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GROUP A - LAQ (15 MARKS) - MODEL ANSWERS

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Question 1: 17-year-old girl with vaginal discharge and abdominal pain (10+5)

Part A: Management (10 marks)

• Onset, duration, and character of discharge (colour, odour, amount)
• Abdominal pain - nature, radiation, relation to menstrual cycle
• Menstrual history: LMP, cycle regularity
• Sexual history (sensitively elicited) - partners, contraceptive use
• History of similar illness, prior treatment
• Social history: marital status, living conditions

• General: temperature, pallor, vitals
• Abdominal: tenderness, guarding, rebound tenderness (adnexal tenderness)
• Speculum exam: nature of discharge, cervical os condition
• Bimanual: cervical motion tenderness (chandelier sign), adnexal mass

• Gram stain and culture of vaginal/cervical swab
• Wet mount (Trichomonas, Clue cells for BV)
• CBC, ESR, CRP
• Urine examination to rule out UTI
• Pregnancy test (urine hCG) - mandatory before treatment
• Ultrasound abdomen/pelvis: rule out tubo-ovarian abscess

• Ceftriaxone 500 mg IM single dose + Doxycycline 100 mg twice daily x 14 days + Metronidazole 400 mg twice daily x 14 days

• Surgical emergency cannot be excluded
• Tubo-ovarian abscess
• Pregnancy
• Severe illness, vomiting
• Failure to respond to oral therapy within 72 hours

• Cefoxitin 2g IV every 6 hours + Doxycycline 100 mg oral/IV every 12 hours, continued for 24 hours after improvement, then oral doxycycline + metronidazole to complete 14 days
• OR: Clindamycin 900 mg IV every 8 hours + Gentamicin 2 mg/kg loading dose, then 1.5 mg/kg every 8 hours

• Partner notification and treatment (contact tracing)
• Counselling on safer sexual practices, condom use
• HIV testing (with consent)
• Reporting as per RNTCP/NACP protocols
• Syphilis serology (RPR/VDRL)

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Part B: Problems faced by a girl child in India (5 marks)

1. Sex-selective abortion and female foeticide - Misuse of ultrasound technology despite PCPNDT Act; skewed sex ratio at birth (914 females per 1000 males, Census 2011)
2. Neglect and discrimination in nutrition - Girls receive less food and healthcare; higher rates of anaemia, stunting, and undernutrition among girl children compared to boys
3. Child marriage - India has the second-highest number of child brides globally; girls married before 18 years face early pregnancy, obstetric complications, and are denied education
4. Denial of education - Higher school dropout rates among girls due to poverty, safety concerns, lack of toilets, household responsibilities, and early marriage
5. Violence and sexual abuse - Physical, sexual, and emotional abuse; child trafficking; female genital mutilation in certain communities
6. Lack of healthcare access - Boys preferentially taken for treatment; girls suffer more from preventable diseases due to delayed care-seeking
7. Child labour - Girls disproportionately involved in unpaid domestic labour, denied childhood and education
8. Social evils - Devadasi system, dowry-related violence, honour crimes

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Question 2: District with high home deliveries - RMNCHA+N and JSY (4+5+3+3=15)

Part A: Indicators for monitoring MCH services at district level (4 marks)

• Maternal Mortality Ratio (MMR) - deaths per 100,000 live births
• Proportion of institutional deliveries (%)
• Antenatal care coverage (at least 4 ANC visits - ANC4)
• Proportion receiving full ANC (TT + IFA + ANC check-ups)
• Percentage of deliveries conducted by skilled birth attendants (SBA)
• Postnatal care (PNC) coverage within 48 hours
• Proportion receiving 3 PNC visits

• Neonatal Mortality Rate (NMR) - deaths per 1000 live births
• Infant Mortality Rate (IMR) - deaths per 1000 live births
• Under-5 Mortality Rate (U5MR)
• Full immunization coverage (%)
• Exclusive breastfeeding rate (0-6 months)
• Proportion of LBW babies (<2500 g) managed at SNCU/NBSU
• Vitamin A supplementation coverage
• ORS use rate in diarrhoea episodes

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Part B: Major interventions under RMNCHA+N for reducing maternal and child mortality (5 marks)

• Contraceptive services: spacing methods (condoms, OCP, IUDs), sterilization (Tubectomy/Vasectomy)
• RTI/STI screening and treatment
• Prevention of gender-based violence

