Early Head Start

Prenatal and postnatal health, nutrition, mental

health and safety services for Early Head Start sites

Pregnancy Policy Packet

Developed by the Early Head Start Maternal Group, Summer of 2013

Edited by Ella Trepashko – Early Head Start

Dietitian, Dominican University

Early Head Start Pregnancy Packet

Sections

DFSS Services to Pregnant Women in Early Head Start

Prenatal Log and Policy

Pregnancy Pathway

Appendix to the Pregnancy Pathway

Prenatal and Postnatal+Infant Nurse Assessment

Pregnancy Risk and Authorization Form

Early Head Start

Pregnancy Packet

Prenatal Log and Policy

Chicago Department of Family & Support Services

Prenatal Visit Log Policy and Procedure

Performance Standard: 45CFR 1304.40(a) (1) (ii)

Purpose: To ensure clients attend prenatal visits as recommended by their prenatal provider.

1. At the first visit with the pregnant mother, document the date of the first prenatal healthcare visit on the prenatal visit log form.

2. Explain to the pregnant mother that it is very important for all prenatal appointments required by the pregnancy primary care provider be kept.

3. The prenatal visit log is a document for the Family Support Worker to use to document all appointments recommended by the prenatal provider and kept by pregnant mothers.

4. If a pregnant mother states that she has missed a scheduled prenatal provider appointment, assist the pregnant mother with calling the prenatal provider to schedule another appointment immediately, and document the reason for the missed visit in your case notes. Try to identify the reason for the missed visit and any barriers to health care (transportation, childcare etc...), and assist the pregnant mother with resources and ideas to overcome the barrier to prenatal health care.

5. If a pregnant mother has missed two or more prenatal appointments, discuss the situation with your supervisor to address ways to assist the pregnant mother to become compliant with prenatal care appointments.

6. A pregnant mother’s risk status may change at any time during the pregnancy. Appointment frequencies may change at any time during the pregnancy based on the pregnant mother’s individual health needs.

Monica Dillon RN, November 8, 2010

(1) Early Head Start grantee and delegate agencies must assist pregnant women to access comprehensive prenatal and postpartum care, through referrals, immediately after enrollment in the program. This care must include:

(ii) Health promotion and treatment, including medical and dental examinations on a schedule deemed appropriate by the attending health care providers as early in the pregnancy as possible;

Chicago Department of Family & Support Services

Prenatal Care Visit Log Clients Name: _________________________ FSW: _________________________ Due Date: _____________________________ Provider’s Name: _______________ Week of Pregnancy Appointment Date

(Medical or Dental Visits) Notes: What happened at the visit? (Sonogram, Non-Stress Tests, etc…)

4 *Every 4 Weeks

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

Chicago Department of Family & Support Services 23

24

25

26

27

28 *Every 2 to 3 Weeks

29

30

31

32

33

34

35

36 *One Visit/Week

37

38

39

40

41

42

Visit schedules may vary. * Denotes recommendation for a low risk pregnancy

Early Head Start

Pregnancy Packet

Pregnancy Pathway

Chicago Department of Family & Support Services Pregnancy Pathway

1 | P a g e

Date Pathway Initiated: Baby’s due Date: Client’s Name FSW’s Name: Trimester when entered the program: 1. *Prenatal Care

A. *Health Care Provider: Name _____________________________________________________ Address ____________________________________________________ Phone Number ______________________________________________ If client does not have a provider, refer to: [Insert Community Prenatal Provider, address and phone number listed on your Medical Provider Cooperative Agreement]

B. *Pregnancy High Risk Assessment: (Use “High Risk” Assessment Form).

A client may become “High Risk” at any time during the pregnancy, labor or delivery. High Risk at Enrollment: Yes _________ No __________ If the client becomes “high risk” anytime during the pregnancy, labor or delivery, enter the date she became “high risk” here _____________________________ And change her risk status in COPA:

C. *Date of first Prenatal Visit:_____________________________________ Start “Prenatal Visit Log” Form

D. Name of Hospital _______________________________________________ E. Hospital Tour done? Yes __________ No ___________ F. Birth Plan done? Yes __________ No ___________

G. What to Expect When Your Expecting Date given to client: _______________

(To be given during 1st trimester when possible)

H. Other Prenatal Written Resources Given to Client: Illinois DHS Feeding your Baby (Ap. 1) Tips on Pregnancy: How much should I gain? (Ap. 2) Weight loss while breastfeeding (Ap. 3) Why prenatal care is important (†BB 18) Expect at first prenatal visit (†BB 19) My Birth Plan (†BB 88) Mother’s Bottle Guide (Ap. 4) Other materials:

Chicago Department of Family & Support Services Pregnancy Pathway

2 | P a g e

* Denotes required data for COPA

2. Nutritional Support

A. WIC Referral Date: ______________

Indicated for all pregnant women, especially those who: -have any medical diagnosis (gestational diabetes, hyper emesis Anemia etc…) -want nutritional counseling -want to breastfeed their baby and would like to be connected to a lactation

counselor, and/or may need a breast pump. Date of first visit to WIC:

B. *Has the “Nutrition Assessment for Pregnant Client” been done?

Prenatal Nutrition Assessment (Ap. 5) Date: Postnatal Nutrition Assessment (Ap. 7) Date:

C. Food Safety and Fish precautions during pregnancy information: (Given during 1st – 2nd Trimester) Food safety during pregnancy (Ap. 9) Fish Facts: Print and Go Guide (Ap. 10) Date:

D. * Breastfeeding information given to client:

Breastfeeding: best for me & my baby (†F6 4) Date: Myths about Breastfeeding (†F6 5) Date:

E. Lactation Counselor Home Visit done six weeks prior to due date?

Yes _________ No _________ Contact Peer Lactation Counselor: [Insert Contact Information] □ Lactation Support Resources for Chicago (Ap. 12) Date:

Does client need assistance with obtaining a breast pump?

Yes _________ No _________

* Denotes required data for COPA

Breast Pumps for WIC clients: may be available for rental at mother’s local WIC center. Each site has varying availability so contact your WIC site for more information on their pump program.

Breast Pumps for Medicaid Eligible Clients: Illinois public aid will reimburse for a double electric pump from Medela. Client will need a prescription from the MD. The script must say: “Electric breast pump for lactating mother,” and have complete MD info on the script. A copy of the public aid card needs to be faxed too. Family Home Care (will ship anywhere): (773)-486-3998 phone or (773)-486-5848 fax Ballin Pharmacy (3330 N. Lincoln): (773)-348-0027 phone

Chicago Department of Family & Support Services Pregnancy Pathway

3 | P a g e

3. Infant Nutrition Information (To be given during 2nd - 3rd Trimesters) _______________________________________

A. How to feed your baby step by step (Ap. 13) Date: B. Is my baby ready for solid foods (†F6 63) Date: C. Suggestions for starting solid foods (†F6 83) Date: D. How does food nourish my baby (†BB 62) Date: E. Healthy things to do for you and your baby (†BB 21) Date:

4. *Health Insurance

________________________________ Make a copy of Medicaid, All Kids or Private Health Insurance Card for the Client File.

A. Medicaid Moms and Babies Program __________ B. All Kids C. Private Health Insurance: ________________________________________ D. Medically Uninsured: __________ If client is uninsured, refer to

Insert Local DHS – Medicaid Office Contact Information

5. *Pregnancy Education/Information

_____________________________________________________________________ Client’s Literacy Level/ Last Grade Completed _________________________

A. Pregnancy/Fetal screening tests and information (1st – 2nd Trimesters)

Date: ____________

B. *Preterm Labor information (1st – 2nd Trimesters) What are the signs of preterm labor (†BB 66) Preterm labor: What to do (†BB 67) Date: ____________

C. Postpartum health information (2nd - 3rd trimesters) Postpartum Concerns (†BB 108) Following a C-Section (†BB 109) Date: ____________

D. Birth Control information and resources (2nd - 3rd Trimesters) Family Planning Choices (†BB 41 1-6) Date: ____________

E. Doula information (1st Trimester) Pregnancy, delivery & after birth professionals (Ap. 15) Date: ____________

F. *The Effects of Alcohol and Drugs during Pregnancy(1st Trimester) How alcohol and drugs can hurt (†BB 13) Date: ____________

Chicago Department of Family & Support Services Pregnancy Pathway

4 | P a g e

G. Exercise and Pregnancy information (1st -3rd Trimesters) Exercising safely during pregnancy (†BB 38) Date: ____________

H. Prenatal Class information(1st – 3rd Trimester Date: ____________

I. *Fetal Development(1st- 3rd Trimesters) First trimester (†BB 28) Second trimester (†BB 53) Third trimester (†BB 93) Date: ____________

J. *Labor and Delivery(2nd – 3rd Trimesters) Labor and Delivery (Ap. 16) Date: ____________

K. *The Effects of Smoking during Pregnancy (1st-3rd Trimesters) How smoking can hurt (†BB 12) Date: ____________

L. Prenatal Home Visit assessment with Community Health Nurse (upon enrollment) Date: ____________

6. *Dental/Oral Health _____________________________ A dental visit during pregnancy is required. If the client does not have an oral health provider, refer to: [Insert dental providers in which you have a cooperative agreement].

A. Date referral made ( documentation received): _______________

B. Written information about oral health during pregnancy: Date: __________

C. Date of Visit: __________________

D. Completed Dental Documentation Received: Yes _____ No _____

E. Name of Dental Provider: ______________________________________ Address: ____________________________________________________ Phone Number: ______________________________________________

F. Infant oral health information given to pregnant mom. Date: _______

Chicago Department of Family & Support Services Pregnancy Pathway

5 | P a g e

7. Environmental Health ____________________________________________

A. Prior history of lead poisoning exposure? Yes_________ No________

B. Client has had lead level test done during pregnancy (if applicable): Yes_________ No________

C. Information about lead poisoning during pregnancy: Date Given: ________

D. Home Environmental Assessment done by the Department of Public Health, Child Lead Division (if lead risk suspected)? Yes_________ No____

E. Information about Childhood Lead Poisoning Prevention (upon enrollment): Date Given: __________

* Denotes Required Data for COPA

8. *Mental Health

Prior History of Mental Health Problems? Yes_________ No________ *Refer to Mental Health Coordinator if yes.

A. Signs/Symptoms of Depression? Yes_________ No________ *Refer to Mental Health Coordinator if yes.

B. Mental Health Referral made? Yes_________ No________

Where? ________________________________________

Date of Referral: _______________________________

C. *Information about Postpartum Depression: Date:____________

D. Postpartum Depression 24 –Hour Crisis Hotline Information given to client:

Date:__________

Signs and Symptoms of depression include: change in sleeping, eating, and/or activity patterns, expressions of hopelessness and helplessness, and other signs described in depression handout. If you are not sure if a client is expressing signs and symptoms of depression, consult with the Mental Health Coordinator.

