Nutrition for Childbearing; McKinney

Recommended weight gain during the first trimester

0.5-2 kg (1.1-4.4 lb)

Alcohol

Because of the association between drinking and fetal alcohol syndrome (see Chapter 24), women should avoid alcohol completely during pregnancy. Alcohol interferes with the absorption and use of vitamin B12, folic acid, and magnesium, and often takes the place of food in the diet (Roth, 2011). Vitamin-mineral supplementation may be necessary for women whose intake of alcohol before pregnancy was large, because their nutrient stores may be depleted.

Nursing Care Nutrition for Childbearing Assessment Reassessing Nutritional Status at Each Visit

At each prenatal visit reassess the woman's dietary status. Ask about any difficulties with her diet. Check weight gain and evaluate hemoglobin and hematocrit levels, if appropriate. Explain what assessments are being made and why.

Nursing Care Nutrition for Childbearing Assessment Physical Assessment

Information about nutritional status includes measurement of weight and examination for signs of nutritional deficiency. Weight gain for pregnancy. The range for weight gain in women of normal prepregnancy weight is 11.5 to 16 kg (25 to 35 lb).

Where weight's gained?

Maternal reserves (4-9.5lb) Extravascular fluids (3.5-5 lb) Breasts (1.3-3 lb) Uterus (2.5 lb) Fetus (7-7.5 lb) Placenta (1-1.5 lb) Amniotic Fluid (2 lb)

Adolescence

Adolescent pregnancies are associated with higher risk for complications for both the expectant mother and the fetus (see Chapter 24). Pregnant adolescents who are the youngest in terms of gynecologic age (number of years since menarche) and those who are undernourished at conception have the greatest nutritional needs (Stang & Larson, 2012). However, excessive weight gain during pregnancy should be avoided by adolescents as well as by adult women. Women who gain weight above the recommendations may have difficulty losing the weight and may become overweight or obese.

Age

Age is an important consideration. The adolescent who is not fully mature needs nutritional support for her own growth. Older women who are in good health, however, have the same nutritional requirements as younger (nonadolescent) pregnant women.

Food Precautions

Although fish are an excellent source of protein and other nutrients, certain precautions should be taken. Large fish often have high levels of mercury, which can damage the fetal central nervous system. Pregnant and lactating women should not eat these fish. Certain fish have smaller amounts of mercury and can be eaten weekly (U.S. Food and Drug Administration [FDA], 2009a). Raw fish may contain parasites or bacteria and should be avoided. Some foods may be contaminated with Listeria monocytogenes, which may cause listeriosis. If contracted during pregnancy, listeriosis may result in abortion, premature labor, infant death, or severe illness of the newborn. Foods that are more likely to be contaminated include luncheon meats and hot dogs unless they are reheated until they are steaming hot. Other foods include soft cheeses, unpasteurized milk or milk products, and raw or undercooked meats and poultry (FDA, 2009b). (See Safety Alert below.) More information about food safety during pregnancy can be obtained from the FDA website at www.fda.gov/Food/ResourcesForYou/HealthEducators/ucm081819.htm. Eggs can be contaminated with harmful bacteria and should not be eaten unless fully cooked. Only eggs that have been pasteurized in the shell are safe to eat raw or partially cooked. Eating meat that is raw or undercooked or unwashed fruits or vegetables may cause toxoplasmosis with severe consequences to the fetus. Toxoplasmosis may also be contracted by contact with cats.

Alcohol Postpartum

Although it was once thought that the relaxing effect of alcohol would be helpful to the nursing mother, the deleterious effects of alcohol are too important to consider this suggestion appropriate today. An occasional single alcoholic beverage may not be harmful, but larger amounts may interfere with the milk-ejection reflex and be harmful to the infant. Alcohol in the milk peaks at 30 to 60 minutes if taken alone and 60 to 90 minutes after consumption with food. When mothers drink alcohol they should not breastfeed for at least 2 hours (Lawrence & Lawrence, 2011).

Protein: Vegetarian

Although most vegetarians get enough protein, intake may be a concern in vegan diets. Complete proteins contain all the essential amino acids. Essential amino acids are those the body cannot synthesize from other sources. Animal and soy proteins are complete, but plant proteins (incomplete proteins) lack one or more of the essential amino acids (Grodner et al., 2012). Even a diet with protein from plant sources only can meet the needs of pregnancy (Penny & Miller, 2008). Combining incomplete plant proteins with other plant foods that have complementary amino acids allows intake of all essential amino acids. Dishes that contain grains (wheat, rice, corn) and legumes (garbanzo, navy, kidney, pinto or soy beans; peas; peanuts) are combinations that provide complete proteins. Complementary proteins do not have to be eaten at the same meal if they are consumed in a single day. Incomplete proteins can also be combined with small amounts of complete protein foods like cheese to provide all amino acids. Therefore women who include even small amounts of animal products meet their protein needs more easily. Many vegetarians use tofu, made from soybeans, which provides protein as well as calcium and iron. Meat analogs that have a texture similar to meat but are made from vegetable protein are available. Some look and taste like hamburgers, bacon, lunch meats, chicken patties, and other commonly eaten foods. Meat analogs may be fortified with nutrients whose levels are often low in vegan diets.

Nursing Care Nutrition for Childbearing Nursing Diagnosis and Planning

Although some women consume more calories than they need during pregnancy, the most common nursing diagnosis concerning nutrition is: • Readiness for Enhanced Nutrition related to desire to learn about the nutrient needs of pregnancy.

Anemia

Anemia is a common concern during pregnancy. Hemoglobin values drop during the second trimester of pregnancy as a result of the dilution of the blood caused by plasma increases. This physiologic anemia is normal (see Chapter 13). During the third trimester, hemoglobin levels generally return to prepregnant levels because of increased absorption of iron from the gastrointestinal tract, even though iron is transferred to the fetus primarily during this time. Fetal iron stores during the third trimester are generally sufficient to prevent anemia in the newborn for the first 4 to 6 months after birth. The woman's iron stores may be measured by determining her serum ferritin level. A ferritin level less than 10 nanograms/100 mL indicates that the anemia is caused by iron deficiency (Pagana & Pagana, 2011). Generally, a woman is considered anemic if her hemoglobin is less than 11 g/dL or her hematocrit is less than 33% in the first or third trimesters or the hemoglobin is less than 10.5 g/dL or the hematocrit is less than 32% in the second trimester (Cunningham et al., 2010). Anemic women need iron supplements and help in choosing foods high in iron. Because high intake of iron inhibits the use of zinc and copper, anemic women may need to increase their intake of these minerals also.

Iron

Approximately 1000 mg of absorbed iron is needed during pregnancy (Cunningham et al., 2010). This provides for the 20% to 30% increase in maternal red blood cells and for transfer to the fetus for storage and production of red blood cells (Blackburn, 2013). Infants use stored iron during the first 4 to 6 months, when their intake of iron is low. Iron is probably the only nutrient that cannot be supplied completely and easily from the diet during pregnancy. Table 14-4 lists common foods high in iron. Many adult women do not meet their daily nonpregnancy requirement for iron and begin pregnancy already anemic or with low iron stores (see Chapter 26). Women often have only 100 mg of nonhemoglobin iron stored at the beginning of pregnancy (Hall, 2011). Iron is transferred to the fetus even if the mother is anemic, so adequate intake is necessary to keep the mother's iron supply at normal levels (Cunningham et al., 2010).

Synopsis of chapter

At no time in a woman's life is nutrition as important as it is during pregnancy and lactation when she must nourish her own body and that of her baby. Nurses have ongoing contact with women and can provide education about nutritional needs throughout this period. This is especially important because many women do not adequately understand the nutritional needs of pregnancy. Nutritional counseling can also be offered before conception to improve chances of a healthy pregnancy.

Calories

Approximately 80,000 additional calories are needed during pregnancy (Cunningham et al., 2010). These extra calories furnish energy for the production and maintenance of the fetus, placenta, added maternal tissues, and increased basal metabolic rate. Most pregnant women need a daily caloric intake of 2200 to 2900 calories depending on their age, activity level, and prepregnancy BMI (ADA, 2008). During the first trimester of pregnancy, no added calories are needed. However, the daily caloric intake for pregnant women should increase by 340 calories during the second trimester and 452 calories during the third trimester (Institute of Medicine, Food, and Nutrition Board, 2002). This increase can be achieved relatively easily with a variety of foods and only a small increase in food. Nutrient density, the quantity and quality of the various nutrients in each 100 calories of food, is an important consideration. Foods of high nutrient density have large amounts of quality nutrients per serving. During pregnancy the increased need for most nutrients may not be met unless calories are selected carefully. The term empty calories refers to foods that are high in calories but low in other nutrients. Many snack foods contain excessive calories and low nutrient density and are high in fat and sodium. Increased calories should be "spent" on foods that provide the nutrients needed in increased amounts during pregnancy. Women often use sugar substitutes to reduce their caloric intake. Saccharin (Sweet'N Low), sucralose (Splenda), and aspartame (Equal or NutraSweet) are considered safe for normal women during pregnancy. However, women with phenylketonuria lack the enzyme to metabolize aspartame and should never use it because it could lead to maternal and fetal brain damage (Pronsky & Crowe, 2012).

Nursing Care Nutrition for Childbearing Assessment Food Preferences

Ask about the woman's food preferences and dislikes. During pregnancy some women experience an aversion to certain foods, such as meats, that they do not have at other times. Determine whether she has food cravings or eats large amounts of any one particular food or group of foods. Discuss pica in a nonjudgmental, matter-of-fact manner to avoid giving an impression of disapproval. In assessing for pica, the nurse might say, "Have you had any cravings for special things to eat during your pregnancy?" This can be followed by, "Women sometimes eat things like ice, clay, or starch during pregnancy. Have you tried these?" This provides an opening for a discussion of substitutes, such as nonfat dry milk powder for laundry starch, the woman may be willing to try.

