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Understanding genetics
Understanding genetics
Workbook: version to print
Workbook
This workbook is designed so you can
respond to the activities within the unit and use your responses as
evidence of your learning and professional development.
Using this workbook
The activities within the unit are repeated
to help you structure your work. You have chosen to work on a printed
workbook by selecting the 'print' version of this workbook. When
you have finished working through the activities you can print off and
sign the certificate at the back of the unit, declaring that you have
met the learning objectives. You should keep the certificate in your
professional portfolio with your workbook, as evidence of your learning.
Note: If you would prefer to work
on screen, go to the Toolbox, select this unit, then select Workbook:
on-screen version.
Working on paper
Each activity will print on a separate
sheet, with space below for your work. If you need more space you can
simply insert extra pages into your workbook.
Activity 1
Self-assessment
This programme has been designed so you
can build on your current skills and to provide you with a framework
to structure the new knowledge and skills you develop. Our intention
is that you will work through the entire unit at core
level, rather than using it to 'dip
into'. You can then go back to work through some or all of it at advanced level
if you feel it is appropriate for your practice. Studying the units
in this way will enrich your existing knowledge, and help to apply it
to your practice more effectively.
As a health professional busy 'doing
the job' it can be difficult to stand back and identify the skills
and knowledge you use in your everyday practice. To get the most out
of studying this unit it is good to be aware of the extent of your existing
knowledge.
This self-assessment below will help
you to think about your knowledge and skills about genetics. It is important
to remember that this is simply an exercise to help you plan your learning.
There are no 'right' or 'wrong' answers, and the responses you
give are for your eyes only.
The self-assessment
1. I understand
the basics of human genetics. ..
2. I can discuss
the role of genetic factors in health and disease. ..
3. I can explain
mode of inheritance in single gene (Mendelian) disorders
(dominant, recessive and sex-linked recessive) and provide examples
of specific conditions. ..
4. I acknowledge
the role of specialist genetic services in health services
and how genetic tests can have implications for prevention of disease
and promotion of health. ..
5. I understand
how genetic services and antenatal diagnostic services
relate to each other. ..
6. I can discuss
the developments in genetics for future healthcare. ..
Identifying your
skills and knowledge
Use the scores you gave
yourself for each statement to identify the areas of your practice you
feel least competent about and where you are very confident. You might
like to make some brief notes about what you would like to learn from
studying the unit and how it could enhance the care you provide.
Activity
2
Chromosome anomaly
Core
1. Read the details
on Down's syndrome given below.
2. Rewrite the details
in your own words or discuss the information with a colleague or friend.
Down's syndrome
Down's syndrome
usually occurs sporadically.
Most people
with Down's syndrome have an extra, whole chromosome 21 in all cells.
The extra
chromosome 21 is acquired during the formation of the sex cells (eggs/ova
or sperm), most commonly in the egg.
Standard trisomy
21 is not inherited so it is not necessary to test parental chromosomes.
There is an increased maternal age-related risk for Down's syndrome.
Down's syndrome
causes learning disabilities and can cause health problems, but different
people are affected differently, and some are more severely affected
than others.
Mother's age at
time of baby's birth Risk of baby being affected with Down's syndrome
15 1
in 1,500
30 1
in 800
45
and over 1 in 50 and greater
(Figures
from the Down's syndrome screening programme website: <a href=http://www.nelh.nhs.uk/screening/dssp/home.htmhttp://www.nelh.nhs.uk/screening/dssp/home.htm)
Advanced
Use the information above
and the Down's Syndrome Screening Programme website to think through
how you would describe the underlying genetic basis for Down's syndrome
to a woman considering screening who asks more about it. Can you find
any resources that would help?
Activity
3
Genetic disorders
Core
Write down (or discuss
with a colleague) three disorders that have a genetic basis that you
have encountered in your antenatal and/or newborn screening practice,
and describe briefly the underlying genetic anomaly.
