UGANDA HEALTH PROFESSIONS ASSESSMENT BOARD
Certificate in Midwifery (Year 2: Semester 2)
Obstetric Pharmacology and Paediatric Nursing II (CM 222)
SECTION A: OBJECTIVE QUESTIONS
20 Marks
1. Formation of a caput succedaneum arises from
Caput succedaneum is diffuse edema of the fetal scalp caused by the prolonged pressure of the fetal head against the dilating cervix during a difficult or prolonged labour.
2. Midwives maintain vaccines at a normal range of
To ensure potency, the standard global cold chain requirement for storing and transporting most vaccines is strictly between +2°C and +8°C.
3. Failure of the vertebral column to fuse in new born babies results in
Spina bifida is the specific congenital neural tube defect characterized by the failure of the vertebral arches to fuse properly over the spinal cord.
4. Which of the following anthropometric measurements do midwives commonly use to assess the nutritional status of children aged 6 months?
Mid-Upper Arm Circumference (MUAC) is specifically introduced at exactly 6 months of age as a rapid, reliable community screening tool for severe acute malnutrition (SAM).
5. Midwives administer Rota vaccine to protect children against
The Rotavirus vaccine provides crucial protection against rotavirus infection, which is the leading global cause of severe, dehydrating diarrhoea in young infants.
6. Which of the following conditions does the midwife suspect in an infant less than 28 days of age presenting with projectile vomiting?
Hypertrophic pyloric stenosis classically presents within the first few weeks of life (often 2-6 weeks) with forceful, non-bilious, projectile vomiting immediately after feeding.
7. Which of the following reconstituted vaccines does the midwife discard after an immunisation session?
BCG and Measles are live-attenuated, freeze-dried vaccines. Once reconstituted with a diluent, they lose stability rapidly and must be discarded after 6 hours to prevent toxic shock syndrome.
8. A rare birth defect characterised by the tissue covering the brain and a portion of the brain protruding through openings in the skull is
An encephalocele is a type of neural tube defect where a sac-like protrusion of the brain and its meninges herniates through a defect in the cranium (skull).
9. Which of the following birth injuries is associated with damage to the nerves?
Erb's palsy is a peripheral nerve injury involving the brachial plexus (C5-C6 roots), commonly resulting from shoulder dystocia or lateral traction on the fetal neck during delivery.
10. Which of the following is NOT a cyanotic heart defect?
Pulmonary valve stenosis is typically an isolated *acyanotic* defect (unless severe enough to force an atrial right-to-left shunt). The others are classic cyanotic defects causing deoxygenated blood to bypass the lungs.
11. The first dose of DPT Hep Hib is administered to babies at the age of ..... weeks.
According to the UNEPI (Uganda National Expanded Program on Immunization) schedule, the pentavalent vaccine (DPT-HepB-Hib) series begins exactly at 6 weeks of age.
12. Which of the following calcium blockers mainly exerts its effects on blood vessels?
Nifedipine is a dihydropyridine calcium channel blocker that acts primarily on vascular smooth muscle to cause vasodilation, unlike Verapamil which acts primarily on the heart.
13. Which of the following drugs is dispensed to supplement iron levels during pregnancy?
Ferrous sulphate is the standard, widely distributed oral iron supplement used in antenatal care to prevent and treat maternal anemia.
14. The antidote administered for a woman presenting with magnesium sulphate toxicity is
Calcium gluconate directly antagonizes the depressant effects of magnesium at the neuromuscular junction and must always be kept at the bedside during MgSO4 administration.
15. Which of the following is a pentavalent vaccine?
The term "pentavalent" means "five-in-one". It combines protection against Diphtheria, Pertussis, Tetanus (DPT), Hepatitis B, and Haemophilus influenzae type b (Hib).
16. Nifedipine administration is recommended treatment option for the management of
In obstetrics, Nifedipine is frequently used off-label as a *tocolytic* agent. It relaxes uterine smooth muscle, helping to delay or halt premature contractions.
17. In which of the following drug categories is hydralazine?
Hydralazine is classified under FDA Pregnancy Category C, indicating that animal studies have shown adverse fetal effects, but potential benefits may warrant use in severe pre-eclampsia/hypertension.
18. The drug administered to counteract maternal hypotension secondary to spinal anaesthesia is
Ephedrine (a vasopressor) is the drug of choice for spinal-induced hypotension during cesarean sections because it effectively raises maternal blood pressure without compromising uterine blood flow.
19. Which of the following drugs does the midwife administer to a new-born to prevent ophthalmia neonatorum?
Applying 1% Tetracycline eye ointment within the first hour of birth is the standard routine prophylaxis against gonococcal and chlamydial ophthalmia neonatorum.
