A 35-year-old multiparous woman is admitted with prolonged labour. She is in shock, and her pulse rate is 150 per minute. The uterus is tonically contracted with Bandl's ring, and the presenting part is not engaged. The appropriate treatment is
A second gravida, whose first baby is alive, has been in the second stage of labour for more than one hour. On examination, her cervix is fully dilated. The pelvis is adequate and the station of the vertex is +2. The occiput is in right, occipito-posterior position and the fetal heart rate is 120/min. The most appropriate management will be
Before the delivery of the second twin having cephalic presentation, the mother develops profuse bleeding per vaginum. The appropriate management will be
A 34-week multiparous gravida comes in labour. On examination, the cervix is fully dilated, the head is at +2 station and the foetal heart rate is 172/min. The appropriate management will be
A 25-year-old primigravida in early labour with vertex presentation in left occipitoanterior position. The head is floating. Her diagonal conjugate measures 11 cm. The appropriate management will be
The following are the predisposing factors for postpartum uterine atony except
A multiparous woman presenting with postpartum haemorrhage due to placenta increta is best managed by
On examination, a woman with post-dated pregnancy is found to have 80% effaced cervix. She requires the induction of labour. This is best done through
Which of the following foetal diameters measure 9.4 cm at term? 1. Biparietal diameter 2. Suboccipitofrontal diameter 3. Submentobregmatic diameter 4. Bitrochanteric diameter Select the correct answer using the code given below:
A multiparous woman delivered by a village dai (midwife) presents on the 22nd postnatal day with bleeding per vaginum with clots. On examination, the uterus is 14-16 weeks, the internal os is open, and there is bleeding through the os. The likely cause of this bleeding is
UPSC-CMS 2012 - Obstetrics and Gynecology UPSC-CMS Practice Questions and MCQs
Question 11: A 35-year-old multiparous woman is admitted with prolonged labour. She is in shock, and her pulse rate is 150 per minute. The uterus is tonically contracted with Bandl's ring, and the presenting part is not engaged. The appropriate treatment is
- A. Do internal podalic version and extraction
- B. Deliver the baby by vaginal route using a vacuum extractor
- C. Perform LSCS (Lower Segment Caesarean Section) (Correct Answer)
- D. Augment labour with oxytocin
Explanation: ***Perform LSCS (Lower Segment Caesarean Section)*** - The presence of a **tonically contracted uterus** with **Bandl's ring**, unengaged presenting part, and the patient being in **shock** (pulse 150 bpm) are all signs of **imminent uterine rupture** due to obstructed labor. - An **emergency LSCS** is immediately indicated to deliver the baby and manage the uterine obstruction, prioritizing the mother's and baby's lives. *Do internal podalic version and extraction* - This procedure is contraindicated in cases of **obstructed labor** with a tonically contracted uterus and Bandl's ring, as it significantly increases the risk of **uterine rupture**. - Internal podalic version is typically performed for malpresentations in the absence of obstruction, often in a less critical maternal condition. *Deliver the baby by vaginal route using a vacuum extractor* - **Vacuum extraction** requires a dilated cervix, engaged head, and the absence of mechanical obstruction. - With an **unengaged presenting part**, tonically contracted uterus, and Bandl's ring, a vaginal instrumental delivery is impossible and highly dangerous, risking uterine rupture. *Augment labour with oxytocin* - **Oxytocin augmentation** is used for hypotonic uterine dysfunction to strengthen contractions. - In a case of **obstructed labor** with a tonically contracted uterus and Bandl's ring, adding oxytocin would further exacerbate the uterine stress and dramatically increase the risk of **uterine rupture**, making it absolutely contraindicated.
