Midwife Licensure Exam High-Risk Pregnancy & Complications (Recognize & Refer) — Complications of Labor & DeliveryCheat Sheet

Section Title

Dystocia: The 4 Ps Framework

Important Facts

• Hypotonic dysfunction requires oxytocin; hypertonic dysfunction requires rest and sedation (NOT oxytocin).
• Before starting oxytocin, rule out CPD—if head is too big for pelvis, augmentation will fail and risk uterine rupture.
• Prolonged latent phase = >8 hours in nullipara or >12 hours in multipara.
• Active phase arrest = <1.2 cm/hour cervical dilation in nullipara or <1.5 cm/hour in multipara.
• Maternal anxiety (psyche) raises catecholamines → inhibits effective contractions; reassurance and hydration help.
• A full bladder mechanically obstructs descent; catheterization can restart labor progress.

Key Definitions

Diagrams To Know

• Cervicograph (Friedman curve) showing normal vs protracted vs arrested labor patterns.
• The 4 Ps of dystocia with examples of each cause.

Common Values

Section Title

Preterm Labor: Tocolytics & Steroids

Important Facts

• Betamethasone: 12 mg IM, repeat 24 hours later (total 2 doses); maximal benefit is 24 hours to 7 days after first dose.
• Dexamethasone: 6 mg IM every 12 hours × 4 doses (alternative to betamethasone).
• Terbutaline 0.25 mg SC; discontinue if maternal heart rate exceeds ~120 bpm; watch for tachycardia, palpitations, and hyperglycemia.
• Magnesium sulfate IV: neuroprotective + tocolytic; toxicity signs: loss of deep tendon reflexes, respiratory depression, oliguria; antidote is calcium gluconate.
• Nifedipine (calcium channel blocker): given PO; watch for maternal hypotension.
• Indomethacin (NSAID): used before 32 weeks only; risk of premature ductus arteriosus closure.
• Tocolytics work for ~48 hours; prolonged use is not indicated and increases maternal/fetal risk.
• Identify and treat infection (most common cause of preterm labor).
• Bed rest and hydration are supportive measures.
• Teach woman to report: regular contractions, low backache, pelvic pressure, fluid leakage.

Key Definitions

Diagrams To Know

• Timeline showing when to give steroids (before 34 weeks) and peak benefit window (24 hours to 7 days).
• Tocolytic medication selection flowchart based on maternal heart rate, renal function, and weeks of gestation.

Common Values

Section Title

Post-Term Pregnancy & Labor

Important Facts

• Post-term pregnancy increases risk of oligohydramnios (low amniotic fluid) → cord compression → variable decelerations.
• Meconium-stained amniotic fluid is common; prepare for neonatal resuscitation.
• Management: serial fetal surveillance (NST, biophysical profile, amniotic fluid index) and induction of labor.
• Do not allow pregnancy to go beyond 42 weeks; earlier delivery in post-term pregnancy is the standard.
• At birth, expect meconium staining of newborn skin/nails; anticipate need for meconium aspiration management if thick meconium is present.

Key Definitions

Diagrams To Know

• Post-term pregnancy complications cascade: placental aging → decreased perfusion → oligohydramnios → cord compression → meconium aspiration.

Section Title

Prolapsed Umbilical Cord - EMERGENCY

Important Facts

• Prolapsed cord is an EMERGENCY—relieve cord compression immediately; every minute counts.
• Risk factors: high/unengaged presenting part, malpresentation (breech, transverse), polyhydramnios, rupture of membranes before engagement.
• Recognition: visible/palpable cord, or sudden fetal bradycardia/variable decelerations right after membrane rupture.
• IMMEDIATE ACTIONS (in order of priority):
• 1. REPOSITION MOTHER to shift fetus off cord: knee-chest position OR Trendelenburg OR steep left-lateral with hips elevated.
• 2. WITH STERILE GLOVED HAND: apply upward pressure on the presenting part to lift it off the cord; keep hand in place until delivery.
• 3. NEVER push the cord back in; if protruding, cover with sterile saline-moistened gauze to prevent drying.
• 4. Give oxygen to mother (increases fetal oxygenation).
• 5. Continuous fetal monitoring.
• 6. Notify provider STAT; prepare for EMERGENCY CESAREAN DELIVERY.
• Do not delay or second-guess—get mother positioned and hand on presenting part within seconds.

