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
review all the things
Concepts Covered:
- Cardiovascular
- Emergency Care of the Cardiac Patient
- Cardiac Disorders
- Shock
- Shock
- Disorders of the Posterior Pituitary Gland
- Endocrine
- Disorders of Pancreas
- Disorders of the Thyroid & Parathyroid Glands
- Hematology
- Gastrointestinal
- Upper GI Disorders
- Newborn Complications
- Liver & Gallbladder Disorders
- Lower GI Disorders
- Multisystem
- Neurological
- Central Nervous System Disorders – Brain
- Renal
- Respiratory
- Urinary System
- Respiratory System
- Noninfectious Respiratory Disorder
- Test Taking Strategies
- Medication Administration
- Respiratory Disorders
- Pregnancy Risks
- Labor Complications
- Fundamentals of Emergency Nursing
- Factors Influencing Community Health
- EENT Disorders
- Basics of Chemistry
- Adult
- Emergency Care of the Neurological Patient
- Acute & Chronic Renal Disorders
- Emergency Care of the Respiratory Patient
- Respiratory Emergencies
- Studying
- Substance Abuse Disorders
- Disorders of the Adrenal Gland
- Behavior
- Documentation and Communication
- Preoperative Nursing
- Endocrine System
- Legal and Ethical Issues
- Basics of NCLEX
- Communication
- Understanding Society
- Immunological Disorders
- Cognitive Disorders
- Musculoskeletal Trauma
- Intraoperative Nursing
- Eating Disorders
- Prenatal Concepts
- Anxiety Disorders
- Depressive Disorders
- Oncology Disorders
- Personality Disorders
- Psychotic Disorders
- Trauma-Stress Disorders
- Gastrointestinal Disorders
- Circulatory System
- Integumentary Disorders
- Neurologic and Cognitive Disorders
- Nervous System
- Microbiology
- Hematologic Disorders
- Emergency Care of the Trauma Patient
- Newborn Care
- Digestive System
- Urinary Disorders
- Postpartum Care
- Infectious Respiratory Disorder
- Integumentary Disorders
- Terminology
- Concepts of Population Health
- Musculoskeletal Disorders
- EENT Disorders
- Postpartum Complications
- Postoperative Nursing
- Neurological Emergencies
- Vascular Disorders
- Disorders of Thermoregulation
- Statistics
- Neurological Trauma
- Cardiovascular Disorders
- Basic
- Concepts of Mental Health
- Health & Stress
- Endocrine and Metabolic Disorders
- Delegation
- Perioperative Nursing Roles
- Developmental Considerations
- Childhood Growth and Development
- Prenatal and Neonatal Growth and Development
- Renal Disorders
- Concepts of Pharmacology
- Integumentary Important Points
- Fetal Development
- Renal and Urinary Disorders
- Community Health Overview
- Developmental Theories
- Labor and Delivery
- Infectious Disease Disorders
- Musculoskeletal Disorders
- Basics of Human Biology
- Psychological Emergencies
- Adulthood Growth and Development
- Growth & Development
- Female Reproductive Disorders
- Sexually Transmitted Infections
- Proteins
- Hematologic Disorders
- Tissues and Glands
- Somatoform Disorders
- Oncologic Disorders
- Skeletal System
- Basics of Sociology
- Bipolar Disorders
- Emotions and Motivation
- Peripheral Nervous System Disorders
- Central Nervous System Disorders – Spinal Cord
- Neonatal
- Male Reproductive Disorders
- Prioritization
- Pediatric
- Psychological Disorders
- State of Consciousness
- Sensory System