trauma & pregnancy

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TRAUMA AND PREGNANCYTRAUMA AND PREGNANCY

LTC Brenda Sowards, Chief Nurse,

141st MDG

Washington Air National Guard1

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EpidemiologyEpidemiology

Trauma is the leading cause Trauma is the leading cause of death in women during of death in women during reproductive yearsreproductive years

The leading nonobstetric The leading nonobstetric cause of death and disability cause of death and disability in pregnant women in pregnant women

Resuscitation priorities are Resuscitation priorities are the samethe same

Obtain early OB consultObtain early OB consult

Proper seat belt placementProper seat belt placement

Improper seat belt placementImproper seat belt placement2

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Mechanisms of InjuryMechanisms of Injuryand Biomechanicsand Biomechanics

Blunt trauma most Blunt trauma most frequent cause of maternal frequent cause of maternal and fetal injury (motor and fetal injury (motor vehicle crashes, falls)vehicle crashes, falls)

Gun shot wounds most Gun shot wounds most common penetratingcommon penetrating

Stab wounds less commonStab wounds less common

(Used with permission from Good (Used with permission from Good Samaritan Hospital. Downers Grove, IL.)Samaritan Hospital. Downers Grove, IL.)

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Types of InjuriesTypes of Injuries

Head injury: Major cause of maternal deathHead injury: Major cause of maternal death Pelvic fractures can result in severe hemorrhage Pelvic fractures can result in severe hemorrhage

and fetal deathand fetal death Other injuriesOther injuries

Diaphragmatic tearDiaphragmatic tear Urinary bladder injuryUrinary bladder injury Uterine injuryUterine injury Fetal injuryFetal injury

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Cardiovascular Changes Cardiovascular Changes

Hypervolemic (by 10th week)Hypervolemic (by 10th week) Hyperdynamic (increased cardiac output)Hyperdynamic (increased cardiac output) ““Anemia” of pregnancyAnemia” of pregnancy Increased heart rateIncreased heart rate Decreased systolic and diastolic pressuresDecreased systolic and diastolic pressures Hypertension may indicate OB complicationHypertension may indicate OB complication Fetus compromised with maternal blood loss (15 Fetus compromised with maternal blood loss (15

to 30%)to 30%)5

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Respiratory ChangesRespiratory Changes

Tidal volume increased by 40%Tidal volume increased by 40% Vital capacity increased 100 to 200 mlVital capacity increased 100 to 200 ml Respiratory rate increased slightlyRespiratory rate increased slightly Arterial blood gases reflect compensated Arterial blood gases reflect compensated

respiratory alkalosis due to hyperventilationrespiratory alkalosis due to hyperventilation PaCOPaCO22 : 30 mm Hg (4.0 KPa) : 30 mm Hg (4.0 KPa)

PaOPaO22 : 101 to 104 mm Hg (13.5 to 13.9 KPa) : 101 to 104 mm Hg (13.5 to 13.9 KPa)

Decreased functional residual capacityDecreased functional residual capacity6

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Abdominal ChangesAbdominal Changes

Physiologic ileus: Decreased gastric motilityPhysiologic ileus: Decreased gastric motility Vomiting/aspiration: Increased emptying Vomiting/aspiration: Increased emptying

time due to hormonal changestime due to hormonal changes Rebound tenderness decreasedRebound tenderness decreased Abdominal guarding decreasedAbdominal guarding decreased

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Urinary ChangesUrinary Changes

Urinary frequency: Increased glomerular Urinary frequency: Increased glomerular filtration and increased pressure of uterus filtration and increased pressure of uterus on bladderon bladder

Bladder elevated out of pelvis (late Bladder elevated out of pelvis (late pregnancy)pregnancy)

Glycosuria (not proteinuria)Glycosuria (not proteinuria)

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Neurologic ChangesNeurologic Changes

