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 Gordon’s 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



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


Ayungon Negros Oriental Date and time of admission: February 15.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. 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 4 . "but this may never be permitted before the donor child is certainly dead". 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. DEMOGRAPHIC DATA Date of Assessment: July 19.

colds. Answer questions shortly. cooperative and response to greetings.History of present illness: LMP is on May 14. 5 . and headache and self-medicate using the over-the-counter medication. 2009. She experienced mild cough. 2008 and EDC is on February 21. Had not submitted her self for prenatal check-up and had not even taken any vitamins or supplements for pregnancy. General Impression: Conscious. coherent. Look pale and tired.

isolation Occurring in Young adulthood. and care within a relationship. support. fearing commitment and relationships can lead to isolation. We explore relationships leading toward longer term commitments with someone other than a family member. we begin to share ourselves more intimately with others.ERIK. Central task: Need for intimacy Ego Quality: Affiliation and love Definition: The giving and receiving of physical and emotional connection.ERICKSON’S THEORY Developmental Milestone Developmental Stage: Young adult: 18-35 years old Psychosocial crisis: Intimacy vs. and sometimes depression. loneliness. love. comfort. safety. Successful completion can lead to comfortable relationships and a sense of commitment. trust and other elements that would typically associate with healthy adult relationship conducive to mating and child-rearing 6 . Avoiding intimacy.

IUFD and Anencephaly. Decision-making is done together by her and her husband. Also seeks attention from her family and friends for the same purpose of attachment.Developmental task: Reciprocal love for and with another person Significant Relations: Marital partners and friends Mrs. She was wed for more than a year now. G4P4 (4-0-03). She wanted to be greatly attached by her husband for companion and love. Relationships with husband and relatives as well as their neighbors are healthy and harmonious. 7 . She was a plain housewife and depends on her husband who was a carpenter/ construction worker. 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. Calingacion is a 20-year-old G1P1. She was a prim and was happy to be a new mother as well as a wife.

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. friends and to her neighbor. She experienced mild cough. D) Past Health History. fishermen. 2009. The environment is quiet and peaceful and the residents were busy doing their individual tasks. Ayungon Negros Oriental with her family.They believe in one God and was baptized as a Roman Catholic. F) Spiritual History.Menarche started at the age of 12. E) Psychosocial History – She lives at Tiguib. She is married and has four children. severe illness/ disease all throughout her life. Ayungon Negros Oriental. She had a good relationship with his family. and headache and self-medicate using the overthe-counter medication. some are farmers. G) Environmental History – Her family resides at Tiguib. drivers. Had not submitted her self for prenatal check-up and had not even taken any vitamins or supplements for pregnancy. 8 . 2008 and EDC is on February 21. carpenters and construction workers. colds.C) HPI – LMP is on May 14. There are some who have engaged into small-scale business. Their main livelihood is farming. A G4P4. The houses in their place are slightly congested. No hospital experience and claimed that she is healthy without complications. although she experienced mild colds. cough and headache. mostly made up of nipa.

even and flexible Uniformly warm Smooth dry with minimal perspiration or oiliness Nails 9 . edema and discharges noted     Skin lifts easily and snaps back immediately to its resting position after lifting Smooth. soft.PHYSICAL ASSESSMENT Vital signs: Taxilla= 37. no scalp lesions and itching experienced. No allergies and rashes on skin experienced PTA. Diet as tolerated.    Have not taken food supplements during her pregnancy. Nails and cuticles were in good Light brown in color and generally uniform except in areas exposed to the sun. Exposure to sun is not too much. Paleness noted No lesions.2 degree celsius PR=80 bpm RR=22cpm BP=100/70mmhg INTEGUMENTARY SYSTEM History of the System Skin Inspection Palpation     No food restrictions PTA.

No lesions noted Hair Resilient and evenly distributed Black in color.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. 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 10 .

equal.Eyes     No history of prior eye surgery.S with a little hesitation and slightly leaning forward.     eyes are parallel to each other eyebrows are symmetrical    Blinks when the cornea is touches No edema. 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. Appetite is good and in DAT. No companions of blurred vision and any discharge of the eyes. 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. Do not use corrective glasses or contract lenses. No problem in hearing and no frequent infections in the ear can smell and sense taste well. with uniform color lens is clear 20/20 O. coordinated manner in all directions 11 .D and O. tenderness over the lacrimal gland No masses noted eyelids are close to the eyeball.

smooth Without nodules . moist. slightly pale and symmetrical lips   Smooth. without lesions No palpable nodules noted 12 .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. masses. 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. lesions Firm No pain felt upon palpation of the mastoid process.

symmetrical Hard palate is pale. and symmetrical Thyroid is in the midline. smooth. controlled movements Able to flex. white and shiny . firm and non tender Lymph nodes are not palpable Neck Symmetrical. extend.         Buccal mucosa with some patchy pigmentation Gums are partly brown Teeth are smooth. 32 teeth Tongue is dull red in color. moist. soft palate is pink No swelling noted    Trachea is in the midline position. and rotate neck RESPIRATORY SYSTEM 13 . centered head position Smooth.

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 .          no masses no tenderness  with resonance sounds  no masses. lumps.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.

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 15 . enlarged Nodularity is increased Round.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.

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.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 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. 1 finger breadths below the umbilicus Bladder 16 . no venous hum .

nail clean and trimmed Good eye contact . motor. skin clean. others. cerebellar function and reflexes are normal . sensory. smiles/ frown appropriately Speech is clear with moderate pace Expresses feelings appropriate to situation Expresses good feelings about self.  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. aware of self 17 Posture. and life. gait.

It’s her first time to undergone childbirth process. edema and 18 . LMP= May 14. 2008 EDC= February 21..    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. 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. P. Delivered via vaginal delivery First menstruation at the age of 12.

Skin edges met as an approximation of the episiotomy     Lochia rubra. earthly odor Discharge amount is moderate Used 4-5 pads in one day Discharge gradually decreases in amount 19 . red in color and compose mainly of blood.generalized tenderness. mucoid.

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

The hair of eyelashes and eyebrows helps keep dust and perspiration out of the eyes. Any other hair on our bodies no longer serves a function. • The integumentary system consists of the skin and accessory structures such as hair. Nails protect the tips of fingers and toes from mechanical injury. Mammary glands produce milk. Ceruminous glands.A major function of the subcutaneous tissue is to connect the skin to underlying tissues such as muscles. and the hair in our nostrils helps keep dust out of the nasal cavities. and Mammary glands. Sebaceous glands are oil producing glands which help inhibit bacteria. keep us waterproof and prevent our hair and skin from drying out. Sebaceous glands. nails and glands Skin 21 . Fingernails give the fingers greater ability to pick up small objects. but is an evolutionary remnant. Sudoriferous glands are sweat producing glands. Hair on the scalp provides insulation from cold for the head. There are four types of glands in the integumentary system: Sudoriferous glands. These are important to help maintain body temperature. Ceruminous glands produce earwax which keeps the outer surface of the eardrum pliable and prevents drying.

Regulation of body temperature 2. The skin is composed of three principal parts: o  Epidermis  The epidermis is composed of stratified squamous epithelium and is separated from the dermis by a thin basement membrane. The seven chief functions of the skin are as follow: 1.• Functions o o Skin is extremely important to normal physiologic function secondary to the roles that it plays in maintaining homeostasis. Synthesis of vitamin D • Structure o Skin is the largest organ of the body.3-4. Blood reservoir 7.0 mm depending on the location on the body. In adults. Protection 3. 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. Immunity 6. Sensation 4. 22 . Excretion 5.

Therefore. 23 . Langerhans cells. The epidermis is not as thick as the dermis and varies in thickness from approximately 0.5 mm on the palms of the hands and soles of the feet. These cells produce a group of pigments known as melanin which are responsible for skin. Melanocytes. all gases.  There are four principal cells that compose the epidermis.These cells arise from the bone marrow and migrate to the epidermis. Merkel cells.3 mm on the eyelids to 1. 3.Comprise approximately 90% of all epidermal cells. The epidermis is an avascular structure. These cells produce a protein mixture known as keratin which helps waterproof and protect the skin. 4. Keratinocytes.Comprise approximately 8% of all epidermal cells. 2. hair and eye color.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. nutrients and waste products must diffuse to & from the capillaries located in the dermis. These cells are as follow: 1. These cells play an important role in the immune response.

Stratum lucidum 5. Stratum basale 2. Stratum corneum 24 . Stratum spinosum 3. Stratum granulosum 4.The epidermis is composed of five layers or strata. These layers from the deepest to the most superficial are: 1.

glands and lymphatic vessels all extend into the dermis. irregular connective tissue. Dermal Layers The dermis can be divided into two indistinct layer: 1. nerve endings. Dermis    The dermis is composed of dense. The dermis varies in its thickness from less than 1 to 4 mm thick. hair follicles. Reticular layer 2. Blood vessels. Papillary layer 25 . smooth muscle.

26 . The primary unction of hair is protection. The hypodermis consist mostly of connective tissue and adipose cells. 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. As much as one half of the body's stored fat is located in the hypodermis   Hair • • Hair develops from the embryonic epidermis.

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. 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. • 27 . The base of the root is expanded and is known as the hair bulb.

Nails 28 .

Also known as the cuticle. Free edge. 29 . 2.Nail Structure • • Nails are plates of hard. 2. Nail body. tightly packed keratinized cells of epidermis. Lunula. Eponychium.The whitish semilunar area of the proximal end of the nail body. Nail matrix.The aspect of the nail that may extend past the distal end of the digit.The visible portion of the nail.Epithelial tissue deep to the nail root where actual nail growth occurs. 3. This is a narrow band of epidermis which extends from the lateral border of the nail wall.The aspect of the nail that is buried underneath a fold of skin. • Nail root. Nails are composed of three principal parts: 1. Other structures associated with the nail include: 1.

nails also provide protection against trauma to the distal ends of the digits. nails allow us to grasp and manipulate small objects. 30 . These glands produce an oily. Glands • The two major glands of the skin are the sebaceous and sweat glands.Nail Function • Functionally. o Sebaceous glands   Sebaceous glands are located in the dermis and are usually connected to hair follicles. white substance known as sebum which oils the hair and skin and thus prevents drying and also provides protection against some bacteria. In addition.

