Postpartum Hemorrhage free essay sample

For these reasons, various authors have suggested that PPH should be diagnosed with any amount of blood loss that threatens the hemodynamic stability of the woman. The diagnosis of PPH is usually reserved for pregnancies that have progressed beyond 20 weeks’ gestation. Deliveries at less than 20 weeks’ gestational age are spontaneous abortions. Bleeding related to spontaneous abortion may have etiologies and management in common with those for PPH. Epidemiology - Frequency United States and industrialized countries The frequency of PPH is related to the management of the third stage of labor. This is the period from the completed delivery of the baby until the completed delivery of the placenta. Data from several sources, including several large randomized trials performed in industrialized countries, indicate that the prevalence rate of PPH of more than 500 mL is approximately 5% when active management is used versus 13% when expectant management is used. We will write a custom essay sample on Postpartum Hemorrhage or any similar topic specifically for you Do Not WasteYour Time HIRE WRITER Only 13.90 / page The prevalence rate of PPH of more than 1000 mL is approximately 1% when active management is used versus 3% when expectant management is used. [7, 8]  See eMedicine article  Management of the Third Stage of Labor. Developing countries The increased frequency of PPH in the developing world is more likely reflected by the rates given above for expectant management because of the lack of widespread availability of medications used in the active management of the third stage. [2]  A number of factors also contribute to much less favorable outcomes of PPH in developing countries. The first is a lack of experienced caregivers who might be able to successfully manage PPH if it occurred. Additionally, the same drugs used for prophylaxis against PPH in active management of the third stage are also the primary agents in the treatment of PPH. Lack of blood transfusion services, anesthetic services, and operating capabilities also plays a role. Finally, the previously mentioned comorbidities are more commonly observed in developing countries and combine to decrease a womans tolerance of blood loss. Etiology PPH has many potential causes, but the most common, by a wide margin, is uterine atony, ie, failure of the uterus to contract and retract following delivery of the baby. PPH in a previous pregnancy is a major risk factor and every effort should be made to determine its severity and cause. In a recent andomized trial in the United States, birthweight, labor induction and augmentation, chorioamnionitis, magnesium sulfate use, and previous PPH were all positively associated with increased risk of PPH. [9] A recently published, large population based study supported these findings with significant risk factors, identified using a multivariable analysis, being: retained placenta (OR 3. 5, 95% CI 2. 1-5. 8), failure to progre ss during the second stage of labor (OR 3. 4, 95% CI 2. 4-4. 7), placenta accreta (OR 3. 3, 95% CI 1. 7-6. 4), lacerations (OR 2. 4, 95% CI 2. 0-2. 8), instrumental delivery (OR 2. 3, 95% CI 1. 6-3. ), large for gestational age (LGA) newborn (OR 1. 9, 95% CI 1. 6-2. 4), hypertensive disorders (OR 1. 7, 95%CI 1. 2-2. 1), induction of labor (OR 1. 4, 95%CI 1. 1-1. 7) and augmentation of labor with oxytocin (OR 1. 4, 95% CI 1. 2-1. 7). [10] PPH is also associated with obesity. In a study by Blomberg, the risk of atonic uterine hemorrhage rapidly increased with increasing BMI; in women with a BMI over 40, the risk was 5. 2% with normal delivery and 13. 6% with instrumental delivery. [11] As a way of remembering the causes of PPH, several sources have suggested using the â€Å"4  T’  s† as a mnemonic: tone, tissue, trauma, and thrombosis. 12] - Tone Uterine atony and failure of contraction and retraction of myometrial muscle fibers can lead to rapid and severe hemorrhag e and hypovolemic shock. Overdistension of the uterus, either absolute or relative, is a major risk factor for atony. Overdistension of the uterus can be caused by multifetal gestation, fetal macrosomia, polyhydramnios, or fetal abnormality (eg, severe hydrocephalus); a uterine structural abnormality; or a failure to deliver the placenta or distension with blood before or after placental delivery. Poor myometrial contraction can result from fatigue due to prolonged labor or rapid forceful labor, especially if stimulated. It can also result from the inhibition of contractions by drugs such as halogenated anesthetic agents, nitrates, nonsteroidal anti-inflammatory drugs, magnesium sulfate, beta-sympathomimetics, and nifedipine. Other causes include placental implantation site in the lower uterine segment, bacterial toxins (eg, chorioamnionitis, endomyometritis, septicemia), hypoxia due to hypoperfusion or Couvelaire uterus in abruptio placentae, and hypothermia ue to massive resuscitation or prolonged uterine exteriorization. Recent data suggest that grand multiparity is not an independent risk factor for PPH. - Tissue Uterine contraction and retraction leads to detachment and expulsion of the placenta. Complete detachment and expulsion of the placenta permits continued retraction and optimal occlusion of blood vessels. Retention of a portion of the placenta is more common if th e placenta has developed with a succenturiate or accessory lobe. Following delivery of the placenta and when minimal bleeding is present, the placenta should be inspected for evidence of fetal vessels coursing to the placental edge and abruptly ending at a tear in the membranes. Such a finding suggests a retained succenturiate lobe. The placenta is more likely to be retained at extreme preterm gestations (especially lt; 24 wk), and significant bleeding can occur. This should be a consideration in all deliveries at very early gestations, whether they are spontaneous or induced. Recent trials suggest that the use of misoprostol for second trimester termination of pregnancy leads to a marked reduction in the rate of retained placenta when compared to techniques using the intrauterine instillation of prostaglandin or hypertonic saline. [13]  One such trial reported rates of retained placenta requiring Damp;C of 3. 4% with oral misoprostol compared to 22. 4% using intra-amniotic prostaglandin (p=0. 