The aim of antenatal fetal surveillance is to identify fetuses that are at risk of suffering intrauterine hypoxia with resultant damage including death. In addition, it is essential to identify fetuses who are already compromised prior to the onset of labour. Every pregnancy should be considered ‘high-risk’ until proven otherwise because current strategies to accurately identify fetuses at an increased risk of intrapartum hypoxic injuries using antenatal ‘risk assessment’ tools are suboptimal. The goal of antepartum fetal heart rate monitoring using a cardiotocograph (CTG) is, therefore, to prevent fetal death and to avoid unnecessary interventions by timely diagnosis of fetuses displaying features of antepartum compromise on the CTG while avoiding overreaction to CTG features that may denote normal fetal behavioural states such as reduced baseline FHR variability in ‘cycling’. Recently, the antenatal ‘CAUTION’ checklist has been proposed to detect both hypoxic and non-hypoxic causes of fetal compromise. This tool incorporates myometrial irritability, which is observed in intra-amniotic infection and concealed abruption.

Prolonged deceleration refers to an abrupt drop in the fetal heart rate (>30 bpm) which persists for longer than 3 minutes but less than 10 minutes due an acute, profound, and sustained interruption of fetal oxygenation. If it persists for more than 10 minutes, it is called a terminal fetal bradycardia. The onset of a prolonged deceleration requires a rapid assessment and timely interventions as this may be indicative of an underlying obstetric emergency. Conversely, overreaction to prolonged decelerations secondary to reversible causes may lead to unnecessary operative interventions. A deeper understanding of the fetal physiological responses to an acute and profound hypoxic stress and a rigorous clinical assessment to determine the underlying aetiology to optimize fetal maternal and fetal well-being is essential. Coexisting risk factors (e.g. fetal growth restriction, chorioamnionitis) may hasten the risk of fetal neurological injury and/or perinatal death. Therefore, one should not blindly use arbitrary time limits to manage all cases of prolonged decelerations and should carefully scrutinize the features on the CTG trace that indicate the need for an urgent intervention.

Risk refers to the likelihood (or probability) of an adverse event or harm, and risk management has been defined by the Australia/New Zealand standard as the culture, processes and structures that are directed towards realizing potential opportunities while managing adverse effects. The principles of risk management include risk identification, risk analysis, risk control and appropriate funding and resources to ensure corrective and preventive actions are developed and implemented to prevent future harm. NHS Resolution has reported that 49% of total clinical negligence cost of harm (£5.1 billion) in 2023/24 relates to maternity, which is approximately £2.5 billion per year or £6.84 million daily. It is essential to focus on prevention of avoidable harm while implementing risk management strategies to avoid poor outcomes. The main ‘root cause’ that could be identified in many of the cases of poor outcomes due to CTG misinterpretation is the use of illogical CTG guidelines which arbitrarily group different CTG categories, and then randomly combine them with unscientific time limits to arrive at an overall classification of CTG traces into ‘normal, suspicious, pathological’.

Cardiotocograph interpretation based on pattern recognition has a poor positive predictive value for intrapartum hypoxia and a high false-positive rate. Only about 40–60% of fetuses with a CTG classified as abnormal by NICE guidelines have confirmed metabolic acidaemia on cord gases after birth. The rates of perinatal deaths, hypoxic encephalopathy and cerebral palsy have remained stable, whereas the rate of operative deliveries among fetuses monitored using CTG has been continuously increasing. There were over 25 different clinical guidelines, each employing different classification systems and indications for continuous electronic fetal heart rate (FHR) monitoring until the mid-1980s. Therefore, the older clinical trials did not use standardized criteria for continuous electronic FHR monitoring. A more individualized care by prelabour risk assesment and a physiological approach may be beneficial in terms of maternal and fetal outcome

Emergency medicine (EM) isn’t just a specialty. It’s a mindset. It’s about how you see problems, how you work through uncertainty, and how you speak when the room is loud and everyone’s looking to you. That mindset shift – from student to emergency physician – is what this book is about. The emergency department (ED) is a crucible, where time is compressed, information is incomplete, and the stakes are high. Patients don’t come in with tidy problems or clear narratives. They come in crashing, confused, or terrified. In those moments, just as critical as your clinical knowledge is your ability to think and speak like an emergency physician: quickly, clearly, and effectively.