Question 12: A second gravida, whose first baby is alive, has been in the second stage of labour for more than one hour. On examination, her cervix is fully dilated. The pelvis is adequate and the station of the vertex is +2. The occiput is in right, occipito-posterior position and the fetal heart rate is 120/min. The most appropriate management will be
- A. Vacuum extraction
- B. Forceps application (Correct Answer)
- C. Wait and watch policy
- D. Caesarean section
Explanation: ***Forceps application*** - With a fully dilated cervix, adequate pelvis, and **vertex at +2 station**, instrumental delivery is indicated to expedite delivery, especially given the **prolonged second stage of labor** (>1 hour in a multigravida). - **Occipito-posterior position** can be managed with rotational forceps (Kielland's forceps) to correct the malposition and facilitate delivery. - The fetal heart rate of 120/min is at the lower end of normal, and combined with the prolonged second stage, instrumental delivery is warranted to prevent further delay and potential complications. *Vacuum extraction* - While vacuum extraction is an option for instrumental delivery, **forceps are generally preferred in cases of occipito-posterior position** as they offer greater control for rotation and extraction. - Rotational maneuvers are more controlled with forceps compared to vacuum extraction. - The risk of **failed extraction** is higher with vacuum in occipito-posterior positions. *Wait and watch policy* - This is inappropriate given the **prolonged second stage** of labor (over one hour in a multigravida with good uterine contractions). - Modern guidelines allow up to 2 hours for second stage in multiparas, but with malposition (occipito-posterior) and lack of progress, active intervention is preferred. - Delaying intervention could lead to **fetal distress**, maternal exhaustion, or obstructed labor. *Caesarean section* - A Caesarean section is too invasive given the favorable conditions for vaginal delivery, including a **fully dilated cervix**, **adequate pelvis**, and **low station of the vertex (+2)**. - Instrumental delivery is the preferred approach with lower maternal morbidity in this scenario. - LSCS in second stage carries higher risks of hemorrhage and bladder injury.
Question 13: Before the delivery of the second twin having cephalic presentation, the mother develops profuse bleeding per vaginum. The appropriate management will be
- A. External cephalic version and oxytocin drip
- B. Deliver the placenta of the first twin
- C. Internal podalic version and breech extraction
- D. ARM (Correct Answer)
Explanation: ***ARM (Artificial Rupture of Membranes)*** - Profuse bleeding between twin deliveries is an **obstetric emergency** requiring **immediate delivery** of the second twin to control hemorrhage. - Since the second twin has **cephalic presentation**, **ARM followed by assisted delivery** is the **fastest and most appropriate intervention**. - ARM stimulates uterine contractions and allows for **immediate vaginal delivery**, preventing maternal **exsanguination** and fetal compromise. *Internal podalic version and breech extraction* - This is **NOT indicated** as the second twin already has **cephalic presentation** (the most favorable presentation). - Internal podalic version is reserved for **transverse or unstable lie**, not for converting an already favorable cephalic presentation to breech. - Converting cephalic to breech would **waste critical time** and **increase maternal and fetal risk** in this emergency. *External cephalic version and oxytocin drip* - **External cephalic version** is inappropriate as the second twin already has **cephalic presentation**. - **Oxytocin** alone does not expedite delivery quickly enough in this **hemorrhagic emergency**. - This approach causes unnecessary delay when immediate delivery is required. *Deliver the placenta of the first twin* - This is **dangerous and absolutely contraindicated** - placenta should only be delivered **after both twins are born**. - Delivering the placenta while the second twin remains in utero can cause **massive hemorrhage**, **uterine contraction**, **entrapment of the second twin**, and **fetal death**.
