EBCOG Part-1-Management of labour & delivery – DAY 3 (SBA)

1.A 26-year-old woman in her first pregnancy presents to the labour ward at 28 weeks and four days gestation with abdominal pain. Maternal observations are all within normal limits.A CTG reveals she is contracting at a rate of three times in 10 minutes, with a normal fetal heart rate. Speculum examination shows the cervix is effaced and dilated 3 cm. The ST3 obstetric trainee wants to know the correct dose of magnesium sulfate for neuroprotection for the baby.Which of the following statements is the most appropriate answer?

2.A 32-year-old woman G2P1 at 30 weeks of gestation in an uncomplicated pregnancy attends the Day Assessment Unit complaining of losing a ‘gush’ of fluid through her vagina 2 hours ago followed by irregular, intermittent abdominal pains. Fetal movements are reassuring, as is the fetal heart rate pattern. The uterus is soft and non-tender with no palpable contractions, and the symphysio–fundal height is appropriate for gestational age, as plotted on her customized growth chart. A sterile speculum examination has revealed clear liquor pooling in the vagina. The cervix is closed. The woman has no past medical history or drug sensitivities.

What is the most appropriate initial management plan?

 3.A 27-year-old woman in her first pregnancy gives a 36-hour history of leaking clear fluid continuously. She is 31 weeks gestation with no abdominal pain or vaginal bleeding. What initial investigation would you request in the management of suspected infection with preterm pre-labour rupture of membranes (PPROM)?

4. One of the following is true regarding preterm pre-labour rupture of membranes:

5. Mrs X, a 28-year-old primigravida has leaking of fluid per vaginam for the past 3 h at 32 weeks of gestation. Per speculum examination confirms leakage of clear amniotic fluid per vaginam. She is clinically stable with no signs of infection. Ultrasound shows a singleton fetus in cephalic presentation, appropriate for gestation with normal liquor and Dopplers. You are explaining her clinical situation to her. You would be correct to say that:

6.A woman attends with regular painful contractions and light vaginal bleeding at 29 weeks of gestation in her first pregnancy. She received steroids one week earlier during a previous admission for threatened preterm labour. Speculum and vaginal examination reveal a cervix that is 7 cm dilated. What is the most appropriate management option?

7. A 35-year-old healthy woman in her second pregnancy at 27 weeks presents to the labour ward with abdominal pain. She had a normal vaginal delivery at term in her first pregnancy three years previously. All observations are within normal limits. A CTG shows one to two irregular contractions every 10 minutes. The fetal heart trace is normal. Vaginal examination reveals the cervix to be 50% effaced but closed. Which of the following is the most appropriate management option?

8.A 35-year-old healthy woman in her second pregnancy at 30+6 weeks presents to the labour ward with abdominal pain. She had a normal vaginal delivery at term in her first pregnancy three years previously. All observations are within normal limits. A CTG shows one to two irregular contractions every 10 minutes. The fetal heart trace is normal. Vaginal examination reveals the cervix to be 50% effaced but closed. What should you do next?  

9.A 36-year-old woman with uncontrolled diabetes and who is 29 weeks pregnant is admitted because of threatened preterm labour. What is your advice regarding steroids for lung maturity?

10.A 29-year-old woman primigravida  with uncomplicated pregnancy presented at 31 weeks of gestation attends the Day Assessment Unit with complaints of a ‘gush’ of fluid leaking through her vagina 2 hours ago followed by intermittent abdominal pains. She is able to appreciate Fetal movements and her CTG is reassuring. The uterus is soft and non-tender with no palpable contractions, and the symphysis–fundal height is appropriate for gestational age, as plotted on her customised growth chart. A sterile speculum examination has revealed clear liquor pooling in the vagina. The cervix os appears closed. What is the most appropriate initial management plan?

11.A 26-year-old woman G2P1L1 at 30 weeks of gestation with otherwise an uncomplicated pregnancy attends the Day Assessment Unit with complaints having broken her waters an hour back following which she has occasional abdominal pain. She is able to perceive fetal movements well. On examination, the uterus is soft and non-tender with no palpable contractions and the symphysis–fundal height is appropriate for gestational age, as plotted on her customized growth chart. The CTG is reassuring and a speculum examination revealed clear liquor pooling in the vagina. The cervix is closed.  What is the single most appropriate combination of therapies?

12. A 23-year-old Primi at 29 weeks of gestation attends the labour ward complaining of regular painful contractions. Her pregnancy has been uneventful with regular midwifery antenatal care. There is no history of rupture of the fetal membranes. Examination reveals a non-tender uterus with palpable contractions occurring three in every 10 minutes. A speculum examination enabled a clear view of the cervix, which is2cm long and 2 cm dilated. The CTG is reassuring and an ultrasound done revealed that the fetus is in an extended breech presentation. Urine analysis is normal with no evidence of infection. What is the most appropriate immediate management of this woman?

13.29 year old Primigravida at 30 weeks of gestation presented to the A&E with complaints of painful contractions. She gives a history of rupture of membranes 2 weeks back for which she was given antibiotics and antenatal steroid prophylaxis. On examination, her temp was 39.6 degree Celsius and she was having three contractions in every 10 minutes lasting for about 30-40 seconds. CTG revealed baseline fetal heart rate of about 184/min with atypical decelerations occurring with more than 50 % of the contractions. On vaginal examination, there was an offensive vaginal discharge and cervix measured 1 cm long and was 2 cm dilated. The unit that u are working is equipped with a level I care. The most appropriate course of action?

