Alane B. Costanzo, MD
That belief is up against some deeply entrenched institutional and economic interests; cordoning off space to collectively resist those interests may necessitate discussion rooted in the same ideological commitment to resistance arteria gastrica sinistra generic zebeta 5mg without a prescription. Defining such spaces as enclaves 191 prone to groupthink not only disregards the typical conventions of digital media usage blood pressure chart age 35 10mg zebeta amex, it risks having feminist activism dismissed as merely the ?private meaning-making rituals of a few blood pressure weight loss order zebeta 2.5mg without prescription, which so happen to be open for ?public view (Tucker) blood pressure 300200 order 10mg zebeta with amex. Rather, I will use case studies of two moments of activism to demonstrate that birth blogs and the social media stream circulating around and through them are ?feminist tools engaging in ?vibrant and effective public discourse in the forms of social activism and resistance (M. Method: Following the Intertextual Circuit into Cyberspace In order to tease out the ways that online media is enabling and catalyzing birth activism, I will continue to follow the overall methodology outlined in Chapter One by traveling what Blake Scott calls the intertextual circuit, chasing discussions of birth where they exist online. Following Warnick and Ratliff, I will construct case studies, limiting my focus to texts devoted to discussing specific events in a given time frame. In the first case study, the nonprofit activist organization the Big Push for Midwives orchestrated an online response to a home birth survey posted on the website of the American College of Obstetricians and Gynecologists, clearly intended only for its members. In order to piece together the ways that digital media gave women a chance to intervene and participate in these two events, one that took place only online and one that also took place in the material world, I followed the online conversation about both as they were happening and bookmarked relevant posts and comment threads. When I returned to the bookmarked sites months later, I also used search engines to uncover other information related to each event that occurred in places other than my primary research sites. I then identified what Clancy Ratliff calls ?hot spots, or blogs central to a discourse community 192 online, and followed links from post to post and from commenter identity to post (many of the commenters are also bloggers). What becomes clear even from this description is that both of these events instigated a conversation, not a series of isolated writings. In each case, many of the bloggers respond to one another by referencing other posts, and several posts contain lists of links related to the events. Many of the commenters who were not also bloggers left comments at a number of blogs, contributing different ideas to different discussions, or reiterating a single position throughout the linked discussion. For the textual analysis that follows in each case below, I focus on blog posts and comment threads because that is where the most extensive discussions occur. However, I want to reiterate that these discussions are further enhanced by the use of other social media outlets that provide venues to direct readers to the blog conversations and ways for fellow advocates to form a more tangible social network, by becoming friends on Facebook or followers on Twitter (Figure 17). Figure 17: this is a ?network map, showing the connections among Twitter users who used the #nihvbac tag the week of the conference. The blogger who posted the image pointed out how many of the users overlap, demonstrating the interconnectedness of the community (at least as defined by their social media usage) (Smith). Looking at these two events side by side shows both the limits and the potential of online activism: in the first case, we will see how social media users engage in an action that has little potential to instigate a dialogue with the institution at which the action is directed; yet, at the same time, the conversation following the action relies on discourse that challenges institutional authority primarily by disrupting the boundaries between data and narrative, between scientific and experiential knowledge, between objectivity and bias. In the second case, members of the birth advocacy community online participated in a dialogue structured by a government-run agency. Though not invited as official members of the press, their writings before, during, and after the event preserve their influence on the conversation in the digital archive. Further, they show that discourse based on general rights, rather than on the specific context of the American medical system, is insufficient to overcome that conflict without widespread systemic critique. Recent reports to the office indicate our members are being called in to handle those emergencies and in some instances have been named in legal proceedings. If you have been called in to attend, whether in the emergency room, operating room or labor and delivery suite, a patient who came to your hospital after an unsuccessful attempt at elective home delivery, please complete the following survey, even if there was no adverse outcome. To help detect any accidental duplicate submissions, please select the numeric value of your birthday month + day (optional). It will take less than five minutes, but having even 25 people do it will send a loud and clear message and may force them to take it down due to bad data. The call was circulated widely on other list-servs, message boards, Facebook, Twitter, and blogs authored by midwives and other birth advocates. For an organization that claims to be dedicated to evidence-based medicine and the safety and health of women, the survey in question seemed disingenuous to many of the women who wrote about it. One doctor asked, ?Isn?t our issue with pseudoscientific surveys per se that do nothing except provide advertising space for those ?fine young men and women (God knows, you got to love them) as we say in the south who turn a dollar based on the