Management of Labour & Delivery Extra Questions

1. Mrs X, Primigravida at term is in second stage of labour. After delivery of the fetal head, shoulder dystocia was diagnosed and the McRoberts manoeuvre has not effected the delivery of the shoulders, which is the next method to be used:

2. Elective caesarean section is best recommended to prevent morbidity from shoulder dystocia in which of the following clinical situations:

3. Which of the following statements about timing of delivery in multiple pregnancy is true?

4. Regarding shoulder dystocia, which of the following statements is true?

5. All of the following are known factors for anal sphincter injury during delivery except:

6. Massive blood loss is defined as loss of:

7. Of the following, the most consistent finding in uterine rupture is:

8. History of previous vaginal birth in a woman with a caesarean section attempting to deliver vaginally is associated with the planned VBAC success rate of:

9. Ms XY is a primigravida, gestational diabetic, 38 weeks in spontaneous labour. She was assessed at 13:00 h and had progressed to 5 cms cervical dilatation. She was examined at 17:00 h and was found to be 6 cms dilated, 0.5 long, with intact mem- branes, vertex at spines. What is the next appropriate step in managing her labour?

10. A 20-year-old woman is 36 weeks pregnant in her second pregnancy and is being reviewed in the antenatal clinic. She has had a previous caesarean delivery. A recent obstetric growth scan confirms cephalic presentation of a normally grown fetus. She has no other complicating medical or obstetric disorders. She is deciding between planned vaginal birth after caesarean (VBAC) and elective repeat caesarean section (ERCS) modes of delivery. Which one of the following is correct in relation to the counselling she will receive?

11. A 32-year-old woman is 36 weeks pregnant in first pregnancy with DCDA (dichorionic diamniotic) twins and is being reviewed in the antenatal clinic. A recent obstetric growth scan confirms both fetuses are normally grown. Both twins are longitudinal lie and cephalic presentation. She has no other complicating medical or obstetric disorders. She is deciding between planned vaginal or elective caesarean modes of delivery. Which ONE of the following is correct in relation to the counsel- ling she will receive?

12. Which one of the following statements is correct in relation to the third stage of labour?

13. Hypoxic-ischaemic encephalopathy (HIE) is a rare neonatal condition that is a consequence of intrapartum fetal oxygen deprivation. Which ONE of the following statements is characteristic of neonates diagnosed with HIE?

14. Which ONE of the following statements represents the correct sequence of events in relation to the mechanism of labour for a vertex presentation?

15. A 38-year-old woman has breech presentation at 39 weeks and is opting for elective caesarean section (LSCS) for mode of delivery. Her BMI is 28. She has no other medical or obstetric disorders and has not had any previous surgery. When counsel- ling about elective LSCS, which one of the following statements is valid?

16. A 25 year old, who is 40 weeks pregnant in her first pregnancy, is in the second stage of labour. She has been actively pushing for 2 h and is exhausted. CTG shows a baseline of 150 bpm, normal baseline variability, occasional accelerations and infrequent typical variable decelerations. She is contracting 3–4 every 10 min. Vaginal examination reveals a fully dilated cervix with the fetal head in a direct occipito-anterior position and at station +1 below spines. Which of the following is the most appropriate next management step?

17. A 25 year old, who is 40 weeks pregnant in her first pregnancy, is in the second stage of labour. She has been actively pushing for 1 h. CTG shows a baseline of 180 bpm, reduced baseline variability, no accelerations and frequent atypical variable decelerations. She is contracting 3–4 every 10 min. Vaginal examination reveals a fully dilated cervix with the fetal head in a direct occipito-anterior position and at station +1 below spines. Which of the following is the most appropriate next management step?

18. Mrs. X, 32-year-old second gravida, previous vaginal birth, suffered a spinal cord injury at the level of T8 at 32 weeks of gestation. She had a singleton fetus with an anterior high placenta, and her fetal scan after the accident revealed an AGA fetus with normal amniotic fluid, fetal activity, Dopplers and no signs of internal bleeding in the placenta. She was managed as an inpatient with multidisciplinary care at the obstetric unit. Which of the following statements is appropriate for her care?

19. You are counselling a 28-year-old primigravida with a singleton pregnancy at the antenatal clinic at 38 weeks regarding her options for delivery. Her clinical history has been normal so far and is perceiving good fetal movements, and she has a fetus in cephalic presentation. Which of the following statements is incorrect?

