Normal Obstetrics

Front 1

An 18-year-old G1P0 woman is seen in the clinic for a routine prenatal visit at 28 weeks gestation. Her prenatal course has been unremarkable. She has not been taking prenatal vitamins. Her pre-pregnancy weight was 120 pounds. Initial hemoglobin at the first visit at eight weeks gestation was 12.3 g/dL. Current weight is 138 pounds. After performing a screening complete blood count (CBC), the results are notable for a white blood count 9,700/mL, hemoglobin 10.6 g/dL, mean corpuscular volume 88.2 fL (80.8 – 96.4) and platelets 215,000/mcL. The patient denies vaginal or rectal bleeding. Which of the following is the best explanation for this patient’s anemia?

Back 1

Relative hemodilution of pregnancy
There is normally a 36% increase in maternal blood volume; the maximum is reached around 34 weeks. The plasma volume increases 47% and the RBC mass increases only 17%. This relative dilutional effect lowers the hemoglobin, but causes no change in the MCV. Folate deficiency results in a macrocytic anemia. Iron deficiency and thalassemias are associated with microcytic anemia.

Front 2

A 34-year-old G3P1 woman at 26 weeks gestation reports “difficulty catching her breath,” especially after exertion for the last two months. She is a non-smoker. She does not have any history of pulmonary or cardiac disease. She denies fever, sputum, cough or any recent illnesses. On physical examination, her vital signs are: blood pressure 108/64, pulse 88, respiratory rate 15, and she is afebrile. Pulse oximeter is 98% on room air. Lungs are clear to auscultation. Heart is regular rate and rhythm with II/VI systolic murmur heard at the upper left sternal border. She has no lower extremity edema. A complete blood count reveals a hemoglobin of 10.0 g/dL. What is the most likely explanation for this woman’s symptoms?

Back 2

Physiologic dyspnea of pregnancy
Physical examination findings are not consistent with pulmonary embolus (e.g tachycardia, tachypnea, hypoxia, chest pain, signs of a DVT) or mitral stenosis (diastolic murmur, signs of heart failure). Physiologic dyspnea of pregnancy is present in up to 75% of women by the third trimester. Peripartum cardiomyopathy is an idiopathic cardiomyopathy that presents with heart failure secondary to left ventricular systolic function towards the end of pregnancy or in the several months following delivery. Symptoms include fatigue, shortness of breath, palpitations, and edema. The history and physical do not suggest a pathologic process, nor does her hemoglobin level.

Front 3

A 24-year-old G4P2 woman at 34 weeks gestation complains of a cough and whitish sputum for the last three days. She reports that everyone in the family has been sick. She reports a high fever last night up to 102°F (38.9°C). She denies chest pain. She smokes a half-pack of cigarettes per day. She has a history of asthma with no previous intubations. She uses an albuterol inhaler, although she has not used it this week. Vital signs are: temperature 98.6°F (37°C); respiratory rate 16; pulse 94; blood pressure 114/78; peak expiratory flow rate 430 L/min (baseline documented in the outpatient chart = 425 L/min). On physical examination, pharyngeal mucosa is erythematous and injected. Lungs are clear to auscultation. White blood cell count 8,700; arterial blood gases on room air (normal ranges in parentheses): pH 7.44 (7.36 – 7.44); PO2 103 mm Hg (>100), PCO2 26 mm Hg (28 – 32), HCO3 19 mm Hg (22 – 26). Chest x-ray is normal. What is the correct interpretation of this arterial blood gas?

Back 3

Compensated respiratory alkalosis.
The increased minute ventilation during pregnancy causes a compensated respiratory alkalosis. Hypoventilation results in increased PCO2 and the PO2 would be decreased if she was hypoxic. A metabolic acidosis would have a decreased pH and a low HCO3. The patient’s symptoms are most consistent with a viral upper respiratory infection.

Front 4

A 28-year-old G1P0 internal medicine resident at 34 weeks gestation wants to discuss the values on her pulmonary function tests performed two days ago because she was feeling slightly short of breath. She is a non-smoker, and has no personal or family history of cardiac or respiratory disease. Vital signs are: respiratory rate 16; pulse 90, blood pressure 112/70; oxygen saturation is 99% on room air. On physical examination: lungs are clear; abdomen non-tender; fundal height is 34 cm. The results of the pulmonary function tests are:

Inspiratory Capacity (IC) increased
Tidal volume (TV) increased
Minute ventilation increased
Functional reserve capacity (FRC) decreased
Expiratory reserve capacity (ERC) decreased
Residual volume (RV) decreased


What is the next best step in the evaluation of this patient?

