4
Follow-up Visits

Checklist

Gathering Information
Questions
  • Behavior changes in response to nutrition-related advice or activities agreed upon during the last visit?

  • Any additional problems or concerns related to food or supplement intake? Weight gain? Gastrointestinal symptoms? Health habits?

Physical Examination
  • Weight; involve the woman in plotting her weight on chart; note weight change

  • Anemia: repeat hemoglobin or hematocrit tests as needed for follow-up

  • Glucose screen at 24 to 28 weeks of gestation

Basic Guidance
  • Reinforce healthful practices

  • Reinforce progress on specific behavior changes (e.g., increased intake of vegetables, eating breakfast, cutting back on cigarettes)

  • Provide support for breastfeeding



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4 Follow-up Visits Checklist Gathering Information Questions Behavior changes in response to nutrition-related advice or activities agreed upon during the last visit? Any additional problems or concerns related to food or supplement intake? Weight gain? Gastrointestinal symptoms? Health habits? Physical Examination Weight; involve the woman in plotting her weight on chart; note weight change Anemia: repeat hemoglobin or hematocrit tests as needed for follow-up Glucose screen at 24 to 28 weeks of gestation Basic Guidance Reinforce healthful practices Reinforce progress on specific behavior changes (e.g., increased intake of vegetables, eating breakfast, cutting back on cigarettes) Provide support for breastfeeding

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Addressing Problems Identify continuing or new nutritional problems or concerns Discomforts of pregnancy? Anemia? Inadequate or excessive weight gain? Access to food? Dietary control of chronic disorders? Inadequate nutrient or energy intake related to food choices? Pica? Inverted nipples? (third trimester) Identify continuing or new obstetrical risk factors with implications for nutrition Multiple gestation? Need for bedrest? Gestational diabetes mellitus? Substance use? Need for vitamin/mineral supplements? Set priorities Create a nutrition plan, focusing on concerns identified Arrange for referral for additional care as needed

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Follow-up Visit These follow-up visits occur at intervals appropriate to the needs of the individual woman. Follow-up visits allow the practitioner to monitor the progression of the pregnancy and determine priorities for nutritional care. Attention is directed toward problems such as low or excessive weight gain, inadequate nutrient intake, multiple gestation, gestational diabetes mellitus, anemia, inadequate resources, or gastrointestinal symptoms. In this chapter, care that is appropriate at every visit is distinguished from care that is most relevant at specific times during the pregnancy.

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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 General If the nutrition questionnaire revealed problems at the time of the initial visit, consider administering it during the second and third trimesters as a quick way to identify continuing problems. At every visit, interview the woman to determine behavioral changes made in response to recommendations at the previous visit (e.g., obtain feedback on referrals and specific changes in diet and substance use) and assess the woman's current status by inquiring about symptoms of nausea, vomiting, heartburn, constipation, and edema and her feelings about body image and weight gain. Discomforts Are you having a problem with nausea, vomiting, heartburn, constipation , or other discomforts? If applicable, say: I notice that you don't drink milk. Does drinking milk cause you any discomfort? If yes, ask: What kind? Have you tried drinking milk recently? How much milk does it take for you to get those symptoms? How do you feel about your weight so far?

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Dietary Practices If food intake is low or a major food group is avoided, ask: Who shops for food in your household? Who plans the meals? Who cooks them? Do other family members complain if you fix something different from usual? At an early prenatal visit, inquire about pica: Some women eat things like clay, starch, or baking soda when they are pregnant. Do you eat any of these kinds of things? What? How much? How often? Sample questions concerning the diet include: Has your appetite changed? How? What special problems or concerns do you have about food or eating? How much X are you eating now? How are you using the milk that you get through WIC? Supplements How often do you take your iron supplement? Do you take it with or without food? What liquid do you take with it? Have you noticed any changes in the way you feel since you started taking the iron? Tell me more about it. If there are young children in the household, ask: Where do you keep the pills? Behavioral Changes What changes in exercise have you made? How much have you been walking? If the woman had been smoking or using some other harmful substance, ask: Have you tried to quit? To cut down? What have you done to stop X (behavior) since you were here last?

