(a) (i) A 22-year-old Unbooked Primigravida at 38 weeks of gestation presents to Emergency with labour pains. How would you…

(a)(i) Obstetric triage and labour management of an unbooked 22-year-old primigravida at 38 weeks

An unbooked woman has had no antenatal screening, so hidden risks (anaemia, hypertension, malpresentation, CPD, HIV/syphilis, gestational diabetes) must be sought at once.

Triage (colour-coded, as in the LaQshya/MoHFW obstetric triage protocol)

• Red (emergency, immediate care): eclampsia, severe hypertension (≥160/110 mmHg), shock, antepartum haemorrhage, cord prolapse, abnormal FHR.
• Yellow (urgent, within 30 minutes): preeclampsia, fever, PROM, severe anaemia, malpresentation, reduced fetal movements.
• Green: normal early labour.
• Tools: vitals are charted on an obstetric early-warning chart (MEOWS).

Evaluation

• History: LMP/EDD or first-trimester scan (if any), onset and frequency of contractions, leaking or bleeding, fetal movements, headache, visual symptoms or fits, and medical illnesses; also Td immunisation and IFA intake.
• General examination: pulse, BP, temperature, SpO₂, pallor, oedema, height (short stature, under 145 cm, suggests CPD) and gait.
• Abdominal examination: fundal height, lie, presentation, engagement (fifths palpable), estimated fetal weight, contractions, FHR; look for scars and a Bandl's ring.
• Vaginal examination (aseptic): dilatation, effacement, station, position, moulding and caput, membranes and liquor colour, and clinical pelvimetry. Placenta praevia is excluded by USG first if there is bleeding.
• Investigations: Hb, blood group and Rh, cross-match; rapid HIV, syphilis and HBsAg tests; urine protein and sugar; random blood sugar; USG for presentation, liquor and placenta where available; CTG if the risk is high.

Management of labour

• Risk-directed plan: CPD, malpresentation, fetal distress, APH or severe preeclampsia lead to an emergency caesarean section or referral to a CEmOC centre. Otherwise, a trial of vaginal labour proceeds.
• First stage: monitor with the WHO Labour Care Guide (2020), where the active phase starts at 5 cm (it replaces the modified partograph with its 4 cm start). Support includes a birth companion, mobility, oral fluids and no routine enema or shaving. Intermittent auscultation of FHR is done every 15–30 minutes (every 5 minutes in the second stage). Vaginal examination is repeated 4-hourly. Oxytocin is used only for a proven delay, with CPD excluded.
• Second stage: upright position and spontaneous pushing; restrictive episiotomy; instrumental delivery if indicated.
• Third stage: AMTSL with oxytocin 10 IU IM within 1 minute, controlled cord traction and uterine massage; delayed cord clamping (1–3 minutes).
• Newborn: essential newborn care (drying, skin-to-skin contact, breastfeeding within 1 hour, vitamin K) and newborn vaccines.
• Mother after delivery: watch for PPH for 2 hours and stay for 48 hours; give anti-D if Rh-negative, Td, IFA and calcium, and postpartum family-planning counselling.
• Programme links: register the woman under JSY and JSSK entitlements.

(a)(ii) Rupture uterus following obstructed labour

Pathogenesis. In neglected obstructed labour, the upper segment retracts progressively while the lower segment stretches and thins. The junction rises as a pathological retraction ring (Bandl's ring). The thinned lower segment tears, usually laterally into the broad ligament, and may involve the bladder.

Clinical features

• Impending rupture: an exhausted, dehydrated, tachycardic woman; tonic or tetanic contractions; a rising Bandl's ring; a tender, distended lower segment; tense round ligaments; haematuria; fetal distress.
• Actual rupture: sudden sharp pain at the height of a contraction, followed by cessation of contractions and temporary relief; shock out of proportion to the vaginal bleeding; abdominal tenderness and guarding; loss of uterine contour; fetal parts easily felt under the abdominal wall with the uterus felt separately; absent FHR; recession of the presenting part on PV; haematuria from bladder injury.
• Types: complete (peritoneum torn) or incomplete (peritoneum intact, broad-ligament haematoma).

