Maternal Primary Survey

• Mother’s ABC takes priority – fetal status improves only if maternal status is stabilised.
• From ~20 weeks, the gravid uterus can compress the IVC → always consider left uterine displacement / tilt.
• Perform a rapid gestational age and fetal viability check once immediate threats to maternal life are addressed.

1. Call for help early; activate trauma/obstetric/emergency team as appropriate.
2. Position: supine with manual left uterine displacement or 15–30° left lateral tilt if ≥ 20 weeks.
3. Airway with cervical spine protection (if trauma) and high-flow oxygen; aim SpO₂ ≥ 95%.
4. Breathing: assess and support ventilation; consider early intubation if needed.
5. Circulation: two large-bore IVs above diaphragm; treat shock aggressively; consider massive transfusion.
6. Disability: quick GCS/AVPU, pupils, blood glucose; manage seizures if present.
7. Exposure: fully expose to look for injuries/bleeding; prevent hypothermia; then assess uterus size and fetal heart.

• Airway:
  • Look for obstruction, vomitus, blood; suction as needed.
  • Use jaw thrust if trauma; protect C-spine.
  • High-flow oxygen via mask; aim SpO₂ ≥ 95% (pregnant women desaturate faster).
  • Early consideration of rapid sequence intubation if:
    • GCS ≤ 8 or inability to protect airway, or
    • Severe respiratory distress, shock, or ongoing seizures.
• Breathing:
  • Inspect, palpate, percuss, auscultate the chest – look for pneumothorax, haemothorax, flail chest.
  • Pregnancy causes reduced FRC and increased oxygen demand → tolerate no hypoxia.
  • Support with bag–valve–mask if needed while preparing for intubation.
  • Adjust ventilator settings in intubated patients to avoid both hypoxia and significant hyperventilation.

• Positioning: if ≥ 20 weeks:
  • Manual left uterine displacement (push uterus up and left) or tilt bed 15–30° to the left.
  • Reduces aortocaval compression and improves venous return and cardiac output.
• IV access & monitoring:
  • Two large-bore IV cannulae above the diaphragm (e.g. antecubital fossa).
  • Continuous BP, HR, SpO₂; consider arterial line if available and patient severely unwell.
• Fluids & blood:
  • Start isotonic crystalloid for suspected hypovolaemia, while arranging blood.
  • Use type O-negative packed red cells if immediate transfusion required and group-specific blood not yet available.
  • For major haemorrhage, activate massive transfusion protocol (e.g. approximate 1:1:1 ratio RBC : plasma : platelets as per local guideline).
  • Administer tranexamic acid early (ideally within 3 hours) in major trauma or postpartum haemorrhage, as per protocol.
• Urine output:
  • Insert a Foley catheter unless contraindicated (e.g. suspected urethral injury in trauma).
  • Target urine output ≥ 0.5 mL/kg/hr; low output suggests inadequate perfusion.

• Disability (neurological):
  • Rapid GCS or AVPU assessment.
  • Check pupils, limb movement, and signs of lateralising deficits.
  • Check capillary blood glucose in all altered patients.
  • If seizure → protect airway, treat with appropriate anti-seizure meds; if pregnant, consider eclampsia and give magnesium sulfate as per protocol.
• Exposure:
  • Fully expose to look for injuries, bleeding, bruising, rashes; gently log-roll if trauma and spine precautions.
  • Pay special attention to abdomen, flank and perineum; look for vaginal bleeding or fluid loss.
  • Prevent hypothermia with warm blankets, warmed IV fluids, and warmed environment.

Once life-threatening maternal problems have been addressed, perform a rapid obstetric assessment.

• Uterine size / gestational age:
  • Palpate uterus from symphysis pubis to fundus (fundal height in cm approximates gestational age in weeks after ~20 weeks).
  • Note:
    • Fundus at umbilicus ≈ 20 weeks.
    • Each finger breadth above/below ≈ 1–2 weeks, roughly.
  • Large/small for dates may indicate multiple pregnancy, polyhydramnios, growth restriction, etc.
• Fetal heart:
  • Use Doppler or fetoscope if equipment available and gestation allows (usually ≥ 12–14 weeks for Doppler).
  • Document rate and rhythm; normal baseline ~110–160 bpm.
  • Absent fetal heart in the resus room does not change initial maternal resuscitation — continue ABCDE and involve obstetrics early.
• Abdominal tenderness / uterine tone:
  • Localised tenderness or rigid “wooden” uterus → think placental abruption.
  • Contractions – frequency, duration and pain; possible labour or uterine irritability after trauma.

• After primary survey, repeat ABCDE as needed and move to secondary survey (full head-to-toe + detailed obstetric assessment).
• Involve:
  • Obstetrics/gynecology (for fetal and uterine assessment, potential delivery decisions).
  • Anaesthetics/ICU (for airway, ventilation, inotropes if needed).
  • Surgery/trauma team in cases of significant injury.
• Document clearly:
  • Time of assessment, gestational age (estimated), uterine size and fetal heart findings.
  • All interventions: oxygen, IV fluids, blood products, drugs (e.g. TXA), and response.