Labor and Delivery Practice Questions

Q: Placenta accreta is associated with which of the following conditions?

Uterine scar. **Explanation:** **Placenta Accreta** refers to an abnormal adherence of the placenta to the uterine wall due to the partial or total absence of the **Nitabuch’s layer** (decidua basalis). 1. **Why Uterine Scar is Correct:** The single most significant risk factor for placenta accreta is a previous **uterine scar**, most commonly from a prior Cesarean section. A scar creates a defect in the endometrial-myometrial junction, allowing chorionic villi to invade directly into or through the myometrium. The risk increases proportionally with the number of previous C-sections. 2. **Why Other Options are Incorrect:** * **Placenta Previa:** While placenta previa is strongly *associated* with accreta (especially when overlying a scar), the primary pathological trigger is the underlying damaged decidua (the scar itself). In the absence of a scar, previa alone has a much lower incidence of accreta. * **Multiple Pregnancy & Multiparity:** These are minor risk factors associated with placental site issues but do not inherently cause the defective decidualization required for accreta. **High-Yield Clinical Pearls for NEET-PG:** * **The "Incidence Rule":** If a patient has 1 prior C-section and a current placenta previa, the risk of accreta is ~11%. With 4 or more C-sections and previa, the risk jumps to **>60%**. * **Classification:** * **Accreta:** Villi attached to myometrium (80%). * **Increta:** Villi invade into myometrium (15%). * **Percreta:** Villi penetrate through the serosa/into bladder (5%). * **Diagnosis:** Antenatal diagnosis is via **Color Doppler Ultrasound** (showing "moth-eaten" placental lacunae and loss of the retroplacental hypoechoic zone). * **Management:** The standard treatment for confirmed placenta accreta is a planned **Cesarean Hysterectomy**.

Q: Artificial rupture of membranes (ARM) is contraindicated in which of the following situations?

When the fetus is dead. **Explanation:** **Why the correct answer is right:** In the case of an intrauterine fetal death (IUFD), the primary goal of management is to ensure a safe delivery while minimizing maternal complications. Artificial Rupture of Membranes (ARM) is strictly contraindicated in a dead fetus because the amniotic sac acts as a vital **protective barrier against infection**. Once the membranes are ruptured, the risk of ascending infection (chorioamnionitis) increases significantly. In a dead fetus, the necrotic tissues and stagnant liquor provide an ideal medium for bacterial growth, which can rapidly lead to maternal sepsis or Clostridium welchii infection. Therefore, membranes should be kept intact as long as possible to allow for a "closed" labor process. **Analysis of incorrect options:** * **A. Pregnancy beyond 40 weeks:** ARM is a standard method for the **induction of labor** in post-dated or post-term pregnancies to initiate uterine contractions or augment labor. * **B. Rh-negative mother:** Being Rh-negative is not a contraindication for ARM. However, care should be taken to avoid trauma to the fetal vessels to prevent feto-maternal hemorrhage; Anti-D prophylaxis is managed according to standard protocols. * **C. Diabetic mother:** Diabetes is an indication for timely delivery (often at 38–39 weeks). ARM is frequently used as part of the induction process in these patients to prevent macrosomia-related complications. **High-Yield Clinical Pearls for NEET-PG:** * **Indications for ARM:** Induction of labor, augmentation of labor, and to assess the color of liquor (e.g., for meconium). * **Prerequisites for ARM:** The head must be engaged (to prevent cord prolapse) and the cervix must be favorable. * **Complications of ARM:** Cord prolapse, accidental fetal injury, and maternal infection. * **IUFD Management:** If labor does not start spontaneously, induction with prostaglandins (Misoprostol) is preferred over ARM.

Q: What is the action of oxytocin in small doses when used as an intravenous infusion in a term uterus?

Induces uterine contractions. **Explanation:** **Mechanism of Action (Why B is correct):** Oxytocin is a peptide hormone synthesized in the hypothalamus and released by the posterior pituitary. At term, the uterus becomes highly sensitive to oxytocin due to a significant increase in the number of oxytocin receptors. When administered in **small doses via intravenous infusion**, oxytocin acts on these G-protein coupled receptors to increase intracellular calcium in the myometrium. This triggers rhythmic, synchronous contractions that mimic natural labor (increasing both frequency and force of contractions). **Analysis of Incorrect Options:** * **Option A:** Oxytocin is a potent **uterotonic** agent; it never relaxes the uterus. Drugs that relax the uterus are called tocolytics (e.g., Nifedipine, Terbutaline). * **Option C:** While cervical dilatation occurs during labor, it is a **secondary effect** of uterine contractions and the downward pressure of the fetal presenting part. Oxytocin does not have a direct biochemical "ripening" or dilatory effect on the cervix itself (unlike Prostaglandins E2). **NEET-PG High-Yield Pearls:** * **Half-life:** Oxytocin has a very short plasma half-life (approx. 3–5 minutes), which is why it must be given as a continuous IV infusion for labor induction. * **Side Effects (High Dose):** In large doses, oxytocin has an **ADH-like effect**, leading to water retention and potential water intoxication (hyponatremia). It can also cause peripheral vasodilation and hypotension if given as a rapid bolus. * **Drug of Choice:** It is the preferred agent for **induction/augmentation of labor** and the first-line drug for the prevention and management of **Postpartum Hemorrhage (PPH)**.

