Operative Obstetrics Practice Questions

Q: An absolute indication of Cesarean Section is?

Cephalopelvic disproportion (CPD). **Explanation:** The correct answer is **Cephalopelvic Disproportion (CPD)**. In obstetrics, an **absolute indication** for a Cesarean Section (CS) refers to a clinical scenario where a vaginal delivery is physically impossible or poses an immediate, life-threatening risk to the mother or fetus. CPD occurs when there is a mismatch between the size of the fetal head and the maternal pelvic dimensions. Since the bony pelvis cannot expand and the fetal head cannot compress beyond a certain limit, vaginal delivery is mechanically impossible. **Analysis of Options:** * **A. Malpresentation:** This is a broad term. While some malpresentations (like transverse lie) require CS, others (like face presentation with mento-anterior position) can be delivered vaginally. Thus, it is a relative indication. * **B. Previous Cesarean Section:** This is a relative indication. Many women are candidates for **VBAC** (Vaginal Birth After Cesarean) provided the previous incision was a low-transverse segment and there are no recurring indications. * **D. Breech Presentation:** Most breech babies are delivered via CS for safety, but vaginal breech delivery is still an option in specific criteria (e.g., frank breech, adequate pelvis, multipara). **High-Yield Clinical Pearls for NEET-PG:** * **Absolute Indications for CS:** Grade IV Placenta Previa (Central), Contracted Pelvis (CPD), Pelvic tumors obstructing the birth canal, and Advanced Carcinoma Cervix. * **CPD Diagnosis:** It is often a retrospective diagnosis made when labor fails to progress despite adequate uterine contractions. * **Trial of Labor (TOL):** Contraindicated in cases of absolute CPD or prior classical CS.

Q: Abortion at 11 weeks of pregnancy can be done by:

Suction evacuation. **Explanation:** The management of abortion is categorized based on the gestational age. For the **first trimester (up to 12 weeks)**, surgical evacuation via **Suction Evacuation (Suction Curettage)** is the gold standard. At 11 weeks, the products of conception are small enough to be safely aspirated using a Karman’s cannula or a rigid suction tip under negative pressure. This method is preferred due to its high efficacy, speed, and lower risk of complications compared to medical induction at this specific stage. **Analysis of Incorrect Options:** * **B. Hypertonic Saline & C. Ethacridine Lactate:** These are methods used for **second-trimester** induction (typically 15–20 weeks). They act as abortifacients by causing fetal demise and stimulating uterine contractions (intra-amniotic or extra-amniotic instillation). They are not used in the first trimester as the amniotic sac is too small for safe instillation. * **D. Oxytocin:** While oxytocin causes uterine contractions, the first-trimester uterus has a **low density of oxytocin receptors**. Therefore, high-dose oxytocin is ineffective for inducing abortion at 11 weeks and carries a risk of water intoxication. **High-Yield Clinical Pearls for NEET-PG:** * **MVA (Manual Vacuum Aspiration):** Can be done up to 12 weeks (ideally <10 weeks) using a handheld syringe. * **EVA (Electric Vacuum Aspiration):** Preferred for 10–12 weeks due to consistent pressure. * **Medical Method (Mifepristone + Misoprostol):** Recommended up to 9 weeks (63 days) as per WHO/RCOG, though some protocols extend this to 12 weeks. * **Dilatation and Evacuation (D&E):** The preferred surgical method for the second trimester (13–24 weeks).

Q: A 32-year-old second gravida, who had a lower segment caesarean section (LSCS) in her first pregnancy, is admitted in labor. The fetus is in cephalic presentation, the head is engaged, and the estimated fetal weight is 3 kg. Uterine contractions are 2 per 10 minutes, and the fetal heart rate is 140 bpm. The cervical dilation is 5 cm. The vertex is felt 1 cm above the ischial spines, and the posterior fontanelle is palpable. The pelvis is adequate, and the membranes are intact. What is the best management option?

