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Iontophoresis has been found delivered by the positive pole of the circuit and nega- useful in a variety of conditions such as bursitis discount 200 mg avanafil visa erectile dysfunction vitamin e, plantar tive by the negative avanafil 100mg otc erectile dysfunction drugs recreational use. The galvanic current penetrates fasciitis buy avanafil canada non prescription erectile dysfunction drugs, Peyronie’s disease, allergic rhinitis, edema, into the corium of the dermis only (about 1 mm), not Bell’s palsy, frozen shoulder, fibrositis, dissolution of very deeply into the tissues. The medication is then scar tissue, osteoarthritis, muscular spasm, arthritis, dispersed via capillary circulation to a larger amount tenosynovitis, healing of skin ulcers, lymphedema, of tissue. While the depth of penetration of the current carpal tunnel syndrome, epicondylitis and temporo- and the ionic dispersal are shallow, the field effect mandibular joint disorders (Agresta 2004). The effect of generated is thought by some to affect ionic molecules iontophoresis is generally considered dependent upon at a greater depth. Safety and contraindications Naturopathic indications and application: The galvanic current is relatively safe. Observation of validation of efficacy = 2 the milliamp rule reduces the likelihood of burning In 1955 the American Association of Naturopathic the patient from application of too high amperage. Electrode pads should not be applied applicable in proper form in practically every case over broken skin. Adjunctive galvanic treatment is also recommended The absorption of energy increases kinetic energy, in dysmenorrhea, abscesses, amenorrhea, adhesion and therefore heat increases cellular metabolism in the resorption, bronchitis, colitis, emphysema, endome- treatment field. This is considered the primary effect of tritis, reducing tonsillar swelling, uterine and intesti- diathermy treatment (Jaskoviak 1993d). Another type nal hemorrhage, incontinence, inflammation in its of diathermy application, pulsed short wave dia- second stage, pelvic inflammation, hepatitis, meningi- thermy, was developed in the 1960s. This type of appli- tis, menorrhagia, metrorraghia, migraine, neuralgia, cation allows a pulsed, non-continuous waveform. This theoretically creates an athermal treat- Cordingley (1937) also discusses two techniques that ment where the energy transferred does not apprecia- he describes as ‘general’ and ‘central’ galvanization. The effect of the General galvanization consists of one electrode treatment is theorized to be a product of the primary applied to the sacrum while the other is moved slowly field effect of the energy rather than the secondary along the spine and extremities. General galvani- Thermal effects zation is applied to enhance lymphatic circulation As the tissues resist the flow of current, the physio- (Post-Graduate Study of Naturotherapy 1938a). The result of the vibration is friction that Diathermy has been in continuous clinical use for creates a heating effect. Diathermy literally means ‘through 1–2 inches (2–5 cm) depending upon type of applica- heat’. The thermal effects increase tissue perfusion, is one of the deepest produced by physiotherapy increase capillary pressure and cell membrane perme- modalities (Jaskoviak 1993d). The heat is generated ability, relax muscles, increase transfer of metabolites by the resistance of the tissues to the passage of the across cell membranes, increase local metabolic rate, current. The current is an electromagnetic one in the increase pain threshold, increase range of motion and radio wave frequency. The first diathermy units had decrease tension in collagenous tissues, and enhance a relatively long wave and have been superseded by tissue recovery (Prentice 1998a, Starkey 1999d). The degree of heat delivered to the tissue by short For a period of time microwave diathermy units were wave units is not a quantified unit. Heating in tissue produced but have demonstrated some deleterious occurs as the equivalent of the current density squared health risk; their clinical use is uncommon today, and multiplied by the resistance. Doses are measured by their use not the subject of this section (Prentice 1988a, verbal communication from the patient as to the per- Starkey 1999d). The waveform can be delivered in a constant or pulsed fashion at a variety of intensity settings. The electromagnetic energy is a Athermal effects non-ionizing form of radiation produced at a high A field effect is proposed for pulsed short wave dia- frequency with low amplitude. The absorption of the thermy that is independent of thermal impressions electromagnetic energy by the tissues in the treatment and due solely to the influence of the