172 Intrapartum Emergencies for the PANCE

Hello and welcome to the Physician Assistant Exam Review Podcast. This is episode 172 and we’re going to be covering intrapartum emergencies. My name is Brian Wallace. I’m the host and creator here at Physician Assistant Exam Review. And we’ve been at this, like I said, about 15 years now. I’m absolutely thrilled to be behind the microphone. This week, we’re going to be covering fetal distress, cord prolapse, shoulder dystocia, and operative deliveries.

And we do that all with the key in mind here is that we’re doing this with the effort to have you retain things longer and score higher on your exams, especially your high stakes exams. So week to week ones, this stuff still works, but that’s not what I’m gearing this for. I’m gearing this to long-term retention. I’m gearing this to your EORs, your PANCE, your PACKRATs, your EOCs, that kind of thing where it has to be taken out of long-term storage, storage, the things that you think that aren’t right on top, the decision making, all those pieces. That’s what we’re looking at. Again, our motto here is think different, work different, score different, but we have to make some changes. We have to do things a little bit differently.

That being said, if that interests you, if you’d love to see an impact in your scores, if you’d love to see things move, today, I’m recording this Tuesday, September 22nd, it probably goes live on Wednesday. The registration period for the October cohort of 33 Days to Pass the PANCE ends on Thursday, the 24th. If we haven’t already sold out by then, we’re getting very, very close. So you might want to go check that out, physicianassistantexamreview.com/33. Or if we’re already past that, you might want to hop on the wait list so you’re notified quite early for December or for February. We run the cohorts every two months and we teach all of these skills inside of there. But the podcast is where I go through the material for you.

We talk about it a little bit. We talk about some study tips, some ways to arrange the information in your brain, some ways to do a little bit better on exams, and that’s what today is for.

So let’s jump in and get started with our priming questions. Let’s go. The turtle sign points to what delivery complication? The turtle sign, I couldn’t resist this one. Points to what delivery complication? A sinusoidal fetal heart rate pattern suggests what diagnosis? Another word I couldn’t resist. Sinusoidal fetal heart rate pattern suggests what diagnosis?

What position takes pressure off a prolapsed umbilical cord? What position takes pressure off a prolapsed umbilical cord? Name three prerequisites for forceps or vacuum delivery. Name three prerequisites for forceps or vacuum delivery. And our lesson for today, what’s the most common sign of uterine rupture during a trial of labor after C-section? What’s the most common sign of uterine rupture during a, excuse me, during labor after a C-section?

All right, backing up just a little bit. Episode 170, we talked about watching throughout delivery, right? So monitoring labor. 171 was normal delivery, normal labor, normal delivery. Today, what we’re going to move into is when things don’t go the way that we want them to. So we’re looking at when the tracings go bad. What do you do?

When the cord comes out first, what do you do? If the shoulder gets stuck, what do you do? So this is all those, when we, so let’s split this up a little bit. The priming questions are pure content. That’s do you know it or do you not know it? Plain and simple. Today’s episode is a little bit more about clinical decision-making.

You have this information, this is what it looks like. What are you going to do next? That’s really what this is about. Then the next episode is going to be the other half of emergency. So ruptured membranes, breeches, twins, that kind of thing.

So let’s jump in today with fetal distress. Fetal distress is non-reassuring fetal status, right? So things don’t look good. What does that mean? Well, the fetal heart tracing suggests the fetus isn’t getting enough oxygen. We have, we’re unhappy. We have non-reassuring fetal, fetal tracings.

Non-reassuring is a term I’m looking for here. This is from ACOG, the American College of Obstetrics and Gynecologists. They want that name, non-reassuring fetal statements. Non-reassuring fetal status. Reassuring is the tracing tells you the fetus is well and oxygenated, right? So category one is baseline 110 to 160, moderate variability, no late or variable decelerations. Remember, late or variable decelerations, we’re comparing that to contractions, right?

That’s when they say late means late in the contraction. Non-reassuring is any of these on the tracing. So any of this on the tracing. Minimal or absent variability. A healthy baby will have beat to beat variability on the tracing. They won’t maintain a perfect heart rate. They continue to adjust it and monitor it.