20. Induction of labour should not be offered if:

21. Ms XY is 30/40 weeks pregnant in her first pregnancy. She is in established preterm labour, although not in advanced labour. The cause of preterm labour appears to be an untreated E. coli UTI. Ms XY is haemo dynamically stable and apyrexial. Her lactate levels are 0.5. Which treatment is most likely to improve neonatal outcome?

22. What is the risk of neonatal transmission with vaginal births and recurrent genital herpes?

23. While counselling a low-risk primigravida about planning her delivery, the following information should be given to her:

24. Ms XY is a G3P2 at 30 weeks with a previous CS done 3 years ago for presumed fetal distress. She would like to attempt a VBAC this time. What success rate would you quote for VBAC?

25. Ms XY is 38/40 weeks pregnant with one previous CS. She presents in spontaneous labour and has an agreed plan for a VBAC. She now complains of pain in the site of the CS scar. Which of the following is most consistently associated with a uterine rupture?

26. Ms XY is 32/40 weeks pregnant with a cervical cerclage inserted at 14/40. She presents to the labour suite with a confirmed diagnosis of PPROM. Inflammatory markers are normal. Ms XY is clinically well and demonstrates no uterine activity. Which of the following treatment options are best suited to her?

27. Which of the following women should be offered intrapartum antibiotic prophylaxis for prevention of early-onset GBS disease in the neonate?

28. You are evaluating Mrs X who has been in first stage of labour for the past 10 h. Which of the following information is least relevant to your further clinical management?

29. A 23-year-old primigravida is in threatened preterm labour at 32 weeks of gestation. As there is a possibility of imminent preterm birth, a decision to administer antenatal corticosteroids is taken. While explaining the rationale of this treatment to her, all of the following statements are correct except that antenatal corticosteroids:

30. A 32-year-old primigravida presents at 38 weeks with history of leaking of clear fluid per vaginam for the last 2 h. On clinical examination, fundal height is about 36 weeks, uterus is relaxed, cephalic presentation (3/5 palpable) and fetal heart rate is normal. Per speculum examination confirms clear fluid leaking. What would you tell her about her condition?

31. The recommended gestational age to offer delivery to an uncomplicated triplet pregnancy is:

32. 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:

33. Which of the following is correct regarding the use of misoprostol for induction of labour.

34. The overall risk of obstetric anal sphincter injury during vaginal deliveries is:

35. A primigravida at term, in first stage of labour had uterine hyperstimulation following oxytocin augmentation. The oxytocin drip was stopped, but after a few minutes, she had hypotension, tachycardia and a feeble pulse showing signs of collapse. Resuscitative efforts could not restore any cardiac output for 4 min, and a decision for perimortem caesarean section was taken. Which of the following is the correct approach in conducting the perimortem caesarean section?

36. Ms XY is 38/40 weeks pregnant in her first pregnancy. She has been treated for a GBS UTI at 32 weeks. She presents with a history of PROM with clear liquor. CTG is reassuring. Which of the following treatment options are best suited to her?

37. Ms XY is a G3P2 and term undergoing an emergency caesarean section under GA, as she presents in labour with previous 2 caesarean sections with an APH. During the CS, an anterior low-lying placenta fails to separate after delivery of the baby. A clear cleavage plane cannot be identified. The bleeding is minimal. She has consented to a sterilisation, as her family is now complete. Which of the following treatment options are best suited to her?

38. Ms XY is primigravida at 41/40 weeks in spontaneous labour. She is Indian (Asian ethnicity) and has a baby in direct OP position. She has been pushing for 2 h and using epidural analgesia. The total duration of her second stage has been 3 h. She has been consented for a trial of instrumental delivery in theatre as birth is not imminent. Which of the following risk factors has the strongest association with obstetric anal sphincter injury?

39. Which type of female pelvis favours direct occipito-posterior position?

40. Ms XY is 39/40 weeks pregnant. She presents to the labour suite in active labour with intact membranes. Her recent vaginal swabs were negative for GBS. Her previous baby has been affected by early-onset neonatal GBS disease. Which of the following treatment options are best suited to her?

41. Ms XY is a primigravida who is 38 weeks pregnant. She presents with a history of PROM for a few hours. Examination reveals clear liquor. Maternal observations are normal. What is the percentage of women that will spontaneously labour in 24 h of PROM at term?

