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dwarfism

Dwarfism (Panhypopituitarism)

Dwarfism (Panhypopituitarism) 

Dwarfism is a medical condition characterized by short stature. 

It is defined as an adult height of 4 feet 10 inches (147 centimeters) or shorter. There are different types of dwarfism, which can be caused by various underlying factors.

It is a condition characterized by the underproduction or deficiency of several hormones produced by the pituitary gland. The primary hormones affected in panhypopituitarism include: 

  1. Growth hormone (GH): GH plays a key role in stimulating growth and development in children. Its deficiency can result in impaired growth and short stature. 
  2. Thyroid-stimulating hormone (TSH): TSH regulates the function of the thyroid gland, which affects metabolism, energy levels, and growth. Deficiency of TSH can lead to thyroid hormone deficiency. 
  3. Adrenocorticotropic hormone (ACTH): ACTH stimulates the production of cortisol by the adrenal glands. Its deficiency can result in adrenal insufficiency. 
  4. Gonadotropins (Luteinizing hormone [LH] and Follicle-stimulating hormone [FSH]): These hormones regulate the function of the gonads (testes in males, ovaries in females) and play a crucial role in reproductive function. Deficiency of gonadotropins can lead to infertility and sexual dysfunction. 
  5. Prolactin: Prolactin is involved in milk production in females. Its deficiency may result in decreased lactation in breastfeeding women.

Types of Dwarfism

There are two main types of dwarfism — disproportionate and proportionate.

Disproportionate dwarfism: Disproportionate dwarfism is characterized by an average-size torso and shorter arms and legs or a shortened trunk with longer limbs. The most common types of dwarfism, known as skeletal dysplasia’s, are genetic. Skeletal dysplasia’s are conditions of abnormal bone growth that cause disproportionate dwarfism.

Skeletal dysplasia’s include:

1.  Achondroplasia: The most common cause of dwarfism which causes disproportionately short stature. This is the most common form of dwarfism, occurs in about one out of 26,000 to 40,000 babies and is evident at birth. People with achondroplasia have a relatively long trunk and shortened upper parts of their arms and legs.

    • This disorder usually results in the following:
    • An average-size trunk
    • Short arms and legs, with particularly short upper arms and upper legs
    • Short fingers, often with a wide separation between the middle and ring fingers
    • Limited mobility at the elbows
    • An adult height around 4 feet (122 cm)
    • a large head with a prominent forehead and a flattened bridge of the nose
    • protruding jaw
    • crowded and misaligned teeth
    • forward curvature of the lower spine
    • Progressive development of bowed legs

2.  Spondyloepiphyseal dysplasia Congenita (SEDC): Another rare cause of disproportionate dwarfism that affects approximately one in 95,000 babies. It refers to a group of conditions characterized by a shortened trunk, which may not become apparent until a child is between ages 5 and 10.

  • A very short trunk
  • A short neck
  • Shortened arms and legs
  • Average-size hands and feet
  • Slightly flattened cheekbones
  • Hip deformities that result in thighbones turning inward
  • Instability of the neck bones.
  • Progressive hunching curvature of the upper spine.
  • Progressive development of swayed lower back
  • Vision and hearing problems.
  • Arthritis and problems with joint movement.
  • Adult height ranging from 3 feet (91 cm) to just over 4 feet (122 cm).
  • club feet (A foot that’s twisted or out of shape).
  • Opening in the roof of the mouth (cleft palate).
  • severe osteoarthritis in the hips
  • weak hands and feet.
  • barrel-chested appearance (Broad, rounded chest)

3.  Diastrophic dysplasia: A rare form of dwarfism, diastrophic dysplasia occurs in about one in 100,000 births. People who have it tend to have shortened forearms and calves (calf muscles-this is known as mesomelic shortening).

achondroplasis

Achondroplasia

SDC

Spondyoepipheseal

Diastrophic

Proportionate dwarfism: In Proportionate dwarfism, the body parts are in proportion but shortened. It usually results from medical conditions present at birth or appearing in early childhood that limit overall growth and development. So the head, trunk and limbs are all small, but they’re proportionate to each other. Because these disorders affect overall growth, many of them result in poor development of one or more body systems. Growth hormone deficiency is a relatively common cause of proportionate dwarfism. It occurs when the pituitary gland fails to produce an adequate supply of growth hormone, which is essential for normal childhood growth.

Signs include:

  • Height below the third percentile on standard pediatric growth charts
  • Growth rate slower than expected for age
  • Delayed or no sexual development during the teen years.

Causes of Dwarfism

  • Most dwarfism-related conditions are genetic disorders, but the causes of some disorders are unknown. Most occurrences of dwarfism result from a random genetic mutation in either the father’s sperm or the mother’s Ovum rather than from either parent’s complete genetic makeup.
  • Dwarfism can be caused by any of more than 200 conditions. Causes of proportionate dwarfism include metabolic and hormonal disorders such as growth hormone deficiency.
  • The most common types of dwarfism, known as skeletal dysplasias, are genetic. Skeletal dysplasias are conditions of abnormal bone growth that cause disproportionate dwarfism.

Other causes include;

  • Deficiency of growth hormone
  • Malnutrition
  • Inherited defect i.e. turners syndrome(Turner syndrome, a condition that affects only girls and women, results when a sex chromosome (the X chromosome) is missing or partially missing. A female inherits an X chromosome from each parent. A girl with Turner syndrome has only one fully functioning copy of the female sex chromosome rather than two)
  • Renal disorders
  • Congenital heart disease
  • Chronic infection in childhood

Diagnosis of Dwarfism

  • Some forms of dwarfism are evident at birth or during infancy and can be diagnosed through X-rays and a physical exam.
  • A diagnosis of achondroplasia, diastrophic dysplasia, or spondyloepiphyseal dysplasia can be confirmed through genetic testing. In some cases, prenatal testing is done if there is concern for specific conditions.
  • Sometimes dwarfism doesn’t become evident until later in a child’s life, when dwarfism signs lead parents to seek a diagnosis. Here are signs and symptoms to look for in children that indicate a potential for dwarfism:
    • Late development of certain motor skills, such as sitting up or walking.
    • Breathing problems
    • Curvature of the spine
    • bowed legs
    • Joint stiffness and arthritis
    • Lower back pain or numbness in the legs
    • Crowding of teeth.
  • Measurements. A regular part of a well-baby medical exam is the measurement of height, weight and head circumference. At each visit, they will be plotted on a chart to show the child’s current percentile ranking for each one. This is important for identifying abnormal growth, such as delayed growth or a disproportionately large head. If any trends in these charts are a concern, the health worker may make more-frequent measurements.
  • Appearance. A child’s appearance may also help to make a diagnosis. Many distinct facial and skeletal features are associated with each of several dwarfism disorders.
  • Imaging technology. Imaging studies, such as X-rays, may be ordered because certain abnormalities of the skull and skeleton can indicate which disorder a child may have. Various imaging devices may also reveal delayed maturation of bones, as is the case in growth hormone deficiency.
  • A magnetic resonance imaging (MRI) scan may reveal abnormalities of the pituitary gland or hypothalamus, both of which play a role in hormone function.
  • Genetic tests. Genetic tests are available for many of the known causal genes of dwarfism-related disorders, but these tests often aren’t necessary to make an accurate diagnosis. If the pediatrician believes the daughter may have Turner syndrome, then a special lab test may be done that assesses the X chromosomes extracted from blood cells.
  • Family history. The pediatrician may take a history of stature in siblings, parents, grandparents or other relatives to help determine whether the average range of height in the family includes short stature.
  • Hormone tests. Tests that assess levels of growth hormone or other hormones that are critical for childhood growth and development may be ordered.

Management of Dwarfism

Treatment for Underlying Cause: Focus on addressing the specific cause of dwarfism, if possible.

Growth Hormone Therapy: GH injections can be administered to stimulate growth in children and adolescents.

Physical Therapy:

  • Improve Mobility: Develop strategies to compensate for mobility limitations.
  • Strengthen Muscles: Improve overall strength and endurance.

Psychological Support:

  • Counseling: Address any emotional issues related to self-esteem, body image, and social integration.
  • Support Groups: Connect with others who have dwarfism to share experiences and build support networks.

Nursing Care:

Education and Support:

  • Provide comprehensive information about dwarfism, its causes, and treatment options.
  • Encourage open communication and emotional support for the individual and their family.

Medication Administration:

  • Administer GH injections accurately and monitor for side effects.
  • Educate patients and families about proper injection techniques and storage.

Physical Care:

  • Assess mobility, and provide assistive devices and adaptive techniques as needed.
  • Promote healthy weight management and encourage regular exercise.

Emotional Support:

  • Empathize with the challenges of living with dwarfism and provide emotional support.
  • Facilitate access to counseling and support groups for the individual and their family.

Advocacy:

  • Advocate for the individual’s needs and rights.
  • Connect them with resources and support services for people with dwarfism.

Nursing Concerns:

  1. Growth Hormone Therapy: Monitor for side effects of GH treatment, such as fluid retention, joint pain, and increased risk of diabetes.
  2. Mobility and Safety: Assess for potential falls and injuries related to mobility limitations. Provide modifications and adaptations to improve safety in the home and community.
  3. Psychological Well-being: Monitor for signs of depression, anxiety, and social isolation. Promote self-esteem and body image through counseling and support groups.
  4. Accessibility: Advocate for accessible environments and accommodations for individuals with dwarfism.
  5. Long-Term Management: Educate individuals and families about the lifelong implications of dwarfism and the need for ongoing care and support.

Surgical Management

  • Surgical procedures that may correct problems in people with disproportionate dwarfism include:
  • Correcting the direction in which bones are growing
  • Stabilizing and correcting the shape of the spine
  • Increasing the size of the opening in bones of the spine (vertebrae) to alleviate pressure on the spinal cord
  • Placing a shunt to remove excess fluid around the brain (hydrocephalus), if it occurs to drain excess fluid and relieve pressure on the brain.

Limb lengthening

  • Some people with dwarfism choose to undergo surgery called extended limb lengthening. This procedure is controversial for many people with dwarfism because, as with all surgeries, there are risks.
  • Because of the emotional and physical stress of multiple procedures, waiting until the person with dwarfism is old enough to participate in the decision to have the surgery is recommended.

Ongoing health care

  • Regular checkups and ongoing care by a doctor familiar with dwarfism can improve quality of life.
  • Because of the range of symptoms and complications, treatments are tailored to address problems as they occur, such as assessment and treatment for ear infections, spinal stenosis or sleep apnea.
  • Adults with dwarfism should continue to be monitored and treated for problems that occur throughout life.

  • In many cases, people with dwarfism have orthopaedic or medical complications. Treatment of those can include:

    • A tracheotomy to improve breathing through small airways.
    • Corrective surgeries for deformities such as cleft palate, club foot, or bowed legs
    • Surgery to remove tonsils or adenoids to improve breathing problems related to large tonsils, small facial structures, and/or a small chest.
    • Surgery to widen the spinal canal to relieve spinal cord compression.

Other treatments may include:

  • Physical therapy to strengthen muscles and increase joint range of motion.
  • Back braces to improve curvature of the spine
  • Placement of draining tubes in the middle ear to help prevent hearing loss due to repeated ear infections.
  • Orthodontic treatment to relieve crowding of teeth caused by a small jaw.
  • Nutritional guidance and exercise to help prevent obesity, which can aggravate skeletal problems.

Life style and home remedies 

  • Talk with the pediatrician or a specialist about home care. Issues particularly critical for children with disproportionate dwarfism include:
  • Car seats. Use an infant car seat with firm back and neck supports. Continue using a car seat in the rear-facing direction to the highest weight and height possible (and beyond the recommended age limit).
  • Infant carriers and play equipment. Avoid infant devices such as swings, umbrella strollers, carrying slings, jumper seats and backpack carriers that don’t support the neck or that curve the back into a C shape.
  • Adequate support. Support the child’s head and neck when he or she is seated.
  • Complications. Monitor the child for signs of complications, such as ear infection or sleep apnea.
  • Posture. Promote good posture by providing a pillow for the lower back and a footstool when the child is sitting.
  • Healthy diet. Begin healthy eating habits early to avoid later problems with weight gain.
  • Healthy activities. Encourage participation in appropriate recreational activities, such as swimming or bicycling, but avoid sports that involve collision or impact, such as football, diving or gymnastics.
  • Coping and support. If a child has dwarfism, a number of steps to help him or her cope with challenges and function independently:
  • Seek help. Organizations provides social support, information about disorders, advocacy opportunities and resources. Many people with dwarfism stay actively involved in this organization throughout their lives.
  • Modify the home. Make changes in the home, such as putting specially designed extensions on light switches, installing lower handrails in stairways and replacing doorknobs with levers.
  • Provide personal adaptive tools. Everyday activities and self-care can be a problem with limited arm reach and problems with dexterity. An occupational therapist also may be able to recommend appropriate tools for home and school use.
  • Talk to educators. Talk to school personnel about what dwarfism is, how it affects the child, what needs the child may have in the classroom and how the school can help meet those needs.
  • Talk about teasing. Encourage the child to talk to you about his or her feelings, and practice responses to insensitive questions and teasing.
  • If the child tells you that bullying occurs in school, seek help from the child’s teacher, principal or the school guidance counselor and ask for a copy of the school’s policy on bullying.

Complications of Dwarfism

Complications of dwarfism-related disorders can vary greatly, but some complications are common to a number of conditions.

Disproportionate dwarfism

  • The characteristic features of the skull, spine and limbs shared by most forms of disproportionate dwarfism result in some common problems.
  • Delays in motor skills development, such as sitting up, crawling and walking.
  • Frequent ear infections and risk of hearing loss.
  • Bowing of the legs.
  • Difficulty breathing during sleep (sleep apnea).
  • Pressure on the spinal cord at the base of the skull.
  • Excess fluid around the brain (hydrocephalus).
  • Crowded teeth
  • Progressive severe hunching or swaying of the back with back pain or problems breathing
  • Narrowing of the channel in the lower spine (spinal stenosis), resulting in pressure on the spinal cord and subsequent pain or numbness in the legs
  • Arthritis
  • Weight gain that can further complicate problems with joints and the spine and place pressure on nerves

Proportionate dwarfism

  • With proportionate dwarfism, problems in growth and development often result in complications with poorly developed organs. For example, heart problems often present in Turner syndrome can have a significant effect on health.
  • An absence of sexual maturation associated with growth hormone deficiency
  • Turner syndrome affects both physical development and social functioning.
  • Pregnancy: Women with disproportionate dwarfism may develop respiratory problems during pregnancy. A C-section (cesarean delivery) is almost always necessary because the size and shape of the pelvis doesn’t allow for successful vaginal delivery.
  • Public perceptions
  • Most people with dwarfism prefer not to be labeled by a condition. However, some people may refer to themselves as dwarfs or little people.
  • People of average height may have misconceptions about people with dwarfism. And the portrayal of people with dwarfism in modern movies often includes stereotypes.
  • Misconceptions can impact a person’s self-esteem and limit opportunities for success in school or employment.
  • Children with dwarfism are particularly vulnerable to teasing and ridicule from classmates. Because dwarfism is relatively uncommon, children may feel isolated from their peers.

Dwarfism (Panhypopituitarism) Read More »

acromegaly and gigantism

Acromegaly & Gingatism (Hyperpituitarism)

Acromegaly/Gigantism (Hyperpituitarism) 

Acromegaly and Gigantism are conditions that result from hyperpituitarism, which is the excessive secretion of growth hormone (GH) by the pituitary gland.

Acromegaly and gigantism can also be referred to as hyperpituitarism and the most common cause is prolonged hypersecretion of growth hormone (GH), usually by a hormone-secreting pituitary tumour. As the tumour increases in size, compression of nearby structures may lead to: hyposecretion of other pituitary hormones of both the anterior and posterior lobes damage to the optic nerves, causing visual disturbances.

  • Gigantism occurs when there is an overproduction of GH in children or adolescents before the closure of the growth plates in bones. This leads to excessive growth in height and overall large stature.
  • Acromegaly occurs when GH overproduction happens in adulthood, after the growth plates have closed. Instead of growing taller, individuals with acromegaly experience abnormal growth of the hands, feet, and facial features, leading to a distinct appearance.

The effects of excess GH include:
>  excessive growth of bones
>  enlargement of internal organs
>  formation of excess connective tissue
>  enlargement of the heart and raised blood pressure
>  reduced glucose tolerance and a predisposition to diabetes mellitus.

Growth hormone stimulates skeletal and soft tissue growth. Growth hormone (GH) excess therefore produces gigantism in children and acromegaly in adults.

Gigantism occur before fusion of the diaphysis and an individual increases in height
reaching 7-8 feet.
Acromegaly occur after fusion of the diaphysis with the epiphysis and there is enlargement of the acral parts
Both are caused due to a pituitary tumor in almost all cases.

Pathophysiology and clinical manifestations of acromegaly/gigantism: 

Pituitary adenomas secrete excessive amounts of GH, which stimulates the production of insulin-like growth factor 1 (IGF-1) in the liver and other tissues. IGF-1 is responsible for the growth-promoting effects of GH. The excessive GH and IGF-1 levels result in tissue overgrowth, primarily affecting bones, cartilage, and soft tissues throughout the body. 

Clinical manifestations Acromegaly and Gigantism:

The clinical manifestations of acromegaly and gigantism are similar and include gradual enlargement and thickening of the bones and tissues. This can lead to changes in facial features, such as;

  • Enlarged hands and feet: The bones and soft tissues in the hands and feet can become enlarged, resulting in larger glove and shoe sizes.
  • Facial changes: This can include a protruding jaw (prognathism), enlarged nose, thickened lips, and a prominent forehead. 
  • Enlarged tongue: The tongue may become larger, potentially causing difficulties with speech and swallowing.
  • Increased size of internal organs: The heart, liver, and other organs may enlarge, leading to various complications.

 The hands and feet may also increase in size. Other manifestations may include 

  • joint pain
  • limited joint mobility
  • increased sweating
  • oily skin
  • sleep apnea, and enlarged nerves.

In children with gigantism, excessive growth can lead to abnormally tall stature. 

