Pregnancy & ANC RH Presesntation

1. REPRODUCTIVE HEALTH
GROUP 4 PRESENTATION
QN. Pregnancy and related problems
– Normal pregnancy, conception, development of
fertilized ovum, placenta functions
– Minor disorders
– Danger signs during pregnancy
– Antenatal care

2. Group members
• Kabategyeki Eunice 22/U/20694/HTG
• Kisembo Ivan 22/U/20696/HTG
• Okabo Walter
• Tumwesigye Stephen

3. Normal Pregnancy
• Pregnancy, process and series of changes that take
place in a woman’s organs and tissues as a result of a
developing foetus.
• The entire process from fertilization to birth takes an
average of 266–270 days, or about nine months.
• Diagnosis of pregnancy is based on Symptoms and
signs; biological tests

4. Symptoms of pregnancy
Amenorrhea
Enlargement and tenderness of the breasts
Nausea and sometimes vomiting
Excessive salivation (ptyalism)
Frequency of micturition
Pica
Constitutional symptoms e.g general tiredness, weakness,
depression etc.
Most of these symptoms subside as pregnancy progresses.

5. Signs of pregnancy
a) First trimester
 Enlargement of the breast
 Increase in size of the nipple and darkening of the areola
 small nodeles (montgomery’s tubercles) develop around the
nipple
 The cervix appears bluish (Jacquesmier’s sign) due to
increased vascularity.
 The cervix becomes more soft (Hegar’s sign) in that in
bimanual vaginal examination fingers of both hand almost
meet especially between the 6th
and 12th
week.
 Abdomen is slightly enlarged
 Increased pulsations in the lateral fornices (osiander’s sign)

6. Cont.
b) Second trimester
 Fetal movements are felt by the mother (quickening) and later
on palpation.
multiparous women usually experience quickening at about 16
weeks while primegravidae recognize it at about 20 weeks.
 Abdominal enlargement . Uterus is palpated slightly at about
symphysis pubis at about 12 weeks, umbilicus at 22 weeks and
xiphiod sternum at about 38weeks.
 From 24 weeks, fetal parts can be felt on palpation and fetal
heart sounds can be heard on auscultation.

7. Biological tests
• Urine and serum HCG

8. Anatomic and physiologic changes of normal pregnancy
Changes in organs and tissues directly associated with
childbearing
Ovaries
A new follicle develops after each menstrual period, and, after
ovulation, forms a new structure (the corpus luteum).
If the egg is fertilized, it is sustained for a short time by the
hormones produced by the corpus
luteum. Progesterone and estrogen, secreted by the corpus
luteum, are essential for the preservation of the pregnancy
during its early months.
Pregnancy, if it occurs, maintains the corpus luteum by means of
the hormones produced by the young placenta.

9. Cont.
• The corpus luteum is not essential in human pregnancy after
the first few weeks because of the takeover of its functions by
the placenta. Gradually the placenta, or afterbirth, begins to
elaborate progesterone and estrogen itself. By the 70th day of
pregnancy the placenta is unquestionably able to replace the
corpus luteum without endangering the pregnancy during the
transfer of function
• During pregnancy, both ovaries usually are studded with fluid-
filled egg sacs as a result of chorionic gonadotropin
stimulation; by the end of pregnancy, most of these follicles
have gradually regressed and disappeared.
• The blood supply to both ovaries is increased during
pregnancy.

10. The uterus
• The greater size of the uterus as a result of pregnancy is due
to a marked increase in the number of muscle
fibres, blood vessels, nerves, and lymphatic vessels in the
uterine wall.
• There is also a five- to tenfold increase in the size of the
individual muscle fiber and marked enlargement in
the diameters of the blood and lymph vessels.
• During the first few weeks of pregnancy, the shape of the
uterus is unchanged, but the organ becomes gradually softer.
By the 14th week it forms a flattened or oblate spheroid.
• The fibrous cervix becomes remarkably softer and acquires a
protective mucus plug within its cavity, but otherwise it
changes little before labour.

11. Physiological changes during pregnancy
The changes occur in the following systems and other organs.
a) Cardiovascular system changes
Major changes occur in the cardiovascular system in pregnancy,
most significantly by 12-16 weeks of gestation.
 With the increasing enlargement of the uterus, the diaphragm
is pushed upwards and the heart is correspondingly displaced,
the apex of the heart is displayed upwards and laterally.
 Cardiac output increased by 20% by week 8 and then further
up to 40% increase, maximal at week20-28.
.

