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Labor - Labor and delivery part 2

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1) A  20-year-old primigravida attends the day assessment unit at 23  weeks gestation

with increased vaginal discharge and abdominal discomfort. Abdominal examination

confirms a soft non-tender uterus, and vaginal examination reveals a soft cervix with no

bleeding or draining. Transvaginal scan shows a cervix of 1.5 cm length.

 

2) A 30-year-old third gravida with dichorionic diamniotic twin pregnancy at 37 week of

gestation has spontaneous onset of labour. Fifteen minutes after the first twin delivery,

uterus is found to be relaxed, with fetal head in the pelvis at –2 station. Fetal heart rate

is 146 bpm with good variability

3) A 30-year-old primigravida is admitted in spontaneous labour at term. She has good

uterine contractions. The partogram reveals cervical dilatation at 12 noon to be 4 cm

and at 4 pm it is 5 cm. Oxytocin infusion is started. At 8 pm she is found to be fully

dilated, when she is encouraged to push. At 10 pm vertex is found to be at +1 station

with ROT position. Manual rotation is attempted twice followed by rotation with kiwi

cup under pudendal block but is unsuccessful. Position is still ROT.

 

4) The CTG shows a baseline rate of 150 beats per minute (bpm). Accelerations are

absent and variability is 7 bpm. There are shallow decelerations occurring with

contractions, and the fetal heart rate is falling by 20 bpm from the baseline and

lasting 30 seconds, mirroring each contraction for 80 minutes. Contractions are

four every 10 minutes. What is the overall classification?

5) A 23-year-old primigravida at 38 weeks gestation complains of reduced fetal movements

for the past 2 days. Her antenatal course was uneventful and her current observations

are within normal limits. Further evaluation shows normal estimated fetal weight on

ultrasound with marked oligohydramnios and normal UA and MCA Doppler study.

She denies any vaginal discharge. Vaginal examination shows a Bishop score of 5 and

membrane sweep has been done.

6) An 18-year-old primigravida attends the day assessment unit at 36  weeks gestation

with loss of fetal movements. She  was diagnosed with obstetric cholestasis and was

started on ursodeoxycholic acid 3 weeks ago. Ultrasound confirms intrauterine fetal

demise. She and her partner are counselled and initial blood tests are done. She opts for

immediate obstetric management.

 

7) A 24-year-old woman is noted to throw tonic-clonic convulsions when she attends the

delivery suite. She is a primigravida at 30 weeks gestation and is being monitored in the

antenatal ward for pre-eclampsia

 

8) 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.

9) 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.

 

10) A 27-year-old woman presents with abdominal cramps and vaginal bleeding at term

+2 days in her second pregnancy. Her blood group is rhesus negative and was given

anti-D after her first delivery. Further tests confirm placental abruption and fetal

demise. She looks pale with a PR of 100 bpm, and her BP is 100/60 mmHG. Her Bishop

score is 3. Immediate intravenous access is obtained and blood tests are sent.

11) A 30-year-old primigravida comes to the delivery suite with regular uterine contractions

and leaking vaginal for 4 hours. She  has completed 39  weeks gestation, with an

uneventful antenatal period. She perceives fetal movements well. On examination, it

was found that her uterus is contracting well and vaginal examination reveals a 4 cm

dilated, well-effaced cervix, with vertex at –3 station. Clear liquor is noted.

12) A 29-year-old primigravida is being reviewed at term +10 in the consultant antenatal clinic.

Her BMI is 28. She  perceives movements well and admission CTG is normal. Vaginal

examination shows a Bishop score of 3 and has had a stretch and sweep by her midwife.

 

13) A primigravida is being induced for oligohydramnios and reduced fetal movements at

39 weeks gestation. She is known to have an 8 cm fibroid near the fundus. Serial growth

scans are within normal limits. Oxytocin infusion is commenced and continuous fetal

heart monitoring is reassuring. She was noted to be 4 cm dilated and an amniotomy was

performed. Four hours later repeat examination shows cervix to be 6 cm dilated, with

minimal clear liquor draining.

