Operative Obstetrics Practice Questions

Q: Cesarean section is preferred in which of the following conditions?

Herpes. **Explanation:** The primary goal of selecting the mode of delivery in viral infections is to prevent vertical transmission. **Why Herpes (HSV) is the correct answer:** Cesarean section (CS) is indicated in patients with **active genital herpes lesions** or prodromal symptoms (burning, itching) at the time of labor. This is because the risk of neonatal herpes—a devastating condition involving the CNS and disseminated organs—is highest (approx. 50%) during vaginal delivery through an infected birth canal, especially in primary infections. Elective CS significantly reduces this risk of transmission. **Why the other options are incorrect:** * **Toxoplasmosis:** Transmission is primarily **transplacental** (in utero). Mode of delivery does not significantly alter the risk of transmission; therefore, CS is not routinely indicated. * **Cytomegalovirus (CMV):** Like Toxoplasmosis, CMV is mostly transmitted **transplacentally** or via breast milk. While it can be found in vaginal secretions, CS has not been proven to prevent neonatal infection, making vaginal delivery the standard approach. * **Varicella Zoster Virus (VZV):** Maternal varicella near term poses a risk of neonatal varicella due to transplacental spread. Management involves administering VZIG to the neonate and acyclovir to the mother; CS is not indicated for preventing transmission. **High-Yield Clinical Pearls for NEET-PG:** * **Acyclovir Prophylaxis:** In women with recurrent HSV, oral acyclovir is typically started at **36 weeks gestation** to suppress outbreaks and reduce the need for CS. * **Timing:** If a patient has active lesions, CS should ideally be performed **before** rupture of membranes or within 4–6 hours of rupture. * **HIV & CS:** CS is indicated if the viral load is **>1,000 copies/mL** near delivery. * **Hepatitis B/C:** These are **not** indications for CS; vaginal delivery is safe.

Q: A 25-year-old primigravida is in labor. The second stage of labor has lasted for 1 hour after complete cervical dilatation. On examination, the leading point of the fetal skull is at +2 station, and rotation is 45 degrees. How should this case be managed?

Applying low forceps. This question tests the ability to classify forceps application based on the **American College of Obstetricians and Gynecologists (ACOG)** criteria, which is a high-yield topic for NEET-PG. ### **Explanation** The classification of forceps delivery is determined by the **station** and **rotation** of the fetal head: 1. **Why Option B is Correct:** According to ACOG, **Low Forceps** application is defined when the leading point of the fetal skull is at **station +2 or lower** (but not on the pelvic floor). In this case, the station is +2. Furthermore, low forceps are subdivided based on rotation: if rotation is ≤45°, it is a simple low forceps; if >45°, it is a rotation-requiring low forceps. Here, the rotation is exactly 45°, fitting the criteria perfectly. 2. **Why Option A is Incorrect:** **Outlet Forceps** require the fetal scalp to be visible at the introitus without separating the labia, the skull to have reached the pelvic floor, and the rotation to be ≤45°. A station of +2 is too high for an outlet application. 3. **Why Option C is Incorrect:** **Mid Forceps** are applied when the head is engaged but the leading point is above +2 station. These are rarely performed today due to high maternal and neonatal morbidity. 4. **Why Option D is Incorrect:** **High Forceps** (application before engagement) are obsolete and strictly contraindicated in modern obstetrics. ### **Clinical Pearls for NEET-PG** * **Station 0:** Head is at the level of the ischial spines (Engaged). * **Prerequisites for Forceps:** Remember the mnemonic **FORCEPS**: **F**etus alive, **O**pthalmic (membranes) ruptured, **R**ectum/Bladder empty, **C**ervix fully dilated, **E**ngaged head, **P**osition known, **S**ize (no CPD). * **Most common indication:** Prolonged second stage of labor (2 hours in primigravida without anesthesia). * **Most common complication:** Perineal tears (Maternal) and Facial nerve palsy (Neonatal).

Q: A 30-year-old primigravida presents with amenorrhea of 36 weeks, experiencing intermittent abdominal pain for 7 days. She has a history of Strassman's metroplasty. What is the best course of management?

