**Maine WIC Nutrition
Program**![](media/image1.png){width="0.5152777777777777in"
height="0.9277777777777778in"}

**Pregnant Women Nutrition Assessment Guidance**

+---------+------------------------------------------------------------+
| **      | **Guidance**                                               |
| Topic** |                                                            |
+---------+------------------------------------------------------------+
| ###     | -   If prepregnancy weight is unknown, do the following:   |
| ######  |                                                            |
|         | \-- *Visually assess woman's weight status category. Use   |
| ###     | professional judgment to decide if she was most likely     |
| ######  | underweight, normal weight, overweight or obese prior to   |
|         | conception.*                                               |
| ####### |                                                            |
| ## Weig | > *\-- Determine exact number of weeks gestation. Using    |
| ht Gain | > the prenatal weight grid, determine the expected weight  |
|         | > gain (**mid-point**) for that number of weeks gestation  |
|         | > for a woman in her weight category.*                     |
|         |                                                            |
|         | \-- Subtract the expected weight gain from the woman's     |
|         | current weight. This is an estimate of prepregnancy        |
|         | weight.                                                    |
|         |                                                            |
|         | -   Record weight obtained at each clinic visit, along     |
|         |     with weeks gestation and total of pounds gained during |
|         |     pregnancy                                              |
|         |                                                            |
|         | -   To calculate pounds/month gained, use the following    |
|         |     formula:                                               |
|         |                                                            |
|         | > *Today's weight -- prenatal weight / weeks gestation =   |
|         | > lbs gained/week X 4.3 = lbs gained/mo.*                  |
|         |                                                            |
|         | -   Assess if weight gain is within normal limits (WNL).   |
|         |     Weight gain will be within normal limits if her weight |
|         |     gain plots between the lines on the prenatal weight    |
|         |     gain grid which correspond to her prenatal weight      |
|         |     category (based on prepregnancy BMI). Weight gain will |
|         |     not be WNL for the following:                          |
|         |                                                            |
|         | > ***Low maternal weight gain:* Assign risk factor A5 if   |
|         | > weight gain is**:                                        |
|         | >                                                          |
|         | > \< 1 lb per month for women with pre-pregnancy BMI \>    |
|         | > 29.0                                                     |
|         | >                                                          |
|         | > \< 2 lb per month for women with pre-pregnancy BMI       |
|         | > 26.1-29.0                                                |
|         | >                                                          |
|         | > \< 4 lb per month for women with pre-pregnancy BMI \<    |
|         | > 19.8                                                     |
|         | >                                                          |
|         | > ***High maternal weight gain*: Assign risk factor A7 if  |
|         | > weight gain is \>7 lb/month.**                           |
|         | >                                                          |
|         | > ***Maternal weight loss:* Assign risk factor A6 if woman |
|         | > has any weight loss below prenatal weight during the     |
|         | > first trimester OR if there is weight loss of            |
|         | > [\>]{.underline}2 lbs. in the 2^nd^ or 3^rd^             |
|         | > trimesters.**                                            |
+---------+------------------------------------------------------------+
| *       | -   Discuss recommended weight gain with pregnant woman.   |
| *Weight |     Ask what her feelings are about the weight gain        |
| Manag   |     recommendations. Assess whether or not she is          |
| ement** |     comfortable with the weight gain goals. *Ask "How do   |
|         |     you feel about the idea of gaining this amount of      |
|         |     weight?"* Discuss woman's efforts to keep weight gain  |
|         |     within normal limits.                                  |
|         |                                                            |
|         | -   If she was pregnant before, find out what her weight   |
|         |     gain was for previous pregnancy(ies).                  |
|         |                                                            |
|         | ```{=html}                                                 |
|         | <!-- -->                                                   |
|         | ```                                                        |
|         | -   If she desires to *limit weight gain*, reinforce the   |
|         |     need for adequate weight gain during pregnancy for the |
|         |     health of the baby, and refer her to MD to talk about  |
|         |     the need for adequate weight gain for baby's growth.   |
|         |                                                            |
|         | -   If prepregnancy BMI is high and/or she has a high rate |
|         |     of weight gain for weeks gestation, or if she gained   |
|         |     more than the recommended weight in a previous         |
|         |     pregnancy, discuss the implications:                   |
|         |                                                            |
|         | > \--weight gained during pregnancy may become weight she  |
|         | > will have difficulty losing after her pregnancy,         |
|         | > increasing the risk of later overweight/obesity.         |
|         |                                                            |
|         | \--high rate of weight gain increases the risk for having  |
|         | a high birth weight infant. This can lead to               |
|         |                                                            |
|         | delivery complications.                                    |
|         |                                                            |
|         | \--D*iscuss strategies for increasing nutrient-rich foods  |
|         | while limiting empty calorie foods in her diet.*           |
|         |                                                            |
|         | *Examples include: **substitute soda with 1% or skim milk; |
|         | replace empty calorie snacks such***                       |
|         |                                                            |
