Regarding fetal oxygenation which of the following is/are true?

• a)
  

  The fetus requires oxygen only to maintain cellular aerobic metabolism

  
  
• b)
  

  Both glucose and oxygen can be stored allowing later mobilisation if required

  
  
• c)
  

  Maternal respiratory complications alone can result in a downstream reduced fetal oxygen supply

  
  
• d)
  

  For there to be a significant reduction in the oxygen supply to the baby it usually requires a combined materno-placento-fetal complication

  
  
• e)
  

  In the event of utilisation of the anaerobic metabolism pathway, it yields 19 times the production of lactic acid compared to aerobic.

Regarding fetal blood supply which of the following is true?

• a)
  

  In the inter-villous space, de-oxygenated blood from the mother’s spiral arteries flows around the fetal chorionic villi, which contain oxygenated blood

  
  
• b)
  

  The two umbilical veins transport deoxygenated blood and waste products from the fetus to the placenta, while the umbilical artery provides the fetus with oxygenated blood and nutrients from the mother.

  
  
• c)
  

  The neonatal acid–base status is best reflected by the umbilical arterial blood

  
  
• d)
  

  The venous umbilical blood contents depend on the maternal acid–base status and placental function

  
  
• e)
  

  Blood from the placenta passes via the umbilical vein almost unhindered through the ductus venosus

Further regarding fetal blood supply which of the following is true?

• a)
  

  The fetal cardiovascular system is designed such that the most highly oxygenated blood is delivered to the myocardium and brain

  
  
• b)
  

  Fetal circulatory adaptations are achieved by the presence of intra-cardiac shunts

  
  
• c)
  

  Fetal circulatory adaptations are achieved by the presence of extra-cardiac shunts

  
  
• d)
  

  The fetal carotid bodies contain baro-receptors for the detection of pressure changes in the fetus

  
  
• e)
  

  The fetal heart is equipped with baro and volume receptors which sense changes in the pressure and volume of blood in the heart.

Regarding fetal metabolism which of the following is/are true?

• a)
  

  Glycolysis results firstly in the conversion of glucose into pyruvate

  
  
• b)
  

  Two ATP molecules are generated after the initial first step of glycolysis

  
  
• c)
  

  Citric acid in the presence of oxaloacetate enters the Acetyl coenzyme A cycle.

  
  
• d)
  

  The reaction CO ₂ + H ₂ O ↔ H ₂ CO ₃ ↔ H ⁺ + HCO ₃ ^– only occurs uni-directionally in the placenta to facilitate CO ₂ elimination

  
  
• e)
  

  The bicarbonate buffer is the main buffer system in plasma accounting for 35% of the fetal buffering capacity in blood

Regarding fetal asphyxia which of the following is/are true?

• a)
  

  Fetal asphyxia almost always occurs as a result of a gradual insufficiency in the umbilical blood flow or insufficient uterine blood flow

  
  
• b)
  

  Occlusion of one or more of the vessels in the umbilical cord impedes the circulation to and from the fetus and during these events both the oxygen content of the fetal blood may decrease and the CO ₂ content may increase

  
  
• c)
  

  Excess fetal CO ₂ is initially removed by a large increase in fetal respiratory rate

  
  
• d)
  

  Prolonged hypoxia leads to a further increase in CO ₂ content and further respiratory acidosis

  
  
• e)
  

  The accumulation of CO ₂ can deplete the buffer system causing failure of the ATP-dependent sodium–potassium pump initiating a cascade that leads to cell injury and death.

Regarding the causes of intrapartum fetal hypoxia/acidosis, the following statement(s) is/ are true?

• a)
  

  Uterine contractions may decrease placental perfusion and reduce umbilical cord circulation.

  
  
• b)
  

  Aorto-caval compression by the pregnant uterus may cause sudden maternal hypotension.

  
  
• c)
  

  Maternal cardio-respiratory arrest is an irreversible cause of fetal hypoxia/acidosis.

