Operative Obstetrics Practice Questions

Q: Absolute indication for LSCS is:

Complete placenta previa. ***Complete placenta previa*** - With **complete placenta previa**, the cervix is completely covered by the placenta, making a vaginal delivery impossible and leading to potentially life-threatening hemorrhage for both mother and fetus if attempted. - This condition presents an **absolute contraindication** to vaginal delivery, necessitating a **cesarean section** to deliver the fetus safely. *Previous LSCS* - A **previous lower segment cesarean section (LSCS)** is a common indication for a repeat LSCS, but it is not absolute; many women with a history of one prior LSCS can successfully undergo a **trial of labor after cesarean (TOLAC)**. - The decision depends on factors like the type of uterine incision, the reason for the prior cesarean, and the absence of other contraindications for vaginal birth. *Breech presentation* - While many **breech presentations** are delivered via LSCS, particularly for nulliparous women or with certain breech types (e.g., footling), it is not an absolute indication. - In selected cases, a **vaginal breech delivery** can be safely attempted under strict protocols and experienced supervision. *Mento-anterior face presentation* - A **mento-anterior face presentation** typically allows for a vaginal delivery as the neck is fully extended, and the smallest diameter of the head (the submentobregmatic) presents. - The mentum (chin) points anteriorly, allowing the head to flex at the pelvic outlet and deliver.

Q: Absolute indication for cesarean section is :

Previous rupture of uterus. ***Previous rupture of uterus*** - A prior **rupture of the uterus** creates a significant risk of **re-rupture** in subsequent pregnancies with labor contractions, posing a severe threat to both maternal and fetal life. - Due to the high risk of catastrophic hemorrhage and fetal distress, **elective cesarean section** before the onset of labor is mandated to prevent recurrence. *Breech presentation* - While many breech presentations result in a cesarean section, it is not an absolute indication, as **vaginal breech delivery** can be attempted in selected cases under strict criteria. - Factors like type of breech, estimated fetal weight, and maternal pelvis can influence the decision, making it a relative rather than an absolute indication. *Dystocia* - **Dystocia**, or difficult labor, is a common reason for cesarean section, but often interventions like **oxytocin augmentation** or **instrumental delivery** (forceps, vacuum) are attempted first. - A cesarean section is indicated when dystocia is severe or fails to respond to other measures, making it a relative indication based on progression of labor. *Fetal distress* - **Fetal distress**, indicated by non-reassuring fetal heart rate patterns, often necessitates prompt delivery, but the mode of delivery depends on the clinical situation. - If vaginal delivery is imminent and safe, it may be preferred, but if not, **cesarean section** is performed; therefore, it's an urgent relative indication rather than an absolute one.

Q: Which nerve block is given in forceps delivery?

Pudendal. ***Pudendal*** - A **pudendal block** anesthetizes the **perineum, vulva, and lower vagina**, providing pain relief for instrumental deliveries like **forceps delivery** and for episiotomy. - It involves injecting a local anesthetic near the **pudendal nerve** as it passes posterior to the **ischial spine**. *Posterior femoral* - The **posterior femoral cutaneous nerve** primarily innervates the skin of the posterior thigh and part of the perineum but does not provide sufficient deep analgesia for a forceps delivery. - Blocking this nerve alone would not adequately cover the extensive area affected during instrumental delivery. *Genitofemoral* - The **genitofemoral nerve** primarily innervates the skin of the upper medial thigh and parts of the genitalia but is not the primary nerve for pain relief during vaginal delivery procedures. - Its blockade would not provide the comprehensive analgesia needed for a forceps delivery. *Ilio inguinal* - The **ilioinguinal nerve** innervates the skin of the groin, mons pubis, and labia majora but does not provide sufficient anesthesia for the deeper structures involved in a forceps delivery. - An ilioinguinal nerve block is more commonly used for pain control in procedures involving the groin or hernia repair, not for instrumental vaginal delivery.

Q: Patient came with H/O prolonged labour (15 hrs) in emergency. On examination there were signs of obstructed labour. Ideal position for the patient to undergo the cesarean section?

Supine with wedge under right hip.. ***Supine with wedge under right hip*** - This position prevents **aortocaval compression** by the gravid uterus, which can lead to **supine hypotensive syndrome** and compromise placental perfusion. - The **left lateral tilt** achieved by the wedge under the right hip optimizes maternal hemodynamics and fetal oxygenation during C-section. *Trendelenburg with legs in stirrup* - This position is primarily used for procedures requiring better visualization of the **pelvic organs**, like gynecological surgeries or to facilitate venous return. - It would not prevent aortocaval compression and could exacerbate respiratory challenges in a pregnant patient. *Semi-Fowler position* - The semi-Fowler position is typically used for patients with **respiratory distress** to aid ventilation or during certain upper abdominal surgeries to improve surgical access. - It does not address the critical issue of aortocaval compression in a pregnant patient undergoing C-section. *Prone position with legs in stirrup* - The prone position is used for **posterior surgical approaches** to the spine or for procedures on the buttocks/perineum. - It is entirely inappropriate for a C-section, as it would make surgical access to the uterus impossible and pose significant risks to both mother and fetus.