Clinical Feature

Acromegaly

Gigantism

Onset

Adulthood (after growth plates have closed)

Childhood or adolescence (before growth plates have closed)

Height

Normal height (since growth plates are closed)

Abnormally increased height (due to prolonged bone growth)

Facial Features

Enlarged jaw, nose, and brow; coarse facial features

Normal facial proportions, but overall larger facial structure

Hand and Foot Size

Enlarged hands and feet, with thickened skin

Large hands and feet relative to body size

Joint Pain

Common due to joint hypertrophy

May occur but less common

Skin Changes

Thick, oily skin; excessive sweating

May have thickened skin

Organ Enlargement (Visceromegaly)

Enlarged organs (heart, liver, kidneys)

Possible, due to overall body enlargement

Cardiovascular Complications

Hypertension, cardiomyopathy

May develop cardiovascular issues due to increased body size

Bone and Soft Tissue Overgrowth

Bone thickening, particularly in the skull and jaw

Generalized overgrowth of bones and soft tissues

Visual Disturbances

Possible due to optic chiasm compression by a pituitary tumor

Possible if tumor compressing optic chiasm

Other Symptoms

Headaches, fatigue, sleep apnea, carpal tunnel syndrome

Headaches, fatigue, may develop other symptoms as they age

Diagnosis and treatment of acromegaly/gigantism: 

Clinical Evaluation:

History: Look for symptoms like:

  • Enlarged hands, feet, and facial features (jaw, nose, forehead)
  • Headaches, vision problems
  • Joint pain and stiffness
  • Sleep apnea, snoring
  • Excessive sweating, fatigue
  • Menstrual irregularities in women
  • Impotence in men
  • Increased ring size, shoe size, hat size
  • Thickened skin, enlarged tongue

Physical Exam: Assess for signs of:

  • Acral enlargement (hands, feet, jaw)
  • Enlarged tongue
  • Hypertrophy of the soft tissues
  • Carpal tunnel syndrome
  • Enlarged organs (liver, spleen)

Biochemical Tests:

  • IGF-1 (Insulin-like Growth Factor-1): The most sensitive and reliable test. Elevated levels are highly suggestive of acromegaly or gigantism.
  • GH levels: Can be measured, but are less reliable than IGF-1 as GH levels fluctuate throughout the day.

Imaging Studies:

  • MRI (Magnetic Resonance Imaging): The gold standard for visualizing the pituitary gland and identifying a tumor.
  • CT (Computed Tomography) scan: Can also be used to assess the pituitary gland, but MRI is preferred.

Investigations:

Pituitary Function Tests:

  • Hormonal evaluation: To assess the function of other pituitary hormones (TSH, ACTH, FSH, LH, prolactin) as other pituitary hormones may be affected by the tumor.

Cardiovascular Evaluation:

  • Echocardiogram: To assess heart size and function, as acromegaly can lead to cardiomegaly and heart failure.
  • Electrocardiogram (ECG): To assess heart rhythm and electrical activity.

Management and Treatment

The primary treatment for acromegaly/gigantism is the surgical removal or reduction of the pituitary adenoma through transsphenoidal surgery.

In cases where surgery is not possible or does not fully resolve the condition, other treatment modalities may include medication (such as somatostatin analogs or GH receptor antagonists) to lower GH levels, radiation therapy to target the tumor, or a combination of these approaches. 

1. Medical Management:

  • Somatostatin Analogues: (e.g., octreotide, lanreotide) are synthetic versions of the naturally occurring hormone somatostatin, which inhibits GH release. They are effective in controlling GH levels and reducing tumor size in some patients.
  • Dopamine Agonists: (e.g., bromocriptine, cabergoline) can be effective in some patients, especially those with GH-secreting tumors that are sensitive to dopamine.
  • Pegvisomant: A GH receptor antagonist that blocks the action of GH at its target tissues. It is effective in reducing GH levels and improving symptoms, but can be associated with liver toxicity.

2. Surgical Management:

  • Transsphenoidal Surgery: This involves removing the pituitary tumor through the nose and sinuses. It can be very effective in treating acromegaly, but it is a major surgery with potential risks.

3. Radiation Therapy:

  • Stereotactic Radiosurgery: This is a non-invasive treatment that delivers a high dose of radiation to the tumor, destroying it gradually. It can be used as a primary treatment or as an adjunct to surgery.

Nursing Care:

  • Patient Education: Educate the patient about acromegaly, its causes, treatments, and potential complications.
  • Symptom Management: Help patients manage symptoms like headaches, joint pain, sleep apnea, and fatigue.
  • Medication Administration: Administer medications as prescribed and monitor for side effects.
  • Monitoring for Complications: Observe signs and symptoms of complications like cardiovascular disease, diabetes, and vision problems.
  • Support and Emotional Care: Provide emotional support and guidance to patients and their families as they adjust to the diagnosis and treatment.
  • Regular Monitoring: Includes regular IGF-1 and GH level monitoring, as well as monitoring for complications.
  • Lifestyle Modifications: Weight management, exercise, and a healthy diet are important for improving overall health and managing complications.
 Nursing interventions for acromegaly/gigantism: 
  1. Monitor and assess the patient’s physical and psychological well-being, including symptoms, vital signs, and emotional state. 
  2.  Educate the patient about the condition, its management, and the importance of treatment compliance. 
  3. Assist in the administration of prescribed medications and monitor for potential side effects. 
  4. Monitor and manage pain, including joint pain and headaches, through appropriate pain management strategies. 
  5. Support the patient in maintaining a healthy lifestyle, including regular exercise and a balanced diet. 
  6. Provide emotional support and counseling to address body image concerns and potential psychosocial challenges. 
  7. Assess and monitor the patient’s endocrine function, including hormonal levels, to evaluate treatment effectiveness and detect any complications. 
  8. Monitor the patient’s cardiovascular health by assessing blood pressure, heart rate, and signs of heart enlargement or dysfunction. 
  9.  Assist with the management of comorbidities that may arise, such as diabetes, hypertension, and sleep apnea. 
  10.  Educate the patient on the importance of regular follow-up appointments, including hormone level monitoring, imaging studies, and other necessary investigations. 
  11. Collaborate with the healthcare team to provide coordinated care and ensure continuity of treatment. 
  12.  Help the patient cope with potential psychological and emotional challenges associated with the condition, such as body image changes, anxiety, and depression. 
  13.  Promote a safe environment by assisting with mobility, falls prevention, and management of joint pain and limited mobility. 
  14.  Encourage the patient to engage in activities that promote overall well-being and quality of life.
  15.  Provide nutritional counseling to ensure a balanced diet that supports bone health.
  16. Foster open communication and a therapeutic relationship with the patient, addressing any concerns or questions they may have.

Complications

  • Sterility in females and importance in males
  • Poor learning ability
  • Lack of sexual development
  • Poor concentration
  • Irritability
  • Heart disease
  • Diabetes mellitus
  • Gallstone
  • Enlargement of internal organs like heart, liver
  • Cancer
  • Polyp formation
Nursing Care Plan for Acromegaly and Gigantism

Assessment

Nursing Diagnosis

Goals/Expected Outcomes

Interventions

Rationale

Evaluation

1. Patient verbalizes anxiety over physical appearance changes (thickened skin, enlarged face, hands, and feet).

Disturbed Body Image related to anxiety over thickened skin and enlargement of face, hands, and feet.

The patient will verbalize acceptance of their appearance and demonstrate behaviors to enhance body image.

– Provide emotional support and counseling to address feelings of self-consciousness.

– Encourage patient participation in grooming and self-care activities.

– Involve the patient in support groups with others experiencing similar conditions.

To reduce anxiety and promote positive coping mechanisms.

Engaging in self-care can enhance self-esteem.

Support groups offer emotional support and shared experiences.

The patient reports reduced anxiety and increased acceptance of physical changes.

2. Patient shows signs of emotional distress, and expresses feelings of helplessness due to changes in appearance.

Ineffective Coping related to change in appearance.

The patient will demonstrate effective coping strategies and verbalize reduced distress.

– Assess the patient’s current coping mechanisms and provide education on effective coping strategies.

– Refer the patient to a psychologist or counselor for additional support.

– Encourage participation in activities that the patient enjoys and finds relaxing.

Understanding current coping methods allows for targeted interventions.

Professional counseling can help the patient develop healthy coping strategies.

Participation in enjoyable activities can reduce stress and improve mood.

The patient demonstrates effective coping strategies and verbalizes reduced emotional distress.

3. Patient reports tingling sensations in the hands and feet, and reduced sensitivity to touch.

Disturbed Sensory Perception related to nerve compression from tissue overgrowth.

The patient will report a reduction in tingling and an improvement in sensory perception.

– Monitor and document changes in sensory perception regularly.

– Educate the patient on the importance of avoiding activities that could lead to injury due to decreased sensation.

– Collaborate with physical therapy to enhance sensory perception.

Regular monitoring helps in identifying worsening or improving conditions.

Educating the patient reduces the risk of injury.

Physical therapy can improve sensory function and prevent complications.

The patient reports reduced tingling and improved sensory perception.

4. Patient reports difficulty sleeping due to soft tissue swelling.

Disturbed Sleeping Pattern related to soft tissue swelling.

The patient will report improved sleep quality and reduced nighttime discomfort.

– Elevate the head of the bed to reduce swelling and improve breathing.

– Encourage the patient to maintain a regular sleep schedule.

– Administer prescribed medications to reduce swelling as needed.

Elevation can help reduce fluid accumulation in tissues.

A regular sleep schedule improves sleep quality.

Medications can help manage swelling and discomfort.

The patient reports improved sleep and reduced nighttime discomfort.

5. Patient shows signs of dehydration (dry skin, decreased urine output).

Fluid Volume Deficit related to increased metabolic demands and soft tissue growth.

The patient will maintain adequate hydration, as evidenced by normal skin turgor and urine output.

– Monitor daily fluid intake and output, and encourage adequate fluid consumption.

– Administer intravenous fluids as prescribed if oral intake is insufficient.

– Educate the patient on the importance of hydration and signs of dehydration to watch for.

Monitoring fluid balance helps prevent complications.

IV fluids provide hydration when oral intake is insufficient.

Education empowers the patient to manage their condition effectively.

The patient maintains normal hydration levels, with normal skin turgor and urine output.

6. Patient expresses anxiety about changes in appearance and possible social implications.

Anxiety related to change in appearance.

The patient will report reduced anxiety and demonstrate relaxation techniques.

– Assess the patient’s level of anxiety and provide reassurance.

– Teach relaxation techniques such as deep breathing and progressive muscle relaxation.

– Encourage open communication about concerns and fears.

Assessing anxiety levels allows for appropriate interventions.

Relaxation techniques help reduce anxiety.

Open communication fosters trust and understanding.

The patient reports reduced anxiety and effectively uses relaxation techniques.

7. Patient shows a lack of understanding about their condition and its management.

Knowledge Deficit related to lack of information about acromegaly/gigantism and its management.

The patient will demonstrate an understanding of their condition and engage in appropriate self-care behaviors.

– Provide comprehensive education about acromegaly/gigantism, including causes, symptoms, and treatment options.

– Encourage the patient to ask questions and participate in care decisions.

– Offer written materials and resources for further learning.

Education empowers the patient to manage their condition effectively.

Involving the patient in care decisions increases adherence to the treatment plan.

Written materials provide ongoing reference and support learning.

The patient demonstrates understanding of their condition and actively participates in their care.

Acromegaly & Gingatism (Hyperpituitarism) Read More »

endocrine system

Endocrine System

Applied Anatomy and Physiology of the Endocrine System

The endocrine system controls the growth of many tissues, like the bone and muscle, and the degree of metabolism of various tissues, which aids in the maintenance of the normal body temperature and normal mental functions.

The endocrine system comprises glands and tissues that produce hormones for regulating and coordinating vital bodily functions, including growth and development, metabolism, sexual function and reproduction, sleep and mood.

Endocrine system is a system of ductless glands, which secrete hormones that are pored in the blood stream to be transported to the target cells.
The endocrine system is composed of the following

  1. Pituitary gland
  2.  Parathyroid gland
  3. Thyroid gland
  4. Adrenal gland
  5. Pancreas
  6. Tests and ovaries

Hormones secreted by these glands act on the specific target tissue away from their site of secretion. Some hormones are protein in nature while others are not.

They act by interacting with specific cell membrane receptors to stimulate the intra cellular Adenylyl cyclase system (membrane-bound enzyme that catalyzes the conversion of Adenosine triphosphate (ATP)-organic compound that provides energy to drive many processes in living cells, such as muscle contraction, nerve impulse to Cyclic adenosine monophosphate (cAMP) – messenger used for intracellular signal induction, which in turn forms ATP to stimulate protein synthesis.

Hormones regulate their own production through a feedback (negative feedback mechanism) system where the increase in concentration of the hormone suppresses its own production.

Structure and function of major endocrine glands: 

The endocrine system consists of several major glands that secrete hormones into the bloodstream. These glands include the pituitary gland, thyroid gland, adrenal glands, and pancreas. 

The endocrine system plays a big role in regulating numerous body functions by releasing hormones, which are chemical messengers, directly into the bloodstream. These hormones travel to target tissues, influencing various physiological activities.

Exocrine vs. Endocrine Glands

Exocrine glands differ from endocrine glands in that they use ducts to transport their secretions, whereas endocrine glands release hormones directly into the bloodstream.

Pituitary Gland: The Master Gland

The pituitary gland, often termed the “master gland,” is a small structure hanging from the base of the brain. It controls other endocrine glands through hormone production, which is regulated by the hypothalamus.

But, hypothalamus is what controls the pituitary gland, making it the master of the master gland 🤣

Pituitary Gland Structure and Function

The pituitary gland is divided into two parts: the anterior and posterior pituitary, each with distinct functions and hormone production.

  • Posterior Pituitary: Produces oxytocin, which stimulates uterine contractions and milk ejection, and antidiuretic hormone (ADH), which helps the kidneys retain water.
  • Anterior Pituitary: Produces several hormones including thyroid-stimulating hormone (TSH), growth hormone (GH), adrenocorticotropin (ACTH), follicle-stimulating hormone (FSH), luteinizing hormone (LH), and prolactin.

The pituitary gland secretes hormones like; (Anterior lobe)

  •  Adrenocorticotrophic hormone (ACTH)
  • Somatotrophic hormone (STH)/(GH)
  •  Thyroid stimulating hormone (TSH)
  •  Follicle stimulating hormone (FSH)
  •  Luteinizing hormone (LH)’
  •  Melanocyte stimulating hormone (MSH)

The Posterior lobe secretes

  • Anti diuretic hormone (ADH),
  • Vasopressin 
  • Oxytocin.

Secretion of the anterior lobe is under the control of Hypothalamus which secretes regulatory hormones.

Growth hormone stimulates muscular and skeletal growth either by regulating synthesis of somatomedins by the liver or by directly stimulating incorporation of amino acids into proteins.
Hypoglycemia is a potent stimulant of growth hormone release; obesity blunts its release.
Excess secretion of growth hormone after epiphyseal fusion produces acromegaly where as before epiphyseal fusion causes gigantism

Image showing hormones produced by the anterior lobe.

Hormones produced by the anterior pituitary gland
Thyroid Gland

Located in the neck just below the larynx, the thyroid gland consists of two lobes connected by an isthmus. It produces thyroid hormones (T4 and T3) that regulate metabolism and calcitonin, which lowers blood calcium levels.

Parathyroid Glands
Parathyroid Glands

These small glands, usually four in number, are located near the thyroid and regulate calcium levels in the body through the secretion of parathyroid hormone.

Pancreas
Pancreas

The pancreas has both endocrine and exocrine functions, for digestion and blood sugar regulation. The endocrine function occurs in the Islets of Langerhans, which contain alpha, beta, and delta cells.

  • Alpha Cells: Release glucagon to increase blood glucose levels.
  • Beta Cells: Produce insulin, which lowers blood glucose by facilitating its uptake into cells.
  • Delta Cells: Secrete somatostatin, which inhibits both glucagon and insulin.
Adrenal Glands
Adrenal Glands

Situated atop the kidneys, the adrenal glands consist of two parts with distinct functions:

  • Adrenal Medulla: Secretes catecholamines (norepinephrine and epinephrine), which are involved in the sympathetic nervous system’s response to stress.
  • Adrenal Cortex: Produces steroid hormones including glucocorticoids (which increase blood glucose), mineralocorticoids (which regulate sodium and potassium), and androgenic hormones.
Gonads
Gonads

The gonads are the reproductive glands with endocrine functions.

  • Ovaries: Located in the female abdomen, they produce estrogen and progesterone under the control of FSH and LH from the anterior pituitary.
  • Testes: Situated in the male scrotum, they produce sperm and testosterone, promoting male growth and secondary sexual characteristics.

Hormones Produced 

The pituitary gland is divided into two parts: the anterior pituitary and the posterior pituitary, each producing different hormones with distinct functions. 

Anterior Pituitary Hormones
  • Thyroid-Stimulating Hormone (TSH): Stimulates the thyroid gland to produce thyroid hormones (T3 and T4), which regulate metabolism, energy levels, and overall growth and development.
  • Growth Hormone (GH): Promotes growth of body tissues, particularly bones and muscles, by increasing protein synthesis, fat metabolism, and cell division.
  • Adrenocorticotropic Hormone (ACTH): Stimulates the adrenal cortex to release cortisol, a hormone that helps the body respond to stress, maintain blood sugar levels, and regulate metabolism.
  • Follicle-Stimulating Hormone (FSH): In females, it stimulates the growth and maturation of ovarian follicles; in males, it promotes sperm production in the testes.
  • Luteinizing Hormone (LH): In females, it triggers ovulation and the production of progesterone; in males, it stimulates the production of testosterone in the testes.
  • Prolactin: Promotes milk production in the mammary glands after childbirth.
Posterior Pituitary Hormones
  • Oxytocin: Stimulates uterine contractions during childbirth and promotes the ejection of milk during breastfeeding.
  • Antidiuretic Hormone (ADH): Helps the kidneys manage the amount of water in the body by increasing water reabsorption, reducing urine volume, and helping maintain blood pressure.

Endocrine System Read More »

Normal First stage of labour

Normal First Stage Of Labour

PHYSIOLOGY OF FIRST STAGE OF LABOUR:
  1. UTERINE ACTION

Fundal dominance;
Each uterine contraction starts from the fundus near the cornua and spreads across and down wards.
The contraction lasts longer in the in the fundus where it is most intense but the peak is reached  simultaneously over the whole uterus and the contractions fade from all parts together.
This permits the cervix to dilate and the strongly contracting fundus to expel the fetus.

normal fundal dominance

Polarity
This is a neuromuscular harmony that prevails between the two poles of the uterus throughout
labour.
During a contraction, these two poles act harmoneously. The upper uterine segment contracts strongly and retracts to expel fetus and the lower pole contracts slightly and dilates to allow expulsion of the fetus. If polarity is disorganized, labour progress is inhibited.


Contraction and retraction
During labour, a contraction does not pass off entirely but muscle fibres retain some of the shortening contractions instead of becoming completely relaxed. This is termed as retraction. This is a unique property of the uterine muscles and because of this,
the upper uterine segment becomes shorter and thicker and diminishes its cavity assisting in expulsion of the fetus.

normal progressive contraction and retraction

Formation of the upper and lower uterine segment
By the end of pregnancy, the body of the uterus has divided into two segments;
 > The upper segment is mainly for contraction and is muscular and thicker while the lower uterine segment is for distension and dilatation and is thinner.
 > The lower segment develops from the isthmus and is about 8-10cm in length.

