FCPS OBG Part 2 Written – Module Mock – Management of Labour Delivery

1. A 30 years old G2P1 has been reffered from an RHCfor lack of progress in labour at 4 cm. Her previous baby weighed 3.1 Kg and was a normal delivery at 38 weeks gestation. On admission, vital signs are normal and CTG was reassuring. On abdominal and vaginal examination diagnosed as breech presentation which was confirmed on scan. The woman is very keen to have a vaginal delivery and decision has been taken to allow labour to continue. After 2 hours, there is no progress in labour and the CTG has become suspicious. What is the most appropriate action?

2. A G4P3 (prev all svds at term) is admitted in preterm labour at 36 + 5 days. Her current pregnancy is complicate with polyhydramnios but relevant antenatal investigations have been normal. An ultrasound scan at 36 weeks gestation had revealed an IUGR baby. On examination, the cervix was 3 cm dilated with intact membranes and a high presenting part. Five minutes after admission there is spontaneous rupture of membranes and the CTG shows fetal bradycardia. What needs to be excluded by a prompt vaginal examination?

3. A primigravida who is a Type 1 diabetic is admitted in labour at 37 + 2 weeks gestation. You have sliding scale insulin infusion. What are the target capillary blood glucose to be maintained during labour?

4. A G3P2 (both full term normal deliveries) is admitted at term with confirmed rupture of membranes and labour has been augmented with syntocinon. The woman has suffered from recurrent herpes during pregnancy and is noted to have recurrent genital lesions on admission. At 4–5 cm dilatation, the liquor is noted to have grade II meconium and the CTG has been suspicious for the last 40 minutes. What is the most appropriate action at this stage?

5. A 26 years old primigravida is admitted to the delivery suite at 32 weeks gestation with painful contractions and confirmed preterm prelabour rupture of membranes (PROM). She is febrile with a temperature of 100F and a pulse of 108/minute. On CTG there is fetal tachycardia of 170 bpm with good variability. A speculum examination had shown the cervix to be 2–3 cm dilated. Two doses of dexamethasone given two weeks back . What is the most appropriate management?

6. What type of headache is associated with a dural puncture?

7. A 24-year-old with a known hypersensitivity reaction to penicillin presents at 36 weeks of gestation in established labour. A high vaginal swab in this pregnancy has noted a growth of group B streptococcus. What intrapartum antibiotic prophylaxis would you offer?

8. A 25-year-old woman with no known drug allergies presents in early labour with ruptured membranes at 39 weeks gestation. She received intrapartum antibiotic prophylaxis (IAP) in her first labour following the identification of group B streptococcus (GBS) bacteriuria during pregnancy. She had a healthy baby with no neonatal problems. What is the most appropriate management?

9. When considering local regimens for intrapartum antibiotic prophylaxis (IAP), what proportion of neonatal infection developing within 48 hours of birth are caused by group B streptococcus (GBS)?

10. A 34-year-old woman presents in spontaneous labour at 38 weeks gestation in her second pregnancy, having had a previous prelabour caesarean section for breech presentation. In the first stage of labour, she develops continuous lower abdominal pain and a tachycardia. The fetal heart rate becomes bradycardic. She is delivered by urgent (category1) caesarean section and uterine rupture is confirmed. What is the risk of perinatal mortality?

11. A 42-year-old woman is 39 weeks gestation in her second pregnancy having had a prior emergency caesarean section for fetal distress three years earlier. She is keen to give birth vaginally but is requesting induction of labour because of concerns regarding the increased risk of perinatal mortality associated with her age. What is the most appropriate method of induction to minimise the risk of uterine rupture in labour?

12. What is the incidence of cord prolapse with breech presentation?

13 The recommended gestational age to offer delivery to an uncomplicated triplet pregnancy is:

14. A G4P3 with previous history of 2 preterm , presented with co lower abdominal pains at 35weeks. She is 4cm dilated with moderate uterine contractions. In otherwise uncomplicated preterm labour, evidence suggests that the use of tocolysis delays delivery. By how long does it delay delivery?

15. Which tocolytic drug is comparably effective and has a similar incidence of maternal side effects to Atosiban when used to suppress preterm labour?

16. A 25-year-old woman with no known drug allergies presents in early labour at 37 weeks gestation in her first pregnancy. Her membrane ruptured an hour prior to admission. Her temperature is 100 F, she is clinically well and the fetal heart rate is normal. What is the most appropriate management?

