March 2017

  • The obstetric team tell you about a patient who is 2 days post-partum with what they suspect is a post-dural puncture headache (PDPH).
    (a) What is the differential diagnosis of post-partum headache? (8 marks)
    (b) What features, in this patient, would lead you to consider a serious underlying cause? (7 marks)
    (c) You diagnose a PDPH and arrange treatment by epidural blood patch (EBP). What are the described
    risks of EBP? (5 marks)
Pass rate 81.3%
This question had the highest pass rate in the paper and also had the highest correlation with overall performance. PDPH is a common problem in obstetric anaesthesia so it is reassuring that the question was well answered and that candidates recognised possibly serious differential diagnoses.
March 2016

  • a)  What factors may contribute to difficulties encountered when securing the airway under general anaesthesia in the pregnant patient? (9 marks)
  • b)  What measures can be taken to reduce airway related morbidity and mortality associated with general anaesthesia in a pregnant woman? (8 marks)
  • c)  What are the recommendations in the 4th National Audit Project (Major Complications of Airway Management in the UK, NAP 4) regarding airway management in the pregnant woman? (3 marks)
Airway management in the pregnant patient Pass rate 57.6% It is encouraging that the pass rate for the mandatory obstetric question was higher in this sitting of the SAQ than in the last several sittings. Knowledge of difficult airway management in the obstetric patient is fundamental to anaesthetic practice. It is disappointing however that the recommendations from NAP4 regarding the pregnant patient (part c), seemed very poorly known.
September 2015

A 25 year-old woman who is 37 weeks pregnant and known to have pre-eclampsia is admitted to your labour ward with a blood pressure of 160/110mmHg on several readings.
  • a)  What is the definition of pre-eclampsia (1 mark) and which related symptoms should pregnant women
    be told to report immediately? (2 marks)
  • b)  How should this patient be managed following admission to your labour ward? (12 marks)
  • c)  What changes would you make to your usual general anaesthetic technique for a pregnant woman, if
    this woman needed a general anaesthetic for caesarean section? (5 marks)
Pre-eclampsia and severe pre-eclampsia Pass rate 16.1% The poor pass rate for this important subject is of concern as pre-eclampsia is a common condition that all candidates should have encountered. Severe pre- eclampsia is an emergency for which the principles of management should be known. Surprisingly few candidates could give an acceptable definition of pre- eclampsia and even fewer knew that control of systolic hypertension is of prime importance in preventing intracerebral bleeding in women with severe pre-eclampsia. Again, as mentioned above, failure to read the question in part (c) meant that some candidates lost marks by not answering what was asked.
March 2015

You are asked to review a woman in the anaesthetic antenatal clinic. She is 30 weeks pregnant and a Jehovah’s Witness. She requires an elective caesarean section at 39 weeks due to a low-lying placenta and a fibroid uterus. a) What specific issues should be discussed with this patient based on the history outlined above? (10 marks)
b) Give the advantages and disadvantages of using intra-operative cell salvage during caesarean section? (10 marks)
Obstetric preoperative discussion Pass Rate 44.6%, 22.5% of candidates received a poor fail
This question was poorly attempted by many candidates. Examiners reported that answers reflected a lack of knowledge or inaccurate reading of the question. Many candidates described anaesthesia for a Jehovah’s Witness patient with placenta praevia and fibroid uterus rather than addressing pre-operative discussions as was asked. Candidates omitted mention of important peri-operative risks such as haemorrhage, hysterectomy and other significant morbidity and mortality. Some candidates demonstrated a worrying lack of knowledge of cell salvage and in particular the disadvantages of this technique.
September 2014


A 28 year-old woman presents for acute appendicectomy - she is 22 weeks pregnant.
  • a)  List the risks to the fetus during anaesthesia for the mother. (5 marks)
  • b)  How can the risks to the fetus be minimised? (10 marks)
  • c)  What additional pre and intraoperative steps would you take to ensure foetal safety if she was 27 weeks
    pregnant? (5 marks)
  • Pass Rate 33%
    The poor pass rate for this important subject is of concern as similar clinical scenarios are commonly encountered. Many candidates wrote principally on the preparation of a pregnant woman for general anaesthesia or on the conduct of a rapid intubation sequence, ignoring the emphasis on the fetus in the question. Teratogenesis by anaesthetic agents was frequently listed as an important consideration although the patient was in the second trimester of pregnancy. Many candidates failed to consider that a fetus of twenty two weeks gestation is highly unlikely to be viable and concentrated on preparation for an unplanned delivery. A clue to this consideration was given in section (c) where the focus was changed to a scenario in which the fetus is potentially viable, but weak candidates ignored this prompt.
March 2014

A 27-year-old woman is 13 weeks pregnant. In the antenatal clinic she is found to have an asymptomatic heart murmur. A subsequent echocardiogram shows moderate to severe mitral stenosis.

