You're in the bay. Once you get over to the bed,
we'll give you the story. Everything's going
to happen super fast. Welcome to the emergency
room. Pulse check! No pulse. And her blood pressure
is off. 45 minutes of CPR and no return of circulation.
Picture this. You just walked onto the labor
and delivery unit for your very first clinical
shift. Oh, that first day is always wild. Right.
So you step into room three, and the patient
is 39 weeks pregnant, gripping the bed rails.
And her eyes are just wide with panic. Absolutely
terrifying for her, yeah. And the fetal monitor
next to her, which have been chiming along with
this really reassuring rhythmic heartbeat, suddenly
drops its pitch. It's sounding this long, sustained,
just terrifyingly slow tone. The dreaded bradycardia
alarm. Exactly. The jagged line on the screen
just falls into a deep valley and it's completely
not coming back up. And then your preceptor turns
to you, the nursing student, and says, well,
what is happening and what exactly do we do right
now? Yeah. That is the ultimate trial by fire
because in that specific moment, you really don't
have the luxury of like pulling out a thousand
page textbook to look up the pathophysiology
of fetal bradycardia. No, not at all. You literally
have seconds. Right. And honestly, the sheer
volume of information thrown at you in nursing
school regarding maternal newborn and women's
health is just it's staggering. It really is.
I mean, you're expected to understand two patients
simultaneously. One of whom you can't even see.
Exactly. In a situation where, you know, normal
physiology can pivot into a catastrophic emergency
in less than three minutes. Which is why the
traditional approach of, like, reading a textbook
from cover to cover just doesn't work for clinical
readiness. No, it fails every time. To be a safe,
competent nurse, you have to filter the noise.
So if you are tuning in right now, consider us
your personal clinical mentors and study coaches.
for the next hour because we are taking all those
massive obstetric sources, all the care plans,
the clinical guidelines, and we are aggressively
applying the Pareto principle. That's the 80
-20 rule. Right. We're hunting for that 20 %
of crucial concepts, the physiological patterns,
and those safety critical red flags that will,
frankly, generate 80 % of your exam points. And
more importantly, keep your future patients alive.
Exactly. So what's our mission today? Well, we
are going to prioritize high -yield material,
but we aren't going to just give you a dry list
of facts to memorize, because rote memorization
completely fails under pressure. Oh, 100%. You
just blank. You do. If you don't understand the
why behind an intervention... Your mind goes
blank when the alarms start sounding. So we're
going to break down the mechanics, the fluid
dynamics, and the raw biology of labor so that
your clinical judgment just becomes instinctive.
I love that. No jargon without explanation, no
academic fluff, just a deep dive into how to
think like an elite OB nurse. Ready to jump in.
Let's do it. Let's back out of that terrifying
room for a second. Because before we can rush
in and save the day during an emergency, we have
to know what a normal day is like. supposed to
look like. You have to know baseline to spot
the abnormal. Right. I always think of this like
flying a commercial jet. You would just throw
a student pilot into a nosedive simulation on
day one. First you teach them how to read the
dashboard while the plane is safely cruising.
That's a really perfect analogy. Because in obstetrics,
when a patient rolls into triage, your dashboard
consists of mapping out three interacting forces.
They're traditionally called the three P's, which
are power, passenger, and passage. The three
P's. Right. If you don't evaluate how these three
are interacting, you are flying blind. OK, let's
break down that dashboard for everyone listening.
Yeah. Power sounds obvious, right? Yeah. Like,
that's the uterine contractions, the engine pushing
the plane. It's the primary force of labor, but
it's not just about... having contractions, it's
about their quality. What do you mean by quality?
Well, we have to assess whether they are strong
enough, frequent enough, and of sufficient duration
to actually do the panicle work. The work of
opening the cervix? Exactly. Opening the cervix
and physically moving the baby down. Then you
have the passenger, which is obviously the fetus.
And for the passenger, we care deeply about the
baby's size, their presentation, meaning what
part of the body is coming first, and their attitude.
Attitude. Grumpy about being born? Huh, no, though
they usually are. Attitude refers to how their
head and limbs are flexed or extended. Oh, got
it. Like, are they tucked into a tight little
cannonball, or are they stretching out? Exactly
that. A tightly flexed head, chin to chest, presents
the absolute smallest possible diameter to the
maternal pelvis. Which is what we want. Right.
But if the baby extends its neck, like looking
up at the ceiling, suddenly the widest part of
the head is trying to squeeze through that narrow
space, which can literally stall labor entirely.
Ouch. Okay, and that brings us to the third P.
Yes, the passage. which is the maternal bony
pelvis and all the soft tissues of the birth
canal. So we have the engine pushing, the passenger
navigating, and the tunnel they have to get through.
That's the setup. But to figure out if this is
actually working, we have to measure the cervix.
And I have to say, this is where I remember getting
completely tangled up in nursing school. That
terminology can be a lot. It is. Effacement,
dilation, station, they just kind of blur together.
Let's untangle them for the listeners. Okay,
think of the cervix before labor as a thick,
firm cylinder. kind of like a really rigid turtleneck
sweater neck about two to three centimeters long.
Okay, a rigid turtleneck. Yeah. And it is tightly
closed to keep the baby safely inside. But when
labor begins, the power, those contractions we
talked about, starts pulling that cylinder upward,
stretching it over the baby's head. So it's pulling
the turtleneck up and over. Exactly. So a facement
is just the measurement of how much that cylinder
has shortened and thinned out. So it goes from
being a thick tube to something like a really
thin sheet of paper. And we measure that in percentages,
right? Correct. 0 % effaced means it is still
a thick, completely unchanged tube. And 100 %?
100 % of faced means it is completely thinned
out. You practically can't even feel it distinguishing
from the rest of the lower uterus. OK, so if
a faceman is thinning, then dilation is the actual
opening of the door. Yes. Dilation is measured
in centimeters from 0, which is locked closed,
to 10 centimeters, which is fully open. 10 centimeters
is the magic number. Right, because 10 centimeters
is generally considered large enough for a full
-term fetal head to pass through? Now here is
the metric that always feels like a trap on exams.
Like, I always got this wrong. Fetal station.
Oh, the numbering system. Yes. When I first learned
this, the numbering system felt completely counterintuitive.
because normally negative numbers mean you're
below something and positive numbers mean you're
above it. But in obstetrics, it's flipped. Right.
Negative numbers mean the baby is high up and
positive numbers mean the baby is low down. Why?