Perform an amniotomy and allow labor to progress. ### Explanation **Correct Option: A. Perform an amniotomy and allow labor to progress** The patient is a candidate for **Trial of Labor After Cesarean (TOLAC)**. She meets the favorable criteria: a single previous LSCS, cephalic presentation, adequate pelvis, and an estimated fetal weight <4 kg. She is already in the active phase of labor (5 cm dilation). In a patient with a scarred uterus, the preferred management is to allow spontaneous labor to progress under close monitoring. **Amniotomy (Artificial Rupture of Membranes)** is a safe intervention to augment labor naturally by increasing endogenous prostaglandin release and improving contact between the presenting part and the cervix. **Why other options are incorrect:** * **B. Oxytocin infusion:** While oxytocin can be used in TOLAC, it must be used with extreme caution due to the risk of **uterine rupture**. Since the patient is already progressing and has 2 contractions per 10 minutes, amniotomy should be the first step. Oxytocin is reserved for secondary arrest or inadequate contractions. * **C. Caesarean section:** There is no immediate indication for a repeat LSCS (ERCS). The fetal heart rate is stable, the pelvis is adequate, and labor is progressing. * **D. Ventouse delivery:** This is premature. Ventouse (vacuum) is an instrumental delivery method used in the **second stage** of labor. The patient is currently only 5 cm dilated (first stage). **Clinical Pearls for NEET-PG:** * **Success rate of VBAC:** Approximately 70–75% in selected cases. * **Contraindications for TOLAC:** Previous classical/T-shaped incision, previous uterine rupture, or more than two prior LSCS (relative). * **Monitoring:** The most reliable early sign of uterine rupture during TOLAC is **fetal heart rate abnormalities** (typically prolonged bradycardia), not abdominal pain. * **Bishop Score:** A score >6 is a favorable predictor for a successful VBAC.

Q: A primigravida at term pregnancy is in labor and on escalating doses of inj oxytocin. CTG shows persistent declarations after each contraction. On pelvic examination, the patient is fully dilated, the fetal vertex is positioned at station above 0 with caput. What is the best management?

Caesarean delivery. **Explanation:** The clinical scenario describes a primigravida in the second stage of labor (fully dilated) with signs of **fetal distress** (persistent late decelerations) and **failure of descent**. **1. Why Caesarean Delivery is correct:** The fetal vertex is at a **station above 0** (high head). In the presence of fetal distress, an operative vaginal delivery (Ventouse or Forceps) is strictly contraindicated unless the head is engaged (at least at station 0, preferably +2 or lower). Attempting an instrumental delivery at a high station is dangerous and constitutes "high forceps," which is obsolete in modern obstetrics. Furthermore, the presence of **caput** suggests a possible cephalopelvic disproportion (CPD) or malposition, making a safe vaginal delivery unlikely. Immediate Caesarean section is the safest mode to rescue the fetus. **2. Why other options are wrong:** * **A. Increase oxytocin:** Oxytocin is already at escalating doses. Increasing it further will worsen uterine hyperstimulation and exacerbate fetal hypoxia (late decelerations). * **B & C. Ventouse/Forceps:** These require the fetal head to be engaged (station 0 or below). Applying instruments at station above 0 carries a high risk of maternal trauma and fetal intracranial hemorrhage. **Clinical Pearls for NEET-PG:** * **Late Decelerations:** Indicate uteroplacental insufficiency; they are a "non-reassuring" CTG pattern requiring immediate action. * **Prerequisites for Instrumental Delivery:** Remember the mnemonic **FORCEPS**: **F**ully dilated, **O**cciput position known, **R**uptured membranes, **C**ephalic presentation/Contracted pelvis absent, **E**ngaged head (Station 0 or below), **P**ain relief, **S**pirit/Bladder empty. * **Station:** If the head is above the ischial spines (negative station), it is not engaged.

Q: In which surgical approach is the tube opened to remove the gestational products, then left unsutured?

