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OB·CA-3 / Fellow

OB: Emergent C-Section

Primigravida at 36 weeks with pre-eclampsia and heavy bleeding. Navigate the difficult OB airway and fetal distress logic.

The stem

A 22 y.o. primigravida presents at 36 weeks with 170/100 BP and proteinuria. Now admitted with heavy vaginal bleeding and FHR late decelerations. PMH: Allergic to penicillin. PHYS: BP 105/85 (falling); P 111. Mallampati 4 airway.

Focus

Hemorrhage management, HELLP syndrome vs pre-eclampsia, and the difficult OB airway.

Examination relevance

Defending your choice between neuraxial and General Anesthesia (GA) in a fetal distress scenario with low platelets. OB scenarios appear in nearly 50% of cycles.

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Expert sample response

This is a life-threatening scenario for both mother and fetus. My priority is rapid delivery while maintaining maternal hemodynamics. Given the 105/85 blood pressure and fetal distress, I will not attempt a neuraxial technique which could fail or cause further hypotension.

I will proceed with a Rapid Sequence Induction. I'll utilize a small-diameter ETT (6.0 or 6.5) due to the physiological edema of pregnancy and her Mallampati 4 status, with a video laryngoscope (VL) as my first line. I will use etomidate or a lower dose of propofol with succinylcholine to minimize fetal depression. If intubation fails, I will immediately move to a supraglottic airway or surgical airway to maintain oxygenation, as 'failed intubation, failed ventilation' in OB is a leading cause of maternal mortality.

Full walkthrough

What the Examiner Is Testing

This case tests your ability to choose between neuraxial and GA in a deteriorating obstetric emergency — and then defend that choice. The examiners specifically want to see whether you understand that a Mallampati 4 airway combined with hemodynamic instability changes your calculus completely.

The Board Trap

The trap is defaulting to a spinal because "that's what we do for C-sections." A falling BP, fetal distress, and a Mallampati 4 airway all point to GA with a careful RSI. A spinal in a hypotensive patient will drop her BP further. You also cannot manage a failed spinal in a patient who is actively deteriorating.

Walk-Through: How This Case Plays Out

Examiner: The patient's BP is now 105/85 and falling. FHR shows late decelerations. How do you proceed?

Me: I would not attempt neuraxial anesthesia. Her hemodynamics are already compromised — a spinal will cause further sympathectomy and could kill her or the baby. My plan is a rapid sequence induction with a video laryngoscope as first line. She's a Mallampati 4 and pregnant, so the airway is edematous — I'm using a 6.0 or 6.5 ETT and I have a smaller tube on the field just in case.

Examiner: She has a penicillin allergy. What's your preoperative plan?

Me: I'd use clindamycin for prophylaxis — standard substitution for penicillin-allergic OB patients. Sodium citrate orally for aspiration prophylaxis, ondansetron for nausea. I also want to confirm whether this is a true anaphylactic allergy or just a GI intolerance, but in an emergency I treat it as real and use the alternative.

Examiner: You attempt RSI. The GlideScope shows a grade III view and you cannot pass the tube. What now?

Me: I would call it a failed intubation immediately — no more than two attempts before escalating. My next step is a supraglottic airway, a second-generation LMA like the LMA Supreme. If I can ventilate with the LMA, I have two choices: wake her up and go regional, or proceed with surgery through the LMA for a true emergency. If I cannot ventilate — CICO — I'm going to the neck. This is exactly why I had a surgical airway kit on the field before I started.

Examiner: Baby is out and stable. The patient starts bleeding heavily. What's your management?

Me: I would call for the massive transfusion protocol and get OB on board for uterotonic therapy — oxytocin first, then methylergonovine, then carboprost if needed. I'd watch for PPH becoming hemorrhagic shock. Two large-bore IVs, level-1 running, blood products arriving in a 1:1:1 ratio. I'd check a TEG to guide targeted resuscitation.

Key Phrases That Score Points

  • "A spinal in a hemodynamically unstable patient will make her worse — I'm going to GA."
  • "Video laryngoscope is my first-line device — this is a Mallampati 4 airway in a pregnant patient, I'm not gambling."
  • "Failed intubation after two attempts — I'm escalating immediately, not trying again with the same blade."
  • "If I can ventilate with the LMA, I have a decision to make about proceeding versus waking her up."
  • "CICO in OB is a leading cause of maternal mortality — I have a surgical airway kit open before I start."

Why This Case Appears on the Boards

OB scenarios appear in nearly 50% of examination cycles. This case specifically tests the intersection of airway crisis and hemodynamic instability — two problems that pull in opposite directions — and forces you to commit to a plan and defend it under pressure.