Diagnosis

• Mainly clinical, and treatment must not be delayed for imaging.
• Bedside USG or FAST shows haemoperitoneum, an extrauterine fetus or an empty uterus.
• Hb, cross-match, coagulation profile and urine for blood.
• The diagnosis is confirmed at laparotomy.

Management

• Resuscitation and laparotomy: activate the obstetric haemorrhage team; start oxygen, two wide-bore IV lines, crystalloids and blood with components (massive-transfusion protocol); insert a Foley catheter; give broad-spectrum antibiotics; proceed to immediate laparotomy with the baby delivered.
• Surgical choice: repair of a clean, recent, linear tear when the woman is stable and wishes to have more children (tubal ligation only with her consent). Subtotal or total hysterectomy is done for extensive, ragged, infected or broad-ligament tears or uncontrollable bleeding. The bladder is repaired and ureteric injury looked for.
• Post-operative care: ICU care, antibiotics and thromboprophylaxis; watch for vesicovaginal fistula and sepsis; counselling. After repair, a future pregnancy needs an elective caesarean before labour, at 36–37 weeks.
• Prevention: antenatal registration, partograph or LCG use, timely referral and caesarean delivery, and no oxytocin in obstructed labour.

(b)(i) Carcinoma rectum: clinical features and diagnostic work-up

Clinical features

• Local features: bleeding per rectum (the commonest, with dark blood mixed with stool); mucus discharge; altered bowel habit with early-morning spurious diarrhoea; tenesmus and a feeling of incomplete evacuation; ribbon-like stools.
• Features of spread: sacral or perineal pain (invasion of the sacral plexus); urinary symptoms or a rectovesical fistula; subacute obstruction.
• Systemic features: anaemia, weight loss, anorexia; jaundice, hepatomegaly or ascites (metastasis).
• Examination: on DRE, a proliferative growth or an ulcer with everted edges, bleeding on touch. Note its distance from the anal verge, circumferential extent, mobility or fixity, and relation to the anorectal ring.

Diagnostic work-up

• Proctosigmoidoscopy and biopsy: confirms the diagnosis, with MMR/MSI testing.
• Full colonoscopy: excludes synchronous lesions (3–5%).
• Local staging: high-resolution pelvic MRI for T stage, nodes, extramural venous invasion and the circumferential resection margin (CRM); endorectal USG for early T1/T2 lesions.
• Distant staging: CECT chest, abdomen and pelvis; PET-CT for equivocal metastases.
• Baseline tests: CEA (for prognosis and follow-up), CBC, LFT and renal function; fitness for surgery.
• Multidisciplinary decision: stage by TNM (AJCC 8th edition) and plan in a multidisciplinary tumour board.

(b)(ii) Dukes' staging

• Dukes A: growth confined to the rectal wall, not beyond the muscularis propria; nodes negative (5-year survival about 90%).
• Dukes B: growth through the muscularis propria into perirectal tissue; nodes negative (about 70%).
• Dukes C: regional lymph nodes involved (about 30–40%). C1 means pararectal nodes only, and C2 means apical (high-tie) nodes are involved.
• Dukes D (Turnbull's addition): distant metastasis (under 10%).

The Astler–Coller modification subdivides B and C by depth (B1, B2, C1, C2). TNM staging has now replaced Dukes' staging in clinical practice.

