There are many reasons we will encounter pregnant patients in the pre-hospital environment. While imminent delivery outside of the hospital is certainly one reason we may be called, there are other more common reasons we need to familiarize ourselves with obstetrical patients. We may be called for a trauma that involves a pregnant patient, or something as seemingly innocuous as fever, however, these patients need to be examined thoroughly with the fact that there are actually 2 patients involved in mind.
Regardless of MOI/NOI, we need to ask some specific questions to every pregnant patient. I like to use the mneumonic GP-DPAVU. This stands for:
Gravida, Para: Gravida refers to the number of times the patient has been pregnant, and Para refers to the number of live births the patient has had.
Due Date: The patient usually knows the expected due date, however some may have only recently discovered they are pregnant and may not yet know. A quick formula to use is Last menstrual period minus three months, plus seven days.
Problems: Has the patient had any issues during this pregnancy or any prior ones. This includes problems for mom and problems for the fetus. Ask about prenatal care, gestational diabetes, pre-eclampsia/eclampsia, abnormal bleeding, and infections.
Abdominal pain: Is the patient currently experiencing any abdominal pain of contractions.
Vaginal discharge: Has the patient had any bleeding or other discharge.
Uterine height: This can be measured during the physical exam. If the fundus (the top of the uterus) can be palpated at the umbilicus we can estimate approximately 20 weeks gestation. At the costal margin, the gestation is assumed to be 36 weeks or greater.
This history is specific to obstetrical patients, but is not limited to obstetrical complaints. It should be included in your assessment of every pregnant patient regardless of their primary problem. It provides important information to the ED and can aid in anticipating additional resources that may need to be called in.
Physical assessment of the obstetrical patient is similar to the standard assessment. We want a full set of vitals including BGL, and cardiac monitoring, as well as potential 12-lead ECG. Auscultate breath sounds early, especially if the patient is in any respiratory distress; however, be aware that due to physiological changes during pregnancy, the respiratory rate will be elevated and shallow. SPO2 should be monitored closely as well, as hypoxia in the mother means hypoxia for the fetus. Physical assessment includes palpation of the abdomen for fundal height, in addition to areas of tenderness, pain, and obvious trauma. Although we do not typically visualize the vaginal area, with the exception of delivery, we do want to ask about any bleeding or sensation of bleeding.
Vitals we really want to pay attention to are BP, HR, RR, SPO2, and skin colour and condition. Mild elevation in BP is expected as blood volume increases during pregnancy, so we may not catch signs of shock unless we watch for a downward trend.
I have already posted about OBS pathophysiology, but I will include common conditions encountered in pregnant patients below:
During pregnancy, several changes occur in the maternal body in order to accommodate fetal life.
Blood volume increases by 45%
Resting HR increases by 10-15 BPM
BP decreases by 10-15 mmHg due to increased abdominal pressure on the IVC.
Respirations increase but become more shallow as there is less room for the thoracic cage to expand during inspiration.
Ectopic(tubal) pregnancy: This occurs when the fertilized ovum implants anywhere outside of the uterine wall. The most common location is in one of the fallopian tubes. Symptoms usually occur early, often within the first 4-8 weeks of pregnancy. Presentation is usually that of sharp, tearing, pain in the lower abdomen; often localized to the affected side. This is why it is important to consider pregnancy a possibility in any female of child bearing age who presents with abdominal pain. Treatment involves maintaining ABCs and supportive care.
Miscarriage/Spontaneous Abortion: This is technically classified as any spontaneous delivery of the fetus before the 20th week of gestation. Surfactant does not develop in the lungs until after the 22nd week, and life is not sustainable outside of the womb prior to the 20th week. Signs and symptoms include cramping, a lot of bleeding, and passing of fetal materials. Treatment involves maintaining ABCs, monitoring vitals, and addressing the emotional needs of the patient.
Abruptio Placenta: This occurs during the 2nd or 3rd trimester, and occurs when there is a sudden partial, or complete, detachment of the placenta from the uterine wall. This presents with severe pain, bight red bleeding, and signs of shock. There may be a history of trauma as a possible causative mechanism. Treatment involves managing ABCs, addressing hypotension conservatively to maintain SBP of 90mmHg, and monitoring for decompensation.
Placenta Previa: Placenta previa occurs when there is a low lying placenta that either partially or completely occludes the cervical opening. This is usually found during routine ultrasound, and caesarian delivery is scheduled. In the prehospital environment we can encounter this if cervical dilation begins to occur, and it presents with painless, bright red, bleeding. Treatment is the same as for abruptio placenta.
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