Postnatal and Neonatal Care

Question 1

What is the recommended dose of acyclovir to be administered to neonates at high risk of vertical transmission of herpes simplex?

a. 2mg/kg
b. 5mg/kg
c. 10mg/kg
d. 20mg/kg
e. 35mg/kg

Answer 1

D - 20mg/kg

Infants born to mothers with recent or active primary genital HSV infection require active management with IV anti-viral medication at birth. The dose is higher per kg than in adults – 20mg/kg 8 hourly.

Question 2

Which of the following is NOT routinely recommended for systemically well infants delivered vaginally to mothers with a history of primary HSV <6 weeks antenatally?

a. Lumbar puncture
b. Skin swabs
c. Breastfeeding
d. IV acyclovir 8 hourly
e. Rectal and oropharyngeal swabs

Answer 2

A - Lumbar puncture

Active investigation and management for potential neonatal HSV infection is recommended in babies born vaginally to mothers with a history of primary genital HSV in the third trimester or <6 weeks pre-delivery including IV acyclovir and rectal, skin, oropharyngeal and conjunctival swabs. Breastfeeding is recommended unless the mother has herpetic lesions around the nipples. There is not indication for routine lumbar puncture in the initial investigation of a well neonate.

Question 3

What percentage of neonatal HSV is though to be acquired postnatally?

a. 5%
b. 10%
c. 25%
d. 35%
e. 50%

Answer 3

C - 25%

Up to 25% of neonatal HSV is thought to be as a result of postnatal contact with the virus – often via an infected relative of the mother. Those with coldsores should not kiss the baby.

Question 4

A neonate born to a mother with undetected primary HSV 4 weeks prior to vaginal delivery presents with disease which appears to be localised to the skin alone. With appropriate antiviral treatment, what is the likelihood of long-term neurological morbidity?

a. <2%
b. 4%
c. 8%
d. 12%
e. 15%

Answer 4

A - <2%

The prognosis is neonatal herpes infection depends largely on the systems involved – infants with localised skin/eye or mouth infection alone have the best prognosis – with appropriate treatment, neurological or ocular morbidity is <2%. Such presentation accounts for ~30% of all neonatal herpes infection.

Question 5

An infant is readmitted from home after a normal vaginal delivery 2 weeks ago with suspected localised CND HSV disease. What are the approximate rates of mortality and long-term neurological impairment associated with such a presentation?

a. Mort. 2% Neuro. 20%
b. Mort. 5% Neuro. 33%
c. Mort 6% Neuro. 70%
d. Mort 10% Neuro. 50%
e. Mort 30% Neuro. 85%

Answer 5

C - Mortality 6%; Neurological Impairment 70%

70% of neonatal herpes infections involve disseminated or localised CNS disease which both carry a considerably worse prognosis than isolated skin disease. In localised CNS disease, mortality is around 6% and neurological morbidity (which may well be lifelong) 70%.

Question 6

An infant is readmitted following vaginal delivery with apparent disseminated HSV infection. What are the respective rates of mortality and long term neurological impairment in this group?

a. Mort. 5% Neuro 33%
b. Mort. 30% Neuro. 80%
c. Mort. 30% Neuro. 17%
d. Mort. 50% Neuro 50%
e. Mort 70% Neuro. 33%

Answer 6

C - Morality 30%; Neurological Impairment 17%

Disseminated neonatal herpes infection unsurprisingly carries the poorest prognosis – 30% morality and 17% long term neurological sequelae. Poorer outcomes in these groups are in part attributed to the fact that symptom onset if often more delayed (~10 days to 4 weeks postnatal typically) meaning further time may elapse before a diagnosis is reached.

Question 7

Which of the following is reported transiently amongst infants born to mothers taking acyclovir in pregnancy?

a. Raised liver enzymes
b. Low platelets
c. Neutropenia
d. Hypocalcaemia
e. Hypophosphataemia

Answer 7

C - Neutropenia

Mothers taking acyclovir as prophylaxis against active lesions at delivery can be reassured that while the drug is not licensed for use in pregnancy, it is not known to be harmful – a transient neonatal neutropenia has been reported in some though with no long term adverse effects.

Question 8

What is the approximate incidence of EOGBS disease of the newborn in the UK?

a. 0.1 in 1000
b. 0.5 in 1000
c. 1 in 1000
d. 2.5 in 1000
e. 3 in 1000

Answer 8

B - 0.5 in 1000

The incidence of EOGBS infection in the UK was 0.57/1000 in 2015 representing a considerable increase since the previous survey in 2000. This equated to 517 cases nationwide in one year.

Question 9

How soon following birth must GBS infection occur to be considered ‘early onset’?

a. 24 hours
b. 3 days
c. 7 days
d. 14 days
e. 6 weeks

Answer 9

C - 7 days

To differentiate it from late-onset GBS, EOGBS is defined as infection occurring within the first 7 days of life. This sad, over 90% of affected infants will display clinical signs or symptoms within 12 hours.

Question 10

What is the case-fatality rate amongst infants affected by EOGBS disease?

a. 1%
b. 5%
c. 10%
d. 20%
e. 35%

Answer 10

B - 5%

While rates of GBS appear to have risen somewhat in recent years, the mortality associated with the condition have fallen drastically from ~10% in 2000 to ~5% in 2015. This is considerably greater for preterm infants (20-30%) than term (2-3%)

Question 11

What proportion of babies affected by EOGBS disease are born prematurely?

a. 1/10
b. 1/8
c. 1/5
d. 1/3
e. 1/2

Answer 11

C - 1/5

22% of infants who developed EOGBS in the 2015 survey were delivered preterm – equivalent to around 1/5. The mortality associated with EOGBS infection in preterms is tenfold higher than term – 20-30% vs. 2-3%.

