5. Mrs. Sima Banerjee, 21 years, Primigravida with 12 weeks of pregnancy comes to Antenatal clinic for 1st antenatal check-up.
(a) What are the purposes of antenatal check-up? (3)
Purposes of Antenatal Checkup The aims and objectives of antenatal care are to ensure a normal pregnancy with the delivery of a healthy baby from a healthy mother. Specific purposes include:
To ensure the health and well-being of the mother: Early detection of maternal complications such as anemia, hypertension, diabetes, infections, etc.
To monitor fetal growth and development: Assess fetal heart rate, movements, growth parameters, and detect abnormalities early.
To identify high-risk pregnancies: Helps classify mothers as normal or high-risk (e.g., preeclampsia, multiple pregnancy, RH incompatibility).
To provide essential antenatal care services: Iron–folic acid, calcium supplementation, tetanus immunization, deworming, etc.
To offer health education and counseling: Nutrition, hygiene, danger signs of pregnancy, breastfeeding, birth preparedness.
To prepare the mother for safe delivery: Planning place of delivery, transport, companion, financial readiness.
To detect and manage complications early: Conditions like polyhydramnios, oligohydramnios, placenta previa, preterm labor.
To maintain records for continuity of care: Antenatal card, lab investigations, ultrasound reports support smooth care during labour.
To promote psychological well-being: Reduce anxiety through guidance, reassurance, and support during pregnancy.
To reduce maternal and perinatal morbidity and mortality: Regular check-ups ensure safer pregnancy outcomes.
Family Planning: To motivate the couple regarding the need for family planning

(b) Enlist the routine investigations to be done in first antenatal visit. (3)
visit:

•   Blood Pressure Measurement
•    Height & Weight (BMI)
  Blood Tests:
• ◦ Complete Blood Count (CBC) including Hemoglobin and Hematocrit.
• ◦ ABO and Rh grouping.
• ◦ Blood glucose.: Fasting/Random Blood Sugar
•   Thyroid Function Test (TSH)
• ◦ VDRL (for Syphilis).
• ◦ Screening for Hepatitis B (HBsAg), HIV, and Rubella immunity.
• ◦ Antibody screening and Hb electrophoresis (if at risk for hemoglobinopathy).
  • Urine Analysis: Routine examination for protein, sugar, and pus cells, as well as a urine culture to detect asymptomatic bacteriuria.
  • Cervical Cytology: Pap smear or Liquid-Based Cytology (LBC) to screen for abnormal cells, unless recently performed.
  • Ultrasonography: To confirm gestational age, viability, and the number of fetuses

(c) What are the positive signs of pregnancy? (3)

The positive signs of pregnancy are those that serve as absolute proof of pregnancy. They include:

1. Ultrasound Evidence: Visualization of the embryo (possible as early as the 6th week) and later the fetus. Visualization of gestational sac, yolk sac, fetus, fetal cardiac activity.2. Fetal Heart Sounds: Auscultation of the fetal heart sounds (FHS).   By Doppler: after 10–12 weeks  By fetoscope: after 18–20 weeks

3. Fetal Movements: Perception of active fetal movements and palpation of fetal parts by the examiner (usually palpable around the 20th week).

4. Radiological Demonstration: Visualization of the fetal skeleton via X-ray (visible from the 16th   week onwards).

              5. Feeling of fetal parts on palpation.

(d) What advice will you give to the woman on the following headings?

(i) Prevention of Anaemia (3)
1. Dietary Advice: Consume a realistic balanced diet rich in iron and protein, such as liver, meat, egg, green vegetables, green peas, figs, beans, whole wheat, onion stalks, and jaggery. Use iron utensils for cooking to increase iron content in the food.

2. Pharmacological Supplementation: Take supplementary iron therapy daily (typically 200 mg of ferrous sulfate containing 60 mg of elemental iron) combined with 1 mg of folic acid. Start this supplementation from 16 weeks onwards, as diet alone often cannot meet the extra demand for iron in the second half of pregnancy. If hemoglobin is below 10 g%, the dose should be increased to 2–3 tablets a day.

3. Absorption and General Health: Avoid drinking tea within 1 hour of taking iron tablets, as it can hinder iron absorption. Treat any underlying conditions that cause blood loss or hinder absorption, such as hookworm infestation, dysentery, malaria, urinary tract infections, or bleeding piles. Ensure adequate birth spacing (at least 2 years) to allow the body to replenish iron stores lost during previous childbirth and lactation.

