Fees in LIHTC Program
The LIHTC program involves various fees, including application fees, optional fees, and non-optional fees. Understanding these fees is crucial for tenants and landlords to ensure compliance with regulations. Application fees may cover income verification, credit checks, and background screenings. Treasury regulations dictate which fees can be considered optional or non-optional. Non-optional fees are required for occupancy and must be included in the gross rent amount. Learn more about the different types of fees in the LIHTC program to navigate the rental process effectively.
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Presentation Transcript
Most maternal injuries occur during the second stage of labour but the diagnosis is made in the third stage after the delivery of the baby. Some of the commoner ones are described below.
PERINEAL TEARS The perineum is the region between the vaginal opening and the anus. The perineum may get injured when there is overstretching or rapid stretching during the delivery of the baby. An inelastic perineum due to the presence of a scar can also lead to a perineal tear. Some of the causes of overstretching of the perineum leading to perineal tear are:
A big baby - usually babies more than 4000 kgs or 9 ounces are considered big. Malpresentation of the baby like occipitoposterior position or face presentation. Average sized baby with a narrow maternal vaginal outlet Forceps delivery or other instrumental deliveries Shoulder Dystocia
Degrees of perineal tear: There are three degrees of perineal tear. First Degree perineal tear: This is only a mild degree of laceration or tear of the skin at the edge of the vaginal opening. The lower part of the vagina as well as the perineal skin may be torn but the major muscles of this region are not affected.
Second degree perineal tear: This involves rupture of the muscles of the perineum with deep tears in the vaginal wall. The tear may extend right up to the anus, but does not involve the anal sphincter. Third degree perineal tear: In a complete perineal tear, the tear extends from the vaginal opening through the posterior vaginal wall and the perineal muscles upto the anus with injuries to the external anal sphincter. The anal or the rectal canal may or may not be involved.
Management/Treatment of Perineal Tears Prevention is the best management. The second stage of labour should be properly conducted. An episiotomy should be performed wherever deemed necessary to prevent tear of the perineum. Immediate Repair: A first degree or second degree tear should be immediately repaired, preferably within the first 24 hours. Delayed Repair: If the tear is diagnosed after 24 hours, then the woman is given antibiotics and the wound dressed so that infection , if any, is controlled. Then the tear is repaired. Third Degree tear: A third degree tear is always repaired after 3 months of the delivery of the baby to allow the tissues to regain the pre-pregnant state.
VAGINAL TEARS Vaginal Tears can occur at any part of the vaginal wall, but are seen mostly at the junction between the lateral and posterior walls. These tears may be superficial with only minor lacerations of the vaginal mucosa. But, sometimes the tears may be deep enough to expose the inner muscles. Vaginal tears can also occur at the region around the urethra - the opening through which urine comes out. These are then called ' Paraurethral tears'. The problem with these type of tears is that there may be profuse bleeding from even a small tear since the region has a large blood supply.
Treatment / Management of vaginal Tears The vagina should always be examined under proper light immediately after the delivery of the baby for any such tears. All tears should be repaired immediately
CERVICAL TEARS Minor tears of the cervix are very common during delivery, especially in a woman who is delivering her first child. But sometimes, major lacerations which can cause severe bleeding may also occur . In fact, cervical tears are the commonest form of traumatic post partum hemorrhage. Cervical tears are commonest at the lateral angle, between the anterior and posterior lips of the cervix.
Causes of Cervical tear: Delivery through an undilated cervix whether spontaneously, or by forceps. Precipitate labour. Rigid cervix due to previous operations like the LEEP procedure, conisation, or cervical amputation. Very vascular cervix as can occur in low level placenta previa.
Treatment / Management of Cervical Tears The aim of treatment is to control bleeding as early as possible by repairing the tear. Minor lacerations without active bleeding does not require to be repaired - they heal spontaneously with no ill effects. Major cervical lacerations or tears need to be repaired in the Operating theater under anesthesia, good light and proper exposure of the tear.
VULVAL HEMATOMA Collection of blood anywhere in the vulval region is called vulval hematoma. Although vulval haematomas can also occur after an injury due to any cause, it is commonly seen after the vaginal delivery of a baby. A Vulval hematoma can occur either spontaneously or after improper repair of an episiotomy wound. Blood from a rupture of the deep veins of this region collects in a closed space with no opening for it to drain out.
Symptoms of Vulval Hematoma: A steadily increasing swelling to one side of the vagina. The swelling is tense and tender to the touch. The woman complains of severe pain, more so on sitting down. There may be difficulty in passing urine if the swelling presses on the urethra. The bleeding can be severe enough to cause the patient to go into shock.
Treatment / Management of Vulval Hematoma The aim of treatment is to ligate the bleeding blood vessels as early as possible and support the patient with IV drips and medicines so that she does not go into shock. An incision is made at the most distended point of the hematoma. The incision is then deepened and the blood clots scooped out. The bleeding vessels are identified and tied up. The incision is closed by applying different layers of stitches. A drain may be put in the wound for 24 hours to allow any oozing blood to flow out. Proper antibiotics are prescribed and the patient kept under close observation. Blood transfusion is given if necessary.
