Title: OBSTETRICAL COMPLICATIONS: Emergent Management in the Pre-hospital Setting
1OBSTETRICAL COMPLICATIONSEmergent Management in
the Pre-hospital Setting
2SOME PREGNANCY FACTS
- PREGNACY IS NOT A PATHOLOGIC CONDITION
- AVERAGE GESTATION IS 38-40 WEEKS
- MAJORITY OF PREGNANCIES WILL BE HEALTHY AND HAVE
NORMAL OUTCOMES - TWO THINGS SEEN IN PRE-HOSPITAL CARE
- Healthy pregnancy with rapid delivery
- Pregnancies with one or multiple complications
3PHYSIOLOGIC CHANGES OF PREGNANCY
4CARDIOVASCULAR
- BLOOD VOLUME INCREASES 30-50
- HEART ENLARGES 10-15
- STROKE VOLUME 10
- HEART RATE 20
- CO HR X SV 25-30
5CARDIOVASCULAR
- VASODILATION DUE TO PROGESTERONE
- TOTAL PERIPHERAL RESISTANCE
- PROGESTERONE
- PLACENTA
- PROSTAGLANDINS
- BP CO X TPR
- DECREASES IN MOST NORMAL PREGNANCIES
- GRADUAL RETURN TO NORMAL NEAR TERM
6POSITIONING CONSIDERATIONS
- LEFT LATERAL RECUMBANT POSITION
- UTERINE DISPLACEMENT VIA LEFT TILT POSITION
7HEMATOLOGICAL CHANGES
- RBC PRODUCTION
- BLOOD VOLUME DUE TO MORE PLASMA, MORE RBCS
- MEANT TO OFFSET BLOODLOSS AT DELIVERY
- SUPPLIES INCREASED VASCULAR SYSTEM
- CLOTTING FACTORS - FIBRIN, FIBRINOGEN
8RESPIRATORY CHANGES
- RATE SLIGHTLY
- TIDAL VOLUME
- MINUTE VOLUME
- PCO2 30mmHg
- ARTERIAL PH TO 7.45
9RENAL CHANGES
- STRUCTURAL
- COLLECTION SYSTEM
- FUNCTIONAL
10FUNCTIONAL RENAL CHANGES
- RENAL BLOOD FLOW
- GLOMERULAR FILTRATION RATE
- CREATININE, UREA, URIC ACID
- URINE OUTPUT 25
- RENAL PHARMACOLOGIC CLEARANCE
11ANATOMIC CHANGES OF PREGNACY
- NEED TO CONSIDER WITH ASSESSMENT
- CONSIDER WHEN POSITIONING
- APPLY MOSTLY TO THIRD TRIMESTER
12CARDIAC CHANGES
- SOFT SYSTOLIC MURMUR
- EXAGGERATED SPLIT HEARD WITH 1ST HEART SOUND
- 2ND/3RD SOUNDS MORE OBVIOUS
13RESPIRATORY CHANGES
- BASAL BREATH SOUNDS
- THORACIC V. ABDOMINAL BREATHING
14ABDOMINAL CHANGES
- ENLARGED UTERUS
- MCDONALDS RULE
15COMPLICATIONS OF PREGNANCY
16THIRD TRIMESTER ASSESSMENT
- HISTORY
- EDD
- LMP DATE
- NAGELS RULE
- FETAL ACTIVITY
- CONTRACTIONS
- VAGINAL DISCHARGE
- URINARY SYMPTOMS
17PHYSICAL EXAM
- VITAL SIGNS
- ABDOMEN
- FETAL HEART TONES
- FUNDAL HEIGHT, UTERINE TENDERNESS, UTERINE TONE
- PELVIC
18PRECIPITOUS DELIVERY
- RARELY DONE IN FIELD
- DO NOT ENCOURAGE TO ACTIVELY PUSH
- SUPPORT PERINEUM IF CROWNING
- MOVEMENTS OF LABOR
- ENGAGEMENT, DESCENT, FLEXION
- INTERNAL ROTATION, EXTENSION, EXTERNAL ROTATION
- EXPULSION
19PRECIPITOUS DELIVERY
- HOLD NEWBORNS HEAD LOWER THAN PERINEUM
- SUCTION
- DRY
- CLAMP CORD X 2 AND CUT
- WARM IMMEDIATELY
- PLACE SKIN TO SKIN
- COVER WITH WARM BLANKETS
- DELAYED DELIVERY OF PLACENTA
20PLACENTAL DELIVERY
