Labor and Delivery — MCQs

Labor and Delivery Indian Medical PG Practice Questions and MCQs

Question 781: A gravida 3 female with two previous second-trimester abortions presents at 22 weeks of gestation with funneling of the cervix. What is the most appropriate management?

A. Administer dinoprostone and bed rest
B. Administer misoprostol and bed rest
C. Apply Fothergill suture
D. Apply McDonald suture (Correct Answer)

Explanation: ### Explanation The clinical presentation of a patient with a history of mid-trimester abortions and current cervical "funneling" (opening of the internal os) at 22 weeks is diagnostic of **Cervical Insufficiency**. **1. Why Option D is Correct:** The management of cervical insufficiency is **Cervical Cerclage**. Since the patient is currently pregnant (22 weeks), a **McDonald suture** is the most appropriate choice. It is a non-absorbable, purse-string suture placed at the cervicovaginal junction to provide mechanical support to the weak cervix, preventing further dilation and premature birth. **2. Why Incorrect Options are Wrong:** * **Options A & B (Dinoprostone/Misoprostol):** These are prostaglandins used for cervical ripening and induction of labor or abortion. Administering them would worsen the condition by further softening the cervix and inducing uterine contractions. * **Option C (Fothergill Suture):** This is a component of the Fothergill (Manchester) operation used for treating **pelvic organ prolapse** in women who wish to retain their uterus. It involves amputation of the cervix and is never performed during pregnancy. **3. High-Yield Clinical Pearls for NEET-PG:** * **Timing:** Cerclage is ideally performed between **12–14 weeks** (Elective/Prophylactic). In this case, it is an **Emergency/Rescue Cerclage** (performed after cervical changes have started). * **Diagnosis:** On Ultrasound, a cervical length **<25 mm** or significant **funneling** (T, Y, V, U shapes) before 24 weeks indicates insufficiency. * **Shirodkar Cerclage:** An alternative technique where the suture is placed higher (submucosal), often requiring bladder dissection. * **Removal:** The suture is typically removed at **37 completed weeks** or at the onset of labor to allow vaginal delivery.

Question 782: Which of the following is a contraindication for the use of ergometrine?

A. Diabetes mellitus
B. Excessive post-partum hemorrhage
C. Heart disease (Correct Answer)
D. Anaemia

Explanation: **Explanation:** Ergometrine (an ergot alkaloid) is a potent uterotonic used to prevent and treat postpartum hemorrhage (PPH). Its primary mechanism involves inducing tetanic uterine contractions and causing generalized **vasoconstriction**. **Why Heart Disease is the Correct Answer:** Ergometrine causes significant peripheral vasoconstriction and a sudden rise in blood pressure. This leads to a rapid increase in venous return (preload), which can overload a compromised heart, potentially triggering **acute heart failure, pulmonary edema, or arrhythmias**. It is also contraindicated in patients with severe hypertension and pre-eclampsia for the same reason. **Analysis of Incorrect Options:** * **A. Diabetes Mellitus:** There is no direct contraindication for ergometrine in diabetic patients, as it does not acutely interfere with glycemic control or insulin sensitivity. * **B. Excessive Post-partum Hemorrhage:** This is actually an **indication** for ergometrine. It is a second-line agent (after Oxytocin) used to manage atonic PPH due to its rapid and sustained contractile effect. * **C. Anaemia:** Anaemia is not a contraindication. In fact, preventing blood loss with uterotonics is crucial in anaemic patients who have low physiological reserves. **High-Yield Clinical Pearls for NEET-PG:** * **Route & Dose:** Usually 0.2 mg IM/IV. IV must be given very slowly. * **Side Effects:** Nausea, vomiting (most common), and transient hypertension. * **Storage:** It is light-sensitive and must be stored in a refrigerator (2–8°C). * **Contraindications Summary:** Heart disease, Hypertension (BP >140/90), Pre-eclampsia/Eclampsia, and Peripheral Vascular Disease (Raynaud’s). * **Active Management of Third Stage of Labor (AMTSL):** While Oxytocin is the drug of choice, Syntometrine (a combination of Oxytocin and Ergometrine) is sometimes used but carries the same cardiac risks.

