Cesarean Section Techniques — MCQs
Best predictor of successful vaginal birth after cesarean (VBAC)?
Which of these is the ONLY true statement regarding Caesarean section?
Which is not an indication for a classical cesarean incision?
Which of the following steps has proven benefit in decreasing puerperal infection following cesarean section?
How do you manage placenta accreta?
An absolute indication for Classical cesarean section is :
Absolute indication for cesarean section is :
A pregnant patient, with a history of classical cesarean section in view of fetal growth retardation in the previous pregnancy, presents to you. She is currently at 35 weeks of gestation with breech presentation. What is the next step in management?
Which of these types of fibroid may be removed at the time of a cesarean section?
Patient came with H/O prolonged labour (15 hrs) in emergency. On examination there were signs of obstructed labour. Ideal position for the patient to undergo the cesarean section?
Cesarean Section Techniques Indian Medical PG Practice Questions and MCQs
Question 1: Best predictor of successful vaginal birth after cesarean (VBAC)?
- A. Previous vaginal delivery (Correct Answer)
- B. BMI <30
- C. Spontaneous labor
- D. Inter-pregnancy interval >24 months
Explanation: ***Previous vaginal delivery*** - A history of prior **vaginal delivery**, especially a prior successful **vaginal birth after cesarean (VBAC)**, is the strongest predictor of successful VBAC. - This indicates a proven capacity for the **pelvis** and **uterus** to accommodate a vaginal birth. *BMI <30* - While a **lower BMI** is associated with higher VBAC success rates, it is not the strongest predictor compared to obstetrical history. - **Maternal obesity** (BMI $\ge$ 30) is considered a risk factor for VBAC failure, but a BMI below 30 alone does not guarantee success. *Spontaneous labor* - The onset of **spontaneous labor** increases the likelihood of a successful VBAC compared to induced labor, but prior vaginal delivery carries greater predictive weight. - Absence of spontaneous labor does not contraindicate VBAC, as **induction** can still be successful in many cases. *Inter-pregnancy interval >24 months* - An **inter-pregnancy interval** of greater than 18-24 months is associated with a lower risk of **uterine rupture** and slightly improved VBAC success rates. - However, it is a less significant predictor of overall success than a history of prior vaginal delivery.
Question 2: Which of these is the ONLY true statement regarding Caesarean section?
- A. Exteriorisation of uterus for repair of uterine incision is detrimental step and hence avoided
- B. Lower segment caesarean has lower risk of scar dehiscence in next pregnancy compared to classical (Correct Answer)
- C. Two layer closure of uterine incision is associated with significantly less risk of scar rupture
- D. All incidental uterine fibroids should be excised during LSCS
Explanation: ***Lower segment caesarean has lower risk of scar dehiscence in next pregnancy compared to classical*** - The **lower uterine segment** is thinner and has less muscular tissue, which heals with a stronger and more pliable scar, reducing the risk of **scar dehiscence** in subsequent pregnancies. - A **classical C-section** involves a vertical incision in the active muscular upper uterine segment, which heals with a weaker scar and carries a significantly higher risk of **uterine rupture** in future pregnancies. *Exteriorisation of uterus for repair of uterine incision is detrimental step and hence avoided* - **Uterine exteriorization** (bringing the uterus out of the abdomen) during C-section for repair is a common practice and is generally considered safe, offering better visualization and easier repair of the **uterine incision**. - While some studies suggest it might lead to more pain or blood loss, the benefits for **hemostasis** and repair quality often outweigh the potential risks, and it is not universally avoided as a detrimental step. *Two layer closure of uterine incision is associated with significantly less risk of scar rupture* - Current evidence suggests that **single-layer closure** of the uterine incision in a **lower segment C-section** is as safe as two-layer closure regarding scar rupture in future pregnancies. - There is no significant difference in the rates of **scar rupture** or other maternal outcomes between one-layer and two-layer closures for the lower uterine segment incision. *All incidental uterine fibroids should be excised during LSCS* - Excision of incidental **uterine fibroids** found during a C-section is generally discouraged due to the significant risk of **heavy bleeding** (**postpartum hemorrhage**) in the highly vascular pregnant uterus. - Myomectomy at the time of C-section is usually reserved for specific situations where the fibroid is obstructing the birth canal or causing significant bleeding, and the patient has consented to the increased risks.
Question 3: Which is not an indication for a classical cesarean incision?
- A. Premature breech
- B. Cannot visualize the lower uterine segment
- C. Transverse lie
- D. Term breech (frank) (Correct Answer)
Explanation: ***Term breech (frank)*** - A **frank breech** presentation at term does not inherently require a classical (vertical) incision, as a **low transverse incision** is generally safe and preferred for its lower risk of uterine rupture in subsequent pregnancies. - The decision for incision type is based more on the accessibility of the **lower uterine segment** and fetal lie than on the specific type of breech at term. *Premature breech* - In a premature fetus, the **lower uterine segment** may be underdeveloped and insufficient to allow safe extraction through a low transverse incision. - A **classical incision** provides a larger opening in the thicker, upper uterine segment, which is safer for a fragile preterm infant. *Cannot visualize the lower uterine segment* - Conditions like **dense adhesions** from prior surgeries, a large **leiomyoma**, or an **anterior placenta previa** can obscure or make the lower uterine segment inaccessible. - In such cases, a **classical incision** in the more visible and accessible upper uterine corpus is indicated to safely deliver the fetus. *Transverse lie* - A **transverse lie** means the fetus is lying horizontally across the uterus, often making a **low transverse incision** difficult or impossible due to the fetal position. - A **classical incision** allows for a larger, more vertical opening that accommodates the fetal spine and shoulders, facilitating safe extraction.
