Добірка наукової літератури з теми "Third and fourth degree tears"

ObjectiveSexuality is an important aspect of human identity and contributes significantly to the quality of life in women as well as in men. Impairment in sexual health after vaginal delivery is a major concern for many women. We aimed to examine the association between degree of perineal tear and sexual function 12 months postpartum.DesignA prospective cohort studySettingFour Danish hospitals between July 2015 and January 2019ParticipantsA total of 554 primiparous women: 191 with no/labia/first-degree tears, 189 with second-degree tears and 174 with third-degree/fourth-degree tears. Baseline data were obtained 2 weeks postpartum by a questionnaire and a clinical examination. Sexual function was evaluated 12 months postpartum by an electronic questionnaire (Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire (PISQ-12)) and a clinical examination.Primary outcome measuresTotal PISQ-12 score and dyspareuniaResultsEpisiotomy was performed in 54 cases and 95 women had an operative vaginal delivery. The proportion of women with dyspareunia was 25%, 38% and 53% of women with no/labia/first-degree, second-degree or third-degree/fourth-degree tears, respectively.Compared with women with no/labia/first-degree tears, women with second-degree or third-degree/fourth-degree tears had a higher risk of dyspareunia (adjusted relative risk (aRR) 2.05; 95% CI 1.51 to 2.78 and aRR 2.09; 95% CI 1.55 to 2.81, respectively). Women with third-degree/fourth-degree tears had a higher mean PISQ-12 score (12.2) than women with no/labia/first-degree tears (10.4).ConclusionsImpairment of sexual health is common among primiparous women after vaginal delivery. At 12 months postpartum, more than half of the women with a third-degree/fourth-degree tear experienced dyspareunia. Women delivering with no/labia/first-degree tears reported the best outcomes overall. Thus, it is important to minimise the extent of perineal trauma and to counsel about sexuality during and after pregnancy.

<strong>Objective</strong>. To identify risk factors for thirdand fourth-degree perineal tears, so as to anticipate and intervene in order to prevent this complication that can severely affect a woman’s quality of life. The study design was a retrospective case control study. <strong>Method</strong>. Ninety-three cases of third- and fourth-degree perineal tears were identified from the birth register of a tertiary referral hospital (Tygerberg Hospital). One hundred and nine patients with normal vaginal deliveries in the same time period were used as control group. <strong>Results</strong>. An analysis of the results revealed that there were no significant differences between cases and controls with regards to age, body mass index (BMI), gestation at delivery, duration of second stage, episiotomy and birth weight. However, there were significantly more primigravidas, assisted deliveries (forceps and vacuum), occipitoposterior positions, HIV negative patients and shoulder dystocia in the study group. <strong>Conclusions</strong>. Antenatal risk factors for thirdand fourth-degree tears are difficult to identify. However, intrapartum occipitoposterior and assisted deliveries, especially in the primigravid patient, should warn the obstetrician/ midwife about the risk of a severe tear. A restrictive episiotomy policy should be practiced. Shoulder dystocia was invariably associated with third- and fourth-degree tears in this study. The higher incidence of HIV negative patients in the study group requires further research.

Background: Perineal trauma is a common complication of childbirth and can have serious impacts on long-term health. Few studies have examined the combined effect of multiple risk factors. We developed and internally validated a risk prediction model to predict third and fourth degree perineal tears using data from a general obstetric population. Methods: Risk prediction model using data from all singleton vaginal deliveries at Cork University Maternity Hospital (CUMH), Ireland during 2019 and 2020. Third/fourth degree tears were diagnosed by an obstetrician or midwife at time of birth and defined as tears that extended into the anal sphincter complex or involved both the anal sphincter complex and anorectal mucosa. We used univariable and multivariable logistic regression with backward stepwise selection to develop the models. Candidate predictors included infant sex, maternal age, maternal body mass index, parity, mode of delivery, birthweight, post-term delivery, induction of labour and public/private antenatal care. We used the receiver operating characteristic (ROC) curve C-statistic to assess discrimination, and bootstrapping techniques were used to assess internal validation. Results: Of 8,403 singleton vaginal deliveries, 8,367 (99.54%) had complete data on predictors for model development. A total of 128 women (1.53%) had a third/fourth degree tear. Three variables remained in the final model: nulliparity, mode of delivery (specifically forceps delivery or ventouse delivery) and increasing birthweight (per 100 gram increase) (C-statistic: 0.75, 95% CI: 0.71, 0.79). We developed a nomogram to calculate individualised risk of third/fourth degree tears using these predictors. Bootstrapping indicated good internal performance. Conclusions: Use of our nomogram can provide an individualised risk assessment of third/fourth degree tears and potentially aid counselling of women on their potential risk.

Background. Perineal tears are one of the most common complications of vaginal delivery. Severe perineal tears can cause various morbidities. There are many factors that affect the occurrence of perineal tears. One of the major factors related to the occurrence of perineal tears is the length of the perineal body. However, until now, no research in Indonesia has concluded that the length of perineal body can predict the perineal tears. Objective. To find the relationship between perineal body length and perineal tears, so it can provide a reference on the use of perineal body length to predict severe perineal tears in vaginal delivery with episiotomy. Methods. This nested case-control study was conducted at RSUD Tangerang and RSUD Karawang in Indonesia from February to September 2017. A total of 126 primigravida patients participated in the study consecutively. The length of the perineal body was then measured and followed until the start of the second stage of labor. Afterwards, the perineal length and degree of perineal tears were assessed using unpaired T-test for bivariate analysis, multivariate analysis, and scoring test to predict the occurrence of third- and fourth-degree of perineal tears with power calculation (β) 80% and Zβ 0.842. Results. There was a significant difference in mean length of the perineal body between the group with first- and second-degree perineal tears and the group with third- and fourth-degree perineal tears ( p < 0.001 ). From the multivariate analysis, adjusted OR was 5.26 (95% CI 1.52–18.17). Score test was performed to predict the occurrence of third- and fourth-grade perineal tears. Perineal body length and head circumference could be used as predicting factors of perineal tears. Perineum length ≤ 3.0 cm and head circumference ≥ 33.5 cm posed a risk of perineal tears of third and fourth degrees (70.52%). Conclusion. The length of the perineal body has a good ability to predict the occurrence of perineal tears.

