1.

The relation of the fetal long axis to that of the mother is termed which of the
following?
a.
b.
c.
d.

Fetal lie
Fetal angle
Fetal position
Fetal polarity
The relation of the fetal long axis to that of the mother is termed fetal lie and
is either e longitudinal or l transverse.Occasionally, the fetal and the maternal axes
may cross at a 45-degree angle, forming an oblique lie. his lie is unstable and
becomes longitudinal or transverse during labor. A longitudinal lie is present in more
than 99 percent of labors atterm. Predisposing factors for transverse fetal position
include multiparity, placenta previa, hydramnios, and uterine anomalies.

2. Which of the following is not a predisposing factor for transverse fetal lie?
a.
b.
c.
d.

Multiparity
Oligohydramnios
Placenta previa
Uterine anomalies
Predisposing factors for transverse fetal position include multiparity, placenta
previa, hydramnios, and uterine anomalies.

3. Which of the following fetal presentations is the least common?

a.
b.
c.
d.

Breech
Cephalic
Compound
Transverse lie
The presenting part is that portion of the fetal body that is either foremost
within the birth canal or in closest proximity to it. It typically can be felt through the
cervix on vaginal examination. Accordingly, in longitudinal lies, the presenting part is
either the fetal head or breech, creating cephalic and c breech presentations,
respectively. When the fetus lies with the long axis transversely, the shoulder is the
presenting part..

4. What percentage of fetuses are breech at 28 weeks' gestation?

a.
b.
c.
d.

1 %
10 %
25 %
50 %

If presenting by the breech, the fetus often changes polarity to make use of the
roomier fundus for its bulkier and more mobile podalic pole. The incidence of breech
presentation decreases with gestational age. It approximates 25 percent at 28 weeks,
17 percent at 30 weeks, 11 percent at 32 weeks, and then decreases to approximately
3 percent at term.
5. When the anterior fontanel is the presenting part, which term is used?
a.
b.
c.
d.

Brow
Face
Vertex
Sinciput
The fetal head may assume a position between these extremes,partially lexed
in some cases, with the anterior (large) fonta-nel, or bregma, presenting (sinciput
presentation)

Longitudinal lie. Cephalic presentation. Differences in attitude of the fetal body in

(A) vertex, (B) sinciput, (C) brow, and (D) face presentations. Note changes in fetal
attitude in relation to fetal vertex as the fetal head becomes less flexed

6. This drawing shows a fetal head in which position?

a.
b.
c.
d.

Left occiput anterior (LOA)

Left occiput posterior (LOP)
Right occiput anterior (ROA)
Right occiput posterior (ROP)

Longitudinal lie. Vertex presentation. A. Left occiput anterior (LOA). B. Left occiput
posterior (LOP).

Longitudinal lie. Vertex presentation A. Right occiput posterior (ROP). B. Right occiput
transverse (ROT).
7. The face presentation in this drawing is described as which of the following?

a.
b.
c.
d.

Left mento-anterior
Left mento-posterior
Right mento-anterior
Right mento-posterior

8. The fetus in this drawing is breech. His position is best described as which of the
following?

a.
b.
c.
d.

Left sacrum anterior

Left sacrum posterior
Right sacrum anterior
Right sacrum posterior

Longitudinal lie. Breech presentation. Left sacrum posterior (LSP).

9. The fetus in this drawing has a transverse lie. The position is best described as which of
the following?

a.
b.
c.
d.

Left acromidorsoanterior (LADA)

Left acromidorsoposterior (LADP)
Right acromidorsoanterior (RADA)
Right acromidorsoposterior (RADP)

Pic Transverse lie. Right acromiodorsoposterior (RADP). The shoulder of the fetus
is to the mothers right, and the back is posterior.
In shoulder presentations, the acromion (scapula) is the portion of the fetus
arbitrarily chosen for orientation with the maternal pelvis. One example of the
terminology sometimes employed for this purpose is illustrated by pic above .The
acromion or back of the fetus may be directed either posteriorly or anteriorly and
superiorly or inferiorly. Because it is impossible to diferentiate exactly the several
varieties of shoulder presentation by clinical examination and because such specific
diferentiation serves no practical purpose, it is customary to refer to all transverse lies
simply as shoulder presentations.Another term used is transverse lie, with back up or
back down,which is clinically important when deciding incision type for cesarean
delivery

10. In shoulder presentations, the portion of the fetus chosen for orientation with the
maternal pelvis is which of the following?
a.
b.
c.
d.

Head
Breech
Scapula
Umbilicus
In shoulder presentations, the acromion (scapula) is the portion of the fetus
arbitrarily chosen for orientation with the maternal pelvis

11. Which of the following could inhibit performance of Leopold maneuvers?

a.
b.
c.
d.