  
  
• d)
  

  Shoulder dystocia may cause umbilical cord compression.

  
  
• e)
  

  Asking the mother not to push during contractions in the second stage of labour may contribute to reducing fetal hypoxia/acidosis.

Regarding adverse fetal outcome, the following statement(s) is/are true?

• a)
  

  Fetal hypoxia/acidosis can be diagnosed by documenting a blood lactate concentration exceeding 10 mmol/l in the newborn circulation during the first minutes of life.

  
  
• b)
  

  Low Apgar scores are a hallmark of intrapartum fetal hypoxia/acidosis.

  
  
• c)
  

  Most newborns with metabolic acidosis and decreased 1-minute Apgar scores will die after birth or develop hypoxic-ischemic encephalopathy.

  
  
• d)
  

  Neonatal encephalopathy is caused by intrapartum hypoxia/acidosis and requires the confirmation of metabolic acidosis.

  
  
• e)
  

  The majority of cases of cerebral palsy cases are caused by intrapartum hypoxia/acidosis.

A full-term neonate has the following blood results from the umbilical artery, obtained immediately after delivery: pH 6.95, p CO ₂ 11 kPa, BDecf 12.3 mmol/l. What is the correct interpretation of this result?

• a)
  

  Normal acid–base status

  
  
• b)
  

  Respiratory acidosis

  
  
• c)
  

  Metabolic acidosis

  
  
• d)
  

  Combined metabolic acidosis with a respiratory component

  
  
• e)
  

  Compensated combined acidosis

The same neonate as in question 8 does not breathe and obtains low Apgar scores both at 1 and 5 minutes. After a few minutes of resuscitation the neonate is transferred to NICU. He breathes spontaneously and during close supervision he demonstrates normal tone, sucking reflex and behaviour. He is discharged to his home on the fifth day of his life. The parents are anxious and ask about risk of brain injury. What is the best advice re development and the risk of developing cerebral palsy (CP)?

• a)
  

  He is likely to develop normally and he has no increased risk of CP

  
  
• b)
  

  He is likely to develop normally but there is an increased risk of CP

  
  
• c)
  

  He is likely to have a delayed development but without increased risk of CP

  
  
• d)
  

  He is likely to have a delayed development and an increased risk of CP

  
  
• e)
  

  No firm advice can be given as the outcome is too uncertain

Which of the following situation(s) constitute a contra-indication(s) to internal FHR monitoring?

• a)
  

  Breech presentation.

  
  
• b)
  

  The mother is seropositive to genital herpes.

  
  
• c)
  

  The membranes have not yet ruptured and the fetal head is not engaged.

  
  
• d)
  

  Gestational age of 33 weeks.

  
  
• e)
  

  The mother is seropositive to human immunodeficiency virus.

Regarding Uterine Contraction (UC) monitoring, the following statement(s) is/are true?

• a)
  

  With external UC monitoring using a tocodynamometer, UCs are sometimes not detected.

  
  
• b)
  

  External UC monitoring using a tocodynamometer allows an accurate evaluation of contraction frequency and amplitude.

  
  
• c)
  

  Internal UC monitoring using an intrauterine pressure sensor is a safe but expensive technique.

  
  
• d)
  

  Internal UC monitoring should be preferred when labour is being induced or augmented.

  
  
• e)
  

  The tension applied to the elastic band supporting the tocodynamometer will influence the location of the basal line on the UC graph.

If there is an ongoing prolonged deceleration (lasting >3 minutes) which of the following is/are true?

• a)
  

  The deceleration will recover to the original baseline heart rate by 9 minutes in 95% of the cases in the absence of vaginal bleeding.

  
  
• b)
  

  The pH drops 0.01/2–3 minutes

  
  
• c)
  

  Due to an umbilical cord prolapse, ‘3, 6, 9, 12 and 15 minute’ Rule should be applied

  
  
• d)
  

  The variability during a deceleration will be maintained within the first 3 minutes in cases of a concealed placental abruption.