Introdução: A laceração obstétrica do esfíncter anal (LOEA) está associado com incontinência anal. A episiotomia foi proposta como uma forma de proteção do esfíncter anal no parto, especialmente a episiotomia mediolateral; entretanto, diversos estudos mostraram que o uso de rotina da episiotomia não reduz o risco de LOEA. Objetivo: Este estudo tem por objetivo analisar se a redução na taxa de episiotomia em hospital escola no Brasil foi associada a um aumento na incidência de lacerações obstétricas do esfíncter anal, além de fatores associados a elas. Métodos: Estudo observacional, transversal e retrospectivo, realizado no Hospital de Clínicas de Porto Alegre, Rio Grande do Sul, Brasil. Foram incluídos todos os partos vaginais de gestações únicas, apresentação cefálica, a partir de 34 semanas de idade gestacional, realizados em 2011-2012 (uso liberal da episiotomia) e 2015-2016 (uso restrito da episiotomia), e comparados em relação a taxa de episiotomia mediolateral e de LOEA. Resultados: foram analisados 4268 partos (2043 no período de 2011-2012, 2225 de 2015-2016), foram analisados 2043 partos. A taxa de episiotomia reduziu de 59.4% para 44.2% (p≤0.0001). No período 2011-2012, ocorreram 10 lacerações obstétricas do esfíncter anal em 2043 partos (0.48%), enquanto que no período 2015-2016, ocorreram 31 lacerações em 2225 partos (1.39%). Houve interação quando comparado os dois períodos em relação a realização de episiotomia e a ocorrência de LOEA (p≤0.0001). A episiotomia foi fortemente associada a não ocorrência de LOEA em 2011-2012 (59.5%), enquanto que não ter episiotomia foi associado ao grupo com (67.7%) e sem LOEA (55.7%) em 2015-2016. Fatores associados a LOEA foram indução do parto e distócia de ombro. Conclusão: Houve um aumento na taxa de lacerações do esfíncter anal com a diminuição da taxa de episiotomia. A episiotomia de rotina foi prote
Introduction: Obstetric anal sphincter tear (OAST) is associated with anal incontinence. Episiotomy was proposed as a form of protection of the anal sphincter at delivery, especially mediolateral episiotomy; however, several studies have shown that routine use of episiotomy does not reduce the risk of OAST. Objective: This study aims to analyse whether the reduction in the rate of episiotomy in a school hospital in Brazil was associated with an increase in the incidence of obstetric lacerations of the anal sphincter, in addition to associated factors. Methods: Observational, cross-sectional and retrospective study, conducted at Hospital de Clínicas, Porto Alegre, Rio Grande do Sul, Brazil. We included all vaginal deliveries of single pregnancies, cephalic presentation, from 34 weeks of gestational age, performed in 2011-2012 (liberal episiotomy) and 2015- 2016 (restricted episiotomy), and compared in relation to the rate of mediolateral episiotomy and OAST. Results: 4268 births were analysed (2043 in 2011-2012 and 2225 in 2015-2016). The episiotomy rate decreased from 59.4% to 44.2% (p≤0.0001). In 2011-2012, there were 10 obstetric anal sphincter lacerations in 2043 births (0.48%), while in the period 2015-2016 there were 31 lacerations in 2225 births (1.39%). There was interaction when comparing the two periods in relation to the episiotomy and the occurrence of OAST (p≤0.0001). Episiotomy was strongly related to 2011-2012 group with no OAST (59.5%), while not having an episiotomy was related to both OAST (67.7%) and no OAST (55.7%) group in 2015-2016. Factors associated with OAST were labor induction and shoulder dystocia. Conclusion: There was an increase in the rate of lacerations of the anal sphincter with a decrease in the rate of episiotomy. Routine episiotomy was protective.

Anal incontinence (AI) has a debilitating and devastating impact on a person’s quality of life. However the impact is often unreported due to the social stigma that surrounds AI and the utilisation of ineffective symptom severity scores which accurately assess the impact on quality of life. There is a significant amount of research literature which addresses the prevalence and cause of AI. Less information addresses the increased risk of AI following vaginal delivery and damage to the anal sphincter. Furthermore, women’s experiences of AI following obstetric anal sphincter injury (OASIS) and the impact on their quality of life are poorly reflected within research literature. The research study reported within this thesis adds to the existing body of knowledge surrounding AI, OASIS and impact on quality of life. Accordingly findings from the reported study will assist health professionals to derive a greater understanding of the issues that surround AI and further promote the development of sensitive appropriate healthcare. The reported interpretive phenomenological study explored and interpreted ten women’s experiences of AI following a history of OASIS, and illuminated the impact of AI on their quality of life. Heidegger’s interpretive phenomenology and Van Manen’s methodological framework guided the reported research study. Semi-structured open ended interviews were adopted as they encouraged a relaxed informal discussion between the researcher and participant eliciting rich in-depth accounts of women’s experiences. Data collection, analysis and interpretation were undertaken utilising Van Manen’s procedural framework. This framework aided the development of three essential themes; grieving for loss, silence and striving for normality. The research findings highlighted the debilitating physical, social and emotional impact of AI on women’s lives. Women described the need to adopt strategies to cope with the impact of AI. These strategies included lifestyle changes, silence, avoidance and denial. Furthermore it was evident from within the findings that new knowledge had arisen. Women grieved the loss of their identity, and ability to form successful relationships and loss of control as an adult, a mother and a partner. Loss was further compounded by the insidious and unpredictable nature of AI which negatively impacted on women’s psychological wellbeing. Findings from the reported research study will challenge the reader’s current assumptions of AI and its impact on women’s quality of life. In addition, health professionals need to be well informed as to the risks and impact of vaginal delivery, OASIS and AI. Recommendations for health professionals practice include adopting a proactive approach in breaking the silence that surrounds AI, illuminating potential health issues and promoting sensitive appropriate health care and informed choice in birthing outcomes. Paucity within research literature and current findings provide the impetus for further research within the area of AI and importantly, the psychological impact of AI on women’s quality of life.
Thesis (M.Nurs.Sc.) -- University of Adelaide, School of Nursing, 2012

博士
國立中正大學
犯罪防治研究所
107
In recent years, due to the increasing popularity of Internet technology, the drug problem has become increasingly widespread. The abuse of the third and fourth degree drugs is the most significant problem, seriously damaging the personality and healthy development of the youth community. Due to the lack of complete, long-term, comprehensive and scientific empirical research in Taiwan, it is necessary to check whether the investigation strategies and legislative models of the third and fourth degree drug crimes are effective. This thesis takes the Taichung city as the research area, focusing on the current situation of third and fourth degree drug crimes in Taichung City, trying to comprehensively examine the current investigation strategies, current situation and effectiveness of the third and fourth degree drug cases in Taichung City. Furthermore, this study assesses the strengths and weaknesses of the current investigation strategies, identifying specific factors that affect the effectiveness of the investigative tactics. At last, this thesis tries to provide some specific suggestions for future investigation strategies and revision of the law. This study adopts In-Depth interview, Focus Group discuss, Secondary Data analysis, and the RE-AIM model. The period of Secondary Data collection was from January 2002 to March 2018. The sources of data were mainly from the Taichung District Prosecutor's Office and the Police Department's official website. Through Convenience Sampling, the author conducted in-depth interviews with five public officials working in Taichung City, from the judiciary, police and health agencies. The author also held two Focus Group discussions with 10 police officers, examining the current investigation strategies of third and fourth degree drug crimes. The study found that there are significant differences in the sources of different degrees of drugs, methods of investigation, difficulties of tracing, methods of targeting suspects, and hot spots policing strategies. There is a positive correlation between the investigation and the occurrence of property crimes. The systems that need improvement include factors such as insufficient funding and manpower of the investigating agencies, excessively rigid reward systems, insufficient sharing of information, and obsolescence of relevant laws and regulations. In order to combat drug crimes, the following points are suggested in this paper.To begin with, the satellite positioning monitoring system should be added, and the APP monitoring mechanism should be improved. Then, the digital collection technology should be strengthened, and the statistical classification method should be revised. Furthermore, an independent special anti-drug agency should be established, the reward mechanism should be adjusted in a timely manner, and the exchange of information channels should be smooth. In addition, new drug control projects should be expanded in the future. Last but not least, different control strategies should be added, and the effectiveness of administrative penalties should be enhanced to improve the comprehensive effects of combating drug crimes.

In the textbook the basic concepts concerning the organization and technology of information work of the student-historian are considered. It includes four sections: the first determines the place of the course's problems in the process of historical knowledge; the second tracks the principal features of facts, sources and research, which can potentially be the sphere of historical research; the third introduces the reader to the principles, conceptual apparatus, laws, methods and judgments as means of knowledge.; the fourth introduces the experience of constructing the text of the study, which sums up a certain result of the work done and allows you to " translate the process of learning a new state of relative knowledge." Meets the requirements of the Federal state educational standards of higher education of the last generation. It is intended for undergraduate students studying the discipline "Information and analytical work". It can be useful to persons preparing for admission to the master's degree in the areas of training "History" and "International relations", as well as all those interested in working with documents and other media.

