((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))

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.

• Ensure scene safety and don appropriate PPE including gloves
• Perform Primary Survey — confirm patent airway, adequate breathing, assess circulation including pulse rate and quality
• Position patient appropriately — supine with legs slightly elevated if haemodynamically compromised, or left lateral position; avoid aortocaval compression (left lateral tilt preferred in pregnancy)
• Provide continuous reassurance — patient is distressed; maintain calm therapeutic communication throughout
• Perform Vital Sign Survey — BP (bilateral if possible), HR, RR, SpO2, GCS, temperature
• 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
• 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)
• 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
• Apply a clean pad and instruct patient to retain all used pads, swabs, and any passed tissue for clinical assessment
• Record duration, amount, colour, consistency, and pattern of blood loss in documentation
• 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
• Call for CSP support immediately if patient becomes haemodynamically unstable (systolic BP <90 mmHg, HR >120, deteriorating GCS) or if ruptured ectopic is suspected
• Scenario ends on arrival of ambulance and IMISTAMBO handover
• Attention to hand hygiene will be given throughout the scenario.

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