- Ngm di li hoc bn trong m 400 mcg misoprostol, theo di trong vng 4 - 6 gi.
- nh gi li tnh trng c t cung, nu t cung cha c chun b tt th c th dng
tip 400 mcg misoprostol.
4.4.2. Ung khng sinh.
4.4.3. Tin hnh th thut.
- Gim au ton thn.
- Khm xc nh kch thc v t th t cung, nh gi tc dng ca thuc i vi c t
cung, khng c tin hnh th thut khi c t cung cha c chun b tt.
- Thay gng v khun.
- St khun ngoi, tri khn sch di mng.
- t van, bc l c t cung v st khun c t cung, m o.
- Kp c t cung.
- Gy t cnh c t cung.
- Nong c t cung.

| 395
- Dng bm hai van vi ng ht ph hp ht nc i v ko phn thai xung thp.
- Tin hnh gp thai, rau. Khng a kp gp qu su trong bung t cung trnh nguy
c thng t cung.
- Nu gp thai kh khn th c th gp thai di siu m.
- Kim tra li bung t cung bng tha cn hoc ng ht.
- Kim tra cc phn thai v rau ly ra nh gi th thut hon thnh hay cha.
- X l dng c v cht thi.
- Tai bin: chong, thng t cung, rch c t cung, chy mu, st thai, st rau, mu
trong t cung, nhim khun.
- X tr theo phc cho tng tai bin (xem ti liu phn bi ging x tr tai bin).
- Theo di mch, huyt p, nhit , ra mu m o, au bng, co hi t cung 30 pht
mt ln trong vng 1 n 2 gi, sau c th cho khch hng v.
- K n khng sinh.
- T vn sau th thut (xem phn t vn chung)

396 |
X L DNG C HT THAI CHN KHNG BNG TAY
Tuyn p dng.
Tt c cc tuyn.
Ngi thc hin.
Cn b cung cp dch v.

Dng c ht thai chn khng bng tay bao gm bm ht v cc ng ht, trong iu
kin l tng ng ht ch dng mt ln, cn bm ht c th dng li nhiu ln. Sau khi ht
thai nu mun s dng li th cc dng c ny cn c tit khun hoc kh khun mc
cao.
Qui trnh x l dng c bao gm bn bc:
- Ngm kh nhim.
- Ra sch.
- Kh khun mc cao hoc tit khun.
- Bo qun dng c.
Hin ti trong cc c s y t ph bin l bm ht thai chn khng bng tay mt van, hai
van vi cc ng ht mm Karman v bm ht thai chn khng MVA Plus vi cc ng ht
Ipas EasyGrip. Qui trnh x l dng c tng t nhau ch c bc kh khun mc cao
hoc tit khun l khc nhau gia hai loi bm ht chn khng mt van, hai van v loi
bm ht MVA Plus.

1. C s vt cht.
C khu vc x l dng c ring, c trang b cc phng tin v ha cht x l
dng c
2. Qui trnh x l dng c.
2.1. Ngm kh nhim.
- Sau khi lm xong th thut, ngi lm th thut ht v pht ngay dung dch clorin
0,5% hoc dung dch kh nhim tng ng vo ng ht v bm ht vi ln.
- Tho ri ng ht ra khi bm ht v pt tng ra khi ng bm.
- Ngm ngp ton b dng c trong dung dch kh nhim trong vng 10 pht.
- Dng tay i gng hoc dng kp gp dng c ra.
Lu :
Dng c nha cn kh nhim trong mt x ring.
Trnh ngm dng c trong dung dch clorin qu lu v s gy r dng c kim loi v
gy bin cht nhanh dng c nha.
Dung dch kh nhim phi thay hng ngy hoc thay mi khi b bn.
2.2. Ra sch.
- Ngi ra dng c phi i gng, eo khu trang v mc tp d, eo knh bo v.
- Tho ri tt c cc b phn ca bm ht k c vng m cao su.
- Ra sch dng c bng bn chi mm, nu c m bm vo trong lng ng th pht
nc nhiu ln ra hoc dng tm bng ra u ng ht.

| 397
- Ra sch ton b dng c bng nc x phng bt (nn ra dng c trong chu ngp
nc, khng nn ra di vi nc chy).
- Ra li bm ht v ng ht bng nc sch.
- Lau kh bng khn sch.
Lu :
Khng c dng cc dng c sc tho vng m cao su m phi tho bng
cch i gng tay va bp va y nh vng cao su nh ra khi rnh v dng tay
kia tho vng cao su ra.
Khng c dng cc que sc nhn ra bn trong lng ng bm hoc thng
lng ng ht
2.3. Tit khun hoc kh khun mc cao.
- Tit khun s dit ht tt c cc vi sinh vt k c nha bo, kh khun mc cao khng
dit c nha bo.
- Bc tit khun hoc kh khun mc cao khc nhau gia loi bm ht chn
khng mt van, hai van vi cc ng ht mm Karman v loi bm ht MVA Plus
vi cc ng ht Ipas EasyGrip.
- Bm ht ch cn kh khun mc , ng ht bt buc phi tit khun hoc kh
khun mc cao.
2.3.1. Tit khun.
C hai cch tit khun l tit khun bng ha cht v tit khun bng nhit.
- Tit khun bng ha cht: p dng cho tt c cc loi dng c.
Ngm ngp ng ht v bm ht (phi tho ri tt c cc b phn k c vng m
cao su) vo dung dch glutaraldehyd 2 % (hoc theo hng dn ca nh sn xut)
hoc dung dch tng ng trong 10 gi.
Gp dng c bng kp v khun.
Trng li bng nc tit khun.
Lau kh bng khn v khun hoc kh t nhin.
Lu : Thay dung dch tit khun theo ch dn ca nh sn xut.
- Tit khun bng nhit: p dng c cho loi bm ht MVA Plus v cc ng ht Ipas
EasyGrip.
Tho ri tt c cc b phn bm v ng ht ra
Hp t ch 121
o
C p sut 106 KPa trong vng 30 pht.
Lu : Tuyt i khng c sy kh bm v ng ht.
2.3.2. Kh khun mc cao.
C hai cch kh khun mc cao l kh khun mc cao bng ha cht v kh
khun mc cao bng nhit.
- Kh khun mc cao bng ha cht: p dng cho tt c cc loi dng c.
Ngm ngp ng ht v bm ht (phi tho ri tt c cc b phn k c vng m
cao su) vo trong dung dch glutaraldehyd 2 % (hoc theo hng dn ca nh sn
xut) hoc dung dch clorin 0,5 % hoc dung dch tng ng trong vng 20 pht.
Gp dng c ra bng kp v khun.
Trng li bng nc tit khun hoc nc un si 20 pht m.

398 |
Lu : Thay dung dch clorin hng ngy hoc dung dch tng ng theo ch dn ca
nh sn xut.
- Kh khun mc cao bng nhit: p dng cho bm ht MVA Plus, ng ht Ipas
EasyGrip, ng ht mm Karman.
Cho ngp dng c c tho ri trong ni nc v tin hnh luc si trong 20
pht, thi gian tnh t khi nc bt u si.
Gp dng c ra bng kp v khun.
Lu : Khng c luc bm ht chn khng mt van, hai van v s lm hng vng m
cao su).
2.4. Bo qun v s dng.
2.4.1. Bo qun.
- Dng c cn c ct gi ti ni kh ro, trong cc hp ng c tit khun, c
np y kn, trn np ngy x l v hn s dng.
- Dng c tit khun th thi gian s dng ti a l 7 ngy cn nu x l bng phng
php kh khun mc cao th thi gian s dng ti a l 3 ngy.
- Dng c luc th ch s dng trong ngy.
- Nu m hp dng c ra th cn phi s dng ngay trong ngy v dng c cha dng
vn phi x l li.
Lu :
Khng nn s dng c trong hp nhiu hn s dng c cn dng trong ngy
trnh nhim khun s dng c cn li.
Khi gp ng ht ra phi dng kp v khun gp vo pha u ni vi bm ca ng
ht.
Bm ht v ng ht phi trong hp ring.
2.4.2. Trc khi s dng:
- Lp li bm ht, bi trn pt tng bng silicon hoc bt k du bi trn no khc khng
phi ngun gc t du m.
- Nu bm ht khng gi c p lc chn khng hoc bt k b phn no b hng th
phi thay b phn khc hoc thay bm khc.
- Kim tra cc dng c hng hoc ht hn s dng thay mi.

| 399

PHN 8
NAM HC

400 |

| 401
MN DC NAM GII

1. nh ngha.
Mn dc nam l tnh trng suy thoi cc c quan trong c th khi cao tui, c bit l
trc h i - tuyn yn - tinh hon lm gim lng testosteron trong mu (bnh thng
lng testosteron mu l: 10 - 35 nanomol/lt).
2. Nguyn nhn.
Ni tit t testosteron mu gim do cc nguyn nhn sau:
2.1. Tui cng cao, cc c quan, trong c tuyn yn - tinh hon, cng b suy thai.
2.2. B cc bnh lm ri lon nhp hot ng ca h thng trc h i - tuyn yn gy ri
lon s sn xut cc ni tit t c lin quan khc.
2.3. Di truyn t th h trc.
2.4. Dng nhiu cc loi thuc c tnh cht khng androgen, v d: dng qu nhiu ni tit
t estrogen, dng cc loi glucocorticoid, mt s thuc loi bucalutamid, flutamid, mt s
thuc cha bnh khc nh cimtidin
2.5. Mt s bnh gy nn nh: tiu ng, suy tuyn yn, cc khi u vng tuyn yn - tinh
hon, u tuyn thng thn v cc khi u cc ph tng khc.
2.6. Mt s thi quen xu nh: nghin ru, thuc l, ma ty
3. Chn on.
3.1. Da vo cc triu chng lm sng.
3.1.1. Gim ham mun tnh dc.
3.1.2. Ri lon cng dng - khng giao hp c.
3.1.3. Tinh trng yu nn kh sinh con.
3.1.4. C nhng ri lon v h thng tim - mch nh huyt p cao, thp bt thng, tim
p nhanh, mt bng, hi hp
3.1.5. Ri lon h hp: kh th v ban m, ngy to.
3.1.6. Long xng, rt d gy xng nhng t th bt thng hoc b cc chn thng
d rt nh.
3.1.7. Gim th tch v trng lc c, cho nn li vn ng v d mi mt. Ton thn teo
tp dn.
3.1.8. Lng m c th tng nht l bo bng.
3.1.9. Da mt nc v rn rm, to ra cc np nhn.
3.1.10. Thn kinh: mt nhy cm ca cc phn x.
3.1.11. Tm thn: trm cm, thch c c, d ti thn.
3.1.12. Ri lon h thng to mu: hng cu, bch cu, tiu cu
Kt lun v chn on lm sng th ch cn 1 triu chng v tnh dc v 2 triu chng
ton thn l cn nh hng vic chn on v mn dc nam gii.

402 |
3.2. Cc triu chng cn lm sng.
3.2.1. Cc xt nghim v sinh ha nh gi chc nng cc ph tng ton thn trong c
th.
3.2.2. Cc xt nghim v chn on hnh nh xc nh cc bnh l khc v chn on
phn bit.
3.2.3. Cc xt nghim v ni tit t, ch yu l ni tit t sinh sn: LH, FSH, prolactin,
estradiol, testosteron tm cc bnh ri lon v ni tit. Trong iu kin hin nay ca Vit
Nam cc bnh vin a khoa tuyn tnh v cc trung tm nam hc chu trch nhim lm iu
ny.
3.2.4. Tiu chun vng xc nh mn dc nam gii l lng testosteron trong mu h
thp di mc bnh thng (bnh thng: 10 - 35 nanomol/lt).
4. Phn tuyn.
4.1. Tuyn x v tuyn huyn.
Khm pht hin ra bnh da vo cc triu chng lm sng, t vn v chuyn ngi
bnh n tuyn tnh v tuyn trung ng.
4.2. Tuyn tnh v trung ng.
Lm cc xt nghim cn lm sng chn on xc nh v iu tr thc th.
5. iu tr.
Bi ph testosteron vo c th.
5.1. Ch nh.
Nhng ngi c lng testosteron thp, c biu hin ca mn dc nam.
5.2. Chng ch nh.
Nhng ngi ang c bnh:
- U lnh ph i tuyn tin lit.
- Ung th tuyn tin lit.
5.3. Cc dng thuc dng testosteron.
5.3.1 Dng vin.
- Undecanoat testosteron 40 mg/vin:
Liu tn cng: 3 - 4 vin/ngy x 30 ngy.
Liu duy tr: 1 - 2 vin/ngy x 30 ngy.
- Mesterolon 25 mg/vin:
Liu tn cng: 4 vin/ngy x 30 ngy.
Liu duy tr: 2 vin/ngy x 30 ngy.
5.3.2 Dng tim.
Mesterolon 250 mg/ng/tun x 4 tun (tim bp).
5.3.3 Dng xoa.
Androgel 50 mg/gi, ngy xoa 1 gi mt trong i hoc lng hoc bng trong 30
ngy.

| 403
6. Nhng im cn t vn v tnh dc khi tui gi.
- Khi c tui, hot ng tnh dc nhn chung gim st nhng ham mun tnh dc v kh
nng tnh dc c th vn cn.
- Nu tnh dc ca mt ngi khng i trong sut cuc i th nhng thay i sinh hc
lin quan n tui t r rt.
- Tnh dc l bnh thng v t nhin, ngi c tui cn nhn bit kh nng tnh dc ca
mnh v tr nn thoi mi hn vi kh nng tnh dc ca mnh.
- C nhiu cch hot ng tnh dc ch khng phi ch quan h tnh dc qua ng m
o: s tay, hn, th dm, c nhiu cch lm a dng ha cch biu hin tnh dc ca
mnh v iu l chp nhn c.
- C th c hot ng tnh dc la tui 70 v trn 70 tui.
- Sc khe tnh dc c th lm li cho sc khe chung tng c nhn c tui.
- Nu c bn khon v sc khe v chc nng tnh dc (v tng tc thuc, cc vn
sc khe mn tnh, cc phu thut,), cn i t vn v iu tr.

404 |
SUY SINH DC NAM

1. nh ngha.
Suy sinh dc l mt bnh bm sinh hay mc phi, gy nn hin tng cc t bo
Leydig ca tinh hon b thai trin, khng sn xut hoc sn xut c t testosteron trong
c th. T s suy gim testosteron gy nn hng lot cc hi chng bnh trn cc ph tng
chu tc ng bi testosteron.
2. Nguyn nhn.
2.1 Ti tinh hon.
2.1.1. B ct tinh hon trong mt s trng hp bnh l v chn thng.
2.1.2. Chn thng: dp nt dn ti x ha hon ton tinh hon.
2.1.3. Vim mn tnh dn ti x teo tinh hon.
2.1.4. Teo tinh hon do tinh hon khng bu m b lc ch sang cc v tr khc nh:
trn np mu, trong bng, ng bn...
2.1.5. Nhng ngi mc mt s bnh nh ung th tuyn tin lit phi dng nhiu loi
thuc iu tr ni tit t khng androgen.
2.2. Ngoi tinh hon.
2.2.1. Cc bnh ri lon v gen gy lon sn tinh hon nh cc hi chng:
- Hi chng Klinefelter (47 XXY).
- Hi chng Turner (45 X).
- Hi chng Turner vi X chromatin dng tnh.
- Hi chng Turner vi X chromatin m tnh.
2.2.2. Cc bnh ri lon v cc men sinh dc.
2.2.3. Bnh suy tuyn yn (bm sinh hoc mc phi) gy suy gim cc hormon LH v FSH.
3. Chn on.
3.1. Cc triu chng lm sng.
- C y cc triu chng lm sng ca hi chng suy gim ni tit t testosteron
trong mu.
- Khm thc th: tinh hon teo nh, tinh hon khng trong bu (s thy tinh hon
trn ng bn hoc khng s thy hon ton tinh hon trong bu).
3.2. Cn lm sng.
3.2.1. nh lng c 5 hormon: LH, FSH, prolactin, estradiol, testosteron tm cc ri
lon v ni tit t sinh sn.
3.2.2. Cc xt nghim v gen.
- Nhim sc th XY.
- Vt th Barr.
- Phn ng di truyn TDF tm du vt ca gen hnh thnh to tinh hon.
3.2.3. Chn on hnh nh tm hnh nh tinh hon v cc b phn ca nam gii.
- Siu m.

| 405
- Chp vi tnh ct lp vng tiu khung.
- Nhp nhy .
4. Phn tuyn.
Lm chn on ban u da vo thm khm lm sng ri chuyn ngi bnh n tuyn
tnh v tuyn trung ng.
4.2. Tuyn tnh v trung ng.
Tip tc thm khm lm chn on xc nh, chn on nguyn nhn v iu tr.
5. iu tr.
5.1. Bi ph LH di dng thuc tim.
Pregnyl 500 v, 1000 v, 1500 v (tim bp). Liu lng ty theo la tui.
5.2. Bi ph testosteron.
5.2.1. Dng ung: liu lng ty theo la tui.
- Undecanoat testosteron 40 mg/vin:
Liu tn cng: 3 - 4 vin/ngy x 30 ngy.
Liu duy tr: 1 - 2 vin/ngy x 30 ngy.
- Mesterolon 25 mg/vin:
Liu tn cng: 4 vin/ngy x 30 ngy.
Liu duy tr: 2 vin/ngy x 30 ngy
5.2.2. Dng tim: liu lng ty theo la tui.
- Mesterolon 250 mg/ng/tun x 4 tun (tim bp).
- Sustanon 250 mg/ng (tim bp).

406 |
V SINH NAM

1. i cng.
nh ngha: mt cp v chng sau 12 thng chung sng, trong sinh hot tnh dc khng
s dng bt k bin php trnh thai no m cha c con c xp vo nhm v sinh.
V sinh nam l v sinh do nguyn nhn ca ngi nam (c hay khng kt hp vi
nguyn nhn t pha n).
- V sinh I: ngi v cha c thai ln no.
- V sinh II: ngi v c thai t nht 1 ln.
2. Nguyn nhn.
C rt nhiu nguyn nhn gy v sinh nam gii. C th chia thnh cc nhm:
2.1. Yu t tnh dc (ri lon cng dng, ri lon xut tinh,)
2.2. Nhim khun h tit niu - sinh dc: vim tinh hon - mo tinh hon, vim niu o,
vim tuyn tin lit
2.3. Nhng bt thng bm sinh.
- Cc bt thng v th nhim sc gii tnh (hi chng Klinefelter v cc bin th ca
hi chng ny: 47XXY, 48XXXY)
- Cc khuyt tt v gen: hi chng Kallmann, hi chng Prader - Willi
- Cc bt thng khc: tt khng tinh hon, tinh hon khng xung bu, khng ng dn
tinh, hi chng ch c t bo Sertoli, cu trc bt thng ca tinh trng
- Tinh dch bt thng t pht (hi chng OAT) hoc khng tm thy nguyn nhn.
2.4. Cc yu t mc phi.
- Nghin ru, ht thuc l, sau ha tr liu, nhim c tia x
- Gin tnh mch tinh.
- Cc ri lon v ni tit t: suy sinh dc (ti tinh hon v ngoi tinh hon), thiu FSH
n thun, bi tit ni tit qu mc (sn xut qu nhiu androgen, bi tit estrogen qu
mc)
- Cc yu t min dch: khng th khng tinh trng gy hin tng ngng kt v bt
ng tinh trng.
- Cc bt thng khc: tc ng dn tinh, chn thng mt tinh hon
3. Chn on.
3.1. Lm sng.
3.1.1. Hi bnh.
- Tin s thi quen ht thuc, ung ru, nhim c, tip xc ha cht
- Tin s hn nhn v thai sn: ly v my nm, thi gian t khi mun c con n nay.
- Tin s bnh tt: quai b, bnh mn tnh, bnh vim nhim - ly truyn qua ng tnh
dc, .
- c im nhu cu sinh l, sinh hot tnh dc xem c ri lon cng dng, ri lon
xut tinh

| 407
- Tin s gia nh v sinh sn: trong gia nh c ai chm con khng?
- Pha v: khm cho v cha? cc bt thng lin quan n sc khe sinh sn ca
ngi v: nhu cu i hi v sinh l, tnh hnh kinh nguyt (chu k kinh, mu sc kinh
nguyt, au khi c kinh), au khi giao hp
3.1.2 Khm bnh.
- Ton thn: trng thi tinh thn kinh, hnh dng bn ngoi
- Thc th: bnh ni tit, tim mch, h tit niu
- Ti ch: b phn sinh dc ngoi: d tt (khng c tinh hon trong bu, l i thp, cong
vo dng vt), vim nhim, chy m hoc dch bt thng. S thy bi gin tnh
mch tinh. C s thy ng dn tinh khng?
3.2. Cn lm sng.
3.2.1. Xt nghim tinh dch : nh gi s lng, tnh cht vt l ca tinh dch, s lng
v cht lng tinh trng.
3.2.2. Xt nghim sinh ha tinh dch: ti tinh cha nhiu fructose, tuyn tin lit cha
phosphatase acid v km, mo tinh hon cha carnitin. Da vo cc c im ny
c th chn on tc on no ca ng xut tinh.
3.2.3. Xt nghim khng th khng tinh trng: ch loi khng th v hiu gi khng th.
3.2.4. Xt nghim y 5 hormon: LH, FSH, prolactin, estradiol, testosteron.
3.2.5. Xt nghim v di truyn hc (v th nhim sc, v gen).
3.2.6. Xt nghim v m hc.
- Chc ht dch mo tinh hon tm tinh trng.
- Sinh thit tinh hon (dng kim sinh thit hoc phu thut sinh thit).
3.2.7. Chn on hnh nh.
- Siu m h tit niu - sinh dc (lu : tuyn tin lit, ti tinh, tinh hon, mo tinh hon,
tnh mch tinh) xem c bt thng khng? C gin tnh mch tinh khng? o kch
thc tinh hon
- Chp ng dn tinh: mc ch tm ch tc trn ng dn tinh.
4. Phn tuyn.
Chn on nh hng da trn cc triu chng lm sng v t vn v phng hng
iu tr.
4.2. Tuyn tnh v tuyn trung ng.
Chn on xc nh, chn on nguyn nhn v iu tr thc th.
5. iu tr.
5.1. Nguyn tc.
iu tr v sinh nam gii cn da vo nguyn nhn.
5.2. iu tr ni khoa.
- iu tr khng sinh c hiu cho cc trng hp vim nhim ng tit niu - sinh dc.
- Dng corticoid trong v sinh c khng th khng tinh trng.
- iu chnh ni tit t trong cc trng hp c ri lon ni tit t: nhm LH, nhm
FSH, nhm androgen,

408 |
- iu tr ri lon cng dng, ri lon xut tinh,
- Dng thuc y hc c truyn (mt s bi thuc b tr).
5.3. iu tr ngoi khoa.
5.3.1 Phu thut mt s bnh gy nh hng n i sng tinh trng.
Tht tnh mch tinh, h tinh hon, nc mng tinh hon
5.3.2 Phu thut to hnh phc hi ng dn tinh v dng vt.
- Ni ng dn tinh - ng dn tinh, ni ng dn tinh - mo tinh hon.
- Phu thut d tt l i, x cng vt hang dng vt
- Ct ni soi m rng ni hoc m rng c ti tinh trong nhng trng hp b cht hp
khng phng xut c tinh dch.
5.3.3 Cc phng php h tr sinh sn:th tinh nhn to (bm tinh trng vo bung t
cung ngi v, th tinh trong ng nghim)

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RI LON CNG DNG

1. i cng.
Ri lon cng dng l tnh trng khng c kh nng t c v duy tr cng
cng ca dng vt a vo m o ngi ph n, tin hnh cuc giao hp mt cch
trn vn.
2. Nguyn nhn.
2.1. Ri lon cng dng do cc bnh ri lon ni tit t.
2.2. Ri lon cng dng do thn kinh.
2.3. Ri lon cng dng do tm thn.
2.4. Ri lon cng dng do ri lon vn mch.
2.5. Ri lon cng dng do cc bin dng ca dng vt.
2.6. Ri lon cng dng do mt s thuc.
3. Chn on.
3.1. Triu chng lm sng.
3.1.1. Tp trung vo bn nhm triu chng sau:
- Hon ton mt hn ham mun tnh dc.
- Vn cn ham mun tnh dc nhng dng vt khng th cng cng c giao hp
nh mun.
- Dng vt cng cng tt nhng khng ng lc.
- Dng vt cng cng trong thi gian rt ngn, cha kp a vo m o hoc cha
kp xut tinh mm xu.
3.1.2. Bng ch s quc t v chc nng cng dng vt
(I.I.E.F - International Index Erection Function).
Thang im ny bao gm 15 cu hi, mi cu hi cho im t 0 n 5. Mc ri
lon cng dng c qui nh nh sau:
6 - 20 im : Mc nng 31 - 59 im : Mc nh.
21 - 30 im : Mc trung bnh. 60 - 75 im : Bnh thng.
3.2. Tin s cc bnh ni khoa v ngoi khoa.
- Cc bnh ni khoa: tim mch, huyt p, tiu ng
- Cc bnh ngoi khoa: chn thng vng chu, c phu thut vng tiu khung v
b phn sinh dc.
3. 3. Khm b phn sinh dc v tng sinh mn pht hin cc bnh.
- Bin i hnh th gii phu dng vt: l i lch thp, dng vt ngn v nh bm
sinh, gii tnh n gi nam, gii tnh nam gi n, lng gii tht: i nam, i n.Bnh x
cng vt hang
- Bnh vim x teo tinh hon, mo tinh hon...

410 |
- Cc bnh vng bn bu: tinh hon n, gin tnh mch tinh...
- nh gi cc phn x vng bn bu - tng sinh mn nh: cm gic quanh hu mn, cm
gic trng lc c vng hu mn, phn x c hnh hang.
3.4. Cc xt nghim.
- Th phn ng HIV.
- ng, lipid, cholesterol mu.
- nh lng ni tit t: LH, FSH, prolactin, estradiol, testosteron.
4. Phn tuyn.
Lm chn on bc u da vo cc triu chng lm sng, khm thc th v lm mt
s xt nghim thng qui. T vn v phng hng iu tr.
Lm chn on xc nh, chn on nguyn nhn v iu tr.
5. iu tr.
5.1. Chng ch nh.
- Bnh tim mch mc nng (nhi mu c tim trong vng 6 thng).
- Nhng ngi mc bnh ton thn nng c khuyn co khng nn quan h tnh dc.
- D ng thuc
- ang dng cc thuc nitrat gy gin mch
- ang cha cc bnh v vng mc
5.2 iu tr ni khoa.
Ri lon cng dng do nhiu nguyn nhn gy ra. V vy khng th c mt phng
php duy nht iu tr c tt c cc chng ri lon cng dng.
5.2.1. Dng tm l liu php.
5.2.2. Chm cu.
5.2.3. Dng cht tho dc.
5.2.4. Dng thuc:
Dng ni tit t
- i vi nhm suy tuyn yn, dng thuc nhm LH nh Pregnyl.
- i vi nhm suy gim lng testosteron, dng cc testosteron bi ph: andriol
testocap, mesterolon...
Cc thuc c ch PDE5
- Sildenafil:
Viagra (Hoa K) 50 - 100 mg/vin
Medovigor (Canada) 50 - 100 mg/vin
Tun dng t 1 - 2 ngy. Mi ngy dng 1 ln, ung 1 vin trc khi giao hp 30
pht.
- Tadalafil: Cialis (Hoa K) 10 - 20 mg/vin. Cch dng nh trn.
- Vardenafil: Levitra (c) 10 - 20 mg/vin. Cch dng nh trn.

| 411
5.3. iu tr phu thut khi c ch nh.
5.3.1. Cc phu thut trn h thng ng mch:
- Hi phc tun hon ng mch ch bng.
- Hi phc tun hon ng mch dng vt: ni ng mch thng v vi ng mch
lng dng vt
5.3.2. Cc phu thut trn h thng tnh mch:
- Lm tc mch mu su.
- Buc ct tnh mch mu su v cc nhnh bn.
- Buc ct tnh mch ngoi vi v ch c cc ng r r tnh mch.
5.3.3. Phu thut lp ghp cc b phn gi:
- Loi vt gi n gin l ng silicon t vo hai bn vt hang. Dng vt c dng
thng ng vnh vin.
- Loi vt gi c bm hi.
5.3.4. Phu thut to hnh:
- iu tr bnh x cng vt hang.
- Lm di dng vt.
- Lm to dng vt.

412 |
XUT TINH SM

1. i cng.
1.1. nh ngha.
Xut tinh sm l tnh trng mt kh nng kim sot v duy tr phn x xut tinh khi t
khai cm cao cho i bn tnh.
1.2. Xut tinh sm c nhiu dng.
- Nam gii va trng thy ngi ph n p xut tinh.
- Va va chm vo c th ngi ph n xut tinh.
- Dng vt cng cng a c vo m o ngi ph n, nhng ch qua vi nhp
dp xut tinh.
- Cuc giao hp c th ko di hn, nhng cha ti 5 pht ngi nam gii b xut
tinh trong khi ngi ph n cha kp nhn cm g.
2. Nguyn nhn.
2.1. Nguyn nhn tm l.
L mt nguyn nhn c nhiu tc gi nhc n. c thi gian giao hp c bnh
thng phi c s thng bng nhp nhng gia qu trnh hng phn v c ch. Hng phn
qu mc c th dn ti xut tinh sm.
Mt trong nhng nguyn nhn hay c nhc n l th dm. Cho n nay, cha c
mt bng chng khoa hc no kt lun th dm s gy xut tinh sm, nhng ngi ta vn
a ra mt gi thuyt cho rng: vic th dm lu di s dn dn hnh thnh nn mt phn
x xut tinh sm c iu kin t dn n vic xut tinh sm trong nhng ln quan h
tnh dc thc s v sau.
2.2. Nguyn nhn thc th.
2.2.1. Qu tng nhy cm vng dng vt.
Qu tng nhy cm vng qui u dng vt lm cho qu trnh hng phn din ra mau
l hn dn ti vic xut tinh nhanh hn.
2.2.2. Cc bnh vim nhim vng chu hng.
Vim tuyn tin lit mn tnh, tr tc mch v gy au, tr ni vim mn tnh, nhim
khun m lin kt quanh tuyn tin lit v r quanh hu mn. iu ny tc ng ln cc
xung ng hng tm t niu o sau lm gim ngng cn thit cho s phng tinh qua
phn x trung gian gy nn xut tinh sm.
2.2.3. Mt s bnh ri lon ni tit nh:
Suy sinh dc, mn dc nam, tng prolactin mu, ri lon cng dng u gy nh
hng n chc nng cng v chc nng xut tinh.
2.2.4. Gi thit v s tng nhy cm ca cc th quan serotonin.
S tng nhy cm ca cc th quan serotonin (th quan 5 - HT2C v 5 - HT1A) thn
kinh trung ng dn n hin tng xut tinh sm c nhiu tc gi tha nhn. Da
trn gi thuyt ny, c nhiu nghin cu ng dng cc thuc chng trm cm (loi c
ch ti hp thu c chn lc serotonin) iu tr xut tinh sm cho kt qu rt kh quan.

| 413
3. Chn on.
3.1. Khai thc bnh s tnh dc.
3.2. S dng cu hi xc nh chn on xut tinh sm nh sau:
Cu hi Bn b xut tinh sm Bn khng b xut tinh sm
Bn t nh gi nh th no
v kh nng kmch xut
tinh ca bn?
* Trung bnh
* Km
* Cc tt
* Rt tt
* Tt.
Tnh hung no trong bn
tnh hung sau miu t ng
nht mc nh hng ca
thi gian xut tinh (I.E.L.T)
i vi bn v bn tnh ca
bn?
* I.E.L.T lmcho ti khng hi
lng.
* I.E.L.T lmcho bn tnh ca
ti khng hi lng.
* I.E.L.T lmcho c hai chng
ti khng hi lng
* C hai chng ti u hi lng.
Thi gian xut tinh (I.E.L.T) l thi gian tnh t lc a dng vt vo m o cho ti khi
xut tinh.
4. Phn tuyn.
4.1 Tuyn x: t vn hng iu tr v tm l
4.2 Tuyn huyn: k n iu tr ni khoa theo phc .
4.3 Tuyn tnh v tuyn trung ng: iu tr ni khoa v cc th thut, phu thut theo
phc .
5. iu tr.
5.1. Dng thuc.
5.1.1. Gabapentin (neurontin 300 mg/vin).
Mt tun ung 3 vin, cch nht ung 1 vin.
Hm nh giao hp: ung trc giao hp 3 gi.
Nhng ngy khng giao hp: ung vo bui ti.
iu tr trong 10 tun l.
5.1.2. Clomipramin 25 mg, ung 25 - 50 mg/ngy trong 2 - 8 tun.
5.1.3. Paroxetin 20 mg, ung hng ngy, 20 mg/ngy, trong 2 - 3 tun.
5.1.4. Fluoxetin 20 mg, ung hng ngy 20 - 40 mg/ngy, trong 4 - 5 tun. Tun u ung
20 mg/ngy, t tun th hai ung 40 mg/ngy.
5.1.5. Sertralin 50 mg, ung 50 - 100 mg/ngy, trong 4 - 8 tun.
5.2. Thuc bi lm t ti ch.
- Dng gel xylocain, lidocain bi ln u dng vt trc khi giao hp 20 pht. Sau
ra sch ri mi giao hp.
- Nht Bn, Trung Quc cng b kem SS iu ch t tho dc.
5.3.Th thut phong b m ri thn kinh cng
Ngi bnh t th qu, u thp mng cao. Xc nh khe khp gia S4 - S5, sau
bm 20 ml dung dch xylocain 0,5 % vo khoang cng. Mi tun tim 1 - 2 ln, trong 5 -
10 tun l lin tc.
5.4. Phu thut.
Ct b dy thn kinh cm gic ngoi vi quanh u dng vt nhm mc ch lm gim
s qu nhy cm u dng vt.

