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The library doesn't have obstetrics/midwifery textbooks, so I'll answer comprehensively from my medical knowledge. Here is the full solved paper:

Rajiv Gandhi University of Health Sciences, Karnataka

IV Year B.Sc. Nursing - Midwifery and Obstetrical Nursing (RS-4) | Q.P. Code: 1771

ESSAYS TYPE (2 x 10 = 20 Marks)

Q1. Mrs. Emma is presenting with amenorrhoea, nausea and vomiting.

a. Identify and explain the appropriate modalities of diagnostic investigation of pregnancy:

Presumptive signs (subjective):

Amenorrhoea (missed period)
Nausea and vomiting (morning sickness) - peaks at 8-12 weeks
Breast tenderness, frequency of micturition, quickening (fetal movement felt ~18-20 weeks in primigravida)

Probable signs (objective, but not conclusive):

Urine Pregnancy Test (UPT): Detects beta-hCG (human chorionic gonadotropin) in urine. Positive from the first missed period (~4 weeks). Sensitivity ~25 mIU/mL.
Serum beta-hCG: Quantitative; confirms pregnancy earlier (10 days post-conception). Doubles every 48 hours in normal intrauterine pregnancy.
Hegar's sign: Softening of the lower uterine segment (6-8 weeks).
Goodell's sign: Softening of cervix.
Chadwick's sign: Bluish-violet discolouration of vagina/cervix.
Ballottement: Internal ballottement at ~16-18 weeks.

Positive (definitive) signs:

Ultrasound (USG): Most important investigation. Transvaginal USG can detect gestational sac at 4-5 weeks, fetal pole at 5-6 weeks, fetal heartbeat (FHB) at 6-7 weeks. Confirms intrauterine pregnancy, gestational age, viability.
Fetal heart sounds (FHS): Detected by Doppler from 10-12 weeks; by Pinard's stethoscope from 18-20 weeks.
Fetal movements: Felt by examiner.
X-ray (obsolete): Shows fetal skeleton after 16 weeks - not used due to radiation risk.

b. List the signs and symptoms of pregnancy:

Trimester	Signs & Symptoms
1st (0-12 wks)	Amenorrhoea, nausea/vomiting, breast tenderness, fatigue, urinary frequency, implantation bleeding
2nd (13-26 wks)	Quickening (~18-20 wks), abdominal enlargement, Braxton-Hicks contractions, linea nigra, striae gravidarum, chloasma
3rd (27-40 wks)	Lightening (engagement of head), Braxton-Hicks more frequent, oedema of ankles, backache

Q2. Mrs. X had previous caesarean section, presents with pain at the incision site and foetal distress noted on CTG.

a. Define Rupture of Uterus:

Rupture of uterus is a full-thickness tear or disruption of the uterine wall occurring during pregnancy or labour, leading to communication between the uterine cavity and the peritoneal or broad ligament spaces. It may be:

Complete: All three layers (endometrium, myometrium, perimetrium/peritoneum) are torn - contents may spill into abdomen.
Incomplete (silent): Peritoneum remains intact (dehiscence) - more common with previous caesarean scar.

b. Outline the etiology of rupture of uterus:

Obstructed labour (most common in unscarred uterus):

Cephalopelvic disproportion (CPD)
Malpresentations (brow, shoulder)
Hydrocephalus

Scarred uterus (most common overall):

Previous lower segment caesarean section (LSCS) - risk ~0.5-1%
Previous myomectomy, hysterotomy
Previous cornual resection

Traumatic/Iatrogenic:

Oxytocin misuse/uterine hyperstimulation
Internal podalic version
Difficult forceps delivery
Manual removal of placenta

Spontaneous (pathological):

Grand multiparity (>4 deliveries) - thin, atrophic uterine wall
Placenta percreta (invasion through uterine wall)
Uterine anomalies

c. Explain the management of rupture of uterus:

Immediate resuscitation:

Call for help - activate emergency team
IV access x2 large-bore cannulae; aggressive fluid resuscitation (crystalloids, blood products)
Foley catheter - monitor urine output
Group & cross-match; arrange blood transfusion
Oxygen by mask
Inform anaesthetist and senior obstetrician

Surgical management (definitive):

Emergency laparotomy under general anaesthesia
Repair of uterus (conservative): If tear is clean, limited, patient desires future fertility, and patient is stable - primary closure in 2 layers.
Subtotal/Total hysterectomy: If tear is extensive, irregular, infected, bleeding uncontrolled, or patient is in haemorrhagic shock.
Deliver baby (may already be in abdominal cavity)
Check bladder and ureters for injury
Drain placement if infection present

