Labor Induction and Post Partum Care Flashcards
Which of the following is NOT a recommended prevention strategy for postpartum hemorrhage (PPH)?
A) Active management of the third stage of labor
B) Routine administration of ergot alkaloids in hypertensive patients
C) Identifying high-risk patients early
D) Uterine massage after placental delivery
Answer: B) Routine administration of ergot alkaloids in hypertensive patients → Incorrect. Ergot alkaloids are contraindicated in hypertension due to vasoconstriction effects.
Explanation:
Prevention Strategies for Postpartum Hemorrhage
A) Active management of the third stage of labor → Correct. This reduces the risk of PPH.
C) Identifying high-risk patients early → Correct. This allows for proactive intervention.
D) Uterine massage after placental delivery → Correct. This helps maintain uterine tone and prevent hemorrhage.
- Uterotonic medications (e.g., oxytocin) is another
Which of the following is a key preventive measure for postpartum hemorrhage?
A) Delaying recognition of abnormal bleeding patterns
B) Timely administration of blood products when needed
C) Routinely using interventions during labor regardless of necessity
D) Avoiding hydration to prevent fluid overload
✅ Correct Answer: B) Timely administration of blood products when needed
Explanation: Early administration of blood products helps manage severe hemorrhage and prevent complications like shock.
❌ A) Delaying recognition of abnormal bleeding patterns → This increases the risk of severe hemorrhage. Timely recognition is crucial.
❌ C) Routinely using interventions during labor regardless of necessity → Unnecessary interventions may increase the risk of complications, including hemorrhage.
❌ D) Avoiding hydration to prevent fluid overload → Hydration is important to maintain blood volume and prevent hypovolemia.
What is the recommended management for retained placenta with excessive bleeding?
A) Allowing spontaneous separation for up to 30 minutes
B) Controlled cord traction
C) Manual removal
D) Administering additional IV fluids and waiting
✅ Correct Answer: C) Manual removal
Explanation: Retained placenta with excessive bleeding is an indication for manual removal to prevent postpartum hemorrhage.
❌ A) Allowing spontaneous separation for up to 30 minutes → The normal separation process usually occurs within 15 minutes. Delaying too long may increase bleeding.
❌ B) Controlled cord traction → This assists with placental expulsion but is not sufficient when excessive bleeding is present.
❌ D) Administering additional IV fluids and waiting → IV fluids are supportive, but waiting too long can worsen blood loss.
What is the main reason for avoiding routine episiotomy?
A) It increases the risk of postpartum hemorrhage
B) It does not reduce perineal trauma overall
C) It prevents shoulder dystocia
D) It eliminates the need for controlled delivery techniques
B) Correct – Routine episiotomy does not significantly reduce overall perineal trauma and can lead to increased pain, longer healing time, and higher risk of severe tears.
A) Incorrect – Episiotomy is not a major risk factor for postpartum hemorrhage.
C) Incorrect – Episiotomy does not prevent shoulder dystocia (which is managed with maneuvers like McRoberts).
D) Incorrect – Controlled delivery techniques (like gentle perineal support) are still needed, even if an episiotomy is performed.
What is the most critical maternal monitoring parameter in the first hour postpartum?
A) Oxygen saturation
B) Uterine blood loss
C) Fetal heart rate
D) Amniotic fluid volume
Answer: B) Uterine blood loss
Correct: Postpartum hemorrhage is a leading cause of maternal morbidity, making blood loss monitoring essential.
Incorrect:
A) Oxygen saturation is important but not the primary postpartum concern.
C) Fetal heart rate monitoring is crucial during labor, not postpartum.
D) Amniotic fluid is no longer present postpartum.
What is Postpartum Hemorrhage?
* Postpartum hemorrhage denotes excessive bleeding following delivery (> 500 mL in vaginal delivery or > 1000 mL in cesarean delivery)
* Blood lost during the first 24 hours after delivery is early postpartum hemorrhage; or blood lost of those volumes aforementioned at one time not cumilatitive that occurs between 24 hours and 6 weeks after delivery is late postpartum hemorrhage.
- Definition: Excessive blood loss following vaginal delivery (5-8% incidence)
- Most common cause of excessive blood loss in pregnancy
- Leading cause of maternal mortality worldwide
- Prevention is key to reducing risk and improving outcomes.
What is the most concerning postpartum complication requiring immediate medical attention?
A) Mild uterine cramping
B) Spotting on a sanitary pad
C) Signs of shock (dizziness, weakness, pale skin)
D) Breast tenderness
Correct Answer: C) Signs of shock (dizziness, weakness, pale skin)
Explanation: These symptoms indicate severe postpartum hemorrhage or hypovolemic shock, requiring urgent medical intervention.
A) Mild uterine cramping – Normal as the uterus contracts postpartum.
B) Spotting – Expected in postpartum recovery.
D) Breast tenderness – Common but not an emergency.
What is the most effective first-line uterotonic agent for postpartum hemorrhage?
A) Misoprostol
B) Oxytocin
C) Ergot alkaloids
D) Magnesium sulfate
Answer: (B) Oxytocin – Correct. Oxytocin is the first-line agent for preventing and treating postpartum hemorrhage due to its strong uterotonic effects.
Explanation:
(A) Misoprostol – Incorrect. While misoprostol is used in low-resource settings, oxytocin remains the first-line treatment.
(C) Ergot alkaloids – Incorrect. These are effective but contraindicated in patients with hypertension.
(D) Magnesium sulfate – Incorrect. Magnesium sulfate is a tocolytic agent used to prevent preterm labor, not to treat postpartum hemorrhage.
Which of the following is NOT a recommended prevention strategy for postpartum hemorrhage?
A) Active management of the third stage of labor
B) Uterine massage after placental delivery
C) Routine administration of terbutaline
D) Early identification of high-risk patients
Answer: (C) Routine administration of terbutaline – Incorrect. Terbutaline is a tocolytic (used to delay labor) and does not prevent postpartum hemorrhage.
Explanation:
(A) Active management of the third stage of labor – Correct. This includes oxytocin administration and controlled cord traction to reduce postpartum hemorrhage risk.
(B) Uterine massage after placental delivery – Correct. This helps promote uterine contraction and reduce bleeding.
(D) Early identification of high-risk patients – Correct. Identifying patients with risk factors (e.g., history of PPH, anemia) allows for preventive measures.
