Trauma in Pregnancy

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Safety is of utmost importance during pregnancy, which is why trauma is an uncommon event for pregnant women. However, accidents cannot be avoided despite the extra carefulness that we incorporate in our daily lives. Planning the care of a pregnant woman who experienced trauma should be one of the skills of a healthcare provider, for this may happen rarely but unexpectedly.

Assessment

Assessment must be done quickly yet thoroughly and both the physiological and physical status must be included.

  • Assessment in an injured pregnant woman must be done concurrently with supportive reassurance to relieve the woman of her fear of fetal damage and also to remind her that she might be injured herself.
  • Anxiety should be first reduced so the woman could cooperate more effectively during the interview.
  • Assess the pregnancy history of the woman as well as her trauma history.
  • Document the circumstances of trauma: what happened, the time of injury, signs and symptoms of injury she is experiencing, and actions she had taken to counteract these.
  • Evaluate whether the woman’s extent of injury is in proportion to the history.
  • Assess the woman’s awareness about common safety measures.
  • Body organs such as the lungs, heart, kidney, or brain must be analyzed first because injury to these body systems could place the fetus’ health in jeopardy.

Types of Trauma


The trauma that a pregnant woman might experience differs in every aspect, and the care given to each case must also be focused on the trauma that occurred.

Open Wounds

  • To assess if infection is occurring, serial measurements must be used because WBC count is normally elevated during pregnancy.
  • A bleeding laceration could be halted by placing pressure at the edges of the lacerations.
  • For punctured wounds, tetanus immunization is given if the woman has not had tetanus immunization within 10 years, and tetanus toxoid for women who has had tetanus immunization within the past 10 years.
  • To determine the depth and extent of the wound, a fistulogram can be done.
  • Pregnant women bitten by animals or snakes can have rabies immune globulin and vaccine, anti-venom serum for snake bites as these are not contraindicated during pregnancy.
  • Caution a pregnant woman to avoid contact with unfamiliar dogs to prevent bites and to avoid feeding wild animals while camping.

Blunt Abdominal Trauma

  • Blunt abdominal trauma usually occurs due to an automobile accident, when the woman’s abdomen strikes the steering wheel or dashboard, or when someone kicks or punches her abdomen.
  • The injured underlying tissue becomes edematous and broken vessels form ecchymoses or hematoma while there is no visible break in the skin.
  • To assess for abdominal bleeding, a diagnostic peritoneal lavage or ultrasound is done.
  • Assessment should be done carefully because a traumatic blow could cause dislodgement of the placenta.
  • To assess for vaginal bleeding or rupture of the amniotic membranes, a pelvic examination can be performed.
  • Assure the woman that the fetus is unharmed by listening to its fetal heartbeat with the use of Doppler.
  • If preterm labor occurred, a tocolytic can be administered and fetal and uterine monitors should be attached too.

Gunshot Wounds

  • Assessment of a gunshot wound includes inspection of the point of entry of the bullet and the point where it exited.
  • If the uterus is punctured, there may be no entry point as the uterine walls are very thick.
  • A gunshot wound is surgically cleaned and debrided and the woman is given a high-dose antibiotic that is safe for pregnant women such as Ampicillin.
  • Incidence of fetal mortality is high if the bullet entered the uterus especially if the placenta is torn by the bullet.
  • Stay with the woman as she recounts the history of the accident with law enforcement officers.

Poisoning

  • A woman should contact the local poison control center and state that she is pregnant and what she accidentally swallowed, then follow the instructions of the personnel at the poison control center.
  • Activated charcoal is the drug of choice to neutralize stomach poison.
  • Investigate the circumstances of the poisoning afterward so you can educate the woman about safety with medications or food and to discover possible suicidal intent.

Choking

  • Dislodging the object that the woman choked on would be difficult because of a lack of space between the uterus and the end of the sternum and the average person could not reach from the rear around a woman’s enlarged abdomen.
  • The rescuer might use successive chest thrusts instead late in pregnancy.

Orthopedic Injuries

  • A woman late in her pregnancy has poor balance and can easily fall, so she automatically reaches out a hand to cushion her fall to prevent landing on her abdomen, which could cause serious wrist injury.
  • Apply ice to the area to decrease the swelling as a first aid measure.
  • To determine if fracture is present, a radiograph can be performed.
  • Assure the woman that a radiograph is safe as long as her abdomen is shielded during exposure.
  • Assist the woman in identifying calcium-rich foods if she has a fracture so both she and the fetus can have adequate calcium for new bone growth.
  • A woman who had a previous knee injury should be re-evaluated early in the pregnancy because a knee immobilizer might be needed for the last 3 months of pregnancy to prevent the joint from dislocating or the ligament from tearing again.