ignorance and ill will? Science, as it is figured here, represents unbiased information collected from credible sources. The blog Science and Sensibility, hosted by Lamaze International, for instance, is based on the idea that women can best prepare for their births by understanding how to read and interpret medical research. The authors regularly come to different conclusions than the professional medical community does. If scientific evidence is subject to interpretation and misinterpretation, then, despite the figuration of science as a knowable (and implicitly static) entity, the very act of interpretation demonstrates that it is, instead, inseparable from the discourse used to communicate and understand it. What rhetoricians of science have argued, of course, is that there can be no final separation of any discrete body of knowledge called science and the discourse used to communicate that knowledge. The assumption, then, is that filling in data for successful home births with answers that do not fit within the expected range of responses is itself a narrative act. They are not even looking at the research yet call themselves a professional medical organization. Nothing is verifiable, therefore there is no trustworthy data to be gleaned this way. And that therefore they are not actually interested in viable data, and were hoping for something to use as a political football. Many of the women who wrote responses to this incident seem to want their stories to matter too. This desire to have their stories valued in creating a more accurate picture of home birth appears in the way many of the commenters frame their response to news of the survey with details from their own experiences. She writes that she is a midwife-in-training who has seen hospital transfers go badly because the physician refused to listen to the midwife or the caregiver, assuming instead that the mother had been poorly cared for: ?Again and again, I have heard of women being abused when seeking medical assistance. She concludes, If only our medical providers would work in concert with our home birth midwives, they would see the good care we offer, and be less frantic when a transport needs to occur because they would have had the opportunity to meet the mother and review her case. People would be less hesitant to transport because the horror stories would be far fewer. Please fill out this short survey so we can demonstrate how pervasive this problem is. While I wish we?d had longer to make an impact, I love that we did make one so graphically that they felt they had to block us out. She tempers that enthusiasm (or cues her tongue-in-cheek, depending on how one reads her tone) later in the post by trying to imagine, from the point of view of obstetricians, why this survey was put up in the first place: ?While we all are thrilled with our wonderful homebirths and so many of us got our voices heard on their site yesterday, it is important to remember they have a reason, a valid reason, for wanting to hear from their constituency. If you believe as I do that no one was responsible [for a bad outcome], that isn?t the point. What I think happens is that doctors are sued much more because of the relationship aspects a midwife develops with her clients. The work of medical anthropologists like Melissa Cheyney illustrates why even one case of a doctor being sued because of a home birth transport can be so impactful. Her research shows that in Oregon, where she lives and works as a midwife, there is a great deal of mistrust between doctors and midwives primarily because of what she calls the ?birth story telephone, in which doctors spread stories of home births gone wrong among each other that bear little, if any, relation to reality. After digging through hospital records across the state, Cheyney and her co-researchers found not a single case of infant death after a home birth transfer (Cheyney and Everson). Women and midwives who have participated in home births particularly seemed to want to add their corrective narratives to the negative stories they feared would pour in from doctors. The problem is that they sought stories from the wrong sources for the wrong reasons, under the auspices of science. What is clear is that the creation of knowledge about childbirth is not the exclusive domain of an institution; online media makes it possible for women to circulate their own versions of what childbirth should mean, who should manage it, and how it should be articulated. They are also, as is clear from these discussions, invested in defining and redefining what we mean when we say ?scientific evidence and who has the right to interpret and disseminate it. They also released a draft of the consensus statement online and invited the public to submit questions, revisions, or suggestions about any part of the document before the conference ended. In addition to the official record of the conference, one can also find reports of the experts testimonies and the final statement in traditional news media sources. There was also considerable activity on Facebook during the conference, as well as what one blogger called ?eleventy-billion tweets with the #nihvbac hash tag (Walden). Many bloggers in the birth advocacy community attended the conference and others blogged and tweeted while watching the webcast in real time. The tweet she reproduces refers to a slide during the first Power Point presentation of the conference, in which the speaker, Caroline Signore, pointed to an energized population of women who are increasingly dissatisfied with their choices about birth after cesarean. A blogger in the audience, Gina Crosley-Corcoran of the Feminist Breeder, snapped a photo of the slide 45 I realize that search engine results change constantly, so this claim is based on my use of three different search engines on a particular day; I have included screen shots of the results in the Appendix. What this small image and its circulation illustrates is both the immediacy digital media affords and its potential to instigate a public discussion. The slide shown was up on the projector at the conference for fewer than five seconds, and the