  Apocrine Sweat Glands   Blood Supply • • • Blood supply to the skin is limited to the capillary plexus of the dermis & hypodermis. eccrine & apocrine. on the eyelids and on the genitalia. genitalia and around the anus. These glands are typically found in the axillae. o Sebaceous glands are located on the lips. are the most common type of sweat glands. based on their structure and location. Eccrine glands are most numerous on the palms of the hands & the soles of the feet. There are approximately 3 to 4 million sweat glands in the human body. These sweat glands are composed of simple coiled tubular glands that opens directly onto the surface of the skin through sweat pores. also known as merocrine sweat glands. Sweat glands are typically divided into two types.  Sweat glands   Eccrine Sweat Glands   Eccrine sweat glands. 31 . Lymphatic vessels of the skin arise in the dermis and drain into larger hypodermic branches. A subcapillary network of veins drains the capillary system. Apocrine sweat glands are composed of compound coiled tubular glands that usually opens into hair follicles superficial to the opening of sebaceous glands.

In the human reproductive process. Reproduction — the process by which organisms make more organisms like themselves — is one of the things that sets living things apart from nonliving matter. or gametes. The genes that parents pass along to their children are what make children similar to others in their family. Both the male and female reproductive systems are essential for reproduction. But even though the reproductive system is essential to keeping a species alive. are involved. like other organisms. The male gamete. The female needs a male to fertilize her egg. 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 32 . and the female gamete. These genes come from the male's sperm and the female's egg. it's not essential to keeping an individual alive. or sperm. meet in the female's reproductive system to create a new individual. the egg or ovum. even though it is she who carries offspring through pregnancy and childbirth.THE FEMALE REPRODUCTIVE SYSTEM All living things reproduce. pass certain characteristics of themselves to the next generation through their genes. 2 kinds of sex cells. which are produced by the male and female reproductive systems. unlike other body systems. Humans. but they are also what make each child unique. the special carriers of human traits.

• • give birth allows passage of the menstrual flow 33 .

Latin for "hill of Venus" is the pad of fat that covers the pubic bone below the abdomen but above the labia.FEMALE EXTERNAL GENITALIA The external female genitals are collectively referred to as 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. Labia Minora 34 . 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. The mons is one of the sexually sensitive zones in women and protects the pubic bone from the impact of sexual intercourse. All of the words below are part of the vulva.

Clitoris The clitoris. a covering of tissue similar to the labia minora. or female prepuce. Urethra The opening to the urethra is just below the clitoris.The labia minora are the inner lips of the vulva. but the glands are not usually visible. Bartholin’s glands themselves are situated more towards the inside. The clitoris is protected by the clitoral hood. Just behind it on either side can sometimes be seen the openings of the para urethral or Skene’s glands. Both the inner and outer labia are quite sensitive to touch and pressure. 35 . but is instead the passage for urine. The openings of Bartholin’s glands are located towards the back on either side of the vaginal opening. and clitoris. visible in picture as the small white oval at the top of the labia minora. The opening of the urethra (urethral meatus) opens into the vestibule between the clitoris and vagina. is a small body of spongy tissue that is highly sexually sensitive. thin stretches of tissue within the labia majora that fold and protect the vagina. urethra. It is not related to sex or reproduction.

and this is apparently natural. Normally hymen. women should always wipe themselves from front to back to avoid infecting the vagina and urethra with bacteria. is a membrane that partially covers the opening. The perineum in women often tears during birth to accommodate passage of the child.The urethra is connected to the bladder. 36 . although being a very thin membrane. From top to bottom can be clearly seen the clitoris. The hymen is the traditional "symbol" of virginity. Because the urethra is so close to the anus. it can be torn by vigorous exercise or the insertion of a tampon. 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. Perineum The perineum is the short stretch of skin starting at the bottom of the vulva and extending to the anus. Vagina and Hymen The above illustrations show the area between the labia minora. urethral opening. and vaginal opening.

possibly four in women who have given birth. After intercourse. the contraction of the vagina will allow the cervix to rest inside the fornix.the opening to the uterus. 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.Vagina | Cervix | Uterus | Ovaries | Fallopian Tube | Vagina The vagina extends from the vaginal opening to the cervix . and is the birth canal through which the baby passes during labor. which in its relaxed state is a bowl-shaped fitting perfect for the pooling of semen. This may seem short in relation to the penis. The vagina receives the penis during sexual intercourse. 37 . The average vaginal canal is three inches long.

apparently to keep the inner labia moist during periods of sexual excitement. estrogen is responsible for development and maintenance of all secondary sex characters such as breast. Further within are the hymen glands. fallopian tubes. The uterus is lined with powerful muscles to push the child out during labor. and sheds a layer at the end of every menstrual cycle if fertilization does not happen. 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. 38 . shape of the body. is the main female internal reproductive organ. or womb. or eggs every month after puberty. Of the two female hormones produced by the ovaries. during ovulation. which produce small amounts of lubricating fluid. Uterus The uterus. The cervix is sometimes plugged with cervical mucous to protect the cervix from infection. and maturity of the reproductive organs such as vagina. which secrete lubricant for the length of the vaginal canal. uterus. etc.At either side of the vaginal opening are the Bartholin's glands. It varies in diameter from 1 to 3 millimeters. Cervix The cervix is the opening to the uterus. which grows and changes during the menstrual cycle to prepare to receive a fertilized egg. The inner lining of the uterus is called the endometrium. this mucous becomes a thin fluid to permit the passage of sperm. and the production of mature ova. depending upon the time in the menstrual cycle the measurement is taken.

the ovaries contain nearly 400. since during an average lifespan she will go through about 500 menstrual cycles. and those are all she will ever have. High progesterone levels suppress menstruation. a journey of three or four days-. the single egg travels down the fallopian tube. At birth. Even if there is no damage to the premature eggs in the uterus.000 ova. However. They are not directly connected to the ovaries but its end widens into a wide flower like opening that lies adjacent to the ovary.Progesterone is produced after the ovum has been released. 39 . those that are released after the age of thirty-five years are "old" and therefore the risk of congenital abnormalities increases. Eggs that are not fertilized are expelled during menstruation along with the inner layer of uterus. It is essential for maintenance of pregnancy and is responsible for regular menstruation and maintaining normal menstrual flow. that is far more than she will need. The tube is about 4" long and hang freely in the pelvic cavity. 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. Fallopian Tube Fallopian tube is the duct through which the egg must pass to reach the uterus.this is the period during which a woman is fertile and pregnancy may occur.

and the hindbrain. This amazing organ acts as a control center by receiving. producing and understanding language. There are three major divisions of the brain. They are the forebrain. and controlling motor function. perceiving. Anatomy of the Brain: Brain Divisions The forebrain is responsible for a variety of functions including receiving and processing sensory information. and directing sensory information throughout the body. interpreting.THE BRAIN The anatomy of the brain is complex due its intricate structure and function. thinking. There are two major divisions of forebrain: the diencephalon and the 40 . the midbrain.

and controlling autonomic functions. These regions assists in maintaining balance and equilibrium. The metencephalon contains structures such as the pons and cerebellum. the cerebral cortex. heart rate. The diencephalon contains structures such as the thalamus and hypothalamus which are responsible for such functions as motor control.telencephalon. relaying sensory information. • • Prosencephalon . and the conduction of sensory information.Forebrain Mesencephalon . The myelencephalon is composed of the medulla oblongata which is responsible for controlling such autonomic functions as breathing. The hindbrain extends from the spinal cord and is composed of the metencephalon and myelencephalon.Hindbrain   41 . This region of the brain is involved in auditory and visual responses as well as motor function. movement coordination. and digestion.Midbrain   Diencephalon Telencephalon Metencephalon Myelencephalon • Rhombencephalon . The telencephalon contains the largest part of the brain. Most of the actual information processing in the brain takes place in the cerebral cortex. The midbrain is the portion of the brainstem that connects the hindbrain and the forebrain. The midbrain and the hindbrain together make up the brainstem.

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

• •

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


• •

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

• •

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


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 .receives sensory information from the olfactory bulb and is involved in the identification of odors Thalamus .• • Olfactory Cortex .

• 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). 46 .

produces cerebrospinal fluid Fourth Ventricle . and the cerebellum Lateral Ventricle .canal that is located between the third ventricle and the fourth ventricle Choroid Plexus .canal that runs between the pons.provides a pathway for cerebrospinal fluid to flow Wernicke's Area • Region of the brain where spoken language is understood 47 .largest of the ventricles and located in both brain hemispheres Third Ventricle .connecting system of internal brain cavities filled with cerebrospinal fluid • • • • • Aqueduct of Sylvius . medulla oblongata.Ventricular System .

Facial area – The facial area is made up of fourteen separate bones. The frontal bone is fused with the parietal bones at the top.This is the rounded area that houses and protects the brain.THE HUMAN SKULL The entire framework of the human body is known as the skeleton. cheeks and nasal area. 2. the upper orbit of the eye and the forward parts of the cranium. Frontal bone-The frontal bone is the one that comprises the forehead. 2. It is made up of two primary groups of bones. Cranium. 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. The eight bones that make up the cranium are: 1. Appendicular skeleton – This is the group of bones that make up the body’s extremities (arms and legs). The frontal bone also contains two air spaces that are called sinuses. maxilla and nasal bones. the sphenoid bones. Axial skeleton – This group of bones are the ones that make up the head and actual trunk of the body. which include those that make up the jaws. It is comprised of eight distinct bones that are fused together in an adult. 48 . 1.

temporal and occipital bones. 3. They are fused down the middle at the top of the skull. Zygomatic-There are two zygomatic bones and they sit on either side of the skull and comprise the higher area of the cheek. Parietal bones. It also forms a part of the frontal floor area of the cranium. 49 . Sphenoid bone-There are two sphenoid bones and they sit behind the eyes and run back towards the temporal bones. In addition to the frontal bones. the parietal bones are also fused to the sphenoid. 6.There is only one ethmoid bone and it has a different consistency that the other bones in the head. The temporal bones also hold the mastoid sinuses as well as parts of the ears. Occipital bone-There is only one occipital bone. 2. Maxillae – There are two maxillae bones. spongy bone that is located between the eyes. there are two distinct temporal bones. Vomer-There is only one vomer bone and it is what forms the lower portion of the nasal septum. the ethmoid bone is a delicate. 3. 4. 4. Where they are hard and dense. The facial bones include: 1. central sides of the skull. Ethmoid bone. These bones are what form the lower. It forms the back base of the skull. Mandible. Lacrimal bones. 5.2. They are what comprise the upper jaw and each one of them contains a large “maxillary” sinus. Temporal bones-Like the parietal bones.There are two small lacrimal bones that sit at the inside corner of each eye.There are two parietal bones which form the largest portion of the top and sides of the cranium.The mandible (lower jaw) is the only moveable bone in the skull. 5.

