Uk housing market

Uk ho apply food grocery store1.INTRODUCTION1.1Introduction1.2A brief history of the UK lodgment marketplace1.3Aims The aim of this query project is to comp atomic number 18 and evaluate the variables that expungeed the FTBs availability to the caparison market all oer the fit 40 old age.1.4ObjectivesThe basic intent is to establish the factors that stomach touch on the shew in mansion tolls former(a) the final 40 long time.The second objective is to round and evaluate how the place market has qualifyd everyplace the finis 40 days with admire to low-cost trapping, and what impact this has had on FTB statistics.The third objective is to review and analyse the change in Private Lender schemes everyplace the stomach 40 years, and the affect this has had on FTB statistics. The fourth objective is to review the relationship amongst variables such(prenominal)(prenominal) as sustenance-time expectancy, retirement days, size of families, wages etc and their all overall ready on FTBs accessibility to the living accommodations market.The fifth objective is to conduct questionnaire surveys using a consume of FTBs to establish the populaces panorama on affordable lodgement.The 6th objective is to conduct questionnaire surveys using a sample of FTBs to establish the most common method utilize.1.5Definitions 1.6 starting line time buyer Is a vocalize comm except used to identify slightlyone who would be buying a field for the number 1 time.Average rest radical monetary protect The sightly price that a house would sell if placed on the market, this price would hap between the bottom 50per cent of house prices and the top 50per cent.Average phratry in make The combined norm gross household income, from sources such as wages, salaries and sundry(a) sources of coronations.Key worker A overt sector worker, linked to professions such as, NHS staff, police officers, t sepa targetlyers, kindly workers, fire fighters, loc al authority planners and prison officers. d well(p)ing house Price to income symmetry The ratio of median house prices to median incomes.1.5 AbbreviationsFTB First time buyerHPIR House price to income ratioCIS Cash motivator SchemeRTA Right to AcquireRTB Right to taint2.LITERATURE REVIEWIn order to comp are and evaluate the variables that affected the FTBs accessibility to the lodgment market over the last 40 years, it is necessary to review existing make work. stunned-of-pocket to a lot of the make works, which were gained from the library non existence up to date, the literature review is in the main based on reports and articles which were gained from online sources. In order for the schooling that is ga on that pointd to be analysed in the most telling manner it leave alone be divided into the various parts Factors that fuss affected the rise in house prices other the last 40 years. Changes in the station market over the last 40 years with respect to afford able housing. Changes in the private loaner schemes over the last 40 years. Variables affecting FTBs accessibility to the housing market.In the late 1980s and earlyish mid-nineties the British housing market experienced unprecedented changes and raised(a) heightened concerns over the affordability of many to gain access to the property market, cod for the most fortune to boost house price to income ratios, which has been labelled as a crisis of affordability in housing provision (Maclennan, Williams, 1990, p. 8).It is only rather y let onhfully that affordability has induce a common term in housing policy in Britain (Whitehead, 1991),and for this debate the retrieveing of affordability has caused much(prenominal) confusion, and since the Government has ruinn no specific rendering for the term, the following definition has been sourced Affordability is concerned with securing some given standard of housing (or divergent standards) at a price or rent which does non im pose, in the eyes of some third party (usually government) an un earthable payload on household incomes. (Maclennan, Williams, 1990, p. 9)2.1 Factors that oblige affected the rise in house prices other the last 40 years.It has fit apparent in recent years that the rise in house prices has become a study issue indoors the UK, which has leave behinded in First Time Buyers (FTB) decision it knotty to gain access to the property ladder. The job go most by acclivitous house prices has been imminent for a long time, alone up until the last decade this problem was mainly confined to London, the South East and a few regional hot spots (Department for Communities and Local Government DCLG, 2006, pageboy 6). But by figureing for at to a greater extent recent figures it has become apparent that high house prices have become a to a greater extent wide spread problem, with grumpy emphasis on rural districts, and littler settlements (DCLG, 2006, page 6). Though in that respect ha s already been a vast hail of search and study on the subject of affordable housing within the UK, namely the Barker review (2003), whose principal reasoning behind the problem was to a greater extent often than not focused on a poor planning outline and constraints on housing supply. Little information was sourced on the drivers and factors which play a major post in determining UK house prices, which go out be the principle aim of this section of the literature review.By analysing literature and data collected from published works this section of the literature review for aim examine the various factors that have played a alter bureau in the rise in house prices within the UK. These imply affair evaluate Supply and ask Rise in tribe and change magnitude way out of households Income Buy to let market Unemployment Confidence2.1.1 Interest judgeMany scholars believe that there is a demand link between house prices and occupy judge however the focus of this repor t aims to suggest, that in fact it is the affordability of housing and public government agency which is instead affected by alterations in saki rates, which in bite engages to changes in house prices. For example, a rise in engross rates would lead to attachd monthly repayments on owes, as mortgage repayments rise, the prospects of buying a house becomes slight attractive, thus lede to a decline in exact for houses and stick in house prices. On the other hand when interest rates are lowered, this would lead to a fall in mortgage repayments, public confidence and use up is plausibly to rise at this point leading to a rise in house prices. If interest rates were to await fall in this manner so would house prices, until the housing market reaches a state of oversupply.McQuinn and ORiley (2006) suggest that lower interest rates mean that mortgage repayments are lower and because the house purchaser washstand potentialityly borrow to a greater extent. This would excess ively lead to an outward shift in the demand curve with prices increasing.The fall in UK interest rates (and unemployment) over time has had two linked effects. It has brought the cost of borrowing overthrow sharply, deviation lenders (and borrowers in terms of pressuring for) with the dilemma as to whether to outgrowth the multipliers applied (i.e. up from three quantify loan to income ratio- LTI) which in knock over has increased demand and through that house prices (Forest, Lee, 2007, p. 168).2.1.2 Supply and demandSupply and demand is specify as, the quantity of beloveds available for sale at a given price, and the train of consumer need for those goods. The balance of supply and demand fluctuates as external frugal factors (such as the cost of materials and the level of competition in the marketplace) influence the level of demand from consumers and the desire and ability of producers to supply the goods (BNET, 2010) Kate Barker, a member of the lodge of England monet ary policy committee, was commissioned by the Treasury to examine housing supply (Guardian, 2008) and establish why house prices in the UK are uphill so fast. Within the report she established that the main reason was due to the supply of housing not keeping up with demand, which she put down to the increased growth in community (Barker, 2004).In an article for the mirror Martin Ellis, housing economist at Halifax puts it best by saying un slight we bed get the supply and demand in balance then that is passing play to lead to more upwards pressure on that ratio of prices to moolah. (House prices have quadrupled, 2010) data collected from the ODPM revealed that housing supply in the UK is before long festering at 150,000 unused homes each year, in comparison to the 190,000 new households each year. This shortfall of 40,000 new homes which would be needed, in order for supply to bear upon demand, could be a signifi smoket factor in the soon rising house prices (Office of subject field Statistics, 2008). In speaking to the Estates Gazette (EG) Yvette Cooper, the former housing and planning minister, revealed that in order to keep up with demand 200,000 new homes would need to be built each year (EGI, 2005), with 3 gazillion new homes built by 2020. However with the credit crunch having s stubtily hit and the uncertain state the economy is in, it is looking less and less likely that the Government ordain be able to meet these targets.2.1.3.Rise in population and increasing add up of householdsAs previously mentioned supply and demand of houses has a direct effect on house prices the aim of this section of the report is to establish how changes in the population seat in period of play have an effect on supply and demand of houses.It is a well k in a flashn fact the UKs population is gradually growing there have been various contributing factors to this, but the main reason is longer life expectancy. The honest life expectancy of a male in the UK has lift from 67.1 in 1970 to 77.53 in 2008, and females life expectancy has risen from 74.7 in 1970 to 81.74 in 2008 (Office of interior(a) Statistics, 2008).The rise in household numbers isnt solely the provide of the rise in life expectancy, theres as well as a build of different demographic factors which have contributed. These include2.1.3.1. Divorce rates.According to the Office for study Statistics, in 2008, the divorce rate in the UK stood at 11.2 divorcing battalion per gravitational constant married this is in comparison to 6.1 in 1971, which is a 46 per cent increase. With the amount of couples acquiring divorced increasing, so too provide the number of households, pushing demand up (Office of National statistics, 2008). 2.1.3.2. Decline in number of marriages.The increase in the number of households in the UK post also be by and large explained by an increase in the mean age that couples are getting married. According to the Office for National Statistics the mean marriage age in the UK has increased from 27.1 in 1970 to 35.6 in 2003 (Office of National Statistics, 2006). With the general public opting to marry at a later stage in their life the number of households is likely to increase as explained before an increase in the number of households is likely to lead to increase in demand for houses, which go forth in turn lead to a rise in house prices.2.1.3.3. Major influx of immigrants.Migration is an important factor in the changes in the UKs population over the last 40 years, when inward migration is greater than outward migration the population would rise at a higher(prenominal) rate. According to the Office of National Statistics 518,000 people immigrated to the UK in 2009, whereas 370,000 emigrated, crowing a net migration figure of 148,000 (Office of National Statistics, 2009). 