Appendix 8
Specialist Trauma Transfer Guidelines - 8.5 Obstetric Trauma

Prehospital Management

• Supplemental oxygen.

• IV access and fluids.

• No woman in the third trimester of pregnancy should be nursed supine. Supine position creates aorto-caval obstruction and hypotension, particularly in the shocked patient.

Aorto-caval compression also renders supine CPR ineffective.

Nurse patient with a 15 degree left tilt (on a spinal board if necessary) with the uterus manually displaced to the left side.

• The pregnant patient with minor injury should also be carefully observed, since even minor injuries may be associated with complications such as foeto-maternal haemorrhage.

Primary Hospital Management

Assessment

• Hypervolaemia of pregnancy means that the patient may lose up to 30-35 per cent of circulating blood volume before becoming hypotensive/showing other signs of shock. The foetus may be compromised even when the mother appears stable.

• Is the foetus viable? Foetus is not viable pre-22 weeks (probably 24 weeks). If the foetus is beyond 24 weeks gestation, obstetric backup at a Major Trauma Service is mandatory. If the foetus is preterm, this will necessitate specialist neonatal facilities if delivered.

• Is there evidence of foetal distress?

• Is there possibility of trauma to the uterus? Assess for uterine contractions, vaginal bleeding or amniotic fluid in the vagina.

• All injured pregnant women should have an obstetric assessment because abruption of the placenta and foetal distress or death may occur with seemingly minor blunt trauma. An obstetrician should be involved as early as possible in determining appropriate obstetric care in conjunction with the trauma team.

Stabilisation

Assessment and resuscitation of the mother must take priority and, ultimately, the welfare of the foetus is optimised by optimal care of the mother.

• Maintain position on left side.

• Early IV access in case of placental hypoperfusion. Prompt fluid replacement-if group O required before a full cross-match is complete, it must be rhesus negative.

• Avoid vasopressors to restore maternal blood pressure.

• Early nasogastric tube decompression and urinary catheter are required.

Investigations

• Standard cervical spine, chest and pelvic radiography is mandatory, notwithstanding the presence of the foetus. Lead shield the pelvis/abdo if not needed in film.

• Ultrasound if blunt trauma of the uterus is suspected.

• Diagnostic peritoneal lavage is a safe procedure in the pregnant patient and should not be withheld, providing the indications are clear. After the first trimester, a supraumbilical method is employed.

Foetal Management

• Optimal care of the foetus is achieved through optimal care of the mother.

• If the foetus is alive and mature enough to survive delivery, it should be monitored continuously.

• Cardiotocographic monitoring initiated early gives adequate warning of a deterioration in foetal condition.

Indications for Transfer to Major Trauma Service (with Obstetric backup)

• Evidence of foetal distress.

• Foetus beyond 24 weeks gestation.

• Possibility of trauma to the uterus.

• All pregnant, injured women should have urgent obstetric assessment.