Field Care of the Mother Following the Delivery of the Newborn CCP

Field Care of the Mother Following
the Delivery of the Newborn
James A Temple NRP,
CCP
2016 National Paramedic
Refresher
Objectives
• Understand the basic understanding of
pregnancy-related physiology
• Identify signs/symptoms and proper care for
gynecological emergencies postpartum
• Identify and describe complications
associated with pregnancy and delivery
• Describe the delivery of the placenta and
fundal massage
• Describe post delivery care of the mother to
include fluid shifts, hyper/hypotention, shock,
hemorrhage and pain control
Baby has been delivered …….
• Now you have two patients
• Delivery is not considered complete until
delivery of the placenta
• Call for ALS care
• Transport to appropriate facility
• Continuous monitoring
• A, B, C, D, E, F
Get a Good History …..
• Gravida, Para, any miscarriages, multiple
births, molar pregnancies
• Know the gestation of the baby
• History of prior deliveries – C-sections,
vaginal birth, prolonged of labor, rapid
labor, hemorrhage
• Complications – placenta previa, placental
abruption, lacerations of the cervix,
coagulation defects
Hypertension
• HTN
– can be chronic (meaning it began prior to
conception or began during gestation and persists
>6 weeks post-partum) or gestational
– We care about this because HTN in pregnancy is
associated with pre-eclampsia, abruption,
prematurity, and stillbirth
….. more history
• Other medical history – DM, GDM,
hypothyroidism, asthma, cardiac history …..
• Have they had prior OB care – was this a
SURPRISE delivery
• Medication list
• Has there been any substance use
Some Important Physiological Changes in
Pregnancy
• Cardiac: increased heart rate, decreased
blood pressure. CO increases
• Respiratory: rate increases, TV increases,
FRV decreases, pCO2 decreases
• Hemodynamics: Volume increases, HCT
drops, WBC increases
PHYSIOLOGIC CHANGES OF
PREGNANCY
• Changes related to gestational age
• Major shift of circulatory system to provide blood
flow to uterus
• Mother at more risk
– Increased risk of injury
– Less able to compensate for shock
CARDIOPULMONARY CHANGES
•
•
•
•
•
Increased cardiac output by 20-30%
Pulse increases by 10-15 beats/minute
BP decreases by 10-15mmHg
Increased resting respiratory rate
Elevation of diaphragm by uterus decreases
thoracic volume
SYSTEMIC BLOOD VOLUME
•
•
•
•
Increased plasma volume
Increased red cell volume
Blood volume increases 45-50%
“Anemia of Pregnancy”
– Rise in plasma volume is greater than the rise in red
cell volume
– Results in a “relative” anemia
Cardiovascular changes
 Inferior vena cava syndrome:
In the supine position, the inferior vena cava is
compressed by the enlarged uterus, resulting in
decreased cardiac output. Some women may have
symptoms that include dizziness, light-headedness, and
syncope.
