Healthy Mom Healthy Baby by wpr1947

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       y Mo
H ealth Baby
      thy                     Table of Contents (Client Handouts are indicated in bold italics)

  Introduction ...................................................................................................................................................................3
  Health Education Plan .................................................................................................................................................4
  What to Discuss on the First Visit .............................................................................................................................6
  Welcome to Pregnancy Care ...........................................................................................................7
  Danger Signs When You are Pregnant .............................................................................................9
  Your Rights as a Client ..................................................................................................................11
  Hospital Orientation ................................................................................................................................................. 13
  Preterm Labor ............................................................................................................................................................. 14
  If Your Labor Starts Too Early .......................................................................................................17
  Kick Counts .................................................................................................................................................................. 19
  Count Your Baby’s Kicks ........................................................................................................................................... 21
  STIs (Sexually Transmitted Infections) .................................................................................................................. 23
  What You Should Know About STDs ..............................................................................................27
  HIV and Pregnancy .................................................................................................................................................... 29
  What You Should Know About HIV ...............................................................................................35
  You Can Protect Yourself and Your Baby from STDs ......................................................................37
  Cautions: Cats/Hot Baths/Raw Foods and Other Concerns ............................................................................ 39
  Causes for Concern During Pregnancy ................................................................................................................ 40
  Workplace and Home Safety .................................................................................................................................. 41
  Keep Safe at Work and at Home ....................................................................................................45
  Oral Health During Pregnancy ............................................................................................................................... 47
  Prevent Gum Problems When You are Pregnant ...........................................................................64
  See a Dentist When You are Pregnant ...........................................................................................66
  Keep Your Teeth and Mouth Healthy! Protect Your Baby, Too. .....................................................68
  Oral Health During Infancy ..................................................................................................................................... 70
  Protect Your Baby from Tooth Decay .............................................................................................80
  Safe Exercise and Lifting During Pregnancy and Postpartum........................................................................ 87
  Exercises When You are Pregnant ..................................................................................................89
  Stay Active When You are Pregnant...............................................................................................93
  Keep Safe When You Exercise.........................................................................................................95
  Tobacco Use .................................................................................................................................................................. 97

  Steps to Take — 2009 • Health Education                                                                                                                                      HE– 1
       y Mo
H ealth Baby
      thy                   Table of Contents (Client Handouts are indicated in bold italics)

  Secondhand Tobacco Smoke................................................................................................................................. 101
 You Can Quit Smoking ................................................................................................................103
  Drug and Alcohol Use ............................................................................................................................................. 105
 You Can Quit Using Drugs or Alcohol ...........................................................................................111
  Family Planning Choices ........................................................................................................................................ 113
  Infant Feeding Decision-Making .......................................................................................................................... 117
  Infant Safety and Health ......................................................................................................................................... 119
  Immunizations and Pregnancy ............................................................................................................................. 122
  Keep Your New Baby Safe ............................................................................................................123
  When Your Newborn Baby is Ill: What to Watch For ...................................................................127
 Your Baby Needs to be Immunized ..............................................................................................129
  Multiple Births — Twins and Triplets .................................................................................................................. 131
  Getting Ready for Twins or Triplets .............................................................................................137
  More About Getting Ready ..........................................................................................................138
  Baby Products, Discounts and Coupons for Families Who Expect Twins or Triplets ....................141
  Health Education Materials ................................................................................................................................... 145

  Steps to Take — 2009 • Health Education                                                                                                                           HE– 2
       y Mo
H ealth Baby
      thy         Introduction

  Pregnancy and expectant parenthood create
  new learning needs and challenges for each                        See the CPSP Provider
  woman, her partner, members of her family, and                    Handbook for a description
  her support system. These needs may include
                                                                    of required health education
  information about health, perinatal care facts and
                                                                    assessment components,
  practice and mastery of new skills or changes in
  current health habits.                                 components of basic health education,
                                                         complex health education conditions
  The goals of health education are to:                  warranting specialized attention,
  •	 provide	clients	with	information                    and required CPSP health education
  •	 assist	clients	in	making	informed	decisions	        personnel.
     about their pregnancies
  •	 help	clients	change	behaviors	to	have	healthier	
     pregnancies and babies

  The following health education guidelines were        Assessment guidelines
  designed	to	provide	information	on	basic	topics	      Complete an initial health education assessment
  from early pregnancy to post-partum. The topics       on	every	client	within	four	weeks	of	entry	into	care.	
  covered	are	not	exhaustive	and	are	limited	to	less	   If the client declines the assessment, document in
  complicated, more commonly occurring health           the	chart.	Offer	assessments	at	future	visits.	Some	
  needs.	The	medical	provider	is	responsible	for	       clients may need to be offered the assessments
  the client’s health education needs, particularly     several	times.
  educational needs for complex conditions.             Offer reassessments at least once every
  All	health	education	interventions	should	be	         trimester and at the postpartum visit. High risk
  preceded by a health education assessment. The        clients	may	need	more	interventions	and	may	be	
  health education assessment will help identify the    seen more frequently.
  client’s knowledge, past experiences, sources of
  support, health practices and personal goals. You
  will also note how she best learns, what she’d like
  to	know	more	about,	and	what	would	motivate	
  her to learn. This information will help you
  develop	an	educational	plan	to	meet	the	needs	of	
  the client.

  Steps to Take — 2009 • Health Education                                                                HE– 3
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H ea th Baby
  eallth Baby
       thy          Health Education Plan

   An	effective	plan	for	health	education	should	         Pregnancy changes/fetal growth
   include	a	set	of	basic	topics	that	cover	everything	
                                                          •	 Identify	basic	terminology	relating	to	anatomy,	
   from early pregnancy through postpartum.
                                                             conception,	fetal	development	and	pregnancy	
   At	a	minimum,	health	education	services	and	              changes.
   written	materials	should	be	available	on	the	topics	
                                                          •	 Describe	the	significance	of	prenatal	exercises	
   listed on these two pages.
                                                             (including Kegels) and how to perform at least
   Some clients may need education on all of these           three.
   topics	whereas	others	may	be	very	experienced	
   with them. Also, clients may ask for education on      Preterm labor/kick counts
   topics that are not included here.
                                                          •	 List	preterm	labor	symptoms	and	describe	
   The timeline to use in addressing these topics will       what to do if she experiences them.
   vary,	depending	on	how	far	along	in	pregnancy	
   the client is when she begins her prenatal care,       •	 Demonstrate	how	to	do	kick	counts.
   what	past	experiences	have	taught	her	and	
   what	her	current	needs	are.	The	objectives	are	        Drugs, smoking, alcohol during
   set up, generally, in order from early prenatal to     pregnancy
   postpartum care.
                                                          •	 Identify	risks	associated	with	use	of	alcohol,	
   Not	all	of	the	topics	listed	here	are	covered	in	         tobacco,	over-the-counter	drugs,	and	street	
   these health education guidelines.                        drugs.
   During the health education process, each client       •	 Consider	reducing,	eliminating,	or	seeking	
   should be able to understand the following topics.        treatment for any non-recommended
   She should also be able to identify her strengths         substance she uses.
   and	concerns	in	these	areas,	and	discover	ways	to	
                                                          •	 State	one	reason	for	alerting	all	of	her	health	
   resolve	any	problems.
                                                             and	dental	care	providers	that	she	is	pregnant.

   Discomforts and danger signs of                        Sexuality, birth control, STIs and HIV
   pregnancy                                              •	 State	her	plan	for	future	childbearing	and,	
    •	 List	at	least	three	common	discomforts	and	           if	applicable,	describe	any	contraceptive	
       three danger signs, and be able to tell the           methods she would consider using.
       difference between those that are discomforts
                                                          •	 Identify	how	STIs,	including	HIV,	are	transmitted,	
       versus	those	needing	immediate	attention.
                                                             their	negative	health	impact,	and	how	to	
    •	 Identify	actions	to	take	and	support	networks	        prevent	infection.
       to use if experiencing a danger sign, including
                                                          •	 State	that	a	medical	treatment	is	a	benefit	of	
       daytimes,	evenings	or	weekends.
                                                             early detection of HIV infection in pregnant
                                                          •	 Identify	a	site	where	she	can	be	tested	for	HIV	if	
                                                             she desires it.

   HE – 4                                                             Steps to Take — 2009 • Health Education
       y Mo
H ealth Baby
      thy          Health Education Plan (cont.)

  •	 Discuss	intimacy	and	sexuality	during	               •	 Make	a	decision	about	circumcision	(in	the	case	
     pregnancy and postpartum.                               of	a	baby	boy)	before	delivery.
                                                          •	 List	items	to	obtain	for	baby,	and	describe	
  Cautions and workplace/home safety                         changes	in	home	environment	to	
  •	 Identify	at	least	four	potentially	dangerous	           accommodate baby.
     activities	or	foods	to	avoid	while	pregnant.
  •	 Discuss	any	reproductive	hazards	at	home	or	         Breastfeeding
     work	she	needs	to	avoid.                             •	 Discuss	breastfeeding	benefits.
                                                          •	 Discuss	her	concerns	about	breastfeeding	and	
  Labor and delivery                                         prepare her for feeding her infant.
  •	 Identify	five	routine	hospital	procedures	           •	 Identify	someone	who	will	provide	her	with	
     used	during	labor	and	delivery,	such	as	IVs,	           support regarding breastfeeding.
     episiotomy, external monitoring, etc.
                                                          •	 Offer	breastfeeding	classes.	
  •	 Discuss	symptoms	of	labor	and	changes	in	
     different stages of labor.
                                                          Infant safety and early detection of
  •	 Identify	at	least	two	reasons	for	having	a	
     cesarean section.
                                                          •	 Discuss	the	schedule	for	routine	immunizations	
  •	 Identify	a	support	person	for	labor	and	delivery.       through age two.
  •	 Identify	a	plan	for	transport	to	the	hospital	for	   •	 Identify	danger	signs	in	the	newborn	and	what	
     delivery	and	return	home	with	the	baby.                 to do if these occur.
                                                          •	 Describe	safety	precautions	required	for	infants,	
  Self-care after delivery                                   including	car	seats	(needed	before	leaving	
  •	 Identify	at	least	2	strategies	for	taking	care	         hospital) and sleeping position (on back).
     of physical and emotional needs during the
                                                          •	 Identify	a	pediatric	care	provider	for	her	baby	
     postpartum period.
                                                             before	she	delivers.

 Adapting to parenthood
  •	 Discuss	life/family	adjustments	needed	to	
     accommodate the new baby.

  Steps to Take — 2009 • Health Education                                                                   HE– 5
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        y Mo
H ea th Baby
  eallth Baby
       thy           What to Discuss on the First Visit

   Client rights and responsibilities                         Services offered
    •	 Encourage	each	client	to	take	an	active	role	          •	 Describe	the	reasons	for	and	how	she	will	
       in her health care and ask questions if she               experience routine medical procedures such as
       doesn’t understand. Discuss the Welcome to                blood samples, urine samples, listening to the
       Pregnancy Care and Your Rights as a Client                baby’s	heartbeat,	pelvic	exams,	etc.
                                                              •	 Describe	the	purpose	of	each	component	of	
    •	 Encourage	her	to	talk	about	any	other	practices	          prenatal	services,	and	related	services	such	
       or substances she uses during pregnancy that              as WIC, hospital tours, childbirth preparation
       might affect her health, so her health care               classes, prenatal classes, referrals to community
       provider	can	have	a	full	understanding	of	her	            agencies, etc.
       health status.
    •	 If	she	will	deliver	at	a	teaching	hospital,	discuss	   Schedule of services
       the	practice	of	having	medical	students	               •	 Describe	the	purpose	of	regular	prenatal	visits	
       examine her. Tell her that she can decline to             and the benefits of perinatal care, such as
       participate in any extra examination, studies,            monitoring the baby’s heartbeat, the baby’s
       or	interviews	if	she	wants	to.	She	might	want	            position, the mother’s urine, etc. for signs of
       to	talk	this	over	with	her	support	person(s)	             problems that can be treated.
       in	advance	so	they	will	be	prepared	to	
       ask questions and make decisions about
                                                              The team of workers
                                                              •	 Explain	briefly	the	experience/training	of	clinic	
                                                                 staff she will meet, such as the differences
   Danger signs of pregnancy/                                    between a nurse practitioner, a nurse, a
   emergency procedures                                          nutritionist, a health educator, a social worker
    •	 Practice	or	role-play	what	she	will	do	of	she	            or a health worker.
       experiences a danger sign (who to call, where
       to	go,	daytime	vs.	evening	or	weekend,	what	           What services are provided
       support	is	available	to	assist	her	in	getting	to	
       the hospital or caring for her other children).        •	 Orient	her	to	the	labor	and	delivery	hospital	
       See the Danger Signs When You are Pregnant                (see following page on Hospital Orientation).
    •	 Ask	her	to	identify	a	family	member	or	friend	
                                                              Emergency procedures
       who will also know what to do, so she can ask          •	 Describe	how	to	use	the	hospital	emergency	
       for their support or assistance if she needs to.          room and how it differs from the health care
                                                                 provider’s	office	or	clinic.

   HE – 6                                                                 Steps to Take — 2009 • Health Education
       y Mo
H ealth Baby
      thy          Welcome to Pregnancy Care

   We have many services.                             We’re here to help!
                                                      There are many kinds of people who may help
   Here are some of our services:                     you during your pregnancy: doctors, nurse
                                                      practioners,	nurse	mid	 ives,	nurses,	health	
   •	 Check-ups	once	a	month	or	more,	the	whole	
                                                      educators, community health workers, social
      time you are pregnant.
                                                      workers, nutritionists, job counselors, Medi-Cal
   •	 Tests	to	check	your	health	and	the	health	of	   workers, and family planning counselors.
      your baby.
   •	 Help	with	how	to	eat	healthy	foods	while	
      you’re pregnant.
   •	 Information	about	where	to	go	for	financial	
      help like CalWORKs, health insurance like
      Medi-Cal or Healthy Families, food programs
      like WIC or food banks.                             On our staff, here are some
                                                          of the people who may be helping
   We can give you:                                       you:

   •	 Classes	and	one-on-one	visits	about	
      pregnancy, childbirth, baby care,
      and breastfeeding.
   •	 Help	with	how	to	cut	down	or	quit	smoking,	
      drinking, or using drugs.
   •	 Counseling	on	problems	you	
      may	have.

   Steps to Take — 2009 • Health Education                                                               HE– 7
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H ealth Baby
      thy           Bienvenida al Cuidado Prenatal

   Le ofrecemos muchos servicios.                      ¡Estamos para servirle!
                                                       Hay muchas diferentes clases de personas
   Estos son algunos de los servicios                  que le pueden ayudar durante el embarazo:
                                                       doctores, enfermeras especialistas, enfermeras
   que ofrecemos:
                                                       parteras, enfermeras, educadoras de salud,
    •	 Exámenes	una	vez	al	mes	por	lo	menos,	          trabajadoras comunitarias, trabajadoras
       durante todo el embarazo.                       sociales, nutricionistas, consejeros de trabajo,
    •	 Pruebas	para	ver	cómo	está	su	salud	y	          trabajadores del Medi-Cal, consejeros de
       la salud de su bebé.                            planificación familiar.

    •	 Ayuda	para	saber	cómo	comer	comidas	
       nutritivas	mientras	está	embarazada.
    •	 Información	acerca	de	adónde	puede	
       ir para ayuda financiera (como CalWORKs),
                                                         Le presentamos a algunas personas
       seguro médico (como el MediCal o Healthy
                                                         de nuestro equipo médico que
                                                         están para ayudarle:
       programas de comida (como WIC o bancos
       de comida).

   Nosotros le podemos dar:
    •	 Clases	y	pláticas	individuales	acerca	del	
       embarazo, el parto, cuidado del bebé,
       y cómo amamantar a su bebé.
    •	 Ayuda	para	disminuir	o	dejar	de	fumar,	dejar	
       de beber licor o de usar drogas.
    •	 Consejos	sobre	problemas	que	pueda	tener.

   HE – 8                                                           Steps to Take — 2009 • Health Education
       y Mo
H ealth Baby
      thy            Danger Signs When You are Pregnant

  Watch for these danger signs                          You may have signs of early labor.
  while you’re pregnant.
                                                        Call right away if:
   Call us right away if you:                           •	 Your	uterus	tightens	up	more	than	5	times	
   •	 Have	a	fever	or	chills.                              in	one	hour,	or	more	often	than	every	10	
   •	 Feel	dizzy.
                                                        •	 You	have	a	lower	backache.	You	may	feel	
   •	 Vomit	or	have	a	bad	stomach	ache.                    pain or a dull pressure in your back.
   •	 Have	any	bleeding	from	your	vagina.               •	 Your	lower	abdomen	may	hurt.	You	may	feel	
   •	 Feel	pain	or	cramps	in	your	abdomen.                 pain or pressure in your thighs or around
                                                           your	vagina.

   Don’t wait. Call right away if:                      •	 You	have	a	stomach	ache	or	cramps	in	your	
   •	 There	is	a	big	change	in	the	way	your	baby	          abdomen.	You	may	have	diarrhea.
      moves,	or	if	your	baby	moves	less	often.          •	 You	see	a	change	in	the	discharge	that	
   •	 You	have	a	sharp	pain	when	you	urinate	              comes	out	of	your	vagina.
   •	 You	have	a	sudden	flow	of	water	or	if	water	
      leaks	from	your	vagina.                              In an emergency call:
   •	 It’s	hard	for	you	to	breathe.
                                                           On weekends or evenings, call:
   •	 You	fall	or	are	in	a	car	accident.

  You should also call
  right away if:
   •	 Your	face	or	hands	swell	up.
   •	 You	have	a	really	terrible	headache,	or	your	
      headaches go on for days.
   •	 You	have	any	change	in	your	eyesight—
      blurred	vision,	flashes	of	lights,	or	spots	in	
      front of your eyes.
   •	 You	gain	too	much	weight	too	quickly.

   Steps to Take — 2009 • Health Education                                                              HE– 9
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H ealth Baby
                      Señales de Peligro Cuando está Embarazada

   Señales de peligro durante su                         Quizás tenga señales de parto
   embarazo.                                             prematuro.

   Llámenos de inmediato si:                             Llame de inmediato si:
    •	 Tiene	fiebre	o	escalofríos.	                      •	 Siente	que	la	matriz	se	le	endurece	más	de	
                                                            5	veces	en	una	hora.	O,	si	cada	dolor	le	viene	
    •	 Se	siente	mareada.
                                                            en menos de 10 minutos.
    •	 Tiene	vómitos	o	un	fuerte	dolor	de	
                                                         •	 Tiene	dolor	de	espalda	(en	el	área	de	la	
                                                            cintura). Puede sentir dolor o presión en la
    •	 Le	sale	sangre	de	la	vagina.                         espalda.
    •	 Siente	dolor	o	cólicos	en	su	abdomen.             •	 Le	duele	la	parte	baja	de	el	estómago.	
                                                            Puede sentir dolor o presión en la cadera o
                                                            alrededor	de	la	vagina.
   No espere. Llame de inmediato si:
    •	 Nota	un	cambio	grande	en	la	manera	en	            •	 Tiene	dolor	de	estómago	o	cólicos.	Puede	
       que	su	bebé	se	mueve,	o	si	se	mueve	con	             tener diarrea.
       menos frecuencia.                                 •	 Ve	un	cambio	en	el	flujo	que	le	sale	de	la	
    •	 Tiene	un	dolor	intenso	cuando	orina.                 vagina.	

    •	 Le	sale	de	repente	un	flujo	de	agua	de	
       la	vagina.	Este	flujo	puede	ser	mucho	o	
    •	 Se	le	hace	difícil	respirar.
                                                              En un emergencia, llame al:
    •	 Se	cae	o	le	ocurre	un	accidente	de	carro.
                                                              En los fines de semana o en la noche,
   También debe llamar de                                     llame al:
   inmediato si:
    •	 Se	le	hincha	la	cara	o	las	manos.
    •	 Tiene	mucho	dolor	de	cabeza,	o	si	el	dolor	le	
       dura	varios	días.
    •	 Se	le	nubla	la	vista,	ve	luces,	o	manchitas	en	
       frente de sus ojos.
    •	 Aumenta	mucho	de	peso	en	muy	poco	

   HE – 10                                                            Steps to Take — 2009 • Health Education
                                                                                                  y Mo
Your Rights as a Client                                                                    H ealth Baby
We can work together to keep you and your baby healthy.

You have the right to get good care.                You can help us give you the care
We promise to:
                                                    you need.
•	 Treat	you	with	respect.                          It is important to:
•	 Make	sure	that	what	you	say	to	us	stays	         •	 Be	honest	about	your	medical	history	and	
   private.	Your	health	care	is	just	between	you	      the	way	you	live.	What	you	tell	us	or	don’t	
   and us. You should know that we may need            tell us may affect you and your unborn
   to	report	abuse	or	violence,	so	that	you	can	       baby’s health.
   get the help you need.                           •	 Ask	questions	about	what	you	don’t	
•	 Explain	to	you	about	what	tests	you	need,	          understand.
   and how we do things at                          •	 Respect	office	policies.	Ask	questions	if	you	
   this office.                                        don’t understand.
•	 Answer	any	questions	you	might	have	             •	 Follow	our	advice	and	instructions.	Let	us	
   about your care.                                    know if you might not be able to follow it
                                                       for some reason.
You have the right to:
                                                    •	 Let	us	know	if	there	is	any	change	in	your	
•	 Take	a	look	at	your	medical	record	with	
   someone from our office.
•	 Help	plan	and	make	choices	about	your	           Be sure to:
   care while you are pregnant, in labor, or        •	 Keep	all	your	appointments.	Please	
   giving	birth.                                       be on time. If you can’t keep your appoint-
•	 Accept	or	refuse	any	care,	treat	 ent,	
                                   m                   ment, tell us 24 hours ahead of time.
   or	service.                                      •	 Tell	us	if	your	address	or	phone	
                                                       number changes.
                                                    •	 Let	us	know	if	you	have	any	ideas	about	
                                                       making	our	services	better.	
                                                    •	 Tell	us	what	you	like	or	don’t	like	about	your	

Steps to Take — 2009 • Health Education                                                               HE– 11
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Sus Derechos Como Cliente                                                               H ealth Baby
Trabajamos juntos para mantener a usted y a su bebé saludable.

Usted tiene derecho de recibir                    Usted puede ayudarnos a
buen cuidado.                                     que le demos el cuidado que
Le prometemos:
•	 Tratarla	con	respeto.                          Es importante que:
•	 Asegurarnos	de	lo	que	nos	dice	mantener	       •	 Sea	sincera	con	respecto	a	su	historia	
   en	privado.	Su	cuidado	de	salud	queda	            médica	y	respecto	a	la	forma	en	que	vive.	Lo	
   entre usted y nosotros. Sin embargo, usted        que nos diga o calle puede afectarla a usted
   debe	saber	que	quizás	sea	necesario	              y a su bebé.
   reportar	el	abuso	o	la	violencia,	para	que	    •	 Haga	preguntas	acerca	de	lo	que	no	
   pueda recibir la ayuda que necesite.              entiende.
•	 Explicarle	qué	exámenes	necesita,	y	cómo	      •	 Respete	los	reglamentos	de	la	oficina.	Haga	
   administramos esta oficina.                       preguntas si no entiende algún reglamento.
•	 Contestar	cualquier	pregunta	que	pueda	        •	 Siga	nuestro	consejo	e	instrucciones.	
   tener acerca de su cuidado.                       Déjenos	saber	si	por	alguna	razón	no	va	a	
                                                     poder seguirlos.
Usted tiene derecho de:
                                                  •	 Avise	si	hay	algún	cambio	en	su	salud.	
•	 Revisar	su	archivo	médico	con	alguien	de	
   nuestra oficina.
                                                  Otras cosas que debe hacer:
•	 Ayudar	a	planear	y	a	tomar	decisiones	         •	 Asista	a	todas	sus	citas.	Llegue	a	tiempo.	Si	
   relacionadas	con	su	cuidado	mientras	está	        no	puede	asistir	a	su	cita,	díganos	con	24	
   embarazada, durante el parto o a la hora de       horas de anticipación.
   dar a luz.
                                                  •	 Díganos	si	su	domicilio	o	número	de	
•	 Aceptar	o	negarse	a	cualquier	cui	 ado,	tra-      teléfono ha cambiado.
   ta	 iento	o	servicio.
                                                  •	 Comparla	sus	ideas	de	cómo	podemos	
                                                     mejorar	nuestros	servicios.
                                                  •	 Háblenos	sobre	lo	que	le	gusta	o	no	le	gusta	
                                                     de su cuidado.

HE – 12                                                        Steps to Take — 2009 • Health Education
       y Mo
H ealth Baby
      thy           Hospital Orientation

   •	 Ask	about	her	expectations,	what	she	has	heard	      – Information about rooming in and choices
      or knows about hospitals.                               she will need to make, such as circumcision,
                                                              and how to feed the baby.
   •	 Show	a	video	of	the	hospital,	or	of	birth	in	a	
                                                           – Information about the hospital staff (who will
      hospital setting, if possible.
                                                              help	her	deliver	the	baby,	and	how	her	blood	
   •	 Schedule	at	least	one	tour	of	the	hospital	for	         pressure and temperature will be monitored
      her, and follow up by asking her to explain             postpartum, for example).
      what	she	expects	during	labor	and	delivery.	A	       – In-hospital education about postpartum care
      second tour may be helpful. Encourage her to            of mother, how to care for her baby, etc.
      bring family members or friends to the tour          –	 Length	of	stay	(for	vaginal	and	Cesarean	
      so	they	can	be	supportive	during	labor	and	             section births).
      delivery.                                            – Breastfeeding support (lactation consultant,
                                                              home	visiting	nurse).
   •	 The	hospital	tour	should	include	the	following,	
                                                           – Hospital security procedures and how she
      as possible:
                                                              can be sure her baby will be safe.
     – Where to park/drop off. If she is non-English       –	 Infant	car	seats,	how	she	will	travel	with	her	
        speaking and plans to take a cab, write out a         infant, and how to get a car seat.
        note	that	can	be	given	to	a	cab	driver	with	       – Time of day clients are usually discharged.
        the hospital name and address. (The hospital
        brochure could be used.)                         In	addition,	the	tour	can	include	classes	available	
     – Entrance doors to use at night (if applicable).   at the hospital before the baby’s birth, such as
     – Information on how to get an interpreter (if      childbirth preparation classes.
     – Personal items to bring to the hospital (as
        well as what not to bring).
     – Forms and cards necessary for admission.
     – Demonstration of fetal monitor and different
        birthing positions in the labor room.
     – Bathroom facilities — where to wash/use the
        toilet, shower or bathe.
     –	 Information	about	beverages/ice	available	
        during labor (and how to get them).
     – Information about who can be with her (such
        as her husband, mother, or sister).
     – Visiting policies for other family and friends,
        and	any	policies	about	video	taping	or	taking	

   Steps to Take — 2009 • Health Education                                                               HE– 13
       y Mo
H ealth Baby
      thy             Preterm Labor

                                              labor     Who’s at Risk?
                           ny of the preterm
         If a client has a                   s how      Low risk women are those who:
                           be sure she know
         warning signs,                      der or
                            ealth care provi            •	 begin	prenatal	care	in	the	first	trimester
          to contact her h                   ly.
                             ber immediate
          emergency num                                 •	 come	to	prenatal	appointments	regularly
                                                        •	 avoid	using	tobacco,	alcohol	or	other	drugs
                                                        •	 eat	a	healthy	balance	of	foods	for	
   Goal                                                    appropriate weight gain
   Help your client:
                                                        High risk women are those with any of the
   •	 understand	preterm	labor	symptoms                 following.
   •	 describe	what	to	do	if	she	experiences	them       •	 history	of	preterm	baby	
                                                        •	 history	of	3	or	more	abortions
   Background                                           •	 preterm	labor	during	the	current	pregnancy
   Between 8 and 10% of babies born in the United       •	 pregnancy	with	twins	(or	more	fetuses)
   States are born prematurely. Preterm births
                                                        •	 abnormalities	of	the	cervix	or	uterus,	
   account for more than 60% of newborn deaths. In
                                                           such	as	incompetent	cervix,	uterine	
   about two-thirds of preterm births, the cause is
                                                           malformations, or fibroids
   never	known.	
                                                        •	 abdominal	surgery	during	current	
   A 1995 study of more than 7.5 million births found      pregnancy
   that preterm births are the main underlying cause
   of stillbirths and infant deaths within four weeks   •	 serious	infection	during	current	pregnancy
   of birth.                                            •	 bleeding	in	the	second	trimester	of	the	
                                                           current pregnancy
                                                        •	 underweight
   Important information
   Preterm labor occurs if a woman less than            •	 placenta	previa	(the	placenta	is	in	front	of	
   37 weeks pregnant begins labor (also called             the	cervix)
   premature labor). Preterm labor that is noticed      •	 DES	exposure.	DES	is	a	drug	that	was	
   in time can often be stopped with medical               formerly	used	to	prevent	miscarriage.	
   treatment and bed rest.                                 Women	today	whose	mothers	were	given	
                                                           DES	during	the	pregnancy	can	have	
   If preterm labor is not noticed in time, uterine
                                                           problems, such as cancer and miscarriage.
   contractions	can	cause	the	cervix	to	open	
   earlier than normal, leading to preterm birth.
   Preterm birth can cause breathing, feeding
   and temperature-regulating problems for the
   baby.	Some	preterm	infants	may	have	mental	or	
   physical disabilities. Preterm babies may die.

   HE – 14                                                         Steps to Take — 2009 • Health Education
He althy Baby
                    Preterm Labor (cont.)

   Steps to Take                                            Braxton-Hicks contractions
   Discuss warning signs with all clients.                  These are normal contractions that can be felt
   Between 20 and 24 weeks of pregnancy discuss             once in a while. Usually they are not painful and
   the warning signs of preterm labor and what to do        do	not	occur	frequently	(not	as	often	as	every	ten	
   if they experience them. Use If Your Labor Starts        minutes).
   Too Early handout.
                                                            Follow-up for all clients
   •	 Explain	the	signs.	Sometimes	the	signs	of	            Ask each client how she will watch for preterm
      preterm	labor	may	be	very	mild	and	hard	to	           labor signs. Encourage her to continue healthy
      detect.	It	may	help	to	have	the	woman	tighten	        behaviors	and	keep	the	Watch and Call idea in
      and relax her arm muscle, as an example of            mind.
      how the uterus might feel.
   •	 Emphasize calling if any of the warning signs         For clients who are at higher risk
      occur.                                                Show each woman how to lie back with her hands
                                                            on her abdomen to feel for contractions. At each
   •	 Give	If Your Labor Starts Too Early to take
                                                            visit,	discuss	warning	signs	and	what	she	will	do	if	
      with her.
                                                            she experiences one. Encourage her to continue
   •	 Be	sure	she	knows	what	number	to	call,	               healthy	behaviors	and	keep	the	Watch and Call
      weekdays,	evenings	or	nights,	and	weekends.	          idea in mind.
   •	 Rehearse	how	she	will	respond	if	she	has	
      warning signs of preterm labor.                       Resources
                                                            Preterm Labor: Information about what a woman
   •	 Explain that if she has preterm labor warning         who experiences preterm labor can expect and
      signs she must be examined by a health care           do, such as bed rest, drugs to suppress labor, and
      provider,	who	will	feel	the	cervix	to	see	if	it	is	   preterm	delivery.
      changing. Because contractions may not affect
      the	cervix	one	day,	but	can	cause	dilation	the	       American	College	of	Obstetricians	&	Gynecologists
      next, she must be checked each time she has           409 12th Street SW
      warning signs.                                        Washington, DC 20024-2188.
   Anticipate problems
                                                            Childbirth Graphics catalog
   Some clients hesitate to call their health care
                                                            (Reading materials to help women cope with such
   providers.	Some	women	want	to	see	if	the	
                                                            things as prolonged bed rest restrictions.)
   symptoms	will	go	away	by	themselves.	Others	
   may feel that the symptoms are too mild to “make
   a	fuss”	over	or	that	they	are	too	busy	to	lie	down	
   for	an	hour	to	evaluate	the	signs.	Others	may	                             who go into pre
                                                                Half of women                     d risk
   want to try their own remedies in the comfort of                            e of the identifie
                                                                labor have non                    call”
   their homes. Show respect for these feelings, but                           size “watch and
                                                                factors. Empha
   continue to encourage her to call her health care                            an.
                                                                 with each wom

   Steps to Take — 2009 • Health Education                                                                  HE– 15
          (Blank page)

HE – 16                  Steps to Take — 2009 • Health Education
       y Mo
H ealth Baby
      thy           If Your Labor Starts Too Early

   If you go into labor before it’s time to have     Here’s what you can do:
   the baby, you need medical care right away.
                                                     If you feel any of these warning signs, do
   Watch for these warning signs:                    this test:
   Your uterus may tighten or harden. These          •	 Drink	3	to	4	glasses	of	water.
   contractions could be normal. Pay attention if:
                                                     •	 Lie	down	and	turn	on	your	side.	
   •	 You	have	more	than	5	in	one	hour.              •	 Place	your	hands	lightly	on	your	
   •	 They	come	more	often	than	every	                  bare belly.
      10 minutes.                                    •	 Feel	for	contractions.	Move	your	hands	
                                                        around. A contraction feels like the muscle
  You may have pain.                                    tightens or hardens. Then it relaxes and
   •	 You	may	have	a	lower	backache.	You	may	feel	      softens.
      pain or a dull pressure in your back.
                                                     •	 Count	the	number	of	contractions	
   •	 Your	lower	abdomen	may	hurt.	You	may	feel	        you feel.
      pain or pressure in your thigh or around
      your	vagina.                                   •	 Do	this	for	up	to	one	hour.

   •	 You	may	have	a	stomach	ache	or	cramps	in	
      your	abdomen.	You	may	also	have	diarrhea.
                                                     Call your health care provider
                                                     right away if:
  You may see a change in the discharge              •	 You	have	more	than	5	contractions	in	
  that comes out of your vagina.                        one hour.
   •	 There	may	be	more	mucus.	
                                                     •	 You	bleed	or	leak	fluid	from	your	vagina.
   •	 It	may	be	bloody	or	watery.
                                                     •	 Any	other	of	the	warning	signs	last	for	
                                                        one hour.

                                                      In an emergency call:

                                                      On weekends and evenings, call:

   Steps to Take — 2009 • Health Education                                                            HE– 17
       y Mo
H ealth Baby
      thy          Si el Parto Comienza Antes de Tiempo

   Si comienza con dolores de parto                  Lo que tiene que hacer.
   antes de tiempo, necesita cuidado                 Si siente cualquiera de estas señales de
   médico de inmediato.                              peligro, haga esta prueba:
                                                     •	 Tome	3	a	4	vasos	de	agua.
   Estas son las señales de peligro:
                                                     •	 Acuéstese	de	lado.
   Puede sentir que la matriz se le endurece o
   se le aprieta.                                    •	 Coloque	sus	manos	suavemente	sobre	
   Estas contracciones pueden ser normales.             su	vientre,	por	debajo	de	su	ropa.
   Tenga cuidado si:                                 •	 Sienta	las	contracciones.	Mueva	sus	manos	
                                                        alrededor. Durante una
   •	 Tiene	más	de	5	dolores	en	menos	de	una	
                                                        contracción se siente que el músculo
                                                        se aprieta y se pone duro. Después se
   •	 Cada	dolor	le	viene	en	menos	de	10	               relaja	y	se	suaviza.
                                                     •	 Cuente	las	contracciones	que	sienta.
   Quizás tenga dolor.                               •	 Haga	esto	por	una	hora.
   •	 Tiene	dolor	de	espalda	(en	el	área	de	la	
      cintura). Puede sentir dolor o presión en la   Llame a su médico de inmediato si:
      espalda.                                       •	 Tiene	más	de	5	contracciones	en	una	hora.
   •	 Le	duele	la	parte	baja	de	el	estómago.	        •	 Le	sale	flujo	o	sangre	de	la	vagina.
      Puede sentir dolor o presión en la cadera o
      alrededor	de	la	vagina.                        •	 Cualquiera	de	las	señales	le	duran	más	de	
                                                        una hora.
   •	 Tiene	dolor	de	estómago	o	cólicos.	Puede	
      tener diarrea.

   Quizás note un cambio en el flujo que le
   sale de la vagina.
   •	 Quizás	tenga	más	flujo.
   •	 Puede	parecer	como	agua	o	con	poca	
      sangre.                                             En un emergencia, llame al::

                                                          En los fines de semana o en la
                                                          noche, llame al:

   HE – 18                                                        Steps to Take — 2009 • Health Education
       y Mo
H ealth Baby
      thy           Kick Counts

                                                        Steps to Take
                                          n of
                         ovement is a sig
         Lack of fetal m                   ents         •	 Discuss	with	the	client	the	importance	of	
                          . Baby’s movem
         possible danger                count              fetal	movement	and	describe	the	agreed-
                          Know how to
          are important!                                   upon method for monitoring kick counts.
                                                        •	 There	are	several	methods	for	assessing	
                                                           kick counts. One of the most popular and
                                                           convenient	methods	is	the	“Count	to	10”	
                                                           technique: In this method, the woman is
                                                           advised	to	feel	for	kick	counts	around	the	
   Help your client:
                                                           same	time	of	day	(usually	in	the	evening	
   •	 Be	aware	of	baby’s	movements	every	day.              while lying on her side). She is then asked to
                                                           record the amount of time it takes to feel 10
   •	 Become	familiar	with	the	various	kick	count	
                                                           fetal	movements.	For	normal	pregnancies,	
                                                           this usually occurs within 1 hour and
   •	 Develop	a	plan	with	the	prenatal	provider	           maximally by 2 hours.
      on how to monitor kick counts and when to
                                                        •	 Discuss	the	Count Your Baby’s Kicks
      contact the clinic or emergency room.
                                                           handout with the client.

   Background                                           •	 Practice	kick	counts	with	the	client.
   If a woman is pregnant for the first time, usually
   she	will	feel	the	baby	moving	(quickening)	          Follow-Up
   between	18	and	22	weeks.	Women	who	have	             •	 Follow-up	with	the	client	on	whether	she	is	
   been pregnant before may be aware of fetal              regularly	monitoring	fetal	movement	and	
   movement	earlier.	This	fetal	movement	helps	            whether there has been any recent change
   show the well-being of the fetus.                       in	the	pattern	of	movement.	Address	her	
   By 22 weeks of pregnancy, the fetus should              concerns. Point out to her that less than 10
   be	felt	moving	regularly.	After	28	weeks	of	            fetal	movements	in	12	hours	could	be	a	
   pregnancy,	lack	of	fetal	movement	over	a	               danger sign that the baby’s health may be
   24-hour period is a sign of possible trouble. It       compromised.
   should	be	checked	by	a	health	care	provider.	

                                                                                             ll the
                                                                           of pregnancy, ca
                                                            After 28 weeks                    has
                                                                            vider if the baby
                                                            health care pro
                                                             not moved in 24

   Steps to Take — 2009 • Health Education                                                              HE– 19
          (Blank page)

HE – 20                  Steps to Take — 2009 • Health Education
       y Mo
H ealth Baby
      thy            Count Your Baby’s Kicks

   It’s a good idea to keep track of
   how often your baby moves.
   Knowing	how	often	your	baby	moves	or	“kicks”	
   is a good way to check on your baby’s health.
   During	your	seventh	month,	you	can	start	to	
   count	your	baby’s	kicks	every	day.	Try	just	after	
   you	eat	a	meal.	Your	baby	is	most	active	after	
   you eat.

   Here’s how to count your
   baby’s kicks.
   •	 Sit	with	your	feet	up	or	lie	down	on	your	left	
   •	 Check	the	clock	to	see	what	time	
      you start.                                          If your baby doesn’t move right
   •	 Put	your	hands	on	your	belly.                       away, don’t worry.
   •	 Count	how	many	times	your	baby	moves.	A	            Your baby may be sleeping. Here’s what
     “move”	is	any	kick,	wiggle,	twist,	turn,	roll,	or	   you can do:
      stretch. Do not count the baby’s hiccups.           •	 Drink	something	cold.
   •	 Count	up	to	10	moves.	This	should	take	less	        •	 Eat	something.
      than one hour.
                                                          •	 Walk	around	for	5	minutes.
   •	 Once	the	baby	has	moved	10	times	in	less	
      than 1 hour, you can stop counting. Then            •	 Then	feel	your	belly	for	one	
      you can go about the rest of your day.                 more hour.