414 |
XUT TINH RA MU

1. i cng.
Xut tinh ra mu l tnh trng c mu ln trong tinh dch khi xut tinh.
Thng thng, xut tinh ra mu l bnh lnh tnh v t khi nhng rt hay ti pht (i
vi nhng ngi tr tui, di 45). Trong mt s t cc trng hp th y li l triu
chng ca mt bnh l c tnh (i vi nhng ngi c tui, trn 45).
2. Nguyn nhn.
2.1. Vim v nhim khun
Vim l mt trong cc nguyn nhn thng gp nht. Qu trnh vim gy kch thch
nim mc dn n hin tng sung huyt v ph n ca cc ng, cc tuyn ca ng dn
tinh, ti tinh, tuyn tin lit, ni v niu o. T gy xut tinh ra mu.
Cc nguyn nhn gy vim l do nhim khun, chn thng v si ti tinh hay calci
ha tuyn tin lit. Nhim khun thng gp nh: enterobacteria (ch yu l escherichia
coli), Chlamydia, gram dng, trc khun lao v mt s loi virus. Cn lu : lao l
nguyn nhn ch yu Vit Nam.
2.2. Tc ti tinh v cc nang ti tinh
Cc nguyn nhn ny gy cng v gin ti tinh lu ngy lm t v cc mch mu di
nim mc.
2.3. Ung th.
Cc loi ung th thng gp phi k n l ung th tuyn tin lit, ung th ng dn
tinh, ung th tinh hon, u lympho.
2.4. Cc bnh ton thn.
Cc bnh ton thn thng gp l ri lon ng mu, hemophili, x gan, tng huyt p.
2.5. Nhm do cc th thut.
Sinh thit tuyn tin lit qua trc trng, t dng c niu o, chy tia x trong ung th
tuyn tin lit, sau tht ng dn tinh, sau ct tinh hon
2.6. Gin tnh mch niu o.
Trng hp ny, tinh dch thng khng c ln mu m ch i mu mt bi sau khi
cng dng vt.
3. Chn on.
3.1 .Chn on xc nh.
- Lm sng: tinh dch c mu hoc mu nu hoc mu r st.
- Xt nghim tinh dch : c nhiu hng cu trong tinh dch.
3.2. Chn on nguyn nhn.
3.2.1. Cc xt nghim nc tiu.
Phn tch nc tiu, nui cy vi khun nc tiu v lm khng sinh , tm t bo c
tnh trong nc tiu.

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3.2.2. Cc xt nghim tinh dch.
Lm tinh dch tm hng cu v bch cu, nui cy vi khun tinh dch v lm
khng sinh , tm t bo c tnh trong tinh dch.
3.2.3. Cc xt nghim mu.
Cng thc bch cu, tc mu lng, cc xt nghim nh gi chc nng ng mu,
khng nguyn c hiu tuyn tin lit (PSA) i vi ngi trn 45 tui.
3.2.4. Cc xt nghim chn on nguyn nhn lao ng tit niu.
Ngoi cc xt nghim; cng thc bch cu, tc mu lng, tm nguyn nhn lao
cn lm thm cc xt nghim sau: mantoux, tm khng th khng lao, phn ng PCR vi
trc khun lao (bnh phm l tinh dch).
3.2.5. Siu m bng.
nh gi tnh trng ca gan, thn, bng quang v tuyn tin lit
3.2.6. Siu m qua trc trng.
L mt phng tin chn on hu hiu chn on cc bnh l khu vc ti tinh v
tuyn tin lit nh: calci ha tuyn tin lit, si ti tinh, gin ti tinh, nang ti tinh hoc
ng phng tinh.
3.2.7. Soi niu o v bng quang.
Soi bng quang, niu o c th pht hin ra cc tn thng niu o, tuyn tin lit.
Thng thng soi niu o, bng quang khi dng vt cng th s xc nh c gin
mao mch v tnh mch ca niu o cng nh l ca tuyn tin lit, cc u mu niu o
mt cch d dng.
3.2.8 .Chp cng hng t vng tiu khung.
Cng hng t l mt phng tin chn on hnh nh c gi tr nht trong thm d ti
tinh v tuyn tin lit, c ch nh trong cc trng hp c nghi ng bnh l trn siu m
qua trc trng.
3.2.9. Ni soi ti tinh.
c ch nh trong trng hp xut tinh ra mu ko di trn 3 thng m khng tm
thy nguyn nhn no. Hoc xut tinh ra mu ko di m c pht hin thy bt thng ti
tinh qua siu m hay qua chp cng hng t.
4. Phn tuyn.
4.1. Tuyn x: pht hin bnh, t vn v chuyn ngi bnh ln tuyn trn.
4.2. Tuyn huyn: chn on xc nh v iu tr ni khoa. Cc trng hp c ch nh
iu tr ngoi khoa phi chuyn ngi bnh ln tuyn trn.
4.3. Tuyn tnh v tuyn trung ng: xc nh nguyn nhn v iu tr thc th.
5. iu tr.
5.1. iu tr ni khoa.
Ch nh cho cc trng hp vim v nhim khun.
5.1.1 Trong trng hp nhim khun do cc loi vi khun thng thng.
iu tr khng sinh theo khng sinh l l tng nht.
Nu khng c khng sinh th dng khng sinh theo kinh nghim..
La chn nhng loi khng sinh no c ph tc dng i vi h enterobacteria (ch
yu l escherichia coli), c bit l nhng ngi tr thuc phi c ph tc dung i vi c
Chlamydia.

416 |
- Nhm quinolon: ciprofloxacin, norfloxacin, levofloxacin hay gatifloxacin. Liu
ung 400 mg/ngy trong vng 2 tun n 1 thng
- Nu khng c quinolon thay th bng:
Trimethoprim/sulfamethoxazol (bactrim) 480 mg/vin, 2 vin/ngy +
doxycyclin 100 mg/vin, 1 - 2 vin/ngy, dng thuc trong 10 - 15 ngy.
Cng c th dng: metronidazon 250 mg, ung 2 vin/ngy +
clindamycin/erythromycin dng trong 2 tun.
Dng phi hp vi cc thuc chng vim, gim ph n, thuc cm mu.
- -chymotripsin 4,2 mg/vin, dng 4 vin/ngy, trong 7 ngy
- Cc thuc cm mu: transamin 250 mg/vin, 2 - 4 vin/ngy, trong 5 ngy
5.1.2. Trng hp lao sinh dc tit niu
iu tr theo phc cha lao.
5.2 iu tr ngoi khoa.
Vic iu tr ph thuc vo tng trng hp c th: phu thut m hay ni soi.
Ch nh trong cc trng hp:
- Bnh l ti ch nh tc ti tinh, nang ti tinh hay si ti tinh
- Cc bnh ung th tuyn tin lit, ung th ng dn tinh (ng dn tinh, ti tinh) v
ung th tinh hon
- Gin tnh mch niu o.

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L I LCH THP

1. i cng.
L i lch thp l d tt bm sinh ca dng vt lm cho niu o, vt hang, vt xp,
qui u v da qui u pht trin khng hon ton. L niu o c th nm bt k v tr
no trn thn dng vt, thm ch c th nm bu hay tng sinh mn.
iu tr l i lch thp cn phi lm thng ng dng vt, to hnh li niu o a
l niu o ra ng v tr qui u. Mc tiu ca qu trnh iu tr l to nn mt dng vt
bnh thng v mt chc nng v gii phu.

2. Phn loi l i lch thp.
Vic phn loi l i lch thp da vo v
tr l niu o m ra trn dc chiu di
ca dng vt v tng sinh mn.
2.1. L i lch thp on trc.
- Phn thp qui u (1)
- Rnh qui u (2)
2.2. L i lch thp on gia hay on
thn dng vt.
- Phn u ca thn dng vt (3)
- Gia thn dng vt (4)
- Phn gc ca thn dng vt (5)
2.3. L i lch thp on sau.
y l th nng nht ca bnh bao gm:
- Ch ni dng vt - bu (6)
- bu (7)
- Tng sinh mn (8)
3. Nhng d tt phi hp vi l i lch thp.
3.1. Tinh hon khng xung bu v thot v bn.
Tinh hon khng xung bu v thot v bn l hai d tt ph bin nht phi hp vi l
i lch thp. Tinh hon n v thot v bn xut hin vi t l 9%. T l ny tng ln khi l
i lch thp on sau.
3.2. D tt ng tit niu.
D tt ng tit niu nhng ngi bnh l i lch thp n thun khng nhiu.
Nhng khi khi l i lch thp c phi hp vi cc bt thng cc c quan khc th t l
ny rt cao. Khong 46% c bt thng ng tit niu trn vi l i lch thp v d tt
khng c hu mn.

418 |
3. 3. Ti bu dc tuyn tin lit (utriculus masculinus).
Ti bu dc tuyn tin lit (utriculus masculinus) l mt ti nh m rng khi niu o
vo nhu m tuyn tin lit. Bt thng ny thy khong 11 % trong cc trng hp l i
lch thp on sau.
3.4. Ri lon bit ha gii tnh.
Di tt ri lon bit ha gii tnh cn phi t ra tt c cc trng hp l i lch thp
on sau phi hp vi tt tinh hon khng xung bu. Cn tin hnh lm xt nghim nhim
sc v xt nghim ni tit t xc nh.
4. Phn tuyn.
Pht hin sm v lm chn on xc nh da vo cc triu chng lm sng v t vn
cho ngi bnh nn ln tuyn trn iu tr.
4.2. Tuyn tnh v truyn trung ng.
iu tr bng phu thut to hnh mt th.
5. iu tr.
5.1. Ch p dng tuyn c chuyn khoa su v tit niu v nam hc.
5.2. Nguyn tc.
Ct b cc m x quanh vt hang dng vt dng thng ng dng vt, ri dng
cc vt da v m cun thnh ng niu o, a l i ra u dng vt. Vt da v m s
dng c th dng:
- Vt da c cung.
- Vt da hoc cc mnh m nim mc t do.

| 419
X CNG VT HANG

1. i cng.
c im ca bnh l s hnh thnh cc mng x hoc cc x cng dng vt. Mng
x ny pht trin trong lp m cng (vt hang) v c th nm mt lng hay mt bng
ca dng vt.
Bnh tin trin t t hay t ngt vi mc t nh n nng. Trong mt s trng
hp nng, mng x cng co ko lm cho dng vt cong, gp v gy au mi khi cng
lm cn tr hot ng tnh dc ca ngi bnh.
Bn cht ca cc mng x l lnh tnh. Khi mng x pht trin mt lng dng vt s
lm cho dng vt cong gp khc ln trn cn khi n pht trin mt bng ca dng vt
s lm cho dng vt cong gp khc xung di. Cng c th mng x nm c hai mt
lm cho dng vt li lm v ngn li.
2. Nguyn nhn.
C nhiu gi thit v nguyn nhn c a ra.
Mt s tc gi cho rng mng x pht trin sau cc chn thng (b cong hay va p
mnh). Cc chn thng ny gy chy mu ti ch bn trong dng vt lu ngy hnh
thnh nn cc mng x hay cc x.
Mt s tc gi khc li cho rng x cng vt hang l do ri lon c ch t min ca c
th.
3. Chn on.
Ch cn da vo lm sng l .
3.1. Du hiu v triu chng ca bnh bao gm:
- au khi cng, au tng ln khi quan h tnh dc.
- Dng vt vo hoc cong khi cng, kh a vo trong m o.
- Gim hoc mt kh nng cng cng.
3.2. Khm thc th khi dng vt cng.
- Xut hin mt di x mt hoc hai bn vt hang dng vt.
- ng knh ca dng vt gim i.
- Dng vt bin dng (li lm v ngn).
4. Phn tuyn.
4.1. Tuyn x.
Chn on, t vn, chuyn tuyn.
4.2. Tuyn huyn.
Theo di hoc iu tr ni khoa.
4.3. Tuyn tnh v truyn trung ng.
iu tr bng phu thut.

420 |
5. iu tr.
5.1. iu tr ni khoa.
Theo di hoc iu tr ni khoa cho tt c cc trng hp t 1 - 2 nm trc khi c ch
nh iu tr ngoi khoa.
- Colchicin 1 mg/vin, ung 1 - 2 vin/ngy, chia 2 ln.
- Vitamin E 400 v/vin, ung 1 - 2 vin/ngy, chia 2 ln.
- Dexamethason (Decadron) 4 mg/ng, tim ti ch vo mng x hoc cc x vi liu
0,2 - 0,5 mg/mi mng x, 1 ln/tun trong 10 tun. C th lp li nhiu t nu cn.
Mi t iu tr khong 2,5 n 3 thng. C th iu tr nhiu t nu cn thit.
5.2.1. Ch nh.
- Bnh mc nng, ngi bnh au, dng vt cong qu mc cn tr vic quan h
tnh dc.
- Theo di 1 - 2 nm m khng c tin trin tt ln.
- iu tr ni khoa tht bi.
5.2.2. Nguyn tc phu thut.
Nguyn tc phu thut l ly b cc x v lm thng dng vt. Ch c tin hnh khi
c cc phu thut vin c kinh nghim.

| 421
TINH HON N TH CAO
1. nh ngha.
1.1. nh ngha.
Tinh hon n l nhng tinh hon dng li trn ng di chuyn ca tinh hon t bng
xung bu trong thi k bo thai. Cc th lm sng c th gp: tinh hon nm trong bng,
l bn su, trong ng bn v ngoi l bn nng. Tinh hon n th cao l cc th lm sng
m tinh hon nm v tr trong bng hoc l bn su.
1.2. Nguy c ca tinh hon n.
Nu khng iu tr c th gp nguy c: ung th ha, kh nng v sinh, thot v bn,
xon tinh hon hay chn thng tinh hon hoc tn thng v tm sinh l do khng c hay
ch c mt tinh hon di bu.
2. Nguyn nhn.
2.1. Ri lon trc h i - tuyn yn - tuyn sinh dc: suy tuyn yn, lm thiu
gonadotropin gy tinh hon n v chng dng vt nh li.
2.2. Sai lch tng hp testosteron: do thiu men 17 hydroxygenlase, 5 reductase
2.3. Hi chng gim kh nng cm nhn ca cc th th androgen.
2.4. Estrogen cng c tc dng lm hng s i xung ca tinh hon: m mang thai dng
diethylstilbesteron hay khng androgen (flutamid).
2.5. Pht trin bt thng ca dy chng tinh hon - bu.
2.6. Cc yu t c hc gy cn tr s di chuyn ca tinh hon nh: cung mch ca tinh
hon ngn, x ha vng ng bn
Nhn chung, phn ln cc trng hp khng xc nh c nguyn nhn.
3. Chn on.
3.1. Lm sng.
Thm khm vng bn bu: bu km pht trin, tinh hon n cng cao th bu cng km
pht trin. Tinh hon n th cao khi khm khng s thy tinh hon.
3.2. Cn lm sng.
3.2.1. Siu m bng, chp ct lp vi tnh bng hay ni soi bng l cc phong tin
thm d t thp n cao nhm xc nh chnh xc v tr ca tinh hon n.
3.2.2. Xt nghim th nhim sc nn c tin hnh mt cch h thng pht hin cc
trng hp gii tnh khng xc nh.
3.2.3. Nghim php hCG l mt nghim php c s dng xc nh xem tinh hon c
hay khng c trong trng hp c hai tinh hon u khng s thy.
3.2.4.Cc xt nghim hormon: LH, FSH, prolactin, estradiol v testosteron.
3.2.5. Cc xt nghim ch im khi u: FP, hCG nn lm pht hin cc trng hp
c tnh.

422 |
4. Phn tuyn.
Da vo hi bnh v thm khm lm sng chn on nh hng v chuyn ln
tuyn trn.
Chn on xc nh v iu tr thc th.
5. iu tr.
Cn pht hin sm v iu tr trc 2 tui
5.1. iu tr ni khoa.
Cc thuc ni tit c dung l:
- hCG (Profasi, Pregnyl 500 v, 1000 v, 1500 v/ng)
Khng nn qu 15.000 v/t v c th gy tc dng ph.
Tr t 1 - 2 tui, dng liu 300 v tim bp, ngy 1 ln, 3 ngy/ln vi tng liu 9
ln; tr t 3 - 7 tui liu 700 v/ln, tim; tr > 7 tui liu 1500 v/ln, tim.
- GnRH c dung di dng xt mi vi liu 1,2 mg/ngy
C th s dng phi hp GnRH v hCG.
5.2. iu tr phu thut.
5.2.1 Ch nh.
- iu tr ni khoa khng kt qu.
5.2.1 Nguyn tc.
- Phi h c tinh hon xung bu.
- Phu thut n tinh hon th cao l mt phu thut cn c bo tn do vy ch c
tin hnh khi c cc phu thut vin c kinh nghim.

| 423
GIN TNH MCH TINH

1. i cng.
nh ngha: gin tnh mch tinh (TMT) l hin tng gin bt thng ca tnh mch
tinh v m ri tnh mch tinh. 90 % gin TMT xy ra mt bn v thng l bn tri.
L do ch yu ngi bnh i khm l au tc vng bn bu hoc him mun con ci.
2. Nguyn nhn.
C ch gy gin TMT l do khng c van hoc thiu nng h thng van, v vy c tro
ngc mu t tnh mch thn vo m ri TMT.
3. Chn on.
3.1. Lm sng.
Khm ngi bnh t th ng, trong nhng trng hp in hnh, c th d dng
nhn thy bi gin tnh mch pha trn v sau tinh hon. Mc gin c th gia tng hn
khi lm nghim php Valsalva.
3.2. Cn lm sng.
3.2.1 Siu m Doppler mu.
Siu m Doppler mu cung mch tinh hon nh gi chnh xc mc gin TMT.
Bnh thng khu knh tnh mch tinh di 2 mm.
Gi l gin TMT khi c t nht mt tnh mch trong m ri tnh mch c ng knh
ln hn 2 mm, c hi lu khin phnh to hn sau khi ngi bnh ng dy hoc cho lm
nghip php Valsalva.
3.2.2 Siu m v chp ct lp vi tnh bng.
L nhng xt nghim cn thit khi c gin TMT nhm loi tr cc trng hp gin
TMT th pht do cc khi u sau phc mc hay tiu khung chn p.
3.2.3 Tinh dch .
Ch nh trong nhng trng hp v sinh nhm nh gi nh hng ca gin TMT i
vi chc nng sinh sn tinh trng.
3.3. Phn gin tnh mch tinh.
3.3.1. 0: gin TMT cha c biu hin lm sng, ch pht hin c khi lm cc thm
d cn lm sng nh siu m
3.3.2. 1: gin TMT s thy hoc nhn thy khi lm nghim php Valsalva.
3.3.3. 2: gin TMT s thy nhng khng nhn thy khi ng thng.
3.3.4. 3: gin TMT nhn thy hin r da bu khi ng thng.
4. Phn tuyn.
Da vo hi bnh v triu chng lm sng chn on nh hng v chuyn ngi
bnh ln tuyn trn.
Chn on xc nh v iu tr phu thut.

424 |
5. iu tr phu thut.
5.1. Ch nh.
5.1.1. Gin TMT gy triu chng au tc vng bn bu ko di nh hng ti sinh hot v
kh nng lao ng.
5.1.2. Gin TMT pht hin trn mt cp v chng v sinh.
5.1.3. Gin TMT kt hp vi teo tinh hon.
5.1.4. Gin TMT km theo bt thng v tinh dch .
5.2. Nguyn tc phu thut.
- Ct v tht hai u tnh mch tinh, lm xp ht mu ng phn tnh mch ngoi vi.
- Khng lm thng tn ng mch tinh.
5.3. Phng php phu thut.
- Phu thut m.
- Phu thut ni soi.

| 425
TNH DC NG GII

1. i cng.
1.1. Tnh dc ng gii (TDG) (homosexuality)
TDG l tnh trng mt ngi c xu hng v s thch quan h tnh dc vi ngi
cng gii. nam gii gi l ng gii nam, n gii gi l ng gii n.
1.2. Tnh dc ngi c cu thnh t bn yu t.
Gii sinh hc (th nhim sc XY, ngoi hnh, hormon), bn sc gii (s t thc v
bn thn mnh thuc vo gii no), vai tr x hi ca gii ( l cc hnh vi, thi c x,
thi ng x theo kiu ca nam hay ca n) v xu hng tnh dc.
1.3. Xu hng tnh dc l s hp dn bn vng v mt tnh cm v tnh dc vi mt
ngi thuc gii no .
C bn xu hng tnh dc:
- Xu hng tnh dc khc gii (heterosexuality): c ham mun v sinh hot tnh dc vi
ngi khc gii nh bnh thng.
- Xu hng tnh dc ng gii (homosexuality): ch ham mun v quan h tnh dc vi
ngi cng gii.
- Xu hng tnh dc lng gii (bisexuality): c ham mun v thch quan h tnh dc
vi c hai gii.
- Khng c xu hng tnh dc vi bt c gii no (asexuality): khng ham mun quan
h tnh dc vi bt c gii no.
Quan im hin nay cho rng xu hng tnh dc c hnh thnh mt c th ngay t
rt sm do tc ng qua li ca rt nhiu yu t sinh hc, tm l v x hi.
2 Nguyn nhn tnh dc ng gii.
C bn nguyn nhn.
2.1. L thuyt phn tm hc ca Freud.
- Theo Freud, bnh thng thi k pht trin tnh dc c tr trai v tr gi u tn ti
mt phc hp p. Chnh nh phc hp ny m tr trai hnh thnh nn nhn cch ca
mt ngi n ng cn tr gi s hnh thnh nn nhn cch ca mt ngi ph n.
- Hin tng ng gii xy ra khi xut hin mc cm p. Tr trai, do mc cm v qu
lo s v yu m mt cch dc tnh nn quay li yu ngi ng gii, cn tr gi
th ngc li do khng th yu cha mt cch dc tnh nn quay li yu ngi ng
gii vi mnh.
2.2 L thuyt v di truyn hc.
Qua nhiu nghin cu trn cc cp sinh i cng trng v khc trng, cc nh di truyn
cho rng gen ng mt vai tr quan trng trong vic hnh thnh xu hng tnh dc ng
gii nhng khng phi l yu t duy nht m cn c tc ng ca cc yu t mi
trng.

426 |
2.3 Ri lon ni tit t.
nam gii ni tit t n tng cao, ngc li ni tit t nam gii li gim thp cho nn
tnh tnh o l v s thch v tnh dc thch n ng. Ngc li, n gii ni tit t nam
tng cao, ni tit t n thp cho nn hnh th bn ngoi ging n ng, tnh nt ging n
ng v s thch tnh dc thch ph n.
2.4 Tp qun sinh hot.
Sng trong mt thi gian qu di vi tp th nhng ngi ng gii cho nn gii
quyt sinh hot tnh dc vi ngi ng gii thnh thi quen v tr thnh mt phn x
c iu kin.
3. Chn on.
3.1 Hi bnh.
Nhng iu kin sinh hot trong gia nh t nh v hon cnh sng hin ti chn
on v khuynh hng pht sinh bnh.
3.2 Khm thc th.
- Tm cc d tt bm sinh trn ng sinh dc.
- Khm tm cc thng tn do tnh dc ng gii gy nn: lot, vim...
3.3 Cn lm sng.
- nh lng 5 yu t hormon: LH, FSH, prolactin, estradiol v testosteron.
- Xt nghim nhim sc .
- Xt nghim HIV v nhng ngi tnh dc ng gii c nguy c cao mc bnh ny (c
th sinh hot tnh dc qua ng hu mn).
4. Phn tuyn t vn v iu tr.
- T vn gip ngi tnh dc ng gii v tm l.
- Vn ng cng ng ng xa lnh k th ngi tnh dc ng gii.
4.2. Tuyn tnh v tuyn ng.
Khm lm sng v cn lm sng tm nguyn nhn v iu tr.
5. iu tr.
- Nu c ri lon ni tit t th phi bi ph thng bng bnh thng ca tng gii.
- iu tr tm l, thuyt phc ngi bnh dng l tr vt qua giai on ny.
- To iu kin thay i mi trng sng.

| 427
CC RI LON BIT HA GII TNH SINH DC

1. i cng.
Trn lm sng gp nhng ngi bnh c bung trng, nhng c quan sinh dc li bit
ha nam tnh hay khng r rng v gii tnh, l trng hp lng tnh gi n; hoc gp
ngi bnh c tinh hon nhng c quan sinh dc ngoi v cc ng sinh dc bit ha nam
tnh khng hon ton cn gi l lng tnh gi nam, l nhng trng hp ri lon
ca bit ha gii tnh sinh dc.
Bit ha gii tnh sinh dc l mt qu trnh phc tp do nhiu yu t quyt nh: gii
tnh th nhim sc, gii tnh tuyn sinh dc v gii tnh hnh th.
Ri lon bt c mt giai on no ca qu trnh bit ha gii tnh sinh dc trong thi
k phi u nh hng n s pht trin ca c quan sinh dc v sinh sn.
Bit ha gii tnh bnh thng:
- Trong giai on hnh thnh thai nhi c vai tr ca cc nhim sc th X v Y, gen quyt
nh gii tnh vng Y (sex determining region Y - SRY) v mt s gen khc nh: gen
WT 1, gen SF 1, gen DAX 1
- Trong qu trnh pht trin thai c cc qu trnh bit ha tinh hon v bung trng, bit
ha cc ng sinh dc, bit ha c quan sinh dc ngoi.
- Khi sinh ra v ln ln c s bit ha gii tnh v phng din tm l.
2. Nguyn nhn.
Khi c s ri lon ca t nht mt trong cc yu t tham gia qu trnh bit ha gii tnh
bnh thng k trn s gy nn bit ha gii tnh bt thng.
3. Chn on.
3.1. Chn on xc nh.
3.1.1. Lm sng.
- Hi bnh.
Biu hin bt thng gii tnh v hnh vi, v d ngi bnh c hnh th ngoi l
nam gii nhng c x nh ngi n, thch chi vi bn nam
Qu trnh pht trin tnh cm, dy th, hn nhn v con ci. Ngoi tr cc trng
hp lng tnh gi n, hu ht cc ngi bnh khng r rng v gii tnh sinh dc t
c kh nng sinh sn.
- Khm bnh.
Ton thn: trng thi tinh thn kinh, hnh dng bn ngoi, h thng lng v ru pht
trin c bt thng? (v d km pht trin),
Thc th: bnh ni tit (v d: tiu ng), tim mch (v d: gin tnh mch, tim
bm sinh), h hp (v d: bnh phi mn tnh), tit niu (v d: d tt h tit
niu), c bp (c bp nho), v to ( ngi bnh Klinefelter),
Ti ch: b phn sinh dc ngoi: d tt (khng c tinh hon trong bu, l i thp,
c c tinh hon v m o,).
3.1.2. Cn lm sng.
- Siu m: c th pht hin c cc bt thng tng nh: d dng thn, bnh l tim
mch,

428 |
- Chp ct lp vi tnh: b sung cho siu m trong pht hin cc bnh l bt thng.
- Ni soi bng tm tinh hon, cc khi bt thng, t cung v bung trng,
- Xt nghim nhim sc th v bn gen.
- Xt nghim ni tit t sinh sn xc nh gii.
3.2. Chn on th bnh.
3.2.1. Cc ri lon bit ha do lon sn tinh hon bao gm.
Hi chng Klinefelter (th bnh thng gp c b nhim sc th 47,XXY): l bnh
thiu nng sinh dc nguyn pht hay gp v thng gy v sinh nam; lc trng thnh c
hnh dng nam gii, tinh hon rn v nh, v tinh v v ph i. Ngi bnh c t nht 2
nhim sc th X v mt s nhim sc th Y, ngoi tr mt s trng hp rt t ch c hai
nhim sc th XX.
Hi chng Turner (b nhim sc th 45,X). Cc du hiu in hnh: thn hnh b nh,
dy th n mun, cc tuyn sinh dc lon sn v teo, nhiu m x, ln da gy c nho;
b mt c nhng nt c bit nh cm nhn, khe mt li, tai vnh, c ngn v bnh hai
bn; c th gp nhng ri lon b phn khc nh: tng huyt p, hp ng mch ch,
thn d dng, cng tay khoo, vo ct sng; cc ng sinh dc c quan sinh dc ngoi
thng bit ha n.
Chn on hi chng Turner da vo b nhim sc th 45,X vi chiu cao gim r rt,
lon sn tuyn sinh dc km theo cc bt thng ca c th, dy th mun km theo nng
FSH huyt tng tng cao.
Lon sn tuyn sinh dc: c cc dng
- Lon sn tuyn sinh dc vi b nhim sc th 46,XX v 46,XY: ngi bnh c
hnh dng ph n, tuyn sinh dc teo nh v khng c nhng biu hin c trng
ca hi chng Turner.
- Lon sn tuyn sinh dc 46,XX do c cc t bin hay khuyt tt gen lm nh
hng n qu trnh pht trin ca bung trng.
- Lon sn tuyn sinh dc 46,XY do c cc t bin hay khuyt tt gen. Ngi bnh
c c quan sinh dc ngoi bit ha n nhng cc tuyn sinh dc teo, ng Muller
vn tn ti nhng m vt ph i.
Lng tnh tht (khi ngi bnh va c tinh hon va c bung trng mt hay c hai
bn tuyn sinh dc, v vy bit ha c quan sinh dc ngoi rt a dng). C quan sinh
dc ngoi c th ging nam hay ging n, nhng phn ln kh phn bit; hay gp tinh
hon n v l i lch thp (tinh hon hay bung trng tinh hon - ovotestis - c th nm
trong bu, mi ln, vng bn hay trong bng), t cung cng hay gp nhng thng teo
nh. Chn on cn tin hnh xt nghim tm b nhim sc th 46,XX/46,XY v pht hin
bung trng tinh hon vng bu - mi ln.
Lng tnh gi n (khi ngi bnh c bung trng, nhng c quan sinh dc li bit ha
nam tnh hay khng r rng v gii tnh). Ngi bnh l n c y bung trng v cc
cu trc Muller bnh thng nhng c quan sinh dc ngoi khng phn nh gii tnh. Thai
nhi n b nam tnh ha do nh hng ca androgen c ngun gc t bn thn thai nhi hay
t m.
Lng tnh gi nam (khi ngi bnh c tinh hon nhng c quan sinh dc ngoi v cc
ng sinh dc bit ha nam tnh khng hon ton). Nguyn nhn dn n lng tnh gi
nam bao gm:
- Tinh hon khng p ng vi hCG v LH.
- Khuyt tt trong sinh tng hp testosteron.

| 429
- Cc m ch khng p ng c vi androgen.
- Cc ri lon di truyn.
3.2.2. Cc ri lon bit ha gii tnh khc:
- Hi chng khng c tinh hon bm sinh (ngi bnh c b nhim sc th 46,XY
nhng khuyt tt tinh hon).
- Hi chng tn ti ng Muller (c c quan sinh dc ngoi nam bnh thng nhng vn
c cc ng Muller).
- L i lch thp: nguyn nhn do di truyn, cc t bo Leydig km hiu qu, khng
t bo ch, bt thng ca th th androgen,
- Dng vt b: nguyn nhn do thiu nng testosteron ca thai nhi, thiu men 5
reductase, khuyt tt ti th th androgen.
- Mt s khuyt tt rt him: khng c dng vt,
4. Phn tuyn.
Chn on nh hng da trn cc triu chng lm sng v t vn v phng hng
iu tr.
Chn on xc nh, chn on nguyn nhn v iu tr thc th
5. iu tr.
5.1. Nguyn tc.
Cn xc nh th bnh v da vo nguyn nhn. Mc ch ca ngi thy thuc trong
iu tr cc ngi bnh khng r rng v gii tnh sinh dc l chn on tnh trng bnh l
v nh hng gii tnh nui dy tr c cuc sng ph hp v tnh dc thch ng sau
tui dy th.
5.2. Liu php tm l.
Mt khi gii tnh c nh hng, cn tip tc cng c gii tnh bng cc
phng php ngoi khoa, ni tit v tm l. Vic nh hng v gii tnh tt nht phi
c thc hin trc 2 tui (l tui bt u pht trin tr tu).
5.3. iu tr ni khoa.
Cn xc nh r nguyn nhn trc khi quyt nh iu tr. V d:
- Hi chng Klinefelter: iu tr androgen thay th, c bit lc dy th mun hay khi
nng testosteron qu thp
- Hi chng Turner: iu tr nhm nng chiu cao ln, thc y cc c im th yu
sinh dc v to iu kin cho ngi bnh c kinh nguyt ng lc. iu tr bng
ni tit t tng trng phi hp vi ni tit t n.
Mt s trng hp phi kt hp vi phu thut.
Mc ch ca iu tr ngoi khoa l tr li ng gii tnh bng to hnh. Cc phu thut
to hnh nn tin hnh trc 6 n 12 thng tui. m vt c th to hnh sm nhng m
o c th i n tui thanh nin.
Tinh hon c lon sn ngi bnh c nhim sc th Y cn c loi b sm phng
ung th tinh hon.

