Abnormal Deliveries: Breech, Limb Presentation, Prolapsed Cord, Shoulder Dystocia, Nuchal Cord, and Multiple Births Practice Questions

25 multiple-choice questions on Abnormal deliveries: breech, limb presentation, prolapsed cord, shoulder dystocia, nuchal cord, and multiple births for paramedic and EMT students, from Chapter 42 (Obstetrics). Read each question, pick your answer, then tap Show answer to check it and read the explanation.

25 practice questions

1. A breech presentation is one in which the fetus presents:

   1. A. Head first, face down
   2. B. With one arm first
   3. C. Shoulder across the os
   4. D. Buttocks or feet first
   Show answer

   Answer: D. Buttocks or feet first

   In breech presentation the buttocks or lower limbs come first; in a normal vertex presentation the head comes first. A single arm presenting is a limb presentation, which cannot be delivered in the field.

2. In a frank breech presentation, the fetus has:

   1. A. Hips and knees both flexed
   2. B. One or both feet coming first
   3. C. Hips flexed and legs extended up
   4. D. One arm extended beside the head
   Show answer

   Answer: C. Hips flexed and legs extended up

   In a frank breech the hips are flexed and the legs extend up toward the face, so the buttocks lead. Hips and knees both flexed describes a complete breech, and a foot first describes a footling breech.

3. A woman at 38 weeks is pushing, and you see the infant's buttocks at the vaginal opening. Transport is 25 minutes away. You should:

   1. A. Pull gently on the legs to speed the delivery
   2. B. Support the body as it delivers itself
   3. C. Push the buttocks back up into the vagina
   4. D. Tell her to stop pushing until arrival
   Show answer

   Answer: B. Support the body as it delivers itself

   Breech births should be allowed to progress on their own while you support the infant's body, because traction can trap the head or injure the neck. Pushing the buttocks back is not possible and can harm both patients.

4. During a breech delivery, the body has delivered but the head has not after 3 minutes. You should:

   1. A. Make a V with two fingers to open an airway
   2. B. Pull firmly on the body to deliver the head
   3. C. Push down hard on the top of the uterus
   4. D. Cut the cord so the head can be released
   Show answer

   Answer: A. Make a V with two fingers to open an airway

   Place a gloved hand in the vagina with fingers on either side of the infant's nose and push the vaginal wall away to create an airway, then transport. Pulling the body can cause spinal cord and nerve injury.

5. During a breech delivery, you should keep the infant's back facing:

   1. A. Downward, toward the mother's back
   2. B. Upward, toward the mother's abdomen
   3. C. Sideways, toward the mother's thigh
   4. D. Whichever way the cord is lying
   Show answer

   Answer: B. Upward, toward the mother's abdomen

   Keeping the infant's back up allows the head to flex and pass under the pubic bone. Letting the infant rotate face up makes the chin catch on the symphysis.

6. A woman in labor has a single arm protruding from the vagina. You should:

   1. A. Pull gently on the arm to deliver it
   2. B. Push the arm back into the uterus
   3. C. Elevate her hips and transport rapidly
   4. D. Wait on scene for it to deliver on its own
   Show answer

   Answer: C. Elevate her hips and transport rapidly

   A limb presentation cannot be delivered vaginally in the field and needs a cesarean. Positioning with the hips elevated reduces pressure on the cord and uterus during rapid transport.

7. A woman at 39 weeks has ruptured membranes, and you see a loop of umbilical cord at the vaginal opening. You should first:

   1. A. Push the cord back into the uterus
   2. B. Clamp and cut the cord right away
   3. C. Have her push hard to deliver the infant fast
   4. D. Push the presenting part off the cord
   Show answer

   Answer: D. Push the presenting part off the cord

   With a gloved hand in the vagina, push the presenting part away from the cord to restore blood flow, and hold it there during transport. Pushing the cord back in or cutting it would stop the fetal oxygen supply.

8. After relieving pressure on a prolapsed cord, the best maternal position for transport is:

   1. A. Supine with the head raised 45 degrees
   2. B. Knee-chest, or supine with hips raised
   3. C. Seated upright with both legs crossed
   4. D. Left lateral with the hips lowered
   Show answer

   Answer: B. Knee-chest, or supine with hips raised

   The knee-chest or hips-up position lets gravity move the fetus away from the pelvis and off the cord. Raising her head lets the fetus press down onto the cord.

