Abnormal labor patterns US Medical PG Practice Questions and MCQs
Practice US Medical PG questions for Abnormal labor patterns. These multiple choice questions (MCQs) cover important concepts and help you prepare for your exams.
Abnormal labor patterns US Medical PG Question 1: A 36-year-old primigravid woman at 26 weeks' gestation comes to the physician complaining of absent fetal movements for the last 2 days. Pregnancy was confirmed by ultrasonography 14 weeks earlier. She has no vaginal bleeding or discharge. She has a history of type 1 diabetes mellitus controlled with insulin. Vital signs are all within the normal limits. Pelvic examination shows a soft, 2-cm long cervix in the midline with a cervical os measuring 3 cm and a uterus consistent in size with 24 weeks' gestation. Transvaginal ultrasonography shows a fetus with no cardiac activity. Which of the following is the most appropriate next step in management?
- A. Plan for oxytocin administration (Correct Answer)
- B. Perform weekly pelvic ultrasound
- C. Perform dilation and curettage
- D. Perform cesarean delivery
- E. Administer magnesium sulfate
Abnormal labor patterns Explanation: ***Plan for oxytocin administration***
- The patient is at 26 weeks' gestation with confirmed fetal demise and an effaced, dilated cervix (2 cm long, 3 cm dilated). This indicates the cervix is already preparing for delivery.
- **Oxytocin** is the most appropriate next step to induce labor and facilitate vaginal delivery in cases of **intrauterine fetal demise** (IUFD) after the first trimester, especially when cervical changes have begun.
*Perform weekly pelvic ultrasound*
- The ultrasound has already confirmed **absent fetal cardiac activity**, making repeated ultrasounds unnecessary as the diagnosis of IUFD is already established.
- This option would delay necessary management and exposure to the deceased fetus in utero could increase risks such as **coagulopathy** if prolonged.
*Perform dilation and curettage*
- **Dilation and curettage (D&C)** is generally reserved for termination of pregnancy or management of miscarriage up to **16-18 weeks' gestation**.
- At **26 weeks' gestation**, the size of the fetus and uterus makes D&C a less safe and less effective procedure compared to labor induction.
*Perform cesarean delivery*
- **Cesarean delivery** for IUFD is typically reserved for cases with maternal indications (e.g., prior classical C-section scar, placenta previa obstructing the birth canal) or when labor induction fails.
- There are no maternal or fetal contraindications to vaginal delivery in this scenario, and a C-section would primarily increase maternal morbidity without fetal benefit.
*Administer magnesium sulfate*
- **Magnesium sulfate** is used for **neuroprotection** in preterm deliveries (usually before 32 weeks) and seizure prophylaxis in **preeclampsia/eclampsia**.
- As the fetus is deceased, neuroprotection is not applicable, and there are no signs of preeclampsia, making this intervention inappropriate.
Abnormal labor patterns US Medical PG Question 2: A 35-year-old G3P2 woman currently 39 weeks pregnant presents to the emergency department with painful vaginal bleeding shortly after a motor vehicle accident in which she was a passenger. She had her seat belt on and reports that the airbag deployed immediately upon her car's impact against a tree. She admits that she actively smokes cigarettes. Her prenatal workup is unremarkable. Her previous pregnancies were remarkable for one episode of chorioamnionitis that resolved with antibiotics. Her temperature is 98.6°F (37°C), blood pressure is 90/60 mmHg, pulse is 130/min, and respirations are 20/min. The fetal pulse is 110/min. Her uterus is tender and firm. The remainder of her physical exam is unremarkable. What is the most likely diagnosis?
- A. Placental abruption (Correct Answer)
- B. Eclampsia
- C. Vasa previa
- D. Preterm labor
- E. Preeclampsia
Abnormal labor patterns Explanation: ***Placental abruption***
- The patient's presentation with **painful vaginal bleeding** after blunt abdominal trauma (motor vehicle accident), a **tender and firm uterus**, maternal **hypotension** and **tachycardia**, and fetal **bradycardia** is highly characteristic of placental abruption.
- Risk factors like **smoking** and trauma further increase the likelihood of placental abruption.
*Eclampsia*
- Eclampsia is characterized by **new-onset grand mal seizures** in a pregnant woman with preeclampsia, which is not present in this scenario.
- While the patient's low blood pressure and tachycardia are concerning, they do not point to eclampsia.
*Vasa previa*
- Vasa previa involves **fetal blood vessels** running within the fetal membranes over the internal cervical os, risking rupture during labor or membrane rupture, leading to **painless vaginal bleeding** and **fetal distress**.
