Operative Obstetrics — MCQs
On this page
A patient underwent LSCS for arrest of second stage of labour. A lateral extension of an angle of uterine incision occurred during delivery of head which was secured. Post operatively after 2 hours patient develops pallor, abdominal distension with tachycardia. Hb dropped from 10 gm% (pre op) to 6.5 gm%. Pelvic exam revealed mild PPH. Next step in management is?
Classical cesarean section is done in?
True statements about vacuum extraction of a fetus: (A) Can be used in incompletely dilated cervix (B) Used in Face presentation (C) Applied 3cm posterior to Anterior fontanel (D) Applied 3cm anterior to posterior fontanel
MVA syringe is used for?
Indications for cesarean hysterectomy are all except:
A 30-year-old multigravida presented with transverse lie with hand prolapse in 2nd stage of labour with dead fetus. The treatment is :
The best method of evacuation of a missed abortion in uterus of more than 12 weeks:
Bleeding in rupture of the uterus associated with a large broad ligament hematoma is controlled most simply by :
35 yr old primigravida conceived after IVF cycle attends obstetrics clinic with 38 weeks gestation. Her obstetric details reveal DiCho-DiAmn twins with 1st twin as breech. Her BP was 140/90 mmHg on 2 occasions with proteinuria +1. How will you manage this case?
Which method is most appropriate for cervical ripening in a term pregnancy with oligohydramnios and reactive NST?
Operative Obstetrics Indian Medical PG Practice Questions and MCQs
Question 261: A patient underwent LSCS for arrest of second stage of labour. A lateral extension of an angle of uterine incision occurred during delivery of head which was secured. Post operatively after 2 hours patient develops pallor, abdominal distension with tachycardia. Hb dropped from 10 gm% (pre op) to 6.5 gm%. Pelvic exam revealed mild PPH. Next step in management is?
- A. Blood transfusion and monitoring
- B. Intrauterine packing and blood transfusion
- C. Immediate exploration in OT (Correct Answer)
- D. Uterotonics for control of PPH and blood transfusion
Explanation: ***Immediate exploration in OT*** - The patient presents with signs of **hypovolemic shock** (pallor, tachycardia, significant drop in Hb) and **abdominal distension** after a lateral extension of the uterine incision, which strongly suggests **internal bleeding**. - Given the rapid deterioration and suspicion of internal hemorrhage, **immediate surgical exploration** is crucial to identify and repair the bleeding source. *Blood transfusion and monitoring* - While a **blood transfusion** is essential for stabilizing the patient, it is not sufficient as the sole intervention in the presence of ongoing, significant internal bleeding. - **Monitoring** alone can delay definitive treatment, leading to further deterioration and potentially life-threatening complications. *Intrauterine packing and blood transfusion* - **Intrauterine packing** is primarily used for **uterine atony** or **diffuse uterine bleeding** within the uterine cavity. - In this case, the bleeding is likely due to the **extension of the uterine incision** into surrounding tissues (e.g., broad ligament, uterine artery), which will not be controlled by intrauterine packing. *Uterotonics for control of PPH and blood transfusion* - **Uterotonics** are effective for **uterine atony**, which is a common cause of **postpartum hemorrhage (PPH)**, but less likely to control bleeding from a lacerated vessel due to an incisional extension. - While PPH is mentioned, the context of the uterine incision extension and rapid progression of shock points to a **surgical bleeding site** that requires direct intervention, which uterotonics cannot address.
Question 262: Classical cesarean section is done in?
