Maternal and Fetal assessment
![Picture](/uploads/1/5/4/1/15416176/5271931.jpg?1395090395)
The assessment of the pregnant patient should proceed in an orderly, systematic and timely fashion and should be nearly identical to that of a non-pregnant patient with a few exceptions. Those exceptions are:
1. The pregnancy must be immediately recognized. This is especially important in patients who may be unable to communicate due to head injury, intoxication, severe respiratory distress or profound shock. A urine pregnancy test should be done on 100% of women of childbearing age. When the pregnancy is clinically obvious, assessment of the fetus is done with the secondary survey.
2. Normal changes in physiology due to the pregnancy must be interpreted in the context of the injury
3. The patient's ability to tolerate and respond to specific injuries must be understood.
4. The trauma team must not be distracted by an obviously gravid uterus during the initial assessment and attempts to stabilize the patient.
Primary Survey
Prior to examination, all clothing must be removed to allow adequate visualization and assessment of injuries. Obvious hemorrhage should be controlled with direct pressure. A rapid neurologic assessment is included which determines orientation and responsiveness, pupillary reaction, motor response and the Glasgow Coma Scale (GCS). Concurrent to all of this, moderate to severely injured patients should have intravenous access established with two large bore IV's.
1. Airway- the highest priority is to establish that the patient has a patent and adequate airway. This can be accomplished in many cases by talking to the patient. A patient who can speak in complete sentences with a normal voice and appropriate responses has a patent airway as well as adequate oxygenation and brain perfusion. If there is evidence of airway compromise, endotracheal intubation should be immediately performed. Rapid sequence intubation (RSI) is the preferred method for intubation.
2. Breathing- Due to the previously discussed physiologic changes in pregnancy, significant trauma in the second or third trimester is associated with a potentially compromised respiratory status. The goal of the physical examination is to identify clinical findings suggestive of chest injury, such as tachypnea, respiratory distress, external chest trauma, and clinical signs of rib fractures, flail segments, pneumothorax or hemothorax. The chest should be examined for expansion, breath sounds, crepitus, subcutaneous emphysema and open wounds. Injuries that may acutely impair ventilation in pregnant women are more difficult to diagnose. Owing to limited thorax excursion, conditions like flail chest or pneumothorax are more difficult to detect in pregnancy because of diminished respiratory reserves with reduced expiratory volumes and functional residual capacity.
3. Circulation- In the first trimester, assessment of circulation is unchanged. In the second and third trimesters, the normal increases in blood volume can mask the typical responses to hemorrhage such as hypotension and tachycardia. Pulse rate and blood pressure may not change until the patient has experienced a 30-35% loss in blood volume. A gravid patient with tachycardia and hypotension will need aggressive resuscitation with fluids and blood products.
Secondary Survey
The secondary survey should be done in the same order and with the same cadence as any other trauma patient. The physical examination should be done once there is response to resuscitative efforts and the condition is stabilized. Particular attention should be given to sites of bleeding, limb injury and entrance/exit wounds. Information should be obtained about the mechanism of the injuries, weapons used, the use of drugs or alcohol and use of seatbelts. A head-to-toe evaluation of the patient with a complete history and physical examination of each region of the body should be performed with constant reassessment of all vital signs. Fetal monitoring may be initiated at this time.
4. Disability- Head injuries account for more than 50% of deaths in trauma patients and are the most frequent cause of maternal death in injured pregnant women. Therefore a complete neurologic assessment should be performed and compared with the initial assessment. The most common underlying neurologic conditions include intoxication, diabetic ketoacidosis, cerebrovascular accidents, and hypovolemic shock. All neck injuries should be presumed to be life threatening until appropriate evaluation can be performed.
5. Exposure/Environmental Control- The same principles as far as complete exposure of a trauma patient with examination of the back apply to the pregnant trauma patient. The trauma team should be cognizant of the development of hypothermia. Due to the hypercoagulability of the pregnancy state, hypothermia can further predispose the pregnant patient to thromboembolic events. If the trauma has induced labor and delivery is imminent, all clothing must be removed to prevent asphyxiation of the fetus in case of precipitous delivery. The patient should be carefully log-rolled to assess for injuries on the back.
6. Full set of vital signs/Focused interventions/ Fetal Assessment- At this time, reassessment of all vital signs is performed and fetal monitoring is initiated. Additional trauma interventions may be necessary at this point if vital signs are not adequate or fetal monitoring shows the presence of fetal distress. Interventions such as the insertion of gastric tubes, indwelling urinary catheters, and FAST exam may be done at this time. Fetal assessment should begin with estimating gestational age by last menstrual period, fundal height, and ultrasonography. Continuous fetal monitoring should be initiated and obstetrical staff must be immediately available to interpret fetal heart tracings while the patient is in a non-obstetric unit.
7. History/ Head-to-Toe Assessment- This assessment should include an abdominal and rectal examination and a complete obstetric examination. It is critical to pay close attention to the abdominal component of a secondary survey, as the protuberant abdomen is more vulnerable to injury. The patient should be checked for bruising and asymmetry. Severe tenderness may reflect an injury to maternal viscera or the enlarged uterus. The obstetric examination should include fundal height, fetal heart tones, uterine tone and presence/absence of contractions, and a pelvic examination. The pelvic examination should be done with a sterile speculum if rupture of membranes is suspected. The fetus may be considered viable if the fundus can be palpated between the umbilicus and the xiphoid process. Contraindications to a pelvic exam include unstable spine, pelvic and femur fractures. Digital examination can be performed if there is no vaginal bleeding or, if there is bleeding, once placental abnormalities have been excluded by ultrasonographic examination.
