Labor and Delivery Practice Questions

Q: Which of the following is not a contraindication for External Cephalic Version (ECV)?

Primigravida. ***Primigravida*** - Being a **primigravida** (first pregnancy) is not a contraindication for ECV, though it might be associated with a slightly lower success rate compared to multiparous women due to a less pliable uterus. - While it may indicate a potentially more challenging ECV due to higher uterine tone, it does not preclude the procedure if other conditions are favorable. *Placenta previa* - **Placenta previa** is a contraindication because the manipulation of the uterus during ECV could dislodge the placenta, leading to **severe hemorrhage** and potential fetal compromise. - This condition involves the placenta covering the cervical opening, making any uterine intervention risky. *Twin pregnancy* - **Twin pregnancy** is a contraindication as ECV is generally not recommended in multiple gestations due to increased complexity and risk of complications. - The risk of **umbilical cord entanglement**, disruption of twin positioning, and potential harm to either fetus makes ECV unsafe in twin pregnancies. *PROM (Premature Rupture of Membranes)* - **Premature Rupture of Membranes (PROM)** is a contraindication due to the increased risk of uterine infection and **cord prolapse** during manipulation. - Once membranes are ruptured, the natural cushioning provided by the amniotic fluid is lost, making ECV potentially traumatic for both the mother and the fetus.

Q: In the image showing twin pregnancy where fetus A (first twin) is in breech presentation and fetus B (second twin) is in cephalic presentation, what is the recommended method of delivery for fetuses A and B respectively?

LSCS in both. ***LSCS in both*** - When the **first twin (Twin A) is in breech presentation**, current guidelines recommend **cesarean section (LSCS) for BOTH twins** - This avoids significant risks including **head entrapment**, **umbilical cord prolapse**, and **birth trauma** associated with vaginal breech delivery of the first twin - Once a cesarean section is performed for Twin A, delivering Twin B through the same uterine incision is **safer and standard practice** rather than attempting vaginal delivery - **ACOG guidelines** and the **Twin Birth Study (2013)** support cesarean delivery for both twins when Twin A is non-cephalic *LSCS, vaginal* - Delivering Twin A by cesarean section and then attempting **vaginal delivery of Twin B is NOT standard practice** and carries unnecessary risks - After opening the uterus for Twin A, delivering Twin B vaginally would leave an **unsutured uterine incision** with risks of hemorrhage and complications - This mixed approach is **not recommended** in modern obstetric practice *Vaginal, LSCS* - Attempting **vaginal breech delivery for Twin A** is associated with significantly higher risks of fetal morbidity and mortality - The sequence described (vaginal then LSCS) is illogical and not practiced clinically *Induce delivery in both* - **Induction of labor** refers to initiating contractions but does not address the **mode of delivery** (vaginal vs cesarean) - The **presentation of Twin A** is the primary determinant of delivery method, and breech presentation of the first twin is an indication for cesarean delivery regardless of induction

Q: A patient presents with infraumbilical flattening and the fetal heart rate is heard laterally. What is the most likely fetal position?

Occipitoposterior. ***Occipitoposterior*** - **Infraumbilical flattening** of the abdomen is a classic sign of an occipitoposterior position due to the fetal spine lying against the maternal spine. - The **heart sounds are heard laterally** because the fetal back, where the heart sounds are best transmitted, is positioned towards the maternal flanks. *Right occipitoanterior* - In a right occipitoanterior position, the fetal spine is anterior and slightly to the right, leading to a more **convex abdomen** and **heart sounds audible anteriorly** and to the right of the midline. - This position does not typically cause infraumbilical flattening. *Right dorsoanterior* - This term is more commonly associated with a **breech presentation** where the fetal back (dorsum) is anterior. - In a cephalic presentation, "dorsoanterior" is not a standard term for fetal position relative to the occiput. *Left occipitoanterior* - In a left occipitoanterior position, the fetal spine is anterior and slightly to the left, resulting in a **convex abdomen** and **heart sounds audible anteriorly** and to the left of the midline. - Infraumbilical flattening is not a characteristic finding for this position.

Q: A pregnant female presents with active herpetic lesions on the vulva. What is the most appropriate management?

