Which side should a pregnant mother be turned to avoid supine hypotension?
|
The midwife should wash her hands with soap and warm water. Cold hands may irritate the uterus causing it to contract making palpation difficult. The woman should be lying in a semi recumbent position with hands and arms relaxed by her side. Her abdomen should be exposed to reveal an area from the xiphisternum to the pubic area, whilst maintaining dignity. Show
Women in advanced pregnancy are subject to supine hypotension due to compression of the inferior vena cava by the fetus and growing uterus. Care should be taken to ensure if women feel faint that they are turned into a left lateral position. Palpation should be systematic commencing with fundal height and proceeding to fundal, lateral and pelvic palpation. To assess the height of the fundus (upper border of the uterus) the midwife should place her hand at the xiphisternum and move it downwards over the abdomen until the curved border of the fundus is found. To measure the symphysis fundal distance the midwife should place a tape measure at the highest point of the fundus and measure downwards to the upper border of the symphysis pubis (not the pubic hair line). The tape measure should be turned so that the inches side is visible to prevent subjectivity and making the tape measure fit the known weeks of gestation. Once the distance has been measured the tape measure should then be flipped over to reveal the measurement in centimetres. The uterus should measure 1cm per week of gestation between 24 and 37 weeks gestation. A uterus measuring 2cm less than confirmed weeks of gestation is said to be small for gestational age, A uterus measuring more than 2cm for the confirmed weeks of gestation is said to be large for gestational age. In both cases further assessment via USS will be necessary. Growth should be plotted on a symphysis-fundal height chart. Your browser does not support video playback
Can you think of other factors which may affect the fundal height?
By pressing the Delete button below you can remove your stored responses. By pressing the Reset Data button below you can restart this activity. Importantly all stored responses will be deleted. As in any trauma patient, the ABCs of trauma resuscitation must be followed in treating the pregnant patient. The mother should always receive supplemental oxygen. Several additional issues must be considered in treating the trauma patient who is pregnant. Note the following:
 Next: Emergency Department CarePatients who have minor trauma and who are at less than 20 weeks' gestation do not require specific intervention or monitoring. All pregnant women beyond 20-24 weeks' gestation who have direct or indirect abdominal trauma should undergo at least 4 hours of cardiotocographic monitoring. Resuscitation of the more serious trauma patient must focus on the mother because the most common cause of fetal death is maternal shock or death. It is important to remember that the mother will maintain her vital signs at the expense of the fetus. Because plasma volume is increased 50% and the mother is able to shunt blood away from the uterus, maternal shock may not manifest itself until maternal blood loss exceeds 30%. During the initial ABC assessment, the fetus is addressed only during evaluation of circulation. If the patient is more than 20-24 weeks' pregnant, the patient should be tilted 15° to the left. Alternatively, one person may be designated to manually displace the uterus to the left. If the patient does not require spinal immobilization, then she can be asked to assume the left lateral decubitus position. A study conducted at a level I trauma center found that implementation of a perinatal emergency response team reduced the mean time to obstetrical evaluation by 30 minutes. [10] Airway and breathingAll pregnant trauma patients should receive supplemental oxygen because the fetus is extremely sensitive to hypoxia and because the oxygen reserve is significantly diminished in the pregnant patient. In general, pregnancy does not affect the decision to intubate, although the risk of aspiration is increased (decreased gastric tone, delayed gastric emptying, and cephalad displacement of intra-abdominal organs). The use of medications for rapid sequence intubation in pregnancy is not well studied; however, no absolute contraindications exist. If a chest tube is placed, enter the chest 1 or 2 interspaces higher than usual, because the diaphragm is elevated during pregnancy. CirculationIt is extremely important to maintain adequate maternal blood volume as a first step in fetal resuscitation. A decrease in maternal blood pressure may result in a decrease in uterine blood flow, even without uterine artery vasoconstriction. Resuscitate the patient with warmed crystalloid administered through large-bore catheters placed for intravenous lines because the relative hypervolemia of pregnancy allows for a 30-35% loss of blood volume before hypotension develops. Rule out occult sources of bleeding because maternal blood flow is maintained at the expense of fetal blood flow. If blood is needed on an emergency basis, use Rh-negative blood unless the patient's Rh status is known. Blood pressure returns to prepregnancy levels as the gestational age approaches 40 weeks. Fetal assessment should be performed early as part of the maternal secondary survey. Admission and discharge criteria for pregnant trauma patientsHospitalization is warranted in pregnant trauma patients with the following:
All serious trauma victims who are beyond 23 weeks EGA require 24 hours of fetal monitoring. Discharge criteria include no abnormal obstetric findings and normal fetal heart tracings. Instruct the patient to return in the event of decreased fetal activity, vaginal bleeding, uterine contractions and/or cramping, or spontaneous premature rupture of the membranes. TransferTransfer the patient to a level I trauma center with obstetric and neonatal intensive care units (NICUs). ConsultationsThe pregnant patient with serious traumatic injury requires a multidisciplinary team, which includes an obstetrician, trauma surgeon, and neonatologist. Previous Medication
References
|
