Copy of MRCOG Part 2 – Management of Labour SBAs

A 20 year old woman presents in spontaneous labour at 38 weeks gestation in her first pregnancy. She has a history of epilepsy for which she has been on long term leviracetam but has experienced increasing seizure frequency in the late third trimester.  What is the risk of seizures in labour for women with epilepsy?

Which of the following is not a risk of intrapartum antibiotic prophylaxis for GBS carrier status?

A 30 year old woman attends antenatal clinic at 36 weeks gestation in her first pregnancy requesting screening for Group B streptococcus (GBS). Which of these statements about GBS screening is incorrect?

Which of the following scenarios is not associated with an increased risk of early onset GBS disease?

A 30 year old woman attends antenatal clinic at 32 weeks gestation in her second pregnancy which is a dichorionic twin pregnancy. Her first pregnancy was a singleton pregnancy where she was induced for postdates at 41 weeks and received intrapartum antibiotic prophylaxis due to a history of GBS bacteriuria.  What is the likelihood of maternal GBS carriage in this current pregnancy?

A 30 year old woman attends antenatal clinic at 32 weeks gestation in her second pregnancy which is a dichorionic twin pregnancy. Her first pregnancy was a singleton pregnancy where she was induced for postdates at 41 weeks and received intrapartum antibiotic prophylaxis due to a history of GBS bacteriuria.  She had an uncomplicated vaginal delivery with her first child and is hoping to aim for a vaginal twin delivery in this pregnancy as both twins are cephalic.  Which of the following intrapartum management should not be offered?

A 30 year old woman is diagnosed with preterm prelabour rupture of membranes at 33 weeks gestation in her first pregnancy. The baby is cephalic with normal fetal growth on ultrasound, maternal observations are normal with normal WCC and CRP on admission. She is commenced on oral erythromycin and receives steroids for fetal lung maturation. She is known to have previously had a Group B streptococcus (GBS) urinary tract infection at booking which was treated with antibiotics.  What is the most appropriate management?

What percentage of women will labour spontaneously by 39 weeks and 6 days gestation?

What percentage of women will labour spontaneously by 41 weeks and 6 days gestation?

A 30 year old woman is diagnosed with preterm prelabour rupture of membranes at 33 weeks gestation in her first pregnancy.  The baby is cephalic with normal fetal growth on ultrasound, maternal observations are normal with normal WCC and CRP on admission. She is commenced on oral erythromycin and receives steroids for fetal lung maturation.  What is the most appropriate recommendation for timing of birth?

A 30 year old woman is diagnosed with prelabour rupture of membranes at 39 weeks gestation in her second pregnancy. The baby is cephalic with normal fetal growth on ultrasound, maternal observations are normal with normal WCC and CRP on admission. She previously had an emergency Caesarean section at 41 weeks for an unsuccessful instrumental delivery and would like to aim for a vaginal birth. What is the most appropriate management?

A 20 year old woman presents in spontaneous labour at 38 weeks gestation in her first pregnancy. She has a history of epilepsy for which she has been on long term leviracetam but has experienced increasing seizure frequency in the late third trimester.  Intravenous access is sited and continuous electronic fetal monitoring is commenced.  On vaginal examination, she is 4cm dilated with intact membranes with normal maternal observations and no proteinuria. The emergency buzzer is pulled when she has a witnessed tonic clonic seizure and she is placed in a left lateral tilt with oxygen via facial mask.  What is the most appropriate initial management?

A 31 year old woman in her first pregnancy has a third trimester growth scan suggestive of a macrosomic baby with estimated fetal weight above the 95^th centile at 38 weeks gestation. She is counselled regarding the risks and benefits of expectant management, induction of labour and Caesarean birth. Which of the following risks is reduced by induction of labour for suspected fetal macrosomia?

A 31 year old woman in her first pregnancy opts induction of labour at 40 weeks gestation after a third trimester growth scan suggestive of a macrosomic baby with estimated fetal weight above the 95^th On admission, she has an initial vaginal examination where the findings are that the cervix is 1cm dilated, 2cm long without effacement, firm in consistency, posterior in position and the presenting part is at -2 station.  What is the most appropriate method of induction?

