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QUESTION 3 [MMC] (2+3+10 = 15 Marks)

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Part A: Define Neonatal Mortality (2 marks)

• Neonatal Mortality Rate (NMR): Number of deaths in the first 28 days of life per 1,000 live births in a given year and area.

• Early neonatal period: 0-6 days (deaths = early neonatal mortality)
• Late neonatal period: 7-27 days (deaths = late neonatal mortality)

India's NMR (2020) ~20 per 1,000 live births (SRS data). Early neonatal deaths account for ~75% of all neonatal deaths.

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Part B: Importance of Neonatal Mortality (3 marks)

1. Magnitude: Neonatal deaths account for ~47% of all under-5 child deaths globally and ~60% in India - making it the single largest contributor to child mortality.
2. Indicator of health system quality: NMR reflects the quality of antenatal care, skilled birth attendance, postnatal care, and newborn management. It is a sensitive indicator of socioeconomic development and healthcare access.
3. Preventability: The majority (up to 75%) of neonatal deaths are preventable with simple, low-cost, evidence-based interventions such as essential newborn care, breastfeeding support, kangaroo mother care, and infection prevention.
4. SDG & National Program targets: Reduction of NMR to ≤12/1,000 live births by 2030 is a key Sustainable Development Goal (SDG-3.2) target and a priority under India's RMNCAH+N strategy.
5. Burden of disease: Neonatal deaths lead to significant Years of Life Lost (YLL), affecting the DALY burden and productivity of nations.

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

1. Thermal Care (Warmth)

• Dry and stimulate the baby immediately at birth using a clean, dry cloth.
• Skin-to-skin (kangaroo) care: place baby on mother's chest.
• Delayed bathing: avoid bathing for at least 24 hours (minimum 6 hours).
• Warm room: maintain room temperature at 25-28°C.
• "Warm chain" - a series of 10 interlinked steps to prevent hypothermia.
• Never leave baby exposed; wrap in clean, dry linen.

2. Cord Care (Infection Control)

• Cut the cord with a sterile blade/scissors after delayed cord clamping (1-3 minutes post birth).
• Tie with a sterile cord clamp or clean thread.
• Apply chlorhexidine 7.1% gel to the cord stump in community/home births (WHO/Government of India recommendation).
• Keep the cord clean and dry - "dry cord care" in facility births.
• Do NOT apply oils, ash, turmeric, or cow dung (major source of tetanus and sepsis).
• Expose the stump to air; fold diaper below stump.

3. Breastfeeding

• Initiate breastfeeding within 30-60 minutes of birth (WHO: within 1 hour).
• Exclusive breastfeeding for 6 months - provides passive immunity (IgA, lysozyme, lactoferrin).
• Colostrum ("liquid gold") is rich in antibodies and must not be discarded.
• Correct positioning and attachment to prevent engorgement and mastitis.

4. Eye Care (Infection Control)

• Instill 1% tetracycline ointment or 0.5% erythromycin ointment in both eyes at birth (prophylaxis against ophthalmia neonatorum from gonococcal/chlamydial infection).
• Wipe eyes from inner to outer canthus with clean, separate swab for each eye.
• Do NOT use silver nitrate (due to chemical conjunctivitis risk).

5. Vitamin K Administration

• Administer Vitamin K1 (phytomenadione) 1 mg IM to all newborns at birth (within 6 hours).
• Prevents hemorrhagic disease of the newborn (HDN/VKDB).
• Premature/LBW babies receive 0.5 mg.

6. Resuscitation Readiness

• Every birth must be attended by a trained person capable of newborn resuscitation.
• "ABCD" - Airway, Breathing, Circulation, Drugs (rarely).
• Use bag-and-mask ventilation with room air (21% O₂); avoid routine suctioning.
• Resuscitation equipment: ambu-bag, face mask, suction device must be sterile/clean.

7. Infection Prevention (Detailed - Most Important for this question)

• Strict 5-moment hand hygiene (WHO guidelines) using soap and water or alcohol-based hand rub.
• All birth attendants, healthcare workers, and family members must wash hands before and after touching the newborn.

• Use of clean delivery kit (CDK): sterile blade, gloves, plastic sheet, cord tie.
• "5 Cleans": Clean hands, clean surface, clean cord tie, clean blade, clean cord care.

• Infected newborns should be isolated.
• Standard precautions: gloves for procedures, gowns when necessary.
• Proper disposal of soiled material (blood, liquor).

• Avoid unnecessary procedures and invasive lines (IV cannulas are portals of entry).
• Any wound, skin breach to be treated aseptically.

• Restrict visitors/family entry to NICU/SNCU.
• Regular disinfection of surfaces, incubators, phototherapy units.
• Rational antibiotic use - avoid prophylactic antibiotics without indication.

• BCG (0.05 mL intradermal, left deltoid) - at birth.
• OPV-0 - at birth.
• Hepatitis B vaccine (birth dose) - within 24 hours of birth.

• Keep mother and baby together to promote breastfeeding and reduce cross-infection from other babies (as in nursery/ward settings).

• Identify early signs of sepsis: temperature instability, poor feeding, respiratory distress, lethargy, abdominal distension, bulging fontanelle.
• Prompt referral or management of suspected sepsis with parenteral antibiotics.

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Summary Table: ENC Components

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QUESTION 4 [MsdMCH] (2+1+2+8+2 = 15 Marks)

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Part A: Identify the Condition and Its Type (2 marks)

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Part B: Does the Baby Require SNCU Admission? Justify. (1+2 = 3 marks, here split as 1+2)

• Birth weight <1800 g (this baby = 1900 g - above threshold)
• Gestational age <34 weeks (this baby = 35 weeks - above threshold)
• Any signs of illness: respiratory distress, cyanosis, poor feeding, seizures, temperature instability

• Weighs 1900 g (>1800 g)
• Is 35 weeks (late preterm, >34 weeks)
• Is "otherwise stable" - no distress, no illness signs

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Part C: Principles of Care of a Stable LBW/Preterm Newborn (8 marks)

1. Kangaroo Mother Care (KMC) - CORNERSTONE of LBW Management

• Continuous skin-to-skin contact between mother and baby (baby placed between mother's breasts, in flexed position).
• Initiated as soon as baby is stable.
• Maintains temperature (replaces incubator), promotes breastfeeding, reduces infection, promotes bonding.
• Practised 24 hours/day; baby wears cap, socks, nappy.
• KMC discharge criteria: Baby gaining weight (>15-20 g/day), breastfeeding well, temperature stable, no illness signs.

2. Thermal Protection

• Maintain axillary temperature: 36.5-37.5°C.
• Warm room (25-28°C), wrap in warm clothes.
• Avoid heat loss: delayed bathing, warm surface for examination.
• Kangaroo position is the best thermal protection.

3. Feeding - Breastfeeding Support

• Exclusive breastfeeding is gold standard.
• Late preterm infants have weak suck reflex - need positioning and attachment support.
• If direct breastfeeding not possible: expressed breast milk (EBM) by cup/paladai/spoon (NOT bottle).
• Feed every 2-3 hours (8-12 feeds/day).
• Assess adequacy: weight gain ≥15 g/kg/day after day 4.
• Never fast a stable LBW baby for >3 hours (risk of hypoglycemia).

4. Prevention and Monitoring of Hypoglycemia

• First feed within 1 hour of birth.
• Monitor blood glucose (heel prick) at 1 hour, then as needed.
• Target: blood glucose ≥45 mg/dL.
• If hypoglycaemia: IV dextrose/supplemental feeds.

5. Infection Prevention

• Strict hand hygiene (5 moments) for all handlers.
• Minimize invasive procedures.
• Rooming-in with mother.
• Cord care: dry and clean.
• Immunization as per schedule (BCG, OPV-0, Hep-B at birth).
• Antibiotics only if sepsis is suspected/proven (PROM >18 hours is a risk factor - monitor for sepsis signs).