2.1.4 IncomeAccording to McQuinn and OReilly (2006), rising income leave behind mean that borrowers green goddess borrow more on the basis of higher inc ome and hence bid a higher price for a property, thus the demand curve for housing will shift outwards with prices increasing. It is also suggested that higher household incomes will moderate in households having more available income, which in turn will lead to increase in normal and sumptuousness goods, since it is assumed that housing is a normal/luxury good, it can also be assumed that demand for housing will increase, and so too will house prices.Keynes best describes this theory as The fundamental psychological law, upon which we are entitled to await with great confidence two a priori and from our knowledge of human disposition and from the detailed facts of experience, is that men are disposed, as a rule and on the come, to increase their consumption, as their income increases, but not by as much as the increases in their income (The General Theory, 1936, p.96)In their book Booms and Busts in the UK lodgement Market Muellbauer and Murphy suggest that income growth on side predicted income growth can lead to an increase in public confidence to spend disposable income this increase in public confidence, respectively lead to a rise in house prices, through demand rising. There has been a mark increase in the number of women in paid employment in the past 60 years (Hogarth et al., 2001) there are a variety of different reasons for this, but one of the most meaningful would be the induction of the Equal pay Act 1970. With many households now having two incomes they can arrange for a joint mortgage, which in effect means they can bid up house prices.2.1.5.Buy to let marketBuy-to-let (BTL) mortgages are where an investor purchases a property for purpose of renting it out the investor rents the property out to tenants with the blueprint of using the money from the rent to pay off his mortgage, with a possible excess which would be kept by the landlord. The landlord would also be looking to make a capital gain on the property over its life time maki ng it a very good investment.Since July 1996 when the intimacy of Residential Letting Agents (ARLA) launched BTL loans, there has been an explosion of investors entering the market hoping to get both income and capital gains from their investment. According to Paragonen Mortgages, BTL now accounts for around 14% of the mortgage market (Stepek, 2007, para. 4)According to the Council of Mortgage Lenders (CML) buy-to-let mortgages outstanding continue to rise, in 2008 there were 1,103,000 BTL mortgages in the UK worth 132.5 billion, which is a rise of 19% by volume and 25% by regard as from a year ago previous (CML, 2008).This surge in investors entering the BTL market has been in part due to the soaring house prices of the late 90s, but also largely due to relaxation in the loaning criteria , the CML have revealed that in 2008 on average, lenders would offer a maximum loan of 83% on the value of the property (CML, 2008). However with more and more investors looking to make an at la rge(p) buck, upward pressure is being put on demand, go awaying in house prices to rise. To add to this, investors have predominantly been buying up smaller homes, consequently making it harder for FTBs to even get small premises.2.1.6 UnemploymentWith unemployment at its lowest since the seventies (http//www.number10.gov.uk/Page15026), there is more people with the potential to gain a mortgage and enter the housing market, this upward pressure on demand is turn going push house prices up. Arm strong and Taylor suggest that, low unemployment leads to higher wages, which in turn lead to an increase in demand for housing and hence higher house prices (Armstrong, Taylor, 2000, p. 208)2.1.7 ConfidenceIn analysing the ingredients that have contributed towards the recent strong growth in house prices analysts have consistently do graphic symbol to the strength of consumer confidence. The implication is that consumer confidence positively impacts upon house price growth. (Report on con fidence)Garratt goes on to say While consumer confidence is not a significant factor in driving household consumption, it does have a role to play in influencing the willingness of households to undertake secured borrowing. (report on confidence, look in my docs for file) notional demand for housing draws new buyers into the housing market on the apprehension of future price increases and associated capital gains. The extra level of demand funded mainly through mortgage finance adds to the existing level of mortgage debt but the speculative demand creates a ratchet effect whereby expectations of higher prices leads to an increase in demand which sends actual house price higher (Riley, 2005, p. 73)Due to the extreme rise in house prices of the mid 90s, public confidence in the housing market grew (further explained in chapter?), which led to a hie in people purchasing property with the expectation of trying to get a piece of the action, which has caused greater demand for houses, pushing prices up.2.2 Changes in the property market over the last 40 years with respect to affordable housing.In order to establish how the changes in the property market over the last 40 years, with respect to affordable housing has affected FTB statistics, it is firstly important to discuss the development of affordable housing within the UK. This will change FTB statistics to be compared to a time-line of these developments, giving an impression of their effectiveness.2.2.1 Right to BuyIn past history a lot homes in the UK would have been council owned, but since the 1980s the proportion of council owned homes has diminished instead favouring towards providing bear to various other forms of social housing. In 1980, under power of Margaret Thatcher the 1980 lodgement Act introduced the Right to Buy scheme (RTB), which offered council tenants (of three years tenancy) the even out to buy their council house, with discounts up to 50per cent, which in 1986 went up to 70per cent for flats (Power, 1993, p. 217). The RTB scheme has fontd lots of criticism since its introduction, said to favour the more affluent home owners rather than the poorer more in need (King, 2006, p. 68). However if we were to look at the policy and whether it met its initial aims, the RTB could be viewed as having been very successful over the past 25 years the RTB scheme has helped broaden owner occupation, particular to the working-class and helped break up municipal housing (King, 2006, p. 68). However it has also been argued that the RTB scheme has lead to a shortage of social housing available, largely due to Government edicts which have prevented councils from spending the proceeds of sales of social housing on new housing (Hallett, 1993, p.230). Accompanied by an increase in demand for affordable housing, this could be a major contributing factor in rise of house prices.2.2.2 HomeBuy Schemes2.3 Changes in the private lender schemes over the last 40 years.This section of the l iterature review aims to look at how, changes in credit available to consumers in the UK has played a role in the increase in house prices over the last 40 years. Aoki, Proudman and Vlieghe (2002, p.10) suggest that credit frictions may be important in understanding the relationship between interest rates, house prices, housing investment and consumption and found that significant effects of households access to credit on consumption and on housing investment in UK aggregate and regional data. Over the last 40 years credit constraint has seen some significant changes, with access to credit more easily available to consumers. This can be largely explained by the removal of exchange controls in 1979 and imprecate lending in 1980, it can be further explained by the make Societies Act 1986, which lifted the restrictions on how building societies operate, which gave them the same status as banks (Aoki, Proudman and Vlieghe, 2002, p. 14). Other significant changes in the last 40 years include the inclusion of non-bank entrants such as department stores, retailers and insurance companies in go credit through services such as credit cards, unbolted loans and mortgage products. Furthermore an increase in internet banking in the 1990s and better credit scoring methods also contributed to better credit conditions (Muelbauer, 2005, p.5).In the 1970s and early 1980s building societies collectively agreed the mortgage and deposit rates they offered (Aoki, Proudman and Vlieghe, 2002, p.14), but due to relaxation in lending criteria and increase in competition between the lenders, the setting of interest rates have been a far more competitive, which has led to lower interest rates for consumers. Interest rates can have a direct effect on the supply of mortgage loans, which in turn will affect house prices. According to the financial money group moneyfacts.co.uk, there are currently 2,003 different mortgages available on the market (Burridge, 2010, p.1), the result of thi s increase in competition, is the reduction of the cost of borrowing , which in turn will encourage more people to take out a mortgage. This increase in demand, as explained before will have an untoward effect on house prices.2.4 Variables affecting FTBs accessibility to the housing market.This section of the literature review aims to establish the various variables that have affected FTBs accessibility to the housing market this will be done through the compend of various scholars opinions on the subject matter.It has become apparent in recent years that the rise in house prices in comparison to incomes has become a major issue within the UK, which has resulted in FTBs finding it ambitious to gain access to the property ladder.As a result of incomes not rising at the same rapidity as house price inflation, the principle problem for FTBs is affordability in the last 20 years the average price a FTB is expected to pay has increased by 294 per cent, with the average UK property now costing five times the average earnings of a full-time male employee (Chesworth, 2004, p. 2). To help emphasis the problem that FTBs face this dissertation will examine the rise in house prices in comparison to income since 1970 in a study by Alliance devote Research Centre they compared the problem facing FTBs with that of their parents when they tried to buy their first property (Alliance Trust, 2006). According to the study house prices have risen from 2.5 times the average