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Midwifery and Obstetrics – Selected Units for Exam

By: Praveen Kumar

College: Saraswati College of Nursing

Unit 7: Antenatal Care (ANC)

(16 Marks Answer Format)

Definition:
Antenatal care refers to the care given to a pregnant woman from the time of conception until
the onset of labour, with the goal of ensuring the health and safety of both mother and baby.

Objectives of Antenatal Care:

1. Ensure safe and normal delivery
2. Promote the health of mother and fetus
3. Detect high-risk cases early
4. Provide necessary treatment and education
5. Prepare the couple for parenthood

Schedule of Antenatal Visits:

• 1st Visit: As early as possible (before 12 weeks)
• 2nd Visit: 14–26 weeks
• 3rd Visit: 28–34 weeks
• 4th Visit: 36–40 weeks

Assessments Done During ANC:

• General examination: height, weight, BP
• Abdominal palpation (Leopold’s maneuvers)
• Fetal heart sound (FHS) auscultation
• Hemoglobin estimation, blood grouping, urine test
• Immunization: 2 doses of Tetanus toxoid (TT)
• Iron and folic acid supplementation

Minor Disorders in Pregnancy and Nursing Management:

Disorder Management
Nausea Small frequent meals, avoid fatty food
Constipation High fiber diet, increased fluids
Heartburn Avoid spicy food, use antacids
Backache Good posture, local heat application
Leg cramps Gentle massage, calcium supplements

Health Education Provided:

• Importance of ANC visits
• Nutritional guidance
• Personal hygiene and rest
• Danger signs in pregnancy
• Breastfeeding and newborn care

Diagram:
• Antenatal assessment chart
• Fundal height vs. gestational age graph

Unit 8: Normal Labour

(16 Marks Answer Format)

Definition:
Labour is the physiological process by which the fetus, placenta, and membranes are expelled
from the uterus through the birth canal.

Stages of Labour:
1. First Stage:
• Onset of true labour to full cervical dilatation (10 cm)
• Subdivided into:
• Latent phase: 0–4 cm
• Active phase: 4–7 cm
• Transition: 8–10 cm
• Duration: 6–12 hours
2. Second Stage:
• Full dilatation to delivery of baby
• Duration: 30–60 minutes
3. Third Stage:
• Delivery of baby to expulsion of placenta
• Duration: 5–15 minutes
4. Fourth Stage:
• First 1 hour after placenta delivery
• Observation for bleeding or PPH

Signs of True Labour:

 • Regular painful contractions
• Show (blood-tinged mucus)
• Progressive cervical dilatation
• Rupture of membranes

Nursing Management During Labour:

• Monitor vital signs
• Use of partograph to record progress
• Emotional support to mother
• Maintain hygiene and privacy
• Prepare for safe delivery
• Immediate newborn care

Diagrams:
• Partograph
• Mechanism of Labour (7 steps)

Unit 9: Normal Puerperium

(16 Marks Answer Format)

Definition:
Puerperium is the period of about six weeks after childbirth during which the mother’s
reproductive organs return to their pre-pregnant state.

Physiological Changes During Puerperium:

• Uterine Involution: Uterus shrinks to normal size
• Lochia Discharge:
• Lochia rubra (1–3 days): red
• Lochia serosa (4–10 days): pinkish-brown
• Lochia alba (10–14 days): whitish
• Breast Changes: Milk secretion begins
• Hormonal Adjustment
• Emotional Changes: “Baby blues”, mood swings

Postnatal Care of Mother:

• Monitor bleeding, pulse, uterus size
• Encourage rest, good nutrition
• Perineal hygiene
• Prevent infection
• Promote early ambulation
• Breastfeeding support
 • Family planning advice

Care of the Newborn:

• Immediate care (drying, APGAR)
• Early breastfeeding (within 1 hour)
• Immunizations: BCG, OPV-0, Hep B
• Cord care, temperature maintenance
• Bathing after 24–48 hrs

Diagrams:
• Uterus involution timeline
• Lochia stages chart

⸻Unit 10: High-Risk Pregnancy

Definition of High-Risk Pregnancy:

A high-risk pregnancy is one where the health of the mother, fetus, or both is at risk due to
existing medical conditions, complications during pregnancy, or other factors. These pregnancies
require close monitoring and, in some cases, medical interventions to ensure the safety of both
the mother and baby.