In addition to the previous bones. The “handle” part attaches to the tympanic membrane and the “head” portion attaches to the incus. These are joined in such a way as to amplify the sound waves received by the eardrum (tympanic membrane).Often called the hammer are the two malleus bones (one in each ear). Stapes.They are the first bones in the inner ear and appear similar in shape to a hammer. Encased within the temporal bones are the six auditory ossicles of the middle ear. and assist in the warming and moistening of air drawn in through the nasal cavities. which also lines the large airways. a protective vault of bone surrounding the brain and brain stem. which are air-filled cavities lined with respiratory epithelium. 1. 50 . is usually not considered as part of the skull. 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 fact. Malleus.6. Fourteen bones form the splanchnocranium.The nasal bones are a pair of small. as it is the only bone that does not articulate with other bones of the skull. slender bones that support the actual bridge of the nose. The exact functions of the sinuses are debatable. 3. supporting the larynx. Components Eight bones form the neurocranium (brain case). Incus-The incus is also called the anvil and it is the middle of the three bones. 2.The stapes is the innermost bone and it appears very similar to a tiny stirrup. they contribute to lessening the weight of the skull with a minimal reduction in strength. The hyoid bone. the stapes is often called the stirrup. there are six tiny bones (three pairs) called ossicles that are located in the ears. they contribute to resonance of the voice. The skull also contains the sinus cavities. Nasal bones. which comprises the bones supporting the face.

it is a "soft spot" on a baby's forehead. sagittal suture. there can be raised 51 . the skull is one of the most durable substances found in nature. of head injury. At birth these regions are fibrous and moveable. The bones of the roof of the skull are initially separated by regions of dense connective tissue called "cranial sutures".Development of the skull The skull is a complex structure. As growth and ossification progress. many of these bony elements gradually fuse together into solid bone (for example. At birth. The bones of the splanchnocranium (face) and the sides and roof of the neurocranium are formed by intramembranous (or dermal) ossification. temporal. sphenoid. and squamosal suture. The six fontanelles are: the anterior fontanelle. however. As growth occurs. Larger regions of connective tissue where multiple sutures meet are called fontanelles. the human skull is made up of 404 separate bony elements." which is where the squamous and lateral parts of the occipital bone meet. Pathology If the brain is bruised or injured it can be life-threatening. the posterior fontanelle. lambdoid suture. but the anterior fontanelle can remain open up to eighteen months. There are five sutures: the frontal suture. In some cases. and ethmoid) are largely formed by endochondral ossification. its bones are formed both by intramembranous and endochondral ossification. necessary for birth and later growth. and the two mastoid fontanelles. coronal suture. the two sphenoid fontanelles. Normally the skull protects the brain from damage through its hard unyieldingness. The posterior fontanelle usually closes by eight weeks. the frontal bone). the connective tissue of the fontanelles is invaded and replaced by bone. This growth can put a large amount of tension on the "obstetrical hinge. while the bones supporting the brain (the occipital. The anterior fontanelle is located at the junction of the frontal and parietal bones. A possible complication of this tension is rupture of the great cerebral vein of Galen. 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.

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. inferior-superior. These two sutures generally form a right angle with one another. 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. medial. The parietals articulate with each other by way of the Mid-Sagittal Suture. the parietals articulate with the Occipital Bone by way of 52 . 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. Externally. as a left or right. each possess a Superior. Posteriorly. posterior-anterior.. to which the temporal muscle is attached. and Inferior Temporal Line. This is why patients with concussion must be watched extremely carefully.e. this can result in significant brain damage or death unless an urgent operation is performed to relieve the pressure. but also permit its exact location and orientation in the body to be determined (i. and with the frontal bone anteriorly by way of the Coronal Suture.). etc.intracranial pressure through mechanisms such as a subdural haematoma. The Parietal Bones The Parietals are paired left and right.lateral.

and Inferior Nuchal Lines to which the muscles at the back of the neck are attached. Slightly posterior to the eminence there may be a Parietal Foramen. The External Occipital Protuberance lies on the superior nuchal line in the mid-sagittal plain. Running inferior from the eminence to the foramen magnum is the Internal 53 . Among the sutures the Lambdoid is by far more serrated than either the Sagittal or the Coronal. Externally. Internally. or grooves which converge at the Confluence of Sinuses. The intersection of the Lambdoid and Sagittal Sutures approximate a 120 degree angle on each of the parietals and the occipital bone. The occipital condyles articulate with the first cervical vertebrae (the Atlas). On the external surface near the center of the bone is the Parietal Eminence. 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. Middle. A single internal Occipital Protuberance or Cruciform Eminence is also found in this area.the Lambdoid Suture. Inferiorly the Parietal articulates with the temporal bone by way of the Squamosal and Parieto-Mastoid Sutures. The Occipital Bone The Occipital Bone consists of a large squamous. the squamous portion of the bone possesses Superior. Lateral to each occipital condyle are the Condylar Fossae and Foramen while the Hypoglossal Canal is medial to them. are the Sagittal and Transverse Sulci.

On the external surface the squamous portion frequently possesses a left and right Frontal Eminence.e. The transverse sulci assist in directing the developing jugular vein to the Jugular Notch on either side of the basilar portion of the occipital. a vertical squamous portion which articulates with the paired parietals along the Coronal Suture and forms the forehead. In early hominids these ridges formed a Torus or large shelf-like process protruding from above the eyes.Occipital Crest which separates the Cerebellar Fossae. 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. which contribute to the ceiling and lateral walls of the left and right eye orbits. is the Frontal Sinus.. the bone possesses two SupraOrbital Ridges (i. and two orbital plates. Additionally. Superciliary or Brow Ridges) which are bumps above each of the eye orbits. The Frontal Bone The frontal bone may be divided into two main portions. The left and right Frontal 54 . With in the bone. and above and the metopic suture. In early life the metopic suture divided the frontal bone into left and right halfs.

Like the sphenoid. and provides the anterior origin of the Temporal Line to which the left and right temporal muscle is attached. the Ethmoid is the second most difficult. the olfactory nerves. it is a single bone that runs through the mid-sagittal plane and aids to connect the cranial skeleton to the facial skeleton.. or Cocks Comb.Crest. It assists in dividing the left and right frontal lobes of the brain. begins at each Zygomatic Process of the frontal bone. found within the cranium. The most superior projection is the Crista Galli. It has a number of features and projections.e. It consists of various plates and paired projections. The nerves brachiate through the porosity of these plates into the nasal cavity below. Lateral projections from the Crista Galli are the left and right Cribriform Plates which in life cradle the first cranial nerves i. but unlike the sphenoid it cannot be seen from various views of the skull. Directly inferior to the 55 . The Ethmoid If the sphenoid is the most difficult cranial bone to describe and invision.

These projections. assist in increasing the surface area within the nasal cavity and thereby the exposure of the brachiating olfactory nerve to inhaled odors. The Sphenoid 56 . like the separate Inferior Nasal Concha. 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. and cannot be viewed through the anterior nasal opening because it is blocked from view by the the more inferior Middle Nasal Conche.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. Each Orbital Plate is rectangular in shape and gives rise to two medial projections. The Superor or Supreme Nasal Conche are smaller. the Superior and Middle Nasal Concha.

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. or trigeminal. The smaller lesser wings posssesses the Optic Foramen through which the optic or second cranial nerve passes before giving rise to the eye. which transmits the the mandibular branch of the same nerve.The Sphenoid is one of the more difficult bones to describe and invision. The Temporal 57 . the Foramen Spinosum which transmits the middle meningial vessels and nerve to the tissues covering the brain. It consists of a hollow body. Just inferior to the supra-orbital fissure near the body of the sphenoid. which allow it to be seen from various views of the skull. Internally upon the body is the Sella Turcica where the pituitary gland rests in life. and the most inferior projecting Pterygoid Processes. The left and right greater wings assist in forming the posterior wall of each of the eye orbits where it forms an Orbital Plate. More posteriorly is the smallest of the three pairs of foramena. cranial nerve. It is a single bone that runs thrugh the mid-sagittal plane and aids to connect the cranial skeleton to the facial skeleton. which contians the Sphenoidal Sinus. Each of these wings also possesses a much larger Foramen Ovale more laterally. 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. each of the greater wings also possess a Foramen Rotundum which in life transmits the maxillary branch of the fifth. It has a number of features and projections. the intermediate Greater Wings. and three pairs of projections: the more superior Lesser Wings.

The squamous portion assists in forming the Squamous Suture which separates the temporal bone from the adjacent and partially underlaying parietal bone. the Squamous Portion. 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.The Temporal Bone is another paired cranial bone which is difficult to describe due to its various features. which is flat or fan-like and projects superiorly from the other. Anterior to the external meatus the Zygomatic Process has its origin. This portion projects anterior and medialy beneath the skull. This process projects forward toward the face and its articulation with the temporal process of the zygomatic. It consists of two major portions. Posterior to the external auditory meatus is the inferiorly projecting Mastoid Process which serves as an attachment for the sternocleidomasotid muscle. Incas and Stapes. and projections. 58 . Projecting inferiorly from the petrosal portion is the slender Styloid Process which is of variable length. Above the mastoid process is the Supramastoid Crest to which the posterior portion of the temporal muscle is attached. the Petrosal Portion. Externaly the petrosal portion possesses the External Auditory Meatus while internally there is an Internal Auditory Meatus. the Malleus. The styloid process serves as a muscle attachment for various thin muscles to the tongue and other structures in the throat. The petrosal portion contains the cavity of the middle ear and all the ear ossicles. very thick and rugged portion.

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

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. use a moist towel to help keep your lips and mouth wet. and may feel the need to concentrate on the process at hand. 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. showers. The cervix is really beginning to open up and you may hear the medical team say you are 4 to 7 centimeters along. During this stage of labor the contractions are stronger. The baby is applying pressure to the mother's bottom area and you may have an overwhelming desire to push against that 60 . and your cervix will become fully dilated to 10 centimeters. vocalization.around. take a warm shower or bath. giving you a back massage. The support person can continue to provide encouragement. massage. Usually you can't talk or walk during contractions. 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. Your support person can participate by keeping you company. such as relaxation. positioning. Women say that during this stage of labor they may feel stronger and longer contractions. longer and less than five minutes apart. To cope with this stage of labour: • • • • use coping techniques. Remember that the goal is 10 centimeters. or engage in breathing patterns to relax. more back pain. taking your cues on how to help. more rapid dilation occurs. and provide comfort measures such as massage or music. It is during this time that the baby is actively trying to get in position to be born. Active Labor — As you progress to Active labor. offering words of encouragement. Transition Phrase — As you enter the Transition phase. the contractions are more intense.

use breathing patterns and your support person to help you through the feelings of pressure and discomfort. Take one contraction at a time. Women go through many emotional moments during the Transition phase of labor including even a desire to go home. Do not push until the medical team instructs you to do so. 61 . 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.pressure. with little time between them. you may experience long. During some labours. strong contractions. During this stage of labor. Communication about what you want and need is important. 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. and remember that the baby is almost here. If it is necessary for you to stop pushing. You may feel an urge to push at the height of each contraction. having your partner provide a steady pressure on your lower back may help.