Retraction ring

This is a ridge formed between the upper and lower uterine segment.
The physiological retraction ring gradually rises when the upper uterine segment contracts and retracts and lower uterine segment thins out to accommodate the descending fetus.
This ring is not usually visible and when cervix is fully dilated and fetus can leave the uterus, it rises no further.
An exaggerated phenomenon of retraction ring in obstructed labour it becomes visible above the
symphysis pubis. This is termed as a bundle’s ring

2. CERVICAL ACTION

Cervical effacement
This is inclusion of the cervical canal. The muscle fibres surrounding the internal os are drawn upwards by the retracted upper uterine segment and the cervix merges into the lower uterine segment.

Cervical dilatation
This is the process of enlargement of the os from a tightly closed aperture to an opening large enough to permit passage of the fetal head.
It is measured in cm. a full dilatation at term equates to 10cm.
Pressure applied by the bag of fore waters and a well flexed fetal head closely applied to the cervix favors efficient dilatation.


Show
This is blood stained mucus which is seen before or at the onset of labour. The mucus is a thick mucoid substance which forms the cervical plug (opeculum) during pregnancy. Blood comes from raptured capillaries when the chorion has become detouched from the dilating cervix.

3. MECHANICAL FACTORS


Formation of fore waters

As the lower uterine segment stretches, the chorion becomes detouched from it and the increased intra uterine pressure causes this loosened part of the sac of fluid to bulge down wards into the dilating internal os. A well flexed head fits snugly into the cervix and cuts off the fluid in front of the head from that surrounding the body. The water in front is known as fore waters and that
behind is called hind waters.
General fluid pressure
When the membranes are intact, the pressure of the uterine contractions is exerted on the fluid and since the fluid is not compressible, the pressure is applied on the uterus and over the fetal
body. This is termed as general fluid pressure.
When membranes rapture and quantity of fluid escapes, the fetal head, placenta and umbilical cord will be compressed between the uterine wall and body of fetus during contraction resulting in reduced oxygen supply to the fetus.

formation of fore and hind waters

Rapture of membranes
The optimum physiological moment for membranes to rapture is at the end of 1st stage of labour when the cervix becomes fully dilated and no longer supports the bag of fore water.
The uterine contractions are also applying increasing expulsive force at this time. Membranes may also rapture days before labour begins or during 1st stage of labour especially in a badly
fitting presenting part.
Occasionally, membranes do not rapture even in 2 nd stage and appear at the vulva as a bulging sac covering the fetal head as it is born. This is known as caul(CAL DE SAC)

Fetal axis pressure

During the contraction, the uterus rises forward and the force of fundal contraction is transmitted to the upper pole of the fetus down the long axis of the fetus and is applied to the cervix by the presenting part. This becomes more significant after rapture of membranes and during 2 nd stage of labour.

Descent of the presenting part.


It refers to the downward and outward movement of this part through the pelvis.
The normal well flexed head twists and turns flexes and extends to maneuver through the pelvis.
There are 3 planes or obstacles involved in the process of descent:
– Pelvic inlet/ brim.
When the presenting part is at the level of the ischial spines, a pelvic brim mark, it indicates the largest part of the head has come through the brim. The head is thus engaged.
The presenting part is now at station 0.
– Pelvic cavity.
When the presenting part has descended to the perineum, the largest part has passed the ischial
spines. The head is now at station +2.
– Pelvic outlet.
Delivery of the head brings it past the 3 rd obstacle ( pelvic outlet), which is under the pubic arch, between the ischial tuberosities and over the coccyx.
NB: station is the relationship of the lowermost part of the presenting part to an imaginary line
drawn between the ischial spines and the woman’s pelvis.

MANAGEMENT OF FIRST STAGE OF LABOUR

Aims

  1. To monitor labour progress.
  2. To prevent maternal exhaustion.
  3. To prevent infections.
  4. To give comfort to the mother and maintain patient’s moral.
  5. To relieve pain.
  6. To prevent complications.
  •  Admission of a mother in labour
    Welcome the mother and her relatives to allay fear and anxiety, create rapport.
  •  Obtain full history and review the antenatal card while the mother is sitting or lying on
    the couch.
    The histories taken include;-
    -Demographic data
    -Date and time of admission
    -When contractions started
    -Frequency and strength of contractions
    -If membranes raptured
  •  Obtain consent from the mother and sign. Make sure mother is given sufficient
    information before she decides to give consent.
  • Vital observations;- pulse ½ hourly if  >100b/m indicates pain, anxiety, infections,
    ketosis, hemorrhage etc.
    – Blood pressure 2 hourly
    – Temperature 4 hourly
    -Respiration 4 hourly (16-20r/m)
  • Investigations e.g.- Urinalysis to rule out acetones, glucose and proteins.- Blood for Hb estimation, grouping and cross matching can be obtained depending on mother’s condition.
  • General examination The midwife examines a mother from head to toe paying more attention to general appearance (health or ill), size, any deformity, signs of anaemia, jaundice, oedema, dehydration, infections, Vericose veins and enlarged glands and veins in the neck. Examine the breasts and notice their suitability for breast feeding.
  • Abdominal examination: The mother’s bladder should be empty. It’s done following 3 steps.

-Inspection:-for size, shape, scars, signs of pregnancy etc
-Palpation: – Noting tenderness, height of fundus, presentation, lie, position, descent,
contractions, frequency, length and strength.
-Auscultation: – Noting rate, regularity and volume.

  •  Vaginal examination.

This is a sterile procedure carried out on a woman through the vagina to rule out obstetrical or
gynecological abnormalities.

Indications of VE during pregnancy

>  To confirm pregnancy
>  To exclude abnormalities e.g. fibroids
>  For pelvic assessment
>  To determine the state of the cervix
>  To confirm the type of abortion
>  To rule out abnormal discharges
>  During labour

During First stage

>  To determine cervical dilation

>  To exclude cord prolapse when membranes rapture
>  To confirm full dilation when mother is bearing down.
>  Before induction of labour to determine state of the cervix
>  In prolonged labour to rule out obstructed labour.
>  To make a positive identification of the presentation.
>  To determine if the presenting part is engaged.

–During Second stage
>  To confirm full dilation of the cervix
>  When there is no descent to determine the delay e.g. face to pubis
>  After delivery of the 1st twin to determine the presentation of the 2nd twin.

-During Third stage
>  In delayed 3rd stage of labour to know whether the placenta is in the birth canal where it can be
removed quickly.
>  To exclude lacerations and expel clots from the birth canal.
>  In emergency i.e. manual removal of placenta.
>  During puerperium
To find out whether the perineum has healed after 6 weeks.
>  To find out whether the reproductive organs have regained their muscle tone and position.
>  To obtain a specimen for examination.
>  In abnormal vaginal discharge to confirm the type of infection.

Contraindications of VE

In APH and elective caesarian section

Complications of VE
-Infections
-Early rapture of membranes.
-Trauma or lacerations to the birth canal

Requirements
Tray containing;
>  Galipot for swabs with antiseptic
> 2 receivers
> Sterile gloves
> Vaginal speculum
> Sterile bowl for lotion.
> Perineal pad/ clean pads
> Sheet and mackintosh.
> Clean gloves.
> Lubricant
At the bed side
> Screen
> Hand washing equipment
> Bed pan

PROCEDURE OF VAGINAL EXAMINATION
  1. Welcome and explain procedure to the mother.
  2. Empty bladder and screen the bed.
  3. Assemble a VE tray.
  4. Ask mother to relax during examination.
  5. Woman’s arms should be down by her sides or across her abdomen to relax her abdominal
    muscles.
  6. Assist her into dorsal position and drape her.
  7. Put on clean gloves
  8. Place mackintosh and draw sheet under the buttocks
  9. Remove gloves and wash hands thoroughly and put on sterile gloves.
  10. Observe the external genitalia. Before the midwife cleans the vulva, should observe the
    following;-
    – Hygiene
    – Labia for signs of varicosities.
    – Oedema
    – Vulval warts
    – Sores
    – If the perineum has old scars for tears, episiotomy, female circumcision.
    – Any discharge from the vaginal opening i.e. blood, raptured membranes, smell of liquor
    and colour.
    – If liquor smells, it indicates infections. If green or meconium stained, indicates fetal
    distress.

  11. Vulva is swabbed using the left hand, swab from the front towards the rectum.
    The 2 fingers of the right hand are dipped in the antiseptic cream for lubrication and gently inserted down wards and backwards into the vagina while the labia majora are held apart by the fingers of the left hand.
    The fingers are directed along the anterior vaginal wall and should not be withdrawn until the
    required information has been obtained. NB: The clitoris should not be touched because it causes discomfort.
vaginal examination
Findings:


Condition of the vagina;

The vagina should feel warm and moist. A hot and dry vagina is a sign of obstructed labour and should not be found in modern obstetric care.
If a mother has a high temperature, the vagina will feel correspondingly hot but not dry.
Previous scar from Perineal wound, cystocele or rectocele.

The cervix;
The normal should feel thin and elastic and well applied to the presenting part.
A spongy feeling may show undiagnosed placenta previa.
The midwife should sweep the examining fingers from side to side to locate the os. It is usually felt in the center but sometimes in early labour, it is very posterior.
The length of the cervical canal assessed through a tightly closed cervix shows that labour has not yet started.
In a PG, the cervix can be completely taken up(effaced) but still closed and in this manner, it will be closely applied to the presenting part and it can be confused with a fully dilated cervix. If poorly applied to the presenting part, then it means there is an ill-fitting presenting part.
Assess cervix for; effacement, dilatation, consistency.

Membranes;
When membranes are intact, they can be felt through the dilating os; they feel tenser on contraction. When the fore waters are shallow, it is not easy to feel membranes.
If the presenting part does not fit well in or at the cervix, some of the fluid from the hind waters escapes into the fore waters causing the membranes to bulge or protrude through the cervix and are liable to rapture early.

Level or station of presenting part;
The presenting part is that part of the fetus that lies over the internal os during labour.
In order to assess the descent of the fetus in labour, the level of presenting part is assessed or estimated in relation to maternal ischial spines.

Position;
On feeling the features of the presenting part, the position of the fetus can be detected. The vertex is the normal presentation and the midwife must be familiar with it. Commonly the first feature to be felt even in early labour is the sagittal suture. The sagittal suture should be followed with a finger until a fontanel is reached.
If the head is well flexed, the posterior fontanel will be felt. This can be judged by feeling the amount of overlapping of the skull bones and can give additional information on position.
The parietal bones override the occipital bone to reduce the distance of the presenting diameter.

Pelvic capacity (pelvic assessment);
Although the pelvis was assessed during ANC period, the midwife should take opportunity to assure herself of its adequacy as she completes vaginal examination.
At completion of examination, withdraw fingers from the vagina and note any blood or amniotic fluid, cleans up the mother and removes gloves.
Record all findings of what was observed on admission on a partograph and observation chart.

Normal First Stage Of Labour Read More »

labour

Labour

It is described as the process by which the fetus, placenta and membranes are expelled through the birth canal after 28 weeks of gestation.
OR
It is defined as rhythmic contraction and relaxation of the uterine muscles with progressive effacement (thinning) and dilatation ( opening) of the cervix, leading to expulsion of the products of conception.

Normal labour

Labour is said to be normal when;

  • It occurs at term.
  • Spontaneous in onset.
  • Fetus presenting by vertex.
  • The process is complete within 12-18 hours.
  • No complications arise.
  • Both mother and fetus suffer no injury.
  • No assistance is given in any way.
THREE P’S OF NORMAL LABOUR
  • Powers – uterine contractions
  • Passage – pelvis including the size and shape.
  • Passenger – Size, position and presentation of the fetus as well as bag of fore waters or amniotic sac.
TYPES OF LABOUR
  1. True labour: This is characterized by regular uterine contractions slight at 1 st but increase in severity and frequency causes the cervix to dilate.
  2. False labour: It is characterized by irregular uterine contractions which do not cause the cervix to dilate. They are painful, appear stronger when a mother is in bed and weaker when she is up and moving around.
    >  No cervical dilatation.
    >  No show.
    >  Pain remains stationary in the lower abdomen.
    >  Pain is continuous without any rhythm.
    >  Pain reduces after enema.
    >  No associated hardening of the abdomen.
Signs of impending labour.

These changes occur in the last weeks of pregnancy. This is termed as pre-labour.

  1. Lightening
    About 2-3 weeks before the onset of labour, the lower uterine segment expands and allows the fetal head to sink lower. The symphysis pubis widens and pelvic floor becomes more relaxed and softened, allowing the uterus to descend further into the pelvis.
  2. Cervical changes
    As labour approaches, the cervix becomes “ripe”. It becomes softer, like a lower lip and there is some degree of effacement and slight cervical dilatation.
  3.  False labour: It consists of painful uterine contractions that have no measurable progressive effect on the cervix and this is an exaggeration of the usually painless Braxton hick’s contractions which have been occurring since about 6weeks of gestation. It may occur for days intermittently even 3-4 weeks before the onset of true labour.
  4.  Premature rapture of membranes: Normally, membranes rapture at the end of 1 st stage of labour. When rapture occurs before the onset of labour, it is termed as PROM and occurs in about 12% of women. In 90% of women with PROM, labour begins spontaneously within 24 hours.
  5. Bloody show: A mucus plug created by cervical secretions from proliferation of cervical mucosal glands in early pregnancy serves as protective barrier and closes the cervical canal throughout pregnancy. Bloody show is the expulsion of this mucus plug.
  6.  Energy spurt: Many women experience an energy spurt approximately 24-48 hours before the onset of labour. After days or weeks of feeling tired (physically tired and tired of being pregnant) they get up one day to find themselves full of energy and vigor.
  7.  G.I.T upset: In the absence of any causative factors for the occurrence of diarrhea, nausea, vomiting and  indigestion, it is thought that they might be indicative of impending labour and there is no known explanation for this.
 
SIGNS OF LABOUR

They are divided into two;

  1. Premonitory signs
  2. Actual signs

Premonitory signs
– Lightening
It occurs 2-3 weeks before onset of labour. The lower uterine segment expands and allows the fetal head to sink further so as to engage. The fundus nolonger crowds the lungs and breathing is easier and the mother experiences relief
– Frequency of micturition
Congestion in the pelvis limits the capacity of the bladder requiring it to be emptied more often
– Effacement of the cervix
This is the taking up of the cervix-the cervix is drawn up and gradually merges into the lower uterine segment.
– Braxton hick’s contractions.
They become exaggerated and mother becomes anxious. She experiences backache or pains while walking due to relaxation of pelvic joints. This makes the mother think that she is in labour.

Actual signs
– Regular uterine contractions.
Mother feels painful, rhythmic uterine contractions slight at first but increase in severity and frequency.
– Dilatation of the cervix.
This is enlargement of the external os from a circular opening large enough to permit passage of the fetus.
– Show.
This is a bloody mucoid discharge which comes from the cervical canal. When it dilates, blood
comes from the raptured capillaries.
– Plus or minus rapture of membranes.
This is not so much relied on because it can occur in late 1 st stage or spontaneously at birth of the baby.

Causes of onset of labour.

The exact cause remains unknown but appears to be a combination of hormonal and mechanical
factors.

Hormonal factors.
Theories regarding the initiation of labour include the following;
1. Oxytocin stimulation theory:
– Although the mechanism is unknown, the uterus becomes increasingly sensitive to oxytocin as the pregnancy progresses.
2. Progesterone withdrawal theory:
– A decrease in progesterone production may stimulate prostaglandin synthesis and enhance the effect of Oestrogen which has stimulating effect on muscles. The fall of progesterone reduces the
relaxing effect of the uterine muscles.
3. Oestrogen stimulation theory: Oestrogen stimulates irritability of uterine muscles and enhances uterine contractions.
The raise in estrogen stimulates the decidua to release prostaglandins. Both prostaglandins and oxytocin cause the uterus to contract.
4. Fetal cortisol theory:
Cortisol may affect the maternal Oestrogen levels.
5. Prostaglandin stimulation theory:
Prostaglandin stimulates smooth muscles to contract.
A combination of the above mechanisms is likely to initiate labour.

Mechanical factors
1. over stretching and over distension of the uterus
2. Pressure from the presenting part on the nerve endings of the cervix stimulates the nerve plexus (cervical ganglion)
3. The increase in the strength and frequency of Braxton hick’s contractions may cause labour to begin.

Stages of labour
  1. First stage
    It begins with onset of regular, rhythmic uterine contractions and is complete when the cervix
    is fully dilated.
    It is a stage of dilation of the cervix.
    It’s divided into 3 phases
    -Latent phase
    -Active phase
    -Transitional phase
    Latent phase:
    This is a period of slow dilation of the cervix from 0-3cm.
    It may last 6-8hours in first time mothers
    Active phase:
    This is the time when the cervix undergoes more rapid dilatation. It begins when the cervix is 4cm dilated and ends when the cervix is 8cm dilated.
    Transitional phase
    It begins when the cervix is 8cm dilated and is complete when Its fully dilated.
    –
  2. Second stage
    It’s that stage of expulsion of the fetus. It begins when the cervix is fully dilated and is complete when the baby is completely born.
    It also has two phases
    – The propulsive phase
    – The expulsive phase

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 delivery of the baby.

3.  Third stage
It’s that stage of separation and expulsion of the placenta and membranes and involves control of bleeding.
OR
It begins with birth of the baby and ends with expulsion of placenta and membranes.
It takes 5-30 minutes. With active management, its completed within 5-15 minutes.

4. Fourth stage
It is also called recovery stage. It is defined as the 1 st one hour after delivery of the placenta.

Labour Read More »

antenatal Care

Antenatal Care

This is a planned methodological care and supervision given to a pregnant woman by a midwife or obstetrician from the time the mother starts attending antenatal clinic until beginning of labour.

