Policy of Medicare System Essay Example for Free

Policy of Medicare System Essay With the evolution of new drug-resistant strains of maladies in the contemporary period, scientists are now going back to nature in pursuit of pristine defenses. Says Dr. Robert Nash, research director of Molecular Nature in the United Kingdom, â€Å"Dandelions, sea pinks, nettles, even bluebells were used to treat diseases. There is a good reason for going back to see if there was anything behind these traditional uses† (Amundsen 132).   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   In our backyard, there is a bed of bluebells and never had it dawned on me that bluebells prove to have anti-virus and anti-cancer properties. That they were used in the 13th century against leprosy (Amundsen 155). Not that I would really want to prepare for any possible leprosy case that may stem at home; but the thought of having nifty bluebells in the garden can give comfort on good health and brainy ancestors.   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   In the library, the books speak of one thing about healthcare; that it is the management of the resources of healing. Darrel Amundsen, in his book Medicine, Society, and Faith in the Ancient and Medieval Worlds, pointed up the wonder of natural medicines and traditional medicine. Stanley Reiser tells us of how medical care evolved from technological point of view. Dorothy Porter’s Social Medicine and Medical Sociology in the Twentieth Century talks about where the health care industry has drifted through different eras. It has had a major impact on how people perceive health on the whole. From the unborn and mothers to all the phases of childhood to the youth and the adults to the older people, health care has been in packages essential at various stages of the human being. Additionally, the practitioners have done a lot of education, investing awe-inspiring sum of finances and effort in educating the public. Professional patronizing and obscure terminology will give way to cooperative educational approaches, and client-oriented rehabilitation. This approach is estimated to provide the most appropriate package of health services suited to ensure a healthy well-being of all age groups. In every industrialized country, excluding the United States (U.S.), the provision of health care has become the financial responsibility of the state over the past 100 years. Taxes on both employers and workers and general tax revenues financed the health care insurance system. This was the procedure in Western Europe and Great Britain (Warner 360-368).   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   The exception of the U.S. can be credited to the native value the Americans placed on self-help and repulsion against dependency. After 80 years of anxiety, the federal government of the U.S. has accepted the system but with some degree of responsibility. When the medical care program was introduced to them, it has become a complex mix of public and private payments. The extent covered the maldistribution of resources and disproportions of access (Porter 9). Nevertheless, across the surveys, the U.S. health care system becomes the country’s largest employer. Approximately, 597,000 are physicians, 137,000 are dentists, 1.8 million are nurses, and nine million are field workers (Warner 356).   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Administering the federal health care activities was charged to the Department of Health and Human Services. Health insurance comprises all forms of insurance against financial loss resulting from injury or illness. The most common health insurance coverage is for hospital care, including the physician services in the hospital. Major medical policies protect the insured against calamitous charges, paying a sum of that ranges from $10,000 to $1,000,000, after the policyholder has paid a preliminary deductible amount (Warner 371). Patients usually have out-of-pocket expenses since doctors’ charges are not entirely covered by the insurance.   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Overheads for healthcare services in the U.S. alone have been mounting sharply for about over a decade. Insurance coverage is potholed. Coverage for home care of the chronically ill is nigh on absent. A fixed sum is paid for a service except for hospital insurance. More often than not, this payment must be supplemented by the patient (Warner 358).   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Problems also arose in the aspect of recruitment and distribution of physicians. About one-fourth of U.S. physicians were engaged in primary patient care. That included obstetrics, internal medicine, pediatrics, and family medicine. In the slums of big cities, physicians are sparse but profuse in the more affluent sub-urban areas (Porter 12). One of the more daunting areas of health care is the prohibitive cost of medicines. At present, there is no governing body that regulates the price of medicine. This means that the manufacturers dictate the prices. With this discretion, expectedly the prices could be set as high as excusably possible. To ornament with justice, their marketing strategy has spawned the mentality that â€Å"branded is better.† Came the managed healthcare system. The genesis of contemporaneous managed care can be trailed to the prepaid plans providing healthcare to rural, shipbuilding and construction workers in the U.S. in the 1920s and 1930s. Managed healthcare have likewise existed in ancient China when doctors were supposedly paid only while they kept their patients healthy. Although many of the procedures used by managed healthcare to regulate expenditures have existed in African countries for a time, it was only since the latter part of the 20th century that the concept of managed care has been both in full swing in an effort to provide Africa with low-priced quality healthcare and denigrated by others (Porter 10-11). But in the U.S., managed healthcare was only firmly established when briskly swelling healthcare costs in the 1970’s and 80’s led to the passing of legislation providing for the establishment of Health Maintenance Organizations (HMOs) (Warner 370).   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   HMOs and the government has since then been on the lookout for effective alternatives. The government and the private sector all face the problem of financing the uncontrolled inflation of cost in the medical care program. Others blame it on the growing numbers of people who seek care. Some on the greater use of laboratory costs and of specialists in diagnosis and treatment (Reiser 16). Needless to say, the synergistic force of the sectors wanted programs that were cheap but were at least, effective.   