Labor and Delivery — MCQs

Labor and Delivery Indian Medical PG Practice Questions and MCQs

Question 911: The engaging diameter of brow presentation is:

A. Submento‐bregmatic
B. Submento‐vertical
C. Suboccipito‐bregmatic
D. Mento‐vertical (Correct Answer)

Explanation: ***Mento-vertical*** - In a **brow presentation**, the fetal head is incompletely extended, and the presenting part is the brow. - The **mento-vertical diameter** is the longest antero-posterior diameter of the fetal head, measuring approximately **13.5 cm**, and is the engaging diameter in a brow presentation. *Submento-bregmatic* - This diameter is measured from the junction of the neck and chin to the anterior fontanelle (bregma), reflecting the engaging diameter in a **face presentation** with full extension. - Its typical measurement is about **9.5 cm**, significantly shorter than the mento-vertical diameter. *Submento-vertical* - This diameter is not a standard engaging diameter used to describe typical fetal head presentations. - Standard obstetrical terminology focuses on submento-bregmatic for face and suboccipito-bregmatic for vertex presentations. *Suboccipito-bregmatic* - This is the engaging diameter for a **flexed vertex presentation** (occiput or crown of the head), which is the most common and favorable presentation. - It measures approximately **9.5 cm**, representing the optimal diameter for passage through the birth canal.

Question 912: Modified Bishop’s score includes all EXCEPT:

A. Position of occiput (Correct Answer)
B. Position of os
C. Consistency of cervix
D. Cervical length and dilatation

Explanation: ***Position of occiput*** - The **position of the occiput** (fetal head position) is assessed during labor but is not a component of either the original or modified Bishop's score. - The Bishop's score universally evaluates **cervical ripeness** and does not incorporate fetal station or position. *Position of os* - The **position of the cervix (os)**, whether anterior, posterior, or mid-position, is a crucial component of the Bishop's score. - A more **anterior cervix** indicates a higher likelihood of successful induction. *Consistency of cervix* - **Cervical consistency** (firm, medium, soft) is a key factor in the Bishop's score, reflecting the degree of cervical ripening. - A **softer cervix** is more favorable for induction and spontaneous labor progression. *Cervical length and dilatation* - **Cervical effacement** (length) and **dilatation** are essential parameters in the Bishop's score, indicating the readiness of the cervix for labor. - A **shorter and more dilated cervix** correlates with a higher Bishop's score and increased success of labor induction.

Question 913: The main cause of perinatal mortality in ‘Frank breech presentation’ is:

A. Prolapse of umbilical cord
B. Trauma to foetal viscera
C. Intracranial haemorrhage (Correct Answer)
D. Foetal abnormalities

Explanation: ***Intracranial haemorrhage*** - In **breech deliveries**, the head, being the largest and least compressible part, is born last, subjecting it to rapid compression and decompression forces. - This can lead to **tentorial tears** and **intracranial haemorrhage**, especially in frank breech presentation where the head is not well-flexed, and the uterine forces are exerted more directly and forcefully on it during the final stages of delivery. *Prolapse of umbilical cord* - While **cord prolapse** is a risk in breech presentations, it is most common in **footling breech** due to incomplete filling of the pelvis by the presenting part. - In **frank breech**, the buttocks and flexed legs tend to fill the lower uterine segment more effectively, making cord prolapse less likely than in other breech types. *Trauma to foetal viscera* - **Visceral trauma** is possible in breech deliveries but is less common as a primary cause of mortality compared to intracranial injury. - It usually results from excessive traction or manipulation during extraction, which can cause injuries to organs like the liver or spleen. *Foetal abnormalities* - Although **foetal anomalies** are an underlying cause of breech presentation in a significant number of cases (up to 15-20%), they are the predisposing factor, not the direct cause of perinatal mortality during delivery itself. - The mortality from "frank breech presentation" refers to the complications arising from the **mode of delivery** rather than the underlying reason for the presentation.

Question 914: A 20 year old full term primigravida is admitted with full dilatation of the cervix and breech presentation. The breech is not engaged. Foetal heart is normal. The proper procedure for the management would be:

A. Caesarean section (Correct Answer)
B. Oxytocin drip augmentation
C. To bring down the leg
D. Breech extraction

Explanation: ***Caesarean section*** - For a **primigravida** with a full-term breech presentation where the foetus is **not engaged** at full dilatation and the **foetal heart is normal**, a Caesarean section is the safest option to prevent complications. - This approach minimizes risks of **foetal distress**, cord prolapse, and trauma associated with vaginal breech delivery in an unengaged presentation, especially in a first pregnancy. *Oxytocin drip augmentation* - Oxytocin is used to **augment contractions** in cases of uterine inertia or slow cervical dilation but is **contraindicated** in breech presentation that is not engaged at full dilation due to the risk of uterine rupture and foetal compromise. - Augmenting contractions in this scenario would increase the risk of an **incomplete, traumatic vaginal delivery** of a breech baby, particularly with an unengaged presentation. *To bring down the leg* - **Bringing down the leg** is a maneuver typically performed during a **planned vaginal breech delivery** to convert a complete or incomplete breech to a single footling breech to aid delivery. - This procedure is not appropriate for a primigravida with an unengaged breech at full dilatation, as it carries a high risk of **cord prolapse** and other complications without prior engagement and favourable conditions for a vaginal delivery. *Breech extraction* - **Breech extraction** is a procedure used in specific circumstances, such as delivery of a second twin or in cases where there is an umbilical cord prolapse and immediate delivery is required. - It is generally **not recommended for a primigravida** with an unengaged breech at full dilatation primarily due to the high risk of **foetal trauma** and maternal complications associated with such an intervention without prior engagement.

