182

CHAPTER 27

Vaginal Delivery

27-1. The most common position for vaginal delivery is 27-6. All except which of the following statements
which of the following? regarding delivery of the fetal body are true?
a. Squatting a. Usually delivers without delay after the shoulders.
Sr
c. Dorsal lithetomy
a Moderate outward traction on the head may
d, None of the above
be used, to help delivery.

27-2. At the time of perineal distention prior to vaginal d. Immediate nasopharyngeal suction should be
delivery, which of the following is correct? performed after delivery.
a. Most presentations are occiput posterior.
27-7. Whar are the bencfits of delayed cord clamping in
b. Infrequently the vertex may be occiput anterior.
preterm infants?
a. Decrease IVH
See
b. Decrease NEC
d. All of the above
c. Decrease need for blood transfusion
27-3. Which of the following maneuvers may protect the
perineum during delivery?
a. Slow delivery of the head 27-8. A 34-year-old primigravida at 41 weeks’ gestation
presents for induction of labor. She tells you she
b. One-hand support of the perineum
would like you to perform delayed cord clamping.
c. Guidance to deliver the smallest head diameter Whar risks are there to delayed cord clamping in the
through the introitus term infant?
a. Lower Apgar scores
b. Postpartum hemorrhage

c. These iypetinabineia
27-4. Which of the following is true regarding nuchal
cords?

d. Respiratory distress syndrome from polycythemia

b. Are more common in preterm infants
27-9. - All except with of the following is true regarding
c. Tight nuchal cords are associated with 10% of all occiput transverse position of the fetal head in the
deliveries maternal pelvis?
d. Presence of a nuchal cord is associated with worse a. Seen with android pelvises
neonatal outcomes
b. Easiest way to rotate is manually
27-5. Following delivery of the fetal head, which of the c. Can be rotated with Kielland forceps
following occurs? eee
a. The head rotates anterior
b. The head undergoes internal rotation
c. The head undergoes external extension
 Vaginal Delivery 183

27-10. Which of the following is true regarding persistent 27-15. A 33-year-old multigravida is in clinic ar 39 weeks’
occiput posterior (OP) position in labor? gestation and believes she has big baby. An ultra-
a. Seen more often in multiparous women sound is performed, and the estimated fetal weight is
rel
ps 9 pounds, Which of the following jis true?
a. Planned cesarean delivery may be offered.
Be
>
a]
b. Elective induction should be scheduled soon.
—
c. Gynecoid pelvises predispose to persistent OP m
ae
position c. Shoulder dystocia may be accurately predicted. bh
d. Epidural analgesia is not a risk for persistent OP
position
ae i |

27-11. For women who deliver vaginally with persistent 27-16. The following illustration demonstrates which
occiput posterior (OP) position, which of the maneuver for reduction of shoulder dystocia?
following is true?
a. Transabdominal ultrasound can aid in identifying
the OP position.
b. There is increased blood loss compared to occiput
anterior position.
c. There are more third- and fourth-degree
lacerations compared to occiput anterior position,

27-12. A 22-year-old primigravida has been pushing for

3 hours. The fetus is in persistent occiput posterior
position with caput, and the fetal head is noted to
protrude slightly through the introitus with each
contraction, Which of the following features must be
considered prior to attempted forceps delivery?

b. At this station the pelvis is adequate

c. Diagnosed visually the station is +5
d. Ar this point low forceps may be applied withour
further evaluation
Reproduced with permision from Cunningham FG, Leveno KJ, Bloom SL, ct al [ecls): Vaginal
delivery, In Williams Obstetrics, 25th ed. New York, MoGraw-Hill, 2018, Figure 27-5,
27-13. Which of the following defines shoulder dystocia?
a. Clinical perception of the delivering physician. a. Wood's screw
b. Maneuvers are needed to free the anterior b. Rubin maneuver
shoulder.
¢. Head to body delivery time is greater than
d. Delivery of the posterior shoulder
60 seconds.

27-17. The most common maneuver used to reduce a

shoulder dystocia is which of the following?
27-14. After a difficult delivery involving shoulder dystocia,
a. Wood's screw
the pediatrician tells you that the infant has suffered
an injury. Which of the outcomes described below is b. Rubin maneuver
most likely?
a. The mother had uterine atony. d. McRoberts maneuver
b. The infane has a humeral fracture,
c. The infant has a clavicular fracture.
 184 Delivery

27-18. Which of the following statistics concerning home 27-24. Approximately 2% of singleton births are accompanied
birth is accurate? by a delayed third stage. Possible reasons for this
a. 0.7% of deliveries in the United States are include which of the following?
wi
pa planned home births. a. Placenta adherens
oY
b. 0.2% of deliveries in the United States were b. Morbidly adherent placenta
am.
oO unplanned home births, c. Lower uterine segment contraction with a trapped
ra c. In Norway 1.1% of unplanned home births placenta
o
ended in neonatal death,
a. Alara 27-25. Which of the following descriptions of third-degree
27-19. Which of the following is true concerning water birth? lacerations is accurate?
a. (1) <50% external anal sphincter tear
b, Increased rates of maternal infection b. (2) 50% of external anal sphincter tear

ce. Risk for cord avulsion is 7/1000 births c. (3a) >50% external anal sphineter tear

d. Greater overall neonatal harm in low-risk a

populations

27-20. The World Health Organization classifies genital 27-26. Risk factors for obstetrical anal sphincter injuries
mutilation into four types. Which of the following include which of the following?
descriptions is true? a. Multiparity
a. Type b Partial or total removal of the clitoris b. Mediolateral episiotomy
and/or prepuce c. Left occiput anterior position
b. Type Tk: Partial or total removal of the clitoris
and the labia minora
c. Type II; Partial or total removal of the labia t7“27, What is true concerning the illustrated perineal
minora and/or majora and infibulation without episioromy below?
or without clitoridectomy

d. All of the above

27-21. When delivering a fetus with a lethal prognosis, you
encounter shoulder dystocia. Which of the following
maneuvers is least appropriate?
a. Cleidowomy

€. Suprapubic pressure
d. McRoberts maneuver

27-22. A 35-year-old multigravida has just undergone a

vaginal birth alter cesarean delivery. Which of the
following is a sign that the placenta is ready to be
delivered?
a. Atonic fundus

