Operative Obstetrics Practice Questions

Q: B-Lynch suture for atonic postpartum haemorrhage:

compresses the uterus. ***compresses the uterus*** - The **B-Lynch suture** is a **compression suture** applied to the uterus to mechanically reduce blood flow through sustained pressure on both anterior and posterior uterine walls. - This mechanical compression helps to achieve **haemostasis** in cases of **atonic postpartum haemorrhage** by bringing the uterine walls together and reducing the uterine cavity size. *ligates the uterine arteries* - **Uterine artery ligation** is a separate surgical procedure that involves directly tying off the uterine arteries to reduce blood flow. - The B-Lynch suture does not ligate these arteries directly; its primary mechanism is compression rather than direct vessel occlusion. *ligates the ovarian vessels* - **Ovarian artery ligation** is also a distinct surgical intervention. The B-Lynch suture is placed around the uterus and does not directly ligate the ovarian vessels. - Ovarian vessels are primarily responsible for supplying the ovaries and part of the fallopian tubes, and their ligation is not the main action of a B-Lynch suture in PPH management. *ligates the utero-ovarian anastomosis* - While there are anastomoses between the uterine and ovarian arterial systems, the B-Lynch suture does not specifically ligate these connections. - Its mechanism is general uterine compression to reduce overall blood flow and promote myometrial contraction rather than specific vessel ligation.

Q: In the process of MTP (Medical Termination of Pregnancy) done by suction and evacuation, it was realized that perforation of uterus occurred with cannula. The next step should be:

Laparotomy with exploration of bowel. ***Laparotomy with exploration of bowel*** - **Uterine perforation** during suction and evacuation abortion with a **cannula** (large instrument) carries high risk of bowel or vascular injury and necessitates surgical intervention. - **Laparotomy** (or laparoscopy in stable patients) allows for direct visualization of the injury, assessment of any associated bowel or vascular damage, and repair of the perforation. - Given the mechanism (cannula perforation), the risk of **intra-abdominal organ injury** is significant, warranting exploration. *Manual vacuum aspiration* - This procedure is used for uterine evacuation, not for managing a **uterine perforation**. - Continuing with aspiration after perforation risks aggravating the injury and causing further damage to internal organs. *Complete the evacuation with curette* - Using a **curette** after perforation would worsen the uterine injury and potentially cause damage to intra-abdominal organs. - The immediate concern is the perforation and its sequelae, not completing the abortion via the transcervical route. *Wait and watch* - While **small uterine perforations** from dilators without suspected visceral injury may be managed conservatively with close observation, **cannula perforation** represents a **high-risk mechanism**. - Given the size of the instrument and risk of bowel injury, immediate surgical exploration is required rather than expectant management.

Q: Which of the following are the pre-requisites of outlet forceps delivery? 1. Bladder should be empty 2. Membranes should be intact 3. Cervix should be fully dilated 4. Fetal skull has reached level of pelvic floor

1, 3 and 4. ***1, 3 and 4*** - For an **outlet forceps delivery**, the **bladder must be empty** to prevent trauma during instrumentation and to create more space in the pelvis. - A **fully dilated cervix** (10 cm) is an absolute prerequisite, ensuring that the fetal head can pass without causing cervical lacerations. The **fetal skull must have reached the pelvic floor**, indicating the head is at or beyond +2 station, and the sagittal suture is in the anteroposterior diameter. *1, 2 and 4* - While an **empty bladder** and the **fetal skull at the pelvic floor** are prerequisites, the **membranes should not be intact** for forceps delivery. - Intact membranes would require artificial rupture (amniotomy) before applying forceps to avoid membrane stripping or fetal injury. *1, 2 and 3* - An **empty bladder** and **fully dilated cervix** are essential, but **intact membranes** are not a prerequisite, as they must be ruptured for a safe forceps application. - The fetal head must also be at the **level of the pelvic floor**, which is missing from this option. *2, 3 and 4* - While a **fully dilated cervix** and the **fetal skull at the pelvic floor** are necessary, **intact membranes** are not desirable for forceps delivery, and an **empty bladder** is a crucial missing prerequisite. - Omitting the requirement for an **empty bladder** significantly increases the risk of maternal injury.