electromagnetic field results in increased kinetic energy and therefore field. The high frequency of the diathermy wave in cellular ion levels and cell membrane potential, due 546 Naturopathic Physical Medicine Figure 12. Photograph courtesy of Mettler Electronics • a more rapid rate of fibrin fiber orientation and deposition of collagen • improvement in collagen formation • stimulation of osteogenesis • improved healing of the peripheral and central nervous systems. Photograph courtesy of Mettler Diathermy has been utilized for decades with a rela- Electronics tively strong safety record (Prentice 1998b). Most of the negative reported effects attributed to diathermy were associated with microwave diathermy and not to the influence of the wave on the cellular sodium with short wave diathermy (Prentice 1998b, Starkey pump that encourages normalization of the cells’ ionic 1999e). This proposed mechanism has not been sub- of pulsed diathermy is not only a validation of the stantiated (Sanservino 1980). Diathermy should not be applied, or only cautiously • increased number of white blood cells, so, directly over most metal implants (dental histiocytes and fibroblasts in a wound fillings and bridgework excluded), as metal selec- • improved rate of edema dispersion tively heats and can burn the patient. Likewise, dia- • enhanced fat activity thermy should not be used over anything wet, as the • encouragement of canalization and absorption water is likely to turn to steam, potentially resulting of hematoma in a burn. Dry towels should always be used and • reduction of the inflammatory process sensible precautions should be taken to ensure that Chapter 12 • Electrotherapy Modalities 547 the area to be treated is dried, so avoiding common thermy treatment is focused primarily upon its clinical errors. Most dental work is safe and no adverse increased local metabolism, muscle relaxation, trigger response to use over fillings or other dental implants point relaxation and increased tissue repair, including has been reported. Patients with a pacemaker or implanted neurological device Naturopathic indications and should not be allowed within a 25 feet (7. These previous indications are all quite useful in the Diathermy is not used directly over the abdomen of daily practice of a naturopathic clinical setting. There pregnant patients, and generally avoided with preg- are quite a number of other applications for which nancy primarily because of its temperature-elevating diathermy has been utilized. The balance of studies on pregnant physio- been reported in a variety of infectious processes and therapist diathermy operators has shown no con- especially various forms of pneumonia (De Groot sistent significant differences in pregnancy outcomes 1964, Kitaigorodskaia 1956, Ravitskii 1954, Saperov or newborn health when compared with controls 1974, Sergeev et al 1986, Uglov 1965). Diathermy (Guberan et al 1994, Larsen 1991, Lerman et al 2001, reduces the viscosity of mucus and is very useful for Taskinen 1990). In an early study of associated with negative outcome appear to involve diathermy, its introduction and use in hospitals the microwave forms of diathermy and the high decreased pneumonia mortality by 50% (Stewart volume of exposure for operators using diathermy 1923). A study on the usefulness of diathermy in all forms of upper re- mutagenicity for short wave radiofrequency has spiratory infections for several decades (Abbott et al demonstrated no negative effect (Hamnerius 1985). Later evaluation of the case reports of patients with pneumonia and high evidence led to a general consensus that the positive fever receiving diathermy treatments with excellent effects were indirect effects primarily of improved outcome have been published (Abbott et al 1945b). If tion of the vis medicatrix naturae and validation of the there is circulatory insufficiency, caution should be naturopathic approach of improving non-specific used with local treatment of an affected area. However, the latter to enhance the natural resolution of infectious admonition will probably change in the future because processes. He categorized that supports local hyperthermia and tumor treat- conditions into constitutional, local or infectious, and ment (Connor et al 1977, Hurwitz et al 2005, Laptev then described the incorporation of diathermy into 2004, Tilly et al 2005). For local conditions such as an ankle sprain in an otherwise healthy indi- vidual a short local application was recommended. If Constant short wave indications: there was constitutional weakness then treatment was validation of efficacy = 5 directed through the liver. Infectious conditions would Diathermy is used wherever deep heating is indi- require a combination of the two strategies – both cated.

