Eduovisual
Pregnancy, Childbirth & Puerperium
Fetal monitoring: interpretation and intervention
— External: Doppler ultrasound (FHR) + tocodynamometer (contractions); non-invasive, less precise
— Internal: fetal scalp electrode (FSE) for FHR + intrauterine pressure catheter (IUPC) for contraction strength in Montevideo units (MVUs); requires ruptured membranes, ≥2 cm dilation, and known presentation
— High-risk pregnancies: preeclampsia, IUGR, oligohydramnios, diabetes, post-term, prior cesarean, meconium-stained fluid, induction with oxytocin, suspected chorioamnionitis, multiple gestation, abnormal antepartum testing
— Any Category II or III tracing on intermittent auscultation
— Decreased fetal movement, IUGR, post-dates (≥41 wk), maternal diabetes, hypertension, prior stillbirth, isoimmunization, cholestasis of pregnancy
— Start at 32 wk (earlier if very high risk); modalities include NST, BPP, modified BPP, contraction stress test, umbilical artery Dopplers
Board pearl: Continuous EFM reduces neonatal seizures but increases cesarean and operative vaginal delivery rates without reducing cerebral palsy or perinatal mortality compared with intermittent auscultation — a favorite test point on counseling and consent questions. Despite this, continuous EFM remains standard of care for high-risk laboring patients in the US.
— Decreased fetal movement (<10 movements in 2 hr of focused counting)
— Vaginal bleeding (abruption, previa, vasa previa)
— Trauma, MVC, domestic violence — monitor ≥4 hr (≥24 hr if contractions, bleeding, or abnormal tracing)
— Preterm contractions, leaking fluid, decreased fundal growth
— Oxytocin augmentation → tachysystole
— Epidural placement → maternal hypotension → prolonged deceleration
— Rupture of membranes → cord prolapse → bradycardia
— Rapid descent → head compression → early decelerations
— Uteroplacental insufficiency (preeclampsia, IUGR, post-dates) → late decelerations
— Gestational age, gravidity/parity, prior cesarean
— Risk factors: HTN, DM, smoking, cocaine, infection
— Labor status: dilation, station, membranes, meconium
— Recent interventions: oxytocin rate, epidural timing, last cervical exam, prostaglandins, amniotomy
— Maternal vitals (fever? hypotension?), recent positional changes
— Hypotension (epidural, supine hypotension from IVC compression)
— Hypoxia (asthma exacerbation, pulmonary embolism, eclampsia, sepsis)
— Hyperthermia (chorioamnionitis → fetal tachycardia + minimal variability)
— Maternal acidosis (DKA), drugs (β-blockers → fetal bradycardia; magnesium → ↓ variability; opioids → ↓ variability + ↓ accelerations)
Step 3 management: When called for an abnormal tracing, your first verbal action is bedside evaluation — confirm the tracing is fetal (not maternal pulse), assess maternal vitals, perform a cervical exam to rule out cord prolapse or rapid descent, and review oxytocin rate. Do not order interventions from the workstation without laying eyes on the patient. CCS will reward "go to bedside" and "cervical exam" orders before pharmacologic moves.
— DR: Determine Risk (maternal/fetal)
— C: Contractions — frequency, duration, intensity; tachysystole = >5 contractions in 10 min averaged over 30 min
— BRa: Baseline Rate (10-min mean, rounded to 5 bpm)
– Normal 110–160 bpm
– Bradycardia <110 (think hypoxia, cord compression, maternal hypothermia, β-blockers, heart block)
– Tachycardia >160 (think chorioamnionitis, maternal fever, hyperthyroidism, terbutaline, fetal anemia, arrhythmia)
— V: Variability (fluctuation amplitude over 10 min)
– Absent (0), minimal (≤5), moderate (6–25, reassuring), marked (>25)
— A: Accelerations — ≥15 bpm × ≥15 sec (≥10×10 if <32 wk); presence virtually excludes acidemia
— D: Decelerations
– Early: mirror contraction, head compression, benign
– Variable: abrupt drop ≥15 bpm × ≥15 sec; cord compression
– Late: gradual onset/nadir after contraction peak; uteroplacental insufficiency — concerning
– Prolonged: ≥2 min but <10 min
— O: Overall impression — Category I, II, or III
— I: baseline 110–160, moderate variability, no late/variable decels, ± early decels, ± accels — continue routine care
— II: indeterminate (everything not I or III) — workup, intrauterine resuscitation
— III: absent variability with recurrent lates/variables OR recurrent bradycardia; OR sinusoidal pattern — prepare delivery
Key distinction: Sinusoidal pattern (smooth undulating 5–15 bpm wave, 3–5 cycles/min, ≥20 min) signals severe fetal anemia (alloimmunization, fetomaternal hemorrhage, parvovirus B19, vasa previa) — pseudosinusoidal from opioids is transient. Sinusoidal is always Category III and mandates delivery or intrauterine transfusion depending on gestational age and stability.
