OSCE OBSTETRIC

1. Look at the picture

a) What is the investigation done? (1 mark)

Doppler velocimetry (USS) of umbilical artery

b) Interpret (A), (B) and (C). (3 marks)

A: Reduced end - diastolic flow
B: Absent end - diastolic flow
C: Reversed end – diastolic flow (most severe one)

c) List 2 purposes of the investigation? (2 marks)

i- To study fetal circulation (systolic and diastolic)
ii- To study placental function

d) List 3 indications of the investigation (2 marks)

i- Intrauterine growth restriction (IUGR)
ii- Hypertension in pregnancy
iii- Heart disease in pregnancy
iv- Anaemia in pregnancy

e) How to monitor IUGR fetus in the ward? (2 marks)

i- FKC (Fetal Kick Chart)
ii- Fetal Heart Rate (FHR) by USS or CTG
iii- Cardiotocography (CTG)
iv- Biophysical Profile (BPP)

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 2. Look at the picture.

A B

a) Name the above investigation (1 mark)

Nuchal translucency

b) When is the most suitable time to do it? (1 mark)

12 weeks of gestation

c) What is the indication of it? (1 mark)

To screen for chromosomal fetal anomalies

d) List 4 pathology can be screen via this test (4 marks)

i- Down’s syndrome
ii- Patau’s syndrome
iii- Turner syndrome
iv- Edward syndrome

e) What and when the next investigation should be done in the ‘high-risk’ group?
Detailed ultrasound scan (USS) at 20 – 22 weeks of gestation; looking for
structural fetal anomalies

f) List common causes of miscarriage in 1st and 2nd trimester.

1st Trimester 2nd Trimester

*Chromosomal fetal anomalies *APLS
*Structural fetal anomalies *SLE

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 3. Look at the picture given: Prostin E2 (Dinoprostone)

a) State the indication for the usage of above drug (1 mark)

Induction of labour (IOL) – in unfavourable cervix assessed by BISHOP score

b) State 4 complications following the usage of the above drug (4 marks)

i- Uterine hyperstimulation

ii- Uterine rupture

iii- Fetal distress

iv- Maternal pyrexia

v- MI in mother with cardiac disease in pregnancy

vi- Nausea, diarrhoea, headache

c) State 2 parameters used to monitor patient after the usage of above drug (2 marks)

i- CTG (maternal contraction, fetal distress)

ii- ECG

d) Name other methods/devices used for the same indication as the above drug (3 marks)

Foley’s catheter (Mechanical induction of labour)

Dilapan
Amniotic hook (Artificial Rupture of Membrane)

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 4. Look at the picture.

a) Name the procedure/maneuver (2 marks)

Controlled Cord Traction (CCT)/Brandt Andrew Maneuver

b) Name 2 other active management of 3rd stage of labour (4 marks)

i- Administration of early uterotonics (IM Syntometrine)
*Precautions: after ruling out presence of another baby (in multiple pregnancy);
1 minute after delivery of baby
ii- Massage the terus (after delivery of placenta)
iii- Delayed cord clamping (in new guideline)

c) 3 signs you would like to observe when performing this procedure (3 marks)
i- Gushing of blood per vaginally
ii- Lengthening of cord 3 Signs of placental separation
iii- Hard globular uterus

d) Immediate complication if it is done improperly (1mark)

Uterine inversion/atony
Cord snap
Retained placenta
Postpartum hemorrhage

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 5. MgSO4 ampule

a) 3 indications (3 marks)
i- Treat & prevent eclampsia
ii- As neuroprotection
iii- As tocolytic

b) 3 side effects (3 marks)

i- Cardiac arrest (worst scenario)
ii- Respiratory arrest
iii- Absent of reflex
iv- Reduced urine output
v- Allergy

c) How & Signs of monitoring after administer the drug (4 marks)

i- Regular tendon reflex: absent reflex
ii- Input output chart: reduce urine output
iii- Count RR & do pulse oximeter: tachypnoeic, reduce SPO₂ reading
iv- Continuous ECG monitoring: cardiac arrhythmia

d) What is the name and dosage of drug given when toxicity occurred?
IV 10mls of 10% Calcium gluconate

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 6.

a) Name the device above (2 marks)

Amniotic hook/Amnihook

b) 2 indications (2 marks)
i- Artificial Rupture of membrane - amniotomy (IOL)
ii- Guided fetal electrode of internal CTG

c) 3 contraindications (3 marks) *contraindication for vaginal delivery as well

i- Placenta praevia
ii- Non-vertex presentation/Malpresentation or fetal head not engage
iii- Cord presentation

d) 3 precautions before you use the above device (3marks)

i- Abdominal examination revealed cephalic presentation and fully fetal head
engagement (at least 2/5th palpable)
ii- Vaginal examination revealed low station of presentation part and no cord
presentation (soft pulsatile mass); excluded vasa praevia (no obvious blood
vessel transversing the foremembranes)
iii- Slowly released the amniotic fluid (to prevent cord prolapse & placenta
abruptio)

e) Name one benefit of it compared to other methods of IOL (1 mark)

Colour of liquor can be assessed as one of an indicator for fetal distress
(thick meconium-stained)

f) 4 complications associated with it

i- Cord prolapse
ii- Placenta abruptio
iii- Fetal distress
iv- Infection (chorioamnionitis)
v- Postpartum hemorrhage//rupture of vasa-praevia

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 7. Picture of partogram.

