Labor and Delivery Practice Questions

Q: Termination of pregnancy in placenta previa is indicated in which of the following situations?

All of these. **Explanation:** The management of placenta previa is primarily guided by the **Macafee and Johnson protocol**, which aims for expectant management (conservative) until fetal maturity (37 weeks), provided the mother and fetus are stable. However, certain clinical scenarios necessitate immediate termination of pregnancy regardless of the gestational age. **Why "All of these" is correct:** 1. **Active Bleeding (Option A):** Severe or continuous hemorrhage is a life-threatening emergency. If the bleeding is brisk or leads to maternal hemodynamic instability (shock), immediate delivery (usually via Cesarean section) is mandatory to save the mother’s life. 2. **Active Labor (Option B):** Once labor starts, cervical effacement and dilatation cause further separation of the placenta from the lower uterine segment, leading to profuse, uncontrollable bleeding. Therefore, if labor is established, termination is indicated. 3. **Fetal Malformation (Option C):** The goal of expectant management is to achieve fetal maturity. If the fetus has a lethal congenital anomaly or is already dead (IUD), there is no benefit in prolonging the pregnancy and risking maternal hemorrhage; hence, the pregnancy is terminated. **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard Diagnosis:** Transvaginal Ultrasound (TVS) is safer and more accurate than transabdominal ultrasound for locating the placenta. * **Contraindication:** **Per-vaginal (PV) examination is strictly contraindicated** in a suspected case of placenta previa unless performed in an Operation Theater (Double Setup Examination) as it can provoke torrential hemorrhage. * **Steroids:** If termination is planned between 24–34 weeks, a course of corticosteroids (Betamethasone) should be administered to accelerate fetal lung maturity. * **Delivery Mode:** For major degrees (Type II posterior, III, and IV), Cesarean section is the rule. For Type I (low-lying), a vaginal delivery may be attempted.

Q: During uterine contraction of labour, what happens to the uterine blood flow?

Decreases. **Explanation:** The correct answer is **A. Decreases**. **Underlying Medical Concept:** During a uterine contraction, the intramyometrial pressure rises significantly. This pressure compresses the intramural vessels (arcuate and radial arteries) as they pass through the interlacing muscle fibers of the myometrium (often called the "living ligatures" of the uterus). As the intrauterine pressure exceeds the venous pressure and eventually approaches the arterial pressure, the blood flow to the intervillous space is significantly reduced. This is a physiological intermittent reduction in perfusion that a healthy fetus can tolerate due to the placental reserve. **Analysis of Incorrect Options:** * **B. Increases:** This is incorrect because the mechanical compression of blood vessels by the contracting myometrium physically restricts flow rather than enhancing it. * **C. Does not change:** This is incorrect as uterine hemodynamics are highly dynamic during labor; flow fluctuates in inverse proportion to the intensity of the contraction. * **D. Temporarily ceases:** This is generally incorrect for a normal physiological contraction. While blood flow is significantly *diminished*, it rarely ceases entirely unless the contraction is pathologically tetanic or hypertonic (e.g., in placental abruption or oxytocin overstimulation). **High-Yield Clinical Pearls for NEET-PG:** * **Placental Reserve:** A healthy fetus relies on the oxygen stored in the intervillous space during the peak of a contraction. * **Fetal Heart Rate (FHR):** If the uterine blood flow is compromised excessively (e.g., tachysystole), it leads to fetal hypoxia, manifesting as **late decelerations** on cardiotocography (CTG). * **Supine Hypotension Syndrome:** In the supine position, the gravid uterus compresses the IVC, further reducing venous return and subsequently decreasing uterine blood flow, which is why the **left lateral position** is preferred during labor.

Q: Induction of labor by amniotomy can lead to which of the following complications?

