Amniocentesis.

- Amniocentesis is a procedure used to diagnose fetal defects in the early second

trimester of pregnancy. A sample of the amniotic fluid, which surrounds a fetus in the womb, is collected through a pregnant woman's abdomen using a needle and syringe. Tests performed on fetal cells found in the sample can reveal the presence of many types of genetic disorders, thus allowing doctors and prospective parents to make important decisions about early treatment and intervention. Since the mid-1970s, amniocentesis has been used routinely to test for Down syndrome , by far the most common, nonhereditary, genetic birth defect, afflicting about one in every 1,000 babies. By 1997, approximately 800 different diagnostic tests were available, most of them for hereditary genetic disorders such as Tay-Sachs disease, sickle cell anemia, hemophilia, muscular dystrophy , and cystic fibrosis. Amniocentesis, often called amnio, is recommended for women who will be older than 35 on their due-date. It is also recommended for women who have already borne children with birth defects, or when either of the parents has a family history of a birth defect for which a diagnostic test is available. Another reason for the procedure is to confirm indications of Down syndrome and certain other defects which may have shown up previously during routine maternal blood screening. The risk of bearing a child with a nonhereditary genetic defect such as Down syndrome is directly related to a woman's agethe older the woman, the greater the risk. Thirty-five is the recommended age to begin amnio testing because that is the age at which the risk of carrying a fetus with such a defect roughly equals the risk of miscarriage caused by the procedureabout one in 200. At age 25, the risk of giving birth to a child with this type of defect is about one in 1,400; by age 45 it increases to about one in 20. Nearly half of all pregnant women over 35 in the United States undergo amniocentesis and many younger women also decide to have the procedure. Notably, some 75% of all Down syndrome infants born in the United States each year are to women younger than 35. One of the most common reasons for performing amniocentesis is an abnormal alpha-fetoprotein (AFP) test. Alpha-fetoprotein is a protein produced by the fetus and present in the mother's blood. A simple blood screening, usually conducted around the 15th week of pregnancy, can determine the AFP levels in the mother's blood. Levels that are too high or too low may signal possible fetal defects. Because this test has a high false-positive rate, another test such as amnio is recommended whenever the AFP levels fall outside the normal range. Amniocentesis is generally performed during the 16th week of pregnancy, with results usually available within three weeks. It is possible to perform an amnio as early as the 11th week, but this is not usually recommended because there appears to be an increased risk of miscarriage when done at this time. The advantage of early amnio and speedy results lies in the extra time for decision making if a problem is detected. Potential treatment of the fetus can begin earlier. Important, also, is the fact that elective abortions are safer and less controversial the earlier they are performed.

Amniotic Fluid Index (AFI)

An ultrasound procedure used to asses the amount of amniotic fluid. The amniotic fluid index is measured by dividing the uterus into four imaginary quadrants (Figure 1). The linea nigra is used to divide the uterus into right and left halves.The umbilicus serves as the dividing point for the upper and lower halves.

The transducer is kept parallel to the patients longitudinal axis and perpendicular to the floor. The deepest, unobstructed, vertical pocket of fluid is measured in each quadrant in centimeters. (Figure 2). The four pocket measurements are then added to calculate the AFI. Normal AFI values range from 5 to 25 cm [1, 4]

