Labor and Delivery — MCQs

Labor and Delivery Indian Medical PG Practice Questions and MCQs

Question 421: A 28-year-old woman at 13 weeks of gestation presents with ultrasound findings of anencephaly and requests medical termination of pregnancy (MTP). Which of the following is NOT a preferred method of MTP in this condition?

A. Menstrual regulation (Correct Answer)
B. Intra-amniotic instillation of urea and PGF2α
C. Extraovular instillation of ethacridine lactate
D. Parenteral administration of PGF2α

Explanation: **Explanation:** The correct answer is **A. Menstrual regulation**. **1. Why Menstrual Regulation is NOT preferred:** Menstrual regulation (MR) is a procedure used for the termination of pregnancy very early in the first trimester, typically within **6 weeks of the last menstrual period (LMP)** or up to 14 days of a missed period. It involves manual vacuum aspiration of the uterine contents. Since the patient in this scenario is at **13 weeks of gestation** (early second trimester), MR is technically inappropriate and unsafe due to the size of the fetus and the advanced gestational age. **2. Analysis of Other Options (Second Trimester MTP Methods):** * **B. Intra-amniotic instillation (Urea/PGF2α):** This is a recognized method for second-trimester termination. Hypertonic solutions or prostaglandins are injected into the amniotic sac to induce uterine contractions and fetal expulsion. * **C. Extraovular instillation (Ethacridine lactate):** Also known as the "Emcredil" method, a Foley catheter is used to instill the solution into the space between the uterine wall and the fetal membranes. It is a classic method for mid-trimester MTP. * **D. Parenteral administration of PGF2α:** Systemic administration (IM or IV) of prostaglandins (like Carboprost) is a highly effective pharmacological method to induce labor in the second trimester. **Clinical Pearls for NEET-PG:** * **MTP Act (India):** Termination is legal up to **24 weeks** for specific categories (including fetal anomalies like anencephaly). * **First Trimester (up to 12 weeks):** Preferred methods are Medical (Mifepristone + Misoprostol) or Surgical (Suction Evacuation). * **Second Trimester (13–24 weeks):** Preferred methods include Dilatation and Evacuation (D&E) or Medical Induction (Prostaglandins/Oxytocin). * **Anencephaly:** This is a lethal neural tube defect; once diagnosed, MTP is indicated regardless of gestational age (within legal limits).

Question 422: Placenta succenturiata may lead to all of the following except?

A. Preterm delivery (Correct Answer)
B. Postpartum hemorrhage
C. Missing lobe
D. Sepsis and subinvolution

Explanation: **Explanation:** **Placenta Succenturiata** is a morphological variation where one or more small accessory lobes of placental tissue are located in the membranes at a distance from the main placental mass. These lobes are connected to the main placenta by fetal vessels (vasa previa risk). **Why Option A is the correct answer:** Preterm delivery is **not** typically caused by a succenturiate lobe. Preterm labor is generally associated with conditions like uterine overdistension (polyhydramnios, twins), infections, or cervical insufficiency. While placental abnormalities like placenta previa or abruption can lead to preterm birth, a succenturiate lobe itself does not trigger early labor. **Analysis of Incorrect Options:** * **B. Postpartum Hemorrhage (PPH):** If the accessory lobe is retained in the uterus after the main placenta is delivered, it prevents effective uterine contraction, leading to atonic PPH. * **C. Missing Lobe:** Upon inspection of the delivered placenta, a "gap" in the membranes with torn vessels extending from the main mass suggests a missing succenturiate lobe remains inside the uterus. * **D. Sepsis and Subinvolution:** A retained accessory lobe acts as a nidus for infection (**Sepsis/Endometritis**) and prevents the uterus from returning to its non-pregnant size (**Subinvolution**). **High-Yield NEET-PG Pearls:** 1. **Vasa Previa:** The most dangerous complication occurs when the connecting vessels run across the internal os. Rupture of these vessels leads to fetal exsanguination (Benckiser’s hemorrhage). 2. **Management:** Always inspect the membranes for torn vessels; if a lobe is suspected to be missing, manual exploration of the uterus is mandatory. 3. **Diagnosis:** Often made via antenatal color Doppler ultrasound.

