Orris

GROUP – B (SAQ-10 MARKS) 1. Outline the package of services for antenatal and postnatal mothers under RMNCAH+N. What is 'Three Delays Model' related to maternal deaths? (6+2+2=10) [MldMCH] 2. A seven days old baby is brought to your OPD with excessive cry, refusal of food and convulsions. i. What is the probable diagnosis? (1) ii. Discuss the management of the above case. (3) iii. How can this condition be prevented? (3) iv. Write the national immunization schedule for infants. (3) [SRIMS] 3. A 4-month-old baby attends RHTC with history of fever, cough and runny nose. On examination, the respiratory rate was 55/min with no chest in drawing. Classify the illness according to IMNCI. Write down the management in brief. Why color coding is important in the IMNCI chart? (2+5+3) [MJNMCH] 4. What are the common physical and psychosocial problems among adolescent population? Outline the services available for this age group in different levels of care. (6+4) [MJNMCH] 5. A Mother brings her 2 years old child of 10 Kg weight, to OPD with complains of frequent episodes of loose stool for last 2 days - As a Medical Officer how will you classify the status of dehydration as per IMNCI guideline. How will you manage the case, if the child is classified as "Some Dehydration"?(4+6) [JIMSH] 6. A Pregnant woman has reported first time in Ayushman Arogya Mandir for ANC at 16 weeks; what services will be provided to her as per RMNCAH+N programme. Enumerate the danger signs of pregnancy during antenatal period. What are the predominant health problems of tribal population in India?(4+2+4) [JHARGRAM] 7. During a National Deworming Day (NDD) session, a school teacher reports that some children refused Albendazole due to fear of adverse events. • State the objective of National Deworming Day. (1 Mark) • Mention the target beneficiaries under NDD. (1 Mark) • Name the drug used and its dose for children aged 1-19 years. (1 Mark) • Mention one common adverse event and its management. (1 Mark) [DHGMCH] 8. Write down the components of RMNCAH+N. Discuss the key intervention of maternal health.(5+10) [CNMCH] 9. What is meant by LBW? How are such babies classified? What measures would you like to adopt as BMOH to reduce LBW in your block? (2+3+5=10) [BGMCH] 10. Define infant mortality rate. Write down causes of infant mortality. Discuss role of under-5 clinic. (2+3+5) [MCK] 11. Define Maternal Mortality Ratio (MMR). Enumerate causes of MMR in India. How has the RMNCAH+N strategy contributed to change in maternal mortality in India? (2 + 3 + 5 = 10) [PCSGMCH] 12. Describe the rationale for IMNCI. Describe the six elements involved in the IMNCI case management process. Apply this process in the management of a 3-year-old child with cough or difficulty in breathing. (2+3+5 = 10) [IQCITY] 13. Define Perinatal Mortality Rate. Enlist the contributory factors to such deaths. Outline the strategies for reduction of this rate. (7+3 = 10) [RGMCH] 14. A recently delivered post-caesarean mother reports that she is facing problems of insufficient breast milk. a) Name 4 common problems of breast feeding? b) What recommendations regarding breastfeeding will you give to counsel her? c) What is the schedule of post-natal visits at home for ASHA? d) Mention 4 benefits of exclusive breast feeding for mother. (2 + 2 + 2 + 2 = 8) [ESIC JOKA]

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Here are detailed answers to all 14 questions based on Park's Textbook of Preventive and Social Medicine and standard Indian community medicine curriculum:

GROUP B - SAQ ANSWERS (10 Marks Each)

Q1. ANC/PNC Services under RMNCAH+N + Three Delays Model (6+2+2)

RMNCAH+N - Full Form

Reproductive, Maternal, Newborn, Child, Adolescent Health + Nutrition

Package of Services for Antenatal Mothers under RMNCAH+N

At Sub-Centre / Ayushman Arogya Mandir (HWC):
  1. Minimum 4 ANC visits (WHO now recommends 8; India follows 4 - at registration, 14-16 wks, 28-32 wks, 36 wks)
  2. Registration of pregnancy (ideally in first trimester)
  3. Weight and height measurement; BMI calculation
  4. Blood pressure measurement at every visit
  5. Abdominal examination - fundal height, fetal heart sounds, lie and presentation
  6. Hemoglobin estimation (Hb <11 g/dL = anemia)
  7. Blood grouping and Rh typing
  8. Urine examination (albumin, sugar)
  9. Blood glucose (random/fasting)
  10. HIV testing (under PPTCT programme)
  11. VDRL/RPR for syphilis
  12. Tetanus Toxoid (TT) / Td immunization - 2 doses (or booster)
  13. Iron Folic Acid (IFA) supplementation - 180 tablets (100 mg elemental iron + 0.5 mg folic acid)
  14. Calcium supplementation (500 mg twice daily from 2nd trimester)
  15. Albendazole 400 mg (single dose in 2nd trimester - after quickening)
  16. Malaria prophylaxis in endemic areas
  17. Counselling - danger signs, nutrition, birth preparedness, SNCU
Pradhan Mantri Surakshit Matritva Abhiyan (PMSMA):
  • Fixed day (9th of every month)
  • Free ANC at CHC/PHC/District hospitals
  • Gynaecologist/physician examination of high-risk pregnancies

Package of Services for Postnatal Mothers under RMNCAH+N

Postnatal Care Visits:
VisitTimingBy Whom
PNC 1Within 24 hours of deliveryANM/Nurse
PNC 2Day 3 (48-72 hours)ASHA/ANM
PNC 3Day 7ANM
PNC 4Day 42 (6 weeks)ANM
Services Provided:
  1. Uterine involution check (subinvolution detection)
  2. Lochia assessment (quantity, colour, smell)
  3. Perineal/episiotomy wound care
  4. Breast examination and breastfeeding support
  5. Counselling on exclusive breastfeeding (EBF) for 6 months
  6. IFA continuation (180 days total)
  7. Calcium supplementation
  8. Family planning counselling and services (IUCD at 48 hours - PPIUCD)
  9. Immunization of newborn - BCG, OPV 0, Hep B 0
  10. Vitamin K injection to newborn
  11. Detection and management of postnatal complications (PPH, eclampsia, sepsis, depression)
  12. JSSK (Janani Shishu Suraksha Karyakram) benefits - free drugs, diet, transport