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Hospitals were responding to increasing cost demands. They attempted to introduce more competent management schemes. Proprietary hospitals have found greater earnings in chain operations. Other efforts to slash costs included hiring less-expensive professional workers, like nurses and paramedics, in the hope of getting basic care to patients at a lower fee (Porter 10). The health care system has indeed been an entrepreneurial idea. However, paradox has it that in due time, antibiotics, vaccines, and other vital medicines will be short of availability at least, among the 5.6 billion people, according to the World Health Organization (Porter 18). Scarcity of producers of medicines has nothing to do with it. Maldistribution and capitalistic exploitation will make the medicines inaccessible to the poor. Over 40 million Americans have some form of heart or blood vessel disease, and the combined costs of treatment and lost income exceed 50 billion dollars annually. About 4 million people, 10 percent of those with cardiovascular diseases, have coronary artery disease. Because of these findings, the Framingham Study considers cardiovascular disease as one of the leading epidemiological diseases in the country. A more distressing fact rings throughout the Third World countries whose healthcare programs are financed by their governments on less than 1 percent cut from the gross domestic product (Porter 15-16). At this reality, whose son or daughter will not be underfed? Every major city had slum areas that housed the poor and unemployed, and declining farm incomes created rural poverty. Amid the growth and confidence of the postwar years, United States leaders initiated programs of aid to help people at home and abroad improve their way of life. Programs of domestic aid included funds for education, medical care for the poor, and urban renewal programs. International air programs begun soon after the war sought to help United States maintain economic and political stability (Fusfeld and Bates, 1984). Poverty-stricken people suffer from the lack of many things they need. For example, they are less likely to receive adequate medical care or to eat the foods they need to stay healthy. The poor have more diseases, become more seriously ill, and die at a younger age than other people do. Poor people often live in substandard housing in socially isolated areas where most of their neighbors are poor. Many low-income families live in crowded, run-down buildings with inadequate heat and plumbing. The jobs most readily available to the poor provide low wages and little opportunity for advancement. Many of these jobs also involve dangerous or unhealthful working conditions. Financial, medical, and emotional problems often strain family ties among the poverty-stricken. Furthermore, the healthcare system of countryside Americans is dense. For instance, Indians are lacking relative to their urban equivalents in many important ways that shape their health: they are unduly economically inferior, proportionately lesser are of working age, and they have not fulfilled as much of education. Topographical access is of principal interest in several rural states. Indians who reside in remote areas, comparatively far from urban areas or centers, sometimes find it hard to get in touch with healthcare personnel or services. In respect of urban inhabitants, rural dwellers have to trek farther to care and tackle other problems such as mediocre road and rail network, and short of public transportation. These problems are distinguished yet their resolution escapes the labors of the U.S. Legislature, and local governments. Culture is another driving factor, including influential customs (Nabokov). The Indians’ unfavorable health behaviors, employment of folk medication, the impact of traditional religion on healthcare, and estrangement from countrywide society all play a part to the way they care for their health. To make the decisions centralized, World Medical Association was founded as an organization of several of the world’s national medical associations. Instituted in 1947, this medical society has embraced an international code of medical ethics and many other ethical pronouncements. The center of operations is in Ferney-Voltaire, France (Porter, 2000). One of the pivotal epidemiological methodologies for an improved healthcare provision is an informed public. If the individual does not understand what he or she must do to preserve health and reduce his or her risk of a probable epidemiological disease, if he or she does not recognize when he or she needs outside help, and if he or she or members of his family are not prepared to take the appropriate steps to obtain this help, then all of the world’s medical knowledge will be of little value. The educational process that would prepare an individual to help preserve his or her own health and reduce his or her epidemiological risk should ideally begin in his or her youth when lifelong patterns are being formed, and continue throughout his or her adult life. A hospital management’s role is twofold: helping to build good health habits in the young, and serving as agents in adult health habits through public information and education programs designed to teach preservation of health and raise the general health consciousness of the people. The practicing physician, emergency medical services, the clinic or neighborhood health center, the hospital as a whole stand to be prepared in implementing medical line of defense. Even at times the nonmedical person who is on the scene when an acute emergency occurs are relied on. In order to be effective, the hospital carrying out the epidemiological measures, together with these individuals and services, are obliged and expected not only to be capable of providing healthcare, but must be prepared to do so in a manner that is acceptable and accessible to, and understood by, the public. The epidemiological measures of a hospital in this area shall also address such things as professional education, healthcare standards, and public information regarding access to care and services. Another approach is that which serves as the underpinning of the rest of the strategies and plans; it is the biomedical research to identify such epidemiological factors as dietary fats, smoking, hypertension, etc., that adversely affect human health and to devise methods for preventing, diagnosing, and treating these conditions and the diseases to which they contribute. In this regard, the hospital has a unique role to play, in that while they cannot the huge sums needed for large-scale clinical trials or epidemiological studies, they claim to have an excellent mechanism for supporting young investigators who are juts beginning their research careers, helping them gain the experience and results necessary to compete for larger grants in the national and international arenas. The emphasis is practically placed on the support of quality research projects having high merit ratings. To adequately develop such improved measures by Medicare, it should have the hospital require a programmed effort that first takes into consideration the fact that the hospital cannot be all things to all people. It may have quite limited resources in terms of money, volunteers, and staff in other departments, and the need for each of these resources