6.1 D) Obstetrics And Gynaecology The Emergency Delivery

Front 1

(Cameron)
What is Naegle's Rule?

Back 1

Naegle's Rule Calculates the Estimated Date of Delivery (EDD) from the last known

menstrual period. {LNMP }

EDD = LNMP - 3 months + 7 days

Front 2

(Cameron)
Which of the following is incorrect regarding the Emergency Delivery?
A. Between 20 to 30 weeks, The gestational age can be correlated with the height of the uterine fundus in cm from the pubic symphysis.
B. A precipitate labour is an extremely rapid labour lasting less than 4 hours.
C. Following a contraction, count the fetal heart rate - if bradycardic, give oxygen and lie left supine.
D. If there is no active vaginal bleeding, A vaginal examination is

performed to confirm vertex presentation, and exclude cord

prolapse.

Back 2

A. 20-35 weeks

Front 3

(Cameron)

List 5 drugs required ( to be available) for the Emergency Department Delivery.

Back 3

1. Adrenaline 1: 10,000
2. Oxyctocin 10 Units
3. Ergometrine 250ug
4. Vitamin K 1mg
5. Lignocaine 1%

Front 4

(Cameron)
Which of the following is correct regarding the ED Delivery?
A. Cervical dilatation < 7 cm in the multiparous patient is an

indication not to transfer to a distant Hospital.
B. Fetal Heart rate should be counted every 5 minutes during active labour.
C. The normal fetal heart rate lies between 110-160 bpm.
D. Cervical dilatation < 6 cm in the primiparous patient is an indication to transfer to another facility for delivery.

Back 4

C.

A = < 6cm
B = Count FHR every 15-30 minutes
D = > 7-8 cm = do not transfer

Front 5

(EMRAP 2006) Which is incorrect regarding the Emergency Delivery?

A. Once the baby is delivered, commence oxytocin.
B. When the head is delivered, check for the nuchal cord.
C. When the head delivers- have head up - and suction
D. If the nuchal cord cannot be reduced, clamp and cut.

Back 5

C. head down

Front 6

(EMRAP 2006)
List the Management options for Shoulder

dystocia.

Back 6

1. McRobert's manouevre
2. Woodscrew manoueuvre
3. Posterior Shoulder delivery
4. Fracture the clavicle.

Front 7

(EMRAP 2006)

Which of the following is correct?
A. With prolapsed umbilical cord, it must be reduced.
B. Uterine inversion is the main cause of PPH.
C. Once the baby is dry and warm in the Resuscitaire warmer, suction both the mouth and nose.
D. If the baby has a HR < 100 bpm, commence CPR.

Back 7

C.

A = Do not attempt to reduce the cord

UNLESS head is compressing the cord
B = Uterine atony

( Uterine inversion 1:2500 deliveries)
D = HR < 60 BPM = commence CPR

Front 8

(EMRAP 2006)

Indications for intubation of the neonate post delivery?

Back 8

1. (Consistent) Floppy tone
2. Decreased HR
3. Decreased RR

Front 9

(Cameron)
In regards to the Resuscitation of the Neonate, which is incorrect?
A. The need for external cardiac massage with chest compressions is MOST UNUSUAL!
B. Most newborns do not require assistance establishing effective

respirations at birth.
C. 10% of infants require some resuscitation at birth.
D. The majority of newborns who require assistance with establishing

respiration only need minimal help to start breathing.

Back 9

C. 5% of infants require some resuscitation at birth

Front 10

(Cameron)
List the potential risk factors for the

requirement of neonatal resuscitation post

delivery.

Back 10

1. Pre-Term Delivery
2. Absent / minimal Antenatal care
3. Maternal illness
4. Complicated / prolonged delivery
5. Previous neonatal death
6. NO RISK FACTORS - UNEXPECTED

Front 11

(CAMERON)

Which of the following is the correct initial

ordering of Neonatal resuscitation directly

after delivery with no breathing/crying or good

muscle tone?
A. Assess HR and RR , give chest compressions if HR , 60 , intubate.
B. Assess HR and RR , give IV fluids bolus and IV adrenaline
C. Dry and Stimulate, warm, position head and neck and clear airway
D. Clear airway, dry and stimulate, warm and assess HR and RR.

Back 11

C.
Correct sequence is :
Dry and Stimulate --> warm--> position head and neck to open airway --> THEN Assess HR and RR --> if HR < 100 or inadequate breathing : Give PPV until HR > 100.