This article argues that Spinoza is a modern republican political philosopher. He combines Machiavelli’s idea of liberty with Hobbes’s version of the social contract. This claim has four basic elements. First, Spinoza rejects Hobbes’s view that the individual must alienate his natural rights to form a state through a contract. Rather, the contract’s validity depends on a continuous and dynamic transfer of power from its citizens, which is defined as participation in public life. Second, the stability of a state depends on how effectively the regime can foster participation in the state. Spinoza uses his theory of the imagination and passions to explain how the state can overcome free-rider problems in the social contract. Hence the republican ideal of government is expressed not so much in any particular constitutional form of the state but in how well each form can foster participation. Although democracy expresses the highest degree of participation—and hence stability—aristocracy and even monarchy can be also optimized. Third, the participation of the individual in the state is not an end in itself but the means to the individual’s own freedom. So, although participation in the state is a necessary condition of individual well-being, it is certainly not sufficient to become virtuous. Fourth, the participation of individuals in the state, the quality and structure of state stability, as a well as the freedom of the state and individual, all depend on the degree of rationality manifest in both the individual and in the institutional structures of the state.

This chapter traces the social movement cause lawyering of black women over the last one hundred years. The discussion examines the legal activism of four generations of black women lawyers, investigating the influence of the civil rights and second-wave feminist movements on their activism. For the earliest generation of black women lawyers, late in the nineteenth century, earning a law degree itself was an onerous struggle. The second generation used their legal skills to advocate for black justice within the civil rights movement. A third generation drew on comparisons of racial and gender discrimination, highlighting similarities and furthering the understanding of gender bias. The fourth generation of black women cause lawyers, often working within the legal academy, has led in developing the intersectionality paradigm, which explains how racism and gender bias intertwine. The chapter concludes by considering the significant impacts of black women cause lawyers, including how their insights reveal law’s operation in the lives of women of color and others influenced by multiple politicized identities.

This chapter examines the goal of Prairie Crossing: to create a geography of somewhere, a place where residents would feel invested enough to volunteer their time to create genuine community. It begins with a discussion of Prairie Crossing's third, fourth, and fifth guiding principles: “a sense of place,” which draws off of and expands many of the concepts espoused by the New Urbanism movement; “a sense of community,” which aims to encourage social interaction among residents and also between Prairie Crossing and the larger communities of Grayslake and Lake County; and “economic and racial diversity,” which seeks to remedy the tendency toward exclusivity and homogeneity in community housing. The chapter also considers the degree of residents' level of satisfaction with the Prairie Crossing Homeowners Association's governance; where Prairie Crossing, as an exemplar of the conservation community policy model, fits in relation to the new town movement; and the Prairie Crossing Charter School.

A strong start in life includes includes getting started in the world of work. Age, race, and education all affect young people’s employability and labor force experiences. First, just a few years can make a big difference among the young. Twenty-four-year-olds are not nearly as raw as 18-year-olds; they may have more education as well. Second, gender matters. Young women have different employment patterns from young men. Third, black and Hispanic youth have more employment difficulties than white and Asian youth. Fourth, college graduates have much better employment prospects than people with less education. Evidence presented here indicates that credentials outweigh experience, partly because so much employment growth is limited to occupations that require a college degree; but this probably applies in other occupations as well. All of these broad patterns replicate year after year, but economic conditions at the time can make them larger or smaller.

This book contains an analysis of the experience of married life by men and women in Christian medieval Europe c. 900–1300. The focus will be on the social and emotional life of the married couple rather than on the institutional history of marriage. The book consists of three parts: the first part (Getting Married) is devoted to the process of getting married and wedding celebrations, the second part (Married Life) discusses the married life of lay couples and clergy, their sexuality, and any remarriage, while the third part (Alternative Living) explores concubinage and polygyny as well as the single life in contrast to monogamous sexual unions. Four main themes are central to the book. First, the tension between patriarchal family strategies and the individual family member’s freedom of choice to marry and, if so, to what partner; second, the role played by the married priesthood in their quest to have individual agency and self-determination accepted in their own lives in the face of the growing imposition of clerical celibacy; third, the role played by women in helping society accept some degree of gender equality and self-determination to marry and in shaping the norms for married life incorporating these principles; fourth, the role played by emotion in the establishment of marriage and in married life at a time when sexual and spiritual love feature prominently in medieval literature.

The British composer, conductor, and pianist Thomas Adès (b. 1971) has achieved a level of recognition and celebrity within the concert world shared by very few living musicians today, and his compositions enjoy a degree of widespread acclaim that places him among the most widely heard composers working now. His critical and popular successes, at least inside the insulated world of classical music, place him within the absolute mainstream of concert life today. Is he merely pecking over the carcass of a tradition, soon to be subsumed by or abandoned in favor of some other cultural practice? Or does his work suggest possibilities for a concert world waiting to be born? This book, which is the first full-length study of Adès’s work as a whole in English, seeks to answer—or at least articulate the terms of response to—these questions and others. In recognition of the diversity of Adès’s output, this book is structured as a series of essays. These essays are organized thematically. The first two essays considers Adès’s arrangements and serialist compositions, respectively. The third looks at how his opera The Tempest illuminates much of his music’s beguiling contradictions. The fourth considers how Adès has been understood as a “surrealist” composer, and the final chapter considers the cosmic sweep of some of his most recent works.

Inflection is the expression of grammatical information through changes in word forms. This confrontation between general principles of syntactic organization and the often idiosyncratic properties of words has brought about systems whose properties—among them an often high degree of complexity—are an important object of investigation in their own right. Because it is something that many languages happily do without, inflection has a curious and often contentious status within linguistics. But even so, there is a fascinating and well-delimited set of facts out there to be explored, for which this handbook will be a guide. The volume is made up of twenty-four chapters, which together take a theoretically ecumenical approach, with particular attention paid to draw the examples from a wide variety of languages. The first section covers the fundamental building blocks of inflectional form and content: morphemes, features, and means of exponence. The second section focuses on what is probably the most characteristic property of inflectional systems, paradigmatic structure, and the non-trivial nature of the mapping between function and form. The third section covers change and variation over time, and the fourth section covers computational issues from a theoretical and practical standpoint. Section five addresses psycholinguistic questions. The final section is devoted to sketches of individual inflectional systems, illustrating a range of typological possibilities across a genetically diverse set of languages from Africa, Asia and the Pacific, Australia, Europe, and South America.

This volume charts the development of protestant Dissent between the passing of the Toleration Act (1689) and the repealing of the Test and Corporation Acts (1828). The long eighteenth century was a period in which Dissenters slowly moved from a position of being a persecuted minority to achieving a degree of acceptance and, eventually, full political rights. The first part of the volume considers the history of various Dissenting traditions inside England. There are separate chapters devoted to Presbyterians, Congregationalists, Baptists, and Quakers—the denominations that traced their history before this period—and also to Methodists, who emerged as one of the denominations of ‘New Dissent’ during the eighteenth century. The second part explores the ways in which these traditions developed outside England. It considers the complexities of being a Dissenter in Wales and Ireland, where the state church was Episcopalian, as well as in Scotland, where it was Presbyterian. It also looks at the development of Dissent across the Atlantic, where the relationship between Church and state was rather more loose. The third part is devoted to revivalist movements and their impact, with a particular emphasis on the importance of missionary societies for spreading protestant Christianity from the late eighteenth century onwards. The fourth part looks at Dissenters’ relationship to the British state and their involvement in campaigns to abolish the slave trade. The final part discusses how Dissenters lived: the theology they developed and their attitudes towards Scripture; the importance of both sermons and singing; their involvement in education and print culture; and the ways in which they expressed their faith materially through their buildings.

