Normal and Abnormal Labour Common MCQs

The scenario describes a woman at 34 weeks gestation with confirmed intrauterine fetal death (IUFD) and signs suggestive of placental abruption (acute abdominal pain, fresh vaginal bleeding, uterine tenderness and hardness). With a cervical os of 4cm and the woman being haemodynamically stable, the most appropriate next step according to RCOG guidelines is induction of labour to deliver the deceased fetus. Prostaglandins (e.g., vaginal pessaries) are often the first-line method for induction in these cases, especially with a partially dilated cervix. Artificial rupture of membranes (ARM) and syntocinon infusion are typically used to augment labour once the cervix is more favourable. Keeping under observation without active management is not appropriate with a confirmed IUFD and potential abruption. Caesarean section is generally reserved for cases of maternal instability or contraindications to vaginal delivery, which are not present here.

In a patient with mitral stenosis and pulmonary hypertension in the active second stage of labour, the choice of analgesia is crucial due to the increased risk of cardiac decompensation with pain and stress. Epidural analgesia provides effective pain relief while minimizing systemic effects on the cardiovascular system compared to systemic opioids like morphine and pethidine, which can cause respiratory depression and hemodynamic instability. Vaginal nitrous oxide offers mild pain relief and may not be sufficient in the active second stage, especially with underlying cardiac conditions. Pudendal block provides local anaesthesia for the perineum in the late second stage but does not address the pain from uterine contractions.

A fetal heart rate of 80 bpm lasting for four minutes is a significant bradycardia and a sign of fetal distress. With a primigravida at 7 cm dilatation and the fetal head palpable 2/5 abdominally (suggesting it is not yet very low in the pelvis), the most appropriate management according to NICE guidelines is immediate delivery by Caesarean section to expedite delivery and minimise the risk of permanent fetal injury from hypoxia. While keeping her in the left lateral position and monitoring is a general supportive measure for fetal distress, it is unlikely to resolve severe bradycardia quickly. Fetal scalp blood sampling is used to assess fetal acidosis in cases of indeterminate CTG findings, but a prolonged bradycardia of 80 bpm is a clear indication for urgent delivery. Instrumental delivery (forceps or vacuum) would require full cervical dilatation and a lower station of the fetal head.

A primigravida at 39 weeks with infrequent contractions (1 in 10 minutes) and a 2 cm dilated cervix is likely in the latent phase of labour. The fetal heart rate is normal. The best initial management is to encourage ambulation, which can sometimes help to stimulate labour, and to review her progress after a period of observation (around 4 hours) as per NICE guidelines for the latent phase. Augmenting labour with oxytocin is not indicated in the latent phase with infrequent contractions and can increase the risk of hyperstimulation. Inserting a prostaglandin pessary is used for cervical ripening when labour has not started spontaneously or induction is indicated. Keeping her fasting is unnecessary at this stage unless active labour is established or there's a high risk of needing anaesthesia soon.

Contraindications for vacuum delivery according to RCOG and NICE guidelines include:

• Face presentation (increased risk of facial trauma).
• Gestational age less than 34 weeks (increased risk of intracranial haemorrhage).
• Maternal immune thrombocytopaenia (increased risk of fetal scalp bleeding).
• Occipito-transverse position is a relative contraindication and requires experienced operators and careful application.
• Previous Caesarean section is not an absolute contraindication but requires careful consideration of the risk of uterine rupture, especially if significant traction is needed.

The scenario describes uterine hyperstimulation (5 contractions in 10 minutes) induced by oxytocin, leading to fetal bradycardia, which is a sign of fetal distress. The immediate priority is to reduce uterine activity to improve fetal oxygenation. The first step in managing oxytocin-induced fetal distress is to stop the oxytocin infusion. Putting the mother in the left lateral position can also improve uteroplacental blood flow. Subcutaneous terbutaline is a tocolytic drug that can be used to stop contractions, but stopping the oxytocin is the quickest and most direct action. Rapid infusion of normal saline is for hydration and does not directly address the hyperstimulation or bradycardia. Urgent LSCS might be necessary if the bradycardia persists after stopping oxytocin and other resuscitative measures.

