Here is the second part of my notes from Kelly’s talk on managing the pregnant female at triage.
Part 1 covered the physiological changes in pregnancy and some tips during the initial evaluation at Triage.
Part 2 covers some of the common pregnancy related presentations that you may encounter at the Triage desk.
As I said in part 1, any errors or omissions are probably due to my poor transcription than from Kelly’s presentation. Corrections/additions welcomed.
OK, lets get midwifical:
Presentations less than 20 weeks.
- Light vaginal spotting. May occur at time of expected period and so may be mistaken for this.
BLEEDING FROM CERVIX
- bright bleeding or spotting
- Resolves spontaneously
- Pregnancy outside uterine cavity.
- ALWAYS Exclude in child bearing age or Hx of sterilization
- Occurs > 6wks. Ectopic pain develops when conceptus grows beyond capacity of tube.
- “Classic” Amenorrhoea, lower abdo pain, vaginal bleeding.
- “Acute” Sudden onset, generalised pain, +/- shoulder tip pain.
- “Sub acute” light period, followed by irreg vaginal bleeding. Also may be reported as abdominal pain & diarrhoea. May not be diagnosed as ectopic.
- High Risk for Haemorrhage, Potentially * Life Threatening
- P V bleeding late sign. There may be signs of shock before this.
- Spontaneous < 12 wk
- Brownish Red = older
- Bright red-active bleeding
- Severe period pain
- Cervical shock- products trapped in cervix cause vagal response and hypotension
- Abnormal Vital Signs and Severe pain warrants urgent medical attention
- Expulsion of products < 20 weeks doesnt usually lead to hypovolaemia as placenta not normally well formed.
- Rh-ve mother should be given Anti-D within 72hrs of foetal maternal blood mixing- (eg miscarriage ,placental abruption) to prevent Rhesus Isoimmunisation.
VOMITING IN PREGNANCY
- “Morning sickness” is not confined to the morning.
- Nausia +/- vomiting common in 1st trimester in 85% women.
- Usually resolves in 12 to 14 weeks.
- Excessive nausea and vomiting requiring treatment
- Commences 4–10wks lasting until 20wks
wt loss up to 10%
- Signs of severe dehydration include
Dryness and reduced skin elasticity.
Dry furry tongue.
- Etiology unknown
- Exclude non pregnancy causes
- Severe- jaundice occurs
Wernicke’s encephalopathy: lack vit B1
Hepatic and renal involvement lead to coma and death
- Termination may be considered to reduce maternal morbidity
Presentations greater than 20 weeks.
- Vaginal bleeding >24 weeks and prior to labour.
- Greater than 15mls blood.
- Immediate threat to mother and foetus.
- Premature separation of abnormally placed placenta. Lower segment implantation near or covering OS. Poorly anchored in uterine muscle….shearing and placental seperation as uterus enlarges or cervix dilates.
- Low lying placenta
- Painless vaginal bleeding
- Bleeding compromises mother and baby
- No Vaginal exam
- Urgent caesarian mother and foetus at risk
- Premature separation of normally placed placenta after 22nd week not asociated with delivery.
Occurs in varying degrees. Partial or complete.
- Abdominal pain +/- visable blood loss.
- Blood loss not a reliable indicator of extent of abruption.
- Predominent symptom: abdominal pain.
Drug use eg cocaine
Hypertension and Fitting
Trauma to uterus
Potential maternal shock
+/- Urgent delivery
HYPERTENSION IN PREGNANCY
- SYSTOLIC BP >/= 140mmHg
- DIASTOLIC >/= 90mmHg
- RISK GROUPS:
Hypertension >120/80 – alert triage of potentially more serious problem .
- Hypertension after 20th week with multisystem organ involvement
- Significant Risk to mother and foetus
RISK OF FITTING, PLACENTAL ABRUPTION AND PLACENTAL UNSUFFICIENCY
PREMATURE RUPTURE OF MEMBRANES
- Occurs < 37 weeks, without onset uterine activity
- Amniotic fluid ñclear straw coloured, distinct odour
- RISK OF
SIGNS OF LABOUR
- ‘Show’: bloody mucous plug
rhythmic and regular
increasing strength and regularity
- +/- Ruptured membranes
Delivery imminent if compulsive urge to push or presenting part on view
- Second stage from full dilation to delivery can last 5–10 minutes up to 2 hours.
- If in labour or ruptured membranes NO NOT transfer (eg to labour ward) on wheelchair or without escort.
- If labour is imminent DO NOT TRANSFER. We are going to have a baby people.