Obstetric Trauma for Certified Emergency Nursing (CEN)
Included In This Lesson
Outline
Obstetric Trauma
Definition/Etiology:
Trauma occurs in 6-8% of pregnancies. Top 3:
- Intimate partner violence (8.307/100,000 live births)
- MVC (207/100,000 live births)
- Falls (49/100,000 live births)
Pathophysiology:
- After 12 weeks gestation, the uterus begins to expand above the pelvis, and is more vulnerable.
- Uterine blood flow is as high as 600 mL/minute in the third trimester and not autoregulated, thus a decrease in maternal systolic blood pressure can cause a significant fall in blood flow, and in turn, fetal oxygenation.
- Cardiac output and heart rate go up during pregnancy.
- Temporary EKG changes and a new cardiac murmur are common during pregnancy.
- Plasma volume increases more than RBC volume during pregnancy, so this creates a dilutional drop in hemoglobin and hematocrit.
Clinical Presentation:
If uterine fundus is at or below the umbilicus, then <20 weeks. If above, then >20 weeks.
22-23 weeks is the youngest considered viable.
Possible presentations due to trauma:
- Premature rupture of membranes
- Preterm labor
- Placental abruption
- Miscarriage
- Fetal injury or death
- Maternal death
- All of the presentations of non-pregnant patients
If maternal hypovolemic shock, coma, exploratory laparotomy, then fetal death is at least 40-50%.
Collaborative Management:
Consult OB during resuscitation so they can help determine if emergency cesarean is indicated:
- To save the fetus (>24 weeks) in the setting of imminent maternal death or a fetal heart rate tracing predictive of fetal acidosis.
- Save the mother’s life if CPR has not been effective within four minutes, regardless of gestational age.
Liberal use of maternal oxygen supplementation.
The gravid uterus compresses the inferior vena cava when supine, and decreases the return of blood to the heart. It’s important to tilt a spinal board 30 degrees if possible during resuscitation.
Monitor fetal heart rate. Normal is 110-160 bpm.
Medications:
- Tetanus immunization is OK to give during pregnancy if a wound requires it.
- If mom is Rh-negative, she may need to receive anti-D immune globulin (RhoGam) because a fetomaternal infusion of blood can occur during trauma.
- All of the same medications in the preterm labor lecture.
Labs:
- Urine drug screen
- Rh-D
- CBC, CMP, Coags
Imaging:
- Ultrasound / FAST exam
- MRI preferred since no radiation, but CT is faster. Decision is case-by-case.
Evaluation | Patient Monitoring | Education:
ACOG recommends using seat belts and airbags. Lap belt should go under uterus, and shoulder belt should go above uterus and between breasts.
- Continuous maternal NIBP, cardiac, and SaO2 monitoring
- Continuous fetal heart rate monitoring
- Liberal use of maternal oxygen supplementation
- Collaborate with L&D team
Linchpins: (Key Points)
- Liberal use of supplemental oxygen.
- Roll pregnant patient 30 degrees laterally to offset the uterus from the inferior vena cava.
- Normal fetal heart rate is 110-160 bpm.
- Call L&D team ASAP in case cesarean is needed.
Transcript
For more great CEN prep, got to the link below to purchase the “Emergency Nursing Examination Review” book by Dr. Laura Gasparis Vonfrolio RN, PHD
https://greatnurses.com/
References:
- Kilpatrick, S. J. (2021, September 9). Initial evaluation and management of major trauma in pregnancy. UpToDate. https://www.uptodate.com/contents/initial-evaluation-and-management-of-major-trauma-in-pregnancy
- Lockwood, C. J. (2022, October 13). Prenatal care: Patient education, health promotion, and safety of commonly used drugs. UpToDate. https://www.uptodate.com/contents/prenatal-care-patient-education-health-promotion-and-safety-of-commonly-used-drugs
Tiona RN
Concepts Covered:
- Studying
- Medication Administration
- Adult
- Emergency Care of the Cardiac Patient
- Intraoperative Nursing
- Microbiology
- Cardiac Disorders
- Vascular Disorders
- Nervous System
- Upper GI Disorders
- Central Nervous System Disorders – Brain
- Immunological Disorders
- Fundamentals of Emergency Nursing
- Dosage Calculations
- Understanding Society
- Circulatory System
- Concepts of Pharmacology
- Hematologic Disorders
- Newborn Care
- Adulthood Growth and Development
- Disorders of Pancreas
- Postoperative Nursing
- Pregnancy Risks
- Neurological
- Postpartum Complications
- Noninfectious Respiratory Disorder
- Peripheral Nervous System Disorders
- Learning Pharmacology
- Prenatal Concepts
- Tissues and Glands
- Developmental Considerations
- Factors Influencing Community Health
- Childhood Growth and Development
- Prenatal and Neonatal Growth and Development
- Developmental Theories
- Basic
- Neonatal
- Pediatric
- Gastrointestinal
- Newborn Complications
- Labor Complications
- Fetal Development
- Terminology
- Labor and Delivery
- Postpartum Care
- Communication
- Basics of Mathematics
- Statistics
- Basics of Sociology
- Cardiovascular
- Shock
- Shock
- Disorders of the Posterior Pituitary Gland
- Endocrine
- Disorders of the Thyroid & Parathyroid Glands
- Liver & Gallbladder Disorders
- Lower GI Disorders
- Respiratory
- Delegation
- Perioperative Nursing Roles
- Acute & Chronic Renal Disorders
- Respiratory Emergencies
- Disorders of the Adrenal Gland
- Documentation and Communication
- Preoperative Nursing
- Legal and Ethical Issues
- Oncology Disorders
- Female Reproductive Disorders
- Musculoskeletal Trauma
- Renal Disorders
- Male Reproductive Disorders
- Sexually Transmitted Infections
- Infectious Respiratory Disorder
- Integumentary Disorders
- Emergency Care of the Trauma Patient
- Urinary Disorders
- Musculoskeletal Disorders
- EENT Disorders
- Neurological Emergencies
- Disorders of Thermoregulation
- Neurological Trauma
- Basics of NCLEX
- Integumentary Important Points
- Multisystem
- Test Taking Strategies
- Urinary System
- Emergency Care of the Neurological Patient
- Central Nervous System Disorders – Spinal Cord
- Respiratory System
- Emergency Care of the Respiratory Patient
- Cognitive Disorders
- Anxiety Disorders
- Depressive Disorders
- Trauma-Stress Disorders
- Substance Abuse Disorders
- Bipolar Disorders
- Psychotic Disorders
- Concepts of Mental Health
- Eating Disorders
- Personality Disorders
- Health & Stress
- Psychological Emergencies
- Somatoform Disorders
- Prioritization
- Community Health Overview
- Gastrointestinal Disorders
- Integumentary Disorders
- Respiratory Disorders
- Neurologic and Cognitive Disorders
- Renal and Urinary Disorders
- Infectious Disease Disorders
- EENT Disorders
- Hematologic Disorders
- Cardiovascular Disorders
- Musculoskeletal Disorders
- Endocrine and Metabolic Disorders
- Oncologic Disorders
- Behavior
- Emotions and Motivation
- Growth & Development
- Intelligence and Language
- Psychological Disorders
- State of Consciousness
- Note Taking
- Concepts of Population Health
- Basics of Human Biology