Chapter 10 Flashcards
(160 cards)
1
Q
what is dystocia?
A
- dysfunctional or difficult labor
- sometimes called “failure to progress”
2
Q
what is the most common reason for a c-section?
A
dystocia
3
Q
what factors are associated with dystocia?
A
- powers: uterine contractions are ineffective
- passenger: fetal presentation, position or development
- passage: bony pelvis is not adequate
4
Q
uterine dystocia indicates __
A
weak or uncoordinated contractions
- hypotonic contractions
- hypertonic contractions
5
Q
hypotonic contractions
A
- low tone
- do not promote cervical dilation
- shape is kind of stretched out
6
Q
hypotonic contractions: what are women at risk for?
A
- exhaustion
- infection
7
Q
hypotonic contractions: what is the fetus at risk for?
A
- intolerance of labor
- asphyxia
8
Q
hypotonic contractions: risk factor
A
multiparous women
9
Q
hypotonic contractions: management
A
- determine cause
- consider augmenting with oxytocin
- amniotomy
- c section
10
Q
hypertonic contractions
A
- uncoordinated contractions
- frequent
- very painful
- shape is very up and down/ ridged
11
Q
hypertonic contractions: what are women at risk for?
A
- exhaustion
12
Q
hypertonic contractions: what is the fetus at risk for?
A
- intolerance to labor
13
Q
hypertonic contractions: risk factor
A
nulliparous women
14
Q
hypertonic contractions: management
A
- hydration to improve perfusion
- pain medication
- continuous monitoring
15
Q
normal contractions are ___ shaped
A
bell
16
Q
hypotonic contractions: nursing interventions
A
- assess maternal fetal status
- admin oxytocin per protocol
- continuous external fetal monitor/ toco
- explain interventions
- minimize infection risk- minimal vaginal exams
17
Q
hypertonic contractions: nursing interventions
A
- admin pain meds: morphine, to allow uterus to rest
-offer epidural - promote relaxation
- hydrate - 250 ml/hr isotonic solution
- explain interventions
18
Q
when do stage 2 of labor disorders take place?
A
- during the pushing phase
- 10 cm to birth
19
Q
what do stage 2 of labor disorders result from?
A
- delayed pushing for extended period of time
- epidurals
- elevated BMI: >35
- LGA babies: >4200g
- occiput posterior positioning
- fetal station
20
Q
stage 2 of labor disorders: risks
A
- risk of morbidity and mortality
- decreases chance of SVD
- fetus: asphyxia
- woman: operative vaginal birth; extensive perineal trauma
21
Q
stage 2 of labor disorders: management
A
- monitor for labor
- augment with pitocin
- assist with vacuum OR forceps
- consider c section
22
Q
stage 2 of labor disorders: nursing actions
A
- help woman by coaching pushing
- try open glottis pushing
- give adequate pain relief
- change positions to allow gravity
- support the patient
23
Q
precipitous labor
A
- lasts less than 3 hours from onset to delivery
- increased pain and anxiety
24
Q
precipitous labor: women are at risk for?
A
postpartum hemorrhage (PPH)
25
precipitous labor: fetus is at risk for?
- hypoxia
- CNS depression if mom had narcotics for pain
26
precipitous labor: risk factors
- grand multiparas
- hx of precipitous delivery
27
precipitous labor: nursing actions
- remain with patient
- monitor FHR continuously or at least q15 minutes
- assess cervical change
- listen to the patient
- support the patient
- anticipate complications such as hypoxia
- prep for delivery
28
fetal dystocia
something about the fetus is delaying delivery
- LGA
- malpresentation
- multifetal pregnancy
- fetal anomaly
29
fetal dystocia: risks
- asphyxia
- fetal injuries
- maternal lacerations
- cephalopelvic disproportion = c section
30
what are the various malpresentations?
- shoulder
- face
- brow
- occiput posterior
- frank breech
- complete breech
- footling breech: single or double
31
what do we do when labor does not happen on its own?
