Anesthesia for Cesarean Delivery — MCQs

10 questions

After 3rd stage of labour and expulsion of placenta, the patient is bleeding heavily. Ideal management would include all except:

A female presents with placenta previa with active bleeding and blood pressure of 80/50 mm Hg and pulse rate of 140 bpm. The choice of anaesthesia for emergency cesarean section in this female is?

How do you manage placenta accreta?

Which of the following agents is used for the treatment of post operative shivering?

Anaesthesia of choice for manual removal of the placenta is?

A two month old infant has undergone a major surgical procedure. Regarding postoperative pain relief which one of the following is recommended:

Which of the following is advised for severe preeclampsia complicating cesarean delivery?

What is the anesthesia of choice for cesarean section in patients with severe pre-eclampsia?

The Anaesthesia technique of choice in severely preeclamptic women for cesarean delivery -

Q10

Anesthesia of choice for cesarean section in severe preeclampsia:-

Anesthesia for Cesarean Delivery Indian Medical PG Practice Questions and MCQs

Question 1: After 3rd stage of labour and expulsion of placenta, the patient is bleeding heavily. Ideal management would include all except:

A. Check for laceration of labia
B. Uterine massage and I/V oxytocin
C. APGAR scoring (Correct Answer)
D. Check for placenta in uterus

Explanation: ***APGAR scoring*** - **APGAR scoring** assesses the newborn's health immediately after birth and is not a management step for **postpartum hemorrhage**. - This intervention would divert critical attention from the mother's life-threatening bleeding. *Check for placenta in uterus* - **Retained placental fragments** are a common cause of **postpartum hemorrhage**, obstructing uterine contraction. - Checking for and removing any retained placenta is a crucial and immediate management step to control bleeding. *Check for laceration of labia* - **Lacerations of the birth canal**, including the labia, vagina, or cervix, can cause significant bleeding after delivery, even with a well-contracted uterus. - Identifying and repairing these lacerations is an essential part of managing **postpartum hemorrhage not due to atony**. *Uterine massage and I/V oxytocin* - **Uterine atony** (failure of the uterus to contract) is the most common cause of **postpartum hemorrhage**. - **Uterine massage** helps stimulate contraction, and **intravenous oxytocin** is a uterotonic agent used to promote uterine contraction and reduce bleeding.

Question 2: A female presents with placenta previa with active bleeding and blood pressure of 80/50 mm Hg and pulse rate of 140 bpm. The choice of anaesthesia for emergency cesarean section in this female is?

A. General anesthesia with intravenous propofol
B. Spinal anesthesia
C. General anesthesia with intravenous ketamine (Correct Answer)
D. Epidural anesthesia

Explanation: ***General anesthesia with intravenous ketamine*** - **Ketamine** maintains sympathetic tone, supporting **blood pressure** in patients with significant **hemorrhage** and **hypovolemic shock**. - Its **bronchodilatory** properties are also beneficial, making it a suitable choice for this emergency scenario where the patient is **hemodynamically unstable**. *General anesthesia with intravenous propofol* - **Propofol** can cause significant **vasodilation** and myocardial depression, which would worsen the patient's existing **hypotension** and **tachycardia**. - Its use in an actively bleeding, **hemodynamically unstable** patient is generally contraindicated due to the risk of further **cardiovascular collapse**. *Spinal anesthesia* - **Spinal anesthesia** is contraindicated in patients with significant **hypovolemia** and **active bleeding** due to the risk of severe **hypotension**. - The sympathetic blockade caused by spinal anesthesia would exacerbate the patient's already compromised **hemodynamic status**, potentially leading to **cardiac arrest**. *Epidural anesthesia* - Similar to spinal anesthesia, **epidural anesthesia** causes **sympathetic blockade** and can lead to **hypotension**, making it unsuitable for a patient with **active bleeding** and **hypovolemic shock**. - The onset of **epidural blockade** is slower than spinal, but the hemodynamic effects are still detrimental in this critically ill patient.

Question 3: How do you manage placenta accreta?

