Operative Obstetrics Practice Questions

Q: Converting frank breech presentation into footling breech presentation within the upper birth canal is called

Decomposition. ***Decomposition*** - **Decomposition** is the correct obstetric term for the maneuver of converting a frank breech presentation into a footling breech presentation. - This involves bringing down one or both feet from the extended position, making them accessible for **assisted breech delivery**. - The term specifically refers to "breaking down" or altering the configuration of the breech presentation within the birth canal. - This maneuver is part of **breech extraction techniques** and may be performed during vaginal breech delivery. *Displacement* - **Displacement** in obstetrics typically refers to pushing the presenting part upward or to the side. - Commonly used in cases of **cord prolapse** where the presenting part is displaced to relieve cord compression. - It does not describe the conversion between different types of breech presentation. *Relaxation* - **Relaxation** is a general term referring to the absence of uterine contractions or muscular tension. - It does not describe any specific obstetric maneuver or presentation change. *Conversion* - **Conversion** is a broader term that can refer to changing one presentation to another (e.g., **external cephalic version** to convert breech to cephalic). - However, the specific technical term for converting frank breech to footling breech is **decomposition**, not conversion.

Q: Outlet forceps means:

Fetal head at or on the perineum (station +2 or more). ***Fetal head at or on the perineum (station +2 or more)*** - **Outlet forceps** is defined by the fetal head being at or on the **perineum** (station **+2 or +3**), meaning the scalp is visible at the introitus without separating the labia. - This represents the **lowest station** and is the **primary defining characteristic** that distinguishes outlet forceps from low or mid-forceps deliveries. - The fetal skull has reached the **pelvic floor**, and delivery is imminent with minimal traction required. *Full cervical dilatation* - While **full cervical dilatation** (10 cm) is indeed a **prerequisite** for any forceps application (outlet, low, or mid-forceps), it is **not the defining feature** of outlet forceps specifically. - This is a **basic requirement** for all operative vaginal deliveries to prevent cervical lacerations and ensure safe passage. *Rupture of membranes* - **Rupture of membranes** commonly occurs before forceps application but is **not a defining criterion** for outlet forceps. - Membranes are usually ruptured by this stage of labor, but this is not specific to outlet versus other types of forceps delivery. *Rotation > 45°* - Outlet forceps requires **rotation ≤ 45°**, meaning the fetal head should be in an **occiput anterior** or nearly anterior position (OA, ROA, LOA). - Rotation **> 45°** would classify the delivery as **low-forceps** or **mid-forceps**, not outlet forceps. - Minimal rotation is a characteristic of outlet forceps, making this option incorrect.

Q: Indications for cesarean hysterectomy are all except:

Couvelaire uterus. ***Couvelaire uterus*** - A **Couvelaire uterus** results from extensive **intramyometrial bleeding** due to severe **placental abruption** and typically **resolves spontaneously** without the need for hysterectomy. - While it looks alarming, the myometrium usually regains its tone, and hysterectomy is generally **not indicated** unless there is concomitant uncontrolled hemorrhage. *Rupture uterus* - A **ruptured uterus** is a life-threatening obstetric emergency often requiring immediate **cesarean section** and exploration. - Extensive or irreparable rupture, especially if associated with uncontrollable bleeding, is a strong indication for **cesarean hysterectomy** to save the mother's life. *Placenta accreta* - **Placenta accreta**, where the placenta abnormally adheres to the uterine wall, often results in severe hemorrhage at attempted delivery. - Due to the risk of massive bleeding from attempts to remove the placenta, **cesarean hysterectomy** is frequently the planned management to prevent maternal morbidity and mortality. *Atonic uterus with uncontrolled PPH* - **Uterine atony** is the most common cause of **postpartum hemorrhage (PPH)**, where the uterus fails to contract after delivery. - If conservative measures (e.g., uterine massage, uterotonic drugs) fail to control severe PPH from an atonic uterus, **cesarean hysterectomy** may be a life-saving intervention.

Q: In heart disease, prophylactic forceps are applied when the fetal head is at which station?

+2. ***+2*** - Prophylactic forceps are applied when the fetal head is at **+2 station** or lower to facilitate a **swift and controlled delivery**. - This approach minimizes the **maternal pushing effort** and associated cardiovascular strain in women with heart disease. *–1* - A fetal head at **–1 station** indicates that it is still relatively high in the birth canal. - Applying forceps at this station would be considered a **mid-forceps delivery**, which carries higher risks and is not typically used prophylactically in cardiac patients. *0* - A fetal head at **0 station**, or engaged, is at the level of the ischial spines. - While engagement is necessary for assisted delivery, applying prophylactic forceps at this station might still require prolonged effort, contradicting the goal of reducing maternal strain. *+1* - A fetal head at **+1 station** is slightly below the ischial spines. - While closer to delivery than 0 station, **+2 station** is preferred for prophylactic forceps to ensure the most efficient and least strenuous delivery.

