Operative Obstetrics Practice Questions

Q: Identify the instrument shown in the image below:

Kielland. ***Kielland*** - Kielland forceps are distinguished by their **lack of pelvic curve** and the presence of a sliding lock mechanism designed for **rotation of the fetal head**. - They are primarily used for **rotational delivery** when the fetal head is in malposition, often in the mid-pelvis. *Simpson* - Simpson forceps have a distinct **cephalic curve** for grasping the fetal head and a **pelvic curve** to conform to the birth canal. - They are commonly used for **outlet and low-cavity deliveries** where minimal rotation is needed. *Wrigley* - Wrigley forceps are a type of **outlet forceps** with a very short shanks and blades, making them suitable only when the fetal head is on the **perineum**. - They are designed for situations where the head is already visible without separating the labia. *Pipers* - Pipers forceps are specifically designed for **delivery of the after-coming head in breech presentations**. - They feature a long, curved shank that allows placement from below the maternal pelvis to grasp the fetal head in this particular presentation.

Q: The flexion point in ventouse (vacuum) delivery is located at:

3 cm anterior to the posterior fontanelle. ***3 cm anterior to the posterior fontanelle*** - This is the **correct location of the flexion point** (also described as approximately 6 cm posterior to the anterior fontanelle along the sagittal suture). - This position optimizes the **flexion-traction axis** during vacuum extraction, ensuring that the fetal head descends through the birth canal in the most favorable attitude with maximum flexion. - Correct placement of the vacuum cup at this site provides a **mechanical advantage**, leveraging the natural pivot point of the fetal head for effective delivery and bringing the **occiput** down first. *3 cm posterior to the anterior fontanelle* - This location is **too far anterior**, only 3 cm from the anterior fontanelle, and does not correspond to the true flexion point. - Placing the cup here would result in **suboptimal flexion** and poor mechanical advantage during traction. - This may lead to **cup slippage**, increased rate of failed vacuum delivery, and potential scalp injury. *6 cm anterior to the posterior fontanelle* - Since the distance between fontanelles is approximately 9 cm, this position would be equivalent to 3 cm posterior to the anterior fontanelle (too anterior). - This is **not the correct flexion point** and would result in the same problems as placing the cup too far anterior. *Midway between the anterior and posterior fontanelle* - While this location (approximately 4.5 cm from either fontanelle) might seem intuitive, it does not precisely correspond to the optimal **flexion point** for vacuum extraction. - The true flexion point is slightly more posterior, at **3 cm anterior to the posterior fontanelle**, which optimizes the mechanism of labor.

Q: Identify the instrument given below.

Cusco's speculum. ***Cusco's speculum*** - This is a **bivalved, self-retaining speculum** with two articulated blades that open and close using a **thumbscrew/locking mechanism** at the handle. - Commonly used for **per speculum examination** to visualize the **cervix and vaginal walls** during gynecological procedures. *Sims' speculum* - A **single-bladed (univalve) speculum** that requires an **assistant to hold** during examination, unlike the self-retaining instrument shown. - Used to retract the **posterior vaginal wall** but lacks the dual-blade design visible in the image. *Graves' speculum* - Similar bivalved design to Cusco's but features **longer and wider blades** for better visualization in larger patients. - More commonly used in the **United States**, with a bulkier appearance than the instrument pictured. *Auvard's speculum* - A **weighted, self-retaining single-blade speculum** used as a **posterior vaginal retractor**. - Completely different design from the bivalved instrument shown, with only **one blade** and no locking mechanism.