Q: Match List-I with List-II and select the correct answer using the code given below the Lists:

A→2 B→3 C→1 D→4. ***A→2 B→3 C→1 D→4*** - **Hand prolapse (A)** occurs when a fetal hand prolapses alongside the presenting part, leading to obstructed labor. If the fetus is dead and vaginal delivery is impossible due to severe obstruction, **Decapitation (2)** may be performed as a destructive procedure to facilitate delivery. - **Placental delivery (B)** is managed by the **Brandt-Andrews maneuver (3)**, which involves controlled cord traction with counter-pressure on the uterus to prevent uterine inversion and facilitate safe placental separation. - **Extended arms of breech at delivery (C)** occurs when the fetal arms are extended above the head during breech presentation. The **Lovset maneuver (1)** is specifically designed to deliver extended arms by rotating the fetus to bring the posterior arm down and anteriorly. - **Deep transverse arrest (D)** occurs when the fetal head arrests in the transverse diameter of the pelvis. **Forceps delivery or vacuum extraction (4)** can be used with manual or instrumental rotation to deliver the fetal head. *A→4 B→1 C→3 D→2* - This incorrectly matches hand prolapse with vacuum extraction, which cannot address the obstruction caused by a prolapsed hand. It also reverses the Brandt-Andrews maneuver and Lovset technique. *A→2 B→1 C→3 D→4* - This incorrectly matches placental delivery with Lovset technique (which is for breech) and extended arms with Brandt-Andrews maneuver (which is for placental delivery). *A→4 B→3 C→1 D→2* - This incorrectly matches hand prolapse with vacuum extraction and deep transverse arrest with decapitation. Decapitation is not indicated for deep transverse arrest, which can be managed with forceps or vacuum.

Q: Which one of the following is not a suitable condition for outlet forceps application?

Head is above ischial spine level. ***Head is above ischial spine level*** - For **outlet forceps** application, the fetal head must be engaged, meaning the **leading point of the skull** is at or below the **level of the ischial spines (+2 station or lower)**. - If the head is above the ischial spines, it indicates a higher station, making **outlet forceps** an inappropriate and potentially dangerous choice, as it could lead to fetal or maternal injury. *Cervix fully dilated* - This is a **prerequisite** for any type of **forceps delivery**, including outlet forceps. - Performing forceps delivery with a partially dilated cervix risks severe **cervical lacerations** and other maternal complications. *Membranes absent* - This condition refers to **ruptured membranes**, which is a **necessary condition** for safe forceps application. - Intact membranes would prevent proper application of the forceps blades to the fetal head and increase the risk of **fetal scalp injury**. *Vertex presentation* - **Outlet forceps** are primarily used for **vertex presentations** (head-first), where the fetal head is oriented optimally for delivery. - Other presentations, such as **breech** or **transverse**, are **contraindications** for outlet forceps and typically require **cesarean section** or other delivery methods.

Q: Identify the maneuver shown in the image:

Mauriceau-Smellie-Veit. ***Mauriceau-Smellie-Veit*** - This maneuver is used for **head delivery in a breech presentation**, where the fetus's body is supported while pressure is applied to the maxilla or mandible to flex the head. - The image typically shows the operator's hand supporting the fetus's body and fingers placed on the fetal jaw to facilitate head flexion and delivery. *Burn Marshall* - The Burn Marshall maneuver involves **delivering the fetal head by applying suprapubic pressure** to the maternal abdomen while the fetal body is gently swept upwards over the maternal abdomen. - This maneuver is generally used for a **spontaneous breech delivery** if the head does not deliver easily after the body. *Lovset* - The Lovset maneuver is employed to **deliver the fetal shoulders** in a breech presentation by rotating the fetal trunk to bring the anterior shoulder under the pubic arch and then the posterior shoulder. - This maneuver aims to extract the shoulders sequentially, which might be necessary if they are impacted. *None of the options* - The visual representation aligns with the steps of the Mauriceau-Smellie-Veit maneuver, making this option incorrect. - This maneuver is clearly depicted by the hand placement and objective of aiding head delivery in breech.

