OB EVALUATION 2- SET A Section A

Flores, Marie Felle 1.Preconceptionalcounselling/care should be sought by those: a. with pre-gestational diabetes mellitus b. contemplating to undergo assisted reproductive technology c. working as xerox operator d. all of the above e. A & B Answer: D. all of the above Rationale: -for those with pre-gestational diabetes,preconceptionalcounselling should be sought for the reason that it is beneficial in many ways. It has been shown to decrease diabetes-related complications at all stages of pregnancy. This includes the avoidance of complications by glucose control before conception. It as well includes a list of assessments from Medical and Obstetrical history, Physical Exam, Lab exam and has a set initial management plan that includes counselling, insulin regimens and monitoring of haemoglobin. -in cases of older women with subfertility problems, the important cause of multifetal gestation in older women follows the use of assisted reproductive technology and ovulation induction. According to the Centers for Disease Control and Prevention, 40 percent of triplet and 17 percent of twin births in the U.S. in 2004 were a result of assisted reproductive technology. Such multifetal pregnancies account for much of the morbidity and mortality in preterm delivery so it is important that this may be discussed in preconceptionalcounselling. -lifestyles and work habits may have an effect on the pregnancy outcome. The influence of work on pregnancy and the influence of pregnancy on work may as well and should be discussed in preconceptionalcounselling. In the case of a Xerox operator, effects of her job on the outcome of her pregnancy may be discussed. If there are no effects, it too may be discussed for clarification that the patient may proceed with what she does for a living. Reference: Williams, 23rd Edition, page 175, 176, 181, 182 Jaurigue, Jaymee 2. Preterm pregnancy is best defined as: Choices a. livebirth less than 37 weeks age of gestation b. livebirth more than 20 weeks but less than 37 weeks AOG c. delivery more than 20 weeks but less than 37 weeks AOG d. delivery after 20 weeks AOG but before the expected date of confinement (EDC) e. delivery after 20 weeks but before 42 weeks AOG Answer: C Rationale: Preterm pregnancy refers to a pregnancy or fetus or neonate that is less than 37 weeks gestation(based on WHO definition) but more than 20 weeks gestation Reference: page 625Sumpaico, et al (2008) Textbook of Obstetrics, 3rd Edition. Abanto, Mara 3. A patient who is very much desirous of getting pregnant came because of amenorrhea for 3months and frequent urination. She has a regular menstrual period since menarche. She claimed to feel brisk fetal movement starting yesterday. On physical examination, the uterine fundus is palpated midway between the symphysis pubis and umbilicus. You requested for pregnancy test. the best evidence that this patient is pregnant is: a. amenorrhea on a background of regular menstrual cycle b. enlarged uterus c. frequent urination d. brisk fetal movement felt by the patient e. positive pregnancy test Answer: E Rationale: -amenorrhea and enlarged uterus are just probable diagnosis for pregnancy. -frequent urination and brisk fetal movement are presumptive diagnosis for pregnancy. -positive pregnancy test indicates a positive diagnosis for pregnancy because it detects HCG which is a pregnancy hormone. HCG prevents the involution of corpus luteum, the principal site of progesterone formation during the first 6 weeks.

Cabalza, Mary Anne

Reference: William's Obstetrics 23rd edition. chapter 8, pp 191- 192 4.A 35 year old PARTURIENT was seen with the following obstetrical history: G1May 2000, delivered a live baby boy at 36 weeks AOG by vaginal but died at 5 years of age G2June 2002, spontaneous abortion at 8 weeks AOG G3July, 2003, delivered live twins by VSD at 37 weeks, both presently alive G4August, 2004, H-mole, suction curettage done at 12 weeks AOG G5September, 2006, ectopic pregnancy at 6 weeks AOG G6October, 2008, delivered alive at 34 weeks AOG by CS for placenta previa, neonatal death The patient is a: a. G6 P3 (1-2-3-1) b. G6 P3 (1-2-3-2) c. G7 P3 (1-2-3-2) d. G7 P4 (1-2-3-2) e. G7 P4 (2-2-3-1) Answer: B. G6 P3 (1-2-3-2) Rationale: G indicates Gravid, meaning a woman who currently is pregnant or she has been in the past, irrespective of the pregnancy outcome. And the P indicates Parity, which is determined by the number of pregnancies reaching 20 weeks and not by the number of fetuses delivered. T indicates Term and post-term pregnancy (37 to >42 weeks), P stand for Preterm pregnancies of >20 weeks to <37 weeks, A stand for Abortion or non-viable pregnancies including ectopic and H-mole and L means Living, children currently alive. The table below was the Obstetrical Score: G 1 P 1 T P 1 A L

G1May 2000, delivered a live baby boy at 36 weeks AOG by vaginal but died at 5 years of age G2June 2002, spontaneous abortion at 8 weeks AOG G3July, 2003, delivered live twins by VSD at 37 weeks, both presently alive G4August, 2004, H-mole, suction curettage done at 12 weeks AOG G5September, 2006, ectopic pregnancy at 6 weeks AOG G6October, 2008, delivered alive at 34 weeks AOG by CS for placenta previa, neonatal death G6 P3 (1-2-3-2)

1 1 1 1

1 2

1 1

1 1 1

References: Cunningham et al, Williams Obstetrical 23rd edition, Chapter 8: Prenatal Care This is also based Lecture of Dr. Chu-Crisostomo, Prenatal Care: January 23,2010 Beatriz, Roxanne 5. A pregnant mother came for prenatal check-up but is not certain of her last normal menstrual period. Her menstrual period became irregular after giving birth to her third child. Asked about her quickening, she is very certain it was 2 weeks ago. She is approximately ___ weeks pregnant. a. 14 - 16 d. 20 - 22 b. 16 - 18 e. cannot be determined c. 18 20 Answer: C Rationale: Quickening is a term in pregnancy referring to the initial motion of the fetus as perceived by the pregnant woman. According to Cunningham, et. al., after a first successful pregnancy, a woman generally may first perceive movements between 16 and 18 weeks. In comparison to a primigravida, fetal movements may not be appreciated until approximately 2 weeks later (18 to 20 weeks). There are many factors affecting maternal perception of fetal movements such as parity and habitus. In a multigravida, her uterus has been more stretched out than it was the first time around and also, she already knows what it is to be felt. Each pregnancy can be different from the other. Quickening can be as late as 26 weeks for a primigravida or when the mother is overweight.

Reference:Cunningham FG, et. al. (2010).Williams Obstetrics, 23rd edition. New York: McGraw-Hill (E-book Chapter 8. Prenatal Care, Section on Organization of Prenatal Care>Diagnosis of Pregnancy>Signs and Symptoms>Perception of FetalMovements) http://pregnancy.about.com/od/yourbaby/a/Feeling-Your-Baby-Move.htm http://www.americanpregnancy.org/duringpregnancy/firstfetalmovement.htm http://www.babiesonline.com/articles/pregnancy/quickening.asp Cruz, Fatima 6. The primary reason for doing internal examination on the first prenatal check up on patient seen early in pregnancy is to determine the: (evals2) a. presence of uterine and adnexal masses b. fetal presenting part c. bony structure of the pelvis (pelvic contraction) d. cervical dilation and effacement Answer: D Rationale: Bimanual examination is completed by palpation, with special attention given to the consistency, length, and dilation of the cervix; to uterine size and any adnexal masses; to the fetal presentation later in pregnancy; to the bony structures of the pelvis; and to any anomalies of the vagina and perineum. References: William Obstetrics 23rd edition Chapter 08 page 197. Holgado, Anna Victoria M. 7. On regular prenatal check-up, vaginal examination is done weekly... a) On the 1st trimester. b) On the 2nd trimester. c) Late in pregnancy. d) If there is vaginal bleeding. e) If there is leaking amniotic fluid. Answer: (c) Late in pregnancy Rationale: Vaginal examination is done as part of prenatal surveillance done at each return visit in order to determine the well-being of the mother and fetus. Furthermore, vaginal examination is done late in pregnancy in order to provide information regarding the following, thus monitoring the mother's progress to labor: > Confirmation of the presenting part and its station > Clinical estimation of pelvic capacity and its general configuration > Consistency, effacement, and dilatation of the cervix -Vaginal examination is not usually done during the early stages of pregnancy, and is contraindicated in cases of vaginal bleeding (as it may induce further bleeding) and possible rupture of the bag of waters (since it may introduce infection). Reference: Cunningham, F.G. et. al (2010) "Chapter 8: Prenatal Care". William's Obstetrics (23rd edition). (Retrieved from Access Medicine, McGraw-Hill) Gail Austin C. Dimapilis 8. Which of the following/s is/are true regarding effects of severe undernutrition during preganancy on the fetus: a. starvation during later pregnancy can cause the baby to be lighter, shorter, and thiner at birth b. early exposure to severe starvation is associated with increased CNS anomalies and schizophreniaspectrum personality disorder c. sever dietary deprivation cause subsequent decrease mental performance d. all of the above e. A and B Answer: (d)all of the above Rationale: Evidences of impaired brain development has been obtained in some animal fetuses whose mothers had been subjected to intense dietary deprivation. Subsequently intellectual development was studied in young male adults whose mothers had been starved during pregnancy. Long term studies of children born to nutritionally deprived mothers have been performed and were recently reviewed, progeny exposed to mid to late pregnancy were lighter, shorter and thinner at birth. Early exposure was also associated with increased central nervous system abnormalities, schizophrenia ans schizophreniaspectrum personality disorders. Reference: Williams 23rd edition, page 201

Jualayba, Elkie

9. The recommended weight that a pregnant woman should gain during pregnancy is based on her: a. pre-pregnancy weight b. pre-pregnancy body mass c. weight on first prenatal check-up d. appetite e. previous birthweights of her children Answer: B Rationale: In 1990, the Institute of Medicine recommended a weight gain of 25 to 35 lb- 11.5 to 16 kg for women with a normal prepregnancy body mass index (BMI). The American Academy of Pediatrics and the American College of Obstetricians and Gynecologists (2007) have endorsed these guidelines. Reference: Williams. 23rd Ed. Page 200

Lapitan, JaecelReyenn e

10. The main factor affecting the accrued weight being retained overtime by a woman after giving birth is her: a. Prepregnancy BMI b. Prenatal weight gain c. Parity d. Age e. Birthweights of her babies Answer: D Rationale: According to the American Academy of Pediatrics and American College of Obstetricians and Gynecologists, there is no relationship between prepregnancy BMI or prenatal weight gain and weight retention. Accruing weight with age, rather than parity, is considered the main factor affecting weight gain over time. Reference: Cunningham, F. G. (2010). Williams Obstetrics. 23rd ed. Chapter 8 page 202.

Fabian, Jeffrey Micahel C.

11.All are supplied by a well-balanced diet except: A. Iron B. Vitamin A C. Vitamin B D. Vitamin C E. Vitamin E ANSWER: A Rationale: All essential vitamins and minerals are supplied by a well balanced diet, except for iron. Reference: Williams, 23rd EDITION, PAGES 202-204

De Lemos, Diordan

12. The type of exercise that the pregnant patient can have depends on her: a. health b. level of activity before pregnancy c. parity d. all of the above e. A and B ANSWER: E (a and b) RATIONALE: -According to Williams, health or over all condition of the pregnant woman is important to know before different exercises must be performed. Pregnant woman do not need to limit exercise, provided that they dont become excessively fatigued or risk injury but of course, there are still conditions or situations that a pregnant mother has, which makes her contraindicated to do exercises. Conditions such as restrictive Lung disease, Pre-eclampsia or pregnancy- induced hypertension, hemodynamically significant heart disease are all contraindicated. -Level of activity before pregnancy is also important to know. The pregnant mothers, especially the obese, may not be well adapted to the exercises during pregnancy and she might get exhausted. Their muscles are not well toned and the can easily experience fatigability which is definitely a contraindication in performing certain forms of exercise. -Parity is not one of the basis,, because it has nothing to do on how and when an exercise has to be done. Regardless if her baby has reached the violability, still, the exercise should not depend on it. REFERENCES: 23rd Edition Williams Obstetrics by Cunninghum et al., page 206.

Cotas, Paola Ysabel D.

13. Sexual intercourse during pregnancy is: a. Contraindicated all throughout pregnancy b. Permitted as long as there is no concomitant obstetrical nor medical complication c. Permitted only after the 37th week of pregnancy d. Not advised among primigravidas e. Advised in all patients nearing postterm Answer: (b) Permitted as long as there is no concomitant obstetrical nor medical complication Rationale: There are actually no adverse effects on pregnancy with regards to sexual intercourse, thus it is not contraindicated ALL THROUGHOUT pregnancy. Although there are studies that show that sexual intercourse during pregnancy may be detrimental to some patients. Letter C: Permitted only after the 37th week of pregnancy and Letter E: Advised in all patients nearing postterm is NOT true because orgasm after 32 weeks gestation age may predispose to premature labor. It is just essential to advise high risk patients about possible adverse effects, thus the answer is LETTER B, PERMITTED AS LONG AS THERE IS NO CONCOMITANT OBSTETRICAL NOR MEDICAL COMPLICATION. Reference: Page 271-272, Chapter 16: Prenatal Care of the Healthy Woman, Textbook of Obstetrics (Physiologic and Pathologic Obstetrics), 3rd edition, Sumpaico et. al.

