Operative Obstetrics — MCQs

Operative Obstetrics Indian Medical PG Practice Questions and MCQs

Question 251: Which of the following is an absolute indication for elective repeat caesarean section in a patient with previous caesarean delivery?

A. Placenta accreta spectrum
B. Previous classical incision (Correct Answer)
C. Failed TOLAC (Trial of Labor After Cesarean)
D. Uterine rupture/scar dehiscence

Explanation: ***Previous classical incision*** - A **classical incision** (vertical uterine incision in the upper uterine segment) carries a **4-9% risk of uterine rupture** in subsequent pregnancies, compared to 0.5-1% with low transverse incisions. - **VBAC (Vaginal Birth After Cesarean) is absolutely contraindicated** with a previous classical incision due to the high rupture risk. - This is a **standing absolute indication** for elective repeat cesarean section at 36-37 weeks gestation. - Other absolute indications include previous T-incision, J-incision, and previous uterine rupture. *Uterine rupture/scar dehiscence* - **Uterine rupture** is a catastrophic **intrapartum emergency** requiring immediate cesarean delivery. - This is not a pre-existing "indication" but rather an **acute complication** that occurs during labor. - Previous uterine rupture (not active rupture) would be an absolute indication for planned repeat C-section. *Placenta accreta spectrum* - This involves abnormal placental invasion and is strongly associated with previous C-sections. - While it requires cesarean delivery with possible hysterectomy, it is a **complication of placental implantation**, not a direct indication based on the previous uterine incision type. - It necessitates C-section but is not specific to the type of previous cesarean scar. *Failed TOLAC (Trial of Labor After Cesarean)* - A **failed TOLAC** means cesarean delivery is required because vaginal delivery could not be achieved. - This is an **intrapartum decision** based on failure to progress or fetal compromise, not a pre-existing indication for planned repeat C-section.

Question 252: Symphysiotomy is indicated in:

A. Contraction of cavity
B. Contraction of outlet (Correct Answer)
C. Contraction of brim
D. All of these

Explanation: ***Contraction of outlet*** - Symphysiotomy is a procedure where the **fibrocartilaginous joint of the pubic symphysis is divided**, temporarily increasing the pelvic diameters. - It is specifically indicated in cases of **outlet contraction** where the fetal head is engaged but cannot pass through the pelvic outlet, often due to a narrow subpubic angle. *Contraction of cavity* - **Mid-pelvic contraction** (cavity contraction) is typically managed with a **cesarean section** if there is significant fetopelvic disproportion, as symphysiotomy may not adequately increase the mid-pelvic dimensions. - The primary purpose of symphysiotomy is to slightly widen the *anterior-posterior* and *transverse* diameters of the outlet, which is less effective for mid-pelvis issues. *Contraction of brim* - **Inlet contraction** (brim contraction) implies that the fetal head cannot engage or enter the pelvis. - In such cases, a **cesarean section** is the standard and safest approach as engagement is impossible and symphysiotomy cannot address the contracted inlet. *All of these* - Symphysiotomy is a niche procedure with specific indications, primarily for **outlet contraction**, and is generally not appropriate for inlet or significant mid-cavity contractions. - Applying it to all forms of pelvic contraction would lead to higher risks and poor outcomes for mother and baby.

Question 253: A pregnant lady with persistent variable decelerations with cervical dilatation of 6 cm is planned for emergency LSCS. Which of the following is NOT done in management while preparing patient for surgery

A. O2 inhalation
B. I.V. fluid
C. Foley catheterization
D. Supine position (Correct Answer)

Explanation: ***Supine position*** - Maintaining a **supine position** in a pregnant woman can lead to **aortocaval compression**, reducing **venous return** and **cardiac output**, which compromises uterine blood flow and fetal oxygenation. - To prevent this, the patient should be placed in a **left lateral tilt** (wedge under the right hip) to displace the uterus off the great vessels. *O2 inhalation* - Administering **oxygen via face mask** increases the mother's partial pressure of oxygen (PaO2), which can improve **fetal oxygenation** and potentially alleviate fetal distress. - This is a standard and safe intervention to maximize oxygen delivery to the fetus, especially in cases of **fetal compromise** indicated by variable decelerations. *I.V. fluid* - Administering **intravenous fluids** helps maintain maternal hydration and **circulatory volume**, crucial for adequate uterine perfusion. - This can improve **placental blood flow**, potentially reducing the frequency or severity of variable decelerations by increasing amniotic fluid volume and relieving **cord compression**. *Foleys catheterisation* - **Foley catheterization** is essential before a Cesarean section to **decompress the bladder**, preventing injury during surgery and improving surgical exposure. - A full bladder can obstruct the surgical field and increases the risk of accidental incision, therefore, it is a routine pre-operative step.

Question 254: A 29-year-old woman with a ruptured ectopic pregnancy is admitted to a hospital for culdocentesis. A long needle on the syringe is most efficiently inserted through which of the following structures?