Elective Cesarean section.. **Explanation:** The core clinical issue in this scenario is the history of **Strassman’s metroplasty**, a surgical procedure used to unify a bicornuate uterus by making a deep incision through the uterine fundus. **1. Why Elective Cesarean Section is Correct:** Strassman’s metroplasty involves a **full-thickness incision** into the uterine wall (transverse incision across the fundus). Similar to a classical Cesarean section or a deep intramural myomectomy, this surgery results in a significant uterine scar. During labor, the intense uterine contractions and the stretching of the lower segment/fundus pose a high risk of **uterine rupture**. To prevent this catastrophic complication, an elective Cesarean section is indicated before the onset of active labor (usually at 37–38 weeks). **2. Why Other Options are Incorrect:** * **Options A & C:** Induction of labor (prostaglandins) or augmentation (oxytocin) are strictly contraindicated. These agents increase uterine pressure and the intensity of contractions, which significantly elevates the risk of rupture at the site of the previous metroplasty scar. * **Option D:** Administering antispasmodics and discharging the patient is dangerous. Given her surgical history and the fact that she is at 36 weeks with abdominal pain, she requires close monitoring and a planned delivery rather than symptomatic relief. **Clinical Pearls for NEET-PG:** * **Strassman’s Metroplasty:** Used for Bicornuate uterus (Unification). * **Jones & Tompkins Metroplasty:** Used for Septate uterus (Excision/Incision). * **Uterine Rupture Risk:** Any surgery that enters the uterine cavity (except uncomplicated cervical cerclage or hysteroscopic resection) generally mandates a Cesarean delivery in subsequent pregnancies. * **Timing:** For patients with a high risk of rupture (like classical CS or metroplasty), elective CS is typically planned between **37 0/7 and 38 6/7 weeks**.

Q: A 37-year-old, gravid 2, with a previous lower segment caesarean section (LSCS) at 37 weeks gestation presents with a blood pressure of 150/100 mmHg and urine albumin++. On pelvic examination, the cervix is soft with 50% effacement, the station is -3, the pelvis is adequate, and the cervical os is closed. What is the most appropriate next step?

Perform a caesarean section.. **Explanation:** The patient is a 37-year-old G2 with a **previous LSCS** presenting at 37 weeks with **Preeclampsia** (BP 150/100 mmHg and proteinuria). The management of preeclampsia at term (≥37 weeks) is delivery. The choice of delivery method depends on the Bishop score and obstetric history. **Why Option D is Correct:** In this case, the patient has a **previous LSCS** and an **unfavorable cervix** (closed os, -3 station, 50% effacement). According to standard obstetric guidelines, induction of labor (IOL) in a patient with a scarred uterus and an unfavorable cervix significantly increases the risk of **uterine rupture** and has a high failure rate. Therefore, a repeat Caesarean Section is the safest and most appropriate management. **Why Other Options are Incorrect:** * **Option A & C:** Induction of labor is contraindicated or highly risky in a patient with a previous scar and an unfavorable cervix (Bishop score <6). Prostaglandins, often used for ripening, are generally avoided in VBAC (Vaginal Birth After Cesarean) due to the risk of rupture. * **Option B:** Observation is inappropriate. At 37 weeks with preeclampsia, the definitive treatment is delivery to prevent maternal and fetal complications (e.g., eclampsia, placental abruption). **Clinical Pearls for NEET-PG:** * **Term Preeclampsia:** Always deliver at 37 weeks regardless of severity. * **VBAC Criteria:** Favorable Bishop score is the most important predictor of success. An unfavorable cervix in a scarred uterus is a strong indication for repeat LSCS. * **Bishop Score:** Components include Dilation, Effacement, Station, Consistency, and Position of the cervix. A score ≤5 is considered unfavorable.

Q: What is the pressure created in a vacuum?

