Rumalaya

William H. Clewell, MD

• Director, Fetal Medicine and Surgery
• Phoenix Perinatal Associates
• Phoenix, Arizona
• Clinical Professor, Obstetrics and Gynecology
• University of Arizona College of Medicine
• Tucson, Arizona

However symptoms checklist buy rumalaya 60 pills overnight delivery, the availability of such technical examinations is not a prerequisite to Everything necessary for an orientating neurological make a diagnosis in many cases symptoms low potassium 60 pills rumalaya mastercard. A small collec ments without the possibility for further testing internal medicine generic 60pills rumalaya free shipping, careful tion of instruments should be at hand symptoms influenza buy 60pills rumalaya fast delivery. With a patellar and thorough history taking and physical examination hammer symptoms 0f pregnancy order genuine rumalaya line, a sharp instrument treatment qt prolongation buy rumalaya 60 pills without prescription. If available, an ophthalmoscope would complete How do I prepare the patient the test battery. But with experience, one develops a quick patient and explain the nature and purpose of the exami and e? The physician normally begins the examination of any How can I draw conclusions from patient with an examination of the appearance of the subject in general, his/her skin and mucous membranes, the neurological examination? An evalua amination, it is advisable to follow a certain stepwise ap tion of vital functions should normally be done at this proach to avoid imperfection. However, following a step time, including blood pressure, pulse, respiration, and wise approach does not mean being overly schematic! Physical Examination: Neurology 81 The examiner develops a quick plan of the se a general familiarization with a coma scale (such as the quence of steps in the examination, which should be famous Glasgow Coma Scale) may be useful. A checklist of activities is to understand and follow instructions, and fully orient often useful for the non-neurologist who is not yet ex ed in time, space, and person. For many, it is easy to follow the examina emotional state (level of anxiety, depression, apathy, dis tion in a rostral caudal direction, but one may? As a bare minimum, the ar any impairment is noted, a full description should be re eas listed below must be assessed in an adult patient. Cognitive skills can quickly assessed using sim What items do I look for in the ple observations during history taking and can then be supplemented by direct examination of speci? Examination of the cranial nerves memory and recall, abstraction, comprehension, read-. Examination of the motor and musculoskeletal ing, drawing, and writing ability can be assessed. Where system (look for deformities, bulk, muscle tone, dysphasia is marked, testing other elements of cognition and bilateral strength) is di? Tenderness over the insertion of the and Romberg test) paraspinal and mastoids on the skull may be elicited. For special diagnostic questions only, certain in patients with neck muscle spasms, while occasional ?technical testing could be useful (laboratory tenderness at the vertex may be elicited in patients with tests, blood tests, cerebrospinal? Palpation for the carotid pulse will establish the presence and symme How do I evaluate ?higher functions? Each nostril should be exam cation (jaw clenching and opening against resistance). Examination of the second cranial nerve is the The seventh nerve is examined by observing most involved, but it a? The optic pathways tempts to wrinkle the forehead (lift the eyebrows), close traverse the whole of the brain from the frontal to the the eyes, show the teeth, or blow out the cheeks. Taste, occipital pole, with the optic radiation opening out to which is also a function of the seventh nerve, is rarely traverse the parietal as well as the temporal lobes. As tested routinely, but it can be tested in the anterior two sess visual acuity roughly using a newspaper, which con thirds of the tongue using sugar or salt on the protruded veniently has type of di? More accurate assessment can be car The ninth, 10th, and 12th nerves are examined ried out using perimetry or tangent screens. One should note the presence of dysphonia, Examination of the optic fundus may reveal in palatal movement symmetry (when the patient says valuable information regarding raised intracranial pres aaah), the gag re? Pharyngeal sensation may be tested using a wooden aches should have a funduscopy done. The state of the probe tipped with cotton wool, testing each side sepa arteries, silver-wiring, venous pulsations, disc color and rately, normally as part of the gag re? The examination of the papillary reactions and The movement of shrugging the shoulders and turning eye movements yields further information on the sec the neck against resistance applied to the side of the jaw ond, the third, the fourth, and the sixth cranial nerves. Check for ptosis (eyelid droop), How do I examine the motor and and note whether it is partial or complete. The presence of nystagmus should General observation for muscle wasting or hypertro be noted and described, remembering that nystagmus phy, deformities, posturing, and presence of involun at extremes of lateral gaze may be normal. Abnormali tary movements (fasciculations, tremors, chorea, or ties of nystagmus re? When necessary, changes Physical Examination: Neurology 83 in muscle mass can further be evaluated by palpating Fast (posterior column, lemniscal, or discrimi as the muscle contracts and/or by measuring the girth natory) sensations that include light touch (tested with of the limbs. Localized atrophy may be due to disuse a wisp of cotton wool), joint position sense, two point because of chronic pain and should be kept in mind as discrimination, and vibration. Slow (spinal thalamic) sensations that tradition Ensure the patient is calm and comfortable before test ally are represented by pain (pinprick) and temperature ing tone and limb mobility. Limb mobility at joints one side initially and then on two sides simultaneously should be tested in all directions allowed by the joint in corresponding parts of the body. One should be aware that sensory extinction where the patient may fail to regis there may be some modi? If any abnormalities are Muscle power is then tested in muscle groups detected, attempts should then follow to accurately map around the joints and in the axial musculature. If the same systems, and therefore it may not be necessary nerve-related weakness is noted, then it is imperative to test for both in the routine patient without neuro that it be graded according to an established scaling pathic pain. Also, establish whether it is upper motor neuron partly been picked up during history taking will need to or lower motor neuron and whether it is segmental, be elucidated further. Myopathic lodynia need to be mapped out accurately, noting that weakness does not respect peripheral nerve or segmen skin hypersensitivity to various stimuli (touch, cold, and tal demarcations and is usually more marked proximal warmth) may be di? Subtle weakness in the lower limbs may occa that they are all fast sensations, because they may be af sionally be picked up by requesting patients to rise from fected di? The jaw jerk, the su pinator, the biceps, the triceps jerks in the upper limbs system? Of particular interest is the symmetry of responses and Suggested neurological examination tests for the pain the least force necessary to elicit the responses which patient by the non-neurologist: may be a more sensitive measure than the grading sys Trendelenburg-test: descending of the hip to tem above. The is positive if pain is felt in the back radiating to the leg hall mark of upper motor neuron de? Truncal ataxia is standing negative (L5) associated with disturbed gait that is typically broad Atrophy of gluteal muscles and standing on one based and reeling and does not get worse when eyes leg negative (L5/S1/S2) are closed. Valleix pressure point test: provoking