Labor and Delivery — MCQs

Labor and Delivery Indian Medical PG Practice Questions and MCQs

Question 351: A 37-week primigravida presents with irregular uterine contractions. On examination, the cervix is 1 cm dilated and poorly effaced. What is the most appropriate management?

A. Cesarean section
B. Amniotomy
C. Oxytocin drip
D. Sedation and wait (Correct Answer)

Explanation: ### Explanation The clinical scenario describes a patient in **False Labor** (also known as Braxton Hicks contractions or pre-labor). The key diagnostic features are irregular contractions and a lack of significant cervical changes (only 1 cm dilated and poorly effaced). **1. Why "Sedation and wait" is correct:** The primary goal in managing false labor is to provide comfort and differentiate it from the latent phase of true labor. Sedation (often with morphine or a similar agent) helps the patient rest. If it is false labor, the contractions will typically subside. If it is the early latent phase of true labor, the contractions will continue and eventually lead to cervical effacement and dilation. Active intervention is contraindicated as it increases the risk of unnecessary instrumental or surgical delivery. **2. Why other options are incorrect:** * **A. Cesarean section:** There is no fetal or maternal distress, and the patient is not in labor. Surgery at 37 weeks without indication is inappropriate. * **B. Amniotomy (Artificial Rupture of Membranes):** This is used to augment active labor. Performing it during false labor increases the risk of cord prolapse and ascending infection (chorioamnionitis). * **C. Oxytocin drip:** Induction or augmentation is not indicated for false labor. Using oxytocin on an "unripe" cervix (low Bishop score) often leads to failed induction and unnecessary C-sections. **3. High-Yield NEET-PG Pearls:** * **True Labor vs. False Labor:** True labor is characterized by regular, painful contractions that increase in frequency/intensity and are associated with **progressive cervical effacement and dilation**. * **Bishop Score:** A score $\leq$ 5 suggests an unripe cervix; sedation/observation is preferred over induction. * **Management of Prolonged Latent Phase:** If the patient is in true labor but the latent phase exceeds 20 hours (primigravida) or 14 hours (multigravida), the first-line management is still **therapeutic rest (sedation)**.

Question 352: All of the following are adverse outcomes associated with threatened abortion, except:

A. Placenta previa
B. Preterm birth
C. Manual removal of placenta
D. Fetal macrosomia (Correct Answer)

Explanation: **Explanation:** Threatened abortion (vaginal bleeding before 20 weeks of gestation with a closed cervix) is not just an isolated early pregnancy event; it is a marker of **defective placentation**. When the early attachment of the placenta is disrupted, it leads to a higher risk of late-pregnancy complications. **Why Fetal Macrosomia is the Correct Answer:** Fetal macrosomia (Option D) is **not** associated with threatened abortion. In fact, the opposite is true. Due to impaired placental function and chronic placental insufficiency following early bleeding, there is an increased risk of **Low Birth Weight (LBW)** and **Intrauterine Growth Restriction (IUGR)**. Macrosomia is typically associated with gestational diabetes or post-term pregnancy. **Analysis of Incorrect Options:** * **Preterm Birth (Option B):** This is the most common late-pregnancy complication of threatened abortion. Inflammation and decidual hemorrhage can trigger premature rupture of membranes or early labor. * **Placenta Previa (Option A):** Early bleeding may be associated with low implantation of the blastocyst. Furthermore, subchorionic hematomas can influence the final position and attachment of the placenta. * **Manual Removal of Placenta (Option C):** Threatened abortion increases the risk of morbidly adherent placenta (Placenta Accreta spectrum) and retained products, often necessitating manual removal due to abnormal placental-decidual interface. **NEET-PG High-Yield Pearls:** * **Most common cause of threatened abortion:** Genetic/Chromosomal abnormalities (e.g., Autosomal trisomy). * **Prognostic Marker:** The presence of fetal cardiac activity on ultrasound in a case of threatened abortion indicates a >90% chance of pregnancy continuation. * **Other associated risks:** Abruptio placentae, Pregnancy-Induced Hypertension (PIH), and increased perinatal mortality.