Bernus, Marie Grace M.

14. Smoking during pregnancy can cause the following, EXCEPT: a. low birth weight infants d. Premature rupture of membranes b. premature labor e. A and B c. postdatism Answer: (c)postdatism Rationale: Many of the substances in tobacco have vasoactive effects or reduce oxygen levels. Smoking has a direct dose-response reduction in fetal growth. According to the study of DSouza and associates (1981), newborns of mothers who smoke weigh an average of 200 g less than those of nonsmokers, and heavy smoking results in more severe weight reduction. Likewise, Werler (1997) concluded that smoking of mothers during pregnancy doubles the risk of low birthweight and increases the risk of fetal-growth restriction two- to threefold. (p. 329). Smoking also may cause a slightly increased incidence of subfertility, spontaneous abortion, placenta previa and abruption, andpreterm delivery. (p. 329) Preterm premature rupture of membranes, which is defined as rupture of the membranes before labor and prior to 37 weeks, can result from intra-amnionic infection, low socioeconomic status, low body mass index, nutritional deficiencies, andcigarette smoking. (p. 811) There are no studies that have been able to conclude that postdatism is related to smoking during pregnancy. Reference:Cunningham, F. G., Williams, J. W., Leveno, K. J., Bloom, S., Hauth, J. C., & Rouse, D. J. (2010). Williams Obstetrics. (3 ed.) (pp. 329, 811) . New York: McGraw-Hill Professional.

Crisanto, Hebe Margaret

15. Travel by air during pregnancy does not jeopardize pregnancy but may cause: a. changes in sleep patterns b. risk of not having immediate competent obstetric care in case of emergency c. increase venous stasis due to prolong sitting d. all of the above e. a and b Answer: d. Rationale: In the absence of obstetrical or medical complications, pregnant women can safely fly up to 36 weeks. It is recommended that pregnant women observe the same precautions for air travel as the general population, including periodic movement of the lower extremities, ambulation at least hourly and use of seatbelts while seated. A significant risk with travel is acquisition of infectious diseases or developing a complication remote from adequate facilities. Reference: Williams Obstetrics 23rd edition (E-book) Chapter 8, Pre-natal care

Carlos, Jason

16. A pregnant woman consulted due to an increase vaginal disharge, chaacterized as whitish yellowish, non foul smelling, un accompanied by pruritus. She should be: a. Prescribed with antibiotics for viginal infection b. Advised to use vaginal douche c. Reassured that it is normal leukorrhea

d. All of the above Answer: c. Reassured that it is normal leukorrhea Rationale: Because the characteristics described from the case are the characteristics which are usually observed on normal leukorrhea. In addition, discharge due to infectins are usually foul smelling. Vaginal douches on the other hand, are strictly contraindicated during pregnancy. Reference: Williams Obstetrics, 23rd edition, pages 211 and 814. Almaden, Vanessa 17. Excessive vomiting during pregnancy causing electrolyte imbalance is called a. pseudocyesis b. hyperemesisgravidarum c. ptyalism d. pica e. none of the above Answer B. HyperemesisGravidarum Rationale: Pseudocyesis is defined as false pregnancy or having symptoms of being pregnant when the person is not pregnant Hyperemesisgravidarum: Nausea and vomiting of varying severity usually commencing between the first and second missed menstrual period and continue until 14-16 weeks. Ptyalism: Profuse salivation Pica: Cravings of pregnant women to strange food like ice, starch or clay which has been considered to be triggered by iron deficiency. Reference: Williams 23rd edition pages 210-211 http://en.wikipedia.org/wiki/False_pregnancy Jurao, Adorissa 18. A pregnant patient on her 32 weeks age of gestation complained of sharp groin pain, more on the right side. She is best managed by: a. activity modification b. analgesia c. abdominal massage d. all of the above e. A and B ANSWER: E RATIONALE: Round ligament pain. These very sharp groin pains are caused by spasm of round ligaments associated with movement. The spasms are generally unilateral and are more frequent on the right side than the left because of the usual dextroversion of the uterus. Patients sometimes awaken at night with round ligament pain after having suddenly rolled over in their sleep. 1 -Pain associated with muscle spasm, frequently present in the lower extremities responds well to analgesics, heat and rest. In some women, motion of the symphysis pubis and lumbosacral joints and general relaxation of pelvic ligaments may be demonstrated. 2 -Activity modification such as having women squat rather than bend over when reaching down will reduce the pain.3 -Abdominal massage is not advisable since it can induce premature labor however light massage to relax tense, taut back muscles is one of the measures to relieve back pain or aches. 4 REFERENCES: 1. Brandon J. and et al. (May 2002). The Johns Hopkins Manual of Gynecology and Obstetrics .(2nd ed). Lippincott Williams & Wilkins Publishers 2. Sumpaico, W. (2008). Textbook of Obstetrics: Physiologic and Pathologic obstetrics. (3 rded). Association of writers of the Philippine Textbooks of Obstetrics and Gynecology, Inc. 3. Cunningham, G., and et. al. (2010). Williams Obstetrics (23rded). The McGraw-Hill Companies, Inc. 4. Pernoll, M. (2001). Benson &Pernolls Handbook of Obstetrics and Gynecology. (10thed). The McGraw-Hill Companies Dela Cruz, Joan Vel S. 19. Constipation is a common problem during pregnancy brought about by a. progesterone induced suppression of bowel motility b. compression of the intestines by the enlarging uterus c. intake of iron supplement d. all of the above e. A and B

Answer: (d) all of the above Rationale: Progesterone is the causative factor contributing to decreased motility, which in turn, leads to esophageal regurgitation, slow emptying of the stomach and reverse peristalsis. With decreased visceral motility and prolonged transit time of gastrointestinal contents, these provide a better avenue for better ferrous and calcium absorption, but increased flatulence and constipation. In addition to the horomonal influences exerted by pregnancy on the intestinal tract, the mechanical pressure exerted by the enlarging abdomen to the rectosigmoid area contributes to constipation and hemorrhoid formation. Reference: Textbook of Obstetrics (Physiologic and Pathologic Obstetrics), 3rd ed., by Sumpaico, et al. page 237. Delos Santos, Christian 20.The backache and pain at the buttocks down to the thighs during pregnancy is due to: a. motion of symphisis pubis d. all of the above b. motion of the lumbosacral joint e. A & B c. relaxation of pelvic ligaments Answer: (d) All of the above Rationale: Pregnant patient may develop backache and pain which are often referred to the region of the buttocks and down to the thighs. Pain associated with music muscle spasm, frequently present in the lower extremities, responds well to analgesics, heat and rest. In some women, motion of the symphisis pubis and lumbosacral joint and genereal relaxation of pelvic ligaments may be demonstrated. Reference: Chapter 10: prenatal care; Section III approach to pregnancy; page 140., Textbook of Obstetrics 2nd edition.; Author: Walfrido W. Sumpaico., M.D. Exconde, Ma. Kathrina 21. The exposure to any teratogen during this time coincides with "all or none period". This is during the _________ period. A. Pre- implantation B. embryonic C. Fetal D. All of the above Answer: A Rationale: The pre- implantation period is the two weeks from fertilization to implantation and has traditionally been called the "all or none" period. The zgote undergoes cleavage, and cells divide into an outer and inner cell mass. An insult damaging a large number of cells usually causes death of the embryo. If only a few cells are injured, compensation is usually possible with continued normal development (Clayton- Smith and Donnai, 1996). Reference: Williams, 22nd Edition, (Chapter 14, page 343). Co, Jeffrey James 22. The period when an insult is introduced to pregnancy will produce an irreparable damage a. pre-implantation c. fetal b. embryonic d. anytime during gestation Answer: (a) pre-implantation Rationale: When an insult is introduced during the pre-embryonic period also called all or none period, it will cause damage to a large number of cells which will definitely lead to abortion of the embryo. Unlike the embryonic and fetal period, an insult to this age will only cause severe, moderate, or mild malformations. Reference: Williams Obstetrics, 21st edition, page 1007 Textbook of Obstetrics, 3rd edition, page 345-346 Constantino, Erwin 23.An example of a drug that inhibits post-translational carboxylation of proteins: a. Angiotensin converting enzymes b. Streptomycin c. Warfarin d. Chloramphenicol Answer: C Rationale: It is stated that Warfarin inhibits the posttranslational carboxylation of coagulation proteins leading to the vitamin K-dependent clotting factors to not be appreciated. The fetus is at risk of

developing warfarin embryopathy if there is exposure during the 6th and 9th weeks. Some data shows that the development of warfarin embryopathy may be dose dependent. Reference:WilliamsEdition 23, page 326 Alcantara, Janus 24. At what period of fetal development (in weeks) is the heart most vulnerable to the effects of a teratogen? a. pre-implantation to 2nd b. 3rd to 6th c. 7th to 10th d. 11th to 14th ANSWER: b. 3rd to 6th RATIONALE: Embryonic period (2nd to 8th week), the period of organogenesis. Teratogen exposure during this period GREATLY affects the HEART REFERENCE: Williams 23rd ed. Fig. 4-3 p. 80 Cabanos, Ronell 25. If there is a marked folic acid deficiency during the period of pregnancy (weeks), the fetal brain will be greatly affected : A. Preimplantation to second week B. 3rd to 16th C. 17th to 20th D. 21st to 24th Answer: B.3rd to 16th Rationale: Below is a generalized overview of periods when development of organ systems is most sensitive to disruption causing major congenital anomalies (dark blue bars). From the diagram, it is apparent that major morphological abnormalities in the brain happens during 3rd to 16th weeks hence consequences of folic acid deficiency is mainly observe in this period. From the diagram, it is apparent that major morphological abnormalities in the brain happens during 3rd to 16th weeks hence consequences of folic acid deficiency is mainly observe in this period.

Reference : http://www.people.virginia.edu/~rjh9u/hdevsum.html Angeles, Ma. Kristina Cassandra S. 26. There will be masculinization of the female fetal external genitalia if the progestational drugs during this period of pregnancy (weeks): a. Preimplantation to 2nd week b. 3rd to 5th c. 6th to 8th d. 9th week till term Answer: D. 9th week till term Rationale: 9th week till term encompasses the organogenesis of the external genitalia. It is the most crucial to structural malformation so giving progestational drug will affect the masculinization of the

female external genitalia during this period. Reference: Williams and Obstetrics 20th edition page 313-314 Bunyi, Maria Athena 27. The effect of retinoids particularly isotretinoin is most evident at the face. The most common form of fetal deformity caused by this drug if given during pregnancy is: a. microcephaly b. microtia c. nasal hypoplasia d. cleft palate Answer: letter B Rationale:Isotretinoin is a synthetic retinoid or vitamin A derivative. The retinoids are involved in the HOX signaling pathways that are used to pattern the branchial arches (pharyngeal arches) during the fourth week of embryonic development. It is not surprising, therefore, that the derivatives of the pharyngeal arches are affected by isotretinoin exposure during pregnancy, namely the central nervous system (CNS), craniofacial features, and cardiac structures. Microtia being the most common deformity is associated with hearing defects. References: Dolan, S. Article on Isotretinoin and Pregnancy - A Continued Risk for Birth Defects. (November 1, 2004). Based on the OB-GY Lecture S.Y. 2011-2012 Andres, Rachel 28. For epidemiological findings to be consistent, there must be at least how many high quality studies that will manifest that the defect is produced by a particular agent? a. 2 b. 3 c. 4 d. 5 Answer: A Rationale: The important criterion for proving teratogenicity is that two or more high quality epidemiological studies should report similar findings. These studies should control for confounding factors, exclude positive and negative biases, include sufficient number of cases and be conducted prospectively. Reference: Williams Obstetrics 23rd edition (page 313) Boac, Ma. Minerva 29.Threshold dose is described as the dosage that a. will produce the effects below the levels of the controls b. can initiate the effects with the maximum amount of its dose c. may produce 50 percent of defects in the entire group of subjects d. can produce the defects by using the half strength of its dose Answer: A. Will produce the effects below the levels of the controls Reference: HUMAN TERATOGENS: A CRITICAL EVALUATION OrnaDiav-Citrin, MD, Gideon Koren, MD, FACCT, FRCPC The Motherisk Program, the Hospital for Sick Children, Toronto, Ontario, Canada http://www.nvp-volumes.org/p2_4.htm De Castro, Jener N. 30. The primary organ responsible for the metabolism of drugs taken during pregnancy: a. Liver b. Kidney c. Skin d. Lungs Answer: A Rationale: Quantitatively, the smooth endoplasmic reticulum of the liver cell is the principal organ of drug metabolism, although every biological tissue has some ability to metabolize drugs. Factors responsible for the liver's contribution to drug metabolism include that it is a large organ, that it is the first organ perfused by chemicals absorbed in the gut, and that there are very high concentrations of most drug-metabolizing enzyme systems relative to other organs. If a drug is taken into the GI tract, where it enters hepatic circulation through the portal vein, it becomes well-metabolized and is said to show thefirst pass effect. According to Sumpaicos book, there is only altered metabolic disposition of drugs occurs during different stages of pregnancy but it is not stated here that there is a change in the site of metabolism.

