Operative Obstetrics Practice Questions

Q: The most important point of reference in the use of forceps is :

Pelvic axis. ***Pelvic axis*** - The **pelvic axis** is the most important reference point during forceps use, as it defines the **curved path** through which the fetal head must be guided during delivery. - **Traction during forceps delivery must follow the pelvic axis** to minimize trauma to both mother and fetus. Incorrect direction of traction can cause serious complications including cervical tears, vaginal lacerations, and fetal injury. - The pelvic axis curves from the **inlet (pointing downward and backward)** through the **midpelvis (pointing backward)** to the **outlet (pointing downward and forward)**. Understanding and following this curve is essential for safe forceps application. *Station of biparietal diameter* - While the **station** (level of descent relative to ischial spines) is crucial for determining **eligibility** for forceps delivery, it is not the primary reference point during the actual use of forceps. - Station confirms adequate engagement and descent (typically ≥+2 required for outlet forceps), but once this prerequisite is met, the **pelvic axis guides the actual procedure**. *Posterior sagittal diameter* - The **posterior sagittal diameter** is a pelvic measurement used to assess pelvic capacity, particularly in cases of potential cephalopelvic disproportion. - While important for overall pelvic assessment, it does not serve as the primary reference during forceps application. *The Plane of greatest dimension* - The **plane of greatest dimension** is an anatomical landmark in the midpelvis, representing the most spacious part of the pelvic cavity. - While it is part of the overall pelvic architecture, it is not the key reference point that guides forceps traction during delivery.

Q: All of the following are contraindications of ventouse extraction, EXCEPT:

Anemia. ***Anemia*** - **Maternal anemia** is generally not considered a contraindication for ventouse extraction, as the procedure primarily assists in the delivery of the fetus. - While **severe maternal anemia** might influence decisions regarding overall maternal health and blood product availability, it does not directly preclude the use of a ventouse for fetal extraction. *Face presentation* - **Ventouse extraction** is contraindicated in face presentation because the application of the cup to the fetal face can cause **severe facial trauma**, including nerve damage and bruising. - The mechanics of traction are also ineffective and potentially harmful in this presentation. *Transverse lie* - A **transverse lie** means the fetus is lying horizontally across the uterus, making a **vaginal delivery** impossible without external or internal version to change the lie. - Ventouse extraction requires the fetal head to be engaged in the maternal pelvis, which is not the case in a transverse lie, thereby categorizing it as a contraindication. *Fetal macrosomia* - **Fetal macrosomia** (excessively large fetus) significantly increases the risk of **shoulder dystocia** and other birth traumas, making ventouse extraction less safe and potentially ineffective. - The forces required for extraction could lead to **fetal injury** (e.g., cephalohematoma, intracranial hemorrhage) or maternal injury (e.g., vaginal lacerations).

Q: Which is not an indication for a classical cesarean incision?

Term breech (frank). ***Term breech (frank)*** - A **frank breech** presentation at term does not inherently require a classical (vertical) incision, as a **low transverse incision** is generally safe and preferred for its lower risk of uterine rupture in subsequent pregnancies. - The decision for incision type is based more on the accessibility of the **lower uterine segment** and fetal lie than on the specific type of breech at term. *Premature breech* - In a premature fetus, the **lower uterine segment** may be underdeveloped and insufficient to allow safe extraction through a low transverse incision. - A **classical incision** provides a larger opening in the thicker, upper uterine segment, which is safer for a fragile preterm infant. *Cannot visualize the lower uterine segment* - Conditions like **dense adhesions** from prior surgeries, a large **leiomyoma**, or an **anterior placenta previa** can obscure or make the lower uterine segment inaccessible. - In such cases, a **classical incision** in the more visible and accessible upper uterine corpus is indicated to safely deliver the fetus. *Transverse lie* - A **transverse lie** means the fetus is lying horizontally across the uterus, often making a **low transverse incision** difficult or impossible due to the fetal position. - A **classical incision** allows for a larger, more vertical opening that accommodates the fetal spine and shoulders, facilitating safe extraction.

Q: Common indications for caesarean section in primigravidae are all except?

