Third stage of labor — MCQs

10 questions

A clinical diagnosis of abruptio placentae is suspected. Which of the following is the most appropriate next step in the management of this patient?

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 34-year-old G5P5 woman gave birth to a healthy infant 30 minutes ago by vacuum-assisted vaginal delivery and is now experiencing vaginal bleeding. The placenta was delivered spontaneously and was intact upon examination. The infant weighed 5.2 kg and had Apgar scores of 8 and 9. No perineal tear or intentional episiotomy occurred. The patient has type 1 diabetes. She had good glycemic control throughout her pregnancy. She took a prenatal vitamin daily. Blood pressure is 135/72 mmHg, pulse is 102/min, and respirations are 18/min. Upon physical examination, the uterine fundus is soft and palpated 4 cm above the umbilicus. There are 3-cm blood clots on the patient’s bed pad. Which of the following is the next best step in management for the patient’s bleeding?

A 29-year-old G1P0 female at 32 weeks gestation presents to the emergency department with vaginal bleeding. She has had minimal prenatal care to-date with only an initial visit with an obstetrician after a positive home pregnancy test. She describes minimal spotting that she noticed earlier today that has progressed to larger amounts of blood; she estimates 30 mL of blood loss. She denies any cramping, pain, or contractions, and she reports feeling continued movements of the baby. Ultrasound and fetal heart rate monitoring confirm the presence of a healthy fetus without any evidence of current or impending complications. The consulted obstetrician orders blood testing for Rh-status of both the mother as well as the father, who brought the patient to the hospital. Which of the following represents the best management strategy for this situation?

A 37-year-old woman, gravida 4, para 3, at 35 weeks' gestation is admitted to the hospital in active labor. Her three children were delivered by Cesarean section. One hour after vaginal delivery, the placenta is not delivered. Manual separation of the placenta leads to profuse vaginal bleeding. Her pulse is 122/min and blood pressure is 90/67 mm Hg. A firm, nontender uterine fundus is palpated at the level of the umbilicus. Hemoglobin is 8.3 g/dL and platelet count is 220,000/mm3. Activated partial thromboplastin time and prothrombin time are within normal limits. Which of the following is the most likely underlying mechanism of this patient's postpartum bleeding?

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 17-year-old teenager presents to the clinic with her parents complaining of headaches and loss of vision which began insidiously 3 months ago. She describes her headaches as throbbing, mostly on her forehead, and severe enough to affect her daily activities. She has not experienced menarche. Past medical history is noncontributory. She takes no medication. Both of her parents are alive and well. Today, her blood pressure is 110/70 mm Hg, the heart rate is 90/min, the respiratory rate is 17/min, and the temperature is 37.0°C (98.6°F). Breasts and pubic hair development are in Tanner stage I. Blood work is collected and an MRI is performed (the result is shown). Decreased production of which of the following hormones is the most likely explanation for the patient's signs and symptoms?

A 54-year-old male comes to the clinic to initiate care with a new physician. He has no complaints at this time. When taking his history, the patient says his medical history is notable for diabetes and hypertension both of which are well managed on his medications. His medications are metformin and lisinopril. A review of systems is negative. While taking the social history, the patient hesitates when asked about alcohol consumption. Further gentle questioning by the physician leads the patient to admit that he drinks 5-6 beers per night and up to 10-12 drinks per day over the weekend. He says that he has been drinking like this for “years.” He becomes emotional and says that his alcohol is negatively affecting his relationship with his wife and children; however, when asked about efforts to decrease his consumption, the patient says he has not tried in the past and doesn’t think he has “the strength to stop”. Which of the following stages of change most accurately describes this patient’s behavior?

A 30-year-old woman, gravida 2, para 1, at 38 weeks' gestation comes to the hospital for regular, painful contractions that have been increasing in frequency. Her pregnancy has been complicated by gestational diabetes treated with insulin. Pelvic examination shows the cervix is 50% effaced and 4 cm dilated; the vertex is at -1 station. Ultrasonography shows no abnormalities. A tocometer and Doppler fetal heart monitor are placed on the patient's abdomen. The fetal heart rate monitoring strip shows a baseline heart rate of 145/min with a variability of ≥ 15/min. Within a 20-minute recording, there are 7 uterine contractions, 4 accelerations, and 3 decelerations that have a nadir occurring within half a minute. The decelerations occur at differing intervals relative to the contractions. Which of the following is the most appropriate next step in the management of this patient?

