Obstetrics and Gynecology

OBSTETRICS AND GYNECOLOGY 1. Following prolonged second stage of labour, your primigravid patient at 42 weeks gestation finally delivers the fetal head, but the anterior shoulder does not release with a normal amount of downward traction. The statement that most accurately is associated with this complication is: A. History of shoulder dystocia in a previous pregnancy does not confer any greater risk of the complication in this pregnancy. B. It is important to stop and suction the newborn before attempting to deliver the anterior shoulder in cases where this complication is anticipated. C. After delivery of the fetal head, pH can be expected to drop by 0.04 per minute due to cord compression. D. Shoulder dystocia rarely occurs in normal birthweight infants. E. Routine induction of labour for macrosomia has been proven to improve perinatal outcomes. 2. Which of the following examples is NOT a risk factor for ectopic pregnancy: A. Prior tubal surgery B. Obesity C. Prior ectopic pregnancy D. Prior tubal infection/PID combination 3. Late in the second stage of labour, your patient develops a non-reassuring fetal heart rate tracing necessitating quick action on your part. Which of the following is a correct statement regarding the use of forceps to assist this delivery: A. The right forcep blade is applied first. B. The fenestration should admit no more than a fingertip when correctly applied. C. The cervix does not need to be fully dilated. D. It is not necessary to know the position of the fetal head. E. An indwelling catheter should be left in the mother's bladder for the first 24 hours. 4. While hypertension and proteinuria are diagnostic for pre-eclampsia, other non-diagnostic findings worth evaluating include: A. Rapid weight gain B. Family history of pre-eclampsia or eclampsia C. Maternal age greater than 40 D. Deep tendon reflexes E. All of the above 5. On the way into the hospital, you witness a sudden cardiac arrest of a woman in the parking lot. When you go to assist her, you discover that she appears to be in the third trimester of pregnancy. Which of the following statements best applies to this scenario: A. Thromboembolic disease is an unlikely cause for her cardiac arrest. B. Increased blood volume in pregnancy reduces the risk of pulmonary embolus. C. Aortocaval compression causes 30% of cardiac output to be sequestered in the lower extremities.

D. Perimortem cesarean delivery is best if performed within the first 15 minutes of absent effective maternal circulation. E. Modifications of ACLS in pregnancy include changes in defibrillation and/or pharmacological therapy. 6. The preferred agent of choice for Group B Strep prophylaxis is: A. Ampicillin 2gm load intravenously, followed by 1gm every 4 hours. B. Clindamycin 900mg intravenously every 8 hours. C. Penicillin G 5 million units intravenously, then 2.5 million units every 4 hours. D. Erthromycin 500 mg intravenously every 6 hours. 7. Your gravida 2, para 1 patient has been pushing for two-and-one-half hours, and you are considering the use of vacuum to assist delivery. This would be contraindicated if: A. The gestational age is less than 35 weeks B. The delivery will not require excessive traction C. The head is fully engaged D. The cervix is completely dilated 8. In which of the following conditions should a vaginal trial of labour be considered: A. Vasa previa B. Placenta previa C. Uterine rupture D. Abruption 9. Which of the following would NOT be a treatment for a non-reassuring FHR pattern: A. Initiate oxytocin B. Acoustic or scalp stimulation C. Amnioinfusion D. Plan immediate delivery 10. While examining a woman in the second stage of labour, you find the fetal vertex at a +1 station; the anterior fontanelle is palpable anteriorly. Which of the following statements most accurately applies to this position: A. Fewer than 10% of fetuses will rotate spontaneously in labour. B. This malposition is incompatible with delivery, unless assisted with vacuum or forceps rotation. C. Back labour characterizes this position. D. Forceps rotation should be performed between contractions in the second stage to convert this position. E. Vacuum assistance requires anterior placement of the vacuum cup over the anterior fontanelle. 11. Dysfunctional labour is: A. More common in parous women B. Defined as protracted or arrested labour C. Requiring early hospitalization D. Normal 12. Getting the help a provider needs when suddenly faced with an unexpected shoulder dystocia requires: A. Consultation available with one phone call. B. Cesarean capability at the institution.

