Labor and Delivery Practice Questions

Q: Which prostaglandin can be used to induce labor at term?

PGE2. **Explanation:** The induction of labor involves the artificial stimulation of uterine contractions before the onset of spontaneous labor. For successful induction, the cervix must be "ripe" (softened and effaced). **Why PGE2 is correct:** **Prostaglandin E2 (Dinoprostone)** is the gold standard pharmacological agent for cervical ripening and labor induction at term. It works by breaking down collagen networks in the cervix (ripening) and simultaneously stimulating myometrial contractions. It is available in various forms, including intracervical gels and sustained-release vaginal inserts. **Why the other options are incorrect:** * **PGF2α (Dinoprost/Carboprost):** While a potent uterine stimulant, it is primarily used for the management of **Postpartum Hemorrhage (PPH)** and second-trimester abortions. It is not used for induction at term because it can cause intense, uncoordinated contractions and significant systemic side effects (bronchospasm). * **PGI2 (Prostacyclin):** This is a potent vasodilator and inhibitor of platelet aggregation. It does not have a clinical role in labor induction. * **PGD2:** This prostaglandin is involved in sleep regulation and allergic responses; it has no role in obstetrics. **High-Yield Clinical Pearls for NEET-PG:** * **Misoprostol (PGE1):** Another common agent used for induction. It is cheaper and more stable than PGE2 but carries a higher risk of uterine tachysystole. * **Bishop Score:** Always assess the Bishop score before induction. A score of **≤6** indicates an unfavorable cervix, necessitating the use of prostaglandins (PGE2). * **Contraindication:** Prostaglandins should be avoided in patients with a **previous Cesarean section** or uterine surgery due to the increased risk of uterine rupture.

Q: All of the following are included in the first stage of labor except?

Crowning of fetal head. **Explanation:** The first stage of labor (Cervical Stage) begins with the onset of true labor pains and ends with the **full dilatation of the cervix (10 cm)**. The primary physiological events during this stage are the preparation of the birth canal to allow the passage of the fetus. * **Why 'Crowning' is the correct answer:** Crowning occurs when the widest diameter of the fetal head (biparietal diameter) stretches the vulval outlet and no longer recedes between contractions. This is a hallmark event of the **second stage of labor** (Stage of Expulsion), which begins after full cervical dilatation and ends with the delivery of the fetus. * **Why other options are incorrect:** * **Effacement and Dilatation (A & B):** These are the cardinal features of the first stage. Effacement is the thinning and shortening of the cervix, while dilatation is the enlargement of the external os. * **Descent of head (D):** While descent is a continuous process throughout all stages of labor (one of the movements in the mechanism of labor), it begins during the first stage as the head engages and moves through the pelvic inlet. **High-Yield Clinical Pearls for NEET-PG:** * **Duration:** In primigravida, the first stage lasts ~12 hours; in multigravida, ~6 hours. * **Phases:** The first stage is divided into the **Latent phase** (slow dilatation up to 4 cm) and the **Active phase** (rapid dilatation from 4 cm to 10 cm). * **Friedman’s Curve:** Used to plot cervical dilatation against time to monitor labor progress. * **Active Management of Labor (AMTSL):** Primarily focuses on the third stage to prevent Postpartum Hemorrhage (PPH).

Q: In a primigravida patient experiencing preterm labor, which of the following agents cannot be used as a tocolytic except?

Ritodrine. **Explanation:** The question uses a double negative ("cannot be used... except"), which essentially asks: **"Which of the following is a tocolytic agent?"** **1. Why Ritodrine is correct:** Ritodrine is a **Beta-2 ($\beta_2$) adrenergic agonist**. It works by increasing intracellular cAMP, which leads to a decrease in intracellular calcium levels, thereby causing relaxation of the uterine smooth muscles (myometrium). While effective, its use has declined due to maternal side effects like tachycardia, pulmonary edema, and hyperglycemia. **2. Why the other options are incorrect:** * **Magnesium sulfate (MgSO4):** While historically used as a tocolytic, current ACOG and RCOG guidelines state that MgSO4 is **not** an effective tocolytic. In preterm labor, its primary role is **neuroprotection** of the fetus (reducing the risk of cerebral palsy) if delivery is imminent before 32 weeks. * **Dexamethasone:** This is a corticosteroid used for **fetal lung maturity** (to prevent RDS, IVH, and NEC). It has no effect on uterine contractions. * **Propranolol:** This is a non-selective **Beta-blocker**. Since $\beta_2$ stimulation causes uterine relaxation, a $\beta$-blocker would theoretically increase uterine tone or cause contractions, making it contraindicated in preterm labor. **High-Yield Clinical Pearls for NEET-PG:** * **First-line Tocolytic:** **Nifedipine** (Calcium Channel Blocker) is currently the drug of choice due to its oral administration and better safety profile. * **Atosiban:** A competitive Oxytocin receptor antagonist; highly specific with the fewest side effects but expensive. * **Indomethacin:** A COX inhibitor used as a tocolytic, especially in cases of polyhydramnios, but contraindicated after 32 weeks due to the risk of premature closure of the **Ductus Arteriosus**. * **Goal of Tocolysis:** To delay delivery for **48 hours** to allow for corticosteroid administration and maternal transport to a tertiary care center.

