Operative Obstetrics — MCQs

A 30-year-old woman with a history of cesarean section presents in labor. Fetal heart rate monitoring shows persistent late decelerations despite intrauterine resuscitation measures (maternal repositioning, oxygen, IV fluids, and discontinuation of oxytocin). What is the most appropriate management?

Q278

G3P2L2 with previous 2 LSCS with anterior placenta previa has got a very high risk of which complication?

Q279

Dilatation & evacuation is done for all except?

Q280

B-Lynch suture is applied on?

Operative Obstetrics Indian Medical PG Practice Questions and MCQs

Question 271: A female with 40 weeks gestation progressed spontaneously and is currently for 2 hours in second stage of labor. She is having contractions 4 in 10 mins, fetal head is at +3 station, caput is present. What is the best management?

A. Low forceps
B. Outlet forceps (Correct Answer)
C. Cavity forceps
D. Ventouse

Explanation: ***Outlet forceps*** - This is the **correct and most appropriate choice** as the fetal head is at **+3 station**, indicating it is at or on the **perineum** (essentially crowning). - By ACOG classification, outlet forceps are indicated when the scalp is visible at the introitus and the fetal skull has reached the pelvic floor. - With **2 hours in second stage** and adequate contractions, assisted delivery is indicated to prevent maternal exhaustion and fetal compromise. - The presence of **caput** suggests prolonged pressure, making timely assisted delivery appropriate. *Low forceps* - This would be indicated if the **leading bony point** of the fetal head is at **+2 station or lower** but the head has not yet reached the pelvic floor. - In this scenario, the head is already at +3 station (on the perineum), making this classification inappropriate. - Low forceps would be more interventionist than necessary given the favorable station. *Cavity forceps (Mid-forceps)* - This intervention is used when the fetal head is engaged but still within the **mid-pelvis**, typically between **0 station and +2 station**. - Given the head is at +3 station, the use of mid-cavity forceps, which requires deeper placement and carries significantly higher maternal and fetal risks, is completely unnecessary and inappropriate. *Ventouse (Vacuum extraction)* - While vacuum extraction could theoretically be considered, it is **less suitable in this scenario** due to the presence of **significant caput**. - Caput formation can lead to **higher failure rates with vacuum** as the device may slip off or fail to provide adequate traction. - At +3 station with caput, **outlet forceps is the preferred method** as it provides more secure grip on the fetal head and allows for controlled delivery. - Vacuum extraction has a higher rate of cephalohematoma and subgaleal hemorrhage, especially when significant molding or caput is present.

Question 272: During her third cesarean section, a 32-year-old woman has dense bladder adhesions. What should be done?

A. Careful dissection (Correct Answer)
B. Classical cesarean
C. Abort surgery
D. Call urology

Explanation: ***Careful dissection*** - **Dense bladder adhesions** in a patient undergoing their third cesarean section necessitate meticulous and **careful dissection** to prevent injury to the bladder or other surrounding structures. - This approach minimizes complications and allows for successful completion of the hysterotomy and delivery. *Classical cesarean* - A **classical cesarean** involves a vertical incision in the uterus and is typically reserved for specific situations like **preterm breech presentation**, placenta previa, or difficult lower uterine segment access. - It results in a weaker scar and is not primarily indicated for **dense bladder adhesions**. *Abort surgery* - **Aborting surgery** is generally not an option in a patient requiring a cesarean section, as it would compromise both maternal and fetal well-being. - The goal is to safely deliver the baby, which requires proceeding with the surgery despite the challenges of adhesions. *Call urology* - While bladder injury can be a complication, the **initial management** of dense bladder adhesions during a cesarean section is typically performed by the obstetric surgeon through careful dissection. - Calling urology might be necessary for **repair of a bladder injury**, but not as the initial and immediate step for managing adhesions themselves, unless the surgeon feels the risk of injury is beyond their expertise.

Question 273: In the management of a pregnant woman with symptomatic gallstones, what is the preferred treatment approach during the second trimester?

