Fetal Monitoring
A low-risk term patient in active labor with reassuring fetal status asks to remove continuous monitors so she can shower.
What is the most appropriate next step?
A. Continue continuous external fetal monitoring because she is age 37
B. Continue monitoring because spontaneous rupture of membranes requires it
C. Remove continuous monitors and use intermittent auscultation
D. Start oxytocin to shorten labor
E. Perform fetal scalp blood pH sampling before allowing ambulation
Correct answer: C. Remove continuous monitors and use intermittent auscultation
Guideline justification:
In a low-risk laboring patient with reassuring fetal status, intermittent auscultation is appropriate and continuous external monitoring does not need to remain the default.
At what cervical dilation does the active phase of labor begin?
A. 3 cm
B. 4 cm
C. 5 cm
D. 6 cm
E. 10 cm
Correct answer: D. 6 cm
Guideline justification:
The active phase of labor begins at 6 cm cervical dilation. Before 6 cm, regular painful contractions with cervical change are considered the latent phase. Cesarean delivery for latent phase arrest should be avoided because there is no accepted definition of latent phase arrest.
Late pregnancy bleeding is defined as vaginal bleeding occurring after what gestational age?
A. 12 weeks
B. 16 weeks
C. 20 weeks
D. 24 weeks
E. 28 weeks
Guideline justification:
Late pregnancy bleeding is defined as any vaginal bleeding after 20 weeks’ gestation. Even small-volume bleeding requires evaluation because emergent causes may initially present with limited bleeding.
Which gestational age correctly defines postterm pregnancy?
A. 40 weeks and 0 days or later
B. 41 weeks and 0 days to 41 weeks and 6 days
C. 42 weeks and 0 days or later
D. 43 weeks and 0 days or later
E. Any pregnancy beyond the estimated due date
Correct answer: C. 42 weeks and 0 days or later
Guideline justification:
Late-term pregnancy is 41 weeks and 0 days through 41 weeks and 6 days. Postterm pregnancy begins at 42 weeks and 0 days.
Which is the most common cause of postpartum hemorrhage?
A. Tone — uterine atony
B. Trauma — birth canal injury
C. Tissue — retained placenta or clot
D. Thrombin — coagulation disorder
E. Amniotic fluid embolism
Correct answer: A. Tone — uterine atony
Guideline justification:
The major causes of postpartum hemorrhage are remembered as the four Ts: Tone, Trauma, Tissue, and Thrombin. The most common cause is decreased uterine tone or uterine atony, accounting for approximately 70% of cases.
Which patient is the best candidate for intermittent auscultation rather than continuous external fetal monitoring?
A. Prior low-transverse cesarean delivery, now in spontaneous labor
B. Active labor with oxytocin augmentation
C. Term labor, clear fluid, reassuring fetal tracing, no diabetes, no hypertension, no prior cesarean
D. Term labor with meconium-stained fluid
E. Suspected fetal growth restriction
Correct answer: C. Term labor, clear fluid, reassuring fetal tracing, no diabetes, no hypertension, no prior cesarean
Guideline justification:
Intermittent auscultation is appropriate for low-risk labor when there is no meconium, abnormal bleeding, abnormal fetal testing, congenital anomaly, growth restriction, prior cesarean delivery, diabetes, hypertension, or need for oxytocin induction or augmentation.
A patient in active labor requests epidural analgesia at 4 cm dilation. The team hesitates because they worry that early neuraxial analgesia will decrease the chance of vaginal delivery.
What is the best guideline-based response?
A. Avoid neuraxial analgesia until at least 6 cm dilation
B. Offer neuraxial analgesia at any stage of labor
C. Recommend IV opioids instead because epidural increases cesarean delivery
D. Delay neuraxial analgesia until the second stage of labor
E. Avoid neuraxial analgesia in latent labor because it prolongs labor arrest
Correct answer: B. Offer neuraxial analgesia at any stage of labor
Guideline justification:
Neuraxial analgesia should be offered during any stage of labor. It provides effective pain relief and does not reduce vaginal delivery rates.