002). [14] Failure of complete separation of the placenta occurs in placenta accreta and its variants. In this condition, the placenta has invaded beyond the normal cleavage plane and is abnormally adherent. Significant bleeding from the area where normal attachment (and now detachment) has occurred may mark partial accreta. Complete accreta in which the entire surface of the placenta is abnormally attached, or more severe invasion (placenta increta or percreta), may not initially cause severe bleeding, but it may develop as more aggressive efforts are made to remove the placenta. This condition should be considered possible whenever the placenta is implanted over a previous uterine scar, especially if associated with placenta previa. All patients with placenta previa should be informed of the risk of severe PPH, including the possible need for transfusion and hysterectomy. Finally, retained blood may cause uterine distension and prevent effective contraction. - Trauma Damage to the genital tract may occur spontaneously or through manipulations used to deliver the baby. Cesarean delivery results in twice the average blood loss of vaginal delivery. Incisions in the poorly contractile lower segment heal well but are more reliant on suturing, vasospasm, and clotting for hemostasis. Uterine rupture is most common in patients with previous cesarean delivery scars. Routine transvaginal palpation of such scars is no longer recommended. Any uterus that has undergone a procedure resulting in a total or thick partial disruption of the uterine wall should be considered at risk for rupture in a future pregnancy. This admonition includes fibroidectomy; uteroplasty for congenital abnormality; cornual or cervical ectopic resection; and perforation of the uterus during dilatation, curettage, biopsy, hysteroscopy, laparoscopy, or intrauterine contraceptive device placement. Trauma may occur following very prolonged or vigorous labor, especially if the patient has relative or absolute cephalopelvic disproportion and the uterus has been stimulated with oxytocin or prostaglandins. Using intrauterine pressure monitoring may lessen this risk. Trauma also may occur following extrauterine or intrauterine manipulation of the fetus. The highest risk is probably associated with internal version and extraction of a second twin; however, uterine rupture may also occur secondary to external version. Finally, trauma may result secondary to attempts to remove a retained placenta manually or with instrumentation. The uterus should always be controlled with a hand on the abdomen during any such procedure. An intraumbilical vein saline/oxytocin or saline/misoprostol injection may reduce the need for more invasive removal techniques. [7] Cervical laceration is most commonly associated with forceps delivery, and the cervix should be inspected following all such deliveries. Assisted vaginal delivery (forceps or vacuum) should never be attempted without the cervix being fully dilated. Cervical laceration may occur spontaneously. In these cases, mothers have often been unable to resist bearing down before full cervical dilatation. Rarely, manual exploration or instrumentation of the uterus may result in cervical damage. Very rarely, the cervix is purposefully incised at the 2- and/or 10-o’clock positions to facilitate delivery of an entrapped fetal head during a breech delivery (Duhrssen incision). Vaginal sidewall laceration is also most commonly associated with operative vaginal delivery, but it may occur spontaneously, especially if a fetal hand presents with the head. Lacerations may occur during manipulations to resolve shoulder dystocia. Lacerations often occur in the region overlying the ischial spines. The frequency of sidewall and cervical lacerations has probably decreased in recent years because of the reduction in the use of midpelvic forceps and, especially, midpelvic rotational procedures. Lower vaginal trauma occurs either spontaneously or because of episiotomy. Spontaneous lacerations usually involve the posterior fourchette; however, trauma to the periurethral and clitoral region may occur and can be problematic. Thrombosis In the immediate postpartum period, disorders of the coagulation system and platelets do not usually result in excessive bleeding; this emphasizes the efficiency of uterine contraction and retraction for preventing hemorrhage. [5]  Fibrin deposition over the placental site and clots within supplying vessels play a significant role in the hours and days following delivery, and abnormalities in these areas can lea d to late PPH or exacerbate bleeding from other causes, most notably, trauma. Abnormalities may be preexistent or acquired. Thrombocytopenia may be related to preexisting disease, such as idiopathic thrombocytopenic purpura, or acquired secondary to HELLP syndrome (hemolysis, elevated liver enzymes, and low platelet count), abruptio placentae, disseminated intravascular coagulation (DIC), or sepsis. Rarely, functional abnormalities of platelets may also occur. Most of these are preexisting, although sometimes previously undiagnosed. Preexisting abnormalities of the clotting system, such as familial hypofibrinogenemia and von Willebrand disease, may occur and should be considered. An expert panel recently issued guidelines to aid in the diagnosis and management of women with such conditions. [15]  An underlying bleeding disorder should be considered in a woman with any of the following: menorrhagia since menarche, family history of bleeding disorders, personal history of notable bruising without known injury, bleeding from the oral cavity or GI tract without obvious lesion, or epistaxis of longer than 10 minutes duration (possibly requiring packing or cautery). If a bleeding disorder is suspected, consultation is suggested. Acquired abnormalities are more commonly problematic. DIC related to abruptio placentae, HELLP syndrome, intrauterine fetal demise, amniotic fluid embolism, and sepsis may occur. Fibrinogen levels are markedly elevated during pregnancy, and a fibrinogen level that would be in the reference range in the nonpregnant state should be viewed with suspicion in the aforementioned clinical scenarios. Finally, dilutional coagulopathy may occur following massive PPH and resuscitation with crystalloid and packed red blood cells (PRBCs). Risk factors and associated conditions for PPH are listed above; however, a large number of women experiencing PPH have no risk factors. Different etiologies may have common risk factors, and this is especially true of uterine atony and trauma of the lower genital tract. PPH usually has a single cause, but more than one cause is also possible, most likely following a prolonged labor that ultimately ends in an operative vaginal birth. Prevention High-quality evidence suggests that active management of the third stage of labor reduces the incidence and severity of PPH. 8]  Active management is the combination of (1) uterotonic administration (preferably oxytocin) immediately upon delivery of the baby, (2) early cord clamping and cutting, and (3) gentle cord traction with uterine countertraction when the uterus is well contracted (ie, Brandt-Andrews maneuver). The value of active management in the prevention of PPH cannot be overstated (see  Management of the Third Stage of Labor). The use of active versus expectant management in the third stage was the subject of 5 randomized controlled trials (RCTs) and a Cochrane meta-analysis. 