Case of the Month
December 2004

34-year-old female — vaginal bleed (39 weeks gestation)

The alarm sounds at 1746 hrs. for a 34 year-old female vaginal bleed. The dispatcher states “full term pregnancy.” You and your partner arrive at the residence and find the husband running out of the front door to meet you. He is frantic and begs for you to help his wife.

You find the patient sitting on the kitchen floor with a pool of blood between her legs. She is conscious and screaming: “please save my baby”. You note her pale, cool skin and barely palpable radial pulse. You tell your partner that you have a “SICK” patient and ask for a medic ETA. A check of vital signs and a physical exam reveal the following:

LOC	—	Alerted/oriented, but scared
RR	—	24/min, without complaint
HR	—	122/min radial… weak, regular
BP	—	84/palp
Skin	—	Pale, diaphoretic
HEENT	—	Pupils-MER
Chest	—	Symmetrical
Lungs	—	No complaint
Adb	—	39 weeks gestation
Ext	—	Mild edema

As your partner prepares the gurney for a rapid transport, you place the patient in a supine position and tell her you need to perform a visual inspection of the perineum to determine if there is presentation. At that time, she tells you that she has a 100% placenta previa and according to her doctor, this baby cannot be born vaginally! You perform a quick visual and find no presentation. The patient is given high flow oxygen with a nonrebreathing mask and you instruct the patient not to “push” during contractions but rather, “breath through the contractions”. You load the patient on your gurney in the Trendelenburg position. You immediately move her to the back of your aid unit and begin transport for a medic intercept.

Based on the patient’s clinical picture (that of a SICK patient), your treatment is built around treating what you know you have for sure…patent airway, breathing (Rx: with high flow oxygen) and circulation (Rx: place patient in the “shock position”) the use of pulse oximetry reveals a reading of 94%. Your update to the medics lets them know that you three minutes out.

En route to the intercept site you perform a SAMPLE history…

S	—	Vaginal bleed, diaphoresis
A	—	No known allergies
M	—	Pre-natal vitamins
P	—	Gravida (4), Para (3)
L	—	Small meal this morning
E	—	Doing dishes at the sink when she felt a contraction and then started to bleed!

Paramedics arrive and jump in your rig and direct you to continue transport. They start IV access, bolus fluids, perform cardiac monitoring, pulse ox and blood glucometry and continue transport to the local hospital after radio communications confirms that they can handle this patient.

Placenta Previa

During normal fetal development, the placenta (attached to the uterine lining) usually migrates to the top (fundus) of the placenta away from the cervical opening. There are cases in which this does not happen and all or a portion of the placenta covers the cervical opening. This condition is known as placenta previa. It is often found in the third trimester of pregnancy through good prenatal care. An OB physician will decide whether the baby can be delivered normally or through C-section.

The lesson learned from this case: As with any SICK patient, speed is critical…both in the decision making as well as the initiation of care. Without knowing all of the facts of the patient’s pre-natal history, the EMTs made sound decisions regarding care and transport. The intercept was as excellent choice and the medics simply continued care without having to take time to change rigs or gurneys…all saving time and ultimately the patient and her unborn child. The patient survived this ordeal as did the baby girl!

View more information on placenta previa — eMedicine.com (external link)