Q: Forceps may be preferred over vacuum for operative delivery due to the following reasons, EXCEPT:

Vacuum requires more clinical skills than forceps. ***Vacuum requires more clinical skills than forceps*** - This statement is **incorrect** - vacuum extraction typically requires **less clinical skill** than forceps application - Forceps application demands precise knowledge of fetal head position, station, and careful maneuvering, requiring more training and expertise - Since vacuum actually requires less skill (not more), this is NOT a valid reason to prefer forceps over vacuum - **This is the correct answer to the EXCEPT question** *Forceps are more commonly associated with fetal facial injury* - This is **true** - forceps application involves direct compression and traction on the fetal head - This increases risk of **facial nerve palsies**, **bruising**, **lacerations**, and **skull fractures** - However, this is a **disadvantage** of forceps, not a reason to prefer them - Despite this, in certain clinical situations (e.g., need for rapid delivery, specific fetal positions), forceps may still be chosen when their advantages outweigh this risk *Vacuum has more chance of formation of cephalhematoma* - This is **true** - vacuum extraction creates suction on the fetal scalp, leading to blood accumulation under the periosteum - **Cephalhematoma** occurs more frequently with vacuum (10-20%) compared to forceps (1-2%) - This is a valid reason why forceps might be preferred when avoiding scalp trauma is important *Vacuum is preferred in certain cases to minimize trauma and reduce transmission risks* - This is **true** - vacuum causes less maternal perineal trauma compared to forceps - In cases of maternal infections (HIV, HSV), vacuum may reduce transmission risk due to fewer maternal lacerations - However, when rapid delivery is essential or specific fetal positions require rotation, forceps may still be chosen despite vacuum having these advantages

Q: 35 yr old primigravida conceived after IVF cycle attends obstetrics clinic with 38 weeks gestation. Her obstetric details reveal DiCho-DiAmn twins with 1st twin as breech. Her BP was 140/90 mmHg on 2 occasions with proteinuria +1. How will you manage this case?

Plan a cesarean for termination. ***Plan a cesarean for termination*** - This patient presents with **preeclampsia** (BP 140/90 mmHg on two occasions with proteinuria +1) at **38 weeks gestation**, making delivery appropriate. - The presence of **DiCho-DiAmn twins** with the **first twin in breech presentation** is a strong indication for **cesarean section** to ensure safe delivery and reduce complications. *Induction of labour* - While induction might be considered for preeclampsia, the **breech presentation of the first twin** in a twin pregnancy significantly increases the risks associated with vaginal delivery, making it less safe than a cesarean. - Given the combined risk factors, **cesarean delivery** is the more appropriate choice for optimizing maternal and fetal outcomes. *Watch for BP and induce for normal delivery on Expected Date of delivery* - Preeclampsia necessitates **delivery when the mother reaches 37 weeks or beyond**, not necessarily waiting until the Expected Date of Delivery, especially with other complicating factors. - Furthermore, attempting a **normal vaginal delivery** with a **breech presenting twin 1** carries high risks for both twins and is generally contraindicated. *Watch for BP and terminate (vaginal/ Cesarean) only when BP is normal.* - Delaying termination until blood pressure normalizes is not appropriate management for **preeclampsia** at term; delivery is the definitive treatment. - A persistent **breech presentation of twin 1** also makes vaginal delivery problematic, regardless of blood pressure status.

Q: A female with 40 weeks gestation progressed spontaneously and is currently for 2 hours in second stage of labor. She is having contractions 4 in 10 mins, fetal head is at +3 station, caput is present. What is the best management?

Outlet forceps. ***Outlet forceps*** - This is the **correct and most appropriate choice** as the fetal head is at **+3 station**, indicating it is at or on the **perineum** (essentially crowning). - By ACOG classification, outlet forceps are indicated when the scalp is visible at the introitus and the fetal skull has reached the pelvic floor. - With **2 hours in second stage** and adequate contractions, assisted delivery is indicated to prevent maternal exhaustion and fetal compromise. - The presence of **caput** suggests prolonged pressure, making timely assisted delivery appropriate. *Low forceps* - This would be indicated if the **leading bony point** of the fetal head is at **+2 station or lower** but the head has not yet reached the pelvic floor. - In this scenario, the head is already at +3 station (on the perineum), making this classification inappropriate. - Low forceps would be more interventionist than necessary given the favorable station. *Cavity forceps (Mid-forceps)* - This intervention is used when the fetal head is engaged but still within the **mid-pelvis**, typically between **0 station and +2 station**. - Given the head is at +3 station, the use of mid-cavity forceps, which requires deeper placement and carries significantly higher maternal and fetal risks, is completely unnecessary and inappropriate. *Ventouse (Vacuum extraction)* - While vacuum extraction could theoretically be considered, it is **less suitable in this scenario** due to the presence of **significant caput**. - Caput formation can lead to **higher failure rates with vacuum** as the device may slip off or fail to provide adequate traction. - At +3 station with caput, **outlet forceps is the preferred method** as it provides more secure grip on the fetal head and allows for controlled delivery. - Vacuum extraction has a higher rate of cephalohematoma and subgaleal hemorrhage, especially when significant molding or caput is present.