A. Anterior wall of the rectum
B. Posterior fornix of the vagina (Correct Answer)
C. Anterior fornix of the vagina
D. Posterior wall of the uterine body

Explanation: ***Posterior fornix of the vagina*** - Culdocentesis is a procedure where fluid is aspirated from the **cul-de-sac (rectouterine pouch)**. - The **posterior vaginal fornix** is the thinnest and most accessible anatomical landmark for safely accessing the rectouterine pouch. *Anterior wall of the rectum* - Puncturing the **anterior rectal wall** could lead to peritonitis and is not the intended approach for culdocentesis. - The rectum is located posterior to the rectouterine pouch, making it an inappropriate entry point. *Anterior fornix of the vagina* - The **anterior fornix** is anatomically adjacent to the vesicouterine pouch (between the bladder and uterus), not the rectouterine pouch. - Puncturing this area would not access the fluid collection from a ruptured ectopic pregnancy, which accumulates in the rectouterine pouch. *Posterior wall of the uterine body* - Puncturing the **posterior wall of the uterine body** would damage the uterus and is not a route to the cul-de-sac. - The procedure aims to access the space behind the uterus, not the uterine organ itself.

Question 255: In anterior colporrhaphy, the best method of suture apposing the vaginal flaps is:

A. Interrupted (Correct Answer)
B. Continuous
C. Interrupted mattress
D. Interlocking

Explanation: ***Interrupted*** - **Interrupted sutures** are preferred in anterior colporrhaphy to allow for drainage and prevent hematoma formation, which can impair healing. - They also distribute tension more evenly across the surgical wound, reducing the risk of wound dehiscence. *Continuous* - **Continuous sutures** are generally avoided in colporrhaphy as they can create a closed space that traps fluid, increasing the risk of infection and hematoma. - If a single point of the suture breaks, the entire closure can unravel, compromising wound integrity. *Interrupted mattress* - While **interrupted mattress sutures** offer strong apposition, they are often more complex and time-consuming to place compared to simple interrupted sutures. - The added bulk and multiple passes through tissue may also increase the risk of tissue ischemia if tied too tightly. *Interlocking* - **Interlocking sutures** are primarily used for hemostasis and are less suitable for mucosal apposition in colporrhaphy. - They tend to create a tighter, more constricting closure that can impede wound drainage and increase tissue tension.

Question 256: Absolute indication for cesarean section is :

A. Breech presentation
B. Dystocia
C. Fetal distress
D. Previous rupture of uterus (Correct Answer)

Explanation: ***Previous rupture of uterus*** - A prior **rupture of the uterus** creates a significant risk of **re-rupture** in subsequent pregnancies with labor contractions, posing a severe threat to both maternal and fetal life. - Due to the high risk of catastrophic hemorrhage and fetal distress, **elective cesarean section** before the onset of labor is mandated to prevent recurrence. *Breech presentation* - While many breech presentations result in a cesarean section, it is not an absolute indication, as **vaginal breech delivery** can be attempted in selected cases under strict criteria. - Factors like type of breech, estimated fetal weight, and maternal pelvis can influence the decision, making it a relative rather than an absolute indication. *Dystocia* - **Dystocia**, or difficult labor, is a common reason for cesarean section, but often interventions like **oxytocin augmentation** or **instrumental delivery** (forceps, vacuum) are attempted first. - A cesarean section is indicated when dystocia is severe or fails to respond to other measures, making it a relative indication based on progression of labor. *Fetal distress* - **Fetal distress**, indicated by non-reassuring fetal heart rate patterns, often necessitates prompt delivery, but the mode of delivery depends on the clinical situation. - If vaginal delivery is imminent and safe, it may be preferred, but if not, **cesarean section** is performed; therefore, it's an urgent relative indication rather than an absolute one.

Question 257: Which nerve block is given in forceps delivery?

A. Posterior femoral
B. Genitofemoral
C. Ilioinguinal
D. Pudendal (Correct Answer)

Explanation: ***Pudendal*** - A **pudendal block** anesthetizes the **perineum, vulva, and lower vagina**, providing pain relief for instrumental deliveries like **forceps delivery** and for episiotomy. - It involves injecting a local anesthetic near the **pudendal nerve** as it passes posterior to the **ischial spine**. *Posterior femoral* - The **posterior femoral cutaneous nerve** primarily innervates the skin of the posterior thigh and part of the perineum but does not provide sufficient deep analgesia for a forceps delivery. - Blocking this nerve alone would not adequately cover the extensive area affected during instrumental delivery. *Genitofemoral* - The **genitofemoral nerve** primarily innervates the skin of the upper medial thigh and parts of the genitalia but is not the primary nerve for pain relief during vaginal delivery procedures. - Its blockade would not provide the comprehensive analgesia needed for a forceps delivery. *Ilio inguinal* - The **ilioinguinal nerve** innervates the skin of the groin, mons pubis, and labia majora but does not provide sufficient anesthesia for the deeper structures involved in a forceps delivery. - An ilioinguinal nerve block is more commonly used for pain control in procedures involving the groin or hernia repair, not for instrumental vaginal delivery.