Aims of antenatal care
  • To monitor the progress of pregnancy in order to support maternal health and normal fetal development.
  • To prepare the mother for labour, lactation and subsequent care for her baby.
  • To detect early and treat appropriately high risk conditions be it medical or obstetrical that would endanger the life of the mother and the baby.
    This is achieved by;
  • Developing a partnership with the woman.
  • Providing a holistic approach to the woman’s care that meets her individual needs.
  • Promoting awareness of the public health issues for the woman and her family.
  • Exchanging information with the woman and her family enabling them to make informed choices.
  • Being an advocate for the woman and her family, supporting her right to choose care that is appropriate for her own needs and those of the family.
  • Recognize complications of pregnancy and appropriately referring women within the multi- disciplinary team.
  • Facilitating the woman to make an informed choice about methods of infant feeding and giving appropriate and sensitive advice to support her decision.
  • Facilitating the woman and her family in their preparations to meet the demands of birth and making a birth plan.
  • Offering health education for parenthood.
Activities done in ANC
  • Registration
  • Booking (history taking)
  • Special tests and investigations
  • Health education
  • Immunization
  • Treatment of minor disorders
  • Provision of supplements
  • Examination i.e. physical and abdominal
  • Orientation of mothers
  • Formulating a birth plan
  • counseling.
  • Referral of cases
INITIAL ASSESEMENT (BOOKING DAY)


Objectives for initial assessment(booking visit)
– To assess the level of health by taking a detailed history and to offer appropriate
screening tests
– To ascertain a base line data of blood pressure, urinalysis, uterine growth and fetal
developmentto be used as standard for comparison as pregnancy progresses.
– To identify risk factors by taking accurate details of the past and present obstetric,
medical, family and personal history.
– To provide an opportunity to discuss any concerns the woman has.
– To give advice pertaining to pregnancy in order to maintain the health of the mother and
the developing fetus.
– To build the foundation for a trusting relationship in which the woman and the midwife
are partners in care.
– To make appropriate referral when additional health care or support needs have been
identified.

HISTORY TAKING

Demographic data
Name
Age
Address
Occupation
NOK; relationship, occupation, contacts.
LOE
Tribe
Religion
Nearest health facility and distance from home.


Social history
Habits
-Smoking; Cigarettes have nicotine which constricts blood vessels leading to placental
insufficiency, which can result in fetal hypoxia, small for dates, abortions etc. The woman should be advised to reduce on the number of sticks gradually to avoid withdrawal syndrome.
-Alcohol; There is a risk of trauma which can result into abortion, placenta abruption, loss of appetite thus malnutrition and small for dates.
Marital status; -Married or single, number of years spent in marriage, find out if she’s happy or not.
Home environment
-House; – Rented or own, number of rooms and number of occupants.
-Environmental hygiene
-Source of water and food.


Family history
Health status of woman’s parents and her siblings (if deceased, note cause of death).
Familial diseases e.g. h/o cancer, diabetes, cardiac diseases, allergies etc.
Other serious illnesses like mental illnesses or complications with pregnancy.

History of multiple pregnancies.
Past surgical history
History of accidents involving the spine, pelvis and lower limbs which would reduce the pelvic diameters.
History of major operations like C/S, and pelvic operations.
History of blood transfusion(risk of exposure to HIV/AIDS and iso immunization)


Past medical history
-Medical conditions that may complicate or be complicated by pregnancy, labour and
puerperiume.g. sickle cell, DM, HTN.
-Child hood illnesses e.g. rickets, polio myelitis which can reduce pelvic diameters, hence
contracted pelvis.
-Infectious diseases like TB, HepB
-Infections like syphilis, gonorrhea,


Gynecological history
Gynae conditions like abortions, ectopic pregnancy, fibroids etc.
Gynae operations like myomectomy, D and C, evacuation etc.
Menstrual history
Menarche, length, interval, amount of flow.
Dysfunctional uterine bleeding (DUB).
Pre- menstrual spotting.
Family planning
Method of F/P ever used any complaint about it, reason for stopping it.


Past obstetrical history
Previous pregnancies; ask about any abnormalities e.g. abortions, still births, living children
and their health status and immunization status.

Interval between pregnancies, length of gestation, birth weight, fetal outcome, length of labour,
presentation and type of delivery. Prenatal and post natal complications, if baby was breast fed
and for how long.
Labour; Any operations, induction, assisted delivery, PPH.
Puerperium; If it was normal, any h/o sepsis, PPH.

Present obstetric history
Gravidity
Parity
LMNP
EDD. This is calculated by adding 9 calendar months and 7 days to the date of the 1 st day of the
woman’s last menstrual period (Naegele’s rule). This method assumes that:
The woman takes regular note of regularity and length of time between periods.
Conception occurred 14 days after the first day of the last period. If the woman has a regular
cycle of 28 days.
The last period of bleeding was true menstruation. Implantation can cause slight bleeding.
Break through bleeding and anovulation can be affected by contraceptive pill thus impacting on
the accuracy of LNMP.
WOA

Present health
– Appetite; It is important to know because poor appetite leads to malnutrition and anaemia.
– Sleep; Find out if the mother sleeps well, if not, find out the cause which could be due to
worries, insects in bed, pain and any signs of illness.
– Micturition; It’s good to know whether the woman passes urine well because UTI is
common in pregnancy due to stagnation of urine in dilated and kinked ureters. In case of
increased frequency without pain, mother is counseled in relation to physiology of pregnancy.

– Bowel action; as constipation is very common in pregnancy, the mother is re assured and
advised to take plenty of fluids and roughages.
NB: Conclude history by asking mother if she has anything else she would like to tell you.

INVESTIGATIONS

  • On the first day, every woman should receive the following investigations
  • Blood pressure
  • Weight
  • Height
  • Urinalysis; – for albumen, acetone and sugars.
  • Albumen is indicative of PET, acetone-
    dehydration, sugar- diabetes.
  • RPR/VDRL; done to exclude syphilis.
  • HIV screening to ensure
  • Emtct
  • Blood grouping
  • Hb level; It should be done on booking day, then at 32-34 weeks and lastly at 36weeks to rule out anaemia.
  • Comb’s test; It’s done to detect anti bodies in blood.
Clinical Tests
  • Weight; this is taken on every visit to ANC. The mother is expected to gain 12.5kg during
    pregnancy, 4kg in the first 20 weeks and 8.5kg in the last 20 weeks. Excessive weight gain could be due to twins, big baby, polyhydramnios etc. Failure to gain weight could be due to poor fetal growth.
  • Height; It’s done on the booking visit or in labour if the mother has not been attending ANC. The normal height should range 152-170cm, below 150cm indicates a small
    pelvis and above 170cm indicates a narrow pelvis.
  • Shoe size; if below 5 indicates a small pelvis. Normal shoe size ranges between 5 and 8
  • Blood pressure; this is done on every visit to ANC. The BP of a pregnant mother ranges from 90/60 to 140/90mmhg.A raised BP is a danger sign and may be due to PET and eclampsia. Any rise of 30mmhg (systolic) and15-20mmhg (diastolic) from what has been considered normal is dangerous and the mother’s urine should be tested for proteins. The mother is asked how she feels generally especially her sight (blurred vision), then referred to the doctor.
PHYSICAL EXAMINATION

This includes a review of the physical systems to ascertain the woman’s general health. The breasts, pelvis and abdomen receive particular attention. The examination is carried out systematically beginning with the head and ending with the pelvis and abdomen.

General appearance;
Body type, weight, energy level, grooming, posture. This is noted when the mother is entering the room or when she is sitting.
Head;
Scalp, hair whether treated and hair pattern distribution.
Eyes; conjunctiva- check for anaemia, sclera- check for jaundice, visions, discharge.
Nose; Sense of smell, bleeding, obstruction, abnormal growth and discharge.
Oral cavity; Toothache, denture, state of lips, chewing or swallowing problems, tongue and gums for anaemia, sense of taste.
Ears; Check for discharges, any hearing loss.
Neck;
Movement, Palpate for swelling or enlarged salivary glands i.e parotid, sub mandibular, sublingual, thyroid, lymph nodes i.e. superficial cervical and deep cervical glands, sub clavicles.
Palpate and observe jugular veins and pulsation of the thyroid gland. Swelling of the thyroid gland may be due to iodine insufficiency though during pregnancy there is a slight enlargement of the glands may be due to chronic cough. Extended jugular veins may be due to cardiac problems or anaemia.
Upper limbs;

They should be two with the same size and length, skin texture and muscle wasting. Palms examined for the colour, finger nails if capillary refill is good and oedema.
Chest; see how the mother is breathing to detect if the mother has problems with respiratory
system like pneumonia.

Breasts;
– Inspection.
Observe for size, equality, shape, pulling of breasts.
Signs of pregnancy, signs of abnormalities like changes in skin e.g. redness, orange like discoloration.
Nipple for prominence, dimpling retraction, size, flat, well protracted or not.
Presence of scars, cracks, sores, axillary extension.

– Palpation
Examined for breast abnormalities and deep seated masses.
This is done to promote proper breast feeding and exclude abnormalities.
Back; Check for any fungal infections, scars, sacral oedema( may indicate PET or Eclampsia)
Lower limbs
Size, muscle wasting, pain or stiffness of joints, pain in the calf muscles, oedema, varicose veins, extra digits, any infections, tibia and ankle oedema.
Feet; Hygiene, any fungal infections, nails check for venous return and colour. Sole of the feet for cleanliness and colour.
Perform a Homan’s test
Assess for maternal efforts.
Vulva;
Check for sores, warts, varicose veins, abnormal discharges etc.

Request mother to cough while observing for discharges.

Abdominal examination

It is carried out from 24 weeks gestation to establish and affirm that fetal growth is consistent
with gestational age during pregnancy.

AIMS
  • To observe signs of pregnancy.
  • To assess fetal size and growth.
  • To assess fetal health by auscultating the fetal heart.
  • To detect any deviations from normal
  • To diagnose the location of fetal growth.
  • To locate fetal parts.

Preparation/ procedure:
 > Ensure mother has emptied the bladder within the last 30 minutes before abdominal examination.
> Ensure privacy
> Mother should be on a couch.
> Wash hands and expose only the area of the abdomen that needs to be palpated and cover the remainder of the woman to provide her privacy and protect her dignity.

STEPS

  • Inspection
  • Palpation
  • Auscultation
Inspection

Stand at the foot of the bed while mother is on her back with abdomen exposed from the xymphy sternum up to the symphysis pubis. Look at the size, shape, operational scars, signs of pregnancy like darkening of linea nigra below and above the umbilicus, fetal movements,
Striae gravidurum etc.

Palpation

> Abdominal palpation is also known as leopold’s maneuvers.
Stand at the right side of the mother, pads and not tips of fingers are used and palpate
as follows;-
>  Superficial palpation for localized tenderness.
>  Hypochondriac palpation for enlarged organs.
>  Height of fundus estimation
Pelvic palpation for presentation
>  Fundal palpation for the lie
>  Lateral palpation for position
NOTE: During a deep pelvic palpation, a midwife grips the fetal head between the thumb and fingers to check for engagement, this maneuver is termed as pawlik’s grip/second pelvic grip.

Auscultation

This is the way of listening the fetal heart to determine fetal wellbeing by use of feto- stethoscope.
Abdominal summary
-Height of fundus
-Presentation
-Lie
-Position
-Fetal heart.
Case summary

Comment on all histories, general and abdominal examination.
> Feed back
> Advice
> Return date

ONGOING ANC

PURPOSE

  • To continue to observe for maternal health and freedom from infections.
  • To assess fetal wellbeing.
  • To ascertain that fetus has adopted a lie and presentation that will allow vaginal delivery.
  • To offer an opportunity to express any fear or worries about pregnancy and labour.
  • To ensure that mother and family are confident to decide when labour starts.
  • To discuss any views about the conduct of labour and formulate a birth plan if required.
  • Risk factors arising during pregnancy
  • Change in fetal mov’t pattern- increased or reduced
  • Hb less than 10g/dl
  • Poor weight gain or weight loss
  • Proteinuria
  • Bp above 140/90mmhg
  • Uterus large or small for dates
  • Excess or decreased liquor
  • Malpresentation
  • Any vaginal bleeding
  • Premature contractions
  • Vaginal infection
  • Head not engaged by 38weeks in PGs

On each visit, do the following
>  Review the card and assess any past complaints
>  Take BP, weight and test urine
>  Carry out general and abdominal examination.
>  Give drugs accordingly.

Indicators of fetal wellbeing
  • Increased maternal weight in association with increasing uterine size.
  • Fetal movements which follows a regular pattern throughout pregnancy.
  • Fetal heart rate between 120-160b/m
FOCUSSED ANC

FANC is goal oriented care that is client centered, timely, friendly, simple beneficial and safe to
pregnant women.
>  It emphasizes quality over quantity of antenatal visits.
>  It also looks at a woman as an individual and schedules the visits according to her needs.
The aim of FANC is to provide timely and appropriate care to women during pregnancy to
reduce the maternal morbidity and mortality as well as achieving the good outcome for the baby.

Goals of FANC
  • Early detection and treatment of existing diseases.
  • Prevention of diseases.
  • Promotion and maintenance of physical, mental and social health of the mother and the baby.
  • Early detection and management of complications during pregnancy, labour, delivery and puerperium.
  • Supporting clients to develop an individual birth plan and readiness plan for possible complications.
Elements of FANC
  • Identification and management of obstetric complications e.g. pre- eclampsia.
  • TT immunization.
  • IPT for malaria.
  • Identification and management of infections including HIV and other STIs.
  • Counseling for healthy behavior including nutrition, breastfeeding and family planning.
Characteristics of effective ANC
  • Well organized and prepared healthy facility.
  • Provision of care from a skilled and motivated health care provider.
  • Preparations for birth and potential complications.
  • Individualized based on mother’s needs.
  • Promotes linkage among providers and facilities to ensure continuity of care.
  • Woman- friendly care and inclusive of her partner or family to become active participants in the care.
  • Culturally appropriate.
FANC VISITS

Women with normal pregnancy should receive atleast 4 thorough, comprehensive, individualized
antenatal visits, spread out during the entire pregnancy.

  • 1st visit: before 16 weeks of gestation.
  • 2nd visit: from 20-24 weeks of gestation.
  • 3rd visit: from 28-32 weeks of gestation.
  • 4th visit: from 36-40 weeks of gestation.

Women of high risks should make 8 visits to ANC and different activities should be done on different visits.

STEPS OF FANC
  1.  Quick check:
    Observation as the woman enters antenatal clinic/ room.
    -General appearance i.e. facial expression, weight, energy, gait and stature.
    Asking general screening questions to identify danger signs and symptoms such as severe
    headache , PV bleeding, fever etc.
  2.  History taking:
    This helps the service provider gather information about a woman.
    It is important to ensure comfort and keeping privacy and keeping the information confidential.
  3.  Physical examination:
    – General appearance
    – Blood pressure
    – Pulse and respiratory rates
    – Weight, height
    – Head to toe assessment
  4.  Investigations
    – Hb, blood group and RH factor.
    – Urinalysis for UTIs, albuminuria and glucosuria
    – Stool for ova
    – VDRL/ RPR for detection of syphilis
    – VCT for HIV
  5.  Health education:
    – Danger signs

For any of the following, seek immediate attention at the health facility

 

MotherFetus
Heavy bleedingBreathing difficulties or no breathing
Severe headacheYellowness of skin and eyes
Swelling of the feet and handsConulsions, twitching
High feverPoor sucking /failure to feed
Placenta not delivered 30 minutes of the baby’s birthInactive child
Offensive vaginal dischargeDiarrhea or constipation
Blurred visionRed swollen eyes
ConvulsionsRedness or pus from umbilicus
Loss of consciousness------------------------------------------------------------
Individual birth plan

The plan includes

  • A birth place where there is a skilled birth attendant
  • Identifying someone to take care of the family in her absence
  • My EDD
  • Her choice of birth companion.
  • Identifying a blood donor.
  • Her choice of clothes for labour.
  • Strategies for labour pain relief.
  • Position for labour and child birth.
  • Place of delivery.
  • Transportation to use and how it will be available
  • How to raise funds for transport and cost of delivery.
  • Family security and feeding provisions.
  • Family planning goals after baby is born.
  • Where to go after delivery.
  • Next appointment.

NB: Involve the partner in the birth planning process. Teach mother how to recognize onset of labour.
– Nutrition
– Sleep and resting
– Sexual counseling
– Hygiene
– Daily activities
– Weight gain
– Postnatal follow-up


6.  Immunization:
– TT

RECORD AND INTERPRETE FINDINGS
  • After taking proper history, done a thorough physical examination and relevant investigations, record all findings in the antenatal card.
  • Interpret the findings so as to identify the risk factors.
  • Give care and management accordingly.
  • Give appointment for the next visit accordingly.

Assignment
Discuss the goal oriented antenatal protocol.

PELVIC ASSESSMENT.

This is estimation of the pelvic cavity so as to see whether its adequate for that particular baby to pass through.
OR It is an examination done by a doctor or midwife on a pregnant woman at or after 36weeks to
see that both the mother and baby are out of danger at the time of delivery.

It is always done at 36weeks because of the relaxation of the pelvic joints due to Relaxin hormone.

Aims
>  To rule out poor obstetric history
>  To ensure normal delivery of the mother without any assistance.
>  To rule out abnormalities like prominent ischial spines, narrow sub pubic arch.
>  To reduce infant and maternal mortality rate.
>  To reduce injuries to both mother and fetus.

Pelvic assessment is done in 2 ways;-
-External Pelvic assessment
-Internal Pelvic assessment

EXTERNAL PELVIC ASSESSMENT /EXTERNAL PELVIMETRY

This is done on the 1st visit. It includes;-

  1.  History taking;

Age – Awoman of the age of 18 years is expected to have a mature pelvis but below 18 years, the bones are not fully ossified. A PG 35 years and above is expected to have difficult delivery because the ligaments of the pelvis are already fused there4 her give of the pelvis is impossible.
Tribe – it’s important to know the tribe because different tribes have different types of pelvis.
The Bakiga and Banyankole have a large normal pelvis but the Basoga and Baganda are at risk of contracted pelvis.
Marital status – It’s important to know the size of the husband because small women marrying giant men may carry big babies which can lead to CPD(Cephalopelvic Disproportion)
Medical history – It’s important to know because some diseases like poliomyelitis may affect the
growth of the pelvic bones and muscles.
Surgical history – Ask mother if she has ever had any accident involving her spine, pelvis and lower limbs.
Past obstetrical history – If the previous labour and delivery were normal, and if the baby weighed atleast 3kgs and over, she is expected to have an adequate pelvis. Hx of instrumental delivery or C/S may give a suspicion of an inadequate pelvis.

2.  Observations

Gait;– always be alert on a woman who walks with a limp or who has muscle wasting of the legs.
A poor gait means a deformed pelvis hence reduced diameter. It indicates congenital hip deformity.
Height;– the normal average height in women is between 152-170 cm, below 152cm, may indicate a contracted pelvis and if above 170cm indicates a narrow birth canal.
Palms;-Those with short palms indicate a small pelvis
Shoe size;– the normal shoe size is 4-8. Shoe size below 4 indicates small pelvis.
Stature;- A woman of small stature and tiny waist is not expected to have an inadequate pelvis.