radiating into the examination room or when he/she is request pain in the leg when palpating along the pathway ed to walk naturally in the room. Tandem walking (10 of the sciatic nerve on the dorsal site of the thighs steps), heel walking, and one leg stances (holding form. Leg-holding test: lifting of the straight leg by 20 more than 10 seconds) can also be tested. Jackknife test: no spasticity at rest, but after pas companied by other neurological manifestations that sive movement of the joints, increasing spasticity help discriminate lesions. Limb coordination to assess followed by a sudden muscle relaxation cerebellar function may be tested using a variety of. His left lower extremity is in a a plaster splint to three sides of the limb?leaving the an temporary cardboard splint, and after a primary evalua terior aspect open to allow room for swelling. He is is comfortable with oral or intramuscular pain medica alert and will talk to you. The vascular and Your initial examination of the left lower ex neurological function of the left foot and ankle seems to tremity shows a swollen calf with a mild angular defor be improved following your reduction, although not com mity and bruised but closed skin. Likewise, the nurse calls you because the patient is having extreme range of motion of the hip cannot be tested. She has given all the pain medi The patient can move his toes and ankle in both cation ordered, and it is not helping. You cannot palpate a dorsalis pedis or posterior with mild discomfort, but if you try to passively? Yesterday you could palpate weak mid-shaft fractures of both bones with some angulation posterior tibial and dorsalis pedis pulses, but now there and minimal displacement?but little comminution. This material may be used for educational 87 and training purposes with proper citation of the source. After examining him on rounds, so you suspect the The value of this feedback loop is better appreciated problem is located: in situations where pain perception is impaired and a. Pain produced by musculosk eletal pathology, trauma, infection, or tumors must be How do you reach a diagnosis? The pain associated with certain chron ments, and the muscles are contained within substan ic pain syndromes appears out of proportion to the tial fascial sheaths. The history and physical examina they swell, increasing the pressure within their com tion provide the key to establishing a working differ partment. It the pressure is not released by dividing the surround is often accompanied by other complaints such as swell ing fascia, the muscle will become permanently non ing, discoloration, or the inability to perform certain functional. A compartment syndrome is one of the tasks, such as walking up stairs, lifting the arm over few surgical emergencies a? They can be remembered by the ?7 P?s?: Pain provides the starting point for the or Pallor?decreased blood? The answers provide the clues we need to Pressure?the compartment involved will feel tight, begin the physical examination. Fortunately the ba and the pressure will measure high sic orthopedic exam is not complex. It consists of a Passive stretch?stretching the muscles of the in rather limited set of maneuvers, coupled with some volved compartment will cause extreme pain; in this knowledge of the anatomy involved. This is an important concept, be Pulselessness?the pulse will not be palpable if the cause if you had continued to increase the pain pressure is high enough, but this is a late sign and is not medication for the patient in the above case history reliable for early diagnosis. In general order of impor 4) Evaluate sensory nerve function of the axillary, tance, these include the skin, vascular supply, nerve, func median, ulnar and radial nerves. Hint: the volar tip of tion, muscle, joint function, including ligament stability, index? If a bone is obviously broken, it may not be prudent to attempt to evaluate range of motion or ligament Elbows: stability in a nearby joint. However, it is possible to 1) Palpate the surface location of the medial and lat examine the joint for swelling, effusion, tenderness, eral epicondyles, the radial head, the olecranon process, and the olecranon bursa. Bones Look for alignment: normal, angled, or rotated; look 3) Evaluate the range of motion of the wrist joint:? Shoulder: 3) Palpate pulses?femoral, popliteal, and anterior 1) Palpate the surface of the clavicle, the acromio and posterior tibial. Normally 2) Test shoulder joint range of motion actively or the ipsilateral pelvic rim will elevate. If the abductor 90 Richard Fisher muscles are weak or if there is a painful hip problem been embarrassed by a slapping sound his foot makes the pelvis will fall and the patient will lean the upper walking down the halls at school. You notice he gets up slowly to move to the exam 1) Palpate the surface location of the patella, the pa table but can stand up straight. Tere is mild tenderness to palpation over the lum 3) Test the stability of the medial and lateral collat bar muscles only. The straight leg raising test (sciatic nerve stretch test) is 7) Check for tenderness along the meniscus inser not painful on the left to 80, but on the right it produces tion at the joint line. Potentially abnormalities of the calf muscles (especial 3) Evaluate the Achilles re? Also, the positive straight leg raising test indi about 12 miles to and from school each day for the past cates irritation at the nerve root level as it is stretched year. Similarly and calf, which is increased by sitting in class, bending the slapping foot and toe extensor weakness involve an forward, or sneezing. Usually?although there are exceptions?the L5 How to examine the spine root is compressed by an abnormal L4?5 disk and the S1 root by an abnormal L5?S1 dis. Pain felt in the calf is a positive test root as in this patient, from a tight anterior compart indicating tension on the involved nerve. Tuberculous infection pres ents with systemic signs, spinal deformity, usually ky Sequentially, the nerves most likely to be phosis, and may have neurological changes. L4 root: femoral nerve: posterior tibial nerve spinal cord, rather than nerve roots, and the physical. Tese are How to examine the back usually of unknown cause, idiopathic, and while they Back pain is a universal problem, which must be ad may progress, they do not cause severe pain; just some dressed carefully in order to separate musculoligamen mild discomfort. Tere are a few particular problems involving and still provide a great deal of information. Chronic pain involves more than the sub sible to have any relief of pain after unsuccessful treat jective experience of the intensity of pain. Believing this can, for example, increase feelings years a biopsychosocial model for understanding chron of helplessness. The main focus is on con is unbearable or ?the pain will never end can have an sulting a doctor and obtaining a cure. For example, and cognitive aspects like anxiety or helplessness in biological processes such as muscle tension can cause coping with chronic pain are correlates that can signi? Depression can lead to more physical passivity, and in Guide to Pain Management in Low-Resource Settings, edited by Andreas Kopf and Nilesh B. This material may be used for educational 93 and training purposes with proper citation of the source. The result can leads to physical inactivity out of fear that the pain be chronic pain. Fear for the future leads the complexity of chronic pain and demand consider to constant increased muscle rigidity and increased agi ation of all the factors involved. Attempts to Case report 1 solve problems are avoided, which increases the anxiety A 40-year-old farm worker su? All attempts at treatment have so far been What are the consequences for without success. Psychological assessment should be an inher Increasingly, he feels helpless, he cannot sleep at night be ent part of the pain diagnostic investigation, in a multi cause of his pain, and he worries about the future.