6. Monitoring and Surveillance

• Weight (daily), temperature (4-hourly)
• Feeding adequacy (number of feeds, urine output: ≥6 wet diapers/day)
• Jaundice (serum bilirubin, visual assessment, threshold for phototherapy is lower in preterm)
• Respiratory status, activity, and tone

7. Phototherapy for Jaundice

• LBW/preterm babies have lower threshold for phototherapy (compared to term babies).
• Treat at lower bilirubin levels as preterm brain is more susceptible to kernicterus.

8. Follow-up and Referral

• Discharge only when: weight ≥1800 g, breastfeeding well, temperature stable in room air, and parents are counseled.
• Follow-up at 7 days, 14 days, 28 days, and monthly.
• SNCU referral if: temperature instability, respiratory distress, poor feeding, jaundice requiring phototherapy, or any deterioration.

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Part D: Four Possible Complications of LBW/Preterm (35 weeks) Baby (2 marks)

1. Hypothermia - immature thermoregulation, less subcutaneous fat and brown fat
2. Hypoglycemia - low glycogen stores, poor feeding, high metabolic demand
3. Respiratory Distress Syndrome (RDS)/Transient Tachypnea of Newborn (TTN) - surfactant deficiency/immature lungs (especially since PROM can increase risk)
4. Neonatal Sepsis/Infection - immature immune system + PROM is a major risk factor for chorioamnionitis and early-onset neonatal sepsis (Group B Streptococcus, E. coli)

• Neonatal jaundice (hyperbilirubinemia)
• Apnea of prematurity
• Necrotizing enterocolitis (NEC)
• Anemia of prematurity
• Intraventricular hemorrhage (IVH)

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QUESTION 5 [KPC] (4+6+5 = 15 Marks)

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Part A: Classification of the Disease According to IMNCI (4 marks)

Step 1: Clinical Assessment Using IMNCI

• Fever (3 days)
• Difficulty in breathing (cough with fast breathing or chest in-drawing)
• History of measles 1 month ago
• Missed measles vaccine at 9 months (immunization defaulter)

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IMNCI Classification - COUGH/DIFFICULT BREATHING:

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IMNCI Classification - FEVER:

• Malaria risk (check RDT/smear)
• Measles (had measles 1 month ago)
• Possible bacterial infection

• If fever >7 days with no obvious cause → FEVER - NO APPARENT CAUSE
• With measles history and complications → MEASLES WITH COMPLICATIONS

1. SEVERE PNEUMONIA / VERY SEVERE DISEASE (difficulty breathing + chest in-drawing)
2. Measles with severe complications (post-measles pneumonia)
3. Check nutritional status (post-measles malnutrition common)

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Part B: Management According to IMNCI Protocol (6 marks)

Immediate Action (Urgent Pre-referral Treatment):

• Give first dose of antibiotics before referral
• Keep child warm, encourage breastfeeding

• First dose of Benzyl Penicillin: 50,000 units/kg IM (or Ampicillin + Gentamicin)
• OR Amoxicillin (oral) if referral not possible
• Treat fever: Paracetamol 15 mg/kg/dose oral if temperature >38.5°C

At Hospital Level Management:

• Benzyl Penicillin IV 50,000 IU/kg/dose every 6 hours for 3 days, then oral Amoxicillin to complete 5 days
• OR Co-Amoxiclav (Amoxicillin-Clavulanate) for broader coverage
• If staphylococcal/post-measles pneumonia suspected: add Cloxacillin or Oxacillin
• Consider Erythromycin/Azithromycin if atypical organisms (Mycoplasma, Chlamydia) suspected

• Oxygen therapy if SpO₂ <90% (target 94-98%)
• Ensure adequate hydration and nutrition (ORS/IV fluids if unable to feed)
• Continue breastfeeding or oral feeds if tolerated

• Vitamin A 200,000 IU orally (child ≥12 months) - mandatory in post-measles cases
• WHO recommends Vitamin A for all measles cases as it reduces mortality and eye complications
• Give on day 1, day 2, and day 14-28 if eye involvement

• Monitor for complications: corneal ulceration → tetracycline/erythromycin eye ointment + Vitamin A
• Mouth ulcers → Gentian violet 0.25% or Nystatin
• Nutritional support

• Assess for malnutrition (MUAC, weight for height)
• If severe acute malnutrition (SAM): manage with F-75/F-100 therapeutic feeds

• Check immunization status: missed Measles vaccine at 9 months → Give Measles vaccine NOW (at current visit, if not already given during illness; wait until recovered)
• Update all missed vaccines (DPT booster, OPV, etc.)

• Respiratory rate, oxygen saturation, temperature every 4-6 hours
• Signs of clinical improvement expected within 48 hours of antibiotics

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Part C: Advice to Mother at Discharge (5 marks)

1. Feeding Advice

• Continue breastfeeding (if applicable) and give adequate complementary feeding.
• Give energy-dense foods 5-6 times/day to compensate for nutritional losses during illness.
• Post-measles "catch-up growth" diet.

2. Danger Signs - Return Immediately to PHC/Hospital if:

• Fast/difficult breathing worsens or recurs
• Child unable to drink or breastfeed
• Child becomes sicker, lethargic, or unconscious
• Fever persists beyond 5 days on antibiotics
• Chest in-drawing develops
• Cloudiness of eyes

3. Medications

• Complete the full course of oral antibiotics (5-7 days) even if child appears better.
• Give Paracetamol for fever as needed.
• Continue Vitamin A supplementation (if remaining doses pending).

4. Immunization

• Child missed Measles vaccine at 9 months - this should be given now.
• Schedule and complete all pending immunizations at the nearest immunization centre.
• Measles vaccine: one dose now; second dose at 15-18 months (under UIP schedule).

5. Hygiene Counseling

• Wash hands before and after feeding, after defecation.
• Safe drinking water and proper food hygiene.
• Avoid overcrowding (measles is highly contagious; protect younger siblings).

6. Follow-up

• Return for review at 2 days (as per IMNCI - FOLLOW UP for pneumonia) for reassessment.
• If improving → complete antibiotics. If not improving → reassess classification, consider referral.

7. Nutrition and Vitamin A

• Ensure diet rich in Vitamin A sources (dark green vegetables, eggs, dairy).
• Enroll under Integrated Child Development Services (ICDS) if eligible.

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QUESTION 6 [SRIMS] (2+3+5+5 = 15 Marks)

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Part A (i): What is Reproductive Health? (2 marks)

"Reproductive health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity, in all matters relating to the reproductive system and to its processes and functions."

• People are able to have a satisfying and safe sex life.
• Capability to reproduce.
• Freedom to decide if, when, and how often to do so.
• The right to information and access to safe, effective, affordable, and acceptable methods of family planning.
• Access to appropriate health care services enabling women to safely complete pregnancy and childbirth.

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Part B (ii): Current Status of Reproductive Health in India (3 marks)

Positive Trends (Achievements):

Persistent Challenges:

• High MMR in some states (UP, Rajasthan, MP, Assam - "high focus states").
• Unmet need for family planning: 9.4% (NFHS-5) - still significant.
• Adolescent pregnancy: High in rural areas; adolescent birth rate still a concern.
• Sex ratio at birth: 929 per 1,000 male births (NFHS-5) - gender bias persists.
• Anaemia in women: 57% of women aged 15-49 are anaemic (NFHS-5) - a major reproductive health concern.
• ANC quality: Only 21% of mothers received all ANC components (NFHS-5).
• STI/HIV burden: India has 2.3 million PLHIV; vertical transmission prevention is ongoing challenge.
• Male participation in family planning: Vasectomy rate only 0.3% - predominantly female-dominated.

