Week 4, 5: Bleeding in late pregnancy, Normal labor, Malpresentations
I. Choose the most correct single answer: (1 Mark each)
1. A 22-year-old G1P0 woman at 34weeks presents with moderate vaginal bleeding, uterus is soft and
non-tender. Her BP is 110/60, HR: 105b/min. Most appropriate sequence of examinations:
a. Speculum examination, ultrasound, digital examination.
b. Ultrasound, digital examination, speculum examination.
c. Digital examination, ultrasound, speculum examination.
d. Ultrasound, speculum examination, digital examination.
e. Digital examination, speculum examination, ultrasound.
2. Bleeding due to placenta previa is characterized by all the followings EXCEPT:
a. Labor pains aggravate bleeding.
b. Commonly in the form of repeated attacks.
c. Rapid fetal distress is characteristic.
d. Higher incidence of pathological adherent place.
e. Abdomen is lax.
3. You are about to counsel a P1 CS at 32 weeks with US showing placenta previa complete centralis
with irregular retroplacental zone and hypervascularity in serosa-bladder interface. She has not had
any episodes of bleeding in this pregnancy. Most appropriate action:
a. Immediate CS.
b. Immediate MRI as it will definitively diagnose or rule out placenta accreta.
c. Plan for elective CS at 36 weeks with appropriate precautions for placenta accreta.
d. Plan for cesarean hysterectomy.
e. Rescan for placental localization at 36weeks as in the majority of cases, there is upward migration
of placenta due to development of the LUS.
4. A 24-year-old G2P1 CS, is 22weeks GA. Her US revealed a low-lying anterior placenta, partially
covering the cervical os. Most appropriate management:
a. Organize elective CS at 38weeks.
b. Organize MRI pelvis at 32weeks to check position of placenta.
c. Re-assess at 38weeks and allow VD if fetal head is engaged and no antenatal bleeding.
d. Repeat US at 32weeks to check position of placenta.
e. Repeat US at 38weeks to check position of placenta.
5. A PG presents at term, with placenta previa complete centralis & major fetal congenital anomalies
incompatible with life, is best managed by:
a. Cesarean section.
b. Oxytocin induction of labor.
c. Prostaglandin induction of labor.
d. Forceps delivery.
e. Rupture of membranes and expectant management.
6. A PG at 30 weeks presents with heavy vaginal bleeding. US reveals a living fetus and total placenta
previa covering the cervix. What is the best management?
a. Corticosteroids and expectant management.
b. Oxytocin infusion.
c. Tocolytics.
d. Cesarean section.
e. Hysterectomy.
7. A 33-year-old woman, with major placenta previa, is now 36 weeks, and complains of sudden onset
of painless heavy vaginal bleeding. BP is 90/ 60, HR: 110, RR: 16, T: 36.7. Abdominal examination is
soft, non-tender, FHR is normal. most appropriate management:
a. Administer repeat antenatal corticosteroid, as the previous course would not be effective.
b. Administer tocolysis as this would help to stop the bleeding and prolong pregnancy.
c. Deliver by emergency CS and involve senior obstetrician and anesthetic staff.
d. Commence blood transfusion and consider delivery if vital signs do not improve.
e. Speculum examination should be performed to help find a cause for the bleeding.
8. A 24-year-old G2P1 at 39 weeks presents with painful uterine contractions with dark, vaginal blood
mixed with some mucous. She is vitally normal, FHS are normal. Abdominal ultrasound shows no
abnormality. The most likely cause of her bleeding is:
a. Placenta previa.
b. Placental abruption.
c. Bloody show.
d. Vasa previa.
e. Cervical lacerations.
9. Which of the following most likely predisposes to pathologically adherent placenta?
a. Molar pregnancy.
b. Repeated caesarean sections.
c. Twin gestation.
d. Preterm labor.
e. Placental anomalies.
