Episiotomy and Repair — MCQs
All are complications of vacuum-assisted delivery over forceps delivery except:
What is the maneuver performed by the obstetrician to sharply flex the legs towards the abdomen when suspecting shoulder dystocia after the delivery of the head during a delivery?
What maneuver is used to deliver the head of a baby during a breech delivery?
Episiotomy incision was extended posteriorly beyond perineal body injuring the structure immediately posterior to it. Which structure has been injured?
In which obstetric condition is assisted head delivery typically performed?
Moschcowitz repair is done for:
Least common complication in outlet forceps is:
Polyglactin 910 suture material ("Vicryl") is a / an
A 30-year-old female, G2L2, with a history of cervical elongation presents for surgical consultation. What is the surgery of choice?
Which of the following statements are correct regarding audit in Obstetrics and Gynaecology? I. It can replace the out of date clinical practices with better ones. II. It is an efficient educational tool. III. It should be based on scientific evidences with facts and figures. IV. It is not labour-intensive. Select the answer using the code given below :
Episiotomy and Repair Indian Medical PG Practice Questions and MCQs
Question 1: All are complications of vacuum-assisted delivery over forceps delivery except:
- A. Subgaleal hematoma
- B. Intracranial hemorrhage
- C. Cephalohematoma
- D. Transient lateral rectus palsy (Correct Answer)
Explanation: ***Transient lateral rectus palsy*** - **Transient sixth nerve palsy** (lateral rectus palsy) in a neonate is **more commonly associated with forceps delivery**, not vacuum-assisted delivery. - This occurs due to **direct compression of the fetal head** during forceps application, particularly compression of the sixth cranial nerve [4]. - It is **NOT a typical complication of vacuum-assisted delivery over forceps delivery**, making it the correct answer to this EXCEPT question. *Subgaleal hematoma* - This is a **serious and specific complication of vacuum-assisted delivery**, occurring when blood collects in the space between the **galeal aponeurosis** and the **periosteum** [1]. - It is **more common with vacuum extraction than forceps delivery**. - Can lead to significant **blood loss** and **hypovolemic shock** in the neonate. *Intracranial hemorrhage* - **Vacuum extraction is associated with higher rates** of intracranial hemorrhage compared to forceps delivery [1]. - The suction and traction forces can lead to **subdural hemorrhage**, **subarachnoid hemorrhage**, and other intracranial bleeding [2]. - Studies show increased risk with vacuum compared to forceps delivery. *Cephalohematoma* - A **cephalohematoma** (blood collection between **periosteum** and skull bone) is a **classic and common complication of vacuum-assisted delivery** [3]. - It is **more frequent with vacuum extraction than forceps delivery** due to the suction cup causing subperiosteal bleeding. - Resolves spontaneously over weeks to months.
Question 2: What is the maneuver performed by the obstetrician to sharply flex the legs towards the abdomen when suspecting shoulder dystocia after the delivery of the head during a delivery?
- A. Rubin's maneuver
- B. Wood Corkscrew maneuver
- C. Zavanelli's maneuver
- D. McRoberts maneuver (Correct Answer)
Explanation: ***McRoberts maneuver*** - This maneuver involves sharply flexing the maternal thighs against the abdomen, which **flattens the sacrum** and rotates the symphysis pubis anteriorly. - This **increases the functional diameter** of the pelvic outlet and often helps dislodge the anterior shoulder in cases of shoulder dystocia. *Rubin's maneuver* - This maneuver involves reaching into the vagina and **rotating the anterior shoulder** to an oblique position or pushing the posterior shoulder anteriorly. - It is used when the McRoberts maneuver fails and aims to **reduce the bisacromial diameter**. *Wood Corkscrew maneuver* - This maneuver involves reaching into the vagina and **rotating the posterior shoulder** 180 degrees in a corkscrew fashion. - It works by sequentially engaging and disengaging shoulders, effectively **"walking" the baby out**. *Zavanelli's maneuver* - This is a **last-resort maneuver** used when other attempts to resolve shoulder dystocia have failed and involves replacing the fetal head back into the birth canal. - It is performed to then proceed with an **emergency cesarean section**.
Question 3: What maneuver is used to deliver the head of a baby during a breech delivery?
- A. Pinards maneuver
- B. Prague maneuver (Correct Answer)
- C. Lovsets maneuver
- D. Burn Marshall method
Explanation: ***Prague maneuver*** - The **Prague maneuver** is used to deliver the aftercoming fetal head in breech delivery when specific traction on the shoulders is needed. - **Prague I (or Prague-Veit)**: Used when the fetal **back is anterior** - the operator's fingers hook over the shoulders while traction is applied. - **Prague II**: Used when the fetal **back is posterior** - less commonly performed. - This maneuver involves supporting the fetal body while applying traction to the shoulders to facilitate head delivery. *Pinard's maneuver* - **Pinard's maneuver** is used to assist with the delivery of the fetal **legs** in a **frank or complete breech** presentation, not the head. - This maneuver involves flexing the hip and knee to bring down a foot, aiding in the delivery of the lower extremities. *Lovset's maneuver* - **Lovset's maneuver** is used during a breech delivery to assist with the delivery of the **shoulders by rotating the fetal trunk**. - It involves rotating the baby's trunk 180 degrees to bring the posterior shoulder anterior under the pubic symphysis, allowing for easier delivery of both arms and shoulders. *Burns-Marshall method* - The **Burns-Marshall method** is another technique used to deliver the aftercoming head in breech delivery. - It involves allowing the fetal body to hang by its own weight until the **nape of the neck and hairline appear** at the vulva, then lifting the body in an arc towards the mother's abdomen to deliver the head by flexion. - While this is also used for head delivery, the **Prague maneuver** involves more direct manual traction and is the answer expected for this examination context.