Pregnancy induced hypertension (PIH)Pregnancy induced hypertension (PIH) Increased blood pressureIncreased blood pressure ProteinuriaProteinuria EdemaEdema May result in seizuresMay result in seizures

Can mimic head injury Can mimic head injury

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Musculoskeletal ChangesMusculoskeletal Changes

Pelvis less susceptible Pelvis less susceptible to fracturesto fractures

Relaxation of sacroiliac Relaxation of sacroiliac (SI) joint: Hormonal (SI) joint: Hormonal changeschanges

Symphysis pubis Symphysis pubis widened 4 to 8 mm (3rd widened 4 to 8 mm (3rd trimester)trimester)

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Premature LaborPremature Labor

Most frequent complication: Maternal injuryMost frequent complication: Maternal injury Signs and SymptomsSigns and Symptoms

Uterine contractions greater than 6 per hourUterine contractions greater than 6 per hour Patient may or may not sense contractionsPatient may or may not sense contractions Back painBack pain Vaginal dischargeVaginal discharge Cervical dilation or effacementCervical dilation or effacement

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Premature LaborPremature Labor

(Used with permission from Good Samaritan (Used with permission from Good Samaritan Hospital. Downers Grove, IL.)Hospital. Downers Grove, IL.) 12

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Abruptio PlacentaAbruptio Placenta

Partial or total separation of placenta from Partial or total separation of placenta from uterine walluterine wall

Signs and SymptomsSigns and Symptoms Vaginal bleeding (absent if retroplacental)Vaginal bleeding (absent if retroplacental) Uterine tendernessUterine tenderness Premature laborPremature labor

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Abruptio PlacentaAbruptio Placenta

Signs and Symptoms Signs and Symptoms (continued)(continued)

Abdominal crampsAbdominal cramps Maternal hemorrhage Maternal hemorrhage

(shock)(shock) Fetal distressFetal distress Increasing fundal Increasing fundal

heightheight

(Used with permission from Barbara Bires, Dayton, OH)(Used with permission from Barbara Bires, Dayton, OH)

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Uterine RuptureUterine Rupture

Seen in patients with extreme compression Seen in patients with extreme compression injury injury

RareRare History of cesarean sectionHistory of cesarean section Associated with bladder ruptureAssociated with bladder rupture Fetal demiseFetal demise Surgery: HysterectomySurgery: Hysterectomy

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Uterine RuptureUterine Rupture

Signs and SymptomsSigns and Symptoms Abdominal painAbdominal pain History of acute pain followed by no painHistory of acute pain followed by no pain Uterine tendernessUterine tenderness Difficulty identifying fundal heightDifficulty identifying fundal height Vaginal bleedingVaginal bleeding Maternal hemorrhage and shockMaternal hemorrhage and shock Absent fetal heart tonesAbsent fetal heart tones

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Maternal Cardiopulmonary Maternal Cardiopulmonary Arrest/Fetal DeliveryArrest/Fetal Delivery

Successful outcome for fetus if:Successful outcome for fetus if: Procedure within 5 minutes of arrest (70% fetal Procedure within 5 minutes of arrest (70% fetal

survival)survival) There is viable fetal gestational age ( > 26 weeks)There is viable fetal gestational age ( > 26 weeks) Continuation of CPR throughout cesarean Continuation of CPR throughout cesarean

sectionsection Availability of a neonatal resuscitation teamAvailability of a neonatal resuscitation team Correction of maternal acidosis Correction of maternal acidosis

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Nursing Care - AssessmentNursing Care - Assessment

HistoryHistory What was the mechanism of injury?What was the mechanism of injury? Was the patient wearing a restraint device?Was the patient wearing a restraint device? Last menstrual period (LMP)?Last menstrual period (LMP)? Estimated date of confinement (EDC)?Estimated date of confinement (EDC)?