Nursing Care Nutrition for Childbearing Assessment 24hr diet history

Ask the woman to recall what she ate at each meal and snack during the previous 24 hours. Use specific questions about the size of portions and ingredients used. Use models of food items and measuring utensils to help discuss portion sizes. Inquire about beverages and snacks. Ask whether this sample is typical of her usual daily food intake. If it is not, ask which foods are more representative. Analyze the diet to determine whether the woman has met the recommendations for specific food groups, calories, and protein. Detailed analysis for individual nutrients is unnecessary.

Nursing Care Nutrition for Childbearing Assessment Eating Habits

Assess the usual pattern of meals to discover poor food habits, such as skipping breakfast or eating fast foods for most lunches. Determine who does the cooking for the family. If someone else does the cooking, discuss nutritional needs during pregnancy with that person.

Disadvantages and Dangers of Nutritional Supplementation

Because they believe supplements are a harmless way to improve their diets, some women take large amounts without consulting a health care provider. No standardization or regulation of the amounts of ingredients contained in supplements is available at this time. Some supplements may not have the amount of an ingredient that is listed on the label and may not fulfill the health claims made for it. The use of supplements may increase the intake of some nutrients to doses much higher than recommended. Excessive amounts of some vitamins and minerals may be toxic to the fetus. Vitamin A can cause fetal anomalies when taken in high doses. Large amounts of vitamin A are taken by women using the drug isotretinoin (Accutane) for acne. In addition, high doses of some vitamins or minerals may interfere with ability to use others. If women understand this, they are more likely not to exceed recommended doses.

Nursing Care Nutrition for Childbearing Assessment Appetite

Begin the interview by discussing the woman's appetite. How does it compare to her appetite before pregnancy? Morning sickness may decrease food intake during the first trimester. Determine the severity and duration of nausea and vomiting. Hyperemesis gravidarum is the most serious form of this problem, and may require intravenous correction of fluid and electrolyte imbalance and parenteral nutrition (see Chapter 25).

Whole Grains

Breads, cereals, rice, and pastas provide complex carbohydrates, fiber, vitamins, and minerals. Whole grains provide more nutrients than processed grain products. MyPlate recommendations are for 6 oz each day for adult women. Pregnant women should have 7 to 9 oz and lactating women should have 6 to 7 oz daily.

Importance of calcium during pregnancy

Calcium is transferred to the fetus, especially in the last trimester, and is important for mineralization of fetal bones and teeth. Although a small amount of calcium is removed from the mother's bones, it is insignificant and does not affect maternal bone mass. A common myth is that calcium is removed from the teeth during pregnancy, leading to excessive decay. Actually, calcium in the teeth is stable and is not affected by pregnancy. Calcium absorption and retention increases during the pregnancy, and it is stored for use in the third trimester when fetal needs are greatest. Women 18 years and younger need more calcium because their bone density is not complete. Calcium needs are unchanged during pregnancy and lactation. The best source of calcium is dairy products. Whole, low-fat, and nonfat milk all contain the same amount of calcium and may be used interchangeably to increase or reduce calorie intake. However, women with lactose intolerance (lactase deficiency resulting in gastrointestinal problems when dairy products are consumed) need other sources of calcium (Box 14-1). Although spinach and chard contain calcium, they also contain oxalates that decrease calcium availability and make them poor sources. Large amounts of fiber also interfere with calcium absorption. Caffeine increases the excretion of calcium. Women who eat inadequate amounts of calcium-rich foods or avoid dairy products because of lactose intolerance, to avoid eating animal products or for other reasons should take supplements. To ensure absorption of calcium, women should take supplements with meals, separately from iron supplements. Taking calcium with vitamin D also increases absorption.

Carbohydrates

Carbohydrates may be simple or complex. Simple carbohydrates include sucrose (table sugar, candy) and those found in fruits and vegetables. Complex carbohydrates are present in starches, such as cereals, pasta, and potatoes. They supply vitamins, minerals, and fiber. Because of their value in providing other nutrients, complex carbohydrates should be the major source of carbohydrates in the diet. Fiber, the indigestible carbohydrate in plant foods, is important because it produces bulk in the diet. Fiber absorbs water and stimulates peristalsis to help prevent constipation. It also slows gastric emptying, causing a sensation of fullness.

Interventions: Evaluating Weight Gain

Compare the woman's weight with a weight gain chart to ascertain whether she has gained the appropriate amount of weight for this point in her pregnancy. Discuss the importance and expected pattern of weight gain for her. Explain the concept of eating foods high in nutrient density when she is increasing calories. For women of normal weight, a monthly gain of less than 1 kg (2.2 lb) should lead to a discussion of possible problems in food intake. A gain of more than 2.9 kg (6.5 lb) per month may signify edema. Errors in calculation of gestation may also reflect a pattern of weight gain different from that expected.

CRITICAL THINKING EXERCISE 14-2

Cheryl, age 22 years, has gained 4.5 kg (10 lb) more than recommended at 31 weeks of pregnancy. She asks the nurse for help because she is very worried about her weight gain and thinking of going on a severe weight loss diet. She started pregnancy at the upper end of the normal body mass index (BMI) and should gain 25 to 35 lb during the pregnancy. She has no apparent edema and no complications of pregnancy. 1. Why is Cheryl's weight gain a problem? 2. What suggestions should the nurse make to help Cheryl with her diet?

Smoking

Cigarette smoking increases maternal metabolic rate and decreases appetite, which may result in a lower weight gain. Infant birth weight decreases in spite of adequate diet as the amount of smoking increases. Prematurity, spontaneous abortion, and other complications may also result. Smoking decreases the availability of some vitamins and minerals, and vitamin-mineral supplements are important during pregnancy. Counseling to help the woman stop smoking or at least decrease the number of cigarettes smoked during pregnancy is essential (see Chapter 13).

Nursing Care Nutrition for Childbearing Assessment Diet History

Diet histories provide information about a woman's usual intake of nutrients. They form a basis for counseling about any changes required to meet pregnancy needs.

Importance of sodium during pregnancy

During pregnancy, foods high in sodium should be consumed in moderation. Expectant mothers should be taught to read labels and to avoid products in which sodium is listed among the first ingredients. Sodium needs are increased during pregnancy to provide for an expanded blood volume and the needs of the fetus. Although sodium is not restricted during pregnancy, excessive amounts should be avoided. Women are advised that a moderate intake of salt or the salting of foods to taste is acceptable, but that intake of high-sodium foods (Box 14-2) should be limited.

DIETARY REFERENCE INTAKES: RECOMMENDED ENERGY AND PROTEIN INTAKES ADULT FEMALE: NONPREGNANT PREGNANCY LACTATION

Energy Varies greatly according to body size, age, and physical activity level Example: Woman, 30 years, active, height 1.65 m (65 in), weight 50.4 kg (111 lb), body mass index (BMI) 18.5: 2267 kcal Same woman, weight 68 kg (150 lb), BMI 24.99: 2477 kcal Ages 14-50: First trimester: No change from nonpregnant needs Second trimester: 340 kcal above nonpregnant needs Third trimester: 452 kcal above nonpregnant needs First 6 months: 330 kcal above nonpregnant needs (with an additional 170 kcal drawn from maternal stores) Second 6 months: 400 kcal above nonpregnant needs Carbohydrate 130 g 175 g 210 g Protein 46 g 71 g 71 g

Energy: Postpartum

During the first 6 months of lactation, the estimated energy requirement (EER) is 330 calories each day in addition to normal needs for women according to age, weight, and height. In addition to the calories consumed, it is estimated that 170 calories per day are drawn from the woman's fat stores. This provides a total of 500 calories each day above prepregnancy requirements to meet the needs of lactation. The EER for the second 6 months of lactation is 400 calories more than prepregnancy needs. Although the infant takes solids after 6 months and decreases milk intake, it is assumed that maternal energy stores have been used, and the calories should come from the woman's daily intake (Institute of Medicine, Food, and Nutrition Board, 2002). Women who were underweight before pregnancy or who had inadequate weight gain during pregnancy need more calories. Those who are overweight may need fewer calories than the EER. Milk volume is usually adequate even if a mother's diet is less than optimal, but the volume may be reduced and maternal stores of nutrients will be depleted with very low caloric intake.

Eating Disorders

Eating disorders include anorexia nervosa (refusal to eat because of a distorted body image and feelings of obesity) and bulimia (overeating, followed by induced vomiting or use of laxatives or diuretics). These conditions are associated with electrolyte imbalance, low birth weight, and small for gestational age infants (Cunningham et al., 2010). Many women with anorexia have amenorrhea and do not become pregnant, but women with bulimia or subclinical anorexia are more likely to become pregnant. All women should be asked about eating disorders and nurses should watch for behaviors that may indicate disordered eating. Some women eat normally during pregnancy for the sake of the fetus, but others continue their previous eating patterns during pregnancy or in the early postpartum period when they do not lose weight immediately. Women with eating disorders need individual counseling to ensure that they meet the increased nutrient needs of pregnancy and understand normal postpartum weight loss.

In order to meet the nutritional requirements of the pregnant vegetarian, the nurse must consider?