Advanced
You might be asked by
women or their families about particular genetic conditions, or you
might be working with a woman with a particular condition and need to
understand what the underlying alteration is. You need to be able to
research these conditions and explain the underlying genetic basis in
basic terms to the woman. Choose one condition from each of the three
groups below. Use the websites listed and/or your own research to complete
the tables:
Diseases (disorders)
may be associated with:
1. Alteration in a
gene - single-gene disorders (eg, cystic fibrosis, sickle cell, beta-thalassaemia)
General
National Electronic
Library for Health Clinical Genetics Specialist Library: <a href=http://libraries.nelh.nhs.uk/genepoolhttp://libraries.nelh.nhs.uk/genepool
Cystic fibrosis
BUPA Health Information: <a href=http://hcd2.bupa.co.uk/fact_sheets/Mosby_factsheets/Cystic_fibrosis.htmlhttp://hcd2.bupa.co.uk/fact_sheets/Mosby_factsheets/Cystic_fibrosis.html
Cystic Fibrosis Trust: <a href=http://www.cftrust.org.uk/http://www.cftrust.org.uk/
Newborn Screening
Programme Centre: <a href=http://www.newbornscreening-bloodspot.org.uk/http://www.newbornscreening-bloodspot.org.uk/
Sickle cell and
thalassaemia
Newborn Screening
Programme Centre: <a href=http://www.newbornscreening-bloodspot.org.uk/http://www.newbornscreening-bloodspot.org.uk/
Schoolscience: <a href=http://www.schoolscience.co.uk/content/5/biology/mrc/7/page1.htmlhttp://www.schoolscience.co.uk/content/5/biology/mrc/7/page1.html
Sickle Cell Society: <a href=http://www.sicklecellsociety.org/http://www.sicklecellsociety.org/
Sickle Cell and Thalassaemia
Screening Programme:
<a href=http://www.kcl-phs.org.uk/haemscreening/publications.htmhttp://www.kcl-phs.org.uk/haemscreening/publications.htm
UK Thalassaemia Society<a href=http://www.ukts.org/http://www.ukts.org/
The
type of disorder
The
factor(s) associated with these genetic diseases (eg, alteration
in a gene)
The
main effects of
the disease and the source(s)
of your information (ie, website, book, article details)
Sources
of further information and support for parents
2. An alteration in
the number of chromosomes - chromosome anomalies (eg, Down's syndrome,
Turner syndrome or Klinefelter syndrome)
General
National Electronic
Library for Health Clinical Genetics Specialist Library: <a href=http://libraries.nelh.nhs.uk/genepoolhttp://libraries.nelh.nhs.uk/genepool
Down's syndrome
Down's Syndrome
Association: <a href=http://www.downs-syndrome.org.uk/http://www.downs-syndrome.org.uk/
Down Syndrome Health
Issues: <a href=http://www.ds-health.com/trisomy.htmhttp://www.ds-health.com/trisomy.htm
Down's Syndrome
Screening Programme: <a href=http://www.nelh.nhs.uk/screening/dssp/medical.htmlhttp://www.nelh.nhs.uk/screening/dssp/medical.html
National
Institute of Child Health and Human Development: <a href=http://www.nichd.nih.gov/publications/pubs/downsyndrome/down.htm#TheChromosomalhttp://www.nichd.nih.gov/publications/pubs/downsyndrome/down.htm#TheChromosomal
Klinefelter syndrome
Klinefelter Syndrome
Association UK: <a href=http://www.ksa-uk.co.uk/http://www.ksa-uk.co.uk/
Klinefelter Syndrome
Support Group: <a href=http://www.klinefeltersyndrome.org/http://www.klinefeltersyndrome.org/
Turner syndrome:
Turner Syndrome Support Society: <a href=http://www.tss.org.uk/http://www.tss.org.uk/
The
type of disorder
The
factor(s) associated with these genetic diseases (eg, alteration
in a gene)
The
main effects of
the disease and the source(s)
of your information (ie, website, book, article details)
Sources
of further information and support for parents
3. The presence of
several different gene variants (that increase disease risk) and their
interactions with environmental factors - multifactorial disorders
(eg, spina bifida, diabetes mellitus, coronary heart disease)
General
Wellcome Trust Polygenic
and Multifactorial Diseases: <a href=http://www.wellcome.ac.uk/en/genome/genesandbody/hg06b010.htmlhttp://www.wellcome.ac.uk/en/genome/genesandbody/hg06b010.html
Coronary heart
disease
British Heart Foundation: <a href=http://www.bhf.org.uk/http://www.bhf.org.uk/
Diabetes
British Diabetic
Association: <a href=http://www.diabetes.org.uk/http://www.diabetes.org.uk/
Spina bifida
Association for Spina
Bifida and Hydrocephalus: <a href=http://www.asbah.org/Spina%20Bifida/Support.htmlhttp://www.asbah.org/SpinaBifida/Support.html
The
type of disorder
The
factor(s) associated with these genetic diseases (eg, alteration
in a gene)
The
main effects of
the disease and the source(s)
of your information (ie, website, book, article details)
Sources
of further information and support for parents
Activity
4
Genetics and inheritance patterns
Core
Read through The Genetics
Primer found on the Genetics, Disease and Dentistry website. This
is a good introduction for all health professionals - it gives clear,
concise information on genetic inheritance launched in 2004 by the National
Coalition for Health Professionals in Genetics NCHPEG).