Question 423: A pregnant woman at 34 weeks gestation presents with antepartum hemorrhage and a blood pressure of 80/something. What is the initial management?

A. Examination in OT and termination of pregnancy
B. Blood transfusion (Correct Answer)
C. Observation
D. Lower segment caesarean section

Explanation: ### Explanation The clinical presentation of antepartum hemorrhage (APH) associated with a blood pressure of 80/something (hypotension) indicates **hypovolemic shock**. In any obstetric emergency involving hemodynamic instability, the priority is always **maternal stabilization** before definitive obstetric intervention. **1. Why Blood Transfusion is Correct:** The patient is hemodynamically unstable. The immediate goal is to restore intravascular volume and oxygen-carrying capacity to prevent maternal organ failure and fetal distress. According to the protocols for major obstetric hemorrhage, aggressive fluid resuscitation followed by blood transfusion is the "initial" step to stabilize the mother. **2. Why Other Options are Incorrect:** * **A. Examination in OT:** This is the "Double Setup Examination" used to diagnose placenta previa. However, it is contraindicated in an unstable patient and has largely been replaced by ultrasound. * **C. Observation:** This is part of expectant management (Macafee-Johnson protocol), but it is only indicated if the mother and fetus are stable and the bleeding has stopped. It is inappropriate in the presence of shock. * **D. LSCS:** While delivery may be the definitive treatment (especially in cases of Abruptio Placentae or Placenta Previa), performing surgery on a patient in shock without prior resuscitation significantly increases maternal mortality. Stabilization must precede surgery. **Clinical Pearls for NEET-PG:** * **Rule of Thumb:** In Obstetrics, "Stabilize the mother first, then worry about the fetus." * **Macafee-Johnson Protocol:** Indicated in APH if gestation is <37 weeks, bleeding is not life-threatening, and the mother/fetus are stable. * **Diagnosis:** Never perform a per-vaginal (PV) examination in a case of APH until Placenta Previa is ruled out by ultrasound, as it can provoke torrential hemorrhage. * **Shock Index:** In pregnancy, a shock index (HR/SBP) > 0.9 suggests significant blood loss requiring transfusion.

Question 424: An AG2 P1L1 (gravida 2, para 1, living 1) female, with a previous history of lower segment cesarean section (LSCs), presents at 36 weeks of gestation with breech presentation. What is the next step in management?

A. External cephalic version (ECV) at 37 weeks (Correct Answer)
B. Planned cesarean section at 38 weeks
C. Immediate cesarean section
D. Induction of labor

Explanation: ### Explanation **Correct Option: A. External cephalic version (ECV) at 37 weeks** The primary goal in managing a breech presentation is to achieve a cephalic presentation to allow for a trial of labor. According to RCOG and ACOG guidelines, a **previous lower segment cesarean section (LSCS) is NOT a contraindication to ECV**. The success rate of ECV in women with a prior scar is similar to those without one, and the risk of uterine rupture is extremely low (<0.5%). ECV is ideally performed at **37 weeks** in multiparous women to minimize the risk of preterm labor while ensuring the fetus is mature enough if an emergency delivery is required. **Why other options are incorrect:** * **B. Planned cesarean section at 38 weeks:** While a repeat CS is an option, it is not the *next* step. Guidelines recommend offering ECV first to provide the patient the opportunity for a Vaginal Birth After Cesarean (VBAC). * **C. Immediate cesarean section:** There is no evidence of fetal distress or active labor. At 36 weeks, the fetus is late-preterm; immediate delivery without indication increases neonatal morbidity. * **D. Induction of labor:** Inducing labor in a breech presentation, especially with a scarred uterus, is contraindicated due to the high risk of cord prolapse and difficult after-coming head delivery. **High-Yield Clinical Pearls for NEET-PG:** * **Prerequisites for ECV:** Reactive NST, adequate liquor (AFI >5), and no uterine anomalies. * **Contraindications to ECV:** Placenta previa, multifetal gestation, ruptured membranes, or any indication for a CS regardless of presentation. * **Success Rate:** Approximately 50% in nulliparous and 60% in multiparous women. * **Tocolysis:** Use of beta-mimetics (e.g., Ritodrine or Terbutaline) during ECV increases the success rate by relaxing the myometrium.

