Labor and Delivery Practice Questions

Q: A 20 year old full term primigravida is admitted with full dilatation of the cervix and breech presentation. The breech is not engaged. Foetal heart is normal. The proper procedure for the management would be:

Caesarean section. ***Caesarean section*** - For a **primigravida** with a full-term breech presentation where the foetus is **not engaged** at full dilatation and the **foetal heart is normal**, a Caesarean section is the safest option to prevent complications. - This approach minimizes risks of **foetal distress**, cord prolapse, and trauma associated with vaginal breech delivery in an unengaged presentation, especially in a first pregnancy. *Oxytocin drip augmentation* - Oxytocin is used to **augment contractions** in cases of uterine inertia or slow cervical dilation but is **contraindicated** in breech presentation that is not engaged at full dilation due to the risk of uterine rupture and foetal compromise. - Augmenting contractions in this scenario would increase the risk of an **incomplete, traumatic vaginal delivery** of a breech baby, particularly with an unengaged presentation. *To bring down the leg* - **Bringing down the leg** is a maneuver typically performed during a **planned vaginal breech delivery** to convert a complete or incomplete breech to a single footling breech to aid delivery. - This procedure is not appropriate for a primigravida with an unengaged breech at full dilatation, as it carries a high risk of **cord prolapse** and other complications without prior engagement and favourable conditions for a vaginal delivery. *Breech extraction* - **Breech extraction** is a procedure used in specific circumstances, such as delivery of a second twin or in cases where there is an umbilical cord prolapse and immediate delivery is required. - It is generally **not recommended for a primigravida** with an unengaged breech at full dilatation primarily due to the high risk of **foetal trauma** and maternal complications associated with such an intervention without prior engagement.

Q: During labour, which one of the foetal heart patterns is ominous?

Late deceleration. ***Late deceleration*** - **Late decelerations** are an ominous sign as they indicate **uteroplacental insufficiency** and **fetal hypoxia**. - They are characterized by a gradual decrease in fetal heart rate that begins after the peak of the uterine contraction and returns to baseline after the contraction has ended. *Variable deceleration* - **Variable decelerations** are characterized by an **abrupt decrease** in fetal heart rate, 15 bpm below baseline and lasting at least 15 seconds. - They are usually associated with **umbilical cord compression** and are not necessarily ominous unless they are prolonged or severe. *Early deceleration* - **Early decelerations** are generally benign and are caused by **head compression** during uterine contractions. - They mirror the contractions, starting and ending with the contraction, and are typically not associated with fetal hypoxia. *Tachycardia* - **Fetal tachycardia** (baseline heart rate >160 bpm) can be caused by various factors, including **maternal fever**, infection, or fetal compromise. - While it can be a sign of distress, it is not as acutely ominous as late decelerations, which directly reflect hypoxemia.

Q: Prophylactic intravenous methergin should not be given in cases of:

Heart disease complicating pregnancy. **Heart disease complicating pregnancy** - **Methergine** (methylergonovine) is an **ergot alkaloid** that causes generalized **vasoconstriction**, leading to an increase in blood pressure. - In patients with **heart disease**, particularly those with conditions sensitive to increased afterload or blood pressure elevation, Methergine can precipitate **cardiac decompensation**, **myocardial ischemia**, or **hypertensive crises**. *Anaemia* - **Anaemia** itself is not a contraindication to **Methergine** use. - The medication primarily affects uterine contractility and vascular tone, with no direct adverse effects on red blood cell production or function. *Hydramnios* - **Hydramnios** (polyhydramnios) is not a contraindication for **Methergine**. - While it may be associated with increased risk of postpartum hemorrhage due to uterine overdistension, Methergine can still be safely used to promote uterine contraction and prevent excessive bleeding. *Multipara* - **Multiparity** is not a contraindication to **Methergine** use. - In fact, multiparous women may have a slightly increased risk of uterine atony and postpartum hemorrhage, making prophylactic uterotonics like Methergine potentially beneficial to prevent excessive bleeding.