Reproduced with permission from Cunningham FG, Levene KJ, Bloom SL, etal feds}: Vaginal
¢. Absence of vaginal bleeding delivery; In Williams Obstetrics, 25th ed. New York, MeCirw-Hill, 2018, Figure 27-14,
d, Fall of the uterus into the pelvis
a. Increased repair time
27-23. Which of the following is true regarding oxytocin?
a. Side effect is hypotension c. Increased rate of sphincter injury
b. Mean half-life of 6-8 minutes d. All of the above

d, Synthetic oxytocin is identical to that produced

in the anterior pituitary
 Vaginal Delivery 185

27-28. Indications for episiotomy include which of the 27-31. After completion of a fourth-degree perineal
following? laceration repair, you order which of the following
a. Breech delivery medications?
(a)
b. Shoulder dystocia a. Zosyn a
P
c. Persistent occiput posterior position b. Ampicillin 3
—_
¢. Dinoprostone a
~~
N
27-29. Which of the following is true regarding the repair a]
of third-degree lacerations? 27-32. A 23-year-old G1P1 without medical problems has
a. Antibiotics are not necessary. just undergone a spontancous vaginal delivery. After
delivery of the placenta, you note continued brisk
b. The preferred suture is chromic.
bleeding. Exam suggests uterine atony, Which of the
following is the next most appropriate medication?
a. Dinoprostone
d. The strength of the closure is derived from the
striated muscle of the sphincter. b. Rectal misoprostol
c. Intravenous magnesium sulfate
27-30. A 25-year-old G1P1 calls your office on postpartum
day 6 complaining of increasing perineal pain
for the last 24 hours. She underwent a successful
forceps-assisted vaginal delivery complicated by a
third-degree laceration. Which of the following is
part of the differential diagnosis?

b. Urinary retention
c. Uterine involution
d. Excessive ambulation
 187

PV
ial ars.)

Breech Presentation

28-1. Which of the following illustrations is labeled

correctly?
b. Complete breech

Reproduced with permission ftom Cunningham FG, Leveno KJ, Bloom SL, etal (ods): Breech Reproduced with ‘ a
: yi permission from Cunningham FG, Leveno K), Bloom SL, et al (eds): Breech
delivery. In Williams Olhatetrics, 25¢h ed. New York, McGraw-Hill, 2018, Figure 28-1. delivery. In Williams Obstetrics, 25th ed, New York, McGraw-Hill, 2018, Figure 28-3,

c. Incomplete breech d. None of the above

Reproduced with permission from Cunningham FG, Leveno KJ, Bloom SL, et al (eds): Breech
delivery, In Williams Obstetrics, 25th ed. New York, McGraw-Hill, 2018, Figure 28-2,
 188 Delivery

28-2. Among singleton pregnancies, breech presentation 28-7. A 29-year-old multigravida is admitted to your
persists in what percentage at term? antepartum service after premature rupture of
a. 1-2% membranes at 22 weeks’ gestation. She is now
Al
eal 22 weeks 3 days and, after consultation with
res) neonatology, she desires full resuscitation options
—
c. 6-7% at 23 weeks’ gestation. Her fetus is breech. She
(eo) d. 89% understands that many factors are involved but
=
i+]
inquires about which mode of delivery she should
28-3. Risk factors for breech presentation include which of anticipate. Which of the following statements is
the following? most appropriate?
a. Nulliparity a. Cesarean would be considered after 23 weeks’
gestation,
c. Singleton gestation
b. Cesarean would be recommended after 25 weeks’
gestation.
d. None of the above
c. Vaginal delivery would be recommended until
28-4, A 24-year-old primigravida presents to labor and 23 weeks’ gestation.
delivery at 38 weeks’ gestation, She is contracting
regularly and on exam she is 4 cm dilated, 25%
effaced, —3 station, and the feral presenting part 28-8. Which of the following is not true regarding maternal
is suspected to be a foot. What is the next most morbidity and mortality in breech delivery?
appropriate step in her management?

b. Anesthesia consultation for pain management b. Hysterotomy extensions can occur with the use
during labor of forceps during cesarean delivery of the breech
¢. Leopold
po maneuvers for further characterization of fetus.
fetal position c. Anesthesia given to aid in uterine relaxation for
d. Preparation for cesarean delivery due to non-cephalic vaginal delivery can increase the risk for postpartum
presentation in labor hemorrhage.
d. Genial tract lacerations can occur with both
28-5. The Term Breech Trial has heavily influenced mode vaginal and cesarean delivery of the breech fetus,
of delivery since its publication. Which of the and the risk of infection is increased,
following is a criticism of the study?
a. Mode of delivery was not randomized. 28-9, A 28-year-old G3P2 presented in advanced labor
with a fetus in frank breech presentation, and
b. More than 10% of study participants had
she delivered vaginally, Her 2-year-old is now
radiologic pelvimetry, which may have influenced
undergoing therapy tor hip dysplasia and Erb
management.
palsy. Which of the following is true regarding her
daughter's condition?
a. Hip dysplasia is a known risk of vaginal breech
delivery due to physical trauma,
d. All of the above b. Since it was not a shoulder dystocia, the Erb palsy
cannot be attributed to the delivery.
28-6. Which of the following best characterizes the state
c. Both the hip dysplasia and Erb palsy could have
of the literature regarding vaginal delivery ofa term
singleton breech? been avoided if she had a cesarean delivery.

b. Literature clearly shows trend co harm with

planned vaginal delivery
c. Literature clearly shows no extra harm with
planned vaginal delivery
d. None of the above
 Breech Presentation 189

28-10. When assessing candidacy for planned vaginal breech = 28-13. During a partial breech extraction, in the step
delivery, why are maternal pelvimetry and fetal pictured below, assisted delivery of the legs involves
ultrasound biometry correlation important? which of the following?
(im)
a. The head is often larger than the breech, na
be
b. The head ofa breech fetus does not undergo =
ma
molding during labor. m
¢. Ultrasound will help identify fetal anomalies that =)
bh
would alter candidacy. oo

28-11. A 24-year-old multigravida at 39 weeks’ gestation

transfers care to you from her midwife due to breech
presentation. She desires an unmedicated vaginal
breech delivery. Which of the following in her
history does not make her a good candidate for a
vaginal breech delivery?
a. Diet-controlled gestational diabetes

€- Uso inated el weigh 4200 gas yt pnt Cini eK a hs

b. A mid-pelvic interspinous distance of 11,9 cm

delivery. In Williams Obsterrics, 25th ed. New York, McGraw-Hill, 2018, Figure 28-5,
d. Desire to avoid anesthesia/analgesia during labor

