Operative Obstetrics Practice Questions

Q: A diabetic mother delivers a baby, but the baby's head is delivered, and the shoulder has not been delivered even after one minute. What is the next course of action?

McRoberts maneuver. **Explanation:** The clinical scenario describes **Shoulder Dystocia**, a life-threatening obstetric emergency where the fetal head is delivered but the anterior shoulder becomes impacted behind the maternal symphysis pubis. The "one-minute" delay and the history of maternal diabetes (a risk factor for fetal macrosomia) are classic diagnostic indicators. **1. Why McRoberts Maneuver is Correct:** The **McRoberts maneuver** is the first-line management for shoulder dystocia. It involves hyperflexing the mother's legs against her abdomen. This action flattens the sacral promontory and rotates the symphysis pubis cephalad, increasing the functional space in the pelvic inlet and allowing the impacted shoulder to slip under the pubic bone. It has a high success rate (up to 90%) and carries the lowest risk of maternal or fetal trauma. **2. Why Other Options are Incorrect:** * **Cleidotomy (A):** This involves surgical fracturing of the fetal clavicle. It is a destructive procedure reserved for a dead fetus or as a last resort in extreme cases. * **Cesarean Section (C):** Once the head is delivered, a standard C-section is not possible. The **Zavanelli maneuver** (pushing the head back into the vagina followed by C-section) is a desperate, final measure with high morbidity. * **Lateral Traction (D):** Strong downward or lateral traction on the fetal head is **contraindicated**, as it significantly increases the risk of **Brachial Plexus Injury (Erb’s Palsy)**. **Clinical Pearls for NEET-PG:** * **Turtle Sign:** The fetal head retracts against the perineum (pathognomonic for shoulder dystocia). * **HELPERR Mnemonic:** A standard protocol (H-Help, E-Episiotomy, L-Legs/McRoberts, P-Suprapubic pressure, E-Enter/Internal rotation, R-Remove posterior arm, R-Roll the patient). * **Suprapubic Pressure (Mazzanti Maneuver):** Often performed alongside McRoberts; never apply fundal pressure as it worsens impaction.

Q: Fimbriectomy is also known as?

Kroener procedure. **Explanation:** **Kroener procedure** is the correct answer because it specifically refers to the surgical technique of **fimbriectomy**. In this method, the distal end of the fallopian tube (the fimbria) is ligated and excised. While it is a relatively simple procedure, it is associated with a higher failure rate compared to other methods because of the potential for "re-fimbriation" or the formation of a tubo-peritoneal fistula, which can lead to ectopic pregnancy. **Analysis of Incorrect Options:** * **Uchida’s procedure:** This involves a subserosal injection of saline/epinephrine to balloon the serosa, followed by resection of a segment of the tube and burying the proximal stump within the broad ligament. It has the lowest failure rate. * **Irving’s procedure:** This involves cutting the tube and burying the proximal stump into a tunnel in the posterior wall of the uterus. It is highly effective but requires more extensive surgery, usually performed during a Cesarean section. * **Pomeroy procedure:** This is the most commonly used method. A loop of the mid-isthmic portion of the tube is ligated with absorbable suture (plain catgut) and then excised. The "modified Pomeroy" is the standard technique for postpartum sterilization. **High-Yield Clinical Pearls for NEET-PG:** * **Most common method:** Pomeroy procedure (due to its simplicity and balance of efficacy). * **Most effective method (lowest failure rate):** Uchida or Irving procedure. * **Highest failure rate:** Madlener procedure (crushing and ligating without excision). * **Ideal time for postpartum sterilization:** Within 24–48 hours of delivery. * **Failure rates:** Usually quoted as 1 in 200 to 1 in 500 depending on the technique.

Q: What is the fate of the inner cell mass in embryonic development?

