Labor and Delivery Practice Questions

Q: All of the following are treatments for deep transverse arrest except:

Craniotomy. ***Craniotomy*** - A **craniotomy** is a destructive procedure performed on the fetal head to reduce its size for delivery, typically reserved for instances of **fetal demise**. - This is **not a treatment for deep transverse arrest in a viable fetus** but a destructive procedure for a non-viable fetus. - In modern obstetric practice, craniotomy is not used for managing deep transverse arrest in living fetuses. *Cesarean section* - A **cesarean section** is a common and appropriate treatment for deep transverse arrest, especially when vaginal delivery is not achievable or safe. - It bypasses the need for rotation and forceps, thus being a direct method of delivery for this type of arrest. *Manual rotation with outlet forceps* - **Manual rotation** converts the transverse arrest to an anterior-posterior position, allowing for vaginal delivery, often assisted by **forceps** once rotated. - This technique is a direct intervention for deep transverse arrest, aiming to achieve a vaginal delivery in cases where the fetal head is arrested in the transverse diameter of the maternal pelvis. - Manual rotation followed by forceps application is a well-established treatment option. *Ventouse* - **Ventouse** (vacuum extraction) is a method to assist vaginal delivery by applying suction to the fetal head and is often used for deep transverse arrest after rotation has been achieved. - It helps to extract the fetus when descent is arrested, acting as a direct delivery method in these scenarios.

Q: Comprehensive emergency obstetric care does not include:

Routine antenatal care. ***Routine antenatal care*** - Routine antenatal care is a **preventive and monitoring service** provided during pregnancy to detect and prevent complications. - Comprehensive Emergency Obstetric Care (CEmOC) specifically refers to **emergency interventions** provided during obstetric complications, not routine preventive services. - According to WHO definitions, CEmOC includes **7 signal functions**: parenteral antibiotics, parenteral oxytocics, parenteral anticonvulsants, manual removal of placenta, removal of retained products, assisted vaginal delivery, cesarean section, and blood transfusion. - Routine antenatal care is provided at basic health facilities and is **not an emergency intervention**. *Manual removal of placenta* - This is a **core signal function** of CEmOC (signal function #4). - Essential intervention for managing **retained placenta**, a common cause of postpartum hemorrhage. - Failure to remove retained placenta can lead to severe hemorrhage, infection, and maternal death. *Cesarean section* - This is a **defining signal function** of CEmOC (signal function #7). - Life-saving intervention for managing obstructed labor, fetal distress, placenta previa, and other complications. - The ability to perform cesarean section is the **key differentiator** between Basic EmOC and Comprehensive EmOC. *Hysterectomy* - While hysterectomy may be performed in facilities providing CEmOC for severe complications like intractable postpartum hemorrhage, it is **not one of the 7 signal functions** that define CEmOC. - It is a surgical capability that may be available but is not a required component for a facility to be designated as providing comprehensive emergency obstetric care.

Q: A 37-year-old G2P1 woman at 38 weeks' gestation presents to the obstetrics clinic for a prenatal visit. The patient had difficulty becoming pregnant but was successful after using in vitro fertilization. She has a history of recurrent herpes outbreaks and is currently experiencing genital pain and tingling. Her first pregnancy was complicated by failure to progress, which resulted in a cesarean birth. Routine rectovaginal culture at 36 weeks was positive for Group B streptococci. Which of the following would be an absolute indication for delivering the child by LSCS (Lower Segment Cesarean Section):

Current symptoms of genital pain and tingling. ***Current symptoms of genital pain and tingling*** - **Genital pain and tingling** in a patient with a history of recurrent herpes outbreaks strongly suggests a **prodromal or active herpes outbreak**. - An active maternal **genital herpes lesion** at the time of labor is an absolute indication for **cesarean delivery** to prevent neonatal herpes simplex virus (HSV) infection, which can be life-threatening. *History of previous cesarean section* - A **prior cesarean section** is a relative indication for a repeat cesarean, but many women are candidates for a **trial of labor after cesarean (TOLAC)** if certain criteria are met. - It is not an absolute contraindication to vaginal delivery itself, especially if the previous cesarean was for a non-recurrent indication like **failure to progress**. *Maternal colonization with Group B streptococci* - **Group B streptococcus (GBS) colonization** is typically managed with **intrapartum antibiotic prophylaxis (IAP)** to prevent early-onset neonatal GBS disease. - It does not necessitate a cesarean section for delivery; rather, antibiotics are given once labor begins or membranes rupture. *In vitro fertilization* - **In vitro fertilization (IVF)** is a method of conception and does not inherently determine the mode of delivery. - Pregnancy achieved through IVF does not, by itself, increase the risk of complications that would mandate a **cesarean section**, unless there are other associated factors like multiple gestations or specific maternal conditions.

