Operative Obstetrics Practice Questions

Q: A 25-year-old primigravida is in labor. The second stage of labor has lasted for 1 hour after complete cervical dilatation. On examination, the leading point of the fetal skull is at +2 station, and rotation is 45 degrees. How should this case be managed?

Applying low forceps. This question tests the ability to classify forceps application based on the **American College of Obstetricians and Gynecologists (ACOG)** criteria, which is a high-yield topic for NEET-PG. ### **Explanation** The classification of forceps delivery is determined by the **station** and **rotation** of the fetal head: 1. **Why Option B is Correct:** According to ACOG, **Low Forceps** application is defined when the leading point of the fetal skull is at **station +2 or lower** (but not on the pelvic floor). In this case, the station is +2. Furthermore, low forceps are subdivided based on rotation: if rotation is ≤45°, it is a simple low forceps; if >45°, it is a rotation-requiring low forceps. Here, the rotation is exactly 45°, fitting the criteria perfectly. 2. **Why Option A is Incorrect:** **Outlet Forceps** require the fetal scalp to be visible at the introitus without separating the labia, the skull to have reached the pelvic floor, and the rotation to be ≤45°. A station of +2 is too high for an outlet application. 3. **Why Option C is Incorrect:** **Mid Forceps** are applied when the head is engaged but the leading point is above +2 station. These are rarely performed today due to high maternal and neonatal morbidity. 4. **Why Option D is Incorrect:** **High Forceps** (application before engagement) are obsolete and strictly contraindicated in modern obstetrics. ### **Clinical Pearls for NEET-PG** * **Station 0:** Head is at the level of the ischial spines (Engaged). * **Prerequisites for Forceps:** Remember the mnemonic **FORCEPS**: **F**etus alive, **O**pthalmic (membranes) ruptured, **R**ectum/Bladder empty, **C**ervix fully dilated, **E**ngaged head, **P**osition known, **S**ize (no CPD). * **Most common indication:** Prolonged second stage of labor (2 hours in primigravida without anesthesia). * **Most common complication:** Perineal tears (Maternal) and Facial nerve palsy (Neonatal).

Q: Which of the following is the most probable cause for the deceleration shown below?

Head Compression. ***Head Compression*** - **Early decelerations** show a characteristic **mirror-image pattern** with uterine contractions, caused by fetal head compression during contractions triggering a **vagal reflex**. - These decelerations are **gradual** in onset and recovery, considered **benign**, and do not indicate fetal compromise. *Cord Compression* - Causes **variable decelerations** with **abrupt onset and recovery**, often described as having a **W or V shape** on CTG. - These decelerations are **unpredictable** in timing and do not follow the contraction pattern like early decelerations do. *Fetal Hypoxia* - Results in **late decelerations** due to **uteroplacental insufficiency**, showing gradual onset but **delayed recovery** after contractions end. - These are **ominous signs** indicating fetal acidosis and require immediate intervention, unlike the benign nature of early decelerations. *Feto-Maternal Hemorrhage* - Typically causes **sinusoidal pattern** on CTG with smooth, undulating baseline resembling a **sine wave**. - Associated with severe fetal anemia and does not produce the **mirror-image deceleration pattern** seen with head compression.

Q: A 30-year-old primigravida presents with amenorrhea of 36 weeks, experiencing intermittent abdominal pain for 7 days. She has a history of Strassman's metroplasty. What is the best course of management?

