4.(a) What do you mean by second stage of labour?  2 marks
Series of events that take place in the genital organs in an event to expel the viable products of conception that is the fetus, the placenta and the membranes out of the womb through the vagina into the external world is called labor.
• Second stage: This begins with the full dilatation of the cervix and ends with the expulsion of the fetus from the birth canal. It has two phases-
  i) propulsive phase: Starts from full dilatation of cervix up to the descent of the presenting part to the pelvic floor.
  ii) Expulsive phase: It is characterised by maternal bearing down efforts and ends with expulsion of fetus from the birth canal.
Total duration of second stage: primi 2 hrs, multipara: 30 minutes.

(b) Enumerate the physiological changes occur during second stage of labour. 5 marks                         

The physiological changes during the second stage of labor, which begins with full cervical dilatation and ends with the expulsion of the fetus, involve complex interactions between uterine activity, maternal expulsive efforts, and the soft tissues of the birth canal.

Phases of the Second Stage Physiologically, this stage is divided into two distinct phases:

The Propulsive (Passive) Phase: This begins at full dilatation and continues until the presenting part descends to the pelvic floor.

The Expulsive (Active) Phase: Distinguished by maternal bearing-down efforts and ends with the delivery of the baby.           Uterine Activity (Primary Powers)

             Contractions: The intensity of pain increases. Contractions occur frequently, at intervals of 2–3 minutes, and last for approximately 1–1.5 minutes. Retraction: During the second stage, retraction becomes pronounced; the upper uterine segment becomes progressively thicker while the lower segment becomes thinner and wider. It helps in descent of fetal part.

Voluntary Expulsive Efforts (Secondary Powers)

Ferguson Reflex:  “bearing down” efforts is initiated by a nerve reflex called the Ferguson reflex, which is triggered by the stretching of the vagina by the presenting part triggers the brain to release oxytocin, that causes stronger uterine contractions, which in turn increases cervical stretch, creating a self-sustaining cycle that pushes the baby out.
Anatomical Changes to the Birth Canal and Pelvic Floor

Membranes: If they haven’t already, the membranes usually rupture with a gush of liquor. Occasionally, this may be delayed until the head bulges through the introitus.

Distension of the Perineum: As the head descends, it distends the perineum. The overlying skin becomes tense and glistening, and the vulval opening initially looks like a slit through which scalp hair is visible.

Anal Changes: The anal sphincter is stretched, and stool may be expelled during contractions.

Crowning: During the expulsive phase, the maximum diameter of the head stretches the vulval outlet. At this point, there is no recession of the head even after the uterine contraction passes off; this is known as crowning.

Maternal Systemic Responses

Cardiovascular System: Cardiac output increases further during labor by 50%. During contractions, the pulse rate increases by 10–15 beats per minute and systolic blood pressure rises by about 10 mm Hg, though these usually settle between contractions.

Maternal General Condition:
Exhaustion: There may be features of maternal exhaustion. Respiration slows down, and perspiration increases.Congestion: During bearing-down efforts, the mother’s face becomes congested, and neck veins may become prominent.

Relief: Immediately following the expulsion of the fetus, the mother typically heaves a sigh of relief.

Fetal Responses

Heart Rate: The fetal heart rate (FHR) may slow by 10–20 beats per minute during contractions due to head compression or transient reduction in placental perfusion. This usually recovers promptly as the contraction passes.

Descent: Descent: There is progressive descent of the head, which can be assessed abdominally by estimating the number of “fifths” of the head palpable above the pelvic brim.If the membranes remain intact during this stage, the adverse effects on the fetus are minimal, as the pressure is distributed evenly (general intrauterine pressure) rather than directly on the fetus.

(c) Explain the active management of 3rd stage of labour. 5 marks

Principles of Management The third stage is the most crucial stage of labor due to the risk of postpartum hemorrhage (PPH). The primary objective is to ensure strict vigilance and follow guidelines to prevent complications, particularly PPH. There are two methods of management: Active Management (AMTSL), which is preferred, and Expectant Management.