Q: Internationally accepted definition of abortion is the expulsion of the products of conception:

Before 20th week of gestation or 500 gms (weight of foetus). ***Before 20th week of gestation or 500 gms (weight of foetus)*** - The internationally accepted definition of abortion, as per organizations like the **World Health Organization (WHO)**, is the expulsion of products of conception before **20 weeks of gestation** or when the fetal weight is less than **500 grams**. - This threshold is used because fetuses weighing less than 500 grams or born before 20 weeks are generally considered non-viable, meaning they have a negligible chance of survival outside the womb. *Before 28th week of gestation or 1 kg (weight of foetus)* - While 28 weeks of gestation is an important milestone for fetal viability, defining abortion at this stage would include many late preterm births that are often viable. - A fetal weight of **1 kg (1000g)** is generally associated with a much higher probability of survival, signifying a preterm birth rather than an abortion by international standards. *Before 20 week of gestation or 750 gms (weight of foetus)* - The gestational age of **20 weeks** is correct, but a fetal weight of **750 grams** is higher than the internationally accepted cutoff of 500 grams for defining abortion. - Fetuses at 750 grams, especially at 20 weeks, are still considered non-viable, but the weight criterion in this option is not the standard international definition. *Before 24th week of gestation or 750 gms (weight of foetus)* - While **24 weeks of gestation** is often considered the threshold of viability in many countries, and is used in some legal definitions, it is not the internationally recognized standard for abortion, which generally uses 20 weeks. - A fetal weight of **750 grams** at 24 weeks would indicate a very early preterm birth with a low but possible chance of survival, whereas the international definition of abortion focuses on absolute non-viability.

Q: An absolute indication for Classical cesarean section is :

Carcinoma cervix. ***Carcinoma cervix*** - A **classical cesarean section** (vertical incision in the uterine body) is indicated in cases of **carcinoma of the cervix** to minimize trauma to the cervix and prevent dissemination of cancer cells. - This approach avoids cutting through the cancerous tissue, which might be necessary with a lower uterine segment incision. *Central Placenta Previa* - While **placenta previa** often necessitates a cesarean section, a **lower segment cesarean section** (LSCS) is generally preferred due to less blood loss and better healing. - A classical cesarean section would only be considered in specific, rare circumstances for placenta previa, such as an exceptionally previa anterior placenta or severe hemorrhage requiring rapid extraction, but it is not an absolute, primary indication. *Breech presentation* - **Breech presentations** are often delivered by **lower segment cesarean section** (LSCS) due to potential risks associated with vaginal delivery. - A classical cesarean section is rarely indicated for breech presentation, typically only for very premature fetuses or if the lower uterine segment is inaccessible. *Multi-fibroid uterus* - A **multi-fibroid uterus** itself is not an absolute indication for a classical cesarean section unless the fibroids obstruct the lower uterine segment, preventing an LSCS. - In most cases, a **lower segment cesarean section** can still be performed, sometimes with careful navigation around or removal of obstructing fibroids (myomectomy at C-section).

Q: In deep transverse arrest with adequate pelvis, what is the best mode of delivery?

