2023 Autumn Osteo Life

Membership renewal

Are you making the most of your membership?

Clinical Care Checklists

Family planning and pre-pregnancy checklists now available

Combating the stereotypes

Osteopathy goes mainstream as we address misconceptions

Legal matters

What steps to take when issued with a subpoena

PRESIDENT’S MESSAGE

Welcome to the autumn Osteo Life magazine

I write this president’s message with slight brain fog from sleep deprivation as my partner and I welcomed our son Gus on 2 February this year. In that same week, our daughter Stevie started her first year of school. Needless to say, it’s been an action-packed start to 2023 juggling readers, sleep schedules, lunch boxes and feeding! A big thank you to our Vice President Matt Cooper who stepped in for me over the month of February.

In early March, we held our Board Strategy Meeting in Melbourne. This meeting is where we align our financial year projects with our strategic plan. It’s imperative that this meeting offers up clear actions for the Board and Osteopathy Australia to deliver to make progress in our strategic plan.

The Board spent its strategic energy working on projects to help support our early career osteopaths and our business owners to navigate some of the issues that we face in private practice. This session was facilitated based on feedback from focus groups that were held in early 2023 with both our Early Career Advisory Group and a range of osteopathic business owners who highlighted some of the challenges.

Osteopathy Australia

T (02) 9410 0099 E info@osteopathy.org.au

W www.osteopathy.org.au

osteopathyaustralia osteoaust osteopathyaustralia osteopathyau

OSTEO LIFE is the quarterly magazine for Osteopathy Australia members. For enquiries, feedback, or to contribute, contact Communications on 02 9410 0099 or comms@osteopathy.org.au. For advertising enquires, email info@osteopathy.org.au.

Editorial and Education Advisory Group

Toby Barker, Casey Beaumont, Amy Lawton, Melissa McDougall, Adam Nicholson, Jade Scott, Sally Tran, Heath Williams

Chief Executive Antony Nicholas

Editor Rebekka Thompson-Jones

Sub Editor Adam Scroggy Designer Stephanie Goh

Advertising info@osteopathy.org.au

Printed by Megacolour OSTEO

We are excited to deliver projects to help the profession, regardless of being a new or longer-term associate or a principle over the next financial year. Stay tuned to see some exciting advancements with buddy systems, group mentoring for early career osteopaths and a range of resources for associates and business owners to support them as they help transition early career osteopaths from university into private practice.

Osteopathy Australia has been engaged in a rebranding exercise that you may have read about over the past two years. This project is culminating in Osteopathic Awareness month in April where our members will have access to a marketing campaign that helps consumers understand what osteopathy is. This campaign’s goal is to reach those Australians with no knowledge of osteopathy to consider osteopathic treatment for their pain. We encourage you to look at this campaign through the lens of someone with zero experience or knowledge of osteopathy.

The Board is excited this year to deliver our first roadshows post-COVID. We

encourage our members to come to these roadshows to discuss any issues that they want and to also talk about certain topics within our strategic plan. This is our first opportunity to see you in a face-toface environment since COVID, and we would love for you all to come along and support these events in each state.

Wishing you all a happy Osteopathic Awareness month in April. We are really looking forward to seeing the impact of our new marketing campaign not only during this month but the strategy to be rolled out over the next 12-months and onwards to make sure that osteopathy is at the forefront of Australians thoughts when it comes to musculoskeletal health.

Michelle Funder, President Osteopathy Australia mfunder.director@osteopathy.org.au

Osteopathy Australia acknowledges the Traditional Custodians and Elders of Country throughout Australia, and their connection to land, sea and community. We pay our respects to Aboriginal and Torres Strait Islander Elders, past, present and emerging.

Practice Management

34 A guide for members on employment practices

36 What is a subpoena and what steps should I take if I receive one?

Advertorials

17

22

27

37 How to grow your business through your professional recommendations

38 Five tips for securing your digital patient records

Osteopathy

Australia does not accept responsibility for any loss, damage, cost or expense incurred by reason of any person using or relying on the information contained in this magazine. The opinions expressed are those of the author and not Osteopathy Australia. All advertisements in this issue are paid advertisements. By registering with any company or affiliation mentioned in advertisements you will be sharing your personal information with the advertiser – please check their privacy policy. Osteopathy Australia takes no responsibility for the way personal information is used.

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Osteopathy Australia news

Combating the osteopath stereotypes

The following article featuring Dr Brett Wiener appeared in TheAge on 23 February 2023

Stereotypes and misconceptions abound about all professions, but when you dig a little deeper you find they’re usually way off the mark.

Are they unqualified quacks waving their hands over you in a woo-woo kind of way? Practitioners of some borderline witchcraft on the very fringes of science-denying alternative healing?

For Australia’s osteopaths, they’ve had their fair share of misinterpretations over the years. “There have been a lot of conclusions drawn based on a few bad eggs and therefore, the profession as a whole has been put into this basket,” says Osteopathy Australia board member Dr Brett Wiener of the idea that osteopaths are not “real” healthcare professionals.

Osteopathy Australia is the national peak body in Australia representing osteopaths, consumers of osteopathy and promoting osteopaths’ role in allied primary healthcare.

Whether you’ve fallen for the misconceptions, or simply don’t quite understand what an osteopath actually does, Wiener says the first thing people need to know is that osteopaths are highly trained, registered and regulated.

“We are university educated, we have in-depth medical knowledge and are exceptionally well-trained across different modalities of healthcare. We always follow best evidence and best practice,” he explains.

If you’re wondering what they do, broadly speaking, osteopathy helps reduce pain and discomfort.

“We listen and take time for a thorough diagnosis. Our point of difference is that we provide effective hands-on techniques and have a whole-person approach,” says Wiener, who also has his own healthcare business in bayside Melbourne, The Sports and Spinal Group.

Most other health professions are sort of rushing people in and out the door, they’re under an extreme amount of time pressure, and they don’t take the opportunity to listen and learn about the whole person,” he says.

It’s why they find that once patients “step into a space with a trusted, well-educated practitioner” rapport builds quickly and patients become very loyal.

Osteopaths focus largely on musculoskeletal conditions, so deal with issues such as chronic lower back pain,

osteopaths can massage, mobilise and manipulate joints, plus offer therapeutic needling techniques, such as dry needling or trigger point therapy, clinical Pilates or exercise rehabilitation in a gym setting.

Wiener points out that their training also covers pharmacology, cardiovascular and respiratory health, and psychology, which means they can provide “emotional and psychological support, not just musculoskeletal support” to their patients, which can be especially useful to those in chronic pain.

Whether you’re a newborn or a 90-year-old, osteopaths can help, although depending on where you are along the lifespan will completely change the management and skill used in treatment.

“We don’t support or perform aggressive manipulative techniques to babies,” Wiener

neck pain, osteoarthritis, rheumatoid arthritis and autoimmune conditions.

“We deal with fibromyalgia and other sorts of complex, muscular and joint problems; postural concerns with ergonomics,” Wiener says, “and then the healthy individual that wants to get stronger and maintain their health.”

Similar in a lot of ways to physiotherapists and chiropractors,

assures, adding that specialty training is required to see paediatric patients. Often, he says osteopaths will be working in a team environment, collaborating with other health specialists such as paediatricians, GPs or OTs.

Whatever reason it is that brings you through their door, Wiener says osteopaths will always “draw on the best clinical evidence available to make assessments on how to best manage a patient”.

OSTEOPATHY AUSTRALIA AIMS TO SUPPORT, ENHANCE AND PROMOTE THE PROFESSION. HERE’S A QUICK RECAP OF EVERYTHING OSTEO FROM THE PAST FEW MONTHS.

“We are university educated, we have indepth medical knowledge and ... always follow best evidence and best practice.”

Notes from the Association

ANTONY NICHOLAS, CHIEF EXECUTIVE, OSTEOPATHY AUSTRALIA

Over the past several months, Osteopathy Australia’s Board and Executive have been reflecting on what makes an effective association.

As the outside world, spiralling inflation, the needs of the profession, the benefits and impact of digitalisation or innovation, plus what other efficiencies can occur. We must always look to an optimised future, and

we must stay up to date. How do we make sure our staff, our services, our partners, or other offerings meet the needs of the breadth of the profession, while accepting we cannot meet all individuals’ needs.

The world of business and associations is ever-changing, forcing us to change certain aspects of our business to remain effective, useful and relevant. A dynamic association looks to common external factors that encourage reform and internal factors which we can be more controllable. The aim is always to optimise member services.

In April, Nicholas Bradshaw, our Deputy CEO moved on after six years working with us. Nick was instrumental in helping steer Osteopathy Australia through many operational and strategic challenges for which we thank him. He is currently rewarding himself by trekking in Nepal.

Our strategic plan remains focused on four strategic pillars – supporting members, benefiting consumers, leading the profession and capacity to deliver. To better deliver on those we have changed some roles and created three new roles. Each new role is directly aligned with our strategic plan.

Many of you already know Leng Warwar. Leng’s remit now covers Membership and Operations Manager to focus on

driving strategies around membership, membership services, learning and development, IT and overall operational efficiency.

Rebekka Thompson-Jones, Communications and Marketing Manager – to transform how we promote osteopathy, raise awareness, particularly among consumers who know nothing or have never seen an osteopath, our website and internal communications with you.

Policy and Advocacy Manager – to increase our lobbying, advocacy and policy work with our current team members and stakeholders. Our advocacy work is incredibly broad, complex and often listed as a key reason why osteopaths join Osteopathy Australia – the informed voice for the profession. This role is currently being recruited. Please share this opportunity with your network.

We understand every osteopath and every business is going through challenging times economically, socially, financially and with the changing workforce dynamic. This is the same for Osteopathy Australia and yet we still focus every day on our vision of osteopathy being a central part of primary healthcare in Australia. To support our members, educate the community and be the professional voice for osteopathy.

Combating stereotypes and promoting osteopathy

Over the past year Osteopathy Australia has been focused on understanding how to engage consumers. Not consumers who already use osteopathy (as data shows they have a better understanding and trust of the profession) but the majority of Australians who know very little or have never seen an osteopath.

We are also going to run some education sessions on this over the coming months to help members understand some of our tactics but also what to avoid in their own promotions. Some of the results will be a bit confronting.

We know most new patients come from word-of-mouth; very few choose osteopathy randomly without prior knowledge, a friendly or professional referral. How do we and you then attract new patients, beyond word of mouth?

The consumer targeted sentiment research assesses what consumers

understand, what the assume, what their perspectives are and their likes or dislikes. This research focused on those who have used osteopathy and most importantly those who have not. Sadly, what it showed was some rather stark realities, particularly among consumers who don’t know much about osteopathy or have never seen an osteopath. They more frequently assumed osteopaths were unqualified, untrustworthy and, worse, potentially dangerous.