1. Active Management of Third Stage of Labor (AMTSL) This is the recommended standard of care as it reduces blood loss by 60% and shortens the duration of the third stage. It involves three key steps:

• Administration of Uterotonics: The basic principle of 3^rd stage management is to incite powerful contractions by administering parenteral uterotonics preferably Oxytocin 10 IU IM, (or methergine0.2mg / misoprostol 800 mcg) is administered within 1 minute of the delivery of the baby. This excites powerful uterine contractions to facilitate placental separation.
2. Delayed Cord Clamping The cord should be clamped and ligated after 1–3 minutes (or cessation of pulsation). This facilitates the transfer of 80–100 mL of blood from the placenta to the infant, increasing the infant’s iron stores and reducing anemia. (contraindicated in RH incompatibility)
3. Controlled Cord Traction (CCT): watch for signs of separation: the uterus becomes globular and firm, there is a gush of vaginal bleeding, and permanent lengthening of the cord. The placenta is delivered using the modified Brandt-Andrews method. One hand is placed above the symphysis pubis to push the uterus upward and backward (guarding the uterus), while the other hand applies steady traction on the cord in a downward and backward direction.
If it fails, wait for 2-3 minutes and then repeat CCT.
If it fails wait for 10 minutes and repeat CCT, if it fails again then go for manual separation.

• Uterine Massage: Immediately after the expulsion of the placenta, the uterus is massaged to ensure it remains hard and contracted, which helps prevent atonic hemorrhage.

4. Examination of Placenta and Genital Tract

• Placenta: The maternal surface is inspected for missing cotyledons, and the membranes are checked for completeness. The cut end of the cord is checked for the number of vessels.

• Genital Tract: The vulva, vagina, and perineum must be inspected carefully for lacerations or injuries, which should be repaired immediately.

(d) List down the complications of 3rd stage of labour.   3 marks

The third stage of labor is a high-risk period where sudden maternal complications may occur. Major complications include:

1. Postpartum Hemorrhage (PPH): Severe bleeding within 24 hours; may occur before or after placenta expulsion.
2. Retained Placenta: Placenta not expelled within 30 minutes (15 minutes by WHO); leads to hemorrhage, shock, and sepsis.
3. Uterine Inversion: Uterus turns inside out due to atony or improper cord traction; causes profound shock and hemorrhage.
4. Shock: Can be hemorrhagic from blood loss or non-hemorrhagic (neurogenic/endotoxic).
5. Pulmonary Embolism: Amniotic fluid or air entering maternal circulation causing DIC and cardiopulmonary collapse.

Or,

• What do you mean by GDM? 2 marks

Gestational Diabetes Mellitus (GDM) is a condition in which glucose intolerance first appears or is first recognized during pregnancy, usually in the second or third trimester. Although the definition applies regardless of whether the condition persists after pregnancy, it includes women who may have had previously unrecognized overt diabetes.
(b) Write down the factors of GDM. 6 marks
Several factors increase the likelihood of developing GDM. These include:

Family History: A positive family history of diabetes in parents or siblings.

Obstetric History: Having a previous birth of an overweight baby (4 kg or more), a history of previous GDM, unexplained perinatal loss, or stillbirth. Recurrent abortion, Congenital anomalies in previous baby.

Current Pregnancy Complications: The presence of polyhydramnios or recurrent vaginal candidiasis (thrush) in the current pregnancy. Excessive weight gain during pregnancy,

Maternal Characteristics: Maternal age over 30 years, obesity, short stature.

Ethnicity: Specific ethnic groups, such as those of East Asian or Pacific Island ancestry.

Medical Conditions: Women with Polycystic Ovary Syndrome (PCOS) or persistent glycosuria are also at risk. Hypertension, Hypothyroidism, Insulin resistance syndrome, Metabolic syndrome

Lifestyle factors: Physical inactivity, Unhealthy diet, High-calorie or high-carbohydrate consumption.

Twin or multifetal pregnancy increases insulin demand → risk of GDM.

(c) Describe the management of Gestational Diabetic Mellitus. 7 marks

Management

The management of GDM involves screening, dietary modifications, and, if necessary, medical and obstetric intervention.

Screening and Diagnosis

Universal Screening: All pregnant women should be screened for GDM between 24 and 28 weeks of gestation, with early screening recommended for those with high-risk factors.

Testing Methods:

A 50 g oral glucose challenge test is often used; a plasma glucose value of 140 mg% or more at 1 hour necessitates a diagnostic Oral Glucose Tolerance Test (OGTT).

Alternatively, the DIPSI (Diabetes in Pregnancy Study Group in India) recommends a one-step procedure using 75 g oral glucose. A 2-hour venous plasma glucose value greater than 140 mg/dL confirms the diagnosis of GDM.

