3
The First Prenatal Visit

Checklist

Use this checklist at the first prenatal visit if the woman has not had a recent preconceptional visit.

Gathering Information
Questions
  • Administer questionnaire and review medical record

  • Ask follow-up questions on eating behaviors, food use, discomforts, weight status

  • Indications of an eating disorder?

  • Infant feeding plans?

Physical Examination
  • General appearance

  • Breast examination

  • Weight-for-height: estimate prepregnancy body mass index category if not charted-for use in giving weight gain advice

  • Anemia: Hemoglobin <11.0 g/dl during first or third trimester, <10.5 g/dl during second trimester (nonsmokers)

  • Glucose screen (if first visit occurs after 24 weeks of gestation)



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3 The First Prenatal Visit Checklist Use this checklist at the first prenatal visit if the woman has not had a recent preconceptional visit. Gathering Information Questions Administer questionnaire and review medical record Ask follow-up questions on eating behaviors, food use, discomforts, weight status Indications of an eating disorder? Infant feeding plans? Physical Examination General appearance Breast examination Weight-for-height: estimate prepregnancy body mass index category if not charted-for use in giving weight gain advice Anemia: Hemoglobin <11.0 g/dl during first or third trimester, <10.5 g/dl during second trimester (nonsmokers) Glucose screen (if first visit occurs after 24 weeks of gestation)

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Basic Guidance Recommended diet for pregnancy Usual weight gain pattern and weight gain recommendations: normal prepregnancy weight, 25 to 35 lb; underweight, 28 to 40 lb; overweight, 15 to 25 lb; obese, at least 15 lb Iron supplementation (~30 mg/day) to begin by the 13th week of gestation to prevent anemia Appropriate physical activity, e.g., walking, swimming Avoidance of harmful substances Promotion of breastfeeding; support for the woman regardless of the feeding method chosen Addressing Problems At any stage of gestation Assist with access to food Treat disorders requiring diet therapy Treat anemia: For iron deficiency—60 to 120 mg of elemental iron daily; at a different time, 15 mg of zinc and 2 mg of copper given as part of a vitamin/mineral supplement Combat the use of harmful substances First trimester Consider folate supplementation to help prevent recurrent neural tube defects Advise about control of nausea and vomiting associated with pregnancy Second and third trimesters Counsel to improve diet (e.g., increasing dietary intake of calcium) and recommend nutrient supplements as needed—may be addressed earlier if control of nausea and vomiting associated with pregnancy is not a problem) Promote appropriate weight gain Advise about control of heartburn and constipation Help plan for eating well if on bed rest Treat inverted nipples (third trimester)

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First Prenatal Visit Modified Checklist Use this checklist for a first-trimester visit following a recent preconception visit. Gathering Information Questions Review medical record Ask follow-up questions on eating behaviors, food use, previous recommendations Infant feeding plans? Physical Examination General appearance Breast Examination Weight Anemia: Hemoglobin <11.0 g/dl (nonsmokers) Basic Guidance Recommended diet for pregnancy Usual weight gain pattern and weight gain recommendations: normal prepregnancy weight, 25 to 35 lb; underweight, 28 to 40 lb; overweight, 15 to 25 lb; obese, at least 15 lb Iron supplementation (-30 mg/day) to begin by the 13th week of gestation Appropriate physical activity, e.g., walking, swimming Avoidance of harmful substances Promotion of breastfeeding; support for the woman regardless of feeding method chosen Addressing Problems Identify continuing or new nutritional problems or concerns Controlling nausea and vomiting associated with pregnancy Access to food?

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Inadequate nutrient or energy intake related to food choices? Pica (the ingestion of nonfood substances)? Dietary control of chronic disorders? Anemia? For iron deficiency—60 to 120 mg of elemental iron daily; at a different time, 15 mg of zinc and 2 mg of copper and given as part of a vitamin/mineral supplement Continuation of folate supplementation to help prevent neural tube defects? Use of harmful substances? Set priorities Create a nutrition plan, focusing on concerns identified Arrange for referral for additional care as needed

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The First Prenatal Visit Ideally, the first prenatal visit will be a follow-up of the preconception/interconception visit. Since preconception visits are not yet common, however, this clinical care outline assumes that a preconception visit has not occurred. The content of the first prenatal visit is influenced by the stage of gestation. For clarity, cross referencing is provided for topics that need to be addressed at specific times during pregnancy (e.g., guidance for controlling diet-related discomforts of pregnancy, testing for glucose tolerance). It is assumed that before meeting with the health care provider the woman will complete a nutrition questionnaire. If the woman has difficulty reading or other special circumstances apply, the questions should be asked in person in the woman's native language, using an approach that invites unguided responses. Information overload is to be avoided. By careful attention to information in the medical record, the nutrition questionnaire, the patient's responses to sample questions, and results of the physical examination and laboratory tests, the provider can set priorities and encourage active patient involvement in addressing those priorities. The provider should consider the need to link the woman with support services, including those provided by case management and home visiting programs, especially when there is concern that this may be the only patient contact until delivery Referral to WIC, when appropriate, is recommended as early in pregnancy as possible. (See "Referral to WIC," Tab 10, page 116.) If the first prenatal visit occurs shortly after a preconception visit, use the modified checklist as a guide.

