NUR 1229- Nutrition for the fetus, pregnant, and lactating mother

Food sources of folate?

Liver: chicken, turkey, goose has 500 mcg+ per serving Liver: lamb, beef, veal 200+ legumes, beans, peas, lentils, asparagus, spinach, papaya, cereal, wheat germ 100+ 50+ broccoli, lima beans, baked beans, pork, collard greens, raw spinach, avocado, oranges, pasta, rice 20+ bread, egg, corn

BMI formula:

weight/ height 2

Protein and pregnancy

-protein supplements increase preterm births -stick to complete protein rich foods like nuts, dairy, beans, whole grains, peas

Cravings and aversions pregnancy discomfort?

-food -pica (iron deficiency seen commonly in African Americans) will eat ice and dirt more influenced culturally and less from something missing in diet Mexican clay has lead (avoid) gas, bloating, belching is common OTC meds-check with MD before taking avoid maylux, Pepsid, and aspirin

Nutrient needs before conception?

-health diet ensures adequate nutrients are available for the unsuspected fetus developing -folic acid prevents neural tube defects -nutritional deprivation in the first eight weeks will cause fetal abnormalities

Constipation and hemorrhoids pregnancy discomfort?

-iron supplements decrease GI motility to increase absorption of nutrients -decreased hormones drink fluids (2 L/day) eat high fiber foods exercise regularly nice walk after meals use laxatives when prescribed no mineral oil (decreases absorption)

How much fiber is needed

28 grams normal 25

Allison is 10 weeks pregnant. She weighs 160 lbs and is 5'3'' tall. What is her BMI? What is the desired weight gain for Allison?

28-overweight weight gain 15-25

Omega 3-fatty acids

300 mg/day of DHA for pregnant women. Some prenatal vitamins contain DHA; fish oil supplements are another source of DHA. Women can get adequate amounts of DHA by eating 8 to 12 ounces of seafood per week.

Serving sizes for pregnancy and lactation:

Grains 6-8 ounce Veggies 2 1/2 - 3 cups Fruit 2 cups Milk, yogurt, cheese 3 cups protein 5 1/2- 61/2 ounces oil (30 ml) or 6 tsp

nursing alert for fish:

High levels of mercury can harm the developing nervous system of the fetus or young child, and certain fish are especially high in mercury. Women who may become pregnant, women who are pregnant or nursing, and young children need to follow some precautions: (1) avoid eating shark, swordfish, king mackerel, and tilefish; (2) check local advisories about the safety of fish caught by family and friends in local bodies of water, but if no advisory is available, limit intake of these fish to 6 ounces and eat no other fish that week; and (3) eat as much as 12 ounces per week of a variety of commercially caught fish and shellfish low in mercury, such as shrimp, salmon, pollock, catfish, and canned light tuna (but limit intake of albacore or "white" tuna and tuna steaks, which contain more mercury, to 6 ounces per week)

What is the rule of thumb for exercise?

don't add anything new increase fluid intake by at least another L keep same amount of physical activity due before pregnant

Calcium sources for women who don't consume milk:

fish, beans, legumes, greens, baked breads, fruits(figs, OJ with calcium added), sauces(creamy pesto sauce, cheese sauce)

What are the mother's nutrient needs during lactation?

-additional 500 cal/days to produce milk -20 cals burned per ounce 3 L/ day of fluid Vitamins and minerals -prenatal vitamins -same or slightly higher need for nutrients except iron until menstruation resumes -use Vitamin C, zinc, protein to help fix mom's body after birth weight decreases rapidly during first 6-8 wks until more sustained -don't restrict calories The typical amount of milk released is 40 ounces/day with 800 cals burned

What are pregnancy complications of dietary insufficiencies?

-anemia -pre-eclampsia -gestational diabetes

Weight gain from pregnancy:

-breast size increased 2 lbs fluid 4 lbs placenta 1 1/2 blood supply to placenta 4 amniotic fluid 2 infant at birth 7 1/2 tissue and muscles 2 mom's fat stores (?) Total is around 30 pounds

What are the potential diagnoses?

-deficient knowledge: related to nutritional needs and community resources -imbalanced nutrition: > body requirements related to excessive intake or inadequate activity levels (or both) -imbalanced nutrition: < body requirements related to inadequate intake of needed nutrients adolescents: social isolation, disturbed body image, deficient knowledge

What are the assessments of nursing care management?