Chicago Department of Family & Support Services Pregnancy Pathway

6 | P a g e

E. Domestic Violence questionnaire done? Date Completed: _____________________

• Have you been hit, kicked, punched or otherwise hurt by someone in the past? Yes_________ No____

• Do you feel safe in your current relationship? Yes_________ No________

• Is there a partner from a previous relationship who is making you feel unsafe? Yes_________ No____

• In the past month, have you had little interest or pleasure in doing things? Yes_________ No____

• In the past month, have you often been bothered by feeling down, depressed or hopeless? Yes_________ No___

F. Referral to Domestic Violence counselor? Yes_________ No____

G. *Use of Alcohol or Drugs? Yes_________ No____

*Referral to Mental Health Coordinator if “yes”

Depression Screening Documentation During and After Pregnancy Each pregnant mother should have a depression screening done at least once (usually twice) during pregnancy and once after delivery of the baby. Document the following information here and in your case notes: Depression Screening done during pregnancy:

• Date completed: Score: ___ • Referral initiated: Yes____ No____ • If yes, referred to: _____________________________________________________ • Who completed the screening with the client? ____________________________

Depression Screening done after pregnancy: • Date completed: Score: ___ • Referral initiated: Yes____ No____ • If yes, referred to: _____________________________________________________ • Who completed the screening with the client? ____________________________

Notify the Mental Health Consultant for scores > 8 and/or if a referral was initiated

Chicago Department of Family & Support Services Pregnancy Pathway

7 | P a g e

9. Infant Health ______________________________________________________

A. *Name of Pediatrician ________________________ Address: ___________________________ Phone Number: _____________________

B. If client does not have a pediatrician, refer to: [Insert pediatric health care provided listed on medial cooperative agreement.] Date: ____________

C. Meet the Pediatrician visit prior to delivery: Date: ____________

D. “How to Select a Pediatrician” Information Questions to ask when choosing a pediatrician (Ap. 17) Date: ____________

E. Immunization Schedule and parent information. CDC immunization schedule (Ap. 18) Immunizations and well-baby visit (†F6 32) When is your baby sick? (†F6 33) Date: ____________

F. “Soft Bedding Alert”/Safe Sleep Information Crib safety and Back to Sleep (Ap. 20) Date: ____________

G. “SIDS” Prevention Information A safe sleep environment for my baby (†BB 52) Date: ____________

H. “When to Go to the Doctor” Information When to call the doctor (Ap. 21) Date: ____________

10. Infant Safety ____________________________________________ Car:

A. Does client have a car seat? Yes_________ No____ B. Referral to a Certified Car Seat Technician: Yes_________ No____ C. Car seat safety information

Basic car seat safety (Ap. 22) Car seat safety (†F6 7) Date: ____________

Other: D. Crib Safety Information

Soft Bedding (Ap. 24) Date: ____________ E. Infant safety handout

Keeping baby safe (†F6 64) Date: _________ F. Pets Date: ____________ G. _____________________________ Date: _________

Chicago Department of Family & Support Services Pregnancy Pathway

8 | P a g e

Home Safety: H. Smoke Detector Date:____________ I. Carbon Monoxide Detector Date:____________ J. Outlet Covers Date:____________ K. Cabinet Locks Date:____________ L. Sharp Objects out of reach Date:____________ M. Locked Doors Date:____________ N. Floor Check Date:____________ O. Childproofing your home (Ap. 25)

* Denotes required data for COPA 11. Post Partum Care

A. Delivery Method Vaginal _____ Cesarean_____ a. If Cesarean- two week incision check done: Date______________

B. OB/Midwife/PCP 6 week check up appointment date: _______________

Did Mom keep appointment? Yes: _____ No: ____

If no, why not: _______________________________________________

C. Newborn/ Post-Partum Home Visit with Community Health Nurse Date: ____________ Newborn Assessment by Program Community/Public Health Nurse should be done within two weeks of the baby’s birth.

D. Did Client Receive a Post-Partum Depression Screening at 6 Week Post-Partum Visit with Pregnancy Provider? Yes _____ No:__

E. If answer is “no” to receiving a post-partum depression screening by the pregnancy by 7 weeks post-partum, refer to Mental Health Coordinator to do a post-partum depression screening. Date Referral Made: ________________

F. Written information about post-partum depression given to mother: (at 2-week visit) Edinburg Scale completed (Ap. 27) Date: ___________

Taking care of your body (†F6 10) Date: ___________

Postpartum Concerns (†BB 108) Date: ___________

G. Postnatal Nutrition Assessment: See Section 2: Nutrition Support

Chicago Department of Family & Support Services Pregnancy Pathway

9 | P a g e

Comments and Response to Teaching: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Additional Written Resources/Information given to client: ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ Date the Pregnancy Pathway Completed: _____________ All pregnancy information entered into COPA: Yes _____ No: ______

Signatures FSW: ________________________ Date _________________ Supervisor: _____________________ Date _________________ Revised by Ella Trepashko for the MCH Work Group August 2013 Please note: All written documents marked with a “” are indicated in the corresponding appendix. Materials from the curriculum from Florida State’s “Partners For a Healthy Baby” are to be obtained from your site. Each Early Head Start should be equipped with the curriculum. Ap. Appendix †BB Partners for a Healthy Baby: Before Baby Arrives †F6 Partners for a Healthy Baby: First 6 Months

Early Head Start

Pregnancy Packet

Pregnancy Pathway Appendix

Chicago Department of Family & Support Services

Appendix Pregnancy Pathway

Appendix Page No. Section *PFHB ver. and No. (prev. No.)

PFHB = Partners for a Healthy Baby BB = Before Baby Arrives F6 = First 6 Months Page i

1. Prenatal Care

H. Illinois Department of Human Services: Feeding your baby 1 Tips on Pregnancy: How much should I gain? (University Tennessee Extension) 2 Weight loss while breastfeeding 3 Why prenatal care is important BB 18(8) What should I expect at my first prenatal visit BB 19(9) My birth plan BB 88(70) Mother’s bottle guide 4

2. Nutritional Support B. Prenatal Nutrition Assessment 5-6 Postnatal Nutritional Assessment 7-8 C. Food safety during pregnancy 9 Fish Facts: Print and go guide (CDC) 10-11 D. Breastfeeding: best for me and my baby BB 51(56) Myths about breastfeeding BB 50 (55) E. Lactation support resources for Chicago Head Start 12

3. Infant Nutrition Information A. How to feed your baby step by step (Oregon Dairy Council) 13-14 B. Is my baby ready for solid foods? F6 63 C. Suggestions for starting solid foods F6 83 D. How does food nourish my baby? BB 62 (44) E. Healthy things to do for you and your baby BB 21 (15)

5. Pregnancy Education/Information

B. What are the signs of preterm labor? BB 66 (46) What to do if you think you are having preterm labor BB 67 (47) C. Postpartum concerns BB 108 Following a C-Section BB 109 D. Family planning choices (6 pages) BB 41 (88) E. Pregnancy, delivery and after-birth professionals 15 F. How using alcohol and drugs can hurt your baby BB 13 (14) G. Exercising safely during pregnancy BB 38 (31) I. How is my baby developing in the first trimester? BB 28 How is my baby developing in the second trimester? BB 53 How is my baby developing in the third trimester? BB 93 J. Labor and Delivery 16 K. How smoking can hurt your baby BB 12

Chicago Department of Family & Support Services

Appendix Pregnancy Pathway

Appendix Page No. Section *PFHB ver. and No. (prev. No.)

PFHB = Partners for a Healthy Baby BB = Before Baby Arrives F6 = First 6 Months Page ii

9. Infant Health D. Questions to ask when choosing a pediatrician 17 E. Immunization schedule (CDC) 18-19 Immunizations and well-baby visit F6 32 When is your baby sick? F6 33 F. Crib safety and Back to sleep (Safe Kids) 20 G. A safe sleep environment for my baby BB 52 H. When to call the doctor 21

10. Infant Safety C. Basic car seat safety (Safe Kids) 22-23 Car seat safety F6 7 D. Soft bedding (CPSC) 24 E. Keeping baby safe F6 64 O. Childproofing your home (USCPSC) 25-26

11. Post Partum Care F. Edinburg Scale 27-28 Taking care of your body F6 10 Postpartum Concerns BB 108

Page 1

Smart Choices...

Janie BurneyAssociate Professor

Family and Consumer Sciences

Tips on Pregnancy: HowTips on Pregnancy: HowTips on Pregnancy: HowTips on Pregnancy: HowTips on Pregnancy: HowMuch Should I Gain?Much Should I Gain?Much Should I Gain?Much Should I Gain?Much Should I Gain?

SP441-E

The Expanded Food andNutrition Education Program

Women who do not gain enough weight may havebabies who are too small. These babies could haveproblems with:

breathing.feeding.behavior.learning.

Babies who are too small may have more illnessesand sometimes die in the first year.

The amount of weight you should gain depends onyour weight before pregnancy. You should gain:

25 to 35 pounds - if you were a healthy weightbefore pregnancy.

28 to 40 pounds - if you were underweightbefore pregnancy.

15 to 25 pounds - if you were overweightbefore pregnancy.

Why is weight gain important?Why is weight gain important?Why is weight gain important?Why is weight gain important?Why is weight gain important?

How much total weight should I gain?How much total weight should I gain?How much total weight should I gain?How much total weight should I gain?How much total weight should I gain?

Uterus (womb)2 - 2 1/2 lbs.

Amniotic Fluid1 1/2 - 2 lbs.

Placenta1 - 2 lbs.

Breasts1 1/2 - 2 lbs.

Blood2 1/2 - 3 1/2 lbs.

Baby7 - 8 1/2 lbs.

Fluid3 - 6 lbs.

The weight you gain during pregnancyThe weight you gain during pregnancyThe weight you gain during pregnancyThe weight you gain during pregnancyThe weight you gain during pregnancyhelps your baby grow. The weight goeshelps your baby grow. The weight goeshelps your baby grow. The weight goeshelps your baby grow. The weight goeshelps your baby grow. The weight goesnot only to the baby, but to othernot only to the baby, but to othernot only to the baby, but to othernot only to the baby, but to othernot only to the baby, but to otherparts of your body.parts of your body.parts of your body.parts of your body.parts of your body.

Where does the weight go?Where does the weight go?Where does the weight go?Where does the weight go?Where does the weight go?

Maternal Fat6 1/2 - 9 lbs.

Page 2

Weight Loss While Breastfeeding

B r e a s t f e e d i n g i s b e s t f o r m o m s a n d t h e i r b a b i e s f o r s e v e r a l

r e a s o n s . B e s i d e s p r o v i d i n g n o u r i s h m e n t a n d h e l p i n g t o p r o t e c t

y o u r b a b y a g a i n s t b e c o m i n g s i c k , b r e a s t f e e d i n g m a y h e l p y o u

l o s e t h e w e i g h t g a i n e d i n p r e g n a n c y . M o d e r a t e e x e r c i s e a n d

e a t i n g l e s s c a n h e l p b r e a s t f e e d i n g m o t h e r s l o s e w e i g h t .

