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Normal third stage of labour

Normal third stage of labour

Normal Third Stage of Labour

The third stage of labor is a critical phase that involves the separation, descent, and expulsion of the placenta and membranes, as well as the prevention of hemorrhage.

Physiology of the Third Stage of Labour:

  1. Contraction and Retraction:
    • The placental separation is initiated by the contraction and retraction of the uterine muscles. These contractions thicken the uterine wall, reducing the capacity of the upper uterine segment and decreasing the area of the placental site.
    • Separation starts from the center of the placenta. As the blood sinuses tear, a retroplacental clot forms, aiding in further placental separation.
  2. Descent of the Placenta:
    • The placenta descends due to the force of gravity acting like a piston on the clot. This propels the placenta from the upper uterine segment into the lower uterine segment.
  3. Separation of Membranes:
    • The membranes become separated as the weight of the placenta peels them off the decidua. However, the membranes may remain adherent around the cervix until the placenta is expelled from the vagina.
  4. Haemostasis (Preventing Hemorrhage):
  • At placental separation, swift control of blood flow is crucial to prevent serious hemorrhage. Several physiological processes play a role in achieving haemostasis:


a. Retraction of oblique uterine muscle fibers leads to the thickening of the uterine muscles, acting as a clamp and securing a ligature action on the torn vessels.

b. Vigorous uterine action after separation brings the uterine walls into opposition, exerting further pressure on the placental site.

c. A fibrin mesh rapidly covers the placental site after separation, utilizing 5-10% of the circulating fibrinogen to aid in clot formation and control bleeding.

d. Breastfeeding stimulates the release of oxytocin, which enhances uterine contractions, contributing to haemostasis.

\"Separation

Separation of the Placenta:

The separation of the placenta during the third stage of labor can occur in two ways, known as the Schultze method and the Mathew Dancan method.

  1. Schultze Method:
  • Separation usually starts centrally, resulting in the formation of a retroplacental clot. This clot exerts pressure at the midpoint of the placental attachment, aiding in the separation process and helping to strip the placenta\’s adherent lateral borders.
  • The increased weight of the placenta also assists in peeling the membranes off the uterine wall, creating a membranous bag enclosing the clot. As the placenta descends, the fetal surface comes out first.
  • This method is associated with more complete shearing of both the placenta and membranes, leading to less fluid blood loss. It is a quick and clean method.
  1. Mathew Dancan Method:
  • Placental separation begins from the sides, and blood escapes from the sides during the process, without the assistance of a retroplacental clot.
  • The placenta descends slipping sideways, with the maternal surface coming out first.
  • This method takes longer and is associated with ragged and incomplete expulsion of membranes, leading to a higher fluid blood loss.

After separation, the uterus contracts strongly, forcing the placenta and membranes to fall into the lower uterine segment and eventually into the vagina.

Signs of Placenta Separation:

  1. The uterus becomes hard, round, and mobile.
  2. The fundus rises to or above the umbilicus.
  3. The cord lengthens or elongates.
  4. There may be a gush of blood.
  5. The placenta can be felt on vaginal examination (VE).
  6. Presence of the placenta at the vulva.
  7. If suprapubic pressure is applied, the cord does not recede into the vagina.

Mechanism of Placental Separation:

  • Placental separation is facilitated by a combination of uterine contractions and involution. 
  • After the delivery of the fetus, the uterus continues to contract approximately every 3-4 minutes. These contractions, along with the process of involution (the shrinkage of the uterus), lead to the site of implantation of the placenta undergoing shrinkage as well.
  • Within 10-15 minutes after the baby\’s delivery, most of the placenta detaches from the uterine wall. This results in an increase in vaginal bleeding from the exposed implantation site, which signals the impending delivery of the placenta.
  • As the placenta is delivered, the uterus continues to contract, closing the spiral arterioles and reducing bleeding. The ongoing contraction of the uterus helps in preventing excessive blood loss.

N.B: It is important to note that the average blood loss from a vaginal delivery is approximately 250-300mls.

Management of the Third Stage of Labour:

Methods of Delivering the Placenta:

  • Controlled cord traction. (active)
  • Maternal efforts(passive management).
  1. Active Management (Controlled Cord Traction):
    • Palpate the abdomen to exclude undiagnosed twin pregnancies.
    • Administer oxytocin 10 IU intramuscularly to enhance uterine contractions.
    • Extend the cord clamp slightly to the vulva to get a good grip. Place the left hand over the fundus of the uterus.
    • During the first contraction, turn the palm of the left hand facing the fundus and apply counter traction above the pubic bone.
    • The right hand grasps the cord clamp and applies steady downward and outward traction until the placenta is visible at the vulva, then applies upward traction to receive the placenta in a cupped hand.
    • Take care to roll the membranes to prevent them from breaking.
    • Deliver the membranes in upward and downward movements.
    • Note the time of placenta and membranes delivery.
    • Rub the fundus to promote further uterine contractions.
    • Quickly examine the placenta for completeness and place it in a receiver.
    • Clean the vulva to remove any blood, and examine the cervix and vagina for lacerations or an extension of an episiotomy.
    • Repair any lacerations or tears.
    • Place a clean pad and ensure the mother is comfortable.
  2. Passive Management (Maternal Efforts):
    • This method is only used when the placenta has already separated from the uterine wall.
    • Wait for signs of placental separation.
    • Once the placenta has separated, ask the mother to push during contractions.
    • Place a flat palm over the mother\’s abdomen to provide resistance for her to push against.
    • Receive the placenta in both hands and deliver it complete.
    • Administer oxytocin 10 IU intramuscularly.

Note: It is essential to keep the mother warm as she has undergone strenuous physical exercise during the first and second stages of labor, leading to significant heat loss from her body.

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Episiotomy

Episiotomy

EPISIOTOMY

An episiotomy is a surgical procedure that involves making an incision on the perineum to widen the vaginal opening before childbirth.

Indications for Episiotomy:

To qicken delivery in the following situations:
a. Pre-eclampsia and eclampsia.
b. Cardiac diseases, to reduce strain on the mother.
c. Maternal distress, to minimize strain during delivery.
d. Fetal distress, aiming to prevent fetal death.
e. Cord prolapse in the second stage of labor, while the baby is still alive.

To prevent excessive trauma in the following cases:
a. Rigid perineum.
b. Forceps delivery.
c. Face to pubis delivery.

To reduce the risk of cerebral damage in the following circumstances:
a. Premature births.
b. Postmaturity.
c. After the baby\’s head emerges in breech deliveries.
d. In cases of a narrow subpubic arch.
e. After previous third-degree tears.

TYPES OF EPISIOTOMY:

  1. Lateral Incision:
    • This incision is made laterally across the labia majora and can be challenging to repair.

    Disadvantages:

    • May lead to excessive bleeding.
    • Risk of damaging the Bartholin\’s glands.
    • Causes discomfort to the mother.
    • Takes longer to heal.
  2. Medial Lateral:
    • This is the most common and recommended type, particularly for midwives.
    • The incision starts from the fourchette and extends in the medial lateral direction of the perineum, typically 2-3cm.

    Advantages:

    • Usually heals well.
    • Easier for a midwife to perform and repair.
    • Minimizes damage to blood vessels.
    • Reduces the risk of excessive perineal tear.
    • Shortens the duration of the second stage of labor.
    • Helps avoid injuries to the Bartholin\’s glands and the anal sphincter.
  3. Medial or Central or Midline:
    • This incision begins at the center of the fourchette and proceeds in the midline towards the anus.

    Advantages:

    • Results in less bleeding.
    • Provides greater comfort to the mother.
    • Simple to perform and easy to repair.

    Disadvantages:

    • May extend to involve the anal sphincter.
    • Poor repair could lead to Rectovaginal fistula (RVF).
  4. J-shaped:
    • Performed by a doctor, this incision starts from the center of the fourchette and curves away from the anal sphincter at a distance of 2.5cm.
  5. Bilateral:
    • Similar to the lateral incision but done on both sides.
    • It starts from the fourchette to the lateral wall.

    Note: Bilateral episiotomy is discouraged due to the potential risk of injury to the Bartholin\’s glands.

Precautions when giving episiotomy:

  1. Timing: Avoid performing the episiotomy too early or too late during labor.
  2. Presentation: In cephalic presentation, the head should be stretching the perineum, and in breech presentation, the anterior shoulder should be stretching the perineum before performing the episiotomy.
  3. Contraction Height: Give the episiotomy during a contraction to ensure better control and precision.

Basic principles prior to repairing the perineum:

  1. Timely Repair: Perform the repair as soon as possible to minimize the risk of bleeding and perineal edema.
  2. Aseptic Technique: Ensure that the repair is done using proper aseptic techniques to reduce the risk of infection.
  3. Equipment Check: Verify that all necessary equipment is in place and count swabs and needles before and after the procedure to avoid leaving any foreign objects inside.
  4. Anesthesia: Make sure the wound is adequately anesthetized before starting the repair to minimize discomfort to the patient.

Basic principles after repair:

  1. Hemostasis: Ensure complete hemostasis to prevent excessive bleeding.
  2. Post-repair Examination: Perform rectal and vaginal examinations to confirm the adequacy of the repair, ensuring no other tears have been missed, and verify that rectal mucosa has not been inadvertently repaired.
  3. Removal of Swabs: Double-check to ensure that all tampons or swabs used during the procedure have been removed.
  4. Detailed Documentation: Make detailed notes of the findings and the repair procedure for accurate medical records.
  5. Post-repair Care: Inform the woman about the use of appropriate analgesia (pain relief), hygiene practices, maintaining a good diet, and performing pelvic floor exercises to aid in recovery.

Method of Infiltration and Method of Performing:

Requirements:

  • A sterile episiotomy pack containing:
    • Pair of episiotomy scissors.
    • Needle and cut gut.
    • Needle holder.
    • Sterile gauze and cotton swabs.
    • Sterile gloves.
    • Syringe.
    • Lignocaine.
    • Hibicet.
Method of Infiltration:
  1. Ensure the procedure is performed under sterile conditions.
  2. Explain the procedure to the mother to keep her informed.
  3. Draw the required amount of lignocaine or local anesthesia (10mls of 0.5% and 5-7mls of 1%).
  4. Swab the vulva to maintain cleanliness.
  5. During a contraction, when the head or presenting part is distending the vulva, place two fingers of the left hand between the fetal head and the perineum to ensure that the drug is injected into the fetal scalp to avoid potential harm to the baby.
  6. Introduce the needle into the perineum and withdraw the piston to check for any blood aspiration. If blood is aspirated, reposition the needle and repeat the procedure until no blood is withdrawn.
  7. Insert two fingers into the vagina and position the blades at the peak of a contraction. Make a single clean cut approximately 3cm in length in a medial lateral direction.
  8. Control hemorrhage by pressing a sterile swab on the area.

Repair Technique:

Before the midwife starts to repair the episiotomy:

  1. Ensure the proper setting:
    • Place the mother comfortably.
    • Remove any soiled linen from under the genitalia.
    • Adjust the light source to have a clear view inside the vagina.
  2. Communicate with the mother, explain the repair procedure, and provide reassurance.
  3. Put on fresh sterile gloves.
  4. Check whether the previously administered local anesthesia is still effective. If the mother feels pain, administer more anesthesia before the repair.
  5. Remove all clots from the birth canal.
  6. Assess the extent of damage to the vagina and locate the apex of the episiotomy.
  7. Insert a roll of vaginal pack and secure the end with artery forceps.
  8. Start suturing the episiotomy from the apex.
  9. Suture the vaginal mucosa using the continuous stitch technique. Pass the needle through the vaginal mucosa from behind and bring it out on the perineum wound.
  10. Continue using the continuous suturing method all the way to the bottom of the wound to close the deep muscle layer. The same technique can be used on the skin.
  11. Remove the vaginal pack, inspect the vagina, and insert a finger in the rectum to ensure closure and exclude involvement of the rectum.
  12. Clean the mother after completing the repair.
  13. Provide a pad for the mother\’s comfort.
  14. Advise the mother on caring for the episiotomy and provide necessary instructions.
  15. Clear away and properly dispose of used materials.

Note: The typical healing time for an episiotomy is around 4-6 weeks, depending on the size of the incision and the type of suture material used to close the wound.

\"Classification

Classification of Perineal Trauma:

  1. First Degree Tear:
    • Injury to the perineal skin only.
  2. Second Degree Tear:
    • Injury to the perineum involving perineal muscles but not the anal sphincter.
  3. Third Degree Tear:
    • Injury to the perineum involving the anal sphincter.
  4. Fourth Degree Tear:
    • Injury to the perineum involving the anal sphincter complex and anal epithelium.
  5. Isolated Buttonhole Injury of the Rectum:
    • Injury to the rectal mucosa without injury to the anal sphincters.

Complications of Perineal Trauma:

  1. May become a 3rd degree tear.
  2. Bleeding.
  3. Infections.
  4. Swelling.
  5. Defect in wound closure.
  6. Local pain and a short-term possibility of sexual dysfunction.

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Normal second stage of labour

Normal second stage of labour

Normal second stage of labour

The second stage of labor commences when the cervix is fully dilated and concludes with the delivery of the baby.

SIGNS OF SECOND STAGE

Premonitory signs
  • Expulsive uterine contractions: Expulsive uterine contractions may occur when the mother is not fully dilated, particularly in occipital posterior position or with a full rectum.
  • Rapture of fore waters: Rupture of fore waters can occur at any time during labor.
  • Dilatation and gaping of the anus: Dilatation and gaping of the anus may happen due to deep engagement of the presenting part and premature maternal effort in the later part of the first stage.
  • Appearance of presenting part: Appearance of the presenting part becomes evident. Excessive molding may lead to the formation of a large caput succedaneum, which can protrude through the cervix before full dilatation. In breech presentation, the presenting part may be visible when the cervix is only 7-8 cm dilated.
  • Show: Show should be distinguished from bleeding caused by partial separation of the placenta, stretched cervix, or vaginal mucosa when the presenting part descends.
  • Congestion of the vulva: Congestion of the vulva is due to enthusiastic premature pushing.
  • Bulging of the perineum.
Confirmatory sign:
  • No cervix is felt on VE (full dilatation – 10cm).