Oligohydramnios
Maternal obesity
Posterior placenta
Supine maternal positioning
Leopold maneuvers may be dificult if not impossible to perform and interpret
if the patient is obese, if there is excessive amnionic luid, or if the placenta is
anteriorly implanted.

12. Which of the following is the correct order for the cardinal movements of labor?
a. Descent, engagement, internal fixation, flexion, extension, external rotation,
expulsion
b. Descent, flexion, engagement, external fixation, extension, internal rotation,
expulsion
c. Engagement, descent, flexion, internal rotation, extension, external rotation,
and expulsion
d. Engagement, flexion, descent, internal rotation, straightening, extension, and
expulsion
The cardinal movements of labor are engagement, descent, flexion, internal
rotation, extension, external rotation, and expulsion. Pic below is illustrated abaout
cardinal movement of labor

13. Regarding engagement of the fetal head, which of the following statements is true?
a. It does not occur until labor commences.
b. Engagement prior to the onset of labor does not affect vaginal delivery rates.
c. It is the mechanism by which the biparietal diameter passes through the pelvic
outlet.
d. A normal-sized head usually engages with its sagittal suture directed
anteroposteriorly.
The mechanism by which the biparietal diameterthe greatest transverse
diameter in an occiput presentationpasses throught the pelvic inlet is designated
engagement. he fetal head may engage during the last few weeks of pregnancy or not
until after labor commencement. In many multiparous and some nulliparous women,
the fetal head is freely movable above the pelvic inlet at labor onset. In this
circumstance, the head is sometimes referred toas loating. A normal-sized head
usually does not engage with its sagittal suture directed anteroposteriorly. Instead, the
fetal head usually enters the pelvic inlet either transversely or obliquely. Segel and
coworkers (2012) analyzed labor in 5341 nulliparous women and found that fetal
head engagement before labor onset did not afect vaginal delivery rates in either
spontaneous or induced labor.
14. On palpation of the fetal head during vaginal examination, you note that the sagittal
suture is transverse and close to the pubic symphysis. The posterior ear can be easily
palpated. Which of the following best describes this orientation?
a.
b.
c.
d.

Anterior asynclitism
Posterior asynclitism
Mento-anterior position
Mento-posterior position
The sagittal suture frequently is delected either posteriorly toward the
promontory or anteriorly toward the symphysis. Such lateral delection to a more
anterior or posterior position in the pelvis is called asynclitism. If the sagittal
sutureapproaches the sacral promontory, more of the anterior parietal bone presents
itself to the examining ingers, and the conditionis called anterior asynclitism. If,
however, the sagittal suture lies close to the symphysis, more of the posterior parietal
bone will present, and the condition is called posterior asynclitism. Withextreme
posterior asynclitism, the posterior ear may be easily palpated.

15. Of the cardinal movements of labor, internal rotation achieves what goal?
a.
b.
c.
d.

Flexes the fetal neck

Brings the occiput to an anterior position
Brings the anterior fontanel through the pelvic inlet
None of the above
This movement consists of a turning of the head in such a manner that the
occiput gradually moves toward the symphysispubis anteriorly from its original

position or, less commonly,posteriorly toward the hollow of the sacrum. Internal
rotation is essential for completion of labor, except when the fetus is unusually small.
16. In what percentage of labors does the fetus enter the pelvis in an occiput posterior
position?
a.
b.
c.
d.

0.5%
5%
20%
33%
In approximately 20 percent of labors, the fetus enters the pelvis in an occiput
posterior (OP) position (Caldwell, 1934). The right occiput posterior (ROP) is slightly
more common than the left (LOP).

17. Which of the following is not a risk factor for incomplete rotation of the posterior
occiput?
a.
b.
c.
d.

Macrosomia
Poor contractions
Lack of analgesia
Inadequate head flexion
In perhaps 5 to 10 percent of cases, however, rotation may be incomplete or
may not take place at all, especially if the fetus is large (Gardberg, 1994b). Poor
contractions, faulty head lexion, or epidural analgesia, which diminishes abdominal
muscular pushing and relaxes pelvic loor muscles, may predispose to incomplete
rotation. If rotation is incomplete, transverse arrest may result. If no rotation toward
the symphysis takes place, the occiput may remain in the direct occiput posterior
position, a condition known as persistent occiput posterior. Pic above show
mechanism of labor for right occiput posterior position showing anterior rotation.

18. This photograph demonstrates which of the following?

a.
b.
c.
d.

