Operative Obstetrics — MCQs
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In episiotomy, the initial markings are made in which location?
Misoprostol has been found to be effective in all of the following conditions except?
What is the single best parameter to assess gestational age in the first trimester?
External cephalic version is contraindicated in all of the following conditions except:
A 22-year-old primigravida at 11 weeks of gestational age has a blood pressure reading of 150/100 mm Hg obtained during a routine visit. The patient denies any headache, visual changes, nausea, vomiting, or abdominal pain. Her repeat BP is 160/90 mm Hg, and urinalysis is negative for protein. Which of the following is the most likely diagnosis?
Ventouse extraction is contraindicated in all except:
Which hormone is responsible for the decidual reaction and Arias-Stella reaction in ectopic pregnancy?
Which is the commonest indication for a classical cesarean section?
In a fetal decapitation, which bone is perforated during the procedure?
Chassar Moir surgery is indicated for which of the following conditions?
Operative Obstetrics Indian Medical PG Practice Questions and MCQs
Question 171: In episiotomy, the initial markings are made in which location?
- A. Left side of the perineal body
- B. On the midline of the perineum
- C. On the line of incision (Correct Answer)
- D. Right side of the perineal body
Explanation: ### Explanation **Correct Answer: C. On the line of incision** In operative obstetrics, the standard technique for performing an episiotomy involves specific preparatory steps to ensure accuracy and safety. Before the actual incision is made with scissors, the clinician uses a finger or a marking instrument to identify and "mark" the intended **line of incision**. This is done to ensure the cut is directed away from the anal sphincter and follows the correct anatomical plane (usually mediolateral). Marking the line of incision helps in visualizing the trajectory and ensuring that the incision begins at the midpoint of the fourchette and extends at the correct angle (45 degrees to the midline). **Analysis of Incorrect Options:** * **A & D (Left/Right side of the perineal body):** While the incision eventually passes through the perineal body, the markings are not restricted to just one "side" of the body itself. The marking defines the entire path of the cut, not just a starting point on the tissue mass. * **B (On the midline of the perineum):** While the incision *starts* at the midline (fourchette), marking only the midline is insufficient for a mediolateral episiotomy, which is the most common type. The marking must represent the actual diagonal path the scissors will take. **Clinical Pearls for NEET-PG:** * **Timing:** Episiotomy is performed during the "crowning" phase when 3–4 cm of the fetal head is visible. * **Most Common Type:** **Mediolateral episiotomy** is preferred globally as it reduces the risk of 3rd and 4th-degree perineal tears (anal sphincter injury). * **Structures Cut:** Skin, subcutaneous tissue, vaginal mucosa, and the **Bulbospongiosus** and **Superficial transverse perineal muscles**. * **Nerve Supply:** The perineum is supplied by the **Pudendal nerve (S2-S4)**; hence, a pudendal block or local infiltration is required before the procedure.
Question 172: Misoprostol has been found to be effective in all of the following conditions except?
- A. Missed abortion
- B. Induction of labor
- C. Menorrhagia (Correct Answer)
- D. Prevention of postpartum hemorrhage
Explanation: **Explanation:** Misoprostol is a synthetic **Prostaglandin E1 (PGE1) analogue**. Its primary mechanism of action involves causing potent **myometrial contractions** and promoting **cervical ripening** (softening and effacement). **Why Menorrhagia is the Correct Answer:** Menorrhagia (heavy menstrual bleeding) is primarily managed by reducing menstrual blood flow through antifibrinolytics (Tranexamic acid), NSAIDs, or hormonal therapy (OCPs, Progesterone, Levonorgestrel-IUS). Misoprostol does not reduce menstrual volume; in fact, its side effect profile includes uterine cramping and spotting, making it inappropriate for treating menorrhagia. **Analysis of Other Options:** * **Missed Abortion:** Misoprostol is a first-line medical management agent used to induce uterine contractions to expel the products of conception. * **Induction of Labor:** It is used for cervical ripening and labor induction (dose: 25 mcg vaginal/oral). Note: It is contraindicated in patients with a previous cesarean scar due to the risk of uterine rupture. * **Prevention of PPH:** According to WHO guidelines, 600 mcg of oral Misoprostol is an effective alternative for the prevention of PPH in resource-limited settings where injectable Oxytocin is unavailable. **High-Yield NEET-PG Pearls:** * **Route of Administration:** Oral, vaginal, sublingual, and rectal. Sublingual has the highest bioavailability. * **PPH Treatment Dose:** 800 mcg (sublingual is preferred for rapid action). * **Side Effects:** Shivering and pyrexia (most common), diarrhea, and abdominal cramps. * **Contraindication:** Previous uterine surgery (when used for induction of labor at term).