Key Definitions

Diagrams To Know

• Knee-chest position, Trendelenburg position, and left-lateral elevated-hips position.
• Cross-section showing prolapsed cord with presenting part compressing it.

Section Title

Uterine Rupture - EMERGENCY

Important Facts

• Most common site: previous lower transverse cesarean scar.
• Causes: excessive oxytocin stimulation, trauma, obstructed labor, macrosomia pushing against weak scar.
• Manifestations (come on suddenly):
• • Sudden, sharp abdominal pain (woman reports 'something tore').
• • Contractions cease abruptly.
• • Loss of fetal station (fetus descends back up as it exits the uterus).
• • Abnormal or absent fetal heart rate.
• • Signs of hypovolemic shock: tachycardia, hypotension, cool/clammy skin.
• • In complete rupture: palpable fetus in abdomen.
• MANAGEMENT (IMMEDIATE):
• 1. Call for emergency team STAT—this is a surgical emergency.
• 2. Establish large-bore IV access (2 lines if possible).
• 3. Aggressive fluid resuscitation + blood products.
• 4. Oxygen via mask/intubation as needed.
• 5. Monitor vital signs and urine output closely.
• 6. Prepare for emergency laparotomy (surgical delivery + repair or hysterectomy).
• PREVENTION: cautious oxytocin use, careful monitoring for uterine tachysystole, avoid high-dose long-term oxytocin.

Key Definitions

Diagrams To Know

• Timeline of uterine rupture: oxytocin overstimulation → tachysystole → fetal distress → sudden pain and shock.
• Cross-section of uterine rupture at cesarean scar site.

Formulas

Common Values

Section Title

Oxytocin Use in Labor: Dosing & Monitoring

Important Facts

• Oxytocin is given ONLY by IV infusion pump; never give as a bolus (risk of tetanic contractions and rupture).
• Monitor continuously for contraction pattern, fetal heart rate, and maternal vital signs.
• Discontinue oxytocin IMMEDIATELY for:
• • Uterine tachysystole (>5 contractions/10 min, contractions >90 sec, high baseline tone).
• • Non-reassuring fetal heart rate (late decelerations, severe variable decelerations, bradycardia <110 bpm).
• After stopping oxytocin:
• 1. Reposition mother to left lateral decubitus.
• 2. Increase IV fluid rate (bolus with 500 mL normal saline).
• 3. Apply oxygen by mask (10–12 L/min).
• 4. Monitor fetal heart rate response (should improve within 5–10 minutes).
• 5. Notify provider; terbutaline may be ordered (0.25 mg SC) to relax uterus.
• Water intoxication: oxytocin has antidiuretic effect; prolonged high doses can cause hyponatremia, seizures, coma. Monitor fluid balance; restrict free water.
• Oxytocin is ineffective in presence of CPD—always rule out mechanical obstruction first.

Key Definitions

Diagrams To Know

• Oxytocin titration protocol: starting dose → incremental increases → target contraction pattern.
• Decision tree for when to stop oxytocin: tachysystole? fetal distress? persistent hyperstimulation?