<a href=http://www.nchpeg.org/dental/genetic_primer/tableofcontent.htmlhttp://www.nchpeg.org/dental/genetic_primer/tableofcontent.html
You can link to and explore
the whole website from: <a href=http://www.nchpeg.org/http://www.nchpeg.org/
Activity
5
Understanding inheritance patterns
Core
Write down in your own
words a brief outline of single-gene (Mendelian) inheritance, including
what you see as the main elements.
Advanced
A mother with whom you
are discussing screening for cystic fibrosis does not understand how
her baby could have the genetic condition since there is no history
of the disease in either her or her partner's family.
How would you explain
autosomal recessive inheritance to her so that she can understand that
her baby can still be at risk?
Activity
6
Cystic fibrosis
- implications for other family members
Core
Read the background information
below, from the NHS Direct online health encyclopaedia and then consider
or/and the questions with a colleague.
Cystic fibrosis
is an autosomal recessive condition in which an altered version of a
protein called Cystic Fibrosis Transmembrane Conductance Regulator (CFTR)
is produced. This is responsible for transporting salts and water across
the cell membranes. This means that in certain parts of the body, the
secretions lack water, becoming thick and sticky. The lungs, pancreas,
intestines and other organs tend to get clogged up with thick, sticky
mucus. Symptoms include poor weight gain, chest infections, coughs,
abnormal stools and salty sweat.
1. Parents of a child
with CF have a 25% chance (one in four) of recurrence for each child
conceived. How do you think this knowledge may affect their decision
to have another child?
2. Imagine you are
working with parents who already have one child who is affected and
are sure they could not cope with another, but would like to have a
second child. What sort of options might be available to them, and how
could you help?
Activity
7
Self-assessment
Look at the six statements
below and rank how much you know about each, and how competent you feel
about completing the task(s) involved in them. Use a scale of 1-5 (1
being NOT very competent and 5 being VERY competent). Compare your scores
with the self-assessment you did before studying the unit.
1. I understand
the basics of human genetics. ..
2. I can discuss
the role of genetic factors in health and disease.
..
3. I can explain
mode of inheritance in single gene (Mendelian) disorders
(dominant, recessive and sex-linked recessive) and provide examples
of specific conditions. ..
4. I acknowledge
the role of specialist genetic services in health services
and how genetic tests can have implications for prevention of disease
and promotion of health. ..
5. I understand
how genetic services and antenatal diagnostic services
relate to each other. ..
6. I can discuss
the developments in genetics for future healthcare.
..
What now?
If you feel you still
need to improve your skills and knowledge you may want to look at the
additional resources listed in the Toolbox. Alternatively, you may need
to study materials provided by the screening programmes, or other units
within this programme
Focus
Activity
Explaining genetics
This focus activity is designed to help
you apply what you have learned by working through the unit to situations
you might encounter in clinical practice.
Catherine has a newborn baby, her first
child, and declined an offer of antenatal screening. She has used the
internet to find out about the Newborn Screening Programme and sickle
cell disorder, and asks: 'If m partner and I have no family history
of sickle cell disorder, why do you want to screen our baby for this
condition?'
How would you explain to Catherine why
her baby is being offered screening for sickle cell disorder as part
of the Newborn Bloodspot Screening Programme?
Think about:
The inheritance pattern of
sickle cell disorder
The potential benefits of
screening in newborn care
The ethical, legal and social
implications for Catherine and her family.
