Cesarean Section: Indications and Techniques — MCQs
Common indications for caesarean section in primigravidae are all except?
Classical cesarean section is done in?
Which is not an indication for a classical cesarean incision?
Incidence of scar rupture in previous lower segment caesarean section:
An absolute indication for Classical cesarean section is :
Absolute indication for cesarean section is :
A pregnant woman comes at 40 weeks' gestation, with a fundal height measuring 34 cm. USG shows a maximum vertical pocket of liquor less than 2 cm and an AFI of 3 cm. Which of the following statements is false regarding the management of this case scenario?
Which maneuver is not performed for shoulder dystocia?
A pregnant female presents with active herpetic lesions on the vulva. What is the most appropriate management?
What is the risk of scar rupture in the lower segment of the uterus in patients with a previous cesarean section?
Cesarean Section: Indications and Techniques Indian Medical PG Practice Questions and MCQs
Question 1: Common indications for caesarean section in primigravidae are all except?
- A. Cephalopelvic disproportion
- B. Dystocia
- C. Malpresentation
- D. Failed induction (Correct Answer)
Explanation: ***Failed induction*** - While a reason for caesarean section, **failed induction** is typically more common in **multigravidae** due to a less favorable cervix or prior uterine scarring, and is less frequently the *initial* indication in primigravidae, who are often started on induction during their first pregnancy. - The other options represent more common, primary indications for caesarean section in **primigravidae**. *Cephalopelvic disproportion* - This is a significant indication in **primigravidae** where the baby's head is too large to pass through the mother's pelvis, often discovered during labor. - The unproven nature of the pelvis in a first pregnancy makes this a common reason for caesarean delivery. *Dystocia* - Refers to **difficult or prolonged labor**, which is a very common indication for caesarean section in **primigravidae**. - This can be due to abnormal uterine contractions, fetal malposition, or cephalopelvic disproportion. *Malpresentation* - Presentations such as **breech** or **transverse lie** are common indications for planned or emergency caesarean sections, especially in **primigravidae**. - Without prior vaginal deliveries, a trial of labor with malpresentation is generally considered riskier.
Question 2: Classical cesarean section is done in?
- A. Placenta previa
- B. Previous cesarean
- C. Carcinoma Cervix (Correct Answer)
- D. Extremely preterm delivery
Explanation: ***Carcinoma Cervix*** - A classical cesarean section, involving a **vertical incision into the fundus of the uterus**, is performed in carcinoma cervix to avoid cutting through **malignant tissue** in the lower uterine segment or cervix. - This is an **absolute indication** to prevent **tumor dissemination** and seeding of malignant cells in the peritoneal cavity. - The incision is made in the upper segment, well away from the cervical pathology. *Placenta previa* - Placenta previa requires cesarean delivery, but a **low transverse uterine incision** (lower segment cesarean section) is the standard approach. - Classical cesarean is **not indicated** for placenta previa alone, as the lower segment can be safely accessed in most cases. - Only in exceptional circumstances (such as anterior placenta previa with poorly developed lower segment) might a classical approach be considered. *Previous cesarean* - A previous cesarean section is **not an indication** for classical cesarean in subsequent deliveries. - A **repeat low transverse cesarean section** or **trial of labor after cesarean (TOLAC)** is the standard approach. - Classical cesarean is only performed if the previous cesarean was classical (which increases rupture risk) and only when lower segment access is not feasible. *Extremely preterm delivery* - While extremely preterm delivery (typically **< 28 weeks**) may be a **relative indication** when the lower uterine segment is poorly developed, it is not an absolute indication. - In most cases, a **low vertical incision** or careful low transverse incision can be performed. - Classical incision is reserved for situations where lower segment access is truly inadequate, making this a **context-dependent** rather than absolute indication. - Compared to carcinoma cervix, this is a less definitive indication for classical cesarean section.
Question 3: Which is not an indication for a classical cesarean incision?
