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For the same reason cheap provera 10mg without a prescription pregnancy exercises, patients with sickle cell disease are at greater risk for osteomyelitis with Sa lmon ella spp buy provera on line menstrual anemia symptoms. Acute chest syndrome is a vaso - occlu sive cr isis wit h in the lu n gs an d m ay b e asso - ciat ed wit h in fect ion or pulmonar y in farct ion purchase provera on line amex pregnancy week 8. It is ch aract er ized by the pr esen ce of the following signs and symptoms: new pulmonary infiltrate cheap provera 10mg without prescription menopause osteoporosis, chest pain, fever, and respiratory symptoms such as tachypnea, wheezing, or cough. T h ese episodes may be precipitated by pneumonia causing sickling in the infected lung segments, or, in the absence of infection, intrapulmonary sickling can occur as a primary event. It is virtually impossible t o clinically dist inguish whet her or not infect ion is present ; thus, empiric antibiotic therapy is used. Aplastic crisis occurs secondary to viral suppression of red blood cell precur- sors, most often by parvovirus B19. It occurs because of t he very short half-life of sickled red blood cells and consequent need for brisk eryt hropoiesis. If red blood cell pr odu ct ion is in h ibit ed, even for a sh or t t ime, pr ofou n d an em ia may r esu lt. Other complications of sickle cell disease include hemorrhagic or ischemic st roke as a result of t h rombosis, pigment ed gallst ones, papillary necrosis of t he kidney, priapism, pulmonary hypertension, and congestive heart failure. Tr e a t m e n t The mainstay of treatment of pain crisis is hydration and pain control with nonste- roidal anti-inflammatory agents and narcotics. O ne must search diligently for any underlying infect ion, and ant ibiot ics are often used empirically when infect ion is suspect ed. In general, blood transfusions may be required for aplastic crisis, for severe hypoxia in acute chest syndrome, or to decrease viscosity and cerebral thrombosis in pat ient s wit h st roke. To protect against encapsulated organisms, all patients with sickle cell disease should receive penicillin prophylaxis and a vaccination against pneumococcus. Hydroxyurea is oft en used t o reduce t he occurrence of painful crisis by st imulat ing h emoglobin F production and thus decreasing hemoglobin S concentration, and should be con- sidered in pat ient s who have repeat ed episodes of acut e chest syndrome or frequent severe pain crises. The ant ineoplast ic agent 5-deoxyazacyt idine (decitabine) may also elevat e levels of hemoglobin F wit hout excessive side effect s. Endothelin receptor agonists such as bosentan can improve pulmonary hypertension caused by sickle cell disease. Becau se of the n u m er o u s t r an sfu sio n s, so m et im es ir o n ch e- lat ors are needed t o prevent iron overload (wh ich may lead t o h eart or liver failure). Em e r g i n g Co n c e p t s Research is being concentrated on allogeneic hematopoietic stem cell transplanta- tion, which can be curative. In children with severe disease, myeloablative stem cell transplantation has been effective with approximately 10% side effects if there is sufficient mat ched donor such as a sibling; however, adult s have more complica- tions and there is ongoing studies to find an optimal stem cell transplantation pro- cess. G en e t h er apy is on ly in it s in it ial st ages of r esear ch but h old s pr om ise. H ydroxyurea and decitabine may decrease the incidence of sickle cell cri- ses by increasing levels of hemoglobin F. Parvovirus B19 is associated with aplastic crisis, especially in individuals wit h sickle cell disease. Pat ient s wit h sickle cell disease are at risk for Sa lmon ella ost eomyelit is. He su ffe re d m u lt ip le co n t u sio n s an d a fe m u r fract u re that was surgically repaired 24 hours ago. His h o sp it a l co u rse h a s b e e n u n co m p lica t e d, a n d the o n ly medications he currently is taking are morphine as needed for pain, and sub- cutaneous enoxap arin for prophylaxis of deep venous thrombosis. He is c u rs in g a the n u rs e s a n d is t r yin g t o g e t o u t o f b e d t o le a ve the h o s p it a l. Wh e n yo u s e e h im, h e is fe b r ile w it h a t e m p e r a t u r e o f 1 0 0. He is disoriented to place and time; he seems to be having auditory hallucinations and is brushing off unseen objects from his arms. On examination, his forehead wound is bandaged, his pupils are dilated but reactive, and he is mildly diaphoretic. His lung sounds are clear to auscultation, his heart rhythm is tachycardic but regular, his abdomen is benign, and he is tremulous. They confirm that prior to his car accident, the patient had no medical problems, had no dementia or psychiatric illness, and was employed as an attorney. They report that he took no medications