Labor and Delivery — MCQs
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Which prostaglandin can be used to induce labor at term?
All of the following are included in the first stage of labor except?
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?
In a primigravida patient experiencing preterm labor, which of the following agents cannot be used as a tocolytic except?
Sher's classification is done in cases of:
What is the primary reason for shock in uterine inversion?
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?
Vaginal delivery is allowed in all of the following conditions except:
Zavanelli's maneuver is performed in which of the following conditions?
The 'double set up examination' is concerned with which of the following conditions?
Labor and Delivery Indian Medical PG Practice Questions and MCQs
Question 431: Which prostaglandin can be used to induce labor at term?
- A. PGE2 (Correct Answer)
- B. PGF2
- C. PGI2
- D. PGD2
Explanation: **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.
Question 432: All of the following are included in the first stage of labor except?
- A. Effacement of cervix
- B. Dilatation of cervix
- C. Crowning of fetal head (Correct Answer)
- D. Descent of head
Explanation: **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).
Question 433: 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?
- A. Acute appendicitis
- B. Torsion of ovary
- C. Acute pancreatitis
- D. Ruptured ectopic pregnancy (Correct Answer)
Explanation: **Explanation:** The clinical presentation of a young female with **acute abdominal pain, hemodynamic instability (hypotension), and syncopal attacks** is a classic triad for a **ruptured ectopic pregnancy** until proven otherwise. The inability to record standing blood pressure due to near-syncope indicates significant **orthostatic hypotension**, suggesting massive internal hemorrhage (hemoperitoneum). **Why Ruptured Ectopic Pregnancy is Correct:** In a woman of reproductive age, sudden onset of severe pain followed by signs of hypovolemic shock (BP 89/40 mmHg, syncope) points toward a vascular catastrophe. Rupture of a fallopian tube during an ectopic pregnancy leads to rapid intraperitoneal bleeding, causing peritoneal irritation and cardiovascular collapse. **Why Other Options are Incorrect:** * **Acute Appendicitis:** While it causes lower abdominal pain, it typically presents with fever, nausea, and localized tenderness (McBurney’s point). It does not cause sudden hemodynamic collapse or massive internal bleeding unless complicated by septic shock, which is a later finding. * **Torsion of Ovary:** This presents with sudden, severe unilateral pain and often a palpable mass. While it can cause nausea/vomiting, it rarely leads to profound hypotension or syncope unless the ovary becomes necrotic and leads to secondary complications. * **Acute Pancreatitis:** This presents with epigastric pain radiating to the back. While severe cases can cause shock, the history and location of pain in this patient are more consistent with a pelvic/gynecological emergency. **High-Yield Clinical Pearls for NEET-PG:** * **Golden Rule:** Any female of reproductive age presenting with abdominal pain and shock is a **Ruptured Ectopic Pregnancy** until a pregnancy test (Urine Pregnancy Test or β-hCG) proves otherwise. * **Arias-Stella Reaction:** Hypersecretory endometrium seen on histology in ectopic pregnancy. * **Management:** The immediate step is aggressive fluid resuscitation followed by **emergency laparotomy** (not laparoscopy if the patient is hemodynamically unstable).
Question 434: In a primigravida patient experiencing preterm labor, which of the following agents cannot be used as a tocolytic except?
- A. Ritodrine (Correct Answer)
- B. Magnesium sulfate (MgSO4)
- C. Dexamethasone
- D. Propranolol
Explanation: **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.
Question 435: Sher's classification is done in cases of:
- A. Uterine prolapse
- B. Puerperal sepsis
- C. Abruption (Correct Answer)
- D. Placenta previa
Explanation: **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 <150 ml. No signs of maternal distress or fetal compromise. * **Grade II (Moderate):** Retroplacental clot 150–500 ml. Classic signs present (tense, tender uterus) with evidence of fetal distress, but the mother is stable. * **Grade III (Severe):** 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.
Question 436: What is the primary reason for shock in uterine inversion?