|         | ***as chips or candy bars with fresh fruit or vegetables;  |
|         | replace fried food items with baked or***                  |
|         |                                                            |
|         | ***broiled foods; increase vegetable intake at meals with  |
|         | salads, stir fry, or cut up vegetables.***                 |
|         |                                                            |
|         | -   Ask if she is physically active.                       |
|         |                                                            |
|         | > \--If she is currently physically active, ask about      |
|         | > preferred activities and how often she does them. Advise |
|         | > her to consult with her physician about her physical     |
|         | > activity (PA) plans if she has not already done so.      |
|         | >                                                          |
|         | > \--If she is not physically active, explain that,        |
|         | > according to the American College of Obstetrics and      |
|         | >                                                          |
|         | > Gynecology, pregnant women can and should try to         |
|         | > exercise moderately for at least 30 minutes on           |
|         | >                                                          |
|         | > most, if not all, days *unless there are medical reasons |
|         | > to avoid it (such as risks of preterm labor or if*       |
|         | >                                                          |
|         | > *mother suffers from serious ailment)*.                  |
+---------+------------------------------------------------------------+
| *       | > \--The benefits of exercise include:                     |
| *Weight |                                                            |
| Manag   | -   Stronger muscles, bones and joints                     |
| ement** |                                                            |
|         | -   Calories burned increase, helping to prevent weight    |
| **(c    |     gain                                                   |
| on't)** |                                                            |
|         | -   Lower risk of premature death, heart disease and other |
|         |     serious illnesses as the woman gets older if she       |
|         |     exercises regularly                                    |
|         |                                                            |
|         | -   She will feel better physically and emotionally        |
|         |                                                            |
|         | -   May help to prevent gestational diabetes               |
|         |                                                            |
|         | -   For those with gestational diabetes, blood sugars may  |
|         |     be easier to control                                   |
|         |                                                            |
|         | -   Stress relief                                          |
|         |                                                            |
|         | -   Increased stamina needed for labor and delivery        |
|         |                                                            |
|         | -   Regular exercise habits may help her to cope better in |
|         |     the postpartum period                                  |
|         |                                                            |
|         | **She should not start a new exercise program or increase  |
|         | PA before the 14^th^ week or after the**                   |
|         |                                                            |
|         | **28^th^ week of her pregnancy. Before week 14,            |
|         | overheating may adversely affect the**                     |
|         |                                                            |
|         | **development of the neural tube. After week 28, the baby  |
|         | must compete for oxygen and**                              |
|         |                                                            |
|         | **glucose if she overexerts herself.** Encourage her to    |
|         | choose things she will enjoy---suggest                     |
|         |                                                            |
|         | walking, dancing, hiking, swimming, or aerobics or yoga    |
|         | classes specifically for pregnant women.                   |
|         |                                                            |
|         | Stress that she should increase her level of activity      |
|         | **gradually** (start 15 min. 3 times/week, progress        |
|         |                                                            |
|         | to 15-30 min 4-5 times/week, avoid exercising in warm,     |
|         | humid places, and drink plenty of fluids                   |
|         |                                                            |
|         | before, during and after PA. A variety of activity may     |
|         | help increase her motivation to keep with it.              |
|         |                                                            |
|         | Stress avoidance of sports that carry a high risk of       |
|         | injury (like downhill skiing, ice hockey, or               |
|         |                                                            |
|         | horseback riding). Pregnant women should                   |
|         | [never]{.underline} scuba dive, since this can cause the   |
|         | dangerous                                                  |
|         |                                                            |
|         | formation of gas bubbles in the baby's circulatory system. |
|         | *After the third* *month, it is important to*              |
|         |                                                            |
|         | *avoid exercises that require her to lie flat on her back, |
|         | since that can restrict the flow of blood to the*          |
|         |                                                            |
|         | *uterus. **If she experiences any problems at all while    |
|         | exercising (like vaginal bleeding,***                      |
|         |                                                            |
|         | ***dizziness, headache, chest pain, decreased fetal        |
|         | movement, pain or contractions, she should***              |
|         |                                                            |
|         | ***[stop]{.underline} right away and consult her           |
|         | physician.***                                              |
|         |                                                            |
|         | -   For more information on physical activity guidelines   |
|         |     for pregnant women, consult any of the following       |
|         |     websites:                                              |
|         |                                                            |