Acyclovir & elective cesarean section (C-section). ***Acyclovir & elective cesarean section (C-section)*** - Active **genital herpetic lesions** at the time of delivery pose a significant risk of transmitting **herpes simplex virus (HSV)** to the neonate. - **Acyclovir** can help suppress viral replication, but a **cesarean section** is necessary to prevent direct contact with the lesions during birth, which could lead to severe neonatal HSV infection. *Wait & watch* - This approach is inappropriate due to the high risk of **vertical transmission** of HSV to the neonate if lesions are active during vaginal delivery, potentially causing life-threatening complications. - **Neonatal HSV** can result in significant morbidity and mortality, including neurological damage and disseminated disease. *Acyclovir & allow spontaneous progression of labor* - While **acyclovir** can reduce viral load, it does not completely eliminate the risk of transmission from active lesions during a vaginal birth. - The primary concern is protecting the neonate from direct contact with the **active lesions** in the birth canal. *Induction of labor* - **Induction of labor** does not mitigate the risk of **vertical transmission** from active lesions during a vaginal delivery. - The focus should be on preventing contact with the lesions, not on expediting vaginal birth once active lesions are present.

Q: After delivering a baby boy, a 25 -year-old mother developed acute PPH and hypovolemic shock, and major blood transfusion occurred. All of the following are complications of blood transfusion except?

Hypokalemia. ***Hypokalemia*** - **Hypokalemia is NOT a typical complication of massive blood transfusion**. In fact, massive transfusion is characteristically associated with **hyperkalemia**, not hypokalemia. - **Stored blood** contains high levels of extracellular potassium due to **red blood cell lysis** during storage (potassium levels can reach 30-50 mEq/L in units stored >21 days). - Rapid transfusion of multiple units delivers a significant **potassium load**, making **hyperkalemia** the expected electrolyte abnormality. - While hypokalemia could theoretically occur later due to **alkalosis from citrate metabolism** or during the **rewarming/correction phase**, this is **indirect, uncommon, and not a recognized acute complication** of the transfusion itself. - Therefore, hypokalemia is the exception among the listed options. *Hypothermia* - **Direct and common complication** when cold blood products (stored at 1-6°C) are rapidly infused without adequate warming. - Can cause **coagulopathy**, cardiac arrhythmias, decreased drug metabolism, and leftward shift of oxygen-hemoglobin dissociation curve. - Prevention requires use of **blood warmers** during massive transfusion. *Hypocalcemia* - **Very common complication** of massive transfusion due to **citrate toxicity**. - **Citrate** (anticoagulant in stored blood) chelates ionized calcium in the recipient's circulation. - Normally metabolized by the liver, but rapid transfusion overwhelms hepatic metabolism, leading to **symptomatic hypocalcemia**. - Can cause **cardiac dysfunction, hypotension, and prolonged QT interval**. *Hypomagnesemia* - Can occur with massive transfusion as **magnesium is also chelated by citrate**, similar to calcium. - Less commonly recognized than hypocalcemia but documented in massive transfusion protocols. - Can contribute to **cardiac arrhythmias and neuromuscular irritability**.

Q: A primigravida is in labor. Her per-vaginal examination revealed a posterior cervix with 5 cm cervical length, 1 cm dilatation, soft consistency, and head at -1 station. Calculate the Bishop score.

5. ***5*** - The Bishop score calculation: **cervical position** (posterior = 0), **cervical effacement** (5 cm length = 0), **dilation** (1 cm = 1), **consistency** (soft = 2), and **station** (-1 = 1). - According to standard **Dutta textbook** references, this totals to 5 points (0 + 0 + 1 + 2 + 1), with soft consistency correctly scoring 2 points. *3* - This score incorrectly assigns only **1 point for soft consistency** instead of the standard 2 points. - The miscalculation underestimates the **cervical readiness** for labor induction. *0* - A score of 0 would require all parameters to be at their **minimum values** (firm consistency, closed cervix, high station). - The given parameters show **1 cm dilation**, **soft consistency**, and **-1 station**, each contributing positive points. *8* - A high score of 8 indicates a **very favorable cervix** with significant effacement, anterior position, and greater dilation. - The current findings show **minimal effacement** (5 cm length), **posterior position**, and only **1 cm dilation**, inconsistent with such a high score.