— Reactive: ≥2 accelerations of ≥15 bpm × ≥15 sec in 20 min (≥10×10 if <32 wk) — reassuring
— Nonreactive → vibroacoustic stimulation, extend to 40 min, then proceed to BPP
— False-positive rate is high (fetal sleep cycles, prematurity, maternal sedatives)
— Components: NST, fetal breathing, gross body movement, tone, amniotic fluid volume (single deepest pocket ≥2 cm)
— 8–10: reassuring
— 6: equivocal — repeat in 24 hr or deliver if term
— ≤4: deliver
— Oligohydramnios alone (regardless of score) → deliver if ≥36–37 wk
— Negative (no late decels) = reassuring
— Positive (late decels with ≥50% contractions) = uteroplacental insufficiency, deliver
— Contraindicated in placenta previa, prior classical cesarean, preterm labor risk
— Elevated S/D ratio → placental insufficiency
— Absent or reversed end-diastolic flow → critical, deliver (timing depends on GA, typically 30–34 wk for AEDF, immediately for REDF)
Board pearl: In a Step 3 stem of decreased fetal movement at 38 weeks, the correct first step is NST, not immediate delivery. Escalate to BPP only if NST is nonreactive. Jumping to cesarean without surveillance data is a common distractor.
— Acceleration in response = pH likely ≥7.20, reassuring
— No acceleration = consider further evaluation or delivery
— Sum of peak amplitudes above baseline over 10 min
— Adequate labor = ≥200 MVUs; useful when arrest of dilation suspected and external toco unreliable
— Place when external monitoring inadequate, induction with poor progress, or VBAC monitoring
— Indications: poor external signal, need for precise variability assessment, twin discrimination
— Contraindications: HIV, hepatitis B/C with high viral load, suspected fetal thrombocytopenia, face/breech presentation, active genital HSV
— Confirm presentation, placental location, amniotic fluid, signs of abruption
— Fever → CBC, blood cultures, urinalysis (chorioamnionitis workup)
— Bleeding → CBC, type and crossmatch, fibrinogen, DIC panel (abruption)
— Suspected fetal anemia → MCA Doppler, Kleihauer-Betke, maternal antibody screen
CCS pearl: When a Category III tracing develops and the cervix is fully dilated with the head at +2 station, the CCS-correct sequence is: call for help, intrauterine resuscitation, prepare for operative vaginal delivery (vacuum/forceps) rather than cesarean — fastest route to delivery wins.
— Identify and treat reversible causes
— Bundle of intrauterine resuscitation maneuvers ("LIONS")
– Left lateral (or right) maternal positioning — relieves IVC compression and cord pressure
– IV fluid bolus (500–1000 mL LR) — corrects maternal hypotension
– O₂ 10 L/min via non-rebreather — controversial; ACOG now recommends against routine use unless maternal hypoxia documented (recent data show no fetal benefit, possible harm)
– Notify provider, stop oxytocin
– Sterile vaginal exam — rule out cord prolapse, assess dilation/station
— Treat tachysystole: discontinue oxytocin; if persistent, terbutaline 0.25 mg SQ
— Treat hypotension after epidural: bolus + phenylephrine (preferred) or ephedrine
— Persistent absent variability with recurrent late or variable decels
— Recurrent bradycardia
— Sinusoidal pattern
— Mobilize OR, anesthesia, neonatology
— Position change → vaginal exam (rule out cord prolapse → if found, elevate presenting part, knee-chest, prep for emergent cesarean) → stop oxytocin → IV fluids → terbutaline if tachysystole → if no recovery in 3–5 min and not imminently deliverable vaginally, emergent cesarean
Step 3 management: Memorize the intrauterine resuscitation bundle as a reflex — Step 3 stems frequently ask "next best step" for a Category II tracing, and the answer is rarely "cesarean." It's the bundle first; cesarean is reserved for failed resuscitation or true Category III.
