Trauma Care and Managing the Injured Pregnant Patient

CNE

Continuing Nursing Education(CNE) Credit

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Managing the Injured Pregnant Patient,’’

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Trauma Care and Managing the InjuredPregnant PatientDaria C. Ruffolo

ABSTRACT

Trauma is the leading cause of maternal death in the United States. Nurses must optimize the well-being of 2 patients

in the pregnant trauma patient. Rapid assessment, initiating immediate interventions for life-threatening injuries, and

transport to a trauma center are critical to optimize maternal and fetal outcome. Understanding these factors can

facilitate an effective resuscitation and optimize the outcome for both mother and baby.

JOGNN, 38, 704-714; 2009. DOI: 10.1111/j.1552-6909.2009.01072.x

Accepted August 2009

The challenges of caring for the pregnant

trauma patient is recorded as far back as

the writings of Ambrose Pare’ in the 16th century.

A great French military surgeon and a well-known

‘‘accoucheur,’’ or male-midwife, he founded a

school for midwives in Paris and wrote extensively

about breech extractions and Cesarean deliveries.

He is credited with performing and supervising Ce-

sarean deliveries on a number of living women but

also on two women that had succumbed to trau-

matic events and had the sections performed after

the death of the mother. He was the ¢rst to describe

the devastation of losing a patient su¡ering from a

penetrating injury to the uterus.We continue to face

these same challenges in the 21st century.

Pregnancy must always be considered when evalu-

ating a female trauma patient of reproductive age.

When caring for the pregnant trauma patient one

must optimize the well-being of two patients ; how-

ever, the health of the mother is of paramount

importance, and fetal survival is directly related

to maternal well-being. Rapid assessment, treat-

ment, and transport are critical to optimizing

maternal and fetal outcome. Evaluation must

be performed with the understanding of the physio-

logical changes that occur in pregnancy. These

changes alter maternal response to trauma and

require adaptations to care. Management requires

a multidisciplinary approach to care with a cohe-

sive team that works together to return both

patients to homeostasis.

EpidemiologyTrauma complicates 6% to 7% of all pregnancies

and is the leading nonobstetric cause of maternal

morbidity and mortality. Pregnancy in and of itself

does not increase maternal mortality from trauma

because mortality seems to be a function of the

injury severity (Fildes, Reed, Jones, Martin, & Bar-

rett, 1992; Muench & Canterino, 2007). However, it

is well known that as the size of the developing

fetus and uterus expand, the risks to the mother

and child increase as the pregnancy progresses.

This is thought to be related to the multiple physio-

logical changes that occur during pregnancy with

a particular emphasis on the movement of the

abdominal organs up from the safe place of lower

abdomen and pelvic region to the more vulnerable

upper abdomen and thoracic cavities. There is a

10% to15% risk of maternal or fetal injury from trau-

ma during the ¢rst trimester, 32% to 40% in the

second trimester, and 50% to 54% during the third

Keywordsresuscitationblunt traumapenetrating traumapregnant

CorrespondenceDaria C. Ruffolo, RN, MSN,ACNP-BC, CCRN, TNS,2160 S. 1st Ave, LoyolaUniversity Medical CenterMaywood, IL [email protected]

The author and planners forthis activity report noconflict of interest orrelevant financialrelationships. The articleincludes no discussion ofoff-label drug or devise use.No commercial support wasreceived for this educationalactivity.

Daria C. Ruffolo, RN,MSN, ACNP-BC, CCRN,TNS, is a trauma/surgicalcritical care and acute carenurse practitioner at theLoyola University MedicalCenter Maywood, IL.

JOGNN I N F O C U S

704 & 2009 AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses http//jognn.awhonn.org

i:/BWUS/jogn/1072/[email protected]











trimester (Curet, Schermer, Demarest, Bieneik, &

Curet, 2000; El-Kady et al., 2004).

Fetal mortality in trauma is reported as high as 65%

from processes such as placental abruption (42%),

direct fetal injury, maternal shock (21%), dissemi-

nated intravascular coagulation, and unexplained

fetal loss (Pearlman & Tintinalli,1991).The emphasis

in trauma and the challenge for the nurse caring for

the pregnant trauma patient is to prevent or reverse

maternal shock and optimize tissue perfusion (Ho¡

et al.,1991; Hyde,Cook,Olson,Weiss, & Dean, 2003;

Pearlman & Tintinalli ; Rogers et al.,1999).

The typical mechanism of injury for pregnant trau-

ma patients is motor vehicle crashes (55%);

however, falls (23%), assaults (21%), and burns

(1%) are causes of maternal trauma (Esposito,

1994; Muench & Canterino, 2007; Pearlman & Tin-

tinalli, 1991). The cause of traumatic injury that has

the most dramatic increase among pregnant wo-

men is that of domestic violence, and there is a

70% association of poly-substance abuse of the

motherand/or partnerof those patients that are vic-

tims of abuse (Canterino, VanHorn, Harrigan,

Ananth, & Vintzileos, 1999). The care-provider of

these patients is obligated to o¡er teaching in injury

prevention and providing a ‘‘safe place’’ plan of care.

