Assisted vaginal delivery via vacuum extraction Unit 1:

Assisted vaginal delivery via vacuum extraction Unit 1:

Assisted vaginal delivery via vacuum extraction Unit 1: Overview Refresher course for health care providers working in crisis settings Welcome Introductions Knowledge pre-test Course agenda and schedule Icebreaker What is your name and where are you from?

Have you treated women in the past who could have benefitted from vacuum-assisted delivery? What is the greatest gift you ever received? Aim To enable trainees to refresh their competencies in performing vacuum extraction in low-resource and/or emergency settings Training objectives At the end of this training, you will be able to:

Describe the indications, conditions, and contraindications for vacuumassisted birth Explain the safety measures applicable to vacuum-assisted birth Describe potential complications in women and newborns Identify the fetal head position and flexion point Describe the preparation of the patient for vacuum-assisted birth Demonstrate the steps in the procedure of vacuum-assisted birth Demonstrate post-procedural care following vacuum-assisted birth, including active management of third stage of labor Demonstrate basic neonatal resuscitative care Training organization Two lecture units Four practical sessions

Trainer demonstration Case study Simulated practice Neonatal resuscitation/partogram Evaluation of simulated practice Assisted vaginal delivery via vacuum extraction Unit 2: Labor assessment and vacuum extraction overview Refresher course for health care providers working in crisis settings

Background In a displaced population, approx. 4% of total population will be pregnant at any given time Maternal deaths: Estimated 289,000 in 2013 Lifetime risk of maternal death: Sub-Saharan Africa: 1 in 38 Oceania: 1 in 140 (PNG 1:35) Southern Asia: 1 in 200 North America: 1 in 10,000 61% of maternal deaths occur in fragile states, many of them affected by conflict and recurring

natural disasters Background Approximately 15% of pregnancies have an obstetric complication at the time of birth Approximately 8% of all maternal deaths are caused by obstructed labor 9-33/1000 babies die in the early neonatal period 25% of birth asphyxia Assisted vaginal delivery can avert maternal and perinatal morbidity and mortality

Signal functions of basic emergency obstetric and newborn care BASIC EmONC COMPREHENSIVE EmONC 1. Antibiotics IV/IM 2. Oxytocic Oxytocic drugs IV/IM

2. Drugs IV/IM 3. Anticonvulsants IV/IM 4. Manual removal of placenta 5. Manual vacuum aspiration of retained products of conception 6. Vacuum extraction 6. Vacuum extraction 7. Newborn resuscitation

8. Surgery, including cesarean section (CS) 9. Blood transfusion A laboring woman is in distress and youve been called to assess her: Check:

1. The status of the mother and the baby. 2. Are there signs of obstructed labor? 3. Is there an indication for vacuum extraction? 4. Is it a safe procedure to perform? 5. Is the proper equipment available? 6. Does the mother understands how you will help her? History Always check the history of the patient first Prior cesarean section? Prior vacuum? Health issues? Greet and reassure the patient, discuss why she has

come for care Check the partogram for progress and observations; particularly the progress of the 2nd stage so far Provide compassionate care be nice Partogram Partogram Physical Exam Contractions: frequency and duration

Normal contractions in the active phase of labor have a frequency of 3 in 10 minutes lasting for 45 seconds. Inadequate contractions should be stimulated/augmented with oxytocin infusion before vacuum extraction procedure is commenced. Abdominal examination Fundal height in cm Presenting part and level of the fetal head Fetal heartbeat Estimated size of baby Estimated amount of fluid

Pelvic examination Cervical dilatation Cervical effacement & application to presenting part Fetal head position and flexion Presence of caput and molding Cervical edema Descent/dilatation with and without a contraction Any signs of Obstructed Labor, Vulval edema, Bandyls ring, active phase of labor more than 20 hours Physical exam

Abdominal palpation for level of the head 0/5 Mola, G., Ed. 2010. Manual of Standard Managements in Obstetrics and Gynecology for Doctors, HEOs and Nurses in Papua New Guinea. 6th Edition Physical exam Degree of molding