Many women get a "second wind" prior to delivery to help them get through this second stage of labor. 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. Panting or blowing to avoid pushing during the birth of the head can mean less straining and tearing. Your medical team will help guide you through the process of pushing and successfully delivering your baby. savor the moment. your body will help you. try to rest between contractions and save your strength for pushing the baby out during the contractions. During this time: • • • • • Allow yourself time to learn how to push. After the head emerges. for you will only get that once in a lifetime with each child you deliver. 62 . and help you focus on your breathing. The contractions get further apart and then closer together again. Although it may be difficult to do. you may feel a stinging sensation as the baby's head reaches the vaginal opening. If you are not using an anesthetic. you may experience a lot of pressure in your bottom area. continue to offer encouragement. You should push as you feel the urge. You may be dozy and unfocused between contractions.STAGE II (Delivery of the Baby) As you move to Stage II. the baby rotates and the shoulders and the body are born. As the baby begins to move down the birth canal. Once your baby is born. Establish your own pushing pattern. Your support person can help you find the most comfortable position. you may feel a renewed burst of energy. Work with your nurse or midwife to help determine the best possible position. The cervix has now fully dilated to 10 centimetres.

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. 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. your physician will do the repair. During this stage. At the same time. suction the nose and mouth. You will have more contractions as the placenta comes out and afterwards. usually within 20 minutes of the delivery of the baby. your baby's medical team will clean your baby. Your physician will examine your vagina and perineum. The placenta emerges and the cord is clamped and cut. They will also assign the baby scores called APGAR scores which assess the baby's overall status after birth. You may have some bleeding. Uterine contractions will help expel the placenta. you may wish to • • • • • cut the cord hold your new baby. If you have some tears. chills or exhaustion. and keep the baby warm. with help if necessary talk to the baby – your voice will be familiar offer your breast when ready relax and recover 63 . You may feel shaky but you may also have a renewed burst of energy. You may feel very emotional at this time.

Enjoy every minute of your new beginning together. Often. and get some rest as you will need all your strength to help you love and care for your new baby. and movement). the brain lacks part or all of the cerebrum (the area of the brain that is responsible for thinking. Give yourself a big hug for a job well done. but in the end so rewarding. 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. 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. the lack of a functioning cerebrum permanently rules out the possibility of ever gaining consciousness. vision.You did it! Congratulations! The work was hard. Reflex actions such as breathing and responses to sound or touch may occur. and unable to feel pain. hearing. The joy of being a parent is exhilarating and exhausting. Although some individuals with anencephaly may be born with a main brain stem. Anencephaly results in only minimal development of the brain. deaf. Mortality/Morbidity 64 . 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. touch. unconscious.

Age Anencephaly is determined by the 28th day of conception and is therefore invariably present at the time of birth. death of the neonate is unavoidable. Race Hispanic and non-Hispanic whites are affected more frequently than women of African descent. implicating multiple genes interacting with environmental agents and chance events.• • Anencephaly is lethal in all cases because of the severe brain malformation that is present. The vast majority of isolated anencephaly cases are multifactorial in their inheritance pattern. Sex Females are affected more frequently than males. What causes anencephaly? Anencephaly is usually an isolated birth defect and not associated with other malformations or anomalies. 65 . Prognosis • The prognosis is exceptionally poor. A significant proportion of all anencephalic fetuses are stillborn or are aborted spontaneously.

and other antimetabolites of folic acid have been shown to increase the chance of an NTD when exposure occurs in early development. pregnant women should avoid hot tubs and other environments that may induce transient hyperthermia. • Maternal type 1. while gestational diabetes does not appear to be associated with any significant increase in NTD risk. While these induced NTDs are usually spina bifida. • Maternal hyperthermia has been associated with an increased risk for NTD. In these cases. anencephaly. Such families may have children or fetuses with spina bifida. and it also delays production of alpha-fetoprotein (AFP) during pregnancy.• Adequate folic acid consumption during pregnancy is protective against anencephaly. • Valproic acid. Presumably. • Anencephaly may be associated with the unbalanced form of a structural chromosome abnormality in some families. 66 . Maternal serum AFP is used as a screening test to detect NTDs. wellcontrolled IDDM confers a lower risk for NTDs. The degree of diabetic control is generally monitored using hemoglobin A1c levels. reproduction is clearly only possible for the individuals with spina bifida since death occurs early in the life of individuals with anencephaly. 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. therefore. the chance of anencephaly is probably increased as well. other malformations and birth defects that are not usually found in isolated cases of anencephaly may be present. rare cases of NTDs are transmitted in an autosomal dominant or autosomal recessive manner in certain families. an anticonvulsant. 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. Similarly. and adjustment of the expected values for AFP in maternal serum must be made if the patient is known to have IDDM. In families with a pedigree suggestive of autosomal dominant inheritance. or other subtypes of NTDs. or pregestational insulin-dependent diabetes mellitus (IDDM) confers a significant increase in the risk for NTDs.

Folding of the ear. including the structures of the head and brain. • • Some basic reflexes. Cleft palate . but without the cerebrum. each child may experience symptoms differently. Congenital heart defects. This can cause disruption of normally formed tissues during development. in which the roof of the child's mouth does not completely close. • • • Missing bones around the front and sides of the head. Anencephaly caused by amniotic band disruption sequence is frequently distinguishable by the presence of remnants of the amniotic membrane.Amniotic band disruption sequence is a condition resulting from rupture of the amniotic membranes. there can be no consciousness and the baby cannot survive.a condition. Always consult your child's physician for a diagnosis. However. The symptoms of anencephaly may resemble other problems or medical conditions. Symptoms may include: • Absence of bony covering over the back of the head. leaving an opening that can extend into the nasal cavity. Complications 67 . 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.

The rate of abnormal fetal presentations during delivery is increased in these pregnancies.) . and to assess blood • • 68 . multiple fetuses. Polyhydramnios is a common complication during pregnancy. Abnormal levels of alpha-fetoprotein may indicate brain or spinal cord defects. Risk of preterm labor is increased. a miscalculated due date.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. Labor may need to be induced in these cases.a protein produced by the fetus that is excreted into the amniotic fluid. Amniocentesis .• • Anencephaly is uniformly fatal. and organs. and patients may experience significant discomfort from the abdominal distention that accompanies this condition. tissues. the risk of the pregnancy progressing into the postterm period is significant. Ultrasounds are used to view internal organs as they function.a diagnostic imaging technique that uses high-frequency sound waves and a computer to create images of blood vessels. The baby's head often appears flattened due to the abnormal brain development and missing bones of the skull. • • • How is anencephaly diagnosed? The diagnosis of anencephaly may be made during pregnancy or at birth by physical examination. spontaneous precipitation of labor may be delayed. or chromosomal disorders. Because the pituitary gland may be absent in persons with anencephaly. Diagnostic tests performed during pregnancy to evaluate the baby for anencephaly include the following: • Alpha-fetoprotein . Ultrasound (Also called sonography. therefore.

Medical Care Because anencephaly is a lethal condition. The presence of family. and this may help to dispel mental pictures. direct personal contact with the baby may help the parents to actualize the medical information they have been given and may help in 69 . approximately 75 percent of infants are stillborn and the remaining 25 percent of babies die within a few hours. heroic measures to extend the life of the infant are contraindicated. days. or weeks after delivery. • Families often want to hold the baby after delivery. A cap or head covering of some sort is useful to minimize the visual impact of the malformation. friends. or clergy may be helpful in many cases. 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. even if the baby is stillborn. Care will be aimed at providing emotional support to the family. and families wanting photographs of the baby with the family are not unusual. Some families want to see the lesion. In most cases. which are often worse than the actual malformations. • Blood tests Treatment of the newborn with anencephaly There is no medical treatment for anencephaly. but they also will need adequate time to grieve and come to closure. 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. Due to the lack of development of the brain.flow through various vessels. • 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.

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. failure to progress. • • Families commonly inquire about organ donation after the diagnosis of 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. screening. For couples who elect to continue the pregnancy. a genetic counselor should be consulted prenatally and should remain involved. Ideally. Diet 70 . and diagnostic testing options for future pregnancies and to assess the family history. the option of pregnancy termination should be presented to the couple. as needed. • • If parents have chosen a name for the baby. The involvement of genetic counselors. oligohydramnios. if available.the process of grief resolution. This cannot practically be arranged without crossing the lines of ethical care. prevention. Patients should be affirmed in their desires to see something meaningful come from the tragedy of having a pregnancy affected with anencephaly. and delayed onset of labor beyond term also should be discussed. Feelings of guilt are normal responses of parents of a baby with serious birth defects. they may be comforted if the doctor refers to the baby by name. With timely prenatal diagnosis of this lethal disorder. may be particularly useful to parents in this situation because of their experience in dealing with a wide range of birth defects. the possibilities of preterm labor. until the family comes to closure after the conclusion of the pregnancy.

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 has been shown to be an effective means of lowering recurrence risks for future pregnancies. however. 0.Folic acid supplementation and/or a folate-enriched diet prior to and during future pregnancies are recommended. For families with multiple occurrences of NTDs. but it is not enough to o o 71 . Obtaining enough folates from diet alone to effectively prevent recurrences in future pregnancies is extremely difficult. supplementation with 4 mg of folic acid daily is indicated. For women who desire pregnancy and have had a child with an NTD with their current partner. Medication Pharmaceutical interventions are not used in cases of anencephaly. In the United States. is 2-4% in subsequent pregnancies. recurrence risks may be higher and must be determined on a case-by-case basis. Follow-up Deterrence/Prevention • The recurrence risk for NTDs. in general. given that a couple has previously had one child with anencephaly or another isolated NTD. regardless of family history. the bioavailability of natural folates in foods is often lower than that of folic acid. wheat flour is fortified with a small amount of folic acid. Folic acid supplementation at these levels is estimated to prevent two thirds of both recurrent as well as occurrent (new) cases of NTD. beginning at least 3 months prior to conception. o For all other women and girls of reproductive age. Increased folate intake also may be achieved through the diet.

