Midwifery and Obstetrical Nursing -II (Question Solution- January 2015)

University of Dhaka

4th year B.Sc in nursing Final Examination of January -2015

Subject: Midwifery and Obstetrical Nursing -II  

Full Mark’s: 70                Time: 2 hours 40 minutes

Solution

Group-A

Q.No.1

a. What is obstetrical nursing and obstetrical shock? 02

b. Mention the classification of obstetrical shock? 03

Answer: a.

Obstetrical nursing:

Obstetric nurses are nurses that specialize in the field of obstetrics, or the branch of medicine that focuses on women and fetus during pregnancy and childbirth. These specialty nurses help care for pregnant women and their little ones during and after pregnancy and delivery.

Obstetrical shock: 

Shock is a state of collapse of circulation so that there is critical reduction of perfusion of tissue by blood with oxygen. Shock in obstetrics develops secondary to some complication of pregnancy and labor although rarely this can develop as a result of conditions peculiar to obstetrics.

Answer: b

Classification of obstetrical shock:

1.Hypovolaemic shock :  hypovolaemic shock includes-

Eg:

a. Hemorrhagic shock.

b. Fluid loss shock.

c. Shock associated with DIC.

2. Septic Shock: Eg:   Endotoxic shock.

3. Cardiogenic shock:

Due to –

a. Left ventricular ejection.

b. Failure of left ventricular filling.

4. Neurogenic shock:

Due to –

a. Chemical injury.

b. Drug injury.

Q.No.2

a. Define APH? 02

b. How will you manage a case of APH?  03

Answer.

(a)

Definition of APH: It is define as bleeding from or into the genital tract after 28th weeks of pregnancy but before the birth of the baby.

(b)

Management of APH:

Clinical feature :

Symptoms:  

1. Vaginal  Bleeding  which is characterize by-

a. Sudden, onset and painless.

b. Apparently causeless and recurrent.

Sign:

General examination:

a. Anemia is present due to blood loss.

b. Cold, clammy skin.

c. Tachycardia, hypotension.

On Abdominal Examination :

1. Size of the uterus:  proportionate to the period of gestation

2. Feeling of uterus: Relax, soft and without tenderness.

3. Presentation:  Breech, transverse and unstable.

4. Fetal head:

a. Persistent development.

b.  Head can’t push down into the pelvis.

5. Fetal heart sound:  Usually present.

6. Per vaginal examination:

1. Contra-indicated.

2. Only inspection is to be done.

7. Diagnosis: 

1. Ultrasonography for the confirmatory diagnosis

2. Blood- Hb%

3. Blood grouping.

General management

1.Nothing per oral.

2. I/V canola.

3. Intravenous fluid infusion: Hartman solution, Normal saline.

4. Blood transfusion at least (2-4 Unit).

5. 10% calcium gluconate.

6. Cathetarization

7. Vital sign monitoring.

Expected treatment:

1. Bed rest completely.

2. Periodic inspection of –

a. Valval pad.

b. Fetal heart sound.

c. USG

3. Iron, folic acid and Zn Supplementation.

Obstetrical treatment: Without internal examination:

Caesarean section.

Per vaginal examination in OT followed by Low rupture of membrane.

Q.No-03

a. Enumerate the different presentation of twin baby. 02

b. How will you differentiate bino-vular from uni ovular? 03

Ans.

(a)

The different presentation of twin baby are given in the below-

Presentation:

a. Both vertex – 60%

b. 1st vertex and 2nd breech-        20%

c. 1st breech and 2nd vertex –      10%

d. Both breech- 10%

(b)

Some point/ characteristics that help us to differentiate between Uniovular and Binovular.

Characteristics/ points         Uni-ovular               Bin-ovular

Placenta                                            One                                 Two

Communicating Vessels                 Present                            Absence 

Intervening membranes                Two                                  Four

Sex Always identical                       Always idntical                May differ

Genetic Features Same                   Same                                Differ

Skin grafting                                     Acceptance                       Rejections.  

Follow up Usually identical             Usually identicle               No identical

Q.No-4

a. What is Pre-eclampsia? 2

b. Write down the effect on Mother and fetus. 3

Ans.

(a)

Preeclampsia:

Pre-eclampsia is a multi system disorder of unknown etiology characterize by development of hypertension to the extent of 140/90 mm Hg or more with proteinuria after the 20th week in a previously normotensive and non proteinnuric patients.

(b)

The effect of pre-eclampsia on mother and fetus are given in the below-

Effect on Mother:

Immediate effect:

1. During pregnancy:

a. Eclamsia (2%)

b. Accidental hemorrhage.

c. Oliguria and anuria.

d. Dimness of vision even blindness.

e. Preterm labor.

f. HELLP syndrome.