                                                          Call your health care provider
                                                          right away if:
                                                          •	 You	do	not	feel	10	moves	in	the	
                                                             second hour.
      In an emergency call:
                                                          •	 You	feel	the	baby	twist,	turn,	or	kick	a	lot	
                                                             more than usual.
      On weekends and evenings, call:

   Steps to Take — 2009 • Health Education                                                                   HE– 21
       y Mo
H ealth Baby
      thy             Cuente los Movimientos de su Bebé

   Es bueno saber con qué frecuencia
   se mueve su bebé.
   Saber	cuántas	veces	se	mueve	o	le	“patea”	su	
   bebé	es	una	buena	manera	de	saber	cómo	está	
   la salud de su bebé.
   Durante su séptimo mes, puede empezar
   a	contar	las	pataditas	de	su	bebé	todos	los	días.	
   Trate de hacerlo después de comer.
   Su	bebé	es	más	activo	después	de	que	
   usted come.

   Cómo contar los movimientos de
   su bebé.
   •	 Siéntese	y	suba	los	pies,	o	acuéstese	de	lado	
      izquierdo.                                        Si su bebé no se mueve
   •	 Mire	el	reloj	para	saber	a	que	hora	empezó.       inmedatamente, no se preocupe.
   •	 Ponga	sus	manos	en	su	vientre.                    Su bebé quizás esté durmiendo. Lo que
                                                        puede hacer:
   •	 Cuente	cuántas	veces	se	mueve	su	
      bebé.	Un	“movimiento”	es	cualquier	patadita,	     •	 Tome	algo	frío.
      meneo,	retorcimiento,	vuelta	o	estiramiento.	     •	 Coma	algo.
      No cuente los hipos del bebé.
                                                        •	 Camine	por	unos	5	minutos.
   •	 Cuente	hasta	10	movimientos.	Esto	debe	
      tardar menos de una hora.                         •	 Entonces	sienta	su	vientre	por	una	
                                                           hora	más.
   •	 En	cuanto	sienta	el	bebé	moverse	10	veces	
      en menos de 1 hora, puede dejar de contar.
                                                        Llame a su médico de inmediato si:
                                                        •	 No	siente	10	movimientos	en	la	segunda	
                                                        •	 Siente	que	el	bebé	se	está	retorciendo,	
                                                           volteando,	o	pateando	mucho	más	que	de	
             En un emergencia, llame al::

             En los fines de semana o en la
             noche, llame al:

   HE – 22                                                           Steps to Take — 2009 • Health Education
       y Mo
H ealth Baby
      thy           STIs (Sexually Transmitted Infections)
                                            n to
                            read from perso
     STIs are infections sp              me STIs
                       xual activity. So                  Bacterial STIs (like syphilis, gonorrhea) can be
     person during se                     nge of
                          through excha                   cured. Viral STIs, (like HIV, herpes, hepatitis B) can
      can also be passed
                       -skin contact.                     never	be	cured	(some	symptoms	are	treatable).
      blood or skin-to
                                                          Herpes can be fatal or cause brain damage to
                                                          infants who acquire it. If a woman has outbreaks
                                                          of	herpes	on	her	cervix	at	the	time	of	delivery,	she	
                                                          may	need	a	Cesarean	delivery	to	reduce	the	risk	of	
                                                          transmission to her baby.
   Help your client:                                      Congenital syphilis can occur if the mother has
                                                          untreated or inadequately treated syphilis during
   •	 understand	how	STIs	are	transmitted
                                                          pregnancy. Infants who acquire congenital syphilis
   •	 why	STIs	are	a	special	concern	to	pregnant	         are at risk for brain damage, heart disease, skeletal
      women                                               problems and other long-term complications.
   •	 symptoms	to	watch	for
   •	 how	to	prevent	transmission                         Steps to Take
                                                          For all clients:
   Background                                                                                      m
                                                          •	 Discuss	STIs	during	the	initial	assess	 ent.	
   In the U.S., STIs are second only to the common
   cold as the most widespread contagious disease.        •	 Review	What You Should Know About STDs
   Teens are especially at risk: two-thirds of all STIs      and You Can Protect Yourself and Your Baby
   occur in people under 25 years of age. Some of the        from STDs with her.
   rates of STIs in California are:                       •	 Use	the	more	familiar	term,	STD,	when	you	talk	
                                                             with her.
   •	 3.6	cases	of	syphilis	per	100,000	women
   •	 92.5	cases	of	congenital	syphilis	per	100,000	      For specific clients:
      babies born                                         Meet client’s needs, based on the following:
                                                          •	 One sex partner, who has no other
   •	 105.4	cases	of	gonorrhea	per	100,000	women
                                                             partner(s). Briefly discuss What You Should
   •	 340.9	cases	of	chlamydia	per	100,000	women             Know About STDs and You Can Protect
   It is estimated that 25 to 50% of people in the U.S.      Yourself and Your Baby from STDs and ask if
   are infected with genital herpes.                         she has any other questions. Encourage her to
                                                             talk openly about her health with her partner
                                                             in case he or she has other sex partners. Also
   Important Information                                     encourage her to know her sex partner’s
   STIs occur more frequently in women than                  history of any STIs. Reaffirm the health benefits
   men, with more serious health consequences.               of her monogamous lifestyle.
   Women	often	have	no	symptoms	and	so	may	not	
                                                          •	 More than one sex partner, or the sex partner
   get	treatment.	Even	with	no	immediate	symptoms,	
                                                             has other partner(s), but no history of STIs.
   STIs can be transmitted to partner(s) or fetuses.
                                                             Discuss the handouts with her.
                                                          •	 History of STIs, STI during this pregnancy, or
                                                             current symptoms of an STI.
   Steps to Take — 2009 • Health Education                                                                   HE– 23
       y Mo
H ealth Baby
      thy              STIs (cont.)

                                                           Go	over	the	handouts	with	her.	Follow	up	at	each	
      STI Risks                                            visit	with	support	and	encouragement	to	get	any	
                                                           STI	diagnosed,	and	to	prevent	future	infections.
      What are the risks?
      Risks for pregnant women infected with an STI
      include spontaneous abortion, transmission           Other protection
      to	the	fetus,	and	even	death	of	the	fetus.	Other	    •	 Discuss	abstinence	(no	intercourse)	if	
      risks	for	the	infants	include	brain	damage,	liver	      appropriate for her.
      or lung damage, blindness, retardation and
      skeletal problems.                                   •	 Review	the	instructions	for	condom	use	found	
                                                              on the next page, if appropriate for her.
      Transmission to fetus can occur in utero or
      during	delivery,	including:	                         •	 If	she	cannot	use	condoms,	or	if	she	wants	
                                                              extra protection from STIs, show her samples
      •	 bacterial	vaginosis                                  of spermicidal foam, jelly, cream, suppositories,
      •	 chlamydia	                                           and	VCF.	These	products	can	help	prevent	STIs	
      •	 genital	warts                                        even	when	no	condom	is	used.
      •	 gonorrhea
      •	 hepatitis	B                                       Concerns for the partner
                                                           To	refer	sex	partner(s)	for	STI	testing,	provide	the	
      •	 herpes
                                                           phone number for the County Health Department
      •	 pus	on	the	cervix	                                or	refer	to	her	primary	health	care	provider	or	a	
         (mucopurulent	cervicitis	MPC)                     community clinic. Ask if she’d like to bring the
      •	 syphilis	                                         partner to her next appointment to discuss STIs.
      •	 trichomonas
      •	 HIV                                               Difficult situations
                                                           Changing	a	behavior	involving	sex,	such	as	
      Who’s at risk?                                       starting	to	use	condoms,	can	be	very	difficult.	
      Low risk                                             When a client feels she cannot ask a partner to use
      •	 woman	has	only	one	sex	partner	and	               condoms, explore ways she feels she could assert
         the partner only has sex with her (a              herself more. Role-playing can be an empowering
         monogamous relationship)                          tool.	Provide	positive	feedback	as	she	improves	
                                                           in protecting her health, such as initiating a
      High risk                                            conversation	with	her	partner,	trying	a	condom	
      •	 partner	with	STI	from	past	relationship	          once,	or	trying	a	non-intercourse	sexual	activity	to	
                                                           reduce her risk.
      •	 more	than	one	sex	partner
      •	 sex	partner	has	other	partners

   HE – 24                                                              Steps to Take — 2009 • Health Education
       y Mo
H ealth Baby
      thy           STIs (cont.)

   Follow-Up                                               Resources
   If the client has discussed using condoms during        How to Use a Condom
   sexual	activity,	ask	about	success	in	trying	them.	     FamPACT	providers
   Support her efforts and ask if she’s had any            EDS
   difficulties.                                           1-800-848-7907
   If the risk of getting an STI increases because a       American	College	of	Gynecologists	&	
   client cannot get her sex partner to use condoms        Obstetricians,
   and she is dependent on him for money, housing,         409 12th Street, NW,
   or for immigration status, understand that she has      Washington, DC 20024-2188,
   many factors to consider. If she understands how        1-800-762-2264
   STIs	are	transmitted,	what	effect	they	can	have	on	
                                                           Educational Programs Associates,
   her	baby	and	how	to	prevent	transmission,	she	
                                                           A	Division	of	California	Family	Health	Council
   must decide how to handle the risk.
                                                           1	West	Campbell	Ave.,	Suite	45,	
                                                           Campbell, CA 95008-1039

       Condom Instructions
      Condoms can help protect against infection           •	 Role-play negotiation with a partner
      for those at risk, or those who engage in risky         about using condoms (focus on issues
      behavior.	To	be	effective,	however,	condoms	            that are important to her, such as not using
      must be used correctly.                                 them for religious reasons, implying a lack
                                                              of trust in the partner, protecting the baby
      Demonstrate condom use with the following
                                                              until both partners can get checked/tested,
       •	 State that condoms should be put on              •	 Discuss difficulties with using condoms
          before sexual intercourse and left on               and solutions that may work for her. For
          until all contact is finished.                      example, if she is too embarrassed to buy
       •	 Advise that only water-based lubricants             condoms:
          should be used. (No lotion, Vaseline, baby          Can the clinic provide them for her?
          oil, etc.) Make sure enough water-based
          lubrication is used.                                Can she order them by mail?

       •	 Demonstrate unrolling the condom and                Is there a store where she would be
          squeezing out air by using a real condom            comfortable buying them?
          and	your	fingers,	her	fingers,	or	a	vegetable.   •	 See if she’s had bad experiences with
       •	 Show how to find the word “latex”                   condoms breaking in the past. Suggest
          on a condom package and the word                    using only latex condoms and water-based
         “spermicidal” or “nonoxynol-9” on a tube of          lubricants.

   Steps to Take — 2009 • Health Education                                                                  HE– 25
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HE – 26                  Steps to Take — 2009 • Health Education
       y Mo
H ealth Baby
      thy           What You Should Know About STDs

   What are STDs?                                       Call right away if you:
   STDs (Sexually Transmitted Diseases) are             •	 Have	burning	or	itching	around	
   diseases	people	get	from	having	sex	with	               the	vagina.
   someone who has an STD.
                                                        •	 Have	pain	in	the	pelvic	area.
   You	may	have	heard	of	gonorrhea,	syphilis, herpes,
   or	chlamydia.	HIV,	the	virus	that	causes	AIDS,	is	   •	 Have	a	strange	discharge	from	your	vagina.	
   also an STD.                                            It may:
                                                             – Smell bad.
                                                             – Be colored or bubbly.
   STDs can spread when:
   •	 You	have	sex	without	a	condom.                    You should also call your health
   •	 You	have	sex	with	more	than	                      care provider if you:
      one partner.                                      •	 Bleed	from	the	vagina.
   •	 Your	sex	partner	has	sex	with	                    •	 Have	pain	when	you	have	sex.
      other partners.
                                                        •	 See	sores,	bumps,	or	blisters	around	your	
                                                           vagina	or	mouth.
   STDs can spread to your
   unborn baby.                                         •	 Have	burning	when	you	urinate	(pee).

   If you do not get treatment, these                   You or your partner may not have
   diseases can cause many problems
   for you and your baby:                               any signs of an STD.
                                                        Even	if	you	don’t	see	any	signs,	it	can	still	spread.	
   •	 The	baby	could	miscarry.                          You	may	have	signs	that	go	away.	But	the	STD	
   •	 The	baby	might	be	born	too	soon.                  stays in the body.

   •	 The	baby	may	have	birth	defects	or	other	
      health problems.
   •	 You	could	get	very	sick.

                                                           You can get tested for STDs.
                                                            That way you can get the care you
                                                            need	if	you	have	an	STD.	This	is	very	
                                                            important when you are pregnant.
                                                            Get	the	care	you	need	right	away	to	
                                                            protect your health and the health of
                                                            your baby.

   Steps to Take — 2009 • Health Education                                                                 HE– 27
   althy Baby
      thy              Lo Que Debe Saber Sobre las ETS

   ¿Que son las ETS?                                         Hable con su médico de inmediato
   Las ETS (Enfermedades Transmitidas                        si:
   Sexualmente) se contraen al tener relaciones
                                                             •	 Tiene	ardor	o	comezón	alrededor	de	la	
   sexuales con alguien que tiene una ETS.
   Quizá	haya	escuchado	hablar	de	la	gonorrea,	
                                                             •	 Tiene	dolor	en	la	área	pélvica.
   la	sífilis,	el	herpes,	o	la	clamidia.	El	VIH,	el	virus	
   que causa el SIDA, es también una ETS.                    •	 Le	sale	un	desecho	raro	de	la	vagina:
                                                               	 –	 Que	tiene	mal	olor.
   Las ETS se transmiten cuando:                               	 –	 Que	tiene	color	o	es	espumoso.
   •	 Usted	tiene	relaciones	sin	usar	un	condón.
   •	 Usted	tiene	relaciones	con	más	de	una	                 También debe llamar a su médico
      persona.                                               si:
   •	 Usted	tiene	una	pareja	que	tiene	relaciones	           •	 Le	sale	un	poco	de	sangre	de	la	vagina.
      con otras personas.
                                                             •	 Siente	dolor	al	tener	relaciones	sexuales.
   Las ETS pueden ser transmitidas a                         •	 Tiene	llagas,	ronchas	o	ampollas	alrededor	
   su bebé antes de nacer.                                      de	la	vagina	o	boca.
   Si no recibe tratamiento, estas                           •	 Siente	dolor	al	orinar.
   enfermedades pueden causar muchos
   problemas para usted y para su bebé:
   •	 Puede	abortar	al	bebé.
                                                             Usted y su pareja tal vez no noten
   •	 El	bebé	puede	nacer	antes	de	tiempo.
                                                             ningún síntoma de una ETS.
                                                             Aunque	no	sientan	ningún	síntoma,	la	
   •	 El	bebé	puede	tener	defectos	de	nacimiento	            enfermedad aún se puede transmitir. Puede
      u otros problemas de salud.                            tener	síntomas	que	desaparecen.	Pero	la	
   •	 Usted	se	puede	enfermar	gravement.                     enfermedad permanece en el cuerpo.

                                                               Puede hacerse pruebas
                                                               contra las ETS.
                                                               De esa manera puede recibir el
                                                               tratamiento que necesita si tiene una
                                                               ETS.	Es	muy	importante	cuando	está	
                                                               embarazada. Obtenga el cuidado que
                                                               necesita de inmediato para proteger
                                                               su salud y la salud de su bebé.

   HE – 28                                                                Steps to Take — 2009 • Health Education
       y Mo
H ealth Baby
      thy            HIV and Pregnancy
                                        S. The
                       that causes AID
      HIV is the virus                         n
                              from one perso
      viru s ccan be passed              ginal         Steps to Take
                        lood, semen, va
      to another in b
                         t milk, or from a
       secretions, brea                                All clients
                         an to her baby.
       pregnant wom                                    In	California,	prenatal	care	providers	must	offer	
                                                       Human Immunodeficiency Virus (HIV) information,
                                                       counseling, and testing to all pregnant women
                                                       during prenatal care.
                                                       Prenatal	care	providers	are	required	to	give	
   Help your client:                                   information and counseling that shall include
   •	 understand	that	HIV-infected	pregnant	           (but not be limited to):
      women benefit from early detection and
      medical treatment                                •	 A	description	of	the	modes	of	HIV	transmission

   •	 know	where	she	can	be	tested	for	HIV	if	she	     •	 A	discussion	of	risk	reduction	behavior	
      desires                                             modifications, including methods to reduce
                                                          the risk of perinatal transmission
   •	 know	how	to	prevent	the	transmission	of	HIV	
                                                       •	 Referral	information	to	other	HIV	prevention	
                                                          and	psychosocial	services,	if	appropriate,	
   Background                                             including anonymous and confidential test
  The rate of women getting AIDS is growing:              sites.
  20% of the new cases of AIDS being diagnosed
  are in women. As of December 1995, nearly
  5,500	women	aged	20	years	or	older	have	been	          Who’s at risk?
  diagnosed with AIDS in California. Many more are       Women at risk for HIV infection are women
  infected with HIV (maybe 10 times as many). Most       who	currently	engage	in	or	have	a	history	of:
  women are infected through heterosexual sex,           •	 Multiple	sexual	partners
  with 72% of the AIDS cases diagnosed in women
                                                         •	 Using	alcohol	and/or	drugs,	especially	
  between the ages of 25 and 44. Approximately
                                                            sharing needles for injecting drugs
  50%	of	women	giving	birth	to	an	HIV	positive	
  infant are not aware of their own HIV status.          •	 Having	sex	with	a	man	who	has	had	sex	
                                                            with other men
   In the U.S., the rate for HIV transmission from
   pregnant women to their babies has been 20            •	 Having	sex	with	a	man	who	has	
   to 25% (1 in 4 babies). One study found that the         hemophilia	and	may	have	received	blood	
   transmission rates were lowered to 8.3% (1 in 12         transfusions
   babies) if the women met certain criteria and         •	 Receiving	blood	by	transfusion	or	blood	
   took	AZT	during	pregnancy	and	delivery	and	their	        products before 1985
   babies took AZT for 6 weeks. Use of AZT treatment     •	 Having	sex	with	a	partner	who	has	had	
   is now recommended for most HIV-infected                 multiple sexual partners or used drugs or
   women who are pregnant.                                  alcohol
                                                         •	 Unprotected	sexual	encounters	

   Steps to Take — 2009 • Health Education
                                                                                                       HE– 29
   althy Baby
      thy           HIV and Pregnancy (cont.)

   When offering testing, the clinician shall include all                         imes one of ma
                                                               HIV risk is somet                      eciding
                                                                                     n considers in d
   of the following:                                           va riables a woma                     nd
                                                                                    ave. Religious a
   •	 The	purpose	of	the	test                                  how she will beh                        from
                                                                                      keep a women
                                                                cu ltural issues can                ning her
                                                                                   or from questio
   •	 The	risks	and	benefits	of	the	test                        using condoms
   •	 The	voluntary	nature	of	the	test                           partner’s fidelit
   Testing must be offered, but the test itself is
   entirely	voluntary.	The	provider	may	arrange	            •		 Discuss	practicing	“safer	sex”	(not	exchanging	
   for HIV testing, which may include referral to a             body	fluids,	avoiding	intercourse,	and	using	
   provider	lab	or	to	anonymous	or	confidential	                condoms and other protection, etc.) and how
   test	sites	approved	by	the	Office	of	AIDS.	                  to	avoid	sharing	needles.	
   Confidentiality will be maintained for women who
   choose	to	have	the	test.	That	decision,	as	well	as	      •		 Refer	immediately	to	a	health	care/social	
   the test results, will be kept confidential.                 services	program	for	HIV-infected	pregnant	
                                                                women. This will help her make an informed
   There is no cure for HIV, but women can take                 decision	about	the	pregnancy,	take	advantage	
   the drug AZT and other drugs to prolong their                of	drug	treatments	and	other	services	
   lives	and	maintain	their	health.	AZT	also	can	               specifically for HIV-infected pregnant women,
   dramatically reduce the chance that HIV will be              and learn about reducing transmission to
   transmitted to the fetus.                                    others.
   Find out what she already knows about HIV
   or AIDS, or has experience with. Find out if she         For HIV information, counseling, and
   understands	how	the	HIV	virus	causes	infection	          testing
   and is transmitted, or if she has other concerns.
                                                            Patient Education Prior to Consent to be Tested

   For clients with earlier testing                         1.	 Provide	information	on	HIV	(See	the	handout	
                                                                What You Should Know About HIV.)
   •	 If	a	client	has	already	had	an	HIV	test,	with	
      negative	results,	be	sure	it	was	at	least	3	to	6	        •	 Transmission/high-risk	behavior
      months after exposure to possible infection                – unprotected sexual encounters
      (such as unprotected sex or needle sharing).               – sharing needles and other drug use
      If the test was a short period after exposure,                paraphernalia	(including	steroids,	vitamins,	
      it should be repeated in 6 months when                        hormones)
      antibodies	have	had	time	to	build	up	in	the	               – other drug/alcohol use that may affect
      body.                                                         decision-making
                                                                 – multiple blood transfusions
   •	 If	the	client	has	had	an	HIV	test	with	positive	         •	 Effects	on	health
      results but no follow-up, recommend a further
      test to rule out any possibility of error.

   HE – 30                                                               Steps to Take — 2009 • Health Education
       y Mo
H ealth Baby
      thy           HIV and Pregnancy (cont.)

   2. Explain testing method.                             •	 Progression	(very	individual)
      •	 A	blood	test                                     •	 Discuss	role	of	AZT	in	reduction	of	perinatal	
      •	 Results	-	one	to	two	weeks                          transmission.
                                                          •	 Provide	appropriate	medical	follow-up	and/
   3. Explain meaning of test results.
                                                             or referral.
      •	 Reactive	(Positive/evidence	of	virus	found)
                                                       5. Explain healthful lifestyles.
      •	 Non-Reactive	(Negative/evidence	of	virus	
         not found)                                        •	 Safer	sex	practices
                                                              – abstinence, monogamy, use condoms
  4. Relate potential misuse of test results.
                                                            	 –	 	 o	not	give	or	receive	any	bodily	fluids
      •	 Employment                                      •	 Don’t	share	needles	or	other	drug	use	
      •	 Insurance                                           paraphernalia
   5. Teach patient how to stay healthy.                 •	 General	good-health	lifestyles
     •	 Abstinence,	monogamy,	safer	sex                       – rest
     •	 Don’t	share	needles	or	misuse	drugs	                  – nutrition
                                                              – exercise
   6. Obtain signed informed consent and
                                                         •	 Do	not	donate	blood	or	body	organs
      document in chart.
                                                       6. Encourage patient to share information with
                                                          significant other(s).
   Disclosure - non-reactive (negative/
                                                       7. Obtain authorization for Disclosure of
   virus not found) - give results
  1. Teach client how to stay healthy.
      •	 Abstinence,	monogamy,	safer	sex
      •	 Don’t	share	needles
                                                       Other considerations
                                                       a. Provide all counseling with complete
   2.	 Reinforce	healthy	behavior.
   3. Determine if retesting is necessary.
                                                       b. Be certain all counseling, including
      •	 Window	period:	high	risk	behavior	within	6	      written or audio materials, is linguistically,
         months                                           culturally, educationally and age
                                                          appropriate for each specific patient.
   Disclosure - reactive (positive/virus
                                                       c. Obtain signed, informed consent for testing.
   found)                                                 Document consent or refusal on the prenatal
  1. Anticipate/prepare for client reaction.              care record.
   2. Allow patient to react.                          d. Check that she understands terms. Use
   3.	 Provide	resources	and	referral	to	agency	and/      words she’s comfortable with (such as bottom
       or	individual	knowledgeable	about	HIV	in	the	      or butt, instead of anus). Even better: use
       community.                                         both the terms “anus” and “butt” so she can
                                                          recognize the word “anus” if she hears it or
  4.	 Provide	information	about		 isease	process.         reads it in the future.
      •	 Symptoms

   Steps to Take — 2009 • Health Education                                                               HE– 31
       y Mo
H ealth Baby
      thy            HIV and Pregnancy (cont.)

   e. HIV can be a difficult topic for women. Some
      may	have	questions	about	a	sexual	partner’s	           Document in the chart (on the assessment
      fidelity	or	needle	sharing	activities,	and	yet	        or in a progress note) that the HIV risk
      not be able to demand using condoms. Others            assessment and HIV prevention education
      may not think the risk is serious, or they may         have been completed. Documentation
      lack skills to negotiate condom use or abstain         that the client will have (or has had) the
      from sex.                                              HIV antibody test, the actual test results,
                                                             or other HIV-related information is
   f.   Demonstrate prevention techniques. This              confidential. Refer to guidelines at your
        may include condom use, how to apply                 site for appropriate documentation.
        spermicide, how to use dental dams or other
        devices	for	oral	sex,	or	how	to	clean	needles	
        with	bleach.	When	possible,	have	samples	and	
        models. See the handout Protection From STIs       •		 Refer others, such as sex partners, for HIV
        and HIV.                                               testing, when possible. Call the numbers
                                                               listed below for referrals for HIV testing.
   g. Encourage uninfected pregnant women
      who practice high risk behavior to avoid             •		 Refer to hotlines for more information.	Give	
      further exposure to HIV and to be retested               numbers to the client so she can make the calls
      for HIV during the third trimester.                      herself, or call for her during the appointment.
   h. Provide access to other HIV prevention and           National:
      treatment services.
                                                           County Public Health Departments, for
                                                           information	on	the	following	services:
   Making referrals
                                                           Alternative	Test	Sites	(ATSs)
   •	   Refer clients who decide to take the HIV
                                                           Infectious Disease Specialists
        test	to	the	on-site	testing	services	or	other	
                                                           Pediatric AIDS Specialists
        appropriate sites. Pre-and post-test counseling
                                                           Drug	and	Alcohol	Recovery	Programs
        and referrals for emotional, physical, and
                                                           Ryan	White	Coordinated	Services
        medical	support	should	be	made	available	on	
                                                           Local AIDS Foundations
                                                           Family Planning
   •	   Explain both confidential and anonymous
                                                           National AIDS Hotline
        testing services. Confidential testing means
        that her test results will be on file— including   English 1-800-367-2437
        her name—in the clinic where she is tested.        Spanish 1-800-344-7432
        Anonymous testing does not use the client’s        Hearing Impaired 1-800-243-7889
        name with her blood sample or test results.
                                                           National HIV/AIDS Teen Hotline
        To help a client decide which type of testing
        would be better for her, ask
                                                           (Friday-Saturday 6:00 pm to 12:00 am)
        Is there any reason you wouldn’t want the
                                                           National HIV/AIDS Teen Hotline
        HIV test results linked with your name, such as
        immigration, health insurance, or other issues?
                                                           (Friday - Saturday 6:00 pm to 12:00 am)

   HE – 32                                                             Steps to Take — 2009 • Health Education
       y Mo
H ealth Baby
      thy          HIV and Pregnancy (cont.)

  Project Information                              Northern California:
  (Treatment Hotline)                              English, Spanish, Tagalog:
  1-800-822-7422                                   1-800-367-AIDS (2437)
  HIV/AIDS Treatment Information                   Filipino: 1-800-345-2437
  1-800-448-0440                                   TTY: 415-864-6606

  National STI Hotline
  1-800-227-8922                                   Follow-Up
                                                   Some clients may decide not to take the HIV
                                                   test	when	it	is	first	offered.	At	subsequent	visits,	
   Southern California:                            they should be offered the opportunity to ask
  English: 1-800-922-AIDS (2437)                   additional	HIV-related	questions	and/or	receive	
  Spanish: 1-800-400-7432                          a referral for testing.
  Asian Pacific-Islander: 1-800-922-2438
  TTY: 1-800-33-2437

         For more information about HIV-infected   State Office of AIDS, California
         pregnant women:                           Department of Health Services
         AIDS Clinical Trial Information Service
         1-800-874-2572                            ACTIS
         HIV Telephone Consultation Service
         1-800-933-3413                            HIV/AIDS Treatment Information Service
         7:30 am to 5:00 pm PST                    1-800-448-0440
                                                   Bay Area Pediatric AIDS Center (BAPAC)
         Pacific AIDS Education and Training       415-206-8919
         CDC National AIDS Information

   Steps to Take — 2009 • Health Education                                                           HE– 33
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HE – 34                  Steps to Take — 2009 • Health Education
       y Mo
H ealth Baby
      thy          What You Should Know About HIV

   HIV is the virus that causes AIDS.                 Every pregnant woman
   Most	often,	the	virus	is	spread	when	people	       should take the HIV test.
   have	sex	or	share	needles	with	someone	            Why?	You	could	have	HIV	and	not	
   who has HIV. If a mother has HIV, she can          know it. You could pass it on to your baby.
                                                      When you get the HIV test, you can find out if
   pass it to her baby when she is pregnant or
                                                      you	have	HIV.	If	you	do	have	HIV,	you	can	get	
                                                      the care you and your baby need.

   What you need to know:                             •	 There	are	great	treatment	programs	now	
   •	 You	can	get	HIV	when	you	have	                     that can help.
      sex	using	the	penis,	vagina,	mouth,	
                                                      •	 Treatment	can	lower	the	chances	of	your	
      or anus.
                                                         baby getting HIV.
   •	 You	can	help	protect	yourself.	Use	
                                                      •	 You	can	choose	to	feed	your	baby	with	
      condoms	every	time	you	have	sex.	Use	
                                                         breast milk from a milk bank or use formula.
      condoms	no	matter	how	you	have	sex.
   •	 HIV	can	spread	if	you	share	needles.	           Be sure to take the HIV test if:
      It is dangerous to share needles no matter      •	 You	or	your	partner	have	had	more	than	
      what you inject.                                   one partner.
   •	 Don’t	share	needles	to	do	drugs,	get	vitamin	   •	 You	have	ever	had	an	STD.
      shots, tattoos, or piercings.
                                                      •	 You	have	had	a	baby	with	HIV.	
  Ask	your	health	care	provider	about	taking	
  the HIV test.                                       It is also important
                                                      to take the test if:
                                                      •	 You	or	your	sex	partner(s)	have	ever	shared	
                                                         needles with other people.
                                                      •	 You	or	your	sex	partners	have	sex	while	
                                                         high on drugs or alcohol.
                                                      •	 You	or	your	sex	partners	had	a	blood	
                                                         transfusion (before 1985).

   Steps to Take — 2009 • Health Education                                                             HE– 35
       y Mo
H ealth Baby
      thy            Lo Quae Saber Sobre al VIH

   El VIH es el virus que                           Toda mujer embarazada debe
   causa el SIDA.                                   hacerse la prueba del VIH.
   En	la	mayoría	de	los	casos,	el	virus	se	         Puede tener el VIH y no saberlo. Se lo puede
   transmite cuando las personas tienen             transmitir a su bebé. Si se hace la prueba del
   relaciones sexuales o comparten agujas           VIH, puede saber si tiene el VIH. Si es que tiene
   y	jeringas.	Si	la	mamá	tiene	el	VIH,	            VIH, puede recibir el cuidado que usted y su
   puede transmitirlo a su bebé cuando              bebé necesitan.
   está	embarazada	o	dando	pecho.	
                                                    •	 Ahora	hay	tratamientos	muy	buenos	que	
                                                       pueden asistirle.
   Lo que necesita saber:
                                                    •	 Con	tratamientos	adecuados	se	reducen	las	
    •	 Puede	contagiarse	con	el	VIH	cuando	tiene	      posibilidades que su bebé se contagie del
       relaciones sexuales usando el pene, la          VIH.
       vagina,	la	boca	o	el	ano.	
                                                    •	 Puede	escoger	alimentara	para	su	bebé	
    •	 Puede	ayudara	protegerse.	Use	                  con leche materna de un banco de leche o
       condones	cada	vez	que	tenga	relaciones	         puedo usar formula.
       sexuales. Use condones sin importar que
       tipo de relación.
                                                    Asegúrese de hacerse
    •	 El	VIH	puede	transmitirse	si	comparte	
                                                    la prueba del VIH:
       agujas. Es peligroso compartir agujas.
       No importalo que se inyecte. No              •	 Si	usted	o	su	pareja	han	tenido	más	de	una	
       comparta agujas                                 pareja.
       para usar drogas,                            •	 Si	ha	tenido	una	ETS.
       inyecciones de                               •	 Si	ha	tenido	un	bebé	con	VIH.
       hacerse tatuajes                             También es importante
       o hacerse                                    hacerse la prueba si:
                                                    •	 Usted	o	su	pareja	han	compartido	agujas	
   Pregúntele a su                                     con otras personas.
   médico acerca
   de hacerse el                                    •	 Usted	o	su	pareja	han	tenido	relaciones	
   examen del VIH.                                     sexuales bajo los efectos de las drogas o
                                                    •	 Usted	o	su	pareja	han	tenido	una	
                                                       transfusión de sangre (antes de 1985).

   HE – 36                                                        Steps to Take — 2009 • Health Education
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H ealth Baby
                     You Can Protect Yourself and Your Baby from STDs

   STDs are dangerous for you                       Don’t share needles to inject
   and your baby.                                   anything.
   STDs	are	diseases	you	could	get	when	you	have	   •	 Use	bleach	to	clean	needles	if	you	do	share	
   sex	with	someone	who	has	one.	You	may	have	         needles.
   heard of HIV,
   chlamydia, gonorrhea, and herpes. There are      •	 Ask	your	health	care	worker	how	to	clean	
   many more STDs.                                     needles.
                                                    •	 Find	out	if	there	are	needle	exchange	
   Here just a few of the problems STDs                programs near you.
   can cause:
   •	 Your	baby	could	be	born	too	early	or	too	     Here are other things that will
   •	 Your	baby’s	eyes	or	lungs	could	              •	 Tell your health-care provider if you have
      be damaged.                                      had STDs in the past.
   •	 Your	baby	could	have	life-long	health	        •	 Get tested for STDs and HIV. The
      problems	or	even	die.                            earlier STDs are found the better!

   It’s important to protect yourself and           •	 If you have an STD, get treated. Make sure
   your baby.                                          your partner gets checked and treated, too.

   Use a latex condom every time you
   have sex.
   That’s really important if:                         For more information, call:

   •	 You	think	your	partner	may	have	other	
   •	 You	know	your	sex	partner	has	sex	with	
      other people.
   •	 You	have	more	than	one	sex	partner.

   Ask your health care worker to
   show you how to use a condom.
   •	 There	are	condoms	for	both	men	
      and women.
   •	 It’s	easy	to	learn.

   Steps to Take — 2009 • Health Education                                                            HE– 37
       y Mo
H ealth Baby
      thy           Puede Protegerse Así Misma y su Bebé

   Las ETS son peligrosas para usted                No comparta agujas para
   y su bebé.                                       inyectarse.
   Las ETS son enfermedades que puede contraer      •	 Use	cloro	para	limpiar	agujas	si	
   al tener relaciones sexuales con alguien que        comparte agujas.
   tiene	una.	Tal	vez	le	han	
   contado del VIH, clamidia, gonorrea, y herpes.   •	 Pregúntele	a	su	trabajador	de	salud	cómo	
   Hay muchas otras ETS.                               limpiar agujas.

   Aquí hay algunos problemas que las ETS           •	 Investigue	si	hay	programas	cerca	de	usted	
   pueden causar:                                      para intercambiar agujas.

   •	 Su	bebé	puede	nacer	antes	de	tiempo	o	
                                                    Hay otras cosas que ayudan:
      nacer	muy	pequeño.
                                                    •	 Dígale a su médico si ha tenido una ETS
   •	 Los	ojos	o	pulmones	de	su	bebé	pueden	           en el pasado.
      estar	dañados.
                                                    •	 Hágase las pruebas para las ETS y el VIH.
   •	 Su	bebé	puede	tener	problemas	de	salud	          Entre más pronto se detectan es mejor
      de	por	vida	o	hasta	morir.	                      para used.

   Es importante que usted se proteja y             •	 Si tiene una ETS, reciba tratamiento.
   que proteja a su bebé.                              Asegúrese de que su pareja también se
                                                       examine y reciba tratamiento.
   Use un condón de latex cada vez
   que tenga relaciones.
                                                       Para mas información, llame al:
   Esto es muy importante si:
   •	 Piensa	que	su	pareja	puede	tener	otras	
   •	 Sabe	que	su	pareja	sexual	ha	tenido	
      relaciones sexuales con otras personas.
   •	 Usted	tiene	más	de	una	pareja	sexual.

   Pídale a su médico que le enseñe
   cómo usar un condón.
   •	 Hay	condones	para	el	hombre	y	la	mujer.
   •	 Es	fácil	de	aprender.	

   HE – 38                                                       Steps to Take — 2009 • Health Education
       y Mo
H ealth Baby         Cautions: Cats/Hot Baths/Raw Foods and Other Concerns

                                   rried                    For clients at risk
                   n activities ca
      Many commo                 can                        •	 Help	her	find	ways	to	avoid	risky	behavior.
                     ant woman
      out by a pregn
                                                            •	 Make	a	note	of	the	risk	in	her	care	plan.	For	
      harm a fetus.
                                                               example,	Discussed	cat	box	cleaning;	review	
                                                               next trimester.

   Goal                                                     •	 Some	clients	may	need	help	problem-solving,	if	
   Help your client:                                           situations are not easy to handle. For example,
                                                               a client may be a child-care worker and may
   •	 understand	that	certain	things	she	does	                 need ideas on keeping cats out of the sandbox,
      normally may be harmful during pregnancy.                or a client may need ideas on how to keep flies
                                                               from food at home. Check with a health care
   •	 find	ways	to	avoid	those		 ctivities.
                                                               provider	if	other	questions	come	up	that	are	
                                                               not addressed here.
   The unborn baby can be harmed by a number
   of things that do not harm children or adults.
                                                            At each trimester reassessment, check how the
   Cleaning cat boxes, taking hot baths, or eating raw
                                                            client	is	handling	any	caution	you	have	discussed.	
   or rare meat can cause conditions that result in
                                                            Help	her	find	ways	to	continue	avoiding	hazards,	if	
   miscarriages, major disabilities in infants, and other
                                                            she needs help.
   serious health consequences. All clients should be
   aware of these special risks for pregnant women
   so	they	can	avoid	them.	See	Causes for Concern           Resources
   on the next page.                                        The American College of Obstetricians and
                                                            Gynecologists	(ACOG)	pamphlets.		For	ordering	
                                                            information call: 1-800-762-2264
   Steps to Take
                                                            Travel During Pregnancy and other titles
   For all clients
   Inform each client that pregnant women need to           March of Dimes, Public Health Information
   be	especially	careful	to	avoid	certain	infections	       For ordering information call 914-428-7100
   and	activities.	Allow	time	for	her	questions	or	         Toxoplasmosis
   concerns.	If	she	desires	more	information,	give	a	
   fuller explanation using Causes for Concern on           Education Programs Associates
   the following page.                                      A	Division	of	California	Family	Health	Council
                                                            1	West	Campbell	Ave.,	Suite	45
                                                            Campbell, CA 95008-1039

   Steps to Take — 2009 • Health Education                                                                   HE– 39
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H ealth Baby
      thy           Causes for Concern During Pregnancy

   Toxoplasmosis                                              Listeriosis
   Cat feces, and raw meat, fish, eggs, or raw milk can       Soft cheese or raw or undercooked meat can
   contain	a	parasite	“ Toxoplasma	Gondii”	which	             contain a bacteria that causes listeriosis. If a
   causes toxoplasmosis in humans. In a pregnant              pregnant woman is infected, she may experience
   woman, the infection can cause a spontaneous               fever	and	generalized	aches	and	pains.	She	could	
   abortion or the infection of the newborn baby              pass the illness on to her fetus through her blood.
   (infection can occur at any time during the                This infection can cause stillbirth or serious illness
   pregnancy).                                                in newborns. See the Food Safety section in the
                                                              Nutrition guidelines for information on eating
   Babies born with a toxoplasmosis infection can
   have	various	abnormalities,	including	blindness,	
   mental retardation, neurological deficits, and
   deafness.                                                  Mercury
   The	number	of	women	who	have	toxoplasmosis	                The mercury content in fish is generally low.
   during pregnancy is between one and eight per              However,	if	a	pregnant	woman	eats	a	diet	high	
   1,000. Ten percent of those transmit the infection         in fish, she may ingest enough mercury to harm
   to their fetuses.                                          her fetus. Pregnant and breastfeeding women
                                                              should not eat shark and swordfish due to
   Most	women	have	no	symptoms	of	toxoplasmosis	              mercury contamination. See Food Safety for
   infection. A blood test is used to detect the              more	information	on	fish	safety	and	give	handout,	
   infection.	If	a	client	is	interested	in	testing,	advise	   Lower Your Chances of Eating Foods with Unsafe
   her to discuss the concern with her health care            Chemicals in Them.