- A. Premature breech
- B. Cannot visualize the lower uterine segment
- C. Transverse lie
- D. Term breech (frank) (Correct Answer)
Explanation: ***Term breech (frank)*** - A **frank breech** presentation at term does not inherently require a classical (vertical) incision, as a **low transverse incision** is generally safe and preferred for its lower risk of uterine rupture in subsequent pregnancies. - The decision for incision type is based more on the accessibility of the **lower uterine segment** and fetal lie than on the specific type of breech at term. *Premature breech* - In a premature fetus, the **lower uterine segment** may be underdeveloped and insufficient to allow safe extraction through a low transverse incision. - A **classical incision** provides a larger opening in the thicker, upper uterine segment, which is safer for a fragile preterm infant. *Cannot visualize the lower uterine segment* - Conditions like **dense adhesions** from prior surgeries, a large **leiomyoma**, or an **anterior placenta previa** can obscure or make the lower uterine segment inaccessible. - In such cases, a **classical incision** in the more visible and accessible upper uterine corpus is indicated to safely deliver the fetus. *Transverse lie* - A **transverse lie** means the fetus is lying horizontally across the uterus, often making a **low transverse incision** difficult or impossible due to the fetal position. - A **classical incision** allows for a larger, more vertical opening that accommodates the fetal spine and shoulders, facilitating safe extraction.
Question 4: Incidence of scar rupture in previous lower segment caesarean section:
- A. 5%
- B. 7%
- C. 6%
- D. 1% (Correct Answer)
Explanation: ***1%*** - The incidence of **uterine rupture** in a subsequent pregnancy after a **low transverse uterine incision** (previous lower segment caesarean section) is approximately **0.5-1%**. This low risk allows for considering a trial of labor after cesarean (TOLAC) in appropriate candidates. - This value represents the general risk and is a critical factor in counseling patients about the safety of **vaginal birth after cesarean (VBAC)**. *5%* - An incidence of **5%** for scar rupture is significantly higher than what is observed for a **lower segment caesarean section**. - This higher percentage might be associated with a **classical uterine incision** (vertical incision in the upper uterine segment) which carries a much greater risk of uterine rupture. *7%* - A **7%** incidence of scar rupture is also substantially higher than the typical risk associated with a previous **lower segment caesarean section**. - This rate would generally be considered prohibitive for most cases of **TOLAC** due to the increased maternal and fetal risks. *6%* - An incidence of **6%** for scar rupture is not consistent with the known rates for a **lower segment caesarean section**. - This figure indicates a risk much higher than the actual average and would likely lead to recommendations against **TOLAC**.
Question 5: An absolute indication for Classical cesarean section is :
- A. Central Placenta Previa
- B. Breech presentation
- C. Carcinoma cervix (Correct Answer)
- D. Multi-fibroid uterus
Explanation: ***Carcinoma cervix*** - A **classical cesarean section** (vertical incision in the uterine body) is indicated in cases of **carcinoma of the cervix** to minimize trauma to the cervix and prevent dissemination of cancer cells. - This approach avoids cutting through the cancerous tissue, which might be necessary with a lower uterine segment incision. *Central Placenta Previa* - While **placenta previa** often necessitates a cesarean section, a **lower segment cesarean section** (LSCS) is generally preferred due to less blood loss and better healing. - A classical cesarean section would only be considered in specific, rare circumstances for placenta previa, such as an exceptionally previa anterior placenta or severe hemorrhage requiring rapid extraction, but it is not an absolute, primary indication. *Breech presentation* - **Breech presentations** are often delivered by **lower segment cesarean section** (LSCS) due to potential risks associated with vaginal delivery. - A classical cesarean section is rarely indicated for breech presentation, typically only for very premature fetuses or if the lower uterine segment is inaccessible. *Multi-fibroid uterus* - A **multi-fibroid uterus** itself is not an absolute indication for a classical cesarean section unless the fibroids obstruct the lower uterine segment, preventing an LSCS. - In most cases, a **lower segment cesarean section** can still be performed, sometimes with careful navigation around or removal of obstructing fibroids (myomectomy at C-section).
