EBCOG Part 1 2 Weeks Crash Course Labour and Delivery and Postpartum problems Day 1 EMQ

A.Do FBS
B. Delivery of the baby category 1 cesarean section
C. Delivery of the baby category 2 cesarean section
D. Look for Causes of tachycardia
E.continue fetal monitoring
F. Start conservative maestros
G.forceps delivery in room
H.forceps in theatre
I. Vacuum delivery in theatre
J.none of the above

Above options show various options of management .following scenarios show various laboring women with CTG .choose most appropriate management option for all these women .You can choose the option once or more than once or none at all.


1.This CTG was recorded in a woman laboring spontaneously at full term in her second pregnancy. Her first baby had been born by cesarean section two years earlier because of a failed post-dates induction of labour. At the time this trace was recorded, she was 4 cm dilated

2.Mrs. X , labouring spontaneously at full term in her first pregnancy. The liquor was thick meconium stained but there were no other risk factors identified and at the time that this recording was obtained, she was 5 cm dilated

Her CTG is as follows

You have started conservative measures for her

What is the appropriate next step ?

3.

The CTG was recorded in a mrs. Rosina, labouring at full term in her second pregnancy. The CTG was commenced when the attending midwife heard a deceleration on intermittent auscultation. There were no other risk factors identified. At the time this trace was recorded, the woman was 6 cm dilated.

The contraction frequency is approximately 3 in 10 minutes. The CTG continues like this for more than 30 minutes.

What is your management ?

The above labelled images show various neonatal injuries secondary to operative delivery . The following scenarios explain various newborns with these injuries .choose appropriate image from list . You can choose an option once , more than once or none at all.
A. Image B
B.Image C
C.Image D
D.Image E
E.Image G
F.Image A
G.Image C&F
H.Image B&F
I.Image A&B
J.Image A&G
K.Image B&G
L.Image F

4.Ms.A has been pushing at full dilatation for over 2 hours now with no obvious progress even with syntocinon infusion.Decided for vacuum delivery .she delivered with third pull , two times vacuum pulled off .Mother  is worried about The swelling on baby’s head which is boggy soft pitting , crossing suture lines ,but baby is absolutely fine active , breastfeeding.no creptus noted.

5.Ms, C had a rotational forceps delivery in theatre , her baby Rosa, had a swelling which increased initially now she is here for-follow up visit on day 7 .Rosa is little jaundiced , she s active taking feed well.Swelling is soft and doesn’t pit on pressure, doesn’t cross suture lines ,has Dustin t margins

6.Ms.  X, primigravida with BMI of 38kg/m2, had a failure of descent of head , she refused  for cesarean section after understanding pros and cons .so consultant had to apply sequential instruments  difficult delivery . Baby needed resuscitation . Shifted to SCHU for ventilators support.From time of birth baby has been   Hypotonic, pale and had an episode of seizure, on examination swelling has been  diffuse and  crossing suture lines .Prognosis is guarded

7.Ms. X primigravida, IVF pregnancy with BMI of 35Kg/m 2 .she was known case of type 2Diabetes mellitus  .she had a vacuum delivery followed by which shoulder dystocia , baby was delivered with internal maneuvers,baby’s birth weight 44475gm.Post natal examination  neonatologist ,mentions baby has brachial plexus injury Comprising ventral rami of spinal nerves C5–C6

8.Ms. X primigravida, IVF pregnancy with BMI of 35Kg/m 2 .she was known case of type 2Diabetes mellitus  .she had a vacuum delivery followed by which shoulder dystocia , baby was delivered with internal maneuvers,baby’s birth weight4255 gas.Post natal examination  neonatologist ,mentions baby has brachial plexus injury Comprising ventral rami of spinal nerves C8-T1

A.Image B
B.Image C
C.Image D
D.Image E
F.Image F
G.Image A

Above images depict various features of CTG ,following scenarios explain different features, match appropriate image to explaination.
U can choose option once more than once or none at all.

9.Uterine hyperstimulation is not only the increase in the frequency of uterine contractions but it is also increased uterine activity (the cumulative effect of strength, frequency and duration).

10.Increase in the reactive tachycardia (or 'shoulder') that follows a variable deceleration is called an overshoot.

11.It is influenced by the autonomic nervous system with an increase seen on stimulation of the sympathetic system and a decrease with stimulation of the parasympathetic system. between 5 and 25 bpm is considered ‘reassuring’.

12.It is a sudden increase from the baseline of at least 15 beats and preferably more lasting at least 15 seconds.Its presence is a reassuring feature and indicates fetal wellbeing.

13.These are not part of the normal CTG and should be regarded as a manifestation of pathological influences. This type of deceleration indicates there is insufficient blood flow to the uterus and placenta.As a result, blood flow to the fetus is significantly reduced causing fetal hypoxia and acidosis

14.These are are an essential feature of a non-labouring CTG, however, in labour the fetus may preserve energy by reducing its movements. Therefore, the absence ofthese in labour is common and is of no known clinical significance.