Q: Identify the instrument shown in the image below: ![img-52.jpeg](img-52.jpeg)

Wrigley. ***Wrigley*** - The image depicts short-bladed forceps with a pelvic curve that is characteristic of Wrigley's forceps. - Wrigley's forceps are designed for **outlet or low-cavity forceps deliveries** where the fetal head is already visible or very low in the birth canal. *Kielland* - Kielland forceps have a very slight pelvic curve or are straight, and they lack a cephalic curve, which is distinct from the instrument shown. - They are primarily used for **rotational deliveries** and can be applied to the fetal head in various positions. *Pipers* - Piper's forceps have very long, curved shanks and are specifically designed for **delivery of the after-coming head in breech presentations**. - The instrument in the image does not show the characteristic long shanks of Piper's forceps. *Simpson* - Simpson's forceps have a prominent **pelvic curve** and a **cephalic curve** with blades that are longer than those depicted in the image. - They are commonly used for **mid-cavity deliveries** when rotation is not the primary concern.

Q: Identify the instrument shown in the image below:

Kielland. ***Kielland*** - Kielland forceps are distinguished by their **lack of pelvic curve** and the presence of a sliding lock mechanism designed for **rotation of the fetal head**. - They are primarily used for **rotational delivery** when the fetal head is in malposition, often in the mid-pelvis. *Simpson* - Simpson forceps have a distinct **cephalic curve** for grasping the fetal head and a **pelvic curve** to conform to the birth canal. - They are commonly used for **outlet and low-cavity deliveries** where minimal rotation is needed. *Wrigley* - Wrigley forceps are a type of **outlet forceps** with a very short shanks and blades, making them suitable only when the fetal head is on the **perineum**. - They are designed for situations where the head is already visible without separating the labia. *Pipers* - Pipers forceps are specifically designed for **delivery of the after-coming head in breech presentations**. - They feature a long, curved shank that allows placement from below the maternal pelvis to grasp the fetal head in this particular presentation.

Q: The flexion point in ventouse (vacuum) delivery is located at:

3 cm anterior to the posterior fontanelle. ***3 cm anterior to the posterior fontanelle*** - This is the **correct location of the flexion point** (also described as approximately 6 cm posterior to the anterior fontanelle along the sagittal suture). - This position optimizes the **flexion-traction axis** during vacuum extraction, ensuring that the fetal head descends through the birth canal in the most favorable attitude with maximum flexion. - Correct placement of the vacuum cup at this site provides a **mechanical advantage**, leveraging the natural pivot point of the fetal head for effective delivery and bringing the **occiput** down first. *3 cm posterior to the anterior fontanelle* - This location is **too far anterior**, only 3 cm from the anterior fontanelle, and does not correspond to the true flexion point. - Placing the cup here would result in **suboptimal flexion** and poor mechanical advantage during traction. - This may lead to **cup slippage**, increased rate of failed vacuum delivery, and potential scalp injury. *6 cm anterior to the posterior fontanelle* - Since the distance between fontanelles is approximately 9 cm, this position would be equivalent to 3 cm posterior to the anterior fontanelle (too anterior). - This is **not the correct flexion point** and would result in the same problems as placing the cup too far anterior. *Midway between the anterior and posterior fontanelle* - While this location (approximately 4.5 cm from either fontanelle) might seem intuitive, it does not precisely correspond to the optimal **flexion point** for vacuum extraction. - The true flexion point is slightly more posterior, at **3 cm anterior to the posterior fontanelle**, which optimizes the mechanism of labor.