A pregnant patient at 31 weeks has late pregnancy bleeding. Placental location is unknown. She is stable, and fetal tracing is reassuring.
Which examination is safe and appropriate as an initial step?
A. Digital cervical examination
B. Sterile speculum examination
C. Manual cervical dilation assessment
D. Foley balloon placement
E. Membrane stripping
Correct answer: B. Sterile speculum examination
Guideline justification:
A sterile speculum examination is safe for evaluating late pregnancy bleeding, even when placental location is unknown. A digital cervical examination should be avoided until placenta previa has been excluded. Ultrasonography should be performed to determine placental location.
A patient had a negative group B streptococcus screen at 36 weeks and 1 day. She is now 41 weeks and 2 days and has not delivered.
What should be done?
A. No repeat testing is needed because the original result remains valid until delivery
B. Repeat group B streptococcus screening
C. Treat empirically with intrapartum antibiotics regardless of repeat testing
D. Perform a biophysical profile instead of repeating the culture
E. Repeat screening only if membranes rupture
Correct answer: B. Repeat group B streptococcus screening
Guideline justification:
Group B streptococcus screening cultures are valid for 5 weeks. If a previously negative screen is older than 5 weeks, repeat screening should be performed.
Which intervention is the most important for prevention of postpartum hemorrhage?
A. Sustained uterine massage after oxytocin administration
B. Prophylactic tranexamic acid for every delivery
C. Oxytocin administration between delivery of the infant and delivery of the placenta
D. Routine uterine balloon tamponade after delivery
E. Delayed placental delivery to allow spontaneous separation
Correct answer: C. Oxytocin administration between delivery of the infant and delivery of the placenta
Guideline justification:
The most effective preventive intervention for postpartum hemorrhage is administration of a uterotonic medication, most commonly oxytocin, between delivery of the infant and delivery of the placenta. Sustained uterine massage is not recommended when oxytocin has already been given.
A labor unit argues that continuous external fetal monitoring should remain the default for all patients because “it detects fetal distress better.”
Which response is most consistent with evidence-based practice?
A. Continuous external fetal monitoring should remain default because it reduces cerebral palsy
B. Intermittent auscultation is reasonable in low-risk patients and reduces operative delivery without worsening major neonatal outcomes
C. Continuous external fetal monitoring should be used only after epidural placement
D. Intermittent auscultation should be avoided because it increases neonatal acidemia
E. Fetal scalp pH sampling should be added routinely to improve outcomes
Correct answer: B. Intermittent auscultation is reasonable in low-risk patients and reduces operative delivery without worsening major neonatal outcomes
Guideline justification:
For low-risk labor, intermittent auscultation decreases cesarean and instrumental vaginal delivery rates without worsening major neonatal outcomes such as neonatal acidemia, NICU admission, low Apgar scores, or perinatal mortality.
A nulliparous patient undergoing induction has ruptured membranes and is receiving oxytocin. She remains in the latent phase, but maternal and fetal status are reassuring.
Before diagnosing failed induction, oxytocin should generally be continued for at least:
A. 4 hours
B. 6 hours
C. 8 hours
D. 12 to 18 hours
E. 24 to 36 hours
Correct answer: D. 12 to 18 hours
Guideline justification:
In induced labor, the latent phase can be significantly longer than in spontaneous labor. If maternal and fetal status are reassuring, oxytocin should generally be continued for at least 12 to 18 hours before diagnosing failed induction.
A 29-week pregnant patient has painless vaginal bleeding. Ultrasound confirms placenta previa. She is hemodynamically stable, fetal tracing is reassuring, and bleeding has resolved.
Which management plan is most appropriate?
A. Digital cervical examination to determine whether she is in labor
B. Hospitalization initially for stabilization and monitoring, then possible discharge if bleeding resolves and maternal/fetal status remains stable
C. Immediate cesarean delivery because any bleeding with previa mandates delivery
D. Strict bed rest until delivery because it prevents recurrent hemorrhage
E. Trial of labor if bleeding stops for 24 hours
Correct answer: B. Hospitalization initially for stabilization and monitoring, then possible discharge if bleeding resolves and maternal/fetal status remains stable
Guideline justification:
Placenta previa with bleeding or contractions should prompt hospitalization for stabilization and monitoring. If bleeding resolves and maternal and fetal status remain stable, outpatient monitoring may be considered. Digital cervical examination is contraindicated with placenta previa.