- LOOK FOR SIGNS OF SEPARATION
- GUSH OF BLOOD
- LENGTHENING OF CORD
- CHANGE IN UTERINE SHAPE
- NO EXCESSIVE TRACTION
- GENTLE FUNDAL MASSAGE
- CHECK CORD VESSELS
- 10U OXYTOCIN IM OR IN 500CC IVF
21THINGS THAT CAN GO WRONG WITH PREGNANCY AND BIRTH
22THIRD TRIMESTER BLEEDING
- DIFFERENTIAL DIAGNOSES
- ABRUPTIO PLACENTA V. PLACENTA PREIVA
23ABRUPTIO PLACENTA
- SHEARING AWAY OF PLACENTA FROM THE WALL OF THE
UTERUS - 0.5 - 1.5 OF PREGNANCIES
- PERINATAL MORTALITY 20
- RECURRENCE RATE 12.5, OR 10 TIMES GREATER IN
FUTURE PREGNANCIES
24RISK FACTORS FOR PLACENTAL ABRUPTION
- MATERNAL HYPERTENSION
- MATERNAL DIABETES
- OTHER VASCULAR DISEASES
- CIGARETTE SMOKING
- MULTIPLE ABORTIONS
- DRUG USE
- ABDOMINAL TRAUMA
25ABRUPTIO PLACENTA PRESENTATION
- PAINFUL, FREQUENT UTERINE CTXS
- SIGNIFCANT UTERINE TENDERNESS
- MODERATE TO LARGE AMOUNT BRIGHT RED VAGINAL
BLEEDING - RISING FUNDAL HEIGHT
- SIGNS/SYMPTOMS OF BLOOD LOSS
26ABRUPTIO PLACENTAPHYSICAL FINDINGS
- HR
- BP
- PALLOR
- RISING FUNDAL HEIGHT
- NAUSEA AND VOMITING
- SHOCK
- URINE OUTPUT
27FETAL EFFECTS
- BASELINE FETAL HEART RATE
- BASELINE VARIABILITY
- LATE DECELERATION PATTERN
- BASELINE RATE
- PROLONGED DECELERATION
- ABSENT FETAL HEART RATE
28INTERVENTIONS
- ESTABLISH LARGE BORE IV LINE
- DRAW LABS IF ABLE
- ADMINISTER CRYSTALLOIDS OR COLLOIDS
- GIVE OXYGEN AT 10L/MIN VIA MASK
29PLACENTA PREVIA
- IMPLANTATION OF PLACENTA NEAR OR OVER CERVICAL OS
- DEGREES OF PLACENTA PREVIA
- 0.5 INCIDENCE AFTER 20 WEEKS
30RISK FACTORS
- PREVIOUS PLACENTA PREVIA
- UTERINE SCARS
- MULTIPLE DC
- PRIOR C/S
- ENDOMETRIOSIS
- PREVIOUS MOLAR PREGNANCY
- AGE gt 35
- VERY LARGE PLACENTA
31PRESENTATION
- PAINLESS VAGINAL BLEEDING
- BRIGHT RED, OFTEN HEAVY
- IRREGULAR OR NO CONTRACTIONS
32PRESENTATION
- SHOCK
- RISING, THREADY PULSE
- PALLOR
- BP
- AIR HUNGER
- FHR RESPONSE
- ABNORMAL FETAL LIE
33INTERVENTIONS
- LARGE BORE IV IN PLACE
- DRAW BLOOD FOR LABS
- RAPID ADMINISTRATION NON-DEXTROSE COLLOIDS
34INTERVENTIONS
- FOLEY
- OXYGEN VIA MASK 10L/MIN
- ESTIMATE BLOOD LOSS
- TOCOLYSIS IF NOT ACTIVE LABOR
35VASOPRESSOR THERAPY
- DOPAMINE, 2-4 MG/KG/MIN
- LOW DOSE, PRESERVES PLACENTAL FLOW
- NOREPHINEPHRINE (LEVOPHED)
- USED IN LIFE-SAVING MODE ONLY
- DECREASED FETAL FLOW
- DOBUTAMINE 5 15 MG/KG/MIN
36FETAL INTERVENTIONS
- MONITOR FETAL HEART RATE
- LEFT LATERAL WEDGE POSITION
37PRETERM LABOR
- OCCURS IN 8-10 OF ALL GESTATIONS
- FACTOR IN 80 OF ALL NEONATAL MORTALITY
- FACTOR IN 50 CHILDHOOD HANDICAPS
38DEFINITION
- PRETERM LABOR VS. PRETERM CONTRACTIONS
- NEW DIAGNOSTIC TOOLS
- FETAL FIBRONECTIN
