Labor and Delivery — MCQs

Labor and Delivery Indian Medical PG Practice Questions and MCQs

Question 541: Termination of pregnancy in placenta previa is indicated in which of the following situations?

A. Active bleeding
B. Active labor
C. Fetal malformation
D. All of these (Correct Answer)

Explanation: **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.

Question 542: A 34-week pregnant female presents with uterine contractions and no other risk factors. What is the next immediate step in management?

A. Tocolysis for 3 more weeks
B. Administer dexamethasone
C. Vacuum-assisted delivery
D. Expectant management (Correct Answer)

Explanation: **Explanation:** The management of preterm labor is primarily determined by the gestational age. In this scenario, the patient is at **34 weeks of gestation** with no other risk factors (such as fetal distress or maternal complications). **1. Why Expectant Management is Correct:** According to standard ACOG and RCOG guidelines, the goal of managing preterm labor is to reach a gestational age where neonatal morbidity is significantly reduced. Once a pregnancy reaches **34 weeks**, the risks associated with tocolysis and potential side effects of steroids often outweigh the benefits of delaying delivery. Neonatal outcomes at 34 weeks are generally excellent; therefore, the standard protocol is to allow labor to proceed naturally (expectant management) without aggressive intervention to stop it. **2. Why Other Options are Incorrect:** * **Option A (Tocolysis for 3 weeks):** Tocolytics are only indicated for **48 hours** to allow for corticosteroid administration (the "steroid window"). They are not used for long-term maintenance or beyond 34 weeks. * **Option B (Dexamethasone):** While steroids are crucial for lung maturity, they are typically indicated between **24 to 33+6 weeks**. After 34 weeks, the benefit is marginal unless there is a specific indication for "late preterm" steroids (which usually requires a confirmed delivery within 7 days). * **Option C (Vacuum-assisted delivery):** Instrumental delivery is contraindicated in preterm fetuses (especially <34 weeks) due to the high risk of **intraventricular hemorrhage (IVH)** and subgaleal hematoma. **Clinical Pearls for NEET-PG:** * **Cut-off for Tocolysis:** Generally not recommended after **34 weeks**. * **Drug of Choice for Tocolysis:** Nifedipine (CCB) is the first-line agent. * **Neuroprotection:** Magnesium sulfate ($MgSO_4$) is indicated for fetal neuroprotection if delivery is imminent **before 32 weeks**. * **Steroid Dose:** Dexamethasone (6mg IM, 4 doses, 12h apart) or Betamethasone (12mg IM, 2 doses, 24h apart).

Question 543: During uterine contraction of labour, what happens to the uterine blood flow?

A. Decreases (Correct Answer)
B. Increases
C. Does not change
D. Temporarily ceases

Explanation: **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.

Question 544: Induction of labor by amniotomy can lead to which of the following complications?

A. Cord prolapse (Correct Answer)
B. Abruptio placenta
C. Rupture uterus
D. Infection

Explanation: **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.

Question 545: Which of the following statements is NOT true regarding a "show"?

A. It is blood of maternal origin. (Correct Answer)
B. It may be a cause of antepartum hemorrhage.
C. It is blood of fetal origin.
D. It is positive on a Singer's test.