Elective Cesarean section.. **Explanation:** The core clinical issue in this scenario is the history of **Strassman’s metroplasty**, a surgical procedure used to unify a bicornuate uterus by making a deep incision through the uterine fundus. **1. Why Elective Cesarean Section is Correct:** Strassman’s metroplasty involves a **full-thickness incision** into the uterine wall (transverse incision across the fundus). Similar to a classical Cesarean section or a deep intramural myomectomy, this surgery results in a significant uterine scar. During labor, the intense uterine contractions and the stretching of the lower segment/fundus pose a high risk of **uterine rupture**. To prevent this catastrophic complication, an elective Cesarean section is indicated before the onset of active labor (usually at 37–38 weeks). **2. Why Other Options are Incorrect:** * **Options A & C:** Induction of labor (prostaglandins) or augmentation (oxytocin) are strictly contraindicated. These agents increase uterine pressure and the intensity of contractions, which significantly elevates the risk of rupture at the site of the previous metroplasty scar. * **Option D:** Administering antispasmodics and discharging the patient is dangerous. Given her surgical history and the fact that she is at 36 weeks with abdominal pain, she requires close monitoring and a planned delivery rather than symptomatic relief. **Clinical Pearls for NEET-PG:** * **Strassman’s Metroplasty:** Used for Bicornuate uterus (Unification). * **Jones & Tompkins Metroplasty:** Used for Septate uterus (Excision/Incision). * **Uterine Rupture Risk:** Any surgery that enters the uterine cavity (except uncomplicated cervical cerclage or hysteroscopic resection) generally mandates a Cesarean delivery in subsequent pregnancies. * **Timing:** For patients with a high risk of rupture (like classical CS or metroplasty), elective CS is typically planned between **37 0/7 and 38 6/7 weeks**.

Q: What is the pressure created in a vacuum?

0.8 kg/cm2. **Explanation:** In operative obstetrics, the vacuum extractor (Ventouse) works on the principle of creating a negative pressure between the cup and the fetal scalp to facilitate traction. **1. Why 0.8 kg/cm² is correct:** To achieve effective traction and ensure the formation of a proper 'chignon' (artificial caput succedaneum), a negative pressure of **0.8 kg/cm²** (equivalent to 600 mmHg) is required. This pressure is reached gradually: initially, a vacuum of 0.2 kg/cm² is created to fix the cup, followed by increments of 0.1 kg/cm² every 2 minutes until the effective pressure of 0.8 kg/cm² is attained. This gradual increase prevents scalp trauma and ensures the cup is well-applied over the flexion point. **2. Analysis of Incorrect Options:** * **0.2 kg/cm² (Option B):** This is the **initial pressure** used to fix the cup to the scalp before increasing to the full therapeutic pressure. It is insufficient for actual traction. * **12 kgs and 18 kgs (Options A & D):** These represent units of **force/weight**, not pressure. While the maximum traction force exerted by a vacuum is roughly 10–12 kg (compared to 18–20 kg for forceps), the question specifically asks for the pressure setting on the gauge. **3. High-Yield Clinical Pearls for NEET-PG:** * **Flexion Point:** The cup should be placed over the flexion point (3 cm anterior to the posterior fontanelle along the sagittal suture). * **Chignon:** The artificial caput created by the vacuum; it usually subsides within 24 hours. * **Contraindications:** Vacuum is contraindicated in preterm babies (<34 weeks) due to the risk of subgaleal hemorrhage and in face/breech presentations. * **Safety Rule:** The "Rule of 3"—abandon the procedure if there are 3 pop-offs, 3 pulls with no descent, or 30 minutes of total application time.

Q: Maternal serum alpha-fetoprotein (MSAFP) is elevated in all of the following conditions EXCEPT:

Chromosomal trisomies. **Explanation:** Maternal Serum Alpha-Fetoprotein (MSAFP) is a glycoprotein produced initially by the yolk sac and later by the fetal liver. It enters the maternal circulation through fetal membranes and kidneys. The concentration of MSAFP is a crucial screening tool used between 15–20 weeks of gestation. **Why Chromosomal Trisomies is the Correct Answer:** In pregnancies affected by **Chromosomal Trisomies (such as Down Syndrome/Trisomy 21 and Edwards Syndrome/Trisomy 18)**, MSAFP levels are characteristically **decreased**, not elevated. In Down Syndrome, the mechanism is thought to involve reduced production by the fetal liver and a smaller-than-normal yolk sac. **Why the other options are incorrect (Conditions with Elevated MSAFP):** * **Neural Tube Defects (NTDs):** Conditions like anencephaly and spina bifida involve "open" defects where AFP leaks directly from the fetal serum/CSF into the amniotic fluid and subsequently into maternal serum. * **Esophageal Obstruction:** Any condition that interferes with fetal swallowing (e.g., esophageal or duodenal atresia) prevents the normal degradation of AFP in the fetal gut, leading to higher concentrations in the amniotic fluid and maternal serum. * **Gastroschisis/Omphalocele:** These are ventral wall defects where the fetal bowel or organs are exposed. Similar to NTDs, AFP leaks directly from the exposed fetal vessels into the amniotic fluid. **High-Yield Clinical Pearls for NEET-PG:** * **Most common cause of elevated MSAFP:** Incorrect gestational age (underestimation of pregnancy dates). * **Other causes of elevated MSAFP:** Multiple gestations, fetal demise, renal anomalies (Finnish-type nephrosis), and placental abruption. * **Triple Test for Down Syndrome:** Decreased MSAFP, decreased unconjugated estriol (uE3), and **increased** hCG. * **Quadruple Test:** Adds **Inhibin-A**, which is **increased** in Down Syndrome.

Q: A 29-year-old female, G2 P1 A1, presents with 16 weeks of amenorrhea, lower abdominal pain, and vaginal bleeding. Ultrasonography shows a snowstorm appearance. What is the most feasible method of treatment?

Suction evacuation. ### Explanation **Diagnosis:** The clinical presentation of 16 weeks amenorrhea, vaginal bleeding, and the classic **"snowstorm appearance"** on ultrasonography is pathognomonic for a **Hydatidiform Mole (Molar Pregnancy)**. **Why Suction Evacuation is Correct:** Suction evacuation (suction curettage) is the **gold standard** and most feasible treatment for a molar pregnancy, regardless of the uterine size. It is preferred because it allows for rapid emptying of the uterus while minimizing the risk of uterine perforation and excessive hemorrhage, which are common risks associated with sharp curettage in these cases. **Why Other Options are Incorrect:** * **Misoprostol & Mifepristone (Medical Management):** These are contraindicated for primary evacuation of a mole. Medical induction increases the risk of heavy hemorrhage and, theoretically, the risk of **trophoblastic embolization** into the maternal venous circulation due to uterine contractions. * **Hysterectomy:** While hysterectomy is an option for women who have completed their family or are over 40 years old (to reduce the risk of post-molar gestational trophoblastic neoplasia), it is not the "most feasible" or first-line method for a 29-year-old G2 P1 who may desire future fertility. **Clinical Pearls for NEET-PG:** 1. **Pre-operative Prep:** Always check thyroid function tests (TFTs) as high hCG can cause **hyperthyroidism** (due to molecular mimicry with TSH). 2. **Theca Lutein Cysts:** Often seen on USG; these are benign and usually regress after evacuation. 3. **Follow-up:** Monitor weekly serum **β-hCG levels** until three consecutive negative results are obtained to rule out Gestational Trophoblastic Neoplasia (GTN). 4. **Rh Isoimmunization:** Rh-negative mothers must receive Anti-D immunoglobulin after evacuation.

Q: Which of the following is NOT an absolute indication for cesarean section in pregnancy?

Non-reassuring fetal heart rate (fetal distress). **Explanation:** In obstetric practice, indications for Cesarean Section (CS) are categorized into **Absolute** (where vaginal delivery is impossible or life-threatening) and **Relative** (where vaginal delivery may be possible but carries higher risk). **Why Option C is the correct answer:** **Non-reassuring fetal heart rate (NRFHR)**, commonly referred to as fetal distress, is a **relative indication**. While it often necessitates an emergency CS, it is not absolute because the mode of delivery depends on the **cervical dilatation and station**. If the cervix is fully dilated and the fetal head is low (at or below the ischial spines), an operative vaginal delivery (forceps or vacuum) is often faster and safer than a CS. **Analysis of Incorrect Options (Absolute Indications):** * **Advanced Carcinoma of the Cervix:** Vaginal delivery is contraindicated as it can lead to torrential hemorrhage, cervical tearing, and potential dissemination of cancer cells. * **Central Placenta Previa (Type IV):** The placenta completely covers the internal os. Any attempt at vaginal delivery will cause massive, life-threatening maternal hemorrhage. * **Contracted Pelvis:** When the pelvic dimensions are significantly reduced (e.g., Outlet contraction or severe Cephalopelvic Disproportion), the fetus physically cannot pass through the birth canal. **High-Yield Clinical Pearls for NEET-PG:** * **Other Absolute Indications:** Pelvic tumors obstructing the birth canal (e.g., large low-lying fibroid), Vasa Previa, and previous classical CS. * **Most common indication for CS overall:** Previous CS. * **Most common indication for primary CS:** Dystocia (failure to progress). * **Rule of Thumb:** If the question asks for an "absolute" indication, look for mechanical obstructions that make the vaginal route physically impossible.

