Initial Maternal and Fetal Assessment

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#1 cause of non-obstetric death in pregnancy= trauma with 6-7% maternal mortality, as high as 60-80% fetal mortality.  Affects 7% of all pregnancies, 50% occur during 3rd trimester. Etiologies are 50% MVC, 22% falls, 22% assault, 2% other. Treat mother 1st and fetus 2nd.


Consider physiologic changes of pregnancy:

  • ↑ blood volume/HR/CO; ↓ SVR/BP (hypervolemia leads to delayed signs of shock)
  • ↑ TV/MV; ↓ FRC/PaCO2
  • ↑ RBF/GFR; ↓ BUN/Cr
  • ↑ GI motility; ↓ GB emptying
  • ↑ WBC volume/hypercoaguability; ↓ RBC volume

Concerning obstetric signs:

  • vaginal bleeding, ruptured membranes, bulging perineum, contractions, and abnormal fetal heart rate/rhythm

Obstetric complications:

  • uterine rupture, placental abruption, fetomaternal hemorrhage/Rh incompatibility, and amniotic fluid embolism

Level 1 Recommendations

  • None

Level 2 Recommendations

  • All pregnant pts > 12 wks gestation (GA) should have Kleihauer-Betke analysis
    • 72 hr window to prevent alloimmunization; Rh immune globulin dose is 300 mcg per 30 ml fetomaternal hemorrhage
  • All pregnant pts > 20 wks GA should have cardiotocographic monitoring for > 6 hrs. Continue evaluation/monitoring for uterine contractions, a non-reassuring fetal heart rate pattern, vaginal bleeding, significant uterine tenderness, serious maternal injury, or rupture of the amniotic membranes.

Level 3 Recommendations

  • Best initial treatment for fetus is resuscitation of mother and early fetal assessment
  • All female pts of childbearing age with significant trauma should have β-HCG and be shielded for all X-rays except pelvic/lumbar imaging.
  • Concern for radiation exposure should not prevent medically indicated maternal diagnostic studies, however alternatives should be considered when possible
  • Exposure <5 rad has not been associated with an increase in fetal anomalies or pregnancy loss and is therefore deemed safe at any gestational age.
  • US/MRI is not associated with known adverse fetal effects, however MRI not recommended in 1st trimester due to limited experience
  • Consult radiology to calculate estimated fetal dose when multiple X-rays performed
  • Perimortem cesarean section should be considered in any moribund pregnant pt ≥ 24 wks GA, should ideally start within 4 min of maternal arrest, must occur within 20 min of maternal death
  • Tilt left side down 15o to prevent supine hypotension syndrome
  • Consult OB for all trauma in pregnancy


Algorithm for Initial Maternal and Fetal Assessment

Special Thanks


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  1. Title: Initial Maternal and Fetal Assessment
  2. Author:  Michigan Medicine
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Initial Maternal and Fetal Assessment,  Michigan Medicine, Dept of Surgery,  “CC BY-NC 4.0”

Last reviewed: 09 June 2021