Front 12

(Cameron)

Which of the following is the correct ordering for the Resuscitation of the neonate post

delivery, after assessment of the HR and RR, and HR < 100?

A. Positive pressure ventilation (PPV) --> given adrenaline if HR not > 100.
B. PPV until HR > 100 --> if HR < 60 or abnormal RR : chest compressions + PPV [ ratio 5:1 ].
C. PPV until HR > 100 --> If HR < 60 or abnormal RR- adrenaline + IV fluids +intubate.
D. PPV until HR > 100 --> if HR < 60 or abnormal RR : CPR + PPV [ ratio 3:1 ] + intubate-LMA / adrenaline / IV fluid bolus

Back 12

D.

PPV until HR > 100 --> if HR < 60 or abnormal RR : CPR + PPV [ ratio 3:1 ] + intubate-LMA / adrenaline / IV fluid bolus

Front 13

(ARC) What is the dose of adrenaline in the Neonate with a HR of 60?

Back 13

0.1 mL/kg 1:10,000 IV

Range 0.1 - 0.3 mL /kg 1:10,000

Front 14

(Cameron) Which of the following is incorrect

regarding neonatal resuscitation?
A. Positive pressure ventilation alone is usually effective in establishing spontaneous respirations, and raising the HR > 100/min.
B. The preferred route of adrenaline administration is intraosseous. (I/O)
C. Adrenaline is indicated if the HR remains < 60 after 1 minute of

ventilations/compressions.
D. Isotonic crystalloid is given at 10mL/kg Intra-umbilical or intraosseous.

Back 14

B. The Umbilical vein

= The single large vessel

( 2 adjacent arteries)

Front 15

(Cameron)
How many stages are there to Labour?

Back 15

3 stages Of Labour :

Stage I : onset of regular contractions to full

cervical dilatation
Stage II : from full dilatation to delivery of the newborn
Stage III : From the birth of the newborn until

delivery of the placenta.

Front 16

(Cameron)
What are the average durations of the first stage of Labour, for Multiparous and

primiparous ?

Back 16

First Stage of Labour :

Multiparous : 6-8 hours
Primiparous : 14 hours

Front 17

(Cameron)
What are the 3 phases of the second stage of Labour?

Back 17

Phase I : delivery of head
Phase II : delivery of shoulders
Phase III : delivery of body and legs.

Front 18

(Cameron)
Which is correct regarding the average range of timing of the second stage of labor in

Primiparous and multiparous women ?

A. 60-100 and 20-60 min.
B. 50-90 and 5-15 min
C. 20-60 and 10-30 min
D. 10-30 and 5-20 min.

Back 18

C. Primiparous : Second stage of Labour

= 20-60 minutes

Multiparous : Second stage of labour

= 10-30 minutes

Front 19

(Cameron)
What re the 2 main Maternal positions for ED

delivery?

Back 19

1. Dorsal lithotomy
2. Lateral Sim's position.

Front 20

(Cameron)
What is the primary indication for performing an episiotomy?

Back 20

To prevent a large, spontaneous, irregular

laceration of the perineum.

Front 21

(Cameron)
What is the directioning of the incision for an episiotomy: midline vs mediolateral ?

Back 21

Mediolateral 5-7 o'clock position.

Front 22

(Cameron)
Which of the following is incorrect regarding the Emergency Delivery?
A. The umbilical cord is wrapped around the newborn's neck in 25-30% cases.
B. Gentle suctioning of the nose and mouth is required in the presence of meconium liquor staining.
C. The newborn is grasped behind the neck and ankles to transfer to the Mother's abdomen.
D. The umbilical clamp is placed 4 cm from the newborn's abdomen.

Back 22

D. Umbilical clamp placed 1-2 cm from

newborn's abdomen

{ Tintinalli : 3 cm }

Front 23

(Cameron) Which of the following is incorrect

regarding oxytocic agents administered post

delivery?
A. The commonest given is Oxytocin at 5 Units slow IV
B. Oxytocin can be given IMI
C. Ergometrine is associated with an increased risk of retained placenta.
D. Ergometrine is given as a slow IV / IMI dose of 500ug.

Back 23

D. Ergometrine : 250ug IV

Front 24

What important facts must be available for the Obstetric Team / Accepting Unit, post delivery and stabilisation of the Mother and Newborn?

Back 24

1. Time of birth

2. Apgar scores of newborn

3. Drugs administered to Mother /Newborn

Front 25

What are the 5 Signs of the Apgar scoring

system?