Around 30% of respondents had never heard of or if they did, didn’t know what you do. Another 38% said they knew a little but have never seen an osteopath. That is a huge proportion of the Australian public as potential customers.

From consumer sentiment and other research, we know that osteopathy appointment length is often 20-50% longer than other colleagues and was a determining factor in why people chose

osteopathy – taking the time to listen. We also understand that considering the whole person is a real positive, even if calling it holistic may not be!

The good news is, once people have seen an osteopath that can change dramatically… but we need to get them in the door first!

So, partly The Age article (page 6) is to capture interest, but also to address some of those misconceptions even if it may appear a tad brutal for osteopaths.

It’s important to remember promotion of osteopathy does not target osteopaths It’s not going to necessarily capture what is most important to you. The aim is to use the research to promote osteopathy in a way that engages new consumers, who know very little, by focusing on the things that interest them most. That way more consumers will try osteopathy for the first time.

The inaugural meeting of the past Presidents of Osteopathy Australia

by Michelle Funder

In late 2022, I arranged the inaugural meeting of the Past Presidents of Osteopathy Australia or, for those who were President pre-2014, before the association rebranded, the Australian Osteopathic Association.

The meeting was well-attended and showcased over 35 years of the rich history of Presidents. It was a great forum for old friends to catch up and new acquaintances to be made. Each former President shared a brief story of their time at Osteopathy Australia and also told us where they are now in their career.

What was evident from everyone’s stories from their time in their roles was their generosity of time, spirit and passion for osteopathy. This generosity is also reflective of all the Board members over the years too, as many of us are aware these positions are voluntary.

We walked through the history of the association over the last 35 years from two associations and state-based registration

to a national scheme of registration and a unified nationwide association, and it was clear in our short history how far both the association and profession have come. From stories of the association being one filing cabinet, one person in a garage – to now, our office in Chatswood with a CEO and team of nine, comprising roles we need to support our members and make an impact for our profession – is a testament to the leadership and strategy of the association over the years.

It is important to remember that we have made huge progress as a profession and association over this short period of time.

At the beginning of the meeting, I posed the question ‘How do we inspire the future leaders of osteopathy?’ There was great discussion around what leadership is in osteopathy, why we were all leaders, and what connected us to osteopathy.

Many of us laughed that during our school teenage years, we were all school prefects and perhaps were always

attracted to positions of leadership. What was common among the group was a passion for osteopathic practice, the history and principles of osteopathy, and the advancement of osteopathy within Australian healthcare. These were the underpinning reasons that people had put their hand up to lead the profession.

So how do we inspire future generations? It’s all about education. Through the right communication channels, we need to educate future osteopaths of the importance of advocacy for osteopathy within the Australian healthcare system.

This was our first meeting of past Presidents, and we are hoping that this becomes a regular occurrence each year. My greatest takeaway from our session was to offer thanks to all the hard work of Presidents and Board members before my time – they have done an incredible job of shaping the association and profession to where it is today. Thank you!

Professional opportunities for students

Work-Integrated Learning (WIL) is a cornerstone of the RMIT Osteopathy program, giving our students industry-relevant education and training, and an opportunity to develop their professional network and career opportunities.

Students benefit greatly from these placements because they gain authentic, practical experience and the clinical skills they need to thrive as they begin their careers as osteopaths.

But there is a lot to be gained for our industry partners as well!

• Share your expertise – hosting a student for clinical placements is a great way to share your industry expertise with the next generation of osteopaths. Our students benefit greatly for having exposure to clinical populations that do not present to the student clinic.

• Develop your leadership and mentoring skills – with the launch of the new Osteopathy Australia Clinical Supervision Modules, there are new opportunities to develop your mentoring skills and become a leader in industry placed clinical education.

• Reduced price consultations – your patients can benefit from the reduced prices offered for appointments with student interns, and you can offer free follow up calls to provide added benefit to your patients.

• Find your next associate and grow your business –many interns go on to join the clinics that hosted them for their clinical placements! This is especially useful if your practice is regional/remote or interstate to the teaching universities.

For more details, please contact: Damian Tyson | Industry Engagement Coordinator | STEM College +61 3 9925 6499 | damian.tyson@rmit.edu.au | Building 91, Level 2 | STEM Hub CRICOS provider code: 00122A

Understanding Chronic Pain Management

The benefits of saffron and PEA and their influence on the endocannabinoid system

Chronic pain is on the rise and sufferers are more likely to experience psychological concerns such as depression, anxiety and sleep disturbances. PEA and saffron have the unique ability to influence the endocannabinoid system and in turn, manage chronic pain and its associated symptoms.

Chronic pain is persistent pain lasting more than 3-6 months. Over the past 10 years, general practitioners have seen a 67% rise in patients experiencing chronic pain.1

Chronic pain is complex and it is often reported that chronic pain sufferers concurrently experience psychological distress and symptoms such as poor mood and sleep.1 The body is equipped with a variety of mechanisms and systems to alleviate and resolve pain, including the endocannabinoid system. Compounds, such as palmitoylethanolamide (PEA) and Crocus sativus (saffron), have the unique ability to influence the endocannabinoid system and in turn, manage chronic pain and its associated symptoms. The endocannabinoid system is involved in the modulation of pain and inflammation.

Cannabinoid 1 (CB1) receptors are located within the brain and central nervous system whilst cannabinoid 2 (CB2) receptors are found primarily in peripheral tissue and cells of the immune system.5 Endocannabinoids are produced endogenously or can be supplied exogenously to manage pain. Whilst PEA is not a cannabinoid itself, it is a naturally occurring endogenous fatty acid that is produced in response to inflammation or injury. In conditions such as chronic pain, it has been noted levels have been altered, highlighting the benefit of PEA supplementation.3

PEA works through:

• Enhancing tissue levels of anandamide, a cannabinoid that acts upon CB1 and CB2 receptors, providing analgesic properties.6

• An affinity to PPAR-α receptors, which reduces inflammation and the secretion of pro-inflammatory signalling molecules.6

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• An affinity to receptors GPR55 and acts to desensitise TRPV1 which is involved in the sensation of pain and heat.7

• Inhibition of mast cell degranulation and subsequent histamine release whilst controlling glial cell behaviours.3

Ultimately, PEA provides analgesic, anti-inflammatory and neuroprotective benefits Due to its fatty nature, PEA has poor absorption. Levagen+ is considered a superior form of PEA which utilises LipiSperse® technology to increase bioavailability.6

Saffron is a notable adjunct therapy to PEA as chronic pain sufferers are more likely to experience psychological concerns such as depression, anxiety and sleep disturbances.1 Saffron has been shown to provide anti-inflammatory, antinociceptive, immunomodulatory, analgesic, antidepressant and anxiolytic effects.8

Saffron works through the following mechanisms:

• Attenuates pro-inflammatory mediators such as TNF-α and IL-6.8

• Reduces eosinophils, neutrophils and lymphocytes, leading to a down-regulation of leukotrienes, prostaglandins, cytokines, ROS and NO.8,9

Partial agonism and selective desensitisation of the TRPA1 channel.10

• Antioxidant activity reduces oxidative damage by attenuating endogenous ROS.11

• Reuptake inhibitor of dopamine, serotonin, and norepinephrine.11

For optimal patient results, choose a standardised form of Saffron such as affron®. affron® is standardised by HPLC (high performance liquid chromatography) to Lepticrosalides® and has been shown to support mood, relaxation and sleep,12 critical for chronic pain sufferers.

REFERENCES UPON REQUEST.

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OSTEOPATHY AUSTRALIA

MAKE THE MOST OF YOUR MEMBERSHIP

ADVOCACY AND POLITICAL LOBBYING

Osteopathy Australia works hard to gain professional rights and recognition for osteopaths in Australia through advocacy and political lobbying.

PROFESSIONAL ADVICE, INFORMATION AND GUIDANCE

The 1800 467 836 number provides phone guidance and information to our members. We also communicate with hundreds of potential patients every week across Australia.

CPD

OPPORTUNITIES

We promote osteopathy in the media, social media and throughout the community to generate positive publicity and raise the public’s awareness and understanding of the profession.

CLINICAL PRACTICE GROUPS

Participate in a variety of Clinical Practice Groups to develop Quality Practice Frameworks and standards of clinical excellence to measure and increase clinical reasoning skillsets, competencies, knowledge and skills.

HR SERVICE

The 1300 143 602 hotline is a dedicated service for you, whether an associate, employee or business owner, to seek direct advice. A comprehensive online library of technical resources is available exclusively for members; including manuals, policies and template contracts and letters.

FIND AN OSTEO

Your clinic details are listed in our popular online directory so that potential patients can find and contact you directly. Your details are also included in the annual member directory.

OSTEO

LIFE

An exclusive quarterly publication that covers the latest news, trends, policies and events for industry professionals. The magazine is available only to Osteopathy Australia members.

Members can enjoy free webinars and access to ClinicalKey, plus discounted registration to the National Conference, courses and seminars. Books and DVDs are also available to hire.

GUILD PROFESSIONAL INDEMNITY INSURANCE

Take advantage of enhanced professional indemnity insurance at a reduced rate. The enhanced policies include the added benefit of legal advice, public liability and “run o ” cover.

MEMBER ADVANTAGE PROGRAM

You and your family can save all year round with discounts on a range of lifestyle, leisure and financial services. Enjoy o ers from Coles, Woolworths, David Jones, BMW, Caltex, Secure Parking, Red Balloon, SpecSavers, JB Hi-Fi, hotels worldwide and various insurance providers.

PARTNERSHIPS

Save hundreds on our member exclusive partnerships that cover a range of courses and products essential to your clinical and professional needs.

ADVERTISING

Take advantage of free or discounted advertising options among our wide network. Be featured or browse opportunities on our classifieds web page, Osteo Life publication or regular eFlyers that are distributed among thousands of contacts.

Clinical Care Checklists

As an osteopath, you are likely to treat a wide range of patients including those who are embarking on their pregnancy journey, those who are currently pregnant or who are in the post-natal period. As such it is essential to be aware of the complexities, concerns and potential difficulties that come with treating these unique patients for the best health outcomes.

To assist in this the Women’s Health clinical interest group have produced six clinical care checklists as practical resources that outline some of the major red and yellow flags and concerns that need to be central considerations when treating patients who are planning pregnancy, are pregnant or in the postnatal period.

Each checklist covers a range of biopsychosocial considerations, details on thorough history taking and referral pathways to assist osteopaths who have had limited experience with this sub-population. They highlight that these patients should not be treated in isolation to their pregnancy experience and that a practitioner should

understand their own limitations and personal scope of practice when treating these patients.

The checklists have been designed to be used as practical educational and training tool, not only demonstrating major areas of concern but also highlighting areas where additional training and education could be undertaken or when external referral should be taken.