Consultation with a genetic counselor may be helpful. • • Prenatal ultrasound and amniocentesis should be offered to any couple with a prior pregnancy affected with an NTD. • Families may wish to participate in one of several ongoing studies of anencephaly or NTDs as a part of the healing process. and the early gestational age at which neural tube development occurs. A number of resources may assist families who are dealing with the loss of a child with anencephaly. Supportive care should be provided for families. 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. in order to establish this practice before entering the childbearing years. Contact the SBAA at (800) 621-3141. o Because of the large number of pregnancies that are not actively planned. pregnancy termination is the only intervention available to prevent the birth of a child with anencephaly that has been diagnosed prenatally. 72 . folate supplementation should be encouraged for all girls. • Anencephaly cannot be treated in utero. Patient Education • • • Parents of babies with anencephaly should be educated about preventive measures for future pregnancies. thus. such screening is appropriate for all pregnant patients and should not be reserved only for those with a positive history. irrespective of the option they choose.achieve maximal preventive benefits against NTD for a woman with an average diet. Since 90-95% of NTDs occur in families without a positive history. beginning at puberty. These include the Spina Bifida Association of America (SBAA) and the March of Dimes (MOD).

PATHOPYSIOLOGY Egg cell and sperm cell unite 73 .

mercury and nickel • Use of radiation. sulfonamides.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. 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 ½ weeks gestation) cranial portion closes 27th –29th (6 weeks gestation) Sacral end closes Neural tube fails to close 74 . salicylates.

after a few minutes.Absence of cranial vault and forebrain (cerebral hemispheres and isocortex). MEDICAL INTERVENTIONS A. midbrain and portions of midbrain are present ANENCEPHALIC FETUS Delivery Interventions: • Offer hydration. hours or days. 2009 RATIONALE 75 . TREATMENT TREATMENT DOCTOR’S ORDER March15. deaf and unconscious. and comfort measures • Artificial ventilation • Surgery • Drug therapy (antibiotics) Features/ signs of anencephaly: • Usually blind.flat.cleft lip or palate may be present.reduced thoracic volume DEATH.enlarged. nutrition.shortened due to low number of vertebrae of the cervical vertebrae • Chest . mouth. neck. unable to feel pain and with heart defects • Eyes-protrude. tongue. nose.

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.• IVF D5 LR +20 units oxytocin at 30-33 gtts/ min • To replace blood loss and provide salts needed to maintain electrolyte balance. To identify the blood type of the patient for future need of blood transfusion To prevent infection. exact mechanisms of action are not known. analgesics and antipyretic activities related to inhibition of prostaglandin synthesis. 76 . To determine the ABO blood group and Rh factor status. Opioid analgesics act by depressing pain impulse transmission at the spinal cord level by interacting with opioid receptors. To provide glucose. to relieve pain and to supply iron loss during delivery Anti-inflammatory. To determine urine composition & possible abnormal components or infection.

77 • DAT • • TPR . 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 client’s food intake Serves as a baseline data in the assessment of the client. then to bone marrow for incorporation into hemoglobin. transferring. Highly protein bound. fumarate contains 33% elemental iron. iron. energy • Multivitamins + Fe 1 cap BID and oxygen transport.• Bided immediately to carrier protein. 30%. ferrous sulfate exsiccated • To prevent and treat postpartum hemorrhage caused by uterine atony or subinvolution • To prevent infection. 20%. Replace iron stores needed for red blood cell development. Elevation or decrease in the vital signs measurement may indicate possible complications. utilization. gluconate 12%. sulfate.

and postpartal record • RATIONALE Identifies factors that place client in high risk category for development/ spread of postpartal infection 78 . intrapartal.NURSING INTERVENTIONS NURSING INTERVENTIONS Independent: • Review prenatal.

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 fowler’s 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


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 client’s 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.


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



LABORATORY TEST February 15, 2009 CBC • hemoglobin •




10.5 g %

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

WNL: do not indicate hemmorage or severe blood loss


32. 7 g %

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

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


10, 700 / 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




5-8 negative trace • • • • 1.straw amber clear • • WNL. the acidity and alkalinity of the urine is balance WNL.010-1.000 • 150-400T/cumm • WNL.• Eosinophil • 5 • 1-4% • Is not WNL and indicate. it means that the blood has the ability to clot URINALYSIS • • • • • • Color Transparenc y Specific gravity pH Glucose protein • • • 6 negative trace • • • 4.Eosinopenia a decrease in eosinophil number and Eosinophilia an increase in eosinophils • Platelet count • 199. there is no increased or decreased of the concentration of solutes in the urine WNL.035 • WNL. do not indicate DM WNL.010 • 1. there is no unusual findings in the appearance of the urine May indicate infection 84 . usually a trace of protein is found in urine as a waste product • • Light yellow hazy • • yellow.

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 DOCTOR’S 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. Increases motor activity of the uterus by direct stimulation of the smooth muscle. causing contraction decreased bleeding. vascular. 85 . INDICATION: To prevent and treat post partum hemorrhage cause by uterine atony and sub involution. shortening the third stage of labor and reducing blood loss. smooth muscle.

cardiac disease. pelvic inflammatory disease.DOSAGE: Adult: PO 200-400 ug q6-12 hours x 2-7 days. transient chest pain. Indication of labor before delivery of placenta. allergic reactions. and in patients with hypertension or toxemia.2 mg/ml CONTRAINDICATIONS: Contraindicated in pregnant patients. peripheral vascular disease. but many people have no. Available forms: Injection 0.2mg/ml in 1ml ampules. seizures CV: hypertension. or minor. respiratory disease. side effects. rash. tablet 0. dysrhythmias CVA. IM/IV 200 ug q2-2 hours for 1-5 days. in patients sensitive to ergot preparations. ADVERSE REACTION. vomiting EENT: tinnitus MUSCULOSKELETAL: Leg cramps RESPIRATORY: Dyspnea SKIN : sweating. hypertension. GI: Nausea. Check with your doctor if any of these most COMMON side effects persist or become bothersome: Nausea. CNS. dizziness. Seek medical attention right away if any of these SEVERE side effects occur: 86 . headache. Possible side effects of Methergine : All medicines may cause side effects. palpitations. vomiting. hypotension.

May cause vasospasm. lips. Discard if discolored. or I. hallucinations.O. 87 . Contractions may continue for up to 45 minutes after I. Use together cautiously.V. difficulty breathing. DRUG INTERACTIONS. Monitor contractions. Instruct patient to report adverse reaction promptly. or stomach pain. and uterine response. leading to ischemia.Severe allergic reactions (rash. NURSING CONSIDERATION: Monitor and record blood pressure. slow. seizure. nicotine May cause excessive vasoconstriction. severe or persistent headache. shortness of breath. which may begin immediately. itching. pulse rate. Explain the use and administration of drug to patient and family. Instruct patient to avoid smoking EVALUATION. Avoid using together. numbness or pain of an arm or leg. character and amount of vaginal bleeding. blood in the urine. light resistant container. face. sudden vision changes. USE. hives. or tongue). Store tablets in tightly closed. fainting.M. use or for 3 hours or more after P. chest pain or tightness. report sudden change in vital signs. frequent periods of uterine relaxation. severe abdominal cramps. Instruct patient to report increase blood loss. vomiting. IMPLEMENTATION. swelling of the mouth. or irregular heartbeat. fast. fever or foul-smelling lochia. tightness in the chest. Increase vasoconstrictions. dizziness. vasopressors.

abdominal pain. increase BUN. G I tract. 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. CONTRAINDICATIONS: Contraindicated in patients hypertensive to cephalosporin. HEMATOLOGIC: Neutropenia.(high doses) GI: Nausea. bone and joint infections and otitis media cause by Escherichia coli and other coli form bacteria. weakness. 25 to 50 mg/kg/day P. Use cautiously in breast feeding women and in patients with history of colitis or renal insufficiency. soft tissues. anorexia. dizziness. dose can be doubled. Leading to cell death by binding to cell wall membrane.Therapeutic response: absence of hemorrhage. bilirubin. GU: proteinuria. usually bactericidal. fever. 250mg to 1g P. INDICATION: Respiratory tract. bleeding. pain. seizures. pruritus. vomiting. chills. diarrhea. DOSSAGE: Adults.O. In severe infections.O. renal failure. ADVERSE REACTION: CNS: Headache. promoting osmotic instability. candidiasis. glossitis. Children. in two to four equally divided doses. q6h or 500mg q12h. skin. vaginitis. anemia 88 . heprotoxicity. paresthesia. Maximum 4g daily.

acids. Use probenecid for this effect. dermatitis RESPIRATORY: Dyspnea Possible side effects of Cephalexin Capsules: All medicines may cause side effects. but many people have no. furosemide. unusual vaginal pain. hallucinations. odor. or minor. probenecids Bleeding (cefamandole. Drug-food: any food. Avoid using together. Amino glycosides: May increase risk of nephrotoxicity. cefotetan) anticoagulants. unusual bruising or bleeding. tightness in the chest. loop diuretics. agitation. severe or bloody diarrhea. antiplatelets.INTEGUMENTARY: rash. yellowing of the eyes or skin. dizziness. red. stomach pain. or discharge. severe tiredness. side effects. or blistered skin. joint pain. NURSING CONSIDERATION. difficulty breathing. may increase absorption. NSAIDs. decreased urination. plimycin. Check with your doctor if any of these most COMMON side effects persist or become bothersome: Diarrhea. dark urine. ). confusion. cefmetazole. Drug-drug. Give drug with food. DRUG INTERACTION: Increase toxicity: amino glycosides. tiredness. severe stomach pain or cramps. urticaria. Seek medical attention right away if any of these SEVERE side effects occur: Severe allergic reactions (rash. thrombolytics. itching. seizures. valproic Increased effect/toxicity: amino glycosides. headache. probenecid. hives. fever. swollen. indigestion. swelling of the mouth. 89 . May increase cephalosporin level.

monitor patient for super infection. If large doses are given or if therapy is prolonged. Shake well after each addition. Tell patient to take drug exactly as prescribed. 90 . awaiting results. EVALUATION.Ask patient about past reaction to cephalosporin or penicillin therapy and obtain specimen for culture and sensitivity tests before giving. IMPLEMENTATION. Tell patient to notify prescribe if rash or signs and symptoms of super infection develop. To prepare oral suspension. Instruct patient not to drink alcohol or use of meds with alcohol: reaction may occur. even after he feels better. Treat group A beta-hemolytic streptococcal infections for a minimum of 10 days. especially if patient is high risk. Don’t confuse drug with other cephalosporin that sound alike. negative C&S. Instruct patient to take drug with food or milk to lessen GI discomfort. Keep tightly closed and shake well before using. add required amount of water to powder in two portions. After mixing store in refrigerator. Therapeutic response: decreased symptoms of infection. Instruct patient to use yogurt or buttermilk to maintain intestinal flora. Start therapy. If patient is taking suspension form. instruct her to shake container well before measuring dose and to store in refrigerator. Mixture will remain stable for 14 days. decreased diarrhea.