Reference: Walfrido W. Sumpaico, Textbook of OBSTETRICS (Physiological and pathologic obstetrics) 2ndedition page 192. http://en.wikipedia.org/wiki/Drug_metabolism Balandan, Patricia Joy C. 31. The following drugs that may produce nasal hypoplasia: a. Tetracyclines b. Aminoglycosides c. Anticonvulsants d. Sulphonamides Answer: CAnticonvulsants Rationale: Craniofacial anomaly is one of the teratogeniceffect of common anti-epileptic drugs. Anticoagulants like warfarin can also cause nasal hypoplasia. Reference: Williams 22nd Edition, page 348. Table 14-4. Atienza, Kriska 32. The group of drugs that is noted to cause oligohydramnios and intrauterine growth restriction: a. aminoglycosides c. ACE inhibitors b. anticoagulants d. NSAIDs Answer: C. ACE Inhibitors Rationale: Aminoglycosides administration on pregnant women can result in toxic fetal blood levels, it can also cause nephrotoxicity and ototoxicity in newborns. NSAIDs are not considered to be teratogenic, but they can have adverse effects when used in the third trimester. Anticoagulants readily cross the placenta, and can cause significant teratogenic and fetal effects. If exposed between the sixth and ninth weeks, the fetus is at risk for warfarin embryopathy. Warfarin derivatives exert their teratogenic effect by inhibiting posttranslational carboxylation of coagulation proteins. ACE inhibitors disrupt the fetal rennin-angiotensin system system, which is essential for normal development. They may provoke prolonged fetal hypotension and hypoperfusion, thus initiating a sequence of events leading to renal ischemia, renal tubular dysgenesis, and anuria. The resulting oligohydramnios may prevent normal lung development and lead to limb contracturtes. Reference: Williams Obstetrics 23rd Edition pages 319 321 and 326 Delos Santos, Sharmen S. 33. This agent promotes closure of ductusarteriosus when given during the last trimester of pregnancy: a. Alcohol b. NSAIDs c. Anticonvulsants d. Angiotensin receptor blockers Answer: b. NSAIDs Rationale: The correct is letter B NSAID. NSAID, particularly Indomethacin is reported to cause constriction of the fetal ductusarteriosus with subsequent pulmonary hypertension [sic]. It is not Alcohol because it causes Fetal Alcohol Syndrome; not Anticonvulsants, particularly Lithium, may cause transient neonatal toxicity;effects have included hypothyroidism, diabetes insipuds, cardiomegaly, bradycardia, electrocardiogram abnormalities, cyanosis and hypotonia; Not ARBs because disrupt fetal renin-angiotensin system which is essential for normal renal development; in addition it may provoke prolong fatal hypotension and hypoperfusion. Reference: Chapter 14: Tetralogy and Medications that affects the fetus p. 319. Williams Obstetrics 23 rd Edition. Hernadez, KristeenKhae B. 34.This group of drugs is noted for ototoxicity even among the adults, a. aminoglycosides c. angiotensin receptor blockers b. anticoagulants d. chloramphenicol Answer: A Rationale: -Antimicrobials (Aminoglycosides) Maternal administration can result in toxic fetal blood levels, but this can be avoided by using lower divided doses (Regev and colleagues, 2000). Although both nephrotoxicity and ototoxicity have been reported in preterm newborns and adults treated with gentamicin or streptomycin, congenital defects resulting from prenatal exposure have not been confirmed. -Anticoagulants It was concluded that two distinct types of defects result from exposure during two different developmental periods. If exposed between the sixth and ninth weeks, the fetus is at risk for warfarin embryopathy. This is characterized by nasal and midface hypoplasia, such as shown in Figure 14-5, and

stippled vertebral and femoral epiphyses. Importantly, vitamin K-dependent clotting factors are not demonstrable in the embryo, and it is thought that warfarin derivatives exert their teratogenic effect by inhibiting posttranslational carboxylation of coagulation proteins (Hall and associates, 1980). The syndrome is a phenocopy of chondrodysplasiapunctata, a group of genetic diseases thought to be caused by inherited defects in osteocalcin. There are data that suggest that the risk of warfarin embryopathy is dose dependent. -Angiotensin-Receptor Blockers It has been known for 20 years that ACE inhibitors are fetotoxic, and more recently they have also been associated with embryotoxicity. The most frequently associated agent is enalapril, although captopril and lisinoprilhave also been implicated. Because angiotensin-receptor blockers exert their effects through a similar mechanism, concerns about toxicity have been generalized to include this entire category of medications. These drugs disrupt the fetal renin-angiotensin system, which is essential for normal renal development (Guron and Friberg, 2000). In addition, they may provoke prolonged fetal hypotension and hypoperfusion, thus initiating a sequence of events leading to renal ischemia, renal tubular dysgenesis, and anuria (Pryde and colleagues, 1993; Schubiger and associates, 1988). The resulting oligohydramnios may prevent normal lung development and lead to limb contractures. Reduced perfusion also causes growth restriction, relative limb shortening, and maldevelopment of the calvarium (Barr and Cohen, 1991). Because these changes occur after organogenesis, and thus during the fetal period, they are termed ACE inhibitor fetopathy (see Evaluation of Potential Teratogens). Cooper and colleagues (2006) recently described 209 children whose mothers were prescribed ACE inhibitors in the first trimester. They reported that 8 percent had major congenital anomalies predominantly cardiovascular and central nervous system malformationsa rate 2.7 times higher than that observed in more than 29,000 control infants. Given the many therapeutic options for treating hypertension during pregnancy, it is recommended that ACE inhibitors and angiotensin-receptor blocking agents be avoided. -Chloramphenicol This readily crosses the placenta and results in significant fetal blood levels. The incidence of congenital anomalies does not appear to be increased in exposed fetuses. When given to the preterm neonate, the gray baby syndrome may develop. This is manifested by cyanosis, vascular collapse, and death. It seems unlikely that fetal serum levels obtained from maternal administration would cause this syndrome. Reference: Electronic book Williams Obstetrics, Twenty-Third Edition. Chapter 14 Teratology and Medications that Affect the Fetus De Los Santos, KathrineAira N. 35. This produces the so called Gray baby syndrome reaction: a. Isotretinoin b. Methotrexate c. Chloramphenicol d. Sulfonamides Answer: c. Chlorampenicol Rationale: The gray baby syndrome, manifested by cyanosis, vascular collapse, and death, has been reported with large doses of Chloramphenicol given to the preterm neonate. This drugreadily crosses the placenta and results in significant fetal blood levels. -First-trimester exposure to Isotretinoin is associated with a high rate of fetal loss and malformations, which typically involve the cranium and face, heart, central nervous system, and thymus. The craniofacial malformation most strongly associated with isotretinoin is bilateral but often asymmetricalmicrotia or anotia, frequently with agenesis or stenoses of the external ear canal. Other defects include maldevelopment of the facial bones and cranium, and cleft palate. The most frequent cardiac defects are conotruncal, and hydrocephalus is the most common central nervous system defect. Thymic abnormalities include aplasia, hypoplasia, or malposition. -Methotrexate is commonly prescribed as an abortifacient, for ectopic pregnancy, and for psoriasis and some connective-tissue diseases. Principal features of fetal methotrexate/aminopterin syndrome are growth restriction, failure of calvarial ossification, craniosynostosis, hypoplastic supraorbital ridges, small posteriorly rotatedears, micrognathia, and severe limb abnormalities. Studies show that firsttrimester exposures and a dose of 10 mg per week is necessary to produce abnormalities. -Sulfonamidesreadily cross the placenta and results in fetal blood levels lower than maternal levels. These drugs compete for bilirubin-binding sites, and may be associated with hyperbilirubinemia if used near delivery in the preterm infant. There have been no studies exploring a possible association of sulfa drugs with congenital anomalies. Reference: Ebook(2010). Cunningham, F.G, K.J. Leveno, S.L. Bloom, J.C. Hauthe, D.J. Rose & C.Y. Spring. Chapter 14: Teratology and Medications that Affect the Fetus. Williams Obstetrics. 23rded. USA: McGraw-Hill

Bonita, Marriane

Companies, Inc. 36. Phase 1 of parturition has the following functions EXCEPT: a. maintains uterine muscle tranquility b. initiates changes in vascularity and size c. promotes uterine excitability d. maintains structural cervical integrity ANSWER: C promotes uterine excitability RATIONALE: Phase 1 of parturition is the period of uterine quiescence and cervical softening. By definition, uterine excitability does not follow quiescence. Also, the phase 1 is characterized as UNRESPONSIVE TO NATURAL STIMULI, which is partly in contrast to uterine excitability. REFERENCE: Salvador, Floriza C. Handout on Physiology of Parturition. 2012

Gozun, Jaecel

37. The extracellular connective tissues involved in cervical changes during phase 1 of parturition include the following EXCEPT: a. collagen b. proteoglycans c. claudins d. elastins ANSWER: c. claudins RATIONALE: Extracellular connective tissue constituents include type I, III, and IV collagen, glycosaminoglycans, proteoglycans, and elastin. Claudins are tight junction proteins that regulate paracellular transport of ion and solutes and maintenance of barrier function. Reference: Cunningham, G. et al (2010).Williams Obstetrics, Twenty-Third Edition. United States of America: McGraw Hill.

Fernandez, Quinnie

38.the substance that promote myometrial relaxation during phase 1 of parturition are: a) prostacylin b) relaxin c) 15-hydroxy prostaglandin dehydrogenase d) all of the above Answer:d) all of the above Rationale: IPprostacyclin or PGI2; PGI2 could potentially act to maintain uterine quiescence by increasing cAMPsignalling. PGI2 have been shown to cause vascular smooth muscle relaxation and vasodilatation in many circumstances. (Lyall, 2002; Olson, 2003, 2007; Smith, 2001; Smith, 1998, and all their colleagues). -Relaxin is a peptide hormone consists of an A and B chain and is structurally similar to the insulin family of proteins (Bogic and associates, 1995; Weiss, 1995). Relaxin mediates lengthening of the pubic ligament, cervical softening, vaginal relaxation, and inhibition of myometrial contractions. Relaxin may promote myometrial relaxation. -Prostaglandin isomerase expression is tissue-specific, thus controlling the relative production of various prostaglandins. An important control point for prostaglandin activity is its metabolism, which most often is through the action of 15-hydroxyprostaglandin dehydrogenase (PGDH). Expression of this enzyme can be regulated in the uterus, which is important because of its ability to rapidly inactivate prostaglandins to their 15-keto metabolites.

Reference : Cunningham,F. MD, Leveno, K. J. MD, et al. (Eds.). (2010) Williams Obstetrics (23rd ed.). McGraw-Hill Companies, Inc., USA
Genovana, Raymond 39. The role/s of progesterone in the phase 1 of parturition is/are: A) Decreases the expression of contraction-associated protein (CAPs) B) Inhibits the expression of connexin 43, a gap junction protein C) Sustains the cervical competency D) All of the above Answer: D) All of the above Rationale: Progesterone likely increases uterine quiescence by direct or indirect effects that cause decreased

expression of the contraction-associated (CAPs). Progesterone has been shows to inhibit expression of the gap junctional protein connexin 43 in several rodent models of labor. (page 151-152). Estrogen can act to promote progesterone responsiveness, thus regulating human uterine activity and cervical competency (page 151) Reference: 23rdediton Williams Obstetrics Barron, Emmanuel John V. 40. To prepare the cervix for phase 2 of parturition, these changes in the cervical structure must have occurred, EXCEPT: a. collagen dispersion b. collagen degradation c. loss of tissue integrity d. enhancement of tissue compliance Answer:b. collagen degradation Rationalization: Cervical ripening which is prominent in phase 2 of parturition correlates with changes in collagens three-dimensional structure rather than its degradation by collagen. Dispersion of collagen fibrils leads to a loss of tissue integrity and increased tissue compliance. Reference: Williams Obstetrics, 23rd edition, page 140 Castro, Sylvester 41. In phase 2 parturition preparing the uterus for labor., these are uterine changes that occur EXCEPT: a. marked increase in oxytocin receptors in the uterine muscles b. obliteration of the tight junction protein c. cervical ripening d. increase in surface area of the gap junction proteins. Answer: b. obliteration of the tight junction protein Rationale: a.) Most myometrial changes during phase 2 prepare it for labor contractions. Thus, myometrial oxytocin receptors markedly increase. (Correct) b.)During Phase 2 cervical ripening, collagen fibrils are disorganized, and there is increased spacing between fibrils. (Correct) c.)There is should be no obliteration of the tight junction proteins in phase 2. (Incorrect) d.) There is increased numbers and surface areas of gap junction proteins such as connexin 43. (Correct) Reference: Williams Obstetrics 23 editions Phase 2 of Parturition: Preparation for Labor pages 374-409 Alaba, Aileen Abigail 42. which of the substance/s is/are increased during phase 3 of parturition to favor labor? a. oxytoxin receptors b. fetal corticotropin releasing hormone c. prostaglandins d. all of the above Answer: d Rationale: The number of oxytocin receptors strikingly increases in myometrial and decidual tissues near end of gestation. oxytocin acts on decidual tissue to promote prostaglandin release.Oxytocin is synthesized directly in decidual and extraembryonic fetal tissues and in the placenta Reference: page: 159 williams obstetrics 23rd edition Fabia , Mary Joyce S. 43. The following conditions belong to phase 3 of parturition EXCEPT: a. Stage of placental separation b. Fetal expulsion c. Presence of cervical dilatation and effacement d. Uterine involution Answer: d. uterine involution Rationale: All fall under phase 3 of parturition except letter D. uterine involution because it falls under phase 4. Phase 1 Prelude to parturition: contractile unresponsiveness, cervical softening Phase 2- Preparation for labor: uterine preparedness for labor and cervical ripening Phase 3- Process which includes 3 stages of Labor: uterine contraction, cervical dilatation and effacement, fetal and placental expulsion Phase 4 Parturient recovery: uterine involution, cervical repair and breastfeeding Reference: Chapter 6. Parturition Section 2 page 137 figure 6-1 The phases of parturition. Williams Obstetrics 23rd Edition.