10. A 39weeks PG develops sudden sharp abdominal pain and collapse. BP:130/90, pulse 120/minute
with tender hard abdomen and absent fetal heart. Most likely diagnosis is:
a. Pulmonary embolism.
b. Constriction ring.
c. Concealed accidental hemorrhage.
d. Rupture uterus.
e. Perforated viscus.
11. A 3rdGP0, at 32 weeks presents with an attack of mild painless bleeding for one day. She is
normotensive and US: normal fetus with fundal posterior placenta. Your next step is:
a. PV examination under anesthesia.
b. Speculum examination.
c. Amniocentesis.
d. MRI.
e. Laparoscopy.
12. Which of the following predisposes to vasa previa:
a. Too long umbilical cord.
b. True knot of the cord.
c. Velamentous cord insertion.
d. Sudden rupture of membranes.
e. Malpositions and malpresentations.
13. A 35-year-old P3+2, 38 weeks is admitted to ER with sudden onset of painless continuous vaginal
bleeding. Patient is vitally stable. Hb 10.5g% and US reveals a cephalic fetus with posterior wall
placenta reaching the edge of the cervix. Most appropriate management:
a. Immediate CS.
b. Induction of labor.
c. Wait for onset of spontaneous labor.
d. Hysterectomy should be done.
e. Decision depends on cervical Bishop score.
14. A 30-year-old multipara, 32weeks was admitted to ER with sudden onset of painless mild vaginal
bleeding. Patient was vitally stable. Hb level was 10.5g/dl and US revealed a normal fetus in breech
presentation with anterior wall placenta 2cm away from the cervix. Most appropriate management:
a. Immediate CS.
b. Induction of labor.
c. Conservative management.
d. Urgent blood transfusion.
e. External cephalic version.
15. The following complications are associated with placenta previa EXCEPT:
a. Increased risk of Cesarean section.
b. Increased risk of Cesarean hysterectomy.
c. Increased incidence of placenta accreta.
d. Increased incidence of postpartum hemorrhage.
e. Increased incidence of postmaturity.
16. The following is the correct order for the cardinal movements of labor:
a. Descent, engagement, internal fixation, flexion, extension, external rotation, expulsion.
b. Descent, flexion, engagement, external fixation, extension, internal rotation, expulsion.
c. Engagement, descent, flexion, internal rotation, extension, external rotation, expulsion.
d. Engagement, flexion, descent, internal rotation, straightening, expulsion.
e. Descent, engagement, flexion, external rotation, extension, restitution, internal rotation.
17. A 20-year-old G1P0 at 39wks presents with severe abdominal pains. cx is closed, she is given
sedation. 4hrs later, her pain stopped. Her cervix is closed. Most likely diagnosis is:
a. False labor.
b. Prolonged latent phase.
c. Prolonged active phase.
d. Arrest of latent phase.
e. Arrest of the active phase.
18. According to Friedmann, the normal rate of active-phase labor in a multipara is:
a. 1cm/hr.
b. 1.2cm/hr.
c. 1.5cm/hr.
d. 2cm/hr.
e. 3cm/hr.
19. The following about the importance of the level of the ischial spine is true, EXCEPT:
a. It is the level of the levator Ani.
b. The internal os of the cervix lie at this level.
c. The obstetric axis changes its direction at this level.
d. The head is considered engaged if the vault is felt at or below this level.
e. Forceps should not be applied when the fetal head is above that level.
20. A partogram is used for assessment of:
a. Maternal wellbeing.
b. Fetal wellbeing during labor.
c. Fetal condition after delivery.
d. Placental insufficiency.
e. Progress of labor.
21. All the following are causes of non-engagement in the last 4 weeks in primigravida PG EXCEPT:
a. Contracted pelvis.
b. Pelvic tumors.
c. Previous CS scar.
d. Polydramnios.
e. Multiple pregnancy.
22. Sure evidence of onset of labor is:
a. Pelvic heaviness.
b. Expulsion of mucus streaked with blood.
c. Reflex bearing down.
d. Head engagement.
e. Progressive cervical dilatation.
