SEIZURES & EPILEPSY

• A seizure is an abnormal behavior caused by abnormal electrical activity in the brain. In

contrast, epilepsy is a group of disorders marked by recurrent seizures over a prolonged period
of time.
• Non-epileptic seizures (also called pseudoseizures) are not accom- panied by unusual
electrical activity in the brain and are most often caused by emotional stress or other
psychological factors (see pam- phlet on psychogenic seizures).
• Provoked seizures are single (isolated) seizures that may be caused by trauma, low blood
sugar (hypoglycemia), low blood sodium, high fever, or alcohol or drug abuse. Fever-related (or
febrile) seizures oc- cur only during early childhood (before age 6). After a careful evalu- ation
to estimate the risk of recurrence, patients who suffer a single seizure may not need treatment.
• Seizure disorder is a general term used to describe any condition in which seizures may be a
symptom. In fact, seizure disorder is so general that it is not a useful term. Unfortunately,
“seizure disorder” is often used to avoid the term epilepsy.
Etiology:
• Epilepsy is a common condition, affecting about 1% of the popula- tion. This is about 20
times more common than multiple sclerosis.
• In the United States, about 2 million people have epilepsy. In fact, about 9% of Americans
will have at least one seizure during their lives.
• Epilepsy can begin at any age.

TYPES OF EPILEPSY

Type of seizures Based on the type of symptoms and electrical brain activity, seizures are
divided into two broad categories: generalized and partial (also called local or focal).
Generalized seizures are produced by electrical impulses from through- out the entire brain,
whereas partial seizures are produced (at least initially) by a relatively small part of the brain.
The part of the brain generating the seizures is sometimes called the focus.

Seizure Types and Characteristics

Generalized Seizures — Produced by the Symptoms

entire brain
1. Generalized tonic clonic (“grand mal Loss of consciousness, fall, convulsions,
muscle rigidity
Absence Brief loss of consciousness and staring
3. Myoclonic Sporadic (isolated), jerking movements
4. Clonic Repetitive, jerking movements
 5. Tonic Muscle stiffness, rigidity
6. Atonic Loss of muscle tone

Partial Seizures — Produced by a small Symptoms

area of the brain
1. Simple (awareness is retained) a. a. Jerking, muscle rigidity, spasms, head-turning
Partial Motor b. Unusual sensations affecting either the vision,
b. Sensory hearing, smell, taste or touch) c. Stomach
c. Autonomic d. Psychological sensation d. Memory or emotional disturbances
2. Complex (Impairment of awareness) (Automatisms such as lip smacking, chewing, fi
dgeting, walking and other repetitive involuntary
movements
3. Partial seizure that becomes general- Begins as partial (simple or complex) and evolves
ized seizure into grand-mal seizure

Generalized Seizures

• The most common and most dramatic is the generalized convul- sion, also called the
generalized tonic clonic (“grand mal”) sei- zure. The patient loses consciousness and usually
collapses. There is generalized body stiffening (called the “tonic” phase) for 30 to 60 seconds,
followed by violent jerking (the “clonic” phase) for 30 to 60 seconds, after which the patient
goes into a deep sleep (the “postictal” or after-seizure phase). During these seizures, injuries
and accidents may occur, such as tongue biting and urinary incon- tinence.

• Absence seizures cause a short loss of consciousness (just a few seconds) with few or no other
symptoms. The patient, most often a child, typically interrupts an activity and stares blankly.
These seizures begin and end abruptly and may occur several times a day. Patients are usually
not aware that they are having a seizure, except that they may be aware of “losing time.”

• Myoclonic seizures consist of sporadic jerks, usually on both sides of the body. Patients
sometimes describe the jerks as brief electrical shocks. When violent, these seizures may result
in drop- ping or involuntarily throwing objects.
• Clonic seizures are repetitive, rhythmic jerks that involve both sides of the body at the same
time.
• Tonic seizures are characterized by stiffening of the muscles.
• Atonic seizures consist of a sudden and general loss of muscle tone, particularly in the arms
and legs, which often result in a fall.
Partial Seizures
 Partial seizures are divided into simple, complex, and those that evolve into (secondary)
generalized seizures. The difference between simple and complex partial seizures is that
during simple partial seizures, patients retain awareness; during complex partial seizures,
they lose awareness.
 Simple partial seizures are further subdivided into four catego- ries according to the nature
of their symptoms: motor, sensory, autonomic or psychological

o Motor symptoms include movements such as jerking and stiff- ening.