Pregnancy PhysiologyCaregivers may be overwhelmed by the manage-

ment of caring for both the mother and the fetus.

However, familiarity with the normal anatomical

and physiological changes that occur during preg-

nancy will enhance the assessment skills of the

caregivers and subsequently optimize the care pro-

vided to the mother and her unborn fetus.

Changes in Laboratory Values DuringPregnancyUnderstanding normal maternal-fetal physiology is

critical in the diagnosis and treatment of those that

have been victims of trauma. Normal clinical and

laboratory ¢ndings in pregnant women would be

suggestive of pathologic ¢ndings in women who

are not pregnant. The nurse should be familiar with

the di¡erences between normal physiology and pa-

thology of these women in order to prevent

unnecessary needle exposures, phlebotomy, and

sometimes dangerous diagnostic testing.

Intravascular Volume and HemodynamicChangesThe rapidly growing uterofetoplacental unit places

increased demands on oxygen delivery and subse-

quently on tissue perfusion to both the mother and

the growing fetus. These demands are met by in-

creasing the oxygen-carrying capacity of the red

blood cells with an increase in blood volume. Oxy-

genation is also enhanced by an increased cardiac

output and minute ventilation (Chames & Pearl-

man, 2008; Tsuei, 2006). The heart rate increases

by 10 to 15 beats per minute above baseline and

the cardiac output increases by 30% to 50% be-

fore it plateaus at the end of the second trimester

(Colburn, 1999; Knudson, Rozycki, & Paquin,

2004). Progesterone-related smooth muscle relax-

ation leads to a signi¢cant decrease in the total

peripheral vascular resistance, and thus the central

venous pressure drops to approximately 4 mm Hg

at the third trimester. Blood pressure gradually

decreases in the ¢rst trimester, reaching its nadir

at the end of the second trimester with a systolic

and diastolic pressures decreasing by 5 to15 mmHg.

During the third trimester the blood pressure gradu-

ally climbs returning to the nearly prepregnancy

readings. The total blood volume increases by 40%

to 50%while red blood cell volume increases by only

30%.This dilutional e¡ect is referred to as the ‘‘phys-

iological anemia’’ of pregnancy with an average

hematocrit of 35% (Esposito, 1994; Knudson et al.;

Muench & Canterino, 2007).

These hyperdynamic and hypervolemic adapta-

tions help the pregnant patient tolerate the

increase in the metabolic demand of the growing fe-

tus and the expected blood loss associated with

childbirth. The typical vaginal or Cesarean delivery

result in a blood and £uid loss of approximately 500

and 1,000 ml, respectively, which occur with little

change in the maternal vital signs. In the face of

trauma, the nurse may be lulled into a false sense

of security in that there may be minimal if any

change in pulse and blood pressure with volume

losses up to and exceeding 2,000 ml (Knudson

et al., 2004; Shah & Kilcline, 2003).

As the uterus grows from 70 to 1,000 g, with the

entire uterofetoplacental unit averaging 4,500 g at

term, positioning of the patient plays a signi¢cant

role. In the supine position the gravid uterus may

compress the inferior vena cava and decrease pre-

load to the point that cardiac output in signi¢cantly

diminished leading to compromised perfusion to

vital structures. A basic tenet of trauma care of the

pregnant female is to facilitate left lateral side posi-

tioning if feasible. The patient may be strapped to

a backboard and the board tipped to the left provid-

ing protection of the cervical and thoracolumbo-

sacral spines. If this is not possible and the patient is

hypotensive, the gravid abdomen may be grasped

JOGNN 2009; Vol. 38, Issue 6 705

Ruffolo, D. C. I N F O C U S

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and the uterus manually lifted from the inferior vena

cava (American College of Surgeons, Committee on

Trauma, 2004; Knudson et al., 2004).

Pulmonary ChangesThe respiratory system undergoes numerous

changes during pregnancy. The pregnancy-related

increase in blood volume results in engorgement of

the mucosa, causing swelling of the nasal and

oral pharynx, larynx, and trachea. This presents

with a clinical picture of voice changes, shortness

of breath, epistaxis, and can result in a more

di⁄cult tracheal intubation if the need should

arise (American College of Emergency Physicians

[ACEP] Clinical Policies Committee and Clinical

Policies Subcommittee on Early Pregnancy, Ameri-

can College of Emergency, 2003).

Beyond anatomical changes there are changes in

the respiratory physiology. These changes are the

result of the increasing metabolic demands and

oxygen delivery to the fetus. Oxygen consumption

increases 15% to 20%, while progesterone stimu-

lates the medullary respiratory center resulting in

hyperventilation and respiratory alkalosis. This

hyperventilation results in a decrease in the PCO2.

There is an elevation of the diaphragm that contrib-

utes to a 25% decrease in the functional residual

capacity. The increasing levels of 2,3-diphospho-

glycerate help to facilitate oxygen release to the fetus

(Clark et al.,1989; Mattox & Goetzl, 2005;Tsuei, 2006).

