EMQ set 2

Options for questions 1-3

A)    Further dose of prostaglandin E2 tablet

B)     Prostaglandin E2 gel

C)    Offer caesarean section

D)    Further attempt at induction of labour in 48 hours

E)     Further attempt at induction of labour in 7 days

F)     Prostaglandin sustained release pessary

G)    Oxytocin infusion

H)    Vaginal misoprostol tablets (100 micrograms)

I)       Vaginal misoprostol tablets (200 micrograms)

J)       Oral misoprostol 25 micrograms

K)    Membrane sweeping

L)     Laminaria tent

For each scenario described below, choose the single most appropriate management from the above list of options. Each option may be used once, more than once, or not at all.

1) A healthy 37 year old woman attends for induction of labour at 42 weeks gestation. She has 3mg prostaglandin E2 tablets at 08:00 and a further 3mg tablet at 14:30. At 21:00, her cervical score remains unchanged at 3 and she is having one contraction every 30 minutes.

2) A 37 year old woman has been an in-patient because of pre-eclampsia with moderate hypertension. Induction of labour is initiated at 38 weeks gestation. Her BP is well controlled and blood tests are normal. Following 2 doses of prostaglandin E2 gel (2mg), her cervical score remains unchanged at 2 and there is no uterine activity.

3) A healthy 35 year old woman with a normal pregnancy attends for induction of labour at 42 weeks gestation. She is re-assessed 24 hours after administration of a sustained release prostaglandin E2 pessary. Her cervical score remains unchanged at 2 and there are no uterine contractions

Options for questions 4-6

A)    Perform amniotomy

B)     Deliver by caesarean section

C)    Reassess in 2 hours

D)    Reassess in 3 hours

E)     Reassess in 4 hours

F)     Commence CTG and reassess in 2 hours

G)    Commence CTG and reassess in 3 hours

H)    Commence CTG and reassess in 4 hours

I)       Perform amniotomy and commence CTG

J)       Commence oxytocin infusion

K)    Commence oxytocin infusion and CTG

L)     Administer vaginal prostaglandin tablets 3mg

M)   No additional intervention

For each scenario described below, choose the single most appropriate management from the above list of options. Each option may be used once, more than once, or not at all.

4) A healthy 23 year old nulliparous woman with a normal pregnancy presents in spontaneous labour at 39 weeks gestation with intact membranes. At 08:00, the cervix is fully effaced and 5cm dilated. At 12:00, the cervix is 7cm dilated. She is contracting 4 in 10.

5) A 34 year old woman with a dichorionic-diamniotic twin pregnancy presents in spontaneous labour at 37 weeks gestation. At 08:00, the cervix is 4cm dilated with intact membranes. At 12:00, the cervix is 5cm dilated with intact membranes. She is contracting 3-4 in 10.

6) A healthy 39 year old woman presents with pre-labour rupture of the membranes at 39 weeks gestation. Re re-attends 8 hours later in spontaneous labour and the cervix is 6cm dilated with a direct occipito-posterior position. Four hour later, the cervix is 7cm dilated with a left occipito-transverse position.

Options for question 7

A)    Perform amniotomy

B)     Deliver by caesarean section

C)    Reassess in 2h

D)    Abdominal and vaginal examination then reassess in 2h

E)     Reassess in 4h

F)     Commence CTG and reassess in 2h

G)    Abdominal and vaginal examination, CTG and reassess in 2h

H)    Commence CTG and reassess in 4h

I)       Perform amniotomy and commence CTG

J)       Commence oxytocin infusion

K)    Commence oxytocin infusion and CTG

L)     Abdominal and vaginal examination, CTG and commence oxytocin

M)   No additional intervention

For each scenario described below, choose the single most appropriate management from the above list of options. Each option may be used once, more than once, or not at all.

7) A healthy 35 year old woman with 3 previous spontaneous vaginal deliveries presents in spontaneous labour at 41 weeks gestation. At 08:00, the cervix is 5cm dilated and she is draining clear liquor. At 12:00, the cervix is 6cm dilated with a direct OP position. At 14:00 the cervix is still 6cm dilated. She is contracting 3-4 in 10.

Options for question 8

A)    Forceps delivery

B)     Ventouse delivery

C)    Perform amniotomy

D)    Deliver by caesarean section

E)     Commence active pushing

F)     Commence oxytocin infusion

G)    Reassess in 1h

H)    Commence active pushing in 2h

I)       Commence active pushing in 4h

J)       Offer epidural anaesthesia

K)    Commence oxytocin infusion and active pushing

L)     Offer epidural anaesthesia and oxytocin infusion

For each scenario described below, choose the single most appropriate management from the above list of options. Each option may be used once, more than once, or not at all

8) A healthy 27 year old primigravida presents in spontaneous labour at term. She has made normal progress and the midwife has just diagnosed full dilatation with a direct occipito-anterior position 1cm below the ischial spines. There is clear liquor draining. She is having 1-2 moderate contractions every 10 minutes lasting ~20-30s. There are no fetal concerns.

