Labor and Delivery Practice Questions

Q: Which of the following is a uterine compression suture during management of atonic postpartum haemorrhage?

B-Lynch suture. **B-Lynch suture** - The **B-Lynch suture** is a specific type of surgical technique involving the placement of sutures across the uterine fundus and lower uterine segment to compress the uterus. - This compression helps to reduce blood loss by mechanically occluding the endometrial vessels, making it highly effective in managing **atonic postpartum hemorrhage**. *Sturmdorf suture* - The Sturmdorf suture is primarily used in **cervical cone biopsy** or **trachelectomy** to close the cervical stump. - It involves everting and suturing the cervical mucosa to provide hemostasis and promote healing of the cervix, not for uterine compression. *Fothergill's suture* - Fothergill's operation (Manchester operation) is used for **pelvic organ prolapse**, particularly uterine prolapse. - It typically involves shortening the cardinal ligaments and repairing the perineum, but does not involve uterine compression for hemorrhage. *Moscowitz suture* - The Moscowitz suture is used for **obliteration of the cul-de-sac (pouch of Douglas)** to prevent **enterocele** formation during pelvic floor repair. - This technique involves plicating the peritoneum over the pouch of Douglas, and is not a uterine compression suture for atonic hemorrhage.

Q: The following are the signs of placental separation except :

The fundal height decreases. ***The fundal height decreases*** - Following placental separation, the uterus often rises in the abdomen due to the pooling of blood behind the placenta, causing the **fundal height to appear to increase**, not decrease. - A decrease in fundal height is not a recognized sign of placental separation. *The uterus becomes hard and globular* - As the placenta separates, the uterus naturally contracts firmly to prevent postpartum hemorrhage, thus becoming **hard and globular** to the touch. - This **sustained contraction** is a key clinical sign indicating effective uterine retrieval and placental detachment. *Permanent lengthening of the cord* - Once the placenta detaches from the uterine wall and descends into the lower uterine segment or vagina, the **umbilical cord will appear to lengthen** permanently outside the vulva. - This external lengthening signifies that the placenta has moved from its intrauterine position. *Fresh bleeding occurs* - Fresh bleeding is expected after placental separation because the detachment process exposes maternal blood vessels, leading to **external blood loss**. - This **active bleeding** is a normal physiological sign indicating the placenta is no longer attached to the uterine wall.

Q: Face to pubis delivery is common in which type of pelvis ?

Anthropoid. ***Anthropoid*** - The **anthropoid pelvis** has an oval inlet with a long anteroposterior (AP) diameter, which favors **persistent occiput posterior (OP) positions**. - In OP position, the fetal occiput faces the maternal sacrum, and the fetal face faces the maternal pubis, resulting in **"face to pubis" delivery**. - This pelvic shape aligns the fetal head to enter and descend in the AP diameter, increasing the likelihood of the occiput remaining posterior throughout labor, leading to delivery in the OP position. *Android* - An **android pelvis** is heart-shaped and narrow, often associated with complications like **failure to progress** and fetal head arrest, but not specifically face to pubis deliveries. - Its narrow forepelvis makes internal rotation difficult, often leading to **transverse arrest** of the fetal head rather than persistent OP position. *Gynaecoid* - The **gynaecoid pelvis** is the ideal and most common female pelvic type, characterized by a rounded inlet and adequate diameters, typically allowing for delivery in the favorable **occiput anterior (OA) position**. - It facilitates **spontaneous internal rotation** to OA position, making face to pubis (OP) delivery uncommon. *Platypelloid* - A **platypelloid pelvis** has a flattened inlet with a short anteroposterior and a wide transverse diameter, often leading to **transverse arrest** of the fetal head. - This shape is unfavorable for vaginal delivery in general and does not specifically predispose to face to pubis presentations.

Q: Normal pH of foetal scalp blood is :

7.30. ***7.30*** - A **normal foetal scalp pH** is generally considered to be above 7.25, with an ideal range being closer to **7.30-7.35**. - A pH of **7.30** indicates adequate oxygenation and acid-base balance, suggesting the foetus is not experiencing significant hypoxia or acidosis. *7.20* - A pH of **7.20** is typically considered a **borderline acidic** value in foetal scalp blood. - While not immediately critical, it often warrants close monitoring or further assessment of foetal well-being, as it may indicate mild **acidosis**. *7.0* - A pH of **7.0** in foetal scalp blood is a significantly **acidotic** value. - This level suggests considerable **foetal distress and hypoxemia**, often necessitating urgent intervention like expedited delivery. *7.10* - A pH of **7.10** is indicative of definite **foetal acidosis**. - This level is a strong indicator of **foetal compromise** and would typically prompt immediate action to resolve the underlying issue or deliver the baby.