|         | ```{=html}                                                 |
|         | <!-- -->                                                   |
|         | ```                                                        |
|         | -   [www.marchofdimes.com/printableArticles/159_515.asp](  |
|         | http://www.marchofdimes.com/printableArticles/159_515.asp) |
|         |                                                            |
|         | -   [www.healthunit.org/pregnancy/pregn                    |
|         | ancy/pregnancy_physical_activity.htm](http://www.healthuni |
|         | t.org/pregnancy/pregnancy/pregnancy_physical_activity.htm) |
|         |                                                            |
|         | -   <http://my.webmd.com/content/article/4/1680_51796>     |
+---------+------------------------------------------------------------+
| *       | -   Find out how eating has changed since the woman has    |
| *Diet** |     become pregnant.                                       |
|         |                                                            |
|         | -   If 24-hour intake is used to assess normal food        |
|         |     intake, comment on findings.                           |
|         |                                                            |
|         | -   Discuss cravings. Emphasize that cravings are          |
|         |     **normal** and that they are **different** for every   |
|         |     woman. Give reassurance that **some days food intake   |
|         |     will be better than others**, and that she should      |
|         |     strive to eat to the best of her ability on most days. |
|         |                                                            |
|         | -   Find out if non-food items are an issue. Ask ***"Often |
|         |     pregnant women have cravings for non-food items. Have  |
|         |     you experienced anything like that?"*** If pica        |
|         |     (ingestion of non-food items such as ice, dirt, clay,  |
|         |     cornstarch, laundry soap or starch, ashes, paint       |
|         |     chips, baking soda, paper), reassure her that this is  |
|         |     not unusual and that it may be a sign of dietary       |
|         |     deficiencies. Encourage replacement behaviors,         |
|         |     including: ***when craving a non-food item, try***     |
|         |     ***chewing sugarless gum,** **take a short walk or     |
|         |     read to a child; or try freezing fruit juice cubes to  |
|         |     chew instead of ice.*** Refer woman to physician if    |
|         |     needed.                                                |
|         |                                                            |
|         | -   Offer strategies that may assist her in improving      |
|         |     dietary quality. Some examples include:                |
|         |                                                            |
|         | > \--if she has difficulty getting 3 glasses of milk per   |
|         | > day, encourage dairy products intake in different forms, |
|         | > including flavored milk, smoothies, yogurt, with cereal, |
|         | > or as a bedtime snack with graham crackers.              |
|         | >                                                          |
|         | > \--if vegetables are not a favorite, talk about eating a |
|         | > variety of colors. Include salads with several colored   |
|         | > veggies; shred vegetables into casseroles; try home made |
|         | > vegetable soups; snack on cut up vegetables.             |
|         | >                                                          |
|         | > \--include fresh fruits for snacks.                      |
|         | >                                                          |
|         | > \--look for whole grain items, including cereals with    |
|         | > whole grains, whole wheat bread and brown rice.          |
+---------+------------------------------------------------------------+
| **H     | -   Ask about prenatal vitamin intake. If not using a      |
| ealth** |     prenatal vitamin, ask about brand of vitamin used.     |
|         |     Discuss need for adequate vitamin/mineral intake       |
|         |     during pregnancy and the need to use a prenatal        |
|         |     supplement. If woman cannot tolerate prenatal because  |
|         |     of nausea, suggest taking the supplement before        |
|         |     bedtime, or ½ in the morning and ½ in the evening at   |
|         |     bedtime. If she reports taking children's vitamins, it |
|         |     is necessary to find out the specific one she is using |
|         |     in order to assess adequacy (*specifically iron and    |
|         |     folic acid levels*). **Refer woman to discuss prenatal |
|         |     vitamin usage with her physician.**                    |
|         |                                                            |
|         | -   Ask about use of any other supplements, including      |
|         |     herbal preparations and teas. Refer to the NIH website |
|         |     <http://nccam.nih.gov/health/supplements.htm> to get   |
|         |     information on specific herbal supplements and their   |
|         |     safety for use in pregnancy.                           |
|         |                                                            |
|         | -   Ask about any prescribed medications---record name of  |
|         |     medication and dosage. Ask what the medication(s) have |
|         |     been prescribed for, and fill in the medical condition |
|         |     in "Problems with" section. Refer to [Medications and  |
|         |     Mother's Milk]{.underline} or the [University of       |
|         |     Rochester hotline]{.underline} (585-275-0088---call    |
|         |     and leave message if necessary; someone will call you  |
|         |     back) to find out if medication is contraindicated in  |
|         |     pregnancy and/or breastfeeding. W*omen receiving       |
|         |     methadone therapy [can]{.underline} breastfeed.        |
|         |     Assessment of the individual situation---maternal HIV  |
|         |     status, her mental health status, her social           |
|         |     situation, and whether or not she is stable in her     |
|         |     recovery program, will need to be considered when      |
|         |     recommending breastfeeding. Refer physicians to the    |
|         |     AAP paper "The Transfer of Drugs and Other Chemicals   |
|         |     Into Human Milk (*PEDIATRICS Vol. 108 No. 3 September  |
|         |     2001, pp. 776-789) *for more information.*             |
|         |                                                            |
|         | -   Ask about other medical problems listed:               |
|         |                                                            |
|         | ```{=html}                                                 |
|         | <!-- -->                                                   |
|         | ```                                                        |
