Operative Obstetrics Practice Questions

Q: In an HIV-infected pregnant woman, when is an elective Cesarean section indicated?

If viral load is greater than 1000 copies/ml. The primary goal of managing HIV in pregnancy is to minimize **Mother-to-Child Transmission (MTCT)**. The mode of delivery is determined by the maternal viral load near the time of delivery (usually measured at 34–36 weeks). ### **Explanation of the Correct Answer** **Option C is correct** because a viral load **>1,000 copies/ml** is associated with a significantly higher risk of vertical transmission during vaginal delivery due to contact with infected cervicovaginal secretions and blood. In such cases, an **Elective Cesarean Section (ELCS)** performed at **38 weeks** (before the onset of labor or ROM) reduces the risk of transmission by avoiding the birth canal and minimizing fetal exposure to maternal fluids. ### **Analysis of Incorrect Options** * **Option A & B:** ELCS is not mandatory for everyone. If a woman is on Effective Antiretroviral Therapy (ART) and has an **undetectable or low viral load (<50–1,000 copies/ml)**, the risk of transmission is <1%, and a **planned vaginal delivery** is recommended. Parity (Primipara vs. Multipara) does not dictate the mode of delivery in HIV. * **Option D:** If Rupture of Membranes (ROM) occurs or labor starts, the protective benefit of a Cesarean section is rapidly lost. ELCS is specifically "elective" to avoid these events. ### **NEET-PG High-Yield Pearls** * **Timing of ELCS:** Performed at **38 weeks 0 days** to prevent spontaneous labor (unlike the standard 39 weeks). * **Zidovudine (AZT) Infusion:** Should be started 4 hours before ELCS if the viral load is >1,000 copies/ml or unknown. * **Procedures to avoid:** Artificial Rupture of Membranes (ARM), fetal scalp electrodes, and instrumental delivery (forceps/vaccum) should be avoided as they increase transmission risk. * **Post-exposure Prophylaxis (PEP) for Neonate:** Usually started within 6–12 hours of birth.

Q: What is the name of the maneuver performed for delivering the aftercoming head of a breech presentation?

Mauriceau-Smellie-Veit maneuver. **Explanation:** The **Mauriceau-Smellie-Veit maneuver** is the gold standard manual method for delivering the **aftercoming head** in a vaginal breech delivery. The primary objective is to promote **flexion** of the fetal head, which ensures the smallest diameters (suboccipitobregmatic) engage the maternal pelvis. In this maneuver, the fetus lies on the physician's forearm; the index and middle fingers are placed on the fetal malar bones (malar flexion), while the other hand applies pressure on the occiput to maintain flexion. **Analysis of Incorrect Options:** * **Lovset Maneuver:** Used for the delivery of the **extended arms** in breech presentation. It involves rotating the fetus 180° while maintaining downward traction to bring the posterior arm under the pubic symphysis. * **Burns Marshall Maneuver:** An alternative method for the aftercoming head where the baby is allowed to hang by its own weight to encourage flexion, then swung upward toward the mother’s abdomen. However, it is less preferred than Mauriceau-Smellie-Veit due to the risk of overextending the neck. * **Pinard’s Maneuver:** Used in **frank breech** to bring down the legs. It involves applying pressure to the popliteal fossa to flex the knee and abduct the thigh. **Clinical Pearls for NEET-PG:** * **Piper’s Forceps:** The most preferred instrument for delivering the aftercoming head (reduces intracranial hemorrhage risk). * **Prerequisite:** The aftercoming head must be delivered within **8 minutes** of the umbilicus appearing at the vulva to prevent fetal hypoxia. * **Zavanelli Maneuver:** Cephalic replacement used in shoulder dystocia (not breech).

Q: A 38-year-old woman, gravida 1, para 0, delivers an appropriate-for-gestational age infant by spontaneous vaginal delivery in the vertex position. The infant is noted to have edematous swelling of the soft tissue of the scalp that crosses the midline. What is the most likely diagnosis?

