Wherever possible, immediately from the time of commencing a primary survey, pregnant patients beyond 20 weeks gestation should be nursed in a manner which reduces compression of the great vessels by the pregnant uterus (aortocaval compression or supine hypotension syndrome). Supine positioning may result in significant compromise in both  circulation and respiratory status.

Avoidance of aortocaval compression can be achieved either by manual left uterine displacement, or by positioning with a left lateral tilt of 15–30 degrees, using a wedge.  Where a wedge is not available, similar effect can be achieved by placing a rolled up towel or bags of saline under the mother’s right hip. Where the patient is immobilised on a spine board, this may mean positioning a wedge beneath the board if manual uterine displacement is not possible.

Increasingly, consensus opinion suggests that manual displacement of the uterus with either a one or two handed technique should be the method of choice, particularly in the haemodynamically unstable or critically injured pregnant patient. Manual left uterine displacement appears to result in less hypotension and less haemodynamic instability than tilting the patient, but does require an additional team member to execute. Manual left uterine displacement also facilitates more effective chest compressions in the event of cardiac arrest, and will facilitate easier access to the patient for the rest of the resuscitation team⁸.

 

 

 

 

 

 

Use a systematic approach based on the ABCDE⁹ survey to assess and treat an acutely injured patient. The goal is to manage any life-threatening conditions and identify any emergent concerns, especially in a pregnant patient who may present with other underlying polytrauma complications.

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 Airway with cervical spine protection

Assess for airway stability

Attempt to elicit a response from the patient.

Look for signs of airway obstruction (use of accessory muscles, paradoxical chest movements and see-saw respirations).

Listen for any upper airway noises and breath sounds. Are they absent, diminished or noisy?

Attempt simple airway manoeuvres if required

Open the airway using a chin lift, jaw thrust and neck tilt. (Do not apply a neck tilt if a spinal injury suspected.)

Suction the airway if excessive secretions are noted or if the patient is unable to clear it themselves.
Insert an oropharyngeal airway (OPA)/nasopharyngeal airway (NPA) if required.

If the airway is obstructed, simple airway opening manoeuvres should be performed, including suction, jaw thrust or chin lift. Care should be taken to not extend the cervical spine.
If the patient is already intubated, document the size and position of the endotracheal tube, including lip level, end-tidal carbon dioxide (ETCO₂)trace, cuff pressure, any intubation difficulty (or Mallampati grade).

Where possible, delegate ongoing airway management to an airway doctor/nurse and continue the initial assessment.
Maintain full spinal precautions if indicated.

Secure the airway if necessary (treat airway obstruction as a medical emergency)

Consider intubation early if there are any signs of decreased level of consciousness, unprotected airway or an uncooperative/combative patient, leading to distress and further risk of injury.

Intubation should be considered earlier in pregnant patients compared with non-pregnant patients because pregnant women desaturate more rapidly and are more susceptible to irreversible hypoxic injury. Crucially, maternal hypoxia is associated with poor fetal outcomes.

However, the likelihood of failed intubation is higher in a pregnant patient, and intubation is increasingly difficult with advanced gestation. Intubation of a pregnant patient should be attempted by the most senior and experienced airway-skilled practitioner. In the event of a failed intubation, sustained cricoid pressure should be maintained to prevent aspiration in the unprotected airway.

Preparations for a difficult intubation should start early, with fibre-optic intubation equipment available for all pregnant women, but particularly for those with a known difficult airway or facial or cervical fractures. Correct airway placement should be confirmed with auscultation, capnography and direct visualisation if possible.

 Breathing and ventilation

Oxygen administration

Administer oxygen to achieve oxygen saturations between 94-98%.
Maternal hypoxia is associated with poor fetal outcomes.

Assess the chest

• Count the respiration rate – high rates are markers of potential lung injury and a warning that the patient may deteriorate. Differential diagnosis to exclude metabolic/traumatic causes is important as patients in the later stages of pregnancy have a reduced functional reserve capacity with increased minute ventilation.
• Note the depth, pattern and equal rise and fall. Remember that underlying chest injuries may also be present.
• Listen to the chest and assess for any wheeze, stridor or decreased air entry.

Record the oxygen saturation (SpO₂)

Consider NGT placement if the patient is in an altered conscious state; insert if intubated. Note relative contraindications with suspected skull fractures.

If required, intercostal catheter(s) should be inserted one or two rib spaces higher (in the third or fourth intercostal space) due to the elevation of diaphragm in pregnancy and potential for inadvertent abdominal insertion.

 Circulation with haemorrhage control

Assess circulation and perfusion

• Note that a pregnant patient may not display signs of haemorrhage until as much as 30% of her blood volume is lost. Tachycardia with normotension may be considered an early sign of potentially significant blood loss. If fetal monitoring is immediately available, it may be used as part of the assessment of maternal volume status.
• Check the mother’s heart rate, blood pressure and neck veins.
• Inspect for any signs of haemorrhage and apply direct pressure to any external wounds. Consider the potential for significant internal bleeding related to the mechanism of injury, which may or may not lead to signs of shock.

Insert two large-bore peripheral intravenous (IV) cannulas, preferably bilaterally. If access is difficult consider intraosseous insertion if the equipment/skills are available.
Fluid resuscitation should be initiated if hypovolemia is suspected to maintain both maternal and fetoplacental perfusion; however, haemorrhage control may be impossible without emergent surgical intervention. Commence resuscitation with up to 1–2 L of crystalloid solution. Blood or blood product transfusion should be considered in subsequent fluid administration.
Review the patient’s skin colour and check her temperature and capillary refill.
Recheck the patient’s position and ensure that manual uterine displacement or a 15–30-degree tilt remains in situ. This position is known to significantly improve blood pressure and is an important intervention in pregnant patients.
If possible, perform a FAST scan. FAST scan may be difficult in pregnancy where the enlarged uterus displaces other organs or obscures views of the retroperitoneum, but a positive FAST scan remains a significant finding in pregnant trauma patients.¹⁰ If the patient is haemodynamically stable and there are no signs of significant internal bleeding then the FAST scan may be delayed until the secondary survey.
Fluid resuscitation should be carefully monitored to achieve satisfactory blood pressure without contributing to ongoing blood loss from uncontrolled haemorrhage sites.

 Disability: neurological status

Assess level of consciousness

Perform an initial Glasgow Coma Scale (GCS) or AVPU assessment (Alert, responds to Voice, responds to Pain, Unresponsive); check the pupillary response.

Perform a blood sugar level test.

Ensure any alterations in level of consciousness are not related to a metabolic cause.

 Exposure/environmental control

Remove the patient’s clothing and any jewellery in order to fully assess all areas of the body.

A pregnant trauma patient may become hypothermic due to IV fluid administration and undressing for assessment, so it is important to monitor her temperature and keep her in a warm environment while administering warm IV fluids. Ideally, the patient’s temperature should be kept above 36.5 °C.