Screening Choices: A resource for health
professionals offering antenatal and newborn care, Workbook
Screening Choices: A resource for health
professionals offering antenatal and newborn care, Workbook
Screening choices:
Understanding genetics
Understanding genetics
Workbook: version to print
Workbook
This workbook is designed so you can
respond to the activities within the unit and use your responses as
evidence of your learning and professional development.
Using this workbook
The activities within the unit are repeated
to help you structure your work. You have chosen to work on a printed
workbook by selecting the 'print' version of this workbook. When
you have finished working through the activities you can print off and
sign the certificate at the back of the unit, declaring that you have
met the learning objectives. You should keep the certificate in your
professional portfolio with your workbook, as evidence of your learning.
Note: If you would prefer to work
on screen, go to the Toolbox, select this unit, then select Workbook:
on-screen version.
Working on paper
Each activity will print on a separate
sheet, with space below for your work. If you need more space you can
simply insert extra pages into your workbook.
Activity 1
Self-assessment
This programme has been designed so you
can build on your current skills and to provide you with a framework
to structure the new knowledge and skills you develop. Our intention
is that you will work through the entire unit at core
level, rather than using it to 'dip
into'. You can then go back to work through some or all of it at advanced level
if you feel it is appropriate for your practice. Studying the units
in this way will enrich your existing knowledge, and help to apply it
to your practice more effectively.
As a health professional busy 'doing
the job' it can be difficult to stand back and identify the skills
and knowledge you use in your everyday practice. To get the most out
of studying this unit it is good to be aware of the extent of your existing
knowledge.
This self-assessment below will help
you to think about your knowledge and skills about genetics. It is important
to remember that this is simply an exercise to help you plan your learning.
There are no 'right' or 'wrong' answers, and the responses you
give are for your eyes only.
The self-assessment
1. I understand
the basics of human genetics. ..
2. I can discuss
the role of genetic factors in health and disease. ..
3. I can explain
mode of inheritance in single gene (Mendelian) disorders
(dominant, recessive and sex-linked recessive) and provide examples
of specific conditions. ..
4. I acknowledge
the role of specialist genetic services in health services
and how genetic tests can have implications for prevention of disease
and promotion of health. ..
5. I understand
how genetic services and antenatal diagnostic services
relate to each other. ..
6. I can discuss
the developments in genetics for future healthcare. ..
Identifying your
skills and knowledge
Use the scores you gave
yourself for each statement to identify the areas of your practice you
feel least competent about and where you are very confident. You might
like to make some brief notes about what you would like to learn from
studying the unit and how it could enhance the care you provide.
Activity
2
Chromosome anomaly
Core
1. Read the details
on Down's syndrome given below.
2. Rewrite the details
in your own words or discuss the information with a colleague or friend.
Down's syndrome
Down's syndrome
usually occurs sporadically.
Most people
with Down's syndrome have an extra, whole chromosome 21 in all cells.
The extra
chromosome 21 is acquired during the formation of the sex cells (eggs/ova
or sperm), most commonly in the egg.
Standard trisomy
21 is not inherited so it is not necessary to test parental chromosomes.
There is an increased maternal age-related risk for Down's syndrome.
Down's syndrome
causes learning disabilities and can cause health problems, but different
people are affected differently, and some are more severely affected
than others.
Mother's age at
time of baby's birth Risk of baby being affected with Down's syndrome
15 1
in 1,500
30 1
in 800
45
and over 1 in 50 and greater
(Figures
from the Down's syndrome screening programme website: <a href=http://www.nelh.nhs.uk/screening/dssp/home.htmhttp://www.nelh.nhs.uk/screening/dssp/home.htm)
Advanced
Use the information above
and the Down's Syndrome Screening Programme website to think through
how you would describe the underlying genetic basis for Down's syndrome
to a woman considering screening who asks more about it. Can you find
any resources that would help?
Activity
3
Genetic disorders
Core
Write down (or discuss
with a colleague) three disorders that have a genetic basis that you
have encountered in your antenatal and/or newborn screening practice,
and describe briefly the underlying genetic anomaly.
