The Daily Differential — Tuesday, May 19, 2026

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Sexual Assault Evaluation

Sexual assault care is time-sensitive, trauma-informed, medical, forensic, and legal. The ED clinician’s job is to treat injuries, prevent...

At the Bedside

First principle: Patient autonomy. Explain every step; obtain consent separately for medical exam, forensic exam, photos, evidence collection, meds, police involvement, and advocate involvement.
Immediate priorities:
ABCs and stabilization if severe trauma/intoxication.
Treat life-threatening injuries first.
Assess safety: Is the assailant nearby? Does the patient have safe discharge housing?
Suicide/self-harm screen.
Trauma-informed approach:
Use nonjudgmental language.
Avoid asking “why” questions.
Let patient choose support person if desired.
Minimize repeated history-taking.
Forensic/SANE involvement:
Offer Sexual Assault Nurse Examiner/forensic exam when available.
Evidence collection timing varies by jurisdiction, often useful up to 72–120 hours or longer depending on circumstances.
Advise before evidence collection, if possible: avoid changing clothes, bathing, brushing teeth, urinating/defecating; but never deny care if they already have.
Preserve clothing in paper bags, not plastic.
History essentials:
Time/date/location of assault.
Type of contact: vaginal, anal, oral, penetration, ejaculation.
Condom use.
Strangulation, head injury, loss of consciousness, drug-facilitated assault.
Pain, bleeding, pregnancy risk, contraception.
Last menstrual period.
Past STI/HIV/HBV status if known.
Exam:
General trauma exam: bruising, bite marks, defensive injuries.
Document injuries objectively: size, location, color, shape.
Look specifically for:
Strangulation signs: neck pain, dysphonia, dysphagia, petechiae, neuro deficits.
Genital/anal trauma if patient consents.
Normal exam does not exclude assault.
Testing:
Pregnancy test for patients with pregnancy potential.
Baseline HIV Ag/Ab, hepatitis B surface antigen/antibody/core Ab depending on protocol, hepatitis C Ab, syphilis testing.
GC/CT NAAT from relevant sites if patient consents.
Trichomonas testing if available/appropriate.
Toxicology testing only if drug-facilitated assault suspected and patient consents; collect ASAP because many agents clear quickly.
Empiric prophylaxis:
Offer empiric STI prophylaxis because follow-up may be poor.
Offer emergency contraception if pregnancy possible.
Assess HIV PEP:
Highest risk: receptive anal/vaginal penetration, ejaculation, mucosal trauma, known HIV-positive assailant, multiple assailants, high local prevalence.
Start ASAP, ideally within 72 hours.
Mandatory reporting:
Adult competent patients generally decide whether to report, but laws vary.
Mandatory reporting usually applies to minors, vulnerable adults, elder abuse, certain weapon injuries, or serious bodily injury depending on jurisdiction.
Know local law and involve social work/SANE.
Disposition:
Discharge if medically stable, safe plan, prophylaxis addressed, follow-up arranged.
Admit/observe if serious injuries, unsafe disposition, suicidality, intoxication without capacity, strangulation complications, or need for operative repair.

A Classic Presentation

A 22-year-old woman presents 8 hours after vaginal sexual assault by an acquaintance. She is medically stable, tearful, and unsure about police involvement. You use trauma-informed language, offer an advocate and SANE exam, obtain consent for each step, perform pregnancy testing and baseline STI/HIV/hepatitis labs, provide ceftriaxone/doxycycline/metronidazole, offer emergency contraception, assess HIV exposure risk and start PEP after shared decision-making, then arrange safe discharge and follow-up.

Study Directive

Create a one-page checklist for sexual assault care: stabilization, consent, SANE, pregnancy, STI prophylaxis, HIV PEP, HBV, safety, follow-up.
Memorize adult empiric STI regimen: ceftriaxone + doxycycline + metronidazole.
Review your state’s mandatory reporting rules for adults, minors, vulnerable adults, and weapon-related injuries.
Practice trauma-informed phrasing: “You are in control of what happens next,” and “You can stop the exam at any time.”