Three Delays Model (Thaddeus and Maine, 1994)

The Three Delays Model explains the determinants of maternal mortality. It identifies three phases of delay that contribute to maternal deaths:
Delay 1: Delay in Decision to Seek Care
  • Failure to recognize danger signs
  • Cultural beliefs (home delivery preference, male dominated decisions)
  • Previous bad experience with health facility
  • Financial constraints
  • Low education / low status of women
  • Interventions: Health education, women empowerment, ASHA mobilization, birth preparedness
Delay 2: Delay in Reaching the Health Facility
  • Poor road connectivity
  • Lack of transport
  • Distance from health facility
  • Cost of transport
  • Interventions: Janani Express / 108 ambulance, JSY incentives, referral linkages
Delay 3: Delay in Receiving Adequate Care at the Facility
  • Shortage of skilled healthcare providers
  • Lack of blood banking / OT facilities
  • Lack of drugs and equipment
  • Inadequate skills of service providers
  • Interventions: CEmONC at CHC level, LSAS training, 24x7 PHCs, FRUs
Key fact for exam: The model was proposed by Thaddeus and Maine (1994) and forms the basis for "Four Too" concept (too young, too old, too close, too many pregnancies).

Q2. 7-Day-Old Baby with Cry, Refusal of Feed, Convulsions (1+3+3+3)

i. Probable Diagnosis

Neonatal Tetanus (Tetanus Neonatorum)
Rationale: Classical triad of excessive cry/irritability, trismus (refusal of feeding due to inability to suck), and convulsions in a 7-day-old neonate. Age of onset is typically 3-14 days (average 7 days - "seven-day disease").

ii. Management

Immediate:
  1. Secure airway - suction secretions, oxygen if cyanosed
  2. Diazepam IV/rectal - 0.1-0.3 mg/kg for acute spasms; maintenance: 0.1-0.2 mg/kg q4-6h
  3. Phenobarbitone - 10-15 mg/kg loading dose IV; then 5 mg/kg/day as maintenance anticonvulsant
  4. Tetanus Immunoglobulin (TIG) - Human TIG 500 IU IM stat (to neutralize unbound toxin)
  5. Tetanus Toxoid to mother (tetanus doesn't confer immunity, so active immunization needed)
  6. Antibiotics: Metronidazole 15 mg/kg/day IV in 2 divided doses OR Penicillin G 100,000 units/kg/day (to eliminate Clostridium tetani)
  7. Wound care: Umbilical stump - clean with spirit/betadine; debride if infected
  8. Nasogastric tube feeding - if unable to suck; ensure nutrition
  9. Nursing in quiet, dark room - minimize stimuli that trigger spasms
  10. Supportive care: IV fluids, thermoregulation, prevent aspiration

iii. Prevention

  1. Maternal immunization with TT/Td:
    • TT1: Early in pregnancy (as soon as possible)
    • TT2: 4 weeks after TT1 (protects for 3 years)
    • TT Booster: if previously immunized within 3 years
    • This provides passive immunity to neonate via IgG transplacental transfer
  2. Clean Delivery Practices (Five Cleans):
    • Clean hands of birth attendant
    • Clean delivery surface
    • Clean cord cutting instrument (new blade/boiled scissors)
    • Clean cord tie (new thread/cord clamp)
    • Clean cord stump (do not apply cow dung, ash, mud)
  3. Skilled Birth Attendance - delivery by trained health worker
  4. Chlorhexidine cord care - 7.1% chlorhexidine gel application to cord stump (reduces omphalitis and neonatal tetanus risk)
  5. Postnatal cord care education to mothers and ASHA workers

iv. National Immunization Schedule for Infants (UIP - Universal Immunisation Programme)

AgeVaccineDoseRoute
BirthBCG0.1 mL (0.05 mL <1 month)Intradermal (left upper arm)
BirthOPV-02 dropsOral
BirthHep B-00.5 mLIM (anterolateral thigh)
6 weeksOPV-12 dropsOral
6 weeksPentavalent-1 (DPT+HepB+Hib)0.5 mLIM
6 weeksIPV-1 (Fractional dose)0.1 mLIntradermal
6 weeksRotavirus-15 dropsOral
6 weeksPCV-10.5 mLIM
10 weeksOPV-22 dropsOral
10 weeksPentavalent-20.5 mLIM
10 weeksRotavirus-25 dropsOral
14 weeksOPV-32 dropsOral
14 weeksPentavalent-30.5 mLIM
14 weeksIPV-2 (Fractional dose)0.1 mLIntradermal
14 weeksRotavirus-35 dropsOral
14 weeksPCV-20.5 mLIM
9 monthsMeasles/MR-10.5 mLSubcutaneous
9 monthsVitamin A (1st dose)1 lakh IUOral
9 monthsJE-1*0.5 mLSC (*endemic districts)
Booster doses at 16-24 months not included in infant schedule.

Q3. 4-Month-Old Baby - RR 55/min, No Chest Indrawing - IMNCI Classification (2+5+3)

Classification: FAST BREATHING (Pneumonia - non-severe)

IMNCI Classification of Cough/Difficulty Breathing (2-12 months):
ClassificationSignsTreatment
Severe Pneumonia or Very Severe DiseaseChest indrawing OR any general danger signRefer urgently; give pre-referral antibiotic + oxygen
Pneumonia (Non-Severe)Fast breathing (RR ≥50/min for 2-12 months) WITHOUT chest indrawingOral Amoxicillin; home care; follow-up in 2 days
No Pneumonia: Cough or ColdNo fast breathing, no chest indrawingHome care; soothe throat; no antibiotic
This baby: RR 55/min + no chest indrawing = NON-SEVERE PNEUMONIA

Management (5 marks)