Question 12

What is the incidence of EOGBS in the newborn where the mother develops a temperature >38C in labour?

a. 1 in 400
b. 1 in 200
c. 1 in 150
d. 1 in 100
e. 1 in 50

Answer 12

B - 1 in 200

Maternal pyrexia >38C in labour increases the risk of EOGBS in the neonate and antibiotics given for this should also cover GBS. The risk is estimated to be approximately 1 in 200

Question 13

A primigravida is booked for midwifery led care in this pregnancy and attends the birthing unit in spontaneous labour at 38/40. On review of her record, the midwife notes that she tested positive for GBS during an admission with suspected, though unconfirmed, membrane rupture at 32/40. She explains to the patient that antibiotic prophylaxis is recommended though the patient declines. How long after birth in such cases should the baby be closely monitored as an inpatient for signs of EOGBS infection?

a. 6 hours
b. 12 hours
c. 24 hours
d. 48 hours
e. 72 hours

Answer 13

B - 12 hours

Infants deemed to be at risk of GBS infection where antibiotic prophylaxis has not been given in labour, should be monitored at birth, 1 hour, 2 hours then 2 hourly thereafter for signs suggestive of GBS infection. Where the mother has received adequate antibiotic prophylaxis (i.e. >4 hours), no additional monitoring is necessary. The exception is mothers with a previously affected baby – these infants should be monitored for 12 hours regardless.

Question 14

A Para 2 with a history of GBS carriage in a previous pregnancy (the baby was not affected) receives IAP in labour this time around. Antibiotics were commenced when she attended delivery suit at 01:00 and she delivered by SVD some 9 hours later at 10:00. How long after birth should be the baby be closely monitored as an inpatient for signs of EOGBS infection?

a. No monitoring required
b. 4 hours
c. 6 hours
d. 12 hours
e. 24 hours

Answer 14

A - No monitoring required

Infants deemed to be at risk of GBS infection where antibiotic prophylaxis has not been given in labour, should be monitored at birth, 1 hour, 2 hours then 2 hourly thereafter for signs suggestive of GBS infection. Where the mother has received adequate antibiotic prophylaxis (i.e. >4 hours), no additional monitoring is necessary. The exception is mothers with a previously affected baby – these infants should be monitored for 12 hours regardless.

Question 15

A Para 1 undergoes induction of labour at term for anxiety after her first child died of GBS infection at 3 days of life. She is treated appropriately and promptly with IV IAP in labour and after a 6 hour labour, delivers by SVD. How long after birth should the baby be closely monitored as an inpatient for evidence of EOGBS?

a. No monitoring necessary
b. Hourly until 6 hours
c. 2 hourly for 24 hours
d. 4 hourly for 48 hours
e. At 1 hour, 2 hours and 2 hourly thereafter for 12 hours

Answer 15

E - At 1 hour, 2 hours and 2 hourly thereafter until 12 hours

Infants deemed to be at risk of GBS infection where antibiotic prophylaxis has not been given in labour, should be monitored at birth, 1 hour, 2 hours then 2 hourly thereafter for signs suggestive of GBS infection. Where the mother has received adequate antibiotic prophylaxis (i.e. >4 hours), no additional monitoring is necessary. The exception is mothers with a previously affected baby – these infants should be monitored for 12 hours regardless.

Question 16

What antibiotic regimen is advised for babies who display symptoms/signs of EOGBS infection after birth?

a. Benzylpenicillin monotherapy
b. Benzylpenicillin/Vancomycin
c. Gentamicin monotherapy
d. Benzylpenicillin/Gentamicin
e. Vancomycin monotherapy

Answer 16

D - Benzylpenicillin/Gentamicin

Babies who display signs suggestive of EOGBS infection should receive both Benzylpenicillin and Gentamicin.

Question 17

What is the relative risk of developing VTE in the post-partum, compared with the ante-partum period?

a. 2x
b. 5x
c. 10x
d. 15x
e. 20x

Answer 17

B - 5x

The risk of VTE is increased 4-6 times in pregnancy when compared with non-pregnant controls. This is an worthwhile consideration when we think how much emphasis is put on considerably smaller increases in risk of VTE on certain contraceptives. The risk is further increased considerably in the post-natal period – around 20 times greater than outwith pregnancy or, put another way, around 5 times greater than antenatally. For this reason, the threshold for prophylactic LMWH is considerably less in the post-natal period.

Question 18

How long after administration of a spinal anaesthetic or siting of an epidural catheter might LMWH safely be administered in at-risk patients?

a. 2 hours
b. 4 hours
c. 6 hours
d. 12 hours
e. 18 hours

Answer 18

B - 4 hours

LMWH should not be given for a minimum of 4 hours following a spinal anaesthetic or removal of an epidural catheter. Where regional anaesthetic has NOT been used, the first dose of LMWH should be given as soon as possible after delivery providing there is no PPH, as pregnancy associated pro-thrombotic changes are maximal immediately following delivery.

Question 19

How long after a dose of prophylactic LMWH might an epidural catheter safely be removed?

a. 4 hours
b. 6 hours
c. 8 hours
d. 12 hours
e. 24 hours

Answer 19

D - 12 hours

An epidural catheter should not be removed less than 12 hours from the last administration of LMWH.

Question 20

A patient on antenatal LMWH prophylaxis for a history of VTE requires a return-to-theatre on day 3 after she develops a large haematoma within her caesarean section scar. What is the incidence of wound haematoma after LSCS in women on prophylactic LMWH?

a. 0.5%
b. 2%
c. 5%
d. 7.5%
e. 10%

Answer 20

B - 2%

Evidence for an increased risk of bleeding amongst patients on LMWH is controversial – some studies suggestive of an increased risk of PPH which is not supported by others. The risk of wound haematoma after caesarean section amongst those on prophylactic LMWH is increased at ~2%.

Question 21

You see a patient on the postnatal ward round who has been on LMWH since developing a DVT in the left calf at 35/40. She is struggling with administering daily heparin injections and enquires about the option of switching to an oral preparation. How long after delivery is it appropriate to switch from LMWH to warfarin?

a. 24 hours
b. 48 hours
c. 5 days
d. 7 days
e. 10 days

Answer 21

C - 5 days

Women should be offered a choice of either LMWH or oral anticoagulants for postnatal therapy though should be advised of the need for regular blood tests for monitoring of warfarin levels, especially during the initial 10 days of treatment. Warfarin should be avoided until day 5 post-partum or long in women at increased risk of PPH.

