UGANDA HEALTH PROFESSIONS ASSESSMENT BOARD
Certificate in Midwifery - Year 2: Semester 2
Midwifery II and Tropical Medicine (Paper Code: CM 221)
SECTION A: OBJECTIVE QUESTIONS
20 Marks
1. The engaging diameter in face presentation is
Explanation: In a fully extended face presentation, the head engages with the submentobregmatic diameter, which measures approximately 9.5 cm, allowing it to pass through a normal pelvis.
2. Which of the following diameters is felt vaginally by the midwife as she examines a labouring woman with occipital position?
Explanation: In standard occipito-anterior positions (like LOA or ROA), the sagittal suture lies in the oblique diameter of the maternal pelvis during engagement and early labour.
3. Which of the following strategies is used in the delivery of impacted shoulders?
Explanation: Shoulder dystocia (impacted shoulders) is managed primarily using the McRoberts manoeuvre, which involves hyperflexing the mother's legs to her abdomen to flatten the sacrum and widen the pelvic outlet. The others are maneuvers for breech delivery.
4. In which of the following presentations does the midwife expect hyper-extension?
Explanation: A face presentation is defined by the complete hyper-extension of the fetal head, causing the occiput to touch the fetal back, making the face the presenting part.
5. While nursing a client with eclampsia the midwife specifically watches out for signs of
Explanation: Pulmonary oedema is a critical, life-threatening complication in eclampsia caused by fluid overload (during MgSO4 administration), endothelial leakage, and cardiac strain. Careful respiratory monitoring is mandatory. *(Note: Abruptio placentae is also a severe risk, but pulmonary fluid monitoring is a continuous specific nursing focus).*
6. Blindness that arises from an eclamptic fit lasts at least........................days.
Explanation: Cortical blindness is a rare but terrifying complication of severe pre-eclampsia/eclampsia due to occipital lobe ischemia/edema. It is usually transient, resolving within 4 to 8 days.
7. Midwives refrain from performing digital vaginal examination in clients suspected of placenta previa for fear of
Explanation: A digital vaginal examination can disturb the abnormally implanted placenta covering the cervical os, triggering a sudden, massive, and potentially fatal maternal hemorrhage.
8. For which of the following reasons does a midwife administer dexamethasone to a pregnant woman with preterm labour?
Explanation: Antenatal corticosteroids (like dexamethasone) are administered between 24 and 34 weeks of gestation to accelerate the production of surfactant, promoting fetal lung maturity and reducing Respiratory Distress Syndrome (RDS).
9. In which of the following twin type is hydramnios more common?
Explanation: Polyhydramnios is much more common in monozygotic (identical) twins, particularly monochorionic twins, because they share a placenta, placing them at high risk for Twin-to-Twin Transfusion Syndrome (TTTS).
10. Which of the following presentations commonly leads to interlocked twins?
Explanation: Locked twins typically occur when Twin 1 is breech and Twin 2 is cephalic. As Twin 1's body delivers, its chin hooks over the chin of the descending cephalic head of Twin 2, halting delivery.
11. Which of the following pregnancy abnormalities is associated with fetal renal agenesis?
Explanation: In the second and third trimesters, amniotic fluid is primarily composed of fetal urine. Fetal renal agenesis (Potter's syndrome) means no urine is produced, leading to severe oligohydramnios.
12. Which of the following plasmodium types causes asymptomatic malaria?
Explanation: While acquired immunity can make falciparum asymptomatic, Plasmodium malariae is medically famous for its ability to persist in the human blood in a chronic, asymptomatic state for years or even decades without causing acute illness.
13. Which of the following outcomes is least expected in a pregnant woman suffering from Measles?
Explanation: Unlike Rubella (German Measles), which is highly teratogenic, classic Measles (Rubeola) does not directly cause congenital malformations or birth defects, though it increases risks of systemic obstetric complications like preterm labour and fetal loss.
14. Patients suffering from severe malaria present with jaundice as a result of
Explanation: Severe malaria causes massive intra-vascular destruction (haemolysis) of infected red blood cells. The breakdown of vast amounts of hemoglobin overwhelms the liver, resulting in pre-hepatic jaundice.
15. Which of the following infestations leads to epilepsy?
Explanation: Taenia solium (pork tapeworm) infection can lead to neurocysticercosis when the larvae migrate and form cysts in the brain, making it a leading infectious cause of acquired epilepsy in developing countries.
16. How many doses of intermittent presumptive treatment should a pregnant woman in Uganda recieve?
Explanation: Under current WHO and Uganda MoH guidelines, pregnant women should receive at least 3 doses of Intermittent Preventive Treatment (IPTp-SP) during ANC visits, starting in the second trimester.
