Antepartum and intrapartum emergencies Flashcards
List the signs of pregnancy.
- Breast tenderness
- Amenorrhea (absence of menstruation)
- Nausea
- Increased thirst
- Increased urination
- Increased lethargy
- Mood swings
- Dizziness
- Increased sensitivity to smell
What can be used to confirm pregnancy?
- Urine dipstick (bHCG) from 6 days; increased levels indicate pregnancy
- Blood test (bhCG)
- Ultrasound (dating scan)
Describe the public model of routine antenatal care.
- Midwifery led care
- Obstetrician overseen
- Birth centre
Describe the private model of routine antenatal care.
- Private obstetrician consultations
- Private midwife
- Birth at home
- Visiting rights at birth centre
List the most common scans and tests associated with antenatal care.
- Dating scan (confirmation of pregnancy 4-11 weeks)
- Nuchal translucency (12-14 weeks) and bloods
- Morphology scan (18-20 weeks)
- Developmental anomalies and placental position
- 28 weeks GTT (2hr blood test series)
- 34 weeks rescan for placenta (if high risk)
- 36 weeks growth scan (if high risk)
Name four tests for foetal chromosomal anomalies during pregnancy.
- Nuchal translucency scan and pathology
- NIPT (non-invasive pregnancy testing) - blood test that gives sex
- Chorionic Villus sampling - samples placenta and gives full genetic breakdown
- Amniocentesis
What chromosomal abnormalities can nuchal translucency detect?
- Trisomy 13 (Patau syndrome, incompatible with life)
- Trisomy 18 (Edwards syndrome, incompatible with life)
- Trisomy 21 (Downs syndrome)
Chorionic Villus sampling has an increased risk of what, and why is the risk generally accepted?
MC; sometimes still accepted as termination can still be performed if chromosomal abnormalities incompatible with life are detected.
Amniocentesis has an increased risk of what?
MC
What is the definition of spontaneous abortion?
The complete loss of the products of conception prior to the 24th week of pregnancy.
____% to ____% of diagnosed pregnancies are lost before 20 weeks.
10-15%
Most pregnancies lost before 20 weeks are lost before what physiological event?
Implantation.
How many pregnancies lost before 20 weeks are clinically recognised as an MC?
~a quarter.
True or false: the incidence of loss is higher in IVF and AMA pregnancies.
What is the definition of early MC?
MC occurring prior to 12-13 weeks gestation.
____% of MC are early MC (before 12-13 weeks gestation).
80%
What is the presentation of early MC?
- Painful or painless PV bleeding (usually not significant volume but can alarm mothers)
- Often associated with lower central abdominal cramping
- Often anxiety and distress
Describe the mx of early MC.
- Rest and reassurance
- Analgesia (morphine - won’t hurt infant at this point)
- Monitor VSS and PV loss
- Ascertain intrauterine scans if available
- Tx to hosp
What is the definition of late MC?
MC which happens from 13-24 weeks gestation.
What is the presentation and mx of late MC?
- Often painful lower abdo cramps or contraction pains
- Often PV fluid or blood loss
- Birth en-caul is common (remove this)
- Birth foetus
- Will be small yet well formed
- May show signs of life
- Breathing, movement, heart beat
- Same basic post-natal cares as for term birth
- Very emotive
- Rx like a baby
- ROLE not required
What are the limits of viability?
- The gestation at which resuscitation is not commenced following preterm birth
- 22 weeks in hospital is viable for resuscitation
- Is mostly futile
- Significant sequelae
- Can be commenced at maternal request from 20K
What is an ectopic pregnancy?
When a fertilised ovum implants itself outside the uterine cavity.
What is the most common site of implantation of an ectopic pregnancy?
Fallopian tube (95% of cases)
Ectopic pregnancy is commonly dx between ____ and ____ weeks gestation.
6 and 10
Though rare, in what other sites might an ectopic pregnancy implant?
- Abdominal cavity
- Ovary
- Cervical canal
What is the presentation of ectopic pregnancy?
- LIF/RIF pain (L and R iliac fossa)
- +/- PV loss
- Hx sexual activity
- Hx of amenorrhoea
- Hx of +Ve urine dipstick
What are the signs of ruptured ectopic pregnancy?