How does this map out? physically. I totally
see why that gets people. You really have to
understand what the zero line is. Okay, where
is zero? In the middle of the maternal pelvis,
there are these two bony prominences called the
ischal spines. If you look at a pelvic skeleton,
these spines jut inward. Like little spikes.
Yeah. They represent the absolute narrowest anatomical
bottleneck that the baby has to navigate. Because
it's the ultimate choke point, Obstetricians
and nurses use the ischial spines as the zero
landmark. Ah, okay. So zero is the equator, the
choke point. Exactly. If the widest part of the
baby's head, the biparietal diameter, has reached
the level of those ischial spines, we say the
baby is at zero station. Which means what clinically?
The baby has officially entered the true pelvis.
Clinically, we call this being engaged. Engaged,
like they are locked in. Right. It's a very reassuring
sign because it proves the baby's head actually
fits into the pelvic inlet. That makes so much
more sense. So if zero is the choke point...
Any number above that choke point is negative?
Right. If the presenting part is above the ischal
spines, we measure the distance in centimeters
as negative numbers. So minus one, minus two,
minus three. So minus five is? If a baby is at
minus five station, it's essentially floating
high up in the false pelvis, completely unengaged.
Which means positive numbers are a positive sign
of progress. Yes. That's a fantastic memory anchor
for exams. Because students see a positive number
and freak out. Exactly. Students see a patient
is at verse plus three station, and they panic,
thinking a high positive number means a high
level of danger. But plus one, plus two, plus
three just means the baby has passed the hardest
part and is moving down the birth canal toward
the exit. And plus four, five. Plus four, plus
five means the head is crowning at the perineum.
So positive numbers mean positive progress toward
birth. I love that. Positive numbers equal positive
progress. Okay, so we check the dashboard. The
patient is 100 % effaced. She's five centimeters
dilated and at zero station. What do we actually
do with this data? Why do nursing instructors
obsess over mapping these exact numbers? Because
labor is a continuum, right? But clinically,
we slice it into four distinct functional stages.
And your nursing interventions completely change
depending on which stage the patient is currently
in. So if you get the stage wrong? If you don't
know where she is on the map, you will choose
the wrong intervention. which is an immediate
safety failure on an exam and obviously in real
life. Let's map out the journey then from the
first contraction to the recovery room. Walk
me through the stages. All right. Stage one is
all about getting the door open. It starts with
the onset of true, regular contractions, and
it doesn't end until the cervix is completely
dilated to 10 centimeters. So it's the longest
part? By far. It is the longest stage, and it's
further divided into phases. The early or latent
phase is really slow. The cervix might only dilate
to 4 or 5 centimeters over many, many hours.
And then... Then there is the active phase where
the contractions become intense and the service
dilates much more rapidly. Now wait, I want to
pause on that word rapidly because I remember
reading about something called the Friedman curve
where doctors used to expect women to dilate
like absolute clockwork. Oh yes, one centimeter
per hour. Right, and if you didn't hit that mark
They called it failure to progress and just wheeled
you to the O .R. for a C -section. Is that still
the gold standard? That is a phenomenal piece
of historical context and honestly it's a major
shift in modern obstetrics that you will be tested
on. Oh really? Yes. Back in the 1950s, Dr. Emmanuel
Friedman plotted thousands of labors on graph
paper and created this sigmoid curve. that became
the absolute law of labor and delivery. The law
of the land. But here's the catch. Dr. Friedman's
patients were largely laboring without epidurals,
and the demographics of maternal weight and age
back then were very, very different. Oh, wow.
So the data's... Basically outdated. Completely
outdated. Massive modern studies have shown that
normal labor can be significantly slower than
the old Friedman curve allowed, especially during
that transition from the latent to the active
phase. I imagine epidural changes things, too.
Huge factor. An epidural can relax the pelvic
floor beautifully, but it can also temporarily
slow contractions. Today, we know that as long
as the fetal monitor looks good and the mother
is safe, we can give her more time. So we don't
just rush to surgery. Exactly. We don't rush
to a cesarean just because she stayed at six
centimeters for three hours. That is sort of
vital clinical insight. We are treating the patient,
not a 70 -year -old graft. Exactly. OK, so stage
one is getting to 10 centimeters. What is stage
two? Stage two is the pushing stage. It begins
the exact second the cervix hits 10 centimeters
and ends with the actual physical birth of the
infant. Wait, I want to clarify a huge trap I
fell for in simulation lab. Oh, let's hear it.
Okay, so if a patient is at eight centimeters,
but she tells me, I feel incredible pressure
I have to push right now. Isn't her body telling
her what to do? Like, why shouldn't she push?
Oh, this is one of the most highly tested safety
priorities on the NCLEX. Really? Why? If she
pushes before, the cervix is completely out of
the way. She is forcing the baby's hard skull
directly into the remaining cervical tissue.
Like trying to force a golf ball through the
neck of a tight sweater. Exactly like that. And
what happens when you traumatize highly vascular
tissue? It swells up. It swells massively. The
cervix will become acutely edematous. It gets
thick, swollen, and super rigid. And once it
swells, it might stop dilating entirely. Oh,
wow. So she could get stuck at eight centimeters
permanently. Yes. You can literally stall the
entire labor, turning a smooth vaginal birth
into an emergency cesarean just because she pushed
too early. That's terrifying. So what do I do
as the nurse? As a nurse, you have to coach her
through the contractions. You have her pan or
blow out her breath like blowing out a candle
to actively discourage pushing until you confirm
she is fully at 10 centimeters. That is the why.
That makes the fact stick. You blow out the candle
to save the cervix. OK, stage three is delivering
the placenta. And most people think the story
ends there. But there is a stage four. Yes. Stage
four is the immediate postpartum period, roughly
the first two to four hours after the placenta
delivers. When everyone is passing the baby around
and taking pictures. Right. The adrenaline of
birth wears off. The room empties out. But physiologically,
this is where maternal biology undergoes a massive
violent shift. It is the highest risk time frame
for maternal mortality due to postpartum hemorrhage.
Because the placenta just detached from the wall
of the uterus, leaving a massive open wound essentially.
A wound the exact size of a dinner plate with
mass or blood vessels completely sheared open.
Which sounds fatal. So how does she not just
bleed to death? The uterus is an incredibly powerful
muscle. In a healthy stage four, the uterus dramatically
clamps down, contracting tightly to physically
pinch those bleeding vessels closed. It's a biological
tourniquet. That is the perfect way to describe
it. And as the nurse, how do I know if that biological
tourniquet is actually working? What's the assessment?