Question 14: A 34-week multiparous gravida comes in labour. On examination, the cervix is fully dilated, the head is at +2 station and the foetal heart rate is 172/min. The appropriate management will be
- A. Immediate LSCS (Lower Segment Caesarean Section) (Correct Answer)
- B. Wait and watch
- C. Apply ventouse and deliver
- D. Apply forceps and deliver
Explanation: ***Immediate LSCS (Lower Segment Caesarean Section)*** - The fetus is **preterm at 34 weeks** with **fetal heart rate of 172/min** indicating **fetal tachycardia** and potential **fetal distress** - Although the cervix is fully dilated and head is at **+2 station**, **instrumental delivery (ventouse/forceps) is relatively contraindicated in preterm deliveries < 34-36 weeks** due to increased risk of **intracranial hemorrhage** and **cephalopelvic trauma** from the fragile preterm skull - **LSCS is the safest mode of delivery** in this scenario to avoid trauma to the preterm fetal head, especially in the presence of fetal distress - Modern obstetric practice favors **caesarean section over instrumental delivery for preterm fetuses** when expedited delivery is required *Apply ventouse and deliver* - **Ventouse extraction is contraindicated in preterm deliveries < 34-36 weeks** due to the fragile fetal skull and increased risk of **subgaleal hemorrhage**, **cephalohematoma**, and **intracranial bleeding** - While the head is at +2 station making instrumental delivery technically feasible, **fetal safety considerations override** the convenience of vaginal delivery in preterm cases - The risk-benefit ratio does not favor instrumental delivery in this preterm scenario *Wait and watch* - The fetal heart rate of **172/min indicates tachycardia** (normal range 110-160 bpm), which could represent **fetal distress** requiring immediate intervention - Expectant management would be inappropriate as it risks further fetal compromise - With full cervical dilatation and concerning fetal status, **immediate delivery is indicated** *Apply forceps and deliver* - **Forceps delivery is also contraindicated in preterm deliveries** due to even greater compressive forces on the fragile preterm skull compared to ventouse - Risk of **intracranial hemorrhage**, **skull fractures**, and **facial nerve injury** is significantly higher in preterm fetuses - The standard teaching is to **avoid all instrumental deliveries in preterm cases < 34-36 weeks** when possible, making LSCS the preferred option
Question 15: A 25-year-old primigravida in early labour with vertex presentation in left occipitoanterior position. The head is floating. Her diagonal conjugate measures 11 cm. The appropriate management will be
- A. Deliver vaginally at home
- B. Give her a trial of labour (Correct Answer)
- C. Deliver by emergency caesarean section
- D. Refer to higher center immediately
Explanation: **Give her a trial of labour** - A **diagonal conjugate of 11 cm** is at the **lower limit of normal** (normal ≥11.5 cm, obstetric conjugate ~9.5 cm), making it borderline adequate for vaginal delivery, but not an absolute contraindication. - The **left occipitoanterior position** is the most favorable presentation for engagement and descent through the pelvis. - While the head is **floating** (unengaged), this is common in early labor, especially for a primigravida; a **trial of labor** allows assessment of labor progression, cervical dilation, and head descent to diagnose potential **cephalopelvic disproportion (CPD)**. - CPD can only be diagnosed during active labor; hence a trial is warranted before considering surgical intervention. *Deliver vaginally at home* - Home delivery is inappropriate and unsafe for a **primigravida** with a **borderline pelvis** and **floating head**, which requires continuous monitoring in a clinical setting. - The risk of obstructed labor and CPD necessitates hospital supervision with capability for emergency intervention if needed. *Deliver by emergency caesarean section* - Emergency cesarean section is **not indicated** at this stage as there are **no signs of fetal distress**, obstructed labor, or proven CPD. - The diagonal conjugate, though borderline, is not an absolute contraindication; surgical intervention should only be considered after failed trial of labor or evidence of maternal/fetal compromise. *Refer to higher center immediately* - There is no immediate indication for referral to a higher center, as the patient is in **early labor** with no complications like severe pre-eclampsia, antepartum hemorrhage, or acute fetal distress. - This case can be managed in a standard delivery unit with capability for cesarean section if trial of labor fails; a **trial of labor** with close monitoring is the appropriate initial management.
