Tutorial 11 August 2014

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11 August 2014

20	EMQ. Labour ward 2.
67	Critically evaluate the uses of the levonorgestrel intra-uterine system, LNG-IUS.
68	A woman attends the antenatal clinic at 36 weeks. She had read an article in a woman’s magazine about the merits of umbilical cord blood banking and would like to have this done. 1. Justify the history you will take.                       4 marks 2. Justify the investigations you will arrange.         2 marks 3. Justify your management.                               14 marks
69	You have been asked to write a protocol for the diagnosis and management of umbilical cord prolapse. 1. Justify the steps you will take.                                        6  marks 2. Justify the key advice you will include in the protocol.   14 marks
70	In relation to coeliac disease and pregnancy. 1. What is coeliac disease and how common is it?                                         4 marks 2. What are the clinical features in the non-pregnant?                                     4 marks. 3. How is coeliac disease diagnosed?                                                            2 marks. 4. What are the implications of coeliac disease for the pregnant woman?        6 marks. 5. Evaluate the management options in relation to pregnancy.                         4 marks

EMQ Labour ward 2.

Abbreviations.

CTG.      cardio-tocograph.

FBS.       fetal scalp-blood sample.

FHR.       fetal heart rate.

Option List.

start protocol for severe hypertension

allow labour to progress and re-assess in 30 minutes

increase syntocinon infusion rate.

increase syntocinon infusion rate and encourage effective pushing.

give misoprostol.

stop syntocinon, give O₂,perform left-lateral tilt and re-assess in 30 minutes

start intra-uterine pressure monitoring

start STAN monitoring

perform fetal blood sampling

arrange category 1 Caesarean section

arrange category 2 Caesarean section

arrange category 3 Caesarean section

arrange category 4 Caesarean section

perform ventouse delivery

perform forceps delivery

perform breech extraction

perform external cephalic version

perform internal podalic version

none of the above

EMQ 1.

A 30-year-old primigravida has labour induced at 39 weeks because of pre-eclampsia.

Her blood pressure had been moderately raised since 36 weeks and a 24-hour urine collection showed 4 gm. protein. (Do you know the cut-offs for mild/moderate/sever hypertension? Answer below.)

ARM was done when the cervix was 4 cm. dilated and an oxytocin infusion was started 2 hours later as the contractions were infrequent.

She reached the 2^nd. stage 6 hours after the ARM. You are called to see her 30 minutes later as the CTG shows variable decelerations and loss of baseline variability.

The fetal head is not palpable abdominally and vaginal examination shows a cephalic presentation 1 cm. below the spines and the position DOA.

What will be your management?

EMQ2.

A 40-year-old grande-multip with BMI 35 goes into labour at 38 weeks. She decides to have an epidural as she has not had one before and would like the experience. An effective block has been sited. She reaches the second stage 4 hours after admission. The epidural is not topped up and active pushing starts 30 minutes later. After 1 hour a FHR deceleration to 60 b.p.m. with slow recovery and loss of variability is noted. On abdominal examination, the head is < 1/5 palpable. Vaginal examination shows the head to be just above the ischial spines with moderate caput and moulding. What will be your management?

EMQ3.

A 29-yr-old woman with IDDM is admitted at 36 weeks’ gestation with ketoacidosis and a blood sugar of 15 mmol/l. A CTG is done and the FHR is 180 b.p.m. with loss of variability and variable decelerations. What will be your management?

EMQ4.

A 30-year-old woman with a previous normal delivery is admitted in labour for a planned vaginal breech delivery. On admission the cervix is 6 cm. dilated and a flexed breech presents 2 cm. below the spines. Two hours later the fetal heart rate rises to 160 b.p.m. with loss of variability and variable decelerations. Fresh meconium is passed. What will be your management.

EMQ5.

A 35-year-old woman with a previous normal delivery is admitted in labour for a planned vaginal delivery. On admission the cervix is 6 cm. dilated and a cephalic presentation is confirmed with the presenting part 2 cm. below the spines. Two hours later the cervix is 9 cm. dilated and the presenting part is on the perineum. The fetal heart rate has risen to 150 b.p.m. with loss of variability and variable decelerations. Fresh meconium is passed. A FBS shows a pH of 7.3. What will be your management?

EMQ6.

A 35-year-old woman with a previous normal delivery is admitted in labour. On admission the cervix is 6 cm. dilated and a cephalic presentation is confirmed with the presenting part 2 cm. below the spines. Two hours later the cervix is fully dilated and the presenting part is on the perineum. The fetal heart rate has risen to 150 b.p.m. with loss of variability and variable decelerations. Fresh meconium is passed. A FBS shows a pH of 7.2. What will be your management?

EMQ 7.

A 20 year-old nulliparous woman is admitted in labour at 33+5 weeks’ gestation. She reaches the 2^nd. stage after 12 hours with the head in an OA position and 2 cm. below the spines. She becomes exhausted after 2 hours of active pushing. The FHR shows variable decelerations + loss of variability. A FBS shows a pH of 7.22. What will be your management?

EMQ8.

A 20 year-old nulliparous woman is admitted in labour at 39+5 weeks’ gestation. An epidural is sited at her request when her cervix is 4 cm. dilated but a dural tap occurs. She complains of headache. What will be your management?