INTRODUCTION- Bleeding, technically known as hemorrhaging or hemorrhaging is blood escaping from the circulatory system. Bleeding can occur internally, where blood leaks from blood vessels inside the body, or externally, either through a natural opening such as the mouth, nose, ear, urethra, vagina or anus, or through a break in the skin. Hypovolemia is a massive decrease in blood volume, and death by excessive loss of blood is referred to as exsanguinations.
CLASSIFICATION-

• Class I Hemorrhage involves up to 15% of blood volume. There is typically no change in vital signs and fluid resuscitation is not usually necessary.
• Class II Hemorrhage involves 15-30% of total blood volume. A patient is often tachycardia (rapid heartbeat) with a narrowing of the difference between the systolic and diastolic blood pressures. The body attempts to compensate with peripheral vasoconstriction. Skin may start to look pale and be cool to the touch. The patient may exhibit slight changes in behavior. Volume resuscitation with crystalloids (Saline solution or Lactated Ringer’s solution) is all that is typically required. Blood transfusion is not typically required.
• Class III Hemorrhage involves loss of 30-40% of circulating blood volume. The patient’s blood pressure drops, the heart rate increases, peripheral hypo perfusion (shock), such as capillary refill worsens, and the mental status worsens. Fluid resuscitation with crystalloid and blood transfusion are usually necessary.
• Class IV Hemorrhage involves loss of >40% of circulating blood volume. The limit of the body’s compensation is reached and aggressive resuscitation is required to prevent death.
CAUSES-
Bleeding arises due to traumatic injury, underlying medical condition, or a combination.
Traumatic Injury
Traumatic bleeding is caused by some type of injury. There are different types of wounds which may cause traumatic bleeding. These include:
• Abrasion – Also called a graze, this is caused by transverse action of a foreign object against the skin, and usually does not penetrate below the epidermis
• Excoriation – In common with Abrasion, this is caused by mechanical destruction of the skin, although it usually has an underlying medical cause
• Hematoma – Caused by damage to a blood vessel that in turn causes blood to collect under the skin.
• Laceration – Irregular wound caused by blunt impact to soft tissue overlying hard tissue or tearing such as in childbirth. In some instances, this can also be used to describe an incision.
• Incision – A cut into a body tissue or organ, such as by a scalpel, made during surgery.
MEDICAL CONDITION-
‘Medical bleeding’ denotes hemorrhage as a result of an underlying medical condition (i.e. causes of bleeding that are not directly due to trauma). Blood can escape from blood vessels as a result of 3 basic patterns of injury:
• Intravascular changes – changes of the blood within vessels (e.g. ↑ blood pressure, ↓ clotting factors)
• Intramural changes – changes arising within the walls of blood vessels (e.g. aneurysms, dissections, AVMs, vasculatures)
• Extra vascular changes – changes arising outside blood vessels (e.g. H pylori infection, brain abscess, brain tumor)

INTRODUCTION- Acanthosis Nigerians is a brown to black; it is used when word is used repeatedly poorly defined, velvety hyper pigmentation of the skin. It is usually found in body folds, such as the posterior and lateral folds of the neck, the armpits, groin, navel, forehead, and other areas.
CLASSIFICATION- Acanthosis Nigerians is conventionally divided into benign and malignant forms, although may be divided into syndromes according to cause:
• Benign This may include obesity-related, hereditary, and endocrine forms of acanthuses Nigerians.
• Malignant. This may include forms that are associated with tumor products and insulin-like activity, or tumor necrosis factor.
An alternate classification system still used to describe acanthuses Nigerians was proposed in 1994. It delineates acanthuses Nigerians syndromes according to their associated syndromes, including benign and malignant forms, forms associated with obesity and drugs, aural acanthuses Nigerians, unilateral acanthuses Nigerians, and mixed and syndrome forms.
SIGNS AND SYMPTOMS- Acanthosis Nigerians may present with thickened, velvety, relatively darker areas of skin on the neck, armpit and in skin folds.
CAUSES- It typically occurs in individuals younger than age 40, may be genetically inherited, and is associated with obesity or endocrinopathies, such as hypothyroidism, acromegaly, polycystic ovary disease, insulin-resistant diabetes, or Cushing’s disease.
DIAGNOSIS- Acanthosis Nigerians is typically diagnosed clinically. A skin biopsy may be needed in unusual cases. If no clear cause is obvious, it may be necessary to search for one. Blood tests, an endoscopy, or X-rays may be required to eliminate the possibility of diabetes or cancer as the cause.
On biopsy, hyperkeratosis, epidermal folding, leukocyte infiltration, and melanocyte proliferation may be seen.
TREATMENT- People with acanthuses Nigerians should be screened for diabetes and, although rare, cancer. Controlling blood glucose levels through exercise and diet often improves symptoms. Topical fade creams (normally used for eliminating age spots) can lighten skin cosmetically in less severe cases. Acanthosis Nigerians malign may resolve if the causative tumor is successfully removed.