Question 16: The following are the predisposing factors for postpartum uterine atony except
- A. Oxytocin induced labour
- B. Multiple pregnancy
- C. Hydramnios
- D. Pre-eclampsia (Correct Answer)
Explanation: ***Pre-eclampsia*** - Pre-eclampsia is a condition of **hypertension** and **proteinuria during pregnancy**; it does not directly predispose to uterine atony. - While it can be associated with other obstetric complications, it is not a direct risk factor for the uterus's inability to contract effectively postpartum. *Oxytocin induced labour* - Prolonged or high-dose oxytocin administration can lead to **receptor desensitization** in the myometrium, potentially leading to uterine exhaustion and atony. - The uterus may become fatigued and less responsive to endogenous oxytocin after extensive stimulation. *Multiple pregnancy* - Multiple pregnancies lead to **overdistension of the uterus**, which can stretch the myometrial fibers beyond their optimal contractile capacity. - This overstretching reduces the uterus's ability to contract effectively after birth, increasing the risk of atony. *Hydramnios* - **Hydramnios (polyhydramnios)**, an excessive amount of amniotic fluid, also causes significant uterine overdistension. - Similar to multiple pregnancies, this overstretching compromises the myometrium's ability to contract and retract postpartum, contributing to atony.
Question 17: A multiparous woman presenting with postpartum haemorrhage due to placenta increta is best managed by
- A. Internal iliac artery ligation
- B. Hysterectomy (Correct Answer)
- C. Hysterectomy with the removal of the adherent placenta
- D. Packing the uterus followed by a course of methotrexate
Explanation: ***Hysterectomy*** - In placenta increta, the chorionic villi invade into the myometrium, causing abnormal placental adherence that cannot be safely separated. - **Total hysterectomy** is the definitive management for placenta increta with active postpartum hemorrhage. - The standard approach is to perform hysterectomy with the placenta left **in situ** (en bloc removal), as attempting to remove the adherent placenta first dramatically increases the risk of **catastrophic hemorrhage**. - This is the most appropriate answer as it represents the gold standard surgical management. *Hysterectomy with the removal of the adherent placenta* - While hysterectomy is correct, this phrasing is potentially misleading as it may imply **manual removal** of the placenta before or during hysterectomy. - In modern practice, the placenta is typically left in place and removed **en bloc** with the uterus to minimize blood loss. - Attempting to remove a placenta increta before hysterectomy can cause **uncontrollable hemorrhage**. *Internal iliac artery ligation* - This procedure reduces blood flow to the uterus by ligating the **internal iliac arteries** but is a temporizing measure or adjunct to other treatments. - It does not address the underlying issue of the **adherent placenta** invading the myometrium and may not be sufficient to control severe hemorrhage in placenta increta. - May be used as part of a fertility-sparing approach in selected stable cases, but not appropriate as definitive management for active PPH. *Packing the uterus followed by a course of methotrexate* - **Uterine packing** is a temporary measure for diffuse atonic bleeding and is generally inappropriate for **placenta increta** due to the risk of concealed hemorrhage. - **Methotrexate** may be considered in highly selected cases where placental tissue is left in situ as part of a conservative/fertility-sparing approach in **stable** patients, but it is not appropriate for active postpartum hemorrhage. - This is not definitive management for acute PPH due to placenta increta.
Question 18: On examination, a woman with post-dated pregnancy is found to have 80% effaced cervix. She requires the induction of labour. This is best done through
- A. Intracervical dinoprostone gel
- B. ARM with oxytocin drip
- C. Carboprost tromethamin intra-muscularly
- D. Oxytocin drip (Correct Answer)
Explanation: ***Oxytocin drip*** - An 80% effaced cervix indicates a **favorable cervix** (high Bishop score), meaning it is ripe and ready for induction. - In such cases, **oxytocin** is the most appropriate method to stimulate uterine contractions for labor induction. *Intracervical dinoprostone gel* - Dinoprostone is a **prostaglandin E2 analog** used primarily for **cervical ripening** when the cervix is unfavorable (low Bishop score), not for an 80% effaced cervix. - It softens and effaces the cervix, but for a cervix already 80% effaced, it's not the primary induction agent. *ARM with oxytocin drip* - **Artificial rupture of membranes (ARM)** can be performed once the cervix is favorable, but it is often done in conjunction with oxytocin if contractions are not strong enough. - However, in a post-dated pregnancy with an 80% effaced cervix, **oxytocin infusion alone** is often sufficient to initiate and maintain effective contractions. ARM can be reserved for further augmentation if needed. *Carboprost tromethamin intra-muscularly* - **Carboprost** is a prostaglandin F2 alpha analog primarily used to treat **postpartum hemorrhage** by inducing strong uterine contractions to reduce bleeding. - It is **not indicated for labor induction** due to its strong and sustained uterine contraction profile and potential for severe side effects.