A great time to lose weight after pregnancy is while breastfeeding. Breastfeeding may make it easier to lose weight because you are using extra calories to

feed your infant. Women who breastfeed exclusively for more than 3 months tend to lose more weight

than those who do not. Those who continue breastfeeding beyond 4-6 months may continue to lose weight.

Continue to visit your doctor or health care provider while you are breastfeeding. He or she can keep track of your weight and tell you if you are losing weight as you should.

If you are not losing weight or losing too slowly, cut back on the calories you are

currently eating. The best way to eat fewer calories is by decreasing the amount of "empty calories" you

are eating. "Empty calories" are the calories from added sugars and solid fats, in foods like soft drinks, desserts, fried foods, cheese, whole milk, and fatty meats. Look for choices that are low-fat, fat-free, unsweetened, or with no-added-sugars. They have fewer "empty calories."

If you are losing weight too fast, you need to eat more calories. You can do this by eating a little more from each food group. Try adding a healthy snack each day, or increasing portion sizes at meals. If you keep losing weight faster than you want to, check with your doctor.

"Weight Loss While Breastfeeding." ChooseMyPlate.gov. May 2013.

http://www.choosemyplate.gov/pregnancy-breastfeeding/weight-loss.html

Page 3

Mother’s Bottle Guide

Cleanliness is key!

• Discard Any content remaining 2 hours after feeding

• Discard Prepared formula after 24 hours

• Breastmilk can be refrigerated or frozen

• Discard Refrigerated breastmilk after 48 hours

• Discard Frozen breastmilk after 2 weeks

• Washing bottles with soap/water then sanitizing chemically (in dishwasher) or by boiling before reuse

• Setting all bottles to air-dry upside-down

Helpful Tips:

• Always washing hands prior to feeding

• Thaw frozen breastmilk in refrigerator or under warm running water

• DO NOT thaw breastmilk by allowing it to sit on the counter for a few

hours/overnight. This stimulates the growth of unhealthy bacteria.

• Use FIFO method: First In, First Out; When using refrigerated/frozen

breastmilk, always use the oldest first

Page 4

Mother’s information: Last: First: M.I. Age:

Home Address: Telephone:

Medical Provider’s Name/ Address/Phone: Name:_ Address: Phone:_ _ When is the due date of your baby? ___/___/___ What is the date of your next scheduled prenatal care visit? ___/___/___ What was the date of your most recent past prenatal care visit? ___/___/___ When mother did first see a physician or attend a clinic for prenatal care? ___/___/___ How much weight have you gained during your pregnancy so far? ______ Do you have any concerns about your current weight or weight gain? ____ How many times have you been pregnant? ___ _ How many children have you given birth to?_ ___ How long has it been since you last delivery? First time: ____ Less than 18 months: ____ More than 18 months: ____ Have you given birth to a child that was under 5lbs? Yes: _____ No: _____ Have you given birth to a child that was over 10lbs? Yes: _____ No: _____ Have you ever been diagnosed with diabetes? Yes: _____ No: _____ If yes what type? Gestational:___ Type I:___ Type II:___ Are you currently taking any medications such as prescriptions, insulin, OTC medications like aspirin? If yes please specify:

Yes: _____ No: _____

Do you currently take a prenatal vitamin, multivitamin or individual vitamin supplement such as iron, folic acid, vitamin C, vitamin B12, or calcium? If yes please specify:

Yes: _____ No: _____

Do you take an iron supplement? Yes: _____ No: _____ Are you currently taking any herbal supplements? Yes: _____ No: _____ If yes please specify: Are you currently consuming or have an appetite for any non-food substances (i.e. clay, chalk, ice chips, cornstarch)?

Yes: _____ No: ____

Have you used any of the following substances during your pregnancy? ___Street Drugs ___Cigarettes/Tobacco ___Caffeine* ___Alcohol ___Prescription Drugs ___Non Rx Drugs ___Iron Supplements ___Exposure to second hand smoke? *Caffeine examples: Red Bull, Soda Products, Tea, Coffee, 5 Hour Energy, Monster

Page 5

Have you participated in any of the following educational groups?

_ Prenatal Exercise _ Preparing for Baby Care _ Personal Development

_ Prenatal General Discussion _ Parenting Education _ Birth Education(i.e. Lamaze)

_ Breast Feeding Preparation _ Doula Other: _

Do you have any interest in pursuing any of the above education? Yes: _____ No: _____ Have you received any breastfeeding resource information? Yes: _____ No: _____ How do you plan on feeding your baby? ___Unsure ___Breastfeed ___Formula Have you received any prenatal care or counseling from someone other than your Primary Care provider? Yes: _____ No: _____ Please specify if yes: _ _ How many times per day do you eat the following foods?

Fruit 0 1 2 3 4 ≥5 Vegetables 0 1 2 3 4 ≥5

Meat/Poultry/Beans/Fish 0 1 2 3 4 ≥5 Grains (Bread, Pasta, Rice) 0 1 2 3 4 ≥5

Dairy (Yogurt, Cheese, Milk) 0 1 2 3 4 ≥5 Sweets/Dessert/Soda 0 1 2 3 4 ≥5

Water (8 ounces) 0 1 2 3 4 ≥5 Do you follow a diet such as vegetarian, cultural or prescribed by doctor? Yes: _____ No: _____ Please specify if yes: _ _ How many times per week to you engage in physical activity? __ _ List type of activity Amount of time (in minutes) spent

Do you participate in the WIC Program, food stamps, or local pantry? _ _ Is there enough safe food for you and the family in the house?__ Do you have any questions about your pregnancy or nutrition during your pregnancy?

_

Mother’s Signature:_ Date: _ Home Visitor Signature:_ Date:_ RN or RD Signature:_ Date:__

Page 6

Mother’s information: Last: First: M.I. Age:

Home Address: Telephone:

Medical Provider’s Name/ Address/Phone: Name:_

Address: Phone:_ _ How much did your baby weigh when it was born? Have you ever been diagnosed with diabetes? Yes: _____ No: _____ If yes what type? Gestational:___ Type I:___ Type II:___

Do you currently take a prenatal vitamin, multivitamin or individual vitamin supplement such as iron, folic acid, vitamin C, vitamin B12, or calcium?

Yes: _____ No: _____ If yes please specify

Do you take an iron supplement? Yes: _____ No: _____ Do you take a vitamin D supplement? Yes: _____ No: _____ Are you currently taking any medications such as prescriptions, insulin, OTC medications like aspirin? If yes please specify:

Yes: _____ No: _____

Are you currently taking any herbal supplements? Yes: _____ No: _____ If yes please specify: Are you currently consuming or have an appetite for any non-food substances (i.e. clay, chalk, ice chips, cornstarch)?

Yes: _____ No: ____

Have you used any of the following substances during your pregnancy? ___Street Drugs ___Cigarettes/Tobacco ___Caffeine* ___Alcohol ___Prescription Drugs ___Non Rx Drugs ___Iron Supplements ___Exposure to second hand smoke?

*Caffeine examples: Red Bull, Soda Products, Tea, Coffee, 5 Hour Energy, Monster

Have you participated in any of the following educational groups?

_ Prenatal Exercise _ Preparing for Baby Care _ Personal Development

_ Prenatal General Discussion _ Parenting Education _ Birth Education(i.e. Lamaze)

_ Breast Feeding Preparation _ Doula Other: _ Have you received any prenatal care or counseling from someone other than your Primary Care provider? Yes: _____ No: _____ Please specify if yes: _ _

Page 7

How are you feeding your baby? ___Breastfeeding ___Formula Other/Details: _ _ How many times per day does your baby feed? _ _ How much formula or breastmilk (if known) does your baby consume? _ __ Do you have any concerns if breastfeeding? Yes: _____ No: _____ If yes, please describe: _ Has mother sought / been given information on lactation resources? Yes: _____ No: _____ How many times per day do you eat the following foods?

Fruit 0 1 2 3 4 ≥5 Vegetables 0 1 2 3 4 ≥5

Meat/Poultry/Beans/Fish 0 1 2 3 4 ≥5 Grains (Bread, Pasta, Rice) 0 1 2 3 4 ≥5

Dairy (Yogurt, Cheese, Milk) 0 1 2 3 4 ≥5 Sweets/Dessert/Soda 0 1 2 3 4 ≥5

Water (8 ounces) 0 1 2 3 4 ≥5 Do you follow a diet such as vegetarian, cultural or prescribed by doctor? Yes: _____ No: _____ Please specify if yes: _ _

How many times per week do you engage in physical activity? __ _ List type of activity Amount of time (in minutes) spent

Do you participate in the WIC Program, food stamps, or local pantry? _ _ Is there enough safe food for you and the family in the house?__ Do you have any additional nutrition questions at this time? _ _

Mother’s Signature:_ Date: _ Home Visitor Signature:_ Date:_ RN or RD Signature:_ Date:__

Page 8

Food Safety During Pregnancy

Pregnant women and their growing babies are at an increased risk to develop a food born illness. It

is important to make sure that you are always practicing good food safety practices.

It is recommended that pregnant women avoid certain foods during their pregnancy:

Alcohol

consumption is harmful to the developing baby.

Deli meats – unless steamed, cooked, or heated before eating

deli meats (like turkey, ham, beef for example) may harbor bacteria that is harmful to a pregnant

mother. Heating the meats before putting them in a sandwich is acceptable. Restaurants may

heat these up for you upon request.

Deli salads made in store

salads (such as potato, tuna, egg) may harbor bacteria that is harmful to a pregnant mother. If

you make a salad, ensure it is stored correctly to prevent against bacterial growth.

Soft cheeses

may harbor bacteria that is harmful to a pregnant mother.

Raw shellfish

may have bacteria that is harmful to a pregnant mother. Cooking shellfish appropriately is

acceptable.

Unpasteurized juice or milk

may harbor bacteria that is harmful to a pregnant mother.

Raw sprouts such as alflafa

may harbor bacteria that is harmful to a pregnant mother.

Uncooked cookie dough or batter

has raw eggs that may harbor bacteria that is harmful to a pregnant mother.

Practice good food safety habits every day:

Make sure all meats, eggs, and fish are cooked thoroughly.

Rinse all produce (fruits and vegetables) before eating.

Avoid cross contamination by keeping raw and cooked foods separate from each other,

especially when preparing foods and using cutting boards.

Wash your hands before cooking, eating, when changing diapers, using the washroom or

covering your mouth when coughing or sneezing.

To learn about food safety, ask your Head Start site about education sessions offered

or visit the website www.FDA.gov. Head Start Nutrition Services

Dominican University: August 2013

Page 9

page 1

H e a lt H y P r e g n a n c y

U.S. Department of Health and Human Services, Office on Women’s Health

http://www.womenshealth.gov

800-994-9662

TDD: 888-220-5446

Fish FactsPrint-and-Go Guide

Fish Facts for Women Who Are Pregnant or Breastfeeding Fish and shellfish are an important part of a healthy diet. They are a great source of protein and heart-healthy omega-3 fatty acids for people of all ages. The nutrients in seafood are important for unborn babies, as well as for infants and young children. Research shows that omega-3 fatty acids eaten by pregnant women may aid in babies’ brain and eye development. Also, some researchers believe depression in women during and after pregnancy may be related to not eating enough fish.