A. Classical cesarean; hysterectomy (Correct Answer)
B. Low vertical cesarean; hysterectomy
C. Low transverse cesarean; hysterectomy
D. Classical cesarean; myometrial resection

Explanation: ***Classical cesarean; hysterectomy*** - A **classical cesarean section** (vertical incision in the upper uterine segment) allows for delivery of the fetus without disturbing the **placenta accreta** in the lower uterine segment. - Subsequent **hysterectomy** is often necessary due to the high risk of severe hemorrhage from the morbidly adherent placenta, which cannot be safely separated. *Low vertical cesarean; hysterectomy* - A **low vertical incision** is made in the lower uterine segment, which could potentially incise through the placenta accreta if it extends to that region, leading to significant hemorrhage. - While hysterectomy is likely indicated, the initial uterine incision might complicate management. *Low transverse cesarean; hysterectomy* - A **low transverse incision** is the most common type for routine cesarean sections but is contra-indicated in placenta accreta as the placenta is frequently implanted in the lower uterine segment. - Incising through the **placenta** during a low transverse cut would cause immediate massive hemorrhage, making this approach unsuitable. *Classical cesarean; myometrial resection* - While a **classical cesarean** would be the appropriate initial step for fetal delivery, **myometrial resection** to remove only the affected area of the myometrium is generally insufficient and carries a high risk of residual placental tissue and severe hemorrhage, often necessitating a hysterectomy anyway. - This approach is typically not recommended as a primary definitive management strategy for established placenta accreta.

Question 4: Which of the following agents is used for the treatment of post operative shivering?

A. Atropine
B. Thiopentone
C. Pethidine (Correct Answer)
D. Suxamethonium

Explanation: ***Pethidine*** - **Pethidine (meperidine)** is a **synthetic opioid** known for its **mu-receptor agonism** and weak anticholinergic properties, making it effective in treating **post-operative shivering**. - Its mechanism in reducing shivering is thought to involve modulation of the **thermoregulatory center** in the hypothalamus. *Atropine* - **Atropine** is an **anticholinergic drug** that primarily blocks muscarinic acetylcholine receptors, leading to effects like increased heart rate and decreased secretions. - It does not directly act on the thermoregulatory centers or muscle activity responsible for shivering. *Thiopentone* - **Thiopentone** is a **barbiturate** used as an intravenous anesthetic, primarily for induction of anesthesia. - While it has CNS depressant effects, it is not indicated or effective for the specific treatment of post-operative shivering. *Suxamethonium* - **Suxamethonium (succinylcholine)** is a **depolarizing neuromuscular blocker** used to induce muscle paralysis, typically for intubation. - It would prevent shivering by paralyzing skeletal muscles, but this is a dangerous and inappropriate treatment for shivering due to its profound respiratory depressant effects.

Question 5: Anaesthesia of choice for manual removal of the placenta is?

A. General Anesthesia (GA)
B. Spinal Anesthesia (Correct Answer)
C. Epidural Anesthesia
D. Paracervical Block

Explanation: ***Spinal Anesthesia*** - Provides **rapid onset** and dense sensory and motor block, which is ideal for a quick procedure like manual placental removal. - The **uterine atony** associated with spinal anesthesia, while a concern, is less pronounced or easier to manage than the deep relaxation often seen with general anesthesia, especially with inhaled anesthetics. *General Anesthesia (GA)* - Can lead to significant **uterine relaxation** (atony), increasing the risk of postpartum hemorrhage, especially with volatile anesthetics. - While it provides excellent pain control, the associated risks of airway management, aspiration, and deeper uterine relaxation make it less desirable as a primary choice. *Epidural Anesthesia* - Provides good analgesia but has a **slower onset** of full surgical anesthesia compared to spinal, which may be critical in an urgent situation. - While it can be titrated to achieve surgical depth, it might not provide the rapid, dense motor block required for comfortable and efficient manual removal. *Paracervical Block* - Primarily provides analgesia to the **cervix and lower uterine segment**, but offers insufficient pain relief for the fundal manipulation and full uterine exploration required during manual placental removal. - This block does not adequately anesthetize the entire uterus or provide the necessary muscle relaxation for a comfortable and safe procedure.