blogging community was mentioned only once in seven hours and forty-four minutes of presentation and discussion from the first day. A price policy is also necessary to fund the establish rate in Dhaka was 75% before needed (Eden et al blood pressure ranges buy zebeta australia. This delivered through a central tries to ensure availability and reduced abandonment by half 3838 Childhood Cancer arteria facial buy zebeta 5mg on-line. Rising to the challenge because families have some travel costs blood pressure chart age buy zebeta 10mg fast delivery, at the same time tor gets postponed blood pressure medication excessive sweating buy zebeta pills in toronto. A relatively where to stay and receive social increasing the chances that the high male-to-female ratio and emotional support from child will remain in treatment reflects traditionally preferential other families, and the parent beyond an initial one or two attitudes towards boys, who are charity funds some drugs. Girls are often neglect Families, too, incur con sequently survival rates equiva ed and receive inferior educa siderable expense. Caring for a lent to those in Europe can be tion, social and medical treat child with illness or disability achieved. Sick girls are medicine mean that many peo this can be achieved through less likely to reach specialist ple seek the help of traditional economic empowerment of the care than boys, thus potentially healers, who are cheaper and family. Innovation programmes distorting knowledge about often more psychologically sup to empower women through incidence and survival rates. In portive and whose treatments small micro-credit programmes Bangladesh, there is a deficit of are compatible with the beliefs have been successful in children under one registered and the cultures. This is most likely therefore to educate parents, example, the Childhood Cancer a result of taboos, where babies but also the traditional and Foundation South Africa, are not to be taken out of the herbal healers. This, unfortunately, is present at an often when curative treatment advanced stage, is no longer possible. The imbalance in access to quality father, who is care by educating and training expected to staff. More and more, the need accompany a to expand quality medical care child to a hos for patients throughout the pital, is usually world is acknowledged, and the only source training programmes for those of income in interested in adult and child the family, so a medicine are being developed. A support group for children with cancer and survivors in India visit to a doc these include ?twinning insti Childhood Cancer. Significant strides Morphine is often in have been made by groups tutions in developed and short supply, and there are few involved with the care of phys underdeveloped countries formal programmes for pallia ically disabled children, which (Ribeiro and Pui 2005; Masera tive and end-of-life care any have developed training pro et al. Such an attitude acknowledge the role of social also contribute at the family ignores the fact that cancer in and cultural beliefs about the and individual level. Social and cul of symptoms, accept the illness children with cancer clearly tural factors contribute at a and take the child for treatment depends on establishing closer public level to the availability of without fear of recrimination, links and greater collaboration treatment. Public understanding rather than relying on tradition between doctors and providing about the prevalence and al healers. National Cancer Control Programmes a normal Finally, during palliative adult quality end-of-life care, psychosocial Resources of life. Failure Screening for late effects is rates and quality of life for chil to understand idiosyncratic an issue for survivors of child dren with cancer throughout beliefs about cancer and social hood cancer. In writing this arti and family norms can jeopardise ple need to understand the cle, we have been impressed by the success of any treatment long-term consequences of the number of people who programme. These matters have been implications for their future Space has precluded inclusion addressed by the World Health health. Health promotion, Caring for children with in terms of advice cancer poses a major challenge, about smoking, sun because the need is not only to exposure and diet, cure the disease, but also to must be appropriate work towards optimising the for the social and Childhood Cancer. We must hope that to school and take part in nor consideration of the needs of mal life as far as possible. These the vulnerable child with a life ideals need to be seen in the threatening disease may con context of countries where tribute to an improved environ many young children have to ment for all children. North-South twinning in paediatric haemato-oncology: the La Mascota programme, Nicaragua. Saving the children improving childhood cancer treatment in develop ing countries. Dr Christoffer Johansen heads the department of psychosocial cancer research in the Institute of Cancer Epidemiology, Copenhagen, Denmark. Its vision is of a world where cancer is eliminated as a major life-threatening disease for future generations. Rising to the challenge 43 Childhood Cancer Rising to the challenge International Union Against Cancer Union Internationale Contre le Cancer. Result: in this paper after implementing care pan based on Johnson model, we have reached the considered goals easily. Conclusion: the child who has been studied in this paper shows the application of nursing process based on Johnson behavioral theory in a clinic in a more expanded environment. Johnson behavioral theory is related to clinical environments and can be used in hospitals as a framework for diagnosing the problems of patient and proposing and evaluating comprehensive nursing care. Keywords: clinical skill, Johnson behavioral model, nursing process, theory-clinical gap Introduction promote their critical thinking and analysis skills (Meleis, 2012; Fawcett, 2006). Introduction to leukemia in children Moreover, it is imagined that nursing theories are Leukemia is an expanded word which refers to a abstract and have a