State 5 elements of partogram and explained (10 marks)

i. Maternal information: Name, Gravida & Para, POA, brief antenatal issues

ii. Maternal well-being

*Vital signs- BP, PR, T
*Maternal urine: protein, acetone, volume

iii. Labour Progress Chart:

*Monitoring 1st stage of labour (Latent & Active phase)
*Abdomen (fetal head engagement – plot as O)
*Vaginal Examination (maternal cervical dilatation- plot as X)
*Timing of strength and frequency of uterine contraction per 10 minutes

iv. Drugs or IV fluid given: Oxytocin, Hydration, Painkiller, DIK regime

v. Fetal well-being: FHR, moulding, liquor stained (post ARM/SRM)

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 8. Look at the picture.

a) Name the instrument (2 marks)

Fetal scalp electrode of internal CTG

b) State 2 indications (2 marks)

i- Maternal obesity (external CTG un-recordable)
ii- Fetal arrhythmia (at-risk fetus)
iii- In cephalic leading twin of multiple pregnancy (when external CTG
cannot detect)
* When complicated labour is expected

c) State 2 uses of it (2 marks)

i- Assessing fetus status by recording fetal heart rate
ii- Documented fetal well-being

d) 2 Contraindications (2 marks)
i- Patient not in labour
ii- Intact fetal membrane
iii- Placenta praevia
iv- High risk mother (HIV, active herpes)
v- Mother’s not keen

e) State 2 complications from it (2 marks)

i- Intrauterine infection
ii- Fetal distress
iii- Fetal injury
iv- Cephalohematoma (risk of bleeding)

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 9. Look at the picture

A B C
a) Name the instrument (3 marks)
A: Silastic cup ventouse
B: Metal cup ventouse
C: Kiwi cup

b) What is it used for?

Assisted vaginal delivery

c) What are 4 indications?

*to shorten 2nd stage of labour

Maternal Fetal
i. Maternal exhaustion v- Fetal distress in 2nd stage of labour
ii. Prolonged 2nd stage of labour
iii. Mother with heart disease
(Heart failure, severe PE,
HPT)

d) What are the pre-requisite of using it?

F: Fully os
O: Occipito-anterior (OA) or occipito-posterior (OP)
R: Ruptured membrane
C: CPD exclude, CBD, cephalic presentation
E: Episiotomy
P: Painkiller (epidural/LA)
S: Sterilized, skillful person

e) List 4 complications associated with it.

i- Vaginal tear
ii- Post-partum hemorrhage
iii- Cephalohaematoma
iv- Subaponeurotic hemorrhage

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10. Look at the picture. Cephalic curve

Pelvic curve Blade (Pelvic curve & cephalic curve)

Shanks

Handle
Lock
A B C

a) Name the instrument (1 mark)

A: Wrigley’s forcep
B: Kielland forcep
C: Neville Barnes forcep

b) List 4 indications of it (4 marks)

*to shorten 2nd stage of labour

Maternal Fetal
i. Maternal exhaustion iv. Fetal distress in 2nd stage of
ii. Prolonged 2nd stage of labour labour
iii. Mother with heart disease
(Heart failure, severe PE,
HPT)

c) What are the pre requisite? (3 marks)

F: Fully os
O: Direct Occipito-anterior (OA) or occipito-posterior (OP)
R: Ruptured membrane
C: CPD exclude, CBD, cephalic presentation
E: Episiotomy
P: Painkiller (epidural/LA)
S: Sterilized, skillful person

d) List 2 complications associated with it (2 marks)

i- Cervical lacerations
ii- Uterine rupture
iii- Post-partum hemorrhage
iv- Facial nerve palsy of baby
v- Faces, nose and eye injury of baby

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 11. Look at the picture.

