Operative Obstetrics — MCQs

Operative Obstetrics Indian Medical PG Practice Questions and MCQs

Question 231: Classical cesarean section is specifically indicated in which of the following conditions?

A. Transverse lie with back down
B. Placenta previa with anterior placenta accreta
C. Cervical cancer involving lower uterine segment (Correct Answer)
D. Previous two cesarean sections

Explanation: ***Cervical cancer involving lower uterine segment*** - A classical cesarean section, involving a **vertical incision into the upper uterine segment**, allows for delivery of the fetus without disturbing the cancerous cervix and lower uterine segment. - This approach minimizes the risk of **tumor dissemination** and excessive bleeding, which would be high with a low transverse incision. *Transverse lie with back down* - A **low transverse cesarean section** is generally preferred for a transverse lie presentation as it aligns better with the uterine architecture and is associated with fewer future uterine rupture risks. - A classical incision is typically reserved for extreme cases of transverse lie (e.g., morbidly obese patient making access difficult or fetal anomaly) or when the **lower uterine segment is not adequately formed**. *Placenta previa with anterior placenta accreta* - This condition typically necessitates a **low transverse cesarean section**, often combined with a **hysterectomy**, due to the abnormal placental adherence to the anterior lower uterine segment. - A classical incision would likely lead to **significant hemorrhage** and may not effectively manage the adherent placenta. *Previous two cesarean sections* - While a previous cesarean section increases the risk of uterine rupture in subsequent pregnancies, it does not automatically indicate a classical cesarean section for the third delivery. - A repeat **low transverse cesarean section** is usually performed as it carries a lower risk of rupture in future pregnancies compared to a classical incision scar.

Question 232: McDonald stitch is applied in the following conditions except:

A. Placenta previa (Correct Answer)
B. Incompetent os
C. Previous history of preterm birth
D. Bad obstetrical history

Explanation: ***Placenta previa*** - McDonald stitch (cervical cerclage) is a procedure to prevent **premature cervical dilation** and is not indicated for **placenta previa** - **Placenta previa** involves the placenta covering the cervical os, which can cause antepartum hemorrhage and usually necessitates a cesarean section - Cerclage is contraindicated as it does not address placental position and manipulation of the cervix could provoke bleeding *Incompetent os* - This is the **primary indication** for McDonald cerclage, as it directly addresses cervical insufficiency that leads to painless cervical dilation and second-trimester pregnancy loss - The cerclage reinforces the weak cervix, preventing **preterm birth** due to cervical incompetence - This can be diagnosed by history, physical examination, or ultrasound findings *Previous history of preterm birth* - A history of **recurrent second-trimester miscarriages** or **preterm deliveries** attributed to cervical insufficiency is a strong indication for prophylactic McDonald cerclage - This is termed **history-indicated cerclage**, performed electively between 12-14 weeks in subsequent pregnancies - Studies show cerclage reduces preterm birth rates in women with prior spontaneous preterm births due to cervical factors *Bad obstetrical history* - Bad obstetric history, particularly with **recurrent second-trimester losses** suggesting cervical insufficiency, is a classic indication for prophylactic cerclage - This overlaps with history-indicated cerclage and aims to prevent recurrence in high-risk patients - Thorough evaluation is needed to confirm cervical etiology rather than other causes of pregnancy loss

Question 233: ECV is absolutely contraindicated in all except :

A. Previous LICS scar (Correct Answer)
B. Septate uterus
C. Severe pre-eclampsia
D. Placenta previa

Explanation: ***Previous LICS scar*** - A **previous lower uterine segment C-section (LICS) scar** is considered a **relative contraindication**, not an absolute contraindication for ECV. - Current guidelines (ACOG, RCOG) indicate that ECV can be attempted in carefully selected women with one prior cesarean delivery, though success rates may be lower. - While there is a theoretical increased risk of **uterine rupture** or **scar dehiscence**, studies have shown this risk remains low (approximately 0.02-0.08%), and many practitioners will offer ECV after thorough counseling and informed consent. - **This is the correct answer** - it is NOT an absolute contraindication. *Septate uterus* - A **septate uterus** (uterine anomaly) is generally considered a **relative contraindication** or significant limiting factor for ECV, though some sources treat it more strictly. - The uterine septum can impair fetal manipulation and reduce success rates significantly, making ECV technically challenging and potentially less likely to succeed. - While not universally classified as "absolute," severe uterine anomalies create substantial barriers to successful version and increase procedural risks, leading many practitioners to avoid ECV in these cases. *Severe pre-eclampsia* - **Severe pre-eclampsia** is an **absolute contraindication** for ECV. - The procedure can exacerbate maternal hypertension, increase risk of **seizures (eclampsia)**, and trigger **placental abruption** or **fetal compromise**. - The physiological stress of ECV is contraindicated in an already unstable maternal-fetal condition. *Placenta previa* - **Placenta previa** is an **absolute contraindication** for ECV. - Any uterine or fetal manipulation carries significant risk of causing **severe hemorrhage** and **placental separation**. - The abnormal placental location makes vaginal delivery contraindicated regardless of presentation, and ECV would serve no clinical purpose while exposing mother and fetus to serious bleeding risks.