23. What is the main task of the physician during the 2nd stage of normal labor?
a. Controlled cord traction (Brand Andrew maneuver) to enhance placental delivery.
b. Jaw flexion shoulder traction to deliver after-coming head in breech presentation.
c. Controlled head extension with perineal support (Ritgen maneuver).
d. Repeated ergometrine injection to ensure strong uterine contractions.
e. Episiotomy once the cervix is fully dilated.
24. The differential diagnosis of large size abdomen includes all the following EXCEPT:
a. Obesity.
b. Polyhydramnios.
c. Multifetal gestation.
d. Leiomyomas.
e. Blighted ovum.
25. Which of the following denotes fetal head engagement:
a. Passage of widest fetal head diameter through the pelvic outlet.
b. Head is totally grasped by 1st pelvic grip.
c. Head is well flexed by 2nd pelvic grip.
d. Auscultation of fetal heart 5cm below umbilicus.
e. By PV the lower most part of head is felt at level of ischial spines.
26. A 25-year-old G2P1 at 28wks had undergone US showing twin pregnancy, EFW of twin A: 500gm,
twin B: 1100gm. AFI of twin A: 2cm, twin B: 26cm. The best next step is:
a. Chorionic villus sampling.
b. Repeat ultrasound in 3weeks.
c. Amniocentesis for twin B.
d. Laser ablation of vessels.
e. Revision of dates for twin B.
27. Vaginal delivery is indicated in all the following, EXCEPT:
a. Breech with extended neck.
b. Mento anterior.
c. Twins with first vertex and second breech.
d. Direct occipto-posterior.
e. Premature rupture of membranes.
28. Failed long rotation in OP with deep transverse arrest of head during labor may be due to:
a. Strong uterine contractions.
b. Well flexed fetal head.
c. Gynecoid pelvis.
d. Early rupture of membranes.
e. Rigid perineum
29. Multifetal gestations have a higher risk of all the following EXCEPT:
a. Preeclampsia.
b. Atonic postpartum hemorrhage.
c. Maternal anemia.
d. Post term pregnancy.
e. Hyperemesis gravidarum.
30. Factors that favor long anterior rotation in OP include all of the following EXCEPT:
a. Epidural anesthesia.
b. Strong uterine contractions.
c. Adequate liquor.
d. Strong pelvic floor.
e. Adequate pelvis.
31. Indications of caesarean section in OP include all of the following EXCEPT:
a. Persistent oblique Occipito-posterior.
b. Deep transverse arrest.
c. Previous three caesarean sections.
d. Face to pubis.
e. Fetal distress.
32. The following is encouraging for a trial of vaginal delivery in breech presentation?
a. Primipara.
b. Preterm breech.
c. Estimated fetal weight between 2.5 – 3.5 kg.
d. Footling presentation.
e. Extended fetal head as detected by ultrasound.
33. Transverse lie in a multipara at full term is best managed by:
a. External cephalic version.
b. Wait for spontaneous correction.
c. Cesarean delivery.
d. Oxytocin induction
e. Internal podalic version and breech extraction.
34. A full-term multipara with twin pregnancy delivered her 1st cephalic VD at home 1 hour ago. She
presented to ER with 2nd baby transverse lie, ROM and a partially closed cervix. Your management:
a. Internal podalic version and breech extraction.
b. External podalic version and abdominal binder.
c. Caesarean section.
d. Wait for spontaneous second twin expulsion.
e. Oxytocin augmentation of contractions.
35. A full-term multipara with twin pregnancy delivered her first cephalic baby vaginally. On
examination, the second baby is found to be in a transverse lie. What is the suggested management?
a. Internal podalic version and breech extraction.
b. External podalic version and abdominal binder.
c. Caesarean section.
d. Wait for spontaneous second twin expulsion.
e. Oxytocin augmentation of contractions.
