All injured pregnant women should have an urgent obstetric review as soon as posssible.

Pre-hospital triage

Any pregnant trauma patient who meets the pre-hospital major trauma triage criteria should be transported to the Royal Melbourne Hospital. However, where the expected transport time to the Royal Melbourne is longer than 45 minutes, the patient is to be transported to the highest level of trauma service within 45 minutes (preferably with obstetric capability).

Any obstetric patient who is more than 20 weeks’ gestation and sustains trauma not meeting the time-critical criteria still faces potential harm to the unborn child and should be transported to a hospital that has both obstetric and trauma capabilities.

For a trauma team to run effectively there must be an identifiable leader who will direct the resuscitation, assess the priorities and make critical decisions. Good communication between the trauma team members is vital, as is ensuring that local senior staff are aware and can provide additional support if required.

Inter-hospital transfer

Once the initial assessment and resuscitation is underway, is it important to plan the next steps in immediate management. Priorities for care must be based on sound clinical judgement, patient presentation and response to therapies. Awareness of limitations in resources as well as training in the emergency field is vital. If escalation of care to senior staff is warranted, then do so early in the patient care episode. Do not wait until the patient deteriorates to ask for assistance.

Frontline clinical staff should initiate contact with ARV early in the patient care pathway or, more importantly, as soon as it is identified that the patient meets the inter-hospital trauma transfer criteria or may have sustained injuries beyond the clinical skill set of the emergency department or urgent care centre. ARV can be contacted at any time throughout the patient care episode to offer or coordinate clinical advice and consultation.

ARV coordinators can facilitate a three-way conversation between the referral health service, specialist obstetric resources and the ARV consultant to discuss the best, timely management of the patient.

The decision of when to transfer an unstable patient should ideally be made by the transferring and receiving clinicians in collaboration with the retrieval service. Clear communication is crucial: the transmission of vital information allows receiving clinicians to mobilise needed resources while the inadvertent omission of such information can delay definitive care. Information should be conveyed in both verbal and written (via the patient record) form and should include the patient’s identifying information, relevant medical history, pre-hospital management and emergency department evaluation and treatment (including any procedures performed and imaging obtained).
It is important that additional communication with the ARV coordinator is initiated when there is:

1. Significant deterioration in

• conscious state
• blood pressure
• heart rate
• respiratory status
• oxygenation

2. Major clinical developments such as significantly abnormal diagnostic tests or new clinical signs
3. The need for major interventions prior to the retrieval team arriving (for example, intubation or surgery). This will ensure the retrieval team is prepared, the patient receives the appropriate care en route and that the patient is referred to the correct facility.
    

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