Q: Which of the following instruments are used in the caesarean section? 1. Bard-Parker blade 2. Doyen's retractor 3. Cusco's speculum 4. Allis forceps 5. Shirodkar's uterine clamp 6. Green Armytage forceps

1,2,4,6. ***Correct: 1,2,4,6*** - **Bard-Parker blade** (scalpel) is used for making the abdominal and uterine incisions in caesarean section. - **Doyen's retractor** is a common abdominal wall retractor used in C-sections to provide good exposure of the uterus. - **Allis forceps** are used to grasp and hold tissues, often the rectus sheath or uterine edges, for traction or approximation during the procedure. - **Green Armytage forceps** are specialized obstetric forceps primarily used to clamp the uterine edges after incision to control bleeding. *Incorrect: 1,2,3,6* - This option incorrectly includes **Cusco's speculum**, which is a vaginal speculum used for gynecological examinations and procedures like colposcopy or Pap smears, not for a caesarean section. - While Bard-Parker blade, Doyen's retractor, and Green Armytage forceps are correct, the inclusion of Cusco's speculum makes this option incorrect. *Incorrect: 1,2,5,6* - This option incorrectly includes **Shirodkar's uterine clamp**. Shirodkar's procedure refers to a type of cervical cerclage, and there isn't a widely recognized "Shirodkar's uterine clamp" used in standard caesarean sections. - Bard-Parker blade, Doyen's retractor, and Green Armytage forceps are correct, but the presence of Shirodkar's uterine clamp makes the option incorrect in the context of a typical C-section. *Incorrect: 1,2,3,5* - This option incorrectly includes both **Cusco's speculum** and **Shirodkar's uterine clamp**. - As explained, Cusco's speculum is for vaginal examination, and Shirodkar's clamp is not a standard instrument for caesarean sections.

Question 1

B-Lynch suture for atonic postpartum haemorrhage:

Accepted Answer

compresses the uterus

Answer

ligates the uterine arteries

Answer

ligates the ovarian vessels

Answer

ligates the utero-ovarian anastomosis

Question 2

In the process of MTP (Medical Termination of Pregnancy) done by suction and evacuation, it was realized that perforation of uterus occurred with cannula. The next step should be:

Accepted Answer

Laparotomy with exploration of bowel

Answer

Manual vacuum aspiration

Answer

Complete the evacuation with curette

Answer

Wait and watch

Question 3

Which of the following are the pre-requisites of outlet forceps delivery?

1. Bladder should be empty
2. Membranes should be intact
3. Cervix should be fully dilated
4. Fetal skull has reached level of pelvic floor

Accepted Answer

1, 3 and 4

Answer

1, 2 and 4

Answer

1, 2 and 3

Answer

2, 3 and 4

Question 4

Match List-I with List-II and select the correct answer using the code given below the Lists:

Accepted Answer

A→2  B→3  C→1  D→4

Answer

A→4  B→1  C→3  D→2

Answer

A→2  B→1  C→3  D→4

Answer

A→4  B→3  C→1  D→2

Question 5

Which one of the following is not a suitable condition for outlet forceps application?

Accepted Answer

Head is above ischial spine level

Answer

Cervix fully dilated

Answer

Membranes absent

Answer

Vertex presentation

Question 6

Identify the maneuver shown in the image:

Accepted Answer

Mauriceau-Smellie-Veit

Answer

Burn Marshall

Answer

Lovset

Answer

None of the options

Question 7

Identify the instrument shown in the image below:
![img-52.jpeg](img-52.jpeg)

Accepted Answer

Wrigley

Answer

Kielland

Answer

Pipers

Answer

Simpson

Question 8

Identify the instrument shown in the image below:

Accepted Answer

Kielland

Answer

Simpson

Answer

Wrigley

Answer

Pipers

Question 9

The flexion point in ventouse (vacuum) delivery is located at:

Accepted Answer

3 cm anterior to the posterior fontanelle

Answer

3 cm posterior to the anterior fontanelle

Answer

6 cm anterior to the posterior fontanelle

Answer

Midway between the anterior and posterior fontanelle

Question 10

Which of the following instruments are used in the caesarean section?

1. Bard-Parker blade
2. Doyen's retractor
3. Cusco's speculum
4. Allis forceps
5. Shirodkar's uterine clamp
6. Green Armytage forceps

Accepted Answer

1,2,4,6

Answer

1,2,3,6

Answer

1,2,5,6

Answer

1,2,3,5

Operative Obstetrics — MCQs

Operative Obstetrics — MCQs

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