Posterior aspect of anterior shoulder

a) Name the procedure (1 mark)

MacRobert maneuvre with manual/external suprapubic pressure

b) What is the indication? (1 mark)

Shoulder dystocia (Obstetric emergency)

c) What is the aim of the maneuvre? (2 marks)

To reduce the antero-posterior (AP) diameter, to help in delivering the
stucked shoulder out
Either by widening the passage- either non-invasive/invasive, making the baby’s
slightly oblique or reduced the diameter of the AP plane shoulder (cleidotomy)
(as shoulder dystocia happened in AP plane – direct OA/OP)

d) Give 4 maneuvre that has the same aim as (c) (4 marks)

i- Rubin II maneuvre (+ episiotomy)
ii- Wood’s Screw maneuvre
iii- Reverse Wood’s screw maneuvre
iv- Delivery of the posterior arm

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 Look at the picture: NIFEDIPINE (CCB)

a) What is the use of the above drug in obstetric? (2 marks)

i- Antihypertensive medication
ii- Tocolytic agent (in preterm contraction)

b) What is the mode of action? (2 marks)

As antiHPT: It is a peripheral arterial vasodilator that directly act on vascular
smooth muslce; which consequently reduce the peripheral resistance and reduces
the arterial blood pressure.

As tocolytic: reduce calcium (Ca²⁺) influx into the cells; subsequently reducing
uterine smooth muscle contractility.

c) What is the maximum dose? (2 marks)

i- As antihypertensive: 30 mg
ii- As tocolytic: 20 mg

d) List 2 contraindications for this drug (2 marks)

i- Hypovolaemia patient with hypoperfusion sign
ii- Hypotension patient
iii- Congestive Cardiac Failure
iv- Severe Asthma/COPD patient

e) List 2 side effects of it (2 marks)

i- Severe headache
ii- Acute hypotension

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 12.

a) What is the above obstetric diagnosis ( 1 mark)

Placenta praevia major

b) What 3 factors predisposes to this problem (3 marks)

i- Previous placenta praevia
ii- Previous LSCS
iii- Previous D&C
iv- Multiple pregnancies

c) What is the most typical symptoms if present (2 marks)

Painless Antepartum haemorrhage (APH)

d) List steps in the acute management ( 4 marks)

i- Resuscitation (Airway, Breathing, Circulation)
ii- IVD, CBD
iii- GXM blood
iv- Once stabilized – scan and admit, conservative/delivery depending on
gestation or if bleeding continues

e) What is the expectant management of this condition? Explain.

Mc’afee regime.
Patient warded at 32 weeks till delivery in centre with 24 hours blood bank and
available OT. Optimize haemoglobin level.

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 13. Look at the picture

a) Name the procedure (1 mark)

External cephalic version (ECV)

b) List 4 pre-requisites before performing the above procedure (4 marks)

i- Placenta praevia excluded
ii- Cephalo-pelvic disproportionate (CPD excluded)
iii- No previous scar
iv- Uncomplicated breech presentation only (normal fetus, normal liquor
& EFW)
v- Reactive-pre procedure CTG, singleton, viable fetus

c) List 5 complications of it (5 marks)

i- Prelabour rupture of membrane
ii- Cord accident/cord prolapse
iii- Placenta abruptio
iv- Uterine rupture
v- Fetal distress
vi- Cord accident, cord-round-neck/knot
vii- Failed ECV

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 14. Look at type of breech presentation.

A B C

Piper’s forcep
a) Label the picture (3 marks)
A: Flexed-breech presentation
B: Extended-breech presentation
C: Footling-breech presentation

b) What is the type of breech that can be delivered per vaginally? (2 marks)
A & B (Flexed & Extended Breech)

c) Name the type of delivery (D)? (1 mark)

Vaginal-assisted breech delivery

d) Name the instrument that can be used to deliver the upcoming head? (1 mark)
Piper’s forcep

e) List 4 complications name in (c)?

i- External genitalia or vaginal tear
ii- Post-partum hemorrhage
iii- Brachial plexus injury/ Erb’s palsy
iv- Head entrapment

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 15. Look at the partogram.

a) What is the diagnosis? (2 marks)

Primary dysfunctional labour (Poor progress of labour)

b) Six possible causes of this condition (6 marks); Power/Passenger/Passage

i- Inadequate maternal contraction
ii- Malpresentation/Malposition (Bow, face, shoulder)
iii- Undiagnosed macrosomia (relative CPD)
iv- Undiagnosed pelvic mass in pregnancy (fibroid/ovarian cyst in pregnancy)
v- Abnormal uterus or cervix
vi- Cervical dystocia
vii- True CPD

c) What is the next management? (2 marks)

Emergency Lower Segment Caesarian Section

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 16. Look at the picture

A B
a) What are (A) & (B)? (2 marks)
A: Cord presentation
B: Cord prolapse

b) List 5 risk factors of (B) (4 marks)

Iatrogenic (ARM when head is not engage, station is high or cord presentation)
Maternal Fetal
CPD IUGR/SGA
Multiparity Malpresentation/abnormal lie
Pelvic mass in pregnancy Polyhydromnios
PPROM/PROM/SROM

c) What are the types of (B)?

