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25 Cards in this Set
- Front
- Back
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Physiological changes
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-Heart will be lifted anteriorly and rotated to the left
-BP will decrease during 2nd trimester only to increase during 3rd trimester -Dilutional anemia occurs as RBC volume increases at a rate less than plasma volume -Functional residual capacity decreases by 20% -Heart rate increases by 15 – 20/min -Elevation of WBC’s -Elevation of progesterone levels causing relaxation of sphincters and vasculature along with capillary engorgement |
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Plasma
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-Plasma volume increases by 40 – 45% and hemoglobin by 30%, thus dilutional anemia
-Plasma carries coagulation factors or the “dynamite” for DIC -Gravid uterus promotes venous stasis in lower vasculature -Increased coag factor and venous stasis and thromboplastin promotes DIC in females -Plasma increased not matched by albumin production resulting in dilutional hypoalbuminemia -Drops osmotic pressure, increased shifting of fluids extracellularly with increased edema |
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Placenta
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-The placenta allows for transfer of gases and nutrients, not blood
-Contains high levels of thromboplastin -Thromboplastin can trigger the extrinsic clotting cascade, which is released when there is tissue damage |
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Pregnant females
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-In pregnant females their sphincter tone will be decreased due to the elevated progesterone levels, Hct will be lower as the dilutional anemia occurs and hormones are significantly elevated
-Pregnant females should be kept in lateral decubitus position to prevent supine hypotensive syndrome -Uterus will impinge upon the vena cava in supine position -Prior to transport consider foley placement, IV LR, measurement of fetal heart tones, movement, and contractions -Effacement refers to the thickness of the cervix and is expressed as a percentage -Station refers to the position of the fetal head in relation to the mothers pubic bone -Cervical dilation of 8-9cm is almost fully dilated, coupled with being fully effaced means the cervix isn’t holding anything back -Station of 0 means the fetus is “cocked and ready to go” as the head has engaged the exit -Variable decelerations are typical of cord problem -Variable deceleration are V or W shaped |
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Failed airways in pregnant females
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-Due to capillary engorgement and airway swelling
-Occurs at a rate of 1:280 vs. 1:2230 in non-pregnant females -May be very predictable using the Mallampati scoring system -Be prepared with smaller endotracheal tubes and bleeding |
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Fetus
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-FHT are normally 120 – 160/min
-FHR reflects interplay between the sympathetic and parasympathetic branches of the autonomic nervous system -FHT less than 120 / min for 5-10min is bradycardia -FHT more than 160 / min for 10min is tachycardia |
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Variability
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-refers to how much the fetal heart rate is varying on a second to second basis
-10-15/min -is the single best predictor of fetal well being and suggests that the neurological system is developed with the fetus responding to external stimulus -Normal variability is indicative of an adequately oxygenated autonomic nervous system -Accelerations (accels) and decelerations (decals) refer to how the fetus’s heart rate changes with stimuli -all OB patients >20 weeks gestation will have FHR monitored continuously and documented q30min -all pt's in active labor or being administered tocolytics are to have FHR monitored continuously and documented q15min |
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Acceleration
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-above baseline are associated with fetal movement, but may occur during contractions
-Accelerations are typically associated fetal movement and response to stimuli |
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Variable decelerations:
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-can occur at any time during contraction, shape include V and W
-due to cord compression, will have short acceleration followed by a rapid deceleration, then a rapid rise and short acceleration before a return to FHR baseline -Correcting action for variable decelerations include having the patient change positions |
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Late decelerations:
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-In reference to the onset of the deceleration in relation to the contraction
-Begins close to the apex of the contraction, gradually decelerates, and gradually returns to the FHR baseline after the contraction is over -Indicates uteroplacental insufficiency, inadequate oxygen exchange in the placenta during a contraction -With severe hypoxia, myocardial depression may be such that the heart is unable to decelerate in response to the stress of the contraction -Uteroplacental insufficiency results form PIH, DM, cardiovascular or kidney disease and smoking |
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Early decelerations
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-Decelerations that begin very close to the beginning of the contraction
-Appear almost as a mirror image of the contraction, and end close to the end of the contraction -Head compression with vagus stimulation causes the deceleration -Frequently occur in active labor when the cervix has dilated 4-7cm |
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Sinusoidal
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-A uniform sine wave pattern indicates fetal hypovolemia or anemia
-May occur in accidental tap of the umbilical cord during amniocentesis, fetomaternal transfusion, placental abruption -Variability will be absent or minimal and acceleration are not seen -Rapid delivery is recommended |