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Gathering Information Check the medical record and the nutrition questionnaire to identify relevant questions and avoid unnecessary repetition. History—Sample Questions Sociodemographic, Obstetric, Medical, and Life-Style Factors What vitamins, minerals, or other supplements are you taking? How much? How often? Why? Have you had anemia, "low blood," or "low iron?" Are you currently breastfeeding? Weight If height and recent weight are not available from the medical record, ask: How much did you weigh at your last period? If the woman is uncertain, ask: Have you noticed a change in how well your clothes fit? Ask all pregnant women: Have you ever been underweight? Overweight? What, if anything, did you do about it? How much weight do you think you should gain during this pregnancy? If a low amount: Does the thought of gaining at least _ lb bother you? How do you feel about your weight so far? What questions or concerns do you have about your weight or weight gain during pregnancy?

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Discomforts and Dietary Practices See Questions 1 through 5 and 11 through 13 on the nutrition questionnaire. Use of Harmful Substances See "Interpretation of Nutrition Questionnaire," Questions 15 through 17. Infant Feeding What have you heard about breastfeeding? Have you ever breastfed? If yes, ask: How did it go? How do most of your friends feed their babies? Physical Examination General Appearance Check for healthy gums, teeth, throat, and skin; overall physique; and amount and distribution of body fat. Observe the woman for signs of depression, poverty, battering, and poor hygiene. Breast Examination Perform a breast examination to identify inverted nipples, breast surgery, cancer, or masses. Weight and Weight-for-Height Status Accurately measure weight and height. Check medical record for recent preconceptional BMI. If unavailable, estimate it using the woman's height and recalled preconceptional weight and the BMI chart. (See Tab 1.) Determine weight-for-height category.

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Laboratory Evaluation Determine the hemoglobin or hematocrit value. If applicable, correct the cutoff value for smoking (Tab 1, page 16) or altitude (Tab 9, page 110) or both. Perform additional tests if appropriate. According to the history, physical examination, and stage of gestation, it may be advisable to do a glucose screen or other indicated blood or urine analyses. Explanations History Sociodemographic, Obstetric, Medical, and Life-Style Factors Nondietary factors may influence a woman's nutrient requirements, affect her ability to achieve adequate nutrition, signal previous problems with nutrition during pregnancy or lactation, or indicate the need for special approaches to care. Excessive use of vitamin and mineral supplements is to be avoided. Vitamin A at high levels is a documented teratogen, and pregnant women should avoid unprescribed supplements that contain vitamin A, especially at dosages exceeding 800 RE (-4,000 IU). Very early in pregnancy, supplemental folate may help prevent neural tube defects among women who have had a pregnancy affected by such a defect. Preventing or resolving anemia is encouraged as part of general health promotion. A pregnant woman who is currently breastfeeding has increased nutritional requirements.

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Weight Usual weight, weight change, and attitudes toward weight may influence the mother's pattern of weight gain during pregnancy. Preoccupation with weight, widely fluctuating weight, or excessive exercise or dieting signals the need to assess for a potential eating disorder. Most women can alert the health care provider to large changes in weight even if they do not know their prepregnancy weight. Some women need special guidance to establish healthful weight gain goals for pregnancy Because of their special concerns about body image, adolescents usually benefit from such guidance. Discomforts and Dietary Practices Women who have poor appetites, who skip meals often, or who are purposely limiting their food intake may eat too little food to support optimal weight gain and fetal growth during pregnancy Women whose intake of food or fluids is minimal for a number of days because of lack of appetite, nausea, and/or vomiting may develop dehydration and ketosis. Usually, occasional nausea, vomiting, or loss of appetite is not a medical or nutritional concern. Almost all women will be free of gastrointestinal disease. However, an occasional woman will have a condition that requires active medical assessment and intervention. Women may need reassurance about their lack of ability to eat normally. Women on special diets for medical conditions may need assistance from a dietitian to modify food intake in support of their own health and a healthy pregnancy. Women who omit a major food group from their diets may have inadequate intakes of nutrients supplied by that food group.