42. Which of the following is recommended as a method of induction of labour?

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

44. Ms XY is 35/40 weeks pregnant in her first pregnancy and presented to her GP with white vaginal itchy discharge. Her vaginal swab collected 2 days ago revealed the presence of Group B streptococcus. She is very concerned and would like antibiotics for the same. Which of the following treatment options are best suited to her?

45. Ms XY is primigravida at 41/40 weeks in spontaneous labour. She is Indian (Asian ethnicity) and has a baby in direct OA position. She has been pushing for 1 h and using epidural analgesia. Birth is imminent. Perineum appears overstretched and dis- tended. What angle of a mediolateral episiotomy is most likely to prevent an OASI?

46. Ms XY is a primigravida who is 38 weeks pregnant. She presents with a history of PROM for a few hours. Examination reveals clear liquor. Maternal observations are normal. What is the risk of serious neonatal infection with ruptured membranes at term?

47. Ms XY is a primigravida who is 39 weeks pregnant in spontaneous active labour. She also has diet-controlled GDM. She is theatre as the FHR/CTG showed a fetal bradycardia for 8 mins. At 9 mins in theatre, the FHR has recovered. Examination reveals she is 7 cms dilated with clear liquor in direct OA position. Ms XY is very keen on a vaginal birth only if it safe for her labour to continue. She is currently using Entonox for analgesia. What should be the next appropriate management plan?

48. Ms XY is 38/40 weeks pregnant. She has developed confirmed primary genital herpes. She is presently being treated with acyclovir. She has confirmed SROM since 2 h. Which of the following treatment options are best suited to her?

49. 32 year old second gravida came in preterm labour at 29 weeks of gestation. She was administered the first dose of antenatal corticosteroids, but she delivered just after 6 h of the first dose. It will be correct to tell her that the effect of the antenatal corticosteroids in her case:

50. You are conducting a lower segment caesarean section on a full-term primigravida with a free-floating fetal head. Peroperatively, there is difficulty is delivering the fetal head. Choose the single best option from the alternatives given below:

51. A 32-year-old gravida 2 Para 1 has been transferred from a midwifery-led unit for lack of progress in labour at 4cm. Her previous baby weighed 3100 g and was a normal delivery at 38 weeks gestation. On admission, her observations are normal and the cardiotocography (CTG) was reassuring. The midwife who examined her has diagnosed a complete breech presentation and this is confirmed on scan. The woman is very keen to have a vaginal delivery and decision has been taken to allow labour to continue. After 2 hours, there is no progress in labour and the CTG has become suspicious. What is the most appropriate action?

52. A Gravida 4 Para 3 (three normal deliveries at term) is admitted in preterm labour at 36 + 5 days. She is known to have polyhydramnios but relevant antenatal investigations have been normal. An ultrasound scan at 36 weeks gestation had revealed the estimated fetal weight to be just below the 10th centile on a customized growth chart. On examination, the cervix was 4cm dilated with intact membranes and a high presenting part. Five minutes after admission there is spontaneous rupture of membranes and the CTG shows fetal bradycardia. What needs to be excluded by a prompt vaginal examination?

53. A primigravida who is a Type 1 diabetic is admitted in labour at 37 + 2 weeks gestation. The midwife has commenced sliding scale insulin infusion. Between which values should the capillary blood glucose be maintained during labour?

54. A gravida 3 Para 2 (both full term normal deliveries) is admit- ted at term with confirmed rupture of membranes and labour has been augmented with syntocinon. The woman has suffered from recurrent herpes during pregnancy and is noted to have recurrent genital lesions on admission. At 4–5cm dilatation, the liquor is noted to have grade II meconium and the CTG has been suspicious for the last 40 minutes. What is the most appropriate action at this stage?

55. You are working in an Obstetric unit with level 2 Neonatal care facilities. A primigravida is admitted to the delivery suite at 32 weeks gestation with painful contractions and confirmed preterm prelabour rupture of membranes (PROM). She is pyrexial with a temperature of 38∘C and a pulse of 108/minute. CTG confirms regular contractions and there is fetal tachycardia of 170 bpm with good variability. A speculum examination had shown the cervix to be 2–3 cm dilated. Two weeks prior to this admission the woman had been seen in the day assessment unit with threatened preterm labour and had received two doses of dexamethasone. What is the most appropriate management?