Key Medications

Empiric STI prophylaxis, adult female regimen commonly recommended:
- Ceftriaxone: 500 mg IM once; use 1 g IM once if weight ≥150 kg.
- Doxycycline: 100 mg PO BID x 7 days.
- Metronidazole: 500 mg PO BID x 7 days. Avoid alcohol; counsel about GI side effects.
Adult male regimen: ceftriaxone 500 mg IM once, plus doxycycline 100 mg PO BID x 7 days.
Emergency contraception:
- Levonorgestrel: 1.5 mg PO once; best within 72 hours, may have reduced efficacy later and with higher body weight.
- Ulipristal acetate: 30 mg PO once up to 5 days; more effective than levonorgestrel later in window. Check pregnancy/breastfeeding considerations.
- Copper IUD: most effective up to 5 days; requires urgent GYN access.
HIV PEP: 28 days; start ASAP and ideally <72 hours.
- Common adult regimen: tenofovir disoproxil fumarate 300 mg/emtricitabine 200 mg PO daily + dolutegravir 50 mg PO daily.
- Alternative: TDF/FTC daily + raltegravir 400 mg PO BID.
- Regimens vary; check institutional protocol/ID reference, especially in pregnancy, renal disease, or medication interactions.
Hepatitis B:
- If unvaccinated/unknown: start HBV vaccine series.
- If assailant known HBsAg-positive and patient unvaccinated: give HBIG 0.06 mL/kg IM once plus vaccine at separate site.
Antiemetic: ondansetron 4 mg PO/IV as needed.
Pediatric note: Pediatric/adolescent sexual assault requires specialized exam, mandatory reporting, and weight-based STI/HIV PEP dosing; involve child advocacy/SANE/peds.

High-Yield Pearls

Normal anogenital exam is common after sexual assault and does not rule it out.
HIV PEP is a time-sensitive shared decision, best started immediately and generally not after 72 hours unless expert guidance suggests otherwise.
Evidence collection requires explicit consent and should not delay treatment of injuries or prophylaxis.

Board Question

A stable adult patient presents 12 hours after sexual assault and consents to medical care but does not want police contacted. Which statement is most appropriate?

A“We cannot treat you unless you file a police report.”
B“A normal genital exam means no assault occurred.”
C“You can receive medical treatment and prophylaxis regardless of whether you report.”
D“Evidence collection is mandatory for all sexual assault patients.”

Reveal answer

Correct: C

Competent adult patients generally control whether to report and whether to undergo evidence collection, although mandatory reporting exceptions vary by jurisdiction. Medical care, prophylaxis, and safety planning should be offered independent of law enforcement involvement.

Recent Literature

Review or guideline International Olympic Committee consensus statement on youth athletic development
Br J Sports Med, 2015 · cited 855×

Full text · open access
Recent clinical Sexually transmitted infection screening in child sexual abuse evaluations: A 20-year retrospective study at a tertiary children's hospital in Japan
J Infect Chemother, 2026

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Shoulder Dystocia

Shoulder dystocia is an obstetric emergency where the fetal head delivers but the anterior shoulder becomes impacted behind the maternal pubic symphysis....