Question 353: Which of the following statements concerning placenta previa is true?

A. Its incidence increases with maternal age
B. The initial hemorrhage is usually painless and rarely fatal (Correct Answer)
C. Management still includes a double setup
D. Vaginal examination should be done immediately on suspicion of placenta previa

Explanation: **Explanation:** Placenta previa occurs when the placenta implants in the lower uterine segment, partially or completely covering the internal os. **Why Option B is correct:** The hallmark of placenta previa is **painless, bright red vaginal bleeding**. This occurs because, as the lower uterine segment stretches and thins in the third trimester, the placental attachments are disrupted. The initial bleed (sentinel bleed) is typically self-limiting and **rarely fatal** to the mother, as it is not usually associated with the massive coagulopathy or concealed hemorrhage seen in placental abruption. **Why the other options are incorrect:** * **Option A:** While maternal age is a risk factor, the **strongest risk factor** is a history of previous Cesarean sections or uterine surgeries (e.g., myomectomy). * **Option C:** The "double setup" (preparing for a vaginal delivery in an OR ready for immediate CS) is largely **obsolete**. Modern management relies on ultrasound for diagnosis. If placenta previa is confirmed, a scheduled Cesarean section is the standard of care. * **Option D:** Digital vaginal examination is **strictly contraindicated** (the "No PV" rule) until placenta previa is ruled out by ultrasound. A finger passed through the cervix can cause catastrophic, life-threatening hemorrhage by piercing the placental substance. **NEET-PG High-Yield Pearls:** * **Best Initial Investigation:** Transabdominal Ultrasound (95% accuracy). * **Gold Standard Investigation:** Transvaginal Ultrasound (TVS) – it is safe and more accurate for measuring the distance from the internal os. * **Maclean-Johnson Protocol:** Expectant management (bed rest, steroids, observation) used for preterm patients (<37 weeks) who are hemodynamically stable. * **Stallworthy’s Sign:** A dip in the fetal heart rate when the head is pushed into the pelvis, suggestive of posterior placenta previa.

Question 354: A hypertensive primigravida developed Sheehan's syndrome after delivery. All of the following are seen with Sheehan's syndrome, EXCEPT?

A. Obesity (Correct Answer)
B. Amenorrhoea
C. Failure to lactate
D. Absence of secondary sexual characteristics

Explanation: **Explanation:** **Sheehan’s Syndrome** is a form of postpartum hypopituitarism caused by ischemic necrosis of the anterior pituitary gland. This occurs due to severe postpartum hemorrhage (PPH) and hypotension, which compromises the blood supply to the pituitary gland (which is already physiologically enlarged during pregnancy). **Why Obesity is the Correct Answer:** In Sheehan’s syndrome, there is a deficiency of various pituitary hormones, including Growth Hormone (GH) and ACTH. While GH deficiency can lead to changes in body composition (increased visceral fat), **weight loss** and cachexia (Simmonds' disease) are more classically associated with chronic panhypopituitarism rather than obesity. Patients often present with anorexia and weight loss due to secondary adrenal insufficiency and hypothyroidism. **Analysis of Incorrect Options:** * **Amenorrhoea (B):** This is a hallmark sign. Ischemia leads to a deficiency in Gonadotropins (FSH and LH), resulting in secondary ovarian failure, atrophy of the endometrium, and permanent cessation of menses. * **Failure to Lactate (C):** This is often the **earliest clinical sign**. Destruction of the anterior pituitary leads to Prolactin deficiency, making the mother unable to initiate or maintain breastfeeding. * **Absence of Secondary Sexual Characteristics (D):** Chronic gonadotropin deficiency leads to the loss of pubic and axillary hair (due to decreased adrenal and ovarian androgens) and atrophy of the breasts and genitalia. **NEET-PG High-Yield Pearls:** * **Most common early sign:** Failure of lactation. * **Most common hormone lost:** Growth Hormone (GH), followed by Prolactin and Gonadotropins. * **Diagnosis:** MRI of the brain (shows an "Empty Sella") and dynamic pituitary hormone stimulation tests. * **Treatment:** Lifelong hormone replacement therapy (Cortisol, Thyroxine, Estrogen/Progesterone). Always replace glucocorticoids *before* thyroxine to avoid precipitating an adrenal crisis.