20. Folic acid is a type of vitamin
Folic acid is a water-soluble B-complex vitamin, specifically designated as Vitamin B9, vital for fetal neural tube development.
SECTION A: FILL IN THE BLANK SPACES
10 Marks
21. Under development of the right or left ventricle in the heart is known as...
→ HYPOPLASTIC HEART SYNDROME
→ HYPOPLASTIC HEART SYNDROME
22. The congenital abnormality where the urethral meatus opens superior of the penis is called...
→ EPISPADIAS
→ EPISPADIAS
23. A condition in which a female newborn menstruates is called...
→ PSEUDOMENSTRUATION
→ PSEUDOMENSTRUATION
24. A monosomal condition where only one sex chromosome exists is referred to as...
→ TURNER SYNDROME (45, X0)
→ TURNER SYNDROME (45, X0)
25. The midwife classifies a child with lethargy, very sunken eyes and skin going back slowly as having...
→ SEVERE DEHYDRATION
→ SEVERE DEHYDRATION
26. Magnesium sulphate depresses the...
→ CENTRAL NERVOUS SYSTEM (CNS)
→ CENTRAL NERVOUS SYSTEM (CNS)
27. One tablet of Fansidar weighs...
→ 525 MG (500mg Sulfadoxine + 25mg Pyrimethamine)
→ 525 MG (500mg Sulfadoxine + 25mg Pyrimethamine)
28. During pregnancy, continuous administration of magnesium sulphate beyond 7 days can lead to decrease in levels of foetal...
→ CALCIUM (Leading to Osteopenia)
→ CALCIUM (Leading to Osteopenia)
29. The layer of the uterus that is stimulated by injection oxytocin is called...
→ MYOMETRIUM
→ MYOMETRIUM
30. Absorption of folic acid occurs in the...
→ JEJUNUM (Proximal Small Intestine)
→ JEJUNUM (Proximal Small Intestine)
SECTION B: SHORT ESSAY QUESTIONS
20 Marks
Question 31: Cerebral Haemorrhage & Birth Injuries
(10 Marks)
(a) Outline five (5) predisposing factors to cerebral haemorrhage:
- Extreme Prematurity: Fragile periventricular germinal matrix blood vessels are highly prone to spontaneous rupture in preterm infants.
- Birth Asphyxia (Hypoxia): Severe oxygen deprivation alters cerebral blood flow, causing sudden vascular engorgement and subsequent bleeding.
- Instrumental Delivery: Traumatic extraction forces applied by obstetric forceps or vacuum extractors can damage intracranial vessels.
- Precipitous Labour: A very rapid, sudden delivery causes abrupt changes in intracranial pressure, tearing delicate cerebral veins.
- Maternal Coagulopathies: Bleeding disorders or Vitamin K deficiency in the mother transferring a bleeding tendency to the fetus.
(b) Outline five (5) causes of birth injuries:
- Fetal Macrosomia: An exceptionally large baby (often >4,000g) struggles to pass through the pelvis, leading to mechanical trauma.
- Cephalopelvic Disproportion (CPD): A mismatch where the maternal pelvis is too small or abnormally shaped to accommodate the fetal head.
- Abnormal Presentations: Breech, face, or transverse presentations lack the smooth, dilating wedge effect of a vertex presentation, increasing traumatic risks.
- Shoulder Dystocia: The fetal head delivers, but the anterior shoulder becomes impacted behind the maternal symphysis pubis, causing nerve and bone injuries during extraction.
- Prolonged or Difficult Labour: Extended hours of intense uterine contractions compressing the fetus against pelvic bones.
Question 32: Magnesium Sulphate Administration
(10 Marks)
(a) Outline five (5) side effects of magnesium sulphate:
- Vasodilation Symptoms: Intense feelings of warmth, facial flushing, and sweating during the initial bolus loading dose.
- Respiratory Depression: A dangerous slowing of the respiratory rate as toxic levels depress the medullary respiratory center.
- Neuromuscular Blockade: Profound lethargy, muscle weakness, and the total loss of deep tendon reflexes (patellar reflex).
- Cardiovascular Effects: Maternal hypotension and bradycardia resulting from smooth muscle relaxation.
- Renal Impact: Oliguria (reduced urine output) which dangerously impairs the body's ability to excrete the drug, worsening toxicity.
(b) Outline five (5) precautions a midwife takes before administering Magnesium sulphate:
- Check Respiratory Rate: Confirm the mother's respiratory rate is strictly at least 16 breaths per minute before every dose.
- Assess Deep Tendon Reflexes: Verify the presence of the knee-jerk (patellar) reflex, as its absence is the first clinical sign of toxicity.
- Measure Urine Output: Ensure strict urinary output is greater than 30 ml per hour, usually maintained via an indwelling Foley catheter.