You systematically palpate the maternal abdomen.
You press your hand into her lower belly to feel
the fundus, which is the top of the uterus. What
should it feel like? It should feel firm, like
a hard grapefruit, located right around the level
of her belly button. And if it doesn't. If you
press down and it feels soft, squishy, like a
water balloon, we call that a boggy uterus. Yeah.
You are in a life -threatening crisis called
uterine atony. Uterine atony. The muscle is exhausted
and it's just relaxed, letting the blood flow
freely. Yes. What is the immediate priority?
Do I run and get the doctor? You do not leave
the room to call the doctor. Okay, good to know.
You drop your hands to her abdomen and you perform
vigorous fundal massage. Very vigorous. You physically
squeeze and knead that uterus through her abdomen
to irritate the muscle fibers into contracting.
It is painful for the patient, but it is 100
% life -saving. And what else? I can't just massage
forever. At the same time, you are yelling for
help and preparing to administer uterotonic medications.
Things like Peterson, Methargyne, or Hemabate
to chemically force the muscle to clamp down.
Let's touch on those meds really quickly because
pharmacology is huge on a Peterson, we know,
but what about methadine and hemabate? Any traps
there? Huge traps. Methadine raises blood pressure.
So if your patient has preeclampsia or high blood
pressure, methadine is strictly contraindicated.
You will cause a stroke. Wow, okay. High BP means
no methadine. and hemabate. Hemabate causes severe
bronchospasm. So if your patient has a history
of asthma, hemabate is contraindicated. See,
this is why I love digging into the mechanisms.
Massage to the fundus sounds like a gentle spa
treatment. Vigorously compress the bleeding organ
and cross -check asthma meds to stop a hemorrhage
is the reality. Exactly. OK, before we move on
from the dashboard, we talked about checking
the cervix to get all these measurements. But
is there ever a time when you absolutely should
not perform a vaginal exam? Yes. And this is
a guaranteed exam question. Status nurse, pen
and paper out. If a patient arrives in triage
complaining of bright red, undiagnosed vaginal
bleeding, a digital vaginal exam is strictly
contraindicated. Why? If she's bleeding, shouldn't
I find out where the blood is coming from? Because
you might be the cause of her bleeding to death.
Wait, really? Yes. She could have a condition
called placenta previa, where the placenta has
implanted abnormally low in the uterus, completely
covering the cervical opening. Oh, wow. If you
blindly insert your fingers into the cervix,
you could literally punch right through the highly
vascular placenta. You will cause a catastrophic
hemorrhage that will exsanguinate the baby and
the mother in minutes. That is terrifying. So
you must wait for a transvaginal ultrasound to
locate the placenta before anyone touches it.
her cervix. Okay, that is a massive safety priority.
Never check a bleeding cervix blindly. So we've
covered the mother's dashboard. We understand
the physical machinery of labor, but there is
a second patient in the room. The one we can't
see. Exactly. Let's pivot to how we know if the
baby is surviving this journey. This brings us
to electronic fetal heart rate monitoring. I
feel like this is the holy grail of obstetrics
exams. It absolutely is because, as we said earlier,
the fetal monitor is the baby's only voice. During
labor, the baby is subjected to tremendous mechanical
and hypoxic stress. Hypoxic stress. Yeah, every
time the uterus contracts, it temporarily squeezes
the blood vessels in the placenta, briefly cutting
off the baby's oxygen supply. It's like doing
a strenuous workout where someone just pinches
your nose every three minutes. Precisely. A healthy,
well -oxygenated fetus with good reserves can
tolerate that intermittent stress perfectly fine.
A fetus that is compromised cannot. The monitor
translates their neurological and cardiovascular
response to that stress right onto a strip of
paper. So we need to learn how to read the language
of the monitor. The guidelines group tracings
into a three -tier system, right? Category one,
two, and three. Let's start with category one.
This is the perfect A -plus baby. Category 1
is normal. It tells you the fetal acid base status
is perfectly balanced. What are the rules to
be category 1? To earn a category 1 rating, the
tracing must meet strict criteria. First, the
baseline heart rate must be between 110 and 160
beats per minute. 110 to 160. Got it. Second,
and most importantly, the baseline variability
must be moderate. I want to spend some time on
variability because I remember staring at these
drifts and just seeing jagged lines. What does
variability actually mean biologically? It is
the most beautiful thing you can see on a monitor.
Variability refers to the tiny, beat -to -beat
fluctuations in the heart rate. Like it shouldn't
be smooth. Right. If you look at the tracing,
it shouldn't look like a straight line drawn
with a ruler. It should look erratic, jagged,
squiggly. But why is erratic good? Usually in
adult cardiology, erratic means you have an arrhythmia
and you're about to code. True, but in a fetus,
it proves that the central nervous system is
intact, oxygenated, and functioning. How so?
The fetal heart is in a constant tug of war between
the sympathetic nervous system, which acts like
the gas pedal trying to speed the heart up. Okay.
Sympathetic is the gas. And the parasympathetic
nervous system via the vagus nerve, which acts
like the brakes trying to slow it down. Gas brake,
gas brake. Exactly. When a healthy oxygenated
fetal brain is managing that tug of war, the
heart rate constantly microadjusts, creating
that squiggly line. We call it moderate variability
when those fluctuations are between 6 and 25
beats per minute in amplitude. So if you see
modern variability. You can take a deep breath
because it virtually guarantees the the baby's
brain is not hypoxic or acidotic at that exact
moment. Okay, so squiggly means the brain is
awake and fighting. What is the opposite? What
makes a tracing category three the ultimate emergency?
Category three means severe fetal hypoxia and
acidemia. The brain is literally shutting down.
And what does that look like? The hallmark of
a category three strip is absent variability.
The line goes completely flat, smooth, like a
ruler. Because the brain doesn't have enough
oxygen to manage the gas and the brake pedals
anymore. Right. The nervous system is deeply
depressed. But absent variability alone isn't
automatically category three. I mean, maybe the
baby is just in a deep sleep cycle or the mother
had narcotic pain medication. Oh, that makes
sense. Meds crossed the placenta. Exactly. It
becomes a category three emergency when that
flat line is combined with pathological decelerations,
specifically recurrent late decelerations, recurrent
severe variable decelerations, or persistent
profound bradycardia. OK, let's unpack these
decelerations. These are the heart rate drops
that happen during the tracing. There are early
late, and variable decelerations. They sound
simple, but I know their underlying physiology
is entirely different. Completely different.
