Municipal Solid wastes at National level Essay Example for Free

Municipal Solid wastes at National level Essay India is one of the largest countries in the world whose multifaceted socio-economic progress occurred in the last 50 years since its independence in 1947 (Gupta, et. al. , 1998). Indian population is second largest in the world with 856 million in 1991 (Gupta, et. al. , 1998) and 1,027 million in 2001(COI, 2001). The country has an average annual growth rate of 1. 3% (Gupta, et. al. , 1998). The growth of the nation is shown by its rapid industrial and economic growth both in the public and private sectors. This has contributed to the changing of the general lifestyle of its people. Soon enough, they have begun to espouse an urban lifestyle (Jha et. al. , 2007). This drastic change in the lifestyle of the people of India triggered an increase in the production and consumption of all sorts of products. It further spawned additional economic activities – new or innovated products and services – that led to an overall great rise in the volume of wastes generated by the city (Sharholy et. al. , 2007; Jhaet. al. , 2007). Even the packaging of products has undergone an evolution. After all, these are all natural consequences of the city’s growth. Indeed the city has grown both in size and population. The number of territorial divisions has increased from 30 in 1919 to 155. The population has similarly increased from 5 lakhs in 1921 to approximately 42 lakhs. The increase in the city’s area is from 27. 6 sq. miles in 1921 to 174 sq. kms. (COC website) Several studies in the past (Bhoyar, et. al. , 1996; Esakku et. al. , 2007; Rathi, 2006) reveal that the composition of MSW in Indian cities have recorded higher percentages of earth and inert materials (35-52%), varying degradable matter (35-84%) and lowest recyclable material (10-20%) (Jha et. al. , 2007) and there has been a gradual increase in total MSW over the past several years in Chennai (COC, 2004). The increasing amounts of MSW have been causing problems that governmental agencies have been attempting to solve. The extent of the problem, which covers threats to the health and welfare of the people and the environment, just seemed to keep growing and there were no conclusive solutions in sight (Srinivas, 1998). With environmental concerns on top of the government’s agenda, the key area which needs an extensive importance at present is the MSW Management (MSWM). The system of garbage disposal and management poses a great challenge to the municipalities and the magnitude of which is not felt much, involves heavy cost, but derives only less concentration (Bhide and Sundersan, 1983). Chennai in past 20 years has shown increasing growth in population (Table 5; Figure 31), also there is substantialgrowth in industrial sector resulting in increased quantities of waste generated in the last 12 years (Table 1) (COC, 2004). MSW in Chennai, like in most other Indian cities is collected and dumped at open landfills. Ecologists and environmentalists around the world term this improper dumping technique, and argue that such open dumping of garbage poses serious health hazards and also disturbs environment leading to ecological imbalance, habitat modification and deterioration of species (Kansalet. al. , 1998; Sharholy et. , al, 2007). A study by Das et. al. (1998) show that about 90% of the wastes generated is disposed of by way of open dumping in landfills and such practice causes serious environmental and human health hazard. The quality of land, water and air also get deteriorated because of dumping at open landfills. They in turn influence an increase in leacheate percolation of environmental pollutants from garbage into naive environment, polluting the wetland and groundwater of the adjacent areas (Sharholy et. al. , 2007). Chennai Wards and Zones Chennai is divided into wards and several wards are grouped together as zones. There are totally 155 wards (Table 2, Figure 2) and 10 zones namely Tondiarpet (Zone I), Basin Bridge (Zone II), Pulianthope (Zone III), Ayanavaram (Zone IV), Kilpauk (Zone V), Ice House (Zone VI), Nungambakkam (Zone VII), Kodambakkam (Zone VIII), Saidapet (Zone IX), Adyar (Zone X) (Figure 3). Zone V (Kilpauk) is the largest zone with an area of 25. 62 sq. km and a population of 542,132 and Zone VI (Ice House) is the smallest zone with an area of 8. 24 sq. km and a population of 341,805 (Table 3) OK. Why does this matter? How does this relate to your overall question? Should this be in your introduction? MSW in Chennai Chennai is under enormous stress for a controlled MSWM and this is predominantly due to uncontrolled urbanization (Lakshumi et. al. ,2006). MSW handling and disposal in Chennai is jointly performed by Corporation of Chennai and Neel Metal Fanalca Environmental Management Private Limited (Figure 3), private-public participation. This is the second time Corporation of Chennai has joined hands with a private concern to collect and dispose MSW in Chennai (COC, 2004). Expand, why the second? What happened during the first? Earlier CES Onxy, a private MSW collection and disposal industry, handled disposal of solid wastes in three zones (zone VI, zone VIII, and zone X) in Chennai, where they cleared approximately 1000 tons/day of MSW between year 2000 and 2007 (COC, 2004). Onyx charged Rs. 1,212/ton (~$30 USD) of garbage cleared. After the contract period with Onyx, Corporation of Chennai called for fresh bid for tender towards solid waste management for the three zones; Kodambakkam (zone VIII), Adyar (zone X), and Ice House (zone VI). The Corporation has also planned to privatize fourth zone namely Pulianthope (zone III) (The Hindu, 2007). OK Chennai shows high quantities of organic wastes among the MSW collected