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Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
CHAPTER 11
Nutrition During Pregnancy and Lactation
Sharon M. Nickols-Richardson
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 2
Maternal Nutrition
and the Outcome of Pregnancy
Early Medical Practice
Two assumptions, now known to be false,
governed practice:
1. The parasite theory: whatever the fetus needs, it
draws from maternal stores despite the maternal diet
2. The maternal instinct theory: whatever the fetus
needs, the pregnant woman instinctively craves and
consumes
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 3
Maternal Nutrition
and the Outcome of Pregnancy – Cont’d
Healthy Pregnancy
A healthy pregnancy has often been defined by
the birth weight of the newborn
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 4
Maternal Nutrition
and the Outcome of Pregnancy – Cont’d
Factors Determining Nutritional Need
Maternal nutrition is critically important to both
the mother and newborn
Age, gravida, and parity determine nutritional
requirements of the woman during her
pregnancy
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 5
Maternal Nutrition
and the Outcome of Pregnancy – Cont’d
Complex Physiologic Interactions
of Gestation
Three distinct biologic entities are involved
during gestation:
1. The woman
2. The fetus
3. The placenta, which nourishes fetal growth
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 6
Basic Concepts Involved
Three basic concepts form a fundamental
framework for assessing maternal nutritional
needs and for planning supportive prenatal
care for the woman:
1. Perinatal concept
2. Synergism concept
3. Life continuum concept
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 7
Preconception Nutrition
Preconception counseling and optimal
preconception nutrition may increase the
odds for a healthy pregnancy and desirable
infant outcome
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 8
Preconception Nutrition – Cont’d
Exercise
Women who exercise before pregnancy
should continue a reasonable exercise
regimen during pregnancy
Kilocalories (kcalories or kcal) must be
consumed to meet the energy cost of
exercise and to promote appropriate maternal
weight gain and fetal growth and
development
Adequate hydration is also vital
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 9
Nutritional Demands of Pregnancy
Kcalories must be sufficient to perform the
following two functions:
1. Supply the increased energy and nutrient
demands created by the increased metabolic
workload, including some maternal fat storage and
fetal fat storage to ensure an optimal newborn size
for survival
2. Spare protein for tissue building
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 10
Nutritional Demands of Pregnancy –
Cont’d
Approximately 340 additional kcal/day are
needed during the second trimester
Approximately 450 additional kcal/day during the
third trimester
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 11
Nutritional Demands of Pregnancy –
Cont’d
Protein
Approximately 71 g/day is needed
More protein is necessary for the following:
• Rapid fetal growth
• Enlargement of the uterus, mammary glands, and placenta
• Increase in maternal circulating blood volume
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 12
Nutritional Demands of Pregnancy –
Cont’d
Protein – cont’d
Approximately 71 g/day is needed – cont’d
More protein is necessary for the following: –
cont’d
• Formation of amniotic fluid
• Storage reserves for labor, delivery, and lactation
Milk, egg, cheese, and meat are complete protein
foods
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 13
Nutritional Demands of Pregnancy –
Cont’d
An adequate supply of essential fatty acids is
needed
Linoleic acid: 13 g/day
Alpha-linolenic acid: 1.4 g/day
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 14
Nutritional Demands of Pregnancy –
Cont’d
Carbohydrates
At least 175 g/day during pregnancy
Whole grain breads, cereals, fresh fruits, and
vegetables should be consumed
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 15
Nutritional Demands of Pregnancy –
Cont’d
Total daily dietary kcalorie intake should
comprise:
15% protein
30% fat
55% carbohydrate
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 16
Nutritional Demands of Pregnancy –
Cont’d
Calcium
1000 mg of calcium per day
Essential element for the construction and
maintenance of bones and teeth
An important factor in the blood-clotting
mechanism and normal muscle action
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 17
Nutritional Demands of Pregnancy –
Cont’d
Iodine
70 µg/day during pregnancy
Vital for thyroid hormone synthesis and
prevention of goiter
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 18
Nutritional Demands of Pregnancy –
Cont’d
Iron
27 mg of iron per day
A daily supplement of 30 to 60 mg of iron may
be prescribed
Maternal iron is needed to supply iron to the
developing placenta and fetal liver
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 19
Nutritional Demands of Pregnancy –
Cont’d
Iron – cont’d
Major food source of iron is liver
Other food sources include meat, legumes,
dried fruit, green leafy vegetables, eggs, and
enriched bread and cereals
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 20
Nutritional Demands of Pregnancy –
Cont’d
Zinc
Increases from 8 to 11 mg/day
Vital for enzymatic reactions
Essential to growth and development due to
its role in deoxyribonucleic acid (DNA) and
ribonucleic acid (RNA) synthesis and protein
production
Seafood, eggs, and meat are primary sources
of zinc
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 21
Nutritional Demands of Pregnancy –
Cont’d
Vitamin A
770 µg of retinol activity equivalents (RAE)
