BC Intrapartum and Postpartum Care

Question 1

A 28 yo primigravid woman at 30 wk’s gestation delivers a 3-Ib 6-oz newborn. Her pregnancy was complicated by premature rupture of the membranes at 25 wks gestation. Ultrasound prior to spontaneous labour showed little amniotic fluid. Apgar scores are 3 and 1 at 1 and 5 minutes respectively. Which of the following is most likely the explanation for the neonatal condition?

a) Hydrops
b) Fetal growth restriction
c) Down syndrome
d) Anemia
e) Pulmonary hypoplasia
f) General dysgenesis 45 X (Turner syndrome)

Answer 1

e) Pulmonary hypoplasia

Question 2

A 30-yo G1P1woman, comes to clinic c/o fever and right breast tenderness for 1 day. She has been breast-feeding her 14-day old newborn. She has type 1 diabetes mellitus well controlled with insulin. Temp is 39.3C, and HR is 122/min. Examination shows engorgement of the breast bilaterally. There is an erythematous, nonfluctuant, tender area in the upper outer quadrant of the right breast. Abdominal exam shows no distension or tenderness. Which of the following is the most likely diagnosis?

a) Lipoma
b) Fat necrosis
c) Breast abscess
d) Mastitis
e) Fibroadenoma
f) Breast carcinoma

Answer 2

d)Mastitis

Question 3

Childbirth may cause fecal incontinence in a woman. This most often occurs with damage to which of the following structure?

a) Bulbs of vestibule
b) Hymen
c) Pelvic diaphragm
d) Perineal body
e) Sphincter urethrae

Answer 3

d)Perineal body

Question 4

Which of the following accurately defines a reactive nonstress test (NST)?

a) Two episodes of fetal heart acceleration of >15 beats per minute over baseline, lasting >15 seconds during a 20 minute observation period
b) Two episodes of fetal heart rate acceleration of >15 beats per minute over baseline, or two accelerations lasting > 15 seconds during a 20 minute observation period
c) Two spontaneous decelerations in fetal heart rate of < 15 beats per minute under baseline, lasting <15 seconds in response to two separate uterine contractions during a 20 minute observation period
d) Two episodes of fetal heart rate acceleration of >15 beats per minute over baseline, lasting <15 seconds during a 20 minute observation period
e) None of the above

Answer 4

a)Two episodes of fetal heart acceleration of >15 beats per minute over baseline, lasting >15 seconds during a 20 minute observation period

Question 5

Diminished beat-to-beat heart rate variability is often an indicator of?

a) Umbilical cord compression
b) Head compression
c) Uteroplacental insufficiency
d) Fetal anoxia or other central nervous system impairment
e) None of the above

Answer 5

d)Fetal anoxia or other central nervous system impairment

Question 6

What is an early deceleration?

Answer 6

Early deceleration:
Gradual decrease in FHR with onset of deceleration to nadir >30 seconds. The nadir occurs with the peak of a contraction.

Question 7

What is a late deceleration?

Answer 7

Late Deceleration:
Gradual decrease in FHR with onset of deceleration to nadir >30 seconds. Onset of the decleration occurs after the beginning of the contraction, and the nadir of the contraction occurs after the peak of the contraction.

Question 8

What is a variable deceleration?

Answer 8

Variable:
Abrupt decrease in FHR of > 15 beats per minute measured from the most recently determined baseline rate. The onset of deceleration to nadir is less than 30 seconds. The deceleration lasts > 15 seconds and less than 2 minutes. A shoulder, if present, is not included as part of the deceleration.

Question 9

Which of the following components is not used in the Biophysical profile?

a) Amniotic fluid volume
b) Fetal heart rate
c) Fetal tone
d) Fetal breathing
e) Fetal body movement
f) All of the above are components of the biophysical profile

Answer 9

b)Fetal heart rate

Question 10

A 32-yo G3P2 T2DM in hospital in labour at 38 wks’. Her first two children via SVD. On admission, the cervix is 2 cm dilated, the membranes are intact and the fundal height is 42 cm. Four hrs after admission, the cervix is completely dilated, and the vertex is occiput and at – 1 station. Over the next 1 hr, contractions occur every 2 mins, last 60 secs, and are normal in intensity, but the cervix and station remain unchanged. FHR N and reactive. 1 hr later, her condition remains unchanged.

Which of the following is the most likely cause?

a) Fetal malposition
b) Cephalopelvic disproportion
c) Shoulder dystocia
d) Contraction of the outlet
e) Hypotonic uterine activity

Answer 10

b)Cephalopelvic disproportion

Question 11

A 24 year old primigravida has been in labor for 6
hours. During the past 2 hours of observation the
contractions have become shorter and weakened. The
membranes are bulging and she has remained at 5 cm
dilation for this 2 hour period. The occiput is at station
(+)1 and there is no molding of the fetal head. Which of
the following should be the next step in management?

a) Administer intramuscular ergometrine
b) Administer buccal oxytocin
c) Apply intracervical prostaglandin gel
d) Observe for 4 hours and reevaluate
e) Perform artificial rupture of the membranes