Q: A patient underwent LSCS for arrest of second stage of labour. A lateral extension of an angle of uterine incision occurred during delivery of head which was secured. Post operatively after 2 hours patient develops pallor, abdominal distension with tachycardia. Hb dropped from 10 gm% (pre op) to 6.5 gm%. Pelvic exam revealed mild PPH. Next step in management is?

Immediate exploration in OT. ***Immediate exploration in OT*** - The patient presents with signs of **hypovolemic shock** (pallor, tachycardia, significant drop in Hb) and **abdominal distension** after a lateral extension of the uterine incision, which strongly suggests **internal bleeding**. - Given the rapid deterioration and suspicion of internal hemorrhage, **immediate surgical exploration** is crucial to identify and repair the bleeding source. *Blood transfusion and monitoring* - While a **blood transfusion** is essential for stabilizing the patient, it is not sufficient as the sole intervention in the presence of ongoing, significant internal bleeding. - **Monitoring** alone can delay definitive treatment, leading to further deterioration and potentially life-threatening complications. *Intrauterine packing and blood transfusion* - **Intrauterine packing** is primarily used for **uterine atony** or **diffuse uterine bleeding** within the uterine cavity. - In this case, the bleeding is likely due to the **extension of the uterine incision** into surrounding tissues (e.g., broad ligament, uterine artery), which will not be controlled by intrauterine packing. *Uterotonics for control of PPH and blood transfusion* - **Uterotonics** are effective for **uterine atony**, which is a common cause of **postpartum hemorrhage (PPH)**, but less likely to control bleeding from a lacerated vessel due to an incisional extension. - While PPH is mentioned, the context of the uterine incision extension and rapid progression of shock points to a **surgical bleeding site** that requires direct intervention, which uterotonics cannot address.

Q: Classical cesarean section is done in?

Carcinoma Cervix. ***Carcinoma Cervix*** - A classical cesarean section, involving a **vertical incision into the fundus of the uterus**, is performed in carcinoma cervix to avoid cutting through **malignant tissue** in the lower uterine segment or cervix. - This is an **absolute indication** to prevent **tumor dissemination** and seeding of malignant cells in the peritoneal cavity. - The incision is made in the upper segment, well away from the cervical pathology. *Placenta previa* - Placenta previa requires cesarean delivery, but a **low transverse uterine incision** (lower segment cesarean section) is the standard approach. - Classical cesarean is **not indicated** for placenta previa alone, as the lower segment can be safely accessed in most cases. - Only in exceptional circumstances (such as anterior placenta previa with poorly developed lower segment) might a classical approach be considered. *Previous cesarean* - A previous cesarean section is **not an indication** for classical cesarean in subsequent deliveries. - A **repeat low transverse cesarean section** or **trial of labor after cesarean (TOLAC)** is the standard approach. - Classical cesarean is only performed if the previous cesarean was classical (which increases rupture risk) and only when lower segment access is not feasible. *Extremely preterm delivery* - While extremely preterm delivery (typically **< 28 weeks**) may be a **relative indication** when the lower uterine segment is poorly developed, it is not an absolute indication. - In most cases, a **low vertical incision** or careful low transverse incision can be performed. - Classical incision is reserved for situations where lower segment access is truly inadequate, making this a **context-dependent** rather than absolute indication. - Compared to carcinoma cervix, this is a less definitive indication for classical cesarean section.

Q: All the following are indications of caesarean section EXCEPT:

Abruptio placenta. ***Abruptio placenta*** - While severe **abruptio placenta** with fetal distress often necessitates an expedited delivery via C-section, a **mild abruption** with a stable mother and fetus may be managed conservatively with vaginal delivery. The question asks for an exception, and not all abruptions automatically indicate C-section. - The decision depends on the **severity of the abruption**, maternal and fetal stability, and gestational age. *Type IV placenta previa* - **Type IV placenta previa**, also known as complete or central placenta previa, means the placenta completely covers the internal cervical os. - This condition is an **absolute indication for C-section** to prevent catastrophic hemorrhage for both mother and fetus during attempted vaginal delivery. *Active herpes genitalis* - **Active herpes genitalis** (visible lesions or prodromal symptoms) in labor is an indication for C-section to prevent vertical transmission of the **herpes simplex virus (HSV)** to the neonate. - Neonatal herpes can cause severe morbidity and mortality due to encephalitis and disseminated disease. *Untreated carcinoma cervix stage IB* - An **untreated carcinoma cervix stage IB** is an indication for C-section because vaginal delivery would likely cause significant hemorrhage and potential dissemination of cancer cells. - This also protects the mother from further trauma and allows for subsequent appropriate oncologic management.

