Maternal trauma in pregnancy: fetal assessment and emergency care

Trauma during pregnancy creates two patients whose needs can compete for attention. A fall, road crash, assault or penetrating injury may cause concealed maternal haemorrhage, placental abruption, uterine rupture and fetal injury even when the abdomen appears unremarkable. Maternal resuscitation is the first priority because placental perfusion depends on the mother’s circulation. Fetal assessment should run in parallel without delaying blood products, imaging or transfer.

Initial risk stratification should combine the mechanism of injury with gestational age, maternal observations, blood loss, pain, uterine tenderness, contractions and fetal movement. Previous caesarean delivery, placenta previa, anticoagulant use and pre-existing hypertension increase concern. A normal initial examination does not exclude serious internal injury, particularly placental abruption, so serial assessment and a low threshold for escalation are essential.

Australian teams often work across long distances between community settings, regional hospitals and tertiary maternity services. The national emergency number is 000, and ambulance dispatch begins the process of locating the patient, determining the receiving facility and arranging maternal and neonatal transport. Clinicians in Melbourne, Sydney, Brisbane and Perth usually have access to advanced obstetric, anaesthetic and imaging services, while hospitals outside metropolitan areas may rely heavily on midwives, general practitioners and retrieval teams.

The archived FAOPS 2020 programme preserves the international scientific programme planned for Tokyo in conjunction with PREBIC AA 2020. The congress was cancelled in April 2020 because of the COVID-19 pandemic and associated travel difficulties. Its emphasis on perinatal research, multidisciplinary care and neonatal outcomes remains relevant to the collaborative systems needed for trauma in pregnancy.

First priorities in the minutes after impact

Use a structured trauma response with maternal airway, breathing, circulation, disability and exposure assessed continuously. After 20 weeks, or earlier when indicated, provide manual left uterine displacement to reduce compression of the inferior vena cava. Establish rapid intravenous access, obtain urgent blood samples and prepare resuscitative fluids and blood products while identifying the source of any bleeding.

External injuries may be minor while internal damage is severe. Inspect the abdomen, pelvis, back and chest for bruising, swelling, tenderness, penetration or a change in fundal contour. Concealed blood can collect behind the placenta or within the uterus, so severe fetal bradycardia or persistent uterine contractions should prompt urgent obstetric review even when little blood is visible.

Assign clear roles early. The obstetric clinician should assess pregnancy-specific injuries, the emergency clinician coordinates trauma care, and anaesthesia leads resuscitation. A neonatal team, blood-bank representative and radiologist should be alerted according to local pathways. Transfer decisions belong with the receiving maternity service; a mother with an unstable airway, shock or suspected uterine rupture should not wait for a routine fetal assessment.

Assessing the fetus without losing the mother

Bedside obstetric ultrasound can assess fetal heart rate, movement, gestational age, amniotic fluid and placental location. It may also reveal fetal trauma or maternal retroplacental fluid. Ultrasound cannot reliably exclude placental abruption after blunt trauma, however, and a normal scan should not override concerning symptoms, observations or fetal monitoring findings.

Where pregnancy is viable and the mother is sufficiently stable, cardiotocography provides information about contractions, baseline fetal heart rate and accelerations or decelerations. Monitoring should continue during resuscitation because maternal hypotension, hypoxia, hyperthermia, pain and medications can all alter the fetal trace. If the trace is concerning, assess the maternal condition alongside the fetus and seek urgent senior obstetric input rather than treating the tracing in isolation.

Document the initial fetal assessment, the time and method of each observation, and any change after maternal resuscitation. Repeat ultrasound or cardiotocography may be needed, with the frequency determined by gestational age, injury severity and local policy. When maternal stability deteriorates, prioritise surgery, transfusion or transfer; the fetus cannot benefit from a prolonged diagnostic investigation performed while the mother’s circulation remains unsupported.

Controlling bleeding and escalating delivery

Activate the unit’s obstetric haemorrhage protocol when bleeding is heavy, concealed, recurrent or accompanied by shock. Guidance on maternal haemorrhage protocols can support prevention and response planning, including early access to blood products, uterotonics, tranexamic acid for eligible postpartum haemorrhage and a clear massive-transfusion pathway.