Figure 1

Figure 2

Antibody.- Antibodies, or Y-shaped immunoglobulins , are proteins found in the blood that help to fight against foreign substances called antigens. Antigens, which are usually proteins or polysaccharides, stimulate the immune system to produce antibodies. The antibodies inactivate the antigen and help to remove it from the body. While antigens can be the source of infections from pathogenic bacteria and viruses , organic molecules detrimental to the body from internal or environmental sources also act as antigens. Genetic engineering and the use of various mutational mechanisms allow the construction of a vast array of antibodies (each with a unique genetic sequence). Specific genes for antibodies direct the construction of antigen specific regions of the antibody molecule. Such antigen-specific regions are located at the extremes of the Y-shaped immunglobulin-molecule. Once the immune system has created an antibody for an antigen whose attack it has survived, it continues to produce antibodies for subsequent attacks from that antigen. This long-term memory of the immune system provides the basis for the practice of vaccination against disease. The immune system, with its production of antibodies, has the ability to recognize, remember, and destroy well over a million different antigens. There are several types of simple proteins known as globulins in the blood: alpha, beta, and gamma. Antibodies are gamma globulins produced by B lymphocytes when antigens enter the body. The gamma globulins are referred to as immunoglobulins. In medical literature they appear in the abbreviated form as Ig. Each antigen stimulates the production of a specific antibody (Ig). Antibodies are all in a Y-shape with differences in the upper branch of the Y. These structural differences of amino acids in each of the antibodies enable the individual antibody to recognize an antigen. An antigen has on its surface a combining site that the antibody recognizes from the combining sites on the arms of its Y-shaped structure. In response to the antigen that has called it forth, the antibody wraps its two combining sites like a "lock" around the "key" of the antigen combining sites to destroy it. An antibody's mode of action varies with different types of antigens. With its two-armed Yshaped structure, the antibody can attack two antigens at the same time with each arm. If the antigen is a toxin produced by pathogenic bacteria that cause an infection like diphtheria or tetanus , the binding process of the antibody will nullify the antigen's toxin. When an antibody surrounds a virus, such as one that causes influenza , it prevents it from entering other body cells. Another mode of action by the antibodies is to call forth the assistance of a group of immune agents that operate in what is known as the plasma complement system. First, the antibodies will coat infectious bacteria and then white blood cells will complete the job by engulfing the bacteria, destroying them, and then removing them from the body.

There are five different antibody types, each one having a different Y-shaped configuration and function. They are the Ig G, A, M, D, and E antibodies. IgG is the most common type of antibody. It is the chief Ig against microbes. It acts by coating the microbe to hasten its removal by other immune system cells. It gives lifetime or longstanding immunity against infectious diseases. It is highly mobile, passing out of the blood stream and between cells, going from organs to the skin where it neutralizes surface bacteria and other invading microorganisms . This mobility allows the antibody to pass through the placenta of the mother to her fetus, thus conferring a temporary defense to the unborn child. After birth, IgG is passed along to the child through the mother's milk, assuming that she nurses the baby. But some of the Ig will still be retained in the baby from the placental transmission until it has time to develop its own antibodies. Placental transfer of antibodies does not occur in horses, pigs, cows, and sheep. They pass their antibodies to their offspring only through their milk. This antibody is found in body fluids such as tears, saliva, and other bodily secretions. It is an antibody that provides a first line of defense against invading pathogens and allergens, and is the body's major defense against viruses. It is found in large quantities in the bloodstream and protects other wet surfaces of the body. While they have basic similarities, each IgA is further differentiated to deal with the specific types of invaders that are present at different openings of the body. Since this is the largest of the antibodies, it is effective against larger microorganisms. Because of its large size (it combines five Y-shaped units), it remains in the bloodstream where it provides an early and diffuse protection against invading antigens, while the more specific and effective IgG antibodies are being produced by the plasma cells. The ratio of IgM and IgG cells can indicate the various stages of a disease. In an early stage of a disease there are more IgM antibodies. The presence of a greater number of IgG antibodies would indicate a later stage of the disease. IgM antibodies usually form clusters that are in the shape of a star. This antibody appears to act in conjunction with B and T-cells to help them in location of antigens. Research continues on establishing more precise functions of this antibody. The antibody responsible for allergic reactions, IgE acts by attaching to cells in the skin called mast cells and basophil cells (mast cells that circulate in the body). In the presence of environmental antigens like pollens, foods, chemicals, and drugs, IgE releases histamines from the mast cells. The histamines cause the nasal inflammation (swollen tissues, running nose, sneezing) and the other discomforts of hay fever or other types of allergic responses, such as hives, asthma, and in rare cases, anaphylactic shock (a life-threatening condition brought on by an allergy to a drug or insect bite). An explanation for the role of IgE in allergy is that it was an

antibody that was useful to early man to prepare the immune system to fight parasites . This function is presently overextended in reacting to environmental antigens. The presence of antibodies can be detected whenever antigens such as bacteria or red blood cells are found to agglutinate (clump together), or where they precipitate out of solution, or where there has been a stimulation of the plasma complement system. Antibodies are also used in laboratory tests for blood typing when transfusions are needed and in a number of different types of clinical tests, such as the Wassermann test for syphilis and tests for typhoid fever and infectious mononucleosis . Antigen.- By definition, anything that makes the immune system respond to produce antibodies is an antigen. Antigens are living foreign bodies such as viruses, bacteria, and fungi that cause disease and infection. Or they can be dust, chemicals, pollen grains, or food proteins that cause allergic reactions.