Q: Which of the following instruments are used in the caesarean section? 1. Bard-Parker blade 2. Doyen's retractor 3. Cusco's speculum 4. Allis forceps 5. Shirodkar's uterine clamp 6. Green Armytage forceps

1,2,4,6. ***Correct: 1,2,4,6*** - **Bard-Parker blade** (scalpel) is used for making the abdominal and uterine incisions in caesarean section. - **Doyen's retractor** is a common abdominal wall retractor used in C-sections to provide good exposure of the uterus. - **Allis forceps** are used to grasp and hold tissues, often the rectus sheath or uterine edges, for traction or approximation during the procedure. - **Green Armytage forceps** are specialized obstetric forceps primarily used to clamp the uterine edges after incision to control bleeding. *Incorrect: 1,2,3,6* - This option incorrectly includes **Cusco's speculum**, which is a vaginal speculum used for gynecological examinations and procedures like colposcopy or Pap smears, not for a caesarean section. - While Bard-Parker blade, Doyen's retractor, and Green Armytage forceps are correct, the inclusion of Cusco's speculum makes this option incorrect. *Incorrect: 1,2,5,6* - This option incorrectly includes **Shirodkar's uterine clamp**. Shirodkar's procedure refers to a type of cervical cerclage, and there isn't a widely recognized "Shirodkar's uterine clamp" used in standard caesarean sections. - Bard-Parker blade, Doyen's retractor, and Green Armytage forceps are correct, but the presence of Shirodkar's uterine clamp makes the option incorrect in the context of a typical C-section. *Incorrect: 1,2,3,5* - This option incorrectly includes both **Cusco's speculum** and **Shirodkar's uterine clamp**. - As explained, Cusco's speculum is for vaginal examination, and Shirodkar's clamp is not a standard instrument for caesarean sections.

Q: A lady with 36-week pregnancy with previous C-section comes with low BP, tachycardia, and on USG fluid present in peritoneum. What is the diagnosis and next management?

Uterine scar rupture with Laparotomy. ***Uterine scar rupture with Laparotomy*** - The presentation of **low blood pressure**, **tachycardia**, and **free fluid in the peritoneum** in a 36-week pregnant woman with a **previous C-section** is highly indicative of uterine scar rupture given the signs of **hemorrhagic shock**. - **Laparotomy** (emergency abdominal surgery) is the immediate and definitive management to repair the ruptured uterus, control bleeding, and deliver the fetus. *Abruptio and C-section* - **Placental abruption** typically presents with painful vaginal bleeding, uterine tenderness, and fetal distress, which are not explicitly mentioned as the primary symptoms here. - While a **C-section** would be indicated for abruption, the presence of free fluid in the peritoneum and hemodynamic instability in a woman with a prior C-section points more towards rupture. *Ectopic pregnancy and abortion* - An **ectopic pregnancy** is ruled out by the 36-week gestational age; these occur much earlier in pregnancy. - An **abortion** refers to the termination of pregnancy and does not cause these specific signs and symptoms at 36 weeks. *Impending dehiscence and Laparoscopy* - **Impending dehiscence** (separation of the uterine scar without complete rupture) would likely cause localized pain but typically not the severe signs of **hypovolemic shock** and free peritoneal fluid seen here. - **Laparoscopy** is a minimally invasive procedure and would not be appropriate for the emergency management of a potentially life-threatening hemorrhage from uterine rupture.

Q: Which of these types of fibroid may be removed at the time of a cesarean section?

Pedunculated fibroid. ***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

Q: Which of the following is consistent with a decision to perform a cerclage?