AbstractThis chapter analyses income inequality and socio-economic segregation in South Africa’s most populous city, Johannesburg. The end of apartheid’s segregation in 1991 has been followed by both continuity and change of urban spatial patterns. There is a considerable literature on the transformation of inner-city areas from white to black, and of the steady diffusion of black middle-class residents into once ‘white’ suburbs. There has been less analysis on the nature and pace of socio-economic mixing. Four key findings from this chapter are as follows. First, dissimilarity indices show that bottom occupation categories and the unemployed are highly segregated from top occupation categories, but that the degree of segregation has decreased slightly between the censuses of 2001 and 2011. Second, the data quantifies the way in which Johannesburg’s large population of unemployed people are more segregated from top occupations than any of the other employment categories, although unemployed people are less segregated from bottom occupations. Third, over the same period, residents employed in bottom occupations are less likely to be represented in affluent former white suburbs. This seemingly paradoxical finding is likely to have resulted from fewer affluent households accommodating their domestic workers on their properties. Fourth, although most post-apartheid public housing projects have not disrupted patterns of socio-economic segregation, some important exceptions do show the enormous capacity of public housing to transform the spatial structure of the city.

AbstractEarly Warning Systems (EWSs) are considered one of the main mechanisms for disaster risk reduction (DRR). In this sense, several efforts have been made by the international science and technology community to support the implementation of the Sendai Framework for Disaster Risk Reduction (SFDRR), giving special attention to the seventh global target focused on increasing the availability and access to multi-hazard early warning systems. Considering that landslides are one of the natural and socio-natural hazards that affect society in various parts of the world, the International Consortium on Landslides (ICL) has taken on the task of establishing regional and global network initiatives that promote the establishment of landslides early warnings systems (LEWSs). Although studies have recognised the significance of LEWSs, research has yet to systematically investigate the degree of implementation around the world. Therefore, and building on previous work, this chapter aims to provide an overview concerning enforcement of LEWSs in Upper Middle-Income Countries (UMIs). Based on a systematic literature review, the overall structure of the study takes the form of five sections. An introduction to the significance of LEWSs is provided in the first part. The second section provides an overview of the common architecture of LEWSs. The third part is concerned with the methodology employed for this study. Results of the study are presented in the fourth section and the final part brings together the key findings. Of the total publications that met the specified criteria and were analysed, only 19, that is, 5%, focused on different dimensions of the actual implementation of the LEWS.

Episiotomy is one of the most commonly practiced obstetric procedures done to enlarge the diameter of the vulval outlet to facilitate the passage for the fetal head and prevent an uncontrolled tear of the perineal tissues in the second stage of labor. Historically, the procedure was indicated to prevent third- or fourth-degree perineal tears as well as for prolonged second stage, macrosomia, non-reassuring fetal heart rate, instrumental delivery, occiput posterior position, and shoulder dystocia. Routine episiotomy is now considered to be obstetrics violence, rates of not exceeding 10% have been recommended by World Health Organization (WHO). Despite this recommendation, episiotomy is still practiced routinely in many settings.

The present study examines the use of Kahoot! as a gamification tool to explore mixed learning strategies. We analyze its use in two different groups of a theoretical subject of the third course of the Degree in Chemistry. An empirical-analytical methodology was used using Kahoot! in two different groups of students, with different frequencies. The academic results of these two group of students were compared between them and with those obtained in the previous course, in which Kahoot! was not employed, with the aim of measuring the evolution in the students´ knowledge. The results showed, in all cases, that the use of Kahoot! has led to a significant increase in the overall marks, and in the number of students who passed the subject. Moreover, some differences were also observed in students´ academic performance according to the group. Finally, it can be concluded that the use of a gamification tool (Kahoot!) in a university classroom had generally improved students´ learning and marks, and that this improvement is more prevalent in those students who have achieved a better Kahoot! performance.

Abstract The analytic manipulator is a manipulator the characteristic polynomial of which is of fourth degree or lower. Three new classes of analytic spherical parallel manipulators with prismatic actuators are proposed. The first is the spherical parallel manipulator with non-similar planar platforms, the second is the spherical parallel manipulator with similar planar platforms, and the third is the spherical parallel manipulator with orthogonal platforms. The forward displacement analysis of these new classes of spherical parallel manipulators is investigated in sequence. Polynomials of degree 4, 2 and 2 in one unknown respectively can be obtained to inscribe this problem. Due to dual solutions of other unknowns, a maximum of eight solutions might be possible for each of the new analytic spherical parallel manipulators.

This paper introduces a reconfigurable one degree-of-freedom spatial mechanism that can be applied to repetitive motion tasks. The concept is to incorporate five pairs of noncircular gears into a six degree-of-freedom closed-loop spatial chain. The gear pairs are designed based on the given mechanism parameters and the user defined motion specification of a coupler link of the mechanism. It is shown in the paper that planar gear pairs can be used if the spatial closed-loop chain is comprised of six pairs of parallel joint axes, i.e. the first joint axis is parallel to the second, the third is parallel to the fourth, …, and the eleventh is parallel to the twelfth. This paper presents the detailed reverse kinematic analysis of this specific geometry. A numerical example is presented.

The purpose of the study aimed to: (a) determine to what extent undergraduates expect their college courses; (b) measure the degree to what extent what degree undergraduates engage in their college courses; (c) measure the degree to what extent undergraduate feel their capability of creativity; and (d) examine the degree to which student engagement and their creativity are associated. The study applied a non-experimental, correlational design and used survey responses from 431 randomly selected undergraduates to address the research questions. The findings are as follows. First, the majority of the students have high expectation on their courses and they put feedback as their first priority. Second, most of the Chinese students still attach great importance to their homework. However, the low percentage in reflection shows that the students still lack the habit of doing self-reflection. Third, Chinese undergraduates have fair creativity ability and the students scored their creativity on behavior highest and the creativity on knowledge system lowest. Fourth, student engagement has a positive relation to their creativity on knowledge system, creativity on behaviors, creativity on personalities and creativity on innovative thinking. Among which, the students’ enhanced engagement has a most direct impact on their creativity on behaviors.

A nonlinear characterization based on modern methods of nonlinear dynamics is performed to identify the effects of a multi-segmented nonlinearity on the response of an aeroelastic system. This system consists of a plunging and pitching rigid airfoil supported by a linear spring in the plunge degree of freedom and a nonlinear spring in the pitch degree of freedom. The multi-segmented nonlinearity is associated with the pitch degree of freedom and contains two different boundaries. The results show that the presence of this multi-segmented nonlinearity results in the presence of a subcritical instability. It is also shown that there are four main transitions or sudden jumps in the system’s response when increasing the freestream velocity. It is demonstrated that the first and second sudden jumps are accompanied by the appearance and disappearance of quadratic nonlinearity induced by discontinuity and static positions. The results show that the first transition is due to a near grazing bifurcation that occurs near the first boundary of the multi-segmented nonlinearity. As for the second transition, it is demonstrated that the sudden jump at this transition is associated with a tangential contact between the trajectory and the first boundary of the multi-segmented nonlinearity and with a zero-pitch velocity incidence which is a characteristic of a grazing bifurcation. In the third and fourth transitions, it is demonstrated that there are changes in the response of the system from simply periodic to two periods having the main oscillating frequency and its superharmonic of order 3 and from chaotic to two periods having the main oscillating frequency and its superharmonic of order 3. Using modern methods of nonlinear dynamics, it is shown that this transition is due to a grazing bifurcation at the second boundary of the multi-segmented nonlinearity.

Abstract A two-degree-of-freedom (2-DOF), analytical model of a hydraulic valve lifter is derived. Special features of the model include the effects of bulk oil compressibility, multi-mode behavior due to plunger check valve modeling, and provision for the inclusion of third and fourth body displacements to aid In the use of the model in extended, multi-DOF systems. It is shown that motion of the lifter plunger and body must satisfy a coupled system of third-order, non-linear differential equations of motion. It is also shown that the special cases of zero oil compressibility and/or 1-DOF motion of lifter plunger can be obtained from the general third-order equations. For the case of zero oil compressibility, using Newtonian fluid assumptions, the equations of motion are shown to reduce to a system of second-order, linear differential equations. The differential equations are numerically integrated in five scenarios designed to test various aspects of the model. A modal analysis of the 2-DOF, compressible model with an external contact spring is performed and is shown to be in excellent agreement with simulation results.

