Dystocia and Abnormal Labor Patterns — MCQs
In a multipara, the most common cause of postpartum hemorrhage is?
What is the first-line maneuver for management of shoulder dystocia?
Which type of pelvis is most commonly associated with dystocia?
Which of these steps is followed first for the management of shoulder dystocia after McRoberts maneuver?
Which of the following is NOT an indicator of impending uterine rupture during labor?
Absolute indication for cesarean section is :
A primigravida is in labor. Her per-vaginal examination revealed a posterior cervix with 5 cm cervical length, 1 cm dilatation, soft consistency, and head at -1 station. Calculate the Bishop score.
What maternal condition is commonly associated with congenital heart defects in the fetus?
A 20 year old primigravida is admitted with full term pregnancy and labour pains. At 4 A.M. she goes into active phase of labour with 4 cm cervical dilatation. Membranes rupture during p/v examination showing clear liquor. A repeat p/v after 4 hours of good uterine contractions reveals a cervical dilatation of 5 cm. What should be the next step in management?
True about uterine rupture during labor:
Dystocia and Abnormal Labor Patterns Indian Medical PG Practice Questions and MCQs
Question 1: In a multipara, the most common cause of postpartum hemorrhage is?
- A. Retained placenta
- B. Uterine atonicity (Correct Answer)
- C. Uterine perforation
- D. Fibroid in the uterus
Explanation: ***Uterine atonicity*** - This is the **most common cause** of postpartum hemorrhage, especially in multiparous women, where the uterus may have lost some of its tone from previous pregnancies. - After delivery, the uterus normally contracts to compress blood vessels and prevent excessive bleeding; **uterine atony** prevents this essential contraction. *Retained placenta* - While a significant cause of postpartum hemorrhage, it is less common than uterine atony overall and often presents with a **non-contracted uterus** despite attempts at fundal massage. - The placenta or fragments of it remain in the uterus, preventing complete uterine contraction and leading to continuous bleeding. *Uterine perforation* - This is a rare and usually iatrogenic cause of postpartum hemorrhage, often associated with operative procedures during delivery or uterine instrumentation. - It involves a tear in the uterine wall, leading to bleeding into the abdominal cavity, which is distinct from the typical presentation of postpartum hemorrhage. *Fibroid in the uterus* - Uterine fibroids can contribute to postpartum hemorrhage by interfering with the uterus's ability to contract effectively after delivery. - However, they are **not the most common cause**; their presence increases the risk, but uterine atony remains the predominant reason for excessive bleeding.
Question 2: What is the first-line maneuver for management of shoulder dystocia?
- A. 90 degree rotation of posterior shoulder
- B. Emergency c-section
- C. Supra pubic pressure
- D. Sharp flexion of hip joints towards abdomen (Correct Answer)
Explanation: ***Sharp flexion of hip joints towards abdomen*** - This maneuver, known as the **McRoberts maneuver**, widens the anterior-posterior diameter of the **pelvis** and flattens the sacrum. - It increases the likelihood of dislodging the impacted fetal shoulder from behind the symphysis pubis. *Supra pubic pressure* - **Suprapubic pressure** is applied to the fetal anterior shoulder to dislodge it from the symphysis pubis and guide it under the maternal pubic bone. - This maneuver is typically performed *in conjunction with* the McRoberts maneuver, but the question specifies "sharp flexion of hip joints towards abdomen," which is McRoberts alone. *90 degree rotation of posterior shoulder* - This describes the **Woods screw maneuver**, which involves rotating the posterior shoulder to facilitate delivery. It is a secondary maneuver used if McRoberts and suprapubic pressure are insufficient. - The question asks for the primary management step, and the McRoberts maneuver (sharp flexion) is usually the first line of intervention. *Emergency c-section* - An **emergency C-section** is generally not indicated for the acute management of shoulder dystocia once the head has delivered, as it is a **delivery complication** happening during vaginal birth. - Management focuses on specific maneuvers to release the impacted shoulders through the vagina.
Question 3: Which type of pelvis is most commonly associated with dystocia?
- A. Android (Correct Answer)
- B. Platypelloid
- C. Gynaecoid
- D. Anthropoid
Explanation: ***Android*** - The **android pelvis** has a **heart-shaped inlet** and converging side walls, which significantly increases the risk of **dystocia** due to restricted passage for the fetal head. - This pelvic shape is more common in men but can also be found in women, leading to a higher likelihood of **cephalopelvic disproportion**. *Platypelloid* - The **platypelloid pelvis** has a **flattened oval inlet** with a short anteroposterior diameter and a wide transverse diameter. - While it can lead to difficulties with engagement and rotation, it is not as commonly associated with severe dystocia as the android type, as the fetal head can often rotate to fit. *Gynaecoid* - The **gynaecoid pelvis** is considered the **ideal female pelvis** with a rounded or slightly oval inlet and well-proportioned diameters. - It is associated with the **easiest and most successful vaginal deliveries** and therefore is least likely to cause dystocia. *Anthropoid* - The **anthropoid pelvis** has an **oval inlet** with a long anteroposterior diameter and a relatively short transverse diameter. - While it can sometimes lead to an **occiput-posterior presentation**, it is not as strongly associated with dystocia as the android pelvis.