A multiparous woman in the second stage of labour with a fully dilated cervix for one hour is within the normal timeframe for the second stage. The presence of caput and significant moulding (3+) suggests cephalopelvic disproportion or malposition, making spontaneous vaginal delivery less likely and increasing the risk of obstructed labour. In this scenario, instrumental vaginal delivery is indicated to assist delivery. Simpson's forceps are commonly used for straightforward deliveries with the head in an occipito-anterior or occipito-posterior position. Keilland's forceps are specifically designed for rotation of the fetal head in cases of malposition (e.g., occipito-transverse). Vacuum delivery is an alternative but might be less effective with significant moulding. Emergency LSCS would be considered if instrumental delivery fails or if there are signs of fetal distress. Assessing for another 4 hours would be inappropriate given the moulding.

Understanding CTG patterns is crucial in labour management:

• Maternal fever is a common cause of fetal tachycardia.
• Cord compression typically causes variable decelerations, which are abrupt dips in heart rate that vary in timing with contractions.
• Uteroplacental insufficiency, often due to conditions like post-maturity or maternal hypertension, can lead to late decelerations, where the heart rate dip starts after the contraction peak and recovers after it ends. Obstruction of the fetal head is more commonly associated with prolonged decelerations or bradycardia.
• Pethidine, an opioid analgesic, can cause a decrease in fetal heart rate variability but does not typically cause type 2 (late) decelerations.
• Tocolytics, drugs used to inhibit uterine contractions, can have various effects on the fetal heart rate depending on the specific drug, but they do not characteristically cause type 2 decelerations.

Risk factors for shoulder dystocia include:

• Gestational diabetes mellitus (DM) leading to macrosomia (large baby).
• Previous history of shoulder dystocia.
• Macrosomia (large baby), even without maternal diabetes.
• Post-term pregnancy.
• Advanced maternal age.
• Multiparity.
• Epidural anaesthesia is associated with a slightly increased risk, possibly due to reduced maternal pushing effort.
• Preterm labour is not a risk factor for shoulder dystocia; it's associated with smaller babies.

The woman is a multipara in the active phase of the first stage of labour (5cm dilatation) with adequate contractions (3/10 mins lasting 4 mins) and a normal fetal heart rate. However, the membranes are intact and bulging. Artificial rupture of membranes (ARM) is a common intervention to augment labour by releasing prostaglandins and allowing the presenting part to descend further onto the cervix. Given that she is multiparous and in the active phase, ARM followed by monitoring of the labour progression (cervical dilatation rate and fetal wellbeing) is the most appropriate next step according to NICE guidelines. Pethidine is for pain relief, not to augment labour. Syntocinon infusion is used for augmentation if contractions remain inadequate after ARM. Allowing labour to progress without ARM might lead to slower progress.

The scenario describes a woman at 34 weeks gestation with confirmed intrauterine fetal death (IUFD) and signs suggestive of placental abruption (acute abdominal pain, fresh vaginal bleeding, uterine tenderness and hardness). With a cervical os of 4cm and the woman being haemodynamically stable, the most appropriate next step according to RCOG guidelines is induction of labour to deliver the deceased fetus. Prostaglandins (e.g., vaginal pessaries) are often the first-line method for induction in these cases, especially with a partially dilated cervix. Artificial rupture of membranes (ARM) and syntocinon infusion are typically used to augment labour once the cervix is more favourable. Keeping under observation without active management is not appropriate with a confirmed IUFD and potential abruption. Caesarean section is generally reserved for cases of maternal instability or contraindications to vaginal delivery, which are not present here.

In a patient with mitral stenosis and pulmonary hypertension in the active second stage of labour, the choice of analgesia is crucial due to the increased risk of cardiac decompensation with pain and stress. Epidural analgesia provides effective pain relief while minimizing systemic effects on the cardiovascular system compared to systemic opioids like morphine and pethidine, which can cause respiratory depression and hemodynamic instability. Vaginal nitrous oxide offers mild pain relief and may not be sufficient in the active second stage, especially with underlying cardiac conditions. Pudendal block provides local anaesthesia for the perineum in the late second stage but does not address the pain from uterine contractions.

