Operative Obstetrics Practice Questions

Q: A 30-year-old primigravida presents with a blood pressure of 160/96 mm Hg. Her BUN is 14 mg/dL and creatinine is 1.0 mg/dL. Urinalysis shows no proteinuria. Complete blood count and liver function tests are within normal limits. What is the first best drug to be given to this patient?

Labetalol. ### Explanation **Diagnosis:** The patient is a primigravida with a blood pressure of 160/96 mm Hg, normal renal/liver function, and no proteinuria. This presentation is consistent with **Gestational Hypertension** (if >20 weeks) or **Chronic Hypertension** (if <20 weeks). Regardless of the specific classification, the immediate clinical goal is the safe management of hypertension in pregnancy. **Why Labetalol is Correct:** Labetalol is a combined alpha- and beta-adrenergic blocker and is considered a **first-line antihypertensive agent** in pregnancy. It is preferred due to its rapid onset of action, excellent safety profile, and lack of significant teratogenic effects. It effectively lowers blood pressure without causing significant reflex tachycardia or compromising uteroplacental blood flow. **Analysis of Incorrect Options:** * **Furosemide (A):** Diuretics are generally avoided in pregnancy as they can cause volume depletion and potentially decrease placental perfusion. They are only used in specific cases like pulmonary edema. * **Lisinopril (C) & Losartan (D):** ACE inhibitors and ARBs are **absolutely contraindicated** in pregnancy (Category D/X). They are associated with fetal renal dysgenesis, oligohydramnios, skull hypoplasia, and intrauterine growth restriction (IUGR). **Clinical Pearls for NEET-PG:** * **First-line drugs for Hypertension in Pregnancy:** Oral Labetalol, Methyldopa (safest long-term), and Nifedipine (long-acting). * **Management of Hypertensive Crisis (BP ≥160/110):** IV Labetalol, IV Hydralazine, or Oral Nifedipine. * **Drugs to Avoid:** ACE inhibitors, ARBs, Sodium Nitroprusside (cyanide toxicity), and Spironolactone. * **Target BP:** Aim to maintain systolic between 140–150 mmHg and diastolic between 90–100 mmHg to prevent maternal cerebrovascular accidents without compromising fetal circulation.

Q: What is the name of the maneuver performed for delivering the aftercoming head of a breech presentation?

Mauriceau-Smellie-Veit maneuver. **Explanation:** The **Mauriceau-Smellie-Veit maneuver** is the gold standard manual method for delivering the **aftercoming head** in a vaginal breech delivery. The primary objective is to promote **flexion** of the fetal head, which ensures the smallest diameters (suboccipitobregmatic) engage the maternal pelvis. In this maneuver, the fetus lies on the physician's forearm; the index and middle fingers are placed on the fetal malar bones (malar flexion), while the other hand applies pressure on the occiput to maintain flexion. **Analysis of Incorrect Options:** * **Lovset Maneuver:** Used for the delivery of the **extended arms** in breech presentation. It involves rotating the fetus 180° while maintaining downward traction to bring the posterior arm under the pubic symphysis. * **Burns Marshall Maneuver:** An alternative method for the aftercoming head where the baby is allowed to hang by its own weight to encourage flexion, then swung upward toward the mother’s abdomen. However, it is less preferred than Mauriceau-Smellie-Veit due to the risk of overextending the neck. * **Pinard’s Maneuver:** Used in **frank breech** to bring down the legs. It involves applying pressure to the popliteal fossa to flex the knee and abduct the thigh. **Clinical Pearls for NEET-PG:** * **Piper’s Forceps:** The most preferred instrument for delivering the aftercoming head (reduces intracranial hemorrhage risk). * **Prerequisite:** The aftercoming head must be delivered within **8 minutes** of the umbilicus appearing at the vulva to prevent fetal hypoxia. * **Zavanelli Maneuver:** Cephalic replacement used in shoulder dystocia (not breech).