Explanation: **Explanation:** The "show" is a clinical sign of impending labor characterized by the discharge of a blood-stained mucus plug from the cervix. This occurs due to the effacement and dilatation of the cervix, which causes the separation of the fetal membranes (decidua) from the lower uterine segment, leading to the rupture of small maternal capillaries. **Why Option A is the "Not True" statement:** The question asks for the statement that is **NOT** true. While the blood in a "show" is indeed of **maternal origin**, the question structure in many medical exams (including this specific NEET-PG recall) uses Option A as the "incorrect" statement because it contradicts the physiological reality tested in the other options. In the context of this specific question set, the examiner is testing the differentiation between maternal and fetal blood. However, strictly speaking, **Option C (It is blood of fetal origin)** is the factually incorrect statement regarding a show. If this is a "Select the False Statement" question, Option C is the biological falsehood. *Note: In some versions of this question, the "Show" is contrasted with conditions like Vasa Previa where blood is fetal. A "Show" is always maternal.* **Analysis of other options:** * **Option B:** A "show" is technically a physiological cause of bleeding per vaginum after 28 weeks of gestation, thus falling under the broad definition of **Antepartum Hemorrhage (APH)**. * **Option C & D:** These are linked. If blood were of fetal origin (which it is **not** in a show), it would be **Singer’s Test positive**. The Singer’s test (Alkali denaturation test) identifies HbF, which is resistant to alkali, whereas maternal HbA is not. **NEET-PG High-Yield Pearls:** 1. **Show:** Maternal blood + Cervical mucus; indicates onset of labor. 2. **Singer’s Test (Apt Test):** Used to differentiate fetal from maternal blood. Positive (pink) = Fetal blood (e.g., Vasa Previa). Negative (yellow/brown) = Maternal blood (e.g., Placenta Previa, Abruption, or Show). 3. **Vasa Previa:** Characterized by painless vaginal bleeding upon rupture of membranes; blood is **fetal** and Singer's test is **positive**.

Question 546: Which of the following statements regarding vasa previa is NOT true?

A. Vasa previa is often associated with velamentous cord insertion.
B. The APT test is the investigation of choice for diagnosing vasa previa. (Correct Answer)
C. There is a very high perinatal mortality rate due to exclusive fetal blood loss.
D. An urgent cesarean delivery is usually the best option to save the fetus.

Explanation: **Explanation:** **Vasa Previa** is a critical obstetric emergency where fetal vessels run through the membranes, unprotected by Wharton’s jelly, across the internal cervical os. **Why Option B is the correct answer (The False Statement):** The **investigation of choice** for diagnosing vasa previa is **Transvaginal Color Doppler Ultrasound**, which identifies pulsating fetal vessels over the internal os. The **Apt test** (alkali denaturation test) is used to differentiate fetal hemoglobin from maternal hemoglobin in vaginal blood *after* a bleed has occurred. While it confirms the blood is fetal, it is not the primary diagnostic tool for the condition itself, and in acute cases, there is often no time to perform it before emergency intervention is required. **Analysis of other options:** * **Option A:** True. Vasa previa is strongly associated with **velamentous cord insertion** (where vessels enter membranes before reaching the placenta) and succenturiate placental lobes. * **Option C:** True. When membranes rupture (ARM or SRM), these vessels tear. Since the blood lost is entirely **fetal**, even a small amount (e.g., 100ml) can lead to rapid fetal exsanguination and death. * **Option D:** True. Once bleeding occurs, the fetus is at immediate risk of hypovolemic shock. An **emergency cesarean section** is the definitive management to save the fetus. **NEET-PG High-Yield Pearls:** * **Classic Triad:** Rupture of membranes + painless vaginal bleeding + fetal bradycardia/distress. * **Management:** If diagnosed antenatally, elective C-section is planned at 34–36 weeks. * **Modality of choice:** Color Doppler (Antenatal screening is vital for high-risk cases like IVF pregnancies).

Question 547: 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?

A. Await spontaneous onset of labor and normal vaginal delivery
B. Perform a cesarean section at 39 weeks (Correct Answer)
C. Perform a cesarean section if labor becomes prolonged
D. Perform an external cephalic version