56. What type of headache is associated with a dural puncture?

57. A 24-year-old with a known hypersensitivity reaction to penicillin presents at 36 weeks of gestation in established labour. A high vaginal swab in this pregnancy has noted a growth of group B streptococcus. What intrapartum antibiotic prophylaxis would you offer?

58. A 25-year-old woman with no known drug allergies presents in early labour with ruptured membranes at 39 weeks gestation. She received intrapartum antibiotic prophylaxis (IAP) in her first labour following the identification of group B streptococcus (GBS) bacteriuria during pregnancy. She had a healthy baby with no neonatal problems. What is the most appropriate management?

59. When considering local regimens for intrapartum antibiotic prophylaxis (IAP), what proportion of neonatal infection developing within 48 hours of birth in the United Kingdom is caused by group B streptococcus (GBS)?

60. A 34-year-old woman presents in spontaneous labour at 38 weeks gestation in her second pregnancy, having had a previous prelabour caesarean section for breech presentation. In the first stage of labour, she develops continuous lower abdominal pain and a tachycardia. The fetal heart rate becomes bradycardic. She is delivered by urgent (category1) caesarean section and uterine rupture is confirmed. What is the risk of perinatal mortality?

61. A 42-year-old woman is 39 weeks gestation in her second pregnancy having had a prior emergency caesarean section for fetal distress three years earlier. She is keen to give birth vaginally but is requesting induction of labour because of concerns regarding the increased risk of perinatal mortality associated with her age. What is the most appropriate method of induction to minimise the risk of uterine rupture in labour?

62. What is the incidence of cord prolapse with breech presentation?

63. When umbilical cord prolapse occurs in the community setting, what is the increase in risk of perinatal mortality?

64. In otherwise uncomplicated Preterm labour, evidence suggests that use of tocolysis delays delivery by how long?

65. Which tocolytic drug is comparably effective and has a similar incidence of maternal side effects to Atosiban when used to suppress preterm labour?

66. A 25-year-old woman with no known drug allergies presents in early labour at 37 weeks gestation in her first pregnancy. Her mem- branes ruptured an hour prior to admission. Her temperature is 38.1∘C, she is clinically well and the fetal heart rate is normal. What is the most appropriate management?

67. A 20-year-old woman presents at 40 weeks gestation in her first pregnancy with irregular contractions, offensive vaginal discharge and reduced fetal movements. She has a temperature of 39.2∘C and a tachycardia. On examination, the cervix is effaced and 4 cm dilated and membranes are absent. The fetal heart rate is 170 bpm. Broad spectrum antibiotics are administered after taking blood cultures. What is the most appropriate subsequent management?

68. A 24-year-old woman with sickle cell disease is admitted for induction of labour at 38 weeks gestation in her first pregnancy that is otherwise uncomplicated. Three hours after commencement of intravenous oxytocin, her oxygen saturation drops to 93%. What is the most appropriate immediate management?

69. A 19-year-old woman is admitted at 34 weeks and 4 days gestation in her second pregnancy with spontaneous rupture of membranes and painful uterine contractions. Her first pregnancy resulted in a spontaneous preterm birth at 32 weeks gestation. On examination, the cervix is fully effaced and 6 cm dilated. What is the most appropriate treatment?

70. A 31-year-old woman with well-controlled Type 1 diabetes is admitted for induction of labour at 38 weeks gestation in her second pregnancy having had a previous spontaneous normal birth at 36 weeks gestation. After vaginal examination confirms that she is 6 cm dilated, her blood sugar drops to 3.5 mmol/l and she has no symptoms of hypoglycemia. What is the most appropriate management?

71. What percentage of women with PROM at term will go into labour within the next 24 hours?

72. A low-risk 25-year-old woman at 40 weeks gestation is labouring in the birthing pool in her local midwifery-led unit. She is 8 cm dilated when her midwife checks the temperature of the water, which is 37.7∘C. What is the most appropriate immediate management?

73. A low-risk 34-year-old woman in her second pregnancy is admit- ted in spontaneous labour at 39 weeks gestation. Her cervix is effaced and 5cm dilated with membranes intact on admission. She is examined again four hours later and is 6 cm dilated; she consents to artificial rupture of membranes (ARM), liquor is clear. What is the most appropriate method of fetal monitoring?