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Part C (iii): Danger Signs of Mother During Antenatal Period (5 marks)

Obstetric Danger Signs (Antenatal):

1. Severe headache - may indicate pre-eclampsia/hypertension
2. Blurring of vision / visual disturbances - sign of severe pre-eclampsia/impending eclampsia
3. Convulsions/fits - eclampsia (life-threatening emergency)
4. Severe abdominal pain - may indicate abruptio placentae, ectopic pregnancy, uterine rupture
5. Vaginal bleeding - antepartum haemorrhage (APH): placenta praevia or abruptio placentae
6. Fever with/without rigors - malaria, urinary tract infection, sepsis
7. Breathlessness / palpitations - severe anaemia, cardiac disease, pulmonary embolism
8. Swelling of face, hands and feet (oedema) - pre-eclampsia, nephrotic syndrome
9. Decreased or absent fetal movements (after 28 weeks) - fetal distress or death
10. Leaking of fluid per vaginum (premature rupture of membranes - PROM)
11. Persistent vomiting - hyperemesis gravidarum
12. Pallor (severe) - severe anaemia (Hb < 7 g/dL)

• 3 main danger signs: Bleeding, Convulsions, High fever

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Part D (iv): Services Under RMNCH+A Programme (5 marks)

Antenatal Care (ANC) Services:

• Register in Mother and Child Protection (MCP) card
• Record LMP, EDD, obstetric history, medical history

• Weight, Height (BMI), Blood pressure (for pre-eclampsia screening)
• Pallor (anaemia), oedema, jaundice
• Abdominal examination: fundal height (expected ~20 cm at 20 weeks), fetal heart sounds by Doppler/Pinard stethoscope
• Breast examination for lactation preparation

• Haemoglobin (Hb) estimation
• Urine for protein and sugar (pre-eclampsia and gestational diabetes)
• Blood group and Rh typing
• VDRL (syphilis screening)
• HIV testing (PPTCT - Prevention of Parent to Child Transmission)
• Malaria RDT/smear in endemic areas
• Blood sugar (gestational diabetes mellitus screening at 24-28 weeks)
• Thyroid function (TSH) in high-risk cases

• Iron and Folic Acid (IFA) tablets: 100 mg elemental iron + 0.5 mg folic acid daily from 12-16 weeks till 180 days
• Calcium supplementation: 500 mg twice daily from 2nd trimester
• Nutritional counseling (diet rich in iron, protein, calcium)

• Tetanus Toxoid (TT)/Td vaccination:
  • TT1: First contact (or early in pregnancy for primigravida)
  • TT2: 4 weeks after TT1
  • Booster: if received 2 doses in previous pregnancy within 3 years
• Under Mission Indradhanush: Td vaccine replacing TT

• Birth preparedness and complication readiness (BPCR) counseling
• Institutional delivery (JSY/JSSK entitlements)
• Breastfeeding and newborn care
• Family planning (post-partum)
• Danger signs (see above)
• HIV/AIDS and STI prevention

• Cash incentive for institutional delivery (₹1400 rural, ₹1000 urban for BPL women)
• ASHA facilitates and escorts to delivery facility

• Free delivery, free C-section
• Free drugs, diagnostics, blood transfusion
• Free transport to facility and back
• Free diet during hospital stay
• Zero out-of-pocket expenditure

• Cash benefit of ₹5,000 in 3 instalments for first live birth (compensates wage loss)

• If any risk factor (anaemia, hypertension, multiple gestation, malpresentation, previous LSCS, PROM) → refer to CHC/FRU/DH

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QUESTION 7 [SSKM] (4+4+7 = 15 Marks)

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Part A: Core MCH Indicators Monitored Under National Programs (4 marks)

Mortality Indicators:

Morbidity/Coverage Indicators:

RMNCH+N Specific Indicators Monitored Under NHM:

• % women registered for ANC in first trimester
• % pregnant women receiving IFA for 180 days
• % pregnant women receiving TT2/booster
• % children fully immunized by 1 year
• % children receiving Vitamin A supplementation
• SNCU/NBCC admission rates and outcomes
• % deliveries under JSY

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Part B: Predominant Medical and Social Causes of Perinatal Mortality in Contemporary India (4 marks)

Medical Causes:

1. Prematurity/Low Birth Weight (LBW) - single most common cause (~40%)
2. Birth asphyxia - intrapartum hypoxia, uterine rupture, cord prolapse (~20-25%)
3. Intrauterine Growth Restriction (IUGR) - placental insufficiency, maternal malnutrition, hypertension
4. Congenital malformations - neural tube defects (folate deficiency), cardiac, chromosomal
5. Maternal infections: Syphilis (TORCH), malaria, HIV - vertical transmission
6. Antepartum haemorrhage (APH): Placenta praevia, abruptio placentae
7. Hypertensive disorders of pregnancy (PIH/pre-eclampsia/eclampsia) - placental abruption, fetal hypoxia
8. Gestational diabetes mellitus - macrosomia, birth asphyxia
9. Umbilical cord complications: Cord prolapse, cord entanglement
10. Neonatal sepsis (especially early-onset from maternal GBS, PROM)

Social Causes:

1. Poverty and low socioeconomic status - poor nutrition, limited healthcare access
2. Maternal malnutrition and anaemia - directly causes IUGR, LBW, preterm
3. Low maternal education - poor health-seeking behavior, late recognition of danger signs
4. Early marriage and early childbearing - adolescent pregnancy (immature pelvis, anaemia)
5. Low utilization of ANC - undetected complications, missed opportunities for intervention
6. High home delivery rate (especially in rural/tribal areas) - lack of skilled birth attendance
7. Poor access to emergency obstetric care (EmOC) - distance, cost, referral delays
8. Gender discrimination - son preference, neglect of girl children, maternal neglect
9. Frequent pregnancies / short birth spacing (<2 years) - depleted maternal nutrition
10. Cultural practices - traditional dais, unclean delivery, delay in referral
11. Inadequate postnatal care - poor recognition of neonatal danger signs

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Part C: Public Policy and Clinical Interventions by Government to Ensure Infant and Child Survival (7 marks)

A. Policy Framework:

1. National Health Mission (NHM) (2005 - present)
   • Umbrella framework for RMNCH+A services
   • ASHA, ANM, AWW community health worker cadre
   • Health and Wellness Centres (HWCs) under Ayushman Bharat
2. RMNCH+A Strategy (2013)
   • Life cycle approach from adolescence through pregnancy, childbirth, newborn, child
   • Identifies high-priority districts and states
3. India Newborn Action Plan (INAP) (2014)
   • Goal: NMR ≤10 and stillbirth rate ≤10 per 1,000 births by 2030
   • Strategic interventions across continuum of care
4. Sustainable Development Goals (SDG 3.1 and 3.2):
   • MMR <70/100,000 live births by 2030
   • U5MR ≤25 and NMR ≤12 per 1,000 live births by 2030

B. Clinical Interventions at Each Level:

• Quality ANC (minimum 8 contacts as per WHO 2016; India: 4 minimum) for early detection of risk factors
• IFA supplementation (180 days) and Calcium supplementation
• TT/Td immunization - prevents neonatal tetanus
• Screening and treatment of anaemia, hypertension, gestational diabetes, syphilis
• Deworming (single dose albendazole in 2nd trimester)
• Malaria prophylaxis in endemic areas
• Pradhan Mantri Surakshit Matritva Abhiyan (PMSMA) - fixed-day ANC on 9th of every month at government facilities (including specialist services - O&G, physician)
• LaQshya Programme - improving quality of care in labour rooms and maternity OTs

• Janani Suraksha Yojana (JSY) - cash incentive for institutional delivery
• Janani Shishu Suraksha Karyakram (JSSK) - free delivery, drugs, diagnostics, transport
• Skilled Birth Attendants (SBA training to ANMs)
• 24×7 delivery services at PHC level
• First Referral Units (FRUs) at CHC for EmOC, C-section
• DAKSHATA programme - improving skilled birth attendance skills of healthcare providers
• Partograph use to monitor labour and detect abnormal progress

• Essential Newborn Care (ENC) - at every birth
• Newborn resuscitation (NRP) - Bag and Mask ventilation for asphyxiated babies
• Kangaroo Mother Care (KMC) - for LBW/preterm babies
• Special Newborn Care Units (SNCUs) at district hospitals (for sick neonates)
• Newborn Stabilization Units (NBSUs) at CHC level
• Newborn Baby Care Corners (NBCCs) at PHC level
• Home Based Newborn Care (HBNC) - ASHA visits 7 times in first 42 days
• Chlorhexidine cord care in community births

