Cesarean Section

Caesarean Section

Q. 1

A 37-year old second gravid, previous LSCS at 37 wks of pregnancy presents with blood pressure of 150/100, urine albumin++. On pelvic examination

cervix is found to be soft with 50% effacement, station is – 3, pelvis adequate and cervical os is closed. Most appropriate step at the moment would be

 A

Antihypertensive regime and then induce labour

 B

Wait and watch for 10 days

 C

Induce labour spontaneously

 D

Do caesarean section

Q. 1

A 37-year old second gravid, previous LSCS at 37 wks of pregnancy presents with blood pressure of 150/100, urine albumin++. On pelvic examination

cervix is found to be soft with 50% effacement, station is – 3, pelvis adequate and cervical os is closed. Most appropriate step at the moment would be

 A

Antihypertensive regime and then induce labour

 B

Wait and watch for 10 days

 C

Induce labour spontaneously

 D

Do caesarean section

Ans. D

Explanation:

Do cesarean section [Ref- Dutta 7/e p. 227-232, COGDT 10/e p. 32-25; Williams Ohs 23/e p. 729]

  • This is case of preeclampsia at 37 weeks.
  • For management purpose preeclampsia is divided into two categories i.e., mild preeclampsia and severe preeclampsia.
  • Severe and mild preeclampsia are managed differently.
  • But this categorization does not matter in this case because of the gestational age of the patient.

– “The gestational age of the patient is 37 weeks and any case of preeclampsia 37 weeks gestational age is delivered immediately irrespective of the severity of the preeclampsia”.

  • The main concern here is the mode of delivery

-The patient presents with unfavourable cervix and a history of previous LS.C.S.

– The best mode of delivery in such a patient with mild preeclampsia is performing an L.S.C.S.


Q. 2

Indications for caesarean section in pregnancy are all except ‑

 A

Eisenmenger syndrome

 B

Aortic stenosis

 C

M.R.

 D

Aortic regurgitaion

Q. 2

Indications for caesarean section in pregnancy are all except ‑

 A

Eisenmenger syndrome

 B

Aortic stenosis

 C

M.R.

 D

Aortic regurgitaion

Ans. A

Explanation:

Eisenmenger syndrome Eisenmenger’s syndrome

  • Maternal mortality rate in Eisenmenger’s syndrome is 30-40%

– Because of high maternal mortality rate patient should he counselled to avoid pregnancy and if pregnant consider termination of pregnancy.

– Because of high maternal mortality rate abortion is the t/t of choice.

If any pregnancy continues upto term in Eisenmenger’s syndrome, there is no evidence to support the choice of either vaginal or cesarean delivery.

  • Maternal mortality rate with normal delivery is 34% and with cesarean section is 75%.

Mitral regurgitation

  • Mitral regurgitation is usually tolerated well during pregnancy. The marked decrease in systemic vascular resistance that occurs during pregnancy alleviates the abnormal physiologic stress imposed by this lesion. Rarely, reactive pulmonary hypertension and severe right heart failure may ensue.
  • There are no specific recommendations for the management of mitral regurgitation during labour and delivery. Prior to labour, symptoms may be managed with diuretics and vasodilators. During labour, regional anaesthesia is usually well tolerated. However, in complicated NYHA class 3-4 cases, cesarean section and general anaesthesia may be required.

Aortic stenosis

  • In general the symptoms of aortic stenosis are masked by progressive left ventricular hypertrophy and are thus easily missed. Overall, patients who were asymptomatic prior to pregnancy usually tolerate pregnancy relatively uneventfully.
  • Echocardiographic determination of valve area is the best guide to severity of aortic stenosis. The hyperdynamic circulation of pregnancy frequently leads to overestimation of the degree of stenosis.
  • These patients tolerate tachycardia, hypovolaemia and systemic vasodilatation poorly, since coronary perfusion is critically dependent upon maintaining aortic diastolic pressure. General anaesthesia and caesarean section, with the aid of invasive haemodynamic monitoring, appears to be the safest means of successful delivery.