|         | -   Heartburn: refer woman to discuss antacid use with     |
|         |     physician. Suggest the following: *5-6 small frequent  |
|         |     meals throughout the day; eat slowly; avoid eating     |
|         |     close to bedtime or lying down shortly after eating,   |
|         |     avoid spicy, rich or greasy foods; when sleeping, use  |
|         |     pillows under the shoulders to keep the upper body     |
|         |     propped up; wear loose clothing.*                      |
|         |                                                            |
|         | -   Nausea/vomiting: Reassure that this is very common     |
|         |     during the first trimester. Assess severity and refer  |
|         |     to physician if the woman is unable to eat             |
|         |     sufficiently to gain weight or is losing weight, or    |
|         |     vomiting more than 3-4 times/day. Offer specific       |
|         |     strategies that may help: *get out of bed slowly in    |
|         |     the morning; keep crackers or dry cereal at the        |
|         |     bedside to eat before getting up; eat small amounts    |
|         |     frequently, even every 2-3 hours; drink a lot of       |
|         |     fluids, especially if solid food will not stay down;   |
|         |     avoid cooking smells, foods with strong odors or       |
|         |     highly spiced foods, or any other odors that lead to   |
|         |     nausea; avoid brushing teeth immediately after eating, |
|         |     as this may lead to vomiting.*                         |
|         |                                                            |
|         | -   Constipation: recommend woman increase water intake    |
|         |     (10-12 cups/day) as well as fresh fruit, vegetable and |
|         |     whole grain intake. Ask about physical activity and    |
|         |     encourage she increase after discussing with MD. Avoid |
|         |     laxative use unless recommended by MD.                 |
|         |                                                            |
|         | -   Headaches: refer to physician. Emphasize the need for  |
|         |     adequate rest, plenty of liquids as well as frequent   |
|         |     well-balanced meals. Headaches in the third trimester  |
|         |     may be indicative of high blood pressure, so emphasize |
|         |     need for woman to notify MD.                           |
|         |                                                            |
|         | -   Dizziness: refer to MD. Emphasize need for *adequate   |
|         |     food and liquids, and to eat frequently, avoiding long |
|         |     periods of time between meals; avoid hot baths or      |
|         |     showers*; *do not stand in one place for long periods  |
|         |     of time; if standing is required, make sure to keep    |
|         |     feet moving to increase circulation; get up slowly     |
|         |     when lying down; do not lie down on back after middle  |
|         |     of 2^nd^ trimester; wear loose comfortable clothing    |
|         |     that will not constrict circulation.*                  |
|         |                                                            |
|         | -   Swallowing difficulties: ask what types of             |
|         |     foods/beverages she is able to consume; refer to       |
|         |     physician if special formula required for adequate     |
|         |     nutrition.                                             |
|         |                                                            |
|         | -   Ask if there are any other medical problems. List      |
|         |     medical conditions not specified above for which       |
|         |     medications have been prescribed.                      |
|         |                                                            |
|         | -   **Ask at each visit: "Are there any other medical      |
|         |     conditions affecting your overall health?"**           |
|         |                                                            |
|         | ```{=html}                                                 |
|         | <!-- -->                                                   |
|         | ```                                                        |
|         | -   Ask if special diet has been prescribed by physician.  |
|         |     If so, find out what diet prescription is. Refer to RD |
|         |     as needed. If being followed by RD, request nutrition  |
|         |     plan in order to offer consistent support.             |
+---------+------------------------------------------------------------+
| Preterm | -   Approach smoking issues using the 3 A's:               |
| Birth   |                                                            |
| Risks   | > \--***Ask** about tobacco use. If woman is smoking, ask  |
|         | > if smoking has changed since she found out about being   |
| **      | > pregnant.*                                               |
| Perterm | >                                                          |
| Birth   | > *\--**Advise** all pregnant women who smoke to stop      |
| Risks   | > smoking. Begin the discussion by saying **"The**         |
| (c      | > **recommendation for you and your baby is for you to     |
| on't)** | > quit smoking."** Focus on her barriers to quitting---for |
|         | > example, increased food cravings, weight gain, or being  |
|         | > around others who smoke. Emphasize the benefits for both |
|         | > her [and]{.underline} her baby, including: more energy;  |
|         | > able to breathe more easily; more money to spend on      |
|         | > other things; clothes, hair, home will smell better;     |
|         | > food will taste better; less risk for low birth          |
|         | > weight/preterm baby (specify dangers of babies being     |
|         | > born too early and/or too small---undeveloped lungs,     |
|         | > potentially lengthy hospitalization after delivery);     |
|         | > less risk for her baby of SIDS and asthma; she will feel |
|         | > good that she has done this for herself and her baby.*   |
|         | >                                                          |
|         | > *\--**Assist** her with a cessation plan---provide       |
|         | > support, self-help materials and referrals for other     |
|         | > support, including the Maine Tobacco Helpline            |
|         | > (800-207-1230). **Follow up at each visit.***            |
|         |                                                            |
|         | -   If exposed to second hand smoke, discuss need to have  |
|         |     all smoke to stay outside the home. Also advise woman  |
|         |     that all smokers must wash hands and change clothes    |
|         |     prior to holding baby to avoid exposing infant to      |
|         |     second hand smoke.                                     |
|         |                                                            |
|         | -   Ask about date of last dental visit, and if woman has  |