List of Relative contraindications to Labor induction:
1. Breech Presentation
Why it’s a relative contraindication:
Vaginal delivery in a breech presentation increases the risk of cord prolapse, birth trauma, and head entrapment.
However, in certain cases (e.g., a frank breech with favorable pelvic dimensions and experienced providers), induction may still be attempted.
Alternative: External cephalic version (ECV) may be attempted before induction.
2. Previous Cesarean Section with a Low Transverse Scar
Why it’s a relative contraindication:
There is a risk of uterine rupture, especially if oxytocin or prostaglandins are used.
However, a low transverse scar has a lower risk (0.5-1%) of rupture compared to a classical incision (5-10%).
Alternative: Trial of labor after cesarean (TOLAC) may be considered if there are no other complications.
3. Oligohydramnios (Low Amniotic Fluid)
Why it’s a relative contraindication:
Reduced amniotic fluid can increase umbilical cord compression, leading to fetal distress (e.g., variable decelerations).
However, in some cases, labor induction may still be preferred over expectant management if the risks of continuing pregnancy (e.g., placental insufficiency) outweigh the risks of induction.
Alternative: Amnioinfusion may be used to improve fluid levels.
4. Multiple Gestation (Twins or More)
Why it’s a relative contraindication:
Increased risk of complications, such as uterine overdistension, preterm labor, malpresentation, and cord prolapse.
However, if the leading twin is in a vertex position and the second twin is not significantly larger, induction may be an option.
Alternative: Cesarean delivery is often preferred if there are concerns about fetal positioning or distress.
5. Grand Multiparity (≥5 Previous Deliveries)
Why it’s a relative contraindication:
Higher risk of uterine atony, postpartum hemorrhage, and uterine rupture due to a weakened or overstretched uterus.
However, induction may still be considered with careful monitoring.
Alternative: Conservative management or spontaneous labor is often preferred unless induction is medically necessary.
6. Prematurity
Why it’s a relative contraindication:
Inducing labor before 37 weeks increases the risk of neonatal respiratory distress syndrome (RDS) and other complications.
However, in cases where continuing the pregnancy poses greater risks (e.g., preeclampsia, intrauterine growth restriction), induction may be necessary.
Alternative: Expectant management or corticosteroids for lung maturity may be considered if delivery can be delayed.
7. Suspected Fetal Macrosomia (Large Fetus, >4,000-4,500 g)
Why it’s a relative contraindication:
Increased risk of shoulder dystocia, birth trauma, and prolonged labor.
However, induction may still be attempted if vaginal delivery is deemed possible (e.g., in non-diabetic mothers with no other complications).
Alternative: Expectant management or cesarean delivery if fetal size is significantly high.
Conclusion
Relative contraindications mean labor induction is not completely ruled out but requires careful assessment, close monitoring, and risk-benefit analysis. In many cases, alternative strategies or modifications to the induction process (e.g., using mechanical methods instead of prostaglandins) may help reduce risks.
Which of the following is a contraindication to labor induction?
A) Gestational diabetes requiring insulin
B) Placenta previa
C) Oligohydramnios
D) Suspected intrauterine growth restriction (IUGR)
✅ Correct Answer: B) Placenta previa
Explanation: Placenta previa (placenta covering the cervix) is an absolute contraindication to induction due to the risk of massive hemorrhage.
❌ A) Gestational diabetes requiring insulin → This is an indication for induction if the pregnancy is at term and there are concerns about fetal macrosomia or placental function.
❌ C) Oligohydramnios → Oligohydramnios (low amniotic fluid) can be an indication for induction if fetal distress or growth restriction is present.
❌ D) Suspected intrauterine growth restriction (IUGR) → IUGR is an indication for induction in cases of fetal compromise.
Which of the following is an absolute contraindication to labor induction?
A) Breech presentation
B) Previous cesarean section with a low transverse scar
C) Placenta previa
D) Oligohydramnios
C) Placenta previa
Explanation: Placenta previa (placenta covering the cervix) is an absolute contraindication because inducing labor could cause severe hemorrhage as the cervix dilates.
Why the others are wrong:
(A) Breech presentation is a relative contraindication because vaginal delivery may be possible in some cases.
(B) A previous low transverse C-section is a relative contraindication because uterine rupture risk is lower compared to a classical incision.
(D) Oligohydramnios is also a relative contraindication because it can be managed depending on severity.
Absolute contraindications to Labor induction:
1. Contracted Pelvis
A contracted pelvis means the pelvic bones are too small or misshapen, making vaginal delivery difficult or impossible.
Inducing labor in this case increases the risk of prolonged labor, fetal distress, and obstructed labor, potentially requiring an emergency C-section.
2. Placenta Previa (Placenta Covering the Cervix)
In placenta previa, the placenta is partially or completely covering the cervix, blocking the baby’s exit.
Inducing labor could cause severe hemorrhage as the cervix dilates, since the placenta would detach prematurely.
The only safe delivery method is a C-section in most cases.
3. Vasa Previa (Fetal Vessels Over Cervix)
Vasa previa occurs when fetal blood vessels (not protected by the placenta or cord) cross the cervix.
When the membranes rupture, these vessels can tear, causing rapid fetal blood loss and death within minutes.
A C-section is required before labor begins to prevent this catastrophic outcome.
4. Previous Classical Cesarean Section (Vertical Uterine Incision)
A classical C-section (vertical incision on the uterus) has a much higher risk of uterine rupture compared to a low-transverse (horizontal) incision.
If labor is induced, the intense contractions could rupture the scar, leading to hemorrhage, fetal distress, and even maternal or fetal death.
5. Myomectomy Entering the Endometrial Cavity
A myomectomy is the surgical removal of fibroids from the uterus.
If the procedure involved cutting into the endometrial (inner) layer of the uterus, it leaves weak scar tissue that can rupture under the stress of labor.
This makes uterine rupture a major risk, similar to a classical C-section.
6. Transverse Fetal Lie
In transverse lie, the baby is positioned sideways in the uterus instead of head-down or breech.
Labor induction won’t help the baby reposition, and vaginal delivery is impossible in this position.
Attempting induction increases the risk of umbilical cord prolapse, which can cut off oxygen to the baby.
A C-section is required for safe delivery.
Which of the following is an early sign of postpartum hemorrhage?
A) Hypotension and tachycardia.
