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Septra

Clarissa Jonas Diamantidis, MD

  • Associate Professor of Medicine
  • Associate Professor in Population Health Sciences

https://medicine.duke.edu/faculty/clarissa-jonas-diamantidis-md

What other parameters should we measure in wards Although we still do not fully understand the develop after major surgery? Although the all major surgery: numbers tend to vary after most types of surgery medicine lodge kansas cheap septra 480 mg amex, about oxygenating treatment cheap septra 480 mg on-line. Position and posture of the patient pain after surgery medications for bipolar generic septra 480 mg fast delivery, and for half of them treatment bulging disc cheap septra on line, the pain will be medications and grapefruit interactions purchase generic septra on-line. Blood pressure treatment 2 prostate cancer order 480 mg septra free shipping, pulse, and central venous pres good pain control, no matter how it is achieved, will sure, when indicated reduce the number of patients experiencing long-term. Constipation may be a problem after pro many patients in these countries can barely tolerate longed use of opioids, and mild laxatives like lactulose the euphoria, drowsiness, and other e? Some patients in poorly resourced coun Renal, bleeding, and other problems can be tries will not accept opioids postoperatively when giv worsened by the use of nonsteroidal anti-in? The drugs marked are not included nations with one another or with opioids and other an in that list but can be very useful. One of the new major developments phine and some other drugs mentioned in the text. Should very ill patients receive Local and regional anesthetics strong analgesics postoperatively? When pain is abolished, Opioids are the most useful in this group, but in some these patients may reveal their ?true blood pressure speci? Morphine causes his ?Coanalgesics tamine release, which may cause vasodilatation, but it is Drugs such as antidepressants and anticonvulsants are usually mild and bene? Intravenous steroids such as dexa prefer to see a patient struggling and showing signs of methasone are becoming more popular for use as anti life rather than pain free and sleeping quietly. Some tie emetics after surgery, but they have not been proven to up such patients to their beds when they are struggling. Others resort to sedatives and hypnotics, such as diaz epam or even chlorpromazine. Many patients are rest Nonpharmacological methods less because they have pain or a full bladder. Tese methods should be Is the pain threshold higher in used more whenever possible. They may, therefore, request more drugs cated about acute pain and its management in the and will be able to tolerate them better. Consent is not normally re ever, no respecter of race or class, and every individ quired except for experimental and research pur ual must be treated as unique. Intravenous, rectal, or oral routes can be used in an upward or How to organize pain management downward stepladder manner depending on the after major surgery circumstances. Pain relief may require the barest mini an important role in any acute pain service and mum of sta? Such equipment, and good monitoring are essential in guidelines help countries, especially those with the least all institutions where major surgery is done. Optimum monitoring of the patient should in ward rounds, run emergency services for com clude equipment for respiratory monitoring, in plications, carry out research, and conduct audits cluding pulse oximetry and cardiovascular moni on pain management. Simple sedation ob service with guidelines and protocols to cover servation charts and early warning charts for ad children and adults in accident and emergency verse events will help manage even the most dif wards, operating rooms, and recovery wards as? Relying on the cases because systemic analgesic drugs may mask symp sympathetic responses caused by pain to arti? Local and re especially in high-risk patients after major sur gional anesthetic blocks are grossly underused. Deep vein thrombosis, bleeding, and other hema ingly used for continuous, patient-controlled, or tological problems a? Women may seem to tolerate pain better than ability of these pumps should improve sooner or men, but this is not a general rule. However, if doses are severe pain, pyloric and bowel surgery with moderate titrated carefully to the desired e? Intrathecal and epidural local anesthetics with and some valve repairs and closure of congenital mal opioids are commonly used. Ac severe pain, craniotomy and resection of brain tumors etaminophen and dipyrine, if they are not contraindi with moderate pain, trauma and skull fractures with cated, will help with the pain and the pyrexia seen in moderate pain) septic patients. Large doses of opioids can cause hypoventilation and increase intracranial pressure. International and national drug regulatory bodies problems and should be planned and practiced in partnership with governments and local sup with clear written guidelines and protocols. Public perceptions of postoperative pain and its should be made to provide enough funds to im relief. Drug policies and control, including essential drugs list Guide to Pain Management in Low-Resource Settings Chapter 15 Acute Trauma and Preoperative Pain O. Aisuodionoe-Shadrach When acute trauma occurs, the diagnosis and purposeful ries that may pose a potential danger to life besides the management of pain should be of paramount concern. The doctor admin of a saloon car without any splint to his injured leg isters 50 mg of pethidine (meperidine) intramuscularly and had jolts of pain every time the car stopped on its. John is received by Dr Omoyemen, the attend tetanus toxoid is administered to prevent tetanus. Finally, while John is awaiting formal orthopedic Fracture immobilization on its own minimizes pain surgical review, his pain is reassessed regularly to deter due to the fracture injury by limiting movement of the mine the e? He is fully conscious, knows who he is, and their probable answers and is well oriented as to time and place. Dr Omoyemen obtains a brief caused by an infection, injury, or the progression of a history of the nature of the accident and proceeds to metabolic dysfunction or a degenerative condition. This material may be used for educational 115 and training purposes with proper citation of the source. Aisuodionoe-Shadrach several assessment tools have been designed to objec Although the multidimensional pain scale was tively measure it. Pain has multiple dimensions with developed for pain research, it can be adapted for use in several descriptions of its qualities, and its perception the clinic. This response could limit recovery from sur acute trauma and preoperative setting? Pain is not merely a clinical symptom but evi Furthermore, the sources of pain in acute trau dence of an underlying pathology. In the acute trauma ma and preoperative settings are mostly of deep somatic and preoperative setting, there is a temptation to over and visceral origin, as may occur in road tra? The in the acute trauma and preoperative settings is usually challenge is to help the health professional realize that the caused by a combination of various stimuli: mechanical, management of both symptoms (pain) and underlying thermal, and chemical. Tese stimuli cause the release pathology (acute appendicitis) should go hand in hand. Is pain an important issue to the patient who is Because of its complex subjectivity, pain is di? Freedom from pain can be considered a human However, a number of assessment tools have been de right. As fanciful as that may seem, it must be empha veloped and standardized to identify the type of pain, sized that pain is a natural accompaniment of acute quantify the intensity of