(ii) Danger signs of pregnancy (3)
The woman should be instructed to report to the hospital immediately if any of the following occur:

• Vaginal Bleeding: Any active vaginal bleeding.
  • Fluid Leakage: Sudden gush of watery fluid per vaginam (suggestive of premature rupture of membranes).
  • Pain: Distressing abdominal pain or painful uterine contractions before term. Could indicate ectopic pregnancy, miscarriage, placental problems.
  • Fetal Movements: Decrease or loss of fetal movements. Needs immediate evaluation for fetal wellbeing.
    Systemic Symptoms: Intense headache, visual changes like blurry vision, scotomata, photopsia (Possible sign of hypertension or preeclampsia.), Swelling of face, hands, or generalized swelling May indicate preeclampsia. Convulsions or loss of consciousness suggestive of eclampsia.  Sudden weight gain or breathlessness: Can be cardiac or preeclampsia related.
    Painful urination or decreased urine output: May indicate UTI or kidney issues.
  •  fever, rigor, or excessive vomiting: May indicate infection or dehydration.
    Extreme tiredness, dizziness, palpitations: suggestive severe anaemia.
• 
  Mrs. Rumela Sen, 35 years old, 3rd gravida, had vaginal delivery at term and started bleeding just after delivery of the placenta. Uterus is flabby.
  (a) What is your diagnosis? (2)
  Diagnosis: Primary Postpartum Hemorrhage (PPH) due to Atonic Uterus.
• Explanation: The bleeding occurred “just after delivery of placenta,” which classifies it as True Postpartum Hemorrhage (a type of Primary PPH). The clinical finding that the “uterus is flabby” confirms that the cause is Atonic Uterus (failure of the uterine musculature to contract and retract), which distinguishes it from traumatic hemorrhage where the uterus is typically found hard and contracted.

(b) Explain the causative factors for this condition. (5)
Atonicity of the uterus is the most common cause of postpartum hemorrhage (80%). The conditions that interfere with the retraction of the uterus include:
Grand Multiparity: While Rumela is a 3rd gravida, multiparity is a known risk factor as inadequate retraction is more common in these cases.
Overdistension of the Uterus: Conditions such as multiple pregnancy, hydramnios, or a big baby (>4 kg) stretch the uterine musculature, leading to imperfect retraction.
Anemia and Malnutrition: Even a slight amount of blood loss can manifest as PPH in anemic women.
Prolonged Labor: Labor lasting longer than 12 hours can cause poor retraction due to muscle exhaustion.
Mismanaged Third Stage of Labor: Practices such as kneading and fiddling with the uterus, pulling the cord, or premature attempts to deliver the placenta can produce irregular contractions and partial separation, leading to atony.
Antepartum Hemorrhage: Conditions like placenta previa and abruptio placenta are risk factors.
Precipitate Labor: Rapid delivery where the uterus does not have time to retract properly before separation occurs.
Other Factors: Use of tocolytic drugs like MgSO4, nifedipine, uterine fibroids, full bladder, or delivery under deep general anesthesia, Obesity (BMI>35), Previous history of PPH. Age >40 years, Morbid adherent placenta (acreta/percreta).
Other causes of PPH are Trauma due to operative delivery/episiotomy, Retained tissues and blood coagulation disorders.

(c) Write down the different preventive measures to avoid this condition. (8)
Postpartum hemorrhage cannot always be prevented. Prevention involves assessing risk factors and following specific guidelines during the antenatal and intranatal periods.
Antenatal Measures:
Health Improvement: Correct anemia and improve nutritional status so the hemoglobin level is maintained above 10 g/dL, allowing the patient to better withstand blood loss.
High-Risk Screening: Screen and identify patients likely to develop PPH (e.g., history of previous PPH, twins, hydramnios, severe anemia) and arrange for delivery in a well-equipped hospital.
Blood Grouping: Determine ABO and Rh grouping for all women to save time during an emergency.
Placental Localization: Use ultrasound or MRI for women with prior cesarean delivery to detect morbidly adherent placenta (placenta accreta).
Intranatal Measures:
Active Management of Third Stage of Labor (AMTSL): This should be a routine practice for all women as it reduces PPH by 60%.
Proper Use of Oxytocics: If labor is induced or augmented with oxytocin, the infusion should continue for at least one hour after delivery.
Controlled Emptying of Uterus: Avoid rapid emptying of the uterus during operative deliveries or in cases of hydramnios.
Examination of Placenta: Routine examination of the placenta and membranes to ensure they are complete and to detect any missing parts early.
Post-Delivery Observation: Observe the patient for about two hours after delivery to ensure the uterus remains hard and well-contracted before transferring her to the ward.
Exploration of the uterovaginal canal for evidence of trauma following delivery.
Bladder Care: Ensure the bladder is empty during labor and delivery, as a full bladder can interfere with uterine contraction.