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If the woman stopped for this pregnancy, ask: Have you been able to stay off? How many cigarettes are you smoking now? If specific strategies were suggested, ask questions such as: What did you think of the AA (or AlaTeen) meeting? Did you attend the class on using WIC foods? Did you pick up your WIC vouchers? How often do you eat the cereal that WIC provides? Physical Examination At every visit, obtain and record objective data: Weigh the woman or have her weigh herself. Plot her weight on the grid. Check the fundal height. Check for pretibial and facial edema. Indications to assess weight gain further are shown in the box. Weight Changes That Signal the Need for Further Evaluation in the Second and Third Trimesters Women of at least moderate weight (Prepregnancy BMI >19.8): Gain of less than 2 lb (1 kg) in any single month Obese women: Gain of less than 1 lb (0.5 kg) in any single month All pregnant women Continuing pattern of less than recommended gain or of much higher than recommended weight gain Gain of more than 6.5 lb (3 kg) in any month

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Laboratory Evaluation Hemoglobin or Hematocrit. Follow-up on anemia in women in whom anemia is suspected or was previously diagnosed. For nonsmokers, hemoglobin should be ≥10.5 g/dl in the second trimester and ≥11.0 g/dl in the first and third trimesters. Glucose screen: A fasting 50-g, 1-hour post-glucose challenge test between 24 and 28 weeks of gestation is ordinarily recommended. Explanations History Discomforts Dietary measures can help relieve nausea (page 47), heartburn and constipation (page 63), and symptoms of lactose intolerance (such as abdominal cramps and explosive diarrhea that occur within an hour after drinking milk) (page 101). No well-conducted studies support special dietary measures for the treatment of leg cramps. Dietary Practices Strategies for dietary improvement may be strongly influenced by the availability of food, the degree of control the woman has over obtaining and preparing food, and her appetite. Specific questions based on the recommendations made during the previous visit demonstrate a concern for the woman. The practice of pica (eating nonfood substances) may limit nutrient intake and have adverse hematologic or gastrointestinal effects.

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Supplements Many women need extra guidance to promote comfort, compliance, and safety when the use of vitamin/mineral supplements is indicated. Behavioral Changes Stopping substance use and improving diet quality are often difficult. Several encounters may be needed to achieve desirable change. Encouragement often helps women who have difficulty making appointments, accessing WIC, and making or maintaining behavioral changes. New problems may occur, which routine screening will help to identify. If desirable changes have occurred, the health professional's affirmation and reinforcement help to improve the woman's sense of self-esteem and promote healthful practices. Physical Examination A typical weight gain in the first trimester is 3 to 8 lb (~1 to 3.5 kg). Weight loss is often a sign of low food intake resulting from the nausea, vomiting, and poor appetite that are normal at this time. It could also be a sign of dehydration or of low intake associated with poor adjustment to pregnancy Lack of weight gain is not ordinarily a major problem in the first trimester. A documented large weight gain during the first trimester may indicate the need for further assessment of dietary intake and physical activity, especially among overweight and obese women. Substantial weight gain by underweight women is usually desirable. Adequate weight gain for BMI status suggests adequate energy intake but does not guarantee diet quality The average weekly amount of weight gained increases in the second trimester, and women may express more concerns about their body image. High or low weight gain may result from measurement errors, dietary prob-

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lems, edema, or other causes. A low weight gain combined with a low fundal height is of concern because of the possibility of fetal growth restriction. Laboratory Evaluation Resolving anemia may improve the mother's sense of well-being by relieving shortness of breath, fatigue, headache, and dizziness. Infants of iron-deficient mothers may have an increased risk of low birth weight, pre-maturity, and perinatal mortality. A positive glucose screen calls for diagnostic testing for glucose tolerance. Basic Guidance General Whenever possible, involve the partner and family or friends in activities to promote social support for improved nutrition and health. Positively reinforce healthful behaviors and progress toward any goals set at the previous visit. Weight At every visit, involve the mother in plotting her weight on her weight gain chart and in interpreting her pattern of gain. Discuss implications. Do you have any more questions or concerns about your weight? On the basis of the assessment, jointly set a new weight gain goal. Aim for the target rate of weight gain, even if it means exceeding the original goal. If this is a multiple gestation, revise weight gain recommendations to about 1.5 lb (0.75 kg) per week for twins, more for triplets.