Energy Protein Calcium Iron Zinc Vitamin B12 Vitamin A Lactose Intolerance Nutrients lost during N&V Anemia

DIETARY REFERENCE INTAKES: RECOMMENDATIONS FOR VITAMINS AND MINERALS ADULT FEMALES: NONPREGNANT PREGNANCY AND LACTATION SOURCES IMPORTANCE IN PREGNANCY

Fat-Soluble Vitamins Vitamin A Ages 14-50: 700 mcg (RDA) Pregnancy: Ages 14-18: 750 mcg Ages 19-50: 770 mcg Lactation: Ages 14-18: 1200 mcg Ages 19-50: 1300 mcg Dark green, yellow, or orange vegetables; whole or fortified lowfat or nonfat milk; egg yolk; butter and fortified margarine Fetal growth and cell differentiation Excessive intake causes spontaneous abortions or serious fetal defects Isotretinoin (Accutane), a vitamin A derivative for acne, should not be taken during pregnancy because it causes fetal defects Vitamin D Ages 14-50: 400 IU (RDA) Pregnancy and Lactation: 600 IU Fortified milk, margarine, and soy products; butter; egg yolks Synthesized in skin exposed to sunlight Vegans who are not exposed to sun and who do not eat fortified foods need supplements Necessary for metabolism of calcium Inadequate amounts may cause neonatal hypocalcemia, hypoplasia of tooth enamel Excessive intake causes hypercalcemia and possible fetal deformities Vitamin E Ages 14-50: 15 mg (RDA) Pregnancy: Ages 14-50: Same as nonpregnant needs Lactation: Ages 14-50: 19 mg (RDA) Vegetable oils, whole grains, nuts, and dark green leafy vegetables Antioxidant, important for tissue growth and integrity of cells, particularly red blood cell membranes Vitamin K Ages 14-18: 75 mcg Ages 19-50: 90 mcg (AI) Pregnancy and Lactation: Same as nonpregnant needs Dark green leafy vegetables Also produced by normal bacterial flora in small intestine Necessary for blood clotting Newborns are temporarily deficient and receive one dose by injection at birth to prevent hemorrhage Water-Soluble Vitamins Vitamin B6 (Pyridoxine) Ages 14-18: 1.2 mg Ages 19-50: 1.3 mg (RDA) Pregnancy: Ages 14-50: 1.9 mg Lactation: Ages 14-50: 2 mg (RDA) Chicken, fish, pork, eggs, peanuts, whole grains, cereals Amino acid metabolism and in blood, hormone, and immune function Vitamin B12 Ages 14-50: 2.4 mcg (RDA) Pregnancy: Ages 14-50: 2.6 mcg Lactation: Ages 14-50: 2.8 mcg (RDA) Meat, fish, eggs, milk, fortified soy and cereal products Cell division, protein synthesis, and formation of red blood cells Prevents megaloblastic anemia Folic Acid Ages 14-50: 400 mcg (RDA) Pregnancy: Ages 14-50: 600 mcg Lactation: Ages 14-50: 500 mcg (RDA) Dark green leafy vegetables, legumes (beans, peanuts), orange juice, asparagus, spinach, and fortified cereal and pasta May be lost in cooking Cell replication and amino acid and hemoglobin synthesis Deficiency in first weeks of pregnancy may cause cleft lip or palate, neural tube and cardiac defects Thiamin Ages 14-18: 1 mg Ages 19-50: 1.1 mg (RDA) Pregnancy and Lactation: Ages 14-50: 1.4 mg (RDA) Lean pork, whole or enriched grain products, legumes, organ meats, seeds, nuts Forms coenzymes necessary to release energy, aids in nerve and muscle functioning. Increased need in pregnancy due to greater intake of calories Riboflavin Ages 14-18: 1 mg Ages 19-50: 1.1 mg (RDA) Pregnancy: Ages 14-50: 1.4 mg Lactation: Ages 14-50: 1.6 mg (RDA) Milk, meat, fish, poultry, eggs, enriched grain products, and dark green vegetables Forms coenzymes necessary to release energy. Increased need in pregnancy due to greater intake of calories Niacin Ages 14-50: 14 mg (RDA) Pregnancy: Ages 14-50: 18 mg Lactation: Ages 14-50: 17 mg (RDA) Meats, fish, poultry, legumes, enriched grains, milk Forms coenzymes necessary to release energy Increased need in pregnancy due to greater intake of calories Vitamin C Ages 14-18: 65 mg Ages 19-50: 75 mg (RDA) Pregnancy: Ages 14-18: 80 mg Ages 19-50: 85 mg Lactation: Ages 14-18: 115 mg Ages 19-50: 120 mg (RDA) Citrus fruit, peppers, strawberries, cantaloupe, green leafy vegetables, tomatoes, potatoes Formation of fetal tissue, collagen formation, tissue integrity, healing, immune response, and metabolism

Fats

Fats provide energy and fat-soluble vitamins. When reduction of calories is necessary, it is important to decrease but not eliminate carbohydrates and fats. If carbohydrate and fat intake provides insufficient calories, the body uses protein to meet energy needs. This use decreases the amount of protein available for building and repairing tissue. Fat intake also is important because it provides essential fatty acids such as alpha linolenic acid and linoleic acid. These help in neurologic and visual development in the fetus. Docosahexaenoic acid (DHA) is also important for fetal visual and cognitive development. These fatty acids are found in canola, soybean, and walnut oil, as well as some seafood such as bass or salmon (Nichols-Richardson, 2011a).

Other Elements

Fats, oils, and concentrated sugars should be eaten sparingly. They provide calories for energy but few other nutrients. Adult women need 5 to 6 teaspoons daily, pregnant women need 6 to 8 teaspoons daily, and lactating women need 6 teaspoons of unsaturated fats per day. Foods containing saturated fats and trans fatty acids should be avoided.

Folic Acid

Folic acid (also called folate) can decrease the occurrence of neural tube defects, such as spina bifida and anencephaly, in newborns. It may also help prevent cleft lip, cleft palate, and some heart defects (CDC, 2010; Peckenpaugh, 2010). Adequate intake of folic acid is especially important just before conception and during the first trimester of pregnancy. Because about half of pregnancies are unplanned, all women of childbearing age should consume adequate amounts of folic acid each day. A Healthy People 2020 goal is for women of childbearing potential to take in at least 400 mcg of folic acid each day (U.S. Department of Health and Human Services, 2010). In the past, the recommended amount of folic acid for women capable of childbearing has been 400 mcg (0.4 mg), but the U.S. Preventive Services Task Force (USPSTF) now recommends 400 mcg to 800 mcg (0.4 mg to 0.8 mg) each day. The dose should be taken for at least 1 month before conception and for 2 to 3 months after conception (USPSTF, 2009). There has been no change in the recommendation of 600 mcg (0.6 mg) of folic acid daily for the rest of pregnancy. Women who are taking anticonvulsant drugs or who have previously had an infant born with a neural tube defect should take 4 mg daily before conception and during the first trimester (CDC, 2010; Johnson, Gregory, & Niebyl, 2007). This practice can decrease the risk of recurrence of neural tube defects by 80% (American Academy of Pediatrics [AAP] & American College of Obstetricians and Gynecologists [ACOG], 2007). Women often do not realize the importance of folic acid in their diet before pregnancy begins, and many do not meet the recommended level, in spite of a national campaign to make the public more aware of this problem. One third of births occur to women age 18 to 24 years, but women in this group have lower intake of supplements containing folic acid and less knowledge of the need for folic acid than older women (CDC, 2008). More education is necessary to increase folic acid use in women of childbearing age. Because of its importance, folic acid is added to all enriched cereal grain products.

Nursing Care Nutrition for Childbearing Assessment Food intake records

Food intake records are used to report foods eaten over 1 or more days. Instruct the woman to list everything she eats throughout the day. The list is more accurate if she writes down each food immediately after eating.

Nutritional Supplementation Purpose

Food is the best source for nutrients. Although health care providers frequently prescribe prenatal vitamin-mineral supplements and many women expect to take them, supplementation may not be necessary during pregnancy if the diet is adequate. The exceptions are iron and folic acid, which may not be obtained in adequate amounts through normal food intake. Expectant mothers who are vegetarians, lactose intolerant, or have special problems in obtaining nutrients through diet alone may need supplements. Assessment of each woman's needs determines whether supplementation is appropriate.

Culture

Food may have special cultural meaning during pregnancy or childbirth. Nurses need knowledge about the habits of a variety of cultures so that they can provide culturally appropriate nutritional counseling. Before making assumptions about the influence of a woman's culture on her diet, the nurse must assess each woman individually. Not all women follow food practices considered typical for their cultures. The nurse should assess the woman's age, how long she has lived in North America, and whether she has adopted any common American eating habits. Some women who usually follow an American diet may return to some aspects of their culture's traditional diet during pregnancy out of respect for elders or to "make sure" they do not harm the fetus. Nurses often use pamphlets as a part of teaching and may be able to obtain them in various languages. The nurse should determine if the woman can read English or her own native language before giving her written materials. People who cannot read may not readily admit it to others. In addition, the reading level may be too complicated for the woman with little education. Having an interpreter discuss the material with the woman helps determine how well she can read and aids in other teaching. People of many cultures believe that certain foods, conditions, and medicines are "hot" or "cold" and must be balanced to preserve health. Foods considered hot in one culture may not fit in that category in another culture, and the designation does not necessarily match the temperature or spiciness of the food. In the Chinese culture, this may be referred to as yin (cold) and yang (hot) and may influence what the mother eats during pregnancy and the postpartum period. Food taboos may determine what some women eat during the childbearing period. For example, Korean women may avoid eggs and duck because these foods are thought to have a harmful effect on the fetus. Samoan women do not eat octopus or raw fish during pregnancy. Haitian women believe eating white foods such as milk, white beans, and lobster after birth will increase the lochia (Callister, 2008). Special foods may be customary during pregnancy or after birth. For example, Russian women may drink milk during pregnancy to give their babies a fair complexion instead of ruddy skin tones (Callister, Getmanenko, & Garvrish, et al., 2007). Punjabi women may drink milk to prevent melasma (Grewal, Bhagat, & Balneaves, 2008). A Korean family may bring the new mother a hot beef and seaweed soup to cleanse her body and increase breast milk production (Callister, 2008). Great variety occurs in cultural preferences for foods. For example, some African-Americans may follow a diet similar to that of people living in the southeastern United States. Common foods include okra, collard greens, mustard greens, ham hocks, black-eyed peas, and hominy or grits. The diet of other African-Americans, however, varies according to the geographic area in which they live. Lactose intolerance is common, resulting in lack of calcium if other sources are not present in the diet. Intake of high-sodium and fried foods may present health problems. Some Jewish women follow a strict kosher diet. They avoid meat from animals with cloven hooves that do not chew their cud (no pork or pork products). Meat must be processed to remove all blood and cannot be eaten in the same meal as milk. Muslim women also do not eat pork and may fast on certain days. The religion exempts pregnant and nursing women from obligatory fasting, but women have to make up the fasting days at some other time. Some choose to fast for spiritual reasons or so they do not have to make up the days later (Kridli, 2011). The diet of Native American women may contain blue cornbread, potatoes, wild greens, legumes, nuts, tomatoes, and squash. Lactose intolerance is common, and milk and cheese are avoided. Meats may include wild game and poultry. Most foods are fried in lard or shortening. Fried dough ("fry bread") is frequently served (Schlenker & Roth, 2011). Low-income Native Americans may receive food vouchers from the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). Food preferences for two cultures, Southeast Asian and Hispanic, are explored further here to show the influence of culture on diet. Immigrants from Southeast Asia are likely to follow diets similar to those in their homelands. Hispanics are a large minority group in the United States, and nurses throughout the United States need information about food preferences prevalent in these groups.

