Chapter 26: Assessment of High-Risk Pregnancy

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Imagine trying to diagnose a patient that you can't see, you can't actually touch, and who is, you know, actively floating in a pool of fluid.

Which is basically the ultimate clinical challenge.

Right.

I mean, for most of medical history, fetal development was just this complete black box.

But today, we are doing a deep dive into Chapter 26 of your Maternity Nursing Text to see how we finally, like, break through that barrier.

Exactly.

We're getting into the assessment of high -risk pregnancy.

And our mission today is to translate this dense textbook material so you, the nursing student listening right now, can master your exams and, you know, walk onto the clinical floor with total confidence.

And that black box is, it's way more crowded than you might think.

I mean, out of the roughly 3 .6 million births in the U .S.

every year, a really significant portion fall into this high -risk category.

Wow, really.

So what does that actually mean clinically?

It basically means the life or health of the mother or the fetus is in jeopardy, like, due to a specific circumstance, either a pre -existing condition or something totally unique to the pregnancy itself.

Got it.

And managing these cases is incredibly complex.

You need this massive interprofessional team.

You're talking obstetricians, maternal fetal medicine specialists, pharmacists, social workers,

and crucially, nurses who are coordinating the entire effort.

So it's kind of like setting up a massive board of dominoes, right?

You'd like that.

Yeah.

Because a high -risk pregnancy isn't usually just one isolated problem.

Like, if one system gets compromised, say, the maternal blood pressure spikes, that's the first domino falling.

Right.

And it forces the whole health care team to reevaluate the entire board because you have to predict exactly where it's going to hit next.

Right.

So to predict those falling dominoes, we have to know exactly who is at risk before we even start running diagnostic tests.

Exactly.

And the clinical guidelines map these out into four main territories.

The first one is biophysical.

Okay, biophysical.

So that's the internal biology.

Yeah, anything originating physically within the pregnant patient or the fetus.

So we're looking at genetics, multiple gestations, nutritional status, and of course, existing medical disorders like poorly controlled diabetes or chronic hypertension.

Okay.

So that covers the internal stuff.

But obviously, biology doesn't happen in a vacuum.

There's the behavioral side, too.

Right.

Which brings us to the second category, the psychosocial factors.

These are maternal behaviors and adverse life events.

Like smoking, I assume.

Smoking is a classic example.

It constricts the blood vessels, which leads to a much higher risk of low birth weight and preterm rupture of membranes.

And then there are things you might not, you know, immediately classify as dangerous, like caffeine.

Wait, really?

I would never have guessed that a standard morning coffee would, like, trigger a clinical warning.

How much caffeine actually poses a risk?

So the clinical threshold is usually right around 200 milligrams a day.

Which is, what, like one cup?

Roughly one 12 -ounce cup of coffee, yeah.

If you go beyond that, the vasoconstrictive properties of caffeine can actually restrict the flow of oxygenated blood to the placenta.

Oh, wow.

Yeah.

And that puts the fetus at a documented risk for intrauterine growth restriction, or IUGR.

And this psychosocial category also encompasses alcohol, illicit drug use, and severe psychological distress.

Okay, so if biophysical is internal and psychosocial is behavioral, we still have to look at the broader environment, right?

The world the patient is navigating.

Exactly.

That's the sociodemographic category.

It looks at the surrounding social context.

So low income is a major one because it directly correlates with a lack of access to early prenatal care.

Right, which makes sense.

Parity is another, you know, the number of previous pregnancies.

And ethnicity plays a really sobering role here, too.

Yeah, the textbook mentions some pretty stark statistics there.

It does.

In the U .S., black women experience rates of preterm birth almost twice as high as other demographic groups.

And the text explicitly points out that this disparity is deeply tied to the chronic physiological stress of living as an ethnic minority within a context of structural racism.

Which is just devastating.

And then there's a fourth category.

Yeah, environmental hazards.

Things like radiation, heavy metals like lead or mercury, and workplace chemical exposures.

You know, looking at that sociodemographic list in the text, age really stands out as a massive red flag.

But the guidelines lump adolescents and mature women, those over 35, into the exact same risk category.

Yeah.

Which seems, I don't know, kind of counterintuitive.

Why put a 15 -year -old and a 40 -year -old in the exact same clinical bucket?

Are we actually looking out for the exact same complications?

No, we really aren't.