-diet history -medical history (i.e. anemia with other pregnancies) diabetes mellitus, renal disease, liver disease, cystic fibrosis or other malabsorptive disorders, seizure disorders and the use of anticonvulsant agents, hypertension, and PKU may affect a woman's nutritional status and dietary needs. -unusual maternal diet -physical exam -labs value -finances (Wick consults help struggling moms get needed nutrients)

What to do for a patient saying "I know I will never get enough calcium because I get sick when I drink milk."

-OJ -supplements -Acidopolis

Nausea during pregnancy?

-nausea teach morning sickness is healthy as Hcg doubles get up slowly after waking eat small, frequent meals avoid sting odors don't lay down after eating eat slow and don't drink too much while eating block under pillow eat crackers or toast after waking iron supplement may cause nausea pericardium 6 pressure point to relieve nausea

What are birth complications that may be nutrition related include:

-preterm infants -low birth weight -neural tube defects

What are other intakes during pregnancy?

-smoking low birth weight from 1st, 2nd, or 3rd hand smoke leads to preterm labor, decreased placental perfusion -women smoking during pregnancy should take Vitamin C alcohol -2 drinks or more impair lactation increased miscarriage fetal alcohol syndrome avoid 3+ drinks a day in 1st trimester caffeine- avoid if possible 80-100 ml (1 cup) 300+ mLs decreases milk absorption, increases infant wakefulness, stunted growth, and low iron absorption, infant anemia (decreased Calcium absorption)

What is the recommended weight gain?

-underweight BMI 28-40 pounds normal BMI 25-35 Ideal weight gain of 31/2 lbs during 1st trimester and then 1 lb/wk overweight BMI 15-25 lbs (never diet during pregnancy) short people should gain around 20 pounds (lower end) adolescent and tall women gain on higher end 35 lbs Teach patient that the weight gained is necessary and will leave after pregnancy

Weight management in pregnancy:

Half of all reproductive age women are overweight or obese and are more likely to have gestational weight gain (GWG) in excess of recommendations. GWG in obese women tends to accelerate during the second trimester • Excessive GWG during pregnancy is associated with poor outcomes, due to gestational diabetes, gestational hypertension, fetal macrosomia , stillbirth, and long-term maternal and childhood obesity • Interventions promoting diet, exercise, or both resulted in significantly less gestational hypertension, and may lower the risk for cesarean birth, fetal macrosomia, and neonatal respiratory distress. Dietary interventions were associated with the best outcomes. Obese and overweight pregnant women benefited the most from interventions

Assessment of a woman's nutritional status includes a diet history, medication regimen, physical exam, and relevant lab tests. A maternity nurse performing such an assessment should be aware that: a) OCP's use may interfere with the absorption of iron b) Illnesses that have created nutritional deficients such as PKU may require nutritional care before conception. c) the woman's socioeconomic status and educational level are not relevant to her exam, they are the province of the social worker, if anybody. d) the only nutrition-related lab test most pregnant women need is testing for diabetes

Illnesses that have created nutritional deficients such as PKU may require nutritional care before conception.

Obstetric and Gynecologic Effects on Nutrition

Nutrition reserves may be depleted in the multiparous woman or one who has had frequent pregnancies (especially three pregnancies within 2 years). A history of preterm birth or the birth of an LBW or small-for-gestational-age (SGA) infant may indicate inadequate dietary intake. Birth of a large-for-gestational-age (LGA) infant often indicates the existence of maternal diabetes mellitus. Contraceptive methods also may affect reproductive health. Increased menstrual blood loss often occurs during the first 3 to 6 months after placement of an intrauterine contraceptive device; consequently the user may have low iron stores or even iron deficiency anemia. Oral contraceptive agents are associated with decreased menstrual losses and increased iron stores; however, oral contraceptives may interfere with folic acid metabolism.

Protein for pregnancy:

Three servings of milk, yogurt, or cheese (four for adolescents) and two servings (5 to 6 oz [140 to 168 g]) of meat, poultry, or fish would supply most of the recommended protein for a pregnant woman. Additional protein is provided by vegetables and breads, cereals, rice, or pasta. Pregnant adolescents, women from impoverished backgrounds, and women adhering to unusual diets such as a macrobiotic (highly restricted vegetarian) diet are those whose protein intake is most likely to be inadequate. High-protein supplements are not recommended because of potentially harmful effects on the fetus.