Kielland forceps. ***Kielland forceps*** - **Kielland forceps** are the **classical instrument of choice** for deep transverse arrest with an adequate pelvis, as they were specifically designed for **rotational delivery**. - They have a **minimal pelvic curve** and a **sliding lock mechanism** that allows for controlled rotation of the fetal head from transverse to occipito-anterior position. - When the pelvis is adequate and the operator is skilled, Kielland forceps provide the **most direct and effective method** for managing deep transverse arrest. - This is the **standard answer** taught in most obstetric textbooks including Williams Obstetrics and Dutta's Textbook of Obstetrics. *Manual rotation followed by forceps* - This is an acceptable alternative approach, especially when **expertise with rotational forceps is limited**. - Manual rotation (using the hand to rotate the fetal head to occipito-anterior) followed by standard forceps or traction is a valid method. - However, it requires **two separate maneuvers** rather than the single-instrument approach with Kielland forceps. *Ventouse* - While ventouse can achieve rotation and traction, it has a **higher failure rate** in cases of deep transverse arrest, particularly at the mid-pelvis level. - Rotation with ventouse is **less controlled** and has higher **cup detachment rates** compared to rotational forceps. - It may be considered when rotational forceps expertise is not available or when minimal rotation is needed. *Cesarean section* - Cesarean section would be indicated if the pelvis were **inadequate** (cephalopelvic disproportion), if there is **fetal distress**, or if **assisted vaginal delivery fails**. - Since the question specifies an **adequate pelvis**, operative vaginal delivery is preferred over the more invasive cesarean section when feasible.

Q: Burns-Marshall technique is used to deliver the:

After-coming head. ***After-coming head*** - The **Burns-Marshall technique** is a method specifically designed for the delivery of the **after-coming head** in a **breech presentation**, typically when the body has already been delivered. - This technique involves suprapubic pressure and gentle upward traction on the baby's ankles to facilitate flexion and delivery of the head. *Leg* - The Burns-Marshall maneuver is not used to deliver the leg; the legs are typically delivered earlier in a **frank or complete breech delivery**. - Delivery of the legs usually involves assisting the natural progression of labor or specific maneuvers if there is a problem. *Placenta* - The **placenta** is delivered in the **third stage of labor**, after the baby has been born, and is not associated with the Burns-Marshall technique. - Methods for placental delivery include spontaneous expulsion or controlled cord traction. *Head* - While the maneuver relates to the head, it is specifically for the **after-coming head** in a breech presentation, not the initial delivery of the head in a **cephalic presentation**. - In a cephalic presentation, the head is typically delivered first through flexion and extension, guided by the maternal pelvis.

Q: Subpubic angle in gynecoid pelvis is?

100o. ***Correct Option: 100°*** - A **subpubic angle of 90-100 degrees** is characteristic of a **gynecoid pelvis**, which is the most favorable pelvis type for childbirth. - The gynecoid pelvis has a **rounded pelvic inlet** and a **wide subpubic arch** (≥90°), allowing optimal space for fetal head descent. - **100 degrees** falls within the normal range and represents a well-formed gynecoid pelvis with an adequate pelvic outlet. *Incorrect Option: 80°* - A **subpubic angle of 80 degrees** is more characteristic of an **anthropoid pelvis** or represents the lower limit of normal. - This narrower angle, while still permitting vaginal delivery, is not the typical measurement for a classic gynecoid pelvis. - Gynecoid pelvis typically has angles **≥90 degrees**. *Incorrect Option: 120°* - A **subpubic angle of 120 degrees** is excessively wide and not characteristic of a gynecoid pelvis. - Such an extreme angle would suggest unusual pelvic anatomy and is not a standard measurement in pelvic classification. *Incorrect Option: 75°* - A **subpubic angle of 75 degrees** is characteristic of an **android (male-type) pelvis**, which has a narrow subpubic arch. - This narrow angle can restrict fetal head passage through the pelvic outlet, increasing the risk of obstructed labor. - This is significantly below the gynecoid pelvis range of ≥90 degrees.

Q: In modern obstetrics, the internal podalic version is indicated in presence of:

Transverse lie of 2nd twin baby. **Transverse lie of 2nd twin baby** - **Internal podalic version** is primarily indicated for the second twin in a transverse or oblique lie to facilitate vaginal delivery after the first twin has been delivered. - This procedure involves inserting a hand into the uterus to grasp the baby's feet and turn it into a **breech presentation**, allowing for extraction. *Extended breech presentation* - For an **extended breech presentation**, **internal podalic version** is generally not the preferred method of management; external cephalic version or planned cesarean section are often considered. - The fetus is already in a longitudinal lie, and the goal is usually to convert to cephalic, not podalic, or to manage the existing breech. *Transverse lie with obstructed labor* - In cases of **transverse lie with obstructed labor**, **internal podalic version** is contraindicated because the uterus is often contracted down on the fetus, making manipulation dangerous and increasing the risk of uterine rupture. - **Obstructed labor** in a transverse lie typically necessitates an emergency cesarean section. *Cord prolapse with live baby* - For **cord prolapse with a live baby**, the immediate priority is to relieve pressure on the umbilical cord and deliver the baby as quickly as possible, usually via emergency cesarean section. - While prompt delivery is crucial, **internal podalic version** is not the primary intervention for cord prolapse itself; rather, it is a method for delivery when other factors align.