|         |     problems with decay or bleeding gums. Discuss poor     |
|         |     oral health link with preterm birth risk. Refer to     |
|         |     dental provider. Review things she can do to improve   |
|         |     the condition of her gums and overall oral health,     |
|         |     including: *brush at least twice a day with a fluoride |
|         |     toothpaste, being sure to reach all tooth surfaces as  |
|         |     well as her tongue; floss at least once each day. It   |
|         |     is normal for gums to become more sensitive during     |
|         |     pregnancy. This is a result of the hormone changes and |
|         |     the resulting reaction to plaque in her mouth. If she  |
|         |     has never flossed before, or flossed infrequently, her |
|         |     gums may be sore and bleed---that's normal. If she has |
|         |     brushed infrequently in the past, her gums may be sore |
|         |     and bleed when she begins to brush more                |
|         |     frequently---that's normal. Things will improve over   |
|         |     time. Mouthwashes and rinses are **not** a substitute  |
|         |     for brushing and/or flossing. Encourage her to change  |
|         |     to a new toothbrush every 3-4 months, or sooner if     |
|         |     bristles begin to fray.*                               |
+---------+------------------------------------------------------------+
| **Other | -   Inquire about alcohol use and if woman is around       |
| Fetal   |     others who drink, since being around others who drink  |
| Risks** |     can make it difficult for the woman to abstain. If     |
|         |     there is *any* alcohol use, discuss risk of Fetal      |
|         |     Alcohol Spectrum Disorders (FASD). Emphasize that no   |
|         |     amount of alcohol is *safe*. Refer to substance abuse  |
|         |     counselor as needed.                                   |
|         |                                                            |
|         | -   FASD includes an entire spectrum of potential          |
|         |     disorders, including: prenatal and postnatal growth    |
|         |     retardation; characteristic facial features; central   |
|         |     nervous system (CNS) dysfunction; learning             |
|         |     disabilities; problems with memory, attention and      |
|         |     judgment; hyperactivity and behavioral problems.       |
|         |     Prenatal alcohol use does not always result in FASD,   |
|         |     but there is no way of knowing which babies will be    |
|         |     born with problems. Some babies will exhibit no        |
|         |     symptoms, others may have mild symptoms, while others  |
|         |     will have many problems. **A baby will never outgrow   |
|         |     FASD---it will be with the child for a lifetime. This  |
|         |     disorder is 100% preventable**. Refer her to **The     |
|         |     Women's Project** as needed.                           |
|         |                                                            |
|         | -   Ask about use of street drugs. If any drugs are being  |
|         |     used, ask about plans/thoughts to D/C. Refer to        |
|         |     recovery/rehab program as needed. See **Health**       |
|         |     section for information on methadone treatment and     |
|         |     breastfeeding.                                         |
+---------+------------------------------------------------------------+
| ###     | -   Ask woman's knowledge about breastfeeding---what she   |
| ######  |     has heard, read or knows about it. Ask about her       |
|         |     perceptions---what she thinks about breastfeeding.     |
| ###     |     *Ask "What do you know about BF? How do you feel about |
| ######  |     that for yourself?"* If she has had children before,   |
|         |     ask *"What personal breastfeeding experience do you    |
| #####   |     have?*" Frequently, knowledge and perception are very  |
| #### BF |     different. It is perceptions that are important and    |
|         |     will guide a woman in the decision-making process.     |
|         |                                                            |
|         | -   Find out if she has family members or friend(s) with   |
|         |     any positive BF experiences. Emphasize that anyone     |
|         |     within her family circle or circle of friends can be a |
|         |     good support person if they have had a positive        |
|         |     experience.                                            |
|         |                                                            |
|         | -   Ask if she wants to learn more about BF so that she    |
|         |     may make an informed decision about infant feeding.    |
|         |     This will help you to understand her readiness to      |
|         |     change, especially if she is closed to the idea of     |
|         |     breastfeeding her baby---**pre-contemplating**         |
|         |     (doesn't want any information), **contemplating**      |
|         |     (will think about it and will be willing to take       |
|         |     information), **preparation** (wants information,      |
|         |     ready to read whatever you will give her).             |
+---------+------------------------------------------------------------+
| ###     | -   Record topics discussed. There may be several things   |
| ######  |     checked off in the various sections, but the counselor |
|         |     chooses to limit the discussion to avoid overloading   |
| ###     |     the participant. ***[It is recommended that            |
| ######  |     discussions be limited to three topics or              |
|         |     less.]{.underline}*** Remember that assessments        |
| ###     |     initially done in the 1^st^ trimester will cover       |
| ######  |     different topics than those done in the third          |
|         |     trimester.                                             |
| #       |                                                            |
| ####### | -   Ask about infant feeding plan at each visit.           |
| # Notes |                                                            |
|         | -   Mom's plans---let the participant set realistic goals  |
|         |     for herself between the first and second visit.        |
|         |     Examples include:                                      |
|         |                                                            |
|         | > *Increase milk intake to 3-8 ounce glasses/day.*         |
|         | >                                                          |
|         | > *Use milk in cereal, smoothies, cooking, etc. in order   |
|         | > to increase Ca intake.*                                  |
|         | >                                                          |
|         | > *Consider BF as infant feeding option.*                  |
|         | >                                                          |
|         | > *Call Tobacco Help Line for help with d/c smoking.*      |
|         | >                                                          |
