Operative Obstetrics

Operative Obstetrics Indian Medical PG Question 1: Match List-I with List-II and select the correct answer using the code given below: List-I (Obstetric Manoeuvres): A) Pinard's manoeuvre B) Lovset's manoeuvre C) Mauriceau-Smellie-Veit manoeuvre D) External cephalic version List-II (Indications/Purposes): 1) Conversion of breech to cephalic presentation 2) Delivery in breech presentation at term 3) Delivery of after-coming head in breech 4) Delivery of anterior shoulder and arms in breech Select the correct matching:

• A. A→4 B→1 C→3 D→2
• B. A→3 B→1 C→4 D→2
• C. A→2 B→4 C→3 D→1
• D. A→1 B→4 C→3 D→2 (Correct Answer)

Operative Obstetrics Explanation: ***A→2 B→4 C→3 D→1*** - **Pinard's manoeuvre** (A) is used for **delivery in breech presentation at term** (2) by flexing the fetal knee and abducting the thigh to bring down extended legs. - This is the correct matching as each manoeuvre corresponds to its specific **obstetric indication**: **Lovset's** for shoulder delivery, **Mauriceau-Smellie-Veit** for after-coming head, and **External cephalic version** for presentation conversion. *A→4 B→1 C→3 D→2* - Incorrectly matches **Pinard's manoeuvre** to shoulder/arm delivery, which is actually the role of **Lovset's manoeuvre**. - **Lovset's manoeuvre** is mismatched to presentation conversion rather than its specific purpose of **delivering shoulders and arms** in breech presentation. *A→3 B→1 C→4 D→2* - **Pinard's manoeuvre** is wrongly matched to **after-coming head delivery**, which is specifically performed by **Mauriceau-Smellie-Veit manoeuvre**. - **Mauriceau-Smellie-Veit manoeuvre** is incorrectly matched to shoulder delivery instead of its actual purpose of **controlled delivery of the fetal head**. *A→1 B→4 C→3 D→2* - **Pinard's manoeuvre** is incorrectly matched to **presentation conversion**, which is performed **antepartum** by **External cephalic version**. - **External cephalic version** is wrongly matched to delivery during labor rather than its **prenatal** role in converting **breech to cephalic presentation**.

Operative Obstetrics Indian Medical PG Question 2: Which is not an indication for a classical cesarean incision?

• A. Premature breech
• B. Cannot visualize the lower uterine segment
• C. Transverse lie
• D. Term breech (frank) (Correct Answer)

Operative Obstetrics Explanation: ***Term breech (frank)*** - A **frank breech** presentation at term does not inherently require a classical (vertical) incision, as a **low transverse incision** is generally safe and preferred for its lower risk of uterine rupture in subsequent pregnancies. - The decision for incision type is based more on the accessibility of the **lower uterine segment** and fetal lie than on the specific type of breech at term. *Premature breech* - In a premature fetus, the **lower uterine segment** may be underdeveloped and insufficient to allow safe extraction through a low transverse incision. - A **classical incision** provides a larger opening in the thicker, upper uterine segment, which is safer for a fragile preterm infant. *Cannot visualize the lower uterine segment* - Conditions like **dense adhesions** from prior surgeries, a large **leiomyoma**, or an **anterior placenta previa** can obscure or make the lower uterine segment inaccessible. - In such cases, a **classical incision** in the more visible and accessible upper uterine corpus is indicated to safely deliver the fetus. *Transverse lie* - A **transverse lie** means the fetus is lying horizontally across the uterus, often making a **low transverse incision** difficult or impossible due to the fetal position. - A **classical incision** allows for a larger, more vertical opening that accommodates the fetal spine and shoulders, facilitating safe extraction.

Operative Obstetrics Indian Medical PG Question 3: How do you manage placenta accreta?

• A. Classical cesarean; hysterectomy (Correct Answer)
• B. Low vertical cesarean; hysterectomy
• C. Low transverse cesarean; hysterectomy
• D. Classical cesarean; myometrial resection

Operative Obstetrics Explanation: ***Classical cesarean; hysterectomy*** - A **classical cesarean section** (vertical incision in the upper uterine segment) allows for delivery of the fetus without disturbing the **placenta accreta** in the lower uterine segment. - Subsequent **hysterectomy** is often necessary due to the high risk of severe hemorrhage from the morbidly adherent placenta, which cannot be safely separated. *Low vertical cesarean; hysterectomy* - A **low vertical incision** is made in the lower uterine segment, which could potentially incise through the placenta accreta if it extends to that region, leading to significant hemorrhage. - While hysterectomy is likely indicated, the initial uterine incision might complicate management. *Low transverse cesarean; hysterectomy* - A **low transverse incision** is the most common type for routine cesarean sections but is contra-indicated in placenta accreta as the placenta is frequently implanted in the lower uterine segment. - Incising through the **placenta** during a low transverse cut would cause immediate massive hemorrhage, making this approach unsuitable. *Classical cesarean; myometrial resection* - While a **classical cesarean** would be the appropriate initial step for fetal delivery, **myometrial resection** to remove only the affected area of the myometrium is generally insufficient and carries a high risk of residual placental tissue and severe hemorrhage, often necessitating a hysterectomy anyway. - This approach is typically not recommended as a primary definitive management strategy for established placenta accreta.