Q: A pregnant lady with 37 weeks gestation has been admitted with a history of premature rupture of membranes for 6 hours. She is best treated with:

antibiotics followed by labour induction. ***antibiotics followed by labour induction*** - For premature rupture of membranes (PROM) at full term (≥37 weeks gestation), **antibiotics** are given to prevent maternal and neonatal infection due to the prolonged rupture, and **labour induction** is recommended to reduce the risk of chorioamnionitis and neonatal sepsis. - The risk of infection increases significantly with the duration of membrane rupture, making active management with induction preferable over expectant management. - Current guidelines recommend induction within 24 hours of membrane rupture at term. *steroids followed by labour induction* - **Antenatal steroids** (e.g., betamethasone, dexamethasone) are primarily used to promote fetal lung maturity in cases of anticipated preterm birth, typically between 24 and 34 weeks gestation. - At **37 weeks gestation**, the fetal lungs are generally mature, so steroids offer no significant benefit and would only delay necessary intervention. *expectant management* - **Expectant management** (waiting for spontaneous labor) at term PROM significantly increases the risk of maternal and neonatal infections including chorioamnionitis, endometritis, and neonatal sepsis. - Studies show that active management with induction reduces infection rates without increasing cesarean section rates. - While most women will go into spontaneous labor within 24 hours, the infection risk during the waiting period outweighs the benefits of avoiding induction. *steroids and tocolytic agents* - As established, **steroids** are not indicated at 37 weeks gestation. - **Tocolytic agents** are used to suppress uterine contractions and prolong pregnancy in cases of preterm labor, which is contraindicated in PROM at term as delaying delivery increases infection risk without providing significant fetal benefit.

Q: Which of the following foetal diameters measure 9.4 cm at term? 1. Biparietal diameter 2. Suboccipitofrontal diameter 3. Submentobregmatic diameter 4. Bitrochanteric diameter Select the correct answer using the code given below:

1 and 3 only. ***1 and 3 only*** - The **biparietal diameter (BPD)** measures the distance between the two parietal eminences and is typically **9.4 cm** at term, representing the widest transverse diameter of the fetal head. - The **submentobregmatic diameter** measures from the junction of the chin and neck to the center of the anterior fontanelle (bregma), typically measuring **9.5 cm** at term (often approximated as 9.4 cm in clinical practice), and is the presenting diameter in a face presentation with complete extension. *1, 2, 3 and 4* - While both biparietal and submentobregmatic diameters are approximately 9.4-9.5 cm, the **suboccipitofrontal** and **bitrochanteric** diameters do not match this measurement at term. - The suboccipitofrontal diameter is larger (~10 cm) and the bitrochanteric measurement varies (9-10 cm). *2 and 4 only* - The **suboccipitofrontal diameter** (from the subocciput to the center of the frontal suture) is typically larger, around **10 cm**, and is the presenting diameter in a well-flexed vertex presentation. - The **bitrochanteric diameter** (between the fetal hip trochanters) is approximately **9-10 cm** at term but is not consistently 9.4 cm and refers to the fetal body, not the head. *1 and 2 only* - While the **biparietal diameter** is indeed 9.4 cm, the **suboccipitofrontal diameter** is typically larger, around **10 cm**, making this option incorrect. - This option misses the **submentobregmatic diameter**, which also measures approximately 9.4-9.5 cm at term.

