CHAPTER 8

Fetal Assessment in
Non-obstetric Settings
etal assessment and care of the pregnant woman can occur i n a
F variety of locations, including the. surgical setting, critical care
units, emergency departments, and separate obstetric tria ge units that
are gaining hold as a critical access area for obstetric patients. These
units function similar ly to emergency departments in that the unit is
able to evaluate and treat pPesenti.ng symptoms, priori tize care, im-
prove utilization of staffi ng and patient services, as well as create a
plan that incorpora tes maternal-fetal \:vell-being L 1J. When the patient
receives care outside of the obstetric set.ting, il is often because the
pregnancy is belovv the limits of viability or requires surgical or med-
ical expertise.
The focus of this chapter is maternal-fetal assessment and man-
agement in the non-obstetric setting. ColJa boration among the mul-
tidiscipli nary team members i n these settings is essential when the
pregnant woman is cared for becau se patients need the righl providers
at the right ti me and in the right setting. Evaluation of the pregnant
patient brings a unique set of dilemmas, but a systematic approach to
patient eval uations should be cond ucted i n the same manner as w·ith
the nonpregmmt patient, beginning wi th a comprehensi. e history and
physical f2l Regardless of the setting, the needs of the fetus should
not be overlooked. The healthcare team must have the req uisite skills
and be qualified to evaluate the fetus based on their education , ex-
perience , and performance standards. Itis imperative that commLmi-
cation between services and healthcare team members arc c1car and
timely to ensure that t he maternal-fetal dyad re-ceives appropriate
care by the most appropriate staff member .

PREGINANCY ANATOMY ANID PHYSIOLOGY

Knowledge of the physiologic and anatomic adaptations of preg-
nancy is crucial because pregnancy al ters anatomy and physiology
to uch an extent that the recognition of cl inical symptoms and non-
obstetric emergencies may be d istorted and normal di scomforts may

189
190 Chapter 8

BOX 8.1 Physiologic Adaptations to Pregnancy

Cardiovascular
• Physiologic anemia, hypervolemia (expansion of plasma volume greater
than expansion of red cell mass)
• Blood volume increases by 30%-40% (1200-1500m l higher than
prepregnant state)
• Plasma increases 70%, cells 30%
• Hematocrit of 32%-34% is not unusua l
• Cardiac output increases 30%-50% (a result of increased blood volume)
• Heart rate and stroke volume increase
• Systemic vascular resistance decreases, with resultant decrease in
blood pressure and mean artenial pressure
• Uteroplacental vascular bed is dilated; passive low resistance system
• Uterofetoplacenta l unit receives 20% of cardiac output
• Peripheral edema; dyspnea; presence of third heart sound
• Pelvic venous congestion
Hematologic:
• Increased clotting factors VII, VIII, IX, and X, and fibrinogen
(hypercoagulable)
• Decreased serum albumin may lower colloid osmotic pressure (predis-
posing to pulmonary edema)
Renal
• Smooth muscle relaxation, increased urinary stasis; hydronephrosis,
hydroureter; increased susceptibility to urinary tract infection
• Increased creatinine clearance
• Decrease in serum crea.tinine and urea nitrogen (BUN)
Respiratory
• Tida l volume increases by 30°.t&-40%; respiratory rate uncharnged
• Oxygen consumption increases by 20%
• Diaphragm elevated by the growing fetus
• Arterial Pco2 decreases as. a result of hyperventilation, re5ulting in a
"compensated" respiratory alkalosis
Gastrointestinal
• Smooth muscle relaxes, increasing gastric emptying time
• Gastric motility decreases, sphincters relax, higher likelihood of aspiration
Musculos.keletal
• Increased risk of ligament injury secondary to relaxin and progesterone
• Shifting center of gravity with growth of fetus, diastasis of the redus
abdominus
• Symphyseal separation

Adapted from references 2 and 6-9.

contri bute to a puzzling picture [3 5]. Some changes are d ramatic

enough that they would be considered pathologic in the nonpregnant
\voman (Box 8.1). For example, the symphysis pubis protect s the
bladder, but in pregnancy the bladder shifts to an intraabdomina l
position , making this area more susceptible to injury L4J . Laboratory
 Fetal Assessment in Non -obstetric Settings 191
values may be altered in the pregnant patient versus the nonpregnant
pati ent because of the adaptations required by the body to support
the preg nancy [2,4]. Not only docs the pregnant woman present with
unique challenges; the fetus also requi res assessment and possi ble in-
tervention .Fetal stability depends on maternal stability. Ifcaregivers
do not understand and support the adaptations of the pregnancy, there
Is potential for ad verse maternal .and fetal outcomes.