A.Administer terbutaline to the mother
B.Ask the attendant midwife to perform a vaginal examination and artificial rupture of fetal membranes
C.Commence oxytocin infusion and reassess progress of the labour in 2 hours
D.Commence oxytocin infusion and reassess progress of the labour in 30 minutes
E.Commence oxytocin infusion and reassess progress of the labour in 4 hours
F.Deliver by category 1 Caesarean section
G.Deliver by category 2 Caesarean section
H.Epidural analgesia to be commenced followed by oxytocin infusion
I.Immediate transfer to the operating theatre for a reassessment with a view to delivery
J.Induce labour by ARM and commence oxytocin infusion
K.Manual cervical dilation prior to instrumental delivery in theatre
L.Perform fetal blood sample for a pH estimation
M.Prepare for assisted/instrumental delivery in the labour room
N.Reassess progress of the labour in 2 hours
O.Reasses progress of the labour in 30 minutes
P.Ultrasound scanning to confirm the fetal presenting part and placental localisation
Q.none of the above


The above options explain the different options for intrapartum management ,the Follwing scenarios explain women in different soatuations,
Kindly choose the appropriate management for all the below scenarios .

15.A 23-year-old P1 has undergone an induction of labour at 41 weeks + 6 days in her first pregnancy. The antenatal care was complicated with an admission to hospital with a small painful antepartum haemorrhage at 34 weeks of gestation. The symptoms settled spontaneously and all investigations and monitoring were normal; her blood group is AB Rh positive. Vaginal prostaglandin gel insertion established labour within 3 hours and the labour progressed such that 4 hours later the cervix was 5 cm dilated with meconium-stained liquor with a satisfactory CTG, and epidural anaesthesia was instigated. Two hours later, the fetal head was nought-fifths palpable abdominally; the cervix was 9 cm dilated; the position was left occipto-anterior with minimal caput and moulding; the CTG had a baseline of 165 beats per minute with no baseline variability; no accelerations or decelerations and a small amount of post-examination vaginal bleeding was noted. The fetal heart rate then unexpectedly drops to 85 beats per minute and does not recover

16.A 34-year-old woman, P2, is is admitted in strong labour at 37 weeks of gestation. She has had all her antenatal care with her community midwife. She has had two normal births of healthy babies both weighing over 3.3 kg. There have been no problems during this pregnancy. As she arrives she begins involuntary pushing, meconium-stained liquor is draining and the attending midwife examines her and diagnoses a breech presentation with sacro-anterior position. The fetal heart rate is dropping to 80 beats per minute with each contraction with recovery back to 120 beats per minute in between contractions. She is contracting three times every 10 minutes and is distressed with pain but pushing well. The breech is descending through the birth canal satisfactorily and the station is now well below the ischial spines. The fetal heart rate baseline is now 110 beats per minute with decelerations down to 50 beats per minute during maternal pushing effort

17.A 31-year-old woman in her first pregnancy and with a BMI of 25 is admitted in spontaneous labour at 41 weeks of gestation after a straightforward normal pregnancy. She has had most of her antenatal care with her community midwife. She reports reduced fetal movements for the last 24 hours and a small amount of fresh vaginal bleeding prior to admission. She is distressed and contracting four times every 10 minutes. On examination: SFH is 34 cm; longitudinal lie; presenting part is cephalic with two-fifths palpable. A vaginal examination reveals that the cervix is 5 cm dilated; presenting part vertex; right occipto-lateral position with minimal caput and moulding; blood-stained liquor is draining. The CTG shows 60 minutes of trace with a normal baseline rate of 140; little or no baseline variability, no accelerations; no decelerations

18.21-year-old woman, P1 and with a BMI of 22, is admitted in spontaneous labour at 37 weeks of gestation after a straightforward normal pregnancy. She has had all her antenatal care with her community midwife and had a normal birth of her first child, birthweight 3305 g. She reports reduced fetal movements for the last 24 hours; there is no history of any vaginal bleeding. She is contracting twice every 10 minutes. On examination: symphysial fundal height (SFH) is 38 cm; longitudinal lie; presenting part is cephalic with three-fifths palpable. The fetal heart rate is 140 beats per minute and regular with one audible deceleration. The CTG shows 20 minutes of trace with a normal baseline rate of 140; little or no baseline variability, no accelerations; no decelerations

19.A 17-year-old woman, in her first pregnancy and with a BMI 21, is admitted from home at 22+6 weeks of gestation in spontaneous labour after a large amount of vaginal bleeding and abdominal pain, which woke her up. Prior to this episode her pregnancy had been progressing normally. She is very distressed and pale. On examination her BP is 140/85 mmHg; pulse is 104 beats per minute; uterus hard and tender; fetal heat rate 104 beats per minute with audible decelerations to 60 beats per minute; vaginal examination cervix is 6 cm dilated; presenting part breech with absent membranes and fresh bleeding and clots

20.A 41-year-old woman, in her first pregnancy and with a BMI of 32, is admitted in spontaneous labour at 39 weeks of gestation after a straightforward normal pregnancy. She has had most of her antenatal care with her community midwife. She reports reduced fetal movements for the last 24 hours; there is no history of any vaginal bleeding. She is distressed and contracting four times every 10 minutes. On examination: symphysial fundal height (SFH) is 35 cm; longitudinal lie; presenting part is cephalic with one-fifth palpable. The fetal heart rate is 140 beats per minute and regular with one audible deceleration. A vaginal examination reveals the cervix is 8 cm dilated; presenting part vertex; occipto-anterior position with minimal caput and moulding; clear liquor is draining. The CTG shows 40 minutes of trace with a normal baseline rate of 140; reduced baseline variability, no accelerations and regular variable decelerations