Operative Obstetrics Practice Questions

Q: Uterine rupture is least common with which type of uterine incision?

Lower segment cesarean section (LSCS). **Explanation:** The risk of uterine rupture in a subsequent pregnancy is primarily determined by the **location and direction** of the previous uterine incision. **1. Why LSCS is the correct answer:** The Lower Segment Cesarean Section (LSCS) involves a **transverse incision** in the non-contractile, thinned-out lower uterine segment. This area undergoes minimal stretching and contraction during subsequent labor compared to the upper segment. Furthermore, the healing is superior due to less muscular interference, resulting in a rupture risk of only **0.2% to 1.5%**. This low risk makes a Trial of Labor After Cesarean (TOLAC) clinically feasible for many patients. **2. Why the other options are incorrect:** * **Classical Cesarean Section:** This involves a vertical incision in the **upper contractile segment** (the corpus). This area is thick, highly vascular, and undergoes intense contractions during labor. The scar is prone to rupture even before the onset of labor, with a high risk of **4% to 9%**. * **Inverted T and T-shaped Incisions:** These occur when a transverse lower segment incision is extended vertically into the upper segment (often due to difficulty in delivery or poor exposure). Because these incisions involve the contractile myometrium of the upper segment, they carry a high risk of rupture (approximately **4% to 9%**), similar to a classical section. **Clinical Pearls for NEET-PG:** * **Highest risk of rupture:** Classical incision (often occurs *before* labor). * **Lowest risk of rupture:** LSCS (transverse). * **Management:** Patients with a history of classical, T-shaped, or J-shaped incisions should undergo elective repeat cesarean section (ERCS) at 36-37 weeks, as TOLAC is contraindicated. * **Most common site of rupture in a scarred uterus:** Along the previous scar. * **Most common site of rupture in an unscarred uterus:** Lower segment.

Q: What procedure should be performed in case of aftercoming head arrest due to contracted pelvis in breech presentation?

Zavanelli maneuver. **Explanation:** The **Zavanelli maneuver** is the procedure of choice when the aftercoming head of a breech is trapped due to a contracted pelvis or cephalopelvic disproportion (CPD), and all other maneuvers (like Mauriceau-Smellie-Veit) have failed. It involves manually flexing the fetal head, rotating it back to an occiput-anterior position, and cephalic replacement into the uterus, followed by an emergency Cesarean section. While rare, it is the definitive step to resolve an irreducible entrapment in a live fetus. **Analysis of Incorrect Options:** * **Craniotomy (A):** This is a destructive procedure used to reduce the size of the fetal head. It is only performed on a **dead fetus** to facilitate delivery and avoid maternal trauma. * **Decapitation (B):** This destructive procedure is indicated in cases of **neglected shoulder presentation** with a dead fetus, not for aftercoming head arrest. * **Cleidotomy (C):** This involves the surgical division of one or both clavicles. It is used to reduce the biacromial diameter in cases of **shoulder dystocia** (cephalic presentation), not for the aftercoming head. **High-Yield Clinical Pearls for NEET-PG:** * **Piper’s Forceps:** The instrument of choice for the controlled delivery of the aftercoming head in breech. * **Burns-Marshall Maneuver:** Used when the baby is hanging by its own weight to deliver the head. * **Prerequisite for Zavanelli:** Tocolysis (e.g., Nitroglycerin or Terbutaline) is often required to relax the uterus before attempting replacement. * **Entrapped Head vs. Arrested Head:** If the head is trapped by a **constriction ring or undilated cervix** (not contracted pelvis), the treatment of choice is **Dührssen’s incisions** (at 2, 6, and 10 o’clock).

Q: Which of the following is NOT an operative procedure for uterine inversion?

Fentoni. **Explanation:** Uterine inversion is a life-threatening obstetric emergency where the uterine fundus collapses into the endometrial cavity. Management follows a stepwise approach: manual replacement (Johnson’s maneuver), followed by hydrostatic methods, and finally surgical intervention if conservative measures fail. **Why Fentoni is the correct answer:** **Fentoni’s procedure** is not a surgery for uterine inversion; it is a type of **perineal incision** (extension of an episiotomy) used to provide more space during difficult vaginal deliveries or to manage shoulder dystocia. It has no role in correcting a displaced uterus. **Analysis of incorrect options (Operative procedures for Inversion):** * **O’Sullivan’s Technique:** This is the **hydrostatic method**. It involves pumping warm saline into the vagina to create pressure that pushes the fundus back into its anatomical position. * **Haultain’s Procedure:** An **abdominal surgical approach**. A posterior incision is made through the cervical ring (constriction ring) to facilitate the repositioning of the fundus. * **Spinelli’s Procedure:** A **vaginal surgical approach**. It involves an anterior incision through the bladder fold and the cervical ring to reposition the uterus. (Note: **Huntington’s** is another abdominal procedure involving upward traction with Allis forceps). **NEET-PG High-Yield Pearls:** * **Immediate Step:** Stop oxytocin, call for help, and start aggressive fluid resuscitation. * **Drug of Choice for Relaxation:** Halothane (general anesthesia) or Nitroglycerin are used to relax the constriction ring for replacement. * **Shock in Inversion:** Often **neurogenic** initially (due to traction on the infundibulopelvic ligaments) before becoming hemorrhagic. * **Order of Management:** Johnson’s maneuver → O’Sullivan’s → Huntington’s/Haultain’s.