income in 1970 to 3.9 times the average income in 2005, equating to a 60 per cent increase in house price to income ratio (Alliance Trust, 2006).The average household income is 38,302, and the house price index report shows that the average house price in the UK is 197,000, meaning the house price to income ratio is about 5.1. These historically high figures mean that young FTBs are finding it increasingly rough to gain access into the property market and can often lead to FTBs having to take on risky mortg ages, for example interest only schemes. This can result in high household debt, which currently stands at 150 per cent of household income (Ratio of House Prices to Income, 2008).Though more recent data collected in November 2008, from the price index published by Nationwide Building Society has revealed that house prices are currently on a downward descent, FTBs are still finding it difficult to purchase their first home (CML, 2008). Though FTBs loan-to-value ratios have been going down, with the average FTB taking a loan out on 84per cent of the value of the property in comparison to 90per cent in 2007 (CML, 2008). This is merely the result of lenders lowering the amount that they will lend in previous housing climates borrowers were able to take out 100per cent mortgages, but with the downturn in the market, lenders are requiring a substantially larger deposit. This subsequently has meant that FTBs are now faced with the prospect of having to find a larger deposit the research r evealed that the average FTB deposit rose from 15,000 in 2007 to 19,000 in 2008 (CML, 2008).Talk about a lot of FTBs in the past would have got the money for the first house from inheritance, from parents and grand parentsbut due to longer life expectancy this isnt forever available.As discussed in chapter? Late marriage can not only have an effect on housing demand, but can also play a part in FTBs accessibility to the housing market. With a lot of people opting to buy their first house once they are married With the mean average age that people are getting married in the UK rising from 27.1 in 1970 to 35.6 in 2003, As already discussed in chapter? The buy to let market has led to a considerable in surge of investors buying up houses, it is typical that these investors will be buying up smaller typical FTB houses, with demand for these houses going up so will price, making it harder for FTBs to gain access to the market.More luxury goods available people spending their money on o ther thingssudden drop in house prices has led to parents being less likely or able to assist their kids in purchasing their first property due to their investments (house) taking a massive drop.Jobs less stable in the past people had jobs for life Contract employment less people on full time 3.METHODOLOGY3.1 Research StrategyThe aim of this research project is to compare and evaluate the variables that have affected the FTBs accessibility to the housing market over the last 40 years. In order to come to the best conclusion to this, it is essential to gather data. This chapter aims to provide a description of how this data will be gathered, and the particular research methods that will be implemented. The data collected can be split into ancient and utility(prenominal) data. Secondary data consists of information that already exists somewhere, having been collected for another purpose. primary coil data consist of information collected for the specific purpose at hand. http//book s.google.co.uk/books?id=6T2R0_ESU5ACpg=PA335dq=what+is+primary+datalr=cd=1v=onepageq=what%20is%20primary%20dataf=false3.1.1 Secondary DataSince the basis of this investigation, is to analyse house prices over the last 40 years and the effect this has had on FTBs accessibility to the housing market, secondary research will be very useful, mainly due to the extensive amount of information and data already available. The bulk of the secondary data collected has been sourced from journals, reports and websites of maestro bodies. However, due to the fact that a lot of the information gathered has the potential to be bias, a variety of different sources will be used and then compared. The majority of the information gathered will be statistical data, which will include economical statistics, demographical statistics and housing market statistics this will enable an analysis of the factors and variables that affect house prices and to spot any trends. Though a lot of these statistics were included in the literature review, the aim of the next chapter is to give a more specific investigation and data analysis.Secondary data includes Academic Journals Internet Sites and Web pages Textbooks Newspaper Articles Other Academic Studies3.1.2 Primary DataIn order to gain the views and opinions of the housing market, questionnaires will be conducted using a sample group of home owners and non home owners. These questionnaires will be conducted using social networking sites, the advantages of using this method is, low cost of data collection and processing, ability to get a wider return rate from all over the country and the disadvantages to using this method is that it allows for errors to be made due to misunderstandings of the questions or lack of knowledge on the subject. So for this reason the questionnaires have been designed in the simplest manner.Another drawback to using questionnaires is that they may not provide an accurate view of the housing market, since only a relatively small sample group was used, it is possible that the information that is gathered may give a distorted view and conflict with the secondary data. Had there been more time it would have been beneficial to the investigation to carry out a questionnaire using a much larger sample group, giving a more accurate representation. To further the research even more it could have been very advantageous to have set up interviews with the governance bodies responsible for setting Government policy on housing and interest rates. Implementing these two methods along with the research already carried out would have allowed for opinions from both sides.3.2 Literature ReviewWith the aim of keeping the literature review as orderly and concise as possible, it was divided into four distinct sections, these sections are listed below. Factors that have affected the rise in house prices other the last 40 years. Changes in the property market over the last 40 years with respect to affordable hou sing. Changes in the private lender schemes over the last 40 years. Variables affecting FTBs accessibility to the housing market.The literature review provided an overview of the factors that have affected house prices over the last 40 years and variables affecting FTBs accessibility to the housing market. Though this research gave a good outline of the broader issues at hand, the literature review alone is insufficient in meeting the aims of the study, so for this reason it is paramount that further investigation is undertaken.3.3 TimelineCarrying out the literature review bought forward the possibility of creating a timeline of changes in the housing market over the last 40 years. The basis of the timeline will be creation Government policy related to housing, as well as any significant changes in private lender schemes over the last 40 years. By analysing this timeline alongside statistics and data gathered from the secondary research, along with the responses from both questionn aires, direct correlations can be examined.3.4 QuestionnaireAs already give tongue to questionnaires will be sent out to two different sample groups, home owners who bought their first house over the last 40 years and non home owners. This will give a reflection on the UK publics perspective of the housing market.The structure of both questionnaires is shown below3.4.1 Questionnaire Property ownersQ1. GENDER manly FemaleQ2. MARITAL STATUS AT THE TIME OF BUYING YOUR original PROPERTY Single Married OtherQ3. AGE 18-30 31-40 41-50 51-60 60 and in a higher placeQ4. WHICH AREA OF THE COUNTRY DID YOU PURCHASE YOUR FIRST PROPERTY? northerly North West North East

Case Summary Hypertension In Pregnancy Health And Social Care Essay

grounds Summary Hypertension In Pregnancy Health And Social palm EssayMdm. SM is a 30-year-old Malay female of gravida 5 coincidence 3+1 who is at 37 weeks and 5 old historic period of gestation. She was diagnosed to engender hypertension in gestation period during antepartum go redirect trial in Klinik Kesihatan Simpang Renggam at 36 weeks and pre-eclampsia ( business line wring 160/ blowmmHg, body of water dipstick ovalbumin 1+) 3 days forwards entree. She was admitted to Hospital Kluang and started on Tab. alpha methyl dopa 250mg TDS. She was advised for deduction of beat back in view of preeclampsia at circumstance and she requested to be transferred to Hospital Batu Pahat (HBP). She did non have whatever signs and symptoms elicitive of severe preeclampsia or labour. During admission to HBP, reassure prostin 1.5mg was inserted into the layabout fornix twice to induce labour notwithstanding in that location was no change in cervical os and symptoms of la bour. Decision was made to sweat artifical rupture of membranes. However, chase the mapping, inwrought monitor incured fetal harm and as spontaneous manner of speaking was not imminent, Mdm. SM was agreeable for speck downhearteder part caes bean section under general anaesthesia. A sizeable infant boy was deliver-coloreded (weight 2.9kg, Apgar cross out 91105) and there were no intra or post-operative complications. by-line the surgery, both give and infant were well in the ward. Mdm. SM was ambulating and tolerating orally and by the 2nd post-op day, both had passed water supply and motion. Wound heed on day 2 showed clean, non-gaping suffer. As she was well, decision was made to cast off her and she was devoted appointment to examine her breed press and operative wound at the postnatal clinic at KKSR. On give up, her stock certificate mechanical press was cxl/70mmHg (without medication) and urine dipstick albumin was trace. Analgesia given on discharg e were mefenemic virulent and paraceta mole. school-age child find capital of Minnesota Kong Fu-Xiang ID NO M0508129 conjure up OF supervisory program Dr. Sharifah Sulaiha revolution midwifery gynaecologyPATIENTS DETAILSI/C NUMBER 800318015794 AGE 30SEX Female DATE OF ADMISSION 20/6/2010R/N 13585932) CLINICAL HISTORYChief ComplaintElevated pedigree pres accepted sight in pregnancy at 36 weeks of gestation. record of Present IllnessMdm. SM is a 30-year-old Malay female of gravida 5 parity 3+1 who is currently at 37 weeks and 5 days of gestation. She was referred to Hospital Kluang from Klinik Kesihatan Simpang Renggam (KKSR) for tremendous argumentation pressure detected on routine antenatal follow-up and subsequently transferred to Hospital Batu Pahat (HBP) for evocation of labour in view of her development of high neckcloth pressure in pregnancy. Her elevated line of credit pressure was earlyish detected during her routine antenatal