pain, and evaluate the e? A pain scale may be either one-dimensional or mul In a study conducted at an accident and emer tidimensional. In the acute trauma/preoperative setting, gency room department of a university hospital in sub where the cause of pain is obvious and pain is expected Saharan Africa, 77% of patients who had preoperative to resolve more or less promptly, one-dimensional scales analgesia considered the analgesic dosage inadequate, are recommended. Often, paying attention to adequate analgesic tively impaired, and persons with language barriers. Nonpharmacological treatments may be helpful a fractured limb, the patient does not know the diagno but should not preclude drug treatment. Unrelieved pain may have negative physical and management of pain be instituted in the acute psychological consequences. Successful evaluation and management of pain treatment are to relieve pain as quickly as possible and is partly dependent on a positive relationship be prevent any adverse physical and psychological respons tween the patient and his or her relatives on the es to acute pain. Don?t believe that the ability to tolerate pain is a nurses play in ensuring that patients in this measure of ?manhood. It may not be practical to expect patients in the degree of pain using the following methodical ap acute trauma/preoperative setting to be absolute proaches: ly pain-free. Tropical Doctor odic intervals by the attending health professional with 2006;36:35?6. Preventing the development of chronic to the application of hot or cold compresses as needed. Avoid misconceptions and recognize culturally Pain: current understanding of assessment, management, and treatments. National Pharmaceutical Council and Joint Commission on Accredi tation of Healthcare Organizations. The perioperative period was uneventful, and the child (accompanied by his moth er) was discharged home, fully awake and comfortable Why is analgesia for minor about 5 hours after the procedure with a prescription surgical procedures a topic of oral paracetamol (acetaminophen). The mother In this section, I will explain why pain may be a com gave him the prescribed analgesic, but the pain per mon and signi? It is obvious that there are various options ing, not only to the patient but often to the whole house for providing e? For our illustrative case above, an example of a typical pharmacological analgesia therapy can be as fol What is minor surgery? Minor surgical procedures anesthetic is administered after induction of anesthe now constitute the majority of procedures carried out sia. This material may be used for educational 119 and training purposes with proper citation of the source. Gen respiratory depressant and sedative effects of erally, more than half or even two-thirds of all surgical opioid drugs outside of immediate supervised cases in health care facilities are usually considered mi medical care. Patients are often very anxious and dis criteria for selection for outpatient surgery is that pain tressed by the hospital and procedure experience, and should be minimal or easily treatable. For the same type of surgical procedure, pliance with the analgesic administration regimen. Unfortunately, when the patient is discharged, What factors lead to poor pain the intensity or continuity of pain care is disrupted. The pain of surgery often outlasts the pain medication or lo control after minor surgery? Contributory factors to poor postoperative pain control To avoid this problem, administer the? The pressures of current ambulatory surgical Preemptive analgesia implies that giving analgesia be practices, which emphasize rapid recovery and fore the noxious stimulus is more e? While this con sulting in anesthesia care givers and surgeons cept has not been convincingly proven in all clinical avoiding or minimizing the perioperative use of studies, what is clear is that more analgesia is often re potent and longer-lasting analgesics and sedatives quired to treat pain that is already established than to that may delay recovery and discharge. One Pain Management in Ambulatory/Day Surgery 121 should therefore aim to preempt or prevent pain if pos An often forgotten or neglected part of the sible or proactively treat pain as early as possible. Psychological and physical therapies comple Avoid analgesic gaps ment medications and should be used whenever possi Analgesic gaps subject the patient to recurring pain and ble. Such gaps tend to occur when ing painful areas, application of cold or hot compresses, the e? Psychological therapies in An appropriate dosing interval based on knowledge of clude behavioral and cognitive coping strategies such the pharmacology of the agent is important to minimize as psychological support and reassurance, guided imag this gap. Studies suggest Apply a multimodal analgesia strategy that these nonpharmacological therapies improve pain Multimodal analgesia implies the use of several analge scores and reduce analgesic consumption. In other intraoperative anesthetic requirements and facili words, the combination provides better analgesia than tate earlier recovery and discharge. Preven cially the long-acting ones like morphine and metha tion is better than cure. Much larger amounts of done, should preferably be avoided or used sparingly as an analgesic are required to treat established pain postoperative analgesics for minor surgery because of than to prevent it. J Anaesth 2001;87:73?87 in the analgesic ladder between the mild non-opioid [3] Shnaider I, Chung F. Tears at bedtime: a pitfall of extending paediatric day-case surgery without extending analgesia. Guide to Pain Management in Low-Resource Settings Chapter 17 Pharmacological Management of Pain in Obstetrics Katarina Jankovic Case report Systemic administration includes the intravenous, in tramuscular, and inhalation routes. As an example, an abnormal fetal pre patients in whom regional techniques are contraindicat sentation, such as occiput posterior, is associated with ed. What are the application routes A systematic review of randomized trials of for analgesia if needed? This material may be used for educational 123 and training purposes with proper citation of the source. Interest respiratory depression in the neonate is the primary ingly, midwifes have rated pethidine much better than reason for selecting a particular opioid. Regarding this parturients, probably because sedation was confused potential, pethidine (meperidine) may be preferred over with analgesia. Tese opioids If an anesthesiologist is not available, pethidine (me are not ?pure agonists of the mu-receptor, but mixed peridine) is usually the drug of choice. It remains the agonists and antagonists, which is the reason for their best investigated and most often used opioid in labor. The dose of pethidine commonly prescribed is 1 mg/ However, as with other opioids, respiratory kg i. To achieve tramuscular route is not recommended because it is that outcome in the neonate, it is recommended to not dependable?the rate of drug-absorption may vary. Higher doses have to teaching is that the neonate should be delivered within be strictly avoided, since pethidine may provoke sei 1 hour or more than 4 hours after the last pethidine zures. Pentazocine should not be used because of its Opioids cross the placenta and may a? This potential to cause dysphoria and sympathetic stimula is manifested in utero by changes in fetal heart rate pat tion. But ideally, naloxone?as most drugs in breastfeeding, but lack of data makes it advisable to pain management, should be titrated intravenously to rely on individual judgment, if only a limited number of its e? Breast-feeding during maternal treatment with If I have various opioids available, which one I paracetamol (acetaminophen) should be regarded as would choose, and why?

