Operative Obstetrics — MCQs

Operative Obstetrics Indian Medical PG Practice Questions and MCQs

Question 181: Forceps delivery is indicated in all the following conditions except?

A. Mentoposterior presentation (Correct Answer)
B. Deep transverse arrest
C. After the head has crowned
D. Severe maternal heart disease

Explanation: **Explanation:** The correct answer is **A. Mentoposterior presentation**. In this position, the fetal chin (mentum) is directed toward the maternal sacrum. Because the fetal neck is already at maximal extension, it cannot extend further to negotiate the pelvic curve. This results in a diameter (submentobregmatic) that is too large to pass through the pelvis, making vaginal delivery impossible. Forceps application is strictly **contraindicated** here; the management of choice is a Cesarean section. **Analysis of other options:** * **B. Deep transverse arrest:** This occurs when the head is arrested in the transverse diameter at the level of the ischial spines. Forceps (specifically Kielland’s forceps) can be used to rotate the head to an occipito-anterior position and effect delivery. * **C. After the head has crowned:** This is the primary indication for **Outlet Forceps**. It is often used to shorten the second stage of labor or to control the delivery of the head to prevent perineal tears. * **D. Severe maternal heart disease:** Forceps are indicated here to **shorten the second stage of labor**, preventing the maternal exhaustion and Valsalva maneuvers that could lead to acute cardiac failure. **High-Yield Clinical Pearls for NEET-PG:** 1. **Prerequisites for Forceps:** Remember the mnemonic **FORCEPS**: **F**etus alive, **O**penned (dilated) cervix, **R**uptured membranes, **C**ephalo-pelvic disproportion absent, **E**ngaged head, **P**osition known, **S**ladder empty. 2. **Mento-Anterior (MA):** Unlike MP, a Mento-anterior presentation **can** be delivered vaginally with forceps. 3. **Classification:** Based on station and rotation, forceps are classified into **Outlet, Low, Mid, and High** (High forceps are now obsolete in modern obstetrics).

Question 182: During a hysterectomy and an oophorectomy, the uterine and ovarian vessels must be ligated. These vessels can be found in which ligaments?

A. Broad and ovarian ligaments
B. Broad and suspensory ligaments (Correct Answer)
C. Round and ovarian ligaments
D. Round and suspensory ligaments

Explanation: **Explanation:** The key to this question lies in understanding the vascular anatomy of the female reproductive system and the specific ligaments that house these vessels. 1. **Uterine Vessels (Broad Ligament):** The uterine artery is a branch of the internal iliac artery. It travels medially through the base of the **broad ligament** (specifically within the cardinal ligament/parametrium) to reach the uterus at the level of the internal os. During a hysterectomy, this is a critical site for ligation. 2. **Ovarian Vessels (Suspensory Ligament):** The ovarian arteries arise directly from the abdominal aorta. They reach the ovary by traveling within the **suspensory ligament of the ovary** (also known as the **infundibulopelvic ligament**). This ligament must be ligated during an oophorectomy to control the primary blood supply to the ovary. **Analysis of Incorrect Options:** * **Ovarian Ligament (Options A & C):** This is a fibrous cord connecting the ovary to the lateral wall of the uterus. It does *not* contain the primary ovarian vessels (which come from the pelvic wall via the suspensory ligament). * **Round Ligament (Options C & D):** This ligament maintains the anteversion of the uterus and travels through the inguinal canal to the labia majora. While it contains the small *Sampson’s artery*, it does not house the main uterine or ovarian vessels. **NEET-PG High-Yield Pearls:** * **"Water under the bridge":** The **ureter** passes inferior to the uterine artery within the broad ligament. This is the most common site of ureteric injury during hysterectomy. * **Suspensory Ligament (IP Ligament):** This is the most common site of ureteric injury during an oophorectomy/adnexectomy because the ureter lies just medial and posterior to the ligation point of the ovarian vessels. * **Broad Ligament Contents:** Uterine artery, ureter, round ligament, ovarian ligament, and the Fallopian tube.

Question 183: Which of the following tests is used to estimate the amount of fetomaternal hemorrhage?