follow-up at Klinik Kesihatan Simp ang Renggam 10 days before admission to HBP. During this visit, her blood pressure was recorded as 150/90mmHg and she in each case complained of slight symmetric swelling of her feet tho otherwise had no other complaints. The feet swelling decide after 3 days. end-to-end the next 7 days, she went to KKSR every jump off day for observe and 3 days before admission to HBP, her blood pressure was noted to be 160/100mmHg with presence of albumin 1+ on urine dipstick that was previously not present. She was immediately given launching pad labetolol 100mg and admitted to Hospital Kluang where she was subsequently started on stamp pad methyldopa 250mg 8-hourly. Three days after admission to Hospital Kluang, she was advised by the doctor to support induction of labour and she thus requested to be transferred to HBP so her family members in Batu Pahat could take condole with of her. During the course of these lawsuits, she did not cognize shortness of breath, clearanceache, bl urring of vision, epigastric suffer, seizures, abdominal pain, vaginal bleeding, nausea, vomiting, palpitations, or recurrence of the foot swelling. At conviction of admission, she did not experience contraction pain, show, leaking of liquor. Fetal movements were good.Systemic ReviewMdm. SM did not have fever. Her appetite was good and her urinary and bowel habits were customary. Her stop was unaffected.Antenatal HistoryThis was an unplanned provided wanted pregnancy. Mdm. SM realise she was pregnant when she missed her period, of which the get going was 28/12/09. She bought a pregnancy test kit and it tested positive. She subsequently did her booking at KKSR at 7 weeks of period of amenorrhoea. At booking, her blood pressure was 120/80mmHg, hemoglobin 13.4g/dL, sugar undetected, and urine albumin negative. Infective screening was negative and blood type O positive. Her expected due visualize was given as 14/8/10. During follow-up 1 month youthfulr, she had her foremost u ltrasonography scan which represent her uterus to be larger than dates. Her due date was revised to 6/7/10. Modified glucose tolerance test through twice during pregnancy were negative. She experienced morning sickness and vomiting during the first 3 months of pregnancy barely it was not severe and she could cope without medication. Throughout the pregnancy, she was diagnosed to have urinary tract infection twice and was treated with antibiotics. A further 3 ultrasound scans were through with(p) and all were approach pattern. She was alike willing to the supplements given throughout pregnancy. There were no other problems during the antenatal follow-up until the detection of elevated blood pressure 10 days before admission to HBP.Past Obstetric HistoryThis is her fifth pregnancy and her last childbirth was in 2008. She has 3 children, 2 boys and a girl, of whom all were natural via vaginal delivery at postdate after induction of labour. descent weights ranged from 2.7 to 3.0 kg, all ar healthy with no complications and were breastfed. However, during her 3rd pregnancy, she suffered a solacebirth during the 12th week and dilatation and curettage was performed during that admission.Gynae Menstrual HistoryMdm. SM achieved menarche at the age of 12. Her menstrual cycles have always been regular with 28 days per cycle and 5 to 7 days of flow. She does not experience menorrhagia or dysmenorrhoea. She has never had a cervical smear through with(p) and has never used oral protective pills. She has not required health curbing attention for all gynaecological problem.Past Medical HistoryMdm. SM has never been diagnosed with each chronic unhealthiness such as diabetes, hypertension, and asthma attack before. She has also never been admitted for non-pregnancy related reasons. She also does not have each known food or drug allergies.Family HistoryMdm. SM is the firstborn of three siblings. Her youngest sister also had gestational hypertension. Her fat her has hypertension and her mother had diabetes, but passed away 2 years ago due to tuberculosis. every last(predicate) family members have been screened and all tested negative for tuberculosis.Social HistoryMdm. SM is now a housewife. She formerly worked in a particularory but decided against returning to work following her last pregnancy in 2008 for her childrens benefit. She is a non-smoker and does not consume alcohol. Her husband is a short-haul lorry driver and smokes, but only out spot their home. They live approximately off Kluang, and it takes them slenderly over an hour to reach HBP, and 15 minutes to reach KKSR.bookman NAME Paul Kong Fu-Xiang ID NO M0508129NAME OF SUPERVISOR Dr. Sharifah Sulaiha revolution midwifery gynaecology3) FINDINGS ON CLINICAL EXAMINATION(Mdm. SM was examined by me on the 2nd day of admission)Mdm. SM was alert, conscious and cooperative. She was not in any pain or distress. She was sitting comfortably on her bed. On interrogation, there was no pallor, jaundice or pedal edema. Her reflexes were not b attempt. Her clinical parameters arBlood Pressure 124/80 mmHgHeart Rate 95 vanquish per minute. Regular rhythmRespiratory Rate 20 breaths per minuteTemperature 37CExamination of the cardiovascular system, respiratory system, fundus, thyroid and breasts were normal.On examination of the abdomen, it was distended with gravid uterus as evidenced by linea nigra, and striae albicans. There was no striae gravidarum, scars, or pulsations noted. On palpations, the abdomen was soft and non-tender, uterus non-irritable, and fetal move felt. The symphysio-fundal height was 36cm, which corresponds to dates. On examination, this is a singleton fetus at granditudinal hypocrisy with cephalic presentation, with the fetal back on the maternal left. The fetal head was four fifths palpable. Estimated fetal weight is 2.8 to 3.0kg. Liquor is adequate. Fetal heart was comprehend and the rate was 142 beats per minute.Vaginal examina tion (by medical officer on admission) revealed no perineal, vulval or vaginal abnormalities. Cervical os was 1 cm with cervix tubular, soft and axial, station high and membrane intact. Bishops score was 3/10. disciple NAME Paul Kong Fu-Xiang ID NO M0508129NAME OF SUPERVISOR Dr. Sharifah Sulaiha rotary motion midwifery Gynaecology4) PROVISIONAL AND DIFFERENTIAL DIAGNOSES WITH REASONINGprovisional DiagnosisPreeclampsia in pregnancyMdm. SM developed new-fangled onslaught elevated blood pressure of 160/100mmHg at 36 weeks of gestation and urine dipstick albumin of 1+ (300mg/L). This fits the minimum requirement of preeclampsia among the hypertensive diseases in pregnancy. However, Mdm. SM did not experience any symptoms to suggest a severe preeclampsia or impending eclampsia such as headache, visual disturbances, epigastric pain, vomiting, liver tenderness. The urine dipstick for albumin is not the go around way to detect proteinuria required for the diagnosis of preeclampsia 3 a nd is usually only used for screening, but as the blood pressure and urine albumin were persistently elevated, it is better to err on the side of caution and treat Mdm. SM as such since uncomplainings with relatively voiced preeclampsia can rapidly gird into severe disease 1. Following the repeated positive detection of urine albumin of only 1+, more definitive tests should be performed to better quantify her proteinuria 2,3. derivative instrument DiagnosisPregnancy-induced hypertension, late approachAs Mdm. SM has been compliant to her antenatal follow-ups and did not have elevated blood pressure detected at any clock time before 36 weeks of gestation, it is likely that she has developed the onset of a hypertensive disease in pregnancy and it appears to be of late onset as it developed only after 32 weeks gestation. However, as subsequent visits showed urine dipstick albumin of 1+, indicating the onset of proteinuria (although poor addressive value and not as significant as 2+) 3, it might prove wiser to be more vigilant and assume that Mdm. SM does indeed have preeclampsia as it would be foolish to brush aside these warning features despite the fact that she does not demonstrate any apocalyptical symptoms because it is viable that even patients with no prodromal signs may suddenly progress into eclampsia 1,3.Essential hypertension in pregnancy with superimposed preeclampsiaanother(prenominal) opening night that we may entertain is that Mdm. SM has had previously undiagnosed congenital hypertension with currently superimposed preeclampsia. However, this seems rather unlikely. Firstly, Mdm. SM is young at the age of 30 and unlikely to suffer from necessity hypertension as this disease common presents after the age of 40. Secondly, at no time throughout antenatal follow-up did she have elevated blood pressure recorded before that particular visit at 36 weeks of gestation. However, following delivery of her infant, she should have her blood pressur e rechecked during postnatal follow-up c be at 6 to 12 weeks post-delivery. If her blood pressure if still elevated at that time, then it will be more likely that she has essential hypertension.STUDENT NAME Paul Kong Fu-Xiang ID NO M0508129NAME OF SUPERVISOR Dr. Sharifah Sulaiha ROTATION Obstetrics Gynaecology5) IDENTIFY AND PRIORITISE THE PROBLEMS1. Elevated blood pressure and its implications in pregnancyMdm. SM has newly discovered elevated blood pressure at 36 weeks of gestation. This is considered late onset but is not uncommon, and gives rise to a spectrum of hypertensive disorders in pregnancy. While it seems that at first she has gestational hypertension, the mildest of the disease spectrum, she demonstrated proteinuria on her subsequent antenatal visit, therefore concluding that she has preeclampsia. Hypertensive disorders in pregnancy have the authority to put both mother and infant at increase risk of mortality. Its complications are elaborated below. During admission, Mdm. SM should be monitored for any change in her condition as she may quickly progress into severe disease states and this would require urgent encumbrance, the most definitive being the delivery of the infant. guard management includes close observation of both mother and infant, and medication to statement the elevated blood pressure.2. Induction of labour in view of preeclampsia at depotTermination of the pregnancy is the only definitive sure for preeclampsia. On presentation, Mdm. SM has features categorized as mild preeclampsia. Normally, severe preeclampsia would dictate the need for antihypertensive and anticonvulsive therapy followed by subsequent delivery and symptoms such as headache, epigastric pain, and visual disturbances may indicate this. The fetal age is usually an important decision making factor when it comes to inducing labour as the treatment goals seek the best outcome for both mother and infant. As Mdm. SM is already at term and there have been no issues previously detected regarding the health of her fetus, it should be just to proceed with induction of labour. There is also no reason to prolong the pregnancy as the risk of eclampsia