Cardiovascular changes
•
•
•
•
•
•
•
•
Stroke volume
+30%
Heart rate
+15%
Cardiac output
+40%
Oxygen consumption
+20%
SVR (systemic vascular resistance) -5%
Systolic BP
-10mmHg
Diastolic BP
-15mmHg
Mean BP
-15mmHg
Hematologic system
• Clotting factors: hypercoagulable,
throboembolism
Fibrinogen (factor I)
Factor VIII
+50% (4.5 vs 3 g/L)
increase
Factors VII, IX, X and XII
increase
Prothrombin time, PT
shortened
ATPP activated partial thromoplastin time
Fibrinolytic activity
shortened
decrease
Respiratory Changes
• Increased 02 Consumption
• Elevated diaphragm
• 30-40% increase in tidal volume and minute
ventilation
• PaC02 = 30-35 mm Hg
• Intubation may be challenging b/o airway
edema
• Relaxed LES + Delayed Gastric Emptying =
Increased Risk of Aspiration
ABDOMEN
• Delayed gastric emptying
– Increased risk of vomiting and aspiration
• Uterus becomes the largest abdominal organ
– More likely to be injured from either blunt or
penetrating trauma
CHANGES IN THE UTERUS
• Uterine blood flow increases
– Nonpregnant = 2% cardiac output
– Pregnant = 20% cardiac output, 10 – 20 % increase in
oxygen demand
• Uterine vessels constrict in response to
catecholamine release in early shock
– 20-30% decrease in uterine blood flow
– Risk fetal hypoxia and death
Postpartum Related Physiology
•
•
•
•
•
Bleeding – vaginal, laceration or episiotomy
Blood Pressure - high or low
Urine output/bladder control
Bowel control
Retention of fluid/swelling
OB Postpartum Emergencies
•
•
•
•
•
Postpartum Hemorrhage
Preeclampsia
HELLP syndrome
Placenta previa
Placenta abruptio
Postpartum Hemorrhage
• Postpartum hemorrhage (PPH) is the leading
cause of maternal mortality
• Average blood loss during vaginal birth is 500
ml and 1000 ml in a C-section
• Most common cause is failure of the uterus to
contract and retract following delivery of the
baby
• Other causes, lacerations, episiotomy,
clotting factors, obesity, trauma
Preeclampsia vs. Eclampsia
• is a medical condition characterized by high
blood pressure and significant amounts of
protein in the urine in a pregnant woman
• if the mother has seizures is considered to
have eclampsia
• Mild - SBP > 140 (or +20 from baseline. Or
DBP >90 (or +10 from baseline), Proteinuria
.3g/24h, +/- Edema, no oliguria, no
associated symptoms, normal labs, no IUGR
• Severe - BP>160/90, proteinuria >5g/24h,
edema, decreased urine output, H/A, visual
symptoms, abdominal pain, dyspnea,
associated labs (dec. plts, inc. LFT, inc. bili,
inc. creatinine, increased uric acid), IUGR
present, HELLP syndrome = very severe,
+RUQ pain, n/v
Postpartum Preeclampsia
• Preeclampsia occurs primarily during
pregnancy, postpartum preeclampsia can
occur for up to six weeks after giving birth
• Postpartum preeclampsia can be caused by
preeclampsia during pregnancy that is not
resolved with the delivery of the baby or can
occur seemingly out of nowhere following
delivery
• Postpartum preeclampsia has several
symptoms, including the new mother having
blood pressure higher than 140/90 and
excess protein in her urine. She may also
experience issues with her vision,
migraines, nausea, dizziness, sudden
weight gain or severe abdominal pain
• These symptoms can be typical in new
mothers, which makes diagnosis of this
condition difficult
• Causes of postpartum preeclampsia is believed to
be caused by insufficient blood flow to the uterus,
issues with the immune system, damage to blood
vessels during delivery and/or a poor diet
HELLP Syndrome ….
• Life-threatening obstetric complication usually
considered to be a variant or complication of
preeclampsia
• Both conditions usually occur during the later
stages of pregnancy, or sometimes after
childbirth
• "HELLP" is an abbreviation of the three main
features of the syndrome:
– Hemolysis
– Elevated liver enzymes
– Low Platelet count
…. HELLP
• S/S - gradual but marked onset of
headaches, blurred vision, and tingling in the
extremities, edema may occur but its absence
does not exclude HELLP syndrome, arterial
HTN is a diagnostic requirement, but may be
mild, rupture of the liver capsule may occur
• If the patient has a seizure the condition has
progressed into full-blown eclampsia
• Treatment – fluid, blood, mag sulfate, FFP
and corticosteroid therapy
Placenta Previa ….
• During a normal pregnancy, the placenta is
attached higher up in the uterus, away from the
cervix
• But in rare cases, the placenta forms low in the
uterus
• If this happens, it may cover all or part of the
cervix and when the placenta blocks the cervix, it
is called placenta previa
• During pregnancy, the placenta moves as the
womb stretches and grows
• Low in early pregnancy and placenta moves to
the top of the womb by the third trimester so the
cervix can open for delivery
…. Placental Previa
• Mothers may know they have it
• May cause hemorrhage
• May lead to Placenta Abrubtio
Placenta
Abrubtio
• Placenta breaks away, or abrupts, from the
wall of the uterus too early, before the baby is
born
• Will cause severe pain and bleeding
• May continue to cause severe pain, bleeding
and retained placenta
• Pt may be in shock, have difficulty breathing,
hemorrhage and become confused and weak
Delivery of the Placenta
•
•
•
•
•
Stage 3 of Labor
Watch for delivery of placenta
Could be immediately , 20 minutes or more
Fundal massage
Very important to keep placenta and take to
hospital
What do we need to do?
