Labor and Delivery

Labor and Delivery Indian Medical PG Question 1: A primigravida presents to the labor room at 40 weeks of gestation with lower abdominal pain. She has been in labor for 3 hours. Which of the following will determine if she is in active labor?

• A. Fetal head 5/5 palpable on abdominal examination
• B. Two contractions lasting for 10 seconds in 10 minutes
• C. Rupture of membranes
• D. Cervical dilatation of 6 cm or more with regular contractions (Correct Answer)

Labor and Delivery Explanation: ***Cervical dilatation of 6 cm or more with regular contractions*** - Active labor is officially defined by **cervical dilatation of 6 cm or more** according to the ACOG and SMFM 2014 consensus guidelines, which redefined the labor curve based on the Consortium on Safe Labor study. - This represents a shift from the traditional Friedman curve definition of 4 cm, recognizing that **significant progressive cervical change** with regular uterine contractions is the hallmark of active labor. - Complete effacement typically occurs during the latent phase, and while regular contractions accompany active labor, **cervical dilatation ≥6 cm is the primary diagnostic criterion**. *Fetal head 5/5 palpable on abdominal examination* - This finding indicates a **high fetal head** that is not engaged (0/5 of the head has entered the pelvis), which does not determine whether active labor has begun. - **Fetal station and engagement** are important for assessing labor progression and potential for cephalopelvic disproportion, but are not the primary criteria for diagnosing active labor. *Two contractions lasting for 10 seconds in 10 minutes* - These contractions are **infrequent and very short**, more characteristic of latent labor or Braxton Hicks contractions. - Active labor typically involves **3-5 contractions in 10 minutes, each lasting 45-60 seconds**, with sufficient intensity to cause progressive cervical change. *Rupture of membranes* - **Rupture of membranes (ROM)**, whether spontaneous or artificial, is an important event but does not by itself indicate active labor. - A woman can have ROM in the **latent phase** or even before labor begins (prelabor ROM or PROM), and **cervical dilatation remains the primary determinant** of active labor.

Labor and Delivery Indian Medical PG Question 2: Which of the following statements represents the PRIMARY obstetric significance at the level of plane of least pelvic dimensions? 1. It is a landmark used for pudendal nerve block analgesia. 2. Deep transverse arrest usually occurs at this plane. 3. It is at this plane that the internal rotation of the fetal head occurs during labour. 4. It marks the beginning of the backward curve of the pelvic axis.

• A. 4. It marks the beginning of the backward curve of the pelvic axis.
• B. 2. Deep transverse arrest usually occurs at this plane.
• C. 3. It is at this plane that the internal rotation of the fetal head occurs during labour.
• D. 1. It is a landmark used for pudendal nerve block analgesia. (Correct Answer)

Labor and Delivery Explanation: ***It is a landmark used for pudendal nerve block analgesia.*** - The **ischial spines**, which define the plane of least pelvic dimensions, are a crucial landmark for administering a **pudendal nerve block**. - This local anesthetic procedure targets the pudendal nerve as it passes by the **ischial spines**, providing pain relief to the perineum, vulva, and lower vagina. - While this is clinically important, it represents a **procedural application** rather than the primary obstetric mechanism at this plane. *Deep transverse arrest usually occurs at this plane.* - **Deep transverse arrest** occurs when the fetal head fails to rotate from the transverse position at the level of the **ischial spines** (plane of least dimensions). - This represents an important **obstetric complication** but is a pathological condition rather than the normal mechanism of labor at this level. *It is at this plane that the internal rotation of the fetal head occurs during labour.* - **Internal rotation** of the fetal head is a critical mechanism that occurs as the head descends to the level of the **ischial spines** and engages with the pelvic floor. - This represents the **normal physiological mechanism** of labor at this plane, where the head rotates to align with the anteroposterior diameter of the outlet. - However, internal rotation is a **process** that begins above and continues through this plane, rather than occurring exclusively at this single level. *It marks the beginning of the backward curve of the pelvic axis.* - The **pelvic axis** (curve of Carus) represents the path of fetal descent through the pelvis. - The axis does change direction at the level of the ischial spines, beginning to curve **posteriorly**. - However, this is an **anatomical description** rather than the primary obstetric significance related to labor mechanisms at this plane. **Note:** The marking of Option 1 as correct reflects the traditional teaching that the **ischial spines as a clinical landmark** is considered the primary significance. However, from a labor mechanism perspective, internal rotation (Option 3) is equally significant. The question tests understanding of the multiple roles of this anatomical plane.

