CENTRAL OBJECTIVES: At the end of one hour and a half of lecture-discussion with the active participation of the learners,

the learners shall gain important knowledge, develop skills and manifest a positive attitude in providing quality, effective and efficient care to client who have delivered an infant with anencephaly.

SPECIFIC OBJECTIVES: At the end of one hour and a half of case presentation the learners shall: 1. gain an overview of the case presentation 2. identify correctly the demographic profile of the client 3. be oriented on the nursing history of the client 4. recognize the physical examination results and findings of the client 5. compare relatively the relationship of the anatomy and physiology of systems involved in the disease condition 6. discuss the system involve in the disease condition thoroughly 7. analyze comprehensively the pathophysiology of the disease condition 8. enumerate the medical interventions appropriately 9. explain in detail the nursing theory applicable to care of the client

10. discuss the possible nursing diagnosis of the client accurately 11. competently identify the Gordons Functional Health Pattern of the client 12. critically analyze the nursing care plans of the client 13. objectively evaluate the presentation and able to raise and answer questions

INTRODUCTION

Doubts about the anencephalic infant's human dignity "have no solid ground and the benefit of any doubt must be in the child's favor. As a general rule, conditions of the human body, regardless of severity, in no way compromise human dignity or human rights", the Committee on Doctrine of the National Conference of Catholic Bishops said in a statement sent to all U.S. Bishops 20 September, following approval of its distribution by the NCCB Administrative Committee. The statement took issue with the argument by some that anencephalic children, "because of their apparent lack of cognitive function, and in view of the probable brevity of their lives", lack human rights "or at least have lives of less meaning or purpose than others", and thus "may be prematurely delivered, even when this would be inappropriate for other children". The committee said, "It can never be morally justified directly to cause the death of an innocent person no matter the age or condition of that person". It said, "The anencephalic child during his or her probably brief life after birth should be given the comfort and palliative care appropriate to all the dying". However, it said, "this failing life need not be further troubled by using extraordinary means to prolong it". The statement includes discussion of the treatment of pathologies in a pregnant mother, baptism and burial for anencephalic infants, and organ donation. (Last year the Council on Ethical and Judicial Affairs of the American Medical Association suspended its controversial 1994 policy decision that would have permitted transplant of organs of anencephalic newborns "even before the neonates die, as long as there is parental

consent and certain other safeguards are followed".) The doctrinal committee said that donating the organs of an anencephalic child to "assist other children" is commendable for parents, "but this may never be permitted before the donor child is certainly dead". DEMOGRAPHIC DATA Date of Assessment: July 19, 2008 Name of patient: Jonalyn Belucora Age: 20 years old Sex: Female Civil status: Married Religion: Roman Catholic Birth date: June 6, 1983 Educational Attainment: Elementary level Address: Tiguib, Ayungon Negros Oriental Date and time of admission: February 15, 2009 @ 10:00 pm Chief Complaints: Labor pains and watery vaginal discharge which started few hours PTA Rm & Bed #: OB/ward B7 Attending Physician: Dr. Roleda

History of present illness: LMP is on May 14, 2008 and EDC is on February 21, 2009. Had not submitted her self for prenatal check-up and had not even taken any vitamins or supplements for pregnancy. She experienced mild cough, colds, and headache and self-medicate using the over-the-counter medication.

General Impression: Conscious, coherent, cooperative and response to greetings. Answer questions shortly. Look pale and tired.

ERIK- ERICKSONS THEORY Developmental Milestone Developmental Stage: Young adult: 18-35 years old Psychosocial crisis: Intimacy vs. isolation Occurring in Young adulthood, we begin to share ourselves more intimately with others. We explore relationships leading toward longer term commitments with someone other than a family member. Successful completion can lead to comfortable relationships and a sense of commitment, safety, and care within a relationship. Avoiding intimacy, fearing commitment and relationships can lead to isolation, loneliness, and sometimes depression. Central task: Need for intimacy Ego Quality: Affiliation and love Definition: The giving and receiving of physical and emotional connection, support, love, comfort, trust and other elements that would typically associate with healthy adult relationship conducive to mating and child-rearing

Developmental task: Reciprocal love for and with another person Significant Relations: Marital partners and friends Mrs. Calingacion is a 20-year-old G1P1. She was wed for more than a year now. She was a prim and was happy to be a new mother as well as a wife. She was a plain housewife and depends on her husband who was a carpenter/ construction worker. Decision-making is done together by her and her husband. Relationships with husband and relatives as well as their neighbors are healthy and harmonious. She wanted to be greatly attached by her husband for companion and love. Also seeks attention from her family and friends for the same purpose of attachment.

Nursing History A) Chief Complaints: Labor pains and watery vaginal discharge which started few hours PTA B) Admitting Impression/ Diagnosis PU 39 1/7 week in labor and delivered spontaneous to a dead baby boy 3 hour prior. G4P4 (4-0-03). IUFD and Anencephaly.

C) HPI LMP is on May 14, 2008 and EDC is on February 21, 2009. Had not submitted her self for prenatal check-up and had not even taken any vitamins or supplements for pregnancy. She experienced mild cough, colds, and headache and self-medicate using the overthe-counter medication. D) Past Health History- Menarche started at the age of 12. A G4P4. No hospital experience and claimed that she is healthy without complications, severe illness/ disease all throughout her life, although she experienced mild colds, cough and headache.

E) Psychosocial History She lives at Tiguib, Ayungon Negros Oriental with her family. She is married and has four children. She had a good relationship with his family, friends and to her neighbor.

G) Environmental History Her family resides at Tiguib, Ayungon Negros Oriental. The houses in their place are slightly congested, mostly made up of nipa. The environment is quiet and peaceful and the residents were busy doing their individual tasks. There are some who have engaged into small-scale business, some are farmers, fishermen, drivers, carpenters and construction workers. Their main livelihood is farming.

F) Spiritual History- They believe in one God and was baptized as a Roman Catholic. She was not a member of any religious organization but is a devotee of the Catholic Church and practices the religious activities of a Roman Catholic.

PHYSICAL ASSESSMENT Vital signs: Taxilla= 37.2 degree celsius PR=80 bpm RR=22cpm BP=100/70mmhg INTEGUMENTARY SYSTEM History of the System Skin Inspection Palpation

No food restrictions PTA.

Have not taken food supplements during her pregnancy. Diet as tolerated. No allergies and rashes on skin experienced PTA. Exposure to sun is not too much, no scalp lesions and itching experienced. Nails and cuticles were in good

Light brown in color and generally uniform except in areas exposed to the sun. Paleness noted No lesions, edema and discharges noted

Skin lifts easily and snaps back immediately to its resting position after lifting Smooth, soft, even and flexible Uniformly warm

Smooth dry with minimal perspiration or oiliness Nails

condition.

Brown pigmentation in longitudinal streaks No signs of dryness Well rounded and convex 160 degrees angle

Smooth and of uniform thickness Capillary refill time: 3 sec. No lesions noted

Hair Resilient and evenly distributed Black in color, thick Variable in amount

No masses noted No tenderness

Scalp With even coloration No dandruffs, lice noted

Smooth Inelastic

Head Head held upright and still Skull is generally round No edema and masses noted No deformities

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Eyes

No history of prior eye surgery. Do not use corrective glasses or contract lenses. No companions of blurred vision and any discharge of the eyes. No problem in hearing and no frequent infections in the ear can smell and sense taste well. Appetite is good and in DAT.

eyes are parallel to each other eyebrows are symmetrical

Blinks when the cornea is touches

No edema, tenderness over the lacrimal gland No masses noted

eyelids are close to the eyeball; lids close symmetric conjunctiva is pale with no discharge noted sclera is blue white

cornea is transparent, smooth and moist

iris and pupil are round, equal, with uniform color lens is clear

20/20 O.D and O.S with a little hesitation and slightly leaning forward. Leads print without difficult at approximately 14 inches Pupils converge and constricts as objects moves in toward the nose Both eyes move in a smooth, coordinated manner in all directions

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Ears

Color is the same as the facial skin Ears are of equal and similar appearance Almost vertical and level with each other Vibration heard equally in both ears Able to hear whispered words

Non tender auricle; smooth Without nodules ; masses; lesions Firm

No pain felt upon palpation of the mastoid process, no tenderness and warm

Client stands straight with minimal swaying Nose

Color is same as face Symmetrical appearance

Smooth No pain reported Non tender No masses and lesions noted

Mucosa pink and moist with uniform color and no lesions Free movement of air through the nares No discharges

Mouth Moist, slightly pale and symmetrical lips

Smooth, moist, without lesions No palpable nodules noted

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Buccal mucosa with some patchy pigmentation Gums are partly brown

Teeth are smooth, white and shiny ; 32 teeth Tongue is dull red in color, moist, symmetrical Hard palate is pale, soft palate is pink No swelling noted

Trachea is in the midline position, and symmetrical Thyroid is in the midline, smooth, firm and non tender Lymph nodes are not palpable

Neck Symmetrical, centered head position Smooth, controlled movements Able to flex, extend, and rotate neck

RESPIRATORY SYSTEM

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History of the System

Inspection entire thorae expands and relaxes regularly with equality of movement

Auscultation

Percussion

Palpation

No problem in breathing and occasionally experience cough at least 2-3 a year.

no masses no tenderness

with resonance sounds

no masses, lumps, nodules tenderness and respiratory excursion noted

chest is symmetrical spine is straight skin is intact

bilateral symmetry of local femitus

no use of accessory muscles in breathing equal chest expansion

HEART AND THE PERIPHERAL VASCULAR SYSYTEM History of the system Heart Inspection Auscultation Palpation

Blood pressure is usually

No pulsation heard

Sounds heard at all area 14

No pulsation noted

100/70 mmHg

No complains of chest pain and irregular heart beat Pulse rate is usually 80 bpm

Peripheral pulses

Not tender upon pulsation

Full palpation in all sites

First IV site was in the right metacarpal vein BREAST AND AXILLAE History of the system Inspection Palpation

She is a multipara and is breastfeeding

Experienced breast tenderness and engorgement and slight pain is felt when breast feeding Does not perform BSE

Breast are relatively equal, enlarged Nodularity is increased Round, everted, tender Presence of colostrums Areola and nipple are dark brown Smooth and intact skin No discharges

Warm With small lumps Slightly tender No lesions and masses Lymph nodes are non palpable

Small Montgomery tubercles present in the areola

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ABDOMEN History of the system Inspection Auscultation Percussion Palpation

Does not experience GI symptoms Bowel characteristics is normal No pain felt to ingestion of foods No history of UTI

Normally pale with presence of linea negra Fine veins observable No rashes or lesions

Bowel sound is high pitched No bruits, no venous hum , no friction rubs

Generalized tympany over bowels Liver span is 9 cm in midsternal line Liver span is 5cm in midsternal line Small area of dullness over liver and spleen

Non tender Soft No masses

Umbilicus is centrally located and is light brown Abdomen is round, symmetrical and no movement or peristalsis Uterus is visible Striae dark red Loose and flabby

Kidneys and splenic border are more palpable No increase in abdominal girth No abdominal pain present Fundus is in the midline

Boggy to firm with slight massage Smooth surface

2 cm, 1 finger breadths below the umbilicus

Bladder

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Approximately 100 cc each voiding Yellowish hazy and mixed with lochia

Bladder is non palpable

NEUROLOGIC SYSTEM History of the system Inspection

No problems in memory Able to retain an recall things Able to communicate well and speak with relevance No mental problems

Posture is relaxed with shoulders back and both feet stable Gait is coordinated and smooth

Motor movements is smooth, coordinated and client alter position occasionally Dress appropriately In good hygiene, skin clean, nail clean and trimmed Good eye contact ; smiles/ frown appropriately Speech is clear with moderate pace Expresses feelings appropriate to situation Expresses good feelings about self, others, and life; aware of self 17

Posture, gait, sensory, motor, cerebellar function and reflexes are normal

Verbalizes positive coping mechanisms Follow instruction/directions accurately Perceptions realistic Listens and responds

FEMALE GENITALIA AND INGUINAL AREA History of the system Inspection Palpation

She was G, P,. Its her first time to undergone childbirth process. Delivered via vaginal delivery First menstruation at the age of 12. LMP= May 14, 2008 EDC= February 21, 2009 a dead anencephalic

Vagina is soft with few rugae Diameter is greater than normal Hymen permanently torn

No enlargement and tenderness noted particularly in the inguinal lymph nodes No swelling Lumps/ nodules are smooth with soft tissue

Labia is symmetrical and dark red in color Perineum

Delivered on baby

Presence of episiotomy, edema and

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generalized tenderness. Skin edges met as an approximation of the episiotomy

Lochia rubra; red in color and compose mainly of blood, mucoid, earthly odor Discharge amount is moderate Used 4-5 pads in one day

Discharge gradually decreases in amount

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ANATOMY AND PHYSIOLOGY OF THE SYSTEM INTEGUMENTARY SYSTEM

The integumentary system consists of the skin, hair, nails, the subcutaneous tissue below the skin, and assorted glands. The most obvious function of the integumentary system is the protection that the skin gives to underlying tissues. The skin not only keeps most harmful substances out, but also prevents the loss of fluids. 20

A major function of the subcutaneous tissue is to connect the skin to underlying tissues such as muscles. Hair on the scalp provides insulation from cold for the head. The hair of eyelashes and eyebrows helps keep dust and perspiration out of the eyes, and the hair in our nostrils helps keep dust out of the nasal cavities. Any other hair on our bodies no longer serves a function, but is an evolutionary remnant. Nails protect the tips of fingers and toes from mechanical injury. Fingernails give the fingers greater ability to pick up small objects. There are four types of glands in the integumentary system: Sudoriferous glands, Sebaceous glands, Ceruminous glands, and Mammary glands. Sudoriferous glands are sweat producing glands. These are important to help maintain body temperature. Sebaceous glands are oil producing glands which help inhibit bacteria, keep us waterproof and prevent our hair and skin from drying out. Ceruminous glands produce earwax which keeps the outer surface of the eardrum pliable and prevents drying. Mammary glands produce milk.

The integumentary system consists of the skin and accessory structures such as hair, nails and glands

Skin

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Functions
o o

Skin is extremely important to normal physiologic function secondary to the roles that it plays in maintaining homeostasis. The seven chief functions of the skin are as follow: 1. Regulation of body temperature 2. Protection 3. Sensation 4. Excretion 5. Immunity 6. Blood reservoir 7. Synthesis of vitamin D

Structure
o

Skin is the largest organ of the body. In adults, the skin covers an area of approximately 2 square meters and accounts for nearly 20% of one's body weight. Its thickness varies from 0.3-4.0 mm depending on the location on the body. The skin is composed of three principal parts:

Epidermis

The epidermis is composed of stratified squamous epithelium and is separated from the dermis by a thin basement membrane.

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The epidermis is not as thick as the dermis and varies in thickness from approximately 0.3 mm on the eyelids to 1.5 mm on the palms of the hands and soles of the feet. The epidermis is an avascular structure. Therefore, all gases, nutrients and waste products must diffuse to & from the capillaries located in the dermis.

There are four principal cells that compose the epidermis. These cells are as follow: 1. Keratinocytes- Comprise approximately 90% of all epidermal cells. These cells produce a protein mixture known as keratin which helps waterproof and protect the skin. 2. Melanocytes- Comprise approximately 8% of all epidermal cells. These cells produce a group of pigments known as melanin which are responsible for skin, hair and eye color. 3. Langerhans cells- These cells arise from the bone marrow and migrate to the epidermis. These cells play an important role in the immune response. 4. Merkel cells- These cells are located in the deepest regions of the epidermis and are associated with sensory neurons and are thought to function in the sensation of touch.