Q10

A 25-year-old G1P0000 presents to her obstetrician’s office for a routine prenatal visit at 32 weeks gestation. At this visit, she feels well and has no complaints. Her pregnancy has been uncomplicated, aside from her Rh negative status, for which she received Rhogam at 28 weeks gestation. The patient has a past medical history of mild intermittent asthma and migraine headaches. She currently uses her albuterol inhaler once a week and takes a prenatal vitamin. Her temperature is 98.6°F (37.0°C), pulse is 70/min, blood pressure is 117/68 mmHg, and respirations are 13/min. Cardiopulmonary exam is unremarkable, and abdominal exam reveals a gravid uterus with fundal height at 30 centimeters. Bedside ultrasound reveals that the fetus is in transverse lie. The patient states that she prefers to have a vaginal delivery. Which of the following is the best next step in management?

Third stage of labor US Medical PG Practice Questions and MCQs

Question 1: A clinical diagnosis of abruptio placentae is suspected. Which of the following is the most appropriate next step in the management of this patient?

A. Vaginal delivery
B. Administration of intravenous oxytocin
C. Administration of intramuscular betamethasone
D. Administration of intravenous fluids (Correct Answer)
E. Administration of intravenous tranexamic acid

Explanation: ***Administration of intravenous fluids*** - In suspected **abruptio placentae**, significant **blood loss** can occur, leading to maternal **hypotension** and compromise. - **Intravenous fluids** are crucial for immediate **volume replacement** and maintaining **hemodynamic stability** in both the mother and fetus. *Vaginal delivery* - While delivery is often necessary, the **route of delivery** depends on the severity of the abruption, fetal status, and maternal stability; immediate vaginal delivery is not the universal first step before stabilization. - In cases of severe abruption or fetal distress, an **emergency C-section** might be more appropriate, but **maternal stabilization** with fluids is paramount first. *Administration of intravenous oxytocin* - **Oxytocin** is primarily used to **induce labor** or augment contractions, and to prevent or treat **postpartum hemorrhage**. - It is not indicated as an initial management step for **abruptio placentae**, as it would not address the acute blood loss or fetal compromise. *Administration of intramuscular betamethasone* - **Betamethasone** is administered to promote **fetal lung maturity** in cases of preterm delivery. - While it might be considered if the fetus is preterm and delivery can be delayed for 24-48 hours, **maternal stabilization** and management of acute abruption symptoms take precedence. *Administration of intravenous tranexamic acid* - **Tranexamic acid** is an **antifibrinolytic** agent used to reduce bleeding in various settings, including postpartum hemorrhage. - However, in acute **abruptio placentae**, the immediate concern is **volume resuscitation** rather than directly inhibiting fibrinolysis as the primary first step.

Question 2: 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)

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.

Question 3: A 34-year-old G5P5 woman gave birth to a healthy infant 30 minutes ago by vacuum-assisted vaginal delivery and is now experiencing vaginal bleeding. The placenta was delivered spontaneously and was intact upon examination. The infant weighed 5.2 kg and had Apgar scores of 8 and 9. No perineal tear or intentional episiotomy occurred. The patient has type 1 diabetes. She had good glycemic control throughout her pregnancy. She took a prenatal vitamin daily. Blood pressure is 135/72 mmHg, pulse is 102/min, and respirations are 18/min. Upon physical examination, the uterine fundus is soft and palpated 4 cm above the umbilicus. There are 3-cm blood clots on the patient’s bed pad. Which of the following is the next best step in management for the patient’s bleeding?