   High body temperature                                      X-rays during pregnancy can expose the fetus to
   Many	studies	have	shown	that	pregnant	women	               harmful	levels	of	radiation,	causing	possible	birth	
   should	avoid	hot	tubs	and	saunas,	especially	in	the	       defects or childhood leukemia. Walking through
   first	trimester.	They	should	also	try	to	prevent	a	        magnetometers (such as security checks at
   high	fever	if	they	are	ill.                                airports) does not pose a health risk.
   Temperature	at	101°F	or	above	can	cause	birth	
   defects. Therefore, if a hot bath raises a pregnant        Douches
   woman’s body temperature to 101°F or higher,               Douching is not necessary for normal hygiene. A
   there is a small chance it could cause deformities         hand-held bulb douche or blowing air into the
   in the fetus.                                              vagina	can	cause	air	to	get	into	the	uterus	and	
   Also, prolonged strenuous exercise should be               possibly the woman’s blood supply, which could
   avoided,	especially	in	hot	weather	or	during	a	fever.	     cause a stroke (embolism). Increased secretions
   Dangers for the pregnant woman include heat                during pregnancy are normal. Washing with water
   exhaustion and heat stroke.                                and a washcloth can help a woman feel fresh.

   HE – 40                                                                 Steps to Take — 2009 • Health Education
       y Mo
H ealth Baby
      thy             Workplace and Home Safety

                          other hazards
           Chemicals and                                  •	 Review chemicals that are probably not
                         t work can harm
           at home and a                                     hazardous to the baby but which may not be
           a pregnancy.                                      good	for	her.	Advise	her	to	handle	these	items	
                                                             carefully. Try not to swallow these items:
                                                           –   ammonia, in many cleaning products
   Goal                                                    –   chlorine, in cleaning products and in pools
   Help your client:
                                                           –   bleach, in cleaning products and in pools
   •	 be	aware	of	health	hazards	in	her	environment        –   asbestos, in old insulation and construction
                                                           –   sulfuric acid
   •	 plan	for	ways	to	avoid	such		 azards                 –   sodium hydroxide, main ingredient in
   Background                                             •	 Review the Food Safety Nutrition guidelines
   A	fetus	is	most	vulnerable	to	harmful	substances	         for	information	on	preventing	food-borne	
   during the first three months of pregnancy. Birth         illnesses through safe food preparation,
   defects	involving	the	organs	or	limbs	are	most	           handling,	and	storage	and	avoidance	of	
   common in that period. Exposure to harmful                potentially harmful foods.
   substances can cause brain damage, low birth
   weight, or small-for-gestational age babies after
   three months. In most cases, the extent of damage
   depends on the amount of harmful substance
   exposure (a dose-response relationship).                     Who’s at Risk?
                                                                All pregnant women are at risk when
   This	is	the	information	available	currently.	It	may	
                                                                they use chemicals. They should
   change in the future, so call the hotlines under
   Resources for up-to-date facts.                              •	 never	mix	cleaning	liquids	
                                                                •	 make	sure	to	get	plenty	of	fresh	
                                                                   air (open windows, use a fan)
   Steps to Take                                                   when using cleaning products or
   For all clients:                                                paints
                                                                •	 limit	the	amount	of	time	spent	
   •	 Discuss the handout Keep Safe at Work and
                                                                   working with substances that
      at Home to see if she uses any hazardous
                                                                   produce fumes
      substances.	Help	her	plan	how	to	avoid	these	
      substances.                                               Work	in	these	settings	gives	special	
   •	 Find out if she is at risk for preterm labor
      due to stress on the job, such as working long            •	   in	a	medical	setting
      hours while standing up and lifting objects,              •	   in	manufacturing
      with no breaks. Lifting objects that are bulky            •	   with	paints	or	nail	polish
      or	very	heavy	may	also	be	dangerous.	Advise	              •	   in	agriculture
      her to discuss these conditions with her health           •	   if	someone	she	lives	with	comes	
      care	provider.                                                 home with chemicals on clothes

   Steps to Take — 2009 • Health Education                                                              HE– 41
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H ealth Baby
      thy           Workplace and Home Safety (cont.)

   For clients who work in at-risk                        •	 California State Disability Insurance.
   settings                                                  Eligibility	requirements	include	having	a	
                                                             social	security	number,	having	SDI	payments	
   •	 Ask	if	there	is	a	safety office or employee            deducted	from	paychecks,	and	having	a	doctor	
      relations office at her job, or perhaps a              determine that the woman is too disabled
      union	representative,	who	can	provide	more	            to work. Length of eligibility depends on
      information about the materials used at work.          the doctor’s recommendations. For more
   •	 Ask	if	she	uses	all	the safety equipment that          information,	call	the	Employment	Development	
      is	available,	or	if	she	feels	additional	safety	       Department	(look	under	“State	Government”	
      equipment	(masks,	gloves)	is	needed.                   listings in front of the white pages in the phone
   •	 Discuss	ways	she	can limit contact with
      hazardous materials by changing how she does        •	 Legal advice related to pregnancy, disability
      her job.                                               and discrimination.	Call	the	Advice	and	
                                                             Counseling	Hotline	of	Equal	Rights	Advocates	
   •	 Make	a	list	of	questions	she	should	ask	her	           at	415-621-0505	(available	at	limited	times	
      employer about possible safety concerns.               during the week), or the Department of Fair
      Role-play how she will ask these questions.            Employment and Housing (look under “State
   •	 Discuss If I’m Pregnant, Can the Chemicals I Work      Government”	listings	in	front	of	the	white	
      With Harm My Baby? (see Resources). Request            pages in the phone book).
      Material Safety Data Sheets for materials she
      works with. (May not mention pregnancy.)            Follow-Up
                                                          If a client is exposed to dangerous substances,
   Disability leave                                       ask her at each appointment how she is limiting
   If	a	client	considers	leaving	work	on	disability,	     her	exposure	to	the	substance.	If	referrals	have	
   review	her	legal	rights	with	her.                      been made, ask if she followed through and what
                                                          recommendations	she	received.
   •	 Employer-provided disability. If pregnancy-
                                                          Provide	support	for	clients	who	need	to	make	
      related symptoms or problems force a woman
                                                          major changes in their jobs or home practices to
      to work less or to stop work, she has a right
                                                          avoid	harmful	substances.
      to	get	the	same	disability	benefits	or	leave	as	
      employees who are disabled by something
      other than pregnancy. Refer client to her
      employer’s benefits coordinator for more

   HE – 42                                                            Steps to Take — 2009 • Health Education
       y Mo
H ealth Baby
      thy           Workplace and Home Safety (cont.)

   Call the following for information and materials:     If I’m Pregnant, Can the Chemicals I Work
   California Teratogen Registry at UC San Diego to      With Harm My Baby? California Occupational
   check	if	a	substance	or	activity	is	harmful	during	   Health	Program.	Hazard	Evaluation	System	
   pregnancy:                                            and	Information	Service,	510-540-3138,	or	
   1-800-532-3749, Monday, Tuesday, Thursday, &
   Friday, 9:00 a.m. to 4:00 p.m.;                       Pregnancy and the Working Woman
   Wednesday, 10:00 a.m. to 4:00 p.m.                    ACOG	Pamphlet,	1985	
                                                         409 12th Street, SW,
   Chemtrec Center (Chemical Referral Center),           Washington, DC
   sponsored by Chemical Manufacturer’s Assoc.           20024-2188
   1-800-262-8200. Can mail “Maternal Safety Data
   Sheets” but no specifics about pregnancy
   National Pesticide Information Center
   Monday - Sunday, 6:30 a.m. to 4:00 p.m. PST
                                                                           to dangerous
   California Center for Childhood Injury                   Limit exposure               !
                                                                          ring pregnancy
   Prevention (CCCIP)                                       substances du
   SDSU Foundation
   6505	Alvarado	Rd.,	Suite	208
   San Diego, CA 92120

   Steps to Take — 2009 • Health Education                                                        HE– 43
          (Blank page)

HE – 44                  Steps to Take — 2009 • Health Education
       y Mo
H ealth Baby
      thy           Keep Safe at Work and at Home

   Find out about your safety, if:                    Here are other things that can
   •	 You	work	in	a	medical	setting.                  hurt you or your baby:
   •	 You	work	in	a	factory	that	uses	chemicals	or	   •	 Some	pesticides,	used	in	farming,	industry,	
      makes things with chemicals.                       and	at	home,	even	flea	bombs!

   •	 You	work	with	paints	or	nail	polish.            •	 X-rays	at	high	levels.
   •	 You	have	a	job	in	farming.                      •	 Gases	used	to	put	you	to	sleep,	if	you	
   •	 You	live	with	someone	who	comes	home	              breathe them in.
      with chemicals on their clothes.                •	 Some	drugs	used	to	treat	cancer.
                                                      •	 Mercury,	if	you	breathe	in	or	
  Take care when you use chemicals.                      swallow it. It is used in doctor or
   •	 Never	mix	cleaning	liquids.                        dentist offices, or in labs.
   •	 Make	sure	to	get	plenty	of	fresh	air	when	      •	 Toluene,	if	you	breathe	it	in.	Some	glues,	
      you clean or paint. Open                           gasoline, and some paint
      windows. Use a fan.                                thinners	have	it	in	them.	(If	you	sniff	glue,	
   •	 Do	not	work	with	products	that	                    it can cause health problems for you and
      make fumes.                                        your baby. Your baby can be born with birth
                                                         defects	or	have	other	life-long	problems.)
   Products you use around the                        •	 Lead,	if	you	swallow	it.	You	may	use	lead	
   house can harm you or your baby.                      if you make batteries, or work with paints,
                                                         ceramics, and glass. You may also use lead in
   Watch out for:                                        pottery glazing and printing.
   •	 Aerosol	sprays
   •	 Cleaning	fluids	or	oven	cleaners
   •	 Paints,	paint	thinners,	paint	removers
   •	 Varnishes
   •	 Antifreeze

   Don’t use:
   •	 Spot	removers
   •	 Spray	on	furniture	polish
   •	 Glues
   •	 Nail	polishes,	polish	removers

   Steps to Take — 2009 • Health Education                                                              HE– 45
       y Mo
H ealth Baby
                   Manténgase Segura en el Trabajo y en el Hogar

   Averigüe las medidas de                       Hay algunas cosas que pueden
   seguridad que tienen, si:                     dañarla a usted y a su bebé:
   •	 Trabaja	en	un	puesto	médico.               •	 Algunos	pesticidas,	usados	en	el	campo,	
   •	 Trabaja	en	una	fábrica	que	usa	químicos	      industria, y en casa ¡hasta las bombas
      o	hace	cosas	con	químicos.                    para matar pulgas!

   •	 Trabaja	con	pintura	o	esmalte	de	uñas.     •	 Rayos	X	a	alto	nivel.
   •	 Tiene	un	trabajo	en	el	campo.              •	 Los	gases	usados	para	dormirla,	
   •	 Vive	con	alguien	que	llega	a	casa	con	        si los respira.
      químicos	en	su	ropa.                       •	 Algunas	drogas	usadas	para	tratar	el	cáncer.

   Tenga cuidado cuando use                      •	 Mercurio,	si	lo	respira	o	se	lo	come.
   químicos.                                     •	 Toluene/Pegamento,	si	lo	respira.	Algunos	
   •	 Nunca	mezcle	los	líquidos	de	limpiar.         pegamentos, gasolina, y
                                                    algunos	solventes	de	pintura	contienen	
   •	 Asegúrese	de	tomar	bastante	aire	fresco	      esto. (Si inhala el pegamento, puede causar
      cuando limpie o pinte. Abra las               problemas de salud para usted y su bebé.
      ventanas.	Use	un	abanico.                     Su bebé puede nacer con defectos de
   •	 No	trabaje	con	productos	que	                 nacimiento o tener
      produzcan	humo	(vapores).                        b m
                                                    pro	 le	 as	de	salud	de	por	vida.)
                                                 •	 Plomo,	si	lo	ingiere.	El	plomo	se	usa	en	
   Hasta los productos alrededor
                                                    el	trabajo	si	hace	baterías;	si	trabaja	con	
   de la casa pueden causarle                       pintura,	cerámica,	vidrio,	pinta	barro,	o	si	
   daño a usted y a su bebé.                        trabaja en una imprenta.
   Cuídese de:
   •	 Aerosoles
   •	 Líquidos	para	limpiar	o	limpiadores	
      de horno
   •	 Pinturas,	solventes	para	quitar	de	
   •	 Barnices	
   •	 Anticongelantes

   No use:
   •	 Líquidos	para	quitar	manchas
   •	 Lustre	para	los	muebles
   •	 Pegamentos
   •	 Esmalte	de	uñas,	acetona

   HE – 46                                                     Steps to Take — 2009 • Health Education
       y Mo
H ealth Baby
      thy             Oral Health During Pregnancy
                                        een to the denti
                      ay have never b
    Some women m                e or no dental ca
    or may ha ve had very littl                          ese    disease. One of the critical factors is that
                                      effort to refer th
     during their lives. Make every                 r dental    decay-causing bacteria can be transmitted from
                                  tist for a regula
     pregnant  women to a den                                   a caretaker (usually mother) to the baby. The
                       eth cleaning.
     check-up and te                                            management of dental caries before, during and
                                                                after pregnancy is of primary importance because
   Goals                                                        active	maternal	caries	is	a	major	risk	factor	for	Early	
                                                                Childhood Caries (ECC) in the baby.
   Help your client:
   •	 Understand	and	identify	oral	health	problems	
                                                                Gingivitis	is	defined	as	inflammation	of	the	gingiva	
      common to pregnant women.
                                                                (gums) causing redness, swelling and bleeding. This
   •	 Understand	the	possible	relation	between	oral	            is one of the most common oral health problems
      disease,	such	as	periodontal	infection,	and	having	       seen	during	pregnancy.	Its	prevalence	has	been	
      a preterm and/or low birth weight baby.                   reported to range from 50% to 70% of all pregnant
                                                                women.	Most	cases	of	gingivitis	are	caused	by	
   •	 Understand	that	dental	caries	(tooth	decay)	is	a	
                                                                poor daily oral hygiene, resulting in the failure
      transmissible infectious disease and realize that
                                                                to	disrupt	and	remove	bacterial	plaque	near	the	
      she can lower the chances of transmitting the
                                                                gingiva.	However,	pregnancy-associated	hormonal	
      bacteria that cause dental caries to her baby.
                                                                and	vascular	changes	can	enhance	and	increase	
   •	 Learn	how	to	prevent	dental	and	gum	diseases.             the inflammation and bleeding caused by poor oral
   Pregnancy is an especially important time for women          If	a	woman	has	gingivitis	before	pregnancy,	the	
   to take care of their oral health. Dental caries is the      condition is likely to worsen during pregnancy. If
   single most common chronic disease of childhood,             untreated,	gingivitis	may	lead	to	periodontitis,	
   and	its	prevalence	can	persist	as	individuals	mature,	       a more serious chronic infection of the gums,
   including in pregnant women. Pregnancy can also              ligaments,	and	bone	supporting	the	teeth.	Advanced	
   contribute to certain conditions in the mouth that           periodontitis will cause tooth mobility, leading to
   may result in the need for dental care. Women                tooth loss. Periodontitis may also contribute to
   should be aware of the following oral conditions             preterm	and/or	low	birth	weight	deliveries	as	well	
   during pregnancy:                                            as	cardiovascular	disease,	stroke	and	other	medical	
                                                                conditions. Diabetic patients with periodontitis may
   •	   tooth	decay	(caries)
                                                                have	a	difficult	time	controlling	their	blood	glucose	
   •	   gingivitis	(gum	disease)                                levels.	Poorly	controlled	diabetes	before	and	during	
   •	   tooth	mobility                                          pregnancy can cause birth defects, miscarriage or
   •	   dry	mouth	(xerostomia)                                  other complications.
   •	   excessive	salivation
                                                                Here	are	typical	signs	of	gingivitis.	The	gums:
   •	   acid	erosion	of	teeth
                                                                •	   Have	a	bright	red	color.	
                                                                •	   Are	swollen.
   Important information dental caries:
                                                                •	   Bleed	easily	when	brushing	and	flossing.
   Dental caries (tooth decay) is the most common oral
                                                                •	   Have	a	smooth	and	shiny	surface.
   health problem. Caries is a multifactorial infectious
                                                                •	   May	be	sensitive	or	tender.

   Steps to Take — 2009 • Health Education                                                                          HE– 47
       y Mo
H ealth Baby
      thy             Salud Bucal Durante el Embarazo
                                                     a, o
                                     unca al dentist
    Algunas muje  res no han ido n              guna,
                              muy poca, o nin               Información importante
    pueden   havber recibido             de hacer
                      en su vida. Trate
     a tención dental          itir a estas muje
     todo lo posible para prm                       gan     Caries dentales
                                    para que se ha
     embarazad   as a un dentista             ental.        Las	caries	dentales	son	el	problema	más	común	
                              una limpieza d
      un exa men de rutina y                                de la salud bucal. Las caries son una enfermedad
                                                            infecciosa multifactorial. Uno de los factores
                                                            críticos	es	que	las	bacterias	que	causan	caries	se	
   Objetivos                                                pueden contagiar de un cuidador (en general
                                                            la madre) al bebé. El cuidado de las caries
   Ayude a su cliente:
                                                            dentales antes, durante y después del embarazo
    •	 A	comprender	e	identificar	los	problemas	            es sumamente importante porque las caries
       de salud bucal comunes en las mujeres                maternales	activas	son	un	factor	de	riesgo	principal	
       embarazadas.                                         de	Caries	de	la	Niñez	Temprana	(ECC,	por	sus	siglas	
    •	 A	comprender	la	posible	relación	entre	las	          en inglés) en los bebés.
       enfermedades dentales, como por ejemplo
       las infecciones periodontales, y tener un bebé       Gingivitis:
       antes de término y/o con bajo peso.                  La	gingivitis	se	define	como	una	inflamación	
    •	 A	comprender	que	las	caries	dentales	son	una	        de	la	gingiva	(encías)	que	causa	enrojecimiento,	
       enfermedad infecciosa contagiosa y que una           inflamación y sangrado. Éste es uno de los
       mujer embarazada puede reducir el riesgo de          problemas	de	salud	bucal	más	comunes	durante	
       contagiar las bacterias que causan las caries        el embarazo. Se ha reportado que afecta a entre el
       dentales a su bebé.                                  50% y el 70% de todas las mujeres embarazadas.
                                                            La	mayoría	de	los	casos	de	gingivitis	son	causados	
    •	 A	aprender	a	prevenir	las	enfermedades	              por mala higiene dental cotidiana, que no perturba
       dentales	y	de	las	encías.                            y	elimina	la	placa	bacterial	cerca	de	las	encías.	No	
                                                            obstante,	los	cambios	hormonales	y	vasculares	que	
   Antecedentes                                             se producen durante el embarazo pueden realzar y
   El embarazo es un momento especialmente                  aumentar la inflamación y el sangrado causado por
   importante para que las mujeres cuiden de su             la mala higiene dental.
   salud bucal. Las caries dentales son la enfermedad       Si	una	mujer	sufre	de	gingivitis	antes	del	embarazo,	
   crónica	más	común	de	la	niñez,	y	pueden	persistir	       el	problema	probablemente	empeorará	durante	
   a medida que uno crece, afectando también a las          el	embarazo.	Si	no	se	la	trata,	la	gingivitis	puede	
   mujeres embarazadas. El embarazo también puede           causar	periodontitis,	una	infección	crónica	más	
   contribuir a ciertos problemas bucales que pueden        seria	de	las	encías,	los	ligamentos	y	los	huesos	que	
   necesitar	atención	dental.	Las	mujeres	deberían	ser	     soportan	los	dientes.	La	periodontitis	avanzada	
   conscientes de los siguientes problemas bucales          puede	causar	movilidad	en	los	dientes,	resultando	
   que pueden ocurrir durante el embarazo:                  en la pérdida de dientes. La periodontitis también
    •	   Caries	dentales                                    puede contribuir a partos prematuros y/o a menor
    •	   Gingivitis	(enfermedad	de	las	encías)
    •	   Movilidad	dental
    •	   Sequedad	en	la	boca	(xerostomía)
    •	   Salivación	excesiva
   HE – 48                                                               Steps to Take — 2009 • Health Education
       y Mo
H ealth Baby
      thy          Salud Bucal Durante el Embarazo

   peso del bebé, y también a enfermedades cardio-
   vasculares,	accidentes	cerebrovasculares	y	otros	
   problemas médicos. Los pacientes diabéticos
   con periodontitis pueden tener dificultades para
   controlar	sus	niveles	de	glucosa	en	la	sangre.	Si	
   la diabetes no se controla bien antes y durante el
   embarazo, puede causar defectos de nacimiento,
   abortos	espontáneos	y	otras	complicaciones.

   Steps to Take — 2009 • Health Education              HE– 49
       y Mo
H ealth Baby
      thy             Oral Health During Prenancy (cont.)
                                                               Steps to Take
                                             l visit if she
                           man for a denta
     Refer a pregnant wo                              ths or   Dental caries
                                    the past 6 mon
     has not bee  n to a dentist in            isease.
                             ptoms of oral d                   Advise your client to do the following to
     if she has signs or sym
                                                               prevent dental caries (tooth decay):
                                                               •	 Brush	teeth	with	fluoride	toothpaste	at	least	
                                                                  twice a day, especially before going to bed.
   Tooth mobility                                              •	 Use	a	soft	toothbrush.
   Generalized	tooth	mobility	(loose	teeth)	may	
   be seen in pregnant women. These changes                    •	 Limit	foods	and	drinks	containing	sugar	to	
   are	probably	related	to	the	degree	of	gingival	                mealtimes only.
   inflammation	(gingivitis)	present	and	to	small	             •	 Rinse	with	0.05%	sodium	fluoride	mouth	rinse	
   changes in the bone supporting the teeth. This                 and/or chlorhexidine prescribed rinse.
   condition	goes	away	after	delivery.	However,	tooth	
                                                               •	 Choose	gum/lozenges	containing	xylitol	after	
   mobility	may	also	be	associated	with	advanced	
   periodontal disease and may not go away after
   pregnancy. An examination by a dentist is needed            •	 Visit	the	dentist	at	least	once	a	year,	or	as	
   to diagnose and treat the condition appropriately.             often as the dentist recommends, for cleaning,
                                                                  examination	and	preventive	treatments	such	
                                                                  as fluoride and dental sealants.
   Dry mouth (Xerostomia)
   Some pregnant women may complain of dry                     Gingivitis
   mouth (xerostomia). Hormonal changes may                    Advise your clients to do the following to
   contribute to this condition.                               prevent gingivitis:
                                                               •	 Use	a	soft	toothbrush.

   Excessive salivation (Ptyalism or                           •	 Floss	every	day.	Be	sure	to	floss	below	the	gum	
                                                                  line, not just between the teeth.
   This is a rare condition. It usually begins at two to       •	 Follow	prenatal	nutrition	guidelines	to	eat	a	
   three weeks of gestation and may stop at the end               healthy diet. Healthy oral tissue depends on a
   of the first trimester. In some cases, it can continue         balanced	diet	with	lots	of	fruits	and	vegetables.	
   until	the	day	of	delivery.	It	may	be	caused	by	the	            Remember that a balanced diet is good for the
   inability of nauseous pregnant women to swallow                mother’s	overall	health,	as	well	as	for	her	oral	
   normal	amounts	of	saliva.                                      health and her baby’s health.
                                                               •	 Take	a	daily	prenatal	vitamin	and	mineral	
                                                                  supplement that includes folic acid. Low
   Acid erosion of teeth                                          levels	of	folic	acid	in	pregnant	women	have	
   This is a rare condition that may cause the enamel
                                                                  been linked to increased chances of cleft lips
   of	teeth	to	wear	away.	Repeated	vomiting	of	
                                                                  and palates in the newborn, as well as other
   gastric contents associated with morning sickness,
                                                                  medical complications. For more information,
   esophageal reflux, and bulimia may cause it.
                                                                  refer to the folic acid handouts in the Nutrition
                                         lost for   every      •	 Do	not	smoke	or	use	tobacco	products.
                       e that a tooth is
    So me people beliv
                     IS NOT TRUE!!!                            •	 Visit	the	dentist	for	a	complete	oral	
    pregnancy. THIS                                               examination and tooth cleaning.
   HE – 50                                                                 Steps to Take — 2009 • Health Education
       y Mo
H ealth Baby
      thy            Salud Bucal Durante el Embarazo
                                                               Pasos a tomar
                             da no ha ido al                   Caries dentales
   Si una m  ujer embaraza                ntomas de
                       eses, o si tiene sí
       los últimos 6 m                          sita dental.
   en                           mítala a una vi                Aconseje a su cliente que haga lo siguiente
    enfermed   ades bucales, ri
                                                               para prevenir las caries dentales:
                                                               •	 Lávese	los	dientes	con	una	pasta	dentífrica	con	
   Movilidad de los dientes                                       flúor	por	lo	menos	dos	veces	por	día,	sobre	
   Las mujeres embarazadas pueden sufrir de                       todo antes de acostarse.
   movilidad	dental	generalizada	(dientes	flojos).	
   Estos	cambios	están	probablemente	relacionados	             •	 Use	un	cepillo	de	dientes	blando.
   con	el	grado	de	inflamación	de	las	encías	                  •	 Coma	alimentos	y	bebidas	que	contengan	
   (gingivitis)	existente	y	con	pequeños	cambios	en	              azúcar sólo durante las comidas principales.
   los huesos que soportan los dientes. Este problema
   desparece después del parto. No obstante, la                •	 Enjuáguese	la	boca	con	fluoruro	de	sodio	al	
   movilidad	dental	también	puede	ser	causada	por	                0.05% y/o un enjuague de clorhexidina bajo
   enfermedad	periodontal	avanzada,	y	en	ese	caso	                receta.
   es posible que no desparezca después del parto. Es          •	 Use	goma	de	mascar	o	pastillas	con	xilitol	
   necesario un examen dental para diagnosticar y                 después de comer.
   tratar el problema adecuadamente.
                                                               •	 Visite	al	dentista	por	lo	menos	una	vez	por	
                                                                  año,	o	con	la	frecuencia	recomendada	por	su	
   Sequedad en la boca (xerostomía)                               dentista, para hacerse una limpieza dental, un
   Algunas mujeres embarazadas se quejan de                       examen	y	tratamientos	preventivos	con	flúor	o	
   sequedad	en	la	boca	(xerostomía).	Los	cambios	                 selladores dentales.
   hormonales pueden contribuir a este problema.
   Salivación excesiva (ptialismo o                            Aconseje a su cliente que haga lo siguiente
   sialorrea)                                                  para prevenir la gingivitis:
   Este	problema	ocurre	rara	vez.	En	general	
                                                               •	 Use	un	cepillo	blando.
   comienza a las dos o tres semanas de gestación y
   puede dejar de ocurrir al final del primer trimestre.       •	 Use	hilo	dental	todos	los	días.	No	se	olvide	de	
   En	algunos	casos	puede	continuar	hasta	el	día	del	             pasar	el	hilo	debajo	de	la	línea	de	las	encías,	no	
   parto. Puede ser causado por la incapacidad de las             sólo entre los dientes.
   mujeres embarazadas de tragar la cantidad normal
                                                               •	 Siga	las	pautas	de	nutrición	prenatal	para	
   de	saliva	cuando	tienen	náuseas.
                                                                  comer una dieta saludable. Para tener un tejido
                                                                  saludable en la zona dental tiene que comer
   Erosión ácida de los dientes                                   una dieta balanceada, con muchas frutas y
   Éste es un problema raro que puede causar el                   verduras.	Recuerde	que	una	dieta	balanceada	es	
   desgaste del esmalte dental. Puede ser causado                 buena para la salud general de la madre, como
   por	los	repetidos	vómitos	del	contenido	gástrico	              también para su salud bucal y la salud del bebé.
   debido	a	náuseas	matinales,	reflujo	gastroe-
   sofágico	y	bulimia.	

   Steps to Take — 2009 • Health Education                                                                      HE– 51
       y Mo
H ealth Baby
      thy          Salud Bucal Durante el Embarazo

   •	 Tome	un	suplemento	diario	de	vitaminas	y	
      minerales	prenatales	que	incluyan	ácido	fólico.	
      Las	mujeres	embarazadas	que	tienen	un	nivel	
      bajo	de	ácido	fólico	corren	un	mayor	riesgo	
      de tener bebés con labios leporinos y paladar
      hendido, como también otras complicaciones
      médicas.	Para	obtener	más	información	
      remítase	al	material	sobre	ácido	fólico	en	la	
      sección Nutrición.
   •	 No	fume	ni	use	productos	con	tabaco.
   •	 Visite	al	dentista	para	hacerse	un	examen	bucal	
      completo y una limpieza dental.

   HE – 52                                               Steps to Take — 2009 • Health Education
       y Mo
H ealth Baby
      thy             Oral Health During Pregnancy (cont.)
                                                             •	 Read	the	“Steps	to	Take”	handouts	about	
                                     regnant is an ex           nausea. Anything that helps reduce morning
   Some people     believe being p               !!
                                 IS IS NOT TRUE!                sickness/nausea	will	help	avoid	acid	erosion	of	
   not to vi sit the dentist. TH                                the teeth.
                                                             •	 Use	fluoride	products	(for	example,	fluoride	
                                                                toothpaste and other forms of fluoride
  Tooth mobility                                                recommended by the dentist) which
   •	 If	your	client	indicates	she	has	loose	teeth,	refer	      help strengthen the surfaces of the teeth
      her immediately to a dentist.                             (remineralize) damaged by acid
                                                             Other considerations
   Dry mouth
                                                             Dental treatment during pregnancy
   Advise your client to:                                    •	 The	emphasis	of	oral	health	care	at	this	time	
   •	 Drink	more	water	and/or	non-sugared,	non-                 is	on	controlling	active	oral	disease	and	
      carbonated	and	non-caffeinated	beverages.                 eliminating potential problems that could
                                                                arise during pregnancy. Dental care, including
   •	 Use	sugarless	or	xylitol	candies,	mints,	and	
                                                                examinations, cleanings and treatment, is safe
                                                                and	effective	during	pregnancy.		Urgent	care	
   •	 Use	a	fluoride	mouth	rinse	for	1-2	minutes	               can	and	should	be	provided	without	delay	
      at least once daily, especially before bedtime.           throughout	pregnancy.		However,	the	best	
      Avoid	using	mouth	rinses	with	alcohol,	such	as	           time for treatment may be during the second
      Listerine (it has 22% alcohol).                           trimester when a pregnant woman is most
                                                                comfortable. Cosmetic or non-urgent care may
   •	 Do	not	smoke	and	do	not	drink	alcohol.                    be	delayed	until	after	delivery.
   •	 Avoid	excessively	dry,	spicy	or	salty	foods.           •	 X-rays	are	particularly	important	for	dental	
   •	 See	the	doctor	or	dentist.		Dry	mouth	may	be	a	           emergencies and are safe during pregnancy
      symptom of a hidden medical condition.                    if	used	selectively	and	with	a	lead	apron	and	
                                                                neck collar.
   Excessive salivation                                      •	 Make	sure	your	client	knows	that	dental	
                                                                emergencies, such as pain and infection, should
   Let her know that there may not be much                      be treated right away. Untreated gum or tooth
   she can do about this. Advise your client to:                infections and increased stress can harm the
   •	 Eat	frequent,	small,	and	balanced	meals.                  mother and may endanger the fetus. All tooth
                                                                decay should be treated as soon as possible.
   •	 See	the	doctor	or	dentist.		This	may	be	a	
      symptom of a hidden medical condition.                 •	 Refer	pregnant	women	to	a	dentist	for	
                                                                additional	advice	and	preventive	treatment,	
   Acid erosion of teeth                                        such as fluoride and dental sealants. A sealant
                                                                is a plastic material that is usually applied
   Advise your client to:                                       to the chewing surfaces of the back teeth—
   •	 Rinse	mouth	with	water	or	an	over-the-counter	            premolars and molars. This plastic resin bonds
      mouth rinse with baking soda (to buffer acids)            into	the	depressions	and	grooves	(pits	and	
      right	after	she	vomits.	This	will	help	protect	           fissures) of the chewing surfaces of back teeth.
      teeth from the damaging action of the acid.               The sealant acts as a barrier, protecting enamel
                                                                from plaque and acids.
                                                                                                            HE– 53
   Steps to Take — 2009 • Health Education
       y Mo
H ealth Baby
      thy            Oral Health During Pregnancy (cont.)

                                          ne are the
                         poor oral hygie
    Den tal plaque and                         ancy, not
                               is during pregn             Examples are:
    major ca  uses of gingivit
                      one levels.                          •	 Toothpaste
    increaded horm
                                                           •	 Mouth	rinse
                                                           •	 Professionally	applied	fluoride	gels	and	
   Systemic vs. topical fluoride                              varnishes	
   Systemic prenatal fluoride supplements are not
   recommended for pregnant women. Recent
   research	has	not	proven	that	use	by	mothers	is	         Oral condition associated with
   effective	in	preventing	cavities	in	their	baby’s	       low birth weight
   teeth.	However,	a	woman’s	own	teeth	will	benefit	       When	it	occurs	during	pregnancy,	a	severe	type	
   from	fluoride	that	bathes	her	tooth	surfaces	over	      of periodontal disease called periodontitis
   a period of time (topical fluoride), such as fluoride   has been associated with preterm and/or low
   toothpaste, rinses, and fluoridated water.              birth	weight	deliveries.	Periodontitis	is	a	severe,	
                                                           chronic	inflammatory	condition	of	the	gingiva	
   Systemic fluoride is fluoride that is swallowed by
                                                           (gums) characterized by loss of attachment of the
   the	individual,	although	any	form	of	fluoride	that	
                                                           periodontal ligament and bony support of the
   bathes the teeth for any period of time also has
                                                           tooth.	Periodontitis	is	thought	to	develop	as	an	
   topical effects.
                                                           extension	of	gingivitis,	a	milder	and	more	common	
                                                           form of gum inflammation.
   Examples are:
   •	 Fluoridated	water	                                   Several studies have suggested that untreated
                                                           periodontal disease in a pregnant woman
   •	 Dietary	fluoride	supplements	                        may lead to an increased risk of delivering a
         –   Tablets                                       premature and/or low birth weight baby. Other
         –   Lozenges                                      studies	have	not	confirmed	this	risk.	Researchers	
         –   Vitamin-fluoride preparations                 theorize about the association between
         –   Liquids and drops                             premature births and periodontal infection. One
                                                           hypothesis is that periodontal infection can
   •	 Fluoridated	salt	(not	available	in	the	U.S.)
                                                           release bacteria and bacteria-produced toxins into
   •	 Any	other	source	of	fluoride	that	is	swallowed	      the blood. These toxins may interfere with fetal
      (e.g., many foods are processed with                 development.		Another	theory	is	that	periodontal	
      fluoridated water)                                   infection causes an inflammatory reaction in
   Tablets	and	lozenges	are	available	with	a	doctor’s	     the gums leading to a production of chemical
   or dentist’s prescription. They should be chewed        mediators. These inflammatory mediators,
   and sucked a minute or two before swallowing in         produced by the mother’s own immune system,
   order	to	provide	both	topical	and	systemic	effects.     may	stimulate	cervical	dilation	and	uterine	
                                                           contractions. Further research continues.
   Topical fluorides applied to the enamel surfaces of
   teeth cause an exchange of chemical compounds,
   making the tooth surface less likely to decay
   (remineralized). Topical fluorides are not intended
   to be swallowed. They can be professionally or

   HE – 54                                                             Steps to Take — 2009 • Health Education
       y Mo
H ealth Baby
      thy           Salud Bucal Durante el Embarazo

                                               es una
                               ue el embarazo
    Algunas p ersonas creen q                       RTO!
                                    ¡ESTO NO ES CIE        •	 Lea	el	material	“Pasos	a	tomar”	sobre	náuseas.	
    excusa para n o ir al dentista.                           Cualquier	cosa	que	ayude	a	reducir	las	náuseas	
                                                              matinales	la	ayudará	a	evitar	la	erosión	ácida	
                                                              de los dientes.
   Movilidad de los dientes
                                                           •	 Use	productos	con	flúor	(por	ejemplo,	pasta	
   •	 Si	su	cliente	reporta	tener	los	dientes	flojos,	        dentífrica	con	flúor	y	otras	formas	de	flúor	
      remítala	inmediatamente	a	un	dentista.                  recomendadas por el dentista) que ayuden a
                                                              reforzar (remineralizar) las superficies de los
   Sequedad en la boca                                        dientes	dañadas	por	el	ácido.	
   Aconseje a su cliente que:
   •	 Tome	más	agua	y/o	bebidas	sin	azúcar,	no	
                                                           Otras consideraciones
      carbonatadas	y	sin	cafeína.                          Tratamiento dental durante el embarazo
   •	 Coma	dulces,	pastillas	mentoladas	y	gomas	de	        •	 Durante	el	embarazo,	el	cuidado	de	la	salud	
      mascar sin azúcar o con xilitol.                        bucal se debe concentrar en controlar toda
   •	 Use	un	enjuague	bucal	con	flúor	por	1	a	2	              enfermedad	bucal	activa	y	eliminar	problemas	
      minutos por lo menos diariamente, sobre                 potenciales que puedan surgir durante el
      todo antes de irse a la cama. No use enjuagues          embarazo. La futura madre puede obtener
      bucales con alcohol, como Listerine (tiene 22%          atención	dental,	como	exámenes,	limpiezas	
      de alcohol).                                            y	tratamientos,	en	forma	efectiva	y	sin	
                                                              poner en peligro su salud. Se puede, y debe,
   •	 No	fume	y	no	tome	alcohol.
                                                              proporcionar todo cuidado de urgencia sin
   •	 Evite	comidas	demasiado	secas,	picantes	o	              demoras durante el embarazo. No obstante,
      saladas.                                                el mejor periodo para hacerse un tratamiento
   •	 Vea	a	su	médico	o	dentista.	La	sequedad	bucal	          puede ser durante el segundo trimestre, que es
      puede ser un signo de un problema médico                cuando la mujer embarazada se siente menos
      oculto.                                                 molesta. El cuidado cosmético o que no sea de
                                                              urgencia se puede demorar hasta después del
   Salivación excesiva                                        parto.
   Comuníquele que es posible que no se
   pueda hacer nada para remediar este                     •	 Las	radiografías	son	particularmente	
   problema. Aconseje a su cliente que:                       importantes durante las emergencias dentales,
   •	 Coma	pequeñas	porciones	de	comidas	                     y no ponen en peligro la salud de la madre ni
      balanceadas con frecuencia.                             del	bebé	si	se	usan	en	forma	selectiva	y	con	un	
   •	 Vea	a	su	médico	o	dentista.	Éste	puede	ser	un	          delantal y collar de plomo.
      signo de un problema médico oculto.                  •	 Es	importante	que	le	comunique	a	su	cliente	
   Erosión ácida de los dientes                               que las emergencias dentales, como el dolor y
   Aconseje a su cliente que:                                 la infección, se deben tratar de inmediato. Las
   •	 Inmediatamente	después	de	vomitar,	use	un	              infecciones	de	las	encías	o	los	dientes	que	no	
      enjuague	bucal	de	venta	libre	con	bicarbonato	          se tratan, y el consiguiente aumento del estrés,
      de	sodio	(para	neutralizar	los	ácidos).	Esto	           pueden	causar	daño	a	la	madre	y	poner	en	
      ayudará	a	proteger	los	dientes	contra	la	acción	        peligro al feto. Cualquier caries se debe tratar lo
      dañina	de	los	ácidos.                                   más	pronto	posible.

