Labor and Delivery — MCQs

A 22-year-old pregnant woman was admitted emergently to the hospital after the baby had begun to appear at the introitus. The baby had presented in the breech position, and it had been necessary to exert considerable traction to complete the delivery. Which of the following structures was most likely injured by the trauma of childbirth?

Q645Easy

What is the most common cause of spontaneous abortion in the first trimester?

Q646Medium

A patient presents at 28 weeks gestation with severe abdominal pain, bleeding, and hypertension. What is the most likely diagnosis?

Q647Medium

Obesity in pregnancy causes all of the following complications except?

Q648Easy

What is the maximum dose of PGE2 cervical gel for cervical ripening in 24 hours?

Q649Easy

Progress of labour is assessed with the help of which of the following?

Q650Medium

Expectant management of placenta previa is contraindicated in which of the following conditions?

Labor and Delivery Indian Medical PG Practice Questions and MCQs

Question 641: Kamla Rani, a 20-year-old female with mitral stenosis class II and rheumatic heart disease, becomes pregnant. Which intervention is NOT indicated in her management during labor?

A. Give prophylactic antibiotics.
B. Apply outlet forceps in the second stage of labor.
C. Give iv furosemide at delivery of the placenta.
D. Give Methergin at delivery of the anterior shoulder. (Correct Answer)

Explanation: **Explanation:** The management of labor in a patient with Mitral Stenosis (MS) focuses on preventing sudden increases in cardiac preload and afterload to avoid pulmonary edema. **Why Option D is the Correct Answer:** **Methergin (Methylergometrine)** is strictly contraindicated in cardiac patients, especially those with Mitral Stenosis. It causes peripheral vasoconstriction and sudden uterine contraction, which leads to a massive shift of blood from the uteroplacental circulation into the systemic circulation (autotransfusion). In MS, the fixed orifice of the mitral valve cannot handle this sudden increase in venous return, leading to acute pulmonary edema and heart failure. **Analysis of Incorrect Options:** * **A. Prophylactic Antibiotics:** Indicated in patients with Rheumatic Heart Disease (RHD) to prevent **Infective Endocarditis**, especially during procedures or if there is an infection, although routine use in uncomplicated vaginal delivery is debated, it remains a standard teaching for RHD in many protocols. * **B. Outlet Forceps:** The second stage of labor involves significant maternal pushing (Valsalva maneuver), which increases intrathoracic pressure and taxes the heart. **Shortening the second stage** using outlet forceps or vacuum is a standard recommendation to reduce cardiac strain. * **C. IV Furosemide:** At the time of placental delivery, "autotransfusion" naturally occurs as the uterus contracts. Giving a diuretic like Furosemide helps counteract this sudden volume overload and prevents pulmonary congestion. **Clinical Pearls for NEET-PG:** * **Drug of Choice for PPH in Cardiac Patients:** Oxytocin (slow IV infusion) is safe; Methergin and Carboprost (PGF2α) are contraindicated. * **Most Critical Period:** The immediate postpartum period (first 24 hours) is the most dangerous time for a cardiac patient due to the sudden increase in preload. * **Position:** Labor should be conducted in the **left lateral recumbent position** with the head elevated to minimize IVC compression and optimize cardiac output.

Question 642: What is the most common cause of an occipitoposterior presentation?

