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Question 1

A 26-year-old woman has just delivered her first baby after a long labour. The baby is placed on her chest for skin-to-skin contact. She has opted for natural delivery of the placenta which hasn’t occurred yet.
What stage of labour is the woman in?

Answer 1

3rd stage - begins after delivery of baby, involves delivery of placenta

Question 2

cervicitis bleeding

Answer 2

light

Question 3

A 32-year-old woman at 28 weeks gestation presents with painless, bright red vaginal bleeding. She has no history of abdominal trauma, and the bleeding is not associated with contractions. The foetus is in a normal position, and the woman’s vital signs are stable.
Which condition is most likely responsible for her bleeding?

Answer 3

placenta praaevia

Question 4

chorioamnionitis organism

Answer 4

group B strep (Streptococcus agalactiae) and E coli

Question 5

Woman G3P2 with PPH first line surgical management

and 2,3,4,5th

Answer 5

Intrauterine balloon tamponade is a first-line surgical intervention for managing postpartum haemorrhage due to uterine atony.

2nd line = B-Lynch suture
3rd = Stepwise uterine devascularisation
4th = Uterine artery embolisation
5th = hysterectomy

Question 6

incomplete vs missed miscarriage Mx

Answer 6

incomplete - Single dose of misoprostol

missed - Oral mifepristone + misoprostol 48 hours later

Question 7

hemodynamically viable patient with an ectopic pregnancy less than 35 mm in size and a serum HCG level under 5000 IU/l, management

Answer 7

For a stable, hemodynamically viable patient with an ectopic pregnancy less than 35 mm in size and a serum HCG level under 5000 IU/l, methotrexate is typically the first line treatment option.

Question 8

ectopic management options

Answer 8

expectant = if low risk and bHCG dropping off, indicating self resolution, no or minimal symptoms, require follow up

medical = methotrexate

surgical

Question 9

when is surgical ectopic management required

Answer 9

1 Patient is unable to attend follow-up
2 - Serum hCG level of 5000 IU/L or higher -
3 Adnexal mass of 35mm or greater -
4 Foetal heartbeat is visible on ultrasound scan -
5 Patient is in significant pain -
6 Patient is haemodynamically unstable

Also offered second line in cases where medical manamgement has failed

The preferred surgical management is a salpingectomy, where the fallopian tube containing the ectopic pregnancy is removed.

Question 10

2ndary PPH cause

Answer 10

Endometritis is the most common cause of secondary postpartum haemorrhage, and typically presents between 2 and 10 days postpartum

Question 11

category 1 c sec indications

Answer 11

cord prolapse, foetal scalp pH under 7.2,

Question 12

at what week can you offer membrane sweep in normal pregnancy

Answer 12

Post-term pregnancy is associated with adverse fetal outcomes. Induction of labour should be offered to all women between 41 and 42 weeks, usually when patient is 12 days post due date (NICE 2008).

Question 13

what would be an abnormal finding on speculum exam in pregnancy

Answer 13

A clear-white, odourless fluid in the posterior vaginal vault during pregnancy could indicate premature rupture of membranes, requiring further assessment for potential preterm labour.

Question 14

is blue cervix normal

Answer 14

yes due to increased blood flow

Question 15

missed miscarriage Mx

Answer 15

200mg mifepristone followed by 800mcg misoprostal 48 hours later

Question 16

causes of polyhydramnios

Answer 16

Excess production can be due to increased foetal urination:
Maternal diabetes mellitus
Foetal renal disorders
Foetal anaemia
Twin-to-twin transfusion syndrome
Insufficient removal can be due to reduced foetal swallowing:
Oesophageal or duodenal atresia
Diaphragmatic hernia
Anencephaly
Chromosomal disorders
Most cases, however, are idiopathic.

Question 17

rupture of membranes followed immediately by vaginal bleeding. ?

