Intrapartum care -Labor and delivery part2
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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?
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
A low-risk woman in her first pregnancy has an uncomplicated labour and delivers by
spontaneous vaginal delivery.
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 membranes, vertex at spines.
What is the next appropriate step in managing her labour?
Delay in the second stage of labour in a primipara. The position is occipitoposterior and
the presenting part is 1 cm below the ischial spines. There is no head palpable abdominally
A 32-year-old G2P1 woman at 39+4 weeks of gestation presents for the second time to the
labour ward with periodic abdominal pains.
Vital signs were stable and on abdominal examination there were palpable uterine contractions, and
the uterus was not tense or tender. Vaginal examination revealed a 2 cm long cervix that was 3 cm
dilated; membranes were intact and the presenting part was at –3 station.
Her urine was normal.
6) What is your proposed diagnosis?
. A 31-year-old woman presents in preterm labour at 34 weeks of gestation. Her labour
progresses quickly and she delivers a baby boy. Both mother and baby appear to be in good health,
and the woman requests delayed cord clamping
What time frame would be recommended for delayed cord clamping in this situation?
A 25-year-old low-risk para 1 woman is admitted to the low risk birthing unit in established
labour. She progresses well and is now fully dilated with no concerns on intermittent auscultation of
the fetal heart. She has significant lower back pain, which is improved by adopting a standing
8) Which of the following statements is associated with the upright position?
9) A parous woman admitted with regular uterine activity at 7 cm with intact membranes
A 28-year-old woman in her first pregnancy is 36 weeks with an uncomplicated pregnancy. She
would like to have a home delivery and wants to know more information about choosing the place
to have her baby. What will you tell her according to the Birthplace Study of 2011?
Which ONE of the following statements represents the correct sequence of events in relation
to the mechanism of labour for a vertex presentation?
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. Th e emergency buzzer is pressed.
What is the next immediate step that should be performed?
13) Which one of the following statements is correct in relation to the third stage of labour?
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?
A 27-year-old primigravida has a vaginal examination at 1100 when she was found to be 6cm
dilated, left occipito-posterior position, vertex is 3cm above the ischial spines with + caput and no
moulding. She is commenced on oxytocinon for confirmed delay in the 1st stage of labour. She is
re-examined at 1400 and found to be 7cm dilated, left occipito-posterior position, vertex is 2cm
above the ischial spines with ++ caput and + moulding.
A 32-year-old woman in her first pregnancy at term has been in established labour for 14 hours
before a vaginal examination at 12:30 hours finds a fully dilated cervix, clear amniotic fluid, and the
fetal head at 0 station and in the right occiput anterior position. At 13:30 hours, she is unable to
resist the urge to push and starts voluntary efforts
17) During labour, flexion of the fetal head occurs
A senior labour ward sister asks you to work with her updating your unit s guideline about
whether mothers should be offered 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 offered delivery on the midwife- led unit?
While counselling a low-risk primigravida about planning her delivery, the following
information should be given to her:
A 28-year-old nulliparous woman on the midwifery-led unit is in advanced labour. She has had
an uncomplicated pregnancy. She has made acceptable progress in the first stage of labour. She is
now contracting three times every 10 minutes, the cervix is fully dilated and the head is 1 cm above
the ischial spines in occipitotransverse position. She has been in the second stage of labour for 30
Which of the following management options would you recommend?
A primigravida at 38+6 weeks of gestation is admitted with a history of abdominal pain and
clear fluid leaking vaginally for 5 hours. There are no other risk factors in her history. On examination
her observations are normal (pulse rate, blood pressure, temperature). She is having regular painful
uterine contractions 3 in 10 minutes and cervical dilatation is found to be 4 cm. Cardiotocography
was performed due to concerns about the fetal heart rate on auscultation. The CTG shows a baseline
fetal heart rate of 140–150 beats/min with no other non-reassuring or abnormal features.
21) What will be the next appropriate step?
A 35-year-old para 1 is transferred to labour suite from the community midwifery unit at 8cm
dilation following a spontaneous rupture of membranes where she was found to have grade 3
meconium. On admission to labour suite she has an urge to push. On examination the presenting
part is crowning. The fetal heart has been 80-90 bpm for four minutes. She does not deliver over
the next two contractions
. A 30-year-old woman in her first pregnancy is in spontaneous labour and has been using
nitrous oxide for analgesia. Vaginal examination a few minutes ago revealed that she is now fully
dilated. She has no urge to push.
