Labor and Delivery — MCQs
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Before the delivery of the second twin having cephalic presentation, the mother develops profuse bleeding per vaginum. The appropriate management will be
A second gravida, whose first baby is alive, has been in the second stage of labour for more than one hour. On examination, her cervix is fully dilated. The pelvis is adequate and the station of the vertex is +2. The occiput is in right, occipito-posterior position and the fetal heart rate is 120/min. The most appropriate management will be
A 35-year-old multiparous woman is admitted with prolonged labour. She is in shock, and her pulse rate is 150 per minute. The uterus is tonically contracted with Bandl's ring, and the presenting part is not engaged. The appropriate treatment is
A vaginal examination conducted during the second stage of labour reveals occipito-posterior position of the vertex. This occipito-posterior position of the vertex was diagnosed on the basis of which of the following findings ?
A pregnant mother is referred with a prolonged second stage of labour. On examination, the foetal heart sound is 120/min, and the head is at -1 station with severe moulding. What will be the most appropriate management?
A fourth-gravida with three living children presents at 38 weeks of pregnancy with abdominal pain and vaginal bleeding. On examination, the uterus is tense and tender, and the foetal heart sounds are absent. What is the probable diagnosis?
Antimicrobial prophylaxis is essential for a woman in labour who has
While making a pelvic assessment in a gravid woman, the obstetrician can measure with examining finger the following diameter:
Match List-I with List-II and select the correct answer using the code given below: List-I (Obstetric Manoeuvres): A) Pinard's manoeuvre B) Lovset's manoeuvre C) Mauriceau-Smellie-Veit manoeuvre D) External cephalic version List-II (Indications/Purposes): 1) Conversion of breech to cephalic presentation 2) Delivery in breech presentation at term 3) Delivery of after-coming head in breech 4) Delivery of anterior shoulder and arms in breech Select the correct matching:
The indications of an elective caesarean section include all of the following, except
Labor and Delivery Indian Medical PG Practice Questions and MCQs
Question 891: Before the delivery of the second twin having cephalic presentation, the mother develops profuse bleeding per vaginum. The appropriate management will be
- A. External cephalic version and oxytocin drip
- B. Deliver the placenta of the first twin
- C. Internal podalic version and breech extraction
- D. ARM (Correct Answer)
Explanation: ***ARM (Artificial Rupture of Membranes)*** - Profuse bleeding between twin deliveries is an **obstetric emergency** requiring **immediate delivery** of the second twin to control hemorrhage. - Since the second twin has **cephalic presentation**, **ARM followed by assisted delivery** is the **fastest and most appropriate intervention**. - ARM stimulates uterine contractions and allows for **immediate vaginal delivery**, preventing maternal **exsanguination** and fetal compromise. *Internal podalic version and breech extraction* - This is **NOT indicated** as the second twin already has **cephalic presentation** (the most favorable presentation). - Internal podalic version is reserved for **transverse or unstable lie**, not for converting an already favorable cephalic presentation to breech. - Converting cephalic to breech would **waste critical time** and **increase maternal and fetal risk** in this emergency. *External cephalic version and oxytocin drip* - **External cephalic version** is inappropriate as the second twin already has **cephalic presentation**. - **Oxytocin** alone does not expedite delivery quickly enough in this **hemorrhagic emergency**. - This approach causes unnecessary delay when immediate delivery is required. *Deliver the placenta of the first twin* - This is **dangerous and absolutely contraindicated** - placenta should only be delivered **after both twins are born**. - Delivering the placenta while the second twin remains in utero can cause **massive hemorrhage**, **uterine contraction**, **entrapment of the second twin**, and **fetal death**.
Question 892: A second gravida, whose first baby is alive, has been in the second stage of labour for more than one hour. On examination, her cervix is fully dilated. The pelvis is adequate and the station of the vertex is +2. The occiput is in right, occipito-posterior position and the fetal heart rate is 120/min. The most appropriate management will be
- A. Vacuum extraction
- B. Forceps application (Correct Answer)
- C. Wait and watch policy
- D. Caesarean section
Explanation: ***Forceps application*** - With a fully dilated cervix, adequate pelvis, and **vertex at +2 station**, instrumental delivery is indicated to expedite delivery, especially given the **prolonged second stage of labor** (>1 hour in a multigravida). - **Occipito-posterior position** can be managed with rotational forceps (Kielland's forceps) to correct the malposition and facilitate delivery. - The fetal heart rate of 120/min is at the lower end of normal, and combined with the prolonged second stage, instrumental delivery is warranted to prevent further delay and potential complications. *Vacuum extraction* - While vacuum extraction is an option for instrumental delivery, **forceps are generally preferred in cases of occipito-posterior position** as they offer greater control for rotation and extraction. - Rotational maneuvers are more controlled with forceps compared to vacuum extraction. - The risk of **failed extraction** is higher with vacuum in occipito-posterior positions. *Wait and watch policy* - This is inappropriate given the **prolonged second stage** of labor (over one hour in a multigravida with good uterine contractions). - Modern guidelines allow up to 2 hours for second stage in multiparas, but with malposition (occipito-posterior) and lack of progress, active intervention is preferred. - Delaying intervention could lead to **fetal distress**, maternal exhaustion, or obstructed labor. *Caesarean section* - A Caesarean section is too invasive given the favorable conditions for vaginal delivery, including a **fully dilated cervix**, **adequate pelvis**, and **low station of the vertex (+2)**. - Instrumental delivery is the preferred approach with lower maternal morbidity in this scenario. - LSCS in second stage carries higher risks of hemorrhage and bladder injury.