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However treatment definition 480mg septra visa, this assumption can only be made under the circumstance that the extractions are performed according to safe practice medicine 666 colds order septra 480mg with visa. Future research on preventive actions treatment for piles septra 480mg without a prescription, such as ultrasound assessment of fetal lie prior the extraction medicine holder generic septra 480 mg visa, the effect of oxytocin symptoms zoloft withdrawal buy genuine septra on line, and operator experience medicine pacifier septra 480mg with visa, needs further inverstigation. Utav dessa barn sa fods ca 8 % (7000 barn/ar) med hjalp utav en sa kallad vakumextraktion, i dagligt tal aven kallad for sugklocka. Forstfoderskor foder oftare med hjalp utav en sugklocka (14 %) jamfort med omfoderskor (3 %). Sugklockan ar ett instrument som anvands i slutet av forlossningen for att snabba pa forlossningen antingen pa grund av att barnet visar tecken pa syrebrist eller att kvinnan medicinska skal inte bor krysta ut barnet pa egen hand eller om forlossningsvarkarna ar for svaga och forlossningen gar for langsamt(varksvaghet). Alternativ till att anvanda en sugklocka ar antingen att forlosa med en tang eller att utfora ett akut kejsarsnitt. De tva absolut vanligaste orsakerna till forlossning med sugklocka ar hotande eller misstankt syrebrist hos barnet eller varksvaghet. Den moderna sugklockan som anvands idag uppfanns pa femtiotalet av den svenska obstetrikern Tage Malmstrom som ett alternativ till forlossningstangen, eftersom tangforlossning var forenat med stora vaginal bristningar. Sugklockan blev snabbt popular i Sverige och anvands idag over stora delar av varlden. Sugklockan bestar av en rund kopp av metall, hard plast eller silikon och pa denna kopp finns det en kedja med handtag samt en slang (v. Tekniken innebar att operatoren lagger pa klockan pa barnets huvud pa en speciell punkt som heter flexion point (v. I och med detta undertryck sa kommer barnets hud och skalp att sugas fast i klockan. Nar klockan sitter fast sa kan obstetrikern eller barnmorskan dra i handtaget samtidigt som kvinnan far en vark och krystar. Att foda eller fodas med hjalp utav en sugklocka ar inte riskfritt for kvinnan eller barnet. For barnet finns en okad risk for blamarken och svullnad pa skalpen, blodningar under skalpen sa kallade kefal hematom och subgalealhematom, intrakraniella blodningar, plexus skador, retinala blodningar och lag Apgar. Om forlossning med sugklocka ar farligt for barnet pa langre sikt ar annu inte klarlagt. Orsaker till komplikationer i samband med sugklocka ar relaterat till kvinnans, forlossningens och barnets status fore extraktionen men aven till hur klockan anvands. Eftersom en forlossning med sugklocka innebar en risk for stora bristningar och aven en negativ forlossningsupplevelse sa rekommenderas ofta att kvinnan ska fa adekvat smartlindring infor forlossningen. Adekvat smartlindring anses vara epidural eller spinal bedovning, pudendusblockad eller om en utgangsklocka anlaggs infiltration av perineum. Innan en sugklocka anvands sa maste ett flertal bedomningar goras for att avgora om sugklocka ar den mest lampliga metoden att forlosa kvinnan och barnet. Krav som ska uppfyllas enligt riktlinjen fran Svensk Forening for Obstetrik och Gynekologi ar:? Indikation: hotande foster asfyxi, varksvaghet, kontraindikation for krystning, uttrottad moder. Ibland sa misslyckas sugklockan och barnet maste forlosas med hjalp av en annan metod, antigen ett akut kejsarsnitt eller med hjalp utav en tang. Hur vanligt det ar med misslyckad sugklocka i Sverige och om en misslyckad sugklocka innebar en okad risk for barnet ar inte kant. Syfte: Trots att forlossning med sugklocka ar en vanlig metod i Sverige sa finns det relativt sett lite forskning gjord inom detta omrade. Denna avhandling ar en del utav ett storre forskningsprojekt som syftar till att kartlagga denna forlossning med sugklocka ur ett flertal aspekter. Att kartlagga hur sugklockan anvands i Sverige med fokus pa teknik samt att jamfora handlaggandet med rekommendationer i lokala riktlinjer pa forlossning med sugklocka (Studie I). I den forsta delstudien granskades 596 journaler pa kvinnor som hade fott med hjalp utav en sugklocka under 2013. Vi samlade in data fran 6 olika sjukhus och varje sjukhus bidrog med data pa 100 forlossningar. Vi samlade in data fran den dokumentationsmall som anvands i Obstetrix for att dokumentera forlossning med sugklocka. Vi samlade in data pa: indikation, gestationsalder, antal dragningar, val av klocka, extraktionstid, antal klockslapp, episiotomi, station i backenet, bjudning och yttre press. Vi samlade aven in aktuella riktlinjer pa forlossning med sugklocka fran varje deltagande klinik. Indikation varksvaghet var den vanligaste bland forstfoderskor och hotande fosterasfyxi bland omfoderskor. De flesta barn forlostes med mindre an 4 dragningar (60 %), utan nagot klockslapp (84 %) och inom 15 minuter (91 %). Majoriteten av alla klockor anlades fran en medelhog station (75 %) och 14 stycken anlades fran en hog station (2,3 %). Operatoren gjorde en episiotomi pa 16 % av alla kvinnor och yttre press anvandes i 11 %. Nasta alla klockor utfordes av en lakare och endast 2,7 % utfordes av en barnmorska. Innehallet i de sex riktlinjerna som granskades var delvis bristfalligt och varierade gallande innehall, definitioner och omfattning. Station i backenet beskrevs i tre utav sex riktlinjer och i dessa tre sa definierades en hog klocka olika. I tva riktlinjer ansags en hog klocka foreligga nar barnets huvud stod vid spinae och i en nar barnets huvud stod ovan spinae. Totalt inkluderades 62 568 kvinnor forlosta med sugklocka i fullgangen tid mellan aren 1998-2008. Vi samlade in data pa olika metoder att smartlindra under en forlossning med sugklocka (epidural blockad, spinal blockad, pudendusblockad och infiltration av perineum) samt andra variabler som kunde utgora en riskfaktor for att fa eller inte fa smartlindring t. Vara resultat i studie I visade att var tredje kvinna blir forlost med en 36 sugklocka utan adekvat smartlindring. Utan adekvat smartlindring menas i detta fall att kvinnan forlostes med sugklocka utan en epidural, spinal eller pudendusblockad. Det var vanligare att omfoderskor inte fick bedovning (ca 50 %) an forstfoderskor (ca 30 %). Nar enbart utgangsklockor granskades och infiltration av perineum inkluderades som adekvat smartlindring var det fortfarande var tredje omfoderska som forlostes utan smartlindring och 15 % av alla forstfoderskor. Riskfaktorer for att forlosas utan smartlindring var framforallt om kvinnan var omfoderska, om det var en utgangsklocka eller om indikationen var hotande fosterasfyxi. Vi samlade in data pa olika graviditetsvariabler och forlossningsvariabler samt fyra olika neonatala diagnoser; lag Apgar < 