at home, did not smoke or use illicit drugs, and drank at least three to four mixed drinks every day after work, sometimes more on the weekends. T his evening he is agitated and combative, and he is trying to leave the hospital. H e is awake, fidgety, and disoriented, and he seems to be having auditory and t act ile hallucinat ions. Family members confirm that the patient had no medical prob- lems and no dementia or psychiatric illness. H e took no medications, did not smoke or use illicit drugs, and drank three to four mixed drinks every day after work. Most likely diagnosis: Delirium as a result of an acute medical illness or pos- sibly alcohol wit hdrawal. Next step: Look for serious or reversible underlying medical causes for the delirium. If no other medical problems are identified, based on the patient’s daily alcohol use, a possible diagnosis is alcohol withdrawal syndrome. Know the special considerations applicable to an elderly demented patient with delirium. Co n s i d e r a t i o n s T his 57-year-old man had been in a normal physical and mental state prior to hos- pitalization. H e then developed an acute change in mental status, with fluctuating consciousness and orientation, the hallmark of delirium. T hese conditions require investiga- tion before ascribing the symptoms to alcohol withdrawal, because they are poten- tially very serious or even fatal. The use of a benzodiazepine such as lorazepam is a fundamental part of the treatment regimen. Many Americans are also habituated to benzodiazepines, and the withdrawal syndrome is similar to alco- hol withdrawal. Thus, with the sudden cessation of alcohol, these excitatory neurotrans- mitters are unopposed, leading to profound effects. The disturbance develops over a short period (usually hours to days) and tends to fluctuate during the course of the day. Evidence that the above feat ures are caused by a medical condit ion, medica- tions, or intoxicants One of the earliest signs of a disturbance of consciousness is an inability to focus or sustain attention, which may be evident as distractibility in conversation. In alcohol withdrawal, signs of autonomic hyperact ivit y predominate, and pat ient s may become hypervigilant and agit ated. As symptoms progress, pat ient s may become lethargic or even stuporous (arousable only to painful stimuli). Regarding changes in cognition or perception, patients may have difficulty with memory, orientation, or speech. It is important to ascertain from family members wh et h er t h ese impairment s were ch ronic, as in dement ia, or developed acut ely.
D uration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock discount provera breast cancer awareness quotes. Sin ce h is o p e ra t io n buy 5 mg provera with mastercard history of women's health issues, the p a t ie n t h a s h a d in t e rm it t e n t fe ve rs t o 3 9 purchase cheap provera on line pregnancy ultrasound at 5 weeks. He h a s o n ly t o le ra t e d m in im a l o ra l fo o d in t a ke s in ce s u rg e r y s e co n d a r y t o abdominal bloating and distension purchase provera in united states online pregnancy knee pain. His indwelling urinary catheter was removed on p ostop e rative day 2, and he d enies any urinary symp toms. The p ulmonary exami- nation reveals normal breath sounds in both lung fields, and his heart rate is re g ular with out m urm urs. His ab d om e n is d iste n d e d an d te n d e r th roug h out, and the surgical skin incision is open without any evidence of infection. His cur- re nt m e d ication s in clud e m ain te n an ce intrave n ous fluid s, m orp h in e sulfate, and intravenous cefoxitin and metronidazole. H is ph ysical exam in at ion d oes n ot r eveal r espir at or y, urinary, or superficial surgical site infection. Most likely diagnosis: Deep surgical space infection or intra-abdominal infect ion. Need for an operation: Although his clinical course and current condition are con cer n in g, h e d oes n ot h ave a clear in d icat ion for r e-explor at ion of the abd o- men at this time. Operative intervention and percutaneous drainage are two import ant met hods t o achieve source cont rol in a pat ient wit h deep surgical space infect ion, if confirmed. Recognize the sources of fever in postoperative patients and become familiar with diagnostic and treatment strategies for these patients. Learn the principles of diagnosis and treatment of intra-abdominal infections in t he postoperat ive pat ient. Co n s i d e r a t i o n s When a patient fails to improve and exhibits persistent fever following definitive surgical t reat ment for an int ra-abdominal infect ious process, we must first ent er- tain the possibility that there are still untreated intra-abdominal infections. We must also consider other potential nosocomial infectious causes, as well as non- infect ious causes for h is fever. Given t he picture of persist ent