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Tetanic contractions
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-are back to back contractions, fetus is being squeezed continually
-Commonly occurs during oxytocin administration, discontinue if this occurs -Titanic contractions can cause stress upon the fetus and will result in an increased oxygen demand, fetal hypoxia will result and be demonstrated by prolonged decelerations, later decelerations, or fetal bradycardia -Fetal heart strip with top waveform usually denotes fetal heart rate while bottom waveform denotes contractions |
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Premature labor/PROM
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-37 weeks gestation
-dilated greater than 4cm and contracting less than 5min -consider antibiotics prior to departure, ampicillin 2gm IV -PROM is defined as the rupture of the amniotic sac prior to the expected date of delivery -if PROM occurs antibiotic therapy should be initiated, note color and amount of fluid -have referring facility perform nitrazine and ferning exam -a pt who is definitely or questionable ruptured membrane, it is necessary to have an evaluation of cervical dilation -the preferable manner of performing a vaginal exam is a visual exam with a sterile speculum after a prep of the perineum -the purpose of not doing a digital exam is to dec the probability of introducing bacteria which could lead to infection, avoid a foley |
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Magnesium
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-for ablation of premature labor, contractions to the 37th week of gestation start Mag, augment with terbutaline
-dilated >4cm and contracting <5min -Best test for mag toxicity is DTR’s -Acute toxicity must be managed with calcium -Chronic Mg toxicity can be typically managed with loop diuretics -initial dose: 4gm in 100ml LR or NS over 15-30min -infusion: 2gm/hr -place 20-25gm of MgS04 in 500ml of LR or NS -if s/s of overdose administer CaCl -monitor DTR and document q15min |
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Terbutaline
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-ablation of premature labor, contractions to the 37th week of gestation
-0.25mg SQ, x2, q 20min |
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PIH
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Develops in:
-African Americans, first time pregnancies, very young and much older woman, pregnancy with multiple fetuses’ -Characteristics include hypertension, proteinuria, edema -Late decelerations are tied most closely with PIH and preeclampsia -Terbutaline is used in OB as tocolytic agent -HELLP refers to hypertension, elevated liver enzyme and low platelets, it is a state of coagulopathey -HELLP is evident in 3rd trimester, presents with headache, photophobia, blurred vision, malaise, nausea/vomiting, edema, and hypertension |
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Eclampsia
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-pre-eclampsia is a syndrome of HTN, proteinuria, and edema,
-systolic BP >160 or diastolic > 110, -3-4 + proteinuria, oliguria, cerebral or visual disturbances, pulmonary edema -eclampsia is a syndrome which includes the s/s of pre-eclampsia and also seizures -administer MgSO4 -initial dose: 4gm in 100ml LR or NS over 15-30min -infusion: 2gm/hr -place 20-25gm of MgS04 in 500ml of LR or NS -consider antihypertensives, labetalol for diastolic BP >110 on two consecutive readings -labetalol: 0.25mg/kg (max 20mg) over a two minutes -repeat once at 0.25mg/kg or 0.50mg/kg (max 40mg) -wait ten minutes, if BP is still high initiate infusion -1-2mg/min gtt -administer versed for seizure -While the patient is seizing the stress and hypoxia induced on the fetus are overwhelming -Eclampsia induced seizures are controlled by immediate termination with a benzodiazepine followed by MgSO4, be prepared for a ‘floppy’ baby needing respiratory support |
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Breach presentation
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-frank breach, complete breach, footling breach
-increased incidence of prolapsed cord with breach -due to inc potential for birth complications, these babies are usually scheduled for delivery by C section -if the patient is in labor it is imperative that the contractions be stopped or slowed enough to complete the transfer -do not manipulate the baby until there is spontaneous delivery of the breach to the level of the umbilicus -inappropriate or aggressive traction could cause extension of the head or entrapment -by allowing natural progression to the level of the umbilicus, the cervix will have time to achieve full dilation -in frank breech, the fetal thighs are pressed against the fetal abd, to facilitate delivery of the legs in order for the baby to deliver -delivery of the legs may be facilitated by lateral rotation of first the lower thigh downward and then the upper thigh upward -as each thigh is rotated at the hip the respective knee will flex and deliver -For breech delivery perform Mariceaus maneuver, which supports the infants body with one hand and forearm while applying gentle pressure to the mothers suprapubic area with your other hand. -As pressure is applied the arm supporting the infant lifts the infant’s body flexing the neck. -It results in the newborn appearing the do a ‘flip’ onto the mother belly with the newborns feet towards moms head |
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Shoulder dystocia
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-head is delivered but shoulder is stuck behind maternal pubic bone, often due to a large baby
-Mcroberts: assist mother to flex hips and knees -Suprapubic pressure: directly above pubic bone to dislodge anterior shoulder from behind pubic bone -do not apply fundal pressure as this will only make things worse |
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Placenta previa
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-During pregnancy, the placenta moves as the uterus stretches and grows. In early pregnancy, a low-lying placenta is very common.