A. Coomb's test
B. Apt test
C. Liley's spectrophotometer
D. Kleihauer-Betke test (Correct Answer)

Explanation: ### Explanation **Correct Answer: D. Kleihauer-Betke (KB) test** The **Kleihauer-Betke test** is the gold standard for quantifying the volume of fetomaternal hemorrhage (FMH). It is based on the principle of **acid elution**. Fetal hemoglobin (HbF) is resistant to acid elution, whereas adult hemoglobin (HbA) is acid-labile. When a maternal blood smear is treated with an acid buffer and stained, adult RBCs appear as pale "ghost cells" because the hemoglobin has leaked out, while fetal RBCs remain dark pink/red. This allows for the calculation of the percentage of fetal cells in maternal circulation, which is then used to determine the required dose of Anti-D immunoglobulin. **Why the other options are incorrect:** * **A. Coomb’s test:** This is used to detect antibodies against RBCs. The *Indirect Coomb’s Test (ICT)* is used to screen for maternal sensitization (presence of anti-D antibodies), while the *Direct Coomb’s Test (DCT)* is performed on the neonate’s cord blood to detect antibodies bound to fetal RBCs. * **B. Apt test:** This is used to differentiate fetal blood from maternal blood in cases of **antepartum hemorrhage** (e.g., vasa previa) or when a neonate has bloody stools/vomitus. It uses alkali (NaOH) denaturation; fetal hemoglobin is alkali-resistant. * **C. Liley’s spectrophotometer:** This was historically used to monitor the severity of fetal hemolysis in Rh-isoimmunized pregnancies by measuring the concentration of **bilirubin in amniotic fluid** (at 450 nm). **High-Yield Clinical Pearls for NEET-PG:** * **Formula for Anti-D dose:** Volume of FMH (mL) = % of fetal cells × 50. * **Standard Dose:** 300 mcg of Anti-D covers up to **30 mL** of fetal whole blood (or 15 mL of fetal RBCs). * **Rosette Test:** This is a qualitative (screening) test used to detect the presence of FMH. If positive, it must be followed by the KB test for quantification. * **KB Test Timing:** Should be performed in all Rh-negative mothers who deliver an Rh-positive infant to ensure adequate immunoprophylaxis.

Question 184: Which of the following is NOT a contraindication for a cervical cerclage operation?

A. Ruptured membranes
B. Signs of chorioamnionitis
C. History of vaginal bleeding
D. Pregnancy beyond 14 weeks (Correct Answer)

Explanation: **Explanation:** Cervical cerclage is a surgical procedure used to treat cervical insufficiency by placing a non-absorbable suture around the cervix. The goal is to provide mechanical support and maintain the structural integrity of the cervical canal. **Why Option D is the Correct Answer:** Pregnancy beyond 14 weeks is **not** a contraindication; in fact, it is the standard timing for the procedure. An **Elective (Prophylactic) Cerclage** is typically performed between **12 and 14 weeks** of gestation, after confirming fetal viability and screening for chromosomal abnormalities (NT scan). Cerclage can also be performed as an "Urgent" or "Emergency" procedure up to 24 weeks if cervical shortening or dilation is noted. **Analysis of Incorrect Options (Contraindications):** * **Ruptured Membranes (A):** If the membranes have ruptured, the risk of ascending infection is extremely high, and the procedure will not prevent preterm birth. * **Chorioamnionitis (B):** Intrauterine infection is an absolute contraindication. Placing a stitch in an infected environment can lead to maternal sepsis. * **Vaginal Bleeding (C):** Active bleeding suggests placental abruption or labor. Cerclage in the presence of uterine activity or abruption can lead to cervical laceration or severe hemorrhage. **High-Yield Clinical Pearls for NEET-PG:** * **McDonald’s Operation:** The most common technique; a purse-string suture is placed at the cervicovaginal junction. * **Shirodkar’s Operation:** A submucosal stitch placed higher up at the level of the internal os. * **Indication:** History of ≥3 unexplained second-trimester losses or preterm births. * **Suture Removal:** Usually performed at **36–37 weeks** or immediately if labor begins, to prevent cervical rupture. * **Most common complication:** Preterm Prelabor Rupture of Membranes (PPROM).

Question 185: During assisted vaginal delivery, where is the vacuum device typically applied?