3.   Abdominal examination

ENGAGEMENT OF THE FETAL HEAD(Head fitting)
NB: It’s no longer being practiced for fear of HIV transmission.
Procedure

  • Explain the procedure to the woman.
  • The bladder should be emptied.
  • The mother is relaxed flat on the bed with support on the pillow.
  • The midwife with the right hand locates the symphysis pubis while the other hand is under the mother’s head.
  • The mother takes a deep breath in and out
  • The head is pushed downwards and inwards
  • The fingers of the right hand should feel if the largest diameter of the fetal head is passing through the brim as the mother is supported to sit upright without relaxing the elbows.
  • The transverse diameter can be pushed through the pelvic brim. This test is called head fitting.

NB: It’s important that from 36weeks onwards, the abdomen is palpated to see if the head is engaged or can be made to engage.

INTERNAL PELVIC ASSESSEMENT(DIGITAL PELVIMETRY)

It’s done under aseptic technique. The midwife should know the measurement of her fingers.

Procedure:
  1. Explain procedure and ask mother to empty bladder and rectum.
  2. Prepare a VE tray and put it on the side of the bed.
  3. Screen the bed
  4. Ask mother to lie on her back and carry out abdominal examination.
  5. The midwife measures the length of her fingers.
  6. Position mother in dorsal and drape her.Right hand is gloved and two fingers of the gloved hand are lubricated, introduced and passed high into the vagina. The following are assessed.
    Sacral promontory;
    An attempt is made to reach the sacropromontory by assessing the diagonal conjugate which is 12-13cm. If short fingers less than 12-13cm reach it that shows it’s prominent.
    Hollow of the sacrum;
    It should be well curved and smooth. It should not be too long, if it’s flat the cavity is reduced and internal rotation of the fetal head will be difficult.
    Pelvic walls;
    These are felt and theyshould be smooth and flat. If they converge down wards, the mid cavity is
    reduced.
    Greater sciatic notches;
    These should feel wide. If reduced, internal rotation of the head will be difficult.
    Ischial spines;
    They are palpated to see whether they are prominent. The distance between them is estimated.
    Sub pubic arch;
    Is measured and should not be less than 90 degrees. It should accommodate 2-3 fingers. A narrow sub pubic arch reduces the AP diameter of the pelvic outlet.         Inter tuberous diameter; The distance between 2 ischial tuberosities can be assessed by inserting a closed fist between them, it should admit 4 knuckles.

NB: After the assessment, record findings and give feedback to the mother.

Antenatal Care Read More »

Drugs used in labor

Normal Pregnancy

Normal Pregnancy refers to growth and development of a fertilized ovum and begins from when the ovum is fertilized until the fetus is expelled from the uterus.

Normally the fetus is expelled at term or 9 months or 40 weeks or 280 days.
If the fetus is expelled before 28 weeks, it is called an abortion and if fetus is expelled after 28
weeks but before 37weeks it’s called premature labour and if born after 42 weeks, the post- mature is used.

Pregnancy is said to be normal when;

  • The fertilized ovum is growing in the cavity of the uterus.
  •  One fetus is forming, one placenta and two membranes.
  •  There is about 1000-1500ml of liquor amnii.
  •  There is vertex presentation.
  •  There is no bleeding until show in first stage of labour.
  •  The mother should remain healthy with no serious disorders of pregnancy.
SIGNS AND SYMPTOMS OF PREGNANCY


When a woman misses a period or two, she may suspect pregnancy and in most cases she is 98% correct if she has been menstruating regularly.


Signs of pregnancy are divided into 3 groups.

  • Presumptive
  • Probable
  • Positive
Presumptive signs


1. Amenorrhea; This is absence of menstruation. Mother may give a history of missing a period or two.
Amenorrhea may also be due to;- use of contraceptives, change of environment, long term illness and emotional upsets.


2. Breast changes; Mother may feel tingling and prickling sensations, breast enlargement and tenderness.


3. Morning sickness(nausea and vomiting); Occurs to 30-50% of the cases, it usually occurs from 4 th -14 th week of pregnancy. Other conditions may give raise to nausea and vomiting but vomiting in conjunction with amenorrhea is suggestive of pregnancy.(may disappear at end of first trimester).


4. Frequency of micturition; Caused by pressure of growing uterus on the bladder usually before 12weeks and decreases when
the uterus rises out of the pelvis at 12 weeks.


5. Skin changes; –
– Striae gravidurum appears on the 16 th week on the abdomen, thighs and breasts.
-Chloasma(mask of pregnancy).
-Linea nigra darkens and can be found below and above the umbilicus.
-Darkening of primary areolar and formation of secondary areolar.
The hormone responsible for the pigmentation of skin is produced by anterior pituitary gland and
it’s called melamine hormone.


6. Quickening; These are the first fetal movements experienced by the mother usually at 18-20 weeks in a PG
and 16-18 in a multi gravida. This helps a midwife to calculate the weeks of gestation if a mother does not know her dates.


7. Fatigue; due to increased blood production, lower blood sugar levels, and lower BP under the influence of progesterone.
Sleep disturbances and nausea may also contribute


8. Mood changes; Due to physical stress, metabolic changes, fatigue or by hormones progesterone and oestrogen.


Probable signs


1. Hagar’s sign;
This is detected from 6th -12th week. It is detected by performing a vaginal examination where 2 fingers are inserted into the anterior fornix of the vagina and another hand presses the uterus abdominally, when the fingers of both hands meet, softening if the isthmus is felt.

2. Jacquemier’s sign;
Is the bluish discoloration of the vaginal walls. It takes place from the 8th week onwards and is due to pelvic congestion an indication of pregnancy.


3. Osiander’s sign;
Its increased pulsation felt on the lateral vaginal fornices due to increased vascularity detected from the 8th week onwards.


4. Softening of the cervix (goodel’s sign)
This happens from the 8 th week onwards. The cervix of a pregnant woman is as soft as the lower lip and in a non- pregnant state is as soft as a tip of the nose.


5. Uterine soufflé;
This is a soft blowing sound heard on auscultation. It usually occurs from the 16th week due to increased vascularity of the uterus.


6. Abdominal enlargement;
The uterus enlarges rapidly and progressively from the 16 th week. This excludes gaseous distension, full bladder, fibroids and ascites.


7. Braxton hick’s contractions;
These are painless contractions which usually occur from the 16th week and are felt on abdominal palpation every 15 minutes.


8. Internal ballottement;
The uterus is given a sharp tap just above the cervix which causes the fetus to float upwards in amniotic fluid. The fetus sinks back again and it is felt by the fingers fixed in the vagina. Its detected from 16th-28th week of pregnancy.


9. Presence of HCG(Human chorionic gonadotrophin);
It can be detected in blood for 9 days and in urine 14 days. HCG can be detected in conditions like hydatid form mole.

Positive signs.


Those are signs that are definitely confirmed as pregnancy. They include;-

1. Fetal heart sounds; fetal heart begins beating by the 24th week following conception. It is audible with a Doppler by 10weeks and with a fetoscope by 24weeks. It should not be confused with uterine soufflé from pulsating fetal arteries. The normal fetal heart rate is 120-160 beats per minute.


2. Ultra sound scanning of the fetus; the gestation sac can be seen and photographed. An embryo as early as the 4th week can be identified. The fetal parts begin to appear by the 10th week of gestation.


3. Palpation of the entire fetus; Palpation must include fetal head, back, upper and lower body parts.


4. Palpation of fetal movement; this is done by a trained examiner. It is elicited after 24weeks of gestation.


5. X-ray; It will identify the entire fetal skeleton by the 12 th week. In utero the fetus receives total body radiation that may lead to genetic or gonadal alterations .An x-ray is not a recommended test for identifying pregnancy.


6. Actual delivery of the baby.

DIFFERENTIAL DIAGNOSIS


Enlargement of the abdomen may be caused by other conditions other than pregnancy, these
include;-

  • Ovarian cysts.
    They may cause abdominal enlargement and when palpated abdominally, the swelling can be separated from the uterus and pregnancy tests will be negative.
  •  Fibroids.
    These may be mistaken for pregnancy and normally a hard mass is felt and when pregnancy tests are done, results are negative.
  •  Distended urinary bladder.
    In case of urine retention, the catheter will be passed and there will be no other signs of
    pregnancy.
  •  Pseudocyesis. In this condition, amenorrhea and other signs suggesting pregnancy will be given by a mother who is anxious to have a baby. When examination is carried out, signs of pregnancy are absent.
PHYSIOLOGY OF PREGNANCY

These are normal natural changes that occur in the body due to pregnancy. These result mainly from alteration of hormones and metabolism.

CHANGES IN THE ENDOCRINE SYSTEM
  1. Hormonal changes:
    The placenta produces several hormones which cause a number of physiological changes.
    Successful physiological adaptation of pregnancy is due to alterations in hormone production by
    the maternal endocrine system and the trophoblast.
  2.  Human chorionic gonadotrophic hormone.
    It is produced by the trophoblast. H.C.G levels increase rapidly in early pregnancy, maximum
    levels being attained at 8-10 weeksof gestation. The main function of HCG is to maintain the
    corpus luteum in order to ensure secretion of progesterone and Oestrogen until placental
    production is adequate after 10-12 weeks after which concentration of HCG gradually decreases
    until it has completely disappeared 2 weeks after birth.
  3.  Progesterone hormone;
    This is produced mainly in the corpus luteum. Its function is to thicken the decidua in order to
    receive a fertilized ovum. It helps to increase the glandular tissue, ducts of the breasts and muscle
    fibres of the uterus.
  4.  Oestrogen;
    It causes growth of the uterus and duct system of the breasts in pregnancy. It is excreted in urine
    and amount present indicates fetal wellbeing.
  5.  Relaxin hormone;
    During the last weeks of pregnancy, it acts on ligaments and joints producing the “give” of the pelvis. It is also produced by decidua and the trophoblast to promote myometrium relaxation and
    may play a role in cervical ripening and rapture of membranes.
  6. HPL ( human placental lactogen): It stimulates the growth of breasts and has lactogenic properties that affect a number of metabolic changes. These changes brought about by HPL ensure that glucose is readily available for body and brain growth in the developing fetus, and protects against nutritional deficiencies.
  7. Pituitary hormones: The follicle stimulating hormone and L.H are suppressed by the high levels of Oestrogen and progesterone. The adrenal gland increases only slightly in size during pregnancy due to hypertrophy and widening in glucocorticoid area which suggests increased secretion of hormones.
  8. Thyroid function: In normal pregnancy, the thyroid gland increases due to hyperplasia of glandular tissue and increased vascularity. There is normally an increased uptake of iodine during pregnancy which may be to compensate for renal clearance of iodine leading to reduced level of plasma iodine.
CHANGES IN THE REPRODUCTIVE SYSTEM
CHANGES IN THE UTERUS:
It stretches and expands to accommodate and nurture the growing fetus. This occurs in the
myometrium. The body grows to provide a nutritive and protective environment in which the fetus will develop and grow.

Uterine muscle layers;
1. Endometrium;
– Menstruation stops.
-It becomes the decidua during pregnancy.
-It becomes thick, soft, spongy and readily supplied with blood.

2 . Myometrium.

  • The enlargement of the body of the uterus is due to 2 factors.
    1. The actual muscle fibres enlarge increasing in length about 10 times and in width about 3 times.
    This process is called hypertrophy (increase in size).
    2. The new muscle cells make their appearance and grow alongside the original muscle cells. This process is called hyperplasia (increase in number).
    The size; as pregnancy advances, the uterus grows from its normal size. The length being 7.5cm,
    width 5cm and thickness 2.5cm. So it becomes 30cm in length, 23cm in width and 20 cm in
    thickness. The weight increases from 60g to 960g.
    The shape; Health growth of the uterus requires adequate space to accommodate the growing fetus, increasing amount of liquor and placental tissue. After conception, the uterus enlarges
    because of Oestrogen. At the beginning of pregnancy, it is pear shaped organ, at the end of 12 weeks, it is globular, from 12-38weeks its oval shaped and when lightening takes place after 38weeks, it turns back to globular.

Muscle layers of the myometrium;

  1.   Outer most longitudinal layer,
    This layer begins in the anterior wall of the upper uterine segment, passes over the fundus and down the posterior wall. It is by contraction and retraction of this muscle layer that the fetus is expelled from the uterus during labour.
  2. Middle oblique layer,
    In this case, muscles are arranged in criss cross manner; the muscle cells surround the blood vessels in the figure of 8 pattern. After separation and expulsion of the placenta, they compress the blood vessels and help to prevent PPH. They are sometimes referred to as living ligatures.
  3.   Inner circular layer,
    This is the weakest of the 3 layers, the muscle fibres pass transversely around the uterus. They are more developed around the cervix, lower uterine segment and the fallopian tubes. They help in cervical dilatation.

3. The perimetrium;
This is the layer of the peritoneum which does not totally cover the uterus, its deflexed over the bladder anteriorly to form the utero vesicle pouch and posteriorly forming pouch of Douglas. After 12 weeks, the uterus rises out of pelvis and becomes an abdominal organ. It loses its ante-version and ante flexed position and becomes erect and leans on its axis on the right.

walls of the uterus
CLINICAL OBSERVATIONS OF THE GROWING UTERUS
  • At 12 weeks

The uterus is out of the pelvis and becomes upright; it is no longer anteverted and ante flexed. The uterus is palpable just above the symphysis pubis and is about the size of a grape fruit.

  • At 16 weeks

Between 12 and 16 weeks, the fundus becomes dome shaped. As it rises, it rotates to the right (dextrorotation) due to the recto sigmoid colon in the left side of the pelvis and exerts tension on the broad and round ligaments.
The conceptus has grown enough to put pressure on the isthmus causing it to open out so that the uterus becomes more globular in shape.

  • At 20 weeks

The fundus of the uterus may be palpated at the level of the umbilicus. The uterus becomes more rounded around the fundus.

  • At 30 weeks

The fundus may be palpated midway between the umbilicus and ximphoid sternum. Enlarging uterus displaces the intestines laterally and superiorly. Abdominal wall supports the uterus and maintains the relationship btn the long axis of the uterus and axis of the pelvic inlet.
In supine position, the uterus falls back to the vertebral column, aorta and inferior venacava.

  • At 36 weeks

By the end of 36 weeks, the enlarged uterus fills the abdominal cavity. The fundus is at the tip of the ximphoid cartilage.

  • At 38 weeks

Between 38 and 40 weeks, there is increase in smoothening and softening of the lower uterine segment. Uterus becomes more rounded with a decrease in fundal height. The reduction in fundal height is known as lightening.

Changes in blood supply: The uterine blood vessels increase in diameter and new vessels develop under the influence of Oestrogen. Blood supply to the uterine and ovarian arteries increases to about 750ml/ min at term to keep pace with its growth and meet the needs of the functioning placenta.


Changes in the fallopian tubes: On either side are more stretched out and are more vascular in pregnancy. Uterine end of the tube is usually closed and fimbriated end remains open.


Changes in the isthmus;
It softens and elongates from 7mm to23mm and forms the lower uterine segment during late pregnancy.


Changes in the ovaries:
The follicle- stimulating hormone {FSH} ceases its activity due to the increased levels of estrogen and progesterone secreted by the ovaries and corpus luteum .This prevents ovulation and menstruation. As the uterus enlarges, the ovaries are raised out of the pelvis. Also both ovaries are enlarged due to increased vascularity and become edematous particularly that containing the corpus luteum.
The corpus luteum enlarges during early pregnancy and may even form a cyst on the ovary. The corpus luteum produces progesterone to help maintain the lining of the endometrium in early pregnancy. It functions until about the 10th and 12th week of pregnancy when the placenta is capable of producing adequate amounts of progesterone and estrogen. It slowly decreases in size and function after the 10th to 12th week.


Changes in the cervix:
It remains tightly closed during pregnancy, providing protection to the fetus and resistance to pressure from above when the woman is in standing position. There is slight growth on the cervix during pregnancy, it becomes softer and this is due to increased vascularity and relaxing effects of hormones.
Under the influence of progesterone racemose glands secrete thicker and more viscous mucus which fills the cervical canal and prevents entry of infection in the uterus. The plug of mucous is called opeculum
Towards the end of pregnancy or at the onset of labour the cervix becomes part of the lower
uterine segment, this is called effacement of the cervix. The external os of the cervix also admits a finger. A short softened cervix or os which admits the
tip of a figure at term is referred to as ripe cervix.


Changes in the vagina:
The muscle layer hypertrophies and capacity of vagina increases and it becomes more elastic
allowing it to dilate during 2 nd stage.
The epithelium becomes thicker with increased desquamation of the superficial cells which
increase the amount of normal white virginal discharge known as leucorrhea. The epithelial cells have high glycogen content. The cells interact with Do-derlein’s bacillus and produce a more acidic environment providing extra degree of protection against some organism and increasing susceptibility to others such as candida albicans. The vagina is more vascular and appears violet in colour.


Changes in the vulva:
The vulva appears bluish in colour due to increased vascularity and pelvic congestion.


Breast changes:
-In early pregnancy, breasts may feel full or tingle and increase in size as pregnancy progresses.
-The nipples become more erectile.
– The areolar of the nipples darken and the diameter increases.
– The sebaceous glands become the Montgomery’s tubercles which enlarge and tend to
protrude.They secrete sebum to lubricate the breast throughout pregnancy and breast feeding.
– The surface vessels of the breast become visible due to increased circulation and turns to bluish
tint on the breasts.
-A little clear, sticky fluid(colostrum) may be expressed from the nipples after the 1 st trimester
which later becomes yellowish in colour.

Changes in the cardiovascular system:

The heart
Due to increased work load, the heart hypertrophies particularly in the left ventricle. The uterus pushes the heart upwards and to the left. Heart sounds are changed and murmurs are common.
The cardiac output is increased by 40%. The heart rate increases by an average of 15 beats per minute. The stroke volume increases from 64 to about 71mls.

Effect on blood pressure
During the first trimester, blood pressure remains almost constant. BP drops in 2 nd trimester due to hormone progesterone which causes vasodilation. It reaches its lowest level at 16-20 weeks and towards term, it returns to the level of the first trimester. The decrease may lead to fainting.
Supine position should be avoided in pregnancy as it leads to supine hypotensive syndrome due to compression of the inferior venacava thus reducing venous return. Poor venous return in late pregnancy may lead to oedema in lower limbs, varicose veins and hemorrhoids.


Blood flow
Blood flow increases to uterus, kidneys, breasts and skin but not to liver and brain. Utero
placental blood flow increases by 10-15% about 75mls per minute at term. Renal blood flow increases by 70-80%.


Blood volume
Increase in blood volume varies according to the size of the woman, number of pregnancies she has had, parity and whether the pregnancy is singleton or multiple.
The total blood volume increases steadily from early pregnancy to reach a maximum of 35 to 45% above the non- pregnant level. A higher circulating volume is required for the following;
-To provide extra blood flow for placental circulation.
-To supply the extra metabolic needs of the fetus.
-To provide extra perfusion of kidneys and other organs.
-To compensate for blood loss at delivery.
-To counterbalance the effects of increased venous and arterial capacity.