Back 4

Routine antenatal care
The results of her PFT are consistent with normal physiologic changes in pregnancy. Inspiratory capacity increases by 15% during the third trimester because of increases in tidal volume and inspiratory reserve volume. The respiratory rate does not change during pregnancy, but the TV is increased which increases the minute ventilation, which is responsible for the respiratory alkalosis in pregnancy. Functional residual capacity is reduced to 80% of the non-pregnant volume by term. These combined lead to subjective shortness of breath during pregnancy.

Front 5

A 24-year-old G1P0 woman at 28 weeks gestation reports difficulty breathing, cough and frothy sputum. She was admitted for preterm labor 24 hours ago. She is a non-smoker. She has received 6 liters of Lactated Ringers solution since admission. She is receiving magnesium sulfate and nifedipine. Vital signs are: 100.2°F (37.9°C); respiratory rate 24; heart rate 110; blood pressure 132/85; pulse oximetry is 97% on a non-rebreather mask. She appears in distress. Lungs reveal bibasilar crackles. Uterine contractions are regular every three minutes. The fetal heart rate is 140 beats/minute. Labs show white blood cell count 17,500/mL with 94% segmented neutrophils. Potassium and sodium are normal. Which of the following has most likely contributed to this patient’s respiratory symptoms?

Back 5

Use of tocolytics
Plasma osmolality is decreased during pregnancy which increases the susceptibility to pulmonary edema. Common causes of acute pulmonary edema in pregnancy include tocolytic use, cardiac disease, fluid overload and preeclampsia. Use of multiple tocolytics increases the susceptibility of pulmonary edema, especially with the use of isotonic fluids. Systemic vascular resistance is decreased during pregnancy. Women with chorioamnionitis are also more likely to develop pulmonary edema, but this is not usually the main cause unless the patient is in septic shock and this patient does not have chorioamnionitis.

Front 6

A 25-year-old G1P0 woman is seen for an initial obstetrical appointment at eight weeks gestation. She has had a small ventricular septal defect (VSD) since birth. She has no surgical history and no limitations on her activity. Vital signs are: respiratory rate 12; heart rate 88; blood pressure 112/68. On physical examination: her skin appears normal; lungs are clear to auscultation; heart is a regular rate and rhythm. There is a grade IV/VI coarse pansystolic murmur at the left sternal border, with a thrill. Chest x-ray and ECG are normal. Which of the following is the correct statement regarding cardiovascular adaptation in this patient?
A. Approximately 2% of women will normally have a diastolic murmur
B. Maternal pulmonary vascular resistance is normally less than systemic vascular resistance
C. The maternal cardiac output will increase up to 33% during pregnancy
D. Maternal systemic vascular resistance increases throughout pregnancy
E. The increase in cardiac output is only du

Back 6

The maternal cardiac output will increase up to 33% during pregnancy
The cardiac output increases up to 33% due to increases in both the heart rate and stroke volume. The SVR falls during pregnancy. Up to 95% of women will have a systolic murmur due to the increased volume. Diastolic murmurs are always abnormal. The systemic vascular resistance (SVR) is normally greater than the pulmonary vascular resistance. If the pulmonary vascular resistance exceeds the SVR, right to left shunt will develop in the setting of a VSD, and cyanosis will develop.

Front 7

A 17-year-old G1P0 woman at 32 weeks gestation complains of right flank pain that is “colicky” in nature and has been present for two weeks. She denies fever, dysuria and hematuria. Physical examination is notable for moderate right costovertebral angle tenderness. White blood cell count 8,800/mL, urine analysis negative. A renal ultrasound reveals no signs of urinary calculi, but there is moderate (15 mm) right hydronephrosis. Which of the following is the most likely cause of these findings?
A. Smooth muscle relaxation due to declining levels of progesterone
B. Smooth muscle relaxation due to increasing levels of estrogen
C. Compression by the uterus and right ovarian vein
D. Elevation of the bladder in the second trimester
E. Iliac artery compression of the ureter

Back 7

Compression by the uterus and right ovarian vein
Some degree of dilation in the ureters and renal pelvis occurs in the majority of pregnant women. The dilation is unequal (R > L) due to cushioning provided by the sigmoid colon to the left ureter and from greater compression of the right ureter due to dextrorotation of the uterus. The right ovarian vein complex, which is remarkably dilated during pregnancy, lies obliquely over the right ureter and may contribute significantly to right ureteral dilatation. High levels of progesterone likely have some effect but estrogen has no effect on the smooth muscle of the ureter.