74. What proportion of intrapartum CTG with reduced fetal heart rate baseline variability and late decelerations results in moderate to severe cerebral palsy in children?

75. When evaluated as an adjunct to CTG for intrapartum fetal monitoring, of which outcome has STAN (ST analysis) been shown to reduce incidence?

76. What is the risk of neonatal herpes infection in a woman with recurrent genital HSV infection if lesions are present at the time of vaginal delivery?

77. A primigravida is in spontaneous preterm labour at 35 + 1 weeks of gestation. She has progressed satisfactorily in labour and has been pushing for ten minutes. Fifteen minutes prior to pushing, a fetal blood sampling had been performed due to a suspicious CTG and the result was normal. You have been asked to attend as the CTG shows prolonged bradycardia. You are not able to feel the fetal head abdominally and the vertex is at +2 station and is less than 45∘ from the occipito-anterior position.

78. A gravida 3 Para 2 is diagnosed with anterior placenta reaching to the os at 20 weeks gestation. She has had 2 previous caesarean sections. Further imaging with colour flow doppler at 32 weeks has confirmed major placenta praevia and placenta accreta. What would be the recommendation for delivery?

79. Sequential use of instruments increases neonatal trauma. By what factor is the incidence of subdural and intracranial haemorrhage increased in this situation?

80. An emergency buzzer has been activated for shoulder dystocia. You are instructing two junior midwives to assist you in delivery with McRoberts’ manoeuvre. What would you ask them to do?

81. The hospital blood transfusion committee requires guidance with regard to the use of cell salvage in Obstetrics. On which occasions of caesarean section is cell salvage recommended?

82. In the case of a massive obstetric haemorrhage, above what level should fibrinogen be maintained?

83. You are asked to assess a woman’s perineum after a vaginal delivery. There is an extensive tear disrupting the superficial muscle and 70 % of the external anal sphincter. There is no disruption of the internal anal sphincter. How would you classify this perineal trauma?

84. A 40-year-old woman is diagnosed with acute myocardial infarction (AMI) at 36 weeks gestation in her second pregnancy, she is clinically stable. She had a previous normal vaginal delivery at term in her local hospital. What is the most appropriate plan for timing and mode of delivery?

85. A 28-year-old woman presents in spontaneous labour at 41 weeks gestation with a cephalic presentation in her third pregnancy having had two previous normal births. At the onset of the second stage, she ruptures her membranes and the fetal heart rate decelerates. Vaginal examination confirms umbilical cord prolapse with the fetal head in direct occipito-anterior position below the level of the ischial spines. What is the optimal management?

86. A 40-year-old woman with Type 2 diabetes is admitted for induction of labour at 38 weeks gestation in her third pregnancy having had two previous spontaneous normal births. She has epidural analgesia for pain relief and her labour is uncomplicated until shoulder dystocia is diagnosed after delivery of the fetal head. Additional help is summoned but the shoulders cannot be delivered with axial traction and suprapubic pressure in McRoberts’ position. What is the most appropriate subsequent management?

87. A low-risk 27-year-old woman is induced at 41+ 5 weeks gestation in her second pregnancy, having had a previous ventouse delivery for fetal distress. She has epidural analgesia for pain relief in labour. Following confirmation of full cervical dilatation and an hour of passive second stage, she pushes with contractions for 90 minutes without signs of imminent birth. She feels well, her contractions are strong, 4 in 10 minutes and the fetal heart rate is normal. What is the most appropriate management?

88. Following a prolonged second stage of labour, a primigravida at term is examined in order to make a decision about operative vaginal delivery. Abdominal examination indicates that the fetal head is not palpable. Vaginal examination shows the presenting part to be in a direct occipito-anterior position with a station of +3, and a decision is made to perform a ventouse (vacuum extraction) delivery. How would you classify this operative vaginal delivery?

89. What is the lower limit of gestational age for the use of the vacuum extractor (ventouse)?

90. What type of morbidity is less likely to be associated with vacuum extraction than with forceps delivery?

91. A 35-year-old para 3 (previous SVDs) at 39 weeks’ gestation presents with no fetal movements, and a diagnosis of IUFD is made. She is given mifepristone and then returns 2 days later for misoprostol to induce labour. Repeated doses are given until contractions commence. Contractions develop quickly but she then reports severe continuous pain. On assessment she is profoundly shocked with a tender abdomen and profuse vaginal bleeding. She is taken to theatre and a laparotomy is performed. The abdomen has 4 L of blood, and the uterus is extensively ruptured. Hysterectomy and extensive resuscitation e orts are performed, but unfortunately the woman dies. An inquiry is held and the dose of misoprostol used is criticized for being too high. What would have been a suitable misoprostol regime to induce labour in this woman?