- The bleeding in this case is described as painful, and the uterine tenderness and firmness are not typical of vasa previa.
*Preterm labor*
- Preterm labor is defined by **regular uterine contractions** causing cervical changes before 37 weeks of gestation, which is not aligned with the patient being 39 weeks pregnant or her symptoms.
- While trauma can initiate labor, the severity of the bleeding and maternal/fetal distress point away from isolated preterm labor.
*Preeclampsia*
- Preeclampsia is characterized by **new-onset hypertension** (blood pressure ≥140/90 mmHg) and **proteinuria** after 20 weeks of gestation.
- This patient presents with hypotension and no mention of hypertension or proteinuria, making preeclampsia unlikely.
Abnormal labor patterns US Medical PG Question 3: A 22-year-old G4P2 at 35 weeks gestation presents to the hospital after she noticed that "her water broke." Her prenatal course is unremarkable, but her obstetric history includes postpartum hemorrhage after her third pregnancy, attributed to a retained placenta. The patient undergoes augmentation of labor with oxytocin and within four hours delivers a male infant with Apgar scores of 8 and 9 at 1 and 5 minutes, respectively. Three minutes later, the placenta passes the vagina, but a smooth mass attached to the placenta continues to follow. Her temperature is 98.6°F (37°C), blood pressure is 110/70 mmHg, pulse is 90/min, and respirations are 20/min. What is the most likely complication in the absence of intervention?
- A. Hypertension
- B. Hemorrhagic shock (Correct Answer)
- C. Tachypnea
- D. Heart failure
- E. Hyperthermia
Abnormal labor patterns Explanation: ***Hemorrhagic shock***
- The presenting symptoms suggest **uterine inversion**, a rare but serious obstetrical emergency where the uterus turns inside out, which is usually accompanied by a **sudden gush of blood** or **postpartum hemorrhage**.
- Without immediate intervention to correct the uterine inversion and manage bleeding, the rapid and significant blood loss will lead to **hemorrhagic shock**, characterized by inadequate tissue perfusion and oxygen delivery.
*Hypertension*
- **Uterine inversion** and associated significant blood loss would typically lead to **hypotension** and shock, not hypertension.
- Hypertension in the postpartum period is usually linked to conditions like **preeclampsia** or **essential hypertension**, which are not indicated here.
*Tachypnea*
- While tachypnea can be a symptom of **hemorrhagic shock** due to metabolic acidosis and compensatory mechanisms, it is a *symptom* of the underlying problem, not the most likely primary complication itself.
- The immediate life-threatening complication from uterine inversion is **massive blood loss**, leading to shock.
*Heart failure*
- **Acute heart failure** due to uterine inversion or postpartum hemorrhage is unlikely unless the patient has pre-existing cardiac conditions or develops severe, prolonged shock leading to multi-organ dysfunction.
- The immediate concern is the **circulatory collapse** from blood loss, not primary cardiac failure.
*Hyperthermia*
- **Hyperthermia** (fever) is typically associated with **infection**, such as endometritis or chorioamnionitis, and not a direct consequence of uterine inversion or immediate postpartum hemorrhage.
- The patient's temperature is normal, indicating no infection at presentation.
Abnormal labor patterns US Medical PG Question 4: Immediately following prolonged delivery of the placenta at 40 weeks gestation, a 32-year-old multiparous woman develops vaginal bleeding. Other than mild asthma, the patient’s pregnancy has been uncomplicated. She has attended many prenatal appointments and followed the physician's advice about screening for diseases, laboratory testing, diet, and exercise. Previous pregnancies were uncomplicated. She has no history of a serious illness. She is currently on intravenous infusion of oxytocin. Her temperature is 37.2°C (99.0°F), blood pressure is 108/60 mm Hg, pulse is 88/min, and respirations are 17/min. Uterine palpation reveals a soft enlarged fundus that extends above the umbilicus. Based on the assessment of the birth canal and placenta, which of the following options is the most appropriate initial step in patient management?
- A. Intramuscular carboprost
- B. Manual exploration of the uterus
- C. Discontinuing oxytocin
- D. Intravenous methylergonovine
- E. Uterine fundal massage (Correct Answer)
Abnormal labor patterns Explanation: ***Uterine fundal massage***
- The patient presents with **postpartum hemorrhage** indicated by vaginal bleeding and a **soft, enlarged fundus** after placental delivery, suggesting **uterine atony**.
