Labor and Delivery Practice Questions

Q: 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:

antibiotics followed by labour induction. ***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.

Q: Which of the following foetal diameters measure 9.4 cm at term? 1. Biparietal diameter 2. Suboccipitofrontal diameter 3. Submentobregmatic diameter 4. Bitrochanteric diameter Select the correct answer using the code given below:

1 and 3 only. ***1 and 3 only*** - The **biparietal diameter (BPD)** measures the distance between the two parietal eminences and is typically **9.4 cm** at term, representing the widest transverse diameter of the fetal head. - The **submentobregmatic diameter** measures from the junction of the chin and neck to the center of the anterior fontanelle (bregma), typically measuring **9.5 cm** at term (often approximated as 9.4 cm in clinical practice), and is the presenting diameter in a face presentation with complete extension. *1, 2, 3 and 4* - While both biparietal and submentobregmatic diameters are approximately 9.4-9.5 cm, the **suboccipitofrontal** and **bitrochanteric** diameters do not match this measurement at term. - The suboccipitofrontal diameter is larger (~10 cm) and the bitrochanteric measurement varies (9-10 cm). *2 and 4 only* - The **suboccipitofrontal diameter** (from the subocciput to the center of the frontal suture) is typically larger, around **10 cm**, and is the presenting diameter in a well-flexed vertex presentation. - The **bitrochanteric diameter** (between the fetal hip trochanters) is approximately **9-10 cm** at term but is not consistently 9.4 cm and refers to the fetal body, not the head. *1 and 2 only* - While the **biparietal diameter** is indeed 9.4 cm, the **suboccipitofrontal diameter** is typically larger, around **10 cm**, making this option incorrect. - This option misses the **submentobregmatic diameter**, which also measures approximately 9.4-9.5 cm at term.

Q: On examination, a woman with post-dated pregnancy is found to have 80% effaced cervix. She requires the induction of labour. This is best done through

Oxytocin drip. ***Oxytocin drip*** - An 80% effaced cervix indicates a **favorable cervix** (high Bishop score), meaning it is ripe and ready for induction. - In such cases, **oxytocin** is the most appropriate method to stimulate uterine contractions for labor induction. *Intracervical dinoprostone gel* - Dinoprostone is a **prostaglandin E2 analog** used primarily for **cervical ripening** when the cervix is unfavorable (low Bishop score), not for an 80% effaced cervix. - It softens and effaces the cervix, but for a cervix already 80% effaced, it's not the primary induction agent. *ARM with oxytocin drip* - **Artificial rupture of membranes (ARM)** can be performed once the cervix is favorable, but it is often done in conjunction with oxytocin if contractions are not strong enough. - However, in a post-dated pregnancy with an 80% effaced cervix, **oxytocin infusion alone** is often sufficient to initiate and maintain effective contractions. ARM can be reserved for further augmentation if needed. *Carboprost tromethamin intra-muscularly* - **Carboprost** is a prostaglandin F2 alpha analog primarily used to treat **postpartum hemorrhage** by inducing strong uterine contractions to reduce bleeding. - It is **not indicated for labor induction** due to its strong and sustained uterine contraction profile and potential for severe side effects.

Q: A 25-year-old primigravida in early labour with vertex presentation in left occipitoanterior position. The head is floating. Her diagonal conjugate measures 11 cm. The appropriate management will be

Give her a trial of labour. **Give her a trial of labour** - A **diagonal conjugate of 11 cm** is at the **lower limit of normal** (normal ≥11.5 cm, obstetric conjugate ~9.5 cm), making it borderline adequate for vaginal delivery, but not an absolute contraindication. - The **left occipitoanterior position** is the most favorable presentation for engagement and descent through the pelvis. - While the head is **floating** (unengaged), this is common in early labor, especially for a primigravida; a **trial of labor** allows assessment of labor progression, cervical dilation, and head descent to diagnose potential **cephalopelvic disproportion (CPD)**. - CPD can only be diagnosed during active labor; hence a trial is warranted before considering surgical intervention. *Deliver vaginally at home* - Home delivery is inappropriate and unsafe for a **primigravida** with a **borderline pelvis** and **floating head**, which requires continuous monitoring in a clinical setting. - The risk of obstructed labor and CPD necessitates hospital supervision with capability for emergency intervention if needed. *Deliver by emergency caesarean section* - Emergency cesarean section is **not indicated** at this stage as there are **no signs of fetal distress**, obstructed labor, or proven CPD. - The diagonal conjugate, though borderline, is not an absolute contraindication; surgical intervention should only be considered after failed trial of labor or evidence of maternal/fetal compromise. *Refer to higher center immediately* - There is no immediate indication for referral to a higher center, as the patient is in **early labor** with no complications like severe pre-eclampsia, antepartum hemorrhage, or acute fetal distress. - This case can be managed in a standard delivery unit with capability for cesarean section if trial of labor fails; a **trial of labor** with close monitoring is the appropriate initial management.