Question 783: Which of the following is NOT a risk factor for placenta accreta?

A. Previous lower segment cesarean section scar
B. Previous curettage
C. Previous myomectomy
D. Previous placenta previa (Correct Answer)

Explanation: **Explanation:** The core pathophysiology of **placenta accreta spectrum (PAS)** is a defect in the **decidua basalis** (specifically the Nitabuch layer), which allows chorionic villi to invade the myometrium. **Why Option D is the correct answer:** The question asks for what is **NOT** a risk factor. While **current** placenta previa (especially when overlying a previous C-section scar) is the strongest risk factor for accreta, a **history of placenta previa in a previous pregnancy** (without a scar) does not inherently damage the endometrial-myometrial interface and therefore does not increase the risk for accreta in a subsequent pregnancy. **Why the other options are incorrect (Risk Factors):** * **Previous C-section (Option A):** This is the most significant risk factor. The scar tissue lacks proper decidualization, allowing villi to penetrate deeply. * **Previous Curettage (Option B):** Vigorous scraping during D&C can cause Asherman syndrome or localized endometrial defects, predisposing to abnormal placentation. * **Previous Myomectomy (Option C):** Any surgery that enters the uterine cavity or disrupts the myometrium (like myomectomy or cornual resection) creates a site where the decidua may be deficient. **High-Yield Clinical Pearls for NEET-PG:** 1. **The "Incidence Rule":** The risk of placenta accreta in a patient with placenta previa increases with the number of previous C-sections: * 1st C-section + Previa: ~3-10% risk * 2nd C-section + Previa: ~11-40% risk * 3rd C-section + Previa: ~60%+ risk 2. **Diagnosis:** Antenatal diagnosis is primarily via **Color Doppler Ultrasound** (look for "placental lacunae" or "moth-eaten appearance"). 3. **Management:** The standard treatment for confirmed accreta is **planned cesarean hysterectomy**.

Question 784: A 32-week pregnant patient presents with a cornual placenta and breech presentation. What is the treatment of choice?

A. Wait and watch (Correct Answer)
B. External cephalic version
C. Elective Cesarean section
D. Vaginal breech delivery

Explanation: ### Explanation **Correct Answer: A. Wait and watch** The core concept here is the **gestational age (32 weeks)** and the **dynamic nature of fetal presentation**. At 32 weeks, the volume of amniotic fluid relative to the fetus is high, allowing the fetus to move freely. Approximately 25% of fetuses are in breech presentation at 28 weeks, but this drops to only 3–4% by full term (37 weeks) as most undergo **spontaneous cephalic version**. A **cornual placenta** (located in the fundal horns) can be a predisposing factor for malpresentation, but it does not mandate immediate intervention at this stage. Management at 32 weeks is expectant ("Wait and watch") because there is a high probability the fetus will turn to a vertex presentation on its own before delivery. **Why other options are incorrect:** * **B. External Cephalic Version (ECV):** ECV is contraindicated before **36 weeks** (in nullipara) or **37 weeks** (in multipara). Performing it at 32 weeks increases the risk of preterm labor and abruptio placentae, and the fetus is likely to flip back to breech. * **C. Elective Cesarean Section:** This is premature. Cesarean sections for malpresentation are typically scheduled at **39 weeks**. Many patients will convert to vertex by then, avoiding surgery. * **D. Vaginal Breech Delivery:** This is a method of delivery, not a management plan for a stable patient at 32 weeks. Furthermore, the safety of vaginal breech delivery is only assessed at term. **High-Yield Clinical Pearls for NEET-PG:** * **Incidence of Breech:** 25% at 28 weeks; 7% at 32 weeks; 3–4% at term. * **Best time for ECV:** 36 weeks in primigravida; 37 weeks in multigravida (to minimize preterm risks). * **Prerequisite for ECV:** Reactive NST, adequate liquor (AFI >5), and no uterine anomalies or placenta previa. * **Cornual Placenta:** Known as the "Cornual fundal sign of Bayee," it is a common cause of persistent breech presentation but does not change management at 32 weeks.