This paper introduces a reconfigurable closed-loop spatial mechanism that can be applied to repetitive motion tasks. The concept is to incorporate five pairs of non-circular gears into a six degree-of–freedom closed-loop spatial chain. The gear pairs are designed based on given mechanism parameters and a user defined motion specification of a coupler link of the mechanism. It is shown in the paper that planar gear pairs can be used if the spatial closed-loop chain is comprised of six pairs of parallel joint axes, i.e. the first joint axis is parallel to the second, the third is parallel to the fourth, ..., and the eleventh is parallel to the twelfth. This paper presents the synthesis of the gear pairs that satisfy a specified three-dimensional position and orientation need. Numerical approximations were used in the synthesis the non-circular gear pairs by introducing an auxiliary monotonic parameter associated to each end-effector position to parameterize the motion needs. The findings are supported by a computer animation. No previous known literature incorporates planar non-circular gears to fulfill spatial motion generation needs.

The paper deals with the development of a non-linear one-dimensional modular dynamic model for the simulation of transient behavior of compression systems. The model is based on balance equations of mass, momentum and energy, which are derived through a general approach and are written by using the finite difference method. The model also takes rotating mass dynamics into account through a lumped parameter approach. Moreover, it reproduces the behavior of the system in the presence of the surge phenomenon through steady-state performance maps, which represent the compressor operation in the inverse flow region by means of a third degree polynomial curve. The model is implemented through the Matlab Simulink tool, where the system of ordinary differential equations is solved by using a fourth and fifth order Runge-Kutta method. A sensitivity analysis is carried out to evaluate the influence on compressor outlet pressure oscillations of the model parameters, of the supplied torque, of ambient conditions and of the shape of the compressor characteristic curves. The results show that the model proves effective in capturing the physical essence of surge phenomenon without being computationally too heavy.

After an extensive research on the fundamental theory, the theoretical basis for the Logix gearing will be presented in this paper. This includes the theory for gear meshing with high degree of contact. In comparison to previous studies, the theory of this paper is more restricted going beyond third order parameters into the fourth order, the teeth profile had one order of contact higher than that of the Logix gearing. So that further improved the contact strength of tooth profile. A large category of gearings with high order of contact was presented, while the Logix gear is only one of them, or the special example in realization of my theory. In the Logix gearing, the zigzag curvature center curve of media rank does not always lay about the pitch line and does not extend along the pitch line continuously and steadily. It goes forward and returns. So that, in terms of properties of the transverse engagement, the Logix gearing has not much improvement over the traditional Novikov gearing (in which the transverse engagement is temporally). In my gearing the curvature center of media rank extend along the pitch line continuously and steadily. The transverse engagement factor is larger than that of Logix gearing.

A series of detailed measurements of various mechanical and hydraulic system states of different excavators was performed. Main purpose of this study was to obtain a reliable information basis for assessing the potentials of hybrid drives, in particular the amount of recoverable energy. Differences concerned the size (tonnage) of the excavators and the hydraulic systems, open center versus load sensing. All machines were tested at the same set of operation scenarios, which are typical for practice, and with different operators. To this end, all test machines have been equipped with pressure, flow rate, temperature, angular and position sensors. These signals (about sixty) and several available from the machines CAN bus were recorded with a standard data acquisition system and electronically stored for later analysis. These raw data were processed to obtain the interesting data, like speeds, power flows, energies. In addition, videos of each test were recorded to facilitate the correct interpretation of the measurements and their correlation with the actual working processes. Power flows from the combustion engine, different pumps, and at each actuator and energetic losses at the different loss sources were plotted for the different operation scenarios. Total efficiencies of the machines for different scenarios and the energy in and outflow at each actuator were computed. From the latter so called relative and absolute recovery degrees for each actuator and for the total machine in the different operation scenarios were derived. The relative recovery degree is the ratio of the total outflow energy (second and fourth quadrant) and the total inflow energy (first and third quadrant). The absolute recovery degree is the ratio of the total outflow energy of an actuator and the total energy delivered by all pumps in an operation scenario. In most operation scenarios the total efficiency of consumed mechanical output energy at the hydraulic actuators relative to delivered hydraulic energy is in the range 15% to 25%. Reasonable recovery potentials do have the swing and the boom drive. For small machines, however, the boom drive dominates.