Women who are pregnant or breastfeeding should eat at least 8 ounces and up to 12 ounces of a variety of seafood per week to get the health benefits. Unfortunately, some pregnant and nursing women do not eat any fish because they worry about mercury in seafood. Mercury is a metal that, at high levels, can harm the brain of your unborn baby even before he or she is conceived. Yet many types of seafood have little or no mercury at all. So your risk of mercury exposure depends on the amount and type of seafood you eat.

Women who are pregnant or breastfeeding can safely eat a large variety of cooked seafood, but should not eat a few kinds of fish that contain high levels of mercury. Keep in mind that removing all fish from your diet will rob both you and your baby of all the nutritional benefits that seafood provides, including important omega-3 fatty acids. To reach the recommended amount of 8 to12 ounces per week while limiting exposure to mercury, follow these tips:

• Eatavarietyofcooked*seafoodthatcontainslittleornomercury,suchasthesetypesthatarehigherinomega-3fattyacids:

• Salmon

• Anchovies

• Herring

• Sardines

• Pacificoysters

• Trout

• AtlanticandPacificmackerel(notKingmackerel)

* Don’t eat uncooked fish or shellfish (such as clams, oysters, scallops), which includes refrigerated uncooked seafood labeled nova-style, lox, kippered, smoked, or jerky. Uncooked seafood may contain bacteria that are harmful during pregnancy.

Page 10

page 2

H e a lt H y P r e g n a n c y

• Limitwhite(albacore)tunato6ounces(about1serving)perweek.

• Donoteatthesefish,whicharehighinmercury:

• Swordfish

• Tilefish

• Kingmackerel

• Shark

• Checkbeforeeatingfishcaughtinlocalwaters.State health departments have guidelines on fish from local waters. Or get local fish advisories from the U.S. EnvironmentalProtectionAgency.Donoteatfishfromlocalwatersunlessyourstatehealth department says that doing so is safe. If you are unsure about the safety of a fish that you have already eaten, don’t eat any other fish that week.

• Eatavarietyofcookedseafoodratherthanjustafewtypes.

FoodssupplementedwithDHA/EPA(suchas“omega-3eggs”)andprenatalvitaminssupplementedwithDHAareothersourcesofthetypeofomega-3fattyacidsfoundinseafood.

Fish Facts was reviewed by:

RafaelPerez-Escamilla,Ph.D.ProfessorofEpidemiology&PublicHealthDirector,OfficeofCommunityHealthYaleSchoolofPublicHealth

ContentlastupdatedAugust22,2011.

U.S. Department of Health and Human Services, Office on Women’s Health

http://www.womenshealth.gov

800-994-9662

TDD: 888-220-5446

Page 11

Breastfeeding Lactation Support Resources for Chicago

Listed are lactation support groups that can be contacted for breastfeeding and lactation support for new

or expecting mothers. Please call ahead for times and meeting locations.

La información de contacto para el grupo de apoyo a la lactancia. Por favor llame para más información.

Abiyamo Omo Society at UIC Medical Center

1740 West Taylor St, Chicago, IL

773-600-8046

Breastfeeding Support Group at Norwegian American Hospital

1044 North Francisco Ave, Chicago, IL

773-292-8228

Bosom Buddy Breastfeeding Mom's Support Group at St. Bernard Hospital

326 West 64th St, Chicago, IL

773-962-4017 (RSVP Required)

Chicago Family Health Center Breastfeeding Program

C.F.H.C. location: 9119 South Exchange, Chicago, IL

773-768-5000 x1029

Roseland Area: 556 E 115th St

773-768-5000 x1512

South Side La Leche Group

Quaker House

5615 South Woodlawn Ave, Chicago, IL

773-783-9905

La Leche Espanol Group

Erie Family Health Center

2750 West North Ave, Chicago, IL

773-790-0419

La Leche Beverly Group

East Meeting Room of St. Barnabas' Convent

10161 South Longwood Dr, Chicago, IL

773-454-1318

Mercy Hospital Breastfeeding Basics

2525 South Michigan Ave, Chicago, IL

312-567-2441

Roseland Community Hospital WIC Program

11255 South Michigan Ave, Chicago, IL

773-785-1173 x17

Page 12

Fo

r th

e f

ull s

ized

do

cu

men

t to

use

fo

r p

are

nt

ed

ucati

on

ple

ase

do

wn

load

fro

m t

he

follo

win

g s

ite f

rom

th

e O

reg

on

Dair

y C

ou

ncil

. h

ttp

://w

ww

.ore

go

nd

air

yco

un

cil.o

rg/r

eso

urc

es/

free_d

ow

nlo

ad

s/d

ow

nlo

ad

s/h

tfyb

_en

glish

_201

2.p

df

For the full-sized document, please see the Oregon Diary Council Website

Page 13

Fo

r th

e f

ull s

ized

do

cu

men

t to

use

fo

r p

are

nt

ed

ucati

on

ple

ase

do

wn

load

fro

m t

he

follo

win

g s

ite f

rom

th

e O

reg

on

Dair

y C

ou

ncil

. h

ttp

://w

ww

.ore

go

nd

air

yco

un

cil.o

rg/r

eso

urc

es/

free_d

ow

nlo

ad

s/d

ow

nlo

ad

s/h

tfyb

_en

glish

_201

2.p

df

For the full-sized document, please see the Oregon Diary Council Website

Page 14

Professionals that work with pregnant mothers during

pregnancy, delivery and after birth

Doula – A doula is professionally trained and experienced in giving social support to birthing

families during pregnancy, labor, and birth and at home during the first few days or weeks

after birth. Those who are trained in breastfeeding can help you be more successful with

breastfeeding after birth.

Doulas can be hired privately by the mother to work with her throughout the pregnancy. They

may also be employed by hospitals or clinics to work with the pregnant/new mothers while at

the facility.

Birth Doula – A birth doula is a person trained and experienced in childbirth who provides

continuous physical, emotional and informational support to the mother before, during and

just after childbirth.1

Postpartum Doula – What a postpartum doula does changes from day to day, as the needs of

the family change. Postpartum doulas do whatever a mother needs to best enjoy and care for

her new baby. Postpartum doulas also make sure the mother is fed, well hydrated and

comfortable. They may assist with breastfeeding education.1

International Board Certified Lactation Consultant (IBCLC)

Lactation consultants are credentialed breastfeeding professionals. IBCLCs

are experienced in helping mothers to breastfeed comfortably by helping

with positioning, latch, and a wide range of breastfeeding concerns. Many

IBCLCs are also nurses, doctors, speech therapists, dietitians, or other kinds

of health professionals.2

Breastfeeding Peer Counselor or Educator

A breastfeeding counselor or educator can teach others about the

benefits of breastfeeding and help women with basic breastfeeding

challenges and questions. A "peer" means a person has breastfed

her own baby and is available to help other mothers.2

1Definitions adapted from the Doulas of North America (DONA) website definitions of Doulas. Found at http://www.dona.org

2Adapted from Office on Women's Health in the Office of the Assistant Secretary for Health at http://womenshealth.gov

Dominican University Head Start Nutrition Services 2013

Page 15

Stages of Labor

The First Stage of Labor

The first stage is the start of labor and lasts until the cervix is fully open at 10 centimeters. This is

the longest stage of labor and can last 12 to 17 hours.

This stage is divided into early labor, active labor and transition.

1. During early labor, the cervix dilates from 0 to 3 centimeters.

Contractions may last 30 to 60 seconds and occur every 5 to 20 minutes. There may be a

pink, slightly bloody or mucous discharge from the vagina. Backache, nausea and diarrhea

may also occur.

2. During active labor, the cervix dilates to about 7 centimeters.

Contractions become stronger and longer, lasting about 1 minute and repeating every 2 to

4 minutes. Pain medicine may be given at this time.

3. During transition, the cervix dilates to 10 centimeters. Contractions are stronger and occur

more often. Intense pressure in the lower back and rectum may be felt.

What you can do:

Relax between contractions. Use the breathing or relaxation techniques you learned in

childbirth classes or ask your nurse for help. Do not push until you are told to do so.

The Second Stage of Labor

The second stage begins when the cervix is fully open and lasts until the baby is delivered,

about 2 to 4 hours based on whether or not this is the first baby and whether an epidural

is in place. During this time, staff will tell you when you can push and help support your

body as you deliver your baby.

What you can do:

You will be encouraged to push with each contraction. You may be told to push more gently

or to stop pushing at times.

The Third Stage of Labor

The third stage is the delivery of the afterbirth called the placenta. This is the shortest stage

of labor, lasting 30 minutes.

What you and your partner can do:

Relax and enjoy this time with your baby.

Talk to the staff if you have any questions or concerns at any time during labor and delivery.

2007 – 1/2012 Health Information Translations

Unless otherwise stated, user may print or download information from www.healthinfotranslations.org for personal, non-commercial use only. The medical information found

on this website should not be used in place of a consultation with your doctor or other health care provider. You should always seek the advice of your doctor or other

qualified health care provider before you start or stop any treatment or with any questions you may have about a medical condition. Wexner Medical Center at The Ohio State

University, Mount Carmel Health System, OhioHealth and Nationwide Children’s Hospital are not responsible for injuries or damages you may incur as a result of your stopping

medical treatment or your failure to obtain medical treatment.

Updated stages of labor from the Nov 2012, Am. College of Obstetrics and Gynecologists, Vol 120, #5.

Page 16

Questions to Ask When Choosing a Pediatrician or Family Practice Doctor

When having a baby there are many decisions to be made. One decision is to select the best pediatrician for your newborn. Take the time to research a couple of pediatricians to make sure you are comfortable with your choice.

It is a good idea to interview potential doctors before the baby is born. Providers usually welcome these appointments and do not charge for prenatal interviews but occasionally some do. Check in advance that the provider accepts your health insurance.

• Come prepared by writing down things you do not want to forget. • Ask questions. If you do not understand, have the doctor explain it again to you.

Repeat back what the doctor says to ensure that the topic is understood clearly. • Make sure you have understood all the information the doctor has given you

by repeating it back from your notes.

Questions you may want to ask:

1. What are your qualifications? 2. Are you a member of the American Academy of Pediatrics or any other specialty

organization? 3. How long have you been in practice? 4. What hospitals do you have privileges? 5. What is your philosophy about child rearing? Do your homework and read up on

your issues of interest before this conversation. For example, our may want to know the doctors views on breastfeeding, co-sleeping, vaccinations or circumcision.

6. Do you return patient calls yourself? 7. Do you have a “sick-child” waiting room? 8. If you share a practice, will my child always see you? 9. Do you have evening or weekend appointments? 10. Is there a 24-hour answering service that can connect me to a doctor or a nurse

call line? 11. Who covers for you when you are on vacation? 12. How much time do you schedule for well-baby visits?