7 vid fem minuters alder, kramper, subgaleala hematom och intrakraniell blodning. Totalt var det 88 418 forlossningar med sugklocka som identifierades och utav dessa misslyckades 4747 st. Fran 1990 till 2010 okade andelen misslyckade sugklockor med 0,5 % fran 4,9 % till 5,4 %. De flesta, 74 %, utav dessa misslyckade sugklockor avslutades med ett akut kejsarsnitt. Utav dessa 26 % misslyckades tangen i 16 % (198 st) och ett slutgiltigt kejsarsnitt fick anvandas. Riskfaktorer for att misslyckas med sugklockan var framst om barnets huvud lag i vidoppen bjudning eller nagon annan avvikande bjudning. Om barnets huvud stod ovan backenbotten sa utgjorde det en risk for misslyckad klocka jamfort med om huvudet hade trangt ner mot backenbotten. Forstfoderskor hade hogre risk for misslyckad klocka jamfort med omfoderskor och korta kvinnor hade hogre risk an langa kvinnor. Barn som forlostes med antingen en tang eller ett kejsarsnitt efter en misslyckad sugklocka hade en sjufaldigt okad risk for att drabbas av ett subgalealt hematom, nastan dubbelt okad risk for kramper och mer an dubbelt sa hog risk for lag Apgar vid fem minuters alder. Det fanns ingen okad risk for intrakraniella blodningar bland barn dar sugklockan misslyckade jamfort med barn som forlostes med en lyckad sugklocka. Kognition mattes i termer av resultatet pa det nationella provet i matematik och det sammanvagda slutbetyget i nionde klass. Alla barn som foddes mellan 1990-1993 i huvudbjudning av en svenskfodd mor utan nagon allvarlig missbildning och som foddes i graviditetsvecka > 33 identifierades i Medicinska fodelseregistret. Den slutgiltiga studiepopulationen bestod av 126,032 barn som grupperades utifran forlossningsatt; spontan vaginal(referens), sugklocka, akut kejsarsnitt, planerat kejsarsnitt och dubbla forlossningsatt (sugklocka + kejsarsnitt). Alla dessa barn foljdes sedan upp i ett register som har information om grundskolebetyg. Information om barnets slutbetyg i matematik baserat pa nationella prov samt slutgiltigt meritvarde samlades in. Barn som forlostes med sugklocka hade statistiskt 37 signifikant lagre medel betyg i matematik och meritvarde i nionde klass jamfort med barn som foddes helt normalt. Barn forlosta med ett akut kejsarsnitt hade ocksa nagot lagre betyg jamfort med barn som foddes spontant vaginalt (matematik 0,51 och meritvarde 1,20). Sammanfattning: De allra flesta forlossningar med sugklockor utfors i enlighet med sakert handlaggande. I ett fatal fall anvandes dock ett potentiellt riskfyllt handlaggande sasom, manga dragningar och lang extraktionstid samt att sugklockan anlades nar fostrets huvud stod ovan spinae (hog station). Att anlagga en klocka pa en hog station anses vara en kontraindikation for sugklocka. Vara resultat pekar at att det finns forbattringar som kan goras i klinik for att oka patientsakerheten i samband med forlossning med sugklocka. Lokala skriftliga riktlinjer pa forlossning med sugklocka bor ocksa revideras och uppdateras i samband med detta forbattringsarbete. Forutom uppdaterade riktlinjer bor forlossningskliniker granska hur forlossningar med sugklocka genomfors pa lokal niva och aterkoppa detta till berord personal for att undvika potentiellt farliga extraktioner. Kvinnor far i hog utstrackning inte den smartlindringen som rekommenderas infor en forlossning med sugklocka och forbattringar kan goras. Anvandning av pudendusblockad och infiltration av perineum bor forbattras och aven utvarderas i framtida studier. Misslyckad sugklocka innebar en okad risk for kramper subgaleala hematom och lag Apgar hos barnet. Riskfaktorer for en misslyckad sugklocka som tex avvikande bjudning, fosterhuvud ovan backenbotten och kvinnans langd gar att bedoma innan klockan anlaggs. Denna riskbedomning bor vagleda vem som ar bast lampad att genomfora sugklockan eller om ett annat forlossningssatt ska anvandas. Det verkar som om ett akut kejsarsnitt ar den sakraste metoden for barnet efter en misslyckad sugklocka. Vad det ar som utgor den okade risken for barnet i samband med en misslyckad sugklocka (t. Forlossning med sugklocka paverkar barnets kognitiva utveckling matt i termer av skolbetyg marginellt. Eftersom bade barn forlosta med sugklocka och ett akut kejsarsnitt hade lagre betyg an barn fodda med en spontan vaginal fodsel sa talar detta for att det snarare ar orsaken till val av forlossningsmetod som orsakar denna sankning i betyg an sjalva metoden i sig. Dessutom kan denna marginella sankning av betyg anses vara sa liten att det inte ar troligt att det kommer att paverka barnets framtida kognitiva formagor. I especially want to thank the following people: Cecilia Ekeus, my main supervisor. Ever since I was a midwifery student, I have admired your enthusiasm and interest in research. You introduced me to the world of epidemiology with kindness and patience, and for this I am ever so grateful. We have worked together on the labor ward and on two different research projects for almost 10 years. You have taught me so much, both clinical practice, excellent team work and how to conduct good clinical research. In times of doubt and even despair, you have been a fantastic support and succeed in making research clear and comprehensive for me. You have called me on the phone practically every day, making me feel like one of the most important people on earth. I am very grateful that I have gotten to know you, and you are today one of my closest friends. Anna Hjelmsted and Margareta Hammarstrom, former Heads at Karolinska Institutet and Sodersjukhuset. Thank you for giving me the opportunity to work as a clinical teacher, doctoral student, and midwife on the labor ward at the same time. Without your support, both in terms of time and different work solutions, this thesis would not have been done. Each time I work with you, I am reminded that midwives are absolutely wonderful, hilarious, and utterly beautiful people. Eva Nissen, Ulla Waldenstrom, Barbro Hedman, Charlotte Ovesen, Helena Lindgren, Vibke Jonas, Mia Barimani, Erica Schytt, Linda Vixner, Sofia Swedberg, Colleagues at the Department of Reproductive Health. See you all again soon and good luck with your research and all the midwifery students. Tekla Lind, Katarina Remeaus and Maria Bruzelius, new friends at the research school. Erika, Julia, Ebba, and Ingrid, jag ar den lyckligaste mamman i hela varlden och jag alskar er oandligt. The studies in this thesis were supported by: the Swedish Research Council, Stockholm County Council, Kvinnokliniken Sodersjukhuset and the Division of Reproductive Health. Vacuum-assisted deliveries and the risk of obstetric anal sphincter injuries-a retrospective register-based study in Finland. Vacuum assisted birth and risk for cerebral complications in term newborn infants: a population-based cohort study. Quality of obstetric care in the sparsely populated sub-arctic area of Norway 2009-2011.