Question 234: 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 235: The most important point of reference in the use of forceps is :

A. Posterior sagittal diameter
B. Station of biparietal diameter
C. Pelvic axis (Correct Answer)
D. The Plane of greatest dimension

Explanation: ***Pelvic axis*** - The **pelvic axis** is the most important reference point during forceps use, as it defines the **curved path** through which the fetal head must be guided during delivery. - **Traction during forceps delivery must follow the pelvic axis** to minimize trauma to both mother and fetus. Incorrect direction of traction can cause serious complications including cervical tears, vaginal lacerations, and fetal injury. - The pelvic axis curves from the **inlet (pointing downward and backward)** through the **midpelvis (pointing backward)** to the **outlet (pointing downward and forward)**. Understanding and following this curve is essential for safe forceps application. *Station of biparietal diameter* - While the **station** (level of descent relative to ischial spines) is crucial for determining **eligibility** for forceps delivery, it is not the primary reference point during the actual use of forceps. - Station confirms adequate engagement and descent (typically ≥+2 required for outlet forceps), but once this prerequisite is met, the **pelvic axis guides the actual procedure**. *Posterior sagittal diameter* - The **posterior sagittal diameter** is a pelvic measurement used to assess pelvic capacity, particularly in cases of potential cephalopelvic disproportion. - While important for overall pelvic assessment, it does not serve as the primary reference during forceps application. *The Plane of greatest dimension* - The **plane of greatest dimension** is an anatomical landmark in the midpelvis, representing the most spacious part of the pelvic cavity. - While it is part of the overall pelvic architecture, it is not the key reference point that guides forceps traction during delivery.

Question 236: Distending media used in hysteroscopy are all except

A. Carbon dioxide
B. Glycine
C. 5% dextrose
D. Hyskon (32% Dextran 70) (Correct Answer)

Explanation: ***Hyskon (32% Dextran 70)*** - **CORRECT ANSWER (NOT commonly used as first-line)** - **Hyskon (32% Dextran 70)** is a **viscous, high-molecular-weight dextran solution** that was historically used for hysteroscopy but has **largely fallen out of favor** due to significant complications. - Major concerns include: **anaphylactic reactions**, **pulmonary edema**, **coagulopathy**, **difficulty cleaning equipment**, and **high cost**. - Most modern hysteroscopy centers **avoid Hyskon** and prefer safer alternatives like normal saline or CO2. - While technically a distending medium, it is **rarely used in current practice** due to these safety concerns. *Carbon dioxide* - **Carbon dioxide (CO2)** is a commonly used **gaseous distending medium** for diagnostic hysteroscopy due to its ability to provide **clear visualization** and rapid absorption. - It is typically administered using an **insufflator** that controls flow rate and pressure, minimizing the risk of gas embolism. - Preferred for **diagnostic procedures** but not suitable when bleeding is present. *Glycine* - **Glycine (1.5%)** is an **electrolyte-free, hypotonic solution** commonly used as a distending medium during **operative hysteroscopy** with monopolar electrosurgery. - Its non-conductive properties prevent dispersion of electrical current, making it safe for use with **monopolar electrosurgical instruments**. - Risk of **hyponatremia** with excessive absorption requires monitoring of fluid deficit. *5% dextrose* - **5% dextrose in water (D5W)** is a commonly used **hypotonic, electrolyte-free fluid** for hysteroscopy, especially when **monopolar electrocautery** is employed. - Its non-conductive nature prevents electrical current dissipation, and it is **physiologically well-tolerated** with lower risk of complications. - Can be used for both diagnostic and operative procedures.