Question 785: Which of the following drugs is not used for induction of labor?

A. Prostaglandin E2 (PGE2)
B. Prostaglandin E1 (PGE1)
C. Mifepristone
D. Betamethasone (Correct Answer)

Explanation: **Explanation:** The correct answer is **Betamethasone**. Induction of labor (IOL) refers to the artificial stimulation of uterine contractions before the onset of spontaneous labor to achieve vaginal delivery. **Why Betamethasone is the correct answer:** Betamethasone is a corticosteroid used in obstetrics for **Antenatal Corticosteroid Therapy (ACT)**. Its primary role is to accelerate fetal lung maturity by stimulating surfactant production in pregnancies at risk of preterm delivery (between 24 and 34 weeks). It has no role in inducing uterine contractions or cervical ripening. **Why the other options are used for induction:** * **Prostaglandin E2 (Dinoprostone):** This is the gold standard for cervical ripening. It acts by breaking down collagen and increasing submucosal water content in the cervix. It is available as intracervical gels or sustained-release vaginal inserts. * **Prostaglandin E1 (Misoprostol):** A synthetic PGE1 analogue. While originally used for peptic ulcers, it is highly effective for both cervical ripening and labor induction. It is administered vaginally or orally (25 mcg for IOL). * **Mifepristone (RU-486):** An anti-progestogen. By blocking progesterone receptors, it increases the sensitivity of the myometrium to prostaglandins and helps in cervical softening. It is often used for IOL in cases of intrauterine fetal death (IUFD). **High-Yield Clinical Pearls for NEET-PG:** * **Bishop Score:** Used to assess "inducibility." A score of $\geq$ 8 suggests a high likelihood of successful vaginal delivery. * **Oxytocin:** The drug of choice for induction when the cervix is already "favorable" (high Bishop score). * **Contraindication for Misoprostol:** It should **not** be used for induction in women with a previous Cesarean section due to the high risk of uterine rupture. * **Betamethasone Dosage:** 12 mg IM, two doses 24 hours apart.

Question 786: Hematuria during labor in a patient with a previous cesarean section is a sign of:

A. Impending rupture of scar (Correct Answer)
B. Urethral trauma
C. Prolonged labor
D. Sepsis

Explanation: **Explanation:** **Correct Answer: A. Impending rupture of scar** In a patient with a previous cesarean section, the bladder is often densely adherent to the lower uterine segment (LUS) due to postoperative adhesions. As the scar thins out and begins to give way (impending rupture), the stretching and shearing forces are transmitted to the posterior wall of the bladder. This leads to mucosal congestion and capillary rupture, manifesting as **hematuria**. In the context of a scarred uterus, hematuria is considered a "warning sign" of uterine dehiscence or rupture and warrants immediate evaluation. **Analysis of Incorrect Options:** * **B. Urethral trauma:** While trauma can cause hematuria, it usually occurs during instrumental delivery (forceps/vacuum) or difficult catheterization, rather than as a spontaneous sign during the course of labor. * **C. Prolonged labor:** Prolonged labor may lead to the formation of a Bandl’s ring or pressure necrosis (potentially causing fistulas later), but hematuria specifically in a post-CS patient is a classic indicator of scar instability. * **D. Sepsis:** Sepsis presents with systemic signs like fever, tachycardia, and foul-smelling liquor. While it can cause multi-organ dysfunction, it is not a primary cause of isolated hematuria during labor. **NEET-PG High-Yield Pearls:** * **Scar Rupture Signs:** The most common sign of uterine rupture is an **abnormal FHR pattern** (usually fetal bradycardia). Other signs include loss of station of the presenting part, cessation of contractions, and maternal tachycardia/shock. * **Scar Tenderness:** Persistent localized tenderness over the lower uterine segment between contractions is a significant clinical sign of impending rupture. * **Management:** If scar rupture is suspected, the immediate step is an emergency laparotomy and delivery of the fetus.

Question 787: HIV transmission to the newborn is most commonly and effectively by which route?

