Operative Obstetrics Practice Questions

Q: End point of D&C is?

Uterine cry. ***Uterine cry*** - A "uterine cry" refers to the characteristic **grating sound** or sensation felt by the surgeon as the curette scrapes the firm, fibrous uterine wall after the removal of softer contents. - This sensation indicates that the **endometrial cavity has been adequately curetted** and that no further tissue, such as retained products of conception, remains. *After 2 strokes* - The number of strokes is **not a reliable endpoint** for a D&C, as the amount and consistency of uterine contents can vary widely. - Relying solely on a fixed number of strokes could lead to **incomplete evacuation** or **unnecessary scraping**, increasing risks. *Presence of fresh bleeding* - While some **fresh bleeding** is expected during and after a D&C, it is **not an endpoint**; excessive or persistent bleeding may indicate retained tissue or complications. - The goal is to **remove uterine contents and minimize bleeding**, not to continue until bleeding stops, which could be misleading. *All of the options* - Only the **uterine cry** is a widely accepted and reliable endpoint indicating thorough evacuation of the uterine cavity during a D&C. - The other options do not accurately represent the completion of the procedure or could indicate a complication.

Q: Internal podalic version is done for:

Transverse lie in 2nd twins. ***Transverse lie in 2nd twins*** - **Internal podalic version** is a procedure used to convert a fetal **transverse lie** into a **breech presentation**, allowing for vaginal delivery, particularly useful for the second twin. - It is often performed when the second twin is in a transverse lie or oblique lie after the first twin has been delivered, to expedite delivery and prevent complications. *Brow presentation* - **Brow presentation** is a cephalic presentation where the fetal head is incompletely flexed, presenting with the brow as the leading part through the birth canal. - Internal podalic version is not indicated for brow presentation; **cesarean section** is often necessary due to the large presenting diameter. *Breech presentation* - **Breech presentation** is when the fetus presents buttocks or feet first. - While external cephalic version (ECV) can be tried for breech presentation, internal podalic version is specifically used to *achieve* a breech presentation from a transverse lie, not to manage an existing breech. *None of the options* - This option is incorrect because internal podalic version has a specific, medically indicated use, as described with the correct option. - The procedure is a classic obstetric maneuver with clear indications in specific delivery scenarios.

Q: An absolute indication for Classical cesarean section is :

Carcinoma cervix. ***Carcinoma cervix*** - A **classical cesarean section** (vertical incision in the uterine body) is indicated in cases of **carcinoma of the cervix** to minimize trauma to the cervix and prevent dissemination of cancer cells. - This approach avoids cutting through the cancerous tissue, which might be necessary with a lower uterine segment incision. *Central Placenta Previa* - While **placenta previa** often necessitates a cesarean section, a **lower segment cesarean section** (LSCS) is generally preferred due to less blood loss and better healing. - A classical cesarean section would only be considered in specific, rare circumstances for placenta previa, such as an exceptionally previa anterior placenta or severe hemorrhage requiring rapid extraction, but it is not an absolute, primary indication. *Breech presentation* - **Breech presentations** are often delivered by **lower segment cesarean section** (LSCS) due to potential risks associated with vaginal delivery. - A classical cesarean section is rarely indicated for breech presentation, typically only for very premature fetuses or if the lower uterine segment is inaccessible. *Multi-fibroid uterus* - A **multi-fibroid uterus** itself is not an absolute indication for a classical cesarean section unless the fibroids obstruct the lower uterine segment, preventing an LSCS. - In most cases, a **lower segment cesarean section** can still be performed, sometimes with careful navigation around or removal of obstructing fibroids (myomectomy at C-section).

Q: In deep transverse arrest with adequate pelvis, what is the best mode of delivery?

