As previously discussed, pregnancy alone can be hard on the mother’s body. Birth can come with its own set of problems, as well. After giving birth, the mother is still not fully in the clear. Problems associated with having given birth can present anywhere from hours to weeks after birth. As the uterus returns to its normal position in the pelvis and hormone levels return to prepregnancy levels, several problems can arise for the new mother after giving birth.
A PE is by far one of the most serious complications of childbirth and is the most common cause of maternal cardiac arrest during the perinatal time frame. Air, thrombus, amniotic fluid, or water (after a water birth) may enter maternal circulation and lodge in the lungs. This will result in the sudden onset of chest pain and shortness of breath, tachycardia, and all the other PE symptoms described in chapter 3. Be prepared to aggressively manage this patient’s airway and provide 100% O2.
Uterine inversions occur for unknown reasons and are therefore unpredictable, although they are believed to happen most frequently when there is strong traction (pulling tension) on the umbilical cord with a placenta that is attached to the uterine fundus (superior portion). It is fortunately relatively rare and is lethal in about 15% of patients who experience it. Uterine inversions are classified by the degree of inversion.
Treatment for uterine inversion is supportive care and includes the provision of 100% O2 and at least 1 intravenous line with fluid delivery titrated to maintain blood pressure; fluid boluses may be required to maintain the pressure, especially in the presence of a postpartum hemorrhage (PPH). Oxytocin should be stopped and withheld once inversion is recognized. Magnesium sulfate or terbutaline can be administered on order from the medical control physician if needed.
PPH is defined as any bleeding in excess of 500 mL during the first 24 hours after vaginal delivery or 1,000 mL after cesarean section. Early PPH occurs within the first 24 hours. Late PPH occurs within the first 6 weeks after delivery. Causes for PPH include the following:
Treatment in the field is rather limited. But take the following steps to treatment while rapidly transporting the patient to the hospital.
This section will focus on both considerations in traumatic events that are unique to the pregnant patient because of both changes in mother’s physiology and the fundus itself. Motor vehicle accidents and domestic violence are the primary causes of trauma in the pregnant patient. The focus then will be on the trauma with which the paramedic should be concerned during each trimester.
During the 1st trimester, the uterine fundus is still well within the pelvic girdle and therefore protected. The abdominal contents have not yet begun to shift, and circulation of the patient has not materially changed. Injuries and sequelae from abdominal trauma are largely unchanged from that of the nonpregnant patient.
During the 2nd trimester, rapid growth of the fundus occurs, often leading to balance issues for the pregnant female and increased falls. The uterus itself is protected early on, but during the course of the trimester, abdominal organs are pushed upward and backward while the abdomen protrudes. The urinary bladder is now more superior and anterior, meaning that it is more susceptible to rupture in blunt or penetrating trauma. The mother’s circulating volume has increased by nearly 50% by the end of the trimester. Consequently, it may take more bleeding to show typical signs of shock, and the mother’s body will sacrifice the baby to save itself during times of severe hemorrhage. Blunt trauma and deceleration injuries increase the chances of abruptio placenta and spontaneous initiation of delivery. All these concerns continue through the 3rd trimester as well.
The fetus through all this is rather well protected. It has the amnion to cushion it and slow its overall movements during rapid decelerations, such as what may happen during falls or motor vehicle accidents. Beyond that, layers of muscle, fat, and other connective tissue provide an added barrier. During penetrating trauma, such as gunshots and stabbings, the mother may actually fare a bit better because of the presence of the fetus. In such attacks, the fetus often bears the brunt of the injuries. During assessment, ask the mother if she has noted any fetal movement since the traumatic event. Ask her if there is any possibility of having ruptured her water or if there is any vaginal bleeding.
Treatment of the fetus is accomplished with excellent treatment of the mother. In trauma patients where the abdomen could have been involved, supplemental O2 is always recommended. O2 is a first-line treatment in all cases of potential fetal distress, abruptio placenta, maternal hypovolemia, or hemorrhage. If the patient’s condition requires a backboard, tilt the backboard to the patient’s left to minimize the chances of supine hypotension syndrome. The pregnant trauma patient can benefit from intravenous fluids, even if hemorrhage is not directly observed. If ventilations are required, breathing slightly faster and closely monitoring EtCO2 is recommended because of the pregnant patient’s normally increased respiratory rate and volume.