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OBSTETRICAL COMPLICATIONS: Emergent Management in the Pre-hospital Setting

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Title: OBSTETRICAL COMPLICATIONS: Emergent Management in the Pre-hospital Setting


1
OBSTETRICAL COMPLICATIONSEmergent Management in
the Pre-hospital Setting
  • SHARON FICKLEY
  • RN, BSN

2
SOME 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

3
PHYSIOLOGIC CHANGES OF PREGNANCY
4
CARDIOVASCULAR
  • BLOOD VOLUME INCREASES 30-50
  • HEART ENLARGES 10-15
  • STROKE VOLUME 10
  • HEART RATE 20
  • CO HR X SV 25-30

5
CARDIOVASCULAR
  • 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

6
POSITIONING CONSIDERATIONS
  • LEFT LATERAL RECUMBANT POSITION
  • UTERINE DISPLACEMENT VIA LEFT TILT POSITION

7
HEMATOLOGICAL 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

8
RESPIRATORY CHANGES
  • RATE SLIGHTLY
  • TIDAL VOLUME
  • MINUTE VOLUME
  • PCO2 30mmHg
  • ARTERIAL PH TO 7.45

9
RENAL CHANGES
  • STRUCTURAL
  • COLLECTION SYSTEM
  • FUNCTIONAL

10
FUNCTIONAL RENAL CHANGES
  • RENAL BLOOD FLOW
  • GLOMERULAR FILTRATION RATE
  • CREATININE, UREA, URIC ACID
  • URINE OUTPUT 25
  • RENAL PHARMACOLOGIC CLEARANCE

11
ANATOMIC CHANGES OF PREGNACY
  • NEED TO CONSIDER WITH ASSESSMENT
  • CONSIDER WHEN POSITIONING
  • APPLY MOSTLY TO THIRD TRIMESTER

12
CARDIAC CHANGES
  • SOFT SYSTOLIC MURMUR
  • EXAGGERATED SPLIT HEARD WITH 1ST HEART SOUND
  • 2ND/3RD SOUNDS MORE OBVIOUS

13
RESPIRATORY CHANGES
  • BASAL BREATH SOUNDS
  • THORACIC V. ABDOMINAL BREATHING

14
ABDOMINAL CHANGES
  • ENLARGED UTERUS
  • MCDONALDS RULE

15
COMPLICATIONS OF PREGNANCY
  • PART TWO

16
THIRD TRIMESTER ASSESSMENT
  • HISTORY
  • EDD
  • LMP DATE
  • NAGELS RULE
  • FETAL ACTIVITY
  • CONTRACTIONS
  • VAGINAL DISCHARGE
  • URINARY SYMPTOMS

17
PHYSICAL EXAM
  • VITAL SIGNS
  • ABDOMEN
  • FETAL HEART TONES
  • FUNDAL HEIGHT, UTERINE TENDERNESS, UTERINE TONE
  • PELVIC

18
PRECIPITOUS 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

19
PRECIPITOUS 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

20
PLACENTAL 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

21
THINGS THAT CAN GO WRONG WITH PREGNANCY AND BIRTH
22
THIRD TRIMESTER BLEEDING
  • DIFFERENTIAL DIAGNOSES
  • ABRUPTIO PLACENTA V. PLACENTA PREIVA

23
ABRUPTIO 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

24
RISK FACTORS FOR PLACENTAL ABRUPTION
  • MATERNAL HYPERTENSION
  • MATERNAL DIABETES
  • OTHER VASCULAR DISEASES
  • CIGARETTE SMOKING
  • MULTIPLE ABORTIONS
  • DRUG USE
  • ABDOMINAL TRAUMA

25
ABRUPTIO 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

26
ABRUPTIO PLACENTAPHYSICAL FINDINGS
  • HR
  • BP
  • PALLOR
  • RISING FUNDAL HEIGHT
  • NAUSEA AND VOMITING
  • SHOCK
  • URINE OUTPUT

27
FETAL EFFECTS
  • BASELINE FETAL HEART RATE
  • BASELINE VARIABILITY
  • LATE DECELERATION PATTERN
  • BASELINE RATE
  • PROLONGED DECELERATION
  • ABSENT FETAL HEART RATE

28
INTERVENTIONS
  • ESTABLISH LARGE BORE IV LINE
  • DRAW LABS IF ABLE
  • ADMINISTER CRYSTALLOIDS OR COLLOIDS
  • GIVE OXYGEN AT 10L/MIN VIA MASK