Fetuses, unlike adults, are not exposed to atmospheric oxygen. When confronted with hypoxia, adults can increase their rate and depth of respiration to enhance the intake of oxygen so as to maintain positive energy balance and protect their myocardium. In contrast, a fetus when exposed to hypoxia cannot increase its oxygen supply, and therefore, it will decrease the heart rate in order to reduce the myocardial workload to maintain a positive energy balance by reducing the myocardial oxygen demand. This reflex response to decrease the heart rate to protect the myocardium against hypoxic or mechanical stress is heard as a deceleration during fetal heart rate (FHR) monitoring, and should be considered a normal cardioprotective reflex response, similar to increasing rate and depths of respiration seen in adults as they undertake hypoxic excercises. They should not be classifed as ‘typical, atypical, uncomplicated, complicated, non-reassuring or reassuring’ purely based on their observed morphology. The intervening baseline FHR should be scrutinized to determine the oxygenation of fetal central organs.

Meconium-staining of amniotic fluid (MSAF) is a physiological finding in many pregnancies, particularly postdates; however, its presence can have detrimental effects on the fetus. Chorioamnionitis is often associated with MSAF. If signs of infection are present with meconium-stained amniotic fluid, hypoxic stress should be reduced or even avoided to reduce the risk of hypoxic-induced encephalopathy. Meconium Aspiration Syndrome is a known complication that can potentially be very severe and lead to respiratory failure in the newborn. The risk of this can be reduced if labour is managed appropriately by avoiding extensive periods of hypoxic stress, such as prolonged periods of pushing or injudicious use of oxytocin infusion. The thickness of meconium should not be classified into significant or non-significant, as possible damage to a fetus can occur with the same amount of meconium regardless of the dilution in different amounts of amniotic fluid. Continuous electronic fetal heart monitoring should be recommended in the presence of meconium, and should be interpreted based on the application of fetal pathophysiology and wider clinical context, including progress of labour.

This clinical vignette describes a young girl who presents with polyuria, polydipsia, fatigue, weight loss, and vomiting. Her physical exam shows signs of dehydration and Kussmaul respirations, while labs confirm hyperglycemia, high anion gap metabolic acidosis, and ketonemia; classic for diabetic ketoacidosis (DKA). This case emphasizes early recognition of pediatric DKA, fluid and insulin management protocols, and the need for close monitoring to prevent complications like cerebral edema. Learners will walk through diagnosis, stabilization, and appropriate admission decisions, reinforcing a systematic approach to metabolic emergencies in pediatric patients.

This clinical vignette guides learners through the emotionally complex task of delivering bad news in the emergency department. After stabilizing a critically ill patient with a life-threatening variceal GI bleed, the physician must update the patient’s spouse with honesty, empathy, and professionalism. This case models how to initiate these conversations using the SPIKES framework and demonstrates the importance of setting, pacing, and word choice when conveying grave prognoses. Learners are introduced to the emotional “residue” left behind by such encounters and are encouraged to process it using Dr. Cline’s DR5 model for reflective practice. By observing and emulating this structured, compassionate approach, trainees develop the communication tools necessary to lead with clarity and kindness; skills that define maturity in emergency medicine and build trust in times of crisis.

In the emergency department, documentation is more than a record. It’s a lifeline that connects team members, supports continuity of care, and safeguards clinical decisions. This chapter equips learners with the tools to write clear, focused, and defensible notes that reflect sound clinical reasoning and facilitate efficient communication across interdisciplinary teams. Drawing from best practices in emergency medicine, readers will learn how to structure their notes to highlight pertinent findings, justify decision-making, and balance concise documentation with legal and billing needs. The chapter also outlines pitfalls in electronic health record use, such as fragmentation and overreliance on structured fields, and offers strategies to maintain clarity and context. From chief complaint to follow-up instructions, every section of the ED note is an opportunity to inform care, protect the provider, and tell a cohesive story. Writing with precision, intention, and confidence not only improves patient safety but enhances professional credibility and communication in a high-stakes environment.

Unusual fetal heart rate patterns such as typical sinusoidal, the Poole shark teeth (atypical sinusoidal), pseudosinusoidal, ZigZag and the porcupine pattern may cause confusion to clinicians, resulting in delay in timely and appropriate management. This is because most CTG guidelines based on ‘pattern recognition’ do not emphasize the significance of these patterns, and many stipulate arbitrary, unscientific time limits before these patterns are being considered ‘suspicious’ or ‘pathological’. Sinusoidal patterns often occur due to non-hypoxic pathways of fetal compromise, and therefore may not be associated with decelerations of the fetal heart rate. This may provide a false sense of security if CTG guidelines that classify the CTG traces into ‘normal, suspicious, pathological’ are used, leading to poor perinatal outcomes. Recent scientific evidence has shown that sinusoidal patterns and the ZigZag pattern may occur during the end stages of chorioamnionitis. Occurrence of the Poole shark teeth pattern in association with fresh vaginal bleeding or a ‘heavy show’ is an ominous sign suggestive of ongoing fetal hypovolaemia and hypotension.