- A. Placenta previa
- B. Previous cesarean
- C. Carcinoma Cervix (Correct Answer)
- D. Extremely preterm delivery
Explanation: ***Carcinoma Cervix*** - A classical cesarean section, involving a **vertical incision into the fundus of the uterus**, is performed in carcinoma cervix to avoid cutting through **malignant tissue** in the lower uterine segment or cervix. - This is an **absolute indication** to prevent **tumor dissemination** and seeding of malignant cells in the peritoneal cavity. - The incision is made in the upper segment, well away from the cervical pathology. *Placenta previa* - Placenta previa requires cesarean delivery, but a **low transverse uterine incision** (lower segment cesarean section) is the standard approach. - Classical cesarean is **not indicated** for placenta previa alone, as the lower segment can be safely accessed in most cases. - Only in exceptional circumstances (such as anterior placenta previa with poorly developed lower segment) might a classical approach be considered. *Previous cesarean* - A previous cesarean section is **not an indication** for classical cesarean in subsequent deliveries. - A **repeat low transverse cesarean section** or **trial of labor after cesarean (TOLAC)** is the standard approach. - Classical cesarean is only performed if the previous cesarean was classical (which increases rupture risk) and only when lower segment access is not feasible. *Extremely preterm delivery* - While extremely preterm delivery (typically **< 28 weeks**) may be a **relative indication** when the lower uterine segment is poorly developed, it is not an absolute indication. - In most cases, a **low vertical incision** or careful low transverse incision can be performed. - Classical incision is reserved for situations where lower segment access is truly inadequate, making this a **context-dependent** rather than absolute indication. - Compared to carcinoma cervix, this is a less definitive indication for classical cesarean section.
Question 263: True statements about vacuum extraction of a fetus: (A) Can be used in incompletely dilated cervix (B) Used in Face presentation (C) Applied 3cm posterior to Anterior fontanel (D) Applied 3cm anterior to posterior fontanel
- A. Applied 3cm posterior to Anterior fontanel
- B. Used in Face presentation
- C. Applied 3cm anterior to posterior fontanel (Correct Answer)
- D. Can be used in incompletely dilated cervix
Explanation: ***Applied 3cm anterior to posterior fontanel*** - The vacuum cup should ideally be placed over the **flexion point** (median or paramedian application), which is approximately **3 cm anterior to the posterior fontanelle** and 6 cm posterior to the anterior fontanelle on the sagittal suture. - This position ensures optimal traction axis, promotes proper **fetal head flexion**, and facilitates safe and effective delivery. - Correct cup placement is crucial to prevent **scalp trauma** (caput succedaneum, cephalohematoma) and ensure successful extraction. *Can be used in incompletely dilated cervix* - Vacuum extraction is **contraindicated** when the cervix is not fully dilated (10 cm). - Attempting extraction with incomplete cervical dilation can lead to severe **cervical lacerations**, trauma, and hemorrhage. - Full cervical dilation is a **prerequisite** for safe vacuum-assisted delivery in standard obstetric practice. *Used in Face presentation* - Vacuum extraction is **contraindicated** in face presentation due to the risk of significant facial trauma and inability to achieve adequate traction. - Face presentation requires the mentum (chin) to be anterior for vaginal delivery; vacuum application can worsen the presentation or cause injury. - **Cesarean section** is often the preferred mode of delivery for persistent face presentations. *Applied 3cm posterior to Anterior fontanel* - Placing the cup 3cm posterior to the anterior fontanelle would be too **anterior** and away from the optimal flexion point. - This malposition can lead to **deflexion** of the fetal head, ineffective traction, failed extraction, and increased risk of scalp injury. - The cup should be more posteriorly placed over the flexion point for successful vacuum delivery.
Question 264: MVA syringe is used for?
- A. 2nd trimester MTP
- B. Vacuum delivery
- C. First trimester MTP (Correct Answer)
- D. All of the options
Explanation: ***First trimester MTP*** - A **manual vacuum aspiration (MVA) syringe** is specifically designed for performing vacuum aspiration procedures during the first trimester of pregnancy. - It creates a **negative pressure** to gently remove uterine contents, commonly used for **medical termination of pregnancy (MTP)** or management of miscarriage. *2nd trimester MTP* - For **second-trimester MTP**, procedures like **dilatation and evacuation (D&E)** or **induction with medication** are typically preferred over manual vacuum aspiration due to larger fetal size and increased uterine wall fragility. - The **MVA syringe** may not provide sufficient suction or capacity for safe and complete evacuation in the second trimester. *Vacuum delivery* - **Vacuum delivery** is a procedure used during childbirth to assist in vaginal delivery by applying suction to the fetal head. - This procedure uses a **vacuum extractor cup** and a specialized pump, not an MVA syringe. *All of the options* - The MVA syringe is only appropriate for **first-trimester MTP** and early miscarriage management, not for late-trimester procedures or vacuum-assisted delivery. - Therefore, choosing "All of the options" would be incorrect.