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Nursing Care - AssessmentNursing Care - Assessment

History (continued)History (continued) Problems or complications during this or Problems or complications during this or

other pregnancies?other pregnancies? Are uterine contractions or abdominal pain Are uterine contractions or abdominal pain

present?present? Is there fetal activity?Is there fetal activity?

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Nursing Care - Nursing Care - Physical AssessmentPhysical Assessment

InspectInspect PerineumPerineum Vaginal openingVaginal opening

ObserveObserve Shape and contour of the abdomenShape and contour of the abdomen Abdomen for signs of fetal movementAbdomen for signs of fetal movement

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Nursing Care -Nursing Care -Physical AssessmentPhysical Assessment

AuscultationAuscultation Fetal heart tones (120 to 160 beats/min)Fetal heart tones (120 to 160 beats/min) Maternal pulse and discriminate between Maternal pulse and discriminate between

the two pulsesthe two pulses

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Nursing Care -Nursing Care -Physical AssessmentPhysical Assessment

PalpationPalpation Height of fundusHeight of fundus

Symphysis pubis: 12 weeksSymphysis pubis: 12 weeks Umbilicus: 20 weeks Umbilicus: 20 weeks Costal margins: 36 weeksCostal margins: 36 weeks

(Reprinted with permission from (Reprinted with permission from Foundations of Foundations of Maternal Newborn NursingMaternal Newborn Nursing. WB Saunders; 1994.). WB Saunders; 1994.)

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Diagnostic ProceduresDiagnostic Procedures

Radiographic StudiesRadiographic Studies Shield fetus from unnecessary radiographsShield fetus from unnecessary radiographs Intravenous pyelogram (IVP)Intravenous pyelogram (IVP) Computerized tomography scanComputerized tomography scan Ultrasonography Ultrasonography

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Laboratory StudiesLaboratory Studies Type and crossmatchType and crossmatch Bicarbonate and lactateBicarbonate and lactate PT and PTTPT and PTT Beta Human Chorionic Gonadotropin (BHCG)Beta Human Chorionic Gonadotropin (BHCG) Kleihauer-Betke Test Kleihauer-Betke Test

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Other ProceduresOther Procedures Diagnostic peritoneal lavageDiagnostic peritoneal lavage Pelvic examPelvic exam Monitor fetal heart tones (FHT) and rateMonitor fetal heart tones (FHT) and rate Monitor uterine contractionsMonitor uterine contractions AmniocentesisAmniocentesis

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Nursing DiagnosesNursing Diagnoses

Aspiration riskAspiration risk Impaired gas exchangeImpaired gas exchange Altered tissue perfusionAltered tissue perfusion Fluid volume deficitFluid volume deficit Infection riskInfection risk Anxiety and fearAnxiety and fear Anticipatory grievingAnticipatory grieving PainPain 26

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Planning and ImplementationPlanning and Implementation

OxygenOxygen Intravenous fluidsIntravenous fluids Maternal vital signsMaternal vital signs Uterine contractionsUterine contractions Uterine/vaginal blood lossUterine/vaginal blood loss Measure and record fundal height every Measure and record fundal height every

30 minutes30 minutes27

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Planning and ImplementationPlanning and Implementation

Insert gastric tubeInsert gastric tube Position on left sidePosition on left side Tilt backboard or displace uterus to the leftTilt backboard or displace uterus to the left Administer medications to inhibit contractionsAdminister medications to inhibit contractions Obtain OB consultObtain OB consult Prepare for operative intervention, admission, or Prepare for operative intervention, admission, or

transfertransfer Provide psychosocial supportProvide psychosocial support

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Evaluation and Ongoing AssessmentEvaluation and Ongoing Assessment

Monitor maternal Monitor maternal cardiovascular status for cardiovascular status for evidence of shockevidence of shock

Assess abdomen and Assess abdomen and uterine activityuterine activity

Monitor fetal activity and Monitor fetal activity and heart rateheart rate

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trauma & pregnancy

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