A. Administer misoprostol
B. Manually remove retained placental fragments
C. Perform uterine massage and administer oxytocin (Correct Answer)
D. Perform uterine artery embolization
E. Perform hysterectomy

Explanation: ***Perform uterine massage and administer oxytocin*** - The patient's presentation of a **soft, boggy uterus** palpated 4 cm above the umbilicus after delivery, along with significant vaginal bleeding and clots, is highly indicative of **uterine atony**. - **Uterine massage** and administration of **oxytocin** are the first-line interventions to stimulate uterine contractions and reduce bleeding by compressing placental site blood vessels. *Administer misoprostol* - **Misoprostol** is a prostaglandin analog that can be used for uterine atony when oxytocin is insufficient or contraindicated, but it is not the *first-line* treatment. - Its onset of action may be slower than immediate uterine massage and IV oxytocin, which are preferred for initial management of acute uterine atony. *Manually remove retained placental fragments* - The question states that the **placenta was delivered spontaneously and was intact upon examination**, which makes retained placental fragments less likely as the primary cause of bleeding. - While retained fragments can cause postpartum hemorrhage, the boggy uterus points more strongly to atony, and manual removal is indicated *after* confirming retained placental tissue. *Perform uterine artery embolization* - **Uterine artery embolization** is an interventional radiology procedure typically reserved for cases of postpartum hemorrhage that are refractory to conventional medical and surgical management. - It is an invasive procedure and not the appropriate *next best step* for initial management of suspected uterine atony. *Perform hysterectomy* - **Hysterectomy** is a last-resort, life-saving measure for intractable postpartum hemorrhage when all other medical and surgical options have failed. - It is a highly invasive and irreversible procedure, certainly not the *next best step* in a patient who has just begun to bleed.

Question 4: A 29-year-old G1P0 female at 32 weeks gestation presents to the emergency department with vaginal bleeding. She has had minimal prenatal care to-date with only an initial visit with an obstetrician after a positive home pregnancy test. She describes minimal spotting that she noticed earlier today that has progressed to larger amounts of blood; she estimates 30 mL of blood loss. She denies any cramping, pain, or contractions, and she reports feeling continued movements of the baby. Ultrasound and fetal heart rate monitoring confirm the presence of a healthy fetus without any evidence of current or impending complications. The consulted obstetrician orders blood testing for Rh-status of both the mother as well as the father, who brought the patient to the hospital. Which of the following represents the best management strategy for this situation?

A. After 28 weeks gestation, administration of RhoGAM will have no benefit
B. If mother is Rh-positive and father is Rh-negative then administer RhoGAM
C. If mother is Rh-negative and father is Rh-negative then administer RhoGAM
D. If mother is Rh-negative and father is Rh-positive, RhoGAM administration is not needed
E. If mother is Rh-negative and father is Rh-positive then administer RhoGAM (Correct Answer)

Explanation: ***If mother is Rh-negative and father is Rh-positive then administer RhoGAM*** - This combination creates a risk for **Rh incompatibility**, meaning the fetus could be Rh-positive and the mother's immune system could form antibodies against fetal red blood cells, which can harm the fetus in future pregnancies. - **RhoGAM (Rh immunoglobulin)** administration prevents the mother from forming these antibodies when there's a risk of maternal-fetal blood mixing, as indicated by vaginal bleeding. *After 28 weeks gestation, administration of RhoGAM will have no benefit* - This statement is incorrect; **RhoGAM is routinely administered around 28 weeks gestation** as prophylaxis in Rh-negative mothers, even without bleeding episodes, to prevent sensitization. - In cases of potential fetal-maternal hemorrhage, such as vaginal bleeding, RhoGAM is indicated regardless of gestational age beyond the first trimester. *If mother is Rh-positive and father is Rh-negative then administer RhoGAM* - This scenario does not pose a risk for **Rh incompatibility hemolytic disease of the newborn**, as the mother already possesses the Rh antigen. - RhoGAM is specifically given to Rh-negative mothers to prevent their immune system from reacting to an Rh-positive fetus. *If mother is Rh-negative and father is Rh-negative then administer RhoGAM* - In this case, both parents are **Rh-negative**, meaning the fetus will also be Rh-negative. - There is no risk of **Rh incompatibility** or sensitization, so RhoGAM administration is not indicated. *If mother is Rh-negative and father is Rh-positive, RhoGAM administration is not needed* - This statement is incorrect and represents a critical misunderstanding of **Rh incompatibility prophylaxis**. - This specific genetic combination creates the highest risk for **Rh sensitization** during pregnancy, especially with events like vaginal bleeding, making RhoGAM administration essential.