A. Lower segment Cesarean section (LSCS)
B. Vaginal delivery (Correct Answer)
C. Perinatal transmission
D. Breast feeding

Explanation: **Explanation:** The transmission of HIV from mother to child (MTCT) can occur during pregnancy (antenatal), labor (intranatal), or breastfeeding (postnatal). **Why Vaginal Delivery is the Correct Answer:** Intranatal transmission (during labor and delivery) accounts for the majority of HIV infections in newborns (**60-75%** of cases in non-breastfeeding populations). During a **vaginal delivery**, the fetus is exposed to infected maternal blood and cervicovaginal secretions in the birth canal. Additionally, "fetal scaling" and micro-transfusions occurring during uterine contractions significantly increase the viral load exposure, making it the most common and effective route of transmission. **Analysis of Incorrect Options:** * **A. Lower segment Cesarean section (LSCS):** Elective LSCS (performed before the onset of labor and rupture of membranes) actually **reduces** the risk of transmission by approximately 50-80%. It avoids the birth canal exposure. * **C. Perinatal transmission:** This is a broad "umbrella term" that encompasses all phases (antenatal, intranatal, and postnatal). The question asks for the specific *route* or mode that is most effective; vaginal delivery is the specific mechanism within the perinatal period that carries the highest risk. * **D. Breastfeeding:** While breastfeeding carries a 10-15% risk of transmission, it is statistically less common than transmission during the delivery process itself. **High-Yield Clinical Pearls for NEET-PG:** * **Most common timing of transmission:** During labor/delivery (Intranatal). * **Zidovudine (AZT):** The drug of choice to reduce MTCT; started at 14 weeks gestation and given IV during labor. * **WHO/NACO Recommendation:** In India, the current regimen is **Lifelong ART (Tenofovir + Lamivudine + Efavirenz)** for all pregnant and breastfeeding women regardless of CD4 count. * **Nevirapine:** A single dose is given to the newborn immediately after birth to further reduce risk.

Question 788: All of the following can be administered in acute hypertension during labor EXCEPT?

A. IV Labetalol
B. IV Esmolol
C. IV Hydralazine
D. IV Nitroprusside (Correct Answer)

Explanation: **Explanation:** The management of acute severe hypertension in labor (Systolic BP ≥160 mmHg or Diastolic BP ≥110 mmHg) aims to prevent maternal cerebrovascular accidents while maintaining placental perfusion. **Why IV Nitroprusside is the Correct Answer:** IV Nitroprusside is generally **avoided** in labor and pregnancy. Its metabolism involves the release of cyanide; while the mother can detoxify small amounts, the fetus lacks the necessary enzymes, leading to potential **fetal cyanide poisoning**. Additionally, it can cause a sudden, drastic drop in blood pressure, potentially compromising uteroplacental blood flow. It is reserved only as a last resort for refractory hypertension when all other agents have failed. **Analysis of Other Options:** * **IV Labetalol (Option A):** A combined alpha and beta-blocker. It is considered a **first-line agent** for acute hypertensive emergencies in pregnancy due to its rapid onset and favorable safety profile. * **IV Esmolol (Option B):** An ultra-short-acting beta-blocker. While not first-line like Labetalol, it can be used in specific acute settings (e.g., during intubation or aortic dissection in pregnancy) under close monitoring. * **IV Hydralazine (Option C):** A direct vasodilator. It is a traditional **first-line drug** for acute hypertensive crisis in pregnancy, though it carries a slightly higher risk of maternal hypotension compared to Labetalol. **High-Yield Clinical Pearls for NEET-PG:** * **First-line drugs for Acute HTN in Pregnancy:** IV Labetalol, IV Hydralazine, and Oral Nifedipine (Immediate Release). * **Drug of Choice for Eclampsia Prophylaxis:** Magnesium Sulfate ($MgSO_4$). * **Contraindicated Antihypertensives in Pregnancy:** ACE Inhibitors and ARBs (due to teratogenicity/renal agenesis) and Sodium Nitroprusside (due to cyanide toxicity). * **Target BP:** Aim to lower BP to 140–150/90–100 mmHg; avoid normalization to prevent placental hypoperfusion.

Question 789: Massive postpartum hemorrhage may warrant which of the following interventions?