Question 893: A 35-year-old multiparous woman is admitted with prolonged labour. She is in shock, and her pulse rate is 150 per minute. The uterus is tonically contracted with Bandl's ring, and the presenting part is not engaged. The appropriate treatment is
- A. Do internal podalic version and extraction
- B. Deliver the baby by vaginal route using a vacuum extractor
- C. Perform LSCS (Lower Segment Caesarean Section) (Correct Answer)
- D. Augment labour with oxytocin
Explanation: ***Perform LSCS (Lower Segment Caesarean Section)*** - The presence of a **tonically contracted uterus** with **Bandl's ring**, unengaged presenting part, and the patient being in **shock** (pulse 150 bpm) are all signs of **imminent uterine rupture** due to obstructed labor. - An **emergency LSCS** is immediately indicated to deliver the baby and manage the uterine obstruction, prioritizing the mother's and baby's lives. *Do internal podalic version and extraction* - This procedure is contraindicated in cases of **obstructed labor** with a tonically contracted uterus and Bandl's ring, as it significantly increases the risk of **uterine rupture**. - Internal podalic version is typically performed for malpresentations in the absence of obstruction, often in a less critical maternal condition. *Deliver the baby by vaginal route using a vacuum extractor* - **Vacuum extraction** requires a dilated cervix, engaged head, and the absence of mechanical obstruction. - With an **unengaged presenting part**, tonically contracted uterus, and Bandl's ring, a vaginal instrumental delivery is impossible and highly dangerous, risking uterine rupture. *Augment labour with oxytocin* - **Oxytocin augmentation** is used for hypotonic uterine dysfunction to strengthen contractions. - In a case of **obstructed labor** with a tonically contracted uterus and Bandl's ring, adding oxytocin would further exacerbate the uterine stress and dramatically increase the risk of **uterine rupture**, making it absolutely contraindicated.
Question 894: A vaginal examination conducted during the second stage of labour reveals occipito-posterior position of the vertex. This occipito-posterior position of the vertex was diagnosed on the basis of which of the following findings ?
- A. Anterior fontanelle not reached
- B. Posterior fontanelle in the subpubic area
- C. Sagittal suture in transverse in the pelvic cavity
- D. Posterior fontanelle positioned posteriorly with the sagittal suture anteroposterior (Correct Answer)
Explanation: ***Posterior fontanelle positioned posteriorly with the sagittal suture anteroposterior*** - In an **occipito-posterior (OP) position**, the **occiput** (and thus the posterior fontanelle) of the fetal head is directed towards the maternal posterior pelvis. - This orientation results in the **sagittal suture** being in an **anteroposterior (AP) direction** within the maternal pelvis, as opposed to transverse, and the posterior fontanelle is palpated towards the mother's sacrum. *Anterior fontanelle not reached* - The **anterior fontanelle** is typically evaluated in relation to the posterior fontanelle to determine the fetal head's flexion and position. - Not reaching the anterior fontanelle alone doesn't confirm an OP position; it could indicate descent or flexion of the head, and it is usually the posterior fontanelle that is palpated in a well-flexed head. *Posterior fontanelle in the subpubic area* - If the **posterior fontanelle** were in the **subpubic area**, it would indicate an **occipito-anterior (OA) position**, which is the most common and favorable presentation for vaginal delivery. - This finding suggests that the occiput is directed towards the maternal anterior pelvis, which is the opposite of an occipito-posterior position. *Sagittal suture in transverse in the pelvic cavity* - A **sagittal suture** in a **transverse position** usually indicates a **transverse arrest** or engagement in a occipito-transverse position. - In an occipito-posterior position, the sagittal suture is typically in an anteroposterior orientation within the maternal pelvis.
Question 895: A pregnant mother is referred with a prolonged second stage of labour. On examination, the foetal heart sound is 120/min, and the head is at -1 station with severe moulding. What will be the most appropriate management?