a) List the causes of mitral stenosis. (15%)

b) How do the cardiovascular changes in pregnancy exacerbate the pathophysiology of mitral stenosis? (45%)

c) Outline the specific management issues when she presents in established labour. (40%)
Pass rate 65.5%

Overall, there was a disappointing lack of knowledge of the pathology of mitral stenosis and some
candidates had no understanding at all. The physiological and clinical aspects were more soundly addressed, and the question proved a very strong discriminator between strong and weak candidates.
September 2013

A primiparous patient with a booking BMI of 55 kg/m2 presents in the high-risk obstetric anaesthetic assessment clinic at 32-weeks gestation. She is hoping for a vaginal delivery.

a) Which specific points do you need to elicit from the history and examination? (30%)

b) What do you need to communicate to the patient? (35%)

c) Document your plan for her management on the delivery suite. (35%)
72.8% pass rate.

This question was a modified version from the May 2006 paper. The implications of morbid obesity on a parturient and the importance of forward planning were well appreciated by most candidates.
March 2013

A woman experiences a headache 24-hours after delivery having had epidural analgesia for labour.

a) List the clinical features of a post-dural puncture headache (PDPH). (25%)

b) What is the differential diagnosis of PDPH? (30%)

c) Outline the conservative treatment options for PDPH. (15%)

d) How is an epidural blood patch performed? (30%)
59.0% Pass rate.
A very basic but and relevant question that was reasonably well-answered. This question was the least discriminatory.
September 2012

a) What are the implications of managing a patient with an intrauterine foetal death (IUFD) at 36-
weeks gestation? (55%)

b) How does the presence of an IUFD influence the choice in the method of pain relief in labour?
(20)%)

c) Which abnormal haematological results would contraindicate epidural analgesia? (25%)
Question 3: Obstetrics/Intrauterine foetal death/analgesia for labour.

49.9% pass rate.

The question was written because the anaesthetist is often involved with the provision of analgesia for labour in these circumstances. Many candidates unnecessarily wrote about the physiological changes of a 36-week pregnancy. Section a) was specifically asking about the implications of intrauterine foetal death (IUFD). The implications of IUFD focused on:
Psychological distress
Method of delivery
Mandatory level 1 care (MEOWS) and possible transfer to level 2 care Exclude possible causes
Provide effective analgesia
Consider sedation
Section a) was answered poorly but fared better in sections b) choice of pain relief and b) haematological results that might contraindicate epidural analgesia.
March 2012

a) Which dermatomes should be blocked prior to an elective Caesarean section (CS) and how may the adequacy of the block be tested? (30%)

b) How might an initially inadequate block be improved sufficiently to allow surgery to proceed? (30%)

c) How could you manage a patient who complains of pain during a spinal CS? (40%)
Question 3: Anatomy/obstetrics/inadequate/spinal anaesthesia at caesarean section

45.7% pass rate

Most candidates knew the dermatome levels and how to test the level of a block, however section b) was less well answered. Some candidates did not read the question carefully enough or appreciated that they were required to improve the block itself rather than provide supplementary analgesia. It was good to see that many candidates understood the importance of patient reassurance and how to manage pain during CS under spinal anaesthesia
September 2011

a) Amniotic fluid embolism (AFE) is one of four major direct causes of maternal mortality in the 2006-
2008 report from Centre for Maternal and Child Enquiries (CMACE). State the other three major
causes. (15%)

b) How does AFE present clinically? (25%)

c) What are the differential diagnoses of AFE? (40%)

d) Describe two possible theories on the pathophysiology of AFE. (20%)
Question11 Critical care/management of airway problem/tracheostomy

76.6% pass rate

In the main was a well-answered question
March 2011

a) How may pain following Caesarean section (CS) performed under general anaesthesia be managed? (35%)

b) What neuraxial techniques may be used to provide postoperative analgesia following CS? (Include appropriate dose ranges). (20%)

c) What are the monitoring requirements after CS following spinal or epidural opioid administration? (15%)

d) List the side effects of neuraxially administered opioids and how may these be managed? (30%)
Question11 Critical care/management of airway problem/tracheostomy

76.6% pass rate

In the main was a well-answered question
September 2010

a) What are i) diagnostic and ii) other clinical features of severe pre-eclampsia? (30%)

b) What are the indications for magnesium therapy in severe pre-eclampsia/eclampsia and which administration regimen(s) should be used? (20%)

c) What are the symptoms and signs of magnesium toxicity (25%) and how should it be managed? (15%)
Question11 Critical care/management of airway problem/tracheostomy

76.6% pass rate

In the main was a well-answered question
March 2010

a) What possible factors may contribute to the development of a postpartum haemorrhage? (30%)

b) List 4 drugs that are of value in the management of uterine atony. Outline the dosage, mechanisms of action and major side effects of these agents. (60%)
Question11 Critical care/management of airway problem/tracheostomy