• Full ANC (minimum 4 visits): BP, weight, Hb, urine examination, TT immunization, IFA supplementation, calcium supplementation
• Skilled attendance at delivery (SBA)
• Emergency Obstetric Care (EmOC) at FRUs and district hospitals
• PostNatal Care: minimum 3 PNC visits; iron-folic acid for 180 days; breastfeeding promotion
• Janani Suraksha Yojana (JSY) - cash incentive for institutional delivery
• Janani Shishu Suraksha Karyakram (JSSK) - free delivery, C-section, transport, drugs

• Essential Newborn Care (ENC): warmth, cord care, early breastfeeding, identification of danger signs
• Newborn Care Corner (NBCC) at all delivery facilities
• Home Based Newborn Care (HBNC) by ASHAs - 7 visits in 42 days
• Special Newborn Care Unit (SNCU) at district hospitals for sick newborns

• Universal Immunization Programme (UIP): BCG, OPV, Pentavalent, PCV, Rotavirus, MR, JE, IPV, Td
• Integrated Management of Neonatal and Childhood Illness (IMNCI)
• Vitamin A supplementation (biannual doses for children 6 months to 5 years)
• Management of Severe Acute Malnutrition (SAM) - NRCs (Nutrition Rehabilitation Centres)
• RBSK (Rashtriya Bal Swasthya Karyakram) - 4D screening (Defects at birth, Deficiencies, Diseases, Developmental delays)

• RKSK (Rashtriya Kishor Swasthya Karyakram): anaemia control, nutrition, menstrual hygiene
• Weekly Iron Folic Acid Supplementation (WIFS)
• Adolescent Friendly Health Clinics (AFHCs)

• POSHAN Abhiyaan (National Nutrition Mission)
• Management of SAM and MAM
• Exclusive breastfeeding promotion
• Complementary feeding from 6 months

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Part C: Role of Janani Suraksha Yojana (JSY) in promoting safe motherhood (3 marks)

• 100% centrally sponsored scheme
• Integrates cash assistance with institutional care during antenatal, delivery, and immediate postpartum period
• ASHA works as a link worker in low-performing states (LPS) - escorts pregnant women to health facilities

• LPS (10 states: UP, MP, Bihar, Rajasthan, Jharkhand, Chhattisgarh, Odisha, Assam, Uttarakhand, J&K): Rural - Rs. 1400 (mother) + Rs. 600 (ASHA) = Rs. 2000; Urban - Rs. 1000 + Rs. 400 = Rs. 1400
• HPS: Rural - Rs. 700 + Rs. 600 = Rs. 1300; Urban - Rs. 600 + Rs. 400 = Rs. 1000

1. Promotes institutional delivery - reduces home deliveries with unskilled attendants
2. Provides financial support - removes economic barrier for poor families
3. ASHA component ensures community mobilization and accompaniment to facility
4. Motivates early ANC registration and postnatal care utilization
5. Includes referral transport assistance (minimum Rs. 250) for pregnant women
6. Eligible for all deliveries in LPS; BPL women in HPS

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Part D: Three priority actions to improve RMNCHA+N indicators in the district (3 marks)

1. Strengthen Skilled Birth Attendance and Institutional Delivery infrastructure:
   • Upgrade sub-centres and PHCs to 24x7 delivery facilities
   • Post trained ANMs/SBAs at all facilities
   • Activate JSY and JSSK cash benefits to incentivize institutional delivery
   • Address physical barriers (transport, distance) through 108 ambulance services
2. Improve ANC coverage and quality through community outreach:
   • Register all pregnant women in the first trimester (by ASHA/ANM)
   • Ensure minimum 4 ANC visits with full package (TT, IFA 180 tabs, BP, Hb, ultrasound)
   • VHSND (Village Health, Sanitation and Nutrition Day) sessions monthly at Anganwadi centres
   • Use RCH register and Mother and Child Protection Card (MCP card) for tracking
3. Strengthen newborn care and postnatal surveillance:
   • Operationalize NBCC in all delivery points and SNCU at district hospital
   • Train ASHAs for HBNC (7 home visits in first 42 days of life)
   • Promote Kangaroo Mother Care (KMC) for LBW babies
   • Ensure timely referral of sick newborns from community to SNCU