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The epidermis is composed of five layers or strata. These layers from the deepest to the most superficial are: 1. Stratum basale 2. Stratum spinosum 3. Stratum granulosum 4. Stratum lucidum 5. Stratum corneum

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Dermis

The dermis is composed of dense, irregular connective tissue. The dermis varies in its thickness from less than 1 to 4 mm thick. Blood vessels, nerve endings, hair follicles, smooth muscle, glands and lymphatic vessels all extend into the dermis.

Dermal Layers The dermis can be divided into two indistinct layer: 1. Reticular layer 2. Papillary layer

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Hypodermis

The hypodermis which is also known as the subcutaneous tissue attaches the skin to underlying bones and muscles and also supplies it with blood vessels and nerves. The hypodermis consist mostly of connective tissue and adipose cells. As much as one half of the body's stored fat is located in the hypodermis

Hair

Hair develops from the embryonic epidermis. The primary unction of hair is protection.

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Hair Structure

A hair is divided into the shaft which is the aspect of the hair that protrudes above the surface of the skin and the root which is the aspect of the hair that is beneath the surface of the skin. The base of the root is expanded and is known as the hair bulb. A hair is composed of numerous columns of dead yet keratinized cells held tightly together in three concentric layers known as the medulla, cortex and cuticle.

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Nails

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Nail Structure

Nails are plates of hard, tightly packed keratinized cells of epidermis. Nails are composed of three principal parts: 1. Nail body- The visible portion of the nail. 2. Free edge- The aspect of the nail that may extend past the distal end of the digit.

Nail root- The aspect of the nail that is buried underneath a fold of skin. Other structures associated with the nail include: 1. Lunula- The whitish semilunar area of the proximal end of the nail body. 2. Eponychium- Also known as the cuticle. This is a narrow band of epidermis which extends from the lateral border of the nail wall. 3. Nail matrix- Epithelial tissue deep to the nail root where actual nail growth occurs.

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Nail Function

Functionally, nails allow us to grasp and manipulate small objects. In addition, nails also provide protection against trauma to the distal ends of the digits. Glands

The two major glands of the skin are the sebaceous and sweat glands.
o

Sebaceous glands

Sebaceous glands are located in the dermis and are usually connected to hair follicles. These glands produce an oily, white substance known as sebum which oils the hair and skin and thus prevents drying and also provides protection against some bacteria.

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Sebaceous glands are located on the lips, on the eyelids and on the genitalia. There are approximately 3 to 4 million sweat glands in the human body. Sweat glands are typically divided into two types, eccrine & apocrine, based on their structure and location.

Sweat glands

Eccrine Sweat Glands

Eccrine sweat glands, also known as merocrine sweat glands, are the most common type of sweat glands. These sweat glands are composed of simple coiled tubular glands that opens directly onto the surface of the skin through sweat pores. Eccrine glands are most numerous on the palms of the hands & the soles of the feet. Apocrine sweat glands are composed of compound coiled tubular glands that usually opens into hair follicles superficial to the opening of sebaceous glands. These glands are typically found in the axillae, genitalia and around the anus.

Apocrine Sweat Glands

Blood Supply

Blood supply to the skin is limited to the capillary plexus of the dermis & hypodermis. A subcapillary network of veins drains the capillary system. Lymphatic vessels of the skin arise in the dermis and drain into larger hypodermic branches.

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THE FEMALE REPRODUCTIVE SYSTEM All living things reproduce. Reproduction the process by which organisms make more organisms like themselves is one of the things that sets living things apart from nonliving matter. But even though the reproductive system is essential to keeping a species alive, unlike other body systems, it's not essential to keeping an individual alive. In the human reproductive process, 2 kinds of sex cells, or gametes, are involved. The male gamete, or sperm, and the female gamete, the egg or ovum, meet in the female's reproductive system to create a new individual. Both the male and female reproductive systems are essential for reproduction. The female needs a male to fertilize her egg, even though it is she who carries offspring through pregnancy and childbirth. Humans, like other organisms, pass certain characteristics of themselves to the next generation through their genes, the special carriers of human traits. The genes that parents pass along to their children are what make children similar to others in their family, but they are also what make each child unique. These genes come from the male's sperm and the female's egg, which are produced by the male and female reproductive systems. The female reproductive system enables a woman to:

produce eggs (ova) have sexual intercourse protect and nourish the fertilized egg until it is fully developed

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give birth allows passage of the menstrual flow

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FEMALE EXTERNAL GENITALIA The external female genitals are collectively referred to as The Vulva. All of the words below are part of the vulva. External View: The Vulva The Parts of the Vulva | Mons Veneris | Labia Majora | Labia Minora | | Clitoris | Urethra | Vagina and Hymen | Perineum | Mons Veneris The mons veneris, Latin for "hill of Venus" is the pad of fat that covers the pubic bone below the abdomen but above the labia. The mons is one of the sexually sensitive zones in women and protects the pubic bone from the impact of sexual intercourse. Labia Majora The labia majora are the outer lips of the vulva, pads of fat again that wrap around the vulva from the mons to the perineum. Labia Minora

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The labia minora are the inner lips of the vulva, thin stretches of tissue within the labia majora that fold and protect the vagina, urethra, and clitoris. Both the inner and outer labia are quite sensitive to touch and pressure. Clitoris The clitoris, visible in picture as the small white oval at the top of the labia minora, is a small body of spongy tissue that is highly sexually sensitive. The clitoris is protected by the clitoral hood, or female prepuce, a covering of tissue similar to the labia minora. Urethra The opening to the urethra is just below the clitoris. It is not related to sex or reproduction, but is instead the passage for urine. The opening of the urethra (urethral meatus) opens into the vestibule between the clitoris and vagina. Just behind it on either side can sometimes be seen the openings of the para urethral or Skenes glands. The openings of Bartholins glands are located towards the back on either side of the vaginal opening, but the glands are not usually visible. Bartholins glands themselves are situated more towards the inside.

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The urethra is connected to the bladder. Because the urethra is so close to the anus, women should always wipe themselves from front to back to avoid infecting the vagina and urethra with bacteria. Vagina and Hymen The above illustrations show the area between the labia minora. From top to bottom can be clearly seen the clitoris, urethral opening, and vaginal opening. Normally hymen, is a membrane that partially covers the opening. The hymen is the traditional "symbol" of virginity, although being a very thin membrane, it can be torn by vigorous exercise or the insertion of a tampon. Perineum The perineum is the short stretch of skin starting at the bottom of the vulva and extending to the anus. The perineum in women often tears during birth to accommodate passage of the child, and this is apparently natural. Some physicians may cut the perineum preemptively on the grounds that the "tearing" may be more harmful than a precise scalpel, but statistics show that such cutting in fact may increase the potential for infection.

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Vagina | Cervix | Uterus | Ovaries | Fallopian Tube | Vagina The vagina extends from the vaginal opening to the cervix - the opening to the uterus. The vagina receives the penis during sexual intercourse, and is the birth canal through which the baby passes during labor. The average vaginal canal is three inches long, possibly four in women who have given birth. This may seem short in relation to the penis, but during sexual arousal the cervix will lift upwards and the fornix (see illustration) may extend upwards into the body as long as necessary to receive the penis. After intercourse, the contraction of the vagina will allow the cervix to rest inside the fornix, which in its relaxed state is a bowl-shaped fitting perfect for the pooling of semen.

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At either side of the vaginal opening are the Bartholin's glands, which produce small amounts of lubricating fluid, apparently to keep the inner labia moist during periods of sexual excitement. Further within are the hymen glands, which secrete lubricant for the length of the vaginal canal. Cervix The cervix is the opening to the uterus. It varies in diameter from 1 to 3 millimeters, depending upon the time in the menstrual cycle the measurement is taken. The cervix is sometimes plugged with cervical mucous to protect the cervix from infection; during ovulation, this mucous becomes a thin fluid to permit the passage of sperm. Uterus The uterus, or womb, is the main female internal reproductive organ. The inner lining of the uterus is called the endometrium, which grows and changes during the menstrual cycle to prepare to receive a fertilized egg, and sheds a layer at the end of every menstrual cycle if fertilization does not happen. The uterus is lined with powerful muscles to push the child out during labor. Ovaries The ovaries are situated on the side of the uterus just below the finger like projections of the fallopian tubes The ovaries perform two main functions: production of female sex hormones -estrogen and progesterone, and the production of mature ova, or eggs every month after puberty. Of the two female hormones produced by the ovaries, estrogen is responsible for development and maintenance of all secondary sex characters such as breast, shape of the body, and maturity of the reproductive organs such as vagina, uterus, fallopian tubes, etc.

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Progesterone is produced after the ovum has been released. It is essential for maintenance of pregnancy and is responsible for regular menstruation and maintaining normal menstrual flow. High progesterone levels suppress menstruation. At birth, the ovaries contain nearly 400,000 ova, and those are all she will ever have. However, that is far more than she will need, since during an average lifespan she will go through about 500 menstrual cycles. These premature eggs are formed when baby is growing in the uterus itself and may be damaged due to x-rays or exposure to toxic substances After maturing, the single egg travels down the fallopian tube, a journey of three or four days-- this is the period during which a woman is fertile and pregnancy may occur. Eggs that are not fertilized are expelled during menstruation along with the inner layer of uterus. Even if there is no damage to the premature eggs in the uterus, those that are released after the age of thirty-five years are "old" and therefore the risk of congenital abnormalities increases. Fallopian Tube Fallopian tube is the duct through which the egg must pass to reach the uterus. The tube is about 4" long and hang freely in the pelvic cavity. They are not directly connected to the ovaries but its end widens into a wide flower like opening that lies adjacent to the ovary.

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THE BRAIN

The anatomy of the brain is complex due its intricate structure and function. This amazing organ acts as a control center by receiving, interpreting, and directing sensory information throughout the body. There are three major divisions of the brain. They are the forebrain, the midbrain, and the hindbrain. Anatomy of the Brain: Brain Divisions The forebrain is responsible for a variety of functions including receiving and processing sensory information, thinking, perceiving, producing and understanding language, and controlling motor function. There are two major divisions of forebrain: the diencephalon and the

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telencephalon. The diencephalon contains structures such as the thalamus and hypothalamus which are responsible for such functions as motor control, relaying sensory information, and controlling autonomic functions. The telencephalon contains the largest part of the brain, the cerebral cortex. Most of the actual information processing in the brain takes place in the cerebral cortex. The midbrain and the hindbrain together make up the brainstem. The midbrain is the portion of the brainstem that connects the hindbrain and the forebrain. This region of the brain is involved in auditory and visual responses as well as motor function. The hindbrain extends from the spinal cord and is composed of the metencephalon and myelencephalon. The metencephalon contains structures such as the pons and cerebellum. These regions assists in maintaining balance and equilibrium, movement coordination, and the conduction of sensory information. The myelencephalon is composed of the medulla oblongata which is responsible for controlling such autonomic functions as breathing, heart rate, and digestion.

Prosencephalon - Forebrain Mesencephalon - Midbrain

Diencephalon Telencephalon Metencephalon Myelencephalon

Rhombencephalon - Hindbrain

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Anatomy of the Brain: Structures The brain contains various structures that have a multitude of functions. Below is a list of major structures of the brain and some of their functions. Basal Ganglia

Involved in cognition and voluntary movement Diseases related to damages of this area are Parkinson's and Huntington's

Brainstem

Relays information between the peripheral nerves and spinal cord to the upper parts of the brain Consists of the midbrain, medulla oblongata, and the pons

Broca's Area

Speech production Understanding language

Central Sulcus (Fissure of Rolando)

Deep grove that separates the parietal and frontal lobes

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Cerebellum

Controls movement coordination Maintains balance and equilibrium

Cerebral Cortex

Outer portion (1.5mm to 5mm) of the cerebrum Receives and processes sensory information Divided into cerebral cortex lobes

Cerebral Cortex Lobes

Frontal Lobes -involved with decision-making, problem solving, and planning Occipital Lobes-involved with vision and color recognition Parietal Lobes - receives and processes sensory information Temporal Lobes - involved with emotional responses, memory, and speech

Cerebrum

Largest portion of the brain Consists of folded bulges called gyri that create deep furrows 43

Corpus Callosum

Thick band of fibers that connects the left and right brain hemispheres

Cranial Nerves

Twelve pairs of nerves that originate in the brain, exit the skull, and lead to the head, neck and torso

Fissure of Sylvius (Lateral Sulcus)

Deep grove that separates the parietal and temporal lobes

Limbic System Structures

Amygdala - involved in emotional responses, hormonal secretions, and memory Cingulate Gyrus - a fold in the brain involved with sensory input concerning emotions and the regulation of aggressive behavior Fornix - an arching, fibrous band of nerve fibers that connect the hippocampus to the hypothalamus Hippocampus - sends memories out to the appropriate part of the cerebral hemisphere for long-term storage and retrievs them

when necessary

Hypothalamus - directs a multitude of important functions such as body temperature, hunger, and homeostasis

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Olfactory Cortex - receives sensory information from the olfactory bulb and is involved in the identification of odors Thalamus - mass of grey matter cells that relay sensory signals to and from the spinal cord and the cerebrum

Medulla Oblongata

Lower part of the brainstem that helps to control autonomic functions

Meninges

Membranes that cover and protect the brain and spinal cord

Olfactory Bulb

Bulb-shaped end of the olfactory lobe Involved in the sense of smell

Pineal Gland

Endocrine gland involved in biological rhythms Secretes the hormone melatonin

Pituitary Gland

Endocrine gland involved in homeostasis 45

Regulates other endocrine glands

Pons

Relays sensory information between the cerebrum and cerebellum

Reticular Formation

Nerve fibers located inside the brainstem Regulates awareness and sleep

Substantia Nigra

Helps to control voluntary movement and regualtes mood

Tectum

The dorsal region of the mesencephalon (mid brain)

Tegmentum

The ventral region of the mesencephalon (mid brain).

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Ventricular System - connecting system of internal brain cavities filled with cerebrospinal fluid

Aqueduct of Sylvius - canal that is located between the third ventricle and the fourth ventricle Choroid Plexus - produces cerebrospinal fluid Fourth Ventricle - canal that runs between the pons, medulla oblongata, and the cerebellum Lateral Ventricle - largest of the ventricles and located in both brain hemispheres Third Ventricle - provides a pathway for cerebrospinal fluid to flow

Wernicke's Area

Region of the brain where spoken language is understood

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THE HUMAN SKULL

The entire framework of the human body is known as the skeleton. It is made up of two primary groups of bones; 1. Axial skeleton This group of bones are the ones that make up the head and actual trunk of the body. 2. Appendicular skeleton This is the group of bones that make up the bodys extremities (arms and legs). The entire group of bones that make up the head is called the skull and it too can be divided into two primary groups: 1. Cranium- This is the rounded area that houses and protects the brain. It is comprised of eight distinct bones that are fused together in an adult. 2. Facial area The facial area is made up of fourteen separate bones, which include those that make up the jaws, cheeks and nasal area. The eight bones that make up the cranium are: 1. Frontal bone-The frontal bone is the one that comprises the forehead, the upper orbit of the eye and the forward parts of the cranium. The frontal bone also contains two air spaces that are called sinuses. The frontal bone is fused with the parietal bones at the top, the sphenoid bones, maxilla and nasal bones.