Antigens that cause allergic reactions are called allergens. A large percentage of any population, in varying degrees, is allergic to animals, fabrics, drugs, foods, and products for the home and industry. Not all antigens are foreign bodies. They may be produced in the body itself. For example, cancer cells are antigens that the body produces. In an attempt to differentiate its "self" from foreign substances, the immune system will reject an organ transplant that is trying to maintain the body or a blood transfusion that is not of the same blood type as itself.

There are some substances such as nylon, plastic, or Teflon that rarely display antigenic properties. For that reason, nonantigenic substances are used for artificial blood vessels, component parts in heart pacemakers, and needles for hypodermic syringes. These substances seldom trigger an immune system response, but there are other substances that are highly antigenic and will almost certainly cause an immune system reaction. Practically everyone reacts to certain chemicals, for example, the resin from the poison ivy plant, the venoms from insect and reptile bites, solvents, formalin, and asbestos. Viral and bacterial infections also generally trigger an antibody response from the immune system. For most people penicillin is not antigenic, but for some there can be an immunological response that ranges from severe skin rashes to death.

Another type of antigen is found in the tissue cells of organ transplants. If, for example, a kidney is transplanted, the surface cells of the kidney contain antigens that the new host body will begin to reject. These are called human leukocyte antigens (HLA ), and there are four major types of HLA subdivided into further groups. In order to avoid organ rejection, tissue samples are taken

to see how well the new organ tissues match for HLA compatibility with the recipient's body. Drugs will also be used to suppress and control the production of helper/suppressor T-cells and the amount of antibodies.

Red blood cells with the ABO antigens pose a problem when the need for blood transfusions arises. Before a transfusion, the blood is tested for type so that a compatible type is used. Type A blood has one kind of antigen and type B another. A person with type AB blood has both the A and B antigen. Type O blood has no antigens. A person with type A blood would require either type A or O for a successful transfusion. Type B and AB would be rejected. Type B blood would be compatible with a B donor or an O donor. Since O has no antigens, it is considered to be the universal donor. Type AB is the universal recipient because its antibodies can accept A, B, AB, or O. One way of getting around the problem of blood types in transfusion came about as a result of World War II. The great need for blood transfusions led to the development of blood plasma, blood in which the red and white cells are removed. Without the red blood cells, blood could be quickly administered to a wounded soldier without the delay of checking for the blood antigen type.

Another antigenic blood condition can affect the life of newborn babies. Rhesus disease (also called erythroblastosis fetalis) is a blood disease caused by the incompatibility of Rh factors between a fetus and a mother's red blood cells. When an Rh negative mother gives birth to an Rh positive baby, any transfer of the baby's blood to the mother will result in the production of antibodies against Rh positive red blood cells. At her next pregnancy the mother will then pass those antibodies against Rh positive blood to the fetus. If this fetus is Rh positive, it will suffer from Rh disease. Tests for Rh blood factors are routinely administered during pregnancy. Biophysical profile.- The biophysical profile is an ultrasound exam that can add additional information to the NST (non stress test). During the biophysical profile, the examiner checks for various characteristics of the baby to evaluate its overall health. These include: fetal movement, fetal tone, breathing movements, and the amniotic fluid volume. Amniotic fluid volume is important because a decreased amount raises the possibility that the baby may be under stress. The five components of the test (NST is also included) are each given a score of 2 for normal (or present), 1 if decreased, and 0 for abnormal. The highest possible score is 10. The "modified" biophysical profile is another option; this includes only the NST and amniotic fluid volume. Clonus .- rhythmical contraction of a muscle in response to a suddenly applied and then sustained stretch stimulus. It is most readily obtained at the ankle and is usually a sign of disease in the brain or spinal cord.