EM EIRG E NCY DEPARTM ENT ASSESS M ENT

AN D CAR E
Pregnant women may seek care through emergency departments for
a va.riety of reasons i ncluding emergency or trau ma situations, lack
of access to primary or obstetric care, inability to schedule an .ap-
pointment , and convenience [1,10]. Initially a. primary survey occurs
when the patlent first presents and is asked, "Why arc you here?" so
that a quick assessment can be completed , which is crucial to deter-
mining triage and treatment priorities. A secondary Sll!l'Vey incl udes
obtai ning detailed i nformation about signs, symptoms, the mecha-
n1sm1 of i njury if appl icable, as wel l .as a thoroug h head-to-toe physi-
cal assessment [4,10]. This is, of course predicated on the woman 's
ability to communicate.
Findings from the primary survey and establishing the gestational
age are usually the best indicators for identifyi ng the depa1iment
In which the woman's care \;\,iOuld be most appropriately managed .
Special attention to the pregnancy is a part of the assessment and not
merely an afterthought.
Pregna nt women may presenl for a variety of nonpFegnancy and
pregnancy-re lated reasons. A decision tree algorithm is useful for
triage of the matemal -fetal dyad to determine whether the \:\'Oman
should remai n in the emergency department or be transferred to sur-
gery, critical care, or the obstetric unit [1,11]. Emergency depa rtment
staff members generall y have algorithms to follow for nonpregnant
patients; however, standard obstetric algorithms are nol as common.
Each institution should have a \.vritten guideline or triage decision
tree that is devdoped jo intly \>vith the emergency department and
obstetric staff tha t addresses at which gestational age care will be
managed i n the emergency d epartment versus the labor and ddiv,ery
unit, which conditions prom pt obstetric consultations, situations in
which an obstetric nurse is present in the emergency department,
and guidcli ncs for di schargc or transfer to another care setting [l ].
Several useful references about caring for the maternal-fetal dyad
in the non-obstetric setting arc avai lable for creati ng or updating
192 Chapter 8

i nsh tutiona l guidelines [11-14]. Before discharge or transfer to an-

other area or facility, an assessment is requ ired to confirm both ma-
ternal and fetal well-being [ 15].
Patients at 20 weeks ' gestati on or greater are typically referred
to an obstetric setting, but this gestational age is not absolute_ The
criteria for an internal transfo r from the emergency department to the
obstetric setting are dependent on institutional pol icies, proced ures ,
and resources. It is important to remember that specific d iagnoses
are limited to certain gestational ages, such as pireeclampsia in the
second and third trimester, and should be included in the treatment
a]gorithms \;<,ihcn addressing assessment of the pregnant patient in
the emergency department Women who present to the emergency
department complaining of well -recognized obstetric concerns (e.g.,
vagina l bleeding, contractions , ru pture of membranes, i ncreased or
watery vagina l discharge, abdomi nal pain, pel vic pressure , decreased
fetal movement) may be transferred immedia tely to the obstctrmc
unit for further assessment and management. For those \vomen with
vague s mptoms , such as headache , edema, nausea and vomiting, or
"just not foel i ng well," the decision about where to evaluate i s not
always so clear unless a policy or guideh ne i s i n place Wel l -meani ng
care in a non-obstetric setting for the wornan with a compl icated dis-
order only found in pregnancy has the poten6al of being detrimental
to both the \Voman and the fetus. Di scussion belween the emergency
department and the obstetric setting may be the best method of deter-
mining whose expertise is most needed for the evaluation and care of
the maternal-fetal dyad .
When a woman presents to the ,emergency department with car-
d iovascular or respiratory complai nts, the materna l vita] signs should
be assessed and documented without del ay_ There are certain abnor-
malities or "triggers " in the patient's vital signs and condition that
point to an emergency that requires immediate acti.vation of d iagnos-
tic and interventi on resources. Recogni tion of these events through
a warning system such as the Modi fied Early Obstetric Warni ng
System (.NIEOWS) can be utilized in emergency departments and
protocols.. In the .MEOWS system, a physician or other qualified
cliniciim is called for prompt bed::>i<le e aluation when the pregnan t
patient exhibits any one warning sign in the red area or two warning
signs in the yellow at any one ti me DLl ,161 (Table 8_ l). Addi hona l
emergency department screening questions, regard[ess of the pre-
senting problem,include but are not limited to:
• Presence or absence of fetal movement (if appropriate for gesta-
tional age, usually 18-20 weeks)
 Fetal Assessment in Non -obstetric Settings 193
TABlE 8.1 MEOWS Color-coded Trigge1r Pa ra meters
Trigger: Red Trigger: Yellow