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2. Parietal bones- There are two parietal bones which form the largest portion of the top and sides of the cranium. They are fused down the middle at the top of the skull. In addition to the frontal bones, the parietal bones are also fused to the sphenoid, temporal and occipital bones. 3. Temporal bones-Like the parietal bones, there are two distinct temporal bones. These bones are what form the lower, central sides of the skull. The temporal bones also hold the mastoid sinuses as well as parts of the ears. 4. Ethmoid bone- There is only one ethmoid bone and it has a different consistency that the other bones in the head. Where they are hard and dense, the ethmoid bone is a delicate, spongy bone that is located between the eyes. It also forms a part of the frontal floor area of the cranium. 5. Sphenoid bone-There are two sphenoid bones and they sit behind the eyes and run back towards the temporal bones. 6. Occipital bone-There is only one occipital bone. It forms the back base of the skull. The facial bones include: 1. Mandible- The mandible (lower jaw) is the only moveable bone in the skull. 2. Maxillae There are two maxillae bones. They are what comprise the upper jaw and each one of them contains a large maxillary sinus. 3. Zygomatic-There are two zygomatic bones and they sit on either side of the skull and comprise the higher area of the cheek. 4. Lacrimal bones- There are two small lacrimal bones that sit at the inside corner of each eye. 5. Vomer-There is only one vomer bone and it is what forms the lower portion of the nasal septum.

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6. Nasal bones- The nasal bones are a pair of small, slender bones that support the actual bridge of the nose. They are fused at the top to the frontal bone and to the maxillae at the area that completes the inside orbit of the eye. In addition to the previous bones, there are six tiny bones (three pairs) called ossicles that are located in the ears. These are joined in such a way as to amplify the sound waves received by the eardrum (tympanic membrane). 1. Malleus- Often called the hammer are the two malleus bones (one in each ear).They are the first bones in the inner ear and appear similar in shape to a hammer. The handle part attaches to the tympanic membrane and the head portion attaches to the incus. 2. Incus-The incus is also called the anvil and it is the middle of the three bones. 3. Stapes- The stapes is the innermost bone and it appears very similar to a tiny stirrup. In fact, the stapes is often called the stirrup. Components Eight bones form the neurocranium (brain case), a protective vault of bone surrounding the brain and brain stem. Fourteen bones form the splanchnocranium, which comprises the bones supporting the face. Encased within the temporal bones are the six auditory ossicles of the middle ear. The hyoid bone, supporting the larynx, is usually not considered as part of the skull, as it is the only bone that does not articulate with other bones of the skull. The skull also contains the sinus cavities, which are air-filled cavities lined with respiratory epithelium, which also lines the large airways. The exact functions of the sinuses are debatable; they contribute to lessening the weight of the skull with a minimal reduction in strength, they contribute to resonance of the voice, and assist in the warming and moistening of air drawn in through the nasal cavities.

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Development of the skull The skull is a complex structure; its bones are formed both by intramembranous and endochondral ossification. The bones of the splanchnocranium (face) and the sides and roof of the neurocranium are formed by intramembranous (or dermal) ossification, while the bones supporting the brain (the occipital, sphenoid, temporal, and ethmoid) are largely formed by endochondral ossification. At birth, the human skull is made up of 404 separate bony elements. As growth occurs, many of these bony elements gradually fuse together into solid bone (for example, the frontal bone). The bones of the roof of the skull are initially separated by regions of dense connective tissue called "cranial sutures". There are five sutures: the frontal suture, sagittal suture, lambdoid suture, coronal suture, and squamosal suture. At birth these regions are fibrous and moveable, necessary for birth and later growth. This growth can put a large amount of tension on the "obstetrical hinge," which is where the squamous and lateral parts of the occipital bone meet. A possible complication of this tension is rupture of the great cerebral vein of Galen. Larger regions of connective tissue where multiple sutures meet are called fontanelles. The six fontanelles are: the anterior fontanelle, the posterior fontanelle, the two sphenoid fontanelles, and the two mastoid fontanelles. As growth and ossification progress, the connective tissue of the fontanelles is invaded and replaced by bone. The posterior fontanelle usually closes by eight weeks, but the anterior fontanelle can remain open up to eighteen months. The anterior fontanelle is located at the junction of the frontal and parietal bones; it is a "soft spot" on a baby's forehead. Careful observation will show that you can count a baby's heart rate by observing his or her pulse pulsing softly through the anterior fontanelle. Pathology If the brain is bruised or injured it can be life-threatening. Normally the skull protects the brain from damage through its hard unyieldingness; the skull is one of the most durable substances found in nature. In some cases, however, of head injury, there can be raised

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intracranial pressure through mechanisms such as a subdural haematoma. In these cases the raised intracranial pressure can cause herniation of the brain out of the foramen magnum ('coning') because there is no space for the brain to expand; this can result in significant brain damage or death unless an urgent operation is performed to relieve the pressure. This is why patients with concussion must be watched extremely carefully. The Individual Bones Each of the bones of the cranium posses a number of distinctive features which not only allow the bone to be identified, but also permit its exact location and orientation in the body to be determined (i.e., as a left or right, medial- lateral, posterior-anterior, inferior-superior, etc.). The Parietal Bones

The Parietals are paired left and right. Externally, each possess a Superior, and Inferior Temporal Line, to which the temporal muscle is attached. The lines run from the Frontal Crest of the anterior frontal bone to the Supra-Mastoid Crest on the posterior portion of the temporal bone. The parietals articulate with each other by way of the Mid-Sagittal Suture, and with the frontal bone anteriorly by way of the Coronal Suture. These two sutures generally form a right angle with one another. Posteriorly, the parietals articulate with the Occipital Bone by way of 52

the Lambdoid Suture. The intersection of the Lambdoid and Sagittal Sutures approximate a 120 degree angle on each of the parietals and the occipital bone. Among the sutures the Lambdoid is by far more serrated than either the Sagittal or the Coronal. Inferiorly the Parietal articulates with the temporal bone by way of the Squamosal and Parieto-Mastoid Sutures. On the external surface near the center of the bone is the Parietal Eminence. Slightly posterior to the eminence there may be a Parietal Foramen. The Occipital Bone

The Occipital Bone consists of a large squamous, or flattened portion separated from a small thick basal portion by the Foramen Magnum on either side of which is a left or right Occipital Condyle. The occipital condyles articulate with the first cervical vertebrae (the Atlas). Externally, the squamous portion of the bone possesses Superior, Middle, and Inferior Nuchal Lines to which the muscles at the back of the neck are attached. The External Occipital Protuberance lies on the superior nuchal line in the mid-sagittal plain. Lateral to each occipital condyle are the Condylar Fossae and Foramen while the Hypoglossal Canal is medial to them. Internally, are the Sagittal and Transverse Sulci, or grooves which converge at the Confluence of Sinuses. A single internal Occipital Protuberance or Cruciform Eminence is also found in this area. Running inferior from the eminence to the foramen magnum is the Internal 53

Occipital Crest which separates the Cerebellar Fossae. The transverse sulci assist in directing the developing jugular vein to the Jugular Notch on either side of the basilar portion of the occipital.

The Frontal Bone

The frontal bone may be divided into two main portions, a vertical squamous portion which articulates with the paired parietals along the Coronal Suture and forms the forehead, and two orbital plates, which contribute to the ceiling and lateral walls of the left and right eye orbits. On the external surface the squamous portion frequently possesses a left and right Frontal Eminence. Additionally, the bone possesses two SupraOrbital Ridges (i.e., Superciliary or Brow Ridges) which are bumps above each of the eye orbits. In early hominids these ridges formed a Torus or large shelf-like process protruding from above the eyes. Associated with each Superior Orbital Margin of the eye orbit the frontal bone may posses a Supra-Orbital Notch or if completely surrounded by bone, a Supra-Orbital Foramen. Above the fronto-nasal suture which allows articulation between the frontal and nasal bones there is generally a trace of the vertical Metopic Suture. In early life the metopic suture divided the frontal bone into left and right halfs. With in the bone, and above and the metopic suture, is the Frontal Sinus. The left and right Frontal

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Crest, begins at each Zygomatic Process of the frontal bone, and provides the anterior origin of the Temporal Line to which the left and right temporal muscle is attached.

The Ethmoid

If the sphenoid is the most difficult cranial bone to describe and invision, the Ethmoid is the second most difficult. It has a number of features and projections, but unlike the sphenoid it cannot be seen from various views of the skull. Like the sphenoid, it is a single bone that runs through the mid-sagittal plane and aids to connect the cranial skeleton to the facial skeleton. It consists of various plates and paired projections. The most superior projection is the Crista Galli, or Cocks Comb, found within the cranium. It assists in dividing the left and right frontal lobes of the brain. Lateral projections from the Crista Galli are the left and right Cribriform Plates which in life cradle the first cranial nerves i.e., the olfactory nerves. The nerves brachiate through the porosity of these plates into the nasal cavity below. Directly inferior to the

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Crista Galli and running in the mid-sagittal plane is the Perpendicular Plate of the ethmoid which articulates with the vomer more inferiorly and assists in separating the left and right nasal passages. The Perpendicular Plate can be viewed anteriorly through the nasal cavity. Descending off each of the Cribriform Plates is a left or right Orbital Plate which aids to form the medial wall of the respective eye orbit. Each Orbital Plate is rectangular in shape and gives rise to two medial projections, the Superior and Middle Nasal Concha. These projections, like the separate Inferior Nasal Concha, assist in increasing the surface area within the nasal cavity and thereby the exposure of the brachiating olfactory nerve to inhaled odors. The Superor or Supreme Nasal Conche are smaller, and cannot be viewed through the anterior nasal opening because it is blocked from view by the the more inferior Middle Nasal Conche.

The Sphenoid

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The Sphenoid is one of the more difficult bones to describe and invision. It has a number of features and projections, which allow it to be seen from various views of the skull. It is a single bone that runs thrugh the mid-sagittal plane and aids to connect the cranial skeleton to the facial skeleton. It consists of a hollow body, which contians the Sphenoidal Sinus, and three pairs of projections: the more superior Lesser Wings, the intermediate Greater Wings, and the most inferior projecting Pterygoid Processes. Internally upon the body is the Sella Turcica where the pituitary gland rests in life. The smaller lesser wings posssesses the Optic Foramen through which the optic or second cranial nerve passes before giving rise to the eye. The Supra-Orbital Fissure separates the lesser wing superiorly from the greater wing below and can best be viewed on the posterior wall of each eye orbit. The left and right greater wings assist in forming the posterior wall of each of the eye orbits where it forms an Orbital Plate. In addition the external surface of the greater wing can be viewed in the the lateral view of the cranium in an area called the Pterion Region. Just inferior to the supra-orbital fissure near the body of the sphenoid, each of the greater wings also possess a Foramen Rotundum which in life transmits the maxillary branch of the fifth, or trigeminal, cranial nerve. Each of these wings also possesses a much larger Foramen Ovale more laterally, which transmits the the mandibular branch of the same nerve. More posteriorly is the smallest of the three pairs of foramena, the Foramen Spinosum which transmits the middle meningial vessels and nerve to the tissues covering the brain. The Temporal

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The Temporal Bone is another paired cranial bone which is difficult to describe due to its various features, and projections. It consists of two major portions, the Squamous Portion, which is flat or fan-like and projects superiorly from the other, very thick and rugged portion, the Petrosal Portion. The squamous portion assists in forming the Squamous Suture which separates the temporal bone from the adjacent and partially underlaying parietal bone. The petrosal portion contains the cavity of the middle ear and all the ear ossicles; the Malleus, Incas and Stapes. This portion projects anterior and medialy beneath the skull. Projecting inferiorly from the petrosal portion is the slender Styloid Process which is of variable length. The styloid process serves as a muscle attachment for various thin muscles to the tongue and other structures in the throat. Externaly the petrosal portion possesses the External Auditory Meatus while internally there is an Internal Auditory Meatus. Anterior to the external meatus the Zygomatic Process has its origin. This process projects forward toward the face and its articulation with the temporal process of the zygomatic. Just anterior of the external meatus and inferior of the origin of the zygomatic process is the Glenoid or Mandibular Fossa which assists in forming the shallow socket of the Tempro-Mandibular Joint. Posterior to the external auditory meatus is the inferiorly projecting Mastoid Process which serves as an attachment for the sternocleidomasotid muscle. Above the mastoid process is the Supramastoid Crest to which the posterior portion of the temporal muscle is attached.

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REVIEW OF RELATED LITERATURE Stages of Labor The labor process occurs after a prolonged time of being pregnant. The baby has been in the uterus (in utero) for almost 40 weeks. By the time the labor actually begins, pregnant women will probably be totally ready to welcome her baby into the world. When it is time for the baby to be born, the body will go through some physical changes designed to bring the baby out of the uterus. In fact, many women will not even realize that they have started their true labor, which can be as simple as a backache, slight cramping, or abdominal pain. Some will only know that their labor has started when their water breaks, which can actually be anything from a trickle of fluid to a big puddle. Once your labor has begun, you will begin to experience "contractions." These are the tightening and relaxing of the uterine muscles as they prepare to send your baby into the world. The contractions will cause your cervix to efface and dilate. (Effacement means a shortening of the cervical canal; dilation involves a gradual widening of the cervical opening.) The cervix will be completely thinned (or effaced) and 10 centimeters open (dilated) when it is time for the baby to be born. STAGE I (Contractions and Dilating) The process of labor is broken down into three stages. The first stage is from the start of true labor to complete dilation of the cervix. This stage is divided into three parts: Latent, Active and Transition. Latent Labor In Latent labor you may experience mild contractions that are anywhere from five to 30 minutes apart. During this Latent labor stage you may also experience backache, mild diarrhea, anxiety and/or excitement. During this initial stage, most women can walk 59

around, take a warm shower or bath, or engage in breathing patterns to relax. Your support person can participate by keeping you company, giving you a back massage, offering words of encouragement, or keeping a log for you of your contractions (how far apart they are and how long they last). You can rate their intensity on a scale of 1 to 10 to help guide you with your progression of labor. You should be aware of all the options--both medical and non-medical--available to you to help you work through your labor and pain. Active Labor As you progress to Active labor, more rapid dilation occurs. The cervix is really beginning to open up and you may hear the medical team say you are 4 to 7 centimeters along. Remember that the goal is 10 centimeters. It is during this time that the baby is actively trying to get in position to be born. Women say that during this stage of labor they may feel stronger and longer contractions, more back pain, and may feel the need to concentrate on the process at hand. The support person can continue to provide encouragement, use a moist towel to help keep your lips and mouth wet, and provide comfort measures such as massage or music. During this stage of labor the contractions are stronger, longer and less than five minutes apart. Usually you can't talk or walk during contractions. To cope with this stage of labour:

use coping techniques, such as relaxation, positioning, massage, showers, vocalization, or pain medication remember to urinate every hour or two drink juice for energy move around as much as possible

Your labor support person should stay with you, taking your cues on how to help. Transition Phrase As you enter the Transition phase, the contractions are more intense, and your cervix will become fully dilated to 10 centimeters. The baby is applying pressure to the mother's bottom area and you may have an overwhelming desire to push against that 60

pressure. Do not push until the medical team instructs you to do so. If it is necessary for you to stop pushing, use breathing patterns and your support person to help you through the feelings of pressure and discomfort. Women go through many emotional moments during the Transition phase of labor including even a desire to go home. It then becomes the important role of the support person to talk the woman through this period and give her the encouragement she needs to finish the job and deliver the baby. During this stage of labor, you may experience long, strong contractions, with little time between them. You may feel an urge to push at the height of each contraction. You may also experience:

trembling vomiting irritability backache despair feeling hot and cold legs shaking

During this period your labor support person should be following your lead and providing the physical and emotional support you need. Communication about what you want and need is important. During some labours, having your partner provide a steady pressure on your lower back may help. Take one contraction at a time, and remember that the baby is almost here.