Question 1

A cesarean section was performed in the previous pregnancy. All of the following would be indications for an elective repeat cesarean section except?

Accepted Answer

Polyhydramnios

Answer

Breech presentation

Answer

Macrosomia

Answer

Post-term pregnancy

Question 2

A 25-year-old primigravida is in labor. The second stage of labor has lasted for 1 hour after complete cervical dilatation. On examination, the leading point of the fetal skull is at +2 station, and rotation is 45 degrees. How should this case be managed?

Accepted Answer

Applying low forceps

Answer

Applying outlet forceps

Answer

Applying mid forceps

Answer

Applying high forceps

Question 3

Which of the following is the most probable cause for the deceleration shown below?

Accepted Answer

Head Compression

Answer

Cord Compression

Answer

Fetal Hypoxia

Answer

Feto-Maternal Hemorrhage

Question 4

A 30-year-old primigravida presents with amenorrhea of 36 weeks, experiencing intermittent abdominal pain for 7 days. She has a history of Strassman's metroplasty. What is the best course of management?

Accepted Answer

Elective Cesarean section.

Answer

Induction of labor with prostaglandins after pelvic assessment.

Answer

Start oxytocin drip and monitor closely.

Answer

Administer antispasmodics and discharge the patient.

Question 5

Which of the following statements is true regarding the management of labor in an HIV-positive mother?

Accepted Answer

Routine suctioning of the newborn should be avoided.

Answer

Cesarean delivery is the preferred method of delivery.

Answer

Early artificial rupture of membranes should be performed to detect meconium, as these patients are at high risk of fetal distress.

Answer

If instrumental delivery is required, vacuum extraction is preferable to forceps.

Question 6

What is the pressure created in a vacuum?

Accepted Answer

0.8 kg/cm2

Answer

12 kgs

Answer

0.2 kg/cm2

Answer

18 kgs

Question 7

Maternal serum alpha-fetoprotein (MSAFP) is elevated in all of the following conditions EXCEPT:

Accepted Answer

Chromosomal trisomies

Answer

Neural tube defects

Answer

Esophageal obstruction

Answer

Gastroschisis

Question 8

Which of the following is true regarding salpingostomy?

Accepted Answer

It poses a higher risk of persistent trophoblastic tissue compared with salpingectomy.

Answer

Laparotomy is the preferred route.

Answer

It requires suture closure of the tubal incision with delayed-absorbable sutures.

Answer

It leads to lower future fertility rates in subsequent pregnancies.

Question 9

A 29-year-old female, G2 P1 A1, presents with 16 weeks of amenorrhea, lower abdominal pain, and vaginal bleeding. Ultrasonography shows a snowstorm appearance. What is the most feasible method of treatment?

Accepted Answer

Suction evacuation

Answer

Misoprostol administration

Answer

Hysterectomy

Answer

Mifepristone

Question 10

Which of the following is NOT an absolute indication for cesarean section in pregnancy?

Accepted Answer

Non-reassuring fetal heart rate (fetal distress)

Answer

Advanced carcinoma of the cervix

Answer

Central placenta previa

Answer

Contracted pelvis

Operative Obstetrics — MCQs

Operative Obstetrics — MCQs

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