limited function in practice big group of malignant disease of the bone marrow (Rolfe, 1993). Leukemia means unlimited clinical witness for critical thinking and decision proliferation of immature white blood cells in the making, Nurses will increase their professional blood-producing tissue. When the nurses use theory and the have been known in children: Acute evidences based on theory in order to form their Lymphoblastic Leukemia and Acute Myeloid skills, it will lead to improving the quality of Leukemia. The peak age of onset of this disease is environment help the students and nurses to Three main consequences include Eliminative, Dependency, of this disease include infections, fever and Aggressive/Protective, Affiliative, Achievement, bleeding. Each subsystem leukemia in children are fever, paleness, fatigue, has at least four structural components which anorexia, bleeding and bone and joint pain. One of involve goal, set, choice and action (Marlain, 2015; challenging situations in nursing cares is taking Alligood, 2014). In Choice, among available options for nursing is helping people to prevent or ameliorate achieving the goal, the individual chooses one. The science and art of nursing Action is a reaction that is shown by system should be concentrate on a patient not on certain against the incentive (Fawcett, 2006). For theorizing, Johnson has used the subsystems has three equal functional needs which principles of behaviorists in psychology and include stimulation, protection and nurturance. Behavioral system theory is very similar to each subsystem maintain its stability, these to biologic system theory in which human has been functional needs should be met permanently by introduced as a biologic system including environment but at sickness or health threatening biological sections and disease is considered conditions, the nurse is a resource for providing resulting from the disruption of biological systems these functional needs (Alligood, 2014). Main presumptions of Johnson theory include individual, nursing, environment Johnson considers nursing different from medicine and health. Johnson considers individual as a because nursing sees patient as behavioral system behavioral system with purposeful, repetitive and and medicine sees patient as biological system patterned ways that causes his relationship with the (Marlain, 2015). He categorizes or external environment will lead to disorder in the environment into two groups of internal and performance. Johnson Health includes adequate and effective didn?t emphasize on nursing process levels but he performance of systems and their behavioral obviously considered the role of nurse as an stability and balance. Nursing interventions are specified behavioral model include: behavior, system, based on Johnson behavioral model with behavioral system, subsystems, balance and dominance, incompatibility, insufficiency and individual (Koshyar, 2008). Johnson has defined seven the patient under study is an eleven-year-old girl subsystems in his theory but according to Grubbs named Zeinab. M, in first grade of secondary model, there are eight subsystems for school who has been hospitalized in infection operationalizing Johnson behavioral model which center because of fever since 29/10/2016. Injecting and as soon as she discharged from hospital, the intramuscular drugs should be avoided as much as fever started that used to be controlled with possible (Restrict) 2. She referred to the hospital and fever through rectal and using suppository should has been hospitalized because of high fever since be avoided (Restrict) 3. The conducted experiments indicate low be used for intravenous injections (Restrict) 4. Considering the After finishing the injection, in order to stop clinical results of experiments of the child, the first bleeding, direct pressure should be imposed for 5 diagnosis was Acute Lymphoblastic Leukemia minutes (defend) 5. She has taken case of need, a fence should be used beside chemotherapy and antibiotics. Severe coughing and blowing nose tightly should Zeinab is tired and weak and doesn?t want to leave be avoided (inhibit) 9.
Children with ataxia have difculty Dyskinesia and movement disorders result in generally with transference of skills blood pressure medication reactions purchase genuine zebeta, and may beneft from a specifc uncontrolled and involuntary movement that includes ath task-oriented approach to treatment blood pressure blurry vision purchase 10mg zebeta amex. For example arteria sacralis discount 2.5mg zebeta, to master etosis blood pressure 9070 discount zebeta american express, rigidity, tremor, dystonia, ballismus, and choreoath stepping onto and of the school bus, it is most efective to 8,10,15,21,28 etosis. Athetosis is most infant who presents with generalized hypotonia through the commonly a secondary movement disorder in conjunction trunk and extremities will often develop spasticity beginning with spasticity. Identifcation desired functional and participation outcomes of the child depends on a combination of suspicious and abnormal signs and family. Harris, using the Movement Assessment in Infants assessment fndings and plan of care. Both Harris and Milani Data Collection Comparetti found that watching the infant move against Date of birth gravity is of greater diagnostic value than intrusive handling Date of assessment 31,32 31 or attempts to stimulate a response. However, the Bayley Motor Overview of function (a few sentences) Scale was extremely sensitive at 1 year of age. This test may be a useful tool to help clinicians make decisions about the provision of intervention services. These fndings substantiate the Musculoskeletal fact that any infant or child who demonstrates neurologic Sensory or behavioral abnormalities should undergo follow-up until early school age. Is there isolated movement at the toes or ankles, or are Cardiovascular the ankles held in plantarfexion or dorsifexion? Is the Integumentary foot everted or inverted, and are the toes held loosely or Gastrointestinal tightly curled? Did the child propel the wheelchair independently, or System impairments was there some assistance? In