6. (a) What is DUB? (2)

Dysfunctional Uterine Bleeding (DUB) is abnormal uterine bleeding without any detectable pelvic, organic, or systemic cause.
It is usually due to hormonal imbalance, especially anovulation.

 (b) What are the causes of DUB? (3)

Cause:
1. Anovulatory (Most common – seen in adolescents & perimenopause): Occurs when ovulation does not happen → unopposed estrogen effect.
Immature hypothalamic–pituitary–ovarian axis (adolescence): No ovulation → no progesterone → endometrium overgrows → irregular shedding → heavy or prolonged bleeding.

• Perimenopausal hormonal fluctuations, polycystic ovarian syndrome (PCOS), Thyroid disorders, Stress, weight changes, excessive exercise

Hyperprolactinemia.
2. Ovulatory DUB

Bleeding with regular ovulation but due to defects in hormone production. Luteal phase defect (low progesterone), Short luteal phase

Prostaglandin imbalance, Coagulation disorders, Endometrial dysfunction.
3. Systemic/Endocrine Causes: Hypothyroidism or hyperthyroidism Obesity Diabetes mellitus Adrenal disorders Medications: anticoagulants, hormonal contraceptives

4. Iatrogenic Causes Improper use of estrogen or progesterone therapy, IUCD side effects,Use of anti-coagulants (warfarin, heparin)

(c) Write down the post-operative management of a woman after vaginal hysterectomy for the first 24 hours by nursing process. (5)

1. Acute pain related to surgical incision and tissue manipulation. – Assess pain every 2–4 hrs. – Administer prescribed analgesics. – Provide comfort measures: positioning, support abdomen while moving. – Encourage relaxation techniques.
2. Risk for hemorrhage related to surgical site. – Monitor vitals every 30 min for 2 hrs then hourly. – Observe perineal pad for amount, color, clots. – Assess fundus and abdomen for signs of internal bleeding. – Maintain IV line. – Report heavy bleeding immediately.
3. Risk for infection related to vaginal wound and catheter. – Maintain aseptic technique. – Perineal hygiene with warm water. – Hand hygiene. – Monitor temperature 4 hourly. – Inspect incision/perineum for redness, foul smell.
4. Urinary retention related to anesthesia and catheter removal. – Ensure catheter drainage. – Monitor urine output hourly (≥ 30 ml/hr). – Encourage fluid intake if allowed.
5. Impaired physical mobility related to postoperative restrictions. – Encourage deep breathing and leg exercises. – Assist patient in turning every 2 hours.
6. Deficient knowledge related to postoperative self-care.

• (a) Define Hypothermia.

In the context of the newborn, hypothermia refers to a body temperature that drops below the normal range. The normal skin temperature in a neonate is 36.0°C to 36.5°C (96.8–97.7°F), and the normal core (rectal) temperature is 36.5°C to 37.5°C (97.7–99.5°F). Hypothermia is identified as a temperature below 36°C. It is a serious condition that can lead to hypoxia, hypoglycemia, metabolic acidosis, shock, and increased mortality.

(b) What are the causes of hypothermia in Labour Room?
Newborns, particularly low birth weight (LBW) and preterm infants, are extremely thermolabile and prone to heat loss due to reduced subcutaneous fat and a large surface area relative to their body weight. Heat loss in the labor room occurs through four specific mechanisms:

Evaporation: Loss of heat when amniotic fluid evaporates from the wet skin of the infant.
Radiation: Loss of heat to cooler solid objects in the vicinity that are not in direct contact with the infant.
Conduction: Loss of heat from the infant to cooler surfaces in direct contact with the skin.

Convection: Loss of heat from the infant to the surrounding air.

Risk factors include:
Preterm/LBW infants: They have diminished brown fat stores and cannot maintain a thermoneutral temperature.
Asphyxia: Asphyxiated babies are often unable to control cardiorespiratory functions and temperature.
Sepsis: Septic shock can manifest with hypothermia (<36°C).

