Rajiv Gandhi University of Health Sciences - IV Year B.Sc. Nursing

Midwifery and Obstetrical Nursing (RS2, RS3 & RS4) - Q.P. Code: 1771

ESSAYS TYPE (3 × 10 = 20 Marks)

Q1. (a) What is Cardiotocography (CTG)?

• Fetal Heart Rate (FHR) - via a Doppler ultrasound transducer placed on the maternal abdomen
• Uterine contractions - via a tocodynamometer (external) or intrauterine pressure catheter (internal)

Q1. (b) Indications of CTG

• Post-term pregnancy (>42 weeks)
• Intrauterine growth restriction (IUGR)
• Reduced fetal movements
• Pre-eclampsia / hypertensive disorders
• Diabetes mellitus
• Antepartum haemorrhage
• Multiple pregnancy
• Oligohydramnios / polyhydramnios
• Previous stillbirth
• Rh isoimmunisation

• Prolonged / augmented labour
• Epidural analgesia
• Oxytocin induction
• Meconium-stained liquor
• Abnormal fetal heart rate on auscultation
• Maternal fever, sepsis
• High-risk pregnancies (above conditions)

Q1. (c) Procedure of Non-Stress Test (NST)

1. Preparation: Explain the procedure to the mother. Obtain informed consent. Ask her to empty her bladder.
2. Position: Place the mother in the left lateral tilt or semi-recumbent position to avoid supine hypotension.
3. Equipment: Attach CTG machine. Apply conductive gel and fix the Doppler ultrasound transducer over the point of maximum fetal heart rate. Attach the tocodynamometer over the uterine fundus.
4. Recording: Run the CTG strip for a minimum of 20 minutes. If the fetus is sleeping (no movements), extend to 40 minutes. A buzzer/vibroacoustic stimulator may be used to wake the fetus.
5. Mother's role: Ask the mother to press the event button each time she feels fetal movement.

• Reactive NST = fetal well-being reassured
• Non-reactive NST = proceed to Contraction Stress Test (CST) or biophysical profile

Q2. A postnatal woman has blood loss >800 ml with feeble pulse and cold extremities.

Q2. (a) Define Shock

Q2. (b) Clinical Features of Haemorrhagic Shock

• Cardiovascular: Rapid, weak/feeble pulse; hypotension; tachycardia
• Skin: Pale, cold, clammy, mottled skin; cold extremities
• Respiratory: Rapid shallow breathing (tachypnoea)
• CNS: Anxiety, restlessness, confusion, drowsiness, loss of consciousness
• Renal: Reduced urine output (oliguria - <30 ml/hour), progressing to anuria
• Eyes: Sunken eyes, blurred vision
• Mouth: Thirst, dry mouth
• GIT: Nausea, vomiting

Q2. (c) Management of Haemorrhagic Shock

1. Position: Place the woman flat with legs elevated (Trendelenburg if not contraindicated). Keep her warm.
2. Airway & Oxygen: Maintain airway; administer 100% oxygen via face mask (10-15 L/min).
3. IV Access: Insert two large-bore IV cannulas (14-16 gauge). Send blood for: CBC, grouping and cross-matching, coagulation profile, RFT, LFT.
4. IV Fluids: Rapid infusion of warm crystalloids (Normal saline / Ringer's lactate). Start with 1-2 litres rapidly (fluid resuscitation). Give colloids (e.g., gelofusine) if needed.
5. Blood Transfusion: Urgent typed blood; O-negative blood if emergency.
6. Monitoring: Monitor vital signs every 5-15 minutes; continuous pulse oximetry, ECG monitoring; insert Foley's catheter to monitor hourly urine output.