   Steps to Take — 2009 • Health Education                                                                 HE– 55
       y Mo
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      thy              Salud Bucal Durante el Embarazo

                                       ne bucal, y no lo
                     l y la mala higie                          	 –	 Preparaciones	vitamínicas	con	flúor	
    La placa denta             s elevado, son la
                                                 s causas       	 –	 Líquidos	y	gotas	
    niveles h ormonales má                             .
                                     nte el embarazo
     principales d e gingivitis dura                         •	 Sal	con	flúor	(no	se	vende	en	los	Estados	
                                                             •	 Cualquier	otra	fuente	de	flúor	que	se	trague	
   •	 Remita	a	las	mujeres	embarazadas	a	un	                    (por ejemplo, muchas comidas se procesan con
      dentista para que reciba consejos adicionales             agua con flúor).
      y	tratamiento	preventivo,	como	flúor	y	sellados	
                                                             Las tabletas y pastillas sólo se pueden comprar
      dentales. El sellado dental es un material
                                                             con una receta del médico o dentista. Se deben
      plástico	que	se	aplica	normalmente	a	las	
                                                             masticar y chupar durante un minuto o dos antes
      superficies de los dientes traseros (premolares
                                                             de tragar, para que tengan tanto un efecto tópico
      y molares) que se usan para masticar. Esta
                                                             como sistémico.
      resina	plástica	se	adhiere	a	las	depresiones	
      y ranuras (pozos y fisuras) de las superficies         El flúor tópico aplicado a las superficies
      molares que se usan para masticar. El sellador         esmaltadas de los dientes puede producir un
      actúa como una barrera, protegiendo el                 intercambio	de	compuestos	químicos,	reduciendo	
      esmalte	contra	placa	y	ácidos.                         la probabilidad de que la superficie de los dientes
                                                             se degrade y cause caries (este proceso se llama
                                                             remineralización). El flúor tópico no se debe tragar.
   Flúor sistémico vs. tópico                                La	madre	se	lo	puede	aplicar	por	sí	misma	o	se	lo	
   No se recomiendan los suplementos sistémicos
                                                             puede hacer aplicar profesionalmente.
   de flúor prenatales para mujeres embarazadas.
   Las	investigaciones	recientes	no	han	probado	la	
   eficacia	de	estos	suplementos	para	prevenir	las	          Ejemplos de flúor tópico son:
   caries de los dientes del bebé. No obstante, los          •	 Pasta	dentífrica
   dientes	de	la	madre	se	beneficiarán	con	flúor	que	
                                                             •	 Enjuague	bucal
   se ponga en contacto con sus superficies dentales
   por un periodo de tiempo (flúor tópico), como             •	 Geles	y	barnices	de	flúor	aplicados	
   pasta	dentífrica,	enjuagues	o	agua	con	flúor.                profesionalmente

   El flúor sistémico es flúor que se traga, si bien toda
   forma de flúor que se ponga en contacto con los           Problemas bucales asociados con
   dientes por un periodo de tiempo también tiene            partos prematuros y/o peso bajo del
   efectos tópicos.                                          bebé
                                                             Un	tipo	de	enfermedad	periodontal	severa,	
   Ejemplos de flúor sistémico son:                          llamada periodontitis, se ha asociado con partos
   •	 Agua	con	flúor	                                        prematuros y/o peso bajo en los bebés, si ocurre
                                                             durante el embarazo. La periodontitis es una
   •	 Suplementos	dietéticos	con	flúor	                      inflamación	severa	y	crónica	de	la	gingiva	(encías)	
         – Tabletas                                          que se caracteriza por una pérdida de adherencia
         – Pastillas                                         del ligamento periodontal y el soporte óseo de los

   HE – 56                                                                Steps to Take — 2009 • Health Education
       y Mo
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      thy           Salud Bucal Durante el Embarazo

   dientes. Se cree que la periodontitis se desarrolla
   como	una	extensión	de	la	gingivitis,	una	forma	
   menos	severa	y	más	común	de	inflamación	de	las	
   Varios estudios han sugerido que la enfermedad
   periodontal en mujeres embarazadas, si no se
   la trata, puede aumentar el riesgo de un parto
   prematuro y/o bajo peso de nacimiento del bebé.
   Otros estudios no han confirmado este riesgo. Los
   investigadores	han	especulado	sobre	la	asociación	
   entre partos prematuros e infección periodontal.
   Una hipótesis es que la infección periodontal
   puede liberar bacterias, y ciertas toxinas producidas
   por	las	bacterias	entran	en	el	torrente	sanguíneo.	
   Estas toxinas pueden interferir con el desarrollo
   del	feto.	Otra	teoría	es	que	la	infección	periodontal	
   causa	una	reacción	inflamatoria	de	las	encías,	
   causando	la	producción	de	mediadores	químicos.	
   Estos mediadores inflamatorios, producidos por el
   sistema inmune de la madre, pueden estimular la
   dilatación del cuello del útero y contracciones del
   útero.	Las	investigaciones	continúan.	

   Steps to Take — 2009 • Health Education                  HE– 57
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      thy            Oral Health During Pregnancy (cont.)

                           ggested that un
   Som   e studies have su                     man may       Dental disease-causing bacteria can also be
                               a pregnant wo
   periodan   tal infection in            ing a preterm      transmitted from the father, other family members
                         d risk of deliver
    lea d to an increase                                     and	other	caretakers	with	similar	behaviors.		
                     th weight baby
    and/or low-bir
                                                             Making referrals
   Dental caries and the transmission of                     Make sure you refer a pregnant woman to a
   bacteria from caretaker to children                       dentist for an oral health examination if she:
   A	growing	body	of	scientific	evidence	suggests	
                                                             •	 Has	not	been	to	the	dentist	in	the	past	6	
   that dental caries is an infectious and transmissible
   disease.	The	primary	bacterium	involved	is	
   Streptococcus mutans. The caries process usually          •	 Shows	any	signs	or	symptoms	of	oral	disease	
   begins with the bacterial transmission from an               or trauma, such as tooth decay, mouth pain,
   adult to the child. The caretaker, usually the mother,       swelling around the jaws, missing or broken
   infects the child. The mother who has untreated              teeth, sore and/or bleeding gums.
   dental caries appears to be most likely to pass the       Every	woman	who	is	considering	pregnancy	
   bacteria to her children.                                 should	have	a	dental	examination,	including	
                                                             a	periodontal	evaluation.	Dental	emergencies	
   Here are ways that mother may lower the                   such as pain and infection should be treated
   chances of transmitting oral bacteria to her              immediately.
                                                             Dental emergencies such as pain and infection
   •	 Avoid	sharing	child’s	eating	utensils	and	food.        should be treated immediately.
   •	 Avoid	pre-chewing	or	blowing	on	the	child’s	
                                                             •	 Dental caries (tooth decay): The dentist should
      food to cool it off.
                                                                treat	decayed	teeth	and	introduce	a	preventive	
   •	 Avoid	licking	the	child’s	pacifier	before	giving	it	      plan to reduce bacterial counts. The use of
      to the child.                                             chlorhexidine rinses, xylitol chewing gum and
                                                                topical fluoride application during pregnancy
   •	 Practice	daily	flossing	and	at	least	twice	daily	
                                                                may	be	useful	in	reducing	the	levels	of	decay-
      brushing with fluoridated toothpaste.
                                                                causing microorganisms in the mother’s mouth.
   •	 Do	not	share	toothbrushes	among	family	
                                                             •	 Gingivitis (gum disease): If you suspect the
                                                                pregnant woman has gum disease, which may
   •	 Rinse	with	a	prescribed	chlorhexidine	rinse.              include periodontal infection, refer her to a
                                                                dentist immediately. Pregnant women should
   •	 Use	gum/lozenges	containing	xylitol	3-5	
                                                                be made aware of the risks of periodontal
      times daily. To get the most benefit from
                                                                disease and the problems it can bring to them
      a product, read the ingredient label; xylitol
                                                                and their babies.
      should be listed as one of the first 3 ingredients,
      preferably first.
   •	 Have	regular	dental	visits	at	least	once	a	year,	or	
      as often as the dentist recommends.

   HE – 58                                                                Steps to Take — 2009 • Health Education
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      thy            Oral Health During Pregnancy (cont.)

   Clients enrolled in Medi-Cal and Healthy Families         •	 Be	sure	to	note	any	changes	that	the	client	
   insurance	programs	may	not	realize	they	have	                might report about her oral health and make
   dental benefits. Please refer to the following list for      appropriate referrals.
   help with dental referrals:
                                                             •	 Provide	the	patient	with	handouts	provided	
   •	 Denti-Cal	Program,	1-800-322-6384	for	                    in this guide on how to take care of her oral
      beneficiary	services                                      hygiene before, during and after pregnancy.                  •	 Dental	caries	(tooth	decay)	is	a	transmissible	
      jsp?fname=ProvReferral                                    infectious disease. Mother, father and other
   •	 Healthy	Families,	1-800-880-5305	for	low-cost	            family members can transmit the bacteria that
      insurance                                                 cause dental caries to their children. Remind                mothers that appropriate oral hygiene to
      choosing.html                                             remove	and	control	decay-causing	bacteria	
                                                                from their mouths will benefit both them and
   •	 Children’s	Health	and	Disability	Prevention	              their babies. In addition, remind mothers not to
      (CHDP) Program                                            share their children’s food and utensils.
      countyoffices.aspx                                     •	 Encourage	mothers	to	take	their	child	to	a	
                                                                dentist	for	the	first	dental	visit	by	age	1	as	
   •	 California	Dental	Association                             recommended by the American Academy                            of Pediatrics, the American Academy of
   •	 American	Academy	of	Pediatric	Dentistry                   Pediatric Dentistry and the American Dental                          Association.	However,	be	aware	that	not	all	
                                                                dentists are comfortable seeing such young
   •	 California	Society	of	Pediatric	Dentistry                 children. Mothers may need to ask their baby’s                      physician for an appropriate referral. To help a
   •	 California	Primary	Care	Association	-	                    mother enroll her child into a public insurance
      Community Clinic and Health Centers                       program	or	find	a	dental	provider	that	accepts                 this insurance, call:
                                                             •	 	1-800-322-6384	for	information	about	Medi-
   Follow-up                                                    Cal dental insurance (Denti-Cal) or look on the
                                                                Medi-Cal website under “Find a Dentist” at:
   •	 Some	women	may	have	had	very	little	or	no	
      dental	care	during	their	lives.	Make	every	effort	
      to refer these women to the dentist for a dental
      check-up and teeth cleaning right away.                •	 1-800-880-5305	for	information	on	Healthy	
                                                                Families insurance programs, or search on
   •	 At	subsequent	visits,	make	sure	to	ask	about	
                                                                the California Healthy Families website under
      the	last	visit	to	the	dentist	and	document	the	
                                                               “Choosing	Plans	and	Providers”	at:
      findings. If the mother has not seen a dentist
      since your last recommendation, make the
      referral again.

   Steps to Take — 2009 • Health Education                                                                 HE– 59
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H ealth Baby
      thy          Oral Health During Pregnancy (cont.)

   •	 The	following	brochures	are	highly	                •	 A	large	variety	of	dental	public	health	materials	
      recommended and are printed by the National           are	available	by	contacting	the	National	
      Institute of Dental and Craniofacial Research in      Maternal and Child Oral Health Resource Center
      English	and	Spanish	and	are	available	FREE	OF	        at 202-784-9771. The web site is http://www.
      CHARGE.	Visit	their	Web	page:	http://www.nidr.	Some	may	be	available	free	as	they	have	additional	publications.	        of charge.
      Phone number is 301/496-4261.                       –		 Women’s	Oral	Health	Resource	Guide
   •	 A	Healthy	Mouth	for	Your	Baby                       – Focus of Oral Health; Volume IV (February
                                                              2001), MCH Program Interchange.
   •	 Snack	Smart	for	Healthy	Teeth                       –	 Early	Childhood	Cares	Resource	Guide.	
   •	 Plaque:	Rx	for	Sound	Teeth	(brushing	and	           – Bright Futures in Practice: Oral Health. Cost is
      flossing)                                               $12.50/copy.
                                                         •	 The	Dental	Health	Foundation	has	a	variety	of	
   •	 Seal	Out	Dental	Decay                                 dental health materials. Check their web site for
   •	 Pregnancy	and	Oral	Health	produced	by	the	            topics and cost at www.dentalhealthfoundation.
      American Dental Association (ADA). Phone              org
      number is 1-800-621-8099. There is a cost for
      the brochure. Visit the ADA Web page at

   HE – 60                                                            Steps to Take — 2009 • Health Education
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H ealth Baby
      thy             Sulud Bucal Durante el Embarazo
                                   ido que la enfe
      Algunos estu dios han suger                            ta,
                                           das, si no la tra          3 ingredientes, preferentemente el primero.
                      m  ujeres embaraza
      periodontal en                e un parto prem
       puede aum  entar el riesgo d                                •	 Visitando	periódicamente	al	dentista	por	lo	
                                       el bebé.
                       e nacimiento d                                 menos	una	vez	por	año,	o	con	la	frecuencia	
       y/o bajo peso d
                                                                      recomendada por su dentista.
                                                                   Las bacterias que causan enfermedades dentales
   Las caries dentales y la transmisión                            también se pueden contagiar del padre, otros
   de bacterias del cuidador a los niños                           familiares y otros cuidadores que tengan
   Los	estudios	científicos	están	demostrando	en	                  conductas	similares	con	respecto	al	niño.
   forma creciente que las caries dentales son una
   enfermedad infecciosa y contagiosa. La bacteria
   principal que causa caries se llama Streptococcus
                                                                   Remita a una mujer embarazada al dentista para
   mutans. La formación de las caries se inicia en
                                                                   un examen bucal si:
   general cuando las bacterias se transmiten de
   una	persona	adulta	al	niño.	El	cuidador,	que	en	                •	 Muestra	signos	o	síntomas	de	enfermedad	
   general	es	la	madre,	infecta	al	niño.	El	contagio	                 o trauma bucal, como caries, dolor en la
   más	probable	de	las	bacterias	de	las	caries	a	un	                  boca,	inflamación	alrededor	de	la	mandíbula,	
   niño	es	por	una	madre	que	tenga	caries	dentales	                   dientes	faltantes	o	rotos,	encías	sensibles	y/o	
   no tratadas.                                                       sangrantes.
                                                                   Toda mujer que contemple quedar embarazada
   La madre puede reducir el riesgo de                             debería	hacerse	un	examen	dental,	incluyendo	
   contagiar las bacterias bucales a su hijo:                      una	evaluación	periodontal.	Las	emergencias	
   •	 No	compartiendo	con	su	hijo	los	utensilios	y	la	             dentales,	como	el	dolor	y	la	infección,	se	deberían	
      comida.                                                      tratar inmediatamente.
   •	 No	masticando	previamente	o	soplando	la	
                                                                   •	 Caries dentales:	El	dentista	debería	tratar	los	
      comida de su hijo para enfriarla.
                                                                      dientes	cariados	e	iniciar	un	plan	preventivo	
   •	 No	chupando	el	chupón	de	su	hijo	antes	de	                      para reducir el conteo bacterial. El uso de
      dárselo.                                                        enjuagues con clorhexidina, goma de mascar
                                                                      con xilitol y la aplicación de flúor tópico
   •	 Usando	el	hilo	dental	diariamente	y	                            durante el embarazo pueden ayudar a reducir
      cepillándose	los	dientes	por	lo	menos	dos	                      los	niveles	de	microorganismos	que	causan	
      veces	por	día	con	pasta	dentífrica	con	flúor.                   caries en la boca de la madre.
   •	 No	compartiendo	los	cepillos	de	dientes	entre	               •	 Gingivitis	(enfermedad	de	las	encías):	Si	
      familiares.                                                     sospecha que la mujer embarazada tiene
   •	 Usando	un	enjuague	bucal	bajo	receta	con	                       enfermedad	de	las	encías,	incluyendo	
      clorhexidina.                                                   infección	periodontal,	remítala	a	un	dentista	
                                                                      inmediatamente. Las mujeres embarazadas
   •	 Mascando	goma	o	chupando	pastillas	con	                         deberían	conocer	los	riesgos	de	las	
      xilitol	(xylitol)	3	a	5	veces	por	día.	Para	obtener	            enfermedades periodontales y los problemas
      el mayor beneficio de un producto, lea la                       que pueden causar, no sólo a ellas sino también
      etiqueta	de	los	ingredientes;	xilitol	debería	                  a su bebé.
      aparecer como uno de los primeros

   Steps to Take — 2009 • Health Education                                                                        HE– 61
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      thy           Salud Bucal Durante el Embarazo

   Quizás	los	clientes	inscritos	en	los	programas	de	    •	 En	visitas	subsiguientes,	no	se	olvide	de	
   seguro Medi-Cal y Healthy Families no sepan que          preguntarle	cuándo	fue	la	última	vez	que	vio	
   tienen beneficios dentales. La siguiente lista lo        al dentista, y anote su respuesta. Si la madre no
   puede ayudar a hacer remisiones dentales:                fue al dentista desde su última recomendación,
                                                            remítala	nuevamente.
   •	 Programa	Denti-Cal,	1-800-322-6384	para	
      servicios	al	beneficiario	                         •	 No	se	olvide	de	anotar	todos	los	cambios	que	el                 cliente haya reportado en su salud bucal, y haga
      jsp?fname=ProvReferral                                las remisiones que corresponda.

   •	 Healthy	Families,	1-800-880-5305	para	seguro	      •	 Entregue	al	paciente	el	material	provisto	con	
      de bajo costo                                         esta	guía	sobre	cómo	cuidar	de	su	higiene	bucal            antes, durante y después del embarazo.
      choosing.html                                      •	 La	caries	dental	es	una	enfermedad	infecciosa	
   •	 Programa	de	Salud	Infantil	y	Prevención	de	           contagiosa.	La	madre,	el	padre	y	demás	
      Discapacidad (CHDP, por sus siglas en inglés)         familiares pueden transmitir las bacterias que           causan caries dentales a sus hijos. Recuerde a las
      countyoffices.aspx                                    madres que una higiene bucal apropiada para
                                                            eliminar y controlar las bacterias que causan
   •	 Asociación	Dental	de	California                       caries dentales puede beneficiarla no sólo a ella                        sino	también	a	su	bebé.	Además,	recuerde	a	las	
   •	 Academia	Norteamericana	de	Odontología	               madres que no deben compartir la comida y los
      Pediátrica                                            utensilios con sus bebés.                   •	 Aliente	a	las	madres	a	que	lleven	a	su	bebé	
   •	 Sociedad	de	Odontología	Pediátrica	de	                al	dentista	por	primera	vez	al	cumplir	1	
      California                                            año,	tal	como	lo	recomienda	la	Academia                  Norteamericana	de	Pediatría,	la	Academia	
                                                            Norteamericana	de	Odontología	Pediátrica	y	la	
   •	 Asociación	de	Atención	Primaria	de	California	–	      Asociación Dental Norteamericana. No obstante,
      Clínicas	Comunitarias	y	Centros	de	Salud              tenga en cuenta que no todos los dentistas se             sienten	cómodos	viendo	a	niños	tan	pequeños.	
    Otras fuentes de remisión dental pueden ser             Es posible que las madres tengan que pedirle
     las escuelas dentales y de higiene dental,             al pediatra del bebé una remisión apropiada.
     sociedades dentales y asociaciones de higiene          Para ayudar a la madre a inscribir a su hijo en
     dental.                                                un programa de seguro público, o encontrar un
                                                            proveedor	dental	que	acepte	su	seguro,	llame	al:	
   Seguimiento                                           •	 1-800-322-6384	para	obtener	información	sobre	
   •	 Algunas	mujeres	han	recibido	muy	poca	o	              el	seguro	dental	de	Medi-Cal	(Denti-Cal),	o	visite	
      ninguna	atención	dental	en	su	vida.	Trate	            el sitio Web de Medi-Cal, sección “Find a Dentist”
      de hacer todo lo posible para remitir a estas         (Encontrar a un dentista) en:
      mujeres a un dentista para que se hagan     
      un examen de rutina y una limpieza dental             jsp?fname=ProvReferral
   HE – 62                                                            Steps to Take — 2009 • Health Education
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      thy          Salud Bucal Durante el Embarazo

   •	 1-800-880-5305	para	obtener	información	sobre	
      los programas de seguro Healthy Families, o
      haga una búsqueda en el sitio Web de Healthy
      Families de California, bajo “Choosing Plans and
      Providers”	(Planes	y	proveedores),	en:

   •	 Folletos	y	afiches	titulados	“Detenga	el	avance	     •	 Academia	Norteamericana	de	Pediatría	–	
      de las caries dentales” (Stop the Spread of Tooth       Enlaces de salud bucal en California
      Decay),	disponible	sin	cargo	en	inglés	y	español.
      Para encargarlos, llame al 916-650-0345 ó               oralhealth/state.cfm?ID=6
      visite	la	página	Web	de	salud	bucal	de	MCAH	y	
      consulte bajo “Publications” (Publicaciones) para    •	 Primeras	Sonrisas	(First	Smiles)	(California)
      descargar una copia.                                              •	 Centro	Nacional	Materno	Infantil	de	Recursos	
      MCAHOralHealth/Pages/default.aspx                       para la Salud Bucal
   •	 También	puede	obtener	folletos	gratuitos	sobre
      caries dentales y enfermedades periodontales
      en	inglés	y	español	en	el	Instituto	Nacional	de	
      Investigaciones	Dentales	y	Craneofaciales.	Visite	
      su	página	Web:
   •	 Para	obtener	enlaces	y	herramientas	adicionales	
      sobre salud bucal:
      Asociación Dental Norteamericana

   Steps to Take — 2009 • Health Education                                                                    HE– 63
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                    Prevent Gum Problems When You Are Pregnant

   It is common to have gum                        Why worry about gum disease?
   problems when you are pregnant.
                                                   You may think that gum disease is not
   Your gums may swell and bleed. This is called
                                                   that important. But you should know
   gingivitis	or	gum	disease.	When	you	are	
   pregnant, gum disease can get worse. It is
   important to brush your teeth often while you   •	 Your	gum	disease	could	get	worse.	The	
   are pregnant.                                      gums, bone, and tissues around your teeth
                                                      may pull away from the teeth. If you don’t
                                                      get treated, you could lose your teeth.
                                                   •	 Your	gum	disease	can	cause	problems	for	
                                                      your	baby.	You	may	have	a	much	higher	
                                                      chance of your baby being born too early
                                                      or too small, or both. This can cause serious
                                                      problems for your baby.

                                                   Here’s what you can do to prevent
                                                   gum disease:
                                                   •	 Brush	your	teeth	at	least	twice	a	day,	or	
                                                   •	 Brush	your	teeth	with	fluoride	toothpaste.	
                                                   •	 Use	a	soft	toothbrush.
                                                   •	 Brush	and	floss	before	you	go	to	bed.	
   Here’s what you should watch
                                                   •	 Floss	every	day.	This	will	help	you	clean	
   out for:                                           between the teeth.
   •	 Your	gums	may	be	a	very	bright,	shiny	red	
      color.                                       •	 Eat	healthy	foods.	Eat	foods	
                                                      high	in	vitamin	C	and	folic	
   •	 Your	gums	may	look	swollen.                     acid, such as oranges
   •	 Your	gums	may	bleed	easily	when	you	            and cereals with folic
      brush or floss.                                 acid added.

   If	you	have	any	of	these	signs,	see	a	          	•	 Go	to	the	dentist	to	
   dentist right away.                                 get your teeth and
                                                       gums cleaned and

   HE – 64                                                      Steps to Take — 2009 • Health Education
       y Mo
  ealth Baby
                    Cómo Prevenir Problemas en las Encías
      thy           Cuando está Embarazada

   Es común tener problemas en las                    ¿Por qué preocuparse sobre la
   encías cuando está embarazada.                     enfermedad de las encías?
   Sus	encías	pueden	inflamarse	y	sangrar.	Esto	
   se	llama	gingivitis	o	enfermedad	de	las	encías.	   Puede creer que la enfermedad de
   Cuando	está	embarazada,	la	enfermedad	de	las	      las encías no es tan importante. Pero
   encías	puede	empeorar.	Es	importante	que	se	       debería saber que:
   cepille	los	dientes	frecuentemente	cuando	está	    •	 Su enfermedad de las encías puede
   embarazada.                                           empeorar.	Las	encías,	el	hueso	y	el	tejido	
                                                         alrededor de los dientes pueden comenzar
                                                         a separarse de la dentadura. Si no la trata,
                                                         puede perder sus dientes.
                                                      •	 Su enfermedad de las encías puede
                                                         causar problemas para su bebé. Puede
                                                         correr	un	riesgo	mucho	más	alto	que	su	
                                                         bebé nazca demasiado temprano o sea
                                                         muy	pequeño,	o	ambos.	Esto	puede	causar	
                                                         un problema serio para su bebé.

                                                      Para prevenir la enfermedad
                                                      de las encías puede hacer lo
   Preste atención a lo siguiente:                    •	 Cepíllese	los	dientes	por	lo	menos	dos	
   •	 Sus	encías	pueden	tomar	un	color	rojo	muy	         veces	por	día,	o	más.
      intenso y brillante.
                                                      •	 Cepíllese	con	una	pasta	dentífrica	con	flúor.	
   •	 Sus	encías	pueden	parecer	inflamadas.
                                                      •	 Use	un	cepillo	de	dientes	blando.
   •	 Sus	encías	pueden	sangrar	fácilmente	
                                                      •	 Cepíllese	y	use	hilo	dental	
      cuando se cepilla o usa el hilo dental.
                                                         antes de irse a dormir.
   Si	tiene	alguno	de	estos	signos,	vea	a	un	
   dentista de inmediato.                             •	 Use	el	hilo	dental	
                                                         todos	los	días.	Esto	la	
                                                         ayudará	a	limpiar	bien	
                                                         entre los dientes.
                                                      •	 Coma	comidas	sanas.	
                                                         Coma alimentos con
                                                         mucha	vitamina	C	
                                                         y	ácido	fólico,	como	
                                                         naranjas y cereales con
                                                         ácido	fólico	agregado.
                                                      	•	 Vaya	al	dentista	para	que	le	limpie	y	
                                                          examine los dientes.
   Steps to Take — 2009 • Health Education                                                              HE– 65
       y Mo
H ealth Baby
      thy           See a Dentist When You are Pregnant

   It’s important to take care of your                You should:
   teeth and gums when you are                        •	 See	a	dentist	for	a	check-up.
   pregnant.                                          •	 Get	your	teeth	cleaned.	

   If you have Medi-Cal or Healthy                    •	 Get	the	treatment	you	need	if	you	have	
                                                         tooth decay or other dental problems.
   Families Insurance, you probably
   have dental coverage. Call 1 (800)
   880-5305 for more information                      You should see a dentist right
   about these programs.                              away if:
                                                      •	 You	have	not	been	to	a	dentist	in	the	last	
   If your teeth and gums are not                        year.
   healthy, you and your baby can                     •	 You	have	pain	in	your	mouth.
   have problems.                                     •	 Your	gums	often	bleed.
    •	 You	may	have	pain	and	tooth	decay.
                                                      •	 You	have	lumps,	sores,	or	anything	else	that	
    •	 You	may	have	bleeding	gums.	                      is not normal in or around your mouth.
    •	 You	may	lose	your	teeth.
                                                      Your dentist may say you need
    •	 Your	baby	may	be	born	too	early,	too	small,	
       or both.                                       x-rays.
                                                      It can be safe to have x-rays while you are
                                                      pregnant. Be sure that you:

                                                      •	 Tell	your	dentist	you	are	pregnant.	
                                                      •	 Ask	to	wear	a	lead	apron	over	your	stomach	
                                                         while	you	have	x-rays	done.	You	should	also	
                                                         wear a lead collar around your neck.
                                                      •	 Have	x-rays	only	when	needed.

   HE – 66                                                         Steps to Take — 2009 • Health Education
       y Mo
H ealth Baby
                   Veo a un Dentista Cuando está Embarazada

   Cuando está embarazada es                       Por todas estas razones, es
   importante que se cuide los                     importante que vea a un dentista
   dientes y las encías.                           cuando está embarazada.
                                                   Si	no	tiene	a	un	dentista,	pídale	a	su	
  Si tiene el seguro de Medi-Cal o                 profesional médico que la remita a uno de su
  Healthy Families, es probable que                confianza.
  ya tenga cobertura dental. Para
  obtener más información sobre                    Debería:
  estos programas, llame al 1 (800)                •	 Ver	al	dentista	para	un	examen	general.
  880-5305.                                        •	 Hacerse	una	limpieza	dental.	

   Si sus dientes y encías no están                •	 Si	tiene	caries	u	otros	problemas	dentales,	
                                                      obtener tratamiento.
   sanos, es posible que usted y su
   bebé tengan problemas.
                                                   Debería ver a un dentista
   •	 Puede	tener	dolor	en	la	boca	y	caries	
      dentales.                                    inmediatamente si:
                                                   •	 No	ha	ido	al	dentista	en	el	último	año.
   •	 Puede	tener	encías	sangrantes.	
                                                   •	 Le	duele	la	boca.
   •	 Puede	perder	sus	dientes.
                                                   •	 Sus	encías	sangran	con	frecuencia.
   •	 Es	posible	que	su	bebé	nazca	antes	de	
      tiempo,	sea	demasiado	pequeño,	o	ambos.      •	 Tiene	bultos,	llagas	o	cualquier	otra	cosa	
                                                      que no sea normal en, o alrededor de, su
   •	 Su	bebé	puede	tener	caries	dentales	más	
      adelante al contagiarse los gérmenes de su
                                                   Su dentista puede decirle que
                                                   tiene que sacarle una radiografía.
                                                   Puede sacarse radiografías mientras
                                                   está embarazada sin peligro. Es
                                                   importante que:
                                                   •	 Le	diga	a	su	dentista	que	está	embarazada.	
                                                   •	 Pida	que	le	pongan	un	delantal	de	plomo	
                                                      sobre su estómago mientras le sacan la
                                                      radiografía.	También	debería	usar	un	collar	
                                                      de plomo alrededor del cuello.
                                                   •	 Se	saque	radiografías	sólo	cuando	sea	

   Steps to Take — 2009 • Health Education                                                           HE– 67
       y Mo
  ealth Baby
                    Keep Your Teeth and Mouth Healthy!
      thy           Protect Your Baby, Too.

   You can protect your teeth.                    Get your cavities filled before your
   You may have been told that you are            baby is born.
   supposed to lose a tooth every time            •	 Germs	cause	tooth	decay.
   you are pregnant. This is not true. It is      •	 You	can	pass	tooth	decay	germs	in	your	
   important to:                                     mouth to your baby.
   •	 Brush	with	fluoride	toothpaste	every	day.
                                                  •	 Your	baby	can	get	cavities	from	the	germs	
   •	 Floss	your	teeth	every	day.	                   in your mouth.

   See a dentist right away if you                Here’s how you can prevent your
   have:                                          baby from getting cavities:
   •	 A	toothache                                 •	 Take	care	of	your	own	teeth.
   •	 Sore	or	bleeding	gums                       •	 Never	share	your	baby’s	spoon	or	fork.
   •	 A	broken	tooth                              •	 Don’t	chew	or	taste	your	baby’s	food	and	
   •	 Pain	or	swelling	inside	your	mouth             then	give	it	to	your	baby.

   •	 Any	other	dental	emergency                  •	 Clean	your	baby’s	pacifier	with	water,	not	by	
                                                     licking it.
                                                  •	 Clean	your	baby’s	teeth	every	day	with	a	
                                                     pea-sized amount of fluoridated toothpaste.
                                                  •	 Take	your	baby	to	see	the	dentist	by	age	1.

   HE – 68                                                    Steps to Take — 2009 • Health Education
       y Mo         Mantenga Sanso sus Dientes y Boca!
H ealth Baby
Heal                Proteja Tambien a su Bebe!

   Puede proteger sus dientes.                Arréglese las caries antes de que
   Le pueden haber dicho que es normal        nazca el bebé.
   perder un diente cada vez que está         •	 Los	gérmenes	pueden	causar	caries.
   embarazada. Eso no es cierto. Es           •	 Puede	contagiar	los	gérmenes	de	su	boca	
   importante que:                               que causan caries a su bebé.
   •	 Se	cepille	los	dientes	con	una	pasta	
      dentífrica	con	flúor	todos	los	días.    •	 Su	bebé	puede	tener	caries	debido	a	los	
                                                 gérmenes que usted le transmita.
   •	 Use	el	hilo	dental	todos	los	días.	
                                              Para evitar que su bebé tenga
   Vea a un dentista de inmediato si          caries:
   tiene:                                     •	 Cuídese	sus	propios	dientes.
   •	 Dolor	de	muelas
                                              •	 Nunca	comparta	con	su	bebé	una	cuchara	
   •	 Encías	inflamadas	o	sangrantes             o tenedor.
   •	 Un	diente	roto                          •	 No	mastique	ni	pruebe	la	comida	antes	de	
   •	 Dolor	o	inflamación	dentro	de	su	boca      dársela	al	bebé.

   •	 Cualquier	otra	emergencia	dental        •	 Limpie	el	chupón	de	su	bebé	con	agua,	no	
                                              •	 Lávele	los	dientes	a	su	bebé	todos	los	
                                                 días	con	una	pequeña	cantidad	de	pasta	
                                                 dentífrica	con	flúor.
                                              •	 Lleve	a	su	bebé	a	ver	al	dentista	cuando	
                                                 cumpla	1	año.

   Steps to Take — 2009 • Health Education                                                   HE– 69
       y Mo
H ealth Baby
      thy             Oral Health During Infancy

                                        r dental insuran      By age 6 or 7 years, the four permanent first molar
                   w ho are eligible fo             edi-Cal
   Many children                 ren who have M               teeth will erupt. These are the first permanent
   are not enro lled. Many child               dental         (adult) teeth to erupt and they erupt right behind
                           verage also have
          lthy Families co                           to
   or Hea                          it. Refer parents          the	last	primary	teeth.	Parents	and	caregivers	
   coverage b  ut may not know                                should pay special attention to these teeth
                      lthy Families.
    Denti-Cal or Hea                                          because they should last a lifetime!

                                                              Early childhood caries
   Goals                                                      Early	Childhood	Caries	(ECC),	previously	known	
   Help your client:                                          as “Baby Bottle Tooth Decay” or “Nursing Caries,”
                                                              is a type of tooth decay caused mainly by
   •	 Understand	and	identify	undesirable	oral	               inappropriate feeding practices in the presence
      conditions common in infancy and early                  of Streptococcus mutans, the primary bacteria
      childhood including Early Childhood Caries              involved	in	the	development	of	dental	caries.	ECC	
      (ECC) and common dental emergencies.                    affects primarily the four upper front baby teeth,
                                                              but	may	involve	other	teeth	as	the	decay	spreads.	
   •	 Learn	how	to	prevent	these	oral	conditions.
                                                              The	overall	prevalence	of	ECC	is	believed	to	be	5%	
   •	 Understand	that	dental	caries	(tooth	decay)	is	a	       among children below the age of 5 years in the US.
      transmissible infectious disease and learn how          However,	in	minority	and	ethnic	populations,	such	
      to reduce the caretaker-to-child transmission.          as	among	Native	Americans,	the	rate	of	ECC	can	be	
                                                              as high as 70%.
   Background                                                 A pregnant woman should be informed of
   Dental caries (tooth decay) is the most common             common oral health conditions that may affect her
   chronic condition affecting children in the U.S. In        baby	as	well	as	ways	to	prevent	and/or	treat	these	
   California, a 2005 study found that 54% of kinder-         conditions.
   gartners had experienced tooth decay and 28%
   of	kindergarteners	had	active	untreated	Early	
   Childhood	Caries	(ECC),	previously	known	as	“Baby	         To prevent ECC tell your client:
   Bottle Tooth Decay.”                                       •	 Do	not	bottle	feed	baby	after	12	months.
   Primary	(baby)	teeth	begin	to	develop	prenatally	          •	 Do	not	put	the	baby	to	sleep	with	a	bottle	
   at 5-6 weeks of pregnancy. The first primary teeth            containing anything other than water.
   usually start to erupt by the time the baby is 6
                                                              •	 Do	not	bottle	feed	with	sugar-containing	
   months old. By age 2 or 3 years, a child has the
                                                                 substances such as juice and soda. When juices
   complete set of 20 primary teeth.
                                                                 are offered, they should be from a cup.
                                                              •	 If	the	baby	likes	to	carry	around	a	training	cup	
                                                                 or sippy cup, make sure it contains water only.

   HE – 70                                                                Steps to Take — 2009 • Health Education
       y Mo
H ealth Baby
      thy           Oral Health During Infancy (cont.)

   Note about breastfeeding: Although                      How to reduce caretaker-child
   breastfeeding	babies	have	much	lower	rates	of	          transmission:
   ECC, breastfeeding does not completely protect
   babies from caries. Some breastfed babies, who          •	 The	mother	should	have	any	active	tooth	decay	
   feed at will for an extended period of time, may           treated by a dentist.
   develop	a	pattern	of	caries	similar	to	that	found	in	   •	 A	dentist	or	a	physician	may	prescribe	
   ECC.                                                       antimicrobial rinses like chlorhexidine during
                                                              the prenatal and postnatal period, and
   •	 Do	not	use	pacifiers	dipped	in	honey,	syrups	or	        make	other	efforts	to	decrease	the	levels	of	
      other	sugars.	Do	not	give	honey	at	all	before	          Streptococcus mutans in the mother’s mouth.
      age one.
                                                           •	 Xylitol	chewing	gum	may	be	recommended.	
                                                              Xylitol is both non-cariogenic and has
   Important Information                                      antibacterial effects (it interferes with the
                                                              colony-forming ability of Streptococcus mutans,
   Bacterial transmission to children                         the primary bacterium causing tooth decay).
   A	growing	body	of	scientific	evidence	indicates	
   that dental caries, including ECC, is an infectious     •	 Refer	the	pregnant	woman	to	the	dentist	for	
   and transmissible disease. Dental caries results           additional information and treatment.
   when bacteria in the mouth metabolize certain
   carbohydrates to produce acids that destroy             Why early prevention and treatment
   (demineralize) tooth surfaces and underlying
                                                           for the child?
   tooth	structure.	The	primary	bacterium	involved	
   is Streptococcus mutans. The caries process usually     •	 If	the	caries	process	goes	untreated	during	
   begins with the transmission of bacteria to the            the first years of life, the child is more likely to
   child from the caretaker, usually the mother. A            have	caries	in	both	the	primary	and	permanent	
   mother who has untreated dental caries appears             teeth.
   to be more likely to pass the bacteria to her child.    •	 Attention	to	a	child’s	oral	health	will	prevent	
   Dental caries can also be transmitted from the             pain and the complications associated with
   father, other family members, and other caretakers.        dental caries.

   How does the transmission occur?
   Although the exact path of transmission has not
   been identified, some most likely ways are:

                                                                                                y of Pediatric
   •	 Caregiver	and	child	share	eating	utensils	and	                           erican Academ
                                                             Rem ember: the Am                            tal visit
      food.                                                                           e child’s first den
                                                             Dentistry recommends th
   •	 Caregiver	prechews	or	blows	on	the	child’s	            by age one.
      food to cool it off.
   •	 Caregiver	shares	the	same	toothbrush	with	the	

   Steps to Take — 2009 • Health Education                                                                     HE– 71
       y Mo
H ealth Baby
      thy            Salud Bucal Durante la Infancia

                                  s para reccibir se        son los primeros dientes permanentes en salir,
  Muchos niños   que son eligible          s que tienen     y lo hacen inmediatamente después de que
                            s. Muchos niño
  dental n o están inscrito                       mbién
                                 lthy Families ta           salieron los últimos dientes de leche. Los padres
  cobertura de  Medi-Cal o Hea                 . Remita a
                              pero no lo saben              y cuidadores deben prestar especial atención a
  tienen co bertura dental,           Families              estos	dientes,	¡porque	deben	durar	toda	la	vida!
                      -Cal o Healthy
   los padres a Denti

                                                            Caries de la niñez temprana
                                                            Las	Caries	de	la	Niñez	Temprana	(ECC,	por	sus	
   Objetivos                                                siglas en inglés), antes conocida como “Caries
   Ayude a su cliente a:                                                                       ,
                                                            de biberón” o “Caries de lactancia” es un tipo de
                                                            caries	causada	principalmente	por	prácticas	de	
   •	 Comprender	e	identificar	los	problemas	               alimentación inadecuadas en la presencia de
      bucales	más	comunes	en	la	infancia	y	la	niñez	        Streptococcus mutans, la bacteria principal que
      temprana,	incluyendo	las	Caries	de	la	Niñez	          causa las caries dentales. La ECC afecta princi-
      Temprana (ECC) y las emergencias dentales             palmente los cuatro dientes de leche superiores
      comunes.                                              frontales	del	bebé,	pero	puede	involucrar	
   •	 Aprender	a	prevenir	estos	problemas	bucales.          otros	dientes	a	medida	que	las	caries	se	van	
                                                            transmitiendo al resto de la dentadura. En los
   •	 Comprender	que	las	caries	dentales	son	una	           Estados Unidos, se cree que la ECC afecta al 5% de
      enfermedad infecciosa contagiosa, y aprender          todos	los	niños	menores	de	5	años	de	edad.	No	
      a	reducir	el	contagio	del	cuidador	al	niño.           obstante, en las poblaciones minoritarias y étnicas,
                                                            como	por	ejemplo	los	indígenas	norteamericanos,	
   Antecedentes                                             la incidencia de ECC puede ser tan alta como el
   La	caries	dental	es	el	problema	crónico	más	             70%.
   común	que	afecta	a	los	niños	en	los	Estados	
                                                            Debería	informar	a	las	mujeres	embarazadas	
   Unidos. En California, un estudio realizado en 2005
                                                            sobre los problemas comunes de salud bucal que
   concluyó	que	el	54%	de	los	estudiantes	de	jardín	
                                                            pueden llegar a afectar a su bebé, y también las
   de	niños	habían	tenido	caries,	y	que	el	28%	tenía	
                                                            maneras	de	prevenir	y/o	tratar	estos	problemas.
   Caries	de	la	Niñez	Temprana	(ECC,	por	sus	siglas	
   en	inglés)	activa	sin	tratar.	La	ECC	se	llamaba	antes	
  “Caries de biberón”  .                                    Para prevenir la ECC, aconseje a su
   Los dientes primarios (de leche) comienzan a             cliente:
   desarrollarse antes de que nazca el bebé, a las 5        •	 Que	no	alimente	a	su	bebé	con	biberón	
   ó 6 semanas de embarazo. El primer diente de                después de los 12 meses de edad.
   leche en general comienza a salir cuando el bebé
                                                            •	 Que	no	ponga	al	bebé	a	dormir	con	un	biberón,	
   cumple	6	meses	de	edad.	A	los	2	ó	3	años	de	edad,	
                                                               a	menos	que	contenga	nada	más	que	agua.
   el	niño	tiene	ya	un	juego	completo	de	20	dientes	
   de leche.                                                •	 Que	no	alimente	al	bebé	con	un	biberón	que	
                                                               tenga sustancias azucaradas, como jugo o
   A	los	6	ó	7	años	de	edad	comenzarán	a	salir	los	
                                                               refrescos.	Cuando	le	dé	jugos,	debería	hacerlo	
   primeros dientes molares permanentes. Estos
                                                               con	un	vaso.

