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OG19.3,OG35.{15-18,20},OG36.3 | Core Procedural Skills — Graded Quiz
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A 35-year-old woman undergoes liquid-based cytology (LBC) as part of a cervical cancer screening programme. Her report returns: 'Negative for Intraepithelial Lesion or Malignancy; TZ type 3; no endocervical/metaplastic cells present.' What is the most appropriate next step?
Correct. A TZ type 3 transformation zone is located entirely within the endocervical canal and is not visible on speculum examination. The absence of endocervical/metaplastic cells indicates the TZ was not sampled. A Cytobrush is added to the Ayre's spatula at repeat sampling to ensure endocervical cells are collected.
TZ type 3 (fully endocervical) with absent endocervical cells = transformation zone not sampled. A Cytobrush must be added at repeat. This is distinct from an 'unsatisfactory' smear but represents a significant sampling limitation.
The critical issue here is TZ type 3 with absent endocervical cells — the transformation zone was not sampled. This is not a 'negative' smear in the clinically reassuring sense; it is an inadequate sample for the relevant at-risk zone. Colposcopy is not warranted for a negative cytology; routine recall ignores the sampling gap. Endocervical brushing must be added at repeat.
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A 42-year-old woman's Pap smear reports 'HSIL (High-grade Squamous Intraepithelial Lesion).' On colposcopy, the entire lesion is visible within the TZ and the squamocolumnar junction is fully visible. What is the most appropriate management?
Correct. A satisfactory colposcopy (entire TZ and SCJ visible) with HSIL cytology mandates directed punch biopsy to obtain histological confirmation (CIN 2 vs CIN 3 vs early invasion) before definitive excisional treatment. 'See and treat' without biopsy is only appropriate in limited circumstances.
HSIL on cytology: satisfactory colposcopy → directed biopsy for histology (CIN 2/3) → excisional treatment (LLETZ). Biopsy before excision is the standard unless 'see-and-treat' criteria are explicitly met.
HSIL cannot be managed by repeat cytology alone. Immediate excision without histological confirmation risks over-treatment if cytology over-called, and may miss invasion. Hysterectomy is not first-line for CIN. The correct pathway is colposcopy-directed biopsy → histological confirmation → excisional treatment (LLETZ/LEEP).
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A multigravida at 40 weeks is in active labour. The cervix is 7 cm dilated, the head is 1/5 palpable abdominally (well-engaged), and progress has been slow for 2 hours. The CTG is normal. ARM is performed. Immediately afterwards, the fetal heart rate drops to 70 bpm and a pulsatile cord is felt at the introitus. What is the most important immediate action?
Correct. This is cord prolapse — an obstetric emergency. The immediate priority is to relieve cord compression by manually elevating the presenting part off the cord (a gloved hand in the vagina) and placing the patient in knee-chest or exaggerated Sims' position. Immediate delivery (instrumental if cervix is fully dilated; caesarean otherwise) must be arranged simultaneously.
Cord prolapse after ARM: knee-chest position + manual elevation of presenting part + call for immediate emergency delivery. The delay between cord prolapse and delivery determines perinatal outcome.
Cord prolapse requires immediate action to relieve compression. Watchful waiting, cord replacement, or delayed surgery are all inappropriate. The presenting part must be manually elevated off the cord immediately while simultaneously arranging emergency delivery. Tocolysis may be used as an adjunct only if operative delivery is delayed.
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A mediolateral episiotomy was repaired 4 hours ago. The midwife notes a tense, fluctuant 5 cm swelling on the right side of the vulva that was not present at the time of repair. The patient has severe perineal pain. What is the most likely diagnosis and management?
Correct. A tense, fluctuant, painful vulval swelling appearing hours after repair is a haematoma — caused by unrepaired dead space (missed apex) or inadequate haemostasis of the incised vasculature. Small haematomas may be managed conservatively; expanding haematomas require surgical drainage, wound re-opening, haemostasis, and closure.
Vulval haematoma after episiotomy repair is caused by missed apex or inadequate haemostasis. Expanding haematomas require surgical drainage. Prevention: always identify and secure the apex of the vaginal incision at the start of repair.