2. During labor:

Eclampsia

Postpartum hemorrhage (may be related with coagulation faction)

3. Puerperium:

a. Eclampsia – usually occurs within 48 hours.

b. Shock

c. Puerperal sepsis.

Effect on fetus:

a. Intrauterine death.

b. Intra uterine growth restriction.

c. Asphyxia

d. Prematurity

EQ Answer

Q.No-1

What is oligoamnions? What are factors responsible to happened this? Write down the treatment and nursing care management of this case?  10 

Oligoamnions:

a. It a condition where the liquor amnii is deficient in amount to the extent of less than 200ml at term.

b. It is defined as the volume of amniotic fluid being less than 300ml during the third trimester of pregnancy.

Responsible factors:  The responsible factors of oliamnions are given in the below-they are-

a. Fetal chromosomal anomalies.

b. Intrauterine infection.

c. Some drugs are responsible as like as –

  • PG inhibitors.
  • ACE inhibitors.

d. Renal agenesis.

e. IUGR associated placental insufficiency.

f. Amnion nodosum.

g. Post maturity.

Medical Management:

Symptoms:

a. Less fetal movement.

b. Less distension of the abdomen.

Sign:

a. Size of the Uterus: Much smaller than the period of gestation.

b. Presentation: Mal-presentation (breech) is common.

c. The uterus is “full of fetus”.

d. Evidences of IUGR may be present.

Investigation:

Ultrasonography of the pregnancy profile.

Surgical management:

a. Vaginal delivery is preferred because of frequent association of fetal congenital malformation.

b. If vaginal delivery is not possible (due to mal presentation) then caesarean section is the treatment of choice.

Nursing care:

a. Health care provider or nurse can frequent evaluate the fetal status though NST, BPP, CST or OCT as indicated.

b. Periodic ultrasound evaluations performed to evaluate fetal renal dysfunction and abnormal fetal growth.

c. Amnioinfusion during labor.

d. Evaluate fetal status EFM.

e. Evaluate maternal vital signs periodically.

f. Note sign of infection especially if oligohydramnions is secondary to PROM.

g. Assist with an amnioinfusion, as indicated.

h. Inform health care provider of fetal intolerance to labor and treat, as indicated.

Q.No-2

Define High risk pregnancy. Mention the main reason of maternal mortality in our country. Explain the referral system of EOC? 

High Risk pregnancy: 

High risk pregnancy is define as one which is complicated by factor or factors that adversely affects the pregnancy outcome- maternal or perinatal or both.

Main reason of maternal mortality: The reason of maternal mortality are given in the below. they are-A. Haemorrhage:  Ante-partum haemorrhage, Postpartum haemorrhage.

B. Sepsis: Puerperal sepsis, Septic Abortion.

C. Pregnancy induce hypertension: Pre-eclampsia, eclampsia

D. Obstructed labor.

E. Ectopic pregnancy.

F. Infective hepatitis.

g. Anaemia. 

H. Thromboembolism

The referral system of EOC:

a. Transport available in health center-yes/no

If yes- inform driver, tell driver to prepare for journey and standby.

If no- arranges transport, send message to arrange transport as soon as possible.

b. Select staff-select midwife, nurse or other person to go with patient.

c. Prepare emergency equipment-Prepare emergency equipment as needed e.g. delivery pack, fluids, drugs etc.

d. Determine blood group if possible.

e. Transport is now available.

f. Reassess for referral-Reassess patient for referral still indicated? Yes/No

If yes – provide final emergency treatment –reassure patient, check all necessary treatment have been given      before journey.

g. Write referral letter.

h. Management of complication-If any complication arises during journey gives clear instruction to the staff about its management to him.

i. Load emergency pack to manage complications.

j. Check position of patient.

k. Sent relatives with patients.

Group-B (SAQ)

Q.No-1

a. what do you mean by malposition and malpresentation. 02

b.Write down the name of some malposition and malpresentation. 03

Ans.

(a)

Malposition:

Malposition means incorrect position of the vertex. This includes occipitoposterior (OP) position and deflection of the head short of below presentation. (Ref. Garrey Govan obstetrical illustrated)

Malpresentation:  It means the presentations other than vertex presentation. Eg. Face, brow, breech, Shoulder.

(b)

Name of some Malposition:

a. Occipito-posterior position.

b. Deep transverse arrest of the head.

Name of some Malpresentation:

a. Breech presentation.

b. Brow presentation.

c. Compound presentation.

d. Cord presentation.

e. Deep transverse arrest

f. Face presentation.

h. Shoulder presentation.

