Labour And delivery ( Platinum ) – EMQ

Choose the most appropriate option for the scenario given. Each option may be used once or more than once or not at all

Option List :

A. Repeat ECV with tocolysis
B. ECV
C. Repeat ECV in one week
D. Elective caesarean section
E. Emergency caesarean section
F. Breech extraction
G. Allow vaginal breech delivery
H. Conduct an assisted vaginal breech delivery
I. Offer ECV at 36 weeks
J. Offer ECV at 37 weeks
K. ECV contraindicated
L. Breech extraction
M. Routine AN care
N. Vaginal breech delivery contraindicated
O. Start syntocinon and then artificial rupture of membranes

1. 30 year old G2P1 has presented to the labour ward at 39 weeks of gestation with labour pains. Her previous pregnancy and delivery was uneventful and had delivered a 3.8 kg male baby. On examination, there was 3 contractions occurring every 10 mins lasting for 20-30 secs, the lower pole seemed to be having the breech and the CTG was reassuring. On vaginal examination, she was 5 cms dilated and the foot was presenting. The most appropriate management option is

2. 30year old nulliparous woman presented herself to the obstetric day assessment unit at 36+weeks of gestation with a mild to moderate vaginal bleeding. No further episodes of bleeding and clinically the woman was stable with breech presentation with adequate liquor and the EFW was 2.9kgs,with no evidence of placenta praevia or placental abruption. Following observation she was discharged home and she then presented herself to the labour ward for ECV because she was booked for ECV. The best management option is

3. 35-year-old G2P1 woman is with previous uncomplicated vaginal delivery of 3.7 kgs presented to the labour room with twin pregnancy and both babies are in a cephalic presentation at 37 weeks of gestation. This pregnancy has been very uneventful and early trimester scan had revealed DCDA twin. The USG done at 36 weeks showed twins are  above the  50th centile for growth with  no discordant  growth with adequate SDP of 5and 6 respectively. She progressed well during the labour with CTG normal throughout labour. The first twin is delivered by vertex uneventfully. After the delivery of the first twin, the second twin is found to be transverse. What would be the best immediate action?

4. 28 year old primigravida was seen at the antenatal clinic at 36 weeks of gestation. Clinical examination revealed breech presentation. Ultrasound revealed an adequately grown fetus with extended breech, normal liquor with an EFW of 2.7 kgs. The appropriate management plan is

Option List :

A. Syntocinonim
B. Syntocinon 5IU intramuscularly
C. Syntocinon 10 IU intramuscularly
D. Syntocinon 5IU infusion
E. Syntocinon 10IU intravenously
F. Carbetocin
G. Carboprost
H. Syntometrine
I. Misoprostol

From the options given above, choose the most appropriate uterotonic agent for the scenario given.Each option may be used once or more than once or not at all

5. 25 year old primigravida with uneventful antenatal period, presented to the labour ward and delivered by spontaneous vaginal delivery. The most appropriate agent is?

6. 28 year old woman conceived with IUI and a  known GDM on insulin with no other co-morbidies with twin gestation, had a spontaneous onset of labour and had a normal progression of labour. Twin 1 was delivered by forceps as there was a delay in the second stage of labour. Twin 2 delivered spontaneously with no problems. The most appropriate uterotonic is.

7. 34year old woman was induced at 37 weeks of gestation for severe pre-eclampsia, but is undergoing emergency LSCS for fetal distress. The most appropriate uterotonic to prevent PPH is

Option List :

A. HDU care , IV fluids and supportive care
B. Stabilisation and Category I CS
C. Category 1 CS
D. Perimortem caesarean section
E. Two-wide bore cannula, CBC, coagulation profile ,U&E’s and cross match
F. Call the consultant
G. Check airway, breathing, oxygen supplementation and IV access
H. Coronary angiography
I. CT pulmonary angiogram
J. Intravenous heparin loading dose followed by infusion

For each of the following scenarios, choose the single most appropriate option from the list given above. Each option may be repeated once or more than once or not at all

8. 28 year old G3P2 was brought to the emergency in a collapsed state with 34 weeks of gestation. She is a smoker who smokes about 10 cigerettes per day. Otherwise she had an uncomplicated pregnancy. She now had complained of severe abdominal pain. At emergency, her pulse is 110/min, and BP is 90/50mm Hg. Her abdominal examination revealed a tender hard uterus and the fetal heart rate is less than 100/min. The initial resuscitative measures have been done. The appropriate management is

9. 39 year old primigravida was found to be high risk on the combined test. She was advised Amniocentesis and was about to undergo amniocentesis. While undergoing the procedure, she suddenly had complaints of breathing difficulty, giddiness and became unconscious. The appropriate management is

