Labor and Delivery — MCQs

A 25-year-old female presents to the casualty with a history of amenorrhea for two and a half months and abdominal pain and bleeding per vaginum for one day. On examination, vital parameters and other systems are normal. On speculum examination, bleeding is found to come from the Os. On bimanual examination, the uterus is of 10 weeks size, soft, and the Os admits one finger. What is the most likely diagnosis?

Q168Medium

What is the ideal management for a 37-week pregnant elderly primigravida with placenta previa and active bleeding?

Q169Easy

What is the designated fetal station when the lowermost portion of the presenting fetal part is at the level of the ischial spines?

Q170Medium

All of the following are true about the delivery of the placenta in the third stage of labor, EXCEPT?

Labor and Delivery Indian Medical PG Practice Questions and MCQs

Question 161: What is the common cause of death in inversion of the uterus?

A. Neurogenic shock
B. Hemorrhage (Correct Answer)
C. Pulmonary embolism
D. Infection

Explanation: **Explanation:** **Uterine inversion** is a life-threatening obstetric emergency where the uterine fundus collapses into the endometrial cavity, often protruding through the cervix. **Why Hemorrhage is the Correct Answer:** While uterine inversion is classically associated with two types of shock—neurogenic and hypovolemic—**hemorrhage (hypovolemic shock)** is the leading cause of death. Once the uterus inverts, the natural mechanism of "living ligatures" (myometrial contraction compressing spiral arteries) fails. This leads to massive, rapid blood loss from the placental site. Furthermore, the inverted uterus often becomes incarcerated, leading to venous congestion and worsening the bleeding. **Analysis of Incorrect Options:** * **A. Neurogenic Shock:** This occurs early due to the sudden traction on the pelvic peritoneum and nerves (parasympathetic stimulation). While it is a classic feature of inversion, it is rarely the primary cause of mortality in modern settings compared to the severity of blood loss. * **C. Pulmonary Embolism:** While a risk in any peripartum patient, it is not a direct or common complication specific to the acute event of uterine inversion. * **D. Infection:** Puerperal sepsis can occur as a late complication (especially in chronic inversion), but it is not the common cause of acute mortality. **Clinical Pearls for NEET-PG:** * **Most common cause:** Excessive fundal pressure or "mismanaged third stage" (strong traction on the umbilical cord with a relaxed uterus). * **Clinical Sign:** A "cup-shaped" defect or "dimple" felt on abdominal palpation; a globular mass felt per vaginum. * **Management:** Immediate manual replacement (**Johnson’s maneuver**). If that fails, surgical methods like **Huntington’s** (abdominal) or **Haultain’s** (posterior incision of the cervical ring) are used. * **Drug Alert:** Stop oxytocics during replacement to allow the uterus to relax; restart them only after the uterus is repositioned to prevent re-inversion.

Question 162: A 30-year-old gravida 3 presents to the Gynaecology OPD with a 6-month history of amenorrhea, vaginal bleeding for 1 day, and significant pallor. Her ultrasound findings indicate a 28-week intrauterine fetal death with placental abruption. What is the best line of management?

A. Immediate cesarean section
B. Artificial rupture of membranes with oxytocin drip
C. Artificial rupture of membranes with Syntocinon drip and arrange for blood transfusion (Correct Answer)
D. Wait for spontaneous onset of labor

Explanation: ### Explanation The clinical presentation of vaginal bleeding, significant pallor, and ultrasound findings of **placental abruption with intrauterine fetal death (IUFD)** at 28 weeks indicates a severe grade of abruption. **1. Why Option C is Correct:** In cases of placental abruption with a dead fetus, **vaginal delivery is the preferred route**. The management goals are twofold: controlling maternal hemorrhage and expediting delivery. * **Artificial Rupture of Membranes (ARM):** This is the first step as it decreases intra-amniotic pressure, which reduces the entry of thromboplastin into maternal circulation (decreasing the risk of DIC) and may stimulate labor. * **Oxytocin (Syntocinon) Drip:** This is used to augment labor to ensure delivery occurs within a reasonable timeframe (ideally within 4–6 hours). * **Blood Transfusion:** Given the "significant pallor" and blood loss, aggressive resuscitation with blood and blood products is vital to maintain hemodynamic stability and manage potential coagulopathy. **2. Why Other Options are Wrong:** * **Option A:** Cesarean section is generally avoided in IUFD unless there are maternal complications like placenta previa, obstructed labor, or failed induction. It increases the risk of surgical bleeding, especially if the patient is developing DIC. * **Option B:** While similar to C, it ignores the critical need for **blood transfusion** in a patient already presenting with significant pallor. * **Option D:** Waiting for spontaneous labor is dangerous as it increases the risk of Consumptive Coagulopathy (DIC) due to the release of tissue thromboplastin from the retroplacental clot. **Clinical Pearls for NEET-PG:** * **Most common cause of DIC in pregnancy:** Placental Abruption. * **Couvelaire Uterus:** A complication of severe abruption where blood extravasates into the myometrium; it is not an absolute indication for hysterectomy unless the uterus is atonic. * **Target in Abruption:** Maintain urine output >30 ml/hr and Hematocrit >30%.