9. While transporting a patient with a prolapsed cord, you should:

   1. A. Wrap the cord tightly to restore flow
   2. B. Cover it with a dry sterile dressing
   3. C. Push the cord gently back inside
   4. D. Keep the exposed cord moist and warm
   Show answer

   Answer: D. Keep the exposed cord moist and warm

   Cover the exposed cord with a moist sterile dressing, because cooling and drying cause the vessels to spasm; a dry dressing lets it dry out. Pushing the cord back in is not attempted, and wrapping it tightly compresses the vessels. The priority remains keeping the presenting part off the cord.

10. After delivery of the head, it pulls back tightly against the perineum and the shoulders do not deliver. This is called the turtle sign and indicates:

    1. A. Shoulder dystocia
    2. B. Nuchal cord
    3. C. Breech position
    4. D. Uterine inversion
    Show answer

    Answer: A. Shoulder dystocia

    In shoulder dystocia the anterior shoulder is caught behind the symphysis pubis, so the head retracts against the perineum. A nuchal cord can make the head retract slightly but does not stop the shoulders from delivering.

11. The first maneuver to try for shoulder dystocia is to:

    1. A. Pull steadily downward on the infant's head
    2. B. Push firmly on the top of the uterine fundus
    3. C. Flex her thighs sharply onto her abdomen
    4. D. Cut the cord, then push the head back inside the vagina
    Show answer

    Answer: C. Flex her thighs sharply onto her abdomen

    The McRoberts maneuver flexes the thighs onto the abdomen, which flattens the pelvis and often frees the shoulder. Pulling on the head or pushing on the fundus can wedge the shoulder tighter and cause nerve injury.

12. During shoulder dystocia, a partner may assist the McRoberts maneuver by applying firm pressure:

    1. A. On top of the uterine fundus
    2. B. Just above the pubic bone
    3. C. Over the mother's lower back
    4. D. On the infant's head and neck
    Show answer

    Answer: B. Just above the pubic bone

    Suprapubic pressure pushes the anterior shoulder down and under the pubic bone. Fundal pressure drives the shoulder into the pubis and makes the dystocia worse.

13. A risk factor for shoulder dystocia is:

    1. A. A first pregnancy in a woman of 20
    2. B. A low-birth-weight preterm fetus
    3. C. Maternal diabetes with a large infant
    4. D. A low-lying placenta at term
    Show answer

    Answer: C. Maternal diabetes with a large infant

    Large infants, especially of diabetic mothers, and obesity raise the risk of dystocia. Small preterm infants are unlikely to have their shoulders caught.

14. After the head delivers, you find the cord loosely around the neck. You should:

    1. A. Slip it gently over the head
    2. B. Clamp and cut it right away
    3. C. Pull on the cord to loosen it
    4. D. Leave it and deliver the shoulders
    Show answer

    Answer: A. Slip it gently over the head

    A loose nuchal cord can usually be slipped over the head. Clamping and cutting is reserved for a cord too tight to slip off, because it cuts off placental oxygen before the infant is born.

15. The cord is wrapped tightly around the neck and cannot be slipped over the head. You should:

    1. A. Pull hard on the cord to stretch it
    2. B. Push the infant's head back inside
    3. C. Deliver the body without touching it
    4. D. Clamp it twice and cut between
    Show answer

    Answer: D. Clamp it twice and cut between

    A tight nuchal cord can strangle the infant or tear as the body delivers, so place two clamps and cut between them, then deliver promptly. Pulling on it may tear the cord and cause fetal blood loss.

16. A woman delivers an infant, but her abdomen remains large and contractions continue. You should suspect:

    1. A. Uterine rupture
    2. B. A second infant
    3. C. Retained urine
    4. D. Uterine inversion
    Show answer

    Answer: B. A second infant

    A persistently large uterus with ongoing contractions after birth suggests twins. Prepare for a second delivery and do not give oxytocin until you are sure no infant remains.

17. After the first twin is born, you should:

    1. A. Pull on the first cord to bring the placenta
    2. B. Give oxytocin to finish the second birth
    3. C. Clamp and cut the first cord, then prepare
    4. D. Transport without preparing for a second
    Show answer

    Answer: C. Clamp and cut the first cord, then prepare

    Clamp and cut the cord of the first twin to prevent blood loss from the second twin, then prepare for the second delivery. Oxytocin before the second twin is born can trap the infant.

18. Twins are more likely than single infants to be:

    1. A. Postterm and large for their dates
    2. B. Free of delivery complications
    3. C. Delivered without any bleeding
    4. D. Preterm and low in birth weight
    Show answer

    Answer: D. Preterm and low in birth weight

    Twins are often born early and small, so they need extra attention to warmth and breathing, and the second twin is often breech. Multiple births also increase the risk of postpartum hemorrhage.