17. A 20-year-old woman presents at 40 weeks gestation in her first pregnancy with irregular contractions, offensive vaginal discharge and reduced fetal movements. She has a temperature of 102∘F and a tachycardia. On examination, the cervix is effaced and 4 cm dilated and membranes are absent. The fetal heart rate is 170 bpm. Broad spectrum antibiotics are administered after taking blood cultures. What is the most appropriate subsequent management?

18. A 24-year-old woman with sickle cell disease is admitted for induction of labour at 38 weeks gestation in her first pregnancy that is otherwise uncomplicated. Three hours after commencement of intravenous oxytocin, her oxygen saturation drops to 93%. What is the most appropriate immediate management?

19. A 19-year-old woman is admitted at 34 weeks and 4 days gestation in her second pregnancy with spontaneous rupture of membranes and painful uterine contractions. Her first pregnancy resulted in a spontaneous preterm birth at 32 weeks gestation. On examination, the cervix is fully effaced and 6 cm dilated. What is the most appropriate treatment?

20. A 31-year-old woman with well-controlled Type 1 diabetes is admitted for induction of labour at 38 weeks gestation in her second pregnancy having had a previous spontaneous normal birth at 36 weeks gestation. After vaginal examination confirms that she is 6 cm dilated, her blood sugar drops to 63mg/dll and she has no symptoms of hypoglycemia. What is the most appropriate management?

21. What percentage of women with PROM at term will go into labour within the next 24 hours?

22 . A 25-year-old low-risk woman delivered a healthy baby at term by an emergency caesarean section for massive APH. Estimated blood loss was 1.5 L, uneventful recovery. What is the risk of abruption in her next pregnancy?

23. A low-risk 34-year-old woman in her second pregnancy is admitted in spontaneous labour at 39 weeks gestation. Her cervix is effaced and 5 cm dilated with membranes intact on admission. She is examined again four hours later and is 6 cmdilated; she consents to artificial rupture of membranes (ARM), liquor is clear. What is the most appropriate method of fetal monitoring?

24. What proportion of intrapartum CTG with reduced fetal heart rate baseline variability and late decelerations results in moderate to severe cerebral palsy in children?

25. A 40-year-old woman, who has had a previous caesarean delivery, experiences brisk vaginal bleeding immediately following vaginal delivery of a 36-week gestation baby (birth weight 3.8 kg). 10 min prior to the delivery, there was acute onset fetal bradycardia and cessation of uterine contractile activity. The urinary catheter shows haematuria. The placenta was delivered without complication. Bimanual compression of the uterus is extremely painful for the woman. Despite an estimated blood loss of 500 ml, she appears pale and clammy with BP 90/30 and pulse 120 bpm. Which one of the following is the most likely cause for the excessive genital tract bleeding?

26. A primigravida is in spontaneous preterm labour at 35 + 1 weeks of gestation. She has progressed satisfactorily in labour and has been pushing for ten minutes. Fifteen minutes prior to pushing, a fetal blood sampling had been performed due to a suspicious CTG and the result was normal. You have been asked to attend as the CTG shows prolonged bradycardia. You are not able to feel the fetal head abdominally and the vertex is at +2 station and is less than 45 degrees from the occipito-anterior position. What is the most appropriate course of action?

27. A G3P2 with previous 2 caesarean sections wass diagnosed with anterior placenta reaching to the os at 20 weeks gestation. Further imaging with colour flow doppler at 32 weeks has confirmed major placenta praevia and placenta accreta. What would be the recommendation for delivery?

28. Sequential use of instruments increases neonatal trauma. By what factor is the incidence of subdural and intracranial haemorrhage increased in this situation?

29. You have been called to deliver a patient who has developed for shoulder dystocia after iinstrumental delivery. You are instructing two junior doctors to assist you in delivery with McRoberts’ maneuvre. What would you ask them to do?

30. The hospital blood transfusion committee requires guidance with regard to the use of cell salvage in Obstetrics. On which occasions of caesarean section is cell salvage recommended?

31. In the case of a massive obstetric haemorrhage, above what level should fibrinogen be maintained?

32. You are asked to assess a woman’s perineum after a vaginal delivery. There is an extensive tear disrupting the superficial muscle and 70 % of the external anal sphincter. There is no disruption of the internal anal sphincter. How would you classify this perineal trauma?