Answer 17

vasa praevia

Question 18

ECV CI

Answer 18

Antepartum haemorrhage during the last 7 days

Question 19

most common place for fertilisation and ectopic

Answer 19

ampulla

Question 20

when is ECV offered

Answer 20

If the foetus is found to be in breech past 36 weeks, management can be undertaken. ECV is the first-line management and is offered at 36 weeks for nulliparous, and at 37 weeks for multiparous women. Therefore, as this woman has previously had a child, ECV should be offered at 37 weeks.

Question 21

what can you give to improve success of ECV

Answer 21

terbutaline

Question 22

Abx in PPROM

Answer 22

In cases of preterm premature rupture of membranes, erythromycin or clarithromycin is recommended to reduce the risk of maternal and fetal infections due to ascending genital tract infection.

Question 23

PPH Mx if not in shock

Answer 23

uterine massage

Question 24

indications for elective C sec

Answer 24

Indications for elective caesarean section include:
Abnormal presentation e.g. breech or transverse.
Twin pregnancy if first twin is not cephalic.
Maternal HIV.
Primary genital herpes in third trimester.
Placenta praevia.
Anatomical reasons

Question 25

bishop score

Answer 25

score is calculated by assessing five key factors: cervical position, consistency, effacement, dilation, and foetal station. Certain circumstances such as pre-eclampsia, previous vaginal deliveries, post-dates pregnancy, and premature pre-term rupture of membranes can add or subtract points to the score.

Question 26

next steps after feeling that water broke early at home

Answer 26

PPROM - In pre-labour rupture of membranes at term, a sterile speculum examination is crucial for confirming the diagnosis, assessing the risk of infection, and evaluating fetal position and cord prolapse.

Question 27

Women at high risk for pre-eclampsia, including those over 40 years old with BMI greater than 35 kg/m² and pregnant after a long interval since last delivery, may be given

Answer 27

low-dose aspirin from week 12 to reduce the risk.

Question 28

Women with polyhydramnios have an increased risk of

Answer 28

cord prolapse during labour. This is because the excess amniotic fluid can prevent engagement of the head and leave room for the cord to extend past the presenting part. This is a serious complication as it may lead to cord compression and subsequent fetal hypoxia

Question 29

maternal factor causing polyhydramnios

Answer 29

Maternal diabetes mellitus is a recognised cause of polyhydramnios as it causes fetal hyperglycaemia. This results in fetal polyuria and thus polyhydramnios

Question 30

when to offer induction of labour after ROM

Answer 30

Following rupture of membranes if spontaneous labour does not occur within 24 hours induction of labour should be offered

Question 31

Tocolysis is contraindicated in cases of

Answer 31

Tocolysis is contraindicated in cases of suspected chorioamnionitis,

Question 32

Maternal treatment during confirmed preterm labour includes

Answer 32

betamethasone for fetal lung maturation and antibiotics such as benzylpenicillin to reduce Group B Streptococcus infection.

Question 33

classical triad of vasa praevia

Answer 33

The classical triad of clinical features is painless vaginal bleeding, rupture of membranes and fetal bradycardia (fetal heart rate <100bpm)

Question 34

Frank breech

Answer 34

A frank breech presentation is where the legs are fully extended up to the shoulders and the presenting part is the buttocks

Question 35

footling breach vs complete breech

Answer 35

Footling breech is where one or both legs are fully extended towards the pelvic inlet, with the foot or feet being the presenting part Complete breech is where the hips and knees are both flexed and the presenting part is the buttocks

Question 36

key signs of placental separation in 3rd stage of labour

Answer 36

Key signs of this stage include a gush of blood, lengthening of the umbilical cord, and ascension of the uterus in the abdomen.

Question 37

3b tear

Answer 37

A third degree (3b) tear extends more than 50% of the thickness of the external anal sphincter, but with the internal anal sphincter remaining intact

Question 38

active management of third stage of labour

Answer 38

Intramuscular oxytocin (10 IU) is given first line in active management Oxytocin is preferred over Syntometrine, which is associated with greater side-effects Active management reduces blood loss in the third stage of labour and reduces the risk of anaemia Oxytocin increases the risk of nausea and vomiting After oxytocin is given, there is lengthening of the cord NICE recommend the use of oxytocin over syntometrine because it is associated with fewer side-effects

Question 39

A 28-year-old woman (para 1, gravida 3) presents to birth options clinic to create a delivery plan for her current dichorionic twin pregnancy. She has no significant medical history other than a previous classical Caesarean section three years ago. Which of the following is the best advice to offer?