Let's start with early decelerations. Early decelerations
are visually apparent gradual symmetrical decreases
in the fetal heart rate. They look like gentle,
shallow U shapes. Okay, shallow U shapes. But
the defining characteristic is their timing.
They perfectly mirror the uterine contraction.
Meaning, as the contraction gets stronger and
goes up on the bottom half of the monitor paper,
the fetal heart rate goes down on the top half.
Yes. The lowest point of the heart rate drop,
the nadir, occurs at the exact same moment as
the peak of the contraction. Okay, I'm putting
myself in the student's shoes here. A contraction
squeezes the baby, heart rate drops. That sounds
bad. Why is this considered an expected... normal
finding. Because of why it's happening. Early
decelerations are caused by pure mechanical head
compression. Head compression. As the uterus
contracts it forcefully swishes the baby's skull
against the maternal pelvis. This physical pressure
on the skull stimulates the fetal vagus nerve,
which reflexively slows the heart rate. Just
a reflex. Exactly. As the contraction fades and
the pressure releases, the heart rate returns
to normal. So it's not a lack of oxygen. Not
at all. It just means the head is descending
into the birth canal. It's actually a sign of
progress. So what's the nursing action? The appropriate
nursing action for early decelerations is to
simply document the finding and perhaps perform
a vaginal exam to see if the patient is fully
dilated and ready to push. Okay, that makes sense.
Now let's shift to late decelerations. These
are the bad ones. How do they look different
and why are they so dangerous? Visually, late
decelerations are also gradual, shallow U -shapes.
So they look the same as earlys? Visually, yes.
But their timing is shifted to the right. The
deceleration does not start until after the contraction
has reached its peak. After the peak. And the
heart rate doesn't return to baseline until well
after the contraction has completely ended. So
the contraction peaks and then a moment later
the heart rate bottoms out. Right. Why the delay?
Because this isn't a mechanical reflex. This
is utero placental insufficiency. It is a true
oxygen crisis. Let's walk through the plumbing
of that. What is actually failing? Well, the
placenta is essentially the baby's lung. Maternal
blood flows into the placenta, transferring oxygen
to the fetal blood. But during the peak of a
contraction, the uterine muscle clamps down so
tightly that it physically halts the flow of
maternal blood into the placenta. Like stepping
on a garden hose. Exactly. For a few seconds,
the baby gets no new oxygen. Now, a healthy placenta
has built up oxygen reserves in the intervillus
spaces, so the baby basically holds its breath,
tolerates the squeeze, and its heart rate doesn't
change. But if the placenta is failing? If it's
failing, perhaps due to maternal hypertension,
gestational diabetes, preeclampsia, or simply
because the mother is two weeks past her due
date, those reserves are completely gone. So
when the contraction peaks and steps on the hose,
the baby instantly runs out of air. Right. And
as the oxygen level in the fetal blood plummets,
chemoreceptors in the baby's brain detect the
hypoxia and trigger the heart rate to slow down
in a desperate attempt to conserve myocardial
energy. It takes a moment for the oxygen level
to drop, the brain to register it, and the heart
to slow down. That's why the drop happens late.
after the contraction has already peaked. Holding
your breath on a treadmill when you already have
bad lungs. That is a terrifying physiological
picture. It is. So if you see recurrent late
decelerations, you know the baby is suffocating.
What about variable decelerations? How do they
fit in? Early decels are gradual and mirror the
contraction. Late decels are gradual and shifted
right. Variable decelerations are abrupt. Abrupt,
like a sharp drop. They are visually sheer cliffs.
The heart rate plummets suddenly, dropping more
than 15 beats per minute in less than 30 seconds.
They look like sharp Vs or Ws on the tracing.
OK, V for variable. Exactly. And they are variable
because they can happen at any time. They don't
have a strict relationship to the contractions.
What causes a sheer cliff drop like that? Umbilical
cord compression. The umbilical cord is the baby's
lifeline. If it gets squished, maybe the baby
rolls over on it, or the fluid is low and it
gets pinched between the fetal shoulder and the
uterine wall, the blood flow is instantly obstructed.
And how does that instantly crash the heart rate?
It's a baroreceptor response. When the cord is
pinched, the fetal blood pressure skyrockets
because the blood has nowhere to go. It was backs
up. Right. Pressure sensors or baroreceptors
in the fetal aorta scream at the brain, pressure
is too high. The vagus nerve fires instantly,
slamming the brakes on the heart to lower the
blood pressure. When the cord is unpinched, the
heart rate shoots right back up. It is amazing
how much of this is just high stakes biological
plumbing and electrical wiring. That's all it
is. Okay, so as the nurse, you are staring at
this monitor. You see a category two or category
three strip say absent variability with recurrent
late decelerations. The baby is hypoxic. What
do you actually do? You immediately initiate
intrarine resuscitation. Your singular goal is
to maximize oxygen delivery to the placenta and
improve umbilical blood flow. Do we use an acronym
for this? I feel like nursing school's 90 % acronyms.
Yes, the acronym LION is very helpful here. L
for left lateral position, I for IV fluid bolus,
O for oxygen, and N for notify provider and stop
pitotin. Let's break down the Y for each one.
Why change the mother's position first? If the
mother is lying flat on her back, The entire
weight of the gravid uterus crushes her inferior
vena cava, drastically reducing blood return
to her heart which drops her blood pressure and
starves the placenta. A vena cava syndrome. Right.
Rolling her to her left or right side takes the
weight off the vena cava, restoring blood flow.
Furthermore, if you are seeing variable decelerations
from a compressed cord, physically shifting the
mother's weight can literally cause the baby
to float off the cord, instantly fixing the problem.
So position change is always, always your first
move for variables? Always. Okay, step two is
an IV fluid bolus, usually lactated rengars.