Question 5: A 37-year-old woman, gravida 4, para 3, at 35 weeks' gestation is admitted to the hospital in active labor. Her three children were delivered by Cesarean section. One hour after vaginal delivery, the placenta is not delivered. Manual separation of the placenta leads to profuse vaginal bleeding. Her pulse is 122/min and blood pressure is 90/67 mm Hg. A firm, nontender uterine fundus is palpated at the level of the umbilicus. Hemoglobin is 8.3 g/dL and platelet count is 220,000/mm3. Activated partial thromboplastin time and prothrombin time are within normal limits. Which of the following is the most likely underlying mechanism of this patient's postpartum bleeding?

A. Defective decidual layer of the placenta (Correct Answer)
B. Impaired uterine contractions
C. Rupture of the fetal vessels
D. Consumption of intravascular clotting factors
E. Rupture of the uterine wall

Explanation: **Defective decidual layer of the placenta** - The patient's history of three previous Cesarean sections significantly increases the risk of **placenta accreta**, where the **placenta abnormally invades the uterine wall** due to a defective decidual layer. - The inability to deliver the placenta an hour after vaginal delivery and subsequent profuse bleeding upon manual separation are classic signs of **placenta accreta spectrum**, as the placenta is morbidly adherent. *Impaired uterine contractions* - This would typically present as a **boggy, soft uterus** on palpation, rather than the "firm, nontender uterine fundus" described. - Uterine atony is the most common cause of postpartum hemorrhage, but it is ruled out by the firm fundus and lack of uterine relaxation. *Rupture of the fetal vessels* - This usually occurs *before* or *during* delivery, presenting as **fetal distress** or **vaginal bleeding originating from the fetus** (e.g., vasa previa), which is not the primary issue here after labor and delivery. - The profuse bleeding is *maternal* and occurs *after* delivery due to placental adherence, not fetal vessel rupture. *Consumption of intravascular clotting factors* - While severe hemorrhage can eventually lead to **disseminated intravascular coagulation (DIC)** and consumption of clotting factors, the patient's normal aPTT and PT indicate that coagulopathy is not the *initial* underlying mechanism of bleeding. - This would be a *secondary complication* rather than the primary cause of undelivered placenta and initial hemorrhage. *Rupture of the uterine wall* - Uterine rupture typically presents with **acute, severe abdominal pain**, **fetal distress** (if it occurs before delivery), and **loss of uterine tone or palpation of fetal parts outside the uterus**. - Although previous C-sections increase the risk, the firm uterine fundus and the specific problem with placental non-separation point away from uterine rupture as the primary cause of hemorrhage here.

Question 6: 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

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.

Question 7: A 17-year-old teenager presents to the clinic with her parents complaining of headaches and loss of vision which began insidiously 3 months ago. She describes her headaches as throbbing, mostly on her forehead, and severe enough to affect her daily activities. She has not experienced menarche. Past medical history is noncontributory. She takes no medication. Both of her parents are alive and well. Today, her blood pressure is 110/70 mm Hg, the heart rate is 90/min, the respiratory rate is 17/min, and the temperature is 37.0°C (98.6°F). Breasts and pubic hair development are in Tanner stage I. Blood work is collected and an MRI is performed (the result is shown). Decreased production of which of the following hormones is the most likely explanation for the patient's signs and symptoms?

A. Antidiuretic hormone
B. Adrenocorticotropic hormone
C. Prolactin
D. Gonadotropins (Correct Answer)
E. Thyroid-stimulating hormone