Patients should be encouraged to participate in behavioral modification programs that have been proven to be successful symptoms 0f high blood pressure order rumalaya 60pills online. These include cognitive-behavioral therapy medications like prozac buy rumalaya 60 pills low price, stress management medications ibs discount rumalaya online master card, relaxation training symptoms 5th week of pregnancy buy generic rumalaya canada, and biofeedback therapy treatment quadratus lumborum order cheap rumalaya. Although active participation in nonpharmacologic treatment may produce a slower response than pharmacologic treatment medications without doctors prescription purchase 60 pills rumalaya with amex, it encourages an active role for patients. These strategies are particularly important when pharmacologic interventions are limited. Pharmacologic treatment of migraine can involve both acute and preventive interventions. Acute treatment is aimed at aborting the headache, whereas preventive treatment is geared toward reducing the frequency and severity of anticipated attacks. In summary, education, behavioral management, acute therapy, and preventive therapy (if appropriate) are the cornerstones of good migraine management. Dietary factors are also frequently reported triggers, although few have been scientifically validated. Although the impact of food triggers probably is not great for the population, their impact could be for the individual. Hormonal headaches are triggered by variations in female estrogen levels and possibly other hormonal factors. Acute treatment is initiated during an attack to relieve pain and disability and to stop progression of the attack. Preemptive treatment is used when a known headache trigger exists, such as exercise or sexual activity, and for patients experiencing a time-limited exposure to a trigger, such as ascent to a high altitude or menstruation. Preventive treatment is maintained for months or even years to reduce attack frequency, severity, and duration. Patients taking preventive medication can also use acute and preemptive medication. Failure to use effective therapy early may increase the pain, disability, and impact of the headache. The route of administration is especially important in patients experiencing severe nausea and vomiting. Treat at least 2 or 3 attacks before judging the effectiveness of the therapeutic choice. If treatment is not working, consider the following: Reconsider diagnosis: Secondary headaches, although not as common, may present with clinical signs and symptoms that resemble migraine. Treat early: Recent studies, both prospective and retrospective, support improved response to triptan therapy when patients treat early in the course of an attack. This is especially pertinent in those who are at risk of developing cutaneous allodynia. Triptans have been shown to be less effective in patients who develop cutaneous allodynia in association with their migraine (summarized in slides below). Dose and route of administration: If the patient is experiencing some relief from the current medication, would a higher dose be more efficacious? If the patient requires more rapid onset of pain relief, would a nasal spray or an injectable formulation of the present medication suffice? Choice of drug: If a nonspecific agent, such as a combination analgesic, is being used, would another nonspecific medication, such as an opioid or a specific medication, such as a triptan, be more effective? Adverse drug interactions: Investigate the use of interfering medications, including other over-the-counter analgesics and medications for depression and heart disease. Adjunctive therapy: Patients experiencing nausea and vomiting may benefit from the addition of adjunctive antiemetics. Additionally, be sure there are no other medications that may be exacerbating or triggering migraine. Specific endpoints to review include number of days missed from work or school, time missed from home and leisure activities, and reduced productivity. Monitoring migraine features: Also, specific headache features should be assessed at each office visit. The assessment should include a discussion of the average duration of each attack, usual time for attack resolution following treatment, and attack frequency. Reviewing use of medical resources: Other ways to assess treatment success include response to a single dose of study medication, such as a triptan, especially if the patient treats early in the course of an attack. Patients with migraine run the risk of overusing medications, which can exacerbate their condition. Evaluating treatment plan tolerability and acceptance: Patients also need to tolerate their medication or else they will not be satisfied with their treatment plan, and may possibly discontinue consulting medical care for the management of their migraine. Ideally, patients seek a pain-free response, but may only achieve a pain-free status. Pain relief or ?headache response is commonly defined as pain intensity originating at a 3 or 4 pain intensity (4 being severe, 0 being no pain) and going to no pain or mild pain by 2 hours. Other important features is to have the patient track how well their medication worked over a 24-hour period. Additionally, patients should monitor their ability to resume normal activities including work, child care, and social or leisure events. Gradual improvements in headache status can be difficult to assess if the patient is not aware of how to monitor improvements or deterioration in migraine patterns. Explaining what to look for and how to track attacks is an important part in determining treatment success or failure. Do not know to take medicine early May not recognize it as migraine g Throbbing, nausea, photophobia g Aggravated by activity Recognize migraine aura Harbor medication so they don?t run out / cost One of the important parts in managing patients with migraine is to help them learn how to manage their own illness. This includes educating them about the cascade of events that occurs with each attack. Understanding that early treatment will improve response to therapy is an important component to also realizing that this approach will lead to less medication use and less disability. Preliminary studies have been done that assess the efficacy of giving triptans during an aura. When given during an aura, triptans do not show consistent efficacy in aborting or preventing the migraine. Therefore, until further studies are done, it is also helpful to educate the patient to not take their triptan during the aura phase but rather early in the pain phase of the attack. Choice of initial acute therapy depends on the severity and intensity of the migraine, the presence of comorbid conditions, patient preferences, and past therapeutic response profile. Prescribe initial acute treatment to abort or reverse the progression of headache. Rescue therapy is an agent that the patient can use at home to treat breakthrough migraine when other agents, such as initial and back-up medications, have failed to provide relief. Medications of choice include potent opioids such as butorphanol and neuroleptics. Although rescue medication may not completely eliminate pain and return the patient to normal activities, it may permit the patient to achieve relief without discomfort and a possible visit to the emergency department. If treatment fails, conduct a thorough follow-up investigation to determine reasons for failure. Practice parameter: evidence-based guidelines for migraine headache (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Evidence-based guidelines for migraine headache: pharmacological management of acute attacks. Step care is the use of medications in a sequential order, based on a predetermined plan. Therapy starts with the lowest level of treatment, independent of the characteristics of the attack. This approach to treatment is not necessarily based on the individual needs of the patient. Some managed care companies have attempted to restrict medication choices in a cost-saving attempt to manage plans and not patients. Stratified care is treatment based on attack characteristics, including peak intensity, time to peak intensity, associated symptoms, and disability. Stratified care takes into account patient preferences for treatment and allows the patient to select medications for each particular attack. The advantages to stratified care are that it is more likely to be effective in reducing pain and disability and improving overall patient satisfaction. It also may have the potential to reduce patient drop-out rates and provide improved, cost-effective care through fewer clinic visits and less failed prescriptions. Even with an ideal stratified care plan, treatment of an individual attack may fail and require back-up or rescue medication. These evidence-based guidelines advise clinicians to base their treatment choice on attack frequency, severity, duration, disability, nonheadache symptoms, patient preference, and prior history of treatment response. The role of headache-related disability in migraine management: implications for headache treatment guidelines. A government-funded meta-analysis of acute migraine therapies permits the categorization of treatments. Group 1 demonstrated the best evidence for efficacy-consistent statistical significance and moderate-to-large effect size. These therapies show substantial empirical evidence and pronounced clinical benefit in migraine. Efficacy and safety of acetaminophen, aspirin, and caffeine in alleviating migraine headache pain: three double-blind, randomized, placebo-controlled trials. Evidence-based