Advanced
You might be asked by
women or their families about particular genetic conditions, or you
might be working with a woman with a particular condition and need to
understand what the underlying alteration is. You need to be able to
research these conditions and explain the underlying genetic basis in
basic terms to the woman. Choose one condition from each of the three
groups below. Use the websites listed and/or your own research to complete
the tables:
Diseases (disorders)
may be associated with:
1. Alteration in a
gene - single-gene disorders (eg, cystic fibrosis, sickle cell, beta-thalassaemia)
General
National Electronic
Library for Health Clinical Genetics Specialist Library: <a href=http://libraries.nelh.nhs.uk/genepoolhttp://libraries.nelh.nhs.uk/genepool
Cystic fibrosis
BUPA Health Information: <a href=http://hcd2.bupa.co.uk/fact_sheets/Mosby_factsheets/Cystic_fibrosis.htmlhttp://hcd2.bupa.co.uk/fact_sheets/Mosby_factsheets/Cystic_fibrosis.html
Cystic Fibrosis Trust: <a href=http://www.cftrust.org.uk/http://www.cftrust.org.uk/
Newborn Screening
Programme Centre: <a href=http://www.newbornscreening-bloodspot.org.uk/http://www.newbornscreening-bloodspot.org.uk/
Sickle cell and
thalassaemia
Newborn Screening
Programme Centre: <a href=http://www.newbornscreening-bloodspot.org.uk/http://www.newbornscreening-bloodspot.org.uk/
Schoolscience: <a href=http://www.schoolscience.co.uk/content/5/biology/mrc/7/page1.htmlhttp://www.schoolscience.co.uk/content/5/biology/mrc/7/page1.html
Sickle Cell Society: <a href=http://www.sicklecellsociety.org/http://www.sicklecellsociety.org/
Sickle Cell and Thalassaemia
Screening Programme:
<a href=http://www.kcl-phs.org.uk/haemscreening/publications.htmhttp://www.kcl-phs.org.uk/haemscreening/publications.htm
UK Thalassaemia Society<a href=http://www.ukts.org/http://www.ukts.org/
The
type of disorder
The
factor(s) associated with these genetic diseases (eg, alteration
in a gene)
The
main effects of
the disease and the source(s)
of your information (ie, website, book, article details)
Sources
of further information and support for parents
2. An alteration in
the number of chromosomes - chromosome anomalies (eg, Down's syndrome,
Turner syndrome or Klinefelter syndrome)
General
National Electronic
Library for Health Clinical Genetics Specialist Library: <a href=http://libraries.nelh.nhs.uk/genepoolhttp://libraries.nelh.nhs.uk/genepool
Down's syndrome
Down's Syndrome
Association: <a href=http://www.downs-syndrome.org.uk/http://www.downs-syndrome.org.uk/
Down Syndrome Health
Issues: <a href=http://www.ds-health.com/trisomy.htmhttp://www.ds-health.com/trisomy.htm
Down's Syndrome
Screening Programme: <a href=http://www.nelh.nhs.uk/screening/dssp/medical.htmlhttp://www.nelh.nhs.uk/screening/dssp/medical.html
National
Institute of Child Health and Human Development: <a href=http://www.nichd.nih.gov/publications/pubs/downsyndrome/down.htm#TheChromosomalhttp://www.nichd.nih.gov/publications/pubs/downsyndrome/down.htm#TheChromosomal
Klinefelter syndrome
Klinefelter Syndrome
Association UK: <a href=http://www.ksa-uk.co.uk/http://www.ksa-uk.co.uk/
Klinefelter Syndrome
Support Group: <a href=http://www.klinefeltersyndrome.org/http://www.klinefeltersyndrome.org/
Turner syndrome:
Turner Syndrome Support Society: <a href=http://www.tss.org.uk/http://www.tss.org.uk/
The
type of disorder
The
factor(s) associated with these genetic diseases (eg, alteration
in a gene)
The
main effects of
the disease and the source(s)
of your information (ie, website, book, article details)
Sources
of further information and support for parents
3. The presence of
several different gene variants (that increase disease risk) and their
interactions with environmental factors - multifactorial disorders
(eg, spina bifida, diabetes mellitus, coronary heart disease)
General
Wellcome Trust Polygenic
and Multifactorial Diseases: <a href=http://www.wellcome.ac.uk/en/genome/genesandbody/hg06b010.htmlhttp://www.wellcome.ac.uk/en/genome/genesandbody/hg06b010.html
Coronary heart
disease
British Heart Foundation: <a href=http://www.bhf.org.uk/http://www.bhf.org.uk/
Diabetes
British Diabetic
Association: <a href=http://www.diabetes.org.uk/http://www.diabetes.org.uk/
Spina bifida
Association for Spina
Bifida and Hydrocephalus: <a href=http://www.asbah.org/Spina%20Bifida/Support.htmlhttp://www.asbah.org/SpinaBifida/Support.html
The
type of disorder
The
factor(s) associated with these genetic diseases (eg, alteration
in a gene)
The
main effects of
the disease and the source(s)
of your information (ie, website, book, article details)
Sources
of further information and support for parents
Activity
4
Genetics and inheritance patterns
Core
Read through The Genetics
Primer found on the Genetics, Disease and Dentistry website. This
is a good introduction for all health professionals - it gives clear,
concise information on genetic inheritance launched in 2004 by the National
Coalition for Health Professionals in Genetics NCHPEG).