B) Decreased uterine tone (boggy uterus).
C) Persistent vaginal bleeding despite fundal massage.
D) All of the above.
✅ Correct Answer: D
A is correct – Hypotension and tachycardia are late but critical signs.
B is correct – A boggy uterus suggests uterine atony, the most common cause of PPH.
C is correct – Persistent bleeding despite massage and uterotonics indicates ongoing hemorrhage.
What is the purpose of the Bishop Score?
A) To estimate the success of labor induction.
B) To assess fetal well-being before delivery.
C) To determine the likelihood of postpartum hemorrhage.
D) To diagnose placenta previa.
✅ Correct Answer: A) The Bishop Score (0-13) assesses cervical readiness and predicts the likelihood of successful labor induction.
B) is incorrect – fetal well-being is assessed using a non-stress test (NST) or biophysical profile (BPP).
C) is incorrect – PPH risk is based on history, anemia, and labor factors, not the Bishop Score.
D) is incorrect – Ultrasound diagnoses placenta previa.
Which of the following IS a valid medical indication for labor induction?
A) Uncomplicated pregnancy at 38 weeks gestation
B) Hypertensive disorders (preeclampsia, eclampsia)
C) A Bishop Score of 3 with no other complications
D) A history of a previous cesarean section with a classical incision
** B) Hypertensive disorders: Preeclampsia and eclampsia pose risks to both mother and baby, often necessitating early delivery.
(A - Incorrect): Elective induction should generally not occur before 39 weeks unless medically necessary.
(C - Incorrect): A low Bishop Score alone does not justify induction unless other risk factors are present.
(D - Incorrect): A previous classical (vertical) cesarean incision is a contraindication due to uterine rupture risk.
Criteria for Induction
* Before induction, assess the following:
* Gestational age confirmation using the best dating method.
* Fetal well-being (non-stress test, biophysical profile).
* Recent estimated fetal weight (EFW).
* Bishop Score to predict induction success.
* Induction should NOT be done before 39 weeks unless medically indicated.
Indications for Labor Induction
Maternal Indications:
* Hypertensive disorders (preeclampsia, eclampsia, HELLP syndrome).
* Diabetes (gestational or pregestational).
* Chronic hypertension.
* Cardiac disease.
* Fetal abnormality requiring delivery.
* Chorioamnionitis (intrauterine infection).
* Premature rupture of membranes (PROM).
* Placental insufficiency or oligohydramnios.
* Suspected intrauterine growth restriction (IUGR).
* Fetal demise.
* Multiple gestation when indicated.
Which of the following is NOT a risk factor for postpartum hemorrhage?
A) History of postpartum hemorrhage
B) Multiple gestation pregnancy
C) Chronic hypertension
D) Induction or augmentation of labor with oxytocin
**(C - Correct): Chronic hypertension is not a direct risk factor for PPH—it affects pregnancy in other ways but does not directly increase hemorrhage risk.
Explanation:
(A - Incorrect): A prior history of postpartum hemorrhage is a strong risk factor for recurrence.
(B - Incorrect): Multiple gestation (twins, triplets) increases uterine distension, raising PPH risk.
(D - Incorrect): Oxytocin use increases uterine hyperstimulation, which can contribute to uterine atony, a major cause of PPH.
Risk Factors for postpartum hemorrhage
* History of PPH or transfusion
* Anemia, grand multiparity, multiple gestation
* Induction/augmentation of labor (oxytocin use)
* Prolonged or rapid labor
Which of the following is a potential fetal complication of labor induction?
A) Polyhydramnios
B) Umbilical cord prolapse
C) Increased fetal lung maturity
D) Decreased risk of fetal distress
✅ Correct Answer: B) Umbilical cord prolapse
Why? Artificial rupture of membranes (amniotomy) may lead to umbilical cord prolapse, which can cause acute fetal distress and require emergency delivery.
❌ A) Polyhydramnios → Not associated with induction; rather, oligohydramnios is a relative contraindication.
❌ C) Increased fetal lung maturity → Induction does not improve lung maturity; corticosteroids are used for this in preterm births.
❌ D) Decreased risk of fetal distress → Induction increases fetal distress risk, especially with excessive oxytocin.
Which medication is FDA-approved for cervical ripening?
A) Oxytocin
B) Misoprostol
C) Dinoprostone
D) Magnesium sulfate
✅ Correct Answer: C) Dinoprostone
Why? Dinoprostone (PGE2) is FDA-approved for cervical ripening.
❌ A) Oxytocin → Used for labor induction/augmentation, not cervical ripening.
❌ B) Misoprostol → Used off-label for cervical ripening but not FDA-approved.
❌ D) Magnesium sulfate → Used for preterm labor (tocolysis), not for induction.
Why is Dinoprostone contraindicated in asthma?
Dinoprostone (PGE2) is contraindicated in asthma because prostaglandins can induce bronchoconstriction. Specifically, PGE2 has complex effects on airway smooth muscle—it can cause bronchodilation in some cases but also induce bronchospasms in susceptible individuals, particularly those with asthma. Asthmatic patients often have heightened sensitivity to prostaglandins due to underlying airway inflammation, making them more prone to bronchoconstriction and respiratory distress.
Cervical Ripening
Prostaglandins for Cervical Ripening
* Misoprostol (PGE1): Off-label but widely used.
* Dinoprostone (PGE2): FDA-approved for cervical ripening.
* Both improve Bishop score and promote cervical changes.
* Meta-analysis: Misoprostol results in shorter time to delivery & lower C- section rate.
What is a major contraindication for using PGE2 (Dinoprostone) for cervical ripening?
A) Asthma
B) Diabetes
C) History of gestational hypertension
D) Fetal macrosomia
✅ Correct Answer: A) Asthma
Why? Dinoprostone (PGE2) can cause bronchospasm and should be avoided in asthma patients.
❌ B) Diabetes → Not a direct contraindication for PGE2.
❌ C) History of gestational hypertension → May require careful monitoring but is not a strict contraindication.
❌ D) Fetal macrosomia → Relative contraindication for induction but not specific to PGE2.
Which of the following is a key safety measure when administering oxytocin for labor induction?
A) Increasing the dose every 5 minutes
B) Monitoring contraction frequency and fetal heart rate
C) Administering it via IV push for rapid effect
D) Combining it with tocolytics for uterine relaxation
✅ Correct Answer: B) Monitoring contraction frequency and fetal heart rate
Why? Oxytocin can cause tachysystole (>5 contractions in 10 minutes) and fetal distress, requiring continuous monitoring.