430 |
nhng ngi bnh c khng androgen hon ton, cc tinh hon c th gi li cho n
lc thanh nin to ngun estrogen nu nh cc tinh hon khng nm mi ln. Lc ,
c th ct b tinh hon v tip tc s dng ni tit t thay th vo tui dy th.
S khng nh gii tnh ch yu da vo s nh hng gii tnh nui dy tr, cch
thc phu thut v s cng c v tm l thi nin thiu kt hp vi cc bin php tng
cng ni tit t vo lc dy th.

| 431

PHN PH LC

432 |

| 433

B Y T
-------
S:17/2005/Q-BYT
CNG HO X HI CH NGHA VIT NAM
c lp - T do - Hnh phc
--------------------------------
H Ni, ngy 01 thng 7 nm 2005

QUYT NH CA B TRNG B Y T
V vic ban hnh danh mc thuc thit yu Vit Nam ln th V

B TRNG B Y T
- Cn c Lut Bo v sc kho nhn dn ngy 11/7/1989 v iu l thuc phng bnh, cha bnh ban
hnh km theo Ngh nh s 23/HBT, ngy 24/01/1991 ca Hi ng B trng (nay l Chnh ph);
- Cn c Ngh nh s 49/2003/N-CP ngy 15/05/2003 ca Chnh ph qui nh chc nng, nhim v,
quyn hn v c cu t chc ca B Y t;
- Theo ngh ca ng Cc trng Cc Qun l dc Vit Nam v ng V trng V Y hc c truyn;

QUYT NH
iu 1. Ban hnh kmtheo Quyt nh ny:
1. Danh mc thuc thit yu Vit Namln th V, bao gm:
- Danh mc thuc thit yu tn dc,
- Danh mc thuc thit yu y hc c truyn.
2. Bn hng dn s dng Danh mc thuc thit yu Vit Nam ln th V.
iu 2.
1. Danh mc thuc thit yu l c s php l :
- Xy dng thng nht cc chnh sch ca Nh nc v: u t, qun l gi, vn, thu lin quan n thuc
phng cha bnh cho ngi nhm to iu kin c thuc trong danh mc thuc thit yu phc v
cng tc bo v chm sc v nng cao sc kho nhn dn.
- C quan qun l nh nc xy dng ch trng, chnh sch trong vic to iu kin cp s ng k lu
hnh thuc, xut nhp khu thuc.
- Cc n v trong Ngnh Y t tp trung cc hot ng ca mnh trong cc khu: Xut khu, nhp khu,
sn xut, phn phi, tn tr, s dng thuc thit yu an ton, hp l t hiu qu cao nhm p ng nhu
cu bo v chm sc v nng cao sc kho nhn dn .
- Cc trng chuyn ngnh y, dc t chc o to, ging dy, hng dn s dng thuc cho cc hc
vin, sinh vin.
2. Cc c s kinh doanh thuc ca Nh nc, t nhn phi mbo Danh mc thuc thit yu vi gi c
thch hp, hng dn s dng thuc an ton, hp l, hiu qu.
iu 3. Quyt nh ny c hiu lc sau 15 ngy, k t ngy ng cng bo v bi b Quyt nh s
2285/1999/Q-BYT ngy 28/7/1999 ca B trng B Y t v vic ban hnh Danh mc thuc thit yu Vit
Namln th IV.
iu 4. Cc ng, b: Cc trng Cc Qun l dc Vit Nam, V trng V Y hc c truyn, V trng
V iu tr phi hp vi cc n v lin quan hng dn, theo di v nh gi vic thc hin Quyt nh
ny.
iu 5. Cc ng, b: Chnh Vn phng, Chnh thanh tra, Cc trng Cc Qun l dc Vit Nam, V
trng V Y hc c truyn, V trng V iu tr v cc V, Cc c lin quan, Th trng cc n v trc
thuc B, Gim c S Y t cc tnh, thnh ph trc thuc Trung ng, Th trng Y t Ngnh chu trch
nhim thi hnh Quyt nh ny.

Ni nhn
- Nh iu 5;
- Vn phng Chnh ph (ng cng bo);
- B K hoch - u t;
- B Thng mi;
- B Ti chnh;
- B Khoa hc cng ngh;
- B cng an;
- B T php (Cc kim tra vn bn);
- V Php ch;
- Lu QLD, YHCT, Tr;
- Lu tr.

B TRNG B Y T

( k)

Trn Th Trung Chin

434 |

B Y T


A. DANH MC THUC THIT YU VIT NAM LN TH V
(Ban hnh km theo Quyt nh s 17/2005/Q-BYT ngy 1 thng 7 nm 2005 ca B trng B Y t)

PHN 1: DANH MC THUC THIT YU TN DC

STT TN THUC
NG DNG, HM LNG,
DNG BO CH
Tuyn s
dng
A B C D
I. THUC GY T, M
1. Thuc gy m v oxygen
1 Fentanyl Tim; ng 0,1 mg/2 ml + +
2 Halothan ng h hp; l 250 ml + +
3 Ketamin Tim; 50 mg/ml ng 10 ml + +
4 Oxygen dc dng ng h hp; bnh kh ho lng + +
5 Thiopental (mui natri) Tim; l 500 mg, 1 g bt pha tim + +
2. Thuc gy t ti ch
6 Bupivacain (hydroclorid) Tim; dung dch 0,25 %, 0,50 %, ng 4 ml + +
7 Ethyl clorid Dung dch phun ti ch; ng 30 ml + +
8 Lidocain (hydroclorid) Tim; dung dch 1 %, 2 %, ng 1 ml, 2 ml,
5 ml, 20 ml
+ + +
9 Procain (hydroclorid) Tim; dung dch 1 %, 3 %, 5 %, ng 1 ml, 2 ml + ++
3. Thuc tin m
10 Atropin (sulfat) Tim; ng 0,25 mg/ml + + +
Tim; ng 1 mg/ml + +
11 Diazepam Tim; 5 mg/ml ng 2 ml + +
12 Morphin (clorhydrat) Tim; ng 10 mg/ml + +
13 Promethazin (hydroclorid) Tim; 25 mg/ml, 50 mg/ml ng 1 ml, 2 ml + +
Ung; siro 5 mg/ml + +
II. THUC GIM AU, H ST, NHM CHNG VIM KHNG SREROID, THUC IU TR
BNH GT V CC BNH XNG KHP
1. Thuc gim au khng c opi, h st, chng vim khng steroid
14 Acid Acetylsalicylic Ung; vin 100 mg, 500 mg, gi 100 mg + ++ +
15 Diclofenac Ung; vin 25 mg, 50 mg, 75 mg, 100 mg + ++ +
16 Ibuprofen Ung; vin 200 mg, 400 mg + ++
17 Meloxicam Ung, vin 7,5 mg, 15 mg + +
Tim, ng 15 mg/1,5 ml + +
18 Paracetamol Ung; vin 100 mg, 500 mg + + + +
Thuc t; vin n 80 mg, 150 mg, 300 mg + ++ +
19 Piroxicam Tim; dung dch 20 mg/ml + +
Ung; vin 10 mg, 20 mg + ++
2. Thuc gim au loi opi
20# Morphin (clorhydrat)
Dng cho cp cu
Tim; ng 10 mg/ml + +
Tim; ng 10 mg/ml + ++ +
21# Morphin (sulfat) Ung; vin 10 mg, 30 mg + +
22 Pethidin (hydroclorid) Tim; 50 mg, 100 mg, ng 2 ml + +
3. Thuc iu tr bnh gt
23 Allopurinol Ung; vin 100 mg, 300 mg + ++
24 Colchicin Ung; vin 1 mg + ++

| 435
STT TN THUC
NG DNG, HM LNG,
DNG BO CH
Tuyn s
dng
A B C D
III. THUC CHNG D NG V DNG TRONG TRNG HP QU MN
25 Alimemazin Ung; vin 5 mg + ++ +
Ung; siro 5 mg/ml, chai 60 ml + ++ +
26 Clorpheniramin (hydrogen maleat) Ung; vin 4 mg + ++ +
27 Dexamethason Ung; vin 0,5 mg, 1 mg + +
28 Epinephrin (adrenalin) Tim; ng 1 mg/ml + ++ +
29 Hydrocortison Tim; l 125 mg hn dch tim + +
30 Mazipredon Tim; ng 30 mg/ml + +
31 Methylprednisolon Tim; l 40 mg + +
32 Prednisolon Ung; vin 5 mg + +
33# Promethazin (hydroclorid) Ung; vin nn 10 mg, 50 mg + ++ +
IV. THUC GII C
1. Thuc gii c c hiu
34# Atropin (sulfat) Tim; ng 0,25 mg/ml + ++ +
Tim; ng 1 mg/ml + +
35 Deferoxamin (mesilat) Timtruyn; l 500 mg, 1 g + +
36 Dimercaprol Tim; ng 50 mg/2 ml + +
37 Hydroxocobalamin Tim; ng 1.000 mcg, 5.000 mcg + +
38 Methionin Ung; vin 250 mg + ++ +
39 Naloxon (hydroclorid) Tim; ng 0,4 mg/ml + +
40 Natri calci edetat Tim; 200 mg/ml ng 5 ml, 10 ml + +
41 Natri thiosulfat Tim; 200 mg/ml ng 10 ml + +
42 Penicilamin Ung; vin 250 mg + +
Tim; l 1 g bt tim + +
43 Pralidoximiod Tim; 20 mg, 50 mg/ml ng 10 ml + +
44 Xanh methylen Tim, dung dch 1 %, ng 1 ml + +
2. Thuc gii c khng c hiu
45 Than hot Ung; bt, vin + ++ +
V. THUC CHNG NG KINH
46 Acid valproic (mui natri) Ung; vin 200 mg, 500 mg +
47 Carbamazepin Ung; vin 100 mg, 200 mg

+ +
48# Diazepam
Dng cho cp cu
Tim; 5 mg/ml ng 2 ml + ++
Tim; 5 mg/ml ng 2 ml + ++ +
Ung; vin 5 mg + ++
49 Magnesi sulfat Tim; dung dch 10 %, 20 %, ng 5 ml, 10 ml,
20 ml
+ +
50 Phenobarbital (mui natri) Tim; 100 mg/ml ng 2 ml + +
Ung; vin 10 mg, 100 mg + ++ +
51 Phenytoin (mui natri) Ung; vin 100 mg + +
VI. THUC TR K SINH TRNG, CHNG NHIM KHUN
1. Thuc tr giun, sn
a. Thuc tr giun, sn ng rut
52 Albendazol Ung; vin 200 mg, 400 mg + ++ +
53 Mebendazol Ung; vin 100 mg, 500 mg + ++ +
54 Niclosamid Ung; vin 500 mg + ++ +
b.Thuc tr giun ch
55 Diethylcarbamazin
(dihydrogen citrat)
Ung; vin 50 mg, 100 mg + +

436 |
STT TN THUC
NG DNG, HM LNG,
DNG BO CH
Tuyn s
dng
A B C D
c. Thuc tr sn l
56 Metrifonat Ung; vin 100 mg + +
57 Praziquantel Ung; vin 600 mg + +
2. Thuc chng nhim khun
a. Cc thuc nhm beta- lactam
58 Amoxicilin (hay amoxicilin
kt hp acid clavulanic *)
Ung; vin 250 mg, 500 mg + ++ +
Ung; bt pha hn dch 125 mg + ++
59 Ampicilin (mui natri) Tim; l 500 mg, 1 g bt pha tim + +
60 Benzathin benzylpenicilin Tim; l 600.000 IU, 1.200.000IU, 2.400.000 IU + + +
61 Benzylpenicilin Tim; ng 1 triu, 5 triu IU + + + +
62 Cefaclor Ung; vin 250 mg, 500 mg + + +
Tim; l 150 mg bt pha tim + +
63 Cefalexin Ung; vin 125 mg, 250 mg, 500 mg + ++ +
64 Cefazolin Tim; l 250 mg, 500 mg, 1 g bt pha tim + +
65 Cefixim Ung, vin 100 mg, 200 mg + +
66 Cefotaxim Tim; l 500 mg, 1 g bt tim + +
67 Cefradin Tim; l 500 mg, 1 g bt pha tim + ++
68 Ceftriaxon (*) Tim; l 250 mg bt pha tim + +
69 Cefuroxim Ung; vin 250 mg, 500 mg + +
70 Cloxacilin Ung; vin 250 mg, 500 mg + ++ +
Tim; l 500 mg bt pha tim + ++
71 Phenoxymethylpenicilin Ung; vin 200.000 IU, 400.000 IU,
1.000.000 IU
+ + + +
72 Procain benzylpenicilin Tim; bt pha tim, l 400.000 IU,
1.000.000 IU
+ + +
b. Cc thuc khng khun khc
* Thuc nhm aminoglycosid
73 Amikacin (*) Tim; l 250 mg, 500 mg bt pha timhoc dung dch +
74 Gentamicin Tim; ng 40 mg, 80 mg/2 ml + ++
75 Spectinomycin Tim; l 2 g bt pha tim + +
76 Tobramycin Tim; ng 80 mg/2 ml + +
* Thuc nhm chloramphenicol
77 Cloramphenicol Tim; l 1 g bt pha tim + +
Ung; vin 250 mg + ++ +
* Thuc nhm glycopeptid
78 Vancomycin (*) Tim; l 500 mg bt tim +
* Thuc nhm nitroimidazol
79 Metronidazol Ung; vin 250 mg, 500 mg + ++ +
Tim; chai 500 mg/100 ml + +
80 Secnidazol Ung; vin 500 mg + +
81 Tinidazol Ung; vin 500 mg + +
* Thuc nhm lincosamid
82 Clindamycin Tim; 150 mg/ml ng 2 ml hay 4 ml + +
Ung, vin 150 mg, 300 mg + + +
* Thuc nhm macrolid
83 Azithromycin (*) Ung; vin 500 mg + +
84 Clarithromycin Ung ; vin 250 mg, 500 mg + +
85 Erythromycin Ung; vin 250 mg, 500 mg + ++ +
Ung; bt pha hn dch 125 mg/5 ml + ++ +

| 437
STT TN THUC
NG DNG, HM LNG,
DNG BO CH
Tuyn s
dng
A B C D
86 Roxithromycin Ung; vin 50 mg, 150 mg + ++
* Thuc nhm quinolon
87 Acid nalidixic Ung; vin 250 mg, 500 mg + ++
88 Ciprofloxacin Ung; vin 250 mg, 500 mg + ++
Tim, 2 mg/ml chai 50 ml, 100 ml + +
89 Norfloxacin Ung; vin 200 mg, 400 mg + +
90 Ofloxacin Tim; ng 400 mg + +
Ung; vin 200 mg + +
* Thuc nhm sulfamid
91 Sulfadimidin (mui natri) Ung; vin 500 mg + ++ +
92 Sulfamethoxazol v
trimethoprim
Ung; vin 400 mg v 80 mg + ++ +
* Thuc nhm tetracyclin
93 Doxycyclin Ung; vin 100 mg + ++ +
c. Thuc cha bnh phong
94 Clofazimin Ung; vin 50 mg, 100 mg + +
95 Dapson Ung; vin 50 mg, 100 mg + +
96 Rifampicin Ung; vin 150 mg, 300 mg + +
d. Thuc cha bnh lao
97 Ethambutol (hydroclorid) Ung; vin 100 mg, 400 mg + ++ +
98 Isoniazid Ung; vin 50 mg, 100 mg, 150 mg, 300 mg + ++ +
99 Pyrazinamid Ung; vin 400 mg + ++ +
100# Rifampicin v isoniazid Ung; vin 150 mg v 100 mg + ++ +
101# Rifampicin Ung; vin 150 mg, 300 mg + ++ +
102 Streptomycin Tim; l 1 g bt pha tim + ++ +
3. Thuc chng nm
103 Amphotericin B Tim; l 50 mg bt pha tim +
104 Clotrimazol Thuc t; vin 50 mg, 100 mg + ++ +
105 Fluconazol Ung; vin 50 mg, 150 mg + +
106 Griseofulvin Ung; vin 250 mg, 500 mg + ++
107 Ketoconazol Ung; vin 200 mg + ++
108 Nystatin Thuc t; vin 100.000 IU + ++ +
Ung; vin 250.000IU, 500.000 IU + ++ +
4. Thuc iu tr bnh do ng vt nguyn sinh
a. Thuc iu tr bnh do amip
109 Diloxanid (furoat) Ung; vin 500 mg + ++
110# Metronidazol Ung; vin 250 mg, 500 mg + ++ +
Tim; 5 mg/ml chai 100 ml + +
b. Thuc iu tr bnh st rt
* Thuc phng bnh
111 Cloroquin Ung; vin 100 mg, 250 mg + ++ +
112 Mefloquin Ung; vin 250 mg + +
* Thuc cha bnh
113 Artemisinin Ung; vin 250 mg + ++ +
114 Artesunat Ung; vin 50 mg, 100 mg + + + +
Tim; L 60 mg bt +0,6ml dd natri carbonate 5 % + +
115# Cloroquin Ung; vin 100 mg, 250 mg + ++ +
116 Primaquin Ung; vin 7,5 mg, 15 mg + ++ +
117 Quinin dihydroclorid Tim; 150 mg/ml ng 2 ml + ++ +

438 |
STT TN THUC
NG DNG, HM LNG,
DNG BO CH
Tuyn s
dng
A B C D
118 Quinin sulfat Ung; vin 300 mg + ++ +
119 Sulfadoxin +pyrimethamin Ung; vin 500 mg +25 mg + +
5. Thuc chng virus
a. Thuc chng virus herpes
120 Aciclovir Ung; vin 200 mg, 800 mg + +
Dng ngoi; kem5 %; tup 2 g, 5 g, 15 g + +
121 Ribavirin Ung, vin 500 mg +
b. Thuc chng virus (**)
122 Efavirenz (EFV hoc EFZ) Ung; vin 50 mg, 100 mg, 200 mg +
Ung; dung dch 150 mg/ 5 ml +
123 Indinavir Ung, vin 200 mg, 400 mg + +
124 Lamivudin Ung, vin 150 mg + +
Ung; dung dch 50 mg/5 ml + +
125 Nelfinavir (NFV) Ung; vin 250 mg +
Ung; gi bt 50 mg +
126 Nevirapin Ung, vin 200 mg + +
127 Zidovudin Ung; vin 300 mg + +
Ung; dung dch 50 mg/5 ml + +
VII. THUC IU TR AU NA U
1. Thuc iu tr cn au cp
128 Ergotamin (tartrat) Ung; vin 1 mg + ++
Tim; ng 0,5 mg/ml + ++
2. Thuc phng bnh
129 Propranolol (hydroclorid) Ung; vin 20 mg, 40 mg + +
VIII. THUC CHNG UNG TH V TC NG VO H THNG MIN DCH
1. Thuc c ch min dch
130 Azathioprin Ung; vin 50 mg +
131 Ciclosporin Ung; vin 25 mg, 50 mg, 100 mg +
2. Thuc chng ung th
132 L - asparaginase Tim ; l 10.000.000 IU +
133 Bleomycin Tim; l15 mg bt pha tim +
134 Carboplatin Tim; ng 50 mg, 150 mg, 450 mg +
135 Cisplatin Tim; ng 10 mg, 50 mg +
136 Cyclophosphamid Ung; vin 25 mg +
Tim; l 100 mg, 200 mg, 500 mg bt pha tim +
137 Cytarabin Tim; l 100 mg, 500 mg bt ng kh +
138 Dactinomycin Tim; l 0,5 mg bt pha tim +
139 Doxorubicin (hydroclorid) Tim; l 10 mg, 50 mg bt pha tim +
140 Etoposid Ung; vin 50 mg, 100 mg +
Tim; l 50 mg, 100 mg bt pha tim +
141 Fluorouracil Tim; 50 mg/ml ng 5 ml +
142 Hydroxycarbamid Ung; vin 250 mg, 500 mg +
143 Ifosfamid Tim; l 1 g bt pha tim +
144 Mercaptopurin Ung; vin 50 mg +
145 Methotrexat Ung; vin 2,5 mg +
Tim; l 10 mg, 50 mg bt pha tim +
146 Mitomycin Tim; l 2 mg, 10 mg bt pha tim +
147 Procarbazin Ung; vin 50 mg +

| 439
STT TN THUC
NG DNG, HM LNG,
DNG BO CH
Tuyn s
dng
A B C D
148 Tamoxifen Ung; vin 10 mg, 20 mg +
149 Vinblastin (sulfat) Tim; 10 mg/ml ng 10 ml +
150 Vincristin (sulfat) Tim; ng 1 mg/ml, 2 mg/2 ml, l 5 mg +
3. Thuc h tr trong iu tr ung th
151 Calci folinat Tim; ng 50 mg, 100 mg +
152 Filgrastim Tim;ng 30IU/ml +
153 Molgramostim Tim; l 3 mg bt ng kh +
154 Ondansetron Tim; 2 mg/ml ng 4 ml +
IX. THUC CHNG PARKINSON
155 Biperiden Ung; vin 2 mg, 4 mg + ++
156 Levodopa v carbidopa Ung; vin 25 mg v 250 mg + ++
X.THUC TC DNG I VI MU
1. Thuc chng thiu mu
157 Acid folic Ung; vin 1 mg, 5 mg + ++
158 Cyanocobalamin Tim; ng 500 mcg, 1000 mcg + ++
159 St sulfat (hay oxalat) Ung; vin 60 mg st + ++ +
160 St sulfat v acid folic Ung; vin 60 mg st v 0,25 mg folic acid + ++ +
2. Thuc tc dng ln qu trnh ng mu
161 Acenocoumarol Ung; vin 2 mg, 4 mg + +
162 Acid aminocaproic Tim; dung dch 200 mg/ml, ng 10 ml + +
163 Acid tranexamic Ung; vin 250 mg, 500 mg + ++
Tim; dung dch 10 %, ng 5 ml, 10 ml + +
164 Carbazocrom Ung; vin 10 mg + +
Tim; ng 15 mg +
165 Heparin (mui natri) Tim; ng 1nghn, 5 nghn, 20 nghn, 25 nghn IU/ml +
166 Phytomenadion (vitamin K1) Ung; vin 2 mg, 5 mg, 10 mg + ++ +
Tim; 5 mg/ml ng 5 ml + ++ +
167 Protamin sulfat Tim; 10 mg/ml ng 5 ml + +
168 Warfarin (mui natri) Ung; vin 1 mg, 2 mg, 5 mg +
3. Loi khc
169 Erythropoietin (*) Tim; ng 1.000IU, 2.000IU, 4.000 IU + +
XI. CH PHM MU - DUNG DCH CAO PHN
1.Dung dch cao phn t
170 Dextran 40 Truyn; dung dch 10 %, chai 250 ml, 500 ml + +
171 Dextran 70 Truyn; dung dch 6%, chai 250 ml, 500 ml + +
172 Gelatin Truyn; dung dch 5 %, 6%, l 500 ml + +
2. Ch phm mu
173 Albumin Tim; dung dch 5 %, 25 %, chai 50 ml, 100 ml +
174 Huyt tng ng lnh Tim; ti 250 ml +
XII. THUC TIM MCH
1. Thuc chng au tht ngc
175 Atenolol Ung; vin 50 mg, 100 mg + ++
176 Diltiazem Ung; vin 30 mg, 60 mg + +
177 Glyceryl trinitrat Ung; vin 2 mg, 2,5 mg, 3 mg, 5 mg + ++
Ngm di li; vin 0,5 mg + ++
Tim, ng 3 mg, 15 mg + +
178 Isosorbid (dinitrat hoc mononitrat) Ung; vin 5 mg, 30 mg, 60 mg + +

440 |
STT TN THUC
NG DNG, HM LNG,
DNG BO CH
Tuyn s
dng
A B C D
2. Thuc chng lon nhp
179 Amiodaron (hydroclorid) Ung; vin 200 mg + ++
Tim; ng 150 mg/3 ml +
180# Atenolol Ung; vin 50 mg, 100 mg + ++
181# Lidocain (hydroclorid) Tim; dung dch 1 %, 2 %, ng 2 ml, 5 ml + +
182# Propranolol (hydroclorid) Ung; vin 40 mg + ++
Tim, ng 1 mg/2 ml, 2 mg/2 ml +
183 Verapamil (hydroclorid) Ung; vin 40 mg, 80 mg + ++
3. Thuc iu tr tng huyt p
184 Amlodipin Ung; vin 2,5 mg, 5 mg + +
185 Captopril Ung; vin 25 mg, 50 mg + ++
186 Enalapril Ung; vin 5 mg, 20 mg + ++
187 Hydroclorothiazid Ung; vin 25 mg, 50 mg + ++ +
188 Methyldopa Ung; vin 250 mg + ++ +
189 Nifedipin Ung; vin 5 mg, 10 mg + ++
Ung, vin tc dng chm 20 mg + ++
190 Propranolol (hydroclorid) Ung; vin 40 mg + ++ +
4. Thuc iu tr h huyt p
191 Heptaminol (hydroclorid) Ung; vin 150 mg + ++
Tim; 62,5 mg/ml ng 2 ml + +
5. Thuc iu tr suy tim
192 Digoxin

Dng cho cp cu
Ung; vin 0,25 mg + +
Tim; dung dch 0,1 mg, 0,5 mg, ng 2 ml + +
Tim; dung dch 0,1 mg, 0,5 mg, ng 2 ml + + + +
193 Dobutamin Tim; ng bt ng kh 250 mg + +
194 Dopamin (hydroclorid) Tim; 40 mg/ml ng 5 ml +
195 Epinephrin (adrenalin) Tim; ng 1 mg/ml + +
6. Thuc chng huyt khi
196 Acid acetylsalicylic Ung; vin 100 mg, gi 100 mg + ++
197 Streptokinase (*) Tim truyn; 1,5 triu IU/l + +
7. Thuc h lipit mu
198 Atorvastatin Ung; vin 10 mg, 20 mg + ++
199 Fenofibrat Ung vin 100 mg, 300 mg + ++
200 Simvastatin Ung, vin 5 mg, 10 mg, 20 mg +
XIII. THUC NGOI DA
1. Thuc chng nm
201 Acid benzoic v acid salicylic Dng ngoi; kem, m 6% v 3 %, tup 5 g, 15 g + + + +
202 Cn A.S.A Dng ngoi; l 15 ml + ++ +
203 Cn BSI Dng ngoi; l 15 ml + ++ +
204# Clotrimazol Dng ngoi; kem1 %, tup 10 g, 20 g + ++ +
205# Ketoconazol Dng ngoi; kem2 %, tup 15 g + ++ +
206 Miconazol Dng ngoi; kem2 %, tup 10 g + ++ +
2. Thuc chng nhim khun
207 Neomycin v bacitracin Dng ngoi; kem5 mg neomycin
v 500 IU bacitracin
+ + + +
208 Povidon iod Dng ngoi; dung dch 10 %,
l 15 ml, 30 ml, 60 ml
+ + + +

| 441
STT TN THUC
NG DNG, HM LNG,
DNG BO CH
Tuyn s
dng
A B C D
3. Thuc chng vim nga
209 Betamethason (valerat) Dng ngoi; m 0,1 % + +
210 Fluocinolon acetonid Dng ngoi; m 0,025 % + ++ +
211 Hydrocortison (acetat) Dng ngoi; m 1 % + + + +
4. Thuc c tc dng lm tiu sng
212 Acid salicylic Dng ngoi; m 3 %, 5 %, tup 15 g + ++ +
5.Thuc tr gh
213 Benzyl benzoat Dng ngoi; dung dch + ++ +
214 Diethylphtalat Dng ngoi; dung dch 10 % + ++ +
Dng ngoi; m, tup 5 g, 15 g + ++ +
6.Thuc c tc dng ngn tia t ngoi
215 Km oxyd Dng ngoi; m, tup 15 g + +
XIV. THUC DNG CHN ON
1. Thuc dng cho mt
216 Fluorescein (mui natri) Nh mt; dung dch 2 %, l 5 ml, 10 ml +
Tim; ng 5 ml dung dch 100 mg/ml +
217 Pilocarpin Nh mt; dung dch 1 mg, 5 mg/ml, l 5 ml, 10 ml +
2. Thuc cn quang
218 Amidotrizoat Tim; ng 2,8g, 16,8g Iod/20 ml + +
219 Bari sulfat Ung; bt hn dch hoc hn dch + +
220 Iohexol Tim; ng 5,82 g, 7,77g/15 ml, 6,47g/10 ml +
221 Iopromid Tim; ng 300 mg iod/ml +
XV. THUC KH TRNG V TY TRNG
222 Clorhexidin (digluconat) Dng ngoi; dung dch 5 % + +
223 Cn 70
0
Dng ngoi, l 60 ml + ++ +
224 Cn iod Dng ngoi; dung dch 2,5 %, l 15 ml + ++ +
225 Nc oxy gi Dng ngoi; dung dch 3 %, l 15 ml, 60 ml + ++ +
226# Povidon iod Dng ngoi; dung dch 10 %, l 15 ml, 30 ml,
60 ml
+ + + +
XVI. THUC LI TIU
227 Furosemid

Dng cho cp cu
Ung; vin 20 mg, 40 mg + ++
Tim; ng 20 mg/2 ml + +
Tim; ng 20 mg/2 ml + ++
228# Hydroclorothiazid Ung; vin 6,25 mg, 25 mg, 50 mg + ++ +
229 Manitol Timtruyn; dung dch 10 %, 20 % + +
230 Spironolacton Ung; vin 25 mg, 50 mg, 75 mg + +
XVII. THUC NG TIU HA
1. Thuc chng lot d dy, t trng
231 Cimetidin Ung; vin 200 mg, 400 mg + ++
Tim; ng 100 mg/ml + +
232 Bismuth (carbonat, trikaliumdicitrato
...)
Ung; vin 120 mg + ++
233 Famotidin Tim; l 20 mg/5 ml + +
Ung; vin 20 mg, 40 mg + +
234 Magnesi hydroxyd v
nhmhydroxyd
Ung; hn dch cha 550 mg magne oxide/10 ml v 320 mg
nhmoxide/5 ml
+ + + +
235 Omeprazol Ung; vin 20 mg + ++
236 Pantoprazol Tim; bt pha tim, l 40 mg +
Ung; vin 40 mg +

442 |
STT TN THUC
NG DNG, HM LNG,
DNG BO CH
Tuyn s
dng
A B C D
237 Ranitidin Ung; vin150 mg, 300 mg + +
2. Thuc chng nn
238 Metoclopramid Ung; vin 10 mg + +
Tim; 5 mg/ml, ng 2 ml + +
239# Promethazin (hydroclorid) Ung; vin bc ng 10 mg, 50 mg + +
3. Thuc chng co tht
240 Alverin (citrat) Tim; 15 mg/ml, ng 2 ml + +
Ung; vin 40 mg, 60 mg + ++ +
241# Atropin (sulfat) Ung; vin 0,25 mg + ++ +
Tim; ng 0,25 mg/ml + ++ +
242 Hyoscin butylbromid Ung; vin 10 mg + +
Tim; ng 20 mg + +
243 Papaverin Tim; ng 40 mg/ml + +
Ung; vin 40 mg + ++ +
4. Thuc ty, nhun trng
244 Bisacodyl Ung; vin 5 mg, 10 mg + ++ +
245# Magnesi sulfat Ung; gi bt 5 g + + + +
5. Thuc tiu chy
a. Chng mt nc
246 Oresol Ung; gi bt 27,9g + ++ +
b. Chng tiu chy
247 Atapulgit Gi bt; 3 g + ++
248 Berberin (hydroclorid) Ung; vin 10 mg + ++ +
259 Loperamid Ung, vin 2 mg + ++ +
6. Thuc iu tr bnh tr
250 Diosmin Ung; vin 150 mg, 300 mg + ++
XVIII. HORMON, NI TIT T, THUC TRNH TH THAI
1. Hormon thng thn v nhng cht tng hp thay th
251# Dexamethason (natri phosphat) Ung; vin 0,5 mg, 1 mg + ++
Tim; ng 4 mg/ml + +
252# Hydrocortison Tim; ng 125 mg hn dch tim + +
253# Prednisolon Ung; vin 1 mg, 5 mg + ++
2. Cc cht Androgen
254 Methyltestosteron Vin ngm di li; vin 5 mg, 10 mg + +
Ung, vin 0,025 mg, 0,1 mg + +
255 Testosteron (acetat, propionat..) Tim; ng 25 mg, 50 mg/ml + +
Ung; vin 40 mg + +
3. Thuc trnh thai
256 Ethinylestradiol v
levonorgestrel
Ung; vin 0,03 mg v 0,15 mg + + + +
257 Ethinylestradiol v
norethisteron
Ung; vin 0,05 mg v 0,1 mg + + + +
258 Levonorgestrel Ung; vin 0,03 mg + ++ +
259 Norethisteron enantat Tim; ng 200 mg/ml +
4. Cht estrogen
260 Ethinyl estradiol Ung; vin 0,05 mg + +
5. Insulin v thuc h ng huyt
261 Acarbose Ung; vin 50 mg, 100 mg +
262 Glibenclamid Ung; vin 2,5 mg, 5 mg + ++

| 443
STT TN THUC
NG DNG, HM LNG,
DNG BO CH
Tuyn s
dng
A B C D
263 Gliclazid Ung; vin 30 mg, 80 mg + + +
264 Insulin Tim; 40 IU/ml ng 10 ml + +
265# Insulin (tc dng nhanh) Tim; 40 IU/ml ng 10 ml + +
266 Metformin Ung; vin 500 mg, 850 mg + ++
267 Rosiglitazon maleat Ung; vin 4 mg, 8mg +
6. Thuc c tc dng thc y qu trnh rng trng
268 Clomifen (citrat) Ung; vin 50 mg +
269 Gonadotropin (human, chorionic, rau
thai) (*)
Ung; bt ng kh 500IU, 1.500 IU +
7. Nhng cht Progesteron
270 Norethisteron Ung; vin 5 mg +
271 Progesteron Tim; ng 10 mg, 25 mg/ml + +
8. Gip trng v khng gip trng
272 Carbimazol Ung; vin 5 mg + +
273 Levothyroxin (mui natri) Ung; vin 0,05 mg, 0,1 mg + +
274 Methylthiouracil Ung; vin 50 mg + +
275 Propylthiouracil Ung; vin 50 mg + +
9. Thuc iu tr i tho nht
276 Pituitrin Tim; ng 5 IU, 10 IU/ml + +
XIX. SINH PHM MIN DCH
1. Huyt thanh v Globulin min dch
277 Gamma globulin Tim; 0,25 mg/liu + +
278 Huyt thanh khng di Tim; ng 1.000IU, 2.000 IU/ml + ++ +
279 Huyt thanh khng un vn Tim; ng 1.500IU, 10.000 IU/ml + ++ +
2. Vaccin
a.Tim chng m rng trin khai phm vi c nc
280 B.C.G (ng kh) Tim; ng + ++ +
281 Vaccin bch hu - un vn
- ho g (DPT)
Tim; ng + ++ +
282 Vaccin si Tim; ng + + + +
283 Vaccin bi lit (OPV) Dung dch ung + ++ +
b. Tim chng m rng trin khai vng trng im
284 Vaccin phng vim gan B Tim; ng + ++ +
285 Vaccin phng vim no
Nht Bn
Tim; ng + ++ +
286 Vaccin phng thng hn Tim; ng + ++ +
287 Vaccin t Dung dch ung + + + +
c. Vaccin khc
288 Vaccin bch hu-un vn Tim; ng + ++ +
289 Vaccin phng di Tim; ng + ++ +
290 Vaccin un vn Tim; ng + ++ +
XX. THUC GIN C V TNG TRNG LC C
291 Neostigmin bromid Ung; vin 15 mg + +
Tim; ng 0,5 mg + +
292 Pancuroniumbromid Tim; ng 4 mg/2 ml + +
293 Suxamethoniumclorid Tim; ng100 mg/2 ml + +