10. 40 year old multiparous woman was brought to the emergency on the 10thpost natal day with history of chest pain, sweating, palpitations and sudden collapse and is a heavy smoker. She was resuscitated with initial measures and was stabilised. The most appropriate investigation option is

Option List :

A. Will continue treatment with tranexamic acid.
B. Counsel the patient directly for hysterectomy considering age, ET and BMI in mind.
C. Undertake outpatient hysteroscopy and endometrial biopsy
D. Undertake outpatient hysteroscopy and endometrial biopsy and discuss risk/benefits of insertion of Mirena LNG-IUS with the woman prior to hysteroscopy.
E. General anaesthetic day-case hysteroscopy and endometrial ablation
F. Request a full blood count, endocrine profile (FSH, LH, testosterone, prolactin, day 21 progesterone, estradiol, TFTs) and fasting glucose/HbA1c.
G. Hysteroscopic polypectomy
H. Undergo imaging, with biomarkers and MDT meeting before any treatment.
I. Laparotomy with hysterectomy
J. Staging Laparotomy with hysterectomy and bilateral salpingectomy
K. Hysteroscopic guided polypectomy with endometrial biopsy
L. Laparoscopic hysterectomy with bilateral salpingo-oopherectomy
M. LNG-IUS followed by EB after 3 months

For each patient described below choose the single most appropriate management option from the list. Each option may be used once, more than once, or not at all.

11. Mrs.X is a 48-year-old woman, para 3, BMI- 38, presenting to secondary care with a 3-year history of worsening HMB with irregularity of her menstrual cycle. She is unresponsive to a 4 month course of transexamic acid treatment. Her cervical smear 12 months ago was normal. The woman's pelvic ultrasound shows endometrial thickness of 15 mm with no uterine structural abnormalities and normal ovaries. What is the further line of management?

12. A 54-year-old woman nulliparous, was operated for breast cancer 3 years back and is on Tamoxifen. She now complains of bleeding per vagina on and off for last 3 months. USG reveals multiple polys. What will be the next step in her management?

13. A 54-year-old woman nulliparous, was operated for breast cancer 3 years back and is on Tamoxifen. She now complains of bleeding per vagina on and off for last 3 months. USG reveals multiple polys. Polypectomy and EB done. Biopsy report reveals atypical hyperplasia. What is management for this patient?

Option List :

A. Amit and stabilize and deliver
B. Oral antibiotics
C. Admit oxygen inhalation,fluid IV gentamycin
D. Do fibronection test
E. No treatment required reassure
F. Anticipate imminent delivery
G. IOL
H. Cefuraxime and metronidazole
I. Ciprofloxical

Three scenarios linked together, what is the next management in each scenario

14. 27 years old G2P1,came in A&E at 31 weeks with mild lower abdominal pain,with vaginal discharge.histroy of preterm labour at 27 weeks due to GBS and chorioamnionitis in last pregnancy.On examination multiparous OS whitish vaginal discharge .Urine dipstick showed nitrate+,no blodd no ketone .Vitally,temp.36.50C,BP 110/72 mmhg,pulse 88/min,RR10/min.C-Reactive protein 9(normal less than 5)WBC count 14000.CTG reactive.

15. Above patient send back home after treatment one day before today at 1800hr brought by her mother in A&E feeling very ill,bilateral Ioin pain fever 38.2C pulse 105/min B.P 110/60mmhg.Normal CTG,abdomen soft no contractions.Cervix fully effaced and 2cm.CRP 90,WBC 19000.

16. Now at 1840 hr,she has urge to pushing,Os fully dilated.Vx+1.Temperature 38.5c,bp 95/65,with tachycardia.Fetal heart 175b/min

Lead in
The above labelled images show various steps of managing postpartum Haemorrhage .The following scenarios explain various scenarios of PostpArtum Haemorrhage . Choose one of the option from above list .you can choose each option once or more than once or none at all.
Option List :
A. Image B&E
B. Image A&C
C. Image A
D. Image E&c
E. Image D
F. Image B
G. Image D&A
H. Image C
I. Image E
J. Image C&D
K. None of the above

17. Ms.Rachel , primigravida in her first pregnancy admitted in labour room , 4cm dilated. On spontaneous rupture of membranes , heavily blood stained liquor with prolonged fetlal bradycardia Is noted, on vaginal examination she is 5 cm dilated vertex high up it was decided to take for emergency cesarean section . Intra operative period , after baby extraction, she started bleeding profusely . PPHproctocolstarted , even after all oxytocics , uterus is stillatonic, consultant decided to do traditional Compression suture which is old and most effective method which can reduce need for hysterectomy in majority of cases

