Labor and Delivery Practice Questions

Q: A primigravida is in labor. Her per-vaginal examination revealed a posterior cervix with 5 cm cervical length, 1 cm dilatation, soft consistency, and head at -1 station. Calculate the Bishop score.

5. ***5*** - The Bishop score calculation: **cervical position** (posterior = 0), **cervical effacement** (5 cm length = 0), **dilation** (1 cm = 1), **consistency** (soft = 2), and **station** (-1 = 1). - According to standard **Dutta textbook** references, this totals to 5 points (0 + 0 + 1 + 2 + 1), with soft consistency correctly scoring 2 points. *3* - This score incorrectly assigns only **1 point for soft consistency** instead of the standard 2 points. - The miscalculation underestimates the **cervical readiness** for labor induction. *0* - A score of 0 would require all parameters to be at their **minimum values** (firm consistency, closed cervix, high station). - The given parameters show **1 cm dilation**, **soft consistency**, and **-1 station**, each contributing positive points. *8* - A high score of 8 indicates a **very favorable cervix** with significant effacement, anterior position, and greater dilation. - The current findings show **minimal effacement** (5 cm length), **posterior position**, and only **1 cm dilation**, inconsistent with such a high score.

Q: Which of the following is a part of AMTSL?

Controlled cord traction. ***Controlled cord traction*** - **Controlled cord traction (CCT)** is a key component of Active Management of Third Stage of Labor (AMTSL) performed during placental delivery. - This technique involves applying gentle, sustained traction to the umbilical cord while simultaneously providing counter-traction to the fundus (Brandt-Andrews maneuver) to prevent **uterine inversion**. - CCT is performed after administering a uterotonic and is the primary active maneuver for delivering the placenta. *Uterine massage* - **Uterine massage** is also a component of AMTSL, but it is performed **after placental delivery** to ensure adequate uterine contraction and prevent postpartum hemorrhage. - The three components of AMTSL per WHO recommendations are: (1) Uterotonic administration, (2) Controlled cord traction, (3) Uterine massage after placental delivery. - While technically part of AMTSL, **controlled cord traction** is the more specific answer as it refers to the active maneuver during placental separation and delivery itself. *Early cord clamping* - **Early cord clamping** (within 60 seconds of birth) has been removed from AMTSL recommendations in favor of **delayed cord clamping** (1-3 minutes or when pulsation stops). - Current WHO guidelines recommend delayed cord clamping for all births while still performing AMTSL, as delayed clamping provides neonatal benefits without increasing maternal hemorrhage risk. *Uterotonics after delivery of placenta* - **Uterotonics** (oxytocin 10 IU IM/IV) are administered **within 1 minute of birth** of the baby, which is *before* placental delivery, not after. - This prophylactic administration is the cornerstone of AMTSL and reduces postpartum hemorrhage risk by approximately 60%. - Administering uterotonics *after* placental delivery does not constitute proper AMTSL timing.

Q: A grand multipara is defined as a woman who has had how many viable pregnancies (≥20 weeks):

>=5. ***>=5*** - A **grand multipara** is defined as a woman who has delivered **five or more** viable fetuses (live births or stillbirths after 20 weeks of gestation). - This classification is important clinically due to the increased risks associated with grand multiparity, such as **postpartum hemorrhage** and complications during labor. *>2* - This definition is too broad, as a woman with 3 or 4 live births is considered a **multipara**, but not specifically a grand multipara. - The term **multipara** generally applies to women who have had two or more live births. *>3* - This definition includes women with 4 live births, who are considered **multipara** but do not meet the stricter criteria for **grand multipara**. - The term **grand multipara** specifically denotes a higher number of deliveries with associated increased obstetric risks. *>4* - While close, this definition would include a woman with 5 live births, but it does not specify "five or more." - The precise definition of a **grand multipara** is five or more, which carries specific clinical implications for pregnancy management.

Q: After a normal delivery in a 27-year-old female, placenta is still attached to the uterus. Most common complication which can occur due to forceful traction of cord?

Uterine inversion. ***Uterine inversion*** - Forceful traction on the umbilical cord when the placenta is still firmly attached can pull the **fundus of the uterus inside out**, leading to uterine inversion. - This is a rare obstetric emergency associated with significant **hemorrhage** and shock. *Hemorrhage* - While hemorrhage is a common complication of retained placenta and uterine inversion, it is a *consequence* of these conditions, not the direct complication of forceful cord traction itself in the same way uterine inversion is. - The direct mechanical complication from forceful traction is the pulling out of the uterus, which then *causes* the significant hemorrhage. *Uterine rupture* - Uterine rupture during the third stage of labor is exceptionally rare and usually associated with a **previously scarred uterus** or excessive uterine overdistension, not typically caused by forceful cord traction. - Forceful cord traction is more likely to cause inversion or avulsion of the cord, rather than a tear in the uterine wall. *Placental abruption* - Placental abruption involves the **premature separation of a normally implanted placenta** *before* the delivery of the fetus. - This event occurs during pregnancy or labor before birth, not after delivery when the placenta is simply retained.