Common Values

Section Title

Fetal Heart Rate Interpretation in Complicated Labor

Important Facts

• Normal baseline: 110–160 bpm; moderate variability is REASSURING; accelerations are REASSURING.
• EARLY DECELERATIONS:
• • Mirror the contraction (onset = contraction start; return = contraction end).
• • Reflect head compression from normal descent through pelvis.
• • Are benign and do NOT require intervention beyond continued monitoring.
• VARIABLE DECELERATIONS:
• • Abrupt V- or U-shaped drops that vary from contraction to contraction.
• • Reflect cord compression (prolapse, oligohydramnios, nuchal cord, cord knot).
• • Management: REPOSITION mother (left side, right side, knee-chest) to decompress cord.
• • If variable decelerations persist or worsen despite repositioning, notify provider and prepare for delivery.
• LATE DECELERATIONS:
• • Gradual decrease beginning after contraction peak; return is also gradual and delayed.
• • Reflect uteroplacental insufficiency (abruption, preeclampsia, maternal hypotension, oxytocin overstimulation, placental infarction).
• • Are OMINOUS and indicate fetal hypoxia.
• • Management: STOP oxytocin, reposition to left side, give IV fluid bolus, apply oxygen, notify provider STAT.
• • If late decelerations persist, prepare for expedited delivery (operative vaginal or cesarean).
• The intrauterine resuscitation bundle (for non-reassuring FHR): 'Turn, IV, Oxygen, Stop the drug'
• 1. TURN mother to left lateral decubitus.
• 2. IV fluid bolus (500 mL normal saline).
• 3. OXYGEN by mask (10–12 L/min).
• 4. STOP oxytocin if infusing; consider terbutaline.
• Persistent late decelerations or severe bradycardia that does not recover = prepare for emergency delivery.

Key Definitions

Diagrams To Know

• FHR tracing patterns: baseline, early deceleration (mirrors contraction), variable deceleration (V-shaped, variable timing), late deceleration (gradual, delayed).
• Intrauterine resuscitation algorithm: recognize non-reassuring FHR → stop oxytocin → reposition → IV fluids → oxygen → notify provider.
• Comparison of three deceleration types: onset timing, shape, relationship to contractions, clinical significance.

Section Title

Cesarean Birth: Indications, Techniques & Nursing Care

Important Facts

• INDICATIONS FOR CESAREAN:
• • Cephalopelvic disproportion (CPD) / mechanical obstruction.
• • Fetal distress (non-reassuring FHR that does not recover with intrauterine resuscitation).
• • Malpresentation (persistent breech, transverse, brow).
• • Placenta previa (low-lying or covering the cervix).
• • Placental abruption with fetal distress or maternal hemorrhage.
• • Cord prolapse (emergency).
• • Uterine rupture (emergency).
• • Failed induction.
• • Active maternal genital herpes (primary or recurrent in third trimester).
• • Previous classical (vertical) cesarean scar (relative contraindication to labor).
• PREOPERATIVE NURSING CARE:
• 1. Obtain and witness INFORMED CONSENT.
• 2. NPO (nothing by mouth) 6–8 hours for solid food, 2–4 hours for clear fluids (per anesthesia guidelines).
• 3. Start large-bore IV access (18–20 gauge); send type and cross.
• 4. Insert indwelling urinary catheter (empty bladder prevents trauma during surgery).
• 5. Administer preoperative medications: antacid (e.g., sodium citrate) ± H2 blocker (e.g., ranitidine) to reduce aspiration risk.
• 6. Ensure preoperative labs (CBC, blood type, urinalysis) are complete.
• 7. Apply support hose and sequential compression device (DVT prophylaxis).
• 8. Shave or clip surgical site per protocol (do NOT shave with razor the day before—risk of infection).
• 9. Administer premedication if ordered by anesthesia.
• 10. Transfer to OR with chart, labs, and blood in hand.
• POSTOPERATIVE NURSING CARE:
• 1. Monitor vital signs closely; assess for hemorrhage (lochia, fundal firmness, incision site).
• 2. Assess fundus every 15 minutes × 1 hour, then every 30 minutes × 2 hours, then every 4 hours; expect it to be firm at midline.
• 3. Monitor lochia: expect scant lochia initially (some absorbed by incision dressing); if copious, check fundal tone and bladder fullness.
• 4. Monitor incision: assess for redness, warmth, drainage (serous, serosanguineous, purulent); report any signs of infection (fever, wound opening).
• 5. Monitor indwelling catheter: remove when stable (usually POD 1–2) and assess for urinary retention.
• 6. Manage pain: give analgesics as ordered; most women need strong analgesia first 48 hours.
• 7. Encourage early ambulation (within hours if mother is stable and pain is controlled) to prevent thromboembolism.
• 8. Teach and encourage leg exercises, calf massage, and sequential compression device use.
• 9. Encourage coughing and deep breathing to prevent atelectasis.
• 10. Support breastfeeding: help position baby to avoid incision; pain control is essential for success.
• 11. Assess for bowel sounds; expect paralytic ileus 24–48 hours post-op; advance diet as bowel function returns.
• 12. Teach incision care: keep dry, shower OK once bleeding stops (usually POD 1–2), avoid soaking.
• COMPLICATIONS POST-CESAREAN:
• • Hemorrhage: monitor lochia, fundal firmness, vital signs.
• • Infection: monitor temperature, incision, lochia for foul odor.
• • Thromboembolic disease: encourage ambulation, leg exercises, compression devices.
• • Paralytic ileus: monitor bowel sounds, advance diet slowly.
• • Urine retention: monitor for overdistended bladder; remove catheter once stable.
• • Respiratory complications: encourage coughing/deep breathing and early ambulation.
• TRIAL OF LABOR AFTER CESAREAN (TOLAC/VBAC):
• • Candidate: prior low transverse or low vertical incision (NOT classical).
• • Contraindications: classical scar, recurrent indication (e.g., CPD), previous uterine rupture, active herpes.
• • Success rate: 60–80% of women achieve vaginal delivery; ~0.3–1% risk of uterine rupture (acceptable).
• • Continuous fetal monitoring required during TOLAC.
• • Must have immediate access to OR, anesthesia, and pediatrics in case of rupture.