0.8 kg/cm2. **Explanation:** In operative obstetrics, the vacuum extractor (Ventouse) works on the principle of creating a negative pressure between the cup and the fetal scalp to facilitate traction. **1. Why 0.8 kg/cm² is correct:** To achieve effective traction and ensure the formation of a proper 'chignon' (artificial caput succedaneum), a negative pressure of **0.8 kg/cm²** (equivalent to 600 mmHg) is required. This pressure is reached gradually: initially, a vacuum of 0.2 kg/cm² is created to fix the cup, followed by increments of 0.1 kg/cm² every 2 minutes until the effective pressure of 0.8 kg/cm² is attained. This gradual increase prevents scalp trauma and ensures the cup is well-applied over the flexion point. **2. Analysis of Incorrect Options:** * **0.2 kg/cm² (Option B):** This is the **initial pressure** used to fix the cup to the scalp before increasing to the full therapeutic pressure. It is insufficient for actual traction. * **12 kgs and 18 kgs (Options A & D):** These represent units of **force/weight**, not pressure. While the maximum traction force exerted by a vacuum is roughly 10–12 kg (compared to 18–20 kg for forceps), the question specifically asks for the pressure setting on the gauge. **3. High-Yield Clinical Pearls for NEET-PG:** * **Flexion Point:** The cup should be placed over the flexion point (3 cm anterior to the posterior fontanelle along the sagittal suture). * **Chignon:** The artificial caput created by the vacuum; it usually subsides within 24 hours. * **Contraindications:** Vacuum is contraindicated in preterm babies (<34 weeks) due to the risk of subgaleal hemorrhage and in face/breech presentations. * **Safety Rule:** The "Rule of 3"—abandon the procedure if there are 3 pop-offs, 3 pulls with no descent, or 30 minutes of total application time.

Q: A 29-year-old female, G2 P1 A1, presents with 16 weeks of amenorrhea, lower abdominal pain, and vaginal bleeding. Ultrasonography shows a snowstorm appearance. What is the most feasible method of treatment?

Suction evacuation. ### Explanation **Diagnosis:** The clinical presentation of 16 weeks amenorrhea, vaginal bleeding, and the classic **"snowstorm appearance"** on ultrasonography is pathognomonic for a **Hydatidiform Mole (Molar Pregnancy)**. **Why Suction Evacuation is Correct:** Suction evacuation (suction curettage) is the **gold standard** and most feasible treatment for a molar pregnancy, regardless of the uterine size. It is preferred because it allows for rapid emptying of the uterus while minimizing the risk of uterine perforation and excessive hemorrhage, which are common risks associated with sharp curettage in these cases. **Why Other Options are Incorrect:** * **Misoprostol & Mifepristone (Medical Management):** These are contraindicated for primary evacuation of a mole. Medical induction increases the risk of heavy hemorrhage and, theoretically, the risk of **trophoblastic embolization** into the maternal venous circulation due to uterine contractions. * **Hysterectomy:** While hysterectomy is an option for women who have completed their family or are over 40 years old (to reduce the risk of post-molar gestational trophoblastic neoplasia), it is not the "most feasible" or first-line method for a 29-year-old G2 P1 who may desire future fertility. **Clinical Pearls for NEET-PG:** 1. **Pre-operative Prep:** Always check thyroid function tests (TFTs) as high hCG can cause **hyperthyroidism** (due to molecular mimicry with TSH). 2. **Theca Lutein Cysts:** Often seen on USG; these are benign and usually regress after evacuation. 3. **Follow-up:** Monitor weekly serum **β-hCG levels** until three consecutive negative results are obtained to rule out Gestational Trophoblastic Neoplasia (GTN). 4. **Rh Isoimmunization:** Rh-negative mothers must receive Anti-D immunoglobulin after evacuation.

Q: Which of the following is NOT an absolute indication for cesarean section in pregnancy?