Nursing Care Nutrition for Childbearing Assessment Food frequency questionnaires

Food-frequency questionnaires contain lists of common foods and provide information about diet over a longer period. Ask the woman how often she eats each of the common foods listed. Analyze the list to determine whether foods from each food group are eaten in adequate amounts to meet pregnancy needs.

Caffeine postpartum

Foods high in caffeine should also be limited. The mother should restrict her caffeine intake to 2 cups of coffee or the equivalent each day. Caffeine in excessive amounts may make the infant irritable.

Vitamins

For most people, the daily intake of each vitamin is not always as high as recommended, but true deficiency states are uncommon in North America. Recommendations for vitamin intake and food sources are shown in Table 14-3. The fat-soluble vitamins (A, D, E, and K) are stored in the liver. Deficiency states are not likely to occur, but fat-soluble vitamins can be toxic in excessive amounts. For example, too much vitamin A can cause fetal defects. The nurse should ask about vitamins and medications taken by pregnant women and alert them about the dangers of excess vitamins. Water-soluble vitamins (B6, B12, and C, folic acid, thiamin, riboflavin, and niacin) are not stored in the body as well as fat-soluble vitamins. Therefore they should be included in the daily diet. Because excess amounts are excreted in the urine, there is less chance of toxicity from excessive intake, but it can occur with megadoses. These vitamins are easily transferred from food to water in cooking. Foods should be steamed, microwaved, or prepared in only small amounts of water. The remaining water can be used in other dishes, such as soups.

Interventions: Providing Reinforcement

Give frequent positive reinforcement when the woman is eating appropriately. Assist her in evaluating any weaknesses in her present diet and planning ways to remedy them (Figure 14-3). If the woman can read, give her written materials on nutrition during pregnancy and review them with her. A small pamphlet with pictures might be placed on the refrigerator to help her remember what foods she needs each day. Demonstrate portion sizes by showing her plastic models of common foods. These are available for ethic foods, as well. Note: Women often make changes in their diets for the good of their unborn children that they would not consider for themselves alone.

Nursing Care Nutrition for Childbearing Assessment Identify potential problems

Identify any obvious areas of potential deficiency. For example, the woman might eat little meat, avoid vegetables, be lactose intolerant, or follow a fad diet. Also determine her knowledge about nutritional needs during pregnancy. Ask about any cultural or religious practices that affect nutrition. Determine if these change during pregnancy and the effect on her nutrient intake. Identify other factors that interfere with adequate nutrition. Women with low incomes may not know about sources of help. Ask the vegetarian how long she has followed the practice and assess her awareness of changes necessary during pregnancy. A woman's smoking habits, alcohol intake, and substance abuse may become obvious during the interview. Determine if she takes medications that interfere with nutrient absorption. Provide an opportunity for the woman to ask about special diet concerns. This may bring out fears about weight gain, worry that specific foods could hurt the fetus, or other issues not yet addressed.

Interventions: Encouraging Supplement Intake

If vitamin-mineral supplements have been prescribed, determine whether the woman takes them regularly. If she forgets to take the supplements, suggest she take them with meals or at bedtime. If iron supplements are causing constipation, suggest increased intake of fluids or high-fiber foods. Let her know that black stools are a harmless side effect of iron supplements.

Effect of Culture on Diet During Childbearing

In Southeast Asian cultures, pregnancy, especially the third trimester, is considered "hot," and women eat "cold" foods to maintain a balance of hot and cold. Their diet includes sour foods, fruits, noodles, spinach, and mung beans but avoids fish, excessively salty or spicy foods, alcohol, and rice. The woman also avoids unfamiliar foods for fear that they may harm her or her fetus. The postpartum period is considered "cold," partly because of the loss of blood, which is "hot." Mothers avoid losing more heat, which would have ill effects on their health. They stay warm physically and choose "hot" foods to eat, including rice with fish sauce, broth, salty meats, fish, chicken, and eggs. They may refuse cold drinks but welcome hot fluids, often requesting tea or plain hot water. Families frequently bring food to the mother while she is in the hospital because hospital food may not meet her preferences.

Abnormal Prepregnancy Weight

In addition to teaching about dietary changes, the nurse should be alert for other problems associated with abnormal prepregnancy weight. The woman who is below normal weight may not have enough money for food or may have an eating disorder. Obese women may have other health problems, such as hypertension, that may affect the nurse's nutritional counseling plan.

Dietary Reference Intakes

In the United States, dietary reference intakes (DRIs) refer to terms that estimate nutrient needs. DRIs include four categories: • Recommended dietary allowance (RDA), the amount of a nutrient that meets the needs of almost all (97% to 98%) healthy people in an age-group. The actual needs of individuals (particularly for calories and protein) may vary according to body size, previous nutritional status, and usual activity level. • Adequate intake (AI), the nutrient intake assumed to be adequate when an RDA cannot be determined. It appears to sustain nutritional status. • Tolerable upper intake level (UL), the highest amount of a nutrient that can be taken by most people without probable adverse health effects. • Estimated average requirement (EAR), the amount of a nutrient estimated to meet the needs of half the healthy people in an age-group. Table 14-2 shows the current recommendations for DRIs for energy, carbohydrates, and protein for adult women.

Lactose Intolerance

Intolerance of lactose is caused by deficiency of the small intestine enzyme lactase, necessary for absorption of the milk sugar lactose. Some degree of lactose intolerance is normal for most of the world's population after early childhood. This includes many African-American, Hispanic, Asian, Pacific Islander, Native American, and Middle Eastern people. Although those with lactose intolerance may tolerate cultured or fermented milk products, such as aged cheese, buttermilk, and some brands of yogurt, symptoms may occur after drinking as little as a cup of milk. Symptoms include nausea, bloating, flatulence, diarrhea, and intestinal cramping. Although the ability to tolerate lactose may increase during pregnancy, women who avoid dairy foods may not consume the recommended amounts of calcium. Most women tolerate small amounts (½ cup) of milk with meals, and they should increase their intake of other foods that provide calcium. Soy milk, low-lactose milk, and milk treated with lactase are available. The enzyme can be purchased to be added to milk or taken as a tablet. Calcium supplements may be necessary for some lactose-intolerant women.

DIETARY REFERENCE INTAKES: RECOMMENDATIONS FOR VITAMINS AND MINERALS ADULT FEMALES: NONPREGNANT PREGNANCY AND LACTATION SOURCES IMPORTANCE IN PREGNANCY

Iron Ages 14-18: 15 mg Ages 19-50: 18 mg (RDA) Pregnancy: Ages 14-50: 27 mg Lactation: Ages 14-18: 10 mg Ages 19-50: 9 mg (RDA) Meats, dark green leafy vegetables, eggs, grain products, enriched bread and cereal, dried fruits, tofu, legumes, nuts, blackstrap molasses Formation of hemoglobin and enzymes for metabolism Expanded maternal blood volume, formation of fetal red blood cells, and storage in the fetal liver for use after birth Calcium Ages 14-18: 1300 mg Ages 19-50: 1000 mg (AI) Pregnancy and Lactation: Same as nonpregnant needs Dairy products, salmon, sardines with bones, legumes, fortified juice, tofu, broccoli Fetal bone and teeth formation, cell membrane permeability, coagulation, and neuromuscular function Zinc Ages 14-18: 9 mg Ages 19-50: 8 mg (RDA) Pregnancy: Ages 14-18: 12 mg Ages 19-50: 11 mg Lactation: Ages 14-18: 13 mg Ages 19-50: 12 mg (RDA) Meat, poultry, seafood, eggs, nuts, seeds, legumes, wheat germ, whole grains, yogurt Fetal and maternal tissue growth, cell differentiation and reproduction, DNA and RNA synthesis, metabolism, acid-base balance Magnesium Ages 14-18: 360 mg Ages 19-30: 310 mg Ages 31-50: 320 mg (RDA) Pregnancy: Ages 14-18: 400 mg Ages 19-30: 350 mg Ages 31-50: 360 mg Lactation: Same as nonpregnant needs Whole grains, nuts, legumes, dark green vegetables, small amounts in many foods Cell growth and neuromuscular function; activates enzymes for metabolism of protein and energy Iodine Ages 14-50: 150 mcg (RDA) Pregnancy: Ages 14-50: 220 mcg Lactation: Ages 14-50: 290 mcg (RDA) Seafood, iodized salt Important in thyroid function Deficiency may cause abortion, stillbirth, congenital hypothyroidism, neurologic conditions

Iron: Vegetarianism

Iron in the vegetarian diet is poorly absorbed because of the lack of heme iron from meats, poultry, and fish. Absorption is enhanced by eating a vitamin C source at the same meal as the nonheme iron. Iron supplementation is important for vegetarian women during pregnancy.

CRITICAL THINKING EXERCISE 14-1

Joan, 6 months pregnant, very hesitantly confides that the reason she is not gaining much weight is that she eats large amounts of ice. She buys several bags of crushed ice daily. "I know I should be gaining more weight, but I'm just not hungry for anything besides ice," she says. How should the nurse handle this situation?

