Trauma in Pregnancy
Objective: Two patients, one stretcher. Displace the uterus off the vena cava, run the trauma first, and go to a place that can manage both mother and fetus.
Why This Is Hard
Anatomy lies. The mother can look “pretty good” while she is bleeding into a belly that hides a liter. Supine hypotension from a gravid uterus on the IVC looks like mystery shock. Teams freeze between “don’t hurt the baby” and MARCH. The evidence-based order is unchanged: save the mother. Fetal survival follows maternal perfusion.
Street Physiology
- After about 20 weeks (fundus at or above the umbilicus as a field clue), supine position can drop venous return. Manually displace the uterus to the left, or tilt the board/stretcher if spine rules allow.
- Blood volume is up; she can lose a lot before hypotension. Pale, tachycardic, anxious pregnant trauma is already late.
- Chest tubes, needle decompression, and tourniquets still work. Do not skip them “because pregnant.”
EMS Priorities
- Same MARCH/ABCs as any trauma. High-flow O₂ as indicated — the fetus hates hypoxia.
- Left uterine displacement. SMR if indicated, with tilt/displacement.
- Two large IVs if you can without delaying transport. Fluids/blood per protocol — permissive hypotension rules for trauma may not apply the same way when a fetus is on board; follow your obstetric-trauma protocol.
- Destination: trauma center with obstetric/neonatal capability when the system has one. Early notification: gestational age if known, fundal height, fetal movement, vaginal bleeding, contractions.
- Viability and emergency c-section are hospital decisions. Your job is a live mother at the door. If she arrests, AHA teaching is high-quality CPR with left uterine displacement — do not delay defibrillation because she is pregnant.
Field Pitfalls
- Leaving her fully supine on a board for a 20-minute ride.
- Skipping indicated trauma care because of radiation worry — imaging is a hospital decision. Do not withhold hemorrhage control, airway, or transport.
- Forgetting Rh / vaginal bleeding in the handoff even though you cannot give RhoGAM.
- Mother first — fetal survival follows maternal perfusion
- Left uterine displacement when fundus is significant (~20 weeks / umbilicus as a field clue)
- Do not withhold indicated trauma care for radiation fear
- Prefer trauma center with obstetric/neonatal capability when your system has one
Practice
60-second drill
Package a “28-week” training patient: LUD/tilt, MARCH priorities, one-breath handoff (gestational age, fundal height, bleeding, destination). Optional: rehearse the handoff in Narrative Coach (fictional only). Related: Hemorrhage, Triage.
Sources & Further Study
Named guidelines for further study. They are not clinical orders and do not replace your protocol or medical direction.
- ATLS / ACS trauma education (pregnancy)
- AHA 2025 CPR & ECC Guidelines — special circumstances: pregnancy / left uterine displacement during CPR
- ACS field triage (special considerations include pregnancy)
- Maternal resuscitation first. Left uterine displacement after ~20 weeks (fundus at the umbilicus as a field clue). Do not withhold indicated trauma care for radiation fear. Prefer a trauma center with obstetric capability.
Education only. Apply learning within your protocols and medical direction. This is not clinical care guidance.
Check Your Understanding
Street decisions from this lesson only. After you check, the key is highlighted. Education practice — not a certification exam.