Community Health Nursing

1. DEFINITION OF FAMILY
Family
 Basic unit in society, and is shaped by all forces surround it.Values, beliefs,
and customs of society influence the role and function of the family (invades
every aspect of the life of the family)
 Is a unit of interacting persons bound by ties of blood, marriage or
adoption.Constitute a single household, interacts with each other in their
respective familial roles and create and maintain a common culture.
 An open and developing system of interacting personalities with structure and
process enacted in relationships among the individual members regulated by
resources and stressors and existing within the larger community (Smith &
Maurer, 1995)
 Two or more people who live in the same household (usually), share a
common emotional bond, and perform certain interrelated social tasks
(Spradly & Allender, 1996)
 An organization or social institution with continuity (past, present, and future).
In which there are certain behaviors in common that affect each other.
The Filipino Family
Based on the Philippine Constitution, Family Code with focus on religious,
legal, and cultural aspects of the definition of family.

2. Section 1
 The state recognizes the Filipino family as the foundation of the nation.
Accordingly, it shall strengthen its solidarity and actively promote its total
development
Section 2
 Marriage, as an inviolable social institution, is the foundation of family and
shall be protected by the state.
Section 3
 The state shall defend –
1. The right of spouses to found a family in accordance with their religious
convictions and the demands of responsible parenthood.
2. The right of children to assistance including proper care and nutrition,
and special protection from all forms of neglect, abuse, cruelty, exploitation and
other conditions prejudicial to their development.
3. The right of the family to a family living wage income.
4. The right of families or family associations to participate in the planning
and implementation of policies and programs of that affect them.
Section 4
 The family has the duty to care for its elderly members but the state may also
do so through just programs of social security
The Filipino Family and its Characteristics
The basic social units of Philippine society are the nuclear family
1. Although the basic unit is the nuclear family, the influence of kinship is felt in all
segments of social organizations
2. Extensions of relationships and descent patterns are bilateral
3. Kinship circles is considerably greater because effective range often includes the
third cousin
4. Kin group is further enlarged by a finial, spiritual or ceremonial ties. Filipino
marriage is not an individual but a family affair
5. Obligation goes with this kingship system
6. Extended family has a profound effect on daily decisions

3. 7. There is a great degree of equality between husband and wife
8. Children not only have to respect their parents and obey them, but also have to
learn to repress their repressive tendencies
9. The older siblings have something of authority of their parents.
Types of Family
There are many types of family. They change overtime as a consequence of
BIRTH, DEATH, MIGRATION, SEPARATION and GROWTH OF FAMILY
MEMBERS.
A. Structure
 NUCLEAR- a father, a mother with child/children living together but apart
from both sets of parents and other relatives.
 EXTENDED- composed of two or more nuclear families economically and
socially related to each other. Multigenerational, including married brothers
and sisters, and the families.
 SINGLE PARENT-divorced or separated, unmarried or widowed male or
female with at least one child.
 BLENDED/RECONSTITUTED-a combination of two families with children
from both families and sometimes children of the newly married couple. It is
also a remarriage with children from previous marriage.
 COMPOUND-one man/woman with several spouses.
 COMMUNAL-more than one monogamous couple sharing resources; choose
to live together as an extended family.
 COHABITATION/LIVE-IN-unmarried couple living together.
 DYAD—husband and wife or other couple living alone without children.
 GAY/LESBIAN-homosexual couple living together with or without children.
 NO-KIN- a group of at least two people sharing a relationship and exchange
support who have no legal or blood tie to each other.
 FOSTER- substitute family for children whose parents are unable to care for
them
FUNCTIONAL TYPE:
1. Family of Procreation- refers to the family you yourself created.
2. Family of Orientation-refers to the family where you came fro

4. B. Decisionsin the family(Authority)
 PATRIARCHAL – full authority on the father or any male member of the
family e.g. eldest son, grandfather.
 MATRIARCHAL – full authority of the mother or any female member of the
family, e.g. eldest sister, grandmother.
 EGALITARIAN- husband and wife exercise a more or less amount of
authority, father and mother decides.
 DEMOCRATIC – everybody is involve in decision making.
 LAISSEZ-FAIRE- “full autonomy”
 MATRICENTRIC- the mother decides/takes charge in absence of the father
(e.g. father is working overseas).
 PATRICENTRIC- the father decides/ takes charge in absence of the mother.
C. Decent(culturalnorms,whichaffiliate a personwith a particular
group of kinsmanfor certain social purposes)
 PATRILINEAL – Affiliates a person with a group of relatives who are related
to him though his father.
 BILATERAL- both parents.
 MATRILINEAL - related through mother.
D. Residence
 PATRILOCAL - family resides / stays with / near domicile of the parents of
the husband.
 MATRILOCAL - live near the domicile of the parents of the wife.
Ackerman States that the Function of Family are:
1. Insuring the physical survival of the species.
2. Transmitting the culture, thereby insuring man’s humanness.

5. Physical functions of the family are met through parents providing food,
clothing and shelter, protection against danger provision for bodily repairs
after fatigue or illness, and through reproduction.
Affections function – the family is the primary unit in which he child test his
emotional reactions.
Social functions - include providing social togetherness, fostering self esteem
and a personal identity tied to family identity, providing opportunity for
observing and learning social and sexual roles, accepting responsibility
for behavior and supporting individual creativity and initiative.
UniversalFunctionof the Family by Doode
REPRODUCTION—
for replacement of members of society: to perpetuate the human species.
 STATUS PLACEMENT of individual in society
 BIOLOGICAL and MAINTENANCE OF THE YOUNG and dependent
members
 Socialization and care of the children;
 Social control
The Family as a Unit of Care
Rationale for Consideringthe Family as a Unit of Care:
 The family is considered the natural and fundamental unit of society.
 The family as a group generates, prevents, tolerates and corrects health
problems within its membership.
 The health problems of the family members are interlocking.
 The family is the most frequent focus of health decisions and action in
personal care.
 The family is an effective and available channel for much of the effort of the
health worker.
The Family as the Client
Characteristics of aFamily as a Client
 The family is a product of time and place
o A family is different from other family who lives in another location
in many ways.
o A family who lived in the past is different from another family who
lives at present in many ways.

6.  The family develops its own lifestyle
o Develop its own patterns of behavior and its own style in life.
o Develops their own power system which either be:
Balance-the parents and children have their own areas of decisions
and control.
Strongly Bias-one member gains dominance over the others.
 The family operate as a group
o A family is a unit in which the action of any member may set of a
whole series of reaction within a group, and entity whose inner
strength may be its greatest single supportive factor when one
of its members is stricken with illness or death.
 The family accommodates the needs of the individual members.
o An individual is unique human being who needs to assert his or
herself in a way that allows him to grow and develop.
o Sometimes, individual needs and group needs seem to find a
natural balance;
1. The need for self-expression does not over shadow
consideration for others.
2. Power is equitably distributed.
3. Independence is permitted to flourish.
 The family relates to the community
o Family develops a stance with respect to the community:
1. The relationship between the families is wholesome and reciprocal; the family
utilizes the community resources and in turn, contributes to the improvement of the
community.
2. There are families who feel a sense of isolation from the community.
a. Families who maintain proud, “We keep to ourselves” attitude.
b. Families who are entirely passive taking the benefits from the community
without either contributing to it or demanding changes to it.
 The family has a growth cycle
o Families pass through predictable development stages (Duvall
& Miller, 1990)
STAGES
Stage 1: MARRIAGE & THE FAMILY
 Involves merging of values brought into the relationship from the families of
orientation.
 Includes adjustments to each other’s routines (sleeping, eating, chores, etc.),
sexual and economic aspects.
 Members work to achieve 3 separate identifiable tasks:
1. Establish a mutually satisfying relationship
2. Learn to relate well to their families of orientation
3. If applicable, engage in reproductive life planning

7. Stage 2: EARLY CHILDBEARING FAMILY
 Birth or adoption of a first child which requires economic and social role
changes
 Oldest child: 2-1/2 years
Stage 3: FAMILY WITH PRE-SCHOOL CHILDREN
 This is a busy family because children at this stage demand a great deal of
time related to growth and development needs and safety considerations.
 Oldest child: 2-1/2 to 6 years old
Stage 4: FAMILY WITH SCHOOL AGE CHILDREN
 Parents at this stage have important responsibility of preparing their children
to be able to function in a complex world while at the same time maintaining
their own satisfying marriage relationship.
 Oldest child: 6-12 years old
Stage 5: FAMILY WITH ADOLESCENT CHILDREN
 A family allows the adolescents more freedom and prepare them for their own
life as technology advances-gap between generations increases
 Oldest child: 12-20 years old.
Stage 6: THE LAUNCHING CENTER FAMILY
 Stage when children leave to set their own household-appears to represent
the breaking of the family
 Empty nests
Stage 7: FAMILY OF MIDDLE YEARS
 Family returns to two partners nuclear unit
 Period from empty nest to retirement
Stage 8: FAMILY IN RETIREMENT/OLDER AGE
Stage 9: PERIOD FROM RETIREMENT TO DEATH OF BOTH SPOUSES
12 BehaviorsIndicating a Well Family
 Able to provide for physical emotional and spiritual needs of family members
 Able to be sensitive to the needs of the family members
 Able to communicate thought and feelings effectively
 Able to provide support, security and encouragement
 Able to initiate and maintain growth producing relationship
 Maintain and create constructive and responsible community relationships
 Able to grow with and through children
 Ability to perform family roles flexibly
 Able to help oneself and to accept help when appropriate
 Demonstrate mutual respect for the individuality of family members
 Ability to use a crisis experience as a means of growth
 Demonstrate concern of family unity, loyalty and interfamily cooperation

8. Family Health Task
 Health task differ in degrees from family to family
TASK- is a function, but with work or labor overtures assigned or
demanded of the person
 Duvall & Niller identified 8 task essential for a family to function
as a unit:
Eight Family Tasks (Duvall & Niller)
1. Physical maintenance- provides food shelter, clothing, and health care to its
members being certain that a family has ample resources to provide
2. Socialization of Family- involves preparation of children to live in the
community and interact with people outside the family.
3. Allocation of Resources- determines which family needs will be met and
their order of priority.
4. Maintenance of Order- task includes opening an effective means of
communication between family members, integrating family values and
enforcing common regulations for all family members.
5. Division of Labor – who will fulfill certain roles e.g., family provider, home
manager, children’s caregiver
6. Reproduction, Recruitment, and Release of family member
7. Placement of members into larger society –consists of selecting
community activities such as church, school, politics that correlate with the
family beliefs and values
8. Maintenance of motivation and morale- created when members serve as
support people to each other
5 Family Health Tasks(Maglaya,A., 2004)
a. Recognizing interruptions of health development
b. Making decisions about seeking health care/ to take action
c. Dealing effectively health and non-health situations
d. Providing care to all members of the family
e. Maintaining a home environment conducive to health maintenance
Family Roles
A. Nurturing figure- primary caregiver to children or any dependent member.
B. Provider – provides the family’s basic needs.
C. Decision maker- makes decisions particularly in areas such as finance,
resolution, of conflicts, use of leisure time etc.
D. Problem-solver- resolves family problems to maintain unity and solidarity.
E. Health manager- monitors the health and ensures that members return to
health appointments.
F. Gate keeper-Determines what information will be released from the family or
what new information cam be introduced.