Question 173: What is the single best parameter to assess gestational age in the first trimester?
- A. Crown Rump Length (CRL) (Correct Answer)
- B. Biparietal Diameter (BPD)
- C. Head Circumference (HC)
- D. Femur Length (FL)
Explanation: **Explanation:** **1. Why Crown Rump Length (CRL) is the Correct Answer:** Crown Rump Length (CRL), measured from the top of the head (crown) to the bottom of the buttocks (rump), is the **most accurate parameter** for dating a pregnancy in the first trimester (specifically between 7 to 13+6 weeks). During this period, fetal growth is rapid and biological variation is minimal because growth is not yet significantly influenced by external factors like maternal nutrition or genetics. The margin of error for CRL is only **± 3–5 days**, making it the gold standard for establishing the Expected Date of Delivery (EDD). **2. Why Other Options are Incorrect:** * **Biparietal Diameter (BPD) & Head Circumference (HC):** These are the most accurate parameters in the **second trimester** (14–26 weeks). However, as pregnancy progresses, biological variation increases, making them less precise than first-trimester CRL. * **Femur Length (FL):** This is used as part of the biometric profile in the second and third trimesters to assess skeletal growth and fetal weight, but it is never the primary parameter for initial dating. **3. High-Yield Clinical Pearls for NEET-PG:** * **Earliest Sign of Pregnancy on USG:** Gestational Sac (seen at ~4.5–5 weeks). * **First Functional Structure:** Yolk Sac (seen at ~5 weeks). * **CRL Validity:** It is used until the CRL reaches **84 mm**. Beyond this, BPD becomes the preferred measurement. * **Rule of Thumb:** If there is a discrepancy between the Last Menstrual Period (LMP) and CRL dating of >5 days in the first trimester, the USG-based EDD should be used. * **Most accurate parameter in 2nd Trimester:** BPD. * **Most accurate parameter in 3rd Trimester:** FL or a combination of parameters (least accurate overall).
Question 174: External cephalic version is contraindicated in all of the following conditions except:
- A. Antepartum haemorrhage
- B. Multiple pregnancy
- C. Contracted pelvis
- D. Breech presentation (Correct Answer)
Explanation: **Explanation:** External Cephalic Version (ECV) is a procedure where a clinician manually rotates a fetus from a non-vertex presentation (breech or transverse) to a vertex presentation through the maternal abdominal wall to facilitate a vaginal delivery. **Why "Breech Presentation" is the correct answer:** Breech presentation is the primary **indication** for performing an ECV, not a contraindication. The goal of the procedure is specifically to convert a breech fetus into a cephalic one to avoid the risks associated with a vaginal breech birth or a Cesarean section. **Analysis of Contraindications (Incorrect Options):** * **Antepartum Haemorrhage (APH):** This is an absolute contraindication. Manipulating the fetus can cause further placental separation (abruption), leading to life-threatening maternal or fetal hemorrhage. * **Multiple Pregnancy:** ECV is contraindicated in twins because there is insufficient space to turn the fetus, and there is a high risk of cord entanglement or premature rupture of membranes. * **Contracted Pelvis:** If the maternal pelvis is too small to allow a vertex delivery, converting the fetus to cephalic serves no clinical purpose, as a Cesarean section will be required regardless of presentation. **NEET-PG High-Yield Pearls:** * **Ideal Timing:** ECV is typically performed at **36 weeks** in primigravidae and **37 weeks** in multigravidae (to allow for spontaneous version and ensure fetal maturity if emergency delivery is needed). * **Prerequisites:** Reactive NST, adequate liquor (AFI >5), and no uterine anomalies. * **Most Common Complication:** Transient fetal bradycardia. * **Tocolysis:** Often used (e.g., Beta-mimetics) to relax the uterus and increase the success rate. * **Rh-Negative Mothers:** Must receive **Anti-D immunoglobulin** after the procedure due to the risk of feto-maternal hemorrhage.