Q: Which of the following is a part of AMTSL?

Controlled cord traction. ***Controlled cord traction*** - **Controlled cord traction (CCT)** is a key component of Active Management of Third Stage of Labor (AMTSL) performed during placental delivery. - This technique involves applying gentle, sustained traction to the umbilical cord while simultaneously providing counter-traction to the fundus (Brandt-Andrews maneuver) to prevent **uterine inversion**. - CCT is performed after administering a uterotonic and is the primary active maneuver for delivering the placenta. *Uterine massage* - **Uterine massage** is also a component of AMTSL, but it is performed **after placental delivery** to ensure adequate uterine contraction and prevent postpartum hemorrhage. - The three components of AMTSL per WHO recommendations are: (1) Uterotonic administration, (2) Controlled cord traction, (3) Uterine massage after placental delivery. - While technically part of AMTSL, **controlled cord traction** is the more specific answer as it refers to the active maneuver during placental separation and delivery itself. *Early cord clamping* - **Early cord clamping** (within 60 seconds of birth) has been removed from AMTSL recommendations in favor of **delayed cord clamping** (1-3 minutes or when pulsation stops). - Current WHO guidelines recommend delayed cord clamping for all births while still performing AMTSL, as delayed clamping provides neonatal benefits without increasing maternal hemorrhage risk. *Uterotonics after delivery of placenta* - **Uterotonics** (oxytocin 10 IU IM/IV) are administered **within 1 minute of birth** of the baby, which is *before* placental delivery, not after. - This prophylactic administration is the cornerstone of AMTSL and reduces postpartum hemorrhage risk by approximately 60%. - Administering uterotonics *after* placental delivery does not constitute proper AMTSL timing.

Q: After a normal delivery in a 27-year-old female, placenta is still attached to the uterus. Most common complication which can occur due to forceful traction of cord?

Uterine inversion. ***Uterine inversion*** - Forceful traction on the umbilical cord when the placenta is still firmly attached can pull the **fundus of the uterus inside out**, leading to uterine inversion. - This is a rare obstetric emergency associated with significant **hemorrhage** and shock. *Hemorrhage* - While hemorrhage is a common complication of retained placenta and uterine inversion, it is a *consequence* of these conditions, not the direct complication of forceful cord traction itself in the same way uterine inversion is. - The direct mechanical complication from forceful traction is the pulling out of the uterus, which then *causes* the significant hemorrhage. *Uterine rupture* - Uterine rupture during the third stage of labor is exceptionally rare and usually associated with a **previously scarred uterus** or excessive uterine overdistension, not typically caused by forceful cord traction. - Forceful cord traction is more likely to cause inversion or avulsion of the cord, rather than a tear in the uterine wall. *Placental abruption* - Placental abruption involves the **premature separation of a normally implanted placenta** *before* the delivery of the fetus. - This event occurs during pregnancy or labor before birth, not after delivery when the placenta is simply retained.

Q: 32 years old lady with twin dichorionic diamniotic pregnancy, first baby breech presentation and second baby cephalic presentation. What is the management?

C - Section. ***C-Section*** - When **twin A is in breech presentation** in a dichorionic diamniotic twin pregnancy, **elective Cesarean section** is the recommended mode of delivery according to ACOG and most international guidelines. - The primary concern is the **increased risk of complications with breech delivery** of the first twin, including **head entrapment**, **cord prolapse**, and **birth trauma**. - While twin B is cephalic (which would be favorable for vaginal delivery if it were the presenting twin), the non-cephalic presentation of twin A dictates the mode of delivery for both twins. *Assisted breech* - While breech extraction may be considered in select cases where **twin A is cephalic and twin B is breech**, attempting vaginal breech delivery when twin A presents as breech is generally not recommended. - The risks of breech delivery for the first twin include **difficulty delivering the aftercoming head**, **cord prolapse**, and **birth asphyxia**, which are unacceptable in an elective situation where cesarean section is readily available. *Instrumental delivery* - Instrumental delivery (forceps or vacuum) is used to assist delivery of a **cephalic presentation** in the second stage of labor. - It cannot be used for **breech presentation** of twin A, making it inappropriate as a primary management strategy in this scenario. *Normal vaginal delivery* - Vaginal delivery with **twin A in non-cephalic (breech) presentation** is contraindicated in most modern obstetric guidelines due to significantly increased perinatal morbidity and mortality. - Even though twin B is cephalic, the presentation of twin A determines the overall delivery approach in twin pregnancies.