Question 258: Patient came with H/O prolonged labour (15 hrs) in emergency. On examination there were signs of obstructed labour. Ideal position for the patient to undergo the cesarean section?

A. Supine with wedge under right hip. (Correct Answer)
B. Semi-Fowler position
C. Prone position with legs in stirrup
D. Trendelenburg with legs in stirrup

Explanation: ***Supine with wedge under right hip*** - This position prevents **aortocaval compression** by the gravid uterus, which can lead to **supine hypotensive syndrome** and compromise placental perfusion. - The **left lateral tilt** achieved by the wedge under the right hip optimizes maternal hemodynamics and fetal oxygenation during C-section. *Trendelenburg with legs in stirrup* - This position is primarily used for procedures requiring better visualization of the **pelvic organs**, like gynecological surgeries or to facilitate venous return. - It would not prevent aortocaval compression and could exacerbate respiratory challenges in a pregnant patient. *Semi-Fowler position* - The semi-Fowler position is typically used for patients with **respiratory distress** to aid ventilation or during certain upper abdominal surgeries to improve surgical access. - It does not address the critical issue of aortocaval compression in a pregnant patient undergoing C-section. *Prone position with legs in stirrup* - The prone position is used for **posterior surgical approaches** to the spine or for procedures on the buttocks/perineum. - It is entirely inappropriate for a C-section, as it would make surgical access to the uterus impossible and pose significant risks to both mother and fetus.

Question 259: Which of these is the ONLY true statement regarding Caesarean section?

A. Exteriorisation of uterus for repair of uterine incision is detrimental step and hence avoided
B. Lower segment caesarean has lower risk of scar dehiscence in next pregnancy compared to classical (Correct Answer)
C. Two layer closure of uterine incision is associated with significantly less risk of scar rupture
D. All incidental uterine fibroids should be excised during LSCS

Explanation: ***Lower segment caesarean has lower risk of scar dehiscence in next pregnancy compared to classical*** - The **lower uterine segment** is thinner and has less muscular tissue, which heals with a stronger and more pliable scar, reducing the risk of **scar dehiscence** in subsequent pregnancies. - A **classical C-section** involves a vertical incision in the active muscular upper uterine segment, which heals with a weaker scar and carries a significantly higher risk of **uterine rupture** in future pregnancies. *Exteriorisation of uterus for repair of uterine incision is detrimental step and hence avoided* - **Uterine exteriorization** (bringing the uterus out of the abdomen) during C-section for repair is a common practice and is generally considered safe, offering better visualization and easier repair of the **uterine incision**. - While some studies suggest it might lead to more pain or blood loss, the benefits for **hemostasis** and repair quality often outweigh the potential risks, and it is not universally avoided as a detrimental step. *Two layer closure of uterine incision is associated with significantly less risk of scar rupture* - Current evidence suggests that **single-layer closure** of the uterine incision in a **lower segment C-section** is as safe as two-layer closure regarding scar rupture in future pregnancies. - There is no significant difference in the rates of **scar rupture** or other maternal outcomes between one-layer and two-layer closures for the lower uterine segment incision. *All incidental uterine fibroids should be excised during LSCS* - Excision of incidental **uterine fibroids** found during a C-section is generally discouraged due to the significant risk of **heavy bleeding** (**postpartum hemorrhage**) in the highly vascular pregnant uterus. - Myomectomy at the time of C-section is usually reserved for specific situations where the fibroid is obstructing the birth canal or causing significant bleeding, and the patient has consented to the increased risks.

Question 260: Which one of the following methods of MTP is associated with the complication of coagulopathy:

A. Ethacrydine lactate
B. Aspirotomy
C. Prostaglandins
D. Hypertonic saline (Correct Answer)

Explanation: ***Hypertonic saline*** - Intra-amniotic instillation of **hypertonic saline** can lead to **disseminated intravascular coagulation (DIC)** due to its toxic effect on fetal endothelial cells and release of thromboplastin-like substances from the placenta. - This method is associated with a higher risk of **coagulopathy**, specifically a decrease in fibrinogen levels, which is a severe complication. - This technique is now largely abandoned due to these serious complications. *Ethacridine lactate (Rivanol)* - **Ethacridine lactate** is an **antiseptic and abortifacient** used for second-trimester MTP via intra-amniotic instillation. - While it can cause prolonged labor and cervical trauma, it is **not primarily associated with coagulopathy** as a major complication compared to hypertonic saline. - Its main adverse effects include fever, gastrointestinal disturbances, and prolonged induction-abortion interval. *Aspirotomy (Vacuum aspiration)* - **Vacuum aspiration** is a surgical method to empty the uterus, and while it carries general risks of infection or uterine perforation, it is **not directly linked to coagulopathy**. - It is one of the safer and more common methods for first-trimester termination. *Prostaglandins* - **Prostaglandins** such as misoprostol or dinoprostone are commonly used for medical and surgical abortion, inducing uterine contractions. - While they have various side effects (nausea, vomiting, diarrhea), they are **not primarily associated with systemic coagulopathy** as a direct complication.

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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