GARIN, CHRISTINE ABIGAIL R.

44. The substance/s that may induce myometrial contraction and thus induce labor is/are: a. cAMP c. cGMP b. RU486 d. all of the above Answer: b. RU486 Rationale: When the steroidal antiprogestin, mifepristone or RU486, is administered during the latter phase of the ovarian cycle, it induces menstruation prematurely. It is also an effective abortifacient during early pregnancy. Mifepristone is a classical steroid antagonist, acting at the level of the progesterone receptor. Although less effective in inducing abortion or labor in women later in pregnancy, mifepristone appears to have some effect on cervical ripening and increasing myometrial sensitivity to uterotonins. These data suggest that humans have a mechanism for progesterone inactivation, whereby the myometrium and cervix becomes refractory to the blocking actions of progesterone. A number of G-protein-coupled receptors that normally are associated with G-mediated activation of adenylyl cyclase and increased levels of cAMP are present in myometrium, thatpromotes myometrial relaxation. These receptors together with appropriate ligands may actin concert with sex steroid hormonesas part of a fail-safe system to maintain uterine quiescence. Atrial and Brain Natriuretic Peptides and Cyclic Guanosine Monophosphate (cGMP) Activation of guanylylcyclase increases intracellular cGMP levels, which also promotes smooth muscle relaxation. Guanylatecyclase activity and cGMP content is increased in pregnant myometrium before labor starts compared with after labor has begun. Intracellular cGMP levels can be stimulated by either atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP) receptors, which are both present in myometrium during pregnancy. Soluble guanylylcyclase is also activated by nitric oxide, which because of its hydrophobic nature, readily penetrates the plasma membrane to enter cells. Nitric oxide reacts with iron and stimulates it to produce cGMP and myometrial relaxation. Nitric oxide is synthesized in decidua, myometrial blood vessels, and nerves. Its role in possible uterine quiescence is not understood. Reference: Williams Obstetrics, Twenty-Third Edition (ebook), Chapter 6 An increase in Calcium promotes myometrial contraction but on the other hand, a decrease in calcium will lead to relaxation of the muscles. The agents that cause an increase in intracellular concentration of cyclic adenosine monophosphate (cAMP) or cyclic guanosine monophosphate (cGMP) also promote uterine relaxation although the exact mechanism is not defined. Reference: Textbook of obstetrics (Physiologic & Pathologic Obstetrics) 3rd edition page 360

Jalea, Jelly Ann

45. The newer understanding regarding the role of estrogen in pregnancy is/are: a. hastens the degradation of progesterone b. indirectly induces progesterone responsiveness c. potentiates further the local effects of estrogen in the myometrium d. has no effect on phase 1 of parturition ANSWER: b. Indirectly induces progesterone responsiveness Rationale: Estrogen can act to promote progesterone responsiveness, and in doing so, promote uterine quiescence. The estrogen receptor act via the estrogen-response element of the progesterone-receptor gene; it induces progesterone-receptor synthesis, which allows increased progesterone-mediated function. Reference: Source (E-book): Cunningham, et. al., Williams Obstetrics 23rd edition (2010). Section II: Anatomy and Physiology, Chapter 6: Parturition

Gatdula, Joanne Karla C.

46. Oxytocin levels are increased during phase ____ and 3 of parturition. a. 1 c. 4 b. 2 Answer: C Rationale:Although little evidence suggests a role for oxytocin in phase 2 of parturition, abundant data support its important role during second-stage labor and the puerperiumphase 4 of parturition. Specifically, there are increased maternal serum oxytocin levels: (1) during second-stage laborthe end of phase 3 of parturition, (2) in the early postpartum period, and (3) during breast feedingphase 4 of

parturition (Nissen and co-workers,1995). Immediately after delivery of the fetus, placenta, and membranescompletion of parturition phase 3firm and persistent uterine contraction and retraction are essential to prevent postpartum hemorrhage. Oxytocin likely causes persistent contractions. Reference: Williams Obstetrics, 23rd Edition pg 159 De Guzman, Geelvie 47. The action/s of relaxin during parturition is/ are: a. Mediates lengthening of pubic ligament b. Induces myometrial contractions c. Promotes cervical ripening d. All of the above Answer: a. Mediates lengthening of the pubic ligament. Rationale: The answer is letter a. According to the book Williams obstetrics 23rd Edition, relaxin mediates the lengthening of the pubic ligament, cervical softening, vaginal relaxation and inhibition of myometrial contraction. Letter b is incorrect since relaxin does not induce myometrial contraction but rather inhibits uterine contractions. Letter c is incorrect as well since relaxin only promotes cervical softening and not cervical ripening. Reference:Cunningham, F. Gary. et. al. Williams Obstetrics 23rd edition. Published 2010 (Chapter 6, page 153) Gabriel, Gretchen 48. During pregnancy, prostaglandin acts as ____ to the uterus. a. Uterotonins b. Anti-inflammatory c. Muscle relaxant d. all of the above Answer: A Rationale: Most myometrial changes during phase 2 preapre it for labor contractions. This shift probably results from alterations in the expression of the key proteins that control contractility. These contraction-associated proteins (CAPs) include the oxytocin receptor, prostaglandin F receptor, and connexin 43 (Smith, 2007). Thus, myometrial oxytocin receptors markedly increase along with the increased numbers and surface areas of gap junction proteins such as connexin 43. Together these lead to increased uterine irritability and responsiveness to UTEROTONINSagents THAT STIMULATE CONTRACTIONS. Jezreel Joy B. Javier 49. The fetal signal/s that may initiate labor is/are: a. Fetal growth b. Production of corticotrophin releasing hormone c. Presence of fetal lung surfactant d. All of the above Answer: D Rationale: Role of Uterine Stretch in Parturition. There is now considerable evidence that fetal growth is an important component in the activation of the uterus seen in phase 1 of parturition. During the course of gestation, and in association with fetal growth, there is a significant increase in myometrial tensile stress and amnionic fluid pressure (Fisk and co-workers, 1992). Potential Roles of CRH in Timing of Parturition. Placental CRH has been proposed to play several roles in the regulation of parturition. First, placental CRH may enhance fetal cortisol production, which would provide positive feedback on the placenta to produce more CRH. The resulting high level of CRH may modulate myometrial contractility. Second, cortisol has been proposed to affect the myometrium indirectly by stimulating the membranes to increase prostaglandin synthesis. Third, CRH has been shown to stimulate fetal adrenal C19-steroid synthesis, leading to increased substrate for placental aromatization. Fetal Anomalies and Delayed Parturition. There is fragmentary evidence that pregnancies with hypoestrogenism are sometimes associated with prolonged gestation. Examples of this include fetal anencephaly, adrenal hypoplasia, and placental sulfatase deficiency. Other fetal abnormalities that prevent or severely reduce the entry of fetal urine into amnionic fluid (renal agenesis) or lung secretions (pulmonary hypoplasia) do not prolong human pregnancy. Reference: Williams Obstetrics, 22nd edition (e-book) p. 101-103

Dizon, Ron

50. Aside from oxytocin, what is/are the other uterotonins that may induce labor? a. Platelet activating factor b. Histamine c. Serotonin d. All of the above e. Answer: D (all of the above) Rationale:Uterotonins that are candidates for labor induction include oxytocin, prostaglandins, serotonin, histamine, PAF, angiotensin II & many others. Source: p 158, Williams Obstetrics 23rd edition 51. In order to cause increase in the cervical dilatation, the uterine contractions should emanate and be greatest in the __________ of the uterus. a. Fundal area c. Cervical segment b. Lower segment d. Corporeal segment Answer:a. Fundal area Rationalization: Uterine contractions of normal labor are characterized by a gradient of myometrial activity. These forces are greatest and last longest at the fundus considered fundal dominance and they diminish toward the cervix (Reynolds and co-workers, 1948). The stimulus starts in one cornu and then several milliseconds later in the other. The excitation waves then join and sweep over the fundus and down the uterus (Larks, 1960). Reference: Williams Obstetrics, 23rd edition, page 467, Types of Uterine Dysfunction

Daniel Christopher J. Carreon

Lapitan, Jemelyn R.

52. As labor progresses, the upper uterine segment becomes progressively: a. Thinner and shorter b. Thinner and longer c. Thicker and shorter d. Thicker and longer Answer: C. Thicker and shorter Rationale: During labor, the myometrium of the upper segment does not relax to its original length after contractions. Instead, it becomes relatively fixed at a shorter length. The upper active uterine segment contracts down on its diminishing contents, but myometrial tension remains constant. The net effect is to take up slack, thus maintaining the advantage gained in the expulsion of the fetus. Concurrently, the uterine musculature is kept in firm contact with uterine contents. As the consequence of retraction, each successive contraction commences where its predecessor left off. Thus, the upper part of the uterine cavity becomes slightly smaller with each successive contraction. Because of the successive shortening of the muscular fibers, the upper active segment becomes progressively thickened throughout the first and second stage labor. This process continues and results in a tremendously thickened upper uterine segment immediately after delivery. Reference: p. 142, Chapter 6, Section 2, Williams Obstetrics, 23rd edition

Luna , Juan Carlos

53. The main force necessary to expel the baby out of the vaginal canal after full cervical dilatation is the ______ pressure. a. Intra-abdominal b. Intra-uterine c. Intracervical d. Intra-vaginal Answer:A. The correct answer is intra-abdominal Rationale: After the cervix is dilated fully, the most important force in the fetal expulsion is that produced by maternal intra-abdominal pressure [sic]. Reference: Chapter 6. Parturition page 143. Williams Obstetrics 23rd Edition.

Jonathan B. Ancheta

54. A woman in labor is seen at the emergency room. The minimum frequency of uterine contraction/s which will confirm the diagnosis that she is in labor and make you recommend that she be admitted is at least ____________ in ten minutes a. One b. Two c. Three d. Four

Answer: b. two Rationale: Pates and colleagues (2007) studied the commonly used recommendations given to pregnant women that, in the absence of ruptured membranes or bleeding, uterine contractions 5 minutes apart for 1hour that is, 12 contraction in 1 hour- may signify labor onset. 1 contraction 5 minutes apart 2 contractions in 10 minutes Reference: Williams Obstetrics 23rd edition Chapter 17 Normal Labor and Delivery, Admission Procedures: Identification of Labor Han, Erika
Agoncillo, Andre Luis R.

55. ----56. A primigravida was admitted due to labor pains with the following Leopolds maneuver findings: LM1 large, nodular mass LM2 smooth board-like mass along right maternal side LM3 Hard, round, ballotable mass On IE you appreciated a soft mass through the cervix which is 5cms dilated. The fetal heart tones are best appreciated in the _____quadrant: a. left upper c. right upper b. left lower d. right lower ANSWER: D Rationale: The Fetal heart tone is commonly heard in either right or left lower. It can be best heard at the fetal back (LM2). Since LM2 is along the right side, therefore the fetal heart tone can be best heard in the right lower quadrant. Reference: http://books.google.com.ph/books?id=c5dn3yh4V5UC&pg=PA1156&lpg=PA1156&dq=fetal+heart+tone +best+heard+in+what+quadrant&source=bl&ots=hb7LtM3uGS&sig=3nJYX6FHZfpGrRr_7h71CXJj38&hl=tl&sa=X&ei=i8pDT8WOEJCSiQeu6rmuDg&ved=0CBwQ6AEwAA#v=on epage&q=fetal%20heart%20tone%20best%20heard%20in%20what%20quadrant&f=false

Ferrer, JanMichael A.

