Labor and Delivery Practice Questions

Q: A pregnant lady presented with painless bleeding in the 3rd trimester. What is the most common cause?

Placenta previa. ### Explanation **Correct Answer: A. Placenta previa** **Why it is correct:** In the third trimester, bleeding per vaginum is termed **Antepartum Hemorrhage (APH)**. The hallmark clinical presentation of **Placenta Previa** (where the placenta is implanted in the lower uterine segment) is **painless, causeless, and recurrent** bright red vaginal bleeding. Since the lower segment stretches and thins out in the third trimester, the inelastic placenta separates from its attachment, leading to open maternal sinuses and bleeding. Because there is no retroplacental clot formation or uterine tension, the patient does not experience pain. **Why the other options are incorrect:** * **B. Abruptio placentae:** This is the premature separation of a normally situated placenta. It typically presents with **painful** vaginal bleeding, uterine tenderness, and a "woody hard" uterus. It is the most common cause of *painful* APH. * **C. Vesicular mole:** While this causes vaginal bleeding, it typically presents in the **first or early second trimester** (usually before 20 weeks). It is characterized by "white currant" or grape-like vesicles and disproportionately high hCG levels. **NEET-PG High-Yield Pearls:** * **Investigation of Choice:** Transvaginal Ultrasound (TVS) is the gold standard for diagnosing the location of the placenta (safer and more accurate than transabdominal). * **The "Golden Rule":** Never perform a per-vaginal (PV) examination in a case of APH until Placenta Previa is ruled out by ultrasound, as it can provoke torrential, life-threatening hemorrhage (Stallworthy's sign). * **Most common cause of APH:** Abruptio placentae (overall), but for *painless* bleeding, it is always Placenta Previa.

Q: What marks the end of the first stage of labor?

Full dilatation of the cervix. The first stage of labor, also known as the **cervical stage**, begins with the onset of true labor pains and concludes with the **full dilatation of the cervix (10 cm)**. This stage is primarily concerned with the effacement and dilatation of the cervix to allow the passage of the fetal head. ### Explanation of Options: * **C. Full dilatation of the cervix (Correct):** This is the physiological landmark that defines the end of the first stage and the beginning of the second stage. At this point, the cervix is no longer palpable on vaginal examination. * **A. Rupture of membranes:** While this often occurs during the first stage (spontaneous rupture), it is not a defining marker for the end of the stage. It can occur before labor starts (PROM) or be performed artificially (ARM). * **B. 3/5 dilatation of the cervix:** This is an arbitrary measurement. In the WHO Partograph, the "Active Phase" of the first stage traditionally began at 4 cm, though recent guidelines (ACOG/WHO) now suggest 6 cm. * **D. Crowning of the fetal head:** This occurs at the end of the **second stage** of labor, just before the delivery of the head. ### High-Yield Clinical Pearls for NEET-PG: * **Duration:** In primigravidae, the first stage lasts approximately 12 hours; in multigravidae, it lasts about 6 hours. * **Phases:** It is divided into the **Latent phase** (slow dilatation) and the **Active phase** (rapid dilatation). * **Friedman’s Curve:** Traditionally used to plot labor progress; however, the **Zhang’s Curve** is now more widely recognized for modern labor patterns. * **Second Stage:** Starts from full dilatation and ends with the delivery of the fetus. * **Third Stage:** Starts from the delivery of the fetus and ends with the delivery of the placenta and membranes.

Q: A 26-year-old primigravid woman at 42 weeks' gestation comes to the labor and delivery ward for induction of labor. The prenatal course was significant for a positive group B Streptococcus culture performed at 35 weeks. Antenatal testing over the past 2 weeks has been unremarkable. The patient is started on lactated Ringer's IV solution. Sterile vaginal examination shows that the patient's cervix is long, thick, and closed. Prostaglandin (PGE2) gel is placed into the vagina, and electronic fetal heart rate monitoring is continued. In approximately 60 minutes, the fetal heart rate falls to the 90s, as the tocodynamometer shows the uterus to be contracting every 1 minute with essentially no rest in between contractions. Which of the following was most likely the cause of the uterine hyperstimulation?

