Operative Obstetrics Practice Questions

Q: A lady with 36-week pregnancy with previous C-section comes with low BP, tachycardia, and on USG fluid present in peritoneum. What is the diagnosis and next management?

Uterine scar rupture with Laparotomy. ***Uterine scar rupture with Laparotomy*** - The presentation of **low blood pressure**, **tachycardia**, and **free fluid in the peritoneum** in a 36-week pregnant woman with a **previous C-section** is highly indicative of uterine scar rupture given the signs of **hemorrhagic shock**. - **Laparotomy** (emergency abdominal surgery) is the immediate and definitive management to repair the ruptured uterus, control bleeding, and deliver the fetus. *Abruptio and C-section* - **Placental abruption** typically presents with painful vaginal bleeding, uterine tenderness, and fetal distress, which are not explicitly mentioned as the primary symptoms here. - While a **C-section** would be indicated for abruption, the presence of free fluid in the peritoneum and hemodynamic instability in a woman with a prior C-section points more towards rupture. *Ectopic pregnancy and abortion* - An **ectopic pregnancy** is ruled out by the 36-week gestational age; these occur much earlier in pregnancy. - An **abortion** refers to the termination of pregnancy and does not cause these specific signs and symptoms at 36 weeks. *Impending dehiscence and Laparoscopy* - **Impending dehiscence** (separation of the uterine scar without complete rupture) would likely cause localized pain but typically not the severe signs of **hypovolemic shock** and free peritoneal fluid seen here. - **Laparoscopy** is a minimally invasive procedure and would not be appropriate for the emergency management of a potentially life-threatening hemorrhage from uterine rupture.

Q: Which of these types of fibroid may be removed at the time of a cesarean section?

Pedunculated fibroid. ***Pedunculated fibroid*** - **Pedunculated subserosal fibroids** are the safest type to remove during cesarean section, particularly those on a **narrow stalk** - They can be easily accessed through the abdominal incision without disrupting the uterine wall integrity - The stalk can be **clamped, ligated, and divided** with minimal risk of hemorrhage if proper hemostatic technique is used - Removal does not compromise the **hysterotomy closure** or future uterine integrity - This is the **only type of fibroid** routinely considered safe for removal during C-section if clinically indicated *Intramural fibroid* - **Intramural fibroids** are embedded within the myometrial wall and their removal is **generally contraindicated** during cesarean section - Myomectomy during C-section carries significant risk of **severe hemorrhage** from the highly vascular pregnant uterus - Removal can compromise **uterine wall integrity** and interfere with proper hysterotomy closure - May increase risk of **uterine rupture** in subsequent pregnancies - Standard obstetric practice is to **avoid myomectomy at cesarean** unless the fibroid is directly obstructing delivery *Broad ligament fibroid* - **Broad ligament fibroids** are located between the layers of the broad ligament, often in close proximity to the **ureter** and **uterine vessels** - Removal carries extremely high risk of **ureteral injury** and **massive hemorrhage** from pedicle vessels - Their excision is **absolutely contraindicated** during cesarean section *Cervical fibroid* - **Cervical fibroids** are located in the cervix with its **rich vascular supply** from cervical branches of uterine arteries - Removal during C-section risks **uncontrollable hemorrhage** and can cause **cervical incompetence** - Excision is **contraindicated** during cesarean section and should be managed separately if needed

Q: Angle of cut in episiotomy is?

60 degrees at the midline. ***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.

Q: Contraindications to ventouse delivery include all of the following except :

Occipito transverse position. ***Occipito transverse position*** - This is **NOT a contraindication** to ventouse delivery and is the correct answer - Ventouse can be successfully used to assist with **rotation** from occipito transverse to occipito anterior position before extraction - Modern ventouse techniques specifically allow for **controlled rotation** during delivery - This is a common indication for instrumental delivery rather than a contraindication *Face presentation* - Applying a ventouse cup to the fetal face is **absolutely contraindicated** due to high risk of **facial trauma**, soft tissue injury, eye damage, and neurological complications - The cup cannot achieve proper placement on the facial bones - Face presentation typically requires **cesarean section** or careful management with forceps only in specific mentum anterior positions *Fetal coagulopathies* - This is a **strong contraindication** to ventouse delivery due to the increased risk of **intracranial hemorrhage** and other bleeding complications in the neonate - Conditions like hemophilia, thrombocytopenia, or Von Willebrand disease make any instrumental trauma potentially life-threatening - The traction and pressure from the ventouse cup can cause **scalp hematomas, subgaleal hemorrhage, or intracranial bleeding** in coagulopathic fetuses *Extreme prematurity* - **Extreme prematurity** (typically <34 weeks gestation) is a contraindication to ventouse delivery due to the **fragility of the fetal skull** and markedly increased risk of **intracranial hemorrhage** - The incompletely ossified skull and delicate cerebral vasculature make preterm infants highly vulnerable to trauma from vacuum extraction - Instrumental delivery in preterm infants carries unacceptably high risk of **intraventricular hemorrhage** and long-term neurological injury