Treatment:
  1. Amoxicillin 40 mg/kg/day in 2 divided doses for 5 days (first-line antibiotic for non-severe pneumonia)
  2. No antibiotic for cold/runny nose - symptomatic only
Home Care Advice (IMNCI "Counsel the Mother"):
  1. Continue breastfeeding / adequate fluids
  2. Clear blocked nose with saline drops
  3. Soothe throat with safe home remedies (if >6 months: honey; if <6 months: avoid)
  4. Do NOT use cough suppressants
  5. Keep child warm
Danger Signs - Return Immediately if:
  • Not able to drink/breastfeed
  • Worsening condition
  • Breathing becomes very fast or develops chest indrawing
  • Fever develops or persists
  • Child becomes sicker
Follow-up in 2 days:
  • Check if breathing improved
  • If worse or not improving: reassess and refer

Importance of Color Coding in IMNCI Chart (3 marks)

Color coding in IMNCI provides a visual triage system that helps health workers quickly identify severity and appropriate action:
ColorClassificationAction
RED (Pink)Severe / UrgentImmediate referral; pre-referral treatment
YELLOWModerate / Specific Treatment neededTreat at facility; counsel; follow-up
GREENMild / No treatment neededHome care; counsel; when to return
Rationale:
  1. Simplifies decision-making for health workers with limited training (ANMs, AWWs)
  2. Reduces diagnostic errors by standardizing criteria
  3. Ensures consistent treatment across levels of care
  4. Facilitates communication between health workers during referral
  5. Prioritizes urgency at a glance - even in busy OPD settings
  6. Minimizes under-treatment of severe cases and over-treatment of mild cases

Q4. Common Problems and Services for Adolescents (6+4)

Common Physical Problems in Adolescents

  1. Nutritional: Anemia (especially girls - due to menstrual loss + poor diet), undernutrition, obesity
  2. Reproductive and Sexual Health: Menstrual disorders (dysmenorrhea, irregular cycles), early marriage, early pregnancy, unsafe abortion, STIs/RTIs
  3. Growth and development disorders: Short stature, delayed puberty, scoliosis
  4. Skin problems: Acne vulgaris (hormonal)
  5. Oral health: Dental caries, malocclusion
  6. Substance abuse: Tobacco, alcohol, drugs - leading to addiction and organ damage
  7. Injuries and accidents: Road traffic accidents (leading cause of adolescent mortality)
  8. Vision and hearing defects: Refractive errors, noise-induced hearing loss
  9. Obesity and metabolic syndrome

Common Psychosocial Problems

  1. Mental health disorders: Depression, anxiety, conduct disorder, ADHD
  2. Suicidal ideation and behavior (2nd leading cause of adolescent death globally)
  3. Peer pressure and bullying (including cyberbullying)
  4. Body image issues - eating disorders (anorexia, bulimia)
  5. Identity crisis - gender identity, sexual orientation confusion
  6. Academic stress - examination anxiety, school dropout
  7. Family conflicts - generation gap, parental divorce
  8. Social media addiction / screen time excess
  9. Violence and abuse - sexual abuse, domestic violence

Services Available at Different Levels of Care

Sub-Centre / Ayushman Arogya Mandir (HWC):
  • WIFS (Weekly Iron Folic Acid Supplementation) - Blue IFA tablets (weekly) + deworming (Albendazole 400 mg biannually)
  • Health education and counselling
  • School health programme
Primary Health Centre:
  • RKSK (Rashtriya Kishor Swasthya Karyakram) - comprehensive adolescent health programme
  • AFHC (Adolescent Friendly Health Clinic) - confidential, non-judgmental services
  • Menstrual hygiene promotion (Free Sanitary Napkins - "Freedays")
  • Nutritional counselling and management of anemia
Community Health Centre / District Hospital:
  • AFHC with trained counsellor
  • Management of reproductive health problems
  • Mental health services
  • ARSH (Adolescent Reproductive and Sexual Health) clinics
  • Referral for substance abuse, eating disorders, mental health
At Community Level:
  • Peer Educator programme (trained adolescent peer educators)
  • Adolescent Health Day (under RBSK/RKSK)
  • SABLA (Scheme for Adolescent Girls) - under ICDS for girls 11-18 years
  • School Health Programme (under RBSK)

Q5. 2-Year-Old, 10 kg, Loose Stools x 2 days - IMNCI Dehydration Classification + Management of "Some Dehydration" (4+6)

Classification of Dehydration (IMNCI - 4 marks)

Assessment criteria (IMNCI diarrhoea assessment):
SignNo DehydrationSome Dehydration (≥2 of these)Severe Dehydration (≥2 of these)
General conditionWell, alertRestless, irritableLethargic/unconscious
EyesNormalSunkenVery sunken, dry
Mouth/TongueMoistDryVery dry
TearsPresentAbsentAbsent
Skin pinchGoes back quickly (<2 sec)Goes back slowly (2-3 sec)Goes back very slowly (>3 sec)
Thirst/drinkingDrinks normallyThirsty, drinks eagerlyDrinks poorly or unable to drink
ClassificationNo Dehydration - Plan ASome Dehydration - Plan BSevere Dehydration - Plan C
Color code: Yellow (Some Dehydration), Red/Pink (Severe Dehydration), Green (No Dehydration)

Management: "Some Dehydration" - ORS Plan B (6 marks)