Temperature, "C <35 or >38 35-36

Systolic blood pressure, mm Hg <90 or >160 150- 160 or 90- 11 00
Diastol i c blood pressure, mm Hg > 100 90-100
H eart rate, beats per minute <40 or >l 20 100-120 or 40 -50
Respi ratory rate, breat hs per < 10 or >30 21 -30
mi nute
Oxygen satu ration, % <95
Pain score 2-3
Neum l ogi c response Unresponsive, Voice
pain
From S. Singh, A. McGlen na n, A. En gland, R. Simons R, A va lidation study of
the CEMACH recommended modified early obstetric warning system (M EOWS),
Anaesthesia 67 (1) (2012) 12-18.

• Presence or absence of crampi ng, pe lvi c pressure, backache, or

contractions
• Presence or absence of vaginal bleeding or lea king of fluid

PR EG NANT TRAUMA VICTI M ASSESS M ENT

AN D CARE
Trauma during pregna ncy i s. a leadi ng contri butor to materna l mortal-
ity in the United States p,8,l7J. Motor vehicle accidents are the most
common mechanism of trauma mostly due to improper or lack of seat-
belt placement.Another major cause of trauma is related to falls l8,17-
19], but it is important lo understand that even the most minor situation
can be life threatening lo the patient and fetus due to the anatomic
and physiologic changes thal occur in pregnancy [6,7]. Certain i1 uries
are unique to the pregnant traunia patient: uteri.ne rupture, placental
abruption , preterm labor and delivery, and intrauterine fetal demise.
Consideration of gestationa l age is an i m portant factor because a de-
cision may need to be made about an operative intervention on behalf
of thc fetus. Trauma concerns specific to pregnancy arc ln Table 8.2.

M aternal-Fetal Transport, Assessment, and Care

fo trauma situations, fi rst res.ponders will provide the initi al eval-
uation and management of the pregnan t trauma patient, which
should be maternall y focused and consistent with ad vanced trauma
life sup port (ATLS) protocols [17,20]. Alerting the emergency
194 Chapter 8

TABLE 8.2 Trau ma Concerns Specific to Pregna ncy

Abruptlon
Resu lt of "shearing" effect when
uterus is deformed by external
forces, causing separation from
placenta
Vaginal bleeding poor predictor
of abruption
Uterine Rupture
Blunt trauma
Maternal-Fetal Hemorrhage
Four to five times more common
in i njured woman than in
noninju1red woman
Fetal Compromise
Nonspecific complication but
most common
Preterm Contra(tlons
Common after bl u n t trauma
Fetal Injuries
Skull fract ures, intracra nial
hemorr hage
Can trigger diffuse intravascular
coagulation because of high
concentration of thromboplastin
in placenta
Electronic feta monitoring is most
sensitive means of detecting
abruption
U l trasou nd most specif ic bu t lacks
sensitivity
May be a later sign; watch for
increasing fundal height
increased uterine activity,
increased p.ain
Use ultrasound, x-ray; palpate fetal
parts outside uterus; assess pai n
Fetal anemia, death, or
isoimmunization
Late decelerations, tachycardia,
loss of variab ility
Abrnption with potential for
fetal hypoxia
More common i n third trimester

