UPSC-CMS 2012 - Obstetrics and Gynecology Practice Questions

Q: 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

Perform LSCS (Lower Segment Caesarean Section). ***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.

Q: 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

Forceps application. ***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.

Q: Before the delivery of the second twin having cephalic presentation, the mother develops profuse bleeding per vaginum. The appropriate management will be

ARM. ***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**.

Q: 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

Give her a trial of labour. **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.

Q: The following are the predisposing factors for postpartum uterine atony except

Pre-eclampsia. ***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.

Q: 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

Oxytocin drip. ***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.

Q: 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:

1 and 3 only. ***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.

Q: 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

Retained bits of placenta and membranes. ***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.

Question 1

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

Accepted Answer

Perform LSCS (Lower Segment Caesarean Section)

Answer

Do internal podalic version and extraction

Answer

Deliver the baby by vaginal route using a vacuum extractor

Answer

Augment labour with oxytocin

Question 2

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

Accepted Answer

Forceps application

Answer

Vacuum extraction

Answer

Wait and watch policy

Answer

Caesarean section

Question 3

Before the delivery of the second twin having cephalic presentation, the mother develops profuse bleeding per vaginum. The appropriate management will be

Accepted Answer

ARM

Answer

External cephalic version and oxytocin drip

Answer

Deliver the placenta of the first twin

Answer

Internal podalic version and breech extraction

Question 4

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

Accepted Answer

Immediate LSCS (Lower Segment Caesarean Section)

Answer

Wait and watch

Answer

Apply ventouse and deliver

Answer

Apply forceps and deliver

Question 5

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

Accepted Answer

Give her a trial of labour

Answer

Deliver vaginally at home

Answer

Deliver by emergency caesarean section

Answer

Refer to higher center immediately

Question 6

The following are the predisposing factors for postpartum uterine atony except

Accepted Answer

Pre-eclampsia

Answer

Oxytocin induced labour

Answer

Multiple pregnancy

Answer

Hydramnios

Question 7

A multiparous woman presenting with postpartum haemorrhage due to placenta increta is best managed by

Accepted Answer

Hysterectomy

Answer

Internal iliac artery ligation

Answer

Hysterectomy with the removal of the adherent placenta

Answer

Packing the uterus followed by a course of methotrexate

Question 8

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

Accepted Answer

Oxytocin drip

Answer

Intracervical dinoprostone gel

Answer

ARM with oxytocin drip

Answer

Carboprost tromethamin intra-muscularly

Question 9

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:

Accepted Answer

1 and 3 only

Answer

1, 2, 3 and 4

Answer

2 and 4 only

Answer

1 and 2 only

Question 10

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

Accepted Answer

Retained bits of placenta and membranes

Answer

Perineal tears

Answer

Excessive postnatal physical work

Answer

Uterine atony

UPSC-CMS 2012 — Obstetrics and Gynecology