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Trauma & Pregnancy
 

Trauma & Pregnancy

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LTC Brenda Sowards, Chief Nurse,

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

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    Trauma & Pregnancy Trauma & Pregnancy Presentation Transcript

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