- intervene when medically indicated
- push to move away from elective inductions
-use Bishop score for elective induction
- labor induction
32
induction of labor is _
the chemical or mechanical initiation of uterine contractions before their spontaneous onset for the purpose of bringing about birth
33
how do you (medically) induce labor
- induction of oxytocin
- cervical ripening prior to oxytocin with cervidil or cytotec
- stripping membranes
- amniotomy
34
induction of labor: cervical ripening methods
purpose: to ripen or soften the cervix
- chemical agents: PGE 1 (cytotec) or PGE 2 (cervidil)
35
induction of labor: mechanical and physical methods
- balloon catheters
- hydroscopic dilators
- amniotic membrane stripping
36
what is not recommended as a method to induce labor?
- sexual intercourse
- nipple stimulation
37
what are some alternative methods to induce labor?
- blue cohosh
- castor oil
- acupuncture
38
amniotomy
artificial rupture of membranes (AROM)
- often used in combination with pitocin
- presenting part MUST be engaged (-2 or below) to prevent cord prolapse
39
labor interventions: induction
- oxytocin induction
-most common agent when cervix is favorable
-bishop score 8 or greater
- nursing care
40
induction of labor: risks
- tachysystole
- category II or III FHR tracings
- failed induction
- water intoxication
41
what is a bishop score?
- a scoring system
- an assessment of the cervix before labor to determine if an induction is likely to be successful
- it can also determine if spontaneous labor may occur soon
42
bishop score of 6 or less
- unfavorable for induction
**if induction is indicated, cervical ripening agents will most likely be used
43
bishop score of 8 or more
- favorable for induction
OR
- a vaginal delivery with induction will be similar to spontaneous labor
44
how does the bishop scoring system work?
- scores of 0,1,2,3
- assesses 5 categories
-dilation
-position of cervix
-effacement
-station
-cervical consistency
45
an operative vaginal delivery could be ___ or ___
- vacuum assisted
- forceps
46
TOLAC stands for __
trial of labor after cesarean
47
VBAC stands for __
vaginal birth after cesarean
48
TOLAC / VBAC: risks
- risk of repeat c/s in 20% - 40%
- risk of uterine rupture
- risk of fetal death
49
TOLAC / VBAC: benefits
- shorter hospital stay
- fewer complications
- fewer neonatal breathing problems
50
possible brain damages due to forceps use
- crushed, sheared and torn neurons
- scalp hematoma
- fracture through occipital bone
- parietal bone overrides occipital bone
51
augmentation is
stimulation of contractions when labor fails to progress
52
augmentation: risks
- stop oxytocin if there is no contraction or abnormal HR
53
augmentation: indications
- add more with contractions that are hypotonic
54
augmentation: nursing care
- ensure informed consent
- intermittent auscultation (when HR remains in normal limits: Cat 1 tracing)
- in presence of risk factors, continuous EFM, evaluate and document FHR q15 mins in active labor and q5 mins in the second stage of labor
- monitor DIF of UCs q30 mins an indicator of oxytocin efficiency
- evaluate uterine resting tone by palpation or IUPC pressure below 20 mmHg to ensure uterine relaxation between contractions
- decrease or d/c oxytocin in event of uterine tachysystole or indeterminate or abnormal fetal status; *lower dose by 1/2 when decreasing
- monitor labor progress with SVE for cervical dilation and fetal descent
- assess the character and amount of AF and amount of bloody show
- assess VS per policy- usually q2 hours
- assess I&O q8 hours, for fluid overload- output should = input
- ensure adequate hydration
55
external cephalic version (ECV): indications
to change fetal position to vertex
56
external cephalic version (ECV): contraindications
placental abnormalities
57
external cephalic version (ECV): risks
severe variable decelerations
58
what are patients often given prior to ECV procedure?
- epidural/spinal
- Terbutaline to relax the uterus
59
bishop score: dilation 0
closed
60
bishop score: dilation 1
1-2
61
bishop score: dilation 2
3-4
62
bishop score: dilation 3
5-6
63
bishop score: position of cervix 0
posterior
64
bishop score: position of cervix 1
mid position
65
bishop score: position of cervix 2
anterior
66
bishop score: position of cervix 3
- (N/A)
67
bishop score: effacement 0
0-30%
68
bishop score: effacement 1
40-50%
69
bishop score: effacement 2
60-70%
70
bishop score: effacement 3
80%
71
bishop score: station 0
-3
72
bishop score: station 1
-2
73
bishop score: station 2
-1, 0
74
bishop score: station 3
+1, +2
75
bishop score: cervical consistency 0
firm
76
bishop score: cervical consistency 1
medium
77
bishop score: cervical consistency 2
soft
78
bishop score: cervical consistency 3
- (N/A)
79
obstetric complications: risks to mom
- difficult labor
- increased injury to perineum
- increased rate of cesarean section
- infections
- PPH
- increased maternal anxiety
80
obstetric complications: risks to fetus
- stillbirth or neonatal death
- macrosomia
- fetal dysmaturity
- oligohydramnios
- meconium aspiration
- placental insufficiency
81
meconium-stained fluid is the result of __
- GI maturation and neural stimulation
- hypoxic stress
82
meconium-stained fluid occurs in what % of births?
