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Rajiv Gandhi University of Health Sciences, Karnataka

IV Year B.Sc. Nursing - Midwifery and Obstetrical Nursing (Q.P. CODE: 1771)

Complete Solved Answer Paper

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SECTION A: ESSAYS TYPE (2 × 10 = 20 Marks)

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Question 1: Cardiotocography (CTG)

(a) What is Cardiotocography (CTG)?

• The fetal heart rate (FHR) - via a Doppler ultrasound transducer placed on the mother's abdomen
• Uterine contractions - via a tocometer (pressure transducer)

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(b) Indications of CTG

• Post-term pregnancy (>41 weeks)
• Pre-eclampsia and hypertensive disorders of pregnancy
• Intrauterine growth restriction (IUGR)
• Gestational diabetes mellitus
• Oligohydramnios or polyhydramnios
• Decreased fetal movements reported by the mother
• Rhesus isoimmunization
• Previous intrauterine fetal death (IUFD)
• Multiple pregnancies
• Antepartum haemorrhage
• Maternal systemic diseases (cardiac, renal, thyroid)
• Premature rupture of membranes (PROM)

• High-risk labours
• Meconium-stained liquor
• Induced or augmented labour
• Preterm labour (<37 weeks)
• Epidural anaesthesia
• Prolonged labour
• Any change in maternal/fetal condition during labour

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(c) Procedure of Non-Stress Test (NST)

1. Preparation:
   • Explain the procedure to the patient and obtain consent
   • Ask the patient to empty her bladder
   • Position the patient in a semi-recumbent (left lateral tilt) position to avoid aortocaval compression
   • Baseline vital signs (BP, pulse) are recorded
2. Equipment:
   • Cardiotocograph machine
   • Two transducers: ultrasound probe + tocometer
   • Ultrasound gel
   • Straps/belts to secure transducers
3. Application:
   • Apply ultrasound gel on the abdomen
   • Place the Doppler ultrasound transducer over the fetal heart to detect FHR
   • Place the tocometer at the uterine fundus to detect contractions/movements
   • Secure both transducers with abdominal belts
   • Ask the patient to press an event marker button every time she feels fetal movement
4. Duration: Monitor for 20 minutes (can extend to 40 minutes if non-reactive, to allow for fetal sleep cycles)
5. Interpretation:

1. Post-procedure: Remove transducers, wipe gel, help patient to comfortable position. Document findings and report to the obstetrician.

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Question 2: Haemorrhagic Shock in a Postnatal Woman

(a) Define Shock

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(b) Clinical Features of Haemorrhagic Shock

• Cardiovascular: Rapid, feeble/thready pulse; hypotension; tachycardia
• Peripheral perfusion: Cold, clammy extremities; pallor; prolonged capillary refill time (>2 sec); cyanosis of lips/fingertips
• Respiratory: Increased respiratory rate (tachypnoea), air hunger
• CNS: Restlessness, anxiety, confusion, dizziness, altered consciousness
• Renal: Oliguria (<30 ml/hour) or anuria
• Skin: Pallor, sweating (diaphoresis)
• Eyes: Sunken eyes; vacant stare
• Pupils: Dilated pupils in severe shock

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(c) Management of Haemorrhagic Shock

• Call for help - activate the obstetric emergency team (MEWS - Modified Early Warning System)
• Position: Flat/Trendelenburg position (head low, feet elevated) - improves venous return to the heart. If uterus still gravid, left lateral tilt.
• Maintain airway - give oxygen 10-15 L/min via face mask
• Keep patient warm with blankets (prevent hypothermia)

• Insert two large-bore IV cannulae (16G or 14G) - one in each antecubital fossa
• Collect blood for: CBC, blood grouping and cross-matching, coagulation profile (PT, APTT, fibrinogen), serum electrolytes, renal function tests, ABG

• Crystalloids first: Rapid infusion of Normal saline or Ringer's lactate - 1-2 litres stat
• Colloids: Plasma expanders (gelatin solutions) if needed
• Blood transfusion: Packed Red Blood Cells (PRBC) - 4-6 units depending on losses. Use O-negative blood if cross-matched blood not available
• Fresh Frozen Plasma (FFP): For coagulopathy - 4 units
• Platelet concentrates: If platelets <50,000
• Cryoprecipitate: For fibrinogen replacement