Provide space at the counter for a butcher paper holder and an art waxer (a piece 7 medicine omeprazole 20mg buy septra without a prescription. It is appropriate to position tables and work surfaces adjacent from each at either end of the center medications not to crush order septra 480 mg, are recommended medications to treat anxiety 480mg septra otc. Toilets should be accessible from one adult medicine expiration order septra 480mg on line, although there should also be a group gathering area treatment 4 lung cancer buy generic septra 480mg line. Recommended finishes include there need to be ?get away areas (alcove like) so children can be by impervious flooring such as linoleum and painted walls above an impervious themselves or in smaller groups treatment efficacy cheap septra on line. One adult toilet should be located in or near the infant and young convenient bins for recycling, at the least, suitable waste paper. Adult Major classroom elements will remain fixed, such as those requiring toilets should be provided with toilet seat cover dispensers. The classroom should provide flexibility for storage of curriculum materials and supplies and for storage of resource these activities. Limited areas of mirrored ceiling tiles, especially about infant areas are desirable. Where low shelves and partitions are used to separate use areas, they must be secured against tipping. A mixed z Classroom and teacher storage age classroom typically provides all elements needed for each age group. Where this is not possible, the classroom must ?borrow the maximum amount of natural z Cot storage light from areas that are located along an exterior wall which has windows. Classrooms require direct access to the central circulation system and as School-Age Classroom: direct as possible to the play yards. Infants and young toddlers must have classrooms z Entrance separate from other age groups. If windows are used they should also be located to allow z Visual separation adult supervision of the areas. General design principles include: z Separate classrooms: Groups of children must be physically sepa z Discreet functional areas need to be planned in the design of the class rated from each other. Sound transmission between classrooms should room even though they will be created primarily with furniture. High noise levels from adjoining z the circulation from equipment such as slides needs to flow away from classroom spaces can disrupt class activities and raise tension levels. Some noise transmission is desirable to allow children to be aware of z Block play is an essential activity and areas must be provided where other groups. Small, strategically placed windows between classrooms blocks can remain in position for more than a day. This means it must is recommended, to allow children the opportunity to view other class be protected from main circulation paths and active play. Placement of windows should not interfer with potential z Do not encumber the space with more tables than necessary for meal placement of classroom furniture. In terms of using the not feasible, at least one window at child and adult level should be pro minimum amount of circulation space, rectilinear tables arranged with grammed. Door locks, light switches, fire alarm and toileting/diapering areas must be clearly separated to diminish the pull stations, and other functional elements should retain adult scale and chance that a caregiver could inadvertently go directly from diapering to be mounted at standard heights. Partitions with vision panels spaces, and other areas of the center used by adults should remain at can be used effectively for this purpose to separate these areas while standard scale. In placing electrical/telecommunication or security equipment, ensure that cords and wire are not placed in such a 7. While the architectural form of the classroom should be an appropriate setting areas of high ceilings in a classroom may be desirable, in spaces which for a child, conveying a definite sense of place while preserving optimal the child perceives as too high to have a residential character (85% of flexibility, with the great majority of the space free of constructed elements. Higher activity levels are often encouraged by hung at no lower than 2285 mm above the occupied floor area below. The probability of higher construction costs must be consid long as headroom is not required for passage. In addition, this provides the opportunity and use up valuable open floor space when they become too large. When used effectively, level changes add interest and create intimate areas Window sills and counters used by children should be child height, for children. Terraces and platforms provide areas for socio-dramatic depending upon the age of the child using the space. Lofts that can mm beneath widow sills (measured to the classroom finish floor) so that accommodate 3-5 children can offer children many possible activities, furniture and equipment can be placed easily along exterior walls. The designer must keep in mind that low level changes can sometimes be a tripping hazard. Furnishings and equipment for children should be child-scaled, such as z Vary wall configurations: Consider modulating partitions to create toilets, hand-washing sinks, and countertops. Countertop height and reach interest, soften a space, to create a more nurturing impression, or to depth should provide children with the opportunities to use them unassisted. The designer z Provide visibility to the staff: Teachers must have an unrestricted must keep in mind that visibility of all areas within the classroom is a key view of the children at all times, both within the classroom and in the factor, so avoid creating ?blind areas that would make teacher supervi play yards. Any interior doors, with the exception of adult and z Locate plumbing fixtures in one area: Elements with plumbing con school-age toilet areas, must have visibility panels. Dutch doors are not nections, such as toilet areas and art sinks, should be grouped together recommended as they pose a hazard for finger pinching. Food preparation must and interior glazing allow visual supervision and allow children to be be separated from diapering and toilet areas, though it can be placed on aware of others in the center. Partitioning at the sides of toileting areas the opposite side of partitions with plumbing. Include devices for display of artwork that do not involve tacks There must be gates with view panels in infant and toddler classrooms to (because they are dangerous around young children) and tape (because prevent children from accessing kitchen and diaper areas. Zone high-activity areas, such as the features such as low partitions in back of cubbies to create the nurturing entrance, eating/table areas, and the exit to the play yard, away from corner spaces. Likewise ?messy ar z Provide natural light: the successful use of natural light benefits cen eas and ?clean areas should be considered by the designer and zoned ters by reducing total energy use for lighting while improving the indoor to provide appropriate separation. Data from two studies on school en vironments, which have similar characteristics to child care centers, Figure 7. Views to atria and planters, common spaces, other classrooms, and circulating pathways also are of benefit. These purchased cubbies are typically approximately 305 mm wide, 305 mm deep, and 455 mm high. The Parents may wish to leave collapsible umbrella strollers or other child entrance must meet all emergency egress requirements. Rods for this purpose classroom entrance, either to the main circulation path or to the play yards, should be provided here or near the