Question 6: A two month old infant has undergone a major surgical procedure. Regarding postoperative pain relief which one of the following is recommended:

A. Spinal narcotics intrathecal route
B. Intravenous narcotic infusion in lower dosage (Correct Answer)
C. Only paracetamol suppository is adequate
D. No medication is needed as infant does not feel pain after surgery due to immaturity of nervous system

Explanation: ***Intravenous narcotic infusion in lower dosage*** - **Intravenous narcotic infusion** provides continuous pain relief and allows for careful titration of the dose, which is crucial in infants due to their developing metabolism and increased sensitivity to opioids. - Lower dosages are recommended because infants have a **reduced capacity for drug metabolism** and excretion, making them more susceptible to side effects like respiratory depression. *Spinal narcotics intrathecal route* - While effective, the **intrathecal route** carries risks such as neurotoxicity and spinal cord injury, which are particularly concerning in infants due to their small size and developing neural structures. - The **pharmacokinetics** of intrathecal narcotics can also be unpredictable in infants, leading to potential for delayed respiratory depression. *Only paracetamol suppository is adequate* - For **major surgical procedures**, a single agent like **paracetamol** is typically insufficient to manage severe postoperative pain effectively. - While paracetamol is a useful adjunct, it lacks the potent analgesic effects of opioids needed for comprehensive pain control after significant surgery. *No medication is needed as infant does not feel pain after surgery due to immaturity of nervous system* - This statement is **incorrect** and a dangerous misconception; infants, even neonates, have a **fully developed pain pathway**, perceive pain, and require appropriate analgesia. - The **pain response** in infants can be more exaggerated due to an immature inhibitory pain system, necessitating careful and effective pain management.

Question 7: Which of the following is advised for severe preeclampsia complicating cesarean delivery?

A. Epidural anesthesia (Correct Answer)
B. Local infiltration
C. Spinal anesthesia
D. Combined spinal-epidural anesthesia

Explanation: ***Epidural anesthesia*** - **Epidural anesthesia** allows for a **gradual decrease in sympathetic tone** and blood pressure, which is beneficial in severe preeclampsia to avoid rapid hemodynamic changes. - It also provides excellent postoperative analgesia and can be used for **blood pressure control** if needed. *Local infiltration* - **Local infiltration** provides inadequate surgical anesthesia for a cesarean delivery and would be insufficient for pain management. - It does not offer any systemic benefits or control over the hemodynamic instability often seen in severe preeclampsia. *Spinal anesthesia* - **Spinal anesthesia** is generally contraindicated in severe preeclampsia due to the risk of a **sudden and profound drop in blood pressure**, which can compromise placental perfusion and maternal vital signs. - The rapid onset and intense sympathetic blockade can lead to **uncontrolled hypotension**, which is dangerous given the already compromised cardiovascular status. *Combined spinal-epidural anesthesia* - While **combined spinal-epidural (CSE)** offers rapid onset (spinal component) and titratability (epidural component), the **spinal component still carries the risk of significant hypotension**, similar to spinal anesthesia alone. - The initial rapid drop in blood pressure from the spinal component can be detrimental in a patient with severe preeclampsia, despite the subsequent epidural control.

Question 8: What is the anesthesia of choice for cesarean section in patients with severe pre-eclampsia?