Question 175: A 22-year-old primigravida at 11 weeks of gestational age has a blood pressure reading of 150/100 mm Hg obtained during a routine visit. The patient denies any headache, visual changes, nausea, vomiting, or abdominal pain. Her repeat BP is 160/90 mm Hg, and urinalysis is negative for protein. Which of the following is the most likely diagnosis?
- A. Preeclampsia
- B. Chronic hypertension (Correct Answer)
- C. Eclampsia
- D. Gestational hypertension
Explanation: ### Explanation **1. Why Chronic Hypertension is Correct:** The diagnosis of hypertensive disorders in pregnancy is primarily based on the **gestational age** at onset. Chronic hypertension is defined as high blood pressure (≥140/90 mm Hg) that is present **before pregnancy** or diagnosed **before 20 weeks of gestation**. In this case, the patient is at 11 weeks (first trimester) with a BP of 150/100 mm Hg. Since the hypertension manifested before the 20-week cutoff, it is classified as chronic hypertension. **2. Why Other Options are Incorrect:** * **Preeclampsia:** This is a multi-system disorder characterized by hypertension arising **after 20 weeks** of gestation, typically accompanied by proteinuria or end-organ dysfunction. Since this patient is only at 11 weeks and has no proteinuria, preeclampsia is excluded. * **Gestational Hypertension:** This refers to new-onset hypertension (without proteinuria) occurring **after 20 weeks** of gestation in a previously normotensive woman. * **Eclampsia:** This is the onset of generalized tonic-clonic seizures in a woman with preeclampsia. This patient is asymptomatic (no seizures, no headache) and does not meet the criteria for preeclampsia. **3. NEET-PG High-Yield Pearls:** * **The 20-Week Rule:** This is the "Golden Rule" for PG exams. Hypertension <20 weeks = Chronic HTN; Hypertension >20 weeks = Gestational HTN or Preeclampsia. * **Exception to the Rule:** If hypertension and proteinuria appear before 20 weeks, consider **Hydatidiform Mole** or multiple pregnancy. * **Superimposed Preeclampsia:** This occurs when a patient with known chronic hypertension develops new-onset proteinuria or sudden worsening of BP/symptoms after 20 weeks. * **White Coat Hypertension:** Defined as elevated BP in the clinic but normal readings at home; it affects up to 15% of pregnant women.
Question 176: Ventouse extraction is contraindicated in all except:
- A. Fetal distress
- B. Face presentation
- C. Transverse lie
- D. Anemia (Correct Answer)
Explanation: **Explanation:** The correct answer is **Anemia (Option D)**. Ventouse (vacuum) extraction is a method of instrumental vaginal delivery. Maternal anemia is **not** a contraindication for its use; in fact, by shortening the second stage of labor, it may reduce maternal exhaustion and potentially limit further blood loss compared to a prolonged, difficult labor. **Why the other options are contraindicated:** * **Face Presentation (Option B):** Vacuum application is strictly contraindicated in face presentations because it can cause severe facial trauma, ocular damage, and intracranial hemorrhage. Forceps are preferred if instrumental delivery is necessary. * **Transverse Lie (Option C):** A transverse lie is a malpresentation where the fetus is positioned horizontally across the uterus. Vaginal delivery (including Ventouse) is impossible and dangerous; a Cesarean section is mandatory. * **Fetal Distress (Option A):** While Ventouse can be used in some cases of fetal distress, it is generally considered a **relative contraindication** if immediate delivery is required. Forceps are faster and more reliable for "crash" deliveries because the vacuum requires time to build pressure and carries a higher risk of "pop-offs" (detachment), which can delay delivery in a critical situation. **Clinical Pearls for NEET-PG:** * **Absolute Contraindications for Ventouse:** Face/Brow presentation, preterm fetus (<34 weeks due to risk of intraventricular hemorrhage), unengaged head, and incomplete cervical dilatation. * **Prerequisites:** The mnemonic **FORCEPS** (Fetus alive, Os fully dilated, Ruptured membranes, Cephalic presentation, Engaged head, Pelvis adequate, Soft tissue/Bladder empty). * **Complication:** The most specific neonatal complication of Ventouse is **Subgaleal Hemorrhage**, which is more dangerous than a simple Cephalhematoma as it can lead to hypovolemic shock.
