SECTION A: OBSTETRICS SINGLE BEST ANSWER QUESTIONS (30 MARKS)

This section consists of 30 statements or questions, each with 5 stems. Select the BEST correct
answer and write the letter of your answer on the provided answer sheet.

Attempt ALL questions.

1. Puerperium:
A. Refer to the first 6 months after delivery.
B. The uterine fundus should not be palpable abdominally by 14 days after delivery.
C. The lochia usually persist for 7 weeks.
D. The incidence of postpartum depression is 50%.
E. Fever due to engorged breast occurs on the second day after delivery.

2. Perinatal mortality rate refers to:

A. Number of stillbirths per 1,000 total births.
B. Number of stillbirths & early neonatal deaths per 1,000 total births.
C. Number of stillbirths & early neonatal deaths per 1,000 live births.
D. Number of early neonatal deaths per 1,000 total births.
E. Number of stillbirths per 1,000 live births.

3. A midwife from Maramba Clinic requests advice with regards to induction of labour
for a woman who is currently 40 weeks gestation. She has had 2 previous vaginal
deliveries at 38 and 39 weeks. The pregnancy has been uncomplicated. What would you
advise?
A. To arrange induction as soon as possible
B. To arrange induction between 41 – 42 weeks and discuss membrane sweep
C. To arrange induction with amniotomy at 41 weeks
D. To continue expectant management even after 42 weeks with fetal surveillance until
labour commences
E. To observe for 10 days and call again if the mother had not delivered

4. Which of the following ultrasonographic measurements provides reliable pregnancy

dating information?
A. Femur length (FL) at 28 weeks
B. Head/ trunk ratio at 18 weeks
C. Gestation sac diameter at 13 weeks
D. Biparietal diameter (BPD) at 6 weeks
E. Crown-rump length (CRL) at 9 weeks
5. A 34-year-old woman attends for her booking in her third pregnancy. She had a
Caesarean section in her first pregnancy 4 years ago and has had a successful vaginal
birth after caesarean section (VBAC) 2 years ago. She has a BMI of 26 kg/m2. What is
the best predictor for a successful VBAC?
A. BMI of less than 30 kg/m2
B. Less than 35 years old
C. Previous vaginal birth
D. Short inter-pregnancy interval
E. Spontaneous onset of labour

6. An 18-year-old G1P0 woman at 38 weeks’ gestation confirmed by a 12-week ultrasound

has a fundal height of 34 cm. The patient has gained weight by 8.6 kg during the
pregnancy. She denies smoking or alcohol or illicit substance use. Her BP is 110/ 70
mmHg. Which of the following is the best management of this patient?
A. Perform a basic ultrasound study
B. Schedule for delivery since the patient has reached a term gestational age
C. Schedule biophysical profile and Doppler studies
D. Screen for TORCH infections
E. Test for malaria

7. A 39-year-old para 2 woman with two previous normal vaginal deliveries presents in
spontaneous labour at 38 weeks’ gestation. She had good progress in labour, but the
CTG became abnormal at 8 cm cervical dilatation with a pH of 7.19 on fetal blood
sampling. She has declined caesarean section as she does not want to have an operation.
She had similar problems in her last pregnancy but had a normal delivery with a
healthy baby. She understands the risks, and you have clearly documented your
discussions with her. What is the most appropriate management option?
A. Discuss with her partner in order to influence her decision.
B. Obtain a second opinion from another doctor.
C. Respect her wishes and review appropriately.
D. Obtain a second opinion from the psychiatry team to assess capacity.
E. Proceed with caesarean section in the best interests of the baby.

8. During normal pregnancy:

A. Oestradiol is the principal circulating oestrogen.
B. Amniotic fluid is mostly composed of fetal urine during the second half of pregnancy.
C. The blood pressure increases in first and second trimester.
D. The tidal volume is reduced.
E. Maternal hydroureters is a serious pelvic condition that requires further investigation.
9. A 30-year-old woman, who is 36 weeks pregnant, is seen in antenatal clinic. This is her
first pregnancy. She is HIV positive. She has been fully compliant with her highly active
antiretroviral therapy (HAART) throughout her pregnancy. Her latest serum viral load
is <50 copies/mL. Apart from HIV, her pregnancy has been uncomplicated, and she has
an appropriately grown fetus in cephalic presentation. Which one of the following is
recommended management and advice?
A. Elective caesarean at 38 weeks gestation.
B. Elective caesarean at 40 weeks gestation.
C. Induce vaginal birth at 38 weeks gestation.
D. Offer spontaneous vaginal birth.
E. Encourage bottle feeding postnatally.