ileus and fevers, t he possibility of intra-abdominal (deep surgical space) infection should be at the top of our differential diagnosis. W ith his current picture, it is not unreasonable to init iat e broad-spect rum ant imicrobial t herapy t arget ing G I t ract microbial flora. W hen identified, some intra-abdominal abscesses can be accessed and drained by percutaneous approaches (Figure 4– 1). Persistent secondary peritonitis can be the result of inappropriate or inad- equat e ant imicrobial t h erapy, wh ich can be addressed wit h addit ional ant imicrobial therapy or modification of antimicrobial regimen. Dive rt icu la r a b sce ss n o t e d b y a rro w (A) an d the n e vacu at e d b y co m p u t e r t o m o g rap h y– guided percutaneous drainage (B). They are treated primarily by wound explorat ion and drainage; systemic ant ibiot ics may be added when t here is ext en- sive surrounding cellulit is (> 2 cm from the incision margin) or if t he pat ient is immunocompromised. D eep surgical site infect ions may be a clinical manifestation of a deep surgical space infection. This type of infect ion in the sett ing of post abdominal surgery can include seconda r y per it on it is, tertiary peritonitis, an d deep surgical space abscess. Recurrence or persistence of this process can be due to insufficient ant imicrobial t herapy or insufficient cont rol of cont aminat ion process (inadequate source cont rol). Very often in these cases, low virulence or opportunist ic pathogens such as Staphylococ- cus epidermis, Enterococcus faecalis, or Candida sp ecies are id en t ified. T h e t r eat m en t for this con dit ion is somewh at un clear because most cases are relat ed t o poor h ost immune responses. T h e response produces loculat ed, infect ed inflam- matory fluid that cannot be eliminated by the host trans-lymphatic clearance pro- cess. W h en the abscesses are sizeable, su r gical or p er cut an eou s dr ain age are n eed ed to resolve this process. In t h ese sit u at ion s, the t h er apy sh ou ld be in it ially br oad an d t ar get Gram-positive and Gram-negative bacteria. The optimal therapeutic duration and end-point s of t reat ment wit h t his st rat egy remains cont roversial. In general, as t he patients improve clinically and culture results become available, de-escalation of treatment is appropriate. Severe sepsis is defined as sepsis plus sepsis-related organ dysfunction or hypoperfusion. Septic shock is defined as sepsis-induced hypotension that persists despite adequate fluid resuscitation. The Surviving Sepsis Campaign h as in t r o d u ced bundles of care for septic patients. These guidelines, based on basic science and clin ical evid en ce, were in it ially int r odu ced in 2001 an d h ave been r egu lar ly up d at ed, valid at ed, an d im p lem en t ed in t er n at io n ally. These can include infect ions related t o t he original disease and the operat ive processes, such as secondary perit onit is, int ra-abdominal abscess, and surgical sit e infec- tion. In addition, hospital-acquired infections can also occur, including urinary tract infection, pneumonia, catheter-related bacteremia, and antibiotic-associ- ated colit is. The approach to a febrile postoperative patient who has undergone abdominal surgery is to presume that there is an intra-abdominal or surgical site related infectious complication until proven otherwise. The severity of the peritoneal contamination is related to the intestinal location of the perforation, which determines the concentration and diversity 11 14 of the endogenous microbes (ie, colon contents with 10 to 10 aerobic and anaerobic 2 3 microbes per gram of contents versus stomach contents with 10 to 10 aerobic microbes per gram of contents). A number of adaptive host defense responses occur following the inoculat ion of bact eria int o the perit oneal cavit y. Removal of the in fect ion occurs with translymphatic clearance of the sequestered microbes and inflamma- tory cells to help resolve the process. Several factors can influence the effectiveness of the host response, and include the following: (1) the size of the micr obial in ocu- lum; (2) the t iming of diagnosis and t reat ment ; (3) the in h ibit or y, synergist ic, or cumulat ive effect s of microbes on the growt h of ot h er microbes; (4) effect iveness of the host peritoneal defense. Tr e a t m e n t G o a l s The goals in the management of secondary peritonitis are directed toward elimi- nating the source of the microbial spillage (eg, an appendectomy for perforated appendicit is or closure of a perforated duodenal ulcer) and early init iat ion of preemptive antibiotic therapy. With appropriate and timely therapy, second- ary peritonit is resolves in most pat ient s; however, approximately 15% to 30% of the treated individuals may develop complications such as recurrent secondary peritonitis, tertiary peritonitis, or intra-abdominal abscesses. Recurrent second- ary peritonit is can be due to inappropriate ant ibiot ics or insufficient ant ibiot ic treatment duration. The initial systemic antibiotics for patients with infect ions from G I sources should include coverage of t he most likely pat hogens. Table 4– 1 cont ains some of the common ant imicrobial agent s or regimens that are used. A r upt ured appen dix wit h pur u lent drain age is n ot ed in the lower abdomen.