1. ORS Therapy (Oral Rehydration Therapy):
  • Give ORS in the health facility for 4 hours (supervised rehydration)
  • Amount of ORS = 75 mL/kg body weight over 4 hours
  • For this child (10 kg): 75 × 10 = 750 mL of ORS over 4 hours
  • Give frequent small sips by spoon/cup; do NOT use bottle
  • If vomiting occurs, wait 10 minutes then restart slowly
2. Continue Breastfeeding - do not stop
3. Zinc Supplementation:
  • Age <6 months: 10 mg/day for 14 days
  • Age >6 months (this child): 20 mg/day for 14 days
  • Reduces severity and duration of diarrhea; prevents recurrence for 3 months
4. Reassess after 4 hours:
  • If rehydrated (no signs of dehydration) → Shift to Plan A (home management)
  • If still "Some Dehydration" → Repeat Plan B for another 4 hours
  • If now "Severe Dehydration" → Shift to Plan C (IV fluids; refer)
5. Plan A (Home Management - after rehydration):
  • Offer extra fluids after each loose stool
    • For 2-year-old: 100-200 mL ORS after each stool
  • Continue feeding; extra feeding during recovery (catch-up)
  • Return signs: blood in stool, not improving, child sicker, persistent vomiting
6. Do NOT give:
  • Antidiarrheal drugs (loperamide, codeine - contraindicated in children)
  • Antibiotics (unless bloody diarrhoea/cholera)
7. Counsel mother on:
  • Hand hygiene with soap
  • Safe drinking water (boiling/chlorination)
  • Food hygiene
  • Sanitation (use of toilet/latrine)

Q6. Pregnant Woman, 16 Weeks, First ANC Visit at Ayushman Arogya Mandir (4+2+4)

Services Provided as per RMNCAH+N at 16 Weeks (4 marks)

  1. Registration of pregnancy in Mother and Child Tracking System (MCTS) / RCH portal
  2. History taking - LMP, EDD calculation, obstetric history (gravida, para, abortions), medical/surgical history
  3. Physical examination: Weight, height, BMI, blood pressure, pallor, edema, thyroid
  4. Abdominal examination: Fundal height (should be at umbilicus at 20 weeks; at 16 weeks ~midway)
  5. Fetal heart sounds if detectable by Doppler
  6. Investigations:
    • Hb estimation (target Hb ≥11 g/dL)
    • Blood group and Rh typing
    • Urine albumin and sugar
    • Random Blood Sugar
    • VDRL/RPR
    • HIV test (ICTC)
    • Urine culture if available
  7. TT/Td immunization: TT1 at this visit (first dose); TT2 after 4 weeks
  8. IFA supplementation: Start 180 IFA tablets
  9. Calcium tablets: Start calcium 500 mg × 2 daily
  10. Albendazole 400 mg - single dose (safe after 14 weeks, i.e., after quickening period)
  11. Counselling: Nutrition (extra 300-400 kcal/day), rest, danger signs, institutional delivery
  12. PMSMA: Advise to attend on 9th of every month for specialist-level ANC
  13. Birth preparedness counselling: Identify birth place, skilled attendant, transport, blood donor, savings
  14. JSY (Janani Suraksha Yojana) registration for institutional delivery cash incentive

Danger Signs During Antenatal Period (2 marks)

Mnemonic: "CHEAPSS"
  1. Convulsions (eclampsia)
  2. Headache - severe, persistent (pre-eclampsia)
  3. Epilepsy-like fits
  4. Abdominal pain - severe (abruptio, ectopic)
  5. Pale appearance + breathlessness (severe anemia)
  6. Swelling of face, hands, feet (pre-eclampsia)
  7. Sudden reduction in fetal movements
  8. Bleeding per vaginum (APH - placenta previa, abruptio)
  9. Blurring of vision (imminent eclampsia)
  10. Fever with chills (malaria, UTI, chorioamnionitis)
  11. Vomiting - excessive (hyperemesis gravidarum)
  12. Leaking per vaginum - premature rupture of membranes

Predominant Health Problems of Tribal Population in India (4 marks)

Tribal population in India: ~8.6% (~104 million); mainly in forested, hilly, and remote areas of Odisha, Jharkhand, MP, Chhattisgarh, Maharashtra, Rajasthan, NE states.
Major Health Problems:
  1. Communicable Diseases:
    • Malaria (P. falciparum predominates; high mortality) - tribes bear 50% of India's malaria burden
    • Tuberculosis - high prevalence due to malnutrition and overcrowding
    • Sickle Cell Disease - high prevalence in tribal communities (UP to 30% carrier rate in some tribes)
    • Kala-azar (Leishmaniasis) in Jharkhand, Bihar
    • Japanese Encephalitis in endemic forested areas
  2. Nutritional Problems:
    • Protein-Energy Malnutrition (PEM) - very high prevalence
    • Anaemia (especially women and children)
    • Vitamin A deficiency (night blindness)
    • Iodine deficiency disorders (remote hill areas)
    • Fluorosis (high-fluoride water in parts of Rajasthan, Gujarat)
  3. Maternal and Child Health:
    • High MMR and IMR
    • Low institutional delivery (reliance on traditional birth attendants)
    • Low immunization coverage
    • High prevalence of childhood malnutrition
  4. Substance Abuse:
    • Alcohol (locally brewed: 'handia', 'mahua')
    • Tobacco chewing and smoking
  5. Other Problems:
    • Sickle cell anemia and thalassemia (genetic)
    • Snake bite (occupational hazard)
    • Occupational diseases (silicosis in miners)
    • Mental health issues
    • Social isolation, poor literacy, no access to healthcare
Government initiatives: PVTG (Particularly Vulnerable Tribal Groups) health programmes, tribal sub-plans, mobile medical units (Jan Arogya Vahini)

Q7. National Deworming Day (NDD) - Questions (1+1+1+1)

Objective of National Deworming Day (1 mark)

To reduce the burden of Soil-Transmitted Helminths (STH) - roundworm (Ascaris lumbricoides), hookworm (Ancylostoma duodenale/Necator americanus), and whipworm (Trichuris trichiura) - among children aged 1-19 years to improve nutritional status, educational outcomes, and overall health.

