Operative Obstetrics — MCQs

Operative Obstetrics Indian Medical PG Practice Questions and MCQs

Question 71: What is the drug of choice for postpartum hemorrhage that is resistant to oxytocin and ergometrine?

A. Carboprost (Correct Answer)
B. Dinoprostone
C. Dinoprost
D. Misoprostol

Explanation: **Explanation:** Postpartum Hemorrhage (PPH) is primarily caused by uterine atony. The management follows a specific pharmacological hierarchy. When first-line agents like **Oxytocin** (the drug of choice for prevention and initial treatment) and **Ergometrine** (a potent vasoconstrictor) fail to achieve adequate uterine contraction, the condition is termed resistant PPH. **Why Carboprost is the Correct Answer:** **Carboprost (15-methyl Prostaglandin F2α)** is the drug of choice for PPH resistant to oxytocin and ergometrine. It is a potent uterotonic that increases uterine tone and controls bleeding in approximately 85-95% of cases. It is administered intramuscularly (0.25 mg) and can be repeated every 15–90 minutes (maximum 8 doses). **Analysis of Incorrect Options:** * **B. Dinoprostone (PGE2):** While it has uterotonic properties, it is primarily used for cervical ripening and induction of labor. It is a vasodilator and can cause hypotension, making it less ideal for acute hemorrhage. * **C. Dinoprost (PGF2α):** This is the naturally occurring prostaglandin. Carboprost is its synthetic analogue; the 15-methyl group in Carboprost prevents rapid metabolism, giving it a longer duration of action and higher potency. * **D. Misoprostol (PGE1):** Though widely used due to its low cost and ease of storage (heat stable), it is generally considered less effective than Carboprost for *resistant* PPH. It is often used as a second-line agent when injectable uterotonics are unavailable. **High-Yield Clinical Pearls for NEET-PG:** * **Contraindication:** Carboprost is strictly contraindicated in women with **Asthma** (due to bronchoconstriction). * **Side Effects:** Most common side effects of Carboprost are diarrhea, vomiting, and pyrexia. * **Ergometrine Contraindication:** Avoid in patients with **Hypertension** or Preeclampsia (due to risk of stroke/convulsions). * **Active Management of Third Stage of Labor (AMTSL):** Oxytocin (10 IU IM) remains the gold standard for prevention.

Question 72: Trial of scar is contraindicated in all except?

A. History of previous classical cesarean section
B. History of previous cesarean section due to contracted pelvis
C. Previous 3 lower segment cesarean sections
D. Previous history of lower segment cesarean section with indication of malpresentation (Correct Answer)

Explanation: **Explanation:** The core concept behind a **Trial of Labor After Cesarean (TOLAC)**, or "Trial of Scar," is whether the original reason for the cesarean section is **recurrent** or **non-recurrent**. **Why Option D is correct:** A previous LSCS for **malpresentation** (e.g., breech or transverse lie) is a **non-recurrent indication**. This means the factor that necessitated the first surgery is unlikely to be present in the current pregnancy. If the current fetus is in a cephalic presentation and there are no other contraindications, the patient is an ideal candidate for TOLAC with a high success rate (approx. 70-80%). **Why the other options are contraindicated:** * **Option A (Classical CS):** A classical (vertical) incision involves the upper uterine segment, which is muscular and active during labor. This carries a high risk of uterine rupture (4-9%) compared to LSCS (0.5-1%). * **Option B (Contracted Pelvis):** This is a **recurrent indication**. If the maternal pelvis is too small to allow the passage of a normal-sized fetus, a trial of labor will inevitably fail and poses a high risk of obstructed labor and rupture. * **Option C (Previous 3 LSCS):** While a trial of scar is often considered after one or sometimes two previous LSCS (in specific guidelines), three or more previous surgeries significantly increase the risk of uterine rupture and morbidly adherent placenta (Placenta Accreta Spectrum). **High-Yield Facts for NEET-PG:** * **Best candidate for TOLAC:** Previous LSCS for a non-recurrent cause (e.g., fetal distress, malpresentation, placenta previa). * **Prerequisite:** Spontaneous onset of labor is preferred; the facility must have "Z-time" capability (emergency CS within 30 minutes). * **Contraindications:** Previous classical/T-shaped incision, previous uterine rupture, extensive myomectomy involving the cavity, and any medical/obstetric contraindication to vaginal delivery. * **Success Rate:** Highest if the patient has had a previous successful vaginal birth (VBAC).

Question 73: 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?

A. Cleidotomy
B. McRoberts maneuver (Correct Answer)
C. Cesarean section
D. Lateral traction

Explanation: **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.

Question 74: Fimbriectomy is also known as?

A. Uchida's procedure
B. Kroener procedure (Correct Answer)
C. Irving's procedure
D. Pomeroy Procedure

Explanation: **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.

Question 75: What is the fate of the inner cell mass in embryonic development?

