Operative Obstetrics Practice Questions

Q: In the repair of a mediolateral episiotomy, what is the correct order of tissue closure?

Mucosa → Muscle → Skin. ***Mucosa → Muscle → Skin*** - Closure of an episiotomy (or a second-degree tear) must start from the deepest layer, which is the **vaginal mucosa**, ensuring the integrity of the vaginal canal. - This is followed by approximation of the **perineal muscles** (perineal body and underlying musculature) to restore structural integrity, and finally, the **perineal skin** is closed. *Skin → Muscle → Mucosa* - This order is incorrect as it attempts to close the most superficial layer (**skin**) first before addressing the deep **vaginal mucosa** layer. - Repair must proceed from the inside out (deep to superficial) to ensure proper anatomical restoration and secure **haemostasis** in the deeper layers. *Muscle → Mucosa → Skin* - Starting with the **muscle layer** is incorrect because the deepest layer, the **vaginal mucosa**, must be repaired first to avoid leaving dead space and ensure a watertight seal. - Correct repair minimizes the risk of infection, persistent bleeding, and **hematoma formation** by sequential layer closure. *Mucosa → Skin → Muscle* - While starting with the **mucosa** is correct, immediately closing the **skin** and skipping the muscle layer leads to inadequate repair of the perineal body. - Failure to approximate the **perineal muscles** compromises pelvic floor integrity, increasing the risk of **perineal laxity** and future uterovaginal prolapse.

Q: Identify the instrument shown:

Kielland forceps. ***Kielland forceps*** - This instrument is characterized by its **sliding lock** and **shallow pelvic curve**, which allows for rotation of the fetal head. - The shanks are **long and straight**, and the blades are fenestrated with a cephalic curve, designed for use in cases of moderate to severe asynclitism. *Wrigley's outlet forceps* - **Wrigley's forceps** are **short and light** with a minimal pelvic curve, designed for **outlet delivery** when the fetal head is already on the perineum. - They lack the sliding lock mechanism and deep pelvic curve seen in Kielland forceps. *Pipers forceps* - **Piper's forceps** are specifically designed for delivery of the **after-coming head** in a breech presentation. - They feature a unique **long, curved shank** that is applied from below the mother's pelvis, unlike the instrument shown. *Elliot forceps* - **Elliot forceps** are **fenestrated** with a deep pelvic curve and often have a **pivot or parallel handles** that can be separated, making them suitable for rotations and high applications. - While they are used for rotation, the specific design, especially the sliding lock, of Kielland forceps distinguishes it.

Q: Identify the instrument shown:

Piper's forceps. ***Pipers forceps*** - The image displays Piper's forceps, identifiable by their **long shank** and **downward curving blades**, designed specifically for aiding delivery of the **aftercoming head in breech presentations**. - They feature a **perineal curve** with an **anterior cephalic curve** and are applied in a **cephalic** rather than a pelvic curve. *Kielland forceps* - Kielland forceps have a **slight cephalic curve** but **no pelvic curve**, and they include a **sliding lock**. - They are primarily used for **rotational deliveries** or when the head is high in the pelvis. *Simpson's forceps* - Simpson's forceps are distinguished by **fenestrated blades** and a **pronounced pelvic curve**, adapted for common straight forward deliveries. - They are one of the most commonly used forceps and have a **non-locking pivot** at the junction of the handle and blades. *Elliot forceps* - Elliot forceps are similar to Simpson's but have an **overlapping shanks** and a **removable pin** to vary the distance between the blades, which facilitates use in cases of significant **asynclitism**. - They also feature **fenestrated blades** and a **pelvic curve**.

Q: All are correct regarding the device shown here except:

Placed 6 cm anterior to posterior fontanelle. ***Placed 6 cm anterior to posterior fontanelle*** - This is the **incorrect statement** - proper vacuum cup placement should be approximately **3 cm anterior to the posterior fontanelle** at the flexion point of the fetal head. - Placing the cup **6 cm anterior** would be too far forward, increasing risk of **cup dislodgement**, **subgaleal hemorrhage**, and ineffective traction. *Should generate effective vacuum of 0.8 Kg / cm^2* - This is a **correct statement** - effective vacuum pressure should be between **0.6 to 0.8 kg/cm^2** (500-600 mmHg). - This pressure range ensures adequate suction for delivery while minimizing risk of **fetal scalp injury**. *Traction at right angles to the cup* - This is a **correct statement** - traction must be applied **perpendicular to the cup plane** for optimal force transmission. - This technique prevents **cup dislodgement** and ensures efficient pulling force along the **birth canal axis**. *Traction is released in between uterine contractions* - This is a **correct statement** - traction should be **released between contractions** to prevent excessive force and allow fetal head repositioning. - Continuous traction can cause **fetal trauma** and **cup dislodgement** due to sustained pressure without uterine support.