10-20%
83
meconium-stained fluid can be ___ by fetus
aspirated by fetus
- can cause respiratory issues
84
assessing for meconium-stained fluid
assess for green-tinge to amniotic fluid
- alert neonatal team
prepare for potential need for neonatal resuscitation
85
obstetric complications: multiple gestation- risks
- PTL
- labor dystocia
- antepartum hemorrhage
- stillbirth
86
obstetric complications: multiple gestation- medical management
- method of delivery is determined based on fetal presentation, subsequent fetal position, and other medical considerations
-ultrasound to determine presentation/placental locations
- hospital birth w/ a level 2 or 3 nursery
- two experienced obstetricians or one OB and one certified nurse-midwife
- delivery is done in a surgical suite
87
obstetric complications: multiple gestation- nursing care
- anticipatory guidance
- ensure placement of large bore IV for fluid replacement
- continuous FHR monitoring- internal monitoring for twin A
- have hemorrhage cart/meds available
- anesthesia provider, circulating nurse, and scrub nurse available
- ensure ultrasound access to confirm position of B after birth of A
- neonatal team should be present for each twin
- have type and cross-matched blood available
88
obstetric complications: intrauterine fetal demise- risk factors
- 1st time mom
- advanced maternal age
- obesity
- DM
- chronic HTN
- african decent
- smoking/alc use
- pregnancy produced by artificial reproductive techniques
- Male > risk
89
obstetric complications: intrauterine fetal demise- management
- induce labor within 24-48 hours of confirmed dx
- stillborn delivery
- vaginal misoprostol is less than 28 weeks
- cervical ripening and induction of labor
90
obstetric complications: intrauterine fetal demise- nursing care
- priest or minister
- support groups
- memory box
- anticipatory guidance in slow, small increments
- allow patient to make decisions about plan of care
- continuity of care
- privacy and comfort
- offer time with fetus to mom and family
91
obstetric complications: intraamniotic infection- risks/ s/x
- biochemical or microbiologic amniotic fluid results consistent with microbial invasion of amniotic cavity
- fetal tachycardia
- elevated white count in mom (>15000)
- pus like vaginal d/c
92
obstetric complications: intraamniotic infection- management
- culture amniotic fluid
- NICU- draw cultures to determine if anything grows in baby's blood
- control maternal temperature with antipyretics & judicious hydration may be required
- intrapartum antibiotics
- antimicrobial agents in case of suspected Triple I
93
obstetric complications: intraamniotic infection- nursing care
- antipyretics
- antibiotics
- communicate findings (fetal tachycardia, maternal WBC, etc.)