Question 265: Indications for cesarean hysterectomy are all except:
- A. Rupture uterus
- B. Placenta accreta
- C. Couvelaire uterus (Correct Answer)
- D. Atonic uterus with uncontrolled PPH
Explanation: ***Couvelaire uterus*** - A **Couvelaire uterus** results from extensive **intramyometrial bleeding** due to severe **placental abruption** and typically **resolves spontaneously** without the need for hysterectomy. - While it looks alarming, the myometrium usually regains its tone, and hysterectomy is generally **not indicated** unless there is concomitant uncontrolled hemorrhage. *Rupture uterus* - A **ruptured uterus** is a life-threatening obstetric emergency often requiring immediate **cesarean section** and exploration. - Extensive or irreparable rupture, especially if associated with uncontrollable bleeding, is a strong indication for **cesarean hysterectomy** to save the mother's life. *Placenta accreta* - **Placenta accreta**, where the placenta abnormally adheres to the uterine wall, often results in severe hemorrhage at attempted delivery. - Due to the risk of massive bleeding from attempts to remove the placenta, **cesarean hysterectomy** is frequently the planned management to prevent maternal morbidity and mortality. *Atonic uterus with uncontrolled PPH* - **Uterine atony** is the most common cause of **postpartum hemorrhage (PPH)**, where the uterus fails to contract after delivery. - If conservative measures (e.g., uterine massage, uterotonic drugs) fail to control severe PPH from an atonic uterus, **cesarean hysterectomy** may be a life-saving intervention.
Question 266: A 30-year-old multigravida presented with transverse lie with hand prolapse in 2nd stage of labour with dead fetus. The treatment is :
- A. LSCS
- B. Cleidotomy
- C. Decapitation (Correct Answer)
- D. Craniotomy
Explanation: ***Decapitation*** - **Decapitation** is the treatment of choice for **neglected transverse lie with hand prolapse** when the **fetus is dead** and vaginal delivery is obstructed in the second stage of labor. - This destructive operation involves **severing the fetal neck** to allow delivery of the trunk and head separately, avoiding the maternal risks of cesarean section when fetal salvage is not a consideration. - The presence of a **dead fetus** is a key indication, as it eliminates the need to preserve fetal life and makes destructive procedures ethically and medically appropriate. - **Decapitation** is safer for the mother than LSCS in this scenario, with lower risks of infection, hemorrhage, and future pregnancy complications. *LSCS* - **Cesarean section** would be indicated for a **transverse lie with a LIVE fetus** or if there are contraindications to destructive operations (such as maternal infection risk or failed destructive procedure). - With a **dead fetus**, LSCS exposes the mother to unnecessary surgical risks including anesthesia complications, hemorrhage, infection, and future uterine rupture risk. - The principle of obstetric management is to avoid major surgery when the fetus is already dead and vaginal delivery (even if requiring destructive operations) is feasible. *Cleidotomy* - **Cleidotomy** (cutting the fetal clavicles) is used for **shoulder dystocia** in cephalic presentations to reduce shoulder width and facilitate delivery. - This procedure does not address **transverse lie**, where the fundamental problem is the fetal axis being perpendicular to the maternal axis, not shoulder width. - Cleidotomy would be ineffective as the presenting part (hand/shoulder) cannot engage properly in a transverse lie. *Craniotomy* - **Craniotomy** (perforation and collapse of the fetal skull) is indicated for **cephalic presentations** with a dead fetus where there is cephalopelvic disproportion or hydrocephalus. - In a **transverse lie**, the head is not the presenting part, making craniotomy inappropriate as the primary procedure. - While craniotomy might be used as an adjunct after decapitation to reduce head size, the primary procedure needed is decapitation to resolve the transverse lie.
