Shoulder dystocia, cord prolapse – Labor and delivery part2

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Shoulder dystocia, cord prolapse - Labor and delivery part2

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

A) All women at term with suspected macrosomia

B) . Diabetic women with suspected macrosomia s

C) Prelabour rupture of membranes at term

D) Previous shoulder dystocia

E) Women with previous two caesarean birth

2) True statement regaerding shouilder dystocia;

A) The majority of shoulder dystocias can be predicted

B) Prenatal ultrasound is a reliable tool in predicting macrosomia

C) Shoulder dystocias occur approximately 10-times more frequently after a mid-cavity forceps delivery than after a SVD

D) All women who have had a previous shoulder dystocia should have an elective caesarean section

E) If a woman has had a shoulder dystocia in her first pregnancy she has a 40-fold increase in risk of having shoulder dystocia in a subsequent pregnancy

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?

A) Anticipation of normal delivery and encouragement to push

B) Bladder filling to displace the fetal head and replacement of the prolapsed umbilical cord

C) Category 1 caesarean section under general anaesthesia

D) Digital elevation of the fetal head and category 2 caesarean section with regional anaesthesia

E) Immediate operative vaginal delivery with ventouse extraction

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?

A) Adopt all fours position

B) Attempt delivery of the posterior arm

C) Attempt Zavanelli maneuvre

D) Downward traction

E) Fundal pressure

. 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

A) Reverse Wood screw

B) Rubin II

C) Symphysiotomy

D) Wood screw

E) Zavanelli

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.

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

A) 1%

B) 4%

C) 10%

D) 22%

E) 31%

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

A) Perform an instrumental delivery

B) Administer subcutaneous terbutaline

C) . Cat 1 ceserean section

D) . Fill urinary bladder

E) Confirm presence of fetal heart with ultrasound

F) Manual replacement of cord

G) . Expectant management

H) Adopt knee to chest positio

10)

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?

A) Amniotic fluid embolism

B) Breech presentation

C) Cord prolapse

D) Placental abruption

E) . Shoulder/arm prolapse

11)

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

A) Perform an instrumental delivery

B) Administer subcutaneous terbutaline

C) . Cat 1 ceserean section

D) . Fill urinary bladder

E) Confirm presence of fetal heart with ultrasound

F) Manual replacement of cord

G) . Expectant management

H) Adopt knee to chest positio

12) All are true in umbilical cord prolapse except

A) Umbilical artery vasospasm leads to asphyxia in the fetus

B) Ultrasound has a high sensitivity for predicting cord prolapse

C) The incidence of cord prolapse in breech presentation is 1%

D) Cord compression can be reduced by filling the bladder with 500 ml saline

E) Cord prolapse can occur without any physical signs and with a normal fetal heart rate pattern

13)

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

A) McRoberts

B) Reverse Wood screw

C) Rubin II

D) Suprapubic pressure

E) Wood screw

14)

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?

A) . Intravenous fluid bolus

B) Left lateral positioning

C) Terbutaline 0.25 mg subcutaneously

D) Trendelenburg position

E) Vaginal examination

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

A) Birth asphyxia

B) Brachial plexus injury

C) . Clavicular fracture

D) Humeral fracture

E) Maternal trauma

17)

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:

A) All-fours position

B) Delivery of posterior arm

C) Suprapubic pressure

D) Internal rotation manoeuvres

E) Zavanelli manoeuvre

18)

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?

A) Ask the woman to push.

B) Change the position of the woman to the all-four position.

C) Do a mild traction in an axial direction to confirm the diagnosis.

D) Do a mild traction in different directions.

E) . Inform the consultant.

19)

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?

A) Downward traction of fetus.

B) Posterior axilla sling with a Foley catheter.

C) Routine axial traction of fetus.

D) Rubin II manoeuvre.

E) Zanvanelli manoeuvre.

20) 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?

A) 1 in 10

B) 1 in 100 C

C) 1 in 1000

D) 1 in 10 000

E) 1 in 100 000

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

A) Perform an instrumental delivery

B) Administer subcutaneous terbutaline

C) . Cat 1 ceserean section

D) . Fill urinary bladder

E) Confirm presence of fetal heart with ultrasound

F) Manual replacement of cord

G) . Expectant management

H) Adopt knee to chest positio

22)

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?