  
  
• e)
  

  If there is a hyperstimulation, oxytocin should be stopped immediately and Terbutaline 250mcg intravenously or subcutaneously should be considered if there is no recovery to the normal baseline fetal heart rate.

Which of the following is/are true regarding chronic hypoxia?

• a)
  

  It is characterized by the presence of late decelerations, reduced baseline variability and a low baseline fetal heart rate secondary to the activation of the parasympathetic nervous system.

  
  
• b)
  

  Management includes induction of labour as damage has already occurred during the antenatal period and the process of labour doesn’t change the outcome.

  
  
• c)
  

  It is characterized by an increase in the baseline rate secondary to release of catecholamines (adrenaline and noradrenaline), reduced variability due to reduced perfusion of the autonomic nervous system and presence of repeated shallow decelerations.

  
  
• d)
  

  It is associated with an increase in the baseline rate secondary to activation of the parasympathetic system.

  
  
• e)
  

  It may progress to a typical ‘step ladder pattern’ to death on the CTG Trace which is not observed in a gradually evolving hypoxia.

When a fetus is exposed to gradually evolving hypoxia the following is/are true:

• a)
  

  The first feature that it will be seen on the CTG trace is the appearance of decelerations.

  
  
• b)
  

  The presence of accelerations at the end of a deceleration (‘overshoots’) reflects a good sign of fetal wellbeing as it indicates that the fetus is well oxygenated.

  
  
• c)
  

  A stable baseline with good variability in the presence of decelerations indicates that the fetus is exposed to stress but is compensating well.

  
  
• d)
  

  In the presence of atypical decelerations, stopping oxytocin infusions can improve the CTG trace as this will reduce the strength, frequency or duration of uterine contractions and hence, improve fetal oxygenation.

  
  
• e)
  

  If there is onset of reduction of baseline fetal heart rate and oxytocin infusion is continued to be increased it can lead to a typical ‘step ladder pattern’ to death.

In relation to specific CTG patterns which of the following is/are true?

• a)
  

  The sinusoidal pattern occurs secondary to subacute hypoxia

  
  
• b)
  

  The saltatory pattern in combination with atypical or late decelerations reflects fetal movements and should be considered as a reassuring feature.

  
  
• c)
  

  In the presence of an atypical sinusoidal pattern, delivery should be expedited and fetal hemoglobin tested immediately after birth as this pattern is suggestive of feto-maternal hemorrhage.

  
  
• d)
  

  The saltatory pattern can also be called ‘cycling’

  
  
• e)
  

  The typical sinusoidal pattern is suggestive of fetal thumb sucking.

Which of the following is/are contra-indications to fetal blood sampling (FBS)?

• a)
  

  Maternal fever

  
  
• b)
  

  Maternal HIV infection

  
  
• c)
  

  Fetal haemophilia

  
  
• d)
  

  Active genital herpes

  
  
• e)
  

  Vaginal group B streptococcus colonisation

When performing a fetal blood sampling, an intervention is indicated in which of the following?

• a)
  

  Fetal scalp pH < 7.25

  
  
• b)
  

  Fetal scalp pH < 7.00

  
  
• c)
  

  Fetal scalp lactate > 4.8 mmol/L

  
  
• d)
  

  Fetal scalp base deficit > 12 mmol/L

  
  
• e)
  

  Fetal heart rate acceleration during sampling

The following statement(s) is/are true about the known shortcomings of standard electronic fetal monitoring (EFM)?

• a)
  

  There is excellent inter- and intra-observer agreement on EFM interpretation

  
  
• b)
  

  Visual interpretation of FHR patterns is a good predictor of fetal compromise

  
  
• c)
  

  Fetal oximetry has improved the accuracy of EFM to assess fetal status.

