Labor and Delivery — MCQs
On this page
At what gestational age should an uncomplicated triplet pregnancy be delivered?
A pregnant woman with a history of LSCS presents with hematuria. What is the most likely diagnosis?
A 27-year-old G1P0 woman at 39 weeks' gestation presents to the labor and delivery suite and progresses through the stages of labor normally. During delivery of the infant, the head initially progresses beyond the perineum and then retracts. Gentle traction does not facilitate delivery of the infant. Which of these options is the first step in the management?
Trial of labor is indicated in which of the following conditions of uterine contraction?
Delayed cord clamping allows how much blood to enter fetal circulation?
Which of the following is NOT a condition for trial of vaginal delivery in VBAC?
A gravida 2 with 1 normal live birth has presented to the clinic with a transverse lie at 36 weeks gestation. What should be the next step of management in this patient?
Breech presentation is associated with increased incidence of perinatal morbidity. What is the percentage of breech presentation at term?
What is the engaging diameter in a deflexed head?
A primigravida presents with vaginal bleeding at term, but her vital signs are normal. What is the most appropriate management?
Labor and Delivery Indian Medical PG Practice Questions and MCQs
Question 591: At what gestational age should an uncomplicated triplet pregnancy be delivered?
- A. 34 weeks (Correct Answer)
- B. 35 weeks
- C. 37 weeks
- D. 38 weeks
Explanation: **Explanation:** The timing of delivery in multiple gestations is a balance between the risks of prematurity and the increasing risk of stillbirth and placental insufficiency as the pregnancy progresses. **1. Why 34 weeks is correct:** For an **uncomplicated triplet pregnancy**, the risk of fetal demise increases significantly after 34 weeks. According to standard guidelines (ACOG and RCOG), elective delivery is recommended at **34 weeks 0 days**. At this stage, the benefits of avoiding potential intrauterine complications outweigh the neonatal risks associated with late preterm birth. Corticosteroids are typically administered prior to delivery to enhance fetal lung maturity. **2. Why the other options are incorrect:** * **35 weeks (Option B):** While only one week later, data shows a sharp rise in the risk of stillbirth in triplet pregnancies beyond the 34-week mark. * **37 weeks (Option C):** This is the recommendation for **uncomplicated twin pregnancies** (specifically dichorionic diamniotic twins). For triplets, 37 weeks is considered "post-term" due to extreme uterine distention and placental exhaustion. * **38 weeks (Option D):** This is the timing for a standard **singleton pregnancy**. Carrying triplets to this age poses a severe risk of maternal complications (preeclampsia, abruption) and fetal death. **High-Yield Clinical Pearls for NEET-PG:** * **Singleton:** 39–40 weeks. * **Twins (DCDA):** 37–38 weeks. * **Twins (MCDA):** 36–37 weeks. * **Twins (MCMA):** 32–34 weeks (delivered via Cesarean). * **Triplets:** 34 weeks. * **Mode of delivery for triplets:** Almost always **Cesarean section** due to the high risk of malpresentation and cord prolapse.
Question 592: A pregnant woman with a history of LSCS presents with hematuria. What is the most likely diagnosis?
- A. Impending scar rupture of the uterus
- B. Ureteral injury (Correct Answer)
- C. Cystitis
- D. Prolonged labor
Explanation: **Explanation:** The correct answer is **Ureteral injury**. In the context of a patient with a previous Lower Segment Cesarean Section (LSCS), the presence of **hematuria** is a classic clinical sign of urinary tract involvement. During a repeat LSCS or in cases where there are dense adhesions from a previous surgery, the bladder and ureters are at a significantly higher risk of accidental trauma. Hematuria occurs because of direct mucosal injury or devascularization of the ureter or bladder during dissection. **Analysis of Options:** * **Ureteral injury (Correct):** Hematuria is a hallmark sign of intraoperative or perioperative urinary tract injury. In a patient with a scarred uterus (previous LSCS), the bladder is often pulled higher and adhesions make the ureters more vulnerable during surgery or labor. * **Impending scar rupture (Incorrect):** While a previous LSCS increases the risk of scar rupture, the classic signs are **fetal distress (most common)**, severe abdominal pain, recession of the presenting part, and vaginal bleeding. Hematuria can occur if the rupture involves the bladder (vesicouterine fistula), but it is not the primary diagnostic feature. * **Cystitis (Incorrect):** While cystitis causes hematuria, it is usually accompanied by dysuria, frequency, and urgency. In a surgical/obstetric context with a previous scar, mechanical injury is a more urgent and likely diagnosis to rule out. * **Prolonged labor (Incorrect):** Prolonged labor can lead to a "Bandl’s ring" or pressure necrosis (leading to future fistulas), but hematuria itself is not a diagnostic criterion for the duration of labor. **NEET-PG High-Yield Pearls:** * **Most common site of ureteral injury** in Gynae-Obs surgery: At the level of the **Ischial spine** (where the ureter passes under the uterine artery—"Water under the bridge"). * **Gold standard investigation** for suspected ureteral injury: Intravenous Pyelogram (IVP) or CT Urogram. * **Most common sign of silent ureteral injury:** Postoperative flank pain and fever. * **Bladder injury** is more common than ureteral injury during LSCS, especially during the creation of the bladder flap.