- **Uterine fundal massage** is the **first-line intervention** to encourage uterine contraction and reduce bleeding by expelling clots and compressing vessels.
*Intramuscular carboprost*
- **Carboprost** is a **prostaglandin F2 alpha analog** used to treat **uterine atony** when initial measures like uterine massage and oxytocin are insufficient.
- It is contraindicated in patients with **asthma** due to its bronchoconstrictive effects, which this patient has.
*Manual exploration of the uterus*
- **Manual exploration of the uterus** is indicated when there is suspicion of **retained placental fragments** or **uterine rupture**.
- While these can cause postpartum hemorrhage, the primary finding of a soft, boggy uterus points more strongly to atony, making massage the immediate priority.
*Discontinuing oxytocin*
- The patient is already on an **intravenous oxytocin infusion**, which is a uterotonic agent used to prevent and treat uterine atony.
- Discontinuing it would worsen **uterine atony** and increase blood loss, directly contradicting the goal of management.
*Intravenous methylergonovine*
- **Methylergonovine** is an **ergot alkaloid** used to treat **uterine atony**, but it is contraindicated in patients with **hypertension**, which is not explicitly present here, but it is a potent vasoconstrictor and second-line.
- It is often used as a **second-line agent** if oxytocin and massage are ineffective and there are no contraindications.
Abnormal labor patterns US Medical PG Question 5: A 22-year-old primigravid woman at 41 weeks' gestation is admitted to the hospital in active labor. Pregnancy has been uncomplicated. She has asthma treated with theophylline and inhaled corticosteroids. She has had 2 surgeries in the past to repair multiple lower limb and pelvis fractures that were the result of a car accident. She is otherwise healthy. Her temperature is 37.2°C (99°F) and blood pressure is 108/70 mm Hg. Examination shows the cervix is 100% effaced and 10 cm dilated; the vertex is at -4 station, with the occiput in the anterior position. Uterine activity is measured at 275 MVUs. Maternal pushing occurs during the contractions. Fetal heart tracing is 166/min and reactive with no decelerations. Epidural anesthesia is initiated for pain relief. After 4 hours of pushing, the vertex is found to be at -4 station, with increasing strength and rate of uterine contractions; fetal heart tracing shows late decelerations. Which of the following is the most likely cause of this patient's prolonged labor?
- A. Deep transverse arrest
- B. Insufficient uterine contraction
- C. Epidural anesthesia
- D. Cephalopelvic disproportion (Correct Answer)
- E. Inefficient maternal pushing
Abnormal labor patterns Explanation: ***Cephalopelvic disproportion***
- The history of **multiple lower limb and pelvis fractures** from a car accident suggests a high likelihood of a **contracted or abnormally shaped pelvis**. This can lead to **cephalopelvic disproportion (CPD)**, where the fetal head cannot fit through the maternal pelvis despite adequate uterine contractions (275 MVUs).
- The combination of **prolonged labor** (4 hours of pushing with no descent), **vertex at -4 station** even after full dilation, increasing contraction strength, and new **late decelerations** (indicating fetal distress due to impaired oxygenation from prolonged compression) points towards an obstruction.
*Deep transverse arrest*
- This occurs when the fetal head rotates into the transverse diameter of the pelvis and fails to rotate anteriorly. While it causes **arrest of descent and dilation**, the primary issue is **malposition**, not a fundamental size mismatch.
- The occiput is described as in the **anterior position**, which does not immediately suggest deep transverse arrest.
*Insufficient uterine contraction*
- The uterine activity is measured at **275 MVUs**, which indicates **adequate contraction strength**. Insufficient contractions would typically be below 200 MVUs.
- While weak contractions can cause prolonged labor, the current uterine activity suggests this is not the primary problem.
*Epidural anesthesia*
- Epidural anesthesia can sometimes prolong the second stage of labor by reducing the urge to push or temporarily decreasing the effectiveness of pushing efforts. However, the patient's **strong uterine activity (275 MVUs)** and previous **pelvic fractures** make a mechanical obstruction (CPD) a more specific and likely cause of arrest in this scenario.
- Furthermore, the vertex remaining at -4 station for 4 hours despite strong contractions points to a physical barrier rather than just altered pushing dynamics.
*Inefficient maternal pushing*
- While inefficient maternal pushing can contribute to prolonged labor, the fetus remaining at -4 station for 4 hours with **strong uterine contractions (275 MVUs)** indicates that the issue is likely beyond just inadequate pushing efforts.