10. Mrs. Kalaluka 24 year old primigravida at 36 weeks’ gestation. She is scheduled for a
Caesarean delivery at 39 weeks’ gestation because she does not want to go through
labour. What is the category of this Caesarean section?
A. 1
B. 2
C. 3
D. 4
E. 5

11. The most common cause of perinatal death in mono-amniotic twin is:
A. Cord entrapment.
B. Cord prolapse.
C. Twin-twin transfusion syndrome.
D. Lethal congenital anomalies.
E. Placental abruption.

12. In order to guide counseling a pregnant woman and plan for intervention, it is
recommended that an anomaly ultrasound scan is done during the antenatal period.
The recommended gestation age for such a scan is:
A. 12 weeks.
B. 16 weeks.
C. 20 weeks.
D. 24 weeks.
E. 28 weeks.
13. In which of the following situation should induction of labour NOT be offered?
A. Multipara, 39 weeks, breech presentation, ECV failed, wanting a vaginal birth
B. Primigravida, 34 weeks, PPROM for 1 week, clinically stable on oral erythromycin no
signs of chorioamnionitis
C. Primigravida, 37 weeks, severe FGR with reduced amniotic fluid and suspicious CTG
D. Primigravida, 40 weeks, uneventful pregnancy so far, requests induction of labour as her
partner is moving abroad
E. Primigravida, 41 weeks AGA fetus, maternal perception of reduced fetal movements but
normal amniotic fluid, normal CTG

14. A 32-year-old G2 P1 has been referred from Namatama Clinic for lack of progress in
labour at 4 cm. Her previous baby weighed 3100 g and was a normal delivery at 38
weeks gestation. On admission, her observations are normal and the cardiotocography
(CTG) was reassuring. The midwife who examined her has diagnosed a complete
breech presentation and this is confirmed on scan. The woman is very keen to have a
vaginal delivery and decision has been taken to allow labour to continue. After 2 hours,
there is no progress in labour and the CTG has become suspicious. What is the most
appropriate action?
A. Advice emergency caesarean section
B. Augment labour with oxytocin
C. Continue observation for one hour
D. Discuss ECV with the mother
E. Perform fetal blood sampling

15. According to the 2016 World Health Organization (WHO) recommendations for routine
antenatal care, the number of contacts for pregnancy checkups in an uncomplicated
pregnancy should be:
A. 4 for multiparous women and 8 for nulliparous women.
B. 4 for nulliparous women and 8 for multiparous women.
C. 4 for all pregnant women.
D. 8 for all pregnant women.
E. 8 for nulliparous women and 6 for multiparous women.

16. Prong 1 of the elimination of transmission of HIV from mother to child includes:
A. Life-long anti-retroviral therapy.
B. Promotion of safe sex.
C. Provision of effective contraceptives.
D. Linkage to support groups.
E. Avoidance of breastfeeding.
17. All pregnant women are advised to take folic acid supplements pre-pregnancy and
antenatally. The recommended dose is:
A. 0.4mg once daily.
B. 0.4mg once weekly.
C. 0.5mg thrice daily.
D. 5mg once daily.
E. 5mg once weekly.

18. A 42-year-old woman is 39 weeks gestation in her second pregnancy having had a prior
emergency caesarean section for fetal distress three years earlier. She is keen to give
birth vaginally but is requesting induction of labour because of concerns regarding the
increased risk of perinatal mortality associated with her age. What is the most
appropriate method of induction to minimise the risk of uterine rupture in labour?
A. Amniotomy and oxytocin
B. Dinoprostone
C. Misoprostol
D. Oxytocin alone
E. Transcervical Foley catheter

19. A 19 year old para 1 woman presents to the maternity clinic 3 weeks after a normal
vaginal delivery at a Health Post. She gives a history of some scanty vaginal bleeding for
one week now. On examination, general condition is fair and she is afebrile. The uterine
fundus about 1cm above the pubic symphysis. The cervix is “admitting tip of a finger”.
The most appropriate management will be:
A. Manual vacuum aspiration (MVA).
B. Dilatation and curettage (D&C).
C. Administration of intramuscular oxytocin.
D. Administration of intramuscular ergometrine.
E. Administration of broad spectrum antibiotics.

20. Which of the following situations in a pregnant woman's history suggests the possibility
of her having diabetes?
A. Intra-uterine growth restriction
B. Past history of twin
C. First trimester bleeding
D. Diabetic husband
E. Unexplained stillbirths
21. The following are pre-requisites for vaginal breech delivery EXCEPT:
A. Flexed breech
B. Platypelloid pelvis
C. Extended breech
D. Fetal weight less than 3500g
E. Anthropoid pelvis

22. A 23-year-old primigravida is admitted to labour ward in active phase of labour.

Vaginal examination reveals cervical dilatation of 7 cm, cephalic presentation and
palpable anterior fontanelle with orbital ridges and nasal bridge felt anteriorly. What is
the presenting diameter of the fetus?
A. 11cm
B. 11.5cm
C. 12.5cm
D. 13cm
E. 13.5cm