Postoperative care:

ICU monitoring
Antibiotics (broad spectrum)
Oxytocics post-repair
Thromboprophylaxis
Grief counselling if baby lost
Future pregnancy counselling - elective LSCS at 37-38 weeks

SHORT ESSAYS TYPE (7 x 5 = 35 Marks)

Q3. Explain the abnormalities of placenta:

Abnormalities of Site/Position:

Placenta praevia: Placenta implanted in the lower uterine segment, partly or wholly covering the internal os. Classified as Type I-IV (marginal to central). Presents with painless, bright-red antepartum haemorrhage (APH).
Placenta accreta/increta/percreta: Abnormal adherence. Accreta (invades myometrium), increta (penetrates myometrium), percreta (through serosa). Risk increases with previous uterine surgery.
Succenturiate lobe: Accessory lobe separated from main placenta; risk of retained placenta/bleeding.

Abnormalities of Shape/Structure:

Bipartite/Bilobed placenta: Two equal lobes connected by membranes - risk of retention.
Circumvallate placenta: Membranes fold back on fetal surface - associated with APH, preterm labour.
Battledore/Marginal cord insertion: Umbilical cord inserts at placental margin.
Velamentous insertion: Cord vessels traverse membranes before reaching placenta - risk of vasa praevia.

Abnormalities of Cord:

Short cord (<32 cm): risk of cord prolapse, abruptio, inversion
Long cord (>100 cm): risk of cord around neck, knots, prolapse
Single umbilical artery: associated with congenital anomalies

Abnormalities of Size:

Large placenta: diabetes, Rh isoimmunisation, syphilis, hydrops
Small placenta: IUGR, hypertension

Q4. Explain the principle movements of normal labour:

These are the 7 cardinal movements (mechanisms of labour) as the fetus adapts to the maternal pelvis:

Engagement: Widest diameter of fetal head (biparietal diameter) passes below pelvic inlet. Occiput at or below ischial spines. Head in OA or OP position.
Descent: Progressive downward movement through the pelvis; continues throughout labour.
Flexion: As head descends and meets resistance from pelvic floor, chin flexes onto chest - presenting diameter changes from occipitofrontal (11.5 cm) to suboccipitobregmatic (9.5 cm).
Internal rotation: Head rotates so that occiput moves from transverse (OT) to anterior (OA) position. Occiput rotates to lie beneath pubic symphysis. Driven by levator ani muscles and pelvic floor shape.
Extension: When occiput reaches the pubic symphysis (hypomochlion), head extends under the symphysis pubis. Head is born by extension - bregma, brow, nose, mouth, chin successively.
Restitution: After delivery of head, it rotates back 45 degrees to align with fetal shoulders (undoes the internal rotation).
External rotation (shoulder rotation): Shoulders rotate from AP to OA position. Anterior shoulder delivers first under symphysis, then posterior shoulder over perineum.

Expulsion: Rest of body delivered by lateral flexion.

Q5. Explain Lochia:

Definition: Lochia is the vaginal discharge after delivery consisting of blood, mucus, necrotic decidua, and uterine secretions. It is a normal physiological process of uterine involution.

Types and characteristics:

Type	Time period	Colour	Composition
Lochia rubra	Days 1-4	Red/dark red	Blood, decidua, trophoblastic debris
Lochia serosa	Days 4-14	Pink/brown/serous	Serum, leucocytes, old blood, wound exudate
Lochia alba	Days 14 - 6 weeks	Creamy/yellowish-white	Leucocytes, mucus, bacteria, epithelial cells

Total duration: 4-6 weeks

Normal characteristics:

Volume: 150-400 mL total
Odour: fleshy/musty (not offensive)
Amount decreases progressively

Abnormal lochia (Lochiometra):

Foul-smelling: infection (endometritis)
Excessive/prolonged rubra: retained products of conception, subinvolution
Return to rubra after serosa: activity too much, infection
Absence: haematometra (retained lochia) - risk of infection

Nursing care: Perineal hygiene, pad change every 4-6 hours, monitor odour and quantity, encourage ambulation.