Question 4: Which of the following steps has proven benefit in decreasing puerperal infection following cesarean section?
- A. Administration of single dose of ampicillin or 1st generation cephalosporin at the time of cesarean (Correct Answer)
- B. Non closure of peritoneum
- C. Single layer uterine closure
- D. Skin closure with staples than with suture
Explanation: ***Administration of single dose of ampicillin or 1st generation cephalosporin at the time of cesarean*** - Prophylactic **antibiotics** administered prior to skin incision significantly reduce the risk of **puerperal infection** (e.g., endometritis, wound infection) following cesarean section. - The timing of administration (within 60 minutes of skin incision) is crucial for optimal effectiveness, typically using a **first-generation cephalosporin** or **ampicillin** for broad-spectrum coverage. *Non closure of peritoneum* - Studies have shown that **non-closure of the visceral and parietal peritoneum** during cesarean section has no significant impact on the rate of puerperal infection. - While it may shorten operative time and reduce pain, it does not offer a demonstrable benefit in reducing postoperative infections. *Single layer uterine closure* - **Single-layer uterine closure** has been found to be comparable to double-layer closure in terms of postoperative infection rates and uterine healing. - There is no strong evidence to suggest that single-layer closure specifically decreases the incidence of puerperal infection more effectively than double-layer closure. *Skin closure with staples than with suture* - The choice between **staples and sutures** for skin closure after cesarean section does not show a consistent difference in the incidence of **wound infection**. - While staples may be faster and might reduce suture-related complications, they do not inherently decrease the overall risk of puerperal infection compared to traditional suturing.
Question 5: How do you manage placenta accreta?
- A. Classical cesarean; hysterectomy (Correct Answer)
- B. Low vertical cesarean; hysterectomy
- C. Low transverse cesarean; hysterectomy
- D. Classical cesarean; myometrial resection
Explanation: ***Classical cesarean; hysterectomy*** - A **classical cesarean section** (vertical incision in the upper uterine segment) allows for delivery of the fetus without disturbing the **placenta accreta** in the lower uterine segment. - Subsequent **hysterectomy** is often necessary due to the high risk of severe hemorrhage from the morbidly adherent placenta, which cannot be safely separated. *Low vertical cesarean; hysterectomy* - A **low vertical incision** is made in the lower uterine segment, which could potentially incise through the placenta accreta if it extends to that region, leading to significant hemorrhage. - While hysterectomy is likely indicated, the initial uterine incision might complicate management. *Low transverse cesarean; hysterectomy* - A **low transverse incision** is the most common type for routine cesarean sections but is contra-indicated in placenta accreta as the placenta is frequently implanted in the lower uterine segment. - Incising through the **placenta** during a low transverse cut would cause immediate massive hemorrhage, making this approach unsuitable. *Classical cesarean; myometrial resection* - While a **classical cesarean** would be the appropriate initial step for fetal delivery, **myometrial resection** to remove only the affected area of the myometrium is generally insufficient and carries a high risk of residual placental tissue and severe hemorrhage, often necessitating a hysterectomy anyway. - This approach is typically not recommended as a primary definitive management strategy for established placenta accreta.
Question 6: An absolute indication for Classical cesarean section is :
- A. Central Placenta Previa
- B. Breech presentation
- C. Carcinoma cervix (Correct Answer)
- D. Multi-fibroid uterus
Explanation: ***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).
Question 7: Absolute indication for cesarean section is :
- A. Breech presentation
- B. Dystocia
- C. Fetal distress
- D. Previous rupture of uterus (Correct Answer)
Explanation: ***Previous rupture of uterus*** - A prior **rupture of the uterus** creates a significant risk of **re-rupture** in subsequent pregnancies with labor contractions, posing a severe threat to both maternal and fetal life. - Due to the high risk of catastrophic hemorrhage and fetal distress, **elective cesarean section** before the onset of labor is mandated to prevent recurrence. *Breech presentation* - While many breech presentations result in a cesarean section, it is not an absolute indication, as **vaginal breech delivery** can be attempted in selected cases under strict criteria. - Factors like type of breech, estimated fetal weight, and maternal pelvis can influence the decision, making it a relative rather than an absolute indication. *Dystocia* - **Dystocia**, or difficult labor, is a common reason for cesarean section, but often interventions like **oxytocin augmentation** or **instrumental delivery** (forceps, vacuum) are attempted first. - A cesarean section is indicated when dystocia is severe or fails to respond to other measures, making it a relative indication based on progression of labor. *Fetal distress* - **Fetal distress**, indicated by non-reassuring fetal heart rate patterns, often necessitates prompt delivery, but the mode of delivery depends on the clinical situation. - If vaginal delivery is imminent and safe, it may be preferred, but if not, **cesarean section** is performed; therefore, it's an urgent relative indication rather than an absolute one.