Mild (+) Moderate (++) Severe (+++) Difficulty of vacuum extraction increases with amount of molding Vacca, A. 2009. Handbook of Vacuum Delivery in Obstetric Practice. 3rd Ed. Vacca Research. A laboring woman is in distress and

youve been called to assess her: Check: 1. The status of the mother and the baby 2. Are there signs of obstructed labor? 3. Is there an indication for vacuum extraction? 4. Is it a safe procedure to perform? 5. Is the proper equipment available? 6. Does the mother understands how you will help her? Activity Divide into pairs

Answer: What causes unsatisfactory progress of labor? What is the risk to the mother and baby? What are possible interventions? What promotes normal progress of labor? Contractions Irregular and weak Unsatisfactory progress of labor Contractions Regular and strong

Cervix False labor Inadequate uterine activity (Latent ) 4 cm (Active) 10 cm

(expulsive) Prolonged labour Latent phase (cervical dilatation < 4cm, > 8 hrs) Active phase (cervical dilatation 4 10 cm, > 12 hrs) Expulsive phase 20

Prolonged labor Inadequate uterine activity Malpresentation or malposition Cephalopelvic disproportion (CPD) A misfit between the fetal head and the pelvis True or relative Obstructed labor Insurmountable barrier preventing fetal descent Secondary arrest of dilatation and descent of presenting part, with large caput and molding +++

Assessment of your findings Is labor obstructed? Yes if: How long she has been in labor? How long have the membranes been ruptured in the ACTIVE phase of labor? >20 - 24hrs? > 12 hours? How long has she been pushing? What are the contractions like?

*In a primigravida, there is often secondary uterine inertia (i.e. the contractions were strong but have now become weak) Is there 1. vulvar edema 2. severe molding of the head 3. 2-3/5th head still above the brim 4. Bandyls ring after drainage of bladder 5. hematuria > 2-3 hours 2-3 / 10 min*

Check for signs of obstruction 1. 2. 3. 4. 5. Yes Yes Yes Yes Yes

Physical exam Signs of obstruction Vulvar edema Hematuria Images used with permission of Dr. Glen Mola Physical exam Bandls ring

Catheterize to empty the bladder. Leave catheter in place for transfer. Do not perform vacuum extraction unless the head is on the perineum.

Refer urgently for cesarean section or perforate the fetal head if the baby is dead. Used with permission of Dr. Glen Mola Plan if labor is obstructed: Ring for advice if possible Prepare for transfer for CS Explain to patient and family IV hydration Antibiotics if fever or membranes ruptured >18 hours

Analgesia if available Transport in left side-lying position Physical exam Check the fetal heart. Is the baby still alive? If the baby has died and labor is obstructed, then it is important to perforate the fetal head as soon as possible to prevent maternal complications (i.e. maternal death from ruptured uterus or obstetrical fistula formation) Plan if the baby has died:

Expedite delivery in the health center unless the patient can be immediately transferred to a higher level of care within an hour. Delay in helping the woman deliver can lead to maternal death from uterine rupture or permanent disability from obstetric fistula. To perforate the skull: 1. Make an incision by pushing sharp

scissors into the dead fetus head and opening and closing them widely a few times. 1 2 Used with permission of Dr. Miriam OConnor, FRANZCOG

2. Rotate the open scissors 90o, and open and close a few times . Used with permission of Dr. Glen Mola 3. Grasp the fetal skull (sides of the hole you have made) with toothed

grasping-forceps (volsellum, tenaculum, Kochers) 4. Apply traction during a contraction with the womans pushing efforts Used with permission of Dr. Glen Mola A laboring woman is in distress and youve been called to assess her:

Check: 1. The status of the mother and the baby 2. Are there signs of obstructed labor? 3. Is there an indication for vacuum extraction? 4. Is it a safe procedure to perform? 5. Is the proper equipment available? 6. Does the mother understand how you will help her? Plan if prolonged labor: Possible interventions depend on stage, cause, and condition of woman and fetus Supportive care

Labor augmentation: oxytocic drug Assisted vaginal delivery: vacuum extraction Symphysiotomy Cesarean section (CS) Plan if prolonged labor: Supportive care: Correct the correctable Hydration? Upright position? Full bladder? Does the woman understand what is happening? Is the baby ok? Contracting ok?