Q: The following manoeuvre is called:

Mauriceau-Smellie-Veit. ***Mauriceau-Smellie-Veit*** - This manoeuvre is used during **breech delivery** to deliver the fetal head. - The operator's hand supports the fetal body, with fingers on the maxilla, while the other hand applies counter pressure on the **occiput** to maintain flexion and aid delivery. *Pinard* - The **Pinard manoeuvre** involves extending a fetal leg from the birth canal in a breech presentation to facilitate delivery. - It is distinct from the head delivery technique shown in the image. *Ritzen* - **Ritzen manoeuvre** is not a recognized obstetric manoeuvre for fetal delivery. - It does not correspond to the depicted technique. *Loveset* - The **Loveset manoeuvre** is used to deliver the arms in a breech presentation by rotating the fetal trunk. - This manoeuvre is for shoulder and arm delivery, not the head as shown.

Q: The following manoeuvre is called:

Mauriceau-Smellie-Veit. ***Mauriceau-Smellie-Veit*** - This maneuver is used for **head delivery in breech presentations**. The image shows a hand supporting the fetal body while another hand (implied or assisting) applies pressure to facilitate the head's flexion and delivery, consistent with the Mauriceau-Smellie-Veit maneuver. - The goal is to keep the **fetal head flexed** to allow its passage through the birth canal, with the baby's body supported on the forearm of the operator. *Pinard* - The **Pinard maneuver** involves external or internal pressure to bring down an extended leg of a fetus during a breech delivery. - The image depicts support of the fetal trunk and head delivery assistance, not the manipulation of a fetal leg. *Burns Marshall* - The **Burns Marshall maneuver** involves holding the fetal feet and allowing the fetal body to hang downwards, using **gravity** to deliver the head. - The image shows direct manipulation and support of the baby's body and head, not a passive hanging technique. *Loveset* - The **Loveset maneuver** is used to deliver the fetal arms in a breech presentation by rotating the fetal trunk to bring each arm to the front. - The image is focused on the delivery of the fetal head, with the arms already delivered or not the primary focus of the depicted action.

Q: Identify the manoeuvre shown:

External cephalic version. ***External cephalic version*** - The image depicts a procedure where external pressure is applied to the maternal abdomen to **rotate the fetus from a breech or transverse presentation to a cephalic (head-down) presentation**. - This manoeuvre aims to enable a **vaginal birth** by positioning the head towards the birth canal. *Loveset manoeuvre* - The Loveset manoeuvre is used during a **breech delivery to assist in the delivery of the fetal arms**. - It involves rotating the fetal trunk to enable the delivery of one arm at a time, which is not what is shown here. *Internal podalic version* - Internal podalic version is a procedure where the obstetrician **inserts a hand into the uterus to grasp the fetal feet and turn the fetus to a breech presentation**. - This is typically performed to deliver a second twin and is done **internally**, unlike the external manipulation shown. *Leopold manoeuvre* - Leopold manoeuvres are a series of four palpations performed on the pregnant abdomen to **determine fetal lie, presentation, position, and engagement**. - They are diagnostic manoeuvres and do not involve actively changing the fetal position as depicted.

Q: Identify the instrument used: (AIIMS Nov 2017)

Episiotomy scissors. ***Episiotomy scissors*** - These scissors are characterized by their **blunt, angled tip** on one blade, which is designed to protect the fetal head during an episiotomy. - The image clearly shows this specific design, making them ideal for cutting soft tissues in a controlled manner without puncturing underlying structures. *Dissection scissors* - Dissection scissors typically have **sharp tips**, either straight or curved, and are used for cutting and separating tissues with precision. - They lack the blunt, angled tip characteristic of episiotomy scissors. *Mayo scissors* - **Mayo scissors** are heavy-duty scissors, typically used for cutting **fascia, sutures, and dense tissues**. - They often have straight or slightly curved blades without the protective blunt tip seen in episiotomy scissors. *Metzenbaum scissors* - **Metzenbaum scissors** are known for their **long handles and relatively short, delicate blades**, designed for cutting and dissecting fine, delicate tissues. - Their blades are typically slender and do not feature the angled, blunt tip of episiotomy scissors.

Q: Which of the following are contraindications to External Cephalic Version (ECV) in breech? I. Pregnancy less than 36 weeks II. Multiple pregnancy III. Previous cesarean delivery IV. Rhesus isoimmunization Select the correct answer using the code given below :