Question 267: The best method of evacuation of a missed abortion in uterus of more than 12 weeks:
- A. Oxytocin infusion
- B. Prostaglandin E1 vaginal misoprostol followed by evacuation of the uterus (Correct Answer)
- C. Intramuscular prostaglandin (15 methyl PGF2a)
- D. Suction evacuation
Explanation: ***Prostaglandin E1 vaginal misoprostol followed by evacuation of the uterus*** - **Misoprostol** (PGE1) effectively induces uterine contractions and cervical ripening, which is crucial for evacuating a missed abortion, especially in the **second trimester** (over 12 weeks). - Following the induction of labor and expulsion of some products of conception, **evacuation of the uterus** (e.g., by D&C or suction) ensures complete removal and prevents retained tissue, which can lead to complications. *Oxytocin infusion* - **Oxytocin** is generally effective for inducing labor in a viable pregnancy at term, but its efficacy in causing uterine contractions for expulsion in a **missed abortion** in the second trimester is limited, especially without prior cervical ripening. - Using oxytocin alone without prior cervical preparation can lead to **cervical lacerations** or incomplete expulsion due to a firm, unripened cervix. *Intramuscular prostaglandin (15 methyl PGF2a)* - While **intramuscular prostaglandins** like carboprost (15-methyl PGF2α) are effective in inducing uterine contractions, they are associated with more frequent and severe **gastrointestinal side effects** (e.g., nausea, vomiting, diarrhea) and can cause bronchoconstriction. - **Vaginal misoprostol** offers comparable efficacy with a more favorable side effect profile and ease of administration. *Suction evacuation* - **Suction evacuation** alone for a missed abortion beyond 12 weeks of gestation carries a higher risk of complications such as **uterine perforation**, hemorrhage, and incomplete evacuation if the cervix is not adequately dilated. - The uterine contents are larger and more adherent in the second trimester, making a primary suction procedure potentially more traumatic and requiring more extensive **cervical dilation**.
Question 268: Bleeding in rupture of the uterus associated with a large broad ligament hematoma is controlled most simply by :
- A. Ligation of hypogastric artery
- B. Ligation of common iliac artery
- C. Suture of laceration
- D. Ligation of uterine artery (Correct Answer)
Explanation: ***Ligation of uterine artery*** - **Ligation of the uterine artery** is the **most simple and direct first-line approach** for controlling bleeding from uterine rupture with broad ligament hematoma. - The uterine artery provides the **primary blood supply** to the uterus and is easily accessible at the lower uterine segment, making it technically straightforward to ligate. - This method effectively controls bleeding by directly cutting off the major vascular supply to the area of rupture and the broad ligament hematoma. - Success rate is 80-90% for controlling hemorrhage, and it preserves blood flow to other pelvic structures. *Ligation of hypogastric artery* - **Ligation of the hypogastric artery** (internal iliac artery) is a **second-line procedure** requiring more extensive retroperitoneal dissection. - While effective, it is technically more difficult and time-consuming compared to uterine artery ligation, making it less "simple." - Reserved for cases where uterine artery ligation fails or when there is widespread pelvic bleeding from multiple sources. - It reduces blood flow to the entire pelvis, including bladder and rectum, not just the uterus. *Ligation of common iliac artery* - **Ligation of the common iliac artery** is an extreme measure with severe consequences, including compromised blood flow to the entire lower limb. - This is **not a standard procedure** for uterine rupture and carries unacceptable risks of leg ischemia and other complications. - Never considered a first-line approach for obstetric hemorrhage due to its extensive and potentially catastrophic effects. *Suture of laceration* - While **suturing the laceration** is essential for repairing the uterine defect, it does not provide adequate vascular control when a large broad ligament hematoma is present. - The hematoma indicates **significant vessel injury** within the broad ligament, requiring proximal vascular control first. - Suturing alone without controlling the bleeding source will not stop the hemorrhage and may lead to continued blood loss. - The correct approach is to first ligate the uterine artery for hemostasis, then repair the uterine tear.