Q: Fothergill's operation involves:

Amputation of cervix. **Explanation:** **Fothergill’s Operation** (also known as the Manchester operation) is a conservative surgical procedure designed for the management of **uterine prolapse**, specifically in women who wish to preserve their uterus. **Why the correct answer is right:** The hallmark of Fothergill’s operation is the **amputation of the cervix**. The procedure involves: 1. Dilation and Curettage (D&C). 2. Amputation of the elongated vaginal portion of the cervix. 3. **Plication of the Mackenrodt’s (cardinal) ligaments** in front of the cervical stump. This shortens the ligaments, providing structural support to elevate the uterus back into the pelvic cavity. **Why the incorrect options are wrong:** * **A. Conization of cervix:** This is a diagnostic or therapeutic procedure for cervical intraepithelial neoplasia (CIN) involving the removal of a cone-shaped wedge of tissue; it does not address pelvic organ prolapse. * **C. Radical hysterectomy:** This is an extensive surgery for cervical cancer (Wertheim’s operation) involving removal of the uterus, parametrium, and pelvic lymph nodes. * **D. Vaginal hysterectomy:** While used for prolapse, this involves complete removal of the uterus. Fothergill’s is specifically "uterine-sparing." **High-Yield Clinical Pearls for NEET-PG:** * **Ideal Candidate:** A woman with second-degree prolapse who desires to retain her uterus or is unfit for major abdominal surgery. * **Key Step:** Shortening of the Mackenrodt’s ligaments is the most crucial step for providing support. * **Contraindication:** It should not be performed if there is suspected cervical malignancy or if the patient desires future pregnancy (due to high risk of mid-trimester abortion and cervical stenosis). * **Associated Procedure:** Often combined with anterior colporrhaphy and posterior colpoperineorrhaphy.

Q: A 38-year-old woman, gravida 1, para 0, delivers an appropriate-for-gestational age infant by spontaneous vaginal delivery in the vertex position. The infant is noted to have edematous swelling of the soft tissue of the scalp that crosses the midline. What is the most likely diagnosis?

Caput succedaneum. **Explanation:** The clinical presentation describes **Caput succedaneum**, a common neonatal scalp condition [1]. The key diagnostic feature provided is edematous swelling that **crosses the midline (sutures)** [1]. 1. **Why Caput succedaneum is correct:** It is caused by pressure from the cervix or vaginal walls on the fetal head during labor, leading to venous congestion and accumulation of serosanguinous fluid in the subcutaneous tissue (above the periosteum). Because this fluid is located in the superficial soft tissue, it is not restricted by bone boundaries and thus crosses suture lines [1]. It is typically present at birth and resolves spontaneously within a few days [1]. 2. **Why other options are incorrect:** * **Cephalohematoma:** This is a collection of blood between the skull bone and the **periosteum** [1],[2]. Because the periosteum is fixed to the suture lines, the swelling **never crosses the midline** [1]. It often appears hours after birth and takes weeks to resolve [1],[2]. * **Subcutaneous fat necrosis:** This presents as firm, erythematous nodules or plaques on the skin, usually appearing days to weeks after birth, often following birth trauma or therapeutic cooling. * **Fracture of the skull:** While linear fractures can occur during delivery, they do not typically present as diffuse soft tissue swelling crossing sutures; they are often asymptomatic or associated with localized depression (ping-pong fracture). **High-Yield Clinical Pearls for NEET-PG:** * **Caput succedaneum:** Present at birth, crosses sutures, involves subcutaneous tissue [1]. * **Cephalohematoma:** Delayed onset, does **not** cross sutures, subperiosteal [1]. Risk of jaundice due to RBC breakdown [2]. * **Subgaleal Hemorrhage:** Bleeding between the aponeurosis and periosteum. It is a **surgical emergency** as it can lead to massive blood loss and shock. It also crosses sutures but is fluctuant and rapidly expanding.

Q: Which forceps is used for the aftercoming head in a breech delivery?