Q: A 22-year-old G3P2 presented with profuse bleeding after a normal spontaneous vaginal delivery. Physical examination reveals a boggy uterus, and a bedside sonogram indicates the presence of retained placental tissue. What is the most probable diagnosis?

Retained placental tissue. ### Explanation **Correct Answer: A. Retained placental tissue** The clinical presentation of profuse postpartum hemorrhage (PPH) associated with a **boggy uterus** and **sonographic evidence** of intrauterine contents points directly to retained placental tissue. While uterine atony is the most common cause of PPH, the presence of retained fragments prevents the uterus from contracting effectively (secondary atony), leading to a boggy feel on palpation. Ultrasound is the gold standard for confirming the presence of these fragments. **Why other options are incorrect:** * **B. Uterine atony:** While a "boggy uterus" is the hallmark of atony, the specific mention of a bedside sonogram showing placental tissue makes "Retained placental tissue" the more specific and accurate diagnosis. Atony is often the *result* of the retained tissue. * **C. Placental abruption:** This is a cause of antepartum hemorrhage (bleeding before delivery), characterized by painful vaginal bleeding and a "woody hard" uterus, not a boggy one postpartum. * **D. Uterine inversion:** This presents with sudden shock out of proportion to blood loss and a characteristic "fundal notch" or a mass protruding through the cervix/vagina. The uterus would not be palpable in its normal abdominal position. **NEET-PG High-Yield Pearls:** * **The 4 Ts of PPH:** **T**one (Atony - 80%), **T**issue (Retained products), **T**rauma (Lacerations), and **T**hrombin (Coagulopathy). * **Management:** For retained placenta, manual removal or suction/evacuation is required. * **Active Management of Third Stage of Labor (AMTSL):** Reduces the risk of PPH by 60%. It includes prophylactic uterotonics (Oxytocin 10 IU IM), controlled cord traction, and uterine massage. * **Uterine Atony vs. Trauma:** If the uterus is **firm** but bleeding persists, suspect a traumatic cause (cervical/vaginal tear). If the uterus is **boggy**, suspect atony or retained tissue.

Q: What is the commonest cause of death in breech delivery?

Intracranial hemorrhage. **Explanation:** In breech delivery, the **commonest cause of death is intracranial hemorrhage**. This occurs primarily due to the rapid compression and subsequent decompression of the fetal head as it passes through the birth canal. Unlike a vertex presentation, where the head has hours to undergo "molding," the after-coming head in a breech delivery must engage and pass through the pelvis quickly. This sudden pressure change can lead to the tearing of the **tentorium cerebelli** or the **great vein of Galen**, resulting in fatal intracranial bleeding. **Analysis of Options:** * **A. Intracranial hemorrhage (Correct):** The lack of gradual molding leads to dural tears and vascular rupture. It remains the leading cause of neonatal mortality in vaginal breech births. * **B & C. Atlantoaxial dislocation/fracture:** These are traumatic injuries caused by excessive traction or hyperextension of the fetal neck (e.g., during the Prague maneuver). While specific to breech complications, they are significantly less common than intracranial trauma. * **D. Aspiration:** While breech infants are at risk of inhaling amniotic fluid or meconium if the breathing reflex is triggered while the head is still in the birth canal, it is a less frequent cause of immediate death compared to hemorrhage. **High-Yield Clinical Pearls for NEET-PG:** * **Most common cause of fetal death overall in breech:** Birth asphyxia (often due to cord prolapse or head entrapment). * **Most common cause of traumatic death:** Intracranial hemorrhage. * **Cord Prolapse:** More common in footling (15%) and complete breech (5%) than in frank breech (0.5%). * **Safe Delivery:** To prevent intracranial trauma, the **Burn-Marshall maneuver** or **Piper’s forceps** are used to control the delivery of the after-coming head and prevent sudden decompression.