Front 8

A 34-year-old G4P2 woman at 18 weeks gestation presents with fatigue and occasional headache. She has a sister with Grave’s disease. On physical exam, vital signs are normal. BMI is 27. Thyroid is difficult to palpate due to her body habitus. The remainder of her exam is unremarkable. Thyroid function studies show:

Results Reference Range
TSH 1.8 mU/L 0.30 -5.5 mU/L
Free T4 1.22 ng/dL 0.76 – 1.70 ng/dL
Total T4 14.2 ng /dL 4.9 – 12.0 ng /dL
Free T3 3.4 ng/dL 2.8 – 4.2 ng/dL
Total T3 200 ng/dL 80 – 175 ng/dL


What is the next best step in the management of this patient?
A. Continue routine prenatal care
B. Check anti-thyroid antibody levels
C. Obtain a thyroid ultrasound
D. Initiate propylthiouracil
E. Initiate methimazole

Back 8

Continue routine prenatal care
Thyroid binding globulin (TBG) is increased due to increased circulating estrogens with a concomitant increase in the total thyroxine. Free thyroxine (T4) remains relatively constant. Total triiodothyroxine (T3) levels also increase in pregnancy while free T3 levels do not change. In a pregnant patient without iodine deficiency, the thyroid gland may increase in size up to 10%. This patient’s thyroid function is normal for pregnancy, and her symptoms of fatigue can be explained by other physiologic changes in pregnancy, including anemia, difficulty with sleep, and increase metabolic demand.

Front 9

An 18-year-old G1P0 woman at 12 weeks gestation reports nausea, vomiting, scant vaginal bleeding and a “racing heart.” These symptoms have been present on and off for the past four weeks. The patient has no significant past medical, surgical or family history. Vital signs are: temperature 98.6°F (37°C); heart rate 120; blood pressure 128/78. On physical examination: uterine fundus is 4 cm below the umbilicus; no fetal heart tones obtained by fetal Doppler device; cervix is 1 cm dilated with pinkish/purple “fleshy” tissue protruding through the os. Labs show: hemoglobin 8.2 gm/dL, quantitative Beta-hCG 1.0 Million IU/mL; thyroid-stimulating hormone (TSH) undetectable; free T4 3.2 (normal 0.7 – 2.5). An ultrasound reveals heterogeneous cystic tissue in the uterus (snowstorm pattern). Which of the following is the most appropriate next step in the management of this patient?
A. Repeat quantitative Beta-hCG
B. Repeat transvaginal ultrasound
C. PET scan
D. Chest x-ray
E. CBC

Back 9

Chest x-ray
This patient’s presentation is classic for a molar pregnancy. Beta-hCG levels in normal pregnancy do not reach one million. A chest x-ray would be the most appropriate step, as the lungs are the most common site of metastatic disease in patients with gestational trophoblastic disease. Though a repeat quantitative Beta-hCG will be required on a weekly basis, an immediate post-operative value will be of little clinical utility. A PET scan is not indicated and the patient already had a CBC done.

Front 10

A 42-year-old G5P4 woman at eight weeks gestation presents for her first prenatal appointment. She has glycosuria noted on urine dipstick in the office. She has a history of four prior vaginal deliveries at full-term with birth weights ranging from 9 to 10.5 pounds. Family history is positive for type 2 diabetes in her mother and two siblings. Weight is 265 pounds and height is 5 feet 4 inches (BMI is 45.5 kg/m2). Which of the following recommendations concerning weight gain during this pregnancy is most appropriate?

Back 10

Gain 11 – 20 pounds
The Institute of Medicine (IOM) has developed guidelines (2009) on weight gain in pregnancy. Historical data show that women who gained within the IOM guidelines experienced better outcomes of pregnancy than those who did not. The recommendations are: underweight (BMI < 18.5 kg/m2) total weight gain 28 – 40 pounds; normal weight (BMI 18.5 – 24.9 kg/m2) total weight gain 25 – 35 pounds; overweight (BMI 25 – 29.9 kg/m2) total weight gain 15 - 25 pounds; and obese (BMI > 30 kg/m2) total weight gain 11 - 20 pounds.