91 .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. Opioid analgesics act by depressing pain impulse transmission at the spinal cord level by interacting with opioid receptors. analgesics and antipyretic activities related to inhibition of prostaglandin synthesis. INDICATIONS.narcotic) DRUG ACTION: Anti-inflammatory. analgesic (non. Anti-inflammatory drug. Ponstel CLASSIFICATION. Products are divided into opiates and non opiates. Relief moderate pain when therapy will not exceed 1 week treatment of primary dysmenorrhea. exact mechanisms of action are not known.

O. ADVERSE REACTIONS. and renal . flatulence. P. Possible side effects of Mefenamic Acid : All medicines may cause side effects. aplastic anemia decrease hemoglobin or hematocrit. vomiting. Use cautiously in patients with long-term alcohol use because therapeutic doses cause hepatotoxicity in these patients. Neutrogena. GI pain. bleeding. Adults: 325-650 mg. headache. Dysuria. HEMATOLOGIC. rhinitis. Check with your doctor if any of these most COMMON side effects persist or become bothersome: 92 .DOSAGE. side effects. or two extended release caplets P. but many people have no. or 1g P.O.O. diarrhea. hepatic .O. insomnia. cardiovascular and GI conditions. don’t exceed 2. constipation. nausea. rash. dizziness. stomatitis. daily. dry mucous membranes. pharyngitis. of 4-6 hours.6g daily unless prescribed and monitored closely by health care provider. Use cautiously with allergies. peripheral edema. brochospasm. dyspepsia. TID or QID. or minor. q8h maximum 4g. tiredness GI. P. RESPIRATORY. For long-term therapy. thrombocytopenia. menorrhagia. eosinophilia. renal impairment DERMATOLOGIC. dyspnea. pancytopenia. Pregnancy and lactation. bone marrow depression. CONTRAINDICATIONS. fatigue. OTHERS. leucopenia. anaphylactoid reactions to fatal anaphylactic shock. prn . purities. gramlocytopenia. sweating. platelet inhibition with higher doses. CNS. GU. Contraindicated in patients hypersensitive to drug. hemoptysis.

Allergic reactions. fast or irregular heartbeat. numbness of an arm or leg. unusual joint or muscle pain. unusual bruising or bleeding. fainting.Constipation. gas. blistered. tarry stools. red. supportive therapy. hives. headache. urticaria. induction of emesis. dark urine. seizures. Seek medical attention right away if any of these SEVERE side effects occur: Severe allergic reactions (rash. vision or speech changes. fever. itching. depression. trouble breathing. one-sided weakness. severe headache or dizziness. be alert for urinary retention. antipsychotics. chills. Give with milk or food to decrease GI upset. or tongue). bloody or black. shortness of breath. change in the amount of urine produced. or feet. vomit that looks like coffee grounds. dysuria. Need for pain medication. swelling of hands. legs. frequency. confusion. or alcohol can increase CNS depression when taken with narcotics. nausea. rash. 93 . DRUG INTERACTIONS. Institute emergency procedures if overdose occurs. Barbiturates. I and O ratio. hypnotics. lips. ringing in the ears. unusual tiredness or weakness. swollen. dizziness. heartburn. other narcotics. sudden or unexplained weight gain. face. diarrhea. stomach upset. swelling of the mouth. or persistent sore throat. mental or mood changes. gastric laxage. NURSING CONSIDERATIONS. tightness in the chest. chest pain. yellowing of the skin or eyes. or peeling skin. use pain scoring. severe or persistent stomach pain or nausea. Arrange for periodic ophthalmologic examinations during long-term therapy. drug should be discontinued if these occurs. severe vomiting.

then to bone marrow for incorporation into hemoglobin. prophylaxis for iron deficiency in pregnancy. gluconate 12%. iron. including decrease in pain. Replace iron stores needed for red blood cell development. energy and oxygen transport. Instruct patient to take drug with food. fumarate contains 33% elemental iron. Instruct to avoid alcohol and other CNS depressants. utilization. Therapeutic response. Teach patient to report any symptoms of CNS changes. vomiting. Ferosal GENERIC NAME. or shortness of breath. Patient verbalize relief from pain Patient and family state understanding of drug therapy DOCTORS ORDER: Multivitamins + Iron 1 cap BID BRAND NAME. anorexia. 20%. 30%.IMPLEMENTATION. 94 . cramps. Bided immediately to carrier protein. transferring. Inform that withdrawal symptoms may occur. INDICATIONS. faintness. Iron deficiency anemia. allergic reactions. EVALUATION. do not take drug longer than 1 week. take only the prescribed dosage. Highly protein bound. sulfate. Inform that physical dependency may result when used for extended periods. fever. Ferrous sulfate CLASSIFICATION: Multivitamins + Iron/ Iron supplements DRUG ACTION. ferrous sulfate exsiccated. including nausea.

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

except egg. If patient misses a dose. Don’t crash or allow patient to chew extended-release forms. Oral iron may turn stools black. Monitor hemoglobin level. tell her to take it as soon as she remembers but not to double the dose. milk products. Have stools tested for presence of blood. hemoglobin. Although this unabsorbed iron is harmless. improvement in hematocrit.NURSING CONSIDERATIONS: Give tablets with juices or water. Advise patient not to substitute one iron salt for another because amount of elemental iron vary. but not in milk or antacids. Patient reports fatigue is no longer a problem daily life 96 . Alert. Instruct patient not to crush or chew extended-release form. inform parents that as few as three tablets can cause poisoning in children. Tell patient that iron will change stools black or dark green. but not with milk or antacids. To avoid staining teeth. coffee and teas enteric-coated or sustained-release product and the foods listed above. GI upset continues. reticulocytes. it could mask presence of Melina. Dilute liquids form in juices or water. hematocrit and reticulocyte count during therapy. but not with milk or antacids. Advice patient to report constipation and change in stool color or consistency. reduce GI upset but also reduce amount disturbed. decreased fatigue and weakness. EVALUATION: Therapeutic response. give suspension or elixir with straw and place drops at back of throat. may give with food. IMPLEMENTATION: Instruct patient to take tablets with juices ( preferably orange juice ) or water.

sick or well. (4)movement. (2)eating and drinking. This model also involves the 14 basic needs of patients that comprise the components of nursing care. Such as (1)breathing. (3)elimination.Patient states appropriate measures to prevent a relieve constipation Patient and family state understanding of drug therapy NURSING THEORY Virginia Henderson’s 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. that clients would perform unaided if they had the necessary strength. (5)rest and sleep. It also involves assisting the client in gaining independence as rapidly as possible. will or knowledge. 97 . in the performance of those activities contributing to health or its recovery.

In caring our client. As we carry our own nursing interventions. (7)body temperature. 2009)  Admitted to the hospital at 10:00 pm  Complains of labor pains and 98 ON-GOING ASSESSMENT (February 17. with her active participation and cooperation. (10)communication. Health Perception. (12)work. it is important to view and treat her as a unique individual. (11)worship. RR=19 CPM . With detailed assessment and knowing her needs. 2009)  T= 36. and (14)learning. both of us can achieve an attainable goal.Health Management  Past illness during the last six months were cough and colds  Self medicate during her INITIAL ASSESSMENT (February 16. quality and humane care will be receive by her. it is indeed a must that we will identify the basic needs of our client. BP= 100/80 mmHg  Verbalized “ Medyo okay na ako . PR=85 BPM .7 degrees celcius . it will promote independence to her part and eventually she can restore her health again and use it to its optimum. (8)clean body and protected integument. Thus. (13)play. This provides the nurse to get inside the skin of each of her patient that enables her/him to know what he needs. GORDON’S FUNCTIONAL HEALTH PATTERN USUAL PATTERN I. we can assure to her that the best. (9)safe environment. Most importantly.(6)suitable clothing. in order to gain independence.

RR=20 CPM .1 cup rice.1 cup rice. 2009) T=36.  Claimed weight is the same  Not choosy when it comes to food. 1-2 serving of banana. nausea and vomiting  Type of diet: DIET AS TOLERATED ^ Breakfast. 1 bowl of linat-ang baka ^ lunch. 2-3 glasses of water ^ Lunch and dinner. ! bowl of vegetables. 9 degrees celcius .        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 ADL’s    • • • •  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 25.1 cup of 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 99 . 1-2 pieces of fish. BP=100/80 mmHg Patient verbalized “medyo kapoy pa jud ko lawas ug sakit gamay ang tinahi-an” “ Dili pajud kayo ka’lihok-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. no food preferences and restrictions  Do not experiencre indigestion. 1piece of fish. 1 bowl of vegetables.1 cup rice . Nutritional Metabolic Pattern  Eats Regular meals everyday ^ Breakfast. 1-2 glasses of water. PR=110 BPM .

nausea. fish and vegetables ^ Dinner. 1 bowl of linat-ang baka ^ Lunch. Elimination Pattern * Bladder  No difficulty and problems in urinating  No assistive device used  Type of diet : DIET AS TOLERATED ^ Breakfast. 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.1 cup rice. when eating III.1 cup rice.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 100 . chewing and feeding self  No food restrictions and preferences  Do not experience indigestion.

breakfast time 9am.Rest Pattern  Sleeps at 9pm and awakes at 6am  Hours slept. prepares breakfast .do the laundry. Activity – Exercise Pattern  Activities of daily living 6 am.entertainment time 9:00-6am.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 101 .prepares dinner 7:00pm. take a bath 11am.rest 11:30 am.lunch time 1:00 pm.dinner time 7:30-9:00pm.prepare food for lunch 12nn. boil water 7am.wakes up .do the household chores 6:00pm.5:00pm.sleep 3pm.sleeping time  A plain housewife  No limitation in mobility  No complains of dyspnea or fatigue V.do house hold chores 8am. Skin has good turgor and no skin problems IV. Sleep.

coherent.” 102 . coherent. Self. family and her child’s 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 family’s welfare To have a happy and healthy family is her health goal Verbalized “Wala gyud mi gadahom na ma=ingon ato ang among anak. No sleep aids and routine used  No problems in sleeping VI. naguol ko.”  She wants to go home already  Verbalized “ maningkamot ko na ako mabuhat ang akong katungdanan asip usa ka inahan ug asawa. 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. 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. 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. pero wala na pud ko mahimo.Perception Pattern  Concerned about health.