guidelines for migraine headache in the primary care setting: pharmacological management of acute attacks. In the majority of patients, the intensity of adverse effects is mild and of short duration. Adverse effects can include chest pressure, flushing, dizziness, drowsiness, and nausea. Patients who are at risk for coronary heart disease, diabetes, obesity, severe uncontrolled hypertension, or hypercholesterolemia should be screened prior to administration of triptans. Practice parameter: evidence-based guidelines for migraine headache (an evidence based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. This study tested the success of triptan therapy when given during the presence vs. Cutaneous allodynia is proposed as gradually developing during the course of the migraine attack in the majority of migraine patients. In this study, 31 patients attended a migraine clinic upon three separate occasions: in the absence of migraine (baseline), within the first hour of one attack, and at 4 hours from onset of another attack. Allodynia was identified based on differences between migraine and baseline pain thresholds to both mechanical and thermal stimulation of periorbital skin. In this study, 34 migraine attacks were associated with allodynia at the time of triptan treatment and 27 attacks were not. Within 2 hours of triptan administration, only 15% (5/34) of attacks achieved a pain-free response to treatment. In patients without cutaneous allodynia, 93% of attacks (25/27) were pain-free at 2 hours. These results suggest that treatment before the development of cutaneous allodynia may improve response to triptan therapy in some patients. Defeating migraine pain with triptans: a race against the development of cutaneous allodynia. Rizatriptan n If one triptan fails, will n Tablet & melt (5, 10 mg) another triptan work? The oral formulation is available in 25-mg, 50-mg and 100-mg doses as either an oral tablet or a rapidly-dissolving tablet. Since its introduction in the early 1990s, over 400 million doses of sumatriptan have been given. Naratriptan is considered to have lower efficacy than sumatriptan with minimal adverse events. It, like naratriptan, has a long half-life, low rate of adverse events, and a low recurrence rate. Onset of action may, for some oral preparations, be delayed by migraine-associated gastroparesis. Among the nonoral formulations, suppositories have the slowest and intravenous drugs the fastest onset of action. Patients may not recognize exacerbating factors such as regular or high levels of daily caffeine intake. Acute medication, if taken too often or in too high a dose, may also cause headache problems. Women taking oral contraceptives or hormone replacement therapy may experience migraine associated with changing estrogen levels. Other medications, such as nitroglycerin or dipyridamole may also lead to exacerbation of headaches. All medications, vitamins, and over-the-counter remedies should be assessed as possible confounding headache triggers. Another challenge for many patients and their physicians is that migraine is often a lifelong illness, so treatment plans need to be reviewed continuously. Routine assessment of sleep hygiene, diet, exercise, concomitant medications, and lifestyle factors will all help identity what may be contributing to migraine. Treatment with triptans during mild pain produces extremely high pain-free rates (85%?90%). Are the benefits of early intervention shared by all migraine drugs or are they specific to the triptans? One concern is that early intervention may lead to treatment failure if nonmigraine headaches are treated. Treatment of mild headache in disabled migraine sufferers: results of the Spectrum study.

Instead medications made from plasma purchase generic rumalaya from india, maximize the use of products made from recycled plastic or recycled plastic/wood composite materials symptoms vaginal cancer cheap rumalaya online, which are inherently durable and weather-resistant treatment zona buy discount rumalaya 60pills online, for benches treatment uveitis order rumalaya australia, etc medications 142 order 60 pills rumalaya visa. The remaining should be provided symptoms estrogen dominance generic rumalaya 60pills otc, allowing children to engage in role playing and make 5% should consist of resins and fibers for strength, and the same color believe activities. These items include elements such as boards, scrap lumber, dress up clothes, cooking utensils, tarpaulin, banners, signs, and other items 6. The props should be Storage facilities should be easily discernible and have a unique, easily easily moved and incorporated into play activities. Storage facilities provide an should be adjacent to and incorporate paths and parking areas for wheeled opportunity for children to learn organization and cooperation skills. Exterior storage Large motor play areas provide for the physical development of children. Fixed equipment such as a superstructure play piece and slides encourage children to explore 6. Sand and water play facilities allow children to pretend and project their ideas in a real and physical way. Sand and water tables should have play surfaces hidden or unforeseen risk is dangerous and often results in injuries. Allow play space and storage for props such as spoons, children when they become hot), enclosed tunnel slides (which make shovels, pails, plastic vehicles and animals, containers, and buckets. These observation difficult and can allow one climbing child above the enclosed props add greatly to the quality of play experiences. The need for a child tunnel to fall on top of another at the tunnel exit), traditional see-saws (which scaled drinking fountain on the playground should be determined during design. Age Groups Small berms and hills, large rocks, stumps, trees or bushes provide settings and obstacles for children to climb over, jump on, dodge around, or hide 6. Playing with wheeled toys, such as tricycles and wagons, helps to develop coordination and Play areas for infants require special design considerations. The large space required for these activities and the spaces for infants should be near toddler play areas, providing visual and boisterous character of this play dictate that this area be situated away audible connections and limited physical contact. Because local licensing has a wide range of interpretation should be exposed to the natural environment, though shielded from the of appropriate play yard design, obtaining their ?buy-in to the design concept extremes of wind and sun. Infant play area surfaces should consist of soft, resilient materials that Play areas should be made accessible to children with disabilities. The protect crawling children and provide a comfortable surface on which they proposed rules are quite complex and the designer should consult with can sit. Soft surfaces should have different textures and (not garish) colors playground equipment manufacturers and refer to the web site: denoting changes in activities and challenges. These To provide a safe environment that still allows gross motor activity, the challenges could take the form of crawling spaces with slight inclines or movement of the children themselves rather than equipment is key. There must be some surface that is hard enough to they have been found to be unsafe in the group care setting: allow the use of wheeled and push toys. The toddler strike a child (There are acceptable, lighter weight rocking toy alterna play environment should allow for a wide range of movement and stimulate tives). Toddlers crave and enjoy semi enclosed spaces such as small play houses or climb-through tunnels. A variety of surfaces and materials should be provided including sand and dirt, pavement, and open grassy areas where toddlers can use an abundance of play objects. All sand areas require fitted water-permeable covers to deter rodents and other pests. Pre-school children regularly interact, socialize, discuss, Criteria and negotiate. A larger, open z Play yards must be enclosed by fences to define the play yard, allow ended play superstructure offering many activities should be provided, but ease of supervision of children, and protect them from unauthorized be designed to lend itself to dramatic play. The design of the fence is one of the most as playhouses, stages, and props that encourage dramatic play. Exposed galvanized provide circulation and allow the play experience to flow through the play wire, which has a highly institutional appearance, is not appropriate. Where these are not safety surfaces, a minimum of 10mm of impact the fence must have no sharp exposed connections accessible to chil resistant topping must be applied over concrete. Facilities for play with sand and water should z Provide bollards, raised planters or other devices to keep automobiles be included and placed adjacent to one another allowing these activities to from veering into the play yard area. Materials for creative play activities such as musical devices, z the transparent or opaque nature of the fence and fence height will painting materials, chalkboards, construction materials, and blocks also depend upon the location and environmental conditions of the center should be included. Generally, for best motor activity in a group care setting, the z It is important that fences be designed so that there are no spaces be children should be moving, not the equipment. These Play areas for school-age children should be separate, but linked to the entrapment dimensions are very important and should receive particu play areas of younger children. Running, jumping, and climbing activities