Question 163: Which of the following is NOT used in the treatment for postpartum hemorrhage?

A. Oxytocin
B. Carboprost
C. Ergometrine
D. Ritodrine (Correct Answer)

Explanation: **Explanation:** Postpartum Hemorrhage (PPH) is primarily caused by **uterine atony** (failure of the uterus to contract after delivery). Management requires **uterotonic agents**—drugs that increase uterine contractions to compress intramyometrial blood vessels. **Why Ritodrine is the correct answer:** Ritodrine is a **Beta-2 agonist**. Its mechanism of action is to relax the uterine smooth muscle (**tocolysis**). It is used to arrest preterm labor, not to treat hemorrhage. Administering a tocolytic during PPH would worsen uterine atony and increase bleeding, making it contraindicated. **Analysis of Incorrect Options (Uterotonics used in PPH):** * **Oxytocin:** The first-line agent for both prophylaxis and treatment of PPH. It acts on G-protein coupled receptors to trigger rhythmic upper segment contractions. * **Carboprost (15-methyl PGF2α):** A potent prostaglandin used when oxytocin fails. It is administered intramuscularly but is contraindicated in patients with **asthma** due to its bronchoconstrictive effects. * **Ergometrine:** An ergot alkaloid that causes tetanic uterine contractions. It is highly effective but contraindicated in patients with **hypertension or pre-eclampsia** as it causes peripheral vasoconstriction. **NEET-PG High-Yield Pearls:** * **Definition of PPH:** Blood loss >500 ml (Vaginal) or >1000 ml (C-section). * **Active Management of Third Stage of Labor (AMTSL):** Reduces PPH risk by 60%; Oxytocin (10 IU IM) is the drug of choice. * **Misoprostol (PGE1):** Often used in resource-limited settings (600–800 mcg sublingual/rectal). * **Surgical Management:** If medical management fails, proceed to uterine artery embolization, B-Lynch sutures, or internal iliac artery ligation.

Question 164: What is the recommended treatment for placenta accreta?

A. Manual separation
B. Hysterectomy (Correct Answer)
C. Leave it alone
D. Hysterectomy and removal of placenta

Explanation: **Explanation:** **Placenta Accreta** is a life-threatening obstetric complication where the chorionic villi adhere directly to the myometrium due to a partial or total absence of the decidua basalis. **Why Hysterectomy is the Correct Answer:** The gold standard and recommended management for placenta accreta is a **planned cesarean hysterectomy**. Attempting to detach the placenta often leads to massive, uncontrollable postpartum hemorrhage (PPH) because the placenta cannot separate naturally from the uterine wall. To minimize blood loss and maternal morbidity, the uterus is removed with the placenta left *in situ* after the delivery of the fetus. **Analysis of Incorrect Options:** * **A. Manual separation:** This is strictly **contraindicated**. Forcing separation leads to profuse hemorrhage, disseminated intravascular coagulation (DIC), and maternal mortality. * **C. Leave it alone:** While "expectant management" (leaving the placenta to resorb) is an option for women strongly desiring future fertility, it is not the *recommended* primary treatment due to high risks of delayed hemorrhage and severe infection/sepsis. * **D. Hysterectomy and removal of placenta:** This is incorrect because the placenta should **not** be removed prior to or during the hysterectomy. Attempting to remove it first triggers the very bleeding the surgery aims to avoid. **High-Yield Clinical Pearls for NEET-PG:** * **Risk Factors:** Most common risk factors are a **previous Cesarean section** and **Placenta Previa**. * **Spectrum:** Accreta (adheres to myometrium), Increta (invades myometrium), Percreta (penetrates through serosa/into bladder). * **Diagnosis:** Antenatal diagnosis is primarily via **Ultrasound/Doppler** (look for "Swiss cheese" appearance/placental lacunae and loss of retroplacental hypoechoic zone). * **Management:** If diagnosed antenatally, the surgery is ideally scheduled at **34 0/7–35 6/7 weeks** of gestation.

