Age: consider in ages 12 years to 55 years Nationality / ethnicity Occupation Economic capabilities and resources Social support system Reproductive history Nutritional Genetic
Subjective Data History of present illness LNMP EDC or + pregnancy test Bleeding, discharge, pain, N&V, fever / chills Visual disturbances Fetal movement ROM ? Contractions Urinary symptoms Trauma
Subjective Data Medical History Reproductive Prenatal care Recent delivery ?? Abd / pelvic surgery Sexual activity Contraceptive use STD’s Substance abuse Meds, Allergies etc.
Objective Data Physical Exam Diagnostic Procedures Radiology Other 12 lead ECG pH for amniotic fluid
Any pregnant patient should be assessed for… EDC / LNMP Reproductive history including complications with current and previous pregnancies Uterine size, tone, presence of contractions Vaginal discharge or bleeding, fluid leaking? FHT’s
ABC’s first IV’s and O2 as indicated Monitor and treat… Hemodynamic status Vaginal bleeding, passage of clots, products of conception Pain Anticipate educational and emotional needs fo patient and family. Anticipate equipment needs
Pediatrics Sexual abuse STD’s / PID Teen preganancy Geriatrics
Vaginal Bleeding in Early Pregnancy / Abortion Vaginal Bleeding in Late Pregnancy Ectopic Pregnancy PIH: preeclampsia / eclampsia Hyperemesis gravidarum Postpartum hemorrhage Emergency Delivery Neonatal Resuscitation Trauma in Pregnancy
Termination of pregnancy before viability (20-24 weeks). 10% to 15% of all recognized pregnancies Etiology Endocrine dysfunction Chromosomal abnormalities Maldevelopment Trauma
Additional factors Maternal infections Malnutrition Substance abuse Immunological incompatibility Surgery Structural abnormalities of the uterus
Subjective and Objective information same for any pregnant patient Diagnostic procedures Pregnancy test - ? Quantitative CBC Blood type and Rh STD Pelvic US
IV access Assist with US, exam Prep for surgery as appropriate Drug Therapy Rh immune globulin to all Rh negative mothers Oxytocin Methergine Analgesics Antibiotics Conscious sedation Supportive / Psychosocial care
Bedrest x hours or until bleeding stops Pelvic rest until bleeding / cramping cease Pads only Temp. four times a day, return for > Save clots / tissue Follow up care with OB
Placenta Previa Abnormally implanted placenta partially or completely obstructs cervical os 45% in second trimester 1% at term Painless bright red bleeding occurs as cervix effaces / dilates Multiparity, multigestation, advanced maternal age, uterine surgery, smoking.
Abruptio placenta 3% of all pregnancies, 15% of all perinatal deaths Partial or complete separation of a normally implanted placenta Significant blood loss Risk for DIC Etiology: HTN, trauma, substance abuse, PROM, …
Implantation of fertilized ovum outside of the normal uterine cavity 95% in the fallopian tube, frequently right Rupture leads to severe pain, intraperitoneal hemorrhage and shock
ABC’s 2 large bore IV’s Reassess hemodynamic status / pain Prepare for OR Methotrexate Supportive care / pregnancy loss
PIH: hypertension unique to pregnancy Preeclampsia: HTN, proteinuria and non-dependent edema after 20 weeks Eclampsia: includes convulsions, coma or both HELLP: hemolysis, elevated liver enzymes, low platelets. The most severe form of preeclampsia.
Exact cause unknown Underlying pathology is vasospasm Complicates 5-8% of preganancies Leading obstetric cause of maternal death
Risk factors: extremes of maternal age,chronic hypertension hx of eclampsia mother or sister with hx multiple gestation diabetes, SLE, vascular disease molar pregnancy More common in primigravida
Headache, weight gain, epigastric or RUQ tenderness, generalized edema, visual disturbances, anxiety BP > 140/90 or 30 mmHg systolic or 15 mmHg diastolic over baseline. 2 BP readings 6 hours apart with Mom on L. side.
Urinalysis: proteinuria greater than 1+ CBC Electrolytes, creatinine, liver enzymes PT / PTT
ABC’s Supplemental O2 Foley - monitor hourly UO Magnesium sulfate for seizure prophylaxis Seizure precautions Benzodiazepines for seizures Antihypertensive therapy Reassess ABC’s, FHT’s, signs of Mg++toxicity (Ca gluconate is antidote)
ABC’s IV access, 1-2 liters NS rapidly Antiemetics as ordered Gradual oral rehydration as tolerated
Blood loss exceeding 500 ml Early – within 24 hours of delivery Uterine atony Retained placental fragments Lower genital tract lacerations Uterine inversion or rupture Maternal coagulopathy Late - usually 6-10 days Retained products of conception Infection Episiotomy breakdown Coital trauma
Overdistention of uterus High parity Prolonged difficult labor, especially after oxytocin induction History of PPH Preeclampsia Placenta previa Precipitous labor
Assessment to include: orthostatic VS, Uterine size / tone, amount / color of bleeding Diagnostics: CBC, T&C, Coagulation profile, fibrinogen, fibrin split products, US 2 large bore IV’s – fluids / blood as appropriate Firm bimanual massage of uterus Oxytocin, Methergine as ordered Prepare for surgery
Rapid obstetric assessment / history Contractions: frequency, intensity, duration Rupture of membranes: time, color, odor Bloody show? Rectal pressure or passage of feces FHT’s Pelvic Exam for effacement, dilation, station
Position side lying or fowlers Encourage mother to “pant” to prevent uncontrolled delivery Allow head to emerge slowly Once head delivered, assess for nuchal cord Loose – slip over head Tight – clamp in 2 places and cut between clamps Wipe infants face, suction mouth then nose. Support head, deliver anterior then posterior shoulder. Body will follow rapidly….slippery, don’t drop
Hold infant head down at level of perineum, suction mouth then nose again Clamp cord 4-5 cm from infants abdomen when cord stops pulsating. Cut between clamps Dry wrap, warm, stimulate infant Apgar at birth and 5 minutes Do not massage uterus until placenta is delivered
Trauma is primary cause of mortality in pregnancy causing up to 22% of maternal deaths Maternal death is leading cause of fetal death Management priorities for pregnant trauma patient are identical to those for any trauma patient.