Why? Physics. More fluid volume in the maternal
intravascular space equals higher maternal blood
pressure, which equals stronger perfusion pressure
driving blood into the placenta. Especially if
she had epidural, right? Exactly, because epidurals
cause vasodilation and drop maternal blood pressure
anyway. Step three, oxygen. Applying a non -rebreather
mask at 10 liters. Yes. You want to hyper oxygenate
the maternal blood so that whatever blood is
making it through the failing placenta is carrying
maximum oxygen capacity to the fetus. And the
final step, which might be the most critical.
turning off the pitocin or oxytocin. If the contractions
are the stressor causing the hypoxia, which they
absolutely are in the case of late decelerations,
you must stop the artificial engine driving the
contractions. Turn off the engine. Pitocin forces
the uterus to contract. You must turn it off
immediately to give the placenta time to rest
and refill with oxygen. Okay, let's talk exam
traps for fetal monitoring. Where do students
usually get tripped up? The most common trap
is misinterpreting the baseline fetal heart rate.
The normal range is 110 to 160. Students see
a tracing where the baseline is 175. It's fetal
tachycardia. And they think what? They often
choose an answer like, the baby is active and
tolerating labor well. Thinking a fast heart
is a strong heart. Right, like the baby's just
jogging. Exactly. But fetal tachycardia is a
massive red flag. While it can be a side effect
of maternal medications like tributylene, the
most dangerous and testable cause of fetal tachycardia
is maternal or intraamniotic infection called
chorioamnionitis. Infection. The fetal heart
rate will often spike hours before the mother
even spikes a fever. It is an early warning siren
for sepsis. That is a phenomenal clinical pearl.
Tachycardia equals suspect infection. So up until
now, we've been talking about this intricate
dance of labor, assuming the timeline is normal,
like a 39 or 40 -week term pregnancy. Right.
But what happens when this entire physiological
dashboard is abruptly moved up by, say, eight
weeks? That changes the entire calculus of risk.
A baby born at 40 weeks has fully developed lungs,
plenty of brown fat for temperature regulation,
and a mature liver. A baby born at 32 weeks has
absolutely none of those things. Which bridges
us perfectly into preterm labor, PP -ROM and
intra -amniotic infection. Let's get the definitions
crystal clear, because I know the NCLE -X loves
to trick people here. What exactly is preterm
labor? Preterm labor is defined as regular uterine
contractions that cause actual measurable cervical
change of facement or dilation occurring between
20 weeks and 36 weeks and six days of gestation.
The key phrase there is cervical change. Because
a woman can have contractions at 30 weeks that
aren't labor, right? Correct. A pregnant woman
can experience Braxton Hicks contractions or
contractions caused by dehydration or a urinary
tract infection. So if she's just dehydrated?
If the uterus is contracting but the cervix remains
long - long, thick, and closed, she is not in
preterm labor. We might hydrate her, treat the
UTI, and send her home. But if those contractions
are actually thinning and opening the cervix,
she is in true preterm labor, and we have to
intervene aggressively. PPPROM stands for preterm
pre -labor rupture of membranes. This is when
the amniotic sac, the bag of waters, spontaneously
breaks before 37 weeks and before any contractions
have even started. Why is that such a massive
emergency? If the water breaks, doesn't that
just mean the baby is coming? It's an emergency
because of what the amniotic sac actually does.
It is a thick, highly resilient, completely sterile
barrier. It is a fortress that protects the fetus
from the billions of bacteria residing in the
vaginal canal. Oh, wow. When that sac ruptures
prematurely, you have essentially lowered the
drawbridge to the fortress. Bacteria can freely
ascend from the vagina directly into the uterine
cavity. Which leads to chorioamnionitis. Exactly.
Chorioamnionitis is a severe ascending bacterial
infection of the amniotic fluid, the membranes,
and the placenta. It creates a highly toxic,
inflammatory, interotorin environment. And that
causes labor. It will trigger aggressive preterm
labor, and if left untreated, it leads to maternal
sepsis, fetal sepsis, and fetal brain damage.
So how do you know if the fortress has been breached
and an infection has taken hold? What are the
signs? You look for the clinical hallmarks. We
already mentioned the earliest sign. Fetal tachycardia.
Right. Then you monitor the mother's temperature.
A fever greater than 38 degrees Celsius or 100
.4 degrees Fahrenheit is highly concerning. You
also assess the mother's uterus. Is it exquisitely
tender to the touch between contraction? Okay,
tender uterus. And finally, you assess the amniotic
fluid itself. What should it look like normally?
Normal amniotic fluid is clear, pale, and relatively
odorless. If the fluid leaking from the vagina
is cloudy, yellow, purulent, or has a foul offensive
odor, you are dealing with a severe intra -amniotic
infection. OK, let's walk through a scenario.
A patient arrives in triage at 31 weeks. She's
having regular contractions, and her cervix has
dilated from 1 centimeter to 3 centimeters in
the last two hours. She is in active preterm
labor. The water is intact. OK, classic preterm
labor. What is our primary goal? Do we try to
stop the labor completely and send her home to
stay pregnant for another nine weeks? Generally,
no. Once the biochemical cascade of true preterm
labor has firmly established itself, it is incredibly
difficult to halt it completely. Our primary
realistic goal is to buy time. Specifically,
we want to buy 48 hours. Why 48 hours? What are
we doing in that window? We need that 48 hour
window to administer intramuscular corticosteroids
to the mother, usually a drug called beta -methasone.
Why steroids? I normally associate steroids with
reducing inflammation, like for asthma or an
allergic reaction. In a premature fetus, the
biggest threat to life is respiratory distress
syndrome. A 31 -week fetal lung has not produced
enough surfactant. Surfactant is the soapy stuff,
right? Yes, the soapy substance that coats the
inside of the alveoli and keeps them from collapsing
flat every time the baby exhales. Without it,
the lungs just stick together. When you inject
beta -methasone into the mother, it crosses the
placenta and aggressively stimulates the fetal
lungs to synthesize and release surfactant. Oh,
wow. So you are chemically accelerating fetal
lung maturity while they're still in the womb.
Exactly. But it takes about 24 to 48 hours for
the drug to reach maximum efficacy. So we have
to pause the contractions just long enough for
the steroids to work. And how do we hit the pause
button on labor? We use medications called tocolytics.
Toco meaning labor, eslytic meaning to break
or stop. These are smooth muscle relaxants. The
sources list three primary high -yield drugs,
terbutylene, nefetapine, and magnesium sulfate.
Let's talk pharmacology because nurses administer
these. Terbutylene. How does it work and what
are the side effects? Tributylene is a beta -2
adrenergic agonist. It binds to receptors in
the uterine muscle and causes them to relax.
However, it also binds to beta receptors in the
heart and lungs. It is notorious for causing
severe maternal tachycardia, palpitations, and
tremors. The mother will often tell you she feels
like her heart is beating right out of her chest.