- Keep Antidote Ready: Ensure a prepared syringe of 10% Calcium Gluconate is physically present at the bedside for immediate reversal if toxicity occurs.
- Baseline Vital Monitoring: Accurately record maternal blood pressure and assess continuous fetal heart rate monitoring for distress prior to infusion.
SECTION C: LONG ESSAY QUESTIONS
50 Marks
Question 33: Immunisation & Cold Chain (25 Marks)
(a) Describe the Uganda National immunisation schedule, following the UNEPI program (15 marks):
The Uganda National Expanded Program on Immunization (UNEPI) follows a strict schedule to ensure early childhood protection against preventable diseases:
- At Birth: BCG (Bacillus Calmette-Guérin) given as 0.05ml intradermally on the right upper arm to protect against severe forms of Tuberculosis. OPV 0 (Oral Polio Vaccine) given as 2 drops orally.
- At 6 Weeks: OPV 1 (2 drops orally). DPT-HepB-Hib 1 (Pentavalent) given 0.5ml intramuscularly (IM) on the left anterolateral thigh. PCV 1 (Pneumococcal Conjugate Vaccine) given 0.5ml IM on the right thigh. Rota 1 (Rotavirus vaccine) given orally.
- At 10 Weeks: OPV 2, DPT-HepB-Hib 2, PCV 2, and Rota 2 are administered using the identical routes and sites as the 6-week schedule.
- At 14 Weeks: OPV 3, DPT-HepB-Hib 3, and PCV 3. Additionally, IPV (Inactivated Polio Vaccine) is introduced, given 0.5ml IM on the right upper thigh.
- At 9 Months: MR (Measles-Rubella vaccine) is given 0.5ml subcutaneously on the left upper arm.
- At 10 Years (Girls only): HPV (Human Papillomavirus) vaccine is given IM in the upper arm, followed by a second dose 6 months later to prevent cervical cancer.
| Age / Timing | Vaccines Given |
|---|---|
| At Birth | Oral Polio Vaccine 0, BCG, Hepatitis B |
| At 6 Weeks (1.5 months) | Oral Polio Vaccine 1, Injectable polio vaccine (IPV1), DPT-Hep B-Hib 1, Pneumococcal Conjugate vaccine 10 (PCV1), Rotavirus vaccine 1 |
| At 10 Weeks (2.5 months) | Oral Polio Vaccine 2, DPT-Hep B-Hib 2, Pneumococcal Conjugate vaccine 10 (PCV2), Rotavirus vaccine 2 |
| At 14 Weeks (3.5 months) | Oral Polio Vaccine 3, Injectable polio vaccine (IPV2), DPT-Hep B-Hib 3, Pneumococcal Conjugate vaccine 10 (PCV3), Rotavirus vaccine 3 |
| At 6 months | Malaria Vaccine 1 |
| At 7 months | Malaria vaccine 2 |
| At 8 months | Malaria Vaccine 3 |
| At 9 Months | Measles - Rubella vaccine 1, Yellow Fever vaccine |
| At 18 Months | Measles - Rubella vaccine 2, Malaria Vaccine 4 |
| 10 Year old girls | Human Papilloma Virus Vaccine (Single dose) |
| Women of child bearing age (15 to 49 years) | Tetanus Diphtheria (Td1) Vaccine |
| 1 Month after 1st dose | Tetanus Diphtheria (Td2) Vaccine |
| 6 Months after 2nd dose | Tetanus Diphtheria (Td3) Vaccine |
| 12 Months (1 year) after 3rd dose | Tetanus Diphtheria (Td4) Vaccine |
| 12 Months (1 year) after 4th dose | Tetanus Diphtheria (Td5) Vaccine |
(b) Describe five (5) equipment used to maintain the cold chain system (10 marks):
- Vaccine Refrigerators: Specialized, purpose-built medical refrigerators (powered by electricity, solar panels, or gas) designed to keep a strictly controlled internal temperature of +2°C to +8°C.
- Cold Boxes: Large, heavily insulated containers lined with ice packs, used to safely transport bulk vaccines over long distances or to store them temporarily during prolonged power failures.
- Vaccine Carriers: Smaller, portable insulated boxes used by midwives and health workers to carry daily vaccine stocks to outreach stations and remote communities.
- Ice Packs: Flat, water-filled plastic packs frozen solidly beforehand, designed to line the inner walls of cold boxes and carriers to maintain the required low temperatures during transport.
- Temperature Monitors/Thermometers: Essential tracking tools, including dial thermometers, digital min-max thermometers, or continuous data loggers, placed directly beside vaccines to verify they have not been exposed to freezing or excessive heat.