   HE – 72                                                              Steps to Take — 2009 • Health Education
       y Mo
H ealth Baby
      thy            Salud Bucal Durante la Infancia

   •	 Si	al	bebé	le	gusta	llevar	consigo	un	vaso	de	           ¿Cómo se produce el contagio?
      adiestramiento	o	vaso	antiderrame,	asegúrese	            Si bien no se ha identificado el trayecto exacto
      que contenga sólo agua.                                  de	la	transmisión,	lo	más	probable	es	que	ocurra	
     Nota sobre lactancia: Si bien los bebés                   cuando:
     amamantados tienen una incidencia mucho                   •	 El	cuidador	y	el	niño	comparten	utensilios	y	
     menor de ECC, el amamantar no protege                        comida.
     completamente a los bebés contra las caries.
                                                               •	 El	cuidador	mastica	previamente	o	sopla	la	
     Algunos bebés amamantados que se alimentan
                                                                  comida	del	niño	para	enfriarla.
     bajo demanda por un periodo extendido de
     tiempo pueden desarrollar un patrón de caries             •	 El	cuidador	comparte	su	cepillo	de	dientes	con	
     muy similar al de la ECC.                                    el	niño.

   •	 No	use	chupones	embebidos	en	miel,	jarabes	u	            Cómo reducir el contagio de
      otras sustancias azucaradas. No le dé miel para
                                                               cuidador a niño:
      nada	antes	de	cumplir	un	año	de	edad.
                                                               •	 La	madre	debe	hacerse	tratar	todas	las	caries	
                                                                  activas	por	un	dentista.	
   Información importante
                                                               •	 El	dentista	o	médico	puede	recetarle	enjuagues	
  Transmisión bacterial a los niños                               antimicrobiales como clorhexidina durante
   Los	estudios	científicos	están	demostrando	                    el periodo prenatal y postnatal, y hacer
   en forma creciente que las caries dentales,                    otros	esfuerzos	para	reducir	los	niveles	de	
   incluyendo la ECC, son una enfermedad infecciosa               Streptococcus mutans en la boca de la madre.
   y contagiosa. La caries dental se produce cuando
   las bacterias de la boca metabolizan ciertos                •	 Puede	recomendar	goma	de	mascar	con	xilitol	
   hidratos	de	carbono,	produciendo	ácidos	que	                   (xylitol). El xilitol es un no cariogénico que tiene
   destruyen (desmineralizan) las superficies de                  también efectos antibacteriales (interfiere
   los dientes y la estructura dental subyacente. La              con la capacidad del Streptococcus mutans,
   bacteria principal que causa las caries se llama               la bacteria que es el causante principal de las
   Streptococcus mutans. El proceso de la caries se               caries, para formar colonias).
   inicia generalmente con el contagio de la bacteria          •	 Remita	a	la	mujer	embarazada	al	dentista	para	
   del	cuidador	(normalmente	la	madre)	al	niño.	El	               información adicional y tratamiento.
   contagio	más	probable	de	las	bacterias	de	la	
   caries	a	un	niño	es	por	una	madre	que	tenga	caries	         ¿Por qué es importante la prevención
   dentales no tratadas. Las caries dentales también           y el tratamiento temprano para el
   se pueden transmitir por el padre, otros familiares
   y otros cuidadores.
                                                               •	 Si	el	proceso	de	la	caries	queda	sin	tratar	
                                      Norteamerican               durante	los	primeros	años	de	vida,	es	más	
                     ciación Dental
   Recuerde: la Aso             ana de Odonto
                                                 logía            probable	que	el	niño	tenga	caries	tanto	en	
   la Academ   ia Norteameric                 ana de              sus dientes de leche como en sus dientes
                             ia Norteameric
   Pediá trica y la Academ            ebé haga su                 permanentes.
                      iendan que el b
    Pediatría recom                     plir su primer a
                      l dentista al cum                        •	 La	atención	de	la	salud	bucal	del	niño	evitará	
    primera visita a
                                                                  el dolor y las complicaciones asociadas con las
                                                                  caries dentales.
   Steps to Take — 2009 • Health Education                                                                      HE– 73
       y Mo
H ealth Baby
      thy            Oral Health During Infancy (cont.)
                                     infectious disea
                    a transmissible
   Dental caries is           retakers can tra
                                               nsmit the       of candy, cookies and juice drinks.
   The moth er and other ca
                                      e baby
                     use caries to th                       •	 Avoid	sweets	between	meals.	Save	sweets	for	
   bacteria that ca
                                                               dessert after a meal.

                                                            Availability of fluoride from various
   Steps to Take                                            sources:
   Ideally, infant oral care begins with prenatal oral
   health counseling for parents.                           •	 Parents	should	start	brushing	their	child’s	teeth	
                                                               every	day	with	fluoride	toothpaste	as	soon	as	
   How	to	help	parents	prevent	dental	caries	from	             the teeth start to erupt into the mouth.
                                                             	•	 Limit	the	amount	of	toothpaste	used	each	time	
   1. Education and counseling of parents by CPSP                to a tiny dab to minimize fluoride ingestion.
                                                            •	 Parents	should	also	be	advised	to	teach	their	
   Parents should learn about:                                 children to spit out the toothpaste during and
   Examining	their	children’s	teeth	and	oral	cavity	on	        after brushing.
   a weekly basis.
                                                            •	 Inform	parents	about	the	need	to	use	fluoride	
   How to examine child’s teeth?                               supplements if the community water is not
   Parent lays child’s back into parent’s lap, tilts the       fluoridated. Parents should contact their
   child’s head back, lifts the child’s lip and looks for      dentist or physician for a prescription.
   early signs of tooth decay (white or brown areas
   near the gum line). This should be done at least         •	 Ask	the	child’s	dentist	or	pediatrician	about	the	
   once a week.                                                need for a topical fluoride application, such as
   •	 Parents	should	clean	gums	and	newly	erupted	             fluoride	varnish.	Medi-Cal	medical	providers	
      teeth with moist, soft, child’s toothbrush or            can	apply	fluoride	varnish	up	to	3	times	a	year	
      with clean washcloth after feeding and before            for children under age 6
                                                            Use of antimicrobial agents by mothers and
   •	 Each	child	should	have	his	own	small	soft	            other caregivers:
      toothbrush.                                           Because a mother can transmit decay-causing
                                                            bacteria to a child, the control of her own oral
   •	 Children	should	be	given	new	toothbrushes	
                                                            health	is	the	key	in	preventing	the	transmission	
      every	3	months,	if	possible.
                                                            of bacteria to the child. Chewing xylitol gum for
   •	 Parents	should	continue	to	supervise	and	             5 minutes, 3 to 5 times a day, will help reduce the
      brush their children’s teeth until about age 6-8      level	of	these	bacteria	in	her	mouth.
                                                            2. Take the child to a pediatric dentist or
   Options regarding diet:                                  general dentist by the first birthday or as
   •	 Choose	foods	that	do	not	have	a	lot	of	sugar	in	      soon as the first tooth comes in. Not all dentists
      them. High fructose corn syrup is type of liquid      are	comfortable	seeing	very	young	children,	so	
      sugar commonly found in processed foods and           you may need to help your patients identify
      drinks. Sugar combined with bacterial plaque          appropriate dentists. The child’s pediatrician may
      creates acid that destroys teeth.                     be able to do an initial oral health assessment,
                                                            help	the	parent	with	home	care	advice,	and	give	
   •	 Give	a	child	fresh	fruits	and	vegetables	instead	     referrals to oral health professionals.
   HE – 74                                                                Steps to Take — 2009 • Health Education
       y Mo
H ealth Baby
      thy             Salud Bucal Durante la Infancia

                                          infecciosa       Opciones dietéticas:
                         na enfermedad
        ries dental es u                        pueden     •	 Elija	comidas	que	no	tengan	mucha	azúcar.	El	
  La ca                         os cuidadores,
  contagiosa   . La madre, y otr                       .
                                      e causa la caries       jarabe	de	maíz	con	alto	contenido	de	fructosa	
                     é la bacteria qu
   transmitir al beb                                          es	el	tipo	de	azúcar	líquida	más	común	en	
                                                              alimentos y bebidas procesadas. El azúcar, en
                                                              combinación	con	la	placa	bacterial,	crea	ácidos	
   Pasos a tomar                                              que destruyen los dientes.
   Idealmente, el cuidado bucal infantil comienza con
   consejos sobre la salud bucal a los padres.             •	 En	vez	de	dulces,	galletas	y	jugos	de	fruta,	déle	
                                                              a	su	niño	frutas	y	verduras	frescas.
   Para	ayudar	a	los	padres	a	prevenir	las	caries	
   dentales:                                               •	 No	le	dé	golosinas	entre	comidas.	Guarde	las	
                                                              golosinas para el postre después de la comida.
  1. Educación y consejería a los padres por parte
  de los proveedores de CPSP:                              Disponibilidad de flúor de varias fuentes:
   Los padres deberían aprender a:                         •	 Los	padres	deberían	comenzar	a	cepillar	los	
   Examinar	los	dientes	y	la	cavidad	bucal	de	sus	            dientes	de	su	hijo	todos	los	días	con	pasta	
   hijos semanalmente.                                        dentífrica	con	flúor	apenas	comiencen	a	salirle	
                                                              los dientes.
  ¿Cómo se examinan los dientes del bebé?
  El	padre	acuesta	al	niño	de	espaldas	sobre	su	falda,	    	•	 Para	prevenir	la	ingestión	de	flúor,	use	sólo	una	
  recuesta	la	cabeza	del	niño	hacia	atrás,	le	levanta	         porción	muy	pequeña	de	pasta	dentífrica.	
  el	labio	y	se	fija	a	ver	si	hay	signos	tempranos	de	     •	 También	se	debe	aconsejar	a	los	padres	que	le	
  caries	(zonas	blancas	o	color	café	cerca	de	la	línea	       enseñen	a	su	hijo	a	escupir	la	pasta	dentífrica	
  de	las	encías).	Esto	se	debe	hacer	por	lo	menos	una	        durante y después de cepillarse.
  vez	por	semana.
                                                           •	 Informe	a	los	padres	sobre	la	necesidad	de	
   •	 Los	padres	deberían	limpiar	las	encías	y	los	           usar suplementos con flúor si el agua corriente
      dientes	recién	salidos	del	niño	con	un	cepillo	         no	tiene	flúor.	Los	padres	deberían	ponerse	
      infantil	blando	humedecido	o	con	un	paño	               en contacto con su dentista o médico para
      limpio después de comer y antes de irse a la            obtener una receta.
                                                           •	 Pregúntele	al	dentista	o	pediatra	de	su	hijo	
   •	 Cada	niño	debería	tener	su	propio	cepillo	              sobre la necesidad de aplicaciones de flúor
      infantil con cerdas blandas.                            tópico, como por ejemplo un barniz de flúor.
   •	 Los	niños	deberían	cambiar	de	cepillo	cada	3	           Los profesionales médicos de Medi-Cal pueden
      meses, de ser posible.                                  aplicar	un	barniz	de	flúor	hasta	3	veces	por	año	
                                                              a	niños	menores	de	6	años	de	edad.
   •	 	Los	padres	deberían	seguir	supervisando	y	
      cepillando los dientes de su hijo hasta que
      cumplan	6	a	8	años	de	edad.

   Steps to Take — 2009 • Health Education                                                                  HE– 75
       y Mo
H ealth Baby
      thy           Salud Bucal Durante la Infancia

   Uso de productos antimicrobiales orales por
   parte de las madres y otros cuidadores:
   Como una madre puede transmitir las bacterias
   que causan caries a su hijo, el control de su salud
   bucal	es	la	clave	para	prevenir	el	contagio.	Para	
   reducir	el	nivel	de	las	bacterias	en	su	boca,	puede	
   usar goma de mascar con xilitol por 5 minutos, 3 a
   5	veces	por	día.
   2. Lleve al bebé a ver a un dentista pediátrico
   o dentista general cuando cumpla un año de
   edad, o apenas salga el primer diente. No todos
   los dentistas se sienten cómodos con bebés muy
   pequeños,	así	que	es	posible	que	tenga	que	ayudar	
   a sus pacientes a ubicar a un dentista apropiado. Es
   posible	que	el	pediatra	del	niño	pueda	hacer	una	
   evaluación	bucal	inicial,	ayudar	a	los	padres	con	
   consejos para el cuidado en el hogar, y remitirlo a
   profesionales dentales.

   HE – 76                                                Steps to Take — 2009 • Health Education
       y Mo
H ealth Baby
      thy            Oral Health During Infancy (cont.)

                                            ins, the
                            when caries beg                  •	 If	bleeding	is	present,	apply	direct	pressure	to	
           unger the child                         rimary
    The yo                        ay in both the p              the area with gauze or cloth.
    greater the risk of future dec
                     t teeth.
     and permanen                                            •	 If	swelling	is	present,	apply	a	cold	compress.
                                                             •	 If	bleeding	cannot	be	controlled	immediately,	
   •	 This	is	a	good	opportunity	for	early	detection	           take the child to a dentist or hospital emergency
      and	prevention	of	Early	Childhood	Caries	(ECC).           room.
   •	 Parents	will	learn	about	various	forms	of	fluoride,	   Avulsed (knocked out) primary (baby) tooth
      including fluoride supplements if the local            •	 Primary	teeth	should	not	be	replanted	(it	could	
      water is not fluoridated.                                 cause damage to the permanent tooth bud in
   •	 Parents	will	learn	how	to	take	care	of	a	child’s	         formation).
      oral health.                                           •	 Take	the	child	to	a	dentist	immediately
   •	 Parents	should	be	motivated	to	take	care	of	
      their child’s oral health as well as their own         Bleeding after primary (baby) tooth falls out
                                                             •	 Pack	a	clean	gauze	or	cloth	over	the	bleeding	
  Dental Emergencies                                            area.	Have	the	child	bite	on	the	gauze	with	
  Injury is the most common cause of a dental                   pressure for 15 minutes. Repeat this one to
  emergency. Most dental injuries occur in children             three times.
  and adolescents. The incidence of injuries among
  children increases with age, due to children’s             •	 If	bleeding	persists,	take	the	child	to	a	dentist.
  increasing	activity.	The	most	common	injuries	
  are to the upper front teeth and surrounding
                                                             Dental abscess
  soft tissues. Some of the most common injuries             •	 Take	the	child	to	the	dentist	immediately.		
  are a fractured crown (broken or cracked tooth),              Infection	from	a	badly	decayed	tooth	may	travel	
  intrusion (tooth is pushed into the gums), and                to the brain and in rare cases cause death.
  avulsion	(tooth	is	knocked	out	of	its	socket).	Soft	
  tissues such as the cheek, tongue, and lips may be         Follow-up
  cut, lacerated, and bruised.                               •	 Remind	the	mother	about	the	importance	of	
                                                                maintaining her own oral health as well as her
  Dental abscesses usually result from untreated                child’s oral health.
  caries, trauma to the tooth, and/or foods/objects
  wedged between tooth and gums. Symptoms may                •	 Remind	the	mother	about	the	concept	of	
  include pain, swelling, and/or a small pimple on              mother-to-child transmission of dental disease.
  gum tissue.                                                   Ask her if she has any additional questions.
                                                             •	 Ask	if	the	mother	and	her	baby	have	visited	the	
  What to do in case of dental                                  dentist. If not, make appropriate referral. The
  emergencies (for baby teeth – up to                           child’s	first	visit	to	the	dentist	should	be	by	age	
  age 5 years)                                                  one year, or as soon as the first tooth erupts.

  Cut or Bitten Tongue, Lip or Cheek                         •	 Remind	mother	to	clean	her	baby’s	teeth,	
                                                                especially before putting the baby to bed. Also,
   •	 If	bruised	areas	are	present,	apply	ice.
                                                                remind the mother to examine her child’s teeth
                                                                at least once a week.

   Steps to Take — 2009 • Health Education                                                                    HE– 77
       y Mo
H ealth Baby
      thy            Salud Bucal Durante la Infancia

                                 l aparecer las ca
   Cuanto men   or sea el niño a          en el futuro,     Qué hacer en caso de emergencias
                          de tener caries
        r será su riesgo                           entes.
   mayo                           e como perman             dentales (para dientes de leche -
   tanto en su s dientes de lech
                                                            hasta 5 años de edad)
                                                            Corte o mordedura de la lengua, labio o
    •	 Ésta	es	una	buena	oportunidad	para	la	
       detección	y	prevención	temprana	de	las	Caries	
       de	la	Niñez	Temprana	(ECC).                          •	 Si	hay	zonas	con	moretones,	aplique	hielo.

    •	 Los	padres	aprenderán	sobre	las	distintas	           •	 Si	hay	sangrado,	aplique	presión	directa	sobre	
       formas de flúor, incluyendo los suplementos de          la	zona	con	una	gasa	o	paño.
       flúor si el agua corriente no tiene flúor.           •	 Si	hay	inflamación,	aplique	una	compresa	fría.
    •	 Los	padres	aprenderán	a	cuidar	de	la	salud	          •	 Si	no	puede	controlar	el	sangrado	
       bucal de su hijo.                                       inmediatamente,	lleve	al	niño	a	un	dentista	o	a	
    •	 Los	padres	deberían	estar	motivados	para	               la sala de emergencia de un hospital.
       cuidar tanto de la salud bucal de su hijo como
       de la suya propia.                                   Dientes de leche avulsados (expulsados)
                                                            •	 No	se	deben	reimplantar	los	dientes	de	leche	
                                                               (pueden	causar	daño	a	la	raíz	del	diente	
   Emergencias dentales                                        permanente	que	se	está	formando).
   La	causa	más	común	de	una	emergencia	dental	
   es	una	lesión.	La	mayoría	de	las	lesiones	dentales	      •	 Lleve	al	niño	a	un	dentista	inmediatamente.
   ocurren	en	niños	y	adolescentes.	La	incidencia	
   de	lesiones	en	los	niños	aumenta	con	la	edad,	           Sangrado después de que se cae un diente
   debido	al	aumento	en	sus	niveles	de	actividad.	Las	      de leche
   lesiones	más	comunes	se	producen	en	los	dientes	         •	 Coloque	una	gasa	o	paño	limpio	sobre	el	área	
   frontales superiores y los tejidos blandos que los          de	sangrado.	Pídale	a	su	hijo	que	muerda	sobre	
   rodean.	Algunas	de	las	lesiones	más	comunes	                la gasa, aplicando presión por 15 minutos.
   son una corona fracturada (diente roto o rajado),           Repita	este	ciclo	de	una	a	tres	veces.
   intrusión (el diente se empuja dentro de las
   encías)	y	avulsión	(el	diente	se	sale	del	casquillo).	   •	 Si	el	sangrado	persiste,	lleve	a	su	hijo	a	ver	a	un	
   Los tejidos blandos, como la mejilla, la lengua y los       dentista.
   labios, se pueden cortar, lacerar o golpear.
                                                            Absceso dental
   Los abscesos dentales son en general una                 •	 Lleve	al	niño	al	dentista	inmediatamente.	La	
   consecuencia de caries sin tratar, trauma en los            infección de un diente muy cariado puede
   dientes y/o alimentos y objetos atascados entre             contagiarse al cerebro y en casos raros causar
   los	dientes	y	las	encías.	Los	síntomas	pueden	ser	          la muerte.
   dolor,	inflamación	y/o	un	pequeño	grano	en	el	
   tejido	de	las	encías.

   HE – 78                                                               Steps to Take — 2009 • Health Education
       y Mo
H ealth Baby
      thy          Salud Bucal Durante la Infancia

   •	 Recuerde	a	la	madre	sobre	la	importancia	de	
      mantener su propia salud bucal, como también
      la salud bucal de su hijo.
   •	 Recuerde	a	la	madre	el	concepto	de	la	
      transmisión de enfermedades dentales de
      madre a hijo. Pregúntele si tiene alguna duda
   •	 Pregunte	si	la	madre	y	su	bebé	han	visitado	a	un	
      dentista. Si no, haga las remisiones pertinentes.
      La	primera	visita	del	bebé	al	dentista	se	debe	
      realizar	al	año	de	edad,	o	apenas	salga	el	primer	
   •	 Recuerde	a	la	madre	que	limpie	los	dientes	
      de su bebé, sobre todo antes de acostarlo.
      Recuerde también a la madre que examine los
      dientes	de	su	bebé	por	lo	menos	una	vez	por	
   •	 Pregúntele	a	la	madre	sobre	los	hábitos	de	
      alimentación	de	su	bebé,	para	prevenir	Caries	
      de	la	Niñez	Temprana	(ECC).	Recuerde	a	la	
      madre que a partir de los 6 meses de edad, el
      bebé	debería	comenzar	a	beber	de	un	vaso.

   Steps to Take — 2009 • Health Education                 HE– 79
       y Mo
H ealth Baby
      thy           Protect Your Baby from Tooth Decay

   Even babies can get tooth decay.
   You can protect your baby!

   Make sure your own teeth and
   mouth are healthy!
   You may not know that:
   •	 Your	baby	can	get	cavities	from	the	germs	
      in your mouth!
   •	 You	can	spread	these	germs	to	your	baby	
      with	your	saliva.	

   These tips can help:
   •	 Get	a	dental	check-up	and	the	treatment	
      you need.
   •	 Never	share	your	baby’s	spoon	or	fork.	           Remember these pointers when
                                                        your baby is 6 months to a year
   •	 Don’t	chew	your	baby’s	food.	
   •	 Clean	your	baby’s	pacifier	with	water,	not	by	    •	 Let	your	baby	drink	with	a	cup	when	your	
      licking it.                                          baby is 6 months old.
                                                        •	 Some	babies	like	to	carry	around	a	bottle	or	
   Here’s what you should do from                          training cup. Make sure it has only water in
   the time your baby is born until                        it.
   your baby is a year old.
                                                        •	 Don’t	let	your	baby	use	a	bottle	after	12	
   •	 Clean	your	baby’s	gums	and	any	teeth	every	          months.
      day. Most babies get their first teeth around
      6 months of age.                                  •	 As	soon	as	your	baby’s	first	tooth	comes	in,	
                                                           check	every	week	for	early	signs	of	tooth	
   •	 Use	a	moist,	soft,	child’s	toothbrush	or	clean	      decay. Look for white or brown areas near
      washcloth.                                           your baby’s gums. If you see any, take your
   •	 Clean	your	baby’s	gums	and	teeth	once	or	            baby to the dentist right away.
      twice a day.                                      •	 Take	your	baby	to	the	dentist	after	your	
   •	 Don’t	put	your	baby	to	bed	with	a	bottle.	If	        baby gets his first tooth. Make sure your
      your baby falls asleep at the bottle, take it        baby sees the dentist by age 1.
      out of the baby’s mouth.

   HE – 80                                                           Steps to Take — 2009 • Health Education
       y Mo
H ealth Baby
      thy          Protect Your Baby from Tooth Decay

   Here’s how to protect your child’s                 Here are helpful hints when your
   teeth from 1 to 2 years of age.                    child is 2 to 3 years of age.
   •	 Stop	bottle-feeding.                            •	 Check	every	week	for	early	signs	of	tooth	
                                                         decay. Look for white or brown areas near
   •	 Some	babies	like	to	carry	a	training	cup	
                                                         your baby’s gums. If you see any, take your
      around. Make sure it has only water in it.
                                                         child to the dentist right away.
   •	 Don’t	give	your	baby	sweet	snacks	between	
                                                      •	 Brush	your	child’s	teeth,	or	watch	your	child	
                                                         brush, 2 or 3 times a day. Be sure your child
   •	 Wash	your	baby’s	gums	and	teeth	with	a	            brushes before bedtime.
      washcloth or soft toothbrush and a small
                                                      •	 Use	a	tiny	dab	of	fluoride	toothpaste	with	
      dab of fluoride toothpaste.
                                                         every	brushing.
   •	 Check	every	week	for	early	signs	of	tooth	
                                                      •	 Teach	your	child	to	spit	out	the	toothpaste	
      decay. Look for white or brown areas near
                                                         after brushing.
      your baby’s gums. If you see any, take your
      child to the dentist right away.                •	 Stay	away	from	sugary	drinks	like	juice	or	
   •	 Take	your	child	to	the	dentist	for	an	exam.		
      Ask about fluoride and sealant treatments.      •	 Don’t	give	your	baby	too	many	snacks	like	
                                                         cookies and candy. Sweet foods help cause
                                                         tooth	decay.	Give	wholegrain	foods,	nuts,	
                                                         fruits	and	vegetables	for	a	healthier	diet.	
                                                      •	 Take	your	child	to	the	dentist	for	an	exam.
                                                         Ask about fluoride and sealant treatments.

                                                      When you take care of your baby’s
                                                      teeth early on, you will:
                                                      •	 Protect	your	baby	from	pain.
                                                      •	 Lower	the	chances	your	child	will	have	
                                                         cavities	when	he	or	she	is	older.
                                                      •	 Help	your	child	have	healthy	teeth	for	a	

   Steps to Take — 2009 • Health Education                                                              HE– 81
       y Mo
H ealth Baby
      thy          Proteja a Su Bebé de las Caries

   Incluso los bebés pueden tener
   caries. ¡Proteja los dientes de su

   ¡Conserve su propia salud bucal y
   Es posible que no sepa que:
   •	 ¡Su	bebé	puede	tener	caries	debido	a	los	
      gérmenes que usted tiene en su boca!
   •	 Puede	contagiar	esos	gérmenes	a	su	bebé	a	
      través	de	la	saliva
    Estos consejos le pueden ser útiles:
   •	 Hágase	un	examen	dental	y	si	fuera	
      necesario reciba tratamiento.                     Recuerde estas recomendaciones
   •	 No	comparta	nunca	la	cuchara	o	tenedor	           cuando su bebé tenga entre 6
      con su bebé.                                      meses y un año de edad.
   •	 No	mastique	la	comida	de	su	bebé.	                •	 Deje	que	su	bebé	comience	a	tomar	de	un	
                                                           vaso	cuando	cumpla	6	meses	de	edad.
   •	 Limpie	el	chupón	de	su	bebé	con	agua,	no	
      chupándolo.	                                      •	 A	algunos	bebés	les	gusta	llevar	un	biberón	
                                                           o	vaso	de	adiestramiento	consigo	a	todos	
                                                           lados. Asegúrese de que sólo tenga agua.
   Desde el momento en que nazca
                                                        •	 No	deje	que	su	bebé	use	el	biberón	
   su bebé hasta que cumpla un año
                                                           después de los 12 meses de edad.
   de edad, haga lo siguiente:
                                                        •	 Apenas	le	salga	el	primer	diente	al	bebé,	
   •	 Limpie	las	encías	y	los	dientes	de	su	bebé	
                                                           examine su boca todas las semanas para
      todos	los	días.	En	la	mayoría	de	los	bebés	los	
                                                           ver	si	tiene	caries.	Fíjese	si	hay	zonas	
      primeros dientes salen alrededor de los 6
                                                           blancas	o	color	café	cerca	de	las	encías	de	
      meses de edad.
                                                           su	bebé.	Si	las	ve,	lleve	al	bebé	al	dentista	
   •	 Use	un	cepillo	infantil	blando	humedecido	           de inmediato.
      o	un	paño	limpio.	
                                                        •	 Lleve	al	bebé	a	ver	al	dentista	después	de	
   •	 Limpie	las	encías	y	los	dientes	de	su	bebé	          que le salga el primer diente. Asegúrese de
      una	o	dos	veces	por	día.                             que	el	bebé	vea	al	dentista	al	cumplir	1	año	
                                                           de edad.
   •	 Nunca	ponga	al	bebé	a	dormir	con	biberón.	
      Si su bebé se queda dormido con el biberón,
      sáqueselo	de	la	boca.	

   HE – 82                                                           Steps to Take — 2009 • Health Education
       y Mo
H ealth Baby
      thy           Proteja a Su Bebé de las Caries

   Para proteger los dientes de su                       He aquí algunos consejos útiles
   hijo entre 1 y 2 años de edad:                        cuando su hijo tenga entre 2 y 3
   •	 Deje	de	alimentarlo	con	biberón.                   años de edad:
   •	 A	algunos	bebés	les	gusta	llevar	consigo	un	       •	 Examine	la	boca	de	su	hijo	todas	las	
      vaso	de	adiestramiento.	Asegúrese	de	que	             semanas	para	ver	si	hay	señales	tempranas	
      sólo tenga agua.                                      de	caries.	Fíjese	si	hay	zonas	blancas	o	color	
                                                            café	cerca	de	las	encías	de	su	bebé.	Si	las	ve,	
   •	 No	le	dé	al	bebé	bocados	dulces	entre	                lleve	a	su	hijo	al	dentista	de	inmediato.
                                                         •	 Cepíllele	los	dientes,	u	observe	mientras	él	
   •	 Lave	las	encías	y	dientes	de	su	bebé	con	un	          se	los	cepilla,	2	ó	3	veces	por	día.	Asegúrese	
      paño	suave	o	cepillo	de	dientes	blando	y	un	          que su hijo se cepille los dientes antes de
      poco	de	pasta	dentífrica	con	flúor.	                  acostarse.
   •	 Examine	la	boca	del	bebé	todas	las	semanas	        •	 Use	una	pequeña	porción	de	pasta	
      para	ver	si	hay	señales	tempranas	de	caries.	         dentífrica	cada	vez	que	se	cepille.
      Fíjese	si	hay	zonas	blancas	o	color	café	cerca	
      de	las	encías	de	su	bebé.	Si	las	ve,	lleve	a	su	   •	 Enséñele	a	su	hijo	a	escupir	la	pasta	
      hijo al dentista de inmediato.                        después de cepillarse.

   •	 Lleve	a	su	hijo	al	dentista	para	exámenes	de	      •	 No	le	dé	bebidas	azucaradas,	como	jugo	o	
      rutina. Pregunte por el tratamiento con flúor         refrescos.
      y con selladores.                                  •	 No	le	dé	a	su	hijo	demasiados	bocados,	
                                                            como galletas y dulces. Los alimentos
                                                            dulces ayudan a causar caries. Déle
                                                            alimentos con cereal integral, nueces,
                                                            frutas	y	verduras,	para	que	tenga	una	dieta	
                                                         •	 Lleve	a	su	hijo	al	dentista	para	exámenes	
                                                            de rutina. Pregunte por el tratamiento con
                                                            flúor y con selladores.

                                                         Si cuida los dientes de su hijo
                                                         desde el comienzo:
                                                         •	 Evitará	que	su	bebé	tenga	dolor.
                                                         •	 Reducirá	el	riesgo	de	que	su	hijo	tenga	
                                                            caries cuando crezca.
                                                         •	 Ayudará	a	que	su	hijo	tenga	dientes	más	
                                                            saludables	toda	la	vida.	

   Steps to Take — 2009 • Health Education                                                                 HE– 83
       y Mo
H ealth Baby
      thy           Oral Health During Infancy (cont.)

   Making referrals
   Remember: Many children who are eligible for
   dental	insurance	don’t	have	it!		Other	children	
   who are currently enrolled in Medi-Cal or Healthy
   Families	may	not	know	they	already	have	dental	
   coverage	and	will	need	a	referral	to	a	dental	office	
   or clinic that accepts this insurance.
   Refer	mothers	to	the	following	for	dental	services:
   Denti-Cal (Medi-Cal) Program, at 1-800-322-6384
   (beneficiary	services),	if	the	client	is	already	on	
   Medi-Cal. If not, refer to Healthy Families Program
   (1-800-880-5305 for an application form) or to
   the	county	social	services	agency	for	eligibility	
   For more resources, refer to the local Child Health
   and	Disability	Prevention	Program	(CHDP)	and/or	
   your local dental society.

   •	 For	additional	publications,	other	patient	          	 Georgetown	University
      educational materials (many of them are                P.O.Box 571272
      available	free	of	charge),	directories,	and	           Washington, DC 20057-1272
      resource guides, contact the:                          Tel: 202-784-9771
                                                             Fax: 202-784-9777
      National Oral Health Information Clearinghouse         Web link:
      1 NOHIC Way, Bethesda, MD 20892-3500                   Toolbox/professionals.html
      Tel: 301-402-7364
      Web	link:                •	 An	informative	book	available	to	download	is:
      OrderPublications/                                     “Bright Futures in Practice: Oral Health–Pocket
      One of its publications is: “A Healthy Mouth           Guide”	–	This	resource	is	designed	to	help	health	
      for Your Baby” brochure. This easy-to-read             professionals implement specific oral health
      brochure is for parents with infants or toddlers.      guidelines during pregnancy and postpartum,
      It highlights the importance of using fluoride to      infancy, early childhood, middle childhood, and
      protect teeth, cleaning your baby’s teeth, and         adolescence, and it addresses risk assessment
      preventing	baby	bottle	tooth	decay.	Publication	       for dental caries, periodontal disease,
      numbers: NR-31(English) and NR-26(Spanish).            malocclusion,	and	injury..		A	PDF	file	version	
                                                             can be found at:
   •	 National	Maternal	and	Child	Oral	Health	               oralhealth/about.html.
      Resource Center

   HE – 84                                                             Steps to Take — 2009 • Health Education
       y Mo
H ealth Baby
      thy            Oral Health During Infancy (cont.)

   Remisiones                                                   para proteger los dientes, limpiar los dientes del
   Recuerde:	¡Muchos	niños	que	son	elegibles	para	              bebé	y	prevenir	la	caries	de	biberón.	Número	de	
   un seguro dental no lo tienen! Es posible que                publicación:	NR-26	(español)	y	NR-31	(inglés)
   otros	niños	que	están	inscritos	actualmente	en	            •	 Centro	Nacional	Materno	Infantil	de	Recursos	para	
   Medi-Cal o Healthy Families no sepan que ya tienen            la Salud Bucal (National Maternal and Child Oral
   cobertura	dental,	y	necesitarán	una	remisión	a	un	            Health Resource Center)
   consultorio	o	clínica	dental	que	acepte	este	seguro.
                                                              	 Universidad	de	Georgetown
   Remita	a	las	madres	a	los	siguientes	servicios	              P.O.Box 571272
   dentales:                                                    Washington, DC 20057-1272
   Si	el	cliente	ya	está	inscrito	en	Medi-Cal,	remítala	al	     Tel: 202-784-9771
   programa Denti-Cal (Medi-Cal), al 1-800-322-6384             Fax: 202-784-9777
   (servicios	para	beneficiarios).	Si	no,	remítala	al	          Sitio Web:
   programa Healthy Families (1-800-880-5305 para               Toolbox/professionals.html
   obtener un formulario de solicitud) o a la agencia         •	 Un	libro	informativo	que	se	puede	descargar	en	
   de	servicios	sociales	del	condado	para	determinar	            línea	es:
   su elegibilidad.
                                                                “Bright Futures in Practice: Oral Health–Pocket
   Para	acceder	a	más	recursos,	remita	al	cliente	
                                                                Guide”	(Un	futuro	brillante	para	su	práctica:	salud	
   al	Programa	de	Salud	Infantil	y	Prevención	de	
                                                                bucal	–	Guía	de	bolsillo)	–	Este	recurso	está	
   Discapacidad (CHDP, por sus siglas en inglés) y/o a
                                                                diseñado	para	ayudar	a	los	profesionales	médicos	
   su sociedad dental local.
                                                                con	pautas	específicas	de	salud	bucal	durante	
                                                                el	embarazo	y	el	posparto,	la	infancia,	la	niñez	
   Recursos                                                     temprana, la escuela media y la adolescencia, y
                                                                describe	la	evaluación	de	riesgo	de	caries	dentales,	
   •	 Para	obtener	publicaciones	adicionales,	otros	
                                                                enfermedades periodontales, maloclusión y
      materiales	educativos	(muchos	disponibles	sin	
                                                                lesiones.	Puede	descargar	una	versión	en	formato	
      cargo),	directorios	y	guías	de	recursos,	póngase	
                                                                PDF en:
      en contacto con:
   •	 Banco	de	Datos	Nacional	de	Información	sobre	
      Salud Bucal (National Oral Health Information
      1 NOHIC Way, Bethesda, MD 20892-3500
      Tel: 301-402-7364
      Sitio	Web:
      Una de sus publicaciones es:
      “Una boca sana para su bebé” (A Healthy
      Mouth for Your Baby) – Éste es un folleto
      fácil	de	leer	para	padres	con	bebés	o	niños	
      pequeños.	Realza	la	importancia	de	usar	flúor	

   Steps to Take — 2009 • Health Education                                                                   HE– 85
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HE – 86                  Steps to Take — 2009 • Health Education
       y Mo
  ealth Baby          Safe Exercises and Lifting During
Heal                  Pregnancy and Postpartum

                                                          •	 Clients	who	have	not	exercised	much	should	
                               se can give a pre             limit a new exercise program to 15 to 20
  As the body  changes, exerci              on, and
                          l-being, relaxati                  minutes per day.
  woma   n a sense of wel                        ken
                                ns need to be ta
   comfort. Bu t certain cautio                           •	 For	more	advanced	exercise,	discuss	Keep Safe
   during this tim                                           When You Exercise.

                                                          Safe lifting
                                                          Practice safe lifting techniques with clients to help
                                                          them	prevent	back	strain	or	injury.	As	pregnancy	
                                                          progresses and the baby weighs more, safe
                                                          lifting techniques will become more important in
   Help your client
                                                          preventing	strain	or	injury.
   •	 understand	the	importance	of	prenatal	
                                                          1.   Back should be straight, knees bent, feet apart,
      exercises (including Kegels). See the handout
                                                               one slightly ahead of the other.
      Exercises when you are pregnant.
                                                          2.	 Brace	the	pelvic	floor	muscles	and	abdominal	
   •	 know	how	to	exercise	and	lift	safely	and	
                                                              muscles (tense stomach area and bottom).
                                                          3. Keep objects/children that are being lifted
   Steps to Take                                             close to the body.
                                                          4. Use leg muscles to do the work, rather than
                                                             back or abdomen.
   •	 Review	with	each	client	how	to	do	Kegel	and	
                                                          Review	this	technique	with	clients,	especially	
      other	recommended	pelvic	exercises.	See	the	
                                                          during	the	third	trimester.	Clients	who	have	
      handout Exercises When You are Pregnant.
                                                          toddlers,	do	housekeeping	or	have	jobs	that	
   •	 Encourage	clients	who	have	been	exercising	         require	lifting	are	of	special	concern.	Review	this	
      before pregnancy to keep exercising                 technique	at	every	visit	for	clients	who	lift	often.
      moderately. Hard exercise is acceptable up to
      30	minutes	per	day.	Review	the	handout	Stay
      Active When You are Pregnant: What You
      Should and Should Not Do with the client.

   Steps to Take — 2009 • Health Education                                                                 HE– 87
       y Mo
H ealth Baby
      thy           Safe Exercise and Lifting (cont.)