57. A primigravida was admitted due to labor pains with the following Leopolds maneuver findings: LM1- Large, nodular mass LM2- smooth, board-like mass along right maternal side LM3- hard, round, ballotable mass What is the fetal lie? a. longitudinal b. oblique c. sagittal d. transverse Answer: a. Longitudinal Rationale:Letter a is correct. The first maneuver permits identification of which fetal pole (cephalic or podalic) occupies the uterine fundus. The breech gives the sensation of a large, nodular mass. What is felt in doing the 2nd maneuver is the back which is felt as a smooth, board-like mass along the right maternal side. After performing the 3rd maneuver, the head (which is not yet engaged) was felt and is represented by a hard, round, ballotable mass. Given the findings, the fetal axis is parallel to the mothers long axis. The presenting part in this case would be the fetal head, creating a cephalic presentation, which is definitely in a longitudinal lie. Reference:Cunningham, F. Gary. et. al. Williams Obstetrics 23rd edition. Published 2010 (Chapter 17 Normal Labor and Delivery pg. 374 377).

Aguila, Julie Ann Dianne M.

58. Fetal attitude refers to the relationship between the fetal head and the body. Which of the following fetal attitudes is correctly defined? a. occiput- head completely flexed b. sinciput- head partly flexed c. face- head partly extended d. brow- head completely extended ANSWER: C. Occiput- head completely flexed. RATIONALE: Following the fetal attitude rule : fetus forms an ovoid mass that correspondeds roughly to the shape of the uterine cavity, the fetal head is then expected to completely flex and hence

present the occipital attitude (vertex/occiput presentation). REFERENCE: Williams, 22nd edition. page 230 (ebook) Garcia, Joyce Ann R. 59. Fetal attitude determines the presenting diameter that will enter the maternal pelvis. If on internal examination the fetal head is assessed to be in complete flexion, the presenting diameter is a. suboccipitobregmatic b. submentobregmatic c. occipitofrontal d. occipitomental Answer. A. Rationale: Note that with complete flexion, the chin is on the chest. The SUBOCCIPITOBREGMATIC diameter, the shortest anteroposterior diameter of the fetal head, is passing through the pelvic inlet. Reference: Williams Obstetrics, 23rd edition. p. 385

Atienza, Emmanuel

60. Fetal presenting diameter most compatible with spontaneous vaginal delivery a. suboccipitobregmatic b. submentobregmatic c. occipitofrontal d. occipitomental ANSWER A RATIONALE: SUBOCCIPITOBREGMATIC because it has the narrowest diameter (9.5cm) and most common fetal presentation. Reference: Williams 22nd edition page 411

Lao, Charles

61. A primagravida was admitted to labor pains. On IE you assess the fetus to be in cephalic presentation. What is the fetal position if the fixed reference point (FRP) is pointing to the mothers right side and closer to her sacrum? a. Right FRP anterior b. Right FRP posterior c. Left FRP anterior d. Left FRP posterior Answer: B Rationale: The Fetal Position describes the location of a fixed reference point on the presenting bars in relation to the four quadrants. Also observed in the fetus is that the head is in flexion or is bowed, the back of the fetus is curved, and the limbs are bent and drawn up to the torso. The fetal reference is in the right or left of the mothers pelvis. O is for Occiput where the fetus is in vertex presentation, M is for Mentum or chin where the fetus is in face presentation, S is for Sacrum where the fetus is in breech presentation, and Scapula or acronio the fetus is in shoulder presentation. Vertex LOA Left Occipito Anterior LOP Left Occipito Posterior LOT Left Occipito Transverse ROA Right Occipito Anterior ROP Right Occipito Posterior ROT Right Occipito Transverse Face LMA Left Mento Anterior LMP Left Mento Posterior LMT Left Mento Transverse RMA Right Mento Anterior RMP Right Mento Posterior RMT Right Mento Transverse Breech LSA Left Sacro Anterior LSP Left Sacro Posterior LST Left Sacro Transverse RSA Right Sacro Anterior RSP Right Sacro Posterior RST Right Sacro Transverse Shoulder LADA Left Acromion Dorsal Anterior LADP Left Acromion Dorsal Posterior RADA Right Acromion Dorsal Anterior RADP Right Acromion Dorsal Posterior

Reference: Williams, Obstetrics http://www.nursingcare101.com/fetal-position Espinoza, 62. Etiology of deflection in attitudes in cephalic presentation include fetal:

Faith Kristine R.

a. neck anomalies b. head anomalies c. macrosomia d. all of the above Answer: D Rationale: A normal fetal attitude is when the head of the fetus is completely flexed towards the chin and the back is markedly convex with the thighs and legs lying over the abdomen. Abnormal exceptions to this attitude occur as the fetal head becomes progressively more extended from the vertex to the brow or face presentation. Causes of these abnormal attitudes include numerous conditions that favor extension or prevent head flexion, such as marked enlargement of the neck or coils of cord around the neck. Fetal malformations, such as anencephaly, and hydramnios are also risk factors for face presentation. Also, extended positions develop more frequently when the pelvis is contracted or the fetus is very large, which may include fetuses with macrosomia. Reference:Williams, 23rd Edition, Pages 371, 474, and 476.

Angeles, Patricia KhayeDanao

63. Fetal presentation is determined by the fetal part which: A. Descends into the maternal pelvis B. Is palpated on Leopolds Maneuver 3 C. Is appreciated as occupying the cervical opening on internal examination D. All of the above ANSWER: D RATIONALE: Cunningham (2010) defined the presenting part as the portion of the fetal body that is either foremost within the birth canal or in closest proximity to it. It can be felt through the cervix on vaginal examination. On the other hand, he explained that Leopolds Maneuver 3 is performed by grasping with the thumb and fingers of one hand the lower portion of the maternal abdomen just above the symphysis pubis. If the presenting part is not engaged, a movable mass will be felt, usually the head. The findings from this maneuver are simply indicative that the lower fetal pole is in the pelvis. As explained by Cunningham (2010), the fetal presenting part therefore descends in the maternal pelvis or birth canal, can be palpated in Leopolds maneuver 3 and can be appreciated as occupying the cervical opening upon internal examination. RESOURCES:F. Cunningham (2010). Williams Obstetrics 23rd edition, page 374 and 377. Mcgraw Hill Companies Inc: USA.

Galang, Kim

64. The most common fetal presentation: a. breech b. cephalic c. face d. shoulder Answer: b. Cephalic Rationale: The most common fetal presentation is the cephalic presentation. Next most common is the breech presentation. Face and shoulder presentation are rarer compared to cephalic and breech presentation Reference: Pages 374-375, Chapter 17, Section IV of Williams Obstetric 23rd edition 65. On internal examination, you are able to palpate the posterior fontanel in full at a lower level compared to the posterior fontanel. What is the most probable presentation? a. brow b. face c. occiput d. sinciput ANSWER: C RATIONALE: Palpation of the fontanels and sutures upon vaginal examination indicate a cephalic presentation. In such cases, differentiation between occiput and sinciput presentations may be made by determining the positions of the anterior and posterior fontanels. If the fetus is in occiput presentation, then the head is fully flexed with the chin coming into contact with the chest. As such, the posterior fontanel will be more accessible compared to the anterior fontanel. Reference: Williams Obstetrics. 22nd edition, Chapter 17: Normal Labor and Delivery

Billiones, Kim Irving D.

Bayting, Ormalyn B.

66. Which plane of the pelvis determines its shape? A. Inlet

B. Midplane C. Outlet D. Sagittal Answer: A. Inlet Rationale: Caldwell and Moloy developed a classification that is based on the shape of the pelvis. The Caldwell-Moloy classification is based on measurement of the greatest transverse diameter of the inlet and its division into anterior and posterior segments. The shapes of these are used to classify the pelvis as gynecoid, anthropoid, android, or platypeloid. Reference: Williams Obstetrics 23rd edition. Page 32 BASUL, CHARINE A. 67. Which pelvic shape is most favorable to normal delivery? A. android B. anthropoid C. gynecoid D. platypeloid Answer:C. gynecoid Rationale: Anatomically, the shape of the inlet is round, the AP segment is almost equal and spacious. Obstetrically, there is no difficulty during engagement of the usual mechanism, there is easy internal rotation in the cavity and no difficulty during delivery from the outlet. Reference:Sumpaico 3rd edition, Page 384, Tables 23.2 A & B Garcia , Paul Mitchell L. 68. Pelvic plane described by the following boundaries: sacral promontory, lineaterminalis and symphysis pubis: a. Inlet b. Midplane c. Midlet d. Outlet Answer: a. Inlet Rationale: The superior strait or Pelvic Inlet: is bounded posteriorly by the promontory and alae of the sacrum, laterally by the lineaterminalis, and anteriorly by the horizontal pubic rami and the symphysis pubis Midpelvis: or the plane of least pelvic dimensions is measured at the level of the ischial spines. Pelvic Outlet: consist of triangular areas (anterior and posterior) that are not in the same place. Common Base: line drawn from two ischialtuberosities Anterior Triangle: Area under the pubic arch Posterior Triangle: Tip of Sacrum bounded laterally by sacrosciatic ligaments and ischialtuberosities Reference:Cunningham, Gary F, et al. Williams Obstetrics. 23rd ed. USA: McGraw-Hill, 2010. P 31 Ereno, Ephraim Adrian 69. Clinical pelvimetry that assesses the inlet a. distance from symphysis pubis and sacral promontory b. vergence of the pelvic sidewalls c. prominence of the ischial spines d. sacral concavity Answer: A Rationale: the diagonal conjugate of the pelvic inlet is the distance between the lower border of the symphysis pubis to the midpoint of the sacral promontory. This is the only anterposterior diameter that can be measured clinically. Reference:Sumpaico, Textbook of Obstetrics, 3rd ed., page 381 Lim, Gerriane R. 70. Distance from the lower border of the symphysis pubis and sacral promontory? A. True Conjugate B. False Conjugate C. Obstetric Conjugate D. Diagonal Conjugate ANSWER: D

Rationalization: Four diameters of the pelvic inlet are usually described: anteroposterior, transverse, and two oblique diameters. The obstetrically important anteroposterior diameter is the shortest distance between the promontory of the sacrum and the symphysis pubis and is designated the obstetrical conjugate. Normally, this measures 10 cm or more. This diameter is distinct from the anteroposterior diameter of the pelvic inlet that has been identified as the true conjugate. The obstetrical conjugate cannot be measured directly with the examining fingers. For clinical purposes, the obstetrical conjugate is estimated indirectly by subtracting 1.5 to 2 cm from the diagonal conjugate, which is determined by measuring the distance from the lower margin of the symphysis to the sacral promontory. Resource: Williams 23rd edition, Chapter 2 (Maternal Anatomy) page 31. Balboa, Barbara Kate P. 71. The cardinal movements of labor occur during what division of labor? a. Preparatory b. Dilatational c. Pelvic Answer: C Rationale: The positional changes in the presenting part required to navigate the pelvic canal constitute the mechanisms of labor. Reference: 23rd Ed. Of Williams, Page no.378 Abejuela, Yoti Gonzales, Daniel Abraham 72.LOA 73.In occiput anterior position, which among the following parts appears first during extension? a. brow b. nose c. mouth d. chin Answer: A Rationale: During occiput anterior position, the parts of the fetus that pass over the anterior margin of the perineum in the following order: the occiput, bregma, forehead, nose, mouth, and finally the chin. Reference: Williams Obstetrics (E-book), Chapter 17 Anacay, Denise B. 74.Expulsion is concerned with the delivery of what fetal body part? a. Head b. Shoulder c. Thorax d. Abdomen Answer: B. Shoulder Rationale: Almost immediately after external rotation, expulsion follows wherein the anterior shoulder appears under the symphysis pubis, and the perineum soon becomes distended by the posterior shoulder. After delivery of the shoulders, the rest of the body quickly passes. Reference: Williams Obstetrics 23rd Edition Chapter 17 page 380 Alcazaren, Ramon Michael Christopher S. 75. As the fetal head engages, the sagittal suture commonly lies, a. Midway between the symphysis pubis and promontory b. Nearer the symphysis pubis c. Nearer the promontory d. Along the oblique diameter Answer: A, Midway between the symphysis pubis and promontory. Rationale: Normal synclitism occurs when the sagittal suture lies midway between the symphysis pubis and sacral promontory. Such lateral deflection to a more anterior or posterior position in the pelvis is called asynclitism. Reference: Williams Obstetrics 23rdedition , Normal Labor and Delivery , Page 379 and page 384 figure 17.12 middle picture. 76. In determining the station of the fetal head, which of the following fetal and maternal landmark relationship is correct? a) Biparietal ischial spines

Ebdani, Alea D.