At the Bedside

Recognition:
Fetal head delivers but retracts tightly against perineum: turtle sign.
Failure of shoulders to deliver with gentle downward traction.
Often unpredictable; risk factors include diabetes, fetal macrosomia, prior shoulder dystocia, obesity, prolonged second stage, operative vaginal delivery.
Immediate actions:
Call for help: OB, anesthesia, neonatal team, extra nursing.
Announce “shoulder dystocia” and start timer.
Stop maternal pushing temporarily.
Avoid excessive traction on fetal head.
Do not apply fundal pressure — worsens impaction.
Episiotomy does not relieve bony obstruction but may allow internal maneuvers.
Maneuver sequence — practical ED approach:
McRoberts maneuver: hyperflex maternal hips onto abdomen. First-line; straightens sacrum/lumbar angle.
Suprapubic pressure: pressure behind anterior shoulder, directed downward/laterally to adduct shoulder. Do not use fundal pressure.
Delivery of posterior arm: sweep posterior arm across chest and deliver hand/forearm, reducing bisacromial diameter.
Rotational maneuvers:
Rubin: push posterior aspect of accessible shoulder to adduct/rotate.
Woods corkscrew: rotate posterior shoulder anteriorly.
All-fours/Gaskin maneuver: reposition to hands-and-knees if feasible.
Last-resort maneuvers:
Intentional clavicle fracture.
Zavanelli maneuver: cephalic replacement and emergent C-section — rare, requires expert OB/anesthesia.
Symphysiotomy — exceptionally rare in US practice.
After delivery:
Neonatal assessment/resuscitation.
Evaluate newborn for brachial plexus injury, clavicle/humerus fracture.
Maternal evaluation for PPH, third-/fourth-degree tears, uterine rupture.
Document:
Time head delivered and body delivered.
Maneuvers used and sequence.
Personnel present.
Neonatal status.
Avoidance of excessive traction/fundal pressure.
Disposition:
Mother and infant need OB/peds evaluation.
Admit/observe for maternal hemorrhage/lacerations and neonatal injury.

A Classic Presentation

A 31-year-old woman with gestational diabetes delivers the fetal head in the ED, but the head retracts against the perineum and the shoulders do not deliver with gentle traction. You announce shoulder dystocia, call OB/NICU/anesthesia, stop fundal pressure, place the mother in McRoberts position, apply suprapubic pressure, then deliver the posterior arm when initial maneuvers fail. The infant delivers and is handed to the neonatal team; the mother is evaluated for lacerations and PPH.

Study Directive

Drill the sequence out loud: “Call help, McRoberts, suprapubic pressure, posterior arm, Rubin/Woods, Gaskin, last-resort.”
Watch one delivery simulation video and narrate each maneuver.
Practice documentation language for shoulder dystocia, especially timing and maneuvers.
Memorize: turtle sign + no fundal pressure + no excessive traction.

Key Medications

No medication fixes shoulder dystocia; it is a mechanical emergency.
Oxytocin postpartum: 10 units IM or 10–40 units in 1 L IV infusion for active management/PPH prevention.
Neonatal resuscitation meds are weight-based and protocolized; follow NRP.
Analgesia/anesthesia: If time and setting permit, regional/local anesthesia may help repair lacerations after delivery, but should not delay maneuvers.
If considering rare uterine relaxation for complex obstetric rescue maneuvers, dosing is highly situation-specific; involve OB/anesthesia and check protocol.

High-Yield Pearls

McRoberts + suprapubic pressure resolves many cases and should be immediate.
Shoulder dystocia is about the bisacromial diameter stuck at the pelvis; posterior arm delivery reduces that diameter.
The dangerous mistake is fundal pressure or forceful traction, which increases brachial plexus injury risk.

Board Question

During vaginal delivery, the fetal head delivers but retracts against the perineum. The shoulders do not deliver with gentle traction. What is the best initial maneuver?

AFundal pressure
BMcRoberts maneuver
CImmediate cesarean delivery
DPull firmly on the fetal head

Reveal answer

Correct: B

This is shoulder dystocia. First-line management is McRoberts maneuver with suprapubic pressure; fundal pressure and excessive traction increase fetal injury and worsen impaction.

Recent Literature

Review or guideline Gestational diabetes mellitus and adverse pregnancy outcomes: systematic review and meta-analysis
BMJ, 2022 · cited 973×

Full text · open access
Recent clinical Preparing Nursing Students for Obstetric Emergencies: Effects of High-Fidelity Simulation on Knowledge, Confidence and Learning
Nurs Rep, 2026

Full text · open access

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The Complicated Delivery and Post-Partum Complications

ED deliveries are often unplanned, under-resourced, and high-risk. The emergency physician must recognize malpresentation, cord emergencies, hypertensive...

