孕產婦健康管理服務規范

一、服務對象

轄區內常住的孕產婦。

二、服務內容

(一)孕早期健康管理

孕13周前為孕婦建立《母子健康手冊》,并進行第1次產前檢查。

1.進行孕早期健康教育和指導。

2.孕13周前由孕婦居住地的鄉鎮衛生院、社區衛生服務中心建立《母子健康手冊》。

3.孕婦健康狀況評估:詢問既往史、家族史、個人史等,觀察體態、精神等,并進行一般體檢、婦科檢查和血常規、尿常規、血型、肝功能、腎功能、乙型肝炎,有條件的地區建議進行血糖、陰道分泌物、梅毒血清學試驗、HIV抗體檢測等實驗室檢查。

4.開展孕早期生活方式、心理和營養保健指導,特別要強調避免致畸因素和疾病對胚胎的不良影響,同時告知和督促孕婦進行產前篩查和產前診斷。

5.根據檢查結果填寫第1次產前檢查服務記錄表,對具有妊娠危險因素和可能有妊娠禁忌癥或嚴重并發癥的孕婦,及時轉診到上級醫療衛生機構,并在2周內隨訪轉診結果。

(二)孕中期健康管理

1.進行孕中期(孕16~20周、21~24周各一次)健康教育和指導。

2.孕婦健康狀況評估:通過詢問、觀察、一般體格檢查、產科檢查、實驗室檢查對孕婦健康和胎兒的生長發育狀況進行評估,識別需要做產前診斷和需要轉診的高危重點孕婦。

3.對未發現異常的孕婦,除了進行孕期的生活方式、心理、運動和營養指導外,還應告知和督促孕婦進行預防出生缺陷的產前篩查和產前診斷。

4.對發現有異常的孕婦,要及時轉至上級醫療衛生機構。出現危急征象的孕婦,要立即轉上級醫療衛生機構,并在2周內隨訪轉診結果。

(三)孕晚期健康管理

1.進行孕晚期(孕28~36周、37~40周各一次)健康教育和指導。

2.開展孕產婦自我監護方法、促進自然分娩、母乳喂養以及孕期并發癥、合并癥防治指導。

3.對隨訪中發現的高危孕婦應根據就診醫療衛生機構的建議督促其酌情增加隨訪次數。隨訪中若發現有高危情況,建議其及時轉診。

(四)產后訪視

鄉鎮衛生院、村衛生室和社區衛生服務中心(站)在收到分娩醫院轉來的產婦分娩信息后應于產婦出院后1周內到產婦家中進行產后訪視,進行產褥期健康管理,加強母乳喂養和新生兒護理指導,同時進行新生兒訪視。

1.通過觀察、詢問和檢查,了解產婦一般情況、乳房、子宮、惡露、會陰或腹部傷口恢復等情況。

2.對產婦進行產褥期保健指導,對母乳喂養困難、產后便秘、痔瘡、會陰或腹部傷口等問題進行處理。

3.發現有產褥感染、產后出血、子宮復舊不佳、妊娠合并癥未恢復者以及產后抑郁等問題的產婦,應及時轉至上級醫療衛生機構進一步檢查、診斷和治療。

4.通過觀察、詢問和檢查了解新生兒的基本情況。

(五)產后42天健康檢查

1.鄉鎮衛生院、社區衛生服務中心為正常產婦做產后健康檢查,異常產婦到原分娩醫療衛生機構檢查。

2.通過詢問、觀察、一般體檢和婦科檢查,必要時進行輔助檢查對產婦恢復情況進行評估。

3.對產婦應進行心理保健、性保健與避孕、預防生殖道感染、純母乳喂養6個月、產婦和嬰幼營養等方面的指導。

三、服務流程

四、服務要求

(一)開展孕產婦健康管理的鄉鎮衛生院和社區衛生服務中心應當具備服務所需的基本設備和條件。

(二)按照國家孕產婦保健有關規范要求,進行孕產婦全程追蹤與管理工作,從事孕產婦健康管理服務工作的人員應取得相應的執業資格,并接受過孕產婦保健專業技術培訓。

(三)加強與村(居)委會、婦聯相關部門的聯系,掌握轄區內孕產婦人口信息。

(四)加強宣傳,在基層醫療衛生機構公示免費服務內容,使更多的育齡婦女愿意接受服務,提高早孕建冊率。

(五)每次服務后及時記錄相關信息,納入孕產婦健康檔案。

(六)積極運用中醫藥方法(如飲食起居、情志調攝、食療藥膳、產后康復等),開展孕期、產褥期、哺乳期保健服務。

(七)有助產技術服務資質的基層醫療衛生機構在孕中期和孕晚期對孕產婦各進行2次隨訪。沒有助產技術服務資質的基層醫療衛生機構督促孕產婦前往有資質的機構進行相關隨訪。

五、工作指標

(一)早孕建冊率=轄區內孕13周之前建冊并進行第一次產前檢查的產婦人數/該地該時間段內活產數×100%。

(二)產后訪視率=轄區內產婦出院后28天內接受過產后訪視的產婦人數/該地該時間內活產數×100%。

附件:
            附件1第1次產前檢查服務記錄表.docx
            附件2第2~5次產前隨訪服務記錄表.docx
            附件3產后訪視記錄表.docx
            附件4產后42天健康檢查記錄表.docx
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