9. Theoretical Approaches to Family Health Care
Family Models
 the use of family model provides a perspective of focus for understanding the
family
 have categorized according to their basic focus as developmental,
interactional structural-functional, and systems model
DevelopmentalModels
Duvall’s and Stevenson’s Family development model
 Evelyn Duvall’ (1977) family developmental framework provides guide to
examine and analyze the basic changes and developmental tasks common to
most families during their life cycle. Although each family has unique
characteristics normative patterns of sequential development are common to
all families.
 These stages and developmental tasks illustrate common family behaviors
that may be expected at specific times in the family life cycle. The stages are
marked by the age of the oldest child however some overlapping occurs in
families with several children.
STAGES OF DEVELOPMENT BASIC FAMILY TASK
Beginning Families
Early childbearing
Families with preschoolers
Families with school children
Families with teen-agers
Launching center families
Middle-aged families
Aging Families
Physical maintenance
Allocation of resources
Division of labor
Socialization of members.
Reproduction, recruitment and release
of Members
Maintenance of order
Placement of members in larger
community
Maintenance of motivation and morale
Duvall’s developmental model is an excellent guide for assessing,
analyzing and planning around basic family tasks developmental stage,
however, this model does not include the family structure or
physiological aspects, which should be considered for a comprehensive
view of the family. This model is applicable for nuclear families with
growing children and families who are experiencing health-related
problems.

10. Stevenson’s Family DevelopmentalModel
Joanne Stevenson (1977) describes the basic tasks and responsibilities of families
in four stages.
STAGES HEALTH TASKS
Emerging family (from
marriage for 7 to 10 years)
Couple strives for independence from their parents
and to develop a sense of responsibility for family life.
Crystallizing family (with
teenage children)
To assume responsibility for growth and
development of individual members and outside
organizations
Interacting family(children
grown and small
grandchildren)
Assumption of responsibility for “continued survival
and enhancement of the nation.”
Actualizing family (aging
couple alone again)
Assume the responsibility for sharing the wisdom of
age, reviewing life and putting affairs in order
She views family tasks as maintaining a common household rearing children
and finding satisfying work and leisure. It also includes sustaining appropriate health
patterns and providing mutual support and acculturation of family members.
This model is useful for nuclear families because it examines psychosocial
patterns to specific stage of development, however, it also does not include family
structure, nor it addresses health promotion and health-related concerns that the
family may face.
Structural-FunctionalModel
Friedman’s Structural- Functional Family Model
 Was developed from sociological frameworks and systems theory by Marilyn
Friedman (1986)
 The family is the focus of this model as it interacts with supra-systems in the
community and with individual family members in the subsystem.
Friedman’s Family Model Components
STRUCTURAL COMPONENTS FUNCTIONAL COMPONENTS
Family composition Affective
Value systems Physical necessities and care
Communication patterns Economic
Role structure Reproductive
Power structure Socialization and social placement
Family coping

11. Structural component examines the family unit, how it is organized and how
members relate to one another in terms of values, communication network, role
system and power while functional components refers to the interaction outcomes
resulting from family organizational structure.
The structural-functional components and parts all intimately interrelate and
interact; the others affect each component and part.
This model provides a broad framework for examining the interactions among
family and within the community. This incorporates physical, psychosocial and
cultural aspects of the family along with interacting relationships.
This model is very applicable to any type of family and their health-related
problems.
Family Apgar Questionnaire (SMILKESTEIN, 1978)
ALWAYS
(2 PTS.)
SOMETIMES
(1 pt.)
HARDLY
EVER
(0 PT.)
I am satisfied with the help I receive
from my family when something is
troubling me.
I am satisfied with the way my family
discovers items of common interest
and shares problem-solving with me.
I find that my family accepts my
wishes to take on new activities or
make changes in my lifestyle.
I am satisfied with the way my family
expresses affection and responds to
my feelings such as anger, sorrow
and love
I am satisfied with the way my family
and I spend time together.
Scoring:
Check one of the three choices:
Total Score:
7-10 = suggests a highly functional family
4-6 = moderately dysfunctional family
0-3 = severely dysfunctional family

12. Roles of Health Care Provider in Family Health Care
A. HEALTH MONITOR
B. PROVIDER OF CARE
C. COORDINATOR
D. FACILITATOR
E. TEACHER
F. COUNSELOR
Family Health Nursing— a family standard care
Nursing Process was first mentioned and defined by LYDIA HALL;
synonymous into the problem solving approaches; to plan and implement care and
also evaluate result. The nursing process is goal-oriented method of caring that
provides a framework to nursing care. It involves six major steps:
A
Assess (what data is collected?)
D
Diagnose (what is the problem?)
O
Outcome Identification - (Was originally a part of the Planning phase, but has
recently been added as a new step in the complete process).
P
Plan (how to manage the problem)
I
Implement (putting plan into action)
R
Rationale (Scientific reason of the implementations)
E
Evaluate (did the plan work?)
FAMILY NURSING PROCESS— systematic, organize method of
planning and providing clarity to individualize.
a. Data collection
b. Data analysis
c. Problem definition

13. ASSESSMENT PHASE
 first major phase of nursing process in family health nursing
 Involves a set of action by which the nurse measures the status of the family
as a client. Its ability to maintain wellness , prevent, control or resolve
problems in order to achieve health and wellness among its members
 Data about present condition or status of the family are compared against the
norms and standards of personal, social, and environmental health, system
integrity and ability to resolve social problems.
 The norms and standards are derived from values, beliefs, principles, rules or
expectation.
TWO MAJOR TYPES
1. FIRST LEVEL ASSESSMENT- a process whereby existing and
potential health conditions or problems of the family are determined.
It involves different types of data:
Family structure and characteristics
Family interaction
Decision making pattern and dynamics
Health problems composition
Demographic data
Health as a Goal of Family Health Care
 HEALTH DEFICIT- this refers to conditions of health breakdowns or
advent of illness in the family.
A. Illness states, regardless of whether it is diagnosed or undiagnosed by
medical practitioner.
B. Failure to thrive/develop according to normal rate
C. Disability-whether congenital or arising from illness; transient/temporary
(e.g. aphasia or temporary paralysis after a CVA) or permanent (e.g. leg
amputation secondary to diabetes, blindness from measles, lameness from
polio)
 HEALTH THREAT- these are the conditions that make it more likely for
accidents, disease or failure to thrive or develop to occur.
A. Presence of risk factors of specific diseases (e.g. lifestyle diseases,
metabolic syndrome)
B. Threat of cross infection from communicable disease case
C. Family size beyond what family resources can adequately provide
D. Accident hazards specify.

14. 1. Broken chairs
2. Pointed /sharp objects, poisons and medicines improperly kept
3. Fire hazards
4. Fall hazards
5. Others specify.
E. Faulty/unhealthful nutritional/eating habits or feeding techniques/practices.
Specify.
1. Inadequate food intake both in quality and quantity
2. Excessive intake of certain nutrients
3. Faulty eating habits
4. Ineffective breastfeeding
5. Faulty feeding techniques
6. Stress Provoking Factors. Specify.
7. Strained marital relationship
8. Strained parent-sibling relationship
9. Interpersonal conflicts between family members
10. Care-giving burden
G. Poor Home/Environmental Condition/Sanitation. Specify.
1. Inadequate living space
2. Lack of food storage facilities
3. Polluted water supply
4. Presence of breeding or resting sights of vectors of diseases
5. Improper garbage/refuse disposal
6. Unsanitary waste disposal
7. Improper drainage system
8. Poor lightning and ventilation
9. Noise pollution
10.Air pollution
H. Unsanitary Food Handling and Preparation
I. Unhealthy Lifestyle and Personal Habits/Practices. Specify.
1. Alcohol drinking
2. Cigarette/tobacco smoking
3. Walking barefooted or inadequate footwear
4. Eating raw meat or fish
5. Poor personal hygiene
6. Self medication/substance abuse
7. Sexual promiscuity
8. Engaging in dangerous sports
9. Inadequate rest or sleep
10.Lack of /inadequate exercise/physical activity
11.Lack of/relaxation activities
12.Non use of self-protection measures (e.g. non use of bed nets in malaria and
filariasis endemic areas).

15. J. Inherent Personal Characteristics-e.g. poor impulse control
K. Health History, which may Participate/Induce the Occurrence of Health Deficit,
e.g. previous history of difficult labor.
L. Inappropriate Role Assumption- e.g. child assuming mother’s role, father not
assuming his role.
M. Lack of Immunization/Inadequate Immunization Status Specially of Children
N. Family Disunity-e.g.
1. Self-oriented behavior of member(s)
2. Unresolved conflicts of member(s)
3. Intolerable disagreement
 FORESEEABLE CRISIS- these are anticipated periods of unusual demand
on the family in terms of time or resources.
A. Marriage
B. Pregnancy, labor, puerperium
C. Parenthood
D. Additional member-e.g. newborn, lodger
E. Abortion
F. Entrance at school
G. Adolescence
H. Divorce or separation
I. Menopause
J. Loss of job
K. Hospitalization of a family member
L. Death of a member
M. Resettlement in a new community
N. Illegitimacy
 WELLNESS POTENTIAL- this refers to states of wellness and the likelihood
for health maintenance or improvement to occur depending on the desire of
the family.
DATA COLLECTION METHODS: SELECT APPROPRIATE METHOD
 OBSERVATION
Done through use of sensory capacities
The nurse gathers information about the family’s state of being and
behavioral responses
The family’s health status can be inferred from the s/sx of problem
areas
 a. communication and interaction patterns expected ,used,
and tolerated by family members
 b. role perception / task assumption by each member
including decision making patterns
 c. conditions in the home and environment

16. Data gathered though this method has the advantage of being subjected to
validation and reliability testing by other observers.
 PHYSICAL EXAMINATION
o Significant data about the health status of individual members can be
obtained through direct examination through IPPA, Measurement of
specific body parts and reviewing the body systems.
o Data gathered from P.A form substantive part of first level assessment
which may indicate presence of health deficits (illness state).
 INTERVIEW
o Productivity of interview process depends upon the use effective
communication techniques to elicit needed
response.
PROBLEMS ENCOUNTERED:
 How to ascertain where the client is in terms of perception of health condition
or problems and the patterns of coping utilized to resolve them.
 Tendency of community health worker to readily give out advice, health
teachings or solutions once they have identified the health condition or
problems.
o Provisions of models for phrasing interview questions utilization of
deliberately chosen communication techniques for an adequate
nursing assessment.
o Confidence in the use of communication skills
o Being familiar with and being competent in the use of type of question
that aims to explore, validate, clarify, offer feedback, encourage
verbalization of thought and feelings and offer needed support or
reassurance.
TYPES:
1. Completing health history of each family member.
 Health history determines current health status based on significant PAST
HEALTH HISTORY e.g. developmental accomplishment, known
illnesses, allergies, restorative treatment, residence in endemic areas
for certain diseases or sources of communicable diseases.
 FAMILY HISTORY e.g. genetic history in relation to health and illness.
 SOCIAL HISTORY e.g. intra-personal and inter-personal factors
affecting the family member social adjustment or vulnerability to stress
and crisis.
2. Collecting data by personally asking significant family members or relatives
questions regarding health, family life experiences and home environment to
generate data on what wellness condition and health problem exist in the family
(first level assessment) and the corresponding nursing problems for each health
condition or problem ( 2nd level assessment).

