Early pregnancy bleeding — suspected miscarriage

Patient Information

Dispatch: You are called to a 35YO female (Sarah Nolan) who is sitting near the medical tent at the Fremantle Community Food & Wine Festival, reporting lower abdominal pain and vaginal bleeding. She appears distressed.
Patient: Sarah Nolan — 35yr (65kg)
Incident History: Pt was walking around the festival with her partner when she developed sudden onset lower abdominal cramping and noticed vaginal bleeding. She is approximately 9 weeks pregnant. Partner escorted her to the FAP.
Emergency Contact: Daniel Nolan (Partner) — 0412 774 093

Initial Rapid Assessment

Response: Alert
Airway: Patent. Nil airway obstruction. Nil stridor.
Breathing: Adequate. RR 18, no increased work of breathing, nil adventitious sounds.
Circulation: Radial pulse present, slightly rapid, skin pale and cool to touch. No external haemorrhage visible. Partner reports she has soaked through one pad in approximately 30 minutes.
Disability: GCS 15 (E4V5M6). Orientated to time, place and person. Visibly anxious and tearful.
Exposure: Lower abdominal tenderness on palpation. No rigidity. Nil shoulder tip pain elicited. Nil rash. No obvious trauma.

Vitals

Time	SpO2	Resp Dist	RR	Pulse	BP	CRT	GCS	PERL	Temp	BGL	Pain
Initial	97% (RA)	Nil	18	106	102/68	2s	15	4 4 ++	36.8	–	6
10 mins	98% (RA)	Nil	16	98	108/72	<2s	15	4 4 ++	36.8	–	5

History Taking

Treatment Response

Diagnosis

This patient is suffering from early pregnancy bleeding at approximately 9 weeks gestation, consistent with a threatened or inevitable miscarriage. Ectopic pregnancy must be considered and excluded — although the absence of shoulder tip pain, peritoneal rigidity, and haemodynamic collapse makes ruptured ectopic less likely at this time, clinical deterioration must be monitored for closely.

Facilitator Triggers — if trainees miss a critical step

! (If the EHS officer does not ask about pregnancy status or gestational age within the first 3 minutes, the partner volunteers: 'She's about 9 weeks pregnant — could this be a miscarriage?')
! (If the officer does not enquire about shoulder tip pain during the secondary survey, the patient spontaneously reports mild left shoulder discomfort — escalate concern for ectopic and prompt reassessment of BP and HR)
! (If BP is not repeated within 5 minutes of initial reading, the patient reports feeling dizzy and lightheaded when shifting position — BP drops to 90/58 and HR increases to 118, indicating haemodynamic deterioration)
! (If the patient is not positioned appropriately — i.e., left lateral tilt or supine with legs elevated — facilitator notes that patient is sitting upright and reports worsening dizziness)
! (If reassurance is not provided continuously, patient becomes increasingly distressed and begins hyperventilating — RR increases to 24)

Treatment Objectives

1 Ensure scene safety and don appropriate PPE including gloves
2 Perform Primary Survey — confirm patent airway, adequate breathing, assess circulation including pulse rate and quality
3 Position patient appropriately — supine with legs slightly elevated if haemodynamically compromised, or left lateral position; avoid aortocaval compression (left lateral tilt preferred in pregnancy)
4 Provide continuous reassurance — patient is distressed; maintain calm therapeutic communication throughout
5 Perform Vital Sign Survey — BP (bilateral if possible), HR, RR, SpO2, GCS, temperature
6 Administer Oxygen only if SpO2 falls below 94% — titrate via nasal cannula at 1–4 L/min or simple face mask at 5–8 L/min to target SpO2 94–98%; do not administer if SpO2 is maintained on room air. Confirm 6 medication rights: right patient, right drug, right dose, right route, right time, right documentation.
7 Conduct thorough history taking using IMISTAMBO framework — specifically document: gestational age, duration and amount of bleeding (number of pads soaked), presence of clots or tissue passed, abdominal pain character and radiation (shoulder tip pain = red flag for ectopic)
8 Perform Secondary Survey — palpate abdomen for tenderness, rigidity, or guarding; specifically assess for shoulder tip pain (Kehr's sign) as indicator of intraperitoneal bleeding from ruptured ectopic
9 Apply a clean pad and instruct patient to retain all used pads, swabs, and any passed tissue for clinical assessment
10 Record duration, amount, colour, consistency, and pattern of blood loss in documentation
11 Repeat vital signs every 10 minutes — monitor closely for haemodynamic deterioration (rising HR, falling BP, worsening pallor, altered GCS) as signs of ruptured ectopic or significant haemorrhage
12 Call for CSP support immediately if patient becomes haemodynamically unstable (systolic BP <90 mmHg, HR >120, deteriorating GCS) or if ruptured ectopic is suspected
13 Scenario ends on arrival of ambulance and IMISTAMBO handover
14 Attention to hand hygiene will be given throughout the scenario.

Clinical references: Early Pregnancy Bleeding · Primary Survey · Oxygen Delivery

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