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Diet and the Avoidance of Harmful Substances At every visit, encourage a healthful diet, reinforce healthy dietary practices and the positive changes that have been made, encourage avoidance of potentially harmful substances, and address the woman's questions and concerns. As needed, try to involve the person responsible for food shopping and meal preparation when discussing strategies for improved dietary intake. Promotion of Breastfeeding Early in pregnancy, if there are no medical contraindications to breastfeeding: Provide information on the advantages and challenges of breastfeeding and bottle feeding. X (name of person) would like to speak with you about her experience with breastfeeding. You can reach her by . . . Support infant feeding decisions and encourage undecided women to breastfeed. As appropriate, provide anticipatory guidance on how to obtain assistance for successful lactation and realistic information about feeding frequency. In the third trimester, resume the discussion of infant feeding. Include the partner in the discussion if possible. If breastfeeding is planned, build on previous experiences, address fears, explore possibilities for family support, and ask about work plans. If the woman's nipples are flat or inverted, consider breast shells and assist with their proper use. Provide education and encouragement. If bottle feeding is planned, address questions and concerns. Provide anticipatory guidance and support the mother.

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If the woman is uncertain about which feeding method to choose, ask what she and her partner see as the advantages and disadvantages of breastfeeding. Clarify misconceptions, provide information (using role models and audiovisuals), and encourage the woman to try breastfeeding at least for a short time. Addressing Problems Low Intake of Fluids and Foods Reassure the woman that occasional nausea and vomiting will not hurt the baby. Suggest strategies for relieving or avoiding nausea and vomiting and ways to maintain adequate fluid and food intake. (See box in Tab 3, page 47.) Discourage use of unprescribed medications. If dehydration or ketosis is present, consider parenteral administration of fluids, electrolytes, and calories. Arrange for appropriate follow-up. Inadequate Nutrient Intake By the first visit in the second trimester, provide counseling to improve the woman's diet. Recommend vitamin/mineral supplementation in addition to improved diet for women with inadequate intakes or unusually high requirements. (For guidance, see the “Indications for Nutrient Supplementation" chart in Tab 1.) Inappropriate Weight Gain If weight gain is below or above the target range, explore possible reasons. (See the box on slow or on rapid weight gain, pages 64 and 65, respectively.) Suggest strategies to adjust food intake, if appropriate.

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Anemia Treat iron deficiency anemia with approximately 60 to 120 mg of ferrous iron daily At a different time of day, give supplemental zinc and copper as part of a vitamin/mineral supplement. (See Tab 9 for details.) Side Effects from Iron Supplements Side effects are dose related and are most common at doses of 120 mg of elemental iron or more. Nausea, cramps, constipation, or diarrhea, if they occur, often persist no longer than 3 to 5 days after the woman begins to take iron supplements. If they do persist, lower the dose temporarily or substitute a slow-release preparation at mealtime. Suggest, as appropriate: Let me give you the name of a liquid or chewable preparation if you have difficulty swallowing tablets. Taking iron to treat iron deficiency anemia helps to reduce fatigue , headache, dizziness, and shortness of breath and increases your ability to adapt to blood loss at the time of delivery. You may notice a darkening in the color of your stools. High doses of iron sometimes cause constipation or (less often)diarrhea. Use safety caps and keep supplements out of the reach of children.

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For the Pregnant Woman: Heartburn Eat small, low-fat meals, and eat slowly. Take low-fat snacks such as melba toast or fruit as needed for extra energy and nutrients. Drink fluids mainly between meals. Go easy on spices. Avoid lying down for 1 to 2 hours after eating or drinking, especially before going to bed. Wear loose-fitting clothing. Constipation Drink 2 to 3 quarts of fluids daily This includes water, milk, juice, and soup. Warm or hot fluids are especially helpful right after you get up. Eat high-fiber cereals and generous amounts of other whole grains, legumes, fruits, and vegetables. Take part in physical activities such as walking and swimming. Avoid taking laxatives unless recommended by your health care provider. Positive Glucose Screen Perform diagnostic testing for diabetes mellitus. If the woman is diagnosed as having gestational diabetes mellitus, complement medical care by the physician by consulting with or arranging for a referral to a dietitian for diet counseling. Such a referral is especially important if insulin therapy is begun.