fundal height.- Fundal height is generally defined as the distance from the top of the uterus to the pubic bone measured in centimeters. After the first 12 weeks of pregnancy, your fundal height measurement often matches the number of weeks you've been pregnant. For example, if you're 27 weeks pregnant, your health care provider would expect your fundal height to be about 27 centimeters. It isn't unusual, however, to measure somewhat smaller or larger than expected. This might happen if you: Have a tall or slim frame Have a short or heavy frame Have a full bladder Are carrying twins or other multiples In other cases, fundal height that measures smaller or larger than expected or increases more or less quickly than expected could indicate conditions such as: Slow fetal growth (intrauterine growth restriction) Rapid fetal growth (macrosomia) Too little amniotic fluid (oligohydramnios) Too much amniotic fluid (polyhydramnios) Uterine fibroids A baby prematurely descending into the pelvis or settling into a breech or other unusual position Depending on the circumstances, your health care provider might recommend an ultrasound or other tests to determine what's causing the unusual measurements. Remember, fundal height is only a tool for gauging fetal growth and gestational age it's not an exact science. Typically, fundal height measurements offer reassurance of a baby's steady growth. If you're concerned about your fundal height measurements, ask your health care provider for details. Gravida.- A pregnant woman. In medicine, gravidity refers to the number of times a woman has been pregnant. The pregnancies may have been interrupted by abortion, fetal death, or may have resulted in a live birth. Gravida/para/abortus (GPA), or sometimes just gravida/para (GP), is a shorthand notation for a woman's obstetric history.

Gravida indicates the number of times the mother has been pregnant, regardless of whether these pregnancies were carried to term. A current pregnancy, if any, is included in this count.Para indicates the number of viable (>20 wks) births. Pregnancies consisting of multiples, such as twins or triplets, count as ONE birth for the purpose of this notation. Abortus is the number of pregnancies that were lost for any reason, including induced abortions or miscarriages. The abortus term is sometimes dropped when no pregnancies have been lost. Therefore, the history of a woman who has had two pregnancies (both of which resulted in live births) would be noted as G2P2. The obstetrical history of a woman who has had four pregnancies, one of which was a miscarriage before 20 weeks, would be noted as G4P3A1. That of a woman who has had one pregnancy of twins with successful outcomes would be noted as G1P1. Rho-Gam.- Rho(D) Immune Globulin is a medicine given by intramuscular injection that is used to prevent the immunological condition known as Rhesus disease (or hemolytic disease of newborn). The medicine is a solution of IgG anti-D (anti-RhD) antibodies that bind to, and lead to the destruction of, fetal Rh D positive red blood cells that have passed from the fetal circulation to the maternal circulation. Therefore, in a Rhesus negative mother it can prevent sensitization of the maternal immune system to Rh D antigens, which can cause rhesus disease in the current or in subsequent pregnancies. With the widespread use of Rho(D) Immune Globulin, Rh disease of the fetus and newborn has almost disappeared. Direct Coombs.This is the test that is done on the newborn's blood sample, usually in the setting of a newborn with jaundice. The test is looking for "foreign" antibodies that are already adhered to the infant's rbcs, a potential cause of hemolysis. This is referred to as "antibody-mediated hemolysis". The two most commonly recognized forms of antibody-mediated hemolysis in newborns are Rh incompatibility and ABO incompatibility. Rh incompatibility occurs when a mother who is type Rh - (and has naturally occuring anti-Rh antibodies in her serum) gives birth to an infant who is Rh+. If any mixing of maternal and fetal blood occurs during pregnancy or the birth process, the mother's anti-Rh antibodies will vigorously attack the baby's Rh+ rbcs by adhering to, and then lysing, the cells. ABO incompatibility occurs by the same general mechanism. Type O mothers are most commonly impacted, since they carry both anti-A and anti-B antibodies. If the infant is type A, type B, or type AB, risk for incompatibility exists. This is frequently referred to as a "set-up". If mixing of maternal and fetal blood occurs during pregnancy or the birth process, these antibodies can also attack the baby's rbcs and cause hemolysis. In general, this reaction is less serious than Rh incompatibility (which can be fatal if severe and untreated), and usually only results in jaundice and mild anemia.

An important thing to remember is that the presence of a positive coombs' test in the lab does not necessarily result in hyperbilirubinemia in the infant. The risk of needing phototherapy is certainly greater, but there are many factors impacting bilirubin levels, and assessment of all of these elements is critical to making an appropriate decision about treatment. Conversely, active hemolysis may be present with a negative coombs' test. Conditions that cause the rbc to be inherently defective in some way (hereditary spherocytosis, G6PD deficiency, etc) can also result in severe hyperbilirubinemia, but because these process do not involve antibodies, the coombs' test will be negative.

