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 

• 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

•  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