Introduction – Adam “was a wonderfully, sweet young man,” his mother said. He was a high school athlete and captain of his team, active in his college fraternity, a good student. He had graduated from college and started working while studying for a professional certification exam when something inside him changed. Adam stopped being careful about his personal appearance. He told his parents he suspected them of communicating with each other in secret ways, such as in sign language which he couldn’t understand. He began to hear his mother’s voice in his head and he asked her why she was sending him messages. he was diagnosed with schizophrenia
Definition-
Schizophrenia is a serious disorder which affects how a person thinks, feels and acts. Someone with schizophrenia may have difficulty distinguishing between what is real and what is imaginary; may be unresponsive or withdrawn; and may have difficulty expressing normal emotions in social situations.
Causes
The cause of schizophrenia is still unclear. Some theories about the cause of this disease include: genetics (heredity), biology (the imbalance in the brain’s chemistry); and/or possible viral infections and immune disorders.
Genetics (Heredity) – Scientists recognize that the disorder tends to run in families and that a person inherits a tendency to develop the disease. Schizophrenia may also be triggered by environmental events, such as viral infections or highly stressful situations or a combination of both.
Similar to some other genetically-related illnesses, schizophrenia appears when the body undergoes hormonal and physical changes, like those that occur during puberty in the teen and young adult years.
Chemistry- Genetics help to determine how the brain uses certain chemicals. People with schizophrenia have a chemical imbalance of brain chemicals (serotonin and dopamine) which are neurotransmitters. These neurotransmitters allow nerve cells in the brain to send messages to each other. The imbalance of these chemicals affects the way a person’s brain reacts to stimuli–which explains why a person with schizophrenia may be overwhelmed by sensory information (loud music or bright lights) which other people can easily handle. This problem in processing different sounds, sights, smells and tastes can also lead to hallucinations or delusions.
Warning Signs of Schizophrenia –
The signs of schizophrenia are different for everyone. Symptoms may develop slowly over months or years, or may appear very abruptly. The disease may come and go in cycles of relapse and remission.
Behaviors that are early warning signs of schizophrenia include:
• Hearing or seeing something that isn’t there
• A constant feeling of being watched
• Peculiar or nonsensical way of speaking or writing
• Strange body positioning
• Feeling indifferent to very important situations
• Deterioration of academic or work performance
• A change in personal hygiene and appearance
• A change in personality
• Increasing withdrawal from social situations
• Irrational, angry or fearful response to loved ones
• Inability to sleep or concentrate
• Inappropriate or bizarre behavior
• Extreme preoccupation with religion or the occult
Schizophrenia affects about 1% of the world population. In the United States one in a hundred people, about 2.5 million, have this disease. It knows no racial, cultural or economic boundaries. Symptoms usually appear between the ages of 13 and 25, but often appear earlier in males than females.
If you or a loved one experience several of these symptoms for more than two weeks, seek help immediately.
Symptoms of Schizophrenia –
A medical or mental health professional may use the following terms when discussing the symptoms of schizophrenia.
Positive symptoms are disturbances that are “added” to the person’s personality.
