Operative Obstetrics Practice Questions

Q: What is the name of the procedure used to resolve head entrapment?

Duhrssen's incisions. **Explanation:** **Duhrssen’s Incisions** are surgical incisions made in the cervix at the 2, 6, and 10 o'clock positions to facilitate the delivery of the **entrapped aftercoming head** of a breech fetus or a trapped head in a cephalic presentation when the cervix is not fully dilated. This procedure is typically a last resort when the cervix is thin and effaced but not sufficiently dilated to allow the head to pass, posing an immediate risk of fetal asphyxia. **Analysis of Incorrect Options:** * **Symphysiotomy (Option A):** This involves the surgical division of the pubic symphysis to increase the pelvic diameters. It is used for obstructed labor or severe shoulder dystocia, not specifically for cervical entrapment of the head. * **Pinard Maneuver (Option B):** This is a maneuver used in breech extraction to bring down the fetal legs in a frank breech presentation by applying pressure to the popliteal fossa. * **Zavanelli Maneuver (Option C):** This involves cephalic replacement (pushing the fetal head back into the uterus) followed by an emergency Cesarean section. It is the definitive management for catastrophic **shoulder dystocia**, not head entrapment by the cervix. **High-Yield Clinical Pearls for NEET-PG:** * **Location:** Incisions are made at **2, 6, and 10 o'clock** to avoid the uterine arteries (located at 3 and 9 o'clock). * **Prerequisite:** The cervix must be fully effaced. * **Complication:** The most significant risk is maternal hemorrhage or extension of the incision into the lower uterine segment. * **Modern Practice:** Due to the availability of Cesarean sections, Duhrssen’s incisions are rarely performed today but remain a critical "rescue" procedure in resource-limited settings or sudden breech entrapment.

Q: Which of the following is an advantage of cesarean delivery over vaginal delivery?

Decreased risk of hemorrhage. **Explanation:** The correct answer is **A. Decreased risk of hemorrhage.** While it may seem counterintuitive because Cesarean Section (CS) is a major surgery, large-scale epidemiological studies (such as those by Liu et al.) have shown that elective or planned cesarean deliveries are associated with a lower risk of **postpartum hemorrhage (PPH)** compared to planned vaginal deliveries. This is primarily because CS allows for controlled delivery and immediate, direct administration of uterotonics. In contrast, vaginal deliveries carry risks of unpredictable complications such as high-grade perineal tears, cervical lacerations, and prolonged third-stage labor, which are significant contributors to hemorrhage. **Analysis of Incorrect Options:** * **B. Decreased risk of hysterectomy:** CS actually **increases** the risk of emergency peripartum hysterectomy, often due to surgical complications or abnormal placentation (Placenta Accreta Spectrum) in subsequent pregnancies. * **C. Decreased rehospitalization rate:** Women undergoing CS have **higher** rates of rehospitalization due to wound infections, endomyometritis, and surgical site complications compared to those who deliver vaginally. * **D. Decreased risk of thromboembolism:** CS is a well-established major risk factor for **Venous Thromboembolism (VTE)**. The Virchow’s triad (stasis, hypercoagulability, and endothelial injury) is more pronounced post-surgery. **NEET-PG High-Yield Pearls:** * **Most common indication for CS (Worldwide):** Previous Cesarean Section. * **Most common indication for Primary CS:** Dystocia (Failure to progress). * **WHO Recommendation:** The ideal rate for cesarean sections is considered to be **10-15%**. * **Vaginal Birth After Cesarean (VBAC):** The success rate is approximately 60-80% in carefully selected cases.