A. Deflexed head
B. Android pelvis (Correct Answer)
C. Gynecoid pelvis
D. Multiparity

Explanation: **Explanation:** The **Android pelvis** (masculine type) is the most common predisposing factor for an **Occipitoposterior (OP) position**. In an android pelvis, the forepelvis is narrow and triangular, while the hindpelvis is shallow. This anatomical configuration prevents the wide occiput from fitting into the narrow anterior segment of the pelvis, forcing it to occupy the more spacious posterior segment (sacroiliac notch), resulting in an OP presentation. **Analysis of Options:** * **Android Pelvis (Correct):** It is the most common cause. Additionally, the **Anthropoid pelvis** is also strongly associated with OP positions because its long anteroposterior diameter favors the head engaging in the AP diameter of the inlet. * **Deflexed Head:** While a deflexed head is a *characteristic feature* of an OP position (due to the opposition of the diameters), it is generally considered a **consequence** of the position rather than the primary cause. * **Gynecoid Pelvis:** This is the normal female pelvis. It favors the Occipito-anterior (OA) position because the forepelvis is roomy enough to accommodate the occiput. * **Multiparity:** Multiparity usually leads to a lax abdominal wall, which more commonly predisposes to transverse lies or malpresentations rather than specifically an OP position. **High-Yield Clinical Pearls for NEET-PG:** * **Most common malposition:** Occipitoposterior (Right OP is more common than Left OP). * **"Face-to-Pubes":** This refers to a persistent OP position where the baby is born with the face looking upward. * **Clinical Sign:** On abdominal examination, you find a "flattening" of the maternal abdomen below the umbilicus and easily palpable fetal limbs anteriorly. * **Labor Pattern:** OP positions are associated with "backward labor" (severe back pain) and a prolonged second stage of labor.

Question 643: A primigravida presents at 32 weeks gestation with acute abdominal pain for 2 hours, vaginal bleeding, and decreased fetal movements. How should she be managed?

A. Immediate cesarean section
B. Immediate induction of labor (Correct Answer)
C. Tocolytic therapy
D. Magnesium sulfate therapy

Explanation: **Explanation:** The clinical presentation of acute abdominal pain, vaginal bleeding, and decreased fetal movements in a third-trimester pregnancy is a classic triad for **Abruptio Placentae**. In this scenario, the priority is to stabilize the mother and proceed with delivery, as placental abruption is a life-threatening obstetric emergency. **Why Option B is Correct:** In cases of placental abruption, **vaginal delivery is the preferred route** if the fetus is dead or if the mother is stable and labor is progressing. Even at 32 weeks (preterm), once a significant abruption occurs, the pregnancy must be terminated to prevent complications like DIC, Couvelaire uterus, or maternal shock. Induction of labor (usually with oxytocin or ARM) is initiated to expedite delivery. **Why Other Options are Incorrect:** * **Option A:** Cesarean section is indicated only if there is fetal distress (live fetus), maternal instability, or obstetric contraindications to vaginal delivery. It is not the "immediate" first choice for all cases. * **Option C:** Tocolytics are strictly **contraindicated** in placental abruption, as they can mask symptoms, worsen hemorrhage, and delay necessary delivery. * **Option D:** While MgSO4 is used for neuroprotection in preterm labor or for eclampsia, it is not the definitive management for the primary pathology (abruption) here. **NEET-PG High-Yield Pearls:** * **Most common cause of DIC in pregnancy:** Placental Abruption. * **Couvelaire Uterus:** Extravasation of blood into the myometrium, seen in severe abruption; managed with oxytocics (rarely requires hysterectomy). * **Key Distinction:** Unlike Placenta Previa (painless bleeding), Abruption presents with **painful** bleeding and a **rigid/tender uterus**.

Question 644: A 22-year-old pregnant woman was admitted emergently to the hospital after the baby had begun to appear at the introitus. The baby had presented in the breech position, and it had been necessary to exert considerable traction to complete the delivery. Which of the following structures was most likely injured by the trauma of childbirth?

A. Radial nerve
B. Upper trunk of the brachial plexus (Correct Answer)
C. Lower trunk of the brachial plexus
D. Median, ulnar, and radial nerves