A patient is 41 weeks and 0 days pregnant with an uncomplicated pregnancy and reassuring fetal status. She prefers to wait for spontaneous labor.
Which monitoring plan is most consistent with guidelines?
A. No fetal testing is needed until 42 weeks
B. Daily NSTs are required until delivery
C. Modified biophysical profile once or twice weekly, or biophysical profile once weekly
D. Contraction stress test twice weekly as the preferred test
E. Doppler velocimetry alone once weekly
Correct answer: C. Modified biophysical profile once or twice weekly, or biophysical profile once weekly
Guideline justification:
For uncomplicated late-term and postterm pregnancies, antepartum fetal surveillance should begin at 41 weeks because stillbirth risk increases with advancing gestational age. Recommended options include a modified biophysical profile once or twice weekly or a biophysical profile once weekly.
A postpartum patient has ongoing hemorrhage. Her heart rate is 118 bpm and systolic blood pressure is 104 mm Hg. The team says she is not in shock because her systolic blood pressure is still above 100.
What is the best interpretation?
A. She is stable because systolic blood pressure is above 100
B. Shock is excluded unless systolic blood pressure is below 90
C. Her shock index is >1, which increases the likelihood of blood transfusion
D. Her shock index is normal because tachycardia is expected postpartum
E. Hemorrhagic shock can only be diagnosed after hemoglobin returns
Correct answer: C. Her shock index is >1, which increases the likelihood of blood transfusion
Guideline justification:
Vital signs may not reflect shock until late after significant blood loss. Shock index is calculated as heart rate divided by systolic blood pressure. A shock index of 0.9 or greater is associated with increased mortality, and a shock index greater than 1 increases the likelihood of transfusion. This patient’s shock index is 118 ÷ 104 = 1.13.
Compared with intermittent auscultation in low-risk laboring patients, continuous external fetal monitoring is best described as causing which outcome pattern?
A. Decreases cerebral palsy and perinatal mortality, but increases cesarean delivery
B. Decreases neonatal seizures, but increases cesarean and instrumental delivery without reducing cerebral palsy or perinatal mortality
C. Decreases NICU admission and hypoxic-ischemic encephalopathy, but does not affect cesarean rate
D. Decreases cesarean delivery but increases instrumental vaginal delivery
E. Has no effect on maternal delivery route but reduces low Apgar scores
Correct answer: B. Decreases neonatal seizures, but increases cesarean and instrumental delivery without reducing cerebral palsy or perinatal mortality
Guideline justification:
Continuous external fetal monitoring increases cesarean and instrumental vaginal delivery rates compared with intermittent auscultation. It does not reduce cerebral palsy, perinatal mortality, cord blood acidosis, hypoxic-ischemic encephalopathy, low Apgar scores, or NICU admission. It may reduce neonatal seizures, but the absolute event rate is low.
A multiparous patient with an epidural reaches complete dilation. After 2.5 hours of active pushing, the fetal head remains at the same station with no rotation or descent despite adequate contractions and good maternal effort. Fetal status is reassuring.
Which management is most consistent with current labor guidelines?
A. Continue pushing indefinitely because multiparity allows longer second stage
B. Perform cesarean delivery immediately because second stage is prolonged
C. Consider operative vaginal delivery before proceeding to cesarean delivery if the patient is an appropriate candidate
D. Delay pushing for another hour because epidural anesthesia is present
E. Perform ultrasonography before operative vaginal delivery because it improves outcomes
Correct answer: C. Consider operative vaginal delivery before proceeding to cesarean delivery if the patient is an appropriate candidate
Guideline justification:
Second stage is prolonged after more than 3 hours of pushing in nulliparous patients or more than 2 hours in multiparous patients. If there is no fetal rotation or descent despite adequate contractions and pushing, operative vaginal delivery should be considered before cesarean delivery when feasible.