Question 34: Oxytocin Administration (25 Marks)
(a) State the legal class, medical class and pregnancy category of oxytocin (3 marks):
- Legal Class: Prescription Only Medicine (POM).
- Medical/Pharmacological Class: Uterotonic agent / Oxytocic hormone.
- Pregnancy Category: Often designated as Category C or X (It is explicitly contraindicated for any elective use in early pregnancy to prevent abortion, but widely indicated for term induction).
(b) Describe the steps the midwife follows while administering oxytocin during induction of labour (13 marks):
A midwife administering oxytocin (Pitocin) for induction of labour follows a strict, safety-focused protocol to initiate uterine contractions, typically targeting 3–4 contractions lasting 40–60 seconds over a 10-minute window. As oxytocin is considered a high-alert medication, these steps emphasize close monitoring, precise titration, and quick action to manage potential uterine overstimulation or fetal distress.
- Pre-Administration Preparation and Assessment:
- Initial Assessment: Perform a vaginal exam to determine the Bishop score to assess cervical readiness, and ensure the patient understands and has consented to the procedure.
- Documentation: Review medical history for contraindications (e.g., previous classical C-section) and confirm the fetal heart rate (FHR) is reassuring.
- Timing with Prostaglandins: Ensure a safe waiting period if other induction methods were used: typically 6 hours after prostaglandins gel (e.g., Prostin) or 4 hours after misoprostol.
- IV Setup: Initiate intravenous access (usually 18 gauge) and set up the oxytocin with an infusion pump to ensure precise control over the dosage.
- Independent Double Check: High-alert medication protocols require that another qualified professional verifies the medication, dose, and infusion rate.
- Initiation of Oxytocin Infusion:
- Dilution: Commonly, 5–10 IU (International Units) of oxytocin is added to 500 mL or 1 L of normal saline or Ringer’s lactate.
- Starting Dose: The infusion starts at a very low rate, such as 0.5–2 mU/min (milliunits per minute) or roughly 5–10 drops/minute.
- Positioning: Position the patient in a comfortable position, often left lateral, to promote optimal uterine blood flow.
- Monitoring and Titration (Increasing the Dose):
- Continuous Fetal Monitoring: Continuous electronic fetal monitoring (CTG) is required while the infusion is running.
- Regular Assessments: The midwife assesses fetal and maternal status every 15–30 minutes, checking for uterine contractions, FHR patterns, and resting tone.
- Titration Schedule: If contractions are not adequate, the dose is increased gradually, usually every 30 minutes, based on local protocols.
- Manual Palpation: The midwife manually palpates the uterus to verify contraction strength, rather than relying only on the monitor.
- Management During Labor:
- Goal Contraction Pattern: The goal is regular contractions, generally defined as 3–4 strong contractions within a 10-minute window.
- Reduction/Stopping: If uterine hyperactivity occurs (5 or more contractions in 10 minutes) or signs of fetal distress arise, the midwife will stop or reduce the oxytocin infusion immediately.
- Fluid Management: Monitor maternal intake and output to prevent water intoxication, which can occur with prolonged oxytocin use.
- Transition to Second Stage (Pushing):
- Maintenance: Once effective, consistent labor is established, the dose is typically kept constant, or sometimes reduced ("weaned") as the body produces its own natural oxytocin.
- Ongoing Monitoring: Continue to monitor for fetal distress, which can increase as labor intensifies.
- Active Management of Third Stage: After delivery, oxytocin is often continued or given via bolus to prevent postpartum hemorrhage.
(c) Outline nine (9) adverse effects of oxytocin (9 marks):
- Uterine Tachysystole / Hyperstimulation: Causing excessively frequent or prolonged contractions that do not allow the uterus to rest.
- Fetal Distress / Hypoxia: Resulting directly from the hyperstimulation restricting placental blood flow.
- Uterine Rupture: A catastrophic tearing of the uterine muscle due to overly forceful, drug-induced contractions.
- Water Intoxication: Because oxytocin has an anti-diuretic effect similar to vasopressin, high prolonged doses in electrolyte-free fluids can cause severe hyponatremia.
- Maternal Hypotension: Especially noted if the drug is accidentally given as a rapid IV bolus instead of a slow, controlled infusion.
- Tachycardia and Arrhythmias: Increased cardiac workload leading to rapid or irregular maternal heart rates.
- Nausea and Vomiting: Common gastrointestinal upset associated with the hormonal surge.
- Postpartum Haemorrhage: Paradoxically, prolonged oxytocin use can exhaust the uterine muscle (uterine atony), causing severe bleeding after the baby is delivered.
- Pelvic Haematomas: Traumatic, rapid descent of the fetal head through the birth canal can cause bleeding into the maternal pelvic tissues.