Prostaglandin (PGE2) gel. **Explanation:** The patient is experiencing **uterine tachysystole** (hyperstimulation), defined as >5 contractions in 10 minutes, which has led to fetal bradycardia (FHR in the 90s) due to impaired placental perfusion during the lack of uterine relaxation. **Why Prostaglandin (PGE2) is the cause:** Prostaglandins (like Dinoprostone/PGE2 and Misoprostol/PGE1) are used for cervical ripening in patients with an unfavorable Bishop score (long, thick, closed cervix). A known and significant side effect of exogenous prostaglandins is **uterine hyperstimulation**. Because PGE2 gel is administered vaginally, its absorption can sometimes trigger excessive myometrial activity. The temporal relationship here—symptoms starting 60 minutes after administration—strongly points to the PGE2 gel as the causative agent. **Why other options are incorrect:** * **Infection:** While chorioamnionitis can cause uterine irritability, it usually presents with maternal fever, fetal tachycardia (not bradycardia), and foul-smelling liquor. * **IV fluids:** Lactated Ringer’s is an isotonic crystalloid used for hydration and does not affect uterine contractility. * **Postdates pregnancy:** While post-term pregnancy (≥42 weeks) increases the risk of placental insufficiency and oligohydramnios, it does not inherently cause uterine tachysystole. **NEET-PG Clinical Pearls:** * **Management of PGE2-induced tachysystole:** The first step is to **remove the insert/gel** (if possible) and place the patient in the left lateral position. If fetal distress persists, **Tocolytics** (e.g., Terbutaline) may be administered. * **Bishop Score:** A score of **≤6** indicates an unfavorable cervix, necessitating ripening agents like PGE2 before starting Oxytocin. * **Contraindication:** Prostaglandins should be avoided in patients with a history of previous Cesarean section due to the increased risk of uterine rupture.

Q: Arrest of labor is defined as failure of the fetal head to descend within:

2 hours. **Explanation:** The diagnosis of **Arrest of Descent** is a critical component of managing the second stage of labor. According to standard obstetric guidelines (ACOG and Williams Obstetrics), in a **nulliparous woman**, arrest of descent is defined as the failure of the fetal head to descend for **2 hours** without regional anesthesia (epidural). If an epidural is present, an additional hour is allowed (total 3 hours). **Why Option B is Correct:** The second stage of labor is characterized by the active descent of the fetus through the birth canal. A period of 2 hours without progress indicates that the mechanical forces of labor (contractions and maternal pushing) are failing to overcome the resistance of the birth canal or that there is cephalopelvic disproportion (CPD). **Analysis of Incorrect Options:** * **Option A (1 hour):** This is too short a duration to diagnose arrest. Many women require more than an hour of active pushing to navigate the pelvic curves, especially in the first pregnancy. * **Option C (3 hours):** This is the threshold for arrest in a **nulliparous woman with an epidural**. It is not the standard definition for a general population without anesthesia. * **Option D (4 hours):** This exceeds the recommended time limits for the second stage and significantly increases the risk of maternal exhaustion, postpartum hemorrhage, and fetal distress. **NEET-PG High-Yield Pearls:** * **Second Stage Limits (Nullipara):** 2 hours (no epidural), 3 hours (with epidural). * **Second Stage Limits (Multipara):** 1 hour (no epidural), 2 hours (with epidural). * **Protraction vs. Arrest:** Protraction is slow progress; Arrest is **zero** progress. * **Friedman’s Curve:** While historically used, modern guidelines (Zhang’s criteria) allow for a longer first stage, but the 2-hour rule for arrest of descent remains a standard benchmark for intervention.

Q: What is a common injury to a neonate during birth?

Fracture of the clavicle. **Explanation:** **Fracture of the clavicle** is the most common birth-related bone injury in neonates. It typically occurs during a difficult vaginal delivery, most frequently associated with **shoulder dystocia** or a high birth weight (macrosomia). The injury occurs when the anterior shoulder is compressed against the maternal symphysis pubis during delivery. * **Clinical Presentation:** The neonate may present with a palpable crepitus, localized edema, or an absent Moro reflex on the affected side (pseudoparalysis). However, many cases are asymptomatic and diagnosed only when a callus forms at the site 7–10 days later. **Analysis of Incorrect Options:** * **Fracture of the humerus (A):** This is the second most common long bone fracture. It usually occurs during breech extractions or when an arm is extended in a cephalic presentation, but it is significantly less frequent than clavicular fractures. * **Fracture of the scapula (C):** This is extremely rare in neonates due to the bone's protected anatomical position and the surrounding musculature. * **Fracture of the femur (D):** This typically occurs during a difficult breech delivery when traction is applied to the lower extremities. While serious, its incidence is much lower than that of the clavicle. **NEET-PG High-Yield Pearls:** * **Most common bone fractured:** Clavicle. * **Management:** Most clavicular fractures are "greenstick" and require no specific treatment other than gentle handling and pinning the sleeve to the chest for immobilization (if painful). * **Risk Factors:** Macrosomia, instrumental delivery (forceps/vacuum), and shoulder dystocia. * **Differential Diagnosis:** Always rule out **Erb’s Palsy** (C5-C6) if the arm is not moving, as both can occur simultaneously following shoulder dystocia.

Q: What is the treatment of choice for a 30-year-old primipara in labor with a transverse lie?