12. In labor there is further increase in cardiac output and then a huge
increase immediately after delivery and followed by return to
normal within around an hour.
Contributing to increase in heart rate of 10-20 beats per minute.
 Blood pressure is lower than normal in the first two trimester
but returns to normal in the 3rs trimester.
 Many women have a 3rd
heart sound after mid-pregnancy
 Systolic flow murmurs are common

13. Cont.
b) Respiratory system changes
 The level of the diaphragm rises and intercostals angle
increase from 680
in early pregnancy to1030
in late pregnancy.
 Breathing is more diaphragmatic than costal
 Respiratory rate does not alter but the amount of the air
inhaled per minute increases from 7 to 11 liters and tidal vol
increase by a bout 200ml, increasing vital capacity and
increasing residual volume.

14. Changes cont.
Alimentary system changes
 Heart burn
 Reflux oesophagistis
 The LOS is displayed through the diaphragm due to increased
intra-abdominal pressure.
 Reduced gastric secretion
 Low gastric motility
 Nausea and vomiting in the early pregnancy
 Increased appetite with specific cravings

15. Cont.
Urinary tract changes
 Increased excretion and reduced blood levels of urea, creating
urate and bicarbonate.
 Gylcosuria and 1 or proteinuria-may occur due to increased
GFR
 Increased water retention causes increased plasma osmolarity
 Bladder smooth muscle relaxes increasing capacity and risk of
UTI’s
 Frequent urination

16. Cont.
Haemotological changes
 Plasma volume increases over the course of pregnancy by
about 50%
 Dilutional anemia due to increased in plasma volume
 Elevated erythropoietin levels the total recell mass by the end
of 2nd
trimester.
 MCV and MCHC are unaffected
 Levels of some clotting factors (VII,VIII,IX and X) and
fibrinogen increased while fibrinolytic activity decreases.

17. Cont.
f) Metabolic changes
BMR increases over the course of pregnancy by15-20%
g) Skin changes
 Hyper pigmentation of the face (chloasma), umbilicus,
abdominal line (linear nigra)
 Stretch marks (striae gravidarum)
 Increased blood vessels supply to the skin usually resulting
into sweating
 The woman feels hotter possibly due to progesterone induced
rise in temperature of 0.50c together with vasodilation.

18. Cont.
h) Maternal weight changes
The most obvious change occurs during pregnancy is
enlargement of the abdomen and increased in body
weight.
Weight gain during pregnancy is derived from both
maternal and fetal sources.

19. The increase in weight is mainly due to;
 Retention of water
 Increased body fat and protein
 Blood volume expansion
 Fetus, placenta and amniotic fluid
There seem to be significant weight gain in the first 12 weeks of
pregnancy. Some women do not gain weight due to reduced food
intake.
In normal/pregnancy, the average weight gain is 0.3kg/week for first
18weeks, 0.45kg/week from 18-28weeks.
Thereafter a slight reduction with a rate of 0.36-0.41kg/week until term.
The total weight gain is about 12.5kg in PG and 11.6kg in
multigravidea.
Immediately after childbirth, there is a weight loss of about 6kg

20. Conception and development of fertilized
ovum
• Within 24 hours after fertilization, the zygote rapidly divides into many
cells. By the eighth week of pregnancy, the embryo develops into a foetus.
• There are three stages of fetal development: germinal, embryonic and fetal
stage
Germinal stage
• The germinal stage is the shortest stage of fetal development. It begins
at conception i.e on fertilization.
• The zygote divides many times, eventually creating two separate structures,
the embryo and the placenta.
• Cell division continues at a rapid pace. Eventually, the zygote turns into a
blastocyst. The blastocyst implants in the uterus.

21. Embryonic stage
• The embryonic stage lasts from about the third week of
pregnancy until the eighth week of pregnancy.
• The blastocyst begins to take on distinct human characteristics.
It’s now called an embryo.
• Structures and organs like the neural tube (which later
becomes the brain and spinal cord), head, eyes, mouth and
limbs form.
• The embryo’s heart and pulse, and limb buds begin to develop
around the sixth week.
• By the end of the eighth week, most of the embryo’s organs
and systems take shape.