  
  
• d)
  

  The three-tier classification of FHR patterns has not improved perinatal outcomes

  
  
• e)
  

  Computerized analysis of FHR patterns has not been shown to reduce perinatal morbidity and mortality

Novel systems for improved intrapartum surveillance will need which of the following element(s)?

• a)
  

  Automated analysis of FHR elements and patterns

  
  
• b)
  

  Access to clinical data of patients entering labour

  
  
• c)
  

  Algorithmic approaches to management of clinical variables

  
  
• d)
  

  Hybrid systems that incorporate neural networks

  
  
• e)
  

  Expert systems that employ sets of rules

Barriers to the development of novel intrapartum surveillance systems include which of the following?

• a)
  

  Failure of previously adopted ancillary assessment methods such as fetal oximetry

  
  
• b)
  

  Industry reluctance to invest in research and development of new systems

  
  
• c)
  

  Clinicians being completely satisfied with present systems and not wanting new approaches developed.

  
  
• d)
  

  Large randomized trials required to demonstrate the effectiveness of new surveillance systems

  
  
• e)
  

  Medico-legal liability implications of novel technology

The following is/are true regarding contemporary classification of CTG patterns?

• a)
  

  They reliably predict fetal acidosis at the time of delivery

  
  
• b)
  

  They reliably predict subsequent neurological injury

  
  
• c)
  

  They reliably prevent intrapartum neurological injury

  
  
• d)
  

  They are most efficacious as the majority of babies with neurological injury are born severely acidotic

  
  
• e)
  

  They reliably prevent intrapartum fetal death

The following statement(s) is/are true about uterine contractions:

• a)
  

  Uterine contractions decrease oxygen availability to the fetus

  
  
• b)
  

  Uterine contractions increase the intracranial pressure in the fetus

  
  
• c)
  

  Excessive contractions are determined by an abnormal response of the fetal heart rate pattern.

  
  
• d)
  

  Excessive contractions are further determined by the amount of rest time between consecutive contractions

  
  
• e)
  

  Pushing increases the fetal intracranial pressure above that of the contraction

The following features in a CTG can be interpreted as follows:

• a)
  

  A normal stable baseline FHT of 110–160 bpm with periods of accelerations with fetal movement indicate that the fetus is neurologically responsive.

  
  
• b)
  

  A normal stable baseline FHT of 110–160 bpm with periods of accelerations with fetal movement indicate that the fetus shows no evidence of diminished oxygen availability

  
  
• c)
  

  A fetus who exhibits a baseline FHT of 170 bpm with absent decelerations suggests the presence of hypoxia

  
  
• d)
  

  A fetus with a normal baseline FHT with moderate and frequent variable decelerations that return promptly to the previous baseline rate requires no intervention or further evaluation.

  
  
• e)
  

  A fetus with a previously normal baseline FHT and moderate variability and variable decelerations that return promptly to the previous baseline rate suddenly reveals a stable baseline tachycardia to 170 with absent variability and diminished amplitude of decelerations requires no intervention or further evaluation.

The conduct of maternal pushing:

• a)
  

  Should never begin prior to full dilatation

  
  
• b)
  

  Should permit adequate time between pushes

  
  
• c)
  

  Need not be discontinued with the presence of early or variable decelerations

  
  
• d)
  

  Resumption of pushing should await recovery of a deceleration to the previously normal baseline rate and variability

  
  
• e)
  

  Is designed to get the baby delivered as quickly as possible

The following criteria is/are necessary to implicate hypoxia/acidosis as a possible cause of CP:

• a)
  

  Metabolic acidosis documented in the umbilical vein by a lactate value ≥ 10 mmol/l

  
  
• b)
  

  Early onset hypoxic-ischemic encephalopathy grade 1

  
  
• c)
  

  Focal unilateral arterial infarction on brain MRI

  
  
• d)
  

  Spastic quadriplegic or dyskinetic types of cerebral palsy

  
  
• e)
  

  Exclusion of a coagulation disorder in the newborn

Regarding neuroimaging in HIE and CP, the following statement(s) is/are true:

• a)
  

  Basal ganglia injury generally affects term infants and is associated with the most favourable outcomes.