17. RECORDS REVIEW
 Gather information through reviewing existing records and reports pertinent to
the client
 Individual clinical records of the family members, laboratory and diagnostic
reports, immunization records reports about home and environmental
conditions
LABORATORY/ DIAGNOSTIC TEST
ANALIZE DATA TO IDENTIFY NEEDS AND PROBLEMS
CRITERIA FOR ANALYSIS:
PROCESS FOR ANALYSIS:
 SORTING OF DATA
 CLUSTERING OF RELATED CUES
 DISTINGUISHING RELEVANT FROM IRRELEVANT CUES
 IDENTIFYING PATTERNS
 COMPARING PATTERNS
 INTERPRETING RESULTS OF COMPARISON
 MAKING INFERENCES AND DRAWING CONCLUSIONS
Health Needs and Problems of the Family
 A situation which interferes with the promotion and / or maintenance of health
 It is a health problem when it stated as the family’s failure to perform
adequately specific health task to enhance the wellness state or manage a
health problem
2. SECOND LEVEL ASSESSMENT- defines the nature or type of nursing
problem that family encounters in performing health task with respect to
given health condition or problem and etiology or barriers to the family’s
assumption of the task.
I. Inability to recognize the presence of the condition or problem due to:
A. Lack of or inadequate knowledge
B. Denial about its existence or severity as a result of fear of consequences of
diagnosis of problem, specifically:
1. Social-stigma, loss of respect of peer/significant others
2. Economic/cost implications
3. Physical consequences
4. Emotional/psychological issues/concerns

18. C. Attitude/Philosophy in life, which hinders recognition/acceptance of a problem
D. Others. Specify _________
II. Inability to make decisions with respect to taking appropriate health action
due to:
A. Failure to comprehend the nature/magnitude of the problem/condition
B. Low salience of the problem/condition
C. Feeling of confusion, helplessness and/or resignation brought about by perceive
magnitude/severity of the situation or problem, i.e. failure to breakdown problems
into manageable units of attack.
D. Lack of/inadequate knowledge/insight as to alternative courses of action open to
them
E. Inability to decide which action to take from among a list of alternatives
F. Conflicting opinions among family members/significant others regarding action to
take.
G. Lack of/inadequate knowledge of community resources for care.
H. Fear of consequences of action, specifically:
1. Social consequences
2. Economic consequences
3. Physical consequences
4. Emotional/psychological consequences
I. Negative attitude towards the health condition or problem-by negative attitude is
meant one that interferes with rational decision-making.
J. In accessibility of appropriate resources for care, specifically:
1. Physical Inaccessibility
2. Costs constraints or economic/financial inaccessibility
K. Lack of trust/confidence in the health personnel/agency
L. Misconceptions or erroneous information about proposed course(s) of action
M. Others specify._________
III. Inability to provide adequate nursing care to the sick, disabled, dependent
or vulnerable/at risk member of the family due to:
A. Lack of/inadequate knowledge about the disease/health condition (nature,
severity, complications, prognosis and management)
B. Lack of/inadequate knowledge about child development and care
C. Lack of/inadequate knowledge of the nature or extent of nursing care needed
D. Lack of the necessary facilities, equipment and supplies of care
E. Lack of/inadequate knowledge or skill in carrying out the necessary intervention
or treatment/procedure of care (i.e. complex therapeutic regimen or healthy lifestyle
program).

19. F. Inadequate family resources of care specifically:
1. Absence of responsible member
2. Financial constraints
3. Limitation of luck/lack of physical resources
G. Significant persons unexpressed feelings (e.g. hostility/anger, guilt, fear/anxiety,
despair, rejection) which his/her capacities to provide care.
H. Philosophy in life which negates/hinder caring for the sick, disabled, dependent,
vulnerable/at risk member
I. Member’s preoccupation with on concerns/interests
J. Prolonged disease or disabilities, which exhaust supportive capacity of family
members.
K. Altered role performance, specify.
1. Role denials or ambivalence
2. Role strain
3. Role dissatisfaction
4. Role conflict
5. Role confusion
6. Role overload
L. Others. Specify._________
IV. Inability to provide a home environment conducive to health maintenance
and personal development due to:
A. Inadequate family resources specifically:
1. Financial constraints/limited financial resources
2. Limited physical resources-e.i. lack of space to construct facility
B. Failure to see benefits (specifically long term ones) of investments in home
environment improvement
C. Lack of/inadequate knowledge of importance of hygiene and sanitation
D. Lack of/inadequate knowledge of preventive measures
E. Lack of skill in carrying out measures to improve home environment
F. Ineffective communication pattern within the family
G. Lack of supportive relationship among family members
H. Negative attitudes/philosophy in life which is not conducive to health maintenance
and personal development
I. Lack of/inadequate competencies in relating to each other for mutual growth and
maturation (e.g. reduced ability to meet the physical and psychological needs of
other members as a result of family’s preoccupation with current problem or
condition.
J. Others specify._________

20. V. Failure to utilize community resources for health care due to:
A. Lack of/inadequate knowledge of community resources for health care
B. Failure to perceive the benefits of health care/services
C. Lack of trust/confidence in the agency/personnel
D. Previous unpleasant experience with health worker
E. Fear of consequences of action (preventive, diagnostic, therapeutic, rehabilitative)
specifically:
1. Physical/psychological consequences
2. Financial consequences
3. Social consequences
F. Unavailability of required care/services
G. Inaccessibility of required services due to:
1. Cost constrains
2. Physical inaccessibility
H. Lack of or inadequate family resources, specifically
1. Manpower resources, e.g. baby sitter
2. Financial resources, cost of medicines prescribe
I. Feeling of alienation to/lack of support from the community, e.g. stigma due to
mental illness, AIDS, etc.
J. Negative attitude/ philosophy in life which hinders effective/maximum utilization of
community resources for health care
Diagnosing phase
Nursing diagnoses represent the nurse's clinical judgment about actual or
potential health problems/life process occurring with the individual, family, group or
community. The accuracy of the nursing diagnosis is validated when a nurse is able
to clearly identify and link to the defining characteristics, related factors and/or risk
factors found within the patients assessment. Multiple nursing diagnoses may be
made for one client.
Planning phase
The nurse prioritizes which diagnoses will receive the most attention first
according to their severity and potential for causing more serious harm. For each
problem a measurable goal/outcome is set. For each goal/outcome, the nurse

21. selects nursing interventions that will help achieve the goal/outcome. A common
method of formulating the expected outcomes is to use the evidence-based Nursing
Outcomes Classification to allow for the use of standardized language which
improves consistency of terminology, definition and outcome measures.
The interventions used in the Nursing Interventions Classification again allow
for the use of standardized language which improves consistency of terminology,
definition and ability to identify nursing activities, which can also be linked to nursing
workload and staffing indices. The result of this phase is a nursing care plan. In
family setting use a long term goal S. M. A. R. T.
Implementing phase
The nurse implements the nursing care plan, performing the determined
interventions that were selected to help meet the goals/outcomes that were
established. Delegated tasks and the monitoring of them are included here as well.
Evaluating phase
The nurse evaluates the progress toward the goals/outcomes identified in the
previous phases. If progress towards the goal is slow, or if regression has occurred,
the nurse must change the plan of care accordingly. Conversely, if the goal has
been achieved then the care can cease. New problems may be identified at this
stage, and thus the process will start all over again.
Characteristics
The nursing process is a cyclical and ongoing process that can end at any
stage if the problem is solved. The nursing process exists for every problem that the
individual/family/community has. The nursing process not only focuses on ways to
improve physical needs, but also on social and emotional needs as well.
 Cyclic and dynamic
 Goal directed and client centered
 Interpersonal and collaborative
 Universally applicable
 Systematic
The entire process is recorded or documented in order to inform all members
of the health care team.

22. Variations and documentation
The PIE method is a system for documenting actions, especially in the field
of nursing. The name comes from the acronym PIE meaning Problem, Intervention,
Evaluation.
SEXUALITY and SEXUAL IDENTITY
Sexuality— multidimensional phenomenon that includes feelings, attitudes,
and actions. It has both biologic and cultural components; it encompasses and gives
direction to a person’s physical, emotional, social and intellectual response
throughout life.
Biologic Gender— term used to denote a person’s chromosomal sex
XX- female XY- male
Gender: refers to the social and cultural codes used to distinguish between
what a particular society considers ‘masculine’ or ‘feminine’ qualities, characteristics,
attributes or behaviors.
Gender Identity (Sexual Identity) — inner sense a person has, being male
or female, which may be the same or as different as biologic gender.
Gender role— male or female behavior a person exhibits, which may or may
not be the same as biologic gender or gender identity.
SEXUAL RESPONSE CYCLE

23. Phase 1: Excitement
General characteristics of the excitement phase, which can last from a few
minutes to several hours, include the following:
 Muscle tension increases.
 Heart rate quickens and breathing is accelerated.
 Skin may become flushed (blotches of redness appear on the chest and
back).
 Nipples become hardened or erect.
 Blood flow to the genitals increases, resulting in swelling of the woman’s
clitoris and labia minor (inner lips), and erection of the man's penis.
 Vaginal lubrication begins.
 The woman's breasts become fuller and the vaginal walls begin to swell.
 The man's testicles swell, his scrotum tightens, and he begins secreting a
lubricating liquid.
Phase 2: Plateau
General characteristics of the plateau phase, which extends to the brink of
orgasm, include the following:
 The changes begun in phase 1 are intensified.
 The vagina continues to swell from increased blood flow, and the vaginal
walls turn a dark purple.
 The woman's clitoris becomes highly sensitive (may even be painful to touch)
and retracts under the clitoral hood to avoid direct stimulation from the penis.
 The man's testicles are withdrawn up into the scrotum.
 Breathing, heart rate, and blood pressure continue to increase.
 Muscle spasms may begin in the feet, face, and hands.
 Muscle tension increases.
Phase 3: Orgasm
The orgasm is the climax of the sexual response cycle. It is the shortest of the
phases and generally lasts only a few seconds. General characteristics of this phase
include the following:
 Involuntary muscle contractions begin.
 Blood pressure, heart rate, and breathing are at their highest rates, with a
rapid intake of oxygen.
 Muscles in the feet spasm.
 There is a sudden, forceful release of sexual tension.
 In women, the muscles of the vagina contract. The uterus also undergoes
rhythmic contractions.
 In men, rhythmic contractions of the muscles at the base of the penis result in
the ejaculation of semen.
 A rash, or "sex flush" may appear over the entire body.