department early duri ng transport allows the staff to inform the

obstetric department of the need for collaborative care immed i-
ately upon arriva l. F i rst respond ,ers must promote maternal circula-
ti on and oxygenation and consider occu lt hemorrhage and shock in
the pregnant trauma victi m. Mod ifications of ATLS guideli nes to
be provided \Vithout delay before transport include supplementary
oxygen, intravenous access, and lateral posi tioning on the patient's
side or with a backboard tilt of 15 degrees in pregnancies greate r
than 20 weeks' gestation to prevent supi ne hy poten sion [20 2 l l .
Vital signs should be assessed al the same frequency as for the
nonpregnant woman, and fetal status should only be considered
once maternal stability has been esta blished [20]. Once maternal
::;tabilization has been confirmed , the FIIR may be evaluated '.Vith
 Fetal Assessment in Non -obstetric Settings 195
a Doppler if available. If the patient is conscious, information re-
gard ing feta l activity and the presence or absence of contractions
should be obtain,cd. Determi nati on of the gestationa l age may lbc
of great benefit in determi ning fetal age and the need for prom pt
obstetric intervention on arrival lo the emergency department be-
cause fetal via bili ty is more probable if the uteri ne fondal height
is between the umbilicus and xiphoid process P,201 (Figure 8. 1).
Simply nohng the height of the uterus as above or below the ma-
ternal u mbilicus may help determine whether the pregnancy is
more than or less than 20 weeks' gestation.

FIGURE .8.1 Uterine size and ·gestational age. (From M.V. Muench,
J .C. Ca nteri no, Traurna in pregnancy, Obstet. Gynecol. Cli11. North
Arn. 34 (3) (2007) 555-58.3.)
196 Chapter 8

Primary and Secondary Su rvey

in the Emergency Department
Primary Survey
Similar to the first responders, the emergency department will com-
plete a primary survey of a pregna nt trauma patient on arrival, whi ch
again will encompass the immediate evaluation of the patient,not the
fetus. ln[lial manageme nt of lhe pregnant pa tient is no different from
that of the nonpregna nt patient, so maternal health will take priority
over fetal health unless the patient is undergoing cardiopulmonary
resusci tation and requires a permmortem cesarean deli very.
The pri mary survey of the pati ent v. th trauma is an assessmen t
based on the letters A-B-C-D-E
The com ponents are [4,21-23]:
Airway
Breathing
Circulation
Disability (neurologic-alert, voice, pain , unresponsive)
Exposure (examine)
f oremost in the primary survey is to assess the establishment of
airway (A) ::itabiliz.ation . Adequate respirations (B, breathing) must
be established, with supplemental oxygen bei ng given to prevent
maternal hypoxia and desaturatio n, which in turn can lead to feta l
hypoxem ia [20]. Pulse oximetry a nd arterial blood gases '\¥ill verify
that the patient is adequately oxygena ted when necessary.
Blood pressure , pulse, and capillary refill (C, circulation) will
typically verify hmv well the patient is being perfused. Uteri ne bl ood
flo"v represents 10% to 15% of maternal cardiac output, or approxi-
mately 700 to 800 mL per minute. Significant blood loss, especially if
blunt or penetrati ng injury has occurred, may set off a cascade of ma-
ternal blood flow being shunted awa from the uterus to permit ma-
ternal self-preservation at the expense of the fetus. The fetus acts as
a n early ·warning system for the woman so the fetal heart rate (Fl-IR)
is frequ ently considered the ••fifth" vital sign because adequate u ter-
ine perfusion can correlate with normal FHR character istics, whereas
abnormal FHR characteristics may reflect i nadequate maternal ox
ygenation and circulation [7,17,20]. This. can manifest into FHR
characteri stics that reflect fetal hypoxemia seconda ry to maternal
hypovolemia and red uced uteroplacental perfusion, incl uding feta l
tachycardia , decreasing variability, and recu rrent decelerations even
before tlnere are changes in maternal vita l si gns [4,7,8]. Compared
198 Chapter 8
• Focused assessment sonographic trauma (FAST) uJtrasound for
potential intraabdomi na.I hemorrhage may be incorporated \,1i th
obstctri c ultrasound
• Obstetric ultrasound wi th capable personnel: fetal number; car-
diac activity ; fetal position ; biometrics; placental location; visu-
alization of possible streaming vesse ls or placental hemaloma
indicati ng placental injury; amniotic fluid volume; biophysica l
profile
• Doppler ult:rasound of middle cerebra] artery identifyi ng possible
acute feta[ anemia
• Kleihauer-Betke kst lo evah1ate for maternal-fetal hemorrhage
The Klcihaue r-Betke test may be performed to detect the degree
of maternal-fetal hemorrhag,e in which fetal cells a re circu lating
in the materna l circula bon in excess of what earn be treated with a
standard dose of Rho(D) immune globulin . This test determine s the
amount of Rho(D) immune globulin that is needed in the unsensi-
tized Rh-negative pregnant trauma patient as additional fetal cells
may come in contact with maternal circulation. The Kleihauer-Betke
is not used to determi ne th e need for RhoGAM [7,20)5]. Jn trauma,
maternal -fetal hemorrhage is more common with an anterior placenta
[26]. Changes in the FHR combi ned with a posi ti ve K lei hauer-Betke
may signal hypoxern ia, fetal anemia, and potenti al fetal compromise.
If significant fetal hemorrhage has occurred , it may ma nifest into
tachycardia or a sinusoidal pattern on the .FHR tracing L25,27,28j .
Doppler ultrasound of the middle cerebral artery may a lso demon-
strate a compensatory response lo hemorrhage.
Electronic fetal monitoring is a valuable adjunict tool for fetal
evalua tion in the pregnant trauma v]ctim with a via ble fetus as long
as i t d oes not i nterfere with vi tal materna[ treatment [19]. Continuous
fetal moni toring versus intem1ittent auscul tation is preferred , be-
cause auscultation is limited in detiecting specific FHR characteris-
tics, such as variability and deceleration type [29]. Loss of variability
and late or prolonged decelerations are the most sensitive findings in
the detection of abruption though other FllR. characteristics such as
tachycardia , bradycardia , and a sinusoidal pattern may be observed
[29.301. It is imperative to establish a baseline FHR. Similar to the
laboring patient, any FI-IR tachycardia should be regarded with sus-
picion and managed as outli ned in Chapter 6.
Although there is a general consensus that electronic fetal moni-
toring i s an integral part of the ongoing assessment of the maternal
fetal dyad, there are no established standards for the duration of
monitoring [19,31]. Experts advocate for a minim um of 2 to 6 hours,
200 Chapter 8
the type of r hythm (shockabl e versus non-shockabl e) [34-36]. The
indication for performing a perimortem cesarean bi rth is less clear
when times reach beyond thi s timcframc [32]. Nonpregnant pati ents
suffer irreversi ble brain damage from anoxi a within 3 to 4- minutes,
but pregnant women become hypoxic more quickly. The neonatal
outcome may be more favorable if a perimorlem cesarea n birth oc-
curs f23l. The optimal location for a perimortem cesarean birth is
at the current location of the trauma patient to avoid delay between
cardiopulmona ry resuscitation and perimoitem cesarean birth f31.
Deli very of the fetus may allo\ for fetal resuscitation and perhaps
a successful maternal resuscitation. A decision tree for the unstabk
pregnant trauma patient may be a uscfuJ r·esource (Figure 8.2).