A fetal heart rate of 80 bpm lasting for four minutes is a significant bradycardia and a sign of fetal distress. With a primigravida at 7 cm dilatation and the fetal head palpable 2/5 abdominally (suggesting it is not yet very low in the pelvis), the most appropriate management according to NICE guidelines is immediate delivery by Caesarean section to expedite delivery and minimise the risk of permanent fetal injury from hypoxia. While keeping her in the left lateral position and monitoring is a general supportive measure for fetal distress, it is unlikely to resolve severe bradycardia quickly. Fetal scalp blood sampling is used to assess fetal acidosis in cases of indeterminate CTG findings, but a prolonged bradycardia of 80 bpm is a clear indication for urgent delivery. Instrumental delivery (forceps or vacuum) would require full cervical dilatation and a lower station of the fetal head.

A primigravida at 39 weeks with infrequent contractions (1 in 10 minutes) and a 2 cm dilated cervix is likely in the latent phase of labour. The fetal heart rate is normal. The best initial management is to encourage ambulation, which can sometimes help to stimulate labour, and to review her progress after a period of observation (around 4 hours) as per NICE guidelines for the latent phase. Augmenting labour with oxytocin is not indicated in the latent phase with infrequent contractions and can increase the risk of hyperstimulation. Inserting a prostaglandin pessary is used for cervical ripening when labour has not started spontaneously or induction is indicated. Keeping her fasting is unnecessary at this stage unless active labour is established or there's a high risk of needing anaesthesia soon.

Contraindications for vacuum delivery according to RCOG and NICE guidelines include:

• Face presentation (increased risk of facial trauma).
• Gestational age less than 34 weeks (increased risk of intracranial haemorrhage).
• Maternal immune thrombocytopaenia (increased risk of fetal scalp bleeding).
• Occipito-transverse position is a relative contraindication and requires experienced operators and careful application.
• Previous Caesarean section is not an absolute contraindication but requires careful consideration of the risk of uterine rupture, especially if significant traction is needed.

The scenario describes uterine hyperstimulation (5 contractions in 10 minutes) induced by oxytocin, leading to fetal bradycardia, which is a sign of fetal distress. The immediate priority is to reduce uterine activity to improve fetal oxygenation. The first step in managing oxytocin-induced fetal distress is to stop the oxytocin infusion. Putting the mother in the left lateral position can also improve uteroplacental blood flow. Subcutaneous terbutaline is a tocolytic drug that can be used to stop contractions, but stopping the oxytocin is the quickest and most direct action. Rapid infusion of normal saline is for hydration and does not directly address the hyperstimulation or bradycardia. Urgent LSCS might be necessary if the bradycardia persists after stopping oxytocin and other resuscitative measures.

A multiparous woman in the second stage of labour with a fully dilated cervix for one hour is within the normal timeframe for the second stage. The presence of caput and significant moulding (3+) suggests cephalopelvic disproportion or malposition, making spontaneous vaginal delivery less likely and increasing the risk of obstructed labour. In this scenario, instrumental vaginal delivery is indicated to assist delivery. Simpson's forceps are commonly used for straightforward deliveries with the head in an occipito-anterior or occipito-posterior position. Keilland's forceps are specifically designed for rotation of the fetal head in cases of malposition (e.g., occipito-transverse). Vacuum delivery is an alternative but might be less effective with significant moulding. Emergency LSCS would be considered if instrumental delivery fails or if there are signs of fetal distress. Assessing for another 4 hours would be inappropriate given the moulding.

Understanding CTG patterns is crucial in labour management:

• Maternal fever is a common cause of fetal tachycardia.
• Cord compression typically causes variable decelerations, which are abrupt dips in heart rate that vary in timing with contractions.
• Uteroplacental insufficiency, often due to conditions like post-maturity or maternal hypertension, can lead to late decelerations, where the heart rate dip starts after the contraction peak and recovers after it ends. Obstruction of the fetal head is more commonly associated with prolonged decelerations or bradycardia.
• Pethidine, an opioid analgesic, can cause a decrease in fetal heart rate variability but does not typically cause type 2 (late) decelerations.
• Tocolytics, drugs used to inhibit uterine contractions, can have various effects on the fetal heart rate depending on the specific drug, but they do not characteristically cause type 2 decelerations.

