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Care of the Pregnant Trauma Patient in the Emergency Department at the University Hospital (5.1.3)

Care of the Pregnant Trauma Patient in the Emergency Department at the University Hospital (5.1.3) - Policies, Clinical, UW Health Clinical, Emergency Response/Management

5.1.3


UW HEALTH CLINICAL POLICY 1
Policy Title: Care of the Pregnant Trauma Patient in the Emergency Department at the
University Hospital
Policy Number: 5.1.3
Category: UW Health
Type: Inpatient
Effective Date: October 19, 2015

I. PURPOSE

To define the plan of action w hen a pregnant trauma patient presents to the University of Wisconsin
Hospitals and Clinics (UWHC) Emergency Department (ED) at the University Hospital (600 Highland
Avenue) in order to optimize the outcome to mother and fetus. This policy does not apply to the Emergency
Department at The American Center.

II. POLICY ELEMENTS

The follow ing general procedures w ill be considered w hen assessing the appropriate care setting for
pregnant trauma patients requiring emergency trauma treatment. Emergency care w ill be provided for the
pregnant w oman and fetus for the purpose of stabilizing the patient and determining definitive care.

III. PROCEDURE

A. Management of Pregnant Trauma Patients
i. Pregnant trauma patients suspected to be greater than or equal to 20 w eeks gestation as identif ied
in UWHC policy 8.11, Adult Trauma policy w ill be designated as a Pregnant Trauma, Level I. The
pregnant trauma patient w ith less than 20 w eeks gestation w ill follow the adult trauma activation
criteria as defined in policy 8.11.
a. Immediate physical response to the ED by the follow ing is required for a Pregnant Level I
Trauma:
1. Trauma Surgeon Attending and Trauma Team
2. Emergency Medicine Attending
3. Senior OB/GYN Resident
4. Maternal Fetal Medicine (MFM) Attending and, if available, the MFM Fellow
5. OB/GYN Nurse from Meriter
6. AFCH NICU Physician/Neonatologist or Advanced Practitioner
7. AFCH NICU Care Team Leader, RN and RT
b. To activate a pregnant trauma response: The Pregnant Trauma Page w ill indicate the
required information for a trauma page w ith the addition of information on the gestational
age of the pregnancy, as available. All of the team members lis ted above are part of the
page.
c. If there is not a response from the MFM Attending or Fellow , The ED Care Team Leader
or designee w ill call Meriter’s Access Center at 417-6261 and indicate a Pregnant Trauma
situation. Ask to speak directly to the Maternal Fetal Medicine physician on call (not the
OB/GYN).
d. Outside facility clinicians and staff w ill be escorted by UWHC staff to the patient’s location,
i.e.: Trauma bay, CT scanner or the OR.
e. The Emergency Medicine Attending Physician w ill assume primary care for the fetus until
MFM and AFCH NICU team arrives, w hile the Trauma Surgeon Attending w ill assume
primary care for the mother.
ii. The Pregnant Trauma patient w ill be roomed in one of the available trauma rooms. The ED OB
delivery cart and fetal monitor/doppler equipment w ill need to be placed in the trauma room.
iii. A second room (preferably next to the room for the pregnant mother) w ill be prepared for
impending delivery, if available. If a second room is not available due to overcrow ded status, set up
in the same room as the patient.
iv. The follow ing equipment w ill be brought to the second room and set up for emergent delivery:
a. ED infant radiant w armer
b. Pediatric emergency equipment cart
v. The AFCH NICU team w ith the Neonatologist and/or Lead NICU Nurse w ill assume care of the
delivered new born if there is an impending delivery. All communications regarding the infant’s care
w ill go through the Neonatologist or the Lead NICU Nurse. The team w ill w ear personal protective



UW HEALTH CLINICAL POLICY 2
Policy Title: Care of the Pregnant Trauma Patient in the Emergency Department at the University Hospital
Policy Number: 5.1.3

