principles of patient assessment in ems. the assessment approach for the pregnant patient

Principles of Patient Principles of Patient Assessment in EMS Assessment in EMS

The Assessment Approach for The Assessment Approach for the Pregnant Patient the Pregnant Patient

IntroductionIntroduction Assessing the pregnant patient is Assessing the pregnant patient is

focused on the patient’s chief focused on the patient’s chief complaint.complaint.

Normal anatomical and physiological Normal anatomical and physiological changes during pregnancy will changes during pregnancy will modify the assessment process.modify the assessment process.

Assessment may involve 2 or more Assessment may involve 2 or more patients. patients.

Normal A&P Changes of Normal A&P Changes of PregnancyPregnancy

Normal gestation is 38-42 weeks.Normal gestation is 38-42 weeks. Pregnancy is broken into 3 – 3 month Pregnancy is broken into 3 – 3 month

segments (trimesters).segments (trimesters). At 12 weeks the fundus (top of At 12 weeks the fundus (top of

uterus) can be palpated above the uterus) can be palpated above the symphysis pubis.symphysis pubis.

Displaces the urinary bladder.Displaces the urinary bladder. Excessive fatigue and SOB is Excessive fatigue and SOB is

common throughout pregnancy.common throughout pregnancy.

Normal A&P Changes Normal A&P Changes (continued)(continued)

Release of progesterone causes:Release of progesterone causes: Relaxation of the GI tract and other Relaxation of the GI tract and other

smooth musclessmooth muscles Slowed peristalsisSlowed peristalsis Nausea/vomiting (increasing the risk of Nausea/vomiting (increasing the risk of

aspiration)aspiration)

© 2003 Delmar Learning, a Division of Thomson Learning, Inc.© 2003 Delmar Learning, a Division of Thomson Learning, Inc.


Circulating blood volume increases Circulating blood volume increases by nearly 50% by full term.by nearly 50% by full term. Hemoglobin does not increase Hemoglobin does not increase

proportionately creating a mismatch proportionately creating a mismatch called “anemia of pregnancy”called “anemia of pregnancy”

During hemorrhagic shock normal During hemorrhagic shock normal signs/symptoms will not be apparent signs/symptoms will not be apparent until 30-35% blood lossuntil 30-35% blood loss

The fetus becomes stressed due to The fetus becomes stressed due to hypoxia before signs and sypmtoms of hypoxia before signs and sypmtoms of shock are apparentshock are apparent



Enlarging uterus displaces main internal Enlarging uterus displaces main internal organs:organs: Diaphragm displaced upward decreasing Diaphragm displaced upward decreasing

functional tidal volumefunctional tidal volume Esophgeal sphincter displaced resulting in Esophgeal sphincter displaced resulting in

refluxreflux Low back pain is common in late pregnancyLow back pain is common in late pregnancy BP decreases slightly in 2BP decreases slightly in 2ndnd trimester and trimester and

returns to normal in the 3returns to normal in the 3rdrd trimester trimester Hypertension during pregnancy is always Hypertension during pregnancy is always

dangerous and requires evaluationdangerous and requires evaluation Heart rate increases 10-20 bpm throughout Heart rate increases 10-20 bpm throughout

pregnancypregnancy© 2003 Delmar Learning, a Division of Thomson Learning, Inc.© 2003 Delmar Learning, a Division of Thomson Learning, Inc.

The Focused HistoryThe Focused History The most common EMS calls are for The most common EMS calls are for

traumatic injury, pain, or vaginal bleeding.traumatic injury, pain, or vaginal bleeding. Pregnant patient’s are not immune from Pregnant patient’s are not immune from

any other causes of abdominal pain (i.e. any other causes of abdominal pain (i.e. appendicitis, gallbladder, or kidney appendicitis, gallbladder, or kidney stones).stones).

Obtain OPQRST and SAMPLE Hx, as well as Obtain OPQRST and SAMPLE Hx, as well as specific information about the current specific information about the current pregnancy and any previous pregnancies.pregnancy and any previous pregnancies.

Identify any possible risk factors for Identify any possible risk factors for complications in pregnancy.complications in pregnancy.