|         | > *Brush and floss twice daily; call dentist for cleaning  |
|         | > appt.*                                                   |
|         | >                                                          |
|         | > *Limit low-nutrient foods (such as soda, candy, etc.) in |
|         | > diet.*                                                   |
|         | >                                                          |
|         | > ***It is acceptable if woman does NOT decide on a        |
|         | > plan---it's ok to leave this blank!***                   |
|         |                                                            |
|         | -   Make a note what should be followed up at the next     |
|         |     appt.                                                  |
+---------+------------------------------------------------------------+

##### Maine WIC Nutrition Program![](media/image1.png){width="0.5152777777777777in" height="0.9277777777777778in"}

**BF/PP Woman Nutrition Assessment Guidance**

+--------+-------------------------------------------------------------+
| **We   | -   Ask woman her thoughts about her current weight. State: |
| ight** |     "*After delivery, women are frequently concerned about  |
|        |     their weight. How do you feel about your current        |
|        |     weight?"* If she desires a change ask *"What change     |
|        |     with your weight would you like to see happen?"* **If   |
|        |     her current BMI is high and she does not desire a       |
|        |     change, she is precomtemplative---respect for that is   |
|        |     important.**                                            |
|        |                                                             |
|        | -   If she desires a change, ask what her weight goal is,   |
|        |     and how she hopes to achieve it. Ask if she needs ideas |
|        |     or suggestions to achieve her goal and provide          |
|        |     appropriate resources.                                  |
|        |                                                             |
|        | -   Ask about physical activity---type and frequency.       |
|        |     Remind her to discuss any physical activity plans with  |
|        |     her MD if she is \<6 weeks PP.                          |
+--------+-------------------------------------------------------------+
| ####   | -   Ask what changes have been made in diet since delivery. |
| #####  |     Many common things that happen to moms after delivery   |
|        |     include: grazing, skipping meals, preparing unbalanced  |
| ####   |     meals due to lack of time to cook and "forgetting" to   |
| #####  |     eat. *Provide her with appropriate tips for improved    |
|        |     nutrition, including: smoothies; cereal with milk and   |
| ####   |     fruit; cheese and crackers; cut up vegetables; toast    |
| #####  |     with peanut butter; hummus with crackers. Remind her    |
|        |     that her body needs a balanced diet to recover and heal |
| ####   |     from pregnancy/delivery.*                               |
| #####  |                                                             |
|        | -   Query about special diet Rx or foods that are being     |
| ####   |     avoided.                                                |
| #####  |                                                             |
|        | -   If 24 hour recall is used to assess normal intake,      |
| ####   |     comment on findings.                                    |
| #####  |                                                             |
|        | -   Ask about *[habits that will lead to healthy feeding    |
| ##     |     relationships with child/children]{.underline}*:        |
| ###### |                                                             |
| # Diet | > ► Ask about *[family meals]{.underline}*. Discuss         |
|        | > importance they play in good eating habits for children.  |
|        |                                                             |
|        | ► Ask how she *[plans for meals and snacks]{.underline}*.   |
|        | Discuss how important planning is in ensuring healthy       |
|        |                                                             |
|        | habits and food budgeting.                                  |
|        |                                                             |
|        | ► Query about *[variety of foods]{.underline}*---*Ask a     |
|        | question such as "What are the vegetables you usually eat*  |
|        |                                                             |
|        | > *during a typical week?*" Discuss need for including a    |
|        | > variety of colors with fruits and vegetables.             |
+--------+-------------------------------------------------------------+
| ####   | -   Ask about folic acid intake. Discuss sources of         |
| #####  |     adequate folic acid, which can come from supplements    |
|        |     *or* foods. Point out the WIC cereals that contain 100% |
| ####   |     DV folic acid, which are identified on the foods list   |
| #####  |     with and asterisk (\*). Discuss folic acid's role in    |
|        |     possibly preventing birth defects, and the need to      |
| ####   |     consume adequate folic acid to protect future           |
| #####  |     pregnancies.                                            |
|        |                                                             |
| ####   | -   Ask about other vitamin or supplement intake, including |
| #####  |     herbal supplements. Refer to the NIH website            |
|        |     <http://nccam.nih.gov/health/>, [Medications and        |
| ####   |     Mothers' Milk]{.underline} or [University of            |
| #####  |     Rochester]{.underline} hotline (585-275-0088---leave    |
|        |     message if necessary and someone will call you back)    |
| ####   |     for information of specific supplements and their       |
| #####  |     compatibility with breastfeeding.                       |
|        |                                                             |
| ####   | -   Query about prescribed medications. If BF, consult      |
| #####  |     [Medications and Mothers' Milk]{.underline} or          |
|        |     [University of Rochester]{.underline} hotline           |
| ####   |     (585-275-0088---leave message if necessary) to identify |
| #####  |     any meds that are contraindicated for BF women. **Ask   |
|        |     about birth control; advise breastfeeding women to talk |
| ####   |     to their doctor about progesterone-only birth control   |
| #####  |     pills if that is the birth control chosen.** W*omen     |
|        |     receiving methadone therapy [can]{.underline}           |
| ####   |     breastfeed. Assessment of the individual                |
| #####  |     situation---maternal HIV status, her mental health      |
| Health |     status, her social situation, and whether or not she is |
|        |     stable in her recovery program, will need to be         |