Flat means we’re doing no good. And now it’s possible that the fetus is asleep or maybe the mom got opioids or there’s some other indicator here, but we want variability. Non-reassuring would also be a recurrent late decel. One late decel, not so much, but recurrent late decels, we talked about this last week, much more concerning. Recurrent variable decelerations also concerning. Prolonged decelerations, two to 10 minutes below baseline. Very concerning. Bradycardia under 110, tachy over 160, right?

These are all things that we want to point out. Sinusoidal pattern, we’ll get to that in a second. What are some causes? We’re just going to review this, we touched on it last week, but we’re going to touch on it again because I think that going through the material multiple times is what makes it sticky. So uteroplacental insufficiency would be a late decel, right? So not enough oxygen in blood getting across the placenta. This is maternal hypotension, so maybe after an epidural, tachysystole, preeclampsia, abruption, growth restriction, all those things may cause those late decels.

You may also get cord compression. This is your variable decel, right? But this is when the cord is being clamped off. Maybe there’s too little amniotic fluid, oligohydramnios, I’ve really just butchered that one. Oligohydramnios, that’s better. So we can get a maternal fever or chorioamnionitis. This results in fetal tachycardia.

That’s really hard to say. I’ve screwed it up several times now. That’s an infection of the amniotic fluid membranes and placenta, maternal fever, uterine tenderness, foul-smelling fluid. If we have a category three or sinusoidal pattern, category three, we need to do something right now. This is absent variability with recurrent late or variable decels or bradycardia or sinusoidal pattern. What that means is a smooth, regular sine wave with no variability. This is pointing to fetal anemia.

Fetal anemia can be from Rh issues, maternal antibodies destroying fetal red blood cells, ruptured vasa previa, ruptured vasa previa. It took me a minute to get my head around this one. What this means is you have a velamentous cord insertion. And what that means is that rather than the umbilical cord implanting directly into the placenta, which implants into the amniotic sac, which implants into the uterus at that point, the cord implants into, from my understanding, the cord implants into the amniotic sac and the vessels will then translate along there to the placenta. That’s really the key here. So those vessels are much more exposed than they normally would be. And during delivery, you can get a rupture of those vessels as they cross over the cervix and they can get torn.

So that’s a reason why you would get fetal anemia. It’s really just that they’re bleeding. So this is a hemorrhage basically of the baby. You can also get it from fetal maternal hemorrhaging. Here, the question stem would likely describe a tracing in words and ask for the next best step, not what the pattern was necessarily. So here we have a woman at six centimeters on oxytocin has decelerations that start after each contraction, peaks and recovers after it ends with minimal variability. What’s the next step?

In this case, it’s reposition, fluid, bolus, stop the oxytocin. As far as diagnostics go here, we can do a fetal scalp stimulation. So we’re going to rub the fetal scalp during a cervical exam to try to get things going to try to motivate it if we think maybe it’s asleep or some kind of a problem. Umbilical cord arterial gas, if we really want to after delivery sent after a bad tracing or depressed newborn to document where the baby was actually hypoxic during labor. What are we going to do about this? So again, what do you do when the tracing goes bad? Everything we’re going to do next is about getting oxygen to the fetus, right?

So I kind of answered this above in that question, but intrauterine resuscitation first and all at once. We do left lateral positioning, takes the uterus off the vena cava. We stop the oxytocin. We IV fluid bolus. So we get epidural hypotension, gets ephedrine or phenylephrine and an IV fluid bolus to help bring that up. We talked about this last week, terbutaline for tachysystole, a beta-2 agonist, similar to albuterol, this is given subcutaneously to relax the uterus. We do a cervical exam to check for cord prolapse.

We can do an amnioinfusion, which is saline into the uterus through an intrauterine pressure catheter for recurrent variable decels. This cushions the cord. That seems kind of strange to me, but I don’t work on that floor. So I don’t know that procedure, but it does make sense. If we have category three situation that doesn’t resolve, we deliver the baby now. If it’s fully dilated with the head low, we do a vaginal delivery. Otherwise we do a C-section.

So with late decels, we assume there’s a problem with the placenta. With recurrent variable decels, we assume there’s a problem with the cord. Sinusoidal pattern, we have fetal anemia. Category three that won’t resolve, we deliver the baby. So that’s fetal distress. Then we have umbilical cord prolapse. We’ll do shoulder dystocia and operative delivery and we’ll be done for today.

