Preparing for the BMAT (biomedical admissions test) Essay

The biomedical admissions test was created to assist medical and veterinary schools in the admissions process. Some of the universities have much more applications than places and the majority of these applications are strong. The BMAT allows the universities to filter out the strongest candidates based on exam performance. The BMAT exam lasts for 2 hours and is split into 3 sections. The examination test date is 31st October 2008. This article will aim to provide you with some advice and give an overview to students who are planning on taking the BMAT exam. †¢ aptitude and skills (1 hour) †¢ scientific knowledge and application (30 minutes) †¢ writing task (30 minutes) The universities which currently require you to take the BMAT are: †¢ The university of Cambridge †¢ The university of Oxford †¢ Imperial college London †¢ The royal veterinary college †¢ University of central London Aptitude and Skills This section aims to explore your problem solving skills, your ability to understand and interpret data and your analytical skills. It is multiple choice for the most. This is the main reason as to why you should guess intelligently, take a look at the given data and take a guess. Practice is key in this section. For the problem solving element of this section look at all the given data carefully. Here are some techniques to help you. †¢ Divide and conquer technique: Break down any large chunks of data into smaller chunks, making the smaller problems which are easier to solve and then once you have solved them put the data back together and form an answer. †¢ Trial and error: Use different approaches to come to a final conclusion and answer. †¢ Working backwards: start with one of the possible answers and work backwards from it. †¢ Incubation: This is a last resort method which seldom works. Put all of the starting details relating to a problem in your mind picture them and then stop focusing on them and carry on with the examination (take an intelligent guess). Your subconscious mind may come up with an answer during the rest of the examination The understanding and interpreting subset involves using the information in front of you, do not make assumptions unless it is appropriate to the question. Analyse all data given carefully not leaving anything out. The data analysis subset involves extracting certain points out of the data and using these to make suitable conclusions, to give the answer. Depending on the starting data you are provided with this could include using statistical methods, interpreting graphs, curve fitting or even eradicating unwanted information and prioritising said data. Scientific knowledge and application This section attempts to make students utilise their scientific knowledge to help them answer questions. Again this section is multiple choice, so make informed guesses when there is a need using the data given. This section also requires practice and revision of scientific principles in order to score high marks, so we advise you do some revision covering the basics of biology, chemistry and physics. Writing task The writing task is asking you to create an essay from a given question. Here are some general pointers to help you achieve a great score. †¢ Read: Read articles, newspapers, journals and book. This will help you to gain an understanding of how to put forward logical thought and will also help improve your English writing skills †¢ Partake in group discussions/debate forums: By doing this you will develop the skills that allow you to analyse certain situations and statements, in addition to developing the ability to generate a fair argument looking at both sides of the situation and can help you produce good conclusion. †¢ Good structure: Ensure you have an introduction, Main body and conclusion. By having an assigned essay structure your ideas will flow more freely and will follow a logical order that makes it easier for the reader to understand. †¢ Snappy conclusion and introduction: the introduction and conclusion can be the sections of your essay that sell it to the reader. Because these are the first and last things they read and so will remain in their mind the longest. An extremely good conclusion will stick in the readers head and maybe it might help you to boost your mark. Conclusion One key aspect for revision regarding the UKCAT is to sit some mock BMAT examinations; this will allow you to get a feel for the allocated time slot for the exam and thus ensure that you can finish all the questions. Some final general pointers I would like to add are 1. Don’t waste too much time on one question. 2. Generate a short plan for your writing task, just pointing out what you are going to cover and in what order. 3. Make sure you get plenty of rest before the exam. 4. If you have time available at the end of the exam use it to check over your answers.

Nigerian Economy, Gdp and Production.

NIGERIAN ECONOMY/GDP AND PRODUCTION Nigeria recorded a Current Account surplus of 11. 60 percent of the country's Gross Domestic Product in 2011. Current Account to GDP in Nigeria is reported by the African Economic Outlook. Historically, from 1980 until 2011, Nigeria Current Account to GDP averaged 1. 2 Percent reaching an all time high of 37. 9 Percent in December of 2008 and a record low of -18. 7 Percent in December of 1986. The Current account balance as a percent of GDP provides an indication on the level of international competitiveness of a country.Usually, countries recording a strong current account surplus have an economy heavily dependent on exports revenues, with high savings ratings but weak domestic demand. On the other hand, countries recording a current account deficit have strong imports, a low saving rates and high personal consumption rates as a percentage of disposable incomes. Nigeria recorded a Current Account surplus of 5035. 99 USD Million in the third quarte r of 2012. Current Account in Nigeria is reported by the Central Bank of Nigeria.Historically, from 2005 until 2012, Nigeria Current Account averaged 2373. 87 USD Million reaching an all time high of 9455. 37 USD Million in December of 2009 and a record low of -4410 USD Million in September of 2010. Current Account is the sum of the balance of trade (exports minus imports of goods and services), net factor income (such as interest and dividends) and net transfer payments (such as foreign aid). INDUSTRIAL PRODUCTION. In 2011 and 2012, Nigeria’s industrial production increased by 0. 10% as reported by the Central Bank of Nigeria.Historically, from 2007 until 2012, Nigeria Industrial Production averaged 3. 15 Percent reaching an all time high of 14. 90 Percent in December of 2011 and a record low of 0. 10 Percent in June of 2007. In Nigeria, industrial production measures the output of businesses integrated in industrial sector of the economy such as manufacturing, mining, and u tilities. This page includes a chart with historical data for Nigeria Industrial Production. The data given on this page shows a year over year change in a seasonally adjusted Industrial Production Index.Industrial Production Index is an economic indicator that measures changes in output for the manufacturing, mining, and utilities. Although these sectors contribute only a small portion of GDP, they are highly sensitive to interest rates and consumer demand. This makes Industrial Production an important tool for forecasting future GDP and economic performance. Industrial Production figures are also used by central banks to measure inflation, as high levels of industrial production can lead to uncontrolled levels of consumption and rapid inflation. Nigerian Economy, Gdp and Production. NIGERIAN ECONOMY/GDP AND PRODUCTION Nigeria recorded a Current Account surplus of 11. 60 percent of the country's Gross Domestic Product in 2011. Current Account to GDP in Nigeria is reported by the African Economic Outlook. Historically, from 1980 until 2011, Nigeria Current Account to GDP averaged 1. 2 Percent reaching an all time high of 37. 9 Percent in December of 2008 and a record low of -18. 7 Percent in December of 1986. The Current account balance as a percent of GDP provides an indication on the level of international competitiveness of a country.Usually, countries recording a strong current account surplus have an economy heavily dependent on exports revenues, with high savings ratings but weak domestic demand. On the other hand, countries recording a current account deficit have strong imports, a low saving rates and high personal consumption rates as a percentage of disposable incomes. Nigeria recorded a Current Account surplus of 5035. 99 USD Million in the third quarte r of 2012. Current Account in Nigeria is reported by the Central Bank of Nigeria.Historically, from 2005 until 2012, Nigeria Current Account averaged 2373. 87 USD Million reaching an all time high of 9455. 37 USD Million in December of 2009 and a record low of -4410 USD Million in September of 2010. Current Account is the sum of the balance of trade (exports minus imports of goods and services), net factor income (such as interest and dividends) and net transfer payments (such as foreign aid). INDUSTRIAL PRODUCTION. In 2011 and 2012, Nigeria’s industrial production increased by 0. 10% as reported by the Central Bank of Nigeria.Historically, from 2007 until 2012, Nigeria Industrial Production averaged 3. 15 Percent reaching an all time high of 14. 90 Percent in December of 2011 and a record low of 0. 10 Percent in June of 2007. In Nigeria, industrial production measures the output of businesses integrated in industrial sector of the economy such as manufacturing, mining, and u tilities. This page includes a chart with historical data for Nigeria Industrial Production. The data given on this page shows a year over year change in a seasonally adjusted Industrial Production Index.Industrial Production Index is an economic indicator that measures changes in output for the manufacturing, mining, and utilities. Although these sectors contribute only a small portion of GDP, they are highly sensitive to interest rates and consumer demand. This makes Industrial Production an important tool for forecasting future GDP and economic performance. Industrial Production figures are also used by central banks to measure inflation, as high levels of industrial production can lead to uncontrolled levels of consumption and rapid inflation.