everyday, primarily vegetable and fruit wastes collected from areas in-and-around the marketplace (Ramakrishnan, 2005) and in most other part of Chennai paper predominates MSW (Jhaet. al. , 2007). But with increasing consumerism, the amount of wastes produced has also been increasing and if this trend continues then the generation of waste would soon outnumber the rapid increasing population. Moreover, as the dumping sites and landfills are also nearly filling up, Corporation of Chennai is on the look for alternate dumpsites and effective MSWM techniques like recycling of wastes (Jha et. al. , 2007). Composition and Sources of MSW Reports from Corporation of Chennai show that organic wastes (food wastes, green wastes, timber) are of greater quantity among the MSW composition than other wastes (Table 4a). Also the main source of MSW waste is generated by the residential (Table 4b) (COC, 2004). Dumping grounds in Chennai Chennai has two open dumping grounds namely Kodungaiyur, which is the north Chennai and Perungudi in South Chennai (Figure 5). 1. Kodungaiyur dumping ground Kodungaiyur dumping ground is located within the city limits (Figure 5, 6 7). It is rectangular and has a total area of 350 acres, where 65 acres is owned by Corporation of Chennai while 285 acres is owned by Chennai Metropolitan Water Supply and Sewerage Board (CMWSSB). The soil type is clayey alluvial flatland. The dumpsite came to operational in 1980. The daily waste disposed from zone I-V at this site was 1600 to 1800 tons. The maximum life expectancy of Kodungaiyur dumping ground is until 2010 (COC, 2004; Jha et. al. , 2007) 2. Perungudi dumping ground Perungudi dumpsite is located outside City limits in South Chennai (Figure 5, 8 9). Perungudi dumpsite is also rectangular with a total area of 600 acres owned by CMWSSB. The dumpsite area is a wastewater disposal marshy land made of silty-clay alluvial soil. Perungudi dumpsite came to operational 7 years after Kodungaiyur dumping ground became operational and has a life expectancy until 2010. About 1500 to 1800 tons of garbage from zone VI-X is dumped here (COC, 2004; Jha et. al. , 2007). MSW Collection Chennai Municipality (Figure 11A) and Neel Metal Fanalca (Figure 11B) employ sanitary workers or sweepers who are either permanent staff or daily-paid temporary workers (Figure 10) who sweep and remove solid waste, like paper, plastics, organic debris, construction wastes etc every day. They sweep about every 50 meters of the roadside before they gather solid wastes on the adjacent roadside. Sanitary workers from Corporation of Chennai or private organizations engage in door-to-door domestic collection (Figure 12) of segregated and/or non-segregated solid wastes (both biodegradable/non-biodegradable and recyclable/non-recyclable) from residents, streets, roadsides and arterial roads in rotomould bins (Figure 13) and tricycles (Figure 12). The solid wastes thus collected in wheel barrows or tricycles are carried to the nearest collection point or collection depots (Sharholy et. al. , 2007). The MSW collection process includes either primary collection and/or the secondary collection. Primary collection of segregated and/or non-segregated wastes involves the transportation of wastes from the collection point to the nearest transfer station (Figure 14 15) or NGO-run recycling units through Light Motor Vehicle (LMVs) or compactors and this technique involves manpower completely in the collection process (Sharholy et. al. , 2007). Whereas in the secondary collection process each MSW collection worker is assigned with work schedules and work areas (COC, 2004) who transfer the accumulated garbage from collection points by way of compactors and tippers, and ferried to the disposal site where they are dumped (Sharholy et. al. , 2007). In many parts of Chennai, a small portion of the waste generated everyday lie around the garbage bins without being collected (Figure 28) and the collected portion is taken for disposal. The efficiency of collection of solid waste can be equated to the amount of garbage collected from the streets to the disposal sites divided by the total volume of MSW generated during that period. Studies made reveal that the two main aspects that contribute to MSW collection efficiency are manpower and transportation facilities (Sharholy et. al. , 2008). Segregation REWORD On an average, the city generates around 3,200 tons of garbage and 500 metric tons of building debris daily, of which recyclable and biodegradable waste would be approximately 40-45% and 40-45% of building debris and the rest non-biodegradable MSW (Sharholy et. al. , 2007; COC, 2004). If this 40-45% of recyclable and biodegradable wastes is removed, the life expectancy of the landfill would substantially increase and this is possible only with source segregation. Source segregation of MSW in Chennai has been a quest for Corporation of Chennai (Malarvizhi, 2007). Although they made efforts in few areas, as part of a pilot study, to improve awareness and segregate wastes at source (Figure 16), yet source segregation technique in Chennai is far to reach common public (Malarvizhi, 2007). On the contrary, few NGOs are also participating in source segregation awareness program and actively helping Corporation of Chennai in door-to-door source segregation programs (Malarvizhi, 2007). Some residents segregate their wastes into dry and wet wastes. Few others also dump the organic wastes in small pits where organic waste get decomposed, converted to compost and used as fertilizers (Rathi, 2006). Also to add, rag pickers play an active role in segregation of wastes, where they segregate wastes into paper, plastic, wood and metals before these are sold in recycling market for money (Figure 17) (Rathi, 2006).

