Cardinal movements of labor US Medical PG Practice Questions and MCQs
Practice US Medical PG questions for Cardinal movements of labor. These multiple choice questions (MCQs) cover important concepts and help you prepare for your exams.
Cardinal movements of labor US Medical PG Question 1: A 34-year-old pregnant woman with unknown medical history is admitted to the hospital at her 36th week of gestation with painful contractions. She received no proper prenatal care during the current pregnancy. On presentation, her vital signs are as follows: blood pressure is 110/60 mm Hg, heart rate is 102/min, respiratory rate is 23/min, and temperature is 37.0℃ (98.6℉). Fetal heart rate is 179/min. Pelvic examination shows a closed non-effaced cervix. During the examination, the patient experiences a strong contraction accompanied by a high-intensity pain after which contractions disappear. The fetal heart rate becomes 85/min and continues to decrease. The fetal head is now floating. Which of the following factors would most likely be present in the patient’s history?
- A. Fundal cesarean delivery (Correct Answer)
- B. Adenomyosis
- C. Intrauterine synechiae
- D. Multiple vaginal births
- E. Postabortion metroendometritis
Cardinal movements of labor Explanation: ***Fundal cesarean delivery***
- The sudden onset of intense pain followed by cessation of contractions, fetal bradycardia, and a floating fetal head in a woman with a prior Cesarean section scar is highly suggestive of **uterine rupture**.
- A previous **classical or fundal Cesarean section** scar carries the highest risk of rupture in subsequent pregnancies due to the incision extending into the contractile upper uterine segment.
*Adenomyosis*
- **Adenomyosis** involves the presence of endometrial tissue within the myometrium, which can cause heavy, painful periods and chronic pelvic pain, but it doesn't directly predispose to uterine rupture during labor.
- While it can complicate pregnancy with an increased risk of preterm birth or miscarriage, it is not associated with the acute presentation described.
*Intrauterine synechiae*
- **Intrauterine synechiae**, or Asherman's syndrome, are adhesions within the uterine cavity, often resulting from endometrial trauma.
- They primarily cause infertility, recurrent pregnancy loss, or abnormal placentation (like placenta accreta), but not uterine rupture.
*Multiple vaginal births*
- A history of **multiple vaginal births** generally *reduces* the risk of uterine rupture in subsequent pregnancies as the cervix and lower uterine segment are often more compliant.
- While prolonged labor or instrumental delivery can rarely increase rupture risk, it's not a primary risk factor like a prior classical Cesarean.
*Postabortion metroendometritis*
- **Postabortion metroendometritis** is an infection of the uterus after an abortion.
- While it can lead to complications such as Asherman's syndrome or infertility, it does not typically increase the risk of uterine rupture in a subsequent pregnancy in the manner described.
Cardinal movements of labor US Medical PG Question 2: A 39-year-old woman, gravida 5, para 4, at 41 weeks' gestation is brought to the hospital because of regular uterine contractions that started 2 hours ago. Pregnancy has been complicated by iron deficiency anemia treated with iron supplements. Pelvic examination shows the cervix is 90% effaced and 7-cm dilated; the vertex is at -1 station. Fetal heart tracing is shown. The patient is repositioned, O2 therapy is initiated, and amnioinfusion is done. A repeat assessment after 20 minutes shows a similar cervical status, and no changes in the fetal heart tracing, and less than 5 contractions in a period of 10 minutes.What is the most appropriate next step in management?
- A. Emergent cesarean delivery (Correct Answer)
- B. Monitor without intervention
- C. Begin active pushing
- D. Retry maternal repositioning
- E. Administer tocolytics
Cardinal movements of labor Explanation: ***Emergent cesarean delivery***
- The fetal heart tracing shows **recurrent late decelerations** unresponsive to **intrauterine resuscitation** (repositioning, O2, amnioinfusion), indicating fetal distress and uteroplacental insufficiency.
- Given the fetal distress and persistent late decelerations despite interventions, **expedited delivery** via cesarean section is indicated to prevent further fetal compromise.
*Monitor without intervention*
- This approach is inappropriate as the fetal heart tracing indicates **fetal distress** with recurrent **late decelerations** that have not resolved with initial interventions.
- Continued monitoring without action would place the fetus at risk for **hypoxia** and acidosis.
*Begin active pushing*
- The cervix is 7-cm dilated, meaning the patient is still in the **active phase of labor** and has not reached **complete cervical dilation** (10 cm) necessary for effective pushing.
