A 34-year-old woman G3P2 arrives to the ED in active labor.  Her bag of waters broke in the car ride here, and as you get her into the gurney she is crowning.  You have an assistant call Obstetrics and have another retrieve the infant warmer and neonatal resuscitation cart.

The mother begins to push and the child’s head is delivered, then it retracts back, his cheeks pressed against the vulva.

Which is the next BEST step to take in the delivery?

    A.  Push the baby’s head back into the birth canal gently, hold there, and transport  to the OR for emergency Caesarean section
    B.  Manipulate the mother’s hips to perform an anterior pelvic tilt
    C.  Have the mother on all fours and then push with contractions
    D.  Coach the mother to continue to push in short, coordinated efforts as she feels the contraction, counting up to 10


In the meantime, a quote –

“Good judgement comes from experience; experience comes from bad judgement.”

– C Lillehei, MD

The 14-year-old girl G1P0 at “three months” gestation you saw last week with complaints of nausea, vomiting, and vague abdominal pain returns today with more of the same symptoms.  Last week you diagnosed her with GERD and possible UTI and sent her to her OB/GYN for a recheck.  She has still been able to eat small meals, but the abdominal discomfort is unrelenting.
 After reading up on appendicitis in pregnancy from last week’s encounter, you realize that one of the following is TRUE:


  A. Acute appendicitis is rare in the pregnant patient, due to the dilating effects of progesterone
  B. Imaging rarely shows a definitive finding, since ultrasound is technically impossible and CT is contraindicated in pregnancy
  C. First choice of imaging modality is MRI with contrast
  D. Pregnant patients with appendicitis have a high perforation rate

To cap off the old academic year, a question of the week in two installments ---   A 14 year-old girl G1P0 at “three months” gestation complains of nausea, vomiting, and vague abdominal pain today.  She has no past medical history and some (incomplete) prenatal care.  Her vital signs are T 99.9F HR 98 100/60 RR 22 98% RA.  Her exam shows a euvolemic pregnant young woman in mild distress due to her nausea, with mild tenderness to palpation throughout her abdomen without rebound or guarding.  Regarding her differential diagnosis, which would be the most common cause of an acute abdomen in this patient?

  A. Small bowl obstruction
  B. Acute cholecystitis
  C. Acute appendicitis
  D. Rupture of corpus luteum cyst

In the meantime, a quote -   "The unlucky doctor treats the head of a disease; the lucky doctor its tail."   -Old Chinese Proverb