Objectives Explain the importance of adequate nutrition and weight gain during pregnancy. Calculate if weight gain is within recommended guidelines. Determine food sources for recommended nutrients. Explain nutritional risk factors as they relate to pregnancy and fetal growth and development. Recognize the role cultural differences/preferences influence nutrition during pregnancy.

Good nutritional status prior to pregnancy is important to conception and healthy fetal development. Weight gain is an important determinant of fetal growth Insufficient weight gain- low birth weight, preterm labor, increased fetal mortality and morbidity Excessive weight gain- macrosomia, prolonged labor, birth trauma-mom and baby, cesarean birth Weight gain from empty calories is not as beneficial as weight gain from a balanced diet.

Effects of maternal nutrition on fetus Deficiencies can interfere with cell and organ growth If deficiencies occur during cell division - permanent consequences If deficiencies occur during cell enlargement - reversible

Recommended weight gain for normal weight pre-pregnant = 25-35 lbs 1st trimester- 1-4 lbs total weight gain 2nd and 3rd trimester- 1 lb. per week Underweight= 28-40 lbs. Overweight= 15-25 lbs. Obese=11-20 lbs. Weight distribution: Fetus, Placenta, Amniotic fluid = 11 lbs Uterus= 2 Breasts= 3 Increased blood volume= 4 Extravascular fluids= 5 Maternal reserves= 5-10

Practice Patient at 34 weeks gestation weighed 135 pre-pregnant now weighs 162. Is her weight gain within normal limits, to much or not enough. 34 weeks -13 weeks (1st trimester) =21 21 + 4 (1st trimester gain)=25 pounds suggested weight gain 162 -135= 27 pounds actual weight gain (+/- 5 Pounds)

For each patient, determine if the weight gain is within normal limits, to much or not enough. 1) Your patient is at 32 weeks gestation. Her current weight is 164. Her pre-pregnant weight was 145. 2) Your client is at 36 weeks gestation. Her current weight is 175. Her pre-pregnant weight was 143. 3) Your client is at 28 weeks gestation. Her current weight is 137. Her pre-pregnant weight was 125.

Weight gain answers 1. 32 weeks- 13 weeks= 19 weeks 19 lbs (1 lb/wk) + 4 lbs (1st trimester) = 23 lbs Recommended 164 lbs-145 lbs= 19 lbs actual Good weight gain 2. 36 weeks-13weeks= 23 weeks at 1 pound /week 23 lbs+ 4 lbs= 27 lbs recommended 175 lbs -143 lbs =32 lbs actual Only 3 pounds from target 35 and has 4 weeks to go. No diet but watch intake 3. 28 weeks -13 weeks =15 weeks 15 lbs+ 4 lbs = 19 lbs recommended 137 lbs-125 lbs= 12 lbs actual Not enough

Calories 1,800-2,200 daily for non-pregnant 1st trimester = no additional calories 2nd & 3rd trimester = +300 calories/day Twins- +600 calories/day

Carbohydrates- 4 calories/gram, essential for energy and fiber Protein- 4 calories/gram, essential for metabolism, tissue synthesis and repair; normally get 44-50 gm/day, need 60 g/day Fats- 9 calories/gram, essential for placenta formation, fetal brain development and fetal visual function

Vitamins True deficiency states are rare in U.S. Fat-soluble- stored in liver, excess can cause fetal defects. (A,D,E & K) Water soluble- are not stored as readily so need to be consumed daily; excreted in urine so less likely to have toxicity. (C & B vitamins) Fat soluble vitamins- Water soluble vitamins-

Folic Acid Decreases chance of neural tube defect by 50-70% Thought to decrease incidence of PTL Needs to be taken prior to conception and during first trimester 0.4 mg daily unless history of neural tube defect then take 4mg daily B12 assists folate in manufacture of new cells Best food sources- green leafy vegetables, legumes, peanuts, liver, whole grains, orange juice, fortified cereal

Protein Needed for fetal development, blood volume expansion, maternal growth of uterus and breast tissue Energy metabolism maternal and fetal Animal protein is of a higher quality than plant protein Best sources- lean meats, fish, poultry, eggs, dairy, soy, legumes, nuts and grains

Iron Two types: Heme – Non-heme- Iron from heme is more readily absorbed and is less affected by other foods Absorption increased if eaten in same meal as ascorbic acid (vitamin C). Foods cooked in cast iron pans have a higher iron content Best food sources: Red meat, legumes (lentils &peas), grains (bran flakes), broccoli, raisins, apricots, cooked spinach, tofu