Factors that Influence Weight Gain

Knowing about factors that may negatively influence nutrient intake and weight gain helps the nurse devise plans for improving nutrition. Women at risk for inadequate weight gain include those who are young, unmarried, low income, poorly educated, in poor general health, or receiving insufficient prenatal care. Multiparas are at higher risk for low weight gain than primiparas. Smoking or substance abuse may interfere with food intake and weight gain.

Labs

Laboratory tests for in-depth analysis of nutrient intake are generally impractical. Hemoglobin, hematocrit, and in some cases serum ferritin tests are used most often to detect anemia.

Foods to Avoid postpartum

Lactating mothers are often concerned about whether they should avoid certain foods that might adversely affect the infant. Studies have shown that eliminating allergenic foods may be helpful for infants under 6 weeks of age with colic and when infants have a confirmed food allergy. However, there is insufficient evidence to recommend an elimination diet for other mothers during lactation. Infants at risk of developing allergies should be breastfed for at least 4 months (List & Vonderhaar, 2010).

Poverty

Low-income women may have deficient diets because of lack of financial resources and nutritional education. Carbohydrate foods are often less expensive than other foods. Therefore the diet may be high in calories but low in vitamins and minerals. A referral to Temporary Assistance for Needy Families (TANF) or WIC may be helpful if the woman's food intake is inadequate because of lack of money. Vitamin and mineral supplementation may be important for the woman, especially if her diet is inconsistent.

Recommended for total weight gain (part II)

Lower weight gain or weight loss for obese women during pregnancy is not recommended at this time as there is insufficient evidence about the effect on neurologic development of the infant. More research is needed in this area (Rasmussen & Yaktine, 2009) In the past, women of small stature were advised to gain to the lower limits of the recommended range for their prepregnancy weight. Adolescents were advised to gain to the upper limits of their prepregnancy weight. However, evidence to support these guidelines has not been found. Therefore, these women should gain according to the recommendations for their BMI (Rasmussen & Yaktine, 2009). Infants of a multifetal pregnancy are often born before term and tend to weigh less than infants born of single pregnancies. A greater weight gain in the mother may help prevent low birth weight. The recommended gain for women of normal prepregnancy weight who are carrying twins is 17 to 25 kg (37 to 54 lb) (Ramussen & Yaktine, 2009). When these women meet the recommended weight gain, they are less likely to deliver their twins before 32 weeks of gestation, and the infants are more likely to weigh more than 2500 gm (5.5 lb) (Fox, Rebarber, Roman, et al., 2010).

Protein Group

Many adults think of meat, poultry, fish, and eggs as the only sources of protein, but legumes (beans, peas, lentils), nuts, and soybean products such as tofu also are good sources. Adult women should consume 5 to 5½ oz of foods from this group each day. Pregnant women need 6 to 6½ oz daily and lactating women need 5½ to 6 oz daily. A typical serving of meat, fish, or poultry varies in size. A 3 oz portion is about the size of a deck of playing cards.

FOODS HIGH IN IRON FOOD AND AMOUNT AVERAGE AMOUNTS OF IRON SUPPLIED (MG)

Meats and Fish (3 oz) Beef, lean chuck 3.1 Beef, ground 15% fat 2.2 Chicken, dark meat 1.3 Tuna, light in water 1.3 Legumes (½ c) Kidney beans, dried, cooked 2.6 Lentils, dried, cooked 3.3 Chickpeas (garbanzo beans), canned 1.6 Soybeans, cooked 4.4 Tofu, firm ¼ block 1.3 Grains Bread, wheat (1 slice) 0.9 Rice, white enriched, cooked (1 c) 3.2 Total Raisin Bran cereal (¾ c) 13.5 Fruits Prune juice (8 oz) 3 Raisins (⅔ c) 1.8 Vegetables Potato, baked with skin, (1 med) 2.2 Sweet potatoes, canned, (1 c) 2.8 Tomatoes, canned, stewed, (1 c) 3.4 Peas, green, cooked (1 c) 2.4

Increasing Nutrients with Traditional Foods

Milk products are not a large part of the traditional Southeast Asian diet, and lactose intolerance is common. Soy milk may be used instead. Some Vietnamese can tolerate dairy products in small amounts. Increasing the intake of commonly used dark green leafy vegetables, such as mustard greens, bok choy, and broccoli, however, increases calcium, iron, magnesium, and folic acid intake. Tofu is a good source of calcium and iron. A broth made from pork or chicken bones soaked in vinegar (which removes calcium from the bones) is frequently served. If the mother avoids fortified milk, she may need vitamin D supplementation. Increasing the intake of meats and poultry elevates levels of vitamin B6 and zinc.

Exercise

Moderate daily exercise during pregnancy is encouraged. Women who exercise more strenuously or are athletes may need modifications of their diet to meet increased nutritional needs. Extra calories may be needed to make up for the energy used during exercise. A serving of fruit, yogurt, or pasta before and after exercise may be sufficient. Additional fluids should be taken during and after exercise as well.

Nausea and Vomiting of Pregnancy

Morning sickness usually ends soon after the first trimester, but some women experience nausea at other times of day. Most women are able to manage frequent, small meals better than three large meals. Protein and complex carbohydrates are often tolerated best, but fatty foods increase nausea. Drinking liquids between meals instead of with meals often helps. At bedtime, a protein snack helps maintain glucose levels through the night. Eating a carbohydrate food such as dry toast or crackers before getting out of bed in the morning helps prevent nausea.

Minerals

Most minerals are supplied in adequate amounts in normal diets. However, dietary intake of iron and calcium may be below recommended levels in women of childbearing age.

RECOMMENDED WEIGHT GAIN DURING PREGNANCY WEIGHT BEFORE PREGNANCY TOTAL GAIN MEAN (Range) WEEKLY GAIN (2nd AND 3rd TRIMESTERS)∗

Normal weight (BMI 18.5-24.9) 11.5-16 kg 25-35 lb 0.42 (0.35-0.5) kg 1 (0.8-1) lb Underweight (BMI <18.5) 12.5-18 kg 28-40 lb 0.51 (0.44-0.58) kg 1 (1-1.3) lb Overweight (BMI 25-29.9) 7-11.5 kg 15-25 lb 0.28 (0.23-0.33) kg 0.6 (0.5-0.7) lb Obese (BMI 30 or higher) 5-9 kg 11-20 lb 0.22 (0.17-0.27) kg 0.5 (0.4-0.6) lb

Fluids postpartum

Nursing mothers should drink fluids sufficient to relieve thirst, which often increases in the early breastfeeding period. Eight to 10 glasses of fluids, other than those containing caffeine, is adequate. Drinking large quantities of fluids is not necessary.

Nutritional Requirements During Pregnancy

Nutrient needs increase during pregnancy to meet the demands of the mother and fetus. Usually the increases are not large and are relatively easy to obtain through the diet.

Nutrition After Birth

Nutritional requirements after birth depend on whether the mother breastfeeds her infant or gives formula. The nurse should review the woman's nutritional knowledge as she returns to her prepregnancy diet and teach the breastfeeding mother how to adapt her diet to meet the needs of lactation.

Nursing Care Nutrition for Childbearing Assessment Signs of Nutrient eficiency

Observe for indications of nutritional status or signs of deficiency. For example, bleeding gums may indicate inadequate intake of vitamin C. Actual deficiency states, however, are not likely to occur in women in most industrialized countries. The exception is iron deficiency anemia, which is common in a mild form. Signs and symptoms include pallor, low hemoglobin level, fatigue, and increased susceptibility to infection.

Nutritional Knowledge

Once pregnancy is confirmed, women often become interested in the relationship between what they eat and the effect on the fetus. Some lack basic understanding about nutrition and have misconceptions based on common food myths. They may seek out information from books, magazines, television, and the Internet. They benefit from help from nurses in learning about nutrition.

Protein

Protein is necessary for metabolism, tissue synthesis, and tissue repair. The daily protein RDA for females is 46 g, depending on their age and size. During the second half of pregnancy, a protein intake of 71 g each day is recommended to expand the blood volume and support the growth of maternal and fetal tissues. This is an increase of 25 g of protein daily (Erick, 2012). Protein is generally abundant in diets in most industrialized nations, but diets low in caloric intake may also be low in protein. If calories are low and protein is used to provide energy, fetal growth may be impaired. The nurse should counsel women at risk for poor protein intake how to determine protein intake and increase food sources. When a woman needs to increase her intake, she should eat more protein-rich foods rather than use high-protein powders or drinks. Protein substitutes do not have the other nutrients provided by foods.

Recommendations for Total Weight Gain

Recommendations for weight gain in pregnancy are based on the woman's pre pregnancy weight for her height or her body mass index (BMI). BMI is calculated by dividing the weight in kilograms by the height in meters squared. Another method is to divide the weight in pounds by the height in inches squared and multiply the result by 703 (Centers for Disease Control and Prevention [CDC], 2009). Tables are available that show the BMI for various weights and heights. Suggested gains vary according to the woman's BMI (or weight for height) before pregnancy (Table 14-1). The recommended weight gain during pregnancy is 11.5 to 16 kg (25 to 35 lb) for women who begin pregnancy at normal BMI. The range allows for individual differences because no exact weight gain is appropriate for every woman. Women who are underweight should gain more to meet the needs of pregnancy as well as to meet their own need to gain weight. They should gain 12.5 to 18 kg (28 to 40 lb). The recommended gain for overweight women is 7 to 11.5 kg (15 to 25 lb). Obesity is a growing problem. Obese women who become pregnant have an increased incidence of spontaneous abortion, gestational diabetes, gestational hypertension, preeclampsia, prolonged labor, cesarean birth, postpartum hemorrhage, wound complications, macrosomia, and congenital anomalies. Their children have an increased risk of childhood obesity (Josefson, 2011). Overweight and obese women should be advised to lose weight before conception to achieve the best pregnancy outcomes. The recommended weight gain for the obese woman is 5 to 9 kg (11 to 20 lb) to provide sufficient nutrients for the fetus.