Question 269: 35 yr old primigravida conceived after IVF cycle attends obstetrics clinic with 38 weeks gestation. Her obstetric details reveal DiCho-DiAmn twins with 1st twin as breech. Her BP was 140/90 mmHg on 2 occasions with proteinuria +1. How will you manage this case?
- A. Plan a cesarean for termination (Correct Answer)
- B. Induction of labour
- C. Watch for BP and induce for normal delivery on Expected Date of delivery
- D. Watch for BP and terminate (vaginal/ Cesarean) only when BP is normal.
Explanation: ***Plan a cesarean for termination*** - This patient presents with **preeclampsia** (BP 140/90 mmHg on two occasions with proteinuria +1) at **38 weeks gestation**, making delivery appropriate. - The presence of **DiCho-DiAmn twins** with the **first twin in breech presentation** is a strong indication for **cesarean section** to ensure safe delivery and reduce complications. *Induction of labour* - While induction might be considered for preeclampsia, the **breech presentation of the first twin** in a twin pregnancy significantly increases the risks associated with vaginal delivery, making it less safe than a cesarean. - Given the combined risk factors, **cesarean delivery** is the more appropriate choice for optimizing maternal and fetal outcomes. *Watch for BP and induce for normal delivery on Expected Date of delivery* - Preeclampsia necessitates **delivery when the mother reaches 37 weeks or beyond**, not necessarily waiting until the Expected Date of Delivery, especially with other complicating factors. - Furthermore, attempting a **normal vaginal delivery** with a **breech presenting twin 1** carries high risks for both twins and is generally contraindicated. *Watch for BP and terminate (vaginal/ Cesarean) only when BP is normal.* - Delaying termination until blood pressure normalizes is not appropriate management for **preeclampsia** at term; delivery is the definitive treatment. - A persistent **breech presentation of twin 1** also makes vaginal delivery problematic, regardless of blood pressure status.
Question 270: Which method is most appropriate for cervical ripening in a term pregnancy with oligohydramnios and reactive NST?
- A. Dinoprostone gel 0.5mg
- B. Foley catheter (Correct Answer)
- C. Misoprostol 25mcg vaginal
- D. Oxytocin infusion
Explanation: **Foley catheter** - **Mechanical methods** like the Foley catheter are preferred for cervical ripening in the presence of **oligohydramnios** because they do not carry the risk of inducing uterine hyperstimulation, which can further compromise fetal well-being. - The reactive non-stress test (NST) indicates the fetus is currently healthy, but oligohydramnios suggests a need to minimize any potential stress, making mechanical ripening a safer choice. *Dinoprostone gel 0.5mg* - **Prostaglandins** like dinoprostone can increase the risk of **uterine hyperstimulation**, which could be particularly dangerous for a fetus with oligohydramnios as it restricts blood flow and oxygen. - While effective for ripening, the risk profile is higher compared to mechanical methods when fetal compromise (like oligohydramnios) is present. *Misoprostol 25mcg vaginal* - **Misoprostol** is a potent prostaglandin analog that carries a significant risk of **uterine tachysystole** and hyperstimulation. - In cases with **oligohydramnios**, any drug-induced increase in uterine activity could further strain fetal oxygenation and well-being. *Oxytocin infusion* - **Oxytocin** is primarily used for **induction of labor** (to stimulate contractions) and not for cervical ripening directly. - Initiating oxytocin without a ripened cervix is less effective and carries a higher risk of failed induction and potentially C-section, and it does not address the need for cervical changes first.
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
Want unlimited practice?
Get full access to all questions, explanations, and performance tracking.
Start For Free