Question 355: What is the management for breech presentation with a footling?

A. Vaginal delivery
B. Cesarean section (Correct Answer)
C. Forceps delivery
D. Internal podalic version

Explanation: **Explanation:** The management of breech presentation depends significantly on the specific type of breech. In **Footling Breech**, one or both feet are the presenting part below the buttocks. **Why Cesarean Section is the Correct Choice:** Footling breech is a contraindication for vaginal delivery. The primary risk is **Umbilical Cord Prolapse**, as the feet do not provide a sufficient seal against the cervix (unlike the broad surface of the buttocks in frank breech or the head in vertex presentation). When the membranes rupture, the cord can easily slip past the feet. Additionally, the small diameter of the feet can lead to the delivery of the lower body through an incompletely dilated cervix, resulting in **entrapment of the after-coming head**, which is a life-threatening emergency. Therefore, a planned Cesarean section is the safest mode of delivery. **Analysis of Incorrect Options:** * **A. Vaginal Delivery:** Generally reserved for Frank or Complete breech under strict criteria (e.g., Term gestation, estimated weight 2.5–3.5kg, flexed head). It is avoided in footling breech due to the high risk of cord prolapse. * **C. Forceps Delivery:** Piper’s forceps are used specifically for the **after-coming head** in a vaginal breech delivery, not as a primary method to manage the presentation itself. * **D. Internal Podalic Version:** This is a procedure used almost exclusively for the delivery of the **second twin** (non-vertex) and is not indicated for a singleton footling breech. **NEET-PG High-Yield Pearls:** * **Most common breech:** Frank breech (thighs flexed, knees extended). * **Highest risk of cord prolapse:** Footling breech (up to 15-18%). * **Prerequisite for Vaginal Breech:** The head must be flexed (diagnosed via USG) to prevent hyperextension ("Star-gazing fetus"). * **Term Breech Trial (2000):** Established that planned CS is safer than vaginal birth for term breech fetuses.

Question 356: Which of the following refers to the part of the fetus that occupies the lower segment of the uterus?

A. The attitude
B. The presenting part
C. The lie
D. The presentation (Correct Answer)

Explanation: **Explanation:** The correct answer is **D. The presentation**. In obstetric terminology, **Presentation** is defined as the part of the fetus that occupies the lower pole of the uterus (the pelvic brim). It is determined by the fetal lie and the presenting part. For example, in a longitudinal lie, the presentation can be either cephalic (head) or breech (podalic). **Analysis of Options:** * **A. The attitude:** Refers to the relationship of the fetal parts to one another (e.g., flexion or extension). The normal obstetric attitude is "universal flexion." * **B. The presenting part:** This is the specific portion of the presentation that overlies the internal os and is felt by the examining finger during a vaginal examination (e.g., in a cephalic presentation, the presenting part could be the vertex, brow, or face). * **C. The lie:** Refers to the relationship between the long axis of the fetus and the long axis of the mother (e.g., longitudinal, transverse, or oblique). **High-Yield Clinical Pearls for NEET-PG:** * **Most common presentation:** Cephalic (96-97%). * **Most common presenting part:** Vertex. * **Denominator:** A fixed bony point on the presenting part used to describe the position (e.g., Occiput in vertex, Mentum in face, Sacrum in breech). * **Position:** The relationship of the denominator to the different quadrants of the maternal pelvis (e.g., Left Occipito-Anterior is the most common position).

Question 357: Which of the following is NOT an indication for oxytocin?

