Blunt trauma in the obstetric patient: monitoring practices in the ED

This study was undertaken to determine the usually used approach to fetal monitoring in the emergency department (ED) of the less severely injured obstetric patient who has sustained blunt trauma. A written survey was sent to clinical directors of teaching programs in emergency medicine (EM) with inquiries on the usual way of monitoring, what studies were performed, and the usual disposition of the less-injured obstetric patient. From the 112 teaching programs surveyed in early 1996, there were 87 responses (78%). Seventy-eight percent of programs generally have fetal monitoring performed for 2 to 4 hours in obstetric trauma patients when the trauma is more than minor extremity injury. In 68%, fetal monitoring was not performed in the ED from the time of the initial assessment of fetal heart tones until the mother went to an obstetric area even though the average estimated time to radiographically clear a cervical spine was 36 minutes. In 92% of programs residents are taught cardiotocographic changes indicative of fetal distress but only 15% have such monitoring equipment in their department. However, 51% do have sonographic equipment in their department. Given a patient with a viable fetus who has no abdominal pain, 46% routinely use fetal monitoring if the mechanism is a simple fall whereas 92% use monitoring only if the mechanism is a rollover motor vehicle collision or a strike to the abdomen. It is generally recognized that fetal distress may occur subtly without overt clinical signs and that obstetric area monitoring for a period of several hours should take place. However, most teaching programs do not institute continuous fetal monitoring during the first 30 to 60 minutes that the mother is undergoing her work-up even though residents are taught such monitoring.