Interventions: Making referrals

Refer women with health problems such as diabetes, celiac disease, or extreme weight problems for a consultation with a dietitian and follow-up with the nurse. Refer women with inadequate financial resources to buy food to public assistance programs such as the WIC program. At the next visit, determine whether the woman obtained the help needed and whether other assistance is necessary.

Factors that Influence Nutrition

The nurse must consider age, knowledge about nutrition, exercise, and cultural background when counseling women about their diets.

Specific Nutritional Concerns

Some women are unlikely to consume the required nutrients and they need special counseling.

Southeast Asian Dietary Practices

Southeast Asians include those from Cambodia, Laos, and Vietnam. Traditional cooking in these countries includes searing fresh vegetables quickly with small portions of meat, poultry, or fish in a little oil over high heat. Meals cooked in this manner are low in fat and retain vitamins. Most meals are accompanied by rice, which increases the intake of complex carbohydrates. A salty fish sauce called nuoc mam and fresh vegetables are also part of most meals (Stauffer, 2008). Tofu and fresh fruits are frequent additions. Many Southeast Asians have added American foods to their diets. The addition of more eggs, beef, pork, and bread has increased nutrients but also fat to the diet. Coffee, candy, soft drinks, butter or margarine, and fast foods have been less favorable influences because they are low in nutrients but high in sugar or fat.

Hispanic Dietary Practices

Spanish-speaking people, such as Mexican-Americans, Puerto Ricans, and Cuban-Americans, are often referred to as Hispanics or Latinos. Like Asians, many Hispanics follow the theories of "hot" and "cold" foods and conditions. They also consider pregnancy to be "hot" and the postpartum period to be "cold" and adjust the diet accordingly. Hispanic women may not take prescribed prenatal vitamins or iron because they are considered "hot" or may take a "cold" food such as fruit juice to neutralize the effect (Galanti, 2008). Hispanic foods are often hot, spicy, and frequently fried. The diet is high in fiber and complex carbohydrates but may also be high in calories and fat. Dried beans (especially pinto beans) are a staple of the Mexican-American diet and are part of most meals, served alone, as refried beans, or mixed with other foods, such as rice. The major grain is corn, which is ground and made into a dough called masa to make corn tortillas, a good source of calcium. Corn or flour tortillas are eaten with most meals. Rice is also an important grain. Many Hispanics are lactose intolerant, but cheese is part of many dishes. Chili peppers and tomatoes are the most common vegetables used. Green leafy and yellow vegetables are seldom included. Puerto Ricans and Cubans may add tropical fruits and vegetables from the homeland, when available. Viandas (starchy fruits and vegetables such as plantain, green bananas, sweet potatoes, yams, and breadfruit) are common. They may be cooked with codfish and onion. Guava, papaya, mango, and eggplant also are used when available.

Substance Use and Abuse

Substance abuse often accompanies a lifestyle that is unlikely to promote good eating habits. The expense of supporting a substance abuse habit may decrease the amount of money available to purchase food. Therefore nutrition in pregnant women who abuse substances should be explored fully. Usually more than one substance is involved, and the effects of various combinations of substances on nutrition are not fully understood. The damaging effects of smoking, alcohol, and drug use on the fetus are further discussed in Chapter 24.

Teaching the Adolescent

Teaching the adolescent about nutrition can be a challenge for nurses. It is essential to establish an accepting, relaxed atmosphere and show willingness to listen to the teenager's concerns. Her lifestyle, pattern of eating, and food likes and dislikes should be explored to determine if changes are needed in her diet. The nurse should keep suggestions to a minimum, focusing on only those changes that are most important. Asking for the adolescent's input increases the likelihood that she will follow suggestions. When changes are necessary, the nurse should explain the reasons. A teenager, like other pregnant women, often makes changes for the sake of her unborn child that she would not consider for herself alone (see Nursing Care Plan). The need to be like her peers is of major importance to the adolescent, especially when she is going through the changes of pregnancy. With education about what foods to choose, she can eat fast foods with her friends and still maintain a nourishing diet. Giving her plenty of examples of alternatives from which she can choose should be very helpful.

Nutrition for the Lactating Mother

The DRIs for lactating women are higher than those for nonpregnant adult women for many nutrients

Vitamins/minerals: postpartum

The DRIs for lactating women are increased above pregnancy needs for vitamins A, B6, B12, C, and E and riboflavin, zinc, iodine, potassium, copper, and selenium. Lactating women who eat a well-balanced diet generally consume adequate amounts of essential nutrients to meet the infant's and their own needs. The vitamin content of the milk may be decreased if the mother's diet is consistently low in vitamins. Lactating women with poor diets may have reduced milk levels of fatty acids, selenium, iodine, vitamin A, and some B vitamins (Erick, 2012; Peckenpaugh, 2010). Vitamin D in the milk may be low if the mother has a low intake, is not exposed to the sun, or has dark skin (Erick, 2012). Mineral levels in the milk may remain constant because some minerals, such as calcium, are drawn from the mother's stores if her intake is poor. Routine vitamin-mineral supplements are unnecessary unless the diet is lacking in vitamins and minerals.

Nutrient Needs

The DRIs for nutrients needed by pregnant adolescents are the same as those for older women for most nutrients. They need more calcium, magnesium, phosphorus, and zinc to meet their own growth needs. Assessment of gynecologic age, nutritional status, and daily diet may indicate the need for added increases in some areas for individual adolescents.

Nutritional Risk Factors

The nurse must identify risk factors that may interfere with a woman's ability to meet the nutritional needs of pregnancy.

Importance of iron during pregnancy

The Recommended Dietary Allowance (RDA) for iron during pregnancy is 27 mg. Although many women take supplements because they do not eat enough iron-containing foods in their daily diet to meet this need, iron in foods is often better absorbed. Therefore the nurse should suggest ways a woman can increase her dietary iron. Iron is present in many foods, but in small amounts. Approximately 25% of iron from animal sources (called heme iron) is absorbed. Only about 5% of nonheme iron (iron from plant sources and fortified foods) is absorbed (Gallagher, 2012). Absorption of iron is affected by intake of other substances. Calcium and phosphorus in milk and tannin in tea decrease iron absorption from nonheme iron if they are consumed during the same meal. Coffee binds iron, preventing it from being fully absorbed. Antacids, phytates (in grains and vegetables), oxalic acid (in spinach), and ethylenediaminetetraacetic acid (EDTA, a food additive) also decrease absorption. Foods cooked in iron pans contain more iron (Yoder, 2009). Foods containing ascorbic acid and meat, fish, or poultry eaten with nonheme iron-containing foods may increase absorption. Because of the difficulty of obtaining enough iron in the diet, health care providers often prescribe iron supplements of 30 mg/day during pregnancy. Women who are anemic may need 60 to 120 mg/day. Women who take high doses of iron also need zinc and copper supplements because iron interferes with the absorption and use of these minerals (Nix, 2009). Supplementation may begin during the second trimester, when the need increases and morning sickness has usually ended. Iron taken between meals is absorbed more completely, but many women find the side effects worse when iron is taken without food. Side effects occur more often with higher doses and include nausea, vomiting, heartburn, epigastric pain, constipation, diarrhea, and black stools. Taking iron at bedtime may make it easier to tolerate. For best absorption, it should be taken with water or juice but not with coffee, tea, or milk. Women should be reminded to keep iron, like all other medicines, out of the reach of children. Accidental overdose with iron is a leading cause of childhood poisoning.

Food Plan

The U.S. Department of Agriculture (USDA) has developed MyPlate, a food plan which provides a guide for healthy eating for adults and children. Guidelines for pregnancy and lactation are discussed below and summarized in Table 14-5. Pregnant or lactating women can go to the website www.choosemyplate.gov to get an individualized diet plan specifically adapted for them and their needs during pregnancy.

Food Supplement Programs

The WIC program is administered by the USDA to provide nutritional assessment, counseling, and education to low-income women and children up to age 5 years who are at nutritional risk. The program also provides food vouchers for foods such as milk, cheese, eggs, tofu, whole grain bread (or brown rice or tortillas), whole grain cereal, fruit juice, dried or canned legumes, peanut butter, fruits, vegetables, and formula to qualified women and their children. Eligibility is based on an income of 185% of the federal poverty level or less. Women are eligible throughout pregnancy and for 6 months after birth if formula feeding or 1 year if breastfeeding. Children at risk for poor nutrition may be eligible until 5 years of age. Further information is available at www.fns.usda.gov/wic.

Zinc: Vegetarianism

The best sources of zinc are meat and fish. Vegetarians may be deficient in this mineral and need supplements.

Vegetables and Fruits

The daily recommendation for vegetables in healthy adult women is 2.5 cups, 3 to 3½ cups for pregnancy, and 2½ to 3 cups for lactation. One and a half to 2 cups of fruits are recommended each day for adult women. Pregnant and lactating women should have 2 cups daily. A wide range of fruits and vegetables provides the best nutrition. Dark green and orange or dark yellow vegetables are especially nutritious.

Dairy Group

The dairy group includes foods such as milk, yogurt, and cheese, which contain approximately the same nutrient values whether they are whole (4% fat), low fat (2% fat), or nonfat (skim), but the calories and fat are less in the latter two forms. The milk group is an especially good source of calcium. Adult women and those who are pregnant or lactating need 3 cups or the equivalent from this group each day.

Common Problems

The diets of teenagers before and during pregnancy are often low in vitamins A, B6, and C, folic acid, calcium, iron, zinc, and magnesium (Hogan, DeLeon, Gingrich, et al., 2007; Nichols-Richardson, 2011b). Supplements may be prescribed, but the adolescent may not take them regularly. This combination of poor intake and unreliable supplementation may further deplete nutrient stores and general nutritional status. Peer pressure is an important influence on nutritional status. Adolescents are often concerned about their body image. If weight is a major focus for a teenager and her peers, she may restrict calories to prevent weight gain during pregnancy. Teenagers tend to skip meals, especially breakfast. The fetus requires a steady supply of nutrients, and the expectant mother's stores may be used if intake is not sufficient to meet fetal needs. Teenagers are often in a hurry, and they want foods that are fast and convenient. Meals may be irregular and often eaten away from home. Fast foods from restaurants or snack machines are a significant part of many teenagers' diets. These foods are often high in fat, sweeteners, and sodium and low in vitamins, minerals, and fiber. Choosing fast foods that do not make her appear different to her peers yet meet her added nutrient needs is important for the pregnant adolescent.