Emergency cesarean section. **Explanation:** In a **transverse lie**, the long axis of the fetus is perpendicular to that of the mother. For a primipara in active labor, the treatment of choice is an **Emergency Cesarean Section**. This is because a transverse lie is an unstable lie that cannot be delivered vaginally. If labor continues, it can lead to serious complications such as cord prolapse (common due to the poorly applied presenting part), hand prolapse, or a "neglected transverse lie" resulting in uterine rupture. **Analysis of Options:** * **Internal Cephalic Version (A):** This is contraindicated in a singleton pregnancy and a live fetus. It is generally only reserved for the delivery of a **second twin** in a malpresentation. * **Wait and Watch (C):** This is dangerous. As labor progresses, the membranes are likely to rupture, leading to cord prolapse or an impacted shoulder, making surgery more difficult and increasing maternal-fetal morbidity. * **External Cephalic Version (D):** While ECV can be attempted before the onset of labor (usually around 36–37 weeks), it is **contraindicated once labor has commenced** and the membranes have potentially ruptured or the cervix has dilated significantly. **Clinical Pearls for NEET-PG:** * **Most common cause** of transverse lie in multipara is abdominal wall laxity; in primipara, it is often due to pelvic contraction or placenta previa. * **Dorso-superior** is the most common variety of transverse lie. * **The "Spontaneous Evolution"** (Denman’s or Douglas’ method) is a rare mechanism where a dead, small fetus is expelled doubled-up, but it should never be anticipated in clinical practice. * **Management Rule:** If the patient is in labor with a transverse lie, the answer is almost always **Cesarean Section**.

Question 1

A pregnant lady presented with painless bleeding in the 3rd trimester. What is the most common cause?

Accepted Answer

Placenta previa

Answer

Abruptio placentae

Answer

Vesicular mole

Answer

None of the above

Question 2

A primigravida with a full-term pregnancy has been in labor for 1 day. She presents to the emergency department after a difficult delivery. On examination, she is dehydrated, slightly pale, with a pulse of 100/min, and BP 120/80 mm Hg. Abdominal examination reveals a fundal height of 36 weeks, cephalic presentation, absent fetal heart sounds, and mild uterine contractions. On per vaginal examination, the cervix is fully dilated, the head is at +1 station, with caput and molding present. The pelvis is adequate. There is foul-smelling, infected discharge. What is the best management option after initial work-up?

Accepted Answer

Ventouse delivery

Answer

Cesarean section

Answer

Oxytocin drip

Answer

Craniotomy and vaginal delivery

Question 3

Treatment of cord prolapse is based on all of the following factors, except?

Accepted Answer

Fetal weight

Answer

Fetal viability

Answer

Fetal maturity

Answer

Cervical dilatation

Question 4

What marks the end of the first stage of labor?

Accepted Answer

Full dilatation of the cervix

Answer

Rupture of membranes

Answer

3/5 dilatation of the cervix

Answer

Crowning of the fetal head

Question 5

A 26-year-old primigravid woman at 42 weeks' gestation comes to the labor and delivery ward for induction of labor. The prenatal course was significant for a positive group B Streptococcus culture performed at 35 weeks. Antenatal testing over the past 2 weeks has been unremarkable. The patient is started on lactated Ringer's IV solution. Sterile vaginal examination shows that the patient's cervix is long, thick, and closed. Prostaglandin (PGE2) gel is placed into the vagina, and electronic fetal heart rate monitoring is continued. In approximately 60 minutes, the fetal heart rate falls to the 90s, as the tocodynamometer shows the uterus to be contracting every 1 minute with essentially no rest in between contractions. Which of the following was most likely the cause of the uterine hyperstimulation?

Accepted Answer

Prostaglandin (PGE2) gel

Answer

Infection

Answer

IV fluids

Answer

Postdates pregnancy

Question 6

What is the definition of fetal position?

Accepted Answer

Orientation of the fetus in relation to the maternal pelvis before delivery

Answer

Vertex presentation before delivery

Answer

Breech presentation before delivery

Answer

Orientation of the uterus in relation to the maternal pelvis before delivery

Question 7

Arrest of labor is defined as failure of the fetal head to descend within:

Accepted Answer

2 hours

Answer

1 hour

Answer

3 hours

Answer

4 hours

Question 8

What is a common injury to a neonate during birth?

Accepted Answer

Fracture of the clavicle

Answer

Fracture of the humerus

Answer

Fracture of the scapula

Answer

Fracture of the femur

Question 9

Surgery for mitral stenosis during pregnancy is ideally performed at which gestational age?

Accepted Answer

14 weeks

Answer

20 weeks

Answer

28 weeks

Answer

32 weeks

Question 10

What is the treatment of choice for a 30-year-old primipara in labor with a transverse lie?

Accepted Answer

Emergency cesarean section

Answer

Internal cephalic version

Answer

Wait and watch

Answer

External cephalic version

Labor and Delivery — MCQs

Labor and Delivery — MCQs

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