Triage of the pregnant female. Part 1.

Triage of the pregnant patient.

My partner Kelly (also an ED nurse and a Midwife) is presenting a talk tomorrow at our triage workshop. She has kindly consented to me posting a bulletpoint summary of her presentation for your midwifical edification.

Remember, this is just a summary (and any errors or non-sencicals are more likely to be from my transcription than Kelly’s presentation)…but her talks are always well received so I thought you might get some useful tidbits from reading over it.

I will split the presentation over 2 posts.
Part 1 covers the initial evaluation at Triage and the physiological changes that occur in pregnancy.
Part 2 will cover some of the common pregnancy related presentations that you may encounter at the Triage desk.

I hope this info will be as useful for you as it was for me.

Triage of the pregnant patient.

• A pregnant woman presenting to the emergency department raises unique challenges to the triage nurse,
  Be aware of normal physiological and anatomical adaptations of pregnancy because these will influence assessment.
• Triaging should consider the wellbeing of mother and foetus and potential threats to either.
• The pregnant woman may present with any disease.
• The presentation of some diseases is modified by pregnancy and some only occur in pregnancy.

AIRWAY:

• Any pregnant woman with a potentially compromised airway requires urgent medical attention.
• Difficult intubations due to patient size, pt positioning and different induction agents required due to cardiovascular requirements.

BREATHING:

• Progesterone thought to alter sensitivity of respiratory centre and increasing the drive to breath
• Increased nasal and airway vascularization and mucosal oedema. *Often complaints about nasal congestion
  1/3 of woman with asthma suffer deterioration of illness during pregnancy

CIRCULATION:

• Pregnancy described as Hyperdynamic state
• Physiological changes start at 6–8 wks
  Increased blood volume
  Increased cardiac output
  Widespread vasodilation
• 20wks +, wt of uterus compresses vena cava when lying on back ,reducing placental blood flow compromising foetal wellbeing & reducing maternal venous return ,CO and BP.
• Changes in blood vessels predispose to spontaneous arterial dissections ie, splenic, subclavian and aortic.

IMPORTANT CONSIDERATIONS:

• Palpitations during pregnancy due to hyperdynamic flow.
• Increased likelihood of cerebral haemorrhageb (sub arachnoid) due to hyperdynamic and high volume blood flow.
• Not uncommon for pregnant women to experience sudden and serious deterioration in condition therefore pregnant woman showing signs of haemodynamic de-compensation require urgent medical assessment
• greater than 20 wks gestation should have L lateral tilt.
• Pulmonary Embolism common due to changes in coagulation system. Risk increases towards end of pregnancy and after delivery.

TRAUMA:

• All usual trauma criteria considered
• Additional considerations include trauma to uterus ,placenta and foetus
• Maternal vital signs may remain stable even when blood loss of 1/3 blood volume has occurred

BEST INITIAL TREATMENT FOR FOETUS IS OPTIMUM RESUSCITATION OF MOTHER

ASSESSMENT:

ALL WOMAN OF CHILD BEARING AGE SHOULD BE CONSIDERED PREGNANT UNTIL PROVEN OTHERWISE (especially in abdo pain or PV bleeding.)

• Look at individual: alert and talking or grimacing, pale SOB etc.
• Presenting Symptom/Complaint
• Pain- position, intensity, character, duration
• Vaginal Loss- type/ colour
• Bleeding- colour (dark, bright, brown), consistency, volume. preceding factors
• Any clots or tissue?
• No of pads used and over what time?
• Gestation-viability. Gestation expressed as weeks/40.

• Observations- Temp ,Pulse, BP, O2 Sats
• Obstetric and Gynaecological Hx
• Gravity: No. times pt has been pregnant regardless of outcome.
• Parity: No. of deliveries of viable foetus
• Complications of previous pregnancies/delivery
  Blood group
• Affect of symptom or complaint on patient-debilitation ,pregnancy effects

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Physiological Changes in Pregnancy.