are z the perimeter of the play yard must be enclosed by an 1830 mm high supplemented by more athletic pursuits such as sports and games. As an alternative, a children of this age have the physical ability to roller skate and ride bicycles. Views from the play yard should specifically geared to this age group which should be referenced for be screened either by the fence itself or with plants or other suitable dimensions. Bollards, raised planters, or other devices should be used to protect play yards located next to driveways or roads where cars could swerve into the play yard area. Use alternate, less toxic termite prevention systems, rather than z Wood fences are not to be specified for new construction, existing ones the application of chemical soil treatment, for wood-framed buildings. Only should be smooth finished and splinter-free and if treated for exterior where soil poisoning is determined to be necessary, use less toxic chemicals use should be guaranteed to be non-toxic. Instead of wood, z Plant materials should be used to bring natural elements to the play maximize the use of products made from recycled plastic or recycled yard environment. Each play plant materials in preference to , or in conjunction with, man-made struc yard will have a vehicle gate to allow service. Main entrance pathways should be 1830 mm to 2440 mm z All openings in the fences must be no more than 88 mm wide. Categories of plant hazards include berries, thorns, and z Handrails must be provided to accommodate the intended age group plants with toxic leaves, stems, roots, or flowers. For children, heights will range between 510 mm above the leading edge of the tread and 915 mm. In certain Design planting and irrigation systems to minimize, down to zero, potable instances, it may be necessary to have two railings mounted at differing water for landscape irrigation. The guardrail should not have openings be Resilient surfaces serve to reduce the impact from falls and are required in tween 87 mm and 228 mm to avoid the possibility of head entrapment. Examples of must be 740 mm above the platform, with no openings greater than 75 approved resilient surface materials are pre-engineered wood accessible mm and no horizontal footholds. A tricycle path cannot run through a the least expensive are the loose fill variety which typically require a much fall zone area. The designer may recommend the more the correct mix of sun and shade is vitally important. At least 50 percent of expensive rubberized solutions for ease of maintenance, but should receive the play area should be exposed to sunlight at any time during the morning written assurances that its impact-absorptive properties are not lessened and afternoon when the play yard will be used. The degree and orientation by exposure to sunlight and the color will not fade significantly. Shade areas, including drainage must be provided under any resilient material, including wood porches, gazebos, and other structures, should provide a minimum shaded chips. A combination of materials such as grass, resilient surface, and area of 1832 mm in any direction. Shading structures and materials that pre-engineered wood chips incorporates the advantages of each material may be used include trees, exterior screened rooms, park shelters and and renders a more natural, less institutional appearance than any one structures, awnings, and umbrellas. A variety wheel chair accessible processed wood fibers, have good impact-ab of ground surface texture is required in a playground. They have proven Acceptable materials include concrete, asphalt, stone or masonry pav problemmatic and are not recommended, unless there is assurance ers, rubberized surfaces, rubber matting, or wood chips. They also require maintenence to ensure pathways should not create trip hazards, and may need to be tapered that proper depths are maintained. Gravel and loose stone wet and are tightly installed so as not to cause tripping hazards. Smooth surfaces provided for be abrasive and convey an ugly, unnatural impression. This material is wheeled toys should not have joints wider than 12 mm because they not recommended for use as a play yard surface. Examples of hard surface materials are concrete, asphalt, stone, materials and provides a pleasant texture to play on, but requires constant or masonry pavers. The durability of each material will vary based on maintenance and may need an irrigation system. The designer should factors such as the method of installation and the thickness of the surface consider using under-turf products to minimize turf root compaction, which material. Surfacing concrete in particular, with 10 mm of rubberized is a major cause of grass detenuation. There must be supervised access surfacing, is highly recommended to minimize abrasions. The severity of weather will affect all paving surfaces, but cast-in-place concrete over a well-compacted subgrade is the most durable, maintenance-free paving material for hard surface areas, although it should be finished to be non-slip. Asphalt paving is an acceptable alternative to concrete in vehicular areas, but degrades more quickly than concrete. Consider the following: z the use of pavers may introduce joints and textures in the paving sur face that can become uneven over time if they are not laid over a con crete base. Asphalt usu ally will be the least expensive and stone or masonry pavers the most expensive. Again, it is possible to use a variety of surface configura tions and materials to increase the impression of ?naturalness in the play yard. Specifications and supervision to ensure excellent compac tion will greatly affect the serviceability of the surface material. This chapter provides concepts and criteria for the design of the center may also include a multiple-purpose space. Major types of purpose space may be used as a meeting or gathering area and as a spaces include entry and circulation, staff, classroom, com large-motor-activity area. The entry to the center and main circulation An isolation sick bay, where a child will wait until taken home by a parent, is pathways unify these areas. The main the center requires space for services including food, laundry, janitorial, circulation provides pathways between discreet functional spaces. Architecturally defined (typically in centers over a population of 74), the reception desk should spaces within classrooms include the entrance, cubby storage, classroom allow children to easily see the adult behind it. It should be a simple desk, and teacher storage, diapering station and storage, toileting and hand not a high counter such as might be seen in a professional office, for washing, sleeping, nursing, and food preparation. The main entrance should be in close Provide views of the short-term-parking area from the entry vestibule and proximity to an adult toilet room for use by parents. This vestibule should consist of two sets of doors to provide Permanent entryway systems (grills, grates, etc. The main entry should include an exterior should be non-intrusive and have a non threatening appearance. Refer to transition area (where a covered bench for good-byes, ?shoe-tying, and Chapter 10 for more information on technical requirements. Secondary entries should have transition areas, but do not require thermal vestibules. This area needs to It may be desirable to alarm secondary entrances also, especially where be warm, bright and welcoming, and as comfortable as possible. The reception area connects the entrance to the main circulation pathways of the center, Fire egress doors should also be alarmed. If it is Ground materials and landscaping leading to the building entry should be provided, it may be designed in a way that allows it to serve several functions. Rough textured ground surfaces are appropriate at these areas, ?mailboxes, or both. A counter, which is typically simpler and less expensive combined with landscaping that keeps soil and foliage away from the path than a reception desk, may also serve these functions. In all events, a child should be able to see the adult behind the desk upon entry. Typical furnishings in the All exterior entries used by children must have transition spaces consisting reception include a sofa, chair, end table, and coffee table. Transition spaces A slotted fee box for tuition checks should be provided near the reception are important in creating a comfortable environment and integrating the area, together with cubicles for parent notices as well as a notice/bulletin exterior and the interior. Select durable finishes that have an informal, comfortable between interior and exterior light levels and temperatures. The transition appearance, and establish a warm, inviting feeling through use of color, spaces also may serve as a ?mud room or may provide an intimate area soft seating, plants, and art work. Recommended finishes include carpeted for children within the outdoor environment. Circulation within classrooms will be discussed in the classroom section of this chapter. It can also be used by the skillful designer to diminish the utilitarian in character. Instead, it should be conceived as a street or a impression of long, double-loaded corridors. There is opportunity tern repeats are often effective to de-emphasize the ?tunnel appear for important social in this space. Likewise, patterns which are not sym parents; a vantage point to see into classrooms, an exhibition space for metrically arranged or which emphasize functional areas (such as en the work of children or prints of other kinds of art, and perhaps even trances to classrooms) are effective means to achieve the same end.