may always seem to exceed the supply. Since there are numerous programs and activities that are capable of improving health of the patients to some degree, hard choices must be made regarding the disposition of these resources. This implies priority setting, which is made more efficient by the establishment and implementation of a hospital-wide, goal-oriented, long-range planning process. Such a process helps the hospital focus its epidemiological measures on high yield, cost-effective projects that either help prevent the healthcare provision, or provide ongoing relief and control, yielding the highest return on time and money invested. All in all, medical institution evolved across time to deal with problems of health and disease using epidemiological measures that are based on mortality, morbidity, disability, and quality. More specifically, medical institution was perceived performing a number of key functions in modern societies. First, it treats and seeks to cure disease. Second, the medical institution attempts to prevent disease through maintenance programs, including vaccination, health education, periodic checkups, and public health and safety standards (administrative medicine). Third, it undertakes research in the prevention, treatment, and cure of health problems (preventive medicine). And fourth, it serves as an agency of social control by defining some behaviors as normal and healthy and others as deviant and unhealthy. Although health care can take its roots back when one of the greatest achievements of civilization was the naissance of medicine, real health comes from within. The quality of life of an individual is governed by the swelling bearing of his positive personal health-seeking activities and behaviors. And with the help of heath care, tomorrow’s health centers will fill out today’s precision diagnostic services with equally scientific self-care and wellness programs. Future healthcare will increasingly concede to the empowerment of the individual. Perhaps the way healthcare began more than two thousand years back differs from the way it will continue in the next two thousand years or so. The gods may still have a role but not for the folks to plead to for kinder nature. A common Supreme Being might then take the place of them and be prayed to in exchange for a kinder world. If in the past, the causes of illnesses may have been shared between man and nature, from this time forth, diseases would be brought about by the caustic arms of industrialization.   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Whose healthcare would not be needed most in the midst of volatile worldwide climate and industrial population? Typhoons come and leave natural borne diseases. McDonald’s open their stores and send resentful stomachs to the healthcare clinics. Who would not consequently draw a smart plot from the commercial appeal of healthcare? For healthcare, this means an upsurge in affliction as well as a digression of resources away from healthcare toward reform. The pandemonium disrupts food supplies, infectious diseases multiply, and alarm triggers stress-induced illnesses. The beginnings of medical care may have been deemed mad and laughable. Then again, its inheritance, with the help of worsened worldwide scenarios, is rendering the underprivileged mad and the moneyed having the last laugh. References Amundsen, Darrel W. (1996). Medicine and faith in early Christianity. Medicine, Society, and Faith in the Ancient and Medieval Worlds. Baltimore: The Johns Hopkins University Press. Chambers, Donald and Kenneth Wedel. Social Policy and Social Programs: A Method for the Practical Public Policy Analyst, 4th edition. Pearson Publishing. Fusfeld, Daniel R., and Timothy Bates. (1984). The Political Economy of the Urban Ghetto. Southern Illinois University Press. McDaniel, W. B. (1959). â€Å"A view of 19th century medical historiography in the United States of America.† The History of Medicine. Nabokov, Peter. Native American Testimony: A Chronicle Of Indian-White Relations From Prophesy To The Present (1492-1992). Penguin Publishing. Porter, Dorothy E. (1975). Social Medicine and Medical Sociology in the Twentieth Century. Cambridge, Mass.: Harvard University Press. Reiser, Stanley J. (1984). â€Å"The machine at the bedside: Technological transformations of practices and values.† The Machine at the Bedside: Strategies for Using Technology in Patient Care. Cambridge: Cambridge University Press. Warner, Martin S. (1985). Medical Practice and Health Care During the Revolutionary War and Early National Periods. Baltimore: The Johns Hopkins University Press.

Active or Passive Third Stage of Labour: Pros and Cons

Active or Passive Third Stage of Labour: Pros and Cons Introduction This dissertation is primarily concerned with the arguments that are currently active in relation to the benefits and disadvantages of having either an active or passive third stage of labour. We shall examine this issue from several angles including the currently accepted medical opinions as expressed in the peer reviewed press, the perspective of various opinions expressed by women in labour and theevidence base to support these opinions. It is a generally accepted truism that if there is controversy surrounding a subject, then this implies that there is not a sufficiently strong evidence base to settle the argument one way or the other. (De Martino B et al. 2006). In the case of this particular subject, this is possibly not true, as the evidence base is quite robust (and we shall examine this in due course). Midwifery deals with situations that are steeped in layers of strongly felt emotion, and this has a great tendency to colour rational argument. Blind belief in one area often appears to stem from total disbelief in another (Baines D. 2001) and in consideration of some of the literature in this area this would certainly appear to be true. Let us try to examine the basic facts of the arguments together with the evidence base that supports them. In the civilised world it is estimated that approximately 515,000 currently die annually from problems directly related to pregnancy. (extrapolated from Hill K et al. 2001). The largest single category of such deaths occur within 4 hrs. of delivery, most commonly from post partum haemorrhage and its complications (AbouZahr C 1998), the most common factor in such cases being uterine atony. (Ripley D L 1999). Depending on the area of the world (as this tends to determine the standard of care and resources available), post partum haemorrhage deaths constitutes between 10-60% of all maternal deaths (AbouZahr C 1998). Statistically, the majority of such maternal deaths occur in the developing countries where women may receive inappropriate, unskilled or inadequate care during labour or the post partum period. (PATH 2001). In developed countries the vast majority of these deaths could be (and largely are) avoided with effective obstetric intervention. (WHO 1994). One of the central argumen ts that we shall deploy in favour of the active management of the third stage of