Labour & Delivery Extra Questions

Options list
A. Break both the clavicles
B. Delivery of the posterior arm
C. Elective caesarean section
D. Emergency caesarean section
E. Episiotomy
F Fundal pressure
G. Lovset manoeuvre
H. McRoberts position and suprapubic pressure
I. Rubin manoeuvre
J. Reverse Wood screw manoeuvre
K Roll over onto all fours
L. Symphysiotomy
M. Suprapubic pressure
N. Wood screw manoeuvre
O. Zavanelli procedure
Instructions: For each clinical scenario described below, choose the single most appropriate management option from the list of options above. Each option may be used once, more than once, or not at all.

1. A 30-year-old woman, para 2, attends the antenatal clinic at 37 weeks of gestation to discuss mode of delivery. She had her last delivery two years ago and gives a history of a difficult forceps delivery following which her child developed Erb palsy.

2. A 30-year-old woman, para 1 (vaginal delivery), presents to the labour ward at 42 weeks of gestation with regular contractions. Clinically, the baby appears bigger than 4 kg (her previous child weighed 3.9 kg). She progresses quickly until 7 cm cervical dilatation but subsequently takes 8 hours to progress to full dilatation of cervix. Vaginal examination reveals an occipito-posterior position of the fetus with presenting part at +1 station. A turtle sign is noted following delivery of the head.

3. A 42-year-old primigravida presents to the labour ward with spontaneous labour at 38 weeks of gestation. She is a type 2 diabetic on insulin. Her last scan at 36 weeks of gestation revealed an estimated fetal weight of 3.7 kg. During labour she needed oxytocin augmentation to progress to full dilatation. Two hours after pushing, she had a spontaneous vaginal delivery with the head on the perineum. An emergency buzzer is pulled by the midwife. On entering the room, you notice the patient in McRoberts position and the midwife is giving traction to the fetal head.

Option list
A. Antenatal corticosteroids
B. Antenatal glucocorticoids and antibiotics
C. Antenatal corticosteroids plus antibiotics plus inpatient monitoring for 48–72 hours
D. Emergency cervical cerclage
E. Elective cervical cerclage
F. Immediate induction of labour with the aim of vaginal delivery plus intravenous antibiotics
G. Immediate delivery by caesarean section plus intravenous antibiotics
H. Prophylactic tocolysis and intravenous antibiotics
I. Prophylactic tocolysis plus antenatal corticosteroids plus intrauterine transfer
J. Reasonable to deliver at 34 weeks of gestation or after
K. Transabdominal amnioinfusion
L. Transvaginal amniocentesis
M. Tocolysis and antenatal

corticosteroids N Tocolysis
Instructions: For each scenario described below, choose the single most appropriate initial management from the list of options above. Each option may be used once, more than once, or not at all.

4. A 34-year-old multiparous woman presents to the labour ward with a gush of fluid through the vagina at 26 weeks of gestation. A speculum examination by the on-call registrar confirms a spontaneous rupture of membranes. Abdominal examination reveals no uterine activity. Clinically, she feels well and vitals are normal.

5. A 38-year-old multiparous woman attends her antenatal clinic appointment at 35 weeks of gestation. She gives a history of PROM at 24 weeks of gestation. Abdominal examination reveals cephalic presentation with no signs of chorioamnionitis. An ultrasound scan reveals oligohydramnios. Her inflammatory markers are normal.

6. A 38-year-old multiparous woman attends her antenatal clinic appointment at 35 weeks of gestation. She gives a history of PROM at 24 weeks of gestation. Abdominal examination reveals cephalic presentation with no signs of chorioamnionitis. An ultrasound scan reveals oligohydramnios. Her inflammatory markers are normal.

7. A 40-year-old multiparous woman attends the obstetric day assessment unit with reduced fetal movements at 32 weeks of gestation. A cardiotocograph (CTG) reveals a normal baseline, variable deceleration with reduced variability and no acceleration. Abdominal examination reveals a cephalic presentation and vaginal examination reveals a 2 cm cervical dilatation. An ultrasound scan confirms the cephalic presentation but also reveals severe oligohydramnios. She is tachypnoeic and tachycardic with spiking temperatures of 38°C. A review of her notes indicates that she had PROM at 28 weeks of gestation.

8. A 40-year-old multiparous woman attends the obstetric day assessment unit
at 35 weeks of gestation. She gives a history of PROM at 30 weeks of gestation following which she received erythromycin for 10 days. She feels well in herself and her vitals are normal. However, her blood test results reveal a raised white blood cell count (19,000 per mm3) and C-reactive protein (104 mg/L). An ultrasound examination reveals cephalic presentation with some liquor around the baby. A fetal cardiotocograph is normal.