Wl
a. While holding the feral buttock with one hand,
28-12. Whar is the best indicator of pelvic adequacy for the other hand sweeps up to find the feral foor
vaginal breech delivery? and downward traction results in delivery of the
a. Fetus in frank breech, right saccum anterior lower extremity.
position b. While holding the fetal buttock with one hand,
b. Computed tomography scan of pelvic the other hand sweeps up to find the popliteal
measurements fossa and exerts pressure ro adduct toward
cc midline and sweep the leg downward.

d. Clinical pelvimetry demonstrating inability to

reach the sacral promontory

d. None of the above

 190 Delivery

28-14. The image shown below demonstrates a ferus in 28-16. To resolve the complication shown in the image
which position? below, which of the following maneuvers should not
be employed?
ea
rm
fo)
ae
°Fa
oo

Reproduced with permiaion from Cunningham FG, Leveno KJ], Bloom SL, et al (eds): Breech
delivery. In Williams Obatetrics, 25th ed. New York, McGraw-Hill, 2018, Figure 28-4,

a. Sacrum posterior Reproduced with permission from Yeornans ER: Vaginal breech delivery. In Yeomans ER,
Hotiman BL, Giltrap LC TIL, et al (edi): Cunningham and Gilseap's Operative Obstetrics,

Ul
Srl ed, New York, McGraw-Hill, 2017, Figure 31-13,
c. Right sacrum anterior
d. Left sacrum transverse eee
28-15. Which of the following statements is false regarding b. The fetus should be rotated 180 degrees clockwise
the tenets of partial breech extraction? in the case of the left arm.
a. The breech is allowed to deliver spontaneously ro c. The fetus should be rotated 180 degrees counter-
the level of the umbilicus. clockwise for the right arm.
b. Following delivery of the legs, the fetal bony d. The fetus is gently pushed upward back into the
pelvis is grasped with both hands with fingers pelvis for second attempt at rotation if a primary
resting on the anterior superior iliac crests and maneuver is unsuccesstul,
thumbs on the sacrum.
c. After delivery of the fetal legs, steady, gentle, down- 28-17. Which of the following correctly describes aspects
ward traction is employed until the lower halves of of the Mariceau maneuver for delivery of the
the scapulae are delivered with no effort to deliver aftercoming head?
shoulders and arms until one axilla is seen. a. Suprapubic pressure is applied by an assistant to
aid in keeping the head extended.
b. Two fingers of one hand grasp the shoulders of
the back-down fetus from below while the other
hand grasps both fetal feet, lifting up and over the
maternal abdomen.

d. Once the suboccipital region of the feral neck

appears under the maternal symphysis, the fetal
body is lowered below the plane of the maternal
perineum to accomplish Hexion and subsequent
delivery of the head.
 Breech Presentation 191

28-18. What is the utility of the maneuver demonstrated in 28-19. Which of the following is true regarding the
the image below? procedure being demonstrated in this image?

Reproduced with permission fiom Cunningham FG, Leveno KJ, Bloom SL, ec al (eds): Breech
delivery, In Williams Obstetrics, 25th ed. New York, McGraw-Hill, 2018, Figure 28-I1c.

a. The blades must be disarticulated prior to fetal

head delivery,
Reproduced with permission from Cunningham PG, Leveno KJ, Bloom SL, et all (eds); Breech
delivery, In Williams Obstetrics, 25ch ed. New York, MeGraw-Hill, 2018, Figure 28-12, b. The blades are most easily placed with the
provider elevated on a stool to achieve greater
a. Safest maneuver for the delivery of the head of a height.
preterm breech,

c. Release of the aftercoming head in the setting of : ;

an incompletely dilated cervix. d. The fetal body, wrapped in the towel, is allowed
d. All of the ab to rest on the shanks, and after the forceps are
RENEE Ree tre correctly placed, the forceps and fetal body are
lowered to effect delivery of the head.

28-20. A 25-year-old G2P1001 at 30 weeks’ gestation has

been on the antepartum service for 2 weeks due to
preterm rupture of membranes. Her most recent
ultrasound showed an appropriately grown fetus in
footling breech presentation with oligohydramnios.
The nurse calls you because there are recurrent fetal
heart rate decelerations to 70 beats per minute on
her nonstress test. What is the initial verbal order
you give ro rhe nurse when you go ta see the patient?
a. Turn the patient on her left side

c. Start oxygen supplementation via facemask

d, Obtain normal saline and an intrauterine pressure
catheter so you can start an amnioinfusion.
 Breech Presentation 193

28-29. Which of the following is an absolute contraindica- 28-32. Internal podalic version is best characterized in
tion to external cephalic version? which of the following?
a. Early labor a. (a)
=
>
a
c, Oligohydramnios
b. Manipulation within the uterus to yield a vertex _
=
d. Fetal-growth restriction
presentation, typically reserved for the delivery of be)
ld
a second twin eo
28-30. Which of the following is true regarding perfor-
mance of external cephalic version? c. Manipulation within the uterus to yield a vertex
presentation for a preterm breech fetus immedi-
a. Immediate induction is indicated if version is
ately after ruprure of membranes
successful,
d. None of the above

— 28-33. A patient presents for her postpartum visit after

c. Increased amnionic fluid is correlated with suc- undergoing cesarean delivery at 40 weeks’ gestation
cess, and amnioinfusion is roucinely performed to for breech presentation. No uterine anomaly was
increase version success. identified during the surgery. Is breech presentation
d. All of the above more likely with her next pregnancy?
a. Yes, with one prior breech presentation at term,
28-31. External cephalic version success is improved with recurrence: is 696s
which of the following?
a, Acute tocolysis aes
b. Intravenous sedation c. Yes, with one prior breech presentation at term, =
c. Amnicinfusion to augment amnionic fluid recurrence is 28%.
volume d. No, in the absence of a uterine anomaly, fetal
d. All of the above presentation is random, and recurrence is not
increased above baseline risk.
 192 Deliveny