Front 11

An African-American couple comes to you for preconception counseling. Neither one has any significant family or genetic history. Based on their African-American descent, which of the following blood tests would you recommend?

Back 11

Sickle cell preparation and CBC

Front 12

A 28-year-old G0 woman presents with her husband for preconception counseling. Her family is Ashkenazi Jewish from Poland. Her husband is 30 years old and is also Jewish. They seek information about preconception and prenatal screening. Carrier screening should be performed for all of the following conditions except:

A. Fanconi anemia
B. Tay-Sachs disease
C. Beta thalassemia anemia
D. Cystic fibrosis
E. Niemann-Pick disease

Back 12

Beta thalassemia anemia
Fanconi anemia, Tay-Sachs disease, Cystic Fibrosis, and Niemann-Pick disease are all autosomal recessive conditions that occur at an increased incidence in Jews of Ashkenazi descent. The Beta thalassemia is seen mainly in Mediterranean populations.

Front 13

A 30-year-old G0 woman presents with her husband for preconception counseling. The patient is of Jewish Ashkenazi descent. Her husband is Irish. The patient has a brother who has a child diagnosed with attention deficit hyperactivity disorder. Which of the following genetic diseases is the most likely to affect their future children?
A. Canavan disease
B. Bloom syndrome
C. Cystic fibrosis
D. Tay-Sachs disease
E. Gaucher’s disease

Back 13

Cystic fibrosis
Non-Hispanic white individuals, including Ashkenazi Jews, are at increased risk for being carriers for cystic fibrosis

Front 14

A 30-year-old G1P0 woman with type 1 diabetes mellitus presents at 10 weeks gestation for a routine visit. She smokes a half a pack of cigarettes per day. Her hemoglobin A1C level is 9.7. What structural anomaly is the fetus at highest risk of developing?

Back 14

Women with poorly controlled diabetes immediately prior to conception and during organogenesis have a four- to eight-fold risk of having a fetus with a structural anomaly. The majority of lesions involve the central nervous system (neural tube defects) and the cardiovascular system. Genitourinary and limb defects have also been reported.

Front 15

A 37-year-old G3P2 woman presents with her husband at 11 weeks gestation for genetic counseling due to advanced maternal age. The patient and her husband are interested in chorionic villus sampling (CVS). In addition to obtaining a karyotype, which of the following can be detected with this procedure?
A. Spina bifida
B. Fetal omphalocele
C. Cystic fibrosis
D. Anencephaly
E. Fetal cardiac anomaly

Back 15

CVS is generally performed at 10-12 weeks gestation. The procedure involves sampling of the chorionic frondosum, which contains the most mitotically active villi in the placenta. CVS can be performed using a transabdominal or transcervical approach. The sampled placental tissue may be analyzed for fetal chromosomal abnormalities, biochemical, or DNA-based studies including testing for the mutations associated with cystic fibrosis. CVS cannot be used to detect neural tube defects. Omphaloceles and neural tube defects are generally diagnosed using prenatal ultrasound.

Front 16

A 28-year-old G1P0 woman is at 15 weeks gestation. Her husband’s cousin has moderate mental retardation. The most common cause of inherited mental retardation in this patient’s child would be?
A. Undiagnosed phenylketonuria (PKU)
B. Neonatal hypothyroidism
C. Fragile X syndrome
D. Down syndrome
E. Autism

Back 16

Fragile X syndrome is the most common form of inherited mental retardation. The syndrome occurs in approximately 1 in 3,600 males and 1 in 4,000 to 6,000 females. Down syndrome is genetic but the majority of cases are not inherited.

Front 17

A 35-year-old G3P2 woman presents for her initial prenatal care visit at 15 weeks gestation, a¬ccording to her last menstrual period. She reports that a home pregnancy test was positive about five¬¬ weeks ago. Review of her history is unremarkable and her entire family is in good health. Physical examination reveals a ten-week size uterus. Which of the following is the most appropriate next step in establishing this pregnancy’s gestational age?
A. Checking fetal heart tones
B. Hysterosonogram
C. Quantitative Beta-hCG
D. Obstetrical ultrasound
E. Quadruple screen