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Diminished embryo implanta- social changes occurring in the late 20th and tion combined with the steep rise in the rate of early 21st centuries order avanafil with visa how do erectile dysfunction pills work, a new epidemic is extend- miscarriage account for the substantial decline ing across the Western world and leading to in fertility noted after the age of 453–6 cheap avanafil online master card erectile dysfunction brands. In mod- increase in conception rates has occurred in ern society buy 100mg avanafil free shipping erectile dysfunction pill identifier, the pressure of achieving fnancial, women aged 40 and over, and this trend has career and relationship fulfllments, whilst persisted with no sign of decline. However, ensuring a spontaneous conception, which has this change is juxtaposed against the biological least impact on the conceptus, optimum preg- irony of a signifcant reduction in fertility after nancy outcome and a capacity to withstand the age of 35, which clearly cannot change8. Geneva bourgeoisie, husbands born in 1600–49 age increased by 36% between 1991 and 2001, Canada, marriages 1700–30 and the rate among women 40–44 years of 9 Normandy marriages, 1760–90 age rose by a remarkable 70%. The risk of 500 The age of menarche has decreased over having a Down’s syndrome baby rises with generations, and life span has increased, maternal age, essentially doubling from 1 in 400 but the age of the menopause has remained 725 at maternal age 32 to 1 in 365 at maternal unchanged. At the same time as they are pursuing ing specifc factors that can negatively affect 0 20 25 30 35 40 45 50 their career, they desire to achieve successful the desired outcome of a pregnancy: declining fertility, miscarriage, chromosomal abnormali- Age of wife ties, hypertensive complications, stillbirth and maternal mortality. The possibility of a However, age 41 is generally considered to be 1992 1994 1996 1998 2000 2002 2004 more than 400 pregnancies per 1000 exposed spontaneous pregnancy occurring is less than the point when fertility stops and subfertility women per year, and then begins to decrease Year 2% around the age of 42 and almost 0% after starts. In actuality, fertility reaches its approximately 10 years after the substantial rate is only 100 pregnancies per 1000 exposed 2,14 Figure 2 Trends in average age of patients nadir after the age of 40. The depleted oocytes undergo women between the ages of 35 and 44 wish- for older women, with trends being apparent but only 400–500 eventually undergo ovula- atresia through apoptosis or necrosis18,19. From puberty onward, the loss of fol- Because the ovarian pool of follicles declines outcome with advancing age, as the number the Confdential Enquiries into Maternal and licles is continuous throughout the woman’s exponentially with advancing age, from the age of gametes available is much lower (Table 2). Medical disorders associated with advanced maternal age Table 4 Risk of Down’s syndrome and chromo- malformation for women aged under 25 is Hypertension Obstetric issues somal abnormalities at live birth, according to around 3. Risk of any sion is doubled by the time a woman reaches can lead to obstetric complications such as Maternal age at Risk of Down’s chromosomal 35, compared to its incidence in the preceding placental abruption, fetal malpresentation and delivery (years) syndrome abnormality 26 dysfunctional labor35. This fact, along with the observed Women aged more than 40 years have a 20 1/1667 1/526 aneuploidy reduction in arterial compliance seen with 25 1/1200 1/476 aging, accounts for the increased incidence poor chance of a successful pregnancy, irre- spective of their reproductive history. The risk of fetal loss according to maternalage at conception followed a J-shaped achondroplasia and Marfan’s syndrome, that whether specifc abnormalities are present. More than one-ffth of all preg- It is not just defects resulting from chromo- for aneuploidy is to help those seeking assisted cate chronic hypertension which then results nancies in 35-year-old women resulted in fetal somal anomalies which are more prevalent in conception treatments for infertility to achieve in complications, such as fetal growth restric- loss, and at 42 years of age more than half of the offspring of the older age group, but also a successful pregnancy and to reduce their risk tion and placental abruption29. Whilst it helps to identify chro- such as cardiac defects, club foot, spina bifda, mosomally abnormal embryos, aneuploidy pre-eclampsia in women aged over 35 was loss. Increas- <30 30–34 35–39 >40 The increased incidence of obstetric compli- confounding factors are involved, including ing maternal age shows an association with Maternal age (years) 38,39 cations is intimately associated with the inci- chromosomal alterations, reduced fertility, intrauterine growth restriction. Primary reasons include fetal Stillbirth rate a steady increase with increasing maternal age distress, malpresentation secondary to pel- at conception from 1. To avoid the effects 0 0 41 weeks46, and antepartum hemorrhage from of radiation and cytotoxicity on embryo/fetus, Under 15 15–24 25–34 35–44 45–54 55–64 65–74 75+ either placental abruption or placenta previa34. These conditions who are older requires an understanding of also result in recognized complications of 20 20 the risks involved that result from the com- pregnancy, such as pregnancy induced hyper- 3 plex interplay between age, existing medical 