Kielland forceps. ***Kielland forceps*** - **Kielland forceps** are the **classical instrument of choice** for deep transverse arrest with an adequate pelvis, as they were specifically designed for **rotational delivery**. - They have a **minimal pelvic curve** and a **sliding lock mechanism** that allows for controlled rotation of the fetal head from transverse to occipito-anterior position. - When the pelvis is adequate and the operator is skilled, Kielland forceps provide the **most direct and effective method** for managing deep transverse arrest. - This is the **standard answer** taught in most obstetric textbooks including Williams Obstetrics and Dutta's Textbook of Obstetrics. *Manual rotation followed by forceps* - This is an acceptable alternative approach, especially when **expertise with rotational forceps is limited**. - Manual rotation (using the hand to rotate the fetal head to occipito-anterior) followed by standard forceps or traction is a valid method. - However, it requires **two separate maneuvers** rather than the single-instrument approach with Kielland forceps. *Ventouse* - While ventouse can achieve rotation and traction, it has a **higher failure rate** in cases of deep transverse arrest, particularly at the mid-pelvis level. - Rotation with ventouse is **less controlled** and has higher **cup detachment rates** compared to rotational forceps. - It may be considered when rotational forceps expertise is not available or when minimal rotation is needed. *Cesarean section* - Cesarean section would be indicated if the pelvis were **inadequate** (cephalopelvic disproportion), if there is **fetal distress**, or if **assisted vaginal delivery fails**. - Since the question specifies an **adequate pelvis**, operative vaginal delivery is preferred over the more invasive cesarean section when feasible.

Q: Which of the following is an absolute indication for elective repeat caesarean section in a patient with previous caesarean delivery?

Previous classical incision. ***Previous classical incision*** - A **classical incision** (vertical uterine incision in the upper uterine segment) carries a **4-9% risk of uterine rupture** in subsequent pregnancies, compared to 0.5-1% with low transverse incisions. - **VBAC (Vaginal Birth After Cesarean) is absolutely contraindicated** with a previous classical incision due to the high rupture risk. - This is a **standing absolute indication** for elective repeat cesarean section at 36-37 weeks gestation. - Other absolute indications include previous T-incision, J-incision, and previous uterine rupture. *Uterine rupture/scar dehiscence* - **Uterine rupture** is a catastrophic **intrapartum emergency** requiring immediate cesarean delivery. - This is not a pre-existing "indication" but rather an **acute complication** that occurs during labor. - Previous uterine rupture (not active rupture) would be an absolute indication for planned repeat C-section. *Placenta accreta spectrum* - This involves abnormal placental invasion and is strongly associated with previous C-sections. - While it requires cesarean delivery with possible hysterectomy, it is a **complication of placental implantation**, not a direct indication based on the previous uterine incision type. - It necessitates C-section but is not specific to the type of previous cesarean scar. *Failed TOLAC (Trial of Labor After Cesarean)* - A **failed TOLAC** means cesarean delivery is required because vaginal delivery could not be achieved. - This is an **intrapartum decision** based on failure to progress or fetal compromise, not a pre-existing indication for planned repeat C-section.

Q: Symphysiotomy is indicated in:

Contraction of outlet. ***Contraction of outlet*** - Symphysiotomy is a procedure where the **fibrocartilaginous joint of the pubic symphysis is divided**, temporarily increasing the pelvic diameters. - It is specifically indicated in cases of **outlet contraction** where the fetal head is engaged but cannot pass through the pelvic outlet, often due to a narrow subpubic angle. *Contraction of cavity* - **Mid-pelvic contraction** (cavity contraction) is typically managed with a **cesarean section** if there is significant fetopelvic disproportion, as symphysiotomy may not adequately increase the mid-pelvic dimensions. - The primary purpose of symphysiotomy is to slightly widen the *anterior-posterior* and *transverse* diameters of the outlet, which is less effective for mid-pelvis issues. *Contraction of brim* - **Inlet contraction** (brim contraction) implies that the fetal head cannot engage or enter the pelvis. - In such cases, a **cesarean section** is the standard and safest approach as engagement is impossible and symphysiotomy cannot address the contracted inlet. *All of these* - Symphysiotomy is a niche procedure with specific indications, primarily for **outlet contraction**, and is generally not appropriate for inlet or significant mid-cavity contractions. - Applying it to all forms of pelvic contraction would lead to higher risks and poor outcomes for mother and baby.