Q: All of the following are relative contraindications for vacuum extraction, EXCEPT:

Occipito-posterior position. ***Occipito-posterior position*** - This is often considered a **relative indication** for vacuum extraction, as it can help rotate the fetal head to an anterior position and facilitate delivery. - While it may make the extraction slightly more challenging, it is not a direct contraindication, unlike the other options which pose greater risks. *Fetal coagulopathies* - **Vacuum extraction** can cause significant trauma to the fetal scalp, leading to **hematomas** and **hemorrhage**. - In cases of **fetal coagulopathies**, the risk of severe bleeding and intracranial hemorrhage is substantially increased, making vacuum extraction highly contraindicated. *Face presentation* - In a **face presentation**, the fetal chin (mentum) is typically the presenting part. - Applying a vacuum cup to the face carries a high risk of **facial nerve damage**, **ocular injury**, and **severe facial bruising**, making it a contraindication. *Extreme prematurity* - The skull of extremely premature infants is **soft and fragile**, making it highly susceptible to injury from the suction forces of a vacuum extractor. - Vacuum extraction in such cases significantly increases the risk of **intracranial hemorrhage** and other serious fetal trauma.

Question 1

All of the following are treatments for deep transverse arrest except:

Accepted Answer

Craniotomy

Answer

Cesarean section

Answer

Manual rotation with outlet forceps

Answer

Ventouse

Question 2

Comprehensive emergency obstetric care does not include:

Accepted Answer

Routine antenatal care

Answer

Manual removal of placenta

Answer

Cesarean section

Answer

Hysterectomy

Question 3

A 37-year-old G2P1 woman at 38 weeks' gestation presents to the obstetrics clinic for a prenatal visit. The patient had difficulty becoming pregnant but was successful after using in vitro fertilization. She has a history of recurrent herpes outbreaks and is currently experiencing genital pain and tingling. Her first pregnancy was complicated by failure to progress, which resulted in a cesarean birth. Routine rectovaginal culture at 36 weeks was positive for Group B streptococci. Which of the following would be an absolute indication for delivering the child by LSCS (Lower Segment Cesarean Section):

Accepted Answer

Current symptoms of genital pain and tingling

Answer

History of previous cesarean section

Answer

Maternal colonization with Group B streptococci

Answer

In vitro fertilization

Question 4

Internationally accepted definition of abortion is the expulsion of the products of conception:

Accepted Answer

Before 20th week of gestation or 500 gms (weight of foetus)

Answer

Before 28th week of gestation or 1 kg (weight of foetus)

Answer

Before 24th week of gestation or 750 gms (weight of foetus)

Answer

Before 20th week of gestation or 750 gms (weight of foetus)

Question 5

An absolute indication for Classical cesarean section is :

Accepted Answer

Carcinoma cervix

Answer

Central Placenta Previa

Answer

Breech presentation

Answer

Multi-fibroid uterus

Question 6

In deep transverse arrest with adequate pelvis, what is the best mode of delivery?

Accepted Answer

Kielland forceps

Answer

Cesarean section

Answer

Ventouse

Answer

Manual rotation followed by forceps

Question 7

Burns-Marshall technique is used to deliver the:

Accepted Answer

After-coming head

Answer

Leg

Answer

Placenta

Answer

Head

Question 8

Subpubic angle in gynecoid pelvis is?

Accepted Answer

100o

Answer

80o

Answer

120o

Answer

75o

Question 9

In modern obstetrics, the internal podalic version is indicated in presence of:

Accepted Answer

Transverse lie of 2nd twin baby

Answer

Extended breech presentation

Answer

Transverse lie with obstructed labor

Answer

Cord prolapse with live baby

Question 10

All of the following are relative contraindications for vacuum extraction, EXCEPT:

Accepted Answer

Occipito-posterior position

Answer

Fetal coagulopathies

Answer

Face presentation

Answer

Extreme prematurity

Labor and Delivery — MCQs

Labor and Delivery — MCQs

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