Although the physiological changes described

above work to accommodate and facilitate the

growth of the fetus, in the presence of trauma these

changes put the mother at risk. Beginning with the

potential for a di⁄cult airway intubation due to

pregnancy-induced edema, the mother is at risk

because there is diminished oxygen reserve and

bu¡ering capacity. In clinical practice this translates

into rapid hypoxia of the mother and an inability

to compensate for the ensuing acidosis. Both are

harbingers of potential life-threatening complications

of trauma (Clark et al.,1989; Knudson et al., 2004).

If the mother is to undergo general anesthesia,

pregnancy critically changes the need for anes-

thetic drugs. Because of the increased minute

ventilation, halogenated agent dosages should be

reduced by 40%. Additionally, due to the reduction

of serum pseudocholiesterase, there is a longer ne-

uromuscular blockade e¡ect with some agents;

therefore, smaller dosages should be administered

with close monitoring for e¡ect (Clark et al., 1989;

Knudson et al., 2004).

Renal Changes and Pelvic ChangesAt week 12 the pregnant uterus moves into the ab-

domen where it becomes more predisposed to

both blunt and penetrating trauma. Perhaps more

importantly, uteropelvic blood £ow increases mark-

edly, and by pregnancy’s end this dramatic increase

in pelvic blood £ow increases the likelihood of ap-

preciable hemorrhage in the presence of pelvic or

uterine injury. Uterine rupture is a relatively uncom-

mon injury occurring in less than 1% of pregnant

trauma patients. This most often results in fetal

death, and maternal death occurs less then 10%

of the time (Esposito, 1994; Knudson et al., 2004;

Muench & Canterino, 2007).

The bladder is displaced anteriorly and superiorly

by the uterus, e¡ectively becoming an abdominal

organ that is much more susceptible to injury. Due

to the increased glomerular ¢ltration rate and com-

pression by the gravid uterus, the bladder is often

in a state of tension and is therefore more vulnerable

to rupture in the presence of blunt trauma (Knudson

et al., 2004; Shah & Kilcline, 2003).

Gastrointestinal ChangesIn the abdominal cavity there is cephalad displace-

ment of the organs with gradual growth and

stretching of the abdominal and peritoneal cavity.

In the face of a blunt trauma, the abdominal organs

are now pushed up and under pressure, which

make them more vulnerable. Under extreme pres-

sure, hollow viscous structures tend to rupture

while solid organs would fracture or become lacer-

ated (Chames & Pearlman, 2008; Muench &

Canterino, 2007). This stretching of the peritoneal

cavity results in what appears to be a desensitiza-

tion of the peritoneum to irritation in the pregnant

patient. Because of these changes, a physical eval-

uation for abdominal tenderness, rebound, and

guardingmay not be present even when there is free

£uid or blood in the peritoneal cavity (Knudson

et al., 2004; Mattox & Goetzl, 2005).

Progesterone decreases gastric motility and relaxes

smooth muscle such as that found in the esopha-

geal and gastric sphincters. Both of these result in

a patient who is at risk for aspiration in the presence

of a decreased level of consciousness or upon tra-

cheal intubation. Care should be taken to optimizing

Domestic violence has exhibited the mostdramatic increase in the volume of injury in the

pregnant population.

706 JOGNN, 38, 704-714; 2009. DOI: 10.1111/j.1552-6909.2009.01072.x http://jognn.awhonn.org

I N F O C U S Trauma Care and the Injured Pregnant Patient

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upright positioning when spine clearance and vital

signs allow (Mattox & Goetzl, 2005; Shah et al.,1998).

Coagulation ChangesPulmonary embolism is a major cause of maternal

death. Thrombosis is more likely to occur for a num-

ber of reasons. The later stage pregnancies are

associated with a higher body mass index (BMI); a

BMI greater than 26 is an independent risk factor for

deep vein thrombosis after trauma. Additionally,

pregnant women have two components of Virchow’s

Triad, venous stasis, and hypercoagulability. The

compression of the gravid uterus upon the vena cava

triples the venous pressure in the lower extremities

with a perfect medium for clot formation (Knudson

et al., 2004; Mattox & Goetzl, 2005; Simpson, 2006).

In addition, estrogen increases the hepatic produc-

tion of coagulation factors, yielding a 30% to 50%

increase in ¢brinogen and Factors VII, VIII, IX, and X

Knudson et al.; Mattox & Goetzl).

Trauma and its associated interventions then com-

plete the third component of Virchow’s triad,

vascular injury. Means for prevention should be

instituted as soon as safely possible, such as low-

dose heparin, intermittent pressure stockings,

and early ambulation (Mattox & Goetzl, 2005;

Simpson, 2006). SeeTable 1 for a review of changes

with pregnancy.

Prehospital CarePrehospital providers face the daunting task of

completing the initial evaluation and resuscitation

of the pregnant trauma patient. Part of this assess-

ment is obtaining as much information as possible

regarding the patients’ history and events sur-

rounding the injury. Care must be taken during the

initial assessment that the presenting symptoms

may not fully re£ect the underlying injuries to

mother and fetus.

General tenets of trauma care apply with some

modi¢cation for the gravid female. Extrication and

spinal immobilization are unchanged with every ef-

fort made to be certain that the entire spine remain

secured until either cleared radiographically and/or

clinically. Supplemental oxygen is applied and ve-

nous access is obtained (American College of

Surgeons, Committee onTrauma, 2004; Eastern As-

sociation for the Surgery of Trauma [EAST], 2005).