What is the most appropriate plan of action?
A woman delivered her first baby spontaneously 40 minutes ago and had oxytocin (Syntocinon)
10 IU intramuscularly for active management of the third stage of labour. The placenta has still not
delivered, with no signs of separation. She is not bleeding, has intravenous access in situ and is
What would be the appropriate action?
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 man- agement?
A 35-year-old woman in her pregnancy at term is in the first stage of labour. She underwent
spontaneous rupture of membranes at 19:30 hours At 21:00 hours, vaginal examination revealed
that the cervix was fully effaced and 4 cm dilated. At 01:00 hours the partogram shows that uterus
has been contracting two to three times every 10 minutes and the cervical findings remain the same.
The fetal head is at −1 station with the sagittal suture in the transverse position.
27) . A primipara has been admitted at 4 cm with a breech presentation
Despite amniotomy at 5 cm, 2 hours later a primiparous woman is still 5 cm and only
contracting two in ten
A 31-year-old woman, G3P2, undergoes induction of labour due to post maturity at 41+5 weeks
of gestation. She had an artificial rupture of the fetal membranes and she was commenced on an
intravenous infusion of synthetic oxytocin (Syntocinon). Four hours later, she is reassessed and
found to be fully dilated with the fetal head at station 0 and a 'brow' presentation
29) Which of the following is the presenting diameter in her case?
While in labour, a woman in her first pregnancy at term is deemed to have an abnormal CTG at
6 cm dilation but is making good progress in labour. Fetal blood sampling (FBS) is performed and the
lactate level is 4.9 mmol/l. There was a small acceleration in the fetal heart rate during the process
of obtaining the blood sample. The cervix is 7 cm dilated after the FBS.
What is the recommended management?
A 32 years G1P0 comes with a history of spontaneous rupture of membranes and in labour. She
is 8 cm dilated and on examination the position of the fetus is left occipito transverse. The station is -
1. There is 2+ of caput and 1+ of moulding. She is contracting 4:10. 4 hours ago she was 8 cm dilated.
. A 23-year-old low-risk woman in her first pregnancy is now in established labour following
spontaneous rupture of membranes. Vaginal examination at 07:30 hours revealed cephalic
presentation and a fully effaced, 4 cm dilated cervix. There are regular uterine contractions of
increasing intensity at three to four every 10 minutes. At 11:30 hours, her cervix is 5 cm dilated with
the sagittal suture in the transverse position and no further descent of the fetal head. There is no
evidence of meconium or caput, and auscultation of the fetal heart is a normal pattern.
A 20-year-old primigravida at 39 weeks gestation was admitted to labour suite with regular
uterine activity. She was examined at 1000 and found to be 5cm dilated, vertex was 2cm above the
ischial spines with intact membranes. She is re-examined at 1400 and found to be 6cm dilated,
vertex is 1cm above the ischial spines with intact membranes
A low-risk 27-year-old G1P0 woman at 40+4 weeks of gestation presents to the labour ward
with regular abdominal uterine contractions. Her observations are normal. On examination the
uterus is soft and non-tender between palpable contractions with cephalic presentation. Vaginal
examination reveals a 5 cm dilated, fully effaced cervix with intact membranes, and the presenting
part is at –2 station above the spines.
She requests to use the birthing pool and pethidine as pain relief.
Regarding the use of pethidine, which of the following statements is correct?
A healthy 28-year-old low-risk, primigravid woman attends a routine antenatal appointment at
28 weeks with her midwife. Th e 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 after delivery would be.
Which would be the best advice?
A 32 year old G7P6 with history of 6 vaginal deliveries is seen on the labour ward. She 41 + 6
weeks and having is 2 contractions every 10mins. Cervical dilatation is 6cm at present. It was 5cm
with a fully effaced cervix 4 hours ago and 4 cm 8 hours ago while she was on the antenatal ward.
A woman with gestational diabetes, but no other medical problems, has just delivered twins.