|        |     considered when recommending breastfeeding. Refer       |
|        |     physicians to the AAP paper "The Transfer of Drugs and  |
|        |     Other Chemicals Into Human Milk (*PEDIATRICS Vol. 108   |
|        |     No. 3 September 2001, pp. 776-789) *for more            |
|        |     information.*                                           |
|        |                                                             |
|        | -   Ask if woman had a C-section this delivery. If yes, ask |
|        |     if there are any problems with healing of the incision. |
|        |     Refer to MD as necessary.                               |
|        |                                                             |
|        | -   Ask about date of last dental visit, and if she has any |
|        |     problems with decay and/or bleeding gums when she       |
|        |     brushes. Discuss need for good oral health of mother to |
|        |     help prevent transmission of decay-causing bacteria to  |
|        |     baby. ***Emphasize the need to avoid practices that     |
|        |     will lead to transfer of bacteria to baby's mouth,      |
|        |     including: cleaning pacifier's in the mouth;* *testing  |
|        |     baby's food temperature before feeding; sharing spoons, |
|        |     cups and other utensils; kissing baby's hands and       |
|        |     mouth.*** Refer to dental provider as needed.           |
+--------+-------------------------------------------------------------+

+------------+---------------------------------------------------------+
| ## Health  | -   Ask about other health problems listed:             |
|            |                                                         |
| *          |     -   Diarrhea: ask about frequency and duration.     |
| *(con't)** |         Remind about need for adequate fluid            |
|            |                                                         |
|            | > intake. Refer to MD if needed.                        |
|            |                                                         |
|            | -   Constipation: discuss need for adequate fluids and  |
|            |     fiber-rich foods. Refer to MD if                    |
|            |                                                         |
|            | > needed                                                |
|            |                                                         |
|            | -   If headaches or dizziness are a problem, refer      |
|            |     to MD. Emphasize need for adequate                  |
|            |                                                         |
|            | > liquids as well as regular meals.                     |
+------------+---------------------------------------------------------+
| #########  | -   Ask about tobacco use, and desire and/or plans to   |
|            |     quit. Ask about methods to quit that have been      |
| #########  |     used. Refer to Tobacco Help Line*(800-207-1230)*    |
|            |     for assistance and support.                         |
| #########  |                                                         |
|            | -   Ask about second hand smoke exposure. If woman is a |
| #########  |     smoker, emphasize that it will be more difficult to |
|            |     quit with other smokers around. Discuss need for    |
| #########  |     smoke-free environment for baby. Stress that second |
|  Substance |     hand smoke will stay on clothing and hand, and that |
|            |     all smokers should change clothes and wash hands    |
| **Abuse**  |     prior to holding baby.                              |
|            |                                                         |
|            | -   Ask about alcohol use. If BF, remind mom that       |
|            |     alcohol passes into breastmilk and will have an     |
|            |     effect on baby. If woman is around others who       |
|            |     drink, ask how being around others who drink makes  |
|            |     her feel. Offer referral brochure to **Women's      |
|            |     Project** if she has an interest. If she has other  |
|            |     questions, discuss risk of FASD for future          |
|            |     pregnancies and the need to avoid alcohol use, and  |
|            |     the fact that it may be difficult to stay sober if  |
|            |     she is around others who drink.                     |
|            |                                                         |
|            | ```{=html}                                              |
|            | <!-- -->                                                |
|            | ```                                                     |
|            | -   If any street drugs are being used, refer to        |
|            |     recovery program.                                   |
+------------+---------------------------------------------------------+
| #########  | -   Ask mom what her breastfeeding duration plans are,  |
|            |     and who she has for support.                        |
| #########  |                                                         |
|            | -   Ask her about any plans to return to work or        |
| #########  |     school, and how she will plan to feed her baby.     |
|            |     Discuss pumping if needed, including type of pump   |
| #########  |     to meet her needs.                                  |
|            |                                                         |
| #########  | -   Ask mom about her perception of how breastfeeding   |
|            |     is going. If she needs help, ask what specific      |
| #########  |     problems she is having. If necessary, refer her to  |
|            |     CLC or IBCLC in agency/area.                        |
| #########  |                                                         |
|            | -   Ask mom about her perception of her milk supply     |
| ###        |     (*subjective*). Ask specific questions about        |
| ###### Bre |     breastfeeding (*objective*) that will help to       |
| astfeeding |     validate milk supply:                               |
|            |                                                         |
|            | ```{=html}                                              |
|            | <!-- -->                                                |
|            | ```                                                     |
|            | -   *Ask how often baby is breastfeeding in 24 hours.*  |
|            |                                                         |
|            | -   *Ask how long baby stays at breast at each feeding, |
|            |     and ask about active suck/swallowing at feedings if |
|            |     baby stays at the breast for extended periods of    |
|            |     time.*                                              |
|            |                                                         |
|            | -   *Ask about the number of wet/dirty diapers per day  |
|            |     and assess for adequacy.*                           |
|            |                                                         |