- A. Hypovolemic shock
- B. Cardiogenic shock
- C. Septic shock
- D. Neurogenic shock (Correct Answer)
Explanation: **Explanation:** **Uterine inversion** is a life-threatening obstetric emergency where the uterine fundus collapses into the endometrial cavity. The primary reason for the immediate, profound shock seen in these patients is **Neurogenic Shock**. 1. **Why Neurogenic Shock is Correct:** When the uterus inverts, it exerts massive **traction on the pelvic peritoneum** and the **broad ligaments**. This stimulates the parasympathetic nervous system (vasovagal response), leading to sudden bradycardia and profound hypotension. Crucially, the degree of shock is often **disproportionate** to the amount of visible blood loss, which is a classic diagnostic hallmark of neurogenic shock in this clinical scenario. 2. **Why Other Options are Incorrect:** * **Hypovolemic Shock:** While significant hemorrhage (Postpartum Hemorrhage) often follows uterine inversion due to uterine atony, it is usually the *secondary* cause of shock. The *initial* collapse is neurogenic. * **Cardiogenic Shock:** This relates to primary heart failure (e.g., MI or peripartum cardiomyopathy), which is not the underlying mechanism here. * **Septic Shock:** This occurs due to overwhelming infection, typically presenting days after delivery, not as an acute event during the third stage of labor. **High-Yield Clinical Pearls for NEET-PG:** * **Degrees of Inversion:** 1st degree (fundus in cavity), 2nd degree (through cervix), 3rd degree (at introitus), 4th degree (total inversion/vagina involved). * **Management Priority:** Do not remove the placenta if still attached (increases bleeding). First, stabilize the patient and perform manual replacement (**Johnson’s Maneuver**). * **Drug of Choice:** Tocolytics (like Nitroglycerin or Terbutaline) or Halothane anesthesia are used to relax the uterus for replacement; Oxytocics are given only *after* the uterus is repositioned. * **Surgical Procedures:** Huntington’s (laparotomy with traction) or Haultain’s (incising the cervical ring).
Question 437: 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?
- A. 7
- B. 8 (Correct Answer)
- C. 9
- D. 10
Explanation: 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 < 0.5 cm):** 3 points (Effacement $> 80\%$ 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.
Question 438: Vaginal delivery is allowed in all of the following conditions except:
- A. Monochorionic monoamniotic twins (Correct Answer)
- B. First twin cephalic and second twin breech
- C. Extended breech
- D. Mento anterior
Explanation: **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.
Question 439: Zavanelli's maneuver is performed in which of the following conditions?
- A. Shoulder dystocia (Correct Answer)
- B. Dystocia due to asynclitism
- C. Retained placenta
- D. Face presentation
Explanation: **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 440: The 'double set up examination' is concerned with which of the following conditions?
- A. Placenta previa (Correct Answer)
- B. Manual removal of placenta
- C. Twin pregnancy
- D. Bicornuate uterus
Explanation: **Explanation:** The **Double Set-up Examination** is a classic clinical procedure historically used to diagnose **Placenta Previa** when ultrasound was unavailable or inconclusive. **Why Placenta Previa is the correct answer:** In cases of suspected placenta previa (painless vaginal bleeding in the third trimester), a routine per-vaginal (PV) examination is strictly contraindicated in the ward because it can provoke massive, life-threatening hemorrhage by dislodging the placenta. A "Double Set-up" involves performing a vaginal examination in an **Operating Theater** with two sets of preparations ready simultaneously: 1. **Set 1:** Personnel and equipment ready for an immediate **Emergency Cesarean Section** if heavy bleeding is triggered. 2. **Set 2:** Equipment ready for a **Vaginal Delivery** if the examination reveals that the placenta is not covering the internal os (low-lying) and the situation is favorable. **Analysis of Incorrect Options:** * **B. Manual removal of placenta:** This is a procedure performed for a *retained* placenta after the baby is delivered; it does not require a double set-up for diagnosis. * **C. Twin pregnancy:** While twins may require a trial of labor in an OT (especially for the delivery of the second twin), the specific term "double set-up" is not the standard nomenclature for this management. * **D. Bicornuate uterus:** This is a structural uterine anomaly diagnosed via imaging (USG/MRI) or laparoscopy, not via a double set-up exam. **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard Diagnosis:** Today, **Transvaginal Sonography (TVS)** is the gold standard for diagnosing placenta previa, making the double set-up exam largely obsolete in modern practice. * **Cardinal Rule:** Never perform a PV exam in a case of APH (Antepartum Hemorrhage) until placenta previa is ruled out by ultrasound. * **Stallworthy’s Sign:** A drop in fetal heart rate when the head is pressed into the pelvic inlet, which recovers when pressure is released; suggestive of posterior placenta previa.
Practice by Chapter
Physiology of Labor
Practice Questions
Stages of Labor and Normal Progression
Practice Questions
Fetal Monitoring Techniques
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Pain Management in Labor
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Induction and Augmentation of Labor
Practice Questions
Operative Delivery (Forceps and Vacuum)
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Cesarean Section: Indications and Techniques
Practice Questions
Dystocia and Abnormal Labor Patterns
Practice Questions
Obstetric Emergencies
Practice Questions
Postpartum Hemorrhage Management
Practice Questions
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