Hydrocephalus
Plagiocephaly
Craniosynostosis
Caput and molding
In vertex presentations, labor forces alter fetal head shape.In prolonged
labors before complete cervical dilatation, the portion of the fetal scalp immediately
over the cervical os becomes edematous. This swelling, known as the caput
succedaneum. In addition to soft tissue changes, the bony fetal head shape is also
altered by external compressive forces and is referred to as molding. Possibly related
to Braxton Hicks contractions, some molding develops before labor.Most studies
indicate that there is seldom overlapping of theparietal bones. A locking mechanism
at the coronal and lambdoidal connections actually prevents such overlapping (Carlan,
1991). Molding results in a shortened suboccipital to bregmatic diameter and a
lengthened mentovertical diameter. These changes are of greatest importance in
women with contracted pelves or asynclitic presentations. In these circumstances, the
degree to which the head is capable of molding may make the diference between
spontaneous vaginal delivery and an operative delivery.

19. Which of the following statements regarding the preparatory division of labor is true?
a.
b.
c.
d.

The cervix dilates very little.

Connective tissue components of the cervix change considerably.
Sedation and conduction analgesia are capable of arresting this labor division.
All of the above

Friedman developed the concept of three functional labor divisions to

describe the physiological objectives of each division as shown in . First, during the
preparatory division, although the cervix dilates little, its connective tissue
components change considerably. Sedation and conduction analgesia are capable of

arresting this labor division. The dilatational division, during which dilatation
proceeds at its most rapid rate,is unafected by sedation. Last, the pelvic division
commences with the deceleration phase of cervical dilatation.
20. When does the latent phase of labor end for most women?
a.
b.
c.
d.

1-2 cm
2-3 cm
3-5 cm
7-8 cm
The onset of latent labor, as deined by Friedman (1972), is the point at
which the mother perceives regular contractions. The latent phase for most women
ends once dilatation of 3 to 5 cm is achieved. his threshold may be clinically useful,
for it deines dilatation limits beyond which active labor can be expected.

21. A 20-year-old G1PO at 39 weeks' gestation presents complaining of strong contractions.

Her cervix is dilated 1 cm. She is given sedation, and 4 hours later, her contractions
have stopped. Her cervix is still 1 cm dilated. Which of the following is the most likely
diagnosis?
a.
b.
c.
d.

False labor
Prolonged latent phase of labor
Arrest of the latent phase of labor
Arrest of the active phase of labor
Factors that afected latent phase dura-tion include excessive sedation or
epidural analgesia; unfavorable cervical condition, that is, thick, unefaced, or
undilated; and false labor. In those who had been administered heavy sedation, 85
percent of women eventually entered active labor. In another 10 percent, uterine
contractions ceased, suggesting that they had false labor.

22. According to Friedman, the minimum normal rate of active-phase labor in a multipara
is which of the following?
a.
b.
c.
d.

1 cm/hr
1.2 cm/hr
1.5 cm/hr
3.4 cm/hr

Turning again to Friedman (1955), the mean duration of active-phase labor in

nulliparas was 4.9 hours. But the standard deviation of 3.4 hours is large, hence, the
active phase was reported to have a statistical maximum of 11.7 hours. Indeed, rates
of cervical dilatation ranged from a minimum of 1.2 up to 6.8 cm/hr. Friedman

(1972) also found that multiparas progress somewhat faster in active-phase labor,
with a minimum normal rate of 1.5 cm/hr.
23. Which stage of labor begins with complete cervical dilatation and ends with delivery of
the fetus?
a.
b.
c.
d.

First stage
Second stage
Third stage
Fourth stage
Second stage begins with complete cervical dilatation and ends with fetal
delivery. he median duration is approximately 50 minutes for nulliparas and about 20
minutes for multiparas, but it is highly variable (Kilpatrick, 1989).

24. A 24-year-old G1PO at 27 weeks' gestation presents in active preterm labor to a hospital
without delivery services or a neonatal intensive care unit. The physician in the
emergency department evaluates the patient. He determines that her cervix is
approximately 4 cm dilated and membranes are intact. He would like to transfer her to
you because you are at the nearest hospital with obstetric and neonatal services qualified
to handle this patient's complications. According to the Emergency Medical Treatment
and Labor Act (EMTALA), which of the following is true?
a. A woman complaining of contractions is not considered an emergency.
b. A screening examination is not required because it will unreasonably slow the
transfer of the patient.
c. The patient cannot be transferred because a woman in true labor is considered
"unstable" for interhospital transfer.
d. This patient can be transferred if the physician certifies that the benefits of
treatment at your facility outweigh the transfer risks.
The deinition of an emergency condition makes speciicreference to a pregnant
woman who is having contractions.Labor is deined as the process of childbirth
beginning with the latent phase of labor continuing through delivery of theplacenta. A
woman experiencing contractions is in true labor unless a physician certiies that after
a reasonable time of observation the woman is in false labor. A woman in truelabor is
considered unstable for interhospital transfer pur-poses until the newborn and
placenta are delivered. An unstable woman may, however, be transferred at the
direction of the patient or by a physician who certiies that the beneits of treatment at
another facility outweigh the transfer risks.
25. When evaluating a pregnant woman for rupture of membranes, which of the following
has been associated with a false-positive nitrazine test result?
a.
b.
c.
d.