1.1 Macroeconomic summary Economic recovery has consistently outperformed the technical staff’s expectations following a steep decline in activity in the second quarter of 2020. At the same time, total and core inflation rates have fallen and remain at low levels, suggesting that a significant element of the reactivation of Colombia’s economy has been related to recovery in potential GDP. This would support the technical staff’s diagnosis of weak aggregate demand and ample excess capacity. The most recently available data on 2020 growth suggests a contraction in economic activity of 6.8%, lower than estimates from January’s Monetary Policy Report (-7.2%). High-frequency indicators suggest that economic performance was significantly more dynamic than expected in January, despite mobility restrictions and quarantine measures. This has also come amid declines in total and core inflation, the latter of which was below January projections if controlling for certain relative price changes. This suggests that the unexpected strength of recent growth contains elements of demand, and that excess capacity, while significant, could be lower than previously estimated. Nevertheless, uncertainty over the measurement of excess capacity continues to be unusually high and marked both by variations in the way different economic sectors and spending components have been affected by the pandemic, and by uneven price behavior. The size of excess capacity, and in particular the evolution of the pandemic in forthcoming quarters, constitute substantial risks to the macroeconomic forecast presented in this report. Despite the unexpected strength of the recovery, the technical staff continues to project ample excess capacity that is expected to remain on the forecast horizon, alongside core inflation that will likely remain below the target. Domestic demand remains below 2019 levels amid unusually significant uncertainty over the size of excess capacity in the economy. High national unemployment (14.6% for February 2021) reflects a loose labor market, while observed total and core inflation continue to be below 2%. Inflationary pressures from the exchange rate are expected to continue to be low, with relatively little pass-through on inflation. This would be compatible with a negative output gap. Excess productive capacity and the expectation of core inflation below the 3% target on the forecast horizon provide a basis for an expansive monetary policy posture. The technical staff’s assessment of certain shocks and their expected effects on the economy, as well as the presence of several sources of uncertainty and related assumptions about their potential macroeconomic impacts, remain a feature of this report. The coronavirus pandemic, in particular, continues to affect the public health environment, and the reopening of Colombia’s economy remains incomplete. The technical staff’s assessment is that the COVID-19 shock has affected both aggregate demand and supply, but that the impact on demand has been deeper and more persistent. Given this persistence, the central forecast accounts for a gradual tightening of the output gap in the absence of new waves of contagion, and as vaccination campaigns progress. The central forecast continues to include an expected increase of total and core inflation rates in the second quarter of 2021, alongside the lapse of the temporary price relief measures put in place in 2020. Additional COVID-19 outbreaks (of uncertain duration and intensity) represent a significant risk factor that could affect these projections. Additionally, the forecast continues to include an upward trend in sovereign risk premiums, reflected by higher levels of public debt that in the wake of the pandemic are likely to persist on the forecast horizon, even in the context of a fiscal adjustment. At the same time, the projection accounts for the shortterm effects on private domestic demand from a fiscal adjustment along the lines of the one currently being proposed by the national government. This would be compatible with a gradual recovery of private domestic demand in 2022. The size and characteristics of the fiscal adjustment that is ultimately implemented, as well as the corresponding market response, represent another source of forecast uncertainty. Newly available information offers evidence of the potential for significant changes to the macroeconomic scenario, though without altering the general diagnosis described above. The most recent data on inflation, growth, fiscal policy, and international financial conditions suggests a more dynamic economy than previously expected. However, a third wave of the pandemic has delayed the re-opening of Colombia’s economy and brought with it a deceleration in economic activity. Detailed descriptions of these considerations and subsequent changes to the macroeconomic forecast are presented below. The expected annual decline in GDP (-0.3%) in the first quarter of 2021 appears to have been less pronounced than projected in January (-4.8%). Partial closures in January to address a second wave of COVID-19 appear to have had a less significant negative impact on the economy than previously estimated. This is reflected in figures related to mobility, energy demand, industry and retail sales, foreign trade, commercial transactions from selected banks, and the national statistics agency’s (DANE) economic tracking indicator (ISE). Output is now expected to have declined annually in the first quarter by 0.3%. Private consumption likely continued to recover, registering levels somewhat above those from the previous year, while public consumption likely increased significantly. While a recovery in investment in both housing and in other buildings and structures is expected, overall investment levels in this case likely continued to be low, and gross fixed capital formation is expected to continue to show significant annual declines. Imports likely recovered to again outpace exports, though both are expected to register significant annual declines. Economic activity that outpaced projections, an increase in oil prices and other export products, and an expected increase in public spending this year account for the upward revision to the 2021 growth forecast (from 4.6% with a range between 2% and 6% in January, to 6.0% with a range between 3% and 7% in April). As a result, the output gap is expected to be smaller and to tighten more rapidly than projected in the previous report, though it is still expected to remain in negative territory on the forecast horizon. Wide forecast intervals reflect the fact that the future evolution of the COVID-19 pandemic remains a significant source of uncertainty on these projections. The delay in the recovery of economic activity as a result of the resurgence of COVID-19 in the first quarter appears to have been less significant than projected in the January report. The central forecast scenario expects this improved performance to continue in 2021 alongside increased consumer and business confidence. Low real interest rates and an active credit supply would also support this dynamic, and the overall conditions would be expected to spur a recovery in consumption and investment. Increased growth in public spending and public works based on the national government’s spending plan (Plan Financiero del Gobierno) are other factors to consider. Additionally, an expected recovery in global demand and higher projected prices for oil and coffee would further contribute to improved external revenues and would favor investment, in particular in the oil sector. Given the above, the technical staff’s 2021 growth forecast has been revised upward from 4.6% in January (range from 2% to 6%) to 6.0% in April (range from 3% to 7%). These projections account for the potential for the third wave of COVID-19 to have a larger and more persistent effect on the economy than the previous wave, while also supposing that there will not be any additional significant waves of the pandemic and that mobility restrictions will be relaxed as a result. Economic growth in 2022 is expected to be 3%, with a range between 1% and 5%. This figure would be lower than projected in the January report (3.6% with a range between 2% and 6%), due to a higher base of comparison given the upward revision to expected GDP in 2021. This forecast also takes into account the likely effects on private demand of a fiscal adjustment of the size currently being proposed by the national government, and which would come into effect in 2022. Excess in productive capacity is now expected to be lower than estimated in January but continues to be significant and affected by high levels of uncertainty, as reflected in the wide forecast intervals. The possibility of new waves of the virus (of uncertain intensity and duration) represents a significant downward risk to projected GDP growth, and is signaled by the lower limits of the ranges provided in this report. Inflation (1.51%) and inflation excluding food and regulated items (0.94%) declined in March compared to December, continuing below the 3% target. The decline in inflation in this period was below projections, explained in large part by unanticipated increases in the costs of certain foods (3.92%) and regulated items (1.52%). An increase in international food and shipping prices, increased foreign demand for beef, and specific upward pressures on perishable food supplies appear to explain a lower-than-expected deceleration in the consumer price index (CPI) for foods. An unexpected increase in regulated items prices came amid unanticipated increases in international fuel prices, on some utilities rates, and for regulated education prices. The decline in annual inflation excluding food and regulated items between December and March was in line with projections from January, though this included downward pressure from a significant reduction in telecommunications rates due to the imminent entry of a new operator. When controlling for the effects of this relative price change, inflation excluding food and regulated items exceeds levels forecast in the previous report. Within this indicator of core inflation, the CPI for goods (1.05%) accelerated due to a reversion of the effects of the VAT-free day in November, which was largely accounted for in February, and possibly by the transmission of a recent depreciation of the peso on domestic prices for certain items (electric and household appliances). For their part, services prices decelerated and showed the lowest rate of annual growth (0.89%) among the large consumer baskets in the CPI. Within the services basket, the annual change in rental prices continued to decline, while those services that continue to experience the most significant restrictions on returning to normal operations (tourism, cinemas, nightlife, etc.) continued to register significant price declines. As previously mentioned, telephone rates also fell significantly due to increased competition in the market. Total inflation is expected to continue to be affected by ample excesses in productive capacity for the remainder of 2021 and 2022, though less so than projected in January. As a result, convergence to the inflation target is now expected to be somewhat faster than estimated in the previous report, assuming the absence of significant additional outbreaks of COVID-19. The technical staff’s year-end inflation projections for 2021 and 2022 have increased, suggesting figures around 3% due largely to variation in food and regulated items prices. The projection for inflation excluding food and regulated items also increased, but remains below 3%. Price relief measures on indirect taxes implemented in 2020 are expected to lapse in the second quarter of 2021, generating a one-off effect on prices and temporarily affecting inflation excluding food and regulated items. However, indexation to low levels of past inflation, weak demand, and ample excess productive capacity are expected to keep core inflation below the target, near 2.3% at the end of 2021 (previously 2.1%). The reversion in 2021 of the effects of some price relief measures on utility rates from 2020 should lead to an increase in the CPI for regulated items in the second half of this year. Annual price changes are now expected to be higher than estimated in the January report due to an increased expected path for fuel prices and unanticipated increases in regulated education prices. The projection for the CPI for foods has increased compared to the previous report, taking into account certain factors that were not anticipated in January (a less favorable agricultural cycle, increased pressure from international prices, and transport costs). Given the above, year-end annual inflation for 2021 and 2022 is now expected to be 3% and 2.8%, respectively, which would be above projections from January (2.3% and 2,7%). For its part, expected inflation based on analyst surveys suggests year-end inflation in 2021 and 2022 of 2.8% and 3.1%, respectively. There remains significant uncertainty surrounding the inflation forecasts included in this report due to several factors: 1) the evolution of the pandemic; 2) the difficulty in evaluating the size and persistence of excess productive capacity; 3) the timing and manner in which price relief measures will lapse; and 4) the future behavior of food prices. Projected 2021 growth in foreign demand (4.4% to 5.2%) and the supposed average oil price (USD 53 to USD 61 per Brent benchmark barrel) were both revised upward. An increase in long-term international interest rates has been reflected in a depreciation of the peso and could result in relatively tighter external financial conditions for emerging market economies, including Colombia. Average growth among Colombia’s trade partners was greater than expected in the fourth quarter of 2020. This, together with a sizable fiscal stimulus approved in the United States and the onset of a massive global vaccination campaign, largely explains the projected increase in foreign demand growth in 2021. The resilience of the goods market in the face of global crisis and an expected normalization in international trade are additional factors. These considerations and the expected continuation of a gradual reduction of mobility restrictions abroad suggest that Colombia’s trade partners could grow on average by 5.2% in 2021 and around 3.4% in 2022. The improved prospects for global economic growth have led to an increase in current and expected oil prices. Production interruptions due to a heavy winter, reduced inventories, and increased supply restrictions instituted by producing countries have also contributed to the increase. Meanwhile, market forecasts and recent Federal Reserve pronouncements suggest that the benchmark interest rate in the U.S. will remain stable for the next two years. Nevertheless, a significant increase in public spending in the country has fostered expectations for greater growth and inflation, as well as increased uncertainty over the moment in which a normalization of monetary policy might begin. This has been reflected in an increase in long-term interest rates. In this context, emerging market economies in the region, including Colombia, have registered increases in sovereign risk premiums and long-term domestic interest rates, and a depreciation of local currencies against the dollar. Recent outbreaks of COVID-19 in several of these economies; limits on vaccine supply and the slow pace of immunization campaigns in some countries; a significant increase in public debt; and tensions between the United States and China, among other factors, all add to a high level of uncertainty surrounding interest rate spreads, external financing conditions, and the future performance of risk premiums. The impact that this environment could have on the exchange rate and on domestic financing conditions represent risks to the macroeconomic and monetary policy forecasts. Domestic financial conditions continue to favor recovery in economic activity. The transmission of reductions to the policy interest rate on credit rates has been significant. The banking portfolio continues to recover amid circumstances that have affected both the supply and demand for loans, and in which some credit risks have materialized. Preferential and ordinary commercial interest rates have fallen to a similar degree as the benchmark interest rate. As is generally the case, this transmission has come at a slower pace for consumer credit rates, and has been further delayed in the case of mortgage rates. Commercial credit levels stabilized above pre-pandemic levels in March, following an increase resulting from significant liquidity requirements for businesses in the second quarter of 2020. The consumer credit portfolio continued to recover and has now surpassed February 2020 levels, though overall growth in the portfolio remains low. At the same time, portfolio projections and default indicators have increased, and credit establishment earnings have come down. Despite this, credit disbursements continue to recover and solvency indicators remain well above regulatory minimums. 1.2 Monetary policy decision In its meetings in March and April the BDBR left the benchmark interest rate unchanged at 1.75%.