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. Sexuality. 2008  Menstruation does not return to normal  Claimed that they would go to the health 103 .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. 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. Role.Relationship Pattern Communication  Spoke in bisaya  Speech is clear  Expressed self verbally when happy.May 14.

mad.” 104  Verbalized “ Ampo lang gyud ug slig sa Ginoo” . • • Verbalized “ Salig lang gyud sa Ginoo” “ Mag-ampo lang gyud niya sige. Menarche started at the age of 12  Is fertile and 4th time of pregnancy  No history of reproductive problems  No use of contraceptives X. angry. or stressed  Claimed that she wants the nurse and doctor to give her and her baby the best and quality care XI. 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. 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”.

 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 105 .



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. T= 36.5-37.5 C PR= 60-100 bpm strong and regular RR=12-20cpm. relief in back dorsiflexion change pain position frequently Reduced respiratory capacity as the uterus presses on the diaphragm results in dyspnea. Reduces discomfort associated with altered calcium levels/calciumphosphorous imbalance. strong and regular RR=12-20cpm. Goals/Objectives Intervention Rationale Evaluation The objective of care was completely met as evidenced by: a. relief in back pain c. manifest reduce discomfort during pregnancy as evidenced by: • Note reports of back a. or with pressure from enlarging uterus compressing nerves 108 . effort Encourage client to BP= 120/80 extend leg and turn mmHg foot upward in b.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. relief in leg cramps Within our 8 hours Independent of care. moderate in depth and without effort BP= 120/80 mmHg b.5-37.5 C Suggest use of lowPR= 60-100 bpm heeled shoes. 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. V/S WNL T= 36. the patient • Assess client’s will be able to respiratory status. V/S WNL strain and altered gait. moderate in • Determine presence of depth and without leg cramps.

absence of dyspnea e. tolerated pain level of uterine contractions supplying the lower extremities.bags c. relief in leg cramps d. d. • Assess for presence/frequency of Braxton Hicks contractions. tolerated pain level of uterine contractions 109 . absence of dyspnea e. These contractions may create discomfort for the multigravida in both second and third trimesters.

5 C PR= 60-100 bpm strong and regular RR=12-20cpm.5 C PR= 60-100 bpm strong and regular RR=12-20cpm. the patient will manifest reduce alteration during elimination as evidenced by: a. urinary incontinence is reduced. Maintains adequate fluid levels and kidney perfusion which relies on dietary sodium. reduced peripheral edema. Rationale Helps client understand the physiological reason for urinary frequency and nocturia. moderate in depth and without effort BP= 120/80 mmHg b. no sign of edema Encourage client to assume lateral position while sleeping. • 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. approximately 2000ml/day. reduced peripheral edema. c.5-37. no sign of edema Intervention Independent Provide information about urinary changes associated with third trimester. c. V/S WNL T= 36. These positions potentiate vena cava syndrome an dreduce venous return.5-37. Provide information regarding need for fluid intake of 6 to 8 glasses/day. Advise client to avoid long periods in upright or supine position. Objective: Temp= 37. moderate in depth and without effort BP= 120/80 mmHg b. urinary incontinence is reduced. V/S WNL T= 36.Cues and Evidences Subjective: Verbalized “ mag-sige ko ug pangihi aning mga panahona”. resulting in frequency. Provide information regarding danger of taking 110 . d. A left or right lateral recumbent position increases GFR and renal blood flow to increase kidney perfusion. Third-trimester uterine enlargement reduces bladder capacity. d.2oC PR= 80 bpm RR= 22 cpm BP= 100/70 • Urinary Incontence • Voided straw to deep amber urine. Sodium losses/restrictions may Evaluation The objective of care was completely met as evidenced by: a. Note reports of nocturia.

111 . overstresses renninangiotensin-aldosterone regulators of fluid levels.diuretics and of eliminating sodium from diet. resulting in severe dehydration.

Evaluation The objective of care was completely met as evidenced by: a. Achieve normal elimination or participate in measures to correct for defects. Verbalized understandin g of the condition b. Achieve normal elimination or participate in measures to correct for defects.3oC PR= 79 bpm RR= 21 cpm BP= 100/80 Incontinence Retention Urine volume • Voided 250ml of urine. c. Palpate bladder Note conditions of skin and mucous membranes color of urine. c. Emphasize importance of keeping area clean and dry. To reduce the risk of infection. • • • Intervention Inspect stomach of urinary diversion for edema. To assess retention. Urinalysis • Color= yellow • Appearance= hazy • pH=6. Identify causative factors.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. Identify causative factors. To help determine level of hydration. • • 112 . Verbalized understandi ng of the condition b.Nursing Care Plans for First Stage of Labor Cues and Evidences Subjective The patient verbalized “maglisod man kog pangihi” Objective Temp= 37. • • • Rationale To reduce the presence of edema. the patient will manifest achievement of normal elimination pattern as evidenced by: a.

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.5 C PR= 60-100 bpm strong and regular RR=12-20cpm. As timely intervention is more likely to be successful is 113 . characteristics.5 C PR= 60-100 bpm strong and regular RR=12-20cpm. onset/duration. 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. Observation may/may not be congruent with verbal reports indicating need for further evaluation.5-37. dili ko kasabot sa kasakit”. Evaluation The objective of care was completely met as evidenced by: vital signs within normal limit T= 36.Cues and Evidences Subjective: Verbalized “sakit akong balat-ang. quality. the uterus patient will manifest reduce level of pain as evidenced by: • vital signs within normal limit T= 36. frequency.5-37. Nursing Diagnosis Goals/Objectives • • Intervention Monitor vital signs Perform a comprehensive assessment of pain: include location. severity. instruct patient to report pain as soon • Pain is a subjective experience and cannot be felt by others. 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 . Accept descriptions of pain • • Rationale Usually altered by acute pain To determine patient’s acceptable the level of pain on a 0 to 10 scale.

. • Provide relaxation technique such as destruction. Provide an honest explanation of what the client can expect. as your health teaching. Enabling the client to manage pain. 114 . etc. • alleviating pain.• • Reduced distraction behavior rated pain 23 from 10 as 10 is the highest and 1 Is the lowest rate of pain as it begins. • 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. meditation.

moderate in depth and without effort BP= 120/80 mmHg • Assess the current situation accurately. fear. Identify ineffective coping • Intervention Identify developmental level of functioning Determine previous methods of dealing w/ life problems. Identify ineffective coping behaviors and consequences .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.5 C PR= 60-100 bpm strong and regular RR=12-20cpm.” Objective Temp= 37. • Rationale People tend to regress to a lower developmental stage during crisis. tu-a sa gawas.5 C PR= 60-100 bpm strong and regular RR=12-20cpm. Knowledge helps reduce anxiety. gahulat. moderate in depth and without effort BP= 120/80 mmHg • Assess the current situation accurately. allows Evaluation The objective of care was completely met as evidenced by: vital signs within normal limit T= 36.5-37. Call patient by name: ascertain how patient refers to be addressed. • • • • • • • • Provide a quite environment/positio n equipment out of view as mush as possible Give updated additional information needed • • • 115 . Using patients name enhances sense of self and promotes individuality selfesteem. To identify successful techniques that can be used in current situation. When anxiety is increased by noisy surroundings. the patient will manifest effective coping as evidenced by: • vital signs within normal limit T= 36.Cues and Evidences Subjective Verbalized “ ako rang bana ako kuyog karon.5-37.

patient to deal with reality. Verbalized awareness of coping abilities.• behaviors and consequenc es. about labor and delivery. • Verbali zed awareness of coping abilities. 116 .

• Rationale Evaluation • • • Auscultate breath sounds.5-37. the patient will manifest improve gas exchange as videnced by: • vital signs within normal limit T= 36. use of accessory muscles. moderate in depth and without effort BP= 120/80 mmHg • Participate in treatment regimen such as breathing exercise • Intervention Monitor respiratory rate/depth.5-37. areas of cyanosis. Monitor vital signs. noting presence/absence and adventitious sounds. &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 117 . note changes in cardiac rhythm.Nursing Care Plans for Second Stage of Labor Cues and Evidences Subjective: Verbalized “maglisod kog ginhawa tungod sa kasakit” Objective: • Dyspnea. abnormal RBC structure. • • • • 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. 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. sensitivity to low oxygen tension Goals/Objectives Within our 8 hours of nursing care. reduced RBC life span/ premature destruction.5 C PR= 60-100 bpm strong and regular RR=12-20cpm.5 C PR= 60-100 bpm Development of strong and regular atelectasis RR=12-20cpm. use of accessory muscles restlessness.

tecniques tension & anxiety & hence the metabolic demand for oxygen • • factors and appropriate interventions. Absence of symptoms of respiratory distress. Demonstrate improve ventilation.• • • within level of ability or situation Verbalized understandin g of causative factors and appropriate interventions . Absence of symptoms of respiratory distress. Demonstrate improve ventilation. 118 .

Verbalized “dili na nako maagwanta ang kasakit ug mura nakog kalibangon”. 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. 119 .5-37. frequency.Cues and Evidences Subjective: Verbalized “sakit na akong tiyan.5 C PR= 60-100 bpm strong and regular RR=12-20cpm. the patient will manifest reduce level of pain as evidenced by: • vital signs within normal limit T= 36.5 C PR= 60-100 bpm strong and regular RR=12-20cpm. murag mugawas na ang bata”. 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. Accept descriptions of pain • • Rationale Usually altered by acute pain To determine patient’s acceptable the level of pain on a 0 to 10 scale. characteristics. Observation may/may not be congruent with verbal reports indicating need for further evaluation. onset/duration. 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. quality. Rated pain as 10 in the scale of 1-10 as 10 is the highest and 1 is the lowest level of pain. As timely intervention is more likely to be successful is alleviating pain. • Pain is a subjective experience and cannot be felt by others. severity. Evaluation The objective of care was completely met as evidenced by: vital signs within normal limit T= 36.5-37.

. meditation. is the highest and 1 Is the lowest rate of pain • Sharing of information about the procedure is more effective than procedure information alone. as your health teaching.• 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. • Enabling the client to manage pain. Provide an honest explanation of what the client can expect. 120 . etc.

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. minimize contact with moisture/ excretions • • Rationale To provide baseline data Skin is at risk because of impaired peripheral circulation. • • • • • Nursing Care Plans for Postpartum 121 . 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. presence of edema. physical immobility and alterations in nutritional status.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. areas of altered circulation or obesity Provide gentle massage around reddened or blanched areas Encourage to use frequent skin care. noting skeletal prominences. minimizing tissue hypoxia Excessive dryness or moisture damages skin and hastens breakdown. Improves blood flow. • • Intervention Monitor vital signs Inspect skin.

onset/duration. the characteristics. use of heat/cold • 122 . change of position.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. frequency and aggravating factors • Note patient’s 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.