Q: Before the delivery of the second twin having cephalic presentation, the mother develops profuse bleeding per vaginum. The appropriate management will be

ARM. ***ARM (Artificial Rupture of Membranes)*** - Profuse bleeding between twin deliveries is an **obstetric emergency** requiring **immediate delivery** of the second twin to control hemorrhage. - Since the second twin has **cephalic presentation**, **ARM followed by assisted delivery** is the **fastest and most appropriate intervention**. - ARM stimulates uterine contractions and allows for **immediate vaginal delivery**, preventing maternal **exsanguination** and fetal compromise. *Internal podalic version and breech extraction* - This is **NOT indicated** as the second twin already has **cephalic presentation** (the most favorable presentation). - Internal podalic version is reserved for **transverse or unstable lie**, not for converting an already favorable cephalic presentation to breech. - Converting cephalic to breech would **waste critical time** and **increase maternal and fetal risk** in this emergency. *External cephalic version and oxytocin drip* - **External cephalic version** is inappropriate as the second twin already has **cephalic presentation**. - **Oxytocin** alone does not expedite delivery quickly enough in this **hemorrhagic emergency**. - This approach causes unnecessary delay when immediate delivery is required. *Deliver the placenta of the first twin* - This is **dangerous and absolutely contraindicated** - placenta should only be delivered **after both twins are born**. - Delivering the placenta while the second twin remains in utero can cause **massive hemorrhage**, **uterine contraction**, **entrapment of the second twin**, and **fetal death**.

Q: A 35-year-old multiparous woman is admitted with prolonged labour. She is in shock, and her pulse rate is 150 per minute. The uterus is tonically contracted with Bandl's ring, and the presenting part is not engaged. The appropriate treatment is

Perform LSCS (Lower Segment Caesarean Section). ***Perform LSCS (Lower Segment Caesarean Section)*** - The presence of a **tonically contracted uterus** with **Bandl's ring**, unengaged presenting part, and the patient being in **shock** (pulse 150 bpm) are all signs of **imminent uterine rupture** due to obstructed labor. - An **emergency LSCS** is immediately indicated to deliver the baby and manage the uterine obstruction, prioritizing the mother's and baby's lives. *Do internal podalic version and extraction* - This procedure is contraindicated in cases of **obstructed labor** with a tonically contracted uterus and Bandl's ring, as it significantly increases the risk of **uterine rupture**. - Internal podalic version is typically performed for malpresentations in the absence of obstruction, often in a less critical maternal condition. *Deliver the baby by vaginal route using a vacuum extractor* - **Vacuum extraction** requires a dilated cervix, engaged head, and the absence of mechanical obstruction. - With an **unengaged presenting part**, tonically contracted uterus, and Bandl's ring, a vaginal instrumental delivery is impossible and highly dangerous, risking uterine rupture. *Augment labour with oxytocin* - **Oxytocin augmentation** is used for hypotonic uterine dysfunction to strengthen contractions. - In a case of **obstructed labor** with a tonically contracted uterus and Bandl's ring, adding oxytocin would further exacerbate the uterine stress and dramatically increase the risk of **uterine rupture**, making it absolutely contraindicated.

Q: The presence of a retraction ring at the junction of upper and lower uterine segment in labour indicates

obstructed labour. ***Obstructed labour*** - A **pathological retraction ring (Bandl's ring)** forms when the upper uterine segment thickens and retracts, while the lower segment thins and distends due to **obstructed labour**. - This is distinct from the normal physiological retraction ring present in all labours—Bandl's ring is abnormally prominent, may be visible or palpable abdominally, and rises progressively higher. - This physical sign indicates an impending **uterine rupture** if the obstruction is not relieved and constitutes an obstetric emergency. *Cervical dystocia* - Refers to a cervix that fails to efface or dilate in the presence of adequate uterine contractions, but it does not directly cause the formation of a **pathological retraction ring**. - While it can lead to prolonged labour, the specific finding of a retraction ring at an abnormally high level points more directly to **obstruction**. *Precipitate labour* - Characterized by rapid labour lasting less than three hours from the onset of contractions to delivery. - It is the opposite of obstructed labour and does not involve the formation of a **pathological retraction ring**. *Prolonged labour* - Refers to labour that exceeds 20 hours for nulliparous women or 14 hours for multiparous women. - While obstructed labour can lead to prolonged labour, the presence of a **pathological retraction ring (Bandl's ring)** is a specific sign of obstruction, indicating a more severe and immediate threat than general prolongation.

Q: B-Lynch stitch is applied on the uterus for the treatment of

atonic PPH. ***atonic PPH*** - The **B-Lynch stitch** is a **compression suture** applied surgically to the uterus to control severe **postpartum hemorrhage (PPH)** caused by **uterine atony**. - It works by mechanically compressing the uterus, thereby reducing blood flow and promoting uterine contraction, which is critical when the uterus fails to contract sufficiently after childbirth. *incompetent os* - An **incompetent cervical os** is typically managed with a **cervical cerclage**, a stitch placed around the cervix to prevent premature dilation during pregnancy. - The B-Lynch stitch is designed for uterine hemostasis, not cervical support. *ruptured ulcerations* - While bleeding might occur from **ruptured ulcerations**, this term is vague in an obstetrical context and does not apply to uterine bleeding specifically. - The B-Lynch stitch is used for severe uterine hemorrhage, most commonly due to atony, not general ulcerations which would require different treatment. *bleeding from placental bed of placenta previa* - **Placenta previa** bleeding often results from the placenta implanting over or near the cervix, which might require a **cesarean section** and careful placental removal. - While a B-Lynch stitch *could* be used as an adjunct in severe cases of PPH following placenta previa if atony develops, it is not the primary or typical treatment for bleeding *from the placental bed itself* which usually involves direct uterine incision or placental site hemostasis.