Q: During her third cesarean section, a 32-year-old woman has dense bladder adhesions. What should be done?

Careful dissection. ***Careful dissection*** - **Dense bladder adhesions** in a patient undergoing their third cesarean section necessitate meticulous and **careful dissection** to prevent injury to the bladder or other surrounding structures. - This approach minimizes complications and allows for successful completion of the hysterotomy and delivery. *Classical cesarean* - A **classical cesarean** involves a vertical incision in the uterus and is typically reserved for specific situations like **preterm breech presentation**, placenta previa, or difficult lower uterine segment access. - It results in a weaker scar and is not primarily indicated for **dense bladder adhesions**. *Abort surgery* - **Aborting surgery** is generally not an option in a patient requiring a cesarean section, as it would compromise both maternal and fetal well-being. - The goal is to safely deliver the baby, which requires proceeding with the surgery despite the challenges of adhesions. *Call urology* - While bladder injury can be a complication, the **initial management** of dense bladder adhesions during a cesarean section is typically performed by the obstetric surgeon through careful dissection. - Calling urology might be necessary for **repair of a bladder injury**, but not as the initial and immediate step for managing adhesions themselves, unless the surgeon feels the risk of injury is beyond their expertise.

Question 1

Converting frank breech presentation into footling breech presentation within the upper birth canal is called

Accepted Answer

Decomposition

Answer

Displacement

Answer

Relaxation

Answer

Conversion

Question 2

Outlet forceps means:

Accepted Answer

Fetal head at or on the perineum (station +2 or more)

Answer

Rupture of membranes

Answer

Rotation > 45°

Answer

Full cervical dilatation

Question 3

Indications for cesarean hysterectomy are all except:

Accepted Answer

Couvelaire uterus

Answer

Rupture uterus

Answer

Placenta accreta

Answer

Atonic uterus with uncontrolled PPH

Question 4

A 30-year-old multigravida presented with transverse lie with hand prolapse in 2nd stage of labour with dead fetus. The treatment is :

Accepted Answer

Decapitation

Answer

LSCS

Answer

Cleidotomy

Answer

Craniotomy

Question 5

In heart disease, prophylactic forceps are applied when the fetal head is at which station?

Accepted Answer

+2

Answer

-1

Answer

0

Answer

+1

Question 6

Forceps may be preferred over vacuum for operative delivery due to the following reasons, EXCEPT:

Accepted Answer

Vacuum requires more clinical skills than forceps

Answer

Forceps are more commonly associated with fetal facial injury

Answer

Vacuum has more chance of formation of cephalhematoma

Answer

Vacuum is preferred in certain cases to minimize trauma and reduce transmission risks

Question 7

Bleeding in rupture of the uterus associated with a large broad ligament hematoma is controlled most simply by :

Accepted Answer

Ligation of uterine artery

Answer

Ligation of hypogastric artery

Answer

Ligation of common iliac artery

Answer

Suture of laceration

Question 8

35 yr old primigravida conceived after IVF cycle attends obstetrics clinic with 38 weeks gestation. Her obstetric details reveal DiCho-DiAmn twins with 1st twin as breech. Her BP was 140/90 mmHg on 2 occasions with proteinuria +1. How will you manage this case?

Accepted Answer

Plan a cesarean for termination

Answer

Induction of labour

Answer

Watch for BP and induce for normal delivery on Expected Date of delivery

Answer

Watch for BP and terminate (vaginal/ Cesarean) only when BP is normal.

Question 9

A female with 40 weeks gestation progressed spontaneously and is currently for 2 hours in second stage of labor. She is having contractions 4 in 10 mins, fetal head is at +3 station, caput is present. What is the best management?

Accepted Answer

Outlet forceps

Answer

Low forceps

Answer

Cavity forceps

Answer

Ventouse

Question 10

During her third cesarean section, a 32-year-old woman has dense bladder adhesions. What should be done?

Accepted Answer

Careful dissection

Answer

Classical cesarean

Answer

Abort surgery

Answer

Call urology

Operative Obstetrics — MCQs

Operative Obstetrics — MCQs

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