14) 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.

 

15) A 38-year-old second gravida with previous normal delivery at term presents at 26 weeks

gestation with leaking vaginal. She denies any pain or bleeding and examination shows a

soft non-tender uterus with no cervical changes. Pooling of liquor is seen in the posterior

fornix. Her antenatal period was otherwise normal and anomaly scan was also normal.

16) The CTG shows a baseline rate of 140 bpm. Accelerations are absent. Variability

has been 3 bpm for 25 minutes. There are variable decelerations present, each

lasting 70 seconds with every contraction for a duration of 40 minutes, with a

delayed recovery and no shouldering. Contractions are three every 10 minutes.

How should the decelerations in the CTG trace be described?

17)  

A  29-year-old lady presents with PPROM at 34  weeks gestation to the delivery

suite. She is not in active labour and receives a course of steroids and erythromycin.

She presents 2 days later feeling unwell. Her abdomen shows a soft non-tender uterus

with reassuring fetal heart. Labour is induced in view of raised CRP. At 4 pm her cervix

is found to be 4 cm dilated with absent membranes. Four hours later, the cervix is found

to be fully dilated and she is encouraged to bear down with the contractions. Two hours

later, fetal heart monitoring reveals late decelerations and the vertex is at +2 station with

LOA position.

18) A 27-year-old woman presents in labour at 6 cm dilated. She is a smoker and

reports a 1-week history of productive cough and pleuritic-type chest pain.

Oxygen saturation is 94% at rest. What labour analgesia in particular should be

avoided for this woman?

19) A  26-year-old woman presents to the delivery suite with painful contractions and

vaginal bleeding. She is currently 35 weeks pregnant and abdominal examination shows

a tense uterus with an uneffaced cervix and vaginal bleeding

 

20) A  22-year-old third gravida presents at 29-week gestation with leaking vaginal. On

examination, she is found to have regular uterine contractions, and her fetus is felt in

the transverse position. Cervix is found to be 4 cm dilated.

 

21) A 23-year-old woman with two previous normal deliveries attends the antenatal clinic at

37 weeks gestation with backache. Her current pregnancy is a dichorionic diamniotic twin

gestation with no comorbidities. Both fetuses show normal growth pattern in cephalic

presentation. Her Bishop score is 5. An elective induction is due at 38 weeks gestation.

22) A  24-year-old-parous woman has a spontaneous water birth at term. After 5 minutes,

profuse bleeding is noted and a big mass is noted at the introitus. The mother then becomes

unconscious.

23) A 22-year-old woman with a history of epilepsy presents in labour. She has been

seizure free for 7 years while not taking any anti-epileptic medications. What

method of pain relief should be avoided in this situation?

 

24) A 30-year-old primigravida presents with loss of fetal movements for the past 2 days

at 30 weeks gestation. She also recollects having dark urine for the past 2 weeks. On

examination she is found to be icteric, dehydrated and tachycardic. Ultrasound

examination, confirms fetal demise and blood analysis shows severely deranged liver

enzymes with INR of 3.0. Vaginal examination shows a very unfavourable cervix

 

25) A 28-year-old woman presents to the antenatal clinic at 32 weeks gestation with loss

of fetal movements for the past 2  days. Her antenatal period was uneventful except

fetal bilateral pelviectasis at 20-week anomaly scan, which was reported to be normal

on a subsequent ultrasound scan. Clinical examination is normal, but an obstetric

ultrasound reveals fetal demise.

 

26) The CTG shows a baseline rate of 150 bpm and accelerations are present.

Baseline variability is 8 bpm, and there are decelerations, with the fetal heart rate

dropping by 50 bpm and lasting 70 seconds. The decelerations start following each

contraction for the last 25 minutes in a 40-minute trace. Contraction frequency is

four every 10 minutes. What is the overall categorisation of the CTG?