Plasma volume
Increases by 40% where the red cell mass decreases by 20%leading to haemodilution (physiological anaemia). These changes begin at 6-8weeks of pregnancy. The acceptable Hb level in pregnancy is 11-12g/dl.

Iron metabolism
Iron of about 1000g is needed. 500g is to increase the red cell mass, 300g to fetus and 200g for daily iron compensation.

In normal pregnancy, only 20% of ingested iron is absorbed. The purpose of iron supplementation is to prevent iron deficiency anaemia not to raise Hb level.


Plasma protein
During the 1st 20 weeks of pregnancy, plasma protein concentration reduces due to increased plasma volume. This leads to lowered osmotic pressure leading to oedema of lower limbs seen in late pregnancy. In absence of disease, moderate oedema is termed as physiological oedema.


Clotting factors
Fibrinogen 7,8,9 and 10 increase leading to a change in coagulation time from 12 to 8 minutes.
The capacity of clotting is increased in preparation to prevent PPH after separation of the placenta.


White blood cells.
These are slightly increased during pregnancy, from 700mm to 10500mm during pregnancy and up to 1600mm during labour. The total count cells rises from 8 weeks and reaches a peak at 30 weeks of gestation. This is mainly because of the increase in the number of neutrophils, polymorphs, nucleus, leucocytes, monocytes and granulocytes are active and efficient phagocytes.


Erythrocytes.
They decrease during pregnancy from 4.5million to 3.7million.


HB.
HB concentration falls from 14g/dl; a falling HB is a physiological. The total iron requirements of pregnancy where as a high HB level can be assign of pathology. The total requirements of
pregnancy is averagely 1000g ,about 500gare required to increase the red cells mass and about 300g are transported to the fetus mainly in the last weeks of pregnancy . The remaining 200g are needed to compensate for insensible loss in skin, stool and urine.

RESPIRATORY SYSTEM.
The basal metabolism rate is increased and the volume of air which enters and leaves the lungs during the normal respiration becomes slightly increased. This is because of increased oxygen consumption by the fetus and the work of maternal heart and lungs.
In the late pregnancy the ribs flare out inhibiting the capacity of the thoracic cavity to expand, the enlarging uterus elevates the diaphragm up wards and compresses the lower lobes of the lungs


CHANGES IN THE URINARY SYSTEM
Renal blood flow and glomerular filtration rate increases by 50%.
There is frequency of micturition in early and late pregnancy. Ureters become elongated and kinked due to progesterone hormone and this results into urine stagnation hence increased favor to UTI in pregnancy.

CHANGES IN THE GIT
-The gums become edematous, soft and spongy and may bleed.
-Increased salivation(ptyalism) is common.
-Nausea and vomiting is common in 70% of the cases.
-Changes in taste becoming metallic.
-Craving for abnormal things like soil or plaster known as pica.
-Increased appetite in most women.
-Heart burn due to of stomach content from decreased space by growing uterus.
-There is reduced GIT motility leading to constipation.

Changes in metabolism
– There is increased metabolism to provide nutrients for the mother and fetus.
-Maternal weight, There is continuing weight increase in pregnancy which is an indication of
fetal growth.
Weight gain in pregnancy is as follows;-
4kg in the 1 st 20 weeks(0.2kg/week)
8.5kg in the last 20 weeks(0.4kg/week)
12.5kg approximate total.

 

Maternal weight gain
Content weight
Uterus 1kg
Breasts 0.4kg
Fat 3.5kg
Blood volume 1.5kg
Extra cellular fluid 1.5kg
Total7.9kg
Fetal weight gain
Fetus 3.4kg
Placenta 0.6kg
Amniotic fluid 0.6kg
Total4.6kg
GRAND TOTAL12.5kg

The following factors influence weight gain.
Maternal oedema.
Maternal metabolic rate.
Dietary intake.
Vomiting or diarrhea.
Amount of amniotic fluid.
Size of the fetus.


CHANGES IN THE MUSCULO-SKELETAL SYSTEM
Progesterone and Relaxin lead to relaxation of pelvic ligaments, joints and muscles. The relaxation allows the pelvis to increase its capacity in readiness to accommodate the presenting part towards term and also during labour. The symphysis pubis and sacroiliac joints soften, the gait of the mother changes as the balance of the body is altered by the weight of the
uterus. Allowing the pelvis to increase its capacity towards term is a process known as a give.

SKIN CHANGES
Increased activity of melanin-stimulating hormone from the pituitary causes varying degrees of pigmentation in pregnant women from the end of 2 nd month until term.The areas that are commonly affected are; areolar of the breasts, abdominal mid line, perineum and axilla. This is because of increased sensitivity of the melanocytes to the hormone or because of greater number of melanocytes in these areas.
-Linea nigra. This is a dark line that runs from the umbilicus to the symphysis pubis and may
extend as high as the sternum. It is hormone induced pigmentation. After delivery, the line begins to fade though it may not ever completely disappear.
-Mask of pregnancy(Cloasma). This is the brownish hyper pigmentation of the skin over the face, fore head, nose, cheeks and neck. It gives a bronze look especially in black complexioned
women.
-Striae gravidurum(stretch marks).
-Sweat glands. Activity of the sweat glands usually increases throughout the body which causes the woman to perspire more profusely during pregnancy.
– A rise in body temperature of 0.5 and increase in blood supply causes vasodilation and makes
woman feel hotter.

MINOR DISORDERS OF PREGNANCY

These are referred to as minor because they are not life threatening.
The causes can be;-

  • Hormonal changes
  • Accommodation changes
  • Metabolic changes and
  • Postural changes


DIGESTIVE SYSTEM
Nausea and vomiting (morning sickness)
This is due to hormonal changes progesterone and Oestrogen and high level of HCG, it occurs from 4-16 weeks. This decreases when the placenta fully takes over.
Management
-Light snacks
-Carbohydratesnack like cassava, a hard crackers
-Avoid sweet things
-Coming out of the bed slowly.
Heart burn
Burning sensation in the media sternal region progesterone relaxes the cardiac sphincter and allows reflux of gastric contents into esophagus most troublesome between 30-40 weeks, because of pressure on stomach from growing uterus.
Management
-Avoid bending

-Small frequent meals
-Sleeping with more pillows
-Persistent heart burn antiacids like magnesium triscilicate.
Excessive salivation (ptyalism)
From 8 weeks, hormones are thought to be the cause. It may accompany heart burn. Counseling is helpful.
Constipation
Progesterone cause relaxation of the plain muscles and decreased peristalsis of the gut.
Management
-Increased intake of water, fresh fruit, vegetables and whole meal foods in diet.
-Glass of warm water in the morning, before tea and breakfast may activate the gut.
– Exercise can be helpful especially walking.
Aperients are only considered as a last resort.
Pica
This is when a mother craves for certain foods or unnatural substances.
The cause is unknown but hormones and changes in metabolism are attributed to it.


MUSCULO SKELETAL SYSTEM
This can be due to hormones Relaxin. Discuss with woman and let her be aware, it will
disappear after delivery.
Leg cramps
Cause of leg cramp in pregnancy is unknown may be due to ischemia or a result from changes in PH or electrolyte status.
Management
-Mother to dorsiflex the foot and raise foot of bed.
-Gentle leg movement before sleeping at night.
-Others-use of vit B complements and calcium.

Backache
The weight of the pregnant uterus and altered posture increase susceptibility which is exacerbated by progesterone and Relaxin causing relaxation and softening of ligaments of the pelvis.
Management
-Avoid high heeled shoes.
-Sit on a comfortable chair or support the back on a wall while seated.
-Have extra rest during the day.


CIRCULATORY SYSTEM
Fainting
In early pregnancy, it may occur due to vasodilation under the influence of progesterone before there has been a compensatory increase in the blood volume.
Management
-Avoid long standing periods.
-Quickly sit or lie down if feels slightly faint,
-Mother should avoid lying on her back except during abdominal examination.
Vericose veins
-Progesterone relaxes smooth muscles of veins and results in sluggish circulation. Varicose veins
may occur in legs, anus and vulva.
Management
During pregnancy
-Support tights increase comfort eg stockings.
-Avoid constipation.
-A sanitary pad may give support.
-Use a crepe bandage on affected leg from below upwards before getting out of bed in the
morning and remove it at night.
-The affected leg should be elevated when resting.

-advise mother to see the doctor if varicose veins appear on the vulva.
-In case of severity, book mother for hospital deliverysince they can easily rapture and cause
severe bleeding.
During labour
-Inform doctor.
-Take off blood for Hb, grouping and x-matching.
-Be careful when shaving the vulva and when performing an episiotomy.
-Sedatives are given to prevent premature pushing.
Hemorrhoids
These are veins of the vulva or rectum and they usually occur due to constipation. They can be painful, edematous and ulcerative.
Management
-Advise mother on diet to avoid constipation.
-Use cold compress gently on the area.
-Doctor may order analgesic like anusol.

Heart palpitations
This occurs due to increased functioning of the heart to meet the demands of the growing fetus
and mother.

NERVOUS SYSTEM
Carpal tunnel syndrome
The mother complains of numbness, pins and needles in her fingers and hands.
It’s caused by fluid retention which causes oedema and pressure on the median nerve by compressing it.
Management
-Wearing a splint at night and rising hands on a pillow at night.

-If it persists, refer to doctor who will give diuretics.
Insomnia
This is failure to get sleep and may be caused by worries, anxietyand it shouldn’t be taken
lightly.
Emotional instability
Hating, irritation,loving i.e. willing to stay closer to partner.

GENITAL URINARY SYSTEM
Leucorrhoea
This is increased, non- irritant, vaginal discharge.
Management
-Ensure hygiene if distressing.
-Wear cotton under pants for easy absorption.
Frequency of micturition
This occurs in early pregnancy when the growing fetus is still in the pelvic cavity and late pregnancy when the PP descends and competes for space needed by bladder.

INTEGUMENTARY SYSTEM
Itching of the skin
This can be due to Striae gravidurum, poor hygiene, heat rash and minor skin rashes.
Management
-Wear cotton clothes which are non-irritating.
-Advise on personal hygiene.
-Apply calamine lotion in case of skin rash.


Disorders which require immediate action

  • Vaginal bleeding.
  • Reduced fetal movements.
  • Frontal or recurrent headache.
  • Sudden swelling or oedema.
  • Early rapture of membranes.
  • Premature onset of contractions
  • Maternal exhaustion at whatever extent.
  • Fits.
  • Excessive nausea and vomiting.
  • Epigastric pain.

Normal Pregnancy Read More »

terminologies

Terminologies

TERMS USED IN MIDWIFERY


Midwifery: It is profession of providing assistance and medical care to women undergoing labour and child birth during antenatal, pre-natal and postnatal period.


Obstetrics: This is abranch of medicine dealing with pregnancy, labour and puerperium.


Caesarian section: Is an incision made on the uterus through the anterior abdominal wall to remove products of gestation after 28weeks of gestation.


Cephalic: Means head.


Cervix: Is the neck of the uterus


Colostrum: This is afluid found in the breast from the 16 th week of pregnancy up to 2 nd and 3 rd day after delivery.


Crowning: This is wherethe largest transverse diameter of the fetal skull escapes under the sub pubic arch and does not recede back between contractions.


Gestation: Pregnancy or maternal condition of having a developing fetus in the body.


Fetus: Human conceptus from the 9 th week to delivery.


Viability: Capability of living usually accepted 24weeks-28 weeks although survival is rare.


Gravida: Woman who is or has been pregnant regardless of pregnancy outcome.


Prime gravida: Woman pregnant for the first time.


Multi gravida: Woman who has been pregnant more than once.


Nuli Para: Woman who is not now and has never been pregnant.


Parity: Is number of children born alive or dead after 28weeks of gestation.


Vernix caseosa: Is a greasy substance that covers the baby’s skin at birth.


Meconium: This is stool of the neonate that is present in the lower bowel at 16weeks of
gestation and is passed within 3 days following birth, its greenish black in colour.


Lightening: This is drop in fundal height.


Show: The bloody stained mucoid discharge seen at the onset of labour

Terminologies Read More »

Parkinson's Disease

Parkinson’s Disease

PARKINSON’S DISEASE

Parkinson’s disease is a neurodegenerative disorder characterized by the progressive loss of dopamine-producing cells in a specific region of the brain called the substantia nigra. 

This loss of dopamine leads to abnormal brain activity and the manifestation of various motor and non-motor symptoms. 

Cause of Parkinson’s Disease

The exact cause of Parkinson’s disease remains unclear, but it is believed to involve a combination of genetic and environmental factors. The exact cause of Parkinson’s Disease (PD) is unknown.

A combination of genetics and environmental factors is believed to trigger PD.

Factors that contribute to PD include:
  • Dopamine deficiency: Parkinson’s disease is characterized by the loss of dopamine-producing neurons in the brain. Dopamine is a neurotransmitter that plays a crucial role in movement control, so a deficiency leads to motor symptoms like tremors and rigidity.
  • Loss of norepinephrine: Norepinephrine is another neurotransmitter affected in Parkinson’s disease. It regulates various functions, including blood pressure, heart rate, and mood. Its loss can contribute to non-motor symptoms such as fatigue and changes in blood pressure.
  • The protein alpha-synuclein: This protein can form abnormal clumps called Lewy bodies in the brains of people with Parkinson’s disease. These clumps are thought to damage nerve cells and contribute to the development of the disease.
  • Genetics: While most cases of Parkinson’s disease are not directly inherited, certain genetic mutations can increase a person’s risk of developing the condition.
  • Environmental factors: Exposure to certain environmental toxins, such as pesticides and heavy metals, has been linked to an increased risk of Parkinson’s disease.
  • Mitochondria: Dysfunction of mitochondria (the energy-producing structures within cells) may play a role in Parkinson’s disease by leading to oxidative stress and cell damage in the brain.
Pathophysiology of Parkinson's disease:

Pathophysiology of Parkinson’s disease: 

Parkinson’s disease is a progressive neurological disorder that affects movement. The disease is believed to be caused by the death of dopamine-producing cells in the substantia nigra, a part of the brain that helps control movement.

This leads to a depletion of dopamine, a neurotransmitter that helps regulate movement. The loss of dopamine causes problems with nerve signaling in the brain, which leads to the characteristic symptoms of Parkinson’s disease, such as tremors, rigidity, bradykinesia (slowness of movement), and postural instability. These symptoms arise due to the imbalance of excitatory and inhibitory neurotransmitters in the corpus striatum.

In details;

  1. Initiating Factors: Antipsychotic drugs, encephalitis, and other causes can initiate the process.
  2. Substantia Nigra Affected: These factors affect the substantia nigra (SN), a brain region critical for motor control.
  3. Destruction of Dopaminergic Neurons: Leads to the destruction of dopaminergic neuronal cells within the substantia nigra, located in the basal ganglia.
  4. Depletion of Dopamine: This destruction causes a depletion of dopamine stores, a key neurotransmitter involved in movement.
  5. Degeneration of Nigrostriatal Pathway: The dopaminergic nigrostriatal pathway, which connects the substantia nigra to the corpus striatum, degenerates.
  6. Neurotransmitter Imbalance: An imbalance occurs between excitatory (acetylcholine, Ach) and inhibitory neurotransmitters in the corpus striatum, disrupting normal signaling.
  7. Motor Control Impairment: Results in difficulty controlling and initiating voluntary movements.
  8. Parkinson’s Disease Manifestation: Ultimately leads to the manifestation of Parkinson’s disease, characterized by:
  • Tremors
  • Rigidity
  • Bradykinesia (slowness of movement)
  • Postural changes
The 5 Stages of Parkinson's Disease

The 5 Stages of Parkinson's Disease

1. Stage One: Mild Symptoms on One Side

In the beginning, symptoms are very mild and only affect one side of the body. You might notice a patient has a slight tremor (shaking) in one hand or leg, or some stiffness. One side of their face may also show less expression. At this stage, the person can usually continue with their daily activities without much trouble.

2. Stage Two: Symptoms on Both Sides

The stiffness and tremors now spread to affect both sides of the body. The person's posture may start to change, and they may walk more slowly. Their face might look more "mask-like" with less blinking, and their speech can become softer or slower. Balance is not yet a major problem, but everyday tasks will take longer to complete.

3. Stage Three: Balance Problems Begin

This is the middle stage where loss of balance becomes the main problem. The person's movements are much slower, and falls become more common. They can still be independent in many ways (like dressing and eating), but activities are now more difficult. They might need some help to stay safe.

4. Stage Four: Needing Help to Stand and Walk

At this stage, the symptoms are severe. The person needs help to stand up and walk, and may use a walker or other assistive device. They are no longer able to live alone safely and will need a lot of help with daily care. While they may still be able to stand or walk for short periods, it is very difficult.

5. Stage Five: Full-Time Care Needed

This is the most advanced stage. Severe stiffness in the legs may make it impossible to stand or walk, so the person may be in a wheelchair or bed-bound. They require 24-hour nursing care for all their needs. Some patients may also experience confusion, hallucinations (seeing things that are not there), or dementia.

Clinical Features of Parkinson’s Disease 

1. Motor Symptoms: 

  • Tremors: Tremor present at rest but not during sleep characterized by rhythmic movements of 4 – 5 cycles a second and can occur in the head, facial muscles, limbs, jaw and lips. Micrographic (tiny handwriting) pill rolling character due to movement of the thumb across the palm also occurs. Tremors are increased by emotions.
  • Rigidity: Muscles are stiff with pain in severe cases; rigidity may be continuous or intermittent. Fine limb movements are difficult to perform. Stiffness or resistance in muscles, making movements less fluid and causing muscle pain or discomfort. 
  • Akinesia: Loss or impairment in power of voluntary movement. Bradykinesia (slowness in walking) and hypokinesia (loss of movement): rising from a chair
    becomes difficult and takes several attempts of falling back.
  • Imbalance: Change in gait, tendency to walk forward on toes with small steps may be accelerated. Fascination (work with short steep with no arm swinging) propels patient either forward or backward propulsively until falling is inevitable
  • Postural Instability: Changes in balance ie stooped over posture when up right, difficult in entertaining balance when sited erect and semi flexed arms.  Impaired balance and coordination, resulting in a tendency to stoop, shuffle while walking, and increased risk of falls. 
  • Bradykinesia: This means slowness of movement and speed (or progressive hesitations/halts) as movements are continued. It is one of the cardinal symptoms of Parkinson’s disease (PD). You must have bradykinesia plus at least either tremor or rigidity for a Parkinson’s diagnosis to be considered.