18. Mrs.Tresa , 24year old woman immigrant of Asian origin ,in her second pregnancy .first delivery by cesareansection.This pregnancy she is diagnosed to have grade 2 placenta Previa , planned for elective CS at 37 weeks as she was asymptomatic . Now she is 35weeks 2days .presented with heavy bleeding decided for emergency cesarean section . Intra operative period , after baby extraction, she started bleeding profusely . PPH proctocolstarted , even after all oxytocics , uterus is still atonic , consultant decided to apply modified vertical compression sutures which helps in reducing uterine blood f low and compressing the bleeding surface.

19. Mrs, Ritu , 34year old multiparous lady , Jehowa witness ,had a precipitated delivery followed. Y which she started having profuse bleeding Diagnosis of Atonic Pph was made . Immediate help was summoned majorPPH protocol was implemented.she was shifted to operation theatre for hemostaticsuturing , stepwise devasularistion.Finally had to proceed withthis procedure as last resort.

20. Mrs, Ritu , 32 old multiparous lady , ,had a forceps delivery followed by which she started having profuse bleeding Diagnosis of Atonic Pph was made . Immediate help was summoned . immediate venepuncture (20 ml) for:–cross-match (4 units minimum)–full blood count–coagulation screen, including fibrinogen–renal and liver function. for baseline monitor temperature every 15 minutes continuous pulse, blood pressure recording and respiratory rate (using oximeter,electrocardiogram and automated blood pressure recording) Foley catheter to monitor urine output.To arrest the bleeding, this is the first step done to stimulate uterine contractions

Option List :

A. Keep the water ready
B. Dry the baby
C. Adjust the position of baby's head
D. Intravenous drugs
E. 60%
F. Chest compression :ventilation(3:1)
G. 90%
H. 70%
I. Chest compression :ventilation -1:3
J. 5 inflation breaths

Each of the following options below relate to various steps of neonatal resuscitation. Choose appropriate Option for the clinical scenarios.Each option may be used once, more than once or not at all.

21. Mrs. Anna has delivered normally but baby is very floppy on arrival. You have quickly alerted neonatal team and allocated scribbler. You have dried the baby. You assess APGAR score, baby is gasping, what is your next step?

22. Mrs. Anna has delivered normally but baby is very floppy on arrival. You have quickly alerted neonatal team and allocated scribbler. You have dried the baby. You assess APGAR score, baby is gasping, open airway and you give first inflation breaths.Chest is not moving with inflation breath. What do u do now?

23. Mrs. X delivered by forceps, baby is floppy at birth.You have dried the baby. You assess APGAR score, baby is gasping, you open airway and give 5 inflation breaths. You checked heart rate at 30 seconds - Heart rate is 54bpm. What would you do next?

24. What is the targeted pre ductal oxygen saturation of a new born at 2 minutes.

For the following clinical scenarios, chose the single most appropriate management option from the list. Each answer may be used once, more than once or not at all.

Option List :

A. Consider operative vaginal delivery after a further 30 minutes,if no change
B. Ask the attendant midwife to perform a vaginal examination and artificial rupture of fetal membranes
C. Do amniotomy and reassess progress of the labour in 4hours
D. Do amniotomy,Commence oxytocin infusion and reassess progress of the labour in 2 hours
E. Do amniotomy and reassess progress of the labour in 2 hours
F. Deliver by category 1 caesarean section
G. Deliver by category 2 caesarean section
H. Repeat FBS now
I. Consider operative vaginal delivery after a further 60 minutes, if no change
J. Commence intravenous oxytocin
K. Perform fetal blood sample for a pH estimation
L. Prepare for assisted/instrumental delivery in the labour room
M. Encourage directed pushing in lithotomy position
N. Reassess progress of the labour in 2 hours
O. Transfer to operating theatre for a reassessment with view to an instrumental delivery
P. Repeat FBS in 30 minutes
Q. Forceps delivery in labour room
R. Operative delivery in Operation theatre.

25. A 23-year-old 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  6  hours  later  the  cervix  was  8  cm  dilated  with  meconiumstained  liquor  with  a  satisfactory  CTG,  and  epidural  anaesthesia  was  instigated.  Three  hours later,  the  fetal head  was  zero -fifth  palpable  abdominally;  the cervix  was  fully dilated;the position  was direct occipito  anterior , 3cm below spines .  with  minimal  caput  and  moulding.  and  a small  amount  of post-examination  vaginal  bleeding  was  noted.   The present CTG is as follows