Q: A pregnant lady with persistent variable decelerations with cervical dilatation of 6 cm is planned for emergency LSCS. Which of the following is NOT done in management while preparing patient for surgery

Supine position. ***Supine position*** - Maintaining a **supine position** in a pregnant woman can lead to **aortocaval compression**, reducing **venous return** and **cardiac output**, which compromises uterine blood flow and fetal oxygenation. - To prevent this, the patient should be placed in a **left lateral tilt** (wedge under the right hip) to displace the uterus off the great vessels. *O2 inhalation* - Administering **oxygen via face mask** increases the mother's partial pressure of oxygen (PaO2), which can improve **fetal oxygenation** and potentially alleviate fetal distress. - This is a standard and safe intervention to maximize oxygen delivery to the fetus, especially in cases of **fetal compromise** indicated by variable decelerations. *I.V. fluid* - Administering **intravenous fluids** helps maintain maternal hydration and **circulatory volume**, crucial for adequate uterine perfusion. - This can improve **placental blood flow**, potentially reducing the frequency or severity of variable decelerations by increasing amniotic fluid volume and relieving **cord compression**. *Foleys catheterisation* - **Foley catheterization** is essential before a Cesarean section to **decompress the bladder**, preventing injury during surgery and improving surgical exposure. - A full bladder can obstruct the surgical field and increases the risk of accidental incision, therefore, it is a routine pre-operative step.

Q: In modern obstetrics, the internal podalic version is indicated in presence of:

Transverse lie of 2nd twin baby. **Transverse lie of 2nd twin baby** - **Internal podalic version** is primarily indicated for the second twin in a transverse or oblique lie to facilitate vaginal delivery after the first twin has been delivered. - This procedure involves inserting a hand into the uterus to grasp the baby's feet and turn it into a **breech presentation**, allowing for extraction. *Extended breech presentation* - For an **extended breech presentation**, **internal podalic version** is generally not the preferred method of management; external cephalic version or planned cesarean section are often considered. - The fetus is already in a longitudinal lie, and the goal is usually to convert to cephalic, not podalic, or to manage the existing breech. *Transverse lie with obstructed labor* - In cases of **transverse lie with obstructed labor**, **internal podalic version** is contraindicated because the uterus is often contracted down on the fetus, making manipulation dangerous and increasing the risk of uterine rupture. - **Obstructed labor** in a transverse lie typically necessitates an emergency cesarean section. *Cord prolapse with live baby* - For **cord prolapse with a live baby**, the immediate priority is to relieve pressure on the umbilical cord and deliver the baby as quickly as possible, usually via emergency cesarean section. - While prompt delivery is crucial, **internal podalic version** is not the primary intervention for cord prolapse itself; rather, it is a method for delivery when other factors align.

Q: All of the following are relative contraindications for vacuum extraction, EXCEPT:

Occipito-posterior position. ***Occipito-posterior position*** - This is often considered a **relative indication** for vacuum extraction, as it can help rotate the fetal head to an anterior position and facilitate delivery. - While it may make the extraction slightly more challenging, it is not a direct contraindication, unlike the other options which pose greater risks. *Fetal coagulopathies* - **Vacuum extraction** can cause significant trauma to the fetal scalp, leading to **hematomas** and **hemorrhage**. - In cases of **fetal coagulopathies**, the risk of severe bleeding and intracranial hemorrhage is substantially increased, making vacuum extraction highly contraindicated. *Face presentation* - In a **face presentation**, the fetal chin (mentum) is typically the presenting part. - Applying a vacuum cup to the face carries a high risk of **facial nerve damage**, **ocular injury**, and **severe facial bruising**, making it a contraindication. *Extreme prematurity* - The skull of extremely premature infants is **soft and fragile**, making it highly susceptible to injury from the suction forces of a vacuum extractor. - Vacuum extraction in such cases significantly increases the risk of **intracranial hemorrhage** and other serious fetal trauma.

