Labor Complications Practice Questions

Q: A 29-year-old G1P0 woman at 39 weeks of gestation is in active labor. She is GBS-positive per rectovaginal culture obtained at 36 weeks. She reports a penicillin allergy described as diffuse urticaria and throat tightening after amoxicillin administration as a child. Sensitivity testing is not available. Fetal heart rate tracing is Category I, cervix is 5 cm dilated. Which of the following represents the most appropriate antibiotic regimen for intrapartum prophylaxis in this patient?

Vancomycin 1 g IV every 12 hours. ***Vancomycin 1 g IV every 12 hours*** - This patient has a **high-risk penicillin allergy** (urticaria and throat tightening), and because **susceptibility testing** for clindamycin is unavailable, **Vancomycin** is the indicated prophylaxis. - It ensures coverage for **Group B Streptococcus** in laboring patients who cannot safely receive beta-lactams and lack confirmed susceptibility to narrower options. *Cefazolin 2 g IV loading dose followed by 1 g IV every 8 hours* - **Cefazolin** is appropriate only for patients with a **low-risk penicillin allergy** (e.g., non-pruritic maculopapular rash). - Because the patient experienced **throat tightening**, there is a significant risk of **cross-reactivity** or anaphylaxis, making cephalosporins unsafe. *Clindamycin 900 mg IV every 8 hours — not appropriate here as GBS susceptibility results are unavailable* - **Clindamycin** can only be used in high-risk penicillin-allergic patients if the GBS isolate is confirmed to be **susceptible** by laboratory testing. - Resistance to clindamycin is common among GBS strains; therefore, it cannot be used **empirically** without susceptibility data. *Ampicillin 2 g IV loading dose followed by 1 g IV every 4 hours* - **Ampicillin** is a penicillin-type antibiotic and is strictly contraindicated in patients with a history of **anaphylaxis** or **urticaria** to penicillins. - Administering this would risk a life-threatening **Type I hypersensitivity reaction** during labor. *Erythromycin 500 mg IV every 6 hours as first-line alternative* - **Erythromycin** is no longer recommended for GBS intrapartum prophylaxis due to extremely high rates of **antibiotic resistance**. - Current ACOG guidelines have removed it from the treatment algorithm in favor of **clindamycin** or **vancomycin**.

Q: A 32-year-old woman presents with a new 2 cm black nodular mass near her episiotomy scar. She reports that the mass is painful and tends to increase in size during menstruation. What is the most likely diagnosis?

Endometriosis. ***Endometriosis*** - The location near an **episiotomy scar**, the **painful black nodular mass**, and its tendency to **increase in size during menstruation** are highly characteristic of an **episiotomy scar endometriosis**, also known as cutaneous endometriosis. - This condition involves the presence of **endometrial tissue** outside the uterus, which responds to hormonal fluctuations, explaining the cyclical pain and size changes. *Melanoma* - While a **black nodular mass** could suggest melanoma, the key differentiating factor here is the **cyclical pain and growth with menstruation**, which is not typical for melanoma. - Melanoma is a **malignant tumor** of melanocytes and usually presents with irregular borders, asymmetry, and color variation, without a direct correlation to the menstrual cycle. *Foreign body granuloma* - A **foreign body granuloma** is an inflammatory reaction to non-degradable foreign material, which could be seen at a surgical site like an episiotomy. - However, this condition typically doesn't exhibit the **cyclical pain and growth with menstruation** that is a hallmark of endometriosis. *Inclusion cyst* - An **inclusion cyst** is a benign cyst that develops when epithelial cells become trapped under the skin surface after trauma or surgery. - While it can occur at an episiotomy site, it is usually a **slow-growing mass** that is typically painless (unless infected) and does not fluctuate in size or pain with the menstrual cycle.

Q: A young woman presents with prolapse, and a mesh is being placed. Where is this mesh typically fixed to?