equipment (PPE) and the “orange” surgical hat (kept on the Trauma PPE cart) to show that they
are caring for the infant.
vi. The fetal monitor w ill be applied to the pregnant patient. Monitor fetal heart rate: apply external
ultrasound device according to the Electronic Fetal/Maternal Monitor Users Guide. Immediately
inform physician if fetal heart rate is not tracing or if rate is less than 110 beats per minute or
greater than 160 beats per minute. The OB/GYN Resident is responsible for the interpretation of
the continuous fetal monitor tracings. The ED Nurse w ill document the care of the patient in the ED
in the Trauma Flow Sheet/ED chart. Once the OB/GYN Nurse arrives, the OB/GYN Nurse should
document the patient’s name/date on the tracing and interventions taken to address any
abnormalities, under the direction of the OB/GYN Resident.
vii. If delivery occurs in the Emergency Department, the neonate w ill be stabilized by Emergency
Medicine and AFCH NICU staff.
viii. The delivered new born w ill be registered and identif ied in accordance w ith the UWHC New born
Naming policy (policy 8.35) by using the mother’s “Unident” name. The registration process cannot
be initiated until there is a birth. Once there is a birth, the Emergency Dept. Coordinator (EDC) can
begin the registration process. See example of registration:
a. Mother’s name: “XxIow a, Unidentif ied21”
b. Baby’s name: “XxIow a, Babygirl Unidentif ied21”
ix. If the patient show s signs of impending delivery:
a. The OR is notif ied via trauma pager of all Pregnant Level I traumas and staff w ill prepare
and set up surgical instruments in the trauma OR suite. Radiant infant w armer w ill be
brought from the ED to the trauma OR suite.
b. If a C-section is indicated:
1. Meriter MFM w ill staff the case, but the OR nurse w ill also notify the GYN
Resident as a backup.
2. Neonatal resuscitation w ill be done by the AFCH NICU staff w ith assistance from
the OR staff.
B. Admission of Pregnant Patient at UW
i. The Trauma Surgeon Attending and Maternal Fetal Medicine Specialist w ill collaborate to
determine the next steps in care of the trauma patient w ho requires admission. The severity of
trauma patient injuries w ill play a role in determining w here the patient w ill be admitted and the
resources required to care for both the injured patient and the fetus. The Trauma Surgeon
Attending w ill assume primary care of the patient until another plan of care is determined.
C. When the injured pregnant trauma patient has injuries requiring Level I trauma care, the patient w ill be
admitted to the f loor or intensive care unit at UWHC. The Trauma Surgeon Attending and MFM Attending
w ill determine the resources needed for the trauma patient and the fetus. We may utilize the Meriter OB
team to assist w ith care.
i. The ED charge nurse or the Nursing Administrator on Call w ill contact Meriter OB Triage at 417-
7588, w ho w ill in turn notify the Birthing Center charge nurse and Meriter nursing administrator of
the situation.
ii. Meriter perinatal nurses w ill collaborate w ith the MFM/Perinatology physician and the UWHC
nursing staff to provide care for the obstetrical component of the patient on the f loor or in the ICU.
Meriter perinatal nurses w ill be responsible for monitoring and interpreting fetal heart rate and
activity, uterine activity, and assessing for potential pregnancy complications per orders of the
Maternal Fetal Medicine Attending and fellow on-call and the CSC Senior OB/GYN Resident. The
patient’s obstetric care remains under the direct care of the Maternal Fetal Medicine Attending and
fellow on-call and the CSC Senior OB/GYN Resident until Meriter nurse(s) arrive. The plan of care
w ill be review ed daily by the UWHC primary care team and the Meriter Perinatal CNS to determine
ongoing need for Meriter nursing staff support, or to plan transfer of patient to Meriter w hen stable.
D. Transfer of Pregnant Patient.
i. The patient w ith limited/stable injuries/illness as determined by the Trauma team w ith a reliable
exam, a negative Focused Assessment w ith Sonography for Trauma (FAST), a Glasgow Coma
Score of 15, and isolated orthopedic or facial trauma, may be transferred to the hospital w here the
patient receives her OB/GYN care, after consultation betw een the Trauma Surgeon Attending, EM
physician, the OB/GYN resident and the Maternal Fetal Medicine Attending and Fellow .
ii. To access Meriter Hospital: Call Meriter’s Access Center at 417-6261 and ask to speak to the
Maternal Fetal Medicine Attending on call. Patient w ill be a direct admit to the Birthing Center at
Meriter Hospital under UW Perinatal Services.



UW HEALTH CLINICAL POLICY 3
Policy Title: Care of the Pregnant Trauma Patient in the Emergency Department at the University Hospital
Policy Number: 5.1.3

iii. To access St. Mary’s Hospital call 258-6825 and ask to speak to the OB attending on call.
iv. If patient transfers to another facility, the ED CTL notify NICU staff to allow communication w ith
their team that they no longer have a potential patient at UWHC.
E. Admissions of the Trauma Patient that no longer has a viable pregnancy.
i. The Trauma Surgeon Attending and Maternal Fetal Medicine Specialist w ill collaborate to
determine the next steps in care of the trauma patient w ho no longer has a viable pregnancy. They
w ill make arrangements for the patient to be taken to the Operating Room for delivery or admission
to the f loor at UWHC as soon as possible.
ii. Consult the NICU staff to provide psychosocial bereavement support to the grieving parents.
F. Other Considerations.
i. ED CTL w ill assess staff of need for critical stress incident debriefing (CISD). If CISD is activated,
include the ED staff as w ell as EMS and other providers involved. The goal is to hold CISD w ithin
24 hours.

IV. COORDINATION

Author(s): Adult Trauma Program Manager, Trauma Support
Senior Management Sponsor: SVP, Patient Care Services and CNO
Approval committees: Nursing Patient Care Policy and Procedure Committee; Gynecology Quality
Improvement Committee; UW Health Clinical Policy Committee; Medical Board
UW Health Clinical Policy Committee Approval: September 21, 2015

UW Health is a cohesive, united and integrated academic medical enterprise comprised of several entities.
This policy applies to facilities and programs operated by the University of Wisconsin Hospitals and Clinics
and the University of Wisconsin Medical Foundation, Inc., and to clinical facilities and programs
administered by the University of Wisconsin School of Medicine and Public Health. Each entity is
responsible for enforcement of this policy in relation to the facilities and programs that it operates.

V. APPROVAL

Peter New comer, MD
UW Health Chief Medical Officer

J. Scott McMurray, MD
Chair, UW Health Clinical Policy Committee

VI. REFERENCES

UWHC policy #8.11, Adult Trauma Policy
UWHC policy #8.35, New born Naming Policy
Care of the Pregnant Patient w ith Contractions Emergency Department Guideline
Nursing Patient Care policy #13.14, Documentation in the Inpatient Clinical Record
Guidelines for Perinatal Care Seventh Edition 2012, American College of Pediatrics
Rotondo, M.F., Cribari, C., Smith, R.S. (Eds.). (2014). Resources for optimal care of the injured patient (6th
ed.). Chicago, IL: American College of Surgeons.

VII. REVIEW DETAILS
Version: Revision
Next Revision Due: February 19, 2018
Formerly Know n as: Hospital Administrative policy #8.62