- Pushing at this stage is unlikely to resolve the fetal distress and can potentially worsen **fetal acidosis** and maternal exhaustion.
*Retry maternal repositioning*
- The patient has already been repositioned and received other intrauterine resuscitation measures (O2 therapy, amnioinfusion) without improvement in the fetal heart tracing.
- Repeated repositioning alone is unlikely to resolve the underlying cause of the **late decelerations** in this context.
*Administer tocolytics*
- Tocolytics are used to **reduce uterine contractions** and manage conditions like **uterine tachysystole** or arrested labor, which are not explicitly present as the primary problem here (less than 5 contractions in 10 minutes).
- While they can temporarily improve uterine blood flow, they do not address the persistent **fetal distress** indicated by the recurrent late decelerations unresponsive to other interventions.
Cardinal movements of labor US Medical PG Question 3: A 4-month-old boy is brought to the physician for a well-child examination. He was born at 39 weeks gestation via spontaneous vaginal delivery and is exclusively breastfed. He weighed 3,400 g (7 lb 8 oz) at birth. At the physician's office, he appears well. His pulse is 146/min, the respirations are 39/min, and the blood pressure is 78/44 mm Hg. He weighs 7.5 kg (16 lb 9 oz) and measures 65 cm (25.6 in) in length. The remainder of the physical examination is normal. Which of the following developmental milestones has this patient most likely met?
- A. Sits with support of pelvis
- B. Grasps small objects between thumb and finger
- C. Transfers objects from hand to hand
- D. Intentionally rolls over (Correct Answer)
- E. Bounces actively when held in standing position
Cardinal movements of labor Explanation: ***Intentionally rolls over***
- Rolling over is a common developmental milestone achieved between **4 to 6 months** of age.
- At 4 months, an infant typically has sufficient **head control** and **trunk strength** to intentionally roll from tummy to back or back to tummy.
*Sits with support of pelvis*
- Sitting with **pelvic support** (tripod sitting) is generally achieved around **6 to 7 months** of age.
- A 4-month-old typically lacks the necessary **trunk stability** and strength for this milestone.
*Grasps small objects between thumb and finger*
- This describes a **pincer grasp**, which is a fine motor skill usually developed around **9-12 months** of age.
- At 4 months, infants primarily use a **palmar grasp** (raking motion) to pick up objects.
*Transfers objects from hand to hand*
- Transferring objects from hand to hand is a fine motor milestone typically achieved between **5 and 7 months** of age.
- A 4-month-old is beginning to reach for objects but usually has difficulty with **smooth transfers** between hands.
*Bounces actively when held in standing position*
- Active bouncing when held in a standing position is typically seen around **6 months** when infants start putting more weight on their legs.
- At 4 months, while an infant might bear some weight, **active bouncing** is usually more rudimentary or absent.
Cardinal movements of labor US Medical PG Question 4: Three hours after the onset of labor, a 39-year-old woman, gravida 2, para 1, at 40 weeks' gestation has sudden worsening of abdominal pain and vaginal bleeding. 18 months ago her first child was delivered by a lower segment transverse cesarean section because of cephalopelvic disproportion. Her temperature is 37.5°C (99.5°F), pulse is 120/min, respirations are 20/min, and blood pressure is 90/50 mm Hg. Examination shows abdominal tenderness and the absence of uterine contractions. The cervix is 100% effaced and 10 cm dilated; the vertex is at -3 station. An hour before, the vertex was at 0 station. Cardiotocography shows fetal bradycardia, late decelerations, and decreased amplitude of uterine contractions. Which of the following is the most specific feature of this patient's condition?
- A. Loss of fetal station (Correct Answer)
- B. Fetal distress
- C. Abdominal tenderness
- D. Absent uterine contractions
- E. Hemodynamic instability
Cardinal movements of labor Explanation: ***Loss of fetal station***
- The sudden **retraction of the presenting part** (vertex moving from 0 to -3 station) after a period of labor progression is a classical and highly specific sign of **uterine rupture**.
- This occurs because the uterus tears, allowing the fetus to partially or wholly slip out of the birth canal into the abdominal cavity.
*Fetal distress*
- While fetal bradycardia and late decelerations indicate **fetal distress**, this is a common finding in many obstetric emergencies, including placental abruption and cord prolapse, and is not specific to uterine rupture.
- Fetal distress reflects the immediate impact on the fetus but doesn't pinpoint the exact maternal pathology.
*Abdominal tenderness*
- **Abdominal tenderness** is a general symptom that can be present in various conditions such as placental abruption, chorioamnionitis, or even normal labor with strong contractions, making it non-specific for uterine rupture.