Sacral promontory. ***Sacral promontory*** - In **sacrocolpopexy**, a common surgical procedure for vaginal prolapse, a mesh is attached from the vaginal apex to the **anterior longitudinal ligament** overlying the **sacral promontory**. - This anatomical landmark provides a strong, stable point of fixation to support the vagina and prevent recurrence of prolapse. *Ischial spine* - The **ischial spine** is a common landmark for identifying the **pudendal nerve** and for performing a **pudendal nerve block**, not for mesh fixation in prolapse repair. - It is also relevant in measuring the **interspinous diameter** of the pelvis during childbirth, but not for surgical mesh attachment in this context. *Ischial tuberosity* - The **ischial tuberosity** is the bony prominence on which one sits and is an attachment point for various muscles of the **thigh** and **pelvic floor**. - It is not used as a primary fixation point for mesh in vaginal prolapse repair due to its position and lack of direct support for the vaginal apex. *Pubic symphysis* - The **pubic symphysis** is a cartilaginous joint connecting the two **pubic bones** in the anterior pelvis. - While part of the pelvic framework, it does not provide the appropriate superior posterior support needed for **vaginal apex suspension** in prolapse surgery.

Question 1

A 34-year-old G2P1 woman at 33 weeks of gestation presents with a 2-hour history of painless bright red vaginal bleeding. She denies contractions or fluid leakage. Vital signs: BP 112/70 mmHg, HR 88 bpm, O₂ saturation 99%. The fetal heart rate tracing shows a baseline of 140 bpm with moderate variability, accelerations present, and no decelerations — a reassuring pattern. Transabdominal ultrasound demonstrates the placenta completely covering the internal cervical os, consistent with complete placenta previa. Fetal biometry is consistent with 33 weeks. The patient is hemodynamically stable and the bleeding has slowed. Which of the following is the most appropriate next step in management?

Accepted Answer

Administer betamethasone 12 mg IM and admit for expectant management with pelvic rest

Answer

Perform immediate cesarean delivery to prevent further hemorrhage

Answer

Administer betamethasone 12 mg IM and proceed to cesarean delivery within 24 hours

Answer

Perform digital cervical examination to assess for labor and plan mode of delivery

Answer

Discharge home with strict pelvic rest instructions and outpatient follow-up in 1 week

Question 2

A 29-year-old G1P0 woman at 39 weeks of gestation is in active labor. She is GBS-positive per rectovaginal culture obtained at 36 weeks. She reports a penicillin allergy described as diffuse urticaria and throat tightening after amoxicillin administration as a child. Sensitivity testing is not available. Fetal heart rate tracing is Category I, cervix is 5 cm dilated. Which of the following represents the most appropriate antibiotic regimen for intrapartum prophylaxis in this patient?

Accepted Answer

Vancomycin 1 g IV every 12 hours

Answer

Cefazolin 2 g IV loading dose followed by 1 g IV every 8 hours

Answer

Clindamycin 900 mg IV every 8 hours — not appropriate here as GBS susceptibility results are unavailable

Answer

Ampicillin 2 g IV loading dose followed by 1 g IV every 4 hours

Answer

Erythromycin 500 mg IV every 6 hours as first-line alternative

Question 3

A 29-year-old woman, G1P0, at 40 weeks of gestation is in the second stage of labor. She has been pushing for 3 hours with an epidural in place. The fetal head is at +2 station, occiput anterior. The CTG strip shown demonstrates absent baseline variability with recurrent late decelerations, consistent with a Category III tracing. Maternal BP is 122/78 mmHg, temperature 37.1°C, and HR 88 bpm. The obstetric team is evaluating the tracing to determine the next course of action. Which of the following represents the most appropriate management?

Accepted Answer

Proceed to immediate operative delivery by vacuum or forceps assistance

Answer

Administer a 500-mL IV crystalloid bolus, reposition to left lateral decubitus, and apply supplemental oxygen while preparing for cesarean delivery

Answer

Discontinue oxytocin if running, administer intrauterine resuscitation measures, and proceed to immediate cesarean delivery if no improvement within 30 minutes

Answer

Continue expectant management with continued pushing and reassess the tracing in 30 minutes

Answer

Perform fetal scalp stimulation; if acceleration is elicited, continue labor with close monitoring

Question 4

A 32-year-old woman presents with a new 2 cm black nodular mass near her episiotomy scar. She reports that the mass is painful and tends to increase in size during menstruation. What is the most likely diagnosis?

Accepted Answer

Endometriosis

Answer

Melanoma

Answer

Foreign body granuloma

Answer

Inclusion cyst

Question 5

A young woman presents with prolapse, and a mesh is being placed. Where is this mesh typically fixed to?

Accepted Answer

Sacral promontory

Answer

Ischial spine

Answer

Ischial tuberosity

Answer

Pubic symphysis

Labor Complications — MCQs

Labor Complications — MCQs

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