Trauma & Pregnancy

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LTC Brenda Sowards, Chief Nurse,
141st MDG
Washington Air National Guard

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Trauma & Pregnancy

  1. 1. TRAUMA AND PREGNANCY LTC Brenda Sowards, Chief Nurse, 141 st MDG Washington Air National Guard
  2. 2. Epidemiology <ul><li>Trauma is the leading cause of death in women during reproductive years </li></ul><ul><li>The leading nonobstetric cause of death and disability in pregnant women </li></ul><ul><li>Resuscitation priorities are the same </li></ul><ul><li>Obtain early OB consult </li></ul>Proper seat belt placement Improper seat belt placement
  3. 3. Mechanisms of Injury and Biomechanics <ul><li>Blunt trauma most frequent cause of maternal and fetal injury (motor vehicle crashes, falls) </li></ul><ul><li>Gun shot wounds most common penetrating </li></ul><ul><li>Stab wounds less common </li></ul>(Used with permission from Good Samaritan Hospital. Downers Grove, IL.)
  4. 4. Types of Injuries <ul><li>Head injury: Major cause of maternal death </li></ul><ul><li>Pelvic fractures can result in severe hemorrhage and fetal death </li></ul><ul><li>Other injuries </li></ul><ul><ul><li>Diaphragmatic tear </li></ul></ul><ul><ul><li>Urinary bladder injury </li></ul></ul><ul><ul><li>Uterine injury </li></ul></ul><ul><ul><li>Fetal injury </li></ul></ul>
  5. 5. Cardiovascular Changes <ul><li>Hypervolemic (by 10th week) </li></ul><ul><li>Hyperdynamic (increased cardiac output) </li></ul><ul><li>“ Anemia” of pregnancy </li></ul><ul><li>Increased heart rate </li></ul><ul><li>Decreased systolic and diastolic pressures </li></ul><ul><li>Hypertension may indicate OB complication </li></ul><ul><li>Fetus compromised with maternal blood loss (15 to 30%) </li></ul>
  6. 6. Respiratory Changes <ul><li>Tidal volume increased by 40% </li></ul><ul><li>Vital capacity increased 100 to 200 ml </li></ul><ul><li>Respiratory rate increased slightly </li></ul><ul><li>Arterial blood gases reflect compensated respiratory alkalosis due to hyperventilation </li></ul><ul><ul><li>PaCO 2 : 30 mm Hg (4.0 KPa) </li></ul></ul><ul><ul><li>PaO 2 : 101 to 104 mm Hg (13.5 to 13.9 KPa) </li></ul></ul><ul><li>Decreased functional residual capacity </li></ul>
  7. 7. Abdominal Changes <ul><li>Physiologic ileus: Decreased gastric motility </li></ul><ul><li>Vomiting/aspiration: Increased emptying time due to hormonal changes </li></ul><ul><li>Rebound tenderness decreased </li></ul><ul><li>Abdominal guarding decreased </li></ul>
  8. 8. Urinary Changes <ul><li>Urinary frequency: Increased glomerular filtration and increased pressure of uterus on bladder </li></ul><ul><li>Bladder elevated out of pelvis (late pregnancy) </li></ul><ul><li>Glycosuria (not proteinuria) </li></ul>
  9. 9. Neurologic Changes <ul><li>Pregnancy induced hypertension (PIH) </li></ul><ul><ul><li>Increased blood pressure </li></ul></ul><ul><ul><li>Proteinuria </li></ul></ul><ul><ul><li>Edema </li></ul></ul><ul><ul><li>May result in seizures </li></ul></ul><ul><li>Can mimic head injury </li></ul>
  10. 10. Musculoskeletal Changes <ul><li>Pelvis less susceptible to fractures </li></ul><ul><li>Relaxation of sacroiliac (SI) joint: Hormonal changes </li></ul><ul><li>Symphysis pubis widened 4 to 8 mm (3rd trimester) </li></ul>
  11. 11. Premature Labor <ul><li>Most frequent complication: Maternal injury </li></ul><ul><li>Signs and Symptoms </li></ul><ul><ul><li>Uterine contractions greater than 6 per hour </li></ul></ul><ul><ul><li>Patient may or may not sense contractions </li></ul></ul><ul><ul><li>Back pain </li></ul></ul><ul><ul><li>Vaginal discharge </li></ul></ul><ul><ul><li>Cervical dilation or effacement </li></ul></ul>
  12. 12. Premature Labor (Used with permission from Good Samaritan Hospital. Downers Grove, IL.)
  13. 13. Abruptio Placenta <ul><li>Partial or total separation of placenta from uterine wall </li></ul><ul><li>Signs and Symptoms </li></ul><ul><ul><li>Vaginal bleeding (absent if retroplacental) </li></ul></ul><ul><ul><li>Uterine tenderness </li></ul></ul><ul><ul><li>Premature labor </li></ul></ul>
  14. 14. Abruptio Placenta <ul><li>Signs and Symptoms (continued) </li></ul><ul><li>Abdominal cramps </li></ul><ul><li>Maternal hemorrhage (shock) </li></ul><ul><li>Fetal distress </li></ul><ul><li>Increasing fundal height </li></ul>(Used with permission from Barbara Bires, Dayton, OH)
  15. 15. Uterine Rupture <ul><li>Seen in patients with extreme compression injury </li></ul><ul><li>Rare </li></ul><ul><li>History of cesarean section </li></ul><ul><li>Associated with bladder rupture </li></ul><ul><li>Fetal demise </li></ul><ul><li>Surgery: Hysterectomy </li></ul>