Question 4: Which of these steps is followed first for the management of shoulder dystocia after McRoberts maneuver?
- A. 90 degree rotation of posterior shoulder
- B. Emergency c-section
- C. Suprapubic pressure (Correct Answer)
- D. Sharp flexion of hip joints towards abdomen
Explanation: ***Suprapubic pressure*** - After performing the **McRoberts maneuver**, applying **suprapubic pressure** is the next step to aid in dislodging the anterior shoulder from behind the pubic symphysis. - This maneuver helps to adduct the fetal shoulders and rotates the anterior shoulder into a more oblique diameter, often allowing for delivery. *90-degree rotation of posterior shoulder* - This describes components of the **Wood's screw maneuver**, which, while effective, is typically attempted *after* suprapubic pressure if initial maneuvers fail. - The Wood's screw maneuver involves rotating the fetal shoulders to disimpact the anterior shoulder, but it is not the *first* step following McRoberts and suprapubic pressure. *Emergency C-section* - An **emergency C-section** is reserved for cases where all other *manual maneuvers* have failed to resolve shoulder dystocia and is not a primary or early step in the management algorithm. - The goal is to first attempt less invasive maneuvers to deliver the baby vaginally, as a C-section carries its own set of risks. *Sharp flexion of hip joints towards abdomen* - This action describes the **McRoberts maneuver** itself, which involves hyperflexing the mother's hips towards her abdomen to flatten the sacrum and rotate the symphysis pubis cephalad. - The question asks for the step *after* McRoberts maneuver, not the maneuver itself.
Question 5: Which of the following is NOT an indicator of impending uterine rupture during labor?
- A. Passage of meconium (Correct Answer)
- B. Hematuria
- C. Fresh bleeding per vaginum
- D. Fetal distress
Explanation: ***Passage of meconium*** - While **meconium passage** in labor is a sign of **fetal stress** or hypoxia, it is not a direct indicator of impending uterine rupture. - It results from increased vagal tone and relaxation of the anal sphincter, often in response to **fetal compromise**, but doesn't specifically point to uterine integrity. *Fetal distress* - **Fetal distress**, as indicated by persistent **fetal heart rate abnormalities** (e.g., late decelerations, prolonged bradycardia), can be a critical sign of impending uterine rupture due to disrupted placental blood flow. - The sudden onset of these changes, especially after a period of normal tracing, should raise high suspicion. *Hematuria* - **Hematuria** (blood in the urine) during labor can result from trauma to the **bladder** caused by the stretching or tearing of the lower uterine segment, which often precedes rupture. - It signifies that the bladder is being compromised or directly damaged, indicating severe pressure or injury alongside uterine compromise. *Fresh bleeding per vaginum* - **Fresh, bright red vaginal bleeding** in labor, especially if sudden and not associated with cervical changes, is a significant sign of impending or actual **uterine rupture**. - This blood often originates from the disrupted uterine vessels and indicates a loss of uterine integrity.
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 primigravida is in labor. Her per-vaginal examination revealed a posterior cervix with 5 cm cervical length, 1 cm dilatation, soft consistency, and head at -1 station. Calculate the Bishop score.
- A. 5 (Correct Answer)
- B. 0
- C. 8
- D. 3
Explanation: ***5*** - The Bishop score calculation: **cervical position** (posterior = 0), **cervical effacement** (5 cm length = 0), **dilation** (1 cm = 1), **consistency** (soft = 2), and **station** (-1 = 1). - According to standard **Dutta textbook** references, this totals to 5 points (0 + 0 + 1 + 2 + 1), with soft consistency correctly scoring 2 points. *3* - This score incorrectly assigns only **1 point for soft consistency** instead of the standard 2 points. - The miscalculation underestimates the **cervical readiness** for labor induction. *0* - A score of 0 would require all parameters to be at their **minimum values** (firm consistency, closed cervix, high station). - The given parameters show **1 cm dilation**, **soft consistency**, and **-1 station**, each contributing positive points. *8* - A high score of 8 indicates a **very favorable cervix** with significant effacement, anterior position, and greater dilation. - The current findings show **minimal effacement** (5 cm length), **posterior position**, and only **1 cm dilation**, inconsistent with such a high score.
Question 8: What maternal condition is commonly associated with congenital heart defects in the fetus?
