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Induction of Labour

By AdminPosted On 05-Oct-2016

1. Induction of Labour

Female Elephant during particular stage of life, travel as much as 20 miles, to eat bark and leaves of the red seringa tree; which they never eat otherwise. Why?


a) To get menstruation

b) To have ovulation

c) To Supplement folic acid

d) To induce labor

e) To avoid male elephant when they are pregnant


Correct Answer: d) To induce labour. Tea made from the leaves and bark of this particular species of tree (Boraginaceae family) induce uterine contractions, since it is often drunk by Kenyan women specifically to induce labor or abortion.


2. Augmentation of Labour

Which should be the first intervention offered in the case of slow progress of labour (less than 1cm dilatation per hour)?


a) Oxytocin

b) Misoprostol (PGE1)

c) Artificial rupture of membranes

d) Dinoprostone gel (PGE2)

e) Membrane sweep


Correct Answer: c) ARM. ARM is the first intervention offered in the case of slow progress of labour (less than 1cm dilatation per hour): this is often sufficient to augment labour. Moreover, oxytocin is often ineffective with intact membranes and can increase the risk of infusion of amniotic fluid into maternal circulation.

If good labor is not established 1hr after ARM, begin oxytocin infusion. (Ref: WHO)


3. ARM and Dinoprostone Gel

ARM should not be performed within how many hours of dinoprostone (PGE2) gel to reduce the risk of uterine hyperstimulation?


a) 2 hrs

b) 4 hrs

c) 6 hrs

d) 8 hrs

e) Can do ARM immediately after dinoprostone (PGE2) gel


Correct Answer: b) 4 hrs. ARM should not be performed within 4 hours of dinoprostone PGE2 gel to reduce the risk of uterine hyperstimulation. Also Oxytocin should not be used within 6 hours of dinoprostone PGE2 vaginal gel insertion for the same reason.


4. Dinoprostone Gel

Dinoprostone gel is used for cervical ripening. Second dose of gel can be administered after how many hours?


a) 2 hrs

b) 4 hrs

c) 6 hrs

d) 8 hrs

e) 10 hrs


Correct Answer: c) 6 hrs. Repeat dose must be more than 6 hours after previous dose, with maximum of 3 doses recommended in 24 hours.


5. Sweep and Stretch

Mechanical stretching of the cervix enhances uterine activity. This phenomenon has been referred to as


a) Babinski’s reflex

b) Chaddock’s reflex

c) Bezold-Jarisch reflex

d) Ferguson reflex

e) Hoffmann’s reflex


Correct Answer: d) Ferguson reflex.

Manipulation of the cervix and stripping the fetal membranes is associated with the increase in the levels of prostaglandin F2 alpha metabolite in blood.

a) Babinski’s reflex – dorsiflexion of the big toe on stimulation of the sole, occurring in lesions of the pyramidal tract.

b) Chaddock’s reflex – n lesions of the pyramidal tract, stimulation below the external malleolus causes extension of the great toe.

c) Bezold-Jarisch reflex – reflex bradycardia and hypotension resulting from stimulation of cardiac chemoreceptors by antihypertensive alkaloids and similar substances.

e) Hoffmann’s reflex – increased mechanical irritability of the sensory nerves in tetany; the ulnar nerve is usually tested.


6. Slow Progress of Labor

Primigravida in spontaneous labour at 39 weeks of gestation. Her cervical dilatation is 5 cm. A further vaginal examination after 3 hrs reveals still at 5 cm. Fetus is in the occipitoposterior position and uterine activity is present (1/ every 10 min/10 s)


a) Amniotomy

b) Commence intravenous oxytocin

c) Membrane sweep

d) Repeat vaginal examination after 2 hours

e) Repeat vaginal examination after 4 hours

f) Cesarean section immediately


Correct Answer: a) Amniotomy.

This case demonstrates slow/no progression during the first stage of labour and malpositioning of the fetus. The most appropriate initial intervention would be an amniotomy (artificial rupture of the membranes).

According to WHO, ARM is the first intervention offered in the case of slow progress of labour (less than 1cm dilatation per hour): this is often sufficient to augment labour.

Moreover, oxytocin is often ineffective with intact membranes and can increase the risk of infusion of amniotic fluid into maternal circulation.

If good labor is not established 1hr after ARM, begin oxytocin infusion.


7. Labour Management

Primi 41 weeks, spontaneous rupture of membranes, cervical dilatation is 3 cm. After 3 hrs cervical dilatation is still 3 cm. Fetus is in the occipitoposterior position and mild uterine activity is present (1/10/10). What is the most appropriate action?


a) Administer prostaglandin per vaginam

b) Caesarean section

c) Commence intravenous oxytocin

d) Membrane sweep

e) Repeat vaginal examination after 4 hours


Correct Answer: a) Commence intravenous oxytocin. The membranes have ruptured already so amniotomy is not required. No progression has been made during the first stage of labour. Therefore, the patient should be administered intravenous oxytocin. Oral Misoprostol is another option to augment the labour.


