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Follow-up Visits
Checklist
Gathering Information
Questions
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Behavior changes in response to nutrition-related advice or activities agreed upon during the last visit?
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Any additional problems or concerns related to food or supplement intake? Weight gain? Gastrointestinal symptoms? Health habits?
Physical Examination
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Weight; involve the woman in plotting her weight on chart; note weight change
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Anemia: repeat hemoglobin or hematocrit tests as needed for follow-up
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Glucose screen at 24 to 28 weeks of gestation
Basic Guidance
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Reinforce healthful practices
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Reinforce progress on specific behavior changes (e.g., increased intake of vegetables, eating breakfast, cutting back on cigarettes)
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Provide support for breastfeeding
Addressing Problems
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Identify continuing or new nutritional problems or concerns
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Discomforts of pregnancy?
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Anemia?
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Inadequate or excessive weight gain?
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Access to food?
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Dietary control of chronic disorders?
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Inadequate nutrient or energy intake related to food choices? Pica?
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Inverted nipples? (third trimester)
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Identify continuing or new obstetrical risk factors with implications for nutrition
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Multiple gestation?
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Need for bedrest?
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Gestational diabetes mellitus?
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Substance use?
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Need for vitamin/mineral supplements?
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Set priorities
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Create a nutrition plan, focusing on concerns identified
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Arrange for referral for additional care as needed
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.
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
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Are you having a problem with nausea, vomiting, heartburn, constipation , or other discomforts?
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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?
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How do you feel about your weight so far?
Dietary Practices
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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?
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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?
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Sample questions concerning the diet include:
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Has your appetite changed? How?
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What special problems or concerns do you have about food or eating?
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How much X are you eating now?
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How are you using the milk that you get through WIC?
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Supplements
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How often do you take your iron supplement? Do you take it with or without food? What liquid do you take with it?
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Have you noticed any changes in the way you feel since you started taking the iron? Tell me more about it.
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If there are young children in the household, ask: Where do you keep the pills?
Behavioral Changes
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What changes in exercise have you made?
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How much have you been walking?
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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?
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How many cigarettes are you smoking now?
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If specific strategies were suggested, ask questions such as:
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What did you think of the AA (or AlaTeen) meeting?
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Did you attend the class on using WIC foods?
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Did you pick up your WIC vouchers?
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How often do you eat the cereal that WIC provides?
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Physical Examination
At every visit, obtain and record objective data:
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Weigh the woman or have her weigh herself.
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Plot her weight on the grid.
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Check the fundal height.
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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):
Obese women:
All pregnant women
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Laboratory Evaluation
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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.
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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.
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-
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
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Whenever possible, involve the partner and family or friends in activities to promote social support for improved nutrition and health.
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Positively reinforce healthful behaviors and progress toward any goals set at the previous visit.
Weight
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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?
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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.
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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.
Diet and the Avoidance of Harmful Substances
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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.
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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:
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Provide information on the advantages and challenges of breastfeeding and bottle feeding.
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X (name of person) would like to speak with you about her experience with breastfeeding. You can reach her by . . .
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Support infant feeding decisions and encourage undecided women to breastfeed.
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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.
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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.
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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
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Reassure the woman that occasional nausea and vomiting will not hurt the baby.
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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.)
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Discourage use of unprescribed medications.
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If dehydration or ketosis is present, consider parenteral administration of fluids, electrolytes, and calories. Arrange for appropriate follow-up.
Inadequate Nutrient Intake
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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
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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.)
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Suggest strategies to adjust food intake, if appropriate.
Anemia
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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
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Side effects are dose related and are most common at doses of 120 mg of elemental iron or more.
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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:
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Let me give you the name of a liquid or chewable preparation if you have difficulty swallowing tablets.
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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.
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You may notice a darkening in the color of your stools. High doses of iron sometimes cause constipation or (less often)diarrhea.
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Use safety caps and keep supplements out of the reach of children.
For the Pregnant Woman: Heartburn
Constipation
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Positive Glucose Screen
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Perform diagnostic testing for diabetes mellitus.
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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.
For the Health Professional: What to Look for If Weight Gain Is Slow or If Weight Loss Occurs
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For the Health Professional: What to Look for If Weight Gain Is Very Rapid
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Pica
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Determine the extent of the practice and its potential for harmful effects.
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If indicated, explore ways to curb or completely eliminate the practice. Guidelines appear in the box.
Bed Rest
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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.
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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.
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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
Keeping Food at Your Bedside
Stimulating Your Appetite
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