A. Hysterectomy (Correct Answer)
B. Thermal endometrial ablation
C. Internal iliac artery ligation
D. Balloon tamponade

Explanation: **Explanation:** The management of **Massive Postpartum Hemorrhage (PPH)** follows a stepwise escalation from medical management to surgical interventions. When conservative measures fail and the patient’s life is at risk due to exsanguination, **Obstetric Hysterectomy** is considered the definitive, "last resort" life-saving procedure. * **Why Hysterectomy is correct:** In cases of intractable PPH (often due to placenta accreta spectrum or uterine atony unresponsive to drugs and compression sutures), removing the uterus is the only way to definitively stop the bleeding and prevent maternal mortality. * **Why Option B is incorrect:** Thermal endometrial ablation is a treatment for Chronic Heavy Menstrual Bleeding (AUB). It is strictly contraindicated in acute PPH as it cannot control massive arterial or myometrial bleeding and would be technically impossible in a soft, enlarged postpartum uterus. * **Why Option C & D are incorrect:** While Internal Iliac Artery Ligation and Balloon Tamponade (e.g., Bakri balloon) are vital steps in the PPH protocol, they are **conservative/fertility-sparing interventions**. In the context of "Massive PPH" where these measures have failed or are insufficient to stabilize the patient, hysterectomy becomes the warranted definitive intervention. **NEET-PG High-Yield Pearls:** * **Definition of Massive PPH:** Loss of >2000ml of blood or a rate of loss >150ml/min. * **Order of Surgical Ligation:** Uterine artery → Ovarian artery → Internal iliac artery (Hypogastric). * **Internal Iliac Ligation:** The ligature is applied to the **anterior division**, 2cm distal to the bifurcation to avoid the posterior division (which supplies the gluteal region). * **Most common indication for emergency obstetric hysterectomy:** Morbidly adherent placenta (Placenta Accreta).

Question 790: Which of the following is NOT true about premature rupture of membranes (PROM)?

A. Amnioinfusion is indicated. (Correct Answer)
B. Amoxiclav antibiotic prophylaxis should be administered.
C. Cervical examination should be performed aseptically.
D. Steroids are used for fetal lung maturation.

Explanation: **Explanation:** **1. Why Option A is the correct answer (NOT true):** Amnioinfusion (instilling saline into the amniotic cavity) is **not** a routine or indicated treatment for Premature Rupture of Membranes (PROM). While it was historically studied to prevent pulmonary hypoplasia or umbilical cord compression, current evidence and major guidelines (ACOG/RCOG) do not recommend it as a standard of care because it does not improve perinatal outcomes and increases the risk of maternal infection (chorioamnionitis). **2. Analysis of other options:** * **Option B (Amoxiclav):** This is a critical point for NEET-PG. In Preterm PROM (PPROM), antibiotics are given to delay delivery (latency). However, **Amoxiclav (Co-amoxiclav) is specifically contraindicated** because it is strongly associated with an increased risk of **Necrotizing Enterocolitis (NEC)** in the neonate. Erythromycin or Ampicillin are the preferred choices. *Note: In many exam contexts, the statement "Amoxiclav should be administered" is considered false/incorrect practice.* * **Option C (Cervical Examination):** Digital vaginal examinations should be **avoided** unless the patient is in active labor to minimize the risk of ascending infection. If necessary, it must be done under strict aseptic precautions, though a sterile speculum exam is the gold standard for diagnosis. * **Option D (Steroids):** Corticosteroids (Betamethasone/Dexamethasone) are indicated in PPROM between 24 and 34 weeks of gestation to reduce the risk of Respiratory Distress Syndrome (RDS), intraventricular hemorrhage, and NEC. **Clinical Pearls for NEET-PG:** * **Diagnosis:** The most specific test is the **Ferning Test** (microscopic crystallization). The **Nitrazine Test** (pH paper) can give false positives with semen, blood, or antiseptic soap. * **Management:** If PROM occurs at **≥37 weeks**, the management is induction of labor. If **<34 weeks**, management is conservative (Expectant management) unless there are signs of infection. * **Antibiotic of Choice:** Erythromycin is the traditional drug of choice for latency in PPROM.

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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