A. Placenta
B. Amniotic membrane
C. Fetus (Correct Answer)
D. Expelled out of the developing embryo by 7 weeks

Explanation: **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.

Question 76: During suction and evacuation, there is a perforation of the uterus. What is the next step?

A. Laparoscopy
B. Hysterotomy
C. Laparotomy (Correct Answer)
D. Hysterectomy

Explanation: **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.

Question 77: Which of the following is the engaging diameter in the fetus in a left occiput anterior (LOA) position?

A. Suboccipitobregmatic (Correct Answer)
B. Mentovertical
C. Submentobregmatic
D. Sternobregmatic

Explanation: ### 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.

Question 78: Karyotyping of the fetus can be done through all of the following invasive methods except?

A. Chorionic villus sampling
B. Cordocentesis
C. Amniocentesis
D. Fetal skin biopsy (Correct Answer)

Explanation: **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 79: 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?

A. Schedule an urgent ultrasound (Correct Answer)
B. Check operating theatre and prepare for external cephalic version
C. Wait and observe for spontaneous breech vaginal delivery
D. Schedule an emergency caesarean section

Explanation: **Explanation:** The management of breech presentation at term requires a systematic approach to determine the safest mode of delivery. In this clinical scenario, the patient is at 37 weeks (term) with early labor signs. **Why Option A is Correct:** Before deciding on the mode of delivery (Vaginal Breech Delivery vs. Cesarean Section), an **urgent ultrasound** is mandatory. The ultrasound serves three critical purposes: 1. **Type of Breech:** To differentiate between Frank, Complete, or Footling breech (Footling is a contraindication for vaginal delivery). 2. **Fetal Attitude:** To check for **hyperextension of the fetal head** ("Stargazing fetus"). If the head is hyperextended, vaginal delivery is contraindicated due to the risk of cervical cord injury. 3. **Estimated Fetal Weight:** To rule out macrosomia (>3.5 or 4kg) or growth restriction, both of which preclude vaginal delivery. **Why Other Options are Incorrect:** * **Option B:** External Cephalic Version (ECV) is typically performed between 36–37 weeks in a non-laboring patient. Once labor has commenced (even mild pains), the uterus is contracting, making ECV difficult and potentially hazardous (risk of placental abruption or cord accident). * **Option C:** Spontaneous vaginal delivery should not be "waited for" without first assessing the favorability criteria via ultrasound and pelvimetry. * **Option D:** While many breech presentations end in C-section, it is not "emergency" status if the maternal and fetal conditions are stable and the os is closed. Assessment comes before surgery. **Clinical Pearls for NEET-PG:** * **Term Breech Trial:** Established that planned C-section is safer than planned vaginal delivery for term breech in terms of perinatal mortality. * **Prerequisites for Vaginal Breech:** Frank/Complete breech, flexed head, fetal weight 2.5–3.5kg, and adequate maternal pelvis. * **Burn-Marshall Maneuver:** Used for delivery of the after-coming head of the breech.

Question 80: Which of the following operations are performed in cervical incompetence?

A. McDonald operation (Correct Answer)
B. Shirodkar operation
C. Purandare's operation
D. Khanna's sling operation

Explanation: **Explanation:** Cervical incompetence (or insufficiency) is characterized by the inability of the uterine cervix to retain a pregnancy in the second trimester in the absence of clinical contractions. The mainstay of surgical management is **Cervical Cerclage**, which provides mechanical support to the weakened internal os. **1. Why McDonald Operation is Correct:** The **McDonald operation** is the most commonly performed cerclage. It involves a simple "purse-string" suture using a non-absorbable material (like Mersilene tape) placed at the level of the vesicovaginal reflection. It is preferred because it is technically easier, involves less blood loss, and does not require bladder mobilization. **2. Analysis of Other Options:** * **Shirodkar Operation:** While this is also used for cervical incompetence, it is a more complex procedure involving the dissection of the bladder and rectum to place the suture as close to the internal os as possible. In many standardized exams, if both are listed, McDonald is often highlighted as the standard "simple" procedure, though both are technically correct for the condition. * **Purandare’s Operation:** This is a **cervico-pexy** (a type of sling surgery) used for the correction of **nulliparous prolapse**, not cervical incompetence. It involves using a strip of rectus sheath to support the cervix. * **Khanna’s Sling Operation:** This is another sling procedure used for **uterine prolapse** (specifically when preserving the uterus is desired), utilizing a Mersilene tape to suspend the cervix to the iliopectineal ligament. **High-Yield Clinical Pearls for NEET-PG:** * **Timing:** Cerclage is ideally performed between **12–14 weeks** of gestation. * **Prerequisite:** Before the procedure, an ultrasound must confirm fetal viability and rule out major congenital anomalies. * **Removal:** The suture is typically removed at **37 weeks** or at the onset of labor to allow for vaginal delivery. * **Contraindications:** Chorioamnionitis, ruptured membranes, and active vaginal bleeding.

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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