Key Definitions

Diagrams To Know

• Low transverse vs. classical uterine incision: location, indications, and impact on future pregnancies.
• Postoperative assessment priorities: vital signs → fundus → lochia → incision → catheter → pain → ambulation.
• Preoperative checklist: consent, NPO, IV, catheter, labs, antacid, DVT prophylaxis, premedication.

Section Title

Shoulder Dystocia - EMERGENCY

Important Facts

• Risk factors: fetal macrosomia (large baby), maternal diabetes (increases fetal size), assisted delivery (vacuum/forceps), prolonged labor, maternal obesity.
• Shoulder dystocia is UNPREDICTABLE—even after ultrasound estimation of weight; may occur with non-diabetic macrosomic infants and in babies not predicted to be large.
• IMMEDIATE ACTIONS (McRoberts + suprapubic pressure maneuver):
• 1. Call for help STAT (provider, anesthesia, pediatrics, OR nurse).
• 2. Reposition mother: SHARP HYPERFLEXION of thighs onto abdomen (McRoberts maneuver) to increase pelvic outlet diameter; this alone resolves ~60% of cases.
• 3. Apply SUPRAPUBIC PRESSURE (NOT fundal pressure): press down and inward on the anterior shoulder just above the symphysis pubis to dislodge it from behind the pubis; this rotates the shoulder and helps it slip under the pubis.
• 4. NEVER apply fundal pressure—this increases impaction.
• 5. Avoid aggressive downward traction on the fetal head.
• If standard maneuvers fail:
• • Episiotomy (may be needed for provider to insert hand for maneuvers; use judiciously).
• • Deliver the posterior arm first (delivery of one arm reduces shoulder diameter).
• • Rubin maneuver: apply pressure to the anterior surface of the posterior shoulder to rotate the fetus into a diagonal position.
• • Zavanelli maneuver (last resort): replacement of fetal head into vagina and emergency cesarean.
• FETAL COMPLICATIONS: brachial plexus injury (Erb palsy), clavicle fracture, humeral fracture, brain injury from hypoxia if shoulder is trapped >5 minutes.
• MATERNAL COMPLICATIONS: severe perineal laceration, bladder/rectal injury, hemorrhage.
• After delivery of baby:
• • Assess infant for: Apgar score, color, tone, ability to cry, movement of arms/hands (signs of brachial plexus injury).
• • Notify pediatrics of shoulder dystocia (infant may need imaging and PT for brachial plexus injury).
• • Conduct thorough perineal exam for lacerations.
• DOCUMENTATION: time of shoulder dystocia, maneuvers used, time to delivery of shoulders, infant status at birth, complications.