State policies to improve the odds for the healthy and alternative shelter arrangements; development and school readiness of infants and toddlers 85 medications that interact with grapefruit rumalaya 60pills low cost. Preventing and reporting child abuse and neglect; parents/guardians should sign a statement that ag medicine used for anxiety order rumalaya 60 pills. Use of pesticides and other potentially toxic substances they have received a copy of the policy and read and/or in or around the facility; understand the content of the policy medications list form purchase rumalaya line. For centers treatment keratosis pilaris purchase rumalaya 60pills with amex, all of these items should be are not able to understand the policies because of a language written medicine 666 order rumalaya 60 pills without prescription. Neither plans nor policies afect quality unless the program has devised a way to implement the plan or policy treatment for chlamydia buy rumalaya in india. Questions and answers about the Americans with Disabilities Act: A quick reference for child care providers. Methods and schedules for conferences or other blanks to customize the policies for a specifc site. Starting with a template such as the one in Policies on: Model Child Care Health Policies can be helpful. Nondiscrimination; Confict over policies can lead to termination of services and d. Policies, plans and procedures Infants and Toddlers should generally be reviewed annually or when any 2. The facility and parents/guardians should exchange and Toddlers information necessary for the safety and health of the child. Collection of clearinghouse the ages of the children enrolled outlined in Standard notes, 1998-1999. Positive methods of discipline create a constructive and Any special health care need of the child and successful supportive social group and reduce incidents of aggression. Research links corporal punishment usually at least ninety days prior to the time that the child with negative efects such as later criminal behavior and will leave the facility or program. Research brief: Desired family outcomes of the early childhood transition process. Information regarding a written plan is developed and followed to ensure that all successful behavior strategies, motivational strategies, and steps in a transition are included and are undertaken in a similar information may be helpful to staf in the setting timely, responsive manner (1). An interdisciplinary It is best if the process of planning begins at least nine process is encouraged. In small and large family child care homes where required representation at the various meetings. Each an interdisciplinary team is not present, the caregivers/ agency can adapt the format to its own needs. However, teachers should participate in the planning and preparation consistent formats for planning and information exchange, along with other care or treatment providers, with parent/ requiring written parental/guardian consent, would be use guardian written consent. Examples of appropriate clothing/footwear include: When several staf shifs are involved, information about a. Children can learn math, science, and language concepts through games involving movement (3,4). The policy can make clear that outdoor Policies and Practices that Promote activity may require special clothing in colder weather or Physical Activity arrangements for cooling of when it is warm. Caregivers/ day outdoors depending on their age, weather permit teachers can be helpful by having extra clean clothing on ting. Type: Structured (caregiver/teacher-initiated) versus sun-protective clothing, and insect repellent, if necessary unstructured activity. A procedure to obtain and maintain updated individual Vector-Borne Diseases care plans for children and staf with special health 3. The fact that adults may be on staf with known health problems or may develop health problems while at work;. Following the infection Red Book: 2015 Report of the committee on infectious diseases. All notifable diseases should be reported to the Facilities may comply by adopting a model policy and health department. Caregivers/teachers can check for other caregivers/teachers may not be a mandatory reporter. Health record information should be reviewed and other children whom the unimmunized child would by the staf of the facility and information sharing between expose to increased risk of vaccine-preventable disease. When age-appropriate health assessments and should receive immunizations on admission or provide use of health insurance benefts are promoted by caregivers/ evidence of an immunization plan to prevent an increased teachers, children enrolled in child care will have increased exposure to vaccine-preventable diseases. Special clinics the child may attend, including sessions Immunizations should be required for all children in child with medical specialists and registered dietitians; care and early education settings. In addition to print versions child care and health care professionals is inadequate of the recommended childhood immunization schedule, communication (1,2). Every child should have a medical home and those enus/advocacy-and-policy/aap-health-initiatives/ with special health care needs may have additional special immunization/Pages/Immunization-Schedule. The primary care provider and a child who has a medical exemption from immunization is needed specialists will create the Care Plan which will be included in child care, reasonable accommodation of that the blueprint for healthy and safe inclusion into child care child requires planning to exclude such a child in the event for the child with special health care needs. They also release an The facility must have accurate, current information regard information form at ucsfchildcarehealth. Not administering a new medication for the frst Information on family health can be gathered by asking time to a child while he or she is in child care; parents/guardians to tell the caregiver/teacher about any 4. Verifying the consent form; The facility should have a written policy for the adminis 2. How the medication is to be administered; cations are in their original container and include the 6. The proper handling and storage of medications, creams, insect repellants, and sun screens; including: 2. Emergency medications?totally inaccessible to chil and ibuprofen; dren but readily available to supervising caregivers/ 3. The procedures to follow when administering medica Because children twenty-four months of age and younger tions. Assigning administration only to an adequately nerable to the possible side efects of medications, extra trained, designated staf; care should be given to the circumstances under which 2. Documenting and reporting any medication errors; aware of each of the medications a child received at child 5. Information about the medication including warnings medication by documenting the process. It The facility should consult with the State Board of Nursing, may assist a health professional in determining whether the other interested organizations and their child care health child is actually getting the medicine, especially when the consultant about required training and documentation for child is not getting better from treatment. Caregivers/teachers must be diligent in efect on the environment if not disposed of properly. Maintaining sanitation for food preparation and Center, Large Family Child Care Home food service. Regular and thorough cleaning of toys, equipment, and rooms helps to prevent References 1. Human waste (such as urine and feces); associated with cough and cold medications: Two states. Medication adminis a routine basis, standard precautions and sanitation pro tration in day care centers for children. Food procurement and storage; A policy about infant feeding should be developed with d. Age-appropriate eating utensils and tableware; mechanical food preparation and feeding devices, l. Promotion of breastfeeding and provision of including blenders, feeding bottles, and food warmers; community resources to support mothers. Whether expressed human milk, formula, or infant A nutritionist/registered dietitian and a food service expert food should be provided from home, and if so, how should provide input for and facilitate the development and much food preparation and use of feeding devices, implementation of a written nutrition plan for the early including blenders, feeding bottles, and food warmers, care and education facility. Prohibiting bottle propping during feeding or encompasses the pertinent nutrition elements will promote prolonging feeding; the optimal health of children and staf in early care and i. Implementation of daily tooth brushing or rinsing the breastfeeding on future overweight explained by decreased maternal mouth with water afer eating; feeding restriction? Age-appropriate oral health educational activities; sleep equipment including their sanitation and disinfection. Alcohol, Illegal Drugs, and Toxic Substances Educational material such as handouts could include infor Facilities should have written policies addressing the mation on the health risks and dangers of these prohibited use and possession of tobacco and electronic cigarette substances and referrals to services for counseling or (e-cigarette) products, alcohol, illegal drugs, legal drugs rehabilitation programs. Any when caregivers/teachers are responsible for the supervision legal edible marijuana products in a family child care home of children, including times when children are transported, should be