Stages:

 Passive:
  • The cervix is fully dilated, but there are no involuntary expulsive contractions. Labour that is progressing well may take one hour. 
Active:
  • The cervix is fully dilated, there are involuntary expulsive contractions, and the baby is visible. The doctor should be informed if the baby has not been delivered after 2 hours in primigravida and 1 hour in multigravida.

Phases:

Propulsive phase:
  • It starts from full dilatation up to the descent of the presenting part to the pelvic floor.
 Expulsive phase:
  • It is distinguished by maternal bearing down efforts and ends with the delivery of the baby.

PHYSIOLOGY OF SECOND STAGE

 Descent:

  • Descent of the presenting part, which began during the first stage of labour and reaches its maximum speed towards the end of the first stage, continues its rapid pace through the second stage until it reaches the pelvic floor.

Uterine action:

  • The contractions become stronger and longer but can be less frequent, allowing a mother and a fetus a recovery period during the resting phase. The recovery period may last for one hour and is longer in primigravidas than in multigravidas. They are of strong intensity and expulsive in nature.
  • Membranes often rupture spontaneously at the onset of the second stage, so the drainage of liquor allows the hard round fetal head to be directly applied to the vaginal tissue, aiding distention. 
  • Fetal axis pressure increases flexion of the head, resulting in smaller presenting diameters, more rapid progress, and fewer traumas to both mother and fetus. 
  • Contractions become expulsive and as the fetus descends further into the vagina, pressure from the presenting part stimulates the nerve receptors in the pelvic floor, and the mother feels the need to push. 
  • Contractions become increasingly expulsive and overwhelming, and the mother responds by contracting abdominal muscles and the diaphragm.

Soft tissue displacement:

 As the fetal head descends, the soft tissue of the pelvis becomes displaced.

  • Anteriorly, the bladder is pushed upwards into the abdomen where it is at less risk of injury during the descent of the fetus. This results in stretching and thinning of the urethra, reducing its lumen.
  • Posteriorly, the rectum becomes flattened in the sacral curve, and the advancing head expels any residual fecal matter.
  • The levator ani muscles dilate, thin out, and are displaced laterally.
  • The perineal body is flattened, stretched, and thinned.
  • The fetal head is seen at the vulva advancing with each contraction and recoiling during the resting phase until crowning takes place.
  • The head is born, and the shoulders and body follow with the next contraction, accompanied by a gush of amniotic fluid and sometimes blood.

MECHANISM OF NORMAL LABOUR

 These are series of movements made by the fetus as it passes through the birth canal in order to be born. 

OR: These are series of passive movements made by the fetus as it negotiates the curves and diameters of the pelvis in order to be born. There is a mechanism for every presentation and position which can be delivered vaginally.

Principles common to all mechanisms:
  • Descent takes place throughout.
  • Whichever part that leads and first meets the resistance of the pelvic floor will rotate forward until it comes under the symphysis pubis.
  • The part that escapes under the symphysis pubis will pivot around the pubic bone.
  • The fetus turns slightly to take advantage of the widest space in each plane of the pelvis, i.e., transverse at the brim and anteroposterior at the outlet.

TERMS USED 

Attitude: This refers to the relationship of the fetal head and limbs to its trunk. The ideal attitude should be one of complete flexion. Flexion of the fetal head enables the smallest diameters to present to the pelvis, resulting in an easier labor.

Presentation: This indicates the part of the fetus that lies in the lower pole of the uterus. The normal presentation is vertex, where the head presents first.

Lie: This denotes the relationship between the long axis of the fetus and the long axis of the uterus. In normal labor, the lie should be longitudinal, which occurs in 99.5% of cases.

Position: This describes the relationship between the denominator of the presentation and specific points on the pelvic brim. Various positions are used in different presentations.

Right occipitoanterior:

  • The occiput points to the right iliopectineal eminence.
  • The sinciput points to the left sacroiliac joint.
  • The sagittal suture is in the left oblique diameter of the maternal pelvis.

Left occipitoanterior:

  • The occiput points to the left iliopectineal eminence.
  • The sinciput points to the right sacroiliac joint.
  • The sagittal suture is in the right oblique diameter of the maternal pelvis.

Right occipitoposterior:

  • The occiput points to the right sacroiliac joint.
  • The sagittal suture is in the right oblique diameter of the pelvis.

Left occipitoposterior:

  • The occiput points to the left sacroiliac joint.
  • The sagittal suture is in the left oblique diameter of the pelvis.

Right occipitolateral:

  • The occiput points to the right iliopectineal line, midway between the iliopectineal eminence and the sacroiliac joint.
  • The sagittal suture is in the transverse diameter of the pelvis.

Left occipitolateral:

  • The occiput points to the left iliopectineal line, midway between the iliopectineal eminence and sacroiliac joint.
  • The sagittal suture is in the transverse diameter of the pelvis.

Presenting part: This is the part of the presentation that lies over the internal os of the cervix.

Denominator: This is the name of the part of the presentation that is used when referring to the fetal position. Each presentation has a different denominator, which includes:

  • In vertex presentation: occiput
  • In breech presentation: sacrum
  • In face presentation: mentum

In the mechanism of normal labor:

  • Attitude is one of complete flexion.
  • Lie is longitudinal.
  • The presentation is cephalic.
  • Position can be either right or left occipitoanterior.
  • The denominator is the occiput.
  • Presenting diameters are the biparietal and occipitofrontal.
  • Engaging diameters are the biparietal (transverse) and suboccipitofrontal (anteroposterior).

MAIN MOVEMENTS 

Engagement: Engagement occurs when the biparietal and suboccipitofrontal diameters pass through the pelvic brim. In primigravidas, engagement often happens before the onset of labor, while in most multigravidas, it occurs in the late first stage.

Descent: Throughout the first stage of labor, uterine muscle contractions and retraction reduce the space in the uterus, exerting pressure on the fetus to descend. After the rupture of the fore waters and with maternal effort, descent speeds up, culminating in the complete expulsion of the fetus. Factors facilitating descent include uterine contraction and retraction, bearing down efforts, and straightening of the fetus after the rupture of membranes.

Flexion: At the beginning of labor, with the position being right occipitoanterior (ROA) or left occipitoanterior (LOA), the fetus is in the attitude of complete flexion. At the onset of labor, the suboccipitofrontal diameter of 10cm presents. With greater flexion, the suboccipitobregmatic diameter of 9.5cm presents, and the occiput becomes the leading part. Resistance from the lower segment, pelvic walls, unfolding cervix, and pelvic floor promotes full flexion of the fetal head.

Internal Rotation of the Head: During a contraction, the presenting part is pushed downward onto the pelvic floor. It first meets resistance with the pelvic floor muscles and then rotates 1/8 of a circle forward, bringing the occiput under the symphysis pubis.

Crowning: With strong uterine contractions, crowning takes place as the occipital eminence escapes under the symphysis pubis and no longer recedes back during contractions. The widest diameter (biparietal) is born. If flexion is maintained, the suboccipitobregmatic diameter of 9.5cm distends the vaginal orifice.

Extension of the Head: After crowning, the fetal head can extend by pivoting on the suboccipital region around the pubic bone. This movement realizes the sinciput, face, and chin, which sweep the perineum and are born by extension.

Restitution: This is the movement of the head after delivery to correct the twist in the neck. The occiput rotates back 1/8 of a circle towards the side where it began.

Internal Rotation of the Shoulders: The shoulders enter the oblique diameter of the pelvic cavity. The anterior shoulder reaches the pelvic floor first and rotates 1/8 of a circle forward, bringing the shoulders in the anteroposterior (AP) diameter of the outlet to lie under the symphysis pubis. The movement can be clearly seen as the head turns at the same time (external rotation of the head). It occurs in the same direction as restitution, and the occiput of the fetal head now lies laterally.

External Rotation of the Head: It occurs at the same time as the internal rotation of the shoulders.

Lateral Flexion: The anterior shoulder escapes under the symphysis pubis, and the posterior shoulder sweeps the perineum. The whole body is born by lateral flexion towards the mother\’s abdomen.

Factors Influencing the Length of the 2nd Stage:
  • Maternal parity
  • Fetal size
  • Force of uterine contractions
  • Presentation
  • Position
  • Pelvic size
  • Method of anesthesia
  • Magnitude of maternal expulsive effort

MANAGEMENT OF SECOND STAGE OF LABOUR

 The woman should be reassured and provided with psychological support to encourage cooperation during the second stage of labor. 

  • Ensure the woman is not left alone and transfer her to the delivery room in a timely manner without rushing. 
  • Prepare the delivery room, necessary equipment, and a cot for the baby well in advance. 
  • Ensure a clean and decontaminated environment, with adequate lighting in the delivery room. 
  • Properly prepare oneself and any assisting personnel by wearing protective gear, washing hands thoroughly with clean water and soap, and wearing sterile gloves. 
  • Before conducting delivery, scrubbing and wearing protective gear should be done. 
  • Position the mother in a dorsal position for delivery.

NURSING CARE

  1. Care of the bladder: Encourage the mother to empty her bladder at the beginning of the second stage. A full bladder may delay the descent of the presenting part, and the bladder may be at risk of injury during the descent of the fetal head.
  2. Hygiene and comfort: Swab the vulva whenever necessary and provide a sterile pad to cover it between contractions. In case of leg cramps, massage, extend, and flex the leg to provide relief.
  3. Emotional support: Offer constant praise and keep the woman informed of her progress. Create a calm and quiet environment with privacy to reduce anxiety. Avoid unnecessary interruptions by other caregivers.
  4. Position: Consider using positions like squatting, kneeling, all fours, standing, left lateral position, or dorsal position during the second stage. These positions may improve the effectiveness of contractions and facilitate the process.
  5. Observations: Monitor the strength, length, and frequency of contractions. Observe the descent of the presenting part, fetal condition (e.g., fetal heart rate, color of amniotic fluid, molding, and state of membranes), and maternal condition (e.g., emotional coping ability, pulse every 30 minutes, and blood pressure hourly).

CONDUCTING 2ND STAGE ( ACTIVE MANAGEMENT)

Requirements

A trolley with;-

Top Shelf Bottom Shelf Beside
Sterile delivery pack containing: Vial of lignocaine A warm cot and baby\’s clothing
– 6 delivery swabs Amp of oxytocin Resuscitation equipment
– 2 cord clamps Measuring jar Gum boots
– 1 pair of cord scissors Apron 2 buckets (one for used gloves, swabs, etc., and one with disinfectant)
– 1 pair of episiotomy scissors 2 pairs of sterile gloves Hamper
– 2 gallipots for swabs and lotion Episiotomy pack Drip stand
– 2 receivers Disinfectant  
– Bulb syringe (mucus extractor) Syringe and needles  
– 2 syringes Mackintosh and towel  
– Perineal pad Clean pads  
– Four delivery towels Safety box  
– Cord ligatures    
– Sterile gloves    
– 4 delivery towels    
Responsibilities of Assistant During 2nd Stage

  1. Reassure the mother: Provide constant reassurance and emotional support to the mother throughout the second stage of labor to help her remain calm and focused.

  2. Position the mother: Assist the mother in assuming the most comfortable and effective position for delivery, whether it\’s dorsal, squatting, kneeling, all fours, standing, or left lateral position.

  3. Instruct mother when to push: Guide the mother and provide clear instructions on when to push during contractions to facilitate the descent and delivery of the baby.

  4. Listen to fetal heart: Monitor the fetal heart rate regularly, especially after each contraction, to assess the well-being of the baby during the delivery process.

  5. Give oxytocin after delivery: Administer oxytocin to the mother within one minute after the baby\’s delivery to help prevent excessive bleeding and facilitate uterine contractions.

  6. Show the sex of the baby: After delivery, if requested, reveal the sex of the baby to the mother and her partner, respecting their preferences and cultural beliefs.

  7. Score the baby: Perform the Apgar scoring at 1 minute and 5 minutes after birth to assess the baby\’s overall health and well-being.

  8. Ensure baby care: After delivery, ensure the baby is promptly dried, kept warm, and placed on the mother\’s breast for skin-to-skin contact and initiating breastfeeding.

\"birth-positions-pictures

Procedure:

  1. Explain the Procedure to the Mother: Communicate the entire delivery process to the mother, ensuring she understands what will happen during the second stage of labor. Address any questions or concerns she may have.

  2. Put on Gum Boots, Gown, and Mask: Prior to conducting the delivery, don gum boots, wear a sterile gown, and put on a mask to maintain a hygienic environment and prevent the spread of infections.

  3. Position the Mother: Assist the mother in assuming a comfortable position for delivery, such as dorsal, squatting, kneeling, all fours, standing, or left lateral position, depending on her preference and the progress of labor.

  4. Scrub Hands before Conducting Delivery: Thoroughly scrub and clean your hands with soap and water to ensure they are free from any potential contaminants.

  5. Put on Two Pairs of Sterile Gloves: Wear two pairs of sterile gloves to maintain a sterile field during the delivery process.

  6. Swab the Perineum and Drape with Sterile Towels: Prepare the perineal area by swabbing it with an antiseptic solution to maintain cleanliness. Then, drape the delivery area and perineum with sterile towels to create a sterile field.

  7. Place a Sterile Pad on the Anus: To prevent contamination from fecal matter, place a sterile pad over the anus, ensuring the delivery field remains clean and sterile.

  8. Confirm 2nd Stage of Labor: Before proceeding, confirm that the mother has entered the second stage of labor, with full dilatation of the cervix and the presenting part of the baby ready for delivery.

Delivery of the Head:
  1. As the fetal head descends at the vulva, keep it flexed by applying pressure with two fingers of the left hand on the vertex, pointing towards the anterior fontanel.
  2. Use the right hand to place a small rectal pad to control fecal matter and maintain the sterile delivery field.
  3. Monitor the descent of the head with your fingers to prevent expulsive crowning and potential perineal laceration.
  4. The head should advance with each contraction. At crowning, ask the mother to stop pushing and pant to maintain pressure on the head and control the birth.
  5. Deliver the head slowly by extending it, bringing the occiput towards the symphysis pubis. Wipe the baby\’s face, swab the eyes inside outwards, and clear the airway as soon as the head is born.
  6. During the resting phase, check for the umbilical cord around the baby\’s neck. If it\’s loose, slip it over. If tight, clamp it with two artery cord clamps and cut between them.
  7. Hold gauze over the incised area to reduce the risk of being sprayed with blood during the procedure.
Delivery of the Shoulders:
  1. Ensure restitution and external rotation of the head to safely deliver the shoulders and avoid perineal lacerations.
  2. External rotation of the head indicates that the shoulders are rotating into the anterior-posterior diameter of the pelvic outlet, ready to be delivered.
  3. Deliver one shoulder at a time to prevent overstretching of the perineum.
  4. Place a hand on each side of the baby\’s head over the ears and deliver the anterior shoulder with a downward movement and the posterior shoulder with an upward movement, sweeping the perineum.
  5. Deliver the rest of the body towards the mother\’s breast.
  6. Note the time of delivery and perform the Apgar score at 1 minute. Congratulate the mother and palpate the abdomen to rule out a second baby.