So what's the nursing implication? You must assess
her heart rate before giving every single dose.
If her pulse is already over 120, you hold the
drug and notify the provider. Nifedipine. I recognize
that as a blood pressure pill. Yes, it's a calcium
channel blocker. The uterine muscle requires
an influx of calcium into its cells to perform
the actin myosin cross -bridging that causes
a contraction. Nifedipine physically blocks the
calcium channels. No calcium, no contraction.
Brilliant. But it's a blood pressure med. Right.
Because it relaxes smooth muscle everywhere,
it also dilates maternal blood vessels. The major
side effects are maternal hypertension, dizziness,
and flushing. You have to monitor her blood pressure
closely to ensure she doesn't bottom out and
drop perfusion to the placenta. That makes perfect
mechanical sense. Now let's talk about the heavy
hitter, magnesium sulfate. I remember this being
the most terrifying drug to manage on the L &D
floor. Oh, it is a high alert medication because
the therapeutic window is very narrow and magnesium
toxicity can be fatal. So what does it do? Magnesium
sulfate is a central nervous system depressant
and a potent smooth muscle relaxant. It can be
used as a tocolytic to relax the uterus. But
there is a second highly testable reason we give
it in preterm labor, completely separate from
stopping contractions. Fetal neuroprotection.
Massive studies showed that if you infuse magnesium
sulfate into a mother delivering before 32 weeks,
it stabilizes the fragile cerebral blood vessels
in the extremely premature fetal brain. Wait,
really? Yes. It drastically reduces the incidence
and severity of devastating intraventricular
hemorrhages and cerebral palsy in the neonate.
So even if the labor is unstoppable and the baby's
coming today, you still hang the mag to protect
the baby's brain. Exactly. And your nursing priority,
while the mother is on a mag drip, is assessing
for toxicity. Right, because you said it's a
CNS depressant. Because it depresses the nervous
system, you must do hourly checks of her deep
tendon reflexes, like the patellar knee jerk.
If her reflexes disappear, her nervous system
is too depressed. No, reflexes are bad. Very
bad. You also check her respiratory rate. If
it drops below 12 breaths per minute, the magnesium
is paralyzing her diaphragm. Oh my god. If either
of those happen, you immediately stop the infusion
and prepare to administer the antidote, which
is calcium gluconate. That is an absolute goldmine
of exam prep right there. Lose the reflexes,
stop the drug, grab the calcium gluconate. OK,
what if the scenario is different? The patient
is 32 weeks and her water breaks. PP prom. She's
not having contractions yet, but the fortress
is breached. What is our priority action? Infection
prevention is your absolute paramount priority.
You do not touch her cervix. You strictly limit
or completely avoid digital vaginal exams. Because
of the bacteria. Right. Every time a provider
introduces a gloved hand into the vaginal canal,
they are physically pushing ascending bacteria
closer to the sterile uterine cavity. You manage
her expectantly. What does expectant management
look like? Monitoring her temperature, monitoring
the fetal heart rate for tachycardia, assessing
the fluid for foul odor, and administering prophylactic
antibiotics to delay chorioamnionitis. Okay,
we've covered the nuances of premature labor.
Let's bring our timeline back to a full -term
pregnancy. Back to 40 weeks. Yes. The patient
is 40 weeks. She's fully dilated. The monitor
looks okay. The baby's is coming down the birth
canal. And then suddenly, everything stops. We
are entering the territory of dystocia and obstetrical
emergencies. This is where we move from physiological
management to mechanical trauma level crisis
management. Dystocia literally translates to
difficult, abnormal, or dysfunctional labor.
Let's set the scene for the most terrifying dystocia
of all. The patient is pushing. The baby's head
crowns and delivers. The head is completely out
in the world. But then, horrifyingly, the head
pulls back tightly against the mother's perineum.
What is happening? You are describing the turtle
sign. It looks exactly like a turtle pulling
its head back into its shell, and it is the diagnostic
hallmark of a shoulder dystocia. Why is the head
pulled back? What is starting? The mechanics
are brutal. The fetal head successfully navigated
the pelvis, but the baby's anterior shoulder,
the shorter facing the ceiling, has become physically
wedged and locked behind the mother's pubic symphysis,
the thick bone at the front of the pelvis. So
it's bone on bone. Exactly. The uterus is contracting,
trying to push the body out, but the bone is
acting like a brick wall blocking the shoulder.
The head pulls back because the neck is being
stretched tight, but the body can't follow. This
sounds horrific. Why is this a drop everything
life or death emergency? Because of the umbilical
cord? Once the baby's head is out, the umbilical
cord is dragged down into the birth canal, and
it is now being severely compressed between the
baby's stuck body and the mother's pelvis. So
the cord is crushed. Oh. and the baby can't breathe.
Right. The baby's head is in the air, but its
chest is compressed inside the tight birth canal,
so it cannot expand its lungs to breathe. And
its oxygen supply from the cord is totally crushed.
You have roughly five minutes to dislodge that
shoulder and deliver the baby before profound,
irreversible hypoxic brain damage occurs. Five
minutes. OK. You see the turtle sign. You hit
the emergency call light. The room floods with
the rapid response team. What are the immediate
hands -on nursing interventions? The standard
first -line intervention is the McRoberts maneuver,
performed simultaneously with suprapubic pressure.
Walk me through the biomechanics of McRoberts.
What am I doing to the mother's body? You and
another nurse grab the mother's legs, remove
them from the stirrups, and sharply, forcefully
hyperflex her thighs tightly back against her
own abdomen. Think knees to nipples. How does
that unstick a shoulder? It alters the geometry
of the pelvis. Hyperflexing the legs straightens
the maternal sacrum and physically rotates the
pubic symthesis upward, opening the angle of
the pelvic inlet. Oh, it pivots the bone. Yes.
It often creates just enough clearance for that
stuffed shoulder to pop free and slide under
the bone. But if McRoberts alone doesn't work,
we add suprapubic pressure. And I know there
is a deadly exam trap here regarding where you
push. This is one of the most critical safety
distinctions you will ever learn. To apply suprapubic
pressure, you stand on a stool, make a fist,
and push downward and inward directly over the
mother's pubic bone, low down on her pelvis.
Over the pubic bone. Your goal is to physically
find the baby's stuck shoulder through the skin
and push it downward, collapsing it so it can
clear the bone. What happens if a student panics
and pushes on the top of the mother's stomach
instead, like up by her ribs? That is called
fundal pressure, and it is absolutely strictly
contraindicated during a shoulder dystocia. Why?