22. Fetal stage
• The fetal stage of development begins around the ninth week
and lasts until birth. This is when the embryo officially turns
into a fetus.
• The fetus gets its assigned sex around nine weeks of
pregnancy, although the healthcare provider can’t detect it on
ultrasound yet.
• The fetus’s major organs and body systems continue to grow
and mature.
• The fetus is able to move its limbs, although mother can only
feel it until 20 weeks of pregnancy.
The majority of growth — in both weight and length — happens
in the fetal stage.

23. Functions of the placenta
The placenta begins to form after a fertilized egg implants in the uterus around seven to
10 days after conception. It takes over hormone production by the end of the first
trimester.
• Blood passes through the placenta and provides oxygen, glucose and nutrients to
the foetus through the umbilical cord.
• The placenta can also filter out harmful waste and carbon dioxide from foetal
blood.
• The placenta enables the exchange of oxygen and nutrients between the
bloodstreams of mother and foetus without ever mixing them. It acts as foetal
lungs, kidneys and liver until birth.
• Towards delivery, the placenta passes antibodies to the foetus to jumpstart its
immunity. This immunity sticks with the baby for the first several months of life.
• The placenta produces several important hormones like lactogen, oestrogen and
progesterone during pregnancy.

24. Minor disorders in Pregnancy
Nausea, vomiting and hyperemesis gravidarum
• Many women have nausea and vomiting in the first trimester (3
months) of pregnancy, which is often called morning sickness.
• Hyperemesis gravidarum is a serious disorder, for which the
woman needs to be admitted to hospital or a health centre.
• The diagnosis of hyperemesis gravidarum is made if the woman
loses 5 kg or more of her body weight due to frequent vomiting,
loss of body fluids and nausea, making her fearful of eating, and
is confirmed by the appearance of acidic chemicals (called
ketone bodies) in her urine

25. Food dislikes and food cravings
• A pregnant woman may suddenly dislike a food that she usually likes.
It is OK not to eat that food, and she will probably begin to like it
again after the birth. She should be careful that the rest of her diet
contains a lot of nutritious food.
• Health education should be done.
• A food craving (also known as pica) is a strong desire to eat a certain
food, or even something that is not food at all, like black soil, chalk or
clay
Heartburn
• A burning feeling or pain in the stomach, or between the breasts, is called
indigestion or heartburn.
• Reassure mother

26. Constipation
• It is caused by hormonal changes that decrease the rhythmic muscular
movements of the gut (peristalsis), which push food along the intestines.
• Advise mother on dietary measures.
Varicosities (varicose veins)
• Swollen blue veins that appear in the legs are called varicosities, or
varicose veins, and are very common in pregnancy.
• Pressure by the enlarging uterus on the veins that return blood to the
heart from the legs is a major factor in the development of varicosities in
the leg veins.
• Very rarely, swollen veins may develop in the external genitalia and these
are very painful.

27. Haemorrhoids (piles)
• Haemorrhoids (also known as piles) are swollen veins around the anus. They
may burn, hurt, or itch. Sometimes they bleed when the woman passes a stool,
especially if she is constipated. Sitting or standing a lot can make haemorrhoids
worse.
Aches and pains
• Back pain. The weight of the baby, the uterus and the amniotic fluid, changes
her posture and puts a strain on the woman’s bones and muscles. Too much
standing in one place, or leaning forward, or hard physical work, can cause back
pain. Most kinds of back pain are normal in pregnancy, but it could also be
caused by a kidney infection.
• Joint pain. Hormones in the third trimester (six to nine months of pregnancy) act
on the woman’s joints so they get softer and looser. This makes her joints more
flexible, including the joints between the bones in her pelvis

28. Sudden pain in the side of the lower belly
• The uterus is held in place ‘suspended’ by ligaments on each
side. A sudden movement will sometimes cause a sharp pain in
these ligaments.
Abdominal cramps in early pregnancy
• It is normal to have mild abdominal cramps (like mild monthly
bleeding cramps) at times during the first trimester of pregnancy.
These cramps happen because the uterus is growing.
• However, cramps that are regular (come and go in a pattern), or
constant (always there), or are very strong or painful, or come
with spotting or bleeding from the vagina, are warning signs