15 2 55 17 15 tension, abnormal fetal growth, placental 8 8 history and antenatal as well as perinatal com- 34 130 abruption and an increased rate of cesarean 10 16 36 10 plications. Moreover, the inevitability of reduced the age of 2, there appear to be no overt dif- to realize that the persisting trend in older age 30 stamina and energy which often accompanies ferences in parenting behavior compared to motherhood is unlikely to be reversed and, 20 older age may have a negative impact on the couples that conceived naturally54. For some, the drive to have children is and outside their control, have found them- Some women will inevitably fall outside of so strong that they willingly risk their liveli- selves facing the prospect of childbearing in this range, for a number of personal and social hoods and even ultimately their own lives for older age. Fertility, family planning, and careers in felds that were conventionally potential beneft in contrast to being a disad- arise from this, as well as to inform women and women’s health: new data from the 1995 occupied by men. Part of this duty includes trying to mount Stat 23 1997;(19):1–114 childbearing in order to reach a point of pro- older parent typically experiences less pres- national and international efforts to facilitate 2. The variability of fessional and fnancial security, or whether the sure in the professional environment, being childbearing with the option of career breaks, female reproductive ageing. Hum Reprod Update pursuit of a better career leads to an unwanted able to spend more time parenting, something an ability to return to full- or part-time work 2002;8:141–54 but inevitable postponement of childbirth. Hum Reprod 1992;7:1342–6 Despite this growing trend, it will probably least, older parents often are better equipped to feel anxious or forced into childbearing 4. The age-related decline in female both parents and children from the perimeno- a child and deal with the hurdles that child- not have to make a choice (however informed fecundity: a quantitative controlled study of pausal pregnancies becomes available to assess rearing presents. For those women who desire to 1996;65:783–90 When children face bereavement and orphan- also mean that older mothers are more conf- have children at an earlier age, they should not 5. Increased maternal age and the Fam Psychol 2004;18:443–52 after age 50: application of oocyte donation Obstet Gynecol 1995;85:65–70 risk of fetal death. It low income may have diffculties with • Patient education regarding pregnancy in all antenatal pregnant women is important to clarify the following points in child care and transportation, or may be risks, management options and reproduc- history on the record: reluctant to seek pre-pregnancy counsel- • Complete blood count with red cell indi- tive alternatives ing. It is for nancy on these conditions and the effect this reason that it was proposed that it be Interventions of such disorders on pregnancy included in a variety of otherwise routine Risk identifcation encounters (see above). The estimated • Referral should be made to a specialist who ment of breasts, thyroid, heart, skin, cervical risk of having a baby with trisomy 21, 18 and cares for patients with diabetes (if contact • Risk factors for adverse outcome These smear and, if indicated, screening for Chlamydia 13 is 6 per 1000 live births at age 35 years, has not been previously established) and, include advancing maternal age, genetic and gonorrhea. Couples should be told that the probability health care provider systems, as numer- of conception is highly dependent on maternal • Women should receive preconceptional Laboratory assessment and screening ous women have multiple risk factors and and, to a lesser extent, paternal age and they folic acid (5mg/day) up to 3 months into are unaware of the adverse pregnancy out- The choice of laboratory tests depends upon should take this into account in family and pregnancy as well as in the months pre- come associated with them. Partners should be screened appropriately and advice sought • Adequate diagnosis and functional assess- Autoimmune disorders (see Chapter 7) if the trait is identifed. Ethnic minorities should be screened or severe disease should be referred to a physician, as preconceptional counseling for particular traits (Asians and Cypri- specialist in asthma therapy and not man- involves knowledge of anti-Ro/La, lupus ots for beta thalassemia; Africans, Afro- Epilepsy (see Chapter 11) aged by the local doctor. Obesity-related hor- • Women who are on mood stabilizing anti- couples who have had a previously abnor- • Megavitamins, non-essential dietary sup- monal changes appear to adversely affect mal fetus, three recurrent fetal losses epileptic drugs should be on 5mg/day of plements and herbal preparations should sperm parameters and can cause erectile or have a personal or family history of a folic acid preconceptionally and during be discontinued, as their risk to the fetus dysfunction. Schizophrenic Caribbeans, Afro-Americans, Asians), Past obstetric and gynecological history is women may be advised to continue main- • All women planning a pregnancy should thalassemia (Mediterranean and Middle important for identifying factors that may con- tenance therapy and discuss the relative be on 400μg/day of folic acid at least 3 Eastern origins), cystic fbrosis, epilepsy, tribute to infertility or pregnancy complica- risks/benefts of the selected agents. Caffeine associated with a reduction in birth weight tion may