Option list
A. Artificial rupture of membranes
B. Augmentation with oxytocin
C. Acyclovir – oral
D. Acyclovir – intravenous
E. Acyclovir – intravenous followed by oral
F. Consider vaginal delivery
G. Elective caesarean section at term
H. Emergency caesarean section
I. Forceps delivery
J. Fetal blood sampling (FBS)
K. Termination of pregnancy
L. Type specific herpes simplex virus (HSV) antibody testing
M. Symptomatic therapy
N. Swabs for virology
O. Screen for other sexually transmitted infections (STIs) plus oral acyclovir
Instructions: For each clinical scenario described below, choose the single most appropriate initial management plan from the list of options above. Each option may be used once, more than once or not at all.

9. A 20-year-old pregnant woman presents at 35 weeks of gestation with a primary genital herpes infection. She is generally fit and well. She is worried about the implications for the baby as she has read about neonatal herpes on the internet.

10. A 30-year-old woman presents at 39 weeks of gestation with a primary active genital herpes infection. She gives a history of labour pains for the last 4 hours. Vaginal examination reveals a 2 cm cervical dilatation and intact membranes.

11. A 35-year-old pregnant woman presents with a history of recurrent herpes at term. She is contracting twice in 10 minutes on abdominal examination, and vaginal examination reveals a 6 cm cervical dilatation with intact membranes.

12. A 32-year-old pregnant woman presents to the labour ward at term with a primary genital herpes infection. She is contracting four times in 10 minutes and is currently 4 cm dilated. She declines caesarean section.

13. A 29-year-old woman comes to the day assessment unit with painful vesicles on the genital area. She is currently 16 weeks pregnant and clinical examination reveals a primary genital herpes infection

Option list
A. Apply a fetal scalp electrode
B. Facial oxygen therapy
C. Continue oxytocin
D. Continuous electronic fetal monitoring
E. Fetal scalp electrode application to monitor fetus
F. Fetal blood sampling (FBS) contraindicated
G. Forceps delivery
H. Intravenous 0.5 mg ergometrine
I. Intrauterine fetal blood transfusion
J. Intravenous fluids
K. Left lateral position
L. Perform FBS
M. Repeat FBS in 30 minutes
N. Reduce the rate of oxytocin
O. Subcutaneous 0.25 mg terbutaline
Instructions: For each scenario described below, choose the single most appropriate initial management from the list of options above. Each option may be used once, more than once, or not at all.

14. A 34-year-old woman, para 3, presents to the labour ward at 40 weeks of gestation with regular contractions. She makes good progress up to 8 cm cervical dilatation but does not progress further. Oxytocin was started at 2 mL/hour for augmentation. A CTG reveals a normal baseline heart rate, variability >5 beats/minute and typical variable decelerations for the last 40 minutes. The tocograph suggests that she is contracting seven times in 10 minutes. The midwife calls you to review the CTG as you are the on-call labour ward registrar for the night.

15. A 34-year-old primigravida is admitted to the antenatal ward for induction of labour at 41 weeks of gestation. She has first prostin at 0800 hours and was reassessed at 1400 hours for artificial rupture of membranes (ARM). A second prostin was inserted due to a poor Bishop score. She was put back on the CTG for fetal monitoring. One hour later CTG showed a fetal heart rate (FHR) of 160 beats/ minute and atypical variable decelerations. A tocograph shows seven contractions in 10 minutes.

16. A34-year-old,para3,attendsthelabourwardat40weeksofgestationwith regular contractions. Booking (her first midwife appointment) blood tests reveal she is positive for hepatitis B (low risk for fetal transmission). She was 4 cm at admission but did not progress further. ARM was performed but revealed thick meconium-stained liquor. She was then augmented by oxytocin and 4 hours later, had progressed to 8 cm cervical dilatation. Currently, the CTG reveals a baseline of 170 beats/minute, variability <5 beats/minute, but no accelerations or decelerations.

17. A 34-year-old woman, para 5, attends the labour ward at 41 weeks of gestation with regular contractions and spontaneous rupture of membranes (SROM). She is admitted to the high-risk side on the labour ward for continuous fetal monitoring in view of high parity and meconium staining of liquor. Four hours later she has progressed to 9 cm cervical dilatation. FBS was performed at this stage as her CTG was pathological by the National Institute for Health and Clinical Excellence (NICE) criteria. The FBS results showed pH 7.26 and BE –0.3 mEq/L. Thirty minutes later the midwife informs you that the CTG has remained the same.

 18. A 34-year-old woman, para 2, attends the labour ward at 40 weeks of gestation with SROM. She was discharged home to return in 24 hours for induction of labour. Twenty-four hours (0800 hours) later she returned contracting with a 4 cm cervical dilatation. She progressed to an 8 cm cervical dilatation at next vaginal examination (1200 hours). However, the CTG reveals a baseline FHR of 165 beats/ minute, variability 5 beats/minute, occasional acceleration and typical variable decelerations for the last 60 minutes.