Q6. Describe the resuscitation of newborn:

Initial assessment (Golden Minute - act within 60 seconds):

Tone (muscle tone)
Breathing/crying
Colour

Steps (Inverted Triangle / ABCD of NNR):

A - Airway:

Provide warmth (warm towels, radiant warmer)
Position: sniffing position (slight neck extension)
Clear airway: suction mouth then nose if secretions present (avoid deep suctioning)
Dry and stimulate (rub back, flick soles)

B - Breathing:

If not breathing / gasping / HR <100 bpm after 30 seconds of initial steps:
Start Positive Pressure Ventilation (PPV) with bag-mask at 40-60 breaths/min, FiO2 21% (air) for term babies
Reassess HR after 30 seconds

C - Circulation:

If HR <60 bpm despite 30 sec of effective PPV:
Begin cardiac compressions: 3:1 ratio (3 compressions : 1 breath), 90 compressions + 30 breaths per minute
Two-thumb encircling technique preferred
Depth: 1/3 of AP diameter of chest

D - Drugs:

If HR remains <60 despite compressions + PPV:
Epinephrine (adrenaline): 0.1-0.3 mL/kg of 1:10,000 solution IV (umbilical vein preferred) or ET
Volume expanders: 10 mL/kg Normal saline if hypovolaemia suspected
Sodium bicarbonate (rarely, for prolonged arrest)

Post-resuscitation: APGAR score at 1 and 5 minutes, blood glucose monitoring, transfer to NICU if required.

Q7. Describe the clinical manifestations, diagnosis and management of vesicular mole (Hydatidiform Mole):

Definition: A gestational trophoblastic disease (GTD) where chorionic villi undergo cystic swelling and trophoblastic proliferation.

Complete mole: No fetal tissue, 46XX (androgenetic), all villi affected.
Partial mole: Some fetal tissue, triploid (69 chromosomes), partial villous change.

Clinical manifestations:

Amenorrhoea followed by irregular vaginal bleeding (dark brown, "prune juice" bleed)
Uterus large for dates (in 50% of cases)
Hyperemesis gravidarum (severe nausea/vomiting) - due to very high hCG
Theca lutein cysts (bilateral enlarged ovaries) - in 25-50%
Early onset pre-eclampsia (<20 weeks) - pathognomonic
No fetal heart sounds, no fetal movements
Passage of grape-like vesicles per vaginum (pathognomonic)
Rarely: thyrotoxicosis (hCG mimics TSH)

Diagnosis:

Serum beta-hCG: Markedly elevated (>100,000 mIU/mL), out of proportion to gestational age
USG: "Snowstorm appearance" - echogenic uterine mass with multiple anechoic spaces (swiss-cheese appearance), no fetal pole, theca lutein cysts
Histopathology: Definitive diagnosis after evacuation

Management:

Suction evacuation (suction curettage) - method of choice, regardless of uterine size
Oxytocin infusion after evacuation begins (to reduce haemorrhage)
Hysterectomy: In women >40 years or completed family who do not wish future fertility
Follow-up: Serial serum beta-hCG every 2 weeks until 3 consecutive normal levels, then monthly for 6-12 months
Contraception: Reliable contraception (oral contraceptive pill) for 6-12 months during hCG surveillance
Chemotherapy (methotrexate or actinomycin-D): If hCG plateau or rise (persistent GTD/choriocarcinoma develops in 15-20%)

Q8. Describe the management of Asphyxia Neonatorum:

Definition: Failure of the newborn to initiate or sustain adequate spontaneous respiration at birth, leading to hypoxia, hypercapnia and metabolic acidosis.

APGAR Score assessment (at 1 and 5 minutes):

7-10: Normal
4-6: Mild-moderate asphyxia
0-3: Severe asphyxia

Management (same as NNR - see Q6, expanded here):

Immediate (delivery room):

Anticipate: Identify high-risk pregnancies (IUGR, meconium-stained liquor, prolonged labour, cord prolapse)
Warm: Radiant warmer, warm towels - prevent hypothermia
Airway: Position, suction only if indicated
Stimulate: Dry, rub back, flick soles x 30 seconds

If APGAR 4-6 (mild-moderate):

Oxygen by mask
PPV with bag-mask if HR <100 or not breathing
Reassess every 30 seconds

If APGAR 0-3 (severe):

PPV + chest compressions (3:1 ratio)
Intubation (endotracheal tube)
Epinephrine IV/ET as above
Treat metabolic acidosis

For meconium-stained liquor:

Do NOT suction at perineum
If baby is vigorous: routine care
If baby is NOT vigorous: intubate, suction under direct vision before PPV

Post-resuscitation care:

Therapeutic hypothermia: For infants ≥36 weeks with moderate-severe hypoxic-ischaemic encephalopathy (HIE) - cool to 33-34°C for 72 hours (reduces neurological damage)
Blood glucose monitoring (hypoglycaemia common post-asphyxia)
Seizure management (phenobarbitone)
IV fluids - restrict (risk of SIADH, renal failure)
Monitor: vital signs, urine output, electrolytes, blood gas
Parental counselling and support

Q9. Define Infertility. Explain its causes:

Definition: Infertility is the failure to conceive after 12 months of regular, unprotected sexual intercourse (in women <35 years) or after 6 months (in women ≥35 years).