1 - D

2 - B

3 - D

4 - C

5 - A

6 - K

7 - B

8 - G

1 D

2 D

3 B

4 M

5 I

6 K

7 G

8 G

1-G( contractions present so not a failed induction. augement contraction with oxytocin)

2-C(preecclampsia with failed induction offer cs)

3-D( no high risk issue, repeat induction in 48 hrs)

4-M(adequate progress no additional intervention)

5-A(twin with intact membranes and suspected delay, perform amniotomy and reasses in 2 hrs, should be already on ctg  as high risk)

6-F (suspected delay but rotation present. stat ctg and reasses in 2 hrs)

7-B( diagnosed delay with absent memberane and adequate contraction  deliver by cs)

8-F( just diagnosed second stage with inadequate contractions, reasses in 1 hr)

1.A      2.C          3.F      4.A        5.I        6.K     7.G      8.G

1 C 2 D 3 C 4 A 5 M 6 K 7 G 8 F

1A, 2L, 3F, 4E, 5E, 6J, 7B, 8G

1-g

2-d

3-c

4-a

5-i

6-k

7-b

8-k

1g

2a

3c

4e

5b

6b

7b

8f

1. D
2. C
3. D
4. A
5. I
6. E
7. B
8. G

1-c   2-d   3-c   4-e   5-a   6-k   7-l   8-l

1-K, 2-B, 3-B, 4-E, 5-A, 6-K, 7-B, 8-F

1.D,2 c,  3 e,  4 a,  5 i,  6 H,  7 B, 8 K

1. C 2. D 3. C 4. A 5.A 6.K 7. G 8.F

1.D 2.D 3.B 4.E 5.I 6.K 7.L 8.K

1A,2C,3D,4E,5A,7L,8F

1   C

2   D

3   C

4   A

5   I

6   J

7   B

8   K

1-G

2-C

3-B

4-M

5-J

6-C

7-J

8-F

hi amswers for EMQ set 2

1. B

2.C

3. F

4.M

5.A

6.K

7.G/B

8.G

hi amswers for EMQ set 2

1. B

2.C

3. F

4.M

5.A

6.K

7.G/B

8.G

hi amswers for EMQ set 2

1. B

2.C

3. F

4.M

5.A

6.K

7.G/B

8.G

1.A   2.C   3. B   4.E    5.I   6.K   7.B    8.F

1.A   2.C   3. B   4.E    5.I   6.K   7.B    8.F

1.A   2.C   3. B   4.E    5.I   6.K   7.B    8.F

1.A   2.C   3. B   4.E    5.I   6.K   7.B    8.F

1-D   2-D  3-D  4-M  5-I  6-K  7-G  8-F

1,k

2 d

3 g

4 a

5 a

6 k

7 c

8 g

1 g

2 c

3 b

4 e

5 i

6k

7k

8 f

1 d

2 c

3 c

4 m

5 a

6 k

7 l

8 k

1. D  2. B  3. B  4. E  5. I  6. K  7. K  8. E

1C  2C  3C  4E  5I  6C  7K  8E

1.  A

2. B

3. C

4. A

5. I

6. K

7. F

8. G

1.C   2.B   3.B   4.C   5.I   6.K   7.B   8.F

1.G

2.C

3.D

4.A

5.I

6.K

7.G

8.K

j  

1.B

2.D

3.D

4.D

5.A

6.K

7.K

8.G

1-d 2-d 3-a 4-a 5-i 6-k 7-l 8-k

1. D
2. D
3. B
4. I
5. A
6. K
7. L
8. G

1. A

2. A

3. B

4. M (or E?)

5. A

6. K

7. B

8. F (or G?)

1- A 

2- A

3- D

4- F

5- I

6- K

7- B

8- K

1- A.    2- A   3- D  4- F   5- I   6- K     7-B     8- K

1) G 2) C 3) D 4) M 5) A 6) K  7) F/B 8) F

1) (C) Offer caesarean section

2) (C) Offer caesarean section

3) (C) Offer caesarean section

NICE IOL Guidelines

Vaginal PGE₂

Vaginal PGE₂ is the preferred method of induction of labour, unless there are specific clinical reasons for not using it (in particular the risk of uterine hyperstimulation). It should be administered as a gel, tablet or controlled-release pessary. Costs may vary over time, and trusts/units should take this into consideration when prescribing PGE₂. For doses, refer to the SPCs. The recommended regimens are:

• one cycle of vaginal PGE₂ tablets or gel: one dose, followed by a second dose after 6 hours if labour is not established (up to a maximum of two doses)
• one cycle of vaginal PGE₂ controlled-release pessary: one dose over 24 hours.

Failed induction

• If induction fails, healthcare professionals should discuss this with the woman and provide support. The woman’s condition and the pregnancy in general should be fully reassessed, and fetal wellbeing should be assessed using electronic fetal monitoring.
• If induction fails, the subsequent management options include:

-     a further attempt to induce labour (the timing should depend on the clinical situation and the woman’s wishes)

-     caesarean section

4) (M) No additional intervention

5) (C) Reassess in 2 hours

6) (C)Reassess in 2 hours

NICE Intra-partum Care guidelines

Recommendation on definition of delay in the first stage of labour

A diagnosis of delay in the established first stage of labour needs to take into consideration all aspects of progress in labour and should include:

• Cervical dilatation of less than 2 cm in 4 hours for first labours
• Cervical dilatation of less than 2 cm in 4 hours or a slowing in the progress of labour for second or subsequent labours
• Descent and rotation of the fetal head
• Changes in the strength, duration and frequency of uterine contractions

Therefore progress of 2cm in 4h is normal and no further intervention is needed.

