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operative vaginal delivery -Labor anddelivery part2

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1)

A 29-year-old woman at term is admitted in spontaneous labour and progresses to being
fully dilated. She has been actively pushing for 90 minutes. On abdominal examination there
is 0/5th of the head palpable. Vaginal examination reveals the position is left
occipitotransverse, and there is evidence moulding of 1and caput 2. The station is 1 below
the ischial spines.

2)

You were asked to see a 29-year-old nulliparous woman in the active second stage of
labour, pushing for about an hour and exhausted, asking for a caesarean section. She was
induced at 38 weeks for type 1 diabetes and suspected macrosomia. She is contracting 4 in
10 minutes and the CTG is normal. Per abdomen, 0/5th head was palpable and you have
confirmed full dilatation, absent membranes, right occipito-posterior (ROP) position with the
vertex at spines and descent to +1 during pushing.
What is the most appropriate management plan?

3)

A 30 year old woman in her second pregnancy at 40 weeks gestation has progressed well in
labour and has been effectively pushing for the last 90 mins. She was fully dilated 2 and half
hours ago. There is no palpable head on abdominal examination. Vaginal examination
shows the vertex to be in occipito anterior position and at 2cm below the ischial spines.
There is 3 + of caput and no moulding. The CTG is showing late decelerations. Her first baby
was delivered by spontaneous vaginal delivery.

4)

30year oldwoman collapsed on the ward following an uneventful Kjelland's forceps
delivery. Her Hb dropped from 12.0 to 6.0 despite no bleeding per vaginum.

5)

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?

6)

You are the Labour Ward specialty trainee called to assess a multiparous woman in
labour at 42 weeks of gestation. Fetal membranes ruptured prior to the onset of
contractions 12 hours ago. Full dilatation was diagnosed 2 hours ago and there has
been no descent of the fetal head despite 1.5 hours of active pushing. Diamorphine
was given for analgesia 3 hours ago. Your examination reveals that the fetus is in
cephalic presentation with 2/5 of the head palpable abdominally. You confirm full
dilatation. The fetus is in the direct occipito–posterior position with a caput of 2+ and

moulding of 1+. The presenting part is at station 1. The fetal CTG is reassuring.
What is the most appropriate management, given the above findings?

7)

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

8)

A gravida 2 para 1 (previous normal vaginal delivery) has gestational diabetes and is
on insulin. She was induced at 38 weeks of gestation. The baby is large for dates.
The second stage has lasted 2.5 hours, and she has been pushing since she was
fully dilated. The CTG shows deep early decelerations. Two fifths pole are palpable
per abdomen. Vaginal findings – vertex at +1 station, LOT, slightly deflexed, caput ++

9)

A 28 year old G2P1 is in spontaneous labour at 41 weeks gestation. She is having 4
contractions every 10 min and on examination the cervix is fully dilated and vertex is at +1
and occipito anterior position. She had spontaneous rupture of membrane while doing the
vaginal examination and cord is felt.

10)

You are called to see a primiparous woman in second stage of labour. She is 39 weeks
pregnant and was fully dilated 1 hour ago. She is having irregular contractions every 4
minutes. The CTG is satisfactory. Vaginal examination shows the vertex to be in left occipito
posterior position, at the level of the ischial spines. There is no caput or moulding.

11)

A primigravida has been in the second stage of labour for 3 hours, and has been
pushing for 2 hours. The head is onefifth palpable. Vaginal findings – vertex is at +1
station, ROP with caput +, moulding +. The CTG is reassuring

12)

A 24 year old G3P2 with one previous caesarean section followed by a successful vaginal
birth is seen on the labour ward at second stage of labour. She is 41 weeks pregnant and
her labour has progressed well in the first stage up to 8cm. Subsequently it took her 5 hours
to progress from 8cm to full dilatation. She has been pushing effectively for1 hour. On
examination there is a fifth of
the fetal head palpable abdominally. On vaginal examination the vertex is in occipito
transverse position with 2 + of caput and reducible moulding. The vertex is at the level of the
ischial spines and the CTG is satisfactory.

13)

A 29-year-old woman at term is admitted in spontaneous labour and has progressed to
being fully dilated. She has been actively pushing for 60 minutes. On abdominal examination
the head is 0/5th palpable. Vaginal examination reveals the position is direct occipitoanterior,
there is no caput and moulding, and the station is 2 below the ischial spines.