In this article we will be featuring the first four that cover the family planning and pre-pregnancy stage and a separate list for each respective trimesters of pregnancy. The post-natal period and general pelvic health will be covered in our next issue.

Each checklist and additional resources will be available for viewing and download on the Osteopathy Australia website under the article - Identifying Red and Yellow flags in pre-pregnancy, pregnancy, the post-natal period and general pelvic health – Clinical Care Checklists as well as a CPD webinar from the checklist creators providing more in-depth descriptions and clinical case studies from their experience.

Many thanks to the following contributors for their help with the checklists: Briony Chase, Lorrae Griffiths, Melissa Arnts, Rebecca Lovett, Daniela Aiello and Elizabeth Johns.

Family Planning Pre-Pregnancy

Occupation and nature of working activities

Understanding work environment and task they perform. If there is high risk of injury or exposure to chemicals (some pesticides, paints and paint thinners or teratogens or can affect fertility) as can radiation

• Will pregnancy impact their ability to work (is their job labour intensive)

• Understanding financial situation and maternity leave implications

Reduce exposure to teratogens and related chemicals.

Refer to social worker or welfare counsellor for work and financial planning assistance

Exercise and nature of exercise undertaken

Is the patient physically active. It is necessary to understand their fitness level, health of cardiovascular system and the types of exercise they are doing

Would pregnancy impact or limit hobbies and interests (for example high impact sports and scuba diving)

Does the patient have any plans to stay active during pregnancy

Has the patient had rehabilitation between pregnancies. If so, what type of rehab and for how long

Refer a pelvic health trained/rehabilitative osteo/ exercise physiologist

Lifestyle activities

Smoking – can decrease fertility by up to 50% 1 Education regarding risks of foetal and maternal effects of smoking while pregnant. Referral to appropriate quitting strategies and encourage support from partner/family

Health history

Overweight/obesity: Almost half of all Australian women of reproductive age are overweight or obese. These women have an increased risk of sub fertility or infertility. They are also at increased risk of developing serious health problems whilst pregnant 2

• Some pre-existing medical conditions can affect fertility, not just those of the reproductive system. The majority of these conditions are immune or auto immune

• Vaccination history: patients considering pregnancy should ensure they have had Hep B, varicella (chicken pox) and MMR vaccines. Patients who have received live vaccines should avoid falling pregnant for 28 days

If weight/obesity is affecting a patient’s fertility, it is important to have a team based, supportive approach. This should include nutritional advice, exercise programs and counselling

GP for appropriate screening of pre-existing medical conditions, vaccination status review and blood test

High blood pressure, pulse or body temperature prior to pregnancy should trigger referral to a GP and/or cardiologist prior to conception

• Be sure to take baseline vitals: BP, pulse, RR and temp

General assessment domains for questioning

Mental health history

Concerns/flags to be attentive to and why important

• History of mental health conditions increases the risk of antenatal/postnatal depression (especially major depressive disorder) and post-partum psychosis (especially bipolar)

• Some medications used to treat mental health conditions are also teratogens that can impact pregnancy prospects

Referral pathway options AND/OR management strategies

• Complete Edinburgh depression scale

• Referral to Perinatal Anxiety and Depression Australia for information panda.org.au

Referral to GP, for mental health plan if necessary to see a psychologist

• Ensure patient understands not to cease any medication use without GP or specialist consultation

Medication/ pre-natal supplements

• Teratogens (compounds which lead to malformations of an embryo)

Some prescription medications are teratogens. Medications in the following categories can affect foetal development:

Anti-convulsant - Blood thinners

Anti-biotics

Anticancer drugs

ACE inhibitors

SSRIs

Tranquilizers - Hormone therapies

Aminopterin - Isotretinoin

Thalidomide - NSAIDs

Lack of folic acid, vitamin D, iodine or iron can impact the conception experience, particularly for patients with a history of spine-bifida and neural tube defects. Risk of reflux and hyperemesis can exist without appropriate pre-natal vitamins

• Consult their GP or specialist

• Consult the Royal Hospital for Women with questions regarding prescription medications and pregnancy and breastfeeding:

http://www.seslhd.health.nsw.gov.au/royalhospital-for-women/services-clinics/directory/ mothersafe

• A document listing the current Australian guidelines for vitamin supplementation for pregnant patients can be found here:

https://www.hps.com.au/wp-content/ uploads/2019/04/Vitamin-and-mineralsupplementation-in-pregnancy-C-Obs-25Review-Nov-2014-Amended-May-2015.pdf

• Prescribing medicines in pregnancy database: https://www.tga.gov.au/products/medicines/ find-information-about-medicine/prescribingmedicines-pregnancy-database

• If women have further questions regarding supplementation, they should consult their GP or dietitian

Nutrition/diet and digestion

• Patients with inflammatory bowel disease should avoid conceiving during active flare ups as their condition can often remain active throughout the pregnancy, increasing risk of miscarriage, premature delivery and low birth weight 3

Patients who plan on becoming pregnant should eat a well-balanced diet, high in vitamins, and continue any supplements they may have been taking prior to conception

• Dietitian referral

• GP referral

• Education on risks of alcohol on foetal development. If the patient has signs of alcoholism, they should be referred for counselling support

• Alcohol consumption- can affect foetal neurological development and increase risk of foetal alcohol spectrum disorder4

Caffeine consumption- limited to 200mg when pregnant 5

• Encourage reduced caffeine consumption in preparation for pregnancy Other

Understanding

Referral

1 Practice Committee of the American Society for Reproductive Medicine, 2008, Smoking and infertility. Fertility and sterility, 90(5), S254-S259

2 Boyle JA, Dodd J, Gordon A, Jack BW, Skouteris H, 2022, Policies and healthcare to support preconception planning and weight management: optimising long-term health for women and children, Public Health Res Pract, 32(3):3232227. doi: 10.17061/phrp3232227. PMID: 36220563

3 Hashash JG, Kane S, 2015, Pregnancy and Inflammatory Bowel Disease, Gastroenterol Hepatol (N Y), (2):96-102. PMID: 27099578; PMCID: PMC4836574

4 Wilhoit LF, Scott DA, Simecka BA, 2017, Foetal Alcohol Spectrum Disorders: Characteristics, Complications, and Treatment. Community Mental Health J, 53(6):711-8

5 Australian guidelines, Healthdirect, https://www.healthdirect.gov.au/caffeine

Clinical issue to explore (biological)

Accesses obstetric/ medical checks advised in the pre pregnancy phase

Period pain

Educate on the availability of pre-genetic screening for issues that could impact conception particularly if there is a known history of adverse pregnancy outcomes such as repeated miscarriage or known familial genetic conditions

• If a patient reports significant pain either during menstruation or ovulation, they may have an underlying medical condition. Reproductive conditions often go undiagnosed or are not found until a patient tries to become pregnant for the first time

Referral to GP for onward referral to specific specialists as required including genetic counsellor

• Refer to GP for pelvic ultrasound and gynaecologist

Gynaecological health generally, including menstrual cycle

• No gynaecological history can leave flags undetected. Full gynaecological screening includes:

- Menarche

- Menstrual cycle duration

- History of changes to cycle (absence, change in duration, increased menstrual pain)

- Blood flow

- Associated symptoms (any bowel or bladder changes that are cyclic)

- Contraceptive history (some hormone-based contraceptives can affect fertility for several months post cessation)

- Previous pregnancies (and their outcomes)

- Previous sexually transmitted diseases

- Pain (with menstruation, non-menstrual cyclic pain, intercourse, bowel motions and urination)

• Referral to GP for onward referral to gynaecologist

Clinical issue to explore (biological)

Childbearing history (caesareans, tears, episiotomies, number of children, miscarriages, and method of conception)

Concerns/flags to be attentive to and why important Referral pathway options AND/OR management strategies

• Understanding a patient’s obstetric history can influence their desires, beliefs and attitudes towards further pregnancies. This area should be discussed with a level of sensitivity and openness

• When taking a birth history, be sure to take the history in chronological order (especially in cases with multiple children) to avoid confusion and missed info

• Apply the GTPAL principle:

- G= gravidity,

- T= term pregnancies,

- P= preterm deliveries,

- A= abortions or miscarriages,

- L= live births

• Pregnancy: previous incompetent cervix

• Births: term of pregnancy, Braxton Hicks, length of labour, length of active labour, interventions, positioning, medications, tears, health of baby at delivery

• Dyspareunia is common after third and fourth degree tearing and therefore may impact method of conception for subsequent pregnancies

• Referral to GP for onward referral to specific specialists as required

Breast feeding patterns/issues (previous pregnancies if relevant)

• Breastfeeding exclusively for the first six months can result in amenorrhoea, but the patient should consult personalised contraceptive advice from their GP

Breastfeeding is very variable and different for each mother

• Issues with breastfeeding with previous children, can impact a patient’s choice to breastfeed with new pregnancies

Patients with pre-existing medical conditions that require prescription medications should also consider if this medication can impact breastfeeding

• It is important to be aware that a patient can still be breastfeeding and conceive

• Referral to Lactation consultant

Pelvic floor integrity, pain, or cramping

• Leaking/incontinence (stress/urge or mixed), prolapse (heaviness or dragging)

History of kidney, bladder and/or urinary conditions

Dyspareunia (pain with intercourse), arousal and/ or penetration

• Referral to pelvic floor health practitioner (osteopath or physiotherapist)

• Referral to urologist

Abdominal pain and abdominal surgical history

Intended method of conception and length of time attempts made

Adhesion formation impacting fertility

If they have had surgery: what was it for, when was it performed, was it successful, were there any complications, does it require regular monitoring

• Consider the patient’s relationship status and sex of their partner (if they have one)

• Are they planning on conceiving naturally or with IUI or IVF

If the patient has been trying to naturally conceive, how long have they been trying for. If they are under 35 and have been trying for one year, consider referral to assess fertility. If they are over 35 and been trying for six to 12 months, they should have their fertility assessed

Referral to GP for onward referral to specialists as required

• Fertility testing (male partners should also be tested). Referral to GP for onward referral as required

Clinical issue to screen (psychosocial)

Stress levels

Trauma

Concerns/flags to be attentive to and why important Referral pathway options AND/OR management

strategies

Social support, partnership status and living situation

• Patients with high day to day stress levels can take up to 30% longer to conceive 6

The pelvis is a very sensitive and personal area, especially around the topic of trauma. Pelvic trauma can include, crush and musculoskeletal injuries, surgical trauma, episiotomy, tearing from previous births and sexual abuse

Patients may be uncomfortable discussing these topics, as well as uncomfortable being touched around the pelvis: full informed consent should be given prior to placing your hands on any patient

• If discussion of this area is clearly quite uncomfortable for the patient, do not force it. Explain to them why you are asking these questions and let them share as much as they want. Developing rapport is vital in these situations

Patients with history of significant pelvic physical trauma should be referred for imaging and fertility discussed

