labour ward

Question 1

From the oracle trial which antibiotic is the best first choice for PROM?

a) amoxyl
b) augmentin
c) erythromycin
d) none of the above

Answer 1

c) erythromycin

Question 2

2. Elective CS for placenta praevia (1x previous CS for CPD last time). After removal of placenta get bleeding form placental bed. Blood loss is 2000ml. Patient is hypotensive and starting blood transfusion.

a) Hysterectomy
b) PGF2alpha
c) Internal iliac ligation

Answer 2

a) Hysterectomy

Question 3

3. A patient has an epidural top up with marcaine for an operative delivery. She immediately has a tonic-clonic seizure then cardiac arrest. What is the LEAST helpful thing you can do?

a) intubate
b) ventilate with mask/100% O2
c) deliver baby urgently
d) ephedrine IV
e) CPR with patient in left lateral tilt

Answer 3

d) ephedrine IV

Question 4

4. Pick the correct response regarding the episiotomy:

a) Essential management of the primigravida patient
b) Episiotomy rate should be 10%
c) To avoid excessive blood loss the episiotomy should be made after locking the blades during a Keillands forceps
d) May avoid the use of forceps in cases of deep transverse arrest
e) None of the above

Answer 4

e) None of the above

Question 5

5. 41/40 essential HT on meds, otherwise uncomplicated, nonreactive trace for 23 minutes. All are reasonable choices except:

a) Continue for further 30mins
b) Contraction stress test
c) VAST ??
d) IOL
e) Send home or CS

Answer 5

e) Send home or CS

Question 6

6. All of the following are complications of beta-mimetics for tocolysis except:

a) hypokalaemia
b) hyperglycaemia
c) chest pain
d) hyponatraemia

Answer 6

d) hyponatraemia

Question 7

7. Primigravida, short 1st stage, slow but steady 2nd stage. After delivery of the head, shoulders do not follow with a strong downward traction or movement in to the oblique (Woods Screw). What should you do next?

a) fundal pressure and increased maternal effort
b) push head back in and do LUSCS
c) fracture clavicle
d) deliver posterior arm

Answer 7

d) deliver posterior arm

Question 8

Multigravida, epidural in situ, just had a low forceps delivery of twin 1 for prolonged second stage. On abdo palp, twin 2 is oblique with head in RIF, FHR 80 bpm. Moderate PV bleeding. Best management is:

a) LUSCS
b) ECV, ARM, Ventouse
c) Internal podalic version, ARM, breech extraction
d) Internal cephalic version, ARM, breech extraction
e) ECV, ARM, encourage mother to push hard

Answer 8

c) Internal podalic version, ARM, breech extraction

Question 9

Multi in labour, epidural top-up with 15ml of ropivicaine 0.5% for instrumental delivery. Suddenly has a seizure and cardiac arrest. Likely cause is:

a) local anaesthetic toxicity
b) total spinal block
c) eclampsia
d) idiopathic epilepsy

Answer 9

a) local anaesthetic toxicity

Overdose of local anaesthetic (or injection of correct dose directly into a blood vessel) will primarily affect the CNS. The patient will feel light headed and dizzy and may become euphoric and confused. She will often complain of ringing in the ears and perioral paraesthesia. She may develop muscle twitching. These symptoms are very important to watch for, because they mean that the patient is likely to have a grand mal convulsion, which maybe followed by coma and respiratory arrest.

Question 10

12. There is a result of 40ml of fetal cells on Kleihauer at delivery of RH negative woman. How much anti-D should she be given?

a) 1 vial
b) 2 vials
c) 5 vials
d) 7 vials
e) 10 vials

Answer 10

d) 7 vials

100IU/ml = 100 x 40 = 4000IU/625IU = 6.4vials
125IU/ml

Question 11

13. Which of the following features is helpful in distinguishing HELLP syndrome from TTP?

a) TTP requires immediate delivery of fetus
b) DIC occurs more commonly with HELLP than TTP
c) Liver dysfunction is more common with TTP

Answer 11

b) DIC occurs more commonly with HELLP than TTP

TTP
o Multi-system disease, often with neurological involvement and fever
o Assoc with pregnancy and the postpartum period
o Underlying aetiology in pregnancy remains unknown
o Fever, normal coagulation, low platelets, haemolytic anaemia, neurological disorders and renal dysfunction
o Platelets 5-100
o Mild – steroids
o Severe – plasma exchange
o Platelets infusions contraindicated, delivery does not alter course although simplifies maternal management

Question 12

Regarding placental sulfatase deficiency, which statement is correct?

a) Premature labour is a feature
b) Equal sex distribution with fetal effects
c) Inheritance is X-linked recessive
d) Associated with neonatal dermatitis