Nonstress test.- A nonstress test (NST) measures the fetal heart rate in response to the fetus' movements. Generally, the heart rate of a healthy fetus increases when the fetus moves. The NST is usually performed in the last trimester of pregnancy. The actual procedure for a NST may vary, but, generally, the procedure is as follows: The test is often performed in a special prenatal testing area of the hospital, or in your physician's office. The mother lies down and has a belt placed around her abdomen with a transducer positioned over the fetal heartbeat, called an external fetal heart rate monitor. The fetal heart rate is recorded on the monitor and on a paper printout. The mother pushes a button on the monitor each time she feels fetal movement. This places a mark on the paper printout. Testing usually lasts for 20 to 40 minutes. Sometimes, the testing occurs during a fetal sleep cycle, when there is little fetal movement. A special acoustic (sound) device is sometimes used to awaken the fetus. It is placed against the mother's abdomen and makes a noise like a buzzer. This is not harmful to the fetus but may help a sleepy fetus become more active. Having the mother eat or drink may also awaken the fetus. Results: reactive (normal) - two or more fetal heart rate increases in the testing period (usually 20 minutes). nonreactive - there is no change in the fetal heart rate when the fetus moves. This may indicate a problem that requires further testing. A nonreactive NST does not always mean there is a problem with the fetus. The fetus may simply be asleep. Or, it may be nonreactive because of fetal immaturity. It is common for preterm fetuses, especially those before 28 weeks, to have nonreactive nonstress tests. Additional prenatal testing may be necessary.

Oligohydramnios .- is a condition in which there is too little amniotic fluid around the fetus. It occurs in about 4 percent of all pregnancies. There are several causes of oligohydramnios. Generally, it is caused by conditions that prevent or reduce amniotic fluid production. Factors that are associated with oligohydramnios include the following:

premature rupture of membranes (before labor) intrauterine growth restriction (poor fetal growth) post-term pregnancy birth defects, especially kidney and urinary tract malformations twin-to-twin transfusion syndrome Amniotic fluid is important in the development of fetal organs, especially the lungs. Too little fluid for long periods may cause abnormal or incomplete development of the lungs called pulmonary hypoplasia. It may also be related to abnormal development of the limbs, and result in abnormal hand, foot, arm, and leg posturing and function. Intrauterine growth restriction (poor fetal growth) is also associated with decreased amounts of amniotic fluid. Oligohydramnios may be a complication at delivery, increasing the risk for compression of the umbilical cord and aspiration of thick meconium (baby's first bowel movement). The following are the most common symptoms of oligohydramnios. However, each woman may experience symptoms differently. Symptoms may include: leaking of amniotic fluid when the cause is rupture of the amniotic sac. Decreased amount of amniotic fluid on ultrasound In addition to a complete medical history and physical examination, a diagnosis is usually made using ultrasound. Pockets of amniotic fluid can be measured and the total amount estimated. Ultrasound can also show fetal growth, the structure of the kidneys and urinary tract, and detect urine in the fetal bladder. Doppler flow studies (a type of ultrasound used to measure blood flow) may be used to check the arteries in the kidneys. Parity.- The number of pregnancies in which the fetus or fetuses have reached viability, not the number of fetuses(e.g. twins) born; not affected by whether the fetus is born alive or stillborn (i.e., showing no signs of life at birth) after viability is reached. Preterm labor.- Born after 20 weeks of gestation but before completion of 37 weeks of gestation. Polyhydramnios.- also called hydramnios is the excessive accumulation of amniotic fluid in the uterus during pregnancy. Polyhydramnios occurs in about 1 percent of pregnancies. Most cases of polyhydramnios are mild and result from a gradual buildup of amniotic fluid during the second half of pregnancy. Severe polyhydramnios may cause shortness of breath, preterm labor or other symptoms. Tocolysis.- Tocolytics (also called anti-contraction medications or labour repressants) are medications used to suppress premature labor (from the Greek tokos, childbirth, and lytic,

