Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) A1–A6

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Best Practice & Research ClinicalObstetrics and Gynaecology

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Caesarean Section: Current Practice – Multiple ChoiceQuestions for Vol. 27, No. 2

1. The following statement(s) is/are true about the risks of Caesarean section:

a) The evidence comparing the risks of planned Caesarean section and vaginal delivery is mainlyhigh quality.

b) The immediate maternal risks from a planned Caesarean section are significantly higher thanthose of a planned vaginal delivery.

c) A vaginal birth is associated with a comparable or higher maternal mortality rate than plannedCaesarean section.

d) A planned Caesarean section increases the rate of unexplained stillbirths at or after 34 weeks infuture pregnancies.

e) An association exists between a prior Caesarean section and subsequent preterm birth, fetalgrowth restriction and spontaneous miscarriage.

2. The following further statement(s) is/are true about the risks of Caesarean section:

a) The risk of early PPH is less with planned vaginal delivery thanwith planned Caesarean section.b) Risk of obstetric shock and the need for blood transfusion is less with planned Caesarean

section than with planned vaginal delivery.c) Studies have confirmed higher maternal satisfaction rates in the immediate postpartum period

with vaginal delivery rather than planned Caesarean section.d) Studies have confirmed highermaternal satisfaction rates at 3 months postpartumwith vaginal

delivery rather than planned Caesarean section.e) Women having planned Caesarean section are significantly more depressed at 3 months

postpartum compared with women having vaginal births.

3. The following statement(s) is/are true about the route of delivery and pelvic floor dysfunction:

a) In women aged 50–64 years, the prevalence of stress urinary incontinence (SUI) is significantlylower if they have had a Caesarean section delivery compared with a vaginal delivery.

b) No difference in the rate of sexual dysfunction has been reported, at 6–18 months, irrespectiveof the mode of delivery.

c) In multiparous women, the rates of SUI are significantly higher in women who have had threevaginal births compared with those that have had three planned Caesarean sections.

d) A vaginal birth carries less than 1% risk of initiating persistent SUI.e) Up to 4% of women suffer fecal incontinence after a vaginal birth and only approximately 40% of

cases of anal incontinence resolve spontaneously.

1521-6934/$ – see front matterhttp://dx.doi.org/10.1016/j.bpobgyn.2013.02.001

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4. Which of the following issues is/are part of the principle basis of beneficence that is/are required ofan obstetrician?

a) First do no harm.b) Respect for the pregnant woman’s right to make informed decisions.c) Respect for the fetal patient’s right to life.d) Seek the greater balance of clinical goods over clinical harms.e) Treat all patients fairly.

5. Respect for autonomy is best defined as an ethical principle that requires the obstetrician to:

a) First do no harm.b) Respect the pregnant woman’s right to make informed decisions.c) Respect the fetal patient’s right to life.d) Seek the greater balance of clinical goods over clinical harms.e) Treat all patients fairly.

6. A pregnant woman during her first pregnancy presents to her obstetrician at the first prenatal visitin early pregnancy and requests a planned Caesarean delivery. Which of the following is/areappropriate ways of managing this?

a) Agreeing to her request and noting in the chart that planned cesarean delivery will be providedafter 39 weeks.

b) Telling the pregnant woman that he is not personally comfortable with her request and willrefer her to another obstetrician if that is her preference.

c) After consulting with Risk Management, implement the patient’s request.d) Recommend against planned Caesarean delivery but provide Caesarean delivery only after

a thorough and reflective decision by the patient to re-affirm her request.e) Recommend against planned Caesarean delivery and refuse to carry out Caesarean delivery

because doing so would be unprofessional.

7. A pregnant woman in her second pregnancy with a previous Caesarean delivery by classicalincision requests trial of labour after Caesarean delivery (TOLAC). Which of the following is/areappropriate ways of managing this?

a) Referring the patient to a colleague who provides TOLAC after a previous classical incision.b) Explaining the clinically unacceptable risks of TOLAC for a patient with a previous classical

incision, recommend against TOLAC, and recommend planned Caesarean delivery.c) After consulting with Risk Management, implement the patient’s request.d) After insuring proper equipment and staffing is available, implement the patient’s request.e) Implement the patient’s request if the obstetrician is personally comfortable with doing so.

8. Which of the following is/are the safest treatment(s) in cases of unexpected placenta accreta in anemergency?

a) Total hysterectomy.b) Subtotal hysterectomy.c) Hysterotomy via the uninvaded area, leaving the placenta in situ and closing the uterus.d) Resection of the invaded area and uterine reconstruction.e) Compression sutures following placental resection.