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STAGE II (Delivery of the Baby) As you move to Stage II, you may experience a lot of pressure in your bottom area. The urges to push are strong and it actually feels helpful to many women to begin pushing as they are now active participants in the process. Although it may be difficult to do, try to rest between contractions and save your strength for pushing the baby out during the contractions. Many women get a "second wind" prior to delivery to help them get through this second stage of labor. Your support person can help you find the most comfortable position, continue to offer encouragement, and help you focus on your breathing. Your medical team will help guide you through the process of pushing and successfully delivering your baby. The cervix has now fully dilated to 10 centimetres. The contractions get further apart and then closer together again. You may be dozy and unfocused between contractions. As the baby begins to move down the birth canal, you may feel a renewed burst of energy. If you are not using an anesthetic, you may feel a stinging sensation as the baby's head reaches the vaginal opening. After the head emerges, the baby rotates and the shoulders and the body are born. During this time:

Allow yourself time to learn how to push. You should push as you feel the urge, your body will help you. Establish your own pushing pattern. Work with your nurse or midwife to help determine the best possible position. Panting or blowing to avoid pushing during the birth of the head can mean less straining and tearing.

Once your baby is born, savor the moment, for you will only get that once in a lifetime with each child you deliver.

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STAGE III (The Placenta) The last stage of labor is Stage III or the time between the delivery of the baby and the delivery of the placenta. Uterine contractions will help expel the placenta, usually within 20 minutes of the delivery of the baby. You may have some bleeding, chills or exhaustion. Your physician will examine your vagina and perineum. If you have some tears, your physician will do the repair. Your nurse will massage your uterus and will be checking it frequently over the next several hours to make sure your uterus is firm and that you are not experiencing any excessive bleeding. At the same time, your baby's medical team will clean your baby, suction the nose and mouth, and keep the baby warm. They will also assign the baby scores called APGAR scores which assess the baby's overall status after birth. The placenta emerges and the cord is clamped and cut. You may feel shaky but you may also have a renewed burst of energy. You will have more contractions as the placenta comes out and afterwards. You may feel very emotional at this time. During this stage, you may wish to

cut the cord hold your new baby, with help if necessary talk to the baby your voice will be familiar offer your breast when ready relax and recover

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You did it! Congratulations! The work was hard, but in the end so rewarding. Give yourself a big hug for a job well done, and get some rest as you will need all your strength to help you love and care for your new baby. The joy of being a parent is exhilarating and exhausting. Enjoy every minute of your new beginning together.

ANENCEPHALY What is anencephaly? Anencephaly is a condition present at birth that affects the formation of the brain and the skull bones that surround the head. Anencephaly results in only minimal development of the brain. Often, the brain lacks part or all of the cerebrum (the area of the brain that is responsible for thinking, vision, hearing, touch, and movement). There is no bony covering over the back of the head and there may also be missing bones around the front and sides of the head. Presentation The National Institute of Neurological Disorders and Stroke (NINDS) describes the presentation of this condition as follows: A baby born with anencephaly is usually blind, deaf, unconscious, and unable to feel pain. Although some individuals with anencephaly may be born with a main brain stem, the lack of a functioning cerebrum permanently rules out the possibility of ever gaining consciousness. Reflex actions such as breathing and responses to sound or touch may occur. Mortality/Morbidity

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Anencephaly is lethal in all cases because of the severe brain malformation that is present. A significant proportion of all anencephalic fetuses are stillborn or are aborted spontaneously.

Race Hispanic and non-Hispanic whites are affected more frequently than women of African descent. Sex Females are affected more frequently than males. Age Anencephaly is determined by the 28th day of conception and is therefore invariably present at the time of birth. Prognosis

The prognosis is exceptionally poor; death of the neonate is unavoidable.

What causes anencephaly? Anencephaly is usually an isolated birth defect and not associated with other malformations or anomalies. The vast majority of isolated anencephaly cases are multifactorial in their inheritance pattern, implicating multiple genes interacting with environmental agents and chance events.

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Adequate folic acid consumption during pregnancy is protective against anencephaly. Exposure to agents that interfere with normal folate metabolism during the critical period of neural tube development (up to 6 wk after last menstrual period) increases the likelihood of an NTD.

Valproic acid, an anticonvulsant, and other antimetabolites of folic acid have been shown to increase the chance of an NTD when exposure occurs in early development. While these induced NTDs are usually spina bifida, the chance of anencephaly is probably increased as well.

Maternal type 1, or pregestational insulin-dependent diabetes mellitus (IDDM) confers a significant increase in the risk for NTDs, and it also delays production of alpha-fetoprotein (AFP) during pregnancy. Maternal serum AFP is used as a screening test to detect NTDs, and adjustment of the expected values for AFP in maternal serum must be made if the patient is known to have IDDM. Presumably, wellcontrolled IDDM confers a lower risk for NTDs, while gestational diabetes does not appear to be associated with any significant increase in NTD risk. The degree of diabetic control is generally monitored using hemoglobin A1c levels.

Maternal hyperthermia has been associated with an increased risk for NTD; therefore, pregnant women should avoid hot tubs and other environments that may induce transient hyperthermia. Similarly, maternal fever in early gestation also has been reported as a risk factor for anencephaly and other NTDs.

While most NTDs are associated with a multifactorial model of inheritance, rare cases of NTDs are transmitted in an autosomal dominant or autosomal recessive manner in certain families. Such families may have children or fetuses with spina bifida, anencephaly, or other subtypes of NTDs. In families with a pedigree suggestive of autosomal dominant inheritance, reproduction is clearly only possible for the individuals with spina bifida since death occurs early in the life of individuals with anencephaly.

Anencephaly may be associated with the unbalanced form of a structural chromosome abnormality in some families. In these cases, other malformations and birth defects that are not usually found in isolated cases of anencephaly may be present.

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Amniotic band disruption sequence is a condition resulting from rupture of the amniotic membranes. This can cause disruption of normally formed tissues during development, including the structures of the head and brain. Anencephaly caused by amniotic band disruption sequence is frequently distinguishable by the presence of remnants of the amniotic membrane. Recurrence risk for anencephaly caused by this mechanism is lower and the risk is not modified by the use of folic acid What are the symptoms of anencephaly? The following are the most common symptoms of anencephaly. However, each child may experience symptoms differently. Symptoms may include: Absence of bony covering over the back of the head.

Missing bones around the front and sides of the head. Folding of the ear. Cleft palate - a condition, in which the roof of the child's mouth does not completely close, leaving an opening that can extend into the nasal cavity. Congenital heart defects.

Some basic reflexes, but without the cerebrum, there can be no consciousness and the baby cannot survive. The symptoms of anencephaly may resemble other problems or medical conditions. Always consult your child's physician for a diagnosis.

Complications

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Anencephaly is uniformly fatal. Polyhydramnios is a common complication during pregnancy, and patients may experience significant discomfort from the abdominal distention that accompanies this condition. Risk of preterm labor is increased. Because the pituitary gland may be absent in persons with anencephaly, spontaneous precipitation of labor may be delayed; therefore, the risk of the pregnancy progressing into the postterm period is significant. Labor may need to be induced in these cases. The rate of abnormal fetal presentations during delivery is increased in these pregnancies.

How is anencephaly diagnosed? The diagnosis of anencephaly may be made during pregnancy or at birth by physical examination. The baby's head often appears flattened due to the abnormal brain development and missing bones of the skull. Diagnostic tests performed during pregnancy to evaluate the baby for anencephaly include the following:

Alpha-fetoprotein - a protein produced by the fetus that is excreted into the amniotic fluid. Abnormal levels of alpha-fetoprotein may indicate brain or spinal cord defects, multiple fetuses, a miscalculated due date, or chromosomal disorders. Amniocentesis - a test performed to determine chromosomal and genetic disorders and certain birth defects. The test involves inserting a needle through the abdominal and uterine wall into the amniotic sac to retrieve a sample of amniotic fluid. Ultrasound (Also called sonography.) - a diagnostic imaging technique that uses high-frequency sound waves and a computer to create images of blood vessels, tissues, and organs. Ultrasounds are used to view internal organs as they function, and to assess blood

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flow through various vessels.

Blood tests Treatment of the newborn with anencephaly There is no medical treatment for anencephaly. Due to the lack of development of the brain, approximately 75 percent of infants are

stillborn and the remaining 25 percent of babies die within a few hours, days, or weeks after delivery. Care will be aimed at providing emotional support to the family.

Medical Care Because anencephaly is a lethal condition, heroic measures to extend the life of the infant are contraindicated. The physician and medical care team should focus on providing a supportive environment in which the family can come to terms with the diagnosis and make preparations for their loss.

Families not aware of the diagnosis of anencephaly prior to birth or for whom the diagnosis is still fresh probably will need extra emotional support and possibly grief counseling. Families who have had some time to adjust to the diagnosis prior to delivery and who have had an opportunity to begin the grieving process ahead of time may seem well prepared, but they also will need adequate time to grieve and come to closure. The presence of family, friends, or clergy may be helpful in many cases.

Families often want to hold the baby after delivery, even if the baby is stillborn, and families wanting photographs of the baby with the family are not unusual. A cap or head covering of some sort is useful to minimize the visual impact of the malformation. Some families want to see the lesion, and this may help to dispel mental pictures, which are often worse than the actual malformations. In most cases, direct personal contact with the baby may help the parents to actualize the medical information they have been given and may help in

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the process of grief resolution.

If parents have chosen a name for the baby, they may be comforted if the doctor refers to the baby by name. Feelings of guilt are normal responses of parents of a baby with serious birth defects. The involvement of genetic counselors, if available, may be particularly useful to parents in this situation because of their experience in dealing with a wide range of birth defects. With timely prenatal diagnosis of this lethal disorder, the option of pregnancy termination should be presented to the couple. For couples who elect to continue the pregnancy, the possibilities of preterm labor, oligohydramnios, failure to progress, and delayed onset of labor beyond term also should be discussed.

Families commonly inquire about organ donation after the diagnosis of anencephaly. This cannot practically be arranged without crossing the lines of ethical care. Patients should be affirmed in their desires to see something meaningful come from the tragedy of having a pregnancy affected with anencephaly.

Consultations Every couple with a child who has anencephaly should consult with a geneticist and/or a genetic counselor to obtain information regarding recurrence risks, prevention, screening, and diagnostic testing options for future pregnancies and to assess the family history. Ideally, a genetic counselor should be consulted prenatally and should remain involved, as needed, until the family comes to closure after the conclusion of the pregnancy. Genetic counselors are trained and are general skillful in helping a family work through the complex psychosocial issues that are commonly encountered in a new diagnosis of anencephaly. Diet

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Folic acid supplementation and/or a folate-enriched diet prior to and during future pregnancies are recommended. Obtaining enough folates from diet alone to effectively prevent recurrences in future pregnancies is extremely difficult. Medication Pharmaceutical interventions are not used in cases of anencephaly. Follow-up Deterrence/Prevention

The recurrence risk for NTDs, in general, is 2-4% in subsequent pregnancies, given that a couple has previously had one child with anencephaly or another isolated NTD. For families with multiple occurrences of NTDs, recurrence risks may be higher and must be determined on a case-by-case basis.

Folic acid supplementation has been shown to be an effective means of lowering recurrence risks for future pregnancies. For women who desire pregnancy and have had a child with an NTD with their current partner, supplementation with 4 mg of folic acid daily is indicated, beginning at least 3 months prior to conception.
o

For all other women and girls of reproductive age, regardless of family history, 0.4 mg (or 400 mcg) per day of folic acid supplementation is appropriate; this amount of folic acid is found in most over-the-counter multivitamins. Folic acid supplementation at these levels is estimated to prevent two thirds of both recurrent as well as occurrent (new) cases of NTD. Increased folate intake also may be achieved through the diet; however, the bioavailability of natural folates in foods is often lower than that of folic acid. In the United States, wheat flour is fortified with a small amount of folic acid, but it is not enough to

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achieve maximal preventive benefits against NTD for a woman with an average diet.
o

Because of the large number of pregnancies that are not actively planned, and the early gestational age at which neural tube development occurs, folate supplementation should be encouraged for all girls, beginning at puberty, in order to establish this practice before entering the childbearing years.

Prenatal ultrasound and amniocentesis should be offered to any couple with a prior pregnancy affected with an NTD. Maternal serum prenatal screening with AFP is available throughout the United States and most developed countries for identification of NTDs. Positive serum screening should be followed with diagnostic testing to exclude the presence of NTDs. Since 90-95% of NTDs occur in families without a positive history, such screening is appropriate for all pregnant patients and should not be reserved only for those with a positive history.

Anencephaly cannot be treated in utero, thus, pregnancy termination is the only intervention available to prevent the birth of a child with anencephaly that has been diagnosed prenatally. Supportive care should be provided for families, irrespective of the option they choose.

Patient Education

Parents of babies with anencephaly should be educated about preventive measures for future pregnancies. Consultation with a genetic counselor may be helpful. A number of resources may assist families who are dealing with the loss of a child with anencephaly. These include the Spina Bifida Association of America (SBAA) and the March of Dimes (MOD). Contact the SBAA at (800) 621-3141.

Families may wish to participate in one of several ongoing studies of anencephaly or NTDs as a part of the healing process.

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PATHOPYSIOLOGY
Egg cell and sperm cell unite

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Conception

Predisposing factors: Family history of neural tube defect Prior neural tube defect-affected pregnancy

Precipitating factors: Severe overweight Hot tub use in early pregnancy Fever during early pregnancy Medication intake for epilepsy (seizures) and women with insulin dependent diabetes High exposure to toxins such as lead, chromium, mercury and nickel Use of radiation, salicylates, sulfonamides, excess carbon dioxide w/ anoxia, low blood levels of some vitamins especially folic acid

Embryo (5-8 weeks) Between 23rd and 26th day of pregnancy Neural groove of the fetus begins to close 24th 25th (5 weeks gestation) cranial portion closes 27th 29th (6 weeks gestation) Sacral end closes Neural tube fails to close 74

Absence of cranial vault and forebrain (cerebral hemispheres and isocortex); midbrain and portions of midbrain are present ANENCEPHALIC FETUS Delivery Interventions: Offer hydration, nutrition, and comfort measures Artificial ventilation Surgery Drug therapy (antibiotics) Features/ signs of anencephaly: Usually blind, deaf and unconscious, unable to feel pain and with heart defects Eyes-protrude, nose- flat, tongue- enlarged, mouth- cleft lip or palate may be present, neck- shortened due to low number of vertebrae of the cervical vertebrae Chest - reduced thoracic volume

DEATH- after a few minutes, hours or days.

MEDICAL INTERVENTIONS
A. TREATMENT TREATMENT DOCTORS ORDER March15, 2009 RATIONALE

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IVF D5 LR +20 units oxytocin at 30-33 gtts/ min

To replace blood loss and provide salts needed to maintain electrolyte balance. To provide glucose, the main fuel for metabolism and to provide and maintain a constant level of medication in the blood

Laboratory Examinations CBC Urinalysis Blood typing and cross matching Medications Ordered Cefalexin 500 mg 1 cap q 6 h Mefenamic acid 500mg 1 cap q 6 h

These tests are used to evaluate patients red and white blood cells and hemoglobin value to help evaluate and monitor the condition of the patient. To determine urine composition & possible abnormal components or infection. To determine the ABO blood group and Rh factor status. To identify the blood type of the patient for future need of blood transfusion

To prevent infection, to relieve pain and to supply iron loss during delivery Anti-inflammatory, analgesics and antipyretic activities related to inhibition of prostaglandin synthesis, exact mechanisms of action are not known. Opioid analgesics act by depressing pain impulse transmission at the spinal cord level by interacting with opioid receptors. 76

Bided immediately to carrier protein, transferring, then to bone marrow for incorporation into hemoglobin. Highly protein bound. Replace iron stores needed for red blood cell development, energy

Multivitamins + Fe 1 cap BID

and oxygen transport, utilization; fumarate contains 33% elemental iron; gluconate 12%; sulfate, 20%; iron, 30%; ferrous sulfate exsiccated To prevent and treat postpartum hemorrhage caused by uterine atony or subinvolution To prevent infection, to cleanse and provide comfort and to promote increase healing time To provide dry heat when other treatments are ineffective or impractical and to promote or increase healing time

Methergine I amp then 1 tab TID P.O hold if BP > 140/90 mmHg

Perineal care BID

Perilight exposure BID

Assess clients food intake Serves as a baseline data in the assessment of the client. Elevation or decrease in the vital signs measurement may indicate possible complications. 77

DAT

TPR

NURSING INTERVENTIONS

NURSING INTERVENTIONS Independent: Review prenatal, intrapartal, and postpartal record

RATIONALE

Identifies factors that place client in high risk category for development/ spread of postpartal infection

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Provide for and instruct client in proper disposal of contaminated linens, dressings, chux and peripads. Initiate/ maintain isolation if indicated

Prevents spread of infection

Demonstrate/ encourage correct perineal cleaning after voiding and defection, and frequent changing of peripads Demonstrate proper fundal massage. Review importance and timing of procedure Monitor temperature, pulse, and respirations. Note presence of chills or reports of anorexia or malaise

Cleaning removes urinary/fecal contaminants. Changing pad removes moist medium that favors bacterial growth. Enhances uterine contractility, promotes involution and passage of retained placental fragments Elevations in vital signs accompany infection; fluctuations, or changes in symptoms, suggest alterations in client status. Note: persistent fever unresponsive to antibiotic therapy may indicate thrombophlebitis.