24. Phase 4: Resolution
During resolution, the body slowly returns to its normal level of functioning,
and swelled and erect body parts return to their previous size and color. This phase
is marked by a general sense of well-being, enhanced intimacy and, often, fatigue.
Some women are capable of a rapid return to the orgasm phase with further
sexual stimulation and may experience multiple orgasms. Men need recovery time
after orgasm, called a refractory period, during which they cannot reach orgasm
again. The duration of the refractory period varies among men and usually lengthens
with advancing age.
CELIBACY— abstinence from sexual activity and the ability to concentrate on
means of giving and receiving love other than through sexual expression.
MASTURBATION: self stimulation for erotic pleasure
 Women use it more than men.
 Sexual self stimulation offers release of tension and anxiety.
 Children 2-6 y/o; discover masturbation as an enjoyable activity as they
explore their bodies.
EROTIC STIMULATION— use of visual materials such as magazines or
photographs for sexual arousal.
FETISHISM— sexual arousal resulting from the use of certain objects or
situations. (Leather, rubber, shoes and feet are frequently perceived to have
erotic qualities)
TRANSVESTISM— a transvestite is one who dresses to take on the role of
the opposite sex. A transvestite may be a homosexual, a heterosexual or a
bisexual.
SANDOMASOCHISM
Sandism— involves inflicting pain— to achieve
Masochism— involves receiving pain— sexual satisfaction
This is a practice considered within the limits of normal sexual expression as
long as the pain involved is minimal and the experience is satisfying to both sexual
partners.
VOYEURISM— obtaining sexual arousal by looking at a person’s body
stalking; a crime that includes elements of voyeurism. Perversion in which a
person receives sexual gratification from seeing the genitalia of others or
witnessing other’s sexual behavior.
AUTOEROTIC ASPHYXIA— extreme practice of causing oxygen deficiency
during masturbation with the goal of producing a feeling of extreme sexual

25. excitement. Some adolescents are not aware that this act may be fatal, and
thus are killed by this practice each year.
EXHIBITIONISM— revealing one’s genitals in public.
PEDOPHILIA— pedophiles are individuals interested in sexual encounters
with children.
BESTIALITY— human sexual relationships with an animal.
NECROPHILIA— human sexual relationships with the dead people.
MENDELIAN FASHION OF GENETICS
The laws of inheritance were derived by Gregor Johann Mendel, a
nineteenth-century Austrian monk.
Objectives:
 To identify how probability is used to predict outcomes of genetic crosses.
 To outline how a Punnett Square helps predict outcomes of genetic crosses.
 To identify how probability can help determine the alleles in a gamete.
 To identify how a testcross is used to determine the genotype of an organism.
 To identify the ratio of phenotypes that appeared in Mendel’s dihybrid
crosses.
 To examine how a pedigree is used in the study of human inheritance.
 To describe how codominance does not follow Mendelian Inheritance.
 To describe how incomplete dominance does not follow Mendelian
Inheritance.
 To identify examples of polygenic traits in humans.
 To outline how heredity and environment can interact to affect phenotype.
A Mendelian trait is a trait that is controlled by a single gene that has two
alleles. One of these alleles is dominant and the other is recessive. Several
inheritable conditions in humans are passed to offspring in a simple Mendelian
fashion.
Medical professionals use Mendel’s laws to predict and understand the
inheritance of certain traits in their patients. Also, farmers, animal breeders, and
horticulturists who breed organisms can predict outcomes of crosses by
understanding Mendelian inheritance.
Is the trait sex-linked or autosomal?
A sex chromosome is a chromosome that determines the sex of an
organism. Humans have two sex chromosomes, X and Y. Females have two X
chromosomes (XX), and males have one X and one Y (XY). An autosome is any
chromosome other than a sex chromosome. If a trait is autosomal it will affect males
and females equally.

26. A sex-linked trait is a trait whose allele is found on a sex chromosome. The
human X chromosome is significantly larger than the Y chromosome; there are
many more genes located on the X chromosome than there are on the Y
chromosome. As a result there are many more X-linked traits than there are Y-linked
traits. Most sex-linked traits are recessive. Because males carry only one X
chromosome, if they inherit a recessive sex-linked gene they will show a sex-linked
condition.
Because of the recessive nature of most sex-linked traits, a female who
shows a sex-linked condition would have to have two copies of the sex-linked allele,
one on each of her X chromosomes. Figure 5 shows how red-green colorblindness,
a sex-linked disorder, is passed from parent to offspring.
Is the TraitDominantor Recessive?
If the trait is autosomal dominant, every person with the trait will have a
parent with the trait. If the trait is recessive, a person with the trait may have one,
both or neither parent with the trait. An example of an autosomal dominant disorder
in humans is Huntington’s disease (HD).
Huntington’s disease is a degenerative disease of the nervous system. It has
no obvious effect on phenotype until the person is aged 35 to 45 years old. The
disease is non-curable and, eventually, fatal. Every child born to a person who
develops HD has a 50% chance of inheriting the defective allele from the parent.
Are the Individuals with the Trait Heterozygous or Homozygous?
If a person is homozygous or heterozygous for the dominant allele of a trait,
they will have that trait. If the person is heterozygous for a recessive allele of the
trait, they will not show the trait. A person who is heterozygous for a recessive allele
of a trait is called a carrier. Only people who are homozygous for a recessive allele
of a trait will have the trait.

27. Maternal Serum Alpha-Fetoprotein Screening (MSAFP)
also Known as Alpha-Fetoprotein Test (AFP) is a screening test that
examines the level of alpha-fetoprotein in the mother’s blood during pregnancy. This
is not a diagnostic test. It is often part of the triple screen test that assesses
whether further diagnostic testing may be needed.
It is very important to remember what a screening test is before getting one
performed.
This will help alleviate some of the anxiety that can accompany test results.
Screening tests do not look only at results from the blood test. They compare a
number of different factors (including age, ethnicity, results from blood tests,
etc.) and then estimate what a person’s chances are of having an abnormality.
These tests DO NOT diagnose a problem; they only signal that further testing
should be done.
How is the MSAFP performed?
Blood is drawn from veins in the
mother’s arm and sent off to a laboratory for
analysis. Results are usually returned
between one and two weeks.
When is MSAFP performed?
MSAFP may be performed between the 14th and 22nd weeks of
pregnancy, however it seems to be most accurate during the 16th to 18th week.
Your levels of AFP vary during pregnancy so accurate pregnancy dating is
imperative for more reliable screening results.
All pregnant women should be offered the MSAFP screening, but it is
especially recommended for:
 Women who have a family history of birth defects
 Women who are 35 years or older
 Women who used possible harmful medications or drugs during pregnancy
 Women who have diabetes

28. What does the MSAFP test look for?
Alpha- fetoprotein (AFP) is found in both fetal serum and also amniotic fluid.
This protein is produced early in gestation by the fetal yolk sac and then later in the
liver and gastrointestinal tract. The true function of AFP is unknown. We do know
that this protein’s level increases and decreases during certain weeks of pregnancy
which is why accurate pregnancy dating is crucial.
The AFP test is measuring high and low levels of alpha-fetoprotein. The
results are combined with the mother’s age and ethnicity in order to assess
probabilities of potential genetic disorders.
High levels of AFP may suggest that the developing baby has a neural tube
defect such as spina bifida or anencephaly. High levels of AFP may also suggest
defects with the esophagus or a failure of your baby’s abdomen to close. However,
the most common reason for elevated AFP levels is inaccurate dating of the
pregnancy.
Low levels of AFP and abnormal levels of hCG and estriol may indicate that
the developing baby has Trisomy 21( Down syndrome), Trisomy 18 (Edwards
Syndrome) or another type of chromosome abnormality.
Abnormal levels may also be a result of the following:
 A multiples pregnancy
 Pregnancies that are more or less advanced than thought
What do MSAFP results mean?
It is important to remember that the AFP is a screening test and not a
diagnostic test. This test only notes that a mother is at risk of carrying a baby with a
potential disorder. There are approximately 25 to 50 abnormal test results for every
1,000 pregnancies tested.
What are the risks and side effects of MSAFP to the mother or baby?
Except for the discomfort of drawing blood, there are no risks or side effects
associated with the MSAFP.
What about further testing?
MSAFP is a routine test that is not an invasive procedure and poses no
known risks to the mother or baby. The MSAFP results may warrant additional
testing. The reasons to pursue further testing or not may vary from person to person
and couple to couple. Performing further testing allows you to confirm a diagnosis
and then provides you with certain opportunities:
 Pursue potential medical interventions that may exist

29.  Begin planning for a child with special needs
 Start addressing anticipated lifestyle changes
 Identify support groups and resources
 Make a decision about carrying the child to term
Some individuals or couples may elect not to pursue further
testing for various reasons:
 They are comfortable with the results no matter what the outcome is
 Because of personal, moral, or religious reasons, making a decision about
carrying the child to term is not an option
 Some parents choose not to allow any testing that poses any risk of harming
the developing baby
It is important to discuss the risks and benefits of further testing thoroughly
with your healthcare provider. Your healthcare provider will help you evaluate if the
benefits from the results could outweigh any risks from the procedure.
Amniocentesis is a diagnostic test carried out during pregnancy.
It can assess whether the unborn baby (foetus) could develop, or has developed, an
abnormality or serious health condition.
Things that increase the risk of an
abnormality include:
 the mother's age
 the mother's medical history
 a family history of inherited genetic
 conditions
Why and when amniocentesis is used?
Amniocentesis can be used to detect a number of conditions, such as:
 Down's syndrome – a genetic condition that affects a person's physical
appearance and mental development
 Spina bifida – a series of birth defects that affect the development of the
spine and nervous system
 Sickle cell anaemia – a genetic disorder that causes a person's red
blood cells to develop abnormally