  
  
• b)
  

  Multi-cystic encephalopathy is frequently related to peri-partum hypoxia/acidosis and is followed by severe neurological impairment.

  
  
• c)
  

  Spastic quadriplegic CP occurs in children born with low birthweight and is associated with para-sagittal brain injury to the periventricular and subcortical white matter.

  
  
• d)
  

  The ‘watershed’ pattern of brain injury correlates with later intellectual performance and usually with absent motor impairment.

  
  
• e)
  

  MRI undertaken between 7 days and 21 days of life appears to be more accurate in defining the timing of hypoxic injury.

Regarding computer systems for analysis of fetal monitoring signals, the following is/are true?

• a)
  

  The development of computer analysis of fetal heart rate (FHR) and uterine contraction signals began in the mid-1990s

  
  
• b)
  

  The development of computer analysis of fetal heart rate (FHR) signals began in an attempt to overcome the subjectivity of visual analysis

  
  
• c)
  

  The first system was suitable for the analysis of intra-partum cardiotocography

  
  
• d)
  

  Antenatal computer analysis poses lesser challenges for algorithms than for intra-partum analysis

  
  
• e)
  

  The development of computer analysis of fetal heart rate (FHR) signals began in an attempt to make health professionals deliver babies more promptly in the presence of CTG changes

Which of the following constitute reasons for the development of computer systems for analysis of fetal monitoring signals?

• a)
  

  Visual analysis of these signals has been shown to have a limited reproducibility

  
  
• b)
  

  Paper records tend to fade away with time

  
  
• c)
  

  Knowledge of an adverse neonatal outcome influences the way CTGs are retrospectively interpreted

  
  
• d)
  

  Healthcare professionals may not always be looking at CTG tracings

  
  
• e)
  

  Frequently there is uncertainty as to the cause of fetal hypoxia/acidosis

Which of the following statements regarding the available computer systems for analysis of intrapartum fetal monitoring signals is/are true?

• a)
  

  IntelliSpace Perinatal ^® system (Philips Healthcare ^® , Eindhoven, Netherlands) uses algorithms for detection of basic cardiotocographic characteristics that are based on the National Institute of Child Health and Human Development guidelines.

  
  
• b)
  

  The Omniview-SisPorto ^® system (Speculum ^® , Lisbon, Portugal) is the only one to have incorporated combined alerts, with analysis of cardiotocographic and fetal electrocardiography-derived ST events.

  
  
• c)
  

  The PeriCALM™ system (LMS Medical systems, Montreal, Canada and PeriGen, Princeton, USA) is the only one to incorporate mathematical algorithms and trained neural networks to evaluate cardiotocographic characteristics.

  
  
• d)
  

  The INFANT ^® system (K2 Medical Systems™, Plymouth, United Kingdom) incorporates colour-coded visual alerts that will elicit a sound alert if not quickly acknowledged.

  
  
• e)
  

  The Trium CTG Online ^® system (GE Healthcare ^® , Little Chalfont, United Kingdom and Trium Analysis Online GmbH, Munich, Germany) uses algorithms for detection of basic cardiotocographic characteristics that are based on the National Institute of Child Health and Human Development guidelines.

Which of the following statements regarding the available scientific evidence on the use of computer systems for analysis of intrapartum fetal monitoring signals is/are true?

• a)
  

  Comparison of these systems with experts has shown that a similar analysis of basic fetal heart rate features is obtained.

  
  
• b)
  

  There is evidence from randomised controlled trials showing that they result in reduced adverse outcomes when compared with conventional CTG.

  
  
• c)
  

  There are several large studies evaluating their capacity to predict fetal hypoxia/acidosis.

  
  
• d)
  

  Uncertainty remains as to which measures should be used to define adverse neonatal outcome.

  
  
• e)
  

  There are no studies comparing the different computer systems.