<a href=http://www.nchpeg.org/dental/genetic_primer/tableofcontent.htmlhttp://www.nchpeg.org/dental/genetic_primer/tableofcontent.html
You can link to and explore
the whole website from: <a href=http://www.nchpeg.org/http://www.nchpeg.org/
Activity
5
Understanding inheritance patterns
Core
Write down in your own
words a brief outline of single-gene (Mendelian) inheritance, including
what you see as the main elements.
Advanced
A mother with whom you
are discussing screening for cystic fibrosis does not understand how
her baby could have the genetic condition since there is no history
of the disease in either her or her partner's family.
How would you explain
autosomal recessive inheritance to her so that she can understand that
her baby can still be at risk?
Activity
6
Cystic fibrosis
- implications for other family members
Core
Read the background information
below, from the NHS Direct online health encyclopaedia and then consider
or/and the questions with a colleague.
Cystic fibrosis
is an autosomal recessive condition in which an altered version of a
protein called Cystic Fibrosis Transmembrane Conductance Regulator (CFTR)
is produced. This is responsible for transporting salts and water across
the cell membranes. This means that in certain parts of the body, the
secretions lack water, becoming thick and sticky. The lungs, pancreas,
intestines and other organs tend to get clogged up with thick, sticky
mucus. Symptoms include poor weight gain, chest infections, coughs,
abnormal stools and salty sweat.
1. Parents of a child
with CF have a 25% chance (one in four) of recurrence for each child
conceived. How do you think this knowledge may affect their decision
to have another child?
2. Imagine you are
working with parents who already have one child who is affected and
are sure they could not cope with another, but would like to have a
second child. What sort of options might be available to them, and how
could you help?
Activity
7
Self-assessment
Look at the six statements
below and rank how much you know about each, and how competent you feel
about completing the task(s) involved in them. Use a scale of 1-5 (1
being NOT very competent and 5 being VERY competent). Compare your scores
with the self-assessment you did before studying the unit.
1. I understand
the basics of human genetics. ..
2. I can discuss
the role of genetic factors in health and disease.
..
3. I can explain
mode of inheritance in single gene (Mendelian) disorders
(dominant, recessive and sex-linked recessive) and provide examples
of specific conditions. ..
4. I acknowledge
the role of specialist genetic services in health services
and how genetic tests can have implications for prevention of disease
and promotion of health. ..
5. I understand
how genetic services and antenatal diagnostic services
relate to each other. ..
6. I can discuss
the developments in genetics for future healthcare.
..
What now?
If you feel you still
need to improve your skills and knowledge you may want to look at the
additional resources listed in the Toolbox. Alternatively, you may need
to study materials provided by the screening programmes, or other units
within this programme
Focus
Activity
Explaining genetics
This focus activity is designed to help
you apply what you have learned by working through the unit to situations
you might encounter in clinical practice.
Catherine has a newborn baby, her first
child, and declined an offer of antenatal screening. She has used the
internet to find out about the Newborn Screening Programme and sickle
cell disorder, and asks: 'If m partner and I have no family history
of sickle cell disorder, why do you want to screen our baby for this
condition?'
How would you explain to Catherine why
her baby is being offered screening for sickle cell disorder as part
of the Newborn Bloodspot Screening Programme?
Think about:
The inheritance pattern of
sickle cell disorder
The potential benefits of
screening in newborn care
The ethical, legal and social
implications for Catherine and her family.
Screening Choices: A resource for health
professionals offering antenatal and newborn care, Workbook
Screening Choices: A resource for health
professionals offering antenatal and newborn care, Workbook