Failed induction. ***Failed induction*** - While a reason for caesarean section, **failed induction** is typically more common in **multigravidae** due to a less favorable cervix or prior uterine scarring, and is less frequently the *initial* indication in primigravidae, who are often started on induction during their first pregnancy. - The other options represent more common, primary indications for caesarean section in **primigravidae**. *Cephalopelvic disproportion* - This is a significant indication in **primigravidae** where the baby's head is too large to pass through the mother's pelvis, often discovered during labor. - The unproven nature of the pelvis in a first pregnancy makes this a common reason for caesarean delivery. *Dystocia* - Refers to **difficult or prolonged labor**, which is a very common indication for caesarean section in **primigravidae**. - This can be due to abnormal uterine contractions, fetal malposition, or cephalopelvic disproportion. *Malpresentation* - Presentations such as **breech** or **transverse lie** are common indications for planned or emergency caesarean sections, especially in **primigravidae**. - Without prior vaginal deliveries, a trial of labor with malpresentation is generally considered riskier.

Q: The triple P procedure for placenta percreta involves all except:

Peripartum hysterectomy. ***Peripartum hysterectomy*** - The **triple P procedure** (or "Pelvic Perfusion and Placenta Praevia Percreta") is a conservative approach aimed at **avoiding hysterectomy** in cases of placenta percreta. - Its goal is to allow for later placental removal, thereby preventing the need for an immediate **peripartum hysterectomy**, which is a high-risk procedure. *Pelvic devascularization* - This typically involves techniques like **internal iliac artery ligation** or **uterine artery embolization** to reduce blood flow to the uterus and placenta. - Reducing perfusion helps to minimize hemorrhage during surgery and **facilitate future placental involution** and separation. *Placental localization using USG* - **Accurate mapping** of the placenta's boundaries and extent of invasion is critical before surgical intervention. - **Ultrasound** (USG) and other imaging modalities like **MRI** are used pre-operatively to guide incisions and determine the optimal approach for placental management. *Myometrial excision for placental nonseparation* - In cases where the placenta has invaded the myometrium (**placenta percreta**), a portion of the **myometrium containing the abnormally implanted placenta** is excised. - This step is crucial for separating the adherent portion of the placenta while preserving the uterus and is a key component of the triple P procedure to **avoid complete hysterectomy**.

Q: All of these may be considered for a classical caesarean section, EXCEPT?

Posterior placenta. ***Posterior placenta*** - A **posterior placenta** is a normal variant and does not necessitate a classical (vertical uterine incision) caesarean section. - The standard approach for a safe delivery in cases of posterior placenta is a **lower uterine segment transverse incision (LSCS)**. *Massive maternal obesity precluding safe access to LUS* - In cases of **severe obesity**, a classical caesarean section may be considered to avoid deep and potentially contaminated subcutaneous fat layers and to achieve safe delivery through a more accessible uterine fundus. - The increased tissue depth can make visualizing and safely incising the **lower uterine segment (LUS)** challenging via a transverse approach. *Previous LSCS with dense bladder adhesions* - **Dense adhesions** from a prior LSCS, especially involving the bladder, can make a repeat transverse lower uterine segment incision technically difficult and increase the risk of bladder injury. - A **classical incision** may be chosen to avoid these adhesions and access an unaffected part of the uterus. *Large lower uterine segment fibroid* - A large fibroid located in the **lower uterine segment** can obstruct the birth canal and prevent a safe transverse incision. - In such situations, a **classical incision** might be necessary to bypass the fibroid and deliver the fetus.

Q: Pressure in ventouse assisted delivery is:

0.8 kg/sq.cm. ***0.8 kg/sq.cm*** - The standard recommended maximum negative pressure for **ventouse (vacuum) assisted delivery** is **0.8 kg/cm²**, which equates to roughly 60 cmHg or 500-600 mmHg. - This pressure level is generally considered effective for traction while minimizing the risk of fetal injury, such as **scalp trauma** or **cephalhaematoma**. *0.6 kg/sq.cm* - While it represents a lower pressure, **0.6 kg/cm²** might not provide sufficient traction for effective delivery in many cases. - Using a lower pressure may lead to **prolonged application time** or **failed vacuum extraction**, necessitating escalation to other delivery methods. *0.4 kg/sq.cm* - This pressure level is generally considered **too low** for most ventouse-assisted deliveries to achieve adequate traction. - Insufficient vacuum will likely result in **detachment of the cup** and failure to progress the delivery. *1.0 kg/ sq.cm* - Applying a pressure of **1.0 kg/cm²** is generally considered **excessive and potentially dangerous** for the fetus during vacuum extraction. - Higher pressures significantly increase the risk of severe **scalp injury**, **intracranial hemorrhage**, and other complications.