• Universal Immunization Programme (UIP)/Mission Indradhanush - BCG, OPV, DPT, Hep-B, IPV, Rota, PCV, MR, JE vaccines
• Intensified Mission Indradhanush (IMI) - targeting unimmunized/under-immunized children
• Integrated Management of Neonatal and Childhood Illness (IMNCI) - community (C-IMNCI) and facility-based
• Vitamin A supplementation - 9 doses from 9 months to 5 years (National Vitamin A Programme)
• Iron and Folic Acid supplementation for children (Weekly IFA under WIFS for school children)
• Nutrition Rehabilitation Centres (NRCs) - for SAM children
• Rashtriya Bal Swasthya Karyakram (RBSK) - 4D screening (Defects, Deficiencies, Diseases, Developmental delays) from birth to 18 years by Mobile Health Teams

• ASHA - community mobilization, referral, HBNC visits, immunization tracking
• Village Health Nutrition Days (VHNDs) at Anganwadi centres
• ICDS - supplementary nutrition, pre-school education, immunization, health referral
• Mother and Child Tracking System (MCTS)/RCH portal - beneficiary-level tracking of pregnant women and children for follow-up

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QUESTION 8 (15 Marks)

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Part A: Essential Components of Antenatal Care Under RMNCAH+N Strategy

1. Registration and Documentation

• Register in first trimester (ideally by 12 weeks) - early registration is a key RMNCAH+N indicator
• Fill Mother and Child Protection (MCP) card (pink booklet)
• Record: Name, Age, LMP, EDD, gravida/para, obstetric history, medical/surgical history, socioeconomic details
• Open RCH II register entry and Mother and Child Tracking System (MCTS) online entry
• Allocate ASHA for home visits and follow-up

2. Physical Examination at Each Visit

• Weight and height (calculate BMI; underweight = <18.5 kg/m²)
• Blood pressure at every visit (early detection of PIH/pre-eclampsia)
• Pallor assessment (anaemia - most common complication in Indian women)
• Oedema of face, hands, and feet
• Obstetric examination:
  • Fundal height measurement (in cm = weeks of gestation ± 3 from 20 weeks)
  • Fetal presentation and lie (from 28 weeks onwards)
  • Fetal heart rate (FHR) - Doppler from 12 weeks, Pinard stethoscope from 20 weeks
  • Fetal movement counting (from 28 weeks)

3. Laboratory Investigations

• Haemoglobin (Hb) estimation
• Blood group and Rh typing (if Rh-negative: partner's blood group, Anti-D at 28 weeks and post-delivery)
• Urine: protein and sugar (dipstick)
• VDRL/RPR (syphilis screening - mandatory)
• HIV test (PPTCT programme) - provider-initiated counseling and testing
• Blood sugar (fasting/random/GCT for GDM screening, especially at 24-28 weeks)
• Malaria RDT/smear (in malaria-endemic areas)
• Stool for helminthiasis (for deworming decision)

• Hb (for anaemia progress)
• Urine protein/sugar
• BP
• GDM screening (if not done earlier)

4. Tetanus Immunization

• TT1: Given at first contact (if primigravida or gap >5 years from last dose)
• TT2: 4 weeks after TT1 (minimum 4 weeks gap, ideally before 36 weeks)
• TT Booster: Single dose if TT2 given in previous pregnancy within last 3 years
• Under UIP: Td (Tetanus-diphtheria) vaccine replacing TT in many states
• Provides protection to mother (against puerperal tetanus) and baby (neonatal tetanus)

5. Nutritional Supplementation (Details in Part B)

• IFA tablets (daily)
• Calcium supplementation
• Vitamin D (where available)

6. Deworming

• Single dose Albendazole 400 mg in second trimester (after 14 weeks) - safe from 2nd trimester
• Not given in first trimester (teratogenic risk)

7. Counseling and Education

• Birth Preparedness and Complication Readiness (BPCR):
  • Identify skilled birth attendant
  • Identify referral facility (FRU/DH)
  • Save money for delivery/emergency
  • Arrange blood donor
  • Arrange transport in advance
• Danger signs counseling (see Q6 above)
• Breastfeeding: initiation within 1 hour, colostrum, exclusive breastfeeding
• Newborn care and immunization
• Family planning (post-delivery)
• JSSK/JSY entitlements

8. Malaria Prevention (Endemic Areas)

• Sleep under insecticide-treated bed nets (ITNs)
• Chemoprophylaxis (Chloroquine prophylaxis in falciparum-non-endemic P. vivax areas - not recommended in India routinely; treatment of confirmed cases with safe drugs)

9. Prevention of Mother to Child Transmission (PMTCT/PPTCT)

• All HIV-positive women: Antiretroviral therapy (ART) from diagnosis regardless of CD4 count (Option B+)
• Cotrimoxazole prophylaxis for HIV-exposed infant
• Counseling on infant feeding (replacement feeding vs breastfeeding with ART)

10. High-Risk Pregnancy Identification and Referral

• Refer to Medical Officer/CHC/FRU/DH if any of the following:
  • Age <18 or >35 years, height <145 cm
  • Hb <7 g/dL (severe anaemia)
  • BP ≥140/90 mmHg
  • Malpresentation at 36 weeks
  • Previous LSCS, bad obstetric history
  • Multiple gestation
  • PROM, bleeding PV
  • Medical disorders: cardiac, renal, diabetes, epilepsy

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Part B: Nutritional Interventions and Prophylactic Measures During Pregnancy

Nutritional Interventions:

• Dosage: 1 tablet daily containing 100 mg elemental iron + 0.5 mg folic acid
• Duration: From 12-16 weeks till 6 months post-delivery (total 180+ days)
• Prevents iron deficiency anaemia - reduces maternal mortality, LBW, preterm delivery
• Side effects: constipation, black stools, nausea - take after meals
• Under NHM: free distribution through ASHA/ANM/HWC

• 0.5-1 mg folic acid daily from at least 3 months preconception to 12 weeks
• Prevention of Neural Tube Defects (NTDs): anencephaly, spina bifida
• Women with previous NTD baby: 5 mg/day periconceptionally
• This is why registration by 12 weeks is critical

• 500 mg calcium twice daily (1000 mg/day) from 2nd trimester to 6 months postpartum
• Reduces risk of pre-eclampsia and eclampsia (particularly in populations with low dietary calcium)
• Source: Calcium carbonate tablets (free under NHM)

• Extra 350-500 kcal/day above normal requirements (2000-2100 kcal/day → 2400-2500 kcal/day)
• Extra 50 g protein/day (dals, legumes, eggs, milk, meat)
• Iron-rich foods: green leafy vegetables, jaggery, dates, dried fruits, meat, organ meats
• Vitamin C-rich foods with iron foods to enhance absorption (citrus fruits, amla)
• Calcium-rich foods: milk, curd, paneer, ragi, sesame seeds
• Avoid tea/coffee with meals (inhibit iron absorption)
• 8-10 glasses of water/day

• Sun exposure + dietary sources (fortified milk/oils)
• Supplement if deficient (600 IU/day)

• Use iodized salt in cooking (mandatory under National Iodine Deficiency Disorders Control Programme)
• Iodine deficiency in pregnancy → cretinism, neonatal hypothyroidism

Prophylactic Measures:

• Albendazole 400 mg single dose in second trimester (after 14 weeks)
• Reduces worm load, improves iron absorption, prevents anaemia

• TT1, TT2/Booster (as detailed above)
• Prevents neonatal tetanus (major cause of neonatal mortality in unvaccinated communities) and maternal tetanus

• ITN use (Insecticide Treated Nets) - especially in tribal/endemic areas
• Prompt treatment of confirmed malaria (Chloroquine safe in pregnancy for P. vivax; Artesunate combinations for falciparum in 2nd/3rd trimester)
• Avoid areas with high malaria transmission

• If mother is Rh-negative and partner/baby is Rh-positive
• Administer 300 mcg Anti-D IM at 28 weeks (antenatal prophylaxis)
• Repeat post-delivery within 72 hours if baby is Rh-positive
• Prevents Rh isoimmunization (erythroblastosis fetalis in subsequent pregnancies)

• Low-dose aspirin (75-150 mg/day from <16 weeks) for women at high risk of pre-eclampsia (previous pre-eclampsia, multiple gestation, chronic hypertension, diabetes)