16, 7, 8]  These trials included more than 6000 women, and the findings are summarized in Table 1. Table 1. Benefits of Active Management Versus Expectant Management  (Open Table in a new window) Outcome| Control Rate, %| Relative Risk| 95% CI*| NNT  Ã¢â‚¬  | 95% CI| PPH of 500 mL| 14| 0. 38| 0. 32-0. 46| 12| 10-14| PPH of 1000 mL| 2. 6| 0. 33| 0. 21-0. 51| 55| 42-91| Hemoglobin lt; 9 g/dL| 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| *CI: Confidence interval †  NNT: Number needed to treat The findings show a conclusive benefit for active management, with an approximate 60% reduction in the occurrence of PPH greater than or equal to 500 mL and 1000 mL, hemoglobin concentration of less than 9 g/dL at 24-48 hours after del ivery, and the need for blood transfusion. An 80% reduction in the need for therapeutic uterotonic agents was noted. These results were all highly significant as indicated by the 95% confidence interval figures. The results indicate that for every 12 patients receiving active rather than physiological management, one PPH would be prevented. For every 67 patients so treated, one patient would avoid transfusion with blood products. One concern regarding active management is that retained placenta may occur more frequently. This concern is not supported by the trials. This is especially true if oxytocin is used as the uterotonic. [17, 18]  The US RCTs mentioned above compared the use of active management protocols in which the oxytocin was administered either immediately after delivery of the baby or immediately after delivery of the placenta. The authors stated that no statistically significant difference was noted in the PPH rate and that delaying administration until after placental delivery was justified. Noteworthy is the finding that early administration of oxytocin (before placental delivery) did not increase the rate of retained placenta. Additionally, the trial showed trends toward a benefit for early administration of oxytocin, including a 25% reduction in PPH and a 50% reduction in the need for transfusion. [9]  These findings are clearly consistent with the previous RCTs and the early administration of oxytocin with delivery of the baby is strongly recommended. They also stated that administration with delivery of the baby did not increase the rate of retained placenta, but they did not point out that this finding clearly supports early administration. Additionally, the trial showed trends toward a benefit for early administration of oxytocin, including a 25% reduction in PPH and a 50% reduction in the need for transfusion. [9]  These differences may be due to chance, but, given the results of the previous RCTs, the administration of oxytocin with delivery of the baby would seem to be strongly warranted. Following delivery, administering a uterotonic drug that lasts at least 2-3 hours is reasonable. [3]  This could be 10 U of oxytocin in 500 mL of intravenous fluid by continuous drip, 200-250 mcg of ergonovine intramuscularly, or 250 mcg of 15-methyl prostaglandin F2-alpha (carboprost [Hemabate]) intramuscularly. The use of misoprostol and a long-acting oxytocin analogue (carbetocin) is being studied for this use. [19]  It has been suggested that distribution of misoprostol ahead of childbirth in communities where home birth is unavoidable can be an effective approach. However, there is insufficient evidence to support this and there are concerns that the drug might be used for starting labor or terminating pregnancy. [20] The presence of significant antepartum or intrapartum risk factors warrants delivery in maternity units that have readily available resources to deal with massive obstetric hemorrhage. All medical facilities should have protocols for dealing with PPH and obstetric hemorrhage. Pathophysiology Over the course of a pregnancy, maternal blood volume increases by approximately 50% (from 4 L to 6 L). The plasma volume increases somewhat more than the total RBC volume, leading to a fall in the hemoglobin concentration and hematocrit value. The increase in blood volume serves to fulfill the perfusion demands of the low-resistance uteroplacental unit and to provide a reserve for the blood loss that occurs at delivery. [6] At term, the estimated blood flow to the uterus is 500-800 mL/min, which constitutes 10-15% of cardiac output. Most of this flow traverses the low-resistance placental bed. The uterine blood vessels that supply the placental site traverse a weave of myometrial fibers. As these fibers contract following delivery, myometrial retraction occurs. Retraction is the unique characteristic of the uterine muscle to maintain its shortened length following each successive contraction. The blood vessels are compressed and kinked by this crisscross latticework, and, normally, blood flow is quickly occluded. This arrangement of muscle bundles has been referred to as the living ligatures or physiologic sutures of the uterus. [5] Uterine atony is a failure of the uterine myometrial fibers to contract and retract. This is the most important cause of PPH and usually occurs immediately following delivery of the baby, up to 4 hours after the delivery. Trauma to the genital tract (ie, uterus, uterine cervix, vagina, labia, clitoris) in pregnancy results in significantly more bleeding than would occur in the nonpregnant state because of increased blood supply to these tissues. The trauma specifically related to the delivery of the baby, either vaginally in a spontaneous or assisted manner or by cesarean delivery, can also be substantial and can lead to significant disruption of soft tissue and tearing of blood vessels. Presentation Although the presentation of PPH is most often dramatic, bleeding may be slower and seemingly less noteworthy but may still ultimately result in critical loss and shock. This is more likely to be true of bleeding secondary to retained tissue or trauma. Nursing practices for routine care in the postpartum period should include close observation and documentation of maternal vital signs and condition, vaginal blood loss, and uterine tone and size. The uterus should be periodically massaged to express any clots that have accumulated in the uterus or vagina. 