Urgency to deliver right now or not? Can I safely take time to deal with these? Plan if prolonged labor: Labor augmentation If the cervix is not dilating at 1 cm per hour, (i.e. partograph crossing action line), and There are no signs of obstructed labor Use oxytocic drug 2.5 units in 500 mL of normal saline, begin at 10 drops/minute Increase by 10 drops/minute every 30 minutes until good contractions (frequency 3 in 10 and duration of > 45 seconds)

Exercise extreme caution with oxytocin: Risk of uterine hyperstimulation causing uterine rupture or fetal distress Plan if prolonged labor: Assisted vaginal birth: Vacuum-assisted or vacuum extraction (VE) Forceps delivery is NOT recommended Vacuum extraction cannot solve all causes of prolonged labor Access to CS or symphysiotomy is essential in case of failed attempt of vacuum extraction

hy is it so important to keep the CS rate down? The risk of dying is greater with a CS than a vaginal birth in lowresource settings It is not possible to manage the longer term problems: increased risk of uterine rupture, placental implantation abnormalities (i.e. placenta previa percreta) For the next pregnancy there is often: No antenatal care No supervised labor and delivery No blood transfusion No anything available or accessible next time Then CS for this delivery will be VERY dangerous for the woman's future.

Vacuum-assisted birth Is designed to produce traction upon the fetal scalp and thereby Assists maternal expulsive efforts so that the mother can deliver vaginally Can assist the fetal head to flex so that autorotation can occur to facilitate vaginal birth, even when there is a malpresentation of the occiput Can fail to deliver the fetus, especially if the rules of the procedure are not followed Indications

Fetal Distress in second stage of labor that requires immediate delivery Fetal heart rate <100 or >180 bpm Thick green or black meconium in fluid Indications Maternal Failure to deliver spontaneously after appropriate 2nd stage management Need to shorten 2nd stage or pushing is contraindicated (maternal medical condition) Maternal exhaustion

There are no absolute indications. Always consider on a case-by-case basis. A laboring woman is in distress and youve been called to assess her: Check: 1. The status of the mother and the baby 2. Are there signs of obstructed labor? 3. Is there an indication for vacuum extraction? 4. Is it a safe procedure to perform? 5. Is the proper equipment available? 6. Does the mother understand how you will help her?

Prerequisites What are the prerequisites for vacuum extraction? Is the procedure safe to do at your facility with the present human resources? Prerequisites Exclude signs of obstruction Appropriate indication: maternal or fetal Adequate contraction pattern At least 3 in 10 minutes, lasting at least 45 seconds

Vertex presentation, at least 0 station No head palpable above the symphysis pubis Fetus at least 34 weeks gestation Cervix fully dilated Prerequisites Ruptured membranes Empty maternal bladder, catheter if needed Appropriate analgesia, as required usually, a local in the perineum is only needed Informed consent Knowledgeable healthn care provider Competent in vacuum-assisted birth

Instrument, its use, possible complications Adequate facilities and back-up available Absolute contraindications Non-vertex presentation (breech, face, brow) Unengaged vertex (i.e. more than 1/5 of head above the brim of the pelvis unless you specifically set the procedure up as a trial with capacity to proceed straight to CS or symphysiotomy if the trial fails) Incompletely dilated cervix (other than an anterior lip that you can push back to apply the cup)