36. In assisted breech delivery:
a. Traction on fetal trunk should be done to assist fetal head delivery.
b. Prague maneuver is routinely used to deliver the aftercoming head.
c. Fetal back should be kept anterior.
d. Once fetal neck appears under symphysis, fetal body is lifted towards mother’s abdomen.
e. Episiotomy should not be done as the buttocks are soft.
37. Which of the following conditions, fetal head is delivered in flexion?
a. Direct occipito-anterior.
b. Face mento-posterior.
c. Oblique occipito-posterior.
d. After coming head of breech.
e. persistent brow.
38. A patient in the labor ward is now fully dilated with cord prolapse. Best next step is:
a. Advise Sims Position whilst awaiting transfer to operating theater.
b. Advise knee chest face‐down position whilst transfer to the operating theater.
c. Speculum and/or digital vaginal examination.
d. Expectant management (wait until you go to him).
e. Administer tocolytics and reassess in 30 minutes.
39. A 23-year-old G1 at 38 weeks presents with 6cm dilated cx & ROM. PV: fetal nose, eyes, lips and
chin can be palpated anteriorly. The FHR tracing is 140b/min with accelerations. Best next step is:
a. Perform immediate cesarean delivery.
b. Allow spontaneous labor with vaginal delivery.
c. Perform ventouse delivery in the second stage of labor.
d. Wait until complete cervical dilatation then perform an IPV with breech extraction.
e. Manual conversion of the face to vertex in the second stage of labor.
40. A 23-year-old G1 at 39 weeks presents with uterine contractions. She has good fetal movement,
no bleeding or leaking fluid. Cx is 1cm dilated, 60% effaced, and the fetal vertex at -1 station. The
patient had the same cervical examination in your office last week. Most appropriate next step:
a. Send her home.
b. Admit her for epidural for pain control.
c. Perform an amniotomy.
d. Administer terbutaline.
e. Augment her labor with oxytocin.
41. A 16-year-old G1 at 38weeks comes to ER for the 2ndtime during the weekend. Cervix is 1cm
dilated, 50% effaced with the vertex station -1, and was sent home after 2hours due to no cervical
change. She returns with increasing pain. Her cervix is unchanged. The best next step is:
a. Perform artificial rupture of membranes to initiate labor.
b. Administer an epidural.
c. Administer oxytocin to augment labor.
d. Achieve cervical ripening with prostaglandin gel.
e. Administer 10mg intramuscular morphine.
42. A 30-year-old G2P1 presents at 36 weeks for routine ANC. Her first pregnancy resulted in VD of
a 4.4kg boy. O/E the fetus is found breech. PV: cervix is closed. The breech is high out of the pelvis.
The EFW is 3.15kg with normal AFI. Best next step:
a. Allow the patient to undergo a vaginal breech delivery whenever.
b. Send the patient to OR immediately for an emergent cesarean delivery.
c. Tell her to return in 1week for reevaluation of fetal presentation.
d. Consider external cephalic version (ECV).
e. Allow the patient to go into labor and do ECV at that time.
43. A 30-year-old P1 with twin pregnancy at 36 weeks, delivers the first cephalic twin. 2nd twin is breech
presentation. ROM occurred with cord prolapse. Most appropriate management is:
a. Transfer to theatre for caesarean section.
b. Deliver by breech extraction.
c. Conduct an assisted breech delivery.
d. Await events for spontaneous breech delivery.
e. Replace the cord and deliver breech by hands-off technique.
Questions 44- 45: A 25-year-old G1P0 at 37weeks comes to ER with ROM and painful uterine
contractions every 3minutes. Cx is 4cm dilated 100% effaced & -3 station. Us reveals a breech
presentation with both hips flexed and knees extended. The EFW is 3.8kg.
44. Which of the following is the best method to achieve delivery:
a. Deliver the fetus vaginally by breech extraction.
b. Delivery the baby vaginally after ECV.
c. Perform an immediate cesarean delivery.
d. Perform an IPV.
e. Perform a forceps-assisted vaginal breech delivery.