A. Laparoscopic cholecystectomy (Correct Answer)
B. Medical management with ursodeoxycholic acid
C. Expectant management until postpartum
D. Open cholecystectomy

Explanation: ***Laparoscopic cholecystectomy*** - **Laparoscopic cholecystectomy** is the safest and most effective treatment for symptomatic gallstones during pregnancy, particularly in the **second trimester**, when the risk to the fetus is minimized and uterine size allows for better surgical access. - Delaying treatment can lead to complications such as **pancreatitis** or **cholangitis**, which pose significant risks to both mother and fetus. *Medical management with ursodeoxycholic acid* - While **ursodeoxycholic acid** can dissolve cholesterol gallstones, it is a prolonged treatment and typically not effective for symptomatic relief of **biliary colic** or in preventing acute complications in symptomatic patients. - Its use is generally reserved for patients unwilling or unable to undergo surgery, or for preventing gallstones in specific high-risk situations like during rapid weight loss, not as a primary treatment for symptomatic stones in pregnancy. *Expectant management until postpartum* - **Expectant management** for symptomatic gallstones during pregnancy carries a high risk of recurrent symptoms and potential complications such as **acute cholecystitis**, **pancreatitis**, or **choledocholithiasis**, which can necessitate emergency surgery and increase maternal and fetal morbidity. - While postponing surgery until postpartum is a consideration for asymptomatic gallstones, it is not recommended for symptomatic cases due to the risk of progression and complications. *Open cholecystectomy* - **Open cholecystectomy** is generally avoided in pregnant women unless laparoscopic surgery is not feasible or in cases of severe complications, due to increased maternal discomfort, larger incision, longer recovery time, and possibly higher risk of uterine manipulation. - It involves a larger abdominal incision, potentially increasing the risk of **postoperative pain** and **incisional complications**, making it a less preferred option than the minimally invasive laparoscopic approach.

Question 274: Which of the following surgical procedures is most appropriate for a hemodynamically stable patient with a ruptured ectopic pregnancy?

A. Laparotomy
B. Expectant management
C. Methotrexate
D. Salpingectomy (Correct Answer)

Explanation: ***Salpinectomy*** - For a **hemodynamically stable** patient with a **ruptured ectopic pregnancy**, **salpingectomy** (removal of the affected fallopian tube) is often the most appropriate surgical intervention. This approach definitively addresses the rupture and prevents further hemorrhage. - While other options might be considered for unruptured ectopic pregnancies or specific patient conditions, a ruptured ectopic pregnancy, even in a stable patient, necessitates surgical removal of the compromised tube to ensure patient safety and prevent significant blood loss. *Methotrexate* - **Methotrexate** is a medical management option typically reserved for **unruptured, hemodynamically stable ectopic pregnancies** with specific criteria (e.g., small gestational sac, low hCG levels). - It is contraindicated in cases of **ruptured ectopic pregnancy** due to the immediate risk of hemorrhage, which requires surgical intervention. *Laparotomy* - **Laparotomy** (open abdominal surgery) is an appropriate surgical approach for a ruptured ectopic pregnancy, especially in **hemodynamically unstable patients** or when minimally invasive techniques are not feasible. - However, for a **hemodynamically stable patient**, a **laparoscopic salpingectomy** is generally preferred due to its less invasive nature, quicker recovery, and reduced morbidity compared to open laparotomy. *Expectant management* - **Expectant management** involves close observation without immediate intervention and is only considered for **unruptured ectopic pregnancies** that are spontaneously resolving, with very low and declining hCG levels, and where the patient is asymptomatic and hemodynamically stable. - It is **contraindicated** in cases of **ruptured ectopic pregnancy** as it carries a significant risk of severe hemorrhage, maternal morbidity, and mortality, necessitating active intervention.

Question 275: A 29-year-old primigravida presents at 36 weeks of gestation with a transverse lie. What is the recommended management?

A. Induce labor
B. Perform amniotomy
C. Schedule cesarean delivery (Correct Answer)
D. Attempt external cephalic version

Explanation: ***Schedule cesarean delivery*** - A persistent **transverse lie** at 36 weeks makes vaginal delivery impossible and requires definitive management. - **Cesarean delivery** is the definitive and safest option for ensuring maternal and fetal well-being when the transverse lie persists. - While external cephalic version may be attempted first, if unsuccessful, contraindicated, or the lie remains transverse near term, cesarean section is mandatory. - Attempting vaginal delivery with transverse lie risks **cord prolapse**, **uterine rupture**, and **obstructed labor**. *Induce labor* - Inducing labor with a transverse lie is **absolutely contraindicated** due to impossibility of vaginal delivery. - The fetal shoulder or arm would present first, preventing engagement and causing **obstructed labor**. - High risk of **cord prolapse**, **uterine rupture**, and severe maternal-fetal complications. *Perform amniotomy* - **Amniotomy** (artificial rupture of membranes) with a transverse lie is extremely dangerous and contraindicated. - Significantly increases the risk of **cord prolapse** as membranes rupture without an engaged presenting part. - Would necessitate immediate cesarean delivery in emergency conditions, worsening outcomes. *Attempt external cephalic version* - While **external cephalic version (ECV)** can be attempted for transverse lie at 36-37 weeks, it has lower success rates (30-50%) compared to breech presentation. - However, the question asks for "recommended management" which refers to the **definitive management plan** - cesarean delivery remains the final recommendation when transverse lie persists. - ECV may be offered as an option to avoid cesarean, but has risks including **placental abruption**, **fetal distress**, and **failure** requiring cesarean anyway. - At 36 weeks with persistent transverse lie, planning for cesarean delivery is the safest definitive approach.