addition to mobility, does the wheelchair provide total postural support for major segments of the body? If the Functional limitations segments are free of support from the wheelchair, are Barriers to participation those segments of the body in good postural alignment Analyze each level and how they interrelate, creating the and do they move freely? Does the child tend to thrust backward in the chair into Analyze the potential for change according to the findings trunk extension? If the child assumes these postures, is Plan of Care Specify the anticipated goals and expected outcomes (long there similar thrusting and tightness in the extremities? Is the child seated symmetrically, or are there signifcant asymmetries in the posture? Strategies of intervention Role of client, family, and other medical and educational Children with less severe movement disorders may professionals ambulate into the department, and the following questions Client-centered programs as appropriate will be helpful in assessing the quality of movement of the ambulatory child. Did the child ambulate with or without an assistive de vice?a walker, cane, or crutches? Does the the arms or lap of the parent can reveal important informa child stand on the balls of the feet? Are the hips and knees locked or stuck in extension dur observation: ing stance phase, or are they falling into gravity or pulled 1. Are the arms held behind the positions provides a guideline by which to assess functional body with the scapulae adducted or are the arms fexed antigravity control: and adducted against the trunk? Pos If the child possesses higher-level skills, the evaluation tural setting occurs as muscles become active around a should be extended to include the following: joint or joints, without obvious movement, in anticipation. Skipping is actively involved in the session and advances from using 39 the child who functions from a wheelchair should be only the feedback responses to feed-forward control. For observed for the following parameters: example, the child experiences the tactile and propriocep tive properties of objects (feedback) when handling and. Therapists used stimu lation of and feedback from optical righting, labyrinthine Assessment of Postural Tone righting, neck righting, body righting on the head, and body righting on the body to facilitate normal righting and equi the clinical term ?tone describes the impairments of spas 39 librium responses in the clients. Abnormally high tone may refexes were inhibited to decrease the abnormal sensory be caused by spasticity, a velocity-dependent overactivity that 10 feedback and facilitate the emergence and integration of the is proportional to the imposed velocity of limb movement. Clinicians tend to use the word ?tone to describe how According to more recent motor science studies, the a muscle or group of muscles feels under their hands human system is no longer thought to function via a hier when the joints of a body part are moved through a par archical model. The sense of abnormally high tone can result to describe the organization and functions of the nervous from hypoextensibility of the muscle because of abnormal 39 10 system. Postural preparations are strategies the child uses before Signs of increased tone include distal fxing (toe-curling a functional movement and increase stability by changing or fisting), difficulty moving a body segment through a the base of support or increasing muscle activation around range, asymmetric posture, retracted lips and tongue, and 40 joints. The child received sensory input of body segments, loss of postural alignment, and inability (feedback) from having completed the task previously and to sustain a posture against gravity. A child may also have makes the necessary postural adjustments to complete fuctuating levels of stifness, which is noted as signs of both the task in the most efcient, efective way. In typically developing babies younger than positioning?places the child at risk for soft tissue contrac 6 months of age, there is an approximate 90-degree angle tures and, over time, bony deformity. As control of the head and the sequence usually seen in atypical motor development trunk develops typically, and as the baby begins to develop and with knowledge of the postural and movement conse a more upright posture, there is a change in this 90-degree quences, the therapist must be alert for areas at risk for con relationship. The results should be documented clearly for to this ability to change the inspired volume, the thoracic later comparison. Muscles whose infuence is exerted across (external intercostal) and abdominal (obliques) muscles act two joints should be examined and elongated over both joints to fx the ribcage. It is the range that the child can access for of trunk flexors and extensors when in an upright posi function. Therapists can slowly and carefully stretch muscles tion with difculty sustaining their postural muscles. As a beyond this point to the second ?catch, or what is called result, there are diferences in motion of the chest wall dur the absolute range. First, the downward slant of the ribs never but the child cannot actively access the muscle beyond the fully develops, thus minimizing the mechanical advantage functional range. The therapist must work with the child and of the pump-handle and bucket-handle motions of inspira caregivers to bring the two values closer together, approxi tion. Second, without the muscle tone necessary to stabi mating the functional range to the absolute range. The lack of thoracic expansion, Mobility of the spine in all planes is necessary for cor in conjunction with the sternal depression, causes shallow rect alignment; for smooth, symmetric movements of the respiratory eforts. The therapist must specifcally facilitate the area is fattened?without the spinous processes showing or postural system muscles, both axial extensor and fexor mus showing less?it is indicative of a decrease in spinal fexion. The pelvis must be stabilized by the ther apist and the trunk taken through the various movements. Note the smoothness of the movement, the end range and Evaluations of the Shoulder