Back 17

Obstetrical ultrasound

Front 18

A 34-year-old G2P1 woman presents at 13 weeks gestation. She did not seek preconception counseling and is worried about delivering a child with Down syndrome, given her maternal age. She has no significant medical, surgical, family or social history. Which of the following tests is most effective in screening for Down syndrome in the second trimester?
A. Quadruple screen
B. Triple screen
C. Amniotic fluid for alpha fetoprotein level
D. Maternal serum alpha fetoprotein level
E. Nuchal translucency measurement with serum PAPP-A (pregnancy associated plasma protein-A) and free Beta-hCG level

Back 18

Quadruple screen

Front 19

A 29-year-old G2P1 woman at 36 weeks gestation is seen for management of her gestational diabetes. Despite diet modification, the patient has required insulin to control her serum glucose levels. She has gained 25 pounds with the pregnancy. She is at risk for all the following complications, except:
A. Polyhydramnios
B. Neonatal hypoglycemia
C. Intrauterine growth restriction
D. Preeclampsia
E. Fetal macrosomia

Back 19

Intrauterine growth restriction
Intrauterine growth restriction is typically seen in women with pre-existing diabetes and not with gestational diabetes. Shoulder dystocia, metabolic disturbances, preeclampsia, polyhydramnios and fetal macrosomia are all associated risks of gestational diabetes.

Front 20

An 18-year-old G1P0 woman presents for prenatal care at 14 weeks gestation. Her medical, surgical, gynecologic, social and family history are unremarkable. Her dietary history includes high carbohydrate intake with no fresh vegetables. Her physical examination is within normal limits except that she is pale and has a BMI of 42. Nutritional counseling should include the following:

Back 20

There should be folic acid supplementation, as well as evaluation for deficiencies in her iron, protein and other nutrient stores. In general, a patient needs approximately 70 grams of protein a day, along with her other nutrients. It would be prudent to caution her that, though aerobic exercise is recommended and would be a benefit to her, it is not advisable to initiate a vigorous program in a woman who has not been routinely working out. Women should gain weight during their pregnancy, and 1200 calories a day is not sufficient for a pregnant woman.

Front 21

A 35-year-old G1 woman with an IVF conceived 12 weeks gestation has a slightly elevated fetal nuchal translucency (2.5 multiples of the median), but her integrated first trimester screen shows no increased risk for Down syndrome or Trisomy 18. Still concerned about the increased nuchal translucency, the patient requests non-invasive testing to exclude other abnormalities. Which of the following is the next best step in the management of this patient?
A. Reassurance
B. Monthly ultrasound to assess for fetal growth
C. Detailed ultrasound and fetal echocardiogram at approximately 18 – 20 weeks gestation
D. Repeat first trimester screening
E. Amniocentesis

Back 21

Detailed ultrasound and fetal echocardiogram at approximately 18 – 20 weeks gestation

Front 22

Which of the following medications should be discontinued because of potential teratogenicity?
A. Metformin
B. Heparin
C. Ibuprofen
D. Oxycodone
E. Warfarin

Back 22

Ibuprofen is safe to take until around 32 weeks gestation, when premature closure of the ductus arteriosis is a risk. While heparin is safe during pregnancy, warfarin has known teratogenic affects and should not be given. If continued anticoagulation is necessary, low molecular weight heparin is the drug of choice.

Front 23

A 23-year-old G1P0 woman at 38 weeks gestation, with an uncomplicated pregnancy, presents to labor and delivery with the complaint of lower abdominal pain and mild nausea for one day. Fetal kick counts are appropriate. Her review of symptoms is otherwise negative. Vital signs are: temperature 98.6°F (37.0°C); blood pressure 100/60; pulse 79; respiratory rate 14; fetal heart rate 140s, reactive, with no decelerations; tocometer shows irregular contractions every 2-8 minutes; fundal height 36 cm; cervix is firm, long, closed and posterior. A urine dipstick is notable for 1+ glucose with negative ketones. Which of the following is the most likely diagnosis in this patient?
A. Appendicitis
B. Gestational diabetes
C. Braxton-Hicks contractions
D. First stage of labor
E. Dehydration

Back 23

Braxton-Hicks contractions
Braxton Hicks contractions are characterized as short in duration, less intense than true labor, and the discomfort as being in the lower abdomen and groin areas. True labor is defined by strong, regular uterine contractions that result in progressive cervical dilation and effacement. This patient’s history does not suggest she is in the first stage of labor. Patients with appendicitis usually present with fever, decreased appetite, nausea and vomiting. Gestational diabetes is diagnosed based on glucose challenge tests. The first test with a 50 gram load is typically performed at 24-28 weeks gestation. It is not abnormal for patients to have glucosuria. This finding is not diagnostic for gestational diabetes. Patients with dehydration frequently present with maternal tachycardia and have ketonuria.