                                                       Some clients should not
   Pamphlets from the American College of              exercise during pregnancy
   Gynecologists	and	Obstetricians,	409	12th	Street	   Any client with the following conditions
   NW, Washington, DC 20024-2188                       should not exercise during pregnancy:
  "Exercise During Pregnancy and the Postpartum
                                                       •	 pregnancy-induced	hypertension
   Period",	ACOG	Technical	Bulletin	Number	189,	
   Feb. 1994                                           •	 preterm	rupture	of	membranes
  "Exercise	and	Fitness:	A	Guide	for	Women",	1992      •	 preterm	labor	during	a	prior	or	current	
  "Positive	Pregnancy	Fitness",	Sylvia	Klein	Olkin,	
   Avery	Publishing	Group,	NY,	1987                    •	 incompetent	cervix/cerclage
                                                       •	 persistent	2nd	or	3rd	trimester	
                                                       •	 intrauterine	growth	retardation

   HE – 88                                                      Steps to Take — 2009 • Health Education
       y Mo
H ealth Baby
      thy           Exercises When You are Pregnant

   Kegel Exercises                                   Pelvic tilt
   Before the 4th month:                             Before the 4th month:
   •	 Lie	on	your	back.	Put	a	pillow	under	your	     •	 Lie	on	your	back	on	the	floor.
      head and neck.
                                                     •	 Press	the	small	of	your	back	against	the	
   •	 Let	your	arms	lie	next	to	your	sides.             floor while you let out your breath.
   •	 Bend	your	knees.	Put	feet	about	12	inches	     •	 Relax	your	spine	while	you	take	in	a	deep	
      apart. Keep your soles flat on the floor.         breath.
   •	 Squeeze	tight	the	muscles	around	your	         •	 Repeat	this	6	or	7	times.
      vagina	and	anus.	Hold	these	muscles	tight	
      for about 5–10 seconds. You can find these     After the 4th month:
      muscles when you pee (urinate). Stop the       •	 Stand	against	a	wall.	
      flow for a second. Those are the muscles you
      want to tighten and relax.                     •	 Press	your	back	next	
                                                        to the wall.
   •	 Slowly	let	your	muscles	relax.
                                                     •	 Do	not	lay	on	
   After the 4th month:                                 your back. Your
                                                        growing uterus
   •	 Stand	or	sit	to	do	Kegels.	
                                                        can put too
   •	 Do	Kegels	up	to	25	times	in	a	row,	5	or	6	        much weight
      times each day.                                   on the
                                                        large blood
   •	 Do	not	lay	on	your	back.	Your	growing	
                                                        vessels	in	
      uterus can put too much weight on the
                                                        your back.
      large	blood	vessels	in	your	back.	You	and	
      your baby may not get enough oxygen if
      you lay on your back.

   Steps to Take — 2009 • Health Education                                                           HE– 89
       y Mo
H ealth Baby
      thy           Exercises When You are Pregnant

   Angry cat

   Do this to take the weight of your
   uterus off your spine.
    •	 Get	on	your	hands	and	knees.	Make	your	
       back flat.
    •	 Keep	your	head	straight	and	neck	straight.
    •	 Arch	up	your	back	like	an	angry	cat.	Pull	in	
       your tummy muscles.
    •	 Then	relax.	Make	your	back	flat	again.
    •	 Do	this	6	or	7	times	each	day.	You	can	also	
       do it when you are in labor.

   HE – 90                                             Steps to Take — 2009 • Health Education
       y Mo
H ealth Baby
      thy           Ejercicios Cuando está Embarazada

   Ejercicios kegel                                     Inclinación de la pelvis
   Antes del cuarto mes:                                Antes del cuarto mes:
   •	 Acuéstese	de	espalda.	Ponga	una	                  •	 Acuéstese	de	espalda	en	el	piso.
      almohada debajo de su cabeza y cuello.
                                                        •	 Ponga	presión	en	la	parte	baja	de	su	
   •	 Deje	que	sus	brazos	descansen	a	sus	lados.           espalda sobre el piso mientras exhala.
   •	 Doble	las	rodillas.	Ponga	los	pies	a	una	         •	 Relaje	su	espina	dorsal	mientras	respira	
      distancia de 12 pulgadas. Mantenga las               profundo.
      plantas de los pies sobre el piso.
                                                        •	 Repita	ésto	de	6	a	7	veces.
   •	 Apriete	fuerte	el	músculo	alrededor	de	la	
      vagina	y	ano.	Mantenga	estos	                     Después del cuarto mes:
      músculos apretados de 5–10 minutos.               •	 Párese	contra	la	pared.
      Puede encontar este músculo cuando
      orina. Deténgase un segundo cuando orine.         •	 Presione	la	espalda	contra	la	pared.
      Estos son los músculos que quiere apretar y       •	 No	se	acueste	de	
      relajar.                                             espalda. La matriz
   •	 Lentamente	deje	que	sus	músculos	se	                 está	creciendo	
      relajen.                                             y puede poner
                                                           mucho peso
   Después del cuarto mes:                                 en	las	venas	y	
                                                           arterias de la
   •	 Párese	o	siéntese	para	hacer	los	Kegels.	
   •	 Haga	25	Kegels	seguidos,	de	5	a	6	veces	por	
   •	 No	se	acueste	de	espalda.	La	matriz	está	
      creciendo y puede poner mucho peso en
      las	venas	y	arterias	de	la	espalda.	Usted	y	su	
      bebé	tal	vez	no	reciban	bastante	oxígeno	si	
      se acuesta de esplada.

   Steps to Take — 2009 • Health Education                                                             HE– 91
       y Mo
H ealth Baby
      thy           Ejercicios Cuando está Embarazada

   El gato bravo

   Haga ésto para quitar el peso de
   la matriz de la espina dorsal.
    •	 Pónganse	de	rodillas	con	las	manos	sobre	
       el piso. Haga que la espalda éste plana.
    •	 Mantenga	la	cabeza	y	cuello	en	linea	recta.
    •	 Arquee	la	espalda	como	un	gato	enojado.	
       Meta los músculos del abdomen.
    •	 Después	relájese.	Regrese	la	espalda	a	la	
       posición	plana	de	nuevo.
    •	 Haga	ésto	de	6	a	7	veces	por	día.	También	
       lo puede hacer cuando tenga los dolores
       de parto.

   HE – 92                                           Steps to Take — 2009 • Health Education
                                                                                                       y Mo
Stay Active When You are Pregnant                                                               H ealth Baby

What you should and should not do

Here are good things to do when                      When you are pregnant, you
you’re pregnant:                                     should NOT:
•	 Walk.                                             •	 Jog	more	than	two	miles	per	day.
•	 Swim.	The	water	should	not	be	too	hot	or	         •	 Sprint.
   too cold.
                                                     •	 Play	contact	sports	like	football	or	
•	 Bicycle.	You	may	want	to	use	a	stationery	           karate.
   bike. It will protect you from falls that can
                                                     •	 Do	exercises	not	made	for	pregnant	women.
   happen as your uterus gets bigger.
                                                     •	 Ride	horseback.
•	 Do	Kegels.
•	 Go	to	exercise	classes	especially	for	
                                                     It can also be dangerous to:
   pregnant women.
                                                     •	 Water	ski,	dive,	surf	or	go	scuba	diving.
•	 Try	to	relax.	You	can	sit	in	a	chair	or	lay	on	
   your side. Breathe in through your nose.          •	 Ski	downhill.
   Breathe out through your mouth slowly.                                  m
                                                     •	 Bicycle	on	wet	pave	 ent	or	when	there	are	
                                                        other dangers.
If you were used to being active                     •	 Skate.	
before you were pregnant,
you may be able to:
•	 Jog	up	to	two	miles	
   per day.
                                                                  Always talk with your doctor before
•	 Swim.                                                          you start an exercise program. It's a
•	 Do	aerobics	for		 renatal	
                   p                                              good idea to exercise at least three
   or postpartum women.                                           times a week.

•	 Lift	weights.	Do	not	
   hold your breath while
   you bear down.
•	 Ski	cross-country	below	
   10,000 feet.
•	 Hike.

Steps to Take — 2009 • Health Education                                                                HE– 93
       y Mo
H ealth Baby
      thy            Ejercicios Cuando está Embarazada

   Hay actividades muy buenas que                          Cuando está embarazada no debe:
   puede hacer durante su embarazo:                        •	 Correr	a	paso	lento	más	de	2	millas	por	día.
    •	 Caminar.                                            •	 Correr	velozmente
    •	 Nadar.	El	agua	no	debe	ser	muy	caliente	o	          •	 Jugar	deportes	de	contacto	como	fútbol	
       muy	fría.                                              americano o el karate.
    •	 Andar	en	bicicleta.	Tal	vez	quiera	usar	una	        •	 Hacer	ejercicios	que	no	son	
                                     t j
       bicicleta	estacionaria.	La	pro	 e	 erá	de	caídas	      recomendados para las mujeres
       que le pueden pasar a medida que la matriz             embarazadas.
       este creciendo.
                                                           •	 Montar	en	caballo.
    •	 Hacer	ejercicios	como	los	Kegels.
    •	 Asistir	a	clases	especiales	de	ejercicios	para	     También puede ser peligroso:
       mujeres embarazadas.
                                                           •	 Esquiar	en	agua,	echar	clavados,	
    •	 Tratar	de	relajarse.	Siéntese	en	una	silla	            usar la tabla hawaiana o bucear.
       o acuéstese de lado. Inhale por la nariz.
                                                           •	 Esquiar	de	bajada	en	la	nieve.
       Y exhale por la boca lentamente.
                                                           •	 Andar	en	bicicleta	en	el	pavimento	mojado	
   Si usted era muy activa antes de                           o cuando hay otros peligros.
   estar embarazada, quizás pueda:                         •	 Patinar.
    •	 Correr	a	paso	lento	
       hasta dos millas por
                                                                 Siempre debe de hablar con su médico
                                                                 antes de empezar a hacer ejercicios.
    •	 Nadar.                                                    Es buena idea hacer ejercicios por lo
                                                                 menos 3 veces a la semana.
    •	 Hacer	ejer	 icios	
       aeróbicos para
       mujeres embarazadas
       o mujeres en
       el	período	del	post-
    •	 Levantar	pesas.	No	
       detenga la respiración
       cuando haga esfuerzo.
    •	 Esquiar	a	lo	plano	en	
       la	nieve.
    •	 Caminar	largas	

   HE – 94                                                               Steps to Take — 2009 • Health Education
       y Mo
H ealth Baby
      thy             Keep Safe When You Exercise

   When you exercise,                        Follow these safety tips:
                       ot	be	higher	
                      e	should	n             •	 Don’t	do	anything	that	could	hurt	your	
    •	 Your	heart	rat
                         a minute.              abdomen. Stay away from karate or other
        than 140 beats
                                                contact sports.
                     et	tired,	stop.	
     •	 When	you	g
                                      .      •	 Don’t	exercise	in	hot	weather.	Wear	light	
                        ounce,	or	jump
      •	 Do	not	jerk,	b                         clothing.
                                             •	 Don’t	lie	on	your	back	after	you	are	4	
                                                months pregnant.
   Stop your exercises if you have
                                             •	 Stay	away	from	activities	that	could	lead	
   these warning signs!
                                                to falls.
   Call your health-care provider right      •	 Don’t	do	full	sit-ups,	or	leg	lifts	with	both	
   away if you:                                 legs.
   •	 Feel	pain	when	you	exercise.
                                             •	 Bend	your	knees	when	you	touch	your	toes.
   •	 Feel	dizzy.
                                             Get the food and water you need:
   •	 Are	short	of	breath.
                                             •	 Drink	plenty	of	water.	You	will	need	at	least	
   •	 Think	you	might	faint.                    8–12 glasses of water a day when you are
  There are other warning signs to           •	 Drink	extra	water	when	you	exercise.
  watch for.
                                             •	 Eat	plenty	of	healthy	food.	Eat	a	healthy	
   Call right away                              snack after you exercise.
   if you:
   •	 Bleed	from	your	                       After you give birth:
      vagina.                                •	 Talk	with	your	doctor	about	when	to	start	to	
                                                exercise again.
   •	 Have	a	rapid	
      heartbeat when                         •	 Go	back	to	your	exercise	program	slowly,	as	
      you rest.                                 you feel you can.
   •	 Have	a	hard	                           •	 Start	out	easy	in	the	first	few	days	after	your	
      time walking.                             baby is born.
   •	 Have	                                  •	 Exercise	longer	and	a	little	harder	day	by	
      contractions.                             day.

   Steps to Take — 2009 • Health Education                                                       HE– 95
       y Mo
H ealth Baby
      thy            Haga Ejercicios Sin Hacerse Daño

    Cuando haga                                   Para su seguridad:
    recuerde que          ser	más	alto	
                       díaco	no	debe	                                            m
                                                  •	 No	haga	nada	que	pueda	lasti	 ar	su	
      •	 Su	ritmo	car
                          por minuto.                abdomen. No haga karate u otros deportes
          de 140 latidos                             de contacto.
                         nse,	pare.
       •	 Cuando	se	ca                            •	 No	haga	ejercicios	cuando	el	clima	está	
                                      scos,	no	
                        vimientos	bru
        •	 No	haga	mo                                caliente. Use ropa ligera.
           saltos ni brinq                        •	 No	se	acueste	de	espalda	después	del	
                                                     cuarto mes de embarazo.
                                                  •	 Evite	actividades	que	puedan	causarle	
   ¡Deje de hacer ejercicios si
   tiene estas señales de peligro!
                                                  •	 No	haga	sentaderas,	ni	eleve	las	dos	piernas	
   Llame a su médico de inmediato si:                al mismo tiempo.
   •	 Siente	dolor	cuando	hace	ejercicios.
                                                  •	 Doble	sus	rodillas	cuando	tenga	que	tocarse	
   •	 Se	siente	mareada.                             los pies.
   •	 Le	cuesta	trabajo	respirar.                 Obtenga la comida y agua
   •	 Cree	que	se	va	a	desmayar.                  que necesita:
                                                  •	 Tome	bastante	agua.	Debe	tomar	por	lo	
   Hay otras señales de peligro que                  menos	de	8	a	12	vasos	de	agua	diarios	
                                                     cuando	está	embarazada.
   debe observar.
                                                  •	 Tome	más	agua	cuando	hace	
   Llame de inmediato si:                            ejercicios.
   •	 Le	sale	sangra	
      de	la	vagina.                               •	 Coma	bastante	comida	saludable.	Cómase	
                                                     un bocadillo después de hacer ejercicios.
   •	 El	corazón	le	
      late                                        Después de dar a luz:
      muy	rápido	                                 •	 Hable	con	su	médico	y	pregúntele	cuando	
      cuando	está	                                   puede empezar a hacer
      descansando.                                   ejercicios.
   •	 Tiene	                                      •	 Vuelva	a	sus	ejercicios	de	rutina	poco	a	poco,	
      dificultad                                     a medida que sienta que puede.
      al caminar.
                                                  •	 Empieze	con	ejercicios	sencillos	al	principio	
   •	 Tiene	                                         después del parto.
                                                  •	 Haga	más	ejercicios	y	de	más	
                                                     dificultad	cada	día	que	pasa.	

   HE – 96                                                     Steps to Take — 2009 • Health Education
       y Mo
H ealth Baby
      thy          Tobacco Use

                  smoking is safe                         Health risks can be lessened if a woman quits
     No amount of                  r cutting
                    en. Quitting o                        smoking by the fourth month of pregnancy.
     p regnant wom
                    priority.                             Even	after	the	fourth	month,	encourage	clients	
     down is a high
                                                          to reduce the number of cigarettes smoked per
                                                          day or to quit. Any decrease is beneficial to the
                                                          health of a pregnant woman and her fetus.
   Help your client:
   •	 identify	risks	associated	with	the	use	of	tobacco
   •	 consider	reducing,	quitting,	or	seeking	
                                                              Stages of Quitting
                                                              Smokers who quit typically go through
      treatment if she smokes
                                                              the following six stages in the process of
                                                              quitting.	It	is	common	to	try	to	quit	several	
   Background                                                 times before being successful.
   Approximately 20 to 25% of women in the U.S.
   smoke cigarettes during pregnancy. Yet smoking             1.   No Interest: not considering quitting
   during pregnancy is a major contributor for the                 or	motivated	to	quit.
   following problems.
                                                              2. Somewhat Interested:
   •	 Pregnancy complications, such as serious                   uncomfortable with smoking but not
      problems with the placenta, bleeding from the              seriously considering quitting.
      uterus and a tendency for later miscarriages            3. Preparation: intends to quit in the
      (after 12 weeks). The risk increases the more              near future; has made small changes
      women smoke and the longer they smoke.                     in	behavior.
   •	 Preterm births,	even	if	the	woman	smokes	less	          4. Action: makes an effort to quit; has
      than one pack a day. Pregnant women aged 35                made a firm decision to quit; needs
      and	older	who	smoke	are	at	even	higher	risk.               support techniques to cope with
   •	 Increased risk of Sudden Infant Death                      urges to smoke.
      Syndrome (SIDS).                                        5. Maintenance:	able	to	overcome	the	
   •	 Intrauterine Growth Retardation (IUGR)—                    temptation	to	smoke;	developing	a	
      the fetus is shorter, underweight, and with                nonsmoking	habit,	but	still	vulnerable	
      smaller head and chest circumferences.                     to the urge to smoke.
      Between 21 and 39% of these cases are low               6. Relapse: prompted to smoke
      birth-weight births. Increased age and amount              by stress; disappointed and less
      smoked heightens the risk.                                 confident that quitting is possible.
   Note: Some pregnant clients want an early birth or
   small	baby	due	to	fear	of	labor	and	delivery.	They	
   may use this as a reason to keep smoking. Babies
   born under these conditions are more likely to
   have	severe	and	lasting	disabilities	and	health	
   problems (see Preterm Labor).

   Steps to Take — 2009 • Health Education                                                                 HE– 97
       y Mo
H ealth Baby
      thy           Tobacco Use (cont.)

                                                                                                   nts, see
   Steps to Take                                                                   counseling clie
                                                                For more help on
                                                                                llowing page.
   Clients who do not smoke                                    "4-As" on the fo
   Praise her healthy lifestyle and ask if she
   knows the dangers of smoking for her and her
   baby. Encourage her not to begin while she is           Teens
   pregnant—or	ever!	                                      Teens often smoke with friends and may need
                                                           extra support to cut down or quit smoking. Appeal
   Clients who do smoke                                    to their interest in their image. Drawbacks of
   Ask if she can explain the connection between           smoking include:
   smoking and health risks to her and her baby. Build
   on her understanding as you explain the health          •	 odors	in	hair,	clothes
   risks of smoking.
                                                           •	 fingers	and	teeth	turn	yellow	or	brown
   Use the following chart to see how the client feels
                                                           •	 bad	breath	and	taste	when	kissing
   about quitting smoking and to check her progress
   and	give	her	a	framework	to	measure	her	success.        •	 dry	skin	with	premature	wrinkling
                                                           •	 burns	on	clothing,	upholstery	and	carpets	
   Ready to cut down
   Suggest to clients who are not ready to quit but        You can also help a teen calculate the amount
   who do want to cut down that they:                      of money she spends each week or month on
                                                           cigarettes and what other things she could buy
   •	 smoke	less	often                                     with that money (music CDs or tapes, concert or
                                                           movie	tickets,	maternity	outfits,	baby	clothes,	etc).
   •	 inhale	less	deeply
   •	 use	low	tar,	low	nicotine	cigarettes                 Additional tips for quitting
                                                           You	can	help	women	move	through	the	stages	of	
   •	 smoke	only	half	of	each	cigarette
                                                           quitting with the following help:
   •	 switch	brands
                                                           •	 Review	with	her	the	health	risks	for	her	and	her	
   Not ready to quit or cut down
   Habits	can	be	very	hard	to	change,	and	nicotine	        •	 Remind	her	that	her	family	needs	a	healthy	
   is	especially	addictive	and	hard	to	quit.	The	client	      mother.
   may	have	other	stresses	in	her	life	and	may	not	feel	
                                                           •	 Increase	her	awareness	of	the	problems	with	
   she	can	handle	changing	her	smoking	behavior.	
                                                              smoking and benefits of not smoking.
   Show her your understanding.
                                                           •	 Give	her	quit	tips.
   At	the	same	time,	share	the	negative	effects	of	
   tobacco for her and the baby. Suggest that she          •	 Support	her	when	she	decides	to	quit.
   may be ready to cut down or quit in the future, and
   that it can be discussed at future appointments.        •	 Remind	her	about	how	to	reduce	stress	and	
   Emphasize that any decrease in the number                  urges to smoke.
   of cigarettes smoked per day will be helpful in         •	 Remind	her	to	reward	herself.
   protecting her health and that of her baby.
                                                           •	 Praise	her	for	her	accomplishment.
   HE – 98                                                              Steps to Take — 2009 • Health Education
       y Mo
H ealth Baby
      thy            Tobacco Use (cont.)

   •	 If	she	relapses,	remind	her	that	she	can	quit.               What makes you want to smoke?
   •	 Give	her	some	materials	on	quitting	that	she	             •	 Readiness	to	quit
      can read.                                                    Are you interested in quitting soon?
   •	 Refer	her	to	a	smoking	cessation	program	in	                 Have you tried to quit or thought about
      her community (see Resources).                               quitting?

                                                                •	 Level	of	confidence
   Follow-Up                                                       Do you believe you can quit?
   Follow	up	at	the	next	visit	with	any	client	who	
                                                                   Have you ever quit another habit?
   uses tobacco or who recently quit . Check on
                                                                   Do you know anyone who has successfully
   her smoking (or chewing). If she’s trying to
   quit, ask if it’s okay to call her at home to offer
   encouragement and support. Discuss handouts                  •	 Social	support	system
   How to Quit Tobacco Use and Coping With                         Who can help if you decide to quit?
   Quitting Alcohol/Drugs for helpful things to do to        2. Advise the pregnant woman about health
   quit for good.                                               risks associated with smoking:
   See the Nutrition guideline Tobacco & Substance              •	 Your	smoking	increases	the	chance	of	your	
   Use for information on tobacco use and nutritional              baby being born too soon, being born
   status and suggestions for food intake.                         underweight, being born dead, being born
   If the client is willing, set up an appointment in the          with birth defects, and SIDS.
   next few weeks to check on her progress.                     •	 Smoking	increases	your	chances	of	
                                                                   developing cancer, chronic diseases, heart
   Congratulate clients for any steps taken toward                 attacks.
   reducing	their	tobacco	use,	even	if	it	is	just	setting	      •	 Your	secondhand	smoke	increases	your	
   a quit date or reducing by one cigarette per day.               children’s chances of breathing problems
                                                                   (such as asthma and bronchitis) as well as ear
   4-A’s model for quitting                                        infections and colds.
  The	4-A’s	model	was	developed	by	the	National	             3. Assist	her	in	developing	a	plan	to	quit	
  Cancer Institute to help smokers quit tobacco use.            smoking by helping her to:
  1.   Ask the pregnant woman about her:                        •	 Focus	on	reasons	to	quit.
       •	 Smoking	status                                        •	 Choose	a	method	of	quitting	(such	as	
          When was the last time you smoked?                       stopping all of a sudden or gradually
          How often are you near someone who smokes                cutting down, etc.) and choose a quit date.
          (in the same room, at the same table, etc.)?          •	 Find	ways	to	deal	with	the	urge	to	smoke,	
                                                                   such as deep breathing, drinking water,
       •	 Smoking	history                                          doing relaxation exercises, talking to friends
          How many cigarettes do you smoke a day?                  and family, exercising, eating low-calorie
          Did you smoke before you knew you were                   snacks, or attending a stop smoking class.

       •	 Reasons	for	smoking
          When do you smoke?

   Steps to Take — 2009 • Health Education                                                                   HE– 99
       y Mo
H ealth Baby
      thy           Tobacco Use (cont.)

   4. Arrange	to	follow	up	at	subsequent	visits	
       •	 Chart	her	smoking	status,	noting	her	
          progress,	and	giving	her	support	and	
       •	 Check	on	her	follow-through	with	any	
          referrals	you	have	made.

                                                         California Smokers’ Helpline,	a	free	service	
   For	You	and	Your	Family:	A	Guide	For	Perinatal	
                                                         for people who are ready to quit using tobacco,
   Trainers and Providers by California Department of
                                                         offering telephone counseling, materials and quit
   Health, Tobacco Control Section (1992)
                                                         kits,	and	referral	services.	Operated	by	University	of	
   Provides	counseling	strategies	and	patient	           California San Diego Cancer Center. Call:
   education materials specifically for African
                                                            English: 1-800-7-NO BUTTS
   American, American Indian, Asian and Hispanic/
                                                            Spanish: 1-800-456-6863
   Latina pregnant women who smoke.
                                                            Mandarin and Cantonese: 1-800-400-0866
   Call the Tobacco Education Clearinghouse                 Vietnamese: 1-800-778-8440
   at 1-800-258-9090 ext. 230, or 831-438-4822              Korean: 1-800-556-5564
   ext. 230, or write to P.O. Box 1830, Santa Cruz, CA      Deaf/Hearing Impaired: 1-800-933-4TDD
                                                         American Lung Association,
                                                         1-800-LUNG-USA	(nationwide)
                                                         American Academy of Family Physicians:

   HE – 100                                                           Steps to Take — 2009 • Health Education
       y Mo
H ealth Baby
      thy          Secondhand Tobacco Smoke

                           is the smoke in
    Seco  ndhand smoke              exhaled by
                                                        situations.	All	exposure	should	be	avoided,	if	
                   g cigarette or
    from a burnin                          abies        possible.	Encourage	her	to	avoid	all	smoke,	even	at	
                          t women and b
    a sm  oker. Pregnan             condhand
                                                        occasional	visits	to	friends	or	other	places.
                    exposed to se
     should not be                       exposure
                         o safe level of                Use the “Four A’s” model
     sm  oke. There is n
      to tobacco sm                                     Assist a client in reducing her exposure to
                                                        secondhand smoke:
                                                        •	 Ask	about	her	frequency	of	smoke	exposure,	
   Goal                                                    and where and when she is around smoke.
   Help your client
                                                        •	 Advise	her	to	avoid	all	smoke,	and	discuss	the	
   •	 identify	where	she	may	be	exposed	to	                negative	health	effects	caused	by	secondhand	
      secondhand smoke                                     smoke.
   •	 take	steps	so	she	and	her	family	can	avoid	       •	 Assist	her	in	finding	ways	to	avoid	secondhand	
      secondhand smoke                                     smoke. Suggest direct communication with
   •	 talk	to	family	members/friends	if	they	expose	       smokers, or indirect (such as posting signs or
      her to secondhand smoke                              bringing home pamphlets). She might like
                                                           to	invite	a	supportive	family	member	to	her	
                                                           appointment	to	help	find	ways	to	avoid	smoke.	
   Background                                              See For You and Your Family (listed under
   Secondhand smoke exposure is the third leading          Resources) for suggestions.
   cause	of	preventable	death	in	the	United	States	
   (after smoking and drinking alcohol). Tobacco        •	 Arrange	to	follow	up	on	her	plan	to	reduce	her	
   smoke	contains	over	4,000	chemicals	and	harmful	        exposure to smoke. Congratulate her on plans
   substances; 40 of them are known to cause cancer.       she makes.

   Studies	have	found	that	exposure	to	secondhand	      Follow-Up
   smoke in women is associated with uterine cancer,    At	the	next	visit,	ask	about	her	success	in	avoiding	
   cervical	cancer,	and	respiratory	illnesses.	         secondhand smoke. Track progress in her chart
                                                        and follow up at each appointment with support,
   When a pregnant woman breathes secondhand            suggestions and resources.
   smoke, her baby is likely to weigh less.
   Babies and children suffer many ill effects
                                                        For excellent suggestions on ethnic-specific
   from breathing secondhand smoke, including
                                                        approaches	to	avoiding	secondhand	smoke,	see	
   pneumonia, bronchitis, ear infections, and asthma.
                                                        the manual For You and Your Family listed in
                                                        the	section	on	Tobacco	Use.	Available	from	the	
   Steps to Take                                        Tobacco Education Clearinghouse.

   Look for secondhand smoke exposure
   Clients may be exposed to smoke from cigarettes,                                          a
                                                                               oke increases
   pipes, or cigars at home, at work or in other              Secondhand sm                 S.
                                                                             dying from SID
                                                              baby's risk of

   Steps to Take — 2009 • Health Education                                                             HE– 101
           (Blank page)

HE – 102                  Steps to Take — 2009 • Health Education
       y Mo
H ealth Baby
      thy           You Can Quit Smoking

   Tobacco can harm your
                                                    Need more information?
   unborn baby.
                                                    Call 1-800-7 NO BUTTS!
   •	 Your	baby	could	be	born	too	early	or	too	
                                                    Call this number for classes
   •	 Your	baby	could	have	problems	                near you:
      later on.
   But you can quit smoking. Talk to your health    _____________________________
   care	provider	about	what	can	help.	Do	not	use	
   nicotine gum or patches.

   Here are some ideas
   to help you quit:
   •	 Write	down	the	date	you	will	quit.
   •	 Keep	a	diary	of	when	and	why	you	smoke.
                                                           s I  want to
   •	 Have	a	list	of	other	things	to	do	besides	
      smoking. You could:
                                                                  will be
        – Take a walk.
                                                     So m y baby
        – Take deep breaths.
        – Eat fresh, healthy snacks.
                                                                  it is so
   It can also help to:                                 B ecause
   •	 Write	down	a	list	of	reasons	why	you	want	        expens
                                                                          ent will
      to quit. Tape them up where you will see
      them often.                                        So my
   •	 Focus	on	one	day	at	a	time.                         smell b
                                                                              to go
                                                                    n ’t have
                                                           So I wo
   •	 Ask	a	family	member	or	friend	to	quit	with	
                                                                 o buy c little
                                                           out t
                                                                     have a
                                                            when I
   •	 Think	how	you	will	use	the	money	you	will	
   Remember	that	if	you	quit	or	even	cut	down,	             baby.
   both you and your baby will be healthier.

   Steps to Take — 2009 • Health Education                                             HE– 103
       y Mo
H ealth Baby
      thy           Puede Dejar de Fumar

   El tabaco puede dañar a su bebé
                                                        ¿Necesita más información?
   antes de que nazca.
                                                        Llame al 1-800 7-662-8887.
   •	 Su	bebé	puede	nacer	antes	de	tiempo	o	
      nacer	muy	pequeño.	
                                                         Llame a éste número para
   •	 Su	bebé	puede	tener	problemas	después.	            clases en su área:
   Pero usted puede dejar de fumar. Hable con
   su médico para que le diga qué puede hacer.           _____________________________
   No use el chicle (goma de mascar) o los parches
   de nicotina.

   Para ayudarle a dejar de fumar:
   •	 Escriba	la	fecha	en	que	va	a	dejar	de	fumar.
   •	 Mantenga	un	diario	de	cuándo	y	por	qué	
                                                     Raz ones de
                                                      de fum
   •	 Tenga	una	lista	de	otras	cosas	que	puede	
                                                                     ebé    crezca
      hacer	en	vez	de	fumar.	Puede:
                                                       Para que mi b
      – Salga a caminar.
      – Respirar profundamente.
      –	 Comer	bocadillos	nutritivos.                           es car    ísimo.
                                                                    mi apar
   También puede ayudarse si:
                                                          Para qu
   •	 Escribe	las	razones	por	las	cuales	quiere	
      dejar de fumar. Póngalas en un lugar donde          huela m
      las	pueda	ver	seguido.	

                                                           Par a que no mprar
                                                                    r a co
   •	 Tómelo	un	día	a	la	vez.
                                                           que sali              bebé
   •	 Le	pide	a	un	miembro	de	la	familia	o	amiga	
                                                                     lo s con un
      que deje de fumar con usted.
   •	 Piense	cómo	va	a	gastar	el	dinero	que	                tan chiq
   •	 Recuerde	que	si	deja	de	fumar	o	menora	lo	
      que	fumar,	usted	y	su	bebé	serán	
      personas	más	saludables.

   HE – 104                                                    Steps to Take — 2009 • Health Education
       y Mo
H ealth Baby
      thy            Drug and Alcohol Use

                            l of drug or alc
    There   is no safe leve                        e-    Women	of	reproductive	age	who	have	sexual	
                                  . Many over-th
    use for pre   gnant women                            intercourse	without	contraception	should	avoid	
                                       gs can
                     rescription dru
     counter and p                     ohol use is
                                                         using any drugs or alcohol. While this may not be
                      orn babies. Alc
     also harm unb             ble cause of bir
                                                th       a realistic choice for many women, this can help
      the le ading preventa                              decrease birth defects, low birth weight babies
      defects.                                           and other health problems in babies and children.
                                                         The	good	news	is	that	many	women	who	have	
                                                         been using drugs or alcohol on a long-term basis
   Goal                                                  may want to quit during pregnancy.

   Help your client
   •	 identify	risks	with	use	of	alcohol,	over-the-
      counter (OTC) drugs, and street drugs                  The Risks
                                                             During pregnancy, drugs and alcohol
   •	 consider	reducing,	eliminating,	or	seeking	            cross the placenta to the fetus and can
      treatment for any non-recommended                      cause the following problems:
      substance she uses
                                                             •	 miscarriages	or	physical	abnormalities	
   •	 know	to	tell	all	of	her	health	and	dental	care	
                                                                during the first 8 weeks following
      providers	that	she	is	pregnant

   Background                                                •	 growth	retardation,	premature	birth,	
  A 1992 study of pregnant women in California                  and neurological damage to the
  found that 11.4% had drugs in their bloodstream               infant after the first 8 weeks following
  at	delivery.	Between	4	and	28%	of	pregnant	                   conception
  women in the U.S. may be using drugs and/or                •	 increased	risks	related	to	the	amount	
  alcohol during pregnancy.                                     of drug or alcohol the woman uses,
  Almost all drugs, including tobacco, cross the                and how far along she is in her
  placenta and enter the baby’s blood. This exposure            pregnancy
  can	cause	babies	to	have	physical,	mental	or	              •	 increased	risk	for	medical	
  emotional problems. Although only some babies                 complications, preterm labor and
  will	have	obvious	problems,	no	one	can	predict	               delivery,	and	death	of	the	baby
  which children will be affected.
                                                             •	 increased	risk	of	death	for	babies	
   Drug/alcohol	use	has	many	facets,	involves	the	              before their first birthday, low birth
   whole family, and may be triggered by complex                weight,	central	nervous	system	
   causes	such	as	domestic	violence,	low	self-esteem,	          damage, withdrawal effects, physical
   and extreme stress. Use can be life threatening and          malformations, and other mental
   impair both physical and social aspects of life. It          deficits that show up when they
   can limit the ability to parent.                             are older

   Steps to Take — 2009 • Health Education                                                               HE– 105
       y Mo
H ealth Baby
      thy           Drug and Alcohol Use (cont.)

                                                          •	 Assess	her	nutritional	status	and	see	the	
                                   to effect
                    ost vulnerable                           Nutrition guideline Tobacco and Substance Use
     The fetus is m                        e first
                           l use during th
     from  drug or alcoho                       ot
                                                             for further information.
                               woman may n
      few mon th — when the
                     she is pregnan
      be aware that                                       Addiction
                                                          If a client continues to use substances once she is
                                                          aware of the possible health risks for her and her
   Steps to Take                                          baby, such use can be considered an addiction that
                                                          interferes with her physical, psychological or social
   All clients                                            well-being. Addiction, or chemical dependency, is
                                                          an illness.
   •	 Ask	all	clients	about	their	use	of	drugs	and	
      alcohol as early as possible in their prenatal      •	 When	possible	refer	clients	who	are	addicted	to	
      care.                                                  substance abuse treatment programs. (see the
   •	 Praise	clients	who	use	no	drugs	or	alcohol.	           Psychosocial	Guidelines)	
      Briefly discuss the effects of alcohol or drug      •		 Continue	to	provide	nonjudgmental	support	
      use during pregnancy so the client will not             and education. In-depth counseling is usually
      be tempted to start using in this or a later            not in the scope of perinatal health education,
      pregnancy. Explain possible problems with               however	counseling	guidelines	are	on	the	
      over-the-counter	drugs.	Encourage	her	to	talk	          following page.
      to	her	health	care	provider	before	she	uses	any	
      medicines.                                          •		 Maintain	open	communication	with	the	client	
                                                              about her use of substances, because she may
                                                              be	motivated	to	seek	treatment	later	in	her	
   Occasional users                                           pregnancy or later in her life.
   Counsel clients with alcohol or illegal drug use, or
   occasional use of OTC or prescription drugs.
                                                          Legal medications
   •	 Ask	about	her	understanding	of	how	these	           Over-the-Counter	drugs	that	may	be	harmful	to	a	
      substances can affect her and her babies.           pregnant woman or her fetus include:
   •		 Share	the	possible	effects	on	the	fetus.	          •	 diet	pills
   •	 Help	her	identify	her	“readiness”	to	cut	down	or	   •	 some	laxatives
      quit.                                               •	 pain	medicine
   •		 Provide	practical	steps	to	cut	down	or	quit,	      •	 some	antacids	(indigestion	medicine)
       and	give	support	during	the	process.	(See	the	     •	 aspirin
       handout You can quit using drugs or alcohol.)
                                                          •	 cough	syrup
   •	 Consider	referring	her	to	treatment	programs	       •	 cold	or	allergy	medicines
      in the community, if appropriate.
                                                          •	 vitamins	(other	than	prenatal	vitamins)

   HE – 106                                                               Steps to Take — 2009 • Health Education
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   Prescription	drugs	to	avoid	during	pregnancy	                                                uit at first
                                                                                not ready to q
                                                             A woman who is                           port
                                                                                     ontinue to sup
   •	 tetracycline                                           may b  e ready later. C           tuation and
                                                                                cognize her si
                                                               er efforts to re                         le.
   •	 tranquilizers	(valium,	librium,	xanax)                 h                        h it as she is ab
                                                              take steps to deal wit
   •	 accutane	(for	acne)
   For more information about the effects of specific
   illegal, OTC, or prescription drugs or alcohol, look   4-A’s model
   in the materials listed under Resources.               If she is somewhat interested in quitting or is
                                                          prepared to take action, use an adaptation of this
                                                          model as a guideline for helping her quit (see
   Stages of quitting                                     the Tobacco Use section for more on the Four-A’s
   Use	these	Stages	of	Quitting	to	assess	the	client’s	
   readiness to cut down or quit using drugs and
   alcohol.                                               1. Ask her about her use (current and past), her
                                                             reasons for using, her confidence that she can
   1. No interest: not considering quitting or
                                                             quit, her social support for quitting.
      motivated	to	quit.
                                                           2.	 Advise	her	about	the	health	risks	for	her	and	
   2. Somewhat interested: feels uncomfortable
                                                               her fetus if she uses drugs or alcohol.
      about using drugs or alcohol but is not
      seriously considering quitting.                      3. Assist her in planning how to quit by focusing
                                                              on her reasons to quit, choosing a method to
   3. Preparation: intends to quit in the near
                                                              quit, and finding ways to deal with urges to
      future;	has	made	small	changes	in	behavior.
                                                              use drugs or alcohol.
   4. Action: makes an effort to quit; has made
                                                           4.	 Arrange	follow-up	at	subsequent	visits	by	
      a firm decision to quit; needs support
                                                               discussing	her	progress,	providing	support,	
      techniques to cope with urges to use drugs or
                                                               checking on her follow-through with any
    5. Maintenance:	able	to	overcome	the	
       temptation	to	use	drugs	or	alcohol;	develops	      Follow-Up
       a	non-using	habit,	but	still	vulnerable	to	the	    At	each	visit,	ask	any	client	who	occasionally	uses	
       urge to use drugs or alcohol.                      drugs or alcohol how she is doing in limiting her
    6. Relapse: prompted to use drugs or alcohol by       use. Support any decrease in use.
       stress; disappointed and less confident that       If the client is willing, schedule extra appointments
       quitting is possible.                              to check-in on her progress with quitting or
   If she has no interest in cutting down or quitting,    cutting down her substance use.
   be sure she understands the possible health risks
   to her baby. Ask again at her next appointment.