Girdle end feel, the symmetry in the trunk, and the amount of and Upper Extremity movement at each joint in the spinal column. Tightness of the pectoralis major muscle per by shortened rectus abdominus and intercostal muscles. Dynamic scapular stability fails to develop, and the sis and lordosis, and whether the curves are structural or scapulae become fxed in downward rotation and a forward functional. Femoral ante the shoulder, which is used to stabilize the head, as well as version is determined by biplane roentgenograms. Antever excessive thoracic spine kyphosis, may produce limitations sion may be suspected on the basis of a simple clinical test. Moving distally, the therapist often fnds limita hip in a position of extension. The Thomas test is also revealed that the amount of anteversion did not decrease used to identify a fexion contracture of the hip. Abduction over the frst few years of life, as occurs with typically devel and adduction of the hip should be assessed with the hip oping children. Internal and external rotation of the hip change in anteversion with either age or ambulation status. Subluxed or dislocated hips can occur in children with 46 Staheli and associates found greater angles of antever very tight hip flexion, adduction, and internal rotation. Any child less than 8 years of age with hip abduction of less than 45 degrees on either side should be referred to Examination of the Knee 10 an orthopedic surgeon for further evaluation. The length of the medial and lateral hamstrings subluxed or dislocated hip is typically shorter than the more and the rectus femoris, all of which cross two joints, should ?normal hip owing to the great majority of subluxations be assessed elongating the muscle over the knee and the hip. Passive straight leg raising or measurement of the popli teal angle will indicate the degree of hamstring tightness.
Thus hypertension signs discount zebeta uk, the threat during intra-uterine life is anaemia but after birth is the accumulation of bile pigments blood pressure chart nih purchase zebeta 2.5mg on line. It is characterised by neck rigidity hypertension range generic 5mg zebeta, nystagmus blood pressure of 100/60 order zebeta 10mg with amex, twitching and death of the neonate may occur. Antenatal Assessment: (I) Maternal antibody level: It is indirect Coombs test that measures specific anti-D Ig G. Anti D gammaglobulin should be given to: q All Rh-negative women having Rh-positive baby in any delivery. El-Mowafi q Cordocentesis: is intravascular transfusion into the umbilical vein under direct vision using the fetoscope. The cord is divided 3 inches from the umbilicus to facilitate exchange transfusion if needed (D) Neonatal Management: (I) Blood is obtained from the umbilical cord for the following investigations: 1. The natural anti-A and anti-B antibodies of group O are IgG so it can cross the placenta to affect the baby, whereas the natural anti-A and anti-B antibodies of group B and A are IgM thus if the mother is of group A or B her antibodies cannot cross the placenta. Mid-trimester abortion: although abortion due to cervical incompetence is relatively painless it may be preceded by mild lower abdominal pain. Stretch of the nerve fibres in the round ligaments: pain in one or both iliac fossae between 16th and 20th week of pregnancy. Pressure symptoms:as engagement of the head, distension of the abdominal wall and pain due to flaring of the ribs particularly in breech presentation. Braxton Hicks contractions: Although it is usually painless, many women find it painful. False labour pain: irregular, not progressively increasing and not associated with bulging of forebag of water or dilatation of the cervix. Acute salpingitis: It is rarely seen because the presence of a pregnancy in the uterus prevents ascending infection and if the disease is chronic infertility is more file:///D|/Webs On David/gfmer/Books/El Mowafi/Abdominal pain pregnancy. This may be due to : a-jutting promontory, b pelvic adhesions, c posterior wall fibroid. Clinical Picture of Incarceration (A) Symptoms: (1) Urinary symptoms: Frequency then difficulty which may progress to acute retention of urine due to elongation and compression of the urethra. El-Mowafi r the cervix is high and directed anteriorly, r the body of the uterus is felt in Douglas pouch as a soft mass. Examine the patient during 14-18 weeks if spontaneous correction was not occur, manual correction is advised. In early pregnancy: manual correction is attempted and if fails, do laparotomy to free the uterus. Pendulous Abdomen It is marked weakness of the anterior abdominal wall leading to forward falling of the pregnant uterus to overhang the symphysis pubis. Ventouse, forceps or breech extraction may be used in prolonged labour to direct the presenting part in the pelvis. Effect of Fibroid on Pregnancy and Labour: (1) Abortion : particularly in submucous myomas due to: i) distortion of the uterine cavity, ii) affection of the decidual development, iii) affection of the vascular supply to the implanted ovum. Effect of Pregnancy and Labour on Fibroid: (1) Increase in size: due to i) oedema and increased vascularity, ii) hypertrophy of the uterine muscles. Management: (A) During pregnancy: (I) No treatment is indicated in the majority of cases. Red degenration which is not responding to the conservative treatment in the form of rest, analgesics, antibiotics to guard against secondary infection. Torsion: is the commonest complication particularly in pedunculated tumours that lie above the pelvic brim. It is more common during puerperium than pregnancy due to; lax abdominal wall, large intra-abdominal space after birth allows free mobility of the tumour. Management: (A) During pregnancy: (I)Cyst less than 6 cm in diameter : is left and followed up by periodic examination and ultrasound as it is usually a functional corpus luteum cyst. Discovered in the first half of pregnancy: is removed after the 12th week when the placenta is formed so there is less liability for abortion. Discovered in the second half of pregnancy: is left to be removed in the first week of puerperium. El-Mowafi (C) During