Operative Obstetrics — MCQs

Operative Obstetrics Indian Medical PG Practice Questions and MCQs

Question 31: A 35-week multigravida presents with epigastric pain, headache, visual symptoms, and proteinuria of 3+. What is the next step in management?

A. Immediate cesarean section
B. Betamethasone for fetal lung maturity
C. Induction of labor for vaginal delivery
D. Start magnesium sulfate therapy (Correct Answer)

Explanation: ### Explanation **Correct Answer: D. Start magnesium sulfate therapy** The patient presents with **Severe Preeclampsia** (35 weeks gestation, proteinuria, and "imminent symptoms" like epigastric pain, headache, and visual disturbances). These symptoms indicate cerebral and hepatic involvement, signaling an extremely high risk of progressing to **Eclampsia** (seizures). In any case of severe preeclampsia or eclampsia, the **immediate priority is stabilization**. Magnesium sulfate ($MgSO_4$) is the drug of choice for seizure prophylaxis and treatment. According to standard protocols (Pritchard or Zuspan), stabilization with $MgSO_4$ and blood pressure control must occur *before* proceeding to delivery, regardless of the planned mode of birth. **Why other options are incorrect:** * **A & C:** While delivery is the definitive treatment for preeclampsia, it should only be initiated *after* the mother is stabilized with $MgSO_4$. The mode of delivery (C-section vs. Induction) depends on obstetric indications (e.g., Bishop’s score, fetal distress); severe preeclampsia itself is not an absolute indication for a Cesarean section. * **B:** While steroids are indicated for fetal lung maturity before 34 weeks, this patient is at **35 weeks**. Furthermore, in the presence of "imminent symptoms," stabilization and delivery take precedence over waiting 48 hours for steroid efficacy. **Clinical Pearls for NEET-PG:** * **Drug of Choice for Seizures:** Magnesium sulfate (Superior to Diazepam/Phenytoin). * **Therapeutic Range:** 4–7 mEq/L. * **First Sign of Toxicity:** Loss of Patellar Reflex (Knee jerk) at 7–10 mEq/L. * **Antidote:** 10 ml of 10% Calcium Gluconate (administered IV over 10 mins). * **Management Goal:** In severe preeclampsia >34 weeks, stabilize and deliver. If <34 weeks and stable, conservative management can be considered.

Question 32: Forceps are applied in all the following obstetric presentations except:

A. Breech presentation
B. Face presentation
C. Occipitoposterior position
D. Brow presentation (Correct Answer)

Explanation: **Explanation:** The primary prerequisite for any forceps application is that the **head must be engaged** and the presenting diameter must be compatible with the pelvic dimensions. **Why Brow Presentation is the correct answer:** In a brow presentation, the presenting part is the area between the orbital ridges and the anterior fontanelle. The engaging diameter is the **mentovertical diameter (13.5 cm)**, which is the largest diameter of the fetal head and exceeds the average diameters of the maternal pelvis. Because the head cannot engage or descend sufficiently in this position, vaginal delivery is impossible unless the presentation converts to a face or vertex. Applying forceps to a brow presentation is contraindicated as it can lead to severe maternal trauma and fetal intracranial injury. **Analysis of other options:** * **Breech presentation:** Forceps (specifically **Piper’s forceps**) are the gold standard for delivering the **after-coming head** of the breech to maintain flexion and protect the fetal head. * **Face presentation:** Forceps can be applied in **Mentoposterior (MP)** positions only if they rotate to **Mentoanterior (MA)**. In a confirmed Mentoanterior position, forceps are used to assist delivery. * **Occipitoposterior (OP) position:** Forceps can be used for either a direct delivery (as a persistent OP) or for rotation to an Occipitoanterior position (e.g., using **Kielland’s forceps**). **High-Yield Clinical Pearls for NEET-PG:** * **Prerequisites for Forceps:** Think of the mnemonic **FORCEPS**: **F**etus alive, **O**p-en os (fully dilated), **R**uptured membranes, **C**ephalic/Engaged, **E**mpty bladder, **P**elvis adequate, **S**top if resistance. * **Piper’s Forceps:** Specifically designed with a perineal curve for the after-coming head in breech. * **Kielland’s Forceps:** Characterized by a minimal pelvic curve and a sliding lock, used for rotation. * **Brow Presentation Management:** Most cases are managed by **Cesarean Section** if the brow persists.