30. Amniocentesis is usually carried out during weeks 15-20 of the pregnancy.
The procedure can be performed earlier than 15 weeks, but this is avoided if
possible because it may increase the risk of causing complications or
a miscarriage (loss of the pregnancy).
What happens during amniocentesis?
They'll also tell you about any alternative tests that may be appropriate,
such as chorionic villus sampling (CVS).If you decide to have amniocentesis,
you'll usually be asked to sign a consent form.
During the procedure, a needle will be used to extract a sample of amniotic fluid, the
fluid that surrounds the foetus in the womb (uterus).Amniotic fluid contains cells
shed from the foetus that can be examined and tested for a number of conditions.
Possible complications
Diagnostic tests, such as amniocentesis, are usually only offered to women
when there's a significant risk their baby will develop a serious condition or
abnormality. This is because the procedure is invasive (involves going into the body)
and has a small associated risk of miscarriage, estimated to be about 1 in 100.
A bacterial infection is another, but rare, possible complication of
amniocentesis. The risk of developing a serious infection from amniocentesis is
estimated to be less than 1 in 1,000.
The symptoms of an infection include:
 a high temperature (fever) of 38ºC (100.4ºF) or above
 tenderness of your abdomen (tummy)
 contractions (when your abdomen tightens then relaxes)
Seek immediate medical attention if you've recently had amniocentesis and you
experience any of these symptoms.
Results
 After you've had amniocentesis, the amniotic fluid sample taken during the
procedure will be tested in a laboratory.
 Most women's test results will be negative and their baby won't have any of
the disorders that were tested for.
 A positive test result means your baby has a disorder that was tested for. The
implications of this will be fully discussed with you.
Chorionic villus sampling (CVS) is a prenatal test that detects
chromosomal abnormalities such as Down syndrome, as well as a host of other
genetic disorders. The doctor takes cells from tiny fingerlike projections on the
placenta called the chorionic villi and sends them to a lab for genetic analysis.

31. Chorionic villi are tiny finger-shaped growths
found in the placenta. The genetic material in
chorionic villus cells is the same as that in the baby's
cells.
During CVS, a sample of the chorionic villus
cells is taken for biopsy. The chorionic villus cells are
checked for problems. The procedure is generally
done late in the first trimester, most often between the
10th and 12th weeks.
The chorionic villus sample can be collected by putting a thin flexible tube
(catheter) through the vagina and cervix into the placenta. The sample can also be
collected through a long, thin needle put through the belly into the
placenta. Ultrasound is used to guide the catheter or needle into the correct spot for
collecting the sample.
If you have a family history of certain diseases, CVS can be used to find
genetic disorders, such as Tay-Sachs disease or hemophilia. It can also find
chromosomal birth defects, such as Down syndrome. CVS cannot find neural tube
defects, and it cannot be used to see if the baby's lungs are mature.
Chorionic villus sampling can be done earlier in pregnancy (at 10 to 12
weeks) than amniocentesis (usually done at 15 to 20 weeks). This allows you to
know the health of your baby and make an earlier decision whether to continue or
end the pregnancy. Results of CVS can be available sooner than amniocentesis
results.
PREGNANCY UTERUS HEIGHT

32. Baby's Growth and Development in Early Pregnancy
Month One of Pregnancy
The amniotic sac is a water-tight sac
that forms around the fertilized egg. It helps
cushion the growing embryo throughout
pregnancy.
The placenta also develops at this
point in the first trimester. The placenta is a
round, flat organ that transfers nutrients from
the mother to the baby, and transfers waste
from the baby.
A primitive face takes form with large dark circles for eyes. The mouth,
lower jaw, and throat are developing. Blood cells are taking shape, and circulation
will begin. By the end of the first month of pregnancy, your baby is around 6-7mm
(1/4 inch) long - about the size of a grain of rice!
Month Two of Pregnancy
Your baby's facial features continue to develop.
Each ear begins as a little fold of skin at the side of the
head. Tiny buds that eventually grow into arms and legs
are forming. Fingers, toes, and eyes are also forming in
the second month of pregnancy.
The neural tube (brain, spinal cord, and other neural
tissue of the central nervous system) is well formed. The
digestive tract and sensory organs begin to develop. Bone
starts to replace cartilage. The embryo begins to move,
although the mother cannot yet feel it.
By the end of the second month, your baby, now a fetus is about 2.54cm (1
inch) long, weighs about 9.45g (1/3 ounce), and a third of baby is now made up of its
head.

33. Month Three of Pregnancy
By the end of the third month of pregnancy,
your baby is fully formed. Your baby has arms,
hands, fingers, feet, and toes and can open and
close its fists and mouth. Fingernails and toenails
are beginning to develop and the external ears are
formed. The beginnings of teeth are forming.
Your baby's reproductive organs also
develop, but the baby's gender is difficult to
distinguish on ultrasound. The circulatory and
urinary systems are working and the liver produces
bile.
At the end of the third month, your baby is about 7.6 -10 cm (3-4 inches) long and
weighs about 28g (1 ounce).
Changes in the Newborn at Birth
Changes in the newborn at birth refer to the changes an infant's body undergoes to
adapt to life outside the womb.
LUNGS, HEART, AND BLOOD VESSELS
The mother's placenta helps the baby "breathe" while it is growing in the
womb. Oxygen and carbon dioxide flow through the blood in the placenta. Most of it
goes to the heart and flows through the baby's body.
At birth, the baby's lungs are filled with amniotic fluid. They are not inflated.
The baby takes the first breath within about 10 seconds after delivery. This
breath sounds like a gasp, as the newborn's central nervous system reacts to the
sudden change in temperature and environment.
Once the baby takes the first breath, a number of changes occur in the
infant's lungs and circulatory system:
 Increased oxygen in the lungs causes a decrease in blood flow resistance to
the lungs.
 Blood flow resistance of the baby's blood vessels also increases.
 Amniotic fluid drains or is absorbed from the respiratory system.
 The lungs inflate and begin working on their own, moving oxygen into the
bloodstream and removing carbon dioxide by breathing out (exhalation).

34. BODY TEMPERATURE
A developing baby produces about twice as much heat as an adult. A small
amount of heat is removed through the developing baby's skin, the amniotic fluid,
and the uterine wall.
After delivery, the newborn begins to lose heat. Receptors on the baby's skin
send messages to the brain that the baby's body is cold. The baby's body creates
heat by burning stores of brown fat, a type of fat found only in fetuses and newborns.
Newborns are rarely seen to shiver.
LIVER
In the baby, the liver acts as a storage site for sugar (glycogen) and iron.
When the baby is born, the liver has various functions:
 It produces substances that help the blood to clot.
 It begins breaking down waste products such as excess red blood cells.
 It produces a protein that helps break down bilirubin. If the baby's body does
not properly break down bilirubin, it can lead to newborn jaundice.
GASTROINTESTINAL TRACT
A baby's gastrointestinal system doesn't fully function until after birth.
In late pregnancy, the baby produces a tarry green or black waste substance
called meconium. Meconium is the medical term for the newborn infant's first stools.
Meconium is composed of amniotic fluid, mucus, lanugo (the fine hair that covers the
baby's body), bile, and cells that have been shed from the skin and intestinal tract. In
some cases, the baby passes stools (meconium) while still inside the uterus.
URINARY SYSTEM
The developing baby's kidneys begin producing urine by 9 - 12 weeks into the
pregnancy. After birth, the newborn will usually urinate within the first 24 hours of
life. The kidneys become able to maintain the body's fluid and electrolyte balance.
The rate at which blood filters through the kidneys (glomerular filtration rate)
increases sharply after birth and in the first 2 weeks of life. Still, it takes some time
for the kidneys to get up to speed. Newborns have less ability to remove excess salt
(sodium) or to concentrate or dilute the urine compared to adults. This ability
improves over time.
IMMUNE SYSTEM
The immune system begins to develop in the baby, and continues to mature
through the child's first few years of life. The womb is a relatively sterile environment.
But as soon as the baby is born, he or she is exposed to a variety of bacteria and
other potential disease-causing substances. Although newborn infants are more
vulnerable to infection, their immune system can respond to infectious organisms.
Newborns do carry some antibodies from their mother, which provide
protection against infection. Breastfeeding also helps improve a newborn's immunity.

35. SKIN
Newborn skin will vary depending on the length of the pregnancy. Premature
infants have thin, transparent skin. The skin of a full-term infant is thicker.
Characteristics of newborn skin:
 A fine hair called lanugo might cover the newborn's skin, especially in preterm
babies. The hair should disappear within the first few weeks of the baby's life.
 A thick, waxy substance called vernix may cover the skin. This substance
protects the baby while floating in amniotic fluid in the womb. Vernix should
wash off during the baby's first bath.
 The skin might be cracking, peeling, or blotchy, but this should improve over
time.
FETAL CIRCULATION
The blood that flows through the fetus is actually more complicated than after
the baby is born (normal heart). This is because the mother (the placenta) is doing
the work that the baby’s lungs will do after birth.
The placenta accepts the bluest blood (blood without oxygen) from the fetus
through blood vessels that leave the fetus through the umbilical cord (umbilical
arteries, there are two of them). When blood goes through the placenta it picks up
oxygen and becomes red. The red blood then returns to the fetus via the third vessel
in the umbilical cord (umbilical vein). The red blood that enters the fetus passes
through the fetal liver and enters the right side of the heart.

36. The red blood goes through one of the two extra connections in the fetal heart
that will close after the baby is born. The hole between the top two heart chambers
(right and left atrium) is called a patent foramen ovale (PFO). This hole allows the
reddest blood to go from the right atrium to left atrium and then to the left ventricle
and out the aorta. As a result the blood with the most oxygen gets to the brain.
Blood coming back from the fetus’s body also enters the right atrium, but the
fetus is able to send this blue blood from the right atrium to the right ventricle (the
chamber that normally pumps blood to the lungs). Most of the blood that leaves the
right ventricle in the fetus bypasses the lungs through the second of the two extra
fetal connections known as the ductus arteriosus.
The ductus arteriosus sends the bluer blood to the organs in the lower half
of the fetal body. This also allows for the bluest blood to leave the fetus through the
umbilical arteries and get back to the placenta to pick up oxygen.
Since the patent foraman ovale and ductus arteriosus are normal findings
in the fetus, it is impossible to predict whether or not these connections will close
normally after birth in a normal fetal heart. These two bypass pathways in the fetal
circulation make it possible for most fetuses to survive pregnancy even when there
are complex heart problems and not be affected until after birth when these
pathways begin to close.
PHYSIOLOGICAL CHANGES DURING PREGNANCY
During pregnancy, your body goes through many emotional and physiological
changes. These changes are a natural part of pregnancy and a better understanding
will help you cope with them. Pregnancy is more than just the growth of the uterus
and the embryo.
Fertilization and early embryo formation cause significant changes in all of
your body's systems. This is how your body prepares and helps the pregnancy
develop into successful childbirth. Each woman is affected differently. Understanding
the changes and effects on the various body systems helps the burden during
pregnancy, reduces anxiety and unnecessary tensions. Some of the symptoms go
away immediately after birth and most of them disappear within six weeks of
delivery.
Normally, the uterus weighs 60 grams and is as large as a chicken egg. By
the end of a pregnancy it will weigh 1 kilogram and contain a baby, a placenta and
more than a quart of water.
As the uterus grows it presses against the woman's abdominal organs. The
uterus presses against the bladder, stomach and lungs, the arteries, veins and
nerves and stretches the abdominal skin. This results in frequent urination,
heartburn, congestion in the veins, difficulty breathing and other conditions that will
pass after birth as the uterus returns to its pre-pregnancy size.