Therapeutic Uses Seizure Disorders Phenobarbital is used for seizure disorders (see Chapter 19) buy cheapest provera women's breast health issues. However purchase provera 5 mg with mastercard breast cancer 993, because they can cause multiple undesired effects discount 2.5 mg provera menstrual gas relief, barbiturates have been replaced by benzodiazepines and related drugs as treatments of choice for insomnia cheap provera 2.5mg fast delivery breast cancer xmas tree. Adverse Effects Respiratory Depression Barbiturates reduce ventilation by two mechanisms: (1) depression of brainstem neurogenic respiratory drive and (2) depression of chemoreceptive mechanisms that control respiratory drive. Doses only 3 times greater than those needed to induce sleep can cause complete suppression of the neurogenic respiratory drive. For most patients, the degree of respiratory depression produced at therapeutic doses is not significant. However, in older-adult patients and those with respiratory disease, therapeutic doses can compromise respiration substantially. Because of their toxicity, the barbiturates are frequently employed as vehicles for suicide and hence should not be dispensed to patients with suicidal tendencies. Abuse Barbiturates produce subjective effects that many individuals find desirable. The barbiturates that are most prone to abuse are those in the short- to intermediate-acting group (e. Although barbiturates are frequently abused in nonmedical settings, they are rarely abused during medical use. Acute Toxicity Acute intoxication with barbiturates is a medical emergency: left untreated, overdose can be fatal. Poisoning is often the result of attempted suicide, although it can also occur by accident (usually in children and drug abusers). Symptoms Acute overdose produces a classic triad of symptoms: respiratory depression, coma, and pinpoint pupils. Treatment has two main objectives: (1) removal of barbiturate from the body and (2) maintenance of an adequate oxygen supply to the brain. Administration Oral administration is employed for daytime sedation and to treat insomnia. Patients should be warned not to increase their dosage or discontinue treatment without consulting the prescriber. Some people have difficulty falling asleep, some have difficulty maintaining sleep, some are troubled by early morning awakening, and some have sleep that is not refreshing. In any given year, about 30% of Americans experience intermittent insomnia, and about 10% experience chronic insomnia. In the United States the direct costs of insomnia total about $16 billion a year, including the costs of testing, prescriber visits, and hypnotic drugs. As a result of sleep loss, insomniacs experience daytime drowsiness along with impairment of mood, memory, coordination, and the ability to concentrate and make decisions. Chronic insomnia is a major risk factor for automotive and industrial accidents, marital and social problems, major depression, coronary heart disease, and metabolic and endocrine dysregulation. Sleep is frequently lost owing to concern regarding impending surgery and other procedures. Basic Principles of Management Cause-Specific Therapy Treatment is highly dependent on the cause of insomnia. Accordingly, if therapy is to succeed, the underlying reason for sleep loss must be determined. When the cause of insomnia is a known medical disorder, primary therapy should be directed at the underlying illness; hypnotics should be employed only as adjuncts. For example, if pain is the reason for lost sleep, analgesics should be prescribed. If insomnia is secondary to major depression, antidepressants are the appropriate treatment. Nondrug Therapy For many insomniacs, nondrug measures may be all that is needed to promote sleep. For some individuals, avoidance of naps and adherence to a regular sleep schedule is sufficient. If environmental factors are responsible for lack of sleep, the patient should be taught how to correct them or compensate for them. All patients should be counseled about sleep fitness (also known as sleep hygiene). This will help condition your brain to see the bedroom as a place where sleep happens. Research has shown that cognitive behavioral therapy is superior to drug therapy for both short-term and long-term management of chronic insomnia in older adults. Cognitive and behavioral interventions include sleep restriction, control of the bedroom