17. Which of the following infestations causes intestinal perforation?
Explanation: A massive infestation of roundworms (Ascaris lumbricoides) can tangle into a bolus, causing mechanical bowel obstruction, and their migratory pressure can lead to intestinal ischemia and ulceration/perforation.
18. In which of the following fluids is schistosoma haematobium detected?
Explanation: Schistosoma haematobium targets the venous plexus of the urinary bladder. Its characteristic terminally spined eggs penetrate the bladder wall and are excreted in the urine, causing hematuria.
19. Trypanasomes are able to evade the host immune system because they
Explanation: African trypanosomes survive in the bloodstream by a mechanism called "antigenic variation," where they continuously shed and replace their Variant Surface Glycoproteins (VSG), rendering the host's antibodies ineffective.
20. Which of the following is a recognised feature of onchocerciasis?
Explanation: Onchocerciasis is also known as "River Blindness." The migration of microfilariae into the eye causes severe inflammation, leading to punctate and sclerosing keratitis, and eventually blindness.
SECTION A: FILL IN THE BLANK SPACES
10 Marks
21. The term used to refer to liquor amni less than 100 mls is...
SEVERE OLIGOHYDRAMNIOS
SEVERE OLIGOHYDRAMNIOS
22. Bloody diarrhoea is a characteristic feature of...
DYSENTERY
DYSENTERY
23. What transits severe pre-eclampsia into eclampsia is presence of...
CONVULSIONS (OR SEIZURES)
CONVULSIONS (OR SEIZURES)
24. Eclampsia occurring suddenly with no warning signs is referred to as...
FULMINATING ECLAMPSIA
FULMINATING ECLAMPSIA
25. Failure of the cervix to dilate despite good uterine contractions is referred to as...
CERVICAL DYSTOCIA
CERVICAL DYSTOCIA
26. Assisted delivery performed by creating a suction in poorly progressing labour is referred to as...
VACUUM EXTRACTION (VENTOUSE)
VACUUM EXTRACTION (VENTOUSE)
27. The treatment of choice for all types of tapeworms is called...
PRAZIQUANTEL
PRAZIQUANTEL
28. Brucellosis suis is acquired by eating poorly cooked...
PORK (PIG MEAT)
PORK (PIG MEAT)
29. Another name for onchocerciasis is...
RIVER BLINDNESS
RIVER BLINDNESS
30. The organ mainly affected by schistosoma haematobium is called...
URINARY BLADDER
URINARY BLADDER
SECTION B: SHORT ESSAY QUESTIONS
20 Marks
Question 31: Anaemia and Urinary Continence
(10 Marks)
(a) Outline five (5) obstetric causes of anaemia in pregnancy. (5 marks)
- Multiple Pregnancy: The presence of twins or triplets creates a significantly higher fetal demand for iron and folate, rapidly depleting maternal stores.
- Antepartum Haemorrhage: Bleeding episodes from conditions like placenta previa or abruptio placentae directly lead to a massive reduction in red blood cell volume.
- Hyperemesis Gravidarum: Severe, prolonged nausea and vomiting prevent the adequate nutritional intake and absorption of essential hematinics like iron and folic acid.
- Frequent, Closely Spaced Pregnancies: Short inter-pregnancy intervals do not allow the mother's body enough time to replenish bone marrow iron stores between births.
- Previous Obstetric Haemorrhage: Entering a new pregnancy without having fully recovered from a severe postpartum haemorrhage in the previous delivery.
(b) Outline five (5) measures midwives teach post partum women to improve urinary continence. (5 marks)
- Pelvic Floor (Kegel) Exercises: Teaching the mother to systematically contract and relax the pubococcygeus muscles daily to rebuild tone and sphincter control.
- Bladder Retraining: Instructing the woman to practice timed voiding (emptying the bladder at regular intervals) to gradually increase bladder capacity and prevent urge incontinence.
- Avoiding Heavy Lifting: Warning the mother against lifting heavy objects or performing strenuous exercises during the puerperium to prevent sudden downward pressure on the weakened pelvic floor.
- Dietary Management to Prevent Constipation: Encouraging a high-fibre diet and adequate fluid intake so the woman avoids straining during bowel movements, which weakens pelvic muscles.
- Weight Management: Educating the woman on gradual, healthy postpartum weight loss, as excess abdominal weight exerts continuous pressure on the bladder and pelvic floor.
Question 32: Brucellosis and Ascariasis
(10 Marks)
(a) Outline five (5) clinical features of brucellosis. (5 marks)
- Undulant Fever: A characteristic fever pattern that rises and falls in waves, typically spiking in the late afternoon and evening.
- Profuse Sweating: Severe, drenching night sweats that often have a distinct, strong, moldy odor.