Page 17

At 1

mon

th o

f age

, Hep

B (1

-2

mon

ths)

, At

2 m

onth

s of a

ge, H

epB

(1-2

m

onth

s), D

TaP,

PCV,

Hib

, Pol

io,

and

RVAt

4 m

onth

s of a

ge, D

TaP,

PCV,

H

ib, P

olio

, and

RV

At 6

mon

ths o

f age

, Hep

B (6

-18

mon

ths)

, DTa

P, PC

V, H

ib, P

olio

(6

-18

mon

ths)

, RV,

and

Influ

enza

(y

early

, 6 m

onth

s thr

ough

18

year

s)*

At 1

2 m

onth

s of a

ge, M

MR

(12-

15

mon

ths)

, PCV

(12-

15 m

onth

s)† ,

Hib

(12-

15 m

onth

s), V

aric

ella

(1

2-15

mon

ths)

, Hep

A (1

2-23

m

onth

s)§ , a

nd In

fluen

za (y

early

, 6

mon

ths t

hrou

gh 1

8 ye

ars)

*At

4-6

yea

rs, D

TaP,

IPV,

MM

R,

Varic

ella

, and

Influ

enza

(yea

rly, 6

mon

ths t

hrou

gh 1

8 ye

ars)

*

2013

Rec

om

men

ded

Imm

un

izat

ion

s fo

r C

hil

dre

n fr

om

Bir

th T

hro

ug

h 6

Yea

rs O

ld

Bir

th1

mon

th2

mon

ths

4

mon

ths

6

mon

ths

12mon

ths

15mon

ths

18mon

ths

19–2

3mon

ths

2–3

years

4–6

years

Hep

B

RV

RV

RV

DTa

P D

TaP

DTa

P D

TaP

Hib

H

ib

Hib

PCV

PC

V

PCV

IP

V

IP

V

IP

V

MM

R

Va

rice

lla

Hep

BH

epB

DTa

P

Hep

A§

MM

RVa

rice

lla

PCV

Hib

IPV

Influ

enza

(Yea

rly)

*

Shad

ed b

oxes

indi

cate

the

vacc

ine

can

be g

iven

dur

ing

show

n ag

e ra

nge.

Is y

our f

amily

gr

owin

g? To

pro

tect

yo

ur n

ew b

aby

and

yo

urse

lf ag

ains

t who

opin

g co

ugh,

get

a T

dap

vacc

ine

tow

ards

the

end

of e

ach

preg

nanc

y. T

alk

to y

our

doct

or fo

r mor

e de

tails

.

NO

TE:

If yo

ur c

hild

mis

ses a

shot

, yo

u do

n’t n

eed

to st

art o

ver,

just

go

back

to y

our c

hild

’s

doct

or fo

r the

nex

t sho

t.

Talk

with

you

r chi

ld’s

doct

or

if yo

u ha

ve q

uest

ions

ab

out v

acci

nes.

FOO

TNO

TES:

*

T wo

dose

s giv

en a

t lea

st fo

ur w

eeks

apa

rt a

re re

com

men

ded

for c

hild

ren

aged

6 m

onth

s thr

ough

8 y

ears

of

age

who

are

get

ting

a flu

vac

cine

for t

he fi

rst t

ime

and

for s

ome

othe

r chi

ldre

n in

this

age

gro

up.

§ Tw

o do

ses o

f Hep

A va

ccin

e ar

e ne

eded

for l

astin

g pr

otec

tion.

The

firs

t dos

e of

Hep

A va

ccin

e sh

ould

be

give

n be

twee

n 12

mon

ths a

nd 2

3 m

onth

s of a

ge. T

he se

cond

dos

e sh

ould

be

give

n 6

to 1

8 m

onth

s lat

er.

Hep

A va

ccin

atio

n m

ay b

e gi

ven

to a

ny c

hild

12

mon

ths a

nd o

lder

to p

rote

ct a

gain

st H

epA.

Chi

ldre

n an

d ad

oles

cent

s who

did

not

rece

ive

the

Hep

A va

ccin

e an

d ar

e at

hig

h-ris

k, sh

ould

be

vacc

inat

ed a

gain

st H

epA.

If yo

ur c

hild

has

any

med

ical

cond

ition

s tha

t put

him

at r

isk

for i

nfec

tion

or is

trav

elin

g ou

tsid

e th

e

Uni

ted

Stat

es, t

alk

to y

our c

hild

’s do

ctor

abo

ut a

dditi

onal

vac

cine

s tha

t he

may

nee

d.

See

bac

k p

age

fo

r m

or

e

info

rm

atio

n o

n

vac

cin

e-

p

rev

ent

abl

e

dis

ease

s an

d t

he

v

acci

nes

th

at

pr

even

t t

hem

.

For m

ore

info

rmat

ion,

cal

l tol

l fre

e

1-80

0-CD

C-IN

FO (1

-800

-232

-463

6)

or v

isit

http

://w

ww

.cd

c.go

v/va

ccin

es

Page 18

Vac

cin

e-P

reve

nta

ble

Dis

ease

s an

d t

he

Vac

cin

es t

hat

Pre

ven

t Th

em

Dise

ase

Vacc

ine

Dise

ase s

prea

d by

Dise

ase s

ympt

oms

Dise

ase c

ompl

icatio

ns

Chick

enpo

xVa

ricell

a vac

cine p

rote

cts ag

ainst

chick

enpo

x.Ai

r, dire

ct co

ntac

tRa

sh, t

iredn

ess,

head

ache

, feve

rIn

fecte

d blis

ters,

blee

ding d

isord

ers,

ence

phali

tis (b

rain

swell

ing),

pneu

mon

ia (in

fectio

n in t

he lu

ngs)

Diph

ther

iaDT

aP* v

accin

e pro

tects

again

st dip

hthe

ria.

Air, d

irect

cont

act

Sore

thro

at, m

ild fe

ver, w

eakn

ess,

swoll

en

gland

s in n

eck

Swell

ing of

the h

eart

mus

cle, h

eart

failur

e, co

ma,

para

lysis,

deat

h

Hib

Hib v

accin

e pro

tects

again

st Ha

emop

hilus

infl

uenz

ae ty

pe b.

Air, d

irect

cont

act

May

be no

sym

ptom

s unl

ess b

acte

ria

ente

r the

bloo

d

Men

ingiti

s (inf

ectio

n of

the c

over

ing ar

ound

the b

rain

and s

pinal

cord

), int

ellec

tual

disab

ility,

epigl

ottit

is (li

fe-

thre

aten

ing in

fectio

n tha

t can

bloc

k the

wind

pipe a

nd

lead t

o ser

ious b

reat

hing p

roble

ms),

pneu

mon

ia (in

fec-

tion i

n the

lung

s), de

ath

Hepa

titis

AHe

pA va

ccine

prot

ects

again

st he

patit

is A.

Dire

ct co

ntac

t, co

ntam

inate

d fo

od or

wat

er

May

be no

sym

ptom

s, fev

er, st

omac

h pain

, los

s of a

ppet

ite, fa

tigue

, vom

iting

, jaun

dice

(yello

wing

of sk

in an

d eye

s), da

rk ur

ine

Liver

failu

re, ar

thra

lgia (

joint

pain)

, kidn

ey, p

ancre

atic,

an

d bloo

d diso

rder

s

Hepa

titis

BHe

pB va

ccine

prot

ects

again

st he

patit

is B.

Cont

act w

ith bl

ood o

r bo

dy flu

ids

May

be no

sym

ptom

s, fev

er, he

adac

he,

weak

ness,

vom

iting

, jaun

dice (

yello

wing

of

skin

and e

yes),

joint

pain

Chro

nic liv

er in

fectio

n, liv

er fa

ilure,

liver

canc

er

Flu

Flu va

ccine

prot

ects

again

st infl

uenz

a.Ai

r, dire

ct co

ntac

tFe

ver, m

uscle

pain,

sore

thro

at, c

ough

, ex

trem

e fat

igue

Pneu

mon

ia (in

fectio

n in t

he lu

ngs)

Mea

sles

MM

R** v

accin

e pro

tects

again

st m

easle

s.Ai

r, dire

ct co

ntac

tRa

sh, fe

ver, c

ough

, run

ny no

se, p

inkey

eEn

ceph

alitis

(bra

in sw

elling

), pn

eum

onia

(infec

tion i

n th

e lun

gs),

deat

h

Mum

psM

MR*

*vac

cine p

rote

cts ag

ainst

mum

ps.

Air, d

irect

cont

act

Swoll

en sa

livar

y glan

ds (u

nder

the j

aw),

fever,

he

adac

he, t

iredn

ess,

mus

cle pa

in

Men

ingiti

s (inf

ectio

n of t

he co

verin

g aro

und t

he br

ain

and s

pinal

cord

) , en

ceph

alitis

(bra

in sw

elling

), infl

am-

mat

ion of

testi

cles o

r ova

ries,

deafn

ess

Pert

ussis

DTaP

* vac

cine p

rote

cts ag

ainst

pertu

ssis

(who

oping

coug

h).

Air, d

irect

cont

act

Seve

re co

ugh,

runn

y nos

e, ap

nea (

a pau

se in

br

eath

ing in

infan

ts)Pn

eum

onia

(infec

tion i

n the

lung

s), de

ath

Polio

IPV v

accin

e pro

tects

again

st po

lio.

Air, d

irect

cont

act,

thro

ugh

the m

outh

May

be no

sym

ptom

s, so

re th

roat

, feve

r, na

usea

, hea

dach

ePa

ralys

is, de

ath

Pneu

moc

occa

lPC

V vac

cine p

rote

cts ag

ainst

pneu

moc

occu

s.Ai

r, dire

ct co

ntac

tM

ay be

no sy

mpt

oms,

pneu

mon

ia (in

fectio

n in

the l

ungs

)Ba

ctere

mia

(bloo

d inf

ectio

n), m

ening

itis (

infec

tion o

f th

e cov

ering

arou

nd th

e bra

in an

d spin

al co

rd),

deat

h

Rota

viru

sRV

vacc

ine pr

otec

ts ag

ainst

rota

virus

.Th

roug

h the

mou

thDi

arrh

ea, fe

ver, v

omiti

ngSe

vere

diar

rhea

, deh

ydra

tion

Rube

llaM

MR*

* vac

cine p

rote

cts ag

ainst

rube

lla.

Air, d

irect

cont

act

Child

ren i

nfec

ted w

ith ru

bella

viru

s som

etim

es

have

a ra

sh, fe

ver, s

wolle

n lym

ph no

des

Very

serio

us in

preg

nant

wom

en —

can l

ead t

o misc

ar-

riage

, stil

lbirth

, pre

mat

ure d

elive

ry, bi

rth de

fects

Teta

nus

DTaP

* vac

cine p

rote

cts ag

ainst

teta

nus.