reception area, but screened to avoid should be considered and may be required for egress, depending on center the appearence of clutter. Place the entrance along a wall, leaving valuable corners every five children and install at approximately 1370 mm to 1525 mm above available for activity areas. If a double storage rod is needed, install the top rod at about main circulation area to classrooms. Near the classroom door, there must 2130 mm and the bottom rod at about 1065 mm above the floor. Provide a be a sign-in counter (with storage below) at approximately 845 mm above retaining rail to keep the lower ends of the strollers in place. They may again need their outdoor backpacks used by children to carry personal items. Satchels and clothing at times during the day to go to the play yard or on excursions and backpacks may be stored on hooks. Parents may linger in the cubby alcove, spending time with properly stored for temperature maintenance and should not be stored in their children or with teachers or other parents. Arrange cubbies in a ?cloak room arrangement so Cubbies for this classroom should be a minimum of 305 mm wide, 305 as not to take up valuable classroom wall space. Two hooks are needed in each compartment areas must include these features: for hanging garments, and a shelf should be included for boxes, boots, or z Compartmentalized open-front, scaled to child size, per child. The bench in this area should be about 255 mm high for z Cubby storage units secured to the floor and wall to prevent tipping children to sit on while putting on their outdoor clothing and boots. These lockers may z A parent bulletin board, locked tuition drop box, and parent mail box be stacked two high if space is limited. The open compartments should be (located at the cubby area or in the reception area). It is also convenient to include a shelf for child safety seats, if Each classroom must have an open, unrestricted activity area, clear of space allows. The design must coordinate with ever-changing response to their needs and activities. The required space allotment along walls to particularly serve counter areas), for items such as ra for this area is found in Chapter 5. Locate out lets for this kind of equipment,at a height of 1370 mm above the finished Requirements for appropriate activities occurring within this space will vary floor so that children cannot access the outlet or pull equipment off of according to the age of the children. Categories of play activities counters by using cords connected to low-mounted outlets. Refer to Chap z Manipulatives with small puzzles and finger toys ter 8 for a complete list of furniture, equipment, and applicable criteria. These may be strips placed at approximately 1000 mm to as z Science, including nature study high as 1370 mm above the finished floor. Locate the open activity area within the classroom to take full advantage of natural light. The design should the infant open activity area offers all the opportunities for discovery and encourage traffic pathways that avoid disruption and do not pass through learning. This area must be a safe, soft, ?print rich, stimulating environment activity areas. Wall or partition patterns with offsets will allow for more in which babies can crawl, explore, and interact with their teachers. Preserve corner areas which provide natural boundaries to set apart Provide the following architectural features in the infant classroom: an activity area. This should be a soft, cushioned space with a Include the following architectural features in the open activity area for variety of textures and coverings made from textile materials that can each age classroom: be easily removed for regular cleaning. Level changes should be slight z Acoustically treat surfaces as required to reduce noise. This should be a z Supplement natural light with energy efficient, full-spectrum lighting, soft, cushioned space with a variety of textures and coverings. Provide a 13 mm radius or beveled edge on all outside corners closed platform height accessed by padded level changes is 455 mm of constructed features and a 25 mm rounded outside corner drywall above the floor. Consider a counter at a portion of the window area for growing plants and conducting nature studies. These can be constructed with low, permanent, soft barriers, or troughs with nearby hooks for smocks and towels. Art sinks shall be provided for older toddlers ror material must be shatterproof: safety glass, acrylic, or reflective metal. Floors that are not padded shall be a material activities, and their level of skills enables them to take part in more advanced tile, linoleum, or wood in order to be mopped and sanitized daily. Soft activities, requiring a greater number of interest areas configured for small areas can be provided using area rugs, floor mats, etc. Provide the following architectural features have anti-slip surfaces to prevent accidents. These include views from adult seating and standing height while or troughs, with nearby hooks for smocks and towels. Sand z Refer to Chapter 8 for a list of furniture and equipment supplied for this and water play can occur in the art sink area or outside. If the the toddler open activity area should offer an even greater range of initial design meetings present a strong predilection towards carpet, opportunities for exploring and greater challenges in developing large motor particularly for quiet areas, then a limited amount of area carpets with skills. Provide the following architectural features in the open activity area for older toddlers: 7. More cooperative play can occur in this classroom, such as z Furnish intimate spaces for toddlers which still retain visual connection group activities and games. An initial design meetings present a strong predilection towards carpet, area for reading should be provided with natural light and a quiet envi particularly for quiet areas, then a limited amount of area carpets with ronment with natural light. Recessed constructed areas provide infants with large, contained spaces z Storage is required for games and supplies. The low retaining sides allow infants z School-age children in summer programs often go on excursions and to pull up and move. Caution must be used in permanently constructing such an area so that it z A listing of furniture and equipment for this area is found in Chapter 8. These areas can offer many activity opportunities z Small intimate spaces and advantages. Lofts must always be designed or positioned with the z Additional spaces for exploration safety of the children in mind. Under these requirements, if adopted, these areas must have impact-attenuation surfacing rated for the height of the following design requirements must be considered in the design of a the equipment to be placed thereon. Surfacing must extend beyond raised equipment if required child to use equipment at any one time. In existing construction, transition pieces are needed going up and a slide coming down will minimize congestion and the to accomodate existing surrounding floor elevations. Please refer to slides and steps offer variety of experience; however, it is best for circulation Chapter 6, Play Yard Surfaces. See Chapter 10 for technical requirements for automatic z Guardrails must be provided to protect children from falling from raised sprinkler systems where lofts cover a space occupied by children. Toddlers must have guardrails on any constructed surface greater than 250 mm above adjacent surfaces. Pre-school children must have guardrails on any raised surface greater than 505 mm above floor level. There can be no openings between 9 mm and steps, should be used between level changes.