Question 425: All of the following can be administered in acute hypertension during labor except?

A. IV labetalol
B. Oral nifedipine
C. IV dihydralazine
D. IV diazoxide (Correct Answer)

Explanation: **Explanation:** The management of acute severe hypertension in labor (Blood Pressure ≥160/110 mmHg) focuses on preventing maternal cerebrovascular accidents while maintaining placental perfusion. **Why IV Diazoxide is the Correct Answer:** IV Diazoxide is a potent vasodilator formerly used for hypertensive emergencies. However, it is **contraindicated** in labor because it causes profound maternal hypotension, which can lead to placental hypoperfusion and fetal distress. Furthermore, it acts as a powerful **tocolytic** (relaxes the uterus), which can arrest the progress of labor and increase the risk of postpartum hemorrhage (PPH). **Analysis of Other Options:** * **IV Labetalol (Option A):** A combined alpha and beta-blocker. It is considered a **first-line agent** due to its rapid onset and excellent safety profile. It avoids reflex tachycardia. * **Oral Nifedipine (Option B):** A calcium channel blocker (immediate-release formulation). It is a **first-line oral agent** used when IV access is difficult. It is effective and easy to administer. * **IV Dihydralazine/Hydralazine (Option C):** A direct vasodilator. It has been a traditional mainstay for acute hypertension in pregnancy. While it may cause reflex tachycardia, it remains a recommended option in many clinical guidelines. **Clinical Pearls for NEET-PG:** * **Target BP:** The goal is not to normalize BP but to bring it down to **140–150/90–100 mmHg** to prevent cerebral hemorrhage. * **Drug of Choice:** Most international guidelines (ACOG/RCOG) list **IV Labetalol** or **Hydralazine** and **Oral Nifedipine** as the three primary options. * **Avoid:** ACE inhibitors and ARBs are strictly contraindicated in pregnancy due to teratogenicity and fetal renal failure. * **Magnesium Sulfate:** Always remember that $MgSO_4$ is the drug of choice for seizure prophylaxis in eclampsia, but it is **not** an antihypertensive agent.

Question 426: What is the most common abnormality leading to a first-trimester abortion?

A. Trauma
B. Placental and membrane abnormalities
C. Chromosomal abnormalities or germ plasm defects (Correct Answer)
D. Uterine retroversion

Explanation: **Explanation:** The most common cause of spontaneous abortion in the first trimester is **chromosomal abnormalities**, accounting for approximately **50–60%** of all early pregnancy losses. These are often "germ plasm defects" resulting from errors in gametogenesis or fertilization. Among these, **Autosomal Trisomy** is the most frequent (Trisomy 16 being the most common specific trisomy), followed by Monosomy X (Turner Syndrome) and Polyploidy. These abnormalities lead to defective embryogenesis, making the pregnancy non-viable. **Analysis of Incorrect Options:** * **A. Trauma:** Contrary to popular belief, physical trauma is a very rare cause of first-trimester loss. The uterus is well-protected within the bony pelvis during the first 12 weeks. * **B. Placental and membrane abnormalities:** While these can cause late miscarriages or fetal growth restriction, they are rarely the primary cause of early first-trimester loss compared to genetic factors. * **D. Uterine retroversion:** A retroverted uterus is considered a normal anatomical variant in many women and does not increase the risk of miscarriage. Only a "persistent incarcerated gravid uterus" (rare) might cause complications, but not routine abortion. **NEET-PG High-Yield Pearls:** * **Most common chromosomal abnormality:** Autosomal Trisomy (50% of all chromosomal causes). * **Most common specific Trisomy:** Trisomy 16 (never seen in live births). * **Most common single chromosomal anomaly:** Monosomy X (45,X). * **Second-trimester abortions:** More likely due to maternal factors (e.g., cervical incompetence, uterine anomalies, or systemic infections).

Question 427: Which of the following is NOT a maneuver used for the treatment of shoulder dystocia?