Expo

sure

thro

ugh c

uts i

n skin

Stiff

ness

in ne

ck an

d abd

omina

l mus

cles,

diffi

culty

swall

owing

, mus

cle sp

asm

s, fev

erBr

oken

bone

s, br

eath

ing di

fficu

lty, d

eath

* DTa

P com

bines

prot

ectio

n aga

inst d

iphth

eria,

teta

nus,

and p

ertu

ssis.

** M

MR c

ombin

es pr

otec

tion a

gains

t mea

sles,

mum

ps, a

nd ru

bella

.La

st u

pdat

ed o

n 03

/20/

2013

• CS

239274-A

Page 19

Safe Kids Worldwide ❉ Baby Safety Basics ❉ 2

Remember that the Cribs for Kids Graco Pack n’ Play was made for

babies who are less than 35 inches tall and weigh less than 30 lbs.

Crib SafetyMore babies die each year in incidents involving cribs, than from any other nursery product. Your baby spends a lot of time unsupervised in the crib, so learn to make it a safer place.

BUYING A SAFE CRIB

All new cribs on the market today meet the safety standards of the Consumer Product Safety Commission (CPSC) and the Juvenile Products Manufacturers Association (JPMA).

Before getting a used crib, check to see if it has been recalled at www.recalls.gov. Also, look for the following suffocation and strangulation hazards:

• Sharp or jagged edges

• Missing, broken or loose parts

• Loose hardware

• Cut out designs in the headboard or footboard

• Crib slats more than 2 3/8 inches apart (width of a soda can)

• Corner post extension over 1/16 of an inch high

• Gaps larger than 2 fingers width between the sides of the crib and the mattress

• Drop side latches that could be easily released by your baby

When using any crib:

• Follow the directions for assembly.

• Don’t try to fix any part of it with tape, wire, a rope, or by putting a broken side up against the wall.

Back to Sleep Soft bedding can suffocate a baby, blocking the baby’s airway during sleep. Babies can suffocate when their faces become wedged against or buried in a mattress, pillow or other soft object. This can also happen when someone in the same bed rolls over onto them.

Room-sharing is a safer option than having your baby sleep in bed with you. Place your baby’s crib, play yard or bassinet in your room during the first 6 months for more convenient feeding and close contact. Remember to always return your baby to his or her own crib when you’re ready to go back to sleep.

DOS AND DON’TS OF SAFE SLEEP DO:

• Lay your baby on his or her back to sleep to reduce the risk of SIDS (Sudden Infant Death Syndrome.)

• Use a safe crib with a firm, tight-fitting mattress covered with a crib sheet and nothing else in it.

• To keep your baby warm, use a sleep sack (wearable blanket).

DON’T:

Do not put your baby to sleep on beds, sofas, recliners, chairs, soft surfaces, bouncy chairs, baby swings, or car seats. • Do not use pillows, loose sheets or blankets, stuffed

toys, crib bumpers, sleep positioners, and other soft bedding products.

Page 20

When to call the doctor

When you are pregnant don't wait to call your doctor or midwife if something is bothering or worrying you. Sometimes physical changes can be signs of a problem.

Call your doctor or midwife as soon as you can if you:

• Are bleeding or leaking fluid from the vagina

• Have sudden or severe swelling in the face, hands, or fingers

• Get severe or long-lasting headaches

• Have discomfort, pain, or cramping in the lower abdomen

• Have a fever or chills (temperature greater than 100.4)

• Are vomiting or have persistent nausea

• Feel discomfort, pain, or burning with urination

• Have problems seeing or blurred vision

• Feel dizzy

• Suspect your baby is moving less than normal after 28 weeks of pregnancy

• Have thoughts of harming yourself or your baby

Page 21

All children must use a car seat, booster seat or seat belt.

My child always rides in a back seat and never in front of an airbag.

Everyone in my car buckles up on every ride using the right car seat, booster seat or seat belt for each person’s age and size.

My child’s car seat has all of its parts, labels and instructions and has never been in a crash.

I follow the instructions for my car and my car seat so that my child is buckled in right.

I never leave my child alone in a car.

If I have any car seat questions, I know I can contact Safe Kids USA.

1

Program Sponsor

Proud Program SupporterSafe Kids USA202-662-0600

1301 Pennsylvania Avenue, NWSuite 1000

Washington, DC 20004

www.safekids.org

Basic Car Seat SafetyDon’t put your child at risk—buckle up the right way on every ride!

Page 22

2©2011 Safe Kids Worldwide

She always rides in a back seat and never in front of an air bag.

She always rides in a car seat made for her size and age.

She sits facing the back of the car in her car seat.

The straps are snug on her, and I can’t pinch the buckled strap.

Her car seat is buckled tightly in the car and doesn’t move more than one inch when I pull it.

She uses a bigger seat rear-facing until she outgrows the harness. Many harnesses go to 35, 40 or 45 pounds.

He always rides in a back seat and never in front of an air bag

He always rides in a car seat made for his size and age.

The straps are snug on him, and I can’t pinch the buckled strap.

His car seat is buckled tightly in the car and doesn’t move more than one inch when I pull it. I use the top tethers designed for the seat.

He uses this car seat until he outgrows the harness. Many harnesses go to 50, 60 or even 80 pounds.

She always rides in a back seat and never in front of an air bag.

She always rides on a booster seat using a seat belt with lap and shoulder straps.

The lap belt sits low on her hips, not her stomach.

The shoulder belt is on her shoulder – not on her neck, under her arm or behind her back.

The seat belt is snug, flat and comfortable on her.

She may be between 8-12 years of age before the seat belt fits.

She always rides in a back seat and never in front of an air bag.

She always uses a seat belt with lap and shoulder straps.

The lap belt sits low on her hips, not her stomach.

The shoulder belt is on her shoulder – not on her neck, under her arm or behind her back.

Her back is firmly against the seat back, her knees bend at the front edge of the seat, and she can sit this way for the whole ride.

The seat belt is snug, flat and comfortable on her. If the seat belt does not fit right, she must use a booster seat.

Babies under 2 use rear-facing car seats

Toddlers and big kids use forward-facing car seatsIf my child is over age 2 AND has outgrown the weight and height limits for the rear-facing seat:

Older, bigger kids use booster seatsIf my child is under 4 feet, 9 inches tall AND has outgrown the weight and height limit of the forward-facing car seat:

Kids ready for seat beltsIf my child is over 4 feet, 9 inches tall and has outgrown the booster seat:

Page 23

U.S. CONSUMER PRODUCT SAFETY COMMISSION • (800) 638-2772 • www.cpsc.gov • www.SaferProducts.gov

Soft Bedding Can Be Hazardous to Babies “Bare is Best”

To prevent infant deaths due to soft bedding, the U.S. Consumer Product Safety Commission (CPSC) recommends the following safe bedding practices when putting infants under 12 months down to sleep.

Placing babies to sleep on their backs instead of their stomachs has been associated with a dramatic decrease in deaths from Sudden Infant Death Syndrome (SIDS). Babies have been found dead on their stomachs with their faces, noses, and mouths covered by soft bedding, such as pillows, quilts, comforters and sheepskins. However, some babies have been found dead with their heads covered by soft bedding even while sleeping on their backs.

Publication 5049 042013

A Safe Sleeping Environment for Your Baby

Safe Bedding Practices for Infants

Place baby on his/her back on a firm tight-fitting mattress in a crib that meets current safety standards.

Remove pillows, quilts, comforters, sheepskins, pillow-like stuffed toys, and other soft products from the crib.

For warmth, dress baby in footed pajamas.

Positioning devices are unnecessary and can be deadly.

Do not place baby on a waterbed, sofa, soft mattress, pillow, or other soft surface to sleep.

Page 24

Each

yea

r, ch

ildre

n ar

e in

jure

d by

haz

ards

in a

nd a

roun

d th

e ho

me.

Th

e go

od n

ews

is th

at th

e ris

k of

inju

ry c

an b

e re

duce

d or

pre

vent

ed

by u

sing

child

-safe

ty d

evic

es a

nd re

min

ding

old

er c

hild

ren

in th

e ho

use

to re

-secu

re s

afet

y de

vice

s af

ter d

isabl

ing

them

. M

ost o

f the

se s

afet

y de

vice

s ar

e ea

sy to

find

and

are

rela

tivel

y in

ex-

pens

ive.

You

can

buy

them

at h

ardw

are

store

s, b

aby

equi

pmen

t sho

ps,

supe

rmar

kets,

dru

g sto

res,

hom

e im

prov

emen

t sto

res,

on

the

Inte

rnet

and

th

roug

h m

ail o

rder

cat

alog

s. S

afet

y de

vice

s sh

ould

be

sturd

y en

ough

to

hind

er a

cces

s an

d ye

t eas

y fo

r you

to u

se.

To b

e ef

fect

ive,

they

mus

t be

prop

erly

insta

lled.

Fol

low

insta

llatio

n in

struc

tions

car

eful

ly. R

emem

ber,

too,

that

no

devi

ce is

com

plet

ely

child

proo

f; de

term

ined

you

ngste

rs h

ave

been

kno

wn

to o

verc

ome

or

disa

ble

them

. H

ere

are

som

e ch

ild s

afet

y de

vice

s th

at c

an h

elp

redu

ce in

jurie

s to

you

ng c

hild

ren.

The

red

num

bers

cor

resp

ond

to th

ose

on th

e im

age

follo

win

g th

e te

xt.

Use

Safe

ty L

atch

es a

nd L

ocks

1 fo

r cab

inet

s an

d dr

awer

s in

kitc

hens

, bat

hroo

ms,

and

oth

er a

reas

to h

elp

prev

ent p

oiso

ning

s an

d ot

her i

njur

ies.

Saf

ety

latc

hes

and

lock

s on

cab

inet

s an

d dr

awer

s ca

n he

lp p

reve

nt c

hild

ren

from

gai

ning

ac

cess

to m

edic

ines

, hou

seho

ld c

lean

ers,

m

atch

es, o

r cig

aret

te li

ghte

rs, a

s w

ell a

s kn

ives

and

oth

er s

harp

obj

ects.

Even

pro

duct

s w

ith c

hild

-resis

tant

pa

ckag

ing

shou

ld b

e lo

cked

aw

ay a

nd

kept

out

of r

each

. Thi

s pa

ckag

ing

is no

t ch

ildpr

oof.

Look

for s

afet

y la

tche

s an

d lo

cks

that

adu

lts c

an e

asily

insta

ll an

d us

e,

but a

re s

turd

y en

ough

to w

ithsta

nd p

ulls

and

tugs

from

chi

ldre

n.

Use

Safe

ty G

ates

2 to

hel

p pr

even

t fal

ls do

wn

stairs

and

to

kee

p ch

ildre

n fro

m e

nter

ing

room

s an

d ot

her a

reas

with

pos

sible

da

nger

s.Lo

ok fo

r saf

ety

gate

s th

at c

hild

ren

cann

ot d

islod

ge e

asily

, but

that

ad

ults

can

open

and

clo

se w

ithou

t diffi

culty

. For

the

top

of s

tairs

, onl

y us

e ga

tes

that

scr

ew to

the

wal

l.Us

e sa

fety

gat

es th

at m

eet c

urre

nt s

afet

y sta

ndar

ds. R

epla

ce o

lder

sa

fety

gat

es th

at h

ave

“V”

shap

es th

at a

re la

rge

enou

gh to

ent

rap

a ch

ild’s

head

and

nec

k.