environment, progressive relaxation, and education about sleep hygiene. The American Academy of Sleep Medicine considers these interventions both effective and reliable and hence recommends them as first- line therapy for chronic insomnia, even if drug therapy is also employed. Therapy With Hypnotic Drugs Hypnotics should be used only when insomnia cannot be managed by other means. Hence, before resorting to drugs, we should implement nondrug measures, and we should treat any pathology that may underlie inadequate sleep. The patient should be reassessed on a regular basis to determine whether drug therapy is still needed. If hypnotic effects are lost in the course of treatment, it is preferable to interrupt therapy rather than elevate dosage. Interruption will allow tolerance to decline, thereby restoring responsiveness to treatment. Patients who snore heavily and those with respiratory disorders have reduced respiratory reserve, which can be further compromised by the respiratory-depressant actions of hypnotics. Hypnotic agents are generally contraindicated for use during pregnancy; these drugs have the potential to cause fetal harm, and their use is rarely an absolute necessity. When hypnotics are employed, care must be taken to prevent drug- dependency insomnia, a condition that can lead to inappropriate prolongation of therapy. Upon cessation of treatment, a mild withdrawal syndrome occurs and disrupts sleep. Failing to recognize that the inability to sleep is a manifestation of drug withdrawal, the patient becomes convinced that insomnia has returned and resumes drug use. Continued drug use leads to heightened physical dependence, making it even more difficult to withdraw medication without producing another episode of drug-dependency insomnia. That is, they should be used in the lowest effective dosage for the shortest time required. Major Hypnotics Used for Treatment Insomnia can be treated with prescription drugs, nonprescription drugs, and alternative medicines. Among the prescription drugs, benzodiazepines and the benzodiazepine-like drugs (zolpidem, zaleplon, and eszopiclone) are drugs of choice. Nonprescription drugs and alternative medicines are much less effective than the first-choice drugs and hence should be reserved for people whose insomnia is mild. Drugs such as flurazepam, which have both a rapid onset and long duration, are good for patients with both types of sleep problems. Benzodiazepines have multiple desirable effects on sleep: they decrease the interval to sleep onset, decrease the number of awakenings, and increase total sleeping time.
A 36-year-old woman in her second pregnancy is admitted in early labour with ruptured membranes purchase discount provera on-line women's health clinic penrith. A 34-year-old woman is seen in the antenatal clinic with a history of lower abdominal pain for the past 4 days purchase 2.5mg provera overnight delivery pregnancy quickening. Gram-negative bacteria Instructions Each clinical scenario described below tests knowledge about the most probable cause of sepsis in a woman postnatally generic 5mg provera amex women's health problems in sri lanka. A 36-year-old woman who had an emergency caesarean section 5 days ago has presented feeling unwell with lower abdominal pain provera 5 mg low cost womens health physical therapy. She is seen by the community midwife, who notices that she looks unwell and checks her temperature, which records 39. The woman is sufering from abdominal pain and loin pain, and was treated for urinary tract infection while pregnant. A 38-year-old woman is brought by ambulance in a state of shock, with sudden-onset lower abdominal pain. She had a baby a week ago and sufered from a recent sore throat, for which she has been taking paracetamol. Breastfeeding is contraindicated if the woman has inverted nipples during the puerperium. Late onset afer one week with signs of bleeding from unusual sites, possibly due to organic pathology 6. Most deaths due to obstetric haemorrhage in the report were due to substandard care. More than 90% of the neonates born vaginally are colonized with chlamydia in the presence of maternal infection. Only half of the exposed neonates will develop conjunctivitis in the frst 1–2 weeks afer birth, in the presence of maternal infection. Anti-D administration is not necessary following a miscarriage afer 20 weeks’ gestation. Partial breast and bottle feeding can be used as lactation amenorrhoea method of contraception E. Ergometrine should be avoided if possible in women with pre-eclampsia as it can cause sudden increase in blood pressure E. About 30% of the blood loss causes mild shock with vasoconstriction in the skin and muscles. Blood loss of 40% or more of blood volume is associated with severe shock afecting heart and brain. The use of postoperative laxatives is recommended to reduce the incidence of postoperative wound