 

27) A 30-year-old woman is labouring in her second pregnancy at 38 weeks gestation. Her first

pregnancy was a planned Caesarean section for breech presentation. Epidural pain relief

is given and she is being monitored by continuous cardiotocography. She has good uterine

contractions and vaginal examination done an hour ago showed 6 cm dilated cervix with

vertex at –3 station. Sudden bradycardia to 82 bpm lasting for 2 minutes is noted.

 

28) A  33-year-old primigravida attends the DAU at 33  weeks gestation complaining of

abdominal pain and leaking vaginal. On examination, she is noted to have regular

uterine contractions with partially effaced cervix.

 

29) A 28-year-old third gravida is admitted in spontaneous labour at term +4 gestation.

Her previous deliveries were normal at term. She is progressing well and is being

monitored by regular, intermittent auscultation. She was noted to be 4 cm dilated and

an amniotomy was done. Clear liquor was seen. Four hours after amniotomy, vaginal

examination is repeated as the uterine contractions are 4–5 in 10 minutes with stronger

intensity. Cervical lips are found to be very thick and edematous with 6 cm dilatation.

Vertex is at –3 station with marked caput and moulding formation.

30) A 27-year-old third gravida presents at 38-week gestation to the obstetric day care unit

with leaking vaginal. On examination, she is noted to have mild contractions. Fetal

heart rate is 140 bpm. Vaginal examination shows a soft pulsatile mass in the vagina.

31) A  28-year-old primigravida is being induced for gestational diabetes. She  is now  at

38 weeks gestation and is on insulin therapy. Her recent blood sugars and HbA1c were

high. She has had vaginal prostaglandin E2 gel instilled the previous night. The following

morning, her cervix is found to be 0.5 cm long and 2 cm dilated. Oxytocin infusion

is started after amniotomy with continuous fetal heart monitoring. Four hours later,

vaginal examination reveals a 4-cm dilated cervix. Four hours later, she is found to

have a fully dilated cervix with vertex presentation at –2 station. She is encouraged to

push and 2 hours later vertex is at +2 station with a small caput and fetal heart rate is

reassuring.

 

32) 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.

33) A 29-year-old primigravida is admitted in spontaneous labour at 39 weeks gestation.

She  is known to have idiopathic thrombocytopenic purpura and is on steroids. Her

current blood reports are normal. She is noted to be fully dilated with vertex at 0 station

4 hours after admission. Amniotomy is done and she is encouraged to push. Vertex is in

LOA at pelvic floor level. Fetal heart shows late decelerations

34) A 30-year-old lady is being induced at 10 days post-term. She has a forceps delivery

under epidural anaesthesia. Thirty seconds following the delivery of the head, difficulty

is encountered.

 

35) A 26-year-old woman is being seen in the antenatal clinic with a history of anxiety.

She wants to avoid any sort of medication in labour. What single non-invasive

measure is likely to provide her with the lowest perception of pain in labour?

 

36) A 24-year-old woman who is a third gravida attends the antenatal clinic with her thirdtrimester ultrasound report at 37  weeks gestation requesting delivery by Caesarean

section. Her previous two pregnancies were spontaneous miscarriages at 8 and 10 week

gestations, respectively. She  underwent surgical terminations and had received

anti-D both times. Her indirect Coombs test has been negative. She is noted to have

polyhydramnios with an AFI of 20. Fetal umbilical and middle cerebral artery Doppler

study is within normal limits. No other obvious anomalies were noted

 

37) A  24-year-old woman in her second pregnancy was referred from the radiology

department following an ultrasound at 24  weeks gestation. She  was diagnosed with

monochorionic diamniotic twin gestation earlier. Her ultrasound study today showed

fetal demise of one twin and a well-grown second twin. Counselling has been offered

and initial blood tests have been sent.

 

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