Question 593: A 27-year-old G1P0 woman at 39 weeks' gestation presents to the labor and delivery suite and progresses through the stages of labor normally. During delivery of the infant, the head initially progresses beyond the perineum and then retracts. Gentle traction does not facilitate delivery of the infant. Which of these options is the first step in the management?
- A. Abduct mother's thigh and apply suprapubic pressure.
- B. Apply fundal pressure.
- C. Flex mother's thigh against her abdomen. (Correct Answer)
- D. Push infant's head back into the uterus and perform a cesarean section.
Explanation: ### Explanation The clinical scenario describes **Shoulder Dystocia**, characterized by the "Turtle Sign" (head retracting against the perineum) and failure of the shoulders to deliver with standard traction. This is an obstetric emergency where the anterior shoulder becomes impacted behind the maternal symphysis pubis. **Why Option C is Correct:** The first-line management for shoulder dystocia is the **McRoberts Maneuver**. This involves hyperflexing the mother's thighs against her abdomen. This action flattens the lumbosacral spine, rotates the symphysis pubis superiorly, and widens the pelvic outlet, which helps disimpact the anterior shoulder. It is the least invasive and most effective initial step, often resolving up to 40% of cases. **Analysis of Incorrect Options:** * **Option A:** While abduction and suprapubic pressure (Mazzanti maneuver) are used, they are typically performed *after* or *simultaneously* with McRoberts. Note: Suprapubic pressure is correct, but McRoberts (flexion) is the specific initial positional change taught as the first step. * **Option B:** **Fundal pressure is strictly contraindicated.** It further impacts the shoulder against the symphysis and increases the risk of uterine rupture and brachial plexus injury (Erb’s palsy). * **Option D:** This describes the **Zavanelli maneuver**, which is a last-resort measure used only after all other maneuvers (Woods' screw, Rubin, posterior arm delivery) have failed. **Clinical Pearls for NEET-PG:** * **Mnemonic (HELPERR):** **H**elp, **E**valuate for episiotomy, **L**egs (McRoberts), **P**ressure (Suprapubic), **E**nter (Internal rotation), **R**emove (Posterior arm), **R**oll (Gaskin maneuver). * **Risk Factors:** Maternal obesity, gestational diabetes, and fetal macrosomia. * **Complications:** Fetal brachial plexus injury (C5-C6), clavicular fracture, and maternal postpartum hemorrhage.
Question 594: Trial of labor is indicated in which of the following conditions of uterine contraction?
- A. Uterine inertia
- B. Hypotonic dysfunction
- C. Minimal contraction of the pelvis (Correct Answer)
- D. Moderate contracted pelvis
Explanation: ### Explanation **Trial of Labor (TOL)** is a clinical test of the factors of labor (Power, Passenger, and Passage) to determine if a vaginal delivery is possible. It is specifically indicated in cases of **borderline or minimal cephalopelvic disproportion (CPD)**. #### Why "Minimal contraction of the pelvis" is correct: The primary indication for a Trial of Labor is a **minor degree of pelvic contraction** (Grade I or II contraction). In these cases, the "test" of labor allows for natural mechanisms—such as **molding of the fetal skull** and **favorable positioning** (flexion)—to overcome the slight spatial deficit. If the uterine contractions are effective and the fetal head descends, a vaginal delivery is achieved safely. #### Why the other options are incorrect: * **Uterine Inertia & Hypotonic Dysfunction (Options A & B):** These refer to inadequate "Power." Trial of labor is a test of the *pelvis* (Passage) under the influence of labor. While these conditions may occur *during* a trial of labor, they are complications to be managed (e.g., with oxytocin) rather than the primary indication for initiating the trial itself. * **Moderate contracted pelvis (Option D):** In cases of moderate to severe pelvic contraction (Grade III or IV), the risk of maternal and fetal trauma, uterine rupture, and obstructed labor is too high. These cases are absolute indications for an **Elective Cesarean Section**. #### NEET-PG High-Yield Pearls: * **Prerequisites for TOL:** Must be a vertex presentation, spontaneous onset of labor, and a favorable cervix. * **Contraindications:** Previous classical C-section, major degree of CPD (Moderate/Severe), or presence of fetal distress. * **Success Criteria:** Success is defined by the engagement of the head and progressive cervical dilatation. * **Management:** A Trial of Labor should always be conducted in a well-equipped hospital with "double setup" readiness (immediate CS capability).