21] The usual presentation of PPH is one of heavy vaginal bleeding that can quickly lead to signs and symptoms of hypovolemic shock. This rapid blood loss reflects the combination of high uterine blood flow and the most common cause of PPH, ie, uterine atony. Blood loss is usually visible at the introitus, and this is especially true if the placenta has delivered. If the placenta remains in situ, then a significant amoun t of blood can be retained in the uterus behind a partially separated placenta, the membranes, or both. Even after placental delivery, blood may collect in an atonic uterus. For this reason, the uterine size and tone should be monitored throughout the third stage and in the so-called fourth stage, following delivery of the placenta. This is accomplished by gently palpating the uterine fundus. If the cause of bleeding is not uterine atony, then blood loss may be slower and clinical signs and symptoms of hypovolemia may develop over a longer time frame. Bleeding from trauma may be concealed in the form of hematomas of the retroperitoneum, broad ligament or lower genital tract, or abdominal cavity. The clinical findings in hypovolemia are listed in Table 2. Table 2. Clinical Findings in Obstetric Hemorrhage[22]  (Open Table in a new window) Blood Volume Loss| Blood Pressure (systolic)| Symptoms and Signs| Degree of Shock| 500-1000 mL (10-15%)| Normal| Palpitations, tachycardia, dizziness| Compensated| 1000-1500 mL (15-25%)| Slight fall (80-100 mm Hg)| Weakness, tachycardia, sweating| Mild| 1500-2000 mL (25-35%)| Moderate fall (70-80 mm Hg)| Restlessness, pallor, oliguria| Moderate| 2000-3000 mL (35-50%)| Marked fall (50-70 mm Hg)| Collapse, air hunger, anuria| Severe| Two important facts are worth bearing in mind. The first is that caregivers consistently underestimate visible blood loss by as much as 50%. The volume of any clotted blood represents half of the blood volume required to form the clots. The second is that most women giving birth are healthy and compensate for blood loss very well. This, combined with the fact that the most common birthing position is some variant of semirecumbent with the legs elevated, means that symptoms of hypovolemia may not develop until a large volume of blood has been lost. 23] Rapid recognition and diagnosis of PPH is essential to successful management. Resuscitative measures and the diagnosis and treatment of the underlying cause must occur quickly before sequelae of severe hypovolemia develop. The major factor in the adverse outcomes associated with severe hemorrhage is a delay in initiating appropriate management. Contraindications Other than nonconsent, absence of surgical expertise or allergy to specific agents, the techniques used in the management of PPH have no absolute contraindications. The vast majority of cases (gt;99%) are handled without what would traditionally be considered surgical intervention. In most cases, surgical intervention is a last resort. An exception is those cases in which uterine rupture or genital tract trauma has occurred and surgical repair is clearly indicated. Transfusion of packed RBC and other blood products may be necessary in the management of severe PPH. Some women may refuse such an intervention on personal or religious grounds. The most widely known group that does not accept blood transfusion are Jehovah’s Witnesses. The wishes of the patient must be respected in this matter. Significant increased risk of maternal mortality due to obstetric hemorrhage has been noted in the Jehovah’s Witness population. The increased risk of death was found to be 6-fold in a recent national review of 23 years experience in the Netherlands and 44-fold in a much smaller study of 391 deliveries in a US tertiary level center. 24, 25]  Discussion regarding the implications of such prohibitions should be undertaken early in the pregnancy whenever possible and subsequently reviewed. In almost all cases in which surgical management is chosen after medical management has failed, not attempting surgery would lead to maternal death. Even an unstable condition cannot be considered a true contraindication. One type of surgery may be chosen over another, but when medical management has failed, surgery is most likely the o nly life-saving option. Proceed to  Workup READ MORE ABOUT POSTPARTUM HEMORRHAGE ON MEDSCAPE RELATED REFERENCE TOPICS * Postpartum Hemorrhage in Emergency Medicine * Hypogastric Artery Ligation * Bakri Balloon Placement| RELATED NEWS AND ARTICLES * Haemostatic Monitoring During Postpartum Haemorrhage and Implications for Management * Dose and Side Effects of Sublingual Misoprostol for Treatment of Postpartum Hemorrhage * Uterine Balloon Effective for Post-Partum Hemorrhage in Developing Countries| About Medscape Reference References 1. Berg CJ, Atrash HK, Koonin LM, Tucker M. Pregnancy-related mortality in the United States, 1987-1990. Obstet Gynecol. 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Potential role of recombinant activated factor VII for the treatment of severe bleeding associated with disseminated intravascular coagulation: a systematic review. Blood Coagul Fibrinolysis. Oct 2007;18(7):589-93. [Medline]. 38. Gibbins KJ, Albright CM, Rouse DJ. Postpartum hemorrhage in the developed world: whither misoprostol?. Am J Obstet Gynecol. Aug 1 2012;[Medline]. 39. OBrien P, El-Refaey H, Gordon A, Geary M, Rodeck CH. Rectally administered misoprostol for the treatment of postpartum hemorrhage unresponsive to oxytocin and ergometrine: a descriptive study. Obstet Gynecol. Aug 1998;92(2):212-4. [Medline]. 40. Lokugamage AU, Sullivan KR, Niculescu I, et al. A randomized study comparing rectally administered misoprostol versus Syntometrine combined with an oxytocin infusion for the cessation of primary post partum hemorrhage. Acta Obstet Gynecol Scand. Sep 2001;80(9):835-9. [Medline]. 41. Vaid A, Dadhwal V, Mittal S, Deka D, Misra R, Sharma JB. A randomized controlled trial of prophylactic sublingual misoprostol versus intramuscular methyl-ergometrine versus intramuscular 15-methyl PGF2alpha in active management of third stage of labor. Arch Gynecol Obstet. Mar 11 2009;[Medline]. 42. Gulmezoglu AM, Forna F, Villar J, Hofmeyr GJ. Prostaglandins for preventing postpartum haemorrhage. Cochrane Database Syst Rev. 2007/07;18;(3):CD000494. 43. [Best Evidence] Winikoff B, Dabash R, Durocher J, Darwish E, Nguyen TN, Leon W, et al. Treatment of post-partum haemorrhage with sublingual misoprostol versus oxytocin in women not exposed to oxytocin during labour: a double-blind, randomised, non-inferiority trial. Lancet. Jan 16 2010;375(9710):210-6. [Medline]. 44. [Best Evidence] Attilakos G, Psaroudakis D, Ash J, Buchanan R, Winter C, Donald F, et al. Carbetocin versus oxytocin for the prevention of postpartum haemorrhage following caesarean section: the results of a double-blind randomised trial. BJOG. Jul 2010;117(8):929-36. [Medline]. 