What does it do? If you push on the fundus, the
top of the uterus, you are applying massive downward
force onto a baby whose shoulder is firmly wedged
against a solid bone. You will impact the shoulder
even tighter. Oh, that makes sense. You're just
jamming it in. You will cause severe brachial
plexus nerve injuries, snapping the clavicle,
and you run a massive risk of physically rupturing
the mother's uterus from the pressure. Super
pubic pressure only. Never fundal. That is a
vivid image to remember. Never push from the
top when they are stuck at the bottom. Yeah.
What about other mechanical dystocia like presentation
issues? Not every baby comes head first. Right.
A normal presentation is vertex with the chin
tucked, but many babies are breech, meaning the
buttocks or the feet are presenting first. What
are the different flavors of breech? There are
three main types. Frank breech is the most common.
The baby's hips are flexed, but their legs are
extended straight up by their ears, like a diver
touching their toes. Okay, Frank is folded in
half. Then there's complete breach, which means
the baby is sitting cross -legged, Taylor -style,
right over the cervix. And footling brooch is
when one or both feet are pointing straight down
and actually drop into the vagina. Why are we
so afraid of delivering breech babies vaginally?
The biggest danger, especially with a footling
breech, is cord prolapse, which we will cover
in a moment. But there is also the massive risk
of head entrapment. Head entrapment. The body
and legs are smaller than the head. In a breech
delivery, the body might deliver easily through
a cervix that is only eight centimeters dilated.
But then the large hard skull gets to the cervix
and gets completely stuck. Oh my god. The body
is out, but the head is trapped. The body is
out, but the head is trapped inside, compressing
the cord. It is catastrophic. Most breach presentations
today are delivered via scheduled cesarean. Is
there any way to fix a breach presentation before
labor starts? Like, can we flip them? Providers
can attempt an external cephalic version, or
ECV. Around 37 weeks, under ultrasound guidance,
the provider places their hands firmly on the
mother's abdomen and physically attempts to roll
the baby into a head -down position. That sounds
like it involves a lot of force. It does, and
it carries risks. It can cause the placenta to
abrupt or can entangle the umbilical cord, causing
immediate fetal distress, requiring a crash C
-section. Is there an exam trap for ECVs? Yes,
regarding blood typing. The forceful manipulation
can cause micro -traumas in the placenta, leading
to a mixing of maternal and fetal blood. Oh,
the RH factor. Exactly. If the mother has an
RH negative blood type, this mixing can cause
her to form antibodies against the baby's blood.
As a nurse, you must ensure that an Rh -negative
mother receives a dose of Rh -immunglobulin,
or ROJAM, whenever an ECV is attempted. Okay,
we've covered the stuck shoulders and the backwards
babies. Let's move to the final module, the drop
-everything emergencies. These are the vascular
and anatomical disasters where minutes equal
brain cells or life and death. Let's start with
the one you just mentioned, prolapsed umbilical
cord. We've talked about the umbilical cord being
compressed inside the uterus during variable
decelerations. A cord prolapse is when the umbilical
cord physically falls out of the cervix and into
the vagina ahead of the presenting part of the
fetus. How does that even happen? It almost always
happens at the exact moment the amniotic sac
ruptures when the water breaks. If the baby's
head is not firmly engaged down in the pelvis,
if they are at a high negative station, like
minus three, there is a gap. between the head
and the cervix. And the fluid just washes it
out. When the water breaks, the sudden gush of
fluid washes the slippery umbilical cord down
through that gap and out the surface. And then
the heavy bony head descends behind it. Yes.
The heavy head comes down and pinches the cord
tightly against the bony walls of the maternal
pelvis. Blood flow is completely and instantly
occluded. The baby is literally sitting on his
own air hose. How do you know this has happened?
The fetal monitor will instantly show profound
sustained fetal bradycardia or massive unrecovering
variable decelerations. The heart rate will crash
to 60 beats per minute and stay there. That's
horrifying. Or you might be performing a vaginal
exam right after the water breaks. And instead
of feeling a hard, smooth skull, your fingers
feel a soft pulsating rope -like cord. OK, this
is where I need to ask a very skeptical question.
Because my instinct, if an organ is falling out
of the body, is to put it back in. Do I gently
push the cord back up into the uterus where it
belongs? Never. That is a massive exam trap and
a fatal clinical error. Really? Never. You never,
ever manipulate, massage, or attempt to stuff
a prolapsed cord back inside. Handling the umbilical
cord causes severe vasospasm. The blood vessels
inside the cord will aggressively clamp shut
from the irritation, permanently cutting off
whatever tiny amount of oxygen was still flowing.
Okay, so I don't touch the cord, what do I do?
Your hand is already in the vagina from the exam,
you keep it there. You take your sterile gloved
fingers, you find the baby's hard skull, and
you push it firmly UP toward the ceiling. Wait,
you want me to push the baby back in? You are
manually lifting the heavy fetal head off the
umbilical cord, creating space for blood to flow.
So I literally hold the baby's head up inside
the mother? Yes. And you do not remove your hand.
You stay in that extremely awkward, physically
exhausting position while you yell for help,
while the team rushes in, while they move the
mother to a stretcher, and you literally ride
on the bed with your hand inside the patient
all the way to the operating room. Oh, man. You
stay there until the surgeon makes the abdominal
incision and pulls the baby out from above. You
are the physical bridge keeping that baby alive.
That is absolutely wild. And it highlights how
critical the nursing role is. What else are we
doing to help gravity? You want gravity to pull
the baby away from the pelvis. You immediately
reposition the mother into an extreme knee chest
position. Knee chest. Where she is on her hands
and knees with her chest resting on the mattress.
Or you put her into steep Trendelenburg where
the head of the bed head is tilted drastically
down and her hips are elevated. Okay, that is
cord prolapse. Head UP, hips UP. What is the
next major emergency? Uterine rupture. This is
the catastrophic tearing apart of the muscular
layers of the uterus. The structural integrity
of the organ fails. The uterus just rips open.