Labor and Delivery Indian Medical PG Question 3: The components of partograph are all EXCEPT:

• A. Fetal heart rate
• B. Time
• C. Maternal respiratory rate (Correct Answer)
• D. Maternal urine analysis

Labor and Delivery Explanation: ***Maternal respiratory rate*** - While important for overall maternal well-being, **maternal respiratory rate** is not a standard component recorded on a partograph. - The partograph primarily focuses on monitoring fetal well-being, cervical dilation, and uterine contractions to track labor progress. *Fetal heart rate* - **Fetal heart rate** is a crucial component of the partograph, regularly plotted to assess fetal well-being and identify signs of distress. - It helps in detecting fetal hypoxia and guiding interventions if necessary during labor. *Time* - **Time** is a fundamental axis on the partograph, allowing for the plotting of all other parameters against a temporal scale. - This enables the healthcare provider to visualize the progression of labor and identify deviations from normal patterns. *Maternal urine analysis* - **Maternal urine analysis** for protein, acetone, or glucose is a standard component of the partograph. - It helps in assessing maternal hydration status and detecting potential complications like pre-eclampsia or gestational diabetes that might impact labor or fetal health.

Labor and Delivery Indian Medical PG Question 4: The progress of labour can be monitored by observing the following except:

• A. Gradual increase in cervical dilatation by vaginal examination
• B. The descent of foetal head by abdominal examination
• C. The formation of caput by vaginal examination (Correct Answer)
• D. The intensity of uterine contractions by abdominal examination

Labor and Delivery Explanation: ***The formation of caput by vaginal examination*** - The formation of a **caput succedaneum** (swelling on the fetal scalp) indicates **prolonged pressure** on the fetal head, which can be a sign of **cephalopelvic disproportion** or prolonged labor, rather than a direct measure of labor progression. - While its presence is noted during labor, caput formation itself does not actively monitor the *progress* of cervical dilatation or fetal descent in a positive way; rather, it often signals a potential **complication** or **stalling** of labor. *Gradual increase in cervical dilatation by vaginal examination* - **Cervical dilatation** is a primary indicator of the **first stage of labor progression**, as the cervix opens to allow passage of the fetus. - Regular **vaginal examinations** determine the rate and extent of cervical opening, crucial for deciding management. *The descent of foetal head by abdominal examination* - **Fetal head descent**, assessed by **abdominal palpation** (e.g., using the "fifths palpable" method), indicates the baby's movement through the birth canal. - This is a key measure of **progress in the second stage of labor** and helps identify potential obstructed labor. *The intensity of uterine contractions by abdominal examination* - The **intensity, frequency, and duration of uterine contractions** directly correlate with the forces driving labor progression. - While palpation provides a good estimate, this helps monitor the **effectiveness of uterine activity** in causing cervical changes and fetal descent.

Labor and Delivery Indian Medical PG Question 5: Consider the following cardinal movements of mechanism of normal labor: 1. Engagement 2. Internal rotation 3. Flexion 4. Restitution 5. Crowning 6. External rotation What is the correct sequence of movements in labor in occipito-lateral position?

• A. 1, 3, 2, 5, 4 and 6 (Correct Answer)
• B. 3, 1, 2, 4, 6 and 5
• C. 1, 2, 3, 4, 5 and 6
• D. 2, 1, 3, 4, 5 and 6

Labor and Delivery Explanation: ***1, 3, 2, 5, 4 and 6*** - This sequence accurately represents the order of events during normal vaginal delivery **in occipito-lateral position**, starting with **engagement** and progressing through the cardinal movements. - The sequence follows: **Engagement (1)** → **Flexion (3)** → **Internal rotation (2)** from occipito-lateral to occipito-anterior → **Crowning (5)** during extension phase → **Restitution (4)** → **External rotation (6)**. - While **crowning** is not technically a cardinal movement, it occurs during the **extension** phase and marks the emergence of the fetal head at the introitus. - In **occipito-lateral position**, internal rotation is essential for converting the position to occipito-anterior for delivery. *3, 1, 2, 4, 6 and 5* - This sequence incorrectly places **flexion before engagement**, which is physiologically impossible as the fetal head must first engage in the pelvic inlet before significant flexion occurs. - **Crowning** is placed after external rotation, but crowning occurs during the extension phase, well before restitution and external rotation. *1, 2, 3, 4, 5 and 6* - This sequence incorrectly places **internal rotation before flexion**, whereas flexion typically occurs first to reduce the presenting diameter and facilitate internal rotation. - The sequence also places **crowning after restitution**, which contradicts the normal progression where crowning occurs during extension, before restitution. *2, 1, 3, 4, 5 and 6* - This sequence incorrectly begins with **internal rotation before engagement**, which is physiologically impossible as the fetal head must be engaged in the pelvis before it can rotate. - **Engagement** must always be the first cardinal movement.