Immediate Care of the Newborn After Birth (Within the First Hour):

  1. Clamp and cut the cord.
  2. Clear secretions from the baby\’s mouth and nostrils.
  3. Tightly ligature the cord.
  4. Warm the newborn and wrap it in a sterile warm towel.
  5. Place the baby on the mother\’s breast if in good condition and not contraindicated.
  6. Perform the Apgar score at 5 minutes.
  7. Show the baby\’s face and sex to the mother.
  8. Provide warmth to the mother.
  9. Put an identification tag on the baby with the mother\’s name, time of delivery, sex, birth weight, and date of delivery.
  10. Note that the baby should have a strong and lusty cry, which helps the lungs expand.

Points to Consider While Conducting Delivery:

  1. Ensure all necessary equipment, including newborn resuscitation equipment, is available and the delivery area is clean and warm.
  2. Make sure the mother\’s bladder is empty before delivery.
  3. Assist the woman in assuming a comfortable position of her choice.
  4. Stay with the mother and provide emotional and physical support throughout the process.
  5. Allow the mother to push as she wishes and avoid urging her to push.
  6. Decontaminate the delivery trolley and set up sterile equipment.
  7. Prepare the delivery environment, decontaminate the bed, and ensure adequate lighting.
  8. Put on protective gear such as a plastic apron and gum boots.
  9. Wear sterile gloves for the delivery procedure.
  10. Ensure controlled delivery of the baby\’s head to prevent complications.

Factors Influencing the Length of the 2nd Stage of Labour:

  1. Maternal parity (number of previous pregnancies).
  2. Fetal size.
  3. Uterine contractile force and strength of contractions.
  4. Presentation of the baby (e.g., vertex or breech).
  5. Position of the baby during delivery (e.g., occipitoanterior or occipitoposterior).
  6. Size and shape of the maternal pelvis.
  7. Method of anesthesia used during labour, if any.
  8. The magnitude of maternal expulsive force.

Possible Complications of 2nd Stage of Labour:

  1. Deep transverse arrest (failure of the baby\’s head to rotate and descend properly).
  2. Obstetrical shock (resulting from severe bleeding or other complications).
  3. Uterine inertia (weak or ineffective uterine contractions).
  4. Maternal distress (emotional or physical strain during labour).
  5. Shoulder dystocia (difficulty delivering the baby\’s shoulders after the head is born).
  6. 3rd-degree tear (severe tear involving the perineum and anal sphincter).
  7. Amniotic embolism (rare but serious condition where amniotic fluid enters the mother\’s bloodstream).
  8. Ruptured uterus (tearing of the uterine wall during labour).
  9. Fetal distress (abnormalities in the baby\’s heart rate or well-being).

Normal second stage of labour Read More »

Tetanus

Tetanus

Tetanus

Tetanus is an acute infectious disease of the central nervous system caused by clostridium tetani and is characterized by spasms of the skeletal muscles frequently attacking the muscles of the jaw. 

Tetanus is commonly known as ‘Lock-jaw.’

Cause of Tetanus

Tetanus is caused by the exotoxins of clostridium tetani.

  • The organism can live for a long time in any condition, especially dirty environments. So it can be found in dust, soil, or grass.
  • The clostridia can be normal organisms in the alimentary canal of animals but when passed out and gain entry to the human body, they become harmful. The organism can be found in cows, horse, sheep, or goat.

Incidence of tetanus:

  • In babies born at home before arrival at the hospital.
  • In homes where domestic animals are kept.

\"route

Pathophysiology of Tetanus

The pathophysiology of tetanus involves the invasion of the body by bacilli or spores, typically through deep puncture wounds or cuts. These bacilli find a suitable environment to multiply in anaerobic conditions. It is crucial to note that all unclean wounds pose a significant risk. Once the clostridium tetani organisms enter the wound, they unleash two forms of exotoxins into the surrounding tissues: tetanospasmin and tetanolysin.

Tetanospasmin, a potent toxin, plays a critical role in producing the disease\’s clinical manifestations. It primarily affects the central nervous system (CNS). The toxins specifically target the motor nerve cells of the spinal cord and the brain. As a result, spasms develop in the muscles that are supplied by the corresponding nerves.

Route of entry

The route of entry for the clostridium tetani organisms includes various pathways, all of which can lead to infection and subsequent tetanus:

  1. Infected ulcerated wound.
  2. Postoperative wounds.
  3. Umbilical stumps (in newborns).
  4. Gun-shot wounds.
  5. Septic abortion.
  6. Jiggers or foreign bodies.
  7. Burns and scalds.

Signs and Symptoms

Tetanus manifests with a set of distinctive signs and symptoms, indicating the severity of the infection:

  1. Stiffness of the muscles, particularly noticeable in the jaw.
  2. Spasms affecting the muscles of the face, especially the cheek and jaw, leading to difficulty in opening the mouth, a condition referred to as trismus.
  3. The angles of the mouth are pulled outwards, causing a forced smile known as risus sardonicus or the \”Devil\’s grin.\”
  4. The head is thrown back, and the back becomes arched due to the rigid muscles in the neck, a condition called opisthotonus.
  5. Signs of inflammation may be evident, such as swelling of the umbilical cord (if present in newborns), a wet cord, offensive smell, or pus discharge from the wound site.
  6. Patients may experience an elevated temperature and rapid pulse.
  7. Weight loss may occur due to difficulties in eating, leading to starvation.
  8. Spasms of the sphincters can result in retention of urine or stool, and in severe cases, sphincter rupture may occur.
  9. Swallowing becomes challenging as the muscles of the mouth and esophagus are affected by spasms.
  10. Spasms affecting the respiratory muscles may lead to prolonged periods without oxygen (anoxia), which can be life-threatening and result in death.
  11. Patients may have a wound or a history of a wound, which could be the point of entry for the tetanus-causing bacteria.

Alblett Classification of Tetanus

There are several grading systems; the scale proposed by Ablett5
is the most widely used . This categorizes patients
into four grades depending upon the intensity of spasms, and
respiratory and autonomic involvement.

\"\"

Management of Tetanus

There\’s no cure for tetanus. A tetanus infection requires emergency and long-term supportive care while the disease runs its course.

Aims of Management

  • To control spasms.
  • To eliminate the causative organism and its toxins.
  • To prevent complications, and ensure adequate nutrition for the patient. 

Specific treatment measures include:

  1. Penicillin: Administering penicillin is a crucial step in destroying the tetanus-causing organism.

  2. Anti-tetanus serum: The administration of anti-tetanus serum helps neutralize the spreading toxins and halt their further detrimental effects.

  3. Sedation and muscle relaxants: Medications like diazepam and chlorpromazine are given to provide sedation and muscle relaxation, effectively alleviating spasms and minimizing discomfort.

  4. Wound management: If there is a wound or focus of infection where the tetanus bacteria may have entered, the dead tissue is excised, and the area is irrigated with hydrogen peroxide. Leaving the wound open without suturing promotes oxygen exposure, hindering the growth of tetanus bacilli, which thrive in anaerobic conditions.

Control of spasms involves the following measures:

  • Absolute rest and isolation: The patient should be kept in a quiet room with dim lighting to minimize triggers for spasms.
  • Prevention of external stimuli: Measures such as fitting the door with suitable closing materials or springs prevent slamming noises that could stimulate the patient.
  • Warming hands before touching: Nurses should warm their hands before touching the patient to avoid any stimulation that might trigger spasms.
  • Medication administration: Sedatives and muscle relaxants, such as chlorpromazine (Largactil), and Diazepam, are given regularly through a nasogastric tube to maintain a controlled state and alleviate spasms.

  • o Example of 6 hourly regimen 

    Drug 

    6-9 

    am

    9-12  

    pm

    12-3  

    pm

    3-6  

    pm 

    6-9 

    pm

    9-12 

    am

    12-3 

    am

    3-6 

    am

    6-9 

    am

    Largactil 

    ✔ 

    ⫼⫼⫼⫼ 

    ✔ 

    ⫼⫼⫼⫼ 

    ✔ 

    ⫼⫼⫼⫼ 

    ✔ 

    ⫼⫼⫼⫼ 

    ✔

    Diazepam 

    ⫼⫼⫼⫼ 

    ✔ 

    ⫼⫼⫼⫼ 

    ✔ 

    ⫼⫼⫼⫼ 

    ✔ 

    ⫼⫼⫼⫼ 

    ✔ 

    ⫼⫼⫼⫼

General Management:

  1. Close observation and airway management: Monitor the patient closely, ensuring a clear airway and using a mucous extractor if necessary.

  2. Vital signs monitoring: Regularly check temperature, pulse, and respirations, noting the severity of the condition. Record the strength, frequency, duration, and body part involved in spasms using a spasm chart.

  3. Nutrition: Maintain adequate nutrition through nasogastric tube feeding to avoid stimulating spasms with injections. Prevent aspiration of fluids into the airway.

  4. Catheterization: Catheterize the patient to maintain proper bladder function.

  5. Fluid balance chart: Monitor and maintain fluid balance, initially using intravenous fluids if necessary and later transitioning to nasogastric tube feeding.

  6. Hygiene: Ensure daily cleaning of the cord with normal saline and perform oral care carefully. Turn the patient every two hours to prevent pressure sores.

  7. Vaccination: Prevent future tetanus cases by ensuring all individuals receive a full course of DPT (diphtheria, pertussis, and tetanus) vaccination.

  8. Use sterile equipment: Prevent cross-infection by using sterile equipment during medical procedures.

  9. Bowel and bladder care: Monitor and assist the patient in passing stool and urine.

  10. Medication: Administer prescribed drugs as instructed.

  11. Physiotherapy: Implement physiotherapy sessions for deep breathing exercises and active limb movements.

Prevention:

  1. Public health education: Raise awareness about the dangers of using unsterilized equipment during childbirth and applying native medicine or other substances to the umbilical cord.

  2. Immunization: Ensure that all women of childbearing age are vaccinated against tetanus.

  3. Safe childbirth practices: Promote safe and clean practices during childbirth to prevent infections.

  4. Discourage harmful practices: Discourage practices like applying cow dung to a child\’s umbilical cord.

  5. Wound care education: Educate people on cleaning wounds thoroughly with water and soap to prevent infections. Encourage covering wounds with sterile dressings and seeking early medical attention for cut wounds.

  6. Protective gear: Encourage the use of gum boots when digging to prevent soil-related infections.

Complications of Tetanus

  1. Fracture of bones or the spine: The intense and frequent muscle spasms can cause fractures in bones or the spine, especially if the spasms are severe and uncontrolled.

  2. Pneumonia: Heavy sedation, a common treatment for managing tetanus spasms, may lead to shallow breathing or difficulty in clearing the airway, increasing the risk of pneumonia, a potentially severe respiratory infection.

  3. Brain damage: The potent toxins produced by the tetanus-causing bacteria can affect the central nervous system, leading to brain damage in severe cases.

  4. Growth retardation: In children affected by tetanus, the disease can interfere with proper nutrition and growth, potentially causing growth retardation.

  5. Exhaustion: The continuous and strenuous muscle spasms can lead to extreme exhaustion, further weakening the patient\’s overall condition.

  6. Respiratory failure: In severe cases, the spasms can affect the respiratory muscles, resulting in respiratory failure, where the patient is unable to breathe adequately on their own.

  7. Retention of urine: Spasms in the pelvic region can cause the sphincters to contract, leading to difficulty in passing urine and possible urine retention.

  8. Death due to airway obstruction: In the most severe cases, the intense spasms, particularly those affecting the muscles of the jaw and neck, can obstruct the airway, leading to suffocation and potential death.

Test Questions

Which bacterium causes tetanus?
a) Streptococcus pyogenes
b) Staphylococcus aureus
c) Clostridium tetani
d) Escherichia coli
Answer: c) Clostridium tetani

Explanation: Clostridium tetani is the bacterium responsible for causing tetanus.

What is the common term used to describe tetanus due to spasms in the jaw muscles?
a) Trismus
b) Opisthotonus
c) Risus sardonicus
d) Tetanospasmin
Answer: a) Trismus

Explanation: Trismus is the medical term for difficulty in opening the mouth due to jaw muscle spasms, which is commonly known as \”Lock-jaw.\”

What is the primary goal of managing tetanus?
a) Preventing complications
b) Destroying the toxin
c) Controlling fever
d) Alleviating pain
Answer: a) Preventing complications

Explanation: The main aim of managing tetanus is to prevent complications associated with the disease and ensure the best possible outcome for the patient.

What is the specific treatment given to destroy the tetanus-causing organism?
a) Penicillin
b) Paracetamol
c) Aspirin
d) Ibuprofen
Answer: a) Penicillin

Explanation: Penicillin is administered to destroy the Clostridium tetani bacterium responsible for causing tetanus.

Which complication of tetanus can lead to respiratory failure?
a) Pneumonia
b) Fracture of bones
c) Brain damage
d) Respiratory muscle spasms
Answer: d) Respiratory muscle spasms

Explanation: Tetanus-induced spasms affecting the respiratory muscles can lead to respiratory failure, where the patient is unable to breathe adequately on their own.

Why is the use of a mucous extractor important in tetanus management?
a) To prevent dehydration
b) To clear the airway
c) To alleviate muscle spasms
d) To prevent fever
Answer: b) To clear the airway

Explanation: A mucous extractor is used to clear the airway and prevent obstruction caused by excessive secretions, which is crucial in tetanus management.

What is the recommended method for feeding tetanus patients to avoid spasms triggered by injections?
a) Intravenous feeding
b) Nasogastric tube feeding
c) Oral feeding
d) Intramuscular injections
Answer: b) Nasogastric tube feeding

Explanation: Nasogastric tube feeding is used to provide nutrition and administer drugs to tetanus patients while avoiding the stimulation of spasms caused by intramuscular injections.