price of greed :: essays research papers

The Price of Greed   Ã‚  Ã‚  Ã‚  Ã‚  Argh matey! Welcome aboard the ship that will lead to a world of pirates. Lets be cautious now the sight of gold can make any man lust with greed and in a blink of an eye they are lost in a world of gluttony. Now will enter a place where the desire for more has taken control over many men that are now doomed. Pirates of the Caribbean: The curse of the Black Pearl is a tale of betrayal and greed; where the greed of man leads to a path of many riches but a life cursed without enrichment. The curse that will leave man always wanting more as well as the lost of their senses of life and feelings of emotions. The code of the pirates like many other codes establishes the rules pirates abide by. One of the rules the pirates go by is if a fellow shipmate gets left behind they stay behind. This gives significance to the word betrayal. In a pirate’s ship everyone is looking out for himself. This is similar to the real world where everyone is trying to get ahead and think of no one but himself or herself. Many choose the path of cheating and betrayals to climb the rope of success leaving behind no regrets and seeing ahead a future of fortune. The thinking of a pirate: fortune.   Ã‚  Ã‚  Ã‚  Ã‚  Captain Jack Sparrow is the captain of the Black Pearl until his crew plots against him to take over the ship. Empowered by greed they were led by a new voice, Barbosa, and left Jack Sparrow in an abandon island. The treasure they seek was Cortez’s gold coins. Even though stories told of a curse the pirates’ greed and need for treasure overtook their rationality. Cortez’s curse did not stop them from stealing and this just demonstrates how greed has the power to destroy the inner morals of any human being. The greed of many is like a craving that hits every second and it cannot be contained; it has to be satisfied. Captain Barbosa tells the story of Cortez’s cursed gold coins and what the curse has done to him and his crew. The curse has made them live forever without senses to taste or feel. They roam the sea looking for the day they could finally break the curse. Captain Barbosa now understood that his greed had taken away from him things he found no value to but now craves for it the most.

Obstetric Brachial Plexus Palsy Health And Social Care Essay

The estimated incidence of OBPP in the UK and the Republic of Ireland is 0.42 [ 1 ] , in the US 1.5 [ 23 ] and in other western states 1-3 per 1000 unrecorded births [ 3,5,9,22,24-30 ] . Variations in the estimated incidence may be explained by differences in populations and in the antenatal and intrapartum direction [ 31,32 ] . A population-based survey from western Sweden estimated that between 1999-2001 the incidence of OBPP was 2.9 per 1000 unrecorded births, and of prevailing OBPP was 0.46 per 1000 births ( REF Lagerkvist ) . . In another survey from Sweden Bager [ 13 ] had antecedently found an addition in the incidence of brachial rete paralysis ( BPP ) from 1.3 per 1000 vaginal bringings in 1980 to 2.2 per 1000 vaginal bringings in 1994. Chauhan et Al. [ 3 ] compared two clip periods ( 1980-1991 1991-2002 ) and found that the incidence of OBPP has non changed significantly ( 0.9 per 1000 and 1.0 per 1000 severally ) . Gurewitsch et Al. [ 10 ] estimated an incidence of 5.8 per 1000 between the old ages 1993 and 2004 and noted that this remained changeless during the period of their survey. Many writers have admitted that an addition in the cesarean subdivision rates over the past few decennaries may hold been counteracted by an increased birthweight. Furthermore, despite the debut of systematic preparation in the direction of shoulder dystocia with usage of standard manoeuvres, manikins and simulators no important decrease of the incidence of OBPP has been noted.Hazard FactorsThe hazard factors for OBPP are foetal, maternal, and obstetric, [ 37 ] the most important being foetal macrosomia [ 3,18,20,22,26-28 ] which is a hazard factor for shoulder dystocia [ 27,38-42 ] . Nesbitt et al conducted a big population based survey and reported the undermentioned rates of shoulder dystocia for single-handed births of nondiabetic female parents: 5.2 % for birthweight 4000-4250g, 9.1 % for 4250-4500g, 14.3 % for 4500-4750g, and 21.1 % for 4750-5000g ( Nesbitt et al. 1998 ) . OBPP after rear of barrel bringings can besides happen, normally in low birthweight foetuss [ 43,44 ] . The upper roots are often affected in these instances and the hurts tend to be more terrible [ 45 ] . Diabetess mellitus [ 22 ] , fleshiness [ 46,47 ] or inordinate weight addition [ 47 ] , maternal age ( & gt ; 35years ) [ 48 ] , maternal pelvic anatomy ( platypelloid, level pelvic girdle ) [ 3,22,27,39,40,49 ] and primiparity [ 50 ] are common maternal hazard factors. Diabetess mellitus is a important hazard factor for OBPP, as it frequently causes foetal macrosomia [ 51 ] . Nesbitt et Al found that the hazard of shoulder dystocia for single-handed births to diabetic adult females was 8.4 % , 12.3 % , 19.9 % , and 23.5 % when the birth weight was 4000-4250g, 4250-4500g, 4500-4750g, or & gt ; 4750g, severally. ( Nesbitt et al. 1998 ) . Mild glucose intolerance in adult females without diabetes is besides