II, III and IV. ***II, III and IV*** - **Multiple pregnancy** is an absolute contraindication to ECV due to significantly increased risks of cord entanglement, placental abruption, premature rupture of membranes, and the complexity of managing two or more fetuses during the procedure. - **Previous cesarean delivery** is generally considered a relative contraindication due to the theoretical increased risk of uterine rupture during ECV, though some centers perform ECV in carefully selected cases with prior cesarean section. - **Rhesus isoimmunization** is a contraindication because ECV carries the risk of fetomaternal hemorrhage, which can worsen existing isoimmunization and increase maternal antibody production, potentially compromising fetal wellbeing. *I, II and III* - While **multiple pregnancy** and **previous cesarean delivery** are valid contraindications, **pregnancy less than 36 weeks** is not a true contraindication to ECV. - The standard timing for ECV is at or after 37 weeks of gestation, but being less than 36 weeks represents inappropriate timing rather than a contraindication. If there were a compelling reason for ECV before 36 weeks, the early gestational age itself would not prohibit the procedure. *I, III and IV* - **Previous cesarean delivery** and **Rhesus isoimmunization** are correct contraindications. - However, **pregnancy less than 36 weeks** is not a standard contraindication - it simply represents a gestational age before the recommended timing for the procedure (≥37 weeks). *I, II and IV* - **Multiple pregnancy** and **Rhesus isoimmunization** are valid contraindications. - **Pregnancy less than 36 weeks** is not a contraindication but rather reflects suboptimal timing, as ECV is typically performed at 37+ weeks when the likelihood of spontaneous version has decreased and the fetus is term.

Q: Indications and prerequisites for delivery with the ventouse include which of the following? 1. Delay in the second stage of labour 2. Non-reassuring fetal heart rate 3. Gestation age less than 34 weeks of pregnancy 4. Vertex presentation.

1, 2 and 4. ***1, 2 and 4*** - **Ventouse delivery** is indicated for **delay in the second stage of labor** and **non-reassuring fetal heart rate**, when expeditious delivery is required. - A crucial prerequisite is **vertex presentation**, ensuring proper application of the vacuum cup to the fetal head. *2, 3 and 4* - **Gestation age less than 34 weeks of pregnancy** is a contraindication for ventouse delivery due to the increased risk of **fetal scalp trauma** and **intracranial hemorrhage** in premature infants. - While **non-reassuring fetal heart rate** and **vertex presentation** are valid points, the inclusion of premature gestation makes this option incorrect. *1, 2 and 3* - Again, **gestation age less than 34 weeks of pregnancy** is a contraindication, not an indication or prerequisite, for ventouse delivery. - Although **delay in the second stage** and **non-reassuring fetal heart rate** are correct factors, the inclusion of prematurity renders this option incorrect. *1, 3 and 4* - This option incorrectly lists **gestation age less than 34 weeks of pregnancy** as a prerequisite. - While **delay in the second stage** and **vertex presentation** are appropriate, the prematurity contraindication makes this an unsuitable choice.

Question 1

In the repair of a mediolateral episiotomy, what is the correct order of tissue closure?

Accepted Answer

Mucosa → Muscle → Skin

Answer

Mucosa → Skin → Muscle

Answer

Skin → Muscle → Mucosa

Answer

Muscle → Mucosa → Skin

Question 2

Identify the instrument shown:

Accepted Answer

Kielland forceps

Answer

Wrigley's outlet forceps

Answer

Pipers forceps

Answer

Elliot forceps

Question 3

Identify the instrument shown:

Accepted Answer

Piper's forceps

Answer

Kielland forceps

Answer

Simpson's forceps

Answer

Elliot forceps

Question 4

All are correct regarding the device shown here except:

Accepted Answer

Placed 6 cm anterior to posterior fontanelle

Answer

Should generate effective vacuum of 0.8 Kg / cm^2

Answer

Traction at right angles to the cup

Answer

Traction is released in between uterine contractions

Question 5

The following manoeuvre is called:

Accepted Answer

Mauriceau-Smellie-Veit

Answer

Pinard

Answer

Ritzen

Answer

Loveset

Question 6

The following manoeuvre is called:

Accepted Answer

Mauriceau-Smellie-Veit

Answer

Pinard

Answer

Burns Marshall

Answer

Loveset

Question 7

Identify the manoeuvre shown:

Accepted Answer

External cephalic version

Answer

Loveset manoeuvre

Answer

Internal podalic version

Answer

Leopold manoeuvre

Question 8

Identify the instrument used: (AIIMS Nov 2017)

Accepted Answer

Episiotomy scissors

Answer

Dissection scissors

Answer

Mayo scissors

Answer

Metzenbaum scissors

Question 9

Which of the following are contraindications to External Cephalic Version (ECV) in breech?
I. Pregnancy less than 36 weeks
II. Multiple pregnancy
III. Previous cesarean delivery
IV. Rhesus isoimmunization

Select the correct answer using the code given below :

Accepted Answer

II, III and IV

Answer

I, II and III

Answer

I, III and IV

Answer

I, II and IV

Question 10

Indications and prerequisites for delivery with the ventouse include which of the following?

1. Delay in the second stage of labour
2. Non-reassuring fetal heart rate
3. Gestation age less than 34 weeks of pregnancy
4. Vertex presentation.

Accepted Answer

1, 2 and 4

Answer

2, 3 and 4

Answer

1, 2 and 3

Answer

1, 3 and 4

Operative Obstetrics — MCQs

Operative Obstetrics — MCQs

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