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.
- 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.
- 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
- Pregnancy described as Hyperdynamic state
- Physiological changes start at 6–8 wks
Increased blood volume
Increased cardiac output
- 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.
- 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.
- 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
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
- Affect of symptom or complaint on patient-debilitation ,pregnancy effects
Physiological Changes in Pregnancy.
- Increased vascularity and secretion
- OPERCULUM = mucous plug protecting against infection
- Increased vascularity, muscle hypertrophy and changes in connective tissue.
- Acid environment protective against ascending infection
Encourages Candida and Trichomonas
- Leucorrhoe = a normal white discharge
- 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
- 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 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
- 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.
- 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
- 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
- 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
- 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.
- 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.
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.