Umbilical cord prolapse. The cord slips down ahead of the presenting part after the membranes rupture and gets compressed against the pelvis. So the cord is delivered first. And then as it’s being delivered, you can imagine it is being compressed against the pelvis by the head or something else. This is an obstetric emergency. We have to do something immediately because the baby’s not getting blood at this point, right? You can picture this.

Now it may be overt. You may see it if you can see the cord out of the vagina or it may be occult where we don’t see it. There’s a different presenting part, but we can understand from the tracing what’s going on. Risk factors or anything that leaves room in the pelvis for the cord to slip past it. So malpresentation, something like a footling breech or transverse lie. You can imagine how we could get a cord prolapse here. Prematurity, so a low birth weight is a problem or can be a problem.

Polyhydramnios can be a problem. And multiple gestation, right? Our second twin can have this issue. Something else we talked about last week was an amniotomy. So breaking the amniotic sac on our own to start labor or to encourage labor. If the head’s not engaged, we do increase the risk of a prolapsed cord. What does that look like?

So our clinical presentation, like we’ve been saying, is sudden fetal bradycardia or severe variable decels right after the membrane’s rupture. Pulsating cord felt on cervical exam. We’re not going to wait on an ultrasound here. We need to get things moving. So for treatment, we’re going to be looking to do a C-section. Elevate the presenting part with the gloved hand in the vagina, lifting it off the cord so we can actually push the baby back in, up into the uterus to get the pressure off the cord. Then there’s some positioning maneuvers you can do.

So steep Trendelenburg, which is a position where if you picture a normal hospital bed or operating room bed, you can lower the head of the bed and not the feet. So now you have the head below the feet on like a 20 degree angle. This is Trendelenburg. So that would be, you can do that in an effort to get the pressure off the cord. You’re going to stop oxytocin. Why are we stopping oxytocin? Well, that makes sense too, because we want to stop those contractions from pushing on the cord.

You also don’t want to push the cord back into the uterus because it can cause vasospasms. If you have a well dilated cervix and the delivery is imminent, from what I read, you can deliver the baby. Again, not my sphere. You may want to check this somewhere else, but all other indications say do a C-section. Keys for your exam here, membranes ruptured plus sudden bradycardia, think cord prolapse. I would link that together and make sure I mark that down. Membrane rupture plus sudden bradycardia, think cord prolapse.

So you can do a Trendelenburg. Do not push the cord back in. And then consider an amniotomy with the head not engaged is the setup for prolapse cord.

Next, we have shoulder dystocia. This is the head delivers, then the anterior shoulder catches behind the pubic symphysis. To me, this is easier if you close your eyes and picture this. If you can picture what the inside of a pelvis looks like. The head delivers, so you have the head through the pelvis, but the anterior shoulder catches on the pubic symphysis. I’m really struggling today. Gentle downward traction will not deliver the rest of the body and you can tell that.

So now we have shoulder dystocia. This is a little tough to predict because it can happen in absolutely normal babies, but our risk factors are fetal macrosomia, right? So the strongest risk factor is weight over 4,000 grams. Maternal diabetes can also be a factor here. Prior shoulder dystocia, maternal obesity or post-dates, prolonged second stage, all those things can be risk factors. Clinical presentation here, this is the turtle sign. So this was our first priming question.

This is where the head delivers, then retracts back. The head delivers and then retracts back. And you can picture, right? So the head’s coming down with a contraction, but the shoulder’s stuck. So when that contraction ends, everything moves back up. So the question stem here, what would it be? So think for a second, what would the question stem be for a shoulder dystocia?

If you have a pregnant person, you would think you’d have either a larger baby or a mom with diabetes or both. And then it would say something like, it’s a normal delivery, but the head delivers and then moves back. What are we looking at? What’s our next steps? That kind of thing is what I would be thinking about as I’m studying this. This is a clinical diagnosis made at the point of delivery. And what we do here, honestly, for starters, is if we have a baby greater than 5,000 grams, we think about doing a C-section.

If we have a mother with diabetes, we think about doing a C-section. It all just depends, right? We’re weighing risks. Treatment is going to be first, there’s an acronym, HELPERR, which is call for help. Evaluate for episiotomy to make room for your hands so that you can assist here. There are different leg maneuvers. McRoberts maneuver: hyperflex the thighs onto the abdomen.