• Treat for shock – mom can loose of to 35% of
her blood volume before showing any signs
of shock
• Oxygen
• IV therapy
• Fundal massage
• Bleeding control
• Pain management
Post Delivery Care
•
•
•
•
•
Fluid Shifts
Hyper/hypotention
Shock
Hemorrhage
Pain Control
What can happen day after birth?
• SOB
• PE
• Continual vaginal
bleeding
• HTN
• Depression
• Retained part of
conception
Emotional Support
• Miscarriage
• Resuscitation of newborn
• Trauma
Odds and Ends
•
•
•
•
Retention of dead fetus
Postpartum depression
Abdominal pain - Ectopic pregnancies
Trauma – if babe has not delivered
resuscitate mom
Spanish lesson:
Seat Belts
• Nearly 20% of pregnant woman surveyed
never or rarely used seat belts
• 22% used them incorrectly
• Proper placement of the lap belt is:
– As low as possible on the pregnancy bulge across
the ASIS and pubic symphysis
– Placement on the uterus causes a 3-4x increase
in force transmitted to the uterus
– Shoulder harness should be positioned between
the breasts
Pearlman MD, Phillips ME. Safety belt use during pregnancy. Obstet Gynecol 1996;88:1026-9
Results
• Falls were the most common mechanism
• MVC 2nd most common
• MVC most common mechanism that lead to
admission
• Assault third most common mechanism and
cause of admission
THE PREGNANT TRAUMA PATIENT
• Two patients with separate
needs
– Mother
– Fetus
• Twin goals of management
– Support mother
– Identify needs of the fetus
CAUSES OF TRAUMATIC FETAL
DEATH
• #1 - Maternal death
• #2 - Maternal shock
• #3 - Abruptio placenta
MVCs result in 50% of prenatal mortality
Results
• Gestational age was the strongest predictor
of fetal, neonatal and infant death
• What and how severe the trauma was not as
strong a predictor as gestational age
• Highest risk at <28 weeks gestation
Fetal Demise
• Rate of fetal demise after blunt trauma 3.438%
• Lead causes
– Placental abruption
– Maternal shock
– Maternal death
• 1,300-3,900 pregnancies are lost due to
trauma each year
• Abruption occurs in 40-50% of pregnant
woman in severe trauma compared to 1-5% in
minor trauma
Placental Abruption
• Uterus consists of many elastic fibers
• The placenta has very few elastic fibers
• This causes an inelastic connection
Uterine Rupture
• 0.6% of all injuries during pregnancy
• Various degrees ranging from seosal
hemorrhage to complete avulsion
• 75% of cases involve the fundus
• Fetal mortality approaches 100%
• Maternal mortality 10%
– Usually due to other injuries
Weintraub AY, Leron E, Mazor M. The Pathophysiology of Trauma in Pregnancy: A Review. J Mat-Fet and
Neo Med 2006;19(10):601-5.
• Pregnant woman can lose 30% (2L) of blood volume
before vital signs change
• At 30 wks GA the uterus is large enough to compress
the great vessels causing
– up to a 30mm Hg drop in systolic BP
– 30% drop in stroke volume
• A series of 441 pregnant trauma victims with no
detectable fetal heart tones showed no fetal
survivors.
•Grossman NB. Blunt trauma in pregnancy. Am Fam Physician. 2004 Oct 1;70(7):1303-10.
•Morris JA Jr, et al. Infant Survival after Cesarean Section for Trauma. Ann Surg 1996;223:481-91.
Connect the Dots!