Q: On examination, a woman with post-dated pregnancy is found to have 80% effaced cervix. She requires the induction of labour. This is best done through

Oxytocin drip. ***Oxytocin drip*** - An 80% effaced cervix indicates a **favorable cervix** (high Bishop score), meaning it is ripe and ready for induction. - In such cases, **oxytocin** is the most appropriate method to stimulate uterine contractions for labor induction. *Intracervical dinoprostone gel* - Dinoprostone is a **prostaglandin E2 analog** used primarily for **cervical ripening** when the cervix is unfavorable (low Bishop score), not for an 80% effaced cervix. - It softens and effaces the cervix, but for a cervix already 80% effaced, it's not the primary induction agent. *ARM with oxytocin drip* - **Artificial rupture of membranes (ARM)** can be performed once the cervix is favorable, but it is often done in conjunction with oxytocin if contractions are not strong enough. - However, in a post-dated pregnancy with an 80% effaced cervix, **oxytocin infusion alone** is often sufficient to initiate and maintain effective contractions. ARM can be reserved for further augmentation if needed. *Carboprost tromethamin intra-muscularly* - **Carboprost** is a prostaglandin F2 alpha analog primarily used to treat **postpartum hemorrhage** by inducing strong uterine contractions to reduce bleeding. - It is **not indicated for labor induction** due to its strong and sustained uterine contraction profile and potential for severe side effects.

Q: A 25-year-old primigravida in early labour with vertex presentation in left occipitoanterior position. The head is floating. Her diagonal conjugate measures 11 cm. The appropriate management will be

Give her a trial of labour. **Give her a trial of labour** - A **diagonal conjugate of 11 cm** is at the **lower limit of normal** (normal ≥11.5 cm, obstetric conjugate ~9.5 cm), making it borderline adequate for vaginal delivery, but not an absolute contraindication. - The **left occipitoanterior position** is the most favorable presentation for engagement and descent through the pelvis. - While the head is **floating** (unengaged), this is common in early labor, especially for a primigravida; a **trial of labor** allows assessment of labor progression, cervical dilation, and head descent to diagnose potential **cephalopelvic disproportion (CPD)**. - CPD can only be diagnosed during active labor; hence a trial is warranted before considering surgical intervention. *Deliver vaginally at home* - Home delivery is inappropriate and unsafe for a **primigravida** with a **borderline pelvis** and **floating head**, which requires continuous monitoring in a clinical setting. - The risk of obstructed labor and CPD necessitates hospital supervision with capability for emergency intervention if needed. *Deliver by emergency caesarean section* - Emergency cesarean section is **not indicated** at this stage as there are **no signs of fetal distress**, obstructed labor, or proven CPD. - The diagonal conjugate, though borderline, is not an absolute contraindication; surgical intervention should only be considered after failed trial of labor or evidence of maternal/fetal compromise. *Refer to higher center immediately* - There is no immediate indication for referral to a higher center, as the patient is in **early labor** with no complications like severe pre-eclampsia, antepartum hemorrhage, or acute fetal distress. - This case can be managed in a standard delivery unit with capability for cesarean section if trial of labor fails; a **trial of labor** with close monitoring is the appropriate initial management.

Q: Before the delivery of the second twin having cephalic presentation, the mother develops profuse bleeding per vaginum. The appropriate management will be

ARM. ***ARM (Artificial Rupture of Membranes)*** - Profuse bleeding between twin deliveries is an **obstetric emergency** requiring **immediate delivery** of the second twin to control hemorrhage. - Since the second twin has **cephalic presentation**, **ARM followed by assisted delivery** is the **fastest and most appropriate intervention**. - ARM stimulates uterine contractions and allows for **immediate vaginal delivery**, preventing maternal **exsanguination** and fetal compromise. *Internal podalic version and breech extraction* - This is **NOT indicated** as the second twin already has **cephalic presentation** (the most favorable presentation). - Internal podalic version is reserved for **transverse or unstable lie**, not for converting an already favorable cephalic presentation to breech. - Converting cephalic to breech would **waste critical time** and **increase maternal and fetal risk** in this emergency. *External cephalic version and oxytocin drip* - **External cephalic version** is inappropriate as the second twin already has **cephalic presentation**. - **Oxytocin** alone does not expedite delivery quickly enough in this **hemorrhagic emergency**. - This approach causes unnecessary delay when immediate delivery is required. *Deliver the placenta of the first twin* - This is **dangerous and absolutely contraindicated** - placenta should only be delivered **after both twins are born**. - Delivering the placenta while the second twin remains in utero can cause **massive hemorrhage**, **uterine contraction**, **entrapment of the second twin**, and **fetal death**.