-But as the pregnancy progresses, the growing uterus should "pull" the placenta toward the top of the womb. -By the third trimester, the placenta should be near the top of the uterus, leaving the opening of the cervix clear for the delivery. -Sometimes, though, the placenta remains in the lower portion of the uterus, partly or completely covering this opening. This is called a previa. -Placenta previa is a complication of pregnancy in which the placenta grows in the lowest part of the womb (uterus) and covers all or part of the opening to the cervix. -PP is a presenting part -vaginal bleeding is usually bright red and painless -can occur suddenly during the 2nd or 3rd trimester -do not attempt to examine patient digitally -preferred transport position is side lying, supine, or trendelenburg -do not transport pt in fowlers position |
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Abruptio placenta
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-separation of placenta from the uterine wall
-experience severe abd pain -palpation of abd will show rigidity -FHT may be absent -administer pain meds -Anticipate abruptio placenta will proceed into active labor that is refractory to tocolysis -Once blood contacts the uterine wall, labor is almost unstoppable, blood is very stimulating to the uterine wall -Management includes continuous fundal height assessment, preparation for blood product administration and DIC, and continuous assessment of fetal movements, FHT and contractions -Abruptio placenta patient should deliver via cesarean section -Oxytocin would further aggravate abruptio placenta |
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Prolabsed umbilical cord
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-prevent mother from bearing down as this can compress the cord
-place the mother in knee chest position or in a supine position with hips elevated on pillow -do not attempt to push back the cord -with a sterile gloved hand in the vagina, gently push the babys presenting part upward (toward the abd cavity), if possible, so the fetal heart does not compress the cord -check for pulsations of the cord -occurs when the umbilical cord becomes wrapped around the fetal neck 360 degrees -is essential prior to the next contraction -Move the cord over the shoulder or cut the cord -Prolapsed umbilical cord need to be assessed for adequate circulation via the umbilical cord |
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General info
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-Bloody show refers to the bloody mucous plug that obturates the cervical opening, being discharged as the cervix begins to dilate, early sign of labor
-Benzodiazepines are not given to pregnant females because they cross the placenta and can precipitate a floppy newborn with inadequate respiratory effort -Sudden onset of respiratory distress with poor Sp02 and unresponsive to supplemental 02 should prompt you to a PE -Pregnancy equals hypercoagulopathic -O negative is the universal donor -Primary reason behind Rh typing is to prevent sensitization of the female to Rh+ blood type -Once sensitized a spontaneous abortion of a Rh+ fetus can occur -Do not administer 0 pos unless absolutely |
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General info cont
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-Uterine inversion management involves manual replacement of the uterus with the gloved hand to its natural position, the uterus cannot adequately reach homeostasis without being in its natural position
-Do not administer oxytocin or any other treatment that will promote uterine contraction -DIC treatment should consist of managing the precipitating event/cause -The most common management strategy with pregnancy induced DIC is blood component replacement therapy -Serial fundal height must be monitored with uterine rupture -Higher incidence of uterine rupture will be seen in prior cesarean section because of the physical defect in the uterine wall -Postpartum hemorrhage is controlled by fundal massage and Oxytocin administration, getting the uterus to clamp down is priority -50% of females under age 40 with a AAA are pregnant -Increased aortic pressures by a gravid uterus, increased circulating volume, and increased aortic ejection pressures contribute to this diagnosis -3rd trimester is the period of maximal hemodynamic stress -Pregnant trauma patients can loose 30-35% before symptoms of hypovolemia develops -A large volume loss must occur before typical signs of hypovolemia -High index of suspicion in pregnant trauma patients regarding MOI and seat belt placement |