labour is the fact that relying on the identification of risk factors for women at risk of haemorrhage does not appear to decrease the overall figures for post partum haemorrhage morbidity or mortality as more than 70% of such cases of post partum haemorrhage occur in women with no identifiable risk factors. (Atkins S 1994). Prendiville, in his recently published Cochrane review (Prendiville W J et al. 2000) states that: where maternal mortality from haemorrhage is high, evidence-based practices that reduce haemorrhage incidence, such as active management of the third stage of labour, should always be followed It is hard to rationally counter such an argument, particularly in view of the strength of the evidence base presented in the review, although we shall finish this dissertation with a discussion of a paper by Stevenson which attempts to provide a rational counter argument in this area. It could be argued that the management of the third stage of labour, as far as formal teaching and published literature is concerned, is eclipsed by the other two stages (Baskett T F 1999). Cunningham agrees with this viewpoint with the observation that a current standard textbook of obstetrics (unnamed) devotes only 4 of its 1,500 pages to the third stage of labour but a huge amount more to the complications that can arise directly after the delivery of the baby (Cunningham, 2001). Donald makes the comment This indeed is the unforgiving stage of labour, and in it there lurks more unheralded treachery than in both the other stages combined. The normal case can, within a minute, become abnormal and successful delivery can turn swiftly to disaster. (Donald, 1979). chapter 1:define third stage of labour, The definition of the third stage of labour varies between authorities in terms of wording, but in functional terms there is general agreement that it is the part of labour that starts directly after the birth of the baby and concludes with the successful delivery of the placenta and the foetal membranes. Functionally, it is during the third stage of labour that the myometrium contracts dramatically and causes the placenta to separate from the uterine wall and then subsequently expelled from the uterine cavity. This stage can be managed actively or observed passively. Practically, it is the speed with which this stage is accomplished which effectively dictates the volume of blood that is eventually lost. It follows that if anything interferes with this process then the risk of increased blood loss gets greater. If the uterus becomes atonic, the placenta does not separate efficiently and the blood vessels that had formally supplied it are not actively constricted. (Chamberlain G et al. 1999). We shall discuss this process in greater detail shortly. Proponents of passive management of the third stage of labour rely on the normal physiological processes to shut down the bleeding from the placental site and to expel the placenta. Those who favour active management use three elements of management. One is the use of an ecbolic drug given in the minute after delivery of the baby and before the placenta is delivered. The second element is early clamping and cutting of the cord and the third is the use of controlled cord traction to facilitate the delivery of the placenta. We shall discuss each of these elements in greater detail in due course. The rationale behind active management of the third stage of labour is basically that by speeding up the natural delivery of the placenta, one can allow the uterus to contract more efficiently thereby reducing the total blood loss and minimising the risk of post partum haemorrhage. (ODriscoll K 1994) discuss optimal practice, Let us start our consideration of optimal practice with a critical analysis of the paper by Cherine (Cherine M et al. 2004) which takes a collective overview of the literature on the subject. The authors point to the fact that there have been a number of large scale randomised controlled studies which have compared the outcomes of labours which have been either actively or passively managed. One of the biggest difficulties that they experienced was the inconsistency of terminology on the subject, as a number of healthcare professionals had reported management as passive when there had been elements of active management such as controlled cord traction and early cord clamping. As an overview, they were able to conclude that actively managed women had a lower prevalence of post partum haemorrhage, a shorter third stage of labour, reduced post partum anaemia, less need for blood transfusion or therapeutic oxytocics (Prendiville W J et al. 2001). Other factors derived from the paper include the observation that the administration of oxytocin before delivery of the placenta (rather than afterwards), was shown to decrease the overall incidence of post partum haemorrhage, the overall amount of blood loss, the need for additional uterotonic drugs, the need for blood transfusions when compared to deliveries with similar duration of the third stage of labour as a control. In addition to all of this they noted that there was no increased incidence of the condition of retained placenta. (Elbourne D R et al. 2001). The evidence base for these comments is both robust and strong. On the face of it, there seems therefore little to recommend the adoption of passive manage ment of the third stage of labour. Earlier we noted the difficulties in definition of active management of the third stage of labour. In consideration of any individual paper where interpretation of the figures are required, great care must therefore be taken in assessing exactly what is being measured and compared. Cherine points to the fact that some respondents categorised their management as passive management of the third stage of labour when, in reality they had used some aspect of active management. They may not have used ecbolic drugs (this was found to be the case in 19% of the deliveries considered). This point is worth considering further as oxytocin was given to 98% of the 148 women in the trial who received ecbolic. In terms of optimum management 34% received the ecbolic at the appropriate time (as specified in the management protocols as being before the delivery of the placenta and within one minute of the delivery of the baby). For the remaining 66%, it was given incorrectly, either after the delivery of the placenta or, in one case, later than one minute after the delivery of the baby. Further analysis of the practices reported that where uterotonic drugs were given, cord traction was not done in 49%, and early cord clamping not done in 7% of the deliveries observed where the optimum active management of the third stage of labour protocols were not followed. >From an analytical point of view, we should cite the evidence base to suggest the degree to which these two practices are associated with morbidity. Walter P et al. 1999 state that their analysis of their data shows that early cord clamping and controlled cord traction are shown to be associated with a shorter third stage and lower