• Continuous monitoring of: Pulse, BP (every 5-15 min), SpO2, respiratory rate
• Insert urinary catheter - monitor hourly urine output (target >30 ml/hour)
• Central Venous Pressure (CVP) monitoring
• Keep a fluid input/output chart

• If uterine atony (most common cause of PPH): Uterine massage, oxytocin infusion, ergometrine, misoprostol, tranexamic acid (TXA)
• If retained products of conception: Manual removal/ERPOC
• If cervical/vaginal lacerations: Suture repair
• If uterine rupture: Emergency laparotomy
• If DIC develops: Treat underlying cause + blood products

• Oxytocin 20 units in 500 ml NS infused over 4 hours
• Ergometrine 0.2 mg IM/IV (contraindicated in hypertension)
• Misoprostol 800-1000 mcg per rectum
• Tranexamic acid 1 g IV stat (given within 3 hours of haemorrhage)
• Vasopressors (dopamine/noradrenaline) if not responding to fluids

• Balloon tamponade (Bakri balloon)
• Compression sutures (B-Lynch suture)
• Uterine artery ligation
• Internal iliac artery ligation
• Hysterectomy (obstetric hysterectomy) - life-saving last resort

• Accurate documentation of all medications and fluids
• Emotional support to patient and family
• Maintain dignity and privacy
• Inform and update the family

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SECTION B: SHORT ESSAYS TYPE (7 × 5 = 35 Marks)

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Question 3: Placenta at Term

• Shape: Circular/discoid, slightly irregular
• Size: Diameter 15-20 cm; thickness 2-3 cm at the centre
• Weight: 500-600 g (approximately 1/6th the weight of the baby)
• Colour: Dark red (maternal surface); grayish-bluish (fetal surface)

1. Maternal surface (Basal plate):
   • Dark red, rough/spongy appearance
   • Divided into 15-30 cotyledons (lobes) by decidual septa
   • Covered by decidua basalis
2. Fetal surface (Chorionic plate):
   • Smooth, shiny, grayish appearance
   • Covered by amnion
   • Fetal blood vessels (branches of umbilical vessels) visible radiating from the cord insertion

• Usually central or paracentral (eccentric)
• Cord length: 40-60 cm, contains 2 arteries and 1 vein (Wharton's jelly surrounds them)
• Battledore placenta = cord inserted at margin
• Velamentous insertion = cord inserts into membranes (abnormal)

• Increased syncytial knots (Tenney-Parker change)
• Increased fibrinoid deposits (Fibrin of Langhans)
• Thinning of the cytotrophoblast layer
• Reduced villous stroma
• Calcification may be present (Grade III Grannum classification)

1. Nutritive - transfers glucose, amino acids, fatty acids, vitamins, minerals
2. Respiratory - O2 and CO2 exchange
3. Excretory - urea, creatinine, bilirubin
4. Endocrine - produces hCG, hPL, oestrogen, progesterone, relaxin
5. Protective (barrier) - prevents some pathogens (not all - e.g., rubella, CMV, toxoplasma can cross)
6. Immunological - transfers maternal IgG (passive immunity)

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Question 4: Significance of the Fourth Stage of Labour

1. Critical Period for Haemorrhage:
   • This is the time when Primary PPH (>500 ml blood loss after vaginal delivery) most commonly occurs
   • The uterus must contract and retract firmly to compress the sinuses (placental site) - this is the "living ligature" mechanism
   • Uterine atony (failure of the uterus to contract) is responsible for 70-80% of PPH cases
2. Active Management of the Third/Fourth Stage:
   • Uterotonic administration (oxytocin 10 IU IM) immediately after birth
   • Controlled cord traction (Brandt-Andrews method)
   • Uterine fundal massage after placental delivery
3. Monitoring Required:
   • Vital signs (BP, pulse) every 15 minutes for the first hour
   • Uterine fundal height and consistency (should be at umbilicus level, hard)
   • Amount of vaginal bleeding (lochia rubra)
   • Bladder - a full bladder displaces the uterus and prevents contraction
   • Perineum - inspect for lacerations, haematoma
4. Early Detection of Complications:
   • PPH (haemorrhage)
   • Retained placenta or membranes
   • Cervical, vaginal, perineal lacerations
   • Uterine inversion
   • Signs of shock (tachycardia, hypotension)
5. Initiation of Bonding:
   • Skin-to-skin contact between mother and baby
   • Initiation of breastfeeding within the first hour ("golden hour")
   • Promotes oxytocin release - helps uterine contraction
6. Recovery Nursing:
   • The woman recovers from the physical stress of labour
   • Pain management (perineal)
   • Nutritional and fluid replacement

