Disposition

The decision to admit or discharge after the emergency assessment and management of a pregnant trauma patient is ultimately based on the nature and severity of presenting injuries. Patients suffering severe multisystem trauma will have their further management assumed by trauma surgeons and consultant obstetricians. Even in cases of seemingly minor but potentially significant injuries, admission to a trauma service capable of further observation and management is appropriate. Patients who demonstrate evidence of fetal distress or uterine irritability during the initial assessment require admission under the extended evaluation and care of an obstetrician capable of emergency delivery as necessary. Patients who must be transferred to other facilities for definitive trauma or obstetric care must be appropriately stabilized prior to transfer, with provisions for an appropriate level of care during transport. There must be strict adherence to transfer policies that comply with COBRA and EMTALA regulations. Clearly, the ongoing need for an interdisciplinary approach to patient management in such cases remains even after admission.

Although external fetal monitoring may be initiated in the emergency department, the monitoring is typically continued in the labor and delivery suite under the direction of an obstetrician. If the extended period of monitoring demonstrates no evidence to suggest fetal or maternal injury or distress, the patient may be discharged. Upon discharge, the patient must be carefully advised to seek medical attention immediately if she should develop abdominal pain or cramping, vaginal bleeding, leakage of fluid, or perception of diminished fetal activity. The decision to discharge an injured pregnant patient from the emergency department must be made carefully. A high index of suspicion should be maintained for occult injuries as well as a low threshold for obstetric consultation when indicated. To screen for the possibility of interpersonal violence, a thorough social services evaluation or referral should be made in all but the most obvious cases of accidental injury. Adequate obstetric follow-up care must be ensured for all pregnant trauma patients when discharged from the emergency department.

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