associated with hazards of OBPP, proposing that there is a continuum of glucose-insulin impact on foetal growing that is correlated to the hazard of OBPP [ 52 ] . Shoulder dystocia is a major hazard factor for OBPP [ 9,22,24,40,54-57 ] . The reported incidence of OBPP in bringings complicated by shoulder dystocia varies widely from 4 % to 40 % [ 14,57,58 ] and the incidence of lasting brachial rete hurt after shoulder dystocia is 1.6 % [ 59 ] . Although foetal macrosomia is the most important hazard factor for shoulder dystocia and is associated with most of the other hazard factors ( maternal diabetes, multiparity, old macrosomic baby, drawn-out gestation, maternal fleshiness or inordinate weight addition ) , about half of the instances of shoulder dystocia occur in babies & lt ; 4000g ( Acker et al. 1985 ) . The hazard of OBPP is increased by labour abnormalcies. OBPP occurs more often in induced labours [ 52 ] . Cephalopelvic or fetopelvic disproportion ( the size or place of the foetal caput or the foetus precludes transition into the maternal pelvic recess ) is a hazard factor for shoulder dystocia and OBPP. A relentless occipito- posterior place [ 65 ] has been associated with an increased incidence of OBPP. Lurie et al [ 60 ] found no difference in rates of distension or continuance of the 2nd phase in instances with shoulder dystocia and concluded that protracted labour was non a hazard factor for it. Gross et al [ 66 ] showed that a drawn-out 2nd phase increased the hazard of OBPP, but concluded that shoulder dystocia can non be predicted from labour abnormalcies. Weizsaecker et al support the association of drawn-out 2nd phase in labour with OBPP independent of macrosomia, diabetes, and other factors [ 52 ] . Several other surveies considered a drawn-out 2nd phase as a hazard fac tor for shoulder dystocia [ 46,62,67-69 ] and for OBPP [ 27,66 ] . In contrast, a high incidence of hasty 2nd phase of labour among babies with OBPP has besides been demonstrated [ 70 ] . However, Poggi et al suggest that although hasty 2nd phase is the most prevailing labour abnormalcy associated with shoulder dystocia, no feature of second-stage of labour predicts lasting brachial rete hurt [ 37 ] . Operative vaginal bringing is another hazard factor for shoulder dystocia and OBPP [ 3,21,22,26,27,68,71,72 ] . In Nesbitt ‘s survey the hazard of shoulder dystocia for operative vaginal bringings to diabetic female parents was 12.2 % for babies 4000-4250g, 16.7 % for those 4250-4500g, 27.3 % for those 4500-4750g, and 34.8 % for those 4750-5000g ( Nesbitt et al. 1998 ) . Cesarean subdivision decreases the hazard, but OBPP may still happen accounting for merely 1-4 % of all instances [ 22 ] [ 73 ] . When looking at combinations of hazard factors including manner of bringing, maternal diabetes and foetal macrosomia [ 22 ] , the incidence of OBPP appears similar in aided vaginal bringings of nondiabetic adult females and self-generated vaginal bringings in diabetic adult females. The combination of maternal diabetes, foetal macrosomia ( & gt ; 4500g ) and assisted vaginal bringing has the highest OBPP rate ( 7.8 % ) . Gilbert et Als have besides shown stronger associations between shoulder dystocia and brachial rete hurt with increasing birth weights. Twenty two per cent of neonates weighing 2.5-3.5kg with OBPP besides had shoulder dystocia, which increases to 74 % in newborns weighing more than 4.5kg. Overall, 53 % of brachial plexus hurt instances were associated with shoulder dystocia. The frequence of diagnosing of other malpresentation was increased ( OR 73.6, 95 % CI 66, 83 ) in this survey. This determination, harmonizing to the writers, suggests that â€Å" brachial rete hurt has other causes in add-on to shoulder dystocia and might ensue from an abnormalcy during the antepartum or intrapartum period † [ 22 ] . A old gestation complicated with OBPP is another hazard factor [ 74 ] . Al-Qattan and al-Kharfy [ 74 ] reported a high return rate in adult females with history of old childbearing with lasting OBPP and advocated elected cesarean bringing in these instances particularly if there is besides foetal macrosomia. However it is non known whether these consequences would use to instances of old impermanent OBPP. Gordon et al [ 6 ] besides found that 14 % of their 59 topics with OBPP were born to female parents who had given birth to babes with OBPP in old gestations.PathogenesisOBPP has been considered as a effect of inordinate grip and sidelong extension exerted on the foetal cervix during bringing, which consequences in stretching, rupturing or avulsing the cervical nervus roots from the spinal cord [ 75 ] . However, OBPP may happen in the absence of any grip or any identifiable hazard factors. During labour, the brachial rete is exposed to two potentially harmful forces: the endogenous ( intrauterine ) forces and exogenic ( grip ) forces applied by the clinician. Mathematical theoretical accounts, manikins and computing machine simulations have been used to quantify the forces applied on the brachial rete and the threshold for doing hurt. Although these surveies attempted to objectively quantify the grade of both endogenous and exogenic forces, their consequences should be interpreted with