Macroeconomic summary Several factors contributed to an increase in projected inflation on the forecast horizon, keeping it above the target rate. These included inflation in December that surpassed expectations (5.62%), indexation to higher inflation rates for various baskets in the consumer price index (CPI), a significant real increase in the legal minimum wage, persistent external and domestic inflationary supply shocks, and heightened exchange rate pressures. The CPI for foods was affected by the persistence of external and domestic supply shocks and was the most significant contributor to unexpectedly high inflation in the fourth quarter. Price adjustments for fuels and certain utilities can explain the acceleration in inflation for regulated items, which was more significant than anticipated. Prices in the CPI for goods excluding food and regulated items also rose more than expected. This was partly due to a smaller effect on prices from the national government’s VAT-free day than anticipated by the technical staff and more persistent external pressures, including via peso depreciation. By contrast, the CPI for services excluding food and regulated items accelerated less than expected, partly reflecting strong competition in the communications sector. This was the only major CPI basket for which prices increased below the target inflation rate. The technical staff revised its inflation forecast upward in response to certain external shocks (prices, costs, and depreciation) and domestic shocks (e.g., on meat products) that were stronger and more persistent than anticipated in the previous report. Observed inflation and a real increase in the legal minimum wage also exceeded expectations, which would boost inflation by affecting price indexation, labor costs, and inflation expectations. The technical staff now expects year-end headline inflation of 4.3% in 2022 and 3.4% in 2023; core inflation is projected to be 4.5% and 3.6%, respectively. These forecasts consider the lapse of certain price relief measures associated with the COVID-19 health emergency, which would contribute to temporarily keeping inflation above the target on the forecast horizon. It is important to note that these estimates continue to contain a significant degree of uncertainty, mainly related to the development of external and domestic supply shocks and their ultimate effects on prices. Other contributing factors include high price volatility and measurement uncertainty related to the extension of Colombia’s health emergency and tax relief measures (such as the VAT-free days) associated with the Social Investment Law (Ley de Inversión Social). The as-yet uncertain magnitude of the effects of a recent real increase in the legal minimum wage (that was high by historical standards) and high observed and expected inflation, are additional factors weighing on the overall uncertainty of the estimates in this report. The size of excess productive capacity remaining in the economy and the degree to which it is closing are also uncertain, as the evolution of the pandemic continues to represent a significant forecast risk. margin, could be less dynamic than expected. And the normalization of monetary policy in the United States could come more quickly than projected in this report, which could negatively affect international financing costs. Finally, there remains a significant degree of uncertainty related to the duration of supply chocks and the degree to which macroeconomic and political conditions could negatively affect the recovery in investment. The technical staff revised its GDP growth projection for 2022 from 4.7% to 4.3% (Graph 1.3). This revision accounts for the likelihood that a larger portion of the recent positive dynamic in private consumption would be transitory than previously expected. This estimate also contemplates less dynamic investment behavior than forecast in the previous report amid less favorable financial conditions and a highly uncertain investment environment. Third-quarter GDP growth (12.9%), which was similar to projections from the October report, and the fourth-quarter growth forecast (8.7%) reflect a positive consumption trend, which has been revised upward. This dynamic has been driven by both public and private spending. Investment growth, meanwhile, has been weaker than forecast. Available fourth-quarter data suggest that consumption spending for the period would have exceeded estimates from October, thanks to three consecutive months that included VAT-free days, a relatively low COVID-19 caseload, and mobility indicators similar to their pre-pandemic levels. By contrast, the most recently available figures on new housing developments and machinery and equipment imports suggest that investment, while continuing to rise, is growing at a slower rate than anticipated in the previous report. The trade deficit is expected to have widened, as imports would have grown at a high level and outpaced exports. Given the above, the technical staff now expects fourth-quarter economic growth of 8.7%, with overall growth for 2021 of 9.9%. Several factors should continue to contribute to output recovery in 2022, though some of these may be less significant than previously forecast. International financial conditions are expected to be less favorable, though external demand should continue to recover and terms of trade continue to increase amid higher projected oil prices. Lower unemployment rates and subsequent positive effects on household income, despite increased inflation, would also boost output recovery, as would progress in the national vaccination campaign. The technical staff expects that the conditions that have favored recent high levels of consumption would be, in large part, transitory. Consumption spending is expected to grow at a slower rate in 2022. Gross fixed capital formation (GFCF) would continue to recover, approaching its pre-pandemic level, though at a slower rate than anticipated in the previous report. This would be due to lower observed GFCF levels and the potential impact of political and fiscal uncertainty. Meanwhile, the policy interest rate would be less expansionary as the process of monetary policy normalization continues. Given the above, growth in 2022 is forecast to decelerate to 4.3% (previously 4.7%). In 2023, that figure (3.1%) is projected to converge to levels closer to the potential growth rate. In this case, excess productive capacity would be expected to tighten at a similar rate as projected in the previous report. The trade deficit would tighten more than previously projected on the forecast horizon, due to expectations of an improved export dynamic and moderation in imports. The growth forecast for 2022 considers a low basis of comparison from the first half of 2021. However, there remain significant downside risks to this forecast. The current projection does not, for example, account for any additional effects on economic activity resulting from further waves of COVID-19. High private consumption levels, which have already surpassed pre-pandemic levels by a large margin, could be less dynamic than expected. And the normalization of monetary policy in the United States could come more quickly than projected in this report, which could negatively affect international financing costs. Finally, there remains a significant degree of uncertainty related to the duration of supply chocks and the degree to which macroeconomic and political conditions could negatively affect the recovery in investment. External demand for Colombian goods and services should continue to recover amid significant global inflation pressures, high oil prices, and less favorable international financial conditions than those estimated in October. Economic activity among Colombia’s major trade partners recovered in 2021 amid countries reopening and ample international liquidity. However, that growth has been somewhat restricted by global supply chain disruptions and new outbreaks of COVID-19. The technical staff has revised its growth forecast for Colombia’s main trade partners from 6.3% to 6.9% for 2021, and from 3.4% to 3.3% for 2022; trade partner economies are expected to grow 2.6% in 2023. Colombia’s annual terms of trade increased in 2021, largely on higher oil, coffee, and coal prices. This improvement came despite increased prices for goods and services imports. The expected oil price trajectory has been revised upward, partly to supply restrictions and lagging investment in the sector that would offset reduced growth forecasts in some major economies. Elevated freight and raw materials costs and supply chain disruptions continue to affect global goods production, and have led to increases in global prices. Coupled with the recovery in global demand, this has put upward pressure on external inflation. Several emerging market economies have continued to normalize monetary policy in this context. Meanwhile, in the United States, the Federal Reserve has anticipated an end to its asset buying program. U.S. inflation in December (7.0%) was again surprisingly high and market average inflation forecasts for 2022 have increased. The Fed is expected to increase its policy rate during the first quarter of 2022, with quarterly increases anticipated over the rest of the year. For its part, Colombia’s sovereign risk premium has increased and is forecast to remain on a higher path, to levels above the 15-year-average, on the forecast horizon. This would be partly due to the effects of a less expansionary monetary policy in the United States and the accumulation of macroeconomic imbalances in Colombia. Given the above, international financial conditions are projected to be less favorable than anticipated in the October report. The increase in Colombia’s external financing costs could be more significant if upward pressures on inflation in the United States persist and monetary policy is normalized more quickly than contemplated in this report. As detailed in Section 2.3, uncertainty surrounding international financial conditions continues to be unusually high. Along with other considerations, recent concerns over the potential effects of new COVID-19 variants, the persistence of global supply chain disruptions, energy crises in certain countries, growing geopolitical tensions, and a more significant deceleration in China are all factors underlying this uncertainty. The changing macroeconomic environment toward greater inflation and unanchoring risks on inflation expectations imply a reduction in the space available for monetary policy stimulus. Recovery in domestic demand and a reduction in excess productive capacity have come in line with the technical staff’s expectations from the October report. Some upside risks to inflation have materialized, while medium-term inflation expectations have increased and are above the 3% target. Monetary policy remains expansionary. Significant global inflationary pressures and the unexpected increase in the CPI in December point to more persistent effects from recent supply shocks. Core inflation is trending upward, but remains below the 3% target. Headline and core inflation projections have increased on the forecast horizon and are above the target rate through the end of 2023. Meanwhile, the expected dynamism of domestic demand would be in line with low levels of excess productive capacity. An accumulation of macroeconomic imbalances in Colombia and the increased likelihood of a faster normalization of monetary policy in the United States would put upward pressure on sovereign risk perceptions in a more persistent manner, with implications for the exchange rate and the natural rate of interest. Persistent disruptions to international supply chains, a high real increase in the legal minimum wage, and the indexation of various baskets in the CPI to higher inflation rates could affect price expectations and push inflation above the target more persistently. These factors suggest that the space to maintain monetary stimulus has continued to diminish, though monetary policy remains expansionary. 1.2 Monetary policy decision Banco de la República’s board of directors (BDBR) in its meetings in December 2021 and January 2022 voted to continue normalizing monetary policy. The BDBR voted by a majority in these two meetings to increase the benchmark interest rate by 50 and 100 basis points, respectively, bringing the policy rate to 4.0%.