   Steps to Take — 2009 • Health Education                                                                 HE– 107
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   Discuss a client’s occasional drug or alcohol use       Resources
   with other staff members in a case conference, so       Alcohol, Tobacco, and Other Drugs May
   all	providers	can	support	and	encourage	the	client	     Harm the Unborn.
   to	quit	and	provide	needed	interventions.	All	staff	    Order from:
   should be aware of goals the client sets so they        National Clearinghouse for Alcohol and Drug
   can	give	support	and	encouragement.	All	staff	          Information
   should	provide	the	same	information	about	risks	        Dept. of Health and Human Resources.
   of	using	substances	(such	as,	there	is	no	safe	level	   1-800-729-6686
   of alcohol intake).
                                                           North Coast Regional Access System and March of
                                                           Dimes Position Statement on Maternal Substance
                                                           Abuse, February 1995.
       Alcoholics Anonymous: fill-in the local             415-476-3868
       phone number from the white pages of
       the telephone directory:
        Local county or health department
        substance	abuse	services:	fill-in	the	local	
        phone number from your telephone

   HE – 108                                                            Steps to Take — 2009 • Health Education
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       Counseling Guidelines

          Note:			Training	on	interviewing	and	         •	 Never	predict	the	outcome	of	a	
          counseling skills is recommended for staff       particular pregnancy, because a
          who work with pregnant women who use             mother	who	uses	may	have	a	healthy	
          drugs or alcohol. See Resources for ideas        baby, and quitting drugs or alcohol
          on further background reading or training        won’t guarantee a healthy baby.
                                                        •	 Show	personal	concern	and	interest;	
          To	effectively	counsel	a	woman	who	uses	         this	is	as	important	as	providing	
          drugs or alcohol while pregnant, do the          information or counseling.
                                                        •	 Be	sensitive	to	communication	styles	
          •	 Focus	on	strengths,	such	as	goals	she’s	      of different groups.
             achieved,	habits	she	has	broken,	her	      •	 Help	clients	understand	and	
             interest	in	improving	her	health.             acknowledge	their	own	risk	behavior.	
          •	 Be	aware	that	women	of	all		 thnic	and	
                                        e                  Acknowledge addiction as an illness.
             socioeconomic backgrounds may not          •	 Recommend	treatment	if	a	client	
             be using drugs and alcohol.                   continues to use drugs after she’s
          •	 Be	aware	that	women	of	all		 thnic	and	
                                        e                  aware of the danger to her fetus
             socioeconomic backgrounds may be              (availability	of	programs	for	women,	
             using drugs and alcohol.                      especially pregnant women, may be
                                                           limited or nonexistent). Recommend
          •	 Keep	messages	clear,	simple,	and	             she get professional help for root
             realistic.	Avoid	humor.	Don’t	                causes of use, such as depression, lack
             exaggerate or increase her fear or            of	money,	violence	in	her	home,	etc.
                                                        •	 Be	sensitive	to	legal	and	economic	
          •	 Encourage	clients	to	believe	they	have	       implications a client may face.
             control	over	these	risk		 actors.
                                                        •	 Be	prepared	to	assist	clients	
          •	 Emphasize	the	positive:                       with special parenting help, or referrals
            –	 stopping	now	will	give	her	a		 etter	       to	services	for	babies	exposed	to	
               chance for a healthy baby                   drugs/alcohol in utero.
            – her concern for her baby will help her
               be a good mother
            – she will feel better when not using
               drugs or alcohol and so will her baby

   Steps to Take — 2009 • Health Education                                                             HE– 109
           (Blank page)

HE – 110                  Steps to Take — 2009 • Health Education
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      thy           You Can Quit Using Drugs or Alcohol

   Drugs and alcohol can hurt your
                                                          For more information, or for
   unborn baby.
   There are things you can do to quit or cut down        help near you, call toll-free
   your use of drugs or alcohol.                          1-800-729-6686.
   For a day or two, write down each time you use
   alcohol or drugs. Ask yourself what caused you
                                                          There are drug and alcohol
   to do so. (Maybe you were worried or scared. Or        treatment agencies in your
   maybe you were with certain friends.)                  area.

   Get help if you:
   •	 Feel	sad	or	depressed.	
   •	 Are	worried	about	money.
                                                                    ings   I like
   •	 Face	violence	or	other	problems.                  Hea lthy Th
                                                        to Do:
                                                                         h  e
   It can also help to:                                          round t
                                                          Walk a
   •	 Decide	what	date	you	will	quit.
   •	 Make	a	list	of	healthy	things	you	like	to	do.
                                                                      the Y.
       – Tape it where you can see it often.                S wim at
       – Look at this list if you get the urge to use
                                                                     y aunt
                                                             Visit m
         drugs or alcohol.
   •	 Ask	a	friend	or	family	member	to	quit	with	you.
                                                                         d lunch
   •	 Join	a	self-help	group	to	get	the	
                                                              Ea t a goo
      support you need.
   •	 Remember,	you	only	need	to	get	through	one	
                                                               G o to a m
      day at a time.

   Steps to Take — 2009 • Health Education                                                HE– 111
       y Mo
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                   Usted Puede Dejar do Usar Drogas o Alcohol

   Las drogas y el alcohol pueden
                                                         Para más información, o para
   dañar a su bebé antes de nacer.
   Hay cosas que puede hacer para dejar de usar o        ayuda en su localidad, llame
   disminuir el uso de drogas o alcohol.                 sin cobrar al 1-800-729-6686.
   Por	un	día	o	dos,	apunte	cada	vez	que	usa	            Hay agencias de tratamiento
   alcohol o drogas. Pregúntese por qué lo hizo.
                                                         para la adicción a las drogas y
   (Quizás	estaba	preocupada	o	asustada.	O	
   quizás	estaba	con	ciertas	amistades.)	                alcohol en su área.

   Obtenga ayuda si:
   •	 Se	siente	triste	o	deprimida.
   •	 Está	preocupada	por	dinero.

                                                                     ue me
                                                            sanas q
   •	 Tiene	que	soportar	una	situación	
      violenta	u	otros	problemas.                    Cosa
                                                      g usta ha
   También ayuda que:                                                      por mi
                                                                 c aminar
   •	 Decida	en	qué	fecha	va	a	dejar	de	usar	las	       Salir a
      drogas o el alcohol.                               vecinda
                                                              al gimn
   •	 Haga	una	lista	de	cosas	saludables	que	le	
      guasta hacer.                                        Ir
                                                                     a mi tía
      –	 	 óngala	en	donde	la	pueda	ver	seguido.
      – Mire la lista si siente el deseo de usar            Visitar
         drogas o alcohol.
   •	 Pídale	a	una	amiga	o	miembro	de	la	familia	
                                                            Salir a
      que deje de usar drogas o
      alcohol con usted.
   •	 Asista	a	un	grupo	de	ayuda	para	recibir	la	
                                                             Ir al ci
      ayuda que necesita.
   •	 Recuerde,	solamente	necesita	vivir	un	día	a	
      la	vez.

   HE – 112                                                     Steps to Take — 2009 • Health Education
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      thy           Family Planning Choices
                             e cornerstone
   Inform   ed consent is th         ordinate
                      education. Co                            breastfeeding) and any new methods she does
    fa mily planning                obtain
                     nning staff to                            not know about that might be appropriate for
    with family pla                  tal clients
                      nt from prena                            her.
     in formed conse                         g
                            family plannin
     for thei r postpartum                                  •	 Some clients may have become pregnant
      methods, when                                            through donor insemination, perhaps
                                                               because their partner is also a woman. Such
                                                               clients may not need birth control education,
                                                               but want to discuss plans for future children.
   Help your client:                                           Use a nonjudgmental and non-assuming
                                                               interview	style.	Ask	open-ended	questions	to	
   •	 state	her	plan	for	future	childbearing
                                                               find	out	the	most	appropriate	way	to	provide	
   •	 describe	any	contraceptive	methods	she	would	            family planning.
      consider using if applicable
                                                            Steps to Take
   Background                                               If the client is unsure of plans for children in the
   Women	have	improved	opportunities	to	decide	             future, or of what birth control methods to use,
   when	and	if	to	have	children.	Family	planning	           explain the benefits of family planning and why
   education empowers women to choose the timing            it is discussed during prenatal care appointments.
   and	number	of	any	children	they	may	have.
                                                            •	 Adequate	spacing	of	children	helps	parents	
  As	new	birth	control	methods	become	available,	              cope with the demands of childrearing
  there are more options to present to clients.                and	with	finances.	It	helps	provide	physical,	
  Hopefully,	this	will	improve	client	satisfaction	with,	      emotional and intellectual nurturing for each
  and	effective	use,	of	birth	control	methods.                 child.
                                                            •	 For	medical	reasons,	a	woman	should	wait	at	
   Items to consider                                           least	15	months	after	having	a	baby	before	
   In each client’s third trimester, ask about her plans       becoming pregnant again.
   for	having	more	children	in	the	future.
                                                            •	 Effective	birth	control	helps	sexually	active	
   •	 Some clients will be unsure of their plans               women	who	want	no	more	children	achieve	
      or of what might be appropriate for them.                their life plans.
      Spend adequate time to help her make these
      decisions. Ask if she wants her partner or other
      support people to join this discussion.                   Consult your on-site family planning
                                                                guidelines for additional help on
   •	 Some clients will know which birth control
                                                                counseling and referring clients.
      method	they	want.	They	may	have	used	it	
      successfully and know what their plans are                If clients wish sterilization, consult the
      for	having	children	in	the	future.	Review	any	            on-site counseling and informed consent
      special considerations she needs, (such as                procedures.

   Steps to Take — 2009 • Health Education                                                                 HE– 113
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      thy           Family Planning Choices (cont.)

   Help clarify plans for having more children         •	 Methods which require use during sex may
   in the future, if appropriate. Women uncertain         not be acceptable to some clients (condoms
   of	future	pregnancy	tend	to	be	less	effective	         and foam).
   using	birth	control	(they	have	more	unplanned	
                                                       •	 Condoms provide the best protection
   pregnancies). Use the model on the next page
                                                          against STIs if she’s at risk. Other barrier
   to	clarify	values,	feelings	and	options	using	a	
                                                          methods	also	provide	some	protection	against	
   problem-solving	format.	
                                                          STIs (such as foam and diaphragms). Use
   Ask about birth control methods she’s used             condoms with a spermicide to make them
   in the past, and her satisfaction with them. Has       more	effective	against	STIs	and	pregnancy.
   she	been	successful	in	avoiding	unplanned	
                                                       •	 If she’s interested in abstinence, or in
                                                          methods which require periods of abstinence
   Determine if the client wants a permanent              (such as Natural Family Planning), recommend
   birth control method (sterilization) or a              a	barrier	method,	available	over	the	counter,	
   temporary one. If she’s interested in no more          as a back-up in case she changes her mind.
   children, but not sure enough to choose                Pregnancy is a time of many changes, but
   sterilization, she may want a long-acting method       feelings may change after birth of the baby.
   (such	as	Depo-Provera	or	Norplant).                    This is a good time to learn about a barrier
                                                          method	if	she	doesn’t	have	experience	using	
   Ask clients who want temporary birth control
   methods (not sterilization) about the following
   factors:                                            •	 If avoidance of unintended pregnancy is of
                                                          high importance, she may want a method that
   •	 Frequency of needing protection (daily,             has	a	high	effectiveness	rate	(Norplant,	Depo	
      weekly, or just occasionally). Barrier methods      Provera,	IUD	and	oral	contraceptives).	
      (condoms, diaphragms, and foams) may be the
      best choice for occasional protection.             Once the client has indicated which methods
                                                         she	is	interested	in,	review	each	method.
   •	 Some methods require a woman to touch
                                                         -	   effectiveness	(theoretical	and	use)
      her genitals for insertion;	not	everyone	is	
                                                         -    the effects/complications and warning signs
      comfortable doing that (diaphragms/ foam).
                                                         -    how to use it and how to get it
                                                         -	   the	impact	it	will	have	on	her	and	her	
                                                         Show samples of all methods she is
                                                         interested in.

   HE – 114                                                         Steps to Take — 2009 • Health Education
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      thy           Family Planning Choices (cont.)

   Family planning for the woman who                       •	 Cervical caps	have	much	higher	failure	rates	
   Is breastfeeding                                           among	women	who	have	delivered	a	baby	
   If	a	client	plans	to	breastfeed,	review	the	effect	        (compared	to	those	who	have	not).	They	should	
   breastfeeding has on a woman’s fertility. For              not be recommended for postpartum use
   women	who	breastfeed	exclusively	(the	infant	              without informing the client of the decreased
   drinks only breast milk, no other food, formula            effectiveness.
   or	beverages),	ovulation	will	generally	be	             •	 IUDs can be inserted within the first 10
   suppressed.	However,	since	ovulation	occurs	               minutes	after	the	placenta	is	delivered	or	after	
   before menstruation, one can not assume that as            the first week postpartum.
   long as she has no period she is not fertile. See the
   Nutrition guideline Breastfeeding for information       •	 Hormonal methods safe for breastfeeding
   on breastfeeding and family planning.                      women include the mini pill (progestin-only),
                                                              Norplant,	and	Depo-Provera.	
   Some women may want to rely on the
                                                               Combined pills (progestin and estrogen) may
   contraceptive	affects	of	breastfeeding	their	infants.
                                                               reduce the mother’s milk supply and are not
   See	Contraceptive	Technology	for	more	                      recommended. Some studies suggest that
   information on counseling women about the                   it’s better to wait until breastfeeding is well
   lactation amenorrhea method.                                established before starting any hormonal
                                                               methods, but other studies show no decrease
   Birth control methods that are recommended for
                                                               in	milk	supply	even	when	hormonal	methods	
   breastfeeding women include:
                                                               are begun immediately postpartum.
   •	 Barrier methods (condoms, foam, the                  •	 Tubal ligation/vasectomy (for male partner)
      diaphragm)	Diaphragms	and	cervical	caps	
                                                           •	 Fertility awareness
      cannot be fitted accurately for six weeks

   Steps to Take — 2009 • Health Education                                                               HE– 115
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      thy            Family Planning Choices (cont.)

                                                                                     l information
   Follow-Up                                                   A sta tewide referra              to a
                                                                                ncome women
                                                               will refer low-i                        st,
   Ask about her need for birth control at the                                          rovides low-co
                                                               clinic near her that p             rvices.
   postpartum visit.                                                             ily planning se
                                                                sliding-fee fam                  Cal.
   Ask if she is still satisfied with her decision and if                       o accept Medi-
   she has any questions about how to obtain the                The clinics als
                                                                               -1      054
   chosen method (if she hasn’t yet). If she has not            Call 1-800-942
   used	the	method	before,	review	how	to	use	it	

   Resources                                                Contraceptive	Technology	Update	
   What is Right For You: Choosing a Birth Control
                                                            American Health Consultants
   Method.	(English/Spanish	available).	This	and	other	
                                                            352 Piedmont Rd.
   materials	are	available	from:	
                                                            Building 6, Suite 400
      Educational Programs Associates                       Atlanta,	GA	30305
      A	Division	of	California	Family	Health	Council	       1-800-688-2421
      1	W.	Campbell	Ave.,	Suite	45	               
      Campbell, CA 95008-1039
   Contraceptive	Technology,	Hatcher,	R.A.	et	al.	
   Irvington	Publishers,	New	York.	Latest	edition	
   available	from:

    	 Bridging	the	Gap	Foundation
      P.O. Box 530
      Tiger,	GA	30576

   HE – 116                                                             Steps to Take — 2009 • Health Education
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      thy            Infant Feeding Decision-Making

                              e best way to
        Brea st is usually th                               Steps to Take
        feed a newborn                                      What are your feelings about
                                                            Your own experience with breastfeeding may
   Goal                                                     affect how well you handle breastfeeding
   Help your client:                                        discussions with the client. You may be surprised
                                                            by the strong emotions people bring to this
   •	 understand	the	benefits	of	breastfeeding
                                                            subject.	A	positive	experience	is	helpful,	but	
   •	 understand	her	own	values	and	perceptions	            it	may	be	difficult	for	you	to	be	objective	and	
      about	the	advantages	and	disadvantages	of	            nonjudgmental if a woman prefers not to
      formula and breastfeeding when deciding how           breastfeed.
      to feed to her infant
                                                            If your own experience did not go well, it may be
                                                            difficult for you to sincerely support the concerns
   Background                                               of	the	client	without	reinforcing	her	negative	
   One of the first decisions a client makes is how she     feelings about breastfeeding. It is important to
   will feed her newborn. Women make this decision          identify your own feelings. It may help to discuss
   based on information and experience passed               your experience and feelings with the health care
   down from family, their partner, friends, the health     provider	and/or	the	Lactation	Consultant	in	your	
   care staff and others. Women who will care for           area.
   their own infants can breastfeed, use formula, or
   use a combination of the two.
                                                            For all clients
   Breastfeeding is the most common and accepted            Ask “what do you know about breastfeeding?”
   infant feeding practice worldwide. But in the U.S.       to see if her ideas are based on up-to-date
   only half of mothers begin feeding their infants         information or more of the common misunder-
   by breastfeeding. Less than 20% breastfeed their         standings.
   infants through age 5 to 6 months. This may be
   due to lack of support, more mothers returning              What do you know about breastfeeding?
   to	work,	less	time	spent	in	hospitals	after	delivery,	      What are your thoughts about breastfeeding?
   and other factors. It can result in more infants            Do you know anyone who has breastfed her
   being admitted to hospitals, more ear and                    baby?
   respiratory tract infections, more diarrhea, and            Have you ever seen anyone breastfeed her baby?
   increases in other illnesses among formula-fed              What	have	you	heard	about	breastfeeding?
                                                            Note:		Avoid	starting	with	the	question	“Do	you	
  There	are	very	few	women	who	can	not	or	should	           plan to breastfeed or use formula?” because it will
  not breastfeed. See the Breastfeeding guidelines          not	reveal	how	the	client	made	her	choice.	The	
  for a list of reasons women can not breastfeed.           woman	does	not	absolutely	have	to	make	up	her	
   If a woman chooses not to breastfeed or will not         mind	about	breastfeeding	before	delivery.	It	is	
   be caring for her infant, such as with adoption, she     more important to discuss her specific concerns
   will need to know how to care for her breasts to         than to focus on her making a decision.
   help the milk dry up.

   Steps to Take — 2009 • Health Education                                                                HE– 117
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      thy           Infant Feeding Decision-Making (cont.)

   Clients who will breastfeed                              – Ask about the most important things that
                                                              come to mind when she thinks of feeding her
   •	 Women	who	are	already	sure	they	want	to	
      breastfeed still benefit from support and
                                                            – Ask her to discuss what benefits she sees in
      education,	particularly	if	they	have	never	
                                                            – Ask her to share her concerns and the
   •	 Women	who	have	breastfed	may	benefit	from	              concerns of those close to her.
      referrals to breastfeeding support programs           – Let her make all her comments before
      later in her pregnancy or postpartum, or be a           correcting any information that is incorrect.
      resource to other mothers.                          •	 Recommend	that	she	talk	to	other	women	who	
   •	 Refer	to	Breastfeeding guidelines for more             have	breastfed,	and	watch	a	mother	breastfeed	
      information and for client handouts on                 her	baby	in	person	or	on	video.	
      initiating and sustaining breastfeeding.            •	 If	a	client	wants	to	both	breastfeed	and	use	
                                                             formula, support this choice. Share guidelines
   Clients who want to use formula                           for making sure the breast milk supply doesn’t
   •	 Ask what her expectations are for using                decrease.
      formula to be sure they are realistic. She may      Refer to the Nutrition Breastfeeding guidelines for
      have	incorrect	ideas	such	as	“formula	fed	          specific breastfeeding instructions and for client
      infants are less clingy” or “formula fed infants    handouts.
      sleep much better than breastfed infants.”
   •	 If she’s made an informed decision, support         Follow-Up
      her choice. Discuss safe and healthy methods        At future appointments, ask each client if she is still
      to	use	such	as	avoid	microwaving	formula	           satisfied with her infant feeding decision. Ask if she
      to	prevent	burns	from	“hot	spots,”	test	            has discussed her plans with family members or
      temperature	of	formula	on	wrist,	never	prop	a	      other support people.
      bottle, wash bottles and nipples in hot soapy
      water. See the handout Keep Your Baby Safe at
      Home.                                               Resources
                                                          Resources for breastfeeding are listed in the
                                                          Breastfeeding Nutrition guidelines.
   Clients who are unsure
   •	 Help	uncertain	clients	decide	whether	or	not	to	
      breastfeed. Help her choose what’s right for her                                     feeding is
                                                                            n about breast
      and her family, either now or in the near future.       Misinformatio                     te facts
                                                                                 o-date, accura
      She might like to bring her partner or a family         com  mon. Find up-t
      member to an appointment to help make the               for clients.

   HE – 118                                                            Steps to Take — 2009 • Health Education
       y Mo
H ealth Baby
      thy            Infant Safety and Health

   Infant safety seats                                        Safety	issues	for	babies	focus	on	car	travel	
   Car	accidents	are	the	number	one	preventable	              and home safety. Maintaining the health
   cause of death in children. Children under 4 years         of	babies	involves	knowing	when	health	
   of	age	or	weighing	less	than	40	pounds	traveling	          problems are serious, when to get medical
   in	motor	vehicles	are	required	by	law	to	be	in	            help, and keeping babies protected from
   safety	seats	at	all	times.	Starting	in	January,	2002,	     serious diseases.
   the law requires that all children under 6 years
   of age or weighing less than 60 pounds ride in a           Help your client:
   car safety seat. While it may be tempting to carry
                                                              •	 know	safety	precautions	required	for	
   an	infant	in	the	arms	or	even	breastfeed	when	
                                                                 infants, including proper use of car
   traveling	in	a	car,	this	is	the	most	dangerous	way	
   for	a	baby	to	travel.
                                                              •	 recognize	early	signs	of	illness	in	
                                                                 infants (birth through 6 months)
   Steps to Take
  Ask the client if she has used an infant safety seat        •	 know	when	to	seek	medical	and	
  before, and if she can tell you about how to use               emergency attention
                                                              •	 understand	the	importance	of	
   Demonstrate how to put an infant safety seat into             protecting her baby with complete
   a	car—or	better—have	her	demonstrate	how	                     and up-to-date immunizations and the
   to put her seat into her car. Use a baby (or doll)            schedule for routine immunizations
   to show how to put an infant into the car seat                through age two
   (snug straps, blankets outside the straps, rolled
                                                              •	 understand	the	importance	of	taking	
   blankets to secure head if needed, etc.). Be sure
                                                                 good care of the baby’s immunization
   the client understands the basic concepts and can
                                                              •	 know	danger	signs	of	illness	in	the	
   •	 Safety	seats	must	be	used	every	time,	even	on	             newborn and what to do if these occur
      the first ride home from the hospital. Be sure
      she has a seat by then.                                 •	 identify	a	pediatric	care	provider	for	
                                                                 her	baby	before	she	delivers
   •	 “Infant	seats”	can	be	used	until	the	baby	weighs	
                                                              The following two pages contain
      20	pounds.	“Convertible	seats”	can	be	used	up	
                                                              information for your use when discussing
      to 40 pounds.
                                                              infant safety and health with your client.
   •	 Infant	safety	seats	should	be	installed	following	
                                                              Be sure to review the Health Education
      the manufacturer’s instructions, in the center of
                                                              handouts with the client and people she
      the	rear	seat	of	the	vehicle,	facing	backwards.
                                                              might bring along who will help with
   •	 Plastic	infant	carriers,	travel	beds,	cloth	carriers	   infant care. Encourage her to keep this
      (slings)	are	not	safe,	even	if	they	are	secured	in	     information handy and also share it with
      the car with a seat belt.                               other parents of newborns.

   Steps to Take — 2009 • Health Education                                                                 HE– 119
       y Mo
H ealth Baby
      thy             Infant Safety and Health (cont.)

   Follow-Up                                                    Resources
   When	the	client	comes	in	for	her	postpartum	visit,	          California Center for Childhood Injury
   ask	if	she	is	using	her	car	seat	correctly.	If	available,	   Prevention	(CCCIP)
   review	the	car	seat	instructions	for	use	with	               SDSU Foundation
   her. Make sure she has safety seats for her other            6505	Alvarado	Rd.,	Suite	208
   children, if needed.                                         San Diego, CA 92120
                            r rent infant sa                    U.S. Consumer Product Safety Commission
      Progra ms that lend o                                     Washington DC 20207:
      seats:                                                    1-800-638-2772
      ________________                                          "Child Safety" pamphlet
                                                                 American Academy of Family Physicians
                                                                 8880 Ward Parkway,
   Resources                                                     Kansas City, MO 64114-2797
   For more information on infant safety seats,                  1-800-944-0000
   call: Safety Belt U.S.A., (800) 745-SAFE, State of           "Care For Your Baby"
   California Passenger Safety Education Project                 California	Department	of	Health	Services,	available	
   For patient education handouts in English, Spanish,           from Miller Litho
   and Vietnamese call the California Center for                 1-800-995-4714 or 831-757-1179
   Childhood	Injury	Prevention	at	(619)	594-3691.
                                                                Steps to Take
   Infant safety in the home                                     •	 Help	the	client	develop	a	plan	for	medical	
   Many	women	have	infant	care	beliefs	and	                         care for her infant. Ask if she has a health care
   practices learned from their families. For example,              provider	for	her	baby.	If	not,	ascertain	any	
   some parents may want to swaddle their infant                    problems	she	may	have	with	her	decision.	See	
   frequently, or keep the infant inside, or want the               if she has reliable transportation to the health
   infant to cry loudly to exercise the lungs. Accept               care	provider.
   practices that are not harmful.
                                                                 •	 Discuss	infant	danger	signs	on	the	handout	
                                                                    When your newborn baby is ill with each client
   Steps to Take                                                    during her third trimester.
   •	 If	the	client	has	taken	care	of	an	infant	in	the	          •	 Advise	her	as	to	when	to	call	for	medical	advice	
      past, briefly discuss the Health Education                    about a condition by discussing the danger
      handout When your newborn baby is ill and                     signs.
      give	a	copy	to	take	home	as	a	reminder.
                                                                 •	 Review	where	she	will	take	her	infant	if	the	
   •	 If	the	client	has	not	had	experience	taking	                  baby	becomes	seriously	ill	on	evenings	and	
      care	of	infants,	review	and	demonstrate	(when	                weekends,	as	well	as	weekdays.	Review	these	
      possible) safety points.                                      points	again	at	the	postpartum	visit.

   HE – 120                                                                  Steps to Take — 2009 • Health Education
       y Mo
H ealth Baby
      thy           Infant Safety and Health (cont.)

   Resources                                                Immunization card
   Write in phone number for any Infant CPR (Cardio-        Before	leaving	the	hospital,	each	newborn	should	
   pulmonary	resuscitation)	classes	available	in	your	      be	given	an	immunization	card	on	which	to	record	
   community.                                               all immunizations. This card should be brought
                                                            to	every	medical	visit	and	kept	in	a	safe	place	at	
  Parents’	Guide	to	Common	Childhood	Illnesses
  Association of Asian Pacific Community Health
  Organizations                                             Emphasize that the card will be required before
  439 23rd Street                                           the child can enter preschools or kindergarten.
  Oakland, CA 94612
  (Available	in	English	and	many	Asian	languages)           Resources
                                                            For low-cost or no-cost immunization clinics, or
                                                            for up-to-date information on immunizations, call
   Immunizations                                            your County Health Department immunization
   Immunizations protect children from serious              unit.
   childhood	diseases	that	can	result	in	severe	illness,	
   	 ospitalization	—	even	death.	

   Steps to Take
   •	 Discuss	the	handout	Your Baby Needs to be                                ne number her
                                                                 Write the pho
      Immunized with the client during the third                                                _______
      trimester.                                                 ____ ____________

   •	 Show	her	an	example	of	an	immunization	card	
      and	explain	that	her	child	must	have	this	card	
      with up-to-date immunizations to start school.
   •	 Ask	if	there	are	barriers	for	her,	such	as	
      transportation	or	cost,	in	having	her	child	
   •	 Refer	her	to	a	clinic	near	her	home,	if	necessary.	

   Steps to Take — 2009 • Health Education                                                               HE– 121
       y Mo
H ealth Baby
      thy           Immunizations and Pregnancy

   Immunizations are not just for infants, they are         Chicken Pox:
   for the entire family!                                   All women of child-bearing age should be
                                                            immune	to	chicken	pox,	either	by	having	the	
   Ideally, all women of child-bearing age should be
                                                            disease	or	through	2	doses	of	the	varicella	
   up-to-date on their immunizations before they
                                                            vaccine.		This	vaccine	is	a	live	virus	vaccine,	so	it	
   become	pregnant.		The	first	encounter,	however,	
                                                            is not recommended during pregnancy. If it is
   may be after the woman becomes pregnant, so
                                                            determined that the woman is not yet protected
   immunization status should be assessed at the first
                                                            during	pregnancy,	she	should	receive	the	vaccine	
   prenatal	visit.		Although	some	vaccines,	particularly	
                                                            shortly	after	delivery	and	a	second	dose	as	
   live	virus	vaccines,	are	not	recommended	during	
                                                            indicated at least 4 weeks later.
   pregnancy, certain immunizations are specifically
   indicated during pregnancy. In addition, all routine
   immunizations	may	be	given	to	a	mother	while	            Tetanus, diphtheria and pertussis
                                                            Pertussis	can	be	deadly	or	have	serious	
   Influenza (flu):                                         complications in young infants who will not
   Pregnant	women	are	at	increased	risk	of	severe	          be fully protected against pertussis until they
   influenza, so it is important that they are              have	received	their	primary	immunizations	at	6	
   appropriately protected. Women who are pregnant          months or later. Tetanus is also a deadly disease
   or	planning	a	pregnancy	should	receive	the	              for	infants	but	can	be	avoided	if	the	mother	and	
   influenza	vaccine	each	autumn	or	winter	to	protect	      child	are	immunized.	The	Tdap	vaccine	is	a	booster	
   themselves	and	families.	Infants	are	at	great	risk	of	   shot against tetanus, diphtheria and pertussis
   severe	influenza	but	are	not	immunized	until	they	       that	has	been	available	since	2005.	All	women	of	
   reach at least 6 months old, so it is important that     child-bearing	age	should	have	received	a	Tdap	
   those around them are immunized. Thus, parents           vaccine	within	the	past	10	years.		Tdap	is	not	
   and	other	family	members	should	receive	the	flu	         contraindicated	in	pregnancy,	so	providers	may	
   vaccine	at	least	several	weeks	prior	to	the	infant’s	    use their discretion when immunizing during
   birth. As a precaution, California law states that       pregnancy.		If	the	woman	has	not	received	Tdap	
   pregnant	women	should	receive	flu	shots	with	little	     by	the	time	of	delivery,	the	mother	should	receive	
   or	no	preservative.                                      Tdap during the immediate postpartum period.
                                                            Protection against pertussis is important for
                                                            anyone who anticipates close contact with the
   Rubella:                                                 newborn.
   All women of child-bearing age should be
   protected against rubella with 2 doses of the MMR
   vaccine.		Rubella	infection	during	pregnancy	can	        Hepatitis B:
   cause miscarriage or a pattern of birth defects such     If protection against hepatitis B is indicated, the
   as deafness and mental retardation (congenital           woman	may	receive	the	vaccine	series	during	
   rubella	syndrome).		Physicians	providing	prenatal	       pregnancy.
   care should check for immunity to rubella through        For more information and resources, see:
   a blood test. Women who not immune to rubella  
   should	be	immunized	with	MMR	vaccine	shortly	
   after	delivery	and	a	second	dose	as	indicated	at	
   least 4 weeks later.
   HE – 122                                                               Steps to Take — 2009 • Health Education
       y Mo
H ealth Baby
      thy            Keep Your New Baby Safe

                                                          Keep your baby safe
                                                          from poisons.
                                                          Your baby could breathe in or swallow
                                                          poisons. Poisons can also be absorbed
                                                          through the skin or eyes.
                                                          •	 Call	right	away	for	help.
                                                          •	 If	you	know	what	your	baby	ate	or	drank,	take	
                                                             the bottle or box to the phone with you. That
                                                             way you can tell the Poison Control staff just
                                                             what your baby got into.
                                                          •	 Have	Syrup	of	Ipecac	and	activated	charcoal	
                                                             on	hand	just	in	case.	Don’t	give	these	or	try	
  Keep your baby safe                                        to make your baby throw up, unless Poison
  in the crib.                                               Control	or	your	health	care	provider	tells	you	
                                                             that you should. Some poisons, like lye, should
   •	 Place	your	baby	on	his	or	her	back	when	you	lay	
                                                             not	be	vomited.	
      him or her down to sleep.
   •	 The	bars	on	the	crib	should	be	no	wider	than	
      2 3⁄8 inches apart. The mattress should be the
      same size as the crib. This will keep your baby’s
      head from getting caught.
   •	 The	mattress	should	be	firm.	Do	not	use	plastic	
      bags to protect the mattress.
                                                                                 ntrol at
                                                                 Call Poison Co
   •	 Don’t	use	soft	toys	or	pillows	in	the	crib.	Your	                          66.
      baby could suffocate.                                      1-800-876-47
                                                                                   e number,
                                                                  If you forget th
  Keep your baby safe
                                                                  just call 911.
  from falls.
   •	 Even	newborns	can	roll	over	or	jerk	or	wiggle	
      their way off the edge and fall.
   •	 Never	leave	a	baby	alone	on	a	surface	up	off	the	
      floor. Your baby could roll off a bed, couch, or
      changing table.

   Steps to Take — 2009 • Health Education                                                              HE– 123
       y Mo
H ealth Baby
      thy             Keep Your New Baby Safe (cont.)

   Keep your baby safe from burns.                     Keep your baby safe
   •	 Do	not	microwave	a	bottle	of	formula	or	         from choking.
      breastmilk.	It	may	have	hot	spots	that	could	
      burn your baby’s mouth.
                                                       It is easy for a baby to choke on
   •	 Here’s	how	to	warm	a	bottle	safely:              •	 Do	not	let	the	baby	have	small	objects.
   •	 Fill	the	bottle	only	2/3	full.	                  •	 Keep	your	baby	away	from	plastic	bags	or	
   •	 Put	the	bottle	in	a	pot	of	hot	water.	Warm	it	      balloons.
      just to room temperature
   •	 Shake	it	up.                                     Your baby could choke on
                                                       many kinds of food.
   •	 Then	test	it.	Pour	a	few	drops	on	
      your wrist.                                      •	 Don’t	give	your	baby	hard	foods,	like	hard	
                                                          candy,	raw	vegetables,	or	
   Here are more ways to keep
                                                       •	 Stay	away	from	food	that	is	just	the	size	of	
   your baby safe from burns:
                                                          your baby’s throat, like grapes or hot dogs.
   •	 Test	bath	water	with	your	wrist	before	you	
      put your baby in the water.                      •	 Don’t	feed	your	baby	sticky	foods,	like	
                                                          peanut butter or honey.
   •	 Do	not	drink	hot	beverages	or	cook	while	
      you	carry	your	baby.	Newborns	can	wave	          •	 Be	sure	to	learn	how	to	help	a	choking	baby.	
      their arms. Babies as young as 3–5 months           Take a class in CPR.
      old can grab things.
   •	 Make	sure	your	smoke	detectors	
      work. Put smoke detectors in your kitchen
      and in the hallway near
      the bedroom(s).
   •	 Never	smoke	cigarettes	while	you	hold	your	
      baby. Keep ashtrays, lighters, and matches
      out of baby’s reach.
   •	 Make	sure	to	keep	a	fire	extinguisher	in	the	

   HE – 124                                                         Steps to Take — 2009 • Health Education
       y Mo
H ealth Baby
      thy           Mantenga Sano y Salvo a Su Bebé

                                                      Evítele envenenamientos.
                                                      Su bebé puede respirar y tragar cosas
                                                      venenosas. Los venenos también
                                                      pueden ser absorbidos por la piel y los
                                                      •	 Llame	de	inmediato	para	pedir	ayuda.
                                                      •	 Si	sabe	qué	comió	o	tragó	su	bebé,	lleve	la	
                                                         botella	o	caja	al	teléfono.	Así	puede	decirle	
                                                         al	personal	de	Control	de	Envenenamientos	
                                                         (Poison Control) qué fue lo que afectó al
                                                      •	 Tenga	Jarabe	de	Ipecac	(Ipecac	Syrup)	y	
                                                         carbón	activado	a	la	mano	por	si	acaso.	
                                                         No le dé estas cosas ni trate de hacerlo
                                                         vomitar,	a	menos	que	el	Control	de	
   Proteja a su bebé en la cuna.                         Envenenamientos	o	su	médico	le	diga	que	
   •	 Ponga	al	bebé	boca	arriba	cuando	lo	               debe	hacerlo	vomitar.	Algunos	venenos	
      acueste a dormir.                                  como	lejía	(lye),	no	deben	vomitarse.	
   •	 Las	tablillas	de	la	cuna	no	pueden	estar	a	
      menos de 2 y 3/8 de pulgadas de
      distancia	entre	sí.	El	colchón	debe	ser	del	
      mismo	tamaño	que	la	cuna.	Esto	
      evitará	que	la	cabeza	de	su	bebé	se	trabe.	
                                                                          ol de
                                                         Llame al Contr
   •	 El	colchón	debe	ser	firme.	No	use	                                 ntos al
      bolsas	de	plástico	para	protejer	el	               Envenenamie
      colchón.                                           1-800-876-47
                                                                                 ero, llame
   •	 No	use	juguetes	suaves	o	almohadas	en	la	
                                                          Si se le olvida el núm
      cuna. Su bebé puede sofocarse.
                                                          al 911.
   Proteja a su bebé de una caída.
   •	 Hasta	los	bebés	recién	nacidos	pueden	
      voltearse	o	moverse	hacia	la	orilla	y	caerse.
   •	 Nunca	deje	a	un	bebé	solo	en	un	lugar	que	
      esté	más	arriba	del	piso.	Su	bebé	puede	
      darse	vuelta	y	caerse	de	la	cama,	sofá,	o	
      mesa de cambiar.

   Steps to Take — 2009 • Health Education                                                           HE– 125
       y Mo
H ealth Baby
      thy          Mantenga Sano y Salvo a Su Bebé

   Proteja a su bebé de las                           Proteja a su bebé de la asfixia.
   quemaduras.                                        •	 Es	fácil	que	un	bebé	se	asfixie	con	algo.
   •	 No	caliente	el	biberón	de	formula	o	la	leche	   •	 No	deje	que	el	bebé	tenga	objetos	
      materna en el horno de                             chiquitos.
      micro	 ndas.	Puede	tener	áreas	calientes	
      que pueden quemar la boca del bebé.             •	 Mantenga	al	bebé	alejado	de	bolsas	de	
                                                         plástico	o	globos.
   •	 Para	calentar	el	biberón	de	un	modo	seguro:
     •	 	 olamente	llene	dos	terceras	partes	del	
                                                      Hay varios alimentos que pueden
     •	 	 onga	el	biberón	en	una	olla	de	agua	
        P                                             asfixiar a su bebé al tratar de
        caliente. Caliéntela solamente a              comérselos.
        temperatura del ambiente.                     •	 He	le	dé	a	su	bebé	alimentos	duros,	como	
     •	 Agítela.                                         dulces,	verduras	frescas	o	
     •	 	 ágale	la	prueba.	Póngase	unas	                 palomitas.
        cuantas	gotas	en	su	muñeca.	
                                                      •	 No	le	dé	alimentar	que	apenas	están	al	
                                                         tamaño	de	su	garganta,	como	las	uvas	or	
   Otras formas de evitarle                              salsichas (hot dogs).
   quemaduras al bebé:
                                                      •	 No	le	dé	a	su	bebé	alimentos	pegajoso	
   •	 Pruebe	la	temperatura	de	la	bañera	en	su	
                                                         como	las	crema	de	maní	or	miel	de	aveja.
      muñeca	antes	de	poner	al	bebé	en	el	agua.
                                                      •	 Aprenda	cómo	ayudar	a	un	bebé	si	se	esta	
   •	 No	tome	bebidas	calientes	o	cocine	
                                                         asfixiando. Tome clases para aprender (CPR).
      mientras carga a su bebé. Los recién
      nacidos	pueden	mover	sus	brazos.	Los	
      bebés de 3 a 5 meses pueden agarrar cosas.
   •	 Asegúrese	de	que	sus	detectores	de	humo	
      estén funcionando. Ponga
      detectores de humo en su cocina y en el
      pasillo junto a los cuartos de dormir.
   •	 Nunca	fume	cigarrillos	mientras	carga	
      a su bebé. Mantenga los ceniceros,
      encendedores, y fósforos fuera del alcance
      del bebé.
   •	 Asegúrese	de	mantener	un	extinguidor	de	
      incendios en la cocina.

   HE – 126                                                        Steps to Take — 2009 • Health Education
                                                                                                     y Mo
When Your Newborn Baby is Ill:                                                                H ealth Baby

What to watch for

If your baby is less than three months old,      Call right away:
here’s what to watch for when your baby
                                                 •	 If	your	baby	does	not	wet	at	least	4–6	
seems ill.
                                                    diapers	every	24	hours.
                                                 •	 If	your	baby	cries	more	than	normal	and	
Call your health care provider                      you cannot comfort or stop your baby
right away:                                         when he or she cries.
•	 If	your	baby’s	temperature	is	100.4°F	or	     •	 If	your	baby	does	not	seem	as	alert	as	
   more. Take your baby’s temperature by the        normal or sleeps more than usual.
   rectum. Ask how to use a thermometer if
   you do not know how.                          •	 If	your	baby	seems	weak	or	floppy.