A. Spontaneous premature labor (Correct Answer)
B. Postpartum hemorrhage
C. Uterine inertia
D. Breast engorgement due to inefficient milk ejection reflex

Explanation: Oxytocin is a potent uterotonic hormone synthesized in the hypothalamus and released by the posterior pituitary. Its primary physiological roles are stimulating uterine contractions and the milk-ejection reflex. **Explanation of the Correct Answer:** **Option A (Spontaneous premature labor)** is the correct answer because oxytocin is **contraindicated** in this scenario. In preterm labor, the clinical goal is to stop contractions (tocolysis) to prolong pregnancy, whereas oxytocin stimulates contractions. Administering oxytocin would accelerate the delivery of a premature infant, increasing the risk of neonatal morbidity. **Explanation of Incorrect Options:** * **Option B (Postpartum hemorrhage):** Oxytocin is the first-line drug for the prevention and management of PPH. It causes rhythmic contractions of the upper uterine segment, compressing blood vessels at the placental site (living ligatures). * **Option C (Uterine inertia):** This refers to weak or infrequent uterine contractions during labor. Oxytocin is the drug of choice for **augmentation of labor** to correct hypotonic uterine dysfunction. * **Option D (Breast engorgement):** While oxytocin doesn't increase milk production (prolactin's role), it causes contraction of **myoepithelial cells** in the mammary alveoli. Intranasal oxytocin can be used to facilitate the milk-ejection reflex, relieving engorgement caused by "let-down" failure. **High-Yield NEET-PG Pearls:** * **Half-life:** Very short (3–5 minutes), requiring continuous IV infusion for labor induction. * **Side Effects:** Water intoxication (due to its ADH-like antidiuretic effect) and uterine rupture if used inappropriately. * **Contraindications:** Cephalopelvic disproportion (CPD), fetal distress, and previous classical cesarean section.

Question 358: A young lady with 6 weeks amenorrhea presents with nausea, vomiting, and severe abdominal pain. Her BP is 100/80 mm Hg. Examination reveals a 5 x 5 cm adnexal mass. What is the plan of management?

A. Plan for immediate laparoscopic surgery (Correct Answer)
B. beta-hCG
C. Methotrexate
D. Give IV fluids, keep NPO and observe for 4-5 days

Explanation: This clinical scenario describes a classic presentation of an **Ectopic Pregnancy**, likely ruptured or impending rupture. The triad of amenorrhea, severe abdominal pain, and an adnexal mass in a reproductive-aged woman is a surgical emergency until proven otherwise. ### **Explanation of the Correct Answer** **Option A (Immediate Laparoscopic Surgery)** is the correct management. The presence of **severe abdominal pain** combined with a significant **5 x 5 cm adnexal mass** indicates a high risk of rupture or an ongoing tubal abortion. While the BP (100/80 mm Hg) is currently stable, the severity of pain and mass size (>3.5–4 cm) are contraindications to medical management. Laparoscopy is the gold standard for both diagnosis and definitive treatment (Salpingectomy or Salpingostomy). ### **Why Other Options are Incorrect** * **Option B (beta-hCG):** While beta-hCG is essential for diagnosing pregnancy, it should not delay surgical intervention in a symptomatic patient with severe pain and a large mass. Diagnosis here is primarily clinical and ultrasound-based. * **Option C (Methotrexate):** Medical management with Methotrexate is contraindicated if the adnexal mass is >3.5–4 cm, if there is severe pain (suggesting rupture), or if the patient is hemodynamically unstable. * **Option D (Observe for 4-5 days):** Expectant management is only for asymptomatic patients with declining beta-hCG levels. Observation in a patient with severe pain is dangerous and can lead to fatal hemorrhagic shock. ### **Clinical Pearls for NEET-PG** * **Classic Triad:** Amenorrhea, abdominal pain, and vaginal bleeding (seen in only 50% of cases). * **Surgical Indications:** Mass >3.5 cm, fetal heart activity, rupture (hemoperitoneum), or hemodynamic instability. * **Medical Management Criteria:** Hemodynamically stable, mass <3.5 cm, no fetal heart activity, and beta-hCG <5000 mIU/mL. * **Gold Standard Diagnosis:** Transvaginal Ultrasound (TVUS) + Serum beta-hCG (Correlation with the "Discriminatory Zone" of 1500–2000 mIU/mL).