Observe perineum/ incision for other signs of infection(e.g., redness, edema, ecchymosis discharge and approximation. Note: subinvolution of uterus, extreme uterine tenderness

Allows early identification and treatment; promotes resolution of infection.

Monitor oral/ parenteral intake, stressing the need for at least 2000 ml fluid per day. Note: urine output, degree of hydration and presence of nausea, vomiting, or diarrhea

Increased intake replaces losses and enhances circulating volume, preventing dehydration and aiding in fever reduction

Encourage semi fowlers position Promote early ambulation balanced with adequate rest. Advance activity as appropriate.

Enhances flow of lochia and uterine/ pelvic drainage Increases circulation; promotes clearing of respiratory secretions and lochial drainage; enhances healing and general well-being. Note: presence of pelvic/ femoral thrombophlebitis may require

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strict bed rest. Encourage client/ couple to prioritize post discharge responsibilities (e.g., homemaking task, child care) Instruct in proper medication use. (e.g., take entire course of antibiotic as prescribed) Bed bath Damp dusting and environmental care Health teaching on the importance of early ambulation Client will require additional rest to facilitate recuperation/ healing. Household duties need to be reassigned or delayed as appropriate Oral antibiotics may be continued after discharge. Failure to complete medication may lead to relapse To give patient feeling of freshness and to cleanse the body To create aesthetic appearance of the clients environment for faster recovery To fasten healing of incision because it promotes blood circulation

Collaborative: Encourage of application of moist heat in the form of sitz baths. And of dry heat in the form of perineal lights for 15 mins 2-4 times daily Demonstrate perineal application of antibiotic creams as appropritate Monitor kaboratory studies, as indicated: culture sensitivity CBC, WBC count differential and EJP; Eradicates local infectious organisms, reducing risk of spreadin infection. Identifies infectious process/ causative organisms reducing risk of spreading infection. Aids in tracking resolution of infectious or inflammatory process. Water promotes cleansing, heat dilates perineal blood vessels increasing localized blood flow and promotes healing.

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Identifies degree of blood loss and determines pressure of anemia. Partial thromboplastin time/ prothrombin time (PTT/PT), clotting times. Administer medications as indicated; antibiotics, initially broadspectrum, then organism specific, as indicated by results of cultures/ sensitivity Oxytocics, such as pitocin and methylergonovine maleate Promotes myometrial contractility to retard the spread of bacteria through the uterine walls, and aids in the expulsion of clots and retained placental fragments. Assist with procedures, such as incision and drainage (I & D) Drainage the infected area and possible insertion of iodoform gauze packing. Promotes healing and reduces risk of rupture into peritoneal cavity. D&C may be needed to remove retined products of conception and or placental fragments. Helps in identifying alterations in clotting associated with development of emboli. Aids in determining effectiveness of anticoagulation therapy Combats pathogenic organisms, helping prevent infection from spreading to surrounding tissues and bloodstream

Or D & C as necessary

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LABORATORY EXAMS AND CORRELATION

LABORATORY TEST February 15, 2009 CBC hemoglobin

RESULT

NORMAL VALUES

CORRELATION

10.5 g %

F= 12-14 g % M= 13-16 g % 82

WNL: do not indicate hemmorage or severe blood loss

hematocrit

32. 7 g %

F= 37-44vol% M=42-50vol%

Decreased:an implication for possible anemia, hemorrhage, hyperthyroidism, dietary deficiency and pregnancy.

WBC

10, 700 / cumm

5-10T/cumm

increased in response to infection, inflammation, trauma

DIFFERENTIAL COUNT Neutrophil seg Lymphocyte. 16 28-35% decreased may be related to leukemia,sepsis and immunodeficiency diseases Monocyte The ratio of monocytes to the total number of white blood cells counted are within normal limit 73 55-60 increased in response to acute infection and stress

1-6%

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Eosinophil

1-4%

Is not WNL and indicate,Eosinopenia a decrease in eosinophil number and Eosinophilia an increase in eosinophils

Platelet count

199,000

150-400T/cumm

WNL; it means that the blood has the ability to clot

URINALYSIS Color Transparenc y Specific gravity pH Glucose protein 6 negative trace 4.5-8 negative trace 1.010 1.010-1.035 WNL; there is no increased or decreased of the concentration of solutes in the urine WNL; the acidity and alkalinity of the urine is balance WNL; do not indicate DM WNL; usually a trace of protein is found in urine as a waste product Light yellow hazy yellow,straw amber clear WNL; there is no unusual findings in the appearance of the urine May indicate infection

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Blood typing / crossmatching blood type Rh Blood compatibi lity positive PRBC may vary PRBC Blood contains Rh factor Compatible to RBC 0 may vary Neither antigen A nor B is present

DRUG STUDY
DOCTORS ORDER: Methylergonovine maleate 500 mg 1 tab 3x a day hold if BP> 140/90 mmHg BRAND NAME: Methergine GENERIC NAME: Methylergonovine maleate CLASSIFICATION: Oxytocic DRUG ACTION: Stimulates uterine, vascular, smooth muscle, causing contraction decreased bleeding. Increases motor activity of the uterus by direct stimulation of the smooth muscle, shortening the third stage of labor and reducing blood loss. INDICATION: To prevent and treat post partum hemorrhage cause by uterine atony and sub involution.

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DOSAGE: Adult: PO 200-400 ug q6-12 hours x 2-7 days. IM/IV 200 ug q2-2 hours for 1-5 days. Available forms: Injection 0.2mg/ml in 1ml ampules; tablet 0.2 mg/ml CONTRAINDICATIONS: Contraindicated in pregnant patients, in patients sensitive to ergot preparations, and in patients with hypertension or toxemia. Indication of labor before delivery of placenta, hypertension, pelvic inflammatory disease, respiratory disease, cardiac disease, peripheral vascular disease. ADVERSE REACTION; CNS; dizziness, headache, seizures CV: hypertension, transient chest pain, palpitations, hypotension, dysrhythmias CVA. GI: Nausea, vomiting EENT: tinnitus MUSCULOSKELETAL: Leg cramps RESPIRATORY: Dyspnea SKIN : sweating, rash, allergic reactions. Possible side effects of Methergine : All medicines may cause side effects, but many people have no, or minor, side effects. Check with your doctor if any of these most COMMON side effects persist or become bothersome: Nausea; vomiting. Seek medical attention right away if any of these SEVERE side effects occur:

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Severe allergic reactions (rash; hives; itching; difficulty breathing; tightness in the chest; swelling of the mouth, face, lips, or tongue); blood in the urine; chest pain or tightness; dizziness; fainting; fast, slow, or irregular heartbeat; hallucinations; numbness or pain of an arm or leg; seizure; severe or persistent headache, vomiting, or stomach pain; shortness of breath; sudden vision changes. DRUG INTERACTIONS; Increase vasoconstrictions; vasopressors, nicotine May cause excessive vasoconstriction. Use together cautiously. May cause vasospasm, leading to ischemia. Avoid using together. NURSING CONSIDERATION: Monitor and record blood pressure, pulse rate, and uterine response; report sudden change in vital signs, frequent periods of uterine relaxation, character and amount of vaginal bleeding. Monitor contractions, which may begin immediately. Contractions may continue for up to 45 minutes after I.V. use or for 3 hours or more after P.O. or I.M. USE. Store tablets in tightly closed, light resistant container. Discard if discolored. IMPLEMENTATION; Explain the use and administration of drug to patient and family. Instruct patient to report adverse reaction promptly. Instruct patient to report increase blood loss, severe abdominal cramps, fever or foul-smelling lochia. Instruct patient to avoid smoking EVALUATION;

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Therapeutic response: absence of hemorrhage. Patient will be free of postpartal bleeding

DOCTORS ORDER: Cefalexin 500mg 1 cap q 6 hours BRAND NAME: Edixin / Duricet GENETIC NAME: Cephalexin Hydrochlorides CLASSIFICATION: Anti-infective / Antibiotics ACTIONS: First generation cephalosporin that inhibits bacterial cell wall synthesis, promoting osmotic instability, usually bactericidal. Leading to cell death by binding to cell wall membrane. INDICATION: Respiratory tract, G I tract, skin, soft tissues, bone and joint infections and otitis media cause by Escherichia coli and other coli form bacteria. DOSSAGE: Adults; 250mg to 1g P.O. q6h or 500mg q12h. Maximum 4g daily. Children; 25 to 50 mg/kg/day P.O. in two to four equally divided doses. In severe infections, dose can be doubled. CONTRAINDICATIONS: Contraindicated in patients hypertensive to cephalosporin. Use cautiously in breast feeding women and in patients with history of colitis or renal insufficiency; ADVERSE REACTION: CNS: Headache, dizziness, weakness, paresthesia, fever, chills, seizures.(high doses) GI: Nausea, vomiting, diarrhea, anorexia, pain, glossitis, bleeding, bilirubin, abdominal pain. GU: proteinuria, vaginitis, pruritus, candidiasis, increase BUN, heprotoxicity, renal failure. HEMATOLOGIC: Neutropenia, anemia

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INTEGUMENTARY: rash, urticaria, dermatitis RESPIRATORY: Dyspnea Possible side effects of Cephalexin Capsules: All medicines may cause side effects, but many people have no, or minor, side effects. Check with your doctor if any of these most COMMON side effects persist or become bothersome: Diarrhea; dizziness; headache; indigestion; joint pain; stomach pain; tiredness. Seek medical attention right away if any of these SEVERE side effects occur: Severe allergic reactions (rash; hives; itching; difficulty breathing; tightness in the chest; swelling of the mouth, ); agitation; confusion; dark urine; decreased urination; fever; hallucinations; red, swollen, or blistered skin; seizures; severe or bloody diarrhea; severe stomach pain or cramps; severe tiredness; unusual bruising or bleeding; unusual vaginal pain, odor, or discharge; yellowing of the eyes or skin. DRUG INTERACTION: Increase toxicity: amino glycosides, loop diuretics, probenecids Bleeding (cefamandole, cefmetazole, cefotetan) anticoagulants, thrombolytics, NSAIDs, antiplatelets, plimycin, valproic Increased effect/toxicity: amino glycosides, furosemide, probenecid. Drug-drug. Amino glycosides: May increase risk of nephrotoxicity. Avoid using together. May increase cephalosporin level. Use probenecid for this effect. Drug-food: any food; may increase absorption. Give drug with food. NURSING CONSIDERATION; acids.

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Ask patient about past reaction to cephalosporin or penicillin therapy and obtain specimen for culture and sensitivity tests before giving. Start therapy, awaiting results. To prepare oral suspension; add required amount of water to powder in two portions. Shake well after each addition. After mixing store in refrigerator. Mixture will remain stable for 14 days. Keep tightly closed and shake well before using. If large doses are given or if therapy is prolonged, monitor patient for super infection, especially if patient is high risk. Treat group A beta-hemolytic streptococcal infections for a minimum of 10 days. Dont confuse drug with other cephalosporin that sound alike.

IMPLEMENTATION; Tell patient to take drug exactly as prescribed, even after he feels better. Instruct patient to take drug with food or milk to lessen GI discomfort. If patient is taking suspension form, instruct her to shake container well before measuring dose and to store in refrigerator. Tell patient to notify prescribe if rash or signs and symptoms of super infection develop. Instruct patient not to drink alcohol or use of meds with alcohol: reaction may occur. Instruct patient to use yogurt or buttermilk to maintain intestinal flora, decreased diarrhea. EVALUATION; Therapeutic response: decreased symptoms of infection, negative C&S.

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Patient is free from infection Patient maintain adequate hydration Patient and family state understanding of drug therapy

DOCTORS ORDER: Mefenamic acid 500mg 1 cap q 8 hours GENERIC NAME: Mefenamic acid BRAND NAME: Ponstan, Ponstel CLASSIFICATION; Anti-inflammatory drug, analgesic (non- narcotic) DRUG ACTION: Anti-inflammatory, analgesics and antipyretic activities related to inhibition of prostaglandin synthesis, exact mechanisms of action are not known. Opioid analgesics act by depressing pain impulse transmission at the spinal cord level by interacting with opioid receptors. Products are divided into opiates and non opiates. INDICATIONS; Relief moderate pain when therapy will not exceed 1 week treatment of primary dysmenorrhea.

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DOSAGE; P.O. Adults: 325-650 mg. P.O. of 4-6 hours; or 1g P.O. TID or QID, prn , or two extended release caplets P.O. q8h maximum 4g. daily. For long-term therapy, dont exceed 2.6g daily unless prescribed and monitored closely by health care provider. CONTRAINDICATIONS; Contraindicated in patients hypersensitive to drug. Use cautiously in patients with long-term alcohol use because therapeutic doses cause hepatotoxicity in these patients. Use cautiously with allergies, and renal , hepatic , cardiovascular and GI conditions. Pregnancy and lactation. ADVERSE REACTIONS; CNS; headache, dizziness, insomnia, fatigue, tiredness GI; nausea, dyspepsia, GI pain, diarrhea, vomiting, constipation, flatulence. RESPIRATORY; dyspnea, hemoptysis, pharyngitis, brochospasm, rhinitis. HEMATOLOGIC; bleeding, platelet inhibition with higher doses, Neutrogena, eosinophilia, leucopenia, pancytopenia, thrombocytopenia, gramlocytopenia, aplastic anemia decrease hemoglobin or hematocrit, bone marrow depression, menorrhagia. GU; Dysuria, renal impairment DERMATOLOGIC; rash, purities, sweating, dry mucous membranes, stomatitis. OTHERS; peripheral edema, anaphylactoid reactions to fatal anaphylactic shock. Possible side effects of Mefenamic Acid : All medicines may cause side effects, but many people have no, or minor, side effects. Check with your doctor if any of these most COMMON side effects persist or become bothersome:

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Constipation; diarrhea; dizziness; gas; headache; heartburn; nausea; stomach upset. Seek medical attention right away if any of these SEVERE side effects occur: Severe allergic reactions (rash; hives; itching; trouble breathing; tightness in the chest; swelling of the mouth, face, lips, or tongue); bloody or black, tarry stools; change in the amount of urine produced; chest pain; confusion; dark urine; depression; fainting; fast or irregular heartbeat; fever, chills, or persistent sore throat; mental or mood changes; numbness of an arm or leg; one-sided weakness; red, swollen, blistered, or peeling skin; ringing in the ears; seizures; severe headache or dizziness; severe or persistent stomach pain or nausea; severe vomiting; shortness of breath; sudden or unexplained weight gain; swelling of hands, legs, or feet; unusual bruising or bleeding; unusual joint or muscle pain; unusual tiredness or weakness; vision or speech changes; vomit that looks like coffee grounds; yellowing of the skin or eyes. DRUG INTERACTIONS; Barbiturates, other narcotics, hypnotics, antipsychotics, or alcohol can increase CNS depression when taken with narcotics. NURSING CONSIDERATIONS; Give with milk or food to decrease GI upset. Arrange for periodic ophthalmologic examinations during long-term therapy. Institute emergency procedures if overdose occurs; gastric laxage, induction of emesis, supportive therapy. I and O ratio, be alert for urinary retention, frequency, dysuria; drug should be discontinued if these occurs. Allergic reactions; rash, urticaria. Need for pain medication; use pain scoring.