14)

You were asked to see a para 2 woman in spontaneous labour at term who
has been in the active second stage of labour for more than an hour and
has maternal exhaustion. She is contracting 4–5 in 10 minutes and the cardiotocograph
(CTG) is normal. Abdominal examination reveals that the head is not palpable per abdomen.
She presents a fully dilated cervix, absent membranes, with a left occipitoanterior position
with the vertex at +1 station.
You have decided to proceed with an operative vaginal delivery with the woman’s consent.
Which one of the operative vaginal deliveries would you be performing at this stage?

15)

A 28yearold woman had an episiotomy performed following a forceps delivery. She
has complained of a painful lump

16)

A 29-year-old woman at term is admitted in spontaneous labour and progresses to being
fully dilated. The woman has been actively pushing for 60 minutes. On abdominal
examination the head is 0/5th palpable. Vaginal examination by the midwife has been unable
to determine the position. The station is at the level of the ischial spines.

17)

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 vari- able 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 man- agement step?

18)

A 32-year-old woman in her first pregnancy has had a low-cavity forceps delivery for
prolonged second stage under spinal anaesthesia. After delivery she is noted to have
excessive vaginal bleeding. On examination she is noted to have excessive blood loss and
to appear pale. The pulse is noted to be 110 beats/minute and blood pressure
120/70mmHg. Abdominal examination reveals that the uterus is well contracted.
Examination of the placenta confirms it to be complete.

19)

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

20)

A gravida 2 para 1 (previous normal vaginal delivery) is in prolonged labour. No pole
is palpable per abdomen. Vaginal findings – vertex at + 1 station, LOA, caput ++
over occiput. CTG shows deep variable decelerations. There is poor pushing in spite
of good contractions due to maternal exhaustion

21)

A primigravida woman with a history of idiopathic thrombocytopenic purpura has been
in the second stage of labour for 2 hours and actively pushing for 1 hour. No pole
is palpable per abdomen. The vertex is at +2 station, ROA, no caput, no moulding

22)

A gravida 2 para 1 (previous normal vaginal delivery) is now in spontaneous labour.
There is normal progress to cervical dilatation of 7 cm, then 6 hours to full dilatation

Contractions are two in 10. No fetal head is palpable per abdomen. The head is at
the spines and is in the direct OP position. The CTG is normal

23)

You are called to see a 31 year old G2P1 with previous baby delivered by spontaneous
vaginal delivery with no complications. You are asked to see her because of CTG
abnormalities. The CTG shows baseline rate 170bpm, reduced variability for the last 30min
and short lasting early decelerations. On vaginal examination, the cervix is found to be 10
cm dilated. It was 6 cm 2 hours ago. The vertex is at the level of the ischial spine, in occipito
anterior position and there is 1+ caput and no moulding. The liquor is significantly meconium
stained.

24)

A 34 year old G2P1 is in the 2nd stage of labour. She is 33+4 weeks gestation. On
examination, the vertex is at +1 and Left occipito transverse position. CTG is abnormal.

25)

You are called to see a 22 year old G2P1 who has not delivered after 1 hour of effective
pushing. On vaginal examination, the fetal mouth, nose and the orbital ridges can easily be
felt. The chin of the foetus can also be felt and it is pointing towards the symphysis pubis of
the mother. The presenting part is about 2 cm below the ischial spines. The CTG is
satisfactory

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.What is the most appropriate
course of action?

26)  

You were asked to see a 29-year-old nulliparous woman in the active second stage of
labour, pushing for about an hour and exhausted, asking for a caesarean section. She was
induced at 38 weeks for type 1 diabetes and suspected macrosomia. She is contracting 4 in
10 minutes and the CTG is normal. Per abdomen, 0/5th head was palpable and you have
confirmed full dilatation, absent membranes, right occipito-posterior (ROP) position with the
vertex at spines and descent to +1 during pushing.

27) What is the most appropriate management plan?

28)

A 42 year old G1P0 is seen on the labour ward rounds. Labour has progressed well and she
has been fully dilated for 2 hours and pushing for the last 1 hour. There is no palpable head
on abdominal examination. Vaginal examination shows the vertex to be in left occipito
anterior position and at 1cm below the ischial spines. There is 1 + of caput and no moulding.
The CTG is normal. She conceived by IVF after trying for 6 yrs.

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