- RIF or LIF pain
- Shock/collapse (unknown origin)
- Pale
- Sweaty
- Tachycardic
- Hypotensive
- Nausea
- Dizziness
- +Ve urine pregnancy test
- +/- intrauterine scan, +/- blood test
- Hx of amenorrhoea and other signs of early pregnancy
- PV bleeding
- Shoulder tip pain (Kehr’s sign)
- Note: it is possible to have an ectopic pregnancy and an intrauterine pregnancy; evidence of an intrauterine scan does not rule out ectopic.
True or false: suspect ruptured ectopic pregnancy for any female of childbearing age with abdominal pain
Describe the mx of ectopic pregnancy.
- Basic cares
- Rest and reassurance
- Analgesia
- Mx shocked pt
- Tx without delay to appropriate facility (obstetric and surgical)
- Note: same mx as for ectopic with added shock care.
How common is morning sickness?
80-85% experience morning sickness; 50% V.
Most have morning sickness symptoms by ____ weeks.
8 weeks.
When does morning sickness resolve?
- By 12-14 weeks for majority
- By 16-20 for 90%
True or false: morning sickness is not confined to mornings in 90% of cases.
Morning sickness is associated with raised levels of ____.
bhCG
What is hyperemesis gravidarum (HG)?
A.K.A. excessive morning sickness, causing severe N+V and possibly leading to faint/dizziness, weight loss, and dehydration, and has marked social, emotional, and psychological impact. Can require hospitalisation.
How common is HG?
1% of women will develop HG.
What is used to rx HG?
- Metaclopramide
- Ondansetron
- Herbal remedies
True or false: UTIs don’t occur in pregnant women.
What is a consequence of urinary stasis in pregnant women?
Increased incidence of UTI
UTIs in pregnancy are often atypical or asymptomatic; what are some other signs of UTI?
- No burning or stinging
- Onset of incontinence
- Increased frequency
True or false: UTI’s can cause ascending infections.
List some possible complications of ascending infections from UTI’s
- Pyelonephritis (12-13% of women)
- Severe flank pain
- Sepsis
- Renal failure
- Premature labour
What is the definition of gestational diabetes mellitus?
Carbohydrate intolerance of variable severity with onset or first recognition during pregnancy.
When is gestational diabetes mellitus (GDM) usually dx?
Around 26-28 weeks gestation when the placenta manufactures hormones (growth hormone and cortisol) that inhibit insulin metabolism.
What is the maternal mx of GDM?
- Diet
- Metformin
- Insulin
Describe the paramedic mx of GDM
- Same as all diabetic presentations
- Hypoglycaemic events
- Food, gel, glucose
- Hyperglycaemic events
- Fluids, tx for insulin
- Consider hx taking
What are the implications of GDM for labour and birth?
- Macrosomic baby (>4.2kg; more likely if poorly mx, less likely if well mx)
- Increased incidence of shoulder dystocia
- Consider best position for birth
- Increased incidence of prolonged labour
- Increased incidence of obstructed labour
- Increased incidence of shoulder dystocia
- If women is antenatal (not in labour/imminent delivery):
- Consider presentation
- Consider pt’s self mx
- If woman is GCS15, not symptomatic, and not imminent birth - taking BGL is not a priority.
What are the maternal implications of GDM after labour and birth?
Insulin requirements fall rapidly; more at risk of hypoglycaemia.
What are the neonatal implications of GDM after labour and birth?
- Breastfeeding/artificial feeding baby within 1 hour is recommended
- Not necessary to take neonatal BGL unless symptomatic
- Normal BGL of neonate is >/= 2.6mmol/L (this low is physiological - drives instinct to feed)
- Feeding is more important - 30mL of formula if not breastfeeding
Describe how blood pressure is measured in pregnancy.
- Seated with feet flat on the floor
- R) arm (preductal [‘preload arm’] so it’s more accurate)
- Arm supported horizontally at level of the heart
- Rest momentarily before measurement
- Use a manual sphygmamonometer and stethoscope
- Palpate brachial pulse
- Measure both arms
- Use correct cuff size and positioning
- Record arm and position of the BP reading if significant result
What is pre-eclampsia?
Pregnancy induced hypertension dx after 20 weeks gestation affecting two or more organ systems. May lead to eclamptic seizures.
List the risk factors of pre-eclampsia
- Primipara
- Multigravida pregnant by a different partner
- Previous pre-eclampsia in a pregnancy by the same partner
- Family hx
- Multiple pregnancy
- Obsesity
- Renal disease, diabetes, SLE, antiphospholipid syndrome, essential HTN
Describe the mx of pre-eclampsia.
- Basic cares
- Analgesia (morphine)
- Antiemetics
- Consider tx
- Dark, quiet environment
- Loud noises/bright environments/sudden movements can instigate seizure activity in unstable pre-eclamptic women
- Note: at risk of spontaneous placental abruption
What are the signs and symptoms of pre-eclampsia?
- Hypertension (systolic >140, diastolic >90 - one or both readings are sufficient)
- Oedema
- Hx of HTN (often medicated with BB)
- Gestation >20 weeks
What are the signs of imminent eclampsia?
- Frontal headache
- Visual disturbance
- Vomiting
- Epigastric pain
- Oliguria
- Hyperreflexia
True or false: eclampsia is a common condition with moderate impacts on mother and baby.
It is a rare condition associated with severe morbidity for mother and baby.
How common is eclampsia?
1 in 2000 pregnancies
What is eclampsia?
Acute life threatening complications of pregnancy characterised by the appearance of tonic-clonic seizures in a pt who had developed pre-eclampsia.
Describe the mx of eclampsia.
- Mx seizure
- ABC’s
- Consider positioning (lateral)
- 5mg midazolam (likely not to work)
- CCP for MgSO4
- Birth is the only ‘cure’
When do women with hx of pre-eclampsia commonly have their first eclamptic seizure? This accounts for what percentage of cases?
Within 48 hours of birth, accounting for 44% of eclampsia cases.
What is the purpose and function of magnesium sulfate in eclampsia?
Anticonvulsant of choice for eclamptic seizures, used for prevention of eclampsia in hospital and as intervention in the PHE.
It inhibits smooth muscle contraction and causes arteriolar dilation; relaxation of resistance arteries lowers peripheral resistance significantly, lowering blood pressure.
Also has an anticonvulsant and neuroprotective effect on the brain.
Is a CCP required for administration of magnesium sulfate in QLD?
Magnesium sulfate prevents ____ ____ ____ and hence results in ____ ____, lowering ____ ____.
Smooth muscle contraction; arteriolar dilation; blood pressure.
What is the dosage of magnesium sulfate?
Loading dosage - 20mmol over 15 minutes.
What is the most common disorder of liver function particular to pregnancy?
Obstetric cholestasis (A.K.A. intrahepatic cholestasis)
Obstetric cholestasis is more common in ____ and ____.
AMA (advanced maternal age); multiples.
Describe the presentation of obstetric cholestasis.
- Pruritus of the extremities
- Usually from 30 weeks
- Caused by bile salts release of histamine
- Presents as pruritus in palms and soles of feet without rash - progresses to body and face
- Excoriation from scratching
- 50% develop jaundice
- Coagulation defects
- Oestrogen
What are the implications of obstetric cholestasis for paramedics?
- Antenatal MH
- Increased risk of PPH due to vitamin K and coagulation defects
What is hyatidiform molar pregnancy?
Benign neoplastic disease with an abnormal growth of cells inside the uterus
True or false: the growth of hyatidiform molar pregnancy is typically small for dates on palpation.
Typically large, resembles a bunch of grapes.
True or false: hyatidiform molar pregnancy can be complete or partial.
True - complete has no foetal products, partial may have some but it is not a viable pregnancy.
What are some signs of hyatidiform molar pregnancy?
- Early onset hypertension
- High levels of HCG (human chorionic gonadotropin)
- Hyperemesis Gravidarum
What are some prehospital implications of hyatidiform molar pregnancy?
- May present as intermittent PV loss with reports of ‘pedicles’ or ‘vesicles’ being lost
- May present as MC
- Significant risk of haemorrhage
True or false: loss of the cervical operculum is a sign on imminent delivery.
What is the function of the operculum (mucous plug)?
Barrier to infection
What does loss of the operculum indicate?
At least slight dilation of the cervix
True or false: the operculum can be lost a week or two prior to the onset of labour.
True or false: SROM is a sign of imminent birth.
In what percentage of cases does SROM occur before the onset of labour?
15%
What should be noted about SROM?
- Time, colour, and consistency
- Pink/clear/bloodstained is normal
- Green/khaki/viscous is likely to be meconium
What should be done if unsure of SROM?
Have lady apply pad and if not contracting, lay R) lateral recubant for tx to allow pooling of amnion and determination of SROM.
What is meconium liquor (mec liq) and why is it significant?
- Amnion changes from clear to mec.
- Foetus passed a bowel motion in utero
- Can be an indication of foetal distress in response to foetal hypoxia
- Commonly occurs in ‘post dates’ babies (40K+, becomes high risk if 12 days past due)
- Khaki tinge to thick pea green liquor
- TL;DR - only a problem if aspirated
What is meconium aspiration syndrome?
When meconium has been passed before birth and enters the lungs during the first few breaths after birth
What are the implications of meconium aspiration syndrome for paramedics?
- If baby cries at birth, mx as normal
- If baby is lethargic:
- Don’t stimulate immediately
- Suction nose and mouth with Y-suction catheter
- Be careful of vagal stimulation
- Resus as required - CCP backup
- Mec aspirator
What does VBAC stand for?
Successful vaginal birth after ceasarean section
What are the risks of VBAC?
- Uterine rupture
- Scar dehiscence
- Placenta accreta
- Intrapartum or neonatal death
Describe the mx of VBAC
- As per normal prehospital birth hx of lower uterine segment caesarean section (LUSCS) or classical incision caesarean section (CICS)
- Recognise uterine scar dehiscence or rupture (high suspicion for anything abnormal)
- Lights and sirens response to appropriate obstetric facility
What are the signs and symptoms of VBAC?
- Constant severe pain (differentiate between contractions)
- Painful to palpate
- Absent foetal movements
Is VBAC a severe obstetric emergency?
Yes, commonly fatal for mother and baby.
What is cord prolapse?
When the membranes have ruptured and a segment of cord is below the presenting part.
In cord prolapse, where might the loop be present relative to the mother’s anatomy?
- At the OS
- In the vagina
- Outside the introitus
What is the incidence of cord prolapse?
As many as 1 in 500 births
What are the implications of cord prolapse for the birth?
- The foetus is totally dependent on oxygenated blood via the umbilical cord
- Cord presentation of any kind may result in severe foetal compromise as a result of asphyxia
- Foetal death may eventuate when cord prolapse occurs in the absence of skilled assistance
- Cord compression may present as variable decelerations or late decelerations slow to return to the baseline
What are some risk factors for cord prolapse?
- Malpresentation (commonly breech)
- Polyhydramnios (excess aminotic fluid)
- Pre-term birth
- Multiple pregnancy
What should be done if the cord presents/prolapses and birth is imminent (head on view, crowning, active pushing)? What if birth isn’t imminent?
Imminent: continue with birth as normal, and expect resuscitation.
Not imminent: Sim’s position (head down, hips up)
What is antenatal haemorrhage?
PV bleeding during the course of pregnancy.
Antenatal haemorrhage has multiple causes, dependent on ____ and ____ ____.
Gestation; clinical presentation.
Describe the mx of antenatal haemorrhage.
- Thorough obstetric hx
- Gestation
- Foetal movements
- Known complications
- Recent hx
- Rx symptomatically
- Tx to appropriate facility
True or false: bleeding from a grade IV praevia is a major obstetric emergency requiring immediate tx to hospital.
What is placental abruption? What can it be caused by?
- Placenta may partially or completely shear away from the wall of the uterus
- Usually the result of direct trauma
- May also result from sustained maternal hypertension (pre-eclampsia, eclampsia)
What are the signs and symptoms of placental abruption?
- Constant pain
- Rigid uterus
- +/- contractions or tightenings
- +/- PV bleeding
- +/- haematoma
- Reduced foetal movements
What is the time range of a pre-term birth?
Birth >24 weeks and <37 weeks gestation.
Describe the mx of pre-term birth
- Mx birth as per normal
- Prepare for neonatal resus
- Consider increased likelihood of breech presentation and cord prolapse
- Dry head thoroughly and place trunk and extremities in polyethylene bag (maintains normothermia; if bag not available, use placenta bag and put placenta in clinical waste bag)
- If born ‘en caul’, break the membranes carefully and commence resuscitation
List five considerations when preparing for neonatal resuscitation with pre-term birth.
- First breath in pre-term neonate will require increased pressure due to underdeveloped lungs
- Do not cut cord prematurely
- Do not expect premature baby to behave like a term baby
- Prolonged resuscitation
- Hypothermia is a significant issue
What is a nuchal cord?
Umbilical cord around the neck and shoulders at birth.
Is the presence of nuchal cord independently a birth emergency?
Describe nuchal cord mx.
- If cord is present but loose, leave the cord and birth the baby through it
- If the ord is firm but able to insert finger underneath, pull a loop of cord around baby’s shoulder and continue to birth baby through it
- If cord is too tight to insert finger, adopt somersault manoeuver (somersault baby towards mother’s inner thigh)
What is shoulder dystocia?
When the normal mechanism of labour stops as the shoulders attempt to enter the pelvic brim but are unable to do so; inability to birth the shoulders without specific manoeuvers.
In shoulder dystocia, the anterior shoulder impacts on the ____ ____.
Maternal symphysis
In shoulder dystocia, the posterior shoulder impacts on the ____ ____.
Sacral promontory
What can cause shoulder dystocia?
- Cephalopelvic disproportion
- Increased bisacromial diameter
- Foetal macrosomia
What is the incidence of shoulder dystocia?
1 in 200 births
What are the maternal outcomes and incidences of shoulder dystocia?
- PPH, 11%
- Third and fourth degree tears, 3.8%
What are the neonatal outcomes and incidences of shoulder dystocia?
- Brachial pexus injury, up to 16%
- Erb’s Palsy
- Klumpke’s Palsy
- Clavicle or humerous #
- Neonatal death
What are the observations used to dx shoulder dystocia?
- Turtle sign (head bobbing/retracting on perineum)
- Standard delivery manoeuvres fail to delivery shoulders (traction)
- Failure to restitute
- Dx after 60 seconds of pushing ‘with contraction’ after birth of the head (this is why it’s important to document time of birth of the head)
What should prompt paramedics to pre-empt shoulder dystocia?
- Prolonged second stage
- Maternal obesity
- Post dates
- Macrosomia
- Hx of macrosomic infant
- Gestational diabetes
- Ethnicity
- Chin fails to deliver
Describe the mx and external manoeuvres for shoulder dystocia.
- Legs: McRoberts manoeuvre
- External pressure - suprapubic
- Enter - rotational manoeuvres
- Remove the posterior arm
- Roll the pt to her hands and knees
What are the basic mx principles of shoulder dystocia?
- Increase the diameter of the pelvis
- Change the orientation of the bisacromial diameter by rotation
- Reduce the diameter of the bisacromial diameter
Describe the McRoberts manoeuvre.
- Supine positioning
- Hyperflexion and abduction of the hips and mothers legs on her abdomen
- TL;DR: knees to nipples
What is the ‘running start stance’?
- All fours position
- Knee on the side of baby’s back, lifted towards mothers shoulder
True or false: when the mother is in the running start position, lateral traction should first be directed downward, then upward.
What is the Gaskins manoeuvre, and what must be considered?
Mother rolling onto all fours; mother’s capability.
What is Rubins I: suprapubic pressure and what does it do?
- Pressure applied in constant, CPR-like motion above the pubic symphysis at a 45 degree angle towards the opposite buttock
- Reduces bisacromial diameter and rotates anterior foetal shoulder in to the wider olique pelvic diameter
Can Rubins I be used together with the McRoberts manoeuvre?
Describe the process of commencing internal manoeuvres.
- Informed onsent
- Communication (avoid alarmist language)
- Explain procedures briefly
- Explain discomfort
- Discourage pushing (can increase impaction an is counterintuitive to the manoeuvres)
- Entry to the vagina
- Use clinical judgement for the most appropriate manoeuvre.
Describe the process of Rubins II.
- Continue McRoberts manoeuvre, cease suprapubic pressure
- Locate posterior aspet of the anterior shoulder
- Rotate shoulder anteriorly (towards baby’s body)
- Once in the oblique diameter, attempt to deliver by lateral traction and maternal pushing (don’t need to wait for contractions)
Describe the process of the Woods’ Screw manoeuvre
- Continue McRoberts and Rubins II
- Continue to discourage pushing
- Insert other hand/fingers to locate anterior aspect of posterior shoulder and rotate anteriorly
- Once in the oblique diameter, continue to attempt birth with lateral traction and maternal pushing
- If unsuccessful, try to rotate through 180 degrees and birth opposite shoulder as anterior
Describe the process of the reverse Woods’ Screw manoeuvre.
- Locate posterior aspects of posterior shoulder
- Attempt to rotate baby 180 degrees anteriorly
- If unsuccessful, attempt to deliver baby through lateral traction and maternal effort
Explain delivery of the posterior arm.
- Insert hand into the sacral hollow
- Local foetal elbow
- Bend foetal arm at the elbow and extend, sweeping over baby’s face in a straight line
- Once arm is birthed, attempt delivery with lateral traction and maternal effort
- Reduces the diameter of the foetal shoulders by the width of the foetal arm
- Humeral # up to 12%
What is the definition of breech birth, and what may the presenting part be?
Birth of a baby with the denominator being the sacrum. Presenting part may be buttocks, foot/feet, knee.
What is external cephalic version?
Turning of the foetal position in utero; cephalic version is turning to make the head present over the internal OS.
List the risks of a breech birth.
- Cord prolapse
- Cord compression
- Head entrapment
- Inco-ordinate contractions
- Failure to progress
- Incomplete dilation of the cervix
- Birth trauma
- Intracranial haemorrhage
- Injuries to internal organs, usually as a result of vigorous manoeuvres
- Meconium aspiration
- Term breech babies often pass mec during birth, increasing the risk
What are the principles of breech birth mx?
- ‘Hands off the breech’
- Moro reflex
- Aspiration
- Encourage a position where the baby can hang freely
- Prepare
When is accoucheur intervention required in breech presentation?
- If legs fail to birth 2 minutes after knees have presented in Frank breech presentation
- Baby is sacral occipital posterior (SOP; back to back)
- Loveset manoeuvre
- Arms fail to deliver after 2 minutes of trunk presenting (suspected extended arms)
- Loveset manoeuvre and delivery of arm/s
- Head entrapment ensues
- Mariceau Smellie Veit and suprapubic pressure as required
Describe the steps taken if legs fail to release 2 minutes after chest is birthed in Frank breech
- Pressure behind popliteal fossa (usually easiest with thumb)
- Thumb or fingers of same hand sweep over baby’s shin to birth the leg
- Can be repeated on other leg if necessary
When is the Loveset manoeuvre used?
For delivery of the shoulders in breech birth when one or both arms are extended, and for rotation of the foetus when in sacral occipito-posterior position (SOP)
Describe the Loveset manoeuvre.
- Grasp the foetus with two hands, holding only the bony prominences of the sacrum
- Exaggerate lateral flexion toward pubic sympysis (enables descent of posterior shoulder into sacral promontory)
- Rotate the body 180 degrees, keeping the back uppermost (posterior shoulder should rotate anteriorly then lie beneath the pubic symphysis)
- Sweep the anterior arm down across the baby’s face and across the perineum
- Rotate the body 180 degrees in the opposite direction so the posterior shoulder is now under the public symphysis
- Sweep the anterior arm down across the baby’s face
- Ensure back is uppermost, then allow the body to hang freely and await birth of the foetal head
What is the purpose of the modified Mauriceau-Smellie Veit manoeuvre?
Birth of the head with flexion and suprapubic pressure if it fails to birth thirty seconds after the birth of the shoulders in breech presentation.
Describe the modified Mauriceau-Smellie Veit manoeuvre.
- Done in a position below and in front of the baby (kneeling is often best)
- One hand and forearm supports the baby’s body which straddles the arm. The ring and index finger on this hand is on the maxillae and the middle finger is placed under the chin (not the mouth)
- The other hand is placed on the baby’s back with a finger pushing down on the occiput to keep the forehead flexed
- The head is birthed slowly by drawing the baby downwards and then raised upwards in an arc
In the modified Mauriceau-Smellie Veit manoeuvre, what is done if the head fails to birth or flexion of the foetal head is difficult to maintain?
Repeat the modified Mauriceau-Smellie Veit manoeuvre and add suprapubic pressure (second officer) to improve flexion of the foetal head.
What should clinicians be prepared for after a breech birth?
- Resuscitation
- Premature birth
- Hypoxia due to head entrapment
- Increased risk of intra-abdominal injuries due to manoeuvres