•	 If	your	baby	skips	two	feedings.              •	 If	your	baby	does	not	cry	as	loudly	as	you	
                                                    are used to.
•	 If	your	baby	throws	up	with	force,	so	that	
   the	vomit	shoots	out.
                                                 Call right away:
•	 If	your	baby	throws	up	more	than	just	
                                                 •	 If	your	baby’s	skin	or	eyes	are	yellow.
  “spitting up” after he or she eats.
                                                 •	 If	your	baby	has	a	purple	rash	that	does	not	
                                                    lighten when you press it.
Call right away when your baby
has diarrhea:
•	 If	your	baby’s	stools	are	not	normal.
•	 If	your	baby	has	loose	or	watery	stools.        Call 911:                         etting	air	in	an
                                                    •	 If	your	bab y	has	trouble	g
•	 If	your	baby’s	stools	have	a	
   very	bad	odor.                                       out.
                                                                         skin	is	turning
•	 If	there	is	blood	or	                             •	  If	your	baby's	
                                                                       is	choking.
   mucous in the                                      •	 If	your	baby	
   stools or urine.

                                                   Write your address and phone number near
                                                   the phone.
                                                   That way you or your baby's caregiver can
                                                   read it to the 911 operator.

Steps to Take — 2009 • Health Education                                                            HE– 127
                                                                                                     y Mo
Cuando su Recién Nacido está Enfermo:                                                         H ealth Baby
 Lo que debe observar

Si su bebé tiene menos de tres meses, ésto       Llame de inmediato si:
es lo que tiene que observar cuando parece       •	 Su	bebé	no	usa	por	lo	menos	de	4	a	6	
que su bebé está enfermo.                           pañales	cada	24	horas.	
                                                 •	 Su	bebé	llora	más	de	lo	normal	y	si	usted	no	
Llame a su médico de inmediato si:                  lo puede consolar o hacer que deje de llorar.
•	 La	temperatura	de	su	bebé	es	de	100.4°F	o	
                                                 •	 Su	bebé	no	parece	estar	alerto	como	de	
   más.	Tome	la	temperatura	de	su	bebé	por	
                                                    costumbre	o	duerme	más	de	lo	normal.
   el	recto.	Pida	que	le	enseñen	cómo	usar	un	
   termómetro si no sabe cómo.                   •	 Su	bebé	parece	estar	débil	o	aguado.

•	 Si	su	bebé	no	quiere	comer	dos	veces	         •	 Su	bebé	no	llora	tan	fuerte	como	de	
   seguidas.                                        costumbre.

•	 Si	su	bebé	vomita	con	fuerza	y	el	vómito	
   sale como si fuera un chorro.                 Llame de inmediato:
                                                 •	 Si	la	piel	o	los	ojos	de	su	bebé	están	
•	 Si	su	bebé	vomita	más	de	lo	que	
   normalmente escupe después de haber
   comido.                                       •	 Si	su	bebé	tiene	salpullido	morado	que	no	
                                                    se le aclara cuando se le presiona.
Llame de inmediato si su bebé
tiene diarrea:
•	 Si	el	excremento	de	su	bebé	no	es	
                                                   Llame al 911:                        l	respirar.
•	 Si	el	excremento	de	su	bebé	es	aguado	o	                             e	problemas	a
                                                   •	  Si	su	bebé	tien
   suelto.                                                                                  oniendo	
                                                                           ebé	se	le	está	p
                                                    •	 Si 	la	piel	de	su	b
•	 Si	el	
   excremento                                                                           o.
                                                                       	está	asfixiand
   de su bebé tiene                                  •	 Si	su	bebé	se
   mal olor.
•	 Si	hay	sangre	o	
   mucosidad en                                   Escriba su domicilio y número de teléfono
   el excremento o en                             junto a su teléfono.
   la orina.
                                                  De esta manera, usted o la niñera de su bebé
                                                  puedan leérselos a la operadora del 911.

HE – 128                                                      Steps to Take — 2009 • Health Education
       y Mo
H ealth Baby
      thy           Your Baby Needs to be Immunized

   Shots can protect your baby from                 Do shots really work?
   dangerous childhood diseases.                    Yes.	When	we	give	children	a	small	amount	
   Your	baby	could	get	very	sick	or	even	           of	vaccine,	they	can	grow	up	without	getting	
   die from these diseases. To be protected,        these diseases. Check with your baby’s
   your baby needs a series of shots at 2, 4, and   health-care	provider.	Make	sure	your	child	has	
   6 months of age, and between 12 to 18 months     gotten all the shots he or she needs.
   of age.
                                                    Are shots safe?
   Protect your baby from                           Almost	all	children	have	only	a	mild	reaction	
                                                    to shots. Your child may be sore where the shot
   these diseases:
                                                    was	given,	or	have	a	slight	fever	or	rash.
   •	 Hepatitis	B
                                                    A	serious	problem	from	shots	is	very	rare.	Call	
   •	 Hib	(meningitis)                              your	health	care	provider	right	away	if	your	
   •	 Diphtheria                                    child	has	a	very	high	fever,	a	rash	all	over	his	
                                                    body,	or	a	lot	of	swelling	where	he	was	given	
   •	 Tetanus	(lockjaw)                             the shot.
   •	 Pertussis	(whooping	cough)
   •	 Polio                                         Schools need a record of
   •	 Chicken	Pox                                   your child’s shots.
                                                    By	law,	children	in	California	must	have	all	their	
   •	 Measles                                       shots before they go to school or day care.
   •	 Mumps                                         Your child needs a written record of these shots.
                                                    Most of the time, you will get a yellow card with
   •	 Rubella	(German	measles)
                                                    the dates your child got the shots. Keep this
   •	 Pneumococcal	disease                          card and all your child’s health records in a safe
   •	 Rotavirus	disease	(severe	gastroenteritis)
   •	 Hepatitis	A
   •	 Influenza

                  's shots
    Get your baby
                   ry time!
    on time — eve

   Steps to Take — 2009 • Health Education                                                              HE– 129
       y Mo
H ealth Baby
      thy            Su Bebé Necesita ser Vacunado

   Las vacunas pueden proteger a su                      ¿Son efectivas las vacunas?
   bebé de enfermedades peligrosas                       Sí.	Cuando	les	damos	a	los	niños	una	pequeña	
                                                         cantidad	de	la	vacuna,	pueden	crecer	sin	tener	
   de la niñez.
                                                         estas enfermedades. Verifique con el médico de
   Su bebé se puede poner muy enfermero o
                                                         su	niño.	Asegúrese	de	que	haya	vacunado	a	su	
   hasta morir de estas enfermedades. Para
                                                         niño	con	todas	las	vacunas.	
   estar protegido, su bebé necesita una serie de
   vacunas	a	los	2,	4,	y	6	meses,	y	entre	los	12	a	18	
   meses.                                                ¿Son seguras las vacunas?
                                                         Casi	todos	los	niños	tienen	una	leve		 eacción	
                                                         a	las	vacunas.	Su	niño	puede	estar	adolorido	
   Proteja a su bebé de estas
                                                         en	el	área	en	que	le	pusieron	la	vacuna,	o	tener	
   enfermedades:                                         una	leve	fiebre	o	erupción	en	la	piel.	
   •	 Hepatitis	B
                                                         Un	problema	serio	de	las	vacunas	es	raro.	Llame	
   •	 H	(meningitis)                                     a	su	médico	de	inmediato	si	su	niño	tiene	
                                                         fiebre alta, le sale erupción en todo el cuerpo o
   •	 Difteria
                                                         tiene mucha hinchazón en donde se le puso la
   •	 Tétano	                                            inyección.
   •	 Pertusis	(tosferina)	
   •	 Polio	                                             Las escuelas necesitan verificación
                                                         de las vacunas de su niño.
   •	 Varicela	                                          Por	ley,	los	niños	en	California	deben	tener	
   •	 Sarampión                                          todas	sus	vacunas	antes	de	poder	asistir	a	la	
                                                         escuela	o	a	una	guardería.	
   •	 Paperas
                                                         Su	niño	necesita	verificación	escrita	de	todas	
   •	 Rubéola	(Sarampión	Alemán)	                        estas	vacunas.	La	mayoría	del	tiempo,	usted	
                                                         recibirá	una	tarjeta	amarilla	con	las	fechas	en	
                                                         que	su	niño	recibió	las	vacunas.	Guarde	esta	
                                                         tarjeta	y	todos	los	datos	de	la	salud	de	su	niño	
                                                         en un lugar seguro.

                                                                          ebé a tiempo
                                                            Vacune a su b
                                                            ¡todo el tiemp

   HE – 130                                                           Steps to Take — 2009 • Health Education
       y Mo
H ealth Baby
      thy           Multiple Births – Twins and Triplets

   Goals                                                 Pay careful attention when a woman expresses
                                                         concern that she might be carrying multiples and
   •	 Understand	the	health	risks	associated	with	
                                                         refer	her	to	the	medical	team	for	evaluation.	
      multiple births
   •	 Understand	the	biology	of	multiples	births	and	    Health risks associated with multiple
      zygosity                                           births
   •	 Educate	the	client	to	reduce	risks	associated	     Plural	pregnancies	significantly	elevate	the	risk	for	
      with a plural pregnancy and multiple births        common pregnancy problems such as anemia and
                                                         toxemia. The greatest prenatal risk is for multiples
   •	 Make	realistic	plans	for	the	postpartum	care	of	   who share a placenta. The mother’s nutrition and
      the client’s multiples                             the pregnancy itself must be monitored carefully
   •	 Develop	a	support	system	for	the	client	and	       to	reduce	the	greatly	elevated	health	risks	to	the	
      access multiple birth resources                    mother and her babies.

   Background                                            Shared placenta
  A	pregnancy	involving	twins,	triplets,	or	more	        In	a	plural	pregnancy,	each	fetus	can	either	have	a	
  is called a plural pregnancy. The birth of twins,      separate placenta or share a placenta with one or
  triplets, or more is called a multiple birth. The      more others. When multiples share a placenta, they
  babies	themselves	are	referred	to	as	multiples.        are at risk for a condition known as twin-to-twin-
                                                         transfusion syndrome and other problems related
                                                         to	interconnection	in	the	placenta	of	veins	and	
   Who has multiples?                                    arteries supplying blood to the babies. Multiples
  The	chances	of	having	multiples	are	higher	for:	       who	share	a	placenta	also	are	more	likely	to	have	
                                                         birth defects or to die, risks 10 times higher than
   •	 African-Americans/Blacks	                          for	multiples	with	separate	placentas.	It	is	very	
   •	 Women	who:	                                        important that women with plural pregnancies
                                                         be screened for a shared placenta by sonogram
     –	 have	a	family	history	of	multiples	or	have	
                                                         between the sixth and twelfth week of pregnancy.
        already	given	birth	to	multiples
     – are aged 34 or older
                                                         Preterm birth
     –	 have	taken	fertility	drugs	
                                                         Good	nutrition,	reduced	physical	activity,	and	
     –	 have	undergone	infertility	treatments	such	
                                                         quick response to the symptoms of preterm
        as	in	vitro	fertilization
                                                         labor	have	been	shown	to	reduce	preterm	birth	
                                                         of multiples. Preterm labor symptoms may be
   What to look for                                      especially difficult to detect in a plural pregnancy
   Symptoms of a plural pregnancy may include:           because many normal conditions of pregnancy—
                                                         fatigue,	nausea,	backache,	changes	in	vaginal	
   •	 early	and	severe	nausea	
                                                         discharge—may be increased and confused
   •	 early	and	rapid	weight	gain	                       with symptoms of early labor. In addition, the
                                                         woman’s muscles may be stretched so tightly
   •	 extra	fetal	movement	
                                                         that she cannot feel contractions. (See the Health
   •	 intuition	or	dreams	of	a	plural	pregnancy	         Education handout If Your Labor Starts Too Early
                                                         for additional information.)

   Steps to Take — 2009 • Health Education                                                               HE– 131
       y Mo
H ealth Baby
      thy           Multiple Births (cont.)

   Zygosity                                                  Steps to take
   (identical or fraternal?)                                 Find out how plural pregnancies are handled in
   Zygosity refers to the two basic kinds of multiples       your practice. If the client will be referred for high
   that are determined by the number of fertilized           risk care, explain the process to her and at what
   eggs	(zygotes)	involved	in	the	pregnancy.	Parents	        point during the pregnancy she can expect to be
   need to know whether or not their multiples are           referred.
   monozygotic (MZ), commonly called “identical”   .
   MZ multiples can be health indicators for each
   other.	For	example,	one	may	develop	a	disease	
                                                             The mother’s weight gain during a plural
   for	which	the	other	may	be	monitored	in	advance.	
                                                             pregnancy has been linked with good outcomes.
   MZ twins are able to donate organs to each other
                                                             The mother’s nutritional requirements increase
   without risk of organ rejection. And because they
                                                             according to the number of babies she is carrying.
   are so similar, MZ multiples may need special help
                                                             Research suggests that a woman expecting twins
   establishing	their	individuality	as	they	grow.	
                                                             should gain 24 pounds by 24 weeks and 1.25
   Two thirds of multiples are dizygotic (DZ), which         pounds	per	week	thereafter.	Given	the	woman’s	
   means they come from two (di) zygotes or two              prepregnancy	weight,	average	recommended	
   eggs. DZ twins are also known as “fraternal” twins.       weight gain in pounds for twin and triplet
   Fraternal is an inaccurate description because they       pregnancies is as follows:
   may be two girls, two boys, or one boy and one
                                                             Note that extra weight gain during the first
   girl.	DZ	twins	occur	when	the	mother	ovulates	two	
                                                             trimester while the babies are small and the
   eggs and each is fertilized by a sperm. These twins
                                                             mother’s womb is not crowded, will assist the
   may be as like or unalike as any two siblings.

                                                               Prepregnancy weight:
   Triplets, quadruplets, quintuplets,                                    low       standard           high
                                                               twins         40–50      35-40          24–35
   Individual	babies	in	a	set	of	triplets	or	higher-order	
                                                               triplets      50–60      45–55          35–45
   multiples may all result from fertilization of
   individual	eggs	(DZ).	Or	they	may	result	from	
   division	of	one	fertilized	egg	(MZ).	They	may	also	
   be a combination of DZ and MZ, such as 1 DZ               mother in attaining recommended weight gains.
   and	2	MZ	babies.	Consequently,	they	may	have	             For	optimal	care,	it	is	essential	that	every	woman	
   individual	placentas,	share	a	placenta,	or	combine	       expecting	multiples	have	early	and	regular	
   individual	and	shared	placentas.	                         contact	with	a	registered	dietitian	to	evaluate	her	
                                                             particular needs. (See the Nutrition section for
                                                             general helpful information.)
   Zygosity testing
   Unless zygosity is already known, all same-sex
   multiples should be tested as soon as possible
   after birth to determine whether they are
   monozygotic (MZ). The best zygosity test currently
   available	is	DNA	sampling,	which	is	not	invasive	
   and is more accurate and less costly than blood
   HE – 132                                                               Steps to Take — 2009 • Health Education
       y Mo
H ealth Baby
      thy            Multiple Births (cont.)

   Exercise and rest                                       Preparing for multiples
  As the babies increase in size, their demands on         The	arrival	of	multiples	has	a	major	impact	on	the	
  the mother’s body increase. Regular, nonstressful        family	system.	Everyone	in	the	household	can	
  exercise is important during a plural pregnancy,         expect to suffer major sleep disruption from the
  just	as	it	is	in	a	single	one.	However,	as	the	babies	   demands of twenty-four-hour baby care. Parents
  grow, it may be necessary for the client to reduce       who gather infant clothing and equipment and
  her	activity	level	and	increase	the	amount	of	rest	      plan a support system ahead of time are better
  she gets during the day. (See the handout Safe           able to manage well during the chaotic first weeks.
  Exercise and Lifting in this section)                    With	sufficient	help	from	friends	and	relatives	and	
                                                           access to twin-specific information and resources,
   If the client has a physically demanding job or
                                                           parents	will	have	a	great	sense	of	satisfaction	
   is experiencing symptoms of preterm labor, she
                                                           accomplishing a job well begun when the babies
   may be required to stop work early and/or reduce
                                                           turn one.
   her	level	of	physical	activity.	Sometimes	home	or	
   hospital bed rest is prescribed. Women expecting        Without help and resources, the quality of family
   multiples need to be aware of these possibilities       life will suffer. Single parents and families who lack
   early in the pregnancy so that they can make plans      people resources must find respite help to ensure
   for	early	work	leave,	help	with	housework,	possible	    their health and safety.
   bed rest, care for older siblings, and shopping for
   baby supplies and equipment.
                                                           Identifying the babies
                                                           At first it may be difficult to tell the babies apart,
   Labor and delivery                                      even	if	they	do	not	look	very	similar.	Sleepy	
   Obstetricians differ in the way they manage             parents	may	temporarily	mix	them	up	and	even	
   multiple births. More than fifty percent of             feed	one	of	the	babies	twice.	To	avoid	this,	it	is	
   multiples	are	delivered	by	caesarean	section.	It	       helpful to dress the babies in different colors and/
   is	possible	for	the	first	multiple	to	be	delivered	     or different styles of clothing. For babies who look
   vaginally	and	the	next	by	caesarean	section.	           very	similar,	it	is	helpful	to	mark	the	toe	of	one	with	
                                                           nail polish.
   If the babies are premature or their birth weights
   are low, they will be cared for in the Neonatal
   Intensive	Care	Unit	(NICU).	If	the	birthing	hospital	   Naming multiples
   does	not	have	NICU	facilities,	one	or	more	of	the	      Distinctive	names	help	people	tell	the	babies	apart	
   babies may need to be transported to a hospital         and	help	the	babies	develop	their	own	senses	of	
   some distance away. Parents benefit from being          who they are.
   prepared for these possibilities ahead of time and
   encouraged to discuss details with the medical
   staff. (See the Hospital Orientation section in the     Clothing, equipment, and supplies
   Health Education guidelines.)                           How parents choose to dress multiples influences
                                                           whether others relate to the babies as a group or
                                                           as	individuals.	Newborn	multiples	are	not	greatly	
                                                           affected	by	the	public	notice	they	receive	when	
                                                           their	parents	take	them	out	dressed	alike.	However,	

   Steps to Take — 2009 • Health Education                                                                  HE– 133
       y Mo
H ealth Baby
      thy            Multiple Births (cont.)

   when twins or triplets are dressed alike all of the       Arrangements can be made to combine breast
   time, they can become so used to the “star effect”        and	bottle	feeding	to	give	the	mother	a	chance	
   that they may feel lost without their co-multiples.       to rest and recuperate from the pregnancy. If any
                                                             of the babies are hospitalized, the mother will
   The	babies	can	share	a	crib	while	they	are	very	
                                                             need to pump breast milk for their feedings. She
   small.	In	fact,	it’s	a	good	idea	because	it	gives	them	
                                                             will need lots of encouragement to sustain this
   the comfort of snuggling together in their fetal
                                                             process, which can be
   position. They can also share baby care supplies, of
   course, but the quantities needed will be greater         difficult and discouraging in the early weeks but is
   than for one baby. At first they won’t need many          ultimately worth the effort. (See the breastfeeding
   toys. As they grow, they can easily share things          guidelines in the Nutrition section and Infant
   like blocks, but they will each need their own            Feeding Decision-Making in this section.)
   toys—even	if	they	are	the	same,	like	pull	toys	or	
   stuffed bears.
                                                             Bottle feeding
                                                             Although	other	adults	may	be	available	to	
   Bonding                                                   help, the mother will need assistance and
   When there are two or more babies, parents may            encouragement to learn to feed the babies
   first bond with the whole group and more slowly           together	so	she	won’t	have	to	prop	their	bottles	
   connect with each baby in special ways. The               when she is alone. She can sit between the twins
   bonding process requires special effort by the            or hold one in her lap and put one in an infant seat
   parents to stay connected if one or more of the           next to her. In the case of triplets or more, she may
   babies has a prolonged hospitalization.                   have	to	rotate	them	from	feeding	to	feeding	so	
                                                             that each has time in her arms. This insures that
                                                             the	babies	have	the	benefit	of	regular	cuddling	
   Breastfeeding                                             with	their	mother	and	other	caregivers.	
   Multiples can be breastfed when the mother is
   willing and healthy and has sufficient help. Breast
   milk	provides	the	best	nutrition	and	immunity	            Sleep
   and is especially beneficial for premature infants.       It may help for the adults in the household to take
   Demands on the mother’s body and the time                 turns sleeping through the night.
   required increase with the number of babies. A
                                                             Ask	a	friend	or	relative	to	come	and	care	for	the	
   registered dietitian should assist the mother
                                                             babies	during	the	evening	while	the	parent(s)	
   in adjusting her diet to meet her increased
                                                             catch a few hours of unbroken sleep. Working
   nutritional requirements.
                                                             toward getting the babies on the same schedule
   It can take about eight weeks to comfortably              for feeding and sleeping will also increase the time
   adapt to breastfeeding. By that time, the                 available	for	rest.	Exhausted	parents	are	less	likely	
   mother	will	have	been	able	to	experiment	with	            to follow up with referrals. You can help by calling
   simultaneous feeding of two babies using pillows          referral resources for them.
   to help support them. Simultaneous nursing
   increases the time the mother can be with each
   of	the	babies	while	reducing	the	time	involved	in	
   feeding them.

   HE – 134                                                               Steps to Take — 2009 • Health Education
       y Mo
H ealth Baby
      thy            Multiple Births (cont.)

   Siblings                                                  Follow-Up
   It is wise to prepare older children in the family        •	 Check	the	client’s	understanding	of	the	
   by explaining the biology of multiples in ways               pregnancy as it progresses and of the
   appropriate to their ages and by including them              symptoms of preterm labor. Remind her of the
   in the planning. If they are old enough, they may            importance of reporting any symptom to the
   be able to help arrange the babies’ clothes and              medical team immediately—day or night.
   furniture as well. The babies will more easily win
   the hearts of their siblings if the babies come           •	 Refer	the	client	to	the	medical	team	to	discuss	
   home with a small gift for each sister and brother.          issues beyond your expertise. Help her prepare
   Young	siblings	especially	love	having	their	own	             her questions and explain her concerns.
  “multiples” in the form of dolls or bears. In caring for   •	 Check	her	weight	gain	and	discuss	any	
   these toys, they can safely express some of their            concerns	she	may	have	about	her	nutrition	
   mixed emotions about the real babies. Parents                plan. Refer her to the dietitian if she is not
   can	remind	expected	visitors	to	the	family	to	pay	           gaining weight appropriately.
   attention to the older children by taping a note
   to the front door that says “Please talk to the big       •	 Review	her	preparations	for	twin	care	and	help	
   kid(s) first!”                                               her connect with referrals. Encourage her to
                                                                develop	a	support	system	and	help	her	to	think	
                                                                of ways she can comfortably ask for and accept
  Transportation                                                help	from	relatives	and	friends.	(Refer	to	the	
  Transporting multiples requires stamina and                   Getting	ready	for	twins	or	triplets	handout	in	
  special equipment. Without a twin stroller and/               this section.)
  or sufficient car seats, a family with multiples is
  in danger of isolation—unable to get to medical
  appointments and shop for food and other
                                                             Provide referrals
                                                             Refer the client to both community resources
                                                             and multiple-birth-specific referrals according to
                                                             her particular needs. Keep in mind that, due to
   Disability and loss                                       exhaustion, the client may need you to call for her.
   Disability of one or more multiples will add major        Refer:
   stress to the family system as they learn to meet
   the baby’s special needs while caring for the             •	 All	parents	expecting	multiples	to	Twin
   other baby(ies). When one or more of the babies              Services and the National Organization of
   dies,	the	parents	have	the	extraordinary	task	of	            Mothers of Twins Clubs	and	give	them	the	list	
   mourning	while	caring	for	the	survivor(s).	(See	the	         of Baby Products Discounts and Coupons
   Birth Defects section and Perinatal Loss section in       •	 Women	expecting	triplets	or	higher	to	the	
   the Psychosocial guidelines.)                                Triplet Connection and MOST
                                                             •	 Women	with	twin-to-twin	transfusion	
                                                                syndrome to the two relevant support
                                                             •	 Women	who	lose	one	or	more	multiples	to	the	
                                                                Center for Loss in Multiple Birth

   Steps to Take — 2009 • Health Education                                                                  HE– 135
       y Mo
H ealth Baby
      thy             Multiple Births (cont.)

   Resources                                               Support groups
   •	 Financial	assistance,	food	supplements,	             •	 The	Triplet	Connection:	
      community respite programs, and churches                209-474-0885
   •	 Sources	of	used	clothing	and	equipment,	such	        •	 Mothers	of	Supertwins	(MOST):	
      as second hand stores and flea markets                  631-859-1110
                                                              Twin Hope, Inc.: 502-243-2110
   •	 La	Leche	League
                                                              (twin-to-twin transfusion syndrome)
   •	 Nursing	Mother’s	Council
                                                           •	 The	Twin	to	Twin	Transfusion	Syndrome	
   •	 Parental	stress	relief		 rganizations
                             o                                Foundation:
   •	 Car	seat	programs
                                                           •	 Center	for	Loss	in	Multiple	Birth	(CLIMB):	
   •	 Taxi	vouchers
   •	 Multiple	birth	specific	resources
   •	 Mothers	of	Twins	Clubs
   •	 The	National	Organization	of	Mothers	of	Twins	
      Clubs (NOMOTC): 877-540-2200, refer to local
      Mothers of Twins clubs, which sometimes offer
      support groups and/or flea market sales of
      used twin clothing and equipment. Video: Your
      Multiples and You: Conception to Six Months
      (available	in	English	and	Spanish).	
   •	 Parenting	education	and	technical	assistance	
      on case management
   •	 Twin	Services:		510-524-0863	(the	TWINLINE).	
      Publishes parenting education materials; offers
      training	for	health	and	family	service	providers;	
      provides	parenting	counseling	on	multiple	
      birth	development,	sliding	scale	fee.	The	Twin	
      Care Handout Collection.

   HE – 136                                                            Steps to Take — 2009 • Health Education
       y Mo
H ealth Baby
      thy           Getting Ready for Twins or Triplets

   Take care of yourself.                             Find people who can help.
   •	 Eat	healthy	foods.	                             You will need help while you are pregnant and
                                                      after your babies are born. You’ll need helpers
   •	 Drink	at	least	8–10	glasses	of	water	           to help:
      a day.
                                                      •	 Shop.
   •	 Get	some	exercise.	Ask	your	health	care	
      provider	about	how	much	you	can	do.             •	 Cook.
   •	 Stay	away	from	heavy	work	and	                  •	 Do	the	laundry.
      long commutes.
                                                      •	 Clean	the	house.
                                                      Find	out	which	of	your	relatives,	friends,	and	
   It is important to rest and relax.                 neighbors can help you with the housework
   •	 Rest.	Do	not	let	yourself	get	too	tired.        before and after the babies are born. There will
                                                      be too much work to do alone.
   •	 Take	naps.
   •	 In	the	2nd	and	3rd	trimester,	rest	on	your	
      left side for one hour. Do this three times a   You’ll also need help with your
      day.                                            children.
   •	 Lower	your	stress.	Talk	to	a	friend	            Find people who can help:
      or a counselor.                                 •	 Care	for	your	older	children.
                                                      •	 Bathe	the	babies.
                                                      •	 Change	diapers.
                                                      •	 Care	for	the	babies	while	you	sleep.
                                                      You may qualify for community respite
                                                      programs.	Ask	your	health	care	provider	about	

   Steps to Take — 2009 • Health Education                                                           HE– 137
       y Mo
H ealth Baby
      thy           More About Getting Ready

   Learn about twins and triplets.                    Gather baby clothes and
   •	 Talk	to	other	parents	with	twins	or	triplets	   equipment.
      for tips on their care.                         •	 Each	baby	will	need	clothes	and	diapers.	
   •	 Ask	at	the	library	for	books	on	twins	and	      •	 They	can	share	a	crib	at	first.	
                                                      •	 When	the	babies	are	small,	you	can	use	a	
   •	 Join	a	Mothers	of	Twins	club	or	                   single stroller for one baby and a baby pack
      support group. Call 1-877-540-2200 to find         for the other. Later on, you may need a twin
      out more.                                          stroller.
                                                      •	 Each	baby	needs	a	car	seat	every	time	they	
   Learn how to breastfeed.                              ride in a car.
   •	 Breast	milk	is	the	best	food	for	
                                                      •	 A	rocking	chair	can	relax	you	and	
      your babies.
                                                         the babies. Baby swings can also be a big
   •	 You	can	breastfeed	two	or	more	babies.	Your	       help.
      body can make enough milk once you and
      the babies start breastfeeding.
                                                      Find ways to save money for
   •	 Breastfeeding	gives	you	and	your	babies	        what you need.
      lots of time together. That will be good for
                                                      •	 Visit,	or	ask	a	friend	to	visit,	local	
      all of you.
                                                         second hand stores for children.
                                                      •	 Ask	the	store	to	call	you	if	they	find	a	twin	
   Help your older children                              stroller.
   get ready for the babies’ birth.
                                                      •	 Call	or	ask	a	friend	to	call	companies	that	
   Let them know what they will need to                  donate coupons or sample products to
   do to help.                                           families with twins or triplets.
   •	 Talk	to	them	about	the	babies	in	ways	they	
                                                      •	 See	the	handout	called	“Baby	Products,	
      can understand.
                                                         Discounts and Coupons.” It has a list of
   •	 Let	them	help	you	get	baby	clothes	                companies who can help.
      together and the crib ready.

                                                           Call the National Organization
                                                           of Mothers of Twins Clubs at

                                                           • Find the club nearest you.
                                                           • Ask your local club if they have
                                                              equipment and baby clothes.

   HE – 138                                                          Steps to Take — 2009 • Health Education
       y Mo
H ealth Baby
      thy             Preparándose para sus Gemelos

   Cuídese.                                           Busque a personas que
   •	 Coma	alimentos	nutritivos.                      puedan ayudar.
                                                      Usted	va	a	necesitar	ayuda	mientras	está	
   •	 Tome	por	lo	menos	de	8	a	10	vasos	de	agua	
                                                      embarazada y después de que nazcan sus
      al	día.
                                                      bebés. Va a necesitar ayudantes para:
   •	 Haga	ejercicio.	Pregúntele	a	su	médico	
      sobre	cuánto	ejercicio	puede	hacer.	            •	 Ir	de	compras.

   •	 No	haga	trabajo	pesado	o	viajes	de	larga	       •	 Cocinar.
      distancias.                                     •	 Lavar.
                                                      •	 Limpiar	la	casa.
   Es importante descansar y
                                                      Averigüe	cuáles	de	sus	parientes,	amigas,	o	
   relajarse.                                         vecinos	pueden	ayudarle	con	el	quehacer	de	la	
   •	 Descanse.	No	debe	cansarse	demasiado.           casa antes y después de que nazcan los bebés.
                                                      Habrá	mucho	trabajo	que	debe	hacer	sola.	
   •	 Tome	siestas.
   •	 En	los	últimos	6	meses,	descanse	del	lado	
      izquierdo	por	una	hora.	Haga	esto	tres	veces	   También va a necesitar ayuda
      al	día.	                                        con sus niños.
   •	 Disminuya	las	presiones.	Hable	con	una	         Busque a personas que le puedan
      amiga o un consejero.                           ayudar a:
                                                      •	 Cuidar	de	sus	niños	mayores.
                                                      •	 Bañar	a	los	bebés.
                                                      •	 Cambiar	pañales.
                                                      •	 Cuidar	de	sus	bebés	mientras	duerme.
                                                      Quizá	califique	para	programas	de	
                                                      descanso de la comunidad. Pregúntele a su
                                                      médico sobre ésto.

   Steps to Take — 2009 • Health Education                                                        HE– 139
       y Mo
H ealth Baby
      thy          Preparándose

   Aprenda más sobre                                  Junte ropita de bebé y aparatos.
   gemelos y trillizos.                               •	 Cada	bebé	va	a	necesitar	ropita	y	pañales.
   •	 Hable	con	otros	padres	de	gemelos	o	            •	 Al	principio	pueden	compartir	la	cuna.
      trillizos para que le den consejos sobre su
      cuidado.                                        •	 Cuando	los	bebés	están	pequeños,	puede	
                                                         usar una careola sencilla para uno de los
   •	 Pregunte	en	la	biblioteca	por	libros	sobre	        bebés y una bolsa para cargar al otro bebé
      gemelos y trillizos.                               en	su	pecho.	Depués,	tal	vez	necesite	una	
   •	 Unase	a	un	grupo	de	Madres	con	Gemelos	            careola para gemelos.
      o un grupo de ayuda. Llame al 1-877-540-        •	 Cada	bebé	necesita	su	propio	asiento	de	
      2200	para	más	información.	                        seguridad	siempre	que	viaje	en	carro.	
                                                      •	 Una	silla	mecedora	puede	ayudar	a	
   Aprenda cómo darles pecho.                            relajarla a usted y a los bebés. También los
   •	 La	leche	materna	es	el	mejor	alimento	para	        columpios para bebés pueden ser de gran
      sus bebés.                                         ayuda.
   •	 Puede	darles	pecho	a	dos	o	más	bebés.	Su	
      cuerpo puede producir suficiente leche          Encuentre formas de ahorrar
      una	vez	que	sus	bebés	empiezen	a	tomar	el	      dinero para lo que necesita.
                                                      •	 Visite,	o	pídale	a	una	amiga	que	visite,	
   •	 Usted	y	sus	bebés	podrán	compartir	más	            tiendas	de	segunda	para	niños.
      tiempo	juntos	si	da	pecho.	Esto	será	bueno	
                                                      •	 Pídale	a	la	tienda	que	le	llame	cuando	
      para todos ustedes.
                                                         encuentren una carreola para gemelos.
                                                      •	 Llame	o	pídale	a	una	amiga	que	le	llame	a	
   Ayude a sus niños mayores.
                                                         compañías	que	donan	cupones	o	muestras	
   Prepárelos para el nacimiento de                      de productos a familias con gemelos.
   los bebés.
                                                      •	 Vea	la	hoja	titulado	“Productos	para	bebés,	
   Déjelos saber cómo pueden ayudar.                     descuentos y cupones.” Tiene una lista de
   •	 Hábleles	acerca	de	los	bebés	en	una	manera	        compañías	que	le	pueden	ayudar.	
      que puedan entender.
   •	 Déjelos	que	le	ayuden	a	preparar	la	ropita	y	       Llame a la Organización Nacional de
      la cuna.                                            Clubs para Madres con Gemelos, al

                                                           • Encuentre el club más cercano a
                                                           • Pregúntele a su club local si
                                                             tienen aparatos y ropita de bebé

   HE – 140                                                        Steps to Take — 2009 • Health Education
                                                                                                       y Mo
                                                                                                  ealth Baby
Baby Products Discounts and Coupons                                                             H

for Families Who Expect Twins or Triplets

Here	is	a	list	of	companies	that	may	give	free	   Fisher Price
products, discounts and/or coupons to families    1-800-432-5437
of twins or triplets (also called multiples).     Offer: Family registry to get coupons/catalogs.

Associated Hygienic Products                      Gerber Baby Food
1-770-497-9800                                    1-800-4-GERBER
Offer: Coupons.                                   Offer:	Coupons,	newsletter,	for	every	stage	of	
Beechnut Baby Food
1-800-523-6633                                    Johnson & Johnson
Offer: New parent packet.                         Baby Products
Buster Brown Shoes                                Offer: Coupons and baby care booklets.
Offer: Parents can check with local stores for
their policies. Shoe stores in general seem       Kimberly Clark
happy	to	give	a	discount	for	twins.	Parents	
should always ask.
                                                  (Huggies or Pull-Ups)
                                                  P.O.	Box	2020,	Dept.	QMB
                                                  Neenah, WI 54927-2020
Earth’s Best Baby Foods                           1-800-544-1847
1-800-442-4221                                    Offer: Write for coupons. Proof of birth is
Offer: Coupons.                                   needed. Also, proof of purchase rewards
                                                  program and mailing list.

Evenflo Products—
Multiple Births                                   McNeil Consumer Products Group
1801	Commerce	Drive                               1-800-962-5357
Piqua, OH 45356                                   Offer:	Coupons	for	over-the-counter	pharma-
1-800-356-2229                                    ceuticals.
Offer: Coupons—return card and proof of birth
for free samples.                                 Proctor and Gamble (Pampers/
The 1st Years                                     1-800-285-6064
Parent Service Center                             Offer: Twins — diaper mailing list for coupons.
Multiple Birth Program                            Triplets or more — coupon for one time diaper
1	Kiddie	Drive                                    sample.
Avon,	MA	02322
Offer:	Free	samples.	Must	have	proof	
of birth.

Steps to Take — 2009 • Health Education                                                             HE– 141
                                                                                           y Mo
                                                                                      ealth Baby
Baby Products Discounts and Coupons                                                 H

for Families Who Expect Twins or Triplets

Sassy, Inc.
1534 College SE
Grand	Rapids,	MI	49507
Attn: Multiples Coordinator
Offer: Buy one, get one free training cup or utensils.
Must	have	proof	of	birth.

Sandoz Pharmaceutical (Triaminic)
Offer: Packet of free samples.

William Carter Company
1124	Carver	Road
Griffin,	GA	30223
Offer: Multiples program for triplets or more—will
send: 2 baby suits (onesies), 2 side snap shirts, 1
stretchy	(sleeper	with	feet)	per	baby.	Must	have	
proof of birth.

HE – 142                                                 Steps to Take — 2009 • Health Education
                                                                                               thy M
Productos para Bebés:                                                                      Heal y Baby

Descumentos y cupones para familias que esparan gemelos o trillizos

Aquí	está	una	lista	de	compañías	que	pueden	       Fisher Price
darle muestras gratis de productos, descuentos     1-800-432-5437
y cupones a familias de gemelos (cuates) o         Oferta – Registre la familia para recibir cupones
trillizos (también llamados múltiples).            y	catálagos.

Associated Hygenic Products                        Gerber Baby Food
1-770-497-9800                                     1-800-4-Gerber
Oferta – Cupones.                                  Oferta – Cupones, noticiero, para cada etapa de
Beechnut Baby Food
1-800-523-6633                                     Johnson & Johnson
Oferta	–	Paquete	para	nuevos	padres.               Baby Products
                                                   Oferta – cupones y libros sobre el cuidado del
Buster Brown Shoes                                 bebé.
Oferta – Los padres pueden comunicarse con
las tiendas locales para sus pólizas. En general
las tiendas de zapatos dan descuentos a            Kimberly Clark
gemelos (cuates). Los padres siempre deben         (Huggies o Pull-Ups)
preguntar.                                         PO	Box	2020	-Dept.	QMB
                                                   Neenah, WI 54927-2020
                                                   Oferta – Escriba para cupones. Necesita
Earth’s Best Baby Foods                            comprobante de nacimiento. Programa de
                                                   comprobante	de	compras	y	lista	de	envío.
Oferta – Cupones.

                                                   McNiel Consumer Products Group
Evenflo Products -                                 1-800-962-5357
Multiple Births                                    Oferta – Cupones para medicina sin receta.
1801	Commerce	Drive
Piqua, OH 45356
1-800-356-2229                                     Proctor and Gamble (Pampers/
Oferta – Cupones - regrese la tarjeta y            Luvs)
comprobante de nacimiento para muestras            1-800-285-6064
gratis.                                            Oferta	–	Gemelos	—	lista	de	envío	de	cupones	
                                                   para	pañales.	Trillizos	o	más	—	cupón	para	
                                                   muestra	de	pañales	una	sola	vez.	
The 1st Years
Parent Service Center
Multiple Birth Program
1	Kiddie	Drive

Steps to Take — 2009 • Health Education                                                             HE– 143
                                                                                      y Mo
                                                                                 ealth Baby
 Productos para Bebés:                                                         H

 Descumentos y cupones para familias que esparan gemelos o trillizos

Sassy, Inc.
1534 College SE
Grand	Rapids,	MI	49507
Attn: Multiples coordinator
Oferta – Compre una taza de principiante
o utensilios, reciba otra gratis. Debe tener
comprobante de nacimiento.

Sandoz Pharmaceutical (Triaminic)
1-800- 453-5300
Oferta – Paquete de muestras gratis.

William Carter Company
1124	Carver	Road
Griffen,	GA	30223
Oferta	–	Programa	para	trillizos	o	más—enviarán:	
4 camisetas y 1 mameluco por bebé. Debe tener
comprobante de nacimiento.

HE – 144                                            Steps to Take — 2009 • Health Education

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