Question 177: Which hormone is responsible for the decidual reaction and Arias-Stella reaction in ectopic pregnancy?
- A. Estrogen
- B. Progesterone (Correct Answer)
- C. hCG
- D. hPL
Explanation: **Explanation:** The correct answer is **Progesterone**. In an ectopic pregnancy, the body produces hormones similar to a normal intrauterine pregnancy. **Progesterone**, secreted by the corpus luteum, is the primary hormone responsible for the structural transformation of the endometrium into the **decidua**. This "decidual reaction" occurs even if the blastocyst is implanted outside the uterus because the endometrium responds to circulating systemic hormones rather than local implantation. The **Arias-Stella reaction** is a specific histological change characterized by hypertrophic, hyperchromatic, and enlarged endometrial glandular nuclei. It is a benign response of the endometrial glands to high levels of progesterone. While most commonly associated with ectopic pregnancy, it is not pathognomonic as it can also be seen in intrauterine pregnancies or with trophoblastic disease. **Analysis of Incorrect Options:** * **Estrogen (A):** While estrogen causes endometrial proliferation, it does not induce the secretory changes or the specialized decidualization required for these reactions. * **hCG (C):** Human Chorionic Gonadotropin maintains the corpus luteum, which in turn produces progesterone. Thus, hCG is an indirect cause, but progesterone is the direct effector hormone on the endometrium. * **hPL (D):** Human Placental Lactogen is involved in fetal growth and maternal metabolism (anti-insulin effect) and has no role in the decidual reaction. **NEET-PG High-Yield Pearls:** * **Decidual Cast:** If the ectopic pregnancy fails, the sudden drop in progesterone leads to the sloughing of the entire decidua as a single triangular piece, known as a decidual cast. * **Arias-Stella Reaction:** It can be mistaken for clear cell carcinoma or endoadenocarcinoma due to its hyperchromatic nuclei; however, the lack of mitosis helps in differentiation. * **Triad of Ectopic Pregnancy:** Amenorrhea, abdominal pain, and vaginal bleeding.
Question 178: Which is the commonest indication for a classical cesarean section?
- A. Transverse lie
- B. Cord prolapse
- C. Dense adhesions in the lower uterine segment (Correct Answer)
- D. Placenta previa
Explanation: **Explanation:** A **Classical Cesarean Section** involves a vertical incision made in the upper contractile segment of the uterus. While the Lower Segment Cesarean Section (LSCS) is the standard of care, a classical incision is reserved for specific clinical scenarios where the lower segment is inaccessible or unsuitable. **Why Option C is Correct:** **Dense adhesions in the lower uterine segment** (often due to previous surgeries, endometriosis, or inflammatory conditions) make it surgically impossible or highly hazardous to reach the lower segment. In such cases, the upper segment is the only safe site for the incision. This is currently considered the most common indication for a classical section in modern practice. **Analysis of Incorrect Options:** * **A. Transverse lie:** While a "back-down" transverse lie may occasionally require a vertical incision, most transverse lies can be managed via a wide transverse lower segment incision or internal podalic version. * **B. Cord prolapse:** This is an indication for an *emergency* CS, but the priority is speed. Since LSCS is generally faster for an experienced surgeon and associated with less blood loss, it remains the preferred method unless other contraindications exist. * **C. Placenta previa:** Specifically, **anterior major placenta previa** with large overhanging vessels (vasa previa) was historically an indication. However, most surgeons now prefer a lower segment incision, either by going around the placenta or cutting through it, to avoid the high morbidity of a classical incision. **High-Yield Clinical Pearls for NEET-PG:** * **Other Indications:** Carcinoma cervix, post-mortem CS, peripartum hysterectomy, and extremely premature fetus in a breech presentation (where the lower segment is poorly formed). * **Major Risk:** The risk of **uterine rupture** in a subsequent pregnancy is highest with a classical scar (4–9%) compared to an LSCS scar (0.2–1.5%). * **Management:** A patient with a previous classical CS **must** undergo a repeat elective CS at 37 weeks; a trial of labor (VBAC) is strictly contraindicated.
Question 179: In a fetal decapitation, which bone is perforated during the procedure?