Q.No-2

a. What is the most common cause of unsatisfactory progress of labor? 02

b. Briefly describe the indication and contraindication of forceps. 03

(b)

Indication of forceps:

Maternal :

a. Inadequate expulsive effort.

b. Maternal exhaustion (distress)

c. Maternal disease: (Cardiac disease, eclampsia, cerebrovascular disease).

Fetal:

a. Non reassuring fetal heart rate

b. Fetal distress ( e.g. low birth weight baby, post maturity).

c. After coming head of breech.

Other:

Prolonged 2nd stage of labor.

To cut short the second stage of labor in case of –severe pre-eclampsia.

i. Cardiac disease.

ii. Post- caesarean pregnancy.

Contraindication:

a. Brow presentation.

b. Cervix not fully dilated

c. Contracted pelvic.

d. Floating head.

Q.No-3

a. Enumerate the causes of sub- involution. 02

b. Who are at high risk mother, shortly describe? 03

Ans. (a)                                                                        

Causes of sub-involution:

Predisposing factors:

a. Grand multiparity.

b. Over distension of uterus.

c. Maternal ill health.

d. Caesarean section.

e. Uterine prolapsed.

f. Uterine fibroid.

Aggravating factors:

a. Retained product of conception.

b. Uterine sepsis.

(b)

High risk mother is one who’s –

Age is –

less than 16 years.

-More than 35 years.

Height

-less than 4.8 inch

Who have previous history of –

Two or more induce labour.

-History of Still Birth.

-History of neonatal death.

-History of preterm labor.

-History of IUGR and large baby.

Who have medical Disorder- like as –

-TB

-bronchial Asthma.

-Renal disease.

– Thyroid disorder.

-Cardiac disease.

– Psychiatric disorder.

Who have previous history surgery of-

-myomectomy

– Repear of complete perinial tears.

Who have positive family History of –

Anemia.

-DM

-HTN

-congenital malformation.

 Q.No.04

a. Define Ectopic pregnancy. 02

b. Write down the clinical features of hydatidiform mole. 03

(a)

Ectopic pregnancy:

When fertilization occurs out site the uterine cavity is called ectopic pregnancy.

(b)

Definition: It is an abnormal condition of the placenta where there are partly degenerative and partly proliferative changes in the young chronic villi.

Clinical feature:

Symptoms:

-White currant in red currant juice vaginal discharge.

-Lower abdominal pain due to-

  • Over distension of the uterus.
  • Concealed haemorrhage.
  • Infection.

Constitutional symptoms: 

patients become sick (without any apparent reason)

-excessive Vomiting.

-Breathlessness.

Thyrotoxic feature.

Sign:

-The patients look more ill.

-Pallor due to blood loss.

-Hypertension, edema, proteinuria (present)

per Abdomen:

The size of the uterus is more than the normal period of amenorrhea.

– Uterus is firm elastic.

– Fetal part is not felt.

– Absence of fetal heart sound.

Vaginal Examination: 

Internal ballottement cannot be elicited.

-Unilateral or bilateral enlargement of the ovary may be palpable.

-Finding of vesicles in the vaginal discharge.

EQ question

Q.No-1, What is breech presentation? How will you recognize a case of breech presentation at term? Explain the different maneuver is used in breech? 10

Ans.

Breech presentation:

In breech presentation the lie is longitudinal and the podalic pole present at the pelvic brim. It is the commonest malpresentation.

Clinical feature/ patients feature that help me to recognize breech presentation. They are-

Fundal grip:

Head- Suggested by hard and globular mass and  ballottable.

Lateral grip: fetal back to one side and irregular limbs to the other.

Pelvic grip:

Breech- suggest by soft, broad, and irregular mass.

  • Not engaged during pregnancy.
  • Usually located at higher level of round about the umbilicus.

FHS: Usually located at the higher level round about the umbilicus.

Examination: that also helps me to recognize breech position.

Per vaginal examination:

Soft and irregular parts are felt thought the fornix.

During labor:

a. Palpation of Ischial tuberosites, sacrum and the feet by the sides of the buttocks.

b. The foot fell is identifying by the prominence of the heel and lesser mobility of the great toe.

Investigation helps to confirmation of the breech position.

a. USG (ultrasonography) is most preferable.

b. Plain X-ray.

The different maneuver is used in breech. They are –

a. Lovset’s maneuver.

b. Pinard’s maneuver.

Lovset’s Maneuver:

It is widely practiced in preference of the classical method of bringing down an arm.

 Principles: Because of the curved birth canal, when the anterior shoulder remains above the symphysis pubis, the posterior shoulder will be below the sacral promontory. If the fetal trunk is rotated keeping the back anterior and maintaining a downward traction, the posterior shoulder will appear below the sumphysis pubis.