DO NOT CONFUSE NORMAL
VITAL SIGNS IN PREGNANCY
FOR SIGNS OF SHOCK
• Pulse is 10-15 beats/min faster
• BP is 10-15mmHg lower
SHOCK IN PREGNANCY
• Can lose 30% of blood volume before having
significant change in BP
• Can have significant occult intrauterine or
abdominal bleeding
– Uterus is very vascular
– May not have abdominal tenderness early even with
significant bleeding
MANAGEMENT
• 100% oxygen
– Very important
– You are treating the fetus also
• Transport with full spinal packaging
– Tilt backboard to the left
• Treat specific injuries
– Control external bleeding
MANAGEMENT OF SHOCK
• IV access
– Two large bore IVs of NS or RL
• May require larger volume of fluids for
resuscitation
– Blood should be given early
• If PASG is indicated, inflate leg compartments
only
Pregnancy Trauma Management
• Prepare for complications of
pregnancy
–Premature labor & delivery
–Hemorrhage complications
• abruptio placenta
• uterine rupture
MATERNAL CARDIAC ARREST
• Manage same as
the nonpregnant
patient
• Perform CPR
• Notify hospital to be
prepared for
possible emergency
c-section
Perimortem Cesarean Section
• ~200 successful cases reported in the
literature
• Maternal CPR <5 minutes, fetal survival
excellent
• <23 weeks gestation survival chance is 0%
• Maternal CPR >20 minutes, fetal survival
unlikely
Fetal Viability
6-month
survival
(%)
0
Survival with
no severe
abnormalities
(%)
0
23
15
2
24
56
21
25
79
69
Weeks
gestation
22
Data from Morris JA Jr et al: Ann Surg 223:481, 1996.
Perimortem Cesarean Section
• 4 Minute Rule:
Maternal CPR
for 4 minutes,
Infant should
be delivered by
the 5th minute.
Remember
What is Best for
the Mother is
Best for the
Fetus!
No Pollo, No Huevo!
Case #1
You were call for a women in labor. When you
arrived on scene you found a 29 y/o female,
G2, P1 who had just delivered her baby. The
dad who is a military medics had already cut
the cord and has the baby wrapped in a
blanket. Patient is AOx3, color is pale – what
would you do next?
Case #2
16 year old female calls 911 from her
boyfriends home stating she has “abdominal
pain”. When you arrive on scene you find the
patient in the living room sitting on the couch
very uncomfortable, AOx3, pale and her
boyfriend states, “she just came over this about
30 minutes ago stating her stomach hurt”.
What is your assessment?
Case #3
You and your partner had delivered a baby in
the back of the rig and everything was going
well and all of a sudden mom who was holding
baby on her chest stops talking. You were
doing a fundal massage and noticed a large
amount of bright red blood coming from her
vaginal area. What do you do next?
Protocols
• Know your protocols
• Know when to call for paramedic
services/tiers
• Know where you are going to stabilize
patient(s)
Questions ???
Placental Abruption
• Uterus consists of many elastic fibers
• The placenta has very few elastic fibers
• This causes an inelastic connection
Uterine Rupture
• 0.6% of all injuries during pregnancy
• Various degrees ranging from seosal
hemorrhage to complete avulsion
• 75% of cases involve the fundus
• Fetal mortality approaches 100%
• Maternal mortality 10%
– Usually due to other injuries
Weintraub AY, Leron E, Mazor M. The Pathophysiology of Trauma in Pregnancy: A Review. J Mat-Fet and
Neo Med 2006;19(10):601-5.
• Pregnant woman can lose 30% (2L) of blood volume
before vital signs change
• At 30 wks GA the uterus is large enough to compress
the great vessels causing
– up to a 30mm Hg drop in systolic BP
– 30% drop in stroke volume
• A series of 441 pregnant trauma victims with no
detectable fetal heart tones showed no fetal
survivors.
•Grossman NB. Blunt trauma in pregnancy. Am Fam Physician. 2004 Oct 1;70(7):1303-10.
•Morris JA Jr, et al. Infant Survival after Cesarean Section for Trauma. Ann Surg 1996;223:481-91.