33. A 40-year-old woman is diagnosed with acute myocardial infarction at 36 weeks gestation in her second pregnancy, she is clinically stable. She had a previous normal vaginal delivery at term in her local hospital. What is the most appropriate plan for timing and mode of delivery?

34. 28-year-old woman G3P2 with previous svds presents in spontaneous labour at 41 weeks gestation with a cephalic presentation. At the onset of the second stage, she ruptures her membranes and the fetal heart rate decelerates. Vaginal examination confirms umbilical cord prolapse with the fetal head in direct occipito-anterior position below the level of the ischial spines. What is the optimal management?

35. A 40-year-old woman with Type 2 diabetes is admitted for induction of labour at 38 weeks gestation in her third pregnancy having had two previous spontaneous normal births. She has epidural analgesia for pain relief and her labour is uncomplicated until shoulder dystocia is diagnosed after delivery of the fetal head. Additional help is summoned but the shoulders cannot be delivered with axial traction and suprapubic pressure in McRoberts’ position. What is the most appropriate subsequent management?

36. A 27-year-old woman G2P1 at 41+ 5 weeks gestation was admitted for induction of labour. She has no risk factor otherwise. She has previous history of ventouse ddelivery. She has epidural analgesia for pain relief in labour. Following confirmation of full cervical dilatation and an hour of passive second stage, she pushes with contractions for 90 minutes without signs of imminent birth. She feels well, her contractions are strong, 4 in 10 minutes and the fetal heart rate is normal. What is the most appropriate management?

37. Following a prolonged second stage of labour, a primigravida at term is examined in order tomake a decision about operative vaginal delivery. Abdominal examination indicates that the fetal head is not palpable. Vaginal examination shows the presenting part to be in a direct occipito-anterior position with a station of +3, and a decision is made to perform a ventouse (vacuum extraction) delivery. How would you classify this operative vaginal delivery?

38. What is the lower limit of gestational age for the use of the vacuum extractor (ventouse)?

39. What type of morbidity is less likely to be associated with vacuum extraction than with forceps delivery?

40. A 22 years old primigravida at term is in second stage of labour. After delivery of the fetal head, shoulder dystocia was diagnosed and the McRoberts manoeuvre has nor effected the delivery of the shoulders, which is the next method to be used:

41. Elective caesarean section is best recommended to prevent morbidity from shoulder dystocia in which of the following clinical situations:

42. All of the following are known factors for anal sphincter injury during delivery except:

43. Massive blood loss is defined as loss of:

44. Of the following, the most consistent finding in uterine rupture is:

45. A 25 year old, who is 40 weeks pregnant in her first pregnancy, is in the second stage of labour. She has been actively pushing for 2 h and is exhausted. CTG shows a baseline of 150 bpm, normal baseline variability, occasional accelerations and infrequent typical variable decelerations. She is contracting 3–4 every 10 min. Vaginal examination reveals a fully dilated cervix with the fetal head in a direct occipito-anterior position and at station +1 below spines. Which of the following is the most appropriate next management step?

46. A 25 year old, who is 40 weeks pregnant in her first pregnancy, is in the second stage of labour. She has been actively pushing for 1 h. CTG shows a baseline of 180 bpm, reduced baseline variability, no accelerations and frequent atypical variable decelerations. She is contracting 3–4 every 10 min. Vaginal examination reveals a fully dilated cervix with the fetal head in a direct occipito-anterior position and at station +1 below spines. Which of the following is the most appropriate next management step?

47. Induction of labour should not be offered if:

48. A 25 years old primigravida at 30 weeks gestation. She is in established preterm labour, although not in advanced labour. The cause of preterm labour appears to be an untreated E. coli UTI. She is haemodynamically stable and afebrilel. Her lactate levels are 0.5. Which treatment is most likely to improve neonatal outcome?

49. A 27years old G2P1 with one previous CS at 38 weeks of gestation. She presents in spontaneous labour and wants trial of VBAC. She now complains of pain in the site of the CS scar. Which of the following is most consistently associated with a uterine rupture?

50. A 28years old G3P2 at 32weeks. She has h/o cervical cerclage inserted at 14weeks of gestation. She presents to the labour suite with a confirmed diagnosis of PPROM. Inflammatory markers are normal. She is clinically well and demonstrates no uterine activity. Which of the following treatment options are best suited to her?