Obstructed labor (unless the head is on the perineum) Relative contraindications Mid-pelvic station (1-2/5 of head still palpable above the brim of the pelvis) < 34 weeks gestation Competence of provider (inexperienced provider should only attempt the most straightforward and simple procedures) Availability of referral facility or senior person to provide backup

A laboring woman is in distress and youve been called to assess her: Check: 1. The status of the mother and the baby 2. Are there signs of obstructed labor? 3. Is there an indication for vacuum extraction? 4. Is it a safe procedure to perform? 5. Is the proper equipment available? 6. Does the mother understand how you will help her? Equipment

Single operator cup Conventional VE creates vacuum manually Narang Medical LTD Assistant Slide cups Metal or plastic hard cups are included in the Inter-agency RH kits.

The metal cup on the extreme left is an obsolete Malmstrom cup from the 1950s and has been superseded by cup that can be more easily placed over the flexion point (i.e. Bird anterior a posterior cups) Assisted vaginal delivery via vacuum extraction

Unit 3: Introductory knowledge for the vacuum extraction procedure Refresher course for health care providers working in crisis settings Anatomy of the fetal head World Health Organization. Managing complications in pregnancy and childbirth: A guide for midwives and doctors. Section 1 Clinical Principles. Anatomy of the fetal head Posterior fontanelle

Occipital bone Sagittal suture Parietal bone Anterior fontanelle Frontal bone World Health Organization. Managing complications in pregnancy and childbirth: A guide for midwives and doctors. Section 1 Clinical Principles. Fetal presentation during labor Early labor Fetal head enters the pelvis in the occiput

transverse position World Health Organization. Managing complications in pregnancy and childbirth: A guide for midwives and doctors. Section 1 - Clinical Principles. Fetal presentation during labor With descent Occiput rotates anteriorly (ROA or LOA) Occiput rotates anterior to the front (OA) (90% of the time this is

the case; 10% of the time occiput rotates posteriorly and this can cause delay in the 2nd stage) For anterior positions, further descent leads to more flexion; for posterior rotations, further descent can lead to deflexion World Health Organization. Managing complications in pregnancy and childbirth: A guide for midwives and doctors. Section 1 - Clinical Principles. Well-flexed vertex

position Optimal diameter for passing through the birth canal Sinciput Occiput World Health Organization. Managing complications in pregnancy and childbirth: A guide for midwives and doctors. Section 1 - Clinical Principles. Preparation for Vacuum Extraction Patient considerations

Check that the prerequisites for VE are present Explain to the woman how you are going to assist her to deliver, and obtain informed consent Ensure emotional support Provide emotional support and encouragement (an informed support person or midwife can serve this role) Preparation: Patient: Empty bladder, lithotomy position Device: Assembled correctly, functional vacuum Assistant: Available for support and fundal procedure Access to a higher level of care in case of failure Pre-requisites for

Vacuum Extraction Gestation >34 weeks, Cephalic presentation Strong contractions (Frequency = 3 in 10, Duration >45 seconds); strengthen contractions with oxytocin drip if contractions are not adequate Head is in the pelvis. No more than 1/5 palpable above the brim on bimanual palpation and vaginal station below spine Fully dilated cervix and empty bladder (drain with a catheter if bladder is not empty) Procedure

Check if the requirements/prequisites are present Locate the flexion point by palpating the fontanelle(s) of the fetal head Apply the cup up under the fetal head to the flexion point Create a vacuum; wait 2 minutes for chignon to form Apply traction only during a contraction in conjunction with maternal pushing efforts Flexion point What is it? Landmark for placement of the center of the vacuum cup

Proper placement of the cup on the flexion point promotes flexion, descent, and autorotation of fetal head during traction Flexion point Where is it? Over sagittal suture 3 cm anterior to the posterior fontanelle The anterior border of the cup should be at least 3 cm posterior to the anterior fontanelle

Flexion point How to locate: Identify the posterior fontanelle Move the finger 3 cm along the sagittal suture Note: the distance from flexion point to posterior fourchette the degree of lateral displacement of flexion point from midline axis of pelvis