37. CHANGES OF THE RESPIRATORY SYSTEM DURING PREGNANCY
a. The respiratory rate rises to 18 to 20 to compensate for increased maternal
oxygen consumption, which is needed for demands of the uterus, the placenta, and
the fetus.
b. Women may feel out of breath and may need to sit a moment to catch their
breath.
CHANGES OF BODY TEMPERATURE DURING PREGNANCY
a. A slight increase in body temperature in early pregnancy is noted. The
temperature returns to normal at about the 16th week of gestation.
b. The patient may feel warmer or experience "hot flashes" caused by
increased hormonal level and basal metabolic rate.
CHANGES OF THE URINARY SYSTEM DURING PREGNANCY
a. The kidneys must work extra hard excreting the mother's own waste
products plus those of the fetus. There is an increase in urinary output and a
decrease in the specific gravity.
b. The patient may develop urine stasis and pyelonephritis in the right kidney.
This is due to pressure on the right ureter resulting from displacement of the uterus
slightly to the right by the sigmoid colon.
c. Frequent urination is a complaint during the first through third trimester. As
the uterus rises out of the pelvic cavity in early pregnancy, pressure on the bladder
decreases and frequency diminishes. When lightening occurs during the final weeks
of pregnancy, pressure on the bladder returns to cause frequency.
CHANGES OF THE SKELETAL SYSTEM DURING PREGNANCY
a. There is a realignment of the spinal curvatures during pregnancy to maintain
balance (see figure 5-3). It is due to the increase in size of the uterus and pressure
on the abdominal wall. The patient walks with head and shoulders thrust backward
and chest protruding outward to compensate. This gives the patient a "waddling"
gait.
b. There is a slight relaxation and increased mobility of the pelvic joints, which allows
stretching at the time of delivery of the infant.

38. Postural changes during pregnancy.
CHANGES OF THE GASTROINTESTINAL SYSTEM DURING PREGNANCY
a. As mentioned in paragraph 5-1, as the pregnancy progresses, the uterus
enlarges. It rises up and out of the pelvic cavity. This action displaces the stomach,
intestines, and other adjacent organs.
b. Peristalsis is slowed because of the production of the hormone progesterone,
which decreases tone and mobility of smooth muscles. This slowing enhances the
absorption of nutrients and slows the rate of secretion of hydrochloric acid and
pepsin. Flare-up of peptic ulcers is uncommon in pregnancy. Slow emptying may
increase nausea and heartburn (pyrosis). Relaxation of the cardiac sphincter may
increase regurgitation and chance for heartburn. Movement through the large
intestines is also slowed due to an increase in water consumption from this area.
This increases the chance for constipation.
c. Nursing implications.
(1) If the mother has difficulty with nausea and/or heartburn, advise her to eat
small, frequent meals.
(2) The patient should eat a well- balanced diet high in protein, iron, and
calcium for fetal growth; high fiber and fluids to prevent constipation.
(3) The mother should not lie flat for 1 to 2 hours after eating because this
may cause heartburn and/or regurgitation.

39. CHANGES OF SELECTED GLANDS OF THE ENDOCRINE SYSTEM
DURING PREGNANCY
a. Parathyroid Gland. This gland increases in size slightly. It meets the increased
requirements for calcium needed for fetal growth.
b. Posterior Pituitary. Near the end of term, the posterior pituitary will begin to
secrete oxytocin that was produced in the hypothalamus and stored there. It will
serve to initiate labor.
c. Anterior Pituitary. At birth, the anterior pituitary will begin to secrete prolactin.
This stimulates the production of breast milk.
d. Placenta. The placenta acts as a temporary endocrine gland during pregnancy. It
produces large amounts of estrogen and progesterone by 10 to 12 weeks of
pregnancy. It serves to maintain the growth of the uterus, helps to control uterine
activity, and is responsible for many of the maternal changes in the body.
CHANGES IN BODY WEIGHT DURING PREGNANCY
a. Normal weight gain is about 24 to 30 pounds during pregnancy.
b. Weight gain in pregnancy.
(1) There is a slight loss of pounds during early pregnancy if the patient
experiences much nausea and vomiting.
(2) She then gains 2 to 4 pounds by the end of the first trimester.
(3) A gain of a pound per week is expected during the second and third
trimesters.
(4) Monitoring of weight gain should be done in conjunction with close
monitoring of blood pressure.
(5) A lack of significant weight gain may be an indication of intrauterine
growth retardation (IUGR) of the infant.
(6) Patients with multiple fetuses will require a higher caloric diet and expect a
higher weight gain than a patient with only one fetus.
c. Adequate protein intake should be emphasized to the patient for development of
the healthy fetus and proper diet reviewed at each prenatal visit.

40. Common Physiological Symptoms During Pregnancy
Frequent Urination - Make sure you drink plenty of water and cranberry juice
in order to prevent urinary tract infections. Perform exercises to strengthen the pelvic
floor (ex.: Kegel exercises) to control unwanted urination. Make sure you relieve
yourself on a regular basis. You must also be careful to maintain proper hygiene to
prevent infection. Perform periodic urine tests during pregnancy to avoid infections.
Heartburn - The growing uterus puts pressure on the sphincter of the
stomach. Eating small, frequent meals, avoiding spicy foods, fried foods, oils, and
eating almonds and ginger can help ease heartburn. Drinking a lot of water or soda
water (seltzer) with small sips, lying on your left side supported by pillows or in a half
sitting position also are helpful in controlling the heartburn. You should try to take
walk after meals. Avoid lying down immediately after eating to relieve and prevent
the onset of heartburn.
Nausea/Vomiting - Nausea and/or vomiting is caused by hormonal and
chemical changes during pregnancy. An empty stomach may increase the feeling of
nausea. Try eating dry snacks, rich in carbohydrates such as, crackers or biscuits
before bed and prior to getting out of bed in the morning.
Fatigue - This is caused by progesterone disturbances. It is a sign that your
body needs to rest.
Sleep disturbances - This can be caused by frequent urination, the inability
to find a comfortable sleeping position in bed, fetal movements or stress and worry.
Avoiding caffeine and using soft cushions to improve comfort can help. Talk through
your fears and anxieties in order to reduce stress.
Constipation - Constipation happened when there is a decrease in intestinal
function. The colon absorbs excess fluid as a result of the rise in progesterone. This
can be alleviated through proper nutrition. Drink 2-3 liters of liquid per day. Drink a
glass of hot water in the morning before a meal. Include a variety of fiber rich foods
in your diet such as fruits, vegetables, whole wheat bread, prunes and dried figs. It is
recommended to keep up physical activity like walking and exercising daily.
Hemorrhoids - Hemorrhoids occur due to the expansion and congestion of
blood vessels. In order to prevent hemorrhoids try to avoid constipation by drinking
plenty of fluids and consuming enough fiber. Hemorrhoids can be relieved by local
treatment and taking warm baths.

41. Back Pain - Back pain is caused by a change in the center of gravity, weight
gain and muscle tension, due to the need to maintain stability of the body. The
relaxing and progesterone hormones sometimes cause softening of the ligaments,
joint laxity and instability in the ankles. Back pain can be reduced by exercise such
as the rolling basin, correct posture, walking, wearing comfortable shoes, back rubs
and pressure applied to the painful area. Try to maintain a straight back when lifting
objects.
Leg Cramps - Leg cramps occur when there is poor absorption of calcium or
local deficiency of blood supply. To relieve leg cramps try lifting the leg that is
cramped, straightening the knee and facing your heel forward while applying
pressure against it. Massage the area with oil or natural cream like Bengay or Tiger
Oil. Taking a hot bath before bed can also help.
Swelling of the Hands and Feet - Swelling is caused by the accumulation of
fluids during pregnancy. Tight jewelry should be removed (such as rings). Elevate
your legs when resting and wear comfortable shoes.
Varicose Veins - Varicose veins are caused due to the expansion and
vascular congestion. Varicose veins usually occur in the legs, vulva and anus. To
relieve these symptoms, raise the end of your bed to 10 cm. This angle reduces
congestion. Wearing elastic socks before starting your day, exercising your feet also
help. Pay attention to any changes and if you notice redness, local heat or bleeding
consult your doctor.
Gum Disease - Gum disease occurs because gum blood vessels are
influenced by pregnancy hormones. As pregnancy progresses the gums might swell
and bleed easily. Brush your teeth (gently) two to three times a day and visit the
dentist or oral hygienist at least once during pregnancy.
Anemia - Anemia is a common problem among pregnant women and is
characterized by feeling constantly tired. To prevent anemia eat iron rich foods such
as green vegetables (green peppers, broccoli, lettuce), nuts and egg yolks, red meat
and turkey, and whole grains. Additionally, you can take iron tablets supplements.
Darkening of the Skin - The pigment of the skin changes due to hormonal
changes and/or sun exposure. Brown spots (chloasma) around the eyes and nose
can appear during the 3rd trimester. Some women will notice a dark line (linea

42. negra) from the naval down. Most symptoms disappear or decrease six months to a
year after delivery.
Mood Swings - Mood swings are a result of hormones and anxiety about the
upcoming birth. Often a heart-to-heart talk can improve your mood and situation in
general.Pregnancy is a normal phenomenon during which you will experience
different and new emotions.
ANTI-INFECTIVE DRUG USE IN OBSTETRICS
Anti-helminthic Drugs
A. Albendazole (C)—This broad-spectrum anti-infective is a member of the
benzimidazole class of anti-helminthic drugs. Albendazole is embryo and fetal toxic
and teratogenic in rats and rabbits, but not mice, at doses less than the
recommended human dose based on body surface area. Studies have not been
conducted on placental transfer, but the low molecular of the drug suggests that it
will cross the placenta. In humans, however, the oral bioavailability is only 1%,
compared to 20% to 30% in rats. Only 61 cases, 10 in the first trimester, of human
pregnancy exposure have been reported.
Normal outcomes were observed in all of these pregnancies. However,
because of the limb reduction defects observed with all doses in one animal study,
and the potential for much greater oral bioavailability of the metabolite if consumed
with a fatty meal, the use of albendazole during human pregnancy should be
avoided if possible, especially during the first trimester. The use of this anti-
helminthic drug has not been reported in breast-feeding women. The potential
effects of exposure on a nursing infant are unknown.
B. Ivermectin (C)—Ivermectin is teratogenic in mice, rats, and rabbits at doses
below or slightly above the recommended human dose on a body surface area
basis. These doses, however, would be maternal toxic so the agent does not appear
to be selectively fetal toxic. It is not known if ivermectin crosses the human placenta.
Inadvertent use of ivermectin in pregnant women (207 cases with 97 in early
gestation) during a mass treatment campaign for onchocerciasis was not associated
with an increase in abortion or birth defects.
Because of the high risk for blindness from onchocerciasis (a nematode or
roundworm), one review concluded that the agent could be given after the first
trimester. Low levels of ivermectin are excreted into human breast milk, but the four
women tested were not breast-feeding. The effects on a nursing infant from
exposure to this agent are unknown.

