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Service providers can share information about the transition to parenting and can encourage women and their partners to attend programs that provide parenting information and social support. Service providers can provide information about specific local parenting workshops, drop in centres, parenting groups etc. Find out about any parenting programs with services specific to parents over age 35. If women give birth to a child with special needs at an advanced maternal age, they may blame themselves for putting the child at risk by delaying the pregnancy or for the choices they made during pregnancy. The special needs of the child, and the feelings of the parents, can impact the attachment process. It is important to assess the needs of the whole family and to offer support and referrals to appropriate services. Concerns in Early Parenting It is important to identify women early who have high expectations of themselves as mothers, lower satisfaction with parenting or inadequate social supports, to allow for early and appropriate intervention. Consideration should also be given for the possibility of postpartum mood disorders (see the Chapter 6). Provide information about parenting programs and services for families with young children. Reflecting on the Trend: Pregnancy After Age 35 69 70 Reflecting on the Trend: Pregnancy After Age 35 10. The increased prevalence of pregnancies over age 35, and the unique needs of this population, have implications for service providers who work with pregnant women and the health care system in Ontario. Preconception and Prenatal Care this population has distinct concerns, opportunities and health risks. Women who are pregnant over the age of 35 can benefit from care that is tailored to their needs. While most prenatal practices remain the same with this population, an understanding of issues related to advanced maternal age can help improve the services provided to women in this population. All providers can benefit from an understanding of the social context, risks, opportunities and strategies for women who are pregnant or considering a pregnancy after age 35. Non-medical staff can consider strategies for advanced maternal age such as having books available for loan to women, distributing brochures or fact sheets to interested women, developing a referral list of local services, or finding out where women can get more information. It is recommended that all service providers who work with pregnant women learn more about the specific needs of pregnant women over the age of 35. This manual provides information and strategies that directly address the health concerns of this population. Women who are planning a pregnancy over the age of 35 can benefit from preconception services because of their higher risk of fertility concerns, pre-existing health concerns, tera to genic expo sures and chromosome anomalies. Women over the age of 35 should be referred early to a fertility specialist if fertility problems become apparent. It is recommended that all pregnant women access prenatal care early in pregnancy.

Syndromes

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This chapter addresses neurological conditions that might compromise the safety of flight. Has the licence holder recovered from the condition without functionally significant residual neurological compromisefi Up to 40 per cent of epileptic individuals have normal electroencephalograms, and a significant proportion of normal individuals have false positive tilt table studies. The medical assessor must remain keenly aware of false positive and false negative labora to ry studies. The to pic of risk assessment and flexibility in medical certification is considered in more detail in Part I, Chapter 2. Migraine headache, cluster headache, transient global amnesia, epilepsy, and the isolated seizure all are represented in the licence holder population, some being commonly encountered. The medical assessor must determine whether unrestricted certification, conditional certification, or disqualification is warranted. In general, a risk of sudden incapacitation exceeding one per cent per year is considered unacceptable for aviation duties of all classes, as well as safety-sensitive air traffic control duties. Clinical features may include a throbbing quality, light and/or sound sensitivity, nausea, vomiting and prostration. Classic migraine: In classic migraine an aura precedes the headache by a number of minutes. Migraine equivalent: In this condition, also known as migraine variant or acephalalgic migraine, there is a classic aura but no after-coming headache. Prodrome: Some migraineurs experience an ill-defined uneasy, anxious or unsettled feeling for a day or more before headache onset, allowing avoidance measures. A tiny scintillating or shimmering crescent in a small fraction of the visual field may be inconsequential, whereas transient loss of half of the visual field would be unquestionably compromising. Rapidity of onset: In some persons rapid onset leads to relative incapacitation within minutes, whereas in others gradual onset over many hours affords ample time for avoidance while flying. Frequency: Intervals between migraines may be years in some, and days or weeks in others. Severity: Severe migraine may be essentially incapacitating due to pain, vomiting and prostration. However, there is a range of severity from this level to a mild throb or almost imperceptible ache. Loss of vision in one half of the visual field would not be acceptable, whereas in-flight occurrence of a minor scintillation in the far periphery of the visual field might not cause significant functional impairment. Slow onset over many hours might allow countermeasures, while rapid onset in minutes would be unacceptable. Satisfac to ry documentation of successful treatment with acceptable medications may allow medical certification.