Caput succedaneum. **Explanation:** The clinical presentation describes **Caput succedaneum**, a common neonatal scalp condition [1]. The key diagnostic feature provided is edematous swelling that **crosses the midline (sutures)** [1]. 1. **Why Caput succedaneum is correct:** It is caused by pressure from the cervix or vaginal walls on the fetal head during labor, leading to venous congestion and accumulation of serosanguinous fluid in the subcutaneous tissue (above the periosteum). Because this fluid is located in the superficial soft tissue, it is not restricted by bone boundaries and thus crosses suture lines [1]. It is typically present at birth and resolves spontaneously within a few days [1]. 2. **Why other options are incorrect:** * **Cephalohematoma:** This is a collection of blood between the skull bone and the **periosteum** [1],[2]. Because the periosteum is fixed to the suture lines, the swelling **never crosses the midline** [1]. It often appears hours after birth and takes weeks to resolve [1],[2]. * **Subcutaneous fat necrosis:** This presents as firm, erythematous nodules or plaques on the skin, usually appearing days to weeks after birth, often following birth trauma or therapeutic cooling. * **Fracture of the skull:** While linear fractures can occur during delivery, they do not typically present as diffuse soft tissue swelling crossing sutures; they are often asymptomatic or associated with localized depression (ping-pong fracture). **High-Yield Clinical Pearls for NEET-PG:** * **Caput succedaneum:** Present at birth, crosses sutures, involves subcutaneous tissue [1]. * **Cephalohematoma:** Delayed onset, does **not** cross sutures, subperiosteal [1]. Risk of jaundice due to RBC breakdown [2]. * **Subgaleal Hemorrhage:** Bleeding between the aponeurosis and periosteum. It is a **surgical emergency** as it can lead to massive blood loss and shock. It also crosses sutures but is fluctuant and rapidly expanding.

Q: Which forceps is used for the aftercoming head in a breech delivery?

Piper forceps. **Explanation:** The correct answer is **Piper forceps**. In breech presentations, the delivery of the aftercoming head is a critical stage. Piper forceps are specifically designed for this purpose, featuring a **long shank with a perineal curve** (downward curve). This unique design allows the blades to be applied to the fetal head while the body of the baby is positioned above the level of the handles, preventing excessive extension of the fetal neck and protecting the head from sudden decompression. **Analysis of Incorrect Options:** * **Kielland's forceps:** These are specialized "rotational forceps" characterized by a minimal pelvic curve and a sliding lock. They are used for correcting asynclitism or rotating a head from an occipito-transverse/posterior position, not for breech. * **Wrigley's forceps:** These are short, light "outlet forceps." They are used for low-cavity or outlet deliveries when the head is on the perineum, often during Cesarean sections, but they lack the length and curve required for the aftercoming head. * **Kocher's forceps:** This is a surgical instrument (hemostat/clamp) used for grasping tissues or clamping vessels; it is not an obstetric forceps used for delivery. **High-Yield Clinical Pearls for NEET-PG:** * **Prerequisite:** For Piper forceps application, the fetal body must be held up by an assistant (the "Prague maneuver" is sometimes used in conjunction). * **Alternative:** The **Burns-Marshall method** and **Mariceau-Smellie-Veit maneuver** are manual techniques for delivering the aftercoming head. * **Key Feature:** Piper forceps lack a pelvic curve but possess a perineal curve to accommodate the fetal trunk.

Q: A previous cesarean section was performed. Which of the following is NOT an indication for an elective repeat cesarean section?