Q: Least common complication in outlet forceps is:

Vulval hematoma. ***Vulval hematoma*** - While possible, a **vulval hematoma** is generally considered a less frequent and often less severe complication specific to outlet forceps compared to tears of the reproductive tract. - Its incidence is lower than that of perineal or cervical tears, which are more directly associated with the mechanics of forceps delivery. *Complete perineal tear* - **Complete perineal tears** (third or fourth-degree) involving the anal sphincter are a significant risk associated with forceps delivery due to the increased tension and pressure on the perineum during extraction. - The instrument and the force applied can overtly stretch or rupture the perineal tissues. *Extension of episiotomy* - An **episiotomy**, often performed during forceps delivery to facilitate delivery and prevent irregular tears, can frequently extend into a more severe laceration, especially under forceful extraction. - The pre-existing incision makes the tissue more vulnerable to further tearing under stress. *Cervical tear* - **Cervical tears** can occur if the cervix is not fully dilated prior to the application and traction of forceps, or if the force applied is excessive. - Undiagnosed or unchecked cervical lacerations can lead to significant hemorrhage.

Q: In breech presentation, the following forceps/methods are used for delivery of the after-coming head EXCEPT:

Wrigley's forceps. ***Wrigley's forceps*** - **Wrigley's forceps** are **outlet forceps** designed for a fully engaged head at the pelvic outlet, with the sagittal suture in the anteroposterior diameter and the fetal scalp visible. - They are used for **cephalic presentations** to assist with delivery of the fetal head when it is low in the pelvis, not for the after-coming head in breech presentation. *Mauriceau-Smellie-Veit technique* - This is a **manual maneuver** specifically used to deliver the after-coming head in a **breech presentation**. - It involves supporting the fetal body and applying pressure to the maxilla to promote head flexion and delivery. *Kielland's forceps* - **Kielland's forceps** are used for **rotational deliveries** and can be applied in **breech presentations** for the delivery of the after-coming head, particularly when some degree of rotation is required. - Their unique design allows for application even when the head is malpositioned or high in the pelvis. *Piper forceps* - **Piper forceps** are specifically designed for the **after-coming head** in **breech delivery**. - They have a perineal curve and downward-angled shanks allowing them to be applied from below the fetal body to engage the head in the pelvis, preventing head extension and facilitating controlled delivery.

Question 1

The most important point of reference in the use of forceps is :

Accepted Answer

Pelvic axis

Answer

Posterior sagittal diameter

Answer

Station of biparietal diameter

Answer

The Plane of greatest dimension

Question 2

All of the following are contraindications of ventouse extraction, EXCEPT:

Accepted Answer

Anemia

Answer

Face presentation

Answer

Transverse lie

Answer

Fetal macrosomia

Question 3

Which is not an indication for a classical cesarean incision?

Accepted Answer

Term breech (frank)

Answer

Premature breech

Answer

Cannot visualize the lower uterine segment

Answer

Transverse lie

Question 4

Common indications for caesarean section in primigravidae are all except?

Accepted Answer

Failed induction

Answer

Cephalopelvic disproportion

Answer

Dystocia

Answer

Malpresentation

Question 5

The triple P procedure for placenta percreta involves all except:

Accepted Answer

Peripartum hysterectomy

Answer

Pelvic devascularization

Answer

Placental localization using USG

Answer

Myometrial excision for placental nonseparation

Question 6

All of these may be considered for a classical caesarean section, EXCEPT?

Accepted Answer

Posterior placenta

Answer

Massive maternal obesity precluding safe access to LUS

Answer

Previous LSCS with dense bladder adhesions

Answer

Large lower uterine segment fibroid

Question 7

Pressure in ventouse assisted delivery is:

Accepted Answer

0.8 kg/sq.cm

Answer

0.6 kg/sq.cm

Answer

0.4 kg/sq.cm

Answer

1.0 kg/sq.cm

Question 8

Least common complication in outlet forceps is:

Accepted Answer

Vulval hematoma

Answer

Complete perineal tear

Answer

Extension of episiotomy

Answer

Cervical tear

Question 9

An elderly multigravida female presents in labor. She has multiple fibroids in the lower uterine segment. Management is:

Accepted Answer

Classical cesarean followed by hysterectomy

Answer

LSCS

Answer

Trial of labor

Answer

Vaginal delivery

Question 10

In breech presentation, the following forceps/methods are used for delivery of the after-coming head EXCEPT:

Accepted Answer

Wrigley's forceps

Answer

Mauriceau-Smellie-Veit technique

Answer

Kielland's forceps

Answer

Piper forceps

Operative Obstetrics — MCQs

Operative Obstetrics — MCQs

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