OBSTETRICAL COMPLICATIONS: Emergent Management in the Pre-hospital Setting

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OBSTETRICAL COMPLICATIONSEmergent Management in
the Pre-hospital Setting

• SHARON FICKLEY
• RN, BSN

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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

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PHYSIOLOGIC CHANGES OF PREGNANCY
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CARDIOVASCULAR

• BLOOD VOLUME INCREASES 30-50
• HEART ENLARGES 10-15
• STROKE VOLUME 10
• HEART RATE 20
• CO HR X SV 25-30

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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

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POSITIONING CONSIDERATIONS

• LEFT LATERAL RECUMBANT POSITION
• UTERINE DISPLACEMENT VIA LEFT TILT POSITION

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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

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RESPIRATORY CHANGES

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

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RENAL CHANGES

• STRUCTURAL
• COLLECTION SYSTEM
• FUNCTIONAL

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FUNCTIONAL RENAL CHANGES

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

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ANATOMIC CHANGES OF PREGNACY

• NEED TO CONSIDER WITH ASSESSMENT
• CONSIDER WHEN POSITIONING
• APPLY MOSTLY TO THIRD TRIMESTER

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CARDIAC CHANGES

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

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RESPIRATORY CHANGES

• BASAL BREATH SOUNDS
• THORACIC V. ABDOMINAL BREATHING

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ABDOMINAL CHANGES

• ENLARGED UTERUS
• MCDONALDS RULE

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COMPLICATIONS OF PREGNANCY

• PART TWO

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THIRD TRIMESTER ASSESSMENT

• HISTORY
• EDD
• LMP DATE
• NAGELS RULE
• FETAL ACTIVITY
• CONTRACTIONS
• VAGINAL DISCHARGE
• URINARY SYMPTOMS

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PHYSICAL EXAM

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

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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

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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

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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

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THINGS THAT CAN GO WRONG WITH PREGNANCY AND BIRTH
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THIRD TRIMESTER BLEEDING

• DIFFERENTIAL DIAGNOSES
• ABRUPTIO PLACENTA V. PLACENTA PREIVA

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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

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RISK FACTORS FOR PLACENTAL ABRUPTION

• MATERNAL HYPERTENSION
• MATERNAL DIABETES
• OTHER VASCULAR DISEASES
• CIGARETTE SMOKING
• MULTIPLE ABORTIONS
• DRUG USE
• ABDOMINAL TRAUMA

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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

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ABRUPTIO PLACENTAPHYSICAL FINDINGS

• HR
• BP
• PALLOR
• RISING FUNDAL HEIGHT
• NAUSEA AND VOMITING
• SHOCK
• URINE OUTPUT

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FETAL EFFECTS

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

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INTERVENTIONS

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

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PLACENTA PREVIA

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

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RISK FACTORS

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

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PRESENTATION

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

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PRESENTATION

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

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INTERVENTIONS

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

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INTERVENTIONS

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

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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

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FETAL INTERVENTIONS

• MONITOR FETAL HEART RATE
• LEFT LATERAL WEDGE POSITION

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PRETERM LABOR

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

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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

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THERAPEUTIC INTERVENTIONS

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

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PHARMACOLOGIC MANAGEMENT

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

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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

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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

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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

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PRETERM, PREMATURE RUPTURE OF MEMBRANES

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

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DIAGNOSING PPROM

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

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PPROM THERAPEUTIC INTERVENTIONS

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

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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

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UMBILICAL CORD PROLAPSE

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

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INTERVENTIONS CORD PROLAPSE

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

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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

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PIH CLASSIFICATION

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

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PIH ETIOLOGY

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

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RISK FACTORS

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

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PRE-ECLAMPSIA CLASSIFICATION

• NEW ONSET HYPERTENSION
• NEW ONSET PROTEINURIA
• EDEMA MAY/MAY NOT BE PRESENT

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MILD PRE-ECLAMPSIA

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

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SEVERE PRE-ECLAMPSIA

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

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ECLAMPSIA WARNING SIGNS

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

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PHARMOCOLOGIC MANAGEMENT

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

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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

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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

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PIH MONITORING

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

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ECLAMPSIA

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

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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

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SYSTEMIC COMPLICATIONS

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

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RENAL FAILURE

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

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HEPATIC FAILURE

• RUQ PAIN/TENDERNESS
• RUQ SWELLING
• SIGNS/SYMPTOMS OF BLOOD LOSS

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HELLP SYNDROME

• HEMOLYSIS
• ELEVATED LIVER ENZYMES
• LOW PLATELETS

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DIC

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

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References

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