increases. If for any reason an obstetric reason arises e.g. fetal distress, delivery should proceed via caesaren section.3. Impending eclampsia and other potential complicationsWarning signs and symptoms of impending eclampsia or severe preeclampsia include headache, visual disturbances, epigastric pain, reduced urine output, edema and ultimately, convulsions. These symptoms should be recognized early so the necessary intervention can take place. Seizures increase the risk of maternal and perinatal morbidity and mortality rates. Some maternal complications are placenta abruption, neurological deficits, aspiration pneumonia, pneumonic edema, cardio pulmonic arrest, and acute nephritic failure. Other major complications that may choke as a result of severe preeclampsia are HELLP syndrome, pulmonary embolism and stroke. Fetal complications include growth restriction, fetal distress, and death.4. Risk of post-partum eclampsiaIt is potential for eclampsia to occur in the postnatal period specially when the patient has reached term. In such cases, up to 44% of eclampsia occurs postpartum 3. As the risk is kinda high, Mdm. SM should continue to be monitored in the ward for the development of any signs and symptoms. As she is comfortable and relatively symptom free while in the ward, it appears unlikely that she may worsen into an eclamptic state but the risk should not be afforded. As there are no guidelines to suggest an optimal postpartum inward observation period, it would depend on her clinical spotlight during the subsequent days following her delivery.5. Hypertension in pregnancy and its long term implicationsAs Mdm. SM has developed preeclampsia during this pregnancy, she is at change magnitude risk to develop hypertensive or metabolic complications in rising pregnan cies. The risk of recurrence is generally higher in earlier onset preeclampsia. At the same time, she should be evaluated in the postpartum period for the possibility of essential hypertension at the 6 week postnatal review. Also, women with preeclampsia are at an increased risk for developing hypertension, diabetes, hyperlipidemia, chronic renal disease, stroke and ischemic heart disease. Mdm. SM should be made sensitive of all these implications and should be educated on how she can counter these via the registration of her lifestyle. She should also be advised to attend preconceptual counseling in the event of a future pregnancy and to come early for booking.STUDENT NAME Paul Kong Fu-Xiang ID NO M0508129NAME OF SUPERVISOR Dr. Sharifah Sulaiha ROTATION Obstetrics Gynaecology6) PLAN OF INVESTIGATION, JUSTIFICATIONS FOR THE SELECTION OF TESTS OR PROCEDURES, AND INTERPRETATION OF RESULTS1. Urine Dipstick for AlbuminTo fashion for the presence of albumin in the urine firstly, to embody proteinuria, and secondly, to evaluate the abrasiveness of the preeclampsia. Urine dipstick for albumin should be repeated daily in the ward. Also, if in doubt, further investigation to quantify proteinuria can be make e.g. urine protein/creatinine spot test 2,3. forgets Urine dipstick albumin on admission was trace. Results at KKSR showed 1+.Interpretation This result could be due to the fact that the blood pressure has lowered as Mdm. SM has been started on methyldopa and her blood pressure is under bidding. This does not mean that she no eternal has preeclampsia. She should be checked daily for any changes in both blood pressure and proteinuria.2. Full Blood CountTo hang for anemia which may require correction, haemoconcentration which may indicate severe preeclampsia 1, and platelet levels as HELLP syndrome is a complication that may arise in preeclampsia. This may also serve as service line in case operative procedures are required.Result TWBC 12.0 x109/L (neutro phils 8.20, lymphocytes 2.70)Hemoglobin 10.7 g/dL Hematocrit 32.3% Platelets 354 x 109/LInterpretation The total white cell count is slightly raised, but this is to be expected in pregnancy. The hemoglobin is slightly low but this is also expected in pregnancy and should be monitored especially if the patient requires surgery or experiences anemic symptoms. There is no haemoconcentration and the platelets are normal.3. Prothrombin Time, INR, Activated Partial Thromboplastin Time (PT/INR/APTT)To obtain a baseline of the coagulation profile in case operative procedures are required and also to look for potential coagulopathy as it is a possible complication of preeclampsia.Result PT 12.3s INR 1.05 APTT 39.6sInterpretation PT/INR/APTT is within normal range. Coagulopathy appears unlikely in Mdm. SM given that her platelets are also normal and her preeclampsia is not severe.4. Renal ProfileTo assess renal functions to look for elevation of creatinine as that would indicate sever e preeclampsia and also to detect acute renal failure which is associated with increased risk of HELLP syndrome, placenta abruption and postpartum hemorrhage 1.Result Urea 1.3mmol/L Sodium 140mmol/L kB 3.7mmol/L Creatinine 51mol/LInterpretation Mdm. SM renal profile is normal and creatinine is not elevated, adding to the indicators that her preeclampsia is of the mild category. Low urea levels and good urine output also rules out acute renal failure.5. Liver Functions TestTo assess liver functions and its comp wiznts such as liver enzymes and haematoidin which would be raised in severe preeclampsia or HELLP syndrome in which there is hemolytic anemia and elevated liver enzymes.Result Total protein 73g/L Albumin 33g/L Globulin 40g/LTotal bilirubin 0.5mg/ml Direct bilirubin 0.2mg/ml Indirect bilirubin 0.3mg/mlALP 121U/L ALT 7 U/L GGT 7 U/LInterpretation Liver enzymes (ALT) and bilirubin levels are not elevated, indicating a mild preeclampsia and no biochemical evidence of HELLP syndrome. The ALP is slightly elevated, but this could be due to compression of the gravid uterus on the hepatobiliary tree.6. serum Uric AcidElevated serum uric acid is an early biochemical sign of preeclampsia 1 and may help to predict maternal complications in preeclampsia 4.Results Serum uric acid 103mol/L Interpretation Serum uric acid levels are not elevated and are in fact, slightly lowered. This result indicates low likeliness of severe preeclampsia or maternal complications.7. Serum Lactate DehydrogenaseTo check for elevated levels which should indicate hemolytic anemia, a component of HELLP syndrome.Results Not make during this admission.8. Cardiotocograph (CTG)Done on admission as a baseline for fetal monitoring.Results baseline fetal heart rate was 130 beats per minute, baseline variability was 5 10, accelerations present with no decelerations.Interpretation CTG is labile with no signs of any fetal compromise. CTG should be repeated following each procedu re e.g. prostin insertion, AROM or if fetal compromise is suspected.9. Transabdominal UltrasonographyThis should be done to confirm fetal age, as confirmation of fetal age is important when it comes to deciding whether or not to induce labour in preeclampsia. Also to check for fetal well-being and growth restriction, but these requires repeated scans and plotting of growth chart over a period of time.Result No ultrasonography was done during this admission. The last scan was done in Hospital Kluang before patient was transferred to HBP. The last scan reports fetal age interchangeable to dates, AFI of 9, and no abnormalities detected with no mention of other findings.Interpretaion As fetal age is corresponding to dates and there is no suggestion of fetal compromise or restriction, it is safe to proceed with induction of labour.10. Urinalysis (UFEME)To check the levels of proteinuria which may be more quantitative than urine dipstick.Results Leukocytes, nitrite, protein, glucose, ke tone, urobilinogen, and bilirubin were not detected.Interpretation No proteinuria was detected. This could mean that the patient does not have preeclampsia but rather gestational hypertension, or it could be undetected as the blood pressure has also become well controlled with medication. However, no risks should be interpreted and Mdm. SM should be closely observed in the ward. Either way, induction of labour and delivery would still be ideal for her as she has already reached term.STUDENT NAME Paul Kong Fu-Xiang ID NO M0508129NAME OF SUPERVISOR Dr. Sharifah Sulaiha ROTATION Obstetrics Gynaecology7) WORKING DIAGNOSIS AND PLAN OF counseling ON ADMISSIONWorking DiagnosisInduction of labour at term in view of mild preeclampsia in pregnancy acknowledge As Mdm. SM has elevated blood pressure and urine dipstick albumin 1+ but has no physical or biochemical features apocalyptic of severe preeclampsia, the working diagnosis is mild preeclampsia. However, she should be monitored closely in the ward for any symptoms indicative of disease progression. As she has reach term, it would also be wise to induce labour in her, especially given her history of postdates as delivery would be the only definitive management in such cases.Plan of management on admission encompass T. Methyldopa 250mg 8-hourlyDaily urine albumin dipstickVital signs monitoring 4-hourlyBaseline cardiotocograph on admissionFetal kick charting andLabour progress chartingTo give the sack immediately if spontaneous rupture of membranesTo notify immediately if strong contractions experienceEncourage orallyFor induction of labour with T. Prostin 1.5mg as Bishops score unfavourableTo notify immediately if any symptoms occurSTUDENT NAME Paul Kong Fu-Xiang ID NO M0508129NAME OF SUPERVISOR Dr. Sharifah Sulaiha ROTATION Obstetrics Gynaecology8) unofficial OF INPATIENT PROGRESS (INCLUDING MAJOR EVENTS, CHANGE OF DIAGNOSIS OR MANAGEMENT AND OUTCOMES)Throughout the first two days of admission, Mdm. SM was comf ortable in the ward with no development of any symptoms of severe preeclampsia, eclampsia, or labour. Her springy signs were stable with blood pressure ranging 122-138/70-84. On the morning of the 2nd day, tablet prostin 1.5mg was inserted into her posterior fornix under aseptic technique. Cardiotocograph was reactive and vaginal examination 6 hours post-insertion showed cervical os 3cm, cervix 2cm, soft and axial, and high station. Therefore, a 2nd tablet of prostin was inserted on the morning of the 3rd day. Once again, post-insertion cardiotocograph was reactive and vaginal examination 6 hours later showed no changes to before. Mdm. SM still did not experience any signs and symptoms of labour. She also did not have any symptoms indicating progression of her preeclampsia. On the morning of the 4th day, it was decided that Mdm. SM should sustain artifical rupture of membranes (AROM) rather than have a 3rd prostin tablet inserted. Cardiotocograph monitoring had been difficult so d ecision was made to insert fetal scalp electrode at the same time for internal monitoring. Following the AROM, internal monitoring revealed a drop of fetal heart rate from 130 to 100 beats per minute with no accelerations. Cervical os was still 3cm with no symptoms of labour. Decision was made to proceed with emergency lower section caesarian section section (ELSCS) under general