Volume loss can occur before there is a noticeable

change in vital signs.

Most pregnant trauma patients should be immedi-

ately transported to a recognized trauma center.

Prehospital ¢ndings of tachycardia, de¢ned as a

heart rate greater than 110 beats per minute, chest

pain, loss of consciousness, and third trimester

pregnancy have been independently associated

with the need for care at a tertiary trauma center.

All care guidelines recognized by Advanced Trau-

ma Life Support and prehospital care of the

pregnant patient are similar to those of the non-

pregnant patient. Life-saving interventions such as

emergency medications, procedures, and diagnos-

tic studies should be undertaken irrespective of the

patient’s pregnancy status (American College of

Surgeons, Committee on Trauma, 2004; EAST,

2005).

Initial Hospital AssessmentThe initial evaluation is organized to identify life-

threatening injuries with the assessment of airway,

Table 1: Changes in Normal Pregnancy

Affected System Change During Pregnancy

Systolic blood pressure Decreased by an average

5-15 mmHg

Diastolic blood pressure Decreased by 5-15 mm Hg

Electrocardiogram Flat/inverted Twaves in III, V1 V2

Blood volume Increased by 30%-50%,

physiological anemia

Hemodynamics Hyperdynamic, hypervolemic,

vena caval compression

Respiratory system Increased oxygen consumption,

hyperventilation, respiratory

alkalosis

Genitourinary tract Mild hydronephrosis, bladder

compressed

Gastrointestinal tract Diminished sphincter function,

increased risk of aspiration,

organs moved superiorly

Musculoskeletal system Widened symphysis pubis and

sacroiliac joints

Peritoneum Small amount of £uid present and

becomes relatively insensate in

the presence of abdominal injury

The practitioner must be aware up to 2L of volumeloss can occur before there is a noticeable change

in vital signs.



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breathing, and circulation. It is with this initial evalu-

ation that interventions are aimed at achieving

maternal cardiopulmonary stability with subse-

quent stabilization of the fetus. Attention at this

level requires a seamless approach to care with a

multidisciplinary team that includes trauma sur-

geons and nurses, obstetric physicians and

nurses, as well as experts in maternal-fetal care.

Primary SurveyThis initial assessment should be completed within

60 seconds and should identify all life-threatening

injuries. While in-line cervical stabilization is main-

tained in neutral position, the airway is assessed

for patency and stability. Respiratory rate and e¡ort

are assessed with the application of high-£ow oxy-

gen. Because of diminished maternal oxygen

reserve, early consideration for intubation should

be entertained. As pregnant patients are at risk for

aspiration due to increased intragastric pressure

and lowered esophageal sphincter tone, securing

the airway o¡ers protection early on.While intubat-

ing this patient, it should be assumed that there is a

full stomach and a cervical spine injury (American

College of Surgeons, Committee on Trauma, 2004;

EAST, 2005; Tweddale, 2006).

Intubation and placement of an airway should be un-

dertaken with caution as airway edema, tongue

enlargement, increased breast size, and generalized

weight gain of pregnancy can make this a di⁄cult

airway. Denitrogenation and preoxygenation

with 100% oxygen is provided before intubation

because of maternal decreased residual capacity

and increased oxygen consumption associated with

pregnancy. Intubation is accomplished with rapid

sequence induction and application of cricoid pres-

sure. As previously discussed, attention to dosages

of agents must be adjusted. Both nondepolarizing

and depolarizing agents cross the placenta and

may result in a £accid and apneic infant (American


EAST, 2005; Mattox & Goetzl, 2005; Simpson &

James, 2005).

The presence of decreased lung sounds, dyspnea,

subcuteanous emphysema, and hypotension may

suggest a tension pneumothorax. Immediate de-

compression may be accomplished by placing a

large gauge catheter into the second intercostal

space at the midclavicular line. After decompres-

sion a chest tube must be inserted. The insertion

site is moved cephalad to the third or fourth inter-

costals spaces, higher than the nonpregnant

patient due to rising diaphragm and increase in the

anteroposterior diameter of the chest (American


Mattox & Goetzl, 2005; Muench et al., 2004).

Both central and peripheral pulses are evaluated

for rate and quality. The skin is assessed for color

and temperature followed by evaluation of capillary

re¢ll. Gross bleeding is addressed while venous ac-

cess is obtained with two large bore intravenous

catheters (ACEP Clinical Policies Committee and

Clinical Policies Subcommittee on Early Pregnancy

& American College of Emergency, 2003; American

College of Surgeons, Committee onTrauma, 2004).

Aggressive £uid resuscitation for the pregnant trau-

ma patient should include 2 L of warmed £uid such

as lactated Ringer’s solution or normal saline in-

fused rapidly to replace volume loss. Fluids are

administered at a 3:1 ratio for the estimated blood

loss, 3 ml of resuscitation volume for every milliliter

of blood loss (American College of Surgeons, Com-

mittee onTrauma; EAST, 2005).