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IMPLEMENTATION; Instruct patient to take drug with food; take only the prescribed dosage; do not take drug longer than 1 week. Teach patient to report any symptoms of CNS changes, allergic reactions, or shortness of breath. Inform that physical dependency may result when used for extended periods. Inform that withdrawal symptoms may occur, including nausea, vomiting, cramps, fever, faintness, anorexia. Instruct to avoid alcohol and other CNS depressants. EVALUATION; Therapeutic response, including decrease in pain. Patient verbalize relief from pain Patient and family state understanding of drug therapy

DOCTORS ORDER: Multivitamins + Iron 1 cap BID BRAND NAME; Ferosal GENERIC NAME; Ferrous sulfate CLASSIFICATION: Multivitamins + Iron/ Iron supplements DRUG ACTION; Bided immediately to carrier protein, transferring, then to bone marrow for incorporation into hemoglobin. Highly protein bound. Replace iron stores needed for red blood cell development, energy and oxygen transport, utilization; fumarate contains 33% elemental iron; gluconate 12%; sulfate, 20%; iron, 30%; ferrous sulfate exsiccated. INDICATIONS; Iron deficiency anemia, prophylaxis for iron deficiency in pregnancy.

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DOSAGE: Iron deficiency adults; 150 to 300 mg P.O. elemental iron daily in three divided doses. Children; give 3 to 6 mg/kg P.O. daily in 3 divided doses. As supplement during pregnancy; Adult; 15 to 30 mg elemental iron P.O. daily during last two trimesters. CONTRAINDICATIONS: Contraindications in patients with primary homochromatic, homosiderosis,hemolytic anemia ( unless iron deficiency anemia is also present) peptic ulcer disease, regional enteritis or ulcerative colitis and receiving repeated blood transfusion. Use cautiously on long-term basis. ADVERSED REACTIONS: GI; Nausea, epigastric pain, vomiting, constipation, diarrhea, black stools, anorexia. Others; suspension and drops may temporarily stain teeth. SIDE EFFECTS: All medicines may cause side effects, but many people have no, or minor, side effects. Check with your doctor if any of these most COMMON side effects persist or become bothersome: Constipation; darkened or green stools; diarrhea; nausea; stomach upset. Seek medical attention right away if any of these SEVERE side effects occur: Severe allergic reactions (rash; hives; itching; difficulty breathing; tightness in the chest; swelling of the mouth, face, lips, or tongue); black, tarry stools; blood or streaks of blood in the stool; fever; vomiting with continuing sharp stomach pain. DRUG INTERACTIONS: Drug- drug antacids, cholesthyramine resin; may decrease iron absorption. Separate doses if possible. Drug- food; cereals, cheese, coffee, eggs, milk, tea, whole grain breads and yogurt; may decreased iron absorption, discourage use together. 95

NURSING CONSIDERATIONS: Give tablets with juices or water, but not with milk or antacids. Dilute liquids form in juices or water, but not in milk or antacids. To avoid staining teeth, give suspension or elixir with straw and place drops at back of throat. Dont crash or allow patient to chew extended-release forms. GI upset continues, may give with food, except egg, milk products, coffee and teas enteric-coated or sustained-release product and the foods listed above, reduce GI upset but also reduce amount disturbed. Oral iron may turn stools black. Although this unabsorbed iron is harmless, it could mask presence of Melina. Have stools tested for presence of blood. Monitor hemoglobin level, hematocrit and reticulocyte count during therapy. IMPLEMENTATION: Instruct patient to take tablets with juices ( preferably orange juice ) or water, but not with milk or antacids. Instruct patient not to crush or chew extended-release form. Alert; inform parents that as few as three tablets can cause poisoning in children. If patient misses a dose, tell her to take it as soon as she remembers but not to double the dose. Advise patient not to substitute one iron salt for another because amount of elemental iron vary. Tell patient that iron will change stools black or dark green. Advice patient to report constipation and change in stool color or consistency. EVALUATION: Therapeutic response; improvement in hematocrit, hemoglobin, reticulocytes; decreased fatigue and weakness. Patient reports fatigue is no longer a problem daily life

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Patient states appropriate measures to prevent a relieve constipation Patient and family state understanding of drug therapy

NURSING THEORY
Virginia Hendersons The Nature of Nursing Model Wherein the patient is viewed as an individual requiring help toward achieving independence and that the practice of nursing is an independent field from the practice of physicians the unique function of the nurse is to assist the clients, sick or well, in the performance of those activities contributing to health or its recovery, that clients would perform unaided if they had the necessary strength, will or knowledge. It also involves assisting the client in gaining independence as rapidly as possible. This model also involves the 14 basic needs of patients that comprise the components of nursing care. Such as (1)breathing, (2)eating and drinking, (3)elimination, (4)movement, (5)rest and sleep, 97

(6)suitable clothing, (7)body temperature, (8)clean body and protected integument, (9)safe environment, (10)communication, (11)worship, (12)work, (13)play, and (14)learning. This provides the nurse to get inside the skin of each of her patient that enables her/him to know what he needs, in order to gain independence. In caring our client, it is important to view and treat her as a unique individual. As we carry our own nursing interventions, it is indeed a must that we will identify the basic needs of our client. With detailed assessment and knowing her needs, we can assure to her that the best, quality and humane care will be receive by her. Thus, with her active participation and cooperation, both of us can achieve an attainable goal. Most importantly, it will promote independence to her part and eventually she can restore her health again and use it to its optimum.

GORDONS FUNCTIONAL HEALTH PATTERN

USUAL PATTERN I. Health Perception- Health Management Past illness during the last six months were cough and colds Self medicate during her

INITIAL ASSESSMENT (February 16, 2009) Admitted to the hospital at 10:00 pm Complains of labor pains and 98

ON-GOING ASSESSMENT (February 17, 2009) T= 36.7 degrees celcius ; PR=85 BPM ; RR=19 CPM ; BP= 100/80 mmHg Verbalized Medyo okay na ako

pregnancy Never been hospitalized General health in the past has been good and is healthy Claimed she is healthy for the past 6 months verbalized healthy ra ako pregnancy ug walay complications Described health this time is not in its optimum verbalized medyo kapoy pajud ako lawas ug sakit gamay ang tinahian Do not perform Breast Self Examination Had not experienced dental check up Do not submit herself for prenatal chek-ups Do not have problems in caring self and in performing ADLs

Cefalexin Mefenamic acid Methylergonovine Maleate Multivitamins + iron Expected that the hospital and its staff will give her and her baby the bets quality care

watery vaginal discharges (February 25, 2009) T=36. 9 degrees celcius ; PR=110 BPM ; RR=20 CPM ; BP=100/80 mmHg Patient verbalized medyo kapoy pa jud ko lawas ug sakit gamay ang tinahi-an Dili pajud kayo kalihok-lihok pa Medication Given:

paminaw Dili napud sakit ang tinahi-an ug maka lihok2x na ako Medication Taken : ~ Cefalexin ~ Mefenamic acid ~ Methylergonvine Mnaleate ~ Multivitamins + iron

II. Nutritional Metabolic Pattern Eats Regular meals everyday ^ Breakfast- 1 cup rice, ! bowl of vegetables, 1piece of fish, 1-2 serving of banana, 2-3 glasses of water ^ Lunch and dinner- 1 cup of rice, 1 bowl of vegetables, 1-2 pieces of fish, 1-2 glasses of water.

Claimed weight is the same Not choosy when it comes to food; no food preferences and restrictions Do not experiencre indigestion, nausea and vomiting

Type of diet: DIET AS TOLERATED ^ Breakfast- 1 cup rice , 1 bowl of linat-ang baka ^ lunch- 1 cup rice, fried fish and soup No food preferences and restrictions Fliud intake is approximately 2000 ml a day Can eat and swallow with out difficulty No food supplements taken Does not experience indigestion and nausea

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 Usual fluid intake can consume 2000-2500ml of water / day Appetite is good Noticed weight gain on her pregnancy There is no problem in the ability to eat like swallowing solid foods, chewing and feeding self No food restrictions and preferences Do not experience indigestion, nausea, when eating III. Elimination Pattern * Bladder No difficulty and problems in urinating No assistive device used

Type of diet : DIET AS TOLERATED ^ Breakfast- 1 cup rice, 1 bowl of linat-ang baka ^ Lunch- 1 cup rice, fish and vegetables ^ Dinner- 1 cup rice and bowl of linat-ang baka Fluid intake 2000ml per day Verbalized Ganahan ko mag sigeg inum ug tubig kay sige ko ug uhawon dayon init pud No difficulty in swallowing and eating No food supplements taken

Urinated 3 times Urine is yellowish mixed with lochia Verbalized medyo sakit sya kung mangihi ko

Urinated twice Urine is yellowish and mixed with lochia Verbalized dili na sakit e-ihi No difficulty in urinatimg

* Bowel Defecates one or twice a day during morning and night Stool is formed and brownish in color No assistive devices used * Skin

Has not defecated yet Has not defecated yet

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 Skin has good turgor and no skin problems IV. Activity Exercise Pattern Activities of daily living 6 am- wakes up , prepares breakfast ; boil water 7am- do house hold chores 8am- breakfast time 9am- do the laundry; take a bath 11am- rest 11:30 am- prepare food for lunch 12nn- lunch time 1:00 pm- sleep 3pm- 5:00pm- do the household chores 6:00pm- prepares dinner 7:00pm- dinner time 7:30-9:00pm- entertainment time 9:00-6am- sleeping time A plain housewife No limitation in mobility No complains of dyspnea or fatigue V. Sleep- Rest Pattern Sleeps at 9pm and awakes at 6am Hours slept- 9 hours Looks pale skin is in good condition and turgor Rashes on abdomen are slightly fading Mobility is improved Still ADL is not followed because of her new role as a mother and present situation/ condition Perceived ability Feeding-2 Bathing-2 Toileting-2 Bed mobility-2 Dressing-2 Grooming-2 General mobility-1 No leisure activities / exercise pattern No complaints of dyspnea or fatigue

Looks pale and tired but skin is in god condition and of good turgor Few rashes on the abdomen were noted Activites of daily living is not performed at all due to her present condition Mobility is limited Perceived ability Feeding-2 Bathing-1 Toileting-1 Bed mobility-2 Dressing-2 Grooming-1 General mobility-1 No leisure activities and exercise pattern at all No complaints of dyspnea or fatigue

Spent her time in sleeping and recovery

Able to take naps and sleep No specific time in sleeping

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 No sleep aids and routine used No problems in sleeping

VI. Cognitive-Perceptual Pattern Highest educational attainment: high school No difficulty in hearing and visual problems Speech is clear Not sensitive / insensitive to cold/heat Able to read and write

Conscious, coherent, able to answer questions and is cooperative Speech is clear and can communicate well Able to read and write No problems in hearing and in seeing objects

Conscious, coherent, able to answer questions and is cooperative Speech is clear and can communicate well Able to read and write No problems in hearing and in seeing objects

VII. Self- Perception Pattern Concerned about health, family and her childs future Present health goal is to be healthy always as well as her husband and baby Describe herself as soft spoken and is friendly Does not get mad/ angry immediately and tries to stay

She was most concern on her dead baby and her familys welfare To have a happy and healthy family is her health goal Verbalized Wala gyud mi gadahom na ma=ingon ato ang among anak, naguol ko, pero wala na pud ko mahimo.

She wants to go home already Verbalized maningkamot ko na ako mabuhat ang akong katungdanan asip usa ka inahan ug asawa.

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away from trouble Being ill made her feel negligence in caring for herself Ask God for good health and to be away or free from disease VIII. Role- Relationship Pattern Communication Spoke in bisaya Speech is clear Expressed self verbally when happy, mad, angry Sometimes uses gestures to express feelings Relationship Live with her husband and children Talks problems with husband Relationship with other family members is healthy Decision-making is made together but took charge on the finances No problems and difficulties in her marital status Do not experience abuse either physically or verbally IX. Sexuality- Sexual Pattern Speaks bisaya Speech is clear and relevant Communicate well Verbally expresses commands and concerns Speaks bisaya Speech is clear and relevant Communicate well Verbally expresses commands and concerns

Her husband is with her as well as the relatives of her husband Decides together with her husband Finances is done by her husband as of now Is happy of her marital status

Her husband is with her Talks with her husband Still finances is done by her husband Sad and eager to go home

LMP- May 14, 2008

Menstruation does not return to normal Claimed that they would go to the health

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 Menarche started at the age of 12 Is fertile and 4th time of pregnancy No history of reproductive problems No use of contraceptives X. Coping Stress Management Pattern Make decisions with her husband Had lost her mother many years ago and was able to cope up Likes herself for being softspoken and for trying to avoid trouble Prefer to be alone and stay calm and quiet when tense, mad, angry, or stressed Claimed that she wants the nurse and doctor to give her and her baby the best and quality care XI. Value Belief Pattern

G4P4 Verbalized Ga-plano me na mugamit ug family plnning

center to ask on family planning

Talks and decides with her husband Looks tired and sad Looks forward to the best and quality care that the nurse and doctor will render to her

Talks and decides with her husband Sad and eager to go home Verbalized mayo unta pagawason na me sa doctor ron.