A research paper of a film Essay Example | Topics and Well Written Essays - 1750 words

A research paper of a film - Essay Example Most importantly, the information is stored for future use and hence conserves the culture of the respective individuals. In most instances, the background of the writers greatly influences the nature of the film. In particular, it is widely agreed that the previous experiences of the writers are commonly highlighted in the films. This is because of the fact that the respective experiences shape the perceptions of the authors as well as the decisions that they make. To a great extent, their previous experiences regarding education and professional develop have a direct impact on the quality of the products that the individuals present on the market. Perhaps the most important aspect pertains to the culture of the author or director of the film. In most instances, this will always be reflected in the piece of work. It is against this background that this paper explores the themes presented in The Wedding Banquet in light of Ang Lee’s experiences. To enhance a harmonic consideration, the paper begins by highlighting the cultural setting of the film. The Wedding Banquet is an Asian-American film that is based on both the American and Asian values, virtues, traditions and culture. Seemingly, it explores the aforementioned cultural aspects through its characters and themes. According to Berry, this is aimed at bridging the gaps between the American and Asian cultures in an effort to come up with a complex and unified version (Berry 33). From a cultural point of view, unification or reconciliation of cultures is an important aspect of enhancing cultural growth. Put differently, this makes the audience to understand and appreciate both cultures. From a business standpoint, this is instrumental in enabling the film to reach a broader and more diversified client base. Undoubtedly, this is critical in enabling the author to meet his or her business goals without compromising the

Healthcare Communication Annotated Bibliography Example | Topics and Well Written Essays - 500 words

Healthcare Communication - Annotated Bibliography Example The methods used to get data on what constitutes communication breakdown among the practitioners were one- to- one interviews and a focus group. This article is useful in researching on the different challenges that bring about communication barriers among the medical providers, as well as the preferred remedy to these challenges. The authors indicate the use of a Joint Communication Note (JNC) as a preferred remedy where all the healthcare professionals will get and relay information from and to one another. This article is crucial to the research on the impact of effective communication amongst the healthcare practitioners. Through its findings, it may form the basis to the research though, not in its entirety. O’Daniel, M., Rosenstein, H. A., (2008). Professional Communication and Team Collaboration. Patient safety and quality: Evidence-Based Handbook for Nurses. Retrieved from; http//www.ahrq.gov/qual/html. In this article O’Daniel & Rosenstein, have brought out the different techniques used to enhance communication among the healthcare providers. This article answers questions such as what ways would enhance communication amongst healthcare providers? What are the common barriers to communication amongst healthcare professionals? They have indicated some of the already used methods in healthcare facilities such as the Simulation- Background- Assessment- Recommendation (SBAR) technique and its effectiveness in enhancing communication. They also propose another method Medical Team Management (MTM) that heavily borrows from the aviation model known as Crew Resource Management (CRM). The strength of this technique is that it was tested and verified at Eglin USAF Regional Hospital and with its advocacy on group formation it can be used in researching the methods to help enhance communication among healthcare professionals. This book by Nemeth emphasizes on the importance of group work and socialization among

Expansion & growth is the topic to write about Essay

Expansion & growth is the topic to write about - Essay Example Later, in the 16th century, California became under the control of Spanish and British colonizers. Gradually, the settlers began to control the indigenous population. The Bear Flag Revolt in the year 1846 in California is symbolic of the rebellious attitude of the settlers and the formation of California Republic. The California Gold Rush (say, between1848 and1855) is another major period in the history of California. During this period, the influx of immigrants in search of gold changed the distribution of population in California. Later, the Compromise of 1850 led to the formation of California as a free state within the United States of America. Earlier than European colonization, California was sparsely populated because the Native Americans used to settle in different areas of California. The European settlement resulted influx of immigrants and rapid urbanization. To be specific, the California Gold Rush or the influx of gold-seekers resulted in the rapid urbanization of California. The small settlements in California rapidly transformed into towns and cities. Now, California enjoys the largest gross state product (GSP) among the states within the United States of America. Ignacio Gonzalez stated that â€Å"In February 2001, California’s unemployment rate dropped to 4.5 percent, the lowest level since the late 1960s† (351). The growth in GSP is most important because it represents the expansion and growth of California. In the present condition, the Californian economy depends upon international trade and commerce. Transportation facilities in California consist of the network of roads (freeways, expressways and highways), airways (commercial and general aviation), seaports (for example, Port of Los Angeles) and rail lines (intercity rail lines, light rail systems etc). Summing, the expansion and growth of California from a small settlement area to a free state and its development is interconnected

Julius Ceasar and william shakespear Essay Example | Topics and Well Written Essays - 1250 words

Julius Ceasar and william shakespear - Essay Example Mark Antony, who was Caesar’s friend, offered an interment oration that remained famous to date. It is fundamental to explore the role of fallacy, omen and divination as demonstrated, and their relationship with the Roman culture and religions, by Brutus, Mark Antony and Julia Caesar. The paper will explore the dynamics among the various characters to establish the role of Shakespeare. Brutus Brutus, being the tragic hero of the play, portrays immense complexity in the character and motivations. Apart from being a powerful figure, he comes out as a loving husband and a good master of his servants. He is also a loving pal and a noble military leader. This character has a rather rigid ideology that doubles up as both his strength and weakness. His quest to put his ambitions on top of everything makes him fit the description of being â€Å"the noblest of the Romans.† Besides, he is also committed to principle, and this works against him always as he consistently makes misc alculations. For instance, when Cassius suggested to him that the conspirators would kill Caesar and Antony, he blatantly ignored. He again showed the naivety of his idealism during Caesar’s funeral when he allowed Antony to make the famous oration over the remains of Caesar. Consequently, he forfeited the authority about the last word of the murder, and this ensured that Antony succeeded in inciting the plebeians to protest against his compatriots (Bowen, Shakespeare, and Garcia 47). Julius Caesar He lived and portrayed an overly ambitious character determined to acquire and wield absolute power over Rome. He strongly comes out as a figure that only lived on the minds of other men. He strongly believed that his hold on Rome was permanent and, therefore, committed his loyalty to principles besides regarding himself as a public institution. Unfortunately, this later proved to be his utmost undoing. When Calpurnia, his wife, shared with him her nightmares, he stubbornly dismiss es them and fails to heed. He also ignores the supernatural omen circulating in the atmosphere. With the prospects of coronation, Caesar allowed his big ambitions to get on top of him. He lived a life of conflation whereby his public image and private self conjure. This led him to embrace a mistaken belief that he is immortal and that his mortal body protects his public self. However, his mortality later comes into play in Act V, Scene iii, when Brutus attributed the misfortunes befalling Cassius to Caesar’s power coming beyond the grave (Bowen, Shakespeare, and Garcia 18). Antony Antony plays a role in disapproving Brutus’ supposed strength. He is naturally improvisatory and impulsive and this perfectly helps him prove that Brutus is weak. He does this by first persuading the conspirators of his support to gain leniency from them. He then persuades the plebeians of the injustices committed by the conspirators against them and subsequently acquires support of the masse s. This makes him a consummate politician who ably could use skilled rhetoric and gestures to his advantage. Besides, he wisely responds to delicate cues from both his friends and enemies to determine his correct mode of conduct in each distinct situation. This always ensured that he gained the biggest advantage among his political peers. When he got an opportunity to eulogize Caesar’s death, he strategically designs his speech and words to please the audience and attract their desires. Interestingly, he ensured