Blood
Semen
Bacterial vaginosis
All of the above

The use of the indicator nitrazine to identify ruptured membranes is a simple

and fairly reliable method. Test papers are impregnated with the dye,and the color of
the reaction between these paper strips and vaginal luids is interpreted by
comparison with a standard color chart. A pH above 6.5 is consistent with ruptured
membranes. False-positive test results may occur with coexistent blood, semen, or
bacterial vaginosis, whereas false-negative tests may result with scant luid
26. When performing a bimanual examination on a pregnant woman, the position of the
cervix is determined by the relationship of the cervical os to which of the following?
a.
b.
c.
d.

Rectum
Uterus
Feta1 head
Pubic symphysis
The position of the cervix is determined by the relationship of the cervical os
to the fetal head and is categorized as posterior, mid-position, or anterior. Along with
position, the consistency of cervix is determined to be soft, firm, or intermediately
between these two.

27. Station describes the relationship between which of the following?

a.
b.
c.
d.

The biparietal diameter and the pdvic oudet

The biparietal diameter and the ischial spines
The lowermost portion of the presenting fetal part and the pelvic inlet
The lowermost portion of the presenting fetal part and the ischial spines
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.

28. A 20-year-old G2Pl presents in active labor at term. The patient requires augmentation
with oxytocin during her labor course. She has a forceps-assisted vaginal delivery and
sustains a second-degree laceration. Which of the following is not a risk factor for
urinary retention in this patient?
a.
b.
c.
d.

Multiparity
Perineal laceration
Oxytocin-augmented labor
Operative vaginal delivery

Risk factors for retention were primiparity, oxytocin-induced or -augmented

labor, perineal lacerations, operative vaginal delivery, catheterization during labor,
and labor duration > 10 hours.
29. What is the median duration of second-stage labor in nulliparas without conduction
analgesia?
a.
b.
c.
d.

20 minutes
40 minutes
50 minutes
90 minutes
The median duration of the second stage is 50 minutes in nulliparas and 20
minutes in multiparas, although the interval can be highly variable

30. What is the median duration of the second-stage labor in multiparas without conduction
analgesia?
a.
b.
c.
d.

20 minutes
40 minutes
50 minutes
90 minutes
The median duration of the second stage is 50 minutes in nulliparas and 20
minutes in multiparas, although the interval can be highly variable

31. A 25-year-old G lPO at 39 weeks' gestation presents in active labor. Her cervix is dilated
4 cm and is completely effaced, and the presenting fetal part has reached 0 station.
Membranes are intact. With examination 2 hours later, you note that the cervix is still 4
cm dilated. At this point, which of the following is the best management?
a.
b.
c.
d.

Cesarean delivery
Rupture of membranes
Insertion of a bladder catheter to assist fetal head descent
Rupture of membranes, placement of internal monitors, and oxytocin augmentation
Women are admitted if active labor (defined as cervical dila-tation of 3 to 4
cm or more in the presence of uterine contractions) is diagnosed or if ruptured
membranes are confirmed. stipulate that a pelvic examination be performed
approximately every 2 hours. Inefective labor is suspected when the cervix does not
dilate within approximately 2 hours of admission. Amniotomy is then performed, and
labor progress determined at the next 2-hour evaluation. In women whose labors do
not progress, an intrauterine pressure catheter is placed to assess uterine function.
Hypotonic contractions and no cervical dilatation after an additional 2 to 3 hours
result in stimulation of labor using the high-dose oxytocin regimen. Pic below is
management guidelines summarized

32. A 19-year-old G1P0 at term presents in active labor. Her cervix is 5 cm dilated, and fluid
is leaking from spontaneously ruptured membranes. You examine her 2 hours later, and
the cervix is still 5 cm dilated. At this point, which of the following is the best
management?
a.
b.
c.
d.

Cesarean delivery
Placement of internal monitors and reassessment in 2 hours
Placement of internal monitors, oxytocin augmentation, and reassessment in 2 hours
Placement of internal monitors, oxytocin augmentation, antibiotics for prolonged
rupture of membranes, and reassessment in 2 hours
See pic above