Question 33: All of the following methods are used for MTP in the 2nd trimester except?

A. Intra-amniotic saline
B. Prostaglandins
C. Hysterotomy
D. Menstrual regulation (Correct Answer)

Explanation: **Explanation:** The correct answer is **Menstrual Regulation (D)**. This is because Menstrual Regulation (MR) is a method used for very early pregnancy termination, typically performed within **14 days of a missed period** (up to 6 weeks of gestation). It involves the aspiration of the endometrial lining using a Karman cannula and a syringe. Since the second trimester begins at 13 weeks, MR is technically and clinically inapplicable. **Analysis of other options:** * **Intra-amniotic saline (A):** This is a classical method for second-trimester MTP (15–20 weeks). Hypertonic saline (20%) is injected into the amniotic sac, causing fetal demise and stimulating uterine contractions. However, it is now largely replaced by prostaglandins due to risks like hypernatremia and DIC. * **Prostaglandins (B):** These are the **gold standard** for second-trimester induction. Drugs like Misoprostol (PGE1) or Carboprost (PGF2α) are used to ripen the cervix and induce labor. * **Hysterotomy (C):** This is a surgical method (similar to a mini-cesarean) used for second-trimester MTP when medical induction fails or when there is a contraindication to vaginal delivery (e.g., central placenta previa). **High-Yield NEET-PG Pearls:** * **MTP Act (India):** Termination is legal up to **24 weeks** for specific categories of women (as per 2021 amendment). * **Best Method (2nd Trimester):** Medical induction with Prostaglandins (Misoprostol) +/- Mifepristone. * **Most Common Complication (2nd Trimester MTP):** Incomplete evacuation and hemorrhage. * **Ethacridine Lactate (Extra-amniotic):** Another historical second-trimester method (Revici's method) that acts by releasing endogenous prostaglandins.

Question 34: A patient with rheumatic heart disease has postpartum hemorrhage (PPH). Which of the following drugs is contraindicated?

A. Mifepristone
B. Methylergometrine (Correct Answer)
C. Oxytocin
D. Carboprost

Explanation: **Explanation:** The management of Postpartum Hemorrhage (PPH) in patients with cardiac disease requires careful selection of uterotonics to avoid hemodynamic instability. **Why Methylergometrine is Contraindicated:** Methylergometrine (Methergine) is an ergot alkaloid that causes generalized vasoconstriction and a sudden increase in peripheral vascular resistance. In patients with **Rheumatic Heart Disease (RHD)**, particularly those with valvular lesions like Mitral Stenosis, this sudden increase in afterload and venous return can lead to acute pulmonary edema, heart failure, or a hypertensive crisis. Therefore, it is strictly contraindicated in patients with heart disease and hypertension. **Analysis of Other Options:** * **Oxytocin:** This is the drug of choice for PPH in cardiac patients. While it can cause transient hypotension if given as a rapid bolus, it is safe when administered as a slow intravenous infusion. * **Carboprost (PGF2α):** While Carboprost is contraindicated in patients with **Asthma** (due to bronchoconstriction), it is not absolutely contraindicated in heart disease. However, it should be used with caution as it can increase pulmonary artery pressure. * **Mifepristone:** This is a progesterone antagonist used primarily for medical abortion or cervical ripening; it is not a standard treatment for active PPH and has no significant cardiovascular contraindications in this context. **NEET-PG High-Yield Pearls:** * **Drug of Choice for PPH in Cardiac Patients:** Oxytocin (Slow IV infusion). * **Methergine Contraindications:** Heart disease, Preeclampsia/Hypertension, and Raynaud's phenomenon. * **Carboprost (15-methyl PGF2α) Contraindications:** Active Asthma, hepatic, or renal disease. * **Misoprostol (PGE1):** Safe in asthma and generally safe in cardiac patients, though less effective than injectable uterotonics for active PPH.