Infosys in China Essay Example | Topics and Well Written Essays - 1750 words

Infosys in China - Essay Example It suggests measures for a better development in China and also other emerging countries. Â  Infosys was started by a group of seven members in the year 1981. It incorporated with the name Infosys Consultant Private Ltd. From the very beginning, Infosys was depended on the overseas business. The founder of Infosys, Narayana Murthy operated its business in India while the other seven went to the US and started working for their corporate clients. Reebok was Infosys first US based client. The company earned revenue of Rs 1.2 million in 1981. 1981 was a period when India did not experience the growth of computers, so licensing of computers would take a longer period. Infosys did not have the space needed to install a computer, thus it hired a premise of a customer where the new employees would be provided training. It also concentrated in the fields like retailing, distribution, finance and telecommunications. Infosys has entered into a joint venture with Kurt Salmon Associate (ICMR, 2006, p.2). Â  Infosys is the first company to get listed on NASDAQ stock exchange. It accounted a net profit of $US 152.1 million at the end of the quarterly result. The USA is its main source of revenue; it is planning to expand in Europe and Asia. Infosys in China is merely focusing on its local clients. It has been recognized as one of the fastest growing companies (IBEF, n.d., p.1). Â  In the year 2000, 78% of revenue came from North America, 14.8% from Europe and only 1.4% from India. By 2005, Infosys mode of operation was proximity development, which consisted of 9 and offshore software development about 17, mainly operating in India. Infosys is also facing a tough competition from other It giants because of the liberalization that has affected India and its economy (ICMR, 2006, p.3). Â  

Language and Mode Assignment Example | Topics and Well Written Essays - 500 words

Language and Mode - Assignment Example Once reading the text, the mode of writing and the language itself captures the reader even more, for example, the first phrase says, â€Å"Some moments are so stunning they live you speechless.† The facial expression defines the phrase; it shows that the phone is so stunning leaving one speechless. The writer continues to give more information about the phone. This information about the features captivates the reader. Another mode for capturing the reader is the â€Å"club nokia,† this may interest the reader as it shows an advantage of owning a nokia phone. It explains how one can enjoy the fun of photo editing, photo sharing with ease. Some vocabularies used in the advert, which capture the reader, include; stunning, which means extremely attractive, in these case defines the uniqueness of the phone. The other word is speechless meaning unable to speak after temporary result of shock; in this case, it expresses the reaction after seeing the phone Test B is an advertisement of the virgin mobile phone network, which is very captivating. The advert has only one photographic design of a beautiful woman lying on a bed, the photographic design captivates the reader immediately making him want to know the meaning of the advertisement. The lady defines the first writers statement that includes the words â€Å"great seducer† which in this case is the girl laying in a seductive posture The writer uses very captivating words and quotes, some of the captivating vocabularies include; great seducer which means a figure or a feature which makes something very attractive, in these case the â€Å"great seducer is the 10 pound discount offer on phones and 15 pound free airtime. Another vocabulary is â€Å"deep reverie† which means pleasant thoughts that make one forget what he or she is doing. In these advert deep reverie means that the offers are too good they will make the reader forget what he or she is

Leadership concept woirksheet Essay Example | Topics and Well Written Essays - 500 words

Leadership concept woirksheet - Essay Example Collaborative Teamwork maintains a series of stages. Stage 2 is where competitiveness occurs, in which â€Å"blaming, defensiveness, destructive disagreement, and test confrontations occur – Especially for those vying for dominant positions in the group†. (Montebello & Buzzota, 1993: 59-60) During COCKTAILS on March 26, several team members point out specific executives who they believe lack the ambition and experience to work on the important IPO project. Again, Teri is singled out, perhaps due to animosity over her recent publicized successes. The fact that John, the Board member, does not automatically agree with his team’s recommendations to remove Charles and Teri (though they may not be justified) will cast doubt on John’s ability to think through the IPO project without personal bias, as Teri is John’s niece. Trust is then diminished regarding John’s decision-making capabilities, likely affecting future team performance. Angela Thomas’ resignation is due to conflicting personal values in relation to senior leaderships’ viewpoint of what constitutes corporate social responsibility, pertaining to the IPO and the appeasement of Wall Street Investors. Angela’s values as a committed researcher conflict with those making the decision to improve the firm’s public image, as she believes it conflicts with the ability to produce higher levels of research and productivity. Hence, the organization may suffer from the loss of her experience and talent. In this situation, failure to communicate the importance of the IPO initiatives, early on, is the likely catalyst for this resignation, suggesting a knowledge management failure on behalf of senior level leadership. â€Å"A socially responsible leader often needs to go against conventional wisdom and push the consciousness of others to consider new and challenging ideas,