I mean, they share the overarching high risk label, but the clinical reasoning for why they are high risk is completely different.

Okay, break that down for me.

Sure.

So, for an adolescent, the body might simply not be finished growing yet.

Their pelvis might not be fully mature.

Oh, right.

Which leads to cephalopelvic disproportion.

Basically meaning the baby's head physically cannot safely navigate the birth canal.

They also face much higher risks for severe anemia and profound socioeconomic disruptions.

Which makes anatomical sense for a teenager, but a 38 -year -old doesn't have a growing pelvis.

No, absolutely not.

For the older demographic, the risks stem from cumulative physiological wear and tear.

Chronic diseases like hypertension and type 2 diabetes, they just become much more prevalent as we age.

Which complicates the vascular network the baby needs.

Exactly.

Plus, the eggs themselves are older, which significantly raises the statistical risk for chromosomal abnormalities.

So, you know, the dominoes fall in entirely different directions, but both age groups require really intense targeted surveillance.

Right.

So, okay, once we identify these high -risk patients, the next obvious step is monitoring.

We need a way to actually look inside that black box.

And in nursing, the golden rule of monitoring is to start with the absolute least invasive method.

You only escalate when medically necessary.

So the ground floor of fetal assessment is the daily fetal movement count, the DFMC.

In practice, you'll almost always hear it called kick counts.

Well, that's entirely non -invasive.

You're just, what, asking the mother to track the physical sensation of movement?

Yes, and it's surprisingly effective.

Robust fetal movement is a really strong reassuring indicator of an intact functioning central nervous system.

Okay.

But if movement suddenly decreases, it can be an early warning sign of hypoxemia.

Basically, the fetus isn't getting enough oxygen, so it actively conserves energy by just, you know, stopping all unnecessary movement.

So as a nurse, how are you actually instructing a patient to track this?

Do they just keep a vague running tally in their head all day?

No, you give them a highly specific protocol.

A really common one is setting aside 60 minutes a day, lying quietly, to concentrate solely on counting fetal movements.

Oh, like 60 minutes.

But here is the critical clinical alert you need to lock in.

If a patient reports zero fetal movement for 12 straight hours, yeah, that is universally recognized as a fetal alarm signal.

It demands an immediate in -person medical evaluation.

Which means we have to escalate to our next diagnostic tool, right?

The ultrasound.

Precisely.

Ultrasonography is basically the cornerstone of modern obstetrics.

We use high frequency sound waves that bounce off dense tissues to create an image.

And there are different types, right?

Like 2D, 3D?

Yeah, we use 2D for flat, standard anatomical measurements.

3D gives us depth and volume.

And 4D is, well, it's basically a 3D movie showing real -time physical movement.

And depending on how far along the pregnancy is, you have to use completely different anatomical approaches.

Like early on, you're using a transvaginal approach, but later you switch to abdominal.

It sounds to me like transvaginal is our macro lens for like extreme first trimester closeups, while the abdominal ultrasound is more like stepping back with a wide angle lens to capture the whole landscape once the baby's bigger.

That is exactly how it functions mechanically.

In the first trimester, the uterus is still tucked really deep down inside the bony pelvis.

So the transvaginal probe, which, remember, requires a protective sheath and lubrication, it bypasses the abdominal wall to get right up next to the embryo.

And crucially, you want the patient's bladder to be completely empty for this.

You don't want it physically blocking the view.

But for the wide angle abdominal shot later on, you actually want a full bladder, right?

It acts like a tripod.

It physically pushes the growing uterus up and out of the pelvic cavity, so the sound waves have a clear liquid window to travel through.

Spot on.

And once we have that window, we look for specific quantifiable markers.

Early on, we measure the crown rump length, or CRL.

Which is exactly what it sounds like.

Literally measuring from the top of the head to the bottom of the torso.

Because early embryonic growth is so uniform, this is the single most accurate method we have for dating a pregnancy and establishing a firm due date.

We're also checking the neutral translucency, the NT, between 10 and 14 weeks, right?

Yes.

Neutral translucency measures the collection of fluid at the nape of the fetal neck.

If that fluid pocket is thicker than 3mm, that's a major red flag.

It indicates a much higher risk for chromosomal abnormalities or severe congenital heart defects.

Got it.

Then, as the pregnancy progresses into the second and third trimesters, the diagnostic focus shifts heavily to the amniotic fluid itself.