Cervix dilated to 3 cm. ***Cervix dilated to 3 cm*** - In the context of **mid-trimester cervical dilation** (before 24 weeks) without contractions or bleeding, this represents **cervical insufficiency** - a potential indication for **emergency (rescue) cerclage**. - While 3 cm dilation is at the **upper limit** and somewhat controversial, emergency cerclage may still be considered if membranes are intact, there are no contractions, and gestational age is <24 weeks. - This is the **only option** that represents a clinical scenario where cerclage might be performed, as the other three options are **absolute contraindications**. - Note: Most clinicians prefer cervical dilation **<2 cm** for rescue cerclage, but individual cases at 2-3 cm may be considered based on clinical judgment. *Gestation of 26 weeks* - Cerclage is typically placed between **12-14 weeks** (prophylactic) or up to **23-24 weeks** (emergency). - At **26 weeks**, cerclage is **contraindicated** - the risks (membrane rupture, infection, preterm labor) outweigh benefits at this advanced gestation. - This is an **absolute contraindication** regardless of cervical findings. *Uterine bleeding* - **Active uterine bleeding** is an **absolute contraindication** to cerclage placement. - Bleeding increases risks of **infection, membrane rupture, and preterm labor**. - Must rule out **placental abruption, placenta previa**, or other complications before considering any cervical intervention. *Uterine contractions* - **Active uterine contractions** are an **absolute contraindication** for cerclage. - Placing cerclage during contractions can precipitate **preterm labor and delivery**. - Contractions indicate the cervix may be responding to labor stimuli, making cerclage ineffective and potentially harmful.

Q: Contraindications to ventouse delivery include all of the following except :

Occipito transverse position. ***Occipito transverse position*** - This is **NOT a contraindication** to ventouse delivery and is the correct answer - Ventouse can be successfully used to assist with **rotation** from occipito transverse to occipito anterior position before extraction - Modern ventouse techniques specifically allow for **controlled rotation** during delivery - This is a common indication for instrumental delivery rather than a contraindication *Face presentation* - Applying a ventouse cup to the fetal face is **absolutely contraindicated** due to high risk of **facial trauma**, soft tissue injury, eye damage, and neurological complications - The cup cannot achieve proper placement on the facial bones - Face presentation typically requires **cesarean section** or careful management with forceps only in specific mentum anterior positions *Fetal coagulopathies* - This is a **strong contraindication** to ventouse delivery due to the increased risk of **intracranial hemorrhage** and other bleeding complications in the neonate - Conditions like hemophilia, thrombocytopenia, or Von Willebrand disease make any instrumental trauma potentially life-threatening - The traction and pressure from the ventouse cup can cause **scalp hematomas, subgaleal hemorrhage, or intracranial bleeding** in coagulopathic fetuses *Extreme prematurity* - **Extreme prematurity** (typically <34 weeks gestation) is a contraindication to ventouse delivery due to the **fragility of the fetal skull** and markedly increased risk of **intracranial hemorrhage** - The incompletely ossified skull and delicate cerebral vasculature make preterm infants highly vulnerable to trauma from vacuum extraction - Instrumental delivery in preterm infants carries unacceptably high risk of **intraventricular hemorrhage** and long-term neurological injury

Q: In modern era, the only indication for Internal Podalic Version is:

Delivery of Second baby of twins. ***Delivery of Second baby of twins*** - **Internal Podalic Version (IPV)** is primarily indicated for the delivery of the second twin in cases where the second twin presents in a **non-cephalic presentation** or has a malpresentation after the delivery of the first twin. - This procedure aims to quickly deliver the second twin by grasping its feet and converting it into a **breech presentation**, reducing the risk of complications such as **abruptio placentae** or fetal distress. *Transverse lie* - While a transverse lie would typically require intervention, **external cephalic version (ECV)** is usually attempted first to convert the fetus to a cephalic presentation. - If ECV fails or is contraindicated, a **cesarean section** is generally the safest approach for a transverse lie in a singleton pregnancy, rather than IPV. *Breech presentation* - For a singleton **breech presentation** at term, management options include planned **cesarean section** or, in select cases, a trial of vaginal breech delivery. - IPV is **not typically performed** for a primary breech presentation in a singleton pregnancy due to potential risks to the fetus and uterus. *Oblique lie* - An **oblique lie** is often unstable and may convert to a longitudinal or transverse lie spontaneously or with intervention. - Similar to a transverse lie, **external cephalic version (ECV)** would be the initial consideration to convert it to a cephalic presentation, or a **cesarean section** if ECV is unsuccessful or contraindicated.