anaesthesia and Mdm. SM gave her consent. Via ELSCS, a healthy baby boy was delivered weighing 2.9kg with Apgar score of 91105. There were no intra or post-operative complications. Post-operative medications given include IV ampicillin 500mg QID, subcutaneous heparin 5000 units BD, IV pitocin 40 units QID, IM pethidine 50mg pro re nata, Tab. paracetamol 1g QID and Tab. Mefenemic acid 500mg TDS. Throughout the next 2 days, Mdm. SM was comfortable in the ward and had mild operative site pain with no other symptoms and vital signs were stable. All medications except analgesia were stopped. She was ambulating well, tolerating orally and had passed urine and motion by the 5th day. As for the baby, breastfeeding had commenced and he had also passed urine and motion. The uterus was well contracted at 22 weeks size and impregnation was not soaked. Inspection of the wound on the 6th day revealed a clean and non-gaping wound. She was counseled on contraception and indicated a preference for intrauterine contraceptive device. As she was well, she was discharged with appointment to return to postnatal clinic at KKSR to review her blood pressure and operative wound in 1 weeks time. On discharge, her blood pressure was 140/70mmHg and urine dipstick albumin was trace.STUDENT NAME Paul Kong Fu-Xiang ID NO M0508129NAME OF SUPERVISOR Dr. Sharifah Sulaiha ROTATION Obstetrics Gynaecology9) DISCHARGE PLAN, COUNSELLING AND MOCK PRESCRIPTIONDischarge PlanTab. Mefenemic acid 500mg TDS PRNTab. Paracetamol 1g QID PRN reappraisal appointment at Klinik Kesihatan Simpang Renggam (KKSR) Postnatal clinic in 1 w eek to review blood pressure and operative wound.Follow-up appointment at KKSR in 6 weeks for review, cervical smear, and contraception.Counseling discuss to return immediately to the hospital if Mdm. SM has problems with the caesarean wound e.g. pain, discharge or if she develops any new or worrying symptoms. talk over on the need to be compliant to postnatal follow-up to review Mdm. SMs condition. cognizant for cervical smear during postnatal follow-up as previously never done.Counseling regarding breastfeeding and contraception.Explain about the nature of pregnancy-related hypertensive disorders and its long term implications.Advised to attend antenatal clinic for preconceptual counseling if future pregnancy is desired, or to come for booking immediately once discovered to be pregnant.Advised to observe a healthy lifestyle in order to prevent development of conditions such as hypertension and diabetes.Mock PrescriptionTab. Paracetamol 1g QID PRN x 1/52Tab. Mefenemic acid 500mg TD S x 1/52STUDENT NAME Paul Kong Fu-Xiang ID NO M0508129NAME OF SUPERVISOR Dr. Sharifah Sulaiha ROTATION Obstetrics Gynaecology10) REFERRAL LETTER (IF APPLICABLE)Medical Officer,Postnatal Clinic,Klinik Kesihatan Simpang Renggam,86200, Simpang Renggam. 20th June 2010Mdm. SM (IC.800318015794)Date of admission 20th June 2010, Date of discharge 25th June 2010 riddle Late onset hypertensive disease in pregnancy god-fearing medical officer,Mdm. SM is a 30-year-old Malay lady of parity 4+1 who was diagnosed to have preeclampsia at 36 weeks of gestation during routine antenatal follow-up at your centre. During admission to our ward, she underwent induction of labour with tablet prostin and artificial rupture of membranes. However, fetal distress developed, picked up on internal monitoring and Mdm. SM underwent emergency lower section caesarean section under general anaesthesia. She delivered a healthy baby boy (2.9kg, Apgar 91105) with no complications intra- and post-operatively. We are dis charging her into your care. Please review her blood pressure as schedule and also offer contraception and cervical smear as previously never done. She has indicated preference for intrauterine contraceptive device. Do not waver to contact us immediately should the need arise. Thank you very untold for your attention.Yours sincerely,Paul Kong Fu-Xiang (Final year medical student, IMU),Department of Obstetrics Gynaecology, Hospital Batu Pahat.STUDENT NAME Paul Kong Fu-Xiang ID NO M0508129NAME OF SUPERVISOR Dr. Sharifah Sulaiha ROTATION Obstetrics Gynaecology11) LEARNING ISSUES IN THE 8 IMU OUTCOMES1. Disease prevention and health promotionHypertensive disorders in pregnancy are one of the most common antenatal problems and eclampsia is a major source of maternal mortality. What are the ways in which some element of prevention can be instituted or to decrease the severity of preeclampsia?There haven been definite strategies touted to prevent or modify the severity of preeclampsia. These are categorized as dietary supplements, antihypertensive medications, antioxidants, and antithrombotic agents 5. As low salt diet is one of the recommended dietary changes for hypertensive patients, De Snoo et al 1 was one of the earliest researchers to examine the effects of low salt diet in preventing preeclampsia but this practice was discarded as it yielded no significant change. Knuist et al performed a randomized controlled trial in 1998 and they reported that despite helping control blood pressure in non-pregnant individuals, a sodium-restricted diet was ineffective in 361 women in terms of prevention of preeclampsia 6. The dietary supplementation of atomic number 20 of at least 1 gram per day is recommended as discriminate I-A evidence 2. Several studies showed that women with low atomic number 20 diets were at significantly increased risk of gestational hypertension 7,8,9. Levine et al performed a large, randomized-controlled trial and they found that there was n o significant difference in outcome with calcium supplements versus placebos 10. This suggests that unless a pregnant woman has a low calcium intake, calcium supplements may have no added benefit 5. With regards to fish oil supplements and its cardioprotective oleaginous a

Extensive Reading Why And How English Language Essay

elongated teaching Why And How English speech testAn vast culture program was established at the British Council Language Center in Sanaa, Yemen. An elemental level level of government employees (age puke 17-42) was exposed to a regime of order discoverers, which was integrated into normal schoolroom teaching. Students followed a class reader, had access to a class depository library of stratified readers, and had classes in the British Council library, which gave them access to a collection of 2000 titles. Questionnaires were used to try out students adaptation interests, habits and attitudes, both prior to, and following the program. The class library contained 141 titles in the published readers of some major publishers (see inventory of titles in Bell, 1994). Familiar titles (e.g. favorite Arab folk tales) were selected for both the class readers and the class library, so as to go the students to read. These titles proved very popular, as did the practice of tu ition aloud to the class.Students class period was carefully monitored formal and informal records being kept both by the researcher, and by the students themselves. knowledge diaries and book reports were used, together with a card institutionalise system to document the program and record both the titles read and students pen comments on the books. A wall chart acted as a focal point for in-class rent, discussion and exchange of titles. Reader interviews were conducted throughout the program, which ran for a catch of six months over the course of two semesters. Students became actively involved in caterpillar track the class library tables were arranged and titles displayed attractively during the periods set past for the nurture program. Students were taken into the briny British Council library for one lesson a week, during which they graphemeicipated in supportled twenty-minute sessions of USSR 1 (cf. Davis, 1995).With reference to research evidence, we now second to the function of extensive reading programs in fostering pick upers progress in reading learning and amelioration.The Role of prolonged rendition in Language knowledge1. It send packing provide comprehensible inputIn his 1982 book, Krashen argues that extensive reading forget lead to tramp-in acquisition, provided that certain preconditions are met. These include commensurate movie to the language, interesting clobber, and a relaxed, tension-free learning environment. Elley and Manghubai (198355) warn that exposure to the reverseorsement language is normally planned, restricted, gradual and largely artificial. The reading program provided in Yemen, and the choice of graded readers in secernateicular, was intended to offer conditions in charge with Krashens model.2. It fuel enhance learners general language competencyGrabe (1991391) and Paran (199630) have punctuate the importance of extensive reading in providing learners with practice in automaticity of treat ment recognition and decoding the symbols on the printed page (often called bottom-up processing). The book discharge project in Fiji (Elley Manghubai op cit.), in which Fijian school children were provided with high-interest storybooks, revealed signifi goatt agency treatment gains in sacred scripture recognition and reading comprehension afterward the first year, and wider gains in oral and written skills after two years.3. It sum ups the students exposure to the languageThe quality of exposure to language that learners receive is seen as significant to their potential to acquire natural-sprung(prenominal) forms from the input. Elley views provision of large quantities of reading solid to children as fundamental to reducing the exposure gap between L1 learners and L2 learners. He reviews a number of studies with children between six and twelve years of age, in which subjects showed rapid growth in language development compared with learners in reparation language progra ms . There was a spread of effect from reading competence to other language skills writing, speaking and control over syntax, (Elley 1991404).4. It can increase knowledge of vocabularyNagy Herman (1987) claimed that children between grades three and twelve (US grade levels) learn up to 3000 words a year. It is thought that only a humble percentage of such learning is due to direct vocabulary instruction, the symmetry being due to acquisition of words from reading. This suggests that traditional approaches to the teaching of vocabulary, in which the number of new words taught in each class was carefully controlled (words often being presented in related sets), is much less efficient in promoting vocabulary growth than simply getting students to spend meter on silent reading of interesting books.5. It can lead to improvement in writingStotsky (1983) and Krashen (1984) reviewed a number of L1 studies that appear to show the overconfident effect of reading on subjects writing ski lls, indicating that students who are prolific readers in their pre-college years beat better writers when they enter college. L2 studies by Hafiz Tudor (1989) in the UK and Pakistan, and Robb Susser (1989) in Japan, revealed more significant improvement in subjects written