Understanding a patient’s biopsychosocial situation will help get an understanding of how to approach the topic of pregnancy. Is the patient single or in a partnership, if they are in a partnership, is their partner male or female. Knowing this will guide discussion to appropriate conception options

• Also understanding who the patient lives withalone, with parents, roommates or other family. It is important to understand who is in the patient’s life and will help them through their pregnancy

• Understanding living situations can also be a factor: do they have a permanent place of residence and is that residence safe for the patient and her soon to come child

• Psychologist referral

• Mindfulness and meditation exercises

Sexual abuse: police, mental health professional

Referral to psychologist or mental health professional

• Referral to GP for onward referral to obstetrician/ gynaecologist

Referral to psychologist, welfare worker or social worker

Psych/counselling

Police

Family violence organisations (safe steps 1800015188 – VIC)

• 1800 RESPECT - National

The Orange Door

https://www.orangedoor.vic.gov.au

6 Lynch CD, Sundaram R, Maisog JM, 2044. Sweeney AM, Buck Louis GM, Preconception stress increases the risk of infertility: results from a couple-based prospective cohort study-the LIFE study, Hum Reprod, 29(5):1067-75. doi: 10.1093/humrep/deu032, PMID: 24664130; PMCID: PMC3984126

Pregnancy: 0-12 Weeks

Discussion with the patient on how pregnancy may affect their ability to complete workplace duties

• Seek consent to follow up with employer/workplace on these concerns

• Understand and relay strategies other employees have implemented

Include discussion with their primary care provider (Midwife/GP/obstetrician) Exercise

Understand current and planned level of activity

Question type, frequency and duration of exercise

• Consider patients level of understanding of benefits of physical activity

Lack of physical activity overall is a yellow flag

Education/communicate current guidelines on physical activity including:

- Pelvic floor exercise

- Muscle strengthening twice a week

- Cardio

- Intensity of moderate (three to seven intensity out of 10), or talk test at a minimum of 150 minutes per week over the course of the week

- Breaking up prolonged sitting

- Exercise should include usual pre-pregnancy preferences and activities unless they are contact sports

- Exercise with light weights and resistance bands recommended

- Heavy lifting, intense repetitive isometric exercises are not recommended as there is some evidence of poor foetal and maternal health outcomes

- Screening of patients should be performed on those with risk factor. Otherwise, healthy patients who have exercised pre-pregnancy should not be required to have clearance from a health professional provided they have no contraindications and remain asymptomatic.

- Patients who exercise at higher intensities or prolonged duration should consult a health professional who is aware of the effects on maternal and foetal well-being. It is expected that exercise be modified throughout the course of the pregnancy

• Complete risk form assessment for contraindications (e.g., PAR-MED)

• Education on risks of trauma of certain exercise/sports

• Make aware of symptoms/flags to be aware of when exercising

Educate about safety of supine exercise- there is no conclusive evidence about this and the risk to study this is too high

Education on lifestyle activities which may need to be altered/adjusted/ceased based on this stage of pregnancy

•

Health history

• Vital signs examination to be used as a baseline

Being aware of any flare up in chronic preexisting medical conditions (thyroid, diabetes, BP, asthma, lupus, clotting/bleeding diseases, kidney and bladder diseases)

• Medication use

• Direct to Quitline 13 QUIT (13 7848)

• Avoid handling cat faecal matter – risk of toxoplasmosis (may cause miscarriage)

• Refer patient to see GP in regards to early pregnancy screening, vaccination history and current medication use

Referral to other specialists in conjunction with GP/ obstetrician

General assessment domains for questioning

Mental health

Concerns/flags to be attentive to and why important

• History of mental health conditions increases the risk of antenatal/postnatal depression (especially major depressive disorder) and postpartum psychosis (especially bipolar) Some medications used to treat mental health conditions are also teratogens that can impact pregnancy prospects

Referral pathway options AND/OR management strategies

• Complete Edinburgh depression scale

Referral to GP, for mental health plan if necessary to see a psychologist

Ensure patient understands not to cease any medication use without GP or specialist consultation.

Referral to Perinatal Anxiety and Depression Australia (PANDA) for information panda.org.au

Medication/ Supplements

Supplement discussion:

- Folate

- Iodine

- Vitamin D

- Iron

• Teratogens (compounds which lead to malformations of an embryo)

Some prescription medications are teratogens. Medications in the following categories can affect foetal development:

- Anti-convulsant

- Blood thinners

- Anti-biotics

- Anticancer drugs

- ACE inhibitors

SSRIs

- Tranquilizers

- Hormone therapies

Aminopterin

- Isotretinoin

- Thalidomide - NSAIDs.

Inform on risks of neural tube defects

Discuss implication of the ‘type’ of folate used e.g., folic acid vs folate

Ensure iron levels are tested in early pregnancy and the patient is aware of increasing needs for iron as the pregnancy progresses

Referral for further education on supplementation with pharmacist/care provider

• Consult the Royal Hospital for Women with questions regarding prescription medications and pregnancy and breastfeeding

• http://www.seslhd.health.nsw.gov.au/royal-hospital-forwomen/services-clinics/directory/mothersafe

A document listing the current Australian guidelines for vitamin supplementation for pregnant patients can be found here

https://www.hps.com.au/wp-content/uploads/2019/04/ Vitamin-and-mineral-supplementation-in-pregnancy-CObs-25-Review-Nov-2014-Amended-May-2015.pdf

Prescribing medicines in pregnancy database

https://www.tga.gov.au/products/medicines/findinformation-about-medicine/prescribing-medicinespregnancy-database

Mode of care for pregnancy and birth

• Outcomes for patients from model chosen

• Midwifery led team where you know your midwife

Pool midwifery

• Private midwife

Shared care with GP and midwife

Obstetrician

• Location:

- Public hospital

- Private hospital

- Home birth

Nutrition/diet Alcohol consumption

• Intake of caffeine

Awareness of food and hygiene risks

Awareness of foods to avoid when pregnant

Provide details of information sources the patient can access.

• Highlight risks of smoking and alcohol consumption and referral for counselling with care provider if required

Update patient on caffeine recommendations in pregnancy (200mg of caffeine from all sources)

Alleviate any fears/concerns the patient may be having with foods they may have already consumed when pregnant.

Educate on avoiding foods that may carry a risk for salmonella, listeria

• Referral to dietician as appropriate

Other health professionals seen/model of care

A coordinated team care approach in pregnancy is vital for important clinical assessments of benefit to the patient and developing child to occur

Help the patient identify who can be a part of their healthcare team and which other professionals may be of assistance to them. A range of professionals is specified in this overall table.

Clinical issue to screen (biological) for in questioning before 12 weeks gestation

Accesses obstetric/ medical checks advised in the pregnancy phase, including early ultrasound, bloods and genetic screening

Concerns/flags to be attentive to and why important Referral pathway options AND/OR management strategies

Educate on the availability of pre-genetic screening for issues that could impact conception particularly if there is a known history of adverse pregnancy outcomes such as repeated miscarriage or known familial genetic conditions.

Limited patient general health literacy

Iron level concerns

Blood sugars and group concerns

• Immunity (rubella)

• Infections (HIV, hepatitis chlamydia and syphilis)

• Screening: sickle cell and thalassaemia

Referral to GP for onward referral to specific specialists as required including genetic counsellor

• Ensure appropriate medical team surrounding patient, commencing with the GP and extending to other specialists or allied health professionals

Blood pressure

Temperature

• Gestational hypertension/hypotension

• GP referral for continual monitoring

Fatigue levels

Infection (fever with rash and joint pain may be a sign of cytomegalovirus (CMV))

Flu

Iron levels

Vitamin D

Excessive vomiting

Hyperemesis Gravidarum

Appropriate nutrition intake

Normal fatigue

Headache, visual perceptive changes

Digestive issues (constipation/reflux)

• High blood pressure

Central vein thrombosis (blood clot in brain)

• Increased risk of haemorrhoids and pelvic floor issues

Immediate GP/ED referral if infection is suspected

Levels tested with the patients care providers Make the patient aware of potential symptoms of deficiency (dizziness, fatigue etc.)

• Dietician referral to discuss appropriate pre-natal diet

• Reassure if screening is negative, pacing advice

• New or different headache, refer to GP Accompanied with visual problems refer to ED

• Referral to dietician and pelvic floor physiotherapist

Educate patient on increasing fluid requirements, exercise and breathing

Discuss food types which may help/hinder bowel movements

• Educate on defecation posture

Morning sickness/ other vomiting

Abdominal/pelvic surgical history

Dehydration

• Hyperemesis Gravidarum

Previous surgery

Hernia

Abdominal weakness

Presence of scarring

Abnormal CST and cervical surgeries performed (may cause an incompetent cervix later)

If patient cannot keep water or fluids down for more than 12 hours referral to GP/midwife on maternity ward

Scar management with an appropriately trained osteopath

• Referral to obstetric care provider to discuss risks with vaginal birth and throughout later stages of pregnancy

Referral to Advanced Exercise Rehabilitative Osteopath (see Find an Osteo) or Exercise Physiologist for abdominal strengthening

Clinical issue to screen (biological) for in questioning before 12 weeks gestation

Pelvic floor integrity, pain or cramping

Concerns/flags to be attentive to and why important Referral pathway options AND/OR management strategies

Leaking/incontinence (stress/urge or mixed), prolapse (heaviness or dragging)

History of kidney, bladder and/or urinary conditions.

