OBSTETRICAL COMPLICATIONS: Emergent Management in the Pre-hospital Setting

1. OBSTETRICAL COMPLICATIONS:Emergent 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 • MCDONALD’S RULE

15. COMPLICATIONS OF PREGNANCY PART TWO

16. THIRD TRIMESTER ASSESSMENT • HISTORY • EDD • LMP DATE • NAGEL’S 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 NEWBORN’S 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 D&C • PRIOR C/S • ENDOMETRIOSIS • PREVIOUS MOLAR PREGNANCY • AGE > 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 <37 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 • >300 MG/24 HR URINE • EDEMA • NON DEPENDENT • WEIGHT GAIN >/= 2LB/WEEK