Q: Sher's classification is done in cases of:

Abruption. **Explanation:** **Sher’s Classification** is a clinical grading system used to assess the severity of **Abruptio Placentae** (premature separation of a normally situated placenta). It is primarily based on the clinical presentation and the degree of retroplacental clot formation. * **Grade I (Mild):** Retroplacental clot 500 ml. Associated with intrauterine fetal death (IUFD) and maternal complications like shock or coagulopathy. **Why other options are incorrect:** * **Uterine Prolapse:** Evaluated using the **POP-Q (Pelvic Organ Prolapse Quantification)** system or Shaw’s classification. * **Puerperal Sepsis:** Assessed using clinical criteria for sepsis (qSOFA) or specific microbiological cultures; no "Sher's classification" exists for this. * **Placenta Previa:** Classified by the distance of the placental edge from the internal os (Type I-IV or the newer classification: Minor/Major). **High-Yield Clinical Pearls for NEET-PG:** * **Couvelaire Uterus:** A complication of severe abruption (Sher’s Grade III) where blood extravasates into the myometrium, giving it a port-wine appearance. * **Most common cause of DIC in pregnancy:** Abruptio Placentae. * **Risk Factors:** Chronic hypertension (most common), preeclampsia, trauma, and sudden uterine decompression. * **Clinical Hallmark:** Painful vaginal bleeding with a "woody hard" or "board-like" uterus.

Q: A 25-year-old primigravida is diagnosed with preeclampsia at 38 weeks gestation. Magnesium sulfate infusion is started for seizure prophylaxis, and labor induction is planned. Her cervix is 3 cm dilated, slightly soft, and located anteriorly. The fetal head is at -1 station, and the cervical length is < 0.5 cm. What is her Bishop score?

8. The **Bishop Score** is a pre-labor scoring system used to predict the likelihood of a successful vaginal delivery following induction of labor. A score of $\geq 8$ suggests a high probability of successful induction, similar to spontaneous labor. ### **Calculation for this Patient:** The Bishop score evaluates five parameters: 1. **Dilation (3 cm):** 2 points (Range: 1–2 cm = 1 pt; 3–4 cm = 2 pts). 2. **Effacement (Cervical length 80\%$ or length $< 0.5$ cm = 3 pts). 3. **Station (-1):** 1 point (Station -3 = 0; -2 = 1; -1/0 = 2; +1/+2 = 3). *Note: In the modified Bishop score, -1 station is often assigned 1 point.* 4. **Consistency (Slightly soft/Medium):** 1 point (Firm = 0; Medium = 1; Soft = 2). 5. **Position (Anterior):** 2 points (Posterior = 0; Mid-position = 1; Anterior = 2). **Total Score: 2 + 3 + 1 + 1 + 1 = 8** ### **Why Other Options are Incorrect:** * **Option A (7):** This would be the score if the cervix were mid-positioned or firm. * **Option C & D (9 & 10):** These scores would require the cervix to be fully soft, more dilated (5+ cm), or the fetal head to be at a lower station (+1 or +2). ### **High-Yield Clinical Pearls for NEET-PG:** * **Interpretation:** A score of $\leq 6$ is considered an "unfavorable" cervix, indicating a need for cervical ripening agents (e.g., PGE2/Dinoprostone). * **Most Important Parameter:** Dilation is often considered the most critical individual component. * **Modified Bishop Score:** Some systems replace "Effacement %" with "Cervical Length (cm)." A length of $< 0.5$ cm is the maximum score (3 points). * **Indication:** In this patient (Preeclampsia at 38 weeks), delivery is indicated. Since her score is 8, she has a favorable cervix for direct induction with Oxytocin/ARM.

Q: Vaginal delivery is allowed in all of the following conditions except:

Monochorionic monoamniotic twins. **Explanation:** The correct answer is **A. Monochorionic monoamniotic (MCMA) twins**. In MCMA twins, both fetuses share a single amniotic sac without a dividing membrane. This poses a high risk of **cord entanglement** and subsequent cord accidents during labor as the fetuses descend. Therefore, elective Cesarean Section (LSCS) is mandatory, typically performed between 32–34 weeks of gestation to prevent intrauterine fetal demise. **Analysis of other options:** * **B. First twin cephalic and second twin breech:** This is a favorable presentation for vaginal delivery. Once the first twin is delivered vaginally, the second twin (breech) can be delivered via assisted breech delivery or internal podalic version. * **C. Extended breech (Frank breech):** This is the most common type of breech presentation and is considered the most stable for a planned vaginal breech delivery, provided other criteria (fetal weight, maternal pelvis) are met. * **D. Mento-anterior:** In face presentations, if the chin (mentum) is anterior, the head can undergo further extension and deliver vaginally. However, **Mento-posterior** is an absolute indication for LSCS because the head is already fully extended and cannot negotiate the pelvic curve. **High-Yield Clinical Pearls for NEET-PG:** * **Twin Delivery Rule:** If the first twin is non-vertex (e.g., breech or transverse), LSCS is indicated regardless of the second twin's position. * **Locked Twins:** Occurs most commonly when the first twin is breech and the second is cephalic (Breech-Cephalic). * **Face Presentation:** "Mento-Anterior delivers, Mento-Posterior lingers (requires LSCS)." * **Brow Presentation:** This is the most unfavorable presentation and usually requires LSCS unless it converts to face or vertex.