Explanation: **Explanation:** The clinical scenario describes a traumatic breech delivery requiring "considerable traction," which is a classic mechanism for a **Brachial Plexus Injury**. **Why the Correct Answer (B) is Right:** During a breech delivery, if the body is delivered but the head is stuck, excessive lateral traction on the neck (stretching the head away from the shoulder) puts immense strain on the **upper trunk (C5-C6 roots)** of the brachial plexus. This leads to **Erb-Duchenne Palsy**. The characteristic clinical presentation is the "Waiter’s tip" deformity (arm adducted, internally rotated, and forearm extended/pronated). **Why the Other Options are Wrong:** * **C. Lower trunk of the brachial plexus (C8-T1):** Injury here results in **Klumpke’s Palsy**. This typically occurs during breech delivery when the arm is hyper-abducted over the head (e.g., bringing down a nuchal arm), not from traction on the neck. It presents with a "Claw hand." * **A & D. Radial, Median, and Ulnar nerves:** These are peripheral branches arising from the cords of the plexus. While they can be affected downstream, the primary site of injury in birth trauma involving neck traction is the proximal trunk/root level. A total plexus injury (Option D) is possible but less common than isolated upper trunk damage in this specific mechanism. **NEET-PG High-Yield Pearls:** * **Erb’s Palsy (C5-C6):** Most common birth palsy. Muscles affected: Deltoid, Biceps, Brachialis, and Brachioradialis. Moro reflex is absent on the affected side. * **Klumpke’s Palsy (C8-T1):** Associated with Horner’s syndrome (if T1 preganglionic fibers are involved). * **Risk Factors:** Fetal macrosomia, shoulder dystocia (in cephalic presentation), and breech extraction. * **Management:** Most cases are neuropraxia and resolve spontaneously with physical therapy; surgical exploration is considered if no recovery occurs by 3–6 months.

Question 645: What is the most common cause of spontaneous abortion in the first trimester?

A. Chromosomal anomalies (Correct Answer)
B. Uterine anomalies
C. Antiphospholipid antibody syndrome
D. Hypothyroidism

Explanation: **Explanation:** **1. Why Chromosomal Anomalies is Correct:** Chromosomal abnormalities are the single most common cause of spontaneous abortion, accounting for approximately **50–60%** of all first-trimester miscarriages. Among these, **Autosomal Trisomy** is the most frequent (Trisomy 16 being the most common specific trisomy), followed by Monosomy X (Turner Syndrome) and Triploidy. These anomalies usually result from errors in gametogenesis (nondisjunction), leading to a non-viable conceptus that the body naturally expels. **2. Why the Other Options are Incorrect:** * **Uterine Anomalies (e.g., Septate uterus):** These are more commonly associated with **second-trimester** losses or recurrent pregnancy loss due to implantation failure or lack of space for fetal growth. * **Antiphospholipid Antibody Syndrome (APS):** While a major cause of **recurrent** pregnancy loss, it is less common than sporadic chromosomal errors in a single first-trimester event. APS typically causes placental thrombosis. * **Hypothyroidism:** Poorly controlled endocrine disorders can increase miscarriage risk, but they represent a much smaller percentage of cases compared to genetic factors. **3. NEET-PG High-Yield Pearls:** * **Most common specific chromosomal anomaly:** Monosomy X (45,X). * **Most common group of anomalies:** Autosomal Trisomies (as a collective group). * **Most common Trisomy:** Trisomy 16 (never seen in live births). * **Risk Factor:** The incidence of chromosomal-related abortions increases significantly with **advanced maternal age**. * **Timing:** Most "genetic" abortions occur before 8 weeks of gestation.

Question 646: A patient presents at 28 weeks gestation with severe abdominal pain, bleeding, and hypertension. What is the most likely diagnosis?

A. Placenta previa
B. Abruptio placentae (Correct Answer)
C. Vasa previa
D. Rupture of ectopic pregnancy

Explanation: **Explanation:** The clinical triad of **severe abdominal pain, vaginal bleeding, and hypertension** in the third trimester is a classic presentation of **Abruptio Placentae** (premature separation of a normally situated placenta). Hypertension (chronic or pregnancy-induced) is the most significant risk factor for placental abruption. The pain results from blood extravasating into the myometrium (Couvelaire uterus), causing uterine hypertonicity and tenderness. **Why the other options are incorrect:** * **Placenta Previa:** Characteristically presents as **painless**, bright red, causeless, and recurrent bleeding. The abdomen is typically soft and non-tender, and the fetal head is usually high or malpresented. * **Vasa Previa:** Presents with painless vaginal bleeding occurring immediately after the **rupture of membranes**. The bleeding is fetal in origin, leading to rapid fetal distress/demise while maternal vitals remain stable. * **Rupture of Ectopic Pregnancy:** While it causes pain and bleeding, it typically occurs in the **first trimester** (usually before 12 weeks). A patient at 28 weeks is in the third trimester. **NEET-PG High-Yield Pearls:** * **Most common cause of DIC in pregnancy:** Abruptio Placentae. * **Couvelaire Uterus:** A complication of abruption where blood seeps into the uterine musculature, giving it a port-wine appearance. * **Management:** If the patient is unstable or there is fetal distress, immediate delivery (usually via Cesarean section) is indicated regardless of gestational age. * **Diagnosis:** Primarily clinical; ultrasound has low sensitivity for detecting retroplacental clots.