Risk factors for shoulder dystocia include:

• Gestational diabetes mellitus (DM) leading to macrosomia (large baby).
• Previous history of shoulder dystocia.
• Macrosomia (large baby), even without maternal diabetes.
• Post-term pregnancy.
• Advanced maternal age.
• Multiparity.
• Epidural anaesthesia is associated with a slightly increased risk, possibly due to reduced maternal pushing effort.
• Preterm labour is not a risk factor for shoulder dystocia; it's associated with smaller babies.

The woman is a multipara in the active phase of the first stage of labour (5cm dilatation) with adequate contractions (3/10 mins lasting 4 mins) and a normal fetal heart rate. However, the membranes are intact and bulging. Artificial rupture of membranes (ARM) is a common intervention to augment labour by releasing prostaglandins and allowing the presenting part to descend further onto the cervix. Given that she is multiparous and in the active phase, ARM followed by monitoring of the labour progression (cervical dilatation rate and fetal wellbeing) is the most appropriate next step according to NICE guidelines. Pethidine is for pain relief, not to augment labour. Syntocinon infusion is used for augmentation if contractions remain inadequate after ARM. Allowing labour to progress without ARM might lead to slower progress.

A primigravida with a fully dilated cervix and the fetal head palpable 1/5th abdominally is in the second stage of labour. The normal fetal heart rate (120 bpm) and normal CTG are reassuring. However, the presence of light meconium staining of the liquor warrants careful consideration. Given the station of the head (high in the pelvis), immediate vaginal delivery might be challenging. However, with a normal FHR
Normal and Abnormal Labour"

When an instrumental delivery (forceps) is planned due to a suspicious CTG in the second stage of labour, adequate pain relief is essential to ensure maternal comfort and cooperation. Epidural anaesthesia provides the most effective and reliable pain relief for instrumental deliveries, allowing for a controlled and potentially prolonged procedure. Bilateral pudendal block provides perineal anaesthesia for the very late second stage and delivery but does not address the pain of uterine contractions. Nitrous oxide with oxygen offers mild pain relief and is often insufficient for instrumental delivery. IM Pethidine can cause drowsiness and has systemic effects, which might not be ideal when close maternal cooperation is needed and fetal wellbeing is a concern. Transcutaneous electrical nerve stimulation (TENS) is generally used for pain relief in early labour.

Wrigley's forceps are low cavity forceps designed for delivery when the fetal head is visible at the vulva without separating the labia. Therefore, they are contraindicated when the fetal head is higher in the pelvis. Palpating 2/5th of the fetal head abdominally indicates that the head is still significantly above the ischial spines and not suitable for Wrigley's forceps. Cervical dilatation must be complete for any forceps delivery. While fetal head position (like right occipito-lateral) might make delivery more challenging and potentially require different forceps (like Kielland's for rotation), it's not an absolute contraindication for all forceps if the head is low enough. Gestational age of 34 weeks is a relative contraindication for vacuum delivery due to the risk of intracranial haemorrhage, but not specifically for all forceps types if indicated for other reasons and performed by an experienced operator.

The primigravida's labour is progressing slowly in the active phase (2 cm dilatation in 4 hours, expected is at least 1 cm per hour). The contractions are infrequent (2 per 10 minutes). With clear liquor and a normal fetal heart rate, the most appropriate next step according to NICE guidelines is to augment labour with an intravenous infusion of oxytocin to improve the frequency and strength of uterine contractions. IM pethidine is for pain relief and does not address the slow progress. Allowing labour to continue without intervention might lead to prolonged labour. Continuous fetal heart rate monitoring is appropriate during oxytocin infusion. Giving a saline infusion is for hydration but does not directly address the slow progress of labour.

The presence of late decelerations on CTG in the context of meconium-stained liquor suggests fetal distress, likely due to uteroplacental insufficiency. This is an indication for urgent intervention to expedite delivery. With a primigravida, a cervix dilated for 30 minutes (this seems like a typo and likely meant fully dilated or a duration in the second stage) and the station at +2, while vaginal delivery might be possible, the fetal distress indicated by late decelerations necessitates the quickest and safest route of delivery, which is usually an emergency Caesarean section (EM-LSCS). Waiting for 30 more minutes risks further fetal compromise. A wide episiotomy facilitates vaginal delivery but does not address the underlying fetal distress. Vacuum extraction is an option for assisted vaginal delivery but might not be the quickest route, and the fetal distress is a greater concern.