What is the chance of transfer to an obstetric unit for low-risk nulliparous women opting for planned home birth?

What is the chance of transfer to an obstetric unit for low-risk multiparous women opting for planned home birth?

What is the most common reason for transfer to an obstetric unit during intrapartum care at an alternative planned place of birth?

Which of the following is an indication for planned birth in an obstetric unit?

A 28 year old woman attends her local stand-alone midwifery led unit in early labour at 40 weeks gestation in her first pregnancy and is assessed. Which of the following is an indication for transfer to an obstetric unit?

A 28 year old woman attends her local stand-alone midwifery led unit in early labour at 40 weeks gestation in her first pregnancy. On examination, her observations are P 90bpm, BP 133/85, T 37.4C, RR 18 and oxygen saturations 99% on room air.  The fetal heart rate is auscultated with a baseline rate of 140bpm and she is contracting 4 in 10.  The baby palpates as longitudinal lie with cephalic presentation 4/5ths palpable and symphysio-fundal height is 45cm.  Vaginal examination confirms that she is 4cm dilated with clear liquor draining. What is the most appropriate management?

A 28 year old woman attends her local stand-alone midwifery led unit in early labour at 40 weeks gestation in her first pregnancy. On examination, her observations are P 90bpm, BP 133/85, T 37.4C, RR 18 and oxygen saturations 99% on room air.  The fetal heart rate is auscultated with a baseline rate of 120bpm and she is contracting 4 in 10.  The baby palpates as longitudinal lie with cephalic presentation 2/5ths palpable and symphysio-fundal height is 39cm.  Vaginal examination confirms that she is 4cm dilated with clear liquor draining. She is admitted for intrapartum care for established labour with intermittent auscultation.  How often should intermittent auscultation be performed in the first stage of labour?

A 28 year old woman attends her local stand-alone midwifery led unit in early labour at 40 weeks gestation in her first pregnancy. On examination, her observations are P 90bpm, BP 133/85, T 37.4C, RR 18 and oxygen saturations 99% on room air.  The fetal heart rate is auscultated with a baseline rate of 120bpm and she is contracting 4 in 10.  The baby palpates as longitudinal lie with cephalic presentation 2/5ths palpable and symphysio-fundal height is 39cm.  Vaginal examination confirms that she is 4cm dilated with clear liquor draining. She is admitted for intrapartum care for established labour with intermittent auscultation. At the next fetal heart rate auscultation, the fetal heart rate is noted to be persistently 100bpm for 1 minute after a contraction with subsequently recovery to baseline rate of 155bpm.  What is the next most appropriate management?

A 20 year old woman presents in spontaneous labour at 38 weeks gestation in her first pregnancy. She has a history of epilepsy for which she has been on long term leviracetam but has experienced increasing seizure frequency in the late third trimester.  Intravenous access is sited and continuous electronic fetal monitoring is commenced.  On vaginal examination, she is 4cm dilated with intact membranes with normal maternal observations and no proteinuria. The emergency buzzer is pulled when she has a witnessed tonic clonic seizure and she is placed in a left lateral tilt with oxygen via facial mask.  The seizure has not terminated after two bolus doses of intravenous lorazepam.  The fetal heart rate remains within normal limits. What is the most appropriate management?

A 28 year old woman is transferred from a stand-alone midwifery led unit to an obstetric unit in the first stage of labour at 40 weeks gestation in her first pregnancy due to concerns regarding decelerations heard during intermittent auscultation. Continuous cardiotocography is commenced. Which of the following CTG features is abnormal?

A 28 year old woman is transferred from a stand-alone midwifery led unit to an obstetric unit in the first stage of labour at 40 weeks gestation in her first pregnancy due to concerns regarding decelerations heard during intermittent auscultation. Continuous cardiotocography is commenced which shows a baseline rate of 150bpm, variability of 5bpm and late decelerations with >50% contractions for 35 minutes. Vaginal examination confirms that she is 4cm dilated with significant meconium, contractions are 4:10 and there is no accelerative response to fetal scalp stimulation.  What is the most appropriate management?

