Induction and Augmentation of Labor — MCQs
Which drug is associated with decreased fetal heart rate during labor?
Active management of 3rd stage of labour involves all EXCEPT:
Which of the following is consistent with a decision to perform a cerclage?
Common indications for caesarean section in primigravidae are all except?
Misoprostol used in the induction of labour is an analogue of which of the following type of prostaglandin?
A 32 year old pregnant woman presents with 36 week pregnancy with complaints of pain abdomen and decreased fetal movements. Upon examination PR= 96/min, BP = 156/100 mm Hg, FHR = 128 bpm. On per-vaginum examination there is altered blood seen and cervix is soft 1 cm dilated. What is the preferred management?
A pregnant female presents with active herpetic lesions on the vulva. What is the most appropriate management?
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 pregnant lady with 37 weeks gestation has been admitted with a history of premature rupture of membranes for 6 hours. She is best treated with:
During delivery of HIV infected women, which of the following are recommended ? 1. Zidovudine (ZDV) is given at the onset of labour. 2. Elective caesarean delivery reduces the risk of vertical transmission. 3. Amniotomy and oxytocin augmentation should be done. 4. Antiretroviral therapy should be given to all neonates. Select the correct answer using the code given below :
Induction and Augmentation of Labor Indian Medical PG Practice Questions and MCQs
Question 1: Which drug is associated with decreased fetal heart rate during labor?
- A. Oxytocin (Correct Answer)
- B. Sodium bicarbonate
- C. IV fluids
- D. Iron
Explanation: ***Oxytocin*** - **Oxytocin** stimulates uterine contractions, which can reduce blood flow to the placenta and temporarily decrease **fetal oxygenation**, leading to **fetal heart rate decelerations**. - Overstimulation of the uterus by oxytocin can result in **tachysystole** (>5 contractions in 10 minutes), potentially causing **fetal hypoxia** and associated changes in fetal heart rate patterns such as late decelerations or bradycardia. *Sodium bicarbonate* - **Sodium bicarbonate** is used to correct metabolic acidosis, but it does not directly affect **fetal heart rate** or uterine activity in a way that causes decelerations. - Its administration is unlikely to impact fetal heart rate unless the underlying condition causing acidosis also affects fetal well-being, which is not a direct drug effect. *IV fluids* - **Intravenous fluids** are often administered during labor to maintain hydration and support maternal circulation, which generally helps improve **fetal well-being** and maintain normal fetal heart rate patterns. - They can help optimize **uterine perfusion**, thereby improving oxygen delivery to the fetus and reducing the risk of fetal distress. *Iron* - **Iron** is essential for red blood cell production and preventing maternal anemia; it has no direct or acute effect on **fetal heart rate** during labor. - Administered as a supplement, iron is not a medication used during labor to impact **uterine contractility** or fetal heart rate in the way oxytocin does.
Question 2: Active management of 3rd stage of labour involves all EXCEPT:
- A. IV oxytocin
- B. Delayed cord clamping
- C. Controlled cord traction
- D. Uterine massage (Correct Answer)
Explanation: ***Uterine massage*** - **Uterine massage** is performed *after* the delivery of the placenta to promote sustained uterine contraction and prevent **postpartum hemorrhage**. - While it's a crucial step in preventing excessive bleeding, it is not considered part of the *active management of the third stage of labor* as defined by WHO guidelines, which focuses on interventions *during* placental separation and expulsion. - Uterine massage is part of **routine postpartum care** rather than AMTSL itself. *IV oxytocin* - Administering **prophylactic uterotonic** (oxytocin 10 IU IM/IV) *immediately* after birth of the baby (within 1 minute) is a **core component** of active management. - Oxytocin stimulates uterine contractions to aid placental separation and significantly **reduces postpartum hemorrhage** risk. *Delayed cord clamping* - **Delayed cord clamping** (clamping the umbilical cord between 1-3 minutes after birth) is recommended by **current WHO guidelines** as part of active management. - This practice provides neonatal benefits (improved iron stores, better hemoglobin levels) while not increasing maternal hemorrhage risk. - This replaced the older practice of early cord clamping in modern AMTSL protocols. *Controlled cord traction* - **Controlled cord traction** with **counter-traction on the uterus** (Brandt-Andrews maneuver) is performed to facilitate placental delivery once signs of placental separation appear. - This maneuver **reduces the duration of third stage**, blood loss, and risk of retained placenta.
Question 3: Which of the following is consistent with a decision to perform a cerclage?