- The type of tenderness and its severity can vary, but by itself, it does not confirm a uterine rupture.
*Absent uterine contractions*
- The cessation of uterine contractions is a significant finding in uterine rupture, as the uterus can no longer effectively contract to expel the fetus.
- However, contractions can also decrease or become absent in cases of maternal exhaustion, failed induction, or excessive analgesia, thus not being entirely specific to rupture.
*Hemodynamic instability*
- The patient's **hypotension** (90/50 mm Hg) and **tachycardia** (120/min) indicate significant blood loss and **hypovolemic shock**, which commonly occur with uterine rupture.
- However, hemodynamic instability can also be seen in other severe obstetric hemorrhages like placental abruption or postpartum hemorrhage from other causes, making it a sensitive but non-specific indicator.
Cardinal movements of labor 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
Cardinal movements of labor 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.
Cardinal movements of labor US Medical PG Question 6: A 68-year-old woman comes to the physician for the evaluation of loss of urine for the last year. The patient states that she loses control over her bladder when walking or standing up. She reports frequent, small-volume urine losses with no urge to urinate prior to the leakage. She tried to strengthen her pelvic muscles with supervised Kegel exercises and using a continence pessary but her symptoms did not improve. The patient is sexually active with her husband. She has type 2 diabetes mellitus controlled with metformin. She does not smoke or drink alcohol. Vital signs are within normal limits. Her hemoglobin A1c is 6.3% and fingerstick blood glucose concentration is 110 mg/dL. Which of the following is the most appropriate next step in the management of this patient?
- A. Tighter glycemic control
- B. Urethral sling (Correct Answer)
- C. Topical vaginal estrogen
- D. Biofeedback
- E. Urethropexy
Cardinal movements of labor Explanation: ***Urethral sling***
- The patient exhibits symptoms consistent with **stress urinary incontinence**, characterized by urine leakage with increased intra-abdominal pressure (e.g., walking, standing), especially since conservative measures have failed.
- A **urethral sling** is a highly effective surgical treatment for stress urinary incontinence, providing support to the urethra and bladder neck.
*Tighter glycemic control*
- While uncontrolled diabetes can contribute to **polyuria** and **diabetic neuropathy** affecting bladder function, this patient's diabetes is well-controlled (HbA1c 6.3%).
- Tighter glycemic control is unlikely to resolve symptoms of stress urinary incontinence when the primary issue is anatomical support.
*Topical vaginal estrogen*
- **Topical vaginal estrogen** is effective for genitourinary syndrome of menopause, which can cause **vaginal atrophy** and **urge incontinence** symptoms.
- It is not the primary treatment for stress urinary incontinence, especially after the failure of conservative measures.
*Biofeedback*
- **Biofeedback** is often used in conjunction with **pelvic floor muscle training** (Kegel exercises) to improve patient awareness and control of these muscles.
- The patient has already tried supervised Kegel exercises without improvement, suggesting that biofeedback alone is unlikely to be sufficient.
*Urethropexy*
- **Urethropexy** is a surgical procedure that repositions and supports the urethra, similar in principle to a urethral sling.
- While it is a surgical option for stress incontinence, **urethral slings** (midurethral slings) are generally preferred due to their high efficacy and minimally invasive nature compared to traditional urethropexy procedures.
Cardinal movements of labor US Medical PG Question 7: A 35-year-old woman, gravida 4, para 3, at 34 weeks' gestation comes to the physician for a prenatal visit. She feels well. She does not note any contractions or fluid from her vagina. Her third child was delivered spontaneously at 35 weeks' gestation; pregnancy and delivery of her other two children were uncomplicated. Vital signs are normal. The abdomen is nontender and no contractions are felt. Pelvic examination shows a uterus consistent in size with a 34-weeks' gestation. Ultrasonography shows the fetus in a breech presentation. The fetal heart rate is 148/min. Which of the following is the most appropriate next step in management?
- A. Internal cephalic version
- B. Intravenous penicillin
- C. Cesarean section
- D. Observation (Correct Answer)
- E. External cephalic version
Cardinal movements of labor Explanation: ***Observation***
- At 34 weeks' gestation, **spontaneous version** from **breech to cephalic presentation** can still occur, especially in multiparous women.
- Waiting until 37 weeks allows time for the fetus to turn naturally before considering interventions.
*Internal cephalic version*
- This procedure involves a physician inserting a hand into the uterus to manually turn the fetus from inside.
