Maternal and Foetal Assessment (Secondary Survey)

Maternal & Foetal Assessment – Secondary Survey

After the primary survey (ABCDE) and initial resuscitation, perform a structured secondary survey focused on detailed maternal examination and foetal wellbeing.

Primary survey done → now detailed maternal & foetal assessment Document GA, foetal heart, movements Unstable mother = resuscitation first Consider CTG / ultrasound if available

Flow of the Secondary Survey

Overview

Step 1

Confirm Stability

Primary survey complete, ABC optimised, vitals reassessed.

Step 2

Maternal Exam

Head-to-toe plus detailed abdominal & pelvic assessment.

Step 3

Foetal Evaluation

Foetal heart, movements, CTG (if available), ultrasound as needed.

Step 4

Stability Decision

Mother stable? Foetus stable? Identify scenario & plan.

Step 5

Disposition

Ongoing monitoring, admission, theatre, or transfer as required.

Detailed Maternal Examination

Mother

General: reassess vital signs, pain, distress level, mental state.
Abdomen:
- Inspect for distension, bruising, surgical scars.
- Palpate uterus for:
  - Tenderness or guarding (consider abruption, uterine rupture).
  - Contraction frequency, duration, intensity.
  - Fundal height and tone.
Perineal & vaginal exam:
- External perineal inspection for bleeding, lacerations, or swelling.
- Sterile speculum exam if indicated:
  - Assess visible cervix, os (open/closed), active bleeding, membranes, amniotic fluid.
- Digital vaginal exam usually done by obstetrics when assessing labour, unless contraindicated (e.g. placenta praevia).
Associated injuries: in trauma, perform a full head-to-toe secondary survey (spine, chest, abdomen, pelvis, limbs).

Foetal Evaluation

Foetus

Foetal heart:
- Check with Doppler or CTG (if ≥ ~26–28 weeks and available).
- Normal baseline ~110–160 bpm.
- Note presence of accelerations, variability, and any decelerations.
Foetal movements:
- Ask mother about her usual pattern vs current movements.
- Reduced or absent movements are a red flag and need urgent obstetric review.
CTG (if available):
- Assess baseline, variability, accelerations, and type of decelerations.
- Non-reassuring or abnormal CTG (repetitive late/variable decels, bradycardia, absent variability) = foetal compromise until proven otherwise.
Ultrasound (where available):
- Confirm foetal viability, lie, presentation.
- Assess placenta (location, abruption suspicion), amniotic fluid, and multiple pregnancy.

Document foetal heart and movements Non-reassuring CTG → urgent obstetric review

Stability Algorithm

Decision

Mother stable, foetus stable

Continue monitoring (CTG or intermittent auscultation) if viable gestation.
Observation period:
- At least 4 hours after minor trauma ≥ 22–24 weeks.
- Longer (up to 24 hours) if contractions, abruption concern, or other complications.
On discharge, advise:
- Monitor foetal movements.
- Return immediately for bleeding, pain, fluid leak, reduced movements, or feeling unwell.

Mother stable, foetus unstable

Urgent obstetric review and continuous foetal monitoring.
Correct reversible causes (hypotension, hypoxia, uterine tachysystole, cord compression position, etc.).
If ongoing foetal distress despite optimisation and foetus is viable:
- Prepare for emergency caesarean section as per obstetric decision.

Mother unstable, foetus unstable

Resuscitate the mother first – improving maternal circulation is the best foetal resuscitation.
If maternal cardiac arrest with no ROSC within 4–5 minutes and uterus ≥ 20 weeks:
- Consider resuscitative hysterotomy (perimortem caesarean) to:
  - Relieve aortocaval compression.
  - Improve chances of maternal CPR success.
  - Potentially salvage a viable foetus.
Requires senior surgical/obstetric + anaesthetic + neonatal support where possible.

Special Considerations & Disposition

Safety

Defibrillation / cardioversion:
- Use standard energy doses – it is safe in pregnancy.
- Foetal monitoring where feasible, but do not delay life-saving treatment to attach CTG.
Resuscitative hysterotomy:
- Consider when maternal circulation is not restored despite optimal resuscitation and gestation is likely viable (≥ ~20–24 weeks).
- Primary aim is maternal survival; foetal survival is a secondary benefit.
Disposition:
- Admit to:
  - ICU/High care if maternal condition unstable or requires close monitoring.
  - Obstetric ward/labour ward if ongoing contractions, risk of abruption, or foetal concerns.
- Even after minor trauma at ≥ 22–24 weeks:
  - Monitor for at least 4 hours with maternal vitals and foetal assessment.

Document maternal + foetal status at each step Call obstetrics early, not late Re-do primary survey if any deterioration