o Sensory symptoms caused by seizures involve unusual sensa- tions affecting any of the fi ve senses (vision,
hearing, smell, taste or touch).
o When simple partial seizures cause sensory symptoms only (and no motor symptoms), they are called
“auras.”
o The only common autonomic symptom is a peculiar sensa- tion in the stomach that is experienced by many
patients with temporal lobe epilepsy.
o Finally, simple partial seizures with psychological symptoms are characterized by various experiences
involving memory (the sensation of deja-vu), emotions (such as fear or pleasure), or other complex
psychological phenomena.

• Complex partial seizures, by defi nition, include impairment of awareness. Patients seem to be
“out of touch,” “out of it” or “star- ing into space” or “in a trance” during these seizures. There
are often odd movements called automatisms, which are involun- tary but coordinated
movements that tend to be purposeless and repetitive. Common automatisms include lip
smacking, chewing, fi dgeting and walking. • The third kind of partial seizure is one that begins
as a focal seizure and evolves into a generalized convulsive (“tonic clonic”) seizure.

TYPES OF EPILEPSY

Most types of seizures occur in different types of epilepsy, and most patients with epilepsy
experience more than one seizure type. This is because seizures are only symptoms. Therefore,
it is essential that your neurologist diagnose your type of EPILEPSY, not just the type(s) of
SEIZURE you are having.
Epilepsy can be divided into two broad categories: idiopathic and symptomatic. Idiopathic
epilepsy is caused by genetic factors, as op- posed to brain damage. Symptomatic epilepsy is
caused by physical defects in the brain. Based on the type of seizure affecting the patient,
idiopathic and symptomatic epilepsies can be further categorized
Major Types of Epilepsy

Types of Epilepsy Generalized Epilepsy Partial Epilepsy

Idiopathic (genetic Childhood absence epilepsy Benign focal epilepsy of
causes) Juvenile myoclonic epilepsy childhood
Epilepsy with grand-mal
seizures only Others
Symptomatic (cause West syndrome Lennox- Temporal lobe epilepsy Frontal
known) or cryptogenic Gastaut syn- drome Others lobe epilepsy Others
(cause unknown)

Type 1: Idiopathic Generalized Epilepsy

• This is a genetic and inherited group of disorders, so there is of- ten, but not always, a family
history of epilepsy.
• Idiopathic generalized epilepsy tends to appear during childhood or adolescence, although it
may not be diagnosed until adulthood.
• In this type of epilepsy, there are no nervous system abnormalities other than the seizures; the
brain is structurally normal.
• People with idiopathic generalized epilepsy have normal intel- ligence, and the results of the
neurological examination and brain scan are normal.
• The results of the electroencephalogram (EEG - a test which mea- sures electrical impulses in
the brain) are also normal, except for the discharges associated with epilepsy.
• The types of seizures affecting patients with idiopathic general- ized epilepsy may include
myoclonic, absence, and generalized tonic-clonic seizures, with one type predominating.
Idiopathic generalized epilepsy is usually treated with medications and is a condition that is
commonly outgrown, as in childhood absence epilepsy.

Type 2: Idiopathic Partial Epilepsies

• Idiopathic partial epilepsy begins in childhood (between ages 5 and 8) and runs in families.
• Also known as benign focal epilepsy of childhood or benign Ro- landic epilepsy, this is one of
the mildest types of epilepsy.
• It is almost always outgrown by puberty and is never diagnosed in adults.
• Seizures tend to occur during sleep and are most often simple partial motor seizures that
involve the face and secondarily gener- alized (grand mal) seizures.

Type 3: Symptomatic Generalized Epilepsy

 • This is caused by widespread brain damage, and injury during birth is the most common
cause.
• When the cause of symptomatic general epilepsy cannot be identi- fi ed, the disorder may be
referred to as cryptogenic epilepsy.
• Specifi c, inherited brain diseases, such as adrenoleukodystrophy (ADL, which was featured in
the movie “Lorenzo’s Oil”), or brain infections (such as meningitis and encephalitis) can also
cause symptomatic generalized epilepsy.
• In addition to seizures, these patients often have other neurologi- cal problems, such as
developmental delay, mental retardation or cerebral palsy.
• These epilepsies include different subtypes—the most typical is the Lennox-Gastaut
syndrome. Multiple types of seizures (gen- eralized tonic-clonic, tonic, myoclonic, tonic, atonic
and absence seizures) are common and can be diffi cult to control.

