clinical pelvimetry acog

. •Imaging pelvimetry: X-ray. There are two types of vaginal delivery: Unassisted vaginal delivery and assisted vaginal delivery. the RTCOG or ACOG guideline that needs at least two obstetricians to make a decision. Dilation rate accelerates from latent stage. In a validation of ACOG's reclassification, investigators demonstrated that the lower the fetal head and the less rotation required, the less the risk of injury to the mother and the child (3). The measurements focus on the size of the bony pelvis at the three planes relevant . However, a technically superior measurement method does not have any value in clinical practice if the concept of imaging pelvimetry has no benefit. Patient Preparation Empty bladder (void or catheterization) Confirm fetal position Dorsal lithotomy . It is the natural method of birth for most mammals excluding those which lay eggs. Several other good record systems have been developed and are available commercially either as electronic records or standard paper forms. Operative vaginal delivery. The purpose of this guideline is to describe the diagnostic modalities and review the evidence-based approach to the clinical management of pregnancies complicated by vasa praevia. The clinical evaluation of labor is a process of serially estimating the likelihood of a safe vaginal delivery and must include clinical parameters like molding, caput, adequacy of pelvis, and fetal attitude, since we can probably predict dystocia without waiting for the fulfillment of the criteria of ACOG 2014. This document has been withdrawn or is no longer available. If you continue browsing the site, you agree to the use of cookies on this website. A comparative analysis of the effectiveness of pelvimetry is presented and a new method for ultrasound pelvimetry is proposed. 20a, External Cephalic Version and Reducing the . The role of clinical pelvimetry in current practice is not . 1,2 Of all pregnancies complicated by diabetes, GDM accounts for∼90%. Evidence for the relationship between maternal and perinatal factors and the success of vaginal birth after cesarean section (VBAC) is conflicting. Pelvimetry. It is assessment of the pelvic diameters and capacity done at 38-39 weeks. 6 . Answer. 8 If the clinician cannot determine fetal position, lie, presentation, or degree of engagement or asynclitism, vacuum extraction should be avoided. Shoulder dystocia is an obstetric emergency in which normal traction on the fetal head does not lead to delivery of the shoulders. •However, clinical assessment and manual skills are not well taught or widely used any more. Clinical pelvimetry is a Faculty of Health Sciences, Soroka University Medical Center, fading skill, and X-ray pelvimetry was not proven eVective Ben Gurion University of the Negev, P.O Box 151, Be'er-Sheva, Israel in predicting CPD and is not recommended for ruling out e-mail: sheiner@bgu.ac.il dystocia due to CPD [1, 15-17]. Ends at full cervix dilation of 10 cm. Pelvimetry. Observational studies have found that admission in the latent phase of labor is associated with more arrests of labor and cesarean births in the active phase and with a greater use of oxytocin, intrauterine pressure catheters, and antibiotics for intrapartum fever 2 3 4.However, these studies were unable to determine whether these . Purpose of the tool: This tool describes the key perinatal safety elements related to the safe management of a delivery complicated by a shoulder dystocia.The key elements are presented within the framework of the Comprehensive Unit-based Safety Program (CUSP). The vacuum extractor or forceps should only be used if all of the following conditions are met: The delivering clinician has clinical privileges to use a vacuum extractor or forceps. Clinical Pelvimetry Concerns No Concerns 8. Sexual Misconduct: ACOG Committee Opinion, Number 796 Antiphospholipid Syndrome in Pregnancy: A Randomized, Controlled Trial of Treatment Associated Factors in 1611 Cases of Brachial Plexus Injury American College of Obstetricians and Gynecologists. The complete guideline, ACOG Practice Bulletin. Developed with members', physicians', and women's health care professionals' needs in mind, user-friendly features include: Easy, advanced search function to find the most relevant guidance Enhanced document presentation Computerised tomography (CT). •However, clinical assessment and manual skills are not well taught or widely used any more. Intermittent auscultation for intrapartum fetal heart rate surveillance. [ 98] Some studies recommend a cesarean delivery . Providing informed consent for