Q: Abnormal foetal heart-rate patterns on electronic foetal monitoring include the following, except

early decelerations. ***Early decelerations*** - **Early decelerations** are considered a **benign finding** on electronic fetal monitoring, reflecting fetal head compression during contractions. - They tend to **mirror the contractions** and do not indicate fetal distress or hypoxia. *Tachycardia >170/minute lasting for 15 minutes* - Fetal **tachycardia** (heart rate >160 bpm) lasting for 10 minutes or more is considered an abnormal finding or baseline change. - A persistent fetal heart rate **>170 bpm for 15 minutes** or longer specifically indicates significant fetal tachycardia, which can be a sign of infection (e.g., chorioamnionitis), maternal fever, or fetal hypoxia. *Bradycardia <120/minute lasting for 15 minutes* - Fetal **bradycardia** (heart rate <110 bpm) lasting for 10 minutes or more is considered an abnormal finding or baseline change. - A fetal heart rate **<120 bpm lasting for 15 minutes** or longer, as specified, indicates significant fetal bradycardia, which can be associated with fetal hypoxia, cord compression, or placental insufficiency. *Late decelerations* - **Late decelerations** are a concerning sign of fetal distress, often indicative of **uteroplacental insufficiency** and fetal hypoxia. - They begin after the peak of the contraction and return to baseline after the contraction ends, reflecting a delayed fetal response to hypoxia.

Question 1

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:

Accepted Answer

antibiotics followed by labour induction

Answer

steroids followed by labour induction

Answer

expectant management

Answer

steroids and tocolytic agents

Question 2

Which of the following foetal diameters measure 9.4 cm at term?

1. Biparietal diameter
2. Suboccipitofrontal diameter
3. Submentobregmatic diameter
4. Bitrochanteric diameter

Select the correct answer using the code given below:

Accepted Answer

1 and 3 only

Answer

1, 2, 3 and 4

Answer

2 and 4 only

Answer

1 and 2 only

Question 3

On examination, a woman with post-dated pregnancy is found to have 80% effaced cervix. She requires the induction of labour. This is best done through

Accepted Answer

Oxytocin drip

Answer

Intracervical dinoprostone gel

Answer

ARM with oxytocin drip

Answer

Carboprost tromethamin intra-muscularly

Question 4

A 25-year-old primigravida in early labour with vertex presentation in left occipitoanterior position. The head is floating. Her diagonal conjugate measures 11 cm. The appropriate management will be

Accepted Answer

Give her a trial of labour

Answer

Deliver vaginally at home

Answer

Deliver by emergency caesarean section

Answer

Refer to higher center immediately

Question 5

Before the delivery of the second twin having cephalic presentation, the mother develops profuse bleeding per vaginum. The appropriate management will be

Accepted Answer

ARM

Answer

External cephalic version and oxytocin drip

Answer

Deliver the placenta of the first twin

Answer

Internal podalic version and breech extraction

Question 6

A 35-year-old multiparous woman is admitted with prolonged labour. She is in shock, and her pulse rate is 150 per minute. The uterus is tonically contracted with Bandl's ring, and the presenting part is not engaged. The appropriate treatment is

Accepted Answer

Perform LSCS (Lower Segment Caesarean Section)

Answer

Do internal podalic version and extraction

Answer

Deliver the baby by vaginal route using a vacuum extractor

Answer

Augment labour with oxytocin

Question 7

A vaginal examination conducted during the second stage of labour reveals occipito-posterior position of the vertex. This occipito-posterior position of the vertex was diagnosed on the basis of which of the following findings ?

Accepted Answer

Posterior fontanelle positioned posteriorly with the sagittal suture anteroposterior

Answer

Anterior fontanelle not reached

Answer

Posterior fontanelle in the subpubic area

Answer

Sagittal suture in transverse in the pelvic cavity

Question 8

The presence of a retraction ring at the junction of upper and lower uterine segment in labour indicates

Accepted Answer

obstructed labour

Answer

cervical dystocia

Answer

precipitate labour

Answer

prolonged labour

Question 9

B-Lynch stitch is applied on the uterus for the treatment of

Accepted Answer

atonic PPH

Answer

incompetent os

Answer

ruptured ulcerations

Answer

bleeding from placental bed of placenta previa

Question 10

Abnormal foetal heart-rate patterns on electronic foetal monitoring include the following, except

Accepted Answer

early decelerations

Answer

tachycardia >170/minute lasting for 15 minutes

Answer

bradycardia <120/minute lasting for 15 minutes

Answer

late decelerations

Labor and Delivery — MCQs

Labor and Delivery — MCQs

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