Nutrients during lactation:

additional 400-500 cals/day -thirst is a good indicator for need of fluids protein +25 g water 3.8 L fiber 29 g calcium 1300 iron 10 zinc 13 iodine 290 magnesium 360 A 1200 D 5 E 19 C 115 folate 500 B12 2.8

Neural tube defects:

anencephaly- neural tube fails to close so the brain is either missing or fails to develop spina bifida- incomplete closure of the spinal chord and its bony encasement

Nutrient needs during pregnancy:

calories 250-450 kcals/day in 2nd and 3rd trimester protein 25 g/day and what women usually intakes vitamins/folate 600 mcg/day supplement- 400 and rest is acquired from diet green, leafy veggies, livers Vitamin B-12 in red meat 2.6 mcg/day vegan moms- take supplement calcium- 1200/day to conserve maternal bone mass, decrease BP, decrease preeclampsia (higher risk of lactose intolerance in asian, African Americans, native Americans- tell them to try yogurt, cheese, lactate supplements) zinc- 11-12 mg fluoride- must know where they get their water source sodium- increase to maintain fluid balance, restricted fore renal and liver failure or hypertension potassium- 8-10 servings of unprocessed fruit and veggies- the most lacking nutrient iron- 2nd trimester sees a 50% increase of maternal blood volume 3rd trimester- iron still continued for liver stores -30 mg/day for mild anemia 50-100mg/day for already established anemia might have black, tarry stools, constipation, diarrhea, take on empty stomach -eggs, tea, coffee, milk decrease absorption -take with juice to increase absorption (Vitamin C) maternal mortality rate increases with anemia flood large blood loss (especially African American) iodine 30 mg Magnesium 400 mg Vitamin A 750 mcg Vitamin D 5 mcg Vitamin E 15 mcg Vitamin C 80 a teen with a low BMI/active/twins will increase these needs

nUrsing implications for weight management during pregnancy:

counseling should include prevention of obesity, ideally from childhood. Prepregnancy weight loss improves fertility and decreases preterm birth, gestational diabetes, preeclampsia, assisted delivery, and fetal anomalies • Nurses are frequently the main educators about nutrition and food choices. Successful interventions for pregnant women have utilized individual or group counseling, goal-setting, food diaries, supportive emails or text messages, with follow-up lasting weeks or months. Messages may need to be tailored to body mass index categories • Activity needs to be frequent, fun, and affordable. An excellent idea is encouraging the patient to walk with other pregnant women, which provides social support and increased safety. Encourage this healthy habit in the postpartum period, to decrease weight retention and improve subsequent pregnancy outcomes. In addition, the nurse can advocate for low-cost indoor facilities in the community.

Energy and nutrient needs:

increases 20% in pregnancy except for iron -during lactation less iron and folic acid is required as body reruns to normal -d/c iron supplement after birth

Heartburn (pyrosis) pregnancy discomfort?

pressure of growing fetus relaxed spinchters allows acid to move more free eat small, frequent meals stay upright 1 hour after eating- walking might help eat slowly, avoid drinking too much water during meals avoid foods and drinks high in acid, spicy, or fat avoid eating a few hours before bed wear tight cloths around abdomen

T/F Pregnant women who contract listeriosis, a disease resulting from infection with the bacteria Listeria, are at increased risk for miscarriage, premature birth, and stillbirth During pregnancy, women should not consume unpasteurized milk or products made with unpasteurized milk, including soft cheeses such as Brie, Camembert, and the soft Mexican cheeses queso blanco, queso fresco, panela, and asadero. Hot dogs, luncheon meats, bologna, and deli meats should be eaten only if they have been reheated to be steaming hot. Deli-made and other store-bought salads such as egg, chicken, ham, and seafood should not be eaten.

true

Indicators of nutritional risk in pregnancy

• Adolescence or less than 2 years postmenarche • Frequent pregnancies: three within 2 years • Poor fetal outcome in a previous pregnancy • Poverty/food insecurity • Poor dietary habits with resistance to change • Use of tobacco, alcohol, or drugs • Weight at conception under or over normal weight • Problems with weight gain • Any weight loss • Weight gain of less than 1 kg/month after the first trimester • Weight gain of more than 3 kg/month after the first trimester • Multifetal pregnancy • Low hemoglobin and/or hematocrit values • Diabetes • Chronic illness, including an eating disorder, that affects intake, absorption, or metabolism of nutrients -diabetes ( consume 4-6 meals and snacks daily with certain carbs)

