Trauma in Pregnancy

Why this matters

The mother can look acceptable while she is bleeding into a uterus and abdomen that hide a large volume. A pregnant uterus can press on the inferior vena cava, the large vein that returns blood to the heart. That pressure can cause low blood pressure when she lies flat, and it can look like unexplained shock.

First, treat the mother. Run MARCH, which is massive hemorrhage, airway, respirations, circulation, then hypothermia and head injury. After about 20 weeks, move the uterus off the vena cava. Do not stop indicated trauma care because you are worried about the fetus. Fetal survival follows the mother's blood flow.

What Changes When She Is Pregnant

• After about 20 weeks, when the fundus is at or above the umbilicus, lying flat can drop blood return to the heart. Move the uterus to the left, or tilt the board or stretcher if spinal precautions allow it.
• Blood volume is higher. She can lose a lot of blood before the blood pressure falls. Pale skin, a fast heart rate, and anxiety in pregnant trauma already mean you are late.
• Indicated procedures still apply. Do not skip a tourniquet, needle decompression, or other trauma care because she is pregnant.

Clinical sequence

1. Run the same MARCH sequence and the same airway, breathing, and circulation priorities as any trauma patient. Give high-flow oxygen as indicated. The fetus does poorly when the mother is hypoxic.
2. Move the uterus to the left. If spinal motion restriction is indicated, tilt the board or stretcher, or displace the uterus. Use a board for the move, then take her off the board. Use a collar only if your protocol says so.
3. Get two large intravenous lines if you can do it without delaying transport. Give fluids and blood per protocol. Give blood only if your service carries it. Permissive hypotension may not apply the same way when a fetus also depends on her blood pressure. Follow your obstetric trauma protocol.
4. Go to a trauma center with obstetric and neonatal capability when the system has one. Notify early. Include gestational age if known, fundal height, fetal movement, vaginal bleeding, and contractions.
5. Viability and emergency cesarean delivery are hospital decisions. A resuscitative hysterotomy is not a field procedure. Your job is a living mother at the door. If she arrests, do high-quality CPR with the uterus moved to the left. Do not delay defibrillation because she is pregnant.

Common errors

• Leaving her fully flat on a board for a long transport.
• Skipping indicated trauma care because of worry about radiation. Imaging is a hospital decision. Do not withhold hemorrhage control, airway care, or transport.
• Forgetting Rh status and vaginal bleeding in the handoff. You cannot give RhoGAM, which is Rh immune globulin, in the ambulance. The receiving team still needs the history.

Practice

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.

• NASEMSO National Model EMS Clinical Guidelines (2022) — U.S. EMS model language; your protocol decides
• ATLS / ACS trauma education (pregnancy)
• AHA 2025 Part 10: Special Circumstances — pregnancy: left uterine displacement during CPR; resuscitative delivery themes when fundal height is at or above the umbilicus
• NAEMSP 2025 — Injured pregnant patients — left uterine displacement from about 20 weeks or the umbilicus; shock signs can be late; mother first; hysterotomy is not a field procedure
• ACS field triage (special considerations include pregnancy)
• Resuscitate the mother first. Move the uterus to the left after about 20 weeks, using the fundus at the umbilicus as a field clue. Do not withhold indicated trauma care because of imaging concerns. Prefer a trauma center with obstetric capability.