Diseases

  • Phenobarbital antenatal infection
  • Retinopathy aplastic anemia neurological abnormalities
  • Muscular dystrophy
  • Hypertropia
  • Paraganglioma
  • Acrocallosal syndrome, Schinzel type
  • Situs inversus, X linked
  • Hypomandibular faciocranial dysostosis

Chil dren playing in the yards and on the streets are likely to come into contact with the faeces treatment low blood pressure cheap septra 480mg with amex. When faecal matter dries up treatment effect generic septra 480 mg with amex, it is likely to be contained in dust that can be blown up and be inhaled treatment west nile virus 480 mg septra for sale. Child-health has been improving as the global under-five mortality declined by 27% from 1990 (90 deaths per 1 treatment 3 antifungal cheap 480mg septra amex,000 live births) to 2008 (65 deaths per 1 medications you cannot eat grapefruit with buy septra 480 mg with amex,000 live births) 5 medications for hypertension buy cheap septra 480mg. The child mortality rates in low-income countries were almost 20 times larger than in high-income countries. Child malnutrition which is measured by poor child growth is an important in dicator for monitoring population nutritional status and health. Global underweight is most common in the regions of South-Central Asia (30%), followed by Western, Eastern, and Middle Africa (22%, 19% and 17%, respectively) and South-Eastern Asia (17%). Ngotho of Eastern and Western Asia, Northern Africa and Latin America and the Caribbe an, where less than 10% of children were underweight (de Onis et al. Children in the poorest households are twice as likely to be underweight as those in the least poor households. Children living in rural areas are more likely to be underweight than those living in urban areas. Childhood malnutrition, including poor growth and micronutrient deficiencies, is an underlying cause of death in an estimated 35% of all deaths among children under five years of age. Maternal mortality Maternal mortality is a health indicator that shows very wide gaps between rich and poor, both between countries and within them. Every day in 2010, about 800 women died due to complications of pregnancy and child birth, including severe bleeding after childbirth, infections, hypertensive disorders, and unsafe abortions. Out of the 800, 440 deaths occurred in sub-Saharan Africa and 230 in Southern Asia, compared to five in high-income countries. A study in Kenya among mothers in poor resource settings from both urban and rural area demon strated delayed health seeking behaviour in rural environments which has a nega tive impact on health and nutrition status of mothers (Muthoka et al. Ma ternal health challenges commonly experienced include long distances to the near est equipped health facility, inadequate skilled health personnel, high costs of transport, and inability to recognise risks early in order to seek timely care. Child malnutrition, when not attended to in time is likely to increase the child mortality rates. Trends in the past decade (1990-2008) indicate global improvements in the reduction of under-five mortality rates by 27%. Women nutritional status and health is further com promised by closely spaced births thus impacting on their capacity as care-givers. Increase in unmet needs in reproductive health can be explained by socio-cultural attitude and poor access to health services. Post-delivery complications are not only a factor of maternal age but are common among undernourished mothers and those within low-resource settings (Muthoka et al. It implies that low in come or poor resource base are contributing factors in limiting access to health services and are likely to impact negatively on maternal health care. Poor decision making and late health-seeking behaviour Education, low incomes, culture and inability to make independent decisions for some rural mothers influences their health-seeking behaviours. Late decision mak ing compromises the management of reproductive related illnesses and infections and easily leads to maternal death, or long admission days at the health centres. These deprive other younger children and maternal care and can lead to the vicious cycle of malnutrition. Education during the visit of antenatal clinics is aimed at sensitising mothers of pregnancy-related risks and enhancing positive attitude on the need to seek treatment once infection or any abnormality is noted. Inadequate resources Low income is usually co-related to education level, with mothers who are less educated having less chances in good-income jobs that can support them and their families. Inadequate resources complex health especially when there is a cost relat ed to treatment at the health facilities. Thus, mothers opt to other cheaper means of delivery or treatment which also increases the risks of infections and complica tions. Although most mothers make at least one antenatal visit during their preg nancy, delivery assisted with skilled health personnel still remains low among communities with low-resource settings and those with limited access to health services either due to distance to health facility and poor road infrastructure (Muthoka et al. Ngotho 4 Interventions Appreciably many interventions have been made to improve the situation of mother and child health. Focussing on the first 1,000 days of pregnancy and early childhood (24 months), due to high impact nutrition interventions (HiNi) aims at preventing malnutrition and reducing child mortality. The supple mentations have also been supported by iodisation of all domestic salts to improve the health outcomes of the population. Improved access to quality curative care through free health care services in all public health facilities for all under-five children has encouraged many mothers to seek health care postnatally. Access to health services gives the mothers a chance to enjoy other hospital-based interventions such as integrated management of childhood illness. This includes immunization and deworming, coupled with nutri tion, sanitation and health education. Other cross-sector intervention include strengthening nutrition surveillance, moni toring and evaluation systems and strengthening coordination and partnership among key nutrition actors and mobilizing essential resources. However, more effort in scaling up nutrition and health are still required to meet the Millennium Development Goals. Maternal-Child Health Interdiscplinary Aspects Within the Perspective of Global Health 29 5 Policy implication? Improving access to food at all times to especially households with low re source base is crucial to enhance adequate dietary intake which directly impacts on nutrition and health of both mother and child. Maternal mortality at the Queen Elizabeth Central Teaching Hospital, Blantyre, Malawi. Enhancing sustainable community health and nutrition security and safe motherhood among rural and low income urban households. Water Sanitation Challenge: Prevalence of Diarrhoea in Children under Age 5 in Slums and Regular Localities in Enugu, South-East Nigeria Pat Obiageli Ndu, Chica Onwasigwe, Silva M. Anika Centre for Environmental Management and Control, University of Nigeria, Enugu Campus, Nigeria. The 2012 update on drinking water shows that even though the world has met the drinking water target, about 780 million people still lack safe potable water for drinking and other uses. There are also indications that globally, sanitation targets would not be met with coverage in sub Saharan Africa, where 30 percent and 45 percent use either shared or unimproved facilities, respectively, and 25 percent practice open defecation. These challenges in the water-sanitation sector have been shown to have link ages to diarrhoeal morbidity in children under the age of five. In Nigeria alone, about 85,921 children under the age of five, die each year from diarrhoeal diseases linked to inadequate sanitation, unsafe water and poor hygiene. The systematical testing of the microbial, physical and chemical quality of water at national and regional levels is considered expensive and logistically complicated. Consequently in the current set of indica tors; the safety and reliability of drinking water supply sources and sanitation facili ties were not addressed. This implies that complete information about