Question 4: Episiotomy incision was extended posteriorly beyond perineal body injuring the structure immediately posterior to it. Which structure has been injured?
- A. External anal sphincter (Correct Answer)
- B. Ischiocavernosus
- C. Urethral sphincter
- D. Bulbospongiosus
Explanation: ***External anal sphincter*** - An overextended **episiotomy incision** that goes beyond the perineal body posteriorly will likely injure the **external anal sphincter**, which is immediately posterior to the perineal body [4]. - Injury to this sphincter can lead to **fecal incontinence** [1]. *Ischiocavernosus* - The **ischiocavernosus muscle** is located more laterally in the perineum and plays a role in clitoral erection, not directly posterior to the perineal body. - An episiotomy extending posteriorly would not typically involve this muscle. *Urethral sphincter* - The **urethral sphincter** is located anterior to the perineal body and surrounds the urethra [3]. - Injury to this sphincter is associated with anterior perineal trauma, not posterior extension of an episiotomy [3]. *Bulbospongiosus* - The **bulbospongiosus muscle** is a superficial perineal muscle that surrounds the vaginal orifice and contributes to the perineal body [4]. - While it can be involved in an episiotomy, the structure immediately posterior to the perineal body itself is the external anal sphincter [2].
Question 5: In which obstetric condition is assisted head delivery typically performed?
- A. Shoulder dystocia
- B. Breech presentation (Correct Answer)
- C. Transverse lie
- D. Normal delivery
Explanation: ***Breech presentation*** - In a **breech presentation**, the baby's buttocks or feet are delivered first, necessitating assisted head delivery to prevent **head entrapment** in the maternal pelvis, which can lead to fetal hypoxia or trauma. - Techniques like the **Mauriceau-Smellie-Veit maneuver** are employed to carefully deliver the fetal head after the body. *Shoulder dystocia* - This condition involves the impaction of the fetal shoulder against the maternal symphysis pubis after the head has been delivered. - The focus of management is on delivering the shoulders, not the head, through maneuvers such as the **McRoberts maneuver** or **suprapubic pressure**. *Transverse lie* - A **transverse lie** means the baby is positioned horizontally across the uterus, preventing vaginal delivery without intervention (e.g., external cephalic version or C-section). - This position requires repositioning or surgical delivery of the entire fetus, and assisted head delivery is not the primary concern. *Normal delivery* - In a **normal (vertex) delivery**, the fetal head presents first and typically delivers spontaneously with minimal assistance. - The head usually flexes and rotates to navigate the birth canal on its own, so specific assisted head delivery techniques are not typically required.
Question 6: Moschcowitz repair is done for:
- A. Vault prolapse
- B. Adenomyosis
- C. Enterocele (Correct Answer)
- D. Chronic inversion of uterus
Explanation: ***Enterocele*** - The **Moschcowitz repair** is a historical procedure designed to repair an **enterocele** by obliterating the cul-de-sac. - It involves placing a series of high **purse-string sutures** in the posterior cul-de-sac peritoneum to elevate it and prevent bowel herniation. *Vault prolapse* - Vault prolapse involves the **prolapse of the vaginal apex** after hysterectomy. - While it can coexist with an enterocele, the Moschcowitz repair specifically targets the **enterocele defect**, not the overall vault support. *Adenomyosis* - **Adenomyosis** is a condition where endometrial tissue grows into the muscular wall of the uterus. - It is managed medically or surgically via **hysterectomy**, and is unrelated to surgical repairs for pelvic organ prolapse. *Chronic inversion of uterus* - **Chronic uterine inversion** is a rare condition where the uterus turns inside out, typically following childbirth. - Management involves **manual or surgical repositioning of the uterus** and is unrelated to the Moschcowitz repair for enterocele.
Question 7: Least common complication in outlet forceps is:
- A. Complete perineal tear
- B. Extension of episiotomy
- C. Cervical tear
- D. Vulval hematoma (Correct Answer)
Explanation: ***Vulval hematoma*** - While possible, a **vulval hematoma** is generally considered a less frequent and often less severe complication specific to outlet forceps compared to tears of the reproductive tract. - Its incidence is lower than that of perineal or cervical tears, which are more directly associated with the mechanics of forceps delivery. *Complete perineal tear* - **Complete perineal tears** (third or fourth-degree) involving the anal sphincter are a significant risk associated with forceps delivery due to the increased tension and pressure on the perineum during extraction. - The instrument and the force applied can overtly stretch or rupture the perineal tissues. *Extension of episiotomy* - An **episiotomy**, often performed during forceps delivery to facilitate delivery and prevent irregular tears, can frequently extend into a more severe laceration, especially under forceful extraction. - The pre-existing incision makes the tissue more vulnerable to further tearing under stress. *Cervical tear* - **Cervical tears** can occur if the cervix is not fully dilated prior to the application and traction of forceps, or if the force applied is excessive. - Undiagnosed or unchecked cervical lacerations can lead to significant hemorrhage.