Aggressive maintenance of systemic blood pressure with vasopressors (e.g. phenylephrine), is paramount to the avoidance of severe hypotension, acute left ventricular failure and cardiac arrest.

  • Spinal anaesthesia is generally contraindicated in these patients. There are reports of the successful management of vaginal delivery under carefully introduced and limited epidural analgesia, but this should be restricted to very experienced hands.

Aortic regurgitation

  • Aortic regurgitation also reduces both cardiac output and coronary blood flow. Like M.R. it is well tolerated in pregnancy. The preferred mode of delivery in A.R. vaginal delivery unless obstetrical indications for cesarean exist. The crux is

i) Both Aortic regurgitation and mitral regurgitation are well tolerated during pregnancy. Vaginal delivery is the preferred mode of termination of pregnancy unless there are obstetrical indications for cesarean section.

ii) Aortic stenosis carries more risk than the above two disorders and the preferred mode of delivery is cesarean section.

iii)  Eisenmenger syndrome carries great risk in pregnancy. The maternal mortality reaches 50%. So, ideally pregnancy should be terminated in patients with Eisenmenger syndrome.

We are not sure, if we have got the correct question.


Q. 3

A patient undergoing caesarean section following prolonged labour under subarachnoid block developed carpopedal spasm. Lignocain was used as anesthetic agent. The most likely diagnosis is:

 A

Amniotic fluid embolism

 B

Lignocaine toxicity

 C

Hypocalcemia

 D

Hypokalemia

Q. 3

A patient undergoing caesarean section following prolonged labour under subarachnoid block developed carpopedal spasm. Lignocain was used as anesthetic agent. The most likely diagnosis is:

 A

Amniotic fluid embolism

 B

Lignocaine toxicity

 C

Hypocalcemia

 D

Hypokalemia

Ans. C

Explanation:

Pain due to prolonged labour may lead to hyperventilation and resultant respiratory alkalosis.

This will cause a decrease in the level of free ionized calcium in the ECF,

resulting in hypocalcemia and precipitating carpopedal spasm.

Ref: Primer on The Metabolic Bone Diseases and Disorders of Mineral Metabolism Edited By Clifford J. Rosen, 7th Edition, Page 354 ; Nutrition Therapy and Pathophysiology By Marcia Nahikian Nelms, 2007, Page 196 ; Essentials of Medical Pharmacology By KD Tripathi, 5th Edition, Page 479

Quiz In Between


Q. 4

A Lower Segment Caesarean section (LSCS) can be carried out under all the following techniques of anaesthesia, EXCEPT:

 A

General anaesthesia

 B

Spinal anaesthesia

 C

Caudal anaesthesia

 D

Combined Spinal Epidural anaesthesia

Q. 4

A Lower Segment Caesarean section (LSCS) can be carried out under all the following techniques of anaesthesia, EXCEPT:

 A

General anaesthesia

 B

Spinal anaesthesia

 C

Caudal anaesthesia

 D

Combined Spinal Epidural anaesthesia

Ans. C

Explanation:

Caudal anaesthesia may be used for perenial operations.

It is not indicated in Lower segment caesarian section.

 Further it is associated with potential risk of penetrating the fetal head in obstetric practice.

Ref:Textbook of Anaesthesia By Aitkinhead, 4th Edition, Pages 568, 641, 643


Q. 5

Absolute indication for caesarean section in pregnancy are all except?

 A

Advanced Carcinoma Cervix

 B

Central Placenta Praevia

 C

Non reassuring FHR (Fetal distress)

 D

Contracted Pelvis

Q. 5

Absolute indication for caesarean section in pregnancy are all except?

 A

Advanced Carcinoma Cervix

 B

Central Placenta Praevia

 C

Non reassuring FHR (Fetal distress)

 D

Contracted Pelvis

Ans. C

Explanation:

Non reassuring FHR is a Relative indication for C-section.


Q. 6

Which of the following is the contraindication for trial of normal labour after caesarean section?

 A

History of previous classical CS

 B

History of previous CS due to CPD

 C

No history of prior vaginal delivery

 D

History of previous CS due to malpresentation

Q. 6

Which of the following is the contraindication for trial of normal labour after caesarean section?