capable of dissolving). They are given when delivery would result in premature birth. The therapy also buys time for the administration of betamethasone, a glucocorticoid drug which greatly accelerates fetal lung maturity, but takes one to two days to work. The suppression of contractions is often only partial and tocolytics can only be relied on to delay birth for several days. Depending on the tocolytic used the mother or fetus may require monitoring, as for instance blood pressure monitoring when nifedipine is used as it reduces blood pressure. In any case the risk of preterm labor alone justifies hospitalization. Ultrasound.- Ultrasound examination, also called sonography or diagnostic medical sonography, is an imaging method that uses high-frequency sound waves to produce precise images of structures within your body. The images produced during an ultrasound examination often provide information that's valuable in diagnosing and treating a variety of diseases and conditions. Most ultrasound examinations are done using a sonar device outside of your body, though some ultrasound examinations involve placing a device inside your body. Despite its valuable uses, ultrasound can't provide images of all areas of your body. But there are several other imaging alternatives. Premature rupture of membranes.- Premature rupture of membranes (PROM) refers to a patient who is beyond 37 weeks' gestation and has presented with rupture of membranes (ROM) prior to the onset of labor. Preterm premature rupture of membranes (PPROM) is ROM prior to 37 weeks' gestation. Spontaneous premature rupture of the membranes (SPROM) is ROM after or with the onset of labor. Prolonged ROM is any ROM that persists for more than 24 hours and prior to the onset of labor. At term, programmed cell death and activation of catabolic enzymes, such as collagenase and mechanical forces, result in ruptured membranes. Preterm PROM occurs probably due to the same mechanisms and premature activation of these pathways. However, early PROM also appears to be linked to underlying pathologic processes, most likely due to inflammation and/or infection of the membranes. Clinical factors associated with preterm PROM include low socioeconomic status, low body mass index, tobacco use, preterm labor history, urinary tract infection, vaginal bleeding at any time in pregnancy, cerclage, and amniocentesis. Eighty-five percent of neonatal morbidity and mortality is a result of prematurity. PPROM is associated with 30-40% of preterm deliveries and is the leading identifiable cause of preterm delivery. PPROM complicates 3% of all pregnancies and occurs in approximately 150,000 pregnancies yearly in the United States. When PPROM occurs remote from term, significant risks of morbidity and mortality are present for both the fetus and the mother. Thus, the physician caring for the pregnant woman whose pregnancy has been complicated with PPROM

plays an important role in management and needs to be familiar with potential complications and possible interventions to minimize risks and maximize the probability of the desired outcome. B. Define the following terms as applicable during the postpartum period: After pains.- Afterpains are sharp abdominal pains that occur in the first few days after childbirth. These are normal uterine contractions that slowly shrink the uterus back to normal size. Afterpains are most noticeable during breast-feeding; breast-feeding triggers the release of oxytocin, which in turn causes the uterus to contract. These pains usually begin to subside by the third day after childbirth. Boggy uterus.- is a finding upon physical examination where the uterus is more flaccid than would be expected. It can be associated with uterine atony. It may also be associated with adenomyosis. Greast Engorgement.Breast engorgement is when the breasts overfill with milk and the breasts become swollen, hard and painful. Large numbers of women experience this, usually in the first few days after giving birth, although it can also occur later on. During a time when mothers are coping with the demands of a new baby it may be particularly distressing. Breast engorgement may mean that women fail to successfully start breastfeeding, cause them to give up breastfeeding, or serious illness can result, including breast infection. The aim of the review was to examine treatments used to relieve the symptoms of breast engorgement. We included eight randomised controlled trials involving 744 women. Studies examined a range of different treatments for breast engorgement including acupuncture, cabbage leaves applied to the breasts, cold gel packs, pharmacological treatments and ultrasound. For some interventions (ultrasound, cabbage leaves, and oxytocin) there was no strong evidence that interventions led to a more rapid resolution of symptoms, as in these studies women tended to have improvements in pain and other symptoms over time whether or not they received active treatment. There was evidence from one study that, compared with women receiving routine care, women receiving acupuncture had greater improvements in symptoms in the days following treatment, although there was no evidence of a difference between groups by six days, and the study was not large enough to be able to detect meaningful differences for other outcomes such as breast abscess. A study looking at cold packs suggested that the application of cold to the breasts does not cause any harm and may be associated with improvements in symptoms, although differences between the control and cold pack groups before treatment started meant that results were difficult to interpret. The overall conclusions of the review are that although some interventions may be promising, there is not sufficient evidence from well designed trials on any intervention to justify widespread uptake of