Question 22

29. How long after switching to warfarin postnatally, should LMWH be continued in patients who develop VTE in pregnancy?

a. LMWH can be stopped immediately on commencing warfarin
b. 3 days
c. 7 days
d. Until INR >2 for 24 hours
e. Until INR >2.5 for 24 hours

Answer 22

D - Until INR >2 for 24 hours

INR should be checked on day 2 of warfarin treatment and subsequent doses titrated to keep INR between 2 and 3 – heparin should be continued until INR is >2 for at least 24 hours. Both warfarin and LMWH are safe in breastfeeding.

Question 23

30. Which of the following risk profiles most accurately reflects the safety of varying thromboprophylaxis agents in breastfeeding mothers?
    LMWH Warfarin NOACS
    a. Safe Safe Safe
    b. Safe Not safe Safe
    c. Safe Safe Not safe
    d. Not safe Safe Not safe
    e. Safe Not safe Not safe

Answer 23

C - LMWH and warfarin safe; NOACs not safe

Neither unfractioned nor low-molecular weight heparin nor warfarin are contraindicated in breastfeeding. Small amounts of heparin may be present in breast milk although as neither form is orally active, this is of little consequence. Warfarin in 99% bound to serum proteins and does not pass into breast milk to any measurable degree. NOACs may be considered in women who are not breastfeeding but data on safety in those who are is severely limited/lacking altogether and they should be avoided.

Question 24

A patient has a spontaneous vaginal delivery following diagnosis of an IUFD at 36/40. What would you offer to suppress lactation as a first line agent?

a. Domperidone 250mg BD for 7 days
b. Bromocriptine 2.5mg BD for 14 days
c. Cabergoline 1mg stat dose
d. Prolactin 32mg stat dose
e. Bromocriptine 5mg stat dose

Answer 24

C - Cabergoline 1mg stat dose

Women should be advised that dopamine agonists successfully suppress lactation in a very high proportion of women and are very well tolerated. Cabergoline at a single stat dose of 1mg is equally effective though simpler to use than Bromocriptine which must be taken twice daily for 14 days. Dopamine agonists are contraindicated in women with pre-eclampsia or hypertension.

Question 25

Dopamine agonists are used successfully in the suppression of lactation following IUFD. In which of the following situations should dopamine agonists be avoided?

a. Cardiac disease
b. Placental abruption
c. Pre-eclampsia
d. Asthma
e. Sepsis

Answer 25

C - pre-eclampsia

Women should be advised that dopamine agonists successfully suppress lactation in a very high proportion of women and are very well tolerated. Cabergoline at a single stat dose of 1mg is equally effective though simpler to use than Bromocriptine which must be taken twice daily for 14 days. Dopamine agonists are contraindicated in women with pre-eclampsia or hypertension.

Question 26

With lactation suppression, how quickly after delivery can fertility return following stillbirth?

a. 9 days
b. 18 days
c. 4 weeks
d. 6 weeks
e. 8 weeks

Answer 26

B - 18 days

While perhaps a difficult subject area, it is important that subsequent fertility and contraception are discussed with women prior to discharge home as many are unaware of how quickly fertility can return. With lactation suppression this can occur as early as day 18 and women may well fall pregnant again before their next menstrual period.

Question 27

What is the most common manifestation of invasive Group A Streptococcal infection following pregnancy?

a. Pneumonia
b. Cellulitis
c. Mastitis/breast abscess
d. Meningitis
e. Endometritis

Answer 27

E - Endometritis

The most common site of sepsis in the puerperium is the genital tract – in particular the uterus – resulting in endometritis – though GAS may cause infection elsewhere including mastitis and pharyngitis

Question 28

It is recommended that NSAIDs be avoided for pain relief in postnatal patients with sepsis – what is the rationale for this?

a. To avoid exacerbation of occult renal failure
b. They increase the incidence of secondary post-partum haemorrhage
c. They impair the ability of polymorph cells to fight GAS infection
d. They diminish the efficacy of the more commonly utilised antibiotic regimens
e. They can lead to both an increase in white cell count and serum lactate which may impede interpretation of such markers in evaluating response to therapy

Answer 28

C - They impair the ability of polymorph cells to fight GAS infection

NSAIDs should be avoided for analgesia in puerperal sepsis as they may impair the ability of polymorph cells to fight potential GAS infection.

Question 29

A patient is readmitted from home by ambulance feeling unwell 3 days postnatal after a normal vaginal delivery. On immediate review on delivery suite she is found to be hypotensive (80/40mmHg), tachycardic (115/min) and tachypnoeic (24/min). Blood are sent including lactate (4.7) and cultures (pending) and prompt antibiotic therapy initiated. In commencing IV fluid rehydration, what blood pressure target should be the aim?

a. Maintain systolic >100mmHg
b. Maintain systolic >90mmHg
c. Maintain MAP >65mmHg
d. Maintain MAP >80mmHg
e. Maintain diastolic >50mmHg

Answer 29

C - Maintain MAP >65mmHg

In the treatment of severe sepsis, fluid resuscitation should be used with the aim of maintaining mean-arterial pressure >65mmHg – if this is not possible following 20ml/kg of crystalloid, vasopressors may need to be considered.

