1. Describe the usual symptoms and clinical manifestations of a second-trimester abortion.
2. Describe the risk factors for, and etiologies of, second-trimester pregnancy loss, such as:
a. Karyotype and structural abnormalities
b. Incompetent cervix
c. Infection
d. Uterine anomalies
3. Perform an accurate physical examination and diagnostic tests to identify the site of genital tract bleeding, assess cervical effacement and dilatation, and evaluate uterine contractions.
4. Perform diagnostic tests to assess patients with threatened second-trimester pregnancy loss, such as:
a. Ultrasonography
b. Genital tract cultures
5. Implement appropriate medical and surgical management (including cervical cerclage) for patients with threatened second-trimester abortion.
6. Manage the complications of second-trimester pregnancy loss, such as:
a. Chorioamnionitis
b. Retained placenta
c. Uterine hemorrhage
7. Counsel patients who have experienced second-trimester pregnancy loss about recurrence risk.
B. Preterm labor
1. Describe the multifactorial etiology of preterm labor.
2. Obtain a complete obstetric history in patients with preterm labor.
3. Perform a thorough physical examination to determine uterine size, fetal presentation, and fetal heart rate and to assess cervical effacement and dilatation.
4. Perform and interpret biophysical, biochemical, and microbiologic tests to assess patients with suspected preterm labor.
5. Recognize the indications for, and complications of, interventions for preterm labor, such as:
a. Antibiotics
b. Tocolytics
c. Corticosteroids
d. Amniocentesis
e. Cerclage
f. Bed rest
6. Describe the expected frequency and severity of neonatal complications resulting from preterm delivery, and describe the survival rates for preterm neonates based on age and weight.
7. Appropriately counsel patients about management and intervention options for the extremely premature fetus.
8. Counsel patients about recurrence risk and preventive measures for preterm delivery.
C. Bleeding in late pregnancy
1. Describe the etiology of bleeding in late pregnancy.
2. Describe the factors that predispose to placenta previa and abruptio placentae.
3. Perform a focused physical examination in patients with bleeding in late pregnancy.
4. Interpret diagnostic tests, such as:
a. Hematocrit
b. Platelet count
c. Coagulation profile
d. Kleihauer-Betke test
e. Apt test
5. Perform the following diagnostic tests:
a. Abdominal ultrasonography to localize the placenta and evaluate for possible placental separation
b. Endovaginal or transperineal ultrasonography to localize the placenta
6. Treat patients with bleeding in late pregnancy:
a. Determine the appropriate timing of delivery.
b. Determine the appropriate method of delivery.
7. Manage serious complications of abruptio placentae and placenta previa, such as hypovolemic shock and coagulopathy.
8. Counsel patients regarding the recurrence risk for placenta previa and abruptio placentae.
D. Hypertension in pregnancy
1. Describe the possible causes of hypertension in pregnancy.
2. Describe the usual clinical manifestations of chronic hypertension, pregnancy-induced hypertension, and preeclampsia.
3. Perform a physical examination pertinent to patients with hypertension.
4. Perform tests to:
a. Determine the etiology of chronic hypertension.
b. Differentiate chronic hypertension from pre-eclampsia and pregnancy-induced hypertension.
c. Assess the severity of chronic hypertension and pregnancy-induced hypertension.
5. Assess fetal well-being in patients with hypertension in pregnancy (see antepartum testing).
6. Treat hypertensive disorders of pregnancy:
a. Describe the indications for, and complications of, antihypertensive medications.
b. Describe the indications for, and complications of, antiseizure medications.
c. Describe the indications for delivery in patients with a hypertensive disorder of pregnancy.
7. Recognize and treat possible maternal complications of hypertension in pregnancy, such as:
a. Cerebrovascular accident
b. Seizure
c. Renal failure
d. Pulmonary edema
e. HELLP (hemolysis, elevated liver enzymes, and low platelet count) syndrome
8. Counsel patients regarding recurrence risk for pregnancy-induced hypertension in a subsequent pregnancy.
E. Intrauterine growth restriction
1. Describe the factors that predispose to fetal growth restriction.
2. Assess uterine size by physical examination and identify size/date discrepancies.
3. Perform an accurate ultrasound examination to assess fetal growth and identify symmetric or asymmetric growth restriction.
4. Monitor a fetus with suspected growth restriction (eg, with antepartum heart rate tests, ultrasonography, and Doppler velocimetry) to determine the appropriate time and method of delivery.
5. Counsel patients about the recurrence risk for intrauterine growth restriction.
F. Premature rupture of membranes
1. Describe the possible causes of premature rupture of membranes (PROM) in preterm and term patients.
2. Perform diagnostic tests to confirm rupture of membranes:
a. Observation of vaginal pooling
b. Identification of a ferning pattern on microscopy
c. Identification of a positive nitrazine test
d. Identification of reduced amniotic fluid volume on ultrasound examination
e. Instillation of dye via amniocentesis
3. Assess patients with PROM for lower and upper genital tract infection.
4. Describe the indications for, and complications of, expectant management in patients with PROM.
5. Describe the indications for, and complications of, induction of labor in patients with PROM.
6. Describe the role and complications of the following interventions in patients with preterm PROM:
a. Tocolytics
b. Corticosteroids
c. Antibiotics
d. Amniocentesis
e. Amnioinfusion
G. Vaginal birth after cesarean delivery
1. Obtain a history of a patient’s previous operative delivery.
2. Counsel a patient concerning risks and benefits of vaginal birth after cesarean delivery (VBAC).
3. Describe the appropriate criteria for, and contraindications to, VBAC.
4. Recognize and treat possible complications of VBAC, such as scar dehiscence, hemorrhage, fetal compromise, and infection (see the list of procedures at the end of this unit).
H. Fetal death
1. Describe the clinical history that characterizes fetal death.
2. Describe the possible causes of fetal death.
3. Confirm the diagnosis of fetal death by ultrasound examination.
4. Perform appropriate diagnostic tests to determine the etiology of fetal death, such as:
a. Postmortem examination
b. Viral serologies
c. Kleihauer-Betke test
d. Karyotype determination
5. Select and perform the most appropriate procedure for uterine evacuation based on considerations of gestational age and maternal history (see the list of procedures at end of this unit):
a. Surgical evacuation
b. Medical induction of labor
6. Describe and treat the principal complications of a retained dead fetus:
a. Infection
b. Hemorrhage
c. Coagulopathy
7. Describe and treat the major complications of surgical and medical uterine evacuation:
a. Uterine perforation or rupture
b. Hemorrhage
c. Infection
d. Retained products of conception
8. Describe the grieving process associated with pregnancy loss and refer patients for counseling as appropriate.
9. Counsel patients regarding recurrence risk for fetal death.
10. Arrange for photographs, total body X-rays, and chromosomal analysis on tissue of the stillborn fetus to help in identifying the etiology.
I. Anesthesia
1. Understand the types of anesthesia that are appropriate for control of pain during labor and delivery:
a. Epidural
b. Spinal
c. Pudendal
d. Local infiltration
e. General
f. Intravenous analgesia/sedation
g. Intranasal analgesia
2. Describe appropriate indications for, and contraindications to, these forms of anesthesia/analgesia.
3. Recognize and treat maternal and fetal complications of anesthesia and analgesia.
4. Perform selected procedures related to anesthesia and analgesia (see the list of procedures at the end of this unit). | 