In the face of continued hemodynamic compromise,

transfusion of typed and crossed blood is preferred

to crystalloid solutions. In an emergent setting,

however, type O Rh-negative blood is utilized

(EAST, 2005; Mattox & Goetzl, 2005). Because va-

sopressors compromise perfusion to vital structure

including the uterofetoplacental unit, it is preferred

to replace volume to augment cardiac output and

blood pressure rather than to use vasopressors. Va-

sopressor therapy may become necessary at some

time during the resuscitation and while norepineph-

rine and epinephrine restore maternal blood

pressure they subsequently compromise uterine

perfusion. Ephedrine and mephentermine increase

maternal blood pressure without compromising

uterine blood £ow (Clark et al., 1989; Knudson

et al., 2004; Mattox & Goetzl ; Simpson, 2006).

To facilitate venous return and stabilization of blood

pressure, the patient should be tipped151 to the left,

o¡-loading the gravid uterus from the inferior vena

cava. This maneuver can increase the cardiac out-

put by 30% (American College of Surgeons,

Committee onTrauma, 2004; Mattox & Goetzl).

A rapid evaluation of the neurological status is ac-

complished by utilizing the Glasgow Coma Scale.

This scale is a gross assessment of neurologi-

cal status used by trauma care providers for a

quick neurological assessment and ranges from

3 5 severe brain damage to 15 5 normal neurolog-

ical functioning. Patients with a score less than 8

typically require tracheal intubation and mechani-

cal ventilation for protection of their airways and to

meet the oxygen demand of tissue beds. Eclampsia



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should be included in the di¡erential diagnosis for

those pregnant trauma patients with an altered level

of consciousness or seizure activity (American Col-

lege of Surgeons, Committee on Trauma, 2004;

EAST, 2005; Sosa, 2008).

There should be a brief period of complete expo-

sure of the patient with removal of all clothing,

which will help facilitate identi¢cation of any life-

threatening injuries. Immediately thereafter, all ef-

forts to prevent or treat hypothermia should be

engaged (ACEP Clinical Policies Committee and

Clinical Policies Subcommittee on Early Pregnancy

& American College of Emergency, 2003; American


EAST, 2005).

Secondary SurveyThis aspect of assessment includes a complete

head-to-toe inspection of the patient in an e¡ort to

identify all injuries that may have been missed once

all life-threatening injuries have been identi¢ed and

treated. It is helpful during this time to obtain as much

¢eld information as available regarding the mecha-

nism of injury such as use of restraint devices,

distance of fall, and other pertinent information. It is

important to obtain a complete medical and obstet-

ric history including last menstrual period, current

and past pregnancy complications, prenatal care,

and estimated gestational age.

Fetal heart tones should be assessed as soon as

possible during the secondary survey. The normal

fetal heart rate ranges from 120 to 160 beats per

minute. Fetal heart tones can be auscultated after

20 weeks gestation and with Doppler ultrasound at

10 to 14 weeks. Fetal monitoring should be continu-

ous for gestational ages that exceed 24 weeks.

Even in the absence of any signi¢cant injury, the

monitoring should continue for 4 to 6 hours after

the traumatic event (American College of Surgeons,

Committee on Trauma, 2004; Chames & Pearlman,

2008; Esposito,1994; Muench & Canterino, 2007).

Fetal compromise may be manifested by brady-

cardia, tachycardia, loss of beat-to-beat variability,

or recurrent decelerations. When the pregnant

female experiences hemorrhage, blood is shunted

from the uterofetoplacental unit; therefore, abnor-

mal fetal heart rates may be the ¢rst indication

that hemodynamic instability is impending. For this

reason, the fetal heart rate is considered the ‘‘¢fth

vital sign’’ in obstetrics (Chames & Pearlman, 2008;

Clark et al.,1989).

Particular attention should be given to the abdo-

men; there should be inspection for ecchymoses

or asymmetry. Findings consistent with injuries to

the liver or spleen include upper abdominal pain,

referred shoulder pain, and acute distension.

Keeping in mind that the gravid abdomen may

make it relatively insensate to peritoneal irritation,

a focused assessment sonography of trauma scan

should be performed to evaluate for intra-abdomi-

nal hemorrhage. If there is need for rapid

evaluation of the presence of intraperitoneal bleed-

ing, a diagnostic peritoneal lavage can safely be

performed on the pregnant female by utilizing the

open or direct technique.This approach is less likely

to result in a potential injury to the underlying struc-

tures that might be inadvertently punctured by

utilizing the percutaneous technique (Ma, Mateer,

& DeBehnke,1996; Shah et al.,1998).

One should assess the uterus to determine gesta-

tional age and to assess for contractions or rigidity.

The distance from the top of the uterine fundus to the

pubic symphysis measured in centimeters corre-

lates to gestational age. Fetal viability is most likely

to occur when the uterus can be palpated at 3 to

4 cm above the level of the umbilicus (Ho¡ et al.,

1991; Muench & Canterino, 2007; Shah et al.,1998).