cautiousness due to their experimental nature. Exogenous ( grip ) forces If the foetal shoulders remain in a relentless anteroposterior place at the pelvic recess, as observed in instances of foetal macrosomia with an increased bisacromial diameter ( e.g. , with maternal diabetes mellitus ) [ 76,77 ] or precipitate 2nd phase of labour [ 54,70 ] the anterior shoulder may go wedged behind the symphysis pubic bone and farther descent of the foetal caput consequences in stretching of the anterior brachial rete. In shoulder dystocia the applied force and the clip to present the foetal shoulders is frequently significantly increased. Forceful downward grip of the caput when the shoulder is impacted under the symphysis pubic bone can potentially ensue in farther impaction and cause overstretching and hurt of the brachial rete. Downward grip of the foetal caput appears strongly associated with OBPP ( OR: 15.2, 95 % C.I. : 8.4-27.7 ) and the hazard is significantly increased with the grip force applied. Rotation of the shoulders into oblique pelvic diameter is bes ides associated with hazard of OBPP ( OR: 5.5, C.I. :1.6-18.9 ) [ 30 ] . Gonik et al [ 88 ] , showed that downward sidelong flexure of the foetal caput was associated with a 30 % addition in brachial rete stretch ( 18.2 % ) compared with axial placement of the caput ( 14 % ) . Furthermore, the foetal caput is in an unnaturally distorted place in relation to the shoulders, as the shoulders remain in the AP diameter at the recess while the caput has rotated in the AP diameter at the mercantile establishment { Sandmire, 2009 # 6162 } . The badness of the hurt may depend on the grade of grip, writhing and extension of the foetal caput { Sandmire, 2008 # 6057 } . The usage of force feeling devices has shown that the applied extremum grip forces are about 47 N for everyday bringings, 69 N for hard bringings, and 100 N for bringings complicated by shoulder dystocia, proposing that, as the badness of dystocia additions, stronger grip is normally observed [ 86 ] . Even in bringings non complicated by shoulder dystocia the forces applied during downward grip can be frequently underestimated as significant forces were found to hold been used in many OBPP instances [ 30 ] . Direct compaction of the symphysis pubic bone against the brachial rete may besides be a conducive factor to injury [ 13 ] . OBPP may happen regardless of the figure and type of manoeuvres used in instances of shoulder dystocia [ 12,14,69 ] , but the trouble to accomplish bringing of the shoulders and the demand for extra manoeuvres is correlated to the hazard of OBPP. Experimental surveies utilizing pelvic and foetal theoretical accounts, tactile feeling baseball mitts and computerised informations acquisition systems have besides shown that as the trouble of the bringing increases with increasing grip forces, there is a concentration of force on the brachial rete from exogenously applied sidelong flexure [ 87 ] . In these experiments it was demonstrated that the wider the foetal shoulder girth, the greater the force demands and the higher the incidence of hurt. In contrast, the McRoberts manoeuvre appeared to cut down the grade of brachial rete stretching. Slightly more than 10 % of the shoulder dystocia instances that resolve with the McRoberts ‘ manoeuvre entirely have brachial plexus hurt [ 78 ] . After an unsuccessful McRoberts ‘ manoeuvre, brachial plexus hurt rates range from 15.7 % if bringing is achieved by the Woods ‘ manoeuvre to 31.8 % if bringing of the posterior arm is undertaken [ 14 ] . Intrauterine causes As several instances of OBPP occur in the absence of grip or any known hazard factors, hurts to the brachial rete may be caused by the normal forces of labour and bringing. In one of the first surveies proposing that OBPPs are non needfully caused by clinician-applied grip, it was estimated that 26 out of the 51 OBPP instances were non associated with a bringing complicated by shoulder dystocia. { Gordon, 1973 # 615 } . Since so, several other surveies have shown that about half of all OBPPs are non associated with shoulder dystocia [ 5,12,13,18,19 ] and many instances have non been preceded by a hard bringing or grip on the anterior shoulder [ 20,79,80 ] . Harmonizing to different series, up to 20 % of lasting OBPPs are non associated with shoulder dystocia { Chauhan, 2005 # 48 } { Sandmire, 2009 # 6162 } . Jennett et al [ 18 ] concluded that brachial plexus hurt might be the consequence of intrauterine maladaptation and should non be needfully considered as leading facie grounds of birth procedure hurt. In the absence of shoulder dystocia, OBPP occurs by a different mechanism [ 81 ] . The bulk of OBPPs in the absence of shoulder dystocia ( 67.7 % ) appear to impact the posterior arm [ 59,84 ] . OBPPs of the posterior arm ( 39 % of all OBPPs { Gherman, 1998 # 114 } ) or after cesarean bringing suggest an intrauterine cause [ 3,4,18,19,27,38,82,83 ] . Brachial plexus stretching may be caused by an wedged posterior shoulder on the sacral headland while the propulsive forces of labour cause farther descent of the foetus { Sandmire, 2002 # 79 } . OBPPs may besides be secondary to compaction of the brachial rete on the sacral headland. Sandmire and DeMott { Sandmire, 2009 # 6162 } back up the impression that after the caput is delivered, the posterior shoulder can non be obstructed as the distance from the headland to the vaginal mercantile establishment ( 12-13 centimeter ) is excessively long to allow obstructor of the posterior shoulder and the foetal cervix can non be stretched that f ar { Sandmire, 2002 # 79 } , It is hence of paramount importance to document the place of the caput and shoulders in a instance of shoulder dystocia, as this type of hurt caused by impaction of the posterior shoulder on the sacral headland is unrelated to any action of the clinician and should non be considered negligent. Mathematical theoretical accounts have been used to gauge the exogenic and endogenous forces on the brachial rete during shoulder dystocia [ 89 ] . The endogenous forces were estimated to be 4 to 9 times higher than the clinician-applied forces ( 91.1 to 202.5 kPa vs 22.9 kPa ) proposing that self-generated endogenous forces may lend well to OBPP. However the writers of this survey acknowledged that their theoretical account did non account for a figure of confusing factors including soft tissue opposition, the dissipation of force throughout the womb or the compound consequence of grip and compaction forces. Further unfavorable judgment on this theoretical account focused on the gross premises made for the impaction site, the parametric quantities specifying the endogenous force distribution and the broad scope of contact force per unit areas between the foetal cervix and the symphysis pubic bone, which includes values that in existent life would transcend the fatal bounds [ 90 ] . Harmonizing to a little series, all of the 6 OBPPs following atraumatic cesarean subdivision had relentless hurt after a twelvemonth [ 85 ] . Brachial rete hurts have occured even when cesarean bringing was performed in early labour [ 82,85 ] . Uterine anomalousnesss, such as a lower uterine section fibroid or an intrauterine septum, may ensue in unnatural intrauterine force per unit areas and hurt to the brachial rete [ 85 ] . OBPP and phrenic nervus paralysis associated with a bicornuate womb have besides been reported [ 80 ] . Allen et Al, utilizing delivering simulators found that greatest stretch occurred in the posterior brachial rete during descent in non-shoulder dystocia bringings, whereas anterior brachial rete stretch, rotary motion, and extension were similar among non-shoulder dystocia, one-sided and bilateral shoulder dystocia bringings. The writers concluded that shoulder dystocia per Se does non present extra hazard of brachial rete stretch over everyday bringings [ 91 ] . However, they admitted that they did non command for loss of musculus tone secondary to hypoxia, the simulations were undertaken merely in occiput anterior place and the continuance of the 2nd phase in their experiment was less than 2 proceedingss. Although these experiments have improved our cognition on the mechanisms of hurt, clinical verification of their consequences is virtually impossible due to the emergent nature of shoulder dystocia and methodological and ethical issues around clinical research on the foetus during labour.Prediction and PreventionOur ability to foretell OBPP is rather limited as the bulk of the affected babies have no identifiable hazard factors [ 67 ] . In a series of 63 OBPPS most of the patients were nondiabetic ( 89 % ) , nonobese ( 76 % ) , had normal labour ( 91 % ) , and did non hold an assisted bringing ( 79 % ) . No hazard factors were identified in about 30 % of OBPP instances in another survey by Peleg et al [ 27 ] . Multiple logistic arrested development analysis utilizing prenatal, intrapartum, and neonatal factors predicted merely 19 % of the brachial rete hurts in the series of Perlow et Al [ 54 ] . Donnelly et Als have besides concluded that OBPP is non predictable by hazard factor hit ing or analysis of the partogram [ 63 ] . Shoulder dystocia, a major hazard factor for OBPP is mostly unpredictable. Statistical theoretical accounts have been developed to gauge this hazard utilizing combinations of birth weight, maternal tallness and weight, gestational age and para [ 92,93 ] . The presence of multiple hazard factors appears to be a forecaster for shoulder dystocia [ 94 ] . Designation of hazard factors and an prenatal direction with tight control of glucose degrees in pregnant adult females with diabetes may cut down the incidence of foetal macrosomia and shoulder dystocia. A program for bringing in high hazard instances should include a multidisciplinary squad attack with a senior accoucheuse or an experient obstetrician available at the 2nd phase. Initiation of labour Initiation of labour has been antecedently recommended in instances of suspected macrosomia, in order to cut down the hazard of shoulder dystocia and birth hurt, nevertheless, a Cochrane reappraisal showed that initiation of labour for nondiabetic adult females with suspected foetal macrosomia does non look to cut down the hazards of maternal or neonatal morbidity [ 95 ] . Cesarean Section The hazard of brachial plexus hurt is lower in cesarean bringings [ 3,96 ] . If identifiable hazard factors are present, an elected cesarean delivery bringing might forestall