9. Which is the best, safest and easiest method of vascular control in cases of unexpected bleedingduring surgery of placenta accreta?

a) Internal iliac ligature.b) Internal iliac occlusion (endovascular).

Appendix / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) A1–A6 A3

c) Uterine packing.d) Internal aortic compression.e) Uterine artery ligation.

10. Which of the following is/are considered effective as a uterine haemostatic method to stop per-sistent bleeding in cases of placenta praevia?

a) Square suture (Cho’s procedure).b) Hayman procedure.c) B-Lynch procedure.d) Uterine arterial embolisation.e) Uterine artery ligation.

11. Apart from internal aortic compression, which of the following is/are an effective method(s) ofstopping uterine bleeding in cases of placenta praevia with shock or coagulopathy?

a) Hysterectomy.b) Uterine arterial embolisation.c) Uterine wrapping with Eschmarch’s bandage.d) Intrauterine balloon.e) Pelvic packing with multiple swabs.

12. Which of the following statement(s) is/are true regarding the rising primary Caesarean sectionrate?

a) It is primarily due to the fear of malpractice.b) It is influenced by time-management issues for parents.c) It is justified by improved fetal outcome.d) It is justified by improved maternal outcome.e) It is principally due to relative increases in request form the “white, middle classes”

13. The decrease in vaginal birth after prior Caesarean delivery (VBAC) rate after 1995 was due to:

a) Increased risks of uterine rupture from that time.b) Increased risks of uterine rupture before that time.c) Increased appreciation of devastating fetal consequences.d) The fear of malpractice.e) The imposition of a demanding informed consent.

14. Informed consent:

a) Is given by the clinician.b) Is given by the patient.c) Is static – once signed it is irrevocable.d) Is an understanding with the patient that demands revision as circumstances change.e) If a patient undergoing VBAC suddenly changes her mind and asks for a Caesarean, this must be

done without question.

15. The average blood loss at Caesarean section, when accurately measured is:

a) 300–400 ml.b) 500–600 ml.c) 700–800 ml.d) 900–1000 ml.e) 1100-1200 ml.

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16. The following is/are true regarding oxytocin administered by intravenous bolus injection forpostpartum haemorrhage (PPH) prophylaxis at Caesarean section:

a) It causes hypertension.b) It may cause hypotension.c) The recommended dose is 10 iu.d) The recommended dose is 2.5–5 iu.e) It is inferior to misoprostol for preventing PPH.

17. The following is/are true regarding Caesarean hysterectomy for PPH at Caesarean section:

a) It is the second line of treatment after failed medical treatment for uterine atony detected atCaesarean section.

b) It may be the first-line treatment for cases of placenta praevia, accreta and uterine rupture.c) The subtotal procedure is usually adequate for arresting haemorrhage.d) In most case studies, the rate of urological injuries is 1–2%.e) There is a risk of re-laparotomy for ongoing haemorrhage in around 10% of women.

18. Common cause for bleeding at Caesarean section include:

a) Uterine atony.b) Extension of the uterine incision.c) Abnormal placentation.d) Chorioamnionitis.e) Poor surgical technique

19. Bleeding at Caesarean section caused by lateral extensions of the uterine incision into the broadligament can be controlled by:

a) Uterine compression sutures.b) Balloon tamponade.c) Ergometrine.d) Uterine artery ligation.e) Haemostatic sutures.

20. Which of the following statements is/are true about breech birth?

a) The TermBreech Trial (TBT) showed that neonatalmortalityand serious neonatalmorbidityweresignificantly lower after planned Caesarean section compared with planned vaginal delivery.

b) At 2 years, infants delivered by Caesarean section in the TBT had significantly better neuro-developmental outcome compared with the vaginally delivered group.

c) In countries with a low perinatal mortality rate, the trial showed no difference in perinatalmortality between a planned Caesarean section and a trial of vaginal breech delivery.

d) A number of current guidelines on term breech birth (e.g. Royal College of Obstetrics andGynaecology) support offering vaginal breech delivery in well-selected cases.

e) Good evidence shows that preterm breech infants weighing between 1500 g and 2500 g arebest delivered by planned Caesarean section.