C. Implementing an institutional protocol that summons personnel and defines their role. D. All necessary equipment be stored in the labour and delivery unit. 13. Of the conditions listed below, which one most accurately describes a risk for preterm labour and birth: A. Caucasian race B. Maternal age between 20 - 25 C. Bicornuate uterus D. One previous first-trimester miscarriage E. Singleton pregnancy 14. When managing a shoulder dystocia, rolling the patient to the "all fours" position: A. Relieves cord compression. B. Is dangerous in the second stage of labour. C. Is a safe, rapid, and effective technique for increasing pelvic diameters. D. Increases the chance of changing an OA presentation to an OP presentation. 15. Which of the following statements is most accurate regarding postpartum hemorrhage: A. Postpartum hemorrhage occurs in 10 to 15 percent of vaginal deliveries. B. Postpartum hemorrhage is defined as: >500 ml blood loss. C. Active management of the third stage of labour does NOT impact the risk of postpartum hemorrhage. D. Postpartum hemorrhage is an uncommon cause of maternal morbidity and mortality world wide. 16. Coagulopathy in the setting of abruption: A. Is common, even with an uncompromised fetus B. Is always an indication for cesarean delivery C. Is caused by consumption of clotting factors and DIC D. Is a sensitive indicator of retroplacental clot 17. Which of the following statements regarding oxytocin is most accurate: A. In the low-dose regimen, the drip rate should be increased every 5 to 10 minutes. B. Oxytocin intensifies uterine contractions and shortens the contraction interval. C. Low-dose oxytocin has been described as an important component of active management of labour. D. It carries no risk for the fetus. E. It should only be considered if the membranes are intact. 18. Which of the following statements is most accurate regarding the physical findings of deep vein thrombosis (DVT): A. No evidence of swelling or discomfort with palpation B. Calf circumference difference of greater than 5cm C. No evidence of superficial phlebitis D. Positive Homan's sign may be present 19. The most accurate statement regarding the diagnosis and management of placenta previa is: A. A full bladder can create the false appearance of an anterior placenta previa.

B. Bleeding is usually accompanied by pain between contractions. C. Usually occurs in first pregnancies. D. Once the diagnosis is made, aggressive management is appropriate, even if the patient is stable and the bleeding has stopped. 20. Amnioinfusion should be considered to reduce which of the following fetal heart-rate patterns: A. Late decelerations B. Variable decelerations C. Persistent bradycardia D. Early decelerations 21. During maternal cardiac arrest, which adjustment is necessary to have at least an 80 percent chest compression force: A. 27-degree chest elevation B. 27-degree leg evaluation C. 27-degree right tilt D. 27-degree left tilt 22. Which statement is most accurate in describing aspects of safety in maternity care: A. Risk-scoring systems developed over the years are highly accurate and should be used. B. Compassion, communication, competence, and charting are important components of risk management. C. Identifying which one individual is most responsible helps to reduce medical errors. D. Confession should not be part of dealing with medical errors and potentially litigious situations. E. Effective functioning of the maternity-care team, while making for an enjoyable birth experience, has little influence over making appropriate management decisions. 23. Which of the following definitions best describes the term "incomplete abortion": A. Some, but not all, products have passed B. Painless dilatation of the cervix C. Uterine bleeding, closed cervix, no products of conception passed D. Cervix dilated, products not passed Questions 24 - 27: The following questions relate to firsttrimester vaginal bleeding. Please match one answer which relates most closely to the condition stated: 24. With any bleeding in early pregnancy: A. Diagnosis of hydatidiform mole B. Exclude ectopic pregnancy C. Perforation of the uterus is a possible complication D. Rh immune globulin should be given to Rh negative mothers E. Provides for equal or better fertility preservation 25. With bleeding and any degree of pain: A. Diagnosis of hydatidiform mole B. Exclude ectopic pregnancy C. Perforation of the uterus is a possible complication D. Rh immune globulin should be given to RH negative mothers E. Provides for equal or better fertility preservation

ANSWERS

26. Medical management of ectopic pregnancy: A. Diagnosis of hydatidiform mole B. Exclude ectopic pregnancy C. Perforation of the uterus is a possible complication D. Rh immune globulin should be given to Rh negative mothers E. Provides for equal or better fertility preservation 27. Ultrasound is the gold standard for making this diagnosis: A. Diagnosis of hydatidiform mole B. Exclude ectopic pregnancy C. Perforation of the uterus is a possible complication D. Rh immune globulin should be given to Rh negative mothers E. Provides for equal or better fertility preservation For questions 28-31: The following questions relate to vaginal bleeding in late pregnancy. Please match one answer which relates most closely to the condition stated:

28. Placenta previa: A. Risk factors include hypertension and cocaine use B. Painless vaginal bleeding C. Apt test or stain for nucleated red blood cells D. Coagulopathy and fetal demise E. Always clearly diagnosed by transabdominal ultrasound 29. Placental abruption: A. Risk factors include hypertension and cocaine use B. Painless vaginal bleeding C. Apt test or stain for nucleated red blood cells D. Coagulopathy and fetal demise E. Always clearly diagnosed by transabdominal ultrasound 30. Severe placental abruption: A. Risk factors include hypertension and cocaine use B. Painless vaginal bleeding C. Apt test or stain for nucleated red blood cells D. Coagulopathy and fetal demise E. Always clearly diagnosed by transabdominal ultrasound 31. Vasa Previa: A. Risk factors include hypertension and cocaine use B. Painless vaginal bleeding C. Apt test or stain for nucleated red blood cells D. Coagulopathy and fetal dimise E. Always clearly diagnosed by transabdominal ultrasound