45. Criscuolo JL, Kibler MP, Micholet S, et al. [The value of antibiotic prophylaxis during intrauterine procedures during vaginal delivery. A comparative study of 500 patients]. J Gynecol Obstet Biol Reprod (Paris). 1990;19(7):909-18. [Medline]. 46. Hallak M, Dildy GA 3rd, Hurley TJ, Moise KJ Jr. Transvaginal pressure pack for life-threatening pelvic hemorrhage secondary to placenta accreta. Obstet Gynecol. Nov 1991;78(5 Pt 2):938-40. [Medline]. 7. Maier RC. Control of postpartum hemorrhage with uterine packing. Am J Obstet Gynecol. Aug 1993;169(2 Pt 1):317-21; discussion 321-3. [Medline]. 48. Seror J, Allouche C, Elhaik S. Use of Sengstaken-Blakemore tube in massive postpartum hemorrhage: a series of 17 cases. Acta Obstet Gynecol Scand. Jul 2005;84(7):660-4. [Medline]. 49. Akhter S, Begum MR, Ka bir Z, Rashid M, Laila TR, Zabeen F. Use of a condom to control massive postpartum hemorrhage. MedGenMed. Sep 11 2003;5(3):38. [Medline]. 50. Brees C, Hensleigh PA, Miller S, Pelligra R. A non-inflatable anti-shock garment for obstetric hemorrhage. Int J Gynaecol Obstet. Nov 2004;87(2):119-24. [Medline]. 51. Johanson R, Kumar M, Obhrai M, Young P. Management of massive postpartum haemorrhage: use of a hydrostatic balloon catheter to avoid laparotomy. BJOG. Apr 2001;108(4):420-2. [Medline]. 52. Propst AM, Thorp JM Jr. Traumatic vulvar hematomas: conservative versus surgical management. South Med J. Feb 1998;91(2):144-6. [Medline]. 53. Lingam K, Hood V, Carty MJ. Angiographic embolisation in the management of pelvic haemorrhage. BJOG. Sep 2000;107(9):1176-8. [Medline]. 54. Stanco LM, Schrimmer DB, Paul RH, Mishell DR Jr. Emergency peripartum hysterectomy and associated risk factors. Am J Obstet Gynecol. Mar 1993;168(3 Pt 1):879-83. [Medline]. 55. Zelop CM, Harlow BL, Frigoletto FD Jr, Safon LE, Saltzman DH. Emergency peripartum hysterectomy. Am J Obstet Gynecol. May 1993;168(5):1443-8. [Medline]. 56. Doumouchtsis SK, Papageorghiou AT, Arulkumaran S. Systematic review of conservative management of postpartum hemorrhage: what to do when medical treatment fails. Obstet Gynecol Surv. Aug 2007;62(8):540-7. [Medline]. 57. Plauche WC. Peripartal Hysterectomy. In: Plauche WC, Morrison JC, OSullivan MJ, eds. Surgical Obstetrics. Philadelphia, Pa: WB Saunders; 1992:447-65. 58. OLeary JA. Uterine artery ligation in the control of postcesarean hemorrhage. J Reprod Med. Mar 1995;40(3):189-93. [Medline]. 59. AbdRabbo SA. Stepwise uterine devascularization: a novel technique for management of uncontrolled postpartum hemorrhage with preservation of the uterus. Am J Obstet Gynecol. Sep 1994;171(3):694-700. [Medline]. 60. Clark SL, Phelan JP, Yeh SY, Bruce SR, Paul RH. Hypogastric artery ligation for obstetric hemorrhage. Obstet Gynecol. Sep 1985;66(3):353-6. [Medline]. 61. Floyd RC, Morrison JC. Postpartum Hemorrhage. In: Plauche WC, Morrison JC, OSullivan MJ, eds. Surgical Obstetrics. 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Technical description of the B-Lynch brace suture for treatment of massive postpartum hemorrhage and review of published cases. Int J Fertil Womens Med. Jul-Aug 2005;50(4):148-63. [Medline]. 67. Hayman RG, Arulkumaran S, Steer PJ. Uterine compression sutures: surgical management of postpartum hemorrhage. Obstet Gynecol. Mar 2002;99(3):502-6. Medline]. 68. Cho JH, Jun HS, Lee CN. Hemostatic suturing technique for uterine bleeding during cesarean delivery. Obstet Gynecol. Jul 2000;96(1):129-131. [Medline]. 69. Dildy GA 3rd. Postpartum hemorrhage: new management options. Clin Obstet Gynecol. Jun 2002;45(2):330-44. [Medline]. 70. Wilkinson C, Enkin MW. Manual removal of placenta at caesarean s ection. Cochrane Database Syst Rev. Jul 18 2007;(3):CD000130. 71. Anorlu RI, Maholwana B, Hofmeyr GJ. Methods of delivering the placenta at caesarean section. Cochrane Database Syst Rev. Jul 16 2008;(3):CD004737. 72. Royal College of Obstetricians and Gynaecologists. Green-top guideline no 27. 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A comparison of active and physiological management of the third stage of labour. Midwifery. Mar 1990;6(1):3-17. [Medline]. 78. Enkin M, Keirse M, Neilson J, et al, eds. A Guide to Effective Care in Pregnancy and Childbirth. 3rd  ed. Oxford, England: Oxford University Press; 2000. 79. Lewis G, Drife J, eds. Hemmorhage. In:  Why Mothers Die 1997-1999: The Confidential Enquiries into Maternal Deaths in the United Kingdom. London, England: RCOG Press; 2001:94-103. 80. Prendiville WJ, Harding JE, Elbourne DR, Stirrat GM. The Bristol third stage trial: active versus physiological management of third stage of labour. BMJ. Nov 19 1988;297(6659):1295-300. [Medline]. 81. Villar J, Gulmezoglu AM, Hofmeyr GJ, Forna F. Systematic review of randomized controlled trials of misoprostol to prevent postpartum hemorrhage. Obstet Gynecol. Dec 2002;100(6):1301-12. [Medline].

Khrushchev and the 1956 hungar essays

Khrushchev and the 1956 hungar essays The overlapping crises in Hungary and Poland in the autumn of 1956 posed a severe challenge for the leaders of the Soviet Communist Party (CPSU). After a tense standoff with Poland, the CPSU Presidium (as the Politburo was then called) decided to refrain from military intervention and to seek a political compromise. The crisis in Hungary was far less easily defused. For a brief moment it appeared that Hungary might be able to break away from the Communist bloc, but the Soviet Army put an end to all such hopes. Soviet troops crushed the Hungarian revolution, and a degree of order returned to the Soviet camp. Newly released documents from Russia and Eastern Europe shed valuable light on the events of 1956, permitting a much clearer and more nuanced understanding of Soviet reactions. This article will begin by discussing the way official versions of the 1956 invasion changedand formerly secret documents became availableduring the late Soviet period and after the Soviet Union disintegrated. It will then highlight some of the most important findings from new archival sources and memoirs. The article relies especially heavily on the so-called Malin notes, which are provided in annotated translation below, and on new materials from Eastern Europe. Both the article and the documents will show that far-reaching modifications are needed in existing Western accounts of the 1956 OFFICIAL REASSESSMENTS BEFORE AND AFTER 1991 The advent of glasnost and new political thinking in the Soviet Union under Mikhail Gorbachev led to sweeping reassessments of postwar Soviet ties with Eastern Europe. As early as 1987, an unofficial reappraisal began in Moscow of the Soviet-led invasion of Czechoslovakia in August 1968. Initially, these reassessments of the 1968 crisis did not have Gorbachevs overt endorsement, but the process gained a...