Q: 32 years old lady with twin dichorionic diamniotic pregnancy, first baby breech presentation and second baby cephalic presentation. What is the management?

C - Section. ***C-Section*** - When **twin A is in breech presentation** in a dichorionic diamniotic twin pregnancy, **elective Cesarean section** is the recommended mode of delivery according to ACOG and most international guidelines. - The primary concern is the **increased risk of complications with breech delivery** of the first twin, including **head entrapment**, **cord prolapse**, and **birth trauma**. - While twin B is cephalic (which would be favorable for vaginal delivery if it were the presenting twin), the non-cephalic presentation of twin A dictates the mode of delivery for both twins. *Assisted breech* - While breech extraction may be considered in select cases where **twin A is cephalic and twin B is breech**, attempting vaginal breech delivery when twin A presents as breech is generally not recommended. - The risks of breech delivery for the first twin include **difficulty delivering the aftercoming head**, **cord prolapse**, and **birth asphyxia**, which are unacceptable in an elective situation where cesarean section is readily available. *Instrumental delivery* - Instrumental delivery (forceps or vacuum) is used to assist delivery of a **cephalic presentation** in the second stage of labor. - It cannot be used for **breech presentation** of twin A, making it inappropriate as a primary management strategy in this scenario. *Normal vaginal delivery* - Vaginal delivery with **twin A in non-cephalic (breech) presentation** is contraindicated in most modern obstetric guidelines due to significantly increased perinatal morbidity and mortality. - Even though twin B is cephalic, the presentation of twin A determines the overall delivery approach in twin pregnancies.

Q: A multigravida woman in labor room, after delivery and placenta removal, uncontrolled bleeding was seen. What is the most common cause of PPH in this woman?

Atony. ***Atonic*** - **Uterine atony** is the most common cause of **postpartum hemorrhage (PPH)**, accounting for approximately 70-80% of cases. The uterus fails to contract adequately after placental delivery, leading to continuous bleeding from the placental bed. - Risk factors for uterine atony include multiparity, prolonged labor, rapid labor, polyhydramnios, and multiple gestations, which can lead to overdistension and fatigue of the uterine muscle. *Clotting factor deficiency* - While **coagulopathies** (clotting factor deficiencies) can cause PPH, they are a less common primary cause than uterine atony. - This cause would be suspected if there is a history of bleeding disorders, liver disease, or if PPH persists despite a well-contracted uterus. *Traumatic PPH* - **Traumatic PPH** results from lacerations of the cervix, vagina, or perineum, or from uterine rupture. These are less common than uterine atony. - This cause is typically suspected when the uterus feels firm but bleeding continues, or when visible trauma is present. *Retained tissues* - **Retained placental tissue** can prevent the uterus from contracting effectively, leading to PPH. However, it is less common than atony. - This cause is usually identified by the presence of placental fragments or membranes in the uterine cavity upon examination.

Q: Angle of cut in episiotomy is?

60 degrees at the midline. ***60 degrees at the midline*** - A **mediolateral episiotomy** is recommended at a **60-degree angle** from the midline, directed towards the ischial tuberosity. - This angle is based on **RCOG guidelines** and standard obstetric practice, providing optimal protection against **third- and fourth-degree perineal tears**. - The 60-degree angle effectively directs the incision away from the **anal sphincter** and **rectum**, while maintaining adequate surgical access. *45 degrees at the midline* - While sometimes used, this angle is **less protective** than 60 degrees against anal sphincter injuries. - Studies show that angles less than 60 degrees have a **higher risk** of extension into the anal sphincter complex compared to the recommended 60-degree angle. *30 degrees at the midline* - This angle is **too shallow** and provides insufficient protection against tearing towards the anal sphincter. - The risk of uncontrolled extension into the **anal sphincter complex** is significantly increased with such a small angle. *15 degrees at the midline* - This angle is **far too shallow** and would provide minimal expansion of the vaginal outlet. - It offers virtually no protection from extension into the **anal sphincter** and would likely result in an uncontrolled tear, making it an impractical choice for episiotomy.