Non-reassuring fetal heart rate (fetal distress). **Explanation:** In obstetric practice, indications for Cesarean Section (CS) are categorized into **Absolute** (where vaginal delivery is impossible or life-threatening) and **Relative** (where vaginal delivery may be possible but carries higher risk). **Why Option C is the correct answer:** **Non-reassuring fetal heart rate (NRFHR)**, commonly referred to as fetal distress, is a **relative indication**. While it often necessitates an emergency CS, it is not absolute because the mode of delivery depends on the **cervical dilatation and station**. If the cervix is fully dilated and the fetal head is low (at or below the ischial spines), an operative vaginal delivery (forceps or vacuum) is often faster and safer than a CS. **Analysis of Incorrect Options (Absolute Indications):** * **Advanced Carcinoma of the Cervix:** Vaginal delivery is contraindicated as it can lead to torrential hemorrhage, cervical tearing, and potential dissemination of cancer cells. * **Central Placenta Previa (Type IV):** The placenta completely covers the internal os. Any attempt at vaginal delivery will cause massive, life-threatening maternal hemorrhage. * **Contracted Pelvis:** When the pelvic dimensions are significantly reduced (e.g., Outlet contraction or severe Cephalopelvic Disproportion), the fetus physically cannot pass through the birth canal. **High-Yield Clinical Pearls for NEET-PG:** * **Other Absolute Indications:** Pelvic tumors obstructing the birth canal (e.g., large low-lying fibroid), Vasa Previa, and previous classical CS. * **Most common indication for CS overall:** Previous CS. * **Most common indication for primary CS:** Dystocia (failure to progress). * **Rule of Thumb:** If the question asks for an "absolute" indication, look for mechanical obstructions that make the vaginal route physically impossible.

Question 1

Cesarean section is preferred in which of the following conditions?

Accepted Answer

Herpes

Answer

Toxoplasmosis

Answer

Cytomegalovirus (CMV)

Answer

Varicella zoster virus

Question 2

A cesarean section was performed in the previous pregnancy. All of the following would be indications for an elective repeat cesarean section except?

Accepted Answer

Polyhydramnios

Answer

Breech presentation

Answer

Macrosomia

Answer

Post-term pregnancy

Question 3

A 25-year-old primigravida is in labor. The second stage of labor has lasted for 1 hour after complete cervical dilatation. On examination, the leading point of the fetal skull is at +2 station, and rotation is 45 degrees. How should this case be managed?

Accepted Answer

Applying low forceps

Answer

Applying outlet forceps

Answer

Applying mid forceps

Answer

Applying high forceps

Question 4

A 30-year-old primigravida presents with amenorrhea of 36 weeks, experiencing intermittent abdominal pain for 7 days. She has a history of Strassman's metroplasty. What is the best course of management?

Accepted Answer

Elective Cesarean section.

Answer

Induction of labor with prostaglandins after pelvic assessment.

Answer

Start oxytocin drip and monitor closely.

Answer

Administer antispasmodics and discharge the patient.

Question 5

A 37-year-old, gravid 2, with a previous lower segment caesarean section (LSCS) at 37 weeks gestation presents with a blood pressure of 150/100 mmHg and urine albumin++. On pelvic examination, the cervix is soft with 50% effacement, the station is -3, the pelvis is adequate, and the cervical os is closed. What is the most appropriate next step?

Accepted Answer

Perform a caesarean section.

Answer

Initiate antihypertensive therapy and then induce labor.

Answer

Observe for 10 days.

Answer

Induce labor spontaneously.

Question 6

What is the pressure created in a vacuum?

Accepted Answer

0.8 kg/cm2

Answer

12 kgs

Answer

0.2 kg/cm2

Answer

18 kgs

Question 7

Which of the following is true regarding salpingostomy?

Accepted Answer

It poses a higher risk of persistent trophoblastic tissue compared with salpingectomy.

Answer

Laparotomy is the preferred route.

Answer

It requires suture closure of the tubal incision with delayed-absorbable sutures.

Answer

It leads to lower future fertility rates in subsequent pregnancies.

Question 8

A 29-year-old female, G2 P1 A1, presents with 16 weeks of amenorrhea, lower abdominal pain, and vaginal bleeding. Ultrasonography shows a snowstorm appearance. What is the most feasible method of treatment?

Accepted Answer

Suction evacuation

Answer

Misoprostol administration

Answer

Hysterectomy

Answer

Mifepristone

Question 9

Which of the following is NOT an absolute indication for cesarean section in pregnancy?

Accepted Answer

Non-reassuring fetal heart rate (fetal distress)

Answer

Advanced carcinoma of the cervix

Answer

Central placenta previa

Answer

Contracted pelvis

Question 10

Classical Cesarean Section is not indicated in which of the following conditions?

Accepted Answer

Fibroid uterus

Answer

Lower segment-dense adhesions

Answer

Carcinoma of the cervix

Answer

Central placenta previa

Operative Obstetrics — MCQs

Operative Obstetrics — MCQs

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