1. The pregnancy must be immediately recognized. This is especially important in patients who may be unable to communicate due to head injury, intoxication, severe respiratory distress or profound shock. A urine pregnancy test should be done on 100% of women of childbearing age. When the pregnancy is clinically obvious, assessment of the fetus is done with the secondary survey.
2. Normal changes in physiology due to the pregnancy must be interpreted in the context of the injury
3. The patient's ability to tolerate and respond to specific injuries must be understood.
4. The trauma team must not be distracted by an obviously gravid uterus during the initial assessment and attempts to stabilize the patient.
Primary Survey
Prior to examination, all clothing must be removed to allow adequate visualization and assessment of injuries. Obvious hemorrhage should be controlled with direct pressure. A rapid neurologic assessment is included which determines orientation and responsiveness, pupillary reaction, motor response and the Glasgow Coma Scale (GCS). Concurrent to all of this, moderate to severely injured patients should have intravenous access established with two large bore IV's.
1. Airway- the highest priority is to establish that the patient has a patent and adequate airway. This can be accomplished in many cases by talking to the patient. A patient who can speak in complete sentences with a normal voice and appropriate responses has a patent airway as well as adequate oxygenation and brain perfusion. If there is evidence of airway compromise, endotracheal intubation should be immediately performed. Rapid sequence intubation (RSI) is the preferred method for intubation.
2. Breathing- Due to the previously discussed physiologic changes in pregnancy, significant trauma in the second or third trimester is associated with a potentially compromised respiratory status. The goal of the physical examination is to identify clinical findings suggestive of chest injury, such as tachypnea, respiratory distress, external chest trauma, and clinical signs of rib fractures, flail segments, pneumothorax or hemothorax. The chest should be examined for expansion, breath sounds, crepitus, subcutaneous emphysema and open wounds. Injuries that may acutely impair ventilation in pregnant women are more difficult to diagnose. Owing to limited thorax excursion, conditions like flail chest or pneumothorax are more difficult to detect in pregnancy because of diminished respiratory reserves with reduced expiratory volumes and functional residual capacity.
3. Circulation- In the first trimester, assessment of circulation is unchanged. In the second and third trimesters, the normal increases in blood volume can mask the typical responses to hemorrhage such as hypotension and tachycardia. Pulse rate and blood pressure may not change until the patient has experienced a 30-35% loss in blood volume. A gravid patient with tachycardia and hypotension will need aggressive resuscitation with fluids and blood products.
Secondary Survey
The secondary survey should be done in the same order and with the same cadence as any other trauma patient. The physical examination should be done once there is response to resuscitative efforts and the condition is stabilized. Particular attention should be given to sites of bleeding, limb injury and entrance/exit wounds. Information should be obtained about the mechanism of the injuries, weapons used, the use of drugs or alcohol and use of seatbelts. A head-to-toe evaluation of the patient with a complete history and physical examination of each region of the body should be performed with constant reassessment of all vital signs. Fetal monitoring may be initiated at this time.
4. Disability- Head injuries account for more than 50% of deaths in trauma patients and are the most frequent cause of maternal death in injured pregnant women. Therefore a complete neurologic assessment should be performed and compared with the initial assessment. The most common underlying neurologic conditions include intoxication, diabetic ketoacidosis, cerebrovascular accidents, and hypovolemic shock. All neck injuries should be presumed to be life threatening until appropriate evaluation can be performed.
5. Exposure/Environmental Control- The same principles as far as complete exposure of a trauma patient with examination of the back apply to the pregnant trauma patient. The trauma team should be cognizant of the development of hypothermia. Due to the hypercoagulability of the pregnancy state, hypothermia can further predispose the pregnant patient to thromboembolic events. If the trauma has induced labor and delivery is imminent, all clothing must be removed to prevent asphyxiation of the fetus in case of precipitous delivery. The patient should be carefully log-rolled to assess for injuries on the back.
6. Full set of vital signs/Focused interventions/ Fetal Assessment- At this time, reassessment of all vital signs is performed and fetal monitoring is initiated. Additional trauma interventions may be necessary at this point if vital signs are not adequate or fetal monitoring shows the presence of fetal distress. Interventions such as the insertion of gastric tubes, indwelling urinary catheters, and FAST exam may be done at this time. Fetal assessment should begin with estimating gestational age by last menstrual period, fundal height, and ultrasonography. Continuous fetal monitoring should be initiated and obstetrical staff must be immediately available to interpret fetal heart tracings while the patient is in a non-obstetric unit.
7. History/ Head-to-Toe Assessment- This assessment should include an abdominal and rectal examination and a complete obstetric examination. It is critical to pay close attention to the abdominal component of a secondary survey, as the protuberant abdomen is more vulnerable to injury. The patient should be checked for bruising and asymmetry. Severe tenderness may reflect an injury to maternal viscera or the enlarged uterus. The obstetric examination should include fundal height, fetal heart tones, uterine tone and presence/absence of contractions, and a pelvic examination. The pelvic examination should be done with a sterile speculum if rupture of membranes is suspected. The fetus may be considered viable if the fundus can be palpated between the umbilicus and the xiphoid process. Contraindications to a pelvic exam include unstable spine, pelvic and femur fractures. Digital examination can be performed if there is no vaginal bleeding or, if there is bleeding, once placental abnormalities have been excluded by ultrasonographic examination.