A. Epidural
B. GA
C. Spinal+epidural
D. Spinal (Correct Answer)

Explanation: ***Spinal*** - **Spinal anesthesia** is generally preferred due to its **rapid onset**, effective block, and minimal fetal exposure to drugs, which is crucial in pre-eclampsia where maternal and fetal well-being are compromised. - It provides **hemodynamic stability** and avoids the risks associated with general anesthesia in patients with severe pre-eclampsia, such as difficult airway and exaggerated pressor response to intubation. *GA* - **General anesthesia** is associated with significant maternal risks in severe pre-eclampsia, including a higher incidence of **difficult or failed intubation**, severe **hypertension** during intubation, and aspiration risks. - There is also a greater potential for **fetal depression** due to anesthetic drug transfer across the placenta. *Epidural* - While an **epidural** can be used, its **slower onset** and the need for incremental dosing make it less ideal for urgent cesarean sections compared to the rapid onset of spinal anesthesia. - It also carries a higher risk of **intravascular injection** and systemic toxicity if local anesthetics are inadvertently administered into the bloodstream. *Spinal+epidural* - A **combined spinal-epidural (CSE)** offers both rapid onset (from the spinal component) and flexibility for prolonged surgical time or post-operative pain control (from the epidural component). - However, in cases of severe pre-eclampsia, the **complexity of the procedure** and the potential for a larger drop in blood pressure with a combined block might be less favorable than a simple spinal, especially if time is critical.

Question 9: The Anaesthesia technique of choice in severely preeclamptic women for cesarean delivery -

A. Spinal Anaesthesia (Correct Answer)
B. General Anaesthesia
C. Epidural Anaesthesia
D. Pudendal block

Explanation: ***Spinal Anaesthesia*** - **Spinal anaesthesia** is generally preferred due to its rapid onset, excellent muscle relaxation, and better hemodynamic stability compared to general anaesthesia when careful fluid management is in place. - It avoids the risks associated with **difficult airway management** and aspiration in preeclamptic patients and minimizes fetal drug exposure. *General Anaesthesia* - **General anaesthesia** carries a higher risk of **rapid, unpredictable increases in blood pressure** during tracheal intubation and extubation, which can be dangerous in preeclampsia with an already compromised cardiovascular system. - It is associated with increased risks of **aspiration**, **difficult airway**, and **postoperative respiratory complications** in preeclamptic women. *Epidural Anaesthesia* - While generally safe, **epidural anaesthesia** has a slower onset compared to spinal anaesthesia, which may not be ideal in emergency situations requiring rapid delivery. - The titration of an epidural can be more challenging in patients with severe preeclampsia, where rapid changes in blood pressure need careful management. *Pudendal block* - A **pudendal block** provides local anaesthesia to the perineum, vulva, and lower vagina. - It is used for pain relief during vaginal delivery and is unsuitable for a **cesarean section**, which requires anaesthesia of the abdominal wall and uterus.

Question 10: Anesthesia of choice for cesarean section in severe preeclampsia:-

A. Spinal (Correct Answer)
B. GA
C. Epidural
D. Combined spinal-epidural (CSE)

Explanation: ***Spinal*** - **Spinal anesthesia** is generally preferred in severe preeclampsia because it provides **rapid onset** of dense block, which can be critical for emergent cesarean sections. - It avoids the risks associated with general anesthesia in these patients, such as difficult intubation and exaggerated **hypertensive response** to laryngoscopy. *GA* - **General anesthesia (GA)** in severe preeclampsia carries increased risks due to **airway edema**, potential for difficult intubation, and significant **blood pressure fluctuations** during induction and intubation. - It can exacerbate the already compromised uteroplacental perfusion due to the sympathetic blockade and the potential for a **hypotensive episode**. *Epidural* - While generally safe in less severe preeclampsia, an **epidural** has a **slower onset** compared to spinal anesthesia, which may be a disadvantage in emergent situations. - The gradual sympathetic blockade with an epidural is often preferred to avoid sudden drops in blood pressure, but the delay in achieving a surgical block might not be acceptable in severe, unstable cases. *Combined spinal-epidural (CSE)* - **Combined spinal-epidural (CSE)** offers the rapid onset of a spinal block with the flexibility of an epidural catheter for prolonged anesthesia or postoperative pain control. - However, in cases of severe preeclampsia where **hemodynamic instability** is a major concern, the relatively larger dose of local anesthetic required for epidural component can lead to a more pronounced or rapid drop in blood pressure.

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