- Musculoskeletal Pain: Severe arthralgia (joint pain) and myalgia (muscle pain), particularly affecting the lower back and large joints.
- Profound Fatigue: Overwhelming weakness and lethargy that can persist for weeks or months, severely impacting daily activities.
- Hepatosplenomegaly: Clinical enlargement of both the liver and the spleen resulting from the reticuloendothelial system's response to the bacteria.
(b) Outline five (5) preventive measures of ascariasis. (5 marks)
- Proper Hand Hygiene: Strict handwashing with soap and water before handling food, before eating, and immediately after using the latrine.
- Safe Excreta Disposal: Ensuring the construction and consistent use of deep pit latrines or flush toilets to completely eliminate open defecation in communities.
- Food Safety Practices: Thoroughly washing raw vegetables and fruits with clean water, or peeling and properly cooking them to destroy any adhering infective eggs.
- Drinking Safe Water: Ensuring all drinking water is sourced from protected boreholes, filtered, or boiled to eliminate waterborne contamination.
- Mass Drug Administration: Participating in routine community or school-based deworming programs (e.g., using Albendazole) in highly endemic areas to break the transmission cycle.
SECTION C: LONG ESSAY QUESTIONS
50 Marks
Question 33: Prolonged Pregnancy & Induction of Labour (25 Marks)
(a) Explain five (5) predisposing factors to prolonged pregnancy. (10 marks)
- Primigravidity: Women experiencing their first pregnancy are statistically at a higher risk of carrying beyond 41 or 42 weeks compared to multiparous women.
- Previous Post-term Pregnancy: A strong clinical history of prolonged pregnancies in previous gestations significantly increases the likelihood of recurrence in subsequent pregnancies.
- Fetal Anomalies (e.g., Anencephaly): The absence of a functioning fetal pituitary-adrenal axis means the fetus cannot produce the cortisol required to trigger the hormonal cascade that initiates spontaneous labour.
- Maternal Obesity: Elevated maternal Body Mass Index (BMI) alters hormonal profiles, specifically estrogen/progesterone ratios, which can delay the natural onset of uterine contractions.
- Placental Sulfatase Deficiency: A rare genetic condition where the placenta fails to convert DHEAS to estriol, a hormone crucially needed to ripen the cervix and stimulate labour.
(b) Outline ten (10) effects of prolonged pregnancy to the woman and her baby. (10 marks)
- Fetal Macrosomia: The baby continues to grow, often exceeding 4kg, significantly increasing the risk of shoulder dystocia during vaginal delivery.
- Maternal Perineal Trauma: Delivering a macrosomic baby increases the likelihood of severe (third or fourth-degree) perineal tears and vaginal lacerations.
- Increased Operative Deliveries: The mother is at a much higher risk of requiring instrumental assistance (vacuum/forceps) or an emergency Caesarean section due to cephalopelvic disproportion.
- Postpartum Haemorrhage (PPH): Over-distension of the uterus from a large baby leads to uterine atony, a major cause of dangerous bleeding after birth.
- Maternal Anxiety: The psychological toll of passing the due date causes significant emotional distress, exhaustion, and frustration for the mother.
- Oligohydramnios: As the placenta ages, amniotic fluid volume drops precipitously, increasing the risk of dangerous umbilical cord compression during labour.
- Fetal Distress/Hypoxia: Placental insufficiency (aging placenta) means the fetus receives inadequate oxygen and nutrients, leading to late decelerations during contractions.
- Meconium Aspiration Syndrome (MAS): Hypoxic stress causes the fetus to pass meconium into the diminishing amniotic fluid, which can be inhaled into the lungs causing severe neonatal respiratory distress.
- Post-maturity Syndrome: The neonate may be born with a distinct appearance: long nails, dry/peeling/parchment-like skin, and loss of subcutaneous fat due to starvation in utero.
- Increased Perinatal Mortality: The culmination of hypoxia, macrosomia, and meconium aspiration leads to a statistically higher risk of stillbirths and early neonatal death.
(c) List five (5) indications for induction of labour. (5 marks)
- Prolonged / Post-term Pregnancy: Gestation exceeding 41 or 42 weeks to prevent post-maturity complications.
- Hypertensive Disorders: Severe pre-eclampsia or eclampsia where the only definitive cure is the delivery of the placenta.
- Premature Rupture of Membranes (PROM): Rupture of membranes at term without the spontaneous onset of contractions, to prevent chorioamnionitis.
- Maternal Medical Conditions: Uncontrolled diabetes mellitus, severe renal disease, or cardiac conditions threatening maternal life.
- Intrauterine Fetal Death (IUFD): Induction is required to deliver the demised fetus and prevent maternal coagulopathy (DIC) and severe psychological trauma.