Cord prolapse. **Explanation:** **Amniotomy**, or Artificial Rupture of Membranes (ARM), is a common method for the induction or augmentation of labor. **Why Cord Prolapse is the Correct Answer:** The most immediate and serious mechanical complication of amniotomy is **umbilical cord prolapse**. When the membranes are ruptured, the sudden gush of amniotic fluid can wash the cord down into the vagina, especially if the fetal presenting part is not well-engaged in the pelvis (high station) or if there is malpresentation. To minimize this risk, amniotomy should ideally be performed only when the cervix is favorable and the fetal head is well-applied to the cervix. **Analysis of Incorrect Options:** * **B. Abruptio Placenta:** While sudden decompression of the uterus (e.g., in polyhydramnios) can theoretically cause placental separation, it is a much rarer complication compared to cord prolapse during routine induction. * **C. Rupture Uterus:** This is typically a complication of obstructed labor or the overzealous use of uterotonic drugs (like Oxytocin), rather than the mechanical act of amniotomy itself. * **D. Infection:** While prolonged rupture of membranes increases the risk of **Chorioamnionitis**, it is a delayed complication. Cord prolapse is the immediate, life-threatening risk associated with the procedure itself. **High-Yield Clinical Pearls for NEET-PG:** * **Prerequisite:** Always check the fetal heart rate (FHR) before and immediately after amniotomy to rule out cord compression/prolapse. * **Contraindication:** Amniotomy should be avoided if the presenting part is high and mobile (ballotable). * **Other complications:** These include vasa previa rupture (if fetal vessels cross the membranes) and fetal scalp trauma. * **Amniotomy + Oxytocin:** This combination is more effective for induction of labor than either method used alone.

Q: All of the following are included in the expectant management of placenta previa, except:

Cervical cerclage. The expectant management of placenta previa, also known as the **MacAfee and Johnson regimen**, aims to prolong pregnancy until fetal maturity is reached without compromising maternal safety. ### **Why Cervical Cerclage is the Correct Answer** Cervical cerclage (Option A) is a surgical procedure used to treat cervical insufficiency. It is **not** a standard component of placenta previa management. In fact, any vaginal or cervical manipulation (including digital exams or invasive procedures) is strictly contraindicated in placenta previa as it can trigger massive, life-threatening hemorrhage by disturbing the placental site. ### **Explanation of Other Options** * **Anti-D administration (Option B):** Essential for Rh-negative unsensitized mothers who experience vaginal bleeding (antepartum hemorrhage) to prevent isoimmunization. * **Corticosteroids (Option C):** Administered between 24 and 34 weeks of gestation to accelerate fetal lung maturity, reducing the risk of Respiratory Distress Syndrome (RDS) in case of preterm delivery. * **Blood Transfusion (Option D):** The primary goal of expectant management is to maintain maternal hemoglobin levels (usually >10 g/dL) to ensure hemodynamic stability in the event of a sudden re-bleed. ### **NEET-PG High-Yield Pearls** * **Ideal Candidate:** Gestation <37 weeks, hemodynamically stable mother, and no active bleeding. * **The "Golden Rule":** Never perform a per-vaginal (PV) examination in a case of antepartum hemorrhage until placenta previa is ruled out by ultrasound. * **Stallworthy’s Sign:** A drop in fetal heart rate when the head is pushed into the pelvis, suggestive of posterior placenta previa. * **Termination:** Expectant management is typically discontinued at **37 weeks**, and delivery is planned. If the placenta is <2 cm from the internal os, Cesarean section is the mode of choice.

Q: What is the incidence of preterm delivery in twin pregnancy?

