Prenatal Weight Gain Grid Template (Page 2 of 3) in pdf

Prenatal Weight Gain Grid

Multifetal Pregnancy

Instructions for Use

Overweight

Determine the woman’s prepregnancy weight for height status using the

table on the top of page 1 or 3. Check box A, B, C, or D, and then select the

Name:______________________________________

corresponding weight gain range on page 1, 2, or 3. Record the name, ID#,

birthdate, EDD (Expected Delivery Date), height, and prepregnancy weight.

If prepregnancy weight is unknown, it must be estimated. See box under

ID#: _______________ Date of Birth: _____________

prepregnancy weight space for instructions.

Each time a current weight measurement is available:

Weight Gain Recommendations

a. On the chart to the left of the grid, enter the date, current weight, number

of weeks pregnant, and total weight gain.

C - Overweight: 31 to 50 lb total

b. On the grid, place an “X” where the number of weeks pregnant intersects

trimester: 3.7 to 5.7 lb gain

the number of pounds gained or lost for the current visit.

& 3

trimesters: 1.0 to 1.6 lb/week

Revised EDD: If the EDD is revised, make a note beside the EDD space on

the form. At that time, begin to plot new weight measurements at the corrected

Check if applicable:

❏

number of weeks pregnant.

Multifetal Pregnancies: Institute of Medicine (IOM) provisional guidelines

for twin pregnancies: normal weight women should gain 37-54 pounds;

overweight women, 31-50 pounds; and obese women, 25-42 pounds(1). There

was insufficient information for the IOM to develop provisional guidelines for

underweight women. A consistent rate of weight gain is advisable. A gain of 1.5

pounds per week during the 2

& 3

trimesters has been associated with a

reduced risk of preterm and low-birth weight delivery in twin pregnancy(2). For

triplet pregnancies, the overall gain should be around 50 pounds with a steady

rate of gain of approximately 1.5 pounds/week throughout the pregnancy(2).

Education by the WIC nutritionist should address a steady rate of weight gain

that is higher than for singleton pregnancies.

Note: Individual needs and medical provider recommendations should be taken

into consideration when determining the desirable prenatal weight gain.

# Wks.

Total

Date

Weight

Preg.

Wt. Gain

EDD: _________________________

Height (no shoes): ______________

Prepregnancy Weight: ___________

If prepregnancy weight is unknown, use

professional judgement to select A, B, C, or D range.

Next, plot the midpoint of the selected range for the

number of weeks pregnant to obtain the Expected

Weight Gain. Then use this equation:

-5

Expected

Estimated

Current

–

Weight

Prepregnancy

Weight

Gain

Weight

-10

References:

(1) Institute of Medicine. Weight gain during pregnancy:

reexamining the guidelines. (Prepublication Copy).

Number of Weeks Pregnant

National Academy Press, Washington, D.C., 2009.

Accessed June 2009.

1st trimester

2nd trimester

3rd trimester

(2) Institute of Medicine. WIC nutrition risk criteria:

a scientific assessment. National Academy Press,

Page 2

Washington, D.C.; 1996.

Prenatal Weight Gain Grid Template Page 2

Related Articles

Related forms

Related Categories