Risk management Essay Example | Topics and Well Written Essays - 2500 words - 1

Risk management - Essay Example Even it is also consisted of implementation of a program for assessing the effectiveness. Therefore, it can be said that risk management is an ongoing process. There are four ways to deal with the risk. The first method consists of just rejecting the risk hopping that it will be resolved automatically. Accepting the risk and initiating appropriate actions against the risk can be another option. Transfer of the risk is another measure which indicates the acceptance of alternative risk, higher than the reasonable risk. Lastly, to mitigate the risk i.e. to implement the physical, administrative and technical controls in order to reduce the risk is the another way. Risk assessment is a process or examination through which it can be understood that what can be harmful for the workplace and how it can be prevented in advance. It is important because it gives the authority an advanced alert for the risk that may occur in future so that the future accidents can be avoided. Apart from accident, risk assessment is also useful for reducing insurance cost and damages in machineries. This is a part of risk management and can be better understood by the following diagram. The main objective of the risk assessment is to determine the risk associated with a particular asset. In order to assess risk successfully, few more steps have to be followed, firstly the critical information regarding the assets have to be gathered and possible threats attached with the asset should be identified. Then, the vulnerabilities of the threats and possibility of exploitation are assessed. For assessment of risk, quite a few steps have to be taken. At the outset, identification of risk is necessary. The assessor must visit each and every corner of the work place to have a better understanding with the present condition of the plants and equipments attached in it along with the premises. They may also take advice of the employees. Then, it has to be made out that who are the

The Media and its Impact on the Range of Understanding Identity in Essay

The Media and its Impact on the Range of Understanding Identity in Adolescents - Essay Example One should consider the gratuitous nature with which sex and sexual relations are discussed within the media. It is nearly impossible to turn on primetime television or read a magazine that does not seek to cheaply engage the reader with a type of frivolous and non-consequential understanding of human sexuality. A series of negative implications are glossed over to include the ever-increasing risk of STDs, pregnancy, emotional/psychological trauma, and the inability to form lasting and meaningful physical relationships due to a high premium being placed upon sex (Samson et al 283). Such common interpretations are no doubt one of the reasons that HPV is represented in one out of every 4 women between the ages of 14-30 within the United States. Likewise, it does not take a specialist to note that there is an ever-increasing incidence of violence in all forms of media. This cannot only be understood as a function of entertainment but also as a function of news programming which takes particular interest in some of the more gruesome elements of violence that exist within society. The representation of violence within the media in all its forms serves to relate an unrealistic view of the world model as it currently exists and no doubt has a profound effect on the way that adolescents view their surroundings. One study put forward that the average child will have viewed around 8,000 murders on television prior to finishing elementary school (Nelson 1). This fact in and of itself gives the reader pause when realizing the sheer size of the problem and demands a response to such an issue.

Economics Essay Example | Topics and Well Written Essays - 500 words

Economics - Essay Example Taking into this account, how might my personal behavior patterns show a different type of decision process? I was at a fast food place once grabbing a burger to eat. Inevitably, â€Å"upselling† at the end of the transaction occurs where they offer fries and a drink. I almost instinctivey said â€Å"Yes†, then began to do marginal analysis. I would save money, but how much? Looking at the menu, I found that the a la carte cost would be thirty cents more. I didn't really want fries and a drink, I would only have purchased it out of an irrational desire not to miss a deal even when the deal is not necessary. I ended up changing my mind and saying no and was very glad to have saved the two dollars. The marginal benefit of the additional food and the beverage did not eclipse the marginal cost, even though I had lost an opportunity and therefore incurred opportunity cost by not pairing the meal. Normally, I would have chosen such a meal: I just happened to be thinking about it. I might even have ingested the calories happily, not realizing I actually hadn't been that hungry, causing me to eat more than my plan for the day. The fast food place thus already has a powerful incentive: The desire for people to avoid a missed opportunity combined with a nominal discount on associated items.

A Critical examination of leaders create organizational culture

A Critical examination of leaders create organizational culture Introduction In area of Management and leadership, one of the most crucial and effective factors that determine the performance and position of an organization in public sector is the organizational culture. Organizational culture has been studied extensively for the past 30 or more years (Schein E. H., 1985). Lots of books have been written and much research has been done about it, and also wide range of words applied to describe this notion. Although much different definitions have been presented on this keyword, most of them place their emphasis on common key aspects. Three comprehensive definitions have been gathered in table below: Definitions of organizational culture The pattern of shared beliefs and values that give members of an institution meaning and provide them with the rules for behaviour in their organizations. (Davis, 1984, p. 1). The set of important understandings (often unstated) that members of a community share in common. (Sathe, 1985, p. 6) A set of understandings or meanings shared by a group of people. The meanings are largely tacit among the members, are clearly relevant to a particular group and are distinctive to the group (Louis, 1985, p. 74) According to these definitions, two features of organizational culture seem bolder; first shared meanings and values among organization members and second introducing clear rules and behaviours in organization. Although, some argues that culture cannot be managed (Rabin, T Wachhaus. A, 2008, p. 1) , a correlation between culture and leadership has been identified (Frontiera, 2010). Schein announced this fact in his famous book-Organizational culture and leadership (2004): Culture is a dynamic phenomenon that surrounds us at all times, being constantly enacted and created by our reactions with others and shaped by leadership behaviour. So, attentions have been paid to culture aiming to manage and improve it in order to achieve defined goals. Leaders as persons who have crucial role in improving performance found it vital in organizational discourse. Schein introduced the mutual relation and effect between leadership and culture by the term intertwined (1992) .While culture can be affected by various factors, Senge pointed out that leaders have the most influence on organizational culture (2002, p. 24) : Building an organizations culture and shaping its evolution is the unique and essential function of leadership In this paper the focus is on the influence of leadership on organizational culture to examine to what extent the view that leaders create organizational culture is true. The approach that has been applied in this paper is studying the ways and channels through which leader creates and affects the culture of organization. Four major states have been studied in this area; model leader, strategist leader, ruling leader, and performance changing. Also, the other factors that create culture have been studied and the effect of culture on leadership has been analyzed. The conclusion shows the indirect role of leader in creating culture except through becoming model. In addition, other factors have decisive role in shaping culture. Before the start of this study, clearing the concept of leadership is required. What is leadership? Who is a leader? The concept of leadership has been defined in various ways. Some stated it as a process, for instance Northouse believe that it is a process whereby an individual influences a group of individuals to achieve a common goal (2007, p. 3). Also, Stogdill analyzed it as influencing the activities of an organized group in its efforts toward goal setting and goal achievement (1974). By these two types of definitions, leader can be known as a person who makes decisions, sets directions, makes things happen and often He is recognisable at the top of organization. Leader carries out this process by applying their leadership knowledge and