Question 359: What is the management for a breech presentation with an extended arm?

A. Cesarean section
B. Pinard's maneuver
C. Lovset's maneuver (Correct Answer)
D. Dührssen's incision

Explanation: **Explanation:** In a breech delivery, the **Lovset’s maneuver** is the specific technique used to deliver the arms when they are extended or impacted above the pelvic brim. The maneuver involves grasping the fetus by the pelvic girdle and rotating the body 180 degrees while maintaining downward traction. This rotation brings the posterior arm under the symphysis pubis, allowing it to be delivered. The body is then rotated 180 degrees in the opposite direction to deliver the other arm. **Analysis of Options:** * **Pinard’s Maneuver (B):** This is used to bring down the legs in a **frank breech** presentation by applying pressure to the popliteal fossa to flex the knee. * **Cesarean Section (A):** While many breech presentations are delivered via C-section today, the question asks for the specific management of a procedural complication (extended arms) during a vaginal breech delivery. * **Dührssen’s Incision (D):** These are incisions made in the cervix at the 2, 6, and 10 o'clock positions to facilitate the delivery of an **entrapped after-coming head** when the cervix is not fully dilated. **Clinical Pearls for NEET-PG:** * **Mauriceau-Smellie-Veit Maneuver:** The gold standard for delivering the **after-coming head** (promotes flexion). * **Burns-Marshall Method:** Another technique for the after-coming head where the baby is allowed to hang to encourage flexion by gravity. * **Prerequisites for Vaginal Breech:** Estimated fetal weight 2.5–3.5 kg, flexed head, and a frank or complete breech presentation. * **Nuchal Arm:** A more severe complication than an extended arm, where the arm is wrapped behind the fetal neck; it also requires Lovset’s maneuver for resolution.

Question 360: Which of the following is the largest skull diameter?

A. Occipitobregmatic
B. Submentovertical
C. Mentovertical (Correct Answer)
D. Occipitofrontal

Explanation: The fetal skull diameters are a high-yield topic in NEET-PG, as they determine the feasibility of vaginal delivery based on the presenting part. ### **Explanation of the Correct Answer** **C. Mentovertical (13.5 cm):** This is the largest diameter of the fetal skull. It extends from the midpoint of the chin (mentum) to the highest point on the sagittal suture (vertex). This diameter presents in a **Brow presentation**, which is clinically significant because it is larger than any diameter of the pelvic inlet, making a spontaneous vaginal delivery of a term fetus impossible. ### **Analysis of Incorrect Options** * **A. Suboccipitobregmatic (9.5 cm):** This is the smallest longitudinal diameter. It presents when the head is **well-flexed** (Vertex presentation). It is the ideal diameter for a smooth labor. * **B. Submentovertical (11.5 cm):** This diameter presents in a **Face presentation** when the head is incompletely extended. * **D. Occipitofrontal (11.5 cm):** This diameter presents in a **deflexed vertex** (military position). It is larger than the suboccipitobregmatic diameter and can lead to a prolonged labor. ### **High-Yield Clinical Pearls for NEET-PG** * **Largest Diameter:** Mentovertical (13.5 cm) – associated with Brow presentation. * **Smallest Diameter:** Suboccipitobregmatic (9.5 cm) – associated with well-flexed Vertex. * **Engaging Diameter in Face Presentation:** Submentobregmatic (9.5 cm) – occurs when the head is completely extended. * **Mnemonic for Brow:** "Brow is Big" (Mentovertical is the biggest diameter). * **Clinical Rule:** Any diameter >10 cm (like Mentovertical) generally cannot pass through the pelvic inlet easily, often necessitating a Cesarean section.

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