92. A 39-year-old primigravida presents at 35 weeks’ gestation with a 48-hour history of absent fetal movement. An IUFD is diagnosed on ultrasound scan. She is otherwise fit and well and antenatal care has been unremarkable until this point. Labour is induced and a macerated stillborn male weighing 2534 g is delivered. The couple consent to postmortem. Which of the following would be part of the initial investigations?

93. After a period of training, an obstetric unit introduces STAN for intrapartum fetal monitoring to the labour ward. Which of the following has STAN been shown to reduce?

94. A 29-year-old para 0 at 40+4 weeks’ gestation presents to the labour ward with pyrexia, malaise and shortness of breath. While transferring onto her labour room bed, she collapses. She is not breathing and there is no pulse. Cardiopulmonary resuscitation (CPR) is commenced and an emergency call is made. The anaesthetist and his operating department practitioner arrive. What would be the best airway protection during CPR in this patient?

95. A 29-year-old para 0 spontaneously labours at 38+3 weeks’ gestation and at 16:00 she is 5 cm dilated. At 18:00 decelerations are heard on intermittentauscultationandaC Giscommenced. Contractionsare 4:10, base rate is 150 bpm variability greater than 5 bpm, there are no accelerations and there are declarations with every contraction, mostly of greater than 60 bpm and o en for greater than 60 seconds. On examination at 18:30 the cervix is 9 cm dilated, and the fetus is direct occiput anterior at spines. A decision is made for fetal blood sampling. Tree good samples are taken at 18:40, and the results are lactates of 4.0, 3.9 and 3.8 mmol/L. What would be the most appropriate course of action?

96. A 35-year-old para 1 is referred from her community midwife to confirm presentation, as this is clinically uncertain. The fetus is cephalic, and she is offered a membrane sweep. The woman is unsure, as she has heard that this is painful, but is also keen to avoid postdates induction if possible. You advise her on the efficacy of membrane sweeping using the number needed to treat. In how many women must a membrane sweep be performed to avoid one formal postdates induction?

97. You assist with the insertion of a cervical cerclage. The medical student observing asks about the indications for this procedure. Which of the following women would be the best candidate for cervical cerclage?

98. A senior labour ward sister asks you to work with her updating your  unit’s guideline about whether mothers should be o ered delivery on the midwife-led unit or the obstetric-led unit, both of which are on the same site. She is keen to ensure the unit is working to national guidance. All women arriving on the unit are rst assessed in a triage area, unless delivery appears to be imminent, and then are directed to the obstetric labour ward or midwifery-led labour ward.
Which of the following women should be o ered delivery on the midwife- led unit?

99. A healthy 28-year-old low-risk, primigravid woman attends a routine antenatal appointment at 28 weeks with her midwife. The woman has always been keen to have a home delivery but wants to do what is safest for her baby. She also had a friend who was transferred to hospital in advanced labour, and the woman wants to avoid this. She asks her midwife if there is any increased risk to her baby from a home delivery compared with a planned delivery in an obstetric unit and what her chance of transfer to hospital in labour or immediately a er delivery would be. Which would be the best advice?

100. A 40-year-old para 3 is delivered by SVD, and oxytocin 10 IU is given intramuscularly. During cord traction the woman screams in severe pain, the uterus is no longer palpable abdominally and the uterine fundus can be felt inverted in the vagina. The emergency buzzer is pressed. What is the next immediate step that should be performed?

101. An F2 doctor is interested in obstetrics. He performs an SVD with the midwife, and he asks you to do a case-based discussion with him on the mechanisms of normal labour. You have a fetal skull model to help. What is the length of the suboccipitobregmatic diameter?

102. An obese 36-year-old primigravid Jehovah’s Witness labours spontaneously at term. The fetal head is delivered but, with the next contraction, the midwife cannot deliver the shoulders. A shoulder dystocia is announced, and help is called for. The woman is put into McRoberts’ position. What is the next most appropriate immediate course of action?