- ULTRASOUND MEASUREMENT OF CERVICAL LENGTH
- STILL VERY HARD TO KNOW WHAT TO TREAT
- PROMPT INTERVENTION TO INCREASE TIME TO DELIVERY
39THERAPEUTIC INTERVENTIONS
- BED REST
- IV HYDRATION
- BETA-MIMETICS
- MgSO4
- CALCIUM CHANNEL BLOCKERS
- INDOMETHICIN
40PHARMACOLOGIC MANAGEMENT
- BETA-MIMETICS
- TERBUTALINE 0.25 mg SQ, Q15MINS, UP TO 3 DOSES
- SIDE EFFECTS
- TACHYDARDIA
- SHAKINESS
- HYPOTENSION
- HYPERGLYCEMIA
41MAGNESIUM SULFATE
- NEVER PRIMARY IV LINE
- 20 SOLUTION
- 4-6 GM LOADING DOSE/15-20 MINS
- 2-5 GM/HR MAINTENANCE
- SIGNIFICANT SIDE EFFECTS
- ANTIDOTE 1GM CALCIUM GLUCONATE IV
42MGSO4 SIDE EFFECTS
- CNS EFFECTS
- HYPOREFLEXIA
- N/V
- FLUSHING/HOT FLASHES
- MALAISE
- WEAKNESS
- RESPIRATORY/CARDIAC ARREST
- CLOSE MONITORING OF HR, BP, REFLEXES, AND FHR
- CAUTION WITH DECREASED RENAL FUNCTION
43PRETERM LABOR MORE PHARMACOLOGIC TREATMENT
- STEROIDS
- BETAMETHASONE 12.5MG IM Q 12HRS, TIMES 2
- DEXAMETHASONE 6MG, Q 6HRS, IM OR IV TIMES 4 DOSES
- ANTIBIOTICS
- COVERS RISK OF GBS INFECTION
44PRETERM, PREMATURE RUPTURE OF MEMBRANES
- PPROM
- RUPTURE OF MEMBRANES lt37 WEEKS
- CLEAR, WATERY VAGINAL DISCHARGE
- CONTINUOUS, ODORLESS, COLORLESS
- AVOID VAGINAL EXAMS
45DIAGNOSING PPROM
- SPECULUM EXAM
- FLUID POOLS
- NITRAZINE PAPER
- PH TEST
- DARK BLUE IF RUPTURED
- SCREENING ONLY
- FERN TEST
- MICROSCOPE
- ULTRASOUND FOR AFI
46PPROM THERAPEUTIC INTERVENTIONS
- HYDRATE WELL
- TOCOLYTIC DRUGS
- ANTIBIOTICS
- STEROIDS
- CLOSE OBSERVATION
- TRANSPORT TO CENTER WITH NICU IF LABORING
47CHORIOAMNIONITIS
- RISK FACTOR WITH PROLONGED RUPTURE OF MEMBRANES
- PATIENT MAY NOT HAVE RECOGNIZED RUPTURE OF
MEMBRANES - SUSPECT IF
- UTERINE TENDERNESS
- MATERNAL FEVER
- VAGINAL DISCHARGE FOUL-SMELLING, CLOUDY, OR
DISCOLORED
48UMBILICAL CORD PROLAPSE
- TRUE EMERGENCY
- RARE 1/275 BIRTHS
- PROMPT RECOGNITION/TREATMENT ESSENTIAL
- 3 TYPES
- FUNIC
- OCCULT
- COMPLETE
49INTERVENTIONS CORD PROLAPSE
- GENTLE ELEVATION OF PRESENTING PART
- MATERNAL POSITION KEY
- KNEE CHEST/TRENDELENBURG
- ESTABLISH IV
- OXYGEN FOR MOTHER
- PREPARE FOR CESAREAN AT HOSPITAL
50PREGNANCY INDUCED HYPERTENSION (PIH)
- HYPERTENSION
- BP 140/90
- RISE FROM BASELINE 30 SYSTOLIC/15 DIASTOLIC
- PROTEINURIA
- gt300 MG/24 HR URINE
- EDEMA
- NON DEPENDENT
- WEIGHT GAIN gt/ 2LB/WEEK
-
51PIH CLASSIFICATION
- PRE-ECLAMPSIA ECLAMPSIA SYNDROME
- CHRONIC HYPERTENSION
- CHRONIC HYPERTENSION WITH SUPERIMPOSED PIH
- TRANSIENT LATE HYPERTENSION
52PIH ETIOLOGY
- NOT REALLY KNOWN
- DELIVERY ONLY REAL CURE
- MULTI-SYSTEM CAUSAL FACTORS
- IMMUNE SYSTEM
- ENDOTHELIAL DISEASE
- ALTERED HEMODYNAMICS
53RISK FACTORS
