1. At the time of perineal distention prior to vaginal delivery, which of the following is correct?

a. Most presentations are occiput posterior.

b. Infrequently the vertex may be occiput anterior.
c. The encirclement of the largest diameter by the vulvar ring is called crowning.
d. All of the above
2. What is true concerning the illustrated perineal episiotomy below?
a. Increased repair time
b. Increased dyspareunia
c. Increased rate of sphincter injury
d. All of the above

3. A 25-year-old G1P1 calls your office on postpartum day 6 complaining of increasing perineal
pain for the last 24 hours. She underwent a successful forceps-assisted vaginal delivery
complicated by a third-degree laceration. Which of the following is part of the differential
diagnosis?
a. Wound infection
b. Urinary retention
c. Uterine involution
d. Excessive ambulation

4. After completion of a fourth-degree perineal laceration repair, you order which of the following
medications?
a. Zosyn
b. Ampicillin
c. Dinoprostone
d. Second-generation cephalosporin

5. Which of the following interventions may reduce maternal perineal laceration during a forceps-
assisted vaginal delivery?
a. Early disarticulation
b. Mediolateral episiotomy
c. Cessation of pushing during disarticulation
d. All of the above

6. A 22-year-old G1P1 presents 6 days after a vaginal delivery. Her course was complicated by
chorioamnionitis and a second-degree perineal laceration. The patient is complaining of pain and
drainage from her vagina. On exam, her laceration repair is open and draining purulent material.
Which of the following would not be a step in your management?
a. Intravenous antibiotics
b. Debridement of necrotic tissue
c. Establishment of adequate analgesia prior to debridement
d. Intravenous antibiotics, debridement of necrotic tissue in the operating room, and then
immediate closure of the laceration
7. You are asked to assess a woman’s perineum after a vaginal delivery. There is an extensive tear
disrupting the superficial muscle and 70 % of the external anal sphincter. There is no disruption
of the internal anal sphincter. How would you classify this perineal trauma?
a. Second degree tear
b. 3a tear
c. 3b tear
d. 3c tear
e. Fourth degree tear

8. Following delivery, a woman is found to have a third degree tear and a trainee wishes to do the
repair under supervision. Which two suture materials have equivalent efficacy when repairing the
external anal sphincter?
a. Polydiaxanone (PDS) and chromic catgut
b. Polydiaxanone (PDS) and nylon (Prolene)
c. Polydiaxanone (PDS) and Polyglactin (Vicryl)
d. Polyglactin (Vicryl and chromic catgut
e. Polyglactin (Vicryl) and nylon (Prolene)

9. An uncomplicated vaginal delivery typically includes which maneuver?

a. Perineal support to decrease perineal trauma
b. An episiotomy to hasten delivery
c. Vacuum extraction if the fetal station is low
d. Forceps to aid maternal efforts
e. The McRoberts maneuver

10. The patient was noted to have a third-degree perineal laceration (affected the external anal
sphincter) that was repaired in normal standard fashion. Which of the following considerations in
the treatment and counseling of these patients are false ?
a. You should provide a rectal examination to ensure that the mucosa is intact
b. She should be on regular stool softeners throughout the postpartum period
c. She should be given narcotic medications for pain control on a PRN basis
d. She should be counseled about her risk of anal sphincter defect and incontinence
e. She should undergo anal endosonography and/or anal manometry in 1 year to evaluate
for sphincter defects