- A. Gestation of 26 weeks
- B. Uterine bleeding
- C. Uterine contractions
- D. Cervix dilated to 3 cm (Correct Answer)
Explanation: ***Cervix dilated to 3 cm*** - In the context of **mid-trimester cervical dilation** (before 24 weeks) without contractions or bleeding, this represents **cervical insufficiency** - a potential indication for **emergency (rescue) cerclage**. - While 3 cm dilation is at the **upper limit** and somewhat controversial, emergency cerclage may still be considered if membranes are intact, there are no contractions, and gestational age is <24 weeks. - This is the **only option** that represents a clinical scenario where cerclage might be performed, as the other three options are **absolute contraindications**. - Note: Most clinicians prefer cervical dilation **<2 cm** for rescue cerclage, but individual cases at 2-3 cm may be considered based on clinical judgment. *Gestation of 26 weeks* - Cerclage is typically placed between **12-14 weeks** (prophylactic) or up to **23-24 weeks** (emergency). - At **26 weeks**, cerclage is **contraindicated** - the risks (membrane rupture, infection, preterm labor) outweigh benefits at this advanced gestation. - This is an **absolute contraindication** regardless of cervical findings. *Uterine bleeding* - **Active uterine bleeding** is an **absolute contraindication** to cerclage placement. - Bleeding increases risks of **infection, membrane rupture, and preterm labor**. - Must rule out **placental abruption, placenta previa**, or other complications before considering any cervical intervention. *Uterine contractions* - **Active uterine contractions** are an **absolute contraindication** for cerclage. - Placing cerclage during contractions can precipitate **preterm labor and delivery**. - Contractions indicate the cervix may be responding to labor stimuli, making cerclage ineffective and potentially harmful.
Question 4: 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 5: Misoprostol used in the induction of labour is an analogue of which of the following type of prostaglandin?
- A. PG E1 (Correct Answer)
- B. PG E2
- C. PG I2
- D. PG F2alpha
Explanation: ***PG E1*** - **Misoprostol** is a synthetic analogue of **prostaglandin E1 (PGE1)**, which is used for cervical ripening and uterine contractions in labor induction. - PGE1 analogues help to soften the cervix, increase its compliance, and stimulate uterine smooth muscle contraction. *PG E2* - **Dinoprostone** is a synthetic analogue of **prostaglandin E2 (PGE2)**, commonly used for cervical ripening and induction of labor. - While PGE2 also induces labor, misoprostol specifically mimics the actions of PGE1. *PG I2* - **Prostacyclin (PGI2)** is primarily known for its role in inhibiting platelet aggregation and causing vasodilation. - It is not routinely used for labor induction due to its primary vascular effects and lack of direct uterine contractile properties at relevant doses. *PG F2alpha* - **Prostaglandin F2-alpha (PGF2α)**, such as **carboprost**, is used for postpartum hemorrhage to cause strong uterine contractions. - While it causes uterine contractions, its primary obstetric use is not for labor induction but rather for stimulating aggressive uterine contraction to stop bleeding.
Question 6: A 32 year old pregnant woman presents with 36 week pregnancy with complaints of pain abdomen and decreased fetal movements. Upon examination PR= 96/min, BP = 156/100 mm Hg, FHR = 128 bpm. On per-vaginum examination there is altered blood seen and cervix is soft 1 cm dilated. What is the preferred management?
- A. Observation and monitoring
- B. Perform cesarean section (Correct Answer)
- C. Initiate labor induction
- D. Administer medications to delay labor
Explanation: ***Perform cesarean section*** - The clinical presentation strongly suggests **placental abruption**: abdominal pain, decreased fetal movements, hypertension (risk factor), and altered blood per vaginum - **Decreased fetal movements** with FHR at 128 bpm (lower end of normal) indicates **potential fetal compromise** - At **36 weeks gestation**, the fetus is viable and immediate delivery is warranted when abruption is suspected with fetal distress - **Emergency cesarean section** is the preferred management for placental abruption with signs of fetal compromise, as it provides the fastest route to delivery - Attempting vaginal delivery in suspected abruption with fetal distress risks further compromise and maternal hemorrhage *Initiate labor induction* - Labor induction is **contraindicated** in suspected placental abruption with fetal compromise - Induction takes hours to achieve delivery, during which time the fetus may deteriorate further and maternal bleeding may worsen - The presence of altered blood, decreased fetal movements, and hypertension makes this a **high-risk scenario** requiring immediate delivery, not a gradual process - Induction might be considered only in very mild, stable cases of abruption without fetal distress, which is not the case here *Observation and monitoring* - The clinical findings indicate an **obstetric emergency** (suspected placental abruption), not a condition suitable for expectant management - **Decreased fetal movements** are a warning sign of fetal hypoxia requiring immediate action - Progressive abruption can lead to **maternal hemorrhage, DIC, and fetal death** if not managed promptly - At 36 weeks with concerning features, continued observation risks catastrophic outcomes *Administer medications to delay labor* - **Tocolytics are absolutely contraindicated** in placental abruption - Delaying delivery when abruption is suspected and fetal compromise is present would worsen both maternal and fetal outcomes - At 36 weeks gestation, the fetus has adequate maturity and there is no benefit to prolonging pregnancy - The goal is **expedited delivery**, not pregnancy prolongation