Target Beneficiaries (1 mark)

Children aged 1 to 19 years enrolled in government schools, anganwadis, and out-of-school children in the community.
  • NDD is conducted twice a year (February and August) in high-endemic states
  • Single round in lower-burden states

Drug and Dose (1 mark)

Age GroupDrugDose
1-2 yearsAlbendazole 400 mgHalf tablet (200 mg) - crushed/chewed
2-19 yearsAlbendazole 400 mg1 tablet (400 mg) - chewed
Drug: Albendazole (single dose, administered on NDD under direct supervision)

Common Adverse Event and Management (1 mark)

Most common adverse event: Nausea, vomiting, abdominal pain, and dizziness - occurs 2-4 hours after ingestion, especially in children with heavy worm burden (due to rapid worm kill causing toxin release).
Management:
  • These are usually mild and transient (self-limiting within 24 hours)
  • Reassure the child and parents
  • Symptomatic treatment: rest, oral fluids
  • Severe reactions: refer to nearest health facility
  • No need to discontinue the programme - Mebendazole can be substituted if repeat NDD is planned

Q8. Components of RMNCAH+N + Key Interventions in Maternal Health (5+10)

Components of RMNCAH+N (5 marks)

R - Reproductive Health:
  • Family planning services
  • Management of RTI/STI
  • PPTCT (Prevention of Parent-to-Child Transmission of HIV)
M - Maternal Health:
  • ANC package
  • Safe delivery (JSSK)
  • Postnatal care
  • Management of obstetric complications (EmONC)
N (Newborn) - Newborn Health:
  • Essential Newborn Care (ENC)
  • Kangaroo Mother Care (KMC) for LBW
  • SNCU (Special Newborn Care Unit)
  • NBSU (Newborn Stabilization Unit)
C - Child Health:
  • IMNCI
  • Immunization (UIP)
  • Nutrition (POSHAN Abhiyaan)
  • RBSK (Rashtriya Bal Swasthya Karyakram)
A - Adolescent Health:
  • RKSK (Rashtriya Kishor Swasthya Karyakram)
  • WIFS (Weekly Iron Folic Acid Supplementation)
  • SABLA
  • Menstrual hygiene
+N - Nutrition:
  • POSHAN Abhiyaan (National Nutrition Mission)
  • ICDS (Anganwadi services)
  • Nutritional supplementation (IFA, Vitamin A, Zinc)

Key Interventions in Maternal Health (10 marks)

A. Antenatal Care:
  1. Early registration (within 1st trimester) - minimum 4 ANC visits
  2. PMSMA - specialist ANC on 9th of every month
  3. IFA, calcium, Albendazole supplementation
  4. Screening for high-risk pregnancy (Hb <7, BP >140/90, gestational diabetes, malpresentation)
  5. Tetanus immunization
  6. Birth preparedness planning
B. Intrapartum Care:
  1. Institutional delivery promotion (JSY cash incentive: Rs. 1400 rural/Rs. 1000 urban BPL)
  2. JSSK - free delivery, drugs, diagnostics, transport, diet, blood transfusion
  3. Skilled Birth Attendance at all deliveries
  4. Active Management of Third Stage of Labour (AMTSL):
    • Oxytocin 10 IU IM within 1 minute of delivery
    • Controlled cord traction
    • Uterine massage
  5. Misoprostol distribution to high-risk women in communities (3 tablets × 200 mcg)
  6. LaQshya programme - quality improvement in labour rooms and maternity OTs
C. Emergency Obstetric Care:
  1. 24x7 PHCs for normal delivery
  2. FRUs (First Referral Units) at CHC level - CEmONC (Comprehensive Emergency Obstetric and Newborn Care)
    • Blood transfusion, emergency C-section, manual vacuum aspiration
  3. LSAS (Life Saving Anaesthesia Skills) and EmOC training for MOs
  4. One-stop crisis centre for women facing domestic violence
D. Postnatal Care:
  1. JSSK benefits for 30 days post-delivery
  2. Vitamin K to newborn
  3. Early initiation of breastfeeding (within 1 hour)
  4. PPIUCD insertion at 48 hours
  5. 42-day follow-up for both mother and newborn
E. Maternal Death Review (MDR):
  • Verbal autopsy-based review of every maternal death
  • Community-based and facility-based MDR
  • Identifies delays (Three Delays Model)
  • Corrective action at facility and system level
F. Numerical Targets (RMNCH+A 2013 strategy):
  • Reduce MMR to <70/lakh LB (SDG target by 2030)
  • India's current MMR: ~97/lakh LB (SRS 2018-20)

Q9. LBW - Definition, Classification, BMOH Measures (2+3+5)

Definition of LBW (2 marks)

Low Birth Weight (LBW): Birth weight less than 2500 grams (2.5 kg), regardless of gestational age.
  • Defined by WHO
  • India's LBW prevalence: ~18% (NFHS-5)
  • Leading cause of neonatal and infant morbidity/mortality

Classification of LBW Babies (3 marks)

By Weight:
CategoryBirth Weight
Low Birth Weight (LBW)<2500 g
Very Low Birth Weight (VLBW)<1500 g
Extremely Low Birth Weight (ELBW)<1000 g
By Gestational Age and Weight (more clinically relevant):
TypeDescriptionCause
Preterm AGA (Appropriate for Gestational Age)Premature (<37 weeks) but weight normal for gestational agePremature labour
Term SGA (Small for Gestational Age)Born at term but weight <10th percentile for gestational age (IUGR)Intrauterine growth restriction
Preterm SGABoth premature AND growth restrictedCombined causes
AGA vs SGA: SGA = weight below 10th percentile for gestational age = IUGR (Intrauterine Growth Retardation)

Measures as BMOH to Reduce LBW (5 marks)

As Block Medical Officer of Health (BMOH):
Antenatal Interventions:
  1. Early ANC registration and minimum 4 ANC visits - early detection of high-risk mothers
  2. Nutritional supplementation: IFA (180 days), Calcium, Protein supplementation (Bal Amrit/Poshak Aahar under ICDS)
  3. Management of anemia - treat Hb <7 g/dL with parenteral iron or blood transfusion
  4. Screen and treat infections: UTI, malaria, syphilis, periodontal disease (all associated with preterm/LBW)
  5. Malaria prophylaxis in endemic blocks (IPTp not yet standard in India, but prompt treatment)
  6. Prevent teenage pregnancy - enforce PCPNDT/PCMA act; promote delayed marriage through RKSK
  7. Screen for PIH/Pre-eclampsia - low-dose aspirin (75-150 mg) in high-risk women from <20 weeks
Community-Based Interventions: 8. ICDS centres - nutrition supplementation to pregnant/lactating women (THR - Take Home Ration) 9. VHND (Village Health, Nutrition and Development Day) - monthly immunization and nutrition sessions 10. ASHA mobilization - ensure all pregnant women are registered and receiving benefits 11. Reduce workload of pregnant women - advise adequate rest; enforce Maternity Benefit Act
Social Interventions: 12. Improve female literacy - correlates strongly with reduced LBW 13. Delayed age of marriage (legal age: 18 years for girls, 21 for boys - Prohibition of Child Marriage Act) 14. Birth spacing - promote 2-3 years interval using family planning 15. Anti-tobacco campaign - smoking and smokeless tobacco are risk factors for IUGR
Facility-Level: 16. Kangaroo Mother Care (KMC) unit at CHC/PHC for LBW babies 17. SNCU (Special Newborn Care Unit) at District Hospital for VLBW babies