A. 3 cm anterior to the posterior fontanelle (Correct Answer)
B. Between the anterior and posterior fontanelle
C. On the posterior fontanelle
D. At 3 cm behind the anterior fontanelle

Explanation: ***3 cm anterior to the posterior fontanelle***- This exact point is known as the **flexion point** (or optimum traction point), which is essential for ensuring that traction causes the fetal head to flex, thus presenting the smallest diameter for delivery.- Applying the vacuum cup at the flexion point ensures that the pull is along the axis of the **fetal head**, minimizing cephalhematoma and increasing the efficacy of the vacuum pull.*At 3 cm behind the anterior fonatnelle*- This position corresponds to the **sinciput** and is too far forward on the fetal head.- Applying traction here could lead to **extension** of the fetal head, making delivery more difficult and increasing the risk of fetal injury or cap detachment.*On the posterior fontanelle*- Placing the cup directly on the **posterior fontanelle** is incorrect as it is a small, soft area and the application would be off-center from the optimal traction point.- This off-center placement could result in **deflecting** the fetal head upon traction, making the pull less effective and potentially causing scalp damage.*Between the anterior and posterior fontanelle*- While the ideal position lies along the sagittal suture between the fontanelles, this description is too vague and does not pinpoint the specific **flexion point** (3 cm anterior to the posterior fontanelle).- Vague placement often results in applied traction that is not fully conducive to optimal **head flexion** and descent.

Question 186: A pregnant woman with a short cervix undergoes a cervical cerclage procedure. The image shows a key step during the procedure. What is the most likely procedure being performed?

A. Shirodkar
B. Modified McDonald's
C. Modified Shirodkar (Correct Answer)
D. McDonald's

Explanation: ***Modified Shirodkar*** - The image displays the dissection of the **vesicocervical mucosa** (bladder flap) which is a crucial step in the Shirodkar procedure, allowing the suture to be placed high on the cervix near the **internal os**. - This technique involves a submucosal placement of a non-absorbable suture (like Mersilene tape) which is then buried, providing better support for an incompetent cervix compared to lower-placed sutures. *Modified McDonald's* - The McDonald's procedure and its modifications are simpler techniques that place a **purse-string suture** around the cervix without any dissection of the cervical mucosa. - This procedure is less invasive but the suture is placed lower on the cervix, which might offer less support than a high cerclage like the Shirodkar. *McDonald's* - This is a transvaginal **purse-string suture** placed around the body of the cervix, cinching it closed. It is a common and relatively simple method of cerclage. - Crucially, it does not involve the **bladder dissection** shown in the image, which is the key differentiating feature of the Shirodkar technique. *Shirodkar* - While the procedure shown is a Shirodkar type, the **Modified Shirodkar** is the version most commonly performed today and is therefore the most precise answer. - The original Shirodkar technique often involved a permanent suture requiring a **cesarean delivery**, whereas the modified version uses a suture that can be removed to allow for a trial of vaginal delivery.

Question 187: A patient develops profuse uterine bleeding after a lower segment cesarean section (LSCS). Despite administration of oxytocin and other uterotonics, the bleeding continues. What is the 1st line conservative surgical management?

A. Hysterectomy
B. Uterine balloon tamponade (Correct Answer)
C. Internal iliac artery ligation
D. Uterine artery embolization

Explanation: ***Uterine balloon tamponade*** - This is the **first-line conservative surgical intervention** when uterine atony persists despite maximum medical management (oxytocin, methylergometrine, carboprost, misoprostol). - Devices like the **Bakri balloon** are inserted rapidly to apply counter-pressure to the uterine walls, effectively halting bleeding in 80-90% of cases while preserving the uterus. - This is a **Tier 2 intervention** that bridges medical management and invasive surgical procedures. *Uterine artery embolization* - This specialized technique requires immediate availability of an **interventional radiology suite** and hemodynamically stable patient for transport. - It is typically pursued after conservative mechanical procedures (tamponade or compression sutures) have failed, or in specialized centers where it's immediately available. - Considered a **Tier 3 intervention**. *Internal iliac artery ligation* - This complex invasive surgical procedure is performed when simpler techniques like **balloon tamponade** or **B-Lynch compression sutures** have failed. - It is typically reserved as a step before hysterectomy, aimed at reducing pelvic blood flow. - Also a **Tier 3 intervention**. *Hysterectomy* - **Hysterectomy** is the **last-resort, life-saving measure** (Tier 4) when all conservative mechanical, surgical, and medical options have failed to control massive hemorrhage. - The goal is to implement conservative measures rapidly to **preserve fertility** before resorting to definitive surgery.

