Paramedics Assessment with Problems in Pregnancy and Complicated Childbirth - Research Paper Example

Paramedics Assessment with Problems in Pregnancy and Complicated Childbirth This is a case of a 26 year old woman who presents with uterine contractions with two previous cesarean sections due to obstructed labor which may be secondary to large fetus, fetal malpresentation, or cephalopelvic disproportion. Taking into consideration her obstetrical history, this patient must be transported to the hospital for cesarean delivery if she is in true labor. Meanwhile, it is important that maternal and fetal vital signs are closely monitored. The patient must be inquired about her prenatal check ups, acquired illnesses especially genitourinary infections, or pain experiences. By estimating her EDC or EDD through ultrasonography or manual calculations by measuring the fundic height or getting the LMP, a rough correlation with her uterine contractions can be deduced to know if the patient is undergoing false or true labor. Rupture of membranes or excretion of a mucus plug may indicate an active labor process. General health must also be assessed if the mother has had allergies, is smoker or alcoholic, or takes any drugs or medications (Complicated childbirth). In ancient times, the mode of delivery for subsequent pregnancies after a history of cesarean section (CS) will always be CS. Currently, there are now options to undergo a trial of labor after a cesarean birth but patients must be aided in their decision making with sufficient understanding about the risks and benefits of a vaginal delivery. With TOLAC, there is a risk of uterine rupture. The following characteristics, increases the success of vaginal delivery: previous vaginal delivery, history of VBAC, spontaneous labor, competent cervix, nonrecurring indications i.e. breech, previa, herpes, preterm delivery, an interpregnancy interval of more than 18 months. Similarly, the risks associated and factors that may contribute to failure of the process are morbid obesity, Hispanic and African American race, increasing birth weight, previous history of cephalopelvic disproportion, diabetes mellitus, failure to progress labor, no history of vaginal deliveries, or a previous cesarean section. In the clinical case given, her risks of undergoing a trial of labor may be high; therefore a cesarean delivery may be recommended (Caughey, n.d.). Condition Clinical presentation Problems/Risks/Complications Management Ectopic pregnancy Signs of pregnancy i.e. amenorrhea, positive pregnancy test Abdominal pain accompanied by shoulder pain as the embryo grows distending the involved structure and compressing adjacent organs If abdominal implantation, signs of shock i.e. hypotension If cervical or fallopian tube implantation, vaginal blood loss Problem: implantation of the embryo in structures other than the uterus Risk: previous ectopic pregnancy, history of tubal surgery, history of tubal infection, progestin-only contraception, intrauterine contraceptive devices Complication: rupture of structure with the growing fetus, hemorrhage causing hypovolemic shock Early diagnosis via β-hCG level determination Transport to a medical facility for possible surgical procedure Correct signs of shock Pain alleviation Pre-term labour Uterine contractions Small amount of cervical effacement or dilatation Problem: premature onset of labor before 38 weeks of gestation Risk: multi-gravid, intrauterine infections, premature rupture of the membranes, uterine or cervical anatomical anomalies, smoker, Complication: preterm birth, low birth weight neonate, fetal distress, infection Prehospital setting: supportive care, decrease level of stress, bed rest Hospital setting: IV salbutamol Pre-eclampsia Hypertension; BP >140/90 mmHg Edema Proteinuria Headaches Visual disturbances Pulmonary edema Hepatic dysfunction Oliguria Thrombocytopenia or haemolysis Problem: biochemical and physiological alteration resulting to widespread vasoconstriction, organ ischemia and edema Risk: obesity, diabetes mellitus, race Complication: progression to eclampsia; brain ischemia, seizure, heart failure, decreased oxygen, nutrient, and blood perfusion to fetal circulation Prehospital setting: monitor maternal vital signs, observe for hyperreflexia, minimize stress, bed rest With convulsion: BLS, IV infusion, Midazolam IM 0.1 mg/kg, hospital transport Hospital setting: IV β blockers, vasodilators (MgSO­4) Condition Clinical presentation Problems/Risks/Complications Management Abortion Confirmed or suspected pregnancy Mild to severe uterine contractions Abdominal pain Vaginal bleeding Passage of tissue Orthostatic vital signs (postural drop) Problem: termination of pregnancy before the age of viability at 20 weeks of gestation Risk: embryological abnormalities, infection, unfavorable intrauterine environment, cervical incompetence Complication: maternal sepsis Basic life support Administer high concentration of oxygen IV or IV’s with saline Do not pack vagina Save any tissue passed Hospital transport Ante-partum haemorrhage With cervical changes: light bleeding Placental