pose a risk to pregnancy should be • Having a clearly documented immunity advised to discuss this with her employer and in excess of 20 units/week is associ- • According to many publications, caffeine to rubella is important, as primary rubella or occupational health department, if pos- ated with intellectual impairment in the is the most widely consumed substance of infection in the frst 8–10 weeks of preg- child. The safe limit in preg- nancy can result in mental handicap, cata- • High levels of alcohol consumption during ract, deafness, cardiac abnormalities and nancy is thought to be 300mg/day, which pregnancy result in the fetal alcohol syn- growth restriction in the fetus. Caffeine is present in chocolate, cola • Varicella infection in the mother during dation, mental retardation, facial anoma- 9,13,15,16,18 and energy drinks as well as in coffee frst 20 weeks of pregnancy can cause con- lies and behavioral problems. Exercise receive the infuenza vaccine, regardless of • Good communication between primary • It is important to identify women who the stage of pregnancy. Pregnant women and secondary care providers is vital to drink heavily and are likely to continue are also being encouraged to have swine • Women who exercise regularly should be optimize a woman’s health prior to con- drinking throughout pregnancy so that fu vaccine. Inadequate (women with multiple sexual partners, parenteral drug users, household contacts, ing risk factors to the woman and her levels of exercise associated with obesity health care workers) should be offered pregnancy. Women restriction, preterm delivery and sudden and changes in the gonadotropin releasing 9,13,19 Occupational and environmental exposure who are diabetic or on antiepileptic medi- infant death syndrome. Initiation of strenuous • Questions about the woman’s work, hob- tion and offered resources to help them exercise in pregnancy should be avoided, bies, pets and home environment can • An up-to-date cervical smear should have quit smoking. J advice given on the use of over-the-coun- mendations to Improve Preconception Health ciation of alcohol consumption with outcome Environ Pathol Toxicol Oncol 1992;11:7 and Health Care – United States A Report of of pregnancy. Alcohol consumption among pregnant and comes and electromagnetic felds: a brief sum- • If applicable, advice should be given Group and the Select Panel on Preconception childbearing-aged women--United States, mary of the epidemiologic literature. The longer dence of spontaneous abortion among normal clinical content of preconception care: care term outcome of children born to moth- ous small baby should be referred to an women and insulin- dependent diabetic women of psychosocial stressors. J Neurol Neurosurg Psychiatry obstetrician/gynecologist or a specialist whose pregnancies were identifed within 21 2008;199:S362 2004;75:1517–8 center for further investigations and dis- days of conception. The clinical content of preconception care: tice guidelines for the management of women associated with excess thyroid hormone expo- women with psychiatric conditions. Geneva: World The association between anti-thyroid antibod- Women with diabetes, chronic hyper- The clinical content of preconception care: Health Organization, 2005 ies and pregnancy loss.

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Constriction of the airways results in wheezing and difficulty in breathing; gastrointestinal symptoms include abdom- inal pain order avanafil 200mg amex erectile dysfunction caused by nervousness, cramps order 50mg avanafil visa erectile dysfunction qof, vomiting and diarrhoea purchase cheap avanafil on line erectile dysfunction pills comparison. Histamine causes the blood vessels to dilate (lowering blood pressure) and fluid to leak from the bloodstream into the tissues (lowering blood volume). Primary (emergency) treatment for anaphylaxis is administration of adrenaline (epinephrine). Adrenaline prevents worsening of the airway constriction, and stimulates the heart to continue beating. Adrenaline (epinephrine) acts on β-2 adrenergic receptors in the lung as a powerful bronchodilator (opening the airways), relieving allergic or histamine-induced acute asthmatic attack or anaphylaxis. Acute-phase proteins are a class of proteins whose plasma concentrations increase (positive acute-phase proteins) or decrease (negative acute-phase proteins) in response to inflammation. The liver responds by producing a large number of acute-phase reactants or reducing the production of others. Cachexia is loss of weight, muscle atrophy, fatigue, weakness and significant loss of appetite. Related syndromes are kwashiorkor and marasmus, although these are most often symptomatic of severe malnutrition. After the virus has infected the cell, two outcomes are possible; either the virus becomes latent and the infected cell continues to function, or the virus becomes active and replicates, and a large number of virus particles are liberated, which can then infect other cells. Over 25 million people are believed to have died of the infection since its recognition in 1981. A course of antiretroviral treat- ment administered immediately after exposure, referred to as post-exposure prophylaxis, is believed to reduce the risk of infection if begun as quickly as possible. Typically, these classes are two nucleoside analogue reverse transcriptase inhibitors, plus either a protease inhibitor or a non-nucleoside reverse transcriptase inhibitor. New classes of drugs, such as entry inhibitors, provide