Question 7: 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 8: 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 9: A pregnant lady with 37 weeks gestation has been admitted with a history of premature rupture of membranes for 6 hours. She is best treated with:
- A. antibiotics followed by labour induction (Correct Answer)
- B. steroids followed by labour induction
- C. expectant management
- D. steroids and tocolytic agents
Explanation: ***antibiotics followed by labour induction*** - For premature rupture of membranes (PROM) at full term (≥37 weeks gestation), **antibiotics** are given to prevent maternal and neonatal infection due to the prolonged rupture, and **labour induction** is recommended to reduce the risk of chorioamnionitis and neonatal sepsis. - The risk of infection increases significantly with the duration of membrane rupture, making active management with induction preferable over expectant management. - Current guidelines recommend induction within 24 hours of membrane rupture at term. *steroids followed by labour induction* - **Antenatal steroids** (e.g., betamethasone, dexamethasone) are primarily used to promote fetal lung maturity in cases of anticipated preterm birth, typically between 24 and 34 weeks gestation. - At **37 weeks gestation**, the fetal lungs are generally mature, so steroids offer no significant benefit and would only delay necessary intervention. *expectant management* - **Expectant management** (waiting for spontaneous labor) at term PROM significantly increases the risk of maternal and neonatal infections including chorioamnionitis, endometritis, and neonatal sepsis. - Studies show that active management with induction reduces infection rates without increasing cesarean section rates. - While most women will go into spontaneous labor within 24 hours, the infection risk during the waiting period outweighs the benefits of avoiding induction. *steroids and tocolytic agents* - As established, **steroids** are not indicated at 37 weeks gestation. - **Tocolytic agents** are used to suppress uterine contractions and prolong pregnancy in cases of preterm labor, which is contraindicated in PROM at term as delaying delivery increases infection risk without providing significant fetal benefit.
Question 10: During delivery of HIV infected women, which of the following are recommended ? 1. Zidovudine (ZDV) is given at the onset of labour. 2. Elective caesarean delivery reduces the risk of vertical transmission. 3. Amniotomy and oxytocin augmentation should be done. 4. Antiretroviral therapy should be given to all neonates. Select the correct answer using the code given below :
- A. 1 and 2 only (Correct Answer)
- B. 2, 3 and 4
- C. 1, 2 and 4
- D. 1, 2 and 3
Explanation: ***1 and 2 only*** - **Zidovudine (ZDV)** is administered intravenously to the mother at the onset of labor and during delivery as part of the **PMTCT (Prevention of Mother-to-Child Transmission)** protocol. It reduces viral load and provides pre-exposure prophylaxis to the fetus, significantly decreasing the risk of **vertical HIV transmission**. - **Elective cesarean section** is recommended for HIV-infected women with **viral loads >1,000 copies/mL** or unknown viral loads near term (performed at 38 weeks). This reduces neonatal exposure to maternal blood and genital tract secretions during vaginal delivery, thereby **reducing perinatal HIV transmission risk by approximately 50%** compared to vaginal delivery in women not on effective antiretroviral therapy. - Statement 3 is **incorrect**: **Amniotomy (artificial rupture of membranes) and oxytocin augmentation are contraindicated** in HIV-infected women as these procedures increase fetal exposure to maternal blood and bodily fluids, thereby **increasing the risk of vertical transmission**. Guidelines recommend avoiding invasive obstetric procedures. - Statement 4 is **incorrect**: While **antiretroviral prophylaxis** (typically zidovudine syrup) is given to all neonates born to HIV-infected mothers for 4-6 weeks, **full antiretroviral therapy (ART)** is only initiated if the infant tests positive for HIV. The statement incorrectly uses "therapy" instead of "prophylaxis." *1, 2 and 3* - This option incorrectly includes statement 3. **Amniotomy and oxytocin augmentation should be avoided**, not recommended, in HIV-infected women as they increase the risk of vertical transmission through increased fetal exposure to maternal blood. *2, 3 and 4* - Statement 3 is **incorrect** as amniotomy and oxytocin augmentation are **contraindicated** in HIV management during labor. - Statement 4 is **incorrect** as all neonates receive **prophylaxis**, not full antiretroviral **therapy**. *1, 2 and 4* - While statements 1 and 2 are correct, statement 4 is **incorrect** because neonates receive **antiretroviral prophylaxis** (not therapy). Full **ART** is reserved for confirmed HIV-positive infants.
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