Q: In modern era, the only indication for Internal Podalic Version is:

Delivery of Second baby of twins. ***Delivery of Second baby of twins*** - **Internal Podalic Version (IPV)** is primarily indicated for the delivery of the second twin in cases where the second twin presents in a **non-cephalic presentation** or has a malpresentation after the delivery of the first twin. - This procedure aims to quickly deliver the second twin by grasping its feet and converting it into a **breech presentation**, reducing the risk of complications such as **abruptio placentae** or fetal distress. *Transverse lie* - While a transverse lie would typically require intervention, **external cephalic version (ECV)** is usually attempted first to convert the fetus to a cephalic presentation. - If ECV fails or is contraindicated, a **cesarean section** is generally the safest approach for a transverse lie in a singleton pregnancy, rather than IPV. *Breech presentation* - For a singleton **breech presentation** at term, management options include planned **cesarean section** or, in select cases, a trial of vaginal breech delivery. - IPV is **not typically performed** for a primary breech presentation in a singleton pregnancy due to potential risks to the fetus and uterus. *Oblique lie* - An **oblique lie** is often unstable and may convert to a longitudinal or transverse lie spontaneously or with intervention. - Similar to a transverse lie, **external cephalic version (ECV)** would be the initial consideration to convert it to a cephalic presentation, or a **cesarean section** if ECV is unsuccessful or contraindicated.

Q: Shirodkar cerclage may be associated with all complications except:

Paresthesia over inner aspect. ***Paresthesia over inner aspect*** - Paresthesia over the inner thigh is typically associated with injury to the **femoral nerve** or its branches, or the **obturator nerve**. - While surgery in the pelvic region always carries some nerve injury risk, a Shirodkar sling operation, which is a cervical cerclage, is **unlikely to directly cause paresthesia** in this specific distribution. *Enterocele* - An **enterocele** is a type of pelvic organ prolapse where the small bowel descends into the lower pelvic cavity, creating a bulge in the vagina. - The Shirodkar sling procedure involves placing a suture around the cervix, which can alter pelvic anatomy and potentially contribute to the development or worsening of an enterocele, by **changing pressure dynamics** or creating adhesion. *Ureteral injury* - The **ureters** pass close to the cervix as they course into the bladder, especially where the uterosacral ligaments attach. - During the placement of the Shirodkar cervical cerclage, there is a risk of **ligating or damaging the ureters** due to their proximity to the surgical field. *Subacute intestinal obstructions* - Any pelvic surgery, including a Shirodkar sling operation, carries a risk of **adhesion formation**. - These **post-surgical adhesions** can involve segments of the bowel, potentially leading to kinking or narrowing of the intestinal lumen, which can cause symptoms of subacute intestinal obstruction.

Q: Classical cesarean section is specifically indicated in which of the following conditions?

Cervical cancer involving lower uterine segment. ***Cervical cancer involving lower uterine segment*** - A classical cesarean section, involving a **vertical incision into the upper uterine segment**, allows for delivery of the fetus without disturbing the cancerous cervix and lower uterine segment. - This approach minimizes the risk of **tumor dissemination** and excessive bleeding, which would be high with a low transverse incision. *Transverse lie with back down* - A **low transverse cesarean section** is generally preferred for a transverse lie presentation as it aligns better with the uterine architecture and is associated with fewer future uterine rupture risks. - A classical incision is typically reserved for extreme cases of transverse lie (e.g., morbidly obese patient making access difficult or fetal anomaly) or when the **lower uterine segment is not adequately formed**. *Placenta previa with anterior placenta accreta* - This condition typically necessitates a **low transverse cesarean section**, often combined with a **hysterectomy**, due to the abnormal placental adherence to the anterior lower uterine segment. - A classical incision would likely lead to **significant hemorrhage** and may not effectively manage the adherent placenta. *Previous two cesarean sections* - While a previous cesarean section increases the risk of uterine rupture in subsequent pregnancies, it does not automatically indicate a classical cesarean section for the third delivery. - A repeat **low transverse cesarean section** is usually performed as it carries a lower risk of rupture in future pregnancies compared to a classical incision scar.

Q: A forceps rotation of 30 degrees from left occiput anterior (LOA) to occiput anterior (OA) with extraction of the fetus from +2 station is described as which type of forceps delivery?