mean blood loss, whereas Mitchelle (G G et al. 2005) found them to be associated with a lower incidence of retained placenta. Other considerations relating to the practice of early cord clamping are that it reduces the degree of mother to baby blood transfusion. It is clear that giving uterotonic drugs without early clamping will cause the myometrium to contract and physically squeeze the placenta, thereby accelerating the both the speed and the total quantity of the transfusion. This has the effect of upsetting the physiological balance of the blood volume between baby and placenta, and can cause a number of undesirable effects in the baby including an increased tendency to jaundice. (Rogers J et al. 1998) The major features that are commonly accepted as being characteristic of active management and passive management of the third stage of labour are set out below. Physiological Versus Active Management . . Physiological Management Active Management Uterotonic None or after placenta delivered With delivery of anterior shoulder or baby Uterus Assessment of size and tone Assessment of size and tone Cord traction None Application of controlled cord traction* when uterus contracted Cord clamping Variable Early (After Smith J R et al. 1999) physiology of third stage The physiology of the third stage can only be realistically considered in relation to some of the elements which occur in the preceding months of pregnancy. The first significant consideration are the changes in haemodynamics as the pregnancy progresses. The maternal blood volume increases by a factor of about 50% (from about 4 litres to about 6litres). (Abouzahr C 1998) This is due to a disproportionate increase in the plasma volume over the RBC volume which is seen clinically with a physiological fall in both Hb and Heamatocrit values. Supplemental iron can reduce this fall particularly if the woman concerned has poor iron reserves or was anaemic before the pregnancy began. The evolutionary physiology behind this change revolves around the fact that the placenta (or more accurately the utero-placental unit) has low resistance perfusion demands which are better served by a high circulating blood volume and it also provides a buffer for the inevitable blood loss that occurs at the time of delivery. (Dansereau J et al. 1999). The high progesterone levels encountered in pregnancy are also relevant insofar as they tend to reduce the general vascular tone thereby increase venous pooling. This, in turn, reduces the venous return to the heart and this would (if not compensated for by the increased blood volume) lead to hypotension which would contribute to reductions in levels of foetal oxygenation. (Baskett T F 1999). Coincident and concurrent with these heamodynamic changes are a number of physiological changes in the coagulation system. There is seen to be a sharp increase in the quantity of most of the clotting factors in the blood and a functional decrease in the fibrinolytic activity. (Carroli G et al. 2002). Platelet levels are observed to fall. This is thought to be due to a combination of factors. Haemodilution is one and a low level increase in platelet utilisation is also thought to be relevant. The overall functioning of the platelet system is rarely affected. All of these changes are mediated by the dramatic increase in the levels of circulating oestrogen. The relevance of these considerations is clear when we consider that one of the main hazards facing the mother during the third stage of labour is that of haemorrhage. (Soltani H et al. 2005) and the changes in the haemodynamics are largely germinal to this fact. The other major factor in our considerations is the efficiency of the haemostasis produced by the uterine contraction in the third stage of labour. The prime agent in the immediate control of blood loss after separation of the placenta, is uterine contraction which can exert a physical pressure on the arterioles to reduce immediate blood loss. Clot formation and the resultant fibrin deposition, although they occur rapidly, only become functional after the coagulation cascade has triggered off and progressed. Once operative however, this secondary mechanism becomes dominant in securing haemostasis in the days following delivery. (Sleep, 1993). The uterus both grows and enlarges as pregnancy progresses under the primary influence of oestrogen. The organ itself changes from a non-gravid weight of about 70g and cavity volume of about 10 ml. to a fully gravid weight of about 1.1 kg. and a cavity capacity of about 5 litres. This growth, together with the subsequent growth of the feto-placental unit is fed by the increased blood volume and blood flow through the uterus which, at term, is estimated to be about 5-800 ml/min or approximately 10-15% of the total cardiac output (Thilaganathan B et al. 1993). It can therefore be appreciated why haemorrhage is a significant potential danger in the third stage of labour with potentially 15% of the cardiac output being directed towards a raw placental bed. The physiology of the third stage of labour also involves the mechanism of placental expulsion. After the baby has been delivered, the uterus continues to contract rhythmically and this reduction in size causes a shear line to form at the utero-placental junction. This is thought to be mainly a physical phenomenon as the uterus is capable of contraction, whereas the placenta (being devoid of muscular tissue) is not. We should note the characteristic of the myometrium which is unique in the animal kingdom, and this is the ability of the myometrial fibres to maintain its shortened length after each contraction and then to be able to contract further with subsequent contractions. This characteristic results in a progressive and (normally) fairy rapid reduction in the overall surface area of the placental site. (Sanborn B M et al. 1998) In the words of Rogers (J et al. 1998), by this mechanism the placenta is undermined, detached, and propelled into the lower uterine segment. Other physiological mechanisms also come into play in this stage of labour. Placental separation also occurs by virtue of the physical separation engendered by the formation of a sub-placental haematoma. This is brought about by the dual mechanisms of venous occlusion and vascular rupture of the arterioles and capillaries in the placental bed and is secondary to the uterine contractions (Sharma J B et al. 2005). The physiology of the normal control of this phenomenon is both unique and complex. The structure of the uterine side of the placental bed is a latticework of arterioles that spiral around and inbetween the meshwork of interlacing and interlocking myometrial fibrils. As the myometrial fibres progressively shorten, they effectively actively constrict the arterioles by kinking them . Baskett (T F 1999) refers to this action and structure as the living ligatures and physiologic sutures of the uterus. These dramatic effects are triggered and mediated by a number of mechanisms. The actual definitive trigger for labour is still a matter of active debate, but