• Dyspareunia (pain with intercourse), arousal and/or penetration

Referral to pelvic floor physiotherapist or pelvic floor trained osteopath to be a part of the patient’s management team

• Referral to GP for onward referral to gynaecologist

Childbearing history (caesareans, tears, episiotomies, number of children, miscarriages and methods of conception)

Understanding a patient’s obstetric history can influence their desires, beliefs and attitudes towards further pregnancies. This area should be discussed with a level of sensitivity and openness

When taking a birth history, be sure to take the history in chronological order (especially in cases with multiple children) to avoid confusion and missed info

Apply the GTPAL principle: - G= gravidity, - T= term pregnancies,

- P= preterm deliveries,

- A= abortions or miscarriages,

- L= live births

Pregnancy: previous incompetent cervix

Births: term of pregnancy, Braxton Hicks, length of labour, length of active labour, interventions, positioning, medications, tears, health of baby at delivery

High risk of miscarriage within the first trimester (<16 weeks)

Referral to psychologist or social worker where required

• Referral to GP for onward referral to gynaecologist and or/obstetrician

Abdominal pain and abdominal surgical history

• Risk of miscarriage

• Ectopic pregnancy (rupture and haemorrhage)

• Systemic fever

• Endometriosis/adhesions

• Previous chronic pelvic pain

• Previous abdominal surgeries

• Cysts or fibroids (can grow with the pregnant uterus, ovarian torsion)

• GP/ED referral

Muscle cramping

Muscle cramping with leg or calf pain or swelling may be associated with thrombosis

ED referral

Presence of blood or bleeding

• Threat of miscarriage

• Miscarriage

• Ectopic pregnancy

• GP/Ob’s/Midwife referral- immediate ultrasound and blood testing

Pain conditions or discomfort (low back, pelvis, foot)

• Non-mechanical Back pain with or without bleeding could be a sign of ectopic pregnancy

Itchiness (Cholestasis, more common >28 weeks)

• Referral for appropriate follow up testing

• If ectopic pregnancy is suspected, immediate ED referral

Clinical issue to screen (psychosocial)

Stress levels

Concerns/flags to be attentive to and why important Referral pathway options AND/OR management strategies

High stress can impact the patient’s conception experience and foetal development or gestational period

Complete some baseline measures in clinic to have an understanding of the patient’s current level of coping. This can bae used as a comparison in later stages of pregnancy

Refer patient to mindfulness/meditation services

Refer patient to psychologists or counsellors to form part of the support team

Trauma

• The pelvis is a very sensitive and personal area, especially around the topic of trauma. Pelvic trauma can include, crush and musculoskeletal injuries, surgical trauma, episiotomy, tearing from previous births and sexual abuse

Patients may be uncomfortable discussing these topics, as well as uncomfortable being touched around the pelvis: full informed consent should be given prior to placing your hands on any patient

• If discussion of this area is clearly quite uncomfortable for the patient, do not force it. Explain to them why you are asking these questions and let them share as much as they want. Developing rapport is vital in these situations

Patients with history of significant pelvic physical trauma should have imaging done and fertility discussed

• Refer patient to their primary care providers especially in a hospital setting so that sensitive and appropriate care can be implemented

• Sexual abuse: police, mental health professional

Referral to psychologist or mental health professional

• Referral to GP for onward referral to obstetrician/gynaecologist

Useful websites: https://panda.org.au

https://www.birthtrauma.org.au

Social support, partnership status and living situation

Unplanned pregnancy

• General consensus of pregnancy status between partners

Increased risk of postpartum mental health issues

Vulnerable, unstable, inconsistent, or unsuitable living arrangements

• Domestic or family violence/abuse

Educate patient on the increased risk and occurrence of mental health issues and their increased vulnerability in the antenatal period of pregnancy

Provide evidence informed information resources and support services that they can access

• Connecting patient with social support where required

Referral to psychologist, social or welfare worker. Other contacts:

- Police

- Family violence organisations (safe steps 1800015188 – VIC)

- 1800 RESPECT - National

- The Orange Door

https://www.orangedoor.vic.gov.au

https://www.whiteribbon.org.au

Pregnancy: 13-27 Weeks

General assessment domains for questioning

Occupation and nature of working activities

Concerns/flags to be attentive to and why important Referral pathway options AND/OR management strategies

• Radiation

• Chemical exposure

• Mechanical load (e.g., lifting)

• Discussion with the patient on how pregnancy may affect their ability to complete workplace duties

Seek consent to follow up with employer/ workplace on these concerns

Understand and relay strategies other employees have implemented

• Include discussion with their primary care provider (midwife/GP/obstetrician)

Exercise and nature of exercise undertaken

• If not yet started, commence pelvic floor exercises

• Consult with a pelvic floor therapist/physio to assess integrity of pelvic floor if there has been previous trauma or dysfunction before starting exercises.

Refer to pre-natal Pilates instructor with specific recommendations if needed.

• Education/communicate current guidelines on physical activity including: - Pelvic floor exercise

- Muscle strengthening twice a week

Cardio

Intensity of moderate (three to seven intensity out of 10), or talk test at a minimum of 150 minutes per week over the course of the week

- Breaking up prolonged sitting

- Exercise should include usual pre pregnancy preferences and activities unless they are contact sports

- Exercise with light weights and resistance bands recommended

- Heavy lifting, intense repetitive isometric exercises are not recommended as there is some evidence of poor foetal and maternal health outcomes

- Screening of patients should be performed on those with risk factor. Otherwise, healthy patients who have exercised pre pregnancy should not be required to have clearance from a health professional provided they have no contraindications and remain asymptomatic

- Patients who exercise at higher intensities or prolonged duration should consult a health professional who is aware of the effects on maternal and foetal well-being. It is expected that exercise be modified throughout the course of the pregnancy

Complete risk form assessment for contraindications (e.g., PAR-MED)

• Education on risks of trauma of certain exercise/sports

Make aware of symptoms/flags to be aware of when exercising

Educate about safety of supine exercise- there is no conclusive evidence about this and the risk to study this is too high

General assessment domains for questioning

Health history

Concerns/flags to be attentive to and why important

Previous diagnoses illness:

- Thyroid

- Blood clotting/embolism/thrombus

- Anaemia

- Diabetes

- Hyper/hypo tension

- Epilepsy

- Blood borne viruses

- Autoimmune

Referral pathway options AND/OR management strategies

Managing physician should be already aware of conditions but if not, ensure patient discloses this immediately with physicians

Mental health

• History of mental health conditions increases the risk of antenatal/postnatal depression (especially major depressive disorder) and post-partum psychosis (especially bipolar) Some medications used to treat mental health conditions are also teratogens that can impact pregnancy prospects

• Complete Edinburgh depression scale Referral to GP, for mental health plan if necessary

• Ensure patient understands not to cease any medication use without GP or specialist consultation.

Medication/ Supplements

• Continue folic acid, magnesium and/or iron if suspected low

Being mindful if patient bleeding to avoid fish oil tablets

Teratogens (compounds which lead to malformations of an embryo)

• Some prescription medications are teratogens. Medications in the following categories can affect foetal development:

- Anti-convulsant

- Blood thinners

- Anti-biotics

- Anticancer drugs

- ACE inhibitors

- SSRIs

- Tranquilizers

- Hormone therapies

- Aminopterin

- Isotretinoin

- Thalidomide

- NSAIDs

Nutrition/diet

Weight loss if patient is still vomiting/nauseated

• Calcium and iron stores need to be maintained and supported

• Draw attention to recommended alcohol, smoking and caffeine consumption guidelines

• Refer to GP for bloods if needing to assess iron/ magnesium supplements

Discuss implication of the ‘type’ of folate used e.g., folic acid vs folate

Ensure iron levels are tested in early pregnancy and the patient is aware of increasing needs for iron as the pregnancy progresses Referral for further education on supplementation with pharmacist/care provider

Consult the Royal Hospital for Women with questions regarding prescription medications and pregnancy and breastfeeding

http://www.seslhd.health.nsw.gov.au/royalhospital-for-women/services-clinics/directory/ mothersafe

A document listing the current Australian guidelines for vitamin supplementation for pregnant patients can be found at:

https://www.hps.com.au/wp-content/ uploads/2019/04/Vitamin-and-mineralsupplementation-in-pregnancy-C-Obs-25Review-Nov-2014-Amended-May-2015.pdf

Prescribing medicines in pregnancy database https://www.tga.gov.au/products/medicines/ find-information-about-medicine/prescribingmedicines-pregnancy-database

Refer to dietitian if losing weight and pregnancy health provider for advice on medication

• Refer to dietitian if previously diagnosed with gestation diabetes (GD)

• Alcohol guidelines https://everymomentmatters.org.au/

Other health professionals seen/ model of care

A coordinated team care approach in pregnancy is vital for important clinical assessments of benefit to the patient and developing child to occur

Help the patient identify who can be a part of their healthcare team and which other professionals may be of assistance to them. A range of professionals is specified in this overall table

Clinical issue to screen (biological) for in questioning

Accesses obstetric/ medical checks advised in the pregnancy phase, including urine testing, results of 20-week ultra-sound, genetic screening

Concerns/flags to be attentive to and why important Referral pathway options AND/OR management strategies

• Urine tests

• Further genetic/pregnancy screening (amniocentesis, chorionic villus sampling 15 weeks)

Routine 20-week scan - morphological scan, high risk pregnancy detection:

- Intra Uterine Growth Retardation

- Foetal abnormalities

- Placental abnormalities

- Cord abnormalities

• Must be aware of mental health and impact high risk pregnancy can have on patient.

• Obstetrician for discussion of high-risk status

Blood pressure

Fatigue levels

• General sign of health/hydration

• Very rare for pre-eclampsia to begin prior to 20 weeks

• Hypertension/hypotension

Assessing for iron deficiency, thyroid dysfunction

• GP/OBGYN

• If high and in combination with other signs of pre-eclampsia (headache/visual disturbance/ itchiness) immediate referral.

Refer to GP

Digestive issues (constipation/ reflux)

Constipation

Haemorrhoids

Vulval varicosities

Morning sickness/ other vomiting

• Dehydration Hyperemesis Gravidarum

Referral to dietician, GP and pelvic floor physiotherapist as needed

• Educate patient on increasing fluid requirements, exercise and breathing

Discuss food types which may help/hinder bowel movements

Educate on defecation posture

• If patient cannot keep water or fluids down for more than 12 hours referral to GP/midwife on maternity ward

Childbearing history (caesareans, tears, episiotomies, number of children, miscarriages and method of conception)

Understanding a patient’s obstetric history can influence their desires, beliefs and attitudes towards further pregnancies. This area should be discussed with a level of sensitivity and openness

When taking a birth history, be sure to take the history in chronological order (especially in cases with multiple children) to avoid confusion and missed info

• Apply the GTPAL principle:

- G= gravidity,

- T= term pregnancies,

- P= preterm deliveries,

- A= abortions or miscarriages,

- L= live births

Pregnancy: previous incompetent cervix

Births: term of pregnancy, Braxton Hicks, length of labour, length of active labour, interventions, positioning, medications, tears and health of baby at delivery

May impact ability to birth vaginally and birth plans may be discussed already with midwife/ obstetrician/gynaecologist

Clinical issue to screen (biological) for in questioning

Concerns/flags to be attentive to and why important

Pelvic floor integrity Leaking, urgency, frequency, pain, bulge sensation, heaviness, dragging, faecal staining or difficulty holding wind

Muscle cramping Magnesium deficiency

Thyroid dysfunction

Electrolyte imbalance and dehydration

COG shift

Presence of blood or bleeding From vagina, rectum and bladder

Late miscarriage infection

Placental abruption

Referral pathway options AND/OR management strategies

Refer for pelvic floor physiotherapist or pelvic floor trained osteopath, or GP for urologist referral

• Recommend that all pregnant patients see a pelvic floor trained practitioner

GP for bloods

Referral for ultrasound (upper or lower limb) to investigate DVT

Referral to GP/pregnancy care provider

Referral to ED

Pain conditions or discomfort (low back, pelvis, foot)

Foetal movement activity (where, when and how often)

• Signs of PPGP (pregnancy pelvic girdle pain)

• Vulval varicosities

• Pre-labour

May not yet be perceived before 25 weeks

After 25 weeks establish a normal pattern of movement, investigate if any variation is detected

• Pelvic health osteo/physio

• GP

• Use of support garments fitted by a practitioner experienced in doing so

Reassurance to patient that movement at this stage is not always expected

https://stillaware.org/

Clinical issue to screen (psychosocial)

Stress levels

Concerns/flags to be attentive to and why important Referral pathway options AND/OR management strategies

Impacting sleep, insomnia

Causes – investigate what may be triggering this

Psychologist

Relaxation yoga

Sleep disturbance - progressive muscle relaxation

• Biopsychosocial model in management approach

Trauma

The pelvis is a very sensitive and personal area, especially around the topic of trauma. Pelvic trauma can include, crush and musculoskeletal injuries, surgical trauma, episiotomy, tearing from previous births and sexual abuse. Patients may be uncomfortable discussing these topics, as well as uncomfortable being touched around the pelvis: full informed consent should be given prior to placing your hands on any patient

• If discussion of this area is clearly quite uncomfortable for the patient, do not force it. Explain to them why you are asking these questions and let them share as much as they want. Developing rapport is vital in these situations

Patients with history of significant pelvic physical trauma should be imaged and fertility discussed.