1. Following prolonged second stage of labour, your primigravid patient at 42 weeks gestation finally delivers the fetal head, but the anterior shoulder does not release with a normal amount of downward traction. The statement that most accurately is associated with this complication is: C. After delivery of the fetal head, pH can be expected to drop by 0.04 per minute due to cord compression. 2. Which of the following examples is NOT a risk factor for ectopic pregnancy: B. Obesity 3. Late in the second stage of labour, your patient develops a non-reassuring fetal heart rate tracing necessitating quick action on your part. Which of the following is a correct statement regarding the use of forceps to assist this delivery: B. The fenestration should admit no more than a fingertip when correctly applied. 4. While hypertension and proteinuria are diagnostic for preeclampsia, other non-diagnostic findings worth evaluating include: E. All of the above 5. On the way into the hospital, you witness a sudden cardiac arrest of a woman in the parking lot. When you go to assist her, you discover that she appears to be in the third trimester of pregnancy. Which of the following statements best applies to this scenario: C. Aortocaval compression causes 30% of cardiac output to be sequestered in the lower extremities. 6. The preferred agent of choice for Group B Strep prophylaxis is: C. Penicillin G 5 million units intravenously, then 2.5 million units every 4 hours. 7. Your gravida 2, para 1 patient has been pushing for two-andone-half hours, and you are considering the use of vacuum to assist delivery. This would be contraindicated if: A. The gestational age is less than 35 weeks 8. In which of the following conditions should a vaginal trial of labour be considered: D. Abruption 9. Which of the following would NOT be a treatment for a nonreassuring FHR pattern: A. Initiate oxytocin 10. While examining a woman in the second stage of labour, you find the fetal vertex at a +1 station; the anterior fontanelle is palpable anteriorly. Which of the following statements most accurately applies to this position: C. Back labour characterizes this position. 11. Dysfunctional labour is: B. Defined as protracted or arrested labour 12. Getting the help a provider needs when suddenly faced with an unexpected shoulder dystocia requires: C. Implementing an institutional protocol that summons personnel and defines their role. 13. Of the conditions listed below, which one most accurately describes a risk for preterm labour and birth: C. Bicornuate uterus 14. When managing a shoulder dystocia, rolling the patient to the "all fours" position: C. Is a safe, rapid, and effective technique for increasing pelvic diameters. 15. Which of the following statements is most accurate regarding postpartum hemorrhage: B. Postpartum hemorrhage is defined as: >500 ml blood loss. 16. Coagulopathy in the setting of abruption: C. Is caused by consumption of clotting factors and DIC 17. Which of the following statements regarding oxytocin is most accurate:

B. Oxytocin intensifies uterine contractions and shortens the contraction interval. 18. Which of the following statements is most accurate regarding the physical findings of deep vein thrombosis (DVT): D. Positive Homan's sign may be present 19. The most accurate statement regarding the diagnosis and management of placenta previa is: A. A full bladder can create the false appearance of an anterior placenta previa. 20. Amnioinfusion should be considered to reduce which of the following fetal heart-rate patterns: B. Variable decelerations 21. During maternal cardiac arrest, which adjustment is necessary to have at least an 80 percent chest compression force: D. 27-degree left tilt 22. Which statement is most accurate in describing aspects of safety in maternity care: B. Compassion, communication, competence, and charting are important components of risk management. 23. Which of the following definitions best describes the term "incomplete abortion": A. Some, but not all, products have passed Questions 24 - 27 relate to first-trimester vaginal bleeding. 24. With any bleeding in early pregnancy: D. Rh immune globulin should be given to Rh negative mothers 25. With bleeding and any degree of pain: B. Exclude ectopic pregnancy 26. Medical management of ectopic pregnancy: E. Provides for equal or better fertility preservation 27. Ultrasound is the gold standard for making this diagnosis: A. Diagnosis of hydatidiform mole Questions 28-31 relate to vaginal bleeding in late pregnancy. 28. Placenta previa: B. Painless vaginal bleeding 29. Placental abruption: A. Risk factors include hypertension and cocaine use 30. Severe placental abruption: D. Coagulopathy and fetal demise 31. Vasa Previa: C. Apt test or stain for nucleated red blood cells