Indigenous Peoples and Tourism Essay Example for Free

Indigenous Peoples and Tourism Essay Theobald (1994) suggested that etymologically, the word tour is derived from the Latin, tornare and the Greek, tornos, meaning a lathe or circle; the movement around a central point or axis. This meaning changed in modern english to represent ones turn. The suffix –ism is defined as an action or process; typical behavior or quality, while the suffix, –ist denotes one that performs a given action. When the word tour and the suffixes–ism and –ist are combined, they suggest the action of movement around a circle. One can argue that a circle represents a starting point, which ultimately returns back to its beginning. Therefore, like a circle, a tour represents a journey in that it is a round-trip, an activities of persons traveling to and staying in places outside their usual environment for not more than one consecutive year for leisure, business or other purposes. In 1941, Hunziker and Krapf defined tourism as people who travel the sum of the phenomena and relationships arising from the travel and stay of non-residents, insofar as they do not lead to permanent residence and are not connected with any earning activity. y these definitions, the tourism industry is inevitable since travelling is always a part of a person’s everyday life. Tourism can be seen as major consideration for both developed and developing countries in terms of adding up value to their potential tourism assets. Today, variety of tourism activities has evolved and is continually practice worldwide. There are also different themes or purposes why people travel from their country origin to their preferred destinations, these are visiting friends and relatives tourism, medical, health and retirement tourism, nature and adventure tourism, nautical or cruise tourism, sun and beach tourism, MICE, Leisure and Entertainment and Shopping Tourism, educational tourism, and lastly, cultural or indigenous tourism. The Indigenous Tourism This kind of tourism has a variety of components and relationships. And each indigenous tourism experience is unique in terms of time, space and participants. In 1966, a frameworks was been presented by Hinch and Butler, which highlights some of the key components of indigenous tourism. However, it was of limited value terms of identifying relationships between these components. The tourism system was been influenced by a variety of sources such as the basic geographic dimension of Leiper’s tourism system (1990), and the important role of the media which was highlighted by Ryan and Trauer, (2005). One of the distinguishing figures of an indigenous tourism system in general is the emphasis on the culture. In the indigenous tourism, where cultural overlay can be found, is much more encompassing compared to the tangible manifestation in a culturally based attraction. Basic values and principles, which were infused in the way an enterprise is operated, also reflect. The final component of this tourism system is the broader environmental context. This component also reflects the reality that tourism is not a closed system. But the main intent of the host (indigenous people), is to have income using the destination and also to export positive images of the destination and themselves. Economic Environment The strong performance of the economic aspects will result in higher levels of discretionary spending for travel and more trips, especially if it’s done in tourist market areas. On the other hand, the weak performance of the economic aspects often results in tourism actively supported as an alternative to struggling primary or secondary industries. Oftentimes, communal approach is a successful liaison with traditional indigenous communities but being questioned in places like Australia by Schmiechena and Boyle, Editor’s Note. Private entrepreneurial approaches are being pursued in indigenous communities (Wuttunee, 1992; Altman and Finlayson, 1993). The growing corporatization of the global economy may reflect in such trends in combination with evolving generational differences and changing socio-political structures and programs that can be seen in indigenous communities. Social Environment. One of the shared features of indigenous people is the â€Å"cultural poverty† in which they live (Frideres, 1988). Poverty means there is an insufficiency in participating effectively in society, not having enough to feed and clothe a family, neither a clinic nor a school to go to, or even own a land or a job to earn one’s living, and not having access to credit. It is not very surprising that the constraints and results of the development goals of indigenous people often vary from the goals of non-indigenous communities. Political Environment. Despite the substantial constraints that the indigenous people face, they become increasingly aware and active, as well as informed of their legal and political rights and have increasingly exercised them. There has been a major increase in land claim settlements which resulted in financial gain and increased resource management roles (Hinch, 2001). The internal politics of indigenous groups has political differences as one of the significant aspects which is not surprising that it is very rare to hear a unified voice speaking on their behalf. In Indigenous communities, there are two levels of governance, one imposed by the dominant culture and one embedded in the traditional practices of the community. Also, the reality of dual governing structures; one of them is an elected body while the other looks to the traditional guidance of elders, whose gonna be taking account valued communal and kinship bonds, build and process consensus in the community. And there are two levels of governance in indigenous communities: first is imposed by the dominant culture and secondly, embedded in the community’s traditional practice. Natural Environment The widespread destruction of natural areas throughout the world, actually increases the value of most traditional indigenous lands (Stevens, 1997). Most of the traditional indigenous lands has been lost due to expropriation and been the cause for the displacement of the indigenous people to peripheral places. The traditional relationship of the indigenous people to their homeland compared to non-indigenous people to their own land is also distinct (Notzke, 2006). Because most of the indigenous people believes that they are unconditionally conjugated or inseparable with the nature, unlike with the non-indigenous people who tend to see the land as a resource for human pleasure (Gary, 1991; Hollinshead, 1992). Given the importance of the environment to the indigenous people, any changes in the environment, have significance on the practice of the indigenous tourism (Gardner and Nelson, 1988). Host- Guest Relationshop and the Socio-Cultural Impacts of tourism It’s been the subject of much debate and research in a variety of disciplines such as anthropology and ethnography, as well as tourism studies. Disassociating the impacts of tourism from the boarder context of social and cultural development, is difficult in many ways. Most of the models cited with impact analysis are considered as less useful as tourists proliferate and destinations diversify. Two best-known models perhaps were (Butler’s Lifecycle Model, 1980 and Doxey’s Irridex, 1975). These models allow us to visualize the progression (more often, regression) of many global destinations, though they are by no means universal. In the past few years, the regeneration or rejuvenation of destination has become a more widespread phenomenon. Many products have been upgraded; some were diversified into new forms of tourism, and are targeting higher spending visitors. Though it is uncommon for tourist to be confined to â€Å"enclaves’ where contact with local residents is minimal. This kind of relationship allows for little spontaneity, but worth questioning how far host-guest relations have ever been truly authentic given the contrived nature and typically short duration of the average holiday. Acculturation, Cultural Drift and the Commodificaiton of Culture The fact of tourism is inevitable that the cultural changes primarily seen to the traditions of indigenous society, customs and values rather than to those of the tourist. Although tourism in some destinations, may be intermittent and seasonal. The level of visitation is constant and can have considerable impact on the social and cultural fabric of the host society. Instead of acculturation, cultural drift take place and is a kind of cultural change that appear within the society. (Mathieson and Wall 1992), states that cultural drift is a phenotypic change to the behavior of the host which take place only when they are in contact with tourists, but when tourists leave, it can go back to normal. The Genotypic behavior is a more permanent phenomenon where cultural changes are handed down from one generation to another. The fears of the culture and identity of the host can be assimilated into more dominant or persuasive culture of the tourist. Homogenization of culture is often exacerbated by tourist whose behaviors are sometimes adapted by local residents. This may simply mean to local people, that they are obliged to learn the language of the tourist in order to communicate well, but can also mean the consumption of non-local food or drink, the wearing of non-traditional fashions, and the desire to indulge in the same forms of entertainment as tourists. The majority of tourists tend to crave Western-style amenities. Not only this create economic leakages, but it also threatens the production of local goods, especially if local people develops and prefer Western-style products as well. Authenticity also becomes a key issue esp. when performing rituals in isolation from their traditional context. Staged authenticity in the form of displaced ceremonies, activities and events has become widespread. Although it is somehow important, the authenticity of tourist experience, it is more crucial to ensure that local communities with their role as performers and entertainers must feel comfortable in any ways. And of course, it should be understood as well that some religious or spiritual cultural practices, for tourists gaze, might not be appropriate spectacles. Measuring the socio-cultural impacts of tourism Culture is dynamic and it changes from time to time irrespective of human development: First, distinguishing the impacts of tourism from those of other social or economic developments is difficult. Second, in measuring socio-cultural impacts, only few reliable tools exist, and assessment is oftentimes used to gather quantifiable data. Cooper and et al (1998) suggests to use a number of techniques in measuring sociocultural