Key Definitions

Diagrams To Know

• McRoberts maneuver: sharp hyperflexion of maternal thighs onto abdomen.
• Suprapubic pressure location and direction: just above symphysis pubis, pressing down and inward.
• Cross-section showing anterior shoulder wedged behind symphysis pubis and mechanism of McRoberts relief.

Section Title

Amniotic Fluid Embolism (AFE) - EMERGENCY

Important Facts

• Incidence: ~1 in 40,000 deliveries; mortality ~25–60% (very high).
• Occurs most often during labor or immediately after delivery, but can occur during cesarean, amniotomy (breaking the bag of water), or abdominal trauma.
• Mechanism: Amniotic fluid (containing fetal cells, meconium, lanugo) enters the maternal venous circulation (usually through a tear in uterine veins or amniotic sac) → allergic/anaphylactoid reaction + physical obstruction of pulmonary and coronary vessels.
• CLASSIC PRESENTATION (comes on suddenly):
• • Severe dyspnea (shortness of breath) and chest pain.
• • Cyanosis (blue appearance).
• • Cardiovascular collapse: hypotension, tachycardia, loss of consciousness.
• • Seizures (from hypoxia and shock).
• • Pulmonary edema (pink, frothy sputum).
• • Cardiac arrhythmia or cardiac arrest.
• • Followed by DIC: coagulopathy, bleeding from IV sites and surgical wound, petechiae.
• DIFFERENTIAL DIAGNOSIS (think of these when sudden maternal collapse occurs):
• • Anaphylaxis (medication allergy).
• • Aspiration (vomitus, blood).
• • Eclampsia / severe hypertension.
• • Placental abruption (hemorrhagic shock).
• • Pulmonary embolism.
• • Myocardial infarction.
• MANAGEMENT (supportive and emergent):
• 1. Call code STAT (activate emergency response); notify obstetrics, anesthesia, ICU, blood bank.
• 2. Position mother supine (for chest compressions if cardiac arrest).
• 3. CARDIOPULMONARY RESUSCITATION (CPR) if cardiac arrest: chest compressions, airway management.
• 4. Oxygen: high-flow O2 by non-rebreather mask or intubation + mechanical ventilation if respiratory distress.
• 5. IV access: two large-bore lines for aggressive fluid resuscitation.
• 6. Fluids: normal saline or balanced crystalloid bolus to maintain perfusion; avoid hypotonic fluids (risk of pulmonary edema).
• 7. Blood products: massive transfusion protocol—type O RBCs, FFP, platelets, cryoprecipitate to correct DIC and ongoing bleeding.
• 8. Medications: epinephrine, vasopressors (norepinephrine, dopamine) to support blood pressure and heart rate.
• 9. Continuous fetal monitoring (if fetus still in utero) and prepare for emergency delivery.
• 10. Acidosis correction: sodium bicarbonate if severe metabolic acidosis.
• COAGULOPATHY MANAGEMENT:
• • Prothrombin time (PT), partial thromboplastin time (PTT), fibrinogen, platelet count STAT.
• • DIC: fibrinogen drops (consume), PT/PTT lengthen (consume factors), platelets drop, D-dimer rises.
• • Transfuse FFP (fresh frozen plasma) and cryoprecipitate (fibrinogen replacement).
• • Massive transfusion: 1:1:1 ratio of RBCs:FFP:platelets.
• FETAL OUTCOME:
• • If fetus is still in utero during maternal collapse, prepare for emergency cesarean (perimortem cesarean) to improve maternal circulation and allow infant to be delivered and resuscitated.
• • Neonatal prognosis depends on duration of maternal hypoxia; severe hypoxia → fetal/neonatal death or severe encephalopathy.
• NURSING PRIORITIES:
• • Recognition of early signs (dyspnea, chest pain) and rapid activation of emergency response.
• • Assist with resuscitation: compressions, airway management, medication administration, fluid/blood product infusion.
• • Monitor vital signs, urine output, coagulation labs, and fetal well-being continuously.
• • Communication with ICU team for possible transfer if mother survives the acute phase.
• • Support for family during crisis.