Vacca, A. 2009. Handbook of Vacuum Delivery in Obstetric Practice. 3 rd Ed. Vacca Research. Flexion point: how to locate A: Left Occipito-Lateral B: Left Occipito-Posterior From Vacca. Choices with childbirth CD-Rom, Vacca Reseach, 2005 with permission Procedure

1. Locate the flexion point 2. Apply the cup to the flexion point: push the cup up under the head of the fetus the required distance to reach the flexion point (i.e. 5 cm in for anterior positions, 10 cm for posterior positions) 3. Create a vacuum 4. Apply traction only during a contraction in conjunction with maternal pushing efforts Apply the cup 1. Wait until there is no contraction 2. Part the labia with one

hand and insert the cup with the other 3. Push the cup underneath the fetal head onto the flexion point Photo credit: Tomo Watanabe, 2010. Used with permission of Dr. Glen Mola. Apply the cup 4. Hold the cup in place with the left hand and pump up the pressure with the right hand

OR Direct your assistant to create the vacuum with the pump (Bird) Photo credit: Tomo Watanabe, 2010. Used with permission of Dr. Glen Mola. Apply the cup Procedure 1. Locate the flexion point

2. Apply the cup to the flexion point 3. Create a vacuum and wait 2 minutes for the chignon to form inside the cup 4. Apply traction only during a contraction in conjunction with maternal pushing efforts Create a vacuum 1. First pump the vacuum to 20 kPa and check that no maternal tissue is caught under the edge of the cup 2. If no maternal tissue is caught under the cup, increase the pressure to 80 kPa (green area on the OmniCup scale)

3. Wait 2 minutes for a chignon to form under the cup so that it does not slip forward when you start pulling 4. If the pressure starts to fall, pump it back up so that it is always between 60 and 80 kPa until the procedure is over 5. Wait for the next contraction Photo credit: Tomo Watanabe, 2010. Procedure 1. Locate the flexion point 2. Apply the cup to the flexion point 3. Create a vacuum and wait 2 minutes for

the chignon to form inside the cup 4. Apply traction only during a contraction in conjunction with maternal pushing efforts Apply traction The non-pulling hand Index finger on scalp and thumb pressing on the cup This two finger grip detects progress, and Detects if the cup is lifting off of the head

Vacca, A. 2009. Handbook of Vacuum Delivery in Obstetric Practice. 3rd Ed. Vacca Research. First contraction/pull: downward First pull is downwards (toward the floor) during a contraction. May need a repeat downwards pull for the head to reach the pelvic floor Used with permission of Dr. Glen Mola.

The head should reach the perineum by the second or third pull Direction of pull when the head has reached the perineum (i.e. starting to bulge out of the introitus): is now outward Direct traction in horizontal plane when the fetal head has descended to the pelvic floor Make an episiotomy at this stage if required

Used with permission of Dr. Glen Mola. Routine episiotomy is not recommended Infiltrate with local anesthesia 3-4 cm mediolateral World Health Organization. 2007. Managing complications in pregnancy and childbirth: A guide for midwives and doctors. WHO.

Crowning phase of the delivery/pull: upward When the head is crowning, the correct direction of pull is now upwards; however, in most cases there is no longer any need to apply traction at this stage When the head is fully delivered, release the suction pressure Used with permission of Dr. Glen Mola. Safety measures

Never attempt vacuum extraction if not at least 3 contractions in 10 minutes lasting at least 45 seconds Never pull without a contraction Always push on the dome of the cup with your thumb (of your non-pulling hand) and place your index finger on the scalp next to the cup during traction to prevent cup detachment and assess slippage Delivery of the head should be slow and controlled, as conducted during normal birth, so as to avoid perineal tears and trauma Safety measures Halt guidelines

Reassess after One (1) pop-off Abandon procedure if If there is no progress with any pull or you have not been able to deliver the woman with 3-4 pulls Three (3) pop-offs Three (3) pulls over 3 contractions without descent to the perineum 30 minutes without achieving delivery