(c) Write down the management of hypothermia.

Management involves both preventions immediately after birth and active treatment if hypothermia occurs.

Preventive Measures (The “Warm Chain”):
Immediate Drying: The infant must be dried immediately after birth to prevent evaporative heat loss.
Skin-to-Skin Contact: Newborns without complications should be kept in skin-to-skin contact with their mothers during the first hour after birth.
Radiant Warmers: The baby should be placed under a preheated (36.5°C) radiant warmer (servo-control) immediately following delivery.
Covering: The baby should be wrapped in a sterile warm towel, ensuring the head is also covered. For babies <28 weeks, plastic bags or occlusive wrapping should be used under warmers.
Environment: The delivery room should be kept warm.

Active Treatment:
Slow Warming: If an infant becomes hypothermic, slow warming should be initiated.
Incubators: Extremely low birth weight (ELBW) babies are best managed in prewarmed double-walled incubators to stabilize temperature and humidity.
Monitoring: It is crucial to monitor for complications such as hypoglycemia and metabolic acidosis, which result from cold stress.

(d) What health education will you give a mother for care of a baby at home?
Mothers should be counseled on the following to ensure the newborn maintains a healthy temperature and general well-being at home:

• Kangaroo Mother Care (KMC): Mothers should be taught to practice skin-to-skin contact, where the infant is placed vertically between the mother’s breasts. This protects the baby against cold stress and hypothermia while promoting breastfeeding.
• Breastfeeding:
  • Early and Exclusive: Mothers should be encouraged to initiate breastfeeding early (within half to one hour of birth) and practice exclusive breastfeeding for 6 months.
  • Frequency: The baby should be fed on demand, usually 8–12 times per day.
  • Technique: Education on proper positioning and attachment (latch-on) is essential to ensure effective milk transfer and prevent nipple trauma.

Bathing: Routine bathing should be delayed until the baby is stable and able to maintain body temperature; water temperature should be checked to ensure it is >97.5°F.
Cord Care: The umbilical cord should be kept exposed to air to dry and fall off naturally; it should not be covered or kept moist.
Rooming-in: The baby should be kept in a cot by the mother’s bedside to establish bonding and facilitate care.
Immunization: Mothers should be informed about the childhood immunization schedule and the importance of vaccines like Hepatitis B.
Follow-up: Mothers should be advised to attend well-baby clinics for weight checks and to report any feeding problems, jaundice, or signs of infection.

8. Write short notes (any three): [5×3=15]
(a) MTP
Medical Termination of Pregnancy (MTP)

• Definition: Deliberate termination of pregnancy either by medical or surgical methods before fetal viability. In India, it is regulated by the MTP Act (1971; amended 2021) allowing termination up to 24 weeks for special categories.
• Indications: Therapeutic (save pregnant woman’s life), Social (contraceptive failure, grave injury to physical/mental health), Eugenic (fetal abnormality), and Humanitarian (rape).
• Permitted Gestational Age (as per 2021 Amendment)
• Up to 20 weeks: 1 registered medical practitioner (RMP).
• 20–24 weeks: 2 RMPs (special categories: rape survivors, minors, differently-abled women, etc.).
• Beyond 24 weeks: Only for severe fetal anomalies (Medical Board approval).
• No upper limit if it is to save mother’s life.

• Methods:
  • First Trimester (up to 12 weeks):
    • Medical: Mifepristone (200 mg) followed by Misoprostol (800 mcg) is highly effective (95%) up to 63 days.
    • Surgical: Vacuum Aspiration (MVA/EVA) or Suction Evacuation
  • Second Trimester (13–24 weeks):
    • Medical: Mifepristone followed by Misoprostol doses, or Misoprostol alone.
    • Surgical: Dilatation and Evacuation (D&E).
• Complications: Hemorrhage, shock, injury to cervix/uterus, sepsis, and incomplete abortion.