This flattens the sacrum and rotates the symphysis up. So it’s just hyperflexing the thighs onto the abdomen. Suprapubic pressure, pushing the anterior shoulder down and under the symphysis. So think about just suprapubic pressure. You’re literally pushing on that shoulder to get under the pubic symphysis. Internal rotation maneuvers. You can bring the posterior arm out and then roll to all fours.

I don’t think you have to know all of these steps. So that’s help, evaluate for episiotomy, legs, pressure, enter would be the internal rotation maneuvers, remove the posterior arm. That sounds kind of funny to say it that way. Roll to all fours. So I don’t think you need to memorize that list, but I think you have to have an idea of what to do in this situation. And here’s really maybe a key point. The first thing you should do is McRoberts plus suprapubic pressure.

This resolves most cases. So what’s McRoberts and suprapubic pressure? So McRoberts was hyperflexion of the thighs up onto the abdomen, right? Suprapubic pressure is just pushing down over top of the bladder to push that shoulder past the pubic symphysis. It kind of should make sense if you picture it a little bit.

Now, something to avoid is fundal pressure. We’re not going to push on the uterus. Think for one second. Why don’t we assist by pushing on the uterus here? Well, because if that shoulder’s stuck, it’s stuck, right? Pushing on it harder isn’t going to help us in this situation. Pushing it down and around under the pubic symphysis is great.

Pushing it harder into it is not going to help us. There is the possibility, something called the Zavanelli maneuver. This is where you push the head back up and deliver by cesarean.

Now, complications from this. You can get brachial plexus injuries. So a C5, C6, or C8, T1. C5, C6 is Erb-Duchenne palsy. This is an upper trunk injury. You get elbow and muscle weakness, elbow, I’m sorry, shoulder and elbow weakness. The hand seems to be okay.

The arm hangs at the side, rotated in the elbow straight, the palm facing back. This is most common and will recover in most cases. C8 to T1 is Klumpke palsy. This is a lower trunk injury. The small muscles in the hand here are weakened, but the shoulder works. You get kind of a claw hand development. This is rare and a worse prognosis than C5, C6, but just so you can tell them apart.

I think that’s probably me, you know, it’s pretty, I don’t suspect you’ll get a question on it, but I would know it because it’s not hard to memorize. It’s just a memorization thing. Erb-Duchenne is C5, C6, hand works, shoulder and elbow are weak, but it gets better. I’m not sure how you pronounce it. Klumpke palsy is C8 to T1. Small muscles in the hand are weak. You get a claw hand.

This is much more likely to be a problem long-term, but it’s much more rare. I think that’s easy to remember. And during these deliveries, you can get a clavicle or humerus fracture as well, right? You can get a hypoxic injury as well. You can get postpartum hemorrhage. You can get third or fourth degree lacerations to think about what we’re doing here.

Exam keys for the section turtle sign equals shoulder dystocia. McRoberts plus suprapubic pressure, we do first, never fundal pressure. Consider diabetes and macrosomia as the setup. And then understand the two different brachial plexus injuries. I think that’s really, there’s a lot of information in there. I think all of that boils down to maybe one question on your PANCE, but definitely some things to know.

All right, let’s talk about our last part, which is operative delivery. I mean, I’m really struggling, operative delivery. Operative vaginal delivery is forceps or a vacuum on the fetal head to finish the second stage or a cesarean delivery is abdominal delivery through uterine incision. An operative delivery, what are the indications? Why would we do, why would we use forceps or a vacuum? And this is one of those things, I don’t want you to memorize the list. I want you to think.

If we have a severely prolonged second stage and mom is exhausted and can no longer participate, she’s going to need some help. If we have an issue where we can’t have mom pushing for one reason or another, if she has cerebrovascular disease or some kind of cardiac issue, there are a number of different reasons why we don’t want, health-wise, why we don’t want mom pushing. Another might be non-reassuring tracing in the second stage. We may want to get this thing delivered as fast as we can. So we want to assist.

Now, what do we have to have in place for to use a vacuum or forceps? Well, we have to have a fully dilated cervix. We cannot pull the baby through a non-dilated cervix. Not a good idea. The head must be engaged, so station zero or lower. We must understand the position of the baby. We’re going to want an empty bladder for the mom.

We’re going to want to have her consent. We’re going to want to have adequate pain relief on board. And we’re going to want to have discussed a C-section if this doesn’t work kind of situation. Now I’ve seen the vacuum, we use it. I have a couple of surgeons who use it during C-sections to help us get the baby out if we’re struggling. It’s kind of a neat little device. Suction cups to the top of the baby’s head and gives you kind of something to pull straight out on and get some pressure to help.