Type 4: Symptomatic Partial Epilepsy

• This is the most common type of epilepsy to begin in adulthood.

• It is caused by a localized abnormality of the brain, which can re- sult from strokes, tumors,
trauma, scarring or “sclerosis” of brain tissue (common in the temporal lobe), cysts or
infections.
• Sometimes these brain abnormalities can be seen on magnetic resonance imaging (MRI)
scans, but often they cannot be identi- fi ed, despite repeated attempts, because they are
microscopic.
• When the cause of symptomatic partial epilepsy cannot be identi- fi ed, the disorder may be
referred to as cryptogenic epilepsy.
PATHOPHYSIOLOGY

Messages from the body are carried by the neurons (nerve cells) of the brain by means of
discharges of electrochemical energy thatsweep along them. These impulses occur in bursts
whenever a nerve cell has a task to perform. Sometimes, these cells or groups of cells continue
firing after a task is finished. During the period of unwanted discharges, parts of the body
controlled by the errant cells may perform erratically. Resultant dysfunction ranges from mild
to incapacitating and often causes unconsciousness
(Greenberg, 2001; Hickey, 2003). When these uncontrolled, ab-normal discharges occur
repeatedly, a person is said to have anepileptic syndrome (Schachter, 2001).Epilepsy is not
associated with intellectual level. People with epilepsy without other brain or nervous system
disabilities fall within the same intelligence ranges as the overall population.Epilepsy is not
synonymous with mental retardation or illness.Many who are developmentally disabled because
of serious neurologic damage, however, have epilepsy as well.

DIAGNOSIS

The evaluation of patients with epilepsy is aimed at determining the type of seizures and their
cause, since different types respond best to specifi c treatments. The diagnosis is based on:
• The patient’s medical history, including any family history of seizures, associated medical
conditions and current medications. Some important questions you will be asked include: o At
what age did the seizures begin? o What circumstances surrounded your fi rst seizure? o What
factors seem to bring on the seizures? o What do you feel before, during and after the seizures?
o How long do the seizures last? o Have you been treated for epilepsy before? What medica-
tions were prescribed and in what dosages? Was the treat- ment effective? o Others who have
often seen you before, during and after seizures, such as family and close friends, should be
pres- ent to provide details of your seizures if they involve loss of consciousness.
• A complete physical and neurological examination —your mus- cle strength, refl exes, eye
sight, hearing and ability to detect vari- ous sensations are tested so your doctors can better
understand the cause of your seizures
• An electroencephalogram (EEG), which measures electrical im- pulses in the brain.
o This is the only test that directly detects electrical activity in the brain, and seizures are defi
ned by abnormal electri- cal activity in the brain. During an EEG, electrodes (small metal
disks) are attached to specifi c locations on your head. The electrodes are attached to a monitor
to record the brain’s electrical activity. The EEG is useful not only to confi rm a diagnosis of
epilepsy, but also to determine the type of epilepsy.
o A routine EEG only records about 20 minutes of brain waves (however, the routine EEG
procedure takes about 90 minutes). Because 20 minutes is such a short amount of time, the
results of routine EEG studies are often normal, even in people known to have epilepsy.
Therefore, pro- longed EEG monitoring may be necessary. Prolonged o EEG-video monitoring
is an even better diagnostic meth- od. During this type of monitoring, an EEG monitors the
brain’s activity and cameras videotape body movements and behavior during a seizure.
Prolonged monitoring often requires the patient to spend time in a special facility for several
days. Prolonged EEG-video monitoring is the only defi nitive way to diagnose epilepsy.
• Imaging studies of the brain, such as those provided by magnetic resonance imaging (MRI).
This can identify the cause of the sei- zures, but the vast majority of patients with epilepsy have
normal MRIs.