❌ A) Increasing dose every 5 minutes → Oxytocin dosing should be gradual and carefully titrated.
❌ C) Administering via IV push → Oxytocin is always given via continuous infusion, not IV push.
❌ D) Combining with tocolytics → Tocolytics (e.g., terbutaline) are used to reduce contractions, not alongside oxytocin.
What is the primary purpose of an amniotomy (artificial rupture of membranes)?
A) To reduce the risk of fetal heart rate decelerations
B) To slow down labor progression
C) To enhance uterine contractions and shorten labor
D) To decrease the risk of cord prolapse
✅ Correct Answer: C) To enhance uterine contractions and shorten labor
Why? Amniotomy can increase contraction strength and duration, potentially accelerating labor progression.
❌ A) To reduce the risk of fetal heart rate decelerations → Amniotomy may cause variable decelerations due to cord compression.
❌ B) To slow down labor progression → It speeds up labor, not slows it down.
❌ D) To decrease the risk of cord prolapse → Amniotomy increases the risk, especially if the fetal head is not engaged.
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Yes, amniotomy releases prostaglandins from the amniotic fluid and fetal membranes, which contribute to increased uterine contractility. When the membranes rupture, arachidonic acid is liberated, leading to the production of prostaglandins (primarily PGE2 and PGF2α), which stimulate uterine contractions.
Additionally, the direct mechanical effect of amniotomy reduces the buffering effect of the amniotic sac, allowing the fetal head to exert more pressure on the cervix, stimulating oxytocin release via the Ferguson reflex, further enhancing contractions.
Which type of breech presentation is most common?
A) Frank breech
B) Complete breech
C) Footling breech
D) Transverse breech
✅ Correct Answer: A) Frank breech
Why? Frank breech (hips flexed, knees extended) is the most common type of breech presentation.
❌ B) Complete breech → Less common, with both hips and knees flexed.
❌ C) Footling breech → Least favorable for vaginal delivery; associated with higher risk of cord prolapse.
❌ D) Transverse breech → Not a true breech; rather, it’s a malpresentation requiring C-section.
Footling breech (C) is the least favorable for vaginal delivery because:
The feet descend first, increasing the risk of cord prolapse, which can lead to fetal hypoxia.
The head may become trapped during delivery, as it is the largest fetal part and lacks the guiding force provided by flexed hips in other breech types.
Can any breech be delivered vaginally?
Frank breech (A) is the most common and often considered the best candidate for vaginal delivery because the fetal buttocks can act as a wedge to dilate the birth canal before the head delivers.
Complete breech (B) can sometimes be delivered vaginally but is riskier than frank breech.
Footling breech (C) and transverse lie (D) require C-section due to the high risks of complications like cord prolapse and head entrapment.
Which of the following is a key advantage of External Cephalic Version (ECV) for breech presentation?
A) Reduces the risk of cord prolapse
B) Increases the likelihood of vaginal delivery
C) Eliminates the need for fetal monitoring
D) Is recommended for all breech presentations before 34 weeks
✅ Correct Answer: B) Increases the likelihood of vaginal delivery
Why? ECV at ≥37 weeks can successfully turn the fetus into cephalic position, increasing the chance of vaginal delivery.
❌ A) Reduces the risk of cord prolapse → ECV does not reduce cord prolapse risk and may actually provoke it in rare cases.
❌ C) Eliminates the need for fetal monitoring → Fetal monitoring is essential during and after ECV.
❌ D) Is recommended for all breech presentations before 34 weeks → ECV is not routinely done before 37 weeks due to the possibility of spontaneous repositioning.
Which of the following is a potential complication of uterine hyperstimulation during labor induction?
A) Uterine rupture
B) Placental abruption
C) Fetal distress
D) All of the above
✅ Correct Answer: D) All of the above
Uterine rupture: Excessive contractions can cause uterine tearing, particularly in women with previous C-sections or uterine surgeries.
Placental abruption: Tetanic contractions can shear the placenta away from the uterine wall prematurely.
Fetal distress: Reduced oxygen supply due to prolonged contractions can lead to hypoxia and abnormal fetal heart rate patterns.
- How does uterine rupture happen?
Mechanism:
The uterus is made up of muscle fibers that stretch during pregnancy.
In women with a previous C-section or uterine surgery, there is a scar on the uterine wall.
When contractions are too strong or too frequent (due to excessive oxytocin or hyperstimulation), the scarred tissue is weaker than the surrounding muscle and may tear.
Consequences:
If the rupture is complete, the baby and amniotic fluid may enter the abdominal cavity, causing severe maternal hemorrhage and fetal distress or death.
Uterine rupture is a life-threatening emergency, often requiring an immediate C-section and potential hysterectomy if bleeding cannot be controlled.
What is a major fetal risk associated with amniotomy (artificial rupture of membranes)?
A) Shoulder dystocia
B) Umbilical cord prolapse
C) Hyperbilirubinemia
D) Meconium aspiration
✅ Correct Answer: B) Umbilical cord prolapse
When the membranes rupture, the sudden release of amniotic fluid can cause the umbilical cord to descend ahead of the fetal presenting part, leading to cord compression and acute fetal distress.
❌ A) Shoulder dystocia is more related to macrosomia and mechanical obstruction.
❌ C) Hyperbilirubinemia is more commonly linked to hemolysis or ABO incompatibility.
❌ D) Meconium aspiration is more likely in post-term pregnancies with fetal distress.
How does umbilical cord prolapse happen after membrane rupture?
Step-by-step process:
The amniotic sac cushions the umbilical cord and the baby inside the uterus.
When the membranes rupture (naturally or through an amniotomy), fluid suddenly gushes out, creating a temporary vacuum effect.
If the baby’s head or presenting part is not fully engaged in the pelvis, the umbilical cord can slip down into the birth canal before the baby.
The baby’s head or body may then press on the cord, cutting off the blood supply and oxygen to the baby, leading to acute fetal distress.
Management:
If umbilical cord prolapse occurs, the provider may elevate the presenting part manually to relieve compression while immediate C-section is performed.
Which breech presentation has the highest risk of umbilical cord prolapse?