Question 35: Which of the following is NOT considered a strong support of the uterus?

A. Uterosacral ligament
B. Round ligament of uterus (Correct Answer)
C. Mackenrodt's ligament
D. Transcervical ligament

Explanation: The supports of the uterus are divided into **Mechanical (Primary)** and **Muscular (Secondary)** supports. Understanding this classification is crucial for NEET-PG. ### Why Option B is the Correct Answer The **Round Ligament** is not a true support. Its primary function is to maintain the uterus in an **anteverted and anteflexed (AVAF)** position. It is a remnant of the gubernaculum and contains smooth muscle; however, it is lax and stretches easily. During pregnancy, it undergoes hypertrophy but does not prevent uterine prolapse. ### Explanation of Incorrect Options (Primary Supports) The primary supports are divided into the **Pelvic Diaphragm** (muscular) and the **Endopelvic Fascia/Ligaments** (visceral). * **Mackenrodt’s Ligament (Option C):** Also known as the **Transverse Cervical Ligament (Option D)** or Cardinal ligament. It is the **strongest support** of the uterus. It attaches the cervix and vaginal vault to the lateral pelvic walls. * **Uterosacral Ligament (Option A):** These ligaments attach the cervix to the sacrum (S2, S3). They pull the cervix backwards, helping to maintain the anteverted position and preventing downward displacement. ### Clinical Pearls for NEET-PG * **Strongest Support:** Mackenrodt’s (Cardinal) ligament. * **Main Muscle Support:** Levator ani (specifically the Pubococcygeus part). * **Level 1 Support (DeLancey):** Includes the Cardinal and Uterosacral ligaments. Damage here leads to **Vault or Uterine Prolapse**. * **Level 2 Support:** Includes the Pubocervical fascia and Rectovaginal fascia. Damage leads to **Cystocele or Rectocele**. * **Surgical Note:** During a Hysterectomy, the clamping of the Mackenrodt’s ligament is a critical step to mobilize the uterus.

Question 36: Cesarean delivery is mandatory in which of the following types of placenta previa?

A. Type 1
B. Type 2
C. Type 3 (Correct Answer)
D. All of the above

Explanation: **Explanation:** The management of placenta previa is primarily determined by the distance between the placental edge and the internal os. Placenta previa is classified into four types: * **Type 1 (Low-lying):** The placenta is in the lower segment but the edge does not reach the internal os. * **Type 2 (Marginal):** The edge reaches the internal os but does not cover it. * **Type 3 (Partial):** The placenta partially covers the internal os. * **Type 4 (Total/Complete):** The placenta completely covers the internal os. **Why Type 3 is the Correct Answer:** In **Type 3 (Partial)** and **Type 4 (Total)** placenta previa, the internal os is physically obstructed by placental tissue. As the cervix dilates during labor, massive maternal hemorrhage is inevitable due to placental separation. Therefore, **Cesarean Delivery is mandatory** to ensure maternal and fetal safety. **Analysis of Incorrect Options:** * **Type 1 (Low-lying):** Vaginal delivery is usually safe and successful as the placental edge is far enough from the os. * **Type 2 (Marginal):** Management depends on whether it is **Type 2 Anterior** or **Type 2 Posterior**. Vaginal delivery is often possible in Type 2 Anterior. However, **Type 2 Posterior** is known as "Dangerous Placenta Previa" because the placenta can be compressed against the sacral promontory by the fetal head, leading to fetal distress or obstructing the pelvic inlet (Stallworthy’s sign). * **Option D:** Incorrect because Type 1 and Type 2 Anterior do not strictly mandate a Cesarean section. **High-Yield Clinical Pearls for NEET-PG:** * **Stallworthy’s Sign:** Associated with Type 2 Posterior placenta previa; it refers to the slowing of the fetal heart rate when the head is pushed into the pelvis, which recovers when pressure is released. * **Macafee’s Regimen:** The expectant management protocol for placenta previa (aiming for 37 weeks) provided there is no active bleeding or fetal distress. * **Double Setup Examination:** Historically used to diagnose previa in the OT, now largely replaced by **Transvaginal Ultrasound (TVS)**, which is the gold standard for localization.