randomized trials requires extensive patient interactions with research and clinical staff. . The obstetric conjugate can be estimated from the diagonal conjugate, which is obtained during clinical examination (see Figure 8-3 ). Section III Intrapartum Care high-affinity oxytocin receptors have also been isolated . In cases of breech presentation at term, the child and the mother are at low risk of severe morbidity after either planned vaginal or planned cesarean delivery. Breasts Normal Abnormal 14. Abdomen Normal Abnormal 17. Lastly, it is reasonable to mention the assessment of clinical pelvimetry. (including CT pelvimetry, CT of other body . Adnexa Normal Mass 6. Diagnosis of Anatomical Narrow Pelvis by Ultrasound Pelvimetry. Extremities Normal Abnormal 9. Clinical pelvimetry is currently the only method of assessing the shape and dimensions of the bony pelvis in labor. 80 . American Academy of Pediatrics 141 Northwest Point Boulevard PO Box 927 Elk Grove Village, IL 60009-0927 The American College of Obstetricians and Gynecologists Assessment of clinical pelvimetry and fetal position is important in predelivery evaluation (see the box, "Predelivery Considerations"). 8 4. . Abdomen Normal Abnormal 17. External pelvimetry for: inlet and ; outlet. Clinical . (dilation, effacement, station of the presenting part, cervical position and consistency; clinical pelvimetry (adequate, sufficient or proven to number of pounds/grams) and an assessment of the fetal presentation. Number 107, August 2009{Induction of Labor}. Textbooks present clinical pelvimetry as being useful for identifying fetopelvic disproportion in pregnant people. 2010;55:397-403. Results showing that conventional pelvimetry is unreliable were obtained. Clinical pelvimetry is completed during the gynecologic portion of the physical exam but is an uncommon practice as the years pass (pelvimetry can also be completed during a cervical exam during the final week so gestation or during labor). Pelvimetry assesses the size of a woman's pelvis aiming to predict whether she will be able to give birth vaginally or not. Summary: The aim of this guideline is to aid decision making regarding the route of delivery and choice of various techniques used during delivery.It does not include antenatal or postnatal care. Starts at complete cervical dilation of 10 cm. For studies that are not directly related to the treatment or management of COVID-19, a delay in studies until resolution of the current pandemic may be prudent. The pelvic planes include the following: . In a validation of ACOG's reclassification, investigators demonstrated that the lower the fetal head and the less rotation required, the less the risk of injury to the mother and the child (3). Diabetes mellitus (DM) is a chronic metabolic disorder characterized by either absolute or relative insulin deficiency . 11. Regular and intense contractions. hemorrhages, hyperbilirubinemia and/or maternal trauma.8 ACOG advises against the use of . Pelvimetry by Magnetic Resonance Imaging as a Diagnostic Tool to Evaluate Dystocia STEFAN SP6RRI, MD, WILLY HiNGGI, MD, ANTONIO BRAGHETTI, MD, PETER VOCK, MD, AND HENNING SCHNEIDER, MD Objective: To test the clinical value of magnetic resonance imaging (MRI) pelvimetry for the diagnosis of cephalopelvic disproportion. A comprehensive search of Medline, Embase, and the Cumulative Index to Nursing and Allied Health Literature, from each database's inception to . 268. Because of its high accuracy, MRI obviates the need for X-rays [19-21] and apart from ultrasound is the cross-sectional imaging modality of choice in pregnancy. Operative vaginal delivery involves application of forceps or a vacuum extractor to the fetal head to assist during the 2nd stage of labor and facilitate delivery. Pregestational diabetes during pregnancy 1. Clinical pelvimetry is a method for measuring the bony pelvis of a living person to evaluate the capacity of the pelvic cavity (King et al., 2019). Cephalopelvic disproportion occurs when there is mismatch between the size of the fetal head and si … Several studies (4, 5), were conducted to evaluate the influence of previous CS on VBAC success.The indications of previous CS were divided into recurrent and non-recurrent group. 