Energy

The energy provided by foods for body processes is calculated in kilocalories. Kilocalories (commonly called calories, the term used in this book) refers to a unit of heat used to show the energy value of foods. Kilocalories are obtained from carbohydrates and proteins, which provide 4 calories in each gram, and fats, which provide 9 calories in each gram.

Caffeine

The evidence regarding the effect of caffeine on nutrition during pregnancy is conflicting, and more research is needed. At this time, it appears that caffeine intake less than 200 mg/day is not a major contributing cause of miscarriage or preterm birth. Until more is known about its effects on nutrition and the fetus, caffeine intake should be limited during pregnancy to less than 200 mg/day (ACOG, 2010). The nurse should discuss usual sources of caffeine. A 6 oz cup of brewed coffee contains about 103 mg; tea contains 36 mg/6 oz; cola beverages contain 35 to 50 mg/12 oz; and cocoa contains 4 mg/6 oz (Mahan, Escott-Stump, & Raymond, 2012). Some medications also contain caffeine. Caffeine changes calcium, zinc, thiamine, and iron absorption or excretion.

Nursing Care Nutrition for Childbearing Assessment Interview

The interview provides an opportunity to develop rapport and to identify any specific problems that affect dietary intake.

Fats: postpartum

The long-chain polyunsaturated omega 3 and omega 6 fatty acids are present in human milk. Therefore they should be included in the mother's diet during lactation.

Vegan Diet

The milk of the vegan mother may contain inadequate vitamin B12 and D, and she and her infant may need supplements. The amounts of vitamin D in the diet also may be low. Vegans can meet their need for other nutrients during lactation by diet alone with careful planning. Those who are not knowledgeable about nutrition should take supplements.

Multiparity and Multifetal Pregnancy

The number and spacing of pregnancies, as well as the presence of more than one fetus, influence nutritional requirements. The woman who has had previous pregnancies may begin a pregnancy with a nutritional deficit. In addition, she may be too busy meeting the needs of her family to be attentive to her own nutritional needs. Closely spaced pregnancies may not allow a woman to make up any nutritional deficits originating during a previous pregnancy. Morning sickness from a new pregnancy may further interfere with an expectant mother's ability to eat an adequate diet. In addition, an interval of less than 6 months between pregnancies increases the risk of preterm and low-birth-weight infants as well as maternal morbidity and mortality (Reinold, Dalenius, Smith, et al., 2009). The woman with a multifetal pregnancy must provide enough nutrients to meet the needs of each fetus without depleting her own stores. The suggested weight gain for women of normal prepregnant weight who are pregnant with twins is 17 to 25 kg (37 to 54 lb), which is 5.5 to 9 kg (12 to 20 lb) more than for women with single pregnancies (Ramussen & Yaktine, 2009). The woman should consume an additional 300 calories per day for each fetus (Stotland, 2009). Supplementation with calcium, iron, magnesium, zinc, and folic acid may also be necessary.

Pattern of Weight Gain

The pattern of weight gain is as important as the total increase. The general recommendation is for an increment of approximately 0.5 to 2 kg (1.1 to 4.4 lb) during the first trimester, when the mother may be nauseated and the fetus needs fewer nutrients for growth. During the rest of the pregnancy, the expected weekly weight gain for women of normal prepregnancy weight is 0.35 to 0.5 kg (0.8 to 1 lb) (Ramussen & Yaktine, 2009).

Nutrition for the Nonlactating Mother

The postpartum woman who is not breastfeeding can return to her prepregnancy diet if it meets the recommendations for adult women. Her diet should contain protein and vitamin C foods to promote healing. She may continue to take her prenatal vitamin-mineral supplements until her supply is finished to ensure adequate intake during the early weeks and help renew nutrient stores. The nurse should assess the mother's understanding of the amount of food she needs from each food group. A review of important nutrient sources for calcium and iron may be relevant. If a woman was anemic during pregnancy, an iron supplement is important until her hemoglobin level returns to normal.

Pica

The practice of eating nonfood or some food components not considered part of a normal diet is called pica. Ice, clay, dirt, and laundry starch or cornstarch are the most common materials involved, but other items, such as chalk, baking soda, toothpaste, freezer frost, coffee grounds, and antacid tablets may be included (Bond, 2011; Gordon, 2007; Nichols-Richardson, 2011a). Pica is practiced by about 20% of pregnant women (Nichols-Richardson, 2011a). Pica is more common in rural areas, inner cities, the southeastern United States, in African-Americans, women who live in poverty, those with poor nutrition, and in those with a childhood or family history of the practice. However, pica is not limited by socioeconomic group or geographic area. Pica may be present before pregnancy occurs. The cause of pica is unknown, although cultural values may make pica a common practice. Pica may be related to beliefs about the effect of the material eaten on labor or the baby. Iron deficiency is often associated with pica. Clay and dirt are not sources of iron and may decrease the absorption of iron and other nutrients (Grodner et al., 2012). Zinc deficiency is also associated with pica. Studies about whether iron and zinc deficiencies are causes or results of pica are inconclusive (Mills, 2007). Substances eaten may be contaminated with parasites, other organisms, or toxins such as lead. Clay and dirt may cause constipation or intestinal blockage. Eating large amounts of ice may cause dental problems. Another concern with pica is that it decreases the intake of foods and therefore essential nutrients. Some women fear that their eating habits are harmful but are unable to ignore the cravings. They often keep their eating practices secret from caregivers who might disapprove

Adolescence Diet Postpartum

The problems of the adolescent diet continue to be of concern during lactation. The adolescent may be deficient in the same nutrients listed for other mothers during lactation, and she may be lacking in iron. If she avoids fruits and vegetables, her intake of vitamin A and C may be inadequate. `

Avoidance of Dairy Products

The recommendation for calcium remains the same for pregnancy and lactation, and the calcium content of breast milk is not affected by maternal intake. Less calcium is excreted in the urine during lactation. Women who do not eat dairy products should obtain calcium from other sources or take a calcium supplement.

Protein: Postpartum

The recommended protein intake for pregnancy and lactation is 71 g each day. Although there is no change in protein needed for lactation, it is important for the woman to keep up her protein intake throughout the breastfeeding period.

Drugs

The use of drugs other than those prescribed during pregnancy increases danger to the fetus and may interfere with nutrition. Marijuana increases appetite, but women may not satisfy their hunger with foods of good nutrient quality. Heroin alters metabolism and may cause the woman to be malnourished. Cocaine acts as an appetite suppressant, interfering with nutrient intake. Cocaine users tend to drink more beverages with alcohol or caffeine. Amphetamines and methamphetamines depress appetite. Women who use amphetamines for dieting should be warned that the drugs should be discontinued during pregnancy.

Nursing Care Nutrition for Childbearing Expected Outcomes

The woman will eat a daily diet that includes the recommended amount of each food group for pregnancy. The woman with a normal BMI before pregnancy will gain approximately 0.5 to 2 kg (1.1 to 4.4 lb) during the first trimester and 0.35 to 0.5 kg (0.8 to1 lb) per week during the second and third trimesters for a total gain of 11.5 to 16 kg (25 to 35 lb).

Nursing Care Nutrition for Childbearing Assessment Weight at initial visit

To get a baseline value for future comparison, weigh the woman at the first prenatal visit. Ask if this is her usual weight or if she has gained or lost weight. Measure her height without shoes. If her weight is low for height, nutritional reserves are marginal. If it is high, she may be overweight or obese.

Interventions: Explaining Nutrient Needs

Use the woman's diet history as a basis to introduce information about nutrition during pregnancy. Help the woman analyze her own diet for the amount of each food group included so she understands the process. Explain which important nutrients are provided in each food group and why they are necessary for her and the fetus. Make a rough estimate of calories, protein, iron, folic acid, and calcium in the diet to help her determine if she eats enough of these foods on a regular basis. Compare the usual sources of these major nutrients with her diet history and favorite foods. Suggest ways she can increase her intake of nutrients she is lacking by increasing foods that are good sources.

Energy: Vegetarian

Vegetarian diets may be low in calories and fat and may not meet the energy needs of pregnancy. The diets are high in fiber and may cause a feeling of fullness before enough calories are eaten. A pregnant woman can increase caloric intake by eating snacks and higher-calorie foods. If carbohydrate and fat intakes are too low, her body may use protein for energy.

Inadequate Diet

Women with cultural or other food prohibitions may need help choosing a diet adequate for lactation. Low-income women may need referral to agencies such as WIC. If the mother must take medications that interfere with absorption of certain nutrients, her diet should be high in foods containing those nutrients.

Vegetarianism

Vegetarianism is eating a diet that contains wholly or mostly of plant foods, and avoiding animal food sources. It occurs in a variety of forms. Vegans avoid all animal products and may have the most difficulty meeting their nutrient needs. Their diet may be lacking in adequate calcium, iron, zinc, riboflavin, and vitamins D, B6, and B12 (Bond, 2011; Stotland, 2009). Vegans may need to take supplements or foods fortified with these nutrients. It is easier for lactovegetarians (those whose diet includes milk products, ovovegetarians (those who include eggs), and lacto-ovovegetarians (those who include milk products and eggs) to meet their nutrient needs. Although the knowledgeable vegetarian may eat a very nutritious diet, she is at higher risk during pregnancy. If she is new to vegetarian food practices, uninformed about pregnancy needs, or careless with her diet, she could fail to meet her nutrient needs. Vegetarians can follow the general guidelines during pregnancy by substituting plant sources for foods from animal sources.