Polyhydramnios. **Explanation:** The decision for a Trial of Labor After Cesarean (TOLAC) versus an Elective Repeat Cesarean Section (ERCS) depends on the risk of uterine rupture and the likelihood of a successful vaginal birth. **Why Polyhydramnios is the correct answer:** Polyhydramnios (excess amniotic fluid) is **not** a contraindication to TOLAC. While it may cause uterine overdistension, it does not significantly increase the risk of uterine rupture in a patient with a previous lower segment cesarean section (LSCS) scar. Management typically involves monitoring for cord prolapse upon rupture of membranes, but it does not necessitate a repeat surgery. **Analysis of incorrect options:** * **Breech presentation:** A malpresentation in a scarred uterus is a standard indication for ERCS. The risks associated with vaginal breech delivery (e.g., head entrapment) combined with the risk of scar dehiscence make TOLAC unfavorable. * **Macrosomia:** An estimated fetal weight >4000g–4500g in a patient with a previous LSCS increases the risk of shoulder dystocia and uterine rupture due to cephalopelvic disproportion (CPD). Most guidelines recommend ERCS in these cases. * **Post-term pregnancy:** Pregnancies exceeding 41–42 weeks often require induction of labor. Induction (especially with prostaglandins) in a scarred uterus significantly increases the risk of rupture compared to spontaneous labor. Therefore, ERCS is often preferred. **High-Yield Clinical Pearls for NEET-PG:** * **Success Rate:** The success rate of Vaginal Birth After Cesarean (VBAC) is approximately **60–80%**. * **Uterine Rupture Risk:** The risk of rupture for a single previous transverse LSCS is **0.5–1%**, whereas for a classical (vertical) scar, it is **4–9%** (absolute contraindication for TOLAC). * **Prerequisite for TOLAC:** The previous surgery must have been a **lower segment** incision, and the current facility must have "emergency backup" for immediate surgery.

Question 1

In an HIV-infected pregnant woman, when is an elective Cesarean section indicated?

Accepted Answer

If viral load is greater than 1000 copies/ml

Answer

In all cases

Answer

In all primipara cases

Answer

Only in cases of premature rupture of membranes

Question 2

A primigravida presents at 41 weeks with premature rupture of membranes (PROM). On pelvic examination, the cervix is 3 cm dilated, and a fetal foot is palpated. The estimated fetal weight is 2.7 kg, and the fetal heart rate tracing is reactive. What is the recommended management for delivery?

Accepted Answer

Cesarean section

Answer

Vaginal delivery by breech extraction

Answer

Vaginal delivery after external cephalic version

Answer

Internal podalic version

Question 3

In cases of Intraventricular Dilation (IVD) with transverse arrest, which of the following procedures can be performed?

Accepted Answer

Craniotomy

Answer

Decapitation

Answer

Evisceration

Answer

Cesarean section

Question 4

On external cephalic version, fetal bradycardia occurred. What is the recommended next course of action?

Accepted Answer

Revert to the original position immediately by external version

Answer

Perform internal podalic version

Answer

Proceed with cesarean section

Answer

Rupture of membranes

Question 5

What is the name of the maneuver performed for delivering the aftercoming head of a breech presentation?

Accepted Answer

Mauriceau-Smellie-Veit maneuver

Answer

Lovset maneuver

Answer

Burns Marshall maneuver

Answer

Pinard's maneuver

Question 6

A 38-year-old woman, gravida 1, para 0, delivers an appropriate-for-gestational age infant by spontaneous vaginal delivery in the vertex position. The infant is noted to have edematous swelling of the soft tissue of the scalp that crosses the midline. What is the most likely diagnosis?

Accepted Answer

Caput succedaneum

Answer

Cephalohematoma

Answer

Subcutaneous fat necrosis

Answer

Fracture of the skull

Question 7

A primigravida with vertex presentation is having a fully dilated cervix. The head is well engaged and is at a station of +2. Fetal heart monitoring shows late decelerations. What is the most appropriate management in this situation?

Accepted Answer

Forceps application

Answer

Observation

Answer

Vacuum extraction

Answer

Immediate Caesarean section

Question 8

Which forceps is used for the aftercoming head in a breech delivery?

Accepted Answer

Piper forceps

Answer

Kielland's forceps

Answer

Wrigley's forceps

Answer

Kocher's forceps

Question 9

Trial of scar is contraindicated in all except?

Accepted Answer

Previous history of lower segment cesarean section with indication of malpresentation

Answer

History of previous classical cesarean section

Answer

History of previous cesarean section due to contracted pelvis

Answer

Previous 3 lower segment cesarean sections

Question 10

A previous cesarean section was performed. Which of the following is NOT an indication for an elective repeat cesarean section?

Accepted Answer

Polyhydramnios

Answer

Breech presentation

Answer

Macrosomia

Answer

Post-term pregnancy

Operative Obstetrics — MCQs

Operative Obstetrics — MCQs

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