Peggy Ohnmacht, CEN/RNC-OB, C-EFM

I have always thought you should learn something new every day. Unfortunately many of us are at that age where what we learn today, we forget tomorrow. BUT, GIVE IT A SHOT ANYWAY!

Normal changes include:

Blood volume increases by 50%, leading to split S1, systolic murmur.

Plasma increases by 50%, cells increase by 20%, leading to

hemodilution. This causes a decrease in COP, putting pregnant

women at higher risk for dependant edema and pulmonary edema.

HR and SV increase by 20% - leading to an increase in CO. Can

increase by 50% by end of pregnancy.

SVR decreases by 20%, causing baseline BP to drop.

Heart is displaced upward and to the left, causing EKG changes.

PHISIOLOGIC CHANGES OF PREGNANCY

Oxygen consumption increases to help grow the baby and to meet mom’s

higher metabolic needs.

Influenced by progesterone, maternal TV increases up to 40%. This

resulting increased depth of respiration, combined with a slight increase in

RR leads to hyperventilation. The enlarging uterus rises up, pushing

on the diaphragm. FRC (functional residual capacity) decreases by 25%.

Hyperventilation & decreased FRC leads to lower O2 reserve and

hypoxia can occur more quickly in a high risk situation.

Mom’s live with a compensatory respiratory alkalosis. PO2 is

increased, CO2 is decreased, leading to a decrease in carbonic acid.

Serum bicarbonate decreases to maintain acid/base balance. Moms in

crisis can develop respiratory and metabolic acidosis quickly.

PHISIOLOGIC CHANGES OF PREGNANCY, cont’d

Pregnancy tips the balance of the coagulation/fibrinolysis equilibrium in favor of coagulation. Fibrinogen rises throughout pregnancy.

Secondary to increased glomerular filtration of about 50%, there is more excretion of glucose, nitrogen waste products and bicarbonate, and decreased serum concentrations of nitrogenous waste. BUN >

12mg/dl, or creatinine >0.8mg/dl, although in the normal range,

are considered abnormal for pregnancy, as is a uric acid in the

5s.

There is a physiologic hydroureter and hydronephrosis, more pronounced on right side.

Pregnant women are more prone to UTIs, secondary to uterine displacement, dilation of the ureters, and decreased bladder tone, hormonally influenced.

PHISIOLOGIC CHANGES OF PREGNANCY, cont’d

Hypotonia leads to decreased gastric motility, delayed emptying of the stomach, constipation, and increased concentration of bile, leading to gallstones. Acute cholecystitis is the second most common non-

OB surgical condition, second to appendicitis.

Mom is at increased risk of aspiration of highly acidic gastric content with anesthesia.

Hyperinsulinemia causes a diabetogenic state, related to increased insulin resistance.

PHISIOLOGIC CHANGES OF PREGNANCY, cont’d

PREGNANCY

IS DIVIDED

INTO THREE TRIMESTERS

Patients may come to the ER for: Spontaneous abortion (miscarriage):

Death or expulsion of a fetus prior to the age of viability. Accounts for 10-15% of all pregnancies. Classified as: threatened, inevitable, incomplete, complete, missed abortion, or septic. Major complications are infection and hemorrhage.

Self-induced or botched AB:

Infection - streptococci, e-coli, clostridium. Hemorrhage/shock - toxic shock syndrome.

Ectopic pregnancy:

Fertilized egg implants outside endometrium, usually in the tubes. Leading cause of maternal death in first trimester. S&S include missed period, abnormal vaginal bleeding, sudden stabbing pain on one side,

hemorrhagic shock. Commonly present at approx. 6 weeks gestation.

Hyperemesis: Vomiting in the first 13 weeks of pregnancy. Usually related to higher levels of pregnancy hormones. Will need to be admitted for dehydration/electrolyte imbalance.

Other medical/surgical conditions unrelated to pregnancy.

1st TRIMESTER (the 1st 13 weeks)

2nd TRIMESTER (14-26 weeks)

During second trimester, the patient may experience:

Placenta previa: Placenta attaches to lower segment near or over the internal os.

Classified as marginal, partial or complete- depending on how much of the cervical os is involved.

S&S include sudden painless vaginal bleeding after 24 weeks, bright red bleeding per vagina, shock.

Occurs in 1 of 200 births.

****NEVER put your hand into the vagina of someone who presents with vaginal bleeding!!!!!!!!**** (The doctor will do a sterile speculum exam to visualize.)