  16. 16. Uterine Rupture <ul><li>Signs and Symptoms </li></ul><ul><li>Abdominal pain </li></ul><ul><li>History of acute pain followed by no pain </li></ul><ul><li>Uterine tenderness </li></ul><ul><li>Difficulty identifying fundal height </li></ul><ul><li>Vaginal bleeding </li></ul><ul><li>Maternal hemorrhage and shock </li></ul><ul><li>Absent fetal heart tones </li></ul>
  17. 17. Maternal Cardiopulmonary Arrest/Fetal Delivery <ul><li>Successful outcome for fetus if: </li></ul><ul><ul><li>Procedure within 5 minutes of arrest (70% fetal survival) </li></ul></ul><ul><ul><li>There is viable fetal gestational age ( > 26 weeks) </li></ul></ul><ul><ul><li>Continuation of CPR throughout cesarean section </li></ul></ul><ul><ul><li>Availability of a neonatal resuscitation team </li></ul></ul><ul><ul><li>Correction of maternal acidosis </li></ul></ul>
  18. 18. Nursing Care - Assessment <ul><li>History </li></ul><ul><li>What was the mechanism of injury? </li></ul><ul><li>Was the patient wearing a restraint device? </li></ul><ul><li>Last menstrual period (LMP)? </li></ul><ul><li>Estimated date of confinement (EDC)? </li></ul>
  19. 19. Nursing Care - Assessment <ul><li>History (continued) </li></ul><ul><li>Problems or complications during this or other pregnancies? </li></ul><ul><li>Are uterine contractions or abdominal pain present? </li></ul><ul><li>Is there fetal activity? </li></ul>
  20. 20. Nursing Care - Physical Assessment <ul><li>Inspect </li></ul><ul><ul><li>Perineum </li></ul></ul><ul><ul><li>Vaginal opening </li></ul></ul><ul><li>Observe </li></ul><ul><ul><li>Shape and contour of the abdomen </li></ul></ul><ul><ul><li>Abdomen for signs of fetal movement </li></ul></ul>
  21. 21. Nursing Care - Physical Assessment <ul><li>Auscultation </li></ul><ul><li>Fetal heart tones (120 to 160 beats/min) </li></ul><ul><li>Maternal pulse and discriminate between the two pulses </li></ul>
  22. 22. Nursing Care - Physical Assessment <ul><li>Palpation </li></ul><ul><li>Height of fundus </li></ul><ul><ul><li>Symphysis pubis: 12 weeks </li></ul></ul><ul><ul><li>Umbilicus: 20 weeks </li></ul></ul><ul><ul><li>Costal margins: 36 weeks </li></ul></ul>(Reprinted with permission from Foundations of Maternal Newborn Nursing . WB Saunders; 1994.)
  23. 23. Diagnostic Procedures <ul><li>Radiographic Studies </li></ul><ul><ul><li>Shield fetus from unnecessary radiographs </li></ul></ul><ul><ul><li>Intravenous pyelogram (IVP) </li></ul></ul><ul><ul><li>Computerized tomography scan </li></ul></ul><ul><ul><li>Ultrasonography </li></ul></ul>
  24. 24. Diagnostic Procedures <ul><li>Laboratory Studies </li></ul><ul><ul><li>Type and crossmatch </li></ul></ul><ul><ul><li>Bicarbonate and lactate </li></ul></ul><ul><ul><li>PT and PTT </li></ul></ul><ul><ul><li>Beta Human Chorionic Gonadotropin (BHCG) </li></ul></ul><ul><ul><li>Kleihauer-Betke Test </li></ul></ul>
  25. 25. Diagnostic Procedures <ul><li>Other Procedures </li></ul><ul><ul><li>Diagnostic peritoneal lavage </li></ul></ul><ul><ul><li>Pelvic exam </li></ul></ul><ul><ul><li>Monitor fetal heart tones (FHT) and rate </li></ul></ul><ul><ul><li>Monitor uterine contractions </li></ul></ul><ul><ul><li>Amniocentesis </li></ul></ul>
  26. 26. Nursing Diagnoses <ul><li>Aspiration risk </li></ul><ul><li>Impaired gas exchange </li></ul><ul><li>Altered tissue perfusion </li></ul><ul><li>Fluid volume deficit </li></ul><ul><li>Infection risk </li></ul><ul><li>Anxiety and fear </li></ul><ul><li>Anticipatory grieving </li></ul><ul><li>Pain </li></ul>
  27. 27. Planning and Implementation <ul><li>Oxygen </li></ul><ul><li>Intravenous fluids </li></ul><ul><li>Maternal vital signs </li></ul><ul><li>Uterine contractions </li></ul><ul><li>Uterine/vaginal blood loss </li></ul><ul><li>Measure and record fundal height every 30 minutes </li></ul>
  28. 28. Planning and Implementation <ul><li>Insert gastric tube </li></ul><ul><li>Position on left side </li></ul><ul><li>Tilt backboard or displace uterus to the left </li></ul><ul><li>Administer medications to inhibit contractions </li></ul><ul><li>Obtain OB consult </li></ul><ul><li>Prepare for operative intervention, admission, or transfer </li></ul><ul><li>Provide psychosocial support </li></ul>
  29. 29. Evaluation and Ongoing Assessment <ul><li>Monitor maternal cardiovascular status for evidence of shock </li></ul><ul><li>Assess abdomen and uterine activity </li></ul><ul><li>Monitor fetal activity and heart rate </li></ul>
  30. 30. Summary

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