Question 30

A primigravida suffers a major PPH following a normal delivery. It is estimated she has lost approximately 1 litre. How much iron will be contains within 1 litre of blood loss?

a. 10mg
b. 100mg
c. 500mg
d. 5 grams
e. 50 grams

Answer 30

29

Question 31

Which of the following drugs carries the highest risk of neonatal adaptation syndrome (NAS) in the newborn?

a. Fluoxetine
b. Paroxetine
c. Citalopram
d. Escitalopram
e. Sertraline

Answer 31

B - Paroxetine

Question 32

What frequency of neonatal observations should be undertaken in infants exposed to significant meconium during labour?

a. Hourly for 6 hours
b. Hourly for 12 hours
c. 1h, 2h, 4h and 6h
d. 1h, 2h then 2 hourly until 12 hours
e. 12, 2h then 2 hourly until 24 hours

Answer 32

D - 1h, 2h then 2 hourly until 12 hours

Question 33

What approach should be taken to suturing the skin in perineal tears following delivery?

a. Continuous subcuticular
b. Interrupted vertical mattress
c. Interrupted horizontal mattress
d. Interrupted
e. Continuous through skin

Answer 33

A - Continuous subcuticular

Question 34

A 25 year old para 2 presents some 8 days following a forceps delivery feeling unwell. Her temperature is elevated at 38C and she is tachycardic. On questioning she reports pain in the left breast and on examination there is an obviously inflamed, tender area. Which of the following statements is correct with respect to mastitis?

a. Group A Streptococcus is the most common causative organism
b. Mastitis may occur in the absence of bacterial infection
c. Breastfeeding should be discontinued from the affected breast
d. Mastitis most commonly occurs in the lower left quadrant of the breast
e. Ultrasound should be performed in all cases, routinely

Answer 34

B - Mastitis may occur in the absence of bacterial infection

In lactating women, the primary cause of mastitis is milk stasis causing an inflammatory response which may or may not become infected. Staph. Aureus is the most common infective organism.

Mothers should be advised to continue feeding from the affected breast as failure to do so can worsen symptoms.

Only women with a suspected breast abscess require routine ultrasound.

Question 35

A Para 2 is reviewed on the postnatal ward round the morning after a normal delivery. She was under obstetric led care in pregnancy on account of her history of depressive illness which was treated with anti-depressant therapy. She is anxious about the safety of her medication in breastfeeding. Which of the following antidepressants is safest during breastfeeding?

a. Doxepin
b. Fluoxetine
c. Citalopram
d. Escitalopram
e. Sertraline

Answer 35

E - Sertraline

Question 36

You have just performed a caesarean section at 33 weeks of gestation for severe pre-eclampsia. The baby is born in good condition and there are no immediate surgical concerns. Which of the following is most appropriate with respect to cord clamping?

a. Clamp the cord as soon as possible
b. Wait at least 30 seconds but no longer than 1 minute
c. Wait at least 30 seconds but no longer than 2 minutes
d. Wait at least 30 seconds but no longer than 3 minutes
e. Wait at least 30 seconds but no longer than 4 minutes

Answer 36

D - Wait at least 30 seconds but no longer than 3 minutes

Question 37

A 26 year old nulliparous woman undergoes a ventouse extraction delivery in theatre. The infant is reviewed by the neonatal team the following morning who are concerned about a well defined swelling over the parietal bone with clear margins. What is the most likely nature of this swelling?

a. Caput succedaneum
b. Cephalhaematoma
c. Chignon
d. Subaponeurotic haemorrhage
e. Subgaleal haemorrhage

Answer 37

B - Cephalhaematoma

Cephalhaematoma is a sub-perioesteal collection of blood between the periosteum and the bone due to rupture of blood vessels and may be associated with skull fracture. These are usually well defined and most commonly found over the parietal bone.

Caput succedaneum is a subcutaneous, extra-periosteal serosanguineous fluid collection caused by the pressure of the presenting part against the dilating cervix.

Chignon is a temporary swelling on the head at the ventouse cup application site.

Subgaleal or subaponeurotic haemorrhage develops where there is bleeding between the periosteum and the scalp galeal aponeurosis. A fluctuant boggy mass develops over the scalp often extending across the entire skull - it is usually secondary to multiple ventouse attempts.

Question 38

A 32 year old woman is brought to the emergency department with a one day history of fever, rigors, abdominal pain and heavy lochia. She had an uncomplicated vaginal delivery two days ago. On arrival she has a temperature of 39C, heart rate of 143, blood pressure of 82/50 and a respiratory rate of 40/min. Following initial resuscitation, what is the most appropriate immediate management?

a. Blood cultures and vaginal swabs
b. Broad spectrum IV antibiotics
c. Evacuate retained products of conception
d. IV dopamine
e. IV immunoglobulins

Answer 38

A - Blood cultures and vaginal swabs

It is vital that blood cultures are taken initially, though IV antibiotics should not be delayed while waiting on cultures.

Question 39

A 25 year old woman is noted to have persistently elevated blood pressure in excess of >150/>100mmHg for 3-4 days following a normal vaginal birth. Her bloods are all normal and there is no proteinuria. She was not known to have blood pressure problems antenatally. She is breastfeeding. Which of the following options is the most appropriate antihypertensive which can be prescribed for her?

a. Amlodipine
b. Bendroflumethiazide
c. Candesartan
d. Enalapril
e. Methyldopa

Answer 39

D - Enalapril

Enalapril and captopril have no adverse effects on breastfeeding infants - evidence for the other ACE inhibitors is lacking. A beta-blocker would have been an appropriate alternative though none are listed.

Question 40

A 21 year old has a normal vaginal delivery at term. The following morning, the midwife on the postnatal ward expresses concern that the baby has a ‘sticky eye’. What is the most common causative organism of infective neonatal conjunctivitis?

a. C. Trachomitis
b. H. Influenzae
c. N. Gonorrhoea
d. Staph. Aureus
e. Strep. Pneumoniae

Answer 40

A - C Trachomitis.

Chlamydial infection accounts for up to 40% of all neonatal conjunctivitis. The risk of the neonate being affected in infected mothers is also 40%.

Question 41

What is the approximate incidence of OASIS in primigravidae compared with multigravidae?

a. 2.4% Pr. 0.4% Mu.
b. 3.6% Pr. 0.7% Mu.
c. 4.5% Pr. 4.1% Mu.
d. 5.3% Pr. 2.3% Mu.
e. 6.1% Pr. 1.7% Mu.

Answer 41

E - 5.3% Pr. 2.3% Mu.

Obstetric anal sphincter injury is a common complication of vaginal birth, occurring in approximately 2.9% of all vaginal births in the UK. Incidence has risen sharply since the late 1990’s/early 2000’s. It is over 3x more likely in primigravidae (6.1%) than multigravidae (1.7%).