Question 915: A case of ante-partum haemorrhage is seen at a Primary Health Centre. The treatment will consist of:

A. Assessment of general condition of the patient, intravenous drip and reference to a hospital (Correct Answer)
B. Packing the vagina to stop the bleeding and then reference to a hospital
C. Internal podalic version and delivery
D. Vaginal examination and reference to a hospital only if diagnosed as placenta praevia

Explanation: ***Assessment of general condition of the patient, intravenous drip and reference to a hospital*** - Initial management of **ante-partum haemorrhage (APH)** at a primary level focuses on **stabilizing the mother** and arranging **urgent transfer** to a facility with comprehensive obstetric care. - An **intravenous drip** helps restore circulating volume and manage shock, while assessing the general condition guides immediate life-saving interventions. *Packing the vagina to stop the bleeding and then reference to a hospital* - **Vaginal packing** is contraindicated in APH as it can worsen bleeding, conceal the amount of blood loss, and potentially compromise fetal circulation, especially in cases of **placenta previa**. - The focus should be on rapid assessment, resuscitation, and transport, not on attempting to stop the bleeding locally. *Internal podalic version and delivery* - **Internal podalic version** is an obstetric maneuver used to change the fetal presentation for vaginal delivery, which is **not indicated** for management of APH. - Delivery decisions for APH, particularly in cases of placenta previa or abruption, often involve careful assessment and may necessitate **cesarean section**, which cannot be performed at a primary health centre. *Vaginal examination and reference to a hospital only if diagnosed as placenta praevia* - A **vaginal examination** should be **avoided** in cases of undiagnosed APH, as it can precipitate or worsen serious bleeding if **placenta previa** is present. - All cases of APH, regardless of the suspected cause, require prompt transfer to a hospital for definitive diagnosis and management, as even a minor bleed can rapidly escalate.

Question 916: During labour, which one of the foetal heart patterns is ominous?

A. Variable deceleration
B. Early deceleration
C. Tachycardia
D. Late deceleration (Correct Answer)

Explanation: ***Late deceleration*** - **Late decelerations** are an ominous sign as they indicate **uteroplacental insufficiency** and **fetal hypoxia**. - They are characterized by a gradual decrease in fetal heart rate that begins after the peak of the uterine contraction and returns to baseline after the contraction has ended. *Variable deceleration* - **Variable decelerations** are characterized by an **abrupt decrease** in fetal heart rate, 15 bpm below baseline and lasting at least 15 seconds. - They are usually associated with **umbilical cord compression** and are not necessarily ominous unless they are prolonged or severe. *Early deceleration* - **Early decelerations** are generally benign and are caused by **head compression** during uterine contractions. - They mirror the contractions, starting and ending with the contraction, and are typically not associated with fetal hypoxia. *Tachycardia* - **Fetal tachycardia** (baseline heart rate >160 bpm) can be caused by various factors, including **maternal fever**, infection, or fetal compromise. - While it can be a sign of distress, it is not as acutely ominous as late decelerations, which directly reflect hypoxemia.

Question 917: The progress of labour can be monitored by observing the following except:

A. Gradual increase in cervical dilatation by vaginal examination
B. The descent of foetal head by abdominal examination
C. The formation of caput by vaginal examination (Correct Answer)
D. The intensity of uterine contractions by abdominal examination

Explanation: ***The formation of caput by vaginal examination*** - The formation of a **caput succedaneum** (swelling on the fetal scalp) indicates **prolonged pressure** on the fetal head, which can be a sign of **cephalopelvic disproportion** or prolonged labor, rather than a direct measure of labor progression. - While its presence is noted during labor, caput formation itself does not actively monitor the *progress* of cervical dilatation or fetal descent in a positive way; rather, it often signals a potential **complication** or **stalling** of labor. *Gradual increase in cervical dilatation by vaginal examination* - **Cervical dilatation** is a primary indicator of the **first stage of labor progression**, as the cervix opens to allow passage of the fetus. - Regular **vaginal examinations** determine the rate and extent of cervical opening, crucial for deciding management. *The descent of foetal head by abdominal examination* - **Fetal head descent**, assessed by **abdominal palpation** (e.g., using the "fifths palpable" method), indicates the baby's movement through the birth canal. - This is a key measure of **progress in the second stage of labor** and helps identify potential obstructed labor. *The intensity of uterine contractions by abdominal examination* - The **intensity, frequency, and duration of uterine contractions** directly correlate with the forces driving labor progression. - While palpation provides a good estimate, this helps monitor the **effectiveness of uterine activity** in causing cervical changes and fetal descent.