29. Headaches and migraines
• Headaches are common in pregnancy, but are usually harmless.
• Headaches may stop if the woman rests and relaxes more, drinks more juice or
water, or gently massages her temples.
• It is OK for a pregnant woman to take two paracetamol tablets with a glass of
water once in a while.
• However, headaches late in pregnancy may be a warning sign of pre-eclampsia,
especially if there is also high blood pressure, or swelling of the face or hands.
Oedema
• Under the force of gravity, the retained fluid tends to sink down the body
and collect in the feet.
• Advise the woman to sit with her feet raised as often as possible, to allow
the fluid to be absorbed back into the circulatory system.
• Swelling of the feet is usually not dangerous, but severe swelling when the
woman wakes up in the morning, or swelling of the hands and face at any
time, can be signs of pre-eclampsia, which is a very serious

30. Frequency of urination
• Urinary frequency is a common complaint throughout pregnancy,
especially in the first and last months.
• This happens because the growing fetus and uterus presses
against the bladder. If urinating hurts, itches, or burns, the woman
may have a UTI.
Vaginal discharge
• Discharge is the wetness all women have from the vagina.
• Pregnant women often have a lot of discharge, especially near the
end of pregnancy. It may be clear or yellowish. This is normal.
• However, the discharge can be a sign of an infection if it is white,
grey, green, lumpy, or has a bad smell, or if the vagina itches or
burns.

31. Danger signs in Pregnancy
• Headache that won’t go away or gets worse over time
• Dizziness or fainting
• Changes in vision
• Fever of 100.4°F or higher
• Extreme swelling of limbs or face
• Thoughts about harming self or baby
• Trouble Breathing
• Chest pain or fast-beating heart
• Severe nausea and throwing up
• Severe belly pain that doesn’t go away
• Baby’s movement stopping or slowing during pregnancy
• Vaginal bleeding or fluid leaking during pregnancy
• Too weak to get out of bed

32. Identification of risk factors and complications during pregnancy
• Height taking
• Weight taking
• BP measuring
• Routine laboratory investigations (Urine, sugar & protein, blood for
MPS, Hb, Syphilis, HIV, Stool ova & Cyst)
• History taking .
• General and obstetric examination.
• History: Age, gravidity, parity,
Hx of abortion, still births, difficult labour, PPH, retained placenta, twins
e.t.c.
• General examinations (Yellowing of mucous membrane,
Lymphadenopathy, Oedema, Vericose veins, cyanosis and systems(Cvs,
RS)

33. The diagnostic tests used to determine high-risk pregnancy
Maternal:
• During ANC, tests such serology for HIV
• VDRL for syphilis
• Hepatitis B, Rubella, HB, sickle cell anemia
• Urine for UTI
Fetal:
• Ultra sound scan
• Screen for down’s syndrome-quadruple test window, measure crown –rump
length to estimate fetal gestation age, measure nuchaltransparency-space at
the back of of fetal neck , then maternal pregnancy associated plasma
protein and human chorionic gonadotrophinhormone.

34. ANTENATAL CARE (ANC)
This is the care given to a pregnant women by a skilled birth
attendant from the time of conception to delivery, aimed at
ensuring a safe and satisfying pregnancy and birth out come.
In simple terms, ANC is a means to identify high risk
pregnancies and they might experience a healthier delivery
and outcome.

35. The main objectives of ANC is to give information on;
 Screening, prevention and Rx of complications
 Emergency preparedness
 Birth planning
 Satisfying the unmet nutritional, social, emotional and
physical needs of the pregnant women.
 Provision of patient education including successful care and
nutrition of the new born.
 Identification of high risk pregnancies
 Encouragement of male partner involvement in antenatal care.

36. KEY TERMS
• Gestation-no of weeks since LNMP
• Term-normal duration of pregnancy
• Preterm/ premature labor-labor occurring after 20 wks before completed
37 weeks
• Post term-labor occurring after 42 weeks
• Gravida-any pregnancy regardless of duration including the present
• Primigravida-pregnancy for the first time
• Multigravida-second or subsequence pregnancy
• Stillbirth-fetus born dead after 20 wks

37. • Ante partum-time between conception and onset of labor
• Intra partum-time from onset of labor until birth of baby and placenta
• Post partum-time from birth until the woman’s body returns to pre
pregnancy state
• Nulligravida-has never been pregnant
• Nullipara -notgiven birth at more than 20 weeks
• Primipara-one birth at more than 20 weeks whether alive or dead
• Multipara-two or more births at more than 20 weeks

38. Components of ANC
 Risk assessment and identification
 Prevention and management of pregnancy related or
concurrent diseases.
 Health education
 Health promotion
 TT vaccination
 IPT (intermittent preventive treatment for malaria during
pregnancy)
 Identification and management of infections e.g. HIV, syphilis
etc.