Question 42

The lining of the anal canal varies along its length owing to the differences in embryological origins of the two parts. What two mucosal types comprise the proximal and distal components respectively?

a. Prox. Columnar Dist. Modified Squamous
b. Prox. Squamous Dist. Columnar
c. Prox. Transitional Dist. Stratified Squamous
d. Prox. Squamous Dist. Transitional
e. Prox. Columnar Dist. Transitional

Answer 42

A - Prox. Columnar Dist. Modified Squamous

The lining of the anal canal varies along its length due to its embryological derivation. The proximal anal canal is lined with rectal mucosa (columnar epithelium) whereas the distal 1–1.5 cm of the anal canal is lined with modified squamous epithelium

Question 43

Which of the following is NOT a recognised risk factor for OASIS:

a. OP position
b. Prolonged second stage
c. Birthweight >4kg
d. Low socio-economic status
e. Asian ethnicity

Answer 43

D - Low socio-economic status

The risk factors for obstetric anal sphincter injury are well described:
•	Asian ethnicity
•	Nulliparity
•	BW >4kg
•	Shoulder dystocia
•	OP position
•	Prolonged second stage (incremental)
•	Instrumental delivery
Unlike many complications occurring in pregnancy, there is no association with socio-economic status.

Question 44

The resultant angle of an episiotomy is the most important consideration when making the incision with perineum at full distension. Ideally at what angle should the incision be made to give the optimum resultant angle of 45 degrees?

a. 50
b. 55
c. 60
d. 65
e. 70

Answer 44

C - 60

With the perineum at full stretch, an episiotomy given at 40 degrees will result in a post-delivery angle of only 22 degrees from the midline which is too close to be maximally protective. A post-delivery angle of 45 degrees which is the gold-standard, can be achieved by making the incision at 60 degrees at full distension. Visual estimation of such an angle is unreliable and special scissors have been developed to assist practitioners in this.

Question 45

What is the single largest risk factor for OASIS?

a. Forceps delivery
b. OP position
c. Nuliparity
d. Shoulder dystocia
e. LFGA

Answer 45

C - Nuliparity

Of all described factors linked to OASIS, nulliparity carries the highest risk – RR 6.97 compared with 2.44 for OP position or even 6.53 in forceps delivery (without episiotomy )

Question 46

Which of the following has NOT been shown to be effective in reducing incidence of 3rd/4th degree tear?

a. Perineal massage
b. Warm compress
c. ‘Hands-on’ technique at delivery
d. Mother not pushing at crowning
e. Optimal episiotomy

Answer 46

A - Perineal massage

A Cochrane review of four trials found that while perineal massage during the last month of pregnancy resulted in a lower incidence of perineal tears requiring suturing, there was no difference in the incidence of third or fourth degree tears. The other methods described have all been shown to have some protective effect against OASIS when used appropriately.

Question 47

What is the reported incidence of suture migration in OASIS?

a. 7%
b. 13%
c. 21%
d. 33%
e. 42%

Answer 47

A - 7%

Suture migration is reported in around 7% of OASIS repairs – this is typified by pain/irritation around the perineum following repair. It may be minimised by trimming suture ends and burying knots in the deep and superficial perineal muscle.

Question 48

In what manner and with what material should the ano-rectal mucosa be repaired in a 4th degree perineal tear?

a. Continuous with PDS
b. Interrupted with PDS
c. Continuous with Vicryl
d. Interrupted with Vicryl
e. Either continuous or interrupted with Vicryl

Answer 48

E - Either continuous or interupted with vicryl

Either continuous or interrupted sutures are an acceptable means of repairing a defect in the ano-rectal mucosa in 4th degree or button-hole tear. Vicryl (Polyglactin) 3-0 is the suture material of choice.

Question 49

What technique should be employed for repair of the internal anal sphincter and with what stitch in obstetric anal sphincter injury?

a. End to end PDS
b. Overlapping PDS
c. End to end Vicryl
d. Overlapping Vicryl
e. End to end – either Vicryl or PDS appropriate

Answer 49

E - End to end - either Vicryl or PDS are appropriate

While most practitioners are more familiar with using PDS for repair of the anal sphincter itself, both PDS and Vicryl are associated with equivalent outcomes. For internal sphincter injury, an end-to-end technique should be used with no attempt made to overlap.

Question 50

A patient undergoes a forceps delivery in OP position for prolonged bradycardia and sustains a 3B perineal tear with the EAS completely transected though no apparent IAS injury. How should the sphincter be repaired and with which material?

a. End to end – PDS
b. Overlapping PDS
c. End to end or overlapping – PDS
d. End to end or overlapping – Vicryl
e. End to end or overlapping – PDS or Vicryl

Answer 50

E - End to end or overlapping - PDS or Vicryl

In repairing the anal sphincter complex, both Vicryl or PDS may be used with equivalent outcomes dependent on surgeon’s preference. For full thickness tears of the EAS, either an end to end or overlapping technique may be employed. If there is a partial thickness tear only, end to end repair should be performed.

Question 51

What percentage of women will be asymptomatic 12 months following repair of an EAS tear (i.e. 3A/B)?

a. 30-40%
b. 40-60%
c. 60-80%
d. 80-90%
e. >90%

Answer 51

C - 60-80%

Of patients sustaining EAS injury only (i.e. 3A/B tears) – 60-80% will be asymptomatic at 12 months postnatal.

Question 52

What is the recurrence risk of OASIS in subsequent vaginal delivery?

a. 2-3%
b. 5-7%
c. 10-15%
d. 15-21%
e. 21-25%

Answer 52

B - 5-7%

The recurrence risk of OASIS in subsequent vaginal delivery is approximately 5-7%. Even in the absence of a repeat OASIS, ~17% of women may find their existing symptoms of faecal incontinence worsening after vaginal birth, particularly where this had been present for the first 3 months following the initial injury.

Question 53

What percentage of women with a history of OASIS will report worsening faecal symptoms after a subsequent vaginal delivery, where recurrence of the OASIS does not occur?

a. 10%
b. 17%
c. 26%
d. 34%
e. 51%

Answer 53

B - 17%

The recurrence risk of OASIS in subsequent vaginal delivery is approximately 5-7%. Even in the absence of a repeat OASIS, ~17% of women may find their existing symptoms of faecal incontinence worsening after vaginal birth, particularly where this had been present for the first 3 months following the initial injury.