Use

Doo

r K

nob

Cove

rs a

nd D

oor

Lock

s 3

to h

elp

prev

ent

child

ren

from

ent

erin

g ro

oms

and

othe

r are

as w

ith p

ossib

le d

ange

rs.

Door

kno

b co

vers

and

doo

r loc

ks c

an h

elp

keep

chi

ldre

n aw

ay fr

om

plac

es w

ith h

azar

ds.

Be s

ure

the

door

kno

b co

ver i

s stu

rdy,

and

allo

ws

a do

or to

be

open

ed q

uick

ly b

y an

adu

lt in

cas

e of

em

erge

ncy.

Use

Ant

i-Sca

ld D

evic

es 4

for f

auce

ts an

d sh

ower

hea

ds a

nd s

et y

our w

ater

hea

ter t

em-

pera

ture

to 1

20 d

egre

es F

ahre

nhei

t to

help

pr

even

t bur

ns fr

om h

ot w

ater

. Ant

i-sca

ld

devi

ces

for r

egul

atin

g w

ater

tem

pera

ture

ca

n he

lp re

duce

the

likel

ihoo

d of

bur

ns.

Use

Smok

e A

larm

s 5

on

ever

y le

vel o

f you

r hom

e, in

side

each

be

droo

m, a

nd o

utsid

e sle

epin

g ar

eas

to a

lert

you

to fi

res.

Sm

oke

alar

ms

are

esse

ntia

l saf

ety

devi

ces

for p

rote

ctio

n ag

ains

t fire

dea

ths

and

inju

ries.

Che

ck s

mok

e al

arm

s on

ce a

mon

th to

mak

e su

re th

ey’re

wor

king

. C

hang

e ba

tterie

s at

leas

t onc

e a

year

or c

onsid

er u

sing

10-y

ear

batte

ries

for a

larm

s.

Use

Win

dow

Gua

rds

and

Safe

ty N

ettin

g 6

to h

elp

prev

ent

falls

from

win

dow

s, b

alco

nies

, dec

ks, a

nd la

ndin

gs.

Che

ck th

ese

safe

ty d

evic

es fr

eque

ntly

to m

ake

sure

they

are

sec

ure

and

prop

erly

insta

lled

and

mai

ntai

ned.

Lim

it w

indo

w o

peni

ngs

to fo

ur

inch

es o

r les

s, in

cludi

ng th

e sp

ace

betw

een

the

win

dow

gua

rd b

ars.

If y

ou h

ave

win

dow

gu

ards

, be

sure

at l

east

one

win

dow

in e

ach

room

can

be

easil

y us

ed fo

r esc

ape

in a

fire

. W

indo

w s

cree

ns a

re n

ot e

ffect

ive

for p

reve

nt-

ing

child

ren

from

falli

ng o

ut o

f win

dow

s.

Use

Corn

er a

nd E

dge

Bum

pers

7 to

he

lp p

reve

nt in

jurie

s fro

m fa

lls a

gain

st sh

arp

edge

s of

fu

rnitu

re a

nd fi

repl

aces

. Be

sure

to lo

ok fo

r bum

pers

that

sta

y se

cure

ly

on fu

rnitu

re o

r hea

rth e

dges

.

Use

Out

let C

over

s an

d O

utle

t Pla

tes 8

to h

elp

prev

ent

elec

trocu

tion.

Out

let c

over

s an

d ou

tlet p

late

s ca

n he

lp p

rote

ct c

hild

ren

from

ele

ctric

al s

hock

and

pos

sible

ele

ctro

cutio

n.

Be s

ure

outle

t pro

tect

ors

cann

ot b

e ea

sily

rem

oved

by

child

ren

and

are

larg

e en

ough

so

that

chi

ldre

n ca

nnot

cho

ke o

n th

em. I

f you

are

re

plac

ing

rece

ptac

les,

use

a ta

mpe

r-res

istan

t typ

e.

Use

a Ca

rbon

Mon

oxid

e (C

O) A

larm

9 to

hel

p pr

even

t CO

po

isoni

ng. A

ll co

nsum

ers

shou

ld in

stall

CO

ala

rms

near

sle

epin

g ar

eas

in th

eir h

omes

. Cha

nge

batte

ries

at le

ast o

nce

a ye

ar.

CPS

C re

com

men

ds u

sing

Cord

less

Win

dow

Cov

erin

gs 1

0

in h

omes

with

you

ng c

hild

ren,

in o

rder

to h

elp

prev

ent s

trang

ulat

ion.

C

hild

ren

can

wra

p w

indo

w c

over

ing

cord

s aro

und

thei

r nec

ks o

r ca

n pu

ll co

rds t

hat a

re n

ot c

lear

ly v

isibl

e bu

t are

acc

essib

le a

nd

beco

me

enta

ngle

d in

the

loop

s. If

you

have

win

dow

blin

ds fr

om 2

000

or e

arlie

r and

you

can

not a

fford

new

, cor

dles

s win

dow

cov

erin

gs,

call

the

Win

dow

Cov

erin

g Sa

fety

Cou

ncil

at 8

00-5

06-4

636

or v

isit

WindowCoverings.org

for a

free

repa

ir ki

t. W

indo

w b

linds

that

hav

e

an in

ner c

ord

(for r

aisin

g th

e sla

ts of

the

blin

ds) c

an b

e pu

lled

by a

ch

ild a

nd fo

rm a

pot

entia

lly d

eadl

y lo

op. C

onsu

mer

s sho

uld

imm

edia

tely

re

pair

thes

e ty

pes o

f blin

ds. C

onsu

mer

s sho

uld

know

that

WC

SC’s

retro

fit k

its d

o no

t add

ress

the

dang

ling

pull

cord

haz

ard

asso

ciat

ed

with

man

y co

mm

on w

indo

w b

linds

.

Use

Anc

hors

to A

void

Fur

nitu

re a

nd A

pplia

nce

Tip-

Ove

rs

11. F

urni

ture

, TVs

and

rang

es c

an ti

p ov

er a

nd c

rush

you

ng c

hild

ren.

De

aths

and

inju

ries

occu

r whe

n ch

ildre

n cli

mb

onto

, fal

l aga

inst

or p

ull

them

selve

s up

on

tele

visio

n sta

nds,

she

lves,

boo

kcas

es, d

ress

ers,

des

ks,

ches

ts an

d ra

nges

. For

add

ed s

ecur

ity, a

ncho

r the

se p

rodu

cts

to th

e flo

or

or a

ttach

them

to a

wal

l. Fr

ee s

tand

ing

rang

es a

nd s

tove

s sh

ould

be

insta

lled

with

ant

i-tip

bra

cket

s.

Use

Laye

rs o

f Pr

otec

tion

with

Poo

ls a

nd S

pas 12

. A b

arrie

r co

mpl

etel

y su

rroun

ding

the

pool

or s

pa in

cludi

ng a

4-fo

ot ta

ll fe

nce

with

se

lf-clo

sing,

sel

f-lat

chin

g ga

tes

is es

sent

ial.

If th

e ho

use

serv

es a

s a

side

of th

e ba

rrier

, doo

rs h

eadi

ng to

the

pool

sho

uld

have

an

alar

m o

r the

po

ol s

houl

d ha

ve a

pow

er s

afet

y co

ver.

Pool

ala

rms

can

serv

e as

an

addi

tiona

l lay

er o

f pro

tect

ion.

Sl

idin

g gl

ass

door

s, w

ith lo

cks

that

mus

t be

re-se

cure

d af

ter e

ach

use,

ar

e no

t an

effe

ctiv

e ba

rrier

to p

ools.

THIS

BRO

CHU

RE B

ROU

GH

T TO

YO

U B

Y:

U.S

. CO

NSU

MER

PRO

DU

CT S

AFE

TY C

OM

MIS

SIO

N43

30 E

ast W

est H

ighw

ay, B

ethe

sda,

MD

2081

4W

eb s

ite: w

ww.

cpsc

.gov

Toll-f

ree

hotli

ne: 1

-800

-638

-277

2

The

U.S.

Con

sum

er P

rodu

ct S

afet

y C

omm

issio

n (C

PSC

) is

a fe

dera

l age

ncy

that

hel

ps k

eep

fam

ilies

and

chi

ldre

n sa

fe in

and

aro

und

thei

r hom

es.

Go

to www.cpsc.gov

to c

heck

for r

ecal

led

prod

ucts

and

sign

up fo

r aut

omat

ic e

-mai

l rec

all n

otifi

catio

ns.

Publ

icat

ion

252

1120

08

0409

13

Page 25

Child

proo

fing

Your

Hom

e1

2 S

AF

ET

Y D

EV

ICE

S T

O

PR

OT

EC

T Y

OU

R C

HIL

DR

EN

Child

safe

ty d

evic

es a

re a

n im

porta

nt a

id

to p

aren

tal s

uper

visio

n. H

ere

are

12 c

hild

sa

fety

dev

ices

that

will

hel

p ke

ep y

our h

ome—

and

child

ren—

safe

r.

Use

SAFE

TY L

ATC

HES

and

LO

CKS 1

for

cabi

nets

and

draw

ers i

n ki

tchen

s, ba

thro

oms,

and

othe

r are

as to

hel

p pr

even

t poi

soni

ngs a

nd o

ther

in

jurie

s.

Use

SAFE

TY G

ATE

S 2

to h

elp

prev

ent f

alls

dow

n sta

irs a

nd to

kee

p ch

ildre

n fro

m e

nter

ing

room

s and

oth

er a

reas

with

pos

sible

dan

gers

.

Use

DO

OR

KN

OB

COV

ERS

and

DO

ORS

LO

CKS 3

to h

elp

prev

ent c

hild

ren

from

ent

erin

g ro

oms a

nd o

ther

are

as w

ith p

ossib

le d

ange

rs.

Use

AN

TI-S

CALD

DEV

ICES

FO

R FA

UCE

TS a

nd

SHO

WER

HEA

DS 4

and

set y

our w

ater

hea

ter

tem

pera

ture

to 1

20 d

egre

es F

ahre

nhei

t to

help

pr

even

t bur

ns fr

om h

ot w

ater

.

Use

SMO

KE

ALA

RMS 5

on

ever

y le

vel o

f you

r ho

me,

insid

e ea

ch b

edro

om a

nd o

utsid

e sle

epin

g ar

eas t

o al

ert y

ou to

fire

s.

Use

WIN

DO

W G

UA

RDS

and

SAFE

TY

NET

TIN

G 6

to h

elp

prev

ent f

alls

from

win

dow

s, ba

lconi

es, d

ecks

, and

land

ings

.