Explanation: **Gonadotropins** - The MRI image shows a **pituitary mass** (indicated by the red arrow) in a 17-year-old girl with **amenorrhea** (has not experienced menarche) and **Tanner stage I breast and pubic hair development**. - This clinical picture, coupled with the mass effect, suggests **hypogonadotropic hypogonadism** due to compression of the pituitary gland, leading to insufficient production of **gonadotropins** (LH and FSH), which are essential for pubertal development and menstrual cycles. *Antidiuretic hormone* - Deficiency of ADH primarily causes **diabetes insipidus**, characterized by **polyuria** and **polydipsia**, which are not mentioned in this patient's symptoms. - While a pituitary mass can affect ADH production, the primary clinical presentation here is related to pubertal delay. *Adrenocorticotropic hormone* - ACTH deficiency would lead to **adrenal insufficiency**, presenting with symptoms such as **fatigue, weakness, weight loss, hypotension, and electrolyte disturbances**. These symptoms are not described in the patient. - Her vital signs (e.g., blood pressure) are within normal limits. *Prolactin* - Elevated prolactin (hyperprolactinemia) can cause **amenorrhea** and **galactorrhea** (if the patient has reached puberty), but it is usually due to a **prolactinoma** or stalk compression. - While a pituitary mass could potentially affect prolactin, the lack of pubertal development (Tanner stage I) points more directly to a general gonadotropin deficiency rather than isolated prolactinopathy. *Thyroid-stimulating hormone* - TSH deficiency would result in **hypothyroidism**, characterized by symptoms like **fatigue, weight gain, cold intolerance, and bradycardia**. - The patient's vital signs are normal, and symptoms of hypothyroidism are not described.

Question 8: A 54-year-old male comes to the clinic to initiate care with a new physician. He has no complaints at this time. When taking his history, the patient says his medical history is notable for diabetes and hypertension both of which are well managed on his medications. His medications are metformin and lisinopril. A review of systems is negative. While taking the social history, the patient hesitates when asked about alcohol consumption. Further gentle questioning by the physician leads the patient to admit that he drinks 5-6 beers per night and up to 10-12 drinks per day over the weekend. He says that he has been drinking like this for “years.” He becomes emotional and says that his alcohol is negatively affecting his relationship with his wife and children; however, when asked about efforts to decrease his consumption, the patient says he has not tried in the past and doesn’t think he has “the strength to stop”. Which of the following stages of change most accurately describes this patient’s behavior?

A. Contemplation (Correct Answer)
B. Maintenance
C. Preparation
D. Precontemplation
E. Action

Explanation: ***Contemplation*** - The patient acknowledges his problem behavior (alcohol consumption) and its negative impact on his family, indicating an awareness of the issue. - He expresses a desire for change ("strength to stop") but has not yet committed to taking action or made concrete plans, which is characteristic of the contemplation stage. *Maintenance* - This stage involves actively sustaining new behaviors and preventing relapse over a long period (typically 6 months or more). - The patient admits he has not tried to decrease his consumption, ruling out any active behavior change or sustainability. *Preparation* - In this stage, individuals are ready to take action within the next month and have often developed a plan for change. - The patient explicitly states he hasn't tried to reduce his alcohol intake and doesn't feel he has "the strength to stop," indicating a lack of readiness for immediate action or planning. *Precontemplation* - Individuals in this stage are unaware or unwilling to acknowledge that a problem exists and have no intention of changing their behavior in the foreseeable future. - The patient clearly recognizes his drinking as a problem affecting his family, which distinguishes him from someone in precontemplation. *Action* - This stage involves actively modifying one's behavior, environment, or experiences to overcome problems. - The patient has not made any efforts to decrease his alcohol consumption, meaning he has not yet entered the action phase.

Question 9: A 30-year-old woman, gravida 2, para 1, at 38 weeks' gestation comes to the hospital for regular, painful contractions that have been increasing in frequency. Her pregnancy has been complicated by gestational diabetes treated with insulin. Pelvic examination shows the cervix is 50% effaced and 4 cm dilated; the vertex is at -1 station. Ultrasonography shows no abnormalities. A tocometer and Doppler fetal heart monitor are placed on the patient's abdomen. The fetal heart rate monitoring strip shows a baseline heart rate of 145/min with a variability of ≥ 15/min. Within a 20-minute recording, there are 7 uterine contractions, 4 accelerations, and 3 decelerations that have a nadir occurring within half a minute. The decelerations occur at differing intervals relative to the contractions. Which of the following is the most appropriate next step in the management of this patient?