Question 918: The most common sign of rupture of previous LSCS scar during labour is:

A. Non-reassuring fetal heart rate pattern (Correct Answer)
B. Cessation of uterine contractions
C. Tenderness in lower abdomen
D. Haemorrhagic shock

Explanation: ***Non-reassuring fetal heart rate pattern*** - A **sudden, sustained deceleration** or **bradycardia** in the fetal heart rate is the **most common and earliest sign** of uterine rupture, occurring in **55-87%** of cases. - This occurs due to compromised uteroplacental blood flow and **acute fetal hypoxia** as the uterus tears. - **Continuous electronic fetal monitoring** during TOLAC (Trial of Labor After Cesarean) is critical for early detection. - Changes may include **prolonged decelerations**, **bradycardia (<110 bpm)**, or sudden loss of variability. *Cessation of uterine contractions* - While a sudden **cessation of contractions** can occur with uterine rupture, it is **not consistently the most common** initial sign. - It often follows other changes, particularly fetal heart rate abnormalities, as the uterus loses its contractile ability. - Detected more reliably with intrauterine pressure catheter monitoring. *Tenderness in lower abdomen* - **Abdominal pain** and tenderness can be present, especially localized to the lower uterine segment scar area. - However, it is often **subjective and masked by normal labor pain**, making it an unreliable early indicator. - Not as specific or consistently observable as fetal heart rate changes. *Haemorrhagic shock* - **Haemorrhagic shock** with hypotension and tachycardia is a **serious late complication** indicating significant intraperitoneal or vaginal bleeding. - It usually manifests **after fetal distress** has already appeared and represents advanced rupture. - Requires immediate surgical intervention but is not an early warning sign.

Question 919: Regimen for medical abortion upto 7 weeks of gestation as per Government of India guidelines includes:

A. 400 mg of mifepristone on D1 followed by 400 µg of misoprostol on D3
B. 400 mg of mifepristone on D1 followed by 800 µg of misoprostol on D3
C. 200 mg of mifepristone on D1 followed by 400 µg of misoprostol on D3
D. 200 mg of mifepristone on D1 followed by 800 µg of misoprostol on D3 (Correct Answer)

Explanation: ***200 mg of mifepristone on D1 followed by 800 µg of misoprostol on D3*** - This is the standard and most effective regimen for **medical abortion** up to 7 weeks of gestation, as per current Indian guidelines. - **Mifepristone** blocks progesterone receptors, detaching the pregnancy, while **misoprostol** induces uterine contractions for expulsion. *400 mg of mifepristone on D1 followed by 400 µg of misoprostol on D3* - The dose of **mifepristone** is higher than necessary, and the dose of **misoprostol** is generally considered insufficient for optimal efficacy. - While mifepristone's effect is often reached at a lower dose, this misoprostol dose might lead to a higher rate of incomplete abortion compared to the recommended regimen. *400 mg of mifepristone on D1 followed by 800 µg of misoprostol on D3* - The **mifepristone** dose is higher than the standard, which does not significantly increase efficacy but may increase potential side effects. - Although the misoprostol dose is appropriate, the combined regimen is not the universally recommended or most cost-effective approach. *200 mg of mifepristone on D1 followed by 400 µg of misoprostol on D3* - While the **mifepristone** dose is correct, the **misoprostol** dose is typically considered suboptimal for high efficacy rates at this gestational age. - A lower misoprostol dose might result in a higher chance of **incomplete abortion** or the need for repeat dosing.

Question 920: A woman with post-term pregnancy with unripe cervix should not be induced with misoprostol if she has:

A. Asthma
B. Decompensated heart disease (Correct Answer)
C. Diabetes
D. Hepatitis B antigen positive

Explanation: ***Decompensated heart disease*** - Misoprostol can cause rapid and significant uterine contractions, leading to a **sudden increase in circulating blood volume** due to displacement from the uterus. - In patients with **decompensated heart disease**, this acute volume shift can precipitate **pulmonary edema** or **cardiac decompensation**, making it a contraindication. *Asthma* - While some prostaglandins can be bronchoconstrictive, **misoprostol (a synthetic prostaglandin E1 analog)** is generally considered safe for use in patients with asthma. - **Uterotonics like carboprost (PGF2a)** are contraindicated in asthma due to their bronchoconstrictive effects, but misoprostol does not share this contraindication. *Diabetes* - **Diabetes mellitus** is not a contraindication for the use of misoprostol for cervical ripening or induction. - Glucose control and fetal surveillance remain important, but misoprostol itself does not typically pose specific risks unique to diabetic patients. *Hepatitis B antigen positive* - **Hepatitis B positivity** in the mother does not contraindicate the use of misoprostol for labor induction. - The primary concern in this scenario is managing the risk of **vertical transmission** to the neonate, which is addressed through immunoprophylaxis, not by altering induction methods.

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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