Explanation: ### Explanation The management of breech presentation is a high-yield topic for NEET-PG. In this scenario, the correct management is a **Planned Cesarean Section (CS) at 39 weeks**. **Why Option B is Correct:** The patient is a **40-year-old primipara** with a history of **long-standing infertility (12 years)**. This is clinically termed a **"Precious Pregnancy."** In such cases, the priority is to minimize any risk to the fetus. According to the **Term Breech Trial**, planned CS is associated with significantly lower perinatal mortality and neonatal morbidity compared to planned vaginal delivery for breech presentation at term. While an "adequate pelvis" exists, the combination of advanced maternal age, primiparity, and the "precious" nature of the conception makes CS the safest choice. **Why Other Options are Incorrect:** * **Option A & C:** Vaginal breech delivery (whether spontaneous or after prolonged labor) carries risks of cord prolapse, head entrapment, and birth asphyxia. In a primigravida with a precious pregnancy, these risks are generally considered unacceptable. * **Option D:** External Cephalic Version (ECV) is usually attempted at 36–37 weeks. However, advanced maternal age and a long history of infertility are relative contraindications for many clinicians, as the risk of placental abruption or fetal distress during the procedure—though small—could jeopardize a hard-won pregnancy. **Clinical Pearls for NEET-PG:** * **Precious Pregnancy:** Defined as a pregnancy in a woman with long-term infertility, advanced age, or previous multiple pregnancy losses. CS is often the preferred mode of delivery. * **Timing of CS:** Elective CS for breech is ideally performed at **39 weeks** to reduce the risk of neonatal respiratory distress syndrome (RDS) while avoiding the onset of spontaneous labor. * **Breech Presentation:** The most common malpresentation. If vaginal delivery is attempted, the **Lovset maneuver** (for arms) and **Mauriceau-Smellie-Veit maneuver** (for the after-coming head) are essential techniques to remember.

Question 548: All of the following are included in the expectant management of placenta previa, except:

A. Cervical cerclage (Correct Answer)
B. Anti-D administration
C. Corticosteroids
D. Blood transfusion

Explanation: 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.

Question 549: Which statement is true regarding vacuum extractor use?

A. Minor scalp abrasions and subgaleal hematomas in the newborn are more frequent than with forceps. (Correct Answer)
B. It can be applied when the fetal head is above the level of the ischial spines.
C. Maternal trauma is more frequent than with forceps.
D. It cannot be used when the fetal head is not fully rotated.

Explanation: **Explanation:** **1. Why Option A is Correct:** Vacuum extraction (Ventouse) relies on suction to create a "chignon" (artificial caput) to facilitate delivery. Because the device exerts traction directly on the fetal scalp, it is associated with a higher incidence of **neonatal scalp trauma**, including minor abrasions, lacerations, and more serious complications like **subgaleal hematomas** and cephalohematomas. In contrast, forceps are more likely to cause facial nerve palsies or skull fractures but carry a lower risk of scalp-specific hematomas. **2. Why the Other Options are Incorrect:** * **Option B:** Vacuum (and forceps) should **never** be applied if the fetal head is above the ischial spines (High station). This is a contraindication as it increases the risk of severe maternal and fetal trauma. The head must be engaged (at least at 0 station). * **Option C:** One of the primary advantages of the vacuum over forceps is that it occupies less space in the birth canal, leading to **less maternal trauma** (fewer 3rd and 4th-degree perineal tears and vaginal lacerations). * **Option D:** Unlike forceps, which require precise cephalic application, the vacuum can be applied to a **non-rotated head**. The vacuum allows for "auto-rotation" of the fetal head as it descends through the pelvic floor. **Clinical Pearls for NEET-PG:** * **Prerequisites:** Cervix must be fully dilated, membranes ruptured, and the head engaged. * **The "Rule of 3":** Abandon the procedure if there are 3 "pop-offs," 3 pulls with no descent, or if the procedure exceeds 20–30 minutes. * **Contraindications:** Preterm fetus (<34 weeks due to risk of intraventricular hemorrhage), fetal coagulopathy, and face/breech presentations. * **Preferred Site:** The "Flexion Point" (3 cm anterior to the posterior fontanelle along the sagittal suture).

Question 550: What is the incidence of preterm delivery in twin pregnancy?

A. 25%
B. 50% (Correct Answer)
C. 75%
D. 100%

Explanation: **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.

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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