puerperium: Tumours discovered for the first time should be removed immediately for fear of torsion. Abortion and preterm labour: due to haemorrhage, infection and general health affection. Cervical dystocia, obstructed labour, cervical laceration and/or uterine rupture may occur. Causes (A) Maternal factors: Age : below 16 years or above 35 years particularly if the patient is primigravida. El-Mowafi the grand multipara Definition: Woman who had 5 or more previous deliveries. Aetiology Unknown, but hereditary, hormonal and non-engagement of the presenting part are suspected factors. Obstructed labour: due to; oversized baby, no moulding of the skull due to more calcification. Management Termination of labour is indicated which may be by: q Induction of labour if the condition is favourable for vaginal delivery using: r 1 amniotomy oxytocin, or r 2 prostaglandins oxytocin. Risk of Prematurity: (1) Birth trauma: particularly intracranial haemorrhage which is aggrevated by hypoprothrombinaemia and capillary fragility present in prematures. A structureless hyaline membrane will develop within the alveolar ducts and atelectasis of the alveoli occurs. El-Mowafi q Dyspnoea and cyanosis develops 1-2 hours after delivery and death occurs after about 30 hours. Rickets and impaired mental development occurs more frequently in children who were prematures. El-Mowafi Prediction Recently, it has been reported that detection of foetal fibronectin, which is a glycoprotein synthesized in the chorio-decidual interface, in the cervico-vaginal sample is a predictor of imminent preterm labour. Diagnosis (1) Uterine contractions of : a frequency every 10 minutes or less, b duration at least 30 seconds and c continue for at least one hour. Treatment of cervical incompetence by circulage in the second quarter of pregnancy. This may be achieved by acting on one or more of the following theories of labour. This will decrease the release of oxytocins as well as antidiuretic hormone from the posterior pituitary. Rest in bed: to reduce the mechanical stimuli from the pressure of the presenting part on the lower uterine segment. Cervical circulage: it is of value in prevention of abortion and preterm labour if done at 14-16 weeks gestation but not so later on. Amniocentesis: was advocated by some authors to reduce the mechanical distension of the uterus in polyhydramnios. The drainage should be slowly aspirating 1 litre of amniotic fluid over 3-4 hours as sudden drop of uterine volume may initiate uterine contractions and causes abruptio placentae. Anaesthesia and analgesia: It is better to avoid the systemic ones that can depress the foetal respiratory center. El-Mowafi generous episiotomy outlet forceps to avoid compression and sudden decompression of the foetal head. Malpresentations as the presenting part is not fitting against the lower uterine segment. Drawback: Vulval pads can be moisted with urine or vaginal discharge which can be mistaken with the amniotic fluid. El-Mowafi 2 Nitrazine paper test: the colour turns from yellow to deep blue due to alkalinity of the amniotic fluid. Drawback: blood, semen or vaginal infection are alkaline media give the same result. Drawback: It carries risk of foetal trauma particularly if a large amount of the amniotic fluid was drained. Oligohydramnios is diagnosed if the measurements of the largest bocket of the amniotic fluid are less than 1? The largest bocket is usually present between the anterior file:///D|/Webs On David/gfmer/Books/El Mowafi/premature rupture of membranes.
Inadequately drained blood can lead to the development of fibrothorax and lung entrapment arteria carotis interna buy 10mg zebeta overnight delivery. In these cases of severe hemorrhage hypertension jnc buy generic zebeta 2.5mg, emergent thoracotomy should be considered to achieve hemostasis blood pressure variation discount zebeta 2.5mg with amex. Rib Fractures Rib fractures are less common in the children when compared to adults hypertension 5 mg order 2.5mg zebeta with visa, secondary to the greater flexibility of the pediatric chest wall. It occurs in only 1% to 2% of pediatric trauma victims and most commonly is the result of blunt trauma from motor vehicle accidents, pedestrian accidents, or child abuse. Physical exam rarely identifies substantial clinical findings and diagnosis is established most frequently by a screening chest radiograph performed at the 306 initial presentation. Although rib fractures alone are usually of minimal clinical significance, 70% of patients with multiple rib fractures have associated injuries in other organ systems. Consequently, the presence of rib fractures in blunt trauma necessitates thorough evaluation for other concomitant injuries. In patients less than 3 years of age, child abuse should be strongly considered in the absence of a plausible mechanism for major trauma or underlying metabolic condition predisposing to fractures, such as rickets or osteogenesis imperfecta. When reasonable causes are excluded, the positive predictive value of rib fractures for child abuse in children younger than 3 years of age is 95% to 100%. In cases suspicious for abuse as the primary etiology, further imaging with a skeletal survey and bone scintigraphy should be pursued and social work involvement should be initiated. The location of rib fractures may prompt further examination for associated organ injuries. First rib fractures indicate a high-energy impact and may be associated with multisystem injury, including shoulder girdle injury, clavicle fracture, pulmonary contusion, hemopneumothorax, vertebral spine injury, or intra-abdominal trauma. However, fractures in the first and second rib are no longer considered to be markers for major vascular injury, nor are they indicators for further angiographic examination. Fractures of the lower ribs, depending on laterality, are associated with hepatic or splenic injuries. Non-steroidal anti-inflammatory medications, intravenous or oral narcotics, and epidural anesthesia are effective options for analgesia and should be used judiciously. This results in an unstable chest wall and is clinically diagnosed as paradoxical chest wall