Which immunization should be given to prevent future tetanus cases?
a) Hepatitis B
b) Measles, Mumps, and Rubella (MMR)
c) Diphtheria, Pertussis, and Tetanus (DPT)
d) Polio
Answer: c) Diphtheria, Pertussis, and Tetanus (DPT)

Explanation: The DPT vaccine provides immunity against diphtheria, pertussis (whooping cough), and tetanus, preventing future tetanus cases.

What measure can be taken to prevent tetanus in newborns with umbilical stumps?
a) Cleaning the stump with cow dung
b) Applying native medicine on the stump
c) Keeping the stump dry and clean
d) Ignoring the stump until it falls off naturally
Answer: c) Keeping the stump dry and clean

Explanation: Maintaining cleanliness and dryness of the umbilical stump can prevent infection and the risk of tetanus in newborns.

What is the purpose of physiotherapy in tetanus management?
a) To provide pain relief
b) To promote muscle strength
c) To control spasms
d) To increase body temperature
Answer: b) To promote muscle strength

Explanation: Physiotherapy aims to promote muscle strength and mobility, which can be helpful in the recovery process of tetanus patients.

Tetanus Read More »

Leprosy

Leprosy

Leprosy

Leprosy, also known as Hansen\’s disease, is a chronic infection caused by the bacteria Mycobacterium leprae and Mycobacterium lepromatosis. 

It primarily affects the skin and peripheral nerves.

Cause of Leprosy

 Leprosy is caused by Mycobacterium leprae and Mycobacterium lepromatosis. M. lepromatosis is a relatively newly identified mycobacterium isolated from a fatal case of diffuse lepromatous leprosy in 2008.

Transmission of Leprosy

  •  Nasal route via secretions 
  •  Transplacental and breast feeding 
  •  Genetic predisposition

\"Types

Types of Leprosy:

  1. Lepromatous leprosy (90%): This is the most common type of leprosy, accounting for about 90% of cases. It is characterized by widespread skin lesions and a weak cellular immune response. The bacteria multiply profusely in the body, leading to severe skin and nerve damage.

  2. Tuberculoid leprosy: In this type, the immune response is stronger, and the skin lesions are few and well-defined. The affected areas may have a loss of sensation, but nerve damage is less severe compared to lepromatous leprosy.

  3. Borderline leprosy: Borderline leprosy lies in between lepromatous and tuberculoid leprosy in terms of immune response and clinical features. It displays mixed characteristics, with moderate skin lesions and nerve involvement.

  4. Undeterminate (Dismorphoid or Undetermined) leprosy: This type is diagnosed when the symptoms and immune response are not well-defined, making it difficult to classify precisely. It often occurs early in the disease\’s progression and may eventually develop into one of the other types.

Differences between Tuberculoid, Lepromatous and Borderline leprosy 

Cutaneous lesion 

Tuberculoid 

Lepromatous 

Borderline 

Characteristic number of lesions 

Few 

Many 

Many 

Size of lesion 

Large 

Small 

Both – large & small

Symmetry of lesions 

Asymmetrical 

Symmetrical 

Symmetrical 

Surface of lesions 

Rough and scaly 

Smooth 

Rough & scaly

Edges 

Sharp 

Vague 

Sharp 

Incubation Period: 

The incubation period of leprosy refers to the time between when a person is exposed to the bacteria Mycobacterium leprae and the onset of symptoms. In leprosy, this period usually lasts from 2 to 5 years. However, in certain cases, especially in lepromatous leprosy, the incubation period may extend to a longer duration, lasting 8 to 12 years before signs of the disease become apparent.

Signs and Symptoms:

 Leprosy presents with a variety of signs and symptoms, which may vary depending on the type and stage of the disease. Some common manifestations include:

  • Anaesthetic skin lesions: These are patches of skin that lose their ability to feel sensation. Individuals may not be able to detect pain, heat, or touch in these areas, making them prone to injuries.

  • Thickened peripheral nerves: Leprosy can affect the peripheral nerves, leading to their thickening and enlargement, often seen as lumps under the skin.

  • Nasal stuffiness: In some cases, leprosy can cause inflammation and swelling in the nasal passages, leading to nasal stuffiness and congestion.

  • Saddled nose (Saddle nose): This refers to the collapse of the nasal bridge due to the destruction of the nasal septum, which can occur in advanced cases of leprosy.

  • Loss of eyebrows and lashes: Leprosy can cause the loss of eyebrows and eyelashes, leading to changes in facial appearance.

  • Erythema nodosum: This is a condition characterized by painful, red nodules that can occur on the skin or under the skin\’s surface.

  • Inflammatory eye changes: Leprosy may affect the eyes, leading to various eye problems, including inflammation and potential vision impairment.

Investigations

To diagnose leprosy and confirm the presence of Mycobacterium leprae, healthcare professionals may conduct several investigations, such as:

  • Histamine test: This test helps assess the level of nerve damage by evaluating the body\’s response to histamine injection.

  • Lepromine test: Lepromine is a substance derived from the leprosy bacteria. The test measures the immune response to lepromine to determine the type of leprosy and the individual\’s immune status.

  • Polymerase Chain Reaction (PCR): PCR is a molecular technique used to detect the genetic material of the bacteria in skin samples, aiding in early and accurate diagnosis.

  • Skin snip for Mycobacterium leprae (modified ZN): A small sample of skin is taken and stained using the modified Ziehl-Neelsen method to visualize the presence of Mycobacterium leprae under a microscope.

Treatment for Leprosy:

  1. Tuberculoid leprosy:

    • Dapsone + Rifampicin

  2. Lepromatous leprosy:

    • Dapsone + Rifampicin + Clofazimine

  3. Borderline leprosy:

    • Dapsone
Non-leprosy drugs used in the management of leprosy:
  • Steroids
  • Vitamin B complex

Drugs for leprosy are commonly administered in fixed drug combinations known as MDT (Multi-Drug Therapy). MDT has been a highly effective approach in treating leprosy and preventing the development of drug resistance.

Complications of leprosy include:

  • Madorosis (loss of eyebrows and eyelashes)
  • Nasal bridge collapse
  • Ocular complications: corneal ulcer, blindness
  • Leonine faces (thickened, lion-like appearance of facial skin)
  • Loss of sensation to heat, pain, and light touch
  • Multiple ulcerations due to nerve damage and loss of sensation
  • Nerve enlargement
  • Orchitis (inflammation of the testicles)
  • Disuse of some parts of the body
  • Contractures and shortening of phalanges, especially the 4th and 5th fingers and toes
  • Elongated soft ear lobes
  • Sterility in men secondary to orchitis
  • Hammer toes (abnormal bending of the toes)
  • Reactional states secondary to successful drug therapy (erythema nodosum leprosum).

Test Questions

Question: Leprosy primarily affects which body parts?
a) Liver and kidneys
b) Skin and peripheral nerves
c) Lungs and heart
d) Brain and spinal cord
Answer: b) Skin and peripheral nerves
Explanation: Leprosy is a chronic infection that primarily affects the skin and peripheral nerves.

Question: What is the incubation period for lepromatous leprosy?
a) 1-2 years
b) 3-5 years
c) 6-8 years
d) 8-12 years
Answer: d) 8-12 years
Explanation: Lepromatous leprosy has a longer incubation period of 8-12 years, compared to other types of leprosy.

Question: Which type of leprosy has well-defined, few skin lesions and less severe nerve damage?
a) Tuberculoid leprosy
b) Lepromatous leprosy
c) Borderline leprosy
d) Indeterminate leprosy
Answer: a) Tuberculoid leprosy
Explanation: Tuberculoid leprosy is characterized by well-defined, few skin lesions and less severe nerve damage.

Question: Which drug combination is used to treat lepromatous leprosy?
a) Dapsone
b) Dapsone + Rifampicin
c) Dapsone + Rifampicin + Clofazimine
d) Rifampicin
Answer: c) Dapsone + Rifampicin + Clofazimine
Explanation: Lepromatous leprosy is treated with a combination of Dapsone, Rifampicin, and Clofazimine.

Question: What are the complications of leprosy that may lead to blindness?
a) Loss of eyebrows and lashes
b) Nasal bridge collapse
c) Corneal ulcer
d) Erythema nodosum leprosum
Answer: c) Corneal ulcer
Explanation: Leprosy can cause corneal ulcers, which may lead to blindness if left untreated.

Question: Which investigation helps diagnose leprosy by detecting Mycobacterium leprae in skin samples?
a) Lepromine test
b) Histamine test
c) PCR
d) Skin snip for Mycobacterium leprae (modified ZN)
Answer: d) Skin snip for Mycobacterium leprae (modified ZN)
Explanation: Skin snip test with modified Ziehl-Neelsen staining is used to visualize Mycobacterium leprae under a microscope.

Question: What is the most common type of leprosy?
a) Tuberculoid leprosy
b) Lepromatous leprosy
c) Borderline leprosy
d) Indeterminate leprosy
Answer: b) Lepromatous leprosy
Explanation: Lepromatous leprosy is the most common type, accounting for about 90% of leprosy cases.

Question: Which type of leprosy has a weak cellular immune response and widespread skin lesions?
a) Tuberculoid leprosy
b) Lepromatous leprosy
c) Borderline leprosy
d) Indeterminate leprosy
Answer: b) Lepromatous leprosy
Explanation: Lepromatous leprosy is characterized by a weak cellular immune response and widespread skin lesions.

Question: What is the term used to describe the thickened, lion-like appearance of facial skin in leprosy?
a) Madorosis
b) Leonine faces
c) Erythema nodosum
d) Nasal bridge collapse
Answer: b) Leonine faces
Explanation: Leonine faces refer to the thickened, lion-like appearance of facial skin seen in some cases of leprosy.

Question: Which non-leprosy drug is commonly used in the management of leprosy?
a) Antibiotics
b) Steroids
c) Antifungals
d) Antivirals
Answer: b) Steroids
Explanation: Steroids are used in the management of leprosy to control inflammation and reduce immune reactions in some cases.

 

Leprosy Read More »

Tuberculosis

Tuberculosis

Tuberculosis

Tuberculosis, commonly known as TB (short for tubercle bacillus), is a widespread and often deadly infectious disease caused by various strains of mycobacteria.

While primarily affecting the lungs, it can also impact other parts of the body. Around one-third of the world\’s population (1 in 3 or 3 out of 10 people) is affected by this condition. Individuals with HIV/AIDS have a higher risk of contracting tuberculosis.

Aetiology:

The disease is caused by mycobacterium tuberculosis, which is a small, aerobic, non-motile bacillus.

Mode of Spread

TB spreads through the air when individuals with an active infection cough, sneeze, or transmit respiratory fluids. Additionally, it can spread through the blood (haematogenous spread).

\"Types

Types of Tuberculosis

  • Pulmonary tuberculosis.
  • Extra-pulmonary tuberculosis.
  • Primary and Secondary tuberculosis.

Clinical Features:

Pulmonary TB:

  • Fever and chills
  • Night sweats
  • Loss of appetite
  • Weight loss
  • Easy fatigability
  • Persistent cough lasting more than 3 weeks, with or without haemoptysis (coughing up blood)
  • Significant finger clubbing (abnormal swelling of the fingertips)
  • Chest pain
  • Productive cough or non-productive cough in smear-negative TB
  • Lymphadenopathy (swollen lymph nodes)

Extrapulmonary TB:

In approximately 15-20% of active TB cases, the infection spreads beyond the lungs, resulting in various forms of extrapulmonary tuberculosis. This type is more common in individuals with weakened immune systems and young children. In people with HIV, extrapulmonary TB occurs in more than 50% of cases.

Notable sites of extrapulmonary infection include:

  • The pleura, leading to tuberculous pleurisy.
  • The central nervous system, causing tuberculous meningitis.
  • The lymphatic system, resulting in TB lymph nodes.
  • The genitourinary system, causing urogenital tuberculosis.
  • The bones and joints, leading to Pott\’s disease of the spine. When it affects the bones, it is known as \”osseous tuberculosis,\” a form of osteomyelitis.
  • Sometimes, a tubercular abscess may burst through the skin, resulting in a tuberculous ulcer. Ulcers originating from infected lymph nodes nearby are typically painless.
  • A potentially severe and widespread form of TB is \”disseminated\” TB, commonly known as miliary tuberculosis. Miliary TB accounts for about 10% of extrapulmonary cases.

Risk factors

Several factors increase the susceptibility of individuals to TB infections:

  • HIV infection is a significant global risk factor, contributing to 13% of all TB cases.
  • Tuberculosis is closely associated with overcrowding and malnutrition, making it a prevalent disease in impoverished communities.
  • Inhabitants and employees of places where vulnerable individuals gather, such as prisons and homeless shelters, face higher risks.
  • Medically underserved and resource-poor communities, as well as high-risk ethnic minorities, are more susceptible.
  • Children in close contact with high-risk patients are at increased risk.
  • Health care providers serving TB patients are also at higher risk.
  • Chronic lung disease is another significant risk factor.
  • Smokers have nearly double the risk of TB compared to nonsmokers.
  • Other conditions like alcoholism and diabetes mellitus can also elevate the risk of developing tuberculosis.

Epidemiology:

  • Approximately one-third of the world\’s population is infected with tuberculosis.
  • TB causes 25% of preventable adult deaths, and three-fourths of these affected individuals are in their productive age.
  • South Eastern Asia has the highest number of TB cases.
  • Africa has the world\’s highest incidence rate, with an annual incidence rate of 345 cases per 100,000 people.
  • The infection rate is higher in men than in women.
Primary Tuberculosis:
  • It occurs in individuals who have never been exposed to tubercle bacilli before.
  • Tubercle bacilli are inhaled and reach the lungs, where they multiply and can spread to the hilar lymph nodes through the lymphatic system and blood.
  • Approximately six weeks after the primary infection, the body\’s immune response kicks in, preventing further multiplication of the tubercle bacilli.
  • Some bacilli may die, and the remaining ones are walled off by immune cells called epithelioid cells, forming a ghon focus. This ghon focus can persist for years in primary tuberculosis.
  • The ghon focus and hilar lymphadenopathy together form a primary complex in primary tuberculosis.
  • Only about 10% of those with primary infection progress to develop tuberculosis disease.
\"ghon
Secondary Tuberculosis:
  • This type of tuberculosis can result from either the reactivation of tubercle bacilli acquired during primary infection or reinfection by tubercle bacilli in a person previously exposed to the organisms.