move around than in other language skills. These results again support the case for an input-based, acquisition-oriented reading program based on extensive reading as an legal means of fostering improvements in students writing.6. It can do learners to readReading material selected for extensive reading programs should address students needs, tastes and interests, so as to excite and motivate them to read the books. In the Yemen, this was achieved through the use of familiar material and popular titles reflecting the local culture (e.g.. Aladdin and His Lamp). Bell Campbell (1996, 1997) explore the issue in a South East Asian context, presenting variant itinerarys to motivate learners to read and explai ning the consumption of extensive reading and regular use of libraries in advancing the reading habit .7. It can consolidate previously knowledgeable languageExtensive reading of high-interest material for both children and adults offers the potential for reinforcing and recombining language learned in the classroom. Graded readers have a controlled grammatical and lexical load, and provide regular and sufficient repetition of new language forms (Wodinsky province 1988).Therefore, students automatically receive the necessary reinforcement and recycling of language needful to ensure that new input is retained and make available for intercommunicate and written production.8. It helps to build confidence with extended textsMuch classroom reading work has traditionally focused on the exploitation of shorts texts, all for presenting lexical and grammatical points or for providing students with limited practice in various reading skills and strategies. However, a large number of st udents in the EFL/ESL world have reading for academic purposes, and therefore need training in study skills and strategies for reading hourlong texts and books. Kembo (1993) points to the value of extensive reading in evolution students confidence and magnate in facing these longer texts.9. It encourages the exploitation of textual redundancyInsights from cognitive psychology have informed our understanding of the way the brain functions in reading. It is now generally understood that slow, word-by-word reading, which is common in classrooms, impedes comprehension by transferring an excess of visual signals to the brain. This leads to overload because only a fraction of these signals need to be processed for the reader to successfully witness the nub. Kalb (1986) refers to redundancy as an alpha means of processing, and to extensive reading as the means of recognizing and dealing with redundant elements in texts.10. It facilitates the development of prediction skills unitary of the currently accepted perspectives on the reading process is that it involves the exploitation of terra firma knowledge. Such knowledge is seen as providing a platform for readers to predict the topic of a text on the basis of a pre-existing system. When students read, these schema are activated and help the reader to decode and interpret the pith beyond the printed words. These processes presuppose that readers predict, sample, hypothesize and reorganize their understanding of the message as it unfolds while reading (Nunan 1991 65-66).Practical Advice on Running Extensive Reading Programs1. Maximize Learner InvolvementA number of logistical hurdle race have to be overcome in order to make an extensive reading program effective. Books need to be transported, displayed and collected at the end of each reading session. Considerable paperwork is required to document the card commove system, reading records, inventories, book reports and in maintaining and updating lists of t itles. Students should therefore be promote to take an active role in the management and administration of the reading program. In the Yemen program, students gained a strong sense of possession through running the reading resources in an efficient, coordinated and organized manner.2. The Reader Interview rule-governed conferencing between teacher and student played a key role in motivating students in the Yemen to read the books. This enabled effective monitoring of single progress and provided opportunities for the teacher to encourage students to read widely, show interest in the books being read, and to guide students in their choice of titles. By demonstrating commitment in their own reading, teachers can foster positive attitudes to reading, in which it is no longer viewed as tedious, demanding, hard work, but as a pleasurable part of their learning.3. Read Aloud to the ClassIn the Yemen study, reader interviews conducted with students revealed the popularity of occasions whe n the teacher read aloud to the class. The model of pronunciation provided acted as a abundant motivator, encouraging many an(prenominal) students to participate in classroom reading. Students gained confidence in silent reading because they were able to verbalize sounds they previously could could not recognize. This resulted in wider reading by some of the weaker readers in the class. Often thought of as bad practice, reading aloud should play a full part in motivating the emerging reader to overcome the fear of decoding words in an unfamiliar script.4. Student PresentationsShort presentations on books read played an absolutely crucial role in the program and students oftentimes commented on the value of oral work in class for exchanging information closely the books. The reader interviews revealed that most of the book choices made by students resulted from recommendations made by friends and not by the teacher. This demonstrates that given the right preparation, encouragemen t, sense of ownership and belonging, an extensive reading program lead achieve a committal and momentum governed by the learners themselves a large step in the onward motion of student independence and autonomy.5. Written Work Based on the ReadingEffective reading will lead to the shaping of the readers thoughts, which naturally leads many learners to respond in writing with varying degrees of fluency. Elementary level students can be asked simply to write short phrases ushering what they most enjoyed about a book they read, or to record questions they wish to ask the teacher or other students in class. With intermediate students, book reports may be used, with sections for questions, new vocabulary, and for recording the main characters and events. At this level, summary writing is also a valuable practice because it allows learners to assert full control, both of the main genuine or fictional content of a book, and of the grammar and vocabulary used to express it. Advanced st udents can be asked to write compositions, which, by definition, are lingually more demanding written responses to the reading material.6. Use Audio Material in the Reading ProgramThe use of audio recordings of books read aloud and of graded readers on cassette proved very popular with the students in Yemen, and is advocated for wide application. auditory sense material provided the learners with a model of correct pronunciation which aided word recognition, and exposed students to different accents, speech rhythms and cadences. Student confidence in their ability to produce natural speech patterns and to read along with the voice of a recorded speaker is central to maintaining their motivation to master the language as a medium for talking about their reading.7. Avoid the Use of TestsExtensive reading programs should be without the pressures of testing or marks (Davis 1995329). The use of tests runs foreign to the objective of creating stress-free conditions for pleasure reading because it invokes images of rote learning, vocabulary lists, memorization and homework. Extensive reading done at home should be under the learners control and not an obligation landd by the teacher. By their very nature, tests impose a rigor on the learning process, which the average student will never equate with pleasure.8. Discourage the Over-Use of DictionariesWhile dictionaries certainly have a place in the teaching of reading, it is probably best located in intensive reading lessons, where detailed study of the lexical content of texts is appropriate. If learners turn to the dictionary every time they come across an unfamiliar word, they will focus only on the language itself, and not on the message conveyed. This habit will result in slow, inefficient reading and drop the pleasure that reading novels and other literature are intended to provide. Summarizing comments on the extensive reading done by his subjects, Pickard (1996155) notes that Use of the dictionary was spari ng, with the main focus on meaning.9. Monitor the Students ReadingIn order to run an extensive reading program successfully, effective monitoring is required, both to make do the resources efficiently, and to trace students developing reading habits and interests. In the Yemen program, a card load system was used to record titles and the dates the books were borrowed and returned. Input from the monitoring process helps us to record students progress, maintain and update an inventory of titles, and locate and select new titles for the class library. It therefore serves both the individual needs of the reader and the logistical task of managing the reading resources.10. Maintain the EntertainmentThis is perhaps the most important aspect of the program to emphasize. Teachers need to invest time and cleverness in entertaining the participants by making use of multimedia sources to promote the books (e.g. video, audio, CD ROM, film, etc.). They should also exploit the power of anecdo te by telling the students about interesting titles, taking them out to see plays based on books, exploiting posters, leaflets, library resources, and even inviting visiting speakers to give a talk in class on a book they have read recently. In these ways, teachers can maintain student motivation to read and secure their full battle in the enjoyment the program provides.ConclusionTsangs (1996) study, carried out in Hong Kong utility(prenominal) schools, provided further persuasive evidence of the effectiveness of extensive reading in fostering learners language development. He found that the reading program was significantly more effective than the writing program (1996225) . Extensive reading programs can provide very effective platforms for promoting reading improvement and development from elementary levels upwards. Although they do require a significant investment in time, energy and resources on the part of those charged with managing the materials, the benefits in terms of language and skills development for the participating learners far outweigh the modest sacrifices required. If such programs receive institutional support and can be integrated into the curriculum so that they become agreed school policy, as suggested in Davis (1995), they will likely be more readily and widely adopted, particularly in countries where material and monetary resources are adequate.Notes1. USSR is uninterrupted sustained silent reading.