• If delay in the established first stage of labour is suspected (when inadequate progress is identified for the first time), amniotomy should be considered for all women with intact membranes, following explanation of the procedure and advice that it will shorten her labour by about an hour and may increase the strength and pain of her contractions.
• In women with intact membranes in whom delay in the established first stage of labour is confirmed (this is by allowing a further 2h then performing VE), amniotomy should be advised to the woman, and she should be advised to have a repeat vaginal examination 2 hours later whether her membranes are ruptured or intact
• Amniotomy alone for suspected delay in the established first stage of labour is not an indication to commence continuous EFM.

7) (L) Abdominal and vaginal examination, CTG and commence oxytocin

NICE Intra-partum Care Guidelines

• Multiparous women with confirmed delay in the first stage should be seen by an obstetrician who should make a full assessment, including an abdominal palpation and vaginal examination, before making a decision about the use of oxytocin.
• All women with delay in the established first stage of labour should be offered support and effective pain relief. Women should be informed that oxytocin will increase the frequency and strength of their contractions and that its use will mean their baby should be monitored continuously. Women should be offered an epidural before oxytocin is started.

8) (L) Offer epidural anaesthesia and oxytocin infusion

Recommendations on interventions for delay in the second stage of labour

• Where there is delay in the second stage of labour, or if the woman is excessively distressed, support and sensitive encouragement and the woman’s need for analgesia/anaesthesia are particularly important.
• Consideration should be given to the use of oxytocin, with the offer of regional analgesia, for nulliparous women if contractions are inadequate at the onset of the second stage
• In nulliparous women, if after 1 hour of active second stage progress is inadequate, delay is suspected. Following vaginal examination, amniotomy should be offered if the membranes are intact.
• Women with confirmed delay in the second stage should be assessed by an obstetrician but oxytocin should not be started. Following initial obstetric assessment for women with delay in the second stage of labour, ongoing obstetric review should be maintained every 15–30 minutes.

dear paul,

i failed to undersatand your answer to the emq question 5, since according to nice guideline, suspected delay in 1st stage should be managed with amniotomy (guideline point no:1.13.2)

thanks

Dear paul,

                    According to nice guidelines, amniotomy should be done for delay in 1st stage so why is answer for q 4 and 5 both different than amniotomy.

Thanks

hello jamil,

in question 4 the lady has made adequate progress hence no intervention is justified.

Dear Paul

In question 7, whilst I take on board the NICE guidelines recommend abdominal and vaginal examination in multips before starting oxytocin, the point is to examine whether there is obstruction. The choices are a little ambiguous, in that we have no details about fifths palpable, caput, moulding, and yet the "correct answer" says examine and start synto. Am I reading too much into this? On the options alone, with no further data on obstruction or not, I  would deliver a multip contracting 3-4 in 10 who has progressed 1cm n six hours by caesarean section.

See algorithm on management of delay in first stage in NICE guidelines. If delay is suspected, you should CONSIDER amniotomy. Once delay is diagnosed then amniotomy should be recommended. The guidelines do not regard amniotomy as the first intervention in women with suspected delay and intact membranes.

Good day Sir!

This was really confusing and therefore very interesting set of EMQ. Good and Thank you that we learned something well before exam.

The lady in question 4, since she has normal progress, I was happy to say that I will examin her in 4 hours but no intervention is needed... When will we examine her then..

And in relation to question 8 can you please tell us (other than EMQ scenario) what would be reply if that particular lady was a multip? As we can not start oxytocin in that case.

Thank you for your consideration.

In question 7, whilst I take on board the NICE guidelines recommend abdominal and vaginal examination in multips before starting oxytocin, the point is to examine whether there is obstruction. The choices are a little ambiguous, in that we have no details about fifths palpable, caput, moulding, and yet the "correct answer" says examine and start synto. Am I reading too much into this? On the options alone, with no further data on obstruction or not, I  would deliver a multip contracting 3-4 in 10 who has progressed 1cm n six hours by caesarean section.

You need to answer the question based on the information given in the question and not consider every other possibility that could occur. If you are going to assume that your examination would identify evidence of obstruction, why not assume that it would not? The option was not: 'Examination then CS'. The option was 'CS' and by selecting this option, you are saying that the information in the question ON ITS OWN is sufficient for you to deliver by CS. This would be incorrect.

The lady in question 4, since she has normal progress, I was happy to say that I will examin her in 4 hours but no intervention is needed... When will we examine her then..

4 hours later unless there are signs of full dilatation

And in relation to question 8 can you please tell us (other than EMQ scenario) what would be reply if that particular lady was a multip? As we can not start oxytocin in that case.

You do nothing