OBPP. Yeo et al suggested that bringings by elected cesarean subdivision for birthweights in surplus of 4kg would forestall 44 % of shoulder dystocias and halve the perinatal mortality among births with shoulder dystocia with a 2 % subsequent addition of the cesarean subdivision rate [ 97 ] . On the other manus, Gilbert et Al found that 92 % of the high hazard patients ( diabetic adult females delivered by operative vaginal bringing with babies of & gt ; 4.5kg birthweight ) did non hold OBPP and cesarean bringing would hold been unneeded [ 22 ] . Although macrosomia is normally associated with OBPP, Rouse et Al [ 32 ] found no benefit to elected cesarean bringing in adult females with estimated foetal weights of & gt ; 4.5 kilogram, unless they were besides diabetic. These writers estimated that when elected ces arean bringing was performed for estimated foetal weights of a†°?4.5kg, 3695 cesarean delivery bringings would be required for the bar of one permanent OBPP, whereas a policy of elected cesarean delivery bringings for birthweights of a†°?4kg was associated with 2345 several cesarean bringings. For diabetic adult females, more favorable ratios for cesarian bringings were estimated: 443 bringings with the 4.5kg policy, and 489 bringings with the 4kg policy. Ecker et al [ 38 ] besides suggested that at most birth weights, the figure of cesarean bringings necessary to forestall a individual hurt is high. In this survey, it was estimated that in nondiabetic adult females, between 19 and 162 cesarean subdivisions would hold been necessary to forestall a individual brachial rete hurt and among diabetic adult females between 5 and 48 extra cesarean delivery subdivisions would hold been required. The writers could hence non recommend the everyday usage of cesarean bringing in insta nces of macrosomia. The Royal College of Obstetricians and Gynaecologists recommends that elected cesarean subdivision can be considered in diabetic adult females when the estimated foetal weight is & gt ; 4.5kg and in nondiabetic adult females when the estimated foetal weight is & gt ; 5kg [ 98 ] . Nonetheless, some writers advocate a policy of offering elected cesarean bringing to adult females with kids with lasting OBPP [ 22 ] . Maneuvers at bringing For the bar of shoulder dystocia, contraceptive manoeuvres at bringing ( McRobert ‘s manoeuvre and suprapubic force per unit area ) have been evaluated, but there is deficiency of clear grounds to back up their modus operandi usage [ 99 ] . Management of shoulder dystocia The purpose of direction should be bar of foetal asphyxia, while avoiding foetal and maternal hurt. The go toing accoucheuse or obstetrician should be able to acknowledge a shoulder dystocia instantly and continue through a bit-by-bit sequence of manoeuvres to hasten bringing. Knowledge of the constructs that underlie manoeuvres and the practical inside informations of their executing appears much more effectual than cognition of the precise definitions or eponyms of each manoeuvre ( Crofts et al. 2008 ) . First line manoeuvres Mc Roberts manoeuvre involves acute flexure of the hips while the adult female is on supine place. This place straightens the lumbosacral angle, leting descent of the posterior shoulder. The maternal pelvic girdle is perpendicular to the way of the maternal expulsive forces. Gonik et al [ 88 ] , utilizing computing machine silent person theoretical accounts showed that with lithotomy placement, both endogenous and exogenic bringing forces were associated with brachial rete stretching during shoulder dystocia ( the per centum of brachial rete nervus stretch was 15.7 % vs 14.0 % , severally ) . McRoberts positioning resulted in 53 % less brachial rete stretch ( 6.6 % ) . Directed suprapubic force per unit area can be uninterrupted or ‘rocking ‘ force per unit area on the posterior facet of the anterior shoulder which may ease adduction of the shoulders, a decrease of the bisacromial diameter and rotary motion to an oblique place. Second line manoeuvres Delivery of the posterior arm is undertaken by infixing the manus in the vagina posteriorly and using soft force per unit area at the antecubital pit to flex the foetal forearm, which is so grasped and swept across the foetal thorax. If bringing of the posterior arm is achieved, the anterior arm rotates posteriorly or descends behind the symphysis pubic bone as Kung et Al showed that the shoulder dimensions are reduced by 2.5cms with this manoeuvre particularly in larger foetuss ( Kung et al. 2006 ) . Rubin ‘s manoeuvre: rotary motion of the shoulders is attempted by insertiong two fingers in the vagina behind the anterior shoulder. The shoulder is pushed frontward and the bisacromial diameter rotates into an oblique place. If unsuccessful, this can so be combined with the Woods ‘ prison guard manoeuvre. Forests ‘ prison guard: force per unit area is applied with two fingers on the anterior facet of the posterior shoulder and use force per unit area taking to revolve the foetus towards the same way as the Rubin manoeuvre. Reverse Woods ‘ prison guard: with two fingers behind the posterior shoulder rotary motion is attempted in the opposite way to the original Woods ‘ prison guard. All these manoeuvres aim to revolve