A primiparous woman with a metallic mitral valve replacement is booked for a planned Caesarean section for breech presentation at 39 weeks gestation. She weighs 65kg and has been on antenatal warfarin since the second trimester of pregnancy. What is the most appropriate management of her anticoagulation?

Which of the following cardiac conditions is not an indication for planned Caesarean birth?

A 30 year old woman is booked for a planned Caesarean birth at 37 weeks gestation in her first pregnancy due to her medical history of Marfan’s syndrome with aortic root dilation of 48mm. What is the most appropriate anaesthetic option for birth?

A 30 year old woman is booked for a planned Caesarean birth at 37 weeks gestation in her first pregnancy due to her medical history of Marfan’s syndrome with aortic root dilation of 48mm. What is the most appropriate first line uterotonic?

A 30 year old woman is booked for a planned Caesarean birth at 37 weeks gestation in her first pregnancy due to her medical history of pulmonary arterial hypertension. What is the most appropriate second line uterotonic?

A woman presents with regular contractions at term in her first pregnancy and on vaginal examination, is found to be 6cm dilated. She has a history of Addison’s disease for which she usually takes hydrocortisone 5mg TDS and fludrocortisone 0.1mg BD.  What is the most appropriate management?

A woman with known immune thrombocytopaenia presents with regular contractions at term in her first pregnancy and on vaginal examination, is found to be 6cm dilated. Her platelet count on admission is 70 x10⁹/L. Which of the following is not contraindicated?

A woman presents feeling generally unwell at 39 weeks gestation in her first pregnancy with prolonged rupture of membranes and regular contractions. On examination, her observations are P130bpm, BP 70/40, T39C, RR 25 and oxygen saturations 88% on room air.  The uterus is generally tender with offensive liquor draining and venous blood gas confirms serum lactate of 4.   She is started on broad spectrum antitbiotics for sepsis.  How often should maternal observations be repeated?

A 20 year old woman presents in spontaneous labour at 38 weeks gestation in her first pregnancy. She has a history of epilepsy for which she has been on long term leviracetam and is requesting pain relief.  Which of the following should be avoided?

A woman presents feeling generally unwell at 39 weeks gestation in her first pregnancy with prolonged rupture of membranes and regular contractions 4 in 10. On examination, her observations are P130bpm, BP 70/40, T39C, RR 25 and oxygen saturations 88% on room air.  Vaginal examination confirms that the cervix is 6cm dilated, the uterus is generally tender with offensive liquor draining and venous blood gas shows serum lactate of 4.   The CTG shows an uncomplicated fetal tachycardia of 160bpm but there are no other non-reassuring features. She is started on broad spectrum antibiotics for sepsis but remains hypotensive and tachycardic despite initial resuscitation.  What is the next most appropriate management?

What is the most common classification of cause of stillbirth?

A 28 year old woman attends with reduced fetal movements at 37 weeks gestation in her first pregnancy. Ultrasound sadly confirms an intrauterine fetal death.  What is the risk of maternal disseminated intravascular coagulation in the first four weeks after intrauterine fetal death?

A 28 year old woman attends with reduced fetal movements at 37 weeks gestation in her first pregnancy. Ultrasound sadly confirms an intrauterine fetal death and the couple opt for post mortem examination of the baby which shows endomyocardial fibro-elastosis.  What is the most important next investigation?

A 28 year old woman attends with reduced fetal movements at 37 weeks gestation in her first pregnancy and ultrasound sadly confirms an intrauterine fetal death. On examination, maternal observations show P80, BP 170/110, RR18, oxygen saturations 99% on room air and T37C.  Urinary protein:creatinine ratio is 400 and blood tests show Hb 95, WCC 17, Plts 100, ALT 170, Cr 100 and LDH 487.  What is the most appropriate management?

A 28 year old woman attends with reduced fetal movements at 37 weeks gestation in her fourth pregnancy and ultrasound sadly confirms an intrauterine fetal death. She has previously had three Caesarean sections and was booked for planned Caesarean at 39 weeks. On examination, maternal observations show P80, BP 170/110, RR18, oxygen saturations 99% on room air and T37C.  Urinary protein:creatinine ratio is 400 and blood tests show Hb 95, WCC 17, Plts 100, ALT 170, Cr 100 and LDH 487.  What is the most appropriate management?