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Question 5: Minor Ailments During Puerperium

1. After-pains (Puerperal cramps):
   • Colicky uterine contractions as the uterus involutes
   • More common in multiparous women and breastfeeding mothers (oxytocin release)
   • Management: Analgesics (paracetamol), reassurance
2. Breast Engorgement:
   • Occurs 2-3 days postpartum when milk "comes in"
   • Breasts become hard, painful, and warm
   • Management: Regular breastfeeding, warm compresses, supportive bra
3. Sore Nipples:
   • Due to incorrect latching technique
   • Management: Correct positioning, air drying, lanolin cream
4. Perineal Discomfort:
   • Due to episiotomy, laceration, or sutures
   • Management: Ice packs initially, sitz baths, analgesics, good hygiene
5. Constipation:
   • Due to reduced bowel motility, fear of pain with defecation, dehydration
   • Management: Adequate fluids, fibre-rich diet, mild laxatives if needed
6. Haemorrhoids (Piles):
   • Pre-existing piles worsen due to straining during labour
   • Management: Local cream (witch hazel), stool softeners, sitz baths
7. Urinary Complaints:
   • Frequency, burning (dysuria), retention of urine
   • Due to perineal oedema, catheterisation, bruising
   • Management: Increased fluids, analgesics, encourage voiding, catheterize if retention occurs
8. Sweating (Diaphoresis):
   • Profuse sweating especially at night as body eliminates excess fluid of pregnancy
   • Management: Reassurance, adequate fluid intake, hygiene
9. Lochia:
   • Normal vaginal discharge post-delivery
   • Lochia rubra (1-4 days): red/bloody
   • Lochia serosa (4-8 days): pinkish-brown
   • Lochia alba (8-14+ days): yellowish-white creamy
   • Management: Good perineal hygiene, frequent pad changes
10. Postnatal Blues (Baby Blues):
    • Occurs 3-5 days postpartum; mild mood swings, tearfulness, irritability
    • Affects ~50-80% of women
    • Self-limiting (48-72 hours); differentiate from postnatal depression
    • Management: Reassurance, partner support

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Question 6: Minor Disorders of the Newborn

1. Physiological Jaundice:
   • Appears on Day 2-3, peaks Day 4-5, resolves by Day 7-10
   • Due to breakdown of fetal haemoglobin and immature liver conjugation
   • Serum bilirubin: Indirect (unconjugated) type
   • Management: Adequate feeding, phototherapy if bilirubin levels rise significantly
2. Milia:
   • Tiny white/yellowish spots (blocked sebaceous glands) over nose, cheeks, forehead
   • Disappear spontaneously in 2-4 weeks
   • Management: Nil - do not squeeze
3. Erythema Toxicum (Newborn rash):
   • Blotchy red rash with small white/yellow papules
   • Appears Day 1-3, benign, self-limiting
   • Management: Reassurance only
4. Mongolian Spots:
   • Bluish-grey pigmented areas over sacrum/buttocks (common in Asian, African babies)
   • Disappear by age 5-7
   • Must be documented to avoid confusion with bruising
5. Vernix Caseosa:
   • White, greasy protective coating on the skin at birth
   • Protective against infection; absorbed into skin naturally
   • Gentle cleaning rather than aggressive removal
6. Lanugo:
   • Fine downy hair on shoulders, back, ears
   • Disappears within 2 weeks postpartum
7. Breast Enlargement (Witch's milk):
   • Seen in both male and female neonates; due to maternal oestrogen crossing placenta
   • Resolves in 2-3 weeks
   • Management: Do NOT squeeze; risk of infection if manipulated
8. Pseudo-menstruation:
   • Slight blood-stained vaginal discharge in female neonates
   • Due to withdrawal of maternal oestrogen
   • Self-limiting; reassure parents
9. Caput Succedaneum:
   • Serosanguineous oedema over the presenting part (crosses suture lines)
   • Resolves in 24-48 hours
   • No treatment required
10. Physiological Weight Loss:
    • Newborn loses 5-10% of birth weight in first 3-4 days
    • Regained by Day 7-10
    • Due to loss of meconium, water, and adjustment to oral feeding

