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OG14.1-3,OG15.1-2 | Abnormal and Operative Obstetrics — Practice Quiz
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A 26-year-old primigravida at 40 weeks gestation has been in active labour for 18 hours. On examination, the cervix is fully dilated but the fetal head remains at the level of ischial spines despite strong uterine contractions for the past 3 hours. The abdomen shows a palpable Bandl's ring at the level of the umbilicus. What is the most appropriate next step?
Correct. A high Bandl's ring (at or above umbilical level) with arrested descent despite adequate contractions indicates obstructed labour with impending uterine rupture. Immediate caesarean section is mandated. Augmentation, vacuum, or forceps would be dangerous and contraindicated.
Bandl's retraction ring at or above the umbilicus, combined with arrest of descent despite strong contractions, is a late sign of obstructed labour. Do NOT augment — proceed immediately to caesarean section.
Bandl's ring at umbilical level is a warning sign of obstructed labour. Augmentation with oxytocin in the presence of obstruction risks uterine rupture. Instrumental delivery requires the head to be at or below the ischial spines (station +2 or lower for vacuum). The only safe option is immediate caesarean section.
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Which of the following is the most common cause of obstructed labour in developing countries?
Correct. Contracted pelvis, often secondary to childhood nutritional rickets or malnutrition causing pelvic deformity, is the most common cause of obstructed labour in developing countries including India.
Contracted pelvis from childhood malnutrition (particularly rickets causing flat pelvis) is the most common cause of obstructed labour in low-resource settings. Fetal macrosomia is more common in high-resource settings.
While fetal macrosomia and malpresentations can cause obstruction, contracted pelvis from childhood malnutrition (rickets) is the leading cause in developing countries. Placenta praevia causes antepartum haemorrhage, not obstruction.
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A 32-year-old woman with a previous lower-segment caesarean section (LSCS) 2 years ago is now in labour at 38 weeks. She suddenly develops severe continuous lower abdominal pain, her uterine contractions cease, and the fetal heart rate drops to 80 bpm with variable decelerations. Vaginal examination reveals recession of the presenting part. What is the most likely diagnosis?
Correct. Recession (retraction) of the presenting part, cessation of contractions, continuous abdominal pain, and acute fetal bradycardia in a scarred uterus are classic features of complete uterine rupture. Emergency laparotomy is required.
Uterine rupture in a scarred uterus: cessation of previously good contractions + recession of presenting part + acute fetal distress. The scar may rupture insidiously — always have a high index of suspicion in VBAC labours.
The combination of cessation of contractions, recession of the presenting part, continuous abdominal pain (not colicky), and acute fetal distress in a woman with a previous CS scar is the hallmark of uterine rupture. Abruption causes tense, tender uterus with persistent contractions. Cord prolapse shows fetal bradycardia on VE. This triad points to rupture.
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A woman with unscarred uterine rupture is stabilised haemodynamically after emergency surgery. The surgeon finds a ragged lateral tear extending into the broad ligament with active arterial bleeding. The patient is 28 years old and desires future fertility. Which surgical option is most appropriate if the tear is repairable and haemostasis can be achieved?
Correct. In a young woman desiring fertility, if the tear is repairable (clean edges, no infected tissue, haemostasis achievable), uterorrhaphy with sterilisation is preferred over hysterectomy. Hysterectomy is reserved for uncontrollable haemorrhage, multiple tears, or infected uterus.
In uterine rupture, the choice between repair and hysterectomy depends on: extent of tear, haemostasis feasibility, presence of infection, patient's age and parity, and desire for future fertility. Young women with repairable tears get uterorrhaphy + BTL; unstable patients with severe damage get hysterectomy.
The principle in uterine rupture surgery is: if the tear is repairable and haemostasis is achievable, conserve the uterus in young women who desire fertility — repair + sterilise. Hysterectomy is the fallback when repair is not feasible. Internal iliac ligation alone is not definitive for arterial tears.
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A primigravida at 39 weeks presents in labour. Leopold's manoeuvres reveal a soft, irregular mass in the fundus and a round, hard mass in the lower pole. On vaginal examination, the examiner feels the sacrum, coccyx, and ischial tuberosities. Both thighs are extended against the abdomen with legs extended at the knees. What type of breech presentation is this?
Correct. Frank (extended) breech: hips flexed, knees extended — the legs lie along the fetal abdomen. Vaginal examination finds the bony sacrum/ischial tuberosities but no feet, as the legs are splinted against the fetal trunk. It is the most common type of breech (65-70%).
Breech types by knee position: Frank (extended) = hips flexed + knees extended (most common, ~65-70%); Complete (flexed) = hips and knees both flexed; Footling (incomplete) = one or both feet presenting first. Denominator for breech is the sacrum.