28-21. The patient in Question 28-20 was determined 28-24. Whar is the name of the process by which a frank
to have two feet and a loop of umbilical cord at breech fetus is manually converted to a footling
the vaginal introitus. Once in the operating room, breech presenration within the uterus during a
a)
m
general anesthesia is emergently induced and the cesarean or vaginal delivery?
am) fetal heart rate is 110 beats per minute. A repeat a. Retroversion
a examination reveals chat the scapulae of the fetus are
(e) b. Dextroflexion
past what feels to be a completely dilated cervix, and
a c. Displacement
oo the feral buttock is at the introitus. Which of the
following is true regarding a vaginal breech delivery
in this serting?
a. The Pinard maneuver is recommended. 28-25, The maneuver described in Question 28-24 has

b. There is an increased sis for head entrapment. which of the following eponyms?
a. Piper maneuver
¢, Uteroronics should be given during delivery
maneuvers, b. Pinard maneuver
d. All of the above
d. Simpson-McLane maneuver
28-22. Which maneuver, performed emergently for head
entrapment, is being demonstrated in the image, and 28-26, For planned vaginal delivery ofa breech fetus, which
at what position are incisions made? of the following is typically the most adequate
method of pain management?
a. A supportive doula
b. Pudendal anesthesia

lil
¢. Epidural anesthesia

28-27. Which of the following is true regarding external

cephalic version?
a, Overall success averages 80%
b. Success rate is lower with transverse lie than frank
breech.
c. It is typically performed in women if breech
persists at 36 weeks’ pestarion.

Reproduced with permission fram Cunningham PG, Leveno KJ, Bloom [Link] al (eels): Breech
delivery. fis Willlarns Obstetrics, 25th ed. New York, MeGriw-Hill, 2078, Figure 28-13,
28-28, A 38-year-old multigravida is being seen for routine
a. Symphysioromy at the symphyseal cartilage prenatal visit ar 34 weeks’ gestation. She had an
b. Symphysiotomy at the symphyseal ligament ultrasound last week showing a fetus in breech
presentation, She desires to avoid cesarean delivery
¢, Diihrssen incisions at 3:00, 9:00, and possibly 6:00
and asks about external cephalic version, Which of
the following statements is crue?
a. Multiparity decreases the likelihood of a successful
28-23. If the procedure performed in Question 28-23 is
version.
not successful, which of the following may aid in
fetal delivery? b. External cephalic version is best offered at or after
36 weeks’ gestation.
a. Piper forceps
c. There is low chance for spontaneous vertex
presentation at this gestational age.
c. Suprapubic pressure
d. Subcutaneous nitroglycerine
 195

CHAPTER 29

Operative Vaginal Delivery

29-1, What is the ratio of vacuum-assisted to forceps- 29-6. Which of the following criteria must be met prior to
assisted vaginal deliveries? performing an operative vaginal delivery?
a. 1:1 a. Adequate anesthesia
b. 2:1 b. Maternal bladder emptied
c 3:1 c. Known fetal head position
deat d. All of the above
29-2. All except which of the following are acceptable 29-7. A 32-year-old multigravida with an epidural in place
indications for operative vaginal delivery? has been pushing for 2 hours with poor descent.
a. Aortic stenosis The fetal head is positioned left occiput posterior,
Forceps delivery of this patient would be classified as
b. Matesnal exhaustion which of the following?
. Pelvic floor protection —
d. 2nd stage labor >2 hours in a multipara with an

Ul
epidural b High
c. Outlet
29-3. A 31-year-old primigravida undergoing induction of d. Low outlet
labor reaches the 2nd stage of labor after 36 hours.
Before beginning to push she says she is too tired 29-8. Which of the following describes forceps that are
and desires an operative vaginal delivery, Which of applied to the fetal head with the scalp visible at the
the following precludes her from having an elective introitus without separation of the labia?
operative vaginal delivery? a, Law
a. Head is at +1 station b. Mid
b. Head is in occiput anterior position c. High
c. Scalp is visible at the introitus without labial [Link]
separation
d, All of the above 29-9. Marernal morbidity with forceps delivery is most
closely predicted by which of the following?
29-4. Which of the following is a prerequisite for vacuum
:
extraction, saad!
but not a forceps-assisted :
vaginal he wc
delivery? b Madan! pasty
a. Epidural anesthesia c:, Feil gestuciaiall age

esis arate d. Length of the second stage

c. Assistant to create suction
d. Minimum 34 weeks’ gestation 29-10. In addition to operative vaginal delivery, which of
the following is a risk factor for urinary retention?
29-5. Which of the following is true of high forceps? a. Parity

b. Indicated for fetal bradycardia ¢. Labial swelling

¢. Forceps applied when the fetal head is engaged d. Length of the second stage
d. Indicated for those with a prolonged second stage
 196 Delivery

29-11. Which of the following occurs more frequently 29-15. A subgaleal hemorrhage is seen more frequently with
with forceps-assisted vaginal delivery compared to which of the following delivery routes?
vacuum-assisted vaginal deliveries? a. Forceps delivery
a)
inal a. Uterine atony b. Cesarean delivery
‘|
4 b. Urinary retention
(e) c. Prolonged hospital stay d. Spontaneous vaginal delivery
rr
oo
29-16. A 32-year-old primigravida with an cpidural has
29-12. Which of the following interventions may reduce been pushing for 3 hours. Fetal position is occiput
maternal perineal laceration during a forceps-assisted posterior, station is +2, and estimated feral weight
vaginal delivery? is 3400 grams. You consider an operative vaginal
a. Early disarticulation delivery for maternal exhaustion. Which of the
following is associated with failure of an operative
b. Mediolateral episiotomy
delivery?
c. Cessation of pushing during disarticulation
a. Primigravida
b. Full maternal bladder
29=13. The perinatal complication shown below is seen
more frequently with which of the following delivery d. Estimated feral weight >3400 grams
routes?
29-17. The opening in this forceps blade mainly serves
which of the following functions?

b. Cesarean delivery
a. Protects the fetal ears
c. Vacuum extraction
d. Spontaneous vaginal delivery
c. Offers a smaller metal surface area against the
29-14. What is che mechanism for the injury pictured in fetal skull
Question 29-13? d. Provides diminished traction forces against the
a. Intracranial hemorrhage maternal vaginal sidewall

During placement of a forceps blade, what is the

b. Shoulder dystocia from aforceps delivery
29-18,
purpose of having the right hand between the fetal
head and the vaginal sidewall?
d. None of the above a. Protects the fetal ears
b. Identifies the ischial spines
c. Reduces maternal discomfort during placement
a
 Operative Vaginal Delivery 197

29-19. In the setting of an ecciput posterior position, 29-24. In attempting a rotation from occiput anterior to
correctly placed blades are equidistant from what occiput posterior, which type of forceps is best
landmark? employed?
a. Fetal ears
b. Sagittal suture b. Luikart
c. Lambdoidal sutures c. Kielland
d. Simpson