- The historical detail of **pelvic fractures** points more strongly to an anatomical obstruction rather than simply ineffective maternal exertion.
Abnormal labor patterns US Medical PG Question 6: A 25-year-old G1P0 at 20 weeks of gestation woman arrives at a prenatal appointment complaining of pelvic pressure. She has had an uncomplicated pregnancy thus far. She takes prenatal vitamins and eats a well-balanced diet. Her medical history is significant for major depressive disorder that has been well-controlled on citalopram. Her mother had gestational diabetes with each of her 3 pregnancies. On physical exam, the cervix is soft and closed with minimal effacement. There is white vaginal discharge within the vagina and vaginal vault without malodor. Vaginal pH is 4.3. A transvaginal ultrasound measures the length of the cervix as 20 mm. Which of the following is most likely to prevent preterm birth in this patient?
- A. Pessary
- B. Vaginal progesterone (Correct Answer)
- C. Metformin
- D. Metronidazole
- E. Prednisone
Abnormal labor patterns Explanation: ***Vaginal progesterone***
- This patient has a **short cervical length** (20 mm at 20 weeks gestation), and **vaginal progesterone** has been shown to reduce the risk of **spontaneous preterm birth** in women with a singleton pregnancy and a short cervix.
- While she has subjective pelvic pressure, the physical exam shows a closed cervix, making her a candidate for prophylactic intervention rather than immediate treatment for active labor.
*Pessary*
- A **cervical pessary** can be used to prevent **preterm birth** in women with a short cervix, but evidence suggests **vaginal progesterone** is often preferred as a first-line intervention in singleton pregnancies due to ease of use and good evidence base.
- While it's an option, it's generally considered secondary to progesterone in this specific scenario.
*Metformin*
- **Metformin** is used to treat **gestational diabetes** or **type 2 diabetes** and is not indicated for the prevention of preterm birth.
- While her mother had gestational diabetes, this patient has not been diagnosed with it, nor is prevention of preterm birth an indication for metformin use.
*Metronidazole*
- **Metronidazole** is an antibiotic used to treat **bacterial vaginosis** or **trichomoniasis**.
- While she has vaginal discharge, the pH of 4.3 and lack of malodor do not suggest bacterial vaginosis or trichomoniasis, and metronidazole does not prevent preterm birth.
*Prednisone*
- **Prednisone** is a corticosteroid used to manage inflammatory conditions or to promote **fetal lung maturity** in cases of threatened preterm labor.
- It is not used to prevent preterm birth and would not be indicated for this patient whose cervix is closed and appears to be experiencing benign pelvic pressure rather than active labor.
Abnormal labor patterns US Medical PG Question 7: A 33-year-old woman, gravida 2, para 1, at 26 weeks' gestation comes to the emergency department because of frequent contractions. The contractions are 40 seconds each, occurring every 2 minutes, and increasing in intensity. Her first child was delivered by lower segment transverse cesarean section because of a nonreassuring fetal heart rate. Her current medications include folic acid and a multivitamin. Her temperature is 36.9°C (98.4°F), heart rate is 88/min, and blood pressure is 126/76 mm Hg. Contractions are felt on the abdomen. There is clear fluid in the vulva and the introitus. The cervix is dilated to 5 cm, 70% effaced, and station of the head is -2. A fetal ultrasound shows polyhydramnios, a median cleft lip, and fused thalami. The corpus callosum, 3rd ventricle, and lateral ventricles are absent. The spine shows no abnormalities and there is a four chamber heart. Which of the following is the most appropriate next step in management?
- A. Initiate misoprostol therapy
- B. Allow vaginal delivery (Correct Answer)
- C. Perform dilation and evacuation
- D. Initiate nifedipine therapy
- E. Perform cesarean delivery
Abnormal labor patterns Explanation: ***Allow vaginal delivery***
- The presence of severe fetal anomalies, including **holoprosencephaly** (median cleft lip, fused thalami, absent corpus callosum, 3rd and lateral ventricles), indicates that the fetus is **incompatible with life**.
- Given the prognosis, the most appropriate and safest approach for the mother is to **allow vaginal delivery**, as there is no benefit to delaying delivery or attempting a surgical intervention that might pose more risks to the mother.
*Initiate misoprostol therapy*
- **Misoprostol** is a prostaglandin analog used to induce labor or abortion, particularly in cases of uterine atony or to ripen the cervix.
- While it aids in cervical ripening and uterine contractions, the cervix is already 5 cm dilated and 70% effaced, indicating a **rapidly progressing labor** not requiring additional induction.