Key Definitions

Diagrams To Know

• AFE pathophysiology: amniotic fluid entry → allergic reaction + physical obstruction → respiratory distress + cardiovascular collapse + DIC.
• Timeline of AFE: labor/delivery → sudden dyspnea/chest pain → cyanosis → cardiovascular collapse → DIC → potential cardiac arrest.
• Emergency response checklist for suspected AFE: call code, CPR if needed, high-flow O2, IV access, fluid bolus, blood products, vasopressors, monitor coagulation.

Common Values

Section Title

Precipitous Labor

Important Facts

• Precipitous labor is more common in multiparous women (women who have given birth before) and in those with a history of rapid labor.
• Risk factors: high parity, large pelvic outlet, small baby, uterine irritability.
• RISKS FOR MOTHER:
• • Severe perineal, vaginal, and cervical lacerations (from rapid stretching).
• • Postpartum hemorrhage (from uterine atony or traumatic bleeding).
• • Uterine rupture (rare, but possible with extremely strong contractions).
• RISKS FOR FETUS/NEWBORN:
• • Hypoxia (rapid labor may not allow adequate placental exchange).
• • Head trauma from rapid descent through pelvis.
• • Intracranial hemorrhage.
• • Aspiration if membranes rupture with meconium.
• NURSING MANAGEMENT:
• 1. Never leave the woman alone—she can deliver unexpectedly at any moment.
• 2. Position mother for spontaneous delivery if birth is imminent (semi-recumbent or lateral).
• 3. Prepare emergency delivery supplies within arm's reach (bulb syringe, towels, blankets, cord clamp, scissors, resuscitation equipment).
• 4. Support (do NOT restrain) the emerging fetus: place hands on fetal head to control descent, support the perineum gently, allow slow emergence of body.
• 5. Once baby is delivered, dry and wrap infant immediately; keep infant close for bonding but monitor for signs of birth trauma or respiratory distress.
• 6. Monitor mother for hemorrhage, shock, and severe laceration; be prepared to call for help and alert provider if needed.
• 7. Anticipate need for perineal repair; hemorrhage management may be urgent.
• DELIVERY SUPPORT (do this while supporting the baby):
• • Do NOT apply downward traction on fetal head—let gravity and contractions do the work.
• • Support the perineum gently to reduce lacerations.
• • Guide the baby's head extension as it delivers (controlled delivery).
• • Once head delivers, support the shoulders and body as they emerge; do not delay—continue with each contraction.
• • Wipe baby's face and mouth to clear fluids; assess color and tone immediately.

Key Definitions

Diagrams To Know

• Precipitous labor timeline: rapid cervical dilation → strong contractions → rapid descent → rapid delivery.
• Nurse's position at bedside for precipitous delivery: gloved hands ready to support head, control descent, and support perineum.

Rank

1

Concept

PROLAPSED CORD IS AN EMERGENCY

Details

Relieve pressure IMMEDIATELY: knee-chest or Trendelenburg, apply upward pressure on presenting part with sterile gloved hand, never push cord back in, cover protruding cord with sterile saline-moistened gauze, give oxygen, prepare for emergency cesarean.

Rank

2

Concept

OXYTOCIN TACHYSYSTOLE & FETAL DISTRESS

Details

STOP oxytocin immediately for >5 contractions/10 min, contractions >90 sec, or non-reassuring FHR. Then: reposition to left side, IV bolus, oxygen, notify provider. Do NOT give more oxytocin; consider terbutaline to relax uterus.