Q: A 35-year-old multiparous woman is admitted with prolonged labour. She is in shock, and her pulse rate is 150 per minute. The uterus is tonically contracted with Bandl's ring, and the presenting part is not engaged. The appropriate treatment is

Perform LSCS (Lower Segment Caesarean Section). ***Perform LSCS (Lower Segment Caesarean Section)*** - The presence of a **tonically contracted uterus** with **Bandl's ring**, unengaged presenting part, and the patient being in **shock** (pulse 150 bpm) are all signs of **imminent uterine rupture** due to obstructed labor. - An **emergency LSCS** is immediately indicated to deliver the baby and manage the uterine obstruction, prioritizing the mother's and baby's lives. *Do internal podalic version and extraction* - This procedure is contraindicated in cases of **obstructed labor** with a tonically contracted uterus and Bandl's ring, as it significantly increases the risk of **uterine rupture**. - Internal podalic version is typically performed for malpresentations in the absence of obstruction, often in a less critical maternal condition. *Deliver the baby by vaginal route using a vacuum extractor* - **Vacuum extraction** requires a dilated cervix, engaged head, and the absence of mechanical obstruction. - With an **unengaged presenting part**, tonically contracted uterus, and Bandl's ring, a vaginal instrumental delivery is impossible and highly dangerous, risking uterine rupture. *Augment labour with oxytocin* - **Oxytocin augmentation** is used for hypotonic uterine dysfunction to strengthen contractions. - In a case of **obstructed labor** with a tonically contracted uterus and Bandl's ring, adding oxytocin would further exacerbate the uterine stress and dramatically increase the risk of **uterine rupture**, making it absolutely contraindicated.

Question 1

Which of the following is a uterine compression suture during management of atonic postpartum haemorrhage?

Accepted Answer

B-Lynch suture

Answer

Sturmdorf suture

Answer

Fothergill's suture

Answer

Moscowitz suture

Question 2

The following are the signs of placental separation except :

Accepted Answer

The fundal height decreases

Answer

The uterus becomes hard and globular

Answer

Permanent lengthening of the cord

Answer

Fresh bleeding occurs

Question 3

Face to pubis delivery is common in which type of pelvis ?

Accepted Answer

Anthropoid

Answer

Android

Answer

Gynaecoid

Answer

Platypelloid

Question 4

Normal pH of foetal scalp blood is :

Accepted Answer

7.30

Answer

7.20

Answer

7.0

Answer

7.10

Question 5

A pregnant lady with 37 weeks gestation has been admitted with a history of premature rupture of membranes for 6 hours. She is best treated with:

Accepted Answer

antibiotics followed by labour induction

Answer

steroids followed by labour induction

Answer

expectant management

Answer

steroids and tocolytic agents

Question 6

Which of the following foetal diameters measure 9.4 cm at term?

1. Biparietal diameter
2. Suboccipitofrontal diameter
3. Submentobregmatic diameter
4. Bitrochanteric diameter

Select the correct answer using the code given below:

Accepted Answer

1 and 3 only

Answer

1, 2, 3 and 4

Answer

2 and 4 only

Answer

1 and 2 only

Question 7

On examination, a woman with post-dated pregnancy is found to have 80% effaced cervix. She requires the induction of labour. This is best done through

Accepted Answer

Oxytocin drip

Answer

Intracervical dinoprostone gel

Answer

ARM with oxytocin drip

Answer

Carboprost tromethamin intra-muscularly

Question 8

A 25-year-old primigravida in early labour with vertex presentation in left occipitoanterior position. The head is floating. Her diagonal conjugate measures 11 cm. The appropriate management will be

Accepted Answer

Give her a trial of labour

Answer

Deliver vaginally at home

Answer

Deliver by emergency caesarean section

Answer

Refer to higher center immediately

Question 9

Before the delivery of the second twin having cephalic presentation, the mother develops profuse bleeding per vaginum. The appropriate management will be

Accepted Answer

ARM

Answer

External cephalic version and oxytocin drip

Answer

Deliver the placenta of the first twin

Answer

Internal podalic version and breech extraction

Question 10

A 35-year-old multiparous woman is admitted with prolonged labour. She is in shock, and her pulse rate is 150 per minute. The uterus is tonically contracted with Bandl's ring, and the presenting part is not engaged. The appropriate treatment is

Accepted Answer

Perform LSCS (Lower Segment Caesarean Section)

Answer

Do internal podalic version and extraction

Answer

Deliver the baby by vaginal route using a vacuum extractor

Answer

Augment labour with oxytocin

Labor and Delivery — MCQs

Labor and Delivery — MCQs

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