impacts of tourism, but usually filtering other influences is impossible. The following list suggests some of the indicators that can used to identify socio-cultural impacts: †¢ Ratio of tourist to locals †¢ Nature of interaction between hosts and guests †¢ Local perceptions of tourism †¢ Concentration of tourism in certain locations †¢ Degree of usage of local products and facilities †¢ Extent and nature of local employment †¢ Degree of commercialization of local culture †¢ Changes in family relationships and the role of women †¢ Demonstration effects †¢ Increased social problems (e. g. drug usage, alcohol abuse, gambling, prostitution). †¢ Rises in crimes Cultural Tourism as a positive development option Cultural tourism can often provide an attractive socio-economic development option for many societies. It can also raise the profile of a destination, attracting the interest of both investors and visitors. There are a number of benefits derived from tourism and have been well documented in tourism literature and may include the creation of employment, the receipt of foreign exchange, the expansion of other economic sectors, and infrastructural developments. Some are intangible benefits including the renewal of cultural pride, revitalization of customs and traditions, and opportunities for cross-cultural exchange and integration. One of the major problems with tourism development is the government of those countries, who perceives tourism as a â€Å"quick fix† solution to the economic problems. As suggested by Lanfant and et al. (1995), it is often perceived as the last chance for countries to propel themselves on to the world of stage and to compete in the global arena. International and non-local investment becomes an attractive prospect, esp. in poverty-stricken countries where there are many local entrepreneurs who are able to afford the inflated land and property prices. However, restriction of the government in the extent of outside investment is needed, as this might lead inevitably to ownership and management of facilities and services o f the non-locals and high economic leakages. Another economic difficulty is for the destinations or countries who were not able to meet demands of their tourism industry with their own local products. Other economic sectors such as fishing or agriculture can be strengthened; supply is unlikely to meet demand if tourism increases rapidly. In cases of small island economies, it might be possible to strengthen inter-island linkages, but there is still the need to import goods and still experience the inevitable economic leakages. Although most tourists do shop and buy local handcrafted goods, it is still difficult to insist the consumption of local cuisine. The need for local and tourist education is being recognized. Tour operators, airlines and Western tourism agencies were encouraged to provide info and codes of conduct for visitors. Codes of conduct may be necessary in areas where the environment of local culture is fragile or sensitive. The final point is the marketing of the destination. Most destination practice selective marketing to ensure that tourism development remains small-scale and appropriate. However, this is a delicate balance since many of the tourists may not be the most cultural sensitive. There are certain forms of tourism that are being developed in accordance with these changing trends, which are more environmentally friendly and culturally sensitive. Indigenous Cultural Tourism. According to Smith (2003), The Indigenous Cultural Tourism is used as an overarching terms for together ethnic and tribal tourism, and any form of tourism that involves contact with the indigenous people and their culture. They usually involve visiting native and indigenous people, such as tribal groups or ethnic minorities. An area that is designated cultural landscape, national park, a jungle, a dessert or a mountainous region. Foreign Studies Tourism Industry Tourism is seen as a labor intensive, seven-day-a-week industry, growing at a rate faster than any sector. It is widely accepted that tourism is gaining more and more importance with the end of 20 th century and especially with the beginning of 21 st century regarding to the changing trends. In the study â€Å"Developing Alternative Modes of Tourism† (Berne Tuzcan, 2007), World Tourism Organization has taken the concept of tourism beyond holiday-making and officially defined it as follows: â€Å"Tourism comprises the activities carried out by people during their holidays and their visit to places different from their usual environment or residence, for a consecutive period of time less than a year, with leisure, business or other purposes. † (McIntosh, Goeldner and Ritchie 1995:11). Accordingly â€Å"Tourism refers to all activities of visitors including both overnight visitors and same day visitors† (Lickorish and Jenkins, 1997: 36). Moreover, it may also be defined as â€Å"the sum of relationships arising from the interaction of tourists, business suppliers, host government, and host communities in the process of attracting and hosting these tourist and other visitors (McIntosh, Goeldner and Ritchie 1995: 9-10). † On the other hand tourists can be defined as people who are visiting a particular place for sightseeing, visiting their friends and relatives, taking a vacation, and having a good time. Indigenous Tourism Indigenous tourism is a „special interest? tourism; its essential components are: first hand, authentic and usually intimate contact with Indigenous peoples whose ethnic and cultural backgrounds are different from those of tourists (Weiler and Harron 84). Indigenous tourism affairs are location-specific, or rather, culture-specific; the history has shown that various Indigenous groups have reacted to tourism in various ways. The approaches of Indigenous communities towards tourism are influenced by a number of factors such as: former experiences with Western world, size of Indigenous population, sedentary or mobile lifestyle, diversity of Indigenous languages in an area, etc. ( Martina Horakova, 2003) Naturally, the overall analysis of Indigenous tourism would require a holistic approach; all the aspects of life in Indigenous communities are influenced by tourism and are interwoven: economic and educational issues, marketing and preservation, land ownership and traditional lifestyles. Indigenous People Indigenous communities are very diverse and specific. No matter where they live, groups from various parts of the world or clans occupying two neighboring regions, all of them are unique and their distinctiveness should be recognized and respected. Thus, to generalize insensitively and refer to all Indigenous peoples as a homogeneous group would be an immense mistake. In Australia, there are more than 700 different nations (Nielsen 213) and as quoted in the said study, â€Å"different groups are responding to tourism in different ways†. In the thesis entitled â€Å"Tourism and its Impact on Traditional Culture: A case study of Sirubari village, Nepal† by Tilak Prasad Kandel (2011) discussed the boom of tourism on indigenous people in the village tourism being practiced by the Gurung people in the Sirubari village of Syangja. For several decades now, this study recognizes the tourism industry as major source of revenue for countries, especially in the Third World. For ethnic tribes such as the Gurung people, Tourism is like a gift. They were given opportunities for employment other than hunting and fishing. Their children was given the benefits for education and they were informed of what it is like outside of their community as they interact with tourists who visited their place. They were proud of their culture but did not deny the fact, that they have the rights for changes and development if choose to. Another study, â€Å"The Impacts of Ethnic Tourism on Hill Tribes in Thailand† (Kayoko Ishii, 2011) stated the economic bene? ts of ethnic tourism for tribal households that affect the division of labor and gender dynamics in the local minority community engaged in the tourism industry. Furthermore, â€Å"Indigenous Tourism in Australia† (Martina Horakova, 2003) deals in analyzing both the positive and negative impacts of tourism in Aboriginal communities in Australia. The thesis shows that no one could really conclude that the overall effect of indigenous tourism on Aboriginal communities is either bad or good. This thesis intends to present that even though there are negative impacts, the positive ones could actually eliminate those and that indigenous tourism could give Aboriginal peoples the opportunity to re-create and state their identities through the interaction and exposure to tourists. The communication between tourists and Aboriginal peoples is productive in many aspects. It provides tourists with information that cannot be obtained elsewhere, and it helps to restore Aboriginal peoples? self-esteem and pride in their cultural heritage. Consequently, they are more willing to share their knowledge with the outer world. And, by telling their stories, they contribute greatly to the reconciliation. Thus, it could be concluded that Indigenous tourism becomes â€Å"reconciliation tourism† (Higgins-Desbiolles 223), when operated sensitively and carefully. Local Literature The Philippine Tourism According to Etravel Philippines (2000), The Philippines, Pearl of the Orient Seas, is very rich in natural resources. Filipinos are by nature creative and intelligent. The richness of the environment is an advantage for their livelihood. Around 15 million hectares, or almost half of the Philippines total land area, are classified as timberland. Most of the land here was densely forested before the 1900s. However, the following century saw the loss of half of Philippine forests. Statistics show that deforestation claimed 204,000 hectares per year from 1950 to 1978. From 1989 to 1995, only 116,332 hectares were vanishing annually. Environmentalist groups are trying to protect Philippine forests, but a lot needs to be done in the campaign for reforestation as well as the fight against illegal logging. Philippine forests produce timber for local consumption and for export. Hardwood products coming from these timbers are globally known for their distinct appearance and high quality, which makes them appropriate as home furnishings. Wooden furniture, such as tables and chairs, are usually made of hardwood, popularly known as narra. Most Philippine forests are of the tropical rainforest type. Besides extensive reserves of tropical evergreen hardwoods, the country also has considerable areas of pine in the mountainous regions of Northern Luzon. With a coastal ecosystem stretching almost 20,000 km, the Philippines is likely to become one of the earliest victims of rising