• Delusions — false ideas–individuals may believe that someone is spying on him or her, or that they are someone famous.
• Hallucinations –seeing, feeling, tasting, hearing or smelling something that doesn’t really exist. The most common experience is hearing imaginary voices that give commands or comments to the individual.
• Disordered thinking and speech — moving from one topic to another, in a nonsensical fashion. Individuals may make up their own words or sounds.
Negative symptoms are capabilities that are “lost” from the person’s personality.
• Social withdrawal
• Extreme apathy
• Lack of drive or initiative
• Emotional unresponsiveness
Types of Schizophrenia –
• Paranoid schizophrenia — a person feels extremely suspicious, persecuted, or grandiose, or experiences a combination of these emotions.
• Disorganized schizophrenia — a person is often incoherent in speech and thought, but may not have delusions.
• Catatonic schizophrenia — a person is withdrawn, mute, negative and often assumes very unusual body positions.
• Residual schizophrenia — a person is no longer experiencing delusions or hallucinations, but has no motivation or interest in life.
• Schizoaffective disorder–a person has symptoms of both schizophrenia and a major mood disorder such as depression.
No cure for schizophrenia has been discovered, but with proper treatment, many people with this illness can lead productive and fulfilling lives.
Treatment –
If you suspect someone you know is experiencing symptoms of schizophrenia, encourage them to see a medical or mental health professional immediately. Early treatment–even as early as the first episode–can mean a better long-term outcome.
Recovery and Rehabilitation
While no cure for schizophrenia exists, many people with this illness can lead productive and fulfilling lives with the proper treatment. Recovery is possible through a variety of services, including medication and rehabilitation programs. Rehabilitation can help a person recover the confidence and skills needed to live a productive and independent life in the community. Types of services that help a person with schizophrenia include:
• Case management helps people access services, financial assistance, treatment and other resources.
• Psychosocial Rehabilitation Programs are programs that help people regain skills such as: employment, cooking, cleaning, budgeting, shopping, socializing, problem solving, and stress management.
• Self-help groups provide on-going support and information to persons with serious mental illness by individuals who experience mental illness themselves.
• Drop-in centers are places where individuals with mental illness can socialize and/or receive informal support and services on an as-needed basis.
• Housing programs offer a range of support and supervision from 24 hour supervised living to drop-in support as needed.
• Employment programs assist individuals in finding employment and/or gaining the skills necessary to re-enter the workforce.
• Therapy/Counseling includes different forms of “talk”therapy, both individual and group, that can help both the patient and family members to better understand the illness and share their concerns.
• Crisis Services include 24 hour hotlines, after hours counseling, residential placement and in-patient hospitalization.
Antipsychotic Medication
The new generation of antipsychotic medications can help people with schizophrenia to live fulfilling lives. They help to reduce the biochemical imbalances that cause schizophrenia and decrease the likelihood of relapse. Like all medications, however, anti-psychotic medications should be taken only under the supervision of a mental health professional.
There are two major types of antipsychotic medication:

• Conventional antipsychotics effectively control the “positive”symptoms such as hallucinations, delusions, and confusion of schizophrenia.
• New Generation (also called atypical) antipsychotics treat both the positive and negative symptoms of schizophrenia, often with fewer side effects.
Side effects are common with antipsychotic drugs. They range from mild side effects such as dry mouth, blurred vision, constipation, drowsiness and dizziness which usually disappear after a few weeks to more serious side effects such as trouble with muscle control, pacing, tremors and facial tick. The newer generation of drugs have fewer side effects. However, it is important to talk with your mental health professional before making any changes in medication since many side effects can be controlled.

INTRODUCTION:- Gastritis is inflammation of the lining of the stomach. It may occur as a short episode or may be of a long duration. The most common symptom is upper abdominal pain. Other symptoms include nausea and vomiting, bloating, loss of appetite and heartburn.
SIGN & SYMPTOMS:- Many people with gastritis experience no symptoms at all. However, upper central abdominal pain is the most common symptom; the pain may be dull, vague, burning, aching, gnawing, sore, or sharp. Pain is usually located in the upper central portion of the abdomen, but it may occur anywhere from the upper left portion of the abdomen around to the back.
Other signs and symptoms may include the following:
• Nausea
• Vomiting (if present, may be clear, green or yellow, blood-streaked, or completely bloody, depending on the severity of the stomach inflammation)
• Belching (if present, usually does not relieve the pain much)
• Bloating
• Early satiety[11]
• Loss of appetite
• Unexplained weight loss
CAUSE:-
Common causes include Helicobacter pylori and NSAIDs. Less common causes include alcohol, cocaine, severe illness and Crohn disease, among others.
Helicobacter pylori
Helicobacter pylori colonizes the stomachs of more than half of the world’s population, and the infection continues to play a key role in the pathogenesis of a number of gastroduodenal diseases. Colonization of the gastric mucosa with Helicobacter pylori results in the development of chronic gastritis in infected individuals, and in a subset of patients chronic gastritis progresses to complications (e.g., ulcer disease, gastric neoplasias, some distinct extragastric disorders) However, over 80 percent of individuals infected with the bacterium are asymptomatic and it has been postulated that it may play an important role in the natural stomach ecology.[14]
Critical illness
Gastritis may also develop after major surgery or traumatic injury (“Cushing ulcer”), burns (“Curling ulcer”), or severe infections. Gastritis may also occur in those who have had weight loss surgery resulting in the banding or reconstruction of the digestive tract.
Diet
Evidence does not support a role for specific foods including spicy foods and coffee in the development of peptic ulcers.
PATHOPHYSIOLOGY:-
Acute
Acute erosive gastritis typically involves discrete foci of surface necrosis due to damage to mucosal defenses NSAIDs inhibit cyclooxygenase-1, or COX-1, an enzyme responsible for the biosynthesis of eicosanoids in the stomach, which increases the possibility of peptic ulcers forming. Also, NSAIDs, such as aspirin, reduce a substance that protects the stomach called prostaglandin. These drugs used in a short period are not typically dangerous. However, regular use can lead to gastritis.
Chronic
Chronic gastritis refers to a wide range of problems of the gastric tissues . The immune system makes proteins and antibodies that fight infections in the body to maintain a homeostatic condition. In some disorders the body targets the stomach as if it were a foreign protein or pathogen; it makes antibodies against, severely damages, and may even destroy the stomach or its lining. In some cases bile, normally used to aid digestion in the small intestine, will enter through the pyloric valve of the stomach if it has been removed during surgery or does not work properly, also leading to gastritis.
DIAGNOSIS:-
Often, a diagnosis can be made based on the patient’s description of their symptoms, but other methods which may be used to verify gastritis include:
• Blood tests:
o Blood cell count
o Presence of H. pylori
o Liver, kidney, gallbladder, or pancreas functions
• Urinalysis
• Stool sample, to look for blood in the stool
• X-rays
• ECGs
• Endoscopy, to check for stomach lining inflammation and mucous erosion
• Stomach biopsy, to test for gastritis and other conditions
Treatment
Antacids are a common treatment for mild gastritis. When antacids do not provide enough relief, medications such as H2 blockers and proton-pump inhibitors that help reduce the amount of acid are often prescribed.
Cytoprotective agents are designed to help protect the tissues that line the stomach and small intestine. They include the medications sucralfate and misoprostol. If NSAIDs are being taken regularly, one of these medications to protect the stomach may also be taken.

DEFINITION-Peptic ulcer is a break the continuity of oesophageal, gastric, or duodenal mucosa.
Types of peptic ulcer-
1. Gastric ulcer
2. Duodenal ulcer
3. Stress ulcer
4. Esophageal ulcer
5. Apthonas ulcer
1. Gastric ulcer- It is ulceration of the mucus lining of stomach. It may extend to sub mucosal layer which tents to heal within few weak within one inch of pylorus of stomach. In an area where gastritis is common. And size of gastric ulcer more than 5 mm.
2. Duodenal ulcer- its higher incidence more than gastric ulcer. This ulcer usually occurs within .6 inch or 1.5 cm of pylorus usually characterized by high gastric hcl secretion.
3. Stress induce ulcer- Sever trauma, burn, aspirin, Nsaid, Steroid, etc. decrease the mucus secretion and break the mucosa stimulate the parasympathetic system.
ETIOLOGY-
1. H. Pylori bacteria infection 90 percent duodenal ulcer and 60 percent gastric ulcer.
2. Defensive resistance of mucosa depend on the following factors-
• Mucosal integrity and regeneration
• Presence of protective mucosal barrier
• Adequate blood flow
• Ability of duodenal inhibitory mechanism to regulate secretion
• Presence of adequate gastro mucosal prostaglandins
• Hyperacidity
• Gastrin secreting begnin & malignant
RISK-FACTORS
– Age 40 to 60 years
– Children & adult
– Stress
– NSAID
– Smoking & alcohol
– Zollinger elision syndrome
– Hepatic & billiary disease

PATHOPHYSIOLOGY-
Due to etiological factor or H. Pylori infection

Increase defensive resistance of the mucosal membrane

Increase HCL secretion

HCL with pepsin damage the mucosal wall

Peptic ulcer
SIGN & SYMPTOMS
1. Pain- Pain is itching, burning,& cramp like pain.
2. In gastric ulcer left upper epigatrium & right epigastrium.
3. Constipation & Diarrhea
4. Acute swelling
5. Nausea & Vomiting
6. Bleeding

COMPLICATION-
• Excessive bleeding
• Perforation
• Obstructions
MANAGEMENT –
1. Antibiotics bismuth salt eradicate H. Pylori
2. Histamine receptor antagonist eg- Rentac, cemetidine
3. Proton pump inhibitor
4. Antacid eg-mgcl
5. Mucosal barrier fortifier e.g.- sucralpate

INCIDENCE:- At the age of 50 of man will have some degree of BPH. Increases more than 80-90 percentage in 75 years of age & is more commonly seen in white man.

DEFINITION:- It is a condition characterized by the enlargment of the prostate gland or tissue secondary to ageing.
ETIOLOGY / CAUSES :-
1. UNKNOWN OR IDEOPATHIC
2. AGEING
3. HEREDITY
4. RACE

PATHOPHYSIOLOGY:-

1. Normal shape of the bladder is trigone when there is a prostate gland enlargement this obstruct the outflow of urine from urinary bladder hence normal trigone shape disappears & bladder becomes spherical.
2. At this stage client can notice some degree of delayed out of micturation . mthere is no other symptoms .
3. As the size of the prostate gland increases detrusor muscle no longer overcome the obstruction . so at this stage the symptoms are-
a. Dificulty in nitiation of micturation
b. Flow rate of urine decreses
c. Retention of urine
4. Any activity which increases intra abdominal pressure like coughing , sneezing , bending, lifting of heavy objects causes bladder to empty involuntory & this condition is called retention with overflow of urine.
a. Recurrent UTI
b. He would have lost all reflex senses
c. Constant dripling of urine
5. As obstruction continues showing degeneration changes & connective tissue fibre starts to develop between muscles fibres & they arrange in the form of trabaculae ( branches of tree)

SIGN & SYMPTOMS:-
1. Inability the empty the bladder
2. Insbility to initiate the act of micturation
3. A sense if inadequate emptying of bladder
4. Poor stream or flow rate is decrease
5. Terminal dripling
6. Recurrent episodes of UTI
7. Onset of fever with rigors
8. Urgency & increased frequency of micturation

Diagnostic measures:-
1. Rectal examination to dectect prostate sizeand consistency
2. Abdominal ultrasound
3. Sample of urine to detect specific gravity 7 urine routine
4. Blood examination
5. Blood urea level is increasedv normal is 15-40 mg/dl
6. Serum creatinine is increased normal is 0.9-1.5
7. Flow rate is determine by using flow meter
8. Prostate specific antigen ( PACA) IS GREATER THAN 4 MG/DL IN CASE OF CANCER CLIENT

MANAGEMENT:-
It is divided into 4 categories.
1. Pharmacological
2. Non- surgical invasive
3. Surgical invasive
4. Nursing mgt

Nursing management:-
1. Reducing theanxiety
2. Restablish the communication with the pts. To assess his understanding of the diagnosis & plan surgical procedure
3. Encourage the pts to verbalize his feelings
4. Relieving discomfort
5. bed rest
6. Monittor voiding pattern
7. Catheterization if required
8. Relieving the pain
9. Assess the causes and location of the pain
10. Divertional therapy
11. Teach the pts about deep breathing maintain the patency of catheter

DEFINITION
Chronic Obstructive Pulmonary Disease (COPD) is an umbrella term used to describe progressive lung diseases including emphysema, chronic bronchitis, refractory (non-reversible) asthma, and some forms of bronchiectasis. This disease is characterized by increasing breathlessness.

CAUSES
SMOKING
ENVIOURMENTAL FACTORS
GENETIC FACTORS

Most cases of COPD are caused by inhaling pollutants; that includes smoking (cigarettes, pipes, cigars, etc.), Smoking and second-hand smoke.
Fumes, chemicals and dust found in many work environments are contributing factors for many individuals who develop COPD.

The main symptoms are:
• A long-lasting (chronic) cough.
• Mucus that comes up when you cough.
• Shortness of breath that gets worse when you exercise.
As COPD gets worse, you may be short of breath even when you do simple things like get dressed or fix a meal. It gets harder to eat or exercise, and breathing takes much more energy. People often lose weight and get weaker.
At times, your symptoms may suddenly flare up and get much worse. This is called a COPD exacerbation (say “egg-ZASS-er-BAY-shun”). An exacerbation can range from mild to life-threatening. The longer you have COPD, the more severe these flare-ups will be.
Genetics can also play a role in an individual’s development of COPD—even if the person has never smoked or has ever been exposed to strong lung irritants in the workplace.
SIGN AND SYMPTOMS
• Increased breathlessness
• Frequent coughing (with and without sputum)
• Wheezing
• Tightness in the chest

 DEFINITION
Human immune deficiency virus infection and acquired immune deficiency syndrome (HIV/AIDS)
CAUSES OF AIDS
• HIV is a viral infection that can be transmitted through sexual contact, through blood or from mother to child during pregnancy, childbirth or breast-feeding.
• By having sex. You may become infected if you have vaginal, anal or oral sex with an infected partner whose blood, semen or vaginal secretions enter your body. The virus can enter your body through mouth sores or small tears that sometimes develop in the rectum or vagina during sexual activity.
• From blood transfusions. In some cases, the virus may be transmitted through blood transfusions. American hospitals and blood banks now screen the blood supply for HIV antibodies, so this risk is very small.
• By sharing needles. HIV can be transmitted through needles and syringes contaminated with infected blood. Sharing intravenous drug paraphernalia puts you at high risk of HIV and other infectious diseases, such as hepatitis.
• During pregnancy or delivery or through breast-feeding. Infected mothers can infect their babies. But by receiving treatment for HIV infection during pregnancy, mothers significantly lower the risk to their babies.
SIGN AND SYMPTOMS
• Fever
• Swollen glands
• Sore throat
• Night sweats
• Muscle aches
• Headache
• Extreme tiredness
• Rash

DIAGNOSIS
 ELISA Test
 Home Tests
 Saliva Tests
 Viral Load Test
 Western Blot
 TREATMENT
Doctors usually recommend medicine for patients who are committed to taking all their medications and have a CD4 count below 500 cells/mm3 (which is a sign that of a weakened immune system). Some people, including pregnant women and people with kidney or neurological problems related to HIV, may need treatment regardless of their CD4 count.
It is extremely important for people with HIV to take all doses of their medications, otherwise the virus may become resistant to the drugs. Therapy always involves a combination of antiviral drugs. Pregnant women with HIV infection are treated to reduce the chance of transmitting HIV to their babies.
People with HIV infection need to become educated about the disease and treatment so that they can be active participants in making decisions with their health care provider.

Introduction:-Blood is a connective tissue. It provides one of the means of the communication between the cells of different parts of the body and external environment.
Functions of blood:-
(1) Oxygen from the lungs to the tissues, & carbon dioxide from the tissue to the lungs for excretion.
(2) Nutrients from the alimentary tract to the tissues, and cell wastes to the excretory organs by kidney.
(3) Hormones secreted by endocrine glands to their target glands & tissues.
(4) Heat produced in active tissues to the other less active tissues.
(5) Protective substances e.g antibodies , to areas of infection
(6) Clotting factors that coagulate blood, minimising bleeding from ruptured blood vessels.

Blood makes up about 7% of body weight about 5.6 litre in a 70 kg man.
Composition of blood:-
Blood is composed of a straw – coloured transparent fluid, Plasma, in which different types of cells are suspended. Plasmaconstitutes about 55% and cells about 45% of blood volume.
Plasma:- The constituents of plasma are water 90- 92% and dissolved substances , including:
• Plasma proteins
• Inorganic salts
• Nutrients from digested foods
• Waste materials
• Hormones
• Gases
(1) Plasma proteins:– It is make about 7% of plasma are normally retained within the blood, because they are too big to escape through the capillary pores into the tissues. Plasma viscosity is due to plasma proteins, mainly albumin and fibrinogen. Viscosity is used as a measure of the body’s response to the some diseases.
(2) Inorganic (minerals) salts:– These are involved in a wide variety of activities, including muscle contraction, transmission of nerve impulses, formation of secretion and maintenance of acid- base balance.
(3) Nutrients :- In the alimentary tract , food is broken down into small molecules, e.g monosaccharides, amino acids, fatty acids & glycerol are absorbed.
(4) Waste products:- Urea, creatinine & uric acid are the waste products of protein metabolism. They are formed in the liver and conveyed in blood to the kidneys for excretion.
(5) Hormones:– These are substances by endocrine glands .Hormones pass directly from the endocrine cells into the blood which, transports them to their targets tissues & organs in the body, where influence cellular activity.
(6) Gases:– oxygen ,carbon dioxide & nitrogen.

Definition-An episiotomy is a surgical cut in the muscular area between the vagina and the anus (the area called the perineum) made just before delivery to enlarge your vaginal opening.
Obstetricians used to do episiotomies routinely to speed delivery and to prevent the vagina from tearing, particularly during a first vaginal delivery, in the belief that the “clean” incision of an episiotomy would heal more easily than a spontaneous tear. Many experts also believed that an episiotomy might help prevent later complications, such as incontinence.
Indications:-
1. Large size baby:-a baby estimated to be 4000gm or more may cause need for an episiotomy either to prevent laceration or in anticipation of a possible shoulder dystocia.
2. Preterm or small for gestational age baby
3. Fetal malpositions & malpresentations.
4. A thick perineum which is rigid &resistant to distention.
5. Prior to an assisted delivery such as forceps & vacuum extraction.
6. To speed up delivery if there is fetal distress.
Types of episiotomy:-
1. Medline or median episiotomy:-
The episiotomy incision is given in the midline, extending from the vaginal opening towards the anus.
The advantages are:
• Less blood loss with this procedure.
• Less pain.
• An easier to perform procedure.
• Wound repair is done easily.
• Better cosmetic results due to less scarring.

2. Mediolateral episiotomy:-
In a mediolateral episiotomy, the incision begins in the middle of the vaginal opening and extends down toward the buttocks at a 45-degree angle.
The primary advantage of a mediolateral episiotomy is that the risk for anal muscle tears is much lower. However, there is much more disadvantages associated with this type of episiotomy, including:
• increased blood loss
• more severe pain
• difficult repair
• higher risk of long-term discomfort, especially during sexual intercourse

Principles:-
The following principles should be observed regardless of which types of episiotomy is cut:-
1. The presenting part of fetus is protected from injury.
2. A single cut in any direction is far preferable to repeated snipping because the latter will leave jagged.
3. The episiotomy should be large enough to meet the purpose for deciding to cut it.
4. The timing should be such that lacerations are prevented & unnecessary blood loss avoided.