treatment options for patients who are infected with viruses already resistant to common therapies, although they are not widely available and not typically accessible in resource-limited settings. Other pathways and cycles (urea cycle, haem biosynthesis, cardiolipin synthesis, quinone and steroid biosynthesis) include steps both outside and inside the mitochondria. Paternal sperm mitochondria are marked with ubiquitin to select them for later destruction inside the embryo. Mitochondrial inheritance is therefore non-Mendelian (Mendelian inheritance presumes that half the genetic material of a fertilised egg derives from each parent). Some in vitro fertilisation techniques, such as the injection of a sperm into an oocyte, may interfere with this pattern. The severity of the defect may be great or small: some may cause ‘exercise intolerance’, with no serious illness or disability; other defects can have severe body-wide impacts. Mitochondrial disease begins to become apparent once the number of affected mitochondria reaches a certain level; this phenomenon is called ‘threshold expression’. It is not (ragged red fibre myopathy maternally inherited but rather occurs sporadically. An inherited disorder that usually affects infants encephalomyelopathy) between the age of three months and two years, but in rare cases teenagers and adults as well. Clinical ophthalmoplegia features include adult onset of weakness of the external eye muscles (ophthalmoplegia) and exercise intolerance. Leber’s hereditary optic Results in degeneration of retinal ganglion cells and their neuropathy (Leber optic axons, causing an acute or sub-acute loss of central vision; atrophy) affects predominantly young adult males. Pearson’s syndrome Characterised by sideroblastic anaemia and exocrine pancreas dysfunction. The few patients who survive into adulthood often develop symptoms of Kearns–Sayre syndrome. Symptoms of mitochondrial myopathies include: • muscle weakness or exercise intolerance • heart failure or rhythm disturbances • dementia • movement disorders • stroke-like episodes • deafness • blindness • droopy eyelids • limited mobility of the eyes • vomiting or seizures. Mitochondrial disease is difficult to identify; symptoms may be apparent at birth or appear later in adult life. Many diseases are suspected to be caused in part by dysfunction of mito- chondria, such as diabetes mellitus, forms of cancer and cardiovascular disease, lactic acidosis, specific forms of myopathy, osteoporosis, Alzheimer’s disease, Parkinson’s disease, stroke and many others. A number of changes occur to mitochondria during ageing: tissues from elderly patients show a decrease in enzymatic activity of the proteins of the respiratory chain; large deletions in the mitochondrial genome can lead to high levels of oxidative stress. Hypothesised links between aging and oxidative stress are not new, but there is much debate over whether mitochondrial changes are causes or merely characteristics of ageing. They are however relatively rare, having an incidence of approximately 2 in 10 000 births. Laboratory studies may include blood plasma or cerebral spinal fluid measurement for lactic acid, ketone bodies, plasma acylcarnitines and organic acids in the urine. They are the core components of the brain, the vertebrate spinal cord and the peripheral nerves. Neurons are ‘maintained’ by glial cells; glial cells provide support, nutrients and oxygen, electrical insulation in the form of myelin, and destroy pathogens and remove dead neurons. This charge difference is referred to as the resting potential and is measured in millivolts (=−65mV). A change in polarity of the membrane, an action potential, results in propagation of the nerve impulse along the membrane. An action potential is a temporary reversal of the electrical potential along the membrane that lasts for a few milliseconds. Sodium gates and potassium gates open in the membrane to allow their respective ions to cross. Sodium and potassium ions reverse positions by passing through membrane protein channel gates; sodium crosses first, to the outside, followed by potassium, to the inside. The changed ionic distributions are reset by the continuously running sodium–potassium pump, eventually restoring the original resting potential. Synapses are ‘terminals’ at which the action potential may be arrested, redirected or relayed; synapses at muscle fibres are called neuromuscular junctions (or myoneural junctions). Functional The somatic nervous system is responsible for coordinating voluntary body movements (i. The autonomic nervous system is responsible for coordinating invol- untary functions, such as breathing and digestion. Electrophysiology Tonic or regular-spiking neurons are typically constantly (or tonically) active, for example the interneurons in the neurostriatum. Fast-spiking neurons are notable for their fast firing rates, for example some types of cortical inhibitory interneurons, cells in the globus pallidus and retinal ganglion cells. Thin-spike neurons have narrow action potentials, for example interneu- rons in the prefrontal cortex. Transmitting the nerve impulse across the synaptic cleft involves an electrical to chemical to electrical event (Figure 17. Action potentials travel down the axon of the neuron to its end(s), the axon terminal(s). The synaptic knob is filled with membrane-bounded vesicles containing a neurotransmitter. Arrival of an action potential at the synaptic knob opens voltage-gated Ca2+ channels in the plasma membrane.