Verbalized Salig lang gyud sa Ginoo Mag-ampo lang gyud niya sige. 104

Verbalized Ampo lang gyud ug slig sa Ginoo

 Roman Catholic Religion and God is important in her life Follows the Roman Catholic practices Believe in superstitious beliefs

LIST OF NURSING DIAGNOSIS Nursing Care Plans for Prenatal

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ACUTE PAIN RELATED TO PHYSICAL CHANGES OF THE BODY SECONDARY TO PREGNANCY ALTERED URINARY ELIMINATION RELATED TO UTERINE ENLARGEMENT AND INCREASING ABDOMINAL PRESSURE

Nursing Care Plans for First Stage of Labor

IMPAIRED URINARY ELIMINATION RELATED TO SEVERE INTRAPARTAL HYPERTENSION SECONDARY TO LABOR ACUTE PAIN RELATED TO CONTRACTION OF THE UTERUS RISK FOR INEFFECTIVE COPING AS EVIDENCED BY SITUATIONAL CRISIS AND INADEQUATE SUPPORTSYSTEMS

Nursing Care Plans for Second Stage of Labor

IMPAIRED GAS EXCHANGE RELATED TO DECREASED OXYGEN CARRYING CAPACITY OF THE BLOOD, REDUCED RBC LIFE

SPAN/PREMATURE DESTRUCTION, UBNORMAL RBC STRUCTURE, SENSITIVITY TO LOW OXYGEN TENSION ACUTE PAIN RELATED TO ATRONG UTERINE CONTRACTION SECONDARY TO STAGE TWO LABOR RISK FOR IMPAIRED SKIN INTEGRITYRELATED TO PRESENCE OF LACERATION SECONDARY TO STAGE TWO LABOR

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Nursing Care Plans for Postpartum

ACUTE PAIN RELATED TO VAGINAL INCISION SECONDARY TO CHILDBIRTH

IMPAIRED PHYSICAL MOBILITY RELATED TO PAIN/DISCOMFORT SECONDARY TO EPISIOTOMY OF THE PERINEUM DISTURBED SLEEP PATTERN RELATED TO ENVIRONMENTAL, PARENTAL, AND PHYSIOLOGICAL FACTORS GRIEVING RELATED TO DEATH OF INFANT

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NURSING CARE PLAN

Nursing Care Plans for Prenatal

Cues and Evidences Subjective Verbalized sigeng magsakit akong likod Verbalized maglisod ko usahay ug katulog tungod sa akong tiyan Objective: Temp= 37.2oC PR= 80 bpm RR= 22 cpm BP= 100/70 Nausea & Vomiting Breast changes Leg cramps Sweating of forehead Restlessness Presence of eye Nursing Diagnosis Acute pain related to physical changes of the body secondary to pregnancy. Goals/Objectives Intervention Rationale Evaluation The objective of care was completely met as evidenced by: a. V/S WNL T= 36.5-37.5 C PR= 60-100 bpm strong and regular RR=12-20cpm; moderate in depth and without effort BP= 120/80 mmHg b. relief in back pain c. relief in leg cramps

Within our 8 hours Independent of care, the patient Assess clients will be able to respiratory status. manifest reduce discomfort during pregnancy as evidenced by: Note reports of back a. V/S WNL strain and altered gait. T= 36.5-37.5 C Suggest use of lowPR= 60-100 bpm heeled shoes. strong and regular RR=12-20cpm; moderate in Determine presence of depth and without leg cramps. effort Encourage client to BP= 120/80 extend leg and turn mmHg foot upward in b. relief in back dorsiflexion change pain position frequently

Reduced respiratory capacity as the uterus presses on the diaphragm results in dyspnea. Lordosis and muscle strain are caused by the influence of hormones on pelvic articulations and a shift in the center of gravity as the uterus enlarges. Reduces discomfort associated with altered calcium levels/calciumphosphorous imbalance, or with pressure from enlarging uterus compressing nerves

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bags

c. relief in leg cramps d. absence of dyspnea e. tolerated pain level of uterine contractions

supplying the lower extremities. Assess for presence/frequency of Braxton Hicks contractions. These contractions may create discomfort for the multigravida in both second and third trimesters.

d. absence of dyspnea e. tolerated pain level of uterine contractions

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Cues and Evidences Subjective: Verbalized mag-sige ko ug pangihi aning mga panahona. Objective: Temp= 37.2oC PR= 80 bpm RR= 22 cpm BP= 100/70 Urinary Incontence Voided straw to deep amber urine, approximately 2000ml/day. Presence of edema AOG= 40 weeks

Nursing Diagnosis Altered urinary elimination related to uterine enlargement and increasing abdominal pressure

Goals/Objectives Within our 8 hours of nursing care, the patient will manifest reduce alteration during elimination as evidenced by: a. V/S WNL T= 36.5-37.5 C PR= 60-100 bpm strong and regular RR=12-20cpm; moderate in depth and without effort BP= 120/80 mmHg b. reduced peripheral edema. c. urinary incontinence is reduced. d. no sign of edema

Intervention Independent Provide information about urinary changes associated with third trimester.

Rationale Helps client understand the physiological reason for urinary frequency and nocturia. Third-trimester uterine enlargement reduces bladder capacity, resulting in frequency. A left or right lateral recumbent position increases GFR and renal blood flow to increase kidney perfusion. These positions potentiate vena cava syndrome an dreduce venous return. Maintains adequate fluid levels and kidney perfusion which relies on dietary sodium. Sodium losses/restrictions may

Evaluation The objective of care was completely met as evidenced by: a. V/S WNL T= 36.5-37.5 C PR= 60-100 bpm strong and regular RR=12-20cpm; moderate in depth and without effort BP= 120/80 mmHg b. reduced peripheral edema. c. urinary incontinence is reduced. d. no sign of edema

Encourage client to assume lateral position while sleeping. Note reports of nocturia.

Advise client to avoid long periods in upright or supine position. Provide information regarding need for fluid intake of 6 to 8 glasses/day. Provide information regarding danger of taking

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diuretics and of eliminating sodium from diet.

overstresses renninangiotensin-aldosterone regulators of fluid levels, resulting in severe dehydration.

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Nursing Care Plans for First Stage of Labor Cues and Evidences Subjective The patient verbalized maglisod man kog pangihi Objective Temp= 37.3oC PR= 79 bpm RR= 21 cpm BP= 100/80 Incontinence Retention Urine volume Voided 250ml of urine. Urinalysis Color= yellow Appearance= hazy pH=6.0 Glucose=0 Protein=0 Nursing Diagnosis Impaired Urinary Elimination related to severe intrapartal hypertension secondary to labor Goals/Objectives Within our 8 hours of nursing care, the patient will manifest achievement of normal elimination pattern as evidenced by: a. Verbalized understandin g of the condition b. Achieve normal elimination or participate in measures to correct for defects. c. Identify causative factors. Intervention Inspect stomach of urinary diversion for edema. Palpate bladder Note conditions of skin and mucous membranes color of urine. Emphasize importance of keeping area clean and dry. Rationale To reduce the presence of edema. To assess retention. To help determine level of hydration. To reduce the risk of infection. Evaluation The objective of care was completely met as evidenced by: a. Verbalized understandi ng of the condition b. Achieve normal elimination or participate in measures to correct for defects. c. Identify causative factors.

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Cues and Evidences Subjective: Verbalized sakit akong balat-ang, dili ko kasabot sa kasakit. Rated pain as 10 in the scale of 1-10 as 10 is the highest and 1 is the lowest level of pain Objective: Sleep disturbance Expressive behavior: Restlessness Moaning Irritability Distraction behavior Seeking out other people Autonomic alteration in muscle tone Autonomic response diaphoresis .

Nursing Diagnosis

Goals/Objectives

Intervention Monitor vital signs Perform a comprehensive assessment of pain: include location, characteristics, onset/duration, frequency, quality, severity. Accept descriptions of pain

Rationale Usually altered by acute pain To determine patients acceptable the level of pain on a 0 to 10 scale.

Evaluation The objective of care was completely met as evidenced by: vital signs within normal limit T= 36.5-37.5 C PR= 60-100 bpm strong and regular RR=12-20cpm; moderate in depth and without effort BP= 120/80 mmHg Reduced restlessness Decreased moaning behavior Reduced crying habit Decreased irritability Reduced distraction behavior

Acute pain related Within our 8 hours to contraction of the of nursing care, the uterus patient will manifest reduce level of pain as evidenced by: vital signs within normal limit T= 36.5-37.5 C PR= 60-100 bpm strong and regular RR=12-20cpm; moderate in depth and without effort BP= 120/80 mmHg Reduced restlessness Decreased moaning behavior Reduced crying habit Decreased irritability

Observe non-verbal cues

Work with patient to prevent pain, instruct patient to report pain as soon

Pain is a subjective experience and cannot be felt by others. Observation may/may not be congruent with verbal reports indicating need for further evaluation. As timely intervention is more likely to be successful is

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Reduced distraction behavior rated pain 23 from 10 as 10 is the highest and 1 Is the lowest rate of pain

as it begins. Provide relaxation technique such as destruction, meditation, etc.. as your health teaching. Provide an honest explanation of what the client can expect.

alleviating pain. Enabling the client to manage pain.

rated pain 2-3 from 10 as 10 is the highest and 1 Is the lowest rate of pain

Sharing of information about the procedure is more effective than procedure information alone.

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Cues and Evidences Subjective Verbalized ako rang bana ako kuyog karon, tu-a sa gawas, gahulat. Objective Temp= 37.3oC PR= 79 bpm RR= 21 cpm BP= 100/80 Inadequate problem solving Poor concentration

Nursing Diagnosis Risk for ineffective coping as evidenced by situational crisis and inadequate support systems

Goals/Objectives Within our 8 hours of nursing care, the patient will manifest effective coping as evidenced by: vital signs within normal limit T= 36.5-37.5 C PR= 60-100 bpm strong and regular RR=12-20cpm; moderate in depth and without effort BP= 120/80 mmHg Assess the current situation accurately. Identify ineffective coping

Intervention Identify developmental level of functioning Determine previous methods of dealing w/ life problems. Call patient by name: ascertain how patient refers to be addressed.

Rationale People tend to regress to a lower developmental stage during crisis. To identify successful techniques that can be used in current situation. Using patients name enhances sense of self and promotes individuality selfesteem. When anxiety is increased by noisy surroundings. Knowledge helps reduce anxiety, fear, allows

Evaluation The objective of care was completely met as evidenced by: vital signs within normal limit T= 36.5-37.5 C PR= 60-100 bpm strong and regular RR=12-20cpm; moderate in depth and without effort BP= 120/80 mmHg Assess the current situation accurately. Identify ineffective coping behaviors and consequences .

Provide a quite environment/positio n equipment out of view as mush as possible Give updated additional information needed

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behaviors and consequenc es. Verbalized awareness of coping abilities.

about labor and delivery.

patient to deal with reality.

Verbali zed awareness of coping abilities.

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Nursing Care Plans for Second Stage of Labor Cues and Evidences Subjective: Verbalized maglisod kog ginhawa tungod sa kasakit Objective: Dyspnea, use of accessory muscles restlessness, confusion tachycardia Decrease venous return Change of vital sign: BP=100/ 80100/70 Nursing Diagnosis Impaired Gas exchange related to decreased oxygen carrying capacity of the blood, reduced RBC life span/ premature destruction, abnormal RBC structure, sensitivity to low oxygen tension Goals/Objectives Within our 8 hours of nursing care, the patient will manifest improve gas exchange as videnced by: vital signs within normal limit T= 36.5-37.5 C PR= 60-100 bpm strong and regular RR=12-20cpm; moderate in depth and without effort BP= 120/80 mmHg Participate in treatment regimen such as breathing exercise Intervention Monitor respiratory rate/depth, use of accessory muscles, areas of cyanosis. Rationale Evaluation

Auscultate breath sounds, noting presence/absence and adventitious sounds. Monitor vital signs, note changes in cardiac rhythm.

Demonstrate and encourage use of relaxation

The objective of care Indicators of was completely met adequacy of as evidenced by: respiratory function or degree of compromise & vital signs therapy within normal needs/effectivene limit ss T= 36.5-37.5 C PR= 60-100 bpm Development of strong and regular atelectasis RR=12-20cpm; &stasis of moderate in depth secretions can and without effort impair gas BP= 120/80 mmHg exchange Compensatory Participate in changes in vital treatment signs and regimen such development of as breathing dysrhythmias exercise within reflect effects of level of ability hypoxia on or situation cardiovascular system Verbalized understanding Relaxation of causative decreases muscle

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within level of ability or situation Verbalized understandin g of causative factors and appropriate interventions . Demonstrate improve ventilation. Absence of symptoms of respiratory distress.

tecniques

tension & anxiety & hence the metabolic demand for oxygen

factors and appropriate interventions. Demonstrate improve ventilation. Absence of symptoms of respiratory distress.

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Cues and Evidences Subjective: Verbalized sakit na akong tiyan, murag mugawas na ang bata. Verbalized dili na nako maagwanta ang kasakit ug mura nakog kalibangon. Rated pain as 10 in the scale of 1-10 as 10 is the highest and 1 is the lowest level of pain. Objectives: Decrease ROM Facial grimacing Restlessness Sweating in the forehead Diaphoresis Guarding the cite of pain

Nursing Diagnosis Acute pain related to strong uterine contraction secondary to stage two labor

Goals/Objectives Within our 8 hours of nursing care, the patient will manifest reduce level of pain as evidenced by: vital signs within normal limit T= 36.5-37.5 C PR= 60-100 bpm strong and regular RR=12-20cpm; moderate in depth and without effort BP= 120/80 mmHg Reduced restlessness Decreased moaning behavior Reduced crying habit Decreased irritability Reduced distraction

Intervention Monitor vital signs Perform a comprehensive assessment of pain: include location, characteristics, onset/duration, frequency, quality, severity. Accept descriptions of pain

Rationale Usually altered by acute pain To determine patients acceptable the level of pain on a 0 to 10 scale.

Evaluation The objective of care was completely met as evidenced by: vital signs within normal limit T= 36.5-37.5 C PR= 60-100 bpm strong and regular RR=12-20cpm; moderate in depth and without effort BP= 120/80 mmHg Reduced restlessness Decreased moaning behavior Reduced crying habit Decreased irritability Reduced distraction behavior rated pain 2-3 from 10 as 10

Observe non-verbal cues

Work with patient to prevent pain, instruct patient to report pain as soon as it begins.

Pain is a subjective experience and cannot be felt by others. Observation may/may not be congruent with verbal reports indicating need for further evaluation. As timely intervention is more likely to be successful is alleviating pain.

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behavior rated pain 23 from 10 as 10 is the highest and 1 Is the lowest rate of pain

Provide relaxation technique such as destruction, meditation, etc.. as your health teaching. Provide an honest explanation of what the client can expect.

Enabling the client to manage pain.

is the highest and 1 Is the lowest rate of pain

Sharing of information about the procedure is more effective than procedure information alone.

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Cues and Evidences Subjective: Verbalized nakabati ko ug hiwa sa pagawas sa bata sa akong kinatawo Objective: Laceration Expulsion of the baby at 11 pm.

Nursing Diagnosis Risk for impaired skin integrity related to presence of laceration secondary to stage two labor

Goals/Objectives Within our 8 hours of nursing care, the patient will manifest maintenance of skin integrity as evidenced by: No signs of infection in the lacerated area Demonstrate techniques to prevent skin breakdown Verbalize understandin g of treatment and therapy regimen.

Intervention Monitor vital signs Inspect skin, noting skeletal prominences, presence of edema, areas of altered circulation or obesity Provide gentle massage around reddened or blanched areas Encourage to use frequent skin care, minimize contact with moisture/ excretions

Rationale To provide baseline data Skin is at risk because of impaired peripheral circulation, physical immobility and alterations in nutritional status. Improves blood flow, minimizing tissue hypoxia Excessive dryness or moisture damages skin and hastens breakdown.

Evaluation The objective of care was completely met as evidenced by: No signs of infection in the lacerated area Demonstrate techniques to prevent skin breakdown Verbalize understanding of treatment and therapy regimen.

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CUES AND EVIDENCES Subjective: Verbalized medyo kapoy pa jud ako lawas ug sakit gamay ang tinahi-an Mosakit siya kung mangihi ko Dili pud kayo ko ka-lihuk-lihok pa.

NURSING DIAGNOSIS Acute pain related to vaginal incision secondary to childbirth

OBJECTIVES OF CARE After our care the patient Will manifest an increased comfort and free from pain as evidenced by: Reporting pain is relieved/ controlled Following prescribed pharmacologica l regimen Verbalizing methods that provide relief Demonstrating use of relaxation skills and diversional activities Have stable v/s T=37c PR=60-100BPM

INTERVENTIONS Independent: Perform a comprehensive assessment of pain, the characteristics, onset/duration, frequency and aggravating factors Note patients locus of control

RATIONALE

EVALUATION After our care the patient had completely met the objectives of care as evidenced by: Reported pain is controlled and relieved Followed prescribed medication Demonstrated use of relaxation skills such as focus breathing Socialized others as a distractive behavior Able to take rest periods when have time available or is not doing something Claimed an increase in

To assess etiology/ precipitating contributory factors

This indicate little or no responsibility for pain management To provide baseline data for vital signs can be altered in acute pain To provide non phar macological pain management by promoting comfort

Objectives: Guarded behavior Sleep is disturbed Irritable at times Tends to turn positions frequently Facial grimacing noted Slight perspiration

Monitor vital signs

Provide comfort measures like back rub, change of position, use of heat/cold

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Self-focusing Narrowed focus; reduced interaction with people and environment

RR=12-20CPM BP=120/80 mmHg

Encourage use of relaxation exercises such as focused breathing Encourage adequate rest periods Encourage diversional distractive activities like socializing with others

To explore methods for alleviation/ control of pain To prevent fatigue form inadequate rest and sleep To control pain by not focusing on the pain felt with the distractive techniques used

comfort and free from pain

Collaborative: Administer analgesics, antibiotics as indicated to maximal dosage as needed Discuss with SO the ways in which they can assist patient and reduce precipitating factors that may cause or increase pain

To maintain acceptable level of pain To promote wellness and provide participation by the SO

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CUES AND EVIDENCES Subjective: Verbalized Wala gyud koy klarong tulog dayon banha ug gin-ot pud. Mag-lisod pud kog katulog kay dili me paigo sa bed. Sakit gamay ang tinahi-an.