- It is typically performed during **labor** to correct a **malpresentation** once the cervix is dilated sufficiently and is not appropriate for an antepartum breech presentation.
*Intravenous penicillin*
- **Penicillin** is administered to prevent **Group B Streptococcus (GBS) transmission** to the neonate, usually during labor for GBS-positive mothers.
- There is no indication for **GBS prophylaxis** in this case, and GBS status is not provided.
*Cesarean section*
- While breech presentation often necessitates a **cesarean section**, it is generally planned for 39 weeks' gestation or when labor begins if other interventions fail.
- It is premature to schedule a **C-section** at 34 weeks, as the fetus might still undergo spontaneous version.
*External cephalic version*
- This procedure involves manually manipulating the fetus through the maternal abdomen to turn it from breech to cephalic.
- It is usually attempted at **37 weeks' gestation** to maximize success rates and minimize risks, as earlier attempts have lower success and higher re-version rates.
Cardinal movements of labor US Medical PG Question 8: A 27-year old primigravid woman at 37 weeks' gestation comes to the emergency department because of frequent contractions for 4 hours. Her pregnancy has been complicated by hyperemesis gravidarum which subsided in the second trimester. The contractions occur every 10–15 minutes and have been increasing in intensity and duration since onset. Her temperature is 37.1°C (98.8°F), pulse is 110/min, and blood pressure is 140/85 mm Hg. Uterine contractions are felt on palpation. Pelvic examination shows clear fluid in the vagina. The cervix is 50% effaced and 3 cm dilated. After 4 hours the cervix is 80% effaced and 6 cm dilated. Pelvic examination is inconclusive for the position of the fetal head. The fetal heart rate is reassuring. Which of the following is the most appropriate next step?
- A. Administer oxytocin
- B. Perform external cephalic version
- C. Administer misoprostol
- D. Perform Mauriceau-Smellie-Veit maneuver
- E. Perform ultrasonography (Correct Answer)
Cardinal movements of labor Explanation: ***Perform ultrasonography***
- The examination notes that the **pelvic examination is inconclusive for the position of the fetal head**, which is a critical piece of information needed for safe delivery. **Ultrasonography** is the most appropriate next step to ascertain the fetal presentation and position, especially given the dilated cervix.
- Determining fetal position is essential to rule out **malpresentation**, such as **breech** or **transverse lie**, which would significantly impact the delivery plan and potentially necessitate a **cesarean section**.
*Administer oxytocin*
- **Oxytocin** is used to induce or augment labor when contractions are insufficient or labor is prolonged, but in this case, the cervix is progressing well (from 3 cm to 6 cm dilation in 4 hours), indicating **active labor**.
- Without knowing the fetal presentation, administering oxytocin could exacerbate issues if there's a **malpresentation**, potentially leading to **fetal distress** or **uterine rupture**.
*Perform external cephalic version*
- **External cephalic version (ECV)** is performed to change a **breech presentation** to a **cephalic presentation** by external manipulation, typically done before labor onset or early in labor at term.
- This patient is already in **active labor** with significant cervical dilation (6 cm), making ECV less likely to be successful and potentially increasing risks like **placental abruption** or **umbilical cord compression**.
*Administer misoprostol*
- **Misoprostol** is a prostaglandin analog used for **cervical ripening** and **labor induction** in cases where the cervix is unfavorable or labor needs to be initiated.
- This patient is already in **active labor** with progressive cervical dilation, making misoprostol unnecessary and potentially harmful due to the risk of **uterine hyperstimulation**.
*Perform Mauriceau-Smellie-Veit maneuver*
- The **Mauriceau-Smellie-Veit maneuver** is a technique used during a **vaginal breech delivery** to deliver the fetal head, specifically in cases of **frank or complete breech** that are being delivered vaginally.
- This maneuver is only performed *during* delivery of a breech baby, and the fetal position is currently unknown. It would be premature and inappropriate to consider this maneuver without first confirming a **breech presentation** and the decision for vaginal delivery.
Cardinal movements of labor US Medical PG Question 9: A 30-year-old G3P0 woman who is 28 weeks pregnant presents for a prenatal care visit. She reports occasionally feeling her baby move but has not kept count over the past couple weeks. She denies any bleeding, loss of fluid, or contractions. Her previous pregnancies resulted in spontaneous abortions at 12 and 14 weeks. She works as a business executive, has been in excellent health, and has had no surgeries. She states that she hired a nutritionist and pregnancy coach to ensure good prospects for this pregnancy. On physical exam, fetal heart tones are not detected. Abdominal ultrasound shows a 24-week fetal demise. The patient requests an autopsy on the fetus and wishes for the fetus to pass "as naturally as possible." What is the best next step in management?