i- Occult prolapse
ii- Funic prolapse
iii- Overt prolapse

d) What is the management of (B)? (3 marks) *CORD mnemonic

[Call for help, Organize+ Position, Relieve pressure, Delivery]
i- Initiate red code alert (obstetric emergency) & call for help
ii- Maintain finger per vaginally, put pillows below the buttock to make it high up,
manually push the presenting part away from the cord, fill in the bladder with 500
ml NS, cover mother with warm blanket, blood taken, informed consent to go in
for caesarian section (if needed)
iii- Deliver the baby (depend on viability of fetus and cervical os dilatation)

e) List 2 prevention of this condition (2 marks)

i- Prevent doing Artificial Rupture of Membrane (ARM) when the head is
not engaged per abdomen (minimum 2/5th palpable) , station is high or
there is cord presentation on VE (soft, pulsatile mass)
ii- Do ARM with cautious by slowly release the amniotic fluid

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 17. Look at the picture.

a) Name the procedure (1 mark)

Episiotomy

b) List 2 types of it (2 marks)

i- Mediolateral incision
ii- Midline incision

c) When is the perfect time to do it? (1 mark)

Crowning of the fetal’s head in the 2nd stage of labour

d) List 4 advantage of the procedure? (4 marks)

i- To prevent extended tear
ii- To prevent profuse bleeding
iii- To prevent PPH
iv- Reduce maternal morbidity post-partum

e) List 2 indications of its use ( 2 marks)

i- In primid to ease the delivery of the baby
ii- In shoulder dystocia of Primid mother, (in Rubin II Maneuvre)

f) What are the complications of this procedure?

i- perineal hematoma
ii- infections
iii- wound breakdown/dehiscence
iv- injury to anal sphincter – incontinence
v- perineal pain, dyspareunia

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 18. Look at the CTG.

a) Interpret the CTG (4 marks)

Baseline fetal heart rate is 120 bpm
Poor beat-to-beat variability
Presence of (early) decelerations
Absence of acceleration
4 contractions in 10 minutes

b) What is the diagnosis/conclusion? (1 mark)

The CTG is non-reactive/suspicious

c) List 3 causes of it (3 marks)

i- Compression of fetal head during contraction
ii- Cord compression
iii- Fetal sleeping/ hypoxia

d) What is your next management? ( 2 marks)

Place the mother in left lateral position and repeat the CTG.
If the result shown persistent non-reactive CTG, prepare for emergency lower
segment caesarean section

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 19. Look at the CTG.

a) Interpret the CTG result

Baseline fetal heart rate is 140 bpm
Poor beat-to-beat variability
Presence of late decelerations
Absence of acceleration
2 contractions in 10 minutes

b) What is your conclusion?

Non-reactive CTG

c) List 2 cause of it.

i- Cord compression/ prolapsed
ii- Intrauterine growth restriction
iii- Uterine rupture/ excessive uterine activity
iv- Maternal hypotension/ hypovolaemia
v- Hypoxia

d) What is your next management?

Prepare for emergency lower segment caesarean section

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 20. Look at the CTG

a) Interpret the CTG

Baseline fetal heart rate is 150 bpm
Poor beat-to-beat variability
Presence of (variable) decelerations
Absence of acceleration
2 contractions in 10 minutes

b) What is your conclusion?

The CTG is non-reactive/suspicious

c) What are the possible causes?

i- Cord compression
ii- Fetal hypoxia

d) What is your next management?

Place the mother in left lateral position, and repeat the CTG.
Reassess the maternal well-being and labour progression.
If the result shown persistent non-reactive CTG, prepare for emergency lower
segment caesarean section

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 21. Look at the picture

a) What is the use of the above drug in obstetric setting? (2 marks)

i- Acute preterm labour (Off-label)
ii- Uterine hyperstimulation

b) What is the mode of action? (1 mark)

Bronchodilator (usually use in Asthma)

c) What are the mode of administration and the effective dose? (2 marks)
Start with: IV terbutaline 2.5 – 5 mcg/min (*increase gradually over 20- 30 min
intervals)
Typical effective dose: 17.5 – 30 mcg/min (some require up to: 70 – 80 mcg/min)
Continue infusion over 12 H following cessation of uterine contraction
(Max up to: < 48 – 72 H); but in patient with kidney dz (GFR < 50mL/min  dose need to be
↓ 50%)

d) List 2 contraindications of this drug? (2 marks)

i- Prolonged premature labour (> 48 – 72 H)
ii- Maternal heart disease/ DM/ overactive thyroid
iii- Maternal allergy to terbutaline or sympathomimetic amine (epinephrine,
albuterol)

e) List 3 side effect of this drug? (3 marks)

i- Hypokalemia
ii- Myocardial infarction (fast & irregular heart beat)
iii- Acute Pulmonary Odema
iv- Hyperglycaemia
v- Drowsiness

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