 A

History of previous classical CS

 B

History of previous CS due to CPD

 C

No history of prior vaginal delivery

 D

History of previous CS due to malpresentation

Ans. A

Explanation:

Prior classical or T-shaped uterine incisions are considered contraindications to labor.

The highest risks of uterine rupture are present with prior vertical incisions extending into the fundus such as the classical incision.

Women with a transverse scar confined to the lower uterine segment have the lowest risk of symptomatic scar separation during a subsequent pregnancy. 

Some Factors for Consideration in Selection of Candidates for Vaginal Birth after Cesarean Delivery (VBAC):
  • One previous prior low-transverse cesarean delivery
  • Clinically adequate pelvis
  • No other uterine scars or previous rupture
  • Physician immediately available throughout active labor capable of monitoring labor and performing an emergency cesarean delivery
  • Availability of anesthesia and personnel for emergency cesarean delivery
Ref: Cunningham F.G., Leveno K.J., Bloom S.L., Hauth J.C., Rouse D.J., Spong C.Y. (2010). Chapter 26. Prior Cesarean Delivery. In F.G. Cunningham, K.J. Leveno, S.L. Bloom, J.C. Hauth, D.J. Rouse, C.Y. Spong (Eds), Williams Obstetrics, 23e.

Quiz In Between


Q. 7

A primigravida at 37 week of gestation reported to labour room with central placenta previa with heavy bleeding per vaginum. The fetal heart rate was normal at the time of examination. Which of the following is the best management option for her?

 A

Caesarean section

 B

Expectant management

 C

Induction and vaginal delivery

 D

Induction and forceps delivery

Q. 7

A primigravida at 37 week of gestation reported to labour room with central placenta previa with heavy bleeding per vaginum. The fetal heart rate was normal at the time of examination. Which of the following is the best management option for her?

 A

Caesarean section

 B

Expectant management

 C

Induction and vaginal delivery

 D

Induction and forceps delivery

Ans. A

Explanation:

Since this patient in labour is having central type placenta previa with heavy vaginal bleeding, the most appropriate step in management is to conduct caesarean section.
 
Indications for caesarean section in placenta praevia are:
  • Severe degree placenta previa (type-II (marginal), type-III (incomplete or partial central), type-4 (central or total).
  •  Lesser degree of placenta previa where amniotomy fails to stop bleeding or fetal distress appears.
  • Complicating factors associated with lesser degrees of placenta previa where vaginal delivery is unsafe.

Vaginal delivery usually is reserved for patients with a marginal implantation and a cephalic presentation. If vaginal delivery is elected, the membranes should be artificially ruptured prior to any attempt to stimulate labor (oxytocin given before amniotomy is likely will cause further bleeding).

Ref: Textbook of Obstetrics By D.C. Dutta, 6th Edition, Pages 251-252 ; Scearce J., Uzelac P.S. (2007). Chapter 20. Third-Trimester Vaginal Bleeding. In A.H. DeCherney, L. Nathan (Eds), CURRENT Diagnosis & Treatment Obstetrics & Gynecology, 10e. 

Q. 8

Which of the following is an absolute indication for Caesarean section?

 A

Placenta Previa

 B

CPD

 C

Previous Cesarean section

 D

Breech presentation

Q. 8

Which of the following is an absolute indication for Caesarean section?

 A

Placenta Previa

 B

CPD

 C

Previous Cesarean section

 D

Breech presentation

Ans. B

Explanation:

Cephalopelvic disproportion is an absolute indication for Caesarean section. Other absolute indications includes central placenta praevia, pelvic mass causing obstruction (cervical or broad ligament fibroid), advanced cervical carcinoma and vaginal obstruction (as in atresia, stenosis).

Relative indications of Caesarean section are:
  • Previous caesarean delivery
  • Non reassuring FHR
  • Dystocia due to relatively large fetus, small pelvis or inefficient contractions
  • Antepartum hemorrhage
  • Malpresentation
  • Failed surgical induction of labour, failure to progress in labour
  • Bad obstetric history
  • Hypertensive disorders
  • Medical gynecological disorders
 
Ref: Textbook of Obstetrics By D.C Dutta, 6th edn, page 589

Q. 9

Which of the following is an indication of Caesarean section after a previous caesarean section?