Question 595: Delayed cord clamping allows how much blood to enter fetal circulation?
- A. 50-100ml (Correct Answer)
- B. 100-200ml
- C. 120-150ml
- D. 150-180ml
Explanation: **Explanation:** **Delayed Cord Clamping (DCC)** refers to the practice of waiting at least **60 seconds** (or until pulsations cease) after the birth of the infant before clamping the umbilical cord. **Why 50-100ml is correct:** During the first minute of life, a significant volume of blood is transferred from the placenta to the newborn via the umbilical vein. This "placental transfusion" provides approximately **80–100 ml** of additional blood (roughly 25-30 ml/kg of body weight). This volume contains about 40–50 mg/kg of extra iron, which significantly boosts the infant's iron stores and reduces the risk of iron-deficiency anemia in the first six months of life. **Analysis of Incorrect Options:** * **B, C, and D (100-200ml+):** These volumes are physiologically excessive. The total blood volume of a term neonate is approximately 80 ml/kg. A transfusion of 150-200ml would represent nearly doubling the infant's blood volume, which would lead to severe circulatory overload and symptomatic polycythemia. **High-Yield Clinical Pearls for NEET-PG:** * **Timing:** WHO and ACOG recommend waiting **at least 30–60 seconds** for both term and preterm infants. * **Positioning:** The infant should be held at or slightly below the level of the introitus (though recent evidence suggests skin-to-skin on the mother's abdomen does not significantly hinder transfusion). * **Benefits:** In **preterm** infants, DCC is crucial as it reduces the need for blood transfusions and decreases the incidence of Intraventricular Hemorrhage (IVH) and Necrotizing Enterocolitis (NEC). * **Risk:** The primary minor risk associated with DCC is a slight increase in **neonatal jaundice** requiring phototherapy; however, the benefits of improved iron stores outweigh this risk. * **Contraindication:** DCC should be avoided in cases of maternal hemorrhage, placental abruption, or if the infant requires immediate resuscitation.
Question 596: Which of the following is NOT a condition for trial of vaginal delivery in VBAC?
- A. Breech presentation
- B. Previous Cesarean section of more than 1 (Correct Answer)
- C. Presence of anesthesiologist
- D. Informed consent
Explanation: **Explanation:** The core principle of **TOLAC (Trial of Labor After Cesarean)** is to balance the success of vaginal birth against the risk of **uterine rupture**. **Why Option B is the Correct Answer:** According to standard guidelines (ACOG and RCOG), a primary contraindication for TOLAC is a history of **two or more previous cesarean sections**. The risk of uterine rupture increases significantly (from ~0.5–0.9% with one scar to nearly 2% or more with multiple scars). Therefore, having more than one previous C-section is generally considered a contraindication, making it "NOT a condition" for a standard trial. **Analysis of Incorrect Options:** * **A. Breech presentation:** While not ideal, breech is not an absolute contraindication for TOLAC. If the patient meets other criteria (e.g., frank breech, adequate pelvis), a trial can be considered, though many clinicians prefer elective repeat C-section. * **C. Presence of anesthesiologist:** This is a mandatory requirement. TOLAC must only be attempted in facilities capable of performing an **emergency cesarean section within 30 minutes**. An anesthesiologist must be immediately available to manage complications or surgical intervention. * **D. Informed consent:** This is a legal and ethical prerequisite. The patient must be counseled on the risks (uterine rupture, fetal demise) versus the benefits (avoiding major surgery) before proceeding. **High-Yield Clinical Pearls for NEET-PG:** * **Best candidate for VBAC:** A woman with one previous low-transverse incision and a prior successful vaginal delivery. * **Absolute Contraindications:** Previous classical (vertical) or T-shaped incision, previous uterine rupture, or any contraindication to vaginal birth (e.g., placenta previa). * **Most reliable sign of uterine rupture:** Fetal heart rate abnormalities (typically **prolonged deceleration or bradycardia**). * **Success Rate:** Approximately 60–80% of women who attempt TOLAC succeed.