Q: The progress of labour can be monitored by observing the following except:

The formation of caput by vaginal examination. ***The formation of caput by vaginal examination*** - The formation of a **caput succedaneum** (swelling on the fetal scalp) indicates **prolonged pressure** on the fetal head, which can be a sign of **cephalopelvic disproportion** or prolonged labor, rather than a direct measure of labor progression. - While its presence is noted during labor, caput formation itself does not actively monitor the *progress* of cervical dilatation or fetal descent in a positive way; rather, it often signals a potential **complication** or **stalling** of labor. *Gradual increase in cervical dilatation by vaginal examination* - **Cervical dilatation** is a primary indicator of the **first stage of labor progression**, as the cervix opens to allow passage of the fetus. - Regular **vaginal examinations** determine the rate and extent of cervical opening, crucial for deciding management. *The descent of foetal head by abdominal examination* - **Fetal head descent**, assessed by **abdominal palpation** (e.g., using the "fifths palpable" method), indicates the baby's movement through the birth canal. - This is a key measure of **progress in the second stage of labor** and helps identify potential obstructed labor. *The intensity of uterine contractions by abdominal examination* - The **intensity, frequency, and duration of uterine contractions** directly correlate with the forces driving labor progression. - While palpation provides a good estimate, this helps monitor the **effectiveness of uterine activity** in causing cervical changes and fetal descent.

Q: The most common sign of rupture of previous LSCS scar during labour is:

Non-reassuring fetal heart rate pattern. ***Non-reassuring fetal heart rate pattern*** - A **sudden, sustained deceleration** or **bradycardia** in the fetal heart rate is the **most common and earliest sign** of uterine rupture, occurring in **55-87%** of cases. - This occurs due to compromised uteroplacental blood flow and **acute fetal hypoxia** as the uterus tears. - **Continuous electronic fetal monitoring** during TOLAC (Trial of Labor After Cesarean) is critical for early detection. - Changes may include **prolonged decelerations**, **bradycardia (<110 bpm)**, or sudden loss of variability. *Cessation of uterine contractions* - While a sudden **cessation of contractions** can occur with uterine rupture, it is **not consistently the most common** initial sign. - It often follows other changes, particularly fetal heart rate abnormalities, as the uterus loses its contractile ability. - Detected more reliably with intrauterine pressure catheter monitoring. *Tenderness in lower abdomen* - **Abdominal pain** and tenderness can be present, especially localized to the lower uterine segment scar area. - However, it is often **subjective and masked by normal labor pain**, making it an unreliable early indicator. - Not as specific or consistently observable as fetal heart rate changes. *Haemorrhagic shock* - **Haemorrhagic shock** with hypotension and tachycardia is a **serious late complication** indicating significant intraperitoneal or vaginal bleeding. - It usually manifests **after fetal distress** has already appeared and represents advanced rupture. - Requires immediate surgical intervention but is not an early warning sign.

Q: A woman with post-term pregnancy with unripe cervix should not be induced with misoprostol if she has:

Decompensated heart disease. ***Decompensated heart disease*** - Misoprostol can cause rapid and significant uterine contractions, leading to a **sudden increase in circulating blood volume** due to displacement from the uterus. - In patients with **decompensated heart disease**, this acute volume shift can precipitate **pulmonary edema** or **cardiac decompensation**, making it a contraindication. *Asthma* - While some prostaglandins can be bronchoconstrictive, **misoprostol (a synthetic prostaglandin E1 analog)** is generally considered safe for use in patients with asthma. - **Uterotonics like carboprost (PGF2a)** are contraindicated in asthma due to their bronchoconstrictive effects, but misoprostol does not share this contraindication. *Diabetes* - **Diabetes mellitus** is not a contraindication for the use of misoprostol for cervical ripening or induction. - Glucose control and fetal surveillance remain important, but misoprostol itself does not typically pose specific risks unique to diabetic patients. *Hepatitis B antigen positive* - **Hepatitis B positivity** in the mother does not contraindicate the use of misoprostol for labor induction. - The primary concern in this scenario is managing the risk of **vertical transmission** to the neonate, which is addressed through immunoprophylaxis, not by altering induction methods.

Q: Consider the following presentations: 1. Brow presentation 2. Left mento anterior position 3. Occipito posterior position 4. Breech presentation In which of the above Vaginal delivery is NOT possible?

1 only. ***1 only*** - A **brow presentation** presents the fetal head at an unfavorable diameter (**mentovertical diameter**), making vaginal delivery impossible due to **mechanical obstruction**. - With the brow presenting, the head cannot adequately mold or engage in the maternal pelvis, necessitating a **cesarean section** for safe delivery. *1, 2 and 3* - While **brow presentation** (1) is not amenable to vaginal delivery, **left mento anterior position** (2) generally allows for successful vaginal delivery. - **Occipito posterior position** (3) can often be delivered vaginally, sometimes requiring rotation, making this option incorrect. *4 only* - **Breech presentation** (4) can sometimes be delivered vaginally, although it carries higher risks and often warrants a **cesarean section**, but it is not universally impossible. - This option incorrectly suggests that only breech presentation is impossible for vaginal delivery, while brow presentation is a definitive contraindication. *1 and 3 only* - **Brow presentation** (1) is indeed a contraindication for vaginal delivery. - However, **occipito posterior position** (3) does not inherently preclude vaginal delivery, as many cases can be delivered vaginally, making this option incorrect.