94
pre-gestational complications: maternal obesity -risks
- shoulder dystocia
- macrosomia
- increased risk of hemorrhage
- delayed wound healing
- increased risk DVT and infection rates
95
obstetrical emergencies
- shoulder dystocia
- prolapse of umbilical cord
- vasa previa
- ruptured uterus
- anaphylactic syndrome
- disseminated intravascular coagulation (DIC)
96
shoulder dystocia: risks to mother
- severe perineal lacerations- 4th degree
- maternal symphyseal separation/peripheral neuropathy
- bladder injury
- postpartum hemorrhage
- emotional trauma
97
shoulder dystocia: risks to fetus
- asphyxia
- neurological injury
- increased intracranial pressure
- encephalopathy
- brachial plexus injuries
- fractures- clavicle and humerus
- death
98
shoulder dystocia: management
- mcRoberts manuever: two assistants sharply flexing each maternal thigh against the abdomen
- suprapubic pressure: apply pressure above the pubic bone with palm/fist; pressure is directed on the anterior shoulder downward and laterally
- if both mcRoberts and suprapubic pressure fail, deliver the posterior arm; Woods corkscrew manuever rotates posterior shoulder 180 degrees to disimpact the anterior shoulder
*avoid fundal pressure
99
shoulder dystocia: nursing actions
- explain situation and interventions to woman and family
- request mom not to push
- request assistance, additional nurses needed to implement maneuvers to resolve shoulder dystocia
- insert straight catheter
- no fundal pressure
- McRoberts maneuver
- variety of techniques can be used to free impacted shoulder: pressure applied above pubic bone or laterally to pubic bone
- notify neonatal team
- prep for neonatal resuscitation
- document interventions and clinical events with time intervals
100
umbilical cord prolapse: risks
- total or partial occlusion of the cord causing rapid deterioration in fetal perfusion and oxygenation
- fetal hypoxia
if not treated quickly:
-long-term sequela
-disability
-death
101
umbilical cord prolapse: management
- vaginal or operative vaginal delivery may be attempted if birth is imminent
- perform emergency c/s
102
umbilical cord prolapse: nursing actions
- elevate presenting part
- request assistance, notify HCP, request immediate bedside evaluation
- explain interventions to woman and family: necessary to expedite delivery and need for her assistance
- recommend position changes to relieve pressure on cord (knee to chest/ trandelenburg)
- admin O2 mask at 10 L/min
- IV fluid hydration bolus
- d/c oxytocin, consider tocolytic to decrease uterine activity
- move toward emergency delivery: vaginal or c/s depending on if birth is imminent or not
103
vasa previa: fetal risks
- fetal asphyxia from cord compression
- fetal death from exsanguination
104
vasa previa: management
- if dx prenatally with ultrasound, plan c/s @ 35 weeks
-improves neonatal survival by 95%
- if dx during labor, urgent c/s in cases of vaginal bleeding with suspected vasa previa
105
vasa previa: nursing actions
- if dx prenatally with ultrasound- patient will be prescribed corticosteroids and scheduled for a planned c/s @ 35 weeks
- if bleeding occurs with SVE by the nurse, an immediate bedside evaluation by the provider is indicated because urgent c/s delivery should be accompanied in cases of vaginal bleeding with suspected vasa previa
106
uterine rupture- risks
- hypovolemic shock
- infection
- hypoxemia
- acidosis
- neurologic damage
- possible death
- maternal complications are primarily due to hypovolemia as a result of hemorrhage
- fetal complications may be due to uteroplacental insufficiency, placental abruption, cord compression, asphyxia, and/or hypovolemia
107
uterine rupture- management
- emergency c/s
- control maternal hemorrhage
- hysterectomy may be necessary
- transfusion may be necessary
108
uterine rupture- nursing actions
- explain interventions will expedite delivery and importance of their assistance
- request assistance and notify provider; request bedside evaluation
- gain/maintain large bore IV access; stabilize woman w/ O2, IV fluids, and blood products
- maintain woman in lateral position to maximize urine blood flow
- prep for emergency c/s: insert foley catheter
109
anaphylactic syndrome/amniotic fluid embolism - risks
-acute pulmonary edema
- resp distress/arrest
- acute heart failure
- DIC
110
anaphylactic syndrome/amniotic fluid embolism- risk factors/causes of
- advanced maternal age (35 +)
- oxytocin use for labor induction
- multiple pregnancies
- placental abnormalities: previa, abruption
- c/s
- operative vaginal delivery
- eclampsia/preclampsia
- cervical laceration
- polyhydramnios
- uterine rupture
111
anaphylactic syndrome/amniotic fluid embolus- nursing actions
- careful assessment, maternal pulse ox, maintain patent IV access, L uterine displacement, notify OB team, implement ACLS protocol, document
- recognize life-threatening dx, ask for help and immediate bedside evaluation
- prep for emergent interventions (ie rapid sequence intubation)
- stabilize woman with O2 and IV fluids
- continuous FHR monitoring
- prep for emergency delivery
- ABCs
- s/ of shock- emergency c/section
112
adverse obstetric events that could trigger DIC
- placental abruption
- severe preeclampsia
- HELLP
- massive obstetric hemorrhage
- amniotic fluid embolism
- acute fatty liver of pregnancy
- sepsis
113
DIC- management
- prompt recognition and understanding is essential to the management of DIC and positive outcome
- transfer to critical care unit
- perinatologist manages the care
114
what is shoulder dystocia?