 A

Hypertension

 B

Type 1 placenta previa

 C

CPD

 D

Multigravida

Q. 9

Which of the following is an indication of Caesarean section after a previous caesarean section?

 A

Hypertension

 B

Type 1 placenta previa

 C

CPD

 D

Multigravida

Ans. C

Explanation:

Indications of C section after a previous caesarean section includes: contracted pelvis, previous two casesarean sections, features of scar dehiscence and previous classical caesarean section.

Common indications of Caesarean section in a:
 
Primigravidae are: CPD, fetal distress, dystocia.
Multigravidae: Previous caesarean delivery, antepartum hemorrhage (placenta previa, placental abruption), and malpresentation.
 
Ref: Textbook of Obstetrics By D.C Dutta, 6th edn, page 589

Quiz In Between


Q. 10

In classical caesarean section more chances of rupture of uterus is in :

 A

Upper uterine segment

 B

Lower uterine segment

 C

Utero cervical junction

 D

Posterior uterine segment

Q. 10

In classical caesarean section more chances of rupture of uterus is in :

 A

Upper uterine segment

 B

Lower uterine segment

 C

Utero cervical junction

 D

Posterior uterine segment

Ans. A

Explanation:

Upper uterine segment


Q. 11

Best management in Mento-posterior presentation:

 A

Vaginal delivery

 B

Forceps delivery

 C

Manual rotation

 D

Caesarean section

Q. 11

Best management in Mento-posterior presentation:

 A

Vaginal delivery

 B

Forceps delivery

 C

Manual rotation

 D

Caesarean section

Ans. D

Explanation:

Caesarean section


Q. 12

Which of the following is an absolute indication for caesarean section in pregnancy associated with heart disease?

 A

Pulmonary stenosis

 B

Coarctation of aorta

 C

Eisenmenger syndrome

 D

Ebstein’s anomaly

Q. 12

Which of the following is an absolute indication for caesarean section in pregnancy associated with heart disease?

 A

Pulmonary stenosis

 B

Coarctation of aorta

 C

Eisenmenger syndrome

 D

Ebstein’s anomaly

Ans. B

Explanation:

Coarctation of aorta

Quiz In Between


Q. 13

True about transient tachypnoea of new born is

 A

Air bronchogram seen

 B

Common in preterm infants

 C

Interlobar fissure effusion

 D

Respiratory distress resolves in 6-10 days

Q. 13

True about transient tachypnoea of new born is

 A

Air bronchogram seen

 B

Common in preterm infants

 C

Interlobar fissure effusion

 D

Respiratory distress resolves in 6-10 days

Ans. C

Explanation:

Ans. is ‘c i.e., Interlobar fissure effusion


Q. 14

A 26 year old third_gravida mother delivered a male baby weighing 4-2 kg at 37 weeks of gestation through an emergency caesarean section, for obstructed labour. The child developed respiratory distress one hour after birth. He was kept nil per orally (NPO) and given intravenous fluids. He maintained oxygen saturation on room air. No antibiotics were given. Chest radiograph revealed fluid in interlobar fissure. Respiratory distress settled by 24 hours of life. What is the most likely diagnosis ?

 A

Transient tachypnea of the newborn

 B

Meconium aspiration syndrome

 C

Persistent fetal circulation

 D

Hyaline membrane disease

Q. 14

A 26 year old third_gravida mother delivered a male baby weighing 4-2 kg at 37 weeks of gestation through an emergency caesarean section, for obstructed labour. The child developed respiratory distress one hour after birth. He was kept nil per orally (NPO) and given intravenous fluids. He maintained oxygen saturation on room air. No antibiotics were given. Chest radiograph revealed fluid in interlobar fissure. Respiratory distress settled by 24 hours of life. What is the most likely diagnosis ?