43. C. Mebendazole (C)— is a broad-spectrum anti-helminthic drug that is used for
treating pinworms, roundworms and hookworms. It was found to be teratogenic in
rats after a single oral dose that was approximately equal to the human dose based
on body surface area. Teratogenicity, however, was not observed in multiple other
animal species. In addition, the drug has very poor human systemic bioavailability,
and this would limit placental transfer.
More than 5,000 cases of human pregnancy exposure have been described
in the literature. No association with abortion or birth defects has been reported. In
fact, in one large study the use of mebendazole during the second trimester for
hookworm infections lowered the incidence of stillbirths and perinatal deaths
compared to controls (1.9% vs. 3.3%, p = 0.0004) and low birthweights compared to
controls (1.1% vs. 2.3%, p = 0.0003). Due to the poor oral absorption (only 2% to
10%) of mebendazole, the agent is not excreted into breast milk in detectable
amounts. Consequently, adverse effects in the nursing infant would not be expected.
D. Praziquantel (B)—reproduction studies in mice, rats, and rabbits with
praziquantel revealed no evidence of impaired fertility or teratogenicity, but an
increase in the abortion rate in rats was observed at a dose about 3 times the
human dose. The drug is rapidly and nearly completely absorbed following oral
administration, but placental transfer studies have not been conducted. Although
praziquantel has been rated a B, only one report of human exposure during
pregnancy has been published. Therefore, it is not possible to assess the fetal risk
from this agent. Moreover, because of the potential for mutagenic and carcinogenic
effects in humans, praziquantel should be reserved for those cases in which
cestodes (tapeworms) or trematodes (flukes) are causing clinical illness or public
health problems. Breast milk levels of praziquantel are about 25% of the maternal
serum level. No reports describing the use of this agent during lactation have been
published. The manufacturer recommends holding breast-feeding on the day of
treatment and for 72 hours after a dose because of the potential for toxicity in the
nursing infant.
E. Pyrantel Pamoate(C)—pyrantel pamoate is an anti-helminthic drug that can
be used for treating pinworms, roundworms and hookworms. The drug was not
found to be teratogenic in rats and rabbits, but no reports describing its use in
human pregnancy have been published.
The oral form of the drug is poorly absorbed from the gastrointestinal tract,
similar to mebendazole. Because of this, the effect on a nursing infant whose mother
is using the drug would probably be minimal; however, this drug has not been
studied during lactation.
F. Thiabendazole (C)—was not teratogenic in mice, rats, and rabbits at doses
near the human dose. However, when the drug was suspended in olive oil, cleft
palate and skeletal defects were observed in offspring of mice. It is not known if
thiabendazole crosses the human placenta. Human pregnancy experience is very
limited; none have occurred during the first trimester, and no reports of teratogenicity
have been published. It is not known if thiabendazole is excreted into breast milk.

44. Anti-Fungal Agents
A. AmphotericinB (B)—was not associated with fetal harm in pregnant rats
and rabbits, and a substantial body of reports indicates that there is no evidence of
adverse fetal effects in human pregnancy. The agent, however, readily crosses the
human placenta. There are no reports of its use during breast-feeding.
B. Caspofungin (C)—the use of this anti-fungal drug has not been reported
during human pregnancy. Animal reproduction studies have shown it to be embryo
toxic in rats and rabbits at systemic exposures equivalent to those used in humans.
Caspofungin crossed the placentas of both animals, but human studies have
not been published. Due to the lack of data, the use of caspofungin is not
recommended, especially in the first trimester.
C. Fluconazole (C)—this synthetic triazole anti-fungal agent causes
teratogenicity and toxicity in the embryos of pregnant rats. The effects were thought
to be consistent with inhibition of estrogen synthesis. It is not known if fluconazole
crosses the human placenta, but its low molecular weight suggests that transfer
should be expected. One case report of use during human pregnancy suggested
that fluconazole might be a human teratogen at doses of 400 mg/day or more.
The anomalies reported in the infant involved the head, face, skeleton, and
the heart. The malformations resembled those observed in the Antley-Bixler
syndrome, which is an autosomal recessive genetic disorder. However, because
some of the anomalies were similar to those seen in the fetal rats, a causal
relationship could not be excluded. Fluconazole is excreted in low amounts into
human breast milk. No adverse effects in exposed nursing infants have been
reported. Moreover, much higher doses, than those obtained from breast milk, have
been given to newborns without causing toxicity.
D. Flucytosine (C)—is metabolized by fungus to 5-fluorouracil, an anti-
neoplastic drug that is a possible human teratogen. The agent is teratogenic in mice
and rats, but not in rabbits. Placental transfer in humans has not been studied.
Human pregnancy experience is limited to three case reports, all after the first
trimester. Although no adverse effects were reported, the data are too limited to
make an assessment of the human fetal risk. However, the agent should probably
be avoided in the first trimester, if at all possible. Breast-feeding is not recommended
because of the potential for serious adverse effects from exposure to the metabolite,
5-fluorouracil.
E. Griseofulvin (C)—the anti-fungal antibiotic, griseofulvin, is embryo toxic and
teratogenic in mice and rats. The agent crosses the human placenta at term. There
was an initial report that griseofulvin might promote the development of conjoined
twins. However, several reports since that time have not confirmed this finding. The
safest course, however, is to avoid griseofulvin during pregnancy because its use is
seldom essential. Due to a lack of reports on the use of griseofulvin during lactation
and the potential for toxicity, the agent should be avoided if the mother is breast-
feeding.

45. F. Itraconazole (C)— is a triazole anti-fungal drug in the same class as
fluconazole. It causes dose-related embryo toxicity and teratogenicity in mice and
rats. Human placental transfer has not been studied, but some degree of fetal
exposure should be expected. Although the data are limited, no reports attributing
human malformations to itraconazole have been published. However, because of
the possibility for teratogenicity with high-dose fluconazole, the use of itraconazole
during organogenesis (the first trimester) is not recommended.
Itraconazole is excreted into human breast milk and widespread tissue
accumulation in a nursing infant may occur with continuous daily dosing. The
potential infant toxicity of this exposure has not been studied, but women taking this
anti-fungal drug should probably not breast-feed.
G. Ketoconazole (C)— inhibits the production of certain steroid compounds in
fungal cells. It is embryo toxic and teratogenic (syndactyly and oligodactyly) in rats. It
is not known if ketoconazole crosses the human placenta, but fetal exposure should
be expected. In humans, use during the first trimester for vaginal candidiasis has not
been associated with adverse fetal outcomes.
Ketoconazole has also been used in high doses (600 mg/day for 5 weeks) for
the treatment of hypercortisolism in one case in the third trimester. A normal infant
was delivered. The agent is probably excreted into breast milk, but no reports of its
use during this period have been located.
H. Nystatin (C)— is poorly absorbed after oral administration. It has not
undergone animal reproductive testing. Human data, limited to two large surveillance
studies, have found no support for an association with congenital malformations or
other adverse outcomes.
I. Terbinafine (B)—No reports describing the use of terbinafine during human
pregnancy have been published. Placental transfer has not been studied. In animal
reproduction studies, no evidence of impaired fertility or fetal harm was found in
pregnant rats and rabbits. Thus, the manufacturer classified it as a pregnancy risk
category B drug. However, there is a lack of human pregnancy experience, which
prevents an assessment of the fetal risk for this anti-fungal agent.
Anti-Protozoal Drugs
A. Atovaquone (C)
B. Pentamidine (C)
Pentamidine is used for the treatment of pneumonia caused
by Pneumocystis Carinii, a protozoa commonly seen in patients infected with HIV.
In rat reproduction studies with doses close to those used in humans, pentamidine
was not teratogenic, but was embryo toxic. Small amounts of the agent cross the

46. human placenta. Limited human pregnancy experience (that involved both the
aerosolized and intravenous forms of the drug) has been reported in all stages of
gestation. In some of these cases, adverse effects occurred in the newborn
(including growth retardation, albinism, and congenital cytomegalovirus infection),
but these problems were probably related to the medical disorder that the mother
was being treated for and thus, the relationship to the drug is unknown. The CDC
and some manufacturers, however, have advised against using the drug in
pregnancy because of the overall lack of information in human pregnancy. Reports
describing the use of pentamidine during lactation have not been published.
Anti-Tuberculosis Agents
A. Para-Aminosalicylic Acid (C)—No reports in animals or in humans have
associated the use of this anti-tuberculosis agent with fetal harm. The drug is
bacteriostatic and is usually used in combination with other agents for the treatment
of multi-drug resistant tuberculosis. Although not studied, the low molecular weight
of the agent suggests that it will cross the human placenta. Small amounts are
excreted into human breast milk.
B. Capreomycin (C)—This injectable polypeptide antibiotic is a mixture of four
active components. The oral absorption is very poor (<1%). The injectable form of
capreomycin was found to be embryo toxic and did produce "wavy ribs" in rats at a
dose 3.5 times the human dose. No reports of human pregnancy experience have
been published. Several reviewers state that the drug should be avoided in
pregnancy because of a risk for ototoxicity and deafness. Although excretion into
human breast milk has not been studied, the very poor oral absorption suggests that
the potential for toxicity in a nursing infant would be remote.
C. Cycloserine (C)—is a broad-spectrum antibiotic. It was not teratogenic in
pregnant rats. Cycloserine has been shown to cross the placenta to the fetus.
Reported human pregnancy experience is very limited (three cases). Because of
this, it is not recommended for use in human pregnancy. Very small amounts are
excreted into human breast milk. No adverse effects in infants have been reported.
The American Academy of Pediatrics (AAP) classifies the drug as compatible with
breast-feeding.
D. Ethambutol (B)—appears to be safe to use during pregnancy. The agent
crosses the placenta resulting in therapeutic concentrations in the fetus and amniotic
fluid. Most reviewers consider ethambutol, isoniazid, and rifampin to be the safest
anti-tuberculosis agents for use in pregnancy. Reproduction studies in animals,
however, have not been conducted. Ethambutol is excreted into human breast milk.
The AAP considers the agent to be compatible with breast-feeding.