Question 54

Rounded to the nearest whole number, what is the overall incidence of obstetric anal sphincter injury in the UK population?

a. 1%
b. 3%
c. 5%
d. 6%
e. 8%

Answer 54

B - 3%

In the UK population as a whole, the incidence of OASIS is 2.9%.

Question 55

A patient sustains a deep perineal tear following a waterbirth on the birthing unit. You examine the patient in lithotomy position and vaginal and rectal examination reveals the external sphincter to have torn completely, though the internal sphincter and rectal mucosa appear intact. What sort of anal sphincter injury is this?

a. 3A
b. 3B
c. 3C
d. 3D
e. 4th

Answer 55

B - 3B

This is a 3B tear – more than 50% of the EAS is torn though the IAS remains intact. There is no such thing as a 3D tear.

Question 56

A primigravida undergoes a forceps delivery in theatre for prolonged second stage. The delivery is somewhat uncontrolled and the operator is unable to perform a timely episiotomy. There is rather extensive perineal injury on close inspection with a high vaginal wall tear on the left side. The anal sphincter complex appears intact although on digital rectal examination, the glove can be seen through an apparent defect in the rectal mucosa around 2cm proximal to the sphincter. What classification of OASIS is this?

a. 3A
b. 3B
c. 3C
d. 4th
e. Rectal button-hole

Answer 56

E - Rectal button hole

Injuries such as that described are rare though often incorrectly classified as 4th degree tears. Infact such tears are known as ‘button-hole’ tears and do not form part of the usual OASIS classification. If not recognised and repaired, there is a significant risk of recto-vaginal fistula.

Question 57

You are called to review a patient on the post-natal ward who had an estimated blood loss of 800ml during a ventouse delivery 24 hours ago. She is feeling well and keen to go home. How would you describe her blood loss?

a. Normal for operative delivery
b. Minor PPH
c. Moderate PPH
d. Major PPH
e. Severe PPH

Answer 57

B - Minor PPH

The traditional definition of primary post-partum haemorrhage is the loss of 500ml or more of blood loss from the genital tract within 24 hours of birth (secondary PPH occurs from 24 hours to 12 weeks post-natal). PPH in the broadest terms is either minor (500-1000ml) or major (>1000ml). Major PPH can then be subdivided into either moderate (1001-2000ml) and severe (>2000ml).

Question 58

You meet a Para 1 in the antenatal clinic who has been referred on account of a history of ‘severe’ post-partum haemorrhage in her first pregnancy. What is the threshold for ‘severe’ post-partum haemorrhage by RCOG definitions?

a. >1000ml
b. >1500ml
c. >2000ml
d. >2500ml
e. >3000ml

Answer 58

C - >2000ml

The traditional definition of primary post-partum haemorrhage is the loss of 500ml or more of blood loss from the genital tract within 24 hours of birth (secondary PPH occurs from 24 hours to 12 weeks post-natal). PPH in the broadest terms is either minor (500-1000ml) or major (>1000ml). Major PPH can then be subdivided into either moderate (1001-2000ml) and severe (>2000ml).

Question 59

A patient attends the delivery suite one week following a normal vaginal delivery with a brisk PV blood loss. Within what time frame following delivery does ‘secondary’ post-partum haemorrhage occur by definition?

a. 6 hours – 1 week
b. 12 hours – 2 weeks
c. 12 hours – 6 weeks
d. 24 hours – 6 weeks
e. 24 hours – 12 weeks

Answer 59

E - 24 hours - 12 weeks

The traditional definition of primary post-partum haemorrhage is the loss of 500ml or more of blood loss from the genital tract within 24 hours of birth (secondary PPH occurs from 24 hours to 12 weeks post-natal). PPH in the broadest terms is either minor (500-1000ml) or major (>1000ml). Major PPH can then be subdivided into either moderate (1001-2000ml) and severe (>2000ml).

Question 60

Prophylactic uterotonics should be offered to all women in the third stage of labour as they reduce the risk of PPH. What drug, at what dose and route of administration is advised?

Drug Vaginal Birth LSCS

a. Oxytocin 5iU IM 10iu IV
b. Oxytocin 10iU IM 10iU IV
c. Oxytocin 10iU IM 5iU IV
d. Syntometrine 2ml IM 1ml IV
e. Syntometrine 1ml IV 1ml IM

Answer 60

C - Oxytocin 10iU IM; 5iU IV

Prophylactic uterotonics should be routinely offered in the management of the third stage of labour as they reduce the risk of PPH by 60% – for women delivering vaginally, 10iU of Oxytocin given intra-muscularly is the agent of choice; at caesarean section, 5iU slow IV should be used. Higher doses are unlikely to be beneficial. In women at high risk of bleeding, ergometrine-oxytocin may be used in the absence of hypertension as it reduces the risk of minor PPH. Tranexamic acid may be used at caesarean section for women at increased risk (0.5-1.0 grams).

Question 61

In healthy patients, pulse and blood pressure are typically maintained at normal limits until how much blood has been lost post-partum?

a. 500ml
b. 750ml
c. 1000ml
d. 1500ml
e. 2000ml

Answer 61

C - 1000ml

Visual estimation of peripartum blood loss is inaccurate. Clinical signs and symptoms should however be used in the assessment of PPH. The physiology of pregnancy means that often the signs of hypovolemic shock become less sensitive – pulse and blood pressure are generally maintained until blood loss exceeds 1000ml; tachycardia, tachypnoea and a slight fall in systolic BP occur at 1000-1500ml while a fall in systolic blood pressure below 80mmHg with worsening tachycardia, tachypnoea and altered mental state usually indicate blood loss >1500ml.

