OB Final Exam PDF

**Intrapartum care** 1. What are the types of breech presentation? - Slide 23 2. What are fetal variations for vertex presentation? - Slide 25  3. What aspects of newborn status are included in...

**Intrapartum care** 1. What are the types of breech presentation? - Slide 23 2. What are fetal variations for vertex presentation? - Slide 25  3. What aspects of newborn status are included in the APGAR score? - Slide 41 - Assessment for infants after birth scored of 10 - 1 min and 5 min - Measures: - Respiratory effort - Heart rate - Muscle tone - Reflex Activity - Color **Fetal Heart Rate Monitoring** 1. What is the primary goal of external fetal heartrate monitoring? a. To interpret and continually assess fetal oxygenation to prevent significant fetal acidemia while minimizing unnecessary interventions and promote family-centered care b. Good fetal oxygenation = good placenta 2. Describe two ways and fetal heart rate monitor may be used in labor: external vs internal c. **External monitoring** detects baseline, variability, accels and decels i. CEFM -- continuous electrical fetal monitoring (US) ii. Intermittent (Doppler) iii. Wireless iv. Contractions are measured via toco transducer d. **Internal monitoring** is an intervention specific for troubleshooting measures v. Place F/ISE (fetal/internal scalp electrode) attached to presenting part of the fetus vi. Place IUPC (intrauterine pressure catheter) vii. Membrane MUST be ruptured to perform internal monitoring 1. f not yet ruptured, must be manually ruptured e. Contraindications: chorio, GBS+, genital herpes, placenta previa  A diagram of a baby in the womb Description automatically generated 3. How are cord blood gasses used to assess newborn status? f. Cord blood gases are collected after birth to help **determine the severity of hypoxia** in labor; one of the first assessments of fetal well-being after delivery 4. Describe a normal fetal heart rate baseline g. **Baseline (BL) FHR** is rounded to 5 bpm in a 10-minute window of time h. **Normal FHR:** **110-160 bpm** x 10 min or more 5. Describe abnormal fetal heart rate baselines i. **Tachycardia** \>160 bpm x 10 min or more j. **Bradycardia** \ xi. Moderate amplitude from peak to trough 6-25bpm **Most reassuring status** xii. Marked \25bpm tachycardia 7. How is an acceleration measured? o. **Visually apparent abrupt increase in FHR above baseline** xiii. ≥ 15 bpm x 15 sec but less than 2 minutes -- if longer than 2 minutes, can indicate baseline change xiv. If preterm \30 seconds to reach nadir (nadir = the slowest FHR recorded and lowest point)Periodi**c xvi. Mirrors contraction (nadir is at the peak of uterine contraction) xvii. Cause = head compression against the pelvis or soft tissue xviii. Reassuring (a good sign) r. **Variable Decels** xix. **Baseline to nadir in \2 min but \6 cm dilation with membrane rupture and 4+ hours of adequate contractions/6+ hours if inadequate contractions - Delivery that happens on its own without requiring doctors to use tools to help pull the baby out - **Induced labor** \>6 cm dilation with membrane rupture or greater than 5 cm w/o membrane rupture and 4+ hours of adequate contractions/6+ hours if inadequate - **Pr**ompting the uterus to contract during pregnancy before labor begins on its own for a vaginal birth - **Second stage arrest disorder** ➔ *failure of fetal head descent* - Arrest of labor after 2 hours of pushing for 3 hours of pushing 4. What are the different fetal presentations that may lead to dystocia? (Malpresentations) ======================================================================================== - **Occiput posterior** - The back of the baby's head is in the posterior portion of the pelvis (closest to your back) instead of the anterior (occiput anterior = back of baby's head is closest to your front) - Face presentation ================= - Fetal head is in extension rather than flexion as it enters the pelvis - Brow presentation ======================================== - Fetal head presents in a position midway between full flexion and extreme extension -- largest diameter of the head in the pelvis - Shoulder presentation ===================== - Fetal spine is vertical to the maternal pelvis -- higher risk of prolapsed cord, C-section is indicated - Compound presentation ============================================ - One or more fetal extremities accompany the presenting part -- also higher risk of prolapsed cord and C-section is indicated - Frank Breech ============ - Fetus's thighs are flexed alongside the body, feet are close to the head - Complete Breech ====================================== - One or both knees are flexed - Footling Breech ====================================== - Either one (single footing) or both (double footing) feet present before the buttocks 5. What are different methods of induction of labor? - **Induction of labor (IOL)** = deliberate stimulation of labor onset of spontaneous labor to facilitate a vaginal birth - There must be an indication for IOL; medically necessary - **[IOL interventions]:** - **Cervical preparation**: the process of physical softening, thinning, and dilating of the cervix in preparation of labor and birth - Mechanical cervical preparation ➔ **balloon catheter** - Pharmacological methods of preparation ➔ **misoprostol, cervidil** - **Oxytocin**: Pitocin titration used to stimulate contractions and labor - **Amniotomy (AROM)**: artificial rupture of membranes used to induce or augment labor - AROM in early labor ➔ increased risk of C-section 6. What does a Bishop Score measure? - **A calculation to predict how close you are to labor** - **Bishop score \>8** - Same likelihood of vaginal delivery with induction of labor as that following spontaneous labor; indicates a successful induction - Bishop score \6 ================ - Favorable for successful induction ================================== 7. What are indications and contraindications or labor augmentation? - **Augmentation** = stimulation of contractions when labor does not progress after the onset of spontaneous labor; goal is to strengthen and regulate contraction - **Indications** - \ 8. What are advantages of a vacuum-assisted delivery compared to forceps? - Advantages of vacuum-assisted delivery compared to forceps: - Easier application - Less anesthesia is required - Less maternal soft tissue damage - Fewer fetal injuries 9. What maternal risks are associated with a shoulder dystocia? - Severe perineal lacerations (4^th^ degree) - Maternal symphyseal separation (separation of the pubic bones) and peripheral neuropathy (weakness, numbness and pain, usually in hands and feet) - Sphincter injuries - Infection - Bladder injury - Postpartum hemorrhage - Intervention ➔ **McRoberts maneuver** - **Prov**ider will flex patient's thighs tightly towards the abdomen while simultaneously shifting the hips away from the body while applying suprapubic pressure 10. What fetal risks are associated with a shoulder dystocia? - Compression of the fetal neck by the maternal pelvis - **[Impairs fetal circulation]** ➔ increased ICP, anoxia, asphyxia, and neurological injury - First sign is a retraction of the fetal head against the maternal perineum after delivery of the head, sometimes called "turtle sign" 11. What is an umbilical cord prolapse? - **Total or partial occlusion of the cord** - Resulting in rapid deterioration in fetal perfusion and oxygenation - Causes fetal hypoxia possibly leading to long-term sequela, disability, or death - Leads to compression which causes FHR decels, including severe sudden decels - often with prolonged bradycardia or recurrent moderate-to-severe variable decels - **Umbilical cord prolapse can be occult or overt** - **Occult prolapse** = neither visible nor palpable, occurs when the cord passes through the cervix alongside the presenting part of the fetus (A) - **Overt prolapse** = the cord presents before the fetus and is visible or palpable within the vagina or even past the labia (B and C) - **Risk Factors r/t fetus** - Malpresentation of the fetus (such as breech), fetal anomalies, intrauterine growth restriction and small for gestational age (SGA), unengaged presenting part - **Risk Factors r/t pregnancy** - Primary iatrogenic cause is the artificial rupture of membranes (AROM) 13\. What is disseminated intravascular coagulation? - When the body breaks down blood clots faster than it can form a clot - Quickly depleting the body of clotting factors leading to hemorrhage and rapidly lead to maternal death - Always a result of another pathological process/injury - placental abruption - amniotic fluid embolism - Amniotic fluid or fetal material (such as squamous cells, vernix, or meconium) enters the maternal circulation through the **uterine veins**, typically during labor, delivery, or shortly after. - Triggers and abnormal immune response and systemic inflammation - sepsis syndrome - acute fatty liver of pregnancy - severe preeclampsia - hemolysis - elevated liver enzymes - low platelet count syndrome - massive obstetric hemorrhage **Care of Cesarean Birth Families** 1. What is the role of the nurse in an unscheduled cesarean birth? a. **Unscheduled** or **emergent C-sections** = stabilize patient and fetus, 30 minute "decision to incision" rule b. [Nursing actions]: i. Complete the appropriate admission assessments (including baseline VS) and required preoperative forms -- surgical and anesthesia consent ii. Ensure labs are completed as ordered; CBC, platelets, blood type and screen/cross match iii. Start an IV line and administer an IV fluid preload as per orders iv. Insert a Foley as per order, usually after anesthesia due to comfort v. Trim the lower abdominal and upper pubic regions with clippers vi. Administer preop meds vii. Prepare the partner or support person with appropriate surgical attire to wear in the OR viii. Complete the surgery checklist -- removal of jewelry, eyeglasses/contact lens, dentures ix. Notify the anesthesia, L&D team, and neonatal personnel of the impending cesarean birth x. Initiate continuous electronic FHR monitoring xi. Administer oxygen when indicated (i.e., signs of fetal intolerance of labor) xii. Assess the patient's vital signs xiii. Provide emotional support 2. What are intraoperative complications associated with cesarean birth? c. Hemorrhage d. Bladder, ureter, and bowel trauma e. Maternal respiratory depression r/t anesthesia f. Maternal hypotension r/t anesthessia increased risk for fetal acidemia g. Inadvertent injection of the anesthetic agent into the maternal bloodstream can lead to unconsciousness and cardiac arrest xiv. Anesthesia management spinal( if epidural not in place), epidural (already present and plan has changed to c-section, and general (emergency cases) 3. What are contraindications for epidural or spinal anesthesia? h. Low platelet count- most common contraindication, especially with preeclampsia and/or HELLP syndrome i. Infection or dermatological issues of concern at the proposed site of needle insertion j. Uncorrected maternal hypovolemia k. Spine abnormalities, injuries, and/or surgeries l. Sepsis 4. What is the nursing role in intraoperative care for cesarean birth? m. Positioning patient xv. During administration of epidural or spinal anesthesia xvi. Hip tilt, Left lateral tilt n. Conduct a time-out o. Continue monitoring FHR p. Foley insertion q. Abdominal skin prep using sterile technique r. Instrument, needle, and sponge count s. Facilitate care for the neonate time of delivery of neonate and placenta one person should be present just for the baby xvii. APGAR scores xviii. Baby should remain in OR if possible skin-to-skin contact xix. ID bands for baby and parents xx. Is neonate unstable transfer to nursery and encourage partner or support to accompany t. Complete intraoperative documentation 5. What is nursing management in immediate post-operative care following a cesarean birth? (First 24 hours) u. Sign of complications post-eclampsia, seizures, spinal headache, neurological deficits, hemorrhage v. Monitor vital signs w. Monitor blood loss, I&Os x. Assess fundus and lochia y. Assess abdominal dressing for drainage/signs of infection z. Assess pain provide pain medication and stool softeners a. Progression of diet b. Assess bowel sounds and flatulence -- advance diet as tolerated c. Auscultate lungs, encourage incentive spirometry d. Regulate IV fluids -- oxytocin added to reduce risk of postpartum hemorrhage r/t uterine atony xxi. Monitor I/Os e. Remove Foley -- must void at least 200 mL within 2-3 hours of removal f. Facilitate skin-to-skin contact with parents and infant g. Assist patient into comfortable position for infant feeding, provide teaching h. Activity level xxii. Levels of sensation **Physiologic Care of the Neonate** 1. What are nursing actions during the newborn transition period? ============================================================== - Maintain body heat - Maintain respiratory function - Decrease risk for infection - Assist parents in providing appropriate nutrition, hydration, and appropriate newborn care 2. Why is a neutral thermal environment needed to support newborn transition? ========================================================================== - **Neutral thermal environment** = an environment that maintains body temperature with minimal metabolic changes and/or oxygen consumption - Needed to prevent cold stress to newborn - Cold stress = excessive heat loss that leads to hypothermia - Brown adipose tissue = a dense and vascular adipose tissue in neonates - Promotes an increase in metabolism - Heat production - Heat transfer to the peripheral system 3. What are nursing interventions for the neonate suffering from hypoglycemia? =========================================================================== - Hypoglycemia is common during the transitional time - Assess for s/sx of hypoglycemia - Blood glucose levels - Maintain a neutral thermal environment - 4. What is the purpose of the Vitamin K injection for the neonate? =============================================================== - After birth, the neonate experiences a decrease in vitamin K and is at - Vitamin K is synthesized in the intestinal flora, which is absent in the newborn - Vitamin K injection is therefore given as prophylaxis to decrease the risk of bleeding r/t Vitamin K deficiency 5. How does newborn stool and urine output change during the first 4 days of life? =============================================================================== - Gastric capacity for the first few days is \~5-10 mL and increases to 60 mL by day 7 - Stomach emptying time is 2-4 hours, so the neonate must eat at that interval - **[Newborn urinary output]** - Full-term neonates excrete 15-60 mL/kg of urine per day for the first few days of life - Urinary output increases to 250-400 mL by the end of the first month of life - **[Newborn stool output]** - Day 1 and 2 will be meconium stool (sticky, thick, and black) - Day 3 will be transitional stool (looser greenish black) - Day 4 will be yellow, soft, and watery - Day 5 ➔ 1 month will be breastfed/formula-fed stool  6. What is considered appropriate weight loss for an infant in the first week of life? =================================================================================== - Neonates lose 5-10% of birth weight during the first week of life due to diuresis (kidneys filter too much bodily fluid, which increases urine production and the frequency) 7. What newborn assessment is used to assess for congenital hip dislocation? ========================================================================= - **Barlow maneuver** -- bringing knees close together - **Ortolani maneuver** -- bringing knees out and away from each other - Unequal gluteal folds and/or positive Barlow and Ortolani maneuvers are associated with congenital hip dislocation 8. What is vernix caseosa? ============================================== - **Vernix caseosa** = protective whitish, cheesy substance notes in auxiliary areas and genital areas of full-term neonates 9. What is the difference between physiologic and pathologic jaundice? When does it appear? ======================================================================================== - **Physiologic jaundice** occurs **AFTER the first 24 hours of** birth and during the first week of life - Increased RBC volume - RBC life span is shorter than adults - High bilirubin production hyperbilirubinemia - Reabsorb more unconjugated bilirubin in the intestine due to lack of intestinal bacteria - **Pathologic jaundice** occurs **WITHIN the first 24 hours of life** - Results when various disorders exacerbate physiological processes that lead to hyperbilirubinemia of the newborn - Lasts for more than 1 week in a full-term neonate or more than 2 weeks in a premature neonate - High bilirubin production hyperbilirubinemia 10. What are newborn reflexes assessed for in the initial newborn exam? =================================================================== - **Moro** -- hold the baby in a semi-sitting position and let the head slightly drop back - Symmetrical abduction and extension of the arms and legs - **Startle** -- make a loud sound near the neonate - Symmetrical abduction and extension of the arms and legs - **Tonic Neck** -- with the neonate in a supine position, turn the head to a side so that the chin is over the shoulder - Neonate assumes a "fencing" position with the arms and legs extended in the direction in which the head was turned - **Rooting** -- brush the side of a cheek near the corner of the mouth - Neonate turns the head towards the direction of the stimulus and opens the mouth - **Sucking** -- place a gloved finger in the neonate's mouth - Sucking motion occurs - **Palmar Grasp** -- examiner places a finger in the palm of the neonate's hand - Neonate grasps fingers tightly - **Plantar Grasp** -- place a thumb firmly against the ball of the infant's foot - Toes flex tightly down in a grasping motion - **Babinski** -- stroke the lateral surface of the sole in an upward motion - Hyperextension and fanning of the toes - **Stepping or dancing** -- hold the neonate upright with the feet touching a flat surface - Neonate steps up and down in place 11. What are common vaccinations given to the newborn in the first 1-2 days of life? ================================================================================ - **Hep B vaccine** -- given in 3 doses to newborn - 1^st^ before hospital discharge - 2^nd^ 1-2 months of age - 3^rd^ 6-18 months of age - **Erythromycin** -- prophylaxis treatment for gonococcal and chlamydial eye infections - **Vitamin K** injection **Postpartum Care** 1. What does the postpartum assessment include? ============================================ - PP immediate afterbirth to 6 weeks PP - Vital signs - Watch out for hypotension -- orthostatic VS may be ordered - PP chills - Lab findings (CBC, Rh factor, Rubella, etc.) - PP immunizations and boosters - **BUBBLE-LE**: Breasts, Uterus, Bladder, Bowel, Lochia, Episiotomy (Perineal Lacerations), Lower extremities (check for edema and DVT), Emotions - Perineal assessment: **REEDA** - Redness - Edema - Ecchymosis (bruising) - Discharge - Approximation of edges of episiotomy or laceration - NI topical anesthetic, sitz bath and icing the perinuem - Head-To-Toe: Cardiovascular, Respiratory, Immune, Endocrine, Urinary, MSK, Nervous and GI systems - Check for: - UTI - Post-eclampsia headaches, visual disruptions - Spinal headache - PP gestational DM high risk in pts with T2DM - Pain administer pain medications - Mastitis 2. What postpartum changes are associated with the gastrointestinal system postpartum? =================================================================================== - GI system returns to normal **[after 2 weeks postpartum]** - Common side effects: - **Constipation** -- tx: give stool softener, milk of magnesia - **Hemorrhoids** -- tx: prep H - **Assessment Tool:** - Subjective - I/Os - Bowel Sounds (s/p C/S) 3. What is the process of uterine involution? ========================================== - **Uterine involution** = the process by which the uterus returns to its pre-pregnancy size, shape, and location and the placental site heals - Complete involution takes between [ **6-8 weeks post birth**] - **Involution Assessment** - Have patient lie flat - palpate location, position, and tone of the fundus - Normal finding: midline, firm, and at the umbilicus 4. What are the different types of lochia? ============================================================== - **Lochia** = bloody discharge from the uterus; the endometrium regenerates in the postpartum period, causing lochia - **[Types of lochia]:** - **Rubra** = PPD 1-3 (PPD = postpartum day) - **Serosa** = PPD 4-10 - **Alba** = PPD 10+ - **Large clots =** report to provider; any presence of tissue may indicate retained placenta 5. What are nursing actions associated with the maternal urinary system postpartum? ================================================================================ - **[Bladder distention], [rapid bladder filling, urethra trauma due to catheterization], and [incomplete emptying] are** common in the first few days - **[S/Sx:]** - Low grade fever - Hematuria - Urinary frequency - Urgency - Suprapubic pain - **Nursing Actions:** - Encourage early voiding within the first 2-4 hours post birth and q3-4hr after that even without urge - Assess I&Os Adequate hydration - Patient teaching ➔ trauma to the body after birth can affect urinary function - If patient unable to void, catheter may be indicated - Review s/sx UTI in light of catheterization - If UTI administer antibiotics monitor UA, CBC, urine culture 6. What risk factors are associated with postpartum hemorrhage? ============================================================ - **Postpartum hemorrhage (PPH)** \500cc vaginal or \1000cc C/S + 10% drop in Hgb/Hct - **How do we assess it?** EBL \>\> QBL (estimated blood loss \>\> quantitative blood loss) - Greatest risk is in the first hour after birth! =============================================== - **Primary PPH** happens within 24 hours of birth - **Secondary (delayed) PPH** occurs between day 1 to 6 weeks - Treatment goal identify cause and prevent hypovolemic shock - **Other risk factors:** - Neonatal macrosomia - Placenta previa/accrete - Multiple gestation - Previous C/S or uterine surgery - Polyhydramnios - Prior PPH - High BMI - Operative vaginal delivery - Chorioamnionitis - Congenital/coagulation defects 7. What are four causes associated with postpartum hemorrhage? =========================================================== - **[The Four T's]:** - **Tone**: uterine atony (boggy \[meaning soft and tender\] fundus); subinvolution (delayed return of the enlarged uterus to normal size and function) - **Tissue**: retained placental fragments -- common cause of secondary PPH - **Trauma**: lower genital tract lacerations -- 2^nd^ most common cause of primary PPH - Hematomas can develop -- when blood from a ruptured vessel collects within the connective tissues of the vagina or perineal areas - **Thrombin disorders**: disseminated intravascular coagulation (DIC), DVT, PE - The body breaks down clots faster than it can form themdepleting the body of clotting factors leading to hemorrhage and death 8. How is postpartum depression distinguished from "baby blues"? ============================================================= - Difference Between Postpartum Blues (Baby Blues) and Postpartum Depression (PPD) - **PPB (Baby Blues)** symptoms disappear without medical intervention, occurs within the [first 2 weeks postpartum], able to safely care for self and baby - **PPD** mild to severe depression requires psychiatric interventions, occurs within the [first6-12 months] [postpartum], unable to safely care for self-and/or baby - **2 weeks of:** - **Loss of interest or pleasure in daily activities** - **Insomnia** - **Decreased energy/fatigue** - **Decreased concentration** - **Feelings of worthlessness or guilt** - **Weight changes** **High Risk Neonatal Nursing Care** 1. What two factors do infant health and survival depend on? ========================================================= - Length of gestation - Birth weight 2. What are signs and symptoms of respiratory distress syndrome in the neonate? ============================================================================ - **Respiratory distress syndrome** = life-threatening lung disorder that results from small, underdeveloped alveoli and insufficient levels of pulmonary surfactant - **[Signs and symptoms of RDS]:** - Tachypnea - Gray or dusky skin - Lethargic and hypotonic neonate 3. What is a patent ductus arteriosus and when should it normally close in the newborn? ==================================================================================== - PDA occurs when the ductus arteriosus remains open after birth - Normally **closes after a few hours to 96 hours post birth** - **[Signs and symptoms of PDA]:** - Tachycardia - Tachypnea - Recurrent apnea - Bounding Pulses 4. What is meconium aspiration syndrome? ===================================== - **Meconium aspiration syndrome** = respiratory failure induced when meconium fluid enters the lungs and causes partial obstruction - Increased risk in postmature newborns (born after 41 weeks' gestation) - **[Nursing Actions]:** - Assess for respiratory distress - Administer O2 if indicated 5. What is breastfeeding jaundice? =============================== - **Hyperbilirubinemia associated with breastfeeding** - Early onset of jaundice **[within the first few days of life]** - Associated with ineffective breastfeeding - Dehydration can occur - Delayed passage of meconium stool promotes reabsorption of bilirubin in the gut - **Treatment** - Encourage early effective breastfeeding without supplementation of glucose water or other fluids 6. What are the five principles of discharge teaching? =================================================== - **Right Time** - **Right Context** -- Is the environment quiet, free of distractions, private, soothing, or stimulating? - **Right Goal** -- Is the patient actively involved, are you and your patient committed to reaching mutually set goals, are the goals realistic and valued by the client? - **Right Content** - **Right Method** 7. - **Lactogenesis** = begins during the 2^nd^ trimester: milk is produced in the alveolar glands and transported to the nipple through lactiferous ducts - **Hormones associated with lactogenesis:** - **Prolactin** -- primary hormone responsible for lactation - High levels of **estrogen** and **progesterone [SUPPRESS lactation]** - Once placenta is delivered ➔ prolactin levels increase; estrogen/progesterone levels decrease estrogen will re-increase 1 week PP - Lactation amenorrhea method - Ovulation suppressed longer for lactating parent **Well-person care** 1. What four phases of life are distinguished with looking at women's health? ========================================================================== - Adolescence ➔ Childbearing years ➔ Perimenopause ➔ post-menopause/geriatric 2. What are the five P's of taking a health history? ================================================= - Partners - Practices - Protection from STIs - Past History of STIs - Pregnancy Intention 3. What is the lactational amenorrhea method of birth control? =========================================================== - **[Using breastfeeding as your birth control]** -- breastfeeding temporarily helps prevent pregnancy since breastfeeding hormones may stop your body from releasing eggs - must be used correctly for it to work -- the three simultaneous conditions that must be fulfilled is: - 1\. The baby is under 6 months - 2\. The mother is still amenorrheic - 3\. The mother practices exclusive or quasi-exclusive breastfeeding on demand 4. What are current methods of long-acting reversible contraception available in the United States? ================================================================================================ - IUD -- Copper = Paragard; Hormone-Releasing = Mirena, Kyleena, Skyla - **Intrauterine device (IUD)** = a small T-shaped device that your health care provider puts through your vagina and cervix into your uterus - A string attached to the IUD comes out of your uterus into the top of your vagina - The string is used to pull out the IUD when you want it removed - **Copper IUD (Paragard)** has no hormones and works **[up to 10 years]** - Changes sperm so sperm cannot fertilize an egg - **Hormonal IUDs** work **[up to 3-5 years]**, depending on which one you choose - Release a small number of hormones called **progestin**, which thickens your cervical mucus to keep sperm from reaching an egg - Hormone implant (Nexplanon) =========================== - Works **[up to 3 years]**, a small rod placed under the skin in the back of your arm - Releases a small amount of progestin, which keeps your ovaries from releasing an egg