A. Zavenelli maneuver
B. Wood's maneuver
C. McRoberts maneuver
D. Lovset maneuver (Correct Answer)

Explanation: **Explanation:** The correct answer is **D. Lovset maneuver**. The **Lovset maneuver** is used during a **breech delivery** to deliver the arms when they are extended or in a nuchal position. It involves rotating the fetal trunk 180 degrees while maintaining downward traction to bring the posterior arm under the symphysis pubis. It is not used for shoulder dystocia, which occurs during a cephalic (head-first) delivery. **Why the other options are incorrect (Maneuvers for Shoulder Dystocia):** * **McRoberts maneuver (Option C):** Usually the first-line intervention. It involves hyperflexing the mother's thighs against her abdomen, which flattens the sacral promontory and rotates the symphysis pubis cephalad, increasing the pelvic outlet. * **Wood’s maneuver (Option B):** Also known as the "Wood’s Screw maneuver." It involves rotating the posterior shoulder 180 degrees in a corkscrew fashion to dislodge the impacted anterior shoulder. * **Zavanelli maneuver (Option A):** A maneuver of last resort. It involves cephalic replacement (pushing the fetal head back into the vagina) followed by an emergency Cesarean section. **High-Yield Clinical Pearls for NEET-PG:** * **Shoulder Dystocia Mnemonic (HELPERR):** **H**elp, **E**pisiotomy, **L**egs (McRoberts), **P**ressure (Suprapubic), **E**nter (Internal rotation/Wood's), **R**emove posterior arm, **R**oll the patient (Gaskin maneuver). * **Suprapubic pressure (Mazzanti maneuver)** is used to dislodge the anterior shoulder; **Fundal pressure** is strictly contraindicated as it worsens impaction and increases the risk of uterine rupture. * The most common neonatal complication of shoulder dystocia is **Erb’s Palsy (C5-C6 injury)**.

Question 428: What is the first-line approach for shoulder dystocia?

A. Woods' corkscrew maneuver
B. McRoberts maneuver (Correct Answer)
C. Zavanelli maneuver
D. Increased fundal pressure

Explanation: **Explanation:** Shoulder dystocia is an obstetric emergency where the fetal head is delivered but the anterior shoulder becomes impacted behind the maternal symphysis pubis. The management follows a specific hierarchy of maneuvers, starting with the least invasive. **1. Why McRoberts Maneuver is Correct:** The **McRoberts maneuver** is the first-line intervention. It involves hyperflexion of the maternal hips against the abdomen. This action flattens the sacral promontory and rotates the symphysis pubis cephalad, increasing the pelvic outlet diameter and facilitating the release of the impacted shoulder. It is often combined with **suprapubic pressure** (Rubin I), which helps adduct the fetal shoulder. Together, these resolve up to 90% of cases. **2. Analysis of Incorrect Options:** * **Woods' corkscrew maneuver:** This is a secondary "internal" maneuver involving the rotation of the posterior shoulder. It is only performed if McRoberts and suprapubic pressure fail. * **Zavanelli maneuver:** This is a "last-resort" procedure involving cephalic replacement (pushing the head back into the uterus) followed by an emergency Cesarean section. It carries high maternal and fetal morbidity. * **Increased fundal pressure:** This is **strictly contraindicated**. Applying fundal pressure further impacts the shoulder against the symphysis and significantly increases the risk of uterine rupture and brachial plexus injury (Erb’s palsy). **NEET-PG High-Yield Pearls:** * **HELPERR Mnemonic:** Used for the sequence of management (H-Call for Help, E-Evaluate for Episiotomy, L-Legs/McRoberts, P-Suprapubic Pressure, E-Enter/Internal maneuvers, R-Remove posterior arm, R-Roll the patient). * **Turtle Sign:** The retraction of the fetal head against the perineum; the classic clinical sign of shoulder dystocia. * **Risk Factors:** Maternal diabetes (macrosomia) and instrumental delivery are the most significant predictors.

Question 429: What is the most common cause of direct obstetric deaths?