Use

CORN

ER a

nd E

DG

E BU

MPE

RS 7

to h

elp

prev

ent i

njur

ies f

rom

falls

aga

inst

shar

p ed

ges o

f fu

rnitu

re a

nd fi

repl

aces

.

Use

OU

TLET

CO

VER

S an

d O

UTL

ET P

LATE

S 8

to

hel

p pr

even

t ele

ctroc

utio

n.

Use

a CA

RBO

N M

ON

OX

IDE

(CO

) ALA

RM 9

ne

ar sl

eepi

ng a

reas

to h

elp

prev

ent C

O p

oiso

ning

.

Use

CORD

LESS

WIN

DO

W C

OV

ERIN

GS 10

in

hom

es w

ith y

oung

chi

ldre

n to

hel

p pr

even

t str

angu

latio

n.

Use

AN

CHO

RS T

O A

VO

ID F

URN

ITU

RE A

ND

A

PPLI

AN

CE T

IP-O

VER

S 11

.

Use

LAY

ERS

OF

PRO

TECT

ION

WIT

H P

OO

LS

AN

D S

PAS 12

.

1

4

12

49 2

3

5

5

6

5

7

118

10

Page 26

Edinburgh Postnatal Depression Scale 1 (EPDS) Name: ______________________________ Address: ___________________________

Your Date of Birth: ____________________ ___________________________

Baby’s Date of Birth: ___________________ Phone: _________________________

As you are pregnant or have recently had a baby, we would like to know how you are feeling. Please check the answer that comes closest to how you have felt IN THE PAST 7 DAYS, not just how you feel today.

Here is an example, already completed.

I have felt happy: Yes, all the time Yes, most of the time This would mean: “I have felt happy most of the time” during the past week. No, not very often Please complete the other questions in the same way. No, not at all

In the past 7 days:

1. I have been able to laugh and see the funny side of things *6. Things have been getting on top of me As much as I always could Yes, most of the time I haven’t been able Not quite so much now to cope at all Definitely not so much now Yes, sometimes I haven’t been coping as well Not at all as usual

2. I have looked forward with enjoyment to things No, I have been coping as well as ever As much as I ever did Rather less than I used to *7 I have been so unhappy that I have had difficulty sleeping Definitely less than I used to Yes, most of the time Hardly at all Yes, sometimes

Not very often *3. I have blamed myself unnecessarily when things No, not at all

went wrong Yes, most of the time *8 I have felt sad or miserable Yes, some of the time Yes, most of the time Not very often Yes, quite often No, never Not very often

No, not at all 4. I have been anxious or worried for no good reason

No, not at all *9 I have been so unhappy that I have been crying Hardly ever Yes, most of the time Yes, sometimes Yes, quite often Yes, very often Only occasionally

No, never *5 I have felt scared or panicky for no very good reason

Yes, quite a lot *10 The thought of harming myself has occurred to me Yes, sometimes Yes, quite often No, not much Sometimes No, not at all Hardly ever

Never

Administered/Reviewed by ________________________________ Date ______________________________

1 Source: Cox, J.L., Holden, J.M., and Sagovsky, R. 1987. Detection of postnatal depression: Development of the 10-item Edinburgh Postnatal Depression Scale. British Journal of Psychiatry 150:782-786 .

2 Source: K. L. Wisner, B. L. Parry, C. M. Piontek, Postpartum Depression N Engl J Med vol. 347, No 3, July 18, 2002, 194-199

Users may reproduce the scale without further permission providing they respect copyright by quoting the names of the authors, the title and the source of the paper in all reproduced copies.

No, most of the time I have coped quite well

Page 27

Edinburgh Postnatal Depression Scale 1  (EPDS) Postpartum depression is the most common complication of childbearing. 2 The 10-question Edinburgh Postnatal Depression Scale (EPDS) is a valuable and efficient way of identifying patients at risk for “perinatal” depression. The EPDS is easy to administer and has proven to be an effective screening tool.

Mothers who score above 13 are likely to be suffering from a depressive illness of varying severity. The EPDS score should not override clinical judgment. A careful clinical assessment should be carried out to confirm the diagnosis. The scale indicates how the mother has felt during the previous week. In doubtful cases it may be useful to repeat the tool after 2 weeks. The scale will not detect mothers with anxiety neuroses, phobias or personality disorders.

Women with postpartum depression need not feel alone. They may find useful information on the web sites of the National Women’s Health Information Center <www.4women.gov> and from groups such as Postpartum Support International <www.chss.iup.edu/postpartum> and Depression after Delivery <www.depressionafterdelivery.com>. 

SCORING QUESTIONS 1, 2, & 4 (without an *) Are scored 0, 1, 2 or 3 with top box scored as 0 and the bottom box scored as 3. 

QUESTIONS 3, 5­10 (marked with an *) Are reverse scored, with the top box scored as a 3 and the bottom box scored as 0.

Maximum score: 30 Possible Depression: 10 or greater Always look at item 10 (suicidal thoughts)

Users may reproduce the scale without further permission, providing they respect copyright by quoting the names of the authors, the title, and the source of the paper in all reproduced copies. 

Instructions for using the Edinburgh Postnatal Depression Scale:

1. The mother is asked to check the response that comes closest to how she has been feeling in the previous 7 days.

2. All the items must be completed.

3. Care should be taken to avoid the possibility of the mother discussing her answers with others. (Answers come from the mother or pregnant woman.)

4. The mother should complete the scale herself, unless she has limited English or has difficulty with reading.

1 Source: Cox, J.L., Holden, J.M., and Sagovsky, R. 1987. Detection of postnatal depression: Development of the 10-item Edinburgh Postnatal Depression Scale.  British Journal of Psychiatry 150:782-786.

2 Source: K. L. Wisner, B. L. Parry, C. M. Piontek, Postpartum Depression N Engl J Med vol. 347, No 3, July 18, 2002, 194-199

Page 28

Early Head Start

Pregnancy Packet

Prenatal & Postnatal+Infant Nurse Assessment

Prenatal Nurse Assessment

Page 1 of 2

Prenatal Record:

Brief narrative:

Mom’s name, age:

Expected due date:

Weeks pregnant:

Social factors-

Who is present during interview?

Any history of drinking?

Any history of smoking?

Any history of drug use?

Type of apartment/house:

Father of baby present or involved:

Has your partner ever hit or threatened you?

1. First Prenatal Care (at how many weeks)

2. Course of Pregnancy: Any complications during this pregnancy such as HTN, DM, pre-eclampsia?

3. How many other children does client have? Ages? Do you have childcare?

Prenatal Nurse Assessment

Page 2 of 2

4. Emotional health during the pregnancy (depression, any history of mental health problems.) Who do you have for support during this pregnancy? (family, friends, husband)

5. Birth plan: Where will you deliver? Plan to get medications/epidural?

Do you plan to circumcise if you have a boy?

Topics to Discuss • Pregnancy complications (s/s pre-term labor, preeclampsia, etc.)

• Importance of prenatal care

• Healthy nutrition during pregnancy

• Breastfeeding

• Birth control/family planning

After visit assessment/recommendations:

• How did the client accept the information?

• Does the client need reinforcement of information? If so which information do you feel

the client needs reinforcement on by home visitor or nurse @ 2 week visit?

• Any recommendations or follow up?

• Client’s questions or concerns? Were they all addressed?

• Home visitor’s questions or concerns? Were they all addressed?

Assessment completed by: Date:

Infant and Postnatal Assessment Template

Page 1 of 6

Prenatal Record: Name of Mother of baby: Brief narrative: Mother of baby’s name, age, social factors, name of hospital where mother delivered, etc. (see example newborn & new mother assessment)

1. Length of Pregnancy

2. First Prenatal Care

3. Course of Pregnancy

4. Position of the babies in the family constellation

5. Emotional health during the pregnancy Labor Record Type of Delivery: Complications:

Infant and Postnatal Assessment Template

Page 2 of 6

Infant Age of Newborn: Infant Health Problems identified prior to birth: Infant health problems identified at birth: Infant health problems identified after birth: Type of feeding: Immunizations: Results of Newborn Hearing Screening:

Physical Assessment General Appearance: Skin:

Infant and Postnatal Assessment Template

Page 3 of 6

General Body Proportions: Weight at Birth: Weight today:

Length at Birth: HC at Birth:

Behavior: Sleep pattern: Head, Ears and Fontanels: Face, Eyes and Mouth:

Cry:

Neck: Chest: Extremities: Abdomen: GU:

Infant and Postnatal Assessment Template

Page 4 of 6

Newborn Needs: Oxygenation: Nutrition: Mother/Baby Bonding: Warmth/Protection from weather extremes: Protection from Infection:

Infant and Postnatal Assessment Template

Page 5 of 6

Mother’s Post-Partum Health Physical Health/Complications: Emotional Health: Family Planning: Post-Partum Nutrition: Post-Partum Visit:

Infant and Postnatal Assessment Template

Page 6 of 6

Written Information Given to MOB: Follow Up Needs: Signature: ________________________________ Date: ______________________

Early Head Start

Pregnancy Packet

Pregnancy Risk and Authorization Form

PREGNANCY VERIFICATION

Dear Health Care Provider,

_________________________________________________ is a mother participating in our Early Head Start program. Federal Performance Standards require us to verify that she is receiving regular prenatal care.

Is this mother receiving prenatal care from you? Yes No

Date of first prenatal visit_________________ at __________ week’s gestation.

How many prenatal visits has she received up to this date? _______

Is her pregnancy considered high risk? Yes No

1. Initial Assessment Weeks Gestation: _________

High Risk Factors

High Risk Factors Very High Risk Factors

� Age: <18 or >35 � Substance Use � Drug Addiction

� Currently involved in a violent relationship.

� Diabetes � 2 or more prior low birth weight infants.

� BMI <18 or >30 � Prior Infant with a Major Health Problem

� 2 or more HIGH RISK FACTORS

� Anemia � Cardiac Problems � Multiple Pregnancy

� Smoking � Rh Sensitization � Other

� Poor Socioeconomic Condition

� Uterine abnormality or an Incompetent Cervix

� Suspected Poor Nutrition � 1 Prior Infant with a Birth weight < 5 ½ lbs.

� Prior Cesarean Section � Hypertension

� Seizures � Kidney Disease

� Chronic Mental Illness � History of a Miscarriage

� Sought Prenatal Care > 20 weeks

� History of a Stillborn Baby

� Other (specify): � Prior baby in the Neonatal Intensive Care Unit

Date of next scheduled prenatal visit________________

AUTHORIZATION FOR MUTUAL EXCHANGE OF INFORMATION

I (name) _______________________________________________________authorize the mutual exchange of information concerning my prenatal care between __________________________________ [Insert delegate program name] and ______________________________________________________________ (health care provider or agency).

Participant's

Signature_________________________________________________________Date______________

Doctor Signature___________________________________________________Date____________

Please fax this form back to [Insert delegate program name] Early Head Start, Home Visiting Program at

[Insert program fax number]. Thank you.

[Insert Program Name, Address and Phone Number]