Launceston General Hospital Clinical Guideline SMDS ID: P2010/0319-001 WACSClinProc1.

8/09 Title: Replaces: Description: Target Audience: Key Words: Policy Supported: Fetal Monitoring Following Trauma in Pregnancy Fetal Monitoring Following Trauma in Pregnancy WACSClinProc1.8/06 Fetal monitoring following trauma in pregnancy Midwives and medical officers, Fetal monitoring, trauma, pregnancy P2010/0318-001 Antenatal Electronic Fetal Monitoring P2010/0305-001 Rh D Immunoglobulin

Purpose: Facilitate the early detection of labour, placental abruption or fetal compromise. Background: Trauma in pregnancy remains a leading cause of morbidity and mortality for women and their babies. Motor vehicle accidents, family violence and falls are the most common causes of blunt trauma in pregnancy. Any viable fetus of 24 or more weeks gestation requires electronic fetal monitoring after a trauma event. This includes all women with no obvious signs of abdominal injury, because direct impact is not necessary for feto-placental pathology to be present. Monitoring should commence as soon as possible after initial stabilisation because most placental abruptions occur shortly after trauma. Continuous electronic fetal monitoring is more sensitive in detecting a placental abruption than ultrasonography, intermittent monitoring, Kleihauer Betke test or physical examination. Procedure: Commence electronic fetal monitoring (as per Antenatal Fetal Monitoring Guideline) for a minimum of fours hours even after minor abdominal trauma. This can be performed in the emergency department (ED) if the womans condition requires specialised care. Assess for: Vaginal bleeding Spontaneous rupture of membranes Fetal heart rate abnormality Uterine contractions High-risk mechanisms of injury (high speed motor vehicle accident, car versus pedestrian injury) Uterine tenderness Abdominal pain Maternal anaesthesia
Fetal Monitoring Following Trauma in Pregnancy Oct-10 1 WACSClinProc1.8/09

If after four hours none of the above are identified then discontinue monitoring and discharge to home with instructions to return to hospital if there is any: bleeding decreased fetal movement loss of fluid vaginally repetitive uterine contractions abdominal pain or tenderness

If any of the above are identified then continue continuous fetal monitoring for 24 hours. Intervene as necessary if fetal compromise occurs. Otherwise discontinue monitoring and allow home. Uterine Activity If after four hours of continuous fetal monitoring there is less than one contraction in 10 minutes, the risk of further complications drops to baseline. The occurrence of more than eight uterine contractions per hour over four hours is associated with a 20% increase in the risk of an antepartum haemorrhage. Rh Negative Women Blood for Kleihauer and antibody screening should be taken from the mother if she is Rh negative and Rh D Immunoglobulin administered if required (as per the Rh D Immunoglobulin Guideline WACSClinProc3.2/09). Attachments
Attachment 1 Attachment 2 Attachment 3 Algorithm for Management of the Pregnant Women after Trauma Unique Problems of the Pregnant Women with Trauma References

Performance Indicators: Evaluation of compliance with guideline to be achieved through

medical record audit annually by clinical Quality Improvement Midwife WACS

Review Date: Stakeholders: Developed By:

Annually verified for currency or as changes occur, and reviewed every 3 years (February 2012). Midwives and medical staff WACS Dr A Dennis Co-Director (Medical) Sue McBeath Co-Director (Nursing & Midwifery) Womens & Childrens Services

Dr A Dennis Co-Director (Medical) Womens & Childrens Services

Sue McBeath Co-Director (Nursing & Midwifery) Womens & Childrens Services

Date: 3/08/2009
Fetal Monitoring Following Trauma in Pregnancy Oct-10 2 WACSClinProc1.8/09

ATTACHMENT 1 ALGORITHM for Management of the pregnant women after trauma

http://www.aafp.org/afp/20041001/1303.html
Fetal Monitoring Following Trauma in Pregnancy Oct-10 3 WACSClinProc1.8/09

ATTACHMENT 2 Unique problems of the pregnant women with trauma. The placenta is devoid of elastic tissue but the myometrium is very elastic, predisposing to shearing. From 16 weeks gestation, abruptio placenta is the most common result of blunt trauma. Following trauma, the most common cause of preterm labour is abruptio placenta. Fetal skull injury is the most common fetal injury, with a mortality rate of 42%. After 12 weeks gestation, the bladder is displaced upward and forward by the enlarge uterus, leading to an increased risk of bladder injury from blunt or penetrating trauma. Because of the enlarging uterus, the diaphragm rises by about 4cm and the diameter of the chest enlarges by about 2%. The trachea is displaced to the right. Upward displacement of the diaphragm and viscera decreases chest compliance with ventilation and makes chest compression in CPR more difficult. As pregnancy progresses, there is decrease in the functional residual capacity of the lungs, coupled with a 20% increase in oxygen consumption, making women more prone to hypoxia. Further, a 30% of pregnant women have airway closure during normal tidal ventilation if they are placed in the supine position. All these alterations predispose the pregnant women to rapid decrease in maternal PaO 2 during periods of apnoea or airway obstruction. Changes in the gastrointestinal tract and increased levels of progesterone make pregnant women more prone to regurgitation of gastric contents and Mendelsons syndrome. Enlarged breast tissue also makes chest compression more difficult.

Fetal Monitoring Following Trauma in Pregnancy Oct-10

WACSClinProc1.8/09

ATTACHMENT 3 REFERENCES: Eastern Association for the Surgery of Trauma (EAST). Practice management guidelines for the diagnosis and management of injury in the pregnant patient: the EAST Practice Management Guidelines Work Group. Charleston (SC): Eastern Association for the Surgery of Trauma (EAST); 2005. 18 p. Online: http://www.guideline.gov/summary/summary.aspx?view_id=1&doc_id=8511 Grossman NB 2004 Blunt trauma in pregnancy American Family Physician 70(7):13031310. Mattox KL, Goetzl L 2005 Trauma in pregnancy Critical Care Medicine 33(10): S385S389 Pairman S, Pincombe J, Thorogood C, Tracy S, Midwifery preparation for practice 2006 Elsevier Australia South Australian Department of Health Perinatal Practice Guidelines 2007 Trauma in Pregnancy Online: http://www.health.sa.gov.au/PPG/Default.aspx?PageContentID=152&tabid=49 Van Hook JW 2002 Trauma in pregnancy Clinical Obstetrics and Gynaecology 45(2):414-424. Williams S 2002 Managing trauma in pregnancy. Physician Assistant 26(1):15-24.

Fetal Monitoring Following Trauma in Pregnancy Oct-10

WACSClinProc1.8/09