Question 8: A pregnant patient, with a history of classical cesarean section in view of fetal growth retardation in the previous pregnancy, presents to you. She is currently at 35 weeks of gestation with breech presentation. What is the next step in management?
- A. Cesarean section at 37 weeks (Correct Answer)
- B. Advice USG and visit after 2 weeks
- C. Internal podalic version followed by vaginal delivery
- D. External cephalic version at 36 weeks
Explanation: ***Cesarean section at 37 weeks*** - A history of **classical cesarean section** is an absolute contraindication to vaginal birth due to the high risk of **uterine rupture**. - Performing the cesarean section at 37 weeks, rather than waiting longer, minimizes the risk of spontaneous labor and rupture while ensuring fetal maturity. *Advice USG and visit after 2 weeks* - This option does not address the critical risk of **uterine rupture** due to the previous classical cesarean section. - Delaying definitive management by two weeks could increase the risk of spontaneous labor and associated complications. *Internal podalic version followed by vaginal delivery* - An **internal podalic version** is a procedure used to change fetal lie during labor, typically for the second twin, and it is **contraindicated** with a previous classical cesarean due to rupture risk. - Given the previous classical incision, a **vaginal delivery is unsafe** and should not be attempted. *External cephalic version at 36 weeks* - **External cephalic version (ECV)** is generally contraindicated in patients with a history of a **classical cesarean section** due to the increased risk of uterine rupture. - Even if successful, the patient would still require a cesarean section for delivery given the previous uterine scar.
Question 9: Which of these types of fibroid may be removed at the time of a cesarean section?
- A. Pedunculated fibroid (Correct Answer)
- B. Broad ligament fibroid
- C. Cervical fibroid
- D. Intramural
Explanation: ***Pedunculated fibroid*** - **Pedunculated subserosal fibroids** are the safest type to remove during cesarean section, particularly those on a **narrow stalk** - They can be easily accessed through the abdominal incision without disrupting the uterine wall integrity - The stalk can be **clamped, ligated, and divided** with minimal risk of hemorrhage if proper hemostatic technique is used - Removal does not compromise the **hysterotomy closure** or future uterine integrity - This is the **only type of fibroid** routinely considered safe for removal during C-section if clinically indicated *Intramural fibroid* - **Intramural fibroids** are embedded within the myometrial wall and their removal is **generally contraindicated** during cesarean section - Myomectomy during C-section carries significant risk of **severe hemorrhage** from the highly vascular pregnant uterus - Removal can compromise **uterine wall integrity** and interfere with proper hysterotomy closure - May increase risk of **uterine rupture** in subsequent pregnancies - Standard obstetric practice is to **avoid myomectomy at cesarean** unless the fibroid is directly obstructing delivery *Broad ligament fibroid* - **Broad ligament fibroids** are located between the layers of the broad ligament, often in close proximity to the **ureter** and **uterine vessels** - Removal carries extremely high risk of **ureteral injury** and **massive hemorrhage** from pedicle vessels - Their excision is **absolutely contraindicated** during cesarean section *Cervical fibroid* - **Cervical fibroids** are located in the cervix with its **rich vascular supply** from cervical branches of uterine arteries - Removal during C-section risks **uncontrollable hemorrhage** and can cause **cervical incompetence** - Excision is **contraindicated** during cesarean section and should be managed separately if needed
Question 10: Patient came with H/O prolonged labour (15 hrs) in emergency. On examination there were signs of obstructed labour. Ideal position for the patient to undergo the cesarean section?
- A. Supine with wedge under right hip. (Correct Answer)
- B. Semi-Fowler position
- C. Prone position with legs in stirrup
- D. Trendelenburg with legs in stirrup
Explanation: ***Supine with wedge under right hip*** - This position prevents **aortocaval compression** by the gravid uterus, which can lead to **supine hypotensive syndrome** and compromise placental perfusion. - The **left lateral tilt** achieved by the wedge under the right hip optimizes maternal hemodynamics and fetal oxygenation during C-section. *Trendelenburg with legs in stirrup* - This position is primarily used for procedures requiring better visualization of the **pelvic organs**, like gynecological surgeries or to facilitate venous return. - It would not prevent aortocaval compression and could exacerbate respiratory challenges in a pregnant patient. *Semi-Fowler position* - The semi-Fowler position is typically used for patients with **respiratory distress** to aid ventilation or during certain upper abdominal surgeries to improve surgical access. - It does not address the critical issue of aortocaval compression in a pregnant patient undergoing C-section. *Prone position with legs in stirrup* - The prone position is used for **posterior surgical approaches** to the spine or for procedures on the buttocks/perineum. - It is entirely inappropriate for a C-section, as it would make surgical access to the uterus impossible and pose significant risks to both mother and fetus.
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