29-20. How is asynclitism resolved after placement of 29-25. In all except which of the following presentations
forceps? may forceps be used?
a. It cannot be resolved a. Menrum anterior
b. Removing and replacing the forceps b. Occiput posterior

d. Occipur transverse
d. Proceeding with downward traction, and it will
spontaneously resolve 29-26. Which of the following is true concerning the
vacuum device pictured below compared to a soft
29=21. What forces are produced by a forceps-assisted cup system?
vaginal delivery?

c. Campression

29-22, Which of the following actions is necessary to rotate

a fetus from an occiput posterior to an occiput
anterior position?

b. Disengaging the fetal head

c. Fundal pressure to allow easier access to the feral
head
d. All of the above

29-23. Which of the following pelvic types is generally a. Allows easier placement
associated with persistent occiput posterior position? b. Allows more traction force
a. Android c. Higher scalp laceration rates
b. Gynecoid

d. Platypelloid
 198 Delivery

29-27. In the diagram below, which letter corresponds to 29-29, Which of the following is the preferred total negative
the flexion point where the center of the cup should pressure generated prior to initiation of traction
be placed? during vacuum extraction?
mi a. 0.2 kg/em*
m
oO
=
o c. 1.2 kg/cm?
ra
C d. 1.6 kg/cm?

29-30. During a vacuum-assisted vaginal delivery, all except

which of the following is the purpose of having the
nondominant hand simultaneously on the cup and
the fetal hand?

b, Gauge traction angle

c. Detect cup separation
d, Judge descent of the fetal head

29-31. In general, vacuum extraction would be

contraindicated in all except which of the following,
clinical settings?
a. 30-week fetus
b. Fetal thrombocytopenia

lll
c. Inability to assess fetal station

Modified with permission from Cunningham FG, Leveno KJ, Bloom SL, et al (eds):
Operative vaginal delivery, In William Obstetrics, 24th ed, New York, McGraw-Hill, 29-32. Ideally, traction during vacuum extraction should be
2014, Figure 29-16, applied in which of the following manners?
a. Continuously
aA
b.B
c. Intermittently and between contractions
e€
d, Intermittently with cycles of 20 seconds of
d. None of the above traction followed by 1 minute of rest
29-28. What is the purpose of placing the cup over the
flexion point?
a. Maximizes traction
b. Minimizes cup detachment
c. Delivers the smallest head diameter
200

CHAPTER 30

Cesarean Delivery and Peripartum Hysterectomy

30-1. Of the following indications for primary cesarean 30-6. A 22-year-old G1 at 39 weeks’ gestation with no
delivery, which is least common? prenatal care arrives on labor and delivery in active
a. Fetal jeopardy labor. When completing her delivery consents she
declines all blood products due to religious beliefs.
b, Labor dystocia
Which of the following interventions would be most
helpful ar this time?
d. Malpresentation a. Minimize blood draws
b. Erythropoietin administration
30-2. Which of the following indications for primary
cesarean delivery is most inappropriate? c. [ron and folic acid administration
a. Malpresentation es
b. Prior cesarean delivery
c, Unknown uterine scar type 30-7. A 20-year-old primigravida presents ac 40 weeks’
gestation with elevated blood pressures and a headache.
She is diagnosed with severe preeclampsia, and
30-3. Which of the following is least likely to have induction of labor is begun. After 28 hours she has
contributed to the rising rate of primary cesarean made no cervical change and the decision is made
delivery between 1970 and 2009? to proceed with primary cesarean delivery. Which
of the following interventions has been proven to
decrease her risk of postoperative wound infection,
b. Electronic feral monitoring
in addition to 2 grams of cefazolin prior to skin
¢. Decrease in rates of vaginal birth after cesarean incision?
delivery
a. Shaving of surgical site
d, Decrease in vaginal delivery rates for breech
presentation
¢. Preparation of the vagina with povidone-iodine
30-4. A 34-year-old primigravida at 39 weeks’ gestation d. All of the above
undergoes primary cesarean delivery on marernal
request. Compared to a woman with a vaginal 30-8. A 29-year-old woman at 40 weeks’ gestation is
delivery, which of the following adverse neonatal scheduled to undergo primary cesarean delivery for
outcomes is more likely to occur? malpresentation, She weighs 310 pounds, with a
a. Infection body mass index of 54 kg/m’. She asks which type of
skin incision is recommended, and you recommend
b. Birth trauma
a periumbilical vertical midline incision, Which of
the following is true regarding a vertical midline as
d. Hypoxic ischemic encephalopathy compared to transverse skin incision for this patient?
a. Decreased risk of neuropathy
30-5. Which of the following maternal obstetrical
b. Greater ease with wound care
complications is increased with cesarean delivery
as compared to vaginal delivery? c. Decreased risk of subfascial hematoma
a. Infection
b. Hemorrhage
c. Thromboembolism

d. All of the above

 Cesarean Delivery and Peripartum Hysterectomy 201

30-9. A 42-year-old G3P2 is scheduled to undergo a 30-13. A 30-year-old G4P3 at 39 weeks’ gestation under-
repeat cesarean delivery, She reports heavy menstrual goes repeat cesarean delivery, which is remarkable
bleeding outside of pregnancy and requests cesarean for extensive adhesive disease, Postoperatively she is
hysterectomy, You inform the patient this is not noted to have minimal urine output, abdominal a
<
an indication for cesarean hysterectomy given the distention, and severe abdominal pain. Her vital A
a
associated risks, You counsel her that cesarean signs are remarkable for mild tachycardia with blood =
hysterectomy increases her risk of which of the pressure 118/78 mmHg, and her hematocrit is noted m
-
following? to be stable from the preoperative value of 32%. Her iv)
a. Infection Foley is replaced and she receives multiple boluses So

of crystalloid without improvement in urine output.