Avoiding nausea during pregnancy (in book)

• Eat dry, starchy foods such as dry toast, melba toast, or crackers on awakening in the morning and at other times when nausea occurs. • Avoid consuming excessive amounts of fluids early in the day or when nauseated (but compensate by drinking fluids at other times). • Eat small amounts frequently (every 2 to 3 hours), and avoid large meals that distend the stomach. • Avoid skipping meals and thus becoming extremely hungry, which may worsen nausea. Have a snack such as cereal with milk, a small sandwich, or yogurt before bedtime. • Avoid sudden movements. Get out of bed slowly. • Decrease intake of fried and other fatty foods. Try high-carbohydrate foods such as toast, rice, or potatoes. Some women find high-protein meals or snacks helpful. • Breathe fresh air to help relieve nausea. Keep the environment well ventilated (e.g., open a window), go for a walk outside, or decrease cooking odors by using an exhaust fan. • Eat foods served at cool temperatures and foods that give off little aroma. Avoid spicy foods. • Avoid brushing teeth immediately after eating. • Try salty and tart foods (e.g., potato chips and lemonade) during periods of nausea. Sucking a lemon slice may help. • Try herbal teas such as those made with raspberry leaf or peppermint to decrease nausea. • Vitamin B6 or a medicine such as Diclegis (made of vitamin B6 and doxylamine) may be recommended by the health care provider. Severe severe and persistent vomiting causing weight loss, dehydration, and electrolyte abnormalities, occurs in up to 1% of pregnant women. Intravenous fluid and electrolyte replacement, enteral tube feeding, and rarely total parenteral nutrition have been used to nourish women with hyperemesis gravidarum

Nutrition care and teaching:

• Educating the woman about nutritional needs during pregnancy and the components of an adequate diet, if necessary • Helping her individualize her diet so that she achieves an adequate intake while conforming to her personal, family, cultural, financial, and health circumstances • Discussing with her strategies for coping with the nutrition-related discomforts of pregnancy • Helping her use nutrition supplements appropriately • Consulting with and making referrals to other professionals or services as indicated

Iron supplementation (in book)

• Iron supplementation should be taken upon the recommendation of the health care provider. • A diet rich in vitamin C (in citrus fruits, tomatoes, melons, and strawberries) and heme iron (in meats) increases the absorption of the iron supplement; therefore include these in the diet often. • Bran, tea, coffee, milk, oxalates (in spinach and Swiss chard), and egg yolk decrease iron absorption. Avoid consuming them at the same time as the supplement. • Iron is absorbed best if it is taken when the stomach is empty; that is, take it between meals with a beverage other than tea, coffee, or milk. • Iron can be taken at bedtime if abdominal discomfort occurs when it is taken between meals. • If an iron dose is missed, take it as soon as it is remembered if that is within 13 hours of the scheduled dose. Do not double up on the dose. • Keep the supplement in a childproof container and out of the reach of any children in the household. • The iron may cause stools to be black or dark green. • Constipation is common with iron supplementation. A diet high in fiber with adequate fluid intake is recommended. Poor iron status, which can result in iron deficiency anemia, is relatively common among women in the childbearing years. Anemic women are poorly prepared to tolerate hemorrhage at the time of birth. In addition, women who have iron deficiency anemia during early pregnancy are at increased risk for preterm birth. Iron deficiency during the third trimester apparently does not carry the same risk. In the United States, anemia is most common among adolescents, African-American women, and women of lower socioeconomic status. A supplement of 30 mg of at least 30 mg ferrous iron daily (World Health Organization, 2017) starting by 12 weeks of gestation helps ensure an adequate iron intake. Iron supplements may be poorly tolerated during the nausea prevalent in the first trimester, and starting the supplement after this point may improve tolerance. If maternal iron deficiency anemia is present (preferably diagnosed by measurement of serum ferritin, a storage form of iron), increased dosages may be required and must be discussed with the woman's health care provider. Certain foods taken with an iron supplement can promote or inhibit absorption of iron from the supplement. See Patient Teaching box later in the chapter regarding iron supplementation. Even when a woman is taking an iron supplement, she should also include good food sources of iron in her daily diet