Penetrating Trauma

Consider a laparotomy on all gunshot wounds or stab wounds to the upper abdomen. Stabs to lower abdomen can receive non-surgical management if the mother and fetus are free of significant injury.

Indications to Consider Cesarean Delivery

• control of maternal hemorrhage
• viable fetus in distress
• gunshot to abdomen with viable fetus
• a peri-mortem Cesarean may be indicated for fetus considered viable

If small uterine wound is present and delivery is not otherwise indicated, a less than 36 week pregnancy can be managed with uterine repair and delay of delivery until 36 weeks. If the fetus is dead and Cesarean section is not ­otherwise indicated, vaginal delivery should be considered.

Maternal Arrest or Death

Consider immediate Cesarean delivery for a viable fetus in any patient who cannot be resuscitated. Immediate Cesarean should be considered in those cases of a brain dead mother with an intact cardiovascular system if there is any evidence of fetal compromise. Consider maintaining life support management until the fetus is at an acceptable level of maturity for delivery. It is usually preferable to allow the fetus to remain in utero based on maturity and evidence of fetal compromise.

CPR ACLS Summary

Effective CPR is difficult in near-term pregnant woman because of a limited ability to perform chest compressions and displace the uterus.

Summary of CPR in pregnant patients over 20 weeks gestation:²⁰

1. Before starting compressions, turn the woman to lateral position.
2. Defibrillation as in non-pregnancy. No significant shock is transferred to fetus. Remove fetal/uterine monitors prior to shock.
3. Establish advanced airway early with c-spine stabilized.
4. Breathing: Ventilation volumes may need to be reduced because of elevated diaphragm.
5. Closed-chest compressions: 100 per minute using 30:2 ratio with ventilations.
6. IV: avoid femoral or other lower extremity lines, as flow may be affected by vena caval compression.
7. ACLS drugs as indicated.
8. If no maternal response after 4 minutes of ACLS, immediate Cesarean delivery should be performed in the emergency department by a qualified physician, with proper support and resources, who has determined the viability of the fetus. Thoracotomy and open cardiac massage may be considered at this time if the patient or fetus is believed to be viable.
   1. age greater than or equal to 24 weeks: attempt to save life of both mother and fetus.
   2. age 20-23 weeks: primary attempt to save life of mother by improving aortocaval blood flow and cardiac output. Fetal survival is unlikely.
   3. age less than 24 weeks: urgent Cesarean unnecessary as aortocaval compromise unlikely.
9. Assessment of fetal heart tones should be done throughout, as allowed by circumstances.

Admission and Monitoring

Viable Fetus

Viability is assumed in patients who are well into their 2nd trimester or beyond. Check with the OB consultant for recommended age of assumed viability. Remember, dates may be inaccurate. When in doubt, presume viability.