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Tears involving the anal This chapter describes the salient points sphincter, however, can have long-term impact that should be covered at the preconceptional on a woman’s quality of life. Bugg and looking for scarring, residual granulation tis- smooth smooth refexes muscle muscle colleagues6 distributed questionnaires on uri- sue and tenderness. At this point, specialist Rectum nary and anal incontinence to 275 primiparous investigations organized to assess anal func- • Rectal sensory function women 10 months after delivery. Interior anal toms of fecal incontinence, the authors noted The apparatus consists of four components: sphincter that only a small proportion had raised the • An intraluminar pressure-sensing catheter External issue with their doctor or midwife. Injury to the pudendal nerve (which is associated with passive anal incontinence, sage of fatus and/or feces) predominates in • Are you able to control your stool? The effect of this type of insult is Having said this, two potentially confound- pareunia and sexual dysfunction also may be also thought to be cumulative and worsens ing factors operate in manometry: frst, large present and play important roles in the wom- • Do you lose fatus when you do not mean with subsequent pregnancies. The following tests help to assess the struc- The rectoanal contractile refex (which are important and are most easily obtained by perusing the patient’s prior delivery related • Do you feel stool coming and you are ture and the physiological function of the anal can be assessed by manometry) is recruited notes. A recent meta-analysis of tears dem- tears at 24–72 hours postpartum using this – a subcutaneous part, which starts onstrated on ultrasound following 717 vaginal modality. They found that the internal sphinc- quantifed by using balloon distension, and at the termination of the internal deliveries showed that the incidence of obstet- the patient may be categorized into the rectal ter was visualized in 100% of patients, while sphincter ric anal sphincter tears was as high as 26. Injury of the external sphincter leads to sional ultrasound allows the digital storage of sensitivity may experience passive (overfow) plete ring around the anal canal formation of avascular scar tissue of uniform volume, employing this method shortens the incontinence, while hypersensitivity may pres- – a deep part. Patients with colleagues12 compared anal endosonogra- had conventional vaginal examination and a Prior to the advent of endoanal ultrasound, fecal incontinence are able to retain as little as phy fndings in nulliparous and age matched study group which was assigned to additional pudendal nerve electrophysiological studies 500ml of saline compared to a normal subject multiparous patients, demonstrating thin- postpartum endoanal ultrasonography. The majority of data come from from small randomized controlled trials, and Asymptomatic Minor symptoms ultrasound studies on nulliparous women and the results larger studies are needed before drawing any should be extrapolated with caution to women conclusions and altering clinical practice. They hypothesized that waiting Cesarean section perineal tears in the study compared to the at least 2 hours before actively pushing would control group, especially in the over 30 years reduce the risk of diffcult operative delivery, of age cohort. Similar results were noted by as measured by cesarean section and midpelvic Figure 4 Flow diagram for the management of obstetric anal sphincter injury in subsequent pregnancies Labrecque and colleagues18 (who reported or low pelvic instrumental delivery rates. Among parous women, this in an attempt to prevent any further com- was similar in women with spontaneous vagi- perineal trauma requiring suturing would Use of episiotomy promise to the sphincter function. Fecally incontinent women who wish to postnatally and found that reported symptoms consider vaginal delivery can have the second- of anal incontinence were similar between the Birthing position otomy caused more posterior perineal trauma ary repair delayed until they have completed two groups (5% vs 8%, p >0. Four women of the origi- who suffered a third or fourth degree tear were second degree lacerations at the time of second was probably attributable to the type of episi- nal 56 had persistent symptoms of anal incon- recruited and followed with anal manometry delivery was 51. In addition, third and fourth injuries in 4015 primiparous deliveries; in ing of their symptoms after the second vaginal were asked to complete a questionnaire per- these women, the recurrence rate of severe birth. Perineal body ing and appears related to the type of episiot- their frst pregnancy and 6–12 weeks postna- thickness was similar irrespective of the degree omy practised in the delivery centers. Br J Surg term anorectal function and quality of life in of women remain fully continent of feces and 1998;105:1262–72 2003;90:1333–7 three groups of women: group 1 consisted of fatus after primary repair and 49% after sec- 2. Management of third and fourth degree peri- next delivered patient with an uncomplicated skill and care, and the consensus statement Obstet Gynecol 2005;106:6–13 neal tears following vaginal delivery. Randomised controlled trial of conserva- Gynecol 2007;29:195–204 and sphincter defects were more persistent in tial litigation become important issues in tive management of postnatal urinary and 16. Prevent- a third of women having their frst vaginal measurements and ultrasound imaging should Obstet Gynecol 1998;92:496–500 ing perineal trauma during childbirth: a sys- delivery may sustain occult sphincter injury39, be counseled that they have a 95% chance of tematic review. Perineal and Anal Sphincter Trauma: Diagno- pushing for nulliparous women in the second recommended that any woman having had an women are carefully examined