Question 62

What rise in fibrinogen levels can be expected from a transfusion of 2 pools of cryoprecipitate?

a. 0.5g/L
b. 1.0g/L
c. 2.0g/L
d. 3.0g/L
e. 3.5g/L

Answer 62

B - 1.0g/L

A single pool of cryoprecipitate contains 5 units from 5 donors and is the method of choice for increasing fibrinogen levels (fibrinogen concentrate is not licensed in the UK for acquired hypo-fibrinogenaemia). 2 pools would be expected to increase the fibrinogen level by about 1g/L.

Question 63

Misoprostol is one of the most common agents used worldwide in the management of post-partum haemorrhage. How long does misoprotol take to increase uterine tone post-administration?

a. 10-15 minutes
b. 30-45 minutes
c. 1 hour – 2.5 hours
d. 3-4 hours
e. >5 hours

Answer 63

C - 1 hour - 2.5 hours

Irrespective of the route of administration, misoprostol (Prostaglandin E1) takes between 1 and 2 ½ hours to increase uterine tone.

Question 64

What is the maximum dose of carboprost in the management of PPH?

a. 0.25mg every 15 minutes; maximum 8 doses
b. 0.25mg every 15 minutes; maximum 4 doses
c. 0.5mg every 15 minutes, maximum 8 doses
d. 0.5mg every 15 minutes, maximum 4 doses
e. 0.5mg every 5 minutes, maximum 6 doses

Answer 64

A - 0.25mg every 15 minutes; maximum 8 doses

Carboprost (Prostaglandin F2), given at a dose of 0.25mg IM every 15 minutes to a maximum of 8 doses forms a key part of the medical management of PPH. If significant atonic haemorrhage continues after a third dose of carboprost however, transfer to theatre for EUA should be considered. Carboprost must be used with care in women with asthma.

Question 65

What is the risk of uterine perforation in surgical evacuation for retained products of conception postnatally?

a. 0.5%
b. 1.5%
c. 5%
d. 7.5%
e. 10%

Answer 65

B - 1.5%

Surgical evacuation of retained products of conception in secondary PPH should be undertaken or supervised by a senior clinician. The procedure carries higher risk of perforation than when performed for early pregnancy loss (1.5% vs. 0.1%). There is also a risk of Asherman’s syndrome. An appropriately trained clinician may consider performing the procedure under ultrasound guidance.

Question 66

How often should temperature be re-checked in patients with major post-partum haemorrhage?

a. Every 15 minutes
b. Every 30 minutes
c. Hourly
d. 2 hourly
e. 4 hourly

Answer 66

A - Every 15 minutes

Patients with major PPH (>1000ml) should have continuous pulse, blood pressure and respiratory rate monitoring performed. Temperature should be checked every 15 minutes. A Foley catheter should be inserted to monitor urine output and 2x 14G peripheral cannulae sited.

Question 67

A 35 year old grand-multigravidae has had a major PPH following a normal delivery – both mechanical and pharmacological methods of controlling bleeding have failed and she is transferred to theatre. There is no retained tissue on examination. What is most appropriate first line surgical management?

a. B-Lynch
b. Balloon-tamponade
c. Internal iliac artery ligation
d. Hysterectomy
e. Selective arterial embolisation

Answer 67

B - Balloon-tamponade

Intra-uterine balloon tamponade is the most appropriate first-line surgical intervention in major PPH where uterine atony is the main cause of haemorrhage.

Question 68

A patient represents 4 days following an emergency caesarean section for fetal distress with fever and swelling around her abdominal incision. On examination the wound is erythematous, warm to touch and discharging a purulent exudate from the left border. What is the risk of wound infection following emergency caesarean section?

a. 4%
b. 7%
c. 10%
d. 14%
e. 18%

Answer 68

C - 10%

A 2014 Cochrane review suggested a rate of wound infection of 97 per 1000 and 68 per 1000 for emergency and elective caesarean respectively.

TOG 2016

Question 69

A patient represents 3 days following an elective caesarean section for breech presentation with a high fever and complaining of swelling around her abdominal incision. On examination the wound is erythematous, warm to touch and discharging a purulent exudate. What is the risk of wound infection following elective caesarean section?

a. 4%
b. 7%
c. 10%
d. 14%
e. 18%

Answer 69

B - 7%

A 2014 Cochrane review suggested a rate of wound infection of 97 per 1000 and 68 per 1000 for emergency and elective caesarean respectively.

TOG 2016

Question 70

A patient represents 4 days following an emergency caesarean section for fetal distress with fever and lower abdominal pain. She also reports an increase in her lochia which has now become offensive. You suspect endometritis. What is the rate of endometritis following emergency caesarean section?

a. 2%
b. 4%
c. 7%
d. 11%
e. 18%

Answer 70

E - 18%

A 2014 Cochrane review found the rates of endometritis following emergency and elective caesarean sections to be 18.4% and 3.9% respectively

TOG 2016

Question 71

A patient develops suspected Ogilvie syndrome following an emergency caesarean section. So far this has failed to respond to pharmacological and conservative measures and the patient remains in considerable pain. The caecal diameter on imaging is estimated to be >12cm. What should be the next step in management?

a. Bowel resection and re-anastomosis
b. Temporary colostomy formation
c. Colonic decompression with rectal flatus tube
d. NG tube insertion
e. Percutaneous needle decompression

Answer 71

C - Colonic decompression with a rectal flatus tube

TOG 2016

Question 72

A patient complains of severe right sided abdominal pain and distension 2 days following an elective caesarean section. Abdominal x-ray demonstrates significant colonic distension around the caecum. You suspect a diagnosis of Ogilvie syndrome. What pharmacological therapy may be of benefit in patients with Ogilvie syndrome?

a. Buscopan
b. Salbutamol
c. Gabapentin
d. Nifedipine
e. Neostigmine

Answer 72

E - Neostigmine

TOG 2016

Question 73

Which of the following statements concerning post-partum ovarian vein thrombosis is incorrect?

a. Fever is a common presenting symptom
b. 80-90% of cases occur in the right ovarian vein
c. A rope-like mass is felt in around 50% of patients on abdominal palpation
d. It is more common following caesarean delivery
e. Over 75% of cases present between 4 and 12 weeks postnatal

Answer 73

E - Over 75% of cases present between 4-12 weeks postnatal

In-fact over 90% of cases present within 10 days of delivery.