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Part C: Key Components of Essential Newborn Care (ENC)

The 10 Components of ENC:

• Dry thoroughly with warm, clean cloth within seconds of birth
• Stimulate by rubbing the back; if no response → begin resuscitation
• Change wet cloth for a dry one

• Clamp and cut umbilical cord 1-3 minutes after birth (while still pulsating)
• Benefits: transfers 80-100 mL of placental blood → increases iron stores, reduces anaemia
• Use sterile blade/scissors; tie with sterile cord clamp

• Place baby prone on mother's bare chest immediately after birth
• Promotes thermal protection, breastfeeding, bonding, reduces sepsis
• Continue for as long as possible (especially LBW babies)

• Initiate within 1 hour (60 minutes) of birth
• Give colostrum - do not discard
• Exclusive breastfeeding for 6 months
• Correct positioning and attachment (WHO technique)

• Warm delivery room (25°C+), warm surfaces
• Dry immediately, cover head (cap)
• Skin-to-skin contact
• Delayed bathing (minimum 24 hours; WHO recommendation)
• Target axillary temperature: 36.5-37.5°C

• Clean, dry cord care in facility births
• 7.1% Chlorhexidine gel application in community/home births
• Do NOT apply harmful substances (cow dung, ash, oils, turmeric)
• Clean hands before touching cord

• Prophylactic 1% Tetracycline or 0.5% Erythromycin ointment in both eyes
• Prevents ophthalmia neonatorum (gonococcal/chlamydial)

• Vitamin K₁ 1 mg IM within 6 hours of birth
• Prevents Vitamin K Deficiency Bleeding (VKDB/HDN)
• LBW: 0.5 mg

• BCG (0.05 mL, ID, left deltoid)
• OPV-0 (2 drops oral)
• Hepatitis B (birth dose) (0.5 mL IM, right thigh) - within 24 hours

• Every birth must have a trained person ready to resuscitate
• Bag-and-Mask Ventilation (BMV) with room air (21% O₂)
• Initial steps: position, suction (only if thick meconium/secretions), stimulate, assess
• Avoid routine oral/nasal suctioning in non-meconium births

Special Component - HBNC (Home Based Newborn Care):

• ASHA visits family 6 times in first month (days 3, 7, 14, 21, 28, and 42)
• Checks: temperature, breastfeeding, umbilical cord, weight, jaundice
• Counseling on danger signs and appropriate care seeking
• Connects to SNCU/referral if needed

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Summary - All 6 Questions Answered

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• Q3 and Q8 overlap on ENC - the infection control angle differentiates Q3; Q8 asks for nutritional/prophylactic measures additionally.
• Q4: The mark scheme (2+1+2+8+2) shows the care principles (8 marks) are most important - write all 8 KMC/feeding/thermal/infection points clearly.
• Q5: Always use the IMNCI 2-box classification table language (Severe Pneumonia vs Pneumonia) - examiners look for it. Don't forget Vitamin A for measles.
• Q6 and Q7: These have high national program overlap - NFHS-5 data, JSY, JSSK, PMSMA, Mission Indradhanush are scoring points.
• Q8 has the most content overlap with Q3 and Q6 - use structured headings to score consistently across all sub-parts.

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QUESTION 4 [MsdMCH] (2+1+2+8+2 = 15 Marks)

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Part A: Identify the Condition and Its Type (2 marks)

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Part B: Does the Baby Require SNCU Admission? Justify. (1 + 2 marks)

• Weighs 1900 g (above the 1800 g SNCU threshold)
• Is 35 weeks gestation (above the 34-week threshold)
• Is clinically stable (as stated in the question)

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Part C: Principles of Care of a Stable LBW/Late Preterm Newborn (8 marks)

1. Kangaroo Mother Care (KMC) - Cornerstone of LBW Management

• Place baby in continuous skin-to-skin contact on mother's chest (prone position between the breasts), secured with a KMC binder/cloth.
• Started as soon as the baby is clinically stable.
• Maintains body temperature equivalent to an incubator - prevents hypothermia.
• Promotes breastfeeding, bonding, and reduces infections.
• KMC is continued 24 hours/day; baby wears cap, socks, and diaper.
• KMC discharge criteria: weight ≥1800 g, fully breastfeeding, temperature stable in room air, no illness, parents fully counseled.

2. Thermal Protection

• Target axillary temperature: 36.5 - 37.5°C
• Warm delivery room and ward (25-28°C)
• Avoid heat loss - no unnecessary exposure, delayed bathing (minimum 24 hours)
• Dress in warm, dry clothes; keep head covered (cap)
• KMC is the single best thermal protection strategy for LBW babies

3. Feeding - Breastfeeding Support

• Exclusive breastfeeding is the standard of care
• Late preterm infants (34-36 weeks) have an immature, weak suck-swallow-breathe coordination - they tire easily
• Support mother with correct positioning and attachment; express breast milk if direct feeding is not possible
• Feed every 2-3 hours (8-12 feeds/day) - do NOT allow fasting for >3 hours
• Assess adequacy by: weight gain ≥15-20 g/kg/day after day 4, ≥6 wet diapers/day, satisfactory alertness
• If unable to feed orally: Expressed Breast Milk (EBM) by paladai/cup/spoon (NOT bottle)
• IV fluids only if enteral feeding is not tolerated

4. Prevention and Early Detection of Hypoglycemia

• First feed within 1 hour of birth
• Blood glucose monitoring at 1 hour, 3 hours, and then 6-hourly for the first 24 hours (heel prick)
• Target blood glucose: ≥45 mg/dL
• If hypoglycemic: give more frequent feeds or IV 10% dextrose
• LBW preterm babies are at high risk due to: low hepatic glycogen stores, immature gluconeogenesis, poor feeding

5. Infection Prevention (Critical given PROM history)

• PROM >18 hours is a major risk factor for early-onset neonatal sepsis (GBS, E. coli)
• Strict hand hygiene (WHO 5-moments) for all caregivers
• Minimize invasive procedures; maintain aseptic technique for any procedure
• Clean, dry cord care; do NOT apply harmful substances
• Rooming-in with mother (reduces cross-infection from other babies)
• Monitor for sepsis signs: temperature instability, poor feeding, lethargy, respiratory distress, abdominal distension, bulging fontanelle
• Antibiotics: Start empirical IV antibiotics (Ampicillin + Gentamicin) if there are any clinical signs of sepsis or if PROM >18 hours (as per unit protocol)

6. Monitoring (Frequency and Parameters)

7. Phototherapy for Neonatal Jaundice

• LBW and preterm babies have lower bilirubin thresholds for phototherapy compared to term babies (preterm brain is more susceptible to bilirubin encephalopathy/kernicterus)
• Start phototherapy at lower bilirubin levels as per AAP/NNF weight/gestation-specific charts
• Monitor bilirubin every 12-24 hours during phototherapy

8. Immunization at Birth

• BCG (0.05 mL intradermal, left deltoid)
• OPV-0 (2 drops oral)
• Hepatitis B birth dose (0.5 mL IM, right thigh) - within 24 hours
• Vitamin K₁ 0.5 mg IM (reduced dose for LBW/preterm <2.5 kg)

Discharge and Follow-up

• Discharge criteria: weight ≥1800 g, fully breastfeeding, temperature stable in room air, no active illness
• Follow-up schedule: Day 7, Day 14, Day 28, then monthly
• Counsel parents on: KMC at home, danger signs, breastfeeding, immunization schedule

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Part D: Four Possible Complications of a Late Preterm LBW Baby (2 marks)

1. Hypothermia - Immature thermoregulatory system, minimal subcutaneous fat and brown adipose tissue; cannot generate adequate heat
2. Hypoglycemia - Low hepatic glycogen stores at birth, immature gluconeogenesis, high metabolic rate, and poor/delayed feeding
3. Respiratory Distress - Either Respiratory Distress Syndrome (RDS) from relative surfactant deficiency at 35 weeks, or Transient Tachypnea of Newborn (TTN) from delayed lung fluid clearance; PROM itself can cause pulmonary hypoplasia in prolonged cases
4. Neonatal Sepsis - Immature immune system (low immunoglobulins, poor neutrophil function) + PROM (ascending infection from maternal genital tract) → high risk for early-onset sepsis caused by Group B Streptococcus, E. coli, Klebsiella