Back 25

1. Heart rate (HR)
2. Respiratory rate (RR)
3. Colour
4. Muscle Tone
5. Reflex irritability when feet stimulated.

Activity

Pulse

Grimace { reflex irritability }

Appearance

Respirations

Front 26

What is the maximum score for Apgar?

Back 26

10

Front 27

List the 3 potential (major) complications of

Delivery.

Back 27

1. Breech delivery
2. Shoulder dystocia
3. Post Partum Haemorrhage (PPH)

Front 28

List the Basic Equipment required for the

Emergency ED Delivery .

Back 28

1. Sterile towels
2. Cord clamp
3. Kelly clamps
4. Scissors
5. Bulb syringe
6. Resuscitaire-Incubator
7. Neonatal Resuscitation equipment

Front 29

What are the 3 types of clamps / scissors

required for the Emergency ED Delivery.

Back 29

1. Scissors x 1
2. Kelly Clamps x 2
3. Umbilical cord clamp

Front 30

Which of the following is correct regarding

Emergency Childbirth ?
A. Emergencies occur in 2% of all deliveries
B. "normal" cephalic presentations occur 98% of the time.
C. Breech presentation occurs in 1%
D. Shoulder dystocia occurs in 0.2 - 2.0% of vertex presentations.

Back 30

D. Shoulder dystocia occurs in 0.2 - 2.0%

( 1 per 100) of vertex presentations.

A = < 1% ( Emergency Delivery < 1 per 100 )

B = Only 93% are normal cephalic presentations
C = 3% of presentations are Breech ( 3 per 100)

Front 31

**** Great question

What are the 3 Main groups of Issues sought in the Emergency Childbirth Presentation ?

Back 31

1. Pre-eclampsia / Eclampsia
2. Bleeding
3. Fetal issues
a. Abnormal presentation
b. Fetal distress

Front 32

What are the 4 signs of an imminent Delivery ?

Back 32

1. Bloody show
2. Broken waters
3. Urge to defaecate
4. Head on view / bulging perineum

Front 33

What are the 3 signs of fetal distress ?

Back 33

1. Fetal bradycardia
2. Meconium staining
3. Evidence of cord prolapse

Front 34

What Staff are required for the Emergency ED Delivery ?

Back 34

For Delivery:
1. Midwife
2. O+G registrar
3. ED Senior Medical / Nursing

For Newborn:
1. Neonatal / Paediatric Team
2. ED Senior Medical / Nursing

Front 35

In regards to Shoulder dystocia, which of the following is incorrect ?
A. It describes the impaction of the posterior shoulder beneath the

symphysis pubis.
B. Complications include Hypoxia and brachial plexus injuries.
C. The 2 Manoeuvres employable are the "McRobert's " and the

" Rubin" Manoeuvres.
D. Moderate suprapubic pressure and gentle traction on the fetal head can be applied.

Back 35

A. Anterior shoulder

Front 36

In regards to Breech Presentation with the Emergency ED Delivery, which of the following is incorrect ?
A. The appearance of feet though the vulva is an indication for

proceeding with immediate delivery.
B. The main mode of treatment is Emergency Caesarian section.
C. there are 3 main types of Breech presentation.
D. It is an extremely challenging delivery.

Back 36

A. This is not actually an indication to proceed with immediate delivery - There may be time to transfer to Theatre / Labour ward.

Front 37

What are the 4 indications for an Episiotomy ?

Back 37

1. Shoulder dystocia
2. Breech delivery
3. Risk of major perineal tear.
4. Fetal macrosomia

Front 38

( ED MCQ Book 2012 )
Which is incorrect regarding Shoulder dystocia?
A. The aim is to deliver the fetus under 5 minutes, to prevent asphyxia.

B. Fundal pressure is applied by an Assistant.
C. The fetal shoulders are in the vertical orientation, rather than the

normal oblique position.

D. It is a "bony obstruction".

Back 38

B. Suprapubic pressure can be applied-gently.

Fundal pressure should never be applied.

Front 39

Tintinalli

What 2 methods can be used to calculate the

gestational age in the ED delivery presentation.

Back 39

1. Näegle Rule : LNMP + 9 months + 7 days

2. Fundal height : cm from pubic symphysis to top of fundus.

Front 40

Tintinalli

Fetal bradycardia = HR < ?

Back 40

Fetal bradycardia = HR < 110 bpm

Front 41

Tintinalli

In regards to "False Labour" which of the

following is incorrect ?