Q: A primipara is in labor and an episiotomy is about to be cut. Compared with a midline episiotomy, an advantage of mediolateral episiotomy is

Less extension of the incision. ***Less extension of the incision.*** - A **mediolateral episiotomy** is less likely to extend into the rectum and anal sphincter, thus preventing a **third- or fourth-degree laceration**. - This oblique incision is directed away from the midline, significantly reducing the risk of involving the **external anal sphincter** and **rectal mucosa**. *Ease of repair* - **Midline episiotomies** are generally easier to repair due to their linear nature and involvement of fewer tissue layers. - Mediolateral episiotomies involve more complex tissue planes and angles, often making their repair more challenging and time-consuming. *Less blood loss* - **Midline episiotomies** typically result in less blood loss because they cut through less vascular tissue. - **Mediolateral incisions** cut across more muscle fibers and blood vessels, often leading to increased blood loss. *Fewer breakdowns* - **Midline episiotomies**, when properly repaired, tend to have a lower risk of tissue breakdown and infection because they are less traumatic to the surrounding structures. - Mediolateral episiotomies involve a larger tissue area and more complex wound architecture, which can increase the risk of delayed healing or breakdown.

Q: A pelvis characterized by an anteroposterior diameter of the inlet greater than the transverse diameter is classified as

Anthropoid. ***Anthropoid*** - An **anthropoid pelvis** is characterized by an **oval-shaped inlet** where the **anteroposterior diameter is greater than the transverse diameter**. - This pelvic shape is often associated with a **more favorable prognosis for vaginal delivery** when the fetal head engages in an occiput anterior or posterior position. *Gynecoid* - The **gynecoid pelvis** is considered the **"true female pelvis"**, with a rounded inlet and approximate equality of the anteroposterior and transverse diameters. - It is the most common pelvic type and is generally associated with the **easiest vaginal delivery**. *Platypelloid* - A **platypelloid pelvis** has a **transversely oval inlet** where the **transverse diameter is greater than the anteroposterior diameter**. - This shape is relatively uncommon and can be associated with **difficulties during labor**, particularly with fetal head engagement and rotation. *Android* - The **android pelvis** has a **heart-shaped or wedge-shaped inlet**, with a **narrower anterior segment** and prominent ischial spines. - This pelvic type is often associated with the **male pelvis** and can lead to **labor dystocia** due to reduced pelvic capacity.

Question 1

A primigravida is in labor. Her per-vaginal examination revealed a posterior cervix with 5 cm cervical length, 1 cm dilatation, soft consistency, and head at -1 station. Calculate the Bishop score.

Accepted Answer

5

Answer

0

Answer

8

Answer

3

Question 2

Which of the following is a part of AMTSL?

Accepted Answer

Controlled cord traction

Answer

Uterine massage

Answer

Early cord clamping

Answer

Uterotonics after delivery of placenta

Question 3

A 32 year old pregnant woman presents with 36 week pregnancy with complaints of pain abdomen and decreased fetal movements. Upon examination PR= 96/min, BP = 156/100 mm Hg, FHR = 128 bpm. On per-vaginum examination there is altered blood seen and cervix is soft 1 cm dilated. What is the preferred management?

Accepted Answer

Perform cesarean section

Answer

Observation and monitoring

Answer

Initiate labor induction

Answer

Administer medications to delay labor

Question 4

A grand multipara is defined as a woman who has had how many viable pregnancies (≥20 weeks):

Accepted Answer

>=5

Answer

>2

Answer

>3

Answer

>4

Question 5

After a normal delivery in a 27-year-old female, placenta is still attached to the uterus. Most common complication which can occur due to forceful traction of cord?

Accepted Answer

Uterine inversion

Answer

Hemorrhage

Answer

Uterine rupture

Answer

Placental abruption

Question 6

32 years old lady with twin dichorionic diamniotic pregnancy, first baby breech presentation and second baby cephalic presentation. What is the management?

Accepted Answer

C - Section

Answer

Assisted breech

Answer

Instrumental delivery

Answer

Normal vaginal delivery

Question 7

A multigravida woman in labor room, after delivery and placenta removal, uncontrolled bleeding was seen. What is the most common cause of PPH in this woman?

Accepted Answer

Atony

Answer

Clotting factor deficiency

Answer

Traumatic PPH

Answer

Retained tissues

Question 8

Angle of cut in episiotomy is?

Accepted Answer

60 degrees at the midline

Answer

45 degrees at the midline

Answer

30 degrees at the midline

Answer

15 degrees at the midline

Question 9

A primipara is in labor and an episiotomy is about to be cut. Compared with a midline episiotomy, an advantage of mediolateral episiotomy is

Accepted Answer

Less extension of the incision

Answer

Ease of repair

Answer

Less blood loss

Answer

Fewer breakdowns

Question 10

A pelvis characterized by an anteroposterior diameter of the inlet greater than the transverse diameter is classified as

Accepted Answer

Anthropoid

Answer

Gynecoid

Answer

Platypelloid

Answer

Android

Labor and Delivery — MCQs

Labor and Delivery — MCQs

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