Q10. Infant Mortality Rate - Definition, Causes, Under-5 Clinic (2+3+5)

Definition of IMR (2 marks)

Infant Mortality Rate (IMR): The number of deaths of infants under 1 year of age per 1000 live births in the same year in a given population.
Formula: IMR = (Deaths in <1 year / Live births in same year) × 1000
  • India's IMR (SRS 2020): 28 per 1000 live births
  • SDG Target: Reduce U5MR to ≤25 per 1000 LB (IMR component)
  • IMR is a sensitive indicator of socioeconomic development and healthcare quality
Components:
  • Neonatal mortality rate (NMR): Deaths in 0-28 days / 1000 LB (~67-75% of IMR)
  • Post-neonatal mortality rate: Deaths from 29 days to 11 months / 1000 LB

Causes of Infant Mortality (3 marks)

Neonatal (0-28 days) - major contributor:
  1. Prematurity and LBW (major cause - ~35%)
  2. Birth asphyxia (~20%)
  3. Neonatal sepsis (~10%)
  4. Congenital anomalies
  5. Neonatal tetanus (declining)
  6. Hypothermia
Post-neonatal (1-11 months):
  1. Diarrhoeal diseases (ORS has reduced mortality significantly)
  2. Acute Respiratory Infections (ARI) / Pneumonia
  3. Malnutrition (PEM as contributory cause)
  4. Vaccine-preventable diseases (measles, pertussis)
  5. Anemia

Role of Under-5 Clinic (Child Welfare Clinic) (5 marks)

The Under-5 Clinic (U5C) or "Well Baby Clinic" is conducted at PHC/CHC level typically once a week to monitor and promote health of children under 5 years.
Functions:
  1. Growth Monitoring and Promotion (GMP):
    • Monthly weighing of children
    • Plotting weight on Road-to-Health (RTH) card / growth chart
    • Early identification of growth faltering and malnutrition (SAM, MAM)
  2. Immunization:
    • Delivery of all UIP vaccines as per schedule
    • Maintain cold chain
    • Follow-up of defaulters
  3. Nutritional Interventions:
    • Vitamin A supplementation (9 months - 5 years, 6-monthly)
    • IFA syrup for 6 months to 5 years
    • Zinc supplementation during diarrhoea
    • Referral to NRC (Nutrition Rehabilitation Centre) for SAM
  4. Curative Services:
    • Management of common illnesses using IMNCI approach
    • ORT corner - management of diarrhoea with ORS
    • Respiratory illness management
  5. Developmental Screening:
    • Milestone assessment (RBSK - screening for 4 Ds: Defects at birth, Deficiencies, Diseases, Developmental delays)
    • Vision screening, hearing screening
  6. Mother Education (KAP):
    • Breastfeeding counselling, complementary feeding advice
    • Personal hygiene and environmental hygiene
    • Danger signs education
    • Family planning counselling
  7. Records and Registers:
    • Maintain child register, growth charts, immunization records
    • Reporting to district for HMIS

Q11. MMR - Definition, Causes, RMNCAH+N Contribution (2+3+5)

Definition of MMR (2 marks)

Maternal Mortality Ratio (MMR): The number of maternal deaths (deaths of women while pregnant or within 42 days of termination of pregnancy from causes related to or aggravated by pregnancy or its management, but not from accidental/incidental causes) per 100,000 live births in the same year.
  • India's current MMR: 97 per lakh live births (SRS 2018-20)
  • SDG Target: <70 per lakh LB by 2030
  • India has reduced MMR from 254 (2004-06) to 97 (2018-20) - a 62% reduction

Causes of MMR in India (3 marks)

HAEMORRHAGE (major cause - ~35%):
  1. Postpartum Haemorrhage (PPH) - most common cause of maternal death worldwide; primary (within 24h) and secondary (24h to 6 wks)
  2. Antepartum Haemorrhage (APH) - placenta previa, abruption placentae
HYPERTENSIVE DISORDERS (~20%): 3. Pre-eclampsia and Eclampsia (convulsions in pregnancy) 4. HELLP syndrome
SEPSIS/INFECTION (~10%): 5. Puerperal sepsis (post-delivery) 6. Unsafe abortion complications
OBSTRUCTED LABOUR (~5%): 7. Prolonged/obstructed labour
OTHER DIRECT CAUSES: 8. Ectopic pregnancy rupture 9. Amniotic fluid embolism 10. Anaesthesia complications
INDIRECT CAUSES (~20%): 11. Severe Anemia (Hb <7 g/dL - aggravates all direct causes) 12. Malaria in pregnancy 13. Tuberculosis 14. Cardiac disease in pregnancy 15. Hepatitis E (fulminant hepatic failure in pregnancy)
Unsafe abortion contributes to ~8% of maternal deaths in India.

