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Now I have enough to answer all three questions from the image. Here are the answers:

Q24 - 2018 November (Vaginal Prostaglandin Induction with Uterine Hyperstimulation)

Scenario: 25-year-old, 2nd para, 40 weeks, induced with vaginal prostaglandin. Now has 5 contractions per 10 minutes (hyperstimulation) with severe abdominal pain.
Answer: b) Perform a Cardiotocography (CTG)
Reasoning: This is uterine hyperstimulation following prostaglandin induction. The first and most critical step is to assess the fetal heart rate pattern immediately with CTG/cardiotocography. Once the FHR is assessed:
  • If the FHR is non-reassuring - initiate intrauterine resuscitation (IV fluid bolus, left lateral positioning, oxygen) AND remove the prostaglandin if possible, or give terbutaline 0.25 mg SC as a tocolytic.
  • If the FHR is reassuring - titrate down/remove the uterotonic agent.
You do NOT start oxytocin (that would worsen hyperstimulation). CTG must come first to guide all further management.
(Pfenninger and Fowler's Procedures for Primary Care - p. 1145)

Q25 - Second Stage Arrest with Face Presentation (Palpable Orbital Ridges, Bridge of Nose, Chin not felt)

Scenario: 30-year-old, in labour 12 hours, cervix fully dilated for 2 hours. VE reveals orbital ridges and bridge of nose palpable, but chin NOT felt.
Answer: c) Perform EM-LSCS
Reasoning: The VE findings (orbital ridges + bridge of nose felt, but no chin palpable) indicate a face presentation in the mentoposterior (MP) position - the chin (mentum) is directed posteriorly.
  • Mentoanterior face presentations can deliver vaginally (chin under symphysis pubis).
  • Mentoposterior face presentations cannot deliver vaginally - the head cannot extend further, making vaginal delivery impossible.
  • The patient is already in the second stage for 2 hours with no progress - this is an obstructed labour.
  • Therefore, emergency LSCS is the appropriate management.

Q26 - Primigravida with Slow Progress (4 cm at 8 am, 7 cm at 12 noon, 3 contractions/10 min, Membranes Ruptured)

Scenario: 27-year-old primigravida, cephalic, FHR 130 bpm, cervix 4 cm → 7 cm over 4 hours, 3 contractions/10 min, membranes ruptured.
Answer: d) Maintain Partogram and allow labour to progress
Reasoning:
  • Progress is 3 cm in 4 hours = 0.75 cm/hour, which meets the minimum acceptable rate of 0.5 cm/hour in active labour.
  • FHR of 130 bpm is normal.
  • 3 contractions per 10 minutes is adequate uterine activity.
  • Membranes are already ruptured (natural or AROM).
  • There is no indication for augmentation or operative delivery at this point. The appropriate step is to continue monitoring with the partogram and allow labour to progress normally.
Starting oxytocin (option a) is not needed as progress is adequate. Operative delivery is not warranted with a normal FHR and adequate progress.
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