- difficulty encountered during delivery of the shoulder after the birth of the head
- often occurs when the passage of the anterior shoulder is obstructed by the symphysis pubis
- may also result from the impaction of the posterior shoulder on the maternal sacral promontory
- unpredictable
- unpreventable
115
what is an umbilical cord prolapse?
when the cord lies between the presenting part of the fetus
- may prolapse in front of the presenting part, into the vagina, or through the introitis
116
what is vasa previa?
abnormal fetal blood vessels that run through the fetal membranes, over or near the endocervical os, and are unprotected by the placenta or umbilical cord
- uncommon (1/2500-5000 pregnancies)
117
what is a ruptured uterus?
spontaneous tearing of the uterus that may result in the fetus being expelled from the peritoneal cavity
- rare
- occurs in late pregnancy or active labor
118
what is anaphylactic syndrome?
- during rupture of membranes, amniotic fluid enters moms circulation, causes huge pro-inflammatory response
119
what is DIC?
disseminated intravascular coagulation
- when the body is breaking down blood clots faster than it can form a clot
- leads to hemorrhage and maternal death
- associated with 25% of maternal deaths (1/4)
120
DIC: what are the maternal trigger parameters?
- temperature
- BP
- HR
- RR
- oxygen saturation
121
critical care in maternity nursing includes
- preexisting conditions/complications
- assess high-risk situations continuously
- A C L S algorithm
- cared for in special obstetrics/gynecology units or in ICU
122
what is the A C L S algorithm?
"advanced cardiac life support" protocol
- displacement of uterus during cardiopulmonary resuscitation facilitates blood return to the heart and is critical to return of spontaneous circulation
- fetal monitor components should be removed prior to defibrillation or cardioversion to decrease potential risks of arcing and damage to monitor components
- hand placement for chest compressions should be slightly higher on maternal chest due to cardiac displacement during pregnancy
- early advanced airway should be considered and performed by an experienced professional, as intubation of pregnant patients can be difficult
123
how many stages of PPH are there?
4
124
PPH: stage 1
- >500 ml (vaginal) and >1000 ml (c/s)
- normal VS and lab values
125
PPH: stage 2
- continues to bleed
- >1500 ml
- > 2 uterotonics
- normal VS and labs
126
PPH: stage 3
- continues to bleed
- >1550 ml
- 2 units of packed RBCs
- abnormal VS and labs
127
PPH: stage 4
- cardiovascular collapse
- profound hypovolemic shock
- amniotic embolism
128
PPH: 4 Ts
tone- uterine atony
tissue- retained placenta
trauma- lacerations
thrombin- coagulation
129
ideal occiput positioning of fetus in passage?
LOA or ROA
**anterior!
130
open glottis pushing
- spontaneous, involuntary bearing-down accompanying the forces of the uterine contraction
- usually characterized by expiratory grunting or vocalizations
- involves 3-4 pushes of 6-8 seconds with each contraction
131
closed glottis pushing
- involuntary: refers to spontaneous pushing against a closed glottis (valsalva) in response to the descent of the fetal presenting part on the perineum
- voluntary: valsalva technique, involves a voluntary directed strenuous bearing-down effort against a closed glottis for at least 10 seconds.
-woman is instructed to take a deep breath and hold it for as long as she can (during each count of 10) using the entire contraction.
-this method usually involves 2-3 pushes of 10 seconds each with each contraction
132
cervidil: dose
- thin, flat, rectangular-shaped, cross-linked, polymer hydrogel that releases dinoprostone from a 10 mg reservoir
133
cervidil: nurse actions
- nurse may perform if within scope of practice
- woman should remain supine or lateral for 2 hours after insertion
- continuous FHR and UC monitoring, and for 15 min post removal
- delay oxytocin for 30-60 min after removal
134
cytotec: dose
- 25 mcg inserted in the posterior vaginal formix q3-6 hours (initial dose for cervical ripening/labor induction)
- not to exceed 50 mcg
135
cytotec: nurse actions
-continuous FHR and UC monitoring
- delay oxytocin for at least 4 hours after last dose
136
how long should oxytocin be delayed after removal of cervidil?
delay oxytocin for 30-60 min after removal
137
what is one major advantage to cervidil?