444 |
STT TN THUC
NG DNG, HM LNG,
DNG BO CH
Tuyn s
dng
A B C D
XXI. THUC DNG CHO MT, TAI MI HNG
1. Thuc chng nhim khun, khng virus
294 Aciclovir Tra mt; m 3 %, tup 2 g, 5 g + + + +
295 Argyrol Nh mt; dung dch 3 % + + +
296# Cloramphenicol Nh mt; dung dch 0,4 %, l 10 ml + ++ +
297# Gentamicin Nh mt; dung dch 0,3 %, l 5 ml + ++ +
298 Neomycin (sulfat) Nh mt; dung dch 0,5 %, l 5 ml + ++ +
299# Ofloxacin Nh mt, tai; dung dch 0,3 %, l 5 ml + +
300 Sulfacetamid natri Nh mt; dung dch 10 %, l 5 ml + ++ +
301 Tetracyclin (hydroclorid) Tra mt; m 1 %, tup 5 g, 10 g + ++ +
2. Thuc chng vim
302# Hydrocortison Tra mt; m 1 %, tup 2,5 g, 5 g + +
3. Thuc gy t ti ch
303 Tetracain (hydroclorid) Nh mt; dung dch 0,5 % +
4. Thuc lm co ng t v gim nhn p
304 Acetazolamid Ung; vin 250 mg + +
305# Pilocarpin Nh mt; dung dch 1 mg/ml, 5 mg/ml,
l 5 ml, 10 ml
+ +
306 Timolol Nh mt; dung dch 0,25 %, 0,5 % +
5. Thuc lm gin ng t
307# Atropin (sulfat) Nh mt; dung dch 0,1 %, 0,5 %, 1,0 %, l 5 ml + +
6. Thuc tai, mi, hng
308# Nc oxy gi Dng ngoi; dung dch 3 %, l 15 ml, 60 ml + ++ +
309 Naphazolin Nh mi, dung dch 0,05 %, l 10 ml + ++ +
310 Neomycin (sulfat) Dng ngoi; dung dch 0,5 % + ++ +
311 Sulfarin Nh mi, dung dch + + + +
312 Xylometazolin Nh mi, dung dch 0,05 %, 0,1 %, l 5 ml + +
XXII. THUC C TC DNG THC , CM MU SAU V CHNG NON
1. Thuc thc , cm mu sau
a. Thuc thc
313 Oxytocin Tim; ng 5IU, 10IU/ml + +
b. Thuc cm mu sau
314 Ergometrin (hydrogen maleat) Tim; ng 0,2 mg/ml + ++
315# Oxytocin Tim; ng 5IU, 10 IU/ml + ++ +
2. Thuc chng non
316# Papaverin Ung; vin 40 mg + ++ +
317 Salbutamol Ung; vin 2 mg, 4 mg + +
Tim, ng 0,5 mg/ml, 5 mg/5 ml + +
XXIII. DUNG DCH THM PHN MNG BNG
318 Dung dch thmphn mng
bng
Ti 3lt, 5 lt + +
319 Dung dch lc thn acetat Ti 3lt, 5 lt + +
XXIV. THUC CHNG RI LON TM THN
1. Thuc chng lon thn
320 Clopromazin
(hydroclorid)
Ung; siro 5 mg/ml l 5 ml + +
Tim; 12,5 mg/ml ng 2 ml + +
Ung; vin 25 mg, 100 mg + +
321# Diazepam Ung; vin 2 mg, 5 mg + +
Tim; 5 mg/ml ng 2 ml + +

| 445
STT TN THUC
NG DNG, HM LNG,
DNG BO CH
Tuyn s
dng
A B C D
322 Haloperidol Ung; vin 1 mg, 5 mg + ++
Tim; ng 5 mg/ml + +
323 Levomepromazin Ung; vin 25 mg + +
Tim; ng 25 mg/ml +
324 Risperidon Ung, vin 1 mg, 2 mg +
325 Sulpirid Ung; vin 50 mg
Tim; ng 50 mg/ml ng 2 ml + +
2. Thuc chng trm cm
326 Amitriptylin (hydroclorid) Ung; vin 25 mg + +
3. Thuc iu chnh v d phng ri lon cm xc
327# Acid valproic Ung; vin 200 mg, 500 mg + +
328# Carbamazepin Ung; vin 100 mg, 200 mg + +
4. Thuc iu tr m nh v hong lon thn kinh
329 Clomipramin Ung; vin 10 mg, 25 mg +
XXV. THUC TC DNG TRN NG H HP
1. Thuc cha hen
330 Aminophylin Tim; 25 mg/ml ng 10 ml + +
331 Beclometason (dipropionat) ng h hp; hp 0,05 mg/liu +
332# Salbutamol (sulfat) Ung; vin 2 mg, 4 mg + ++
ng h hp; hp 0,1 mg/liu + + +
333 Terbutalin Tim; ng 0,5 mg/ml + +
2. Thuc cha ho
334 Acetylcystein Ung; vin 100 mg, 200 mg + ++ +
Ung; gi 200 mg bt pha hn dch + ++ +
335 Alimemazin Ung; siro 2,5 mg/5 ml + ++ +
336 Bromhexin (hydroclorid) Ung; vin 4 mg, 8mg + +
337 Dextromethorphan Ung; vin 15 mg + ++ +
XXVI. DUNG DCH IU CHNH NC IN GII V CN BNG ACID-BASE 1. Thuc ung
338# Oresol Ung; gi bt 27,9 g/l + ++ +
339 Kali clorid Ung, vin 600 mg + + + +
2. Thuc tim truyn
340 Dung dch acid amin Timtruyn; dung dch 5 %, 10 %, chai 250 ml, 500 ml + +
341 Dung dch glucose Tim; ng 20 ml, dung dch 5 % v 30 % + ++
Timtruyn; Chai 250 ml, 500 ml, dung dch
5 % v 30 %
+ + +
342 Dung dch ringer lactat Timtruyn; chai 250 ml, 500 ml + + +
343 Dung dch calci clorid Timtnh mch; dung dch 10 %, ng 5 ml, 10 ml + +
344# Kali clorid Timtruyn; dung dch 11,2 %, ng 5 ml +
345 Natri clorid Timtruyn; chai 500 ml dung dch 0,9% + ++
Timtruyn, ng 10 ml dung dch 10 % + +
346 Natri hydrocarbonat Timtruyn; chai dung dch 1,4 %, 8,4 % +
3. Thuc khc
347 Nc ct pha tim Tim; ng 2 ml, 5 ml, 10 ml + ++ +
XXVII. VITAMIN V CC CHT V C
348 Calci gluconat Ung; ng 10 ml dung dch 10 % + ++ +
349 Vitamin A Ung; vin bc ng 5.000 IU + ++ +
350 Vitamin A v D Ung; vin 5.000 IU vitaminA v 500 IU
vitaminD

+ + + +

446 |
STT TN THUC
NG DNG, HM LNG,
DNG BO CH
Tuyn s
dng
A B C D
351 Vitamin B1 Ung; vin 10 mg, 50 mg, 100 mg + ++ +
Tim, ng 25 mg, 100 mg + ++
352 Vitamin B2 Ung; vin 5 mg + ++ +
353 Vitamin B6 Ung; vin 25 mg, 100 mg + ++ +
354 Vitamin C Ung; vin 50 mg, 100 mg, 500 mg + ++ +
Tim, ng 500 mg + +
355 Vitamin PP Ung; vin 50 mg + ++ +

Tng cng: 355 tn thuc ca 314 hot cht

Ghi ch:
* Cc thuc c hot cht trng, t ln th hai tr i c nh s th t kmk hiu #
* C th s dng cc bit dc c cng hot cht thay th
* Tuyn s dng:
Tuyn A: bnh vin hng 1, 2
Tuyn B: bnh vin hng 3 v khng hng
Tuyn C: c s y t c bc s (phng khm, y t c quan, trng hc, trm y t x)
Tuyn D: c s y t khng c bc s (phng khm, y t c quan, trng hc, trm y t x)

B TRNG B Y T

( k)

Trn Th Trung Chin

| 447
B. BN HNG DN S DNG DANH MC THUC THIT YU VT NAM LN TH 5
(Ban hnh km theo Quyt nh s: 17/2005/Q-BYT ngy 01 thng 7 nm 2005
ca B trng B Y t)

I. Quan nim v thuc thit yu:
Thuc thit yu l:
- Nhng thuc p ng nhu cu chm sc sc kho ca i a s nhn dn.
- c m bo bng Chnh sch thuc quc gia, gn lin nghin cu, sn xut, phn phi thuc vi nhu
cu thc t chm sc sc kho ca nhn dn.
- Lun sn c bt c lc no vi cht lng m bo, s lng cn thit, di dng bo ch ph hp,
an ton, gi c hp l.
II. Nguyn tc la chn thuc thit yu:
1. Thuc thit yu c la chn trn cc nguyn tc:
- m bo c hiu qu, hp l, an ton,
- Phi sn c vi s lng y , c dng bo ch ph hp vi iu kin bo qun, cung ng, s dng,
- Ph hp vi m hnh bnh tt, phng tin k thut, trnh cn b chuyn mn ca tuyn s dng,
- a s l n cht, nu l a cht phi chng minh c s kt hp c hiu qu hn khi dng tng
thnh phn ring r v tc dng cng nh an ton. Nu c hai hay nhiu thuc tng t nhau phi la
chn trn c s nh gi y v hiu lc, an ton, cht lng, gi c, kh nng cung ng.
- Gi c hp l.
2. Ngoi ra, thuc thit yu y hc c truyn (YHCT) cn c la chn trn nhng nguyn tc sau:
- Nhng thuc c a vo phn Danh mc thuc ch phm phi l nhng thuc c cp s ng k,
sn xut, lu hnh ti Vit Nam v hin ti cn hiu lc ca s ng k.
- Danh mc thuc ch phm tp trung vo nhng ch phm c phng, nhng ch phm c uy tn trn th
trng v nhng ch phm c cng thc trong Dc in Vit Nam.
- Thuc phi gi c phng php bo ch truyn thng ca thuc c truyn, ng thi phi c dng bo
ch thun tin cho s dng, bo qun v lu thng phn phi, nhm thc hin tt cng tc kt hp y hc
c truyn vi y hc hin i .
III. Qui nh s dng thuc thit yu:
Danh mc thuc thit yu l c s xy dng Danh mc thuc ch yu s dng ti c s khm bnh,
cha bnh.
1. Danh mc thuc thit yu tn dc.
- Cc thuc iu tr c hiu bnh phong, tm thn, ng kinh, v sinh, lao v vc xin timchng s dng
thuc theo qui nh hin hnh ca B Y t v thuc ca cc chng trnh.
- Cc thuc hn ch s dng, l cc thuc c ch dn bi k hiu(*). y l cc thuc c coi l cc
thuc d tr, c s dng trong cc trng hp c bit, trng hp cc thuc khc cng nhmkhng
c hiu qu trong iu tr.
- Cc thuc khng virus k hiu(**), khi dng iu tr nhim HIV, khng cha c cn bnh nhim HIV
ch c tc dng tm thi lmchm li s pht trin ca virus v ci thin cc triu chng bnh. Thuc
iu tr HIV/AIDS ch c s dng khi c ch nh ca bc s chuyn khoa.
2. Danh mc thuc thit yu y hc c truyn.
- Danh mc thuc ch phm v Danh mc v thuc c dng cho tt c cc tuyn v cc c s khm
cha bnh YHCT: Cc bnh vin YHCT, khoa YHCT ca cc bnh vin a khoa, trm Y t, phng chn
tr YHCT v cc c s kinh doanh ng dc trong c nc.
- Danh mc cc cy thuc trng ti vn thuc mu s dng cho vn thuc nam ti trm Y t x, bnh
vin Y hc c truyn cc tnh, thnh ph trc thuc Trung ng, cc Trng i hc Y - Dc, cc Hc
vin.....
- Ch :
Cc c s iu tr c th s dng cc ch phm c cp s ng k v cn hiu lc c cng thc
hoc cng dng tng t thay th.

448 |
Cc c s iu tr xy dng danh mc thuc thit yu cho n v mnh theo danh mc thuc ch
phm v danh mc v thuc quy nh, trong qu trnh xy dng nu c b sung thmdanh mc
cho ph hp vi m hnh bnh tt ca a phng th phi c thng qua Hi ng thuc v iu
tr (i vi bnh vin tuyn Trung ng) hoc thng qua S Y t a phng trc khi a vo s
dng.
i vi Danh mc cy thuc nam: trong qu trnh thc hin cc a phng cn c vo danh mc
quy nh c th thay th mt s cy thuc khc sn c ca a phng trng cho ph hp vi
m hnh bnh tt ca mnh, (khng vt qu 15% tng s cy) hoc b sung thmv s lng ngoi
60 cy quy nh.

B TRNG B Y T

( k)

Trn Th Trung Chin

| 449

TH TNG CHNH PH

S: 120/2008/Q-TTg
CNG HA X HI CH NGHA VIT NAM


QUYT NH
V vic quy nh iu kin xc nh ngi b phi nhim vi HIV, b nhim HIV do
tai nn ri ro ngh nghip
TH TNG CHNH PH
- Cn c Lut T chc Chnh ph ngy 25 thng 12 nm 2001;
- Cn c Lut Phng, chng nhim vi rt gy ra hi chng suy gim min dch mc phi ngi
(HIV/AIDS) ngy 29 thng 6 nm 2006;
- Xt ngh ca B trng B Y t,

QUYT NH
iu 1. Phm vi iu chnh
Quyt nh ny quy nh iu kin xc nh ngi b phi nhimvi HIV, ngi b nhimHIV do tai nn ri
ro ngh nghip; th tc cp Giy chng nhn b phi nhim vi HIV, giy chng nhn b nhimHIV do tai
nn ri ro ngh nghip.

iu 2. i tng p dng
1. Cn b, cng chc, vin chc, ngi ang lm vic trong lc lng v trang, ngi c hp ng lao ng
theo quy nh ca php lut v lao ng ang lm vic trong:
a. C s y t;
b. C s cha bnh c thnh lp theo quy nh ti iu 26 ca Php lnh x l vi phmhnh chnh
ngy 02 thng 7 nm 2002;
c. C s cai nghin ma tu c thnh lp theo quy nh ca Ngh nh s 135/2004/N-CP ngy 10
thng 6 nm 2004 ca Chnh ph v vic quy nh ch p dng bin php a vo c s cha bnh, t
chc hot ng ca c s cha bnh theo Php lnh x l vi phm hnh chnh v ch p dng i vi
ngi cha thnh nin, ngi t nguyn vo c s cha bnh v Ngh nh s 147/2003/N-CP ngy 01
thng 12 nm 2003 ca Chnh ph v iu kin, th tc cp giy php v qun l hot ng ca cc c
s cai nghin ma tu t nguyn;
d. C s chnh hnh - phc hi chc nng thuc ngnh Lao ng - Thng binh v X hi qun l;
. C s bo tr x hi.
2. Cn b, chin s thuc cc lc lng v trang nhn dn, ngi c hp ng lao ng theo quy nh ca
php lut v lao ng ang lm vic trong tri giam, tri tmgiam, nh tmgi, c s gio dc, trng gio
dng thuc B Cng an qun l hoc ang lm vic trong tri giam, tri tmgiamthuc B Quc phng
qun l.
3. Cn b, chin s thuc cc lc lng v trang nhn dn khi ang thi hnh cng v theo s phn cng ca
Th trng c quan, n v.
4. Thnh vin t cng tc cai nghin quy nh ti iu 11 v T trng t dn c theo quy nh ti iu 12
ca Ngh nh s 56/2002/N-CP ngy 15 thng 5 nm 2002 ca Chnh ph v t chc cai nghin ti gia
nh v cng ng.
5. Cn b, cng chc chuyn trch phng chng t nn x hi cp trung ng, tnh, huyn khi ang thi hnh
cng v theo s phn cng ca Th trng c quan, n v.
6. Hc sinh thc tp ti cc c s y t (bao gmc cc c s y t ngoi cng lp).

450 |
iu 3. iu kin xc nh ngi b phi nhim vi HIV do tai nn ri ro ngh nghip
Ngi c xc nh b phi nhim vi HIV do tai nn ri ro ngh nghip khi c cc iu kin sau:
1. B mt trong ba tai nn sau y khi ang thi hnh nhimv:
a. B kim, vt nhn m, vt sc ca xuyn qua da hoc vt lm da b try xc, nt n m nhng vt
ny tip xc vi mu, sn phmmu hoc dch c th ngi nghi nhimHIV;
b. B mu, sn phmmu, dch c th ngi nghi nhimHIV tip xc trc tip vi da b try xc, nt n;
c. B mu, sn phmmu, dch c th ngi nghi nghimHIV tip xc trc tip vi nimmc mt, mi, ming.
2. C Bin bn tai nn ri ro ngh nghip (theo mu Ph lc I ban hnh km theo Quyt nh ny). Bin bn
ny phi c lp trong vng 48 gi k t khi xy ra tai nn, c xc nhn ca ngi lm chng v c Th
trng c quan qun l trc tip ngi b phi nhimvi HIV k, xc nhn.
3. Kt qu xt nghimHIV bng k thut ELISA ca ngi b phi nhim vi HIV l m tnh. Mu mu
c s dng xt nghim phi c ly t ngi b phi nhimtrong vng 72 gi k t thi im xy ra
mt trong ba tai nn quy nh ti khon 1 iu ny.
iu 4. iu kin xc nh ngi b nhim HIV do tai nn ri ro ngh nghip
1. C Giy chng nhn b phi nhimvi HIV ca c quan c thmquyn quy nh ti iu 5 Quyt nh
ny.
2. Kt qu xt nghimHIV ca ngi b phi nhimvi HIV ti mt trong ba thi im01 thng, 03 thng,
06 thng sau khi b tai nn ri ro ngh nghip l dng tnh do c s y t c thmquyn cp.
iu 5. C quan tip nhn h s v thm quyn cp Giy chng nhn b phi nhim vi HIV do tai
nn ri ro ngh nghip, Giy chng nhn b nhim HIV do tai nn ri ro ngh nghip.
1. Vic tip nhn h s ngh cp Giy chng nhn b phi nhimvi HIV do tai nn ri ro ngh nghip,
Giy chng nhn b nhim HIV do tai nn ri ro ngh nghip v thm quyn cp Giy chng nhn b phi
nhim vi HIV do tai nn ri ro ngh nghip, Giy chng nhn b nhim HIV do tai nn ri ro ngh nghip
thc hin nh sau:
a. Cc Qun y thuc B Quc phng tip nhn h s ngh v xt cp Giy chng nhn b phi nhim
vi HIV do tai nn ri ro ngh nghip, Giy chng nhn b nhimHIV do tai nn ri ro ngh nghip cho
ngi b phi nhimvi HIV hoc b nhimHIV do tai nn ri ro ngh nghip ang cng tc, thc tp
ti cc n v thuc B Quc phng qun l;
b. Cc Y t thuc B Cng an tip nhn h s ngh v xt cp Giy chng nhn b phi nhim vi
HIV do tai nn ri ro ngh nghip, Giy chng nhn b nhim HIV do tai nn ri ro ngh nghip cho
ngi b phi nhimvi HIV hoc b nhimHIV do tai nn ri ro ngh nghip ang cng tc, thc tp
ti cc n v thuc B Cng an qun l;
c. Cc Phng, chng t nn x hi thuc B Lao ng - Thng binh v X hi tip nhn h s ngh
v xt cp Giy chng nhn b phi nhimvi HIV do tai nn ri ro ngh nghip, Giy chng nhn b
nhimHIV do tai nn ri ro ngh nghip cho ngi b phi nhimvi HIV hoc b nhimHIV do tai
nn ri ro ngh nghip ang cng tc, thc tp ti cc n v thuc B Lao ng - Thng binh v X
hi qun l;
d. S Y t thuc B Giao thng vn ti tip nhn h s ngh v xt cp Giy chng nhn b phi
nhimvi HIV do tai nn ri ro ngh nghip, Giy chng nhn b nhim HIV do tai nn ri ro ngh
nghip cho ngi b phi nhimvi HIV hoc b nhimHIV do tai nn ri ro ngh nghip ang cng
tc, thc tp ti cc n v thuc B Giao thng vn ti qun l;
. Cc Phng, chng HIV/AIDS thuc B Y t tip nhn h s ngh v xt cp Giy chng nhn b
phi nhim vi HIV do tai nn ri ro ngh nghip, Giy chng nhn b nhimHIV do tai nn ri ro ngh
nghip cho ngi b phi nhimvi HIV hoc b nhimHIV do tai nn ri ro ngh nghip ang cng
tc, thc tp ti cc n v trc thuc B Y t v ca cc B, ngnh khc ngoi cc B, ngnh quy nh
ti ima, b, c, d v e khon 1 iu ny;
e. S Y t tnh, thnh ph trc thuc Trung ng (sau y gi tt l S) tip nhn h s ngh v xt
cp Giy chng nhn b phi nhimvi HIV do tai nn ri ro ngh nghip, Giy chng nhn b nhim
HIV cho ngi b phi nhimvi HIV hoc b nhimHIV do tai nn ri ro ngh nghip ang cng tc,
thc tp ti cc c quan, n v thuc quyn qun l ca y ban nhn dn tnh, thnh ph Trung ng.
2. T chc v hot ng ca Hi ng t vn chuyn mn:
a. Hi ng t vn chuyn mn do Th trng c quan c thmquyn quy nh ti khon 1 iu ny
thnh lp v phi bao gm nhng thnh phn ti thiu sau:
i din Lnh o c quan quy nh ti khon 1 iu ny l Ch tch hi ng;

| 451
Cn b ph trch Phng xt nghim HIV c php khng nh cc trng hp HIV dng tnh
thuc quyn qun l ca cc c quan quy nh ti khon 1 iu ny hoc Phng xt nghim HIV
c php khng nh cc trng hp HIV dng tnh ni gn nht.
i din c quan bo him x hi ni ngi b phi nhim vi HIV tham gia bo him y t;
Cn b ca c quan tip nhn h s quy nh ti khon 1 iu ny l th k Hi ng.
b. B trng B Y t quy nh c th Quy ch t chc, trch nhimv hot ng ca Hi ng t vn
ca cc c quan quy nh ti khon 1 iu ny.
iu 6. H s ngh cp Giy chng nhn b phi nhim vi HIV do tai nn ri ro ngh nghip, Giy
chng nhn b nhim HIV do tai nn ri ro ngh nghip
1. H s ngh cp Giy chng nhn b phi nhimvi HIV do tai nn ri ro ngh nghip gmc:
a. Bin bn tai nn ri ro ngh nghip;
b. Bn sao hp php kt qu xt nghim HIV mtnh ca ngi b phi nhim, bao gm c bn c kt
qu xt nghimbng k thut ELISA;
c. Cng vn ngh cp Giy chng nhn b phi nhimvi HIV ca c quan, n v ni ngi b phi
nhimvi HIV ang cng tc.
2. H s ngh cp Giy chng nhn b nhimHIV do tai nn ri ro ngh nghip gmc:
a. Giy chng nhn b phi nhimvi HIV do tai nn ri ro ngh nghip;
b. Bn sao hp php kt qu xt nghim HIV dng tnh ca ngi b phi nhimvi HIV sau khi c
cp Giy chng nhn b phi nhimvi HIV theo quy nh ti khon 2 iu 4 ca Quyt nh ny, bao
gmc bn c kt qu xt nghimbng k thut ELISA;
c. Cng vn ngh cp Giy chng nhn b nhimHIV do tai nn ri ro ngh nghip ca c quan, n
v ni ngi b nhim HIV ang cng tc.
iu 7. Th tc cp Giy chng nhn b phi nhim vi HIV do tai nn ri ro ngh nghip, Giy
chng nhn b nhim HIV do tai nn ri ro ngh nghip
1. Trnh t xemxt vic ngh cp Giy chng nhn b phi nhimvi HIV do tai nn ri ro ngh nghip,
Giy chng nhn b nhimHIV do tai nn ri ro ngh nghip:
a. Sau 05 ngy lm vic, k t ngy nhn h s theo quy nh ti iu 6 ca Quyt nh ny th c
quan tip nhn h s phi t chc hp Hi ng t vn chuyn mn thm nh h s ngh cp Giy
chng nhn b phi nhimvi HIV do tai nn ri ro ngh nghip, Giy chng nhn b nhim HIV do tai
nn ri ro ngh nghip;
Trng hp h s cha ng quy nh ti iu 6 ca Quyt nh ny th trong thi hn 02 ngy lm
vic, k t ngy tip nhn h s, c quan tip nhn h s phi c vn bn thng bo r l do cho c s
ngh cp Giy chng nhn b phi nhimvi HIV do tai nn ri ro ngh nghip, Giy chng nhn b
nhimHIV do tai nn ri ro ngh nghip bit c s b sung hoc hon chnh h s.
b. Sau 02 ngy lmvic, k t ngy hp thm nh, Hi ng t vn chuyn mn phi trnh bin bn
thm nh ln Lnh o c quan quy nh ti khon 1 iu 5 ca Quyt nh ny xemxt v quyt
nh cp Giy chng nhn b phi nhimvi HIV do tai nn ri ro ngh nghip, Giy chng nhn b
nhimHIV do tai nn ri ro ngh nghip; trng hp khng cp th phi c vn bn tr li v nu r l
do.
2. Mu Giy chng nhn b phi nhimvi HIV, Giy chng nhn b nhim HIV theo quy nh ti Ph lc II
ban hnh kmtheo Quyt nh ny.
iu 8. Hiu lc thi hnh
Quyt nh ny c hiu lc thi hnh sau 15 ngy, k t ngy ng Cng bo.
iu 9. Trch nhim thi hnh
Cc B trng, Th trng c quan ngang B, Th trng c quan thuc Chnh ph, Ch tch y ban nhn
dn tnh, thnh ph trc thuc Trung ng chu trch nhimthi hnh Quyt nh ny.

KT. TH TNG
PH TH TNG

k

Trng Vnh Trng

452 |
PH LC I
MU BIN BN TAI NN RI RO NGH NGHIP
(Ban hnh km theo Quyt nh s 120/2008/Q-TTg ngy 29 thng 8 nm 2008 ca Th tng Chnh ph)


BIN BN
Tai nn ri ro ngh nghip

H v tn: .............................................................. Tui: ...................... Gii tnh: .....
Ngh nghip: .....................................................................................................................................
Ni cng tc: .....................................................................................................................................
Hon cnh xy ra tai nn: (tng trnh chi tit)
.................................................................................................................................
.................................................................................................................................
Thng tin v vt thng, tnh trng phi nhim:
..........................................................................................................................................................
..........................................................................................................................................................
Thng tin v ngun ly nhim:
..........................................................................................................................................................
..........................................................................................................................................................
x tr nh th no:
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
Tnh trng sc kho ca cn b b tai nn:
..........................................................................................................................................................
..........................................................................................................................................................

...................., ngy ...... thng .......... nm .......
Cn b b tai nn Ngi chng kin Th trng n v
(K tn, ng du)

| 453
PH LC II
MU GIY CHNG NHN B PHI NHIM VI HIV DO TAI NN RI RO NGH NGHIP, GIY
CHNG NHN B NHIM HIV DO TAI NN RI RO NGH NGHIP
(Ban hnh km theo Quyt nh s 120/2008/Q-TTg ngy 29 thng 8 nm 2008 ca Th tng Chnh ph)

Mu 1.
GIY CHNG NHN
B PHI NHIM VI HIV DO TAI NN RI RO NGH NGHIP
TN C QUAN
CP GIY CHNG NHN

S: /GCN

GIY CHNG NHN
B phi nhim vi HIV do tai nn ri ro ngh nghip
......................................... chng nhn:
ng/B: ........................................................................................................... Tui: .....................................
Ngh nghip: ..................................................................................................................................................
Ni cng tc: ..................................................................................................................................................
b phi nhimvi HIV do tai nn ri ro ngh nghip.
........., ngy.... thng ... nm ........
TH TRNG N V
(K tn, ng du)

454 |
Mu 2.
GIY CHNG NHN
B NHIM HIV DO TAI NN RI RO NGH NGHIP
TN C QUAN
CP GIY CHNG NHN

S: /GCN

GIY CHNG NHN
B nhim HIV do tai nn ri ro ngh nghip
......................................... chng nhn:
ng/B: ................................................................................................................. Tui: .................................
Ngh nghip: ....................................................................................................................................................
Ni cng tc: ...................................................................................................................................................
b nhim HIV do tai nn ri ro ngh nghip.
........., ngy.... thng ... nm ........
TH TRNG N V
(K tn, ng du)

| 455

B Y T

S: 4361/Q-BYT



QUYT NH

V vic ban hnh Quy trnh chm sc v iu tr d phng ly truyn HIV t m
sang con

B TRNG B Y T

Cn c Ngh nh s 49/2003/N-CP ngy 15-5-2003 ca Chnh ph v vic quy nh chc nng, nhimv,
Cn c Quyt nh s 432/Q-TTg ngy 20-5-2005 ca Th tng Chnh ph v vic thnh lp Cc Phng,
chng HIV/AIDS Vit Namthuc B Y t;
Theo ngh ca Cc trng Cc Phng, chng HIV/AIDS Vit Nam, V trng V Sc kho Sinh sn, V
trng V iu tr,

QUYT NH:

iu 1. Ban hnh kmtheo Quyt nh ny bn Quy trnh chm sc v iu tr d phng ly truyn HIV
t m sang con.
iu 2. Quyt nh ny c hiu lc k t ngy k ban hnh.
iu 3. Cc ng, b: Chnh Vn phng, Cc trng Cc Phng, chng HIV/AIDS Vit Nam, V trng V
Sc kho Sinh sn, V trng V iu tr - B Y t, Th trng cc n v trc thuc B, Gim c S Y t
cc tnh, thnh ph trc thuc Trung ng, Th trng Y t cc ngnh v cc n v lin quan chu trch
nhim thi hnh Quyt nh ny.

Ni nhn:
- Nh iu 3;
- Trang web B Y t;
- Lu: VT, Tr, AIDS, SKSS, PC.