Placental abruption may produce painful bleeding, a tender hypertonic uterus, maternal shock or fetal compromise. Uterine rupture is more likely where a previous uterine scar exists and may present with severe pain, loss of contractions, fetal bradycardia or sudden deterioration. Both conditions require immediate senior obstetric review. Delivery may need to proceed urgently when the mother is unstable or the fetus is compromised, and the team should prepare for induction, operative birth, neonatal resuscitation and haemorrhage at the same time.

Treat the cause of bleeding while restoring circulation. Apply direct pressure or appropriate tamponade to accessible trauma, activate blood products early and use a massive-transfusion protocol when indicated. Give uterotonics after delivery according to the usual obstetric protocol. Check blood group and Rh status, arrange anti-D prophylaxis for eligible patients under current guidance, and consider fetomaternal haemorrhage testing when relevant. Trauma and pregnancy also increase venous thromboembolism risk, so prophylaxis planning should follow bleeding, mobility and operative status.

Adapting care to Australian conditions

Regional and remote hospitals need pathways that recognise when bedside care has reached its limit. Aeromedical retrieval, including RFDS operators in several jurisdictions, can provide critical care support, but a transfer request should communicate gestational age, maternal instability, suspected injury and fetal status rather than a general request for “maternity transport”. Weather, aircraft availability and the need for a neonatal team may affect the safest route.

Australian maternity care combines public hospitals with a substantial private obstetric market, and emergency presentations frequently cross between these systems. Major cities generally offer immediate obstetric ultrasound, cardiotocography, blood-bank support and theatre, while smaller hospitals may have limited after-hours imaging or reliance on visiting specialists. Equipment and medication availability should therefore be checked against the actual referral pathway rather than assumed from a metropolitan hospital formulary.

Privacy and consent remain important during rapid assessment and transfer. The Privacy Act 1988 and Australian Privacy Principles govern the handling and sharing of health information, including records sent to retrieval teams or interstate hospitals. State and territory mandatory-reporting laws may apply when assault, neglect or substance-related concerns place a child at risk. Aboriginal and Torres Strait Islander women should be offered culturally safe care, access to Aboriginal Health Practitioners where available, and communication that respects their experience without assumptions.

Preparing people, equipment and transfers

A written protocol has little effect unless the team can apply it under pressure. Conference programmes can refresh clinical knowledge, and resources such as Barany 2022 may support wider professional learning. Unit-based simulation should then connect that knowledge to the local blood system, monitoring equipment, theatre arrangements and retrieval contacts.

Clinical readiness

• Keep a current one-page pathway for maternal collapse, placental abruption, uterine rupture and obstetric haemorrhage.
• Check CTG and ultrasound availability, resuscitation equipment, neonatal warming and blood-request procedures every shift.
• Assign resuscitation, fetal assessment, blood-bank, documentation and family-support roles in advance.
• Rehearse massive haemorrhage and emergency birth with obstetric, emergency, anaesthetic, neonatal and laboratory staff.

A second routine should cover communication during transfers and unexpected deterioration. Handover should state gestational age, estimated fetal weight, mechanism, maternal observations, estimated blood loss, fetal monitoring findings, allergies, Rh status and procedures already performed.

Communication and coordination

• Use a structured handover format, such as SBAR or ISBAR, for ambulance, retrieval and receiving teams.
• Record consent, privacy-compliant information sharing and any interpreter or cultural-support requirements.
• Keep families updated by a named staff member while protecting confidential clinical discussions.

After each event, conduct a brief clinical and systems debrief covering maternal and neonatal outcomes. Review delayed blood products, inaccurate handover, unavailable monitoring, transfer decisions and the need for follow-up fetal surveillance. Feed identified changes back into the pathway and confirm them during the next simulation.

Matching the response to the injury

Several injuries can coexist, and their signs overlap. The speed of maternal deterioration, the fetal trace and the mechanism should influence the response rather than waiting for a definitive diagnosis.

Placental abruption and uterine rupture can both cause rapid fetal deterioration with few external findings. Persistent fetal bradycardia should therefore prompt simultaneous maternal resuscitation and urgent delivery planning. Normal ultrasound findings should not provide false reassurance, and an apparent improvement in the fetal trace may reflect improved maternal circulation rather than resolution of the injury.

Make the pathway operational now: keep the algorithm accessible in triage and the labour ward, confirm blood and monitoring access every shift, and run a scenario with the complete response team. Use the cited haemorrhage guidance to align escalation and responsibilities. A prepared response protects fetal oxygenation by protecting maternal circulation and gives both patients the best chance when minutes matter.