It does.

Amniotic fluid volume is a massive indicator of ongoing fetal well -being.

Too little fluid is called oligohydromyos.

And how is that measured?

Clinically, it's defined as an amniotic fluid index, an AFI of less than 5cm total, or finding a single fluid pocket that's less than 2cm deep.

Okay.

And the opposite?

The opposite is polyhydromyos.

Too much fluid, meaning an AFI over 25cm.

We can also use Doppler blood flow analysis to track the actual speed of red blood cells moving through the umbilical and fetal middle cerebral arteries.

And what does that speed tell us?

If the flow is sluggish or worse moving backward, it tells us there is severe vascular resistance, which often points to profound growth restriction.

The text also mentions MRI.

But if ultrasound gives us all this vital fluid and blood flow data, why put a pregnant patient in an MRI tube?

Well, MRI gives unparalleled high -resolution images of deep soft tissue structures, like the complex folds of the fetal brain.

And it does it without exposing the baby to ionizing radiation like a CT scan would.

But there's a patch, I assume?

Yeah.

MRIs take 20 to 60 minutes.

If the fetus moves, the image blurs.

So it's strictly reserved for highly specific complex anatomical evaluations when an ultrasound just isn't clear enough to, say, make a surgical plan.

OK, so we have all these disparate data points floating around.

Fluid measurements, movement logs, Doppler speeds.

If you're a nurse on the night shift and the high -risk specialist on the day shift needs a quick objective summary of the baby's health, you can't just hand them an unorganized pile of raw ultrasound images.

Right.

Nobody wants that.

We need a way to standardize this into a unified clinical picture.

We do.

And it's called the biophysical profile, or BPP.

If you look at table 26 .2 in your textbook,

it lays out this highly structured dynamic assessment.

It pairs a detailed ultrasound with a fetal heart rate monitor called a non -stress test.

And it measures five distinct physiological variables.

Yep.

Five variables.

Fetal breathing movements, general fetal body movements, fetal tone, amniotic fluid volume, and the results of that non -stress test.

And how is it scored?

To keep the scoring perfectly objective across different providers, there is absolutely no nuance in the grading.

Each of those five variables gets a score of two if the finding is totally normal, or a zero if it's abnormal.

Wait, there are no ones.

Nope, no ones.

Just two or zero.

Which means a perfect healthy score is a ten.

Exactly.

A score of eight or ten is considered normal.

It tells us the fetus is highly unlikely to be suffering from chronic asphyxia.

Okay.

And if it's lower?

A score of six is equivocal.

It's suspicious enough that we will likely repeat the test the very next day.

But a score of four, or below, is a clinical emergency.

We strongly suspect the fetus is actively experiencing chronic asphyxia.

And depending on how far along the pregnancy is, the team will often need to deliver the baby immediately.

Okay.

Looking closely at these five variables, I have a physiology question for you.

Sure.

Lay it on me.

So fetal tone, movement, breathing, and the heart rate.

Those all tell us how the baby's central nervous system is functioning right this exact second.

Right.

Like if they have oxygen right now, they move and breathe.

Correct.

But why is amniotic fluid volume on this list?

How does the size of a fluid puddle tell us anything about oxygenation?

That is actually the mechanical genius of the BPP.

You are absolutely right that movement and heart rate are acute markers, they tell us about right now.

But amniotic fluid volume is our chronic marker.

Chronic meaning over time.

Yes.

It tells us the historical story of placental function over the last several weeks.

Because the fluid is mostly composed of fetal urine in the later stages of pregnancy, right?

Exactly.

If the placenta has been slowly, quietly failing over time, it gradually delivers less oxygen to the fetus.

And the fetus is smart,

it immediately shunts whatever precious oxygenated blood it has to the most vital organs,

the brain and the heart.

So it steals that blood away from non -vital organs, like the kidneys.

Yes.

Less blood to the kidneys means the kidneys produce less urine.

Ah.

Unless urine output over weeks means the amniotic fluid levels drop, resulting in oligohydromyos.

You got it.

So a low fluid score on the BPP tells you this isn't a sudden acute problem.

This baby has been struggling to survive for a while.

It is so vital that many clinics use a modified BPP.

What's a modified version?

It just strips away the breathing and movement and pairs the non -stress test directly with the amniotic fluid index.