*Perform dilation and evacuation*
- **Dilation and evacuation (D&E)** is typically performed in the second trimester for fetal demise or termination of pregnancy, usually before 24 weeks' gestation.
- At 26 weeks' gestation with advanced labor and significant cervical dilation, D&E is a **high-risk procedure** for the mother and less appropriate than vaginal delivery.
*Initiate nifedipine therapy*
- **Nifedipine is a tocolytic** used to suppress preterm labor by relaxing the uterine muscles.
- Given the **lethal fetal anomalies** and the advanced stage of labor (5 cm dilated, 70% effaced, intense contractions), stopping labor would only prolong a non-viable pregnancy and increase maternal risk.
*Perform cesarean delivery*
- **Cesarean delivery** would expose the mother to surgical risks (e.g., infection, hemorrhage, future pregnancy complications) without any benefit to the fetus, who has anomalies **incompatible with survival**.
- A previous cesarean section does not preclude a vaginal delivery in this context, especially when **fetal viability is not a concern**.
Abnormal labor patterns US Medical PG Question 8: A 15-year-old girl is brought to the physician by her mother because of lower abdominal pain for the past 5 days. The pain is constant and she describes it as 7 out of 10 in intensity. Over the past 7 months, she has had multiple similar episodes of abdominal pain, each lasting for 4–5 days. She has not yet attained menarche. Examination shows suprapubic tenderness to palpation. Pubic hair and breast development are Tanner stage 4. Examination of the external genitalia shows no abnormalities. Pelvic examination shows bulging, bluish vaginal tissue. Rectal examination shows an anterior tender mass. Which of the following is the most effective intervention for this patient's condition?
- A. Administer gonadotropin-releasing hormone agonist therapy
- B. Administer ibuprofen
- C. Perform vaginal dilation
- D. Administer oral contraceptives pills
- E. Perform hymenotomy (Correct Answer)
Abnormal labor patterns Explanation: ***Perform hymenotomy***
- The patient's inability to achieve **menarche** despite advanced **Tanner staging** (indicating hormonal maturity) and cyclical lower abdominal pain strongly suggests **cryptomenorrhea** due to an **imperforate hymen**.
- A **hymenotomy** is a surgical procedure to incise the hymen, allowing the accumulated menstrual blood (hematocolpos) to drain, resolving the pain and preventing complications.
*Administer gonadotropin-releasing hormone agonist therapy*
- **GnRH agonists** are used to suppress ovulation and menstrual cycles, typically for conditions like endometriosis or precocious puberty.
- This patient's issue is a physical obstruction to menstrual flow, not a hormonal imbalance requiring suppression.
*Administer ibuprofen*
- **Ibuprofen (NSAIDs)** can alleviate pain, but it would only mask the symptoms without addressing the underlying obstruction.
- The patient has **hematocolpos** due to an imperforate hymen, which requires a definitive surgical solution.
*Perform vaginal dilation*
- **Vaginal dilation** is used to treat conditions causing vaginal stenosis or agenesis, like **Mayer-Rokitansky-Küster-Hauser syndrome**.
- This patient has a physically obstructed hymen, not a narrowed or absent vagina, so dilation is not appropriate.
*Administer oral contraceptives pills*
- **Oral contraceptive pills (OCPs)** regulate menstrual cycles and can reduce menstrual pain or flow.
- They would not resolve the physical obstruction caused by an **imperforate hymen** and would still lead to accumulation of menstrual blood.
Abnormal labor patterns US Medical PG Question 9: A 9-year-old boy is brought to the physician for evaluation of short stature. He is at the 5th percentile for height, 65th percentile for weight, and 95th percentile for head circumference. Examination shows midface retrusion, a bulging forehead, and flattening of the nose. The extremities are disproportionately short. He was adopted and does not know his biological parents. The patient’s condition is an example of which of the following genetic phenomena?
