Operative Obstetrics Practice Questions

Q: A 29-year-old primigravida presents at 36 weeks of gestation with a transverse lie. What is the recommended management?

Schedule cesarean delivery. ***Schedule cesarean delivery*** - A persistent **transverse lie** at 36 weeks makes vaginal delivery impossible and requires definitive management. - **Cesarean delivery** is the definitive and safest option for ensuring maternal and fetal well-being when the transverse lie persists. - While external cephalic version may be attempted first, if unsuccessful, contraindicated, or the lie remains transverse near term, cesarean section is mandatory. - Attempting vaginal delivery with transverse lie risks **cord prolapse**, **uterine rupture**, and **obstructed labor**. *Induce labor* - Inducing labor with a transverse lie is **absolutely contraindicated** due to impossibility of vaginal delivery. - The fetal shoulder or arm would present first, preventing engagement and causing **obstructed labor**. - High risk of **cord prolapse**, **uterine rupture**, and severe maternal-fetal complications. *Perform amniotomy* - **Amniotomy** (artificial rupture of membranes) with a transverse lie is extremely dangerous and contraindicated. - Significantly increases the risk of **cord prolapse** as membranes rupture without an engaged presenting part. - Would necessitate immediate cesarean delivery in emergency conditions, worsening outcomes. *Attempt external cephalic version* - While **external cephalic version (ECV)** can be attempted for transverse lie at 36-37 weeks, it has lower success rates (30-50%) compared to breech presentation. - However, the question asks for "recommended management" which refers to the **definitive management plan** - cesarean delivery remains the final recommendation when transverse lie persists. - ECV may be offered as an option to avoid cesarean, but has risks including **placental abruption**, **fetal distress**, and **failure** requiring cesarean anyway. - At 36 weeks with persistent transverse lie, planning for cesarean delivery is the safest definitive approach.

Q: B-Lynch suture is applied on?

Uterus. ***Uterus*** - The **B-Lynch suture** is a surgical technique involving the uterus to control **postpartum hemorrhage**. - It works by mechanically compressing the uterus, reducing blood flow, and promoting uterine contraction. *Cervix* - While sutures can be applied to the cervix (e.g., for **cervical cerclage**), the B-Lynch suture is specifically designed for uterine compression. - Cervical sutures are typically used for cervical insufficiency, not for acute postpartum hemorrhage from the uterine body. *Fallopian tubes* - Sutures on the fallopian tubes are typically related to procedures like **tubal ligation** or tubal repair, not for controlling uterine bleeding. - The fallopian tubes are not the primary site of bleeding in postpartum hemorrhage that the B-Lynch suture addresses. *Ovaries* - Sutures involving the ovaries are generally part of ovarian surgery, such as **cystectomy** or oophorectomy. - The B-Lynch suture is not indicated for bleeding originating from the ovaries.

Q: Dilatation & evacuation is done for all except?

Threatened abortion. ***Threatened abortion*** - In a threatened abortion, the cervix is **closed** with vaginal bleeding and abdominal pain, indicating a potential for the pregnancy to continue, making **dilation & evacuation (D&E)** unnecessary and potentially harmful. - The primary goal is to **preserve the pregnancy**, not to evacuate the uterine contents. - Management involves **bed rest, progesterone support**, and monitoring, not evacuation. *Inevitable abortion* - This condition involves an **open cervix**, with bleeding and uterine contractions, indicating that the abortion will proceed, and **D&E** is performed to complete the evacuation of uterine contents. - D&E helps to **prevent complications** like hemorrhage or infection once the abortion is confirmed to be in progress. *Incomplete abortion* - In an incomplete abortion, some **products of conception** remain in the uterus, and **D&E** is performed to remove these retained tissues. - This procedure is crucial to **prevent infection** and continued bleeding from retained placental fragments. *Missed abortion* - In missed abortion, the **fetus has died** but is retained in the uterus with a closed cervix and no expulsion. - **D&E** is indicated to evacuate the retained dead fetal tissue and prevent complications like **infection or coagulopathy**.

Q: Which of the following is an absolute indication for caesarean section?