• Neonatal jaundice (hyperbilirubinemia) - immature hepatic conjugation
• Apnea of prematurity - immature respiratory centre
• Feeding difficulties - poor suck-swallow coordination
• Anemia of prematurity - shortened red cell survival + inadequate erythropoietin response

QUESTION 5 [KPC] (4+6+5 = 15 Marks)

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Part A: Classification According to IMNCI Protocol (4 marks)

Background - IMNCI Approach

1. Cough/Difficulty in breathing → assess for pneumonia
2. Fever → assess for malaria/measles/bacterial infection

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Classification 1: COUGH AND DIFFICULT BREATHING

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Classification 2: FEVER

• Fever present: assess duration (3 days here - <7 days)
• Check for stiff neck (meningitis), runny nose, measles rash, mouth ulcers, eye discharge (measles/complications)
• Check for malaria risk area (RDT/blood smear)
• History of measles 1 month ago is key

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Additional Classification: NUTRITIONAL STATUS

• Post-measles children are at high risk of Severe Acute Malnutrition (SAM)
• Check MUAC (Mid-Upper Arm Circumference):
  • <11.5 cm = SAM
  • 11.5-12.5 cm = MAM
• Check weight-for-height, visible severe wasting, bilateral pitting oedema
• Classify accordingly (Severe Acute Malnutrition / Moderate Malnutrition / Normal)

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Summary of IMNCI Classifications for this Child:

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Part B: Management According to IMNCI Protocol (6 marks)

Step 1: Pre-Referral Emergency Treatment (at PHC level)

• Benzyl Penicillin 50,000 IU/kg IM - first dose at PHC before sending
• OR Ampicillin 50 mg/kg IM if Penicillin unavailable

• Paracetamol 15 mg/kg/dose oral if temperature ≥38.5°C

• Encourage breastfeeding/oral fluids before departure
• Give oral sugar water if child not feeding

• Vitamin A 200,000 IU oral immediately (child ≥12 months)
• This is a critical IMNCI action for ALL measles cases regardless of severity
• WHO recommends two doses: Day 1 and Day 2 (and Day 14-28 if eye involvement)

• Explain why urgent referral is needed
• Note pre-referral treatment given on referral slip
• ASHA to accompany if possible

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Step 2: Management at Hospital Level

• Bacterial: Streptococcus pneumoniae, Staphylococcus aureus, H. influenzae
• Viral: Measles virus directly (giant cell pneumonia)
• Opportunistic: in severely malnourished children

• Administer oxygen if SpO₂ <94% or severe respiratory distress
• Target SpO₂: 94-98%
• Use nasal prongs (0.5-1 L/min for infants) or face mask

• Day 1: 200,000 IU oral (≥12 months)
• Day 2: 200,000 IU oral (second dose)
• Day 14-28: 200,000 IU oral (third dose if eye complications: corneal ulcer, xerophthalmia)
• Vitamin A reduces measles mortality by 50% and prevents corneal blindness
• This is mandatory under India's National Vitamin A Programme and WHO guidelines

• Continue breastfeeding/age-appropriate complementary foods
• If SAM detected: admit to Nutrition Rehabilitation Centre (NRC); manage with F-75 → F-100 → RUTF protocol
• High-calorie, high-protein diet during recovery (post-measles "catch-up growth")

• IV fluids if unable to feed orally (maintain hydration)
• Maintain warmth
• Elevate head end of bed (30°)
• Frequent monitoring: RR, SpO₂, temperature, feeding every 4-6 hours

• Improvement expected within 48 hours of antibiotics
• If no improvement at 48 hours → reassess classification, broaden antibiotic cover, consider resistant organisms

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Step 3: IMNCI Follow-Up Schedule (if managed at PHC without referral)

• Follow-up in 2 days for Pneumonia
• At follow-up: check breathing, fever, feeding
  • If improving: complete antibiotics
  • If worse: reclassify and refer

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Part C: Advice to Mother at Discharge (5 marks)

1. Danger Signs - Return IMMEDIATELY if:

• Difficulty in breathing returns or worsens
• Child is unable to drink or breastfeed
• Child becomes more sick
• Child develops convulsions (fits)
• High fever that does not come down
• Child becomes lethargic/unconscious
• Eyes become red, watery, or child develops cloudiness of eyes (measles eye complication)

2. Complete Medication Course

• Give all antibiotic doses for the full prescribed duration (5-7 days) even if the child looks well
• Do NOT stop medicines early - incomplete treatment leads to relapse and antibiotic resistance
• Give Paracetamol for fever as needed (NOT aspirin - risk of Reye's syndrome in children)
• Continue Vitamin A supplementation if remaining doses are pending

3. Feeding Advice

• Continue breastfeeding (if still breastfeeding) - breast milk provides antibodies and nutrition
• Give frequent small feeds of energy-rich foods: dal-rice, khichdi, mashed vegetables, eggs, banana
• Extra feeding during recovery - child needs additional calories for catch-up growth after measles
• Do NOT reduce food during illness (old practice of "starvation during fever" is harmful)
• Ensure adequate fluid intake - ORS/clean water/coconut water/juices

4. Immunization - Critical Action

• Child missed Measles vaccine at 9 months - this is a priority
• Give Measles/MR vaccine NOW at discharge (or at earliest well-child visit after full recovery)
• Under India's Universal Immunization Programme (UIP):
  • MR (Measles-Rubella) vaccine: 9-12 months (first dose - missed) → give now
  • MR second dose: 15-18 months
• Check and complete all other missed vaccines (DPT, OPV, Hep-B boosters)
• Register child at nearest immunization centre/Anganwadi

5. Hygiene and Infection Prevention

• Handwashing with soap - before feeding, after defecation, before handling the child
• Safe drinking water (boil or filter)
• Clean, covered food storage
• Measles is highly contagious (R₀ = 12-18) - advise mother to inform about exposure to other unvaccinated children (younger siblings especially)
• Ensure younger siblings in the family are vaccinated

6. Nutritional Counseling

• Post-measles children are prone to Vitamin A deficiency and malnutrition
• Feed Vitamin A-rich foods: dark green leafy vegetables, carrots, pumpkin, eggs, milk, liver
• Enroll in ICDS (Anganwadi centre) for supplementary nutrition, growth monitoring
• If child is underweight/wasted - refer to NRC (Nutrition Rehabilitation Centre)

7. Follow-up Schedule

• Follow-up in 2 days (standard IMNCI pneumonia follow-up) to reassess breathing and fever
• If fully recovered at 2-day visit: continue rest of medicines, next visit at 14 days
• Routine well-child visit at 6 weeks for immunization and growth monitoring

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Quick Revision Summary for Exam:

QUESTION 6 [SRIMS] (2+3+5+5 = 15 Marks)

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Part (i): What is Reproductive Health? (2 marks)

Definition (WHO, 1994 - International Conference on Population and Development, Cairo):

"Reproductive health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity, in all matters relating to the reproductive system and to its processes and functions."