MEDICAL MANAGEMENT
The management of epilepsy is individualized to meet the needs of each patient and not just to
manage and prevent seizures. Management differs from patient to patient because some forms
of epilepsy arise from brain damage and others are due to altered brain chemistry.
PHARMACOLOGIC THERAPY
Many medications are available to control seizures, although the mechanisms of their actions
are still unknown (Karch, 2002).The objective is to achieve seizure control with minimal side
effects. Medication therapy controls rather than cures seizures.
Medications are selected on the basis of the type of seizure being treated and the effectiveness
and safety of the medications (Shafer,1999a, 1999b; Winkelman, 1999). If properly prescribed
and
taken, medications control seizures in 50% to 60% of patientswith recurring seizures and
provide partial control in another 15% to 35%. The condition is not improved by any available
medication in 20% and 35% of patients with generalized and partial epilepsy, respectively
(Devinsky, 1999).
Treatment is usually started with a single medication. The starting dose and the rate at which
the dosage is increased depend on the occurrence of side effects. The medication levels in the
blood are monitored because the rate of drug absorption varies among patients. Changing to
another medication may be necessary if seizure control is not achieved or if toxicity makes it
impossible to increase the dosage. The medication may need to be adjusted because of
concurrent illness, weight changes, or in-
creases in stress. Sudden withdrawal of these medications can cause seizures to occur with
greater frequency or can precipitate the development of status epilepticus (Greenberg, 2001).
Side effects of antiseizure agents may be divided into three
groups:
(1) idiosyncratic or allergic disorders, which present primarily as skin reactions;
(2) acute toxicity, which may occur when the medication is initially prescribed; or
(3) chronic toxicity,which occurs late in the course of therapy.
The manifestations of drug toxicity are variable, and any organ system may be involved.
Gingival hyperplasia (swollen and tender gums) can be associated with long-term use of
phenytoin (Dilantin), for example (Karch, 2002). Periodic physical and dental examinations and
laboratory tests are performed for patients receiving medications known to have hematopoietic,
genitourinary, or hepatic effects.

SURGICAL MANAGEMENT
Surgery is indicated for patients whose epilepsy results from intracranial tumors, abscess, cysts,
or vascular anomalies. Some patients have intractable seizure disorders that do not respond to
medication. There may be a focal atrophic process secondary to trauma, inflammation, stroke,
or anoxia. If the seizures originate in a reasonably well-circumscribed area of the brain that can
be excised without producing significant neurologic deficits, the removal of the area generating
the seizures may produce long-term control and improvement (Wiebe, Blume, Girvin et al.,
2001)
.This type of neurosurgery has been aided by several advances, including microsurgical
techniques, depth EEGs, improved illumination and hemostasis, and the introduction of
neuroleptanalgesic agents (droperidol and fentanyl). These techniques,combined with use of
local anesthetic agents, enable the neurosurgeon to perform surgery on an alert and cooperative
patient.Using special testing devices, electrocortical mapping, and the pa-tient’s response to
stimulation, the boundaries of the epileptogenic focus are determined (Huntington, 1999). Any
abnormal epileptogenic focus (ie, abnormal area of the brain) is then removed (Wiebe et al.,
2001).As an adjunct to medication and surgery in adolescents and adults with partial seizures, a
generator may be implanted under the clavicle. The device is connected to the vagus nerve in
the cervical area, where it delivers electrical signals to the brain to control and reduce seizure
activity (Kennedy & Schallert, 2001). An external programming system is used by the
physician to change stimulator settings. Patients can turn the stimulator on and off with a
magnet.

NURSING PROCESS:
THE PATIENT WITH EPILEPSY
Assessment
The nurse elicits information about the seizure history. The pa-tient is asked about the factors or
events that may precipitate the seizures. Alcohol intake is documented. The nurse determines if
the patient has an aura (a premonitory or warning sensation) be-fore an epileptic seizure, which
may indicate the origin of the seizure (eg, seeing a flashing light may indicate the seizure
originated in the occipital lobe). Observation and assessment during and after a seizure assist in
identifying the type of seizure and its management.
The effects of epilepsy on the patient’s lifestyle are assessed (Buelow, 2001). What limitations
are imposed by the seizure disorder? Does the patient have a recreational program? Social
contacts? Is the patient working, and is it a positive or stressful experience? What coping
mechanisms are used?