Question 276: A 32-year-old woman presents with a positive pregnancy test and a history of two previous cesarean sections. What is the most appropriate mode of delivery?

A. Vaginal birth after cesarean (VBAC)
B. Elective repeat cesarean section (Correct Answer)
C. Induction of labor
D. Trial of labor

Explanation: ***Elective repeat cesarean section*** - With a history of **two previous cesarean sections**, an **elective repeat cesarean section** is the **most commonly recommended** and safest standard approach. - The risk of **uterine rupture** during trial of labor increases to approximately **1.5%** (compared to 0.5-1% with one prior cesarean), making elective cesarean the more conservative choice. - This approach **minimizes maternal and fetal risks** while avoiding potential complications associated with attempted vaginal delivery. - For standardized exam purposes and in the absence of specific patient preferences or favorable factors, this is the most appropriate answer. *Vaginal birth after cesarean (VBAC)* - VBAC is **not absolutely contraindicated** after two previous cesarean sections according to current **ACOG and RCOG guidelines**. - However, it requires **careful patient selection**, individualized counseling, and increased surveillance due to the elevated uterine rupture risk. - Success rates for VBAC after two cesareans are approximately **70%**, but this option requires informed consent and specific favorable conditions. - In standard practice without additional favorable factors mentioned, elective cesarean remains preferred. *Induction of labor* - **Induction of labor** carries a **higher risk of uterine rupture** in women with previous cesarean sections, particularly when prostaglandins are used. - The risk increases substantially with two or more prior cesarean sections, making this a less favorable option. - If labor induction is considered, it should only be in carefully selected cases with close monitoring. *Trial of labor* - A **trial of labor after cesarean (TOLAC)** can be considered in selected women with two previous cesarean sections, but requires thorough counseling about increased risks. - Risk factors that would contraindicate TOLAC include: classical or T-shaped uterine incision, previous uterine rupture, or other absolute contraindications. - Without specific mention of favorable prognostic factors (prior vaginal delivery, spontaneous labor, favorable cervix), elective cesarean is the safer standard recommendation.

Question 277: A 30-year-old woman with a history of cesarean section presents in labor. Fetal heart rate monitoring shows persistent late decelerations despite intrauterine resuscitation measures (maternal repositioning, oxygen, IV fluids, and discontinuation of oxytocin). What is the most appropriate management?

A. Continue monitoring
B. Amnioinfusion
C. Immediate cesarean section (Correct Answer)
D. Oxytocin administration

Explanation: ***Immediate cesarean section*** - **Persistent late decelerations despite intrauterine resuscitation** indicate **severe uteroplacental insufficiency** that is not responding to conservative measures, meaning the fetus is experiencing ongoing hypoxia. - Once intrauterine resuscitation measures (maternal repositioning, oxygen administration, IV fluid bolus, and stopping oxytocin) have failed to resolve the late decelerations, **expedited delivery** is mandatory to prevent further fetal compromise. - Given the patient's history of a previous cesarean section, **repeat cesarean section** is the safest and most efficient method of delivery, avoiding the risks of uterine rupture associated with prolonged labor or operative vaginal delivery attempts in this emergent situation. *Continue monitoring* - Continuing to merely monitor when **persistent late decelerations** have already failed to respond to resuscitative measures would be inappropriate and potentially harmful, as it delays necessary delivery. - This approach does not address the underlying severe uteroplacental insufficiency and could lead to worsening fetal distress, fetal acidosis, or irreversible neurological injury. *Amnioinfusion* - **Amnioinfusion** is primarily used for **variable decelerations** caused by **umbilical cord compression**, where introducing fluid into the uterine cavity can relieve pressure on the cord. - It is not an effective treatment for **late decelerations**, which are due to placental insufficiency, not cord compression. - In this scenario with persistent late decelerations despite resuscitation, amnioinfusion would not address the underlying problem and would delay definitive management. *Oxytocin administration* - **Oxytocin** increases the frequency and intensity of uterine contractions, which would further compromise an already compromised uteroplacental blood flow in the presence of late decelerations. - This would exacerbate **fetal hypoxia** and is therefore absolutely contraindicated when late decelerations are observed, especially when they persist despite resuscitative efforts.