Pathogenesis:

  • TB infection starts when mycobacteria reach the pulmonary alveoli and invade and replicate there.
  • In addition to the lungs, tuberculosis can spread through the bloodstream, leading to infection in distant sites like peripheral lymph nodes, kidneys, brain, and bones.
  • The infection triggers an inflammatory response, resulting in the formation of granulomas. Granulomas are collections of activated macrophages, T lymphocytes, B lymphocytes, and fibroblasts.
  • The tubercle bacilli are surrounded by lymphocytes, forming a peripheral rim and creating a Ghon focus. (see image below)
  • Inside the granulomas, the bacteria can become dormant, causing latent infection. Caseation, a type of abnormal cell death, occurs in the center of the tubercles.
  • In severe cases, where TB bacteria enter the bloodstream from damaged tissue, multiple foci of infection can develop throughout the body, appearing as tiny white tubercles in the tissues. This condition is known as miliary tuberculosis and is more common in young children and individuals with HIV.
  • Tissue destruction and necrosis are balanced by healing and fibrosis. Scarring and cavities filled with caseous necrotic material replace affected tissue.

Diagnosis (Investigations):

When tuberculosis is suspected, the following investigations can aid in confirming the diagnosis:

  1. Signs of lung disease or constitutional symptoms lasting longer than two weeks.
  2. Chest X-ray: Imaging the chest can reveal characteristic abnormalities, such as infiltrates, cavities, or nodules, which can indicate tuberculosis.
  3. Multiple sputum cultures for acid-fast bacilli (AFB): Sputum samples are collected at different times, typically spot samples and early morning samples, to increase the chances of detecting the tuberculosis bacteria.
  4. Tuberculin skin tests: Also known as the Mantoux or Heaf test, it is commonly used to assess TB infection in children and identify individuals at risk of developing tuberculosis.
  5. Haematological tests:
    • Full blood cell count (FBC): This test helps evaluate any abnormalities in blood cell counts that may be indicative of an infection or inflammation.
    • Erythrocyte Sedimentation Rate (ESR): An elevated ESR can raise suspicion of tuberculosis, as it indicates inflammation in the body.
  6. Tissue biopsy: In cases where tuberculosis affects extrapulmonary sites or when other tests are inconclusive, a biopsy of the affected tissue may be performed to examine the presence of tubercle bacilli.

Relationship between HIV and TB:

Effects of HIV on TB:
  1. Development of active TB: Individuals infected with HIV have a higher risk of developing active tuberculosis once exposed to the TB bacteria.
  2. High risk of re-infection: HIV-positive individuals are more susceptible to being infected with a second strain of TB after already having the infection.
  3. Increased incidence of TB: The overall incidence of tuberculosis increases due to the higher prevalence of HIV, which weakens the immune system and makes individuals more susceptible to TB.
  4. Changes in TB presentation: TB in HIV-positive individuals may present with clinical and bacteriological changes, such as a non-productive cough, absence of hemoptysis (coughing up blood), and a miliary pattern on imaging instead of cavitations.
  5. Quicker development of TB complications: HIV accelerates the progression of TB and its associated complications.
Effects of TB on HIV:
  1. Increased HIV replication: TB infection can enhance the replication of HIV, leading to a higher viral load and faster progression to AIDS.
  2. Common opportunistic infection: TB is one of the most common opportunistic infections in individuals living with HIV and is a leading cause of death in this population.
  3. Interference with ARV treatment: Some anti-TB medications, such as Rifampicin, can interfere with certain antiretroviral drugs (ARVs), like Nevirapine and protease inhibitors, necessitating adjustments in treatment.

Consequences of dual infection with HIV and TB:

  • Increased morbidity and mortality.
  • Higher recurrence rate of TB after completing treatment.
  • Drug resistance leading to multidrug-resistant TB (MDR-TB) and extensively drug-resistant TB (XDR-TB).
  • Higher rates of treatment non-adherence due to overlapping medication regimens.
  • Increased risk of drug toxicity from the combined treatment.

Management of HIV and TB co-infection:

  • Prioritize TB treatment before starting ARVs.
  • Start ARVs if CD4 count is below 350 cells/mm³, either after finishing TB treatment or during the intensive phase, depending on the clinical situation.
  • Consider drug interactions between TB and HIV regimens when selecting medications.
  • Use directly observed therapy (DOTs) for TB treatment and closely monitor patients for toxicity and adherence.
  • Administer prophylaxis for opportunistic infections as indicated.

Complications of TB:

  • Pleural effusion: Accumulation of fluid in the pleural space of the lungs.
  • Pericardial effusion: Accumulation of fluid around the heart.
  • Empyema: Pus-filled cavity in the pleural space.
  • Pneumothorax: Presence of air or gas in the pleural cavity, causing lung collapse.
  • Lung fibrosis: Scarring of lung tissue, leading to impaired lung function.
  • Lung collapse: Collapse of a lung or part of a lung due to blockage or compression.
  • Extra-pulmonary TB: TB affecting organs other than the lungs, such as TB meningitis.

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Treatment of TB:

Aims of TB Treatment:

  • To cure the patient of tuberculosis.
  • To prevent complications and death from TB.
  • To reduce the transmission of TB to others.

Case Definitions:

  1. New Case: A person who has never received TB treatment or has taken TB treatment for four weeks or less.
  2. Relapse: A patient who was previously diagnosed with TB, completed the course of anti-TB drugs, was declared cured, but has now become smear positive again.
  3. Failure: A person who continues to be smear positive at five months, despite adequately taking anti-TB drugs, or who was smear negative and becomes smear positive at two months.
  4. Defaulter: A patient who starts taking anti-TB drugs for more than four weeks but interrupts treatment (stops taking the drugs) for four weeks or more.
Drugs Used in TB Treatment:
  1. Rifampicin (R)
  2. Isoniazid (H or INH)
  3. Ethambutol (E)
  4. Pyrazinamide (Z)
  5. Streptomycin (S)
Standard TB Treatment Regimen: 

The World Health Organization (WHO) recommends a standard six-month treatment regimen for drug-sensitive TB cases, which typically includes the following four drugs for the first two months:

  1. Rifampicin (R)
  2. Isoniazid (H)
  3. Pyrazinamide (Z)
  4. Ethambutol (E)

This initial phase is followed by a continuation phase for the next four months, during which the drugs used may vary depending on the patient\’s response to treatment and drug sensitivity testing.

It\’s important to note that TB treatment should be administered under direct observation (DOTs) whenever possible to ensure proper adherence and to prevent the development of drug-resistant TB strains. Check DOT below in details.

Treatment regimen 

 Short course TB treatment regimen

Patient category (type of TB) 

Initial phase 

Continuation phase

1. New smear positive 

2. New smear negative 

3. Severe extra-pulmonary

2EHRZ 

6EH

4. Previously treated smear  POSITIVE: 

– Relapse 

– Failure to respond 

– Return after interruption

2SEHRZ/1EHRZ 

5EHR

5. Any form of TB in children

6. Adult non-severe extra pulmonary

2HRZ 

4HR
Non-anti-TB Drugs Used in TB:

  1. Pyridoxine (Vitamin B₆): Administered to prevent or treat peripheral neuropathy, a side effect of Isoniazid (H) used in TB treatment. Pyridoxine supplementation helps prevent nerve damage caused by Isoniazid.

  2. Steroids: Used as adjunct therapy in specific forms of TB to reduce inflammation and improve outcomes. Steroids are commonly used in the treatment of:

    • TB Meningitis
    • TB Pericarditis
    • TB of Adrenals
DOTS (Directly Observed Therapy Short course):

How it works:

  • DOTS is a community-based TB care approach adopted by countries to improve TB treatment outcomes.
  • Trained workers or treatment supporters ensure that patients take their daily treatment doses and record the administration on the TB card.
  • DOTS is the standard of care for all TB cases and suspects.
  • It helps decrease relapse, defaulter rates, and the development of acquired drug resistance.
  • When combined with other measures, DOTS promotes treatment adherence.
  • After diagnosing TB and initiating treatment, the diagnostic center records the information in the health unit\’s TB register.
  • The sub-county health worker transfers this information to the sub-county health worker register and identifies a treatment supporter in the patient\’s village.
  • The treatment supporter is trained to observe the patient taking their treatment, record it on the TB card, keep the drugs, and remind the patient of follow-up assessments at the health unit at 2 months, 5 months, and 8 months.
  • The sub-county health worker collects medication from the health unit and delivers it to the treatment supporter.

Prevention of TB:

  • Early detection and proper management of TB cases.
  • Early case findings to identify and treat TB cases promptly.
  • Health education to raise awareness about TB transmission and prevention.
  • Training of all health workers to recognize early signs of TB.
  • Vaccination of children with the Bacille Calmette-Guérin (BCG) vaccine to protect against severe forms of TB in childhood.
  • Prophylaxis with Isoniazid for individuals at high risk of developing TB, such as those with latent TB infection or individuals with HIV.
  • Prevention and management of medical conditions like HIV, which increase the risk of TB.
  • Implementation of the DOTS program to improve treatment adherence and outcomes.

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Test Questions

Question: Which bacterium is responsible for causing tuberculosis?

a) Streptococcus pneumoniae
b) Mycobacterium tuberculosis
c) Escherichia coli
d) Staphylococcus aureus

Answer: b) Mycobacterium tuberculosis
Explanation: Mycobacterium tuberculosis is the specific bacterium that causes tuberculosis.

Question: What is the most common site of TB infection in the human body?
a) Liver
b) Lungs
c) Heart
d) Kidneys

Answer: b) Lungs
Explanation: Pulmonary tuberculosis is the most common form of TB, affecting the lungs.

Question: In HIV-positive individuals, the risk of developing active tuberculosis:
a) Decreases
b) Stays the same
c) Increases
d) Remains unaffected

Answer: c) Increases
Explanation: HIV weakens the immune system, making individuals more susceptible to developing active tuberculosis once infected with Mycobacterium tuberculosis.

Question: Which of the following is NOT a clinical feature of pulmonary tuberculosis?
a) Fever and chills
b) Night sweats
c) Loss of appetite
d) Severe abdominal pain

Answer: d) Severe abdominal pain
Explanation: Severe abdominal pain is not a typical clinical feature of pulmonary tuberculosis.

Question: What is the standard duration of treatment for drug-sensitive tuberculosis?
a) 3 months
b) 6 months
c) 9 months
d) 12 months

Answer: b) 6 months
Explanation: The standard treatment regimen for drug-sensitive TB lasts for 6 months.

Question: In which form of TB, patients may present with a non-productive cough and a miliary pattern on imaging?
a) Drug-resistant TB
b) Extrapulmonary TB
c) Latent TB
d) Multidrug-resistant TB

Answer: b) Extrapulmonary TB
Explanation: Extrapulmonary TB can present with atypical symptoms like a non-productive cough and a miliary pattern on imaging.

Question: What is the main purpose of the DOTS program in TB management?
a) To prevent TB transmission
b) To promote TB vaccination
c) To monitor drug resistance
d) To improve treatment adherence

Answer: d) To improve treatment adherence
Explanation: The main aim of the DOTS program is to ensure that patients adhere to their TB treatment, which leads to better outcomes and reduced relapse rates.

Question: Which non-anti-TB drug is used to prevent or treat peripheral neuropathy, a side effect of Isoniazid?
a) Vitamin C
b) Vitamin D
c) Pyridoxine (Vitamin B₆)
d) Folic acid

Answer: c) Pyridoxine (Vitamin B₆)
Explanation: Pyridoxine is used to prevent or treat peripheral neuropathy caused by Isoniazid.

Question: TB Meningitis is best managed with the addition of which adjunct therapy?
a) Antibiotics
b) Antifungals
c) Antivirals
d) Steroids

Answer: d) Steroids
Explanation: TB Meningitis is often treated with the addition of steroids to reduce inflammation and improve outcomes.

Question: What is the primary aim of TB prevention?
a) Eradicate Mycobacterium tuberculosis from the environment
b) Reduce the incidence of drug-resistant TB
c) Prevent the transmission of TB from person to person
d) Increase vaccination coverage in high-risk populations

Answer: c) Prevent the transmission of TB from person to person
Explanation: The primary aim of TB prevention is to break the chain of transmission by preventing the spread of Mycobacterium tuberculosis from infected individuals to others.

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Measles

Measles

Measles

Measles, also known as Morbilli, is a highly contagious acute infection of the respiratory system caused by the morbillivirus. 

It is characterized by a widespread skin rash, fever, and inflammation of the mucous membranes.

The transmission of measles occurs through respiration, mainly by coming into contact with fluids from the nose and mouth of an infected person. Due to its high contagion, it can easily spread among individuals.

The incubation period for measles typically lasts from 9 to 12 days.

 Risk Factors

Several risk factors increase the likelihood of contracting measles, including:

  1. Immunodeficiency in children.
  2. Traveling to regions where measles is common or having contact with individuals who have visited these areas.
  3. Malnutrition, which can weaken the immune system.
  4. Pregnancy, as it may increase susceptibility to the virus.
  5. Vitamin A deficiency, which can compromise the body\’s ability to fight infections.

\"Signs

Signs and symptoms of measles/Stages

Measles, an acute and highly communicable infection caused by the morbillivirus, presents a clinical picture that can be divided into three distinct stages: prodromal, eruptive, and convalescent. Suspecting measles becomes crucial when patients exhibit the classic triad of the three \”Cs\”: cough, conjunctivitis, and coryza.

Stage 1: Prodromal Stage

  • The incubation period lasts approximately 10-14 days.
  • Patients may not show any signs or symptoms during this stage.
  • Abrupt onset of mild to moderate symptoms, characterized by:
    • Fever
    • Headache
    • General malaise
    • Loss of appetite (anorexia)
    • Enlarged neck lymph nodes
    • Abdominal pain
    • Diarrhea
    • Vomiting

Stage 2: Eruptive Stage

  • Abrupt onset with severe symptoms, including:
    • Very high fever
    • Cough
    • Photophobia (sensitivity to light)
    • Red eyes and conjunctivitis
    • Hoarseness of the voice
    • Distinctive Koplik spots on the mucous membrane of the mouth, next to the molar teeth. These spots may disappear once the rash appears.
  • Temperature rises on the first day (37.8-39.4 degrees Celsius), may slightly fall on the third day, then rise again on the fourth day with the onset of the rash.
  • The rash appears around the fourth day and starts on the forehead, behind the ears, neck, and then spreads over the face and entire body. The rash is a red maculo-papular eruption, giving the face a bloated, swollen appearance.

