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一、病历摘要余××,女,38岁,孕次6,产次5,于1973年7月10日晚10时25分急诊入院。主诉为足月妊娠,规则宫缩约半小时。此患者曾足月顺产4次,年前行人工流产1次,末次月经1972年10月12日。体格检查:体温36.6℃,血压110/70毫米汞柱,脉搏80次/分,呼吸18次/分。发育良好,营养中等,神志清楚。腹膨隆如足月妊娠,宫底于剑突下3横指,胎位为左枕前位,胎心°×136次/分,头先露,已固定,肛查宫口开1指尖,先露部于坐骨棘上约0.5厘米,胎膜未破,阴道少量流血。
First, the medical record summary Yu XX, female, 38 years old, pregnant times 6, production 5, at 10:25 on the evening of July 10, 1973 emergency admission. Chief complaint is full-term pregnancy, the rules of contractions for half an hour. This patient had full-term 4 months, abortion 1 year ago, the last menstrual October 12, 1972. Physical examination: body temperature 36.6 ℃, blood pressure 110/70 mm Hg, pulse 80 beats / min, breathing 18 beats / min. Well-developed, moderate nutrition, conscious. Abdominal bulging, such as full-term pregnancy, at the end of the Palace in the xiphoid 3 horizontal refers to the fetal position for the left anterior occipital, fetal heart ° × 136 beats / min, the first first exposed, has been fixed, anal check Palace mouth open a fingertip, first Dew on the ischial spine about 0.5 cm, the membranes are not broken, a small amount of vaginal bleeding.