KT. B TRNG
TH TRNG

( k)

Trn Ch Lim

456 |

B Y T


Quy trnh Chm sc v iu tr d phng ly truyn HIV t m sang con
(Ban hnh km theo Quyt nh s 4361/Q-BYT
ngy 07 thng 11 nm 2007 ca B trng B Y t)

Chng I

NHNG QUY NH CHUNG

Quy trnh ny quy nh cc hot ng lin quan n chm sc v iu tr d phng ly truyn HIV t m
sang con, bao gm t vn xt nghim HIV, iu tr d phng bng thuc khng HIV, chm sc h tr cho m
v con trc, trong v sau khi sinh v t chc thc hin cc hot ng phng ly truyn HIV t m sang con.

iu 2. i tng p dng
Quy trnh ny p dng i vi tt c cc c s y t cng lp v ngoi cng lp c thamgia cc hot ng
chm sc v iu tr d phng ly truyn HIV t m sang con.

iu 3. Gii thch t ng
1. Xt nghimsng lc HIV l xt nghim HIV vi mc ch kim tra xem mu bnh phm c khng th
HIV hay khng. Xt nghim sng lc thng dng cc phng php c nhy cao nh cc th nghim
nhanh hoc SERODIA, ELISA.
2. Xt nghimkhng nh HIV l xt nghimnhmkhng nh mu bnh phm dng tnh vi xt nghim
sng lc ban u c thc s c khng th HIV hay khng. Xt nghim khng nh thng dng cc phng
php c c hiu cao nh Western Blot hoc cc xt nghim khc v phi tun th cc quy nh hin hnh
v c s y t c php khng nh HIV dng tnh.
3. Tr phi nhimvi HIV l tr sinh ra t ngi m nhimHIV hoc ngi m c xt nghim sng lc HIV
dng tnh cho n khi tr c kt qu xt nghimkhng nh nhim HIV hoc khng nhimHIV.

iu 4. Nguyn tc chm sc v iu tr d phng ly truyn HIV t m sang con
1. Tt c ph n mang thai n c s y t u c khuyn khch t nguyn xt nghim HIV, c cung cp
cc dch v chm sc v iu tr d phng ly truyn HIV t m sang con.
2. Tr phi nhimvi HIV c iu tr d phng theo quy nh ca php lut, c gii thiu n c s
chm sc v iu tr HIV/AIDS theo di tnh trng nhim HIV, chm sc v iu tr.
3. Cc hot ng chm sc v iu tr d phng ly truyn HIV t m sang con c lng ghp vi cc hot
ng ca chng trnh phng chng HIV/AIDS, chm sc sc kho sinh sn, dinh dng, chn on v iu
tr cc nhimkhun ly truyn qua ng tnh dc.

| 457
Chng II

QUY TRNH CHM SC V IU TR D PHNG LY TRUYN HIV
T M SANG CON

iu 5. Can thip trong thi gian mang thai
1. T vn xt nghimHIV cho ph n mang thai cha bit tnh trng HIV
a) T vn trc xt nghim
- T vn nhm: khi c nhiu ph n n khm thai
- T vn c nhn: cho nhng ph n mang thai sau khi t vn nhmcn c nhu cu t vn ring hoc
cha bit tnh trng HIV trong khi chuyn d. T vn khi chuyn d nn c tin hnh ngn gn.
- T vn trc xt nghim phi cung cp y cc thng tin v HIV, nguy c ly truyn HIV t m
sang con, li ch ca xt nghim HIV, iu tr d phng nu m nhim HIV; thai ph t nguyn
xt nghim HIV v cc nhim khun ly truyn qua ng tnh dc (giang mai, hc pt sinh dc
v.v...) cng vi cc xt nghim thng quy khc trong khm thai.
b) Xt nghim sng lc HIV theo mt trong hai hnh thc ghi tn hoc giu tn tu theo la chn ca
ngi ph n.
c) Xt nghim khng nh HIV cho ngi c kt qu sng lc dng tnh ti cc phng xt nghim
iu kin khng nh cc trng hp HIV dng tnh c B Y t cng nhn.
d) T vn sau xt nghimcho tt c ph n khi tr kt qu xt nghim, k c HIV m tnh, dng tnh
hoc cha xc nh theo cc quy nh ca php lut. i vi nhng ph n c kt qu xt nghimHIV
dng tnh cn tp trung t vn cc vn sau:
- T vn h tr tm l;
- Tho lun cch x tr vi thai nghn, nguy c ly truyn HIV t m sang con v cc can thip d
phng ly truyn HIV t m sang con, phng php v k hoch chm sc, iu tr v nui dng
tr;
- T vn v k hoch ha gia nh, s dng bao cao su trong quan h tnh dc;
- Gii thiu n cc nhm v cc c s h tr x hi;
- Tho lun v vic thng bo kt qu xt nghim cho chng, t vn xt nghim HIV cho chng;
- Vic thng bo kt qu xt nghim cho cc i tng khc ngoi bn thn ngi ph n phi tun
theo cc quy nh ca php lut;
2. nh gi tnh trng thai nghn v x tr
a) Xc nh tui thai v nh gi tnh trng thai nghn theo quy nh.
b) Trng hp ngi ph n HIV dng tnh mong mun ph thai th cung cp dch v ph thai ph hp
vi tui thai theo cc quy nh hin hnh.
c) Trng hp ngi ph n la chn sinh con th tin hnh cc bc quy nh ti cc iu 6, 7, 8, 9 ca
Quy trnh ny.
d) Gii thiu n cc dch v chuyn ngnh lin quan (lao, da liu v.v...) phi hp hi chn, chm sc
v iu tr nu c ch nh.
iu 6. Can thip bng thuc khng HIV
1. Ph n nhim HIV ang iu tr bng thuc khng HIV c pht hin c thai cn c:
a) Hi chn gia c s sn khoa vi c s chm sc, iu tr HIV/AIDS iu chnh (thay i hoc tm
ngng) phc nu cn, t vn s dng thuc trong ba thng u ca thi k mang thai.
b) Theo di iu tr bng thuc khng HIV ti c s chm sc, iu tr HIV/AIDS.
c) Qun l thai ti c s sn khoa.
2. Ph n c pht hin nhimHIV khi mang thai cn c:
a) Gii thiu n c s chm sc, iu tr HIV/AIDS nh gi v theo di v lmsng, xt nghim,
tiu chun iu tr thuc khng HIV; gii thiu n cc nhm v cc c s h tr x hi.
b) Nu ph n mang thai c ch nh iu tr thuc khng HIV th thc hin quy trnh iu tr thuc
khng HIV ti c s chm sc, iu tr HIV/AIDS, ng thi tip tc theo di, qun l thai ti c s sn
khoa.

458 |
c) Nu ph n mang thai cha c ch nh iu tr thuc khng HIV th iu tr d phng ly truyn
HIV t m sang con bng phc ph hp vi tui thai ti thi impht hin nhim HIV theo Hng
dn chn on v iu tr nhim HIV/AIDS nh sau:
- Trong hai tun u ca liu trnh iu tr d phng thuc khng HIV: hng tun, cp pht thuc
cng vi t vn v nh gi tun th iu tr;
- T tun th ba cho n khi sinh con: cp pht thuc khng HIV hng thng cng vi lch hn ti
khmv qun l thai nh k.
iu 7. Can thip trong khi chuyn d, sinh
1. S dng thuc khng HIV:
a) Ph n ang iu tr bng thuc khng HIV: Tip tc iu tr bng thuc khng HIV trong khi chuyn
d, sinh v sau sinh theo ch nh ca bc s iu tr HIV/AIDS trc .
b) Ph n ang iu tr d phng ly truyn HIV t m sang con trong khi mang thai: Tip tc phc
d phng ly truyn HIV t m sang con bng thuc khng HIV trong thi gian chuyn d theo quy nh
ca php lut.
c) Ph n cha c xt nghimHIV:
- T vn trc xt nghim;
- Xt nghim sng lc HIV, nu kt qu sng lc dng tnh th t vn gii thch ngha ca kt qu
sng lc v t vn s dng phc nevirapine liu duy nht;
2. Cc can thip sn khoa:
a) Cc can thip sn khoa i vi ph n mang thai nhimHIV phi tun th theo cc nguyn tc chung
nh i vi ph n mang thai khng nhimHIV bo mmt cuc chuyn d v sinh con an ton.
b) Nhn vin y t cn tun th cc nguyn tc phng, chng nhimkhun khi chm sc sn khoa cho
ph n c HIV m tnh, dng tnh hoc cha xc nh.
c) Hn ch ti a cc th thut c th gy tn thng ng sinh sn ngi m hoc tn thng cho con
nh ct tng sinh mn, gic ht, phooc xp, t in cc vo u thai nhi; hn ch bm i sm v thm
khm m o.
iu 8. Can thip ngay sau sinh
1. Chm sc tr:
a) Khi ht dch ng mi, hu hng sau sinh cn s dng cc loi ng thng mm, thao tc nh nhng,
trnh gy tn thng; tmcho tr hoc lau kh cht dch ca m trn ngi tr bng khn mm, trnh
xy xc.
b) Cho tr ung thuc khng HIV theo phc d phng ly truyn HIV t m sang con. Ngng thuc
nu m c kt qu khng nh
mtnh.
2. T vn cho m:
T vn cho ngi ph n sau sinh cng vi t vn cho ngi chng v ngi thn nu c s ng ca
bn thn ngi ph n, bao gm:
a) T vn h tr tml.
b) T vn v dinh dng v chm sc c nhn.
c) T vn v k hoch ha gia nh, s dng bao cao su trong quan h tnh dc.
d) T vn h tr ngi m v cch nui dng v chm sc tr an ton:
- Li ch v dinh dng v min dch cng nh nguy c ly truyn HIV ca vic nui con bng sa
m, li ch v nguy c ca vic dng thc n thay th;
- Nu ngi m quyt nh nui con bng thc n thay th th hng dn nui con hon ton bng
thc n thay th bo m an ton, hp v sinh (hng dn cch pha sa, v sinh dng c v.v);
- Nu ngi m quyt nh cho con b th hng dn cch cho b v v sinh bu v, hng dn nui
con bng sa m hon ton v ngng cng sm cng tt, mun nht l khi tr c 6 thng tui. Khi
ngng nui con bng sa m cn chuyn ngay sang s dng thc n thay th;
- Khng nui con kt hp sa m vi bt c loi thc n thay th hoc b sung no khc;
) T vn, hng dn cho tr tip tc ung thuc khng HIV sau khi xut vin.
e) T vn v s cn thit ca tim chng, iu tr d phng, theo di tng trng ca tr v xt nghim
HIV cho tr.

| 459
iu 9. Chuyn tuyn, chuyn tip sau sinh
1. Ph n c xt nghimsng lc dng tnh trong khi chuyn d cn c:
a) Tin hnh xt nghimkhng nh sm;
b) T vn sau xt nghimcho tt c ph n khi tr kt qu xt nghimkhng nh, k c HIV mtnh,
dng tnh theo cc quy nh ca php lut;
c) Gii thiu ngi ph n sau sinh n c s chm sc, iu tr HIV/AIDS nh gi giai on lm
sng nu kt qu khng nh dng tnh.
2. Ph n nhimHIV:
a) Gii thiu n c s chm sc, iu tr HIV/AIDS :
- Theo di qun l sc khe lu di nu cha iu tr thuc khng HIV;
- Theo di v tip tc iu tr nu ang iu tr thuc khng HIV;
b) Gii thiu v cung cp a ch cc c s h tr tml, kinh t dnh cho ngi nhimHIV, cc nhm
h tr x hi khc.
c) Gii thiu n cc dch v chuyn ngnh lin quan phi hp iu tr v chm sc tip tc nu c
ch nh.
d) Gii thiu n cc dch v k hoch ha gia nh, ngun cung cp bin php trnh thai, bao cao su.
3. Tr phi nhimvi HIV:
Gii thiu tr n c s chm sc, iu tr HIV/AIDS nhi khoa :
a) iu tr d phng cotrimoxazole cho tr theo quy nh.
b) Tip tc hng dn nui dng tr an ton, chm sc tr, ng thi nh k theo di tng trng ca
tr.
c) Xc nh smtnh trng nhimHIV cho tr:
- T chc tin hnh xt nghim pht hin khng nguyn sm nu c iu kin;
- Xt nghim pht hin khng th khi tr c 18 thng tui;
d) Timchng, theo di nh gi tnh trng lmsng v min dch cho tr, iu tr nhim trng c hi v
iu tr thuc khng HIV khi c ch nh.
) Gii thiu cc dch v h tr x hi cho tr sinh ra t m nhim HIV. (S 1, 2, 3 - Ph lc 1 ban
hnh km theo Quy trnh ny)

Chng III
T CHC THC HIN QUY TRNH

iu 10. C quan iu phi
1. Tuyn trung ng: V Sc kho sinh sn ch tr, phi hp vi Cc Phng, chng HIV/AIDS Vit Nam,
Bnh vin Ph sn trung ng v cc c quan lin quan iu phi cc hot ng d phng ly truyn HIV t
m sang con.
2. Tuyn khu vc: Ban iu hnh phng chng HIV/AIDS khu vc chu trch nhimv chuyn mn, k
thut trong phmvi qun l v h tr, ch o tuyn theo quy ch hot ng hin hnh.
3. Tuyn tnh: Trung tmChm sc sc kho sinh sn lmu mi phi hp vi Trung tmPhng, chng
HIV/AIDS (hoc Trung tmY t d phng cc tnh cha thnh lp Trung tmPhng chng HIV/AIDS) v
cc c quan lin quan lp k hoch, t chc trin khai thc hin Quy trnh chm sc v iu tr d phng ly
truyn HIV t m sang con v
theo di gimst, nh gi hot ng trn a bn tnh.
4. Tuyn huyn: Trung tmY t d phng huyn l u mi t chc trin khai, theo di v gimst cc hot
ng ca Quy trnh chm sc v iu tr d phng ly truyn HIV t m sang con trn a bn huyn.
iu 11. C quan thc hin
1. Tuyn trung ng:
a) C s sn khoa (Bnh vin Ph sn trung ng, khoa Sn thuc cc Bnh vin a khoa trung ng
thuc B Y t):
- Thc hin cc can thip d phng ly truyn HIV t m sang con c quy nh ti iu 5, 6, 7, 8,
9 ca Quy trnh ny;

460 |
- H tr nui dng tr phi nhim vi HIV bng thc n thay th sa m trong 06 tun u nu
ngi m quyt nh nui con bng thc n thay th;
- Phi hp cc chuyn khoa v tip nhn cc bnh nhn nng, chn on phc tp v sn khoa t
tuyn di chuyn ln v chuyn bnh nhn v tuyn di sau khi n nh;
- Chuyn ph n mang thai nhim HIV ang c qun l thai n c s chm sc, iu tr
HIV/AIDS hoc mi hi chn khi c ch nh. Chuyn ngi m sau sinh v tr phi nhim vi HIV
n c s chm sc, iu tr HIV/AIDS ph hp v gii thiu n cc dch v h tr khc;
- Theo di, kim tra, gimst, o to, h tr k thut v ch o tuyn di t chc thc hin cc
hot ng chuyn mn d phng ly truyn HIV t m sang con;
- Bo co, qun l iu tr d phng ly truyn HIV t m sang con theo quy nh ca php lut.
b) C s nhi khoa (Bnh vin Nhi trung ng; khoa Nhi thuc cc Bnh vin a khoa trung ng thuc
B Y t):
- Chm sc v qun l tr phi nhim vi HIV theo cc ni dung c quy nh ti Khon 3, iu 9
ca Quy trnh ny;
- T vn nui dng tr, tip tc hng dn v h tr nui dng bng thc n thay th t tun th
07 n ht thng th su nu ngi m quyt nh nui con bng thc n thay th;
- Phi hp cc chuyn khoa v tip nhn cc bnh nhn nng, chn on phc tp t tuyn di
chuyn ln v chuyn bnh nhn v tuyn di sau khi n nh;
- Theo di, kim tra, gimst, o to, h tr k thut v ch o tuyn di t chc thc hin cc
hot ng chuyn mn theo di v chm sc tr phi nhim vi HIV;
- Bo co, qun l theo di v chm sc tr phi nhim vi HIV theo quy nh ca php lut.
2. Tuyn tnh:
a) C s sn khoa (Bnh vin chuyn khoa ph sn, khoa Ph sn cc Bnh vin a khoa tnh v cc
bnh vin ngnh):
- Thc hin cc can thip d phng ly truyn HIV t m sang con c quy nh ti iu 5, 6, 7, 8,
9 ca Quy trnh ny;
- H tr nui dng tr phi nhim vi HIV bng thc n thay th sa m trong 06 tun u nu
ngi m quyt nh nui con bng thc n thay th;
- Phi hp cc chuyn khoa v tip nhn cc bnh nhn nng, chn on phc tp v sn khoa t
tuyn di chuyn ln v chuyn bnh nhn v tuyn di sau khi n nh;
- Chuyn ph n mang thai nhim HIV ang c qun l thai n c s chm sc, iu tr
HIV/AIDS hoc mi hi chn khi c ch nh. Chuyn ngi m sau sinh v tr phi nhim vi HIV
n c s chm sc, iu tr HIV/AIDS ph hp v gii thiu n cc dch v h tr khc;
- Phi hp vi cc c s tuyn tnh trong cng tc theo di, kim tra, gim st, tp hun, h tr cc
hot ng chuyn mn k thut v d phng ly truyn HIV t m sang con cho tuyn qun, huyn
v tuyn x, phng;
b) C s nhi khoa (Bnh vin chuyn khoa nhi, khoa Nhi thuc cc Bnh vin a khoa tnh v cc bnh
vin ngnh):
- Chm sc v qun l tr phi nhim vi HIV theo cc ni dung c quy nh ti Khon 3, iu 9
ca Quy trnh ny;
- T vn nui dng tr, tip tc hng dn v h tr nui dng bng thc n thay th t tun th
07 n ht thng th su nu ngi m quyt nh nui con bng thc n thay th;
- Phi hp cc chuyn khoa v tip nhn cc bnh nhn nng, chn on phc tp t tuyn di
chuyn ln v chuyn bnh nhn v tuyn di sau khi n nh;
- Theo di, kim tra, gimst, tp hun, h tr cc hot ng chuyn mn k thut trong chm sc tr
phi nhim vi HIV cho tuyn qun, huyn v tuyn x, phng;
- Bo co, qun l theo di v chm sc tr phi nhim vi HIV theo quy nh ca php lut.
c) Trung tm Chm sc sc kho sinh sn:
- T vn v HIV/AIDS, t vn xt nghim HIV;
- T vn la chn cc bin php trnh thai, cung cp cc dch v trnh thai, bao cao su;
- Gii thiu ph n mang thai nhim HIV n c s sn khoa c theo di, chm sc v iu tr
d phng ly truyn HIV t m sang con;

| 461
- Phi hp vi cc c s tuyn tnh trong cng tc theo di, kim tra, gim st, tp hun, h tr k
thut cho tuyn qun, huyn v tuyn x, phng.
d) Trung tm Phng, chng HIV/AIDS (hoc Trung tm Y t d phng):
- T vn v HIV/AIDS, t vn xt nghim HIV cho mi i tng c nhu cu;
- Gii thiu ph n mang thai nhim HIV n c s sn khoa c theo di, chm sc v iu tr
d phng ly truyn HIV t m sang con;
- iu phi, t chc thc hin v h tr quy trnh chuyn tip gia cc dch v t vn xt nghim t
nguyn, chm sc v iu tr HIV/AIDS, tr phi nhim vi HIV, tr nhim HIV, d phng ly
truyn HIV t m sang con v cc dch v khc c lin quan;
- Phi hp vi cc c s tuyn tnh trong cng tc theo di, kim tra, gim st, tp hun, h tr k
thut cho tuyn qun, huyn v tuyn x, phng.
3. Tuyn huyn:
L tuyn trng im thc hin cc hot ng chm sc v iu tr d phng ly truyn HIV t m sang
con.
a) Trung tmY t d phng qun, huyn, th x, thnh ph trc thuc tnh (sau y gi tt l huyn) chu
trch nhimt chc trin khai thc hin Quy trnh chm sc v iu tr d phng ly truyn HIV t m
sang con:
- Phi hp vi cc ban ngnh, on th v cng ng trong cc hot ng tuyn truyn v d phng
ly truyn HIV t m sang con;
- Ch o tuyn x, phng trong cng tc tuyn truyn phng chng HIV/AIDS cho ph n mang
thai v t vn dinh dng cho tr phi nhim vi HIV;
- T chc v bo m cht lng t vn xt nghim HIV cho ph n mang thai ti cc trm y t x,
phng;
- Thc hin cc can thip d phng ly truyn HIV t m sang con c quy nh ti iu 5, 6, 9 ca
Quy trnh ny;
- Gii thiu ph n mang thai nhim HIV n cc c s cung cp dch v d phng ly truyn HIV t
m sang con khc khi cn thit;
- Phi hp vi bnh vin huyn t vn nui dng tr, hng dn v h tr nui dng tr bng thc
n thay th n ht thng th su nu ngi m quyt nh nui con bng thc n thay th, t chc
xt nghim khng nh cho tr phi nhim vi HIV;
- H tr chm sc ngi nhim HIV v tr phi nhim vi HIV ti cng ng;
b) Bnh vin huyn:
- Ti cc qun, huyn trin khai Quy trnh chm sc v iu tr d phng ly truyn HIV t m sang
con:
Thc hin cc can thip d phng ly truyn HIV t m sang con c quy nh ti iu 5, 6, 7, 8,
9 ca Quy trnh ny;
Phi hp, chuyn bnh nhn khm v iu tr lao, cc nhim khun ly truyn qua ng tnh dc,
chm sc v iu tr HIV/AIDS v.v... cng nh gii thiu cc dch v h tr tm l, x hi v kinh
t khc cho bnh nhn, tip nhn cc bnh nhn iu tr n nh t tuyn tnh chuyn v v
chuyn ln tuyn tnh cc trng hp nng, chn on phc tp;
Phi hp vi Trung tmY t d phng huyn t vn nui dng tr, hng dn v h tr nui
dng tr bng thc n thay th n ht thng th su nu ngi m quyt nh nui con bng thc
n thay th;
Bo co, qun l iu tr d phng ly truyn HIV t m sang con theo quy nh ca php lut;
- Ti cc qun, huyn cha trin khai ton b Quy trnh chm sc v iu tr d phng ly truyn HIV
t m sang con: C s sn khoa c trch nhim gii thiu ph n mang thai c nguy c nhim HIV
n cc c s cung cp dch v d phng ly truyn HIV t m sang con, ng thi khmv qun l
thai cho tt c ph n mang thai, k c nhng ngi HIV dng tnh, m tnh hoc cha xt nghim
theo cc quy nh hin hnh.

462 |
4. Tuyn x, phng: Trmy t x, phng, th trn chu trch nhim:
- Cung cp thng tin tuyn truyn phng chng HIV/AIDS cho ph n mang thai, gii thiu cc dch v
d phng ly truyn HIV t m sang con sn c;
- Phi hp vi Trung tm Y t d phng huyn t chc t vn xt nghim HIV cho ph n mang thai;
- Gii thiu ph n mang thai c nguy c hoc nghi ng nhim HIV n c s sn khoa tuyn huyn,
tuyn tnh c trin khai cc hot ng chm sc v iu tr d phng ly truyn HIV t m sang con;
- Tin hnh chm sc sau sinh, cung cp bin php k hoch ho gia nh cho ph n nhim HIV v theo
di tng trng cho tr phi nhim vi HIV nh mi tr khc;
- Theo di, gimst iu tr d phng bng cotrimoxazole, iu tr triu chng v chuyn tuyn trn khi
nghi ng bnh nhn mc cc nhim trng c hi;
- Phi hp h tr, theo di tun th iu tr cho b m nhim HIV v tr sau sinh;
- Phi hp vi cc t chc x hi, cc ban ngnh, nhm h tr ng ng trong cng tc chm sc v h
tr b m nhim HIV v tr phi nhim vi HIV ti cng ng;

iu 12. T chc trin khai Quy trnh chm sc v iu tr d phng ly truyn HIV t m sang con
1. Cng c mng li trin khai hot ng chm sc v iu tr d phng ly truyn HIV t m sang con:
- Cc c s chm sc sc kho sinh sn, c s hot ng phng chng HIV/AIDS, bnh vin t tuyn
huyn tr ln c trch nhim phi hp tham gia cung cp dch v chm sc v iu tr d phng ly
truyn HIV t m sang con;
- S Y t ch o cc n v trc thuc tin hnh la chn cc c s iu kin trin khai Quy trnh
chm sc v iu tr d phng ly truyn HIV t m sang con v tng bc m rng hot ng chng
trnh. Ty theo tnh hnh thc t ca a phng, S Y t c trch nhim ch nh:
Cc bnh vin thamgia thc hin quy trnh, cung cp cc dch v chm sc v iu tr d phng ly
truyn HIV t m sang con;
Cc c s y t thc hin vic h tr s dng thc n thay th sa m ph hp v theo di tr phi
nhim vi HIV.
2. Tp hun, hng dn thc hin quy trnh: V Sc kho sinh sn, Cc Phng, chng HIV/AIDS Vit Nam,
Bnh vin Ph sn trung ng, Ban
iu hnh phng chng HIV/AIDS khu vc v S Y t cc tnh t chc tp hun hng dn trin khai thc
hin quy trnh theo quy nh.
3. Ch o thc hin, theo di, gimst, nh gi v h tr k thut trong qu trnh trin khai thc hin quy
trnh: V Sc kho sinh sn, Cc Phng, chng HIV/AIDS Vit Nam, Bnh vin Ph sn trung ng phi
hp vi cc Ban iu hnh phng chng HIV/AIDS khu vc v S Y t cc tnh.

iu 13. Ch bo co v qun l s liu
1. Bo co chuyn mn nh k:
Thi gian bo co, trnh t bo co thc hin theo cc quy nh ti Quyt nh s 26/2006/Q-BYT ngy
06/9/2006 ca B trng B Y t v vic ban hnh Quy ch bo co v Biu mu bo co hot ng phng,
chng HIV/AIDS;
2. Bo co t xut:
Thc hin theo cc quy nh ti Quyt nh s 26/2006/Q-BYT ngy 06/9/2006 ca B trng B Y t v
vic ban hnh Quy ch bo co v Biu mu bo co hot ng phng, chng HIV/AIDS;
3. Biu mu ghi chp, qun l v bo co s liu (Ph lc 2 ban hnh kmtheo Quy trnh ny):
a) Phiu bo co s liu:
Cc c s cung cp dch v chm sc v iu tr d phng ly truyn HIV t m sang con bo co s
liu theo tng hot ng chuyn mn trin khai ti c s bng phiu Bo co chm sc v iu tr d
phng ly truyn HIV t m sang con v Theo di v chm sc tr emsinh ra t m nhimHIV (tr
phi nhim) (Ph lc 2.1).
b) Ghi chp v qun l s liu:
- C s sn khoa:
S dng bnh n khm thai ngoi tr v Phiu theo di v gii thiu dch v (Ph lc 2.2) cho
tng ph n mang thai nhim HIV nhn dch v;

| 463
S dng S ng k t vn v xt nghim cho ph n qun l thai (Ph lc 2.3) cho ph n mang
thai c t vn xt nghim HIV v S theo di chng trnh phng ly truyn HIV t m sang
con ti c s sn khoa (Ph lc 2.4) cho ph n mang thai HIV dng tnh c nhn dch v
tng hp s liu.
- C s nhi khoa:
S dng bnh n ngoi tr nhi cho tng tr phi nhim vi HIV nhn dch v;
S dng S qun l v theo di tr phi nhim HIV ti c s nhi khoa (Ph lc 2.5) tng hp
s liu qun l v theo di tr phi nhim vi HIV.

KT. B TRNG
TH TRNG

( k)

Trn Ch Lim

464 |
PH LC 1

1.1. S 1. Quy trnh cung cp dch v chm sc v iu tr d phng ly truyn HIV t m sang con cho
ph n trong qu trnh mang thai

1.2. S 2. Quy trnh cung cp dch v chm sc v iu tr d phng ly truyn HIV t m sang con cho
ph n khng bit tnh trng HIV khi chuyn d

1.3. S 3. Quy trnh qun l ph n mang thai nhimHIV

| 465
S 1.

Quy trnh cung cp dch v chm sc v iu tr d phng
ly truyn HIV t m sang con cho ph n trong qu trnh mang thai

nh gi lm sng v min dch
(phi hp vi c s chm sc v
iu tr HIV/AIDS)
Cha tiu chun iu tr
thuc khng HIV
tiu chun iu tr thuc
khng HIV
Ph n c
xt nghimHIV (+)

Hi tin s iu tr thuc
khng HIV (hoc phiu
chuyn t c s chm sc
v iu tr HIV/AIDS)
iu tr thuc
khng HIV
Cha iu tr thuc
khng HIV
HIV dng tnh HIV mtnh
T vn
sau xt nghim
iu tr thuc khng HIV iu tr d phng ly truyn
HIV t m sang con
T vn
sau xt nghim
Ph n c xt nghim
HIV (-) trc >3 thng
T vn trc xt nghim
Ph n khng bit tnh
trng nhimHIV
Xt nghim Khng Xt nghim

Ln khm
Nu khng thc hin
c iu tr khng HIV

466 |
S 2.

Quy trnh cung cp dch v chm sc v iu tr d phng
ly truyn HIV t m sang con ph n khng bit tnh trng HIV khi chuyn d

Dng tnh

Ph n khng bit
tnh trng nhimHIV
T vn trc xt nghim

Xt nghimxng lc

mtnh

Xt nghimkhng nh
HIV dng tnh
T vn sau xt nghim
v t vn h tr sau sinh
T vn h tr sau sinh cho m
iu tr bng thuc khng HIV cho con con
phng ly truyn HIV t m sang con

Xt nghimkhng nh
HIV mtnh
T vn sau xt nghimv ngng d
phng bng thuc khng HIV
iu tr thuc khng HIV cho m phng
ly truyn HIV t m sang con
T vn sau xt nghim

T vn sau xt nghim

Theo di v gii thiu chuyn tip cho m v con

| 467
S 3.

Quy trnh qun l ph n mang thai nhim HIV

Tip nhn ph n mang thai
nhim HIV
nh gi
- Tnh trng thai nghn
- Tnh trng lm sng (phi hp v gii
thiu n c s chm sc v iu tr
HIV/AIDS)
Ph n mang thai tiu chun
iu tr thuc khng HIV
Phi hp v gii thiu n c
s chm sc v iu tr HIV
iu tr v theo di iu tr
Ph n mang thai
cha tiu
chun iu tr
thuc khng HIV
Ph n nhim HIV ang iu tr
thuc khng HIV v c thai
Phi hp v gii thiu n c s
chm sc v iu tr HIV, theo
di di iu tr thuc khng HIV
T vn h tr
- T vn gii thiu c s chm sc
v iu tr
- T vn h tr tm l,
- Gii thiu n cc nhm h tr,
cc t chc x hi
- Tho lun v cc can thipd
phng ly truyn t m sang con,
cch chm sc v nui dng tr
iu tr d phng LTMC
theo hng dn Quc gia
Khi chuyn d v
- Hn ch ti thiu chn thng cho m v tr
- Tip tc iu tr thuc khng HIV i vi ph n ang iu tr hoc
- iu tr thuc khng HIV d phng LTMC theo phc
iu tr thuc khng HIV
theo hng dn quc gia
Qun l v chm sc tr phi nhim
HIV ti c s nhi khoa hoc c s chm
sc v iu tr HIV/AIDS ni gn
nht
- Tr phi nhim trc khi xut vin
- Bt buc iu tr thuc khng HIV
phng LTMC trong vng 48h
Qun l v chm sc ph n sau ti c s chm sc v
iu tr HIV/AIDS ni gn nht
Gii thiu n cc nhmh tr, cc t chc x hi
- B m sau ti c s sn khoa, trc khi xut vin
- T vn h tr nui dng tr, iu tr thuc khng HIV
cho tr, d phng cotrimoxazole cho tr, k hoch
chm sc tr
- T vn cc bin php KHHG
Sau
Ph n mang
thai xt nghim
HIV dng tnh
khi chuyn d
Nu khng thc
hin c iu
tr thuc khng

468 |
Ph lc 2

2.1. Bo co chm sc v iu tr d phng ly truyn HIV t m sang con

2.2. Phiu theo di v gii thiu dch v

2.3. S ng k t vn v xt nghimcho ph n qun l thai

2.4. S theo di chng trnh phng ly truyn HIV t m sang con ti c s sn khoa

2.5. S qun l v theo di tr phi nhimti c s nhi khoa

| 469

n v ch qun:
n v bo co:


. . . . . , ngy . . . thng . . . nm . . . . . .
BO CO CHM SC V IU TR D PHNG
LY TRUYN HIV T M SANG CON

Giai on bo co: t ngy . . . thng . . . nm . . . . .. n ngy . . . thng . . . nm . . . . .

TT Ch s S lng
1. S c s sn khoa cung cp dch v phng ly truyn t m sang con theo hng dn
ca B Y t

2. S ph n mang thai n khmthai
3. S ph n mang thai c t vn xt nghim HIV trc khi sinh con
4. S ph n mang thai c xt nghimHIV
5. S ph n mang thai xt nghim HIV dng tnh
6. S ph n mang thai c t vn v xt nghim HIV quay tr li ly kt qu xt
nghim

7. S ph n mang thai nhn c t vn sau khi xt nghimHIV
8. S ph n mang thai HIV dng tnh c iu tr d phng ly truyn
HIV t m sang con

Trong :
9. S ph n nhim HIV c iu tr d phng ly truyn HIV t m sang con bng
phc 2 hoc 3 thuc n lc sinh v sinh con

10. S ph n nhim HIV c iu tr d phng ly truyn HIV t m sang con bng
nevirapine liu duy nht v sinh con

11. S tr emsinh ra t b m nhimHIV cn sng
12. S tr emsinh ra t b m nhim HIV c iu tr d phng ly truyn
HIV t m sang con

Theo di v chm sc tr em sinh ra t m nhim HIV
(tr phi nhim)
TT Ch s S lng
1. S tr em di 18 thng tui c chm sc v qun l ti nh
2. S tr em c xt nghim HIV trong thi gian t khi sinh n 18 thng tui
3. S tr em c xt nghim khng nh HIV dng tnh trong thi gian t khi sinh
n 18 thng tui

4. S tr em c iu tr d phng bng Cotrimoxazole theo hng dn ca B Y t
5. S tr em c cung cp sa ung thay th sa m trong 6 thng
TH TRNG N V NGI LP BO CO

470 |
Trang 4
Trang 1

ach c s iu tr PLTMC: ..................................................................................................
in thoi: ............ Ngi linh (nu c) ..................................................
Trang 1
n v ch qun: ...................................................................................................
C s iu tr: .........................................................................................................
PHIU THEO DI V GII THIU DCH V

Ms
H vtnm: .......... Nm sinhTui:.