21. Which of the following statement is/are true about twin delivery?

a) Uncomplicated twins are best delivered electively between 37 and 39 weeks.b) Large epidemiological studies have failed to show that the second twin is at higher risk of

adverse perinatal outcome compared with the first twin.c) Good evidence supports planned Caesarean delivery of all twins where the first twin is non-

vertex.

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d) Good evidence supports planned Caesarean delivery of all twins where the second twin is non-vertex and the first twin is vertex presenting.

e) In vertex/vertex twin vaginal delivery, up to 20% of cephalic second twins will change pre-sentation spontaneously after twin 1 is delivered.

22. On the basis of the 10-group classification, the following statement(s) about Caesarean sectionrates is/are true:

a) Groups 1, 2 and 5 contribute to one-third of most overall Caesarean section rates.b) Group 5 is the largest individual group contributor to the overall Caesarean section rate.c) The Caesarean section rate in group 9 is always 100%.d) Caesarean section in breech pregnancies and multiple pregnancies contribute to one-half of

most overall Caesarean section rates.e) The Caesarean section rate in group 3 is always the lowest of all the groups.

23. The following statements about the Multidisciplinary Quality Assurance Programme is/are true(MDQAP):

a) Its purpose is to reduce the overall Caesarean section rate.b) Its purpose is to produce a standardised Annual Clinical Report.c) It is simple to implement.d) Its success depends on obstetricians.e) Audit should be continuous.

24. The following statement(s) is/are true regarding indications for Caesarean sections when formallymonitored and classified:

a) In labour they can be classified into fetal or dystocia.b) In labour they vary in different groups of women.c) In labour they reflect the use of oxytocin.d) In labour the most common indication is suspected fetal distress.e) Maternal request is a well-defined indication.

25. The 10-group classification:

a) Is only useful for analysing Caesarean sections.b) Does not include all women.c) Does not facilitate the use of indications.d) Needs a computer system to be implemented.e) Cannot be used prospectively.

26. The following is/are true concerning the relationships between the duration of decision-to-delivery interval and adverse fetal outcome:

a) Randomised-controlled trials show that prolonged decision-to-delivery interval is not asso-ciated with any adverse fetal outcome.

b) One of the reasons that many existing studies show that prolonged decision-to-delivery in-terval is associated with a better fetal outcome is selection bias, as clinicians tended to act morepromptly in those more severe cases of fetal distress.

c) The duration of bradycardia-to-delivery interval is shown to be inversely correlated with cordarterial pH in cases of irreversible causes of fetal bradycardia.

d) Existing studies have consistently proven that it is not possible to achieve a decision-to-delivery interval of less than 30 mins even for life-threatening cases in level 3 units.

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e) The latest American Academy of Obstetrics and Gynaecology (ACOG) guideline states that it isthe requirement for all obstetric units to deliver all emergency Caesarean sections within30 mins after decision for delivery is made.

27. The following is/are true concerning the management of fetal distress:

a) The Royal College of Obstetrics and Gynaecology recommends that the decision-to-deliveryinterval should not exceed 75 mins for category 1 urgent Caesarean section.

b) Cord prolapse, placental abruption and uterine rupture are classified under the urgent categoryof Caesarean section.

c) Fetal distress caused by iatrogenic hyperstimulation is a life-threatening conditions thatrequire category 1 urgent Caesarean section.

d) Amnioinfusion has been shown to be effective in reducing the incidence of life-threateningfetal distress and emergency Caesarean section rate.

e) Regional analgesia may cause fetal distress by inducing hypertonic uterine contractions.

28. Which of the following clinical factors have been found to increase the risk of uterine ruptureduring a trial of labour after Caesarean delivery?

a) Fetal weight greater than 4000 g.b) Previous vaginal delivery.c) Inter-delivery interval less than 18 months.d) High doses of oxytocin.e) Induction of labour.

29. The Objective Structured Assessment of Technical Skill (OSATS) tool in the specialty trainingprogramme:

a) Represents the sole criterion for progression at the waypoints of the training programme.b) Identifies three distinct purposes.c) Does not capture the decision to undertake a given procedure.d) Does not require a trainee to undertake further assessment in a given procedure once com-

petence has been demonstrated successfully.e) Has uniform requirements for progression across the various procedures assessed by the tool.

30. The OSATS tool in assessing technical competence to carry out Caesarean section:

a) Has distinct assessments for each stage of the procedure.b) Identifies three different levels of procedure complexity.c) Documents levels of procedure complexity clearly.d) Has specific technical checklists for each levels of procedure complexity.e) Can assess performance better in more straightforward procedures.