• Tone (atony): Bimanual compression; Oxytocin 10 IU IV/IM; Ergometrine; Misoprostol 800-1000 mcg rectally; Tranexamic acid 1g IV
• Tissue: Manual removal of retained placenta
• Trauma: Suture lacerations
• Thrombin: Fresh Frozen Plasma (FFP), platelets, cryoprecipitate for DIC

• Brace sutures (B-Lynch suture)
• Uterine artery ligation
• Internal iliac artery ligation
• Obstetric hysterectomy (last resort)

• Urine output >30 ml/hour indicates adequate resuscitation
• Assess for DIC (disseminated intravascular coagulation)
• ICU admission for severe cases

SHORT ESSAYS TYPE (7 × 5 = 35 Marks)

Q3. Explain Placenta at Term

• Disc-shaped, round/oval
• Diameter: 15-20 cm
• Thickness: 2.5-3 cm at centre, thin at edges
• Weight: 500 g (1/6th of fetal weight)
• Maternal surface (basal plate): Dark red, rough, divided into 15-20 cotyledons by septa, covered with decidua basalis
• Fetal surface (chorionic plate): Smooth, shiny, pale, covered by amnion; umbilical cord attached (usually centrally - central insertion)

• Length: 50-60 cm
• Contains 2 umbilical arteries + 1 umbilical vein (AVA arrangement)
• Covered by Wharton's jelly

• Functional unit: Chorionic villi
• At term: villous trophoblast is thinned (Langhans layer disappears); syncytiotrophoblast remains
• Syncytial knots (Tenney-Parker change) appear

1. Nutrition (transfer of glucose, amino acids, fatty acids)
2. Respiration (O2 and CO2 exchange)
3. Excretion (waste products)
4. Endocrine (produces hCG, hPL, oestrogen, progesterone)
5. Immunological (IgG transfer; immune tolerance)
6. Barrier (limits some microorganisms and drugs)

Q4. Justify the Significance of the Fourth Stage of Labour

1. Highest risk of PPH: The uterus must contract firmly (retraction) to compress the placental bed sinuses. If it fails, severe haemorrhage occurs. 80% of PPH occurs in this period.
2. Active monitoring required:
   • Vital signs (BP, pulse, temperature) every 15 minutes
   • Uterine fundus palpation (should be firm, at/below umbilicus)
   • Estimation of blood loss
   • Perineal inspection for haematoma or ongoing bleeding
3. Oxytocin administration: Active management in this phase prevents uterine atony.
4. Bladder care: Ensure the bladder is empty (full bladder prevents uterine contraction).
5. Maternal bonding: Skin-to-skin contact with the baby; initiation of breastfeeding (breastfeeding stimulates endogenous oxytocin release, aiding uterine contraction).
6. Early detection of complications: Shock, perineal haematoma, urinary retention, retained placental fragments.
7. Fluid and pain management: IV fluids continued if needed; analgesia provided.

Q5. Explain Minor Ailments During Puerperium

Q6. Enumerate Minor Disorders of the Newborn

1. Physiological jaundice - Appears day 2-3, peaks day 4-5, resolves by day 7-10; due to RBC haemolysis + immature liver
2. Milia - Tiny white sebaceous cysts on nose and cheeks; resolve spontaneously
3. Erythema toxicum neonatorum - Blotchy red rash with white/yellow centre; self-limiting
4. Mongolian spots - Blue-grey patches over sacral area; common in Asian/dark-skinned babies; fade over years
5. Caput succedaneum - Boggy scalp swelling crossing suture lines; due to birth pressure; resolves in days
6. Cephalohaematoma - Subperiosteal collection; does NOT cross suture lines; resolves in weeks
7. Breast engorgement ("witch's milk") - Due to maternal oestrogen; resolves in 2 weeks; do NOT squeeze
8. Pseudo-menstruation - Vaginal bleeding in female neonates due to maternal oestrogen withdrawal
9. Subconjunctival haemorrhage - Red eye from birth trauma; resolves in 1-2 weeks
10. Physiological weight loss - Up to 10% of birth weight in first week; regained by day 10-14
11. Skin desquamation (peeling) - Especially in post-term babies; self-resolving
12. Umbilical stump odour - Normal drying; resolves; watch for true omphalitis
13. Nasal stuffiness - Narrow nasal passages; normal