— Tachysystole → late or prolonged decels → discontinue, restart at half the rate once recovered
— Start 1–2 mU/min, increase by 1–2 mU/min q15–30 min, max ~20–40 mU/min
— Antidiuretic effect at high doses → water intoxication, hyponatremia (use isotonic fluids)
— 0.25 mg SQ for tachysystole-related fetal distress
— Side effects: maternal tachycardia, pulmonary edema (avoid >48 hr cumulative use; black box warning)
— Contraindicated in maternal cardiac disease, poorly controlled DM, hyperthyroidism
— Causes decreased FHR variability without indicating acidemia — do not over-react
— Decreased variability, decreased accelerations, transient pseudosinusoidal pattern
— Naloxone in newborn if respiratory depression (avoid in chronic opioid use → withdrawal)
— Maternal hypotension → uteroplacental hypoperfusion → prolonged deceleration
— Pre-load with 500–1000 mL crystalloid; treat hypotension with phenylephrine 50–100 mcg IV bolus
— May transiently decrease variability and fetal movement for 24–72 hr — anticipate, do not deliver for this alone
Board pearl: Magnesium-induced decreased variability in a preeclamptic patient is not an indication for delivery. The question tests recognition that the medication, not hypoxia, is the cause.
— Prerequisites: full dilation, ruptured membranes, known position, empty bladder, adequate anesthesia, experienced operator, consent, willingness to abandon
— Vacuum contraindicated <34 wk, suspected fetal coagulopathy, prior scalp sampling
— Complications: cephalohematoma, subgaleal hemorrhage, shoulder dystocia, maternal lacerations
— Abandon after 3 pop-offs, 20 min total, or no descent with 3 pulls
— Decision-to-incision goal <30 min; <10 min for true crash
— Anesthesia: spinal if time permits; general anesthesia for true emergencies
— Vertical skin incision and classical uterine incision rarely needed (very preterm, transverse lie, anterior placenta previa with bleeding)
— Diagnose by palpation of pulsating cord at cervix
— Elevate presenting part manually, place patient in knee-chest or Trendelenburg, fill bladder with 500–700 mL saline, terbutaline for tocolysis, do not replace cord, emergent cesarean
— Continue manual elevation until uterus incised
— Warmed saline via IUPC, 250–500 mL bolus then 60–180 mL/hr
— Also reduces meconium aspiration in some studies (controversial)
— Help, Episiotomy consider, Legs (McRoberts), suprapubic Pressure, Enter (Rubin, Woods screw), Remove posterior arm, Roll to all fours
CCS pearl: Order "prepare for emergent cesarean" simultaneously with resuscitation maneuvers — don't sequence them. CCS rewards parallel orders. Also order: type & screen, anesthesia consult, NICU to bedside, foley catheter, antibiotic prophylaxis.
— External monitoring frequently inadequate → low threshold for FSE/IUPC
— Higher rates of failed induction, cesarean, anesthesia complications
— Increased risk of macrosomia, shoulder dystocia, fetal acidemia
— Antepartum testing weekly starting 32 wk (A2GDM, pregestational); twice weekly NST + AFI common
— Tight intrapartum glycemic control (80–110 mg/dL) — hyperglycemia → fetal hyperinsulinemia → neonatal hypoglycemia
— Uteroplacental insufficiency → late decels, IUGR
— Magnesium reduces variability — interpret cautiously
— Antihypertensive (labetalol, hydralazine, nifedipine) hypotension → prolonged decel
— Avoid Valsalva in pulmonary HTN, severe AS — operative vaginal delivery preferred at second stage
— Continuous EFM and maternal telemetry
— Magnesium dosed cautiously (renally cleared) — risk of toxicity → respiratory depression → fetal effects
— Frequent monitoring, may require more dialysis sessions
— Increased stillbirth risk → delivery at 36–37 wk; antepartum testing twice weekly though predictive value limited
— Hyperthyroidism → fetal tachycardia; Graves antibodies cross placenta
— Hypothyroidism, well-controlled → routine monitoring
Key distinction: Magnesium toxicity vs fetal hypoxia in a preeclamptic on Mg with decreased variability — check maternal reflexes, respiratory rate, Mg level. Areflexia or RR <12 → stop magnesium, give calcium gluconate 1 g IV. Don't deliver for tracing changes that are pharmacologic.