Question 647: Obesity in pregnancy causes all of the following complications except?

A. Abnormal uterine action
B. Fetal neural tube defect
C. Precipitate labor (Correct Answer)
D. Venous thrombosis

Explanation: **Explanation:** Obesity in pregnancy (BMI >30 kg/m²) is associated with significant maternal and fetal morbidity. The correct answer is **Precipitate labor** because obesity is actually associated with **prolonged labor**, not rapid delivery. **1. Why Precipitate Labor is the Correct Answer:** Precipitate labor is defined as labor lasting less than 3 hours. In obese women, labor is typically slower, particularly in the first stage. This is attributed to increased soft tissue resistance in the birth canal and a higher incidence of **abnormal uterine action** (inefficient contractions), leading to a higher rate of induction and cesarean sections. **2. Why the other options are complications of obesity:** * **Abnormal uterine action:** Excess adipose tissue is thought to alter myometrial function and hormonal signaling (e.g., leptin and cholesterol levels), leading to poor uterine contractility and dystocia. * **Fetal neural tube defects (NTDs):** Obesity is a known independent risk factor for NTDs. This may be due to metabolic disturbances, undiagnosed hyperglycemia, or difficulties in achieving adequate folate levels. * **Venous thrombosis:** Pregnancy is a hypercoagulable state; obesity further increases venous stasis and inflammation, significantly raising the risk of Deep Vein Thrombosis (DVT) and Pulmonary Embolism. **Clinical Pearls for NEET-PG:** * **Shoulder Dystocia:** Obese women have a higher risk due to fetal macrosomia. * **Anesthesia risks:** Increased difficulty with regional anesthesia and "failed intubation" in general anesthesia. * **Postpartum Hemorrhage (PPH):** Higher risk due to uterine atony and trauma. * **Dosing:** Obese patients often require higher doses of prophylactic anticoagulants and folic acid (5mg/day).

Question 648: What is the maximum dose of PGE2 cervical gel for cervical ripening in 24 hours?

A. 2 mg
B. 1 mg
C. 1-5 mg (Correct Answer)
D. 4 mg

Explanation: **Explanation:** **1. Why the Correct Answer is Right:** PGE2 (Dinoprostone) cervical gel is a gold-standard pharmacological agent used for cervical ripening in patients with an unfavorable Bishop score. The standard dose is **0.5 mg** (contained in a 2.5 ml syringe) administered endocervically. According to standard obstetric protocols (including Williams Obstetrics and ACOG guidelines), this dose can be repeated every 6–12 hours if there is no adequate cervical change or uterine activity. The **maximum cumulative dose recommended within a 24-hour period is 1.5 mg** (3 doses). Therefore, the range **1.5 mg** (often rounded or represented as 1-1.5 mg in various texts) is the clinical limit to prevent uterine tachysystole. **2. Analysis of Incorrect Options:** * **A (2 mg):** This exceeds the standard 24-hour limit for the *gel* formulation (though 2 mg is the starting dose for the *vaginal suppository* formulation). * **B (1 mg):** This represents only two doses; while safe, it is not the *maximum* allowable limit. * **D (4 mg):** This is a dangerously high dose for PGE2 gel and significantly increases the risk of uterine rupture and fetal distress. **3. High-Yield Clinical Pearls for NEET-PG:** * **Bishop Score:** Cervical ripening is indicated when the Bishop score is **≤ 6**. * **The "Wait Time":** After the last dose of PGE2 gel, you must wait at least **6–12 hours** before starting Oxytocin to avoid synergistic uterine hyperstimulation. * **Contraindications:** Avoid PGE2 in patients with a previous cesarean section or major uterine surgery due to the high risk of **uterine rupture**. * **Storage:** Dinoprostone gel must be stored in a refrigerator (2°C to 8°C). * **Side Effect:** The most common side effect is **uterine tachysystole** (>5 contractions in 10 minutes).

