As you arrive on scene, dispatch calls with additional information; "Caller states the patient is 34 weeks pregnant." Your abdominal pain call just became an obstetrics call.
In addition to your EMS kit, you grab the OB and pediatric resuscitation kits. The patient's mother answers the door and leads you to the patient, a 23-year-old female who's lying on her side on the bed and in apparent distress. You're able to ascertain she's 34 weeks into her first pregnancy (primigravida). She hasn't had any complications and tells you she has not had prenatal care since early in the pregnancy. You learn the pain has been occurring intermittently over the past couple of hours, and the patient noticed a small amount of vaginal bleeding. The pain has been increasing in frequency and severity. In your head, you start to quickly mull over the causes of bleeding and abdominal pain in the later stages (i.e., third trimester) of pregnancy.
A pregnancy is considered full term after 37 weeks. Week 28 through delivery is referred to as the third trimester. During this time, the fetus is going through the final stages of development: Hair is growing, eyes are opening; organs are functioning and the fetus is getting fat. The fetus is preparing for extrauterine life. The uterus begins uncomfortable, irregular contractions -- known as Braxton Hicks contractions. These contractions are preparing the uterus for delivery. They aren't typically considered to be painful, nor do they increase in severity. The cervix begins to dilate (open) and efface (thin) in preparation for delivery.
Your patient is complaining of pain that's increasing in severity. There are two causes of third trimester bleeding EMS providers should always consider, both of which can result in death of mother and baby.
Causes of Prenatal Bleeding
Placenta previa is painless vaginal bleeding caused when the placenta is low in the uterus over the cervical opening. The placenta can cover the cervix completely or partially. This is seen in about five out of every 1,000 births. As the cervix begins to dilate and efface, the wall of the placenta is exposed. This allows bleeding from the mother and the placenta. Bleeding may be intermittent. The goal of prehospital care is to recognize the problem and transport the patient for evaluation and treatment. If the bleeding stops in the hospital, the pregnancy will be allowed to continue with the mother on bed rest. If the bleeding can't be controlled, the baby may need to be delivered via caesarean section.
Placenta abruption, which is painful, can also cause third trimester bleeding. Slightly more frequent than placenta previa, it's seen in about six out of every 1,000 births. Placenta abruptio occurs when the placenta tears away from the wall of the uterus, which causes bleeding. Risk factors for placenta abruptio include hypertension, trauma to the abdomen and smoking. When the placenta tears from the wall of the uterus, the mother will experience moderate to severe pain. This tearing can result in vaginal bleeding.
In some cases, however, the center of the placenta will tear away with the surrounding tissue of the placenta remaining attached. If this happens, the bleeding will be confined between the wall of the uterus and placenta, and the mother will experience sudden, abdominal pain with the absence of vaginal bleeding. As with placenta previa, EMS must recognize this condition and transport rapidly to an appropriate facility.
Both of these conditions should be monitored and the patient treated for shock as necessary. Be cautious about placing the mother flat on her back. When a pregnant woman lies supine, the weight of the fetus can compress the inferior vena cava and decrease the blood return to the heart, causing a drop in blood pressure. This is known a supine hypotension syndrome.
The pregnant patient should be placed on her side or, if placed on her back, have several pillows or blankets wedged underneath her side to tilt the fetus off of the inferior vena cave. If allowed by protocol, start an IV. Administer oxygen, and keep her warm.
The other possibility with our patient is that she's going into preterm labor. Preterm labor is defined as labor before 37 weeks of gestation and is one of the leading causes of neonatal death in the U.S. The concern of preterm labor is that the fetus isn't prepared to survive outside the uterus. The lungs may have a difficult time adapting to the breathing process, and many of the normal, physiologic changes that happen with birth may be delayed or may not occur at all. Premature infants will typically require some form of resuscitation, usually involving breathing. Be prepared. Premature infants have the greatest chance of survival after the 25th week of gestation.
Your patient is 34 weeks pregnant and is going into premature labor. There are no signs of imminent delivery, such as crowning while on scene. So, the decision to transport is made. Your transport to the emergency department is uneventful. The patient is quickly transferred to the labor and delivery floor, where she delivers a healthy baby boy. Congratulations!
- American Pregancy Association.http://www.americanpregnancy.org/labornbirth/prematurelabor.html
- Medline Plus.http://www.nlm.nih.gov/medlineplus/ency/article/000901.htm
- American Journal of Epidemiology.http://aje.oxfordjournals.org/cgi/content/full/153/4/332