Q7. Enumerate the Complications of Multiple Pregnancy

1. Hyperemesis gravidarum (severe morning sickness)
2. Anaemia (iron and folate deficiency)
3. Pre-eclampsia / hypertension (2-3x increased risk)
4. Gestational diabetes
5. Antepartum haemorrhage (placenta praevia, abruption)
6. Polyhydramnios
7. Preterm labour (most common - occurs in >50%)
8. Malpresentation (breech, transverse)
9. Cord prolapse
10. Postpartum haemorrhage (PPH)
11. Puerperal sepsis
12. Operative delivery (caesarean section)

1. Preterm birth - leading cause of neonatal mortality
2. Low birth weight (IUGR)
3. Twin-to-Twin Transfusion Syndrome (TTTS) - in monochorionic twins
4. Cord entanglement - in monoamniotic twins
5. Conjoined twins (rare)
6. Congenital anomalies (higher incidence)
7. Vanishing twin syndrome
8. Intrauterine fetal death
9. Birth asphyxia

Q8. Enumerate the Measures to Prevent Birth Injuries

1. Good antenatal care: Identify risk factors early (large baby, malpresentation, CPD)
2. Correct assessment of pelvis (pelvimetry): Detect cephalopelvic disproportion early
3. Monitoring fetal size: Regular ultrasound for fetal growth; anticipate macrosomia
4. Partograph use: Detect prolonged/obstructed labour early
5. Skilled birth attendant: Trained midwife/doctor at every delivery
6. Correct use of oxytocin: Avoid uterine hyperstimulation
7. Proper use of instruments: Careful, indication-based use of forceps/vacuum (ventouse)
8. Caesarean section when indicated: CPD, malpresentation, failed progress
9. Careful management of shoulder dystocia: HELPERR mnemonic (Call Help, Episiotomy, Legs - McRoberts, Pressure - suprapubic, Enter - internal rotation, Remove posterior arm, Roll)
10. Episiotomy: When necessary to prevent perineal and fetal head trauma
11. Controlled delivery of head: Ritgen manoeuvre
12. Prevention of precipitate labour: Slow, controlled delivery
13. Cord management: Avoid nuchal cord traction

Q9. List the Artificial Reproductive Techniques (ART). Explain any one.

1. Intrauterine Insemination (IUI)
2. In Vitro Fertilisation and Embryo Transfer (IVF-ET)
3. Gamete Intrafallopian Transfer (GIFT)
4. Zygote Intrafallopian Transfer (ZIFT)
5. Intracytoplasmic Sperm Injection (ICSI)
6. Surrogacy (traditional and gestational)
7. Oocyte/Embryo donation
8. Cryopreservation (sperm, eggs, embryos)

• Blocked or absent fallopian tubes
• Severe male factor infertility (used with ICSI)
• Unexplained infertility
• Endometriosis
• Ovulation disorders
• Failed IUI cycles

1. Ovarian stimulation (superovulation): FSH/LH injections (gonadotrophins) for 10-14 days to stimulate multiple follicle development; monitored with USS and oestradiol levels
2. Trigger injection: hCG (10,000 IU) given 36 hours before egg collection to induce final maturation
3. Oocyte retrieval (egg collection): Transvaginal ultrasound-guided aspiration of follicles under sedation
4. Fertilisation: Oocytes mixed with prepared sperm (or ICSI used for severe male factor) in incubator for 16-18 hours
5. Embryo culture: Fertilised eggs (zygotes) cultured for 3-5 days to blastocyst stage
6. Embryo transfer: 1-2 best quality embryos transferred into uterine cavity via thin catheter (painless, no anaesthesia)
7. Luteal support: Progesterone pessaries/injections for 2 weeks
8. Pregnancy test: Blood beta-hCG at 2 weeks post transfer