Answer 11

e) Perform artificial rupture of the membranes

Question 12

Postpartum depression:

a) Is a fairly common disorder arising in as many as 25% of pregnancies
b) Often involves an element of post-partum psychosis that is responsive to antidepressant and/or antipsychotic medication
c) Occurs with higher frequency among patients with a history of major depression
d) Occurs with equal frequency among patients with a history of major depression and those without such a history
e) None of the above

Answer 12

c) Occurs with higher frequency among patients with a history of major depression

Question 13

A 34 year old woman has just delivered monozygotic twins via normal vaginal delivery. Weights are 5.6 and 6.2 lbs. She is now bleeding profusely from the uterus. On the basis of this information alone, which of the following causes is highest on your list of differential diagnoses:

a) Uterine hyperstimulation
b) Retained placental fragments
c) Vaginal laceration
d) Uterine atony
e) None of the above

Answer 13

d) Uterine atony

Question 14

An 18 year in ER and names you as her doctor (haven’t seen her in 6y). The nurse who is panicking calls you at 0230 to say that your patient says she is 37 ½ weeks GA, looks and acts stoned, can’t give a history, has no fixed address, has multiple old and new bruises everywhere and is bleeding per vaginal with clots. Her blood pressure and pulse are stable. What do you do?

Answer 14

1) Start large bore intravenous 18 gauge with lactated ringers or normal saline
2) Monitor the fetal heart (externally) as well as uterine activity
3) Take blood for blood group, type and cross, hemoglobin, hematocrit, platelet, clotting studies
4) Consider ordering oxygen
5) No vaginal exam until the physician arrives

Question 15

An 18 year in ER and names you as her doctor (haven’t seen her in 6y). The nurse who is panicking calls you at 0230 to say that your patient says she is 37 ½ weeks GA, looks and acts stoned, can’t give a history, has no fixed address, has multiple old and new bruises everywhere and is bleeding per vaginal with clots. Her blood pressure and pulse are stable. What is the ddx?

Answer 15

1) In labor with show/spontaneous rupture of membranes
2) Abruptio placenta
3) Placenta previa
4) Vasa praevia
5) Localized bleeding i.e cervical or vaginal

Question 16

What does the APT test do?

Answer 16

Explanation: blood is mixed with a small amount of tap water to cause hemolysis. The solution is centrifuged for several minutes to separate the debris from a pink supernatant containing hemoglobin. The supernatant is mixed with 1 cc of 1% NaOH (0.25 normal) for every 5 cc of supernatant. The color is read in 2 minutes-fetal hemoglobin stays pink and adult hemoglobin changes to yellowish brown. The purpose of the test is to distinguish fetal from maternal blood as a source of bleeding.

Question 17

A 26 year old primigravida presents at 40 weeks in active labour with contractions every two minutes. She is diagnosed as having a transverse lie with the back up. Which of the following would be the most appropriate next step?

a) Start vasodilan (Isoxuprine)
b) Perform an external version
c) Prepare for an immediate caesarean section
d) Rupture membranes and then perform and internal version
e) None of the above

Answer 17

c)Prepare for an immediate caesarean section

Question 18

A 30 year old primigravida delivered a 4500 g male
infant vaginally and subsequently had severe
postpartum hemorrhage due to placental
retention. The patient attempted to breastfeed the
infant thereafter, but this failed. During an office
visit at 20 weeks’ postpartum, she complains of
severe fatigue and failure to resume menstruation.
Which one of the following is the most likely diagnosis?

a) Post partum thyroiditis
b) Panhypopituitarism
c) Post-partum depression
d) Grave’s disease
e) Asherman’s syndrome

Answer 18

b) Panhypopituitarism

Question 19

A 24 year old G1P0 at 38 weeks presents with a 4 hour history of vaginal bleeding.
What are the two more important things to rule out?

Answer 19

1)Placenta previa
2)Placental abruption
3)Vasa previa
Most common——bloody show

Question 20

A 24 year old G1P0 at 38 weeks presents with a 4 hour history of vaginal bleeding. Ddx?

Answer 20

Most common; 
1. Placenta Previa 
2. Placental Abruption
3. Vasa Previa 
What are other potential diagnoses? 
4)Coagulopathy
5)Vaginal/cervical/uterine lesion
6)Bloody show
7)Post-coital trauma
8)Infection
9)Uterine rupture

Question 21

A primigravid female, following a prolonged first stage
of labor, has been in the second stage of labor for 3
hours with arrest of descent and rotation. She has caput
succedaneum at station-1, in an occipitoposterior (OP)
position. Which of the following management
options is most appropriate?

a) Simpson forceps and delivery in OP position
b) Kjelland forceps rotation and delivery
c) Lower segment cesarean section
d) Manual rotation and forceps delivery
e) Vacuum extraction delivery

Answer 21

c)Lower segment cesarean section

Question 22

Which one of the following presentations would indicate a vaginal delivery?

a) Persistent brow presentation
b) Transverse lie (shoulder presentation)
c) Footling breech presentation
d) Vertex presentation with umbilical cord prolapse
e) Face presentation (mentum anterior)

Answer 22

e)Face presentation (mentum anterior)

Question 23

In the hypertensive patient, each of the following is a useful therapeutic measure for postpartum hemorrhage, EXCEPT:

a) Oxytocin
b) Ergotamine
c) IV fluids
d) Prostaglandins
e) Premarin

Answer 23

b)Ergotamine