XN khng nhHIV (+) ngy:../../.
nh gi lm sng:.... ngy:.././
S t bo Lymph .../mm3 ngy:../...../
CD4: ......./mm3 ngy:../...../.
Kinhcui cng: ngy:.../../..... D kin : ngy:././.....
Phc ARV:.Bt ut: .. /. /.. , tui thai:... tun
Ngy pht S lng thuc ARVcp pht
Ghi ch
(tnhhnhtunth,
tc dng ph)
1. ..../..../.. - thuc 1: s lng, hm lng
- thuc 2: s lng, hm lng

2. ..../..../..

3. ..../..../..

4. ..../..../..

5. ..../..../..

6. ..../..../..

7. ..../..../..

Ghi ch:
- Bn chnh c in v lu ti c s chm sc v iu tr d phngly truyn HIVt m sang con
- Khi gii thiu cc dch v khc, c s y t sao li chi tit qu trnhchm sc, in thmcc thngtin v dch v gii
thiu, k xc nhn vgiaophiu cho ngi m

KHM V QUN L THAI

| 471
Trang 2

XN HIV khi chuyn d: ( ) c ( ) khng ( ) xt nghimt trc
Kt qu sng lc: kt qu khng nh .. ngy././..

AVR dng trong chuyn d v sau :
Ln dng, ngy gi S dng thuc ARV
1. ..../..../..
. gi . pht
- thuc 1: s lng, hm lng, ng dng
2. ..../..../..

3. ..../..../..

4. ..../..../..

lc .. ngy ../../ ngy xut vin .././..

Cch :

TR S SINH

S con sng: Cnnng: .g
Thuc ARV dng: ( ) khngdng ( ) c dng
Tn thuc v cch dng
AZT pht v nh sau : . (s ngy/s liu)
S hp sa pht: .., mi hp:. .. g
Ngy tr xut vin: ././..

Trang 3

GII THIU N DCH V KHC (ch in vo bn sao)

M cgii thiu n:.
ach: ...
in thoi: . Ngi lin h (nu c) .

CON cgii thiu n: .
ach: ...

CC DCH V KHC
Gii thiu n:.
ach: ...

Gii thiu n:.
ach: ...

Bc s
(k v ghi r h tn)

lc . gi ngy: ././..
PHNG /SAU Nhp vin ngy: ././.. Gi: (theo 24h)
472 |

S Y T

S NG K T VN V XT NGHIM HIV
CHO PH N MANG THAI

n v: .

| 473
HNG DN IN THNG TIN

Ct (1): Ghi s th t PNMT n c s ng k qun l thai.
Ct (2): in ngy PNMT n c s ng k qun l thai.
Ct (3): in y h tn hoc ms (trng hp khng ng ghi tn) ca PNMT n c s ng k qun l thai.
Ct (4): Ghi tui thai nhi ti thi im PNMT n ng k qun l thai.
Ct (5): Nu c thc hin t vn cho PNMT th ghi "C", nu khng th ghi "K".
Ct (6): Nu kt qu mtnh ghi (-), dng tnh ghi (+).
Ct (7): Nu kt qu mtnh ghi (-), dng tnh ghi (+), khng xc nh ghi KX.
Ct (8): Nu PNMT quay li nhn kt qu xt nghimghi "C", khng quay li ghi "K".
Ct (9): Nu c thc hin t vn cho PNMT th ghi "C", nu khng th ghi "K".
Ct (10): in ngy PNMT c gii thiu n c s y t khac c thec di, chm sc.
Ct (11): Ghi tn c s y t m PNMT c gii thiu n

474 |

TT Ngy H v tn hoc m s
Tui
thai
T vn XN
(c/khng)
Kt qu XN
sng lc
(mtnh,
dng tnh)
Kt qu XN
khng nh
(m tnh, dng
tnh, khngxc
nh)
Nhn kt
qu XN
(c/khng)
T vn sau
XN
(c/khng)
Gii thiu chuyn tuyn/chuyn tip
Ngy Ni chuyn n

| 475
S Y T

S THEO DI
CHNG TRNH D PHNG LY TRUYN
HIV T M SANG CON

(dnh cho c s sn khoa)

n v: .

476 |
HNG DN IN THNG TIN

Ct (1): Ghi s th t PNMT ng k tham gia chng trnh.
Ct (2): Ghi y h tn ca PNMT n ng k tham gia chng trnh.
Ct (3): Ghi r ach vs in thoi lin lc ni PNMT ng k thng tr hay tmtr di hn.
Ct (4): Ghi ms ca PNMT tham gia chng trnh theo quy nh.
Ct (5): Ghi ngy PNMT ng k thamgia chng trnh.
Ct (6): Ghi dy d tn thuc, liu lng cc thuc trong phc , ngy bt du dng vngy kt thc, tc dng ph cathuc nu c.
Ct (7): Ghi r phc s dng, thi imbt u s dng sau sinh, liu lng dng cho n khi chuyn tr n c s nhi khoa.
Ct (8): Ghi r loi sacp, trng lng hp sa vs hp sa cp cho tr.
Ct (9): Ghi chnh xc tn c s y t mbm c chuyn n tip tc c theo di chm sc v HIV/AIDS
Ct (10): Ghi chnh xc tn c s y t m tr phi nhim c chuyn n tip tc c theo di chm sc v HIV/AIDS.
Ct (11): Dng ghi ch nhng vn d cn thit trong qu trnh theo di PNMT vtr phi nhimti c s

| 477

TT H v tn a ch M s Ngy sinh
Phc ARVtrong khi
mang thai, chuyn d v sau

(ghi r phc , ngy bt u
vkt thc ca tng phc d
cho n khi xut vin sau )
Thuc
ARV sau
cho con
S hp
sa v s
lng cp
cho con
sau
Chuyn tip sau
M chuyn n
Con chuyn
n
Ghi ch

478 |

S Y T

S QUN L V THEO DI
TR PHI NHIM HIV

(dnh cho c s nhi khoa)

n v: .

| 479

HNG DN IN THNG TIN

Ct (1): in s th t tr phi nhim n ng k qun l ti c s y t.
Ct (2): in y h tn tr phi nhim.
Ct (3): Ghi s h s trn bnh n ngoi tr catr c qun l ti c s y t.
Ct (4): in tn m, ach vs in thoi ni bm ng k thng tr hoc tmtr di hn.
Ct (5): Ghi ngy tr bt u n ng k ti c s y t c chm sc theo di cng vi tui catr (thang tui)
Ct (6): in tn c s y t gii thiu tr n c tip tc thec di vchm sc.
Ct (7): Ghi r phc ARV dng cho bm (ang iu tr ARV, d phng LTMC trong khi mang thai, d phng LTMC khi chuyn d)
Ct (8): Ghi r phc ARV dng iu tr PLTMC cho tr.
Ct (9) (11): Ghi thi gian bt u nui dng tr theo ch nui dng mbm chn lavc ct tng ng.
Ct (12): Ghi r liu lng theo cn nng vngy bt u d phng cho tr.
Ct (13): in ngy tr c tin hnh lmxt nghimkhng th khng nh (Ch : xt nghimkhng th khng nh c thc hin khi tr 18 thng tui).
Ct (14): in kt qu vngy tr li kt qu xt nghimkhng th khng nh.
Ct (15): in ngy tr c tin hnh lmxt nghimPCR ln th nht.
Ct (16): in phng php xt nghim, kt qu xt nghimvngy tr li kt qu xt nghimPCR ln th nht.
Ct (17): in ngy tr c tin hnh lmxt nghimPCR ln th hai.
Ct (18): in phng php xt nghim, kt qu xt nghimvngy tr li kt qu xt nghimPCR ln th hai.
Ct (19): in cc ghi ch khc lin quan n qutrnh theo di tr ti c s.

480 |

S
TT
Thng tin chung v tr
Tin s
dng
ARV
ca m
Tin s
dng
ARV ca
con
Ch nui dng
tr
D phng
Cotrimoxa
zole (ngy
bt u, liu
lng)
Xt nghim
khng th
ELISA
Xt nghim
PCR ln 1
Xt
nghim
PCR ln 2
Ghi ch
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n

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h

a

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s
n

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K
t

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n
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Ngy xt nghim khng
nh loi tr nnhieemx
HIV, ngy chuyn iu tr
ARV, ngy chuyn c s
y t khc, t vong v.v
(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16) (17) (18) (19)

481 |

B Y T
---------
S: 06/2007/Q-BYT
----------------------------------


QUYT NH
V vic ban hnh Quy ch truyn mu

B TRNG B Y T

- Cn c Lut Dc ban hnh ngy 14/6/2005 v Ngh nh s 79/2006/N - CP ngy 09/8/2006 ca
Chnh ph quy nh chi tit thi hnh mt s iu ca Lut Dc;
- Cn c Ngh nh 49/ 2003/ N - CP ngy 15/ 5/ 2003 ca Chnh ph quy nh v chc nng, nhim v,
- Theo ngh ca ng V trng V iu tr - B Y t,

QUYT NH

iu 1. Ban hnh kmtheo Quyt nh ny Quy ch Truyn mu.
iu 2. Quy ch Truyn mu c p dng trong cc c s y t cng lp v ngoi cng lp.
iu 3. Quyt nh ny c hiu lc sau 15 ngy k t ngy ng cng bo;bi b Quyt nh s 937/BYT-
Q ngy 04/9/1992 ca B trng B Y t v vic ban hnh iu lnh truyn mu.
iu 4. Cc ng, B: Chnh Vn phng, V trng V iu tr, Chnh Thanh tra, V trng cc V, Cc
trng cc Cc thuc B Y t, Gim c cc bnh vin v Vin trng cc Vin c ging bnh trc thuc
B Y t, Gim c S Y t cc tnh, thnh ph trc thuc Trung ng v Th trng y t cc ngnh chu
trch nhimthi hnh Quyt nh ny.

B TRNG

Trn Th Trung Chin

482 |

B Y T


QUY CH TRUYN MU
(Ban hnh km theo Quyt nh s 06 /2007/Q-BYT ngy 19/01/2007
ca B trng B Y t)

Chng I
QUY NH CHUNG

Quy ch ny quy nh v cc hot ng chuyn mn trong truyn mu, bao gm: Tuyn chn ngi
hin mu, thu gom mu v cc thnh phn mu, xt nghim, iu ch, bo qun, vn chuyn, d tr, cung
cp, s dng mu v ch phm mu, truyn mu t thn, x l cc tc dng khng mong mun lin quan n
truyn mu.
iu 2. i tng p dng
Quy ch ny p dng i vi cc t chc, c nhn Vit Nam v cc t chc, c nhn nc ngoi ti
Vit Nam c cc hot ng chuyn mn v truyn mu.
iu 3. Gii thch t ng
Trong Quy ch ny, cc t ng di y c hiu nh sau:
1. Ngi hin mu l ngi kho mnh, c iu kin theo quy nh v t nguyn hin mu ton phn hoc
mt s thnh phn ca mu.
2. C s truyn mu l c s y t c lp hoc n v trong vin, bnh vin, c chc nng thc hin mt hoc
nhiu hot ng chuyn mn thuc phm vi iu chnh quy nh ti iu 1 ca Quy ch ny.
3. C s thu gom mu l c s truyn mu c chc nng thc hin hot ng thu gommu, cc thnh phn
mu.
4. C s iu ch cc ch phm mu l c s truyn mu c chc nng thc hin hot ng iu ch cc ch
phmmu.
5. C s cung cp mu l c s truyn mu c chc nng cung cp mu v cc ch phm mu cho cc c s
iu tr s dng mu. C s cung cp mu bao gm c s c lp hoc c s trc thuc vin, bnh vin.
6. C s iu tr s dng mu l c s y t iu tr ngi bnh c thc hin hot ng truyn mu lmsng.
7. Truyn mu lm sng l cc hot ng lin quan n vic a mu v cc ch phmmu vo mch mu
ca ngi nhn.
8. Mu ton phn l mu c ly t mch mu ca ngi, bao gmtt c cc cc loi t bo v thnh phn
huyt tng.
9. Ch phm mu l cc sn phmc cha mt hoc nhiu thnh phn mu.
10. iu ch cc ch phm mu l vic s dng cc k thut to ra cc ch phm mu t mu ton phn
hoc trc tip t ngi hin mu.
a) iu ch trong h thng h l vic iu ch c thc hin ct, ni gia ti ng mu ton phn v ti
ng ch phm mu;
b) iu ch trong h thng kn l vic iu ch c s dng cc b ti gm nhiu ti gn sn vi nhau
hoc s dng thit b ct ni t ng v trng;
c) Gn tch (apheresis) thnh phn mu l vic ly mt hoc nhiu thnh phn mu trc tip t ngi
hin mu bng k thut th cng hoc t ng.
11. Cc ch phm hng cu
a) Khi hng cu (hoc hng cu lng) l phn cn li ca mu ton phn tch huyt tng;
b) Khi hng cu m c l khi hng cu khng b sung thmdung dch khc;
c) Khi hng cu c dung dch bo qun l khi hng cu c b sung dung dch bo qun;

| 483
d) Khi hng cu gim bch cu l khi hng cu c loi b bt bch cu;
) Khi hng cu lc bch cu l khi hng cu c loi b bch cu bng b lc bch cu;
e) Khi hng cu ra l khi hng cu c loi b phn ln huyt tng bng cch ra nhiu ln vi
dung dch mui NaCl ng trng, sau pha long trong dung dch mui NaCl ng trng hoc dung
dch bo qun hoc huyt tng thch hp;
g) Khi hng cu ng lnh l khi hng cu bo qun trng thi ng lnh;
h) Khi hng cu chiu x l khi hng cu c chiu x tia gamma bt hot cc bch cu lympho.
12. Cc ch phm tiu cu
a) Huyt tng giu tiu cu l ch phm huyt tng cha nhiu tiu cu tch t mu ton phn;
b) Khi tiu cu l ch phm tiu cu m c;
c) Khi tiu cu gn tch (apheresis) l khi tiu cu c gn tch trc tip t ngi hin mu;
d) Khi tiu cu gim bch cu l khi tiu cu c loi b bt bch cu;
) Khi tiu cu lc bch cu l khi tiu cu c loi b bch cu bng b lc bch cu;
e) Khi tiu cu ra l khi tiu cu c loi b huyt tng bng cch ra nhiu ln vi dung dch
mui NaCl ng trng, sau pha long trong dung dch bo qun hoc huyt tng ph hp;
g) Khi tiu cu chiu x l khi tiu cu c chiu x tia gamma bt hot cc bch cu lympho.
13. Khi bch cu ht l khi bch cu c iu ch t nhiu n v mu ton phn hoc bng gn tch trc
tip t ngi hin mu.
14. Cc ch phm huyt tng
a) Huyt tng l phn dung dch khng cha cc t bo mu, c iu ch t n v mu ton phn
hoc ly trc tip t ngi cho bng gn tch;
b) Huyt tng ng lnh l huyt tng c lm ng lnh v bo qun nhit thp hn -18
o
C;
c) Huyt tng ti l huyt tng c iu ch t mu ton phn tt nht trong 06 gi v ti a khng
qu 18 gi k t sau khi ly mu. Nu mu ton phn trong thit b chuyn dng nhit t 20 -
24
o
C, c th iu ch huyt tng ti ti a trong thi gian 24 gi k t sau khi ly mu t ngi hin
mu;
d) Huyt tng ti ng lnh l huyt tng ti c lm ng lnh v bo qun nhit ng lnh
thp hn -18
o
C;
) Ta lnh (giu yu t VIII) l ch phm gm phn ta hnh thnh trong qu trnh tan ng chm huyt
tng ti ng lnh nhit thp.
15. Pool l cc ch phm cng loi v cng nhm mu c trn cng trong mt ti ch phm m bo
liu iu tr.
16. Hn dng l khong thi gian ti a m cc ch phm c php s dng cho ngi bnh khi bo qun
iu kin ph hp theo quy nh.
17. Nhit bo qun l nhit duy tr trong khoang cha ca thit b bo qun mu v ch phm.
18. Nhit phng l nhit phng lmvic c s dng h thng iu ho nhit duy tr trong khong
t 18 - 24
o
C.
19. Truyn mu t thn theo k hoch l vic ly mu ngi bnh theo k hoch iu ch, bo qun v
truyn li cho chnh ngi bnh .
20. Pha long mu ng tch l vic ly mu, b lng dch tng ng cho ngi bnh v truyn tr li
n v mu cho chnh ngi bnh trong phu thut.
21. Truyn mu hon hi l vic ly mu ngi bnh t vng phu thut, x l v truyn tr li cho chnh
ngi bnh .
iu 4. Nguyn tc hot ng truyn mu
1. V mc ch nhn o, khng v mc ch li nhun.
2. T nguyn i vi ngi hin mu.
3. Ch s dng mu v cc ch phmmu vo vic cha bnh, ging dy, nghin cu khoa hc.
4. Gi b mt v cc thng tin c lin quan n ngi hin, ngi nhn mu v ch phmmu.
5. Bo m an ton i vi ngi hin, ngi c truyn mu, ch phm mu v nhn vin y t c lin quan
n truyn mu.
6. Truyn mu theo nhu cu hp l i vi tng ngi bnh.

484 |
iu 5. Cc hnh vi b cm
1. p buc ngi khc phi hin mu, ch phmmu.
2. Khng thc hin theo ng cc quy nh ti Quy ch ny.

Chng II
TUYN CHN NGI HIN MU V THU GOM MU

Mc 1
TUYN CHN NGI HIN MU

iu 6. iu kin i vi ngi hin mu
1. Ngi hin mu phi c giy chng minh nhn dn, h chiu, giy chng minh ca qun i, cng an.
2. C tr li Bng hi tnh trng sc kho ngi hin mu v camkt t nguyn hin mu (theo Mu s 1).
3. Tui:
a) Namt 18 - 60 tui;
b) N t 18 - 55 tui.
4. Trng lng c th v th tch mu ly mi lt i vi c hai gii:
a) Hin mu ton phn:
Ngi hin mu phi c trng lng c th t nht l 45 kg;
Th tch mu mi lt hin mu ly khng qu 09 ml/kg cn nng v khng c qu 450 ml mu
ton phn.
b) Hin cc thnh phn mu bng gn tch:
Ngi hin mu phi c trng lng c th t nht l 50 kg v hin mi lt khng qu 500 ml tng cc loi
thnh phn (huyt tng, tiu cu, bch cu, hng cu, t bo gc).
5. Tiu chun sc kho:
a) Tin s: Khng mc cc bnh mn tnh ca cc c quan h hp, tun hon, tit niu, tiu ho, tmthn
kinh; khng mc cc bnh ly truyn qua ng mu, quan h tnh dc;
b) Lmsng:
- Ngi hin mu c tnh trng kho mnh, tnh to, tip xc tt, khng c cc biu hin bt thng bnh
l cp tnh v mn tnh.
- Huyt p:
Huyt p ti a: 100 - 140 mmHg;
Huyt p ti thiu: 60 - 90 mm Hg.
- Tn s tim u: 60 - 90 ln/pht;
- Khng c cc biu hin sau:
St cn nhanh (trn 10% trng lng c th trong 06 thng);
Hoa mt, chng mt;
V m hi trm;
Hch to;
St;
Ph;
Ho, kh th;
a chy;
Xut huyt cc loi;
Xut hin cc tn thng bt thng trn da.
b) Mt s ch s sinh hc v xt nghim trc khi hin mu:
- Nng hemoglobin:
Phi t t nht l 120 g/l i vi c hai gii;
Ngi hin 450 ml mu ton phn phi c nng hemoglobin t nht l 125 g/l;

| 485
- Nng protein trong mu: Ngi hin huyt tng bng gn tch phi c nng protein huyt thanh
trong gii hn sinh l bnh thng v phi xt nghim li t nht 4 thng mt ln;
- S lng tiu cu: Ngi hin tiu cu, bch cu ht, bch cu n nhn, t bo gc bng gn tch phi
c s lng tiu cu t nht l 20010
9
/l;
- Xt nghim sng lc nhanh HBsAg cho kt qu m tnh i vi ngi hin mu ln u ti nhng khu
vc c t l ngi kho mang virus vimgan B cao.
iu 7. Nhng ngi khng c hin mu
1. Nhng ngi sau y khng c hin mu
a) Ngi nghin ma tu, nghin ru;
b) Ngi hoc ang s dng thuc Etretinate;
c) Ngi tn tt.
2. Khng c hin mu trong 12 thng i vi nhng ngi sau:
a) Ngi c phu thut;
b) Ngi mc st rt v ang iu tr bnh st rt;
c) Ngi timvacxin phng v iu tr bnh di;
d) Ph n ang trong thi gian mang thai hoc nui con nh di 12 thng tui;
) Ngi c truyn mu v sn phm mu, c min dch bng cc ch phm iu ch t mu;
e) Ngi n t cc vng, quc gia c dch bnh c th ly truyn qua ng mu.
3. Khng c hin mu trong 06 thng i vi nhng ngi hin mu, k t khi:
a) Xm tr trn da, bm di tai, bm mi, rn hoc cc v tr khc ca c th;
b) Phi nhim vi mu v dch c th t ngi c nguy c hoc nhim cc bnh truyn qua ng mu;
c) c quan h tnh dc khng an ton vi ngi tim chch ma tu, vi ngi mc cc bnh ly
truyn qua ng tnh dc v ng mu, vi ngi c quan h tnh dc ng gii.
4. Khng c hin mu trong 03 thng i vi nhng ngi timvacxin phng cc bnh (tr timvacxin
bnh di theo im c Khon 2 iu 7);
5. Khng c hin mu trong 07 ngy i vi nhng ngi s dng Aspirin hoc trong thnh phn thuc c
Aspirin, ring i vi hin mu bng gn tch tiu cu th nhng trng hp ny phi tm hon trong 10 ngy
k t khi ngng thuc;
6. Cc trng hp khc:
a) Ngi c vng da d nh ly mu tnh mch b tn thng, xy xt, nhim trng: Khng c hin mu
khi cha iu tr khi cc tn thng ;
b) Ngi s dng cc thuc hoc trong thnh phn thuc c hot cht nguy c gy t bin di truyn, gm:
Finasteride, Tretinoin, Isotretinoin: Khng c hin mu t nht trong 01 thng sau khi ngng s
dng thuc;
Acitretin: Khng c hin mu t nht trong 03 nm sau khi ngng s dng thuc;
c) Ngi s dng cc loi thuc khc do bc s xem xt, cn nhc khi khmtuyn ngi hin mu.
iu 8. Khong cch gia cc ln hin mu v cc ch phm mu
1. Hin mu ton phn: Khong cch t nht gia cc ln hin l 12 tun. Trong mt nm, mi ngi hin
khng qu 04 n v mu ton phn.
2. Hin cc thnh phn mu v huyt tng:
a) Hin huyt tng: Khong cch gia cc ln ly huyt tng t nht l 02 tun;
b) Hin tiu cu: Khong cch t nht gia cc ln hin tiu cu l 04 tun;
c) Hin bch cu ht trung tnh v t bo gc t mu ngoi vi: Ti a khng qu 03 ln trong mt tun;
Ngi kho mnh c th hin mt hoc nhiu loi thnh phn mu khc nhau, tuy nhin mi ngi hin
khng qu 24 ln trong mi nm.
3. Nu khng th truyn tr li khi hng cu cho ngi c gn tch thnh phn mu th phi xc nh
ngi l hin mu ton phn khi xem xt khong cch t nht cho ln hin sau.

486 |
4. Nu ly xen k mu ton phn v cc ch phm cng mt ngi hin mu th khong cch ti thiu gia
cc ln hin c xemxt theo khong cch ca loi ch phm hin ln gn nht.

Mc 2
QUYN LI V TRCH NHIM CA NGI HIN MU

iu 9. Quyn li ca ngi hin mu
1. c cung cp thng tin v nguy c ly truyn virt vimgan, HIV v cc bnh ly truyn khc t ngi
hin mu sang ngi nhn mu, c ch dn cc du hiu v triu chng ca cc bnh ly truyn qua ng
truyn mu;
2. c gii thch v quy trnh ly mu, cc biu hin khng mong mun c th xy ra, cc xt nghim s
thc hin trc v sau khi hin mu;
3. c thng bo v bo m b mt v kt qu khmlm sng, kt qu xt nghim; c hng dn cch
t chm sc sc kho; t vn v cc bnh mi pht hin sau khi khmsc kho v hin mu;
4. c chm sc, iu tr min ph khi c cc tc dng khng mong mun xy ra trong v ngay sau hin
mu;
5. c tn vinh, khen thng v hng cc quyn li khc v tinh thn, vt cht theo quy nh ca php
lut.
iu 10. Trch nhim ca ngi hin mu
1. Tr li trung thc v tnh trng sc kho v chu trch nhimv ni dung tr li ca mnh.
2. K xc nhn hiu r cc thng tin v t nguyn hin mu, sau khi c gii thch v hng dn theo
quy nh ti iu 9 ca Quy ch ny.
3. T gic khng cho mu nu xt thy bn thn khng iu kin hin mu theo quy nh ti Quy ch ny.
4. Phi bo ngay cho c s thu gom mu v s khng an ton ca n v mu va cho, nu t xt thy bn
thn c nguy c mc bnh vim gan, nhimHIV v cc bnh ly truyn khc.
5. Khng li dng vic hin mu kimtra sc kho c nhn.
iu 11. Trch nhim bo m quyn li ca ngi hin mu
C s thu gom mu c trch nhim:
1. Bo mcc quyn li ca ngi hin mu theo quy nh ti iu 9 ca Quy ch ny.
2. Chu trch nhim phng nga v x tr cc tai bin trong v sau khi ly mu ngi hin mu.
a) Trang b thuc v trang thit b y t cn thit bo m cp cu khi c tai bin xy ra.
b) Nhn vin chu trch nhimx l cc tai bin ly mu phi c o to, hun luyn v c kh
nng thc hin nhimv c giao.

Mc 3
LY MU

iu 12. Yu cu trc khi ly mu
1. Phi hng dn, gii thch, gip ngi hin mu hiu r v tr li chnh xc Bng hi tnh trng sc kho
ngi hin mu (theo Mu s 1).
2. Phi t chc khmsc kho v xt nghim bo m thc hin theo ng quy nh ti iu 6, iu 7,
iu 8 ca Quy ch ny.
iu 13. Yu cu v ly mu
1. Vic ly mu phi bo mv trng, hn ch tn thng t chc.
2. Lng mu ly phi ph hp vi lng dung dch chng ng c sn theo quy nh ca nh sn xut ti
ng mu; phi trn u mu v dung dch chng ng; th tch mu thc t ly phi c ghi trn nhn
ti mu. Nu lng mu ly t hoc nhiu hn 10% so vi quy nh cho mi loi ti ng th phi ghi r trn
nhn v khng s dng iu ch sn phmmu.
iu 14. Yu cu v ly mu mu xt nghim
Cc mu mu dng cho cc xt nghim theo quy nh ti iu 17, iu 19 phi c ly cng thi im ly
mu hoc ch phm mu, c ghi nhn r rng v chuyn n ni lm xt nghim sng lc.

| 487
iu 15. Yu cu v bo qun sau khi ly mu
Cc n v mu phi c bo qun ngay sau ly mu theo cc yu cu sau:
1. n v mu ton phn khng s dng iu ch phi c bo qun nhit t 2-6
o
C.
2. n v mu ton phn dng iu ch khi tiu cu, khi bch cu phi c bo qun iu kin nhit
t 20 - 24
o
C.

Chng III
XT NGHIM CC N V MU
Mc 1
CC XT NGHIM BO M AN TON TRUYN MU

iu 16. Chn la sinh phm s dng trong xt nghim bo m an ton truyn mu
Phi s dng cc thuc th, sinh phm, dng c, trang thit b c B Y t cho php lu hnh. Ch s
dng cc thuc th, sinh phm trong hn s dng.
iu 17. Cc xt nghim phi thc hin i vi mi n v mu v ch phm mu
1. Cc n v mu ton phn hoc ch phm mu thu c bng gn tch phi c thc hin cc xt nghim
bt buc sau: nh nhmmu ABO, Rh(D), xt nghimsng lc HIV, vimgan virt B, vimgan virt C,
giang mai, st rt.
2. Cc xt nghim quy nh ti Khon 1 iu ny phi bo mtheo yu cu sau:
a) nh nhm hng cu ABO: Phi nh nhmbng huyt thanh mu v hng cu mu;
b) nh nhmhng cu Rh(D);
c) Xt nghim sng lc HIV: Phi thc hin xt nghim sng lc khng th chng HIV 1 v HIV 2 bng
k thut c nhy v c hiu tng ng hoc cao hn k thut ELISA;
d) Xt nghimsng lc vimgan virt B: Phi thc hin xt nghimsng lc HBsAg bng k thut c
nhy v c hiu tng ng hoc cao hn k thut ELISA. Cc n v mu ly t ngi hin
mu xt nghimsng lc nhanh vim gan B trc khi hin mu vn phi thc hin xt nghimsng
lc ny.
) Xt nghimsng lc vim gan virt C: Phi thc hin xt nghim sng lc khng th chng HCV
bng k thut c nhy v c hiu tng ng hoc cao hn k thut ELISA;
e) Xt nghim sng lc giang mai: Phi thc hin xt nghimsng lc giang mai bng k thut c
nhy v c hiu tng ng hoc cao hn k thut VDRL.
g) Xt nghim sng lc st rt: Phi thc hin xt nghim sng lc st rt bng k thut c nhy
tng ng k thut tmk sinh trng st rt trn tiu bn git c c bng knh hin vi quang hc
hoc bng k thut nhy hn.
3. Khng c s dng kt qu xt nghim sng lc ca cc mu mu ly t ngi hin mu thi im
khc vi thi imly mu.
iu 18. X l cc n v mu v ch phm mu khng t tiu chun xt nghim
Cc n v mu v ch phm mu c lin quan n cc n v mu khng t tiu chun xt nghim phi c
hu b theo quy nh ca php lut v x l cht thi y t.
iu 19. Mt s xt nghim b sung
Cc c s truyn mu c iu kin k thut hoc khi cn truyn mu trong mt s tnh trng bnh l c
bit c th thc hin cc xt nghimb sung theo ngh ca c s truyn mu v c c quan qun l
cp trn trc tip chp thun bng vn bn.
1. Cc xt nghimb sung gm:
a) Xt nghimsng lc cc khng th bt thng.
b) Xt nghimmen gan Alanin Aminotransferase.
c) Xt nghimsng lc cc bnh ly qua ng truyn mu: xt nghimNucleic Acid Test (NAT) sng
lc HBV, HCV, HIV; khng th HBc IgM, khng th CMV IgM, khng th HTLV-I v HTLV-II,
Parvovirus B19, ...
2. Cc n v mu v ch phm mu c lin quan n cc xt nghimb sung khng t tiu chun phi
c x l theo quy nh ti iu 18 ca Quy ch ny.