- A. Induction of labor now (Correct Answer)
- B. Dilation and evacuation
- C. Dilation and curettage
- D. Induction of labor at term
- E. Caesarean delivery
Cardinal movements of labor Explanation: ***Induction of labor now***
- With a confirmed **fetal demise at 28 weeks**, induction of labor is the most appropriate and respectful approach, allowing the patient's request to pass "as naturally as possible" to be honored and initiating the grieving process.
- Delaying labor induction can lead to increased risks of **coagulopathy** (disseminated intravascular coagulation) due to retained fetal tissue, and also prolonged emotional distress for the patient.
*Dilation and evacuation*
- While D&E is a common method for second-trimester termination or fetal demise, it is typically performed earlier in pregnancy (up to 24 weeks) and may not align with the patient's wish for the fetus to pass "as naturally as possible" for a 28-week demise.
- Given the patient's strong emotional investment in this pregnancy and desire for an autopsy, a D&E might be perceived as less respectful or less natural than labor induction.
*Dilation and curettage*
- **Dilation and curettage (D&C)** is primarily used for first-trimester miscarriages or early second-trimester procedures and is not suitable for a 28-week fetal demise due to the size of the fetus.
- Performing a D&C at this gestational age would be technically difficult and carry a higher risk of complications, including uterine perforation.
*Induction of labor at term*
- Waiting until term for a known fetal demise at 28 weeks is medically inappropriate and dangerous due to the significant risk of **disseminated intravascular coagulation (DIC)** developing from retained fetal tissue.
- Prolonged retention of a deceased fetus also significantly increases the emotional and psychological burden on the patient.
*Caesarean delivery*
- **Caesarean delivery** is generally reserved for live births where there is a medical indication for surgical delivery or in cases of an intact dilation and extraction procedure which is not typically first line for fetal demise at this gestation.
- Performing a C-section for a fetal demise offers no benefit to the fetus and carries unnecessary surgical risks for the mother, including infection, hemorrhage, and complications in future pregnancies.
Cardinal movements of labor US Medical PG Question 10: A 28-year-old woman, gravida 2, para 1, at 40 weeks of gestation is admitted to the hospital in active labor. The patient has attended many prenatal appointments and followed her physician's advice about screening for diseases, laboratory testing, diet, and exercise. Her pregnancy has been uncomplicated. She has no history of a serious illness. Her first child was delivered via normal vaginal delivery. Her vital signs are within normal limits. Cervical examination shows 80% effacement, 5 cm dilation and softening without visible fetal parts or prolapsed umbilical cord. A cardiotocograph is shown. Which of the following options is the most appropriate initial step in management?
- A. Operative vaginal delivery
- B. Repositioning (Correct Answer)
- C. Administration of beta-agonists
- D. Amnioinfusion
- E. Urgent Cesarean delivery
Cardinal movements of labor Explanation: ***Repositioning***
- The cardiotocograph likely shows **variable decelerations**, which are often caused by **umbilical cord compression**.
- **Maternal repositioning** (e.g., to the left lateral side) can relieve cord compression and improve fetal oxygenation, making it the most appropriate initial, non-invasive step.
*Operative vaginal delivery*
- This is a more invasive procedure and should not be the initial step for a potentially correctable issue like cord compression, especially with a cervix that is only 5 cm dilated and no visible fetal parts.
- It's typically considered for **prolonged second stage of labor** or **fetal distress** with a fully dilated cervix when less invasive measures have failed.
*Administration of beta-agonists*
- Beta-agonists (like terbutaline) can relax the uterus, potentially reducing uterine contractions and improving uterine blood flow, which might be considered in cases of **uterine hyperstimulation** or persistent decelerations, but generally not as the first line for variable decelerations.
- This intervention is more appropriate when there is evidence of excessive uterine activity rather than simply cord compression.
*Amnioinfusion*
- **Amnioinfusion** involves introducing saline into the uterine cavity and is considered for **recurrent severe variable decelerations** due to **oligohydramnios** or cord compression that doesn't respond to repositioning.
- It is a more invasive procedure than repositioning and should not be the initial step.
*Urgent Cesarean delivery*
- **Cesarean delivery** is reserved for situations where there is persistent fetal distress despite conservative management or when there is an obstetric indication that precludes vaginal delivery.
- It is a major surgical procedure and premature for a situation that might be resolved with a simple maternal position change.
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