Previous pelvic trauma/sexual abuse. Must be very mindful of your palpation and examination as it may trigger traumatic response

Association with birth preferences

Outcome measures screening in clinic (K10, Edinburgh)

Psychologist

Access Medicare subsidised sessions through GP

Refer patient to their primary care providers especially in a hospital setting so that sensitive and appropriate care can be implemented

Sexual abuse: police or mental health professional

Referral to psychologist or mental health professional

• Referral to GP for onward referral to obstetrician/ gynaecologist

• Useful websites: https://panda.org.au

https://www.birthtrauma.org.au

Social support, partnership status and living situation

Unplanned pregnancy

General consensus of pregnancy status between partners

• Increased risk of postpartum mental health issues

Vulnerable, unstable, inconsistent or unsuitable living arrangements

Domestic or family violence/abuse

Educate patient on the increased risk and occurrence of mental health issues and their increased vulnerability in the antenatal period of pregnancy

Provide evidence informed information resources and support services that they can access

• Connecting patient with social support where required

Referral to psychologist, social or welfare worker.

Other contacts:

- Police

- Family violence organisations (safe steps 1800015188 – VIC)

- 1800 RESPECT - National

- The Orange Door

https://www.orangedoor.vic.gov.au

https://www.whiteribbon.org.au

Pregnancy: 28-40 Weeks

General assessment domains for questioning

Occupation and nature of working activities

Concerns/flags to be attentive to and why important Referral pathway options AND/OR management strategies

• Falls risk, carrying/lifting heavy objects

• When the pregnant patient will likely be finishing up work/starting maternity leave

If not yet started, commence (or continue) pelvic floor exercises

• Being aware of exercise recommendations as previously discussed and how naturally exercise choice may change throughout the later stages of pregnancy

• Coning or bulging of abdominals may indicate presence of diastasis recti

• Discuss lighter duties with employer if/when possible

Discuss appropriate transition into maternity leave

Consult with a pelvic floor practitioner to assess integrity of pelvic floor

• Stop one legged exercises, change positions or intensity of exercise, change to free weights or bands

Modify exercise and monitor (no pounding exercise, change to sitting or side lying positions, reduce wide legged positions)

No straining with any exercise

Educate that diastasis recti is present in 100% of patients at 35 weeks.

Refer to knowledgeable practitioner (osteo/EP/ physio)

Lifestyle activities

• Ergonomic positions

Avoid lying on back

Avoid semi-reclined positions

Sleep positioning (left side)

• Other children at home

• Duties in the household

• Support system

• Remind smoking guidelines

All contribute to treatment plan and potential increased risk factors to other post-partum/ pelvic health concerns

• Discuss safe, appropriate positions for baby health and pelvic health

Government sleep positioning guidelines

https://www.health.nsw.gov.au/ kidsfamilies/MCFhealth/maternity/ Pages/side-sleeping-clinicians. aspx?fbclid=IwAR3kXpN13S8vCbkAnlaJWD6Y7_ D0Q_Jt5Q0r7aGvsanJft0JpHRM8ACLAWg

• Useful websites:

- Social worker

- The Orange door

https://www.orangedoor.vic.gov.au

Health history

Previous obstetric and gynaecological history

Previous surgical history

Previous diagnosed illness (thyroid, vascular, autoimmune)

Managing physician should be already aware of conditions but if not, ensure patient discloses this immediately with physicians

Mental health history

• How patient feels they have managed throughout pregnancy so far

Personal history of depression or anxiety

• Refer to psychologist/therapist

• *See below mental health section for further detail

Nutrition/diet

Gestational diabetes

Dehydration

Anaemia (fatigue, weakness, yellowish colour, dizziness/lightheaded, headache, chest pain, cold hands + feet, SOB)

• Oxytocin stimulation (reduces 1st stage of labour)

Remind alcohol and caffeine guidelines

Refer to dietician if diagnosed with gestational diabetes (GD)

• Occurs 24-48 hours in advance, increase fluids especially in the third trimester

• Refer to care providers for blood tests and management (supplementation/iron infusion)

6 dates per day from 34 weeks (make sure patient is not intolerant to fructose)

General assessment domains for questioning

Medication/ Supplements

Concerns/flags to be attentive to and why important

• Continue folic acid, and/or iron if suspected low

• Vitamin D, probiotics, fish oil, magnesium

• Teratogens (compounds which lead to malformations of an embryo)

Some prescription medications are teratogens. Medications in the following categories can affect foetal development:

- Anti-convulsant

- Blood thinners

- Anti-biotics

- Anticancer drugs

- ACE inhibitors

- SSRIs

- Tranquilizers

- Hormone therapies

- Aminopterin

- Isotretinoin

- Thalidomide

- NSAIDs.

Referral pathway options AND/OR management strategies

• Refer to GP for bloods if needing to assess iron/ mg supplementation

Discuss all changes to medication with OBYGN/ midwife

Remind patient to continue taking supplements following birth of baby (common time for depletion)

Discuss implication of the ‘type’ of folate used e.g., folic acid vs folate

Ensure iron levels are tested in early pregnancy and the patient is aware of increasing needs for iron as the pregnancy progresses

• Referral for further education on supplementation with Pharmacist/care provider

Consult the Royal Hospital for Women with questions regarding prescription medications and pregnancy and breastfeeding

http://www.seslhd.health.nsw.gov.au/royalhospital-for-women/services-clinics/directory/ mothersafe

• A document listing the current Australian guidelines for vitamin supplementation for pregnant patients can be found here

https://www.hps.com.au/wp-content/ uploads/2019/04/Vitamin-and-mineralsupplementation-in-pregnancy-C-Obs-25Review-Nov-2014-Amended-May-2015.pdf

• Prescribing medicines in pregnancy database

https://www.tga.gov.au/products/medicines/ find-information-about-medicine/prescribingmedicines-pregnancy-database

Clinical issue to screen (biological) for in questioning

Routine or additional medical care

Concerns/flags to be attentive to and why important Referral pathway options AND/OR management strategies

• Growth scan (usually at 32 weeks)

• Whooping cough vaccination (between 20-28weeks)

COVID-19 vaccination

Influenza vaccination

Glucose tolerance tests (GTT) (26-28 weeks) for gestational diabetes

Group B Streptococcus (GBS) swab (35-37 weeks)

• CTG monitoring (for reduced foetal movement, diabetes, thyroid or other high-risk conditions)

• Stretch and sweep (may initiate labour)

• Post-term pregnancy (40-42 plus weeks, increased chance of stillborn)

• Reliability of these beyond 20 weeks is low, whole clinical picture should be considered

• Vaccinations offered free of charge in pregnancy by GP or health nurse

GTT can be optional for low-risk patients (fasting glucose can be done in this case)

• Contentious, can discuss pros/cons with patient if informed

• Provides a snapshot of the babies heart rate

• Performed in consultation with health provider, in attempt to initiate labour, mucous plug loss, contractions or no change

Blood pressure

Must be checked each visit

Major red flags

- Pre-eclampsia

- Blood pressure 140/90 or over on two occasions

- Swelling of face, arms, legs

- Headache, visual disturbances

• Eclampsia develops from preeclampsia (nausea, vomiting, weight gain, high bp, reduced urinary output, shoulder pain, right abdominal pain).

Can result in organ failure of mother and still birth for baby

HELLP syndrome

- Associated with pre-eclampsia and eclampsia

- Fatigued and feeling unwell, nausea and vomiting, upper abdominal pain, headache. Can result in death

Refer to medical provider for urine test and repeat blood pressure testing within a few days

• If visual disturbances present, refer on same day If suspected eclampsia or HELLP syndrome immediate ED referral

Other vascular issues

Vulval varicosities, varicose veins or spider veins. Caused from increased pressure on blood vasculature and hormones.

• Pulmonary embolism

• Sudden pleuritic pain/abdominal pain

• Unilateral leg swelling

Often improves after birth but may persist Immediate hospital attendance

Gastrointestinal issues

Reflux

Heart burn, abdominal and chest wall burning sensation

Constipation

Haemorrhoids

Blood after bowel movements, painful bowel movements, raised area near the anus, itching, burning or swelling

Dietary and lifestyle advice, over the counter medication, medications from GP if required Avoid straining, check medication/ supplementation, appropriate toilet posture, GP or dietician if required

• Wet wipes instead of toilet paper, avoid constipation with increasing fluids, fibre and exercise

Clinical issue to screen (biological) for in questioning

Abdominal pain

Concerns/flags to be attentive to and why important Referral pathway options AND/OR management strategies

Pulmonary embolism (as above)

HELLP syndrome (as above)

Eclampsia (as above)

Cholelithiasis (gall stones)

Thoracic/abdominal pain/shoulder tip pain when eating fatty foods

• Appendicitis (R lower abdominal pain, abdominal pain, diarrhoea, vomiting or fever)

Infection

Urinary tract infection

- urgency and/or frequency, burning or cramping in lower abdomen or back, burning on urination, cloudy urine with unusual odour or blood in urine)

• Kidney infection (severe/unremitting back pain)

Chorioamnionitis (an infection of the placenta and the amniotic fluid)

- Fever (38°C for more than an hour)

- Tender and rigid uterus

- Maternal tachycardia (>100BPM)

Pelvic floor Prolapse (heaviness, dragging or visualisation of a lump in/out of vagina)

• Incontinence

Muscle Cramping

• Cramping

• Magnesium or thyroid deficiency or electrolyte imbalance dehydration

Refer to GP or pregnancy health provider for urine analysis and blood tests if required