Question 6: Absolute indication for cesarean section is :
- A. Breech presentation
- B. Dystocia
- C. Fetal distress
- D. Previous rupture of uterus (Correct Answer)
Explanation: ***Previous rupture of uterus*** - A prior **rupture of the uterus** creates a significant risk of **re-rupture** in subsequent pregnancies with labor contractions, posing a severe threat to both maternal and fetal life. - Due to the high risk of catastrophic hemorrhage and fetal distress, **elective cesarean section** before the onset of labor is mandated to prevent recurrence. *Breech presentation* - While many breech presentations result in a cesarean section, it is not an absolute indication, as **vaginal breech delivery** can be attempted in selected cases under strict criteria. - Factors like type of breech, estimated fetal weight, and maternal pelvis can influence the decision, making it a relative rather than an absolute indication. *Dystocia* - **Dystocia**, or difficult labor, is a common reason for cesarean section, but often interventions like **oxytocin augmentation** or **instrumental delivery** (forceps, vacuum) are attempted first. - A cesarean section is indicated when dystocia is severe or fails to respond to other measures, making it a relative indication based on progression of labor. *Fetal distress* - **Fetal distress**, indicated by non-reassuring fetal heart rate patterns, often necessitates prompt delivery, but the mode of delivery depends on the clinical situation. - If vaginal delivery is imminent and safe, it may be preferred, but if not, **cesarean section** is performed; therefore, it's an urgent relative indication rather than an absolute one.
Question 7: A pregnant woman comes at 40 weeks' gestation, with a fundal height measuring 34 cm. USG shows a maximum vertical pocket of liquor less than 2 cm and an AFI of 3 cm. Which of the following statements is false regarding the management of this case scenario?
- A. Do induction if vaginal delivery is not contraindicated
- B. During labour, cord compression is common in these patients
- C. Strict intrapartum fetal surveillance
- D. If cervix is unripe, immediate LSCS should be considered (Correct Answer)
Explanation: ***If cervix is unripe, immediate LSCS should be considered.*** - This statement is **false**. In cases of **oligohydramnios** at term, particularly with a favorable cervix, **labor induction** is generally preferred over immediate C-section. - An unripe cervix does not automatically necessitate an immediate C-section; rather, cervical ripening agents (e.g., prostaglandins) can be used to prepare the cervix for induction. *Do induction if vaginal delivery is not contraindicated* - This is a **correct management strategy** for oligohydramnios at term, provided there are no contraindications to vaginal birth (e.g., placenta previa, severe fetal distress pre-labor). - **Induction** allows for controlled labor and delivery with close fetal monitoring. *During labour, cord compression is common in these patients* - This statement is **true**. **Oligohydramnios** (AFI ≤ 5 cm or maximum vertical pocket < 2 cm) significantly increases the risk of **umbilical cord compression** during labor. - Reduced amniotic fluid means less cushioning protection for the umbilical cord, leading to potential variable decelerations and fetal compromise. *Strict intrapartum fetal surveillance* - This statement is **true** and crucial for managing oligohydramnios during labor. Given the increased risk of **fetal compromise** (e.g., from cord compression), continuous electronic fetal monitoring is essential. - This allows for early detection of **fetal distress** and timely intervention, if necessary.
Question 8: Which maneuver is not performed for shoulder dystocia?