A. Vibroacoustic stimulation
B. Routine monitoring (Correct Answer)
C. Administer tocolytics
D. Emergent cesarean delivery
E. Placement of fetal scalp electrode

Explanation: ***Routine monitoring*** - The presented FHR tracing exhibits a **normal baseline rate** (145/min), **moderate variability** (≥15/min), and the presence of **accelerations**, indicating a reassuring fetal status. - The described decelerations are **variable decelerations** due to their sudden onset, nadir within 30 seconds, and variable relationship to contractions, which are generally benign unless prolonged, deep, or repetitive. Given the otherwise reassuring status, continued routine monitoring is appropriate. *Vibroacoustic stimulation* - This intervention is used to elicit **fetal accelerations** or movement during non-stress tests (NSTs) when the fetus is quiet or shows a non-reactive pattern. - In this case, the fetus is already showing **accelerations** and moderate variability, so stimulation is not needed to assess fetal well-being. *Administer tocolytics* - **Tocolytics** are used to stop or slow down labor, typically in cases of preterm labor or uterine tachysystole causing fetal distress. - This patient is at **38 weeks' gestation** and in active labor, and there are no signs of fetal distress warranting the cessation of contractions. *Emergent cesarean delivery* - **Emergent cesarean delivery** is indicated for acute fetal distress, such as prolonged decelerations, significant bradycardia, or absent variability in conjunction with other concerning FHR patterns. - The FHR tracing described is largely reassuring with moderate variability and accelerations, and the variable decelerations are not indicative of immediate threat, making emergent delivery unnecessary. *Placement of fetal scalp electrode* - A **fetal scalp electrode** provides a more accurate and continuous measure of the FHR, often used when external monitoring is difficult or when there are concerns about the reliability of the tracing. - While it can be useful in some situations, the current tracing is **interpretable as reassuring**, making invasive monitoring currently unnecessary.

Question 10: A 25-year-old G1P0000 presents to her obstetrician’s office for a routine prenatal visit at 32 weeks gestation. At this visit, she feels well and has no complaints. Her pregnancy has been uncomplicated, aside from her Rh negative status, for which she received Rhogam at 28 weeks gestation. The patient has a past medical history of mild intermittent asthma and migraine headaches. She currently uses her albuterol inhaler once a week and takes a prenatal vitamin. Her temperature is 98.6°F (37.0°C), pulse is 70/min, blood pressure is 117/68 mmHg, and respirations are 13/min. Cardiopulmonary exam is unremarkable, and abdominal exam reveals a gravid uterus with fundal height at 30 centimeters. Bedside ultrasound reveals that the fetus is in transverse lie. The patient states that she prefers to have a vaginal delivery. Which of the following is the best next step in management?

A. Expectant management (Correct Answer)
B. Caesarean section at 38 weeks
C. Weekly ultrasound
D. Immediate external cephalic version
E. External cephalic version

Explanation: ***Expectant management*** - Many fetuses in **transverse lie** at **32 weeks gestation** will spontaneously convert to a **cephalic presentation** by term. - Interventions like external cephalic version are generally postponed until closer to term (e.g., 36-37 weeks) to allow for spontaneous version and optimize success rates. *Caesarean section at 38 weeks* - This is a definitive intervention for an uncorrected transverse lie, but it is **premature** considering the possibility of spontaneous version. - A C-section should only be scheduled if the transverse lie persists closer to term and external cephalic version is unsuccessful or contraindicated. *Weekly ultrasound* - While monitoring fetal position is important, **weekly ultrasounds** are not typically necessary at this stage for an uncomplicated transverse lie. - Less frequent monitoring is usually sufficient, as spontaneous version is common. *Immediate external cephalic version* - Performing an **external cephalic version (ECV)** at **32 weeks is generally discouraged** because of the high likelihood of spontaneous version and a lower success rate compared to performing it closer to term. - ECV carries risks, and delaying it minimizes interventions when they may not be needed. *External cephalic version* - While ECV is a viable option for **transverse lie**, it is typically considered around **36-37 weeks gestation**, not at 32 weeks. - The rationale for delaying is to maximize the chances of **spontaneous resolution** and improve the success rate of the procedure when performed.

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