• Have a satisfying and safe sex life
• Have the capability to reproduce
• Have the freedom to decide if, when, and how often to do so
• Have access to safe, effective, affordable, and acceptable methods of family planning
• Have access to appropriate health-care services enabling women to safely go through pregnancy and childbirth

Components of Reproductive Health:

1. Maternal and child health
2. Family planning services
3. Prevention and management of STIs including HIV/AIDS
4. Prevention of unsafe abortion
5. Adolescent reproductive health
6. Treatment of infertility
7. Prevention of gender-based violence and harmful practices (early marriage, FGM)

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Part (ii): Current Status of Reproductive Health in India (3 marks)

A. Mortality Indicators (Progress Made):

B. Coverage/Service Indicators (NFHS-5, 2019-21):

C. Persistent Challenges:

1. High MMR in high-focus states: UP, Assam, Rajasthan, MP, Odisha, Bihar still account for majority of maternal deaths
2. Severe anaemia in women: 57% of women aged 15-49 years are anaemic (NFHS-5) - one of the highest globally; a major direct and indirect cause of maternal mortality
3. Adolescent pregnancy: India has a high adolescent birth rate; early marriage persists in rural and tribal belts (23% women married before 18 years - NFHS-5)
4. Sex ratio at birth: 929 females per 1,000 males (NFHS-5) - reflects ongoing sex-selective practices despite PCPNDT Act
5. Unmet need for family planning: 9.4% - predominantly female sterilization (37.9%) with negligible male participation (vasectomy: 0.3%)
6. STI/HIV burden: India has ~2.3 million People Living with HIV (PLHIV); vertical (mother to child) transmission remains a concern despite PPTCT programme
7. Quality of ANC: Only ~21% of mothers received all components of ANC (NFHS-5) - showing a gap between quantity and quality of services
8. Unsafe abortion: An estimated 6-7 million unsafe abortions annually; contributes to maternal mortality
9. Regional disparities: Wide gap between southern states (low MMR, high institutional delivery) and northern/eastern states

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Part (iii): Danger Signs of Mother During Antenatal Period (5 marks)

The 12 Danger Signs of Pregnancy:

• First trimester: abortion, ectopic pregnancy
• Second/third trimester: antepartum haemorrhage (APH) - placenta praevia (painless), abruptio placentae (painful)
• Any bleeding per vaginum = medical emergency

• Indicates eclampsia - one of the top 3 causes of maternal mortality in India
• May be preceded by severe headache, blurring of vision, high BP (pre-eclampsia)
• Requires immediate Magnesium Sulphate and referral

• May indicate pre-eclampsia/hypertension, hypertensive encephalopathy
• Especially if associated with visual disturbances and elevated BP

• Symptom of severe pre-eclampsia - indicates cerebral involvement
• Can progress to eclampsia if untreated

• Abruptio placentae (painful APH with board-like rigid abdomen)
• Ruptured ectopic pregnancy (first trimester)
• Preterm labour
• Uterine rupture (in obstructed labour, previous LSCS scar)
• Urinary tract infection/pyelonephritis

• Can indicate: malaria (very common in India - causes anaemia, miscarriage, LBW), UTI/pyelonephritis, septicaemia, chorioamnionitis (with PROM)
• Malaria in pregnancy = high risk of severe disease and adverse fetal outcomes

• Severe anaemia (Hb <7 g/dL) - most common cause in India
• Cardiac disease decompensating in pregnancy
• Pulmonary oedema (pre-eclampsia/eclampsia)
• Pulmonary embolism (rare but fatal)

• Normal: mild ankle oedema in late pregnancy
• Abnormal/Danger sign: facial oedema + pitting oedema of hands - indicates pre-eclampsia, nephrotic syndrome, or cardiac failure
• Rapid onset of oedema especially with rising BP = severe pre-eclampsia

• Normal: ≥10 fetal movements in 12 hours (Cardiff "count to ten" method)
• Reduced or absent movements = fetal distress or intrauterine fetal death (IUFD)
• Requires immediate fetal assessment (cardiotocography, USG)

• Premature Rupture of Membranes - risk of ascending infection → chorioamnionitis → neonatal sepsis
• Prolapse of umbilical cord in acute PROM
• Requires immediate assessment; <37 weeks = preterm PROM (high-risk)

• Normal morning sickness: first 12-14 weeks, manageable
• Danger: inability to keep any food or water down → dehydration, electrolyte imbalance, Wernicke's encephalopathy (Vitamin B1 deficiency)
• Requires IV fluids, antiemetics, hospitalisation

• Indicates severe anaemia (Hb <7 g/dL)
• Causes: iron deficiency, hookworm infestation, haemoglobinopathies (thalassaemia, sickle cell)
• Severe anaemia = high maternal mortality risk (heart failure, PPH, infection)

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Memory Aid (Mnemonic):

"3 Main Danger Signs: Bleeding, Convulsions, High Fever" - refer immediately

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Part (iv): Services Provided Under RMNCH+A Programme (5 marks)

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A. Registration and Documentation

• Register in Mother and Child Protection (MCP) Card (pink card - national standard tool)
• Record: Name, age, address, LMP, EDD (Naegele's rule: LMP + 9 months + 7 days), blood group, ANC history
• Open entry in RCH-II register and update on Mother and Child Tracking System (MCTS) / Reproductive and Child Health (RCH) portal for beneficiary-level follow-up
• Assign an ASHA worker for community-level support and escort to facility

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B. Clinical Examination at Sub-centre

• Weight (expected weight at 20 weeks: ~57-60 kg if normal BMI; assess gestational weight gain)
• Blood Pressure (normal <140/90; screen for PIH)
• Pallor of conjunctiva, tongue (screen for anaemia)
• Oedema of feet, hands, face
• Pulse, respiration, temperature

• Fundal height: at 20 weeks = at or just below the umbilicus (~20 cm by tape)
• Fetal heart sounds by Pinard fetoscope or Doppler (audible from 18-20 weeks)
• Fetal movements (may just be starting to be felt at 20 weeks - quickening)

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C. Laboratory Investigations (at Sub-centre or referred to PHC)

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D. Nutrition and Supplementation

• Dietary counseling: Extra 350-500 kcal/day; increase protein (dals, eggs, milk, meat); iron-rich foods (green leafy vegetables, jaggery); Vitamin C-rich foods to enhance iron absorption; calcium-rich foods (milk, curd, ragi); avoid tea/coffee with meals

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E. Immunization

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F. Counseling Services

• Identify and plan for a Skilled Birth Attendant (SBA)
• Identify the nearest 24×7 delivery facility / FRU
• Save money in advance for any emergency
• Identify a blood donor (same blood group)
• Arrange transport well in advance (including night-time emergency plan)
• Keep emergency contact numbers handy (ASHA, ANM, 108 ambulance)

• Danger signs (all 12 signs as above)
• Importance of institutional delivery
• Breastfeeding: initiation within 1 hour, exclusive breastfeeding for 6 months
• Newborn care and immunization schedule
• Post-delivery family planning options
• Nutrition and rest during pregnancy
• Personal hygiene, safe water, sanitation

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G. Financial Entitlements and Schemes

• Cash incentive for institutional delivery
• Rural BPL: ₹1,400 to mother + ₹600 to ASHA
• Urban BPL: ₹1,000 to mother + ₹400 to ASHA
• Encourages facility-based delivery to reduce maternal and neonatal mortality

• Free and cashless entitlements at government facilities:
  • Free normal/operative delivery
  • Free caesarean section
  • Free drugs and consumables
  • Free diagnostics (blood tests, USG, etc.)
  • Free blood transfusion
  • Free diet during hospital stay (3 days normal delivery, 7 days C-section)
  • Free transport from home to facility and back
  • Free treatment of sick newborn up to 30 days
  • Zero out-of-pocket expenditure

• Cash benefit of ₹5,000 in 3 instalments for the first live birth
• Compensates for wage loss during pregnancy and early childcare
• Instalment 1: ₹1,000 (on registration, if LMP ≥6 months ago)
• Instalment 2: ₹2,000 (after first ANC check-up ≥6 months of pregnancy)
• Instalment 3: ₹2,000 (after child's birth registration and first cycle of BCG, OPV, DPT vaccination)

• Fixed-day ANC on the 9th of every month at government facilities
• Provides comprehensive antenatal check-up including specialist services (Obstetrician, Physician, Radiologist for USG)
• Identifies high-risk pregnancies for special follow-up

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H. Referral and High-Risk Identification

• Severe anaemia (Hb <7 g/dL)
• Blood pressure ≥140/90 mmHg
• Urine protein positive (pre-eclampsia)
• Malpresentation (too early to diagnose at 20 weeks, but noted)
• Multiple gestation
• Previous bad obstetric history (previous stillbirth, LSCS, PPH)
• Medical disorders (cardiac disease, epilepsy, diabetes, thyroid disease)
• HIV-positive (for ART initiation under PPTCT)
• Age <18 or >35 years
• Height <145 cm (high risk for CPD)