Burns

  • Burns can cause thermal injury and inhalation of carbon monoxide from the fire which could lead to extreme fetal hypoxia.
  • Prostaglandins are produced in response to severe trauma which could cause preterm labor.
  • If more than 50% of the body surface area is burned, both the mother and the fetus could be in grave danger.
  • Burn tissue heals quickly during pregnancy probably because of overall increased metabolism and an increase in the corticosteroid levels.

Practice Quiz: Trauma in Pregnancy


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Questions


1. A pregnant woman received a laceration on her leg from an automobile accident. Why are lacerations of lower extremities potentially more serious in pregnant women than in others?

A. Healing is limited during pregnancy, so these will not heal until after birth.
B. Lacerations can provoke allergic responses because of gonadotropic hormone.
C. Increased bleeding can occur from uterine pressure on lower extremity veins.
D. A woman is less able to keep the laceration clean because of her fatigue.

2. When should a woman who is punctured given with tetanus toxoid?

A. If she has had a tetanus immunization within the past 10 years.
B. If she has had no tetanus immunization within 10 years.
C. Immediately after she was punctured.
D. Tetanus toxoid is not safe for pregnant women.

3. A pregnant woman came in with blunt abdominal trauma. Which of the following should the nurse do upon assessment?

A. Position the woman in a left side lying position to avoid compression of the vena cava.
B. Inform the woman that the fetus would not be able to survive the trauma.
C. Assess abdominal bleeding through ultrasound.
D. Assess vaginal bleeding through diagnostic peritoneal lavage.

4. The physician ordered an oral administration of Ampicillin for a pregnant woman with gunshot wound. What would the nurse do?

A. Do not administer the medication and report the physician to the hospital board of directors.
B. Assess the patient’s heart rate first before administering the medication.
C. Administer the medication since Ampicillin is safe for pregnant women.
D. Convince the physician to avoid antibiotics since this is not safe for pregnancy.

5. What is the drug of choice for poisoning in pregnant women?

A. Cephalosporins
B. Activated charcoal
C. Proton pump inhibitors
D. Gastric lavage

Answers and Rationale


1. Answer: C. Increased bleeding can occur from uterine pressure on lower extremity veins.

  • C: Because venous pressure is greatly increased during pregnancy. Because venous pressure is greatly increased during pregnancy.
  • A: Increased metabolism and increased corticosteroid levels enable the tissues to heal quickly during pregnancy.
  • B: Lacerations could trigger allergic reactions due to the object that came into contact with the skin, not because of gonadotropic hormones.
  • D: The laceration can be easily cleaned by the woman or with the help of a support person.

2. Answer: A. If she has had a tetanus immunization within the past 10 years.

  • A: If the woman has had a tetanus immunization within 10 years, she cannot have tetanus toxoid.
  • B: If the woman does not have any tetanus immunization within 10 years, tetanus immunization is given.
  • C: Tetanus toxoid is only given with consideration to the woman’s tetanus immunization history.
  • D: Tetanus toxoid could be safely administered to pregnant women.

3. Answer: C. Assess abdominal bleeding through ultrasound.

  • C: Internal bleeding must be assessed first since there is no visible break in the skin with blunt abdominal trauma.
  • A: This is a correct intervention in general yet could be done once the extent of bleeding and trauma is already established to promote adequate blood circulation to the fetus.
  • B: Thorough assessment with the use of fetal and uterine monitors must be done first.
  • D: Vaginal bleeding is assessed through pelvic examination.

4. Answer: C. Administer the medication since Ampicillin is safe for pregnant women.

  • C: Ampicillin is one of the high-dose antibiotics that can be safely administered to pregnant women.
  • A: The medication is safe for administration and there is no need to report the physician to the hospital board.
  • B: Assessing the heart rate before administering the medication is not necessary.
  • D: There are certain antibiotics that are safe for pregnant women, and Ampicillin is one of them.

5. Answer: B. Activated charcoal

  • B: Activated charcoal is the drug of choice for poisoning in pregnant women.
  • A: Cephalosporins are antibiotics.
  • C: Proton pump inhibitors are used for dealing with hyperacidity.
  • D: Gastric lavage is not a drug but could be used as an intervention to evacuate the poison.

Extreme carefulness of a woman during pregnancy is not a guarantee that accidents would not happen. Healthcare providers must thoroughly educate the client and her family about safety to avoid trauma that could compromise both the mother and the fetus, and this should be given priority and never ignored.

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