• • Self-focusing Narrowed focus. 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 • 123 . 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.

• 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 . parental.” • “ Mag-lisod pud kog katulog kay dili me paigo sa bed. feeling rested washing hands/face. 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.” NURSING DIAGNOSIS Disturbed sleep pattern related to environmental.CUES AND EVIDENCES Subjective: • Verbalized “ Wala gyud koy klarong tulog dayon banha ug gin-ot pud.” • “ Sakit gamay ang tinahi-an.

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 patient’s ability to fall asleep to increase the time/ feeling rested to enhance patient’s 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 • • 125 .Noisy and warm environment • Noxious odor • Pain felt is 5 Taxilla= 36.

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 client’s 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. guilt freely and effectively • acknowledge impact and effect of the grieving process • look toward plan for future. Enhance sense of trust and nurse-client 126 . angry behavior. guilt • • to assess appropriateness of client’s reaction to the situation promotes a free discussion of feelings and concern to show respect and build a trusting relationship. 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. crying • provide an open environment and trusting relationship • use therapeutic communication skills of active listening. guilt freely and effectively • acknowledged impact and effect of the grieving process • looked toward plan for future. naguol ko. pero wala na pud ko mahimo.CUES AND EVIDENCES Subjective: • Verbalized “Wala gyud mi gadahom na ma=ingon ato ang among anak. 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.” 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.

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. counseling/psycother apy . community support groups • to meet ongoing needs ad facilitate grief work 127 . such as pastoral care.• v/s: Taxilla= 37.

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. Those born with this condition require surgery to close the spine or they will die. Until the development of ultrasound technology. which now detects a fetus with this condition. It was estimated that one in every 1000 births were at one time affected with spina bifida. 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. The Food and Drug Administration (FDA) decided that the importance of folic acid was so great that all grain products in the U. the hapless parents were not aware of the child’s defect until its birth. Anencephaly is a defect in which the cerebrum is missing causing profound loss of functionality. The exact timeframe in which this defect can potentially occur is between the 21st and 27th day of gestation. Spina bifida is a disorder which involves the failure of the spine to close during gestation. Even with surgery they are often crippled and mentally retarded.S. have been required to be enriched with folic acid since 1998. 128 . 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.

SUMMARY Folic acid is extremely important because of its use by the human body in production of DNA and RNA. orange juice and fortified breakfast cereals. women of childbearing age are advised to take 400 micrograms of folic acid per day and 600 mcg per day for pregnant women. 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. Its absence is also associate with other defects such as heart defects and limb malformations. lentils. Food sources of folates include green leafy vegetables. 129 . That’s 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. Food sources that are rich in foliate are found in green leafy vegetables. garbanzo beans. orange juice and fortified breakfast cereals. This is the same Recommended Dietary Allowance (RDA) as men have but the emphasis is greater for women of child-bearing age. garbanzo beans. Although folates are necessary for all persons the medical community is especially concerned with adequate folic acid intake in women who may become pregnant. As recommended by the RDA and as encourage by the United Sates Public Health Service. The RDA for pregnant women is 600 mcg of folic acid per day.Folic acid is extremely important because of its use by the human body in production of DNA and RNA. especially during pregnancy. lentils.

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. 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. After all. Complete Information on Anencephaly with Treatment and Prevention By Juliet Cohen 130 . One way of empowering patient education.REACTION As a health care provider one of our roles is to educate and give health teachings to our clients. prevention is better than cure.

and unable to feel pain. is chaotic with the scalp majority forehead. Anencephaly occurs when the head end of the neural tube fails to close. It is important to understand that the type of neural tube defect can differ the second time. Children with this disorder are born without a forebrain. the skull. The symptoms of anencephaly may resemble other problems or medical conditions. Anencephaly may be associated with the unbalanced form of a structural chromosome abnormality in some families. while spina bifida occurs when the neural tube fails to close somewhere along the spine. The cause of anencephaly is unknown. The anencephaly come for when the neural tube does not succeed at the basis of the skull. In these cases. 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 lack of a functioning cerebrum is usually thought of as ruling out the possibility of ever gaining consciousness. Infants with this disorder are born without a forebrain (the front part of the brain) and a cerebrum.Article Posted: 04/24/2008 Anencephaly is the cause to a nervous system tube slight defect. 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. unconscious. while the second child could have spina bifida. Infants born with anencephaly are usually blind. which controls autonomic and regulatory function. resulting in the absence of a major portion of the brain.not covered by bone or skin. Although some individuals with anencephaly may be born with a rudimentary brainstem. 131 . Although it is thought that a mother's diet and vitamin intake may play a role. and scalp. even though it has been disputed specifically. creates lacks the brain. skull. For example. one child could be born with anencephaly. The remaining brain tissue is often exposed . deaf. Reflex actions such as breathing and responses to sound or touch may occur. other malformations and birth defects that are not usually found in isolated cases of anencephaly may be present. the largest part of the brain consisting mainly of the cerebral hemispheres. scientists believe that many other factors are also involved.

Usually the child with anencephaly is blind. however does not totally eliminate the possibility of having it. Often. but does not totally eliminate the possibility. vision. SUMMARY Anencephaly is a condition present at birth that affects the formation of the brain and the skull bones that surround the head. Many foods are now fortified with folic acid to help prevent these kinds of birth defects. the brain lacks part or the entire cerebrum (the area of the brain that is responsible for thinking. Folic acid had been proven to significantly reduce the risk of having a baby with a neural tube defect. Women who are pregnant or planning to become pregnant should take a multivitamin with folic acid every day. and unable to feel pain. There is no treatment or standard treatment for anencefalie and the forecast for influenced individuals is bad. 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. The maternal serum alpha-fetoprotein and detailed fetal ultrasound can be useful. A physician may prescribe even higher dosages of folic acid for women who have had a previous pregnancy with a neural tube defect. unconscious. They may live after a short while from birth but then die eventually. Anencephaly possibly frequently diagnoses before the birth through the ultrasonic wave test. Folic Acid can significantly reduce the risk of having a baby with a neural tube defect. Experience of the loss of a child can very traumatic be. 132 . Grief counseling services are available to help you cope with the loss of your child. touch. and movement).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. hearing. It results in only minimal development of the brain. deaf. Anencephaly caused by amniotic band disruption sequence is frequently distinguishable by the presence of remnants of the amniotic membrane.

the mothers would always say that they haven’t submitted their selves for prenatal check-up. As a health care provider. Upon assessment of the reason of having such baby.REACTION As what is experienced by us during our LR-DR Rotation. That’s why they had no idea that their baby had anencephaly. 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 133 . mothers who have given birth to a child with anencephaly is increasing in number.

with interaction of multiple genes as well as environmental factors. although neither the genes nor the environmental factors are well characterized. generally follows a multi-factorial pattern of transmission. 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. The mother who carries to term a child who will soon die deserves our every possible support. Anencephaly. BIBLIOGRAPHY A. 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. 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. leading to fetal loss. The cerebrum and cerebellum are reduced or absent. In some cases.Anencephaly is a serious developmental defect of the central nervous system in which the brain and cranial vault are grossly malformed. 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. stillbirth. but the hindbrain is present. The baptism of the child assures the parents of the child's eternal happiness. like other forms of NTDs. our role here is mainly supportive. BOOK 134 . As a health care provider. or it may be part of a more complex process involving single-gene defects or disruption of the amniotic membrane. anencephaly may be caused by a chromosome abnormality. or neonatal death. This defect results when the neural tube fails to close during the third to fourth weeks of development. Anencephaly is a part of the neural tube defect (NTD) spectrum.

B. Pharmacology: A Nursing Process Approach. (5th ed. Operative Gynecology. (9th ed.). (2003). process. New Jersey: Pearson Education Inc.: New Jersey.. et. C. (2003. Pathophysiology: Clinical Concepts of disease process.) Elsvier Science.et. Drug Handbook. Inc.Pillitteri. (4th ed). Danfroth’s Obstetrics and Gynecology (9th ed.R. et. al. (2003). .(2005). Shannon. B. Upper Saddle River. DICTIONARY 135 . (2008). M.).et. ) Lipincott Williams and Wilkins Price. Rock. Stang. Essentials of Anatomy and Physiology. and Hayes. Sylvia A. Kozier. J. John A.) Lipincott Williams and WilkinsScott. B. et. (2002). Schilling. Inc.al. Prentice Hall’s Nurse’s Drug Guide. Elvesier Science: USA. . (6th ed. .. ) Lipincott Williams and Wilkins Porth.al.al.al. R. and practice (7th ed. McGraw-Hill Companies. M. MOSBY Inc. James R. (2003).. E. Carol M.) Lipincott Williams and Wilkins Seeley.. (4th ed. (28th ed. Fundamentals of nursing: concepts. Pearson Education.. Maternal & Child Health Nursing. Pathophysiology: Concepts of Altered Health States. Adele. (2004). Wilson. (2004). (6th ed.) Lipincott Williams and Wilkins Kee..

com/mb/jessicasjourney/info.medscape.htm http://emedicine.htm http://kidshealth.edu/ency/article/001580sym.healthscout. Blackwell ltd C.angelfire. (2005).healthsystem.htm http://www. 3rd ed.nih.Bantam (2000).cfm http://en.org/display/PPF/DocID/22499/router.edu/uvahealth/peds_neuro/anenceph.com/ency/1/001580.gov/disorders/anencephaly/anencephaly. Inc Dawn Freshwater. Blackwell Science LTD and C and E Publishishing. The bantam medical dictionary.org/parent/system/medical/prenatal_tests.com/article/1181570-overview http://www.org/wiki/Anencephaly http://miscarriage. Blackwell’s Dictionary of Nursing.chw. INTERNET http://www.asp http://www. USA: Market House Books Ltd.umm.virginia.about.com/od/pregnancylossbasics/g/anencephaly.html http://www.ninds. Blackwell’s Nursing Dictionary 2nd edition.wikipedia.html http://www.html 136 .

womenshealthmatters. get rid of Anencephaly 137 .health-care-guide.org/ and http://www.Anencephaly information.rg/e/index.htm Juliet Cohen writes articles for http://www. Anencephaly prevention methods.http://www.anencephalie-info.com/ . Related Articles .ca/centres/pregnancy/childbirth/stages.php http://www.diseasesatoz. http://www.disordersatoz.com/library/philadelphia/EPHlabor.expectantmothersguide. Anencephaly treatment tips.html http://www.com/.

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