Central placenta previa. ***Central placenta previa*** - This condition involves the **placenta completely covering the internal cervical os**, blocking the birth canal. - A vaginal delivery would lead to severe, life-threatening **hemorrhage** for both the mother and the fetus, making a C-section mandatory. *Breech presentation* - While many breech presentations are delivered by C-section, it is not an absolute indication. - In certain situations, such as **frank breech** with adequate maternal pelvis and experienced obstetrician, a **vaginal delivery can be attempted** after careful evaluation. *Bad obstetric history* - This refers to a history of adverse pregnancy outcomes, but it is a **relative indication** and not an absolute one for C-section. - The decision for C-section would depend on the **specific nature of the previous adverse outcomes** and current pregnancy complications. *Previous caesarean delivery* - A prior C-section is a very common indication for repeat C-section, but it is **not an absolute indication** for all subsequent deliveries. - Many women with a previous C-section can safely undergo a **trial of labor after cesarean (TOLAC)**, especially if the prior incision was a low transverse uterine incision.

Q: A pregnant patient, with a history of classical cesarean section in view of fetal growth retardation in the previous pregnancy, presents to you. She is currently at 35 weeks of gestation with breech presentation. What is the next step in management?

Cesarean section at 37 weeks. ***Cesarean section at 37 weeks*** - A history of **classical cesarean section** is an absolute contraindication to vaginal birth due to the high risk of **uterine rupture**. - Performing the cesarean section at 37 weeks, rather than waiting longer, minimizes the risk of spontaneous labor and rupture while ensuring fetal maturity. *Advice USG and visit after 2 weeks* - This option does not address the critical risk of **uterine rupture** due to the previous classical cesarean section. - Delaying definitive management by two weeks could increase the risk of spontaneous labor and associated complications. *Internal podalic version followed by vaginal delivery* - An **internal podalic version** is a procedure used to change fetal lie during labor, typically for the second twin, and it is **contraindicated** with a previous classical cesarean due to rupture risk. - Given the previous classical incision, a **vaginal delivery is unsafe** and should not be attempted. *External cephalic version at 36 weeks* - **External cephalic version (ECV)** is generally contraindicated in patients with a history of a **classical cesarean section** due to the increased risk of uterine rupture. - Even if successful, the patient would still require a cesarean section for delivery given the previous uterine scar.

Q: Uterine rupture is most common in -

Classical cesarean section. ***Classical cesarean section*** - A **classical cesarean section** involves a vertical incision in the uterine fundus, which heals less strongly and is more prone to rupture in subsequent pregnancies or labor due to the higher muscle content and poorer healing. - The **thinness and weaker scar tissue** in the fundus compared to the lower segment contribute significantly to the increased rupture risk. *Anterior lower segment C.S* - A **lower segment transverse incision** is the most common type of cesarean section today and has a significantly lower risk of uterine rupture (around 0.2-0.5%) compared to classical incisions. - This is because the lower uterine segment is thinner and contains less muscle, leading to a **stronger and more robust scar**. *Placenta previa* - While **placenta previa** is a serious obstetric complication that can cause massive hemorrhage, it is not directly associated with uterine rupture. - It involves the placenta covering the cervical os, leading to bleeding, but does not inherently weaken the uterine wall to cause rupture. *Normal labor* - Uterine rupture in an unscarred uterus during normal labor is extremely rare, often associated with factors like **grand multiparity**, improper use of oxytocin, or obstructed labor. - The intact uterine wall is generally resilient enough to withstand the forces of labor without rupturing spontaneously.

Q: Which nerve block is commonly used in forceps delivery?

Pudendal. ***Pudendal*** - A **pudendal nerve block** provides anesthesia to the perineum, vulva, and lower vagina, which is crucial for pain control during a **forceps delivery** and any necessary episiotomy or repair. - The pudendal nerve carries sensory innervation from the areas that are manipulated and stretched during instrument-assisted vaginal delivery. *Ilioinguinal* - The **ilioinguinal nerve** innervates the skin of the groin, labia majora, and upper inner thigh, making its block useful for procedures like **inguinal herniorrhaphy** but not for deep perineal pain in delivery. - It does not provide adequate pain relief for the extensive perineal and vaginal stretching required for a forceps delivery. *Genitofemoral* - The **genitofemoral nerve** innervates the skin of the mons pubis and labia majora (genital branch) and the upper anterior thigh (femoral branch), thus a block would be insufficient for a **forceps delivery**. - This nerve's distribution does not cover the primary areas of pain and manipulation during an instrumented vaginal delivery. *Posterior femoral* - The **posterior femoral cutaneous nerve** primarily provides sensory innervation to the skin of the posterior thigh and part of the gluteal region. - Blocking this nerve would not provide the necessary anesthesia for the **perineum and vagina** required during a forceps delivery.