that intervention. More research is needed on treatments for this painful and distressing condition. Colostrum.- is a form of milk produced by the mammary glands of mammals in late pregnancy. Most species will generate colostrum just prior to giving birth. Colostrum contains antibodies to protect the newborn against disease, as well as being lower in fat and higher in protein than ordinary milk. Newborns have very small digestive systems, and colostrum delivers its nutrients in a very concentrated low-volume form. It has a mild laxative effect, encouraging the passing of the baby's first stool, which is called meconium. This clears excess bilirubin, a waste product of dead red blood cells, which is produced in large quantities at birth due to blood volume reduction, from the infant's body and helps prevent jaundice. Colostrum is known to contain antibodies called immunoglobulins such as IgA, IgG, and IgM in mammals. IgA is absorbed through the intestinal epithelium, travels through the blood, and is secreted onto other Type 1 mucosal surfaces. These are the major components of the adaptive immune system. Other immune components of colostrum include the major components of the innate immune system, such as lactoferrin, lysozyme, lactoperoxidase, complement, and proline-rich polypeptides (PRP). A number of cytokines (small messenger peptides that control the functioning of the immune system) are found in colostrum as well, including interleukins, tumor necrosis factor, chemokines, and others. Colostrum also contains a number of growth factors, such as insulin-like growth factors I, and II,[ transforming growth factors alpha, beta 1 and beta 2, fibroblast growth factors, epidermal growth factor, granulocyte-macrophage-stimulating growth factor, plateletderived growth factor, vascular endothelial growth factor, and colony-stimulating factor-1. Colostrum is very rich in proteins, vitamin A, and sodium chloride, but contains lower amounts of carbohydrates, lipids, and potassium than normal milk. The most pertinent bioactive components in colostrum are growth factors and antimicrobial factors. The antibodies in colostrum provide passive immunity, while growth factors stimulate the development of the gut. They are passed to the neonate and provide the first protection against pathogens. CVA tenderness.- is elicited when gently tapping the area of the back overlying the kidney producing pain in people with an infection around the kidney (perinephric abscess) or pyelonephritis or renal stone. Since the kidney lies directly below this area, known as the costovertebral angle, tapping disturbs the inflamed tissue causing pain. Diastasis recti .- Diastasis recti is a separation between the left and right side of the rectus abdominis muscle, which covers the front surface of the belly area. Episiotomy.- Episiotomy is a procedure in which the skin between the vagina and anus is cut. (This area is called the perineum.) Episiotomy is done occasionally to enlarge the vaginal opening so that a baby can be more easily delivered.

Just before the baby is born, the obstetrician numbs the vaginal area opening and makes one of two cuts: A mediolateral cut is angled down away from the vagina and into the muscle. A midline cut is made straight down between the vagina and anus. The cut makes the opening to the vagina bigger. The cut is stitched closed after the baby and placenta have been delivered. Homans sign.- Homans' sign is a sign of deep vein thrombosis (DVT). A positive sign is present when there is pain in the calf or popliteal region with examiner's abrupt dorsiflexion of the patient's foot at the ankle while the knee is flexed to 90 degrees. This sign is frequently elicited in clinical practice because of the ease of use, although it is falling into disfavor because of poor reliability and because it is frequently positive in individuals without DVT. A positive Homans' sign does not positively diagnose DVT (poor positive predictive value), and a negative Homans' sign does not rule out the DVT diagnosis (poor negative predictive value). It is named for the American physician John Homans. Fundus.- The fundus of the uterus is the top portion, opposite from the cervix. Fundal height, measured from the top of the pubic bone, is routinely measured in pregnancy to determine growth rates. If the measurement is smaller or larger than what would be expected for gestational age, it can be a crude indicator of an abnormality (for example, a breech or sideways presentation, twins, or a placental issue), requiring further tests such as ultrasound to determine the exact nature of the problem, if any. Lochia.- lochia is post-partum vaginal discharge, containing blood, mucus, and placental tissue. Lochia discharge typically continues for 4 to 6 weeks after childbirth. It progresses through three stages. Lochia rubra (or cruenta) is the first discharge, red in color because of the large amount of blood it contains. It typically lasts no longer than 3 to 5 days after birth. Lochia serosa is the term for lochia which has thinned and turned brownish or pink in color. It contains serous exudate, erythrocytes, leukocytes, and cervical mucus. This stage continues until around the tenth day after delivery. Lochia alba (or purulenta) is the name for lochia once it has turned whitish or yellowish-white. It typically lasts from the second through the third to sixth week after delivery. It contains fewer red blood cells and is mainly made up of leukocytes, epithelial cells, cholesterol, fat, and mucus. Lochia generally has an odor similar to that of normal menstrual fluid. Any offensive odor indicates contamination by saprophytic organisms and should be reported to a healthcare