Labor and Delivery Indian Medical PG Question 6: Which one of the following statements is NOT true regarding general physiological changes after delivery?

• A. Blood volume returns to normal by second week
• B. Pulse may be raised on first day
• C. Temperature should not be above 99°F
• D. Cardiac output remains unchanged after delivery (Correct Answer)

Labor and Delivery Explanation: ***Cardiac output remains unchanged after delivery*** - This statement is incorrect because **cardiac output** actually undergoes significant changes postpartum. It **increases immediately after delivery** due to autotransfusion from the now-empty uterus and removal of uteroplacental shunt, peaking within the first hours, before gradually declining to pre-pregnancy levels over several weeks. - The drop in cardiac output after delivery is not immediate or complete, with initial increases followed by a gradual decrease, which refutes the idea of it remaining unchanged. *Blood volume returns to normal by second week* - This statement is generally true; after an initial increase immediately postpartum due to the relief of vena caval compression and autotransfusion, **blood volume progressively decreases** and typically returns to pre-pregnancy levels within the **first few weeks** following delivery. - The excess plasma volume accumulated during pregnancy is lost through diuresis and diaphoresis, bringing total blood volume back to normal. *Pulse may be raised on first day* - This statement is also true; many women experience a **transient increase in heart rate (tachycardia)** during the first 24-48 hours postpartum. - This can be attributed to several factors including **pain**, excitement, **blood loss**, and the rapid physiological changes occurring as the body adjusts after delivery. *Temperature should not be above 99°F* - This statement is largely true, as a **postpartum temperature** above 100.4°F (38°C) on two successive occasions and remaining elevated for more than 24 hours is typically considered a sign of **puerperal fever** and warrants investigation. - A transient rise to 100.4°F (38°C) within the first 24 hours can occur due to **dehydration** or the stress of labor, but sustained elevation above 99°F without a clear explanation should prompt further assessment for infection.

Labor and Delivery Indian Medical PG Question 7: McRoberts manoeuvre is used during labour for management of:

• A. Delivery of after coming head of breech
• B. Shoulder dystocia (Correct Answer)
• C. Normal labour to assist extension of head
• D. Extended arms of breech during assisted breech delivery

Labor and Delivery Explanation: ***Shoulder dystocia*** - **McRoberts manoeuvre** involves sharp flexion of the maternal thighs against the abdomen, which straightens the **sacrum** and rotates the **symphysis pubis** anteriorly. - This maneuver increases the functional size of the pelvic outlet and helps to dislodge the impacted fetal shoulder in cases of **shoulder dystocia**. - It is the **first-line intervention** for managing shoulder dystocia and is successful in resolving the majority of cases. *Delivery of after coming head of breech* - Management of an after-coming head in breech delivery typically involves maneuvers like the **Mauriceau-Smellie-Veit** maneuver or **Prague maneuver**. - **McRoberts manoeuvre** does not directly facilitate the delivery of the fetal head in a breech presentation. *Normal labour to assist extension of head* - In normal labor, the fetal head typically delivers by **extension** as it passes under the symphysis pubis, and no specific maneuver is usually required. - McRoberts manoeuvre is a specific intervention for a complication (**shoulder dystocia**), not a routine aid for head extension during normal delivery. *Extended arms of breech during assisted breech delivery* - Extended arms in a breech presentation are managed by maneuvers designed to free the arms, such as **Løvset's maneuver**. - **McRoberts manoeuvre** primarily addresses shoulder impaction, not arm entrapment in breech delivery.

Labor and Delivery Indian Medical PG Question 8: Which of the following features are correct regarding onset of true labour? 1. Regular uterine contractions 2. Progressive cervical dilation and effacement 3. Presence of show 4. Labour and delivery are synonymous Select the answer using the code given below.

• A. 2, 3 and 4
• B. 1, 2 and 3 (Correct Answer)
• C. 1, 3 and 4
• D. 1, 2 and 4

Labor and Delivery Explanation: ***Correct: 1, 2 and 3*** - **Regular uterine contractions** (statement 1) are a hallmark of true labor, occurring at regular intervals with increasing frequency, duration, and intensity. - **Progressive cervical dilation and effacement** (statement 2) is the definitive diagnostic criterion for true labor, distinguishing it from false labor (Braxton Hicks contractions). - **Presence of 'show'** (statement 3) - the expulsion of the cervical mucus plug mixed with blood - is a common and reliable indicator of true labor onset. - Statement 4 is **incorrect**: labor and delivery are **not synonymous**. **Labor** is the entire process of childbirth (contractions, cervical changes, descent of fetus), while **delivery** refers specifically to the expulsion of the baby. *Incorrect: 2, 3 and 4* - Incorrectly includes statement 4, which falsely claims labor and delivery are synonymous. - Omits statement 1 (regular uterine contractions), which is a fundamental feature of true labor. *Incorrect: 1, 3 and 4* - Incorrectly includes statement 4 about labor and delivery being synonymous. - Critically omits statement 2 (progressive cervical dilation and effacement), which is the most important diagnostic criterion for true labor. *Incorrect: 1, 2 and 4* - Incorrectly includes statement 4, which is false. - Omits statement 3 (presence of show), which is a valid indicator of true labor onset.