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Question 7: Complications of Multiple Pregnancy

1. Anaemia - increased fetal demand for iron and folate
2. Hyperemesis gravidarum - elevated hCG levels cause severe nausea/vomiting
3. Pre-eclampsia/Eclampsia - occurs 3-4 times more frequently
4. Gestational diabetes - increased hormonal opposition to insulin
5. Antepartum haemorrhage (APH) - placenta praevia (due to large placental site)
6. Polyhydramnios - especially in monochorionic twins
7. Preterm labour - most common complication (>50% twins deliver before 37 weeks)
8. Malpresentation - increased incidence of breech, transverse lie
9. Obstructed labour - interlocking twins (rare)
10. PPH - over-distended uterus leads to uterine atony
11. Operative delivery - higher Caesarean section rate
12. Maternal exhaustion - increased physiological burden

1. Prematurity - leading cause of neonatal morbidity/mortality
2. IUGR (Intrauterine Growth Restriction) - placental insufficiency
3. Twin-to-Twin Transfusion Syndrome (TTTS) - in monochorionic twins; donor twin becomes anaemic/IUGR; recipient twin develops polycythaemia/hydrops
4. Congenital anomalies - higher incidence, especially in monozygotic twins
5. Cord accidents - cord prolapse, cord entanglement (monoamniotic twins)
6. Stillbirth - higher perinatal mortality rate (x3-5 compared to singleton)
7. Birth asphyxia
8. Acardiac twin (TRAP sequence) - in monochorionic twins

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Question 8: Measures to Prevent Birth Injuries

1. Accurate clinical assessment:
   • Measure pelvic dimensions (clinical pelvimetry)
   • Assess fetal weight (ultrasound)
   • Identify malpresentations early (transverse, brow, face presentations)
   • Diagnose CPD (Cephalopelvic Disproportion) before labour
2. Timely Caesarean Section:
   • Planned C-section for diagnosed CPD, breech at term (if ECV fails), major placenta praevia
   • Reduces risk of birth trauma

1. Proper monitoring: Continuous CTG to detect fetal distress early
2. Controlled delivery of the head: Modified Ritgen maneuver to control the speed of delivery
3. Avoid traumatic operative delivery:
   • Proper technique for forceps (avoid excessive traction, rotation in wrong plane)
   • Correct application of vacuum cup; avoid >3 pulls and >20-minute application
4. Episiotomy: Judicious use to prevent uncontrolled perineal tearing and shoulder dystocia
5. Management of shoulder dystocia:
   • McRobert's maneuver (hyper-flexion of maternal thighs)
   • Suprapubic pressure
   • Woods screw maneuver
   • Zavanelli maneuver (as last resort)
6. Breech delivery technique: Correct assisted breech delivery; Burns-Marshall technique; Mauriceau-Smellie-Veit maneuver for the aftercoming head
7. Avoid prolonged labour: Augmentation with oxytocin when indicated; avoid precipitate labour
8. Skilled birth attendant: All deliveries should be conducted by trained midwives/doctors

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Question 9: Artificial Reproductive Techniques (ART) - List and Explain One

1. In Vitro Fertilization (IVF)
2. Intrauterine Insemination (IUI)
3. Intracytoplasmic Sperm Injection (ICSI)
4. Gamete Intrafallopian Transfer (GIFT)
5. Zygote Intrafallopian Transfer (ZIFT)
6. Donor Egg/Embryo Transfer
7. Surrogacy (Gestational/Traditional)
8. Ovulation Induction (with timed intercourse)
9. Frozen Embryo Transfer (FET)
10. Preimplantation Genetic Diagnosis/Testing (PGD/PGT)

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• Bilateral tubal blockage/damage (most common original indication)
• Severe male factor infertility (used with ICSI)
• Unexplained infertility after 2-3 years
• Endometriosis
• Failed IUI cycles
• Ovulatory dysfunction unresponsive to other treatment
• Diminished ovarian reserve

• GnRH agonist/antagonist is given to suppress natural cycle
• Gonadotropins (FSH/LH injections) are given daily for 10-14 days to stimulate multiple follicle development
• Monitored by serial transvaginal ultrasound and serum oestradiol levels

• When leading follicles reach ≥18 mm, trigger injection (hCG 10,000 IU) is given
• 36-38 hours later, transvaginal ultrasound-guided oocyte aspiration is performed under IV sedation
• Typically 8-15 oocytes retrieved