we can observe that the myometrium becomes significantly more sensitive to oxytocin towards the end of the pregnancy and the amounts of oxytocin produced by the posterior pituitary glad increase dramatically just before the onset of labour. (GÃ ¼lmezoglu A M et al. 2001) It is known that the F-series, and some other) prostaglandins are equally active and may have a role to play in the genesis of labour. (Gulmezoglu A M et al. 2004) >From an interventional point of view, we note that a number of synthetic ergot alkaloids are also capable of causing sustained uterine contractions. (Elbourne D R et al. 2002) chapter 2 discuss active management, criteria, implications for mother and fetus. This dissertation is asking us to consider the essential differences between active management and passive management of the third stage of labour. In this segment we shall discuss the principles of active management and contrast them with the principles of passive management. Those clinicians who practice the passive management of the third stage of labour put forward arguments that mothers have been giving birth without the assistance of the trained healthcare professionals for millennia and, to a degree, the human body is the product of evolutionary forces which have focussed upon the perpetuation of the species as their prime driving force. Whilst accepting that both of these concepts are manifestly true, such arguments do not take account of the natural wastage that drives such evolutionary adaptations. In human terms such natural wastage is simply not ethically or morally acceptable in modern society. (Sugarman J et al. 2001) There may be some validity in the arguments that natural processes will achieve normal separation and delivery of the placenta and may lead to fewer complications and if the patient should suffer from post partum haemorrhage then there are techniques, medications and equipment that can be utilised to contain and control the clinical situation. Additional arguments are invoked that controlled cord traction can increase the risk of uterine inversion and ecbolic drugs can increase the risks of other complications such as retained placenta and difficulties in delivering an undiagnosed twin. (El-Refaey H et al. 2003) The proponents of active management counter these arguments by suggesting that the use of ecbolic agents reduces the risks of post partum haemorrhage, faster separation of the placenta, reduction of maternal blood loss. Inversion of the uterus can be avoided by using only gentle controlled cord traction when the uterus is well contracted together with the controlling of the uterus by the Brandt-Andrews manoeuvre. The arguments relating to the undiagnosed second twin are loosing ground as this eventuality is becoming progressively more rare. The advent of ultrasound together with the advent of protocols which call for the mandatory examination of the uterus after the birth and before the administration of the ecbolic agent effectively minimise this possibility. (Prendiville, 2002). If we consider the works of Prendiville (referred to above) we note the meta-analyses done of the various trials on the comparison of active management against the passive management of the third stage of labour and find that active management consistently leads to several benefits when compared to passive management. The most significant of which are set out below. Benefits of Active Management Versus Physiological Management Outcome Control Rate, % Relative Risk 95% CI* NNT 95% CI PPH >500 mL 14 0.38 0.32-0.46 12 10-14 PPH >1000 mL 2.6 0.33 0.21-0.51 55 42-91 Hemoglobin 6.1 0.4 0.29-0.55 27 20-40 Blood transfusion 2.3 0.44 0.22-0.53 67 48-111 Therapeutic uterotonics 17 0.2 0.17-0.25 7 6-8 *95% confidence interval Number needed to treat (After Prendiville, 2002). The statistics obtained make interesting consideration. In these figures we can deduce that for every 12 patients receiving active management (rather than passive management) one post partum haemorrhage is avoided and further extrapolation suggests that for every 67 patients managed actively one blood transfusion is avoided. With regard to the assertions relating to problems with a retained placenta, there was no evidence to support it, indeed the figures showed that there was no increase in the incidence of retained placenta. Equally it was noted that the third stage of labour was significantly shorter in the actively managed group. In terms of significance for the mother there were negative findings in relation to active management and these included a higher incidence of raised blood pressure post delivery (the criteria used being > 100 mm Hg). Higher incidences of reported nausea and vomiting were also found although these were apparently related to the use of ergot ecbolic

Integrating Democracy with Tibetan Buddhism :: Politics Political

Integrating Democracy with Tibetan Buddhism The combination of a religion and a political philosophy do not automatically allow for the most congruous applications. Tibetan Buddhism has been the main stay of a country that has been ruled by a monarchy, through a religious figurehead, and by a socialist republic, all of which seem to have their political frustrations in preserving the Tibetan society. The political spectrum now questions how well the Buddhist tradition integrates the values of democratic theory. The previous applications of Buddhism in a role of government are necessary to analyze in order to properly investigate the application of the Buddhist tradition into a political framework. The structure of the Tibetan government before the invasion of the Chinese in 1950 was a mixture of the monastic influence and the nobles. The authority of the Dalai Lama reigned over the monasteries and religious order as well as over the administrative obligations of the Country. The search for the reincarnation of the Dalai Lama ensures not only leadership of the country from the Buddha of Compassion but also implies that the reign of government is not hereditary, but based on wisdom and guidance for the people and much less on political situations, although these would still much be a factor in ruling. The hierarchical establishment of this division remained partially mixed so that the monks in office balanced the nobles and the monks were checked by the nobles, however the mona stic influence remained the dominant of the two. The legacy of the aristocracy was more an element of the older reign of Tibet from a monarchy and class distinction and the religious influence was more dominant with the newer establishment and really established until the fourteenth century with the teacher Tsong Khapa. This checks and balances involved in the government may only be the confluence of an older tradition mixing in with the new in order to maintain a smooth transition, but it may also exhibit the balance necessary to a government lead by Buddhist thought. Buddhism is not merely a doctrine that is automatically to be accepted and instilled as the truth, rather it has to be taught and allow the people to come to it.