Low forceps. ***Low forceps*** - A **low forceps delivery** is defined when the leading point of the fetal skull is at station **≥+2 cm** (at or below +2 station) but **not on the pelvic floor**. - The rotation must be **≤45 degrees** for standard low forceps. - In this scenario, the fetal head is at **+2 station** with a **30-degree rotation** from LOA to OA, which fits the criteria for low forceps delivery. *Mid forceps* - **Mid forceps deliveries** are performed when the fetal head is **engaged** but the station is **between 0 and +2 cm** (above +2 station). - Since this scenario describes a head **at +2 station**, it is too low to be classified as mid forceps. *Outlet forceps* - **Outlet forceps** requires: (1) scalp visible at the introitus **without separating the labia**, (2) fetal skull on the **pelvic floor**, and (3) sagittal suture in AP diameter or ROA/LOA/ROP/LOP position with rotation **≤45 degrees**. - Although the 30-degree rotation meets the rotation criterion, at **+2 station** the fetal head is typically **not yet on the pelvic floor** with the scalp visible at the introitus without separating the labia, which are required for outlet forceps classification. *High forceps* - **High forceps** involves application of forceps **before engagement** of the fetal head. - This procedure is **obsolete** and not performed in modern obstetrics. - At **+2 station**, the head is clearly engaged and descended, so this classification does not apply.

Q: All are complications of vacuum-assisted delivery over forceps delivery except:

Transient lateral rectus palsy. ***Transient lateral rectus palsy*** - **Transient sixth nerve palsy** (lateral rectus palsy) in a neonate is **more commonly associated with forceps delivery**, not vacuum-assisted delivery. - This occurs due to **direct compression of the fetal head** during forceps application, particularly compression of the sixth cranial nerve [4]. - It is **NOT a typical complication of vacuum-assisted delivery over forceps delivery**, making it the correct answer to this EXCEPT question. *Subgaleal hematoma* - This is a **serious and specific complication of vacuum-assisted delivery**, occurring when blood collects in the space between the **galeal aponeurosis** and the **periosteum** [1]. - It is **more common with vacuum extraction than forceps delivery**. - Can lead to significant **blood loss** and **hypovolemic shock** in the neonate. *Intracranial hemorrhage* - **Vacuum extraction is associated with higher rates** of intracranial hemorrhage compared to forceps delivery [1]. - The suction and traction forces can lead to **subdural hemorrhage**, **subarachnoid hemorrhage**, and other intracranial bleeding [2]. - Studies show increased risk with vacuum compared to forceps delivery. *Cephalohematoma* - A **cephalohematoma** (blood collection between **periosteum** and skull bone) is a **classic and common complication of vacuum-assisted delivery** [3]. - It is **more frequent with vacuum extraction than forceps delivery** due to the suction cup causing subperiosteal bleeding. - Resolves spontaneously over weeks to months.

Question 1

A lady with 36-week pregnancy with previous C-section comes with low BP, tachycardia, and on USG fluid present in peritoneum. What is the diagnosis and next management?

Accepted Answer

Uterine scar rupture with Laparotomy

Answer

Abruptio and C-section

Answer

Ectopic pregnancy and abortion

Answer

Impending dehiscence and Laparoscopy

Question 2

Which of these types of fibroid may be removed at the time of a cesarean section?

Accepted Answer

Pedunculated fibroid

Answer

Broad ligament fibroid

Answer

Cervical fibroid

Answer

Intramural

Question 3

Angle of cut in episiotomy is?

Accepted Answer

60 degrees at the midline

Answer

45 degrees at the midline

Answer

30 degrees at the midline

Answer

15 degrees at the midline

Question 4

Contraindications to ventouse delivery include all of the following except :

Accepted Answer

Occipito transverse position

Answer

Face presentation

Answer

Fetal coagulopathies

Answer

Extreme prematurity

Question 5

In modern era, the only indication for Internal Podalic Version is:

Accepted Answer

Delivery of Second baby of twins

Answer

Transverse lie

Answer

Breech presentation

Answer

Oblique lie

Question 6

Shirodkar cerclage may be associated with all complications except:

Accepted Answer

Paresthesia over inner aspect

Answer

Enterocele

Answer

Ureteral injury

Answer

Subacute intestinal obstructions

Question 7

Classical cesarean section is specifically indicated in which of the following conditions?

Accepted Answer

Cervical cancer involving lower uterine segment

Answer

Transverse lie with back down

Answer

Placenta previa with anterior placenta accreta

Answer

Previous two cesarean sections

Question 8

ECV is absolutely contraindicated in all except :

Accepted Answer

Previous LICS scar

Answer

Septate uterus

Answer

Severe pre-eclampsia

Answer

Placenta previa

Question 9

A forceps rotation of 30 degrees from left occiput anterior (LOA) to occiput anterior (OA) with extraction of the fetus from +2 station is described as which type of forceps delivery?

Accepted Answer

Low forceps

Answer

Mid forceps

Answer

Outlet forceps

Answer

High forceps

Question 10

All are complications of vacuum-assisted delivery over forceps delivery except:

Accepted Answer

Transient lateral rectus palsy

Answer

Subgaleal hematoma

Answer

Intracranial hemorrhage

Answer

Cephalohematoma

Operative Obstetrics — MCQs

Operative Obstetrics — MCQs

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