29
PLACENTA PREVIA
  • IMPLANTATION OF PLACENTA NEAR OR OVER CERVICAL OS
  • DEGREES OF PLACENTA PREVIA
  • 0.5 INCIDENCE AFTER 20 WEEKS

30
RISK FACTORS
  • PREVIOUS PLACENTA PREVIA
  • UTERINE SCARS
  • MULTIPLE DC
  • PRIOR C/S
  • ENDOMETRIOSIS
  • PREVIOUS MOLAR PREGNANCY
  • AGE gt 35
  • VERY LARGE PLACENTA

31
PRESENTATION
  • PAINLESS VAGINAL BLEEDING
  • BRIGHT RED, OFTEN HEAVY
  • IRREGULAR OR NO CONTRACTIONS

32
PRESENTATION
  • SHOCK
  • RISING, THREADY PULSE
  • PALLOR
  • BP
  • AIR HUNGER
  • FHR RESPONSE
  • ABNORMAL FETAL LIE

33
INTERVENTIONS
  • LARGE BORE IV IN PLACE
  • DRAW BLOOD FOR LABS
  • RAPID ADMINISTRATION NON-DEXTROSE COLLOIDS

34
INTERVENTIONS
  • FOLEY
  • OXYGEN VIA MASK 10L/MIN
  • ESTIMATE BLOOD LOSS
  • TOCOLYSIS IF NOT ACTIVE LABOR

35
VASOPRESSOR 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

36
FETAL INTERVENTIONS
  • MONITOR FETAL HEART RATE
  • LEFT LATERAL WEDGE POSITION

37
PRETERM LABOR
  • OCCURS IN 8-10 OF ALL GESTATIONS
  • FACTOR IN 80 OF ALL NEONATAL MORTALITY
  • FACTOR IN 50 CHILDHOOD HANDICAPS

38
DEFINITION
  • 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

39
THERAPEUTIC INTERVENTIONS
  • BED REST
  • IV HYDRATION
  • BETA-MIMETICS
  • MgSO4
  • CALCIUM CHANNEL BLOCKERS
  • INDOMETHICIN

40
PHARMACOLOGIC MANAGEMENT
  • BETA-MIMETICS
  • TERBUTALINE 0.25 mg SQ, Q15MINS, UP TO 3 DOSES
  • SIDE EFFECTS
  • TACHYDARDIA
  • SHAKINESS
  • HYPOTENSION
  • HYPERGLYCEMIA

41
MAGNESIUM 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

42
MGSO4 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

43
PRETERM 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

44
PRETERM, PREMATURE RUPTURE OF MEMBRANES
  • PPROM
  • RUPTURE OF MEMBRANES lt37 WEEKS
  • CLEAR, WATERY VAGINAL DISCHARGE
  • CONTINUOUS, ODORLESS, COLORLESS
  • AVOID VAGINAL EXAMS

45
DIAGNOSING PPROM
  • SPECULUM EXAM
  • FLUID POOLS
  • NITRAZINE PAPER
  • PH TEST
  • DARK BLUE IF RUPTURED
  • SCREENING ONLY
  • FERN TEST
  • MICROSCOPE
  • ULTRASOUND FOR AFI

46
PPROM THERAPEUTIC INTERVENTIONS
  • HYDRATE WELL
  • TOCOLYTIC DRUGS
  • ANTIBIOTICS
  • STEROIDS
  • CLOSE OBSERVATION
  • TRANSPORT TO CENTER WITH NICU IF LABORING

47
CHORIOAMNIONITIS
  • 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

48
UMBILICAL CORD PROLAPSE
  • TRUE EMERGENCY
  • RARE 1/275 BIRTHS
  • PROMPT RECOGNITION/TREATMENT ESSENTIAL
  • 3 TYPES
  • FUNIC
  • OCCULT
  • COMPLETE

49
INTERVENTIONS CORD PROLAPSE
  • GENTLE ELEVATION OF PRESENTING PART
  • MATERNAL POSITION KEY
  • KNEE CHEST/TRENDELENBURG
  • ESTABLISH IV
  • OXYGEN FOR MOTHER
  • PREPARE FOR CESAREAN AT HOSPITAL

50
PREGNANCY 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

51
PIH CLASSIFICATION
  • PRE-ECLAMPSIA ECLAMPSIA SYNDROME
  • CHRONIC HYPERTENSION
  • CHRONIC HYPERTENSION WITH SUPERIMPOSED PIH
  • TRANSIENT LATE HYPERTENSION