The OPQRST HistoryThe OPQRST History O – When did the pain, bleeding, labor or O – When did the pain, bleeding, labor or

traumatic injury or other complaint begin?traumatic injury or other complaint begin? P – What was the patient doing at the P – What was the patient doing at the

onset and are there any complications of onset and are there any complications of pregnancy?pregnancy?

Q – Describe the pain and compare to Q – Describe the pain and compare to previous episodes.previous episodes.

R – Any radiation from the point of origin? R – Any radiation from the point of origin? Did she do anything for relief?Did she do anything for relief?

S – Rate the pain on the 1 to 10 scale.S – Rate the pain on the 1 to 10 scale. T – When did it begin? Any life-threats and T – When did it begin? Any life-threats and

imminent delivery indications?imminent delivery indications?© 2003 Delmar Learning, a Division of Thomson Learning, Inc.© 2003 Delmar Learning, a Division of Thomson Learning, Inc.

The SAMPLE HistoryThe SAMPLE History S – amenorrhea, nausea, vomiting, breast S – amenorrhea, nausea, vomiting, breast

tenderness, back pain, abdominal pain, cramping, tenderness, back pain, abdominal pain, cramping, vaginal discharge, urinary or bowel problems, vaginal discharge, urinary or bowel problems, abnormal weight gain, generalized edema, etc.abnormal weight gain, generalized edema, etc.

A – Any increased sensitivity to environmental A – Any increased sensitivity to environmental allergens?allergens?

M – Any drugs during the pregnancy?M – Any drugs during the pregnancy? P – Is there a prior pregnancy history or high risk P – Is there a prior pregnancy history or high risk

situations?situations? L – When was the last menstrual period and last L – When was the last menstrual period and last

oral intake?oral intake? E – What events lead to EMS being called (i.e. E – What events lead to EMS being called (i.e.

ruptured waters, labor pain, trauma, ruptured waters, labor pain, trauma, hemorrhage)?hemorrhage)?


The Physical ExamThe Physical Exam Perform the Initial Assessment (MS-Perform the Initial Assessment (MS-

ABCs) as with any other patient.ABCs) as with any other patient. The depth of the PE is focused on the The depth of the PE is focused on the

patient’s chief complaint.patient’s chief complaint. For the female in late 2For the female in late 2ndnd or in 3 or in 3rdrd

trimester positioning is an important trimester positioning is an important factor for comfort and circulation.factor for comfort and circulation. Let the patient assume the position of Let the patient assume the position of

comfortcomfort Immobilized patient’s need to be tilted Immobilized patient’s need to be tilted

to avoid supine hypotensionto avoid supine hypotension© 2003 Delmar Learning, a Division of Thomson Learning, Inc.© 2003 Delmar Learning, a Division of Thomson Learning, Inc.

The Vital SignsThe Vital Signs Keep in mind normal vs changes in Keep in mind normal vs changes in

each trimester.each trimester. Assess skin CTC, note presence of Assess skin CTC, note presence of

generalized edema.generalized edema. Respiratory rate – unusually normal Respiratory rate – unusually normal

or slightly increased.or slightly increased. Heart rate – increases 10 – 20 bpm Heart rate – increases 10 – 20 bpm

throughout the pregnancy.throughout the pregnancy.


BP – decreases (10 to 15 mmHg) BP – decreases (10 to 15 mmHg) during 2during 2ndnd trimester, returns to trimester, returns to normal in 3normal in 3rdrd.. BP varies with positioning (supine BP varies with positioning (supine

hypotension)hypotension) New onset hypertension is abnormal and New onset hypertension is abnormal and

dangerous > 140/90 may indicate dangerous > 140/90 may indicate preeclampsia and eclampsiapreeclampsia and eclampsia

The Vital SignsThe Vital Signs


The SkinThe Skin Changes in skin color are normal due Changes in skin color are normal due

to increased estrogen levels.to increased estrogen levels. Chloasoma or “mask of pregnancy” – Chloasoma or “mask of pregnancy” –

mild darkening of the facemild darkening of the face Linea nigra – darkened midline from Linea nigra – darkened midline from

umbilicus to public boneumbilicus to public bone Areolar, armpits, perineum and inner Areolar, armpits, perineum and inner

thigh may also darkenthigh may also darken


Changes Assessed During Changes Assessed During VisualizationVisualization

Postural changes:Postural changes: LordosesLordoses KyphosisKyphosis Protruding abdomenProtruding abdomen

Widened rib cage, flaring of the lower Widened rib cage, flaring of the lower ribs.ribs.