Q: Which of the following is NOT true regarding Duncan's mechanism of placental separation?

It is the most common method of placental separation.. **Explanation:** The third stage of labor involves the separation and expulsion of the placenta. There are two primary mechanisms of placental separation: **Schultze** and **Duncan**. **Why Option D is the correct answer:** Option D is incorrect (and thus the right answer for this "NOT true" question) because **Schultze mechanism** is the most common method, occurring in approximately **80%** of cases. In Schultze, separation begins at the center of the placenta, leading to the formation of a retroplacental hematoma that aids in complete detachment. Duncan’s mechanism occurs in only about 20% of cases. **Analysis of other options:** * **Option A & B:** In **Duncan’s mechanism**, separation starts at the **periphery (margins)**. Because the edges detach first, the placenta slides down sideways, and the **maternal surface** (rough, cotyledonous side) presents first at the vulva. * **Option C:** Duncan’s mechanism is associated with **more visible blood loss** during the process. Unlike Schultze, where the blood is trapped behind the membranes (retroplacental) until the placenta is delivered, in Duncan’s, the blood escapes immediately from the margins. **NEET-PG High-Yield Pearls:** * **Schultze Mechanism (80%):** "Center first." Fetal surface (shiny side) presents. Less external bleeding. * **Duncan Mechanism (20%):** "Edges first." Maternal surface (dirty/rough side) presents. More external bleeding. * **Memory Aid:** **S**chultze = **S**hiny (Fetal surface) and **S**afe (less bleeding). **D**uncan = **D**irty (Maternal surface).

Question 1

Placenta accreta is associated with which of the following conditions?

Accepted Answer

Uterine scar

Answer

Placenta previa

Answer

Multiple pregnancy

Answer

Multiparity

Question 2

Dystocia dystrophia syndrome is seen in which type of pelvis?

Accepted Answer

Android pelvis

Answer

Platypelloid pelvis

Answer

Anthropoid pelvis

Answer

Gynaecoid pelvis

Question 3

A woman G3P2 at 34 weeks of gestation presents with abdominal pain, uterine tenderness, and bleeding per vaginum. Her vital signs are stable, and fetal heart rate tracing is regular. Which of the following steps is NOT required?

Accepted Answer

Tocolysis to arrest labor

Answer

Amniotomy or prostaglandins to induce labor

Answer

Arrange for blood products

Answer

Intravenous crystalloids and colloids

Question 4

Artificial rupture of membranes (ARM) is contraindicated in which of the following situations?

Accepted Answer

When the fetus is dead

Answer

Pregnancy beyond 40 weeks

Answer

When the mother is Rh-negative

Answer

When the mother is diabetic

Question 5

What is the action of oxytocin in small doses when used as an intravenous infusion in a term uterus?

Accepted Answer

Induces uterine contractions

Answer

Relaxes the uterus

Answer

Causes cervical dilatation

Answer

All of the above

Question 6

A 22-year-old G3P2 presented with profuse bleeding after a normal spontaneous vaginal delivery. Physical examination reveals a boggy uterus, and a bedside sonogram indicates the presence of retained placental tissue. What is the most probable diagnosis?

Accepted Answer

Retained placental tissue

Answer

Uterine atony

Answer

Placental abruption

Answer

Uterine inversion

Question 7

Fetal position refers to which of the following?

Accepted Answer

The relationship of an arbitrarily chosen portion of the fetal presenting part to the right or left side of the birth canal.

Answer

That portion of the fetal body that is either foremost within the birth canal or in closest proximity to it.

Answer

The relation of the fetal long axis to that of the mother.

Answer

The form of an ovoid mass that corresponds roughly to the shape of the uterine cavity.

Question 8

What is the commonest cause of death in breech delivery?

Accepted Answer

Intracranial hemorrhage

Answer

Atlantoaxial dislocation

Answer

Atlantoaxial fracture

Answer

Aspiration

Question 9

What is the TRUE statement regarding the management of monoamniotic pregnancy?

Accepted Answer

Termination should be planned electively at 32 to 34 weeks by elective LSCS.

Answer

A trial of labor can be given after ruling out conjoint twins.

Answer

With regular fetal monitoring, pregnancy may be carried on up to term.

Answer

Prophylactic tocolytics should be started from 28 weeks to prevent preterm labor.

Question 10

Which of the following is NOT true regarding Duncan's mechanism of placental separation?

Accepted Answer

It is the most common method of placental separation.

Answer

Separation occurs from the maternal surface.

Answer

The maternal surface presents at the vulva.

Answer

There is typically more blood loss.

Labor and Delivery — MCQs

Labor and Delivery — MCQs

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