Stage 3: Convalescent Stage

  • Improvement and disappearance of signs and symptoms begin.
  • Key features include:
    • Desquamation of the skin (shedding of the rash)
    • A decline in body temperature
    • Resolution of hoarseness of the voice
    • Weight gain as the patient\’s condition improves.

Nursing Care/Management for a Patient within 72 Hours of Measles:

Aims of Care/Management:

  1. To reduce body temperature.
  2. To correct dehydration.
  3. To prevent further complications.

Admission:

  1. Admit the child to a well-ventilated room in an isolation unit in the children\’s ward.
  2. Record the patient\’s particulars, including name, age, next of kin, and full address on the admission forms.
  3. Reassure the mother/caregiver about the child\’s condition.

Observations:

  1. Monitor vital signs (Temperature, pulse, respiration, blood pressure, and weight) and record them in an observation chart for baseline monitoring.
  2. Conduct a comprehensive head-to-toe assessment to identify any abnormalities such as jaundice, edema, dehydration, cyanosis, anemia, and lymphadenopathy. Document findings in the patient file.
  3. Inform the doctor about the patient\’s condition and prepare for any required investigations and medical treatments.
  4. Carry out procedures, such as tepid sponging, based on the patient\’s findings (e.g., in case of high fever).
Investigations:
  1. Conduct necessary investigations to rule out other diseases, such as:
    • Blood slide for malaria parasites
    • Full blood count (FBC) to rule out other infections
    • Urinalysis
    • Salivary measles-specific IgA testing (rarely done).
Medical Treatments:
  1. There is no specific treatment for measles; it is managed symptomatically.
  2. Prescribe the following drugs based on symptoms:
    • Antibiotics to treat underlying infections (e.g., Cephalexin or Amoxyl syrup).
    • Intravenous Ceftriaxone for severe cases.
    • Analgesics to reduce pain and fever (e.g., Syrup Cetamol).
    • Antihistamines to reduce itching (e.g., Calamine lotion).
    • Vitamins A capsules for children below 1 year to prevent eye complications.
    • Grovit drops or syrup multivitamin to improve appetite.

Fluids and Diet:

  1. Provide plenty of oral fluids to replace lost fluids due to vomiting and diarrhea.
  2. Offer easily digestible foods rich in vitamins and proteins for quick recovery.
  3. Encourage the child to take frequent small meals.
  4. Use a nasogastric tube for feeding if the child cannot eat or drink.
  5. Administer intravenous fluids in cases of severe dehydration.

Skin Care:

  1. Pad the fingers to prevent excessive scratching of the skin.
  2. Apply prescribed calamine lotion to relieve itching.

Mouth and Eye Care:

  1. Emphasize oral hygiene with frequent mouth care using warm saline.
  2. Keep the nostrils clean and maintain cleanliness around the nasogastric tube.
  3. Apply gentian violet 1% for mouth ulcers.
  4. Use glycerin borax to lubricate the lips and prevent cracking.
  5. Clean the eyes with warm saline and avoid rubbing them.
  6. Apply TEO ointment if necessary.
  7. If one eye is affected, encourage the child to lie on the affected side to prevent infecting the other eye.
  8. Avoid direct sunlight on the eyes.

Hygiene and Bed Rest:

  1. Give the patient a daily bath and change bedding frequently.
  2. Use appropriate precautions for discharging ears and administer antibiotics as needed.
  3. Disinfect used soiled linen and utensils.
  4. Properly dispose of used swabs, discharges, or secretions.

Visitor and Ward Management:

  1. Restrict visitors and maintain visiting hours.
  2. Keep radio and TV volumes low to allow for patient rest.
  3. Encourage dim lighting due to photophobia.
  4. Encourage adequate sleep by switching off lights and minimizing noise.

Observations:

  1. Continue monitoring the patient\’s general condition and vital signs regularly.
  2. Take note of any deviations from the normal and act accordingly.
  3. Perform tepid sponging, give cold drinks, and apply cold compress on the forehead if the temperature is very high.

Bowel and Bladder Care:

  1. Observe and treat diarrhea or constipation as needed.
  2. Monitor and address any issues with the child\’s urine output.

Exercises and Health Education:

  1. Encourage the patient to do active and passive exercises, including deep breathing exercises.
  2. Stimulate the child\’s mind with play objects like toys.
  3. Educate the mother/caregiver about the mode of spread, signs, symptoms, and prevention of measles.

Complications of Measles:

  • Pneumonia
  • Acute Laryngo-Tracheo-Bronchitis (LTB)
  • Otitis media leading to deafness
  • Conjunctivitis
  • Encephalitis
  • Acute gastroenteritis
  • Malnutrition (PEM) – Kwashiorkor and marasmus
  • Subacute sclerosing panencephalitis.

Test Questions

MCQ: Which virus causes measles?
a) Influenza virus
b) Morbillivirus
c) Respiratory syncytial virus
d) Rotavirus
Answer: b) Morbillivirus
Explanation: Measles is caused by the morbillivirus, a member of the Paramyxoviridae family.

MCQ: During which stage of measles does the characteristic red maculo-papular rash appear?
a) Incubation stage
b) Prodromal stage
c) Catarrhal stage
d) Convalescence stage
Answer: c) Catarrhal stage
Explanation: The characteristic red maculo-papular rash appears during the catarrhal or eruptive stage of measles.

MCQ: What is the primary aim of nursing care in managing measles?
a) To reduce the risk of bacterial infection
b) To relieve itching and rash discomfort
c) To prevent complications and dehydration
d) To administer specific antiviral medication
Answer: c) To prevent complications and dehydration
Explanation: The primary aim of nursing care in managing measles is to prevent complications and dehydration, as there is no specific antiviral medication for measles.

MCQ: Which symptom is part of the classic triad used for suspecting measles?
a) Fever
b) Cough
c) Diarrhea
d) Jaundice
Answer: b) Cough
Explanation: The classic triad for suspecting measles includes cough, conjunctivitis, and coryza (common cold).

MCQ: What is the incubation period for measles?
a) 2-5 days
b) 7-10 days
c) 10-14 days
d) 21-28 days
Answer: c) 10-14 days
Explanation: The incubation period for measles typically lasts from 10 to 14 days.

MCQ: Which vitamin is administered to prevent eye complications related to measles in children below one year?
a) Vitamin B
b) Vitamin C
c) Vitamin D
d) Vitamin A
Answer: d) Vitamin A
Explanation: Vitamin A capsules are administered to children below one year to prevent eye complications associated with measles.

MCQ: Which stage of measles is characterized by an abrupt onset of severe symptoms, including very high fever and photophobia?
a) Incubation stage
b) Prodromal stage
c) Catarrhal stage
d) Convalescence stage
Answer: c) Catarrhal stage
Explanation: The catarrhal or eruptive stage of measles is characterized by an abrupt onset of severe symptoms, including very high fever and photophobia.

MCQ: What is the primary mode of measles transmission?
a) Contact with contaminated food
b) Direct skin-to-skin contact with an infected person
c) Airborne droplets from an infected person\’s respiratory secretions
d) Ingestion of contaminated water
Answer: c) Airborne droplets from an infected person\’s respiratory secretions
Explanation: Measles is primarily transmitted through airborne droplets when an infected person coughs or sneezes.

MCQ: Which of the following is NOT a risk factor for measles?
a) Immunodeficiency in children
b) Travel to areas where measles is endemic
c) Malnutrition
d) Taking vitamin supplements
Answer: d) Taking vitamin supplements
Explanation: Immunodeficiency, travel to endemic areas, and malnutrition are risk factors for measles, but taking vitamin supplements is not directly associated with measles risk.

MCQ: Which stage of measles marks the beginning of improvement, characterized by skin desquamation and a decline in body temperature?
a) Incubation stage
b) Prodromal stage
c) Catarrhal stage
d) Convalescence stage
Answer: d) Convalescence stage
Explanation: The convalescence or recovery stage of measles marks the beginning of improvement, characterized by skin desquamation, a decline in body temperature, and the resolution of symptoms.

Measles Read More »

Malaria

Malaria

Malaria

Malaria is an infectious disease caused by a parasite belonging to the Plasmodium genus. It is primarily transmitted from one person to another through female mosquitoes of the Anopheles genus. The illness presents with acute febrile symptoms, including cycles of chills, fever, pain, and sweating.

Historical records indicate that malaria has been afflicting humans since ancient times. There are four main species of malaria parasites that affect humans, namely:

  1. Plasmodium falciparum
  2. Plasmodium vivax
  3. Plasmodium malariae
  4. Plasmodium ovale
  5. Plasmodium knowlesi

Among these, Plasmodium falciparum stands out as the most virulent malaria parasite worldwide and also happens to be the most prevalent one in Uganda.

Signs and Symptoms of Malaria

Malaria manifests through a variety of signs and symptoms, with fever being the most prominent and characteristic feature. The fever in malaria follows an intermittent pattern, coming and going repeatedly. A typical malaria attack can be categorized into three phases:

  1. The Cold Stage: During this stage, the patient experiences a sensation of coldness and shivers.

  2. The Hot Stage: In this stage, the patient feels intense heat and feverish.

  3. The Sweating Stage: This stage is accompanied by profuse sweating and a sense of relief from symptoms.

Apart from fever, other common symptoms of malaria include:

  • Loss of appetite
  • Weakness and lethargy
  • Nausea and vomiting
  • Headache
  • Joint and muscle pains
  • Diarrhea
  • Dehydration
  • Enlarged spleen (spleenomegaly)

In severe and complicated cases of malaria, the following symptoms may arise:

  • Changes in behavior, confusion, or drowsiness
  • Altered level of consciousness or coma
  • Convulsions
  • Hypoglycemia (low blood sugar levels)
  • Acidosis (excess acid in the body)
  • Difficulty in breathing, often due to pulmonary edema or respiratory distress syndrome
  • Acute renal failure
  • Severe anemia
  • Shock
  • Presence of hemoglobin in urine (haemoglobinuria)
  • Oliguria with very dark urine (similar to the color of coca-cola or coffee)
  • Jaundice (yellowing of the skin and eyes)
  • Bleeding tendency
  • Prostration (extreme weakness)
  • High levels of malaria parasites in the blood (hyperparasitaemia)
  • Extremely high body temperature (hyperpyrexia)
  • Severe vomiting

Transmission of Malaria

Malaria is transmitted to humans through the bite of an infected female Anopheles mosquito, which injects malaria parasites (sporozoites) into the bloodstream. The life cycle of the malaria parasite (Plasmodium) is complex and involves two hosts: humans and Anopheles mosquitoes.

\"Illustration

Illustration of the Malaria Parasite Life Cycle:

  1. Infection begins when an infected female Anopheles mosquito bites a person, introducing Plasmodium sporozoites into the bloodstream.
  2. The sporozoites swiftly move into the human liver.
  3. Over the next 7 to 10 days, the sporozoites multiply asexually in liver cells, causing no noticeable symptoms.
  4. The parasites, now in the form of merozoites, are released from liver cells and travel through the heart to the lungs, where they settle within lung capillaries. The vesicles eventually disintegrate, releasing merozoites into the blood phase of their development.
  5. In the bloodstream, the merozoites invade red blood cells (erythrocytes) and undergo further multiplication until the cells burst. They then invade more erythrocytes, repeating this cycle and causing fever each time they break free and infect new blood cells.
  6. Some of the infected blood cells deviate from the asexual multiplication cycle and instead develop into sexual forms of the parasite known as gametocytes, which circulate in the bloodstream.
  7. When an infected mosquito bites a human, it ingests these gametocytes, which further mature into sexually active gametes within the mosquito.
  8. The fertilized female gametes transform into mobile ookinetes that penetrate the mosquito\’s midgut wall, forming oocysts on its exterior surface.
  9. Inside the oocyst, numerous active sporozoites develop. Eventually, the oocyst bursts, releasing sporozoites into the mosquito\’s body cavity, which then migrate to its salivary glands.
  10. The cycle of human infection begins anew when the mosquito bites another person.
Incubation Period:

The period between the mosquito bite and the onset of malarial illness typically ranges from one to three weeks (7 to 21 days). 

However, certain types of malaria, such as P. vivax and P. ovale, may take much longer, up to eight to 10 months, to cause symptoms. These parasites remain dormant (inactive or hibernating) in the liver cells during this extended period. 

Unfortunately, some dormant parasites may persist even after a patient recovers from malaria, leading to the possibility of relapsing malaria, wherein the patient may fall ill again.

Diagnosis of Malaria

Diagnosing malaria involves considering the patient\’s clinical signs and symptoms, which can be challenging due to the similarity of malaria symptoms with other diseases, including yellow fever, typhoid fever, respiratory tract infections, meningitis, otitis media, tonsillitis, skin sepsis, and measles.

The following investigations are crucial in accurately confirming a malaria diagnosis:

  1. Blood Smear Examination (Malaria Parasite Smear – MPS): The classic and widely used diagnostic test for malaria involves examining a blood smear under a microscope. A small amount of the patient\’s blood is placed on a microscope slide, stained, and then observed for the presence of malaria parasites inside red blood cells. This test helps identify the Plasmodium species.

  2. Rapid Diagnostic Tests (RDTs): Rapid diagnostic tests detect specific malaria antigens or proteins in the patient\’s blood. RDTs are especially useful in areas with limited access to microscopy facilities and can provide rapid results for immediate management.

  3. Complete Blood Count (CBC): A CBC is essential for evaluating the overall health of the patient and can reveal valuable information about the levels of different blood components, including red blood cells and white blood cells. In malaria, a decrease in red blood cells (anemia) is often observed.

  4. Hemoglobin Estimation: Hemoglobin estimation provides information about the patient\’s hemoglobin levels, which can be significantly affected in malaria due to the destruction of red blood cells.

  5. Liver Function Tests (LFTs): In certain cases, liver function tests may be conducted to assess liver health, as the malaria parasites initially multiply in the liver.