Answer 12

c) Inheritance is X-linked recessive

Question 13

15. A woman presents at 30/40 with increasing abdominal pressure. Examination shows a 35cm fundal height and no evidence of chorioamnionitis. CTG rate 200bpm with no decelerations. She is O+. US shows fetal pleural and pericardial effusions. What is your next step in management?

a) Perform fetal pericardiocentesis
b) Commence maternal digoxin
c) Perform amniocentesis for karyotope
d) Delivery
e) Repeat US in 1 weeks

Answer 13

b) Commence maternal digoxin

SVT common > 90% of fetal arrhythmias
Rates >. 220 can develop into hydrops
The baby has fetal SVT with evidence of early heart failure which may resolve with digoxin if heart rate slows.
Cardiac compromise manifests by cardiac chamber enlargement and fluid collection in pericardial and abdominal spaces
Structural heart disease rare in patients with tachycardias
Digoxin is first line treatment in SVT due to favourable side effect profile, acceptable transplacental passage when the fetus is healthy and moderate inotropic support.
Other – IV amiodarone if rapid control needed due to hydrops, sotolol, flecanide

Question 14

16. A 29 yo Rh+ woman has been a poor ANC attender presents at 30/40 in labour and delivers a hydropic fresh stillbirth. All of the following investigations are indicated except:

a) Maternal urinary drug screen
b) Placental histology
c) Fetal karyotype
d) Maternal serum screen for Kell antibodies
e) Hb electrophoresis of baby’s blood – hydropic baby therefore potential heart failure from beta or alpha thal

Answer 14

a) Maternal urinary drug screen

Question 15

17. Which is not characteristic of a variable deceleration?

a) Response to hypoxia
b) Activation of baroreceptors
c) Result of head compression
d) Stimulation of the carotid sinus

Answer 15

c) Result of head compression

Variable decels
•	Cause – cord compression
•	Receptors – aortic arch baroreceptors (in response to hypertension of fetus)
Early decels
•	Cause – fetal head compression
•	Receptors – cerebral chemoreceptors
Late decelerations 
•	Cause – fetal hypoxia and uteroplacental insufficiency
•	Receptors – aortic arch chemoreceptors
Prolonged decels
•	Cause – total cord occlusion, maternal hypotension, etc
•	Receptors – aortic arch chemoreceptors

Question 16

18. A woman delivers a severely macerated fetus and placenta. PV bleeding is within normal limits. Platelets 50,000, HCT 38%. Most appropriate management is:

a) Observe for bleeding
b) Give fibrinogen
c) Give platelets
d) Give fresh whole blood
e) Give heparin

Answer 16

a) Observe for bleeding

Question 17

19. Steroids in a preterm baby will

a) Reduce RDS
b) Reduce IVH
c) Reduce NEC
d) All of the above
e) A and B but not C

Answer 17

d) All of the above

Question 18

20. A woman with severe idiopathic cardiomyopathy is having an atonic PPH. EBL 800-1000ml. You have given 10 units Syntocinon but she is still bleeding. Next agent should be?
    a) Further 10 units Syntocinon
    b) 40 units Syntocinon in a 1L flask
    c) Intramyometrial PGF2alhpa
    d) IV ergometrine – no

Answer 18

b) 40 units Syntocinon in a 1L flask

Question 19

21. Regarding syntocinon. Which is true?
    a) Causes hypernatraemia-
    b) May cause hypotension in the mother
    c) Water intoxication is seen because it is given in 5% dextrose
    d) Should be given in 5% dextrose to reduce the risk of electrolyte incompatibility

Answer 19

b) May cause hypotension in the mother

Question 20

Damage to a 32/40 breech presenting fetus’s liver can be avoided by?

a) pinard’s manoeuvre - A method for delivering a fetus in breech position in which one leg is bent and passed along the thigh of the other leg as the foot of the bent leg is brought down and out.
b) Lovsett’s manoeuvre
c) Keeping the back uppermost until the shoulders have delivered
d) Only holding the fetal thighs
e) Using pure maternal effort to deliver past the shoulders

Answer 20

d) Only holding the fetal thighs

Question 21

23. Tocolysis. Which is true?

a) IV GTN gives a short lived significant tocolytic effect
b) Halothane is more effective than enflurane or isoflurane at equivalent doses in causing uterine relaxation
c) Syntocinon has no effect on maternal BP –

Answer 21

a) IV GTN gives a short lived significant tocolytic effect

Question 22

24. *The dose of IV salbutamol for sudden tonic contraction causing fetal distress is

a) 500 mcg
b) 100 mcg
c) 25 mcg
d) 10 mcg

Answer 22

b) 100 mcg

Question 23

25. A woman at 28/40 complained of reduced movements for several days, so a CTG was performed. CTG shos baseline 140, with persistent late decelerations. The least helpful thing you could do is:

a) Immediate LUSCS
b) Reassess via CTG in 12/24
c) Biophysical profile
d) Fetal blood sampling
e) Discharge home