Safety measures if procedure has failed Stop the procedure: Turn off the oxytocin and put up IV of normal saline Roll the mother onto her left side

Analgesia Prepare to perform symphysiotomy* or refer urgently for cesarean *Perform symphysiotomy, depending on clinical skills Post-delivery care Maternal care Active management of 3rd stage of labor (AMTSL) Check for genital tract trauma and repair

Baby care Vigorously dry the skin of the baby with a nappy or towel, then ensure the baby is dry and warm Check the babys scalp Where is the chignon? Was cup on flexion point? Is there a subgaleal hemorrhage present? Check for sings of hypoxia or hypovolemia Complications Usually result from:

Not observing the conditions of cup application Continuing traction beyond the halt guidelines Maternal Tears to the cervix and vagina Fetal Innocuous scalp markings subgaleal hemorrhage > 30 mLs in size needs urgent resuscitation with normal saline drip (IV or intraosseous) Safety measures after delivery Be ready to prevent/manage PPH:

Risk factors: long second stage, big baby, febrile? Consider AMTSL and extra measures: Fundal massage for longer Consider IV oxytocin infusion for 2-4 hours Keep the bladder empty Consider insertion of misoprostol 3 tablets into the maternal rectum Innocuous scalp markings Chignon/ Caput

Fetal scalp findings that are not clinically significant Residual ring/ bruise 18 hours later Small laceration Photo credits: Dr. Aldo Vacca. Used with permission.

Cephalohematoma Vacca, A. 2009. Handbook of Vacuum Delivery in Obstetric Practice. 3rd Ed. Vacca Research. From Vacca. Choices with childbirth CD-Rom, Vacca Reseach, 2005 Subgaleal hemorrhage (SGH) SGH is d angerou s an d require

s imme treatme diate nt! Vacca, A. 2009. Handbook of Vacuum Delivery in Obstetric Practice. 3rd Ed. Vacca Research. Used with permission of Dr. Glen Mola. Subgaleal hemorrhage Treatment Immediate fluid resuscitation 100-200 mL normal saline (2-3x blood loss) Refer if IV or intraosseous access unavailable on site

02 via face mask (02 is not useful if the baby is hypovolemic / in shock fluid resuscitation is then required) Keep baby warm Important Clean instruments 1. 2. 3. 4. With brush under water Soak in 0.5% chlorine solution for 10 min

Sterilize relevant components of the equipment Reassemble and store under hygienic conditions Document Indications for the vacuum extraction Position and station of the fetal head at the start of the intervention Outcome of the intervention Mnemonic (A-J) A Address the patient

Ask for help Anesthesia Adequate pain relief Neonatal support B Bladder Empty maternal bladder C

Cervix Fully dilated, ruptured membranes D Determine Dystocia/obstruction Position of the head, station, pelvic adequacy Think possible shoulder dystocia

E Equipment ready Extractor ready Inspect vacuum cup, pump and tubing Check pressure Adapted or reprinted with permission from ALSO, Other Copyright American Academy of Family Physicians. All Rights Reserved. Mnemonic (A-J) F

Fontanelle Feel Place cup in proper relation to the posterior fontanelle Sweep (only relevant for anterior positions extraction) finger around cup to feel for and clear maternal tissue G Good strong traction H

Halt Only pull with contractions and maternal pushing effort, assistant helps with fundal pressure, follow the pelvic curve: always pull DOWNWARDS to begin with Traction between contractions If no progress with 3 pulls with 3 contractions If cup pops off 3 times No significant progress after 20 minutes I

Incision Consider episiotomy when head is crowning* J Jaw Remove vacuum when jaw is reachable or delivery is assured Adapted or reprinted with permission from ALSO, Other Copyright American Academy of Family Physicians. All Rights Reserved.

