Pregnant Pause

Third-trimester emergencies: What do you do?

The day has been unusually busy for the Attack One crew. It’s been full of injuries, several severe, and it seems almost every patient has required transport to the regional trauma center. As the crew cleans the kitchen after dinner, the tones drop for a response to a “woman ill.” That should be a different type of patient on this day of blood and injury—or maybe not.

“She is bleeding like crazy!” says the lady who answers the door. “She keeps bleeding and seems about to pass out!”

“I am feeling really light-headed,” the young woman lying in the bathroom tells the crew as they walk in to assess her.

She is 26 years old and says she began bleeding from her vagina about an hour earlier. Her lower abdomen has some mild crampy pain. She is pale, and her heart rate is elevated as the EMT kneels next to her to begin an assessment. The paramedic begins to get a rapid history: “Ma’am, do you know why you might be bleeding so much? Is this usual for you? Are you on your menstrual period?”

The woman asks that the door to the bathroom be closed and that the older woman be asked to leave.

As this occurs the female EMT finishes getting vital signs and, as part of her examination, presses on the patient’s abdomen. She notes that hidden under her clothes appears to be a protuberant lower abdomen. The EMT looks at the paramedic, and as the door to the bathroom closes asks the patient, “Are you pregnant?”

“I think I am,” the woman replies, “but I haven’t been checked for a long time, and I don’t want my mother to know I am. That’s why I wanted her to leave.”

The EMT asks if she can examine the young lady’s abdomen, and the patient consents. She pulls up her shirt, and it certainly appears she’s pregnant from the size of the uterus above the umbilicus. The uterus and the rest of the abdomen are not tender on palpation, and the EMT confirms that bright red blood and clots are coming from the patient’s vagina.

The paramedic begins to move quickly through the rest of the evaluation and asks that the crew prepare for rapid transport. He also notices the woman’s pulse is very difficult to palpate, and her heart rate is rapid. Her skin is pale, she’s a little sweaty, and her capillary refill is slow. These signs of poor perfusion are consistent with an initial pulse oximeter reading in the low 90s, indicating a need for rapid transport.

“Where have you been examined for your pregnancy, and where are you going to deliver your baby, ma’am?” the paramedic asks.

“I don’t know. I was seen in a clinic, where they told me I was around 14 weeks pregnant, and I haven’t seen anyone else. I don’t have a hospital I go to. Can you just take me to the hospital up the street, and I’ll tell my mother to come later and pick me up? I don’t want her to know anything.”

“How long ago were you told you were 14 weeks pregnant?” the paramedic asks.

“It was a while ago—maybe 4 months.”

Quickly doing the math, the paramedic estimates the woman would now be at least 30–32 weeks pregnant. The EMS protocol for emergencies with pregnant women calls for the patient to be transported, if possible, to a hospital capable of dealing with a crisis delivery, with a high-level neonatal intensive care unit for the child. That means the closest hospital, the one “up the street,” will have to be bypassed, as it has no labor and delivery unit.

“Ma’am, there is obviously an emergency going on with the bleeding you’re having,” the paramedic says. “The hospital up the street does not have any of the services you need. We’ll need to take you to a hospital that has a women’s services unit. Can you please tell your mother that we are transporting you to that hospital? We will not say anything about the reason. You’ll probably need to stay at that hospital for a while, so don’t expect your mother to be picking you up today.”

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