Question 165: True labor pains is represented by:

A. Pain and discomfort in the abdomen
B. Show (Correct Answer)
C. Relieved by enema and administration of sedative
D. Dull in nature

Explanation: **Explanation:** The diagnosis of **True Labor** is based on the presence of regular, rhythmic uterine contractions that increase in frequency and intensity, leading to progressive cervical effacement and dilatation. **Why "Show" is correct:** "Show" refers to the expulsion of the cervical mucus plug mixed with a small amount of blood (from the rupture of small capillaries as the cervix dilates). It is a classic clinical sign of true labor, indicating that cervical changes are actively occurring. While not every patient experiences a visible show, its presence is a strong diagnostic indicator of true labor. **Analysis of Incorrect Options:** * **A. Pain and discomfort in the abdomen:** In true labor, pain typically starts in the **back** and radiates to the front of the abdomen. Pain confined only to the lower abdomen or groin is more characteristic of false labor. * **C. Relieved by enema and administration of sedative:** This is a hallmark of **False Labor**. True labor pains are not relieved by sedatives, enemas, or walking; in fact, they often intensify with activity. * **D. Dull in nature:** True labor pains are described as **colicky and rhythmic**, not dull. They have a distinct pattern of contraction and relaxation. **NEET-PG High-Yield Pearls:** * **The Definitive Sign:** The single most important feature of true labor is **progressive cervical dilatation and effacement**. * **False Labor (Braxton Hicks):** Characterized by irregular contractions, no cervical changes, and relief with sedation/rest. * **Formation of Bag of Waters:** In true labor, the membranes become detached from the lower uterine segment, leading to the formation of the "bag of waters" due to cervical dilatation.

Question 166: Regarding insulin management during labor, all are true except?

A. Usual dose of intermediate-acting insulin is given at bedtime.
B. Morning dose of insulin is withheld.
C. Once labor begins, normal saline infusion is changed to 5% dextrose.
D. Blood glucose level during labor should be maintained above 140 mg/dL. (Correct Answer)

Explanation: The management of diabetes during labor aims to maintain euglycemia to prevent neonatal hypoglycemia while meeting the high metabolic demands of uterine contractions. ### **Explanation of the Correct Answer (D)** Option D is the incorrect statement because the target blood glucose during labor is **70–120 mg/dL** (some guidelines suggest up to 140 mg/dL, but never *above* it). Maintaining levels above 140 mg/dL is dangerous as maternal hyperglycemia leads to fetal hyperglycemia, which stimulates the fetal pancreas to secrete insulin. This results in profound **neonatal hypoglycemia** immediately after birth when the maternal glucose supply is severed. ### **Analysis of Other Options** * **Option A:** The usual dose of intermediate-acting insulin (NPH) is given at bedtime the night before induction/labor to maintain basal insulin levels. * **Option B:** On the morning of induction or once active labor begins, the morning dose of insulin is withheld because labor is an energy-intensive process that naturally lowers blood glucose. * **Option C:** Once active labor starts or glucose levels drop below 70 mg/dL, the infusion is switched from Normal Saline to **5% Dextrose** (usually at 100–150 mL/hr) to provide the necessary calories for uterine work and prevent ketosis. ### **High-Yield NEET-PG Pearls** * **Gold Standard Monitoring:** Check capillary blood glucose every **1–2 hours** during active labor. * **Insulin Type:** If glucose exceeds 120 mg/dL, use **Short-acting (Regular) insulin** via IV infusion (not subcutaneous). * **Postpartum Shift:** Insulin requirements **drop precipitously** immediately after the delivery of the placenta (the source of anti-insulin hormones like hPL). Dosage should be reduced by 50% or reverted to pre-pregnancy levels. * **Goal:** Euglycemia in labor = Prevention of neonatal hypoglycemia.