Question 37: Vacuum extraction is contraindicated in which of the following conditions?

A. Premature babies (Correct Answer)
B. Heart disease
C. Microcephaly
D. Polyhydramnios

Explanation: **Explanation:** Vacuum extraction (Ventouse) is a method of instrumental vaginal delivery that relies on suction to apply traction to the fetal scalp. **Why Premature Babies is the Correct Answer:** Prematurity (typically defined as **<34 weeks gestation**) is an absolute contraindication for vacuum extraction. The primary reasons are: 1. **Fragility of scalp and skull:** Preterm infants have softer skulls and more delicate scalp tissues, increasing the risk of severe trauma. 2. **Risk of Intracranial Hemorrhage:** Preterm infants have a fragile germinal matrix. The negative pressure and traction applied by the vacuum significantly increase the risk of subgaleal hematoma and intraventricular hemorrhage (IVH). Forceps delivery is generally preferred if an instrumental delivery is required in preterm cases (between 34–36 weeks). **Analysis of Incorrect Options:** * **B. Heart Disease:** Maternal heart disease is actually an **indication** for instrumental delivery (Forceps or Vacuum) to shorten the second stage of labor and prevent the mother from performing the Valsalva maneuver, which can strain the heart. * **C. Microcephaly:** While a small head might make application slightly different, it is not a contraindication. Contraindications usually relate to fetal bleeding diathesis or malpresentations (e.g., face presentation). * **D. Polyhydramnios:** This is a condition of excess amniotic fluid. While it may lead to malpresentation or cord prolapse, it does not contraindicate the use of a vacuum once the patient is in the second stage of labor with a vertex presentation. **NEET-PG High-Yield Pearls:** * **Absolute Contraindications for Vacuum:** Prematurity (<34 weeks), Face/Breech presentation, non-engaged head, incomplete cervical dilatation, and fetal coagulation disorders. * **The "Chignon":** The temporary swelling of the scalp caused by the vacuum. * **Maximum Pulls:** If there is no descent after 3 pulls or if the cup pops off 2-3 times ("three-pull rule"), the procedure should be abandoned in favor of a Cesarean section.

Question 38: Which of the following is NOT a contraindication to external cephalic version?

A. Contracted pelvis
B. Antepartum hemorrhage
C. Multiple pregnancy
D. Hydramnios (Correct Answer)

Explanation: ### Explanation **External Cephalic Version (ECV)** is a procedure used to turn a fetus from a non-cephalic presentation (breech or transverse) to a cephalic presentation to facilitate a vaginal delivery. **Why Hydramnios is the Correct Answer:** Hydramnios (Polyhydramnios) is **not** a contraindication; in fact, it makes the procedure technically easier because the increased amniotic fluid volume provides more space for the fetus to turn. However, the risk of the fetus reverting back to a malpresentation is higher in these cases. Conversely, **Oligohydramnios** is a relative contraindication because the lack of fluid makes the version difficult and increases the risk of cord compression or placental abruption. **Analysis of Incorrect Options (Contraindications):** * **Contracted Pelvis:** This is an absolute contraindication. If the pelvis is too small for a vaginal delivery, performing an ECV is futile as a Cesarean section will be required regardless of the fetal presentation. * **Antepartum Hemorrhage (APH):** ECV is contraindicated in APH (like placenta previa or abruptio placentae) because the manipulation can trigger massive maternal hemorrhage or further placental separation. * **Multiple Pregnancy:** ECV is contraindicated in twins/triplets due to the lack of intrauterine space and the high risk of cord entanglement or premature rupture of membranes. **High-Yield Clinical Pearls for NEET-PG:** * **Ideal Time:** ECV is usually performed at **36 weeks** in primigravida and **37 weeks** in multigravida (to allow for spontaneous version and ensure fetal maturity if emergency delivery is needed). * **Prerequisites:** Reactive NST, adequate liquor, and no uterine scars (previous LSCS is a relative contraindication). * **Tocolysis:** Use of Beta-mimetics (e.g., Ritodrine or Terbutaline) increases the success rate of ECV by relaxing the uterus. * **Most Common Complication:** Transient fetal bradycardia. * **Most Serious Complication:** Placental abruption.