Refer immediately for monitoring if before 37 weeks/steroids

• Immediate hospital attendance

Contractions/ Uterine cramping

Braxton hicks

- Intermitted tightening in abdomen that comes and goes

Uterine irritability

- Painful contractions before 37 weeks (not relieved by rest)

Pre-term labour

- tightening in the abdomen that intensifies, persists accompanied by other labour symptoms

Assessment by pelvic floor practitioner, obstetrician or midwife

• Pelvic floor exercises, pessary if required (pelvic health practitioner), diet and exercise changes

• GP for bloods

• Referral for ultrasound (upper or lower limb) to investigate DVT

Breathing techniques, relaxation

• Refer to medical practitioner for management

• Refer to pregnancy care provider or ED

Bleeding

• Cervical problems – infection, growth, inflammation, placenta previa, placental abruption, premature labour, cervical incompetence, or uterine rupture

• Haemorrhoids

UTI

Musculoskeletal conditions

• Pregnancy pelvic girdle pain

• Pubic symphysis dysfunction

Rib sprains

• Headaches (musculoskeletal, preeclampsia, hormonal)

Round ligament pain

• Pudendal neuralgia (perineal pain and/or numbness, bowel urgency urinary frequency, pain sitting)

Carpal Tunnel Syndrome

• Immediate referral to health care provider

• Osteopath

Pelvic health physio

• GP

• Hand therapist

Clinical issue to screen (biological) for in questioning

Skin

Concerns/flags to be attentive to and why important Referral pathway options AND/OR management strategies

• Shingles- Pain or itchiness in one dermatome

PUPPS

Itchy and painful rash

• Refer within the 96hour window for symptom prevention treatment

Refer any unknown rash to care provider

Foetal considerations

• Oligohydramnios

- Too little fluid for gestational age on ultrasound

Foetal mal-positioning after 34-36weeks

- Breech, transverse, posterior or high Intrauterine Growth Retardation (IUGR)

- Anaemia, severe diabetes, chronic renal disease, placenta previa, severe malnutrition

Decline in foetal health

Change in foetal movement – different pattern, decreased frequency or absent (less than 10 movements in two hours)

• Healthcare provider will monitor through ultrasound

Seek medical opinion on labour management, Spinning babies website, manual therapy

Care providers for foetal growth ultrasound

• Immediate referral to hospital or care provider for CTG (within two hours)

stillaware.org

Breast Feeding Status

May be expressing colostrum - from 36 weeks

• Pre-delivery breast feeding education and preparation

Lactation consultant

• Breast Feeding Australia

www.breastfeeding.asn.au

Clinical issue to screen (psychosocial)

Stress levels

Concerns/flags to be attentive to and why important Referral pathway options AND/OR management strategies

• Perinatal mental health conditions increase with past mental health conditions, isolation, life stressors including:

- Family problems

- Loss

- Family violence

- Disability

- Multiple trauma

Sleep/insomnia

• Work stresses

• Financial

• Partner relationship

• Social supports and relationships

• Antenatal depression, risk increases with:

- Unplanned/unwanted pregnancy

- High neuroticism,

- Psychosocial stressors in the previous year

• Anxiety (one in five in the 3rd trimester) No validated assessment tools

Trauma

The pelvis is a very sensitive and personal area, especially around the topic of trauma. Pelvic trauma can include, crush and musculoskeletal injuries, surgical trauma, episiotomy, tearing from previous births and sexual abuse

• Patients may be uncomfortable discussing these topics, as well as uncomfortable being touched around the pelvis: full informed consent should be given prior to placing your hands on any patient

• If discussion of this area is clearly quite uncomfortable for the patient, do not force it. Explain to them why you are asking these questions and let them share as much as they want. Developing rapport is vital in these situations

Patients with history of significant pelvic physical trauma should be imaged and fertility discussed

Social support, partnership status and living situation

• Unplanned pregnancy

• General consensus of pregnancy status between partners

Increased risk of postpartum mental health issues

Vulnerable, unstable, inconsistent, or unsuitable living arrangements

• Domestic or family violence/abuse

• Ensure adequate support in place – regular trusted GP, mental health support team

Access Medicare subsidised sessions through GP Outcome measures screening in clinic (K10, Edinburgh)

Above and access to resources including

- PANDA panda.org.au

- The Orange door orangedoor.vic.gov.au

- RedNose - for loss rednose.org.au

- Sands - for loss www.sands.org.au

• As above and:

- Mindfulness Apps

- If sleep is affected - progressive muscle relaxation

- Yoga

Outcome measures screening in clinic (K10, Edinburgh)

• Psychologist or mental health professional

• Access Medicare subsidised sessions through GP

• Refer patient to their primary care providers especially in a hospital setting so that sensitive and appropriate care can be implemented

Sexual abuse: police, mental health professional Referral to psychologist or mental health professional

• Referral to GP for onward referral to obstetrician/ gynaecologist

Useful websites:

https://panda.org.au

https://www.birthtrauma.org.au

• Educate patient on the increased risk and occurrence of mental health issues and their increased vulnerability in the antenatal period of pregnancy

• Provide evidence informed information resources and support services that they can access

Connecting patient with social support where required

Referral to psychologist, social or welfare worker.

Other contacts: - Police

- Family violence organisations (safe steps 1800015188 – VIC)

- 1800 RESPECT - National

The Orange Door

https://www.orangedoor.vic.gov.au

https://www.whiteribbon.org.au

SaffroPEA

With highly bioavailable PEA, clinically trialled Saffron extract and supportive Vitamin D3

SaffroPEA features a unique formulation of highly bioavailable PEA, combined with saffron extract, affron® at the studied daily dose, and supportive vitamin D3.

1 in 5

Australians are living with persistent pain.

Disruption of sleep, mood and immune function can contribute to a person’s perception of pain.

Key features and benefits

• Relieves pain including mild joint pain and soreness with highly bioavailable PEA, Levagen®+.

• Supports a healthy mood balance and improves sleep quality with affron® saffron extract.

• Daily dose of SaffroPEA aligns with the studied dose of 28 mg of affron® a day.

• Supports the function of the immune system, muscles, and nervous system with vitamin D3.

Bioavailable PEA Levagen®+ to relieve pain

Clinically trialled saffron, affron® at the studied daily dose, for healthy mood and improved sleep quality

Vitamin D3 to support healthy immune, muscle and nervous system function

ACTIVE INGREDIENTS

Each capsule contains:

Herbal:

Crocus sativus (saffron) extract dry conc. (affron®) 12.6 mg equiv. dry stigma 42 mg

Nutrient:

Palmidrol (Levagen®+) 300 mg

Vitamin:

Colecalciferol (vitamin D3 500 IU) 12.5 micrograms

SIZE: 42 hard capsules.

DOSE:

Adults: Take 1 capsule two times a day, or as professionally prescribed.

WARNINGS: Do not use during pregnancy or breastfeeding. Adults only. Not to be used for more than 21 consecutive days. The medicine may interact with other prescription analgesic medicines, please consult your healthcare practitioner before use. If symptoms persist talk to your health professional.

MOOD SLEEP

A guide for members on employment contracts

Written employment contracts have not always been commonplace, but they are a crucial tool to protect the rights of employees and employers. They can often be confusing or overwhelming however, so it is important to be aware of what should and should not be typically included in one.

The Osteopathy HR Advisory Service is here to help all members – whether new or long-term employees, associates or business owners – to better understand employment contracts. We look at the common features of contracts and the most frequently asked questions.

WHAT IS AN EMPLOYMENT CONTRACT?

An employment contract establishes the terms and conditions of an employment relationship, and while it is possible for a contract to simply be a verbal agreement, it is best practice to have a written contract. This way both parties can be clear as to their rights and obligations and it makes it easier to resolve any future disputes.

HOW DO EMPLOYMENT CONTRACTS RELATE TO OUR INDUSTRIAL RELATIONS SYSTEM?

While an employment contract establishes the terms and conditions of an employment relationship, it cannot provide terms that are less favourable than the relevant employment legislation and industrial instrument (such as an award) which underpins it. In Australia, the most fundamental piece of employment legislation is the Fair Work Act 2009, which also contains the National Employment Standards (NES)*. In Osteopathy, the main modern award (for private practice) is the Health Professionals and Support Services Award 2020. To reiterate, an employment contract cannot provide terms which are less favourable than those provided by the Fair Work Act 2009 (including the NES) OR the Health Professionals and Support Services Award 2020.

* Note: this information applies to business in the National System and excludes unincorporated entities in Western Australia, who are covered by their state system.

COMMON FEATURES OF AN EMPLOYMENT CONTRACT

Employment Status

The contract should outline the employee’s type of employment –permanent full-time or part-time or casual. This ensures no grey area about employee entitlements, such as leave, and notice of termination.

Further, terms specifying casual employment minimise the risk that an employee would be later deemed a permanent employee and not a casual employee.

Hours of Work

For a permanent employee, it is necessary to stipulate the number of ordinary hours of work they will perform each week, or the average hours over a set period. For a part-time employee under the Health Professionals and Support Services Award 2020, an employer is also required to agree in writing on their days of work, hours of work each day, and the start and finish time of these shifts.

Award Classification

For award-covered employees, most awards require an employer to inform their employee of their classification under the award. This classification will determine the employee’s minimum hourly rate.

Remuneration

The contract should clearly outline the employee’s rate of pay. This may

be through an hourly rate, an annual salary, or a commission and retainer arrangement. Some employers may want to pay a higher rate than the minimum for all hours worked with the intention that this leaves the employee better off overall. This can be done through a “set-off clause” in the contract that specifies this arrangement.

Notice of Termination

A contract should set out the required notice that must be provided by an employer or employer if they want to terminate employment. The Health Professionals and Support Services Award 2020 adheres to the minimum notice required under the NES, in which the required notice increases in accordance with an employee’s length of service.

If an employer requires a greater notice than the minimum, it can often be more difficult to legally justify enforcing the contract term if the employee only provides the minimum notice under the award.

Lastly, the amount of notice should be the same for both parties.

POST-EMPLOYMENT RESTRICTIONS

Some employment contracts contain clauses that impose obligations on an employee to not engage in certain activities following the end of employment.

Usually, it will act to prevent an employee from working for a competitor of their former employer for a specific period within a specific area. It can also act to prevent an employee from sharing confidential information with anyone who is not authorised to have access to such information.

It is worth noting that post-employment restrictions are not automatically enforceable. To be enforced, the clause needs to be assessed and determined to be reasonable given the circumstances. This will involve the employer challenging their former employee for breach of contract and submitting the matter to the Courts or another relevant authority who will assess the reasonableness of the restraint.

WHAT CAN’T BE INCLUDED IN AN EMPLOYMENT CONTRACT?

An employment contract cannot contain terms that are illegal – either from a criminal or employment law perspective. For example, the notice period provided in an employment contract can’t be less than the minimum notice period provided for in an award. Similarly, an employment contract cannot promise remuneration that is less than the relevant award minimum rate.