CERVIX:

• Increased vascularity and secretion
• OPERCULUM = mucous plug protecting against infection

VAGINA:

• Increased vascularity, muscle hypertrophy and changes in connective tissue.
• Acid environment protective against ascending infection
  Encourages Candida and Trichomonas
• Leucorrhoe = a normal white discharge

UTERUS:

• Increased wt 60gms to 1000gms
• Abdominal organ by 12wks
• Blood supply at term 500–700ml/min. Significant factor in haemorrhage being the leading cause of maternal death.
• Displaces bowel
• Risk of inferior vena cava compression of patient in supine position from second trimester. Decreased venous return. Decreases uterine blood flow.
  3rd trimester forms upper & lower segment. If the placenta embeds in lower segment

RESP SYSTEM:

• Increased pulmonary blood flow
• Hyperaemia and oedema of upper respiratory mucosa = nasal congestion, epistaxis, voice changes.
• Rib cage displaced upwards with flaring of lower rib cage to increase tidal volumes.
• Diaphragm elevated with enlarging uterus
• Increased O2 consumption by 20% at rest to meet increase in metabolic demands.

Maternal respiratory response:

• Tidal volume increased 30–40%
• Decreased airway resistance
• Increased sensitivity chemoreceptors to PaCO2
• Hyperventilation of pregnancy
• 40% Increase in ventilation 7L/min to 10L/min
• Increased PaO2 (102mmHg)
• Decreased PaCO2( 32mmHg)
• Mild alkalaemia (7.40–7.45) Decreased PaCO2 is accompanied by plasma fall in Bicarbonate (facilitates O2 release to foetus)
• Minimal change in resp rate (breathing deeper at rest).

HEART:

• Heart enlarges 12%. Chambers dilated
• Heart displaced upwards and left. Great vessels unfolded (ECG may show L axis deviation)
• ECG changes ,increased extrasystoles, increased risk SVT
• Increased cardiac output 30–50% by 20wk (from 5ltrs to 7litres /min). Cardiac output extremely sensitive to changes in position. Large variations in HR, BP may follow anxiety, activity and pts posture.
• Heart Rate increases 10–15 beats/min

BLOOD:

• Increased plasma volume 45 % by 32wks with only 25% increase in RBC – *Physiologic anaemia
• Decreased peripheral vascular resistance vasodilatation , allows for increased blood volume
• Reduced viscosity improves capillary flow
• Increased platelets & increased tendency to aggregate ñIncreases risk of thromboembolism. Increased clotting tendency is to protect the placental area from bleeding at birth.
• Coagulation times may decrease by 30% near end of pregnancy.

GIT:

• Gums soft and oedematous- bleed easily
• Stomach displaced upward after 20wks
• Intestine moves upward and laterally
• 50% report nausea & vomiting
• Increased risk of mechanical obstruction & constipation due to decreased motility and increased absorption
• Reflux common due to oesophageal sphincter relaxation and increased intra abdominal pressure by enlarging foetus

HEPATIC SYSTEM:

• Increased metabolic demands increase hepatic workload
• Usually no change in liver size
• Gallbladder dilated
• Increased viscosity and residual volume of bile in gallbladder- Gallstone formation
• Pruritis- reduced bile flow and retained bile salts

RENAL SYSTEM:

• Kidneys increase in wt and length
• Increased renal flow & increased filtration rate
• Dilatation of ureters and renal pelvis
• Decreased bladder tone
• Urinary stasis increases risk UTI in pregnancy
• Glycosuria-? Infection susceptibility
• Increased urea and creatinine clearance
• Aldosterone- reduces sodium and H20 loss

ENDOCRINE SYSTEM:

• Mild Hyperthyroid state: increased metabolic state to meet pregnancy demands.
• Adrenal glands: glucocorticoids stimulate release of glucose stores into plasma.
• Increased production of insulin but decreased sensitivity ( to allow greater availability or glucose to the foetus): may lead to pregnancy induced diabetes.

SKELETAL SYSTEM:

• Oestrogen: connective tissue becomes more pliable.
• Progesterone: relaxes or weakens pelvic ligaments.
• Posture: alters to compensate for enlarging uterus.
  Lordosis shifts the center of gravity. Also leads to lower back pains.

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In part 2 Kelly will cover some of the common pregnancy related presentations that you may encounter at the Triage desk.
Feedback, comments, corrections and additions, as always, welcomed.