— Baseline tends higher (toward 160); accelerations defined as ≥10 bpm × ≥10 sec
— Decreased variability is normal at very early gestations
— Antenatal steroids (betamethasone) → transient decreased variability and movement 24–72 hr — anticipate
— Magnesium for neuroprotection <32 wk → also blunts variability
— Consider gestational age in delivery decision; viability and resuscitation discussions essential <25 wk
— Delivery indications must outweigh neonatal morbidity (RDS, TTN, hypoglycemia, feeding issues)
— Antenatal steroids in late preterm (34 0/7 – 36 6/7) if delivery anticipated within 7 days and not previously given
— Increased stillbirth, meconium, macrosomia, oligohydramnios
— Antepartum testing twice weekly from 41 wk; induce by 42 0/7 (many now induce at 39 wk per ARRIVE for low-risk nulliparas)
— Continuous EFM both fetuses required in labor; ideally one external + one FSE on presenting twin
— Antepartum testing weekly from 32 wk (dichorionic), earlier for monochorionic (28 wk) due to TTTS, sIUGR risk
— Monoamniotic twins: hospitalized monitoring from 24–28 wk, deliver 32–34 wk by cesarean
— Umbilical artery Doppler is primary surveillance tool
— Deliver at 37 wk for isolated IUGR; 34 wk for absent end-diastolic flow; 30 wk (or earlier with steroids) for reversed end-diastolic flow
Board pearl: In monochorionic-diamniotic twins, fetal surveillance starts at 16 wk with q2-wk ultrasound for TTTS screening — well before NST/BPP testing begins. This timing distinguishes mono- from di-di on tests.
— Defined by neonatal encephalopathy + cord pH <7.0, base deficit ≥12, Apgar ≤5 at 5 and 10 min, multi-organ dysfunction
— Cerebral palsy attributable to intrapartum events accounts for only ~10% of CP cases
— Therapeutic hypothermia (33.5°C × 72 hr) for moderate-severe HIE in neonates ≥36 wk, initiated within 6 hr of birth
— Meconium-stained fluid → universal precautions; routine intubation of vigorous infants NOT recommended; tracheal suction only if non-vigorous and obstruction suspected
— Brachial plexus injury (Erb's palsy, Klumpke), clavicle/humerus fracture, hypoxia
— Maternal: postpartum hemorrhage, 3rd/4th degree lacerations, symphyseal separation
— Neonatal: cephalohematoma, subgaleal hemorrhage (life-threatening blood loss into potential space), retinal hemorrhage, facial nerve injury (forceps)
— Maternal: extensive lacerations, anal sphincter injury, urinary retention
— Hemorrhage, infection, VTE, bladder/bowel injury, future placenta accreta, scar dehiscence
Step 3 management: When HIE is suspected, the next step is therapeutic hypothermia within 6 hours — neuroprotective and decreases death/disability. Step 3 will test recognition of the time-sensitive 6-hour window and the criteria (GA ≥36 wk, encephalopathy, acidosis).
— Category III tracing not corrected within minutes
— Suspected cord prolapse, placental abruption, uterine rupture
— Maternal cardiac arrest, severe hemorrhage, eclamptic seizure
— Shoulder dystocia
— Senior obstetrician, anesthesiologist, neonatology/NICU team, OR nursing, blood bank notified
— Use closed-loop communication and SBAR handoffs — patient safety standard
— Level I (basic) → Level III/IV (subspecialty/regional) for: previable PPROM, severe preeclampsia <34 wk, suspected placenta accreta spectrum, complex cardiac disease, fetal anomalies requiring immediate neonatal surgery
— Maternal transfer preferred over neonatal transfer when feasible
— Persistent nonreassuring antepartum testing in a previable or near-term fetus when delivery not yet indicated
— Severe preeclampsia, suspected abruption with stable maternal/fetal status, monoamniotic twins
— Stable IUGR with normal Dopplers — twice-weekly testing, growth scans q2–3 wk
— Gestational diabetes A1 — weekly NST from 32 wk
— Periviable delivery (22–25 wk) counseling
— Maternal refusal of cesarean for nonreassuring tracing — see ethics chunk
CCS pearl: In CCS, after stabilizing a Category III tracing, "transfer to L&D" or "transfer to operating room" are valid orders that advance the case clock — use them. Don't forget continuous fetal monitoring during transport and anesthesia consult as concurrent orders.