It's much faster to perform, but it still gives you that really powerful combination of the acute and the chronic picture.

Wow.

Okay.

So ultrasounds and BPPs are incredible for observing structure and behavior, but they only let us look through the window, so to speak.

They don't tell us anything about the actual genetic code driving that behavior or the microscopic maturity of the organs.

To get that, we have to actually bypass the physical barriers and get to the cells themselves.

Which brings us to biochemical assessment.

Invasive testing.

Exactly.

And the most well -known is amniocentesis.

Using ultrasound guidance to avoid the fetus, a long needle is inserted through the maternal abdomen directly into the uterus to withdraw a sample of amniotic fluid.

And this is usually done after 15 weeks of gestation, right?

Right.

We wait until 15 weeks because the uterus needs to be large enough to be an abdominal organ and there needs to be enough fluid volume so that taking a sample doesn't compress the baby.

Makes sense.

We use amnio to look for chromosomal abnormalities, but later in the third trimester we use it to test for fetal lung maturity.

Okay.

When you say testing for lung maturity, we're not just looking at the lungs inflating on an ultrasound.

The textbook throws around a lot of alphabet soup here, LS ratio, PG.

What exactly are we looking for in that fluid sample?

We are looking for surfactants.

Surfactants are these soapy, lipid -based substances that coat the inside of the alveoli, the tiny air sacs in the lungs.

And without them?

Without surfactant, those air sacs would just stick together and collapse every time the baby exhales.

Oh, that's bad.

Very bad.

So the L and S in the LS ratio stand for lecithin and sphynchomyelin, which are two key surfactants.

By 35 weeks, the amount of lecithin spikes, giving us an LS ratio of two to one.

Which means what?

That two to one ratio strongly indicates the lungs are mature enough to breathe air outside the womb.

Got it.

And what about PG?

Phosphatidylglycerol.

It's just another crucial surfactant lipid.

If PG is present in the fluid, it's a virtually foolproof sign of lung maturity.

Though,

honestly, nowadays many labs just do a lamellar body count.

Lamellar bodies.

They are the actual cellular storage structures for surfactant.

If we count 50 ,000 or more per microliter, those lungs are good to go.

Okay, so amnio happens at 15 weeks.

But what if there's a severe genetic concern really on and the family just can't bear waiting almost four months for answers?

Then we do chorionic villus sampling, or CVS, between 10 and 13 weeks.

Instead of pulling fluid, we go in either through the cervix or the abdomen and take a tiny biopsy of solid tissue directly from the placenta.

Just a piece of the placenta itself.

Yeah, because the chorionic villon originate from the exact same fertilized egg as the fetus.

So that tissue reflects the exact genetic makeup of the baby.

We can also do PBS percutaneous umbilical blood sampling, where we stick a needle directly into the fetal umbilical vein.

That sounds intense.

It is, and it's rare now, but it is the gold standard if the fetus has severe anemia and needs a direct in utero blood transfusion.

There is a massive mechanical difference between CVS and amniocentesis, though, and that dictates what we can actually test for.

Right.

CVS just grabs a piece of solid tissue, amnio grabs the fluid, and because CVS doesn't pull any fluid, it is completely blind to neural tube defects like spina bifida.

Exactly.

An open neural tube defect leaks specific proteins directly into the amniotic fluid.

If you don't sample the fluid, you simply can't detect the leak.

Wow.

So if a patient specifically needs screening for spina bifida, CVS won't help them at all.

They have to wait for the amnio.

And if you are learning this material to apply in a clinical setting, this next point is your red alert priority.

Yes, listen up.

Every single one of these invasive tests, amnio, CVS, PBS, involves jabbing a needle into the highly vascular intra -rotor environment.

That carries a significant risk of fetal -maternal hemorrhage, where the baby's blood cells cross over and mix into the mother's bloodstream.

And that is a potentially catastrophic problem if their blood types are incompatible.

It is a critical, non -negotiable nursing action to verify the mother's blood type before these procedures.

Always check the blood type.

Always.

If the mother is RH -negative, you must ensure she receives an injection of ROE -D immune globulin, which is often called ROGAM, immediately after the procedure.

And what happens if you forget?

If you fail to do this, and some RH -positive fetal blood leaked into her system, her immune system will permanently generate antibodies that will attack and destroy the red blood cells of this baby, or, frankly, any future baby she carries.

Which is terrifying.

