Chapter 33: High-Yield Final Review

IBSC domain: Exam Preparation
Estimated study time: 180–240 minutes
Difficulty: Advanced
Review date: July 2026

Learning objectives

After completing this chapter, you should be able to:

1. Recall the most testable distinctions from all seven blueprint domains.
2. Recognize red-flag maternal and fetal findings that require escalation or diversion.
3. Match major medications with indications, contraindications, monitoring, and rescue therapy.
4. Differentiate common obstetric hemorrhage, hypertensive, infectious, metabolic, and cardiopulmonary emergencies.
5. Apply pregnancy-specific airway and ventilation principles.
6. Use a final-week plan that reinforces weak areas without creating cognitive overload.

1. Physiology: numbers mean something different in pregnancy

• Pregnancy is a high-output, low-resistance state.
• Plasma volume increases more than red-cell mass, producing physiologic anemia.
• Maternal hypotension can be late in hemorrhage; fetal deterioration may appear first.
• After approximately 20 weeks, supine positioning can reduce venous return; use left tilt or manual uterine displacement.
• Functional residual capacity falls while oxygen consumption rises, causing rapid desaturation during apnea.
• Normal PaCO₂ is lower; a value near 40 mm Hg may indicate relative hypoventilation.
• Serum creatinine is normally lower because glomerular filtration rises.
• Pregnancy is hypercoagulable; pulmonary embolism remains a critical differential.
• Uterine blood flow depends heavily on maternal perfusion and is not strongly autoregulated.

2. Transport safety and logistics

• Transport is a clinical intervention with risk, not merely movement.
• Confirm the receiving facility has the immediate maternal, fetal, neonatal, surgical, blood-bank, and critical-care capabilities required.
• Pause transport when the patient is likely to deliver, arrest, hemorrhage catastrophically, or lose the airway without adequate capability en route.
• Oxygen and battery calculations must include delay and diversion reserve.
• Secure patient, clinicians, devices, pumps, and equipment before movement.
• Verify fetal-monitor limitations and artifact in motion.
• Carry a delivery kit, neonatal warming/resuscitation supplies, suction, hemorrhage devices when applicable, and manual airway backup.
• Update the receiving team whenever the diagnosis, maternal status, fetal status, treatment, or arrival time changes.

3. Pharmacology: indication, contraindication, monitoring, rescue

4. Pathophysiology: discriminating findings

Hypertensive disease

• Preeclampsia can exist without proteinuria when severe features are present.
• Severe-range blood pressure requires urgent treatment.
• Magnesium prevents or treats seizures; it is not the primary antihypertensive.
• HELLP involves hemolysis, elevated liver enzymes, and low platelets.
• Pulmonary edema demands cautious fluid strategy.

Antepartum hemorrhage

Preterm labor and membrane rupture

• PPROM is membrane rupture before labor and before 37 weeks.
• Avoid repeated digital examinations because infection risk rises.
• Infection, fetal compromise, abruption, or active advanced labor may outweigh the benefit of delay.
• Corticosteroids, latency antibiotics, magnesium neuroprotection, GBS prophylaxis, and tocolysis have different indications.

Postpartum hemorrhage

Use the four Ts: Tone, Trauma, Tissue, Thrombin. Quantify cumulative loss, massage an atonic uterus, administer appropriate uterotonics, give early tranexamic acid when indicated, activate blood products, replace calcium, prevent hypothermia, and pursue source control.

Cardiac and respiratory disease

• Peripartum cardiomyopathy causes systolic dysfunction late in pregnancy or postpartum.
• Pulmonary embolism may present with dyspnea, pleuritic pain, syncope, tachycardia, hypoxemia, or shock.
• Amniotic fluid embolism can cause sudden hypoxemia, hypotension, and coagulopathy.
• Severe asthma can produce a quiet chest and hypercapnia as fatigue develops.

DKA and sepsis

• DKA can occur at lower glucose levels in pregnancy.
• Potassium must be known and managed before and during insulin therapy.
• Maternal sepsis does not require fever; do not delay antibiotics for cultures.
• Source control and perfusion matter as much as the antibiotic choice.

5. Assessment: patterns, not isolated values

History

Know GTPAL, gestational age, prior cesarean/uterine surgery, placenta location, multiple gestation, membrane status, bleeding, contractions, fetal movement, blood type/Rh, GBS, and current medications.

Labor

• Active labor generally begins around 6 cm cervical dilation.
• Station describes descent relative to the ischial spines.
• Tachysystole is more than five contractions in 10 minutes averaged over 30 minutes.
• Imminent birth is suggested by involuntary pushing, crowning, bulging perineum, and rapidly progressive pressure.

Fetal heart rate

• Moderate variability is reassuring.
• Early decelerations mirror contractions and usually reflect head compression.
• Variable decelerations suggest cord compression.
• Late decelerations suggest uteroplacental insufficiency.
• Category III includes absent variability with recurrent late/variable decelerations, bradycardia, or a sinusoidal pattern.
• Verify that the displayed rate is fetal rather than maternal artifact.

Laboratories

• Platelets, AST/ALT, creatinine, hemolysis markers, and protein assessment support hypertensive-disease evaluation.
• Fibrinogen is normally elevated in pregnancy; a “normal” nonpregnant value can be concerning in hemorrhage.
• A creatinine that appears normal may represent renal injury in pregnancy.
• Kleihauer-Betke testing estimates fetomaternal hemorrhage but is not a test for abruption severity.

6. Special situations

• Trauma: stabilize the mother, displace the uterus, do not withhold indicated imaging, and monitor for abruption.
• Cardiac arrest: standard CPR/defibrillation, manual uterine displacement, early airway and reversible-cause treatment, and immediate preparation for resuscitative delivery when indicated.
• Toxicology: treat the toxidrome and maternal physiology; do not wait for a screening test.
• Refusal: a capable pregnant patient retains the right to refuse recommended treatment.
• EMTALA: appropriate transfer requires screening, stabilizing treatment within capability, acceptance, records, and qualified personnel/equipment.

7. Airway and ventilation

• Anticipate edema, smaller glottic opening, aspiration, and rapid desaturation.
• Position head-up/ramped and relieve aortocaval compression.
• Maximize preoxygenation and have suction, video laryngoscopy, bougie, SGA, and emergency airway equipment ready.
• Limit attempts and change strategy after failure.
• Continuous waveform capnography confirms and monitors ventilation.
• Use predicted body weight for tidal volume.
• DOPES organizes sudden ventilator deterioration.
• Begin postintubation analgesia and sedation immediately.

8. Final seven-day review plan

Do not attempt to learn an entire new textbook on the final evening. Use focused recall, missed-question review, and sleep.

9. High-yield summary

1. Maternal stabilization is often fetal resuscitation.
2. Trends and mechanisms are more useful than isolated numbers.
3. Know medication indication–contraindication pairs.
4. Painful firm-uterus bleeding suggests abruption; painless bleeding suggests previa.
5. Magnesium treats seizure risk, not severe blood pressure by itself.
6. DKA can occur with modest glucose and requires potassium-aware insulin therapy.
7. Category III fetal patterns require immediate evaluation and escalation.
8. Failed oxygenation is more urgent than failed intubation.
9. The original destination must change when current capability needs change.
10. Final review should target distinctions and weak domains.

References

1. International Board of Specialty Certification. Maternal Fetal Transport Microcredential Candidate Handbook. Updated April 2026.
2. Clinical references cited throughout Chapters 1–31 of this study guide.