held in a locked and child-resistant storage device. Secondhand tobacco smoke and The hazards of second-hand and third-hand smoke expo smoke-free homes. Excerpts from the health consequences of involuntary exposure to tobacco smoke: A report of the Surgeon General. Residual National Center for Chronic Disease Prevention and Health Promotion, Ofce on Smoking and Health. Alcohol and drug use, including the misuse of prescrip Secondhand Smoke What It Means to You. Outcomes in children and young adults who are hospitalized for frearms-related injuries. Changes in health information may require changes in the Centers for Disease Control and Prevention. Assurance that the frst aid kits are resupplied following Urgent Medical Care or Threatening each frst aid incident, and that required contents are Incidents maintained in a serviceable condition, by a monthly The facility should have a written plan for reporting and review of the contents; managing what they assess to be an incident or unusual h. Policy for staf supervision following an incident when The management, documentation, and reporting of the a child is lost, missing, or seriously injured. Death of a child or staf member, including a death that an approach requires written plans, policies, procedures, was the result of serious illness or injury that occurred and record-keeping so that there is consistency over time on the premises of the child care facility, even if the and across staf and an understanding between parents/ death occurred outside of child care hours; guardians and caregivers/teachers about concerns for, i. The presence of a threatening individual who attempts and attention to , the safety of children. Facilities must have a plan for records with other service providers; what to do in such situations (1-3). Notifcation of parent/guardian(s); Medical Services for Children National Resource Center. This site also lists internet The care plan for a child with special health care needs links to emergency plans for specifc health needs such as should cover emergency care needs and be shared with diabetes, asthma, seizures, and allergic reactions. Resources and discussed between parents/guardians and caregivers/ for emergency response to non-medical incidents can be teachers prior to an emergency situation (1). Parents/guardians should be notifed, vent poor judgments made under the stress of an emergency. Such an approach requires written access of a threatening individual to the facility and the plans, policies, procedures, and record-keeping so that means of alerting others in the facility as well as summon there is consistency over time and across staf and an un ing the police if such an event occurs. It should be reviewed with each employee upon Communication employment and yearly thereafer in the facility to ensure Facilities should consider how to prepare for and respond that policies and procedures are understood and followed to emergency or natural disaster situations and develop in the event of such an occurrence. Administering medicine and implementing other power outage, and other situations that may require instructions as described in individual special evacuation, lock-down, or shelter-in-place. This tracking procedures and corrective actions, modify Emergency/Disaster Plan should include: ing exclusion and isolation guidelines, coordinating a. Details on collaborative planning with other groups consultants, health professionals, or emergency personnel and representatives (such as emergency management qualifed and experienced in disaster preparedness and agencies, other child care facilities, schools, emergency response. Diferent types of emergency and disaster situations services); and when and how they may occur; h. Developing personal and family preparedness plans; 396 Caring for Our Children: National Health and Safety Performance Standards g. Supporting and communicating with families; ofcial may announce or declare a state of emergency, h. Location of emergency documents, supplies, medica unsure of what to do, the frst point of contact in any situa tions, and equipment needed by children and staf tion should be the local health authority. The local health with special health care needs; authority, in partnership with emergency personnel and j. Community resources for post-event support such as and they are typically customized to the type of emer mental health consultants, safety consultants; gency or disaster; geographical area; identifed needs and l. Which individuals or agency representatives have available resources; applicable federal, state, and local regu the authority to close child care programs and schools lations; and the incident command structure in place at the and when and why this might occur; time. Each state is Communicating with Parents/Guardians: required to maintain a state disaster preparedness plan Facilities should share detailed information about facility and a separate plan for responding to a pandemic infuenza. Portions of the Emergency/Disaster Plan relevant to State Department of Health, an individual associated with parents/guardians or the public; the agency that licenses child care facilities for that state, b. Description of how parents/guardians will receive information and updates during or afer a potential To develop an Emergency/Disaster Plan that is efective emergency or disaster situation; and in compliance with state requirements, the facility d. Situations that might require parents/guardians to have must identify who their key contact would be (and what a contingency plan regarding how their children will be the requirements for their program might be in an emer cared for in the unlikely event of a facility closure. By brainstorming and thinking through a variety to the state disaster preparedness and response system. Providing clear, accurate, and helpful information to parents/guardians as soon as possible is crucial. In these situ ting them know how they will receive information and ations, facilities should make every efort to meet or exceed updates, will help them understand what to expect. Sometimes, it will be neces development or child care may be asked to support the sary to provide information to parents/guardians before development of or help to implement emergency, tempo all details are known. The plan should physical, physiological, developmental, and psychological include information on: diferences from adults that can and must be anticipated in a. Forming a committee of staf members, parents/ care professionals, and child advocates can and should guardians, and the child care health consultant to prepare to assume a primary mission of advocating for produce/review a plan for dealing with the fu each children before, during, and afer a disaster (1). Reviewing the seasonal fu plan during and afer fu in whatever manner presents, in whatever capacity is season so that key staf could discuss how the program required at the moment. Including the infection control policy and procedure (National Child Care Information Center); (see below) and a communication plan (see below) in.

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Please don?t bring too much into hospital as space is always limited and be careful with valuables as we cannot ensure their safety. New baby practical session covers what to expect in the early weeks of becoming a parent. However, by the risk of having a baby with neural making healthy changes to your diet tube defect (such as spina bi? Diet supplements Vegetarian, vegan and special diets It is best to get vitamins and A varied and balanced vegetarian diet minerals from the food you eat, should give enough nutrients for you but when you are pregnant you and your baby. Talk to your doctor or midwife about how you can make sure Vitamin D that you are getting enough of these Vitamin D is needed for healthy bones. Also talk to your Your baby relies on your stores to doctor or midwife if you have a provide enough Vitamin D for the? Foods that women from South Asia, Africa, the contain high levels of vitamin A Caribbean or the Middle East. This risk with hard cheeses such as advice has now been changed as the cheddar cheese, or cream or latest research shows no clear cottage cheese, feta, parmesan evidence that eating or not eating and processed cheese). Caffeine is cooked until the whites and yolks found in coffee, tea, energy drinks are solid. Store raw foods separately You may have heard that some women from ready-to eat foods so there is no have, in the past, chosen not to eat risk of contamination. This is previously advised avoiding eating to avoid catching toxoplasmosis which peanuts during pregnancy if there was is harmful in pregnancy. However being overweight does increase the risk of complications for both you and your baby. This information explains the extra care you will be offered and how you can minimise the risks in this pregnancy and any future pregnancy. Your healthcare professionals will not judge you for being overweight and will give you all the support that you need. Thrombosis a blood clot in your legs Risks for your baby (venous thrombosis) or in your lungs (pulmonary embolism). Pregnant Miscarriage 20 in every 100 women have a higher risk of pregnancies miscarry before 12 developing blood clots compared weeks. By working together with your healthcare professionals, the risks to you and your baby can be reduced by: Healthy eating you reach your 12th week of the amount of weight women may pregnancy. Even if you have not gain during pregnancy can vary started taking it