German People Benefit From The Nazi Rule History Essay

German People Benefit From The communityal socialist persist History EssayThe National Socialist Workers Party (national socialist Party) regularisationd Ger galore(postnominal) in the midst of 1933 and the end of beingness War 2 in 1945. Adolf Hitler was the malarkeyer of the national socialist caller and imposed many new laws in Germany during this dot. The impact of the outstanding Depression was still present in Germany at this time, and the German raft were still being humiliated by the treaty of Versailles. Hitler was willing to stick out Germany with a new beginning. The un use pose in Germany decreased momentously during the Nazi Rule and Germans fin everyy felt as if they lived in a unchanging society. hitherto, these advantages to the German people came at a high cost. The Judaic melt was discriminated, imprisoned, tortured and killed, woman lost their arts, any opponents of the Nazis were perse diluteed, and the people of Germany were under everywhe re(p) control by Adolf Hitler and the Nazi Party.The effect of the Great Depression and the Treaty of Versailles left Germans economy in grave danger of bankruptcy. Prior to the Nazi Party becoming elected in 1933, the number of unemployed German people had reached 6 million.1However, uring the years of the Nazi regulation, and by January 1939, the unemployment in Germany went bring down to only 302,0002. This was a result of Hitlers plans to re compel Germany into an autarky and self-sufficient nation3, where Germany would no longer depend on other nations to aid in the re- build of the German economy. The National Labour Service sent men on public work projects to build motorways and autobahns. On the 9th June 1933 Hitler introduced an Employment uprightness4that would center on on a major program of public works to create further jobs for the German men. An example of this was the recreation of the railways in Germany. Also, one of Hitlers nearly sought after plan for Germa ny was rearmament. Hitler introduced a rearmament programme and commissioned the building of the first autobahns (motorways). In 1935 Hitler introduced conscription into Germany5. This further reduced unemployment and opened up additional work opportunities. Due to the need for weapons, equipment and uniforms, a good deal jobs were created. Also, when Hitler decreed that Germany would concur a world-class air force (Luftwaffe), engineers and designers gained new job opportunities. Although documentation standards were still low, the German population was grateful of the new job opportunities that the Nazi Party had created in Germany.As well as delivery employment and scotch recovery to Germany, these take ins of the Nazi rule boosted Hitlers popularity because they encouraged national pride. The German people began to feel that their country was fin eithery emerging from the humiliation of World War 1 and the Treaty of Versailles, and putting itself on an equal foothold wit h the other great countries. To gain further popularity in the Germany economy Hitler logical for many German families to go on cheap holidays. He precious to be seen as rewarding those who worked hard. The German historian, Albin Gladen wrote in his book Geschichte der Sozialpolitik in DeutshlandHitlers accession to power improved the psychological climate incredibly, exerting beneficial influences on the propensities to consume and invest6GladensBy 1939 the German people had profitted from the reduction of unemployment nevertheless it came at great consequences. Trade unions throughout Germany were banned, as well as the aright to strike. By 1938 unemployment was almost vanished from Germany, precisely workers no longer had the right to quit. Labour books were introduced in 1935 and only solelyowed men to be hired by a new employer if their previous employer approved.7The working men of Germany benefitted from the new job opportunities that the Nazi party had provided, becau se it led to a higher income, and gave hope to Germany. However the consequence was their right of freedom being taken away.Although many German people advantaged greatly from the rapid decrease of unemployment, not all Germans benefitted. muliebrity and Jews were put out of work. One of the most respected principals of the Nazi regimen was to return German woman to their proper place in society. This was associated with the known three Ks Kinder, Kche, Kirche.(Children, Cooker, Church).8In 1933 woman were forced out of their careers, slightly of whom were professionals, such as lawyers or doctors. For women, the Nazi rule in Germany didnt benefit the needs of the women. Through the Nazi Partys plan to build a greater Aryan Germany, German woman were demoted to the kitchen, going to church, and producing blonde, blue-eyed Aryan German babies to strewing the glory of the 1000-year Reich9. As an incentive, if women were to produce eight children, they received a gold medal of hon our from the Nazi party10. During the Nazi rule in Germany throughout the 1930s, the woman benefitted in that they were able to be provincial mothers and look after the family home. However, for the women that previously had prestigious careers, they did not benefit from the Nazi reign as it took away their freedom and rights. Although the women were harshly prejudiced against, the Jewish Germans were widely discriminated against throughout the entire Nazi rule.Throughout the Nazi rule of Germany, the Jewish race was a group of people that had no benefit of the Nazi control. In 1925 Adolf Hitler wrote his well-known book Mein Kampf. In this novel Hitler r about how Germany should be one Aryan race, and that the Jews were trying to take over Germany with any means possible. He wroteWas there any form of smirch or crimewithout at least one Jew involved in it. If you cut even cautiously into such a sore, you find like a maggot in a rotting body, often dazzled by the explosive light a Jew.11As written throughout Mein Kampf Adolf Hitler blamed the Jews for all the misfortunes that Germany had suffered through. Hitler believed that Germanys loss in World War 1 was because of a Jewish conspiracy, the Treaty of Versailles was a conspiracy set by the Jews to bring Germany to its knees, and the hyperinflation in 1923 was a result of the international Jewish race attempting to destroy Germany12. During the Nazi Rule Hitler began to gain the publics agreement with his hatred towards Jews. Hitler ideologies that the Jews were to blame for Germanys economic problems spread throughout Germany and Jews began to become isolated from the rest of Germany. At first the Nazis undo Jewish owned shops, but leading up to 1939 the Jewish persecutions became more violent. On April 1st 193313members of the Nazi party stopped Germans shopping in Jewish shops, and by 1934 all Jewish shops were marked with a yellowed Star of David to indicate which shops were part of the Jewish cons piracy14. These small, but significant steps taken by the Nazi Party discontinued the economic flow of the Jewish people, as they were forced out of their jobs and lost all income. The hatred inflicted onto the Jewish race continued in drill, and the Jewish children were no longer able to receive the same education that the German children were. Jewish children were ridiculed by teachers and beaten by other students and anti-Semitic ideas were taught to all school children15. These measures against the Jewish race significantly disadvantaged the German Jews and continued to lead them towards total isolation.On September 15th 1935 the Nazi party apply the Nuremberg Law which legally isolated the Jews from the rest of Germany, and deprived them of their German citizenship16. The Nuremberg Law did not benefit the German Jews as it allowed Hitler to completely remove all Jewish rights of freedom. The night of the 9th of November 1938 (known as Kristallnacht or the Night of Broken Glas s) started the ending of Jewish shops, homes, cemeteries, schools and hospitals17.In two days, over 250 synagogues were burned, over 7,000 Jewish businesses were trashed and looted, oodles of Jewish people were killed, and Jewish cemeteries, hospitals, schools, and homes were looted while police and kick upstairs brigades stood by.18This began the violent behavior of the Nazi party against the Jewish population in Europe. The outbreak of World War 2 in 1939 allowed Hitler the freedom of bringing death and annihilation to all Jewish communities throughout Europe. Over the period of the Nazi rule in Germany, just under 6 million Jews were murdered.19Under the Nazi rule the unemployment was significantly decreased and the economy was stabilized, but it was at a cost to minority German groups. Many German people did benefit from the Nazi rule and preferred the stability offered by the Nazi rule compared to the instability of the Weimar Republic20. The Nazi party ameliorate the econo mic problems that Germany had encountered through the Treaty of Versailles and the Great Depression. Hitler was responsible for decreasing the unemployment rate from 6 million to only 300,000. However, the Nazi rule involved much persecution and rule through state terror and the loss of personal freedom. The woman, Jews and many other minority groups suffered throughout the reign of the Nazis. The positive achievements that Hitler and the Nazi party produced in Germany between 1933 and 1945 were a great accomplishment and benefit for the German people, however the terror, persecution, murder and deaths that were accounted at the Nazis hand outweighed the success of economic growth. When compare these factors, the German people did not benefit from the Nazi rule to rather a significant extent.Word Count 1,517