Editorial

Trauma in pregnancy: an underappreciated cause of maternal death

Traumatic maternal cardiac arrest (MCA) is a challenging scenario for the healthcare team. Expanding the focused assessment with sonography for trauma (FAST) and modifying cardiopulmonary resuscitation (CPR) is necessary. Critical components in the resuscitation of reproductive-age women with traumatic cardiac arrest are highlighted using recommendations from Obstetric Life Support™.

A morbidly obese female presented to the Emergency Department (ED) with ongoing CPR and massive hemorrhage from two gunshot wounds to the chest. Ultrasound used during secondary survey, revealed an intrauterine pregnancy, with uterine fundus palpated above the umbilicus. Four minutes after arrival at the ED, the trauma surgeon initiated a resuscitative cesarean delivery (RCD) by transverse abdominal incision. The on-call obstetrician completed the procedure, and the neonate was resuscitated and transferred to the neonatal intensive care unit (NICU). Multiple agents and surgical techniques were required to control ongoing uterine and abdominal wall hemorrhage during intermittent return of spontaneous circulation (ROSC). Despite ongoing CPR and management of the patient's chest, pelvic and abdominal wounds, eventually, there was no return of cardiac activity, no organized cardiac rhythm, no measurable end-tidal carbon dioxide, and no palpable pulse. Further resuscitation and initiation of extracorporeal cardiopulmonary resuscitation (ECPR) were deemed futile by the multidisciplinary team and stopped at the 60-minute mark.

Our case summarizes essential techniques addressing MCA recommended in OBLS™ courses. Including 1) expanding the FAST exam to assess for pregnancy status, 2) estimating gestational age by fundal height or point-of-care ultrasound, 3) performing a RCD via midline vertical incision at 4 min if pregnancy is suspected to be ≥20 weeks' gestation (fundal height at or above the umbilicus, femoral length of ≥30 mm or biparietal diameter of ≥45 mm), and 4) execution of ECPR for refractory cardiac arrest.

Trauma and trauma-related health conditions are common during pregnancy, but there is little evidence and guidance on how doulas (trained lay birth assistants) can provide trauma-informed care. The purpose of this narrative review is to critique and synthesize the existing evidence for trauma-informed doula care and to offer guidelines for practice.

We conducted a narrative review of existing evidence in the peer-reviewed and gray literatures on trauma-informed care in maternity and perinatal settings including doula training curricula and community-based doula guidelines on trauma-informed doula care. Materials were analyzed for relevant data on trauma and pregnancy, evidence-based approaches for trauma-informed doula and perinatal care, and strengths/weaknesses of the evidence including research design, gaps in the evidence base, and populations included.

This narrative review focuses on trauma-informed doula care in the United States, although the evidence and guidelines provided are likely applicable in other settings.

To be trauma-informed, doulas must first realize the scope and impact of trauma on pregnancy including possible ways to recovery; then recognize signs and symptoms of trauma during pregnancy; be ready to respond by integrating evidence and sensitivity into all doula training and practices; and always resist re-traumatization. Trauma-informed doula care also centers on these 6 principles: safety; trustworthiness and transparency; peer support with other survivors; collaboration and mutuality; resilience, empowerment, voice, and choice; and social, cultural, and historical considerations. In practice, this includes universal trauma-informed doula care offered to all clients, trauma-targeted care that can be offered specifically to clients who are identified as trauma survivors, and connection to trauma specialist services.