Incorporated into the secondary survey of the preg-

nant female is that of a sterile-speculum vaginal

examination. This is to evaluate for ruptured mem-

brane and for vaginal bleeding. Vaginal bleeding

may indicate preterm labor, abruption, pelvic frac-

ture, or uterine rupture. Included into this part of the

evaluation is a manual cervical and rectal examina-

tion.These parts of the survey should be deferred to

the team member with the most experience in car-

ing for the gravid female (Esposito, 1994; Tsuei,

2006; Tweddale, 2006).

A complete assessment of the patient continues

from head to toe to observe for any abnormalities,

lacerations, ecchymosis, and tenderness. Retained

foreign bodies, such as knives, should not be re-

moved until there is an environment that can

provide a rapid surgical intervention should the

need arise. After full assessment adjuncts such as

naso/orogastric tubes and foley catheters may be

inserted (American College of Surgeons, Commit-

tee onTrauma, 2004; EAST, 2005).

Initial laboratory studies of the pregnant trauma

patient should include hemoglobin, hematocrit, co-

agulation studies, type and crossmatch, and a

urinalysis. Blood alcohol and a urine drug screen



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may also be indicated. In severe trauma a blood gas

analysis or serum lactate may be obtained, as there

is data to suggest that maternal acidosis is linked to

fetal survival, the more profound the acidotic state

of the mother the less likely to have an optimal out-

come for the fetus (Ho¡ et al.,1991; Mattox & Goetzl,

2005; Shah et al., 1998). A ¢brinogen level that is

normal in the nonpregnant female may be abnor-

mal for pregnancy and be an early indicator of

placental abruption (Mattox & Goetzl). A Kleihauer-

Betke test should be considered in all trauma pa-

tients because it may be an indicator of the severity

of uterine-placental traumaand those that are at risk

for preterm labor (Muench et al., 2004). An Rh-nega-

tive patient with a positive test should be treated with

Rh-immune globulin (300 mg initially with an addi-

tional 300 mg for each 30 ml of estimated whole fetal

blood) to reduce the risk of isoimmunization.The Rh-

negative patient with signi¢cant trauma and a posi-

tive Kleihauer-Betke test should have additional

antibody screening done 24 to 48 hours after injury

(EAST, 2005; Mattox & Goetzl ; Muench & Canterino,

2007; Muench et al.).

Diagnostic tests should be obtained in the pregnant

trauma patient in the same manner as indicated for

the nonpregnant patient. Normal chest radiographic

¢ndings in a pregnant female include mild cardiome-

galy, a widened mediastinum, elevated diaphragms,

and prominence of pulmonary vasculature. The pel-

vic X-ray reveals a widening of the symphysis pubis

and sacroiliac joints (ACEP Clinical Policies Commit-

tee and Clinical Policies Subcommittee on Early

Pregnancy, American College of Emergency, 2003;

Shah et al.,1998).

No study to date has shown any increase in

teratogenicity for a fetus exposed to less than

10 rads or 100 mGy (Lowe, 2004; North, 2002).

Growth restriction, microcephaly, and mental retar-

dation can occur with high-dose radiation well

above that prescribed in medical imaging (Lowe;

North; Osei & Faulkner, 1999). The fetus is most at

risk for central nervous system e¡ects at 8 to 15

weeks and the threshold appears to be at least

20 to 40 rads or 200 to 400 mGy. The American

College of Obstetricians and Gynecologists has

published recommendations for diagnostic imaging

during pregnancy. They state that that 5 rad or

50 mGy exposure to the fetus is not associated with

any increased risk of fetal loss or birth defects

(North; Osei & Faulkner).

The fetal dosage without shielding is 30% of that

to the mother. Mandatory shielding of the fetus

decreases this exposure and should be performed

during all studies except for pelvis, lumbar plain

¢lms, and computed tomography. If multiple diag-

nostic studies are to be employed then a consul-

tation to a radiation specialist for radiation dosages

should be obtained and use of other investigative

techniques such as ultrasonography should be

considered (Lowe, 2004; Ma et al., 1996; Osei &

Faulkner,1999).

Blunt Trauma

Blunt trauma in pregnancy may be a result of motor

vehicle crashes, falls, and violence.The mechanism

may present with di¡erent abdominal injuries when

comparing the gravid to the nongravid female.

Because the uterus changes location of the

abdominal contents, transmission of energy is al-

tered and the injury pattern is di¡erent. Due to the

increase vascularity during pregnancy there is a

signi¢cant increase in splenic and retroperitoneal

injury (Knudson et al., 2004; Scorpio, Esposito,

Smith, & Gens,1992).Up to 25% of pregnant women

with severe blunt trauma present with hemodynam-

ic compromise secondarily to signi¢cant hepatic

or splenic injury. Conversely, bowel injury occurs

with less frequency (Dahmus & Sibai,1993; Knudson

et al.; Scorpio et al.).

Fractures of the pelvis may result in signi¢cant

bleeding, and management is not di¡erent than

that of the nonpregnant patient. Evaluation for

associated injuries such as bladder, urethra, and

rectosigmoid should be considered. The presence

of a pelvic fracture is not an absolute contraindica-

tion for a vaginal delivery. If the pelvic architecture is

not substantially disrupted, then a vaginal delivery

can safely be performed (Knudson et al., 2004;

Loegters et al., 2005; Muench & Canterino, 2007).