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Question 3: Neonatal Mortality - Definition, Importance, Essential Newborn Care with Infection Control (2+3+10=15)

Definition (2 marks)

• Early Neonatal Mortality: Deaths in first 7 days (0-6 days) of life
• Late Neonatal Mortality: Deaths between 7-28 days of life

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Importance (3 marks)

1. Epidemiological significance: Neonatal deaths account for approximately 40-50% of all under-5 deaths in India. About 2/3 of infant deaths are neonatal deaths.
2. Indicator of maternal and child health services: NMR reflects the quality of obstetric care, newborn care, and nutrition services. High NMR indicates poor ANC quality, unskilled delivery attendance, and inadequate newborn care.
3. SDG and national target: Sustainable Development Goal 3.2 aims to end preventable deaths of newborns - target NMR ≤12 per 1000 live births by 2030. India's National Health Policy 2017 targets NMR ≤16 by 2025.
4. Preventable burden: Major causes (birth asphyxia ~24%, prematurity/LBW ~30%, sepsis ~20%, congenital defects) are largely preventable with simple, cost-effective interventions - making improvement in NMR achievable.
5. Social and economic impact: Infant and neonatal mortality leads to repeat pregnancies, high fertility rates, and perpetuates poverty - reducing NMR breaks this cycle.

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Components of Essential Newborn Care with Special Reference to Infection Control (10 marks)

• Warm delivery room (>25°C)
• Immediate drying with warm cloth after birth
• Skin-to-skin contact (Kangaroo Mother Care)
• Delayed bathing (at least 6 hours, preferably 24 hours)
• Proper wrapping and capping
• Radiant warmer for sick/preterm newborns

• Clear airway by gentle suction only if secretions present
• Basic newborn resuscitation: stimulation, positioning, bag-and-mask ventilation
• Avoid routine suction (increases infection risk)
• APGAR score assessment at 1 and 5 minutes

• Initiate within 30-60 minutes of birth (first hour - "golden hour")
• Colostrum feeding - provides passive immunity (IgA, lysozyme, lactoferrin)
• Exclusive breastfeeding for first 6 months
• Prevents sepsis, diarrhoea, and respiratory infections

• Clean cord cutting with sterile blade/scissors
• Tie cord with clean thread or sterile clamp
• Dry cord care: WHO recommends keeping the cord clean and dry
• Apply 7% chlorhexidine gel to cord stump within first day of life in home deliveries (India policy) - reduces omphalitis and neonatal sepsis by 23%
• Avoid applying cow dung, ash, oil, or traditional substances (major infection risk)
• Watch for signs of omphalitis: redness, swelling, discharge, fever

• 1% tetracycline eye ointment or 1% silver nitrate drops in both eyes at birth
• Prevents gonococcal ophthalmia neonatorum (leading cause of neonatal blindness)

• Treat maternal RTI/STI before delivery
• GBS screening and prophylaxis (where available)
• Clean delivery practices (5 cleans): clean hands, perineum, cord cutting, cord tying, cord dressing

• Clean delivery environment
• Hand washing with soap and water (20 seconds) before and after handling newborn
• Use of sterile/clean gloves
• Sterile equipment for cord cutting

• Hand hygiene - single most important measure; WHO 5 moments of hand hygiene
• Clean wrapping material
• Avoid overcrowding in nurseries
• Cohorting of infected newborns
• Standard precautions: gloves, gowns when handling blood/secretions
• Antibiotic prophylaxis for high-risk newborns (PROM >18 hours, maternal fever, GBS positive)

• Poor feeding, lethargy
• Fever (>38°C) or hypothermia (<36°C)
• Fast breathing (>60/min), grunting, retractions
• Bulging fontanelle
• Yellow skin/eyes appearing within 24 hours
• Convulsions

• Ampicillin + Gentamicin (first-line, WHO recommended)
• Refer to SNCU if at peripheral facility

• BCG at birth (within first week)
• OPV-0 (birth dose) within first 24 hours
• Hepatitis B birth dose within 24 hours

• IM Vitamin K 1 mg at birth - prevents haemorrhagic disease of newborn (HDN)

• Identify LBW (<2500 g), preterm, sick, or asphyxiated newborns
• Refer to appropriate level of care (NBCC → NBSU → SNCU)