b) Biparietal pelvic inlet c) Presenting part ischial spines d) Presenting part pelvic inlet Answer: c) Presenting part ischial spines Rationale: The presenting part is that portion of the fetal body that is either foremost within the birth canal or in closest proximity to it. The level or station of the presenting fetal part in the birth canal is described in relationship to the ischial spines, which are halfway between the pelvic inlet and the pelvic outlet. Reference: Williams Obstetrics, 23ed Chapter 17 Normal Labor and Delivery Genoroso, Veronica H. 77. Which among the following cardinal movements of labor requires the resistance of the pelvic floor? a) Descent b) Internal rotation c) Extension d) Expulsion Answer: C. Extension Rationale: With further descent and full flexion of the head, the base of the occiput comes in contact with the inferior margin of the symphysis pubis. Upward resistance from the pelvic floor and downward forces from the uterine contractions cause the occiput to extend and rotate around the symphysis. Reference: Textbook of Obstetrics by Sumpaico et al, 3rd Ed. p399 Basnet, Archana 78. Which of the following cardinal movement of labor may take place even before the onset of labor in primipara? a. Engagement b. decent c. flexion d. inernal rotation Answer : b decent Rationale: the movement is the first requisite for birth of newborn in nulliparas, engagement may take place before the onset of labor, and further descent may not follow until the onset of the second stage. References: Williams obstetrics edition 23rd; chapter 17, normal and delivery> De Leon, Jana Pamela Y. 79.Restitution occurs during what cardinal movement of labor? a. Extension b. Descent c. internal rotation d. External rotation ANSWER: D Rationale: External rotation or Restitution refers to the return of the fetal head to the correct anatomic position in relation to the fetal torso. Reference:Sumpaico, Textbook of Obstetrics, 3rd ed., page 400. Lopez, Edison 80. Engagement is determined by what Leopolds Maneuver? Choices: I , II , III , IV Answer: III Rationale: First Maneuver purpose is to determine fetal presentation Second Maneuver purpose is to determine fetal position. Third Maneuver- purpose is to determine engagement of fetal presenting part. Fourth Maneuver- purpose is to determine fetal altitude. Reference: http://nursingcrib.com/nursing-notes-reviewer/maternal-child-health/how-to-performleopolds-maneuver/ 81. The purpose of external rotation is to bring the _______ diameter of the fetus along the anteroposterior diameter of the pelvic outlet. A. Bisacromial B. Bitemporal C. Biparietal

David Layug

D. Mentoccipital Answer: A. Bisacromial Rationale: Restitution of the head to the oblique position is followed by completion of external rotation to the transverse position. This movement corresponds to rotation of the fetal body and serves to bring its bisacromial diameter into relation with the anteroposterior diameter of the pelvic outlet. Reference: Williams Obstetrics 23rd Edition, Page 380 Fernandez, Edna Joyce M. 82. When the cervix become fully dilated with the presenting part in LOT, station +2, what cardinal movement should take place next? a. flexion b. internal rotation c. extension d. external rotation Answer: a. flexion Rationale: - Fetal Station describes descent of the fetalbiparietal diameter in relation to a line drawn between maternal Ischial spines. - In most cases, the vertex enters the pelvis with the sagittal suture, lying in the transverse pelvic diameter. The fetus enters the pelvis in LOT position in 40% of the cases & ROT position in 20%. The mechanism of labor in all these presentations is usually similar. - The positional changes in the presenting part required to navigate the pelvic canal constitute the mechanisms of labor. The cardinal movements of labor are engagement, descent, flexion, internal rotation, extension, external rotation, and expulsion. - During labor, these movements not only are sequential but also show a great temporal overlap. - Descent of the leading edge of the presenting part to the level of the ishial spines (0 station) is defined as engagement - According to the cardinal movements, descent is the next step which was depicted in the question by stating that the presenting part is now in station +2 - Hence, following descent, the next cardinal movement that should take place next is Flexion as the descending head meets resistance, whether from the cervix, walls of the pelvis, or pelvic floor. Reference: p. 144, Ch. 6 Parturition pp. 380 & 392, Ch.17 Normal Labor & Delivery p. 469, Ch. 20 Abnormal Labor 23rd ed. Williams Obstetrics

Feliciano, Christian Mico G.

83. . A parturient arrives at the emergency room with a bulging perineum and anterior fontanel palpable over the posterior rim of the vaginal opening. What cardinal movement of labor is taking place? A. Internal rotation B. Extension C. Restitution D. Expulsion Answer: B Extension Rationale: After internal rotation, the sharply flexed head reaches the vulva and undergoes extension. If the sharply flexed head, on reaching the pelvic floor, did not extend but was driven farther downward, it would impinge on the posterior portion of the perineum and would eventually be forced through the tissues of the perineum. When the head presses upon the pelvic floor, however, two forces come into play. The first force, exerted by the uterus, acts more posteriorly, and the second, supplied by the resistant pelvic floor and the symphysis, acts more anteriorly. The resultant vector is in the direction of the vulvar opening, thereby causing head extension. This brings the base of the occiput into direct contact with the inferior margin of the symphysis pubis (see Fig. 17-16). With progressive distension of the perineum and vaginal opening, an increasingly larger portion of the occiput gradually appears. The head is born as the occiput,bregma, forehead, nose, mouth, and finally the chin pass successively over the anterior margin of the perineum (see Fig. 17-17). Immediately after its delivery, the head drops downward so that the chin lies over the maternal anus. Reference:

Cunningham, F. G., Williams, J. W., Leveno, K. J., Bloom, S., Hauth, J. C., & Rouse, D. J. (2011). Williams obstetrics. (23 ed., p. 380 and 383). McGraw-Hill Professional.

Bejasa, Cana

84.The straightening and extension of the fetal body during a uterine contraction promotes which mechanism of labor? a. Flexion b. Internal Rotation c. Descent d. Extension Answer: (c) Descent Rationale: Descent is brought about by one or more of four forces: (1) pressure of the amnionic fluid, (2) direct pressure of the fundus upon the breech with contractions, (3) bearing down efforts of maternal abdominal muscles, and (4) extension and straightening of the fetal body. Reference: Williams Obstetrics, 23rd Edition. Page 380

Galicia, Jose Maria F.

85. The sagittal suture is noted to be deflected towards the symphysis pubis. What bone is palpable in vaginal examination? a. posterior parietal c. frontal b. anterior parietal d. occipital Answer: A Rationale: If the sagittal suture lies close to the symphysis, more of the posterior parietal bone will present, and the condition is called posterior asynclitism. Rererence: Cunningham FG, Leveno KJ, Bloom SL, Hauth JC, Rouse DJ, Spong CY: Williams Obstetrics, 23rd Edition, Chapter 17: http://www.accessmedicine.com (E-Book)

Lugtu ,Ryan Christopher B.

86. During the second stage of labor, the presenting part is noted to be directly behind the symphysis pubis. What cardinal movement has taken place? a. flexion c. descent b. internal rotation d. extension ANSWER: B RATIONALE: Because as internal rotation is defined, it is the movement that consists of a turning of the head in such a manner that the occiput gradually moves toward the symphysis pubis anteriorly from its original position or less commonly, posteriorly toward the hollow of the sacrum, thus this definition is answer to the question that has been asked and as soon as internal rotation has end the next cardinal movement that could be appreciated is extension where in the sharply flexed head reaches the vulva and undergoes extension. Flexion is when the descending head meets the resistance. Descent is the further movement of the fetus. REFERENCE: Williams Obstetrics 23rd edition e-book, Chapter 17

Caraveo, Julien Nicole C.

87. A primigravid is admitted on her 8th hour of labor with the following findings on vaginal examination: cervix 4-5 cms. Dilated, both fontanels are palpated easily, station 0. Which of the following cardinal movements of labor has taken place? a. engagement b. descent c. flexion

d. internal rotation ANSWER: A RATIONALE:Station 0 refers to when the lowest portion of the fetal skull is at or below the level of the maternal ischial spine. Usually engagement has taken place when they say station 0. REFERENCE: Sumpaico3rd Edition, p. 398 Eufracio, Ma. Christine Angela D. 88. A primigravid is admitted on her 8th hour of labor with the following findings on vaginal examination: cervix is 4-5 cms dilated, both fontanels are palpated easily, station 0. What is the significance of the findings on the station of the presenting part? a. The fetal head is small b. The pelvic inlet is inadequate c. Vaginal delivery is highly anticipated d. Fetal membranes are likely to rupture Answer: CVaginal delivery is highly anticipated Rationale: Station 0 is very important since, if the vertex is at station 0 or below, chances for vaginal delivery are greatly increased. Reference: Sumpaico, etal. Textbook of Obstetrics, 2nd Edition p.250 Collante, Maria Lourdes M. 89. On the 12th hour of labor, the cervix is dilated to 8-9cm. The triangular fontanel is palpated easily but not the diamond-shaped fontanel. What cardinal movement of labor has taken place? a. descent b. flexion c. internal rotation d. extension Answer: B. flexion Rationale: The flexion of the fetal head usually happens when the descending head of the fetus meets resistance, whether from the cervix, walls of the pelvis, or pelvic floor. Here, the chin of the fetus is brought into contact with the thorax. Therefore, if the physician checks for the presentation of the fetus, the triangular or the posterior fontanel will be palpated. As soon as the descending head meets resistance, whether from the cervix, walls of the pelvis, or pelvic floor, flexion of the head normally results. In this movement, the chin is brought into more intimate contact with the fetal thorax, and the appreciably shorter suboccipitobregmatic diameter is substituted for the longer occipitofrontal diameter. Reference: Cunningham, M. F., Leveno, M. K., Bloom, M. S., Hauth, M. J., Gilstrap III, M. L., & Wenstrom, M. K. (2007). Williams Obstetrics (E-book). The McGraw-Hill Companies. Chapter 17. Lagamayo, Dian Case: A primigravida is admitted on her 8th hour of labor with the following findings on vaginal examination: cervix is 4-5 cms, dilated, both fontanels are palpated easily, station 0. 90. One hour after the cervix becomes fully dilated, the presenting part remains in LOT. What cardinal movement of labor failed to take place? A. Descent B. Flexion C. Internal rotation D. Extension Answer: C Rationale: The fetus enters the pelvis in the left occiput transverse (LOT) position in 40 percent of labors and in the right occiput transverse (ROT) position in 20 percent (Caldwell and associates,1934). During internal rotation there is a turning of the head in such a manner that the occiput gradually moves toward the symphysis pubis anteriorly from its original position or less commonly, posteriorly toward the hollow of the sacrum. It is essential for the completion of labor, except when the fetus is unusually small. (Lifted directly from Williams) Internal rotation refers to the rotary movement of the fetal head from transverse to the anteroposterior position, so that the fetal head may negotiate the shorter midpelvic transverse diameter into the pelvis. This movement brings the anteroposterior diameter of the head in line with the

anteroposterior diameter of the outlet. (Lifted directly from Sumpaico) Since the cervix is fully dilated for about an hour and the presenting part is still in the Left occiput transverse, labor is still not completed since internal rotation has not taken place yet. Further decent to the level of the introitus occurs with the head in the AP plane. Reference: Williams Obstetrics, 22nded (eBook) chapter 5: Maternal Physiology, page 233 Sumpaico Textbook of Obstetrics (Physiologic and Pathologic) 3rd ed. Chapter 25: Mechanism of Labor, page399 Barzaga, Gillian T. 91. Animal studies have shown an adverse effect and there are no adequate and well-controlled studies done on pregnant women. A. Category A B. Category B C. Category C D. Category D E. Category X Answer: C.Category C Rationale: Below are the categories for drugs and medications by the Food and Drug Administration. Category C has been emphasized. Category A: Studies in pregnant women have not shown an increased risk for fetal abnormalities if administered during the first (second, third, or all) trimester(s) of pregnancy, and the possibility of fetal harm appears remote. Fewer than 1 percent of all medications are in this category. Examples include levothyroxine, potassium supplementation, and prenatal vitamins, when taken at recommended doses. Category B: Animal reproduction studies have been performed and have revealed no evidence of impaired fertility or harm to the fetus. Prescribing information should specify kind of animal and how dose compares with human dose. Or Animal studies have shown an adverse effect, but adequate and well-controlled studies in pregnant women have failed to demonstrate a risk to the fetus during the first trimester of pregnancy, and there is no evidence of a risk in later trimesters. Examples include many antibiotics, such as penicillins, macrolides, and most cephalosporins. Category C:Animal reproduction studies have shown that this medication is teratogenic (or embryocidal or has other adverse effect), and there are no adequate and well-controlled studies in pregnant women. Prescribing information should specify kind of animal and how dose compares with human dose. Or There are no animal reproduction studies and no adequate and well-controlled studies in humans. Approximately two thirds of all medications are in this category. It contains medications commonly used to treat potentially life-threatening medical conditions, such as albuterol for asthma, zidovudine and lamivudine for human immunodeficiency viral infection, and many antihypertensives, including -blockers and calcium-channel blockers. Category D: This medication can cause fetal harm when administered to a pregnant woman. If this drug is used during pregnancy or if a woman becomes pregnant while taking this medication, she should be apprised of the potential hazard to the fetus. This category also contains medications used to treat potentially life-threatening medical conditions, for example: systemic corticosteroids, azathioprine, phenytoin, carbamazepine, valproic acid, and lithium. Category X:This medication is contraindicated in women who are or may become pregnant. It may cause fetal harm. If this drug is used during pregnancy or if a woman becomes pregnant while taking this medication, she should be apprised of the potential hazard to the fetus. There are a few medications in this category that have never been shown to cause fetal harm but should be avoided nonetheless such as the rubella vaccine. (Lifted directly from Williams Obstetrics) Reference: Williams Obstetrics, 23e (e-book) > Chapter 14. Teratology and Medications That Affect the Fetus Angue, Kendy Q. 92. Adequate and well controlled studies have not shown an increase risk of abnormalities a. Category A b. Category B c. Category C d. Category D