Before performing a forceps delivery, several criteria must be met according to RCOG and NICE guidelines:

• Cervical dilatation must be complete (10 cm).
• Membranes must be ruptured.
• The fetal head must be engaged (presenting part at or below the ischial spines, typically palpable 2/5 or less abdominally).
• The position of the fetal head must be known.
• There should be no cephalopelvic disproportion.
• Maternal bladder should be empty to prevent obstruction and injury.
• Adequate analgesia should be in place.

Late decelerations on CTG indicate fetal distress due to uteroplacental insufficiency. In a preterm primigravida at 32 weeks with the fetal head palpable 2/5 abdominally (high station) and in the OP position, the most appropriate management according to RCOG and NICE guidelines is usually a Caesarean section (LSCS) to expedite delivery and minimize fetal compromise. Preterm fetuses are more vulnerable to hypoxic injury. While maternal hydration and oxygen administration are supportive measures, they do not address the underlying fetal distress requiring prompt delivery. Kielland's forceps delivery is for rotation and delivery in malpositions but requires an engaged head and experienced operator, and the fetal distress is the primary concern. Vacuum delivery is also an option for assisted vaginal delivery but might be difficult with a high station and OP position, and the urgency due to late decelerations favours LSCS.

A woman with a previous LSCS in the second stage of labour complaining of severe abdominal pain, fetal tachycardia, and fresh vaginal bleeding is exhibiting signs highly suggestive of uterine rupture. This is a catastrophic obstetric emergency requiring immediate surgical intervention. Performing an emergency Caesarean section (EM-LSCS) is crucial to deliver the baby and repair the uterine rupture, minimizing maternal and fetal morbidity and mortality. Supportive measures like saline infusion, pain relief, hydration, and left lateral position with oxygen are important but are secondary to the urgent need for surgery. Observation in this situation is extremely dangerous and can lead to severe consequences.

A primigravida at term with intermittent lower abdominal pain for 1 hour, 50% effaced, and 1.5cm dilated cervix is in the latent phase of labour. Pain management in the latent phase should be conservative. Paracetamol is a safe and often effective first-line analgesic for mild to moderate pain in early labour. Diclofenac Na suppository is a stronger NSAID and might be considered if paracetamol is insufficient, but it's not usually the first choice in early labour. Nitrous oxide inhalation is typically offered in the active phase of labour. IV pethidine provides stronger analgesia but has systemic effects and is usually reserved for the active phase. Nifedipine is a calcium channel blocker used for preterm labour or hypertension, not for pain management in term labour.

A woman with a cervical os of 5cm is likely in the active phase of the first stage of labour, where pain intensity typically increases. While paracetamol and diclofenac might offer some relief for mild to moderate pain, they may not be sufficient for the increasing pain of active labour. Tramadol is a stronger opioid analgesic but can have significant side effects and may not provide the same level of consistent pain relief as an epidural. Epidural analgesia is the most effective method of pain relief in active labour, providing significant and often complete pain relief while allowing the woman to remain alert.

A primigravida whose cervical dilatation has remained at 4cm for 4 hours in the active phase of labour is experiencing slow progress (a rate of 0 cm per hour over 4 hours). According to NICE guidelines, if the rate of cervical dilatation is less than 2 cm in 4 hours in the active phase, augmentation of labour with oxytocin should be considered, provided there are no contraindications and fetal wellbeing is confirmed. Immediate LSCS is not indicated at this stage without signs of fetal distress or obstructed labour. Forceps delivery is only for the second stage of labour with a fully dilated cervix. Reviewing for another 4 hours would further delay necessary intervention. Asking the patient to bear down is for the second stage of labour.

The CTG showing fetal bradycardia along with prolonged and frequent uterine contractions (lasting 90 seconds with a 30-second interval indicates uterine hyperstimulation) induced by oxytocin suggests fetal distress. The immediate first step in management, according to NICE guidelines, is to stop the oxytocin infusion to reduce uterine activity and improve fetal oxygenation. Turning the mother to the left lateral position can also help improve uteroplacental blood flow. Giving oxygen is a supportive measure for fetal distress. Starting terbutaline infusion is a tocolytic that can stop contractions but stopping the causative agent (oxytocin) is the most direct and immediate action.