Fetus. **Explanation:** The development of the blastocyst is a high-yield topic in embryology. Around day 4–5 after fertilization, the morula develops a fluid-filled cavity, becoming a **blastocyst**. This structure differentiates into two distinct cell populations: 1. **Inner Cell Mass (Embryoblast):** These are the internal cells that are pluripotent. They eventually differentiate into the **fetus** (via the epiblast and hypoblast layers). 2. **Outer Cell Mass (Trophoblast):** these cells form the outer lining and are responsible for implantation and the development of the **placenta** and chorion. **Analysis of Options:** * **A. Placenta:** Incorrect. The placenta is derived from the **trophoblast** (specifically the cytotrophoblast and syncytiotrophoblast). * **B. Amniotic membrane:** Incorrect. While the amnion is derived from the epiblast (which comes from the ICM), the primary "fate" or ultimate product of the ICM is the fetus itself. * **D. Expelled out:** Incorrect. The ICM is the essential core of the developing pregnancy; its loss would result in a blighted ovum or early miscarriage. **Clinical Pearls for NEET-PG:** * **Totipotency vs. Pluripotency:** Zygomeres (up to the 8-cell stage) are *totipotent* (can form embryo + placenta). The Inner Cell Mass is *pluripotent* (can form all fetal tissues but not the placenta). * **Implantation:** Occurs 6–7 days after fertilization (the "Window of Implantation"). * **Dizygotic Twins:** Result from two separate ova; **Monozygotic Twins** result from the splitting of a single embryo. If the ICM splits between days 4–8, it results in Monochorionic Diamniotic (MCDA) twins.

Q: During suction and evacuation, there is a perforation of the uterus. What is the next step?

Laparotomy. **Explanation:** Uterine perforation is a serious complication of suction and evacuation (S&E). The management depends on the clinical scenario, but in the context of a **suction procedure**, the risk of visceral injury is high. **Why Laparotomy is the Correct Choice:** When perforation occurs during suction and evacuation, there is a significant risk that the suction cannula or forceps has entered the peritoneal cavity and injured the **bowel, bladder, or major blood vessels**. A **laparotomy** is the gold standard because it allows for a full, systematic exploration of the abdominal cavity to identify and repair any visceral injuries, control hemorrhage, and ensure the uterus is completely evacuated under direct visualization. **Analysis of Incorrect Options:** * **Laparoscopy (A):** While laparoscopy can be used for stable patients with suspected "silent" perforations (e.g., during a simple D&C), it is generally avoided if a suction cannula was used, as bowel injuries can be extensive and difficult to manage laparoscopically in an emergency setting. * **Hysterotomy (B):** This involves cutting into the uterus to remove the fetus. It does not address the primary concern of potential extra-uterine visceral damage caused by the perforation. * **Hysterectomy (D):** This is a radical measure reserved only for cases where the uterine damage is irreparable or there is uncontrollable life-threatening hemorrhage. It is not the immediate "next step." **High-Yield Clinical Pearls for NEET-PG:** * **Most common site of perforation:** The uterine fundus. * **Immediate Sign:** Sudden "loss of resistance" or the instrument passing deeper than the measured uterine sound. * **Management Rule:** If perforation occurs with a **blunt instrument** (uterine sound) in a stable patient, observation is acceptable. If it occurs with a **suction cannula or sharp curette**, surgical exploration (Laparotomy) is mandatory to rule out bowel injury.

Q: Which of the following is the engaging diameter in the fetus in a left occiput anterior (LOA) position?

Suboccipitobregmatic. ### Explanation In the **Left Occiput Anterior (LOA)** position, the fetal head is in a state of **complete flexion**. When the head is well-flexed, the smallest possible diameter of the fetal skull presents to the pelvic inlet. **1. Why Suboccipitobregmatic is Correct:** The **Suboccipitobregmatic (SOB)** diameter extends from the undersurface of the occiput (at the junction with the neck) to the center of the bregma (anterior fontanelle). It measures approximately **9.5 cm**. This is the engaging diameter in all vertex presentations where the head is fully flexed (OA, LOA, ROA). **2. Analysis of Incorrect Options:** * **Mentovertical (13.5 cm):** This is the engaging diameter in **Brow presentation**, where the head is midway between flexion and extension. It is the largest diameter of the fetal head and usually results in obstructed labor. * **Submentobregmatic (9.5 cm):** This is the engaging diameter in **Face presentation** when the head is completely extended. While the measurement is the same as SOB, the landmark (mentum/chin) is different. * **Sternobregmatic:** This is not a standard obstetric diameter used to describe fetal head engagement. **3. Clinical Pearls for NEET-PG:** * **Vertex Presentation (Well-flexed):** Engaging diameter is **Suboccipitobregmatic (9.5 cm)**. * **Vertex Presentation (Deflexed/Military):** Engaging diameter is **Occipitofrontal (11.5 cm)**. * **Brow Presentation:** Engaging diameter is **Mentovertical (13.5 cm)**. * **Face Presentation:** Engaging diameter is **Submentobregmatic (9.5 cm)**. * **LOA** is considered the most common "ideal" position for delivery as it facilitates the normal mechanism of labor.

Q: Karyotyping of the fetus can be done through all of the following invasive methods except?