76.6% pass rate

In the main was a well-answered question
September 2009

a) What are i) diagnostic and ii) other clinical features of severe pre-eclampsia? (30%)

b) What are the indications for magnesium therapy in severe pre-eclampsia/eclampsia and which administration regimen(s) should be used? (20%)

c) What are the signs and symptoms of magnesium toxicity and how should it be managed? (40%)
Question11 Critical care/management of airway problem/tracheostomy

76.6% pass rate

In the main was a well-answered question
April 2009

a) Describe the pain pathways associated with the 1st and 2nd stages of labour. (40%)

b) Explain how and why the nature of the pain experienced changes as labour progresses. (20%)

c) Why is it essential to achieve a higher dermatomal level of regional block for Caesarean section than for analgesia in labour. (20%)

d) Why do you sometimes observe bradycardia during regional anaesthesia for Caesarean section? (10%)
Question11 Critical care/management of airway problem/tracheostomy

76.6% pass rate

In the main was a well-answered question
April 2008

a) In the Confidential Enquiry into Maternal and Child Health covering the period 2003-2005, what risk factors were identified as contributing to maternal death? (40%)

b) What are the principle causes of direct maternal death in the United Kingdom? (25%)

c) What clinical features would you include in a ward-based Early Warning Scoring system designed to
alert staff to a deterioration in maternal well being? (25%)
Question11 Critical care/management of airway problem/tracheostomy

76.6% pass rate

In the main was a well-answered question
October 2007

a) List the specific problems and risks associated with a twin pregnancy. (45%)

b) What are the important considerations and options when planning the anaesthetic management for the
delivery of twins around term? (45%)
Question11 Critical care/management of airway problem/tracheostomy

76.6% pass rate

In the main was a well-answered question
April 2007

Three common regimens used to reduce the incidence of hypotension seen during spinal anaesthesia for caesarean section are:
1) Giving fluid before the spinal (preload) (30%)
2) Giving fluid at the time of the spinal (coload or cohydration) (10%)
3) Drug administration (50%)

Describe each technique and outline the physiological and pharmacological basis of each regimen.
Question11 Critical care/management of airway problem/tracheostomy

76.6% pass rate

In the main was a well-answered question
May 2006

A consultant obstetrician has asked you to review a woman in her first pregnancy in the anaesthetic ante-natal assessment clinic. Her body mass index is 45kg.m-2. There are no other abnormalities and at 32 weeks gestation she is hoping for a vaginal delivery.

Write a summary recording the details you would wish to cover during the appointment and your recommendations for her management when she is admitted in labour.
Question11 Critical care/management of airway problem/tracheostomy

76.6% pass rate

In the main was a well-answered question
October 2005

List the causes of mortality directly and indirectly related to anaesthesia in the UK triennial maternal mortality (CEMACH) report (2000-2002). (40%)
What are the concerns associated with general anaesthesia for delivery in the obstetric patient ? (60%)
Question11 Critical care/management of airway problem/tracheostomy

76.6% pass rate

In the main was a well-answered question
October 2004

Define primary post partum haemorrhage (10%)
List the pharmacological agents that may be used post partum to reduce uterine atony and any precautions with their use. (50%)
Outline the management of a significant primary postpartum haemorrhage. (40%)
Question11 Critical care/management of airway problem/tracheostomy

76.6% pass rate

In the main was a well-answered question
May 2004

What advice, for and against, would you give a primagravida who is asking if she might eat and drink during her labour ?
Give reasons.
Question11 Critical care/management of airway problem/tracheostomy

76.6% pass rate

In the main was a well-answered question
October 2003

What potential problems and risks do you consider when planning the anaesthetic management of the delivery of twins?
Question11 Critical care/management of airway problem/tracheostomy

76.6% pass rate

In the main was a well-answered question
October 2002

List the three commonest causes of direct maternal deaths in the United
Kingdom. What anatomical and physiological changes of pregnancy affect your ability to resuscitate a woman who has suffered cardiovascular collapse at full term?
Question11 Critical care/management of airway problem/tracheostomy

76.6% pass rate

In the main was a well-answered question
May 2001

What is an appropriate intervertebral space at which to insert a spinal needle to administer a subarachnoid anaesthetic for a Caesarean section? Give your reasons and describe how you would locate the space.
Question11 Critical care/management of airway problem/tracheostomy

76.6% pass rate

In the main was a well-answered question
May 2001

When obtaining consent for an epidural for a primigravida in labour, what complications do you mention? Quote their incidence if known. What can be done to reduce the likelihood of these problems?
Question11 Critical care/management of airway problem/tracheostomy

76.6% pass rate

In the main was a well-answered question