- PRIMIGRAVIDA
- MATERNAL AGE gt 40
- FAMILY HISTORY
- CHRONIC HTN, RENAL DISEASE, DIABETES
- ANTIPHOSPHOLIPID SYNDROME
- COLLAGEN VASCULAR DISORDERS
54PRE-ECLAMPSIA CLASSIFICATION
- NEW ONSET HYPERTENSION
- NEW ONSET PROTEINURIA
- EDEMA MAY/MAY NOT BE PRESENT
55MILD PRE-ECLAMPSIA
- MILD
- BP gt 140/90, lt 160/110
- PROTEINURIA
- gt 1, lt 3-4
- gt 300MG TOTAL PROTEIN, lt 5 Gm
56SEVERE PRE-ECLAMPSIA
- SEVERE
- BP gt 160/110
- PROTEINURIA gt 5 Gm
- OLIGURIA
- CNS DISTURBANCES
- HEPATIC INVOLVEMENT
- THROMBOCYTOPENIA
- PULMONARY, CARDIAC COMPLICATIONS
- ECLAMPSIA
- HELLP
57ECLAMPSIA WARNING SIGNS
- ECLAMPSIA SEIZURE
- HEADACHE
- SCOTOMATA
- HYPERREFLEXIA
- EPIGASTRIC PAIN
- ANXIETY SENSE OF DOOM
58PHARMOCOLOGIC MANAGEMENT
- MAGNESIUM SULFATE
- DECREASED CNS SENSITIVITY
- BLOCKS ACETYLCHOLINE _at_ NEUROMUSCULAR JUNCTION
- DEPRESSES VASOMOTOR CENTER
59MGSO4 THERAPY
- 4-6 GM LOADING DOSE OVER 15-30 MINUTES
- 2 GM/HR MAINTENANCE INFUSION
- MONITOR MATERNAL VS CLOSELY
- ANTIDOTE CALCIUM GLUCONATE 1GM IV
60ANTI-HYPERTENSIVES
- PLACENTAL PERFUSION WHEN PRESSURES gt160/110
- HYDRALAZINE 5-10 MG IV Q 20-30 MIN
- CO AND HR
- LABETALOL 10-20 MG IV Q 10-20 MINUTES
- ALPHA AND BETA ADRENERGIC BLOCKADE
- TOTAL DOSE 300 MG
61PIH MONITORING
- THINK OF SYSTEMS INVOLVED
- RESPIRATORY
- CARDIAC
- RENAL
- MAY NEED CVP MONITORING
- FHR MONITORING
62ECLAMPSIA
- ONSET OF SEIZURES DEFINES
- SEIZURES ARE USUALLY SELF-LIMITING
- PROTECT AIRWAY
- IV ACCESS
- MGSO4 THERAPY
63OTHER MEDICATIONS
- CONTROVERSIAL
- POTENTIAL RESPIRATORY DEPRESSION
- POTENTIATE EFFECTS OF MAGNESIUM
- DIALNTIN 100MG IV
- BENZODIAZAPENES VALIUM 5-10MG IV, MAX 20MG
- BARBITURATES AMOBARBITAL 20-60 MG IV
- ATIVAN 1-2MG IV
64SYSTEMIC COMPLICATIONS
- PULMONARY EDEMA
- MAY BE RAPID ONSET
- PT ANXIOUS, FEELS UNABLE TO BREATHE
- AUSCULTATE BREATH SOUNDS
- PULSE OXIMETRY
- POTENTIATED BY MAGNESIUM, TERBUTALINE
65RENAL FAILURE
- GLOMERULAR FILTRATION RATE
- RENAL BLOOD FLOW
- URIC ACID CLEARANCE
- PLASMA VOLUME
- SENSITIVITY TO ANGIOTENSIN II
- MONITOR RENAL FUNCTION LABWORK
66HEPATIC FAILURE
- RUQ PAIN/TENDERNESS
- RUQ SWELLING
- SIGNS/SYMPTOMS OF BLOOD LOSS
67HELLP SYNDROME
- HEMOLYSIS
- ELEVATED LIVER ENZYMES
- LOW PLATELETS
68DIC
- CONSUMPTIVE COAGULOTHOPY
- ACCELERATION OF COAGULATION
- ACTIVATION OF FIBRINOLYTIC SYSTEM
- FIBRINOGEN LYSIS
- LOW FIBRINOGEN LEVELS
- INCREASE FIBRINOGEN SPLIT PRODUCTS
- PLATELETS DEPLETED
69References
- Orshan, S. (Ed). (2008). Maternity, Newborn, and
Womens Health Nursing Comprehensive Care
Across the Lifespan. Baltimore Lippincott,
Williams, Wilkins.