Question 167: A 25-year-old female presents to the casualty with a history of amenorrhea for two and a half months and abdominal pain and bleeding per vaginum for one day. On examination, vital parameters and other systems are normal. On speculum examination, bleeding is found to come from the Os. On bimanual examination, the uterus is of 10 weeks size, soft, and the Os admits one finger. What is the most likely diagnosis?

A. Threatened abortion
B. Missed abortion
C. Inevitable abortion (Correct Answer)
D. Incomplete abortion

Explanation: **Explanation:** The clinical presentation of amenorrhea, vaginal bleeding, and abdominal pain in the first trimester suggests a spontaneous abortion. The definitive diagnostic feature in this case is the **dilated internal cervical os** (admits one finger) in the presence of vaginal bleeding. 1. **Inevitable Abortion (Correct):** This is defined as a clinical state where the pregnancy is complicated by vaginal bleeding and abdominal pain, and the **internal os is open**, making the continuation of pregnancy impossible. The uterine size usually corresponds to the period of amenorrhea (10 weeks in this case). 2. **Threatened Abortion (Incorrect):** While bleeding and pain are present, the hallmark of threatened abortion is a **closed internal os**. The pregnancy is potentially viable. 3. **Missed Abortion (Incorrect):** This refers to the retention of a dead fetus in utero for several weeks. Typically, the **internal os is closed**, and the uterine size is **smaller** than the period of amenorrhea. 4. **Incomplete Abortion (Incorrect):** In this condition, some products of conception have been expelled while some remain. The **os is open**, but the uterine size is typically **smaller** than the period of amenorrhea due to partial evacuation. **High-Yield Clinical Pearls for NEET-PG:** * **Os Status is Key:** If the Os is **Closed**, it is either Threatened, Missed, or Complete abortion. If the Os is **Open**, it is either Inevitable or Incomplete abortion. * **Management of Inevitable Abortion:** If <12 weeks, Suction & Evacuation (S&E) is the treatment of choice. If >12 weeks, uterine contraction is induced via Oxytocin or Prostaglandins. * **Uterine Size:** In Inevitable abortion, Uterine Size = Period of Amenorrhea. In Incomplete/Missed abortion, Uterine Size < Period of Amenorrhea.

Question 168: What is the ideal management for a 37-week pregnant elderly primigravida with placenta previa and active bleeding?

A. Labor induction
B. Cesarean section (Correct Answer)
C. Vaginal delivery
D. Expectant management

Explanation: **Explanation:** The correct management is **Cesarean section** because the patient is at term (37 weeks) and presenting with active bleeding due to placenta previa. In placenta previa, the placenta is implanted over the internal os; as the cervix dilates, the placental attachments are sheared, leading to life-threatening maternal hemorrhage and fetal distress. 1. **Why Cesarean Section is Correct:** At 37 weeks, the fetus is mature. Since the placenta obstructs the birth canal, vaginal delivery is contraindicated as it would cause massive bleeding. Immediate delivery via Cesarean section is the definitive treatment to save both mother and child when there is active bleeding at term. 2. **Why other options are incorrect:** * **Labor induction/Vaginal delivery:** These are contraindicated in placenta previa (especially if the edge is <2cm from the os) because the presenting part cannot engage, and cervical dilation will cause catastrophic hemorrhage. * **Expectant management (MacAfee regime):** This is only indicated if the pregnancy is <37 weeks, the bleeding is slight/stopped, and both mother and fetus are stable. Since this patient is 37 weeks (term) and has active bleeding, expectant management is no longer appropriate. **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard Diagnosis:** Transvaginal Ultrasound (TVS) is the most accurate and safe method to localize the placenta. * **Contraindication:** Never perform a per-vaginal (PV) examination in a case of antepartum hemorrhage until placenta previa is ruled out, as it can provoke torrential bleeding (the "Stallworthy's sign" may be seen on abdominal exam). * **Elderly Primigravida:** This factor increases the risk of complications, further favoring a controlled surgical delivery.

Question 169: What is the designated fetal station when the lowermost portion of the presenting fetal part is at the level of the ischial spines?

