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Obstetric and gynecological issues are a common reason for patients to seek urgent and emergent care. The most significant of these for the prehospital provider involve some component of vaginal bleeding. When assessing the patient with vaginal bleeding, determining certain key factors are important such as duration of bleeding as well as quantity. Oftentimes, significant or brisk vaginal bleeding is defined by the patient changing one or more pads per hour. A family or personal history of a bleeding disorder may also provide key information as to the etiology of the bleed. Associated symptoms such as weakness, lightheadedness, and shortness of breath should be noted.


  • Describe the initial prehospital evaluation and management of vaginal bleeding.

  • Describe the initial prehospital evaluation and management of patients in active labor (delivery procedure covered in Chapter 64).

  • Describe the initial prehospital evaluation and management of pregnant patients with trauma.

  • Discuss the indications for prehospital perimortem C-section (procedure covered in Chapter 64).

  • Discuss the criteria for determining stability when evaluating for interfacility transport of an obstetrical patient (also discussed in Chapter 16).


Physical examination of the patient with vaginal bleeding should initially focus on careful assessment of vital signs. Tachycardia and/or hypotension can indicate significant hypovolemia secondary to blood loss. Marked pallor or delayed capillary refill may indicate associated hypoperfusion. Signs and symptoms of shock must be recognized and addressed. An associated tender abdomen on examination may indicate a significant intra-abdominal hemorrhage and must be communicated to ED staff. Conversely, a patient who is normotensive without an elevated heart rate and a soft benign abdomen most likely has less significant pathology.


One of the more common reasons for vaginal bleeding or spotting in the nonpregnant patient is dysfunctional uterine bleeding (DUB). DUB is excessive noncyclic endometrial bleeding also described as anovulatory bleeding and most common in peri- and postmenopausal patients. DUB commonly presents as a slow persistent bleed, but excessive bleeding can occur.


A more acute life-threatening cause of vaginal bleeding the prehospital provider must be familiar with is ectopic pregnancy. The incidence of ectopic pregnancy is as high as 19.7 per 1000 reported pregnancies.1 Normally, implantation of a fertilized egg takes place within the endometrium of the uterus and is therefore referred to as an intrauterine pregnancy or IUP. Implantation in an ectopic pregnancy is inappropriately outside the uterus, most commonly within the fallopian tubes. Other possible locations for an ectopic pregnancy include the cervix, an ovary, and the abdomen. As the ectopic pregnancy progresses, the risk is organ rupture increases and can cause rapid, life-threatening interabdominal hemorrhage. Early consideration and recognition are imperative.

Ectopic pregnancy must be considered with a report of abdominal pain, missed or late ...

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