- A. Occiput (Correct Answer)
- B. Parietal
- C. Palate
- D. Frontal
Explanation: In operative obstetrics, **decapitation** is a destructive procedure performed on a dead fetus in a transverse lie with an impacted shoulder when a Cesarean section is not feasible. ### **Explanation of the Correct Answer** The procedure involves using a **Blond-Heidrich decapitating wire saw** or a **Jardine’s decapitating hook**. The primary objective is to sever the fetal neck to allow for the separate delivery of the body and the head. During the second stage of the procedure (delivery of the severed head), the head is stabilized at the pelvic brim. To facilitate extraction, the **Occiput** (specifically the area near the foramen magnum) is perforated using a **Smellie’s perforator**. This allows for the reduction of intracranial pressure and provides a firm grip for instruments like the **Winter’s cranial bone forceps** to extract the head. ### **Analysis of Incorrect Options** * **B. Parietal:** Perforation of the parietal bone is the standard approach in **Craniotomy** for cephalic presentations (to reduce head size), but it is not the primary site for decapitation-related extraction. * **C. Palate:** Perforation through the hard palate is sometimes used in the **after-coming head of a breech** (Prague maneuver/Wigand-Martin-Winckel) but is not the anatomical target in decapitation. * **D. Frontal:** The frontal bone is avoided due to its thickness and the risk of the instrument slipping toward the maternal soft tissues. ### **High-Yield Clinical Pearls for NEET-PG** * **Indications:** Dead fetus, transverse lie, impacted shoulder, cervix fully dilated. * **Key Instrument:** Blond-Heidrich wire saw (preferred over the hook to minimize maternal trauma). * **Sequence:** The body is delivered first by traction on the prolapsed arm, followed by the delivery of the severed head. * **Safety:** Always protect the maternal vaginal walls with the fingers or a speculum during perforation to prevent vesicovaginal or rectovaginal fistulas.
Question 180: Chassar Moir surgery is indicated for which of the following conditions?
- A. Uterine inversion
- B. Vesicovaginal fistula repair (Correct Answer)
- C. Ureterovesical fistula repair
- D. Retroverted uterus
Explanation: **Explanation:** **Chassar Moir surgery** is a classic surgical technique used for the repair of a **Vesicovaginal Fistula (VVF)**. It is a vaginal approach (transvaginal) that utilizes the principle of "saucerization." In this procedure, the edges of the fistula are denuded and excised in a funnel shape, followed by a tension-free, layered closure. It is particularly effective for small to moderate-sized fistulae located in the mid-vaginal area. **Analysis of Options:** * **Option A (Uterine Inversion):** This is managed by the **Johnson’s maneuver** (manual replacement) or surgical methods like **O'Sullivan's** (hydrostatic), **Huntington’s**, or **Haultain’s** procedures. * **Option B (Vesicovaginal Fistula):** Correct. Chassar Moir is the standard vaginal repair. Other repairs include the **Latzko procedure** (partial colpocleisis for post-hysterectomy VVF) and the **O'Conor procedure** (transabdominal approach). * **Option C (Ureterovesical Fistula):** These usually require ureteric reimplantation into the bladder (**Ureteroneocystostomy**), such as the **Boari flap** or **Psoas hitch**. * **Option D (Retroverted Uterus):** Historically treated with "ventrosuspension" procedures like the **Gilliam’s surgery**, though rarely performed today. **NEET-PG Clinical Pearls:** * **Most common cause of VVF:** In developing countries, it is **obstructed labor**; in developed countries, it is **iatrogenic (post-hysterectomy)**. * **Gold Standard Investigation:** The **Three-swab test** (Moir’s test) is used to differentiate VVF from ureterovaginal fistula. * **Timing of Repair:** Traditionally, a wait of 3–6 months is advised after the injury to allow inflammation to subside, though "early repair" is gaining favor in non-radiated cases.
Practice by Chapter
Cesarean Section Techniques
Practice Questions
Vaginal Birth After Cesarean
Practice Questions
Instrumental Deliveries
Practice Questions
Breech Delivery
Practice Questions
Episiotomy and Repair
Practice Questions
Management of Multiple Gestation
Practice Questions
Cervical Cerclage
Practice Questions
Obstetric Hysterectomy
Practice Questions
Surgery During Pregnancy
Practice Questions
Surgical Complications in Obstetrics
Practice Questions
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