Question 278: G3P2L2 with previous 2 LSCS with anterior placenta previa has got a very high risk of which complication?

A. Vasa previa
B. Abruption
C. Placenta accreta (Correct Answer)
D. None of the options

Explanation: ***Placenta accreta*** - A history of **previous cesarean sections (LSCS)** and **placenta previa** significantly increases the risk of placenta accreta, where the placenta abnormally adheres to the uterine wall. - The combination of a disrupted uterine wall from previous surgeries and a low-lying placenta on a scarred segment predisposes to deep placental invasion. *Vasa previa* - This condition involves **fetal blood vessels** running within the membranes over the cervical os, susceptible to rupture, not abnormal placental adherence to the uterine wall. - While it can occur with placenta previa, the primary risk for **vasa previa** is typically with velamentous cord insertion or bilobate placenta, not directly linked to prior LSCS as a direct cause. *Abruption* - **Placental abruption** is the premature separation of the placenta from the uterine lining, often associated with **hypertension**, trauma, or smoking. - While previous LSCS can increase the risk of certain placental complications, it's not the primary risk factor for abruption compared to the strong association with **placenta accreta** in this clinical scenario. *None of the options* - Given the specific clinical presentation of **prior LSCS** and **anterior placenta previa**, there is a very high and well-documented risk of **placenta accreta**.

Question 279: Dilatation & evacuation is done for all except?

A. Inevitable abortion
B. Incomplete abortion
C. Missed abortion
D. Threatened abortion (Correct Answer)

Explanation: ***Threatened abortion*** - In a threatened abortion, the cervix is **closed** with vaginal bleeding and abdominal pain, indicating a potential for the pregnancy to continue, making **dilation & evacuation (D&E)** unnecessary and potentially harmful. - The primary goal is to **preserve the pregnancy**, not to evacuate the uterine contents. - Management involves **bed rest, progesterone support**, and monitoring, not evacuation. *Inevitable abortion* - This condition involves an **open cervix**, with bleeding and uterine contractions, indicating that the abortion will proceed, and **D&E** is performed to complete the evacuation of uterine contents. - D&E helps to **prevent complications** like hemorrhage or infection once the abortion is confirmed to be in progress. *Incomplete abortion* - In an incomplete abortion, some **products of conception** remain in the uterus, and **D&E** is performed to remove these retained tissues. - This procedure is crucial to **prevent infection** and continued bleeding from retained placental fragments. *Missed abortion* - In missed abortion, the **fetus has died** but is retained in the uterus with a closed cervix and no expulsion. - **D&E** is indicated to evacuate the retained dead fetal tissue and prevent complications like **infection or coagulopathy**.

Question 280: B-Lynch suture is applied on?

A. Cervix
B. Uterus (Correct Answer)
C. Fallopian tubes
D. Ovaries

Explanation: ***Uterus*** - The **B-Lynch suture** is a surgical technique involving the uterus to control **postpartum hemorrhage**. - It works by mechanically compressing the uterus, reducing blood flow, and promoting uterine contraction. *Cervix* - While sutures can be applied to the cervix (e.g., for **cervical cerclage**), the B-Lynch suture is specifically designed for uterine compression. - Cervical sutures are typically used for cervical insufficiency, not for acute postpartum hemorrhage from the uterine body. *Fallopian tubes* - Sutures on the fallopian tubes are typically related to procedures like **tubal ligation** or tubal repair, not for controlling uterine bleeding. - The fallopian tubes are not the primary site of bleeding in postpartum hemorrhage that the B-Lynch suture addresses. *Ovaries* - Sutures involving the ovaries are generally part of ovarian surgery, such as **cystectomy** or oophorectomy. - The B-Lynch suture is not indicated for bleeding originating from the ovaries.

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

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Management of Multiple Gestation

Practice Questions

Cervical Cerclage

Practice Questions

Obstetric Hysterectomy

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Surgery During Pregnancy

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Surgical Complications in Obstetrics

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