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For the Health Professional: What to Look for If Weight Gain Is Slow or If Weight Loss Occurs Is there a measurement or recording error? Is the overall pattern acceptable? Was a lack of gain preceded by a higher than expected gain? Was there evidence of edema at the last visit and is it resolved? Is nausea, vomiting, or diarrhea a problem? Is there a problem with access to food? Have psychosocial problems led to poor appetite? Does the woman resist weight gain? Is she restricting her energy intake? Does she have an eating disorder? If the slow weight gain appears to be a result of self-imposed restriction, does she understand the relationship between her weight gain and her infant's growth and health? Is she smoking? How much? Is she using alcohol or drugs (especially cocaine or amphetamines)? Does her energy expenditure exceed her energy intake? Does she have an infection or illness that requires treatment?

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For the Health Professional: What to Look for If Weight Gain Is Very Rapid Is there a measurement or recording error? Is the overall pattern acceptable? Was the gain preceded by weight loss or a lower than expected gain? Is there evidence of edema? Has the woman stopped smoking recently? The advantages of smoking cessation offset any disadvantages associated by gaining some extra weight. Are twins or triplets a possibility? (A large increase in fundal height may be the earliest sign.) Are there signs of gestational diabetes? Has there been a dramatic decrease in physical activity without an accompanying decrease in food intake? Has the woman greatly increased her food intake? (Get a diet recall, making special note of high-fat foods. However, rapid weight gain is often accompanied by normal eating patterns, which should be continued. If intake of high-fat or high-sugar foods is excessive, encourage substitutions.) If serious overeating is occurring, explore why. (Stress? Depression? Eating disorder? Boredom?) Is there a need for special support or a referral?

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Pica Determine the extent of the practice and its potential for harmful effects. If indicated, explore ways to curb or completely eliminate the practice. Guidelines appear in the box. Bed Rest If bed rest is advised, emphasize the importance of achieving adequate energy and nutrient intake for the growth of the fetus, even though the mother's activity level is low Provide anticipatory guidance. (See box on the next page.) Expect weight fluctuations. Arrange for a referral for home health care or homemaker services if indicated. For the Health Professional: Pica Identify pica practices that may be harmful because they interfere with the ingestion of adequate amounts of food, they may lead to intestinal obstruction or impaction, or they may involve toxic substances. Explore possible substitutions for pica substances and behaviors with the woman. When you feel the urge to eat X, what else could you do instead? Take a short walk? Read to your child? Would you try chewing sugarless gum when you get the urge to eat X? Instead of chewing ice, try freezing fruit juice cubes to chew.

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For the Pregnant Woman: Eating Well When on Bed Rest When on bed rest, planning helps you get the energy and nutrients needed to help your baby grow. If problems arise, the dietitian can give you some practical advice. Shopping Prepare a grocery list for the person who will shop for you or that you can call in to a store that delivers. Choose nutritious foods that are easy to eat, easy to prepare or ready to eat, enjoyable cold or at room temperature, and not messy. Convenient choices include individual cans, bottles, or boxes of juice; pieces of fresh fruit; heat-and-serve (microwave) dinners; sandwiches; hard-boiled eggs; nuts; and cheese, milk, and other dairy products. To help avoid constipation, include some high-fiber foods like whole grains and fruits and vegetables. Try nutritious take-out foods such as pizza, salads, grilled chicken, and burritos. Avoid eating fried foods. You are likely to feel more comfortable and to meet your nutrient needs better. Keeping Food at Your Bedside Keep a pitcher of water handy. You need lots of fluids. Keep an ice chest nearby for cold drinks and snacks such as milk, cottage cheese, yogurt, fruit juices, sandwiches, cheese, cut-up raw vegetables, and sliced fruit. Keep perishable foods cold. Keep whole-grain crackers or bread and peanut butter within reach. Stimulating Your Appetite Make eating enjoyable: plan for variety and for attractive color and texture combinations; eat meals with family or friends. Eat small amounts often.

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