Medical Nutrition Therapy (Diet and Exercise)

Dietary Intake: Medical Nutrition Therapy (MNT) is a primary treatment. The recommended intake is 2,000–2,500 kcal/day for women of normal weight and restricted to 1,200–1,800 kcal/day for overweight women.

Composition: The diet should consist of 40–50% carbohydrates (preferably complex), 20% protein, and 30–40% fat (with less than 10% saturated fat).

Exercise: Regular exercise, such as aerobic activity or brisk walking for 30 minutes daily, 5 days a week, is safe and may eliminate the need for insulin therapy. Walking for 10–15 minutes after meals also helps control postprandial glucose levels.

Pharmacotherapy and Obstetric Management

Medication: If dietary measures fail to meet glycemic targets (e.g., fasting plasma glucose >95 mg/dL or 2-hour postprandial >120 mg/dL), pharmacotherapy is indicated. While insulin is the primary medication, metformin is also recommended as a first-line treatment.

Timing of Delivery:

Women with GDM well-controlled on diet should plan for delivery between 39 weeks and 40 weeks 6 days.

Women on insulin or oral medication should generally plan for delivery between 39 weeks and 39 weeks 6 days.

Those with suboptimal control may require delivery between 37 and 38 weeks.

Mode of Delivery: Cesarean delivery is performed in the majority of cases (>50%) to avoid complications such as shoulder dystocia and birth injuries, particularly when the fetus is macrosomic.

5.(a) What do you understand by the term Menopause? 2 marks

Menopause: Menopause literally translates to the “end of monthly cycles” and signifies the permanent cessation of menstruation at the end of a woman’s reproductive life. It results from the loss of ovarian follicular activity. A clinical diagnosis is confirmed when there has been a stoppage of menstruation (amenorrhea) for twelve consecutive months without any other underlying pathology. The average age of menopause is 45 years in India and 51 years in the West.
(b) What are the changes occur after Menopause? 6 marks

 Following menopause, the body undergoes various physiological and anatomical changes due to estrogen deprivation:

• Endocrinal Changes: Due to low negative estradiol feedback, Follicle Stimulating Hormone (FSH) levels rise to 50–150 mIU/mL. Progesterone secretion from the ovary ceases because ovulation fails. While serum testosterone levels do not fall appreciably, the adrenal cortex secretes the rest of the androstenedione and testosterone.
• Genital Organ Atrophy:
• Uterus and Ovaries: The uterus becomes small and fibrotic, and the endometrium atrophies. The ovaries reduce to approximately 5 cm in size with a furrowed surface and exhausted follicles.
• Vagina: Vaginal dryness occurs due to reduced estrogen. The pH increases, making the vagina prone to vaginitis, and dyspareunia (painful intercourse) may occur due to the decreased size of the introitus and reduced lubrication.
• Vulva and Pelvic Floor: The vulva atrophies with narrowing of the vaginal orifice. Loss of muscle tone can lead to uterine descent, and pelvic cellular tissue becomes scanty.
• Breast Changes: Glandular tissue atrophies, causing the breasts to become flabby and pendulous due to fat deposition.
• Cardiovascular Changes: Postmenopausal women lose the protective effect of estradiol against ischemic coronary heart disease, causing the incidence to rise and equal that of men. There is an increased risk for myocardial infarction, atherosclerosis, and stroke.
• Musculoskeletal and Physical Changes:
• Osteoporosis occurs due to estrogen insufficiency, leading to a reduction in bone mass and an increased risk of vertebral and forearm fractures.
• Body weight generally decreases after 65 years, skin becomes less elastic with wrinkles, and fat deposits shift to the hips and thighs.
• Urinary Changes: The urethral and bladder epithelium becomes thin, leading to dysuria, frequency, urgency, or stress incontinence.
• Psychological and Vasomotor Symptoms: Women may experience hot flushes, sweating, insomnia, and headaches. Psychological changes include emotional lability, nervousness, depressed mood, irritability, and mood swings.

(c) How will you counsel and educate a women regarding Menopause?  7 marks

Health education and counseling aim to help the woman understand her changing body and maintain quality of life.