Question 34: Severe Malaria in Pregnancy (25 Marks)
(a) List ten (10) clinical features of severe malaria. (10 marks)
- Cerebral Malaria: Unrousable coma, severe confusion, or profound alteration of mental status.
- Severe Anaemia: Extreme pallor, fatigue, and a hemoglobin count dropping below 5 g/dL due to massive red blood cell destruction.
- Respiratory Distress: Acidotic breathing (deep, rapid Kussmaul respirations) indicating metabolic acidosis.
- Pulmonary Oedema: Fluid accumulation in the lungs causing severe dyspnea, hypoxia, and crackles on auscultation.
- Hypoglycaemia: Dangerously low blood sugar (below 2.2 mmol/L), often exacerbated by quinine therapy.
- Acute Kidney Injury: Oliguria or anuria resulting from renal ischemia and tubular necrosis.
- Spontaneous Bleeding: Coagulopathy or Disseminated Intravascular Coagulation (DIC) causing bleeding from gums, venepuncture sites, or the birth canal.
- Generalized Convulsions: Experiencing more than two seizures within a 24-hour period.
- Jaundice: Yellowing of the sclera and skin indicating severe hemolysis or hepatic dysfunction.
- Macroscopic Haemoglobinuria: Passing dark, "Coca-Cola" colored urine (Blackwater fever) due to extreme intravascular hemolysis.
(b) Outline ten (10) specific actions the midwife performs for a woman at 28 weeks of gestation admitted with severe malaria for the first 24 hours. (10 marks)
- Immediate Admission and Positioning: Admit the mother to a High Dependency Unit (HDU), place her in a left lateral position to prevent supine hypotension, and ensure strict bed rest.
- Establish Intravenous Access: Immediately secure a wide-bore IV cannula (18G or 16G) to facilitate the rapid administration of emergency fluids and parenteral medications.
- Administer Parenteral Antimalarials: Promptly initiate the prescribed IV Artesunate (the drug of choice) or IV Quinine infusion strictly according to maternal weight and protocols.
- Fetal Heart Rate Monitoring: Frequently assess the fetal heart rate using a Doppler or Pinard stethoscope to detect signs of fetal hypoxia or distress.
- Temperature Control: Administer prescribed antipyretics (e.g., Paracetamol) and apply mechanical cooling methods like tepid sponging to reduce fever and prevent fetal tachycardia.
- Blood Glucose Monitoring: Perform 2-4 hourly random blood sugar (RBS) checks to detect and promptly treat hypoglycemia, providing 50% Dextrose IV if levels drop dangerously low.
- Fluid Balance Management: Insert a Foley catheter to meticulously monitor input and output, ensuring the kidneys are functioning while avoiding fatal pulmonary edema from fluid overload.
- Respiratory Support: Maintain a clear airway, assess respiratory rate and oxygen saturation (SpO2), and administer supplemental oxygen via nasal prongs or mask if hypoxia is detected.
- Laboratory Investigations: Draw emergency blood samples for Malaria Parasite (mRDT/smear), Full Blood Count (to check for severe anaemia), and renal/liver function tests.
- Seizure Precautions: Pad the bed rails, keep suction apparatus ready, and prepare anticonvulsant drugs (like Diazepam or MgSO4) in case the condition deteriorates into cerebral malaria with fits.
(c) Outline five (5) complications of malaria in pregnancy. (5 marks)
- Maternal Severe Anaemia: The most common complication, leading to maternal exhaustion, heart failure, and increased risk of fatal postpartum haemorrhage.
- Spontaneous Abortion / Miscarriage: High fever and placental parasitemia in the first or second trimester can lead to the loss of the pregnancy.
- Preterm Labour: The systemic inflammatory response to the malaria parasite can trigger early uterine contractions and premature rupture of membranes.
- Intrauterine Growth Restriction (IUGR): Parasites sequestering in the placenta disrupt nutrient and oxygen exchange, resulting in a Low Birth Weight (LBW) infant.
- Intrauterine Fetal Death (IUFD): Severe maternal hypoxia, extremely high fever, or overwhelming placental infarction can result in fetal demise/stillbirth.
References & Verification Data
- WHO Malaria in Pregnancy Guidelines: Validation of IPTp-SP standard (minimum 3 doses during ANC), definitions of Severe Malaria, and rationale for hypoglycemia management.
- Myles Textbook for Midwives: Principles of prolonged pregnancy complications, mechanisms of shoulder dystocia (McRoberts), and engagement diameters (Sub-mentobregmatic for Face Presentation).
- Tropical Medicine Textbooks: Validation of Taenia solium link to epilepsy (neurocysticercosis), Plasmodium malariae chronicity, and Schistosoma haematobium urinary involvement.