Maternal: the antepartum to postpartum arc
A single arc rising through the antepartum, cresting at the intrapartum, and descending through the postpartum, with danger flags rising from the arc at the phase each belongs to.
Three phases, each with its own short list of things that go wrong. The exam does not ask the candidate to manage a pregnancy. It asks whether the candidate recognizes the phase-specific emergency and acts before there are two patients in trouble.
Antepartum danger signs
- Vaginal bleeding, leaking fluid, decreased fetal movement.
- Persistent headache with visual changes, epigastric pain, sudden swelling of the face or hands.
- Painless bright red bleeding suggests placenta previa. No vaginal examination is performed.
- Painful dark bleeding with a rigid, tender uterus suggests abruption.
The hypertensive pathway
Preeclampsia with severe features brings severe hypertension, headache, visual disturbance, epigastric or right upper quadrant pain, and hyperreflexia. A seizure makes it eclampsia. During magnesium sulfate therapy the nurse monitors deep tendon reflexes, respiratory rate, urine output, and level of consciousness, because reflexes disappear before respirations slow. Calcium gluconate is kept available as the antidote. The room is kept quiet and dim, and seizure precautions are in place.
Postpartum: the fundus decides
| Finding | What it means | First action |
|---|---|---|
| Heavy bleeding, soft boggy uterus, fundus above the umbilicus or displaced | Uterine atony | Massage the fundus with the bladder emptied |
| Heavy bleeding, firm midline fundus | Laceration or retained tissue | Notify the provider |
| Fundus deviated to the side | Full bladder displacing the uterus | Have the patient void, then reassess |
The fundus descends approximately one fingerbreadth per day after birth. A fundus that stays high, or rises, is telling you something.
Margin notefirm fundus and still bleeding means look elsewhere.
Watch outa headache with visual changes in the third trimester is preeclampsia until proven otherwise.
TakeawayPhase decides the danger, and after birth the fundus decides the action.
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