A 28 year old woman attends with reduced fetal movements at 37 weeks gestation in her first pregnancy and ultrasound sadly confirms an intrauterine fetal death. On examination, maternal observations show P80, BP 170/110, RR18, oxygen saturations 99% on room air and T37C.  Urinary protein:creatinine ratio is 400 and blood tests show Hb 95, WCC 17, Plts 100, ALT 170, Cr 100 and LDH 487.  She has an uncomplicated induction of labour and vaginal birth and expresses a wish to avoid lactation postpartum.  What is the most appropriate management?

Which of the following statements regarding the legal requirements for medical certification of stillbirth is correct?

Which method of induction has the highest risk of uterine hyperstimulation?

Which method of induction has the lowest risk of Caesarean section and uterine hyperstimulation?

A 19 year old primiparous woman is brought in by ambulance with massive antepartum haemorrhage of 2.0L at 30 weeks gestation. She has already received 2L of crystalloid fluid and a first unit of packed red cells through two large gauge cannulae. On examination, she is contracting 5-6:10 and the uterus is generally tender on palpation. On vaginal examination, the cervix is 5cm dilated with ongoing active heavy vaginal bleeding.  Maternal observations show a HR: 140bpm, BP: 70/40, RR: 28, T 35.8, Sats 98% RA.  The CTG is classified as suspicious due to reduced variability.  What is the most appropriate management?

A woman is transferred to a tertiary hospital with a Level 3 neonatal intensive care unit at 24 weeks gestation in her first pregnancy with threatened preterm labour and bulging membranes. She is counselled by the neonatal team regarding the outcomes for babies born at extremely preterm gestations.  What is the survival rate from the onset of labour of babies born at 24 weeks gestation?

A woman is transferred to a tertiary hospital with a Level 3 neonatal intensive care unit at 24 weeks gestation in her first pregnancy with threatened preterm labour and bulging membranes. She is counselled by the neonatal team regarding the outcomes for babies born at extremely preterm gestations.  What is the survival rate without disability from the onset of labour of babies born at 24 weeks gestation?

A woman is transferred to a tertiary hospital with a Level 3 neonatal intensive care unit at 24 weeks gestation in her first pregnancy with threatened preterm labour and bulging membranes. On ultrasound scan, the baby is found to a footling breech presentation and a multidisciplinary discussion regarding mode of birth is undertaken.  What is the incidence of classical Caesarean section at 24 weeks gestation?

A woman in spontaneous labour requests epidural analgesia. What is the most common adverse effect of epidural analgesia in labour?

A woman in spontaneous labour requests rapid effective analgesia. She has a history of immune thrombocytopaenia with platelet count of 70 on admission therefore is not able to have epidural analgesia and opts to have a remifentanil patient-controlled analgesia (PCA). Which of the following is a rare adverse effect of remifentanil PCA analgesia in labour?

A woman in spontaneous labour requests epidural analgesia. Which of the following is a contra-indication to regional anaesthesia in labour?

A woman in spontaneous labour requests epidural analgesia. Which of the following is not recommended when siting regional analgesia?

What forms the lateral border of the pelvic inlet?

What forms the lateral border of the pelvic outlet?

Which is the widest diameter of the bony pelvis?

A 38 year old woman presents to hospital at 38 weeks gestation in her first pregnancy with painful contractions. She has been under consultant led care during her pregnancy as it is an IVF pregnancy and the placenta was noted to have a velamentous cord insertion at her anomaly ultrasound scan.  During a vaginal examination, she is found to be 4cm dilated and the fetal membranes rupture spontaneously.  Fresh vaginal bleeding is noted and the CTG becomes abnormal with a sinusoidal fetal heart rate pattern.  What is the likely diagnosis?

Which of the following presentations has the largest presenting fetal head diameter?

What is the risk of stillbirth in women over the age of 40 in the UK?

What is the relative risk of stillbirth at 41 weeks gestation in women aged over 40 compared to women under the age of 35?

Which of the following is the most common cause of maternal collapse?