Answer 39

Recommend a Caesarean section at 37 weeks gestation A previous classical Caesarean section is an absolute contraindication to normal vaginal delivery. There is a risk of uterine rupture and the foetus may be expelled into the peritoneal cavity. Women with dichorionic twin pregnancies should be offered elective birth from 37 weeks 0 days

Question 40

A 20-year-old patient at 38 weeks gestation presents to labour ward concerned that she 'her waters have broken'. Examination is significant for offensive-smelling liquor stained underwear. She appears sweaty and distressed. Her observations are: T38.1C, HR 89, BP 112/78mmHg. Which of the following is the most appropriate next step?

Answer 40

Take blood cultures This patient likely has chorioamnionitis, which requires treatment with broad spectrum antibiotics. Blood should be taken for culture before antibiotics are given

Question 41

A 30-year-old trans man has had a long second stage of labour and is becoming exhausted. In addition, he is finding it increasingly difficult to push as a consequence of his epidural. He decided to attempt Ventouse delivery, however there is no foetal descent with 3 pulls. Which of the following is the most appropriate next step in management?

Answer 41

Convert to lower segment Caesarean section When attempting instrumental delivery, the procedure should be abandoned if there is no foetal descent following 3 pulls. A lower segment caesarean section is the gold standard approach for surgical delivery following this.

Question 42

You receive a bleep from a midwife who is attending a patient after her delivery. They estimate that the patient has lost around 800ml of blood and is still bleeding. The patient's heart rate is 97bpm and blood pressure is 100/75mmHg. Which of the following is the most appropriate first step in management?

Answer 42

Insert large bore IV cannulae for group and save, cross match, FBC and coagulation studies and start fluid resuscitation Postpartum haemorrhage is a medical emergency and as such resuscitation measures must be the first priority. The patient is becoming shocked and continuing to become more hypovolaemic. As such, the above blood tests and fluid resuscitation should be the first step in management whilst awaiting blood products.

Question 43

You are bleeped to a patient on labour ward who has just delivered a healthy baby. The midwife reports that while he was performing controlled cord traction, the patient began to bleed and the uterine fundus is no longer palpable in the abdomen. Given the most likely diagnosis, what is the most appropriate next step in management?

Answer 43

Immediately replace the fundus through the cervix with the palm of the hand Swift action is required when there's a concern of uterine inversion, aiming to restore the normal position of the uterus as soon as possible to prevent severe bleeding and other complications.

Question 44

2 indications for category 1 C sec

Answer 44

Scalp pH <7.2 is an indication for category 1 Caesarean section, as is cord prolapse

Question 45

what follows delivery of fetal head

Answer 45

Following delivery of the fetal head, the fetus externally rotates (restitution) to bring the shoulders into an antero-posterior position to facilitate delivery of the anterior shoulder and then body.

Question 46

prophylactic before C sec

Answer 46

A prophylactic proton-pump inhibitor is given before Caesarean sections, as pregnant women are physiologically at increased risk of gastric reflux.

Question 47

when to give anti D

Answer 47

rhesus negative mother with positive baby

Question 48

CI to PV exam

Answer 48

Undiagnosed vaginal bleeding is a contraindication to digital vaginal examination, due to the risk of haemorrhage in cases of placenta praevia.