Question 597: A gravida 2 with 1 normal live birth has presented to the clinic with a transverse lie at 36 weeks gestation. What should be the next step of management in this patient?
- A. External cephalic version (Correct Answer)
- B. Internal cephalic version
- C. Cesarean section
- D. Wait and watch
Explanation: ### Explanation **Correct Option: A. External Cephalic Version (ECV)** In a multigravida (G2P1) at 36 weeks gestation with a transverse lie, the management of choice is **External Cephalic Version (ECV)**. At 36 weeks, the fetus is near term, but there is still sufficient amniotic fluid and uterine space to attempt manual rotation of the fetus into a cephalic presentation through the maternal abdominal wall. In multigravidas, the success rate of ECV is higher (approx. 60%) compared to primigravidas due to increased uterine laxity. **Why other options are incorrect:** * **B. Internal Cephalic Version:** This is an intrauterine procedure performed only during the second stage of labor, specifically for the delivery of the **second twin** in a twin pregnancy. It is contraindicated in singleton pregnancies due to high risks of uterine rupture and fetal trauma. * **C. Cesarean Section:** While a persistent transverse lie at term (39 weeks) or in labor requires a C-section, it is not the *immediate* next step at 36 weeks if there are no contraindications to ECV. * **D. Wait and Watch:** While spontaneous version can occur, 36 weeks is the standard window to intervene with ECV to prevent the risks associated with transverse lie (e.g., premature rupture of membranes and cord prolapse). **Clinical Pearls for NEET-PG:** * **Timing of ECV:** Usually performed at **36 weeks in primigravidas** and **37 weeks in multigravidas** (to minimize the risk of preterm labor while maximizing success). * **Prerequisites for ECV:** Reactive NST, adequate liquor (AFI >5), and no placenta previa. * **Most common cause of Transverse Lie:** In multiparous women, it is **pendulous abdomen/lax abdominal wall**. In primigravidas, always suspect **placenta previa** or pelvic contraction. * **Management at Term:** If ECV fails or is contraindicated, an elective Cesarean section is performed at 38–39 weeks.
Question 598: Breech presentation is associated with increased incidence of perinatal morbidity. What is the percentage of breech presentation at term?
- A. 1%
- B. 2%
- C. 3% (Correct Answer)
- D. 5%
Explanation: **Explanation:** The correct answer is **C (3%)**. **1. Understanding the Concept:** Breech presentation occurs when the fetal buttocks or feet are the leading parts in the birth canal. The incidence of breech presentation is inversely proportional to the gestational age. In early pregnancy, the fetus is mobile and the volume of amniotic fluid is relatively high, leading to a higher incidence of malpresentation (approx. 25% at 28 weeks). As the fetus grows and the uterus becomes more cramped, the fetus typically rotates into the cephalic position to accommodate the larger head in the wider fundus. By **term (37+ weeks)**, the incidence stabilizes at approximately **3-4%**. **2. Analysis of Options:** * **A (1%) & B (2%):** These figures are too low for term pregnancies. While the incidence decreases as term approaches, it rarely drops below 3% in the general population. * **D (5%):** This is slightly higher than the standard statistical average for term breech. 5% is more representative of the incidence around 34-36 weeks of gestation. **3. NEET-PG High-Yield Pearls:** * **Most common cause:** Prematurity is the most common cause of breech presentation. * **Types:** Frank breech (most common at term), Complete breech, and Footling breech (highest risk of cord prolapse). * **Management:** External Cephalic Version (ECV) is typically offered at 36 weeks in primigravida and 37 weeks in multigravida to reduce the incidence of breech at delivery. * **Risk Factors:** Hydrocephalus, uterine anomalies (septate/bicornuate), placenta previa, and polyhydramnios. * **Delivery:** Planned Cesarean section is generally preferred (based on the Term Breech Trial), though vaginal delivery may be considered in specific criteria.
Question 599: What is the engaging diameter in a deflexed head?