• ASHA conducts 7 visits in first 42 days (days 1, 3, 7, 14, 21, 28, 42)
• Promotes breastfeeding, warmth, cord care, immunization
• Early identification and referral of sick newborns

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Question 4: LBW Preterm Baby 1900g at 35 weeks - PROM (2+1+2+8+2=15)

Identify the condition and its type (2 marks)

• Gestational age: 35 weeks (preterm = < 37 weeks) - Late preterm (34-36+6 weeks)
• Birth weight: 1900 g - between 1500-2499 g = Moderate LBW (some classify as Moderately Low Birth Weight)
• Not intrauterine growth restricted (weight appropriate for 35 weeks gestation)

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Does the baby require admission in SNCU? Justify (1+2=3 marks... per marking scheme 2+1=2 marks here, then justify separately)

1. Gestational age 35 weeks - Late preterm infants have immature organ systems and are at high risk for respiratory distress, feeding difficulties, hypoglycaemia, and hypothermia
2. Birth weight 1900 g - LBW babies need specialized monitoring and often require tube feeding, temperature regulation, and monitoring for apnoea
3. PROM as risk factor - Premature rupture of membranes is a major risk factor for early-onset neonatal sepsis (Group B Streptococcus, E. coli, Listeria); the baby needs antibiotic prophylaxis and close monitoring

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Principles of care of a stable newborn with this condition (8 marks)

• Maintain neutral thermal environment (skin temperature 36.5-37.5°C)
• Kangaroo Mother Care (KMC): continuous skin-to-skin contact between mother and baby - maintains temperature, promotes breastfeeding, reduces apnoea
• Servo-controlled incubator or radiant warmer if KMC not feasible
• Monitor axillary temperature every 3 hours

• Encourage exclusive breastfeeding - expressed breast milk (EBM) if direct sucking not possible
• Cup/spoon or nasogastric tube feeding if sucking-swallowing coordination poor (common in preterms <34 weeks, may persist to 35 weeks)
• Small frequent feeds (8-12 times/day)
• Monitor for feeding tolerance: gastric residuals, abdominal distension
• Kangaroo Mother Care facilitates breastfeeding

• Empirical antibiotics given risk of infection from PROM (Ampicillin + Gentamicin)
• Monitor for sepsis signs: poor feeding, temperature instability, respiratory distress, lethargy, jaundice
• CBC, blood culture, CRP if sepsis suspected

• Monitor respiratory rate (normal 40-60/min)
• Watch for respiratory distress syndrome (RDS) - less common at 35 weeks but possible
• Supplemental oxygen if SpO2 <90% (target 91-95% in preterm)

• Early breastfeeding (within 30-60 min)
• Blood glucose monitoring: at 1 hour, 3 hours, then before each feed for first 24-48 hours
• Target blood glucose >45 mg/dL (WHO: >2.6 mmol/L)
• IV dextrose (10%) if unable to feed or blood glucose low

• LBW preterm infants at high risk for significant hyperbilirubinemia
• Monitor clinical jaundice - measure serum bilirubin
• Phototherapy if bilirubin above treatment thresholds (lower thresholds for preterm vs. term)

• Dry cord care, chlorhexidine application
• Hand hygiene by all caregivers

• Minimize painful procedures
• Promote parental involvement through KMC
• Reduce noise and light in SNCU environment

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Four possible complications (2 marks)

1. Respiratory Distress Syndrome (RDS) - surfactant deficiency; tachypnoea, retractions, grunting
2. Neonatal Sepsis - particularly early-onset (from PROM); Gram-negative sepsis
3. Hypoglycaemia - poor glycogen stores, inadequate feeding
4. Neonatal Jaundice (Hyperbilirubinemia) - immature conjugation, polycythaemia, sepsis
5. (Other acceptable answers: NEC, apnoea of prematurity, retinopathy of prematurity, intraventricular haemorrhage)

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Question 5: 1-year-old with fever + breathing difficulty, post-measles, missed immunization - IMNCI (4+6+5=15)

Classification of disease according to IMNCI protocol (4 marks)

• Cannot drink/breastfeed?
• Vomits everything?
• Convulsions now or recently?
• Abnormally sleepy/unconscious?
• If any present: SEVERE CLASSIFICATION - refer urgently

• Respiratory rate: Count for 1 full minute
  • Fast breathing in this age group (12-59 months) = ≥ 40 breaths/min
• Chest indrawing (lower chest wall goes IN when child breathes IN)
• Stridor (harsh noise on inspiration)