motion with respiration. Two main factors associated with the morbidity of flail chest are paradoxical wall motion and underlying pulmonary contusion. The primary goal in treating flail chest is supportive respiratory measures and adequate analgesia. However, in cases of severe respiratory compromise, such as hypoxia or hypercarbia, intubation and mechanical ventilatory support may be necessary. Rib fixation for the treatment of flail chest has been described in the adult literature with promising results. Open reduction and internal fixation of flail rib segments stabilizes the chest wall and improves pulmonary mechanics. Morbidity is consequently reduced because there is an appreciable reduction in time on the mechanical ventilator, as well as length of stay in the intensive care 308 unit. Available prosthesis includes stainless steel wires, metal plates or struts, and absorbable plates and screws. Reports of rib fixation in children are sparse in the pediatric literature and it is still largely uninvestigated. Although it has been shown to be beneficial in adults and short-term results may potentially be reproducible in children, there are concerns regarding rib fixation with metal plates or struts in children. Other concerns include the long-term risk of infection of embedded hardware and need for subsequent surgeries to modify or remove hardware. Additional studies are required to define the appropriate indications in the pediatric population and assess long-term outcomes in children. On physical exam, a chest wall contusion may be visualized and pain may be elicited with palpation of the sternum. The most common location of fracture occurs at the sternomanubrial junction of the sternum. Although the majority of sternal fractures are usually isolated injuries, they are associated with cardiac dysrhythmias. A significant amount of energy transfer is required in order to fracture the scapula and associated injuries are seen in 90% of patients with this injury. Scapular fractures that are non-displaced can be managed non-operatively with a sling, while surgical intervention may be required for deformed or significantly displaced fractures. Tracheobronchial Injuries Tracheobronchial injuries in children are rare, occurring in less than 1% of pediatric traumas. Although rare, these injuries have a 30% mortality and half of the deaths occur within the first hour of injury. Disruption of the trachea or bronchi may result from a direct penetration injury or from high energy blunt chest trauma. The most common causes of tracheobronchial injuries are motor vehicle accidents, pedestrian accidents, and falls. Mechanisms for airway rupture in blunt trauma include abrupt increase in intraluminal pressures from chest compression with a closed glottis, violent acceleration-deceleration of the tracheobronchial tree and lungs, or anterio-posterior compression of the sternum against the spine causing sudden displacement of lungs laterally. Up 310 to 80% of injuries occur within 2 cm of the carina, most commonly the proximal right main stem bronchus. Physical findings suggestive of an airway injury include hoarseness, cervical crepitus, substernal tenderness, or hemoptysis. On chest x-ray, the common radiographic findings are subcutaneous emphysema, pneumomediastinum, or pneumothorax. In rare cases where there is complete transection of a distal mainstem bronchus, a ?fallen lung sign may be seen on chest x-ray. This highly suggestive finding refers to the collapsed lung in a dependent position, hanging only by its vascular attachments. In the absence of clear physical or radiographic findings, clinical suspicion should be raised when there is a large, persistent air leak after chest tube placement for pneumothorax. Tracheobronchial disruption is potentially fatal and requires early diagnosis and intervention. Fiberoptic bronchoscopy can be used to confirm and measure the extent of airway injury. In addition, interventional maneuvers may be done at the time of bronchoscopic diagnosis, such as occlusion of the defect with an endobronchial blocker or selective bronchial intubation of the unaffected side. Delay in surgery may result in respiratory failure in the acute setting or eventual stenosis in the future. The disrupted tracheobronchial tree may be repaired through a standard posterolateral thoracotomy. The right thoracic 311 approach allows access to the trachea and right-sided bronchial injuries, while the left approach permits access to left bronchial injuries. Tenuous repairs may be reinforced with a well-vascularized tissue buttress from an intercostal muscle pedicle flap. Esophageal Injuries Traumatic esophageal injuries are extremely rare in pediatric trauma. This is primarily because it is a mobile mediastinal structure in children and it is well-protected in the posterior mediastinum of the thoracic cavity. Although it is an uncommon injury, it remains clinically significant because esophageal perforation with mediastinal contamination is associated with high morbidity and mortality. Perforation or rupture of the esophagus can rarely occur with rapid intraluminal pressure elevation following high-impact blunt force trauma. More commonly esophageal injuries are the result of penetrating injury to the neck or chest. Esophageal injuries tend to have an occult presentation, therefore suspicion should be raised in patients with the appropriate mechanism to prevent delay in diagnosis. Depending on the location of the esophageal injury and degree of esophageal leakage, a pleural effusion may also be present. Up to 15% of perforations may be missed with water-soluble contrast, so a negative study should be followed by a barium contrasted esophagram. Once an esophageal injury is identified, prompt intervention is necessary to prevent mediastinitis. Operative repair is directed to the site of injury with goals to debride areas of contamination, primarily close the perforation with autologous tissue reinforcement, and control for esophageal leak with tube thoracostomy drainage. Order 5mg zebeta with amex. Dr Trust AONE Galaxy Blood pressure monitor with MDI - Unboxing (Measurement during Inflation). |