• Partner provides semen sample by masturbation (on same day)
• Semen is processed (washing, swim-up technique) to select motile, morphologically normal sperm

• Mature oocytes (MII stage) are mixed with prepared sperm in culture dish
• If severe male factor: ICSI (one sperm injected directly into egg)
• Fertilization confirmed after 18 hours (2 pronuclei = fertilized = zygote)

• Embryos cultured for 3-5 days
• Day 3 embryo (cleavage stage, 6-8 cells) or Day 5 blastocyst (more preferred, higher implantation rate)

• 1-2 best embryos selected for transfer (PGT may be done before selection)
• Transcervical embryo transfer using a thin catheter under ultrasound guidance
• Patient rests for 30 minutes; normal activity resumed after
• Progesterone supplementation given (pessaries or injections) for luteal support

• Serum beta-hCG measured 14 days after embryo transfer
• Positive result: Continue progesterone; scan at 6-7 weeks for viable intrauterine pregnancy

• Ovarian Hyperstimulation Syndrome (OHSS) - most serious
• Multiple pregnancy (twins, triplets)
• Ectopic pregnancy
• Ovarian torsion
• Miscarriage

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SECTION C: SHORT ANSWERS (10 × 2 = 20 Marks)

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Question 10: Components of Pre-Conception Care

1. Medical history - identify and manage chronic conditions (diabetes, epilepsy, hypertension, thyroid disorders)
2. Reproductive history - previous pregnancies, miscarriages, congenital anomalies
3. Genetic counselling - family history of genetic disorders; carrier testing
4. Nutritional assessment - correct anaemia; Folic acid 400 mcg/day (reduces neural tube defects)
5. Immunization - MMR (rubella), Hepatitis B, Varicella, Influenza (if not immune)
6. Screening - STIs (HIV, syphilis, gonorrhoea), diabetes screening
7. Medication review - stop teratogens (ACE inhibitors, valproate, warfarin); substitute safe alternatives
8. Lifestyle counselling - stop smoking, alcohol, recreational drugs; weight optimisation (BMI 18.5-24.9); exercise
9. Psychosocial assessment - mental health screening, domestic violence screening
10. Dental care - periodontal disease linked to preterm birth

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Question 11: What is Ovulation?

• Occurs on approximately Day 14 of a 28-day menstrual cycle
• Triggered by a LH (Luteinizing Hormone) surge ~24-36 hours before ovulation
• The secondary oocyte is released and swept into the fallopian tube by fimbriae
• The follicle becomes the corpus luteum after ovulation (produces progesterone)
• The oocyte is viable for 12-24 hours after release
• Detected clinically by: basal body temperature rise (0.5°C), LH surge detection kits, mid-cycle transvaginal ultrasound, Mittleschmerz (ovulation pain)

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Question 12: Protein Hormones (of Placenta)

1. Human Chorionic Gonadotropin (hCG) - produced from day of implantation; maintains corpus luteum; basis of pregnancy test; peaks at 10-12 weeks
2. Human Placental Lactogen (hPL) / Chorionic Somatomammotropin - promotes fetal growth, prepares breasts for lactation, anti-insulin effect
3. Placental Growth Hormone
4. CRH (Corticotropin-Releasing Hormone) - implicated in timing of labour
5. ACTH (Adrenocorticotropic Hormone)

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Question 13: BCG - Expand and Purpose

• Provides immunization against tuberculosis (TB), especially the severe forms in children: tuberculous meningitis and miliary TB
• Also protects against leprosy (partially), Buruli ulcer, and certain other mycobacterial infections
• Recommended at birth (0 day) under India's Universal Immunization Programme (UIP)
• Administered as intradermal injection over the left upper arm (deltoid region), 0.05 ml at birth / 0.1 ml after 1 month

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Question 14: Glucose Tolerance Test (GTT)

• Patient fasts for 8-12 hours overnight
• No smoking, strenuous exercise before test
• Patient should have had normal diet for 3 days prior

1. Fasting blood glucose drawn (baseline)
2. Patient drinks 75 g glucose dissolved in 250-300 ml water within 5 minutes
3. Blood glucose measured at 1 hour and 2 hours
4. Patient remains seated; no food or exercise during the test

• Fasting: ≥ 92 mg/dl (5.1 mmol/L)
• 1-hour: ≥ 180 mg/dl (10.0 mmol/L)
• 2-hour: ≥ 153 mg/dl (8.5 mmol/L)