— Pathophysiology: chemoreceptor-mediated response to fetal hypoxemia during contraction-induced reduction in placental blood flow
— Oligohydramnios, nuchal cord, true knot, cord prolapse
— Amnioinfusion may help; severe/recurrent → operative delivery
— Risk factors: hypertension, cocaine, trauma, prior abruption, smoking
— Management: stabilize, deliver (route depends on status); watch for DIC
— TOLAC is highest risk (~0.5–1% with prior low transverse); much higher with classical incision
— Emergent laparotomy
— Diagnosed antenatally by transvaginal Doppler; deliver by scheduled cesarean at 34–35 wk
— Treat with broad-spectrum antibiotics (ampicillin + gentamicin ± clindamycin), proceed with delivery
Key distinction: Vasa previa vs abruption when bleeding occurs at ROM — vasa previa bleeding is fetal (small volume, rapid fetal compromise, sinusoidal/bradycardic tracing); abruption is maternal (variable volume, painful, board-like uterus). Apt test on fluid can differentiate but is rarely needed in emergencies.
— Asthma exacerbation, pneumonia, pulmonary embolism, amniotic fluid embolism, eclampsia
— Treatment: maternal oxygenation, treat underlying — improves fetal status
— Fetal tachycardia, decreased variability mirror maternal physiology
— MVC, IPV, falls — monitor ≥4 hr; if uterine activity, bleeding, abnormal tracing, or ROM → 24 hr
— Kleihauer-Betke to detect fetomaternal hemorrhage in Rh-negative patients → dose RhIg accordingly
— High-quality CPR, left uterine displacement, perimortem cesarean within 4 minutes if no ROSC and fetus ≥23 wk
— Fetal arrhythmia: SVT (sustained >180), heart block (sustained <110 with normal variability) — fetal echo, possible transplacental antiarrhythmics (digoxin, flecainide)
— Fetal anemia: parvovirus B19, alloimmunization, fetomaternal hemorrhage → sinusoidal tracing, MCA Doppler peak systolic velocity >1.5 MoM → IUT
— Congenital anomalies / chromosomal: persistently abnormal tracings without explanation
— Fetal infection (CMV, toxoplasmosis): nonimmune hydrops, abnormal BPP
Board pearl: Maternal DKA: never deliver a fetus during active DKA unless absolutely necessary — fetal acidemia and tracing abnormalities resolve as maternal acidosis corrects. Delivery in DKA carries high maternal/fetal mortality.
— Cord blood gases (arterial and venous) for any Category II/III tracing, operative delivery, or low Apgars — medicolegal documentation and clinical correlation
— Placental pathology for IUGR, abruption, suspected infection, unexplained Category III, stillbirth
— Pediatric/neonatology evaluation; therapeutic hypothermia if criteria met
— Standard postpartum care, VTE prophylaxis after cesarean
— Iron supplementation if anemia from blood loss
— Pelvic floor evaluation after operative vaginal delivery, especially with 3rd/4th degree laceration
— After cesarean: discuss TOLAC vs ERCS at next pregnancy — success rate ~70% for VBAC; rupture risk ~0.5–1% with prior low transverse; absolute contraindications include prior classical cesarean, prior uterine rupture, T or J incision
— After abruption: 5–15% recurrence; aspirin 81 mg from 12 wk to reduce preeclampsia/IUGR risk if also at risk
— After preeclampsia: low-dose aspirin from 12–28 wk in next pregnancy
— After unexplained stillbirth: antepartum testing starting at 32 wk (or 1–2 wk earlier than gestation of prior loss)
— Formal debrief after emergency deliveries — supports team learning and patient processing
— Trauma-informed postpartum follow-up; screen for PTSD and postpartum depression at 2-, 4-, 6-wk visits
— Save tracing strips; document interpretations, interventions, and timestamps contemporaneously — primary defense in litigation
Step 3 management: Postpartum visit at 2–3 wk (initial) and comprehensive at 6 wk per ACOG. Reframe postpartum as a continuum, not a single visit — screen depression (EPDS), contraception, BP if hypertensive disorder, glucose tolerance test 4–12 wk postpartum if GDM.