After 4 minutes
of CPR iriitiate
del very
Primary survey
Airway
Breathing
Circulation
Disabilty (alert. voic!l.patn.unr!lspons ve)
E11>po5 re ,
Oygen !ind IV II.l d reuscil!!ilion I

Same treatment . . Uterine

...-- ----..T
0 !2 0 weeks
Uterine displacement
as nonJ)regnant S l!Ce 15 degree:s to the lefl

High risk: of abruption
Consumptive coagulopathy
Stabilize maternalinjuries
Lnducdon or labor
Sewndsry survey
Fast scan
Fetal ultrasound (biophysical
profile, middle cerebral
artery Doppler-if available)
Kleihauer 5e ke screenin9 rn
all paliants al blunt trauma
X ·ray and lab studies as nGedod

.....-------= ·-·_.·...,_•• •••••, f..• Absent Fetan heart .acti11ity Present

Ob;:;e;ve for 2 11iouts
olfetal monitoring if Contractions <4 per hour
minor trauma and negalivo KB test Ir;itiata continuous
Longer monitoring may- (low inc
iden of preterm ele<::lronlcle'lalmonltorln9
be c<:meidered wilh labor or abruplion) Treatment olmaterna linjuries
severe maternal njury
Schedulelollow-up
ultra.,.oumlin 2 weell1>
Contractions >4 per hour Fetal distress.
and/or positive KB test Intrauterine resuscitation
>1.0 mL (highincidernce of (lluids. o>:ygen, position change)
Admit lor mlnimum pret erm labor or abrupllrm)
of 12-24 ho..rs for
observation and
moni ori. ng No response
>23 w eks
o..1iver

FIGURE 8.2 Maternal trauma algorithm. (From M.V. Muench,J .C.

Canter ino,Trauma in pregnancy,Obstet. Gynecol. Clin. North Am.
34 (3) (2007) 555-583.)

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