Q: True statements about vacuum extraction of a fetus: (A) Can be used in incompletely dilated cervix (B) Used in Face presentation (C) Applied 3cm posterior to Anterior fontanel (D) Applied 3cm anterior to posterior fontanel

Applied 3cm anterior to posterior fontanel. ***Applied 3cm anterior to posterior fontanel*** - The vacuum cup should ideally be placed over the **flexion point** (median or paramedian application), which is approximately **3 cm anterior to the posterior fontanelle** and 6 cm posterior to the anterior fontanelle on the sagittal suture. - This position ensures optimal traction axis, promotes proper **fetal head flexion**, and facilitates safe and effective delivery. - Correct cup placement is crucial to prevent **scalp trauma** (caput succedaneum, cephalohematoma) and ensure successful extraction. *Can be used in incompletely dilated cervix* - Vacuum extraction is **contraindicated** when the cervix is not fully dilated (10 cm). - Attempting extraction with incomplete cervical dilation can lead to severe **cervical lacerations**, trauma, and hemorrhage. - Full cervical dilation is a **prerequisite** for safe vacuum-assisted delivery in standard obstetric practice. *Used in Face presentation* - Vacuum extraction is **contraindicated** in face presentation due to the risk of significant facial trauma and inability to achieve adequate traction. - Face presentation requires the mentum (chin) to be anterior for vaginal delivery; vacuum application can worsen the presentation or cause injury. - **Cesarean section** is often the preferred mode of delivery for persistent face presentations. *Applied 3cm posterior to Anterior fontanel* - Placing the cup 3cm posterior to the anterior fontanelle would be too **anterior** and away from the optimal flexion point. - This malposition can lead to **deflexion** of the fetal head, ineffective traction, failed extraction, and increased risk of scalp injury. - The cup should be more posteriorly placed over the flexion point for successful vacuum delivery.

Question 1

Absolute indication for LSCS is:

Accepted Answer

Complete placenta previa

Answer

Previous LSCS

Answer

Breech presentation

Answer

Mento-anterior face presentation

Question 2

Absolute indication for cesarean section is :

Accepted Answer

Previous rupture of uterus

Answer

Breech presentation

Answer

Dystocia

Answer

Fetal distress

Question 3

Which nerve block is given in forceps delivery?

Accepted Answer

Pudendal

Answer

Posterior femoral

Answer

Genitofemoral

Answer

Ilioinguinal

Question 4

Patient came with H/O prolonged labour (15 hrs) in emergency. On examination there were signs of obstructed labour. Ideal position for the patient to undergo the cesarean section?

Accepted Answer

Supine with wedge under right hip.

Answer

Semi-Fowler position

Answer

Prone position with legs in stirrup

Answer

Trendelenburg with legs in stirrup

Question 5

Which of the following steps has proven benefit in decreasing puerperal infection following cesarean section?

Accepted Answer

Administration of single dose of ampicillin or 1st generation cephalosporin at the time of cesarean

Answer

Non closure of peritoneum

Answer

Single layer uterine closure

Answer

Skin closure with staples than with suture

Question 6

Which of these is the ONLY true statement regarding Caesarean section?

Accepted Answer

Lower segment caesarean has lower risk of scar dehiscence in next pregnancy compared to classical

Answer

Exteriorisation of uterus for repair of uterine incision is detrimental step and hence avoided

Answer

Two layer closure of uterine incision is associated with significantly less risk of scar rupture

Answer

All incidental uterine fibroids should be excised during LSCS

Question 7

A patient underwent LSCS for arrest of second stage of labour. A lateral extension of an angle of uterine incision occurred during delivery of head which was secured. Post operatively after 2 hours patient develops pallor, abdominal distension with tachycardia. Hb dropped from 10 gm% (pre op) to 6.5 gm%. Pelvic exam revealed mild PPH. Next step in management is?

Accepted Answer

Immediate exploration in OT

Answer

Blood transfusion and monitoring

Answer

Intrauterine packing and blood transfusion

Answer

Uterotonics for control of PPH and blood transfusion

Question 8

Classical cesarean section is done in?

Accepted Answer

Carcinoma Cervix

Answer

Placenta previa

Answer

Previous cesarean

Answer

Extremely preterm delivery

Question 9

All the following are indications of caesarean section EXCEPT:

Accepted Answer

Abruptio placenta

Answer

Type IV placenta previa

Answer

Active herpes genitalis

Answer

Untreated carcinoma cervix stage IB

Question 10

True statements about vacuum extraction of a fetus:
(A) Can be used in incompletely dilated cervix
(B) Used in Face presentation
(C) Applied 3cm posterior to Anterior fontanel
(D) Applied 3cm anterior to posterior fontanel

Accepted Answer

Applied 3cm anterior to posterior fontanel

Answer

Applied 3cm posterior to Anterior fontanel

Answer

Used in Face presentation

Answer

Can be used in incompletely dilated cervix

Operative Obstetrics — MCQs

Operative Obstetrics — MCQs

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