Question 8: Polyglactin 910 suture material ("Vicryl") is a / an
- A. Absorbable natural suture
- B. Non-absorbable synthetic suture
- C. Non-absorbable natural suture
- D. Absorbable synthetic suture (Correct Answer)
Explanation: ***Absorbable synthetic suture*** - **Polyglactin 910**, marketed as **Vicryl**, is a **synthetic copolymer** of glycolide and lactide that undergoes hydrolysis in the body. - This hydrolysis leads to its eventual reabsorption over 56-70 days, classifying it as an **absorbable** material. - Vicryl maintains tensile strength for approximately 21 days before being fully absorbed. *Absorbable natural suture* - Natural absorbable sutures, such as **catgut** (plain and chromic), are derived from animal tissues and are absorbed enzymatically within the body. - **Polyglactin 910** is **synthetic**, not natural, despite being absorbable. *Non-absorbable synthetic suture* - Non-absorbable synthetic sutures (e.g., **nylon**, **polypropylene**, **polyester**) retain their tensile strength and remain in the body indefinitely or require removal. - Vicryl is designed to be **absorbed** over time through hydrolysis, distinguishing it from non-absorbable types. *Non-absorbable natural suture* - Examples of non-absorbable natural sutures include **silk** and **cotton**, which are derived from natural sources and are not reabsorbed by the body. - Polyglactin 910 is both **synthetic** and **absorbable**, making this option incorrect.
Question 9: A 30-year-old female, G2L2, with a history of cervical elongation presents for surgical consultation. What is the surgery of choice?
- A. Fothergill (Correct Answer)
- B. McCall
- C. Lefort
- D. Hysterectomy
Explanation: **Fothergill** - The Fothergill operation, or **Manchester procedure**, is a surgical technique used for **cervical elongation** and **genital prolapse**, specifically involving suspension of the cardinal ligaments and cervical amputation. - This procedure addresses both the elongated cervix and associated pelvic organ prolapse without removing the uterus, making it suitable for women who wish to retain their uterus. *McCall* - The McCall culdoplasty is primarily performed to correct **vaginal vault prolapse** and is typically done during a hysterectomy or for post-hysterectomy prolapse. - It involves plicating the uterosacral ligaments to provide support to the vaginal vault; it does not directly address cervical elongation. *Lefort* - The Lefort colpocleisis is a **partial vaginal closure** procedure performed for severe pelvic organ prolapse in elderly women who are no longer sexually active. - This operation reduces symptoms of prolapse but closes off a significant portion of the vagina, making it unsuitable for sexually active patients or those desiring uterine preservation for fertility. *Hysterectomy* - A hysterectomy involves the **surgical removal of the uterus**, which would address cervical elongation by default as the cervix is part of the uterus. - However, for a 30-year-old female who may wish to retain reproductive function or avoid an extensive surgery if other options are available, hysterectomy is usually not the first-line choice for isolated cervical elongation.
Question 10: Which of the following statements are correct regarding audit in Obstetrics and Gynaecology? I. It can replace the out of date clinical practices with better ones. II. It is an efficient educational tool. III. It should be based on scientific evidences with facts and figures. IV. It is not labour-intensive. Select the answer using the code given below :
- A. I, II and IV
- B. I, II and III (Correct Answer)
- C. I, III and IV
- D. II, III and IV
Explanation: ***Correct: I, II and III*** - Statement I is correct: Clinical audit aims to improve **patient care** and **outcomes** by systematically reviewing care against explicit criteria, identifying areas for improvement, and implementing changes that **replace outdated practices** with evidence-based approaches. - Statement II is correct: Audit serves as a powerful **educational tool** by providing feedback to clinicians, highlighting best practices, and encouraging critical appraisal of current methods. - Statement III is correct: Effective audits must be based on **scientific evidence** with facts and figures to ensure validity, robustness, and clinical relevance. - Statement IV is **incorrect**: Clinical audit is **labour-intensive**, requiring significant time, resources, and coordination for data collection, analysis, meetings, implementation of changes, and follow-up assessments. *Incorrect: I, II and IV* - While statements I and II are correct, statement IV is incorrect because audit is generally **labour-intensive**, not the opposite. Effective audits involve substantial resource-demanding tasks. *Incorrect: I, III and IV* - While statements I and III are correct (audit replaces outdated practices with evidence-based approaches), statement IV is incorrect as thorough audits require **considerable effort and resources**. *Incorrect: II, III and IV* - While statements II and III are correct (audit as educational tool based on scientific evidence), statement IV is incorrect; audits often require **substantial time and effort** for all phases of the audit cycle.
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