CHAPTER 36 Obstetric Trauma

Major traumatic injury is a primary cause of mortality during pregnancy, and it accounts for up to 22% of all maternal deaths. It is estimated that 1 in 12 pregnant women will have some type of injury during pregnancy, with the majority of injuries occurring during the third trimester. Pregnant women are also at a higher risk for developing aortic dissection. The number of maternal deaths resulting from penetrating forces, suicide, homicide, and motor vehicle crashes has steadily risen. Many of these trauma patients are treated in emergency departments, but hospital admission is required in only 4 out of 1000 incidences. The potential for pregnancy must be considered in any female trauma patient between the ages of 10 and 50 years. The most common type of injury in pregnant women is blunt force trauma resulting from motor vehicle crashes, which account for approximately 60% of all major injuries. Other mechanisms include falls, burns and inhalation injury, firearm and stab wound injuries, and intimate partner violence. Approximately 17% of injured pregnant patients experience trauma as a result of another person, and 60% of these patients will have repeated episodes of domestic violence. The incidence of domestic violence and intentional injury increases as the pregnant woman reaches her due date. Homicide and suicide are leading causes of maternal mortality during pregnancy, and the fetus becomes increasingly susceptible to injury after 24 weeks’ gestation.

Head injury and shock are the most frequent causes of maternal death in pregnancy-related trauma. The most common cause of fetal death is maternal death. The second leading cause of fetal death is maternal shock; fetal demise results 80% of the time the mother experiences hemorrhagic shock.

Diagnostic procedures and therapeutic procedures should benefit both the mother and the fetus. Resuscitation should not be delayed if pregnancy is suspected or until it is confirmed. Stabilization of the mother is the first priority. Evidence suggests that the best chance for fetal survival is to ensure maternal survival. Therefore, it is critical to direct medical attention toward maternal well-being. The outcome of trauma in pregnancy is a function of the same factors as with any injured patient: magnitude of the injury, organ systems involved directly and indirectly, success and rapidity of resuscitation, and the ability of the patient’s physiologic reactions to respond and reach the preinjury state.

Assessment of the pregnant trauma patient may be more difficult because of the anatomic and physiologic changes that occur during pregnancy (Table 36-1). These changes can mask normal physiologic responses to traumatic injury and must be considered early in the treatment of the pregnant trauma patient. It is essential to have an understanding of these changes when the trauma patient is pregnant.

Table 36-1 ANATOMIC AND PHYSIOLOGIC CHANGES IN PREGNANCY

I. GENERAL STRATEGY

A. Assessment

1. Primary and secondary assessment/resuscitation (see Chapters 1 and 31)

2. Focused assessment

a. Subjective data collection

1) History of present injury/chief complaint

a) Mechanism of injury (seeChapter 30)

(1) Restraint use

(2) Position in vehicle

b) Loss of consciousness: eclampsia may mimic head injury

c) Pain (see Chapter 9)

d) Vaginal bleeding or fluid leak

e) Uterine contractions/abdominal pain

f) Fetal movement prior to and since injury

g) Efforts to relieve symptoms

(1) Home remedies

(2) Alternative therapies

(3) Medications

(a) Prescription

(b) Over-the-counter/herbal

2) Past medical history

a) Current or preexisting diseases/illness

b) Last normal menstrual period, expected date of confinement

c) Reproductive history

d) Prenatal care

e) Previous surgical procedures

f) Smoking history

g) Substance and/or alcohol use/abuse

h) Current medications

(1) Prescription

(2) Over-the-counter/herbal

(3) Clergy or religious support

i) Allergies

j) Immunization status

3) Psychological/social/environmental factors related to trauma in pregnancy

a) Support network

(1) Family

(2) Friends

b) Stress factors

(1) Lifestyle

(2) Coping patterns

(3) Precipitating event

(4) Possible/actual assault, abuse, or intimate partner violence situations (see Chapter 3)

c) Psychological illnesses

b. Objective data collection

1) General appearance

a) Level of consciousness, behavior, affect

b) Vital signs

c) Odors

d) Gait

e) Hygiene

f) Level of distress/discomfort

2) Inspection

a) Abdominal girth, uterine size

b) Abdominal ecchymosis

c) Uterine contractions

d) Vaginal lacerations

e) Vaginal bleeding/discharge/fluid leak

f) Crowning/presenting fetal parts

3) Auscultation

a) Fetal heart tones

b) Bowel sounds

4) Palpation

a) Abdominal tenderness

b) Fundal height

c) Palpable fetal parts

3. Diagnostic procedures

a. Laboratory studies

1) Complete blood count (CBC) with differential

2) Serum chemistries including glucose, blood urea nitrogen (BUN), and creatinine

3) Coagulation profile: prothrombin time (PT), partial thromboplastin time (PTT), fibrinogen, fibrin split products

4) Blood type and Rh determination, and crossmatch

5) Urinalysis, pregnancy test

6) Serial hemoglobin and hematocrit

7) D-dimer

8) Kleihauer-Betke test: detection of fetomaternal hemorrhage

9) Serum and urine toxicology screen, blood alcohol level

10) Arterial blood gas (ABG) determination: carbon dioxide (PACO₂) of 35 to 45 may indicate impending respiratory failure because CO₂ levels are lower during pregnancy

11) pH of vaginal secretions/fluid or bedside point-of-care test

b. Imaging studies

Indicated imaging examinations should not be deferred because of pregnancy, but fetal exposure should be limited as much as possible. Radiologic examinations must be interpreted in the context of pregnancy-related changes.

1) Maternal radiographic procedures as indicated

2) Abdominal, pelvic, or transvaginal sonography

3) Computed tomography (CT) scan

a) Head and chest CT if indicated

b) Abdominal CT should be avoided in early pregnancy if possible; if CT is necessary, both oral and intravenous (IV) contrast media should be administered

c) Transabdominal sonography/Focused Assessment Sonography for Trauma (FAST)

c. Other

1) Possible diagnostic peritoneal lavage (DPL)

2) 12- to 15-lead electrocardiogram (ECG): ectopic beats may increase during pregnancy

3) Cardiotocography: monitoring fetal heart rate and uterine contractions

B. Analysis: Differential Nursing Diagnoses/Collaborative Problems

1. Risk for ineffective airway clearance

2. Risk for ineffective breathing patterns

3. Impaired gas exchange

4. Risk for decreased cardiac output

5. Ineffective tissue perfusion

6. Deficient fluid volume

7. Impaired skin integrity

8. Risk for infection

9. Pain

10. Anxiety/fear

11. Anticipatory grieving

12. Risk for ineffective coping

13. Risk for other-directed violence

14. Deficient knowledge

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