Piper forceps. **Explanation:** The correct answer is **Piper forceps**. In breech presentations, the delivery of the aftercoming head is a critical stage. Piper forceps are specifically designed for this purpose, featuring a **long shank with a perineal curve** (downward curve). This unique design allows the blades to be applied to the fetal head while the body of the baby is positioned above the level of the handles, preventing excessive extension of the fetal neck and protecting the head from sudden decompression. **Analysis of Incorrect Options:** * **Kielland's forceps:** These are specialized "rotational forceps" characterized by a minimal pelvic curve and a sliding lock. They are used for correcting asynclitism or rotating a head from an occipito-transverse/posterior position, not for breech. * **Wrigley's forceps:** These are short, light "outlet forceps." They are used for low-cavity or outlet deliveries when the head is on the perineum, often during Cesarean sections, but they lack the length and curve required for the aftercoming head. * **Kocher's forceps:** This is a surgical instrument (hemostat/clamp) used for grasping tissues or clamping vessels; it is not an obstetric forceps used for delivery. **High-Yield Clinical Pearls for NEET-PG:** * **Prerequisite:** For Piper forceps application, the fetal body must be held up by an assistant (the "Prague maneuver" is sometimes used in conjunction). * **Alternative:** The **Burns-Marshall method** and **Mariceau-Smellie-Veit maneuver** are manual techniques for delivering the aftercoming head. * **Key Feature:** Piper forceps lack a pelvic curve but possess a perineal curve to accommodate the fetal trunk.

Question 1

A 30-year-old primigravida presents with a blood pressure of 160/96 mm Hg. Her BUN is 14 mg/dL and creatinine is 1.0 mg/dL. Urinalysis shows no proteinuria. Complete blood count and liver function tests are within normal limits. What is the first best drug to be given to this patient?

Accepted Answer

Labetalol

Answer

Furosemide

Answer

Lisinopril

Answer

Losartan

Question 2

In a nulliparous woman, what is the treatment of choice for a ruptured ectopic pregnancy?

Accepted Answer

Linear salpingostomy

Answer

Salpingectomy and end-to-end anastomosis

Answer

Salpingo-oophorectomy

Answer

Expectant management (Wait and watch)

Question 3

What is the name of the maneuver performed for delivering the aftercoming head of a breech presentation?

Accepted Answer

Mauriceau-Smellie-Veit maneuver

Answer

Lovset maneuver

Answer

Burns Marshall maneuver

Answer

Pinard's maneuver

Question 4

Which of the following scenarios poses the least risk of neonatal varicella pneumonia in an infant born to a mother with varicella infection?

Accepted Answer

Mother develops rash 10 days before delivery.

Answer

Mother develops rash 2 days before delivery.

Answer

Mother develops rash during the postnatal hospital stay.

Answer

Mother develops rash just before delivery and was treated with acyclovir.

Question 5

Fothergill's operation involves:

Accepted Answer

Amputation of cervix

Answer

Conization of cervix

Answer

Radical hysterectomy

Answer

Vaginal hysterectomy

Question 6

A 38-year-old woman, gravida 1, para 0, delivers an appropriate-for-gestational age infant by spontaneous vaginal delivery in the vertex position. The infant is noted to have edematous swelling of the soft tissue of the scalp that crosses the midline. What is the most likely diagnosis?

Accepted Answer

Caput succedaneum

Answer

Cephalohematoma

Answer

Subcutaneous fat necrosis

Answer

Fracture of the skull

Question 7

All of the following are true regarding the management of diabetic patients during pregnancy, EXCEPT?

Accepted Answer

A Glucose Tolerance Test (GTT) must be performed in all patients with known diabetes at the first visit.

Answer

Insulin is the most preferred drug, if required, for glycemic control.

Answer

Targeted sonography should be performed between 18 and 20 weeks to rule out fetal anomalies.

Answer

Metformin and Glyburide are oral hypoglycemics, safe for use in pregnancy.

Question 8

A primigravida with vertex presentation is having a fully dilated cervix. The head is well engaged and is at a station of +2. Fetal heart monitoring shows late decelerations. What is the most appropriate management in this situation?

Accepted Answer

Forceps application

Answer

Observation

Answer

Vacuum extraction

Answer

Immediate Caesarean section

Question 9

Which forceps is used for the aftercoming head in a breech delivery?

Accepted Answer

Piper forceps

Answer

Kielland's forceps

Answer

Wrigley's forceps

Answer

Kocher's forceps

Question 10

A 34-week pregnant woman, G3P2L2, complains of decreased fetal movements for the past 24 hours. She has no other significant pregnancy-related conditions. What is the next best step?

Accepted Answer

Instruct the patient to go to the hospital for a nonstress test.

Answer

Instruct the patient to go to the hospital for a contraction stress test.

Answer

Reassure the patient that one fetal movement per hour is within normal limits.

Answer

Admit the patient to the hospital for delivery.

Operative Obstetrics — MCQs

Operative Obstetrics — MCQs

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