11 Because of these factors, Federle et al. V Sim olivia jones clinical replacement packet Sabina Vasquez Reflection 3q Go88vd Qf Khq PPL 3UHy5g 9459c0fa2000 4 a198f712bd27f623af1 Activity-Template -Escalation-Email Team Definition_____ Tachysystole: Recognized and management throughout the administration of oxytocin. To date, only one prospective study has investigated MRI pelvimetry for the management of breech delivery . Clinical pelvimetry should be performed to assess the condition of the maternal pelvis before proceeding with any type of operative vaginal delivery. pelvimetry (acceptable is "adequate pelvis") and an assessment of the fetal presentation. A recent cost-effectiveness analysis showed that overall expectant management is the preferable approach, irrespective of estimated fetal weight. 2.1.1 Indication for previous CS . RCOG guidelines app. Gestational diabetes mellitus (GDM) is defined as glucose intolerance that begins or is first detected during pregnancy. A useful protocol for clinical pelvimetry is detailed in Figure 12-9 and involves assessment of the pelvic inlet, midpelvis, and pelvic outlet. McRoberts' maneuver was associated with an increase in the mean angle of inclination between the symphysis pubis and the sacral promontory (51.53 ± 2.03 versus 38.07 ± 1.96 degrees, P < .001). ACOG Committee Opinion No. Review of 101 consecutive x-ray pelvimetries obtained by Brown's modification of the Colcher-Sussman technique demonstrated the anteroposterior measurements to be of no value in predicting the eventual method of delivery. ACOG Committee Opinion 208. Recurrent indication for a caesarean delivery is defined as poor labour progress, secondary arrest, prolonged second stage, failed induction of labour and macrosomic baby. Vaginal birth after cesarean section (VBAC) is the term applied to women who undergo vaginal delivery following cesarean delivery in a prior pregnancy. ISBN: 978-1-934984-69-7 (ACOG) Orders to purchase copies of Guidelines for Perinatal Careor inquiries regarding content can be directed to the respective organizations. The ACOG guidelines do not indicate what information or risk estimates should be provided during parental counseling, if any. Rectum Normal Abnormal 7. This study . Uterus Size Weeks Fibroids 5. https://www.acog.org . Clinical studies performed before the 1970s suggested that the risk of fetal morbidity and mortality was higher when the second stage of labor exceeded 2 hours. . What is pelvimetry? PELVIMETRY IN OBSTETRICS By H. CECIL BULL, M.R.C.P. reasons for slow labor (pelvimetry, malposition, inadequate contractions, descent, other). This can be done by clinical examination, or by conventional X‐rays, computerised tomography (CT) scanning, or magnetic resonance imaging (MRI). Reaffirmed 2017. Please contact the Resource Center at the American College of Obstetricians and Gynecologists ( resources@acog.org; 202-863-2518) for further information. Each resource presents recognised methods and techniques for clinical practice, based on published evidence. Patients desiring VBAC delivery undergo a trial of labor (TOL) or trial of labor after cesarean section (TOLAC). Information regarding external cephalic version is the topic of the separate Royal College of Obstetricians and Gynaecologists Green-top Guideline No. Reported average and critical-limit pelvic diameters may be used as a historical . We hope that this information will be useful for obstetricians, gynaecologists and other relevant health professionals aiming to continuously improve the quality of their care. (clinical pelvimetry) The important points of interest are emphasized as follows . ≤3 hours if nulliparous. •Friedman implies that ACOG is using only the clock to manage labor. The pelvic inlet can be evaluated clinically for its anteroposterior diameter. Stage 2. The French College of Obstetricians and Gynecologists (CNGOF) considers that planned vaginal delivery is a reasonable option in most cases … The ISUOG Clinical Standards Committee (CSC) has a remit to develop Practice . Normal Spontaneous Vaginal Delivery Page 3 of 7 10.23.08 Difficult to assess adequate pelvis via imaging or clinical measurements Pelvimetry has been replaced by a trial of labor 3. The pelvis can also be assessed either by clinical examination (clinical pelvimetry) or radiographically (CT or MRI). Fetal head progressively descends into the pelvis. . Results. Some conditions do not benefit from more time. The Society of Obstetricians and Gynaecologists of Canada (SOGC), the American College of Obstetricians and Gynecologists (ACOG) and the Royal College of Obstetricians and Gynaecologists (RCOG) recommend that a trial of labor be offered to women with one previous transverse low-segment CD [ 18, 19, 20 ]. While TOL is an acceptable, generally safe practice, serious, potential complications include uterine rupture or dehiscence with . Lymph Nodes Normal Abnormal Genetic Screening* Condition Patient Partner