103. A senior obstetric trainee spends the day with an obstetric anaesthetist as part of his training in advanced labour ward practice. During a caesarean section the spinal block is not su ciently e ective, and a decision is made to perform a general anaesthetic. What is the most commonly used induction agent in obstetric anaesthetic practice in the UK?

104. A 29-year-old para 2 with a booking BMI of 56 presents at 39+3 weeks’ gestation in labour. She is found to be 4 cm dilated and contracting 3:10 regularly. The presentation is uncertain, and the obstetric S 3 is called to con rm fetal presentation. During the ultrasound the woman has a spontaneous rupture of membranes. Ultrasound suggests a footling breech presentation. On examination the woman is dysmorphic looking. Vaginal examination con rms 4 cm dilatation, but with a cord prolapse, and an emergency call is made. The S 3 anaesthetist and S 7 paediatrician attend immediately, and the midwife telephones the consultant obstetrician and anaesthetist to come in from home. The S 3 anaesthetist is concerned and alerts you to an antenatal assessment examination that includes ‘Mallampati 3, thyromental distance 5 cm’. The C Ghasabaselinerateof140,variabilitygreaterthan5, noaccelerations and variable decelerations with fast recovery lasting less than a minute with every contraction. What would be the most appropriate immediate course of action?

105. A 29-year-old para 2 with a booking BMI of 56 presents at 39+3 weeks’ gestation in labour. She is found to be 4 cm dilated and contracting 3:10 regularly. The presentation is uncertain, and the obstetric S 3 is called to con rm fetal presentation. During the ultrasound the woman has a spontaneous rupture of membranes. Ultrasound suggests a footling breech presentation. On examination the woman is dysmorphic looking. Vaginal examination con rms 4 cm dilatation, but with a cord prolapse, and an emergency call is made. The S3 anaesthetist and S7 paediatrician attend immediately, and the midwife telephones the consultant obstetrician and anaesthetist to come in from home. The S 3 anaesthetist is concerned and alerts you to an antenatal assessment examination that includes ‘Mallampati 3, thyromental distance 5 cm’. The C Ghasabaselinerateof140, variabilitygreaterthan5, noaccelerations and variable decelerations with fast recovery lasting less than a minute with every contraction. What would be the most appropriate immediate course of action?

106. A 27-year-old primigravida from Somalia presents in labour, 5 cm dilated. The midwife suspects female genital mutilation (FGM) and, a er discussion with the woman, con rms that this took place as a child. On examination there is evidence of clitoridectomy. The labia are fused together, having apparently been stitched together as a child leaving a small introitus. She explains that intercourse took numerous painful episodes before it was possible a er her marriage. An epidural is given and a midline anterior episiotomy is performed. She goes on to have an SVD. What type of FGM?

107. A 28-year-old primigravida spontaneously labours at 40+6 weeks’ gestation. The rst stage of labour is augmented at 5 cm labour and lasts for 11 hours. After 1 hour of passive second stage, she pushes for 2 hours and is exhausted. On examination the fetus is cephalic with 2/5 of the head palpable per abdomen. The cervix is fully dilated, direct OP position with 2+ caput, 3+ moulding and station −1. She is contracting strongly at 4:10. The C G is normal, and the epidural is working well. Which would be the best management?

108. A 33-year-old primigravida with an IVF pregnancy labours spontaneously at 38+6 weeks’ gestation. Despite augmentation and good contractions her labour does not progress past 6 cm, and a category 2 caesarean section is arranged. The woman consents to caesarean but is distressed to be told that hysterectomy is a possible complication. She asks how common this is. How would you best describe the frequency of caesarean hysterectomy?

109. A 25-year-old para 1 is on her frst day after a forceps delivery and is reviewed on the postnatal ward. She is obese, and the epidural in labour had been difficult. There were extensive vaginal tears that took some time to repair. She now complains of le foot drop with paraesthesia over the dorsum and calf over this side. Other than this, peripheral neurologic examination is normal, and she has been mobilizing. What is the most likely cause?

110. A 32-year-old primigravida with paraplegia after a 5 spinal cord injury presents in spontaneous labour at 37+0 weeks’ gestation having self-palpated her contractions. On examination the cervix is 6 cm dilated. Her BP is 102/68 mm Hg. Fifteen minutes later her BP is found to be 145/93 mm Hg. The C G is normal. What is the best immediate management?