- A. Start pitocin drip
- B. Apply ventouse and deliver
- C. Apply obstetric forceps and deliver
- D. Perform LSCS (Correct Answer)
Explanation: ***Perform LSCS*** - The combination of **prolonged second stage of labor**, fetal head at **-1 station**, and **severe molding** strongly suggests **cephalopelvic disproportion** or **obstructed labor**. - **LSCS is the safest option** to prevent maternal complications (uterine rupture, cervical lacerations) and fetal complications (hypoxia, trauma), as the severe molding indicates prolonged compression and failed descent despite adequate time in second stage. *Start pitocin drip* - **Contraindicated** with severe molding and high station as it suggests **cephalopelvic disproportion**. - Increased contractions could lead to **uterine rupture** without achieving delivery and would worsen fetal head molding, potentially causing **fetal distress**. *Apply ventouse and deliver* - **Contraindicated** - Ventouse requires fetal head engagement (preferably **+2 station or below**), but the head is at **-1 station**. - At -1 station with severe molding, ventouse application would be **ineffective and dangerous**, with risk of scalp lacerations, **cephalohematoma**, and failed extraction. *Apply obstetric forceps and deliver* - **Contraindicated** - Forceps require fetal head to be engaged (at least **0 station**), but at **-1 station**, forceps application is **dangerous and inappropriate**. - Attempting forceps at high station risks severe **maternal trauma** (cervical lacerations, uterine rupture) and **fetal injury**, as standard obstetric guidelines prohibit forceps use above 0 station.
Question 896: A fourth-gravida with three living children presents at 38 weeks of pregnancy with abdominal pain and vaginal bleeding. On examination, the uterus is tense and tender, and the foetal heart sounds are absent. What is the probable diagnosis?
- A. Vasa praevia
- B. Ectopic pregnancy
- C. Placenta praevia
- D. Accidental haemorrhage (Correct Answer)
Explanation: ***Accidental haemorrhage*** - The combination of **abdominal pain**, **vaginal bleeding**, a **tense and tender uterus**, and **absent fetal heart sounds** strongly indicates accidental hemorrhage (placental abruption). - This condition involves the premature separation of the **placenta** from the uterine wall, leading to concealed or revealed bleeding and frequently resulting in fetal demise. *Vasa praevia* - Characterized by **fetal blood vessels** crossing the cervical os, making the fetus vulnerable to hemorrhage. - While it causes **painless vaginal bleeding**, it typically does not present with a **tense and tender uterus** or immediate fetal demise unless there is membrane rupture. *Ectopic pregnancy* - Occurs when a fertilized egg implants outside the uterus, most commonly in the fallopian tube. - Presents with **abdominal pain** and **vaginal bleeding**, but this occurs in the **first trimester**, not at 38 weeks of pregnancy. *Placenta praevia* - Involves the placenta covering the cervical os, leading to **painless vaginal bleeding**. - Unlike accidental hemorrhage, the uterus is typically **soft and non-tender**, and fetal heart sounds are usually present.
Question 897: Antimicrobial prophylaxis is essential for a woman in labour who has
- A. Hypertension
- B. Diabetes mellitus
- C. Renal disease
- D. Heart disease (Correct Answer)
Explanation: ***Heart disease*** - Historically, women with certain types of heart disease, especially those with **valvular abnormalities** or a history of **infective endocarditis**, were considered to require antimicrobial prophylaxis during labor and delivery. - **Important Note**: Current guidelines (AHA 2007 onwards, ACOG) **no longer recommend routine antimicrobial prophylaxis** for prevention of infective endocarditis during uncomplicated vaginal delivery or cesarean section, even in women with valvular heart disease. - Prophylaxis may still be indicated if there are **infected tissues**, **chorioamnionitis**, or other **infectious complications** during delivery. - This question reflects **older clinical practice** when antimicrobial prophylaxis was more broadly recommended for cardiac patients during labor. *Hypertension* - **Hypertension** during labor, whether **chronic** or **gestational**, does not increase the risk of infectious complications requiring antimicrobial prophylaxis. - Management focuses on **blood pressure control** and monitoring for complications like pre-eclampsia or eclampsia. *Diabetes mellitus* - While women with **diabetes mellitus** may have slightly increased infection risk, it is **not an indication** for routine antimicrobial prophylaxis during labor for endocarditis prevention. - Prophylaxis during labor is indicated for **Group B Streptococcus (GBS) colonization** or specific obstetric indications, not diabetes itself. *Renal disease* - **Renal disease** itself is **not an indication** for antimicrobial prophylaxis during labor. - Management focuses on monitoring the renal condition and managing fluid and electrolyte balance during pregnancy and delivery.