ocean temperatures and levels. Centuries-old coral reefs are dying almost overnight, and the destruction is being witnessed not only by divers in remote spots. Regional marine science studies estimated in the middle of 1999 that the Philippines magnificent underwater world would be gone by around 2100. Reports say that increased sea temperatures were causing mass coral bleaching events in the worlds best coral reefs. Something has to be done to reduce global warming caused by the burning of oil, coal, and gas. The Philippines has extensive but small river systems and streams, which are mostly depicted by the mountain ranges. The fluvial system of Luzon is made up of (1) Rio Grande de Cagayan and its tributaries (a stream that flows into a larger body of water), which drain the Cagayan Valley; (2) the Agno Grande which drains Benguet and the valleys of Nueva Ecija, Pangasinan and Tarlac; (3) the Abra River system, which receives its tributaries from the Cordillera and drains Lepanto, Bontoc, and the Abra; and (4) the Rio Grande de Pampanga and its tributaries, which drain the fertile valfeys of Nueva Ecija, Pampanga, and Bulacan. Schoolmeester (2004), expound that most of the islands in the Philippines are very small. Many of these small islands as well as the bigger islands, have a lot to offer to tourists. There are many possibilities for typical sun, sea and beach holidays and for specific adventure holidays. You can even meet the whale sharks and swim close to them. For tourists who want to discover geographically interesting landscapes or who want to meet mountain tribes, the Philippines has it all! As an archipelagic island, the Philippines offers countless attractions to see, such as the famous white sand beaches of Boracay, big shopping centers of Metro Manila, rice terraces of Ifugao, diving sites of Palawan, lush forests of Bohol, heritage houses in Vigan, and the cultural attractions of Manila. Metro Manila, the national capital region of the country, is known for being one of the best shopping destinations in Asia; its wide collection of shopping centers offer a range of local and international shops. Numerous shopping malls can be found around the metropolis, especially in the business and financial districts of Ortigas Center and Bonifacio Global City, while high-end shopping centers are mostly located at the Ayala Center in Makati. Despite the rise of modern shopping centers, traditional Filipino shopping areas still remain around the metropolis. Located just approximately 315 km (196 mi) south of Manila is Boracay; it is known for its white sand beaches and has been a favorite island destination for local and foreign visitors. In 2012, Boracay received the best island award from the international travel magazine Travel + Leisure. Boracay was also named as the second best beach in the world. Aside from its white sand beaches, Boracay is also known for being a popular destination for relaxation, tranquility and for an exciting nightlife (Malig, 2012). Mindanao, the southernmost island of the Philippines is home to the countrys tallest mountain, Mount Apo. The mountain features a wide range of flora and fauna and is home to over 272 bird species, 111 of which are endemic to the area. Mount Apo is also home to the countrys national bird, the Philippine Eagle. Mount Apo is a popular destination for hiking and mountain activities. The Indigenous People in the Philippines Jocano (1998) said that the earliest known attempt of classifying Filipinos into specific racial groupings were based mainly on anthropometric measurements and ocular inspections of skeletal remains as well as the physical appearances of living populations. The inhabitants of the country could be divided into: (1) Negritos – the small, dark-skinned group, which included the Negrito of Bataan, Ata of Luzon, and Mamanwa of Mindanao; (2) Malays – the brown-skinned group, which included the inhabitants of Bicol, Bisayas, and southern Luzon (Montano suspected the Malays to have Chinese, Indonesian, and Arabic blood); (3) Indonesian group – the group similar to the Malays in complexion, which included the Samal, Bagobo, Guianga, Ata, Tagakaolo, Tagbanua, Manubo, Mandaya, and Bilaan. Group 2 and 3 were said to have reached the Philippines in two waves of migration. The Indonesians were the first to come, followed by the Malays. The Aetas in the Philippines Of the scores of indigenous communities that comprise roughly 14 per cent of the Filipino people, the Agta are unquestionably the most widely distributed geographically. Popularly regarded as aboriginal, they are variously known as Mamanua in Surigao, Ata Manobo in Davao, Ati in Panay, Ata and Ati in Negros, Batak in North Central Palawan, Ayta and Ita in Central Luzon, Ata in Western Cagayan, and Agta or Aggay along the Sierra Madre Mountain Range facing the Pacific Ocean or more accurately the Philippine Sea from Palaui Island off San Vicente in Santa Ana, Cagayan south or northern Isabela Province. Farther south of the range, in Aurora and Quezon provinces, they are called Dumagat (Galang, 2006). The Aeta live in the northern part of the Philippines on the island of Luzon. Historians and Anthropologists debate precisely when and how they migrated here, the consensus being that they crossed from the island of Borneo between 20 and 30 thousand years ago, using a land bridge that was partially covered by water around 5,000 years ago – the remaining part of which is now part of Palawan. Whatever the migration path was, they are without doubt among the first – if not the first – inhabitants of the Philippines. One area of that country where the Aetas had lived for thousands of years was Mount Pinatubo (Waddington, 2002). Aetas are known to be one of the descendants of the original inhabitants of the Philippines. They previously occupied the outlying areas near the coastline and riverbeds, but were forced to resettle in the mountains by the coming of the migrants. Belonging to the ethnic group, Negrito, these mountain dwellers are classified and identified as Aytas or Aetas small stature, kinky hair, dark brown skin, and big brown eyes (Hiromu Shimizu, 1989). The small body of Aetas is nicely proportioned of strong, hardy stock, muscular and able to endure hardship of their life, such as going with little food for several days; they also have high forehead, prominent cheek bones, flat nose, round black eyes and scanty beard. They have highly trained and keen sense of hearing and sight since one of their sources of living is hunting. They also have bright, inquisitive minds and an extensive knowledge of woodcraft but they lack of abstract ideas and can hardly count beyond 4 or 5. Though their happiness is like a child’s happiness, they smile and laugh even if they are worried; they are kind and peaceful little folks and very devoted to their relatives, friends and with high moral standard like honesty (Wilson, 1953) The Pinatubo Aytas (Aytas in Zambales). Studies of cultural change following the occurrence of the natural hazards like volcanic eruptions usually focuses on the propensity of the stricken society to suffer from damage caused by an event, they stress the vulnerability or the condition of a society which makes it possible for a hazard to become a disaster (Canoon, 1994). According to Shimizu (1992), In the early years following the awakening of Mt. Pinatubo in 1991, there was a generalized fear that the eruption might turn into a cultural disaster for the Aeta ethnic minority of Central Luzon which was expected to be in a crisis of survival. A decade after the disaster, a certain level of cultural change has indeed been observed in the indigenous society. prior to the eruption, the Aeta in Zambales occupied only the slopes of the Mt. Pinatubo and, in particular, the tablelands stretching from the volcano to the coast range between Botolan and San Marcelino. In April 2001, Banzon-Bautista with the initial signs of the restlessness of the volcano, almost all of the Aetas communities were immediately evacuated. However, an unknown number of Aetas refused to leave their homes and perished during the eruption. According to oral accounts, a score of Aeta found shelter in caves that were eventually buried by pyroclastic flowers. According to Gaillard (2006), All the Aeta communities located on the upper flanks of Mt. Pinatubo prior to the eruption had to abandon their small villages which had been buried under these thick, hot pyroclastic and ash fall deposits, which prevent the immediate reoccupation of the settlements. Most of these Aeta have been relocated in the government resettlement sites, either on the lower slopes of the volcano or on the foothills. Today, these resettlement sites are the largest Aeta settlements. All these settlements are nowadays concentrated on the lower flanks of Mt. Pinatubo in the immediate proximity of lowland villages and towns occupied by Kapampangan people, the dominant ethnic group of the Southwestern part of the Central Plain of Luzon. Henceforth, there are no Aeta communities left isolated on the upper flanks of Mt. Pinatubo. All have established regular contact with the lowlanders. According to 1973 census, the Pinatubo Aytas covers almost majority of the 20,000 population of the Negrito groups. Pinatubo Aytas declined to accept and entertain the influence of the outside forces or the lowlanders and continually preserve their distinct culture and tradition until the Mount Pinatubo eruption in 1996 when they were forced to go down the plains and mountains and lived in the resettlement areas together with the lowlanders. These endanger their culture and tradition because they learned to adapt the ways of the lowlanders (Tubera, 2006). In line with this, they no longer possess their original language instead they adopted the lowlanders’ language called Sambal Language, thus, the acceptance of the jurisdiction of the municipal government which opened them further to the culture of the lowlanders whom they called as bawbanowa (town people). They have not just acquired the Sambal Language but also their techniques and rituals in agriculture; and their concepts of spirits, curing rituals, and burial customs. However, the Aytas assimilated only those cultural elements suitable to their social reality. This selective assimilation contributed to the stability and continuity of the Aytas’ culture. The feeling of antagonism towards the lowlanders made them preserve their own cultural heritage. Despite of being aware of the changing environment and society downhill they insisted to not to adopt and or develop a well integrated sociopolitical system beyond the family groupings and the village order. Hence, without the presence of the integrated system their history is not detailed, only those eve.