early, there is still a greatly. It will also help you to maintain a healthy weight after you have had your Vitamin D supplements baby. You may be referred to a All pregnant women are advised to dietician for specialist advice about take a daily dose of 10 micrograms of healthy eating. This is particularly important if you are obese Exercise as you are at increased risk of vitamin Make activities such as walking D de? Vitamin D is available cycling, swimming, low impact without prescription from your chemist. You sitting for long periods watching may need to have injections of low television or at a computer. Physical molecular weight heparin to reduce activity will not harm you or your your risk. Folic acid helps to reduce the risks of your baby having a neural tube defect Pre-eclampsia (such as spina bi? If there is any higher dose than the usual pregnancy concern your midwife will refer you to dose, and it needs to be prescribed the Maternity Assessment Unit for by a doctor. You may anaesthetic given into the space also need further scans because it around the nerves in your back to can be more dif? Planning for labour and birth An injection in the top of your leg is Because of possible complications, normally recommended to help with you should have a discussion with the delivery of the placenta to reduce your obstetrician and/or midwife about the risk of heavy bleeding. The have no other problems you are able midwives will advise you how best to to remain under midwifery led care. If you birth of your baby and this will be want to lose weight once you have monitored. You should stockings if you have been advised aim to lose weight gradually (up to to wear them. Remember even a small weight heparin injections for at weight loss can give you signi? If you are not yet ready to baby regardless of whether you lose weight, you should be given deliver vaginally or by caesarean contact details for support for when section. You should be re you reach your 12th week of tested for diabetes about 6 weeks pregnancy. Our hospital and community staff will provide you with all of the help and support that you need. Carbon monoxide and other harmful chemicals will clear from the body and oxygen levels will return to normal. When you smoke, 4000 chemicals and a poisonous gas called carbon monoxide pass into your lungs making less oxygen available for the baby which means the baby will be smaller than it should be. For every cigarette you smoke the oxygen supplied to the baby is disrupted and your baby experiences reduced blood? There is also Nicotine gum which allows nicotine to be absorbed through the lining of your mouth. Your baby cannot remove alcohol as quickly as you can, so is exposed to the harmful effects of alcohol for much longer. The effects of alcohol on the baby are greater if you also smoke, binge drink or have a poor diet. Even if your baby does not show all the signs of Fetal Alcohol Syndrome your baby may still be affected. We feel that it is safest not to drink any alcohol during pregnancy Help and guidance All parents want the best for their baby and most women are able to stop using alcohol completely during pregnancy. If alcohol has become part of your life, we can help you plan a safer pregnancy for you and your baby. Only you can change your alcohol use, but there are lots of people who can give you support and guidance. It is important that you get the right treatment to help you cut down or stop the amount you drink. To be on the safe side X rays always check with your doctor, X rays should be avoided if possible midwife or pharmacist before taking when pregnant. Talk to your doctor if you take regular medication ideally before you start Complementary therapies trying for a baby or as soon as you It is your choice if you wish to use? Use as few complementary therapies, however, over the counter medicines as few have been proven as being safe possible. It is important that you inform your Medicines and treatments that are therapist that you are pregnant if you usually safe include paracetamol, are using a complementary therapy. In these cases we aim to use the lowest dose and the smallest number of medicines possible. In every case we can help by providing up to date safety information to help you to make the right choice at each stage of your pregnancy. If you use any of these drugs please let us know so we can provide you with advice and support. Heroin, Methadone, Codeine, Benzodiazepines and other Buprenorphine tranquillisers What are the risks to my unborn baby? If you use heroin, your baby can be If you take benzodiazepines or born early and can be smaller. After tranquillisers, like Diazepam or birth there is an increased risk of cot Temazepam, your baby can be born death. There is also your usual drugs or medication thought to be a higher risk of babies without professional help. We recommend that you be on a treatment programme under work with a doctor to safely reduce the the supervision of a doctor. This might mean taking other prescriptions (scripts) are free and medications that are safer for baby. Treatment We will offer extra care in pregnancy programmes are a safer option than to make sure baby is growing well. This can happen even if you have been on prescribed medication (a script) and may not happen straight away. Extra use of heroin on top of a script increases the chance of your baby withdrawing. You will be helped to look out for the signs of withdrawal as early treatment is very important for the safety of your baby. We Stimulants include cocaine, crack will also offer extra care in pregnancy to make sure baby is growing well. We born to women who smoke heavily recommend you stop using all can show signs of being irritable in the stimulants when pregnant. We ask that you and your baby stay on the postnatal ward for about 5 days so we can help you to look for signs of withdrawal and treat it quickly. There are many ways to help your baby, including skin to skin contact and breastfeeding your baby. Breastfeeding has been found to reduce the chances of withdrawal as well as being the best start in life. If withdrawal happens, we might need to give your baby a small amount of medicine by mouth. We will show you how to give this medicine so that you can give it to your baby when you return home if it is still needed. If this happens you will get a lot of advice and support from the staff, even after you go home and the baby will still be under the care of the doctors. Babies who are withdrawing may cry more than usual and may take a while to settle. All babies like to feel their mother close by, this makes them feel secure and safe. Your voice and gentle touch will help your baby to feel loved and calm and may help settle a baby who is unhappy. Give your baby smaller amounts more often rather than trying to give baby a big feed that then comes up as vomit. Breastfeeding may make withdrawal less likely and it also reduces the chance of cot death. Sexual intercourse during pregnancy is not thought to be harmful to you or your baby. If you have heavy bleeding during your pregnancy or if your placenta is low lying (placenta praevia) you will probably be advised to avoid sexual intercourse. You should tell your employer as soon as you can that you are pregnant so that a work place assessment can be carried out to avoid hazards at work. Your employer may ask you to provide evidence such as an appointment card or letter. All employed women are now entitled to 52 weeks maternity leave no matter how long they have worked for their employer. Maternity leave can start as early as 11 weeks before your expected date of delivery, so from 29 weeks of pregnancy. You must tell your employer the following things by the time you are 25 weeks pregnant. Citizens Advice Bureau, law centres and other advice agencies will also be able to advise you. Car Travel Road accidents are one of the most common causes of injury to pregnant women. To protect you and your unborn baby always wear a seatbelt with the diagonal strap across your body between your breasts and the lap belt over your upper thighs. Air travel If your pregnancy has no complications, the best period to travel is between 14 and 28 weeks gestation. Long haul air travel is associated with increased risk of venous thrombosis (blood clots) although it is unclear if the risk is greater in pregnancy so the advice is to wear correctly? If you are travelling to Europe, make sure that you have a European Health Insurance Card (formerly known as E111), which entitles you to free treatment while abroad. Waiting times in clinics can vary, and this can be particularly difficult if you have young children with you. Your antenatal team While you are pregnant you should provide care to all pregnant women normally see a small number of and often provide the link to hospital healthcare professionals, led by your services. They want to make trained to assess pregnant women you feel happy with all aspects of the and their developing baby, plan their care you receive, both while you are care and to carry out all appointments pregnant and when you have your as long as there are no problems baby. If you Medical or Health Centres alongside have had problems in this or a General Practitioners, Health Visitors previous pregnancy a more detailed and Dieticians. If you deliver are based in locations within the city your baby in hospital your community close to the women and families to midwife team will visit you following whom they provide care.

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