Twin 1 was delivered by forceps due to a delay in the second stage of labour. Twin 2 delivered
A 37 year old G2P1 is transferred from the antenatal ward where she is having induction of
labour at 41 weeks + 5 days to the labour ward. On rupturing the membranes, there is prolapse of
the umbilical cord. The CTG is normal, cervix is 3cm dilated and she is not contracting
A 26-year-old woman – G1P0 at 38+5 weeks of gestation – presents to the labour ward with
regular painful contractions for the past 3 hours, preceded by a gush of clear fluid. On examination,
she is contracting twice in every 10 minutes. Abdominal examination reveals that the fetus is in
cephalic presentation with the fetal head 3/5 palpable. Initial vaginal examination reveals an effaced
cervix, which is 5 cm dilated. The head is at station –1 to the spines with no caput or moulding. The
position is not defined and there is clear liquor draining. At 4 hours later, a second examination
reveals that the head remains at station –1 and the cervix is still 5 cm dilated. The frequency of
contractions has increased to five in every 10 minutes for the past 30 minutes
Which is the most appropriate action?
A 33-year-old woman is induced at 38 weeks because of mild pre-eclampsia. She wants to know
how she would benefit from continuous electronic fetal monitoring as she felt it may limit her
freedom of movement during labour.
What will you tell her?
A 27-year-old woman is in labour for the second time. Clinical findings on vaginal examination
are as follows. At 06:30 hours, there is cephalic presentation, and a 4 cm dilated, 0 5 cm long central,
soft cervix. At 10:30 hours, there is cervical dilation of 5 cm and a fully effaced cervix and intact
membranes. At 12:30 hours, the cervical findings are unchanged, but no membranes are felt.
. 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
A 26-year-old G2P1 woman with a low risk pregnancy presents at 41 weeks of gestation in
spontaneous labour. She was transferred to the labour ward from the birth unit as she has been
pushing for 2 hours and not yet delivered.
She has had a normal progress in labour to date and no CTG concerns on arrival. Findings were:
• vital signs normal
• per abdominal examination – less than one-fifth palpable
vaginal examination – os fully dilated, presenting part vertex at spines, ROP, caput + and
43) What would be your preferred line of management?
A 26-year-old G1P0 at 40+5 weeks of gestation presents to the labour ward with regular painful
contractions for the past 3 hours. On examination, she is contracting 4 in every 10 minutes and the
contractions are strong. Abdominal examination reveals that the fetus is in a cephalic presentation
with the fetal head 3/5 palpable. Initial vaginal examination reveals an effaced cervix, which is 4 cm
dilated. The fetal membranes are intact and the head is at station -1 to the spines with no caput or
moulding. The position is not defined. At 4 hours later, a second examination reveals that the head
remains at station –1 and the cervix is still 4 cm dilated despite ongoing adequate contractions.
44) Which is the most appropriate management intervention?
What is the recommended uterotonic regime for routine management of the third stage at
. A 30-year-old nulliparous woman is in established labour at term in a low-risk birthing unit. She
is transferred to an obstetric unit with thick meconium and her cervix is 6 cm dilated. A continuous
CTG is commenced.
46) Which of the following indicates an abnormal CTG?
A 40-year-old para 1 is admitted to labour suite in spontaneous labour. She has been fully
dilated for two hours. She is examined and found to be fully dilated, left occipito-anterior position,
vertex is 1cm below the ischial spines with + caput and no moulding.
A 32-year-old primigravida at 41 weeks gestation had an amniotomy for confirmed delay in
the first stage of labour at 5cm dilated. She is contracting three times in ten minutes.
. A low-risk 34-year-old woman in her second pregnancy is admitted 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?
50) What percentage of women with PROM at term will go into labour within the next 24 hours?
A 25 year G2P0 who is 37 weeks pregnant is having induction of labour for Obstetric
Cholestasis. She had propess followed by 3 mg of prostin. The Bishops score remains 1. She has a
history of multiple abdominal surgeries as a child.
A 36 year old G1P0 in established labour is seen on the labour ward. She is having 4
contractions every 10 min. No liquor has been seen. Cervical dilatation was 4 cm 4 hours ago and is
A woman in the first stage of labour is diagnosed with inadequate progress. The CTG trace is
classified as suspicious, and a plan is made to conduct a category 2 caesarean section.
Within how many minutes from the decision should the baby be delivered?
54) . A primipara admitted at 4 cm with intact membranes who, 3 hours later, is 5 cm
A 37 year old G2P1 is transferred from the antenatal ward to labour ward. She is having
induction of labour at 41 weeks + 5 days. On examination, something pulsating is felt through the
membranes. The CTG is normal and the cervix is 3cm dilated. She is not contracting.
Your score is