This clinical vignette describes a young man presenting with unilateral blurry vision after being struck in the eye by yard debris. Learners are prompted to construct a focused ophthalmologic differential and workup strategy. The case emphasizes the utility of fluorescein staining and slit lamp examination to confirm a corneal abrasion and exclude more serious ocular injuries such as open globe or traumatic iritis. Management includes topical antibiotics to prevent infection from potential organic contamination and follow-up with ophthalmology. Learners also review the importance of proper eye protection and counseling for injury prevention.

This clinical vignette features a 23-year-old female college student presenting with a gradual-onset, left-sided, throbbing headache accompanied by photophobia, phonophobia, and nausea. With stable vitals and no focal neurologic deficits, her history and physical exam are consistent with a primary headache disorder, likely migraine. The case illustrates a methodical approach to ruling out serious secondary causes of headache, such as subarachnoid hemorrhage, meningitis, encephalitis, cerebral venous sinus thrombosis, and toxic exposures, through targeted history, neurological exam, and pregnancy testing. The absence of red flags allows for a clinical diagnosis of migraine and the initiation of evidence-based symptomatic therapy, including IV fluids, antiemetics, NSAIDs, and rescue therapy with droperidol. This case emphasizes the importance of differentiating benign from life-threatening etiologies in young adults and reinforces key diagnostic and therapeutic strategies in migraine management within the emergency department.

This case presents a clinical vignette of a 32-year-old woman with exertional chest pain and dyspnea. The learner is given an opportunity to formulate their own presentation and documentation before being shown a model of effective communication and note writing. The case highlights the importance of identifying pulmonary embolism in patients with risk factors such as recent travel and hormonal contraceptive use. It emphasizes the limitations of PERC in tachycardic patients, the utility of the Wells criteria for risk stratification, and appropriate use of D-dimer testing and CT pulmonary angiography. Learners are guided through the reasoning that led to diagnosis, evaluation of hemodynamic stability, and shared decision-making regarding outpatient anticoagulation. The case reinforces structured diagnostic thinking, documentation clarity, and patient-centered care in the ED.

Human fetuses, similar to adults, demonstrate a predictable response to a gradually evolving hypoxic stress due to a progressive increase in the frequency, duration, and strength of ongoing uterine contractions. Initial attempts to protect the myocardial workload to maintain the positive energy balance and preservation of aerobic metabolism within the myocardium is manifested by the onset of decelerations on the CTG trace. If the hypoxic stress progressively worsens, the fetus will release catecholamines to increase cardiac output and tissue perfusion, as well as to redistribute oxygenated blood from ‘non-essential’ organs by peripheral vasoconstriction to fetal central organs to ensure continuation of aerobic metabolism due to this ‘centralization’. Failure of these compensatory responses either due to poor fetal reserve, worsening intensity of hypoxia, or exhaustion of fetal reserves will lead to fetal decompensation and the onset of anaerobic metabolism within fetal central organs (i.e. brain, heart, and adrenal glands). These changes can be predicted by application of the knowledge of fetal physiological responses to a gradually evolving hypoxic stress.

This clinical vignette centers on the evaluation and management of a rattlesnake envenomation in an older adult. The learner is presented with an opportunity to develop a diagnostic and treatment plan, followed by an ideal presentation and note to compare their clinical reasoning. The case emphasizes early recognition of systemic toxicity, appropriate use of antivenom, and key decisions around pain management and surgical intervention. Special attention is given to distinguishing envenomation from mimics like cellulitis or allergic reactions and understanding when fasciotomy is not indicated. Learners are reminded that close monitoring—not reflexive intervention—is often the safest course. This case reinforces critical thinking around toxicology, emergency pharmacology, and the importance of targeted supportive care in resource-intensive settings.

Delivering bad news is one of the most emotionally challenging responsibilities in emergency medicine, yet it is a vital skill for any intern. This chapter provides a compassionate and structured approach to these difficult conversations using the SPIKES protocol: setting, perception, invitation, knowledge, empathy, and summary. Learners are guided through each step, from preparing the environment and assessing a patient’s understanding, to breaking complex information into clear, digestible language and managing emotional responses with empathy. Emphasis is placed on situational awareness, cultural sensitivity, and nonverbal communication. The chapter also addresses the importance of follow-up, summarizing the conversation, and offering emotional support through next steps. Reflection and debriefing after such conversations are encouraged to support physician wellness and resilience.