Primary infertility: Never conceived previously.
Secondary infertility: Previous conception but currently unable to conceive.
Affects ~10-15% of couples.

Causes:

Female factors (40-50%):

Ovulatory dysfunction (25%): PCOS (most common), hypothalamic amenorrhoea, hyperprolactinaemia, thyroid disorders, premature ovarian failure
Tubal/peritoneal factors (30%): PID (chlamydia, gonorrhoea), endometriosis, previous pelvic surgery, adhesions
Uterine factors: Fibroids (submucous), Asherman's syndrome (intrauterine adhesions), congenital anomalies (septate uterus), endometrial polyps
Cervical factors: Cervical stenosis, hostile cervical mucus, anti-sperm antibodies
Vaginal factors: Vaginismus, vaginal agenesis

Male factors (30-40%):

Spermatogenic failure: Oligospermia (<15 million/mL), azoospermia, teratospermia
Varicocele: Most common correctable cause in males
Obstruction: Vas deferens blockage (vasectomy, post-infection), epididymal block
Endocrine: Hypogonadism, hyperprolactinaemia, thyroid disorder
Sexual dysfunction: Erectile dysfunction, ejaculatory failure
Genetic: Klinefelter's syndrome (47 XXY), Y-chromosome microdeletions

Combined/Unexplained (10-15%):

Both partners have minor issues
Anti-sperm antibodies
Immunological factors

SHORT ANSWERS (10 x 2 = 20 Marks)

Q10. Define perinatal mortality rate: Number of deaths occurring from 28 weeks of gestation up to 7 days after birth, per 1000 total births (live + still births). It includes stillbirths + early neonatal deaths.

Formula: (Stillbirths + Early neonatal deaths in first 7 days) / Total births x 1000

India's perinatal mortality rate is approximately 32-34 per 1000 births (varies by region).

Q11. Name the abnormalities of pelvis:

Gynaecoid pelvis - normal female (most favourable for labour)
Android pelvis - male-type, funnel-shaped, narrow outlet - unfavourable
Anthropoid pelvis - long AP diameter, narrow transverse - deep transverse arrest risk
Platypelloid pelvis - flat, wide transverse, short AP - transverse arrest, face presentation risk
Contracted pelvis (inlet/outlet/generally contracted) - associated with rickets, osteomalacia
Rachitic flat pelvis - due to vitamin D deficiency/rickets
Osteomalacic pelvis - triradiate/beaked shape

Q12. What is Naegele's formula?

Used to calculate the Expected Date of Delivery (EDD):

EDD = LMP + 9 months + 7 days OR: EDD = LMP - 3 months + 7 days + 1 year

(LMP = Last Menstrual Period - first day)

Example: LMP = 1st January → EDD = 8th October Assumes a regular 28-day cycle and ovulation on Day 14.

Q13. Write the composition of colostrum:

Colostrum is the first milk secreted from 2nd trimester until 2-4 days postpartum. It is thick, yellowish, and rich in:

Component	Value (vs. mature milk)
Protein	Very high (~87 g/L) - IgA, lactoferrin
Fat	Lower
Lactose	Lower
Secretory IgA	Very high - passive immunity
Lactoferrin	High - antimicrobial
Leukocytes	High - immunoprotection
Vitamin A	High (6x mature milk)
Vitamin K	High
Energy	~67 kcal/100 mL

It acts as the "first immunization" of the newborn, providing passive immunity especially against gut pathogens.

Q14. Enumerate the possible inferences of NST (Non-Stress Test):

NST monitors fetal heart rate (FHR) accelerations in response to fetal movement. Done after 32 weeks.

Reactive (Normal): ≥2 accelerations of ≥15 bpm above baseline, lasting ≥15 seconds, within 20 minutes. Indicates fetal well-being.
Non-reactive: Failure to meet reactive criteria in 40 minutes. Requires further evaluation (BPP, contraction stress test).
Sinusoidal pattern: Smooth, sine-wave FHR pattern - associated with severe fetal anaemia (Rh isoimmunisation), urgent intervention needed.
Fetal bradycardia: FHR <110 bpm - concerning.
Decelerations: Late/variable decelerations during test - ominous.