References PATH. Poster: Procedure for use of vacuum extractor in assisted vaginal delivery. Adapted from: World Health Organization (WHO)/Department of Reproductive Health and Research. Managing Complications in Pregnancy and Childbirth: a Guide for Midwives and Doctors. Geneva. WHO. 2010. Putta, Lakshmidevi and Jeanne Spencer. Assisted vaginal delivery using the vacuum extractor. American Family Physician, no 62. (September 2000): pp1316-20. WHO Images: http://hetv.org/resources/reproductive-health/impac/Clinical_Principles/Normal_labour_ C57_C76.html World Health Organization. Managing complications in pregnancy and childbirth: A guide for midwives and doctors. Geneva. 2007. Vacca, Aldo. Handbook of Vacuum Delivery in Obstetric Practice. 3rd ed. Brisbane. Vacca

Research. 2009. Primary Mothercare and Population, by King M and Mola GDL, Spiegl press 2002, University of Papua New Guinea Press (2nd Edition): [email protected] or [email protected]

Recently Viewed Presentations

  • Amino acidopathies: defects in amino acid metabolism

    Amino acidopathies: defects in amino acid metabolism

    Metabolic defects in amino acid metabolism. Inborn errors of metabolism are commonly caused by mutant genes that generally result in abnormal proteins, most often enzymes. The inherited defects may be expressed as a total loss of enzyme activity or as...
  • Serial Communication Interface (SCI)

    Serial Communication Interface (SCI)

    SCI module on the HCS12Billy Allen. The SCI Module communicates over PS1 (Tx) and PS0 (Rx). Writing to the SCI Data Registers transmits data over the Tx line. Incoming Rx data is automatically stored in the SCI Data Register. Flags...
  • MANE 4240 &amp; CIVL 4240 Introduction to Finite Elements

    MANE 4240 & CIVL 4240 Introduction to Finite Elements

    MANE 4240 & CIVL 4240 Introduction to Finite Elements Prof. Suvranu De Shape functions in 1D MANE 4240 & CIVL 4240 Introduction to Finite Elements Shape functions in 1D Reading assignment: Lecture notes, Logan 2.2, 3.1 Summary: Linear shape functions...
  • Chapter 3

    Chapter 3

    Use the contribution margin format. Suppose David anticipates sales of $2,800,000 next year because he expects African art to come into fashion. Calculate expected profit. The new level of fixed costs is $1,600,000. Why is it reasonable to think of...
  • Integration of Design and Control : Robustness and IMC control

    Integration of Design and Control : Robustness and IMC control

    Integration of Design and Control : Robust approach using MPC and PI controllers N. Chawankul, H. M. Budman and P. L. Douglas Department of Chemical Engineering
  • SALES T SALES TAXTHE FUTURE California Society of

    SALES T SALES TAXTHE FUTURE California Society of

    SALES T. SALES TAX…THE FUTURE. California Society of Municipal Finance Officers. February 21, 2013. Bob Champion - Founder and President of Champion Real Estate Company which since 1987, has worked with local jurisdictions to complete over 2 million square feet...
  • The ITU-T protocols developed for e-Health and protection

    The ITU-T protocols developed for e-Health and protection

    Summary Introduction The protocols developed by ITU-T E-Health protocol Architecture of e-Health X.th1 X.th2 to X.th6 Common Alerting Protocol Conclusion Introduction E-Health is an area rich and complex, so safety is an essential element in this type of technology because...
  • Photo-oxidation of 2-(1H-inden-1-ylidene)-1-methyl-1,2-dihydropyridine (IMDP) S. Cogan and Y.

    Photo-oxidation of 2-(1H-inden-1-ylidene)-1-methyl-1,2-dihydropyridine (IMDP) S. Cogan and Y.

    Figure 1: IMDP E-Z isomerization. Figure 4: IMDP experimental FTIR spectrum (top) E- and Z-Isomer IR calculated (B3LYP/cc-pVDZ) spectra (bottom) The reason for this unusual behavior is the fact that the electronic wavefunction (EWF) of this compound in the ground...