dehiscence. Rectovaginal and anovaginal fstulas are common complications of third- and fourth-degree perineal tears. Hence prophylactic oxytocics should be ofered to all women routinely in the third stage of labour. Answer 2: B Neonatal complications of diabetic pregnancy include hypoglycaemia, hypocalcaemia, hypomagnesaemia, hypothermia, respiratory distress syndrome, jaundice, polycythaemia, cardiomegaly and birth trauma including shoulder dystocia leading to Erb’s palsy, fractures and birth asphyxia. Answer 3: C The umbilical cord contains two umbilical arteries and one umbilical vein embedded into the Wharton’s jelly. The arteries carry deoxygenated blood from the fetus to the placenta and the umbilical vein carries oxygenated blood to the fetus from the placenta. Answer 4: B Puerperal pyrexia is defned as a maternal temperature of ≥38°C maintained over 24 hours or recurring in the frst 10 days afer childbirth or abortion. Prolonged labour, prolonged rupture of membranes, intrapartum pyrexia, operative delivery, multiple pelvic examinations, episiotomy, vaginal tears, vulvovaginal hematomas and anaemia are predisposing factors. Answer 5: E Puerperal psychosis is a psychiatric emergency, occurring in about 1 in 500 pregnancies and associated with a suicide rate of 5% and an infanticide rate of up to 4%. It usually presents within 2 weeks of delivery and symptoms include delusions, hallucinations, irritable behaviour and suicidal thoughts or thoughts of harming the baby. Active surveillance by the British Paediatric Surveillance Unit reported an incidence of 1:60,000 live births annually. Disseminated infection with multiple organ involvement Infant mortality is <2% with treatment in localized skin, eye and mouth infection. In disseminated herpes in the newborn mortality is around 30% if treated with antiviral treatment. Answer 8: C If maternal infection occurs at term, there is a signifcant risk of varicella of the newborn. Ideally elective delivery should normally be avoided until 5–7 days afer the onset of maternal rash to allow for the passive transfer of antibodies from the mother to the fetus. In this case, this woman presents with spontaneous onset of labour and has delivered within 7 days of onset of chickenpox rash. The newborn baby should be monitored for signs of infection until 28 days afer the onset of maternal infection. If the newborn baby develops neonatal varicella, the treatment would involve intravenous acyclovir following discussion with a neonatologist and virologist. Postnatally, if there is contact with chickenpox in the frst 7 days of life, no intervention is required if the mother is immune (the baby would have received passive immunity from the mother). C The most likely diagnosis is endometritis in view of the history, symptoms and signs of high temperature, lower abdominal pains, and uterine tenderness with a heavy ofensive lochia. E Postnatal depression usually occurs within the frst 4 to 6 weeks and the symptoms include one or more of the following: tearfulness, irritability, low mood for long durations, lack of interest in herself or her baby, unable to cope and sleep, feeling guilty, thoughts of harming herself or baby. Postpartum blues occur between days 3 to 10 afer delivery and the symptoms spontaneously resolve within a few days without any treatment. Symptoms can include brief episodes of mood lability, tearfulness, poor sleep and irritability; reassurance and support are the mainstay of management. G If suppression of lactation is not done with bromocriptine-related preparations in women with intrauterine fetal death or stillbirths, breast engorgement occurs during the frst day or two. Supportive measures and expression of breast milk are the mainstays of treatment while lactation suppression becomes efective. C Brachial plexus injury is one of the most important complications of shoulder dystocia though its overall incidence is low. Other fetal complications associated with shoulder dystocia include fractures of the humerus and clavicle, pneumothoraces and hypoxic brain damage. G Asphyxia is a state where placental or pulmonary gas exchange is compromised resulting in cardiorespiratory depression. Terapeutic neonatal hypothermia, where the body temperature is lowered to 33–34°C for 72 hours, is benefcial in reducing the rate of neurodevelopmental disability in survivors. H Chignon is the well-recognized mound of scalp tissue and oedema formed at ventouse delivery as the fetal scalp is drawn into the ventouse cup during the creation of vacuum. C For uncompromised babies, a delay in cord clamping of at least one minute from the complete delivery of the infant is recommended by the neonatal resuscitation council. Infuenza vaccination can also be safely administered in pregnancy and the decision to immunize depends on the time of year.
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