A woman presents with spontaneous rupture of membranes at term and is known to be a carrier of Group B Streptococcus. She is offered intrapartum antiobiotic prophylaxis and immediate induction of labour.  Shortly after commencing her first dose of intravenous benzylpenicillin, she collapses with severe hypotension, obvious facial oedema and stridor.  What is the most appropriate immediate management?

A woman presents with spontaneous rupture of membranes at term and is known to be a carrier of Group B Streptococcus. She is offered intrapartum antiobiotic prophylaxis and immediate induction of labour.  Shortly after commencing her first dose of intravenous benzylpenicillin, she collapses with severe hypotension, obvious facial oedema and stridor and receives immediate treatment for suspected anaphylaxis.  What is the most appropriate investigation?

A pregnant woman is admitted for induction of labour for post-dates at 41 weeks gestation. On the antenatal ward, she suddenly collapses and is found to be in cardiac arrest.  The obstetric emergency team commences advanced life support, securing her airway, ventilating with a bag-valve mask and starting chest compressions.  What is the next most appropriate management?

A pregnant woman is admitted for induction of labour for post-dates at 41 weeks gestation. On the antenatal ward, she suddenly collapses and is found to be in cardiac arrest.  The obstetric emergency team commences advanced life support, securing her airway, ventilating with a bag-valve mask and starting cardiopulmonary resuscitation (CPR) with manual displacement of the uterus.  A defibrillator is attached and shows the following rhythm:

What is the most appropriate management?

A pregnant woman is admitted for induction of labour for post-dates at 41 weeks gestation. On the antenatal ward, she suddenly collapses and is found to be in cardiac arrest.  The obstetric emergency team commences advanced life support, securing her airway, ventilating with a bag-valve mask and starting cardiopulmonary resuscitation (CPR) with manual displacement of the uterus.  A defibrillator is attached and shows the following rhythm:

What is the most appropriate management?

A pregnant woman is admitted for induction of labour for post-dates at 41 weeks gestation. On the antenatal ward, she suddenly collapses and is found to be in cardiac arrest.  The obstetric emergency team commences advanced life support, securing her airway, ventilating with a bag-valve mask and starting cardiopulmonary resuscitation (CPR) with manual displacement of the uterus.  A defibrillator is attached and shows the following rhythm:

Despite ongoing CPR and advanced life support, there is no return of cardiac output after 5 minutes.  What is the next most appropriate management?

A 38 year old woman presents to hospital at 38 weeks gestation in her first pregnancy with painful contractions.  She has been under consultant led care during her pregnancy as it is an IVF pregnancy and the placenta was noted to have a velamentous cord insertion at her anomaly ultrasound scan.  During a vaginal examination, she is found to be 4cm dilated and the fetal membranes rupture spontaneously.  Fresh vaginal bleeding is noted and the CTG becomes abnormal with a sinusoidal fetal heart rate pattern.  What is the most appropriate management?

A woman with severe early onset pre-eclampsia receives a 4g bolus dose magnesium sulphate prior an emergency Caesarean for severe fetal growth restriction at 32 weeks gestation in her first pregnancy.Post-operatively, a magnesium sulphate infusion is commenced. She reports feeling flushed and nausea and subsequently becomes increasingly drowsy and unable to move move her legs.  Serum magnesium levels show concentrations of 5mmol/L.  What is the most appropriate management?

A pregnant woman is admitted for induction of labour for post-dates at 41 weeks gestation. She receives one dose of vaginal prostaglandin E2 gel and after four hours is found to be 6cm dilated so is transferred to the labour ward for one-to-one care in labour.  She requests an epidural which is sited but is not fully effective and she receives a top up dose of bupivacaine.  Subsequently she reports feeling agitated and confused with a metallic taste and perioral numbness.  She subsequently has a witnessed seizure and becomes unresponsive.  On assessment, she is in cardiac arrest and the defibrillator confirms a ventricular fibrillation rhythm.  The obstetric emergency team commences advanced life support, securing her airway, ventilating with a bag-valve mask and starting cardiopulmonary resuscitation (CPR) with manual displacement of the uterus.  What is the most appropriate next management?

What is the maternal survival rate after maternal cardiac arrest in pregnancy?

What is the most frequent cause of severe early onset infection in newborn infants?

What percentage of pregnancy women are carriers of Group B streptococcus?