A 36-week pregnant patient with chronic hypertension presents with vaginal bleeding and abdominal pain. The uterus is irritable but not frankly hypertonic. Fetal monitoring shows recurrent decelerations. Ultrasound does not show retroplacental clot.
Which statement is most accurate?
A. Placental abruption is unlikely because ultrasound is negative
B. Placental abruption requires the triad of bleeding, pain, and uterine hypertonicity
C. Placental abruption should remain high on the differential, and care should not be delayed for ultrasound confirmation
D. Placental abruption is excluded if bleeding is not heavy
E. Cesarean delivery is mandatory for all suspected abruptions, even if maternal and fetal status are stable
Correct answer: C. Placental abruption should remain high on the differential, and care should not be delayed for ultrasound confirmation
Guideline justification:
Placental abruption is primarily a clinical diagnosis. The classic triad of vaginal bleeding, pain, and uterine hypertonicity is uncommon. Vaginal bleeding with fetal heart rate abnormalities is a more common presentation. Ultrasound has limited sensitivity, so a negative ultrasound does not exclude abruption.
A low-risk nulliparous patient with accurate first-trimester dating is 39 weeks and 2 days pregnant. She asks whether elective induction increases her risk of cesarean delivery.
Which counseling statement is most accurate?
A. Elective induction before 41 weeks should be avoided because it increases cesarean delivery
B. Elective induction at 39 weeks may be offered and may reduce cesarean delivery without increasing maternal or neonatal harm
C. Elective induction at 39 weeks is recommended for all patients regardless of parity
D. Elective induction should only be offered after 42 weeks
E. Elective induction at 39 weeks reduces stillbirth but increases hypertensive disorders of pregnancy
Correct answer: B. Elective induction at 39 weeks may be offered and may reduce cesarean delivery without increasing maternal or neonatal harm
Guideline justification:
Elective induction may be offered to low-risk nulliparous patients starting at 39 weeks based on patient preference, available resources, and clinical setting. It does not increase maternal or neonatal harm and may reduce cesarean delivery and hypertensive disorders of pregnancy.
A patient develops postpartum hemorrhage after vaginal delivery. Estimated blood loss is 650 mL. She is still bleeding. Delivery occurred 90 minutes ago.
Which tranexamic acid regimen is most appropriate?
A. No tranexamic acid because blood loss is less than 1,000 mL
B. Tranexamic acid 1 g IV over 10 minutes now; repeat once if bleeding continues after 30 minutes
C. Tranexamic acid 2 g IV push immediately
D. Tranexamic acid only if disseminated intravascular coagulation is confirmed
E. Tranexamic acid after 24 hours if bleeding persists
Correct answer: B. Tranexamic acid 1 g IV over 10 minutes now; repeat once if bleeding continues after 30 minutes
Guideline justification:
Tranexamic acid is recommended for postpartum hemorrhage with blood loss of at least 500 mL after vaginal delivery or 1,000 mL after cesarean delivery. It should be given as 1 g IV over 10 minutes within 3 hours of delivery. A second dose may be given if bleeding continues 30 minutes after the first dose.
A 39-week patient in active labor has clear fluid, reassuring fetal testing, no prior cesarean, no diabetes, no hypertension diagnosis, and no oxytocin use. She has one BP of 142/78, repeated 15 minutes later as 124/72. She asks to remove continuous external fetal monitoring so she can shower.
Which factor would most clearly change her from low-risk to not low-risk, making continuous external fetal monitoring more appropriate?
A. Advanced maternal age
B. Spontaneous rupture of membranes
C. One isolated elevated systolic BP that normalizes
D. Need for oxytocin augmentation
E. Multiparity with two prior vaginal deliveries
Correct answer: D. Need for oxytocin augmentation
Guideline justification:
Low-risk labor generally excludes patients with meconium-stained fluid, abnormal bleeding, abnormal fetal testing, congenital anomaly, intrauterine growth restriction, prior cesarean delivery, diabetes, hypertension, or need for oxytocin induction or augmentation. Oxytocin augmentation would move this patient out of the low-risk group.