A. Anemia
B. Hemorrhage (Correct Answer)
C. Obstructed labor
D. Infection

Explanation: **Explanation:** The correct answer is **Hemorrhage**. Globally and in India, hemorrhage remains the leading cause of direct maternal mortality. **1. Why Hemorrhage is Correct:** Direct obstetric deaths result from obstetric complications of the pregnant state (pregnancy, labor, and puerperium). **Obstetric Hemorrhage**, specifically **Postpartum Hemorrhage (PPH)**, is the most common cause. It is characterized by rapid blood loss (often >500ml in vaginal delivery or >1000ml in C-section) leading to hypovolemic shock and death if not managed within the "Golden Hour." The primary etiology is uterine atony. **2. Analysis of Incorrect Options:** * **Anemia:** While a major contributor to maternal mortality in India, it is classified as an **indirect cause** (a pre-existing disease aggravated by pregnancy). It often acts as a predisposing factor that makes a woman less likely to survive a hemorrhage. * **Obstructed Labor:** This is a significant cause of morbidity (e.g., fistulas) and mortality, but it ranks lower than hemorrhage and sepsis in modern statistics due to better access to emergency cesarean sections. * **Infection (Sepsis):** Puerperal sepsis is the second or third most common direct cause, but it typically follows a more subacute course compared to the rapid fatality of hemorrhage. **3. High-Yield Clinical Pearls for NEET-PG:** * **Most common cause of Maternal Mortality (Global & India):** Hemorrhage (Direct). * **Most common cause of Indirect Maternal Death:** Anemia (followed by Heart Disease). * **Most common cause of PPH:** Uterine Atony. * **The "Big Three" Direct Causes:** 1. Hemorrhage, 2. Sepsis, 3. Hypertensive disorders (Eclampsia). * **MMR Definition:** Number of maternal deaths per 1,00,000 live births.

Question 430: A 24-year-old woman underwent a normal vaginal delivery of a term infant. After the delivery, the placenta does not deliver even after 30 minutes. What is the next recommended step for this patient?

A. Wait for an additional 30 minutes
B. Attempt a manual extraction of the placenta (Correct Answer)
C. Initiate oxytocin
D. Hysterectomy

Explanation: **Explanation:** The clinical scenario describes a **Retained Placenta**, defined as the failure of the placenta to deliver within 30 minutes of the birth of the baby in the third stage of labor. **1. Why Option B is Correct:** Once the 30-minute threshold is crossed, the risk of postpartum hemorrhage (PPH) increases significantly. The standard management for a retained placenta is **Manual Removal of Placenta (MROP)**. This procedure is performed under effective anesthesia (usually regional or general) to manually shear the placenta from the uterine wall and extract it. **2. Why Other Options are Incorrect:** * **Option A:** Waiting further increases the risk of life-threatening hemorrhage and infection. 30 minutes is the globally accepted cutoff for intervention. * **Option C:** While oxytocin is used for the active management of the third stage (AMTSL) to prevent PPH, it is usually already administered at the delivery of the anterior shoulder. If the placenta is morbidly adherent (e.g., Placenta Accreta), oxytocin will not facilitate delivery. * **Option D:** Hysterectomy is a last resort, reserved for cases of **Placenta Accreta Spectrum** where manual removal fails or causes massive, uncontrollable bleeding. **3. High-Yield Clinical Pearls for NEET-PG:** * **Third Stage Duration:** 15 minutes with active management; 30 minutes with expectant management. * **Signs of Placental Separation:** Gush of blood, lengthening of the umbilical cord, and the uterus becoming firm, globular, and rising in the abdomen (Schultze or Duncan mechanisms). * **Risk Factors:** Previous C-section, curettage, or uterine surgery (increases risk of morbidly adherent placenta). * **Complication:** The most common complication of MROP is **hemorrhage and infection**; hence, prophylactic antibiotics are mandatory post-procedure.

Practice by Chapter

Physiology of Labor

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Stages of Labor and Normal Progression

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Fetal Monitoring Techniques

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Pain Management in Labor

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Induction and Augmentation of Labor

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Operative Delivery (Forceps and Vacuum)

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Cesarean Section: Indications and Techniques

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Dystocia and Abnormal Labor Patterns

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Obstetric Emergencies

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Postpartum Hemorrhage Management

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