Calcium: Vegetarianism

Vegetarians who include milk products in their diet may meet their pregnancy needs for calcium. Vegans obtain calcium from dark green vegetables and legumes, but their high-fiber diet may interfere with calcium absorption. Calcium-fortified juice or soy products, such as soy milk or tofu may meet the requirements. Calcium supplements may be necessary. Vitamin D supplementation is especially important if the woman drinks no milk and has little exposure to sunlight. Soy milks may be enriched with vitamin D.

Vitamin A: Vegetarianism

Vitamin A is abundant in vegetarian diets. If the woman uses a daily multiple vitamin-mineral supplement, she may take in excessive amounts of vitamin A. Toxic effects include anorexia, irritability, hair loss, dry skin, and damage to the fetus. Supplementation should be individualized for each woman, based on her diet and her needs.

Vitamin B12: Vegetarianism

Vitamin B12 is obtained only from animal products. Because vegetarian diets contain large amounts of folic acid, anemia caused by inadequate intake of vitamin B12 may not be apparent at first. Vegans may eat fortified foods such as cereal and some soy products or take B12 supplements.

Water

Water is important during pregnancy for the expanded blood volume and as part of the increased maternal and fetal tissues. Women should drink approximately 8 to 10 cups of fluids each day, with water constituting most of the fluid intake (Erick, 2012). Fluids low in nutrients should be limited because they are filling and replace other more nutritious foods and drinks.

Nursing Care Nutrition for Childbearing Assessment Weight at subsequent visits

Weigh the woman at each visit on the same scale with approximately the same amount of clothing. Record the weight on a weight chart at each visit throughout the pregnancy (Figure 14-2). Use a chart that allows examination of the pattern as well as the total gain to date. Be careful not to overemphasize weight gain. In some instances, a woman may be afraid that caregivers will be disapproving if she gains weight and consequently she may diet or fast a day or two before her prenatal visit.

Weight Gain During Pregnancy

Weight gain during pregnancy, especially after the first trimester, is an important determinant of fetal growth. Insufficient weight gain during pregnancy has been associated with low birth weight (less than 2500 g, or 5.5 lb), small-for-gestational age infants, preterm birth, and failure to initiate breastfeeding. Poor maternal weight gain indicates not only lower caloric intake but also low intake of other important nutrients. Excessive weight gain is another problem. It is associated with increased birth weight (macrosomia), cesarean birth, postpartum weight retention, low Apgar scores, hypoglycemia, and overweight in children (American Dietetic Association [ADA], 2008; Viswanathan, Siega-Riz, Moos, et al., 2008).

Weight Loss

When her baby is born, a woman can expect to lose about 5.5 kg (12 lb) immediately. She loses approximately another 4 kg (9 lb) in the next 2 weeks and 2.5 kg (5.5 lb) by 6 months after delivery. If her weight gain during pregnancy has not been excessive, she will probably lose all but approximately 1.4 kg (3 lb) if she follows a well-balanced diet (Cunningham et al., 2010). She should decrease her caloric intake to her normal nonpregnant levels to avoid retaining weight. Some women are impatient with slow weight loss. Because they need energy to meet the demands of infant care, new mothers should wait at least 3 weeks to start dieting to lose weight. Suggestions for sensible calorie reduction combined with exercise are appropriate. Women who gain excess weight during pregnancy may have more difficulty losing it after birth and may need help from a dietitian in planning a weight loss program. Women who don't lose the weight gained during pregnancy risk beginning the next pregnancy overweight, and this may lead to further retention of weight after birth. Therefore women need help with learning how to decrease their energy intake so they can return to their normal weight. Mothers are sometimes so involved with the needs of the infant that they fail to eat properly. They may snack instead of planning meals for themselves, especially during the early weeks. The nurse should remind them that snacking often involves high-caloric intake without meeting nutritional needs. Meals and snacks should be high in nutrient content.

FOOD PLAN FOR PREGNANCY AND LACTATION FOOD (EQUIVALENT OF 1 OZ OR 1 CUP) RECOMMENDED INTAKE FOR PREGNANCY∗ RECOMMENDED INTAKE FOR LACTATION

Whole grains (1 oz = 1 slice bread, ½ c rice or pasta) 7-9 oz 7 oz Vegetables 3-3½ c 3 c Fruits 2 c 2 c Milk group (1 c milk or yogurt, 1½ oz cheese) 3 c 3 c Meat/Beans (1 oz meat/poultry/fish, 1 egg, ¼ c dried beans [cooked], 1 tbsp peanut butter) 6-6½ oz 6 oz Example is for a woman 5 feet, 4 inches tall and weighing 125 lb before pregnancy. Specific food plans for other women can be found at www.choosemyplate.gov. † Amounts are for exclusive breastfeeding. If formula is also being used, 1 oz less of grains, ½ c less of vegetables, and ½ oz less of meat/beans is recommended.

Food Cravings and Aversions

Women may have a strong preference or a strong dislike for certain foods that is present only in pregnancy. Cravings for pickles, ice cream (not necessarily together), pizza, chocolate, cake, candy, spicy foods, and dairy products are common. Food aversions are most often to coffee, alcoholic beverages, highly seasoned or fried foods, and meat. The cause of cravings and aversions is not known, but they may be a result of changes in the sense of taste and smell. They are generally not harmful, and some, like aversion to alcohol, may be beneficial. Satisfying cravings is common in many cultures. Some Ethiopian women believe that unfulfilled cravings during pregnancy may cause miscarriage (Spector, 2009). Women from India may believe cravings during pregnancy should be satisfied because they come from the fetus (Chatterjee, 2008).

Maternal and Fetal Distribution

Women often wonder why they should gain so much weight when the fetus weighs so much less. Explaining the distribution of weight helps them understand this need (Figure 14-1).

Dieting: Postpartum

Women who are concerned about losing weight after pregnancy need special consideration. After the initial losses in the first month, weight gradually decreases as maternal fat is used to meet a portion of the energy needs of lactation. However, breastfeeding does not necessarily result in weight loss, and some women maintain or even gain weight during lactation. This is more likely when weight gain during pregnancy was excessive. Dieting should be postponed for at least 3 weeks after birth to allow the woman to recover fully from childbirth and establish her milk supply if she is breastfeeding. Gradual weight loss is preferable and should be accomplished by a combination of moderate exercise and a diet high in nutrients. Nursing mothers should avoid appetite suppressants, which may pass into the milk and harm the infant. Weight loss of approximately 0.45 to 0.68 kg (1 to 1.5 lb) a week is safe and will not affect milk supply or content (Bronner, 2010).

Other Risk Factors

Women who follow food fads may not meet the nutritional requirements of pregnancy. Those who have followed a severely restricted diet may have depleted nutrient stores. The nurse can help them understand dietary changes needed during pregnancy. Women with complications of pregnancy, such as diabetes, heart disease, and preeclampsia, may need dietary alterations. Those with other medical conditions, such as extreme obesity, cystic fibrosis, and celiac disease, may need nutritional counseling from a dietitian.

Weight increases with the greatest fluctuation are those attributed to

extravascular fluids (edema) and maternal reserves of fat

CALCIUM SOURCES APPROXIMATELY EQUIVALENT TO 1 CUP OF MILK

¾ c yogurt, fruit, low fat 1½ oz cheddar cheese 1¼ c cottage cheese 4 oz almonds 3¾ c dried pinto beans, cooked 2 c cereal, Cheerios 3 packets instant oatmeal 3 English muffins 1 c collard greens, cooked 5 oz canned salmon with bones 3 oz canned sardines ½ block tofu made with calcium sulfate and magnesium chloride This list can be used to counsel women who are vegans or lactose intolerant. Lactose-intolerant women can often eat small amounts of yogurt and cheese without distress. Although the amounts of some foods listed are more than would be likely to be eaten within a day, they serve for comparison.

SAFETY ALERT: Food Safety During Pregnancy and Lactation

• Do not eat shark, swordfish, king mackerel, and tilefish. • Eat up to 6 oz canned albacore weekly. • Eat up to 12 oz shrimp, canned light tuna, salmon, pollack, and catfish each week. • Do not eat raw or undercooked fish, meat, poultry, or eggs. • Avoid luncheon meats and hot dogs unless reheated until steaming hot. • Avoid soft cheeses (brie, feta, blue cheese, Camembert, blue-veined cheeses, queso blanco, queso fresco, queso panela) unless made with pasteurized milk. • Do not consume refrigerated pâté or meat spreads, refrigerated smoked seafood, raw or undercooked eggs or meat, or raw (unpasteurized) milk or milk products.

Interventions: Evaluation

• Does the woman report eating the recommended amount of each food group daily? • Does the woman gain 0.5 to 2 kg (1.1 to 4.4 lb) during the first trimester and 0.35 to 0.5 kg (0.8 to 1 lb) per week during the second and third trimesters? • Is her total pregnancy weight gain between 11.5 and 16 kg (25 and 35 lb)?

FOODS HIGH IN SODIUM

• Products that contain the word "salt," "soda," or "sodium," such as table salt, seasoning salt, monosodium glutamate, bicarbonate of soda (baking soda) • Foods that taste salty, including snack foods like popcorn, potato chips, pretzels, crackers • Condiments and relishes, such as catsup, horseradish, mustard, soy sauce, bouillon, pickles, green and black olives • Smoked, dried, or processed foods, such as ham, bacon, lunch meats, corned beef • Canned soups, meats, and vegetables unless label states low in sodium • Packaged mixes for sauces, gravies, cakes and other baked foods • Canned tomato and vegetable juices

PATIENT-CENTERED TEACHING: Vitamins and Minerals

• Take only vitamin and mineral supplements prescribed by your health care provider. Ask your provider about over-the-counter supplements because they may not be formulated to meet your individual needs and could be harmful to you and your baby. • Take iron between meals, if possible. If you have nausea, heartburn, constipation, or diarrhea, try taking your iron at bedtime or with meals or a snack. Taking it with orange juice or another source of vitamin C may increase absorption. Do not take iron with calcium supplements, milk, tea, or coffee because these substances decrease absorption. • Keep all vitamin and mineral supplements away from children because they may cause accidental poisoning.