A) Frank breech
B) Complete breech
C) Footling breech
D) Transverse breech
✅ Correct Answer: C) Footling breech
Since the feet descend first, there is more space for the cord to slip below the presenting part, increasing the risk of prolapse and fetal distress.
❌ A) Frank breech (hips flexed, knees extended) is the most common and safest for vaginal delivery.
❌ B) Complete breech (hips and knees flexed) has a lower risk of prolapse.
❌ D) Transverse breech is a malpresentation that requires a C-section rather than vaginal delivery.
What is the most effective initial maneuver for managing shoulder dystocia?
A) Zavanelli maneuver
B) Symphysiotomy
C) McRoberts maneuver
D) Fundal pressure
✅ Correct Answer: C) McRoberts maneuver is the first line treatment for Dystocia with a 42% success rate.
McRoberts maneuver involves hyperflexing the mother’s legs onto the abdomen, which flattens the sacrum and rotates the pelvis, relieving shoulder impaction.
❌ A) Zavanelli maneuver is a last-resort method where the fetal head is pushed back into the uterus for emergency C-section.
❌ B) Symphysiotomy (cutting the pubic symphysis) is rarely used due to severe maternal morbidity.
❌ D) Fundal pressure is contraindicated, as it increases the risk of fetal injury (brachial plexus injury, fractures).
Which of the following is the recommended management for a persistent breech at term (≥39 weeks)?
A) Immediate C-section for all cases
B) External Cephalic Version (ECV) at 37+ weeks
C) Induction of labor with prostaglandins
D) Allow spontaneous vaginal breech delivery without intervention
✅ Correct Answer: B) External Cephalic Version (ECV) at 37+ weeks
ECV is a manual procedure to turn the fetus into a cephalic position, reducing the need for a C-section.
❌ A) Immediate C-section is not always required—vaginal breech delivery is possible in select cases.
❌ C) Induction of labor with prostaglandins is not recommended because breech presentation increases the risk of complications like cord prolapse.
❌ D) Allowing spontaneous vaginal delivery without an experienced team is unsafe.
Procedure:
Timing: Usually performed at 37+ weeks when the baby is full-term but before labor begins.
Preparation:
The mother may receive a tocolytic drug (e.g., terbutaline) to relax the uterus.
Ultrasound is used to confirm fetal position and placenta location (ECV is not done if placenta previa is present).
Continuous fetal heart monitoring is done before, during, and after the procedure.
Technique:
The provider places their hands on the mother’s abdomen and gently pushes the baby’s bottom up while guiding the head down into a head-first position.
If successful, the baby remains in a cephalic position, increasing the chances of vaginal delivery instead of C-section.
Success Rate: About 50-60% effective.
Risks: Rare but include fetal distress, placental abruption, and water breaking.
Which stage of labor is the longest?
A) First stage
B) Second stage
C) Third stage
D) Fourth stage
✅ Correct Answer: A) First stage
Explanation: The first stage of labor involves cervical changes and fetal descent, which includes the latent, active, and transition phases, is the longest stage. It begins with the onset of regular contractions and ends when the cervix is fully dilated (10 cm).
Latent Phase (Early Labor)
Management:
* Encourage rest, hydration, and movement.
* Provide reassurance and non-pharmacologic pain relief (e.g., warm baths, breathing techniques).
* Monitor fetal heart rate (FHR) intermittently in low-risk cases.
* Avoid unnecessary interventions unless complications arise.
First Stage - Active Phase
Management:
* Monitor maternal vitals and FHR more frequently.
* Consider pharmacologic pain relief (epidural, IV analgesia, nitrous oxide).
* Encourage movement and comfortable positioning (upright, hands and
knees, side-lying).
* Assess for labor dystocia if dilation is slow.
First Stage - Transition Phase Management (Most intense Part of Labor):
* Provide continuous emotional and physical support.
* Assist with breathing techniques to prevent early pushing.
* Encourage comfortable positioning (leaning forward, squatting, side-
lying).
* Prepare for delivery.
❌ Incorrect Answers:
B) Second stage (Pushing): This stage involves pushing and delivery of the baby; it’s usually shorter.
Management:
* Support spontaneous pushing (avoid coached or forced pushing unless needed).
* Encourage upright positions to aid fetal descent.
* Monitor fetal status closely.
* Prepare for potential perineal support or repair.
C) Third stage (Placental Delivery): This is the placental delivery stage, typically lasting 5-30 minutes.
Management:
* Active management recommended: Administer oxytocin, gentle cord traction, uterine massage to reduce postpartum hemorrhage.
* Inspect placenta for completeness.
* Monitor for postpartum hemorrhage.
D) Fourth stage: This refers to the immediate postpartum period, lasting 1-2 hours.
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Fourth Stage of Labor (Immediate Postpartum)
* First 1–2 hours after delivery, critical for maternal stabilization.
* Monitor vital signs, bleeding, uterine tone, bladder function.
* Encourage early breastfeeding and skin-to-skin contact.
* Watch for signs of postpartum hemorrhage or uterine atony.
What is the primary mechanical issue in shoulder dystocia?
A) The fetal head is too large to pass through the pelvis.
B) The anterior fetal shoulder becomes impacted behind the pubic symphysis.
C) The umbilical cord is wrapped around the neck, restricting movement.
D) The placenta separates from the uterus too early, causing fetal distress.
✅ Correct Answer: B) The anterior fetal shoulder becomes impacted behind the pubic symphysis.
Explanation: Shoulder dystocia occurs when the baby’s anterior shoulder is trapped behind the mother’s pubic bone, preventing delivery.
❌ Incorrect Answers:
A) The fetal head is too large to pass through the pelvis: This describes cephalopelvic disproportion (CPD), not shoulder dystocia.
C) The umbilical cord is wrapped around the neck: This is called a nuchal cord, not shoulder dystocia.
D) The placenta separates from the uterus too early: This describes placental abruption.
Which maneuver involves applying pressure above the pubic symphysis to help dislodge a fetal shoulder during shoulder dystocia?
A) McRoberts maneuver
B) Suprapubic pressure
C) Rubin maneuver
D) Zavanelli maneuver
✅ Correct Answer: B) Suprapubic pressure
Explanation: Suprapubic pressure is used to dislodge the anterior shoulder by applying pressure just above the pubic symphysis. This increases success rates when combined with the McRoberts maneuver (54-58%).