But sticking needles into the uterus obviously carries risks.

Thankfully, the diagnostic landscape has evolved a lot.

We can actually pull an astonishing amount of data about the fetus just by drawing a standard vial of blood from the mother's arm.

Right.

Maternal assays.

Which is basically non -invasive screening, right?

Exactly.

It usually starts with maternal serum, alpha -fetoprotein, or MSAFP.

Alpha -fetoprotein is a protein produced by the fetal liver.

And a predictable amount of it naturally crosses the placenta into the mother's blood.

If we test the mother's blood between 15 and 20 weeks and find that the AFP levels are unusually high, it suggests that extra protein is leaking out of the fetus, which points heavily toward an open neural tube defect.

So a patient gets her lab results back, sees elevated AFP, and understandably just panics.

But the very first clinical action shouldn't be scheduling a high -risk surgical consult, right?

Not at all.

The first action is always to schedule a standard ultrasound to verify the gestational age.

Why is that?

Because AFP levels rise exponentially as the fetus grows.

A massive percentage of elevated AFP results aren't because the baby has a neural tube defect.

It's simply because the mother was actually 18 weeks pregnant when we calculated she was only 15 weeks pregnant.

Wow.

Just wrong dates causing false positives.

It happens all the time.

We also look for chromosomal anomalies using multiple marker screens, right?

Yes.

So instead of looking at one isolated protein, we look at a combination of biochemical markers, pieces of the puzzle like HCG, Estriol, Inhibin A, and PPPA.

By measuring the specific ratios of these placental and fetal proteins in the maternal blood, we can statistically flag pregnancies that are at a high risk for Trisomy 21, which is Down syndrome, or Trisomy 18.

But the absolute game changer in maternal blood testing has to be CFDNA, cell -free DNA.

Oh, absolutely.

When fetal cells naturally break down and die in the placenta, they release microscopic of genetic material, and that fetal DNA crosses the placenta and just floats freely in the mother's bloodstream.

It is an incredibly powerful concept.

It's like standing outside a heavily soundproofed concert hall.

You can't see the band and you can't open the doors.

But if you have sensitive enough equipment, you can capture the tiny fragmented sound waves leaking through the ventilation shafts into the street.

That's a great way to picture it.

Right.

And if you analyze those fragments, you can figure out exactly who is playing inside.

We are literally isolating the fetus's genetic music from the background noise of the mother's own blood.

And the fidelity of that music is stunning.

Cell -free DNA screening detects over 99 % of Trisomy 21 cases.

That's incredible.

But we do have to understand the physical limitations.

You need enough of those sound waves to make a recording.

We call that the fetal fraction.

And you usually need at least 4 % fetal DNA in the sample.

So you can't do it right away.

Right.

That means you can't test before 10 weeks of gestation.

Also, if a patient has a higher BMI, the increased maternal blood volume essentially dilutes the fetal DNA, making the test much less sensitive.

And it is crucial to remember that CFBNA, no matter how accurate, is still just a screening test.

It is not diagnostic.

Exactly.

If it flags an abnormality, it must be confirmed with an amnio or CBS.

And if the diagnosis is confirmed, the clinical pathway shifts dramatically.

The family is referred to a specialized fetal care center.

And this is where nurses transition from running tests to becoming vital care coordinators, helping parents navigate ethics boards, pediatric surgeons, and sometimes planning for neonatal palliative care.

Now, as we move deep into the third trimester, the primary goal of our assessments shifts again.

We aren't really hunting for genetic anomalies anymore.

No, by then the central question becomes, is the intratodderin environment still safe enough to support this fetus, or do we need to deliver them right now?

And we answer that using electronic fetal monitoring.

We're looking at stress versus non -stress.

We always start with the non -stress test, the NST.

Pretty simple.

The patient reclines in a chair, tilted to her left side to prevent the heavy uterus from compressing her major blood vessels.

We strap a transducer to her belly to monitor the fetal heart rate, and another to monitor any uterine contractions.

And then we just watch.

We're looking for a reactive result.

Clinically speaking, a reactive result means the baby's central nervous system is highly oxygenated and functioning perfectly.

For a healthy, full -term baby, the textbook definition of reactive is the 15 -by -15 rule.

Yes, the 15 -by -15 rule.

Over a 20 -minute window, we need to see the fetal heart rate accelerate at least twice.