Q15. What is postpartum depression?

A moderate-to-severe depressive disorder occurring within 4 weeks to 12 months after childbirth (most commonly 2-6 weeks postpartum), distinct from the milder "baby blues" (days 3-5, self-limiting).

Features: Persistent low mood, tearfulness, loss of interest, insomnia, poor bonding with baby, feelings of inadequacy, sometimes thoughts of harming self or baby.

Risk factors: Previous psychiatric illness, poor social support, stressful life events, difficult delivery, previous PPD.

Management: Counselling/CBT, antidepressants (sertraline - safe in breastfeeding), social support.

Q16. What is Kernicterus?

Kernicterus (also called bilirubin-induced neurological dysfunction/BIND) is brain damage in a neonate caused by very high levels of unconjugated bilirubin crossing the blood-brain barrier and depositing in the basal ganglia, hippocampus, and brainstem nuclei.

Causes: Severe neonatal jaundice - Rh/ABO incompatibility, G6PD deficiency, sepsis.

Clinical features:

Acute: Hypotonia → hypertonia, high-pitched cry, retrocollis, opisthotonus, seizures, coma
Chronic (sequelae): Choreoathetoid cerebral palsy, sensorineural deafness, upward gaze palsy, intellectual disability

Prevention: Early phototherapy, exchange transfusion when bilirubin approaches dangerous levels.

Q17. Name/Describe oxytocics (partially visible in paper):

Oxytocics are drugs that stimulate uterine contractions:

Oxytocin (Syntocinon): Synthetic hormone; IV infusion for induction/augmentation of labour; IM for PPH (10 IU)
Ergometrine (Ergonovine): Causes sustained uterine contraction; IM/IV; used in PPH. Contraindicated in hypertension.
Syntometrine: Oxytocin + Ergometrine combination - AMTSL (Active Management of Third Stage of Labour)
Misoprostol (PGE1): Oral/sublingual/rectal/vaginal; used for PPH, induction of labour (cervical ripening)
Carboprost (PGF2α): IM; for PPH refractory to oxytocin
Dinoprostone (PGE2): Cervical ripening, induction

Q18. Four methods of temporary contraception:

Combined Oral Contraceptive Pill (COCP): Oestrogen + progestin; inhibits ovulation; taken daily for 21 days. Failure rate <1% with perfect use.
Condom (male/female): Barrier method; also STI protection. Failure rate ~2-15% typical use.
Intrauterine Device (IUD) - Copper T: IUCD inserted into uterine cavity; prevents fertilisation/implantation; effective 5-10 years. Reversible.
Depo-Provera (injectable DMPA): 150 mg medroxyprogesterone acetate IM every 3 months. Highly effective, reversible.

Other options: Diaphragm, cervical cap, implants (Implanon/Nexplanon).

Q19. What is emergency contraceptive? Give an example:

Definition: Emergency contraception (EC) refers to contraceptive methods used after unprotected sexual intercourse to prevent pregnancy. It is NOT an abortifacient - it works before implantation.

Mechanism: Delays or inhibits ovulation, alters sperm motility, or alters endometrium to prevent implantation.

Examples:

Levonorgestrel (Plan B / I-Pill): 1.5 mg single dose or 0.75 mg x 2 doses 12 hours apart, taken within 72 hours of unprotected sex. Most commonly used. Effective in ~85% of cases.
Copper IUD (Cu-T 380A): Inserted within 5 days of unprotected sex. Most effective EC method (>99%). Also provides ongoing contraception for 10 years.
Ulipristal acetate (EllaOne): Selective progesterone receptor modulator; 30 mg single dose within 120 hours (5 days). Slightly more effective than levonorgestrel.
Yuzpe regimen (older): Combined OCP - 100 mcg ethinyl estradiol + 0.5 mg levonorgestrel x 2 doses 12 hours apart within 72 hours.

Summary of marks distribution answered:

Essays (Q1, Q2): 20 marks
Short Essays (Q3-Q9): 35 marks
Short Answers (Q10-Q19): 20 marks
Total: 75 marks

All answers above are based on standard obstetrics and midwifery references including Dutta's Obstetrics, Williams Obstetrics, and Myles' Textbook for Midwives. Clinical values and guidelines reflect standard practice as taught in Indian nursing curriculum.

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