45. What type of breech presentation is described:
a. Frank.
b. Incomplete, single footling.
c. Incomplete, double footling.
d. Complete.
e. Knee position.
Questions 46- 47: A full-term multipara comes to ER after prolonged labor &ROM. A fetal arm was seen
coming out from the vulva, cervix is fully dilated and FHR absent.
46. This condition is called:
a. Shoulder dystocia.
b. Shoulder presentation.
c. Neglected shoulder.
d. Obstructed labor.
e. Arrest of 1st stage.
47. The above condition is best management is:
a. External cephalic version to allow normal cephalic delivery.
b. External podalic version and breech extraction.
c. Internal podalic version and breech extraction.
d. Wait for full cervical dilatation.
e. Upper segment CS.
Questions 48- 49: A 35-year G5P4CS is diagnosed with placenta accreta at 28wks by US.
48.When is the placenta accreta most likely to cause bleeding:
a. During the first stage of labor.
b. Antepartum period.
c. After rupture of membrane.
d. During attempts to remove the placenta.
e. Postpartum.
49.What is the best surgical technique for this patient:
a. Lower segment CS.
b. Upper segment CS.
c. Upper segment CS and then proceed to hysterectomy.
d. Bilateral internal iliac ligation.
e. Hysterectomy with bilateral salpingooopherectomy.
Questions 50- 52: A 39-year-old PG at 30weeks presents to ANC clinic with mild painless vaginal
bleeding that was recurrent since last week. She feels good fetal kicking. BP was 120/80 and pulse 82.
50. What is the next step in the management of this case:
a. Send her home and reassurance.
b. Perform a sterile digital examination.
c. Perform an amniocentesis to rule out infection.
d. Perform a sterile speculum examination.
e. Perform an abdominal ultrasound examination.
51.What is the most likely diagnosis:
a. Cervical polyp.
b. Preterm labor.
c. Placental abruption.
d. Placenta previa.
e. Submucous uterine fibroid.
52.What is the appropriate next step in the management of this patient:
a. Conservative management.
b. Immediate termination by rupture of membrane.
c. Immediate delivery by cesarean section.
d. Initiate blood transfusion.
e. Immediate induction of labor by oxytocin infusion.
Questions 53- 62 are preceded by a list of lettered options. Select the one letter that is most closely
associated with it. Each letter may be used once, more than once, or not at all:
a. Placenta previa.
b. Bloody Show.
c. Concealed accidental hemorrhage.
d. Revealed accidental hemorrhage.
e. Vasa previa.
f. Pathologically adherent placenta.
53. After control of eclamptic fit in a 36 weeks PG, abdomen is felt hard with absent fetal heart and
the patient vital signs started to deteriorate.
54. A 24-year-old G2P1 at 39weeks presents with painful uterine contractions. She also complains of
dark, vaginal blood mixed with some mucous. PV and US are normal, FHS are normal.
55. A full term P5+3 suddenly develops severe attack of vaginal bleeding during 1st stage of labor.
Previous milder attack occurred to her 1 month ago.
56. Following an ECV, a 36 weeks PG has moderate vaginal bleeding with lax abdomen and normal
fetal heart.
57. A full term P1+0 with mild vaginal bleeding and rupture of membranes after falling down from
stairs. Abdomen is felt lax with audible fetal heart.
58. A G2P1 at 36weeks, presents with painful uterine contractions and mild vaginal bleeding. US:
anterior placenta with velamentous insertion of the cord with vessels crossing the internal os. FHS
shows severe bradycardia.
59. A 32 weeks P2+1, previous 2 CS, presents with preterm labor pains. US reveals anterior wall
placenta 1 cm from the cervix with multiple lacunae and no retroplacental demarcation.
60. A hypertensive PG at 32 weeks develops abdominal pain and tenderness, also she noted sudden
increase in the size of her abdomen and decrease her DFMC. No vaginal bleeding detected.