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Labour in special circumstances Women with an uterine scar Some women will have a pre-existing uterine scar, usually because of a previous caesarean section. It is estimated that uterine rupture or dehiscence (scar separation) occurs in approximately 1 in 200 women who labour spontaneously with a pre-existing lower segment uterine scar. Signs of uterine rupture include severe lower abdominal pain, vaginal bleeding, haematuria, cessation of contractions, maternal tachycardia and fetal compromise (often a bradycardia, Figure 12. Uterine rupture carries serious maternal risks (shock, need for blood transfusion and operative repair, possibly a hysterec to my) and also serious fetal risks (including hypoxia, permanent neurological injury and perinatal death). Rupture of the uterus is more likely to occur late in the first stage of labour, with induced or accelerated labour and in association with a large baby. The chances of a successful vaginal birth depend on a number of fac to rs, including a previous his to ry of vaginal birth, size of the baby and the original indication for a caesarean section. If a woman with a previous his to ry of a caesarean section delivery is admitted in labour, close surveillance is required to identify early signs of uterine rupture. In general, there is minimal danger of rupture of a myomec to my scar unless the uterine cavity was opened during the procedure. Malpresentation Breech presentation the antenatal management of breech presentation and the mechanics of the delivery are discussed in Chapter 6, Antenatal obstetric complications. The majority of breech presentations recognized at term (fi37 weeks) are delivered by caesarean section. Although this is evidence based and it is probably safer for breech babies to be delivered this way, there is still a place for a vaginal breech delivery in certain circumstances. Maternal choice and the failure to detect breech presentation until very late in labour mean that obstetricians need to be expert in the skills of breech vaginal delivery and aware of the potential complications. Poor progress in a breech labour is taken by most to be an indication for caesarean section. However, some obstetricians support the use of augmentation with oxy to cin if contractions are infrequent. Complications of a breech labour and delivery Increased risk of cord prolapse: particularly with footling breech. Mechanical difficulties with the delivery of the shoulders and/or after-coming head, leading to damage of the visceral organs or the brachial plexus. Delay in the delivery of the head may occur with a larger fetus, leading to prolonged compression of the umbilical cord and asphyxia.

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Improve communication of health information between providers and users, including interpersonal communication, written information and health promotion campaigns. Include health literacy in the education of adults, children and health care providers. Several national initiatives relating to one or more of these areas are underway (Box 4. It allows patients to select questions they want to ask at the appointment and prepare for questions the doc to r may ask them. As outlined in this snapshot, there are limited Australian data available on health literacy (related to the individual or environment). While there is evidence to inform the improvement of some aspects of health literacy, work has yet to be fnished in creating a common measurement scale to evaluate the efectiveness of new strategies. Further work to develop suitable performance measures and identify the most appropriate data to collect would be useful. Information on the Choosing Wisely initiative is available on the Choosing Wisely website. Information on the Question Builder initiative is available on the Health Direct website. The unrecognized psychosocial fac to rs contributing to bleeding risk in warfarin therapy. Health literacy and public health: a systematic review and integration of defnitions and models. Even small changes to our daily exercise routines or body weight could substantially reduce disease burden. The analysis also estimates the contribution of various risk fac to rs to disease burden. Burden of disease estimates are designed to inform health policy for the prevention, early intervention and treatment of diseases and risk fac to rs, as well as to inform health promotion and management strategies and resource allocation. It does this by measuring the health consequences of living with ill health and injury (non-fatal burden) and of dying prematurely from illness and injury (fatal burden). The attributable burden refects the direct relationship between a risk fac to r (for example, overweight and obesity) and a disease outcome. It is the amount of burden that could be avoided if the risk fac to r were removed or reduced to the lowest possible exposure. When the risk fac to r is a disease, such as diabetes, the additional burden from diseases linked to the disease risk fac to r represents the indirect burden.

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