How RMNCAH+N has Contributed to Reduction in MMR (5 marks)

  1. JSY (Janani Suraksha Yojana): Financial incentive for institutional delivery has increased institutional births from ~38% (2005) to ~89% (NFHS-5, 2019-21) - massively reducing home delivery deaths
  2. JSSK (Janani Shishu Suraksha Karyakram): Cashless services (delivery, C-section, drugs, blood, transport) removed financial barriers to care-seeking
  3. 24x7 PHCs and FRUs: Availability of skilled birth attendance round the clock; CEmONC at FRU level for emergency C-section and blood transfusion
  4. LaQshya programme: Improved quality of care in labour rooms and maternity OTs - reduced birth asphyxia and PPH deaths
  5. AMTSL (Active Management of Third Stage of Labour): Universal use of Oxytocin 10 IU IM at all deliveries has significantly reduced PPH deaths
  6. Iron Folic Acid supplementation and WIFS: Reduced anemia prevalence (anemia is a major indirect cause of maternal deaths)
  7. Misoprostol distribution: Community-level prevention of PPH in high-risk women
  8. Pre-eclampsia screening and low-dose aspirin: Reduced eclampsia-related deaths
  9. ASHA and community mobilization: ASHAs accompany women to facility, reducing all Three Delays
  10. Maternal Death Surveillance and Response (MDSR) / MDR: Every maternal death reviewed; system-level corrective action taken
  11. PMSMA (Pradhan Mantri Surakshit Matritva Abhiyan): Early identification and management of high-risk pregnancies

Q12. Rationale for IMNCI + Six Elements + Application (2+3+5)

Rationale for IMNCI (2 marks)

Integrated Management of Neonatal and Childhood Illness (IMNCI) was introduced by WHO/UNICEF in India in 1997-98.
Rationale:
  1. 5 conditions account for >70% of under-5 deaths: ARI/pneumonia (19%), diarrhoea (18%), malaria, measles, malnutrition (synergistic)
  2. Children often present with multiple simultaneous illnesses - single-disease approach misses co-morbidities
  3. Syndromic approach is feasible at first-referral level without expensive diagnostics
  4. Integrated approach improves efficiency (one visit, multiple conditions assessed)
  5. Standardized training improves quality and consistency of care at primary level
  6. Color-coded chart booklet simplifies decision-making for health workers

Six Elements of IMNCI Case Management Process (3 marks)

  1. ASSESS - Take history and perform clinical examination using IMNCI checklist (general danger signs, then individual illness assessment)
  2. CLASSIFY - Categorize illness using color-coded classification table (Red/Yellow/Green)
  3. IDENTIFY TREATMENT - Based on classification, select appropriate treatment from IMNCI chart
  4. TREAT - Administer pre-referral treatment for severe cases; treat non-severe cases at facility
  5. COUNSEL - Counsel mother on home care, feeding, fluids, when to return
  6. FOLLOW-UP - Schedule follow-up visit; reassess at follow-up

Application: 3-Year-Old Child with Cough/Difficulty Breathing (5 marks)

Step 1 - ASSESS:
  • Check General Danger Signs first: Unable to drink/breastfeed? Vomiting everything? Convulsions? Lethargic/unconscious?
  • Ask: How long? Blood in sputum? Previous TB?
  • Look: Chest indrawing? Stridor?
  • Count respiratory rate for 60 full seconds:
    • For child 12 months to 5 years: Fast breathing = RR ≥40/min
Step 2 - CLASSIFY:
If child has:Classify as:Color
Any general danger sign OR chest indrawing OR stridor in calm childSevere Pneumonia or Very Severe DiseaseRED
Fast breathing (RR ≥40 for this age)PneumoniaYELLOW
No fast breathing, no chest indrawingNo Pneumonia: Cough or ColdGREEN
Step 3 - IDENTIFY TREATMENT:
  • Severe Pneumonia (RED): Give 1st dose Amoxicillin IM/Ampicillin IM + Oxygen → REFER URGENTLY
  • Pneumonia (YELLOW): Oral Amoxicillin 40 mg/kg/day × 5 days; follow-up in 2 days
  • No Pneumonia (GREEN): No antibiotic; soothe throat with safe remedy
Step 4 - TREAT: For non-severe pneumonia in 3-year-old (~15 kg):
  • Amoxicillin: 40 × 15 = 600 mg/day = 300 mg twice daily for 5 days
Step 5 - COUNSEL:
  • Continue feeding; extra fluids
  • Return signs: breathing worsens, fever persists, child unable to drink
Step 6 - FOLLOW-UP:
  • In 2 days for pneumonia
  • If improved: complete antibiotic course
  • If not improved: reassess, check for alternative diagnosis (TB? Foreign body?), refer

Q13. Perinatal Mortality Rate - Definition, Contributory Factors, Strategies (7+3)

Definition of Perinatal Mortality Rate (PMR)

Perinatal Mortality Rate (PMR): The number of perinatal deaths (stillbirths after 28 weeks + early neonatal deaths in first 7 days of life) per 1000 total births (live births + stillbirths after 28 weeks).
Formula: PMR = [(Stillbirths ≥28 weeks) + (Early neonatal deaths 0-7 days)] / (Total births ≥28 weeks) × 1000
  • India's PMR: approximately 24-26 per 1000 total births (SRS data)
  • Perinatal period: from 28 weeks of gestation to 7 days after birth (WHO definition)
    • Some definitions use 22 weeks to 28 days (extended perinatal period)

Contributory Factors to Perinatal Deaths (7 marks)

Maternal Factors (Antepartum):
  1. Maternal age <18 or >35 years
  2. High parity (grand multiparity ≥5)
  3. Malnutrition and low pre-pregnancy weight
  4. Anemia (Hb <7 g/dL - placental insufficiency)
  5. Hypertensive disorders - pre-eclampsia causes IUGR and abruption
  6. Gestational Diabetes - macrosomia, stillbirth
  7. Infections: Malaria, syphilis (major causes of stillbirth), UTI
  8. Antepartum hemorrhage (APH) - placenta previa, abruption placentae
  9. Multiple pregnancy
  10. Low Socioeconomic Status and poor nutrition
Intrapartum Factors: 11. Birth asphyxia (most common cause of early neonatal death) 12. Prolonged/obstructed labour 13. Malpresentation (face, brow, transverse lie) 14. Cord complications (prolapse, knot, compression) 15. Shoulder dystocia 16. Delivery by untrained birth attendant (TBA) 17. Birth trauma (forceps/vacuum injury)
Newborn Factors: 18. Prematurity and LBW - respiratory distress syndrome (RDS/HMD) 19. Congenital anomalies (neural tube defects, cardiac defects) 20. Neonatal sepsis (early-onset - GBS, Listeria; late-onset - Staphylococcus) 21. Hypothermia 22. Meconium aspiration syndrome (MAS)