- A. Biparietal diameter
- B. Occipitofrontal diameter (Correct Answer)
- C. Suboccipitobregmatic diameter
- D. Bitemporal diameter
Explanation: In fetal skull mechanics, the **engaging diameter** is determined by the degree of flexion or extension of the fetal head as it enters the pelvic brim. ### **Explanation of the Correct Answer** In a **deflexed head** (also known as the military position), the head is neither flexed nor extended. The chin is not tucked against the chest, causing the **Occipitofrontal diameter** to present at the pelvic inlet. This diameter measures approximately **11.5 cm**, which is larger than the diameter of a well-flexed head, often leading to a more difficult or prolonged labor. ### **Analysis of Incorrect Options** * **A. Biparietal diameter (9.5 cm):** This is the widest transverse diameter of the fetal head. While it must pass through the pelvic inlet, it is not the longitudinal engaging diameter that changes with flexion/deflexion. * **C. Suboccipitobregmatic diameter (9.5 cm):** This is the engaging diameter of a **well-flexed head** (vertex presentation). It is the smallest and most favorable diameter for vaginal delivery. * **D. Bitemporal diameter (8.0 cm):** This is the shortest transverse diameter between the two temples and is not the primary engaging diameter in the context of head attitude. ### **High-Yield Clinical Pearls for NEET-PG** * **Well-flexed head:** Suboccipitobregmatic (9.5 cm) * **Deflexed head (Military):** Occipitofrontal (11.5 cm) * **Partial extension (Brow):** Mentovertical (13.5 cm) — *Largest diameter, usually requires C-section.* * **Complete extension (Face):** Submentobregmatic (9.5 cm) * **Rule of Thumb:** As the head deflexes, the engaging diameter increases until it reaches the Brow presentation, then decreases again as it moves toward a Face presentation.
Question 600: A primigravida presents with vaginal bleeding at term, but her vital signs are normal. What is the most appropriate management?
- A. Immediate low-cesarean section
- B. Examination under anesthesia with amniotomy (Correct Answer)
- C. Conservative management
- D. Classical cesarean section
Explanation: ### Explanation The clinical presentation describes a stable primigravida at term with antepartum hemorrhage (APH). In cases of late-pregnancy bleeding where the mother is hemodynamically stable and the fetus is at term, the primary goal is to determine the cause and proceed with delivery. **Why Option B is Correct:** The standard protocol for managing stable APH at term is the **Double Setup Examination** (Examination Under Anesthesia - EUA). This is performed in an operating theater prepared for an immediate cesarean section if needed. 1. If a low-lying placenta (Placenta Previa Type I or II anterior) is ruled out or confirmed to be minor, an **Artificial Rupture of Membranes (Amniotomy)** is performed. 2. Amniotomy serves two purposes: it helps diagnose Abruptio Placentae (revealing blood-stained liquor) and initiates/accelerates labor by reducing intrauterine pressure, which often controls bleeding in minor degrees of placenta previa or abruption. **Why Other Options are Incorrect:** * **Option A & D:** Immediate Cesarean Section (Low-segment or Classical) is indicated only if there is maternal instability, fetal distress, or major degrees of placenta previa (Type II posterior, III, or IV). Since the vitals are normal, a vaginal trial via amniotomy is preferred first. * **Option C:** Conservative management (MacAfee regime) is only indicated if the pregnancy is **preterm (<37 weeks)** and there is no active bleeding or fetal distress, aiming to gain fetal maturity. At term, delivery is the definitive management. **Clinical Pearls for NEET-PG:** * **Double Setup:** Always performed in the OT to manage sudden torrential hemorrhage. * **Stallworthy’s Sign:** A drop in fetal heart rate when the head is pushed into the pelvis; suggests a posterior placenta previa (dangerous as it can compress the cord). * **Amniotomy** is the treatment of choice for **Abruptio Placentae** to prevent complications like DIC and Couvelaire uterus by reducing intrauterine pressure.
Practice by Chapter
Physiology of Labor
Practice Questions
Stages of Labor and Normal Progression
Practice Questions
Fetal Monitoring Techniques
Practice Questions
Pain Management in Labor
Practice Questions
Induction and Augmentation of Labor
Practice Questions
Operative Delivery (Forceps and Vacuum)
Practice Questions
Cesarean Section: Indications and Techniques
Practice Questions
Dystocia and Abnormal Labor Patterns
Practice Questions
Obstetric Emergencies
Practice Questions
Postpartum Hemorrhage Management
Practice Questions
Want unlimited practice?
Get full access to all questions, explanations, and performance tracking.
Start For Free