e. Category X Answer: A Rationale: A- Controlled studies in humans show no risk. Adequate, well controlled studies in pregnant women have failed to demonstrate risk to the fetus. B- No evidence of risk in humans. Either animal findings show risk, but human findings do not; or, if no adequate human studies have been done, animal findings are negative. C- Risk cannot be ruled out. Human studies are lacking and animal studies are either positive for fetal risk, or lacking as well. However, potential benefits may justify potential risk. D- Positive evidence of risk. Investigational or post marketing data show risk to the fetus. Nevertheless, potential benefits may outweigh the potential risk. X- Contraindicated in pregnancy. Studies in animals or human, investigational or post-marketing reports have shown fetal risk which clearly outweighed any possible benefit to the patient Reference: Sumpaico 3rd edition, page 347 Garcia, Ray Wilson M. 93. Studies that are adequate well controlled and observational in pregnant women or animals have shown fetal abnormalities a. Category A b. Category B c. Category C d. Category D e. Category X ANSWER: E. CATEGORY X Rationale: Category A: studies in pregnant women have not shown an increased risk for fetal abnormalities if administered during any trimester of pregnancy, and the possibility of fetal harm appears remote. Category B: animal reproduction studies have been performed and have revealed no evidence of impaired fertility of harm to the fetus. Or Animal studies have shown an adverse effect, but adequate and well-controlled studies in pregnant women have failed to demonstrate a risk a risk to the fetus during first trimester nor in the later trimesters of pregnancy Category C: animal reproduction studies have shown that this medication is teratogenic, and there are no adequate and well-controlled studies in pregnant women. Or There are no animal reproduction studies and no adequate and well-controlled studies in humans. Category D: this medication can cause fetal harm when administered to a pregnant woman. If this drug is used during pregnancy or if a woman becomes pregnant while taking this medication, she should be apprised of the potential hazard to the fetus Category X: this medication is contraindicated in women who are or may become pregnant.If this drug is used during pregnancy or if a woman becomes pregnant while taking this medication, she should be apprised of the potential hazard to the fetus. CATEGORY A B INTERPRETATION Adequate, well-controlled studies in pregnant women have not shown an increased risk of fetal abnormalities to the fetus in any trimester of pregnancy. Animal studies have revealed no evidence of harm to the fetus, however, there are no adequate and well-controlled studies in pregnant women. OR Animal studies have shown an adverse effect, but adequate and well-controlled studies in pregnant women have failed to demonstrate a risk to the fetus in any trimester. Animal studies have shown an adverse effect and there are no adequate and wellcontrolled studies in pregnant women. OR No animal studies have been conducted and there are no adequate and wellcontrolled studies in pregnant women. Adequate well-controlled or observational studies in pregnant women have

demonstrated a risk to the fetus. However, the benefits of therapy may outweigh the potential risk. For example, the drug may be acceptable if needed in a life-threatening situation or serious disease for which safer drugs cannot be used or are ineffective. X Adequate well-controlled or observational studies in animals or pregnant women have demonstrated positive evidence of fetal abnormalities or risks. The use of the product is contraindicated in women who are or may become pregnant.

Reference:Williams Obstetrics 23rd Edition page 315 TABLE 14-3 http://www.perinatology.com/exposures/Drugs/FDACategories.htm Aguinaldo, Mary Angeli M. 94. No adequate and well controlled studies have been conducted in pregnant women and animals. Choose from the following FDA categories: A. Category A B. Category B C. Category C D. Category D E. Category X Answer: C Category C Rationale: For a category C drug, the criteria are as follows: there are no adequate studies for either animal or human, or there are adverse fetal effects in animal studies but no available human data. The criteria for the other categories are: Category A controlled studies in humans have shown no fetal risks; Category B animal studies indicate no fetal risks, but human studies are lacking, or adverse effects have been shown in animals but not in human studies; Category D there is evidence of fetal risk, but benefits outweigh the risks; Category X proven fetal risks outweigh the potential benefits. Reference: Williams Obstetrics 21st edition. p 1009 table 38-2 Amer, Muhammad Rajhi 95. Animal studies have shown an adverse effect, but adequate and controlled studies on pregnant women have not shown risk to the fetus CHOICES: A. Category A B. Category B C. Category C D. Category D E. Category X ANSWER: B RATIONALE: According to FDA Categories for drug and medications, Category B is described as an, animal studies have shown an adverse effect, but adequate and well-controlled studies in pregnant women have failed to demonstrate a risk to the fetus during the first trimester of pregnancy, and there is no evidence of risk in later trimesters. REFERENCE: 23rd Edition Williams Obstetrics by Cunningham, et.al. Page 315 Table 14-3 Chua, Hedley Ghizel L. 96. N.R. has missed her period for the first time and she decided to seek consult with an OB-Gyn where an internal examination revealed a soft and closed cervix. Select what phase of parturition each situation belongs. a. Phase 1 b. Phase 2 c. Phase 3 d. Phase 4 Answer: A Rationale: Phase 1 is prelude to parturition where in uterine quiescence, contractile unresponsiveness, and cervical softening is involved. Reference: Williams Obstetrics 23rd ed. Page 136 - 138 Abad, Mary RainaAngeli Z. 97. A.B. experienced labor pains of eight hours duration. She consulted at the ER and examination revealed a five cm cervical dilatation, fully effaced, cephalic presentation and intact membranes. a. Phase 1 b. Phase 2

c. Phase 3 d. Phase 4 Answer: C Phase 3 Rationale: The patient is already in Phase 3 of parturition which is the stimulation and processes of labor because of the cervical dilatation and effacement. In Phase 3, there are three stages. The changes that occurred in the patient correspond to the first stage oflabor. The first stage of labor in Phase 3, therefore, is the stage of cervical effacement and dilatation. Reference: Williams, page 141 Dizon, Melissa N. 98. O.P. is on her 36 weeks of pregnancy. She claimed that the baby seemed to have "dropped". Choices: A. Phase 1 B. Phase 2 C. Phase 3 D. Phase 4 Answer: b. Phase 2 Rationale: In phase 2, the lower uterine segment from the isthmus is formed. With this development, the fetal head often descends to or even through the pelvic inlet which is called "lightening". The abdomen also undergoes a change in shape, sometimes described as, the "the baby dropped". Reference: Williams obstetrics, p.204 (1st question) and p. 138 (2nd question) Coronel, Marie France 99. Select at what phase of parturition this situation belongs. DW is currently breastfeeding and is seeking opinion regarding family planning Choices: a) Phase 1 b) Phase 2 c) Phase 3 d) Phase 4 Answer: d) Phase 4 Rationale: According to Williams, Phase 4 occurs 4-6 weeks after birth and is dependent on the duration of breast feeding. Phase 4 is the period of involution and parturient recovery. In this phase, uterine involution, cervical repair and breast feeding happens until fertility is restored. Reference: 23rd Edition of Williams Obstetrics page 137 and 147 Andres, Raphael 100. L.L. is at the Labor Room. She has reached full cervical dilatation and the nurse is preparing her for vaginal delivery. a. Phase 1 c. Phase 3 b. Phase 2 d. Phase 4 ANSWER: c. Phase 3 RATIONALE: Phase 1 of Parturition: Uterine Quiescence and Cervical softening Phase 2 of Parturition: Preparation for Labor Phase 3 of Parturition: Labor Phase 3 is synonymous with active labor, that is, uterine contractions that bring about progressive cervical dilatation and delivery. Clinicaly, phase 3 is customarily divided into the 3 stages of labor. 1. The first stage begins when widely spaced uterine contractions of sufficient frequency, intensity, and duration are attained to bring about cervical thinning, termed effacement. This labor stage ends when the cervix is fully dilated - about 10 cm to allow passage of the fetal head. The first stage of labor, therefore, is the Stage of cervical effacement and dilatation. 2. Stage of fetal expulsion 3. Stage of placental separation and expulsion Phase 4 of Parturition: The Puerperium REFERENCE: Dela Cruz, Doris Joan Williams OBSTETRICS 23rd Edition (page 141)

101. Enumerate the drugs not given during 1st trimester of pregnancy.

Answer: Alcohol Anti-convulsant Medications: o Valproate o Phenytoin o Carbamazepine o Phenobarbital Angiotensin Converting Enzyme Inhibitor and Angiotensin Receptor Blocker o Enalapril o Captopril o Lisinopril Anti-Neoplastic Agents o Cyclophosphamide o Methotrexate and Aminopterin Antivirals o Amantadine o Ribavirin Bosentan Hormones Mycophenolatemofetil Radioactive Iodine Isotretinoin Thalidomide Warfarin Rationale: Alcohol is one of the most potent teratogens known; cause Fetal Alcohol Syndrome. Anticonvulsant medications cases Fetal Hydantoin Syndrome (craniofacial deformities, fingernail hypoplasia, cardiac defect, cleft lip). ACE inhibitors causes cardiovascular and central nervous system malformations. Anti-neoplastic agents especially cyclophosphamide results in growth restriction, failure of calvarial ossification, craniosynostosis, hypoplastic supraorbital ridges, small posteriorly rotated ears, micrognathia, and severe limb abnormalities. Antivirals like Amantadine are embryotoxic at animal levels and may cause possible cardiac defects. Bosentan is rated Category X causing abnormalities of the head, face, and large blood vessels, and it is also carcinogenic in rats and mice. Hormone intake between 7 and 12 weeks are responsive to exogenous androgens and exposure can result in full masculinization. MycophenolateMofetil 45 % of pregnant mothers experience spontaneous loss. Radioactive Iodine is contraindicated during pregnancy because it readily crosses the placenta and is avidly concentrated in the fetal thyroid by the end of the first trimester; increase the future risk for childhood thyroid cancer. Isotretinoin when taken during first-trimester is associated with a high rate of fetal loss. Thalidomide produces limb defects like phocomelia Warfarin will cause nasal and midface hypoplasia, stippled femoral and vertebral epiphyses. Reference: Williams 23rd edition (EBOOK) Section III. Chapter 14. Teratology and Medications that affect the Fetus Co, Lizette Ann Jennifer 102. Question: Identify 3 drugs that may be given anytime during pregnancy. Answer: Acetaminophen, Cefotetan&Cefoxitin (Cephalosporins), Dextromethoprhan Rationale: Acetaminophen is routinely used in all stages of pregnancy for pain relief and fever. There were no detectable risk with cephalosporin antibiotics, such as Cefotetan and Cefoxitin, found in conducted studies. Dextrometorphan is an antitussive that is considered to be safe for consumption during pregnancy due to low incidence of congenital defects in surveillance studies. Reference: Briggs GG, Freeman RK, Yaffee FJ. Drugs in Pregnancy and Lactation: Reference Guide to Fetal and Neonatal Risk. 7th ed. Baltimore: Williams & Wilkins; 2005. (pg. 8, 227-228, 395)

Kalalo, Gerard Michael C.

103.Enumerate 3 vaccines that can be given safely during pregnancy. Answer: 1. Influenza Vaccine a. This is indicated for all pregnant women, regardless of the trimester, during the flu season. b. It is an inactivated virus vaccine administered one dose IM every year. 2. Rabies a. Indicated for prophylaxis not altered by pregnancy but each case should be considered individually. b. It is a killed-virus vaccine and health authorities should be consulted as to dosage, indications, and route of administration. 3. Hepatitis B a. Used for pre-exposure and post-exposure for women at risk of infection. b. It is used with hepatitis B immune globulin for some exposures. Exposed newborn needs birth-dose vaccination and immune globulin as soon as possible. All infants should receive birth dose vaccine. It is administered at three doses IM at 0, 1, and 6 months. Reference: Williams Obstetrics, 23rd ed. Page 208 104. Enumerate 3 vaccines that cannot be given safely during pregnancy 3 vaccines that cannot be given safely during pregnancy are 1. Small Pox 2. MMR [Measles-Mumps-Rubella] 3. Varicella The small pox live attenuated virus vaccine is the only vaccine that is known to cause fetal harm and is contraindicated not only to the parturient but also those in her household. The live attenuated virus vaccines, MMR and Varicella pose theoretical risks/ teratogenicity to the fetus and thus are contraindicated during pregnancy. However these have yet to show any ill effects to the fetus. Reference: Williams Obstetrics 23rd Edition Page 207-209

Banzon, Tracy

Buenafe, Jonas Joaquin R.