61. A G3P4 presents at 36weeks with sudden painless vaginal bleeding. She was not on ANC, but gives
irrelevant medical and surgical histories. Her baby is kicking well.
62. A PG at term, presents to labor ward with contractions, ROM and 1st attack of mild vaginal
bleeding. Abdomen is soft in between contractions FHS is persistently 70/min and decreasing.
Questions 63- 70, choose the SINGLE most appropriate answer. Each lettered option may be used once,
more than once, or not at all.
a. Active First stage of labor.
b. Second stage of labor.
c. Third stage of labor.
d. Effacement.
e. Latent phase of labor.
f. Fourth stage of labor.
63. Ends with complete dilatation of the cervix.
64. Ends by delivery of the placenta.
65. Ends with the delivery of the fetus.
66. The thinning out and shortening of the cervical canal.
67. Lasts two hours after delivery of the placenta.
68. Time between onset of labor and 3-4cm cervical dilatation.
69. Should be considered abnormal if lasting more than 30minutes.
70. Conventionally should last no longer than 1 hours in multiparous women.
Questions 71- 75, choose the SINGLE most appropriate answer from the below list of options. Each
option can be used once, more than once or not at all.
a. Transverse.
b. Frank breech.
c. Extended breech.
d. Footling breech.
e. Cephalic.
f. Unstable lie.
g. Complete breech.
71. Longitudinal lie where the presenting part is a foot.
72. The fetal long axis runs perpendicular to the maternal long axis.
73. Women should routinely be admitted to the antenatal ward at term.
74. The fetus presents by the buttocks with fully flexed knees and hips.
75. The position intended to be achieved by external cephalic version.
Questions 76- 80, choose the SINGLE most appropriate answer from the below list of options. Each
option can be used once, more than once or not at all.
a. ECV.
b. Emergency CS.
c. IPV and breech extraction.
d. Allow spontaneous delivery.
e. Elective CS at 36weeks.
f. Refer to tertiary referral.
g. Forceps delivery.
76. You review a woman who is 24wks with monochorionic diamniotic twins. US shows the deepest
pocket of first twin ˂2cm, while that of second twin is ˃10cm. The bladder of first twin is not
visualized.
77. You review a woman who is 20wks with monochorionic monoamniotic twins. She asks your
opinion regarding timing and mode of delivery. How could u advise her.
78. You are called to labor ward for the delivery of 37wks dichorionic diamniotic twins. first twin has
delivered cephalic. twin 2 is shoulder but high up in the pelvis with membranes intact. When u arrive,
there are decelerations in CTG.
79. A 37-year-old G2P1 is having induction of labor at 41 weeks + 5 days. PV: something pulsating is
felt through the membranes. The CTG is normal and the cervix is 3cm dilated. She is not contracting.
80. You review a woman who is 37wks with dichorionic diamniotic twins. First is cephalic. She asks
your opinion regarding timing and mode of delivery. How could u advise her.
81. A full term PG in first stage of labor, rupture membranes, 9 cm dilated, fully effaced, and brow
presentation.
82. A full term PG with infrequent abdominal pains and fluid escape from vagina. PV: cx is 4 cm,
60% effaced and a foot was coming out from the cervix. Pelvic cavity was felt adequate and
buttocks were felt at -1 station.
83. A PG with full term twin pregnancy, dichorionic diamniotic, presented during the 1st stage of
labor. Her examination revealed a 7 cm dilated cervix ,90% effaced, 1st presenting fetus in a
transverse lie with intact membranes.
84. A 37-year-old G2P1 is having induction of labor at 41 wks + 5. On rupturing the membranes,
there is prolapse of the umbilical cord. The CTG is normal, cervix is 3cm dilated and she is not
contracting.
85. A P2 is in spontaneous labor. When the cervix is fully dilated, fetal head is 1cm below the ischial
spine, a cord prolapse is felt, no caput and small moulding.
Best of Luck☺