At the Bedside

Initial ED delivery approach:
Call OB, NICU/peds, anesthesia if delivery imminent or complicated.
Maternal ABCs, left uterine displacement if late pregnancy, IV access, monitor.
Determine gestational age, parity, prenatal care, complications, fetal movement, rupture of membranes, bleeding, contractions.
Focused exam:
Vitals, mental status.
Abdomen: fundal height, contractions, tenderness.
Sterile speculum if concern for ROM/bleeding and not crowning.
Avoid digital cervical exam if placenta previa suspected.
Bedside US:
Fetal cardiac activity.
Presentation: cephalic, breech, transverse.
Placental location if bleeding.
Free fluid if rupture/trauma.
Breech delivery:
Call OB immediately; prepare neonatal resuscitation.
Do not pull on fetus.
Allow spontaneous delivery to umbilicus if imminent.
Support body; keep sacrum anterior if possible.
Deliver legs if needed by flexing knees.
For arms: sweep across chest.
For head: Mauriceau-Smellie-Veit maneuver or appropriate head flexion technique by trained clinician.
Biggest risk: head entrapment and cord compression.
Umbilical cord prolapse:
Suspect with sudden fetal bradycardia after ROM or visible/palpable cord.
Immediate management:
Call OB for emergent C-section unless delivery is immediately achievable.
Manually elevate presenting part off cord with gloved hand.
Position mother knee-chest or steep Trendelenburg.
Keep exposed cord moist with warm saline gauze; avoid manipulating cord.
Consider bladder filling with saline if prolonged transfer to OR.
Nuchal cord:
If loose: slip over fetal head.
If tight: attempt somersault maneuver or clamp/cut if necessary.
Uterine inversion:
Presents with PPH, shock, severe pelvic pain, and fundus absent abdominally or visible vaginal mass after delivery.
Management:
Call OB/anesthesia, resuscitate, MTP if needed.
Immediate manual replacement: push fundus upward toward umbilicus.
Stop uterotonics until uterus replaced.
Consider uterine relaxation if needed.
After replacement: uterotonics to maintain tone.
Retained placenta:
Placenta not delivered by ~30 minutes or heavy bleeding.
Avoid excessive cord traction.
OB/manual extraction; prepare for hemorrhage.
Postpartum preeclampsia/eclampsia:
Can occur up to 6 weeks postpartum.
Symptoms: headache, visual changes, RUQ/epigastric pain, dyspnea, edema, seizure.
Workup: CBC/platelets, CMP/AST/ALT/Cr, urine protein, LDH if HELLP concern.
Treat severe-range BP and give magnesium for seizure prophylaxis/treatment.
Postpartum endometritis:
Fever, uterine tenderness, foul lochia, lower abdominal pain; higher risk after C-section, prolonged ROM, retained products.
Broad-spectrum IV antibiotics and OB admission.
Mastitis/breast abscess:
Mastitis: focal breast pain, erythema, fever; continue breastfeeding/pumping.
Abscess: fluctuance or persistent symptoms; ultrasound and drainage.
Postpartum VTE/PE:
Postpartum period is hypercoagulable; PE may present with dyspnea, pleuritic pain, syncope, tachycardia.
Workup like other adults but maintain low threshold for imaging. D-dimer often less useful postpartum.
Peripartum cardiomyopathy:
Heart failure in last month pregnancy through months postpartum.
Dyspnea, orthopnea, edema, pulmonary edema; echo shows reduced EF.
Treat acute heart failure; avoid teratogenic meds if pregnant, but postpartum options broaden depending on breastfeeding.
Disposition:
Complicated delivery, abnormal presentation, cord prolapse, inversion, retained placenta, postpartum fever, severe hypertension, seizure, cardiopulmonary symptoms, or hemorrhage → OB admission/transfer.
Stable uncomplicated delivery still needs maternal/newborn observation.

A Classic Presentation

A 34-year-old woman, 5 days postpartum, presents with severe headache, visual spots, BP 178/112, brisk reflexes, and RUQ pain. She had an uncomplicated vaginal delivery and was discharged well. Labs show thrombocytopenia and elevated AST/ALT. You diagnose postpartum preeclampsia with severe features/possible HELLP, give magnesium sulfate, treat BP with IV labetalol or hydralazine, call OB, and admit for monitoring.