Strategies for Reduction of PMR (3 marks)

1. Antenatal Interventions:
  • Early ANC registration; minimum 4 visits
  • Identification and management of high-risk pregnancies
  • IFA and nutrition supplementation; treat anemia
  • Syphilis screening and treatment (VDRL at ANC)
  • Malaria prophylaxis in endemic areas
  • Folic acid supplementation (preconception) - prevents NTDs
2. Intrapartum Interventions:
  • Institutional delivery with skilled birth attendance
  • 24x7 PHC; FRU/CEmONC availability
  • Partograph use to detect prolonged/obstructed labour
  • Emergency C-section availability at FRU level
  • Basic neonatal resuscitation training for all birth attendants (NRP - Neonatal Resuscitation Programme)
  • "Helping Babies Breathe" (HBB) programme
3. Neonatal Interventions:
  • Essential Newborn Care (ENC) - warmth, dry-stimulate-reposition, delayed cord clamping, early breastfeeding
  • SNCU for sick neonates; NBSU at CHC
  • Kangaroo Mother Care (KMC) for preterm/LBW
  • Surfactant therapy for RDS (at district hospital level)
4. Community-Level:
  • Home-Based Newborn Care (HBNC) by ASHA - 7 visits in first 42 days
  • Community awareness about danger signs
  • Improve female literacy and nutritional status
5. Surveillance:
  • Perinatal Death Review (PDR) - similar to MDR
  • Corrective action at facility level

Q14. Post-Caesarean Mother - Breastfeeding Problems (2+2+2+2 = 8 marks)

a) 4 Common Problems of Breastfeeding (2 marks)

  1. Sore/cracked nipples - due to poor latch/attachment; most common
  2. Engorgement - bilateral breast fullness, hardness, pain; due to milk accumulation; prevents effective attachment
  3. Mastitis - infective inflammation of breast; unilateral; fever, redness, pain; Staphylococcus aureus; needs antibiotics
  4. Inverted/flat nipples - difficulty with latch; requires nipple shields or Hoffman's exercises
  5. (Additional) Insufficient milk / perceived milk insufficiency - most common reason for stopping breastfeeding prematurely; usually due to poor technique, not true insufficiency
  6. (Additional) Breast abscess - complication of mastitis; requires I&D + antibiotics
(Any 4 of the above for 2 marks)

b) Recommendations for Breastfeeding Counselling (2 marks)

  1. Initiation: Start breastfeeding within 1 hour of delivery (even post-C-section - once mother is awake and stable)
  2. Colostrum: Give all colostrum (yellowish "first milk") - rich in IgA, lactoferrin, growth factors; do NOT discard
  3. Exclusive Breastfeeding (EBF) for 6 months - no water, no other food/fluid during this period
  4. Correct positioning and attachment - baby's mouth covers areola, not just nipple; ensure wide gape
  5. On-demand feeding - 8-12 times per 24 hours; not scheduled
  6. Night feeding - essential; maintains prolactin levels and milk supply
  7. Avoid bottle/pacifier - nipple confusion reduces breastfeeding success
  8. Continued breastfeeding up to 2 years - with complementary feeding from 6 months
  9. Maternal nutrition: Extra 500 kcal/day; adequate fluid intake
  10. Medications safe in breastfeeding - most antibiotics (post-C-section) are safe; avoid chloramphenicol, ciprofloxacin, metronidazole (single doses acceptable)

c) Schedule of Postnatal Home Visits by ASHA (2 marks)

HBNC (Home-Based Newborn Care) Schedule - 7 visits:
Visit No.TimingFocus
Visit 1Day 1 (within 24 hours of home delivery)Ensure warmth, breastfeeding initiation, cord care, danger signs
Visit 2Day 3Feeding assessment, jaundice check, cord care, immunization (BCG/OPV0/HepB0)
Visit 3Day 7Weight check, feeding, cord condition
Visit 4Day 14Growth monitoring, developmental check
Visit 5Day 21
Visit 6Day 28
Visit 7Day 42Final review; family planning counselling
For institutional deliveries - first visit within 48-72 hours post-discharge
For VLBW/sick neonates: Additional visits on days 5, 9, 15, and daily monitoring if needed
What ASHA does at each visit:
  • Weigh newborn (detect <2500g or excess weight loss)
  • Assess breastfeeding (position, attachment, frequency)
  • Check for danger signs (jaundice, cold, not feeding, redness around cord, convulsions)
  • Counsel mother on exclusive breastfeeding, cord care, warmth
  • Refer urgently if danger signs present

d) 4 Benefits of Exclusive Breastfeeding for the Mother (2 marks)

  1. Lactational Amenorrhoea (LAM): Natural contraception - breastfeeding suppresses ovulation via prolactin; ~98% effective if baby <6 months, fully breastfed, and mother amenorrhoeic
  2. Reduced risk of Postpartum Hemorrhage (PPH): Oxytocin released during suckling causes uterine contraction (speeds involution, reduces bleeding)
  3. Reduced risk of breast cancer - EBF reduces lifetime risk of breast cancer (dose-dependent)
  4. Reduced risk of ovarian cancer - hormonal suppression during lactation is protective
  5. (Additional) Faster return to pre-pregnancy weight - breastfeeding burns ~500 extra kcal/day
  6. (Additional) Emotional bonding - oxytocin release promotes mother-baby bonding and reduces risk of postnatal depression
(Any 4 for 2 marks)
All answers based on Park's Textbook of Preventive and Social Medicine (24th Edition), IMNCI chart booklet (India adaptation), RMNCAH+N operational guidelines (MoHFW, Government of India), and National Health Mission programme guidelines.
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