(b)(iii) Surgical options for carcinoma rectum

• Principle: total mesorectal excision (TME) is the standard, done by open, laparoscopic, robotic or transanal (TaTME) approach. Locally advanced (T3–T4 or N+) tumours receive neoadjuvant chemoradiotherapy or total neoadjuvant therapy first.
• Early tumours (T1N0, favourable): local excision by TEMS or TAMIS, or transanal excision.
• Upper and middle third: anterior resection or low anterior resection with TME, a colorectal or coloanal anastomosis (with or without a colonic J-pouch) and a temporary diverting ileostomy.
• Very low tumours clear of the external sphincter: ultra-low anterior resection or intersphincteric resection with a coloanal anastomosis (sphincter-saving).
• Lower third involving the sphincters or levators: abdominoperineal resection (Miles), or extralevator APR (ELAPE), with a permanent end colostomy.
• Emergency or unfit patients: Hartmann's procedure (resection, end colostomy and closure of the rectal stump).
• Locally advanced tumours invading adjacent organs: pelvic exenteration (anterior, posterior or total).
• Palliative options: defunctioning colostomy, self-expanding metallic stent, laser or ablative debulking; resection of isolated liver or lung metastases in selected patients.
• "Watch and wait": for a complete clinical response after neoadjuvant therapy, in selected centres.

(c) HIV/AIDS control and the National AIDS Control Programme (NACP)

(i) 95-95-95 targets

The UNAIDS Fast-Track targets have three steps:

• 95% of all people living with HIV (PLHIV) know their status.
• 95% of those diagnosed receive sustained ART.
• 95% of those on ART achieve viral suppression.

Together these mean that about 86% of all PLHIV are virally suppressed. NACP Phase V (2021–26) adopted the targets for 2025–26, alongside an 80% reduction in new infections and AIDS-related deaths from the 2010 baseline, elimination of vertical transmission of HIV and syphilis, and elimination of stigma.

India's position (NACO 2024 estimates):

• About 25 lakh PLHIV and over 18 lakh on ART.
• New infections about 64,500, down about 49% since 2010.
• AIDS-related deaths about 32,200, down about 81%.
• Viral suppression of about 97% among those tested on ART.

The weakest link is the first 95, testing. Community-based and HIV self-testing, index-partner testing and the "Test and Treat" policy are the key strategies. Implementation of the national viral-load testing programme is also important.

(ii) Categorisation of districts

NACP-III (2007) categorised districts by HIV sentinel surveillance data to target resources:

• Category A: over 1% ANC prevalence at any site in the last 3 years.
• Category B: under 1% ANC prevalence at all sites, but over 5% prevalence in any high-risk group (FSW, MSM, IDU) or STD clinic attendees.
• Category C: under 1% ANC and under 5% HRG prevalence, but with known hotspots or vulnerable populations (migrants, truckers).
• Category D: under 1% ANC and under 5% HRG prevalence, with poor or no data and no known hotspots.

A and B districts received priority for District AIDS Prevention and Control Units (DAPCUs), targeted interventions, link ART centres and ICTCs. NACP-IV and NACP-V refined this into data-triangulated, differentiated prioritisation of high-burden and high-incidence districts, and services were integrated with the general health system.

This approach concentrates scarce resources where transmission occurs. It relies, however, on surveillance quality, and it can neglect low-prevalence districts with rising migration-linked epidemics, as recent upswings in some north-eastern and northern states show.

(iii) TB-HIV coordination to reduce mortality

TB is the leading cause of death among PLHIV, and HIV is the strongest risk factor for TB. NACO and the National TB Elimination Programme (NTEP) run a joint national framework with state and district TB-HIV coordination committees. Its components are:

• Intensified case finding: four-symptom screening of every PLHIV at each ART or ICTC visit, with upfront molecular testing (CBNAAT/Truenat) for presumptive TB and urine LF-LAM in advanced HIV disease.
• Bidirectional testing: HIV testing for every notified TB patient, and cross-referral with a single-window service.
• TB preventive therapy: 6H or 3HP for PLHIV after active TB is ruled out.
• Infection control: airborne infection control at ART centres and health facilities.
• Early ART: ART for all TB-HIV patients, started within 2 weeks of anti-TB treatment. ART is deferred 4–8 weeks in TB meningitis. Dolutegravir is given twice daily with rifampicin.
• Co-trimoxazole preventive therapy.
• Advanced-disease package: includes cryptococcal antigen screening.
• Tracking and nutrition: joint reporting on Ni-kshay and SOCH (the NACO IT platform), and nutritional support under the Ni-kshay Poshan Yojana.

These measures cut mortality by detecting TB early, preventing it in PLHIV, and ensuring early combined ART and ATT with adherence support.