skills. (Jago, 1982) Hence leader is placed at top of organization and clarifies strategies and directions, has most effects on the culture of organizations. In following next parts some ways by which leader affects culture have been examined. Leader; as a model In an organization the leadership and the behaviours of leader become an ideal pattern for followers, and a stream of organizational deportment would flow from top (leader) to down (followers). This case often happens in transformational type of leadership in which leader has charismatic features (Harms, p Crede, M, 2010). Bass and Avolio described transformational leader as able to motivate others to do more than they originally intended and often more than they thought possible (1993). As the organizational culture is made of behaviours and manners, charismatic leader cultivates a particular method of comportment in climate. Culture of an organization consists of different areas; competitiveness, social responsibility, innovation, stability, performance orientation, and supportiveness. So, the manner of leader affects every area of organizational culture and this top-down influence can lead to affirmative or mortal outcomes in performance (Sarros, J. Gray, J and Densten, I, 2002). By way of illustration, this can be studied in realm of Innovation and change; Fishman and Kavanaugh claimed that the culture of an organization and how people respond to change and innovation is shaped substantially by the behaviours of the leader (1989). Smith revealed that leaders behaviours can be followed by employees (2010); Leaders are the role models and when they walk the talk long enough, fairly soon these values become standard procedure. Leaders are lent very crucial and decisive position by which they influence the culture of organization through leading motivation, attendance and attitude of followers in organizational operation. This can be found in Amabile suggestion (1998): By influencing the nature of the work environment and organizational culture, leaders can affect organizational members attitude to work related change and motivation. Schein assumed culture begins from leaders who impose their own values and assumptions on a group (2004, p. 2). Leader as a ruler Leaders externalize their own assumptions and embed them into structures, mission, goals and working procedures gradually and consistently (Schein E. H., 2004, p. 406). In one hand, a leader make decisions and determine rules, and in the other hand organizational culture is described as a set of structures, routines, rules and norms that guide the constrain behaviour (Schein E. H., Organizational Culture and Leadership, 2004). So, leadership manipulates organizational culture through ruling in organization. Dull reflected this fact in the other way (2010): Public sector leaders attempt to cultivate organizational culture as a means of controlling administrative behaviour and building organizational competence, defined as the skill and capacity to accomplish necessary tasks Here the culture described as a tool for improving procedures to facilitate achieving goal. This case can be examined when leader feels sure about a needful innovation in organization. For promoting change, beside other necessities, leader has to provide a firm ground for implementing innovation; this ground is formal procedures and actions. As Armenakis et al. claimed leaders can modify formal structures, procedures, and human resource management practices (1999). So, leader initiates change and clarifies orientation of organization; he arrives to alter proceeds for reaching ends. In reality, changing procedures interpreted as changing culture. Leader as strategist Stewart declared that the strategy of an organization gives it identity based on its functions, Also it clarifies what an organization is and what it is doing (2004). Strategy forms culture of through highlighting tasks, directions, positions and behaviours . The change management strategy or approach selected by leaders will result in shifts in organizational culture. (Kavanagh, H Ashkanasy, N, 2006) By understanding the importance of strategy and its relation with culture, leader enters this relation and influence culture in two ways; first standing between strategy and culture, second use the strategy as a tool for modifying culture. Fernandez and Rainey interpreted strategy as a course of action for implementing changes (2006). Despite strategy plays a crucial role in organization, this is the role of leader to translate it into a course of actions. Goldsmith explains to CEO (chief executive officer) how leaders are needed to communicate and execute an organization s strategy. (2009) When leaders and their executive teams take an active role in implementing strategies, this is a commitment to ensure the ideas or strategies become part of the organisation. Insightful leaders realise that for strategies to be successfully integrated into their organisations, they must align, measure, market and package the strategy to their business, customers and investment community as they would with any marketing campaign. While strategy introduces direction of an organization, it is just on the paper. The best-planned strategy is no more than wishful thinking if it cannot be translated from concept to reality (Hsieh, T and Yik, S, 2005) .Here it is leader who translates it from language of paper to a course of actions. Speculand has studied the decisive role of leadership and placed his special emphasis on leaders in success and failure of implementing strategies (2009). So, leader as a median interprets strategy into organization procedure, role, and belief. This action forms the culture; in this area culture is set of behaviours and procedures that are defined by strategy. In this process leader injects strategy into the body of organization. In reality, leader makes strategy feasible, and at the same time forms culture. But it is not whole the story about relation of strategy and culture. Leader alters climate of organization by applying strategy as a tool too. In other words, leader stands at the top and place strategy between him and culture; actually, leader applies strategy as a means to influence organizational culture. This is deducted from the role of leader in designing strategies, Where Abramson and Lawrence claimed (2001): Managerial leaders must develop a course of action or strategy for implementing change. Convincing the members of an organization of the need for change is obviously not enough to bring about actual change. The new idea or vision must be transformed into a course of action or strategy with goals and a plan for achieving it Changing performance The performance of an organization is effective factor through which leader influence the culture. Wikipedia defined Performance defined as the activity of a unit (be it individual, team, department, or division) of an organization intended to accomplish some desired result (2011). This item is evaluated by measuring outputs and outcomes. There is a multilateral and at the same time mutual relation among leadership, culture and performance. In other words, they are interdependent (i.e. leadership and climate are subject to affect by the status of performance of organization). To understand this linkage a circle of relation between leader, climate and performance should be studied. It can be understood from this circle that leader can affect culture through changing performance. In this network of linkage leader affects culture and alter its elements through changing performance and informing employees about it. This influence occurs through the Feedback. Feedback typically consists of information provided to an individual for the purpose of an increase in performance (Kluger, A. N. Denisi, A., 1996). There is variety of feedback forms, which are described by different aspects. One kind of feedback is outcome feedback in which information concerning performance outcomes. (Balcazar, F., Hopkins, B. L., Suarez, Y, 1986) It seems positive and constructive, to inform employees about high performance and improvement of outcomes. Geister et al. concluded in their case study that information and feedback about the team situation is crucial to improving the motivation, satisfaction, and performance of members in virtual teams. (2006) Leader affects the culture of organization indirectly through improving performance and diffusing information about it, an action which leads to a healthy, motivate and more evolutionary climate. If decisions and policies leader applied led to quality performance, it encourages atmosphere of hardworking, competition, integration and responsibility but in fragile situation and poor performance culture would collapse. Culture creates leader, a challenge While the impact of leader on culture is a considerable fact and has been studied and proved in many cases, some opinions challenged it. In an attempt to address this theoretical disagreement, Sarros et al. surveyed over 1,900 managers in Australia and found that leadership was a far more prominent predictor of culture than culture was of leadership. (2002) As it has been mentioned there are an interdependent relations among leadership, culture and performance, so