Question 649: Progress of labour is assessed with the help of which of the following?

A. Cervicograph
B. Partogram (Correct Answer)
C. Dilatation chart
D. Growth curve

Explanation: **Explanation:** The **Partogram** (or Partograph) is the gold-standard tool used globally to monitor the progress of labor. It is a composite graphical record of maternal and fetal parameters against time. **Why Partogram is correct:** The Partogram allows for the early identification of deviations from normal labor. It primarily tracks three components: 1. **Fetal Condition:** Fetal heart rate, state of membranes, and liquor. 2. **Progress of Labor:** Cervical dilatation (the most important indicator), descent of the fetal head, and uterine contractions. 3. **Maternal Condition:** Pulse, BP, temperature, and urine parameters. By plotting cervical dilatation against time, clinicians can visualize the "Alert" and "Action" lines, which help in deciding when to intervene (e.g., augmentation with oxytocin or Cesarean section). **Why other options are incorrect:** * **Cervicograph:** This is a component of the partogram (specifically the graph of cervical dilatation vs. time) but is not the comprehensive tool used in clinical practice. * **Dilatation chart:** A generic term that refers only to the measurement of the cervix; it lacks the holistic monitoring of fetal and maternal well-being. * **Growth curve:** Used in antenatal care (e.g., Lubchenco charts or symphysio-fundal height curves) to monitor fetal weight and development over weeks, not the acute progress of labor. **High-Yield Clinical Pearls for NEET-PG:** * **Friedman’s Curve:** The historical basis of the partogram (Sigmoid curve). * **WHO Modified Partograph:** Starts only in the **Active Phase** (≥ 4 cm dilatation). It eliminates the latent phase to reduce unnecessary interventions. * **Paperless Partograph:** A recent advancement focusing on the "Action Line" to simplify monitoring in low-resource settings. * **Active Phase Duration:** In the WHO partograph, the alert and action lines are usually 4 hours apart.

Question 650: Expectant management of placenta previa is contraindicated in which of the following conditions?

A. Preterm fetus
B. Live fetus
C. Breech presentation
D. Active labor (Correct Answer)

Explanation: **Explanation:** The primary goal of **expectant management (MacAfee and Johnson regimen)** in placenta previa is to prolong the pregnancy until fetal maturity is reached, provided the mother and fetus are stable. **Why Active Labor is the Correct Answer:** Expectant management is strictly contraindicated in **active labor**. As the cervix dilates and effaces, it causes further separation of the placenta from the lower uterine segment, leading to massive, life-threatening maternal hemorrhage. Once labor begins, the priority shifts to immediate delivery (usually via Cesarean section) to ensure maternal safety and fetal survival. **Analysis of Incorrect Options:** * **A. Preterm fetus:** This is the *primary indication* for expectant management. If the fetus is <37 weeks and there is no active bleeding or distress, we wait to improve fetal lung maturity. * **B. Live fetus:** A live, non-distressed fetus is a prerequisite for expectant management. If there is fetal distress or fetal death, immediate delivery is indicated. * **C. Breech presentation:** Malpresentations (breech, transverse) are common in placenta previa because the placenta occupies the lower segment, preventing the head from engaging. This is not a contraindication to expectant management; it simply influences the mode of delivery later. **High-Yield Clinical Pearls for NEET-PG:** * **Prerequisites for MacAfee Regimen:** Hemodynamically stable mother, pregnancy <37 weeks, absence of active labor, and absence of fetal distress. * **Termination Point:** Expectant management is usually terminated at **37 weeks** of gestation. * **Vaginal Examination:** Digital vaginal examination is **strictly contraindicated** (can cause torrential hemorrhage) unless performed as a "Double Setup" in the operating theater. * **Steroids:** Administer corticosteroids (Betamethasone) if the gestation is <34 weeks to accelerate lung maturity.

Practice by Chapter

Physiology of Labor

Practice Questions

Stages of Labor and Normal Progression

Practice Questions

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

Practice Questions

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