A nulliparous patient is at 7 cm dilation with ruptured membranes. An intrauterine pressure catheter shows 220 Montevideo units. She has had no cervical change for 3 hours. Fetal tracing is reassuring.
What is the most appropriate next step?
A. Diagnose active phase arrest and proceed to cesarean delivery
B. Continue labor management because arrest criteria are not yet met
C. Diagnose failed induction and continue oxytocin for 12 to 18 hours
D. Begin immediate pushing
E. Perform cesarean delivery because adequate contractions have been present for more than 2 hours
Correct answer: B. Continue labor management because arrest criteria are not yet met
Guideline justification:
Active labor begins at 6 cm dilation. Active phase arrest requires at least 6 cm dilation, ruptured membranes, and no cervical change after either 4 hours of adequate contractions or 6 hours of oxytocin with inadequate contractions. Adequate contractions are generally defined as more than 200 Montevideo units. This patient has had only 3 hours without change.
A 33-week pregnant patient presents immediately after spontaneous rupture of membranes with small-volume vaginal bleeding. Fetal tracing rapidly shows recurrent late decelerations followed by bradycardia. Prior ultrasound showed a resolved low-lying placenta. Maternal vital signs are stable.
What is the most appropriate next step?
A. Perform digital cervical examination to assess dilation
B. Obtain Kleihauer-Betke testing before deciding delivery route
C. Proceed with emergent cesarean delivery with neonatal team prepared for transfusion and resuscitation
D. Observe for 4 hours because bleeding is small volume and maternal vitals are stable
E. Administer corticosteroids and delay delivery for fetal lung maturation
Correct answer: C. Proceed with emergent cesarean delivery with neonatal team prepared for transfusion and resuscitation
Guideline justification:
This presentation is concerning for vasa previa rupture, especially with a history of low-lying or resolved placenta previa. Vasa previa can cause fetal hemorrhage after membrane rupture, with late decelerations, sinusoidal tracing, bradycardia, or absent fetal heart tones. Because fetal blood volume is small, even limited bleeding can be catastrophic. Management is emergent cesarean delivery with neonatal resuscitation and transfusion preparation.
A low-risk patient at 41 weeks and 3 days declines induction. Antepartum testing shows a reactive NST with two accelerations in 20 minutes. Ultrasound shows a single deepest vertical pocket of 1.8 cm. Fetal movement is reported as normal.
What is the most appropriate recommendation?
A. Continue expectant management because the NST is reactive
B. Repeat testing in 1 week because fetal movement is normal
C. Strongly recommend induction of labor
D. Diagnose postterm pregnancy and proceed directly to cesarean delivery
E. Use amniotic fluid index instead because single deepest pocket is not recommended
Correct answer: C. Strongly recommend induction of labor
Guideline justification:
At 41 weeks or later, antepartum fetal surveillance is recommended. A modified biophysical profile is normal only when the NST is reactive and the single deepest vertical pocket is greater than 2 cm. A single deepest pocket of 2 cm or less indicates oligohydramnios and should prompt delivery planning. In this setting, induction is strongly recommended.
A patient has persistent postpartum hemorrhage after vaginal delivery. She has already received oxytocin, additional uterotonics, uterine massage, IV fluids, and tranexamic acid. Bleeding continues, but she is not yet in advanced shock. The team suspects the uterus is the source.
What is the most appropriate next nonsurgical intervention?
A. Proceed directly to hysterectomy
B. Place uterine balloon tamponade
C. Give sustained uterine massage only
D. Delay intervention until hemoglobin drops by 30%
E. Start oral iron and observe if blood pressure is stable
Correct answer: B. Place uterine balloon tamponade
Guideline justification:
Uterine balloon tamponade is recommended for refractory postpartum hemorrhage despite uterotonic medications and tranexamic acid. It is both diagnostic and therapeutic because stopping bleeding confirms an intrauterine source. When used before advanced shock, it controls more than 80% of refractory cases.