❌ Incorrect Answers:
A) McRoberts maneuver: Involves hyperflexing the mother’s thighs to flatten the sacrum and rotate the pubic symphysis.
C) Rubin maneuver: Involves rotating the fetal shoulder to a more favorable position.
D) Zavanelli maneuver: Involves pushing the fetal head back into the uterus before performing a C-section—used as a last resort.
Which of the following is NOT a common indication for cesarean delivery?
A) Malpresentation (e.g., breech position)
B) Non-reassuring fetal heart rate patterns
C) Presence of a support person during labor
D) Failure to progress (dystocia)
✅ Correct Answer: C) Presence of a support person during labor
Explanation: Having a trained doula or support person can actually reduce the likelihood of cesarean delivery. It is not an indication for cesarean.
❌ Incorrect Answers:
A) Malpresentation: Babies in a breech or transverse position may require cesarean delivery.
B) Non-reassuring fetal heart rate patterns: Signs of fetal distress may prompt an emergency cesarean.
D) Failure to progress: When labor does not advance despite adequate contractions, a cesarean may be needed.
Which of the following is an effective strategy to reduce unnecessary cesarean deliveries?
A) Routine amniotomy in all laboring patients
B) Elective repeat cesarean without attempting vaginal birth
C) Providing continuous labor support, such as a doula
D) Avoiding trial of labor after a previous cesarean (TOLAC)
✅ Correct Answer: C) Providing continuous labor support, such as a doula
Explanation: Having a trained support person can improve labor outcomes and reduce the need for a cesarean.
❌ Incorrect Answers:
A) Routine amniotomy: Artificial rupture of membranes without medical necessity may increase cesarean risk.
B) Elective repeat cesarean: Choosing cesarean without attempting vaginal birth after a previous cesarean increases overall cesarean rates.
D) Avoiding TOLAC: Many women (about 75%) have successful vaginal births after cesarean (VBAC), reducing the need for repeat cesarean.
Counseling on Trial of Labor After Cesarean (TOLAC) Considerations:
* Balancing maternal and neonatal risks.
* Assessing individual patient preferences.
* Providing thorough counseling on potential outcomes.
Which of the following is NOT a recommended thromboprophylaxis strategy after cesarean delivery?
A) Early ambulation for low-risk patients
B) Intermittent pneumatic compression for moderate-risk patients
C) Routine aspirin use for all postpartum patients
D) Low molecular weight heparin (LMWH) for high-risk patients
Thromboprophylaxis Recommendations
* Low-Risk Patients:
* Early ambulation is encouraged; additional prophylaxis typically not
required.
* Moderate-Risk Patients:
* Use of mechanical prophylaxis (e.g., compression stockings or intermittent pneumatic compression devices) is advised.
* High-Risk Patients:
* Combination of pharmacologic (e.g., low molecular weight heparin) and mechanical prophylaxis is recommended.
✅ Correct Answer: C) Routine aspirin use for all postpartum patients
Explanation: While aspirin is beneficial in some cardiovascular conditions, it is not routinely recommended for thromboprophylaxis after cesarean delivery.
❌ Incorrect Answers:
A) Early ambulation: Helps prevent blood clots in low-risk patients.
B) Intermittent pneumatic compression: Recommended for moderate-risk patients.
D) LMWH: Used for high-risk patients to prevent deep vein thrombosis (DVT).
What is the approximate success rate of Trial of Labor After Cesarean (TOLAC) leading to a vaginal birth? Also What percentage of births in the United States are cesarean deliveries?
A) 25% and 10%
B) 50% and 20%
C) 75% and 33%
D) 90% and 50%
✅ Correct Answer: C) 75%
Explanation: About 75% of women who attempt a trial of labor after cesarean (TOLAC) achieve a successful vaginal birth.
❌ Incorrect Answers:
A) 25% & B) 50%: These underestimate the actual success rate.
D) 90%: While TOLAC is often successful, this is an overestimation
Second Part of the Answers
A) 10% & B) 20%: These percentages are too low compared to actual cesarean rates.
D) 50%: This overestimates the prevalence of cesarean births.
Which of the following postoperative complications is a patient at increased risk for after a cesarean delivery?
A) Endomyometritis
B) Deep vein thrombosis (DVT)
C) Wound dehiscence
D) All of the above
✅ Correct Answer: D) All of the above
Explanation: Cesarean delivery increases the risk of infection (e.g., endomyometritis), blood clots (DVT), and wound complications (dehiscence, infection).
❌ Incorrect Answers:
A, B, and C individually: While each is correct, the best choice is D (all of the above) because cesarean delivery increases multiple risks.
Complications for increased risk after Cesarean:
Pain Management
A cesarean section involves an abdominal incision through multiple layers of tissue, including skin, fascia, muscle, and the uterus. Postoperative pain is expected due to surgical trauma and inflammation. Effective pain management is essential to support recovery and mobility while minimizing the need for excessive opioid use.
Infections
Endomyometritis (infection of the uterine lining and muscle) can occur due to bacterial contamination during surgery, particularly if membranes have been ruptured for an extended period before the procedure.
Wound infections may develop due to bacterial infiltration at the surgical site, especially in individuals with diabetes, obesity, or poor wound care.
Wound Complications
Wound separation (dehiscence) occurs when the surgical incision partially or fully reopens, often due to poor healing, infection, or excessive strain.
Hematomas or seromas (fluid collections under the incision) can also delay healing and increase infection risk.
Urinary Tract Infections (UTIs)
Cesarean delivery often requires catheterization, which increases the risk of bacterial introduction into the urinary tract.
Postoperative immobility and dehydration can further contribute to urinary stasis, creating an environment for bacterial growth.
Gastrointestinal Issues
Ileus (temporary bowel paralysis) can occur due to the effects of anesthesia and surgical manipulation of the intestines, leading to bloating, nausea, and delayed bowel movements.
Constipation is common due to reduced mobility, pain medications (especially opioids), and fluid shifts after surgery.
Thromboembolic Events
Surgery increases the risk of deep venous thrombosis (DVT) due to prolonged immobility, changes in blood clotting factors, and vascular injury during the procedure.
Septic thrombophlebitis (infected blood clot) is a rare but serious complication, particularly in individuals with an underlying infection or those at higher risk for clotting disorders.
Which gastrointestinal complication is a concern after cesarean delivery?