Q: In which of the following scenarios is the risk of uterine rupture the least?

Lower segment incision. ***Lower segment incision*** - A **low transverse uterine incision** (often called a lower segment incision) is made in the thinnest, most contractile part of the lower uterine segment, which heals with a **stronger scar**. - This type of scar is less likely to rupture in subsequent pregnancies compared to other incision types. *Classic cesarean section* - A **classic cesarean section** involves a **vertical incision in the upper, contractile part of the uterus**, which heals less strongly due to its higher muscle content and greater stretching during subsequent pregnancies. - This incision carries the **highest risk of uterine rupture** in future pregnancies, often necessitating repeat cesarean deliveries. *Inverted T incision* - An **inverted T incision** is a variation of a classic cesarean, occurring when a low transverse incision tears vertically, or is intentionally extended vertically, leading to a **T-shaped scar**. - This type of incision creates a **compromised and weaker scar** that is at a higher risk of rupture in future pregnancies, similar to a classic cesarean. *Low vertical incision* - A **low vertical incision** is made in the lower uterine segment but is oriented vertically instead of transversally. - While it is generally less risky than a classic cesarean, it still carries a **higher risk of rupture** compared to a low transverse incision, as vertical scars are inherently weaker than transverse ones.

Question 1

A 29-year-old primigravida presents at 36 weeks of gestation with a transverse lie. What is the recommended management?

Accepted Answer

Schedule cesarean delivery

Answer

Induce labor

Answer

Perform amniotomy

Answer

Attempt external cephalic version

Question 2

A 32-year-old woman presents with a positive pregnancy test and a history of two previous cesarean sections. What is the most appropriate mode of delivery?

Accepted Answer

Elective repeat cesarean section

Answer

Vaginal birth after cesarean (VBAC)

Answer

Induction of labor

Answer

Trial of labor

Question 3

A 30-year-old woman with a history of cesarean section presents in labor. Fetal heart rate monitoring shows persistent late decelerations despite intrauterine resuscitation measures (maternal repositioning, oxygen, IV fluids, and discontinuation of oxytocin). What is the most appropriate management?

Accepted Answer

Immediate cesarean section

Answer

Continue monitoring

Answer

Amnioinfusion

Answer

Oxytocin administration

Question 4

B-Lynch suture is applied on?

Accepted Answer

Uterus

Answer

Cervix

Answer

Fallopian tubes

Answer

Ovaries

Question 5

Dilatation & evacuation is done for all except?

Accepted Answer

Threatened abortion

Answer

Inevitable abortion

Answer

Incomplete abortion

Answer

Missed abortion

Question 6

Which of the following is an absolute indication for caesarean section?

Accepted Answer

Central placenta previa

Answer

Breech presentation

Answer

Bad obstetric history

Answer

Previous caesarean delivery

Question 7

A pregnant patient, with a history of classical cesarean section in view of fetal growth retardation in the previous pregnancy, presents to you. She is currently at 35 weeks of gestation with breech presentation. What is the next step in management?

Accepted Answer

Cesarean section at 37 weeks

Answer

Advice USG and visit after 2 weeks

Answer

Internal podalic version followed by vaginal delivery

Answer

External cephalic version at 36 weeks

Question 8

Uterine rupture is most common in -

Accepted Answer

Classical cesarean section

Answer

Anterior lower segment C.S

Answer

Placenta previa

Answer

Normal labor

Question 9

Which nerve block is commonly used in forceps delivery?

Accepted Answer

Pudendal

Answer

Ilioinguinal

Answer

Genitofemoral

Answer

Posterior femoral

Question 10

In which of the following scenarios is the risk of uterine rupture the least?

Accepted Answer

Lower segment incision

Answer

Classic cesarean section

Answer

Inverted T incision

Answer

Low vertical incision

Operative Obstetrics — MCQs

Operative Obstetrics — MCQs

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