A. False labour = Braxton Hicks contractions

B. It is defined as uterine contractions that do not lead to cervical changes

C. It is a generalised abdominal contractions

D. the contractions are irregular and brief.

Back 41

C. usually confined to lower abdominal

contractions.

The contractions are irregular in intensity and duration.

Front 42

Tintinalli

In regards to "True Labour" which of the

following is incorrect ?

A. Characterised by painful repetitive uterine contractions-which

increase in duration and intensity.

B. The pains begin in the lower abdomen and radiate upwards and to the lower back.

C. There is progressive effacement and dilation of the cervix.

D. There are 3 stages to true labour.

Back 42

B. The pains begin in the fundal and upper

abdominal area, radiating to the pelvis and

lower back.

Front 43

Tintinalli

what are the various "station" calculations?

Back 43

Negative = above ischial spines

Zero = level with ischial spines

+1

+2

+3 = visible scalp at introitus = impending

delivery

Front 44

Tintinalli

How common is nuchal cord presentation?

Back 44

Common : 25-35% of all Term deliveries.

Front 45

Tintinalli

What are the 6 cardinal movements of foetal

descent during labour and delivery of a vertex presentation ?

Back 45

1. Engagement

2. Flexion

3. Descent

4. Internal rotation

5. Extension

6. External rotation.

Front 46

Tintinalli

In regards to umbilical Cord prolapse, which of the following is incorrect ?

A. Cord compression is life threatening to the foetus: A "True Obstetric Emergency"

B. It complicates 0.4% of all deliveries.

C. It mandates emergent vaginal delivery.

D. No attempt should be made to reduce the prolapsed cord.

Back 46

C. It requires emergent Caesarian Section.

Front 47

Tintinalli

Pelvic examination to exclude umbilical cord

prolapse occurs in what 3 situations?

Back 47

1. Rupture of Membranes ( ROM)

2. Appearance of variable decelerations

3. Foetal bradycardia

Front 48

Tintinalli

in regards to Shoulder dystocia, which of the

following is incorrect ?

A. It complicates 0.1% of all deliveries

B. it involves the "Turtle Sign"

C. Initial management requires 2 main proceduralists : One delivering the head/shoulder, the other applying suprapubic pressure

D. The bladder should be drained.

Back 48

A. 1% of deliveries

Front 49

Tintinalli

List 3 risk factors for shoulder dystocia.

Back 49

1. Diabetes

2. Macrosomia

3. Post Term delivery

4. Prior History of shoulder dystocia

Front 50

Tintinalli

List the complications of shoulder dystocia.

Back 50

1. Immediate life threat : fetal asphyxia and

hypoxia

a. impaired respirations

b. Compression of umbilical cord

c. Compromised foetal circulation

2. Brachial plexus injury from over-aggressive

traction.

Front 51

Tintinalli

List the Management options for Shoulder

dystocia.

Back 51

1. Positional

- extreme dorsal lithotomy

(McRobert's Manoeuvre )

2. Suprapubic pressure

3. Bladder drainage

4. Generous Episiotomy

5. Woods Corkscrew Manoeuvre ( 180 degree

rotation to deliver posterior shoulder

anteriorly)

Front 52

Tintinalli

Which of the following is incorrect regarding Breech Delivery ?

A. It occurs in 3-4% of Term pregnancies.

B. It occurs more commonly in Preterm deliveries ( < 28 weeks)

C. It is associated with umbilical cord prolapse.

D. There are 3 presentation types.

Back 52

D.

4 Presentation types :

1. Frank

2. Complete

3. Incomplete

4. Footling

Front 53

Tintinalli

In regards to Breech Delivery which of the

following is incorrect ?

A. The main aim of the Emergency Physician (other than calling for

Emergent Obstetric help) is to let the delivery happen spontaneously.

B. 25-35% of all preterm infants present in breech position.

C. Caesarian section is the Delivery method of choice.

D. Footling and incomplete breech presentation are better vaginally

delivered.

Back 53

D. Footling and Incomplete breech positions are not considered safe for vaginal delivery -due to the possibility of :

1. Cord prolapse

2. Incomplete dilation of cervix.

Front 54

Tintinalli

True or False For Breech Presentation :

The main aim of the Emergency Physician (other than calling for Emergent Obstetric help) is to let the delivery happen spontaneously.

Back 54

True

The Examiner shoulder refrain from touching the foetus until the umbilicus appears.