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Question 15: Prophylactic Measures to Prevent DVT (Deep Vein Thrombosis)

1. Early ambulation - Encourage the mother to get up and walk as soon as possible after delivery (within 6-12 hours post-vaginal delivery)
2. Leg exercises - Ankle dorsiflexion, circular ankle movements, calf pumping exercises (especially in bedridden patients)
3. Adequate hydration - Oral fluid intake to prevent haemoconcentration
4. Compression stockings (TED stockings) - Graduated elastic compression stockings to prevent venous stasis
5. Intermittent Pneumatic Compression (IPC) devices - Pneumatic leg pumps for immobile/post-C-section patients
6. Low Molecular Weight Heparin (LMWH) - e.g., Enoxaparin 40 mg SC daily for high-risk women (previous DVT, thrombophilia, obesity, prolonged immobility)
7. Avoid prolonged immobility - Avoid sitting with legs dangling; avoid tight clothing
8. Elevate lower limbs - Slight elevation of foot end of bed
9. Avoid dehydration - Common after prolonged labour
10. Risk assessment - All postnatal women should be assessed for DVT risk (RCOG Green-top guideline score)

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Question 16: Define Omphalitis

• Causative organisms: Staphylococcus aureus, E. coli, Streptococcus, Gram-negative organisms; can become polymicrobial
• Signs: Redness (erythema), warmth, swelling, and purulent discharge around the umbilical stump; foul-smelling discharge; may progress to periumbilical cellulitis (necrotizing fasciitis if severe)
• Prevention: Keep cord clean and dry; "dry cord care" recommended by WHO; avoid applying anything to the cord
• Treatment: Topical antiseptics (chlorhexidine) or systemic antibiotics if cellulitis/sepsis

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Question 17: Nurse's Responsibilities in Administering MgSO₄ (Magnesium Sulphate)

• Verify doctor's order; check correct dose/route
• Baseline vitals: BP, pulse, respiratory rate
• Assess deep tendon reflexes (DTR) - specifically patellar reflex (knee jerk)
• Check urine output (catheter in situ; >25-30 ml/hr required)
• Respiratory rate must be ≥16/min before each dose
• Have 10 ml of 10% Calcium Gluconate drawn up at bedside (antidote)
• Explain procedure to patient

• Loading dose: MgSO₄ 4 g (20 ml of 20% solution) IV over 15-20 minutes (slow push)
• Maintenance dose: MgSO₄ 1 g/hour IV infusion or 5 g deep IM (each buttock) 4-hourly
• Monitor continuously: RR, DTR, urine output every 15-30 minutes
• Administer via infusion pump for accurate rate control

• Loss of patellar reflex (first sign of toxicity)
• Respiratory rate <12/min (respiratory depression)
• Urine output <25 ml/hr
• Serum Mg level >7-10 mEq/L = toxicity

• STOP MgSO₄ infusion immediately
• Give Calcium Gluconate 10 ml of 10% solution IV over 10 minutes (antidote)
• Give oxygen; prepare for intubation if respiratory arrest

• Continue monitoring for 24-48 hours postpartum
• Document all observations, drug dosage, and times accurately

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Question 18: Define Infertility

• Primary infertility: The couple has never achieved a pregnancy
• Secondary infertility: The couple has had at least one previous pregnancy but is unable to conceive again

• Female factors: Ovulatory disorders (PCOS), tubal factors, uterine/cervical causes, endometriosis
• Male factors: Oligospermia, azoospermia, asthenospermia, teratospermia
• Combined (both partners): ~30%
• Unexplained infertility: ~20%

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Question 19: Define Eligible Couple

• Used in the context of National Family Planning Programme (India)
• Each eligible couple is expected to accept a family planning method to achieve the desired number of children
• Eligible couple register (ECR) is maintained by ANM (Auxiliary Nurse Midwife) at the primary health care level
• Target: Every eligible couple should ideally have a maximum of 2 children (small family norm)
• Helps in calculating Couple Protection Rate (CPR) - percentage of eligible couples currently using contraception

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Summary Table of All Answers

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All answers are based on standard midwifery/obstetrical nursing curriculum aligned with Rajiv Gandhi University of Health Sciences, Karnataka. Key references include Dutta's Obstetrics, Myles' Midwifery, and current WHO/RCOG guidelines.