NURSING DIAGNOSIS Disturbed sleep pattern related to environmental, parental, and physiological factors

OBJECTIVES OF CARE

I NTERVENTIONS

RATIONALE

EVALUATION After our care the patient had completely met the objectives of care as evidenced by: responded to interventions/ teaching and actions performed attained progress toward desired outcomes developed an effective sleep/rest pattern by establishing a routine sleep and wake pattern performed comfort measures like washing of hands and face and arranging/cleaning bed before sleeping limited intake of water prior to bed time able to take naps when have time available or is not busy

Objective: Restlessness Noted eye bags Expressionless face Changes in posture/position frequently Yawning Time spent in sleeping is less

Within our care Independent: patient will manifest a assist the client regular sleep pattern in identifying the as evidenced by: causative or contributing reporting factors that improvement in contributes to sleep/ rest sleep pattern pattern disturbances verbalizing assess the appropriate time normal sleep interventions to pattern of the promote sleeping patient able to sleep even though the environment is warm and noisy provide comfort and report measures like increased of back rub, feeling rested washing hands/face, verbalize cleaning and increased straightening comfort sheets in have stable vital preparation for signs: sleep T= 37 c establish routine PR= 60-100 BPM 124

to identify causative/ contributing factors

to know the usual sleep pattern and provide comparative baseline to promote sleep

to assist patient

Noisy and warm environment Noxious odor Pain felt is 5 Taxilla= 36.8 degrees celcius PR=85 BPM RR=22 CPM BP=100/70 mmHg

RR=12-20 CPM BP=120/80 mmHg

bedtime and arising

to establish optimal sleep/rest pattern to reduce need for night time elimination

recommend limiting intake of chocolate and caffeine prior to bedtime and also limit fluid intake explore other sleep aids like warm bath/ milk before bedtime encourage napping

to enhance patients ability to fall asleep to increase the time/ feeling rested to enhance patients ability to fall asleep to provide accurate and necessary interventions of the problem

Collaborative: use sleeping medications sparingly if prescribed refer to sleep specialist/ laboratory for treatment when indicated

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CUES AND EVIDENCES Subjective: Verbalized Wala gyud mi gadahom na ma=ingon ato ang among anak, naguol ko, pero wala na pud ko mahimo.

NURSING DIAGNOSIS Grieving related to death of infant

OBJECTIVES OF CARE Within our care patient will manifest a regular sleep pattern as evidenced by: identify and express feeli ngs like sadness, guilt freely and effectively acknowledge impact and effect of the grieving process look toward plan for future, one day at a time have stable vital signs: T= 37 c PR= 60-100 BPM RR=12-20 CPM BP=120/80 mmHg

INTERVENTIONS Independent: evaluate clients perception of cultural and religious loss and it meaning to her and identify cultural and religious belief that may impact sense of loss note emotional responses such as withdrawal, angry behavior, crying provide an open environment and trusting relationship use therapeutic communication skills of active listening, silence and acknowledgement

RATIONALE

EVALUATION After our care the patient had completely met the objectives of care as evidenced by: identified and expressed feeli ngs like sadness, guilt freely and effectively acknowledged impact and effect of the grieving process looked toward plan for future, one day at a time have stable vital signs: T= 37 c PR= 60-100 BPM RR=12-20 CPM BP=120/80 mmHg

grief can provoked a wide range of intense and often conflicting feelings

Objective: Restlessness Expressionless face Changes in posture/positio n frequently Verbal expressions of distress Loss, guilt

to assess appropriateness of clients reaction to the situation promotes a free discussion of feelings and concern to show respect and build a trusting relationship. Enhance sense of trust and nurse-client

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 v/s: Taxilla= 37.2degrees celcius PR=80 BPM RR=22 CPM BP=100/70 mmHg

incorporate family members in theproblem-solving

relationship encourages family to support and assist client with situation while meeting needs of family members

Collaborative: refer t additional resources, such as pastoral care, counseling/psycother apy , community support groups

to meet ongoing needs ad facilitate grief work

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ANNOTATED READINGS Folic Acid and Its Importance to Pregnant Women By Vincent Platania Article Posted: 05/02/2007 Until very recently medical science was sadly unable to ferret out the cause and effect relationship between the absence of folic acid in the diets of pregnant women and the incidence of neural tube defect in their offspring. The exact timeframe in which this defect can potentially occur is between the 21st and 27th day of gestation. The simple omission of this single nutrient was responsible for severe and lifelong suffering of countless children who were born with spina bifida or anencephaly. Anencephaly is a defect in which the cerebrum is missing causing profound loss of functionality. Spina bifida is a disorder which involves the failure of the spine to close during gestation. It was estimated that one in every 1000 births were at one time affected with spina bifida. Those born with this condition require surgery to close the spine or they will die. Even with surgery they are often crippled and mentally retarded. Until the development of ultrasound technology, which now detects a fetus with this condition, the hapless parents were not aware of the childs defect until its birth. The Food and Drug Administration (FDA) decided that the importance of folic acid was so great that all grain products in the U.S. have been required to be enriched with folic acid since 1998. It is now estimated that cases of NTD have been reduced by 60% to 100% when folic acid is supplemented for a period of one month before and one month after pregnancy begins.

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Folic acid is extremely important because of its use by the human body in production of DNA and RNA. Its absence is also associate with other defects such as heart defects and limb malformations. Although folates are necessary for all persons the medical community is especially concerned with adequate folic acid intake in women who may become pregnant. It is for that reason that women of child bearing age are encouraged by the United States Public Health Service to take 400 micrograms of folic acid per day. This is the same Recommended Dietary Allowance (RDA) as men have but the emphasis is greater for women of child-bearing age. The RDA for pregnant women is 600 mcg of folic acid per day. Food sources of folates include green leafy vegetables, lentils, garbanzo beans, orange juice and fortified breakfast cereals.

SUMMARY Folic acid is extremely important because of its use by the human body in production of DNA and RNA, especially during pregnancy. Thats why its absence or deficient is linked to anencephaly and other defects such as heart defects and limb malformations. This single nutrient was responsible for severe and lifelong suffering of countless children who were born with spina bifida or anencephaly. As recommended by the RDA and as encourage by the United Sates Public Health Service, women of childbearing age are advised to take 400 micrograms of folic acid per day and 600 mcg per day for pregnant women. Food sources that are rich in foliate are found in green leafy vegetables, lentils, garbanzo beans, orange juice and fortified breakfast cereals.

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REACTION As a health care provider one of our roles is to educate and give health teachings to our clients. One way of empowering patient education, is to educate women of childbearing age and especially pregnant women to increase their intake of folic acid to prevent from developing a child with anencephaly. Motivating these groups of women to adhere strictly to the appropriate doses they should take would be a good step towards eliminating children who have suffered from being born with spina bifida or anencephaly. After all, prevention is better than cure.

Complete Information on Anencephaly with Treatment and Prevention By Juliet Cohen

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Article Posted: 04/24/2008

Anencephaly is the cause to a nervous system tube slight defect, creates lacks the brain, the skull, is chaotic with the scalp majority forehead. Anencephaly occurs when the head end of the neural tube fails to close, resulting in the absence of a major portion of the brain, skull, and scalp. Infants with this disorder are born without a forebrain (the front part of the brain) and a cerebrum. The cause of anencephaly is unknown. Although it is thought that a mother's diet and vitamin intake may play a role, scientists believe that many other factors are also involved. It is known that women taking certain medication for epilepsy and women with insulin dependent diabetes have a higher chance of having a child with a neural tube defect. Genetic counseling is usually offered to women at a higher risk of having a child with a neural tube defect to discuss available testing. The anencephaly come for when the neural tube does not succeed at the basis of the skull, while spina bifida occurs when the neural tube fails to close somewhere along the spine. Children with this disorder are born without a forebrain, the largest part of the brain consisting mainly of the cerebral hemispheres. The remaining brain tissue is often exposed - not covered by bone or skin. It is important to understand that the type of neural tube defect can differ the second time. For example, one child could be born with anencephaly, while the second child could have spina bifida. Anencephaly may be associated with the unbalanced form of a structural chromosome abnormality in some families. In these cases, other malformations and birth defects that are not usually found in isolated cases of anencephaly may be present. The symptoms of anencephaly may resemble other problems or medical conditions. Infants born with anencephaly are usually blind, deaf, unconscious, and unable to feel pain. Although some individuals with anencephaly may be born with a rudimentary brainstem, which controls autonomic and regulatory function, the lack of a functioning cerebrum is usually thought of as ruling out the possibility of ever gaining consciousness, even though it has been disputed specifically. Reflex actions such as breathing and responses to sound or touch may occur.

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Genetic counseling may be recommended by the physician to discuss the risk of recurrence in a future pregnancy as well as vitamin therapy that can decrease the recurrence for open neural tube defects. Anencephaly caused by amniotic band disruption sequence is frequently distinguishable by the presence of remnants of the amniotic membrane. Anencephaly possibly frequently diagnoses before the birth through the ultrasonic wave test. The maternal serum alpha-fetoprotein and detailed fetal ultrasound can be useful. There is no treatment or standard treatment for anencefalie and the forecast for influenced individuals is bad. Experience of the loss of a child can very traumatic be. Grief counseling services are available to help you cope with the loss of your child. Women who are pregnant or planning to become pregnant should take a multivitamin with folic acid every day. Many foods are now fortified with folic acid to help prevent these kinds of birth defects. A physician may prescribe even higher dosages of folic acid for women who have had a previous pregnancy with a neural tube defect. Folic Acid can significantly reduce the risk of having a baby with a neural tube defect, but does not totally eliminate the possibility.

SUMMARY Anencephaly is a condition present at birth that affects the formation of the brain and the skull bones that surround the head. It results in only minimal development of the brain. Often, the brain lacks part or the entire cerebrum (the area of the brain that is responsible for thinking, vision, hearing, touch, and movement). There is no bony covering over the back of the head and there may also be missing bones around the front and sides of the head. Usually the child with anencephaly is blind, deaf, unconscious, and unable to feel pain. They may live after a short while from birth but then die eventually. Folic acid had been proven to significantly reduce the risk of having a baby with a neural tube defect, however does not totally eliminate the possibility of having it.

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REACTION As what is experienced by us during our LR-DR Rotation, mothers who have given birth to a child with anencephaly is increasing in number. Upon assessment of the reason of having such baby, the mothers would always say that they havent submitted their selves for prenatal check-up. Thats why they had no idea that their baby had anencephaly. As a health care provider, it is best to educate those pregnant women to submit their selves for prenatal check-up, for early detection or complications that may aris

CONCLUSION

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Anencephaly is a serious developmental defect of the central nervous system in which the brain and cranial vault are grossly malformed. The cerebrum and cerebellum are reduced or absent, but the hindbrain is present. Anencephaly is a part of the neural tube defect (NTD) spectrum. This defect results when the neural tube fails to close during the third to fourth weeks of development, leading to fetal loss, stillbirth, or neonatal death. Anencephaly, like other forms of NTDs, generally follows a multi-factorial pattern of transmission, with interaction of multiple genes as well as environmental factors, although neither the genes nor the environmental factors are well characterized. In some cases, anencephaly may be caused by a chromosome abnormality, or it may be part of a more complex process involving single-gene defects or disruption of the amniotic membrane. Anencephaly can be detected prenatally with ultrasonography and may first be suspected as a result of an elevated maternal serum alpha-fetoprotein (MSAFP) screening test. Folic acid has been shown to be an efficacious preventive agent that reduces the potential risk of anencephaly and other NTDs by approximately two thirds. As a health care provider, our role here is mainly supportive. The profound and personal suffering of the parents of an anencephalic child gives us cause for concern and calls for compassionate pastoral and medical care as the parents prepare for the pain and emptiness that the certain death of their newborn child will bring. The mother who carries to term a child who will soon die deserves our every possible support. The baptism of the child assures the parents of the child's eternal happiness, and the provision of Christian burial of the deceased infant gives witness to the Church's unconditional respect for human life and the recognition that in the face of every human being is an encounter with God.

BIBLIOGRAPHY

A. BOOK

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Pillitteri, Adele, (2003), Maternal & Child Health Nursing, (4th ed.) Lipincott Williams and WilkinsScott, James R. ,et.al., Danfroths Obstetrics and Gynecology (9th ed. ) Lipincott Williams and Wilkins Porth, Carol M., (2002), Pathophysiology: Concepts of Altered Health States, (6th ed. ) Lipincott Williams and Wilkins Price, Sylvia A. (2003, Pathophysiology: Clinical Concepts of disease process. (6th ed.) Elsvier Science, MOSBY Inc. Rock, John A. ,et.al., (2003), Operative Gynecology, (9th ed.) Lipincott Williams and Wilkins Seeley, R.R., et.al.(2005), Essentials of Anatomy and Physiology, (5th ed.), McGraw-Hill Companies, Inc. Schilling, M. et.al. , (2008), Drug Handbook, (28th ed.) Lipincott Williams and Wilkins Kee, J. and Hayes, E. (2003). Pharmacology: A Nursing Process Approach, (4th ed). Elvesier Science: USA. Kozier, B. et. al. (2004). Fundamentals of nursing: concepts, process, and practice (7th ed.). Upper Saddle River, New Jersey: Pearson Education Inc. Wilson, B., Shannon, M., Stang, C. (2004). Prentice Halls Nurses Drug Guide. Pearson Education, Inc.: New Jersey.

B. DICTIONARY
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Bantam (2000). The bantam medical dictionary. 3rd ed. USA: Market House Books Ltd. Blackwells Dictionary of Nursing, Blackwell Science LTD and C and E Publishishing, Inc Dawn Freshwater. (2005). Blackwells Nursing Dictionary 2nd edition. Blackwell ltd C. INTERNET
http://www.healthsystem.virginia.edu/uvahealth/peds_neuro/anenceph.cfm http://en.wikipedia.org/wiki/Anencephaly http://miscarriage.about.com/od/pregnancylossbasics/g/anencephaly.htm http://www.ninds.nih.gov/disorders/anencephaly/anencephaly.htm http://emedicine.medscape.com/article/1181570-overview http://www.umm.edu/ency/article/001580sym.htm http://kidshealth.org/parent/system/medical/prenatal_tests.html http://www.healthscout.com/ency/1/001580.html http://www.chw.org/display/PPF/DocID/22499/router.asp http://www.angelfire.com/mb/jessicasjourney/info.html

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http://www.anencephalie-info.rg/e/index.php http://www.womenshealthmatters.ca/centres/pregnancy/childbirth/stages.html http://www.expectantmothersguide.com/library/philadelphia/EPHlabor.htm Juliet Cohen writes articles for http://www.disordersatoz.com/, http://www.health-care-guide.org/ and http://www.diseasesatoz.com/ . Related Articles - Anencephaly information, Anencephaly treatment tips, Anencephaly prevention methods, get rid of Anencephaly

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