19. During a field delivery with shoulder dystocia, the first two standard maneuvers have not freed the shoulder. A reasonable next step that many EMS protocols include is to:

    1. A. Roll her onto her hands and knees
    2. B. Apply firm pressure to the fundus
    3. C. Pull harder on the infant's head
    4. D. Push the head back in and wait
    Show answer

    Answer: A. Roll her onto her hands and knees

    The all-fours (Gaskin) position changes the pelvic dimensions and often frees a shoulder after McRoberts positioning and suprapubic pressure fail; trained providers may instead try delivering the posterior arm, and the hospital should be notified at once. Fundal pressure drives the anterior shoulder harder against the pubic bone and is avoided. Pulling harder on the head is the main cause of brachial plexus injury. Pushing the head back in (cephalic replacement) is a last-resort hospital procedure followed by immediate cesarean, not a field step. (ACOG Practice Bulletin 178; Bruner 1998.)

20. Which fetal presentation found during a field delivery cannot be delivered vaginally and needs rapid transport for cesarean delivery?

    1. A. Frank breech with the buttocks first
    2. B. Transverse lie, shoulder first
    3. C. Vertex with the occiput anterior
    4. D. Vertex with the occiput posterior
    Show answer

    Answer: B. Transverse lie, shoulder first

    When the fetus lies across the uterus, a shoulder or arm presents and the body cannot pass through the pelvis, so the mother needs a cesarean; position her to reduce pressure and transport rapidly. A frank breech can deliver vaginally if you support the body and let it deliver itself. Occiput anterior is the normal vertex position. Occiput posterior causes back pain and slower labor, but most such infants still deliver vaginally. (Caroline, abnormal presentations.)

21. A woman at 39 weeks delivers within minutes of your arrival after only a few strong contractions. This precipitous delivery puts the infant at increased risk of:

    1. A. Injury from a rapid descent
    2. B. Shoulder dystocia from the fast descent
    3. C. Hypoglycemia after birth
    4. D. Cord prolapse after the head delivers
    Show answer

    Answer: A. Injury from a rapid descent

    A rapid, uncontrolled delivery can injure the infant's head and tear the mother's perineum and cervix. Supporting the head with gentle palm pressure helps control the speed. Shoulder dystocia is linked to a large infant rather than a fast descent, a short labor does not cause neonatal hypoglycemia, and cord prolapse happens before the presenting part delivers, not after the head is out.

22. A woman whose infant is in the occiput posterior position, facing up, is most likely to have:

    1. A. A precipitous second stage
    2. B. Face presentation with chin first
    3. C. Back pain and slower labor
    4. D. Shoulder dystocia at delivery
    Show answer

    Answer: C. Back pain and slower labor

    When the infant faces up, the hard occiput presses on the mother's sacrum, causing back labor and slower progress. It is a variant of head-first (vertex) presentation, not a face presentation, it tends to slow rather than speed the second stage, and it is not a recognized cause of shoulder dystocia. Most occiput posterior infants still deliver vaginally.

23. You arrive to find a woman at 24 weeks delivering a very small infant. Your greatest immediate concern for the newborn is:

    1. A. Excessive birth weight for dates
    2. B. Meconium aspiration risk
    3. C. Shoulder dystocia
    4. D. Heat loss and weak breathing
    Show answer

    Answer: D. Heat loss and weak breathing

    Preterm infants lose heat quickly and often have weak breathing, so dry, wrap, and keep them warm, and support ventilation as needed. Large infants, not preterm ones, are at risk of shoulder dystocia.

24. A woman at term with a footling breech presentation is pushing, and a foot is at the vaginal opening. The main danger to the fetus is:

    1. A. Prolapse of the cord
    2. B. Shoulder dystocia from size
    3. C. Placenta previa with bleeding
    4. D. Uterine inversion after birth
    Show answer

    Answer: A. Prolapse of the cord

    The small presenting part of a footling breech leaves room for the cord to slip past it, so cord prolapse is more likely. Shoulder dystocia is related to large infants in a head-first birth.

25. When a woman has an abnormal presentation that you cannot deliver in the field, the general approach is to:

    1. A. Stay on scene until labor stops itself
    2. B. Try to turn the fetus from the outside
    3. C. Position her and transport immediately
    4. D. Ask her to push hard to try to deliver
    Show answer

    Answer: C. Position her and transport immediately

    Abnormal presentations that cannot be delivered need surgery, so position to reduce pressure on the cord and transport without delay. Attempting to turn the fetus from the outside is a hospital procedure.