drinking water safety is not available for global monitoring. There is a chance that some of these sources may not have been adequately maintained and would not provide safe water and a possibility that the number of people using safe water supplies may be overestimated. There is now a push to include water quality in the monitoring program to ac commodate testing for the presence of E. This would address the information gap created by the current regimen which has a limiting effect on the usability of data obtained with the proxy method for water quality. This study took into account the im portance of parameters like drinking water quality, water availability, per capita water consumption per person within households, water treatment at point of use, correct hand washing practices among others. The household survey was conduct ed in three regular localities and three slums in Enugu Metropolis of South-East Maternal-Child Health Interdiscplinary Aspects Within the Perspective of Global Health 33 Nigeria; Trans Ekulu, New Haven, Uwani, Agu-Owa, Ugbo-Okonkwo, and Ikiri ke. Of the 610 questionnaires shared across localities, 578 were duly completed and returned (94. The questionnaire captured information on demographic and socio-economic variables, water indicators covering water sources, access, availability, per capita consumption and water treatment practices; sanitation indicators covering facility types, adequacy of facility, hand-wash prac tices and waste management. Correlation and regression analysis were used to determine relationship and strength of association between use of unimproved water and unimproved toilet facilities and diarrhoea prevalence in children. All the water samples analysed did not meet the stipulated standards and branded unsatisfactory including pipe-borne and table water samples collected from the localities. There was a significant relationship between the use of unimproved water sources and prevalence of diarrhoea and R as the measure of the strength of relationship was 0. The correlation for relationship between prevalence of diarrhoea in children under the age of 5 and the use of un improved sanitation facilities was 0. These findings on diarrhoeal prevalence were both startling and in conflict with the picture painted by the diarrhoea records of the University of Nigeria Teaching Hospital and studies conducted by Nnodu et al. The dry season was captured as the season for diarrhoea in these studies and records. Two months in the period were dry season March to April; four months May to August were in the wet season. Four weeks in the dry season belt was used for the pilot survey leaving only one month of dry season for the main survey. Of the six localities in the study, Trans Ekulu recorded a diarrhoea prevalence rate of 14. The very high prevalence rates in relation to the national average raises questions around possible confounding variables. The rates were higher in the slums where both water and sanitation infrastructure were either absent or not enough. These dispar ities within localities show that water and sanitation challenges require a multifacet ed intervention program that would address the heterogeneity of the issues in the sector. Government at the three tiers should allocate human and material resources to tackle issues in the sector and also begin to see slum eruptions as a ?cry for help. There must be a conscious effort to mount programs and intervention schemes that would reduce prevalence of diarrhoeal disease in children under the age of five. The life of every child must count irrespective of the localities they find themselves in by accident of birth. If all the fresh water on the planet were divided equally among the global population, there would be 5,000 6,000 m3 available for everyone per year. This population growth coupled with industrialization and urbanization concentrates large numbers of people in small areas resulting in increased demand for potable water. One of the health problems linked to the water-sanitation challenge is diar rhoea loosely defined as; a symptom of gastrointestinal infection characterized by the passage of loose watery stools more frequently than normal. Diarrhoea could be just watery as in cholera or passed with blood as in dysentery. It can be caused by a bacteria, viruses and parasitic organisms spread by contaminated water or food. Enugu Metropolis, South East Nigeria has witnessed tremendous population growth in over 100 years of its existence. This expansion could be linked to the loss of investments to the ?abandoned property saga in various parts of the country by the Igbos of South East extraction following the Nigeria-Biafra civil war. Many rebuilt their post-war lives in their homeland and Enugu the capital of the then East Central State was a popular choice resulting in the birth of new localities; a trend not matched with expansion of water and sanitation facilities. Slums whose basic features are the absence of clean water, electricity, good road network, toilet facilities, and waste management plans (Wambui et al. Maternal-Child Health Interdiscplinary Aspects Within the Perspective of Global Health 35 3 Study area Figure 1: Map of Nigeria showing Enugu State Source: Wikipedia, 2013 the founding of Enugu was influenced by the discovery of coal by an itinerant party of geologists between 1908 and 1909. Prior to this discovery, the virgin land had no historical, economic or political importance. Although the British authori ties transformed Enugu into a beautiful city; their interest was purely economic. Enugu became a second-class township in 1917 under the name Enugu-Ngwo but Ngwo was dropped in 1928 to distinguish the town from the Enugu village in Ngwo town. The topography of the area influenced the decision of the natives to call the area enu-ugwu (Enugu) meaning ?hill top (Fig. Enugu Metropolis is in the tropical rain-forest zone with a derived savannah experiencing between 1,520 and 2,030 mm of rain annually (Egboka, 1985). The wet season lasts from May to October with the heaviest rainfall occurring between June and July and a break in August referred to as ?August Break. The other weather condition is the Harmattan; a dusty trade wind originating from the Sahara desert blowing southwards lasting a few weeks from December to January. Anika Enugu Metropolis became the headquarters of the Eastern Province in 1936, capi tal of Eastern Nigeria in 1951, and capital of East Central State in 1967 in the wake of the Nigerian civil war. In 1976, it was made the capital of the old Anambra State and finally the capital of the present Enugu State in 1991. The Capital Territory is made up of three local Governments Areas Enugu East, Enugu North and Enu gu South. The seeming noncha lance by the federal government left the people no option than to self-preserve because the people figured that a government that won?t safeguard the lives of its citizens had no claim to their allegiance and the victims sought their safety in other ways including secession (Achebe, 2012). The investments accumu lated over the years in the banks and real estate was suddenly labelled ?abandoned and confiscated by the different military governors in the states. It did not matter how much money they left in the banks prior to the war, each individual was given twenty pounds at the end of the pogrom. In spite of the ?no victor, no vanquished declaration; the average Igbo man felt defeated and lost faith in the project called Maternal-Child Health Interdiscplinary Aspects Within the Perspective of Global Health 37 Nigeria. The water and sanitation facilities were not expanded adequately to accommodate the influx of the people into Enugu. Suddenly, rapid population growth, corruption, poor planning, and insensitivity of the leaders changed all that. This report ranked Nigeria third behind China and India in the list of countries with the largest population without access to improved drinking wa ter. Enugu Municipal in that time frame also used to discharge the water needs of the residents into homes through pipes and faucets. Households were informed through radio and television announcements when Water Corporation needed to do turnaround maintenance of equipment in their facility.

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