Marginal Partial Complete

Preterm labor (age of viability somewhere around 24-25 weeks) Contractions of the uterus or tightening of the abdomen occurring every 10 minutes

or more often.

Menstrual-like cramps

Abdominal cramping with or without diarrhea

Pressure or pain in the pelvic region

Low backache

Change in the color or amount of vaginal discharge

Preeclampsia/eclampsia

Medical/surgical complications unrelated to pregnancy: Cholecystitis

Appendicitis

Asthma

Trauma

2nd TRIMESTER (14-26 weeks), cont’d

Some of the things we may see during 3rd trimester would include:

Placental abruption: Premature partial or complete separation of placenta from uterine wall.

History of bleeding, enlarging uterus, painful abdomen.

Risk factors include: elevated BP, cigarette smoking, cocaine use, abdominal trauma, PROM.

Common cause of fetal death after MVAs.

Can develop as late as 48 hours after trauma.

Abruptio placenta accounts for 2/3 of all cases of antepartum hemmorrhage.

It is the most common cause of DIC in pregnancy.

3rd TRIMESTER (27 weeks ‘til term)

Revealed Abruption

Concealed Abruption

3rd TRIMESTER (27 weeks ‘til term), cont’d

Preeclampsia/Eclampsia/ HELLP Syndrome

Second leading cause of maternal mortality.

Multisystem disorder associated with elevated BP, proteinuria, edema, and CNS irritability, as well as coagulopathies and abnormal liver function .

Risk factors include: age extremes, primagravida, multiple gestation, underlying disease.

S&S include SBP>140, DBP> 90, 2+ proteinuria on dipstick, edema of face, hands and sacrum, visual changes, headache, nausea, epigastric /RUQ pain, increased DTRs with clonus.

Treatment includes bed rest on side, quiet environment, meds for elevated BP, delivery.

Eclampsia is progression of the disease to the convulsive state.

HELLP is a variant of severe preeclampsia characterized by Hemolysis, Elevated Liver enzymes, Low Platelets.

3rd TRIMESTER (27 weeks ‘til term), cont’d

Cord Prolapse:

Anytime the cord precedes the infant through the vagina. EMERGENCY! O2 to baby is cut off. Knee/chest or trendelenburg. SVE to elevate presenting part - once the hand goes in - DO NOT REMOVE! Keep cord moist. Be ready for vigorous resuscitation of newborn.

Preterm labor: Regular contractions prior to 37 weeks, leading to the delivery of a premature fetus. Second most common obstetric problem after trauma. Most common cause is dehydration. Also consider silent UTI. Mom will present with vague abdominal cramps, low back pain, actual contractions. (Increase seen in summer with mom’s sitting at poolside, and during the holidays.) Patient needs rehydration, wedge to side to improve blood flow to uterus and enhance O2 delivery, possibly antibiotics.

3rd TRIMESTER (27 weeks ‘til term), cont’d

Uterine rupture: Rare, but may occur in patients who have had multiple Caesareans or those with

extreme compression injury. Often results in fetal demise. Rarely repairable, usually requires C/S. S&S include:

Abdominal pain Change in the normal contour Difficulty identifying the fundal height Vaginal bleeding Signs of shock Palpable fetal parts/mass

Labor: Regular pattern of contractions that result in the cervix dilating and delivery of a

fetus. Average 1st labor is 12-20 hours, second labors are usually half as long. First time mom can push from 1-3 hours, while it is not unusual for a multiparous

patient to push once or twice.

3rd TRIMESTER (27 weeks ‘til term), cont’d

MOM IN LABOR

Information necessary:

Name, age

What pregnancy is this?

Gravida - How many times has she been pregnant?

Para - How many pregnancies have gone beyond 20 weeks, regardless of how many fetuses she is carrying.

Have there been any complications with this pregnancy?

Any complications with previous pregnancies?

Allergies?

Last time she ate?

When is her due date?

Has your water broken; What time and what color was the fluid?

When did the contractions begin? How far apart are they now? Where are you feeling them? Are you feeling the baby move? Has there been any bleeding/bloody show? Do you feel the need to have a BM? (Are you seeing/hearing the mom bear

down/grunt?)

Oxygen is not necessary, but can keep mom calm until she reaches L&D.

Position of comfort with wedge under one side (*not flat on back*) Breathe with patient, offer reassurance, stay calm! Inspect before getting on the elevator. Much more likely to be having a precipitious delivery if mom is a multip, but it can happen at any time. Do you see bulging of the perineum, or fetal hair/scalp peeking through? If so, prepare for delivery. Notify L&D to attend.