Question 898: While making a pelvic assessment in a gravid woman, the obstetrician can measure with examining finger the following diameter:
- A. True conjugate
- B. Diameter of pelvic inlet
- C. Obstetric conjugate
- D. Diagonal conjugate (Correct Answer)
Explanation: ***Diagonal conjugate*** - This is the only pelvic inlet diameter that can be directly measured clinically by the **examining finger**. - It extends from the **lower border of the pubic symphysis** to the **sacral promontory**. *True conjugate* - The true conjugate extends from the **upper border of the pubic symphysis** to the sacral promontory and cannot be directly measured due to the bladder. - It is an **estimated measurement**, usually derived by subtracting 1.5 to 2 cm from the diagonal conjugate. *Diameter of pelvic inlet* - This is a general term referring to various diameters of the pelvic inlet, some of which are not clinically measurable. - While one of its components, the diagonal conjugate, is measurable, the phrase "diameter of pelvic inlet" is too broad, and specific diameters are not directly accessible. *Obstetric conjugate* - This diameter is taken from the **innermost aspect of the pubic symphysis** to the sacral promontory, representing the shortest anteroposterior diameter the fetal head must pass. - Like the true conjugate, it cannot be directly measured clinically and is also estimated from the diagonal conjugate (approximately 0.5 cm less than the true conjugate).
Question 899: Match List-I with List-II and select the correct answer using the code given below: List-I (Obstetric Manoeuvres): A) Pinard's manoeuvre B) Lovset's manoeuvre C) Mauriceau-Smellie-Veit manoeuvre D) External cephalic version List-II (Indications/Purposes): 1) Conversion of breech to cephalic presentation 2) Delivery in breech presentation at term 3) Delivery of after-coming head in breech 4) Delivery of anterior shoulder and arms in breech Select the correct matching:
- A. A→4 B→1 C→3 D→2
- B. A→3 B→1 C→4 D→2
- C. A→2 B→4 C→3 D→1
- D. A→1 B→4 C→3 D→2 (Correct Answer)
Explanation: ***A→2 B→4 C→3 D→1*** - **Pinard's manoeuvre** (A) is used for **delivery in breech presentation at term** (2) by flexing the fetal knee and abducting the thigh to bring down extended legs. - This is the correct matching as each manoeuvre corresponds to its specific **obstetric indication**: **Lovset's** for shoulder delivery, **Mauriceau-Smellie-Veit** for after-coming head, and **External cephalic version** for presentation conversion. *A→4 B→1 C→3 D→2* - Incorrectly matches **Pinard's manoeuvre** to shoulder/arm delivery, which is actually the role of **Lovset's manoeuvre**. - **Lovset's manoeuvre** is mismatched to presentation conversion rather than its specific purpose of **delivering shoulders and arms** in breech presentation. *A→3 B→1 C→4 D→2* - **Pinard's manoeuvre** is wrongly matched to **after-coming head delivery**, which is specifically performed by **Mauriceau-Smellie-Veit manoeuvre**. - **Mauriceau-Smellie-Veit manoeuvre** is incorrectly matched to shoulder delivery instead of its actual purpose of **controlled delivery of the fetal head**. *A→1 B→4 C→3 D→2* - **Pinard's manoeuvre** is incorrectly matched to **presentation conversion**, which is performed **antepartum** by **External cephalic version**. - **External cephalic version** is wrongly matched to delivery during labor rather than its **prenatal** role in converting **breech to cephalic presentation**.
Question 900: The indications of an elective caesarean section include all of the following, except
- A. cephalopelvic disproportion (Correct Answer)
- B. carcinoma cervix
- C. previous lower segment caesarean section
- D. placenta previa
Explanation: ***Cephalopelvic disproportion*** - **Cephalopelvic disproportion (CPD)** is a diagnosis made during labor when the fetal head cannot fit through the maternal pelvis, preventing vaginal delivery despite adequate contractions. - This condition is typically diagnosed *during* labor when there is **failure to progress**, making it an indication for an **emergency** or **intrapartum** cesarean section, not an elective one. *Carcinoma cervix* - **Cervical cancer** can obstruct the birth canal and is associated with a risk of excessive bleeding and tumor dissemination during vaginal delivery. - An **elective cesarean section** is indicated to avoid trauma to the tumor and prevent potential spread of cancer cells. *Previous lower segment caesarean section* - A history of a **previous lower segment cesarean section (LSCS)** carries a risk of **uterine rupture** in subsequent pregnancies, especially if attempting a **vaginal birth after cesarean (VBAC)**. - Many women (or their doctors) with a prior LSCS opt for a **repeat elective cesarean section** to mitigate this risk. *Placenta previa* - **Placenta previa** occurs when the placenta covers part or all of the cervix, blocking the birth canal. - Vaginal delivery is contraindicated due to the high risk of severe **hemorrhage** to both mother and fetus, making an **elective cesarean section** necessary.
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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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