provider. Lochia which is retained within the uterus is known as lochiostasis or lochioschesis. Lochiorrhea is the term used when there is abnormal flow of lochia. Perineal lacerations.- laceration of the perineal area such as by the birth of a foal. Three degrees of severity are recognized. First degree laceration is when only the mucosa of the vulva and vagina are involved. Second degree is when the submucosa and muscularis layers of the vulva, the anal sphincter and the perineal body are involved. Third degree is when there is also tearing through the rectovaginal septum, the muscles of the vagina and rectum, and the perineal body. 1st degree perineal lacerations are least serious. There may be nicks and tears around the opening of the vagina, but the tears are only skin deep. The tears are so superficial that they dont require any suturing. 1st degree lacerations heal very quickly, because they area is endowed with a rich blood supply. 2nd degree perineal lacerations are a bit more involved. These tears penetrate the vaginal mucosa and into the muscles. These tears are sutured with stitches that dissolve in a few weeks. By the time the tears are healed the stitches are gone. 3rd and 4th degree perineal lacerations occur most likely when an episiotomy has been preformed. As the baby is delivered the area that has been cut with an episiotomy tears on its own; the head and shoulders of the baby stretch the tissue that has been cut by the episiotomy. Women most at risk for 4th degree perineal lacerations are first time mothers with an episiotomy; however 4th degree perineal lacerations can occur with a very large baby, or if the deliver is being assisted with forceps. A posterior delivery, one in which the baby is born with its face pointing up, is another factor that could cause huge tears. If at all possible when the baby is presenting face up, the doctor will try to turn the baby before the delivery. Sometimesif the baby is bigto prevent the trauma of 4th degree perineal lacerations, the doctor will decide to take the baby by Cesarean Section. Both 3rd and 4th degree lacerations require suturing. A pudendal block is usually administered an injection of local anesthesia into the pudendal nerve in the vaginato numb the vagina and perineal and also rectal area. Repair of 3rd and 4th degree perineal lacerations are very involved. The physician has to suture the area at each layer of muscle and then finally suture on the surface of the perineal area. Postpartum blues/ Postpartum depression.- Postpartum depression is moderate to severe depression in a woman after she has given birth. It may occur soon after delivery or up to a year later. Most of the time, it occurs within the first 3 months after delivery.

Women commonly have mood changes during pregnancy, especially after delivery. These mood changes may be caused by changes in hormone levels. Many non-hormonal factors may also affect mood during this period: Changes in your body from pregnancy and delivery Changes in work and social relationships Having less time and freedom for yourself Lack of sleep Worries about your ability as a mother Feelings of anxiety, irritation, tearfulness, and restlessness are common in the week or two after pregnancy. These feelings are often called the postpartum or "baby blues." These symptoms almost always go away soon, without the need for treatment. Postpartum depression may occur when the baby blues do not fade away or when signs of depression start 1 or more months after childbirth. You may have a higher chance of postpartum depression if you: Are under age 20 Currently abuse alcohol, take illegal substances, or smoke (these also cause serious medical health risks for the baby) Did not plan the pregnancy, or had mixed feelings about the pregnancy Had depression, bipolar disorder (for example, manic depression), or an anxiety disorder before your pregnancy, or with a previous pregnancy Had a stressful event during the pregnancy or delivery, including personal illness, death or illness of a loved one, a difficult or emergency delivery, premature delivery, or illness or birth defect in the baby Have a close family member who has had depression or anxiety Have a poor relationship with your significant other or are single Have financial problems (low income, inadequate housing) Have little support from family, friends, or your significant other

Symptoms The symptoms of postpartum depression are the same as the symptoms of depression that occurs at other times in life. Along with a sad or depressed mood, you may have some of the following symptoms: Agitation or irritability Changes in appetite Feelings of worthlessness or guilt Feeling withdrawn or unconnected Lack of pleasure or interest in most or all activities Loss of concentration Loss of energy Problems doing tasks at home or work Negative feelings toward the baby Significant anxiety Thoughts of death or suicide Trouble sleeping A mother with postpartum depression may also: Be unable to care for herself or her baby Be afraid to be alone with her baby Have negative feelings toward the baby or even think about harming the baby (Although these feelings are scary, they are almost never acted on. Still you should tell your doctor about them right away.) Worry intensely about the baby, or have little interest in the baby. Postpartal chills.An interesting phenomenon of. the immediate puerperium during its first hour is the occurrence of "postpartal chills," which occur in up to a fourth of patients, particularly those who have had an operative delivery under regional anesthesia. One hypothesis is that the chills represent a fetomaternal transfusion reaction, although the cause has not been established.

REEDA.- Evaluating postpartum healing. For wound assessment: RRedness, EEdema, E Ecchymosis, DDischarge / Drainage, A-Approximation Uterine involution.-