Rank

3

Concept

LATE DECELERATIONS = UTEROPLACENTAL INSUFFICIENCY

Details

Late decelerations begin AFTER contraction peak and return AFTER contraction ends—ominous sign of fetal hypoxia. Use intrauterine resuscitation: stop oxytocin, left lateral position, IV fluid bolus, oxygen, notify provider STAT. Prepare for expedited delivery.

Rank

4

Concept

UTERINE RUPTURE: SUDDEN PAIN + SHOCK

Details

Rupture presents with sudden sharp abdominal pain ('something tore'), cessation of contractions, fetal distress/absent FHR, and signs of hypovolemic shock (tachycardia, hypotension). EMERGENCY laparotomy. Treat shock: large-bore IV, fluids, blood, oxygen, monitor output.

Rank

5

Concept

HYPOTONIC vs. HYPERTONIC DYSTOCIA

Details

Hypotonic (weak, infrequent contractions in ACTIVE phase) → treat with OXYTOCIN. Hypertonic (frequent, uncoordinated contractions in LATENT phase, no dilation) → treat with REST & SEDATION, NOT oxytocin. Wrong drug = worse labor.

Rank

6

Concept

PRETERM LABOR STEROIDS: TIMING & DOSE

Details

Betamethasone 12 mg IM, repeat in 24 hours (2 total doses); OR dexamethasone 6 mg IM every 12 hours × 4 doses. Give when birth expected <34 weeks. Benefit peaks 24 hours to 7 days after first dose. ALWAYS give magnesium sulfate for neuroprotection if <32 weeks.

Rank

7

Concept

TERBUTALINE: HOLD AT MATERNAL HR ~120

Details

Terbutaline 0.25 mg SC is a tocolytic but stop if maternal heart rate exceeds ~120 bpm. Risk of tachycardia, palpitations, tremor, hyperglycemia. Never give prolonged terbutaline (maternal cardiac risk). Use for 48-hour window only.

Rank

8

Concept

SHOULDER DYSTOCIA: MCROBERTS + SUPRAPUBIC PRESSURE

Details

Turtle sign (head retracts) = shoulder dystocia. Do McRoberts (sharp hyperflexion of thighs onto abdomen) + suprapubic pressure (press down and inward just above symphysis). NEVER use fundal pressure. Deliver posterior arm if needed. Risk: brachial plexus injury, clavicle fracture, perineal trauma.

Rank

9

Concept

LOW TRANSVERSE ALLOWS VBAC; CLASSICAL DOES NOT

Details

Low transverse (horizontal) uterine incision has <1% rupture risk in next pregnancy, permitting trial of labor (VBAC). Classical (vertical) incision has ~4–9% rupture risk and CONTRAINDICATES future labor—must have repeat cesarean. Know the difference for every patient.

Rank

10

Concept

AMNIOTIC FLUID EMBOLISM: DYSPNEA + COLLAPSE + DIC

Details

AFE is rare but often fatal: sudden dyspnea, cyanosis, cardiovascular collapse, DIC. No specific cure—treat symptomatically: CPR if arrest, high-flow O2, IV fluids, massive transfusion protocol (RBCs:FFP:platelets 1:1:1), vasopressors. Maternal survival is <50%; immediate recognition and emergency response are critical.

Rows

Columns

• Feature
• Hypotonic Dysfunction
• Hypertonic Dysfunction

Table Title

Dystocia Type Comparison: Hypotonic vs. Hypertonic

Rows

Columns

• Feature
• Early Deceleration
• Variable Deceleration
• Late Deceleration

Table Title

Deceleration Types: Early vs. Variable vs. Late

Rows

Columns

• Drug
• Dose & Route
• Mechanism
• Benefit
• Adverse Effects / Cautions
• When to Use/Avoid

Table Title

Tocolytic Medications: Comparison

Rows

Columns

• Feature
• Low Transverse (Pfannenstiel)
• Classical (Vertical)

Table Title

Cesarean Incision Types & Implications

Rows

Columns

• Steroid
• Dose
• Interval
• Total Doses
• Peak Benefit

Table Title

Preterm Labor Corticosteroids: Dosing Schedule