Study Directive

Draw a decision tree for third-trimester/postpartum emergencies: bleeding, seizure/headache, fever, dyspnea, abnormal delivery.
Memorize severe postpartum hypertension treatment thresholds and first-line agents.
Run through a cord prolapse simulation: hand elevates presenting part, knee-chest/Trendelenburg, moist cord, emergent C-section.
Review one video each on breech delivery and uterine inversion replacement.

Mechanism Pearl of the Day: Many obstetric emergencies are mechanical problems with physiologic consequences: atony causes hemorrhage because uterine muscle fails to compress spiral arteries; shoulder dystocia and cord prolapse cause fetal hypoxia through obstructed delivery or cord blood flow; uterine inversion causes hemorrhage and vagal shock because the fundus is physically displaced and cannot contract effectively.

Key Medications

Magnesium sulfate for eclampsia/severe preeclampsia:
- Loading: 4–6 g IV over 15–20 minutes.
- Maintenance: 1–2 g/hr IV infusion.
- Recurrent seizure: additional 2 g IV bolus may be used.
- Monitor reflexes, respiratory rate, urine output.
- Toxicity antidote: calcium gluconate 1 g IV over ~10 minutes.
Severe hypertension in pregnancy/postpartum:
- Labetalol: 20 mg IV, then 40 mg, then 80 mg every 10 minutes as needed; max cumulative commonly 220–300 mg depending on protocol. Avoid in asthma, heart block, decompensated HF.
- Hydralazine: 5–10 mg IV every 20 minutes as needed.
- Nifedipine immediate-release: 10 mg PO; repeat 20 mg in 20 minutes if needed, then 10–20 mg every 2–6 hours per protocol. Use caution with hypotension.
Postpartum endometritis:
- Clindamycin 900 mg IV q8h + gentamicin 5 mg/kg IV q24h commonly used. Dosing varies with renal function/weight; check protocol.
- Add ampicillin if enterococcus suspected or no improvement.
Mastitis:
- Dicloxacillin 500 mg PO QID x 10–14 days or cephalexin 500 mg PO QID x 10–14 days.
- If MRSA risk: clindamycin 300 mg PO TID/QID or TMP-SMX DS 1 tab PO BID; consider infant age/G6PD/jaundice and breastfeeding safety.
Uterine inversion relaxation options: nitroglycerin IV, terbutaline, or anesthesia-assisted relaxation may be used; dosing varies and should be guided by OB/anesthesia/protocol.
PPH uterotonics: see PPH section.

High-Yield Pearls

Postpartum preeclampsia/eclampsia can occur after a normal pregnancy and delivery, often after discharge.
In cord prolapse, the priority is relieve cord compression manually while moving toward emergent delivery.
In uterine inversion, replace the uterus before uterotonics; after replacement, give uterotonics to keep it contracted.

Board Question

A woman 1 week postpartum presents with headache, blurry vision, and BP 172/110. While in the ED she has a generalized tonic-clonic seizure. What is the best medication to prevent recurrent seizures?

APhenytoin
BMagnesium sulfate
CLevetiracetam
DDiazepam as sole therapy

Reveal answer

Correct: B

Postpartum eclampsia can occur up to 6 weeks after delivery. Magnesium sulfate is first-line for treatment and prevention of recurrent eclamptic seizures; benzodiazepines may be used for persistent seizures but do not replace magnesium.

Recent Literature

Review or guideline ACOG Practice Bulletin No. 196: Thromboembolism in Pregnancy
Obstet Gynecol, 2018 · cited 484×
Recent clinical Postpartum care utilization among high-risk pregnancies in an urban safety-net health system
J Matern Fetal Neonatal Med, 2026

Full text · open access

TheDaily Differential

Postpartum Hemorrhage

At the Bedside

Study Directive

Recent Literature

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Sexual Assault Evaluation

Shoulder Dystocia

The Complicated Delivery and Post-Partum Complications

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