Vaginal Bleeding in the Field

Why this matters

They may call it a heavy period. The blood pressure is 78. First, ask about pregnancy in anyone who can be pregnant, and treat shock. Ectopic pregnancy and bleeding after birth are the two emergencies that kill. Do not pack the vagina. You will not do a speculum exam in the ambulance.

Clinical sequence

1. Ask about pregnancy in anyone who can be pregnant.
2. Use external pads. Do not pack the vagina.
3. If this is after birth, feel the fundus if you are trained. Massage a soft uterus. Give oxytocin if you carry it and the protocol allows it.
4. Treat shock. Keep them warm. Go to a hospital that can manage obstetrics or operate.

Teaching points

• Ectopic pregnancy. Pelvic pain, bleeding that can be light, fainting, and shock. Shoulder pain can be referred pain from blood in the abdomen. An intrauterine device or a prior ectopic pregnancy raises the risk.
• Miscarriage can still cause shock. Treat the shock. Do not call it a heavy period and leave.
• Postpartum hemorrhage. Bleeding within 24 hours is the primary teaching window. Massage the fundus. Give oxytocin if your protocol includes it. A pelvic binder does not treat a soft uterus. The destination should be able to manage obstetrics.
• Do not pack the vagina. Use external pads, two large-bore IVs per your shock protocol, and keep them warm.

Common errors

• Do not accept a “heavy period” refusal in a hypotensive 28-year-old.
• Do not pack the vagina.
• Do not forget fundal massage when the uterus is soft.

Practice

Related: Oxytocin, Shock.

Sources & Further Study

Named guidelines for further study. They are not clinical orders and do not replace your protocol or medical direction.

• NASEMSO National Model EMS Clinical Guidelines (2022) — U.S. EMS model language; your protocol still decides care
• ACOG postpartum hemorrhage — atony, massage, uterotonics — protocol owns the drug
• ACOG — ectopic pregnancy is a surgical emergency — field job is shock and destination