Labor and Delivery Indian Medical PG Question 9: What procedure is being demonstrated in the image?

• A. Artificial rupture of membranes
• B. Fetal scalp pH monitoring
• C. Amniocentesis (Correct Answer)
• D. Paracervical block

Labor and Delivery Explanation: ***Amniocentesis*** - The image clearly depicts a needle being inserted through the maternal abdomen into the **amniotic sac** to withdraw **amniotic fluid**, which is the procedure for amniocentesis. - This procedure is typically performed for prenatal diagnosis of genetic conditions, **fetal lung maturity assessment**, or to evaluate for uterine infections. *Artificial rupture of membranes* - This procedure involves using a specialized instrument (amniohook) to **break the amniotic sac** through the cervix during active labor to facilitate delivery, which is not what is shown. - The image shows an abdominal approach and aspiration of fluid, not membrane rupture through the vagina. *Fetal scalp pH monitoring* - Fetal scalp pH monitoring involves taking a small **blood sample from the fetal scalp** during labor to assess for fetal acidosis, typically done vaginally and not via abdominal puncture. - The instrument shown is a needle for fluid aspiration, not a blood sampling device or pH electrode. *Paracervical block* - A paracervical block is a regional anesthetic procedure involving injections into the **cervical tissue** to relieve pain during labor, which is not depicted in the image. - The image shows a procedure involving access to the amniotic fluid, not local anesthesia of the cervix.

Labor and Delivery Indian Medical PG Question 10: What is the instrument shown below used for?

• A. Dilate urethral strictures
• B. Measure uterus size in pregnancy
• C. Measure thickness of uterine wall
• D. Dilating the ostium uteri (Correct Answer)

Labor and Delivery Explanation: ***Dilating the ostium uteri*** - The image depicts a set of **Hegar dilators**, which are instruments used to **dilate the cervical os (ostium uteri)**. - They come in graduated sizes and are inserted sequentially to gradually widen the cervical canal for procedures like D&C, IUD insertion, or hysteroscopy. *Dilate urethral strictures* - While dilators are used for urethral strictures, the instruments shown are specifically designed with a curvature and length optimized for the **cervical canal**, not the male or female urethra. - **Urethral stricture dilators** generally have a different shape, often longer and straighter or with a specific angle for the male urethra. *Measure uterus size in pregnancy* - Measuring uterus size in pregnancy is typically done by **fundal height measurement** with a tape measure or **ultrasound**, not with these solid dilators. - Hegar dilators are for dilating, not measuring length or size of the uterus during pregnancy. *Measure thickness of uterine wall* - The thickness of the uterine wall is measured using **imaging techniques** like **ultrasound** or MRI. - These dilators are solid instruments designed for mechanical dilation and cannot measure tissue thickness.

Labor and Delivery Flashcard 1 of 10

Question: The fourth stage of labour is a stage of observation for at least _____ after the full expulsion of the placenta.

Answer: an hour

Labor and Delivery Flashcard 2 of 10

Question: neonatal care corner is located _____

Answer: in the labor room 

Extra Information: 

Labor and Delivery Flashcard 3 of 10

Question: A transverse lie is managed by _____

Answer: caesarean section.

Labor and Delivery Flashcard 4 of 10

Question: On a partograph, fetal heart rate is recorded every _____

Answer: 30 mins

Labor and Delivery Flashcard 5 of 10

Question: Diameter of engagement is anteroposterior in _____ pelvis

Answer: anthropoid

Labor and Delivery Flashcard 6 of 10

Question: Labor is called a precipitate when the combined duration of the first and second stages is less than _____ hours

Answer: 3

Labor and Delivery Flashcard 7 of 10

Question: _____ decelerations are caused by mechanical compression of the umbilical cord, and managed by repositioning the mother into lateral decubitus position

Answer: Variable

Labor and Delivery Flashcard 8 of 10

Question: What is the position of the vertex in the given image: _____

Answer: Right occipito-anterior

Labor and Delivery Flashcard 9 of 10

Question: The given image shows _____ position of fetus:

Answer: right occipito posterior

Labor and Delivery Flashcard 10 of 10

Question: Cervidil vaginal insert provides the release of _____ mg/hr of Prostaglandin E2

Answer: 0.3