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Use of Harmful Substances Cigarette smoking is a major cause of low birth weight, other perinatal health problems, and many health problems unrelated to pregnancy and lactation. A safe lower limit for alcohol consumption during pregnancy is not known. Therefore, the only surely safe level of alcohol consumption for pregnant women is none. See box, page 26. Infant Feeding Breastfeeding is recommended for all infants in the United States under ordinary circumstances.2 Many women make their infant feeding decisions before pregnancy or early in pregnancy—often without having contact with breastfeeding women or encouragement from health care providers. Physical Examination General Appearance Signs of an eating disorder include dental enamel erosion, little subcutaneous fat, and (rarely) swollen parotid glands and callouses on the knuckles. Untreated dental disease, depression, battering, and other problems may interfere with adequate nutrient intake. Poor hygiene may be suggestive of life circumstances that interfere with adequate nutrient intake. Breast Examination Intervention for inverted nipples is recommended in the third trimester, but early in pregnancy women may need reassurance about their ability to breastfeed.

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Weight and Weight-for-Height Status The total amount of weight gain recommended for pregnant women depends largely on their BMI before pregnancy. (See the box on the next page.) Laboratory Evaluation Consider the nonsmoker anemic if her hemoglobin is below 11.0 g/dl in the first or third trimester or below 10.5 g/dl in the second trimester. A positive screen for anemia calls for iron therapy or additional testing. No other tests need to be done routinely solely to screen for nutritional problems. Basic Guidance General Affirm something positive, such as: By coming for prenatal care [or to this class], you are starting to take care of your baby. Encourage healthful eating and weight gain. Encourage walking, swimming, dancing, or other appropriate exercise. Dietary Practices Using appropriate materials, provide guidance on sound eating practices based primarily on the Dietary Guidelines. Use an approach that considers the woman's learning style, learning ability, literacy, native language, and other learner characteristics. People who do not organize eating by meals or food groups may benefit from dietary guidance that focuses mainly on foods, as in these examples:

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Recommended Total Weight Gain Ranges for Pregnant Women.a,b   Recommended Total Gain Prepregnancy Weight-for-Height Category lb kg Low (BMI <19.8) 28-40 12.5-18 Normal (BMI 19.8 to 26) 25-35 11.5-16 High (BMI >26.0 to 29.0) 15-25 7.0-11.5 Obese (BMI >29.0) ≥15 ≥7.0 a Adapted from Nutrition During Pregnancy.1 b For singleton pregnancies. The range for women carrying twins is 35 to 45 lb (16 to 20 kg). Young adolescents (<2 years after menarche) and African-American women should strive for gains at the upper end of the range. Short women (<62 in. or <157 cm) should strive for gains at the lower end of the range. Which of these snacks and fast foods do you like? (Use the box in Tab 7.) When would be a good time for you to eat a bowl of cereal with milk and fruit? Assist with dietary improvement: reinforce positive aspects of the diet; help the woman to set realistic goals (e.g., one change at a time or small changes in related behaviors); and encourage her to commit to one change, possibly in writing (a contract for change). What will you change? How much change is realistic right now? When will you do it? Where? How? Who might help you? If the woman is currently breastfeeding and plans to continue, emphasize the importance of careful food selection and give concrete suggestions.

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For the Pregnant Woman: Special Dietary Recommendations for Pregnant Women Eat enough food to gain weight at the rate recommended by your health care provider, as shown on your weight gain chart. Include fruits, vegetables, grains, meat or meat alternates, and milk products in your meals and snacks every day. Eat small to moderate-sized meals at regular intervals, and eat nutritious snacks. This will help you to be comfortable and to have the best chance of getting all the nutrients you and your baby need. Take 3 or more servings of milk products daily, either with or between meals. One cup (1/2 pint) of milk is an example of one serving. Choose low-fat or skim milk products often. To absorb more iron, include some meat, poultry, fish, or vitamin-C-rich foods (such as orange juice, broccoli, or strawberries) in meals. Salt your food to taste unless your physician advises you to curb your salt intake because of a medical problem. Your need for salt increases somewhat during pregnancy. If you drink coffee or other caffeinated beverages such as cola, do so in moderation (2 to 3 servings or less daily). While you are pregnant, the only sure way to avoid the possible harmful effects of alcohol on the fetus is to avoid drinking alcoholic beverages entirely.

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Weight Explain the weight gain recommendations for pregnancy shown in the box on page 44: Adequate gain reduces the risk of low birth weight. Aim for a steady rate of weight gain: weight gain in early pregnancy goes mainly toward the mother's tissues (such as placenta, amniotic fluid, uterus, expanded blood volume, energy reserves) to support the baby's growth; weight gain in later pregnancy goes mainly toward the growth of the baby During the second and third trimesters, the recommended rate of gain is slightly more than 1 lb (0.5 kg) per week for women with low prepregnancy BMI, approximately 1 lb (0.5 kg) per week for women with moderate BMI, and 2/3 lb (0.3 kg) per week for women with high BMI. Identify factors that may call for a higher weight gain during pregnancy (low prepregnancy weight for-height status, young age [82 years post menarche], African-American background, multiple gestation) or for weight gain at the lower end of the range (short maternal height). Use the appropriate weight gain chart to show the range and rate of weight gain recommended. Jointly agree upon a total weight gain goal, focusing on a range rather than a single number. Show the woman how to plot her prepregnancy weight (if it is available) and her current weight on the weight gain chart. Offer her a chart and help her start to use it. Suggest: Please bring it with you next time. Use the current measured weight as a baseline, and jointly set a realistic weight goal for the next visit. Explain that: Weight can go up and down. Continue to eat well even if you think you're gaining weight too fast.