• Counseling Approach:
• Communication: Counseling is used to understand the client’s feelings and help them make decisions. It involves listening skills and building confidence.
• Emotional Support: Menopause is often perceived as a loss of youth; therefore, the counselor must provide psychological assurance, allay fears, and inculcate a positive attitude towards life.
• Information: The counselor should explain the interpretation of symptoms to the woman.
• Education and Lifestyle Advice:
• Diet: Women are encouraged to adopt a suitable natural diet with fresh vegetables and fruits to avoid weight gain and maintain health.
• Exercise: A daily walk for 30 minutes and weight-bearing exercises are recommended to burn calories and prevent osteoporosis.
• Contraception: Advice on contraception is necessary until amenorrhea has lasted for 12 months.
• Habits: Smoking and alcohol intake should be discouraged.
• Stress Reduction: Techniques such as yoga, meditation, massage, acupressure, and listening to music can help manage stress and anxiety.
• Personal Care: Bladder training is effective for stress incontinence, and maintaining personal hygiene helps manage dry vagina and infections.
• Mental Engagement: Engaging in new creative hobbies is important to deal with “Empty Nest Syndrome” and keep the woman productively occupied.

Or,

(a) Describe common factor for cervical cancer.

common risk factors for cervical cancer (Cervical Intraepithelial Neoplasia / Invasive Carcinoma):

1. Persistent Infection with High-Risk Human Papillomavirus (HPV): Persistent infection with “high-risk” strains of HPV is the primary underlying etiology for the development of cervical intraepithelial neoplasia (CIN) and invasive squamous cell carcinoma of the cervix.
2. Sexual Risk Factors and Behaviors: Factors that increase exposure to STIs and HPV—such as an early age at first sexual intercourse, having multiple sexual partners, or having a male partner with multiple previous partners—significantly increase the risk.
3. Long-term Use of Combined Oral Contraceptives (COCs): Prolonged use of combined oral contraceptive pills (especially for more than 5 years) is associated with an increased risk of cervical cancer, which is linked to persistent exposure to HPV during coitus.

(Other contributing factors mentioned in the sources include immunosuppression, smoking, and inadequate screening.)

(b) Explain investigations for cervical cancer. 6 marks

The investigations for cervical cancer are:

1. Screening & Primary Detection

• Cervical Cytology (Pap Smear / Liquid-Based Cytology): Routine cytological screening detects dyskaryotic cells and precursor cervical intraepithelial neoplasia (CIN) before invasive carcinoma develops.
• High-Risk HPV Testing: Concurrent screening for high-risk Human Papillomavirus (HPV) DNA identifies persistent viral infections that lead to cervical dysplasia and invasive carcinoma.

2. Colposcopy

• Colposcopic Examination: Indicated when abnormal or dyskaryotic cells are found on routine cervical cytology. A colposcope provides a magnified view of the cervical epithelium and transformation zone to highlight abnormal vascular patterns and lesions.

3. Tissue Biopsy (Confirmatory Diagnosis)

• Colposcopy-Directed Biopsy / Punch Biopsy: A targeted tissue sample is taken directly from visible suspicious lesions or colposcopically abnormal areas to confirm the histological diagnosis of invasive squamous cell carcinoma or adenocarcinoma.
• Cone Biopsy (Conization): Used when microinvasive disease is suspected or when the squamocolumnar junction is not fully visible, providing a definitive tissue diagnosis and assessing margin status.

4. Imaging Studies for Local Extension & Staging

• Magnetic Resonance Imaging (MRI): Highly effective for assessing local disease spread, depth of stromal invasion, tumor volume, and parametrial invasion.
• Computed Tomography (CT) / Ultrasonography: Utilized to evaluate pelvic lymph node involvement, hydronephrosis, or distant organ metastases (such as in the liver or lungs).

5. Endoscopic Staging Procedures

• Cystoscopy & Sigmoidoscopy: Performed in cases of advanced invasive disease to evaluate direct extension of the tumor into the bladder mucosa or rectal mucosa.

(c) Write down nurses’ responsibilities regarding preoperative preparation for woman with cervical cancer. 6 marks

The nurse’s preoperative preparation responsibilities for a patient undergoing surgical management for cervical cancer are-

1. Psychological Support & Informed Written Consent

• Informed Consent: The nurse ensures that informed written consent is properly obtained for the surgical procedure, anesthesia, and potential blood transfusions after the medical team explains the operation.
• Counseling: The nurse provides emotional support, addresses fears and anxiety regarding the cancer diagnosis and major pelvic surgery, and explains the surgical sequence using simple language.