With a cesarean delivery, what’s the most common indication for a cesarean delivery? This is easy. You don’t even have to know. You’re so good at this. You don’t even have to know this to know it. What’s the most common indication for a cesarean delivery? Prior cesarean delivery, right?

Any prior C-section, we’re going to lean towards another C-section. Doesn’t mean we have to, but we want to consider it. If labor stops, mom’s exhausted, can’t continue. Same kind of the same reasons. So we were talking about before, non-reassuring fetal status, mal-presentation, breech, placenta previa, right? If for the placenta previa, obviously we have to do a cesarean. Do you remember what placenta previa is?

Placenta previa is when the placenta, instead of implanting along the uterus and maybe the sidewall, it is implanted over the cervical os. So we can’t deliver the baby through the placenta, right? That doesn’t make any sense. Not only would it cause significant bleeding, but it’s going to be difficult. So labor would tear through the placenta. We want to avoid that. So we’re going to schedule an earlier C-section.

We talked about vasa previa before where we have bare fetal vessels in the membranes running across the cervix. We want to be careful here. And we’re also going to do a C-section. If we have a transverse lie or a prior classical incision, what’s a prior classical incision here? You know what that means. So currently we do a Pfannenstiel incision. So it’s a low transverse incision across the abdomen and a relatively low transverse incision across the uterus in order to get the baby.

In a classical incision, it’s up and down. So we’re doing an up and down incision. And the reason we don’t want to do a labor after a classical incision is that it weakens the uterus. We also are going to do a cesarean if we have active genital herpes because we don’t want to give that to the baby. Complications from C-sections. Again, this is not hard stuff. Think about this.

What are some complications from C-section? Hemorrhage, right? Bladder or bowel injury. We’re going into the abdominal cavity. Infection. Endometritis is something you want to watch out for. We do give Ancef within 60 minutes before the incision, but that’s on the list.

Now, what are some issues or what are some other complications further down the line? Well, each cesarean section increases the risk for placenta previa and accreta because I’m scarring the inside of the uterus in more places. So I’m giving the placenta less places to attach comfortably. Comfortably. Again, we do that low transverse incision, which allows us to do a trial of labor afterwards. So in the next repeat section, I’m sorry, the repeat pregnancy, we might be able to try what’s known as a VBAC, vaginal birth after cesarean, although I think they’ve changed the terminology on that again, but that’s what I’m used to calling it. I’m just looking through my notes here.

I talk about the classical incision again, but I don’t really need to cover that here. For you guys, the uterine rupture, what does that look like? So we get a sudden fetal bradycardia, is the most common sign, and the loss of fetal station. So we knew where the baby was, and it’s no longer has descended. Mom has abdominal pain, vaginal bleeding, and contractions stopping. Here, we need an emergency laparotomy. So we have to open up mom right away.

You can imagine this is a major, major deal. I have never seen this. I’ve never been around it, thankfully, but you can imagine what this would look like.

All right, exam keys. Forceps or vacuum: fully dilated, ruptured membranes, head engaged, position known. Vacuum, we can get a cephalohematoma, and subgaleal hemorrhage, forceps, maternal lacerations, and facial nerve palsy. So there’s sort of a trade-off there as to which you would like to go with. We’re going to do low transverse incision in a C-section, which will allow for attempted labor with the next one.

All right, so let’s run through a little bit of this. Recurrent late decels tied to contractions are uteroplacental insufficiency. We’re going to deal with that right there and there. Sudden bradycardia, right after the membranes rupture, this is cord prolapse, right? Sudden bradycardia plus loss of station and a scarred uterus. Now we’re talking about uterine rupture and laparotomy. Head out of the body, stuck head, I’m sorry, head out, body stuck, head pulls back.

What is that? What is it? When the head’s out, but the head pulls back. This is shoulder dystocia. Do you remember what we do there? Well, McRoberts and then suprapubic pressure. So that was a quick run through, quick review of everything we’ve done today.

So we covered a lot of ground as far as difficult labors, difficult issues, things we don’t like there. What I want you to understand for our study tip for today, or what I want to talk about for our study tip today, is that this section is a lot less what is it and a lot more what happened before or what do you do next? This is more of our clinical decision area. So it’s a little bit of what is it, but it’s a lot more of here are the signs, what do you think just happened and what do we do about it? So things like the water broke and the heart rate dropped. What do we have, what happened, what do we do? You need to understand those terms and what they mean.