High Risk Pregnancy and Women with Complex Health

High Risk Pregnancy and Women with Complex Health For this assignment I have been asked to look at the care I have seen and been involved in giving to a woman with a high risk pregnancy. I intend to identify how my practice could be developed to meet the similar needs of women in the future. To do this I am going to use a reflective approach. I am going to look at the normal anatomy and physiology and analyse the patho-physiology in relation to high risk pregnancy and birth. For most women, their midwife is their first point of contact so they have a crucial role to play in identifying any risks. Included in their extensive role is facilitating pregnancy and childbirth as a positive and fulfilling experience. This is most fundamental for those women whose childbearing experience has been categorised as high risk (Page, 2006). A pregnancy is classed as high risk if there are any factors that may adversely affect the fetal or maternal outcome. Risk factors must be identified as early as possible to increase the chances of an improved outcome (Queenan et al, 2007). When a woman is booked for her maternity care, her medical and obstetric history is taken to ascertain whether she would be suitable for midwifery led care (low risk) or consultant or obstetric led care (high risk). A woman can change from either group during her pregnancy. For example, she may start her care as low risk but then something may happen or a condition may develop so she may therefore require consultant input into her care. Factors which could mean a woman has a high risk pregnancy include epilepsy, diabetes, cardiac problems, multiple pregnancy, hypertension, obesity and previous obstetric complications, i.e. caesarean section, previous haemorrhage (whether that be antepartum, intrapartum or postpartum), recurrent miscarriages or previous intra-uterine death. Using Gibbs (1988) reflective cycle, I am going to discuss a woman I recently cared for whilst working on Central Delivery Suite, whose pregnancy had been assessed as high risk. This was due to her having had a previous emergency caesarean section and a previous ventouse delivery. In accordance with The Code (NMC, 2008) I have changed all names mentioned to respect their confidentiality. Description: Laura, aged 39 years old, was 39+1 weeks pregnant, gravida three, para two. As just mentioned, her obstetric history meant she would see an obstetric consultant during her pregnancy. As Laura was planning on having a vaginal birth after caesarean section (VBAC) this increased her risk. It was also apparent she had tested positive for Group B Streptococcus (GBS) in both her previous pregnancies. Laura had gone into spontaneous labour. Laura and her partner had both requested antibiotics to be started as soon as possible due to the previous GBS. This was not something my mentor could agree to as Laura had not tested positive for it at any point during this pregnancy. However, due to Lauras admission temperature reading being 38.1 °C and in view of the previous two pregnancies testing positive for GBS, it was decided by the obstetric consultant on duty that she would receive antibiotics during labour. We confirmed she was in established labour by performing a vaginal examination, with consent, and finding the cervix was 4-5 cms dilated, partially effaced and membranes were felt intact. After Laura was cannulated, the antibiotic Benzylpenicillin (Penicillin G) 3g was administered intravenously. Then at four-hourly intervals she was given 1.5g until delivery. Due to Lauras high risk status a cardiotocograph (CTG) was commenced to keep a trace on the fetal heart rate and the uterine contractions. Laura laboured for approximately 6 hours in total, and went on to have a normal vaginal delivery of a healthy baby boy. Postnatally, Lauras observations were taken and baby observations were also taken six hourly and observed for a minimum of twelve hours in accordance with Local Trust Guidelines (Local Trust, 2005). Feelings: This event particularly sticks in my mind due to my own curiosity about Group B Streptococcus. When Laura was showing a temperature of 38.1 °C, I recognised this was out of the normal range so I informed my mentor. I knew a high temperature could indicate a sign of infection so it was important I made my mentor aware. I felt calm at the time and knew my mentor and the obstetric consultant had the matter under control. My mentor made me feel included in the situation and explained fully what she was doing and when. She went through the process of preparing the drugs and the IV line with me. I was very happy with the outcome of the situation. At the end of the day, we all wanted a normal, natural delivery of a healthy baby and that was achieved. Evaluation: The ultimate goal of this situation was a healthy mother and baby, which was successfully achieved. I am glad the consultant made the decision that Laura would be started on antibiotics as I was aware of how anxious she was. Analysis: The final outcome was Laura had a healthy baby with no signs of GBS disease. Contributing factors to this were how I relayed important information to my mentor and how the obstetric consultant made the right choice offering Laura antibiotics, even though she had not tested positive for GBS in this pregnancy. I believe Laura should have been offered a test for GBS to confirm if it was present in this pregnancy or not. She was very anxious about the situation so I feel this would have at least helped put her mind at rest knowing either way. Her and her partner had come to CDS demanding antibiotics as a precaution anyway, and luckily for her, her high temperature meant she received them. Had she not had the high temperature that decision would have been down to the consultant. Conclusion: I learnt from this experience the correct drugs to be given in labour, and the quantities and times stages they should be given. I also learnt the drug to be given if the woman is allergic to the primary choice drug. Plus, from using this topic as my high risk assignment, the further reading I have undertaken has also taught me a lot. Action Plan: If the situation happened again, I would feel more confident in my knowledge of explaining to the woman and her family why we would advise her to have the antibiotics. In this particular situation, Laura knew a lot about GBS due to her previous pregnancies being tested for it and she was then subsequently treated during the labours. However, if a woman I was caring for had little knowledge of GBS, I feel I could explain it. Laura was classified as high risk due to her previous obstetric history. However, I am going to concentrate on the Group B streptococcus (GBS) she was concerned she had, after having it in both previous pregnancies. I also have a personal interest around GBS as this was something I tested positive for during my pregnancy and I did not really understand what it was or the complications of it. I was screened routinely as I was living in Spain at the time. Laura was only aware of her GBS, in her previous pregnancies, due to routine screening in Germany. She had not been screened here in the UK for GBS in this pregnancy, due to the uncertainty of clinical evidence and cost effectiveness of the routine screening (NICE, 2003). As mentioned in my reflection, this was something Laura was concerned about and requested she receive antibiotics during her labour as a precaution. Group B streptococcus is a common type of streptococcus bacterium. Approximately a third of men and women are carriers of GBS in their intestines and a quarter of women carry it in their vagina. Most people are unaware they are carriers as it can be difficult to detect and does not cause any symptoms. Carrying it is perfectly normal as it is one of many different bacterias that live within our bodies. Problems can arise when GBS is transmitted to the fetus. This could happen if the membranes rupture, during labour or the delivery. The fetus could come into contact with GBS if the bacterium travels upwards from the womans vagina and into the uterus due to the membranes not being there to protect the fetus. If there are prolonged rupture of membranes there is increased risk of transmission due to more time for the micro-organisms to be transported from the vagina into the cervix, and then to the uterus. According to the Group B Strep Association there is also evidence that GBS may cross intact membranes to expose the fetus whilst it is still in the womb. This could therefore cause preterm births, stillbirths or miscarriages. The fetus could also be exposed while passing through the birth canal. A preterm infant would be more susceptible as their lesser-developed bodies and immune systems are more vulnerable to GBS infection than older infants. The fetus could become infected if they swallow or inhale the bacteria (GBSA, 2011). If the fetus acquires GBS in utero this is known as early onset (Chapman, 2003). GBS can also be found on the hands and in the respiratory tract of a colonised person. So once a baby is born, GBS could be passed on to it from the hands. This is why, especially within the first 3 months of a babys life, it is so important for anyone who comes into contact with a baby, washes and dries their hands thoroughly. If the baby was to develop the disease from repeated exposure, this is called late onset (Chapman, 2003). In Lauras case, we were concerned about in utero transmission which could cause early onset GBS disease. This gave us the option for the administration of prophylactic antibiotics during labour, and at least two hours before delivery, which has been shown to reduce the frequency of neonatal GBS infection (Local Trust Guideline, 2009). Antibiotics given during labour can be very effective at preventing this transmission. A guideline written by The Royal College of Obstetricians and Gynaecologists (RCOG, 2003) state a woman should be offered intrapartum antibiotic prophylaxis if they have the following risk factors: à ¢-  previous baby affected by GBS à ¢-  GBS bacteriuria detected during the current pregnancy à ¢-  preterm labour (less than 37 completed weeks of pregnancy) à ¢-  prolonged rupture of the membranes (more than 18 hours before delivery) à ¢-  fever in labour (a temperature of more than 37.8 °C) Although Laura