Answer 23

e) Discharge home

Question 24

26. 35/40 gestation, complaining of several days of reduced fetal movements. CTG show flat trace, persistent shallow decelerations. The least helpful thing you could do is:

a) Immediate LUSCS
b) IOL
c) Repeat CTG in 12/24
d) Fetal blood sampling

Answer 24

c) Repeat CTG in 12/24

Question 25

27. A 28 yo primip, at 26/40 attends ANC. Fundal height is &laquo_space;dates. US – BPD/AC and FL all < N. Appropriate managements is:

a) karyotype
b) maternal antiphospholipid screen

Answer 25

a) karyotype

Question 26

28. Regarding nitric oxide: which is wrong

a) Contracts smooth muscle
b) Equally effective at 48 hrs as Ventolin
c) Acts via cyclic GMP

Answer 26

a) Contracts smooth muscle

Question 27

29. Regarding smooth muscle contraction, which is wrong:
    a) Voltage dependent Ca channels
    b) Receptor mediated calcium channels
    c) Smooth endoplasmic reticulum uptake of calcium

Answer 27

c) Smooth endoplasmic reticulum uptake of calcium (?release) – decrease ca efflux from cell and retention of intracellular calcium from sarcoplasmic reticulum

Question 28

Alloimmune thrombocytopenia, management, correct option:

a) IV immunoglobulin
b) Plasmapheresis
c) Prednisolone
d) Betamethasone
e) Fetal platelet transfusion

Answer 28

a) IV immunoglobulin

Treatment
 Immunoglobulin infusion – first line
o Reduced anti-plt antibody production via negative feedback
o Reduced platelet destruction by RES via blocking Fc receptor
o 1mg/kgwk
o 80% response
 Corticosteroids for non-responders
o Prednisolone 60mg daily
o 50% response
o reduced antibody production
o inhibition of lysis of antibody fixed platelets
 IU platelet transfusion
o Indication – inadequate respone to immunoglobulin and steroids
o Platelet specific antigen negative platelets
o Weekly due to short half life of platelets – fall approx 50 x 10to the 9/day

Question 29

Relaxin, incorrect option

a) Main production from corpus luteum
b) Not associated with adverse outcome if not present
c) Similar to growth hormone
d) RCT has not shown that it is useful for ripening the cervix

Answer 29

b) Not associated with adverse outcome if not present – incorrect

a) Main production from corpus luteum – ( CL releases Progesterone, inihibin and relaxin ) – True
b) Not associated with adverse outcome if not present – incorrect
c) Similar to growth hormone - correct
d) RCT has not shown that it is useful for ripening the cervix - true

Relaxin — Relaxin is a member of the insulin-like growth factor family of proteins. Plasma levels are highest at 8 to 12 weeks of gestation and thereafter decline to low levels, which persist until term [80]. The primary source of relaxin is thought to be the corpus luteum.

Relaxin appears to act indirectly to promote myometrial relaxation by stimulating myometrial prostacyclin production. This effect can be negated by inhibitors of prostaglandin synthesis. Relaxin also has been implicated in cervical ripening and/or rupture of the fetal membranes, but this remains controversial [81].

Question 30

32. Breech delivery, incorrect option:

a) LUSCS at 30/40 will prevent cord prolapse at 40/40
b) All women should be told to have LUSCS
c) RCT showed decreased perinatal mortality with LUSCS
d) LUSCS should be performed after 39/40 but before the onset of labour

Answer 30

b) All women should be told to have LUSCS

Question 31

33. Cerebral palsy, incorrect option:

a) 20 times more likely if Apgars <4 at 5 mins -
b) 5% will develop CP if Apgars <4 at 5 mins -
c) Triplets 45 per 1000 develop CP
d) Twins 15 per 1000 develop CP
e) Singleton 2 per 1000 develop CP
f) 25% infants with grade 3 IVH develop CP –

Answer 31

f) 25% infants with grade 3 IVH develop CP

Dx of CP due to intrapartum event
1. Neonatal signs consistent with acute peripartum or intrapartum event
Apgar score of <5 at 5 minutes and 10 minutes
Fetal umbilical artery acidemia: fetal umbilical artery pH <7.0, or base deficit ≥12 mmol/L, or both
Neuroimaging evidence of acute brain injury seen on brain MRI or MRS consistent with hypoxia-ischemia
Presence of multisystem organ failure consistent with hypoxic-ischemic encephalopathy
2. Type and timing of contributing factors consistent with intrapartum event
3. Developmental outcome is spastic quadriplegia or dyskinetic CP

Question 32

34. CTG abnormality, incorrect option:

a) decreased variability with pethidine
b) tachycardia with hydralazine -
c) non-reactive with beta blocker
d) absent variability with methyl dopa
e) sinusoidal trace with parvovirus

Answer 32

d) absent variability with methyl dopa