When imminent delivery is suspected When imminent delivery is suspected examine external vagina for the examine external vagina for the presence of crowning, prolapsed cord, presence of crowning, prolapsed cord, or the progression of labor.or the progression of labor.


Changes Assessed During Changes Assessed During PalpationPalpation

Neck – enlarged thyroid gland is Neck – enlarged thyroid gland is normal.normal.

Thorax – costal angle may be Thorax – costal angle may be wider than normal.wider than normal.


Abdomen – note any tenderness, Abdomen – note any tenderness, guarding and the fundal height.guarding and the fundal height. > 12 weeks fundus can be palpated above > 12 weeks fundus can be palpated above

symphysis pubissymphysis pubis At 20 weeks at the level of the umbilicusAt 20 weeks at the level of the umbilicus At 36 weeks it has reached the ribs or costal At 36 weeks it has reached the ribs or costal

marginmargin When contractions are reported measure When contractions are reported measure

duration and time between the start of one duration and time between the start of one until the start of another. Perform a fetal until the start of another. Perform a fetal assessmentassessment

Changes Assessed During Changes Assessed During PalpationPalpation


Changes Assessed During Changes Assessed During AuscultationAuscultation

Abnormal heart sounds develop Abnormal heart sounds develop during pregnancy in some women.during pregnancy in some women.

S-1 may be louder than normal.S-1 may be louder than normal. S-3 may be heard.S-3 may be heard. A systolic murmur may be heard.A systolic murmur may be heard. Fetal heart tones may be heard > 12 Fetal heart tones may be heard > 12

weeks gestation.weeks gestation.


Fetal AssessmentFetal Assessment Includes:Includes:

Measuring fundal height and fetal heart Measuring fundal height and fetal heart raterate

Fetal movement and contractions (when Fetal movement and contractions (when present)present)

Assess during active labor for signs Assess during active labor for signs of distress.of distress.


Fundal height:Fundal height: In supine position, place the zero mark of the In supine position, place the zero mark of the

measuring tape at the top of the symphysis measuring tape at the top of the symphysis pubis. Measure in the midline up and over the pubis. Measure in the midline up and over the abdomen to the top of the fundus, note the abdomen to the top of the fundus, note the mark (1cm = approx. 1 wk gestation)mark (1cm = approx. 1 wk gestation)

A smaller/larger uterus, than expected, is an A smaller/larger uterus, than expected, is an abnormal findingabnormal finding

12 wks at the symphysis pubis, 16 wks 12 wks at the symphysis pubis, 16 wks between pubis and umbilicus, 36 wks at between pubis and umbilicus, 36 wks at coastal margincoastal margin

> 24 wks is age where the fetus is survivable > 24 wks is age where the fetus is survivable outside the womboutside the womb

Fetal AssessmentFetal Assessment


Fetal Heart Rate Fetal Heart Rate Fetal heart tones (FHT) may be heard 12 Fetal heart tones (FHT) may be heard 12

to 14 wks with a Doppler or handheld to 14 wks with a Doppler or handheld ultrasound or by a Fetoscope by 20 wks.ultrasound or by a Fetoscope by 20 wks.

Normal FHT range is 110 to 160.Normal FHT range is 110 to 160. Brief rate changes are normal during fetal Brief rate changes are normal during fetal

movement, sleep and contractions.movement, sleep and contractions. Locating the FHT may be difficult. Most Locating the FHT may be difficult. Most

often other tasks take priority.often other tasks take priority. Place the mother supine for listening:Place the mother supine for listening:

Place the microphone on the abdomen and Place the microphone on the abdomen and move in slow circles until the FHT are heardmove in slow circles until the FHT are heard


Fetal Heart Rate (continued)Fetal Heart Rate (continued)

Count for a minute. Repeat as you Count for a minute. Repeat as you repeat the maternal vital signs.repeat the maternal vital signs.