Q: Which of the following is a recurrent indication for cesarean delivery?

Pelvic deformity. ### Explanation The core concept behind this question is distinguishing between **recurrent** and **non-recurrent** indications for a Cesarean Section (CS). **Why Pelvic Deformity is Correct:** A **recurrent indication** is a permanent anatomical or physiological condition that persists from one pregnancy to the next, making a vaginal delivery consistently unsafe or impossible. **Pelvic deformity** (e.g., contracted pelvis due to rickets, osteomalacia, or previous pelvic fractures) is a structural abnormality. Since the bony architecture of the pelvis does not change between pregnancies, a patient with a pelvic deformity will require a repeat CS in all subsequent deliveries. **Analysis of Incorrect Options:** * **Breech presentation:** This is a **non-recurrent** indication. Malpresentation in one pregnancy does not mean the fetus will be breech in the next; most subsequent pregnancies will have a cephalic presentation. * **Placenta previa:** This is a transient placental implantation site specific to a single pregnancy. The risk of recurrence is low (approx. 4–8%), making it a **non-recurrent** indication. * **Fetal distress:** This is an acute, event-specific indication related to the fetal response to the labor process of a specific pregnancy. It is highly unlikely to recur under normal circumstances in a subsequent labor. **High-Yield Clinical Pearls for NEET-PG:** * **Common Recurrent Indications:** Contracted pelvis (CPD), pelvic tumors obstructing the birth canal, and previous classical CS (due to high risk of rupture). * **VBAC (Vaginal Birth After Cesarean):** Is generally considered for patients with one previous lower segment CS (LSCS) for a **non-recurrent** indication (like fetal distress or breech). * **Absolute Contraindication for VBAC:** Previous classical CS, previous hysterotomy, or any permanent pelvic obstruction.

Q: All of the following statements are true for episiotomies except?

Allows widening of the birth canal. **Explanation:** The correct answer is **A (Allows widening of the birth canal)**. This is a common misconception. An episiotomy is a surgically planned incision on the perineum and the posterior vaginal wall. While it facilitates the delivery of the fetal head by enlarging the **vaginal introitus (outlet)**, it does **not** widen the bony birth canal or the pelvic diameters. The dimensions of the birth canal are fixed by the maternal pelvis. **Analysis of other options:** * **Option B:** Episiotomies are classified based on the direction of the incision. The two most common types are **mediolateral** (most common in the UK/India to prevent sphincter damage) and **midline** (common in the US). * **Option C:** Perineal tears are graded 1 to 4. A **third-degree tear** specifically involves the external and/or internal anal sphincter complex. A fourth-degree tear involves the rectal mucosa. * **Option D:** **Midline episiotomies** have several advantages: they follow the natural fibrous raphe of the perineum, leading to less bleeding, easier anatomical repair, and faster healing with less dyspareunia compared to mediolateral incisions. However, they carry a significantly higher risk of extension into the anal sphincter. **NEET-PG High-Yield Pearls:** * **Timing:** Episiotomy should be performed during a contraction when the perineum is bulging and **3–4 cm of the scalp** is visible (crowning). * **Muscle involved:** The primary muscle cut in a mediolateral episiotomy is the **Bulbospongiosus** (and sometimes the superficial transverse perineal muscle). * **Nerve Block:** Usually performed under **Pudendal Nerve Block** or local infiltration. * **Current Practice:** Routine episiotomy is no longer recommended; restrictive/selective use is the current standard of care to prevent severe perineal trauma.

Q: A patient underwent suction evacuation for a 10-week pregnancy. Three days later, she presented with profuse vaginal bleeding and abdominal pain. What is the most likely diagnosis?