52
PIH ETIOLOGY
  • NOT REALLY KNOWN
  • DELIVERY ONLY REAL CURE
  • MULTI-SYSTEM CAUSAL FACTORS
  • IMMUNE SYSTEM
  • ENDOTHELIAL DISEASE
  • ALTERED HEMODYNAMICS

53
RISK FACTORS
  • PRIMIGRAVIDA
  • MATERNAL AGE gt 40
  • FAMILY HISTORY
  • CHRONIC HTN, RENAL DISEASE, DIABETES
  • ANTIPHOSPHOLIPID SYNDROME
  • COLLAGEN VASCULAR DISORDERS

54
PRE-ECLAMPSIA CLASSIFICATION
  • NEW ONSET HYPERTENSION
  • NEW ONSET PROTEINURIA
  • EDEMA MAY/MAY NOT BE PRESENT

55
MILD PRE-ECLAMPSIA
  • MILD
  • BP gt 140/90, lt 160/110
  • PROTEINURIA
  • gt 1, lt 3-4
  • gt 300MG TOTAL PROTEIN, lt 5 Gm

56
SEVERE PRE-ECLAMPSIA
  • SEVERE
  • BP gt 160/110
  • PROTEINURIA gt 5 Gm
  • OLIGURIA
  • CNS DISTURBANCES
  • HEPATIC INVOLVEMENT
  • THROMBOCYTOPENIA
  • PULMONARY, CARDIAC COMPLICATIONS
  • ECLAMPSIA
  • HELLP

57
ECLAMPSIA WARNING SIGNS
  • ECLAMPSIA SEIZURE
  • HEADACHE
  • SCOTOMATA
  • HYPERREFLEXIA
  • EPIGASTRIC PAIN
  • ANXIETY SENSE OF DOOM

58
PHARMOCOLOGIC MANAGEMENT
  • MAGNESIUM SULFATE
  • DECREASED CNS SENSITIVITY
  • BLOCKS ACETYLCHOLINE _at_ NEUROMUSCULAR JUNCTION
  • DEPRESSES VASOMOTOR CENTER

59
MGSO4 THERAPY
  • 4-6 GM LOADING DOSE OVER 15-30 MINUTES
  • 2 GM/HR MAINTENANCE INFUSION
  • MONITOR MATERNAL VS CLOSELY
  • ANTIDOTE CALCIUM GLUCONATE 1GM IV

60
ANTI-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

61
PIH MONITORING
  • THINK OF SYSTEMS INVOLVED
  • RESPIRATORY
  • CARDIAC
  • RENAL
  • MAY NEED CVP MONITORING
  • FHR MONITORING

62
ECLAMPSIA
  • ONSET OF SEIZURES DEFINES
  • SEIZURES ARE USUALLY SELF-LIMITING
  • PROTECT AIRWAY
  • IV ACCESS
  • MGSO4 THERAPY

63
OTHER 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

64
SYSTEMIC COMPLICATIONS
  • PULMONARY EDEMA
  • MAY BE RAPID ONSET
  • PT ANXIOUS, FEELS UNABLE TO BREATHE
  • AUSCULTATE BREATH SOUNDS
  • PULSE OXIMETRY
  • POTENTIATED BY MAGNESIUM, TERBUTALINE

65
RENAL FAILURE
  • GLOMERULAR FILTRATION RATE
  • RENAL BLOOD FLOW
  • URIC ACID CLEARANCE
  • PLASMA VOLUME
  • SENSITIVITY TO ANGIOTENSIN II
  • MONITOR RENAL FUNCTION LABWORK

66
HEPATIC FAILURE
  • RUQ PAIN/TENDERNESS
  • RUQ SWELLING
  • SIGNS/SYMPTOMS OF BLOOD LOSS

67
HELLP SYNDROME
  • HEMOLYSIS
  • ELEVATED LIVER ENZYMES
  • LOW PLATELETS

68
DIC
  • CONSUMPTIVE COAGULOTHOPY
  • ACCELERATION OF COAGULATION
  • ACTIVATION OF FIBRINOLYTIC SYSTEM
  • FIBRINOGEN LYSIS
  • LOW FIBRINOGEN LEVELS
  • INCREASE FIBRINOGEN SPLIT PRODUCTS
  • PLATELETS DEPLETED

69
References
  • Orshan, S. (Ed). (2008). Maternity, Newborn, and
    Womens Health Nursing Comprehensive Care
    Across the Lifespan. Baltimore Lippincott,
    Williams, Wilkins.
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