Q: Among the following the plane of least pelvic dimension is:

Mid-cavity. ***Mid-cavity*** - The **mid-cavity** or **mid-pelvis** is the plane of smallest dimensions during labor, defined by the ischial spines laterally [1]. - This plane is crucial for determining if a fetus can successfully navigate the birth canal, as it represents the narrowest point [1]. *Inlet* - The **pelvic inlet** is the widest part of the pelvis and usually poses less of a restriction during the descent of the fetal head [1]. - It is bounded by the sacral promontory, arcuate line, pectineal line, and pubic crest [2]. *False pelvis* - The **false pelvis** is the upper, broader part of the pelvis and does not play a direct role in guiding the fetal head through the birth canal [1]. - Its boundaries are largely abdominal and do not define crucial dimensions for passage [2]. *Outlet* - The **pelvic outlet** is the final opening that the fetal head must pass through, and while its dimensions are important, the mid-cavity is generally the narrowest point. - Its dimensions are measured from the pubic arch to the tip of the coccyx [3].

Question 1

Which of the following is not a contraindication for External Cephalic Version (ECV)?

Accepted Answer

Primigravida

Answer

Placenta previa

Answer

Twin pregnancy

Answer

PROM (Premature Rupture of Membranes)

Question 2

In the image showing twin pregnancy where fetus A (first twin) is in breech presentation and fetus B (second twin) is in cephalic presentation, what is the recommended method of delivery for fetuses A and B respectively?

Accepted Answer

LSCS in both

Answer

Vaginal, LSCS

Answer

Induce delivery in both

Answer

LSCS, vaginal

Question 3

A patient presents with infraumbilical flattening and the fetal heart rate is heard laterally. What is the most likely fetal position?

Accepted Answer

Occipitoposterior

Answer

Right occipitoanterior

Answer

Right dorsoanterior

Answer

Left occipitoanterior

Question 4

A pregnant female presents with active herpetic lesions on the vulva. What is the most appropriate management?

Accepted Answer

Acyclovir & elective cesarean section (C-section)

Answer

Wait & watch

Answer

Acyclovir & allow spontaneous progression of labor

Answer

Induction of labor

Question 5

After delivering a baby boy, a 25 -year-old mother developed acute PPH and hypovolemic shock, and major blood transfusion occurred. All of the following are complications of blood transfusion except?

Accepted Answer

Hypokalemia

Answer

Hypothermia

Answer

Hypocalcemia

Answer

Hypomagnesemia

Question 6

A primigravida is in labor. Her per-vaginal examination revealed a posterior cervix with 5 cm cervical length, 1 cm dilatation, soft consistency, and head at -1 station. Calculate the Bishop score.

Accepted Answer

5

Answer

0

Answer

8

Answer

3

Question 7

Which of the following is a part of AMTSL?

Accepted Answer

Controlled cord traction

Answer

Uterine massage

Answer

Early cord clamping

Answer

Uterotonics after delivery of placenta

Question 8

After a normal delivery in a 27-year-old female, placenta is still attached to the uterus. Most common complication which can occur due to forceful traction of cord?

Accepted Answer

Uterine inversion

Answer

Hemorrhage

Answer

Uterine rupture

Answer

Placental abruption

Question 9

32 years old lady with twin dichorionic diamniotic pregnancy, first baby breech presentation and second baby cephalic presentation. What is the management?

Accepted Answer

C - Section

Answer

Assisted breech

Answer

Instrumental delivery

Answer

Normal vaginal delivery

Question 10

Among the following the plane of least pelvic dimension is:

Accepted Answer

Mid-cavity

Answer

Inlet

Answer

False pelvis

Answer

Outlet

Labor and Delivery — MCQs

Labor and Delivery — MCQs

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