Diagnosis
NURSING DIAGNOSES
Based on the assessment data, the patient’s major nursing diagnoses may include the following:
• Risk for injury related to seizure activity
• Fear related to the possibility of seizures
• Ineffective individual coping related to stresses imposed by epilepsy
• Deficient knowledge related to epilepsy and its control

COLLABORATIVE PROBLEMS/ POTENTIAL

COMPLICATIONS
The major potential complication of patients with epilepsy is as follows:
• Status epilepticus

Nursing Interventions
1. PREVENTING INJURY
Injury prevention for the patient with seizures is a priority. If at risk for injury (depending on
the seizure type), the patient should be placed on the floor and any obstructive items should be
removed. The patient should never be forced into a position, nor should anyone attempt to insert
anything into the patient’s mouth once a seizure has begun. Patients on seizure precautions
should have pads applied to side rails while in bed.
2. REDUCING FEAR OF SEIZURES
Fear that a seizure may occur unexpectedly can be reduced by the patient’s adherence to the
prescribed treatment regimen. Cooperation of the patient and family and their trust in the
prescribed regimen are essential for control of seizures (Schachter, 2001). It should be
emphasized that the prescribed antiseizure medication must be taken on a continuing basis
without fear of drug dependence or addiction. Periodic monitoring is necessary to ensure the
adequacy of the treatment regimen and to prevent side effects.In an effort to control seizures,
factors that may precipitate them are identified: emotional disturbances, new environmental
stressors, onset of menstruation in female patients, or fever(Greenberg, 2001). The patient is
encouraged to follow a regular and moderate routine in lifestyle, diet (avoiding excessive
stimulants), exercise, and rest (sleep deprivation may lower the seizurethreshold). Moderate
activity is therapeutic, but excessive exercise should be avoided. Photic stimulation (bright
flickering lights, television viewing) may precipitate seizures; wearing dark glasses or covering
one eye may be preventive. Tension states (anxiety, frustration) induce seizures in some
patients. Classes in stress management may be of value. Because seizures are known to occur
with alcohol intake, alcoholic beverages should be avoided.

3. IMPROVING COPING MECHANISMS

It has been noted that the social, psychological, and behavioral problems frequently
accompanying epilepsy can be more of a handicap than the actual seizures. Epilepsy may be
accompanied by feelings of stigmatization, alienation, depression, and uncer- tainty. The patient
must cope with the constant fear of a seizure and its consequences (Buelow, 2001). Children
with epilepsy may be ostracized and excluded from school and peer activities. These problems
are compounded during adolescence and add to the challenges of dating, not being able to drive,
and feeling different. Adults face these problems in addition to the burden of finding
employment, concerns about relationships and childbearing, insurance problems, and legal
barriers. Alcohol abuse may compli-cate matters. Family reactions may vary from outright
rejection of the person with epilepsy to overprotection. As a result, many people with epilepsy
have psychological and behavioral problems. Counseling assists the individual and family to
understand the condition and the limitations imposed by it. Social and recreational opportunities
are necessary for good mental health. Nurses can improve the quality of life for patients with
epilepsy by educating them and their families about symptoms and their management (Rice,
2000).
4. PROVIDING PATIENT AND FAMILY EDUCATION
Of all the care contributed by the nurse to the person with epilepsy, perhaps the most valuable
facets are education and efforts to modify the attitudes of the patient and family toward the
disorder. The person who experiences seizures may consider every seizure a potential source of
humiliation and shame. This may result in anxiety, depression, hostility, and secrecy on the part
of the patient and family. Ongoing education and encouragement should be given to patients to
enable them to overcome these feelings. The patient with epilepsy should carry an emergency
medical identification card or wear a medical information bracelet.The patient and family need
to be educated about medications as well as care during a seizure.

5. MONITORING AND MANAGING POTENTIAL COMPLICATIONS

Status epilepticus, the major complication, is described below. Another complication is the
toxicity of medications. The patient and family are instructed about side effects and are given
specific guidelines to assess and report signs and symptoms indicating medication overdose.
Many antiseizure medications require careful monitoring for therapeutic levels. Patients should
plan to have serum drug levels drawn at regular intervals. There are also many known drug
interactions with antiseizure medications. A complete pharmacologic profile should be
reviewed with the patient to avoid interactions either potentiating or inhibiting the effectiveness
of the medications.