- A. Wood's maneuver
- B. Zavanelli maneuver
- C. McRoberts maneuver
- D. Mauriceau-Smellie-Veit technique (Correct Answer)
Explanation: ***Mauriceau-Smellie-Veit technique*** - This technique is a maneuver used in the delivery of the **aftercoming head** in a **breech presentation**, not for shoulder dystocia. - It involves **flexing the fetal head** upon the chest to facilitate delivery, often requiring an assistant to apply pressure above the symphysis. *McRoberts maneuver* - The **McRoberts maneuver** is a common and effective initial intervention for shoulder dystocia, involving hyperflexion of the mother's hips towards her abdomen [1]. - This action changes the **pelvic tilt**, rotating the symphysis pubis superiorly to free the impacted shoulder [1]. *Wood's maneuver* - **Wood's maneuver** is a technique used to resolve shoulder dystocia, where the posterior shoulder is rotated to a more oblique diameter within the maternal pelvis [1]. - This involves applying pressure to the posterior aspect of the fetal clavicle to spin the shoulder. *Zavanelli maneuver* - The **Zavanelli maneuver** is a rare and extreme intervention for severe shoulder dystocia, involving the **replacement of the fetal head back into the uterus** for subsequent cesarean delivery. - It involves head flexion, reverse rotation, and pushing the head back into the vagina to allow for a laparotomy.
Question 9: A pregnant female presents with active herpetic lesions on the vulva. What is the most appropriate management?
- A. Wait & watch
- B. Acyclovir & elective cesarean section (C-section) (Correct Answer)
- C. Acyclovir & allow spontaneous progression of labor
- D. Induction of labor
Explanation: ***Acyclovir & elective cesarean section (C-section)*** - Active **genital herpetic lesions** at the time of delivery pose a significant risk of transmitting **herpes simplex virus (HSV)** to the neonate. - **Acyclovir** can help suppress viral replication, but a **cesarean section** is necessary to prevent direct contact with the lesions during birth, which could lead to severe neonatal HSV infection. *Wait & watch* - This approach is inappropriate due to the high risk of **vertical transmission** of HSV to the neonate if lesions are active during vaginal delivery, potentially causing life-threatening complications. - **Neonatal HSV** can result in significant morbidity and mortality, including neurological damage and disseminated disease. *Acyclovir & allow spontaneous progression of labor* - While **acyclovir** can reduce viral load, it does not completely eliminate the risk of transmission from active lesions during a vaginal birth. - The primary concern is protecting the neonate from direct contact with the **active lesions** in the birth canal. *Induction of labor* - **Induction of labor** does not mitigate the risk of **vertical transmission** from active lesions during a vaginal delivery. - The focus should be on preventing contact with the lesions, not on expediting vaginal birth once active lesions are present.
Question 10: What is the risk of scar rupture in the lower segment of the uterus in patients with a previous cesarean section?
- A. 0.5 - 1.5% (Correct Answer)
- B. 15 - 25%
- C. 2.5 - 3.5%
- D. 3.5 - 4.5%
Explanation: ***0.5 - 1.5%*** - The risk of **uterine scar rupture** in a **lower segment Cesarean section** (LSCS) is generally low, ranging from 0.5% to 1.5% during a Trial of Labor After Cesarean (TOLAC). - This low risk is why **Vaginal Birth After Cesarean (VBAC)** is often considered a safe option for selected patients. *15 - 25%* - This percentage is significantly higher than the actual risk for a **lower segment Cesarean scar rupture**. Risks this high would generally lead to reconsideration of VBAC as a safe option. - Such a high risk is usually associated with a **classical (vertical) incision** on the uterus or multiple previous Cesarean sections. *2.5 - 3.5%* - This range is higher than the typical risk for a single **lower segment Cesarean scar rupture**. - While still relatively low, it might be observed in specific populations or with certain risk factors like a short inter-delivery interval or a single-layer uterine closure. *3.5 - 4.5%* - This risk is considerably elevated compared to the established risk for a **lower segment Cesarean scar rupture** and would generally lead to a more cautious approach to TOLAC. - This range can be associated with specific risk factors for scar dehiscence or rupture such as a history of multiple previous Cesarean sections or certain uterine anomalies.
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