Question 19: Which of the following foetal diameters measure 9.4 cm at term? 1. Biparietal diameter 2. Suboccipitofrontal diameter 3. Submentobregmatic diameter 4. Bitrochanteric diameter Select the correct answer using the code given below:
- A. 1 and 3 only (Correct Answer)
- B. 1, 2, 3 and 4
- C. 2 and 4 only
- D. 1 and 2 only
Explanation: ***1 and 3 only*** - The **biparietal diameter (BPD)** measures the distance between the two parietal eminences and is typically **9.4 cm** at term, representing the widest transverse diameter of the fetal head. - The **submentobregmatic diameter** measures from the junction of the chin and neck to the center of the anterior fontanelle (bregma), typically measuring **9.5 cm** at term (often approximated as 9.4 cm in clinical practice), and is the presenting diameter in a face presentation with complete extension. *1, 2, 3 and 4* - While both biparietal and submentobregmatic diameters are approximately 9.4-9.5 cm, the **suboccipitofrontal** and **bitrochanteric** diameters do not match this measurement at term. - The suboccipitofrontal diameter is larger (~10 cm) and the bitrochanteric measurement varies (9-10 cm). *2 and 4 only* - The **suboccipitofrontal diameter** (from the subocciput to the center of the frontal suture) is typically larger, around **10 cm**, and is the presenting diameter in a well-flexed vertex presentation. - The **bitrochanteric diameter** (between the fetal hip trochanters) is approximately **9-10 cm** at term but is not consistently 9.4 cm and refers to the fetal body, not the head. *1 and 2 only* - While the **biparietal diameter** is indeed 9.4 cm, the **suboccipitofrontal diameter** is typically larger, around **10 cm**, making this option incorrect. - This option misses the **submentobregmatic diameter**, which also measures approximately 9.4-9.5 cm at term.
Question 20: A multiparous woman delivered by a village dai (midwife) presents on the 22nd postnatal day with bleeding per vaginum with clots. On examination, the uterus is 14-16 weeks, the internal os is open, and there is bleeding through the os. The likely cause of this bleeding is
- A. Perineal tears
- B. Retained bits of placenta and membranes (Correct Answer)
- C. Excessive postnatal physical work
- D. Uterine atony
Explanation: ***Retained bits of placenta and membranes*** - Postnatal bleeding with clots on day 22, an enlarged uterus (14-16 weeks size), and an open internal os are **classic features of retained products of conception**. - Retained placental fragments prevent proper **uterine involution** and interfere with myometrial contraction, leading to **secondary postpartum hemorrhage** (PPH occurring after 24 hours up to 12 weeks postpartum). - The open internal os with bleeding through it strongly suggests intrauterine retained tissue. *Perineal tears* - Perineal tears cause **immediate postpartum bleeding**, typically bright red and continuous, identified and repaired at the time of delivery. - They would **not explain** an enlarged uterus, subinvolution, or delayed bleeding with clots on **day 22 postpartum**. *Excessive postnatal physical work* - While physical overexertion may delay recovery or cause fatigue, it does **not directly cause vaginal bleeding with clots** and an enlarged uterus. - This clinical presentation requires an **obstetric pathology** such as retained products. *Uterine atony* - Uterine atony is the most common cause of **primary PPH** (within 24 hours of delivery), presenting with a soft, boggy uterus and profuse bleeding. - However, on day 22 with an **open os and retained tissue**, the primary issue is retained products rather than atony alone.