Those accelerations must peak at least 15 beats per minute above their baseline, and they have to stay elevated for at least 15 seconds.

Exactly.

Physical movement causes the heart rate to spike, just like when you or I jog up a flight of stairs.

But fetuses sleep a lot.

So you might hook up the monitor and see a perfectly flat, non -reactive heart rate, purely because the baby is in a deep sleep cycle.

So if they're sleeping, how do we wake them up without being invasive?

We use VAS vibroacoustic stimulation.

We press a specialized device against the mother's abdomen right over the fetal head, and it delivers three seconds of loud sound and vibration.

Basically buzzing them awake.

Exactly.

It startles the fetus awake.

If their oxygenation is good, you'll immediately see those 15 -by -15 accelerations on the monitor.

But if you buzz them and wait, and the heart rate still doesn't accelerate, you have a non -reactive NST.

That tells us the baby might be compromised, so we have to escalate to the contraction stress test, the CST.

A non -stress test just watches the baby resting.

A contraction stress test actively chokes off their oxygen supply for a few seconds to see if they can survive it.

Which sounds intense.

It is.

During a uterine contraction, the blood vessels in the placenta are physically squeezed shut.

It is a massive physiological stressor.

For a CST, we force contractions either by having the patient massage her nipples, which releases natural oxytocin, or we administer ADD oxytocin.

And for this test, we want a negative result, right?

Yes.

Negative means there are no late decelerations in the fetal heart rate.

The baby's heart handles the squeeze without dipping.

And a positive result.

A positive result is the exact opposite.

It's highly dangerous.

It means the fetal heart rate drops late in the contraction cycle, during 50 % or more of the contractions.

It tells us the placenta is failing, and if we put this baby through the grueling marathon of labor, they will not tolerate it.

Because the CST gives us such a definitive picture of placental function during labor, you might wonder why we don't just use it for everyone.

Right, why not just test everyone?

But the reason is clinical contraindications.

You are intentionally causing real contractions.

Therefore, you never perform a CST on a patient who absolutely cannot give birth vaginally, or who is at a high risk for preterm labor.

Exactly.

If a patient has placenta previa, where the placenta is covering the cervix, or if they have a previous classical cesarean scar,

forcing contractions could literally cause a life -threatening hemorrhage, or even rupture their uterus.

It is a powerful tool, but dangerous in the wrong hands.

We've covered an immense amount of technical ground today.

The biophysical profiles, the intricate lipid ratios of lung surfactants, the genetic music of CFDNA, and the intense algorithms of stress testing.

That's a lot.

But as a nurse, you are never just looking at a monitor.

You are standing next to a bed, holding the hand of a vulnerable, terrified human being.

The high -risk label carries a devastating psychological toll.

It triggers an intense situational crisis.

Parents feel overwhelming anxiety, guilt, and frustration.

It completely disrupts their psychological attachment to the pregnancy.

Instead of painting a nursery or going to birthing classes, this mother might be on strict bed rest, staring at the ceiling, waiting for the results of an amniocentesis.

Your role isn't just to memorize the scoring system on table 26 .2.

You are the one performing the NST.

You are the one who has to provide anticipatory guidance and translate dense medical jargon into something a panicked family can actually understand.

You are the critical bridge between the terrifying science and the human experience.

Absolutely.

That is the essence of the nursing profession.

The technology changes, but the human requirement remains the same.

And as you review this chapter, I want you to consider how that evolving technology impacts the families you'll treat.

Think about cell -free DNA.

Because it is so accurate and can be done so early, it is radically shifting the timeline of human emotions.

Ten or twenty years ago, parents wouldn't face major genetic diagnoses until halfway through the pregnancy.

Now, a couple is receiving

profound life -altering diagnoses about their child's genetics at ten weeks.

They are receiving this massive, devastating news before they even really look pregnant, before they have felt a single kick, before they've even told their extended family they're expecting.

Think about how that shifted timeline fundamentally alters the way you, as their nerves, will need to approach their psychological care.

Exactly.

The shock, the grief, the complex decision -making, it all happens so much sooner now.

And navigating them through that dark, murky landscape is going to require every ounce of your clinical knowledge and your empathy.

You have the tools you need to master this material.

Keep studying, keep asking the difficult questions, and keep fighting for your patience.

A warm thank you from us here at the Last Minute Lecture Team.

See you next time.