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Shoulder dystocia, cord prolapse - Labor and delivery part2

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1) True statement regaerding shouilder dystocia;

2) A primip has a shoulder dystocia requiring delivery of the posterior arm to deliver the baby.

What is the approximate chance, in the general population, of having a permanent brachial plexus
injury from shoulder dystocia?

3) Episiotomy

A primip is in the assessment unit. She has so far been midwifery led care, but scan today for
presentation showed the baby to be cephalic with an estimated fetal weight of 4235g.

4) What is the approximate chance of shoulder dystocia occuring for this woman?

5)

Flexion of the fetal head with pressure superiorly until the fetal head is back in the vagina,
and then deliver by caesarean section

You undertake an instrumental delivery on a 30-year-old primip for prolonged second stage. You
notice the turtle sign and diagnose shoulder dystocia with the next contraction when you are unable
to deliver the shoulders.

6) What manoeuvre is where you insert your fingers posterior to the anterior shoulder of the baby?

7)

Mrs X, primigravida at term is in second stage of labour. After delivery of the fatal head,
shoulder dystocia was diagnosed and the McRoberts manoeuvre has nor effected the delivery of
the shoulders, which is the next method to be used:

8)

A 28-year-old woman presents in spontaneous labour at 41 weeks gestation with a cephalic
presentation in her third pregnancy hav- ing had two previous normal births. At the onset of the
second stage, she ruptures her membranes and the fetal heart rate decel- erates. 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?

9)

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

10) Reverse wood screw

11)

A Gravida 4 Para 3 (three normal deliveries at term) is admitted in preterm labour at 36 + 5
days. She is known to have polyhy- dramnios but relevant antenatal investigations have been
normalAn 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 mem- branes 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?

12)

A 27-yr old woman presents in her third pregnancy. Her second delivery was complicated by
shoulder dystocia following a post-dates induction of labour. The baby weighed 3.6 kg and is fit
and well now. Her old notes are not available but she recalls the midwives moving her legs and
the baby came out . She is now at 20weeks and has not yet thought about the delivery of this
baby

13)

A woman known to have an unstable lie calls the labour ward describing leaking fluid and a
cord dangling between her legs. Your colleague arranges ambulance transfer for the woman

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

15) . McRoberts

16)

. In shouldr dystocia, following manuover is known as;
Flexion of the fetal head with pressure superiorly until the fetal head is back in the vagina, and then
deliver by caesarean section

17)

Flexion and abduction of the maternal hips, with pressure behind the anterior shoulder down
and laterally.

18) All are true in umbilical cord prolapse except

19)

A 38-yr old woman in her first pregnancy with gestational diabetes is seen at 37 weeks
following a growth scan. The growth velocity is normal, with an estimated fetal weight of 4.8 kg,
normal AFI and normal Dopplers. She is keen for the safest mode of delivery for her baby.

A primip is in the assessment unit. She has so far been midwifery led care, but scan today for
presentation showed the baby to be cephalic with an estimated fetal weight of 4235g.

20) How many cases of shoulder dystocia have at least one significant risk factor?

21)

A grandmultiparous woman in precipitant labour is found to have a cord prolapse. She is fully
dilated on vaginal examination. CTG shows a prolonged deceleration

22) What is the most common reason for litigation following a shoulder dystocia?

23)

A woman attends the labour ward by ambulance after experiencing a cord prolapse when
her membranes ruptured at home at 36 weeks of gestation. There are no signs of labour

24) Rubin II

25)

You return from gynaecology theatres and hear the emergency buzzer going off on labour
ward. On arrival you find a multiparous woman with no analgesia in the McRoberts position, with
a large episiotomy. Your junior obstetrician tells you that he has tried all of the internal
manoeuvres as well as suprapubic pressure but the baby has not been delivered after three mins.
An obstetric emergency call has been put out.

26)

.In shoulder dystocia, following manuover is known as;
Flexion and abduction of the maternal hips, with pressure behind the anterior shoulder down and
laterally.

27)

A para 0+5 (5 miscarriages), IVF pregnancy, gestation of 23+0, is confirmed to have
premature rupture of membranes and a cord prolapse

28)

You arrive in the labour ward room following the emergency buzzer. The midwife tells you
she has diagnosed shoulder dystocia. The woman has an epidural and is in McRoberts position,
with the coordinator applying suprapubic pressure.

29)

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

30)

An obese 36-year-old primigravid Jehovah s Witness labours spontaneously at term. T e 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. T e woman is put into McRoberts position.

shoulder dystocia is announced, and help is called for. T e woman is put into McRoberts position.
What is the next most appropriate immediate course of action?

31)

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

32)

You are called to assess a 25-year-old G3P2 in labour at 39 weeks of gestation.
She has an epidural in situ and is contracting strongly and regularly at 4:10. At the last vaginal
examination 1 hour ago she was 5 cm dilated. Spontaneous rupture of the fetal membranes
occurred 20 minutes ago, since which there have been late decelerations associated with each
contraction.
A. Intravenous fluid bolus
B. Left lateral positioning
C. Terbutaline 0.25 mg subcutaneously
D. Trendelenburg position
Which of the following is your first action?

33)

A 25-year-old healthy woman has a normal labour and a spontaneous delivery of the fetal
head. On expulsion of the head, the head remains tightly applied to the vulva. The midwife
activated the emergency buzzer and declared that there is shoulder dystocia. You attended
immediately.
How will you confirm your diagnosis?

34)

A community midwife attending a planned home birth experiences a cord prolapse at 4 cm
dilatation. She has called an ambulance.

35) Suprapubic pressur

36) Regarding shoulder dystocia, which of the following statements is true?

37)

You pop your head into birthing unit room 3 as the junior midwife has called for assistance at
her third delivery as a qualified midwife. The woman is just delivering and you notice that there
was difficulty in delivering the head and the chin. There is no restitution. You pull the emergency
buzzer for help.

38)

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?

39) Fingers posterior to the anterior shoulder

40)

A woman is brought to the labour ward by ambulance at 40 weeks of gestation. Her community
midwife was performing a stretch and sweep at home when the fetal membranes ruptured 30
minutes ago. Cord was palpated below the vertex. The cervix is 2 cm dilated.
What is your immediate management?

You are conducting a low forceps delivery for a prolonged second stage of labour on a
multiparous woman at 42 weeks of gestation. Labour was of spontaneous onset but required
oxytocin augmentation during the first stage. The head has delivered slowly in an occipito–anterior
position and has not undergone restitution.
With the next contraction you apply gentle traction in an axial direction (with reference to the fetal
spine) for 30 seconds. Delivery is not achieved.

41) What is the first most appropriate step in your management?

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