- A. Variable expressivity
- B. Anticipation
- C. Codominance
- D. Imprinting
- E. Complete penetrance (Correct Answer)
Abnormal labor patterns Explanation: ***Complete penetrance***
- Complete penetrance means that **all individuals who inherit the disease-causing allele will express the phenotype** associated with that allele
- This patient presents with classic features of **achondroplasia**: short stature at 5th percentile, midface retrusion, bulging forehead, flattened nose, and disproportionately short extremities
- Achondroplasia is caused by a mutation in the **FGFR3 gene** (autosomal dominant) and demonstrates **nearly 100% penetrance** - virtually all individuals with the mutation manifest the characteristic skeletal abnormalities
- This is a textbook example of complete penetrance where genotype reliably predicts phenotype
*Incorrect: Variable expressivity*
- Variable expressivity refers to differences in the **severity or clinical manifestations** among individuals with the same genetic mutation
- While achondroplasia may show some variation in severity, the question describes typical features without emphasizing variability in expression
- This patient shows the classic, expected phenotype rather than unusual expressivity
*Incorrect: Anticipation*
- Anticipation occurs when a genetic disorder becomes **more severe or presents at an earlier age in successive generations**
- This is characteristic of **trinucleotide repeat disorders** (e.g., Huntington disease, myotonic dystrophy, fragile X syndrome)
- Achondroplasia does not demonstrate anticipation; most cases arise from **de novo mutations** rather than inherited mutations
*Incorrect: Codominance*
- Codominance occurs when **both alleles are fully expressed** in the heterozygous state, with neither being dominant or recessive
- Classic examples include **ABO blood groups** and **HbS in sickle cell trait**
- Achondroplasia is an **autosomal dominant** condition, not codominant
*Incorrect: Imprinting*
- Genomic imprinting refers to **parent-of-origin effects** where gene expression depends on whether the allele was inherited from mother or father
- Examples include **Prader-Willi syndrome** (paternal deletion) and **Angelman syndrome** (maternal deletion)
- Achondroplasia shows no parent-of-origin effects
Abnormal labor patterns US Medical PG Question 10: A 25-year-old G2P1001 at 32 weeks gestation presents to the hospital with painless vaginal bleeding. The patient states that she was taking care of laundry at home when she experienced a sudden sensation of her water breaking and saw that her groin was covered in blood. Her prenatal history is unremarkable according to the clinic records, but she has not seen an obstetrician for the past 14 weeks. Her previous delivery was by urgent cesarean section for placenta previa. Her temperature is 95°F (35°C), blood pressure is 125/75 mmHg, pulse is 79/min, respirations are 18/min, and oxygen saturation is 98% on room air. Cervical exam shows gross blood in the vaginal os. The fetal head is not palpable. Fetal heart rate monitoring demonstrates decelerations and bradycardia. Labs are pending. IV fluids are started. What is the best next step in management?
- A. Cesarean section (Correct Answer)
- B. Betamethasone
- C. Red blood cell transfusion
- D. Vaginal delivery
- E. Lumbar epidural block
Abnormal labor patterns Explanation: ***Cesarean section***
- This patient presents with signs highly suggestive of **placenta previa with possible vasa previa or placental abruption**, with life-threatening complications for both mother and fetus. The presence of **painless vaginal bleeding**, a prior **cesarean section for placenta previa**, and **fetal heart rate decelerations/bradycardia** necessitate immediate delivery via cesarean section to prevent **fetal demise** and severe **maternal hemorrhage**.
- The rapid deterioration of the fetal status, indicated by **decelerations and bradycardia**, confirms the urgency. A **cesarean section** is the quickest and safest way to deliver the baby and address the underlying obstetric emergency.
*Betamethasone*
- **Betamethasone** is administered to promote **fetal lung maturity** in cases of preterm delivery. While this patient is preterm at 32 weeks, the critical nature of the fetal distress and bleeding requires immediate delivery, making the delay for betamethasone administration inappropriate.
- The benefits of steroids for lung maturity are outweighed by the **immediate risk of fetal demise** and severe maternal complications if delivery is delayed.
*Red blood cell transfusion*
- While the patient is actively bleeding and may eventually require a **blood transfusion**, starting IV fluids and proceeding with an **immediate cesarean section** are higher priorities to stabilize the mother and rescue the fetus.
- Transfusions are supportive measures once the source of hemorrhage is addressed and vital signs are stabilized during or after surgery.
*Vaginal delivery*
- Given the patient's history of **placenta previa**, current **painless vaginal bleeding**, and signs of **fetal distress**, a vaginal delivery is contraindicated due to the high risk of **exsanguinating hemorrhage** for the mother and severe fetal compromise.
- The prior **cesarean section for placenta previa** also increases the risk of recurrent previa and **placenta accreta spectrum**, further contraindicating vaginal delivery.
*Lumbar epidural block*
- A **lumbar epidural block** is used for pain management during labor, but in this emergent situation with active bleeding and fetal distress, immediate delivery is paramount.
- The time required to safely administer an **epidural**, along with the potential for **hypotension** in a hypovolemic patient, makes it an inappropriate next step.
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