b. Chronic pelvic pain
c. TREE
What is the next best step in management?
a. Transfusion
d. None of the above
b. Lasix administration
30-10. The patient in Question 30-9 is completing the c. Intravenous pyelography
consent for her repeat cesarean delivery, You discuss
the risks of bowel, bladder, and ureteral injury, Which
of the following most closely approximates the risk of
ureteral injury at the time of cesarean delivery? 30-14. A 30-year-old G3P3 presents to the emergency
a. 1 in 500 department on postoperative day 4 complaining of
24 hours of severe abdominal pain and intractable
b. 1 in 1000
nausea and vomiting. Her oral temperature is 39 °C:
c. 1 in 2000 she is tachycardic with a heart rare of 140 bpm and
appears pale and diaphoretic. What is the best next
step in management?
30-11. A 25-year-old G2P1 at 39 weeks’ gestation is a. Intravenous antibiotics
undergoing trial of labor after a cesarean delivery
in her previous pregnancy. She progresses to the
second stage of labor, but after 3 hours of maternal c. Placement of nasogastric tube, bowel rest
effort a fetal bradycardia occurs for which an d. None of the above
emergent cesarean delivery is performed. Which
of the following circumstances increases her risk of 30-15. Which of the following is a risk factor for urinary
unintentional cystotomy? retention after cesarean delivery?
a. History of prior cesarean delivery a. Hemorrhage
b. Need for emergent cesarean delivery b. Prior cesarean delivery
c. Cesarean delivery in the second stage of labor
d. All of the above

30-12. During the delivery in Question 30-11, an

unintentional cystotomy occurs, It is noted to be
present in the dome of the bladder, and good efflux
is noted from bilateral ureteral orifices, Which suture
is most appropriate for repair of the bladder mucosa
and muscularis layers?

b. 1.0 chromic
ce. 2.0 chromic
d. 4.0 monoeryl

212 of 448
 202 Delivery

30-16. A 21-year-old primigravida at 41 weeks’ gestation 30-17. Although not recommended by the American
is undergoing labor induction for oligohydramnios. College of Obstetricians and Gynecologists, elective
She progresses to the second stage of labor, but the cesarean delivery on maternal request should only be
“ fetal head does not descend below 0 station despite considered as an option when which of the following
aa
fa) 3 hours of pushing efforts. Cesarean delivery is criteria have been met?
= undertaken, but extraction is difficult and requires a. Permanent sterilization will be pertormed
oO upward pressure from the vagina. A radiograph
= b, There is concern for inadequate pain control in
Cy of the newborn head is shown here and reveals a
labor
depressed skull fracture (white arrow). Approximately
what percentage of cesarean deliveries is complicared ee
by some type of fetal injury?
d. The patient has a history of fetal injury in a prior
delivery

30-18. Which of the following preoperative interventions is

no longer recommended to decrease maternal risk at
the time of cesarean delivery?
a. Antacid administration
b. Foley catheter placement

d. Administration of antibiotics prior to skin

incision

30-19. Recommendations for antibiotic prophylaxis at

cesarean delivery for women with a significant
penicillin allergy include a single dose of which of
the following agents?
a. Levofloxacin
b. Clindamycin

d. Vancomycin plus piperacillin-tazobactam

30-20. To reduce postoperative morbidity, the American

College of Obstetricians and Gynecologists
recommends antibiotic prophylaxis be given within
how many minutes prior to skin incision?
a. 10 minutes
Reproduced with permission from Cunningham FG, Leyeno KJ, Bloom $L, et al (eds): b. 30 minutes
Diseases and injuries of the term newborn. In Williams Obstetrics, 24th ed. New York,
McGraw-Hill, 2014, Figure 33-1.
d. 90 minutes
a. 0.1%
b. 0.5%
30-21. When creating a Pfannenstiel skin incision, which
vessels should be anticipated halfway between the
skin and fascia, several centimeters from the midline?
d. 2.0% a. Inferior epigastrics
b. External pudendals

d. Superficial circumflex iliacs

 Cesarean Delivery and Peripartum Hysterectomy 203

30-22. Compared with a vertical midline incision, a 30-25. Failure to recognize dextrorotation of the uterus
PAannenstiel incision offers which of the following prior to hysterotomy increases the risk of damage to
benefits? which structure? a
a. Less postoperative pain a. Left ureter =
b. Improved cosmetic result b. Right ureter =
c. Less risk of incisional hernia c. Leff urerine artery, m
d. All of the above d. Right uterine artery He
So

30-23. When performing dissection through a Pfannenstiel 30-26. Extension of the hysterotomy may be accomplished
incision, the two fascial layers are incised as with two different methods, as shown below.
illustrated in this image. The first layer encountered, Compared with blunt extension, the use of bandage
which is incised in this image, is the aponeurosis of scissors for sharp extension has been associated with
what muscle? an increase in which of the following?

Amnionic

Ml
sac

Reproduced with permission fram Cunningham FG, Leveno KJ, Bloom SL, ct al (eds):
\ Cesarean delivery and periparcum hysterectomy, Lo’ Williams Obsterrics, 25ch ed. New
York, McGraw-Hill, 2018, Figure 30-5,
Reproduced with permission from Word L, Haffman BL: Surgeries for benign gynecologic
conditions. [In Hoffman BL, Schorge JO, Schaffer JI, et al (eds) Williams Gynecology: 2nd
ed, New York, McGraw-Hill, 2012, Figure 41-2.1. a. Blood loss
b. Operative time
a. Transversalis c. Unintended extensions
b. Internal oblique d. All of the above

d. Transversus abdominis

30-24. Which of the following benefits are seen with low

transverse uterine incisions in comparison to classical
incisions?
a. Ease of closure
b. Less likely to rupture in subsequent pregnancies
c. Lower risk of incisional adhesions to bowel or
omentum
 204 Delivery

30-27. During cesarean delivery a hysterotomy is made in 30-28. Compared with manual extraction, spontaneous
the lower uterine segment, as shown here. In which delivery of the placenta with fundal massage, as
of the following settings should the incision be made shown below, has been shown to reduce the risk of
va) relatively higher on the uterus to avoid uterine vessel which complication?
a
(ica laceration or unintended entry into the vagina?
za Lower uterine
o segment
ra
rs Uterine incision

Reproduced with permission from Cunningham FG, Leveno KJ, Bloom SL, et al (eds):
Reproduced with permission from Cunningham FG, Leveno KJ, Bloam SL, et al (eds):
Cesarean delivery and peripartum hysterectomy. In Williams Obstetrics, 25th ed. New
Cesarean delivery and peripartam hysterectomy. In Williams Obstetrics, 25th ec. New
York, McGraw-Hill, 2018, Figure 30-9.
York, McGraw-Hill, 2018, Figure 30-4,

a. Maternal anemia a. Retained placenta

b. Fetal malpresentation b. Postpartum infecion
c. Deep-vein thrombosis
d. Cesarean performed prior to onset of labor d. Amniotic fluid embolism
 Cesarean Delivery and Peripartum Hysterectomy 205

30-29. Which of the following is a disadvantage of uterine 30-32. Which of the following is a theoretical benefit of
exteriorization for repair of the hysterotomy, as show using a monofilament suture such as polydioxanone
below? (PDS) to close the fascial layer, as opposed to a
Cy
braided suture such as polyglactin (vicryl)?
a. ane
b. Lower halflife tensile strength
as
>
a|
nl
m
¢, Decreased risk of knot slippage -
i)
d. All of the above S

30-33. Which of the following is a potential indication for a

classical hysterotomy, as shown below?