2. Non-Motor Symptoms: 

  • Cognitive Changes: Some individuals with Parkinson’s disease may experience mild cognitive impairment, memory problems, difficulty with executive functions, and in later stages, dementia. 
  • Sleep Disorders: Including insomnia, restless leg syndrome, excessive daytime sleepiness, and rapid eye movement sleep behavior disorder (acting out dreams during sleep). 
  • Autonomic Dysfunction: Symptoms may include orthostatic hypotension (low blood pressure upon standing), constipation, urinary problems, excessive sweating, and sexual dysfunction. 
  • Mood and Behavioral Changes: Depression, anxiety, apathy, and changes in mood or behavior are common in Parkinson’s disease. 
  • Sensory Symptoms: Loss of sense of smell (anosmia) and visual disturbances such as blurred or double vision. 
  • Speech and Swallowing Difficulties: Speaking softly, slurred speech, difficulty swallowing (dysphagia), and drooling may occur. 
  • Pain and Fatigue: Some individuals with Parkinson’s disease may experience pain, muscle cramps, and fatigue.

Diagnosis of Parkinson’s Disease

1. Medical History: The doctor will begin by taking a detailed medical history, including asking about the patient’s symptoms, their duration, and any family history of Parkinson’s disease. 

2. Physical Examination: A thorough physical examination will be conducted to assess motor symptoms such as tremors, rigidity, bradykinesia (slowness of movement), and postural instability. The doctor will also look for other possible causes of these symptoms. 

3. Assessment of Symptoms: The doctor may use standardized rating scales, such as the Unified Parkinson’s Disease Rating Scale (UPDRS), to evaluate the severity of symptoms and track disease progression. 

4. Response to Medication: Parkinson’s disease symptoms often respond positively to dopaminergic medications. The doctor may prescribe a trial of medication, such as levodopa, to observe if there is a significant improvement in symptoms. This can help support the diagnosis of Parkinson’s disease. 

5. Neurological Examination: A neurological examination may be performed to evaluate other neurological signs and rule out alternative diagnoses. 

6. Imaging Studies: While imaging studies are not mandatory for diagnosis, they can help exclude other conditions that mimic Parkinson’s disease. Imaging techniques such as magnetic resonance imaging (MRI) or computed tomography (CT) scans can be used to assess the brain structure and rule out other causes. 

7. Laboratory Tests: There are no specific blood tests to diagnose Parkinson’s disease. However, blood tests may be performed to rule out other medical conditions that can present with similar symptoms. 

 

Management of Parkinson’s Disease 

Unfortunately, as of 2025, Parkinson’s disease can’t be cured, but medicines can help control the symptoms. Medicines often work very well. When medicine is no longer helping, Surgery may be considered.

Aims of Management

  • The primary goal in the management of PD is to treat the symptomatic motor and nonmotor features of the disorder, with the objective of improving the patient’s overall quality of life.
  • To relieve symptoms and maintain functioning to improve quality of life.
Medical Management

1. Levodopa (L-Dopa) – Class: Dopamine Precursor 

  • Dosage: 50 – 125 mg three times daily immediately after meals. 
  • Side Effects: Nausea, vomiting, orthostatic hypotension (low blood pressure upon standing), dyskinesias (involuntary movements), hallucinations, confusion, and sleep disturbances. – Contraindications: Use with caution in patients with a history of psychosis, glaucoma, or melanoma. Avoid concurrent use with non-selective monoamine oxidase inhibitors (MAOIs).

2. Carbidopa-Levodopa – Class: Dopamine Precursor with Decarboxylase Inhibitor 

  • Dosage: The dosage is based on the ratio of carbidopa to levodopa, such as 25/100 8 hourly or 25/250 8 hourly. 
  • Side Effects: Similar to levodopa alone, but carbidopa helps reduce the peripheral side effects of levodopa, such as nausea and vomiting. 

3. Dopamine Agonists – Class: Dopamine Receptor Agonists 

  • Examples: Pramipexole, Ropinirole, Rotigotine 
  • Dosage: The dosage varies depending on the specific medication and individual needs. It is initiated at a low dose and gradually increased. 
  • Side Effects: Nausea, dizziness, orthostatic hypotension, hallucinations, impulse control disorders (such as gambling or hypersexuality), and sleep disturbances. 

4. MAO-B Inhibitors – Class: Monoamine Oxidase-B Inhibitors 

  • Examples: Selegiline, Rasagiline 
  • Dosage: The dosage varies depending on the specific medication. It is usually taken once or twice daily. 
  • Side Effects: Nausea, headache, insomnia, and potential interactions with certain foods and other medications. 
  • Contraindications: Use with caution in patients with a history of psychosis, cardiovascular disease, or peptic ulcer disease. Avoid concurrent use with non-selective MAOIs. 

Specific Nursing Interventions for a patient with Parkinson’s disease: 

1. Promote Safety: 

– Assess the patient’s environment for potential hazards and remove obstacles to prevent falls. 

– Encourage the use of assistive devices such as canes or walkers to improve stability and reduce the risk of falls.

– Provide education to the patient and their caregivers about fall prevention strategies and home safety modifications. 

2. Assist with Mobility: 

– Encourage regular physical exercise and activities tailored to the patient’s abilities to improve mobility, balance, and coordination. 

– Collaborate with physical and occupational therapists to develop a personalized exercise and rehabilitation plan. 

– Use appropriate techniques to assist the patient with transfers, ambulation, and maintaining proper body alignment. 

3. Facilitate Communication: 

– Encourage the patient to speak slowly and clearly, taking breaks between phrases to improve speech clarity. 

– Use visual cues, gestures, or written communication aids to supplement verbal communication. 

– Refer the patient to a speech therapist for evaluation and management of speech difficulties. 

4. Support Swallowing: 

– Provide the patient with a modified diet, including texture modifications or swallowing strategies as recommended by a speech therapist. 

– Offer small, frequent meals to minimize fatigue and aid digestion. 

– Encourage the patient to maintain an upright position while eating and drinking to facilitate swallowing. 

5. Optimize Medication Management: 

– Collaborate with the healthcare team to ensure timely administration of prescribed medications for symptom management. 

– Monitor the patient’s response to medications and report any side effects or changes in symptoms. 

– Educate the patient and caregivers about the importance of medication adherence and the proper administration of medications. 

6. Manage Constipation: 

– Encourage the patient to maintain a high-fiber diet and an adequate fluid intake. 

– Recommend regular exercise and physical activity to promote bowel regularity. 

– Discuss with the healthcare team the use of stool softeners or laxatives if necessary. 

7. Provide Emotional Support: 

– Offer empathetic and compassionate care to address the emotional and psychological impact of the disease. 

– Encourage the patient to express their feelings and concerns, providing a supportive and non-judgmental environment.

– Refer the patient and their caregivers to support groups or counseling services to connect with others facing similar challenges. 

8. Monitor Mental Health: 

– Assess the patient for signs of depression, anxiety, or cognitive impairment. 

– Collaborate with the healthcare team to manage and treat mental health symptoms. 

– Encourage engagement in activities that promote mental stimulation, such as puzzles, reading, or social interactions. 

9. Promote Sleep Hygiene: 

– Educate the patient about good sleep hygiene practices, such as maintaining a regular sleep schedule, creating a comfortable sleep environment, and avoiding stimulants before bedtime. 

10. Educate the Patient and Caregivers: 

– Provide education on Parkinson’s disease, its symptoms, and expected progression. 

– Teach self-management strategies, including medication management, exercise, and symptom recognition. 

– Inform the patient and caregivers about available community resources and support services. 

Possible Nursing Diagnosis 

 

1. Impaired Physical Mobility related to bradykinesia and rigidity as evidenced by inability to initiate movement, staying in the same position for long and needing support to carry out voluntary movement. 

– Explanation: The characteristic motor symptoms of Parkinson’s disease, such as bradykinesia, rigidity, and postural instability, can significantly impair the patient’s ability to move, walk, and perform daily activities independently. Observation of the patient’s gait abnormalities, reduced range of motion, and difficulty with motor tasks can provide evidence for this diagnosis. 

2. Risk for Falls related to tremors and orthostatic hypotension: 

– Explanation: Parkinson’s disease can increase the risk of falls due to postural instability, gait disturbances, and reduced coordination. The patient may exhibit shuffling gait, decreased arm swing, and a stooped posture. History of falls, presence of orthostatic hypotension, and environmental hazards in the patient’s living area can further support this diagnosis. 

3. Impaired Swallowing related to muscle weakness involved in swallowing as evidenced by difficulty in swallowing, choking during eating, coughing and food sticking in the throat(verbalisation/facial grimace) :

– Explanation: Parkinson’s disease can lead to dysphagia (difficulty swallowing) due to muscle weakness, impaired coordination, and decreased mobility of the muscles involved in swallowing. The patient may exhibit prolonged meal times, coughing or choking during meals, or complaints of food sticking in the throat. Evaluation by a speech therapist and observations during meals can provide evidence for this diagnosis. 

4. Risk for Impaired Verbal Communication related to speech muscle involvement:

 – Explanation: Parkinson’s disease can affect the muscles involved in speech production, leading to reduced volume, slurred speech, and monotone voice. The patient may demonstrate difficulty in articulating words and expressing thoughts. Assessment by a speech therapist and observation of the patient’s speech patterns can support this diagnosis. 

5. Risk for Impaired Skin Integrity related to immobility, incontinence: 

– Explanation: The combination of bradykinesia, rigidity, and postural instability in Parkinson’s disease can lead to decreased mobility and changes in body alignment. These factors, along with sensory disturbances, can increase the risk of pressure ulcers and skin breakdown. Observation of the patient’s skin condition, areas of pressure, and assessment of skin integrity can provide evidence for this diagnosis. 

 

 Surgical Management of Parkinson’s disease.

Deep Brain Stimulation (D.B.S):

  • Is a surgical procedure in which electrodes are placed in specific areas of the brain, electrodes are connected to a generator which is programed to send electrical pulses to the brain.
  • The procedure may help to alleviate the following symptoms; tremor, rigidity, stiffness & slowed movement

Facial Nerve Decompression Surgery

  • Management of acute facial paralysis may involve facial nerve decompression surgery in cases of virally-induced facial paralysis (Bell’s palsy, Ramsay-Hunt syndrome) or primary facial nerve repair/grafting in cases of resection or transection of the facial nerve
Facial Nerve Decompression Surgery
Nursing care
  • Perform motion exercises to all joints 3 time a day, massage skeletal muscles to relieve stiffness and use a broad base support when ambulating.
  • Advise patient care givers to avoid pyridoxine protein food and alcohol when using levodopa
  •  Modify home environment to remove hazards and alert the patient on effects of stress, heat and excitement
  • Avoid staying in one position for a long time and try walking with hand clasped behind.
  • Motor patient weight weekly, follow plans for small frequent meals and avoid eating high protein meals at medication time. Ensure adequate fiber and fluid intake.
  • Perform exercise voice regulation by singing or reading loud.
  • Monitor sleep pattern, thought disorders and hallucination.
  • Respond promptly to the urge of urination, defecation and ensure emptiness. Use stool softeners if needed, keep urinal at bedside and monitor bowel habits.
  • Avoid carpets and rugs on floor as a patient sticks on them, use walking aids and offer shoes that are easy to put with smooth soles on to the patient.
  • Alternative medicine i.e massage, tai chi , yoga, pet therapy ,meditation
  • Joining support groups

Diagnosis of Parkinson’s Disease

1. Medical History: The doctor will begin by taking a detailed medical history, including asking about the patient’s symptoms, their duration, and any family history of Parkinson’s disease. 

2. Physical Examination: A thorough physical examination will be conducted to assess motor symptoms such as tremors, rigidity, bradykinesia (slowness of movement), and postural instability. The doctor will also look for other possible causes of these symptoms. 

3. Assessment of Symptoms: The doctor may use standardized rating scales, such as the Unified Parkinson’s Disease Rating Scale (UPDRS), to evaluate the severity of symptoms and track disease progression. 

4. Response to Medication: Parkinson’s disease symptoms often respond positively to dopaminergic medications. The doctor may prescribe a trial of medication, such as levodopa, to observe if there is a significant improvement in symptoms. This can help support the diagnosis of Parkinson’s disease. 

5. Neurological Examination: A neurological examination may be performed to evaluate other neurological signs and rule out alternative diagnoses. 

6. Imaging Studies: While imaging studies are not mandatory for diagnosis, they can help exclude other conditions that mimic Parkinson’s disease. Imaging techniques such as magnetic resonance imaging (MRI) or computed tomography (CT) scans can be used to assess the brain structure and rule out other causes. 

7. Laboratory Tests: There are no specific blood tests to diagnose Parkinson’s disease. However, blood tests may be performed to rule out other medical conditions that can present with similar symptoms. 

Complications of Parkinson’s Disease 

1. Falls and Fall-related Injuries:

– Due to impaired balance, postural instability, and motor symptoms, individuals with Parkinson’s disease are at an increased risk of falls. Falls can result in injuries such as fractures, head trauma, and soft tissue damage. 

2. Dysphagia and Aspiration Pneumonia: 

– Parkinson’s disease can lead to difficulty swallowing (dysphagia), which increases the risk of food or liquid entering the airway (aspiration). Aspiration pneumonia, a lung infection caused by inhaling foreign material, is a potential complication of dysphagia. 

3. Psychiatric and Mood Disorders: 

– Depression, anxiety, and apathy are common psychiatric conditions that can occur in Parkinson’s disease. These mood disorders can significantly impact the patient’s quality of life and may require treatment and psychological support. 

4. Cognitive Impairment and Dementia: 

– As Parkinson’s disease progresses, some individuals may develop cognitive impairment, including problems with memory, attention, and executive functions. In some cases, this can progress to Parkinson’s disease dementia, which affects thinking, judgment, and daily functioning. 

5. Sleep Disorders: 

– Parkinson’s disease is associated with various sleep disturbances, such as insomnia, restless leg syndrome, and rapid eye movement (REM) sleep behavior disorder. These sleep disorders can lead to excessive daytime sleepiness, fatigue, and overall reduced quality of sleep. 

6. Medication-related Complications: 

– Long-term use of medications for Parkinson’s disease, such as levodopa, can lead to complications known as motor fluctuations and dyskinesias. Motor fluctuations are changes in the response to medication, resulting in periods of good symptom control (on periods) and periods of poor symptom control (off periods). Dyskinesias are involuntary, abnormal movements that can occur during certain periods.

Nursing Care Plan: Parkinson’s Disease

Assessment

Nursing Diagnosis

Goals/Expected Outcomes

Interventions

Rationale

Evaluation

Patient presents with resting tremors, bradykinesia, rigidity, and postural instability. Difficulty initiating voluntary movements.

Impaired Physical Mobility related to muscle rigidity and bradykinesia as evidenced by difficulty walking, shuffling gait, and tremors.

– Patient will demonstrate improved mobility and engage in physical activities with minimal assistance. 

– Patient will perform range-of-motion (ROM) exercises daily. 

– Patient will maintain safety while ambulating.

1. Encourage regular physical activity, including passive and active ROM exercises. 2. Provide assistive devices (walker, cane) as needed. 

3. Teach the patient to use the “rocking” technique to initiate movement. 

4. Educate on maintaining an upright posture and taking large, deliberate steps. 

5. Collaborate with a physical therapist for mobility training.

1. Helps prevent stiffness and maintain joint flexibility. 

2. Promotes independence and reduces fall risk. 

 

3. Overcomes movement initiation difficulties. 

 

4. Improves gait and reduces the risk of falls. 

5. Enhances mobility and functional ability.

– Patient engages in physical activity with minimal assistance. 

– Patient reports improved mobility. 

– Patient remains free from falls and injuries.

Patient reports difficulty holding utensils, dressing, and writing. Increased time required for daily tasks. (Dressing, Eating, Grooming) 

Decreased Self-Care Deficit syndrome related to bradykinesia and tremors as evidenced by inability to button clothes, feed self, or use utensils effectively.

– Patient will demonstrate improved ability to perform self-care activities with minimal assistance. 

– Patient will use adaptive devices to enhance independence. 

– Patient will maintain personal hygiene and grooming.

1. Encourage the use of adaptive utensils and clothing with Velcro fasteners. 

2. Allow extra time for the patient to complete tasks. 

3. Provide cues and step-by-step instructions for self-care activities. 

4. Encourage family involvement in assisting the patient as needed. 

5. Refer to an occupational therapist for fine motor skill training.

1. Facilitates independence despite motor difficulties. 

 

2. Reduces frustration and promotes dignity. 

 

3. Supports cognitive function and task completion. 

4. Ensures patient receives necessary support while promoting autonomy. 

5. Helps improve the patient’s ability to perform daily activities.

– Patient demonstrates improved ability to dress, eat, and groom. 

– Patient uses adaptive devices effectively. 

– Patient experiences less frustration with self-care.

Patient exhibits soft, monotone speech, masked facial expression, and difficulty swallowing.

Impaired Verbal Communication related to muscular rigidity and bradykinesia as evidenced by slow speech, decreased voice volume, and difficulty articulating words.

– Patient will use alternative communication methods as needed. 

– Patient will engage in speech therapy exercises. 

– Patient will demonstrate improved ability to express needs.

1. Encourage the patient to speak slowly and exaggerate pronunciation. 

2. Suggest deep breathing exercises to strengthen vocal cords. 

3. Use communication aids such as writing boards or voice amplifiers. 

4. Encourage speech therapy to improve articulation and voice control. 

5. Provide a calm, quiet environment to enhance communication.

1. Helps improve clarity of speech. 

2. Strengthens respiratory muscles and voice projection. 

 

3. Compensates for verbal communication difficulties. 

4. Enhances the ability to communicate effectively. 

5. Reduces frustration and improves comprehension.

– Patient reports improved ability to communicate. 

– Patient uses communication aids effectively. 

– Patient participates in speech therapy sessions.

Patient has difficulty swallowing, risk of aspiration, and reports choking episodes.

Inadequate nutritional intake related to impaired swallowing (dysphagia) as evidenced by coughing, drooling, and difficulty swallowing food and liquids.

– Patient will swallow safely without signs of aspiration. 

– Patient will maintain adequate nutritional and hydration status. 

– Patient will use modified diet strategies to prevent aspiration.

1. Assess swallowing ability and risk for aspiration. 

2. Position patient upright (90-degree angle) during meals and for at least 30 minutes after eating. 

3. Encourage small, frequent meals with thickened liquids if needed. 

4. Teach patient to use the “chin tuck” technique while swallowing. 

5. Refer to a speech therapist for swallowing evaluation and therapy.

1. Identifies patients at high risk for aspiration. 

 

2. Promotes safe swallowing and reduces aspiration risk. 

 

3. Prevents choking and maintains adequate nutrition. 

 

4. Helps direct food away from the airway. 

 

5. Enhances swallowing ability and safety.

– Patient swallows safely without choking or aspiration.