488 |
Mc 2
LU GI MU HUYT THANH CA NGI HIN MU

iu 20. Thi gian lu gi mu huyt thanh
Mu huyt thanh ca ngi hin mu phi c lu gi ti c s thu gom mu trong 2 nm k t khi ly mu.
i vi n v mu v ch phm mu c thi hn s dng di hn 1 nm th thi gian lu gi mu huyt thanh
phi ko di thm ti thiu l 1 nm tnh t thi im ht hn ti a s dng n v mu v ch phm mu .
iu 21. iu kin lu gi
1. Phi c lm ng lnh v bo qun nhit thp hn -18
o
C cc mu huyt thanh c tch t cng
mu mu dng xt nghimsng lc cc n v mu.
2. Mu huyt thanh lu gi phi c qun l, bo qun v tiu hu bo m an ton, d dng tra cu v
kimsot.
Chng IV
TRCH NHIM CA C S THU GOM MU V C S IU TR
S DNG MU KHI PHT HIN N V MU HIN B NHIM HIV

iu 22. Trch nhim ca c s thu gom mu
1. Khi n v mu c xt nghim sng lc HIV dng tnh, c s thu gommu phi gi mu n v mu
kimtra ti c s xt nghim c B Y t cng nhn iu kin khng nh cc trng hp HIV dng
tnh.
2. Sau khi c c s xt nghimthng bo kt qu xt nghimkhng nh HIV dng tnh, c s thu gom
mu phi thc hin ngay cc yu cu sau y:
a) Gi mu huyt thanh ca ln ly mu trc gn nht ca chnh ngi hin mu , kimtra ti c
s xt nghim c B Y t cng nhn iu kin khng nh cc trng hp HIV dng tnh; nu kt
qu khng nh dng tnh th tip tc kimtra li mu ly ln hin trc ;
b) Lp danh sch cc n v mu v ch phm mu c lin quan n ngi hin b nhim HIV t cc ln
hin trc (ln hin mu gn nht v cc ln hin trong 06 thng trc ln c kt qu sng lc dng
tnh) v thng bo kp thi cho cc c s iu tr nhn n v mu v ch phm mu ;
c) Ghi kt qu xt nghim HIV dng tnh vo h s ngi hin mu, gii thiu ngi nhim HIV n
cc Trung tmphng, chng HIV/AIDS hoc Trung tm y t d phng a phng c tip tc t
vn, qun l, hng dn chm sc sc kho theo quy nh hin hnh;
d) Bo co c quan qun l cp trn theo quy nh hin hnh.
iu 23. Trch nhim ca c s iu tr s dng mu v ch phm mu
Khi nhn c thng bo ca c s truyn mu v danh sch cc n v mu v ch phmmu c lin quan
n ngi hin b nhim HIV, c s iu tr phi thc hin ngay cc yu cu sau y:
1. Mu v ch phm lin quan cha s dng: Hu ngay sau khi nhn thng bo theo quy nh ti iu 18
ca Quy ch ny.
2. Lp danh sch ngi bnh nhn n v mu v ch phm c lin quan n ngi hin b nhimHIV.
3. Gii thiu ngi bnh n Trung tmphng, chng HIV/AIDS hoc Trung tmy t d phng
a phng c t vn, xt nghimkhng nh v hng dn chm sc sc kho theo quy nh hin
hnh.
Chng V
IU CH, BO QUN, VN CHUYN MU V CC CH PHM MU

iu 24. iu kin thc hin iu ch cc ch phm mu
1. Cc c s iu ch cc ch phmmu phi tun th cc nguyn tc, tiu chun thc hnh tt sn xut
(GMP) hoc cc iu kin do B Y t quy nh i vi cc c s iu ch cc ch phmmu.
2. Cc c s thnh lp mi iu ch cc ch phmmu phi thc hin ngay theo quy nh ti Khon 1 ca
iu ny. Cc c s ang iu ch cc ch phm mu phi c k hoch trin khai chmnht n nm
2012 thc hin c theo quy nh ti Khon 1 ca iu ny.
3. B Y t thmnh v cp giy chng nhn iu kin i vi c s iu ch cc ch phmmu.
4. B Y t thm nh v cp ng k cho cc ch phm mu c s dng trong cc c s iu tr.

| 489
iu 25. Mu ton phn
1. Lng hemoglobin khng thp hn 10 g/100 ml mu ton phn c chng ng.
2. Th tch thc ca n v mu ton phn phi trong khong th tch quy nh 10%.
3. Mu ton phn phi bo qun nhit t 2 - 6
o
C. Phi bo qun mu ton phn theo quy nh ti Khon
1 iu 27 v Khon 1 iu 28 ca Quy ch ny khi iu ch cc ch phmtiu cu, khi bch cu.
4. Mu ton phn bo qun nhit t 2 - 6
o
C c hn dng theo quy nh ca nh sn xut ti ly mu.
5. Mu ton phn bo qun nhit t 2 - 6
o
C trong dung dch chng ng bng Heparin c hn dng
khng qu 24 gi k t khi ly mu.
6. Mu ton phn lc bch cu iu ch trong h thng h:
a) Bo qun nhit t 2 - 6
o
C c hn dng khng qu 24 gi k t khi iu ch;
b) Bo qun nhit phng (theo quy nh ti Khon 18 iu 3) c hn dng khng qu 06 gi k t
khi iu ch.
7. Mu ton phn lc bch cu iu ch trong h thng kn v bo qun nhit t 2 - 6
o
C c hn dng
khng thay i so vi trc khi lc bch cu.
8. Mu ton phn chiu x bo qun nhit t 2 - 6
o
C c hn dng khng qu 14 ngy k t khi chiu x
v khng qu hn so vi trc khi c chiu x.
iu 26. Cc ch phm hng cu
1. Tnh theo iu ch t 100 ml mu ton phn, lng hemoglobin trong khi hng cu cn t :
a) Khi hng cu ng lnh c lng hemoglobin khng c thp hn 8,0 g;
b) Khi hng cu gim bch cu, khi hng cu lc bch cu, khi hng cu ra c lng hemoglobin
khng c thp hn 9,5 g;
c) Cc loi khi hng cu khc c lng hemoglobin khng thp hn 10,0g.
2. Hematocrit ca cc loi khi hng cu khng vt qu 75%.
3. Khi hng cu m c bo qun nhit t 2 - 6
o
C c hn dng nh mu ton phn theo Khon 4,
Khon 5, Khon 6 iu 25 ca Quy ch ny.
4. Khi hng cu c dung dch bo qun: Khi iu ch trong h thng kn, bo qun nhit t 2 - 6
o
C c
hn dng theo ngh ca nh sn xut ti mu, nhng khng qu 42 ngy k t khi ly mu.
5. Khi hng cu gimbch cu bng phng php ly tm:
a) Phi loi b trn 70% bch cu c trong n v mu ton phn ban u v s lng bch cu tn d
ti a khng qu 0,2710
9
/ th tch khi hng cu iu ch t 100 ml mu ton phn;
b) Khi iu ch trong h thng kn, bo qun nhit t 2 - 6
o
C c hn dng tng t nh trc khi
gimbch cu;
c) Khi hng cu gim bch cu iu ch trong h thng h, bo qun nhit t 2 - 6
o
C c hn dng
khng qu 24 gi tnh t lc iu ch; nu bo qun nhit phng (theo quy nh ti Khon 18 iu
3) c hn dng khng qu 06 gi tnh t khi iu ch.
6. Khi hng cu lc bch cu:
a) S lng bch cu cn li t hn 0,1210
6
/th tch khi hng cu iu ch t 100 ml mu ton phn;
b) Khi iu ch trong h thng kn, bo qun nhit t 2 - 6
o
C, c hn dng tng t nh trc khi
lc bch cu;
c) Khi iu ch trong h thng h, bo qun nhit t 2 - 6
o
C, c hn dng khng qu 24 gi tnh t
khi iu ch; nu bo qun nhit phng (theo quy nh ti Khon 18 iu 3) c hn dng khng qu
06 gi tnh t khi iu ch.
7. Khi hng cu ra:
a) Khi hng cu ra bo qun nhit t 2 - 6
o
C, c hn dng khng qu 24 gi k t khi bt u
iu ch;
b) Khi hng cu ra bo qun nhit phng (theo quy nh ti Khon 18 iu 3) c hn s dng
khng qu 06 gi k t khi bt u iu ch.
8. Khi hng cu ng lnh: C hn s dng l 20 nm tnh t khi iu ch vi iu kin sau:
a) ng lnh trong 40% glycerol v bo qun nhit thp hn -80
o
C;
b) ng lnh trong 20% glycerol v bo qun nhit thp hn -120
o
C;

490 |
9. Khi hng cu ng lnh, sau ph ng v loi b glycerol:
Lng hemoglobin t do thp hn 0,2 g/n v;
iu ch trong h thng kn v bo qun nhit t 2 - 6
o
C c hn dng khng qu 2 tun tnh t khi ra;
iu ch trong h thng h v bo qun nhit t 2 - 6
o
C c hn dng khng qu 24 gi tnh t khi ra.
10. Khi hng cu chiu x bo qun nhit t 2 - 6
o
C c hn dng khng qu 14 ngy k t khi chiu x
v khng qu hn dng nh khi hng cu trc khi chiu x.
11. Mu ton phn v cc ch phm hng cu khi vn chuyn phi c bo qun nhit t 1 - 10
o
C.
Khi hng cu ng lnh khi vn chuyn phi duy tr nhit bo qun theo quy nh ti Khon 8 iu ny.
iu 27. Cc ch phm tiu cu
1. Ch phmtiu cu (bao gmkhi tiu cu v huyt tng giu tiu cu) phi iu ch t mu ton phn
bo qun nhit t 20 - 24
o
C trc khi iu ch v khng qu 24 gi sau ly mu.
2. Huyt tng giu tiu cu: C s lng tiu cu ti thiu l 1410
9
tnh theo iu ch t 100 ml mu ton
phn.
a) Mt n v huyt tng giu tiu cu truyn cho ngi bnh l ngi ln c s lng tiu cu ti
thiu l 7010
9
v vi th tch huyt tng khng di 200 ml;
b) Huyt tng giu tiu cu iu ch t nhiu n v mu c cng nhm mu v c trn cng trong
mt ti ch phm trc khi truyn hoc c truyn ring r trong cng mt lt truyn.
3. Khi tiu cu pool: C s lng tiu cu ti thiu l 1410
9
tnh theo iu ch t 100 ml mu ton phn.
a) Mt n v khi tiu cu truyn cho ngi bnh (l ngi ln) c s lng tiu cu ti thiu l
14010
9
vi th tch huyt tng khng di 150 ml;
b) Khi tiu cu iu ch t nhiu n v mu c pool trc khi truyn hoc c truyn ring r
trong cng mt lt truyn.
4. Khi tiu cu gn tch c iu ch t mt ngi cho: S lng tiu cu ti thiu phi l 30010
9
trong
th tch huyt tng khng di 300 ml vi mi lt gn tch.
5. Khi tiu cu gimbch cu: C s bch cu thp hn 0,1210
9
trong mt n v truyn.
6. Khi tiu cu lc bch cu: C s bch cu thp hn 0,510
6
trong mt n v truyn.
7. Khi tiu cu ra: c bo qun nhit t 20
o
C - 24
o
C, hn s dng khng qu 06 gi k t khi bt
u iu ch.
8. Khi tiu cu chiu x: Bo qun v hn dng ging nh khi tiu cu khng chiu x.
9. iu kin bo qun v hn dng cc ch phmtiu cu:
a) iu ch trong h thng kn, ng trong ti do chuyn dng c cp ng k, bo qun nhit
t 20 - 24
o
C kmlc lin tc c hn dng theo khuyn ngh ca nh sn xut ti do, nhng khng
qu 05 ngy k t khi ly mu;
b) iu ch trong h thng h, bo qun nhit t 20 - 24
o
C kmlc lin tc c hn dng khng qu
24 gi k t khi iu ch;
c) Bo qun nhit phng (theo quy nh ti Khon 18 iu 3) khng lc, c hn dng khng qu 12
gi k t khi iu kin ny v khng qu hn bo qun chung.
d) Bo qun nhit t 2 - 6
o
C, khng lc, c hn dng khng qu 24 gi k t khi iu ch;
) Phi duy tr pH trong khong t 6,6 - 7,4 trong sut thi gian bo qun.
10. Khi truyn cc ch phmtiu cu cho tr nh v ngi bnh c nguy c qu ti tun hon, c th gim
th tch truyn bng cch loi b bt huyt tng t cc khi tiu cu. Cc ch phmtiu cu ny c thi hn
bo qun khng qu 06 gi tnh t khi loi b bt huyt tng.
11. Vn chuyn ch phmtiu cu:
a) Cc ch phm tiu cu phi vn chuyn nhit phng (theo quy nh ti Khon 18 iu 3) hoc
nhit t 20 - 24
o
C;
b) Nu khng duy tr lc tiu cu trong vn chuyn, thi gian khng lc phi di 12 gi.
iu 28. Khi bch cu ht
1. Khi bch cu phi iu ch t mu ton phn bo qun nhit t 20 - 24
o
C v khng qu 24 gi k t
khi ly mu.
2. Khi bch cu ht cha ti thiu 1010
9
bch cu ht trong mt lt truyn.

| 491
3. Khi bch cu ht cn s dng sm ngay sau iu ch; nu khng th truyn ngay th phi bo qun
nhit phng (theo quy nh ti Khon 18 iu 3) hoc nhit t 20 - 24
o
C, khng lc v hn dng
khng qu 24 gi tnh t khi ly mu.
4. Khi bch cu khi vn chuyn, phi duy tr nhit phng (theo quy nh ti Khon 18 iu 3).
iu 29. Cc ch phm huyt tng
1. Huyt tng ti v huyt tng ti ng lnh: c nng yu t ng mu VIIIc t 0,7 n v quc
t /ml.
2. Huyt tng v huyt tng ng lnh: c nng protein ton phn khng di 50 g/l.
3. Ta lnh v ta lnh pool:
a) t ti thiu 15 n v quc t (tnh theo iu ch t 100 ml mu ton phn);
b) Ta lnh c iu ch t huyt tng ca nhiu n v mu ton phn s dng trong mt ln truyn
c tng lng yu t VIII t ti thiu 250 n v quc t.
4. Nhit bo qun v hn dng :
a) Hn dng khng qu 12 thng khi bo qun ng lnh nhit t -18 n -25
o
C ;
b) Hn dng khng qu 24 thng khi bo qun ng lnh nhit -25
o
C hoc thp hn;
c) Huyt tng khng ng lnh c iu ch trong h thng kn, bo qun nhit t 2 - 6
o
C c hn
dng nh i vi mu ton phn;
d) Huyt tng ti, ta lnh khng ng lnh, bo qun nhit t 2 - 6
o
C c hn dng khng qu 06
gi k t khi iu ch;
) Huyt tng ti ng lnh, ta lnh tan ng phi s dng ngay, hoc bo qun nhit t 2 -
6
o
C trong thi gian khng qu 6 gi t khi tan ng;
e) Huyt tng ti ng lnh tan ng nu bo qun nhit t 2 - 6
o
C trong thi gian qu 06 gi
khng c coi l ti v phi thay nhn ph hp;
g) Huyt tng ng lnh tan ng phi s dng sm, hoc bo qun nhit t 2 - 6
o
C trong thi
gian khng qu 05 ngy t khi tan ng.
5. Vn chuyn cc ch phmhuyt tng:
a) Cc ch phmhuyt tng ng lnh khi vn chuyn phi duy tr nhit thp hn -18
o
C ;
b) Cc ch phm huyt tng khng ng lnh khi vn chuyn phi duy tr nhit thp t 1 - 10
o
C.
iu 30. Nhn n v mu, ch phm mu
1. Nhn n v mu v ch phm mu phi thc hin theo ng quy nh ti Ngh nh s 89/2006/N- CP
ngy 30 thng 9 nm 2006 ca Chnh ph v Nhn hiu hng ho v c cc thng tin sau:
a) Tn loi ch phm;
b) Ch hoc m s xc nh n v mu hoc ch phm;
c) Th tch;
d) Tn v th tch dung dch chng ng hoc dung dch bo qun (vi mu ton phn v khi hng cu);
) Nhm mu ABO v Rh(D);
e) iu kin bo qun;
g) Ngy, thng, nm ly mu hoc iu ch;
h) Ngy ht hn s dng;
i) Tn, a ch c s thu gom hoc iu ch;
2. Ni dung cc thng tin trn nhn phi ghi bng ting Vit, bo mr rng, chnh xc; ch vit tay phi
dng mc bn mu.

Chng VI
D TR, CUNG CP MU V CH PHM MU

iu 31. iu kin cung cp mu, ch phm mu cho cc c s iu tr s dng mu khng trong cng
mt Vin, Bnh vin
1. Phi c hp ng trch nhimgia c s iu tr s dng mu vi c s cung cp mu v ch phmmu.
2. C s iu tr s dng mu khi lnh mu cn phi:

492 |
a) C nhn vin y t n lnh mu;
b) C Phiu d tr, cung cp mu v ch phm mu (theo Mu s 3) vi ch k xc nhn ca ngi ph
trch hoc ngi c u quyn; nu lnh mu trong gi trc th phi c ch k xc nhn ca ngi trc
lnh o c s iu tr hoc ngi c u quyn.
c) C phng tin bo qun, vn chuyn mu v ch phmmu ph hp.
3. Vic gi tr li hoc i mu gia cc c s truyn mu thc hin theo quy nh ti hp ng trch nhim
c tho thun gia cc bn.
iu 32. iu kin cung cp mu, ch phm mu cho c s iu tr s dng mu trong cng mt Vin,
Bnh vin
C s iu tr khi lnh mu, ch phm mu phi :
1. C nhn vin y t i lnh mu;
2. C Phiu d tr, cung cp mu v ch phmmu (theo Mu s 4) vi ch k ca bc s iu tr;
3. C mu mu xt nghimca ngi bnh;
4. C phng tin bo qun, vn chuyn mu v ch phmmu ph hp.
iu 33. Trch nhim ca c s cung cp mu v ch phm mu cho ngi bnh c iu tr trong
cng vin, bnh vin
Khi cung cp mu, ch phm mu, c s cung cp mu v ch phmmu phi thc hin:
1. nh nhmh ABO mu mu ngi bnh v n v mu, ch phmmu bng hai phng php huyt
thanh mu v hng cu mu.
a) Ch phmtiu cu, huyt tng v ta lnh phi nh nhm bng phng php hng cu mu.
b) Vic nh nhm mu ngi bnh phi do hai nhn vin thc hin hai ln trn cng mt mu mu hoc
trn hai mu mu ca cng mt ngi bnh.
2. nh nhmRh(D) mu mu ngi nhn: Ch thc hin khi cn truyn mu ton phn, khi hng cu, khi
bch cu.
3. Thc hin xt nghimho hp:
a) Truyn mu ton phn, khi hng cu, khi bch cu:
- Xt nghim ho hp trong ng nghim mi trng nc mui sinh l, nhit phng (theo quy
nh ti Khon 18 iu 3):
ng 1: Gia hng cu ca n v mu, ch phm mu vi huyt thanh ngi nhn;
ng 2: Gia huyt tng ca n v mu, ch phm mu vi hng cu ngi nhn.
- Xt nghim ho hp dng huyt thanh chng globulin:
Thc hin xt nghimho hp gia hng cu ca n v mu, ch phmhng cu, khi bch cu vi
huyt thanh ngi nhn theo k thut s dng huyt thanh chng globulin nhit 37
o
C.
b) Khi truyn ch phmtiu cu, huyt tng: Thc hin xt nghimho hp gia huyt tng ca n
v mu, ch phmmu vi hng cu ngi nhn trong ng nghim mi trng mui v nhit phng
(theo quy nh ti Khon 18 iu 3).
4. Khi nghi ng c s khng ho hp nhm mu gia mu ngi bnh vi n v mu, ch phm mu, cn
phi:
a) Kim tra, i chiu h s, cc thng tin c lin quan;
b) Phi hp vi bc s iu tr thc hin cc xt nghim tm, xc nh khng th bt thng, chn n v
mu, ch phmmu ho hp min dch.
5. La chn mu v ch phm ho hp min dch da trn kt qu nh nhmmu v xt nghim ho hp
min dch:
a) Kt qu nh nhm: ch c khng nh nhmABO khi hai ln nh nhm cho kt qu ging nhau v
cc kt qu ca phng php huyt thanh mu, hng cu mu ging nhau;
b) Kt qu xt nghimho hp mi trng mui, nhit phng (theo quy nh ti Khon 18 iu 3)
v huyt thanh chng globulin:
- Ch pht mu khi xt nghim ho hp c kt qu m tnh (-);
- Khi mt hoc nhiu xt nghim ho hp c kt qu dng tnh (+) v cp thit phi truyn mu, ch
phm mu cho ngi bnh, bc s chuyn khoa huyt hc truyn mu phi thc hin cc bin php
chn la mu v ch phm ho hp theo cc quy nh ti iu 34 ca Quy ch ny.
iu 34. Mt s nguyn tc chn la mu v ch phm mu ho hp min dch

| 493
1. Truyn mu ton phn v ch phm hng cu ho hp nhmh ABO vi huyt thanh ngi nhn.
Chn la mu ton phn v ch phmhng cu theo yu cu sau:
NHM MU NGI CHO
NHM MU NGI NHN
MU TON PHN CH PHM HNG CU
O O O
A A hoc O A
B B hoc O B
AB AB hoc A hoc B hoc O AB
2. Truyn cc ch phmhuyt tng ho hp nhmh ABO vi hng cu ngi nhn.
Chn la cc ch phmhuyt tng theo yu cu sau:
NHM MU NGI CHO NHM MU NGI NHN
O hoc B hoc A hoc AB O
A hoc AB A
B hoc AB B
AB AB
3. C th s dng ta lnh khng ho hp nhmh ABO vi hng cu ngi nhn.
4. Hng cu, tiu cu trong khi tiu cu phi ho hp nhmh ABO vi huyt thanh ngi nhn.
5. Hng cu trong khi bch cu phi ho hp nhmh ABO vi huyt thanh ngi nhn.
6. Chn la cc ch phmtiu cu v bch cu ht theo yu cu sau:
NHM MU NGI CHO
NHM MU
NGI NHN
CH PHM CN HUYT
TNG NGUYN THU
CH PHM LOI B HUYT
TNG NGUYN THU
O O O
A A hoc O A
B B hoc O B
AB AB hoc A hoc B hoc O AB

7. Chn la cc ch phmhng cu, tiu cu, bch cu ht theo nhm Rh(D) nh sau:
NHM MU NGI CHO NHM MU NGI NHN
D(-) D(-)
D(-) D yu
D(+) hoc D yu hoc D(-) D(+)
8. Khi xc nh c khng th bt thng ngi nhn, khng truyn mu ton phn hoc khi hng cu c
khng nguyn c hiu tng ng vi khng th bt thng pht hin.
iu 35. Cung cp mu trong trng hp khng c mu v ch phm mu cng nhm hoc khng xc
nh c nhm mu ngi bnh.
Khi khng c mu v ch phm mu cng nhm hoc khi khng xc nh c nhm mu ngi bnh, nu
c s ng ca bc s iu tr, c th cung cp mu nh sau:
1. Truyn khi hng cu nhm O cho ngi bnh c ch nh truyn ch phmhng cu.
2. Truyn huyt tng nhm AB cho ngi bnh c ch nh truyn huyt tng.
3. Ch truyn mu nhm Rh(D) dng (+) cho ngi nhn mang nhmRh(D) m(-) trong trng hp e do
tnh mng ngi bnh v c 2 iu kin:
a) Phn ng ho hp min dch s dng huyt thanh chng globulin nhit 37
o
C cho kt qu mtnh;
b) C s ng trong kt qu hi chn gia ngi ph trch c s cung cp mu, bc s iu tr v c
s ng ca ngi bnh hoc ngi nh.
iu 36. Lu tr mu n v mu, ch phm mu v mu mu ngi bnh nhn mu
1. Mu mu ngi bnh nhn mu v mu n v mu, ch phmmu truyn phi lu gi t nht 48 gi
nhit t 2 - 6
o
C sau khi cp mu.
2. Trong trng hp cn thit, ngi ph trch c s cung cp mu c quy nh thi gian lu gi ko di
hn theo quy nh ti Khon 1 nu trn.
iu 37. Vic tr li mu v ch phm mu cha s dng trong cng mt Vin, Bnh vin.
1. Khi khng s dng mu, ch phm mu, c s iu tr phi tr li mu, ch phmmu v c s cung cp
mu;

494 |
2. C s cung cp mu ch s dng mu, ch phmmu tr li truyn cho ngi bnh khc khi p ng
cc iu kin sau:
a) n v mu v ch phmcn nguyn vn;
b) Khng c biu hin tan mu c pht hin bng mt thng, khng c mu sc bt thng;
c) Mu v ch phm mu tr li phi c bo qun, vn chuyn iu kin thch hp theo ng quy
nh. Nu mu v ch phmmu tr li c bo qun nhit vt ngoi khong 2 - 6
o
C qu 30 pht
th khng c dng truyn cho ngi bnh;
d) C giy cam oan n v mu, ch phmmu cn nguyn vn v bo qun iu kin thch hp cho
tng loi theo ng quy nh ca Quy ch ny trong sut thi gian t lc nhn n lc tr li c s cung
cp mu. Giy cam oan phi c xc nhn ca ngi ph trch c s iu tr s dng mu.

CHNG VII
S DNG MU V CH PHM MU TI C S IU TR

iu 38. Ch nh truyn mu.
Khi ch nh truyn mu, c s iu tr phi thc hin cc yu cu sau:
1. Chun b phng tin, dng c, thuc thc hin truyn mu v x tr kp thi khi c tai bin truyn
mu.
Nhng thuc cp cu v dng c ti thiu cn c:
- Adrenalin;
- Khng histamin;
- Corticoid dng tim;
- Heparin;
- Li tiu ng tim;
- Kh oxy, bng ambu.
2. Lp k hoch, d tr mu, ch phmv thng bo ti c s cung cp mu ca bnh vin.
3. Ch nh truyn mu v ch phmmu khi thc s cn cho ngi bnh, khng c bin php iu tr thay
th, cn nhc n li ch, nguy c ca truyn mu v ph hp vi kh nng sn c ca mu v ch phm.
4. Thng bo cho ngi bnh hoc ngi nh v li ch v nguy c c th xy ra do truyn mu. Trong
trng hp khn cp cn truyn mu ngay nhng khng th thng bo c do ngi bnh b hn m, khng
c ngi nh th bc s phi ghi r vi s xc nhn ca mt nhn vin y t vo trong bnh n.
Ngi bnh hoc ngi nh ngi bnh phi xc nhn v k vo bnh n nu t chi vic truyn mu, ch
phmmu.
5. Ch dn cc biu hin ca cc tc dng khng mong mun c lin quan n truyn mu ngi bnh,
ngi nh ngi bnh c th h tr vic theo di, pht hin v thng bo kp thi cho nhn vin y t.
iu 39. Thc hin truyn mu, theo di kt qu truyn mu
C s iu tr s dng mu c trch nhim:
1. Phi c nhn vin ly mu mu xt nghim v lnh mu theo quy nh ti iu 32.
2. Thc hin kim tra, i chiu.
3. nh li nhmmu ti ging:
a) Truyn mu ton phn, ch phmhng cu, bch cu: s dng huyt thanh mu nh li nhmmu
ABO ca ngi bnh v n v mu trc truyn;
b) Truyn ch phm tiu cu, huyt tng: s dng huyt thanh mu nh li nhm mu ABO ca ngi
bnh v lmphn ng cho gia mu mu ngi bnh v mu ch phm.
4. Phi theo di cht ch tnh trng ngi bnh trong v sau truyn mu pht hin v x tr kp thi phn
ng bt li lin quan n truyn mu.
5. Phi ghi chp y mi din bin tnh trng ngi bnh vo Phiu truyn mu (theo Mu s 5).
6. Thng bo cc phn ng lin quan n truyn mu cho c s cung cp mu phi hp x tr kp thi.
7. Bo co kt qu truyn mu v cc tc dng khng mong mun (nu c) cho Phng K hoch Tng hp,
Ban An ton Truyn mu bnh vin v c s cung cp mu.

| 495
iu 40. m mu
Vic m mu khng c lmtan mu, khng lm tng nguy c nhimkhun v phi theo yu cu sau:
1. Khng c mmi n v mu, ch phmmu qu 30 pht.
2. Thi gian t khi m n khi kt thc truyn mu khng qu 06 gi.
3. m mu khng vt qu nhit 37
o
C.

Chng VIII
TRUYN MU T THN

iu 41. Cc nguyn tc chnh khi truyn mu t thn
1. Cc bc s iu tr, bc s phu thut, bc s gy m hi sc, bc s huyt hc truyn mu c trch nhim
ch nh v phi hp thc hin cc loi truyn mu t thn, bao gm: Truyn mu t thn theo k hoch, pha
long mu ng tch, truyn mu hon hi.
2. Vic ly mu dnh cho truyn mu t thn theo k hoch v pha long mu ng tch c thc hin khi
c s ng ca ngi bnh.
3. Cc n v mu ly t thn phi c qun l, bo qun ring v s dng ng mc ch.
4. Khi cn iu ch cc n v mu truyn t thn th phi thc hin theo quy nh v iu ch, bo qun mu
v ch phmmu.
5. Ngi lnh o c s iu tr phi ph duyt cc quy trnh thc hin truyn mu t thn ph hp vi iu
kin ca c s.
iu 42. Truyn mu t thn theo k hoch.
1. iu kin chn ngi bnh truyn mu t thn theo k hoch:
a) T 18 - 60 tui i vi c namv n;
b) Trng lng c th khng di 45 kg;
c) Th tch ly mu mi ln khng qu 07 ml/kg cn nng;
2. Tiu chun sc kho:
a) Lm sng: Theo quy nh ti imb Khon 5 iu 6 ca Quy ch ny;
b) Cc xt nghimbt buc trc khi ly mu i vi ngi bnh truyn mu t thn theo k hoch:
Nng hemoglobin phi t t nht l 110 g/l.
nh nhm mu ABO;
Xt nghim cc bnh ly truyn qua ng truyn mu, ti thiu gm: HBsAg, khng th chng
HIV 1 v HIV 2, khng th chng HCV, giang mai, st rt.
Cc kt qu xt nghim ny c thng bo cho ngi bnh.
3. Bc s iu tr ngi bnh truyn mu t thn theo k hoch c quyn bit kt qu cc xt nghim v c
quyn quyt nh vic truyn nhng n v mu t thn c kt qu bt thng vi cc xt nghimnu trn.
4.Vic cung cp, xt nghimho hp min dch trc truyn mu t thn phi thc hin theo quy nh v d
tr, cung cp mu v ch phmmu.
iu 43. Pha long mu ng tch
1. iu kin i vi ngi bnh c thc hin pha long mu ng tch truc m:
a) T 18 - 60 tui i vi c namv n;
b) Trng lng c th khng di 45 kg;
c) Phu thut c s dng k thut tin m hoc gy m ton thn.
2. Tiu chun sc kho:
a) Lm sng: Theo quy nh ti imb Khon 5 iu 6 ca Quy ch ny;
b) Mt s ch s sinh hc v xt nghim trc khi thc hin ly mu:
Nng hemoglobin phi t t nht l 110 g/l;
Hematocrit ca ngi bnh phi t t nht l 34%.
3. Nhng yu cu trong khi thc hin pha long mu ng tch v truyn li mu cho ngi bnh:
a) Hematocrit ca ngi bnh khng di 25% sau khi thc hin ly mu v truyn dch thay th;
b) Bo mduy tr cn bng th tch mu ly ra v lng dch truyn;

496 |
c) Bo mtruyn tr li cc n v mu ng cho ngi bnh c ly mu.
iu 44. Truyn mu hon hi
Khng truyn mu hon hi trong cc trng hp sau:
1. V tng rng;
2. xc nh thi gian chy mu qu 06 gi;
3. Mu c nguy c nhimkhun;
4. C biu hin tan mu.
iu 45. Nhn cc n v mu truyn t thn
Nhn cc n v mu truyn t thn phi c thc hin theo ng quy nh v iu ch, bo qun, vn
chuyn mu v ch phmmu. Ngoi ra cn phi bo mcc yu cu:
1. Trn nhn ghi r Ch dng cho truyn mu t thn;
2. Nu xt nghimbnh ly truyn quy nh ti th ba imb Khon 2 iu 42 cho kt qu dng tnh, th
cn ghi r: "Thn trng khi tip xc".