Front 24

A 22-year-old G3P0 woman at 37 weeks gestation with an uncomplicated pregnancy presents to labor and delivery with decreased fetal movements for one day. She denies contractions, loss of fluid, or bleeding. Vital signs are temperature 98.6°F (37.0°C); blood pressure 100/60; pulse 79; respiratory rate 13; fetal heart rate 140s, reactive, with no decelerations. Tocometer reveals one contraction every eight minutes. Fundal height 36 cm, amniotic fluid index is 9. Cervix is firm, long, closed and posterior. What is the next best step in the management of this patient?
A. Discharge home with labor warnings
B. 24 hour observation
C. Biophysical profile
D. Contraction stress test
E. Induction of labor

Back 24

Discharge home with labor warnings
The patient has reassuring fetal testing and may be discharged home with labor warnings: contractions every five minutes for one hour, rupture of membranes, fetal movement less than 10 per two hours or vaginal bleeding. A reactive non-stress test and normal AFI (modified biophysical profile) are sufficient to assess fetal well being at this time. Additional testing and interventions are not indicated at this time.

Front 25

A 16-year-old G1P0 woman at 39 weeks gestation presents to labor and delivery reporting a gush of blood-tinged fluid approximately five hours ago and the onset of uterine contractions shortly thereafter. She reports contractions have become stronger and closer together over the past hour. The fetal heart rate is 140 to 150 with accelerations and no decelerations. Uterine contractions are recorded every 2-3 minutes. A pelvic exam reveals that the cervix is 4 cm dilated and 100 percent effaced. Fetal station is 0. After walking around for 30 minutes the patient is put back in bed after complaining of further discomfort. She requests an epidural. However, obtaining the fetal heart rate externally has become difficult because the patient cannot lie still. What is the most appropriate next step in the management of this patient?
A. Place the epidural
B. Apply a fetal scalp electrode
C. Perform a fetal ultrasound to assess the fetal heart rate
D. Place an intrauterine pressure catheter (

Back 25

Apply a fetal scalp electrode

Front 26

A 26-year-old G2P1 woman at 41 weeks gestation is brought in by ambulance. The emergency medical technician reports that a pelvic examination performed 20 minutes ago when the patient had a severe urge to push revealed that she was fully dilated and the fetal station was +2. Fetal heart tones were confirmed to be in the 150s, with no audible decelerations. When the patient is placed on the fetal monitor, the heart rate is noted to be in the 60s. The maternal heart rate is recorded as 100. Without pushing, the fetal scalp is visible at the introitus. A repeat pelvic exam shows that the infant is in the left occiput anterior position. What is the most appropriate next step in the management of this patient?
A. Emergent Cesarean delivery
B. Amnioinfusion
C. Assisted operative vaginal delivery
D. Confirm the fetal heart rate with an internal fetal scalp electrode
E. Use ultrasound to assess the fetal heart rate

Back 26

Assisted operative vaginal delivery
If the patient cannot deliver the infant with one or two pushes, the next best choice given the fetal station and presentation is to perform an emergent outlet forceps or vacuum-assisted delivery. None of the other options offer an expedient mode of delivery. Since the patient’s heart rate is distinct from the fetal heart rate, it is not necessary to check the fetal heart rate with an ultrasound. This will potentially delay the time until delivery of the fetus. Amnioinfusion is not indicated given the imminent delivery.

Front 27

A 25-year-old G2P1 woman at 38 weeks gestation presents to labor and delivery with spontaneous onset of labor and spontaneous rupture of membranes. Cervical examination was 5 cm at presentation and 5 cm at last check, two hours ago. Presently, the patient is uncomfortable and notes strong contractions. You decide to place an intrauterine pressure catheter (IUPC). On placement, approximately 300 cc of frank blood and amniotic fluid flow out of the vagina. What is the most appropriate next step in the management of this patient?
A. Emergent Cesarean delivery
B. Withdraw the IUPC, monitor fetus and then replace if tracing reassuring
C. Begin amnioinfusion
D. Begin Pitocin augmentation
E. Keep IUPC in position and connect to tocometer

Back 27

Withdraw the IUPC, monitor fetus and then replace if tracing reassuring
If an intrauterine pressure catheter is placed, and a significant amount of vaginal bleeding is noted, the possibility of placenta separation or uterine perforation should be considered. In this case, withdrawing the catheter, monitoring the fetus and observing for any signs of fetal compromise would be the most appropriate management. If the fetal status is found to be reassuring, then another attempt at placing the catheter may be undertaken.