Yes. The amniotic fluid, the placenta, and sometimes
the entire fetus itself can be expelled out of
the torn uterus directly into the maternal abdominal
cavity. That sounds like something out of a horror
movie. Yeah. Who is at risk for their uterus
just tearing open? In the United States, the
single greatest risk factor is a scarred uterus
from a previous cesarean section. Ah, the scar
tissue. Right. When a woman opts for a TOLAC,
a trial of labor, After cesarean attempting a
vaginal birth, she is monitored continuously
specifically for this risk. The old surgical
scar on the uterus is the weakest point. So if
contractions get too strong? If the uterus is
hyper stimulated, perhaps by aggressive doses
of pedicine driving contractions too hard and
too fast, that scar tissue can just give way
under the immense pressure. How do you spot a
rupture before it's too late? What are the clinical
signs? It is sudden and violent. The classic
presentation is the patient screaming in acute,
severe, tearing abdominal pain that is distinctly
different from her contraction pain. In the monitor?
On the monitor, you will see a sudden loss of
uterine tone. The rhythmic contraction mountains
just disappear into a flat line because the torn
muscle can no longer contract. The fetal heart
rate will crash into profound bradycardia as
the placenta shears off. And what happens to
the physical exam? Yeah. Where is the baby? This
is a highly testable finding. A sudden loss of
fetal station. Loss of station. If you checked
her 10 minutes ago and the baby was at plus two
station deep in the pelvis and now she is in
agonizing pain and you check again and you can't
feel the head at all, the baby has slipped back
up and out of the torn uterus into the abdomen.
Sudden pain, flat contractions, baby disappears.
What is the intervention? Immediate crash laparotomy
in cesarean. Your role is prepping for massive
maternal hemorrhagic shock. You need two large
-bore IVs, 18 gauge or larger, pumping in rapid
fluid resuscitation and preparing for massive
blood transfusions. The mother is bleeding out
internally, and the baby is suffocating. Which
brings us to the final emergency, which also
involves massive bleeding. Placental abruption,
or a placenta? Yes. The placenta is supposed
to remain firmly attached to the uterine wall
until stage three of labor, after the baby is
born. An abruption is the premature separation
of the placenta from the uterine wall while the
baby is still inside. It just tears away. It
can be a partial separation at the edges or a
complete devastating separation. When the placenta
tears away, what is the immediate consequence?
Two things happen simultaneously. First, the
area of the placenta that detached is no longer
exchanging oxygen, so the fetus instantly experiences
hypoxia, leading to late decelerations or bradycardia.
And the second. Second, the maternal spiral arteries
that were feeding that placenta are now sheared
open and bleeding massively. But I've heard that
sometimes with an abruption, you don't even see
any blood. How is that possible? That is a crucial
distinction. It depends on where the placenta
separates. If it separates at the edges, the
blood flows down past the membranes and out the
cervix, presenting as visible, dark, red, vaginal
bleeding. But if it's not at the edges? If it
separates directly in the center, the edges remain
sealed to the uterine wall. The blood pumps out
and pools behind the placenta, creating a massive
retroplacental hematoma. Oh, a concealed hemorrhage.
Exactly. The mother could lose a liter of blood
into her uterus and you wouldn't see a drop on
the bedsheets. That is terrifying. If I can't
see the blood, how do I know it's happening?
Pain and rigidity. As the blood fills the enclosed
space of the uterine muscle, it irritates the
myometrium, causing continuous, severe, knife
-like abdominal pain. So it hurts continuously,
not just during a contraction. Right. And the
uterus becomes hypertonic. It refuses to relax.
If you palpate the mother's abdomen, it will
feel rock hard, rigid, and board -like. A rigid,
board -like abdomen. That is a massive red flag.
It is the classic clinical sign of a severe abruption.
The treatment is the same as a rupture. hemodynamic
support, oxygen, and an immediate emergency cesarean
to save the baby and stop the bleeding. Okay,
we have covered an incredible, intense amount
of ground today. From the calm baseline of a
normal dashboard, down the steep cliffs of decelerations,
and into the absolute chaos of prolapsed cords
and ruptures. What strikes me is how interconnected
all of this is. It's all connected. You can't
understand a late deceleration if you don't understand
placental perfusion. You can't understand a shoulder
dystocia if you don't understand the anatomy
of the maternal pelvis. And that is exactly what
the NCLE -X and your clinical instructors are
testing. They are not testing your ability to
just regurgitate a definition. They are testing
your clinical judgment. Can you look at a rigid
abdomen and a crashing fetal heart rate, recognize
the pattern of an abruption, understand the underlying
physiology of hemorrhagic shock, and prioritize
your actions to start an IV and prep the OR?
That is what makes you a safe nurse. Before we
sign off, I want to pivot slightly. We spent
this entire hour hyper -focused on the physical
interventions, the clued boluses, the oxygen
masks, the McRoberts maneuver, the raw mechanics
of saving a life. But there is another layer
to this that often gets lost in the adrenaline.
The psychological impact? Yes. I want you, the
listener, to pause and consider the psychological
trauma of a stat crash c -section or a severe
postpartum hemorrhage. Think about the patient's
perspective. She came in with a birth plan. Maybe
she had soft music playing and dim lighting.
She was expecting a beautiful natural transition
to motherhood. And in the span of 60 seconds,
her reality shatters and alarm sounds. A dozen
strangers and scrubs sprint into her room. The
lights are thrown on. Someone yells, cord prolapse.
It's pure chaos. You leap onto her bed and insert
your hand into her body. She's thrown onto a
gurney, sprinted down a hallway, strapped to
an operating table, and put to sleep under general
anesthesia before she can even ask if her baby
is going to die. It is an acute, profound psychological
crisis. And surviving the physical emergency
is only step one. The challenge I want to leave
you with to mull over as you prepare for your
career is this. As a future nurse, you are the
face of that trauma. You really are. How will
your communication, your eye contact, your tone
of voice, and your calm, authoritative presence
in those frantic, terrifying 10 minutes alter
that patient's mental health recovery for the
next 10 years? It's a powerful question. A technician
can start a large borvée. A truly excellent nurse
manages the physical pathophysiology while fiercely
protecting the patient's dignity, validating
her fear and providing a sense of psychological
safety even in the midst of absolute chaos. Even
if it's just looking her in the eye as they wheel
her down the hall and saying, I am right here
with you and we're going to take care of your
baby. That is the art of nursing layered right
over the science. Well said. To all the nursing
students out there, take a deep breath. Review
these physiological patterns. Trust your training.
Remember that behind every alarm is a physical
mechanism you can understand, and behind every
patient is a human being looking to you for safety.
Go confidently tackle those exams and your clinicals.
You've got this. We'll see you on the next Deep
Dive.