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For the Pregnant Woman: Strategies for Managing Nausea and Vomiting Keep crackers, melba toast, or dry cereal within reach of your bed. Eat some before getting up. Eat frequent small meals. Try to take adequate fluids even if you can't handle solids—for example, try clear juices and flat sugar-sweetened soft drinks. Avoid drinking coffee and tea. Avoid drinking citrus fruit juices and water upon arising. Drink liquids mainly between meals. Try to avoid cooking odors that make you feel ill. Avoid or limit your intake of high-fat and spicy foods. Comfort Provide anticipatory guidance for the woman's comfort. First trimester: control of nausea and vomiting, and early weight changes. Later in pregnancy: control of heartburn, constipation (see Tab 4). Use of Supplements and Medications If not anemic: Start taking a low-dose (~30 mg of elemental iron )iron supplement such as ferrous gluconate daily by ___________ (the thirteenth week of gestation). Avoid using any kind of medication unless it is prescribed or approved by a physician who knows you are pregnant.

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Infant Feeding If interest is expressed in breastfeeding and there are no medical contraindications, support the choice. Offer educational materials, information about local classes, and a visit with a peer counselor. If bottle feeding is chosen, ask: Have you considered breastfeeding? What have you heard about breastfeeding? Offer written information on breastfeeding or alert the woman and her family to sources of visual and oral information, including breastfeeding counselors. Videotapes may be helpful. If the woman reports a history of breastfeeding problems or early discontinuation of breastfeeding, offer information that addresses these issues. For women with inverted nipples, reassure them by saying: You have inverted nipples. We'll give you some extra help in the third trimester to make them ready for breastfeeding. Document the treatment plan. Addressing Problems Problems with Access to Food Provide assistance or refer the woman so that she can obtain assistance with food, housing, insurance, and income support programs. (See Tab 10 for information about federal food and nutrition assistance programs and about referrals to WIC.) Low Food or Nutrient Intake Help the woman develop a concrete plan for eating enough food to gain weight. (See Tabs 7 and 8.) Engage her in identifying acceptable food sources of needed nutrients. (For this purpose, try using

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“Examples of Nutritious Snacks and Fast Foods" or "Ways to Increase Your Calcium Intake If You Avoid Most Milk Products" in Tab 7.) Jointly decide on strategies for increasing intake of nutrients from foods. Consider vitamin/mineral supplementation for women at risk of inadequate nutrient intake. For guidelines see the "Indications for Nutrient Supplementation" chart in Tab 1. Disorders Requiring Diet Therapy For women with common nutrition-related conditions (e.g., obesity, low body weight, lactose intolerance, or diet-related discomforts of pregnancy), do one or more of the following: Provide individual or group counseling. Refer the woman to the dietitian. If a woman has diabetes mellitus, phenylketonuria, renal disease, serious gastrointestinal disease, or other conditions requiring diet therapy, she should receive care from an experienced physician and dietitian. These providers should be consulted about appropriate follow-up care. (See "Referral to a Registered Dietitian," Tab 10.) Women with eating disorders require comprehensive care from a specialized team. Anemia For hemoglobin levels below 11.0 g/dl in the first and third trimesters or below 10.5 g/dl in the second trimester (nonsmokers), start a therapeutic regimen of approximately 60 to 120 mg/day of ferrous iron. At a different time, give zinc and copper as part of a vitamin/mineral supplement. (See Tab 9.) Check hemoglobin level again in about 1 month.

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Use of Harmful Substances Provide reinforcement for any constructive steps that have already been taken, provide assistance with quitting, and refer the woman to evaluation or treatment programs as needed. Encourage the woman to view stopping or cutting down on substance use as a gift to her unborn child. Assist women in recovery to develop a sense of reasonable amounts of food to eat, especially if they are concerned about high weight gain. History of Delivering an Infant with a Neural Tube Defect If the first prenatal visit occurs in the first trimester of pregnancy, the Centers for Disease Control recommends: "Unless contraindicated, they [women who have had a pregnancy involving a fetus or infant affected with a neural tube defect] should be advised to take 4 mg per day of folic acid . . . through the first 3 months of pregnancy The dose should be taken only under a physician's supervision."15Folate supplementation after the third month of pregnancy does not protect against neural tube defects.