- A. ACE inhibitor
- B. GDM
- C. Pregestational DM (Correct Answer)
- D. Valproate
Explanation: ***Pregestational DM*** - **Pre-existing diabetes** in the mother is a significant risk factor for various **congenital anomalies**, including **congenital heart defects**, due to suboptimal glycemic control during early embryogenesis. - Poorly controlled **maternal hyperglycemia** leads to increased oxidative stress and altered cellular metabolism in the developing fetus, impacting cardiovascular development. *ACE inhibitor* - **ACE inhibitors** are teratogenic, primarily causing **renal dysfunction** (e.g., renal tubular dysplasia, oligohydramnios, anuria) and **fetal growth restriction**, especially when used in the second and third trimesters. - While they can have adverse fetal effects, their association with **congenital heart defects** is less pronounced compared to other teratogenic exposures. *GDM* - **Gestational diabetes mellitus (GDM)** typically develops in the second or third trimester when major organogenesis is complete, making its association with **structural congenital anomalies**, including heart defects, significantly lower than pregestational diabetes. - GDM is more commonly associated with fetal **macrosomia**, **hypoglycemia**, and respiratory distress syndrome at birth. *Valproate* - **Valproate** is a known teratogen associated with a specific pattern of anomalies, most notably **neural tube defects** (e.g., spina bifida), and facial dysmorphisms. - While it can be associated with an increased risk of some congenital heart defects, its primary and most significant fetal risk is **neural tube defects**.
Question 9: A 20 year old primigravida is admitted with full term pregnancy and labour pains. At 4 A.M. she goes into active phase of labour with 4 cm cervical dilatation. Membranes rupture during p/v examination showing clear liquor. A repeat p/v after 4 hours of good uterine contractions reveals a cervical dilatation of 5 cm. What should be the next step in management?
- A. Oxytocin drip
- B. Reassess for occipitoposterior position and cephalopelvic disproportion (Correct Answer)
- C. Immediate caesarean section
- D. Reassess after 4 hours
Explanation: ***Reassess for occipitoposterior position and cephalopelvic disproportion*** - The patient has **protracted active phase** with only 1 cm cervical dilatation in 4 hours (from 4 cm to 5 cm), which is significantly slower than the expected rate of at least 1 cm/hour in primigravidas. - Crucially, the question states she has **"good uterine contractions"**, which means the slow progress is NOT due to inadequate uterine activity. - When labor progress is slow DESPITE adequate contractions, this indicates a **mechanical obstruction** such as occipitoposterior position, cephalopelvic disproportion, asynclitism, or other malpresentation. - The next step is to **assess for these mechanical factors** through clinical examination (abdominal palpation, vaginal examination to assess position, station, molding, caput) before considering augmentation. - **Augmentation with oxytocin is contraindicated** when contractions are already adequate, as it may lead to uterine hyperstimulation without improving progress if there's mechanical obstruction. *Oxytocin drip* - Oxytocin augmentation is indicated for **hypotonic uterine dysfunction** (inadequate contractions causing slow progress). - In this case, contractions are described as **"good"**, so oxytocin is NOT appropriate as the first-line intervention. - Using oxytocin when contractions are already adequate without first ruling out mechanical obstruction can be dangerous and may lead to uterine rupture or fetal compromise. *Immediate caesarean section* - While caesarean section may ultimately be needed if mechanical obstruction is confirmed, it is **premature** without first assessing the cause of slow progress. - A diagnosis must be established before proceeding to operative delivery. *Reassess after 4 hours* - Further expectant management without intervention or diagnosis is **inappropriate** as the patient has already demonstrated inadequate progress. - Prolonged labor increases risks of maternal exhaustion, infection, and fetal compromise. - Active management requires diagnosis and intervention, not continued observation.
Question 10: True about uterine rupture during labor:
- A. Not associated with fetal distress
- B. Best treated conservatively
- C. Always causes pain
- D. Occurs more with previous cesarean (Correct Answer)
Explanation: ***Occurs more with previous cesarean*** - A prior **cesarean section** poses a significant risk factor for uterine rupture during subsequent labors due to the presence of a uterine scar that can dehisce. - The risk of uterine rupture increases with the number of previous C-sections, especially in cases of short inter-pregnancy intervals or specific types of uterine incisions. *Not associated with fetal distress* - **Fetal distress** is a very common and critical sign of uterine rupture, often manifesting as sudden **severe bradycardia** or **late decelerations** due to placental compromise or direct fetal injury. - The disruption of the uterine wall can lead to **hypoxia, acidosis, and fetal demise** if not urgently addressed. *Best treated conservatively* - **Uterine rupture is a medical emergency** requiring **immediate surgical intervention**, typically a **laparotomy** for repair of the uterus and delivery of the fetus. - Conservative management is generally inappropriate and can lead to **severe maternal hemorrhage, fetal anoxia, and death** due to rapid blood loss and lack of oxygen to the fetus. *Always causes pain* - While often accompanied by **sudden, severe abdominal pain**, uterine rupture can sometimes present with less obvious symptoms, particularly if it's a **dehiscence of an old scar** without complete rupture. - In some cases, the primary sign might be **fetal distress** or **vaginal bleeding** with minimal maternal pain, especially if the mother has an **epidural analgesia** in place masking pain.
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