Salpingostomy. **Explanation:** The correct answer is **Salpingostomy**. This surgical procedure is a conservative management technique for ectopic pregnancy, typically performed when the patient desires future fertility and the contralateral tube is damaged. 1. **Why Salpingostomy is correct:** In a salpingostomy, a longitudinal incision is made on the antimesenteric border of the fallopian tube over the site of the ectopic pregnancy. The products of conception are removed (often via suction or irrigation), and the incision is **left open to heal by secondary intention**. This minimizes scarring and potential tubal occlusion that might occur with suturing. 2. **Why other options are incorrect:** * **Salpingotomy:** This involves making an incision to remove the products of conception, but the incision is **primarily closed with sutures**. * **Salpingectomy:** This is the total or partial **removal of the fallopian tube**. It is the treatment of choice if the tube is ruptured, there is uncontrollable bleeding, or the patient has completed her family. * **Salpingorrhaphy:** This refers to the **suturing/repair** of a fallopian tube, usually following a traumatic injury or rupture. **High-Yield Clinical Pearls for NEET-PG:** * **Indication:** Conservative surgery (Salpingostomy/otomy) is preferred if the ectopic mass is <4 cm, unruptured, and the patient is hemodynamically stable. * **Monitoring:** After conservative surgery, serial **β-hCG levels** must be monitored weekly until they reach <5 mIU/mL to rule out **Persistent Trophoblastic Tissue** (occurs in ~5-10% of cases). * **Site:** The most common site for ectopic pregnancy is the **Ampulla** (also the most common site for salpingostomy). * **Risk:** There is a slightly higher risk of recurrent ectopic pregnancy in the same tube following salpingostomy compared to salpingectomy.

Q: Which drug is being administered?

Ethacrydine lactate (0.1%). ***Ethacrydine lactate (0.1%)*** - The **yellow color** of the solution is pathognomonic for **ethacrydine lactate (Rivanol)**, which is specifically used for **intra-amniotic instillation** in second-trimester MTP. - It works by causing **uterine contractions** and **cervical ripening** through prostaglandin release, with a dose of **0.1% solution** instilled into the amniotic cavity. *20% mannitol* - Mannitol is a **colorless, clear solution** used as an osmotic agent, not yellow like the solution shown. - Primarily used for **cerebral edema** and **increased intracranial pressure**, not for pregnancy termination procedures. *50% Urea* - Urea solution is also **colorless and clear**, lacking the characteristic yellow appearance seen in the image. - While used for intra-amniotic instillation, it requires **higher concentrations (20-25%)** and has largely been replaced by safer alternatives. *Misoprostol* - Misoprostol is administered as **oral tablets** or **vaginal suppositories**, not as an intravenous yellow solution. - It's a **prostaglandin E1 analog** used for cervical ripening and uterine contractions, but not given intra-amniotically.

Q: A G2P1L1 patient presents with active labor. Her cervix is 8 cm dilated; fetal head is at +2 station, with Meconium Stained Liquor (MSL+). A Type 2 deceleration is seen on the Non-Stress Test (NST). What is the next step in management?

Low Cesarean Section. ### Explanation The patient is in the **active phase of labor** with signs of **fetal distress**, indicated by Meconium Stained Liquor (MSL+) and **Type 2 decelerations** (late decelerations). Late decelerations are a hallmark of uteroplacental insufficiency and signify fetal hypoxia. **1. Why Low Cesarean Section (LSCS) is the correct answer:** The definitive management for fetal distress in the first stage of labor is immediate delivery. Although the fetal head is at +2 station, the **cervix is only 8 cm dilated**. For any instrumental vaginal delivery (Forceps or Vacuum) to be performed, the **cervix must be fully dilated (10 cm)**. Since the first stage of labor is not yet complete, an emergency LSCS is the fastest and safest way to deliver the fetus and prevent birth asphyxia. **2. Why other options are incorrect:** * **A & B (Vacuum/Forceps):** These are contraindicated because the cervix is not fully dilated. Attempting instrumental delivery through an undilated cervix can lead to cervical tears, maternal hemorrhage, and fetal trauma. * **D (Continue monitoring):** In the presence of Type 2 decelerations and MSL, "watchful waiting" is inappropriate as it risks permanent fetal neurological damage or stillbirth. **Clinical Pearls for NEET-PG:** * **Prerequisites for Instrumental Delivery (FORCEPS mnemonic):** **F**etus alive, **O**ptiput position known, **R**uptured membranes, **C**ervix fully dilated, **E**ngaged head, **P**elvis adequate, **S**ubstantial anesthesia/Bladder empty. * **Type 2 Decelerations:** Associated with fetal hypoxia; the nadir of the deceleration occurs *after* the peak of the contraction. * **Station +2:** Indicates the leading bony part of the fetal head is 2 cm below the ischial spines. While the head is engaged, the incomplete cervical dilatation remains the deciding factor for LSCS here.