Early pregnancy listen in the midline Early pregnancy listen in the midline between the symphysis pubis and between the symphysis pubis and the umbilicus.the umbilicus.

Late pregnancy listen in the right or Late pregnancy listen in the right or left upper quadrant. left upper quadrant.


Fetal Movement/ContractionsFetal Movement/Contractions Mother feels movement in the 2Mother feels movement in the 2ndnd

trimester.trimester. May feel movement during May feel movement during

auscultation (especially in the 3auscultation (especially in the 3rdrd trimester).trimester).

Ask the mother when last movement Ask the mother when last movement was felt.was felt.

Assess contractions or movement by Assess contractions or movement by placing one hand on the top of the placing one hand on the top of the fundus.fundus.


A contraction is felt as a muscle A contraction is felt as a muscle tensing.tensing.

Measure duration and time of onset of Measure duration and time of onset of one to another.one to another.

True labor is persistent regular True labor is persistent regular contraction.contraction.

False labor (Braxton-Hicks) is irregular False labor (Braxton-Hicks) is irregular and inconsistent.and inconsistent.

Preterm labor is true labor prior to 38 Preterm labor is true labor prior to 38 wks gestation. wks gestation.

Fetal Fetal Movement/ContractionsMovement/Contractions


Pregnancy Associated Pregnancy Associated ComplicationsComplications

Most OB/GYN emergent complaints Most OB/GYN emergent complaints are of pain, bleeding or both.are of pain, bleeding or both.

Complications are not common. The Complications are not common. The goal is to rapidly identify life-goal is to rapidly identify life-threatening conditions:threatening conditions: EclampsiaEclampsia Ectopic pregnancyEctopic pregnancy Determine if delivery is imminentDetermine if delivery is imminent


Ectopic PregnancyEctopic Pregnancy When pregnancy is unknown or in 1When pregnancy is unknown or in 1stst

trimester and the c/c is lower trimester and the c/c is lower abdominal pain with/without bleeding abdominal pain with/without bleeding suspect ectopic pregnancy.suspect ectopic pregnancy.

In 1In 1stst trimester, ectopic or trimester, ectopic or miscarriage may be life-threatening miscarriage may be life-threatening conditions when unrecognized and conditions when unrecognized and untreated.untreated.


The c/c is usually lower abdominal The c/c is usually lower abdominal pain, vaginal bleeding or both.pain, vaginal bleeding or both.

Uncontrolled vaginal bleeding can Uncontrolled vaginal bleeding can lead to hypovolemia, shock or death lead to hypovolemia, shock or death for both the mother and fetus. for both the mother and fetus.

Ectopic PregnancyEctopic Pregnancy


Spontaneous Abortion Spontaneous Abortion (miscarriage)(miscarriage)

A loss of pregnancy < 20 wks A loss of pregnancy < 20 wks gestation.gestation.

Occurs in 20 to 30 % of all Occurs in 20 to 30 % of all pregnancies.pregnancies.

c/c is vaginal bleeding with or c/c is vaginal bleeding with or without abdominal pain. Often there without abdominal pain. Often there is passing of fetal tissue (blood clot). is passing of fetal tissue (blood clot).


DiabetesDiabetes

In 2In 2ndnd trimester hormones trigger a trimester hormones trigger a release of increased insulin.release of increased insulin.

New onset or gestational diabetes New onset or gestational diabetes typically begins in 2typically begins in 2ndnd or 3 or 3rdrd trimester trimester and subsides after delivery.and subsides after delivery.

Diabetes requires carefully Diabetes requires carefully monitoring due to increased risk of monitoring due to increased risk of birth defects, hypertension, birth defects, hypertension, eclampsia and an oversized fetus. eclampsia and an oversized fetus.


HypertensionHypertension

BP (>140/90) is always abnormal BP (>140/90) is always abnormal during pregnancy.during pregnancy.

Can progress to stroke, acute Can progress to stroke, acute pulmonary embolism, renal failure, pulmonary embolism, renal failure, preeclampsia, eclampsia, or death.preeclampsia, eclampsia, or death.