Iron is important in hemoglobin formation Will be transferred to fetus even if maternal intake is inadequate causing depletion of mother’s stores. Need 30 mg/day unable to get in diet alone so iron supplements are often prescribed starting in 2nd trimester

Nursing Education avoid taking with milk (calcium), coffee (binds it) and tea (tannins). Take with Orange juice to increase absorption Take at night because of nausea Increase roughage

Zinc Necessary for tissue growth Increases immunity Deficiencies can contribute to preterm birth Need supplement if take large doses of iron Best Food Sources- beef, poultry, seafood, nuts, seeds, legumes, whole grains and yogurt

Calcium Necessary for: fetal bone and teeth formation maintenance of cell membrane permeability coagulation neuromuscular function Need 1,000-1,300 mg/day (4 cups of milk) Calcium will be drawn from bones if woman’s calcium intake is inadequate- easily restored after pregnancy

Caffeine increases excretion of calcium and decreases intestinal absorption Vitamin D increases absorption Better absorbed when taken with meals but separately from iron supplement Best sources: dairy products, legumes, nuts, broccoli, dried fruits, dark green leafy vegetables (except spinach), sardines (fish with bones left in), fortified orange juice

Iodine- needed for brain development Sodium needs are increased to provide for an expanded blood volume and needs of the fetus. does not have to be restricted but high salt food should be limited Iodine- needed for brain development American Academy of Pediatrics recommends supplement in Pregnancy and while breastfeeding Food Sources- iodized salt and seafood

Supplements Food is the best source of nutrients and often only need folic acid and iron supplements. Vitamins are not food substitutes and do not contain all the nutrients needed during pregnancy. Each woman needs to be assessed for her needs

Water Important for expanded blood volume Minimum of eight 8 oz glasses of fluid each day with water being the majority Limit carbonated beverages, coffee, tea, or juice drinks that are high sugar and little real juice.

Complex vs Simple Carbs Simple carbs are digested quickly Contain refined sugar and few essential vitamins and minerals Fruits, fruit juice, milk, yoghurt, honey, molasses and sugar Complex Carbs take longer to digest Packed with fiber, vitamins and minerals Vegetables, breads, cereals, legumes and pasta Are high fiber foods which improve digestion, stabilize blood sugar, maintain energy levels. Cause weight gain in most people and can cause withdrawal symptoms.

Vegetarians Protein sources: peanut butter, tofu, legumes, nuts, oatmeal Iron sources: legumes, grains, fruits, vegetables, tofu Calcium sources: fortified juices, black strap molasses, fortified tofu May need vitamin supplement Vegans- Lacto-vegetarians- Ovo-vegetarioans- Lacto-ovovegetarians-

Daily servings 7 whole grains- provide complex carbs 4 fruits- vitamins, minerals, and fiber 5 vegetables- vitamins, minerals, and fiber 1-2 dairy- same nutrient value whole, low-fat and skim 7oz protein- in addition to meat, poultry, fish and eggs- legumes, nuts and soybeans Oils, fats and concentrated sugars- sparingly 2 tablespoons of unsaturated fats

Limit/Avoid Limit fish to 6-12 oz/week- mercury- damages fetal CNS. Light tuna less mercury than albacore. Never swordfish, shark, king mackerel No raw eggs- salmonella. Avoid saturated fats and trans fats Avoid raw fish Avoid cold cuts, deli meats, hot dogs unless heated thoroughly. soft cheeses (brie, feta, blue cheese) unless pasteurized. no refrigerated potted meats and pate, raw or undercooked meats and poultry- listeria .Canned pates and potted meat OK

Risk Factors Be aware of cultural differences Nutrition Knowledge Patient age Vegetarians Substance abuse- -alcohol- FAS -drugs -caffeine -smoking Assess for eating disorders Strenuous exercise

Risk Factors (cont.) Multifetal pregnancy- higher calorie needs Lactose intolerant Multiparity -5 or more closely spaced pregnancies -may have nutritional deficits Socioeconomic status

WIC Women, Infants and Children: U.S. government program to ensure proper adequate nutrition to women and newborns til 5 years of age.

PICA http://www.magneticclay.com/eating-clay.php

Nursing role in Nutrition Education Monitor weight every visit Nutrition/dietitian referral WIC, social services

High Risk Pregnancy Preeclampsia- lose protein Diabetics- watch glucose