  6. Blood Chemistry Panel: A blood chemistry panel may be performed to evaluate various parameters, including electrolyte levels, kidney function, and liver enzymes, providing a comprehensive picture of the patient\’s overall health status.

  7. Polymerase Chain Reaction (PCR): PCR is a highly sensitive molecular technique that can detect the genetic material of malaria parasites in the blood. It is particularly useful for detecting low levels of parasites and differentiating between various Plasmodium species.

  8. Serological Tests: Serological tests detect specific antibodies produced by the body in response to malaria infection. These tests may not be suitable for early diagnosis but can be valuable for determining past exposure to malaria.

Treatment of Malaria

  1. Treatment of Uncomplicated Malaria:
  • The recommended first-line medication for uncomplicated malaria is Artemether/Lumefantrine (Coartem).
  • In case Artemether/Lumefantrine is unavailable, the first-line alternative treatment is Atesunate + Amodiaquine.
  • The recommended second-line medication is Dihydroartemisinin + Piperaquine (Duocotecxin).
  1. Treatment of Severe and Complicated Malaria:
  • Parenteral Artesunate is the recommended treatment for managing severe malaria in all patients.
  • In the absence of Artesunate, Parenteral Quinine or Artemether can be used as alternatives.
  1. Treatment of Malaria in Pregnancy:
  • Uncomplicated malaria:
    • First trimester: Quinine tablets.
    • Second and third trimesters: Artemether/Lumefantrine or Quinine tablets.
  • Severe malaria in pregnancy should be treated with intravenous Artesunate.
Additional Treatment Measures:
  1. Antipyretic to Reduce Body Temperature:
  • Paracetamol: 10mg/kg body weight every six hours in children, 1g 6-8 hourly in adults.
  • Tepid sponging or fanning can also be used to reduce fever.
  1. Anticonvulsants:
  • Diazepam: 0.2mg/kg body weight intravenously or intramuscularly in adults.
  1. Treat Detectable Causes of Convulsions:
  • For example, hypoglycemia can be managed with Dextrose administration.
  1. Nursing Care:
  • Provide supportive care and symptomatic treatment, such as tepid sponging for fever.
  • Regularly observe temperature, pulse, respiration rate, and blood pressure. Record all observations.
  • Educate patients on personal protection, malaria prevention, and the importance of adhering to treatment.
  • Administer antiemetic medicine 30 minutes to 1 hour before antimalarial drugs if vomiting occurs.
  • Advise patients to rest for 1-2 hours after taking the medicine to avoid dizziness, vomiting, and hypotension.
  • Offer psychological support and comfort to patients.
  • Encourage a nourishing diet with plenty of oral fluids. In cases of difficulty in eating or drinking, consider passing a naso-gastric tube.
  • Monitor fluid intake and output and maintain a fluid balance chart.
  • Ensure proper patient and environmental hygiene.

Complications of Malaria:

  • Impaired consciousness/coma
  • Severe anemia
  • Renal failure
  • Pulmonary edema
  • Acute respiratory distress syndrome
  • Shock
  • Spontaneous bleeding
  • Acidosis
  • Hemoglobinuria (hemoglobin in urine)
  • Jaundice
  • Repeated generalized convulsions.

\"Prevention

Prevention and Control of Malaria

  1. Implement Effective Treatment and Prophylaxis:
  • Early diagnosis and prompt treatment are essential to eliminate parasites from the human population. Timely treatment helps prevent the spread of malaria.
  • Vulnerable groups, such as pregnant women, should receive chemoprophylaxis (preventive medication). The following drugs are used for this purpose: Chloroquine, Doxycycline, Mefloquine, and Primaquine.
  • All pregnant women should be provided with Intermittent Preventive Treatment (IPT) to protect both the mother and the unborn child from malaria.
  1. Reduce Human-Mosquito Contact:
  • Encourage the use of insecticide-treated nets (ITNs) while sleeping to create a physical barrier between individuals and malaria-carrying mosquitoes.
  • Implement indoor residual spraying of dwellings with insecticides or use knockdown sprays to control adult mosquitoes within households.
  • Advise individuals to wear clothing that covers the arms and legs, and to use mosquito repellent coils and creams when sitting outdoors at night to prevent mosquito bites.
  1. Control Breeding Sites:
  • Eliminate stagnant water collection sites where mosquitoes breed, such as empty cans/containers, potholes, old car tires, and plastic bags. This can be achieved through proper disposal, draining, or covering with soil.
  • Use insecticides to treat stagnant water bodies to destroy mosquito larvae, or employ biological methods such as introducing larvae-eating fish to these water sources.
  1. Provide Public Health Education:
  • Conduct public health education campaigns to raise awareness about malaria prevention measures, including the use of mosquito nets, personal protection measures, and the importance of seeking early diagnosis and treatment.
  • Educate communities about the significance of eliminating breeding sites and promoting good environmental hygiene to reduce mosquito populations.

Test Questions.

What is the primary mode of transmission of malaria to humans?
a) Contaminated food and water
b) Contact with infected animals
c) Bites from female Anopheles mosquitoes
d) Airborne droplets from infected individuals
Answer: c) Bites from female Anopheles mosquitoes
Explanation: Female Anopheles mosquitoes transmit malaria by injecting malaria parasites (sporozoites) into the bloodstream during their bite.
Which diagnostic test is considered the gold standard for confirming malaria infection?

a) Rapid Diagnostic Test (RDT)
b) Polymerase Chain Reaction (PCR)
c) Complete Blood Count (CBC)
d) Blood smear examination
Answer: d) Blood smear examination

Explanation: The blood smear examination under a microscope is the classic and most widely used diagnostic test for malaria. It allows visualization of malaria parasites inside red blood cells, helping to identify the Plasmodium species and guide appropriate treatment.

What is the recommended first-line treatment for uncomplicated malaria?
a) Artemether/Lumefantrine (Coartem)
b) Dihydroartemisinin + Piperaquine (Duocotecxin)
c) Quinine tablets
d) Doxycycline
Answer: a) Artemether/Lumefantrine (Coartem)

Explanation: Artemether/Lumefantrine is the recommended first-line medicine for treating uncomplicated malaria cases.

Which antimalarial drug is used as chemoprophylaxis to protect vulnerable groups from malaria?
a) Paracetamol
b) Chloroquine
c) Artemether
d) Diazepam
Answer: b) Chloroquine

Explanation: Chloroquine is one of the drugs used for chemoprophylaxis to protect vulnerable groups, such as pregnant women, from contracting malaria.

What intervention can help reduce human-mosquito contact and prevent malaria transmission?
a) Wearing clothes that cover the arms and legs
b) Spraying dwellings with insecticides
c) Drinking boiled water
d) Applying sunscreen
Answer: a) Wearing clothes that cover the arms and legs

Explanation: Wearing clothes that cover the arms and legs can help reduce mosquito bites and lower the risk of malaria transmission.

In severe malaria cases, what is the recommended first-line treatment for all patients?
a) Parenteral Quinine
b) Parenteral Artesunate
c) Intramuscular Artemether
d) Parenteral Mefloquine
Answer: b) Parenteral Artesunate

Explanation: Parenteral Artesunate is the recommended first-line treatment for severe malaria in all patients.

How long is the incubation period for malaria?
a) 1-3 days
b) 1-3 weeks
c) 1-3 months
d) 1-3 years
Answer: b) 1-3 weeks

Explanation: The incubation period for malaria is usually 1-3 weeks (7 to 21 days) after the mosquito bite.

Which complication of malaria is characterized by the presence of hemoglobin in urine?
a) Severe anemia
b) Jaundice
c) Acidosis
d) Hemoglobinuria
Answer: d) Hemoglobinuria

Explanation: Hemoglobinuria is the presence of hemoglobin in urine, which can occur as a complication of malaria.

What method is used to control mosquito breeding sites and prevent malaria transmission?
a) Introducing larvae-eating fish
b) Using insect repellent coils
c) Administering antimalarial drugs
d) Fumigating dwellings with pesticides
Answer: a) Introducing larvae-eating fish

Explanation: Introducing larvae-eating fish to stagnant water bodies is a biological method used to control mosquito larvae and prevent malaria transmission.

How can midwifery students contribute to malaria prevention in pregnant women?
a) Administering chemoprophylaxis during pregnancy
b) Providing insecticide-treated nets to pregnant women
c) Educating pregnant women about personal protection measures
d) All of the above
Answer: d) All of the above

Explanation: Midwifery students can play a vital role in malaria prevention for pregnant women by administering chemoprophylaxis, distributing insecticide-treated nets, and educating them about personal protection measures against malaria.

Malaria Read More »

Typhoid Fever (Enteric Fever)

Typhoid Fever (Enteric Fever)

Typhoid Fever (Enteric Fever)

Typhoid fever is an acute bacterial infection characterized by fever and is primarily spread through contaminated food and water.

Causes

Typhoid fever is caused by Salmonella typhi and Salmonella paratyphi A and B.

Transmission:

  • Typhoid fever is contracted by the ingestion of the bacteria in contaminated food or water.
  • Patients with acute illness can contaminate the surrounding water supply through stool, which contains a high concentration of the bacteria.
  • About 3-5% of patients become carriers of the bacteria after the acute illness. Some patients suffer a very mild illness that goes unrecognized, and these patients can become long-term carriers of the bacteria.
  • The bacteria multiply in the gallbladder, bile ducts, or liver and pass into the bowel.
  • The bacteria can survive for weeks in water or dried sewage.
  • The chronic carriers may have no symptoms and can be the source of new outbreaks of typhoid fever for many years.

\"Signs

Signs and Symptoms of Typhoid Fever

Classically, the course of untreated typhoid fever is divided into four stages, each lasting approximately one week.

First week:

  • In the first week, there is a gradual rise in temperature (step-ladder fashion) accompanied by bradycardia, malaise, headache, generalized body aching, restlessness, and cough.
  • Epistaxis (nosebleeds) is observed in about a quarter of cases.
  • Abdominal pain may also be present.
  • Leukopenia, eosinopenia, and relative lymphocytosis are evident in blood tests.
  • The classic Widal test, used to detect antibodies against Salmonella, is negative in the first week, but blood culture reveals the presence of Salmonella typhi.
  • The payer patches of the distal end of the ileum are invaded by the bacillus and become inflamed, resulting in various manifestations such as slow pulse rate, severe persistent frontal headache, general malaise, anorexia, nausea, vomiting, intestinal upset (diarrhea and constipation), and depression of bone marrow.

Second week:

  • The payer patches form a slough (a layer of dead skin).
  • In the second week of the infection, the patient becomes severely ill with high fever, often reaching around 40°C (104°F), and bradycardia.
  • Delirium is common, characterized by a state of calmness or, at times, agitation.
\"Rose
  • Rose spots, which are pink spots, appear on the lower chest and abdomen in about one-third of patients.
  • The abdomen becomes distended and painful, especially in the right lower quadrant.
  • Diarrhea may occur, with stool appearing green and having a characteristic smell resembling pea soup. However, constipation can also be frequent.
  • The spleen and liver enlarge (hepatosplenomegaly) and become tender.
  • The Widal reaction shows strong positivity with anti-O and anti-H antibodies, while blood cultures may still be positive at this stage.
  • The tongue is coated with a brownish fur, and sordes indicate severe toxemia.
  • Dehydration becomes evident.

Third week:

  • In the third week of typhoid fever, several complications may arise:
    • The slough separates, leaving deep ulcers in the intestines.
    • Ulcers may erode blood vessels, leading to hemorrhage, or perforate the ileum, causing leakage of intestinal contents into the peritoneal cavity.
    • The patient becomes extremely ill and toxic.
    • Temperature remains very high and intermittent.
    • Pulse becomes feeble.
    • The patient lapses into a typhoid state, experiencing delirium and confusion.
    • Twitching of limbs may occur due to loss of calcium in the diarrhea state.
    • Carforragic picking may lead to clotting issues and blood-stained clothes.
    • Tough dries and flurried lips are observed due to severe dehydration from profuse diarrhea.
    • Signs of congestive cardiac failure (CCF) due to weakened myocardium may be present.
    • The patient may experience coma every eight hours.
    • Peritonitis, inflammation of the peritoneum, may occur.
  • By the end of the third week, the patient becomes emaciated, fever starts to subside, abdominal symptoms become more pronounced, and mental disturbances become prominent.

Fourth week:

  • The ulcers begin to heal through granulation.
  • At the beginning of the fourth week, the fever begins to decline, and the other symptoms gradually reduce as the patient\’s temperature returns to normal.
  • Recovery is slow during this stage, and relapses are common.
  • If left untreated, typhoid fever can prove fatal in up to 25% of all cases.

Investigations for Typhoid Fever:

  1. Stool Culture: Stool culture involves collecting a sample of the patient\’s stool and incubating it under specific conditions to identify and isolate the causative bacteria, usually Salmonella typhi or Salmonella paratyphi. The presence of these bacteria in the stool confirms the diagnosis of typhoid fever. 

  2. Blood Culture:  Blood sample is collected and cultured in a suitable medium to identify and isolate the bacteria causing typhoid fever. A blood culture is an effective method to confirm the diagnosis, especially in the early stages of the disease when stool cultures might be negative.

  3. Widal Test: The Widal test is a serological test used to detect antibodies produced by the body in response to the infection by Salmonella typhi. The test measures the presence of specific antibodies, including anti-O and anti-H antibodies, in the patient\’s blood. A positive Widal test suggests a recent or past infection with typhoid fever. However, it is important to note that the Widal test results should be interpreted cautiously, as false-positive results can occur due to cross-reactivity with other infections or previous vaccinations.

Additional Investigations (optional):

  1. Polymerase Chain Reaction (PCR) Test: PCR is a molecular diagnostic test that can detect the genetic material (DNA or RNA) of the Salmonella bacteria directly from clinical samples, such as blood or stool. PCR is a highly sensitive and specific method, and it can provide rapid results, aiding in early detection and timely treatment of typhoid fever.

  2. Typhoid Serology: Typhoid serology involves analyzing the patient\’s blood for specific antibodies against Salmonella typhi. This test, similar to the Widal test, helps in confirming a recent or past infection, but it may have limitations in terms of sensitivity and specificity.

