Management of Labour & Delivery Extra Questions Batch B – MCQ

1. A 32-year-old gravida 2 Para 1 has been transferred from a midwifery-led unit for lack of progress in labour at 4cm. Her previous baby weighed 3100 g and was a normal delivery at 38 weeks gestation. On admission, her observations are normal and the cardiotocography (CTG) was reassuring. The midwife who examined her has diagnosed a complete breech presentation and this is 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 Gravida 4 Para 3 (three normal deliveries at term) is admitted in preterm labour at 36 + 5 days. She is known to have polyhydramnios but relevant antenatal investigations have been normal. An ultrasound scan at 36 weeks gestation had revealed the estimated fetal weight to be just below the 10th centile on a customized growth chart.

On examination, the cervix was 4cm dilated with intact mem- branes 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. The midwife has commenced sliding scale insulin infusion. Between which values should the capillary blood glucose be maintained during labour?

4. A gravida 3 Para 2 (both full term normal deliveries) is admit- ted 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 4–5cm 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. You are working in an Obstetric unit with level 2 Neonatal care facilities. A primigravida is admitted to the delivery suite at 32 weeks gestation with painful contractions and confirmed preterm prelabour rupture of membranes (PROM). She is pyrexial with a temperature of 38∘C and a pulse of 108/minute. CTG confirms regular contractions and there is fetal tachycardia of 170 bpm with good variability. A speculum examination had shown the cervix to be 2–3 cm dilated. Two weeks prior to this admission the woman had been seen in the day assessment unit with threatened preterm labour and had received two doses of dexamethasone.

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 in the United Kingdom is 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. When umbilical cord prolapse occurs in the community setting, what is the increase in risk of perinatal mortality?

14. In otherwise uncomplicated Preterm labour, evidence suggests that use of tocolysis delays delivery by how long?

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 mem- branes ruptured an hour prior to admission. Her temperature is 38.1∘C, 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 39.2∘C 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 3.5 mmol/l 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 low-risk 25-year-old woman at 40 weeks gestation is labouring in the birthing pool in her local midwifery-led unit. She is 8 cm dilated when her midwife checks the temperature of the water, which is 37.7∘C. What is the most appropriate immediate management?

23. A low-risk 34-year-old woman in her second pregnancy is admit- ted in spontaneous labour at 39 weeks gestation. Her cervix is effaced and 5cm dilated with membranes intact on admission.
She is examined again four hours later and is 6 cm dilated; 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. When evaluated as an adjunct to CTG for intrapartum fetal monitoring, of which outcome has STAN (ST analysis) been shown to reduce incidence?

26. What is the risk of neonatal herpes infection in a woman with recurrent genital HSV infection if lesions are present at the time of vaginal delivery?

27. 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∘ from the occipito-anterior position.

28. A gravida 3 Para 2 is diagnosed with anterior placenta reaching to the os at 20 weeks gestation. She has had 2 previous caesarean sections. Further imaging with colour flow doppler at 32 weeks has confirmed major placenta praevia and placenta accreta.

What would be the recommendation for delivery?

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

30. An emergency buzzer has been activated for shoulder dystocia. You are instructing two junior midwives to assist you in delivery with McRoberts’ manoeuvre. What would you ask them to do?

31. 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?

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

33. 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?

34. A 40-year-old woman is diagnosed with acute myocardial infarction (AMI) 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?

35. A 28-year-old woman presents in spontaneous labour at 41 weeks gestation with a cephalic presentation in her third pregnancy having had two previous normal births. 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?

36. 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?

37. A low-risk 27-year-old woman is induced at 41+ 5 weeks gestation in her second pregnancy, having had a previous ventouse delivery for fetal distress. 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?

38. Following a prolonged second stage of labour, a primigravida at term is examined in order to make 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?