Types of High-Risk Pregnancies:

1. Maternal Risk Factors:
• Pre-existing health conditions: Diabetes, hypertension, heart disease, thyroid disorders,
etc.
• Age: Women under 18 or over 35 are at higher risk.
• Obesity or underweight: Can lead to complications like gestational diabetes,
hypertension, or preterm birth.
• Previous history of complications: History of pre-eclampsia, miscarriage, preterm birth,
or cesarean section.
2. Fetal Risk Factors:
• Multiple pregnancies: Twins, triplets, or higher-order multiples have a higher risk of
premature birth, growth restrictions, and other complications.
• Fetal abnormalities: Structural or chromosomal abnormalities (e.g., Down syndrome,
heart defects).
• Intrauterine growth restriction (IUGR): When the fetus doesn’t grow at the expected
rate.
3. Pregnancy-related Complications:
• Gestational diabetes: A form of diabetes that develops during pregnancy and can cause
complications for both mother and baby.
• Hypertensive disorders: Includes gestational hypertension, pre-eclampsia, and
eclampsia, all of which increase the risk of complications.
• Placental complications: Placenta previa (placenta covering the cervix), placental
abruption (premature separation of the placenta), etc.

Management of High-Risk Pregnancy:

1. Monitoring and Early Detection:
• Regular prenatal visits: Monitoring maternal blood pressure, weight gain, fetal heart
rate, and growth.
• Ultrasound scans: To detect fetal growth, abnormal positions, or structural anomalies.
• Blood tests: Screening for gestational diabetes, infections, and genetic disorders.
• Urine tests: To monitor for protein (sign of pre-eclampsia) or infections.
2. Medical Interventions:
• Medication: Antihypertensives, insulin for gestational diabetes, or corticosteroids for
fetal lung development in preterm labor.
• Bed rest: For certain conditions like pre-eclampsia or threatened preterm labor.
• Hospitalization: In cases of severe complications, close monitoring in the hospital may
be necessary.
• Early delivery: In cases of severe pre-eclampsia or fetal distress, delivery may be
induced early.
3. Lifestyle Modifications:
• Dietary changes: A balanced diet with controlled sugar intake for gestational diabetes
or salt restriction for hypertension.
• Regular monitoring of blood pressure and blood sugar at home.
• Adequate rest and stress management.

Common Complications of High-Risk Pregnancy:

1. Pre-eclampsia:
• A condition characterized by high blood pressure, proteinuria (protein in urine), and
edema (swelling). It can lead to eclampsia (seizures) if untreated.
2. Gestational Diabetes:
• A form of diabetes that develops during pregnancy and increases the risk of
complications like macrosomia (large baby), preterm birth, and neonatal hypoglycemia.
3. Placental Complications:
• Placenta previa: Placenta partially or completely covers the cervix, leading to
complications during delivery.
• Placental abruption: Premature separation of the placenta from the uterine wall,
leading to heavy bleeding and fetal distress.
4. Preterm Labour:
 • Labour that starts before 37 weeks of gestation. Causes include infections, multiple
pregnancies, or maternal conditions like hypertension.

Assessment of Fetal Well-Being in High-Risk Pregnancy:

1. Non-Stress Test (NST):
Measures fetal heart rate patterns to assess if the fetus is getting enough oxygen.
2. Biophysical Profile (BPP):
Combines NST with ultrasound to assess fetal movement, tone, breathing, and amniotic fluid
level.
3. Doppler Ultrasound:
Measures blood flow in the umbilical cord to assess the oxygen supply to the fetus.
4. Amniocentesis:
A test to check for genetic abnormalities and fetal lung maturity.

Diagrams for Unit 10:

1. Flow Chart of High-Risk Pregnancy Management
(Includes steps for monitoring, early intervention, and delivery options)
2. Pre-eclampsia: Signs and Symptoms
(Shows the common signs such as hypertension, proteinuria, and edema)

Unit 12: Abnormal Labour (Dystocia)

Definition:

Abnormal labour, also called dystocia, refers to difficult or prolonged labour due to abnormalities
in the powers (uterine contractions), passage (pelvis), or passenger (fetus). It increases the risk of
complications for both mother and baby and often requires medical or surgical intervention.

Types of Abnormal Labour:

1. Prolonged Labour:
• Labour lasting more than 18 hours in primigravida or 12 hours in multigravida.
• May occur in any stage (latent, active, second stage).
2. Obstructed Labour:
• Labour in which the fetus cannot progress through the birth canal despite strong
uterine contractions.
• Common causes: cephalopelvic disproportion (CPD), malpresentation, pelvic tumors.
3. Precipitate Labour:
• Very rapid labour and delivery (less than 3 hours).
• May cause uterine rupture, trauma to the birth canal, and neonatal injuries.