Choir Changed My Life :: Narrative Essay

Choir Changed My Life Freshmen year of High School changed my life for the better, although at first I was very reluctant to think so. My mom and her boyfriend had been commuting for two years after he was offered a much better job in Las Vegas. We decided it would be best for me to finish up middle school and freshman year of high school, head out for the gambler’s city. This change was extreme for me and had I not gone, I would have never joined the choir, which is where this story begins. I walked into McKinney North High School (where all freshmen had to attend that year) and signed up for my first year of high school classes. My mom thought it’d be a good idea to join a club or an interactive, fun, and exciting class. I had my doubts at first, but I decided to join the school Choir. I wouldn’t have had much of a problem walking in on my first day, but Las Vegas school’s start a few weeks later than McKinney†¦so they were on their second nine weeks and had all gotten a chance to get to know each other. I on the other hand, walked in and silenced the room. Mr. Nelms, the Choir teacher, introduced me to the Choir and had me sing†¦in front of everyone. I was beyond nervous. Turns out I did OK and I was from then on, an alto. I realized I would be moving to McKinney High School from North after the re-zoning of school’s which I was actually very excited about. I had to face another new choir, and a new teacher Mr. Garms. Mr. Nelm’s referred a handful of us to be in Concert Choir. It turns out I was one of the few. I was too nervous to accept, for I didn’t think I was Concert Choir material quite yet. Turns out I made a lot of friends in Chamber Singers (the choir I ended up in) and couldn’t of been happier with my decision to stay. I was put in Concert Choir again my Junior year but still didn’t think I was quite ready, so again I got out of it and stayed in Chamber. I became the leader of my Choir and was the best sight reader.

Exploring Gardners Theory on Multiple Intelligences Essay -- Educatio

Howard Gardner used to define intelligence as â€Å"the ability to solve problems or to create products that are valued within one or more cultural settings† (Gardner 33). The modern day human being would most likely include the words â€Å"smart† and â€Å"dumb† in their definition of intelligence. Gardner questioned the belief of only one intelligence so he created his own theory that involved seven different discoveries. He didn’t want to call these discoveries â€Å"skills† or â€Å"talents† or gifts† because those all suggested a drawback so he decided on the word â€Å"intelligence,† creating his theory of multiple intelligences (Gardner 33). Gardner’s theory of multiple intelligences including, linguistic, logical/mathematical, musical, bodily-kinesthetic, spatial, intrapersonal and interpersonal, has many implications for modern education and culture. Howard Gardner grew up in Pennsylvania in the late 1940’s, although his parents were originally from Germany. He attended Harvard as an undergraduate with the hopes of becoming a lawyer and with a major in history. However, as soon as he became the mentee of Erik Erikson, a well-known psychoanalyst, his interests started to change. Gardner entered the doctoral program at Harvard and received his PhD in 1971 with a dissertation on style sensitivity in children. During his years of doctoral study he became a part of the Project Zero, which does research on arts education, and he now co-directs the project. Gardner’s work with Project Zero led to the Project on Human Potential, which resulted in his first well-known book, Frames of Mind. He has written many books since then including, The Shattered Mind and Multiple Intelligences, and he is â€Å"currently Hobbs Professor of Cognition and Education at the Har... ...ly. It’s not Gardner’s goal to take over the education system and have it all reformed, but he does want educators to rethink their everyday lessons and see if they can improve them using his theory in order to broaden the comprehension of ideas to all students. Now all our society has to do is learn how to use this theory as an advantage and put all the intelligences to work. Gardner has started this concept of multiple intelligences but no one knows where it will end and what other implications it will have along the way. Works Cited Gardner, Howard. Intelligence Reframed: Multiple Intelligences for the 21st Century. New York, NY: Basic, 1999. Print. Smith, Mark K. "Howard Gardner, Multiple Intelligences and Education." The Encyclopedia of Informal Education. 2008. Web. 23 Feb. 2011.