39. Focused/goal oriented ANC
• The goal for ANC vary depending on the timing of the
visit/duration of pregnancies, aim for atleast 4 routine visits.
First AN visit (10-20wks)
This visit usually creates an everlasting impact of the client.
To large extent, the 1st
visit will determine whether the client will
come back or not.
Goal. – risk assessment
- Health education
- Plan for delivery

40. First visit cont.
History taking in ANC
Record name, age, marital status, occupation, education, ethnic origin,
residence.
Inquire if a client has any problems and obtain details.
Physical examination
a) General physical exam
b) Obstetric examination
- symphysio- fundal, lie, presentation, fetal heart sounds, presence of
multiple gestation.
- Vulva (vaginal) exam
Investigations
- Blood – ABO and Rh grouping, RPR, Hb, HIV (partner testing ) HB Ag.
- Urine – albumin (protein), glucose

41. Routine medication in pregnancy
Record all medications given on the ANC card
Folic acid 5mg
All pregnant women should take folic acid
throughout the first trimester (ideally from
conception)
Tetanus toxoid
Check on TT immunization status and
vaccinate if required
Mabendazole De-warm with mebendazole 500mg single
dose (2nd
trimester)
Ferrous 200mg + folic acid (400mcg)
Ferrous (200mg) + folic acid (400mcg) once
daily to prevent iron and folate deficiency.
Sulphadoxine/pyrimthamine (sp) Sp single dose (3 tabs) every month from
13weeks to end of the pregnancy.

42. Second antenatal visit (20-28wks)
Goals
Address problems
 Take action if abnormal laboratory results
 Ensure TT vaccination
 Exclude multiple pregnancy
 Assess for signs of pregnancy-include hypertension
 Check fetal growth
 Exclude aneamia
 Assess the degree of patient’s risk

43. 2nd
visit cont.
History taking
 Interval history taking symptoms and 1 or problems e.g
vaginal bleeding (antepartum haemorrhage), drainage of liquor
 Date of first fetal movements.
Examination
As for 1st
antenatal visit plus;
Weight
Lab investigation

44. Third antenatal visit (28-36)
Goals
Check fetal growth
Exclude anemia
Assess for signs of pregnancy- include hypertension
Review delivery plan
History taking as for 2nd
visit
Lab investigations
Examination – same as for 2nd
visit PLUS
Discuss labor/early rapture of membrane
Fourth antenatal visit (after week 36)
As for 3rd
visit plus, exclude abnormal presentation / lie.

45. Abdominal examination:
The aims:
• To observe the signs of pregnancy
• Assess fetal size and growth
• Auscultate the fetal heart
• To locate fetal parts
• To detect any deviation from normal
Preparation:
• Ask the woman to empty bladder and be comfortable
• There should be privacy and uncover only the parts to be
examined, the arms should be on the sides
• And engage the woman giving feedback throughout the
examination

46. Abdominal examination cont…………..
Divided into :
• Inspection: observe the size and shape of the abdomen.
Observe the signs of pregnancy and the skin color changes
Observe any other like scars, abnormal swelling etc and
find out more from the woman duration and cause.
• Palpation: to determine the fundal height , the midwife
palpates gently where the resistance is. Then places the
tape measure at the upper border of the symphysis
pubis stretching to where the resistance is then read the
centimeters which equal to weeks.