only had one of the above risk factors, she was offered the antibiotics at the discretion of the consultant. Women must also be reminded of the risks with taking antibiotics and be given all the information so they can make an informed choice. The antibiotics a woman receives will also depend if she has any allergies to medication. The recommended antibiotic for those allergic to penicillin is clindamycin, 900mg administered intravenously, from onset of labour and every 8 hours until delivery (GBSS, 2007, Local Trust Guideline, 2005). During my placement on the Neonatal Unit, I also cared for a baby that had to be admitted for antibiotics as its mother had tested positive for GBS during her pregnancy. She was unable to receive antibiotics as the the delivery was so fast and there was not enough time. Therefore the baby was admitted to the Neonatal Unit so he could receive antibiotics. Blood cultures from the baby were obtained and he was treated with penicillin until the culture results were available. This enhanced the importance of the woman receiving the prophylactic antibiotics during labour. In any high risk situation it is vital that maternal and fetal well being is monitored. As Laura was high risk she was placed on continuous cardiotocograph (CTG) monitoring. This gave us a recording and trace of the fetal heart rate so we could indentify any deviation from the norm, in comparison with the baseline for that baby. The primary aim of the CTG is to identify a fetus that may be hypoxic so additional assessments of fetal well-being can be used (i.e. fetal blood sampling) or the fetus being delivered by an instrumental vaginal birth or caesarean section. The use of this kind of technology is justified in being able to save the life a fetus that is shown to be in distress. The CTG detects the fetal heart rate (FHR) and the uterine activity (toco) simultaneously and displays it in the form of graph. It is important to check the maternal pulse at the same time as applying the CTG, to ensure the machine is recording the fetal heart rate, and not the mothers. The modern machines we use at my Trust have a maternal pulse sensor which the mother applies to her finger, which then records the maternal pulse rate on the graph that is printed out. The continuous electronic monitoring using the CTG is vital to get a contemporaneous recording of the fetal heart rate. It will give us the baseline heart rate (usually between 110-160 beats per minute), accelerations (momentary increases in the fetal heart rate) and decelerations (momentary decreases in the fetal heart rate). Some aspects of labour will cause natural alterations in the FHR patterns. For example, the pattern will be different when the fetus is asleep or awake. External factors, like uterine contractions and maternal movement can cause the FHR to change. The FHR can also be affected by opiate based painkillers, like pethidine. Some of these changes are quite subtle and can only be detected by continuous CTG e.g. baseline variability, temporal shape of decelerations. To be a competent midwife, it is imperative I have knowledge on how to interpret the recorded traces of a CTG. I have seen many CTG traces whilst on my hospital placement due to the high number of high risk women my Trust cares for. However, I still feel I am learning new things every time I see one, as everyone is different. I can distinguish between baseline tachycardia (where the fetal heart rate baseline rises above 160 beats per minute) and baseline bradycardia (the opposite, where the fetal heart rate baseline goes below 110 beats per minute) (Mukherjee, 2007). Baseline tachycardia could be physiological if the trace is from a preterm fetus due to immaturity or secondary to maternal pyrexia or dehydration. It could also be a sign of fetal hypoxia. The fetus would try to increase the cardiac output mainly by increasing the heart rate to supply vital organs with oxygen and nutrients. Baseline bradycardia could be physiological if the trace is from a post-term fetus or possibly a large fetus, provided there are also accelerations present and there baseline variability is above the normal range (>5 beats per minute). If it is just baseline bradycardia with no other normal or reassuring factors, this would need immediate action. Another form of technology used within Lauras pregnancy was screening. When she was initially booked for her antenatal care, her blood and urine would have be sent for screening, after she consented to this. She would also have attended ultrasound scans which are also a form of screening. This is something that is offered to all pregnant women and regardless of their risk status, it is used in both low and high risk pregnancies. It is a process which has been developed, which was not done previously due to lack of knowledge and technology. The standard screening during the antenatal period is urine; to check for any sign of infection, and blood; to check the womans blood group, her rhesus status, her iron levels, if she is immune to rubella, and to check for hepatitis B, syphilis and HIV (NHS Choices, 2011). In line with the National Institute for Clinical Excellence (2003) pregnant women should be offered evidence based information and support to enable them to make informed decisions regarding their care. This means women should be informed of all screening tests available to them. I believe this should include information about screening which is not necessarily available within the NHS but could be carried out privately, for example, GBS screening. There are arguments for and against introducing routine screening for GBS in the UK. Plumb, Holwell and Clayton (2007) argue that in the UK, GBS prevention is inadequate. They believe the NHS should offer testing for GBS in late pregnancy, thus giving women the opportunity to establish whether their baby is at higher risk of developing the GBS infection. My current Trust guideline (2005) state there is not enough evidence for it at this time. GBS awareness campaigners, Group B Strep Support, are pushing for routine testing to be introduced in the UK (Prince, 2011). According to GBSS, Western countries that routinely test, have a lower incidence of infection in new born babies, where as cases in the UK are on the rise. Even since the introduction of the Royal College of Obstetrics and Gynaecologists guideline for preventing GBS infection in newborns, in 2003, there has not been a decrease in either the number or the incidence of GBS infections in babies (GBSS, 2007). The table below shows the how the GBS infection in babies has increased throughout England, Wales and Northern Ireland. Year report published Number All cases (babies 0-90 days old Incidence per 1000 live births Number Early onset (babies 0-6 days old) Incidence per 1000 live births Number Late onset (babies 7-90 days old) Incidence per 1000 live births Number 2003/3004 311 0.48 207 0.32 104 0.16 0.48 2006/2007 409 0.61 248 0.37 161 0.24 0.61 2007/2008 421 0.61 258 0.37 163 0.24 0.61 2008/2009 470 0.66 279 0.39 191 0.27 0.66 (data published by the Health Protection Agency taken from www.gbss.org.uk/filepool/GBS_Infections_on_the_Increase.doc) Table 1 Number and rate (per 1000 live births) of group B streptococcal bacteraemia reports in infants 0à ¢Ã¢â€š ¬Ã‚ 90 days old in England, Wales and Northern Ireland: 2003-2009. The overall number of GBS infections within adults is also reported to have increased by more than 72% from 2001 to 2008: (data published by the Health Protection Agency taken from www.gbss.org.uk/filepool/GBS_Infections_on_the_Increase.doc) Table 2 Number of GBS infections in both males and females within England, Wales and Northern Ireland: 2001-2008. A better indication of the rise in GBS infections would be taken from women only, who are 35-37 weeks pregnant. I believe this would give more of an insight into pregnancy GBS infection rates. While the evidence states the increase in rates, I could not find any reasons for the increases. Some factors I believe may contribute to the rise include the lack of personal hygiene, modern living or even due to lifestyle. For example, many years ago clothing and underwear used to be boiled when washing but now people may be washing their clothes on a 40 °C wash and this may not be enough to kill all the bacteria. It may not be due to any of these factors; it may just be we have a better awareness of GBS now then what we did years ago. With the constant improvement of technology, we will also be finding out new things. Although the internet is not a form of technology we use within midwifery, it is certainly a form of technology we definitely need to be aware of. Within the last ten years or so, the internet has become increasingly popular. This means the general public can find about anything, more importantly medical information they may not have been able to access before. Therefore, we need to be aware of those women that we care for, that may have either some basic knowledge or an in-depth knowledge of a medical issue, for instance GBS. The NHS even has a website called NHS Choices (www.nhs.uk) which people can access to check symptoms and research illnesses and also pregnancy. I think this is mainly a good thing, although women may read so much into something they find online and it may make them more anxious or worried. It should not replace the direct contact with their midwife. The Nursing and Midwifery Council (NMC, 2008), state we should be delivering care based on the best available evidence. By reading the research I have found to write this assignment I am adhering to The Code by giving women evidence based advice. I may not be able to radically change my operational practice but I will definitely be more aware of what to look for and how to manage the situation. I will also ensure I am aware of those women who may have a more in-depth knowledge about GBS and understand their anxieties. From writing this assignment I have identified the risks of GBS, who the risks affect and to what degree it could affect them. I feel I would be able to recognise the signs and be aware of the treatment and management. I have acknowledged the main technology used is for the screening of GBS within the laboratory investigation systems and believe this should be carried out routinely within the UK. Final Word Count: 3,361