|            | -   *Ask if mom pumps. If she does, ask what type of    |
|            |     pump she is using, how often she is pumping, and    |
|            |     what her results are. If she is exclusively         |
|            |     pumping, ask about plans to get baby to go to       |
|            |     breast. Refer to CLC or IBCLC as needed.*           |
|            |                                                         |
|            | -   *Ask if baby has been weighed since discharge from  |
|            |     hospital, and what that weight was. Compare to      |
|            |     weight obtained at clinic visit.*                   |
|            |                                                         |
|            | ```{=html}                                              |
|            | <!-- -->                                                |
|            | ```                                                     |
|            | -   If there are specific breastfeeding problems        |
|            |     detected, SOAP note the visit and refer as needed.  |
|            |                                                         |
|            | -   Query if there are any of the problems listed.      |
|            |     Refer to lactation help (CLC or IBCLC) if needed.   |
+------------+---------------------------------------------------------+

##### Women Health Assessment Form

##### Guidance

+---------------------------+------------------------------------------+
| ## Question               | **Suggested Action**                     |
+---------------------------+------------------------------------------+
| Woman's physician/dentist | If no MD---refer to local hospital       |
|                           | physician referral service               |
|                           |                                          |
|                           | If no dentist---refer to area clinics.   |
+---------------------------+------------------------------------------+
| Health Insurance          | If none, refer to MaineCare              |
+---------------------------+------------------------------------------+
| What services do you      | Enter appropriate code in "Other         |
| currently receive?        | Services" field.                         |
+---------------------------+------------------------------------------+
| Do you live in or spend   | ###### If *                              |
| time in a home built      | *yes** to either question is selected--- |
| before 1978?              |                                          |
|                           | -   Discuss risk for lead exposure and   |
| If yes, is the home being |     importance of lead testing of baby   |
| remodeled?                |     at 12 and 24 months                  |
|                           |                                          |
|                           | -   Share ways to reduce lead exposure:  |
|                           |     frequent **wet**, rather than dry,   |
|                           |     **dust removal**; **paint over**     |
|                           |     peeling paint; **remove shoes** at   |
|                           |     door; keep **paint chips** away from |
|                           |     young children.                      |
+---------------------------+------------------------------------------+
| Were there any days last  | ###### If **yes** selected---            |
| month when your family    |                                          |
| did not have enough food  | Give referral information for area       |
| to eat or enough money to | resources, including Food Stamps, Food   |
| buy food?                 | Banks and/or the SHARE program.          |
+---------------------------+------------------------------------------+
| Do you have problems      | ###### If **yes** is selected---         |
| refrigerating or          |                                          |
| heating/cooking your      | -   Adjust food package accordingly      |
| food?                     |                                          |
|                           | Refer to area resources for assistance   |
+---------------------------+------------------------------------------+
| Do you feel unsafe for    | If **yes** selected, refer to area       |
| yourself or your children | shelters for women.                      |
| in your current           |                                          |
| relationship?             |                                          |
+---------------------------+------------------------------------------+
| **For those who have been | If **yes**, assign appropriate risk      |
| pregnant before:**        | code.                                    |
|                           |                                          |
| Did you have problems     |                                          |
| during any pregnancy or   |                                          |
| delivery?                 |                                          |
+---------------------------+------------------------------------------+
| Were any of your babies:  | -   assign risk factor P8                |
|                           |                                          |
| -   Stillborn             | -   assign risk factor P7 if baby born   |
|                           |     [\>]{.underline}3 weeks early        |
| -   Born early/premature  |                                          |
|                           | -   assign risk factor P7                |
| -   Weigh 5 lb 8 oz or    |                                          |
|     less at birth         | -   assign risk factor P6                |
|                           |                                          |
| -   Weigh 9 lb or more at |                                          |
|     birth                 |                                          |
+---------------------------+------------------------------------------+
| **For those who have      | If **yes**, assign appropriate risk      |
| recently given birth:**   | code.                                    |
|                           |                                          |
| Did you have problems     |                                          |
| during this pregnancy or  |                                          |
| delivery?                 |                                          |
+---------------------------+------------------------------------------+
| Over the past 2 weeks,    | ###### Stress that it is normal for      |
| have you ever felt down,  | women to experience changes in mood afte |
| depressed, or hopeless?   | r delivery. See attached reference from  |
|                           | *National Mental Health Association* or  |
| Over the past 2 weeks,    | go to http://www.nmha.org/index.cfm?obje |
| have you felt little      | ctid=C7DF956C-1372-4D20-C88192E11CCAA8E4 |
| interest or pleasure in   |  for more information. **Refer to MD or  |
| doing things?             | area mental health provider as needed.** |
+---------------------------+------------------------------------------+