SHORT ANSWERS (10 × 2 = 20 Marks)

Q10. Components of Pre-Conception Care

1. Nutritional counselling (folic acid 400 mcg/day to prevent NTDs)
2. Screening for chronic diseases (diabetes, hypertension, thyroid disease)
3. Vaccination review (rubella, varicella, hepatitis B)
4. Review of current medications (teratogenic drugs to be stopped)
5. Genetic counselling (family history of hereditary disorders)
6. STI/HIV screening and treatment
7. Cessation of smoking, alcohol, recreational drugs
8. Achieving healthy BMI
9. Cervical smear (PAP smear) if due
10. Iron and haemoglobin assessment

Q11. What is Ovulation?

Q12. Protein Hormones of Pregnancy

1. hCG (Human Chorionic Gonadotrophin) - produced by syncytiotrophoblast; maintains corpus luteum; basis of pregnancy test
2. hPL (Human Placental Lactogen / Somatomammotrophin) - insulin antagonist; promotes fetal growth
3. ACTH - produced by placenta
4. TSH-like substance - from placenta
5. Relaxin - loosens pelvic ligaments
6. Inhibin - suppresses FSH

Q13. Expand BCG. Write its Purpose.

• BCG is a live attenuated vaccine derived from Mycobacterium bovis
• Given to newborns at birth (intradermally, right arm, 0.05 ml)
• Provides protection against tuberculosis (TB), especially severe forms: tuberculous meningitis and miliary TB in infants and young children
• Also protects against leprosy and Buruli ulcer to some extent
• Part of National Immunisation Schedule in India
• Produces a characteristic scar at injection site

Q14. Describe Glucose Tolerance Test (GTT)

1. Patient fasts for 8 hours overnight
2. Fasting blood glucose measured
3. 75g of glucose dissolved in 300 ml water given orally
4. Blood glucose measured at 1 hour and 2 hours

• Fasting: ≥92 mg/dL
• 1-hour: ≥180 mg/dL
• 2-hour: ≥153 mg/dL

Q15. Prophylactic Measures to Prevent DVT (Deep Vein Thrombosis)

1. Early ambulation post-surgery/delivery
2. Hydration - adequate oral/IV fluids
3. Compression stockings (graduated elastic stockings)
4. Pneumatic compression devices (intermittent pneumatic compression)
5. Low Molecular Weight Heparin (LMWH) - e.g., enoxaparin, for high-risk patients
6. Leg exercises (ankle pumps, calf exercises) while in bed
7. Avoid prolonged immobility - encourage frequent position changes
8. Avoid tight clothing around legs
9. Elevated leg positioning when at rest
10. Thromboprophylaxis risk assessment on admission for all obstetric patients

Q16. Define Omphalitis

Q17. Nurse's Responsibilities in Administering MgSO4 (Magnesium Sulphate)

1. Check the 6 Rs: right drug, right dose, right route, right patient, right time, right documentation
2. Monitor respiratory rate - must be ≥16/min before each dose (toxicity causes respiratory arrest)
3. Monitor urine output - must be ≥25-30 ml/hour (MgSO4 excreted by kidneys)
4. Check patellar reflex (knee jerk) - must be present before next dose (absent = sign of toxicity)
5. Keep 10% calcium gluconate 10 ml at bedside as antidote for toxicity
6. Monitor serum magnesium levels (therapeutic: 4-7 mEq/L; toxic: >7 mEq/L)
7. Monitor fetal heart rate and maternal vital signs continuously
8. Ensure IV line patency and correct infusion rate
9. Document all observations accurately
10. Alert physician immediately if signs of toxicity appear

Q18. Define Infertility

• Primary infertility: The couple has never achieved a pregnancy
• Secondary infertility: Inability to conceive after a previous pregnancy (regardless of outcome)

Q19. Define Eligible Couple