23. Oligohydramnios is associated with which of the following?

A. Gestational diabetes
B. Fetal renal agenesis
C. Fetal cleft lip and palate
D. Multiple pregnancy
E. Fetal oesophageal atresia

24. What type of morbidity is LESS likely to be associated with vacuum extraction than
with forceps delivery?
A. Vaginal and perineal trauma
B. Cephalohematoma
C. Low Apgar score at 5 minutes
D. Neonatal jaundice
E. Retinal haemorrhage

25. Liz had a Caesarean section 4 days ago. She is now complaining of a cough and lower
abdominal pain. She has a low-grade fever and erythema around the skin incisional
wound. There is no pelvic pain or vaginal bleeding. The most likely diagnosis is:
A. Pulmonary embolism
B. Wound infection
C. Pneumonia
D. Endometritis
E. Deep vein thrombosis
26. Which one of following is a major indicator of fetal hypoxia?
A. Old meconium-stained amniotic fluid at the time of induction of labor.
B. More than two accelerations within 10 minutes.
C. Type I (early) decelerations in the second stage of labour.
D. Type II (late) decelerations in the latent phase of labour.
E. Excessive fetal movements

27. During normal pregnancy, the cardiac output increases by what percentage?
A. 20%
B. 30%
C. 40%
D. 50%
E. 60%

28. Which of the following statements is true with regards to the placenta?
A. The decidua capsularis forms part of the placenta.
B. The fetal side of the placenta is divided into 30 – 40 cotyledons.
C. The intervillous space contains fetal blood.
D. Anatomically the placenta is fully formed by 30 weeks.
E. Fetal blood vessels develop in the mesenchymal core of the chorionic villi.

29. The most common congenital anomaly associated with diabetes is:
A. Congenital heart disease.
B. Neural tube defect.
C. Sacral agenesis.
D. Renal agenesis.
E. Caudal regression.

30. A 30-year-old nulliparous woman in a prolonged second stage of labour was delivered
by ventouse. The baby has a large well-defined swelling over the parietal bone of the
fetal head with clear margins. Which one of the following conditions is the most likely
diagnosis for this swelling?
A. Caput succedaneum
B. Cephalhaematoma
C. Chignon
D. Subaponeurotic haemorrhage
E. Subgaleal haemorrhage

……………….. END OF SECTION A ………………..

SECTION C: CLINICAL CASE SCENARIO QUESTIONS (40 MARKS)

This section consists of 4 clinical case scenario questions. Each of the questions carries 10
marks. Start answering each question on a fresh sheet of the provided answer book.

Attempt ALL questions.

1. Mrs. Alice Banda is a 23 year old primigravida at 11 weeks’ gestation. She is referred from
Libuyu Clinic because of a positive rapid diagnostic test (RDT) for malaria.

a) What does the RDT detect, and after how long can it still be positive after treatment?
.. (2 marks)

b) Why does malaria tend to be severe in pregnancy? (2 marks)

c) GIVE six (6) complications of malaria. (3 marks)

d) How does malaria cause disseminated intravascular coagulation (DIC)? (1 mark)

e) How is first trimester malaria managed? (2 marks)

2. Mrs Joy Chanda is a 28-year old nulliparous woman. She presents to the hospital with
abdominal pain at 37 weeks 2 days’ gestation. The booking blood pressure was 132/81
mmHg. The antenatal blood tests were normal. The ultrasound scan at 14 weeks revealed a
low lying place with lower margin 1cm away from the internal cervical os and no uterine
masses.

a) List any three (3) possible pregnancy-related causes of Mrs Chanda’s abdominal pain. .
… (1.5 marks)

This morning, she started experiencing some mild abdominal pain, which has been gradually
increasing in intensity. The pain is associated with “a bit” of vaginal bleeding. She is
perceiving foetal movements but they have reduced in frequency.

On examination, she is warm and well perfused. Her blood pressure is 138/82 mmHg and
heart rate is 98/min. The symphysio-fundal height is 36 cm and the fetus is in cephalic
presentation with 3/5 of the head palpable abdominally. Moderate uterine tenderness is noted.
On digital vaginal examination, the cervical os is 3 cm dilated and there is mild bleeding.
Urinalysis showed trace protein, negative blood, negative leucocytes and negative nitrites.
The cardiotocograph (CTG) is shown below.

b) Given that each small box represents 30 seconds, describe the findings depicted by the
CTG tracing. (2 marks)

c) What is the comprehensive diagnosis of Mrs Chanda’s condition? (3 marks)

d) What features of the provided scenario support your diagnosis? (6 marks)

e) Briefly describe the management of this woman. (6 marks)

f) What complication would you expect during the immediate postpartum period? Mention
two (2) possible primary causes of this complication. (1.5 marks)