Q: Zavanelli's maneuver is performed in which of the following conditions?

Shoulder dystocia. **Explanation:** **Zavanelli’s maneuver** is a procedure of last resort used in the management of **Shoulder Dystocia**. It involves the cephalic replacement of the fetal head back into the birth canal, followed by an emergency Cesarean section. The maneuver is performed by manually flexing the fetal head and pushing it back into the vagina, reversing the movements of labor. It is only attempted when all other maneuvers (e.g., McRoberts, suprapubic pressure, internal rotation) have failed, as it carries a high risk of maternal and fetal morbidity. **Analysis of Incorrect Options:** * **B. Dystocia due to asynclitism:** Asynclitism refers to the tilting of the fetal head toward the maternal sacrum or symphysis. This is managed by monitoring labor progress or instrumental delivery; Zavanelli’s is never indicated here. * **C. Retained placenta:** This is a third-stage complication managed by controlled cord traction, manual removal of the placenta (MROP), or uterotonics. * **D. Face presentation:** Most face presentations (mentum anterior) deliver vaginally. Mentum posterior may require Cesarean section, but cephalic replacement is not a standard intervention. **High-Yield Clinical Pearls for NEET-PG:** * **HELPERR Mnemonic:** The standard sequence for shoulder dystocia: **H**elp, **E**pisiotomy, **L**egs (McRoberts), **P**ressure (Suprapubic), **E**nter (Internal rotation), **R**emove posterior arm, **R**oll the patient (Gaskin). * **McRoberts Maneuver:** The first-line management (hyperflexion of maternal thighs). * **Turtle Sign:** The clinical hallmark of shoulder dystocia where the fetal head retracts against the perineum. * **Complications:** Be alert for Erb’s palsy (C5-C6) and postpartum hemorrhage (PPH) in these cases.

Question 1

Which prostaglandin can be used to induce labor at term?

Accepted Answer

PGE2

Answer

PGF2

Answer

PGI2

Answer

PGD2

Question 2

All of the following are included in the first stage of labor except?

Accepted Answer

Crowning of fetal head

Answer

Effacement of cervix

Answer

Dilatation of cervix

Answer

Descent of head

Question 3

A young married female presents to the emergency department with lower abdominal pain, severe dizziness, and two episodes of syncope in the last 12 hours. On arrival, her blood pressure was 89/40 mm Hg, and standing blood pressure could not be recorded due to near syncope upon sitting. What is the most likely diagnosis to rule out in this patient?

Accepted Answer

Ruptured ectopic pregnancy

Answer

Acute appendicitis

Answer

Torsion of ovary

Answer

Acute pancreatitis

Question 4

In a primigravida patient experiencing preterm labor, which of the following agents cannot be used as a tocolytic except?

Accepted Answer

Ritodrine

Answer

Magnesium sulfate (MgSO4)

Answer

Dexamethasone

Answer

Propranolol

Question 5

Sher's classification is done in cases of:

Accepted Answer

Abruption

Answer

Uterine prolapse

Answer

Puerperal sepsis

Answer

Placenta previa

Question 6

What is the primary reason for shock in uterine inversion?

Accepted Answer

Neurogenic shock

Answer

Hypovolemic shock

Answer

Cardiogenic shock

Answer

Septic shock

Question 7

A 25-year-old primigravida is diagnosed with preeclampsia at 38 weeks gestation. Magnesium sulfate infusion is started for seizure prophylaxis, and labor induction is planned. Her cervix is 3 cm dilated, slightly soft, and located anteriorly. The fetal head is at -1 station, and the cervical length is < 0.5 cm. What is her Bishop score?

Accepted Answer

8

Answer

7

Answer

9

Answer

10

Question 8

Vaginal delivery is allowed in all of the following conditions except:

Accepted Answer

Monochorionic monoamniotic twins

Answer

First twin cephalic and second twin breech

Answer

Extended breech

Answer

Mento anterior

Question 9

Zavanelli's maneuver is performed in which of the following conditions?

Accepted Answer

Shoulder dystocia

Answer

Dystocia due to asynclitism

Answer

Retained placenta

Answer

Face presentation

Question 10

The 'double set up examination' is concerned with which of the following conditions?

Accepted Answer

Placenta previa

Answer

Manual removal of placenta

Answer

Twin pregnancy

Answer

Bicornuate uterus

Labor and Delivery — MCQs

Labor and Delivery — MCQs

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