If an employment contract contains illegal terms, such terms will be considered void, even if the employee has agreed to them. This is consistent

with the idea that an employee cannot sign their rights away.

Recent changes from the Secure Jobs, Better Pay Bill now also prevent “pay secrecy” clauses – which used to be employed to prevent employees from discussing their pay amongst themselves.

CAN THE TERMS OF AN EMPLOYMENT CONTRACT BE CHANGED?

The terms of an employment contract can only be changed by mutual agreement between employer and employee. An employer cannot unilaterally change the contract terms without the agreement of the employee, and it is common for employment contracts to contain a term stating that any changes must come by written agreement.

WHAT IS SHAM CONTRACTING?

Sham contracting occurs when a worker is engaged as an independent contractor when the working relationship more closely resembles an employer/employee relationship. This is done either intentionally or

unintentionally for the purposes of avoiding the responsibility of providing them their entitlements as an employee. There are serious penalties when an employer is found to have engaged in sham contracting – this is regardless of whether the worker claims they are happy to work as a contractor rather than as an employee.

IN SUMMARY

Employment contracts are a key employment document, so it’s crucial to get them right. The Osteopathy HR Advisory Service provides contract templates for members to access, and we also offer contract reviews for employers that want to make sure their employment contracts are legally compliant.

For more assistance, please contact the Osteopathy Australia HR Service on 1300 143 602, or via email at HRHotline@osteopathy.org.au.

Alternatively a suite of dedicated resources for members is also available at www.osteopathy.org.au 24 hours a day, seven days a week.

What is a subpoena and what steps should I take if I receive one?

Kellie Dell’Oro of Meridian Lawyers discusses the basics of a subpoena, who issues it, and what to do if you get one. We’ll also cover the validity of a subpoena, objections that can be made, and what to do if you’re called to appear as a witness.

WHAT IS A SUBPOENA?

A subpoena is a legal document, issued as part of court proceedings, which compels a person to either attend court to give evidence, or to produce documents to the court.

WHO ISSUES SUBPOENAS?

A subpoena is prepared by a solicitor in the course of gathering evidence for their client’s case, however the document is issued by a court or a tribunal. When you are subpoenaed to produce documents, you should produce them to the court or tribunal directly, and not the solicitor who delivered the subpoena. The details of where to produce the documents will be contained within the subpoena.

DO I HAVE TO COMPLY?

Provided the subpoena is valid, you are required to comply or you can be found to be in contempt of court. This means that for production of documents, you should pay close attention to the date required for production. If the subpoena requires you to attend to give evidence, you should attend court on the date specified. If you have concerns regarding the date of production or date of attendance, you should discuss those concerns with the solicitor who issued the subpoena or obtain your own legal advice.

It is important to check that the document you have received is a valid subpoena, and not simply a letter from a solicitor requesting documents. If you receive a letter from a solicitor requesting documents, you should not provide any documents without the consent of the patient or someone authorised to give consent on their behalf.

WHEN IS A SUBPOENA VALID?

The subpoena should be dated, have the name and address of the court from which it was issued, and be authenticated by the court with a court seal or the signature of a court officer. A subpoena will contain a ‘last date for service’ which is the last day that the subpoena can be validly served on you. You should check this date when the subpoena is being served on you, and if it has already passed you may inform the person serving you that you refuse to accept service.

CAN I OBJECT TO THE SUBPOENA?

The fact that subpoenaed documents are clinical records is not usually in itself a basis to object. However, if there are specific entries of a sensitive nature, for example references to family violence or information that if disclosed may impact the mental health of a vulnerable patient, then there may be a basis to object to producing some or all of the documents. If you have concerns about releasing sensitive information you should obtain legal advice.

CAN I INFORM THE CLIENT?

Yes you can, but there is no obligation for you to do so.

CAN I CHARGE FOR COMPLYING WITH A SUBPOENA?

You are entitled to recover reasonable expenses of complying with a subpoena, such as photocopying requested documents or attending court. If you seek to recover expenses you should write to the solicitor who served the subpoena, with details of the expenses you propose to recover.

WHAT SHOULD I DO IF I AM CALLED TO APPEAR AS A WITNESS?

There can be a range of reasons a practitioner may be called to appear as a witness. The most common is where your patient has suffered injury that is the subject of court proceedings (such as where they have been the victim of a crime or injured due to negligence), and the court seeks your opinion in relation to their health condition.

It is important that you understand why it is that you are called to attend so that you can properly prepare. Sometimes this might already be clear to you, but you are still welcome to phone the solicitor or Police Informant who has served the subpoena to enquire what the court seeks your assistance with. Understanding the scope of your involvement is important so that you can prepare and identify if you will need support.

If you have any concerns or questions in regard to appearing in court as a witness you are encouraged to contact Osteopathy Australia.

If you are called to appear as a witness in an Inquest or Inquiry (such as a Coronial Inquest), you should contact Osteopathy Australia as soon as possible as you may require legal support.

Kellie Dell’Oro Principal Meridian Lawyers www.meridianlawyers.com.au

This information is current as of March 2023. This article does not constitute legal advice and does not give rise to any solicitor/client relationship between Meridian Lawyers and the reader. Professional legal advice should be sought before acting or relying upon the content of this article.

How to grow your business through your professional recommendations

Dr. George Michael BSc.MHSc.Dip Acu

became acutely aware that practice success relies on patient consultations. But what about other revenue str can support your practice? We don’t often talk about it, but there are many adjunct products and services to help patients in their treatment and recovery where they value your expertise and advice. This may be helping them perform exercises effectively at home or a night of truly restful sleep.

Osteopathy Australia do the legwork

An easy step to take in implementing this additional offering is to look at the products and services already endorsed by Osteopathy Australia that can become part of your treatment recommendations. They’ve been extensively assessed for their features and alignment to the osteopathic philosophy. Whilst some products are low value and won’t have a significant impact on revenue, others are in a financial bracket that puts a higher value on your professional recommendation.

Professional confidence

Patients turn to osteopaths for advice when they feel their mattress or pillow is not supporting recovery. It’s a significant investment and challenging shopping experience. Rather than a mattress in a box bought online, I prefer the DrRest mattress, endorsed by OA and backed by trials in clinical settings that give me the confidence to recommend to patients. Patients may ask for my recommendation or when they wake up with back pain, even after treatment, we begin a conversation about their mattress. Without getting into

a complicated combination of mattress choices (soft, firm, side sleeper etc.) DrRest is a mattress that actually customises to each individual to support pain reduction and functionality. It’s one mattress that provides the solution that I can confidently recommend, knowing it’s designed by health professionals to support my patient and provide a profit for my practice.

Making a difference

Choosing products and services for your clinic means finding alignment, trust and benefits for patients. They need to make a difference. I recommend looking to research and results the brand can provide. For a mattress, I look for how it supports the correct alignment of the spine and the real-patient photos seen with DrRest were a game changer. No spine CGI/animation, these are real osteopathy patients lying on the mattress and finding spinal alignment no matter their body size or shape.

I could clearly see that DrRest supports spinal alignment to take the pressure off your lumbar, thoracic, and cervical spine. As a part of the DrRest research team, we tested out this pressure relief by looking at interface pressure, which is the pressure the mattress exerts on you when you lay on

it. Whether it feels plush, firm or medium, that’s the interface pressure. So to have spinal alignment with really low interface pressure, that’s a unique attribute of DrRest.

With this technology and the inclusion of Technogel© in an exclusively designed shoulder zone, it offers patients access to an optimal sleep surface.

Avoiding growing pains

Growing your business and increasing its financial success can be achieved with professional recommendations, but you don’t want it to add hours, paperwork and inventory control that takes away from your work with patient consultations. Mattresses in particular need an online ordering option that’s easy for practitioner or patient to purchase and for the profit margin to flow into your system. By becoming a DrRest partner I can simply make an online wholesale order and then a retail transaction for my patient.

Find out more

Consider becoming a DrRest partner at www.drrest.com.au for a positive impact on your patients and practice profitability.

With the average annual salary for osteopath jobs in Australia ranging from $75k to $90k, adding additional revenue options might be important to you Your expertise and advice can extend beyond the consultation room.

Five tips for securing your digital patient records

As an osteopath, you can never be too careful with your patients’ health information. Here are five basic safety measures you can take to dramatically increase the security of your electronic data:

1

Install updates on all of your devices

Whether it’s your phone, computer, tablet, or even an app, install those updates! Most system updates include some security fixes, and the longer you delay installation, the more vulnerable you become.

2

Use strong passwords and keep them guarded on all your accounts

When it comes to creating a password, opt for something longer like a phrase or a song lyric. Creating a lengthy password is far more secure than using a mix of uppercase, lowercase, numbers, and symbols (even though that’s what most of us have been taught to do).

Also avoid reusing passwords on multiple sites. It’s very tempting, we know! But it makes you susceptible to data breaches. If you’re struggling to keep track of all your passwords, rather than doubling up on them, think about subscribing to a password management system to store them safely for you.

4

Encrypt your data

3

Enable two-factor authentication (2FA) in as many places as you can 2FA requires not only your username and password but also an additional code which is sent to a separate physical device such as your phone or tablet. Essentially, 2FA requires something you know (your email and password) as well as something you have (your phone).

2FA is the single most secure thing you can do to protect your online account, because it requires that you have your phone with you—it’s very unlikely that someone trying to access your accounts is also going to have your phone!

If you lose your laptop, even if it’s password-protected, the information could still be accessed. With encryption turned on, your data is much safer because if anyone gains access to the information, they’ll be unable to decipher it.

5

Safely store and backup your data

Even with encrypted devices, strong passwords, and other security measures in place, this won’t prevent data loss if your information isn’t backed up. Your laptop might be password protected to the moon and back, but if you drop it in the lake, retrieving what was on it might not be possible. If you’re a Cliniko customer, we handle data backups for you. If you’re not, make sure you’re backing up regularly.

While there are other precautions you can take, following these steps will give you a good baseline level of security. You’ve probably already undertaken some of the actions on this list, but it’s important to do everything, rather than picking and choosing. The extra time these precautions require to set up is worth it—for both data security and your peace of mind!

Find out more

At Cliniko, security shapes every decision we make and, when you’re using our practice management software, you can rest easy knowing your patient data is protected.

Take a free trial today at cliniko.com/oa-member - the trial is 90 days for OA members.

We know that managing your insurance isn’t always at the top of your to-do list. That’s why we’ve redeveloped PolicyHub, our online self-service portal that you can access anytime, designed with you in mind.

We’ve made it simpler to see all your policy documents within the one easy-to-use platform:

• View your payment history

• Download an invoice, payment summary or Certificate of Currency

• Finalise your renewal, and much more!

knowing your data is protected with multi-factor authentication.

for PolicyHub