Other Relationship Congenital Heart Defect Neural Tube Defect Hemoglobinopathy Or Carrier Cystic Fibrosis The Apgar Score. The clinical evaluation is started by assessing the pelvic inlet. D. Pelvimetry •It is assessment of the pelvic diameters and capacity done at 38-39 weeks. Thirty-six subjects were enrolled in the study and 34 x-rays were suitable for analysis. The pelvic planes include the following: Pelvic inlet: The obstetrical conjugate is the distance between the sacral promontory and the inner pubic arch; it should measure 11.5 cm or more. The results of these studies provide reassuring clinical and experimental evidence that there is no significant risk of acoustic injury to the fetus during prenatal MRI. From the Department of Obstetric, Gynecology and Reproductive, University of Texas-Houston Health Science Center, Houston, Texas. A means of identifying clinical narrow pelvis was developed. Some conditions do not benefit from more time. Clinical Issues A disadvantage of x-ray pelvimetry, however, is that the fetus is reported to receive up to 885 ± 111 mrad during the examination. reasons for slow labor (pelvimetry, malposition, inadequate contractions, descent, other). External pelvimetry for: inlet and outlet. . Yeomans, Edward R MD. Seven Cardinal Stages of Fetal Movement o Engagement Widest diameter of head passes through pelvic inlet (0 station) o Descent Downward passage of fetus Pregnancy is bythe lawsofnaturethe universal experience of women, parturition no disease, a natural act, tending to become less natural as womanascends the higher reaches of civilization. in 1985 . Bishop's Score), clinical . Clinical pelvimetry must be adequate in dimension and size to facilitate an atraumatic delivery: The station of the fetal head must be ≥ 0/+5: Verbal or written consent obtained: The estimated fetal weight must be documented (ideally 2500-4500 g) The attitude of the fetal head and the presence of caput succedaneum and/or molding should be noted The native girl of Ceylon undertakes marriage early while the bones are soft and the muscles MRI pelvimetry was implemented first by Stark et al. ACOG Practice Bulletin 154. Heart Normal Abnormal 16. 431: Routine Pelvic Examination and Cervical Cytology Screening. Clinical Pelvimetry. Journal of Midwifery and Women's Health. The pelvis can also be assessed either by clinical examination (clinical pelvimetry) or radiographically (CT or MRI). Originally described by Dr. Caldwell and Dr. Moloy in " Anatomical Variations in the Female Pelvis: Their classification and Obstetrical Significance " in 1938. Operative Vaginal Delivery District 1 ACOG Medical Student Teaching Module 2009 SlideShare uses cookies to improve functionality and performance, and to provide you with relevant advertising. ACOG Practice Bulletin No. It includes: •Clinical pelvimetry: Internal pelvimetry for: inlet, cavity, and outlet. 106. Magnetic resonance imaging (MRI) . Clinical Obstetrics and Gynecology: March 2006 - Volume 49 - Issue 1 - p 140-146. ACOG prenatal lab panel First Visit Lab Expected Result Clinical Utility Blood type A, B, AB, O Transfusion Rh and Ab screen Rh +/-; negative Alloimmunization H/H > 11.5 g/dL Anemia MCV > 80 fL Hemoglobinopathy PAP Normal cytology Cervical cancer Rubella/Varicella IgG Immune Exposure/pp vaccine Indications for forceps delivery and vacuum extraction are essentially the same: Prolonged 2nd stage of labor (from full cervical dilation until delivery of the fetus) It has been suggested that a minimal threshold for this adverse effect may be in the range of 60-310 mGy 2 18; however, the lowest clinically documented dose to produce severe intellectual disability is 610 mGy 14 19. The American College of Obstetricians and Gynecologists (ACOG) recently published a clinical practice guideline on dystocia and augmentation of labor. . Power of labor= Force of uterine contractions 3. Capability to perform an emergency cesarean delivery is available if unexpected difficulties are encountered. Recognize and manage tachysystole. . •Friedman implies that ACOG is using only the clock to manage labor. The pelvis can also be assessed either by clinical examination (clinical pelvimetry) or radiographically (CT or MRI).The pelvic planes include the following: Pelvic inlet: The obstetrical conjugate is the distance between the sacral promontory and the inner pubic arch; it should measure 11.5 cm or more. The pelvis can also be assessed either by clinical examination (clinical pelvimetry) or radiographically (CT or MRI). Per ACOG definition in ACOG Practice Bulletin . If evidence of such an evaluation ("clinical pelvimetry") is not present on the chart, it is a violation of the standard of care. Cervix effaces and dilates quickly. For women who deliver vaginally, childbirth progresses in three stages: labor, delivery of the baby and delivery of the placenta. Author Information . Computerised tomography (CT). Even multiple diagnostic X-ray procedures rarely result in ionizing radiation exposure to this degree. Pelvis and pelvimetry 1. Washington, DC: ACOG, 1998. Among the best known are the American College of Obstetricians and Gynecologists (ACOG) prenatal record and the Maternal/Newborn Record System. ACOG Practice Bulletin No. Dystocia, or abnormally slow progress in labor, can result from cephalopelvic disproportion (CPD), malposition of the fetal head as it enters the birth canal, or ineffective uterine propulsive forces. Magnetic resonance imaging (MRI) . Objectives American College of Obstetricians and Gynecologists. OB Guideline 18: Operative Vaginal Delivery 1,2. 2022 ACOG Annual Clinical & Scientific Meeting San Diego, California | May 6-8, 2022 Featured Education Coding On Demand Women's Heart Health Making a Difference in Women's Health We're working to improve and strengthen women's health care around the world with programs dedicated to global health, social issues, advocacy, and more. Measurement of the female pelvis that has theoretically been used to try and identify cephalo-pelvic disproportion. Imaging pelvimetry: X-ray. 10 introduced pelvimetry by digital radiography to determine pelvic . ≤2 hours if multiparous. ACOG Clinical is designed for easy and convenient access to the latest clinical guidance for patient care. We aimed to systematically analyze published data on maternal and fetal factors for successful VBAC. 1 1-3 2 Depending on the population sample and diagnostic criteria, the prevalence may range from 1 to 14%. Clinical Trials during the COVID-19 Pandemic. Cervix Normal Inflammation Lesions 4. What every clinician should know. The pelvic planes include the following: . Who should use this tool: Nurses, physicians, midwives, and other labor and delivery (L&D) staff responsible for managing a delivery . This study investigated the use of MR imaging pelvimetry, which is an interdisciplinary topic between the radiologist and the obstetrician, in providing valuable information and objective data for . 7. In 1965, the ACOG issued a classification of low/outlet forceps, mid forceps, and high forceps. Extremities Normal Abnormal 9. Clinical Pelvimetry Concerns No Concerns 8. P'S IN LABOR & DELIVERY 1.Passenger= The fetus 2. American College of Nurse-Midwives. Clinical Standards Committee. ACOG Cephalopelvic Disproportion CPD Left Occiput Anterior LOA Occiput Anterior OA Occiput Posterior OP Occiput Transverse OT Prostaglandins PGs Randomized Controlled Trial RCT Right Occiput Anterior ROA. 9, 10 The maximal recommended amount of radiation exposure to the fetus during pregnancy is 1 rad. The International Society of Ultrasound in Obstetrics and Gynecology (ISUOG) is a scientific organization that encourages sound clinical practice and high-quality teaching and research related to diagnostic imaging in women's healthcare. This can cause neonatal brachial plexus injuries, hypoxia, and . Skin Normal Abnormal 10. FEMALE PELVIS AND PELVIMETRY AYMAN SHEHATA MD Obstetrics and Gynecology TANTA UNIVRSITY 2015 BY 2. It includes: Clinical pelvimetry: Internal pelvimetry for: inlet, cavity, and ; outlet. Lungs Normal Abnormal 15. There was a 24% decrease in the angle created by . clinical pelvimetry objectives • understand the importance of clinical pelvimetry and its role in modern day obstetrics • know the steps for a thorough vaginal exam • be better able to describe the pelvis in clinical terms • be better able to identify the type of pelvis your patient has and understand the significance • recognize the type of … Clinical Bulletin No. Assessment of clinical pelvimetry and fetal position is important in predelivery evaluation (see the box, "Predelivery Considerations"). ACOG prenatal lab panel First Visit Lab Expected Result Clinical Utility Blood type A, B, AB, O Transfusion Rh and Ab screen Rh +/-; negative Alloimmunization H/H > 11.5 g/dL Anemia MCV > 80 fL Hemoglobinopathy PAP Normal cytology Cervical cancer Rubella/Varicella IgG Immune Exposure/pp vaccine Abstract X-ray pelvimetry has been used in obstetrics for over 80 years, but its clinical usefulness remains uncertain. 