May 4, 2026

This month, we are focusing on the care of obstetric patients. While these calls are relatively uncommon in EMS, they are high-risk and time-sensitive encounters. A strong understanding of pregnancy physiology is essential to providing safe and effective prehospital care. 

Pregnancy causes significant physiologic changes that affect how patients present, how they compensate, and how quickly they can deteriorate.

The easiest way to think about this is through the lens of the ABCs of our primary survey. 

Airway:  

Hormonal changes lead to swelling and increased blood flow in the airway tissues, making them more edematous and prone to bleeding. This means that what might normally be a straightforward airway can quickly become challenging. Visualization may be more difficult, and even minor trauma can cause bleeding that obscures landmarks. Pregnant patients are also at an increased risk of aspiration due to delayed gastric emptying. If an airway intervention is needed, approach this procedure with extra preparation. Anticipate difficulty, have suction ready, and be prepared to use adjuncts or backup strategies early. 

Breathing:  

As the uterus enlarges, it pushes the diaphragm upward, which reduces the amount of oxygen the lungs can hold in reserve. At the same time, the body’s oxygen demand increases to support the fetus. Even though pregnant patients compensate by breathing slightly faster and deeper, they ultimately have less reserve. This is why they can desaturate much more quickly than other patients, especially during periods of apnea or respiratory compromise. This means we need to intervene early — apply oxygen sooner, monitor closely, and avoid delays if respiratory status begins to decline. 

Circulation:  

Pregnancy has a significant impact on a patient’s cardiovascular system. Blood volume and cardiac output both increase, allowing pregnant patients to compensate for blood loss better than non-pregnant patients. However, this also means that classic signs of shock — especially hypotension — may not appear until later. A pregnant patient can lose a substantial amount of blood before their blood pressure drops, and when they do decompensate, it can happen quickly. Because of this, it is important to recognize early signs of hypoperfusion, such as tachycardia, pallor, or altered mental status, and resuscitate early! 

Positioning is another key consideration. In later pregnancy, the uterus can compress the inferior vena cava when the patient is lying flat. This decreases blood return to the heart and can worsen hypotension, particularly in already unstable patients. Simply shifting the uterus off midline — either manually or by placing the patient in a left lateral tilt — can significantly improve circulation. This is a simple intervention that should be used routinely in patients beyond mid-pregnancy. 

Finally, pregnancy creates a hypercoagulable state. While this helps reduce bleeding during delivery, it also increases the risk of serious conditions like pulmonary embolism and stroke. This is important to keep in mind when evaluating pregnant patients with unexplained shortness of breath, chest pain, or neurologic symptoms. 

This Week’s Take-Home Message:  

Pregnant patients are not our “standard” patients. They may appear stable longer than expected and can deteriorate quickly once their compensatory mechanisms fail. Understanding these physiologic differences directly impacts how we assess and resuscitate these patients in the field. 

Thank you, 

Shauna Combs, DO

May 11, 2026

Vaginal bleeding in early pregnancy is a common reason for patients to seek medical attention. While many patients are ultimately stable, first trimester bleeding can be a life-threatening emergency. For EMS providers, the key is recognizing which patients may be experiencing significant hemorrhage and intervening quickly. 

In the prehospital setting, any patient of childbearing age with abdominal pain, syncope, or vaginal bleeding should be presumed pregnant until proven otherwise. A focused history — including last menstrual period, pregnancy status, and symptom onset — can provide critical clues early in the encounter. 

Two diagnoses should immediately come to mind with bleeding in early pregnancy: ectopic pregnancy and spontaneous abortion. Differentiating between them in the field can be difficult, but identifying signs of instability is far more important than making a definitive diagnosis. 

An ectopic pregnancy occurs when a fertilized egg implants outside the uterus, most commonly in the fallopian tube. As the embryo grows, the surrounding tissue stretches until rupture occurs, leading to internal hemorrhage. Although ectopic pregnancies account for only a small percentage of pregnancies, they remain one of the leading causes of maternal death in the first trimester. 

Patients often present with lower abdominal pain, vaginal bleeding, and a missed period. Pain may be unilateral, and symptoms can progress rapidly once rupture occurs. Tachycardia, hypotension, syncope, or altered mental status should raise immediate concern for hemorrhagic shock. Importantly, visible vaginal bleeding may be minimal despite significant internal blood loss.

Management priorities for suspected ectopic pregnancy include rapid assessment, early IV or IO access, fluid resuscitation, and close monitoring for decompensation. These patients often require emergent surgical management, making rapid transport to an appropriate facility essential.

Spontaneous abortion affects approximately 15-20% of known pregnancies. Patients typically present with cramping abdominal pain and vaginal bleeding, sometimes with passage of tissue. While these patients are often more hemodynamically stable than those with ectopic pregnancy, significant blood loss can still occur.

Management is largely supportive and focused on patient stability. Monitor vital signs closely, establish IV access when indicated, provide fluids if needed, and remember the importance of compassionate communication during what is often an emotional experience.

One of the biggest challenges in early pregnancy emergencies is that patients may initially appear stable before deteriorating quickly. Maintaining a high index of suspicion and recognizing early signs of shock are critical to preventing delays in care. 