History of Hrm Essay

HISTORY OF HRM HRM is traced back to the 19th century with the beginning of the Welfare System. The Welfare System was an important development in terms of voluntary initiatives undertaken to improve conditions of factory workers, in relation to pay, working hours and health and safety. The voluntary initiative originated from Quakers. Welfare officers were appointed and became the forerunner to HR practitioners. The early 1900’s saw the appointment of welfare officers in Irish companies such as Jacobs and Maguire & Patterson in Dublin. The impact of the Welfare approach is still apparent in HR practice in terms of dealing with issues such as health, working conditions and personal problems. Another early influence on the emergence of HRM was Taylorism (Frederick Taylor). Early 20th century improvements in technology and the increase in company sizes made way for new advancements in creating a system which focused purely on efficiency and profitability whereby workers were treated as economic machines. Scientific Management led to a shift in the emphasis of HR away from the employee caring approach towards the more managerial, efficiency and profitability benefits to be gained through greater standardisation of work systems and methods. The emergence of the Behavioural Science Movement gave a great impetus to HRM by establishing a body of knowledge to underpin many aspects of HR work such as selection, motivation, training, industrial relations and payments.

Culture and Cuisine Essay

Food is one of legion(predicate) factors that distinguishes one horticulture from a nonher. It has been used for ceremonial purposes, sacrificial rites, and some nutriment correcttide so holds symbolic meaning based on worship. Why do sight of the Jewish and Islamic faith choose not to ingest pork? Why is make whoopie and alcohol oft associated with parties and celebrations? The origin of galore(postnominal) of straightaways cuisine and dine traditions bath be traced back thousands of years, and often have a apparitional consequence. trust has influenced peoples fare choices and traditions since antediluvian patriarch times, and much of its impact is button up bragging(a) in todays world. In everyday life, it is easy for anyone to take remark of religious beliefs charge in nutrient and different types of cuisine. In securities industry stores and supermarkets, nutritions ar often labeled as Kosher or Halal and with holidays such as Lent and Ramadan, it is illumine that umteen traditions that began thousands of years ago are save important to people in todays society. The ban of pork products within the Jewish and Islamic faith, for example, dates back to antediluvian patriarch Egypt.The ancient Egyptians were known for having a operose dislike perhaps even misgiving of the blur. For this reason, go throughs were never depicted in hieroglyphics, even though they were present. Believing that the animals carried parasites and leprosy, it was only Egyptians of the last(a) social class who were s fuddle herders, and they were banned from unveiling any temples or places of worship. Maguelonne Toussaint-Samat suggests that is why the pig has become a forbidden food source That attitude could be at the root of the Jewish and Muslim rampart of pig meat.Moses declared the animal draggled this taboo slowed down Islamic working out into China, for the Chinese love pork as much as carp and ducks straightaway a certain amount of pig meant eaten in Europe, particularly ham, comes from China. (370) This shows how religion has influenced not only what a certain culture chooses to eat, but in any case how it has affected share and migration patterns throughout the worlds development. It is clear that food can hold so much religious significance, that it can even prevent two cultures from integrating with to each one other, as shown by the lack of Islamic presence in China.With various religious beliefs, comes various opinions about certain foods. Patterns of style vary among followers of different religions, resulting from different norms (Heiman, Just, McWilliams, and Zilberman). An example of clashing viewpoints is the difference betwixt Greek, Muslim, and Chinese opinions about wine. The ancient Greeks are some of historys greatest lovers of wine. They used wine for celebrations and studyd it to be a drink of the gods as it was made by Dionysus, the god of wine. Alternatively, some Muslims forbade wine. This is nigh in all probability because of their fear of its effects, and drunkenness was looked down upon. at that place was, however, a Muslim mystic by the name of Nabulsi who declared that wine was the drink of prognosticate love. Like Nabulsi, some chose to believe the Chinese proverb that states it is not wine that intoxicates man is the one who becomes intoxicated, because he is rickety (Toussaint-Samat 234). These different views of wine, or alcohol in general, is still evident today as some Muslims choose to drink it mend some choose not to. In Christianity, wine is symbolic of the blood of Jesus, and holds significance particularly in the Catholic church service for occasions such as communion.Symbolism, perhaps, is the most obvious connection between food and religion it is not the food itself that is sacred or significant, but what it stands for. Michel Desjardins explores how food can be a symbol in different religions and cultures At times, food as well f unction symbolically for example, when prayer onward eating express thanks for divine concern, when the Passover meal commemorates mythic stories, or when the Arabic Muslim and Christian coffee ritual calls on the divine. Other times food is offered directly to deities(153)Not only does religion affect what some people eat and do not eat, but also the types of meals that are made, the preparation, and the rituals that are paired with the food. Christian traditions involve praying before partaking in a meal, and Jewish customs call for compute feasts that are prepared by traditional methods. Another common use for food is sacrificing or offering certain foods to deities. Buddhists often present rice and or fruits to statues of Buddha a long-standing religious tradition.Religion has greatly impact the culinary world in the past, as well as today. The combination of religion and cuisine has proven to be deep rooted in the history of domain and the development of different cultures , as people all over the globe still maintain these traditions. Whether one is partaking in wine during communion, preparing Shabbat dinner, setting food before Buddha, or makes a lifelong decision not to eat pork, religion has an obvious presence in todays society. full treatment Cited Desjardins, Michel. instruct about Religion with Food. Teaching Theology and Religion. 3rd ed. Vol. 7. Oxford Blackwell Ltd. , 2004. 153-58. Heiman, Amir, David Just, Bruce McWilliams, and David Zilberman. Religion, Religiosity, Lifestyles and Food Consumption. Ebscohost. Web. . Toussaint-Samat, Maguelonne. A History of Food. Paris Wiley-Blackwell, 1992.