8. Bishop score includes all the followings EXCEPT


a) Dilation of the cervix.

b) Position of the cervix.

c) The presenting part of the fetus.

d) Length of the cervix.

e) Consistency of the cervix.

Correct Answer: c) The presenting part of the fetus. Fetal station in relation to ischial spine is a part of Bishop score not presentation.


9. Which Intravenous fluid should be used for administration of Oxytocin infusion?

a) 5% Dextrose

b) NS

c) RL

d) Isolyte M

e) Colloid

Correct Answer: b) NS and c) RL. Oxytocin has amino-acid homology similar to arginine vasopressin. Thus not surprisingly, it has similar antidiuretic action, and when infused at dosages of 20mIU/min or more, renal free water clearance decreases markedly. If aqueous fluid are infused in appropriate amounts along with oxytocin, water intoxication can lead to convulsions, coma, and even death. In general, if oxytocin is to be administered in high doses for a considerable period of time, its concentration should be increased rather than increasing the flow rate of more dilute solution. Consideration also should be given to use of either normal saline or lactated Ringer solution in these circumstances.

Oxytocin infusion for Induction of labour pain.


10. Oxytocin Infusion

If we have to start Oxytocin for induction of labor @ 5mIU/min with macrodrip set (1ml=16 macrodrops)


a) 5U:500ml @ 8drops/min

b) 10U:500ml @ 8drops/min

c) 5U:500ml @ 16drops/min

d) 2.5U:500ml @ 8drops/min

e) 2.5U:500ml @ 16drops/min

Correct Answer: a and e. 5U:500ml or 10Uin 1000ml = 10000mIU/1000ml = 10mIU/ml. If we have to start 5mIU/min = 1/2ml = 8drops/min. Similarly 2.5U:500ml or 5Uin 1000ml = 5000mIU/1000ml = 5mIU/ml. If we have to start 5mIU/min = 1ml = 16drops/min.


11. Uterine Hyperstimulation

G3P2 at term PROM since 3 hrs. Vertex presentation, not in labor, 2 cm dilated. Fetal heart rate is normal and reactive. Oxytocin induction started. Three hours later, patient has contractions every minute and lasting for approx 1 minute. Bradycardia in the 90s. Cervix is 6 cm dilated. Which of the following is the most appropriate next step in management?


a) Discontinue oxytocin

b) Start magnesium sulfate

c) Perform forceps assisted vaginal delivery

d) Perform vacuum assisted vaginal delivery

e) Perform cesarean delivery

Correct Answer: a) Discontinue oxytocin

This patient has uterine hyperstimulation. Because oxytocin has a very short half-life (3-5 minutes), discontinuing the oxytocin often resolves the hyperstimulation quickly.

If uterine hyperstimulation induced by oxytocin does not respond to shutting the oxytocin off, one can start magnesium sulfate or give terbutaline.

To perform a cesarean delivery would not be appropriate prior to trying other steps. This fetus most likely is not suffering a metabolic acidemia. Its bradycardia is directly related to the hyperstimulation.


12. Actions of Oxytocin include EXCEPT

a) Anti-diuretic activity.

b) Production of transient hypertension.

c) Decrease in uterine muscle contractility.

d) Activation of myoepithelial cells of the breast.

Correct Answer: c) Oxytocin increases uterine muscle contractility. Whereas true oxytocin, which is similar to vasopressin, causes hypertension, synthetic oxytocin causes hypotension and should be given slowly. A bolus of 10U synthetic oxytocin was shown to lower MAP 40%, and SVR 59% (thus cardiac output actually increased), an effect not seen when infused over 10 minutes.


13. Oxytocin Ampule

Oxytocin comes in ampule of 10U=1ml. How to add 1U Oxytocin to the drip?


a) Tuberculin syringe

b) 2 cc syringe

c) Other


Correct Answer: c). Dilute in 10 cc NS and administer 1 cc of that solution. Tuberculin syringe or insulin syringe is not to be used and it is not practical also.


14. What is the half life of Oxytocin

a) b) 3 min.

c) 10 – 15 min.

d) 20 – 30 min.

e) > 30 min.

Correct Answer : b) 3 min. When oxytocin is stopped, its concentration in plasma rapidly falls because the mean half-life is approximately 5 minutes. When oxytocin infusion is stopped if woman develops tetanic contraction, it takes 3-5 minutes for its concentration to fall in plasma. Discontinuing the oxytocin often resolves the hyperstimulation quickly.

If uterine hyperstimulation induced by oxytocin does not respond to shutting the oxytocin off, one can start magnesium sulfate or give terbutaline.


15. Hyper-stimulation with Oxytocin

When oxytocin infusion is stopped if woman develops tetanic contraction, how much time it takes for its concentration to fall in plasma?


a) 1 min

b) 2 min

c) 5 min

d) 10 min

e) >10 min

Correct Answer: c) 5 min. When oxytocin is stopped, its concentration in plasma rapidly falls because the mean half-life is approximately 5 minutes.

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