 A

Transient tachypnea of the newborn

 B

Meconium aspiration syndrome

 C

Persistent fetal circulation

 D

Hyaline membrane disease

Ans. A

Explanation:

Ans. is ‘a’ i.e., Transient tachypnea of newborn

o Respiratory distress, which resolves within 24 hours without any respiratory support and fluid in interlobar fissure on chest X-ray suggest the diagnosis of TTN.


Q. 15

A 21 year old lady with a history of hypersensitivity to neostigmine is posted for an elective caesarean section under general anesthesia. The best muscle relaxant of choice in this patient should be:

 A

Pancuronium

 B

Atracurium

 C

Rocuronium

 D

Vecuronium

Q. 15

A 21 year old lady with a history of hypersensitivity to neostigmine is posted for an elective caesarean section under general anesthesia. The best muscle relaxant of choice in this patient should be:

 A

Pancuronium

 B

Atracurium

 C

Rocuronium

 D

Vecuronium

Ans. B

Explanation:

B i.e. Atracurium

You might be thinking that this Q has never been asked, but think a while and try to understand that around which concept the Q is based. In other words, they are trying to ask that which muscle relaxant will not require reversal? I think now you need no explanation 

– In pancuronium reversal is often required d/ t its longer duration of action

– Ve/Ro-curonium seldom require reversal unless repeated doses have been given

– In atracurium & cis-atracurium reversal is mostly not required due to its unique feature of spontaneous non eyzmatic degradation (Hoffmann elimination) Q.

Quiz In Between


Q. 16

A 30 year old woman with coarctation of aorta is admitted to the labour room for elective caesarean section. Which of the following is the anaesthesia technique of choice:

 A

Spinal anaesthesia

 B

Epidural anaesthesia

 C

General anaesthesia

 D

Local anaesthesia with nerve block

Q. 16

A 30 year old woman with coarctation of aorta is admitted to the labour room for elective caesarean section. Which of the following is the anaesthesia technique of choice:

 A

Spinal anaesthesia

 B

Epidural anaesthesia

 C

General anaesthesia

 D

Local anaesthesia with nerve block

Ans. C

Explanation:

C i.e. General anesthesia

In coarctation of aorta any decrease in cardiac output or cardiac return is deleterious to the fetus because the placental circulation is already comprised on account of coarctation. So any anesthetic procedure/drug which causes hypotension should be avoided.

Regional anaesthic procedure such as spinal anesthesia and epidural anesthesia should be avoidedQ in these patients because hypotension is the most common side effect of these procedure.

General anesthesia is technique of choiceQ for performing cesarian section in a patient with coarctation of aorta, as it has advantage of – rapid induction, better airway & ventilation and less hypotension.


Q. 17

A multigravida woman was posted for emergency caesarean section. Correct statements are all of the following except-           

September 2006

 A

Cricoid pressure is applied while intubating

 B

Isoflurane should not be used as it causes placental insufficiency

 C

CS is done to prevent fetal distress and meconiumm aspiration

 D

Cord clamping to be done after a few minutes

Q. 17

A multigravida woman was posted for emergency caesarean section. Correct statements are all of the following except-           

September 2006

 A

Cricoid pressure is applied while intubating

 B

Isoflurane should not be used as it causes placental insufficiency

 C

CS is done to prevent fetal distress and meconiumm aspiration

 D

Cord clamping to be done after a few minutes

Ans. B

Explanation:

Ans. B: Isoflurane should not be used as it causes placental insufficiency

General anaesthesia for CS:

It is given for fetal distress/if there is contraindication for spinal anaesthesia.

  • Prophylaxis against aspiration should be taken.
  • Intubation with Sellick’s manoeuvre (cricoid pressure)
  • Give drugs in minimum doses
  • Avoid premedication
  • Induction by thiopentone in minimum doses
  • All inhalational agent relax the uterus and cause post-partum hemorrhage in dose related manner.
  • Isuflurane is the agent of choice as it maintains the cardiac output thus minimally compromising the fetal circulation.