Front 28

A 19-year-old G1P0 woman at 39 weeks gestation presents in labor. She denies ruptured membranes. Her prenatal course was uncomplicated and ultrasound at 18 weeks revealed no fetal abnormalities. Her vital signs are: blood pressure 120/70; pulse 72; temperature 101.0° F (38.3° C); fundal height 36 cm; and estimated fetal weight of 2900 gm. Cervix is dilated to 4 cm, 100% effaced and at +1 station. She receives 10 mg of morphine intramuscularly for pain and soon after has spontaneous rupture of the membranes. Light meconium-stained fluid was noted and, five minutes later, the fetal heart rate tracing revealed variable decelerations with good variability. What is the most likely cause for the variable decelerations?
A. Umbilical cord compression
B. Meconium
C. Maternal fever
D. Uteroplacental insufficiency
E. Umbilical cord prolapse

Back 28

Variable decelerations are typically caused by cord compression and are the most common decelerations seen in labor. Placental insufficiency is usually associated with late decelerations. Head compression typically causes early decelerations. Oligohydramnios can increase a patient’s risk of having umbilical cord compression; however, it does not directly cause variable decelerations. Umbilical cord prolapse occurs in 0.2 to 0.6% of births. Sustained fetal bradycardia is usually observed.

Front 29

A 34-year-old G1P0 woman at 39 weeks gestation presents in active labor. Her cervical examination an hour ago was 5 cm dilated, 90 percent effaced and 0 station. The baseline is 140 beats/minute. There is a deceleration after the onset of each of the last four contractions. She just had spontaneous rupture of membranes and is found to be completely dilated with the fetal head is at +3 station. What is the most likely etiology for these decelerations?
A. Oligohydramnios
B. Rapid change in descent
C. Umbilical cord compression
D. Uteroplacental insufficiency
E. Head compression

Back 29

Uteroplacental insufficiency
This patient is having late decelerations. Late decelerations are associated with uterine contractions. The onset, nadir, and recovery of the decelerations occur, respectively, after the beginning, peak and end of the contraction. Late decelerations are associated with uteroplacental insufficiency.

Front 30

A 34-year-old G2P1 woman is 40 weeks gestation. She was admitted to labor and delivery in active labor 2 hours ago. Her cervix was 6 cm dilated and 100% effaced on admission. Her fetus was vertex and – 3 station. You are called to examine the patient after she experiences spontaneous rupture of membranes. The cervix is completely dilated and the fetal head is occiput anterior (OA) at +1 station. You palpate a 5 cm long section of umbilical cord in the patient’s vagina. The fetal heart tracing is reassuring. The baseline is 130 beats per minute. There are multiple accelerations and no decelerations. The patient is having regular uterine contractions every 2-3 minutes. She has an epidural and is not feeling the contractions. What is the most appropriate next step in the management of this patient?

Back 30

Elevate the fetal head with a vaginal hand and perform a Cesarean delivery
his patient has an umbilical cord prolapse. Although fetal surveillance is reassuring, the most appropriate management is to continue to elevate the fetal head with a hand in the patient’s vagina and call for assistance to perform a Cesarean delivery. It is important to elevate the fetal head in an attempt to avoid compression of the umbilical cord. Once an umbilical cord prolapse is diagnosed, expeditious arrangements should be made to perform a cesarean section.

Front 31

A 25-year-old G1P0 woman presents to labor and delivery with contractions. She is at 40 weeks gestation. Her cervix is 6 cm dilated and 100% effaced. The fetus is in the occiput anterior presentation at +1 station. Fetal heart tones are reassuring with a baseline in the 140s, multiple accelerations and no decelerations. The patient had a fetal ultrasound three days ago which reported an EFW of 2900 grams. The patient’s older sister had a forceps assisted vaginal delivery and has anal incontinence. The patient would like to avoid having this same complication. Which of the following management plans is most appropriate for this patient?

A. Cesarean delivery
B. Vaginal delivery with no episiotomy
C. Vaginal delivery with a small, controlled midline episiotomy
D. Forceps assisted delivery with no episiotomy
E. Vacuum assisted delivery with no episiotomy

Back 31

Vaginal delivery with no episiotomy