Q: Vacuum extraction is CONTRAINDICATED in:

Premature babies. ***Premature babies*** - The **skull bones of premature babies are very soft and poorly calcified**, making them highly susceptible to **cephalhematoma** and **intracranial hemorrhage** if vacuum extraction is attempted. - The risk of **neonatal injury** with vacuum extraction is significantly increased in preterm infants due to their fragility. *Heart disease* - While certain **maternal heart conditions** might influence the choice of delivery mode to minimize maternal exertion, vacuum extraction itself is not an absolute contraindication if the mother can tolerate some pushing. - The primary concern is **maternal hemodynamic stability**, not the fetal head integrity, which vacuum extraction primarily impacts. *Microcephaly* - **Microcephaly** indicates a small head size, which would not typically hinder a vaginal delivery and might even make it easier. - The fetal head size (even if small) doesn't inherently contraindicate vacuum extraction, as the problem in vacuum extraction usually relates to large or improperly positioned heads, or the fragility of the skull itself. *Polyhydramnios* - **Polyhydramnios** refers to an excess of amniotic fluid and is a condition related to the uterine environment, often associated with fetal anomalies or maternal diabetes. - While it can complicate pregnancy and labor, it does not directly contraindicate the use of **vacuum extraction** during the second stage of labor.

Question 1

End point of D&C is?

Accepted Answer

Uterine cry

Answer

After 2 strokes

Answer

Presence of fresh bleeding

Answer

All of the options

Question 2

Internal podalic version is done for:

Accepted Answer

Transverse lie in 2nd twins

Answer

Brow presentation

Answer

Breech presentation

Answer

None of the options

Question 3

An absolute indication for Classical cesarean section is :

Accepted Answer

Carcinoma cervix

Answer

Central Placenta Previa

Answer

Breech presentation

Answer

Multi-fibroid uterus

Question 4

In deep transverse arrest with adequate pelvis, what is the best mode of delivery?

Accepted Answer

Kielland forceps

Answer

Cesarean section

Answer

Ventouse

Answer

Manual rotation followed by forceps

Question 5

Which of the following is an absolute indication for elective repeat caesarean section in a patient with previous caesarean delivery?

Accepted Answer

Previous classical incision

Answer

Placenta accreta spectrum

Answer

Failed TOLAC (Trial of Labor After Cesarean)

Answer

Uterine rupture/scar dehiscence

Question 6

Symphysiotomy is indicated in:

Accepted Answer

Contraction of outlet

Answer

Contraction of cavity

Answer

Contraction of brim

Answer

All of these

Question 7

A pregnant lady with persistent variable decelerations with cervical dilatation of 6 cm is planned for emergency LSCS. Which of the following is NOT done in management while preparing patient for surgery

Accepted Answer

Supine position

Answer

O2 inhalation

Answer

I.V. fluid

Answer

Foley catheterization

Question 8

In modern obstetrics, the internal podalic version is indicated in presence of:

Accepted Answer

Transverse lie of 2nd twin baby

Answer

Extended breech presentation

Answer

Transverse lie with obstructed labor

Answer

Cord prolapse with live baby

Question 9

All of the following are relative contraindications for vacuum extraction, EXCEPT:

Accepted Answer

Occipito-posterior position

Answer

Fetal coagulopathies

Answer

Face presentation

Answer

Extreme prematurity

Question 10

Vacuum extraction is CONTRAINDICATED in:

Accepted Answer

Premature babies

Answer

Heart disease

Answer

Microcephaly

Answer

Polyhydramnios

Operative Obstetrics — MCQs

Operative Obstetrics — MCQs

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