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?

A. 4 g intravenous bolus of magnesium sulfate over five minutes, followed by an intravenous infusion of 1 g per hour until the birth or for 24 hours.
B. 4 g intravenous bolus of magnesium sulfate over 10 minutes, followed by an intravenous infusion of 1 g per hour until the birth or for 24 hours.
C. 4 g intravenous bolus of magnesium sulfate over 15 minutes, followed by an intravenous infusion of 1 g per hour until the birth or for 24 hours.
D. 4 g intravenous bolus of magnesium sulfate over 20 minutes, followed by an intravenous infusion of 1 g per hour until the birth or for 24 hours.
E. No need for magnesium sulfate.

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?

A. Admit to the antenatal ward and prescribe co-amoxiclav 375 mg orally three-times daily and a course of antenatal steroids
B. Admit to the antenatal ward and prescribe erythromycin 250 mg orally four-times daily and a course of antenatal steroids
C. Admit to the labour ward and commence intravenous atosiban and a course of antenatal steroids
D. Discharge home and prescribe co-amoxiclav 375 mg orally three-times daily and a course of antenatal steroids
E. Discharge home and prescribe erythromycin 250 mg orally four-times daily and a course of antenatal steroids

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)?

A. Amniocentesis
B. Biophysical profile
C. Cardiotocography
D. Transabdominal ultrasound assessment of cervical length
E. Ultrasound assessment for growth

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

A. Chorioamnionitis commonly presents with symptoms of pyrexia, uterine tenderness, and foul-smelling liquor
B. Full blood count and C-reactive protein tests have high sensitivity for the detection of chorioamnionitis
C. Once the diagnosis has been established, weekly high vaginal swabs should be performed to detect chorioamnionitis early
D. Tests such as rapid immunoassay AmniSure® have a specificity of 100% and sensitivity of 99%
E. Ultrasound examination is the most accurate investigation to confirm the diagnosis of PPROM

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:

A. Almost 10 % of pregnancies have PPROM.
B. Digital vaginal examination is recommended to help to assess her Bishop score.
C. Erythromycin should be given orally for 10 days following diagnosis of PPROM.
D. Erythromycin for 10 days, it is better to deliver her by 34 weeks under steroid cover.
E. Vaginal PGE2 can be used for inducing her labor now.

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?

A. A further dose of steroids
B. Atosiban for tocolysis
C. Fetal fibronectin
D. Magnesium sulphate for fetal neuroprotection
E. Rescue cerclage

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?

A. Perform transvaginal scan to check the cervical length.
B. Perform a fetal ﬁbronectin test.
C. Start treatment with intravenous beta-mimetics.
D. Start treatment with oxytocin receptor antagonists.
E. Start treatment with oral nifedipine

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?

A. Perform transvaginal scan to check the cervical length.
B. Perform fetal ﬁbronectin test.
C. Start treatment with intravenous beta-mimetics.
D. Start treatment with oxytocin receptor antagonists.
E. Start treatment with oral nifedipine

9.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?

A. 4 g intravenous bolus of magnesium sulfate over ﬁve minutes, followed by an intravenous infusion of 1 g per hour until the birth or for 24 hours.
B. 4 g intravenous bolus of magnesium sulfate over 10 minutes, followed by an intravenous infusion of 1 g per hour until the birth or for 24 hours.
C. 4 g intravenous bolus of magnesium sulfate over 15 minutes, followed by an intravenous infusion of 1 g per hour until the birth or for 24 hours.
D. 4 g intravenous bolus of magnesium sulfate over 20 minutes, followed by an intravenous infusion of 1 g per hour until the birth or for 24 hour
E. No need for magnesium sulfate.

10.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?

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?
B. Steroids can be administered but only after her glycosylated haemoglobin has been controlled to 6.1.
C. Steroids can be administered if her pre- and postprandial blood glucose level is stable at 5 mmol/L and 7 mmol/L.
D. Steroids are administered with additional insulin and close monitoring.
E. Uncontrolled diabetes is not a contraindication.

11.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?

A. Admit to the antenatal ward and prescribe co-amoxiclav 375 mg orally three-times daily and a course of antenatal steroids
B. Admit to the antenatal ward and prescribe erythromycin 250 mg orally four-times daily and a course of antenatal steroids
C. Admit to the labour ward and commence intravenous atosiban and a course of antenatal steroids
D. Discharge home and prescribe co-amoxiclav 375 mg orally three-times daily and a course of antenatal steroids
E. Discharge home and prescribe erythromycin 250 mg orally four-times daily and a course of antenatal steroids

12.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?

A. Erythromycin 250 mg orally four-times daily for 10 days and betamethasone 6 mg intramuscularly, four doses at 12 hours apart
B. Erythromycin 250 mg orally four-times daily until 34 weeks gestation and betamethasone 12 mg intramuscularly, two doses 24 hours apart
C. Erythromycin 250 mg orally four-times daily for 10 days and dexamethasone 6 mg intramuscularly, four doses 12 hours apart
D. Erythromycin 250 mg orally four-times daily for 10 days and betamethasone 12 mg intramuscularly, two doses 24 hours apart
E. Erythromycin 250 mg orally four-times daily until 34 weeks gestation and betamethasone 6 mg intramuscularly, four doses 12 hours apart

13. 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?

A. Tocolysis with ECV
B. Caesarean section
C. Intravenous ritodrine and commence a course of antenatal steroids
D. Intravenous atosiban and commence a course of antenatal steroids
E. Intravenous magnesium sulphate and commence a course of antenatal steroids

14.29 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?