Procedure: 

The baby is grasped, using both hands by femoro-pelvic grip keeping the thumbs parallel to the vertebral column. The maneuver should start only when the inferior angle of the anterior scapula is visible underneath the pubic arch.

Step-1:

The baby is lifted slightly to cause lateral flexion. The trunk is rotated through 180 degree keeping the back anterior and maintaining a downward traction. This will bring the posterior arm to emerge under the pubic arch which is then hooked out.

Step-2: The trunk is then rotated in the reverse direction keeping the back anterior to deliver the erstwhile anterior shoulder under the symphysis pubis.

Pinard’s maneuver:

Is done by intrauterine manipulation to convert a frank breech to a footling breech. This is possible when the membranes have ruptured recently. In pinard’s maneuver the middle and the index fingers are carried upto the popliteal fossa. It is then pressed and abducted so that the fetal leg is flexed. The fetal foot is then grasped at the ankle and breech extraction is accomplished.

Q.No-2

Write down the concept of induction of labor. What are the indication and contraindication of it? What thing will you monitor during induction a patient? 10

Ans.

Induction of labor:Induction of labor means initiation of uterine contraction by any method (medical, surgical or combined) for the purpose of vaginal delivery.

Indication:

a. Hypertensive disorder’s in pregnancy: Pre-eclampsia, eclampsia.

b. Maternal medical complication:Diabetes mellitus, Chronic renal disease.

c. Post maturity.

d. Abruptio placenta.

e. Intra-uterine growth restriction.

f. Rh-Iso immunization.

g. Premature rupture of membrane.

h. Fetus with major congenital anomaly.

i. Intra-Uterine death of fetus.

j. Oligohydramnions, polyhydramnions.

Contraindications:

a. Contracted pelvis.

b. Cephalo-pelvic disproportion.

c. Mal-presentation: (transverse, Oblique lie)

d.  Previous classical caesarean section.

e. Previous hysterectomy.

f. Utero-placental factors;

  • Unexplained vaginal discharge.

–      Vasa praevia.

g. Placenta praevia.

h. High risk pregnancy with fetal compromise.

i. Active genital herpes infection.

j. Heart disease.

k. Pelvic tumor.

l. Elderly primigravida with obstructed.

Monitor during induction:

a. Color of the amniotic fluid.

b. Status of cervix.

c. Station of the head.

d. Detection of cord prolapsed.

e. Quality of heard rate.

f. Vital sign.

Q.No-3

A 34 weeks pregnant lady has come to you with H/O per-vaginal discharge and lower abdominal pain?    10

a. Write your diagnosis, and risk factors

b. Explain the midwifery

Ans: Diagnosis is  ( PROM)

Definition: Spontaneous rupture of membranes any time during pregnancy beyond 28 weeks but before the onset of labor is called premature rupture of membrane.

Causes of PROM

a. Spontaneous due to lytic effect of some bacterial enzymes on the membrane.

b. High head

c. Unstable lie and other malposition

d. Multiple pregnancy

e. Hydramnios

f. Maternal infection-

  • UTI
  • Chorioamnionitis

g. Cervical incompetence

h. Weakness of the chorion and membrane

Clinical Features

Symptoms

a. Watery discharge per vagina.

b. Staining of cloths or sanitary pad.

Signs

a. Fundal height < period of gestation.

b. Fever if long standing case.

c. Sweet odour. May be meconium stained.

d. Speculum examination: liquor escaping out through the cervix.

Investigation

a. Routine pregnancy test

b. Urine R/M/E

c. USG

d. Full blood count

e. High vaginal swab for culture.

Management:

According to duration of pregnancy, presence of infection and neonatal support.

a. If >34 weeks: Conservative treatment to prolong the pregnancy till the fetus sufficiently mature before delivery.

b. Immediate hospitalization.

c. Bed rest, bed pan must be used.

d. Diet –normal.

e. I/V antibiotic for 48 hours.

f. Dexamethasone 12 mg IM 12 hourly for 7 days.

g. Close follow up-

  • Fetal movement
  • EHS
  • Temperature
  • Pulse
  • Amount of liqor

h. P/V all time wear sanitary pad.

  • Amount of soaking
  • Color
  • Smell

i. Delivery is advised after 37 weeks/

j. If patient at 36 weeks: Same as above but 24 hours-no need P/V.

k. If patient after 37 weeks: C/S.

Complications of PROM

a. Premature labor

b. Prematurity

c. Ascending infection

d. Cord prolapsed

e. Dry labor

f. Chrioamnionitis

g. Placental abruption

h. Fetal respiratory distress syndrome.

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Abu nayeem 
TMMC (Nursing Unit)

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