Causes of Abnormal Labour – The 3 Ps:

1. Power (Uterine Contractions):
• Hypotonic uterine contractions: Weak and ineffective contractions.
• Hypertonic contractions: Strong but uncoordinated, causing pain and fetal distress.
2. Passenger (Fetus):
• Malpresentations: Breech, face, brow, transverse lie.
• Macrosomia (large baby)
• Multiple pregnancy
3. Passage (Pelvis and Soft Tissues):
• Cephalopelvic disproportion (CPD)
• Contracted pelvis
• Cervical rigidity or obstruction due to fibroids

Signs and Symptoms of Abnormal Labour:

• Prolonged duration of labour
• Poor cervical dilatation
• No descent of fetal head
• Signs of maternal exhaustion
• Fetal distress (abnormal heart rate, meconium-stained liquor)
• Bandl’s ring in obstructed labour (pathological retraction ring)
• Uterine tenderness and distension

Diagnosis:
• Partograph:
A graphical representation of labour progress; helps in early identification of abnormal labour.
• Alert and action lines
• Cervical dilatation, fetal descent, uterine contractions, maternal vitals
• Pelvic examination:
To assess presentation, position, station of fetal head, and cervical dilatation.
• Abdominal palpation & auscultation:
Leopold’s maneuvers and fetal heart rate monitoring.
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Management of Abnormal Labour:

1. Medical Management:
• IV fluids to prevent dehydration.
• Pain relief: Epidural or analgesics.
• Oxytocin drip (only in hypotonic contractions with no obstruction).
• Antibiotics if prolonged rupture of membranes.
2. Surgical Interventions:
• Forceps delivery or vacuum extraction: If second stage is prolonged and fetal head is
low.
• Cesarean section: In CPD, fetal distress, obstructed labour, or failure to progress.
3. Nursing Management:
• Continuous monitoring of maternal and fetal vitals.
• Psychological support to the mother.
• Strict input/output charting.
• Observing for signs of uterine rupture or fetal distress.
• Maintaining asepsis during all procedures.

Complications of Abnormal Labour:

Maternal:
• Uterine rupture
• Postpartum hemorrhage (PPH)
• Genital tract injuries
• Sepsis
• Psychological trauma

Fetal:
• Birth asphyxia
• Neonatal sepsis
• Brain damage due to prolonged hypoxia
• Death

Prevention:
• Early detection of high-risk cases during antenatal visits
• Proper pelvic assessment
• Timely use of partograph
• Skilled birth attendance
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Important Diagrams for Unit 12:

1. Partograph Chart – showing alert and action lines.
2. Types of Fetal Malpresentation – breech, face, brow, shoulder.
3. Bandl’s Ring – indicating obstructed labour.

Unit 12 Summary:
Early diagnosis and prompt management of abnormal labour is essential to prevent
complications. Using the partograph and understanding the 3 P’s (power, passenger, passage) can
help guide appropriate intervention.
Unit 14: Obstetric Emergencies

Definition:

Obstetric emergencies are life-threatening conditions that occur during pregnancy, labour, or
postpartum period which require immediate medical attention to save the life of the mother
and/or baby.

Common Obstetric Emergencies:

1. Postpartum Hemorrhage (PPH)

Definition:
Blood loss >500 mL after vaginal delivery or >1000 mL after cesarean section.

Causes (4 T’s):
• Tone: Uterine atony (most common)
• Tissue: Retained placenta or clots
• Trauma: Genital tract lacerations
• Thrombin: Coagulation disorders

Management:
• Fundal massage
• IV fluids + blood transfusion
• Oxytocin, misoprostol, ergometrine
 • Manual removal of placenta
• Surgery (e.g., uterine artery ligation, hysterectomy if not controlled)

2. Eclampsia

Definition:
Onset of seizures in a woman with pre-eclampsia (hypertension + proteinuria).

Signs:
• Severe headache, visual disturbances
• Edema, high BP, convulsions
• Proteinuria

Management:
• Magnesium sulfate (drug of choice)
• Control BP with labetalol/hydralazine
• Oxygen support
• Delivery of baby once stable

3. Uterine Rupture

Definition:
Tearing of uterine wall, usually during labour.

Causes:
• Obstructed labour
• Previous cesarean scar
• Overuse of oxytocin

Signs:
• Sudden abdominal pain
• Vaginal bleeding
• Cessation of contractions
• Fetal parts easily palpable
• Fetal heart sound absent

Management:
• Immediate laparotomy
• Blood transfusion
• Repair or hysterectomy
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4. Cord Prolapse

Definition:
Umbilical cord slips ahead of the presenting part after rupture of membranes.

Types:
• Overt (visible at vulva)
• Occult (hidden beside presenting part)

Management:
• Knee-chest or Trendelenburg position
• Push presenting part up manually
• Emergency cesarean section

5. Shoulder Dystocia

Definition:
After delivery of the head, shoulders fail to deliver due to impaction behind pubic bone.

Signs:
• Turtle sign (head retracts back after coming out)

Management:
• McRoberts maneuver
• Suprapubic pressure
• Delivery of posterior arm

6. Amniotic Fluid Embolism

Definition:
Entry of amniotic fluid into maternal circulation → sudden collapse.

Signs:
• Sudden respiratory distress
• Hypotension
• Cyanosis
• DIC (disseminated intravascular coagulation)
Management:
• Oxygen
• ICU support
• Manage DIC with blood products

7. Inversion of Uterus

Definition:
Uterus turns inside out during delivery of placenta.

Signs:
• Shock, severe pain
• Visible mass at vagina

Management:
• Manual repositioning of uterus
• Uterotonics after repositioning

Nursing Responsibilities in Obstetric Emergencies:

• Stay calm and act quickly
• Call for help (doctor/anesthetist)
• Start IV line, monitor vitals, give oxygen
• Assist in emergency procedures
• Prepare for emergency delivery if needed
• Maintain sterile field
• Provide emotional support to the mother and family

Important Diagrams:
1. PPH – 4 T’s Flowchart
2. Eclampsia – Signs & Magnesium Sulfate Regimen
3. Uterine Rupture – Before & After View
4. McRoberts Maneuver for Shoulder Dystocia

Unit 14 Summary:
Obstetric emergencies require prompt recognition, rapid intervention, and team coordination.
Early identification and preparedness can significantly reduce maternal and neonatal morbidity
and mortality.
**Unit 15: Medico-L

Unit 15: Medico-Legal and Ethical Issues in Midwifery

Introduction:

Midwifery practice involves caring for women during pregnancy, childbirth, and postpartum. Due
to its sensitive nature, midwives must adhere to legal responsibilities and ethical principles to
ensure safe, respectful, and lawful care.

Medico-Legal Issues in Midwifery:

1. Consent:
• Must be obtained before any examination, procedure, or treatment.
• Should be informed, voluntary, and documented.
• For minors or unconscious patients, guardian consent is required.
• Types:
• Implied consent – through patient’s actions.
• Written consent – required for surgeries and invasive procedures.
• Informed consent – explaining risks, benefits, and alternatives.

2. Negligence:
• Failure to provide standard care, resulting in harm to the patient.
• Examples in midwifery:
• Not monitoring fetal heart rate
• Delayed referral in high-risk pregnancy
• Incorrect medication dosage
• To prove negligence:
• Duty existed
• Duty was breached
• Damage occurred
• Direct link between breach and damage
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3. Documentation:
• Legal record of all care provided.
• Should be accurate, complete, dated, and signed.
• Includes:
• Antenatal, intranatal, and postnatal records
• Partograph
• Drug administration charts
• Incident reports

4. Confidentiality:
• Patient’s personal and medical information must be protected.
• Only shared with authorized persons or by legal requirement.

5. Safe Record Keeping:

• All records must be stored securely.
• Retention period:
• Maternal records – minimum 21 years
• Neonatal records – 21 years or more

6. Legal Acts Relevant to Midwifery:

1. The Medical Termination of Pregnancy (MTP) Act, 1971:
• Regulates legal abortion.
• Can be done up to 24 weeks under specific conditions.
2. The Pre-Conception and Pre-Natal Diagnostic Techniques (PCPNDT) Act, 1994:
• Prevents sex determination and female feticide.
3. The Infant Milk Substitutes Act, 1992:
• Promotes breastfeeding.
• Bans advertisement of infant formula.
4. Registration of Births and Deaths Act, 1969:
• Compulsory registration within 21 days.

Ethical Principles in Midwifery:

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1. Autonomy:
• Respect the woman’s right to make decisions about her body and care.