Se releay
Reproduced with permission from Cunningham FG, Leveno KJ, Bloom SL, et al (eds):
Cesarean delivery and peripartum hysterectomy, In Williams Obstetrics, 25ch ed. New
Yorks McGraw-Hill, 2018, Figure 30-10, Reproduced with permission from Cunningham PG, Leveno KJ, Bloom SL, et al (eds):
Cesarean delivery and periparcum hysterectomy, In Williams Obsterrics, 25th ed. New
York, McGraw-Hill, 2018, Figure 30-12.
a. Increased blood loss
b. Increased febrile morbidity a. Maternal morbid obesity
¢. Increased nausea and vomiting b. Densely adherent bladder
d. Increased postoperative infection ¢. Back-down transverse feral lie

30-30. Which of the following interventions is most likely

d, All of the above
to decrease adhesion formation at the time of 30-34. A 33-year-old G3P2 with two prior cesarean
cesarean delivery? deliveries presents at 35 weeks’ gestation with active
a. Achieving hemostasis vaginal bleeding and fetal heart rate decelerations.
b; Closure of the peritoneum She e taken for emergent repeat cesarean delivery
and is found to have a placenta previa with accreta
c. Placement of an adhesion barrier at the that requires cesarean hysterectomy, Compared
hysterotomy with patients who have this procedure planned, this
d. All of the above woman is at increased risk for which of the following
complications?
30-31. Whar is a potential advantage of closure of the a. Bladder injury
parictal peritoncum prior to closure of the fascia at
the time of cesarean delivery? b. Ureteral injury
a. Shorter operative time i: Bisa seesietsicn
b. Less adhesion formation d. All of the above

€. Decreased postoperative pain 30-35. Women who have normal blood volume expansion
ce in pregnancy and a hematocrit of at least 30%
will usually tolerate blood loss up to what volume
without hemodynamic compromise?
a. 2000 mL
b. 3000 mL
c. 4000 mL
d, 5000 mL
 207

CHAPTER

Prior Cesarean Delivery

31-1. Which of the following factors favors a successful 31-4. You are taking care ofa 25-year-old G2P1 at
trial of labor in a woman with a prior cesarean delivery? 36 weeks’ gestation who underwent emergent primary
cesarean delivery for suspected fetal distress in her
first pregnancy, Her uterine incision closure from
b. Single mother
the time of surgery is pictured, If she chooses a trial
¢. Increased maternal age of labor for this pregnancy, what is her absolute risk
d. Short interdelivery interval of uterine rupture?

What is the estimated relative risk of uterine rupture

in women undergoing trial of labor after cesarean
delivery compared to those choosing elective repeat
cesarean delivery?
a. 5
b. 10
G 15

31-3. Which maternal complication is not increased in

women undergoing trial of labor after cesarean
delivery compared to those electing repeat cesarean
delivery?
a. ‘T'ransfusion

a. 3/1000
c. Urerine infection
d. Uterine dehiscence
c. 13/1000
d. 19/1000

Which of the following neonatal morbidities are

increased with trial of labor after cesarean delivery
compared to elective repeat cesarean delivery?
a. Respiratory distress syndrome
b. Hypoxic ischemic encephalopathy
c. Transient tachypnea of the newborn
d. All of the above
 208 ~—— Delivery

31-6. You are caring for a 26-year old G2P1 who 31-10. You see a patient at 34 weeks’ gestation. She had a
presents at 39 weeks’ gestation in active labor. She primary low-transverse cesarean delivery for failure
has a history of prior cesarean delivery for breech to progress 18 months ago. On ultrasound, the
a) presentation in her last pregnancy. This pregnancy lower uterine segment thickness measures 2.6 mm.
Cc has otherwise been uncomplicated. What is her How should you counsel the patient based on the
= approximate chance of a successful trial of labor? sonographic findings?
4 a. 30% a. This finding has no prognostic significance.
r b. 55% ding
©. 75% rupture

d. 95% c. This finding is associated with a high risk of

uterine rupture.
31-7. What is the chance of uterine rupture based on the d. This finding is associated with an intermediate
scar type shown in the photograph? risk of uterine rupture.

31-11, A 30-year-old G2P1 presents for her confirmation

of pregnancy visit. She underwent cesarean delivery
during her last pregnancy | year ago for malpresentation,
Her ultrasound results are shown below. What is the
most appropriate counseling based on the findings?

a. 0.2-—0.9%

b. 1-7%
c. 2-6%

31-8. The majority of women delivering via cesarean a. Her risk of uterine rupture is negligible.
delivery prior to 26 weeks’ gestation require what Se . ,
eo ‘ “ me 4 b. Her risk of uterine rupture 1S decreased because ot
type of uterine incision? it
Cun the ultrasound findings.
of uterine rupture
b. Pfannenstiel incision aaa
nd finding:
c. Low-vertical incision d. Her risk of uterine rupture is further increased
d. Low-transverse incision because of the ultrasound findings.

31-9. You are performing a primary low-transverse 31-12. Which risk factor confers the highest risk of uterine
cesarean delivery on a term patient for failure rupture in a subsequent pregnancy?
to progress. Which of the following operative a. Interdelivery interval <6 months
techniques may decrease her risk of uterine rupture
in a subsequent pregnancy?
: ; c. Maternal body; mass index >30 kg/m*
a. Locking stitches
d. Smallest myometrial thickness <2.0 mm
b. Double-layer closure ,
c. Placement of Floseal over the hysterotomy
 Priar Caesarean Delivery 209

31-13. What is the approximate chance of successful vaginal 31-16. Which of the following statements is true regarding
birth after cesarean delivery in a patient with a body elective repeat cesarean deliveries based on the figure
mass index exceeding 40 kg/m’? that is shown?
fa)
a. 50% 20- @ Any adverse outcome
Be
>
@ RDS or TTN a|
c. 70% ® Sepsis is
d. 80% 15
=
31-14. Which of the following is true regarding a woman
who attempts a trial of labor with a 32-week preterm