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Quick Revision Summary for Exam:

QUESTION 7 [SSKM] (4+4+7 = 15 Marks)

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Part A: Core MCH Indicators Monitored Under National Programs (4 marks)

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I. Mortality Indicators

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II. Coverage / Service Indicators

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III. Program-Specific MCH Indicators (Monitored Under NHM/RMNCH+A):

• % pregnant women receiving 180+ IFA tablets
• % pregnant women receiving TT2/booster
• % deliveries under JSY (beneficiaries)
• % newborns breastfed within 1 hour of birth
• % children fully immunized by 1 year of age
• SNCU occupancy rate and neonatal case fatality rate
• % pregnant women screened for HIV (PPTCT)
• % Severe Acute Malnutrition (SAM) cases treated at NRCs

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Part B: Predominant Medical and Social Causes of Perinatal Mortality in Contemporary India (4 marks)

Definition Recap:

• Perinatal period: From 28 completed weeks of gestation to 7 completed days after birth
• Perinatal mortality = Still births + Early neonatal deaths (0-6 days)
• India's PMR is approximately 24 per 1,000 births

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I. Medical Causes of Perinatal Mortality

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II. Social Causes of Perinatal Mortality

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Part C: Public Policy and Clinical Interventions by Government to Ensure Infant and Child Survival (7 marks)

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I. Policy Framework

• Overarching framework encompassing NRHM (rural) + NUHM (urban)
• Strengthened health infrastructure: sub-centre, PHC, CHC, district hospital
• Created the ASHA (Accredited Social Health Activist) cadre - 10.5 lakh ASHAs nationwide as community health workers
• Ayushman Bharat - Health and Wellness Centres (HWCs): Upgraded sub-centres and PHCs to provide comprehensive primary care including maternal and child health services

• Addresses Reproductive, Maternal, Newborn, Child and Adolescent health in a continuum
• Identifies and focuses on high-priority districts in 8 high-focus states (UP, Bihar, MP, Rajasthan, Jharkhand, Odisha, Uttarakhand, Chhattisgarh)
• Targets disease burden across the entire life cycle

• National commitment to end preventable newborn deaths and stillbirths
• "ENRICH" framework: Every Newborn Rapid Integrated Coverage with High-impact interventions
• Target: NMR ≤10 and SBR ≤10 per 1,000 births by 2030

• MMR <70/1,00,000 live births by 2030
• U5MR ≤25 and NMR ≤12/1,000 live births by 2030

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II. Antenatal Interventions (Preventing Perinatal Deaths Before Birth)

• Minimum 4 ANC visits (India); WHO recommends 8 contacts
• Early registration (by 12 weeks) at HWC/Sub-centre
• Screening for anaemia, hypertension, GDM, syphilis, HIV at every visit
• High-risk pregnancy identification and referral to FRU/DH

• Free, fixed-day comprehensive ANC on 9th of every month at government facilities
• Specialist services (Obstetrician, Physician, Radiologist) provided
• Identifies high-risk pregnancies for dedicated follow-up and management
• "Surakshit Matritva Assurance" (SUMAN) for zero-denial policy at all public facilities

• IFA supplementation (100 mg iron + 0.5 mg folic acid) for 180+ days
• Calcium 1000 mg/day from 2nd trimester (reduces pre-eclampsia)
• Albendazole deworming in 2nd trimester
• Anemia Mukt Bharat programme - targets anaemia at all life stages

• TT1 + TT2 (or booster) during every pregnancy
• Prevents neonatal tetanus - once a major cause of neonatal mortality in India
• Neonatal tetanus is now nearly eliminated in India due to this programme

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III. Intrapartum Interventions (Preventing Birth Asphyxia and Obstetric Deaths)

• Cash conditional transfer for institutional delivery (₹1,400 rural / ₹1,000 urban for BPL)
• ASHA incentivized to escort women to facility
• Has contributed to the rise in institutional delivery from ~38% (2005) to ~88.6% (NFHS-5)
• One of the largest conditional cash transfer programmes in the world

• Entitlements: Free delivery, C-section, drugs, diagnostics, blood, transport, diet
• Eliminates out-of-pocket expenditure - a major barrier to institutional delivery
• Extends to sick newborns up to 30 days of age

• Training ANMs and nurses in skilled birth attendance (partograph use, Active Management of Third Stage of Labour - AMTSL, newborn resuscitation)
• DAKSHATA programme: Training of health care providers in labour room skills

• 24×7 EmOC including C-section, blood transfusion at CHC/District Hospital level
• LaQshya Programme (2017): Improving quality of care in labour rooms and maternity OTs (NICU/SNCU attachment)

• Free emergency transport for obstetric emergencies
• Reduces the "second delay" (delay in reaching facility) - a critical bottleneck in rural India

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IV. Newborn Interventions (Reducing NMR and ENMR)

• Package of simple, evidence-based care at every birth: thermal care, cord care, early breastfeeding, resuscitation, immunization, Vitamin K
• Mandatory at every delivery point

• Every delivery must be attended by personnel trained in Newborn Resuscitation Protocol (NRP)
• Bag-and-mask ventilation at birth prevents asphyxia-related deaths

• Over 900 SNCUs operational across India under NHM

• Skin-to-skin care for LBW/preterm babies
• Replaces incubator in resource-limited settings
• Reduces hypothermia, sepsis, improves breastfeeding
• KMC wards established at district hospitals

• ASHA visits the newborn at home 6 times in first month (days 3, 7, 14, 21, 28, and 42)
• Checks: temperature, feeding, cord, jaundice, weight
• Identifies danger signs and refers to SNCU/facility
• ASHA incentivized: ₹250 per newborn surviving to 42 days (LBW: ₹400)

• 7.1% Chlorhexidine gel applied to cord stump in community/home births
• Reduces umbilical cord infections and neonatal sepsis significantly

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V. Infant and Child Survival Interventions (Reducing IMR and U5MR)

• Mission Indradhanush (2014): Intensified catch-up immunization targeting unimmunized/under-immunized children in high-risk areas
• Intensified Mission Indradhanush (IMI 3.0): Targeting children and pregnant women missed during COVID-19 pandemic

• Training healthcare providers in standardized assessment and treatment of childhood illness (pneumonia, diarrhoea, malaria, measles, malnutrition, neonatal conditions)
• Community IMNCI (C-IMNCI): Training ASHAs and AWWs in community-level care and danger sign recognition

• 9 doses of Vitamin A from 9 months to 5 years:
  • 1,00,000 IU at 9 months (with MR vaccine)
  • 2,00,000 IU every 6 months from 18 months to 5 years
• Reduces all-cause child mortality by ~23%, measles mortality by ~50%, diarrhoea deaths by ~33%
• Delivered through biannual rounds (VHNDs and outreach sessions)

• ORS + Zinc protocol (national standard since 2004):
  • ORS for rehydration
  • Zinc 20 mg/day for 14 days - reduces duration and severity of diarrhoea, prevents future episodes
• Reduces diarrhoea mortality significantly

• Amoxicillin (oral) as first-line treatment for pneumonia at PHC level (IMNCI protocol)
• Referral for severe pneumonia with oxygen therapy
• Cotrimoxazole + Amoxicillin availability at sub-district level

• "4D" Screening of all children (birth to 18 years) for:
  • Defects at birth (congenital)
  • Deficiencies (nutrition, micronutrient)
  • Diseases (common childhood illnesses)
  • Developmental delays including disabilities
• District Early Intervention Centres (DEICs) for management of identified conditions
• Screening done by mobile health teams (2 doctors per block) at Anganwadis and schools

• Beneficiary-level tracking of every pregnant woman from registration to delivery
• Tracks each child from birth to completion of immunization schedule
• Enables ASHA/ANM to identify and follow up defaulters
• Generates due lists for immunization, ANC visits, postnatal care

• Monthly fixed-day outreach at Anganwadi centre
• Services: immunization, ANC, growth monitoring, supplementary nutrition, health education
• Platform for community-level delivery of all RMNCH+A services

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Quick Revision Summary for Exam: