Risk Factors Age under 17 over 35 Gravida and Parity
Socioeconomic status Psychological well-being Predisposing chronic
illness diabetes, heart conditions, renal Pregnancy related
conditions hyperemesis gravidarum, PIH
Slide 3
Goals of Care for High Risk Pregnancy Provide optimum care for
the mother and the fetus Assist the client and her family to
understand and cope through education
Slide 4
Slide 5
Slide 6
Abortions Termination of pregnancy at any time before the fetus
has reached the age of viability Either: spontaneous occurring
naturally induced artificial
Slide 7
Types of Abortions Threatened Imminent Complete Incomplete
Missed Recurrent/Habitual
Slide 8
Question??? What are two main complications related to a missed
abortion? 1. 2.
Slide 9
Cerclage procedure -- purse-string suture placed around the
internal os to hold the cervix in a normal state
Slide 10
Key Concepts Related to Bleeding Disorders If a woman is Rh-,
RhoGam is given within 72 hours of abortion Provide emotional
support. Feelings of shock or disbelief are normal Encourage to
talk about their feelings. It begins the grief process
Slide 11
Ectopic Pregnancy Implantation of the blastocyst in ANY site
other than the endometrial lining of the uterus (5) Cervical
ovary
Slide 12
Assessment Ectopic Pregnancy Early: Missed menstruation
followed by vaginal bleeding (scant to profuse) Unilateral pelvic
pain, sharp abdominal pain Referred shoulder pain Cul-de-sac mass
Acute: Shock blood loss poor indicator Cullens sign -- bluish
discoloration around umbilicus Nausea, Vomiting Faintness
Slide 13
Treatment Options / Nursing Care Combat shock / stabilize
cardiovascular Type and cross match Administer blood replacement IV
access and fluids Laparotomy Psychological support Linear
salpingostomy Methotrexate used prior to rupture. Destroys fast
growing cells
Slide 14
Gestational Trophoblastic Disease Hydatiform Molar Pregnancy A
DEVELOPMENTAL ANOMALY OF THE PLACENTA WITH DEGENERATION OF THE
CHORIONIC VILLI As cells degenerate, they become filled with fluid
and appear as fluid filled grape- size vessicles.
Slide 15
Assessment: Vaginal Bleeding -- scant to profuse, brownish in
color (prune juice) Possible anemia due to blood loss Enlargement
of the uterus out of proportion to the duration of the pregnancy
Vaginal discharge of grape-like vesicles May display signs of
pre-eclampsia early Hyperemesis gravidarium No Fetal heart tone or
Quickening Abnormally elevated level of HCG Question 6
Slide 16
Interventions and Follow-Up Empty the Uterus by D & C or
Hysterotomy Extensive Follow-Up for One Year Assess for the
development of choriocarcinoma Blood tests for levels of HCG
frequently Chest X-rays Placed on oral contraceptives If the levels
rise, then chemotherapy started usually Methotrexate
Slide 17
Critical Thinking Exercise A woman who just had an evacuation
of a hydatiform mole tells the nurse that she doesnt believe in
birth control and does not intend to take the oral contraceptives
that were prescribed for her. How should the nurse respond?
Slide 18
Placenta Previa Low implantation of the placenta in the uterus
Etiology Usually due to reduced vascularity in the upper uterine
segment from an old cesarean scar or fibroid tumors Three Major
Types: Low or Marginal Partial Complete Question 8
Slide 19
Interventions and Nursing Care Placenta Previa Bed-rest
Assessment of bleeding Electronic fetal monitoring If it is low
lying, then may allow to deliver vaginally Cesarean delivery for
All other types of previa
Slide 20
Abruptio Placenta Premature separation of the placenta from the
implantation site in the uterus Etiology: Chronic Maternal
Hypertension Short umbilical cord Trauma History of previous
delivery with separation Smoking / Caffeine / Cocaine Vascular
problems such as with diabetes Multigravida status Defined as
marginal, partial or complete
Slide 21
Treatment and Nursing Care Abruptio Placenta Cesarean delivery
immediately Combat shock blood replacement / fluid replacement
Blood work assessment for complication of DIC
Slide 22
Placenta Previa PAINLESS vaginal bleeding Bright red bleeding
First episode of bleeding is slight then becomes profuse Signs of
blood loss comparable to extent of bleeding Uterus soft, non-tender
Fetal parts palpable; FHTs countable and uterus is not hypertonic
Blood clotting defect absent Abruptio Placenta Bleeding accompanied
by PAIN Bleeding accompanied by PAIN Dark red bleeding Dark red
bleeding First episode of bleeding usually profuse First episode of
bleeding usually profuse Signs of blood loss out of proportion to
visible amount Signs of blood loss out of proportion to visible
amount Uterus board-like, painful and low back pain Uterus
board-like, painful and low back pain Fetal parts non-palpable,
FHTs non-countable and high uterine resting tone (noted with IUPC)
Fetal parts non-palpable, FHTs non-countable and high uterine
resting tone (noted with IUPC) Blood clotting defect (DIC) likely
Blood clotting defect (DIC) likely
Slide 23
Signs of Concealed Hemorrhage Increase in fundal height Hard,
board-like abdomen High uterine baseline tone on electronic fetal
monitoring Persistent abdominal pain and low back pain Systemic
signs of hemorrhage
Slide 24
Critical Thinking Mrs. A., G3 P2, 38 weeks gestation is
admitted to L & D with scant amount of dark red bleeding. What
is the priority nursing intervention at this time? A. Assess the
fundal height for a decrease B. Place a hand on the abdomen to
assess if hard, board-like, tetanic C. Place a clean pad under the
patient to assess the amount of bleeding D. Prepare for an
emergency cesarean delivery
Slide 25
Disseminated Intravascular Coagulation (DIC) Anti-coagulation
and Pro-coagulation effects existing at the same time.
Slide 26
Etiology Defect in the Clotting Cascade An abnormal
overstimulation of the coagulation process Activation of
Coagulation with release of thromboplastin into maternal
bloodstream Thrombin (powerful anticoagulant) is produced
Fibrinogen fibrin which enhances platelet aggregation and clot
formation Widespread fibrin and platelet deposition in capillaries
and arterioles
Slide 27
Resulting in Thrombosis (multiple small clots) Excessive
clotting activates the fibrinolytic system Lysis of the new formed
clots create fibrin split products These products have
anticoagulant properties and inhibit normal blood clotting A stable
clot cannot be formed at injury sites Hemorrhage occurs Ischemia of
organs from vascular occlusion of numerous fibrin thrombi Multisite
hemorrhage results in shock and can result in death
Slide 28
Assessment & Intervention Precipitating factors Abruption
PIH/HELLP syndrome Sepsis Anaphylactoid Syndrome Labs to review PT,
PTT, Platelets, D-Dimer, FSP Interventions Remove the cause Replace
fluids (Blood or blood products) Meds
Slide 29
Slide 30
Assessment Persistent nausea and vomiting Weight loss from 5 -
20 pounds May become severely dehydrated with oliguria AEB
increased specific gravity, and dry skin Depletion of essential
electrolytes Metabolic alkalosis -- Metabolic acidosis
Starvation
Slide 31
Nursing Care / Interventions Hyperemesis Gravidarium Control
vomiting Maintain adequate nutrition and electrolyte balance Allow
patient to eat whatever she wants If unable to eat Total Parenteral
Nutrition Combat emotional component provide emotional support and
outlet for sharing feelings Mouth care Weigh daily Check urine for
output, ketones
Slide 32
Slide 33
Classification of HTN in Pregnancy Gestational HTN = Systolic
BP > or equal to 140/90 after 20 weeks (replaces term of PIH),
protein negative or trace Pre-eclampsia = BP > or equal to
140/90 after 20 weeks, proteinuria, edema considered nonspecific
Eclampsia = other signs plus convulsions not attributable to other
causes Chronic HTN = BP > or equal to 140/90 that was known to
exist before pregnancy or does not resolve after 6 weeks after
delivery
PATHOLOGICAL CHANGES PIH is due to: GENERALIZED ARTERIOLAR
CYCLIC VASOSPASMS INCREASED PERIPHERAL RESISTANCE; IMPEDED BLOOD
FLOW ( in blood pressure) Endothelial CELL DAMAGE Intravascular
Fluid Redistribution (decrease in diameter of blood vessel)
Decreased Organ Perfusion Multi-system failure Disease
Slide 36
Rationale for HYPERTENSION The blood pressure rises due to:
ARTERIOLAR VASOSPASMS AND VASOCONSTRICTION causing (Narrowing of
the blood vessels) an increase in peripheral resistance fluid
forced out of vessels HEMOCONCENTRATION Increased blood viscosity =
Increased hematocrit
Slide 37
Key Point to Remember ! HEMOCONCENTRATION develops because:
Vessels became narrowed forcing fluid to shift out of the vascular
space Fluid leaves the intravascular space and moves to
extravascular spaces Now the blood viscosity is increased
(Hematocrit is increased) **Very difficult to circulate thick
blood
Slide 38
Proteinuria With renal vasospasms, narrowing of glomerular
capillaries which leads to decreased renal perfusion and decreased
glomerular filtration rate PROTEINURIA Spilling of 1+ of protein is
significant to begin treatment Oliguria and tubular necrosis may
precipitate acute renal failure
Weight Gain and Edema Clinical Manifestation: Edema may appear
rapidly Begins in lower extremities and moves upward Pitting edema
and facial edema are late signs Weight gain is directly related to
accumulation of fluid
Slide 41
The difference between dependent edema and generalized edema is
important. The patient with PIH has generalized edema because fluid
is in all tissues. The Nurse Must Know
Slide 42
Placenta Due to Vasospasms and Vasoconstriction of the vessels
in the placenta. Decreased Placental Perfusion and Placental Aging
Fetal Growth is retarded - IUGR, SGA Positive CST /
__________Decelerations With Prolonged decreased Placental
Perfusion:
Slide 43
Oliguria 100ml/4 hrs or less than 30 cc. / hour Edema moves
upward and becomes generalized (face, periorbital, sacral)
Excessive weight gain greater than 2 pounds per week
Slide 44
Central Nervous System Changes Cerebral edema -- forcing of
fluids to extracellular Headaches -- severe, continuous
Hyper-reflexia LOC changes changes in affect Convulsions /
seizures
Slide 45
Visual Changes Retinal Edema and spasms leads to: Blurred
vision Double vision Retinal detachment Scotoma (areas of absent or
depressed vision)
Slide 46
Nausea and Vomiting Epigastric pain often sign of impending
coma
Slide 47
Pre-Eclampsia Mild Severe 140/90 Protien 1+ to 2+ Edema 1+ to
lower legs < 1lb/ week Reflexes 1+ to 2+ 160/90 Protein 3+ to 4+
Edema 3+ to 4+ >2 lb/ week Reflexes 3+ to 4+ (hyperreflexia)
Clonus present Blurred vision or Scotoma Retinal detachment
N&V, Epigastric pain Elevated Liver enzymes Headache or change
in LOC Premature aging of placenta, IUGR, & or late
decelerations
Slide 48
Interventions and Nursing Care Home Management Decrease
activities and promote bed rest Sedative drugs Lie in left lateral
position Remain quiet and calm restrict visitors and phone calls
Dietary modifications increase protein intake to 70 - 80 g/day
maintain sodium intake Caffeine avoidance Weigh daily at the same
time Keep record of fetal movement - kick counts Check urine for
Protein
Slide 49
Hospitalization If symptoms do not get better then the patient
needs to be hospitalized in order to further evaluate her
condition. Common lab studies: CBC, platelets; type and cross match
Renal blood studies -- BUN, creatinine, uric acid Liver studies --
AST, ALT, LDH, Bilirubin DIC profile -- platelets, fibrinogen, FSP,
D-Dimer
Slide 50
Hospital Management Nursing Care Goal 1. Decrease CNS
Irritability 2. Control Blood Pressure 3. Promote Diuresis 4.
Monitor Fetal Well-Being 5. Deliver the Infant
Slide 51
Decrease CNS Irritability Provide for a Quiet Environment and
Rest 1. MONITOR EXTERNAL STIMULI Explain plans and provide
Emotional Support Administer Medications 1. Anticonvulsant --
Magnesium Sulfate 2. Sedative -- Diazepam (Valium) 3. Vasodilator--
Apresoline (hydralazine) Assess Reflexes Assess Subjective Symptoms
Keep Emergency Supplies Available
Slide 52
Magnesium Sulfate ACTION CNS Depressant, reduces CNS
irritability Calcium channel blocker- inhibits cerebral
neurotransmitter release ROUTE IV effect is immediate and lasts 30
min. IM onset in 1 hour and lasts 3-4 hours Prior to
administration: Insert a foley catheter with urimeter for
assessment of hourly output
Slide 53
Magnesium Sulfate NURSING IMPLICATIONS 1. Monitor respirations
> 14-16; < 12 is critical 2. Assess reflexes for
hypo-reflexia -- D/C if hypo-refexia 3. Measure Urinary Output
>100cc in 4 hrs. 4. Measure Magnesium levels normal is 1.5-2.5
mg/dl Therapeutic is 4-8mg/dl.; Toxicity - >9mg/dl; Absence of
reflexes is >10 mg/dl; Respiratory arrest is 12-15 mg/dl;
Cardiac arrest is > 15 mg/dl. Have Calcium Gluconate available
as antagonist
Slide 54
Test Yourself ! A Woman taking Magnesium Sulfate has a
respiratory rate of 10. In addition to discontinuing the
medication, the nurse should: a. Vigorously stimulate the woman b.
Administer Calcium gluconate c. Instruct her to take deep breaths
d. Increase her IV fluids
Slide 55
Control Blood Pressure Check B / P frequently. Give
Antihypertensive Drugs Hydralazine Labetalol Nifedipine Check
Hematocrit Do NOT want to decrease the B/P too low or too rapidly.
Best to keep diastolic ~90.Do NOT want to decrease the B/P too low
or too rapidly. Best to keep diastolic ~90. WHY?WHY?
Slide 56
Promote Diuresis ** Dont give Diuretic, masks the symptoms of
PIH Bed rest in left or right lateral position Check hourly output
-- foley catheter with urimeter Dipstick for Protein Weigh daily --
same time, same scale
Slide 57
Monitor Fetal Well-Being FETAL MONITORING-- assessing for late
decelerations. NST -- Non-stress test CST contraction stress test
BPP biophysical profile If all else fails ---- Deliver the
baby!!
Slide 58
HELLP Syndrome A multisystem condition that is a form of severe
preeclampsia - eclampsia H = hemolysis of RBC EL = elevated liver
enzymes LP = low platelets
HELLP Syndrome Assessment: 1. Right upper quadrant pain and
tenderness 2. Nausea and vomiting 3. Edema 4. Flu like symptoms 5.
Lab work reveals a. anemia low Hemoglobin b. thrombocytopenia low
platelets. < 100,000. c. elevated liver enzymes: - AST
asparatate aminotransferase (formerly SGOT) exists within the liver
cells and with damage to liver cells, the AST levels rise > 20
u/L. - LDH when cells of the liver are lysed, they spill into the
bloodstream and there is an increase in serum > 90 u/L/
Slide 61
HELLP Intervention: 1. Bedrest any trauma or increase in intra-
abdominal pressure could lead to rupture of the liver capsule
hematoma. 2. Volume expanders 3. Antithrombic medications
Slide 62
Slide 63
Urinary Tract Infection Most common infection complicating
Pregnancy Etiology Pressure on ureters and bladder causing Stasis
with compression of ureters Reflux Hormonal effects cause decrease
tone of bladder Assessment Dysuria, frequency, urgency lower
abdominal pain; costal vertebral pain fever
Slide 64
T O R C H A Infections T = Toxoplasmosis O = Other Syphilis,
Gonorrhea, Chlamydial,Hepatitis A or B R = Rubella C =
Cytomegalovirus H = Herpes A = Aids
Slide 65
Toxoplasmosis Etiology Protozoan infection. Raw meat and cat
litter Maternal and Fetal Effects Mom - flu-like symptoms,
lymphadenopathy Fetus still, premature birth, microcephaly; mental
retardation * Instruct to cook meat thoroughly * Avoid changing cat
litter * Advise to wear gloves when working in the garden
Treatment: Sulfa drugs
Slide 66
Syphilis Etiology Spirochete Treponema Pallium Maternal and
Fetal Effects May pass across the placenta to fetus causing
spontaneous abortion. Major cause of late, second trimester
abortion Infant born with congenital anomalies
Slide 67
Syphilis Intervention: 1. Penicillin 2. Advise to return for
prenatal visits monthly to assess for re-infection 3. Advise that
if treated early, fetus may not be infected
Slide 68
Gonorrhea Etiology Neisseria Gonorrhoeae Maternal and Fetal
Effects: May get infected during vaginal delivery causing
Ophthalmia neonatorium (blindness) in the infant Mom will
experience dysuria, frequency, urgency Major cause Pelvic
Inflammatory Disease which leads to infertility. Treated with
Rocephin Spectinomycin Treat partner!!
Slide 69
Chlamydia Three times more common than gonorrhea. Etiology -
Chlamydia trachomatis Maternal and Fetal Effects Mom pelvic
inflammatory disease, dysuria, abortions, pre-term labor Fetus --
Stillbirth, Chylamydial pneumonia Interventions Erythromycin,
doxycycline, zithromax Advise treatment of both partners is very
important
Slide 70
Hepatitis A or B Highly contagious when transmitted by direct
contact with blood or body fluids Maternal and Fetal Effects: All
moms should be tested for Hep B during pregnancy Fetus may be born
with low birth weight and liver changes May be infected through
placenta, at time of birth, or breast milk Intervention: Recommend
Hepatitis B vaccination to both mother and baby after
delivery.
Slide 71
Rubella Etiology Spread by droplet infection or through direct
contact with articles contaminated with nasopharyngeal secretions.
Crosses placenta Maternal and Fetal Effects Mom fever, general
malaise, rash Most serious problem is to the fetus--causes many
congenital anomalies (cataracts, heart defects) Intervention
Determine immune status of mother. If titer is low, vaccine given
in early postpartum period
Slide 72
CYTOMEGALOVIRUS Etiology -- Member of the Herpes virus Crosses
the placenta to the fetus or contracted during delivery. Cannot
breast feed because transmitted through breast milk Effects on Mom
and Fetus Mom no symptoms, not know until after birth of the baby
Fetus -- Severe brain damage; Eye damage Intervention No drug
available at this time Teach mom should not breast feed baby
Isolate baby after birth
Slide 73
Herpes Simplex Type 2 Maternal and Fetal Effects Painful
lesions, blisters that may rupture and leave shallow lesions that
crust over and disappear in 2-6 weeks Culture lesions to detect if
Herpes, No cure If mom has an outbreak close to delivery, then
cannot deliver vaginally. Must deliver by Cesarean birth *Virus is
lethal to fetus if inoculated at birth Intervention: Zovirax
Slide 74
HIV/AIDS Etiology: Human Immunodeficiency Virus, HIV
Transmission of HIV to the fetus occurs through: The placenta;
birth canal Through breast milk **The virus must enter the babys
bloodstream to produce infection.
Slide 75
Diagnosis: ELISA test identifies antibodies specific to HIV. If
positive = person has been exposed and formed antibodies Western
Blot used to confirm seropositivity when ELISA is positive. Viral
load - measures HIV RNA in plasma. It is used to predict severity
lower the load the longer survival. CD4 cell count markers found on
lymphocytes to indicate helper T4 cells. HIV kills CD4 cells which
results in impaired immune system. Goal: reduce viral load to below
50 copies /ml. and increase the CD4 cell count.
Slide 76
Nursing Care: **Provide Emotional Support **Teach measures to
promote wellness AZT oral during pregnancy IV during labor liquid
to newborn for 6 weeks. **Provide information about resources
Slide 77
Fetal Demise/ Intrauterine Fetal Death
Slide 78
Assessment: 1. First indication is usually NO fetal movement 2.
NO fetal heart tones Confirmed by ultrasound 3. Decrease in the
signs and symptoms of pregnancy
Slide 79
Slide 80
Diabetes in Pregnancy Diabetes creates special problems which
affect pregnancy in a variety of ways. Successful delivery requires
work of the entire health care team
Slide 81
Endocrine Changes During Pregnancy increase There is an
increase in activity of maternal pancreatic islets which result in
increase production of insulin. Counterbalanced by: a. Placentas
production of Human Chorionic Somatomammotropin (HCS) b. Increased
levels of progesterone and estrogen--antagonistic to insulin c.
Human placenta lactogen reduces effectiveness of circulating
insulin d. Placenta enzyme-- insulinase
Slide 82
Gestational Diabetes Diabetes diagnosed during pregnancy, but
unidentifable in non-pregnant woman Known as Type III Diabetes -
intolerance to glucose during pregnancy with return to normal
glucose tolerance within 24 hours after delivery Glucose tolerance
test: 1 hr oral GTT if elevated, do 3 hour GTT Gestational diabetes
if: Fasting 95 mg / dl 1 hour - 180 mg/ dl 2 hour - 155 mg/ dl 3
hour 140mg/dl
Slide 83
Treatment Controlled mainly by diet May use insulin No use of
oral hypoglycemics
Slide 84
Effects of Diabetes on the Pregnancy MATERNAL Increase
incidence of INFECTION Fourfold greater incidence of Pre-eclampsia
Increase incidence of Polyhydramnios Dystocia large babies Rapid
Aging of Placenta FETAL increase morbidity Increase Congenital
Anomalies neural tube defect (AFP) Cardiac anomalies Spontaneous
Abortions Large for Gestation Baby, LGA Increase risk of RDS
Slide 85
Effects of Pregnancy on the Diabetic Insulin Requirements are
Altered First Trimester--may drop slightly Second Trimester-- Rise
in the requirements Third Trimester-- double to quadruple by the
end of pregnancy Fluctuations harder to control; more prone to DKA
Possible acceleration of vascular diseases
Slide 86
Interventions/ Nursing Care Diet Therapy Diet Therapy Insulin
Regulation Insulin Regulation Blood Glucose Monitoring Blood
Glucose Monitoring Exercise Exercise Monitor Fetal Well Being
Monitor Fetal Well Being
Slide 87
Heart Disease in Pregnancy
Slide 88
Cardiac Response in All Pregnancies Increase in Cardiac Output
30% - 50% Expanded Plasma Volume Increase in Blood (Intravascular)
Volume Every Pregnancy affects the cardiovascular system A woman
with a healthy heart can tolerate the stress of pregnancy,but a
woman with a compromised heart is challenged Hemodynamically and
will have complications
Slide 89
Effects of Heart Disease on Pregnancy Growth Restricted Fetus
Spontaneous Abortion Premature Labor and Delivery
Slide 90
Effects of Pregnancy on A Diseased Heart The Stress of
Pregnancy on an already weakened heart may lead to cardiac
decompensation (failure). The effect may be varied depending upon
the classification of the disease
Slide 91
Classification of Heart Disease Class 1 Uncompromised No
alteration in activity No anginal pain, no symptoms with activity
Class 2 Slight limitation of physical activity Dyspnea, fatigue,
palpitations on ordinary exertion comfortable at rest
Slide 92
Class 3 Marked limitation of physical activity Excessive
fatigue and dyspnea on minimal exertion Anginal pain with less than
ordinary exertion Class 4 Symptoms of cardiac insufficiency even at
rest Inability to perform any activity without discomfort Anginal
pain Maternal and fetal risks are high
Slide 93
Nursing Care - Antepartum Decrease Stress teach the importance
of REST! watch weight assess for infections - stay away from crowds
assess for anemia assess home responsibilities Teach signs of
cardiac decompensation
Slide 94
Assess for Signs of CHF Cough (frequent, productive,
hemoptysis) Dyspnea, Shortness of breath, orthopnea Palpitations of
the heart Generalized edema, pitting edema of legs and feet Moist
rales in lower lobes, indicating pulmonary edema
Slide 95
Education Diet high in iron, protein low in sodium and calories
( fat ) Weight gain Medications Supplemental iron Heparin, not
coumadin monitor lab work Diuretics very careful monitoring
Antiarrhythmics Digoxin, quinidine, procainamide. *Beta-blockers
are associated with fetal defects. Reinforce physicians care
Slide 96
Nursing Care: During Labor Labor in an upright or side lying
position Restrict fluids On O 2 per mask throughout labor and
cardiac monitoring. Sedation / epidural given early Report fetal
distress or cardiac failure Stage 2 - gentle pushing, high forceps
delivery
Slide 97
Nursing Care Postpartum The immediate post delivery period is
the MOST significant and dangerous for the mom with cardiac
problems because: Following delivery, fluid shifts from
extravascular spaces into the blood stream for excretion Cardiac
output increases, blood volume increases Strain on the heart! Watch
for cardiac failure
Slide 98
Test Yourself ! Mrs. B. has mitral valve prolapse. During the
second trimester of pregnancy, she reports fatigue and palpitations
during routine housework. As a cardiac patient, what would her
functional classification be at this time? a. Class I b. Class II
c. Class III d. Class IV