Q. 18

Absolute indication for caesarean section is:

March 2013

 A

Previous LSCS

 B

Type IV placenta previa

 C

Fetal distress

 D

Breech presentation

Q. 18

Absolute indication for caesarean section is:

March 2013

 A

Previous LSCS

 B

Type IV placenta previa

 C

Fetal distress

 D

Breech presentation

Ans. B

Explanation:

Ans. B i.e. Type IV placenta previa

Caesarean section

Indications of classical caesarean section

  • Previous classical cesarean section
  • Neglected shoulder with anhydramnios
  • Structural abnormality making approach to lower segment difficult
  • Constriction ring due to neglected labor
  • Fibroids in lower segment
  • Anterior placenta accreta and praevia
  • Very preterm fetus, where lower segment is poorly formed.

Quiz In Between


Q. 19

Ideal management of a 37 weeks pregnant elderly primigravida with placenta praevia and active bleeding:

September 2007

 A

Labour induction

 B

Caesarean section

 C

Vaginal delivery

 D

Expectant treatment

Q. 19

Ideal management of a 37 weeks pregnant elderly primigravida with placenta praevia and active bleeding:

September 2007

 A

Labour induction

 B

Caesarean section

 C

Vaginal delivery

 D

Expectant treatment

Ans. B

Explanation:

Ans. B: Caesarean Section

An initial assessment to determine the status of the mother and fetus is required.

It is now considered safe to treat placenta praevia on an outpatient basis if the fetus is at less than 30 weeks of gestation, and neither the mother nor the fetus are in distress.

Immediate delivery of the fetus may be indicated if the fetus is mature or if the fetus or mother are in distress. Blood volume replacement (to maintain blood pressure) and blood plasma replacement (to maintain fibrinogen levels) may be necessary.

In cases of fetal distress, associated complicating factors like malpresentation, elderly primigravidae, pregnancy with a previous caesarean section and contracted pelvis, a caesarean section is indicated.

Caesarean section is contraindicated in cases of disseminated intravascular coagulation.

Placenta praevia increases the risk of puerperal sepsis and postpartum haemorrhage because the lower segment to which the placenta was attached contracts less well post-delivery


Q. 20

Which of the following types of placenta complicates third stage of labour and is associated with a past history of caesarean section: 

September 2011

 A

Placenta succenturita

 B

Placenta extracholis

 C

Placenta membranecae

 D

Placenat accrete

Q. 20

Which of the following types of placenta complicates third stage of labour and is associated with a past history of caesarean section: 

September 2011

 A

Placenta succenturita

 B

Placenta extracholis

 C

Placenta membranecae

 D

Placenat accrete

Ans. D

Explanation:

Ans. D: Placenta accreta

Most important risk factors for placenta accreta are the placenta praevia and prior caesarean delivery It complicates 3rd stage of labour (haemorrhage, shock, infection and rarely inversion of the uterus) Other types of placenta:

  • Biscoidal placenta: Placenta have 2 discs
  • Lobed placenta: Placenta divided into lobes
  • Placenta succenturita: Small part of placenta separated from the rest
  • Febestrated: Placenta having a hole in centre
  • Circumvallate: Edge of placenta is covered by circular fold of decidualis

Q. 21

Incidence of scar rupture in previous lower segment caesarean section:         

March 2012

 A

1%

 B

5%

 C

6%

 D

7%

Q. 21

Incidence of scar rupture in previous lower segment caesarean section:         

March 2012

 A

1%

 B

5%

 C

6%

 D

7%

Ans. A

Explanation:

Ans: A i.e. 1%

Incidence of scar rupture in lower segment CS is less (0.5-1.5%) whereas there is more risk of scar rupture in classical CS (4-9%).


Q. 22

Risk of rupture of uterus with previous classical caesarean section is:           

March 2011

 A

0.5-1.5%

 B

2-4%

 C

4-8%

 D

8-16%

Q. 22

Risk of rupture of uterus with previous classical caesarean section is:           

March 2011

 A

0.5-1.5%

 B

2-4%

 C

4-8%

 D

8-16%

Ans. C

Explanation:

Ans. C: 4-8%

Classical caesarean section carries more risk of scar rupture (4-8%) Scar rupture in lower segment CS is less (0.5-1.5%)

Quiz In Between



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