A) Fecal impaction
B) Ileus
C) Peptic ulcer disease
D) GERD (gastroesophageal reflux disease)
✅ Correct Answer: B) Ileus
Explanation: Ileus (temporary paralysis of the intestines) can occur after cesarean delivery due to anesthesia and abdominal surgery.
❌ Incorrect Answers:
A) Fecal impaction: Not as common as ileus but may occur with severe constipation.
C) Peptic ulcer disease: Not typically linked to cesarean delivery.
D) GERD: Pregnancy itself may cause GERD, but it’s not a major post-cesarean concern.
Which labor management strategy is most effective in reducing cesarean delivery rates?
A) Routine use of epidural anesthesia
B) Early induction of labor in all patients
C) Continuous labor support (e.g., doula)
D) Prolonged second-stage pushing for all patients
✅ Correct Answer: C) Continuous labor support (e.g., doula)
Explanation: Studies show that having a support person during labor (e.g., doula) reduces cesarean rates by promoting effective coping strategies.
❌ Incorrect Answers:
A) Routine epidural use: While effective for pain, it does not necessarily reduce cesarean risk.
B) Early induction in all patients: Increases cesarean risk if not medically indicated.
D) Prolonged pushing: May increase fetal distress and does not lower cesarean rates.
Which maternal condition increases the likelihood of planned cesarean delivery?
A) Well-controlled gestational diabetes
B) Placenta previa
C) Previous vaginal delivery
D) History of preeclampsia without complications
✅ Correct Answer: B) Placenta previa
Explanation: Placenta previa (placenta covering the cervix) requires cesarean delivery due to the risk of life-threatening hemorrhage.
❌ Incorrect Answers:
A) Well-controlled gestational diabetes: Not an automatic indication unless macrosomia or other complications arise.
C) Previous vaginal delivery: Actually reduces the likelihood of cesarean delivery.
D) History of preeclampsia (without complications): Not an absolute indication for cesarean unless severe.
Which of the following is NOT a common indication for elective repeat cesarean delivery (ERCD)?
A) Patient preference without trial of labor
B) Prior uterine rupture
C) Breech presentation
D) Non-reassuring fetal heart rate patterns
✅ Correct Answer: D) Non-reassuring fetal heart rate patterns
Explanation: Non-reassuring fetal heart tones usually lead to an emergency cesarean, not an elective repeat cesarean (ERCD).
❌ Incorrect Answers:
A) Patient preference: Women can opt for ERCD without attempting vaginal birth.
B) Prior uterine rupture: A major risk factor for ERCD due to the high risk of recurrence.
C) Breech presentation: Often leads to scheduled cesarean to prevent complications.
Which of the following best describes the primary source of pain during the first stage of labor?
A) Distension of the pelvic floor and perineum
B) Stretching and dilation of the cervix
C) Compression of the sciatic nerve
D) Ischemia of the uterine muscles
✅ Correct Answer: B) Stretching and dilation of the cervix
Explanation: Pain in the first stage of labor mainly results from cervical dilation and stretching of surrounding tissues.
❌ Incorrect Answers:
A) Distension of the pelvic floor and perineum: Occurs in the second stage, not the first.
C) Compression of the sciatic nerve: Not a major mechanism of labor pain.
D) Ischemia of the uterine muscles: Not the primary cause of labor pain, though contractions may temporarily reduce blood flow.
Which non-pharmacological method can help reduce labor pain by stimulating specific points on the body?
A) Hydrotherapy
B) Acupuncture and Acupressure
C) Continuous labor support
D) Ambulation and position changes
✅ Correct Answer: B) Acupuncture and Acupressure
Explanation: Acupuncture and acupressure involve stimulating pressure points, which may help alleviate pain during labor.
❌ Incorrect Answers:
A) Hydrotherapy: Uses warm water to relax muscles, but does not involve pressure points.
C) Continuous labor support: Provides emotional and physical reassurance but does not directly stimulate pressure points.
D) Ambulation and position changes: Help with comfort and labor progression but do not directly target pressure points.
According to the Complementary Therapies for Labour and Birth (CTLB) study, which outcome was significantly improved in the intervention group?
A) Higher epidural use
B) Increased need for labor augmentation
C) Lower cesarean section rates
D) Increased perineal trauma
✅ Correct Answer: C) Lower cesarean section rates
Explanation: The CTLB program led to a reduction in cesarean deliveries (16.9% vs. 32.2% in the control group).
❌ Incorrect Answers:
A) Higher epidural use: Epidural use was actually lower (23.9% vs. 68.7%).
B) Increased need for labor augmentation: The need for augmentation was lower (30.7% vs. 56.3%).
D) Increased perineal trauma: Perineal trauma was reduced in the intervention group.
Which hormone plays a key role in enhancing pain relief and promoting bonding during labor?
A) Adrenaline
B) Beta-endorphins
C) Cortisol
D) Dopamine
✅ Correct Answer: B) Beta-endorphins
Explanation: Beta-endorphins act as natural pain relievers, reducing the perception of pain during labor.
❌ Incorrect Answers:
A) Adrenaline: Increases in response to stress and can actually slow labor.
C) Cortisol: A stress hormone, not a direct pain reliever.
D) Dopamine: Plays a role in pleasure and motivation but is not a primary labor pain modulator.
Which of the following statements about postpartum care is FALSE?
A) Regular check-ups should assess maternal recovery and mental health.
B) Neonates should be monitored for jaundice, weight loss, and hydration.
C) Mothers should seek immediate help for heavy bleeding, fever, or severe headaches.
D) Routine maternal check-ups are unnecessary if there were no complications at birth.
✅ Correct Answer: D) Routine maternal check-ups are unnecessary if there were no complications at birth.
Explanation: Postnatal check-ups are essential even if the birth was uncomplicated to monitor recovery, mental health, and newborn health.
❌ Incorrect Answers:
A) Regular check-ups should assess maternal recovery and mental health: True, as postpartum depression is a major concern.
B) Neonates should be monitored for jaundice, weight loss, and hydration: True, as these are key indicators of newborn well-being.
C) Mothers should seek immediate help for heavy bleeding, fever, or severe headaches: True, as these are signs of infection or postpartum hemorrhage.
Which of the following non-pharmacological pain management techniques involves the use of low-voltage electrical currents?