Essential factor in cell differentiation, organ
formation, maintenance of strong epithelial
tissue, tooth formation, and normal bone
growth
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 22
Nutritional Demands of Pregnancy –
Cont’d
Vitamin A – cont’d
Good sources: Liver, egg yolk, butter and
fortified margarine, dark green and yellow
vegetables, and fruits
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 23
Nutritional Demands of Pregnancy –
Cont’d
B Vitamins
Special need for thiamin, riboflavin, niacin,
pyridoxine, cobalamin, pantothenic acid, and
folate during pregnancy
Coenzyme factors in a number of metabolic
activities related to energy production, tissue
protein synthesis, and function of muscle and
nerve tissue
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 24
Nutritional Demands of Pregnancy –
Cont’d
Folate
600 µg/day during pregnancy
500 µg/day during lactation
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 25
Nutritional Demands of Pregnancy –
Cont’d
Vitamin C
85 mg/day for the pregnant woman
Essential to the formation of intercellular cement
substance in developing connective tissues and
vascular systems
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 26
Nutritional Demands of Pregnancy –
Cont’d
Vitamin D
5 µg cholecalciferol (200 IU/day)
Used to promote the absorption and utilization of
calcium and phosphorus
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 27
General Daily Food Pattern
Two useful general principles:
1. Eat an appropriate quantity of food
2. Eat regularly, avoiding fasting or skipping
meals, especially breakfast
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 28
Alternative Food Patterns
With the increasing ethnic diversity in the United
States, it is especially important to use the
woman’s personal cultural food patterns in
dietary counseling
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 29
Dietary Supplements
“Prenatal vitamins” are often prescribed for
pregnant women
Supplements include a variety of vitamins
and minerals and are intended to add to
nutrient intake from foods rather than replace
food and nutrient consumption
Herbal and botanical supplement use during
pregnancy is discouraged
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 30
Weight Gain During Pregnancy
An average weight gain during normal
pregnancy is about 11 to 16 kg (25 to 35 lb)
Normal weight women with body mass index
(BMI) of 19.8 to 26.0: 11.5 to 16 kg (25 to 35
lb)
Underweight women with BMI of less than
19.8: 13 to 18 kg (28 to 40 lb)
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 31
Weight Gain During Pregnancy – Cont’d
Overweight women with BMI of greater than
26.0 to 29.0: 7 to 11.5 kg (15 to 25 lb)
Obese women with BMI of greater than 29.0:
minimum of 7 kg (15 lb)
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 32
Quality of Weight Gain
Foods consumed should be nutrient dense,
not full of empty kcalories
Analysis of the total tissue gained in an
average pregnancy shows that the largest
component, 62%, is water
Fat accounts for 31% and protein for 7%
Weight reduction should never be undertaken
during pregnancy
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 33
Rate of Weight Gain
Approximately 1 to 2.3 kg (2 to 5 lb) is an
average weight gain during the first trimester
An average weight gain of about 0.5 kg (1
lb)/week during the remainder of the
pregnancy is usual
Some women may need to gain more
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 34
Rate of Weight Gain – Cont’d
Sodium Intake
1.5 to 2.3 g/day
Limiting sodium beyond this general use is
contrary to physiologic need in pregnancy
and is unfounded
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 35
Functional Gastrointestinal Problems
Nausea and Vomiting
Usually mild and short term, the so-called
“morning sickness” of early pregnancy
At least 50% of all pregnant women experience
this condition
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 36
Functional Gastrointestinal Problems –
Cont’d
Hyperemesis
Approximately 3.5:1000 pregnancies
Severe form of persistent nausea and vomiting
occurs that does not respond to usual treatment
May develop into the more serious pernicious
form of hyperemesis gravidarum
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 37
Functional Gastrointestinal Problems –
Cont’d
Constipation
Contributes to discomfort and concern
Placental hormones relax the gastrointestinal
muscles
The pressure of the enlarging uterus on the
lower portion of the intestine may make
elimination somewhat difficult
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 38
Functional Gastrointestinal Problems –
Cont’d
Constipation – cont’d
Increased fluid intake, the use of naturally
laxative foods containing dietary fiber, and
exercise may help
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 39
Functional Gastrointestinal Problems –
Cont’d
Hemorrhoids
Common complaint during the latter part of
pregnancy
May cause considerable discomfort, burning,
and itching
Problem is usually controlled by the dietary
suggestions given for constipation
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 40
Functional Gastrointestinal Problems –
Cont’d
Heartburn and Gastric Pressure
Discomforts occur especially after meals and are
usually caused by the pressure of the enlarging
uterus crowding the stomach
Usually remedied by dividing the day’s food into
a series of small meals
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 41
High-Risk Pregnancies
Plan Personal Care
Once early assessment identifies risk factors,
practitioners can then give more careful
attention to these women
A food plan can be developed with the
woman to ensure an optimal intake of energy
and nutrients to support her pregnancy
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 42
High-Risk Pregnancies – Cont’d
Recognize Special Counseling Needs
Several special needs require sensitive
counseling
Include the age and parity of the woman; any
use of harmful agents such as alcohol,
cigarettes, drugs, or pica; and socioeconomic
problems
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 43
High-Risk Pregnancies – Cont’d
Age and Parity
Nulligravida (no prior pregnancy) who is 15
years of age or younger
Especially at risk because her own growth is
incomplete
Sufficient weight gain and the quality of her diet
are particularly important
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 44
High-Risk Pregnancies – Cont’d
Age and Parity – cont’d
Primigravida (first pregnancy) older than 35
years also requires special attention
May be more at risk for hypertension and need
more attention to the rate of weight gain and
amount of sodium used
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 45
High-Risk Pregnancies – Cont’d
Social Habits
Alcohol
Fetal alcohol syndrome (FAS), which is currently a
leading cause of mental retardation
Cigarettes
Cause fetal damage and special problems of
placental abnormalities
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 46
High-Risk Pregnancies – Cont’d
Social Habits – cont’d
Drugs
Abnormal fetal heart rate
Fetal damage
Poor prenatal weight gain
Very short (less than 3 hours) or prolonged labor
Operative delivery
Other perinatal problems
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 47
Complications of Pregnancy
Anemia
Associated with the normal maternal blood
volume increase of 40% to 50% and a
disproportionate increase in red cell mass of
about 20%
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 48
Complications of Pregnancy – Cont’d
Iron Deficiency Anemia
Iron requirement typically exceeds the available
reserves in the average woman
Daily supplement or higher therapeutic dose
may be required
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 49
Complications of Pregnancy – Cont’d
Folate Deficiency Anemia
Fetus is sensitive to folate inhibitors and
therefore has increased metabolic requirements
for folate
Dietary Reference Intake (DRI) standard
recommends 600 µg of folate per day during
pregnancy
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 50
Complications of Pregnancy – Cont’d
Hemorrhagic Anemia
Anemia caused by blood loss is more likely to
occur during labor and delivery than during
pregnancy
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 51
Pregnancy-Induced Hypertension
Disease that principally affects young women
with their first pregnancy
Diets poor in kcalories, protein, calcium,
magnesium, potassium, and dietary fiber
have been associated with risk of pregnancy-
induced hypertension (PIH)
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 52
Pregnancy-Induced Hypertension –
Cont’d
Clinical Symptoms
Abnormal and excessive edema, albuminuria,
and, in severe cases, convulsions or coma, a
state called eclampsia
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 53
Pregnancy-Induced Hypertension –
Cont’d
Treatment
Regular diet with adequate dietary protein and
calcium and one that is rich in fruits and
vegetables, providing magnesium, potassium,
and dietary fiber
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 54
Multiple Fetuses
Energy intake must be increased beyond the
needs of a singleton pregnancy such that the
recommended weight gain for multiple
fetuses is achieved
Adequate folate intake is critical to reduce
risks of low birth weights
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 55
Multiple Fetuses – Cont’d
Supplemental iron may be necessary
Additional calcium and vitamin D are needed
Zinc, copper, and pyridoxine supplementation
may also be required
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 56
Maternal Disease Conditions
Some of these problems can be prevented by
initial screening and continued monitoring by
the prenatal nurse, with referral to the clinical
nutritionist for a plan of care:
Hypertension
Diabetes mellitus
Phenylketonuria (PKU)
Acquired immunodeficiency syndrome (AIDS)
Eating disorders
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 57
Nutrition During Lactation
Approximately 71% of mothers initiate breast-
feeding
Exclusive breast-feeding by well-nourished
mothers can be adequate for periods ranging
from 2 to 15 months
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 58
Nutrition During Lactation – Cont’d
The basic nutritional needs for lactation
include the following additions to the mother’s
prepregnancy needs:
Energy: Caloric increase is 330 kcal/day (plus
170 kcal/day from maternal stores) for first 6
months and 400 kcal/day in the second 6 months
Protein: 71 g/day during first 6 months
Calcium: 1000 mg/day
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 59
Nutrition During Lactation – Cont’d
The basic nutritional needs for lactation
include the following additions to the mother’s
prepregnancy needs: – cont’d
Vitamins: DRI for Vitamin C during lactation is
120 mg/day
Fluids: A pale yellow color of the urine suggests
adequate fluid intake
Dietary supplements: Continue the woman’s
prenatal nutrient supplements during lactation
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 60
Nutrition During Lactation – Cont’d
The basic nutritional needs for lactation
include the following additions to the mother’s
prepregnancy needs: – cont’d
Rest and relaxation: Both parents may benefit
from counseling focused on reducing the stresses
of their new family situation
Maternal medical conditions: Some conditions
exist for which it is recommended that women in
the United States not breast-feed