can be easily and quickly removed in the event of uterine tachysystole or other complications
138
what has been associated with cytotec? (hint: negative outcomes)
- tachysystole
- indeterminate/abdnormal FHR changes
- uterine rupture (rare)
139
how long should oxytocin be delayed after administration of cytotec
at least 4 hours after the last dose
140
cervical change of __ cm/hr indicates sufficient progress
1 cm/hr
141
s/sx of fluid overload
- decreased uterine output
- edema
- increased BP
- pulmonary edema
142
if vacuum pops off, indicates ____
indicates too much pressure was used
143
vacuum: fetal risks
- cephalohematoma
- increased rates of jaundice
- intracranial hemorrhage and retinal hemorrhage
- scalp lacerations or bruising
144
forceps: maternal risks
- extension of episiotomy
- hemorrhage
- bruising of perineal: perineal hematoma
- bladder trauma
- vaginal and cervical lacerations
- perineal wound infection
145
forceps: fetal risks
- facial nerve lac
- corneal abrasion
- facial palsy
- trauma to face
- skull fracture
- intacranial hemorrhage
- skin laceration or bruising
- nerve injuries: craniofacial and brachial plexus injuries
- cephalohematoma
146
when would we use forceps?
-last resort, need to get kid out
147
vacuum: maternal risks
- vaginal or cervical lacerations
- extensions of episiotomy
- hemorrhage related to uterine atony, uterine rupture
- bladder trauma
- perineal wound infection
148
forceps
- outlet: when head is visible on the perineum and the skull has reached the pelvic floor, and rotation is < 45 degrees
- low: when skull is at +2 station or lower in maternal pelvis and not on the pelvic floor, and rotation is > 45 degrees
149
advantages to vacuum over forceps
- easier application
- less anesthesia required
- less maternal soft tissue damage
- fewer fetal injuries
150
guidelines for vacuum application
- fetal head needs to be engaged and cervix completely dilated
- maximum of 3 attempts "3 pull rule"
- want mom to empty bladder first
- during a contraction- use uterine strength
- if not successful, c/s
151
indications for vac-use
- suspicion of immediate or potential fetal compromise
- need to shorten the second stage for maternal benefit
- prolonged second stage
-nullip: lack of continuous progress 3hr w/ anesthesia, or 2hr w/out
-multip: lack of continuous progress 2hr w/ anesthesia or 1hr w/out
152
indications for forceps-use
- fetal head is engaged and cervix is completely dilated
- suspicion of immediate or potential fetal compromise
- to shorten stage 2 of labor for maternal benefit
- prolonged 2nd stage
-nullip: lack of continuous progress 3hr w/ anesthesia, or 2hr w/out
-multip: lack of continuous progress 2hr w/ anesthesia or 1hr w/out
- high level of regional anesthesia that inhibits pushing
- maternal cardiac or pulmonary disease that contraindicates pushing efforts
153
IUFD
- 1/160 pregnancies
- intraunterine death after 20 weeks
154
intraamniotic infection is also known as
chorioamnionitis
- an infection with a resultant inflammation of any combination of the amniotic fluid, placenta, fetus, fetal membranes, or decidua
155
anaphylactic syndrome/amniotic fluid embolus- management
- manage cardiopulmonary arrest, hypotension and coagulopathy
*management goals:
- improve oxygenation
- optimize cardiac output
- correct coagulopathy
- deliver fetus
156
what other kind of rupture is associated with uterine rupture?
bladder rupture
157
vasa previa: risk factors/causes
- low-lying placenta or placenta previa
- pregnancies in which placenta has accessory lobes
- multiple gestation
- IVF pregnancies
158
umbilical cord prolapse: risk factors/causes
- r/t fetus:
-malpresentation (breech)
-fetal anomalies
-IUGR/SGA
-unengaged presenting part
- r/t pregnancy:
-primary iatrogenic cause is AROM
-polyhydramnios
-multiple gestation
-spontaneous ROM
-preterm ROM
-grand multiparity
159
McRoberts maneuver
sharply flexing the thigh onto the maternal abdomen to straighten the sacrum
- used with shoulder dystocia fetuses
160
shoulder dystocia: risk factors/causes
- fetal macrosomia (> 4500 g)
- maternal diabetes
- hx of shoulder dystocia
- prolonged 2nd stage of labor
- excessive weight gain