Q: Shirodkar cerclage may be associated with all complications except:

Paresthesia over inner aspect. ***Paresthesia over inner aspect*** - Paresthesia over the inner thigh is typically associated with injury to the **femoral nerve** or its branches, or the **obturator nerve**. - While surgery in the pelvic region always carries some nerve injury risk, a Shirodkar sling operation, which is a cervical cerclage, is **unlikely to directly cause paresthesia** in this specific distribution. *Enterocele* - An **enterocele** is a type of pelvic organ prolapse where the small bowel descends into the lower pelvic cavity, creating a bulge in the vagina. - The Shirodkar sling procedure involves placing a suture around the cervix, which can alter pelvic anatomy and potentially contribute to the development or worsening of an enterocele, by **changing pressure dynamics** or creating adhesion. *Ureteral injury* - The **ureters** pass close to the cervix as they course into the bladder, especially where the uterosacral ligaments attach. - During the placement of the Shirodkar cervical cerclage, there is a risk of **ligating or damaging the ureters** due to their proximity to the surgical field. *Subacute intestinal obstructions* - Any pelvic surgery, including a Shirodkar sling operation, carries a risk of **adhesion formation**. - These **post-surgical adhesions** can involve segments of the bowel, potentially leading to kinking or narrowing of the intestinal lumen, which can cause symptoms of subacute intestinal obstruction.

Question 1

Identify the instrument shown in the image below:

Accepted Answer

Kielland

Answer

Simpson

Answer

Wrigley

Answer

Pipers

Question 2

The flexion point in ventouse (vacuum) delivery is located at:

Accepted Answer

3 cm anterior to the posterior fontanelle

Answer

3 cm posterior to the anterior fontanelle

Answer

6 cm anterior to the posterior fontanelle

Answer

Midway between the anterior and posterior fontanelle

Question 3

Identify the instrument given below.

Accepted Answer

Cusco's speculum

Answer

Sims' speculum

Answer

Graves' speculum

Answer

Auvard's speculum

Question 4

Which of the following instruments are used in the caesarean section?

1. Bard-Parker blade
2. Doyen's retractor
3. Cusco's speculum
4. Allis forceps
5. Shirodkar's uterine clamp
6. Green Armytage forceps

Accepted Answer

1,2,4,6

Answer

1,2,3,6

Answer

1,2,5,6

Answer

1,2,3,5

Question 5

A lady with 36-week pregnancy with previous C-section comes with low BP, tachycardia, and on USG fluid present in peritoneum. What is the diagnosis and next management?

Accepted Answer

Uterine scar rupture with Laparotomy

Answer

Abruptio and C-section

Answer

Ectopic pregnancy and abortion

Answer

Impending dehiscence and Laparoscopy

Question 6

Which of these types of fibroid may be removed at the time of a cesarean section?

Accepted Answer

Pedunculated fibroid

Answer

Broad ligament fibroid

Answer

Cervical fibroid

Answer

Intramural

Question 7

Which of the following is consistent with a decision to perform a cerclage?

Accepted Answer

Cervix dilated to 3 cm

Answer

Gestation of 26 weeks

Answer

Uterine bleeding

Answer

Uterine contractions

Question 8

Contraindications to ventouse delivery include all of the following except :

Accepted Answer

Occipito transverse position

Answer

Face presentation

Answer

Fetal coagulopathies

Answer

Extreme prematurity

Question 9

In modern era, the only indication for Internal Podalic Version is:

Accepted Answer

Delivery of Second baby of twins

Answer

Transverse lie

Answer

Breech presentation

Answer

Oblique lie

Question 10

Shirodkar cerclage may be associated with all complications except:

Accepted Answer

Paresthesia over inner aspect

Answer

Enterocele

Answer

Ureteral injury

Answer

Subacute intestinal obstructions

Operative Obstetrics — MCQs

Operative Obstetrics — MCQs

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