A. -2
B. -1
C. 0 (Correct Answer)
D. +1

Explanation: ### Explanation **Correct Option: C (0)** **Underlying Medical Concept:** Fetal station is a clinical measurement used to describe the descent of the presenting part (usually the fetal head) through the birth canal in relation to the maternal **ischial spines**. The ischial spines serve as the fixed anatomical landmark for **Station 0** because they represent the narrowest diameter of the pelvic mid-cavity. When the leading bony part of the fetus reaches this level, the biparietal diameter has typically entered the pelvic inlet, signifying that the head is **engaged**. **Analysis of Incorrect Options:** * **Option A (-2) and B (-1):** These represent stations **above** the ischial spines. Negative numbers indicate the distance in centimeters (e.g., -2 is 2 cm above the spines). These are seen during the early stages of labor before engagement is complete. * **Option D (+1):** Positive numbers represent stations **below** the ischial spines. A +1 station means the presenting part is 1 cm below the level of the spines, moving toward the pelvic outlet. **Clinical Pearls for NEET-PG:** * **Engagement:** Defined as the passage of the widest transverse diameter (biparietal diameter) through the pelvic inlet. Clinically, this corresponds to Station 0. * **DeLee vs. Modified System:** While the traditional DeLee system divided the pelvis into 1/5ths, the modern **ACOG classification** uses centimeters (-5 to +5). * **Caput Succedaneum:** Be cautious during vaginal exams; significant scalp edema (caput) can give a false impression of a lower station than the actual bony vault. * **Ischial Spines:** These are also the landmark for performing a **Pudendal Nerve Block** during the second stage of labor.

Question 170: All of the following are true about the delivery of the placenta in the third stage of labor, EXCEPT?

A. Separation of the placenta always manifests as revealed bleeding per vaginam, and is the most specific sign. (Correct Answer)
B. Lengthening of the umbilical cord is a sign of placental separation.
C. The fundus of the uterus must be palpated after placental delivery to rule out atonicity.
D. Placenta accreta may be a cause for retained placenta.

Explanation: In the third stage of labor, the placenta separates from the uterine wall due to sudden uterine contraction and retraction. **Why Option A is the Correct Answer (The False Statement):** While a "gush of blood" is a classic sign of placental separation, it is **not always present** and is certainly **not the most specific sign**. In the *Schultze mechanism* (80% of cases), the placenta separates centrally, forming a retroplacental hematoma that remains concealed until the placenta is expelled. Therefore, bleeding may not be "revealed" immediately. The most reliable and specific sign of separation is the **permanent lengthening of the umbilical cord** (the Schroeder/Alpheld sign). **Analysis of Other Options:** * **Option B:** Correct. As the placenta descends into the lower uterine segment or vagina, the umbilical cord visible at the vulva lengthens. * **Option C:** Correct. Post-delivery, the uterus must be palpated to ensure it is "hard and globular" (contracted). A soft, boggy uterus indicates atonicity, the leading cause of Postpartum Hemorrhage (PPH). * **Option D:** Correct. Placenta accreta (abnormal adherence to the myometrium) prevents the physiological cleavage plane from forming, leading to a retained placenta. **NEET-PG High-Yield Pearls:** 1. **Signs of Placental Separation:** 1) Gush of blood, 2) Lengthening of the cord, 3) Uterus becomes firm, globular, and rises in the abdomen (supra-umbilical). 2. **Schultze vs. Matthews-Duncan:** Schultze (central separation, "shiny" fetal side first, less bleeding); Matthews-Duncan (peripheral separation, "dirty" maternal side first, more continuous bleeding). 3. **Active Management of Third Stage (AMTSL):** Includes prophylactic uterotonics (Oxytocin 10 IU IM), Controlled Cord Traction (Brandt-Andrews maneuver), and uterine massage. This reduces the risk of PPH by 60%.

Practice by Chapter

Physiology of Labor

Practice Questions

Stages of Labor and Normal Progression

Practice Questions

Fetal Monitoring Techniques

Practice Questions

Pain Management in Labor

Practice Questions

Induction and Augmentation of Labor

Practice Questions

Operative Delivery (Forceps and Vacuum)

Practice Questions

Cesarean Section: Indications and Techniques

Practice Questions

Dystocia and Abnormal Labor Patterns

Practice Questions

Obstetric Emergencies

Practice Questions

Postpartum Hemorrhage Management

Practice Questions

Want unlimited practice?

Get full access to all questions, explanations, and performance tracking.

Start For Free