• If chest indrawing OR stridor in calm child → SEVERE PNEUMONIA / VERY SEVERE DISEASE (Red category)
• If fast breathing ONLY (≥40/min), no chest indrawing → PNEUMONIA (Yellow category)
• If no fast breathing, no chest indrawing → NO PNEUMONIA: COUGH OR COLD (Green category)

• Post-measles pneumonia is often caused by bacterial superinfection or measles giant cell pneumonia

• History of rash + fever = Measles confirmed
• Complications: mouth ulcers, clouding of cornea, deep/extensive skin infection, pneumonia → indicates SEVERE COMPLICATED MEASLES
• Vitamin A deficiency risk (missed immunization at 9 months means missed Vitamin A dose at 9 months also)

• Severe Pneumonia (if chest indrawing/stridor present)
• Severe Complicated Measles (pneumonia as complication)

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Management according to IMNCI protocol (6 marks)

• First dose of Amoxicillin (oral) before referral if mild pneumonia
• For severe pneumonia: IM Benzylpenicillin (Ampicillin 50 mg/kg IM/IV every 6 hours) + Gentamicin (7.5 mg/kg IM/IV daily)
• Alternative: Cotrimoxazole for pneumonia at community level (if hospital not accessible)
• If no improvement in 48 hours - consider Chloramphenicol (possible Staph/MRSA in post-measles)

• Oxygen therapy: maintain SpO2 >94%
• IV fluids: only if unable to feed; avoid excess (pneumonia: risk of SIADH)
• IV antibiotics: Ampicillin + Gentamicin for 5-7 days, or Benzyl penicillin
• Nebulized bronchodilator if wheeze present (post-measles bronchiolitis component)

• Vitamin A supplementation (MANDATORY):
  • 200,000 IU orally immediately (Day 1)
  • 200,000 IU next day (Day 2)
  • 200,000 IU at 2-4 weeks (if malnutrition/vitamin A deficiency present)
  • Rationale: Vitamin A reduces measles mortality by 50% and prevents corneal scarring/blindness
• Treat mouth ulcers: Gentian violet application
• Eye care: antibiotic eye drops/ointment if conjunctivitis or corneal clouding

• Paracetamol 15 mg/kg per dose if temperature ≥38.5°C
• Tepid sponging

• Continue/encourage feeding throughout illness
• Extra fluids

• The child missed measles vaccine at 9 months - now had measles (natural infection provides immunity)
• Complete pending vaccines: check and give OPV, DPT/Pentavalent boosters as applicable

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Advice to mother during discharge (5 marks)

• Child is unable to drink or breastfeed
• Becomes sicker or condition worsens
• Develops fast breathing or chest indrawing again
• Develops fever again (high temperature)
• Convulsions

• Continue breastfeeding (if still breastfeeding)
• Give extra food during and after illness (catch-up feeding)
• Give extra fluids (breastmilk, ORS, clean water)
• Do not stop feeding during illness

• Give all tablets as prescribed (complete 5 days of Amoxicillin)
• Do not stop even if child improves

• Explain importance of Vitamin A in preventing blindness and reducing severity of future infections
• Give third dose as per schedule (2-4 weeks)

• The child has missed the 9-month vaccines (Measles vaccine + Vitamin A dose)
• Natural measles infection provides immunity, but all other vaccines must be completed
• Visit nearest PHC/immunization session for catch-up vaccines (DPT booster, OPV boosters, MR vaccine per current schedule)
• Bring child for 15-month MR2 dose at appropriate time

• Frequent handwashing with soap (before feeding, after defecation)
• Safe drinking water
• Proper sanitation (ODF behavior)

• Child should receive adequate diet (cereals, pulses, green vegetables, eggs, milk) to rebuild immunity after measles
• Measles causes severe immune suppression for 6-8 weeks (immune amnesia)
• Regular weighing at AWC/growth monitoring

• Return to PHC after 2 days (within 2 days) even if improving, for IMNCI follow-up assessment
• If worsening at any time, come earlier

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Key References: Park's Textbook of Preventive and Social Medicine (24th edition), WHO IMNCI training materials, NHM RMNCHA+N guidelines, WHO essential newborn care guidelines, JSY scheme guidelines (MoHFW, GoI)