50%. **Explanation:** The correct answer is **50%**. **1. Why 50% is correct:** Preterm delivery (defined as birth before 37 completed weeks) is the most common complication of multifetal gestations. In twin pregnancies, the primary mechanism is **uterine overdistension**, which leads to early activation of the stretch receptors in the myometrium, increased gap junction formation, and premature cervical ripening. Statistically, approximately **50–60% of twin pregnancies** result in preterm birth, compared to only about 10% in singleton pregnancies. The average gestational age at delivery for twins is approximately **35–36 weeks**. **2. Why other options are incorrect:** * **A (25%):** This significantly underestimates the risk. While 25% might represent the rate of "early" preterm birth (before 34 weeks), the total incidence including late preterm is much higher. * **C (75%):** This is more characteristic of **triplet pregnancies**, where the incidence of preterm birth exceeds 90% with an average delivery age of 32 weeks. * **D (100%):** While the risk is high, nearly half of twin pregnancies do reach full term (37+ weeks), particularly in uncomplicated dichorionic diamniotic (DCDA) twins. **High-Yield Clinical Pearls for NEET-PG:** * **Average duration of pregnancy:** Singleton (40 weeks), Twins (35-36 weeks), Triplets (32 weeks), Quadruplets (30 weeks). * **Monochorionic Monoamniotic (MCMA) twins:** Elective delivery is recommended at **32–34 weeks** via Cesarean section due to the high risk of cord entanglement. * **Prediction:** A cervical length of **<25 mm** on transvaginal ultrasound between 20–24 weeks is a strong predictor of preterm birth in twins. * **Prevention:** Prophylactic cerclage or routine tocolysis is **not** recommended for uncomplicated twin pregnancies.

Question 1

Termination of pregnancy in placenta previa is indicated in which of the following situations?

Accepted Answer

All of these

Answer

Active bleeding

Answer

Active labor

Answer

Fetal malformation

Question 2

A 34-week pregnant female presents with uterine contractions and no other risk factors. What is the next immediate step in management?

Accepted Answer

Expectant management

Answer

Tocolysis for 3 more weeks

Answer

Administer dexamethasone

Answer

Vacuum-assisted delivery

Question 3

During uterine contraction of labour, what happens to the uterine blood flow?

Accepted Answer

Decreases

Answer

Increases

Answer

Does not change

Answer

Temporarily ceases

Question 4

Induction of labor by amniotomy can lead to which of the following complications?

Accepted Answer

Cord prolapse

Answer

Abruptio placenta

Answer

Rupture uterus

Answer

Infection

Question 5

Which of the following statements is NOT true regarding a "show"?

Accepted Answer

It is blood of maternal origin.

Answer

It may be a cause of antepartum hemorrhage.

Answer

It is blood of fetal origin.

Answer

It is positive on a Singer's test.

Question 6

Which of the following statements regarding vasa previa is NOT true?

Accepted Answer

The APT test is the investigation of choice for diagnosing vasa previa.

Answer

Vasa previa is often associated with velamentous cord insertion.

Answer

There is a very high perinatal mortality rate due to exclusive fetal blood loss.

Answer

An urgent cesarean delivery is usually the best option to save the fetus.

Question 7

A 40-year-old primipara, infertile for 12 years, presents at 37 weeks gestation. The fetus is in breech presentation, with an estimated fetal weight of 3 kg. The pregnancy is otherwise uncomplicated, and the pelvis is adequate. What is the best management option?

Accepted Answer

Perform a cesarean section at 39 weeks

Answer

Await spontaneous onset of labor and normal vaginal delivery

Answer

Perform a cesarean section if labor becomes prolonged

Answer

Perform an external cephalic version

Question 8

All of the following are included in the expectant management of placenta previa, except:

Accepted Answer

Cervical cerclage

Answer

Anti-D administration

Answer

Corticosteroids

Answer

Blood transfusion

Question 9

Which statement is true regarding vacuum extractor use?

Accepted Answer

Minor scalp abrasions and subgaleal hematomas in the newborn are more frequent than with forceps.

Answer

It can be applied when the fetal head is above the level of the ischial spines.

Answer

Maternal trauma is more frequent than with forceps.

Answer

It cannot be used when the fetal head is not fully rotated.

Question 10

What is the incidence of preterm delivery in twin pregnancy?

Accepted Answer

50%

Answer

25%

Answer

75%

Answer

100%

Labor and Delivery — MCQs

Labor and Delivery — MCQs

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