A 32-year-old G1P0 woman comes to your office for her first prenatal care visit. She has
recently read an article about the rising Cesarean section rate
... [Show More] in the United States and asks you
about the rate in your hospital. What do you explain as the major cause of higher Cesarean
delivery rates?
A. The rate of breech presentations has increased
B. Less women are having vaginal births after Cesarean
C. Obstetricians' reluctance to perform forceps delivery
D. Increased rate of fetal macrosomia due to uncontrolled gestational diabetes
E. Rate of twins has increased ✔✔B. The rate of vaginal birth after Cesarean (VBAC) has
decreased in recent years due to studies that showed an increased risk of complications,
especially uterine rupture. This is one factor that has led to the increased Cesarean section rate.
In addition, although the rate of breech presentation is stable, there are significantly fewer
obstetricians who are willing to perform vaginal breech deliveries. Many obstetricians do not
perform instrumental vaginal deliveries, such as forceps and vacuum extractions, furthercontributing to the rising rate. Gestational diabetes is a well-known pregnancy complication with
clear clinical guidelines.
A 23-year-old G1P0 woman at 40 weeks gestation presents to labor and delivery with
contractions. At 10:00 am, her cervical exam is 2 centimeters dilated, 70% effaced and the vertex
at 0 station. Clinical pelvimetry reveals an adequate pelvis and membranes are intact. The fetus
is in a cephalic presentation and EFW is 3500 gms. Contractions are occurring every 3-4
minutes, based on the external monitor. Her labor slowly progresses and, at 1:00 pm, the patient
has spontaneous rupture of membranes. Fetal surveillance remains reassuring. Her cervical exam
is 5 centimeters dilated, 100% effaced, and 0 station. At 4:00 pm, the patient's cervical exam is
unchanged. Contractions are occurring every 5-6 minutes. Which of the following is the most
appropriate next step in the management of this patient?
A. Perform a biophysical profile
B. Have the patient ambulate
C. Consent the patient for a Cesarean section secondary to ✔✔E.
A 34-year-old G2P1 woman at 40 weeks gestation, with a history of one prior vaginal delivery,
strongly desires an induction of labor, as she is unable to sleep secondary to severe back pain.
Her cervical exam is closed, 20% effaced and -2 station. The cervix is firm and posterior. Which
of the following is the most appropriate next step in the management of this patient?A. Wait until 42 weeks for induction
B. Administer cytotec
C. Insert a foley bulb in the cervix
D. Perform artificial rupture of membranes
E. Perform a Cesarean delivery ✔✔B. The patient is multiparous at term and waiting until she
reaches 42 weeks may increase the risk of perinatal mortality. Since she is uncomfortable with
back pain, it is reasonable to induce labor. Her cervix is unfavorable; therefore, cytotec
administration is appropriate prior to pitocin induction. A foley bulb or artificial rupture of
membranes cannot be achieved in a patient with a closed cervix. At this time, there are no
indications to perform a Cesarean delivery in this patient.
A 22-year-old G1P0 woman at 39-weeks gestation presents in active labor. Her pregnancy is
complicated by diet controlled gestational diabetes. She has a history of uterine fibroids. On
examination, she is found to be 4 cm dilated in breech presentation. An ultrasound confirms the
breech presentation, amniotic fluid index is 5, and the estimated fetal weight is 3900 g. Which of
the following is the most likely cause of the breech presentation in this patient?
A. Gestational diabetes
B. Uterine fibroids
C. Oligohydramnios
D. MacrosomiaE. Gravidity ✔✔B. Prematurity, multiple gestation, genetic disorders, polyhydramnios,
hydrocephaly, anencephaly, placenta previa, uterine anomalies and uterine fibroids are all
associated with breech presentation.
A 20-year-old G1 woman at 40 weeks gestation presents to labor and delivery complaining of
painful contractions every 3-4 minutes since midnight. Her examination on admission was 2
centimeters dilated, 90% effaced and 0 station. Three hours later, her exam is unchanged. The
patient is still having contractions every 3-4 minutes. She is discouraged about her lack of
progress. Which of the following is the most appropriate next step in the management of this
patient?
A. Laminaria placement
B. Artificial rupture of membranes
C. Counseling about latent phase of labor and rest
D. Manual cervical dilation
E. Cesarean section for arrest of labor ✔✔C. The patient is in the latent phase of labor and has
not yet reached the active phase (more than 4 cm). A prolonged latent phase is defined as >20
hours for nulliparas and >14 hours for multiparas, and may be treated with rest or augmentation
of labor. Artificial rupture of membranes is not recommended in the latent phase as it places the
patient at increased risk of infection. Cervical dilation or laminaria placement are not indicated.A 29-year-old G1P0 woman at 28 weeks gestation who is the wife of basketball player is
diagnosed with gestational diabetes. Her mother had a delivery complicated by shoulder dystocia
and she is concerned about her own risk. Which of the following is her biggest risk factor for
shoulder dystocia?
A. Family history
B. Tall husband
C. Age
D. Gestational diabetes
E. Parity ✔✔D. Fetal macrosomia, maternal obesity, diabetes mellitus, postterm pregnancy, a
prior delivery complicated by a shoulder dystocia, and a prolonged second stage of labor are all
associated with an increased incidence of shoulder dystocia. Although a family history can be
indicative of large babies which might place her at additional risk, her gestational diabetes
represents her largest risk factor.
A 30-year-old G2P1 woman at 38 weeks gestation presents to labor and delivery with
contractions every 2-3 minutes. Her membranes are intact. Her cervical examination is 5
centimeters dilated, 100% effaced, and -1 station. The fetal heart rate tracing is category I. Two
hours later, she progresses to 7 cm and 0 station and receives an epidural for pain. Four hours
after that, her exam is unchanged (7/100/0). Fetal heart rate tracing remains category I. Which of
the following is the most appropriate next step in the management of this patient?
A. Allow her to ambulate and return when she is ready to pushB. Perform a contracti [Show Less]