Fetal skin biopsy. **Explanation:** The core objective of prenatal karyotyping is to obtain viable fetal cells that can be cultured to visualize chromosomes. While several invasive procedures yield these cells, the choice of method depends on the gestational age and the specific diagnostic requirement. **Why Fetal Skin Biopsy is the Correct Answer:** Fetal skin biopsy is a highly specialized, invasive procedure used primarily for diagnosing **severe genodermatoses** (e.g., Epidermolysis bullosa or Ichthyosis) when DNA-based testing is unavailable. While skin cells contain the fetal genome, it is **not** a standard or routine method for karyotyping because it carries a significantly higher risk of fetal injury and pregnancy loss compared to other methods. It is considered a "last resort" for structural skin defects, not chromosomal analysis. **Analysis of Other Options:** * **Chorionic Villus Sampling (CVS):** Performed at **10–13 weeks**. It involves sampling trophoblastic tissue. It is the earliest invasive method for karyotyping. * **Amniocentesis:** The "gold standard" for prenatal diagnosis, typically performed at **15–20 weeks**. It collects fetal thyrocytes, skin cells, and gastrointestinal cells shed into the amniotic fluid. * **Cordocentesis (Percutaneous Umbilical Blood Sampling):** Performed after **18 weeks**. It provides rapid karyotyping (within 48–72 hours) by culturing fetal lymphocytes. **High-Yield Clinical Pearls for NEET-PG:** * **Earliest Karyotyping:** CVS (10 weeks). * **Most Common Method:** Amniocentesis. * **Rapid Karyotyping:** Cordocentesis (useful for late presenters or mosaicism confirmation). * **Risk of Procedure-Related Loss:** CVS (~0.5–1%) > Amniocentesis (~0.1–0.5%). * **Pre-procedure Requirement:** Always check maternal Rh status; administer Anti-D immunoglobulin if the mother is Rh-negative.

Question 1

What is the drug of choice for postpartum hemorrhage that is resistant to oxytocin and ergometrine?

Accepted Answer

Carboprost

Answer

Dinoprostone

Answer

Dinoprost

Answer

Misoprostol

Question 2

Trial of scar is contraindicated in all except?

Accepted Answer

Previous history of lower segment cesarean section with indication of malpresentation

Answer

History of previous classical cesarean section

Answer

History of previous cesarean section due to contracted pelvis

Answer

Previous 3 lower segment cesarean sections

Question 3

A diabetic mother delivers a baby, but the baby's head is delivered, and the shoulder has not been delivered even after one minute. What is the next course of action?

Accepted Answer

McRoberts maneuver

Answer

Cleidotomy

Answer

Cesarean section

Answer

Lateral traction

Question 4

Fimbriectomy is also known as?

Accepted Answer

Kroener procedure

Answer

Uchida's procedure

Answer

Irving's procedure

Answer

Pomeroy Procedure

Question 5

What is the fate of the inner cell mass in embryonic development?

Accepted Answer

Fetus

Answer

Placenta

Answer

Amniotic membrane

Answer

Expelled out of the developing embryo by 7 weeks

Question 6

During suction and evacuation, there is a perforation of the uterus. What is the next step?

Accepted Answer

Laparotomy

Answer

Laparoscopy

Answer

Hysterotomy

Answer

Hysterectomy

Question 7

Which of the following is the engaging diameter in the fetus in a left occiput anterior (LOA) position?

Accepted Answer

Suboccipitobregmatic

Answer

Mentovertical

Answer

Submentobregmatic

Answer

Sternobregmatic

Question 8

Karyotyping of the fetus can be done through all of the following invasive methods except?

Accepted Answer

Fetal skin biopsy

Answer

Chorionic villus sampling

Answer

Cordocentesis

Answer

Amniocentesis

Question 9

A 25-year-old woman, G2P1L1, presents at 37 weeks gestation with mild labor pains. On examination, she has a breech presentation with a closed os and a partially effaced cervix. What is the next management step?

Accepted Answer

Schedule an urgent ultrasound

Answer

Check operating theatre and prepare for external cephalic version

Answer

Wait and observe for spontaneous breech vaginal delivery

Answer

Schedule an emergency caesarean section

Question 10

Which of the following operations are performed in cervical incompetence?

Accepted Answer

McDonald operation

Answer

Shirodkar operation

Answer

Purandare's operation

Answer

Khanna's sling operation

Operative Obstetrics — MCQs

Operative Obstetrics — MCQs

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