Operative Obstetrics Practice Questions

Q: 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?

Outlet forceps. ***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.

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

Careful dissection. ***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.

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

Schedule cesarean delivery. ***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.

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

Salpingectomy. ***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.

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

Placenta accreta. ***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**.

Q: Dilatation & evacuation is done for all except?

Threatened abortion. ***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**.

Q: B-Lynch suture is applied on?

Uterus. ***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.

Question 1

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?

Accepted Answer

Outlet forceps

Answer

Low forceps

Answer

Cavity forceps

Answer

Ventouse

Question 2

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

Accepted Answer

Careful dissection

Answer

Classical cesarean

Answer

Abort surgery

Answer

Call urology

Question 3

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

Accepted Answer

Laparoscopic cholecystectomy

Answer

Medical management with ursodeoxycholic acid

Answer

Expectant management until postpartum

Answer

Open cholecystectomy

Question 4

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

Accepted Answer

Schedule cesarean delivery

Answer

Induce labor

Answer

Perform amniotomy

Answer

Attempt external cephalic version

Question 5

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

Accepted Answer

Salpingectomy

Answer

Laparotomy

Answer

Expectant management

Answer

Methotrexate

Question 6

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?

Accepted Answer

Elective repeat cesarean section

Answer

Vaginal birth after cesarean (VBAC)

Answer

Induction of labor

Answer

Trial of labor

Question 7

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?

Accepted Answer

Immediate cesarean section

Answer

Continue monitoring

Answer

Amnioinfusion

Answer

Oxytocin administration

Question 8

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

Accepted Answer

Placenta accreta

Answer

Vasa previa

Answer

Abruption

Answer

None of the options

Question 9

Dilatation & evacuation is done for all except?

Accepted Answer

Threatened abortion

Answer

Inevitable abortion

Answer

Incomplete abortion

Answer

Missed abortion

Question 10

B-Lynch suture is applied on?

Accepted Answer

Uterus

Answer

Cervix

Answer

Fallopian tubes

Answer

Ovaries

Operative Obstetrics — MCQs

Operative Obstetrics — MCQs

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