Placental injury during blunt trauma presents a

threat to both patients. The placenta does not con-

tain elastic tissue and does not have the capacity

to expand and contract, in comparison to the

uterus, which contains pliable tissue and can react

to the acceleration-deceleration forces that are as-

sociated with blunt trauma. The two opposing

structures then result in increased intrauterine pres-

sure that produces a shearing e¡ect that results in

a separation of the placenta from the uterine wall

(Dahmus & Sibai, 1993; Hyde et al., 2003; Mattox &

Goetzl, 2005). This is the most common mechanism

for abruption in blunt trauma and presents approxi-

mately 40% of the time in severe maternal trauma

(Muench & Canterino, 2007). With abruption as

seen in signi¢cant blunt trauma, fetal death occurs

60% of the time, second only to maternal death for

the frequency of fetal death in trauma (Muench &



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Canterino). Examination of this patient may reveal

abdominal tenderness, uterine contractions, vagi-

nal bleeding, and back pain. Signs of fetal distress

as previously discussed will be present (Dahmus &

Sibai ; Muench & Canterino).

Direct fetal injuries and fractures complicate less

than 1% of all cases of severe blunt trauma. This is

accounted for by the protective nature of maternal

soft tissue, uterus, amniotic £uid, and the mandatory

use of seatbelt/shoulder restraints and airbags. Most

cases of fetal injury occur in late pregnancy when

there is thinning of the uterine wall and diminished

amniotic £uid. The most common mechanism is that

of fetal brain and skull injury that is much more com-

mon when fetal engagement has occurred and is

associated with maternal pelvic fractures (Dahmus

& Sibai,1993; Scorpio et al.,1992; Tyroch, Kaups, Ro-

han, Song, & Beingesser,1999).

PenetratingTrauma

The most common cause of penetrating trauma in

pregnancy is gunshot wounds. Maternal death from

gunshot wounds is 4% in comparison to 13% of the

nonpregnant patient (Muench & Canterino, 2007).

Additionally, the death rate from stab wounds is low-

er as well. This reduction in mortality arises from the

anatomical changes that occur during pregnancy.

The visceral organs are displaced superiorly by the

uterus and results in what is referred to as the ‘‘pro-

tective-e¡ects’’ of the uterus (Knudson et al., 2004;

Lowe, 2004; Muench & Canterino). However, when

penetrating injury involves the upper abdomen, a

pregnant woman is more likely to sustain a visceral

injury than a nonpregnant woman (Lowe). Fetal mor-

tality occurs in approximately 50% of penetrating

injuries to the uterus and results from either prema-

ture delivery or direct fetal injury (Ho¡ et al.,1991).

Management of the penetrating abdominal injury

to the pregnant patient often takes on a di¡erent

approach to care. Traditional trauma care of a pen-

etrating injury to the abdomen warrants exploration

whether through a laparotomy or laparoscopic

exam (American College of Surgeons, Committee

on Trauma, 2004; EAST, 2005) With the displace-

ment of the visceral organs cephalad in later

pregnancy other approaches to care on the hemo-

dynamically stable mother and fetus might include

a contrast-enhanced CT scan, local wound

exploration, or even observation (Chames & Pearl-

man, 2008; Knudson et al., 2004; Mattox & Goetzl,

2005). Any approach to care requires vigilant obser-

vation with the ability to convert the treatment

plan to surgical intervention with short notice.

The exploratory laparotomy involves investiga-

tion of all organs with attention to the uterus. Deliv-

ery of the fetus is rarely necessary unless there

is direct penetrating injury to the uterus (Ho¡

et al.,1991).

Domestic Violence

The nurse caring for the pregnant trauma patient

should have a heightened awareness of the associ-

ation between pregnancy and intimate partner

violence. Typically the pattern of abuse demon-

strated is as the pregnancy progresses the abuse

may increase in frequency and intensity. A common

occurrence is for the mother to come to the emer-

gency department reporting falls, household

accidents, and other reasons that result in injury.

The nurse should be aware of the pattern of abuse

with an emphasis on the abdomen, breast, and

genitals (Canterino et al., 1999). The most common

fetal injuries include abruption, early delivery, and

low birth weight associated with compromised pla-

cental blood £ow (Sharps, Laughon, & Giangrande,

2007). The most e¡ective strategies for identifying

domestic abuse are screening questions such as,

‘‘Do you feel safe? Since you have been pregnant

have you been slapped, hit, kicked or hurt by some-

one?’’ This initial evaluation should be followed by a

consultation with social services to be certain a

protective plan of care is in place (Canterino et al.).

If the nurse believes domestic violence has oc-

curred, then mandatory reporting laws require the

nurse to notify local authorities.

Trauma Prevention

The most common mechanism of trauma for preg-

nant patients is motor vehicle crashes. Nurses can

be instrumental in trauma prevention for pregnant

patients by educating mothers about safe driving

habits, the importance of wearing seatbelts, and

avoiding dangerous driving conditions. Domestic

violence, drug, and alcohol screening are also tools

that can aid the nurse in preventing traumatic inju-

ries to their pregnant patients.