14. 28-year-old G3P2L2 presents to the labour ward with PPROM at 34+6 weeks of gestation. She had a cervical suture placed at 17 weeks of gestation following USG shortening of her cervix. Her previous pregnancy ended up in a preterm delivery at 30 weeks of gestation. She shows no signs of chorioamnionitis, with no contractions palpable clinically and the baby is adequately grown for the gestational age. The CTG is normal and USG revealed that the fetus is normally grown with cephalic presentation and normal Doppler studies. What is the most appropriate management step?

15. A 35-year-old healthy woman in her second pregnancy at 27 weeks presents to the labour ward with abdominal pain. She had a normal vaginal delivery at term in her first pregnancy three years previously. All observations are within normal limits. A CTG shows one to two irregular contractions every 10 minutes. The fetal heart trace is normal. Vaginal examination reveals the cervix to be 50% effaced but closed. Which of the following is the most appropriate management option?

16. A 35-year-old healthy woman in her second pregnancy at 30+6 weeks presents to the labour ward with abdominal pain. She had a normal vaginal delivery at term in her first pregnancy three years previously. All observations are within normal limits. A CTG shows one to two irregular contractions every 10 minutes. The fetal heart trace is normal. Vaginal examination reveals the cervix to be 50% effaced but closed. What should you do next?  

17. A 36-year-old woman with uncontrolled diabetes and who is 29 weeks pregnant is admitted because of threatened preterm labour. What is your advice regarding steroids for lung maturity?

18. You have recently started working at a new Trust as an ST3 grade. A woman with threatened preterm labour arrives at 29 weeks’ gestation. In the hospital guideline for the management of preterm labour, you notice that the first-line drug choice is nifedipine. You have not previously used this drug for tocolysis. When you consult the British National formulary, you note that nifedipine is not licensed for this use. What is the most appropriate course of action?  

19.22 years old PG presented in A&E, with sudden water broke at 23 weeks of gestattion, on ultrasound single alive fetus with severe oligohydroamnios, with small for gestational age also.On examination vitally stable, mild tightening. What is the best management option for her.

20. The most common type of breech presentation is

21. 33 year old P1L1 previously delivered by vaginal delivery, no present at 38+ weeks in spontaneous labour. She has had ECV at 37 weeks which failed. The baby is in breech position and she is progressing well in labour with no evidence of fetal compromise. After discussion, and with no other contraindications for a vaginal breech delivery, she wishes to attempt vaginal breech delivery. When conducting her vaginal breech delivery, an experienced practitioner should routinely:

22.You are supervising an ST2 performing an elective Caesarean section for breech presentation. He makes a small laceration on the baby’s right buttock when incising the uterus. It is not actively bleeding and is approximately 1.5cm in length and superficial. The ST2 is extremely upset about this complication. What is the single most appropriate next step?

23.A 33-year-old P1 presents in clinic with a history of previous caesarean section for breech presentation. Her booking BMI is 34 and she is currently at 40+10 gestation. She is very keen for vaginal birth. What are her chances of a successful vaginal birth?

24.What is the approximate incidence of breech presentation at 28 weeks of gestation?

25.A 20-year-old primigravida presents to the delivery suite with rupture of membranes and labour pains for one hour. She is currently 32+4 weeks pregnant and a scan 5 days ago showed flexed breech with mild oligohydramnios. The estimated baby weight according to the last scan was 2050 grams. She has regular contractions and the cervix is 5 centimetres dilated, fully effaced with breech presentation at 0 station. She is transferred to theatre. On examination the breech has delivered with fetal head inside with a tight cervix. What is the best intervention for a safe delivery in this situation?

26.Ms XY is 35/40 weeks pregnant in her fi rst pregnancy. Her USS today reveals a baby with extended breech presentation.  What is the incidence of breech presentation at term?

27. A 23-year-old primiparous woman comes to see you at 38 weeks gestation with breech presentation, following a failed external cephalic version. She has come to discuss the benefits of an elective caesarean section versus a normal vaginal breech delivery. What place of information about the baby should be given to her regarding the benefits of an elective caesarean section?

28.A 32-yr old woman is referred in at 36 weeks with a continuing breech presentation. She has had one previous normal delivery. She has been seen in the community setting throughout and she is keen on a home birth. On examination today, the baby’s presentation is breech.The best management option is

29.You are a grand multiparous woman (4 SVD followed by 2 CS) who has now reached 40+12 weeks gestation. She has had a breech presentation throughout her pregnancy. She is keen on a vaginal birth should labour occur spontaneously but there are no signs of labour. A recent ultrasound scan suggests an estimated fetal weight of 3.9 kg

30.Mrs.Xavier , 27-yr old P1L1 previous vaginal delivery now 36-+ pregnant woman has come with breech presentation and labour pains. On examination, she is found to be 4-5 cm dilated with an well effaced cervix and contracting 3 in 10. CTG is reassuring and the baby appears to be an average sized baby. The membranes ruptured on examination and appear clear

31. The dose for tocolysis during ECV is