A) Breathing techniques
B) Transcutaneous Electrical Nerve Stimulation (TENS)
C) Yoga techniques
D) Visualization and relaxation
✅ Correct Answer: B) Transcutaneous Electrical Nerve Stimulation (TENS)
Explanation: TENS delivers low-voltage electrical stimulation to reduce pain perception.
❌ Incorrect Answers:
A) Breathing techniques: Focuses on controlled respiration, not electrical stimulation.
C) Yoga techniques: Uses postures and movement to promote relaxation.
D) Visualization and relaxation: Involves mental imagery and does not use electrical currents.
Which of the following is NOT a reason for seeking immediate medical care in the postpartum period?
A) High fever or foul-smelling vaginal discharge
B) Persistent jaundice in the newborn
C) Mother experiencing moderate fatigue and mild sleep disturbances
D) Difficulty breathing or bluish skin in the newborn
✅ Correct Answer: C) Mother experiencing moderate fatigue and mild sleep disturbances
Explanation: Mild fatigue and sleep disturbances are common postpartum and do not necessarily indicate a medical emergency.
❌ Incorrect Answers:
A) High fever or foul-smelling vaginal discharge: Signs of infection (e.g., endometritis).
B) Persistent jaundice in the newborn: Can indicate serious conditions like kernicterus.
D) Difficulty breathing or bluish skin in the newborn: Signs of hypoxia, which requires urgent intervention.
Which of the following statements about labor pain transmission is correct?
A) Pain signals are transmitted through spinal nerves to the central nervous system.
B) Pain in the second stage of labor is primarily due to uterine contractions.
C) Nociceptive stimuli during labor are only perceived in the lower abdomen.
D) Pain during labor is purely psychological.
✅ Correct Answer: A) Pain signals are transmitted through spinal nerves to the central nervous system.
Explanation: Nociceptive pain signals travel via spinal nerves to the CNS, where they are perceived as pain.
❌ Incorrect Answers:
B) Pain in the second stage of labor is primarily due to uterine contractions: In the second stage, pain is mostly from perineal and pelvic floor stretching, not just contractions.
C) Nociceptive stimuli during labor are only perceived in the lower abdomen: Labor pain can also radiate to the back, thighs, and pelvis.
D) Pain during labor is purely psychological: While psychological factors influence pain perception, physiological mechanisms are the primary cause.
Immediate Postpartum Safety Considerations
Which of the following is the most important safety consideration during skin-to-skin contact (SSC) in the immediate postpartum period?
a. Ensuring the newborn is placed in a side-lying position for comfort.
b. Encouraging parents to use cell phones to document the bonding experience.
c. Closely monitoring the newborn’s respiration, activity, perfusion, position, and tone.
d. Allowing SSC only for term infants, as preterm infants require immediate incubator care.
Correct Answer: (c) Closely monitoring the newborn’s respiration, activity, perfusion, position, and tone.
✅ Explanation: Continuous monitoring using the R.A.P.P.T. checklist (Respirations, Activity, Perfusion, Position, Tone) ensures early identification of potential concerns during SSC.
❌ (a) Incorrect: While positioning is important, newborns should be in an upright position on the parent’s chest, not side-lying.
❌ (b) Incorrect: Cell phone use can be distracting and is discouraged during SSC.
❌ (d) Incorrect: Kangaroo Care is beneficial even for preterm infants, as long as it is medically appropriate.
Which of the following is NOT a benefit of Kangaroo Care for the newborn?
a. Stabilization of heart and breathing rates.
b. Reduction of infection risk.
c. Increased stress levels due to close physical contact.
d. Improved sleep quality and neurodevelopment.
Correct Answer: (c) Increased stress levels due to close physical contact.
✅ Explanation: Kangaroo Care reduces stress in newborns by promoting warmth, comfort, and physiological stability.
❌ (a) Incorrect: Kangaroo Care helps stabilize the infant’s vital signs.
❌ (b) Incorrect: It reduces infection risk by promoting colonization with the family’s bacteria rather than hospital bacteria.
❌ (d) Incorrect: It enhances sleep quality and neurodevelopment.
Role of Parents in Kangaroo Care
How does Kangaroo Care support parents during the postpartum period?
a. It increases their confidence in caring for their infant.
b. It reduces the success of breastfeeding by making latching more difficult.
c. It separates parents from the healthcare team, making them less involved in decision-making.
d. It should only be performed in a hospital setting under strict supervision.
Correct Answer: (a) It increases their confidence in caring for their infant.
✅ Explanation: Kangaroo Care enhances parental confidence, bonding, and involvement in infant care.
❌ (b) Incorrect: Kangaroo Care promotes breastfeeding success by encouraging early feeding behaviors.
❌ (c) Incorrect: Parents remain integral members of the healthcare team.
❌ (d) Incorrect: Kangaroo Care can continue at home, not just in a hospital setting.
Which factor is most likely to negatively impact the development of a preterm infant?
a. Early skin-to-skin contact with parents.
b. Exposure to bright lights and loud noises in the NICU.
c. Consistent positive tactile stimulation.
d. Breastfeeding within the first hour of life.
Correct Answer: (b) Exposure to bright lights and loud noises in the NICU.
✅ Explanation: The NICU environment can be stressful, with excessive light and noise negatively affecting neurodevelopment.
❌ (a) Incorrect: Early skin-to-skin contact is beneficial for preterm infants.
❌ (c) Incorrect: Positive tactile stimulation helps infant development.
❌ (d) Incorrect: Early breastfeeding supports immunity and bonding.
Which of the following is the best practice when implementing Kangaroo Care?
a. Limiting Kangaroo Care to full-term infants without medical conditions.
b. Encouraging at least one-hour Kangaroo Care sessions to allow for sleep cycle completion.
c. Using only incubators for thermoregulation in preterm infants.
d. Avoiding Kangaroo Care for infants requiring medical equipment.
Correct Answer: (b) Encouraging at least one-hour Kangaroo Care sessions to allow for sleep cycle completion.
✅ Explanation: One-hour sessions allow for physiological regulation and sleep cycle completion.
❌ (a) Incorrect: Preterm and medically stable infants can also benefit from Kangaroo Care.
❌ (c) Incorrect: Kangaroo Care provides better thermoregulation than incubators in many cases.
❌ (d) Incorrect: Medical equipment does not automatically exclude infants from Kangaroo Care, though consultation with the healthcare team is advised.