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

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

41. A 35-year-old para 3 (previous SVDs) at 39 weeks’ gestation presents with no fetal movements, and a diagnosis of IUFD is made. She is given mifepristone and then returns 2 days later for misoprostol to induce labour. Repeated doses are given until contractions commence. Contractions develop quickly but she then reports severe continuous pain. On assessment she is profoundly shocked with a tender abdomen and profuse vaginal bleeding. She is taken to theatre and a laparotomy is performed. The abdomen has 4 L of blood, and the uterus is extensively ruptured. Hysterectomy and extensive resuscitation e orts are performed, but unfortunately the woman dies. An inquiry is held and the dose of misoprostol used is criticized for being too high.

What would have been a suitable misoprostol regime to induce labour in this woman?

42. A 39-year-old primigravida presents at 35 weeks’ gestation with a 48-hour history of absent fetal movement. An IUFD is diagnosed on ultrasound scan. She is otherwise fit and well and antenatal care has been unremarkable until this point. Labour is induced and a macerated stillborn male weighing 2534 g is delivered. The couple consent to postmortem.

Which of the following would be part of the initial investigations?

43. After a period of training, an obstetric unit introduces STAN for intrapartum fetal monitoring to the labour ward. Which of the following has STAN been shown to reduce?

44. A 29-year-old para 0 at 40+4 weeks’ gestation presents to the labour ward with pyrexia, malaise and shortness of breath. While transferring onto her labour room bed, she collapses. She is not breathing and there is no pulse. Cardiopulmonary resuscitation (CPR) is commenced and an emergency call is made. The anaesthetist and his operating department practitioner arrive.

What would be the best airway protection during CPR in this patient?

45. A 29-year-old para 0 spontaneously labours at 38+3 weeks’ gestation and at 16:00 she is 5 cm dilated. At 18:00 decelerations are heard on intermittentauscultationandaC Giscommenced.Contractionsare 4:10, base rate is 150 bpm variability greater than 5 bpm, there are no accelerations and there are declarations with every contraction, mostly of greater than 60 bpm and o en for greater than 60 seconds. On examination at 18:30 the cervix is 9 cm dilated, and the fetus is direct occiput anterior at spines. A decision is made for fetal blood sampling.

T ree good samples are taken at 18:40, and the results are lactates of 4.0, 3.9 and 3.8 mmol/L.

What would be the most appropriate course of action?

46. A 35-year-old para 1 is referred from her community midwife to confirm presentation, as this is clinically uncertain. The fetus is cephalic, and she is offered a membrane sweep. The woman is unsure, as she has heard that this is painful, but is also keen to avoid postdates induction if possible. You advise her on the efficacy of membrane sweeping using the number needed to treat.

In how many women must a membrane sweep be performed to avoid one formal postdates induction?

47. You assist with the insertion of a cervical cerclage. The medical student observing asks about the indications for this procedure. Which of the following women would be the best candidate for cervical cerclage?

48. A senior labour ward sister asks you to work with her updating your  unit’s guideline about whether mothers should be o ered delivery on the midwife-led unit or the obstetric-led unit, both of which are on the same site. She is keen to ensure the unit is working to national guidance. All women arriving on the unit are rst assessed in a triage area, unless delivery appears to be imminent, and then are directed to the obstetric labour ward or midwifery-led labour ward.

Which of the following women should be o ered delivery on the midwife- led unit?

49. A healthy 28-year-old low-risk, primigravid woman attends a routine antenatal appointment at 28 weeks with her midwife. T e woman has always been keen to have a home delivery but wants to do what is safest for her baby. She also had a friend who was transferred to hospital in advanced labour, and the woman wants to avoid this. She asks her midwife if there is any increased risk to her baby from a home delivery compared with a planned delivery in an obstetric unit and what her chance of transfer to hospital in labour or immediately a er delivery would be.

Which would be the best advice?

50. A 40-year-old para 3 is delivered by SVD, and oxytocin 10 IU is given intramuscularly. During cord traction the woman screams in severe pain, the uterus is no longer palpable abdominally and the uterine fundus can be felt inverted in the vagina. T e emergency buzzer is pressed.

What is the next immediate step that should be performed?