ConclusionTrauma is the leading cause of nonobstetric mater-

nal death. It is important for the nurses caring for

the mother and fetus be familiar with the basic prin-

An interdisciplinary team of trauma, perinatal and neonatalnurses, and physicians is optimal for the best maternal

and fetal outcome.



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ciples of trauma care, from the importance of get-

ting the patient to a tertiary trauma center to

understanding the anatomic and physiological

changes present in pregnancy. Added to this is a

need to understand mechanism of injury and how

it impacts the pregnant patient di¡erently than the

nonpregnant. The goal of the nurse is to assist in

stabilization and resuscitation of the mother and in

doing so facilitating a good outcome for the fetus.

For the best outcome, an interdisciplinary team of

trauma, perinatal and neonatal nurses and physi-

cians is optimal. This group of patients provides an

opportunity for nurses and physicians frommultiple

specialties to come together to provide seamless

and expert care.

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175-180.

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Tyroch, A. H., Kaups, K. L., Rohan, J., Song, S., & Beingesser, K. (1999).

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Continuing Nursing Education

To take the test and complete the evaluation, please visit

http://JournalsCNE.awhonn.org.

Certi¢cates of completion will be issued on receipt of the

completed evaluation form, application and processing

fees. Note: Accredited status does not imply endorsement

by AWHONN or ANCC of any commercial products dis-

played or discussed in conjunction with this activity.

Learning Objectives

After reading this article, the reader will be able to

1. Describe the anatomical and physiological di¡er-

ences between the pregnant trauma patient and the

nonpregnant patient and how these di¡erences im-

pact this population’s response to injury.

2. Summarize the contents of primary and secondary

survey and integrate the components as they apply

to the assessment of the trauma patient.

3. Specify the di¡erences in symptoms and care ap-

proaches to blunt and penetrating trauma injuries.

Post Test Questions1. The primary focus on caring for the two victims

of trauma in pregnancy is

A. rapid assessment and transport

B. stabilization of the mother

C. understanding the changes in vital signs

associated with pregnancy

2. Pregnancy alone does not increase the likeli-

hood of mortality from trauma. The most

signi¢cant factor is

A. age of the patient

B. degree of shock

C. injury severity

3. The distribution of mechanism of injury in-

cludes motor vehicle crashes, falls, assaults

and burns. The mechanism with the largest in-

crease in volumes is

A. assaults

B. falls

C. motor vehicle crashes

4. During pregnancy, the increasing demands of

oxygen carrying capacity to the fetus is ac-

complished in the following manner:

A. decrease in heart rate

B. increase in cardiac output

C. increase in total peripheral vascular resis-

tance

5. There is compromised venous return from

compression of the inferior vena cava by the

gravid uterus. A maneuver to prevent this is

A. high Fowlers position

B. left lateral positioning or manual displace-

ment of the uterus

C. right lateral positioning and elevation of

knees

6. The increasing metabolic demands of preg-

nancy put the pregnant woman in a state of

A. metabolic Alkalosis

B. respiratory acidosis

C. respiratory alkalosis

7. The increasing stretch of the abdominal and

peritoneal cavities results in

A. desensitization to blood and/or £uid in the

intra-abdominal cavity

B. decreased blood £ow to organ beds

C. increased rebound tenderness and referred

pain

8. Pre-hospital care of the pregnant trauma victim

includes

A. assessment of fundal height

B. supplemental oxygen and venous access

C. transfer to a neonatal center

9. The primary survey is de¢ned as follows:

A. Airway-Breathing-Circulation- Designation

and should be completed in 5 minutes

B. Airway-Breathing-Circulation-Details and

should be completed in 90 seconds

C. Airway-Breathing-Circulation-Disability

and should be completed in 60 seconds

10. Management of the pregnant trauma victim

with chest injury may include all of the follow-

ing except

A. needle decompression below the ¢rst rib

space

B. chest tube insertion 1-2 intercostal spaces

higher then the non-pregnant patient

C. supplemental oxygen and intubation as

needed



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11. The basic tenet of volume resuscitation in the

pregnant female is

A. administer 3 ml of crystalloid £uid for every

1ml of blood loss and re-evaluate

B. in an emergent setting the universal donor

O Rh-positive may be administered

C. minimize £uid due to £uid overload from

pregnancy

12. The ‘‘¢fth vital’’ sign of obstetrics augments

care of the mother and fetus in that it alerts

the caregiver to instability. This is de¢ned as

A. fetal heart tones

B. measurement of the uterine fundus

C. vaginal examination

13. Signs of uterine abruption include all of the

following except

A. Back pain

B. Boggy abdomen

C. Vaginal bleeding

14. The evaluation of the trauma victim entails

multiple diagnostic studies. The care in the

pregnant victim includes

A. Order studies in the same manner as one

would for the non-pregnant patient

B. Order studies that have the minimal radia-

tion exposure

C. Rely on clinical evaluation and invasive in-

terventions

15. Initial management of the patient with a re-

tained impaled object include the following:

A. immediate removal

B. obtain a stat x-ray to determine the length

and trajectory of the impaled object

C. secure and evaluate under controlled cir-

cumstances and obtain venous access



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Documents

Trauma Care and Managing the Injured Pregnant Patient