it is a noticeable reality that leader is affected by culture too. Hatch claimed that it is difficult for leaders to have any impact on culture, as culture has a larger influence on leaders. (1993) Schein asserted that while leaders create culture in the early stages of an organization, culture creates leaders as an organization matures. He claimed that culture is deep, broad, and stable. It can be an unconscious determinant of who gets hired, who gets promoted and rewarded, and indeed, how the vision, mission, and strategy are lived. (2004) Culture of organization is a very decisive factor, so leader has to apply appropriate way of leading which does work in that climate. Smith et al. have sought for a proper model of leadership in China by regarding effects of cultural backgrounds (1997), which reflect the crucial role of culture in determining leadership style. It seems imperfect and naÃÆ'Â ¯f to study the relation of leader and climate unilaterally. The relation is mutual and should be studied in this way to achieve a perfect view. Other factors as actors While leadership plays a core role in creating organizational culture, other factors affect climate and even can take it out of control of leader. Culture can be affected by different internal and external factors. As the culture has defined as meanings and behaviours of members, the organizational members are effective actors. Krizek views culture as patterns of meaning and interpretation-whether these patterns emerge among management or employees. So, before leader creates culture, it has been constituted by members beliefs and thoughts as internal actors (2005). As another internal factor, type of function and business of organization conducts the elements of culture. (Schein E. H., Organizational Culture and Leadership, 1992) In other words the mission of organization is a set of beliefs about its core competences (Schein E. H., Organizational Culture and Leadership, 2004, p. 89). External forces may or may not influence the communicative and cultural makeup of an organization. (Cheney, 2001) Examples of external forces include, but are not limited to, economics, education, family, law, media, politics, religion, and technology. External environment and constraints have a considerable role in determining climate of organizations. As, leader has to make situation and organization ready to cope with external environment, any change in environment leads to change policies, behaviours and routines and finally innovates the culture. Schein pointed out that if the environmental context is changing such conflict can be a potential source of adaption and new learning. (2004, p. 108) Organizational culture is influenced by social and national culture of the area in which it is situated. National beliefs, stories, type of thinking and values affect the climate of organization. So, leader is situated in a set of actors that shape culture and is not exclusive actor. Conclusion In this paper the view that leaders create organizational culture has been examined critically. At the first the culture defined as a set of routines, behaviour, meanings and understandings that is shared among members of an organization. Leader defined as who make decision, determine directions and make things happen or not to happen. It has been proved that leaders have a noticeable role in creating organizational climate. The first way through which culture forms by leader is by the stream of meaning, behaviour and beliefs as an ideal method or pattern from top (leader) to down (employees). In this statement employees are assumed as followers who are affected by the nature of leader. As a short explanation, Leadership consists of attributes and skills that determine not only the nature of enterprise, in all its manifestations, but the overall nature of society and the world (Sarros, J. Gray, J. Densten, I, 2002). In this way leaders are charismatic persons by whom followers behaviours consciously or unconsciously are affected. The second conduit for influencing culture is ruling. Leader is top ruler in organization who directs routines, structures and procedures. It has been assumed that by doing these affairs, leader is manipulating culture or changing its elements. In this statement changing culture described as changing procedures and formal administrative process. In third way the focus has been put on strategy. Strategy is the manifestation of mission, directions, tasks and rules and has a strong correlation with culture. It has been expressed that leader affects culture through strategy in two ways. First way is attempt to codify and provide strategy. In this state leader as a strategist inject beliefs and preference into strategy and determine culture through it. The second channel is to standing between strategy and culture in order to interpret and implement it in preferred way. The other area which has been studied is performance. It assumed that leader plays remarkable role in changing performance and the status of outcomes of organization affect the culture directly. The impact of high performance in healthy culture and poor one in weak climate mentioned in this paper. These four ways illustrate the crucial role of leadership in creating culture. But in last two sections of paper this role has been challenged in two statements. First is that while leader creates culture, culture creates leader too. As mentioned, culture is stable and has elements that determine which style of leadership is required and who can be the organizational leader. As, Schein assumes leadership and culture as two sides of one coin, cultural norms define how a given nation or organization will define leadership. (2004) In addition, some factors like external environment, employees beliefs, business of organization, and national culture introduced as factors which affect organizational culture. In conclusion, it should be claimed that the effects of leadership in shaping culture is noticeable and can be realized by studying it through different ways. But the more crucial point is that the effect is not directly except in first way in which leader becomes a pattern for followers. In all conditions leader can apply some policies by which affects culture. Employees play decisive role in changing climate, and leaders dont change culture, they merely invite their people to change the culture (Hillis). So, leader is not the exclusive actor in influencing culture. Other factors should be studied so that an effective innovation and successful change in culture can be achieved.

Reading Comprehension: From Research to Classroom Essay -- Educational

Language plays a central role in almost all aspects of our lives. This paper will focus on examining the cognitive processes that are involved in using and understanding written language. Because language almost always involves units of language larger than an individual word or a single sentence, it is important to emphasize how people understand connected discourse, such as stories. Understanding these central cognitive processes will help school psychologists understand how to facilitate reading comprehension in the classroom setting. Although most of these psychological studies do not deal with specific methods on how to how to comprehend a story, these studies do indicate some of the more powerful factors that influence whether comprehension occurs. The purpose of this paper is to provide an integration of the current approaches of research in reading comprehension with ways of facilitating comprehension in the classroom. First, a summary of the current approaches to comprehensi on is given, highlighting the most central concepts arising from several different perspectives. Second, a review of the empirical research is included, illustrating how recent advances in theory have increased awareness of the comprehension skills of children, especially at an early age. Third, some of the main conclusions and issues in the area are discussed in terms of theoretical and empirical advances and applications to school settings. One of the central approaches to comprehension is termed schema theory. This approach can be used to interpret how readers interpret the text that they read. The core components of schema theory are derived from Sir Frederic Bartlett’s (1932) use of the word schemata and his interpretation of adults’ memory for s... ...Learning and Verbal Behavior, 11, 717-726. Ericsson, K.A., & Charness, N. (1994). Expert performance: Its structure and acquisition. American Psychologist, vol. 49(8), pp. 725- 747. Kintsch, W. (1998). Comprehension: A Paradigm for Cognition. N.Y: Cambridge University Press. Hart, B., & Risley, T.R. (1992). American parenting of language-learning children: Persisting differences in family-child interactions observed in natural home environments. Developmental Psychology, 28(6), 1096-1105. Nagy, W.E., & Scott, J. (2000). Vocabulary Processes in Kamil, M. et al., Handbook of Reading Research, vol. III. Mahwah, N.J.: Erlbaum. Thorndike, P.W., & Hayes-Roth, B. (1979). The use of schemata in the acquisition and transfer of knowledge. Cognitive Psychology, 11, 82-106. Solso, R.L., Maclin, O.H., & Maclin, M.K. (2008). Cognitive Psychology: Eight Edition.