PPOVT is a rare complication of pregnancy - patients typically present with lower abdominal pain (80-90% of cases are on the right, more tortuous ovarian vein) and fever. A ‘rope-like’ mass is felt in the iliac fossa in around 50% of patients.

Up to 15% of patients will have concurrent PE and risk factors are more of less identical for both - with a higher incidence seen in patients undergoing caesarean section than vaginal birth.

TOG 2016

Question 74

What increase in blood volume within the ovarian vein is seen at term compared with the non-pregnant state?

a. 2x
b. 5x
c. 10x
d. 20x
e. 60x

Answer 74

E - 60%

TOG 2016

Question 75

A 30-year-old had an emergency caesarean section in the second stage for a persistent bradycardia 6 days ago. She now presents with progressive abdominal distension, which was initially painless but has become increasingly painful. The pain is localised mainly to the right side. She is tachycardiac on examination and also pyrexial. What is the most likely diagnosis?

a. Bowel obstruction from adhesions
b. Bowel perforation
c. Faeculent peritonitis
d. Infected haematoma
e. Ogilvie syndrome

Answer 75

E - Ogilvie syndrome

The classic presentation of Ogilvie syndrome is progressive abdominal distension, which may initially be painless and associated with varying degrees of constipation. As the caecum becomes more dilated, the pain worsens, localising to the right-hand side, and is associated with tachycardia. Eventually there is caecal ischaemia, perforation and peritonitis.

TOG StratOG Resource 2016

Question 76

A 30-year-old woman presents 7 days after an emergency caesarean section with abdominal pain and a fever of 37.7°C . This isassociated with nausea, vomiting and mild abdominal distension. She is started on antibiotics and sent home but 3 days later she re-presents with no improvements in her symptoms and features of paralytic ileus. She is examined and found to have a tube-like mass in her abdomen on deep palpation. A request is made for an ultrasound scan of the abdomen and pelvis. What is the most likely cause of this woman’s symptoms?

a. Infected haematoma
b. Postpartum ovarian vein thrombosis (POVT)
c. Pyelonephritis
d. Torted ovarian cyst
e. Tubo-ovarian abscess

Answer 76

B - Postpartum ovarian vein thrombosis (POVT)

POVT presents with abdominal pain, pyrexia, nausea, vomiting, malaise and ileus with the fever persisting despite antibiotics. On deep palpation there is typically a mass in the adnexa that represents the thrombosed vein surrounded by an inflammatory mass – this is found in approximately 50% of cases. Most cases present within 10 days postnatally and the palpated mass is typically tube-like. Differential diagnoses include appendicitis, peritonitis, adnexal torsion, tubo-ovarian disease, infected haematoma and pyelonephritis.

TOG StratOG Resource 2016

Question 77

A 26-year-old woman was seen 7 days after a ventouse delivery for maternal exhaustion in the second stage with a fever, nausea, vomiting and abdominal pain. When examined she had a temperature of 38°C, mild abdominal distension, an abdominal mass on deep palpation on the right adnexum and absent bowel sounds. An ultrasound scan of the abdomen and pelvis showed features consistent with an ovarian vein thrombosis. What treatment should this patient be offered?

a. Intravenous antibiotics for 7−10 days and fully anticoagulated with fragmin or unfractionated heparin and then continue with warfarin for 3−6 months
b. Intravenous antibiotics for 7−10 days and intravenous heparin followed by warfarin for 3−6 months
c. Intravenous heparin followed by warfarin for 3−6 months
d. Intravenous heparin for 3−6 months
e. Intravenous heparin for 4−5 days followed by subcutaneous heparin for 3−6 months

Answer 77

A - Intravenous antibiotics for 7−10 days and fully anticoagulated with fragmin or unfractionated heparin and then continue with warfarin for 3−6 months

The recommended management of POVT is a combination of intravenous antibiotics and heparin. The antibiotics should be administered for 7−10 days and the recommendation is to continue with this until 48 hours after leukocytosis has resolved. A combination of piperacillin/tazobactam or carbapenem plus clindamycin provides a broad coverage in cases of suspected sepsis. The recommended anticoagulation should follow the standards in haematology as recommended, which is 3−6 months.

TOG StratOG Resource

Question 78

A 42 year old woman is found dead at home some time after undergoing an elective caesarean section for breech presentation. After what time period from delivery is a maternal death considered ‘late’?

a. 7 days
b. 28 days
c. 42 days
d. 6 months
e. 12 months

Answer 78

C - 42 days

Early maternal deaths are those occurring during or within 6 weeks of pregnancy; late maternal deaths occur beyond 6 weeks

Question 79

Which of the following is the most reliable predictor of outcome in infants born at 23-24 weeks of gestation?

a. Umbilical artery pH
b. Umbilical vein pH
c. Birth weight
d. 1 minute APGAR
e. 5 minute APGAR

Answer 79

E - 5 minute APGAR

Although largely related to long‐term survival, the 5‐minute Apgar score is associated with short‐term outcomes for infants born at 23–24 weeks of gestation, with this association being stronger for infants born at 24 weeks

TOG 2018

Question 80

Which of the following statements about infants born at the threshold of human viability, is false?

a. Survival is greatest amongst infants between the 50th and 85th centile for birth weight
b. Female sex is independently associated with a more favourable prognostic outcome
c. Tocolysis should not be used in women <26+0/40 with suspected pre-term labour
d. Repeat courses of steroids for fetal lung maturity have been shown to be associated with a small reduction in head size at birth though there is no evidence of significant harm in early childhood
e. All women in confirmed preterm labour should be offered intra-partum antibiotic prophylaxis

Answer 80

C - Tocolysis should not be used in women <26+0/40 with suspected pre-term labour

At the low gestational ages at the threshold of viability (22+0 weeks to 25+6 weeks of gestation), the absolute benefits for the baby of treatments such as steroids and tocolysis are much higher than at later gestational ages (for example, >29+6 weeks). Thus, there are greater implications for failing to treat a woman who is truly in threatened preterm labour but is misdiagnosed to be at low risk of delivery

TOG 2018