Postpartum oedema is diffuse and not fluctuant. Dehiscence presents as wound opening, not a tense swelling. Cellulitis develops over 24–48 hours, not hours after repair. A tense, fluctuant, rapidly expanding swelling after episiotomy repair = haematoma requiring evaluation for surgical drainage.
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A nurse attempts urethral catheterisation in a postpartum patient. After two unsuccessful attempts, the catheter is coiled in the vagina both times. What is the most appropriate next step?
Correct. A catheter entering the vagina indicates the urethral meatus was not correctly identified. The urethra opens anterior to the vaginal introitus. Adequate lighting and labial retraction are required to visualise the meatus before re-attempting. If meatus identification remains difficult, a 'finger in vagina' technique provides a posterior guide.
Catheter entering the vagina = urethral meatus not correctly identified. Ensure adequate lighting, labial retraction, and patient positioning before re-attempt. The meatus is anterior to the vaginal introitus.
Forcing the catheter or using a dilator risks urethral injury. Abandonment is inappropriate if the patient cannot void (postpartum urinary retention is a significant risk). The correct approach is methodical re-identification of the urethral meatus with good lighting and labial retraction before any further attempt.
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A 32-year-old parous woman had a CuT 380A inserted 3 years ago. She presents because she cannot feel the strings on self-examination. Urine pregnancy test is negative. What is the most appropriate initial investigation?
Correct. Absent IUCD strings with a negative pregnancy test should prompt transvaginal ultrasound as the first investigation. TVUS can confirm whether the device is correctly sited within the uterine cavity (strings coiled within os is a common finding) or identify malposition/expulsion.
Absent IUCD strings + negative pregnancy test: TVUS first. TVUS confirms intrauterine position (strings coiled within cervical canal), malposition, perforation, or expulsion. Plain X-ray is reserved for when TVUS cannot locate the device and perforation/ectopic device is suspected.
CT delivers significant radiation and is not first-line. Pelvic X-ray can identify a displaced device but cannot determine intrauterine position relative to cavity anatomy and exposes the patient to radiation unnecessarily. Laparoscopy is invasive and premature. TVUS is accurate, non-invasive, and the correct first step.
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A 25-year-old woman presents 5 days after unprotected intercourse requesting emergency contraception. She has no absolute contraindications to IUD insertion. What is the most effective method available to her?
Correct. The copper IUCD is the most effective emergency contraceptive available, with a failure rate below 0.1% when inserted within 5 days (120 hours) of unprotected intercourse. It is more effective than any available emergency contraceptive pill, including ulipristal acetate and levonorgestrel.
Copper IUCD is the gold-standard emergency contraceptive (failure rate <0.1%, effective up to 5 days). It also provides ongoing long-acting contraception. Offer it as first choice when there are no contraindications and the patient presents within 5 days.
Levonorgestrel pills are effective up to 72 hours with declining efficacy. Ulipristal extends to 120 hours with better efficacy than LNG but is still inferior to the copper IUCD. Mifepristone at 10 mg is not approved as emergency contraception in India. The copper IUCD has the highest efficacy of all emergency contraceptive options.
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During a laparoscopic tubal ligation using bipolar coagulation, the surgeon asks you what the minimum length of tube that should be coagulated to ensure effective occlusion. Which answer best reflects accepted standards?
Correct. Bipolar coagulation technique requires coagulation of at least 3 cm of the fallopian tube at the isthmic segment in two or more adjacent burns to achieve effective occlusion and minimise the risk of failure from partial coagulation.
Bipolar coagulation tubal ligation: coagulate at least 3 cm of the isthmus at 2–3 adjacent sites. Single-site coagulation increases failure rates. The isthmus is the preferred segment — it is the narrowest portion and the most reliably identified.
Single-site 1 cm coagulation has an unacceptably high failure rate. Coagulating the entire tube is unnecessary and increases pelvic adhesion risk. Ampullary coagulation is not the standard technique. Three centimetres of isthmic coagulation in adjacent sites is the accepted standard for bipolar technique.
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A 34-year-old woman undergoes minilaparotomy tubal ligation using modified Pomeroy technique. On the third postoperative day she develops fever (39°C), abdominal rigidity, and ileus. Which early intraoperative complication is most likely responsible?
Correct. Fever with abdominal rigidity and ileus on postoperative day 3 is a peritonitis presentation, most consistent with delayed presentation of an unrecognised bowel injury (thermal spread from diathermy or direct trocar/scissor injury). This is a surgical emergency.
Delayed peritonitis after tubal ligation suggests unrecognised bowel injury — particularly from diathermy thermal spread (may manifest 48–72 hours later as the coagulated wall sloughs). This is the most serious complication of laparoscopic sterilisation and requires emergency surgical re-exploration.
Suture reaction produces wound inflammation, not generalised peritonitis. Normal post-laparotomy response does not include fever, rigidity and ileus on day 3. Tubal ligation does not affect hormonal status. Peritonitis with ileus = suspect bowel injury, particularly delayed thermal bowel injury from diathermy spread.
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Following colposcopy-directed punch biopsy at 3 o'clock position on the cervix, brisk bleeding persists despite direct pressure for 5 minutes. What is the most appropriate haemostatic measure?
Correct. Monsel's solution (ferric subsulphate) is the standard topical haemostatic agent for cervical biopsy bleeding. It is applied directly to the biopsy site with a swab under colposcopic visualisation and achieves haemostasis rapidly in the majority of cases.
Monsel's solution (ferric subsulphate) is the standard haemostatic agent for cervical punch biopsy bleeding. It is applied under colposcopic visualisation. Alternatives include silver nitrate, but Monsel's is preferred for its efficacy and minimal tissue damage.
Vaginal packing and theatre represent significant over-escalation for punch biopsy bleeding. Suturing the cervix is technically difficult and unnecessary for biopsy-site bleeding in the outpatient setting. Silver nitrate may cause tissue necrosis and interfere with healing. Monsel's solution is the appropriate first-line haemostatic agent for cervical biopsy.
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A 26-year-old primigravida at 38+2 weeks is being induced with oxytocin for gestational hypertension. Contractions are every 3 minutes. The cervix is 3 cm dilated and 80% effaced. The presenting part is 2/5 palpable abdominally. ARM is considered to accelerate labour. What is the MOST important assessment before proceeding?
Correct. Before ARM, vaginal examination must exclude cord presentation, cord loops, or a compound presentation (limb alongside the head). Even with a 2/5 palpable head (engaged), cord presentation can exist alongside a cephalic presentation. An occult cord presenting part would prolapse immediately with ARM.
Always perform a vaginal examination immediately before ARM to exclude cord presentation or a compound presentation, even when the head appears engaged abdominally. Occult cord prolapse is the most feared immediate complication of ARM.
Blood pressure and platelets are clinically relevant for the broader management but are not the most critical assessment before the specific decision to rupture membranes. Caesarean consent and BPP are not required pre-ARM. The critical pre-ARM assessment is vaginal examination to exclude cord/compound presentation.
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A Foley catheter is inserted before a planned emergency lower segment caesarean section. After inflation of the 10 mL balloon, the patient reports severe pain and the balloon inflates but then immediately deflates. What is the most likely explanation?
Correct. Severe pain on balloon inflation with immediate deflation (or inability to hold the balloon) is the classic sign of intraurethral balloon inflation. The urethra is too narrow to accommodate the expanded balloon — it expels it. This causes urethral pain and potential trauma. The catheter must be withdrawn and reinserted correctly.
Intraurethral balloon inflation: severe pain + balloon does not hold. Withdraw immediately. Confirm urine drains freely before inflating the balloon — urine flow confirms the catheter tip is in the bladder.
A defective balloon fails to inflate, not inflate-and-deflate. Entering the bladder is the goal, not a complication. An empty bladder does not cause balloon deflation. Severe pain on balloon inflation = balloon in urethra, not bladder. Withdraw the catheter immediately and reinsert correctly.
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