Chng IX
X L CC TC DNG KHNG MONG MUN
C LIN QUAN N TRUYN MU
iu 46. Pht hin v x tr cc tc dng khng mong mun c lin quan n truyn mu
1. Pht hin v x tr cc tc dng khng mong mun trong truyn mu v ngay sau truyn mu:
a) Khi xut hin cc triu chng bt thng bnh nhn ang truyn mu hoc ch phm mu, phi
ngng truyn ngay v bo co bc s iu tr x tr kp thi. Khi cn thit, phi mi bc s hoc ngi
ph trch ca c s cung cp mu phi hp x tr;
b) Trng hp bnh nhn c phn ng nng hoc t vong c lin quan n truyn mu th c s cung
cp mu phi bo co ngay vi lnh o bnh vin v c s cung cp mu phi hp tmnguyn nhn
v xut kin gii quyt;
Lp Bo co tc dng khng mong mun lin quan n truyn mu (theo Mu s 6), bn giao cho c s cung
cp mu cc ti mu, ch phmmu, dy truyn mu v cc loi thuc tim, dch truyn khc s dng cho
ngi bnh vo thi imxy ra tc dng khng mong mun. Thi gian lu gi cc bnh phmtrn v cc
mu mu c lin quan t nht l 14 ngy k t lc xy ra tc dng khng mong mun;
C s cung cp mu phi xt nghim cc mu bnh phm xc nh nguyn nhn v lp Phiu xt nghim
tc dng khng mong mun lin quan n truyn mu (theo Mu s 7);
2. Pht hin v x tr tc dng khng mong mun xy ra chmsau truyn mu:
C s iu tr s dng mu cn phi hp vi c s cung cp mu xc nh nguyn nhn tc dng khng
mong mun xy ra chm v p dng cc bin php theo di v iu tr tch cc theo quy nh ca B Y t.
iu 47. Bo co cc tc dng khng mong mun c lin quan n truyn mu
1. Khoa, phng iu tr v c s cung cp mu ca bnh vin phi bo co cc trng hp ngi bnh c cc
tc dng khng mong mun lin quan n truyn mu vi:
a) Lnh o Bnh vin, Hi ng Truyn mu v Phng K hoch Tng hp;
b) C s cung cp mu ngoi bnh vin c lin quan.
2. C s cung cp mu phi thc hin bo co nh k v cc tc dng khng mong mun lin quan n
truyn mu ln c s chuyn khoa huyt hc truyn mu cp trn. C s chuyn khoa huyt hc truyn mu
cp trn c trch nhim bo co ln Vin Huyt hc Truyn mu Trung ng. Trng hp din bin nghim
trng hoc gy t vong cho ngi bnh th phi bo co ngay trong vng 24 gi.
3. Vin Huyt hc Truyn mu Trung ng phi thc hin ch bo co nh k vi B Y t (V iu tr)
v cc tc dng khng mong mun lin quan n truyn mu v bo co t xut khi c din bin nghim
trng hoc gy t vong cho ngi bnh.
iu 48. Chm sc, iu tr ngi bnh b ly nhim bnh do truyn mu v xc nh nguyn nhn ly
nhim
1. Khi nghi ng ngi bnh b ly nhim bnh do truyn mu, c s cung cp mu (bao gmc c s cung
cp mu khng trong cng mt Vin, Bnh vin) phi phi hp vi c s iu tr s dng mu xc nh
nguyn nhn b ly nhimbnh qua ng truyn mu theo cc yu cu sau:

| 497
a) Xt nghimkimtra tt c cc mu huyt thanh lu ca cc n v mu v ch phm mu truyn
cho ngi bnh trong vng 6 thng trc ln xt nghimgn nht ngi bnh c kt qu mtnh cho
n thi im hin ti.
b) Xt nghimkimtra li tc nhn ly nhim ngi hin mu cho n v mu nghi ng ly truyn
bnh cho ngi bnh.
c) Tmhiu kh nng ngi bnh b ly nhimdo nguyn nhn khc.
2. C s iu tr phi hp vi c s truyn mu c trch nhim chm sc, iu tr ngi bnh b ly nhim
bnh do truyn mu.
Chng X
T CHC THC HIN
iu 49. Ch bo co
Theo phm vi hot ng, chc nng v trch nhim c giao, mi c s truyn mu phi thc hin ch
bo co nh k hng nm v bo co t xut vi c quan qun l nh nc cp trn v c s truyn mu
tuyn trn.
1. Ni dung bo co nh k hng nm gmcc thng tin sau:
a) S lng ngi hin mu v s lt hin mu;
b) S lng n v mu tiu chun v khng tiu chun theo tng loi;
c) Cc phn ng bt li ngi hin mu (nu c);
d) S lng n v ch phmmu mi loi c gn tch;
) K thut, s lng, loi sinh phm dng xt nghim sng lc v t l pht hin cc tc nhn ly
truyn ngi hin mu v theo lt hin mu, danh sch cc trng hp cho kt qu nghi ng v
dng tnh vi cc bnh ly qua ng truyn mu;
e) S n v mu khng c xt nghimsng lc (nu c) v l do;
g) Hot ng iu ch cc ch phmmu;
h) Hot ng cung cp, s dng mu v ch phmmu;
k) Tnh hnh cc phn ng bt li c lin quan n truyn mu (nu c);
2. Ni dung bo co t xut: Thc hin theo ni dung yu cu ca c quan qun l hoc theo yu cu thc
t m n v cn bo co ln cp trn.
iu 50. H s lu tr ti c s truyn mu
Mi c s truyn mu phi c h thng h s c lu tr theo cc yu cu sau:
1. H s bao gm:
a) Ti liu v ly mu:
Tr li ca ngi hin mu theo Bng hi tnh trng sc kho ngi hin mu (theo Mu s 1);
H s sc kho ngi hin mu (theo Mu s 2) bao gm cc thng tin v hnh chnh, khm lm
sng, xt nghim sng lc ngi hin mu, kt qu hin mu, cc tc dng bt li (nu c) ca ngi
hin ;
Cc quy trnh chuyn mn k thut c lin quan.
b) Ti liu v n v mu v ch phmmu:
Thng tin v thu nhn mu mu; loi, l, hn s dng, kim tra cht lng sinh phm xt nghim;
x l s liu v tr li kt qu; bo qun, kim tra v tiu hu mu bnh phm lu.
Trong trng hp cc n v mu v ch phm mu c hn bo qun qu 02 nm, phi lu tr thng
tin lin quan vi cc ch phm ny t nht l 08 nm tnh t thi im ht hn s dng cc ch phm
.
Thng tin v tn loi ch phm, phng thc iu ch, trang thit b, dng c s dng, m hiu,
nhm mu, ngy iu ch, ngy ht hn s dng, tn c s ly mu, c s iu ch.
Cc quy trnh chuyn mn k thut c thc hin.
c) Ti liu v ngi bnh nhn mu v ch phmmu:
Thng tin v ngi bnh nhn mu;
Thng tin v n v mu v ch phm mu;
Thng tin v xt nghim, cung cp mu v ch phm mu;
Thng tin v truyn mu lm sng, theo di v x tr cc phn ng bt li c lin quan n truyn
mu (nu c);
Thng tin v bnh ly nhim qua ng truyn mu (nu c).

498 |
d) Cc bo co gi cho cc c quan khc.
2. H s phi y , d tmkimv tra cu, bo mt, an ton.
3. H s c lu tr 10 nm tnh t ngy cp nht thng tin ln cui cng.
iu 51. Trch nhim thc hin
1. Trch nhimca cc V, Cc, Thanh tra B Y t.
a) V iu tr c trch nhim ch tr, phi hp vi cc V, Cc c lin quan ch o, hng dn, kim
tra hot ng truyn mu trong phmvi c nc;
b) Cc Y t d phng Vit Namc trch nhimch tr, phi hp vi V iu tr v cc V, Cc c lin
quan t chc vic thm nh v trnh B trng B Y t cp giy chng nhn c s c iu kin iu
ch cc ch phmmu v cp ng k cho cc ch phm mu c s dng trong c s iu tr.
c) V K hoch - Ti chnh c trch nhimch tr, phi hp vi V iu tr v cc c quan c lin quan
hng dn ch ti chnh mbo cc hot ng truyn mu;
d) Thanh tra B Y t c trch nhimch tr, phi hp vi V iu tr v cc V, Cc c lin quan t
chc vic thanh tra hot ng truyn mu trong phmvi c nc.
2. S Y t tnh, thnh ph trc thuc trung ng c trch nhimch o, hng dn, kimtra, thanh tra hot
ng truyn mu trong phm vi a phng.
3. Vin Huyt hc Truyn mu Trung ng l Vin chuyn khoa trc thuc B Y t c trch nhimch o
v chuyn mn k thut bo mcht lng, an ton truyn mu trong phmvi c nc.
4. Cc Trung tmtruyn mu khu vc c trch nhim ch o v chuyn mn k thut bo mcht
lng, an ton truyn mu i vi cc c s c B Y t giao ph trch.
5. Cc bnh vin c trch nhim bo m cht lng, an ton truyn mu trong bnh vin. Mi bnh vin
phi t chc Hi ng Truyn mu tham mu cho Gim c Bnh vin trong vic bo m cht lng, an
ton truyn mu.
6. Cc c s truyn mu c trch nhim:
a) Thc hin hot ng chuyn mn theo nhimv c giao, ph hp vi iu kin c s vt cht,
nhn lc, trang thit b hin c v phi theo ng quy nh, quy trnh chuyn mn k thut v an ton
truyn mu.
b) Phi hp, h tr cc c s iu tr thc hin truyn mu lmsng an ton.
c) Phi hp vi cc t chc, on th trong cng tc vn ng hin mu tnh nguyn.
7. Cc c s iu tr s dng mu chu trch nhim:
a) Thc hin vic truyn mu lm sng theo ng quy nh, quy trnh chuyn mn k thut v an ton
truyn mu.
b) Phi hp vi c s truyn mu mbo an ton truyn mu lmsng.

B TRNG

( k)

Trn Th Trung Chin

| 499
PH LC

(Ban hnh km theo Quyt nh s 06 /2007/Q-BYT ngy 19/01/2007
ca B trng B Y t)

1. Mu s 1. Bng hi tnh trng sc kho ngi hin mu
2. Mu s 2. H s sc kho ngi hin mu
3. Mu s 3. Phiu d tr v cung cp mu, ch phm mu cho cc c s khng cng vin, bnh vin
4. Mu s 4. Phiu d tr v cung cp mu, ch phm mu cho cc c s trong vin, bnh vin
5. Mu s 5. Phiu truyn mu
6. Mu s 6. Bo co tc dng khng mong mun lin quan n truyn mu
7. Mu s 7. Phiu xt nghimtc dng khng mong mun lin quan n truyn mu

500 |
BIU MU 1
MU S 1
BNG HI TNH TRNG SC KHO NGI HIN MU

I. Phn thng tin chung:
1. H v tn:
2. Ngy sinh:
3. Gii:
4. Quc tch:
5. Dn tc:
6. Ngh nghip:
7. a ch c quan, trng:
8. a ch thng tr:
9. a ch lin lc:
10. in thoi (nu c):
11. Email (nu c):
12. S chng minh th / h chiu (nu c):
13. Ni cp:
14. Th hin mu s:
II. Phn dnh cho ngi hin mu
1. Cmgic bn thn v sc kho hin ti ca ngi hin mu:
2. S ln hin mu v ln hin mu gn nht:
3. Tin s sc kho chung v bnh tt:
- Bnh tim mch:
- Bnh gan, vimgan cc loi:
- Bnh thn:
- Ni tit:
- Bnh lao v h h hp:
- Bnh mu:
- Bnh tmthn kinh:
- St rt:
- Giang mai:
- HIV/AIDS:
- Cc bnh ly truyn khc:
- Tin s v phu thut, cc th thut y t:
- Tin s timvacxin v cc ch phmsinh hc, truyn mu v cc ch phm mu; ghp c quan, t chc;
xm tr; phi nhimvi mu v dch c th t ngi khc....
4. Cc biu hin bt thng bnh l:
- St cn khng r l do,
- Ra m hi trm,
- Xut hin u, bu trn da hoc nim mc,
- Hch to ko di trn 1 thng,
- Ri lon tiu ho,
- St trn 37
o
5 ko di trn 10 ngy.
5. Tin s c s dng cc cht gy nghin:
6. Tin s quan h tnh dc vi ngi mc vim gan, HIV/AIDS, ngi c quan h tnh dc ng gii:
7. Tnh trng mang thai, nui con nh di 12 thng tui:
8. Li cam oan ca ngi hin mu v:
- Hiu v tr li trung thc cc cu hi;
- Khng hin mu nu t thy c nguy c ly truyn bnh cho ngi khc;
- Cmthy tht s kho mnh;
- Tnh nguyn hin mu;
- Sau khi hin mu, nu mi pht hin thy bn thn c nguy c lm ly truyn bnh cho ngi c
truyn, t nguyn bo ngay cho c s thu gom mu v s khng an ton ca n v mu va cho.
9. Ngy thng nm thc hin bn t khai
10. Ch k v h tn ca ngi hin mu
11. Ch k v h tn ca ngi hng dn tr li cu hi
12. Ch k v h tn ca ngi khm sc kho

B Y t hoc S Y t
Tn c s thu gommu

| 501
MU S 2
H S SC KHO NGI HIN MU

I. Phn thng tin chung
1. H v tn:
2. M hiu ngi hin mu:
3. Ngy sinh:
4. Gii:
5. Dn tc
6. S chng minh th, h chiu:
7. Ngy v ni cp:
8. a ch hin ti:
9. S in thoi nh:
10. Ngh nghip:
11. Ni lm vic:
12. S in thoi ni lm:
13. Cho mu ln u nm:
14. Tin s sc kho chung v bnh tt:
- Bnh timmch:
- Bnh gan, vimgan cc loi:
- Bnh thn:
- Ni tit:
- Bnh lao v h h hp:
- Bnh mu:
- Bnh tm thn kinh:
- St rt:
- Giang mai:
- HIV/AIDS:
- Cc bnh ly truyn khc:
- Tin s v phu thut, cc th thut y t:
- Tin s timvacxin v cc ch phm sinh hc, truyn mu v cc ch phm mu; ghp c quan, t
chc; xm tr; phi nhim vi mu v dch c th t ngi khc....
15. Chiu cao:
16. Cn nng:
17. Nhmmu ABO:
18. Nhmmu khc:
19. Ngy lp h s ln u hin mu:
20. Nhn vin lp h s v ch k:
II. Phn khm v xt nghim mi ln hin mu
1. Ngy khm:
2. Biu hin chung:
3. Mu sc da, nim mc:
4. Cn nng:
5. Mch:
6. Huyt p:
7. Nhit c th:
8. Hemoglobin:
9. S lng tiu cu (khi cn gn tch tiu cu):
10. HBsAg:
11. Anti-HCV
12. Anti-HIV 1/2:
B y t hoc S y t
Tn c s ly mu

502 |
13. Giang mai:
14. St rt:
15. ng niu hoc ng huyt:
16. Kt qu cc xt nghim khc:
17. Kt lun tnh trng sc kho v kh nng hin mu:
18. Tn bc s khm, kt lun v ch k:

III. Phn ly mu
1. Loi ch phm mu ly:
2. Th tch:
3. M hiu n v mu:
4. Tc dng khng mong mun trong, sau khi ly mu v x tr (nu c):
6. Cc ghi ch khc:
7. Tn nhn vin ly mu v ch k:

| 503
MU S 3
PHIU D TR V CUNG CP MU, CH PHM MU
CHO CC C S KHNG CNG VIN, BNH VIN
B Y t hoc S Y t
Tn bnh vin . . . . . .

PHIU D TR MU V CH PHM MU
STT Chng loi mu v ch phm
Nhmmu ABO
v Rh
Th tch 1 n
v
S n v

Trc lnh o bnh vin
(Khi Ph trch Khoa HHTM vng mt)

Ph trch Khoa HHTM
. . . gi . . ngy / /200.
Ngi d tr

B Y t hoc S Y t
Tn c s cung cp mu v ch phm mu . . . . . . . . .

PHIU CUNG CP MU V CH PHM MU

STT Chng loi mu v ch phm
Nhmmu
ABO v Rh
Th tch 1
n v
S n v

Ph trch c s cung cp mu v ch phm
hoc ngi c u quyn
. . . gi . . ngy / /200.
Ngi thc hin

504 |
MU S 4
PHIU D TR V CUNG CP MU, CH PHM MU CHO CC C S TRONG VIN, BNH VIN
PHN LU TI CC KHOA LM SNG PHN LU TI KHOA CUNG CP MU

PHIU D TR MU V CH PHM MU

PHIU CUNG CP MU V CH PHM MU
H tn ngi bnh: . . . . . . . . . . . . . . . . . . . . . . . . . Tui: . . . . Gii :. . . H tn ngi bnh: . . . . . . . . . . . . . . . . . . . . . . . . . . Tui: . . . . Gii:. . . .
Chn on: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Chn on: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Khoa/phng: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .S ging: . . . . . . . Khoa/phng: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .S ging: . . . . . . . .
Nhmmu ABO: . . . .. Nhmmu Rh : . . . . .S ln truyn: . . . . . Nhmmu ABO: . . . .. Nhmmu Rh : . . . . .S ln truyn:. . . . . . .
Loi ch phm cn truyn: . . . . . . . . . . . . . . . . . . . S lng: . . . . .
. . . . . . . . . . . . . . . . . . . S lng: . . . . .
Loi ch phm cn truyn: . . . . . . . . . . . . . . . . . . . S lng: . . . . .
. . . . . . . . . . . . . . . . . . . S lng: . . . . .
Hi. . . . gi . . . . ngy . . . thng . . . nm 200. . Hi. . . . gi . . . . ngy . . . thng . . . nm 200. .
Ph trch khoa phng iu tr
(H tn vch k)
Bc s iu tr
(H tn vch k)

Ph trch khoa phng iu tr
(H tn vch k)
Bc s iu tr
(H tn vch k)

Loi ch phm cp: . . . . . . . . . . . . . . . . . . S lng . . . . . . . . . v Loi ch phm cp: . . . . . . . . . . . . . . . . . . S lng . . . . . . . . . . v
Bao gm cc n v mu vch phm c tn ngi cho/mhiu nh sau:
1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Nhmmu . . . . . Th tch:. . . . .
2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Nhmmu . . . . . Th tch:. . . . .
3. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Nhmmu . . . . . Th tch:. . . . .
Bao gm cc n v mu vch phm c tn ngi cho/mhiu nh sau:
1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Nhmmu . . . . . Th tch:.. . . . .
2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Nhmmu . . . . . Th tch:.. . . . .
3. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Nhmmu . . . . . Th tch:.. . . . .
Hi. . . . gi . . . . ngy . . . thng . . . nm 200. . . . Hi. . . . gi . . . . ngy . . . thng . . . nm 200. . . .
Y tiu dng
(H tn vch k)
Ngi ph trch
(H tn vch k)
Ngi pht mu
(H tn vch k)
Y t iu dng
(H tn vch k)
Ngi ph trch
(H tn vch k)
Ngi pht mu
(H tn vch k)

B Y t hoc S y t
Tn bnh vin . . . .
B Y t hoc S y t
Tn bnh vin
505 |

PHIU TRUYN MU
PHN I. XT NGHIM HO HP MIN DCH TRUYN MU
H tn ngi bnh: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Tui: . . . . . .Gii : . . . .
Chn on: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Khoa/phng: . . . . . . . . . . . . . . S ging: . . . .
Loi ch phmtruyn: . . . . . . . . . . . . . . . . . . . . . . . S lng: . . . . . . . ml
Tn ngi cho mu / M s: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Ngy ly mu / iu ch: . . . . . . . . . . . . . . . . . . . . . . . Hn dng: . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . .
Nhm mu ABO ngi bnh: . . . . . .Rh . . . Kt qu xt nghimho hp
Nhm mu ABO ngi cho: . . . . . . .Rh . . . Mi trng mui Anti globulin
Cc xt nghimkhc: . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . .
ng 1
ng 2
Hi . . . . gi . . . . . ngy . . . . thng . . . nm 200 . .
NGI PH TRCH XT
NGHIM
(Ch k v h tn)

. . . . . . . . . . . . . . . . . . . . . . . .
NGI LM XT NGHIM
TH 1
(Ch k v h tn)

. . . . . . . . . . . . . . . . . . . . . . . .
NGI LM XT NGHIM
TH 2
(Ch k v h tn)

. . . . . . . . . . . . . . . . . . . . . . . .
PHN II. THEO DI TRUYN MU LM SNG
Ln truyn mu th: . . . . . . . .
nh nhm ngi cho: . . . . . nh nhm ngi nhn: . . . . . Phn ng cho ti ging: . . . .
Bt u truyn hi: . . . . . . . . . .gi . . . . . .ngy . . . . . thng . . . . . nm 200. .
Thi
gian
Tc
truyn
(git/ph)
Mu sc
da, nim
mc
Nhp th
(l/pht)
Mch
(l/pht)
Huyt p
(mmHg)
Thn
nhit
(
o
C)
Nhng din bin
khc

Ngng truyn hi:. . . . . . . gi . . . . . . ngy . . . . . thng . . . . . nm 200. . . .
S lng mu thc t truyn: . . . . . . . . ml
Nhn xt qu trnh truyn mu: . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

BC S IU TR Y T IU DNG TRUYN MU
(Ch k v h tn) (Ch k v h tn)
B y t hoc s y t
Tn bnh vin . . . .
MU S 5

506 |
MU S 6
BO CO TC DNG KHNG MONG MUN
LIN QUAN N TRUYN MU

H tn ngi bnh: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Tui: . . . . . . . . . .Gii: . . . . .
Chn on: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Nhm mu h ABO: . . . . Rh: . . . .
Khoa/phng: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S ging: . . . . . . . . . . . . . .
Ngy gi bt u truyn mu: . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Tn ngi cho mu /M s n
v mu

Loi ch phm
Th tch n v (ml)
Tc truyn (git/ph)
Ngng truyn lc
Th tch truyn (ml)
Nhmmu h ABO
Nhmmu h Rh
Ngy ly mu
Hn s dng
Tn c s ly mu v iu ch
Cc loi dung dch, thuc c timtruyn trong khong thi gian ngay trc khi xut hin du hiu bt
thng : . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
M t tmtt biu hin v tin trin lmsng:
- Du hiu u tin l: . . . . . . . . . . . . . . . Thi imxut hin du hiu u tin: . .. . . . . .
- Din bin v x tr thc hin: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
nh nhmABO ti ging ngay sau : Mu bnh nhn: . . . . . . n v mu truyn: . . .
Thi imly mu mu ngi bnh sau khi xy ra du hiu u tin: . . . . . . . . . . . . . . . .
HI . . . . . . . . GI . . . . . NGY . . . . . THNG . . . . . . NM 200 . .
Y t iu dng truyn mu
(H tn v ch k)
Bc s iu tr
(H tn v ch k)

B y t hoc s y t
Tn bnh vin . . . .

| 507

MU S 7
PHIU XT NGHIM
TC DNG KHNG MONG MUN LIN QUAN N TRUYN MU

H tn ngi bnh: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Tui: . . . . . . . Gii: . . . .
Chn on: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Nhm mu: . . . Rh : . . .
Khoa/phng: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. S ging : . . . . . . . . . .
Tn ngi cho/M s n v mu nghi ng: . . . . . . . . . . . . . . . . . . . Loi ch phm: . . . . . . . . .
Th tch n v ch phm: . . . . . . . . . . . . . . . . . . . .
Thi imbt u truyn n v mu nghi ng gy phn ng: . . . . . . . . . . . . . . . . . . . .
Thi imxut hin du hiu u tin: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Thi imngng truyn: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Th tch ch phm truyn: . . . . . . . . . . . . . . . . . . . . . . . . . .
Thi imnhn thng bo v mu mu ca ngi bnh: . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Kt qu xt nghim:
Mu mu
Kt qu
Mu mu bnh nhn
trc truyn
Mu mu bnh nhn
sau truyn
Mu mu t n v
mu nghi ng gy tc
dng ph
T ngng kt
Huyt tng (huyt thanh)
c tan mu

Mu sc mu mu
nh nhm ABO
nh nhm Rh
Xt nghim chng globulin
trc tip

Xt nghim chng globulin
gin tip

Xt nghim tm khng th
bt thng

Cc xt nghim khc
Kt lun
v ngh
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . .
HI . . . . . . . GI . . . . . NGY . . . . THNG . . . . NM 200 . . .
Ngi ph trch xt nghim
(H tn v ch k)
K thut vin xt nghim
(H tn v ch k)

B y t hoc s y t
Tn bnh vin

508 |

B Y T
-------------
S:12/2005/Q-BYT


QUYT NH CA B TRNG B Y T
V vic ban hnh Quy nh chuyn mn trong cng tc
xt nghim HIV bo m an ton truyn mu

B TRNG B Y T

- Cn c Ngh nh 49/2003/N-CP ngy 15/5/2003 ca Chnh ph quy nh chc nng, nhimv, quyn
hn v c cu t chc ca B Y t;
- Cn c Php lnh phng, chng nhim vi rt gy ra hi chng suy gimmin dch mc phi ngi
(HIV/AIDS) ngy 31/5/1995;
- Cn c Ngh nh s 34/CP ngy 01/6/1996 ca Chnh ph hng dn thi hnh Php lnh phng, chng
nhimvi rt gy ra hi chng suy gimmin dch mc phi ngi (HIV/AIDS);
- Theo ngh ca ng Cc trng Cc Y t d phng v Phng chng HIV/AIDS, V trng V iu tr
B Y t,

QUYT NH

iu 1. Ban hnh kmtheo Quyt nh ny Quy nh chuyn mn trong cng tc xt nghim HIV bo
man ton truyn mu
iu 2. Quyt nh ny p dng i vi cc c s khmbnh, cha bnh ca Nh nc, t nhn v bn cng.
iu 3. Quyt nh ny c hiu lc sau 15 ngy k t ngy ng cng bo v thay th Quyt nh s
175/2001/Q-BYT ngy 18/01/2001 ca B trng B Y t v Quy nh chuyn mn trong cng tc xt
nghimmu phng ly nhimHIV/AIDS.
iu 4. Cc ng b: Chnh Vn phng, Chnh Thanh tra, V trng, Cc trng cc V, Cc thuc B Y t,
Gim c S Y t tnh, thnh ph trc thuc Trung ng, Th trng cc n v thuc B Y t v Th
trng Y t ngnh chu trch nhimthi hnh Quyt nh ny.

KT. B TRNG B Y T
TH TRNG

( k)

Trn Ch Lim

| 509

B Y T



QUY NH CHUYN MN TRONG CNG TC
XT NGHIM HIV BO M AN TON TRUYN MU
(Ban hnh km theo Quyt nh s: 12 /2005/Q-BYT
ngy 28 thng 3 nm 2005 ca B trng B Y t)

I. CC QUY NH CHUNG:
1. Quy nh ny hng dn vic xt nghimsng lc HIV i vi cc trng hp truyn mu, truyn ch
phmmu, thc hin cc k thut h tr sinh sn v ghp m, b phn c th ngi ti cc c s y t ca nh
nc, t nhn v bn cng (sau y gi tt l c s y t).
2. Vic xt nghimsng lc HIV phi tun th cc quy nh v chuyn mn k thut do B Y t ban hnh.
II. CC QUY NH C TH:
1. Quy nh v xt nghim sng lc HIV:
a) C s y t bt buc phi tin hnh xt nghimsng lc HIV i vi:
- Ti mu trc khi truyn (k c trong trng hp cp cu) hoc iu ch cc sn phmmu.
- Ngi cho tinh trng, non, m hoc b phn c th ngi.
b) Vic xt nghim sng lc HIV phi c thc hin bng cc loi sinh phm chn on HIV c B Y
t cp giy chng nhn ng k lu hnh ti Vit Nam.
2. Quy nh v vic ghi chp, lu tr v tr li kt qu xt nghim HIV:
a) Cc kt qu xt nghimHIV phi c ghi chp y vo h s ca ngi cho mu, thnh phn mu,
tinh trng, non, m hoc b phn c th cng nh s lu kt qu xt nghimca phng xt nghim.
b) Trong s lu kt qu xt nghim phi ghi y cc ni dung sau:
- Ngy, thng, nm lm xt nghim.
- Tn, tui, gii, a ch ngi cho mu, thnh phn mu, m hoc b phn c th. Nu l ngi cho mu th
phi c thmnhm mu. Vi ngi cho tinh trng, non th khng nht thit phi ghi mc ny nhng phi c
m s ca mu mu xt nghimHIV trng hp vi m s ca tinh trng, non lu tr.
- Kt qu xt nghim: Nu l HIV dng tnh th phi ghi r bng ch dng tnh hoc nu l HIV m tnh
th phi ghi r bng ch mtnh.
- Loi sinh phmxt nghim, k thut xt nghim.
- Bc s hoc k thut vin lmxt nghim: Ghi r h tn.
c) Vic tr li kt qu xt nghim HIV cho ngi cho mu, thnh phn mu, tinh trng, non, m hoc b
phn c th phi tun theo ng quy nh mc 4 ca Ch th s 11/2001/CT-BYT ngy 31/10/2001 ca B
trng B Y t v vic Tng cng cng tc xt nghimpht hin vi rt HIV.
d) Phiu kt qu xt nghimHIV ca ngi cho mu, thnh phn mu, tinh trng, non, m hoc b phn c
th phi c lu vo h s theo quy nh ca bn Quy ch bnh vin ban hnh kmtheo Quyt nh s
1895/ 1997/Q-BYT ngy 19/9/1997 ca B trng B Y t.
3. Quy nh v lu mu bnh phm xt nghim sng lc HIV trong truyn mu:
a) Mi mt ti mu sau khi ly mu xong phi hn v tch ra mt on ng di khong 7cm - 10 cm t on
dy ly mu, trn c m s ca ti mu.

510 |
b) on ng sau khi tch ra khi ti mu phi c ly tm, hn tch ring phn huyt tng v hng cu.
on ng huyt tng vi m s y c lu tr ngn hoc t lnh su - 30
o
C (m ba mi C)
trong 2 nm.
c) B phn xt nghimchu trch nhimqun l quy lnh lu tr bo qun bnh phm theo quy ch qun l
ring. Vic tra cu bnh phm hoc s dng bnh phm vo mc ch nghin cu hoc cc mc ch khc
ch c thc hin khi c s ng ca Gim c c s y t.
d) Trong s theo di ly mu, pht mu, nhn vin y t phi ghi thmm s ca ti mu, m s ca sn phm
mu tin tra cu khi cn thit.
4. Quy nh v bo co cc trng hp HIV dng tnh:
a) Khi xt nghim sng lc pht hin HIV dng tnh, cc c s y t phi gi mu mu n c s xt
nghim c B Y t cng nhn iu kin khng nh cc trng hp HIV dng tnh xt nghim
khng nh.
b) Sau khi xt nghimv khng nh, c s xt nghimphi thng bo cho c s y t ni gi mu bit t
vn i vi ngi cho mu, thnh phn mu, tinh trng, non, m hoc b phn c th, ng thi thc hin
vic bo co theo ng quy nh trong Thng quy gimst HIV/AIDS Vit Nam ban hnh kmtheo
Quyt nh s 1418/2000/Q-BYT ngy 04/5/2000 ca B trng B Y t.

KT. B TRNG B Y T
TH TRNG

( k)

Trn Ch Lim

| 511
DANH SCH CC C NHN V T CHC THAM GIA
QU TRNH XY DNG V CP NHT HNG DN QUC GIA V
CC DCH V CHM SC SKSS

1. Ban iu hnh Son tho
(Theo Q ca B trng B Y t s 1416 ngy 16 thng 4 nm 2007)
ng Trn Ch Lim Th trng B Y t Trng Ban
ng Nguyn nh Loan V trng V Sc khe sinh sn Ph Trng Ban
ng Lng Ngc Khu Ph V trng V iu tr Ph Trng Ban
ng Trng Vit Dng V trng V Khoa hc v o to y vin
ng Nguyn Duy Kh Ph V trng V Sc khe sinh sn y vin
B inh Th Phng Ha Ph V trng V Sc khe sinh sn y vin
B Lu Th Hng Ph V trng V Sc khe sinh sn y vin
ng Nguyn Huy Quang Ph V trng Php Ch y vin
ng Nguyn Vit Tin Gim c Bnh vin Ph sn TW y vin
ng PhmVit Thanh Gim c Bnh vin t D
Ph V trng V Sc khe sinh sn
y vin
ng Phm Vn Hin Vin trng Vin Da Liu y vin
B Khu Th Khnh Dung Ph gim c Bnh vin nhi TW y vin
B Trn Th Phng Mai Ging vin B mn Ph sn
i hc Y H ni
y vin
2. T Th k
B NghimTh Xun Hnh Chuyn vin V Sc khe sinh sn T trng
ng Nguyn Trng Khoa Chuyn vin V iu Tr Thnh vin
ng Nguyn c Vinh Chuyn vin V Sc khe sinh sn Thnh vin
ng Nguyn Minh Tun Chuyn vin V Sc khe sinh sn Thnh vin
B Nguyn Th L Chuyn vin V Sc khe sinh sn Thnh vin
ng Hong Anh Tun Chuyn vin V Sc khe sinh sn Thnh vin

3. T chuyn gia trong nc
Nhm Hng dn chung/Lm m an ton
PGs.Ts.Nguyn c Hinh
Ts.Lu Th Hng
Ts. PhmTh Hoa Hng
Ts. Nguyn Th Ngc Khanh
Gs.Ts.Trn Th Phng Mai
Bs. Ph c Nhun
Bs. Nguyn Th Ngc Phng
PGs.Ts. Ng Vn Ti
PGs.Ts. Cao Ngc Thnh
PGs.Ts. Nguyn Vit Tin
Bs.CKII.Trn nh T

512 |
Nhm Chm sc s sinh
Ts. Khu Th Khnh Dung
PGs.Ts. inh Th Phng Ha
Bs. CKII. TrmTh Minh Hng
Bs. CKII. Nguyn Th KimNga
Ts. CamNgc Phng
Ts. Ng Minh Xun
Nhm K hoch ho gia nh
Ts. Nguyn V Quc Huy
Ts. Trn Sn Thch
Bs. Trnh Hu Th
Nhm Nhim khun ng sinh sn v cc bnh ly truyn qua ng tnh dc
PGs.Ts. Trn Lan Anh
ThS. L Hu Doanh
PGs.Ts. Phm Vn Hin
Ts. Nguyn Duy Hng
Nhm Sc kho sinh sn v thnh nin/T vn
ThS. Hong T Anh
ThS. Nguyn Quc Chinh
ThS. Nguyn Thu Giang
Bs. Trnh Hu Th
Nhm Ph thai an ton
PGs.Ts. Nguyn c Hinh
ThS. H S Hng
Bs.CKII. Nguyn Th Hng Minh
Bs. Phan Vn Qu
ThS. Hong DimTuyt
Nhm Nam hc
Gs.Trn Qun Anh
ThS. V Nguyn Khi Ca
Bs. Nguyn Hoi Bc
ThS. Trnh Hong Giang
ThS.Nguyn Phng Hng
ThS. Nguyn Quang
Nhm Phng chng bo lc gia nh
ThS. Hong T Anh
ThS.Nguyn Vn Anh
Bs. Nguyn Th Ho Bnh
Bs. o Xun Dng
Ts. PhmTh Hoa Hng
Ts. Lu Th Hng
Ts. L Th Phng Mai
Nhm th k gip vic cc t chuyn gia
ThS. NghimTh Xun Hnh
ThS. L Quang Dng
Bs. Hong Anh Tun
Bs. Nguyn Minh Tun
ThS. Nguyn c Vinh

| 513
Cn. Nguyn Hng Linh
Bs Nguyn Vn Phng
Bs. Ng Thy Nga
Bs. Nguyn Thi L
Bs. Dng Thy Li
Cn. Trn Minh Ngha
Cn. Nguyn Qunh Nh

4. Cc t chc quc t h tr ti chnh v k thut cho qu trnh son tho
Qu Dn s Lin hip quc (UNFPA)
Qu Nhi ng Lin hip quc (UNICEF)
T chc Y t th gii (WHO)
T chc Pathfinder International
T chc IPAS
Qu cu tr nhi ng M (SCUS)
Qu Ford (Ford foundation)

Huong Dan Quoc Gia CSSKSS 2009

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