— GDM A1: weekly NST + AFI from 32 wk
— GDM A2 / pregestational DM: twice-weekly NST/BPP from 32 wk
— Chronic HTN / preeclampsia: weekly to twice-weekly from 32 wk (earlier if severe)
— IUGR: weekly umbilical artery Doppler + growth scan q2–3 wk
— Post-term (≥41 wk): twice-weekly NST + AFI
— Prior stillbirth: weekly from 32 wk or 1–2 wk before prior loss
— Cholestasis of pregnancy: twice weekly though limited predictive value
— Decreased fetal movement: NST first, escalate as needed
— Uncomplicated term: 39–41 wk (induction at 39 wk reasonable per ARRIVE)
— GDM A1: 39–40 6/7
— GDM A2 well-controlled: 39 0/7 – 39 6/7
— Chronic HTN no meds: 38 0/7 – 39 6/7
— Preeclampsia without severe features: 37 0/7
— Preeclampsia with severe features: 34 0/7
— IUGR isolated: 36 0/7 – 37 6/7
— IUGR with abnormal Doppler (AEDF): 34 0/7
— Cholestasis: 36 0/7 – 37 0/7
— Monoamniotic twins: 32 0/7 – 34 0/7 by cesarean
— Vasa previa, placenta previa: 34–37 wk
— Kick counts after 28 wk: 10 movements in 2 hr; call if not met
— Signs to call: bleeding, leaking fluid, persistent abdominal pain, severe headache, vision changes, decreased movement
— Reinforce continuous EFM trade-offs (sensitivity vs cesarean rate) when informed consent obtained at admission
CCS pearl: On CCS, when managing a post-dates patient, set the advance clock to schedule the NST/BPP, then advance to the appointment — don't sit at admission. Use "counsel patient" orders for kick counts, fetal movement, and induction options.
— Patients should be told that continuous EFM increases cesarean and operative delivery rates without reducing CP — but is standard for high-risk labor
— Intermittent auscultation is an alternative for low-risk patients (q15 min in first stage, q5 min in second)
— Capacitated adult pregnant patients have the right to refuse any procedure, including cesarean, even when fetal life is at stake
— Court-ordered cesareans are unethical and not legally enforceable in most US jurisdictions
— Response: thorough counseling, multidisciplinary discussion, ethics consult, document refusal with risks/benefits/alternatives reviewed
— Do not coerce; respect autonomy; continue best supportive care
— FHR tracings are #1 source of OB malpractice litigation
— Document tracing category, interventions, response, communication, and rationale in real time
— Use NICHD terminology, not subjective terms ("worrisome," "ominous")
— Closed-loop communication and SBAR handoffs reduce errors
— Shift handoffs at the bedside with tracing review reduce missed deterioration
— Antepartum → L&D admission: confirm prior testing, blood type, GBS status, allergies
— L&D → postpartum: communicate intrapartum events, EBL, labs pending
— Suspected IPV during pregnancy → screen (HITS, AAS), document, offer resources; reporting depends on state law and patient safety
— Substance use in pregnancy → state laws vary; many require neonatal toxicology reporting, some criminalize maternal use (controversial); always offer treatment, not punishment
— Must be available at facility with immediate cesarean capability
Board pearl: A laboring patient with capacity refusing cesarean for a Category III tracing — the correct answer is respect her autonomy, continue supportive measures, and document; never "obtain a court order" or "proceed against her wishes." This is a frequent ethics question.
Step 3 management: When choosing between answers, moderate variability in any tracing is a powerful "this fetus is not acidemic right now" signal — even with decelerations, moderate variability favors expectant management.
— Answer: Intrauterine resuscitation — reposition, stop/reduce oxytocin, IV fluids, vaginal exam. Not immediate cesarean (moderate variability reassuring; reversible cause likely).
— Answer: Manual elevation of presenting part, knee-chest position, emergent cesarean — classic cord prolapse.
— Answer: Emergent laparotomy — uterine rupture.
— Answer: Continue current management — magnesium causes decreased variability; not hypoxia.
— Answer: NST (not immediate delivery or BPP first).
— Answer: Vasa previa with fetal hemorrhage → emergent cesarean.
— Answer: Delivery now (or 30 wk with steroids if earlier GA).
— Answer: Therapeutic hypothermia within 6 hours.
— Answer: Respect autonomy, document, continue supportive measures — not court order.
Key distinction: Step 3 stems test the next single step, not the comprehensive plan. Pick the most immediate, reversible action first (bundle), then escalate if that fails.
Fetal heart rate monitoring is interpreted with the NICHD three-tier system — moderate variability is the strongest single predictor that a fetus is not acidemic, Category II tracings warrant structured intrauterine resuscitation, and Category III tracings demand immediate correction or delivery within 30 minutes.
Board pearl: When in doubt on any FHR question — look for variability. Moderate variability favors expectant management with intrauterine resuscitation; absent variability with recurrent decelerations or persistent bradycardia favors delivery. That single decision rule answers a majority of Step 3 fetal monitoring stems.