MOM IN LABOR, cont’d

EMERGENCY DELIVERY PROCEDURE

Place mom either in supine or side lying position.

Pad the bed.

Have available baby blanket and towel, bulb syringe, scissor, 2 clamps.

Remain calm, offer encouragement, reassurance and guidance.

Ask mom to pant or bear down gently.

Apply gentle pressure as head appears to avoid rapid expulsion.

Support perineum to reduce tears. Allow for natural rotation.

EMERGENCY DELIVERY PROCEDURE, cont’d

Examine for nuccal cord. Reduce or clamp and cut as necessary.

If bag is still intact, rupture and pull away from face.

Suction mouth then nose to clear mucous.

Deliver shoulders by putting gentle traction downward to deliver ant. shoulder, then upward pressure to deliver post. shoulder.

Remainder of baby will deliver quickly, note time!

Take a breath!!

Again bulb suction the baby, dry and stimulate. Place baby on mom’s abdomen.

Transfer stable mom and baby’s care to the MCH team, exhale and go on break!

Early crowning of the head- perineal bulging

•Fingers slide down to neck to assess for a cord around the neck •If there is none she can continue to push •If there is a cord can you loosen it- get some slack and gently lift it over the baby’s head- if yes-do it •When cord is too tight: • 2 kelly clamps applied

•Clamp off a section of the cord •Cut between with a bandage scissor •Unravel from around baby’s neck •Deliver infant •Now the perfusion has been cut off

TRAUMA Leading cause of maternal death for non-obstetrical reasons,

affecting up to 7% of all pregnancies.

Premature labor is the most common complication- may suggest

as yet to be discovered maternal complications.

Incidence increase throughout pregnancy.

Uterus rises out of pelvis by 2nd trimester, becoming an abdominal

organ; predisposed to higher likelihood of trauma.

Mild to moderate blood loss (1500-2000cc) may be masked by normal

pregnancy hypervolemia.

Can be blunt vs. penetrating; blunt is most frequent cause of both maternal and fetal injury.

TREATMENT

Resuscitation priorities are the same as for a non-pregnant patient. Stabilization of mom is ALWAYS the 1st priority - allows for best chance for fetal survival and recovery.

Rapid primary assessment: A B C Ds (AVPU).

Head-to-toe secondary assessment.

Medical history: AMPLE (allergies, medicine, previous problems, last meal, events leading up to this).

Assess abdomen/uterus: fundal height, uterine tone, contractions, bleeding, fetal movement.

Start 2 large bore IVs immediately (18 or greater), infuse LR or NS. Fluid resuscitation & transfusion should be based on estimate of current blood loss & continued expected blood loss, NOT ON Hgb, and

regardless of apparent stability of patient. Because of the hypervolemic state of the pregnant patient, signs of shock can be delayed until well advanced.

Give O2- hypoxemia can occur more quickly and is not well tolerated.

Normal compensated met. alkalosis may mask signs of metabolic acidosis (shock) until well advanced.

Pregnant patients can continue to have high urine output with dilute urine in the face of hypovolemia.

TREATMENT, cont’d

Hormones cause relaxation of gastric sphincter and decreased motility of the digestive tract increase the likelihood of a full stomach. Pregnant women at increased risk of aspiration. Quick intubation may be necessary to protect airway.

Gravid uterus presses on both vena cava and aorta, causing decreased preload and decrease in CO, leading to hypotension and dyspnea. Displace uterus to side (wedge). If pt is boarded, tip entire board.

Remember you have 2 patients- reassess fetal status regularly. Remember to include OB team early in resuscitation.

If CPR necessary, consider thorocotomy and open chest massage if no response.

Consider emergency C/S after 4-5 minutes (*sometimes delivery may enhance maternal resuscitation efforts.) Continue CPR throughout C/S.

TREATMENT, cont’d

Lab Tests Normal/non-pregnant Pregnancy

Hgb/Hct 12-15/36-45

Fibrinogen 200-400,000

WBC 4-10,000

Platelets 150-450,000

,000 BUN/Creat. 6-20/0.6-1.1

Uric acid 2.6-6.0

Hct decreases to 31-34%

Increased

Increased to 15,000, but with normal differential

May be slightly decreased, but remains above 100,000

Due to increased glomerular filtration, BUN should be <12, and creatinine < 0.8

Should be no higher than in the 4S

Kleinhauer-Betke test- detects fetal cells in maternal circulation (Rh sensitization)

Watch the little things

A small leak will sink a great ship!

~Benjamin Franklin