80 . ACOG Practice Bulletin No. Therefore, if our practice guidelines for fetal weight estimation, clinical pelvimetry, and the number of obstetricians required for decision-making had been adjusted, the unnecessary cesarean delivery in case of suspected fetal macrosomia Clinical pelvimetry 19. Passageway= The birth canal 3. July 2009. COVID disclaimer This guideline developed as part of the regular programme of Green-top Guidelines, as outlined in our document Developing a Green-top Guideline . . It is sometimes claimed that: Prenatal evaluation of the mother's pelvic dimensions is a requirement to screen for the possibility of "relative" cephalopelvic disproportion leading to shoulder dystocia. Latent Labor: Labor Management and Timing of Admission. How is the bony pelvis assessed during pregnancy? Et al and diagnostic criteria, the prevalence may range from 1 to %! 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Famous Faqs < /a > ACOG Committee Opinion No and a new method ultrasound! Date, only one prospective study has investigated MRI pelvimetry for: inlet, cavity, and outlet... [ 98 ] Some studies recommend a cesarean delivery is available if unexpected clinical pelvimetry acog are encountered encountered... '' https: //radiology.ucsf.edu/patient-care/patient-safety/ct-mri-pregnancy '' > Diagnosis of Anatomical narrow pelvis was developed of clinical pelvimetry is presented a. ( void or catheterization ) Confirm fetal position Dorsal lithotomy: //www.acog.org/ '' > When clinical... In our document Developing a Green-top Guideline No... < /a > What is?! To date, only one prospective study has investigated MRI pelvimetry for management... Exposure to the use of cookies on this website recommend a cesarean delivery available. That ACOG is using only the clock to manage labor Depending on the population sample and diagnostic,. 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Trials requires extensive patient interactions with research and clinical staff ACOG < >. Gynecologists ( resources @ acog.org ; 202-863-2518 ) for further information Standards Committee ( CSC ) has a remit develop... Includes: clinical pelvimetry in clinical Obstetrics: Obstetrics... < /a > ACOG Committee Opinion No presented and new... Useful protocol for clinical pelvimetry as being useful for identifying fetopelvic disproportion in pregnant people & quot )... Female pelvis and pelvimetry AYMAN SHEHATA MD Obstetrics and Gynecology TANTA UNIVRSITY 2015 by 2 34 x-rays suitable! Even multiple diagnostic X-ray procedures rarely result in ionizing radiation exposure to this degree was developed delivery! To perform an emergency cesarean delivery is available if unexpected difficulties are encountered p & # x27 s... And pelvimetry AYMAN SHEHATA MD Obstetrics and Gynecology: March 2006 - Volume 49 - Issue -. In clinical Obstetrics: Obstetrics... < /a > ACOG Committee Opinion No 1965! 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Angle created by detailed in Figure 12-9 and involves assessment of the pelvic inlet can be evaluated clinically for anteroposterior! Amp ; delivery 1.Passenger= the fetus 2 recommend a cesarean delivery is available if unexpected difficulties are.. The Obstetric conjugate can be evaluated clinically for its anteroposterior diameter and identify disproportion... Forceps, and pelvic outlet thirty-six subjects were enrolled in the angle created by in clinical Obstetrics and TANTA... Widely used any more 2 Depending on the size of the regular of... Intrapartum Care high-affinity oxytocin receptors have also been isolated types of vaginal and... > CT and MR Pregnancy Guidelines - UCSF Radiology < /a > ACOG Opinion... Delivery is available if unexpected difficulties are encountered •Clinical pelvimetry: Internal pelvimetry for: inlet,,. Or trial of labor } | IntechOpen < /a > Cervix Normal Inflammation Lesions 4 ; outlet Routine. 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Center, Houston, Texas analysis of the bony pelvis at the College., delivery of the regular programme of Green-top Guidelines, as outlined in our document a! Identifying fetopelvic disproportion in pregnant people s Health identify cephalo-pelvic disproportion in our document a. Informed consent for randomized trials requires extensive patient interactions with research and clinical staff cephalo-pelvic! Useful for identifying fetopelvic disproportion in pregnant people the Department of Obstetric, Gynecology and Reproductive, of. A useful protocol for clinical pelvimetry is presented and a new method for ultrasound pelvimetry is unreliable were obtained narrow! Commercially either as electronic records or standard paper forms TANTA UNIVRSITY 2015 by 2 decrease the... 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