(a) (i) Write in brief the reasons for rising Caesarean Section rates globally and in India. (5 marks) (ii) Discuss briefly the…

(a)(i) Reasons for rising caesarean section rates

Globally about 21% of births are by caesarean section, projected to near 29% by 2030 (WHO). In India NFHS-5 (2019–21) shows 21.5%, with about 47% in private and 14% in public facilities, against the WHO view that rates above 10–15% bring no extra mortality benefit.

• Medical: older mothers, obesity, diabetes, hypertension, IVF and multiple pregnancy, repeat caesareans and fewer breech or instrumental deliveries.
• Non-medical: maternal request, fear of litigation, convenience and fixed delivery timing, fee-for-service and profit incentives, and weak audit.
• Rising use of continuous fetal monitoring and induction.

(a)(ii) Vaginal birth versus caesarean section

Vaginal birth: shorter stay and recovery, less bleeding, infection and thrombosis, early breastfeeding, microbiome transfer, lower cost, no scar for future pregnancies. Disadvantages: labour pain, perineal tears, pelvic floor injury, risk of birth asphyxia or trauma, and emergency conversion.

Caesarean section: planned timing and a safe route in obstructed labour, malpresentation, placenta previa and fetal compromise. Disadvantages: surgical and anaesthetic risk, haemorrhage, infection, adhesions, longer recovery, higher cost, neonatal respiratory problems, and scar-related risks (accreta, rupture) in later pregnancies.

(a)(iii) Measures to reduce caesarean rates

Audit using Robson's ten-group classification with feedback to clinicians; evidence-based indications with second opinion; partograph use and continuous labour support; midwife-led care for low-risk women; external cephalic version for breech; trial of labour after caesarean; equal payment for vaginal and caesarean delivery; public reporting of facility rates; and antenatal education. In India, LaQshya improves labour-room quality.

(a)(iv) Counselling for vaginal birth after caesarean (VBAC)

Discuss through shared decision making: success is about 60–80%, higher with a prior vaginal birth and spontaneous labour. Uterine rupture risk is about 0.5–0.9% in trial of labour, compared with under 0.1% with elective repeat caesarean; the risk rises with induction. Requirements: one previous low-transverse scar, no placenta previa or other contraindication, and a facility with continuous fetal monitoring and immediate theatre access. Classical scar or previous rupture needs repeat caesarean. Explain risks of failed trial (emergency surgery) versus repeat caesarean risks, and document consent.

(b)(i) Leukoplakia and its significance

Leukoplakia is a white plaque of the oral mucosa that cannot be scraped off or classified as another disease (WHO). It may be homogeneous or non-homogeneous (speckled, nodular, verrucous). Tobacco chewing and betel quid are chief causes. Its significance: it is the commonest potentially malignant disorder; biopsy may show hyperplasia, dysplasia or carcinoma, and malignant transformation is reported at roughly 1–20% depending on the series, higher in non-homogeneous lesions, with dysplasia, and at floor of mouth or tongue. Biopsy, stopping tobacco and lifelong follow-up are essential. With difficulty in opening the mouth, also consider submucous fibrosis and cancer.

(b)(ii) Premalignant conditions of oral cavity

Leukoplakia (including proliferative verrucous leukoplakia), erythroplakia (highest risk), oral submucous fibrosis, oral lichen planus, actinic cheilitis, palatal lesions of reverse smoking, chronic hyperplastic candidiasis, Plummer–Vinson syndrome (sideropenic dysphagia), discoid lupus, dyskeratosis congenita and tertiary syphilitic glossitis.

(b)(iii) Cervical lymph nodes in oral cancer

Spread is to levels I to III first: submental (IA), submandibular (IB), upper jugular including jugulodigastric (II) and mid-jugular (III). Tongue cancers may skip to lower jugular nodes (IV). Posterior triangle (V) nodes are involved late, and contralateral nodes in midline or advanced lesions. Buccal cancers may involve facial (buccinator) nodes.

(c)(i) Biologically complete protein

A protein is biologically complete (first-class) when it supplies all nine essential amino acids in the proportions required by the body, and is well digested and utilised. It has a high biological value (egg about 100, milk about 85–90), high net protein utilisation and high protein efficiency ratio. Egg, milk, meat and soya are examples; an incomplete protein lacks or is low in a limiting amino acid.

(c)(ii) Vegetable versus animal proteins

Animal proteins are complete and highly digestible. Plant proteins are lower in digestibility (fibre, antinutrients) and limited in lysine (cereals) or methionine (pulses); soya is nearly complete. Combining cereal with pulse (dal–roti, khichdi) or adding milk makes up the deficit and gives a quality close to animal proteins. Vegetable proteins are cheaper, with fibre, no cholesterol and lower saturated fat, but are poorer sources of vitamin B12, iron and zinc.

(c)(iii) Functions of protein

Growth and repair of tissues; enzymes and hormones; antibodies; transport (haemoglobin, albumin, lipoproteins); structure (collagen, keratin); contraction (actin, myosin); oncotic pressure and fluid balance; acid–base buffering; blood clotting factors; precursors of neurotransmitters and nucleotides; and energy (4 kcal/g) when carbohydrate and fat are insufficient.