Injuries in pregnancy
All injured women of childbearing age are considered pregnant until proven otherwise
- Be aware that pregnancy may trigger or increase domestic/family violence — if suspected make sure woman is safe and refer her to support services
Best thing for baby is to take good care of mother — always assess and resuscitate woman first then assess baby
- Be aware of mandatory reporting requirements in your state/territory
Abdominal injury in pregnancy
- Any abdominal injury in pregnancy can be serious
- Usual signs of abdominal injury are not reliable — soft, non-tender abdomen does not rule out serious injury
- Placental abruption can happen even after a minor abdominal injury
- In late pregnancy baby can be directly injured — foetal distress may not be obvious until hours after injury
Do not
- Do not do vaginal exam unless skilled and asked to by doctor
Do first
See Assessing trauma — primary and secondary survey — initial priorities same as for any injured person
Important extra points about Airway, Breathing, Circulation in pregnancy
A — Airway
- Increased risk that women will vomit and aspirate (get vomit in lungs)
- If airway or intubation needed — always put in nasogastric or orogastric tube as well
B — Breathing
- Give oxygen to target O2 sats 94–98%
C — Circulation
- Position woman on left side with uterus pushed over to left — after 20 weeks pregnant the uterus presses on major blood vessels if woman lies flat on back — may cause low BP, foetal distress
- Control obvious external bleeding for transport and assessment
- If spinal injury suspected — immobilise then tilt spinal board 15–30° to the left by putting wedge or rolled-up blanket under it
- If positioning on left side or lateral tilt not possible
- Place rolled up towel under right hip to tilt uterus to the left side
- Use manual displacement of uterus — stand on woman’s left, put both hands around pregnant abdomen and pull abdomen toward yourself
Any change indicating shock is very serious.
- Detecting shock is difficult — pregnant woman can lose up to 1,200–1,500mL of blood before any changes in pulse or BP
- Signs of shock
- Increased RR
- Pulse weak and fast (more than 100bpm) or difficult to feel
- Central capillary refill longer than 2 seconds
- Pale, cool, moist skin
- Restless, confused, drowsy, occasionally unconscious
- Low BP for age or relative to person's previously recorded values
- Put in IV cannula — largest possible, insert 2 if time
- If you can't get IV cannula in — put in intraosseous needle
- If shock suspected — give 1L normal saline or Hartmann's solution as fast as possible, even if BP normal
- Further IV fluids — medical consult
At end of trauma assessment — must do medical consult even if injury seems minor
Ask
- Exactly how injury occurred
- A complete history will help you work out likelihood of serious injury
- In motor accidents ask specifically about type and position of seat belt
- Pain, contractions, baby movements
- How many weeks pregnant, due date for birth, obstetric ultrasound report
- Vaginal fluid loss, bleeding
- Is woman RhD negative
Check
- Calculate REWS — AVPU, RR, O2 sats, pulse, BP, Temp
- Weight, BGL
- U/A
- Head-to-toe exam – with attention to
- Abdomen – shape, bruising, surgical scars. Feel for tenderness, rigidity, guarding
- Uterus and baby – feel if soft or hard, for tenderness or contractions, assess position of baby
- Vulva and perineum – look for blood or fluid coming from vagina or urethra – note colour, amount, smell
- POC Test — Hb
Do
- Medical consult
- If results not known take blood for FBC, blood group, antibodies and Kleihauer test (test for amount of foetal blood in maternal circulation)
- If abdominal injury and mother RhD negative with no Anti-D antibodies — woman will need RhD-Ig IM
- Under 12 weeks pregnant and miscarriage or painful vaginal bleeding — 250IU
- Over 12 weeks pregnant — 625IU
- Over 20 weeks pregnant — start with 625IU. Kleihauer test results will determine if more needed