Retained products of conception. **Explanation:** The clinical presentation of delayed profuse vaginal bleeding and abdominal pain following a suction evacuation is a classic sign of **Retained Products of Conception (RPOC)**. **1. Why "Retained Products of Conception" is correct:** Suction evacuation aims to completely empty the uterine cavity. If placental or fetal tissue remains, the uterus cannot contract effectively to compress the spiral arteries (the "living ligatures"). This leads to secondary postpartum/post-abortal hemorrhage. The pain is caused by the uterus attempting to expel the retained tissue through rhythmic contractions. Symptoms typically manifest a few days after the procedure, as seen in this case. **2. Why other options are incorrect:** * **Uterine Atony:** This is the most common cause of *immediate* hemorrhage following evacuation. It rarely presents for the first time three days later. * **Cervical Injury:** Lacerations to the cervix cause bright red bleeding immediately during or after the procedure, not after a three-day asymptomatic interval. * **Uterine Perforation:** While a serious complication of suction evacuation, it usually presents acutely with severe abdominal pain, signs of internal hemorrhage (tachycardia, hypotension), or peritonitis. While it can cause bleeding, the delayed presentation with cramping is more characteristic of RPOC. **Clinical Pearls for NEET-PG:** * **Gold Standard Investigation:** Pelvic Ultrasound (USG) is the initial investigation of choice to identify an echogenic mass or thickened endometrial stripe. * **Management:** Re-evacuation (D&C) under antibiotic cover is usually required. * **Triad of RPOC:** History of recent uterine procedure + Vaginal bleeding + Open cervical os/enlarged boggy uterus. * **Prophylaxis:** Always check the aspirated tissue for "villous patterns" or "fetal parts" to ensure completeness of the procedure.

Question 1

Uterine rupture is least common with which type of uterine incision?

Accepted Answer

Lower segment cesarean section (LSCS)

Answer

Classical cesarean section

Answer

Inverted T-shaped incision

Answer

T-shaped incision

Question 2

What procedure should be performed in case of aftercoming head arrest due to contracted pelvis in breech presentation?

Accepted Answer

Zavanelli maneuver

Answer

Craniotomy

Answer

Decapitation

Answer

Cleidotomy

Question 3

Which of the following is NOT an operative procedure for uterine inversion?

Accepted Answer

Fentoni

Answer

O'Sullivan

Answer

Haultain

Answer

Spinelli

Question 4

Which statement is true regarding vacuum extractor use?

Accepted Answer

Minor scalp abrasions and subgaleal hematomas in the newborn are more frequent than with forceps.

Answer

It can be applied when the fetal head is above the level of the ischial spines.

Answer

Maternal trauma is more frequent than with forceps.

Answer

It cannot be used when the fetal head is not fully rotated.

Question 5

Which of the following is a recurrent indication for cesarean delivery?

Accepted Answer

Pelvic deformity

Answer

Breech presentation

Answer

Placenta previa

Answer

Fetal distress

Question 6

All of the following statements are true for episiotomies except?

Accepted Answer

Allows widening of the birth canal

Answer

Can be either midline or mediolateral

Answer

Involvement of the anal sphincter is classified as a third-degree perineal tear.

Answer

Midline episiotomies bleed less, are easier to repair, and heal more quickly

Question 7

A patient underwent suction evacuation for a 10-week pregnancy. Three days later, she presented with profuse vaginal bleeding and abdominal pain. What is the most likely diagnosis?

Accepted Answer

Retained products of conception

Answer

Uterine atony

Answer

Cervical injury

Answer

Uterine perforation

Question 8

Which of the following statements accurately describes the instrumental delivery system?

Accepted Answer

Ventouse (vacuum extraction) is used when forceps are not suitable or have failed.

Answer

Forceps are only used when the cervix is fully dilated.

Answer

Ventouse can be used in rotational deliveries for occipito-posterior and transverse presentations.

Answer

Forceps can be used in breech deliveries.

Question 9

A patient presents at 8 weeks of pregnancy with complaints of excessive vomiting, nausea, inability to tolerate oral intake, and decreased frequency of urination. What is the most appropriate management?

Accepted Answer

Admit, administer IV fluids, IV antiemetics, and monitor input/output

Answer

Pyridoxine plus doxylamine with plenty of oral fluids

Answer

Administer intravenous hydrocortisone

Answer

Administer intravenous promethazine

Question 10

Which of the following is NOT an indication for a classical cesarean section?

Accepted Answer

Breech presentation

Answer

Densely adhered bladder

Answer

Leiomyoma in the lower uterine segment

Answer

Back-down transverse fetal lie

Operative Obstetrics — MCQs

Operative Obstetrics — MCQs

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