Operative Obstetrics Practice Questions

Q: 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?

Immediate exploration in OT. ***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.

Q: Classical cesarean section is done in?

Carcinoma Cervix. ***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.

Q: 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

Applied 3cm anterior to posterior fontanel. ***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.

Q: MVA syringe is used for?

First trimester MTP. ***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.

Q: Indications for cesarean hysterectomy are all except:

Couvelaire uterus. ***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.

Q: 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?

Plan a cesarean for termination. ***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.

Q: Which method is most appropriate for cervical ripening in a term pregnancy with oligohydramnios and reactive NST?

Foley catheter. **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.

Question 1

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?

Accepted Answer

Immediate exploration in OT

Answer

Blood transfusion and monitoring

Answer

Intrauterine packing and blood transfusion

Answer

Uterotonics for control of PPH and blood transfusion

Question 2

Classical cesarean section is done in?

Accepted Answer

Carcinoma Cervix

Answer

Placenta previa

Answer

Previous cesarean

Answer

Extremely preterm delivery

Question 3

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

Accepted Answer

Applied 3cm anterior to posterior fontanel

Answer

Applied 3cm posterior to Anterior fontanel

Answer

Used in Face presentation

Answer

Can be used in incompletely dilated cervix

Question 4

MVA syringe is used for?

Accepted Answer

First trimester MTP

Answer

2nd trimester MTP

Answer

Vacuum delivery

Answer

All of the options

Question 5

Indications for cesarean hysterectomy are all except:

Accepted Answer

Couvelaire uterus

Answer

Rupture uterus

Answer

Placenta accreta

Answer

Atonic uterus with uncontrolled PPH

Question 6

A 30-year-old multigravida presented with transverse lie with hand prolapse in 2nd stage of labour with dead fetus. The treatment is :

Accepted Answer

Decapitation

Answer

LSCS

Answer

Cleidotomy

Answer

Craniotomy

Question 7

The best method of evacuation of a missed abortion in uterus of more than 12 weeks:

Accepted Answer

Prostaglandin E1 vaginal misoprostol followed by evacuation of the uterus

Answer

Oxytocin infusion

Answer

Intramuscular prostaglandin (15 methyl PGF2a)

Answer

Suction evacuation

Question 8

Bleeding in rupture of the uterus associated with a large broad ligament hematoma is controlled most simply by :

Accepted Answer

Ligation of uterine artery

Answer

Ligation of hypogastric artery

Answer

Ligation of common iliac artery

Answer

Suture of laceration

Question 9

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?

Accepted Answer

Plan a cesarean for termination

Answer

Induction of labour

Answer

Watch for BP and induce for normal delivery on Expected Date of delivery

Answer

Watch for BP and terminate (vaginal/ Cesarean) only when BP is normal.

Question 10

Which method is most appropriate for cervical ripening in a term pregnancy with oligohydramnios and reactive NST?

Accepted Answer

Foley catheter

Answer

Dinoprostone gel 0.5mg

Answer

Misoprostol 25mcg vaginal

Answer

Oxytocin infusion

Operative Obstetrics — MCQs

Operative Obstetrics — MCQs

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