Question 39: What procedure is the instrument shown below typically used for?

A. Papanicolaou smear (Correct Answer)
B. Visual inspection with acetic acid
C. Visual inspection with Lugol's iodine
D. Colposcopy

Explanation: ***Papanicolaou smear*** - The **Ayre's spatula** and **cervical cytobrush** are specifically designed to collect **exfoliated cervical cells** from the transformation zone for cytological examination. - This procedure is the gold standard for **cervical cancer screening** and detecting **precancerous lesions** (dysplasia). *Visual inspection with acetic acid* - Uses **3-5% acetic acid** applied directly to the cervix, causing abnormal areas to appear **acetowhite**. - Does not require specialized collection instruments like spatulas or brushes, only **visual examination**. *Visual inspection with Lugol's iodine* - Involves applying **Lugol's iodine solution** to the cervix, where normal tissue stains **mahogany brown** while abnormal areas remain **unstained**. - This is a **naked-eye examination** technique that doesn't involve cell collection instruments. *Colposcopy* - Utilizes a **colposcope** (binocular microscope) to magnify the cervix **6-40 times** for detailed visualization. - While **biopsy forceps** may be used during colposcopy for tissue sampling, the primary instrument is the colposcope, not collection spatulas.

Question 40: A G2P1L1 patient presents with active labor. Her cervix is 8 cm dilated; fetal head is at +2 station, with Meconium Stained Liquor (MSL+). A Type 2 deceleration is seen on the Non-Stress Test (NST). What is the next step in management?

A. Vacuum-assisted delivery
B. Forceps-assisted delivery
C. Low Cesarean Section (Correct Answer)
D. Continue monitoring and await spontaneous delivery

Explanation: ### Explanation The patient is in the **active phase of labor** with signs of **fetal distress**, indicated by Meconium Stained Liquor (MSL+) and **Type 2 decelerations** (late decelerations). Late decelerations are a hallmark of uteroplacental insufficiency and signify fetal hypoxia. **1. Why Low Cesarean Section (LSCS) is the correct answer:** The definitive management for fetal distress in the first stage of labor is immediate delivery. Although the fetal head is at +2 station, the **cervix is only 8 cm dilated**. For any instrumental vaginal delivery (Forceps or Vacuum) to be performed, the **cervix must be fully dilated (10 cm)**. Since the first stage of labor is not yet complete, an emergency LSCS is the fastest and safest way to deliver the fetus and prevent birth asphyxia. **2. Why other options are incorrect:** * **A & B (Vacuum/Forceps):** These are contraindicated because the cervix is not fully dilated. Attempting instrumental delivery through an undilated cervix can lead to cervical tears, maternal hemorrhage, and fetal trauma. * **D (Continue monitoring):** In the presence of Type 2 decelerations and MSL, "watchful waiting" is inappropriate as it risks permanent fetal neurological damage or stillbirth. **Clinical Pearls for NEET-PG:** * **Prerequisites for Instrumental Delivery (FORCEPS mnemonic):** **F**etus alive, **O**ptiput position known, **R**uptured membranes, **C**ervix fully dilated, **E**ngaged head, **P**elvis adequate, **S**ubstantial anesthesia/Bladder empty. * **Type 2 Decelerations:** Associated with fetal hypoxia; the nadir of the deceleration occurs *after* the peak of the contraction. * **Station +2:** Indicates the leading bony part of the fetal head is 2 cm below the ischial spines. While the head is engaged, the incomplete cervical dilatation remains the deciding factor for LSCS here.

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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