47. E. Ethionamide (C)—is teratogenic in mice, rats, and rabbits. The relatively low
molecular weight suggests that it would cross the placenta to the fetus, but this has
not been studied to date. There is limited human pregnancy experience, but one
report found an increased incidence of birth defects. In that report, however, two of
the seven cases of defects were Down Syndrome, a known chromosomal
abnormality, and therefore not caused by the drug. The other reports found no
association with congenital malformations. Although a causal relationship to birth
defects seems unlikely, the data are too limited to fully assess the risk. No studies
have reported the use of ethionamide in human breast milk and the risk to a nursing
infant is unknown.
F. Isoniazid (C)—is frequently used during human pregnancy for the prevention
and treatment of pulmonary tuberculosis. The drug does have a metabolite that is
hepatotoxic in some individuals. Isoniazid was not found to be teratogenic in mice,
rats, and rabbits, but was embryo toxic in the latter two species. Isoniazid crosses
the human placenta resulting in fetal concentrations similar to maternal serum
concentrations. From extensive human pregnancy experience, however, isoniazid
appears to be safe and effective. It is considered the drug of choice for tuberculosis
infection in a pregnant woman. Moreover, the American Thoracic Society states that
untreated tuberculosis is a much greater risk to the fetus than the treatment of the
disease. Both isoniazid and its hepatotoxic metabolite are excreted into breast milk.
No reports of adverse effects in the nursing infant have been published, but a
potential for interference with nucleic acid function and for hepatotoxicity exists. The
AAP classifies isoniazid as compatible with breast-feeding.
G. Pyrazinamide (C)—animal reproduction tests have not been conducted with
this synthetic derivative of niacinamide. The very low molecular weight of
pyrazinamide suggests that it crosses the human placenta. Only a single case report
has noted the use of this drug in pregnancy. Although no adverse effects were
mentioned, the lack of other reports prevents an assessment of the fetal risk.
Pyrazinamide is excreted into breast milk. The effects of exposure on a nursing
infant from the drug are unknown.
H. Rifampin (C)—dose-related teratogenicity in mice (spina bifida and cleft
palate), in rats (spina bifida), but not in rabbits, have been observed with rifampin.
Rifampin crosses the human placenta to the fetus. Although birth defects have been
reported in pregnant women exposed to rifampin, other reports have not found an
association with malformations. Further, most reviewers have concluded that
rifampin was not a proven teratogen and recommended the agent be used in
pregnancy if necessary. Rifampin, however, has been implicated as an agent
capable of causing hemorrhagic disease of the newborn. Prophylactic vitamin K1
(phytonadione) should be given to the newborn. No reports of adverse effects have
been described in nursing infants exposed to the small amounts of rifampin excreted
into breast milk. The AAP classifies the drug as compatible with breast-feeding.

48. I. Rifapentine (C)—is indicated for the treatment of pulmonary tuberculosis. The
agent is teratogenic in rats (cleft palate, aortic arch defect, delayed ossification, and
increased number of ribs) and rabbits (ovarian agenesis, pes varus – inward
angulation of the feet, arhinia – absent nose, microphthalmia – small eyes, and other
facial defects) at doses less than the recommended human dose. Rifapentine also
caused embryo toxicity in rats (abortion, stillbirth, and retarded growth). It is not
known if rifapentine crosses the human placenta, but the molecular weight suggests
that some degree of transfer will occur. Reported use in pregnancy is limited to six
cases: two spontaneous abortions (one in a woman abusing alcohol and the other in
an HIV-infected patient), one elective abortion, one lost to follow up, and two normal
infants. Hemorrhagic disease of the newborn may occur when rifapentine is used in
the last few weeks of pregnancy. As with rifampin, vitamin K1 should be given to the
newborn soon after birth. No information is available on the excretion of rifapentine
into human breast milk or on the potential for toxicity in a nursing infant.
HEALTH PROMOTION ISSUES DURING PREGNANCY
Health promotion— refers to any activity that aims to achieve better health in a
community or a country. It includes the health education of individuals to enable
them to control and change their lifestyles so that their health is improved. This is the
main focus of this study session, in the context of your role as a health educator of
pregnant women during antenatal care visits.
But as you know from Study Session 2 of this Module, health promotion
activities go far beyond this focus on individual behaviour, and include a wide range
of social and environmental interventions that increase health and wellbeing in
populations as well as individuals.
Health promotion also includes disease prevention — actions taken to
prevent a disease from developing, and health screening — the routine testing of
individuals to see if they are at risk of developing a health problem.
EATING WELL
Eating well— means eating a variety of healthy foods and also
eating enough food. This combination helps a pregnant woman and her baby stay
healthy and strong because it:
 Helps a woman resist illness during her pregnancy and after the birth
 Keeps a woman’s teeth and bones strong
 Gives a woman strength to work
 Helps the baby grow well in the mother’s uterus
 Helps a mother recover her strength quickly after the birth
 Supports the production of plenty of good quality breast milk to nourish the
baby.

49. EATING A VARIETY OF FOODS
It is important for pregnant women (like everyone else) to eat different kinds
of food main foods (carbohydrates), grow foods (proteins), glow foods (vitamins and
minerals), and go foods (fats, oils and sugar), along with plenty of fluids. We will
describe each of these food groups in more detail later in the study session.
Eating well means eating a variety of foods to get all the right nutrients,
especially during pregnancy and breastfeeding, and eating enough food for good
health.
EAT MORE FOOD
Pregnant women and women who are breastfeeding need to eat more than
usual. The extra food gives them enough energy and strength, and helps their
babies grow. They need to increase their usual food intake by at least 200 calories
per day, or even more than this if they were underweight before they became
pregnant. There are many ways to increase daily food intake by this amount: for
example, one more serving of maize porridge and 12 groundnuts a day would meet
this additional requirement.
Some pregnant women feel nauseated and do not want to eat. But pregnant women
need to eat enough — even when they do not feel well. Simple foods like injera or
rice can be easier for these women to eat. For women who suffer from nausea,
encourage small and frequent meals.
PROBLEMS FROM POOR NUTRITION
Poor nutrition can cause tiredness, weakness, difficulty in fighting
infections and other serious health problems. Poor nutrition during pregnancy is
especially dangerous. It can cause miscarriage or cause a baby to be born very
small or with birth defects. It also increases the chances of a baby or a mother dying
during or after the birth.
The five most important vitamins and minerals
Pregnant and breastfeeding women need more of these five vitamins and
minerals than other people do — iron, folic acid, calcium, iodine and vitamin A.
They should try to get these vitamins and minerals every day.

50. IRON
Iron helps make blood healthy and
prevents anaemia (you will learn about
diagnosing and treating anaemia. A
pregnant woman needs a lot of iron to have
enough energy, to prevent too much
bleeding at the birth, and to make sure that
the growing baby can form healthy blood
and store iron for the first few months after
birth. It is also important in the production of
good breast milk.
Pregnant and breastfeeding women should try to eat at least one iron-rich food
every day.
These foods contain a lot of iron
 Poultry (chicken)
 Fish
 Dark leafy green vegetables
 Meat (especially liver, kidney and other organ meats)
 Whole grain products
 Dried fruit
 Nuts
 Iron-fortified bread
 Egg yolk.
Taking iron pills
It can be difficult for a pregnant woman to get enough iron, even if she eats
iron-rich foods every day. She should also take iron pills (or liquid iron drops) to
prevent anaemia. These medicines may be called ferrous sulfate, ferrous gluconate,
ferrous fumerate or other names (ferrous comes from the Latin word for iron).
Iron pills or drops can be obtained from pharmacies and health institutions,
but throughout Ethiopia you will give iron pills routinely to pregnant women as part of
focused antenatal care. She should receive 300 to 325 mg (milligrams) of ferrous
sulphate once a day taken by mouth, preferably with a meal. This dosage is usually
supplied in a single tablet combined with folate (see below).

51. The iron pills may cause nausea, make it hard for the woman to pass stool
(constipation), and her stool may turn black, but it is important for the woman to keep
taking the iron pills because anaemia can cause complications during pregnancy,
during delivery, and after the baby is born. It is helpful for the woman to take the iron
pill with a meal, drink plenty of fluids, and eat plenty of fruits and vegetables to avoid
nausea and constipation. The black colour of the stool is a normal side-effect from
the iron and is not harmful.
FOLATE (FOLIC ACID)
Lack of folate can cause anaemia in
the mother and severe birth defects in the
baby. To prevent these problems, it is
important if possible for a woman to get
enough folic acid in her diet before she
becomes pregnant and she should certainly
do this in the first few months of pregnancy.
 Dark green, leafy vegetables
 Whole grains (brown rice, whole wheat)
 Meat (especially liver, kidney and other organ meats)
 Fish
 Peas and beans
 Eggs
 Sun flower, pumpkin and squash seeds
 Mushrooms.
As well as eating as many of these foods as she can, all pregnant women
should also take 400 mcg (micrograms) of folic acid tablets orally every day during
pregnancy. She should be able to get these tablets from you as part of Focused
Antenatal Care.

52. CALCIUM
A growing baby needs a lot of
calcium to make new bones,
especially in the last few months of
pregnancy. Women need calcium for
strong bones and teeth.
 Yellow vegetables (hard squash, yams)
 Lime (carbon ash)
 Milk, curd, yogurt and cheese
 Green, leafy vegetables
 Bone meal and egg shells
 Molasses and soybeans
 Sardines
Women can also get more calcium in these ways:
 Soak bones or eggshells in vinegar or lemon juice for a few hours. Then use the
liquid to make soup or eat with other foods.
 Add lemon juice, vinegar or tomatoes when cooking bones.
 Grind eggshells into a fine powder and mix into food.
 Soak maize in lime (carbon ash) before cooking it.
IODINE
Iodized salt is the easiest way to get enough
iodine in the diet. Iodine prevents goiter (swelling of
the neck) and other problems in adults. Lack of
iodine in a pregnant woman can cause her child to
have cretinism, a disability that affects thinking and
physical features.
The easiest way to get enough iodine is to use
iodized salt instead of regular salt .It is available in packet
form labeled ‘Iodized salt’ in many market places.