Q: For vaginal breech delivery, ideal selection criteria would include: 1. Fetus not compromised 2. Adequate pelvis 3. Flexed breech presentation 4. Estimated fetal weight < 3.5 kg Select the correct answer using the code given below:

1, 2, 3 and 4. ***1, 2, 3 and 4*** - All listed criteria (fetus not compromised, adequate pelvis, **flexed breech presentation**, and estimated fetal weight < 3.5 kg) are considered **ideal selection criteria** for a safe vaginal breech delivery. - **Flexed (frank) breech** with hips flexed and knees extended is the **most favorable type** for vaginal delivery, as it presents the smallest diameter and has the lowest risk of cord prolapse. - While many institutions now favor elective cesarean section for breech presentations, these criteria represent conditions under which a **vaginal delivery can be safely attempted** with minimal risk. *2 and 4 only* - This option is incomplete as it correctly identifies adequate pelvis and estimated fetal weight < 3.5 kg but omits other crucial factors like **fetal well-being** and the **type of breech presentation**. - A successful vaginal breech delivery also requires the fetus to be **uncompromised** and ideally in a **flexed (frank) breech** presentation. *1, 3 and 4 only* - This option overlooks the critical importance of an **adequate maternal pelvis**, which is fundamental for allowing the passage of the fetus during vaginal delivery regardless of fetal presentation. - While fetal status, presentation, and weight are important, a **contracted or inadequate pelvis** would contraindicate vaginal delivery. *1, 2 and 3 only* - This option excludes the **estimated fetal weight** being less than 3.5 kg, which is a significant factor in assessing the feasibility of vaginal breech delivery. - Larger fetuses (typically >3.5-4 kg) have a **higher risk of birth trauma** and **head entrapment** during vaginal breech delivery, even with an adequate pelvis and favorable presentation.

Q: A 25 year old, G2P1L1 came with amenorrhoea of two and half months followed by bleeding PV and pain abdomen. On examination cervical OS is open with slight bleeding. The uterus is 10 weeks size with no tenderness in the fornices. The probable clinical diagnosis is:

Inevitable abortion. ***Inevitable abortion*** - The presence of **amenorrhea** followed by **vaginal bleeding** and **abdominal pain**, with an **open cervical os**, indicates that the abortion process cannot be halted. - Critically, there is **no history of passage of products of conception**, which means the abortion is inevitable but has not yet occurred. - The uterus size being consistent with **10 weeks of gestation** confirms an intrauterine pregnancy in the process of being expelled. *Incomplete abortion* - This diagnosis also involves vaginal bleeding and an open cervical os, but it is characterized by the **partial expulsion of products of conception**. - The key differentiator is that incomplete abortion requires **history or evidence of tissue passage**, which is not mentioned in this clinical scenario. - In inevitable abortion, the os is open and bleeding is present, but expulsion has not yet begun. *Missed abortion* - A missed abortion involves fetal demise without symptoms like bleeding or pain, and a **closed cervical os**. - This patient presents with active bleeding and pain, and an open cervical os, which contradicts the features of a missed abortion. - The uterus may be smaller than expected for dates in missed abortion. *Ectopic pregnancy* - Although an ectopic pregnancy can cause amenorrhea, vaginal bleeding, and abdominal pain, the uterus in an ectopic pregnancy is typically **smaller than expected for gestational age** or normal in size, and there is often **significant adnexal tenderness or mass**. - The finding of a **10-week sized uterus** strongly suggests an intrauterine pregnancy rather than ectopic, and the absence of adnexal tenderness makes ectopic pregnancy unlikely.