  3. Complete Blood Count (CBC): A CBC is a routine blood test that provides information about the number and types of blood cells. In typhoid fever, the CBC may show leucopenia (low white blood cell count), eosinopenia (low eosinophil count), and relative lymphocytosis (increased lymphocyte percentage). These abnormalities can help in supporting the diagnosis of typhoid fever.

  4. Liver Function Tests (LFTs): Liver function tests assess the health of the liver and its ability to function properly. In typhoid fever, liver involvement is common, and LFTs can reveal elevated liver enzymes and other liver-related abnormalities.

  5. Urinalysis: Urinalysis may be performed to check for the presence of white blood cells or other indicators of kidney involvement, which can occur in severe cases of typhoid fever.

Complications of Typhoid Fever:

I. Gastrointestinal Complications:
A. Perforation: The ulcerated areas in the intestines can lead to perforation, causing leakage of intestinal contents into the abdominal cavity. This can result in severe abdominal pain and peritonitis.
B. Hemorrhage: The erosion of blood vessels by ulcers can cause gastrointestinal bleeding, leading to blood loss and anemia.
C. Peritonitis: Perforation of the intestine can lead to peritonitis, an inflammation of the peritoneum (the lining of the abdominal cavity), causing severe abdominal pain and tenderness.

II. Gallbladder Complications:
A. Cholecystitis: The infection can spread to the gallbladder, causing inflammation known as cholecystitis, which leads to abdominal pain, fever, and tenderness in the right upper abdomen.

III. Respiratory Complications:
A. Pneumonia: In severe cases, typhoid fever can lead to pneumonia, a lung infection characterized by fever, cough, and difficulty breathing.

IV. Cardiovascular Complications:
A. Heart Failure: Severe and untreated typhoid fever can put a strain on the heart, leading to congestive heart failure, a condition where the heart fails to pump blood effectively, resulting in fluid accumulation in the body.

V. Musculoskeletal Complications:
A. Osteomyelitis: In rare cases, typhoid fever bacteria can spread to the bones, causing osteomyelitis, which is an infection of the bone and bone marrow.

VI. Neurological Complications:
A. Encephalitis: Typhoid fever can lead to encephalitis, which is inflammation of the brain. This can cause symptoms such as headache, confusion, and altered mental state.

B. Meningitis: In some instances, the infection may also spread to the meninges, the protective membranes covering the brain and spinal cord, leading to meningitis. 

C. Mental Confusion: During the advanced stages of the disease, mental confusion and delirium may occur due to the systemic effects of the infection on the central nervous system.

Management of Typhoid Fever

  1. Hospital Admission:
  • In severe cases of typhoid fever, hospital admission is necessary to provide close monitoring and appropriate medical care.
  1. Isolation or Barrier Nursing:
  • Patients with typhoid fever should be isolated or barrier nursed to prevent the spread of the infection to others.
  1. Investigations:
  • Blood for Culture and Sensitivity (C/S) should be performed during the first week to identify the causative bacteria and determine its sensitivity to antibiotics.
  • Full Blood Sample (FBS) analysis will reveal low Hemoglobin (Hb) levels, low White Blood Cell (WBC) count, and an increased Erythrocyte Sedimentation Rate (ESR).
  • The Widal test can be done around 10/7 days after the onset of symptoms to detect antibodies against typhoid bacilli.
  • Blood Smear (B/S) examination should be conducted to rule out malaria.
  • Stool analysis and urinalysis are important to assess gastrointestinal and urinary involvement in typhoid fever.
  1. Drug Therapy:
  • Antibiotic therapy is a cornerstone of typhoid fever management:
    • Ciprofloxacin at a dose of 500-750 mg twice daily for 10/7 (10 days).
    • Azithromycin at a dose of 10 mg/kg daily.
    • Cotrimoxazole at a dose of 960 mg twice daily for 3/7 (3 days) or as per a weight-based calculation for 10/7 (10 days).
  1. Long-Term Carriers:
  • After signs have passed, stool tests should be conducted to check if Salmonella typhi bacilli are still present. Patients may become potential long-term carriers of the bacteria, requiring a 28-day course of antibiotics to eliminate the bacteria until they are free from it.
  1. Fluid and Electrolyte Management:
  • Monitor intravenous (IV) fluid administration for rehydration.
  • Correct fluid and electrolyte imbalances with Normal Saline (N/S), Dextrose 5% (D5%) solutions, and oral fluids.
  1. Nutrition:
  • Ensure adequate nutrition and provide a soft, easily digestible diet, unless the patient has abdominal complications or ileus.
  1. Antipyretics:
  • Administer antipyretics like Paracetamol (PCM) to manage fever.
  1. Hygiene and Infection Control:
  • Pay close attention to handwashing and limit close contact with individuals during the acute phase of the infection to prevent its spread.
  • Encourage proper waste disposal, covering of food, and proper food preparation to reduce contamination risks.
  • Encourage early screening and management to prevent the worsening of the disease.
  1. Proper Water Treatment and Storage:
  • Educate patients on the proper treatment and storage of water to avoid waterborne transmission of the bacteria.
  1. Regular Follow-Up and Monitoring:
  • Ensure regular follow-up and monitor for complications and clinical relapses.
  1. Management of Delirium:
  • Encourage the use of Phenobarbital at a dose of 30-60 mg in case of delirium.

Prevention:

  • Maintain cleanliness in the premises and ensure proper disposal of rubbish.
  • Keep hands clean and maintain trimmed fingernails.
  • Wash hands thoroughly with soap and water before eating or handling food and after using the toilet or changing diapers.
  • Drinking water should be free from microorganisms; it is preferable to boil water before consumption.
  • Avoid high-risk foods, such as raw or semi-cooked food.
  • During food preparation, wear clean, washable aprons, and caps.
  • Clean and wash food thoroughly, including scrubbing and rinsing fruits in clean water.
  • Store perishable food in the refrigerator, covering it properly.
  • Cook food thoroughly before consumption.
  • Consume food as soon as it is prepared.
  • If necessary, refrigerate cooked leftover food and consume it promptly. Reheat it thoroughly before consumption.
  • Exclude infected individuals and asymptomatic carriers from handling food and providing care to children.
  • Consider immunization, especially for those traveling to high-risk areas, where vaccines are available in oral and injectable forms.

Test MCQ Questions

Question 1:
What is the primary mode of transmission for typhoid fever?
A) Mosquito bites
B) Contaminated food and water
C) Airborne droplets
D) Direct physical contact

Question 2:
Which bacterium is responsible for causing typhoid fever?
A) Escherichia coli
B) Salmonella typhi
C) Streptococcus pneumoniae
D) Staphylococcus aureus

Question 3:
Which of the following complications can occur in severe cases of typhoid fever?
A) Fractures
B) Renal failure
C) Dental caries
D) Cholecystitis

Question 4:
Which diagnostic test is used to identify the presence of Salmonella typhi in the blood?
A) Blood smear examination
B) Stool culture
C) Urinalysis
D) Blood culture

Question 5:
What is the recommended antibiotic therapy for treating typhoid fever?
A) Penicillin
B) Amoxicillin
C) Ciprofloxacin
D) Erythromycin

Question 6:
Why is hospital admission often recommended in severe cases of typhoid fever?
A) To provide psychological support to the patient
B) To administer vaccines for long-term immunity
C) To ensure isolation and prevent disease transmission
D) To allow close monitoring and provide appropriate medical care

Question 7:
What is the primary preventive measure to avoid typhoid fever transmission in the community?
A) Proper handwashing with soap and water
B) Mosquito net usage
C) Wearing masks in public places
D) Vaccination against other bacterial infections

Question 8:
Which gastrointestinal complication can occur due to typhoid fever?
A) Pneumonia
B) Peritonitis
C) Otitis media
D) Conjunctivitis

Question 9:
Which of the following is NOT a recommended step to prevent typhoid fever?
A) Drinking untreated water from natural sources
B) Cooking food thoroughly
C) Washing hands properly before eating
D) Proper waste disposal

Question 10:
Who should be excluded from handling food and providing care to children during a typhoid fever outbreak?
A) Asymptomatic carriers and infected individuals
B) Healthcare professionals only
C) Pregnant women
D) Children under 5 years of age

Answers:

  1. B – Contaminated food and water
  2. B – Salmonella typhi
  3. D – Cholecystitis
  4. D – Blood culture
  5. C – Ciprofloxacin
  6. D – To allow close monitoring and provide appropriate medical care
  7. A – Proper handwashing with soap and water
  8. B – Peritonitis
  9. A – Drinking untreated water from natural sources
  10. A – Asymptomatic carriers and infected individuals

Explanation:

  1. Typhoid fever is primarily spread through contaminated food and water, making option B the correct answer.
  2. Salmonella typhi is the bacterium responsible for causing typhoid fever, making option B the correct answer.
  3. Cholecystitis is one of the gastrointestinal complications associated with typhoid fever, making option D the correct answer.
  4. Blood culture is used to identify the presence of Salmonella typhi in the blood, making option D the correct answer.
  5. Ciprofloxacin is one of the recommended antibiotics for treating typhoid fever, making option C the correct answer.
  6. Hospital admission is recommended in severe cases of typhoid fever for close monitoring and appropriate medical care, making option D the correct answer.
  7. Proper handwashing with soap and water is the primary preventive measure to avoid typhoid fever transmission, making option A the correct answer.
  8. Peritonitis is a gastrointestinal complication that can occur due to typhoid fever, making option B the correct answer.
  9. Drinking untreated water from natural sources is NOT a recommended step to prevent typhoid fever, making option A the correct answer.
  10. Asymptomatic carriers and infected individuals should be excluded from handling food and providing care to children during a typhoid fever outbreak, making option A the correct answer.

Typhoid Fever (Enteric Fever) Read More »

Dysentery

Dysentery

Bacillary Dysentery (Shigellosis):

Bacillary dysentery is an acute bacterial disease that primarily affects the large and small intestine, leading to symptoms such as bloody mucoid diarrhea.

 It is important not to confuse bacillary dysentery with diarrhea caused by other bacterial infections, as one of the distinguishing characteristics of bacillary dysentery is the presence of blood in the stool, resulting from the invasion of the pathogen into the mucosa.

Cause:

    • Bacillary dysentery is caused by different types of Shigella bacteria, including Shigella sonnei, Shigella flexneri, and Shigella dysenteriae.

Mode of Transmission:

    • Bacillary dysentery can be transmitted directly through fecal material of a patient or carrier.
    • It can also be transmitted indirectly through contaminated food and water.
    • Infection can occur even after consuming a small number of bacteria, making household spread and transmission in institutions highly likely.
    • Young children are particularly susceptible to this infection.

Clinical Features:

    • Incubation period: 1-3 days (can extend up to 7 days).
    • Common symptoms include:
      • Sudden onset of mucoid bloody diarrhea.
      • Fever.
      • Nausea and vomiting.
      • Abdominal cramps.
      • Tenesmus (sensation of desire to defecate without producing significant amounts of feces).
      • Flatulence.
      • Headache and fatigue.
      • Dehydration.

Diagnosis:

    • Fresh stool samples are collected for culture and sensitivity testing, as well as microscopy to identify the causative bacteria.

Management:

    • Admission to a medical ward in isolation.
    • Strict personal hygiene (barrier nursing) to prevent infecting others.
    • Disinfection of the patient\’s bed and other items used.
    • Proper disposal of fecal matter and vomit into a pit latrine.
    • Regular monitoring of temperature, pulse, respiration, blood pressure, hydration levels, and level of consciousness.
    • Providing reassurance and support to the patient and relatives.
    • Fluid intake maintenance using Oral Rehydration Solution (ORS) or intravenous fluids in severe cases.
    • Antibiotic treatment with drugs like nalidixic acid or ciprofloxacin.
    • Implementing a BRAT diet (bananas, rice, applesauce, toast) to aid in recovery.
    • Use of a nasogastric tube for feeding and medication administration if oral intake is not possible.
    • Medications for managing nausea and vomiting, such as metoclopramide (plasil).
    • Close monitoring of hydration levels and maintenance of a fluid balance chart.

Prevention:

    • Maintain cleanliness in premises and kitchen utensils.
    • Proper disposal of rubbish.
    • Practice proper hand hygiene before eating or handling food, and after using the toilet or changing diapers.
    • Boil or treat drinking water.
    • Avoid high-risk foods like shellfish, raw or semi-cooked food.
    • Use clean washable aprons and caps during food preparation.
    • Thoroughly clean and wash food items, including fruits, in clean water.
    • Store perishable food in a well-covered refrigerator.
    • Ensure thorough cooking of food before consumption.
    • Consume food promptly or refrigerate leftovers and reheat thoroughly before eating.
    • Exclude infected individuals and asymptomatic carriers from handling food or providing care to children.

Amoebic Dysentery (Amoebiasis)

Amoebic dysentery is a parasitic infection of the gastrointestinal system that is caused by the parasite Entamoeba histolytica. 

The infection is most commonly acquired through oral-fecal contamination, which can occur by consuming contaminated food or water, or by coming into contact with contaminated feces and not washing your hands properly.

Symptoms of amoebic dysentery 

  • Violent diarrhea, often with blood and/or mucus in the stools
  • Severe colitis
  • Frequent flatulence
  • Dehydration
  • Abdominal cramps and tenderness
  • Slight weight loss
  • Moderate anemia
  • Moderate fever
  • Mild fatigue
  • Unrelated symptoms such as liver abscess, lung involvement, amoeboma swelling, and anal ulceration

Diagnosis

The diagnosis of amoebic dysentery is usually made by examining a stool sample under a microscope to look for cysts or motile organisms. Ultrasound scans may also be performed.

Treatment

The treatment of amoebic dysentery involves several steps:

  1. Correcting any dehydration
  2. Initiating a 10-day course of the antimicrobial drug metronidazole (Flagyl) or tinidazole to eliminate the infection
  3. Administering amoebicidal (lumenal) drugs such as diloxanide furoate, paromomycin, or iodoquinol to eradicate any remaining parasites
  4. Isolating infected individuals to prevent further spread of the infection
  5. Emphasizing personal hygiene practices

Prevention

To prevent the occurrence and transmission of amoebic dysentery, the following preventive measures should be followed:

  • Educate the public about proper handwashing before eating and appropriate fecal disposal practices.
  • Ensure the proper management of carriers of the infection.
  • Promote the use of clean drinking water and safe food handling practices.

Dysentery Read More »

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