A. Start broad spectrum antibiotics, repeat steroids and await spontaneous progression if temperature settles
B. Start broad spectrum antibiotics and transfer to a hospital level 3 neonatal care unit
C. Start atosiban, broad spectrum antibiotics and transfer to hospital with level 2 unit neonatl care
D. Start broad spectrum antibiotics, category II Cs and plan ex-utero transfer
E. Start broad spectrum antibiotics, category I CS and plan ex-utero transfer

15. 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?

A. Give betamethasone and atosiban and remove cerclage after 48 hours
B. Give betamethasone and erythromycin and remove cerclage after 48 hours
C. Give betamethasone and erythromycin and remove cerclage when there are signs of labour
D. Perform a category 3 caesarean section
E. Remove the suture and consider induction if spontaneous labour does not occur

16. 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?

A. Perform transvaginal scan to check the cervical length.
B. Perform a fetal ﬁbronectin test.
C. Start treatment with intravenous beta-mimetics.
D. Start treatment with oxytocin receptor antagonists.
E. Start treatment with oral nifedipine

17. 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?

A. Perform transvaginal scan to check the cervical length.
B. Perform fetal ﬁbronectin test.
C. Start treatment with intravenous beta-mimetics.
D. Start treatment with oxytocin receptor antagonists.
E. Start treat ment with oral nifedipine

18. 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?

A. 4 g intravenous bolus of magnesium sulfate over ﬁve minutes, followed by an intravenous infusion of 1 g per hour until the birth or for 24 hours.
B. 4 g intravenous bolus of magnesium sulfate over 10 minutes, followed by an intravenous infusion of 1 g per hour until the birth or for 24 hours.
C. 4 g intravenous bolus of magnesium sulfate over 15 minutes, followed by an intravenous infusion of 1 g per hour until the birth or for 24 hours.
D. 4 g intravenous bolus of magnesium sulfate over 20 minutes, followed by an intravenous infusion of 1 g per hour until the birth or for 24 hour
E. No need for magnesium sulfate.

19. 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?

A. Steroids are contraindicated because of her uncontrolled diabetes.
B. Steroids can be administered but only after her glycosylated haemoglobin has been controlled to 6.1.
C. Steroids can be administered if her pre- and postprandial blood glucose level is stable at 5 mmol/L and 7 mmol/L.
D. Steroids are administered with additional insulin and close monitoring.
E. Uncontrolled diabetes is not a contraindication.

20. 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?

A. Contact the on-call pharmacist for advice.
B. Omit the tocolysis and just prescribe steroids.
C. Prescribe atosiban instead as you are more familiar with it.
D. Prescribe the nifedipine but explain to the patient it is unlicensed and document this.
E. Refuse to prescribe nifedipine as it is unlicensed

21.22 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.

A, Dexamethasone
B, caesarean section
C, Expectant management
D, Augmentation of labour may be Induction of labour

22. The most common type of breech presentation is

a. Flexed breech
b. Extended breech
c. Footling breech
d. Knee presenting breech
e. Compound presentation

23. 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:

a. Consider suprapubic pressure to deliver the fetal head by flexion.
b. Encourage active maternal pushing once she achieves full cervical dilatation.
c. Offer epidural anaesthesia.
d. Use Lovset’s manouevre to deliver the arms.
e. Use the lithotomy position for delivery.

24.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?

A. Ask the ST2 to go and explain it to the parents in recovery as it was their complication.
B. Fill in an incident form and notify the delivery suite manager.
C. Go to the parents with the junior doctor, explain and apologize about the complication and document it in the notes.
D. Reassure your colleague that it is a non-signiﬁcant complication and it happens to everyone.
E. Tell the paediatrician and ask them to highlight it to the parents at the baby check.

25.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?

(a) 10%
(b) 25%
(c) 55%
(d) 75%
(e) 90%

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

(a) 4%
(b) 8%
(c) 10%
(d) 15%
(e) 20%

27.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?

(a) Injection of terbutaline
(b) Emergency caesarean section and use lower segment incision
(c) Emergency section and use vertical midline uterine incision
(d) Lateral cervical incisions
(e) Deliver head by Burns Marshall technique

28.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?

A. <1 %
B. 1–2 %
C. 3–4 %
D. 4–8 %
E. 8–10 %

29. 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?

A. Reduces long-term neonatal morbidity
B. Reduces neonatal mortality
C. Reduces perinatal mortality and early neonatal morbidity
D. Reduces perinatal mortality and intermediate term neonatal morbidity
E. Reduces perinatal mortality and long-term neonatal mortality

30.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

a. Offer ECV at 37 weeks
b. Planned elective LSCS
c. Await spontaneous version
d. Ultrasound for growth and liquor
e. Admit and offer ECV

31.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

a. Offer ECV
b. Planned elective LSCS
c. Induction of labour
d. Emergency LSCS
e. Await spontaneous labour and then perform breech extraction

33.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

a. Perform an emergency LSCS
b. Steroids
c. Tocolysis and ECV
d. Breech extraction
e. Assisted vaginal breech delivery

33. The dose for tocolysis during ECV is

a. 250 micrograms of salbutamol in 10ml of NS slow IV
b. 250 micrograms of salbutamol in 5ml of NS i.m
c. 250 micrograms of salbutamol in 25 ml of NS slow IV
d. 250 micrograms of salbutamol in 50 ml of NS slow IV
e. 250 micrograms of salbutamol in 100ml NS slow IV

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