Q: In case of Labour complicated with cord prolapse, which of the following statements are correct? 1. Reposition the patient in exaggerated Sims position 2. To replace the cord in the vagina 3. To replace the cord inside the uterus 4. Early amniotomy can prevent cord prolapse Select the correct answer using the code given below:

1 only. ***Correct: 1 only*** **Statement 1 - Reposition the patient in exaggerated Sims position** ✓ - **Correct** - Immediate repositioning (knee-chest, Trendelenburg, or exaggerated Sims position) is crucial to reduce pressure on the prolapsed cord and relieve compression - This helps displace the presenting part away from the cord using gravity **Statement 2 - To replace the cord in the vagina** ✗ - **Incorrect** - Manipulation or replacement of the prolapsed cord is **contraindicated** as it can cause vasospasm and further compromise fetal circulation - The correct approach is to **elevate the presenting part manually** (pushing it up off the cord) while keeping the cord moist and warm, NOT to reposition the cord itself **Statement 3 - To replace the cord inside the uterus** ✗ - **Incorrect** - This is contraindicated as it carries high risk of uterine infection, cord trauma, and vasospasm - Does not reliably prevent recurrence of prolapse **Statement 4 - Early amniotomy can prevent cord prolapse** ✗ - **Incorrect** - Early amniotomy actually **increases** the risk of cord prolapse, especially when the presenting part is not well-engaged - It removes the cushioning effect of forewaters that help keep the cord in place **Correct management of cord prolapse includes:** - Immediate repositioning (Trendelenburg/knee-chest position) - Manual elevation of presenting part to relieve cord compression - Keeping the prolapsed cord moist and warm - Avoiding cord manipulation - Emergency cesarean delivery or instrumental delivery if feasible *Incorrect: 1 and 2 only* - While statement 1 is correct, statement 2 (replacing the cord in vagina) is medically incorrect and contraindicated *Incorrect: 3 and 4 only* - Both statements are incorrect as explained above *Incorrect: 1, 2, 3 and 4* - Only statement 1 is correct; statements 2, 3, and 4 are all incorrect

Question 1

A 20 year old full term primigravida is admitted with full dilatation of the cervix and breech presentation. The breech is not engaged. Foetal heart is normal. The proper procedure for the management would be:

Accepted Answer

Caesarean section

Answer

Oxytocin drip augmentation

Answer

To bring down the leg

Answer

Breech extraction

Question 2

During labour, which one of the foetal heart patterns is ominous?

Accepted Answer

Late deceleration

Answer

Variable deceleration

Answer

Early deceleration

Answer

Tachycardia

Question 3

Prophylactic intravenous methergin should not be given in cases of:

Accepted Answer

Heart disease complicating pregnancy

Answer

Anaemia

Answer

Hydramnios

Answer

Multipara

Question 4

The progress of labour can be monitored by observing the following except:

Accepted Answer

The formation of caput by vaginal examination

Answer

Gradual increase in cervical dilatation by vaginal examination

Answer

The descent of foetal head by abdominal examination

Answer

The intensity of uterine contractions by abdominal examination

Question 5

The most common sign of rupture of previous LSCS scar during labour is:

Accepted Answer

Non-reassuring fetal heart rate pattern

Answer

Cessation of uterine contractions

Answer

Tenderness in lower abdomen

Answer

Haemorrhagic shock

Question 6

A woman with post-term pregnancy with unripe cervix should not be induced with misoprostol if she has:

Accepted Answer

Decompensated heart disease

Answer

Asthma

Answer

Diabetes

Answer

Hepatitis B antigen positive

Question 7

Consider the following presentations:

1. Brow presentation
2. Left mento anterior position
3. Occipito posterior position
4. Breech presentation

In which of the above Vaginal delivery is NOT possible?

Accepted Answer

1 only

Answer

1, 2 and 3

Answer

4 only

Answer

1 and 3 only

Question 8

For vaginal breech delivery, ideal selection criteria would include:

1. Fetus not compromised
2. Adequate pelvis
3. Flexed breech presentation
4. Estimated fetal weight < 3.5 kg

Select the correct answer using the code given below:

Accepted Answer

1, 2, 3 and 4

Answer

2 and 4 only

Answer

1, 3 and 4 only

Answer

1, 2 and 3 only

Question 9

A 25 year old, G2P1L1 came with amenorrhoea of two and half months followed by bleeding PV and pain abdomen. On examination cervical OS is open with slight bleeding. The uterus is 10 weeks size with no tenderness in the fornices. The probable clinical diagnosis is:

Accepted Answer

Inevitable abortion

Answer

Incomplete abortion

Answer

Missed abortion

Answer

Ectopic pregnancy

Question 10

In case of Labour complicated with cord prolapse, which of the following statements are correct?

1. Reposition the patient in exaggerated Sims position
2. To replace the cord in the vagina
3. To replace the cord inside the uterus
4. Early amniotomy can prevent cord prolapse

Select the correct answer using the code given below:

Accepted Answer

1 only

Answer

1 and 2 only

Answer

3 and 4 only

Answer

1, 2, 3 and 4

Labor and Delivery — MCQs

Labor and Delivery — MCQs

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