47. Abdominal examination cont…………..
• Fundal Palpation: determine what is presenting, usually
the breech or the head.
Use both hands on either sides with fingers held close
curving round the fundus
Apply some pressure with the palms and determine soft
round consistency with unclear outline, which is the
breech. If you feel a hard round smooth mass and well
defined, then it is the head.
It will be mobile or ballotable

48. Abdominal exam. Cont………..
• Lateral palpation: used to locate the fetal back to determine
position.
Place both hands on either side of the abdomen at the level of the
umbilicus.
Apply some pressure alternately to identify where there is
resistance, or steady one side of the uterus and apply a slight push to
map out the back as a continuous curve from the breech to the neck
Do the same on the other side, which will reveal the limbs as
irregular nodules and mobile under the examining fingers
Continue to walk the fingertips of both hands across the abdomen to
locate the position of the fetal back

49. Abdominal exam. Cont…………..
• Pelvic palpation: is to identify the pole of the fetus in the
pelvis.
Without causing discomfort, place the hands on either side
of the uterus at the level of umbilicus with the fingers
directed inwards and downwards then feel for the presenting
part.
The head will be ballotable hard and round.
Feel for the palpable part above the brim to determine
engagement.

50. Terms used in abdominal palpation
• Engagement: is when the widest presenting transverse
diameter of the fetal head has passed through the pelvic brim.
In prime gravid woman, the head engages usually by 37 weeks of
gestation
Causes of non-engagement are,
• occipital-posterior
• Full bladder
• Polyhydramnios
• Placenta praevia
• Multiple pregnancy
• Fetal and pelvic abnormality

51. Terms cont…………………
• Presentation: part of the fetus that lies at the pelvic
brim or in the lower pole of the uterus
Presentation can be vertex, breech, shoulder, face or brow
When the head is well flexed, the vertex presents and
when fully extended the face presents and when partially,
the brow presents
• Auscultation: listening to the fetal heart using a Pinard’s
fetoscope from the fetal back. The mother’s pulse is
taken at the same time to ensure it is fetal heart.

52. Terms cont…………………
• Lie: is the relationship between the long axis of the fetus
and the long axis of the uterus and usually longitudinal
It can also be oblique when the fetus lies diagonal or
transverse when the lie is across the long axis of the uterus
• Attitude: relationship of the fetal head and limbs to its
trunk which should be one of flexion, curled up with chin
on chest and limbs flexed forming a mass that can utilize
the space.
When fetus is flexed small diameters present and delivery
will be most effective with good contractions

53. Terms cont…………………
• Denominator is the name given to the presenting
part of the fetus used when referring to fetal position
• In vertex presentation, the occiput is the
denominator
• In breech presentation, the denominator is the
sacrum
• In face presentation the denominator is the mentum

54. Terms cont………………
• Position is the relationship between the
denominator of the presentation and the pelvic
brim(right and left occipito-anterior, right and left
occipito-posterior, right and left occipito-lateral)
Anterior position is more favorable than posterior
• In conclusion, findings from the abdominal
palpation should be considered part of holistic and
baseline findings of the woman’s and fetus health

55. Health education to pregnant mothers.
• Health education is very crucial, either
individual or as a group to communicate
important message for the good of the
mother and the growing fetus
• Prepare teaching lessons on relevant topics
and focused – Hygiene
- Nutrition, etc

56. ANTENATAL CARD
• This is the tool that is used to screen for risk factors and complications during
pregnancy. It also gives an idea on fetal growth and maternal well being.
• Parts of an Antenatal Card
• Institutional Characteristics
- Name of health facility
- Out patient No.
• Client Characteristics/bio data: Name, age, address,
religion, marital status, occupation , education level,tribe,
NoK, relationship, occupation,address, gravidity,
parity,abortions.
• Where will she deliver from and go after delivery.

57. Parts of ANC card cont…..
• Previous illnesses: medical, surgical, gynecology and obstetrics history
• Social history
• Family history
• Menstrual and contraceptive history
• History of present /current pregnancy
• Physical examination.
• Pelvic examination
• Previous obstetric history
• Antenatal Progress examination/ obstetric assessment and treatment
• Laboratory investigations and findings
• Ultrasound reports and dates
• Risk factors and recommendation for delivery
• Other /treatment

58. How to use ANC Card
• 1st
Visit: On the 1st
visit, the following are filled in
card:
– Registration number
– Clients characteristics
– Previous medical, surgical, gynecology and obstetrics
history
– History of current pregnancy
– Laboratory test findings
• Examination findings (Physical, general and
obstetrics

59. How to use ANC card cont……..
– Treatment: Referral when necessary or advise
given
– Date of next appointment
• Subsequent Visits
– Findings of physical and laboratory examinations
– Advise given, referral
– Date of next visit

60. Thanks for
listening