Question 49

type of pressure needed in shoulder dystocia

Answer 49

suprapubic

Question 50

A 25-year-old parous woman attends her local maternity unit in established labour at 39+7 weeks. She had a spontaneous vaginal delivery 2 years prior and has had no problems during either pregnancy. She is experiencing regular, painful contractions. She has not experienced any vaginal loss. A cardiotocograph is performed upon admission, which reveals a foetal heart rate of 110 beats per minute, with deep decelerations with contractions that are slow to recover. The woman is transferred to theatre for an emergency caesarean section, and a live male infant is delivered. As the midwife examines the placenta to check the membranes are complete, she describes the umbilical cord as "velamentous". What is the most likely cause of the intrapartum foetal distress?

Answer 50

Vasa praevia Vasa praevia occurs when the vessels in the umbilical cord run within the foetal membranes. These vessels may rupture spontaneously in early labour. Vasa praevia can be divided into types; in type 1 vasa praevia, the umbilical cord is inserted into the membranes rather than directly into the placenta (also known as a velamentous insertion) and in type 2 vasa praevia, the umbilical vessels run from the placenta to a succenturiate placental lobe.

Question 51

induction -A midwife performs a vaginal examination and describes her cervix as long, closed, firm, and posterior. Her Bishops score is 0. What is the most appropriate management?

Answer 51

Intravaginal prostaglandin E2 analogue e.g. Propess Intravaginal prostaglandin E2 analogues such as Propess and Prostin are the first-line treatment in the induction of labour where there are no contraindications. These aim to soften and ripen the cervix in preparation for labour. Artificial rupture of membranes An artificial rupture of membranes (ARM) can only be performed where the cervix is favourable, the foetus is well engaged, and there is space to access the cervical os.

Question 52

A patient has been admitted with severe pre-eclampsia and has been advised that she will need regular blood tests and asks for more information about these. Which of the following represents the tests she will need and their frequency?

Answer 52

U&E, FBC, transaminases and bilirubin three times per week Patients with severe pre-eclampsia should have blood tests three times per week to anticipate if a patient is developing HELLP syndrome, a complication of pre-eclampsia involving haemolysis, elevated liver enzymes and low platelets

Question 53

In multipsarous women near term labour with sudden onset of foetal bradycardia and decelerations, and a gush of fluid, consider

Answer 53

umbilical cord prolapse as a possible diagnosis.

Question 54

prolonged second stage of labour ?

Answer 54

This is defined as three hours or more from full dilatation in a nulliparous woman with epidural anaesthesia. forceps

Question 55

first stage of labour normal CTG

Answer 55

Baseline rate: 125bpm. Variability: 15bpm. Accelerations: present. Decelerations: absent

Question 56

multiple pregnancy and VTE

Answer 56

give LMWH prophylactically

Question 57

explain mcroberts

Answer 57

Hyperflex and abduct her hips so they are against her abdomen

Question 58

PPROM examination

Answer 58

In a patient with suspected preterm prelabour rupture of membranes, a sterile speculum examination is indicated to check for amniotic fluid draining from the cervix after the mother has been laying down for 30 minutes and to check for cord prolapse.

Question 59

PPROM vaginal exam\?

Answer 59

NO Vaginal examination is appropriate here to rule out cord prolapse. However, in prelabour premature rupture of membranes, vaginal examination is avoided to minimise the infection risk.

Question 60

waiters tip - erbs palsy

Answer 60

C5-6

Question 61

33 year old woman at 22 weeks of gestation presents with decreased foetal movements. She has a history of two prior miscarriages and a past medical history of myocardial infarction, Hashimoto's thyroiditis, and type 1 diabetes mellitus (T1DM). Transvaginal ultrasound reveals no foetal movements, confirming intrauterine foetal death. Which of the following will be the most useful investigation to identify the underlying cause?

Answer 61

Lupus anticoagulant and anticardiolipin antibodies The patient has multiple risk factors for antiphospholipid syndrome (APS), including recurrent pregnancy loss, a history of myocardial infarction (suggesting hypercoagulability), and an autoimmune disease (Hashimoto's thyroiditis). APS is a major cause of second-trimester IUFD. NICE and RCOG recommend testing for acquired thrombophilia, particularly with lupus anticoagulant and anticardiolipin antibodies.