(b) Magnesium Sulphate
Magnesium Sulphate (MgSO4)
Group name: Anticonvulsant drug

Trade name: MagSulf

• Indications: It is the drug of choice for the prevention (in severe pre-eclampsia) and treatment of convulsions in eclampsia. It is also used for neuroprotection of the fetus in preterm labor (<32 weeks).
• Mechanism: It acts as a membrane stabilizer and neuroprotector by reducing motor endplate sensitivity to acetylcholine and blocking neuronal calcium influx. It causes cerebral vasodilation.
• Dosage (Pritchard Regimen): Loading dose of 4 g IV (20% solution) plus 10 g IM (5 g in each buttock); maintenance dose of 5 g IM every 4 hours.
  Nurse’s Responsibilities:
• Check baseline vitals—BP, pulse, respirations.
• Assess deep tendon reflexes (DTRs) before each dose.
• Monitor respiratory rate (must be >12/min).
• Monitor urine output (must be >30 mL/hr to avoid toxicity).
• Keep antidote ready: 10% Calcium Gluconate, 10 mL IV.
• Monitor for signs of toxicity:
  • Loss of patellar reflex
  • Respiratory depression
  • Oliguria
  • Hypotension
• Toxicity & Antidote: Toxicity leads to loss of reflexes, respiratory depression, and cardiac arrest. The antidote is Calcium Gluconate (1 g IV).
  Contraindications
• Myasthenia gravis
• Renal failure / severe renal impairment
• Heart block
• Hypocalcemia
• Respiratory depression
• Caution in congestive cardiac failure

• 
  (c) Female Permanent Contraceptive Method
  Definition: Female sterilization is a permanent method of contraception in which the fallopian tubes are blocked, cut, or sealed to prevent the ovum from meeting the sperm. It is safe, effective, and widely used.
  Timing:
  • Puerperal: Done 24–48 hours after delivery (technically simple).
  • Interval: Done >3 months post-delivery, usually post-menstrual.
  • Concurrent: With MTP or Cesarean Section.
• Methods:

Minilaparotomy (Mini-Lap): Small abdominal incision; commonly uses the Pomeroy technique (ligation and excision of a loop of the tube).

Laparoscopy: Occlusion using rings (Falope ring), clips (Filshie), or electrocoagulation. It is popular for interval sterilization.

• Efficacy: Highly effective with a failure rate of about 0.5 per 100 women years.
  Mechanism
• Prevents the sperm from reaching the ovum → no fertilization.
  Advantages

Permanent, highly effective (99.5%)

Simple, safe, short procedure

No effect on hormones, menstruation, or sexual life

No long-term side effects

Disadvantages

Surgical risks (bleeding, infection, anesthesia risk)

Not easily reversible

Requires trained providers and sterile setup

Does NOT protect from STIs or HIV

Contraindications

Pregnancy, Pelvic Infection / PID, Severe anemia, uncontrolled diabetes,Heart disease (relative)

• Counseling: It should be considered permanent. Reversal is difficult and not always successful. It does not protect against STIs,
    Need for rest for 1 week. Follow-up after 7 days or if complications occur

(d) Respectful Maternity Care

Definition:
Respectful Maternity Care (RMC) refers to the ethical, human-rights–based approach to care during pregnancy, childbirth, and postpartum that ensures dignity, privacy, autonomy, and freedom from abuse for every woman.

Principles / Components of RMC

Freedom from Harm and Ill-Treatment

No verbal, physical, or emotional abuse.

No discrimination or neglect.

Right to Information, Informed Consent, and Autonomy

Explain procedures clearly.

Obtain consent before examinations.

Respect women’s choices (birth position, companion).

Privacy and Confidentiality

Use curtains/screens during examinations.

Maintain confidentiality of medical information.

Dignity and Respect

Treat every woman politely.

Use supportive communication and empathy.

Presence of Birth Companion

Allowing a chosen companion reduces stress and improves outcomes.

Continuous Support

Provide emotional, physical, and informational support throughout labour.

Non-Discrimination

Equal care irrespective of caste, religion, age, socioeconomic status, or parity.

Right to Timely, High-Quality Care

Prompt attention in labour.

Adequate pain relief, monitoring, and emergency care.

During child birth:  No induction / augmentation of labor without sound clinical indication.
Freedom to choose comfortable position during birthing, No out of pocket expenditure for drugs/ medications
as gratitude.

Importance of RMC

Improves maternal satisfaction and trust in health facilities.

Reduces fear, anxiety, and trauma during childbirth.

Increases institutional delivery rates.

Helps prevent maternal and newborn complications by ensuring timely care.

Protects women’s fundamental rights and dignity.

Nurse’s Role in RMC

Provide respectful communication and emotional support.

Ensure privacy, informed consent, and safe clinical practices.

Avoid harmful or unnecessary procedures (slapping, shouting, unconsented procedures).

Advocate for the woman’s rights during maternity care.