In frank/extended breech, hips are flexed and knees extended — feet are near the fetal face, not presenting. Complete/flexed breech has both hips and knees flexed (feels like a 'ball'). Footling breech has one or both feet presenting. The clue here is legs extended at knees against the abdomen.
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A woman is in active labour with an occipitoposterior (OP) position. Which of the following clinical features is most characteristic of OP malposition during labour?
Correct. OP malposition is characterised by severe persistent backache (occiput pressing on sacrum), prolonged labour (both first and second stages), and anterior cervical lip oedema from uneven pressure. Long second stage with maternal exhaustion is typical.
OP malposition triad: severe backache + prolonged labour (arrested second stage) + anterior lip of cervix oedema. OP is present in ~5% of labours at onset but most rotate spontaneously to OA. Persistent OP ('direct OP') requires rotational forceps, manual rotation, or CS.
OP position causes prolonged, painful labour — NOT short active phase. The occiput in the posterior position presses on the maternal sacrum causing severe backache. The deflexed head presents a larger diameter (occipitofrontal ~11 cm vs suboccipitobregmatic 9.5 cm), prolonging descent. Anterior cervical lip oedema from uneven fetal head pressure is characteristic.
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Which of the following is an absolute prerequisite for all instrumental vaginal deliveries (both vacuum and forceps)?
Correct. Full cervical dilatation (10 cm) is an absolute prerequisite for all instrumental vaginal deliveries. The other prerequisites include: vertex presentation, known fetal head position, engaged head (station ≥0 for forceps, station ≥0 for vacuum with +2 for outlet), adequate pelvis, empty bladder, and skilled operator.
Absolute prerequisites for instrumental delivery: full dilatation, vertex presentation, known position, engaged head, ruptured membranes, adequate pelvis, empty bladder, adequate analgesia, informed consent, operator skilled and prepared to abandon for CS.
Full cervical dilatation is the mandatory prerequisite — you cannot apply forceps or vacuum through an incompletely dilated cervix as it will lacerate the cervix. Station +3 is optimal for outlet forceps but not required for all instruments. Membranes need not be ruptured for a specific duration. Gestational age criterion is relevant but not an absolute GO/NO-GO for all cases.
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In vacuum extraction, where must the cup be placed for a correct application?
Correct. The flexion point is the critical landmark for vacuum cup placement — it lies approximately 3 cm anterior to the posterior fontanel, centred on the sagittal suture. Correct placement promotes flexion and reduces traction force needed, minimising scalp injury.
Flexion point = 3 cm anterior to the posterior fontanel, centred on the sagittal suture. Correct cup placement here promotes flexion, reduces required traction, and minimises complications. Any placement anterior to this (paramedian, sinciput) is a malposition of the cup.
The flexion point (not the fontanel itself) is the target for vacuum cup placement. It is approximately 3 cm anterior to the posterior fontanel on the sagittal suture. Placement over the anterior fontanel (sinciput application) is a deflexing maldirection that increases traction force and scalp trauma. The posterior fontanel landmark and the 3 cm anterior offset are both required to identify the correct site.
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A 30-year-old patient at 38 weeks requires external cephalic version (ECV) for a breech presentation. Which of the following is an absolute contraindication to ECV?
Correct. Placenta praevia is an absolute contraindication to ECV — manipulating the uterus risks catastrophic haemorrhage from the low-lying placenta. Other absolute contraindications include multiple pregnancy, ruptured membranes, and any indication for caesarean delivery.
ECV absolute contraindications: placenta praevia, multiple pregnancy, compromised fetal status, severe oligohydramnios, previous uterine surgery (in some guidelines), and any condition requiring CS. Relative contraindications include previous CS scar, oligohydramnios, and anterior placenta.
Anterior placenta is a relative caution (increases procedure difficulty), not an absolute contraindication. Oligohydramnios makes ECV more difficult and is a relative contraindication. Previous CS is a relative contraindication in some guidelines but not absolute. Placenta praevia is always an absolute contraindication because ECV could displace or shear the placenta causing massive haemorrhage.
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A mediolateral episiotomy is being performed. Which of the following describes the correct direction and length of the incision?
Correct. Mediolateral episiotomy: 45–60 degrees from the posterior midline (to avoid the anal sphincter), minimum 4 cm long (shorter incisions extend uncontrollably), cut at crowning with scissors. The midline technique has higher risk of sphincter extension (third/fourth degree tears).
Mediolateral episiotomy: direction = 45–60° from midline; length = ≥4 cm (never cut shorter); timing = at crowning (crowning = head visible at introitus, greatest perineal tension); instrument = sharp scissors (not scalpel). WHO 2018: selective use only, not routine.
Mediolateral episiotomy is directed 45–60 degrees from the midline, not parallel to the sphincter and not midline. It must be at least 4 cm — a short cut is more likely to extend in an uncontrolled direction. It is cut at crowning (head distending the perineum), not at the start of the second stage. Midline incisions have a higher rate of sphincter involvement.
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