Percent
10
gestation?
a. The chance of uterine rupture is lower than with
a term gestation.
b. The chance of successful vaginal delivery is higher
than with a term gestation.
c. There is an increased risk of perinatal morbidity
and mortality compared to a term gestation, T T T T T T
a7 38 39 40 41 42
Gestational age (weeks)
31-15; Which of the following does not support performing Reproduced with permission from Cunningham PG, Leveno KJ, Bloom SL, et al feds):
an elective repeat cesarean delivery at 39 weeks’ Prior cesarean delivery, In Williams Obstetrics, 25th ed. New York, McGraw-Hill, 2018,
gestation without confirmation of fetal lung maturity Figure 31-4.
by amniocentesis?
a. Fetal heart sounds have been documented for
30 weeks by Doppler ultrasound.
b. A positive serum or urine 3-hCG test result has b. The risk of any adverse neonatal ourcome is
been documented for =36 weeks, highest at 37 weeks’ gestation.
¢. Sonographic measurements taken before 20 weeks’ c. There is no increased neonatal morbidity with
gestation support a gestational age >39 weeks. elective cesarean delivery at 38 weeks’ gestation.
d. None of the above

31-17. Which of the following induction agents or methods

confers the highest risk of uterine rupture in a
woman with a prior cesarean delivery?
a. Oxytocin

c. Prostaglandin F,,,
d, Transcervical foley catheter

31-18. What is the most likely sign or symptom ofa uterine

scar rupture in a laboring woman with a history ofa
prior cesarean delivery?
a. Pain
b. Bleeding
c. Decreased fetal movement
 210 ~—_— Delivery

31-19. Which of the following has been demonstrated in 31-23. Uterine scar rupture can mimic which of the follow-
women with a labor epidural who have an increased ing obstetric emergencies?
risk of uterine rupture? a. Placental abruption
ba a. Adequate pain relief is never achieved b. Pulmonary embolus
‘al -

=| Deiat Se end eee H BORE JS ASHES c. Amniotic fluid embolus

oO ¢. Successful epidural placement is more difficult d All: ofthe above
Fd
= d. None of the above
31-24, Which of the following findings is not helpful to
31-20. What percentage of successful vaginal births after diagnose a uterine rupture during labor?
cesarean delivery were completed via operative @.. Rewlidinasis
assistance with either vacuum or forceps? 5
b. Uterine tenderness
a. 5%
c. A firmly contracted uterus
b. 15%

d. 35%
31-25. As you are caring for a laboring patient at term who
31-21. Which of the following starements is true regarding is attempting a vaginal birth after having a previous
uterine scar exploration following successful vaginal cesarean delivery, you observe sudden and prolonged
birth after previous cesarean delivery? fetal bradycardia based on a fetal scalp electrode
a. Routine scar examination isrecommended. monitor. You proceed with an emergent cesarean
&. The:chance of identifying a defter is <0,1%. delivery with the intraabdominal findings pictured.
The fetus has been extruded into the abdominal
c. Any identified defect requires immediate explor- cavity. What are the chances of feral survival in this
atory laparotomy. situation?

Ul
31-22. You are augmenting a term patient who is arrempting a
vaginal birth after cesarean delivery. She is 6 cm dilared,
90% effaced, and —1 station and was comfortable with
her epidural anesthesia when you checked her 10 min-
utes ago. You notice the heart rate tracing abnormalities
thar are pictured. You recheck the patient, but can no
longer feel the fetal head. The maternal heart rate is

85 beats per minute, blood pressure 84/46 mmHg, and.

respirations 18 breaths per minute. What is the best
intervention based on the findings?

Reproduced with permission from Cunningham PG. Leveno KJ. Bloom SL, et al (eds):
Obstetrical hemorrhage. In Williams Obstetrics, 25th ed, New York, McGriw-Hill, 2018,
Figure 41-13.

Reproduced with permission from Cunningham FG, Leveno KJ, Bloom SL, et al (eds): Prior a. 5-15%

se .
cesarean delivery, In Williams Obstetrics, 25th ed. New York, McGraw-Hill, 2018, Figure 31-5.
b. 10-25%
a. Administer ephedrine €. 25-50%
b. Reposition the patient d. 50-75%

c. Attempt forceps placement

 Prior Cesarean Delivery 211

31-26. According to published studies, what is the critical 31-29. In a conservative approach to trial of labor follow-
time threshold from decision to delivery to avoid ing cesarean delivery, which of the following would
long-term neurological impairments in the infant? not be considered cautionary before pursuing a labor
(a)
a. Less than 9 minutes induction in a patient with a history of cesarean a
delivery? >
a]
a. High station |
c. Less than 31 minutes m
=
d. Less than 45 minutes re
c. Unknown incision rype al

31-27, Ina developed country, what are the risks of mater- d. Closed cervix at 41 weeks
nal and neonaral mortality, respectively, ifa uterine
rupture does occur during labor? 31-30. When should discussion of the risks and benefits
ofa wial of labor following cesarean delivery ideally
begin?
b. 0.5% and 7%
c. 0.2% and 7%
b. At the first prenatal visit
d. 0.5% and 5%
c. Prior to the start of the second trimester
31-28. Which of the following statements is true based on d. After the patient presents to labor and delivery

the figure that is shown? with contractions

® Wound/uterine infection 31-31. Which of the following led to the decrease in rates of
® Placenta previa trial of labor after cesarean delivery after 1996?
® Transfusion a. Reports of maternal mortality from uterine
® Hysterectomy rupture
® Placenta accreta b. Reports of perinatal mortality from uterine
rupture
Risk for complication (percent)

c. American College of Obstetricians and Gynecolo-

gists recommended that a physician be immediately
available
i

31-32. Which of the following is associated with the highest

vaginal birth after cesarean delivery rate?
a. Prior vaginal delivery
b. Normal body mass index
c. Estimated fetal weight <4000 grams
ee
7 r T T T

First Second Third Fourth > Fifth

(6201) (15,808) (6324) (1452) (347)
Number of repeat cesarean deliveries
(Number of women)

Reproduced with permission from Cunningham FG, Levene K], Bloom SL, et al (eds):
Prior cesarean delivery. In Williams Obstetrics, 25th ed, New York, McGraw-Hill, 2018,
Figure 51-6,

a, Placenta previa complicates approximately 6% of

first repeat cesarean deliveries.
b. The risk of wound infection is halved with the
second repeat cesarean delivery.
c. The risk of placenta accreta continues to increase
as the number of repeat cesarean deliveries
increases.