Question 188: The ureter is safe in which type of hysterectomy?

A. Robotic
B. Laparoscopy
C. Vaginal (Correct Answer)
D. Open laparotomy

Explanation: ***Vaginal*** - The lack of deep **lateral pelvic dissection** in a vaginal approach minimizes the surgical field near the area where the **ureter** crosses the **uterine artery**. - The main approach is through the vaginal cuff and supporting structures, placing the ureter at the **lowest risk** of **ligation** or **transection** compared to abdominal routes. - This is the **safest approach** for the ureter among all hysterectomy types. *Open laparotomy* - This approach requires extensive dissection of the **cardinal ligaments** and **parametrium**, placing the ureter (which runs under the uterine artery) in close proximity to the operative field, increasing the risk of injury. - The ureter can be easily inadvertently clamped or ligated during securement of the **uterine pedicles**. *Laparoscopy* - Despite magnified visualization, laparoscopic dissection requires the use of energy devices (e.g., electrocautery) near the **uterine vessels**, potentially exposing the ureter to a higher risk of **thermal injury**. - Deep lateral dissection near the cervix increases the risk of mechanical injury, often compounded by difficulty in **depth perception** during pedicle clamping. *Robotic* - Similar to laparoscopy, robotic assistance involves deep dissection of the broad and **cardinal ligaments** where the **ureter** is vulnerable as it passes near the **uterine artery**. - Although visualization and dexterity are improved, the instruments still operate close to the ureter during securing of the **uterine pedicles**, maintaining a significant risk of injury.

Question 189: This instrument is contraindicated for?

A. After coming head of breech
B. Obstructed labor (Correct Answer)
C. Caesarean section
D. Occipital posterior position

Explanation: ***Obstructed labor*** - Using forceps in obstructed labor, such as in cases of **cephalopelvic disproportion (CPD)**, is absolutely contraindicated as it can cause severe maternal trauma like **uterine rupture** and significant fetal injury. - The definitive management for true obstructed labor is a **Caesarean section** to safely bypass the mechanical obstruction. *Caesarean section* - Wrigley's forceps are commonly used during a Caesarean section to assist in delivering the fetal head, especially when it is deeply engaged in the pelvis (a "lift-out" forceps application). - Therefore, a Caesarean section is an *indication* for the use of these specific forceps, not a contraindication. *After coming head of breech* - Forceps can be used to deliver the aftercoming head in a breech presentation to control delivery and prevent sudden decompression of the fetal head. **Piper's forceps** are specifically designed for this purpose. - This situation represents a specific indication for an assisted delivery, not a contraindication. *Occipital posterior position* - A persistent occiput posterior position can lead to a prolonged second stage of labor, which is a common indication for operative vaginal delivery. - Depending on the fetal head station, rotational forceps (like **Kielland's**) or outlet forceps (like **Wrigley's**) may be used to either rotate the head or deliver it directly in the posterior position.

Question 190: Which of the following is the process of breaking the clavicle during delivery?

A. Cleidotomy (Correct Answer)
B. Zavanelli manoeuvre
C. Craniotomy
D. Symphysiotomy

Explanation: ***Cleidotomy*** - This is a destructive obstetric procedure where the fetal clavicle is intentionally broken or cut to reduce the **bisacromial diameter**. It is utilized primarily in cases of severe, unrelieved **shoulder dystocia**, especially if the fetus has already succumbed (**Fetal demise**). *Craniotomy* - This is a destructive procedure aimed at reducing the size of the **fetal head** by crushing or perforating the skull. It is performed when the fetal head is impacted and delivery is otherwise impossible, usually only if there is **fetal demise**. *Symphysiotomy* - This procedure involves surgically incising the **fibrocartilage** of the **pubic symphysis** to widen the pelvic outlet. It is used to relieve **obstructed labor** due to minor cephalopelvic disproportion, allowing vaginal delivery. *Zavanelli manoeuvre* - This is an emergency procedure for severe **shoulder dystocia** where the delivered fetal head is pushed back into the birth canal (**cephalic replacement**). It mandates immediate delivery via **Cesarean section** following the replacement.

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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