 – Patient maintains adequate nutritional intake. 

– Patient follows recommended swallowing techniques.

Patient expresses sadness, frustration, and social withdrawal due to disease progression.

Chronic confusion related to chronic illness and functional decline as evidenced by social isolation, low mood, and frustration with self-care difficulties.

– Patient will verbalize feelings and express emotions appropriately. 

– Patient will participate in social activities as tolerated. 

– Patient will demonstrate coping strategies to manage frustration.

1. Encourage the patient to express emotions and frustrations. 

2. Provide emotional support and active listening. 

3. Encourage participation in support groups or therapy. 

4. Promote enjoyable activities that the patient can engage in despite limitations. 

5. Monitor for signs of severe depression or suicidal thoughts and refer to a mental health professional if needed.

1. Helps the patient process emotions and reduce distress. 

 

2. Provides reassurance and support. 

 

3. Promotes socialization and reduces isolation. 

 

4. Encourages engagement in life despite limitations. 

 

5. Ensures early intervention for severe depression.

– Patient reports improved mood and emotional well-being.

 – Patient engages in social activities.

 – Patient verbalizes coping strategies effectively.

NANDA 2024-25

Nursing Concerns in Parkinson’s Disease:

Risk of Falls:

Concern for the patient’s increased risk of falls due to impaired balance and coordination.

Implementation of fall prevention strategies and regular assessments of gait and stability.

Functional Independence:

Concern for the preservation of the patient’s functional independence.

Promotion of activities that enhance independence in daily living.

Psychosocial Well-being:

Concern for the patient’s mental health and emotional well-being.

Regular assessment of mood, addressing any signs of depression or anxiety.

Communication Difficulties:

Concern for potential communication challenges.

Monitoring the patient’s ability to express needs and facilitating communication support as required.

Nutritional Status:

Concern for maintaining adequate nutrition.

Regular assessments of the patient’s nutritional intake and collaboration with dietitians to address any deficits.

 

Parkinson’s Disease Read More »

BELL’S PALSY (FACIAL NERVE PALSY)

BELL’S PALSY (FACIAL NERVE PALSY)

BELL’S PALSY (FACIAL NERVE PALSY)

Bell’s Palsy is a disorder characterized by disruption of the motor branch of the facial nerve (CN VII) or paralysis of one side of the face in absence of stroke.

Bell’s palsy is a type of facial paralysis that results in a temporary inability to control the facial muscles on the affected side of the face due to compression of the seventh cranial nerve.

The onset is mostly rapid and unilateral.

Sir Charles Bell, Scottish Surgeon, first described in early 1800’s based on trauma to facial nerves

Causes of Bell’s Palsy

The exact cause is unknown but can be triggered by bacterial or viral infections like :

  • Herpes simplex, Herpes zoster and epstein barr virus.
  • HIV
  • Sarcoidosis, which is the growth of tiny collections of inflammatory cells in different parts of the body
  • Lyme disease (bacterial infection caused by infected ticks)

It is also believed to occur due to localized inflammatory reactions of the facial nerve at the stylomastoid foramen.

  • Demyelination of the nerve can trigger bell’s palsy.
Pathophysiology of Bell’s Palsy

Pathophysiology of Bell’s Palsy

The facial nerve has motor nerves that innervate/supply the muscles of expression on the face and sensory that supplies the tongue. Disruption of the nerve leads to rapid weakening or paralysis of the facial muscles on one side creating a mask-like appearance (angry face). Paralysis develops in 24-36 hours and the eye of the affected side tears constantly.
The condition accompanies an outbreak of herpes vesicles around the ear.

  1. Etiology: The initial cause/factor is an inflammation of the facial nerve.
  2. Compression and Occlusion: The inflamed and swollen nerve gets compressed, potentially leading to damage or blockage of its blood supply.
  3. Ischemia: This compression results in reduced blood flow, causing ischemia (lack of oxygen and nutrients).
  4. Necrosis: The lack of blood supply leads to nerve tissue death (necrosis).
  5. Paralysis: The death of the facial nerve ultimately causes paralysis of the facial muscles.
Signs and symptoms of Bells palsy (1)

Signs and symptoms of Bell’s palsy

  1. Facial Weakness: Drooping of the face and difficulty in performing facial expressions like smiling.
  2. Eye-related Issues: Inability to close the affected eye, leading to dry eyes, and the eye may fail to roll upward.
  3. Drooling and Speech Difficulties: Dribbling of saliva from the affected mouth angle, and speech difficulties due to muscle weakness.
  4. Challenges in Eating: Difficulty in closing the affected eye may result in food collecting between teeth and cheeks on the affected side.
  5. Whistling Difficulty: Inability to whistle due to muscle weakness on the affected side.
  6. Bell’s Sign: Failure of the eye to close and roll upward on the affected side.
  7. Mouth Deviation: Deviation of the mouth toward the normal side.
  8. Loss of Taste: Unilateral loss of taste sensation.
  9. Pre-paralysis Symptoms: Pain behind the ear before facial paralysis, accompanied by fever, tinnitus, or hearing difficulty.
  10. Muscle Twitches: Facial muscles may experience involuntary twitches.
  11. Dry Eyes and Mouth: Reduced tear and saliva production leading to dry eyes and mouth.
  12. Headaches: Individuals may experience headaches, possibly related to facial muscle tension.
  13. Sensitivity to Sound: Increased sensitivity to sound may be observed.

Diagnostic Evaluation of Bell’s Palsy

Diagnosis is often based on symptoms, ruling out other causes of paralysis like a stroke.

  1. No Definitive Test: No specific test confirms Bell’s Palsy; diagnosis relies on clinical evaluation.
  2. History of Onset of Symptoms: The patient’s experience, including the timing and progression of symptoms, is a key factor in diagnosing Bell’s palsy.
  3. Observation and Examination: Careful observation of the patient’s facial movements helps confirm the diagnosis. This includes assessing upper and lower facial weakness by observing actions like closing the eyes, lifting eyebrows, smiling, and frowning.
  4. Neurological Examination: A thorough neurological examination is conducted to assess the patient’s facial motor capacity. This involves testing the ability to perform facial movements, such as closing the eyes, lifting the eyebrows, smiling, and frowning.
  5. Blood Tests: Blood tests are needed only to rule out other conditions that might cause similar symptoms. These tests examine for viral infections or other risk factors known to be associated with Bell’s palsy.
  6. Electromyography (EMG): This test measures the electrical activity of the facial muscles when stimulated. EMG helps to confirm the presence and severity of nerve damage. It also aids in differentiating Bell’s palsy from a stroke.
  7. Imaging Studies (CT or MRI): Computed tomography (CT) or magnetic resonance imaging (MRI) are used to visualize the affected area and rule out any abnormalities or causes of pressure on the facial nerve. These studies are particularly helpful in excluding other potential causes, such as a brain tumor or a stroke.

Complications of Bell’s Palsy:

  • Malnutrition: Difficulty in eating and drinking due to facial muscle weakness can lead to malnutrition.
  • Psychological Withdrawal: Changes in facial appearance may cause psychological withdrawal and social challenges.
  • Dehydration: Reduced ability to close the affected eye can lead to excessive tear evaporation, contributing to dehydration.
  • Muscle Stretching and Facial Spasms: Prolonged muscle weakness may result in muscle stretching and facial spasms.
  • Synkinesis: Involuntary contraction of certain muscles while attempting to move others, leading to uncoordinated facial movements.
  • Excessive Dryness in Eyes: Inability to close the eye properly may cause excessive dryness, increasing the risk of eye infections and potential blindness.
  • Mucous Membrane Trauma: Difficulty in maintaining normal oral and nasal moisture can lead to mucous membrane trauma.
  • Corneal Abrasion: Insufficient eye protection may result in corneal abrasion, posing a risk to eye health.
  • Facial Spasms and Contractures: Persistent facial spasms and contractures can impact facial muscle function and appearance.
  • Changes in Appearance: Facial asymmetry and changes in appearance may contribute to psychological distress.
  • Speech Difficulties: Impaired muscle coordination may lead to difficulties in articulation and speech.
  • Chronic Eye Issues: Long-term complications may include chronic eye problems and discomfort.
Management of Bell’s Palsy

Management of Bell’s Palsy

There is no specific treatment of the condition and hospitalization is not required;

Aims of management.

  • Reduce Inflammation and Nerve Damage: This involves controlling the inflammation of the facial nerve, preventing further damage, and promoting nerve regeneration.
  • Preserve Facial Function: The goal is to minimize the severity and duration of facial paralysis and to prevent permanent facial muscle weakness.
  • Reduce Pain and Discomfort: Pain, especially in the ear or behind the ear, is common in Bell’s palsy. Pain management is important for the patient’s well-being.

MEDICAL MANAGEMENT

Medications:

1. Corticosteroids: The drugs of choice. Prednisone, a steroid medication, is often prescribed to reduce inflammation and swelling of the facial nerve.

  • Prednisone may be started immediately!
  • Best if initiated before paralysis is complete
  • Taper off over 2 weeks(tapering is the process of stopping all opioids or reducing opioids quickly over a few days or weeks, decreasing the dose by 25% to 50% to 75% to 100%)
  • Analgesics e.g. ibruprofen may be needed for pain

2. Antiviral Medications: Antiviral medications, such as Acyclovir (Zovirax) or famciclovir, because HSV is implicated in 70% of cases. They are sometimes prescribed, particularly if a viral infection is suspected.

3. Analgesics: Over-the-counter or prescription pain medications are used to manage pain and discomfort.

Facial Exercises: Facial exercises are an essential part of Bell’s palsy management, particularly after the initial inflammatory phase. These exercises aim to improve muscle strength and coordination, minimize muscle atrophy, and help regain facial function.

Examples of Conventional Exercises:

  • Eye Exercises: Closing the eye tightly, blinking repeatedly, and gently massaging the eyelids.
  • Brow Exercises: Raising the eyebrows, furrowing the brow, and moving the eyebrows from side to side.
  • Mouth Exercises: Smiling broadly, pursing the lips, puffing out the cheeks, and blowing air out of the mouth.
  • Chin Exercises: Moving the jaw side to side, clenching and unclenching the jaw.
  • Facial Massage: Gently massaging the affected side of the face to improve circulation and muscle tone.

Other Therapies:

  • Physical Therapy: A physical therapist can provide personalized facial exercise programs and teach techniques to improve facial muscle function.
  • Occupational Therapy: Occupational therapists can help with activities of daily living, such as eating, grooming, and communication, and can recommend adaptive strategies for coping with facial weakness.
  • Speech Therapy: Speech therapists can help address speech problems that may arise from facial paralysis, such as slurred speech or difficulty articulating words.

Surgery: Surgical intervention is rarely necessary for Bell’s palsy. In cases of persistent facial paralysis, nerve grafting or muscle transfers might be considered.

Physiotherapy:

  • Facial Massage: Regular facial massage is crucial for maintaining circulation and keeping the skin supple.Massage should be performed in an upward direction, avoiding downward strokes that can stretch the paralyzed muscles and worsen the condition.
  • Taping/Splinting: These methods help to reduce facial asymmetry by supporting the paralyzed side of the face and encouraging muscle balance. They can be customized by a physical therapist or occupational therapist.
  • Muscle Re-education: Faradic Re-education: This technique uses electrical stimulation to re-educate the facial muscles. It is only suitable for patients who can tolerate sensory stimulation.
  • Visual Feedback Exercises: Encouraging patients to perform facial exercises in front of a mirror allows them to observe their progress and improve their technique. This visual feedback can significantly aid in muscle re-education.

Conventional Exercises which include;

  • Elevate eyebrows, after brushing the forehead.
  • Elevate the corner of the lips (like saying “E”), after brushing the affected side of the face.
  • Close eyes slowly and alternately close one eye at a time.
  • Wrinkle and open the wings of the nose.
  • Open the mouth and say “a”, “o”, and alternate between “e”, “a”, “o”.
  • Smile with and without showing teeth.
  • Wind up the cheeks with closed lips.
  • Read and speak aloud.

Eye Care:

  • It is essential to protect the eye on the affected side. The patient should be advised to wash their eyes regularly with saline solution and wear protective goggles or eye patches to prevent dust, debris, or foreign particles from entering the eye.

Alternative Medicine: There is limited scientific evidence to support the effectiveness of alternative medicine for Bell’s palsy, but some individuals may find relief from:

  • Acupuncture: This involves inserting thin needles into specific points on the body, aiming to stimulate nerves and muscles.
SPECIFIC NURSING CARE;
  1. Pain Relief: Apply a warm, moist sponge to alleviate pain.
  2. Eye Care: Pad the dry eye to prevent excessive dryness and potential complications.
  3. Nutrition: Monitor and support the patient’s nutrition, addressing challenges in eating and drinking.
  4. Physiotherapy and Facial Massage: Implement physiotherapy and facial massage to stimulate facial muscles.
  5. Speech Therapy: Provide speech therapy to address potential speech difficulties.
  6. Support Groups: Encourage the patient to join support groups for emotional well-being.
  7. Facial Symmetry: Utilize a face strap to help symmetrize the lips.
  8. Eye Protection: Advise the patient to stay in warm environments, avoid dust and wind, and use eye protection in dangerous exposures.
  9. Swallowing Precautions: Instruct the patient to sit upright while eating, chew on the non-paralyzed side, consume small portions, and maintain a balanced nutrition intake to prevent complications in swallowing.
  10. Privacy during Meals: Respect the patient’s privacy during mealtime to avoid embarrassment.
  11. Mouth Care: Perform careful mouth care, as food may accumulate between the lip and gingiva.
  12. Muscle Tonus Maintenance: Massage the patient’s face with upward strokes for 5-10 minutes to maintain muscle tone, and encourage self-massage.
  13. Active Exercise: If ready, ask the patient to perform active exercises, such as smiling in front of a mirror.
  14. Eye Protection Outside: Suggest using eye protectors, especially when going outdoors. Sterile eyes

NURSING CARE PLAN FOR A PATIENT WITH BELL’S PALSY

Assessment

Nursing Diagnosis

Goals/Expected Outcomes

Interventions

Rationale

Evaluation

Facial asymmetry with drooping on one side, difficulty in closing the eye, and drooling from the mouth.

Post trauma syndrome related to inflammation of the facial nerve as evidenced by inability to close the eye and drooping of the mouth on one side.

Improve facial muscle strength and function, evidenced by the ability to close the eye and reduced drooling within 2 weeks.

– Teach facial exercises to stimulate muscle function.

– Administer prescribed corticosteroids to reduce inflammation and swelling.

– Encourage the use of assistive devices like eye patches to protect the eye.

– Facial exercises can help stimulate the muscles and improve function. 

– Corticosteroids reduce inflammation, which can relieve nerve compression. 

– Eye protection prevents corneal damage due to dryness.

Patient demonstrates improved ability to close the eye and reduced drooping, indicating improved muscle strength and function.

Patient reports difficulty swallowing and frequently chokes on liquids.

Impaired swallowing related to weakness of facial muscles as evidenced by frequent choking and difficulty swallowing.

Prevent aspiration and improve swallowing ability, evidenced by the ability to swallow liquids without choking.

– Instruct the patient on swallowing techniques, such as chin-tuck during swallowing.

– Offer thickened liquids to reduce the risk of aspiration.

– Position the patient upright during meals and for 30 minutes afterward.

Proper swallowing techniques and thickened liquids can reduce the risk of aspiration. 

– Upright positioning helps gravity assist in swallowing and reduces aspiration risk.

Patient swallows liquids without choking, indicating improved swallowing ability.

Patient reports difficulty in articulating words clearly and being understood by others.

Impaired verbal communication related to facial muscle paralysis as evidenced by difficulty articulating words.

Enhance communication ability, evidenced by the patient being understood by others.

– Provide alternative communication methods, such as writing or using communication boards.

– Encourage the patient to speak slowly and clearly.

– Refer to speech therapy if needed.

Alternative communication methods reduce frustration and improve understanding. 

– Speech therapy can help retrain muscles and improve articulation.

Patient is able to communicate effectively using alternative methods or improved speech clarity.

Patient complains of a dry and irritated eye.

Ineffective Dry eye self-management related to incomplete eyelid closure as evidenced by patient complaints of dryness and irritation.

Prevent corneal damage and reduce discomfort, evidenced by the patient reporting no eye irritation and maintaining eye moisture.

– Administer artificial tears or lubricating eye drops as prescribed.

– Apply an eye patch during sleep to protect the eye.

– Teach the patient to manually close the eyelid periodically.

Lubricating eye drops prevent dryness and irritation. An eye patch protects the cornea during sleep, reducing the risk of damage.

Patient reports no eye irritation and maintains eye moisture, indicating effective prevention of corneal damage.

Patient’s affected side of the face is sensitive, and they report discomfort.

Acute pain related to facial nerve inflammation as evidenced by patient complaints of pain on the affected side.

Reduce pain and discomfort, evidenced by the patient reporting a decrease in facial pain.

– Administer prescribed analgesics to manage pain.

– Apply warm compresses to the affected area to alleviate discomfort.

– Educate the patient on gentle facial massage techniques.

Analgesics relieve pain, warm compresses reduce discomfort, and facial massage can help stimulate circulation and reduce pain.

Patient reports reduced pain and discomfort, indicating effective pain management.

Patient expresses anxiety and emotional distress about their appearance and the sudden onset of facial paralysis.

Excessive Anxiety related to the sudden onset of facial paralysis as evidenced by patient verbalizing concerns about appearance, and presenting with emotional distress.

Reduce anxiety and improve emotional well-being, evidenced by the patient reporting reduced distress and improved coping.

– Provide emotional support and reassurance about the potential for recovery.

– Encourage the patient to express feelings and concerns.

– Refer to counseling or support groups if needed.

Emotional support and reassurance can help reduce anxiety. 

– Counseling or support groups provide a space for the patient to process emotions and learn coping strategies.

Patient reports reduced anxiety and improved emotional well-being, indicating effective emotional support.

NANDA 2024-26

Nursing Concerns for Bell’s Palsy

  1. Risk for Aspiration: Facial weakness can affect swallowing, increasing the risk of aspiration.
  2. Risk for Corneal Abrasion: The inability to close the eye completely can lead to corneal dryness and damage.
  3. Impaired Communication: Facial weakness can make it difficult for the patient to speak clearly.
  4. Disrupted Body Image: The facial paralysis can have a significant impact on the patient’s self-esteem.
  5. Risk for Infection: The affected eye is more susceptible to infection due to dryness and decreased blinking.
  6. Risk for Delayed Recovery: The patient may experience anxiety and frustration due to the slow recovery process.
  7. Risk for Social Isolation: The facial paralysis can make the patient feel self-conscious and withdraw from social interactions.

BELL’S PALSY (FACIAL NERVE PALSY) Read More »

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