abruption: mild to moderate bleeding, continuous knife-like abdominal pain, rigid tender uterus, signs of hypovolaemia, varying contraction patterns Placenta previa: painless, bright-red vaginal bleeding, soft non-tender uterus, no contractions, signs of hypovolaemia Problem: vaginal bleeding during the last trimester of pregnancy due to cervical physiological changes or abnormal presentation of placenta (placenta previa) and premature placental separation (placental abruption) Risk: Placenta previa: increasing age, multiparity, previous caesarean sections; Placental abruption: old maternal age, hypertension, multigravid, trauma Complication: hypovolemic shock Placenta previa: placental insufficiency, fetal hypoxia Determine severity of case Blood loss assessment Give high flow oxygen Infuse IV saline Left lateral recumbent position Transport to hospital Placental abruptions managed with aggressive IV fluid administration Multiple pregnancy presents with larger uterine size than the expected age of gestation, multiple fetal heartbeats and increased levels of maternal serum alpha-fetoprotein. Physiologic maternal perinatal manifestations include anemia, elevated cardiac stress, aspiration, supine hypotension, dyspnea, increased lumbar lordosis back edema, uterine atony and polyhydramnios (Capogna & Celleno, 1997). Multiple gestations predisposes mother to preterm delivery. Delivery of more than one baby poses threat to both the mother and child. Fetal complications include intrauterine growth restriction which occurs after 29 weeks in twins or 27 weeks in triplets, congenital anomalies, or cord entanglement, malpresentation, or birth asphyxia. Also, there is risk of twin-twin transfusion syndrome (TTTS) which is due to vascular anastomoses between circulations usually of monozygotic twins. Clinical manifestations of the donor are anemia, growth retardation and oligohydramnios while the recipient presents with hypervolemia, polycythemia, increased growth, polyhydramnios and cardiac hypertrophy. Hydrops fetalis may also develop. Demise of one fetus puts the survivor in danger for exsanguination, acute hypotension, embolization, limb amputation, intestinal atresia or gastroschisis (Multiple Births, 2004). Maternal complications include pregnancy induced hypertension, preterm labor and birth, anemia, or antepartum hemorrhage (Multiple pregnancy, 2011). The following antenatal and postpartal maternal complications are noted in patients with triplets: PROM, gestational diabetes mellitus, pre-eclampsia/eclampsia, or postpartum haemorrhage (Al-Suleiman et al., 2006). Management through bed rest and hydration, home monitoring of uterine contractions or cardiotopography, cervical cerclage or tocolytic agents were used but there are no well-established documents that would support their effectiveness. Mode of delivery usually depends on presentation of the first fetus. Vaginal delivery is indicated if first baby is vertex in position, no factors leading to fetal distress or there is minimal duration of second stage for the second twin (Capogna & Celleno, 1997). If the first baby is breech gently lift the body and move downward to deliver the anterior shoulder then pull simultaneously with the next contraction. In case of cord prolapse, cord is covered with warm saline soaked packs. Administer oxygen to the mother and put her in exaggerated Sim’s position to elevate the cord. It may be pushed back with during contraction. With complications of postpartal hemorrhage, an efficient management is to leave the cord uncut and allow spontaneous placental delivery. Allow baby to breastfed to induce release of oxytocin or massage uterus to aid uterine contraction. With excessive bleeding, cord is clamped and cut and applied with cord traction. Otherwise, referral to specialized hospital is necessary for monochorionic monoamniotic twin or triplet pregnancies, monochorionic/ dichorionic diamniotic triplet pregnancies, fetal anomaly or death, or TTTS (Multiple pregnancy, 2011). Reference Al-Suleiman, J., et al. 2006. Obstetric complications and perinatal outcome in triplet pregnancies. Journal of Obstetrics and Gynaecology; 26(3): 200 – 204 Barrett, J., et al. 2000. Management of Twin Pregnancies (Part 1). Journal SOGC Capogna, G. & Celleno, D. 1997. Management of Multiple Pregnancy and Breech Delivery. Obstétrique. Caughey, A. n.d. Vaginal Birth After Cesarean Delivery. Available at http://emedicine.medscape.com Accessed on April 13, 2011. Complicated Child Birth: Pregnancy, Child Birth and the Neonate. Module 3-4. PARA3002 Clinical Decision Making Goldenberg, L. 2002. The Management of Preterm Labor. Vol. 100, NO. 5, PART 1. Elsevier Science Inc. NICE guideline draft 2011, Multiple pregnancy: The management of twin and triplet pregnancies in the antenatal period. Pregnancy: Pregnancy, Child Birth and the Neonate. Module 3-1. PARA3002 Clinical Decision Making Problems in Pregnancy: Pregnancy, Child Birth and the Neonate. Module 3-2. PARA3002 Clinical Decision Making The Regents of the University of California. 2004. Multiple Births. Intensive Care Nursery House Staff Manual. Read More