2. Beneficence:
• Act in the best interest of mother and baby.

3. Non-maleficence:
• “Do no harm” – avoid any action that may cause injury.

4. Justice:
• Provide fair and equal care to all, regardless of caste, religion, or status.

5. Fidelity:
• Be loyal and keep promises made to the patient.

6. Veracity:
• Be truthful in all interactions with patients.

Common Ethical Dilemmas:

• Refusal of treatment by mother
• Religious beliefs vs. medical interventions
• Teenage pregnancy
• HIV-positive mother and disclosure
• Birth at home vs. hospital

Nursing Responsibilities:
• Follow hospital policies and legal guidelines
• Educate women about their rights
• Obtain proper documentation
• Maintain professional behavior and ethics
• Provide non-judgmental care

Important Diagrams/Flowcharts:
1. Ethical Principles Chart – autonomy, beneficence, non-maleficence, etc.
2. Steps in Obtaining Informed Consent
3. Negligence – Elements with Example Cases
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Unit 15 Summary:

Midwives play a critical role in ensuring legal compliance and ethical care during pregnancy and
childbirth. A strong understanding of medico-legal responsibilities protects both the client and
the nurse, and promotes trust in maternity care services.
Unit 16: Family Welfare Services

Definition:

Family Welfare Services are government-supported initiatives aimed at improving the health and
well-being of families, particularly focusing on population control, maternal-child health, and
reproductive health services.

These services are a core part of National Health Programs in India and are essential components
of primary health care.

Objectives of Family Welfare Services:

1. Control population growth
2. Promote maternal and child health (MCH)
3. Provide contraceptive services
4. Reduce infant and maternal mortality rates
5. Encourage small family norms
6. Promote health education and responsible parenthood

Components of Family Welfare Services:

1. Maternal and Child Health (MCH) Services:

• Antenatal, intranatal, and postnatal care
• Immunization (under Universal Immunization Programme)
• Nutrition supplementation (under ICDS)
• Safe delivery services
• Growth monitoring of children

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2. Family Planning Services:

Temporary (Spacing) Methods:

• Oral contraceptive pills (OCPs)
• Condoms (Nirodh)
• Intrauterine devices (IUCDs) – Copper-T
• Injectable contraceptives (DMPA)
• Emergency contraceptive pills (ECPs)

Permanent Methods:
• Tubectomy (female sterilization)
• Vasectomy (male sterilization)

Natural Methods:
• Rhythm method
• Withdrawal
• Lactational amenorrhea method (LAM)

3. Infertility Services:
• Counseling and referral services
• Investigations and treatment of infertility

4. Medical Termination of Pregnancy (MTP):

• Legal and safe abortion services under MTP Act
• Done by trained professionals in registered centers

5. Adolescent Reproductive and Sexual Health (ARSH):

• Awareness about menstruation, STIs, and contraceptive use
• Services provided through RKSK (Rashtriya Kishor Swasthya Karyakram)

Family Welfare Program in India:

• Launched in 1952, the first national family planning program in the world.
• Renamed as Family Welfare Programme in 1977.
• Implemented through health sub-centers, PHCs, CHCs, and district hospitals.
• Integrated with Reproductive and Child Health (RCH) and National Health Mission
(NHM).

Role of Nurse in Family Welfare Services:

1. Health Education:
• Counsel couples about family planning methods.
• Promote spacing and small family norms.
2. Service Delivery:
• Distribute contraceptives (OCPs, condoms).
• Assist in IUCD insertion and follow-up.
• Identify eligible couples.
3. Community Mobilization:
• Organize camps and outreach programs.
• Encourage participation in MCH services.
4. Record Keeping:
• Maintain eligible couple register (ECR).
• Update contraceptive users’ list.
5. Follow-Up and Referral:
• Track clients for follow-up and manage side effects.
• Refer complicated cases to higher centers.

Important Schemes under Family Welfare:

Scheme Features
Janani Suraksha Yojana (JSY) Financial aid for institutional delivery
Janani Shishu Suraksha Karyakram (JSSK) Free delivery, drugs, diagnostics, transport
Mission Parivar Vikas High-focus districts for family planning
Pradhan Mantri Matru Vandana Yojana (PMMVY) Maternity benefit scheme (INR 5000)
RKSK Adolescent health program

Challenges in Family Welfare Services:

• Illiteracy and lack of awareness
• Myths and misconceptions about contraception
• Religious and cultural resistance
• Gender inequality
• Poor access in rural and remote areas
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Important Diagrams/Flowcharts:
1. Eligible Couple Register Format
2. Classification of Contraceptive Methods
3. Hierarchy of Family Welfare Services in India

Unit 16 Summary:

Family Welfare Services aim to create healthy families and a balanced population. Nurses play a
key role in educating, counseling, and delivering services at the grassroots level, making family
welfare a cornerstone of community health.