2. Physical & Local Skin Preparation

• Surgical Scrubbing: The nurse assists with or performs pre-operative abdominal and vulvoperineal scrubbing using soap and water, with hair clipping performed if required.
• Antiseptic Cleansing: Skin and vulvoperineal preparation is completed using recommended antiseptic lotions (such as povidone-iodine or chlorhexidine) to establish surgical cleanliness and prevent postoperative surgical site infections.

3. Gastrointestinal Preparation & Antacid Protocols

• Fasting (NPO): The nurse enforces strict fasting (nothing by mouth for at least 6 hours prior to elective surgery) to prevent gastric contents from being aspirated during anesthesia.
• Acidity & Bowel Management: To prevent Mendelson’s syndrome (aspiration pneumonitis), the nurse administers oral H2-blockers (e.g., ranitidine 150 mg) the night before and non-particulate antacids (e.g., 0.3 M sodium citrate 30 mL) prior to transferring the patient to the operating theater. Lower bowel emptying via an enema or laxative is performed as ordered.

4. Infection Control & Prophylactic Medication

• Prophylactic Antibiotics: The nurse administers prescribed broad-spectrum IV antibiotics (such as first-generation cephalosporins like cefazolin) approximately 1 hour before skin incision to reduce the incidence of post-operative wound infection, endomyometritis, and pelvic sepsis.

5. Vascular Access & Venous Thromboembolism (VTE) Prophylaxis

• IV Access & Blood Reservation: A large-bore IV cannula is inserted to initiate crystalloid infusions (e.g., Normal Saline or Ringer’s lactate), and cross-matched blood products are secured and kept ready for potential intraoperative blood loss.
• Thromboembolism Prevention: Because extensive pelvic surgery for gynecological malignancy carries a high risk of deep vein thrombosis (DVT), the nurse applies mechanical graduated compression stockings or sequential pneumatic compression devices before surgery.

6. Bladder Care & Baseline Assessment

• Bladder Catheterization: The nurse ensures complete bladder emptying via a self-retaining Foley catheter under strict aseptic conditions to collapse the bladder, keeping it out of the surgical field and reducing the risk of accidental intraoperative bladder injury.
• Baseline Vital Signs: Complete baseline vital signs (blood pressure, pulse, temperature, and respiratory rate) and lab investigation reports (hemoglobin, blood grouping, coagulation profiles) are verified and recorded on the pre-operative checklist.

6.(a) Define low birth weight. 2 marks

A low birth weight infant is defined as one whose birth weight is less than 2500 g irrespective of gestational age. The incidence of LBW varies between 5% and 40% of live births globally.

LBW infants are further classified based on absolute birth weight:

• Low Birth Weight (LBW): <2500 g.

• Very Low Birth Weight (VLBW): <1500 g.

• Extremely Low Birth Weight (ELBW): <1000 g.

Clinically, these infants may be preterm (born before 37 completed weeks) or small for gestational age (SGA) due to fetal growth restriction,

   (b) Discuss the management of low birth weight baby under the following —
    (i) KMC   4 marks

Management of LBW Baby:  KMC (KANGAROO MOTHER CARE)

Kangaroo Mother Care (KMC) is a method of caring for low birth weight (LBW) and preterm babies by providing continuous skin-to-skin contact between the mother (or caregiver) and the baby, along with exclusive breastfeeding whenever possible. It consists of three main components:

• Kangaroo Position: Baby wears only a diaper, cap, and socks. Baby is placed upright between the mother’s breasts. Head turned to one side, neck slightly extended. Hips flexed in a “frog” position. Covered with the mother’s clothing or a blanket.
• Kangaroo Nutrition: Encouraging and maintaining exclusive breastfeeding. Encourage frequent breastfeeding on demand. If the baby cannot suck effectively, give expressed breast milk by cup or spoon.
• Kangaroo Discharge: Stable babies can be discharged early.  Regular follow-up for weight, feeding, temperature, and overall health.
• Procedure

Wash hands before handling the baby.

Ensure the baby is clinically stable.

Position the baby correctly for skin-to-skin contact.

Secure the baby using a KMC wrap or binder.

Continue KMC for as many hours as possible each day (preferably 8–24 hours/day).

Monitor the baby’s breathing, temperature, feeding, and colour regularly.

The primary benefits of KMC are protecting the vulnerable baby against cold stress and hypothermia, while also stimulating increased breast milk production for the mother

    (ii) Prevention of infection 4 marks

Preterm and LBW babies have deficient natural and acquired immunity, making them highly susceptible to infections (incidence increased by 3–10 folds). Prevention strategies include:

• Umbilical Cord Care: The cord should be kept exposed to air and allowed to dry to promote detachment. Topical antiseptics or antibiotics, such as triple dye or neosporin powder, may be applied to the stump to reduce bacterial colonization.

• Skin Care and Hygiene: Routine bathing is delayed until the baby is thermally stable. Excess vernix or blood should be wiped gently with sterile moist swabs.

• Eye Care: The eyes should be kept clean using cotton wool soaked in sterile normal saline. Prophylactic erythromycin (0.5%) or tetracycline (1%) ointment or gentamicin drops are used to prevent ophthalmia neonatorum.

• Aseptic Handling:

    ◦ Thorough hand washing is essential before touching the baby to prevent nosocomial infections.

    ◦ Feeding utensils (bottles/teats) must be cleaned and sterilized by boiling before and after each feed.

    ◦ Infected babies should be isolated.

• Prophylactic Antibiotics and Immunization:

    ◦ Prophylactic antibiotics (e.g., ampicillin and amikacin) are commonly used for VLBW infants pending culture results due to the high risk of sepsis.

    ◦ Hepatitis B vaccine is administered at birth.

    ◦ Intravenous gamma globulin therapy may be given to prevent infections in selected cases.

• Write short notes (any three):
  (a) Antenatal Diet

Antenatal Diet
An adequate antenatal diet is essential to maintain maternal health, support optimal fetal growth and development, provide physical strength during labor, and prepare the mother for successful lactation. The diet should ideally be light, nutritious, easily digestible, and rich in proteins, essential minerals, and vitamins.       
1. Energy & Caloric Requirements

• Caloric Increase: During the second half of pregnancy, maternal basal metabolic rate (BMR) and tissue expansion increase energy demands. An additional 300 kcal/day over the non-pregnant baseline is required, bringing the total daily intake to approximately 2,500 kcal/day.

2. Target Weight Gain based on Pre-Pregnancy BMI

Maternal weight gain should be monitored regularly to prevent both fetal macrosomia and growth restriction:

• Normal BMI (18.5–24.9 kg/m²): Target weight gain is 11–16 kg (approx. 25–35 lbs).
• Underweight (<18.5 kg/m²): Target weight gain is 12.5–18 kg (28–40 lbs).
• Overweight (25.0–29.9 kg/m²): Target weight gain is restricted to 7–11.5 kg (15–25 lbs).

Obese (≥30 kg/m²): Weight gain should be limited to 5–9 kg (11–20 lbs).
Quality: The diet should be light, nutritious, easily digestible, and rich in protein, minerals, and vitamins.

• Composition: The diet should include at least half to one liter of milk, plenty of green vegetables, and fruits. At least half of the total protein should be first-class (animal) protein.

3. Essential Dietary Components & Daily Requirements

4. Supplementary Nutritional Therapy

• Iron & Folic Acid Supplementation: Since dietary iron is insufficient to meet daily demands during late pregnancy, routine oral iron supplementation (e.g., 1 tablet containing 60 mg elemental iron and 1 mg folic acid daily) is instituted for all mothers from 16 weeks of gestation onwards.
• Vitamins: Supplementary vitamins (A, D, C, and B-complex) are added from the 20th week to compensate for cooking losses.
• Hydration: Drink 8–10 glasses of safe water daily. Coconut water, lemon water, soups are beneficial.
• Avoid harmful foods: Excess tea/coffee, spicy/junk food, soft drinks, raw meat, unpasteurized milk, alcohol, tobacco, and smoking.

           5. Practical Dietary Advice

• Meal Pattern: Meals should be taken in small, frequent portions rather than large single meals to alleviate acidity and heartburn caused by progesterone-induced esophageal relaxation.
• Fluid Intake: Plentiful fluids, fruits, and green leafy vegetables are recommended to promote regular bowel movements and reduce constipation.
• Nausea & Morning Sickness: Eating dry toast or biscuits before rising and avoiding greasy/spicy foods help alleviate early morning nausea.
• Salt Intake: Routine salt restriction is not recommended unless indicated for underlying pre-existing medical conditions.

(b) Vitamin-K
1. Classification
Generic name: Phytomenadione (Phytonadione/ Phylloquinone) Drug class: Fat-soluble vitamin; haemostatic agent Category: Vitamin K₁ Common brands: Konakion, Mephyton,

              Chemical class: Vitamin K₁ (Phylloquinone).

2. Mode of action

Vitamin K acts as a cofactor for the hepatic synthesis of clotting factors: Factor II (Prothrombin), Factor VII, Factor IX, Factor X Protein C and Protein S:

Mechanism: Vitamin K helps in gamma-carboxylation of glutamic acid residues in clotting factors, enabling them to bind calcium and participate in the coagulation process.

Promotes normal blood coagulation and prevents or treats bleeding due to vitamin K deficiency.

3. Dose and route of administration

Important: Doses vary with indication, age, formulation and clinical condition. IV administration should be slow and carefully monitored due to the risk of severe hypersensitivity reactions.

4. Indications

1. Prevention of vitamin K deficiency bleeding (VKDB) in newborns.
2. Treatment of vitamin K deficiency.
3. Treatment of bleeding caused by vitamin K deficiency.
4. Reversal of excessive anticoagulant effect of warfarin.
5. Obstructive jaundice and malabsorption conditions associated with vitamin K deficiency.
6. Prolonged prothrombin time (PT/INR) due to vitamin K deficiency.
7. Deficiency caused by prolonged antibiotic therapy or inadequate dietary intake.

8. Maternal Supplementation: It is prescribed to pregnant women with conditions that increase bleeding risks, such as obstetric cholestasis or hepatic dysfunction. It is also given orally (10 mg/day) in the last two weeks of pregnancy to women taking certain anticonvulsants (like phenytoin) to prevent neonatal hemorrhage.
9. Therapeutic Use: It is used as an adjuvant treatment for bleeding disorders like Disseminated Intravascular Coagulation (DIC) to replenish consumed clotting factors (5-10 mg IM), or to treat active bleeding disorders in newborns (1 mg IV or IM).

5. Contraindications

• Known hypersensitivity to phytomenadione or its components.
• Avoid unnecessary administration in patients with normal vitamin K levels.
• IV administration requires particular caution because severe anaphylactoid reactions may occur.
• Use cautiously in patients with severe liver disease, as the response may be limited if hepatic clotting-factor synthesis is impaired.

6. Side effects

Pain, redness and swelling at injection site., Flushing., Dizziness, Altered taste ,Sweating.

Serious adverse effects:

• Anaphylaxis or anaphylactoid reactions, especially with IV administration, Hypotension, Dyspnoea or bronchospasm, Tachycardia, Severe hypersensitivity reactions.

7. Nursing responsibilities

Verify the correct dose and route.

Administer IM using aseptic technique.

Observe the baby for any adverse reactions.

Explain to parents the importance of vitamin K in preventing serious bleeding.

Document the dose, route, time, and site of administration.

(c) Oral Contraceptions

Oral Contraceptives

Definition: Oral contraceptives are hormonal pills taken by women to prevent pregnancy by inhibiting ovulation, thickening cervical mucus, and altering endometrial lining.
Types:
• Combined Oral Contraceptive Pills (COCs): Contain estrogen + progestin (e.g., Ethinyl estradiol 0.03mg+ Levonorgestrel 0.15mg): Mala N/ Mala D: 21 tab pills +7 iron tablets.
taken from 5^th day of menstrual cycle to 21^st day.
• Progestin-Only Pills (POPs): Contain only progestin (e.g., levonorgestrel 75mcg): taken daily.
• Emergency Contraceptive Pills: Ezypill High-dose hormones taken within 72 hours after unprotected intercourse (e.g., Levonorgestrel 1.5 mg).

Non steroidal weekly pill: Chaya/Saheli contains Centchroman 30 mg, twice weekly first 3 month then once week, it prevents implantation in the uterus.
once a month pill: quinestrol + short acting progestin.
Mechanism of Action:
• Inhibit ovulation by suppressing FSH & LH.
• Thicken cervical mucus → prevents sperm entry.
• Thin endometrium → prevents implantation.
• Reduce tubal motility.
Advantages:
• Highly effective & reversible.
• Regulates menstrual cycle, reduces dysmenorrhea, decreases menorrhagia.
• Lowers risk of ovarian, endometrial cancer, benign breast disease.
• Improves acne, reduces PMS.
Contraindications:
• Pregnancy, breastfeeding <6 months (for COCs).
• Hypertension, migraine with aura, history of thromboembolism.
• Smokers >35 years.
• Liver disease, breast cancer.
Side Effects:
• Nausea, breast tenderness, spotting.
• Weight gain, mood changes.
• Rare: thrombosis, hypertension.
Nurse’s Responsibilities:
• Assess medical history & contraindications.
• Ensure pill compliance & teach “same time daily” rule.
• Counsel on missed pill management.
• Educate on side effects & danger signs (ACHES: Abdominal pain, Chest pain, Headache, Eye problems, Severe leg pain).
• Teach that OCPs do not protect against STIs—condom advised.

(d) Phototherapy

Definition:
Use of visible light (blue spectrum 430–490 nm) to treat neonatal hyperbilirubinemia by converting unconjugated bilirubin into water-soluble forms for excretion.

Purpose:
• Prevent bilirubin encephalopathy (kernicterus)
• Reduce serum unconjugated bilirubin
• Avoid need for exchange transfusion

Mechanism of Action:
It uses special blue or blue-green lights (optimally 420–470 nm wavelength Blue LEDs) to break down bilirubin through photo-oxidation and structural isomerization. This converts the bilirubin into less toxic, water-soluble isomers like lumibilirubin, which the infant can easily excrete in their bile and urine without needing liver conjugation.
Application:
It is best used for moderate cases where bilirubin rises above 12 mg/dL. The infant’s maximum surface area is exposed to the light, and double phototherapy (using overhead lights plus a fiberoptic blanket underneath) can be used for double the effectiveness.

Indications:
• Neonatal jaundice above treatment threshold
• Premature infants with rising bilirubin
• Hemolytic diseases (ABO/Rh incompatibility)

Types of Phototherapy:
• Conventional fluorescent tube phototherapy • LED phototherapy• Fiber-optic (biliblanket)

Advantages:
• Non-invasive• Effective and safe• Can be continuous

Complications / Side Effects:
• Dehydration• Loose green stools• Hyperthermia or hypothermia• Skin rashes, bronze baby syndrome
• Eye damage (if unprotected)• Increased insensible water loss
Discontinuation: Therapy is typically stopped once serum bilirubin drops below 13 mg/dL in term infants or 11 mg/dL in preterm infants, though a rebound increase can sometimes occur after stopping.
Contraindications

•Conjugated (direct) hyperbilirubinemia is generally not treated with phototherapy because it is ineffective and may cause bronze baby syndrome.

Nurse’s Responsibilities:
• Ensure proper eye protection for newborn• Maintain thermoregulation
• Monitor bilirubin levels as ordered• Keep infant naked except diaper
• Change position every 2 hours
• Assess hydration: weight, urine output
• Check phototherapy unit intensity
• Educate parents

(e) Role of Nurse for mother after delivery

Role of the Nurse for Mother After Delivery (Postnatal Period)

The nurse’s role in caring for a mother after delivery (the puerperium period) focuses on restoring her physical health, preventing infection, and supporting newborn care. Key responsibilities include:

Immediate Monitoring: For at least the first hour after delivery, the nurse closely monitors the mother’s pulse, blood pressure, respiratory rate, and temperature. They regularly check that the uterus is firm and well-retracted while observing for any abnormal vaginal bleeding to prevent postpartum hemorrhage.

Ongoing Assessment: The nurse maintains a chart recording vital signs, the height of the uterine fundus, and the amount and character of lochia (vaginal discharge). They also ensure the mother voids her bladder within 6 hours of birth to prevent urinary retention.

Pain Management: Assess pain regularly. Administer prescribed analgesics. Teach relaxation techniques and proper positioning.

Hygiene and Wound Care: The nurse helps clean the vulva and perineum, applying sterile pads. If the mother has an episiotomy or perineal tear, the nurse performs wound dressings using strict sterile techniques and may provide cold sitz baths or medications for pain relief.

Promoting Recovery: The nurse encourages early ambulation (getting out of bed) to prevent blood clots, ensures the mother receives an adequate diet and hydration, and monitors her bowel movements.

Lactation and Bonding: The nurse supports “rooming-in” by keeping the baby by the mother’s bed to foster bonding. They also assist the mother with correct breastfeeding positioning and breast hygiene.

Documentation: Nurse records all assessments, nursing care, medications, breastfeeding status, and health education provided.

Discharge Education: Before the mother goes home, the nurse provides guidance on postnatal exercises, continuing iron supplements, baby care, and family planning or contraception options, teach perineal hygiene and handwashing. Explain danger signs: Excessive bleeding, Fever, Foul-smelling lochia, Severe abdominal pain, Breast redness or swelling, Schedule postnatal follow-up visits.