You need to think them through. So this section is not just a memorization piece. This is test taking. This is not pure content. You have to know this content, but it’s not pure content, if that makes sense. You want to be able to identify if we have a cord prolapse, but then you need to know what to do about it. It’s rarely going to just ask you for what is cord prolapse.

It’s rarely going to ask you for when should we consider a C-section, maybe, but I would know those next steps. I hope that that makes sense.

All right, let’s jump in and answer our priming questions. The turtle sign points to what delivery complication? We got this nailed. We’ve gone over this 10 times now. Shoulder dystocia, the head delivers and pulls back against the perineum. A sinusoidal fetal heart pattern suggests what diagnosis? Oh, this was at the beginning.

Don’t know if you’re going to remember this one. Fetal anemia, fetal anemia. We could get this from Rh problems, ruptured vasa previa, fetal maternal hemorrhage, et cetera. What position takes pressure off a prolapsed umbilical cord? What was our position? Do you remember? There were two things I said to do.

What was the positioning for a prolapsed umbilical cord? So you can put the knees on the chest or Trendelenburg, right? Knees on the chest or Trendelenburg. That was that, if you’d kind of put mom upside down a little bit in the bed. Name three prerequisites for a forceps or vacuum delivery. Three prerequisites for forceps or vacuum. This is a very straightforward content-based question that I think you should totally know.

Cervix has to be fully dilated, membranes have to be ruptured and the head has to be engaged. And also throw in there fetal position, but those are three. What’s the most common sign of a uterine rupture during a trial of labor after C-section? Fetal bradycardia, and then loss of fetal station. Pain is actually secondary on this list, oddly enough. I would think that would be right, right, right at the top, but apparently not.

All right, that’ll take us through labor and delivery. We’ll pick up again next week. Thank you so much for participating. Thank you so much for being here today. Really appreciate it. Like I said, this is, I’m struggling with some of the vocabulary in this section. This is not my main section.

Not the main thing that I do, but there are serious keys we can see inside of this. We can still see how the test questions are written. We can still see what’s most important to study. And to me, that’s what’s really valuable. There’s a couple of things. One is understanding the things that you understand, it’s sort of easy to get, but there’s a skill in learning, retaining and being able to answer questions on the things that aren’t your main thing, right? So if you have dreams of going into cardiology, you still have to get the musculoskeletal stuff right.

If you have dreams of going into ortho, you still have to get the ID stuff right. And the pulmonary stuff, right? So it’s how do you, even the things you have a little trouble wrapping your head around, the things you’re not 100% comfortable with, how do you get those? And maybe that’s what I’ve been demonstrating through this section for you guys, is how to work through the sections that you aren’t 100% comfortable with, that aren’t your bread and butter, that aren’t the things that you feel great about. There are lots of sections I’m super comfortable with, right? This obviously, this is not one of them, but I still have to know it. I still have to be able to figure it out.

I still have to retain it. And that’s a skill in itself, right? So it’s okay to stumble, it’s okay to not know things, it’s okay to struggle pronouncing things, especially as we’re learning, it’s absolutely okay. But we have to be strong enough to work through it, we have to be able to figure it out, we have to have the skill of perseverance and still seeing how test questions are going to come.

Fantastic. All right, if you’d like to gain some of these skills, if you’d like to work more on test questions, if you’d like to learn more on how to retain things, if you’d like to understand how we can make it so that your neural networks get built out stronger and last longer, I would love for you to join us for the October cohort of 33 Days to Pass the PANCE coming up. Registration, like I said, closes on Thursday at physicianassistantexamreview.com/33 to find out more. Would 100% love to have you on board. If you’re struggling in PA school in any way, you’re feeling lost, you’re feeling like you don’t understand things, you’re feeling like you can’t keep up with the struggle, that is 100% what this course is for. It’s to get you in a place where you can study better, study less, retain more, watch your scores go up, get your anxiety under control, get your test taking skills up so that we can absolutely crush our high stakes exams, whether that’s the EOC, the PANCE, the EORs, whatever it is, that’s what we trained for. Love to see you in there.

Either way, take care. I’ll see you next week. So long.