A) Caesarean section, category 1

B) Confirm the presence of a fetal heart by an ultrasound scan

C) . Expectant management

D) . Manually replace any loops of prolapsed cord

E) Terbutaline 0.25 mg subcutaneously

23)

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

A) Perform an instrumental delivery

B) Administer subcutaneous terbutaline

C) . Cat 1 ceserean section

D) . Fill urinary bladder

E) Confirm presence of fetal heart with ultrasound

F) Manual replacement of cord

G) . Expectant management

H) Adopt knee to chest positio

24) Rubin II

A) Facilitates access

B) . Reduces the bisacromial diameter of the fetus

C) Reduces anteropost diameter of pelvis

D) . Moves shoulders to larger diameter of the pelvis

E) . Increases the anteroposterior diameter of the pelvis

F) Increases transverse diameter of pelvis

25) Reverse wood screw

A) Facilitates access

B) . Reduces the bisacromial diameter of the fetus

C) Reduces anteropost diameter of pelvis

D) . Moves shoulders to larger diameter of the pelvis

E) . Increases the anteroposterior diameter of the pelvis

F) Increases transverse diameter of pelvis

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.

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

A) . Call for help

B) . Internal manoeuvres

C) McRobert's position

D) Suprapubic pressure

E) Zavanelli's maneouvre

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.

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

A) Reverse wood screw

B) Rubin II

C) . Symphysiotomy

D) Wood screw

E) Zavanelli

29) . McRoberts

A) Facilitates access

B) . Reduces the bisacromial diameter of the fetus

C) Reduces anteropost diameter of pelvis

D) . Moves shoulders to larger diameter of the pelvis

E) . Increases the anteroposterior diameter of the pelvis

F) Increases transverse diameter of pelvis

30)

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?

A) Hyperflex and abduct maternal thighs onto her abdomen

B) Hyperflex and adduct maternal thighs on her abdomen

C) . Perform an episiotomy

D) Place the mother in a lithotomy position

E) Provide fundal pressure

31)

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

A) Perform an instrumental delivery

B) Administer subcutaneous terbutaline

C) . Cat 1 ceserean section

D) . Fill urinary bladder

E) Confirm presence of fetal heart with ultrasound

F) Manual replacement of cord

G) . Expectant management

H) Adopt knee to chest positio

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

A) A large majority of infants with a birth weight of ≥4500 g do not develop shoul- der dystocia.

B) All women with history of shoulder dystocia should be offered elective caesarean section in their subsequent pregnancies.

C) Conventional risk factors predicted about 96 % of shoulder dystocia that resulted in infant morbidity.

D) Induction of labour prevents shoulder dystocia in nondiabetic women with a suspected macrosomic fetus.

E) While managing shoulder dystocia, suprapubic pressure should not be used

33) Suprapubic pressur

A) Facilitates access

B) . Reduces the bisacromial diameter of the fetus

C) Reduces anteropost diameter of pelvis

D) . Moves shoulders to larger diameter of the pelvis

E) . Increases the anteroposterior diameter of the pelvis

F) Increases transverse diameter of pelvis

34) Episiotomy

A) Facilitates access

B) . Reduces the bisacromial diameter of the fetus

C) Reduces anteropost diameter of pelvis

D) . Moves shoulders to larger diameter of the pelvis

E) . Increases the anteroposterior diameter of the pelvis

F) Increases transverse diameter of pelvis

35)

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

A) Reverse Wood screw

B) Rubin II

C) Symphysiotomy

D) Wood screw

E) Zavanelli

F) Suprapubic pressure

36)

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

A) Reverse Wood screw

B) Rubin II

C) Symphysiotomy

D) Wood screw

E) Zavanelli

F) Suprapubic pressure

37)

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

A) . 2 times

B) 4 times

C) 6 times

D) 8 times

E) 10 times

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.

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

A) . 10%

B) 25%

C) 31%

D) 50%

E) 60%

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

A) 0.1%

B) . 0.2%

C) 0.6%

D) 1%

E) 2%

41) Fingers posterior to the anterior shoulder

A) Reverse Wood screw

B) Rubin II

C) Symphysiotomy

D) Wood screw

E) Zavanelli

F) Suprapubic pressure

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