Q: All of the following are known side effects with the use of tocolytic therapy except:

Fever. **Explanation:** Tocolytics are drugs used to suppress uterine contractions to delay preterm labor. The correct answer is **Fever**, as it is not a side effect of any standard tocolytic agent. Fever in a patient with preterm labor is more likely an indicator of **chorioamnionitis**, which is actually a contraindication to tocolytic therapy. **Analysis of Options:** * **Tachycardia (Option A):** This is a classic side effect of **Beta-mimetics** (e.g., Ritodrine, Terbutaline) due to cross-reactivity with $\beta_1$ receptors in the heart. It can also occur with **Nifedipine** (Calcium Channel Blocker) as reflex tachycardia due to peripheral vasodilation. * **Hypotension (Option B):** This is primarily associated with **Nifedipine** and **Magnesium Sulfate** ($MgSO_4$). Nifedipine causes systemic vasodilation, while $MgSO_4$ can cause hypotension through smooth muscle relaxation and potential toxicity. * **Hyperglycemia (Option C):** This is a specific metabolic side effect of **Beta-mimetics**. Stimulation of $\beta_2$ receptors in the liver promotes glycogenolysis, leading to increased blood glucose levels. This makes Beta-mimetics contraindicated in diabetic pregnant women. **High-Yield Clinical Pearls for NEET-PG:** * **Drug of Choice (DOC):** **Nifedipine** is currently the first-line tocolytic due to its oral efficacy and better safety profile. * **Atosiban:** An Oxytocin receptor antagonist; it has the fewest side effects but is expensive. * **Indomethacin:** A PG-synthetase inhibitor; used before 32 weeks. After 32 weeks, it carries a high risk of **premature closure of the Ductus Arteriosus** and oligohydramnios. * **Pulmonary Edema:** A dangerous complication shared by Beta-mimetics and $MgSO_4$, especially when used with aggressive IV fluids.

Q: During application of the cup in Ventouse, the 'knob' of the cup points towards which anatomical landmark?

Occiput. **Explanation:** The **Ventouse (Vacuum Extractor)** is an instrument used for assisted vaginal delivery. The "knob" or "pointer" on the vacuum cup is a critical safety feature designed to assist the clinician in orientation and correct placement. **Why Occiput is correct:** The goal of vacuum application is to place the center of the cup over the **flexion point**. This point is located on the sagittal suture, approximately **3 cm anterior to the posterior fontanelle** and 6 cm posterior to the anterior fontanelle. When the cup is correctly positioned, the **knob points toward the leading point of the fetal head, which is the Occiput**. This ensures that traction promotes flexion of the head, minimizing the presenting diameter (suboccipitobregmatic) and facilitating easier passage through the birth canal. **Why other options are incorrect:** * **Brow and Chin:** If the knob points toward the brow or chin, the cup is likely placed too far anteriorly. This causes **deflexion** of the fetal head, increasing the presenting diameter and the risk of failure or trauma. * **Neck:** The neck is not a landmark for cup orientation; the cup must remain on the bony cranium to be effective and safe. **High-Yield Clinical Pearls for NEET-PG:** * **Flexion Point:** 3 cm anterior to the posterior fontanelle. * **Pressure:** Should not exceed **0.8 kg/cm²** (600 mmHg). * **Rule of 3s:** Abandon the procedure if there are 3 "pop-offs," 3 pulls with no progress, or if the procedure exceeds 30 minutes. * **Contraindication:** Vacuum is contraindicated in **preterm births (<34 weeks)** due to the risk of intraventricular hemorrhage.

Q: In twin pregnancy, delivery by cesarean section is advocated in all the following conditions except:

Second twin in transverse lie position. In twin pregnancies, the mode of delivery is primarily determined by the presentation of the **first twin (Twin A)** and the gestational age/weight. **Explanation of the Correct Answer:** **Option A (Second twin in transverse lie)** is the correct answer because it is **not** an absolute indication for Cesarean Section (CS). If Twin A is in a longitudinal lie (cephalic), vaginal delivery can proceed. Once Twin A is delivered, the transverse lie of Twin B can often be corrected via **internal podalic version** followed by breech extraction or **external cephalic version** to a longitudinal lie. **Analysis of Incorrect Options (Indications for CS):** * **B. First twin in transverse lie:** If the presenting twin is transverse or oblique, vaginal delivery is impossible and carries a high risk of cord prolapse. CS is mandatory. * **C. Monoamniotic twins:** These carry a high risk of **cord entanglement** and fetal demise during labor. Elective CS at 32–34 weeks is the standard of care to prevent intrapartum complications. * **D. Weight less than 1500 gm:** Very low birth weight (VLBW) twins, especially those <32 weeks, are highly susceptible to intracranial hemorrhage and birth trauma during vaginal delivery. Most protocols advocate for CS to protect the fragile after-coming head of the second twin. **High-Yield Clinical Pearls for NEET-PG:** 1. **Cephalic-Cephalic (40%):** Vaginal delivery is the preferred route. 2. **Cephalic-Non-cephalic (40%):** Vaginal delivery is acceptable (with internal version for Twin B), though CS is often performed based on clinician expertise. 3. **Non-cephalic Twin A:** Always requires a Cesarean Section. 4. **Locked Twins:** Occurs when Twin A is breech and Twin B is cephalic; the chins lock, preventing descent. This is a surgical emergency.

Question 1

What is the name of the procedure used to resolve head entrapment?

Accepted Answer

Duhrssen's incisions

Answer

Symphysiotomy

Answer

Pinard maneuver

Answer

Zavanelli maneuver

Question 2

Which of the following is an advantage of cesarean delivery over vaginal delivery?

Accepted Answer

Decreased risk of hemorrhage

Answer

Decreased risk of hysterectomy

Answer

Decreased rehospitalization rate

Answer

Decreased risk of thromboembolism

Question 3

What is the most common site of obstetric injury leading to uretero-vaginal fistula?

Accepted Answer

Infundibulopelvic ligament

Answer

Vaginal vault

Answer

Distal to uterine artery near vaginal vault

Answer

Below cardinal ligament where uterine artery crosses

Question 4

A primigravida with a full-term pregnancy has been in labor for 1 day. She presents to the emergency department after a difficult delivery. On examination, she is dehydrated, slightly pale, with a pulse of 100/min, and BP 120/80 mm Hg. Abdominal examination reveals a fundal height of 36 weeks, cephalic presentation, absent fetal heart sounds, and mild uterine contractions. On per vaginal examination, the cervix is fully dilated, the head is at +1 station, with caput and molding present. The pelvis is adequate. There is foul-smelling, infected discharge. What is the best management option after initial work-up?

Accepted Answer

Ventouse delivery

Answer

Cesarean section

Answer

Oxytocin drip

Answer

Craniotomy and vaginal delivery

Question 5

All of the following are known side effects with the use of tocolytic therapy except:

Accepted Answer

Fever

Answer

Tachycardia

Answer

Hypotension

Answer

Hyperglycemia

Question 6

Which of the following is an indication for Cesarean section after a previous Cesarean section?

Accepted Answer

Cephalopelvic disproportion (CPD)

Answer

Hypertension

Answer

Type 1 placenta previa

Answer

Multigravida

Question 7

During application of the cup in Ventouse, the 'knob' of the cup points towards which anatomical landmark?

Accepted Answer

Occiput

Answer

Brow

Answer

Chin

Answer

Neck

Question 8

In which of the following conditions is external cephalic version (ECV) contraindicated?

Accepted Answer

Pregnancy-induced hypertension (PIH)

Answer

Anemia

Answer

Primigravida

Answer

Flexed breech

Question 9

All of the following statements are true regarding comparison between vacuum delivery and forceps delivery, EXCEPT:

Accepted Answer

Intracranial pressure rises during traction.

Answer

Retinal hemorrhage, intracranial hemorrhage, and subgaleal hemorrhage are more common in ventouse delivery than forceps.

Answer

Cephalohematoma is more common with vacuum extraction.

Answer

Less maternal trauma by vacuum as compared with forceps.

Question 10

In twin pregnancy, delivery by cesarean section is advocated in all the following conditions except:

Accepted Answer

Second twin in transverse lie position

Answer

First twin in transverse lie position

Answer

Monoamniotic twins

Answer

Weight less than 1500 gm

Operative Obstetrics — MCQs

Operative Obstetrics — MCQs

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