105. A 27 years-old pregnant patient came from prenatal check-up. She complains of nausea, vomiting and constipation. She has a regular 28-30 days menstrual cycle. Asked about her last menstrual cycle, she gave the following days: - November 28, 2011 vaginal spotting, reddish brown in color - November 29, 2011 moderate flow, red in color - November 30, 2011 profuse - December 01, 2011 more bleeding Question: What is the expected date of delivery? The average duration of pregnancy from the last normal menstrual period (LNMP) is very close to 280 days or 40 weeks. For the determination of expected date of delivery (EDC), it is customary to apply the Naegeles rule. Following this rule: LNMP: November 28, 2011 or 9/28/2011 We add 7 days to the LNMP: November 28 + 7 days = December 5 We then move back three months: December (12th month) will become September (9th month) The resulting dateSeptember 5, 2012will be the EDC.

Afaga, Desiree

106. What explanation will you give to the pregnant patient regarding the cause of her nausea and vomiting?

Answer: The cause of nausea and vomiting is unknown but it probably can be caused by a combination of physical changes in the body during pregnancy. Rationale: Nausea and vomiting usually begin between the first and second missed menstrual period and continue until 14 to 16 weeks. Physical changes that may cause nausea and vomiting include the following: Increased Human Chorionic Gonadotropin hormone levels Increased estrogen levels Enhanced sensitivity to smell and odors Reference: Williams Obstetrics 23rd Edition (E-book), Chapter 8 Prenatal Care Cruz, Spica E. 107.What advice will you give to the patient as how to alleviate/manage her nausea and vomiting? Answer & Rationale To alleviate/manage nausea and vomiting, it is advised to eat small meals at more frequent internals but stopping short of satiation is valuable. Use of herbal remedy, ginger, is likely effective according to another study. Vitamin B6 is given along with doxylamine in which mild symptoms usually respond to, but some women require phenothiazine or H1-receptor blocker antiemetics. Reference: Williams Obstetrics 23rd Chapter 8. Prenatal Care ebook Bustos, Nikki Elinor G. 108. A 27 year old pregnant patient came for prenatal check up. She complains of nausea, vomiting, and constipation. She has a regular 28- 30 days menstrual cycle. Asked about her menstrual cycle, she gave the following dates: October 28, 2011 Vaginal spotting, reddish brown in color October 29, 2011 Moderate flow, red in color October 30, 2011 Profuse October 31, 2011 Minimal flow November 1, 2011 No more bleeding What is the age of gestation of pregnancy? (Date today: February 24, 2011) Answer: AOG = 119 days or 17 weeks Computation: Oct 3 days Nov 30 days Dec 31 days Jan 31 days Feb + 24 days 119 days/ 7 days/ 1 week = 17 weeks Reference: Cunningham et al., Williams Obstetrics, 23rd Edition, Section II Chapter 4 Fetal Growth and Development. McGraw- Hill N.Y. 2010 Camarinta, Karla Mae I 109.What advise will you give to the patient on how to alleviate/manage her problem of constipation? Answer: High-fiber diet and bulk forming laxatives References: Muscular relaxation of the colon is accompanied by increased absorption of water and sodium that predisposes to constipation, which is reported by almost 40 percent of women at some time during pregnancy (Everson, 1992). Such symptoms are usually only mildly bothersome, and preventive measures include a high-fiber diet and bulk-forming laxatives. Treatment options have been reviewed by Wald (2003). Reference: Williams 23rd Edition, Chapter 49. Gastrointestinal Disorders. Fresnido, Kyle Thomas 110. Give 2 reasons why pregnant patients are prone to have constipation during pregnancy. Answer: Constipation is common, presumably because of (1) prolonged transit time and (2) compression of the lower bowel by the uterus or by the presenting part (see Chap. 49, p. 1115). In addition to discomfort caused by passage ofhard fecal material, bleeding and painful fissures may develop in the edematous and hyperemic rectal mucosa. There is also greater frequency ofhemorrhoids and, much less commonly, prolapse of the rectal mucosa. Women whose bowel habits are normal before pregnancy may prevent constipation during pregnancy. This is done by ingesting sufficient quantities of fluid along with reasonable amounts of daily exercise.

This regimen may be supplemented when necessary by a mild laxative, such as prune juice, milk of magnesia, bulk-producing substances, or stool-softening agents. Reference Williams 22nd edition, section III Antepartum ,chapter 8 Prenatal Care, page 214) Kamantigue, Janine E. 111. Enumerate the phase/s and stage/s of labor included in the pelvic division of labor. Answer: The pelvic division of labor is the third among the three functional divisions of labor according to Friedman. The pelvic division includes the end of the Active Phase of the 1st stage of labor, which is the deceleration phase, and the entire 2nd stage of labor. Rationale: According to Williams Obstetrics, the pelvic division of labor begins with the deceleration phase of cervical dilatation. The classic mechanisms of labor, which involve the cardinal movements of the fetus, take place principally during the pelvic division of labor. The onset of the pelvic division is seldom clinically identifiable separate from the dilatational division of labor.

The pelvic division encompasses both deceleration phase and second stage while concurrent with the phase of maximum slope of decent. Reference: Cunningham, F. G., et al. (1997). Williams Obstetrics (20thEdition), pp. 268-269. Appleton & Lange. Fernando, Emily Anne T. 112. What are the mechanical forces in the 1st stage of labor. Answer: 1. Begins when widely spaced uterine contractions of sufficient frequency, intensity, and duration are attained to bring about cervical effacement. 2. Ends when the cervix is fully dilated (about 10cm) to allow fetal head passage 3. This is the stage of cervical effacement and dilatation. 4. Friedman developed 3 functional divisions of labor: Preparatory division; Dilatational division; Pelvic division. 1. Preparatory division a. cervix dilates minimally b. connective tissue components of the cervix considerably c. sedation and analgesia are capable of arresting this division 2. Dilatational division a. time where dilatation proceeds at its most rapid rate b. unaffected by sedation or conduction analgesia c. divided into 2 phases: i. Latent phase 1. Point where the mother perceives regular contractions 2. Ends between 3-5 cm of cervical dilatation ii. Active phase 1. Cervical dilatation of more than 3-5cm in the presence of uterine contractions d. An indication of progress in labor 3. Pelvic division a. Commences with the deceleration phase of cervical dilatation b. Involves the cardinal fetal movements of the cephalic presentation: i. Engagement ii. Flexion iii. Descent iv. Internal rotation v. Extension vi. External rotation

Reference: Williams Obstetrics(22nd edition) page 153-154; 421-423 Arcaira, Joshua A. 113.Enumerate the phase/s and stage/s included in the preparatory division of labor. Answer: 1st Stage of labor Latent phase of cervical dilatation Acceleration phase of the active phase of cervical dilatation REFERENCE: Williams 23rd Edition, pages 384, 386, and 388. 114. What are the leopoldsmanuever endings in occiput presentation? ANSWER: Leopold maneuvers (A-D) performed in fetus with a longitudinal lie in the left occiput anterior position (LOA). Abdominal PalpationLeopold Maneuvers Abdominal examination can be conducted systematically employing the four maneuvers. The mother lies supine and comfortably positioned with her abdomen bared. 1. The first maneuver permits identification of which fetal polethat is, cephalic or podalic occupies the uterine fundus. The breech gives the sensation of a large, nodular mass, whereas the head feels hard and round and is more mobile and ballottable 2. Performed after determination of fetal lie, the second maneuver is accomplished as the palms are placed on either side of the maternal abdomen, and gentle but deep pressure is exerted. On one side, a hard, resistant structure is feltthe back. On the other, numerous small, irregular, mobile parts are feltthe fetal extremities. By noting whether the back is directed anteriorly, transversely, or posteriorly, the orientation of the fetus can be determined 3. The third maneuver is performed by grasping with the thumb and fingers of one hand the lower portion of the maternal abdomen just above the symphysis pubis. If the presenting part is not engaged, a movable mass will be felt, usually the head. The differentiation between head and breech is made as in the first maneuver. If the presenting part is deeply engaged, however, the findings from this maneuver are simply indicative that the lower fetal pole is in the pelvis, and details are then defined by the fourth maneuver 4. To perform the fourth maneuver, the examiner faces the mother's feet and, with the tips of the first three fingers of each hand, exerts deep pressure in the direction of the axis of the pelvic inlet. In many instances, when the head has descended into the pelvis, the anterior shoulder may be differentiated readily by the third maneuver. Reference: Cunningham, F., et.al.(2010). Normal Labor and Delivery.Williams Obstetrics (22nd ed., p.229-231). United Sates of America: The McGraw-Hill Companies, Inc. Francesca Debbie L. Liu 115. Question: Explain why at station 0, engagement has already occurred. Answer: At Station 0, the size of the pelvic inlet is suitable for the size of the fetal head or the biparietal diameter, thus, it is engagement. Engagement means that the fetal head is already inside the pelvic inlet. Rationale: The levelor stationof the presenting fetal part in the birth canal is described in relationship to the ischial spines, which are halfway between the pelvic inlet and the pelvic outlet. When the lowermost portion of the presenting fetal part is at the level of the spines, it is designated as being at zero (0) station. In the past, the long axis of the birth canal above and below the ischial spines was arbitrarily divided into thirds by some and into fifths (approximately 1 cm) by other groups. In 1989, the American College of Obstetricians and Gynecologists adopted the classification of station that divides the pelvis above and below the spines into fifths. Each fifth represents a centimeter above or below the spines. Thus, as the presenting fetal part descends from the inlet toward the ischial spines, the designation is 5, 4, 3, 2, 1, then 0 station. Below the spines, as the presenting fetal part descends, it passes +1, +2, +3, +4, and +5 stations to delivery. Station +5 cm corresponds to the fetal head being visible at the introitus. If the leading part of the fetal head is at 0 station or below, most often the fetal head has engaged thus, the biparietal plane has passed through the pelvic inlet. If the head is unusually molded or if there is an extensive caput formation or both, engagement might not have taken place although the head appears to be at 0 station. Reference: Williams Obstetrics 23rd edition Chapter 17

Licudan, Lester D.

Beredo, Charleen Joy A.

116. Explain what is achieved with flexion. Answer: As soon as the descending head meets resistance, whether from the cervix, walls of the pelvis, or pelvic floor, then flexion of the head normally results. In this movement, the chin is brought into more intimate contact with the fetal thorax, and the appreciably shorter suboccipitobregmatic diameter is substituted for the longer occipitofrontal diameter. This is what achieved with flexion. Reference: F. Gary Cunningham, M.D. & Kenneth J. Leveno, M.D.C et al (2010). 23rd edition of Williams Obstetrics. In M. F. Gary Cunningham, M. Kenneth J. Leveno, M. Steven L. Bloom, M. John C. Hauth, M. Dwight J. Rouse, & M. Catherine Y. Spong, 23rd edition of Williams Obstetrics (p. Chapter 17). United States of America.: The McGraw-Hill Companies, Inc. 117. Define Engagement. Engagement is the mechanism by which the biparietal diameter, the greatest transverse diameter of the fetal head in occiput presentations, passes through the pelvic inlet. The fetal head may engage during the last few weeks of pregnancy or not until after the commencement of labor. Reference: Reference: F. Cunningham et al., Williams Obstetrics 22nd edition. Chapter 17. Normal Labor and Delivery. 118.Enumerate two forces that facilitate extension. Answer: The two forces that facilitate extension are: 1) the force exerted by the uterus, 2) the force supplied by the resistant pelvic floor and the symphysis Rationale: The first force exerted by the uterus acts more posteriorly while the second force supplied by the resistant pelvic floor and the symphysis act more anteriorly. The resultant vector is in the direction of the vulvar opening which eventually leads to head extension. Reference: Cunningham, Leveno, Bloom, Hauth, Gilstrap III, Wenstrom: Williams Obstetrics 23 nd edition. Ebook. Section IV , Chapter 17

Anacan, KeightArren R.

Gnilo, Darlene

Boussati, Jamela

119.(evals1, setA, 72)In the maternal circulation of placenta, deoxygenated blood exits through the: a. vena cava b. ovarian vein c. uterine vein d. umbilical cein Answer: C. Uterine Vein Rationale:Exchange occurs with fetal blood as maternal blood flows around the villi. Umbilical arteries carry deoxygenated fetal blood to the placenta. Umbilical vein carries oxygenated blood to the fetus. Maternal blood enters through the basal plate and is driven high up toward the chorionic plate by arterial pressure before laterally dispersing; maternal blood gets into the intervillous spaces in a region delimited by the anchoring villi. Subsequently the blood leaves the intervillous spaces via the UTERINE VEINS that are arranged in the periphery of the intervillous space. Reference: Williams Obstetrics 23rd Edition P. 56

Cruz, Arcturus

120.

Question # 72 of Set A 2ndEvals Which of the following cardinal movements of labor continuously takes place until the completion of the second stage of labor? a. Descent b. Flexion c. Internal Rotation d. Extension Answer Descent Rationale All throughout the continuous labor Fetal Descent is taking place even though it will Do all that is mentioned. Reference: (Williams Ebook) (23rd edition) (chapter 1)