Signs and Symptoms of pregnancy Signs and Symptoms of pregnancy induced HTN include:induced HTN include: Increase of 30 mm Hg systolic or 15 mmHg Increase of 30 mm Hg systolic or 15 mmHg

diastolic above baselinediastolic above baseline Abnormal weight gainAbnormal weight gain Headaches and visual disturbancesHeadaches and visual disturbances Abdominal pain and generalized edemaAbdominal pain and generalized edema Decreased urine output (oliguria)Decreased urine output (oliguria) Protein in the urine on clinical analysisProtein in the urine on clinical analysis

HypertensionHypertension


Preeclampsia and EclampsiaPreeclampsia and Eclampsia

Leading cause of maternal/fetal Leading cause of maternal/fetal morbidity and mortality.morbidity and mortality.

Signs and symptoms are the same as Signs and symptoms are the same as pregnancy-induced HTN.pregnancy-induced HTN.


More severe symptoms include:More severe symptoms include: Severe headachesSevere headaches Blurred vision and diplopiaBlurred vision and diplopia Nausea and vomitingNausea and vomiting RUQ or epigastric painRUQ or epigastric pain Anuria and hematuriaAnuria and hematuria Oliguria, dizziness, confusionOliguria, dizziness, confusion Fetal distress and abruptio placentaeFetal distress and abruptio placentae

Without rapid treatment may progress to Without rapid treatment may progress to eclampsia (seizures, coma and death). eclampsia (seizures, coma and death).

Preeclampsia and EclampsiaPreeclampsia and Eclampsia


Abruptio Placentae / Placenta Abruptio Placentae / Placenta PreviaPrevia

Abruptio Abruptio A sudden separation of the placenta from A sudden separation of the placenta from

the uterine wallthe uterine wall S & S vary with the extent of the S & S vary with the extent of the

detachmentdetachment Severe abdominal pain with or without Severe abdominal pain with or without

bleeding, but (+) signs of shockbleeding, but (+) signs of shock PreviaPrevia

Abnormal implantation of the placenta in Abnormal implantation of the placenta in a lower uterine sitea lower uterine site

S & S include signs of shock and vaginal S & S include signs of shock and vaginal bleeding without abdominal painbleeding without abdominal pain


Prehospital DeliveryPrehospital Delivery

Active labor typically progresses Active labor typically progresses slowly in the female who has never slowly in the female who has never given birth and rapidly in the female given birth and rapidly in the female who has.who has.

Assessment includes:Assessment includes: Palpate / measure the contractionsPalpate / measure the contractions Establish Hx of fundus (gestational age)Establish Hx of fundus (gestational age) Inspect external genitalia for presenting Inspect external genitalia for presenting

fetusfetus Ask about ruptured membranesAsk about ruptured membranes


Determine if birth is imminent:Determine if birth is imminent: Urge to move bowelsUrge to move bowels Mother says it is timeMother says it is time CrowningCrowning

Prehospital DeliveryPrehospital Delivery


ConclusionConclusion

Approach to the pregnant patient is Approach to the pregnant patient is directed by the c/c, which is typically directed by the c/c, which is typically pain bleeding or both.pain bleeding or both.

Obtain acute details in the FH.Obtain acute details in the FH. When pregnancy is unknown, or in 1When pregnancy is unknown, or in 1stst

trimester, all abdominal pain in lower trimester, all abdominal pain in lower abdomen with/ without bleeding is a abdomen with/ without bleeding is a possible ectopic pregnancy. possible ectopic pregnancy. (manage as a life-threat!)(manage as a life-threat!)


Consider preexisting conditions (i.e. Consider preexisting conditions (i.e. HTN or diabetes).HTN or diabetes).

Consider other causes of abdominal Consider other causes of abdominal pain (i.e. appendicitis or reflux).pain (i.e. appendicitis or reflux).

Include the patient’s priorities and Include the patient’s priorities and concerns. concerns.

ConclusionConclusion

principles of patient assessment in ems. the assessment approach for the pregnant patient

Documents

late pregnancy low

late pregnancy bp

pregnancy heart rate

anemia of pregnancy

pregnant patient slide

delmar learning

division of thomson

physiological changes