Banco de la República provides a comprehensive overview of Colombia’s finan¬cial infrastructure in its Payment Systems Report, which is an important product of the work it does to oversee that infrastructure. The figures published in this edition of the report are for the year 2020, a pandemic period in which the con¬tainment measures designed and adopted to alleviate the strain on the health system led to a sharp reduction in economic activity and consumption in Colom¬bia, as was the case in most countries. At the start of the pandemic, the Board of Directors of Banco de la República adopted decisions that were necessary to supply the market with ample liquid¬ity in pesos and US dollars to guarantee market stability, protect the payment system and preserve the supply of credit. The pronounced growth in mone¬tary aggregates reflected an increased preference for liquidity, which Banco de la República addressed at the right time. These decisions were implemented through operations that were cleared and settled via the financial infrastructure. The second section of this report, following the introduction, offers an analysis of how the various financial infrastructures in Colombia have evolved and per¬formed. One of the highlights is the large-value payment system (CUD), which registered more momentum in 2020 than during the previous year, mainly be¬cause of an increase in average daily remunerated deposits made with Banco de la República by the General Directorate of Public Credit and the National Treasury (DGCPTN), as well as more activity in the sell/buy-back market with sovereign debt. Consequently, with more activity in the CUD, the Central Securi¬ties Depository (DCV) experienced an added impetus sparked by an increase in the money market for bonds and securities placed on the primary market by the national government. The value of operations cleared and settled through the Colombian Central Counterparty (CRCC) continues to grow, propelled largely by peso/dollar non-deliverable forward (NDF) contracts. With respect to the CRCC, it is important to note this clearing house has been in charge of managing risks and clearing and settling operations in the peso/dollar spot market since the end of last year, following its merger with the Foreign Exchange Clearing House of Colombia (CCDC). Since the final quarter of 2020, the CRCC has also been re¬sponsible for clearing and settlement in the equities market, which was former¬ly done by the Colombian Stock Exchange (BVC). The third section of this report provides an all-inclusive view of payments in the market for goods and services; namely, transactions carried out by members of the public and non-financial institutions. During the pandemic, inter- and intra-bank electronic funds transfers, which originate mostly with companies, increased in both the number and value of transactions with respect to 2019. However, debit and credit card payments, which are made largely by private citizens, declined compared to 2019. The incidence of payment by check contin¬ue to drop, exhibiting quite a pronounced downward trend during the past last year. To supplement to the information on electronic funds transfers, section three includes a segment (Box 4) characterizing the population with savings and checking accounts, based on data from a survey by Banco de la República con-cerning the perception of the use of payment instruments in 2019. There also is segment (Box 2) on the growth in transactions with a mobile wallet provided by a company specialized in electronic deposits and payments (Sedpe). It shows the number of users and the value of their transactions have increased since the wallet was introduced in late 2017, particularly during the pandemic. In addition, there is a diagnosis of the effects of the pandemic on the payment patterns of the population, based on data related to the use of cash in circu¬lation, payments with electronic instruments, and consumption and consumer confidence. The conclusion is that the collapse in the consumer confidence in¬dex and the drop in private consumption led to changes in the public’s pay¬ment patterns. Credit and debit card purchases were down, while payments for goods and services through electronic funds transfers increased. These findings, coupled with the considerable increase in cash in circulation, might indicate a possible precautionary cash hoarding by individuals and more use of cash as a payment instrument. There is also a segment (in Focus 3) on the major changes introduced in regulations on the retail-value payment system in Colombia, as provided for in Decree 1692 of December 2020. The fourth section of this report refers to the important innovations and tech¬nological changes that have occurred in the retail-value payment system. Four themes are highlighted in this respect. The first is a key point in building the financial infrastructure for instant payments. It involves of the design and im¬plementation of overlay schemes, a technological development that allows the various participants in the payment chain to communicate openly. The result is a high degree of interoperability among the different payment service providers. The second topic explores developments in the international debate on central bank digital currency (CBDC). The purpose is to understand how it could impact the retail-value payment system and the use of cash if it were to be issued. The third topic is related to new forms of payment initiation, such as QR codes, bio¬metrics or near field communication (NFC) technology. These seemingly small changes can have a major impact on the user’s experience with the retail-value payment system. The fourth theme is the growth in payments via mobile tele¬phone and the internet. The report ends in section five with a review of two papers on applied research done at Banco de la República in 2020. The first analyzes the extent of the CRCC’s capital, acknowledging the relevant role this infrastructure has acquired in pro¬viding clearing and settlement services for various financial markets in Colom¬bia. The capital requirements defined for central counterparties in some jurisdic¬tions are explored, and the risks to be hedged are identified from the standpoint of the service these type of institutions offer to the market and those associated with their corporate activity. The CRCC’s capital levels are analyzed in light of what has been observed in the European Union’s regulations, and the conclusion is that the CRCC has a scheme of security rings very similar to those applied internationally and the extent of its capital exceeds what is stipulated in Colombian regulations, being sufficient to hedge other risks. The second study presents an algorithm used to identify and quantify the liquidity sources that CUD’s participants use under normal conditions to meet their daily obligations in the local financial market. This algorithm can be used as a tool to monitor intraday liquidity. Leonardo Villar Gómez Governor