by digital rectal sis and Clinical Management. London: Springer, stage of labor with continuous epidural anal- instrumental delivery or sustaining a perineal tear examination following subsequent delivery 2006:123 gesia. Tocophobia is an intense anxi- or friends and the support of those caring for ety or fear of pregnancy and childbirth, with them, for others the fear and anxiety remain some women avoiding pregnancy and child- intense and can best be described as ‘a morbid birth altogether3. Under these a flm depicting childbirth early in life with no the woman’s self assessment of how she has what appears to be constant is that intense circumstances, a ‘birth refection’ experience support or explanation. This 11 antenatal period has been associated with an desiring a cesarean section , whereas British pened, why intervention was necessary and may result in a decision to terminate the preg- increased risk of postnatal depression; bond- obstetricians note that their patients are more the implications for future births. By allowing nancy3 or to seek an elective cesarean section ing and attachment towards the baby can also likely to ask for a cesarean section on ‘mater- women the opportunity to go through their as their only alternative2. In one Scandina- continues amongst the obstetric community ary tocophobia) can be identifed and, where Secondary tocophobia regarding the woman’s right to choose how vian study, anxiety and fear were associated necessary, offered support. For some, this may be the frst time childbirth only increases to a phobic level after tify women with intense fear related to child- Primigravidas and multigravidas display simi- they are able to verbalize the trauma they felt they have become pregnant. In Sweden, nearly all obstetric depart- lar symptoms, their fear being so intense that and express their views about future child- people with different phobias who may be able ments have specialized teams to deal with it forces them to request a cesarean section, birth. Others are able to say that although they to have some control over their situation by patients exhibiting intense anxiety; these as labor and vaginal birth are too diffcult to means of avoidance, the pregnant woman can- teams include experienced midwives, obste- wanted more children, they felt their previous contemplate3. She is caught in a tricians, psychologists, social workers and experience and the fear surrounding it pre- cal symptoms may also be present in the form situation for 9 months until she is forced to occasionally a psychiatrist11. In allowing wom- of sleeplessness, crying episodes, restlessness approach the unknown, uncontrollable and efforts underscores the fnding of Saisto et al. Such women may birth affected about 1 in 20 women6; of those anxiety in relation to childbirth, the quality have broken down at an antenatal appoint- Raphael-Leff states that a woman’s mental affected, approximately 50% feared for the and intensity of the fear is different for wom- ment or walked out of a parent education class state, particularly her anxiety level during baby’s health and 40% feared the pain itself. However, there was a strong sense A woman presenting with secondary tocopho- ment if she so wished, thus allowing the wom- valued, unable to share their real fear of dying. The community midwife recog- labor ward and obstetric theaters, and intro- second stage being described, as like trying to fear they were able to share something that nized her distress and offered her support. The ducing the woman (and partner, if present) to get ‘something the size of a melon through an was so profound to them, this fear and dread woman sobbed uncontrollably as she remem- members of staff. The woman labored well and They felt that a cesarean section was their only build the trust between the midwife counselor one of a traumatic experience where she felt achieved a spontaneous vaginal birth. This fear was so great that they also and the women who were able to learn how no one had listened to her or involved her in er refection of her birth, her experience was appeared to be in denial of their pregnancy. The mid- natal depression for 2 years following the birth that people had listened to her and included years, although few in numbers, they all pre- wife counselor, with the permission of the and was treated with medication. Eventually with pressure from their ive, there were staff who felt that all women caught, because she also felt she could not go partner, they agreed to have a baby and, while have anxieties about birth and that this was through labor again. In our experience, primigravi- were overjoyed by the pregnancy, the women staff were in the minority, one cannot ignore to share her feelings with the midwife coun- das had not shared their fear with anyone, even were struck by fear and in denial, seeking the fact. They often avoided antenatal the idea of a vaginal birth as opposed to a cesar- inside of her, and felt sickened when anyone when pressure from a partner to start a family classes or only attended some of them. Although support was applied that they were able to confde that also disclosed, in the attempt not to confront the midwife counselor discussed with the was provided it was not until the 36th week they had a fear of childbirth, and in some cases their pregnancy, that they were often unable women the possibility of a vaginal birth. These of pregnancy that she dared think about ‘the this did not happen until well into the preg- to enter baby shops to look at baby equipment women often stated that they really wanted a alien’ as her baby. The common factor that they all shared or clothes, and often were unable to buy any vaginal birth but that a cesarean section was herself to walk past baby items and purchase was that in the process of giving birth and in of the items required to create a nursery.

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