the shoulders and enable bringing by conveying the anterior shoulder posteriorly. Interpolation of the whole manus in the vagina may enable better push on the shoulder and facilitate rotary motion ( Crofts et al. 2008 ) . All-fours: the adult female is on her custodies and articulatio genuss and soft grip is applied taking to present the buttocks shoulder which may fall due to gravitation and to a possible addition of the anteroposterior diameter of the maternal pelvic girdle. Clavicular break: although the bisacromial diameter is reduced with this manoeuvre, there is an increased hazard of iatrogenic brachial rete hurt, vascular and soft tissue foetal injury. Third line manoeuvres Zavanelli manoeuvre involves flexure of the foetal caput, reversal of damages, rotary motion of the caput back to the occipito-anterior place, and replacing into the womb. Tocolytics and general anesthetic agents are used for uterine relaxation. The foetus is so delivered by cesarean subdivision. Although this manoeuvre has success rates of up to 92 % , it is associated with terrible fetal and maternal morbidity including foetal hurts and deceases, uterine and vaginal rupture. Symphysiotomy requires surgical expertness and is associated with important hazards of lower urinary tract hurt. The patient is on a supine place and the thighs are abducted no more than 45IS from the midplane. A urethral catheter is inserted and the urethra is displaced laterally. Following local infiltration with lignocaine, a perpendicular pang scratch is made on the symphysis with a scalpel. The symphysis is normally partly separated by cutting through the fibers by rotational motion of the blade. This allows the anterior foetal shoulder to be disimpacted. In instances of shoulder dystocia, the hazards of OBPP may be reduced if manoeuvres are conducted suitably and forceful downward grip of the caput is avoided ( figure 1 ) . Gonik et al [ 88 ] , showed that downward sidelong flexure of the foetal caput was associated with a 30 % addition in brachial rete stretch ( 18.2 % ) compared with axial placement of the caput ( 14 % ) . Fundal force per unit area should be avoided as it can decline shoulder dystocia and grip combined with fundal force per unit area can be associated with neurological complications [ 57 ] . Consequences may be better and hazards of OBPP lower if there is no terror, force per unit area on the fundus, sidelong grip or pivoting of the caput at the cervix and when tortuosity or rotational motion of the caput to revolve the shoulders is avoided { Doumouchtsis, 2009 # 6174 } .DecisionOBPP is a potentially annihilating complication of childbearing. Shoulder dystocia is merely one of a battalion of hazard factors for OBPP, most of which may be hard to foretell. Future research should be directed in prospective rating of the mechanisms of hurt, in order to enable accoucheurs, accoucheuses and other wellness attention professionals identify modifiable hazard factors, develop preventative schemes and better perinatal results.

Exposing the Weakness of Saint Anselm of Canterbury’s...

Exposing the Weakness of Saint Anselm of Canterbury’s Ontological Argument In a world of scientific inquiry, atheism, and the assassination of God, we are often neglectful of our Glorious God’s existence. With new theories of neuropsychology, quantum physics, gene therapy, evolution, and psychobiology, we are constantly forced to edge God out of our lives, to be replaced with cold, empty scientific thought. What, with meme theory, genetic predisposition, evolutionary spontaneous generation, dark matter, super string theory, multi-layered universes, and the neurological reasons behind consciousness, we are becoming more and more distant from the reality that is God. This is disappointing. This is painful. And thankfully, this†¦show more content†¦His major contribution to apologetics and theology is now called the Ontological Proof, which, essentially, is a set of logical steps which show that God must exist. One thousand years later, his proof is still a powerful argument against the plague of atheism. With it, we can turn the tables on physicists, biologists, chemists, and psychologists. We can fall asleep at night knowing in our soul that God does indeed exist. We can use the scientist’s weapons of logic and rhetoric to injure that scientist’s theories. But, the skeptic asks, how can we use a one thousand year old argument now, in the year 2000? Is it not out of date? Is it still applicable in a world of black holes, nuclear physics, Einstein-Rosen bridges, and self-replicating memes? I answer in the affirmative, and I will relate the Ontological Argument in a more contemporaneous way, with the hope that my more simplistic, understandable methods will prove effective. Anselm’s Ontological Argument: The essential points of Anselm’s arguments are these: God exists, for there is goodness in the world, and goodness can be good only through a supreme good that is good through itself, and only God is good through Himself. God exists, for since whatever exists does so only through something, there must be a supremely great being that exists through itself and through which all other things exist. God exists, for there are degrees of worth in