STATUS EPILEPTICUS
Status epilepticus (acute prolonged seizure activity) is a series of generalized seizures that occur
without full recovery of consciousness between attacks (Greenberg, 2001). The term has been
broadened to include continuous clinical or electrical seizures lasting at least 30 minutes, even
without impairment of consciousness. It is considered a medical emergency. Status epilepticus
produces cumulative effects. Vigorous muscular contractions impose a heavy metabolic
demand and can interfere with respirations. There is some respiratory arrest at the height of
each seizure that produces venous congestion and hypoxia of the brain.Repeated episodes of
cerebral anoxia and edema may lead to irreversible and fatal brain damage. Factors that
precipitate status epilepticus include withdrawal of antiseizure medication, fever,and concurrent
infection.

Medical Management
The goals of treatment are to stop the seizures as quickly as possible, to ensure adequate
cerebral oxygenation, and to maintain the patient in a seizure-free state. An airway and adequate
oxygenation are established. If the patient remains unconscious and unresponsive, a cuffed
endotracheal tube is inserted. Intravenous diazepam (Valium), lorazepam (Ativan), or
fosphenytoin (Cere- byx) is given slowly in an attempt to halt seizures immediately .Other
medications (phenytoin, phenobarbital) are given later to maintain a seizure-free state.An
intravenous line is established, and blood samples are obtained to monitor serum electrolytes,
glucose, and phenytoin levels (Greenberg, 2001). EEG monitoring may be useful in
determining the nature of the seizure activity. Vital signs and neurologic signs are monitored on
a continuing basis. An intravenous infusion of dextrose is given if the seizure is due to
hypoglycemia.If initial treatment is unsuccessful, general anesthesia with a short-acting
barbiturate may be used. The serum concentration of the antiseizure medication is measured
because a low level suggests that the patient was not taking the medication or that the dosage
was too low. Cardiac involvement or respiratory depression may be life-threatening. There is
also the potential for postictal cerebral edema.

Nursing Management
The nurse initiates ongoing assessment and monitoring of respiratory and cardiac function
because of the risk for delayed depression of respiration and blood pressure secondary to
administration of antiseizure medications and sedatives to halt the seizures. Nursing assessment
also includes monitoring and documenting the seizure activity and the patient’s responsiveness.
The patient is turned to a side-lying position if possible to assist in draining pharyngeal
secretions. Suction equipment must be
available because of the risk for aspiration. The intravenous line is closely monitored because it
may become dislodged during seizures. A person who has received long-term antiseizure
therapy has a significant risk for fractures resulting from bone disease (osteoporosis,
osteomalacia, and hyperparathyroidism), a side effect of therapy. Thus, during seizures, the
patient should be protected from injury using seizure precautions and monitored closely. No
effort should be made to restrain movements. The patient having seizures can inadvertently
injure nearby people, so nurses should protect themselves.

GUIDELINES FOR SEIZURE CARE

Nursing Care During a Seizure
• Provide privacy and protect the patient from curious on-lookers. (The patient who has an aura
[warning of an impending seizure] may have time to seek a safe, private place.)
• Ease the patient to the floor, if possible.
• Protect the head with a pad to prevent injury (from striking a hard surface).
• Loosen constrictive clothing.
• Push aside any furniture that may injure the patient during the seizure.
• If the patient is in bed, remove pillows and raise side rails.
• If an aura precedes the seizure, insert an oral airway to reduce the possibility of the tongue or
cheek being bitten.
• Do not attempt to pry open jaws that are clenched in a spasm to insert anything. Broken teeth
and injury to the lips and tongue may result from such an action.
• No attempt should be made to restrain the patient during the seizure because muscular
contractions are strong and restraint can produce injury.
Nursing Care During a Seizure
• Provide privacy and protect the patient from curious on-lookers. (The patient who has an aura
[warning of an impending seizure] may have time to seek a safe, private place.)
• Ease the patient to the floor, if possible.
• Protect the head with a pad to prevent injury (from striking a hard surface).
• Loosen constrictive clothing.
• Push aside any furniture that may injure the patient during the seizure.
• If the patient is in bed, remove pillows and raise side rails.
• If an aura precedes the seizure, insert an oral airway to reduce the possibility of the tongue or
cheek being bitten.
• Do not attempt to pry open jaws that are clenched in a spasm to insert anything. Broken teeth
and injury to the lips and tongue may result from such an action.
• No attempt should be made to restrain the patient during the seizure because muscular
contractions are strong and restraint can produce injury.