Operative Obstetrics Indian Medical PG Question 4: Angle of cut in episiotomy is?

• A. 45 degrees at the midline
• B. 30 degrees at the midline
• C. 60 degrees at the midline (Correct Answer)
• D. 15 degrees at the midline

Operative Obstetrics Explanation: ***60 degrees at the midline*** - A **mediolateral episiotomy** is recommended at a **60-degree angle** from the midline, directed towards the ischial tuberosity. - This angle is based on **RCOG guidelines** and standard obstetric practice, providing optimal protection against **third- and fourth-degree perineal tears**. - The 60-degree angle effectively directs the incision away from the **anal sphincter** and **rectum**, while maintaining adequate surgical access. *45 degrees at the midline* - While sometimes used, this angle is **less protective** than 60 degrees against anal sphincter injuries. - Studies show that angles less than 60 degrees have a **higher risk** of extension into the anal sphincter complex compared to the recommended 60-degree angle. *30 degrees at the midline* - This angle is **too shallow** and provides insufficient protection against tearing towards the anal sphincter. - The risk of uncontrolled extension into the **anal sphincter complex** is significantly increased with such a small angle. *15 degrees at the midline* - This angle is **far too shallow** and would provide minimal expansion of the vaginal outlet. - It offers virtually no protection from extension into the **anal sphincter** and would likely result in an uncontrolled tear, making it an impractical choice for episiotomy.

Operative Obstetrics Indian Medical PG Question 5: Which of the following is/are required for a registered medical practitioner to qualify for performing Medical Termination of Pregnancy (MTP), as per revised rules of MTP Act? 1. Certified for assisting at least 25 MTP in an authorized centre 2. Diploma or degree in Obstetrics and Gynaecology 3. House surgeon training for 6 months in Obstetrics and Gynaecology 4. Certified training for 6 months in laparoscopic surgeries Select the correct answer using the code given below:

• A. 2 only
• B. 1 only
• C. 1, 2 and 3 (Correct Answer)
• D. 1, 2 and 4

Operative Obstetrics Explanation: ***1, 2 and 3*** - As per the **MTP (Amendment) Act 2021 and Rules**, a registered medical practitioner (RMP) can perform MTP if they meet **any one** of the following qualifications: - Assisted at least **25 MTPs** in an authorized center - Hold a **diploma or degree in Obstetrics and Gynaecology** - Completed **house surgeon training for 6 months** in Obstetrics and Gynaecology in a recognized institution - All three statements (1, 2, and 3) represent valid pathways for qualification under the MTP Act, making this the correct answer. *2 only* - While a **diploma or degree in Obstetrics and Gynaecology** is indeed a valid qualification, it is not the *only* pathway recognized by the MTP Act. - Other pathways including practical experience (25 MTPs) and house surgeon training are equally valid qualifications. *1 only* - Assisting at least **25 MTPs** in an authorized center is a valid standalone qualification under the MTP Act. - However, this option is incorrect because statements 2 and 3 are also valid qualifications, not just statement 1 alone. *1, 2 and 4* - **Certified training for 6 months in laparoscopic surgeries** is **not a requirement** for performing MTP under the MTP Act. - While surgical skills are valuable, laparoscopic surgery training is not specifically mandated for MTP qualification, which primarily involves medical and surgical abortion procedures that don't necessarily require laparoscopic techniques.

Operative Obstetrics Flashcard 1 of 5

Question: Perimortem cesarean delivery should be considered if there is no return of spontaneous circulation in _____ minutes

Answer: 5

Operative Obstetrics Flashcard 2 of 5

Question: The nerve most commonly injured during cesarean section is _____ nerve and Ilioinguinal nerve

Answer: Iliohypogastric

Operative Obstetrics Flashcard 3 of 5

Question: _____ maneuver is used for the delivery of extended legs in case of frank breech delivery.

Answer: Pinard s

Operative Obstetrics Flashcard 4 of 5

Question: _____ incision is the most common skin incision made in caesarean delivery.

Answer: Pfannenstiel

Operative Obstetrics Flashcard 5 of 5

Question: _____ location of placenta will impede with performing the external cephalic version

Answer: Anterior