Question 1

An absolute indication of Cesarean Section is?

Accepted Answer

Cephalopelvic disproportion (CPD)

Answer

Malpresentation

Answer

Previous Cesarean section

Answer

Breech presentation

Question 2

Abortion at 11 weeks of pregnancy can be done by:

Accepted Answer

Suction evacuation

Answer

Hypertonic saline

Answer

Ethacrynine lactate

Answer

Oxytocin

Question 3

A 32-year-old second gravida, who had a lower segment caesarean section (LSCS) in her first pregnancy, is admitted in labor. The fetus is in cephalic presentation, the head is engaged, and the estimated fetal weight is 3 kg. Uterine contractions are 2 per 10 minutes, and the fetal heart rate is 140 bpm. The cervical dilation is 5 cm. The vertex is felt 1 cm above the ischial spines, and the posterior fontanelle is palpable. The pelvis is adequate, and the membranes are intact. What is the best management option?

Accepted Answer

Perform an amniotomy and allow labor to progress

Answer

Perform an amniotomy and commence an infusion of oxytocin

Answer

Perform a caesarean section

Answer

Perform a ventouse delivery in the second stage

Question 4

A primigravida at term pregnancy is in labor and on escalating doses of inj oxytocin. CTG shows persistent declarations after each contraction. On pelvic examination, the patient is fully dilated, the fetal vertex is positioned at station above 0 with caput. What is the best management?

Accepted Answer

Caesarean delivery

Answer

Increase oxytocin infusion rate

Answer

Ventouse delivery

Answer

Outlet forceps delivery

Question 5

Which of the following is a contraindication to External Cephalic Version?

Accepted Answer

Hydramnios

Answer

Contracted pelvis

Answer

Antepartum hemorrhage

Answer

Multiple pregnancy

Question 6

In which surgical approach is the tube opened to remove the gestational products, then left unsutured?

Accepted Answer

Salpingostomy

Answer

Salpingotomy

Answer

Salpingectomy

Answer

Salpingorrhaphy

Question 7

Which drug is being administered?

Accepted Answer

Ethacrydine lactate (0.1%)

Answer

20% mannitol

Answer

50% Urea

Answer

Misoprostol

Question 8

Forceps are applied in all the following obstetric presentations except:

Accepted Answer

Brow presentation

Answer

Breech presentation

Answer

Face presentation

Answer

Occipitoposterior position

Question 9

Vacuum extraction is contraindicated in which of the following conditions?

Accepted Answer

Premature babies

Answer

Heart disease

Answer

Microcephaly

Answer

Polyhydramnios

Question 10

A G2P1L1 patient presents with active labor. Her cervix is 8 cm dilated; fetal head is at +2 station, with Meconium Stained Liquor (MSL+). A Type 2 deceleration is seen on the Non-Stress Test (NST). What is the next step in management?

Accepted Answer

Low Cesarean Section

Answer

Vacuum-assisted delivery

Answer

Forceps-assisted delivery

Answer

Continue monitoring and await spontaneous delivery

Operative Obstetrics — MCQs

Operative Obstetrics — MCQs

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