Question 237: All of the following are contraindications of ventouse extraction, EXCEPT:

A. Face presentation
B. Transverse lie
C. Anemia (Correct Answer)
D. Fetal macrosomia

Explanation: ***Anemia*** - **Maternal anemia** is generally not considered a contraindication for ventouse extraction, as the procedure primarily assists in the delivery of the fetus. - While **severe maternal anemia** might influence decisions regarding overall maternal health and blood product availability, it does not directly preclude the use of a ventouse for fetal extraction. *Face presentation* - **Ventouse extraction** is contraindicated in face presentation because the application of the cup to the fetal face can cause **severe facial trauma**, including nerve damage and bruising. - The mechanics of traction are also ineffective and potentially harmful in this presentation. *Transverse lie* - A **transverse lie** means the fetus is lying horizontally across the uterus, making a **vaginal delivery** impossible without external or internal version to change the lie. - Ventouse extraction requires the fetal head to be engaged in the maternal pelvis, which is not the case in a transverse lie, thereby categorizing it as a contraindication. *Fetal macrosomia* - **Fetal macrosomia** (excessively large fetus) significantly increases the risk of **shoulder dystocia** and other birth traumas, making ventouse extraction less safe and potentially ineffective. - The forces required for extraction could lead to **fetal injury** (e.g., cephalohematoma, intracranial hemorrhage) or maternal injury (e.g., vaginal lacerations).

Question 238: Termination of pregnancy in placenta previa is indicated in: a) Active bleeding b) Active labour c) Gestational age > 34 weeks with live fetus d) Fetal malformation e) Unstable lie

A. acd
B. ab (Correct Answer)
C. e
D. abd
E. abc

Explanation: ***ab*** - **Active bleeding** in placenta previa is an absolute indication for immediate delivery (usually by cesarean section) due to the risk of life-threatening maternal and fetal hemorrhage. - **Active labour** with placenta previa is a critical indication for immediate cesarean delivery, as progressive cervical dilation causes placental separation leading to catastrophic hemorrhage. *acd* - While active bleeding is an indication, gestational age > 34 weeks alone does not mandate immediate delivery in stable placenta previa patients. Expectant management until 36-37 weeks is standard practice. *e* - Unstable lie is not an indication for termination of pregnancy in placenta previa. While it may necessitate cesarean section at term, it does not indicate immediate delivery. *abc* - Active bleeding and active labour are correct indications, but gestational age > 34 weeks with a live fetus is NOT an isolated indication for immediate delivery in stable patients without bleeding. *abd* - Active bleeding and active labour are correct indications, but fetal malformation is not a specific indication for termination in the context of placenta previa management. Fetal malformation decisions are made independently of placenta previa status.

Question 239: Which is not an indication for a classical cesarean incision?

A. Premature breech
B. Cannot visualize the lower uterine segment
C. Transverse lie
D. Term breech (frank) (Correct Answer)

Explanation: ***Term breech (frank)*** - A **frank breech** presentation at term does not inherently require a classical (vertical) incision, as a **low transverse incision** is generally safe and preferred for its lower risk of uterine rupture in subsequent pregnancies. - The decision for incision type is based more on the accessibility of the **lower uterine segment** and fetal lie than on the specific type of breech at term. *Premature breech* - In a premature fetus, the **lower uterine segment** may be underdeveloped and insufficient to allow safe extraction through a low transverse incision. - A **classical incision** provides a larger opening in the thicker, upper uterine segment, which is safer for a fragile preterm infant. *Cannot visualize the lower uterine segment* - Conditions like **dense adhesions** from prior surgeries, a large **leiomyoma**, or an **anterior placenta previa** can obscure or make the lower uterine segment inaccessible. - In such cases, a **classical incision** in the more visible and accessible upper uterine corpus is indicated to safely deliver the fetus. *Transverse lie* - A **transverse lie** means the fetus is lying horizontally across the uterus, often making a **low transverse incision** difficult or impossible due to the fetal position. - A **classical incision** allows for a larger, more vertical opening that accommodates the fetal spine and shoulders, facilitating safe extraction.

Question 240: All of the following operations are done for uterine prolapse except:

A. Abdominocervicopexy
B. Shirodkar (Correct Answer)
C. Khanna
D. Manchester

Explanation: ***Shirodkar*** - The **Shirodkar procedure** is a type of **cervical cerclage** used to address **cervical insufficiency** during pregnancy, to prevent preterm birth. - It involves placing a stitch around the cervix to keep it closed and is **not used for uterine prolapse**. *Abdominocervicopexy* - This procedure involves attaching the **cervix** to the **abdominal wall** using a sling-like material. - It is a recognized surgical technique for correcting **uterine prolapse**, particularly in younger women who wish to retain their uterus. *Khanna* - The **Khanna sling operation** is a specific type of **vaginal sling technique** used to support the uterus or vaginal vault. - It aims to suspend the prolapsed organ to stabilize its position within the pelvis. *Manchester* - The **Manchester operation** (also known as Fothergill's operation) is a classic procedure for **uterine prolapse** when the cervix is elongated. - It involves **cervical amputation**, **repair of the cardinal ligaments**, **anterior colporrhaphy**, and **posterior colpoperineorrhaphy**.

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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