Thank you, 

Shauna Combs, DO

May 18, 2026

As pregnancy progresses into the second and third trimesters, the complications EMS providers encounter become increasingly high-risk for both mother and baby. Many of these emergencies involve either the placenta or severe hypertension, and both can lead to rapid deterioration if not recognized early. 

The placenta is the baby’s source of oxygen and nutrients throughout pregnancy. When placental function becomes disrupted, fetal distress and maternal hemorrhage can occur quickly. One of the most dangerous causes of bleeding in late pregnancy is placental abruption, where the placenta prematurely separates from the uterine wall. 

Patients with placental abruption typically present with abdominal pain, uterine tenderness, contractions, and vaginal bleeding. However, an important point is that not all of the bleeding is visible. Blood can collect behind the placenta, meaning patients may appear significantly sicker than the amount of external bleeding would suggest. This is why a pregnant trauma patient with abdominal pain, tachycardia, or hypotension should raise immediate concern for occult hemorrhage and placental injury. 

Trauma is a common trigger for abruption because sudden deceleration forces can shear the placenta from the uterus. Hypertension, cocaine use, and smoking also increase risk. As placental separation worsens, both maternal blood loss and fetal oxygen deprivation occur simultaneously. 

Placenta previa is another important cause of bleeding later in pregnancy. In this condition, the placenta implants over or near the cervix. As the cervix begins to thin and dilate, bleeding can occur from the disruption of placental blood vessels. Unlike placental abruption, placenta previa classically presents with painless vaginal bleeding. This distinction between painful and painless bleeding is an important clinical clue in the field. 

Management for both conditions is largely supportive and focused on maintaining maternal perfusion. Establish IV or IO access early, administer fluids as indicated, monitor closely for shock, and transport rapidly to an appropriate facility. It is also important to avoid any vaginal examination in the field, as this can worsen bleeding in placenta previa. 

Hypertensive emergencies are another major cause of maternal morbidity and mortality in late pregnancy. Pre-eclampsia occurs after 20 weeks gestation and involves elevated blood pressure with signs of end-organ dysfunction. Patients may complain of headache, vision changes, nausea, abdominal pain, or altered mental status. Severe hypertension can progress to eclampsia, where patients develop seizures due to cerebral edema and irritation. 

These patients can deteriorate rapidly and require aggressive management. Magnesium sulfate remains the treatment of choice for eclamptic seizures because it stabilizes the nervous system and reduces further seizure activity. Early recognition, airway management, seizure precautions, and blood pressure management are all critical components of prehospital care. 

HELLP syndrome is a severe form of pre-eclampsia involving hemolysis, elevated liver enzymes, and low platelets. Patients may initially present with vague symptoms such as abdominal pain, nausea, or malaise before rapidly worsening. 

In summary, late pregnancy emergencies can deteriorate quickly and often involve significant maternal hemorrhage or hypertensive crisis. Painful bleeding should raise concern for placental abruption, while painless bleeding suggests placenta previa. Early recognition, supportive resuscitation, magnesium for eclampsia, and rapid transport are critical to improving outcomes for both mother and baby. 

Thank you, 

Shauna Combs, DO

May 25, 2026

Few calls can raise stress levels like a patient in labor. Fortunately, most deliveries are uncomplicated, and the most important thing clinicians can bring to the scene is preparation, calmness, and an organized approach.

Recognizing when delivery is imminent is key. Patients may report contractions becoming more frequent and intense, rupture of membranes, pressure in the pelvis, or the urge to push. Crowning — the visible appearance of the baby’s head at the vaginal opening — is a clear sign that delivery is about to occur and transport should no longer be prioritized over on-scene management.

Once delivery is unavoidable, focus on creating a calm and controlled environment. Request additional resources early when available, and prepare equipment including towels, suction, clamps, scissors, and neonatal resuscitation supplies.

As the baby delivers, remember that less is often more. Support the head without pulling or excessive manipulation. Once the head is delivered, check for a nuchal cord by feeling around the neck for the umbilical cord. In many cases, the cord can simply be slipped over the baby’s head. If it is too tight to reduce, it can be clamped and cut.

After the head delivers, the shoulders typically follow with gentle guidance. The anterior shoulder is delivered downward first, followed by upward guidance for the posterior shoulder. The rest of the body usually follows quickly afterward. Once delivered, immediately dry and stimulate the newborn, and keep them warm.

One important reminder during delivery calls is that there are now two patients to monitor. Assess the newborn’s breathing, color, tone, and responsiveness while continuing to reassess the mother. Delayed cord clamping for approximately one minute is preferred when feasible and when the newborn is stable.

Labor is not over when the baby is out. The placenta may take up to 30 minutes to deliver naturally. Providers should never pull on the umbilical cord, as this can cause significant complications. The patient should be monitored closely for bleeding.

Postpartum hemorrhage remains one of the most dangerous complications after delivery. Uterine massage and administration of oxytocin per protocol help stimulate uterine contraction and reduce bleeding. If hemorrhage becomes severe, additional resuscitation measures — including IV fluids and TXA per protocol — may be necessary.

Remember, the majority of EMS deliveries are successful with supportive care and calm management. Trust the basics, follow protocol, and remember that controlling the scene often helps control the situation.

Thank you, 

Shauna Combs, DO