Chapter 9

Why Nutrition Before and During Pregnancy Matters

• Maternal-fetal significance:

  • Nutrition influences fetal growth, placental development, maternal health, pregnancy outcome, and potentially the child’s long-term health.

• Risks of poor nutritional status:

  • Inadequate nutrition or inappropriate weight gain increases the risk of low birth weight, fetal growth restriction, and preterm birth.

• Preconception care:

  • Assess weight, height, dietary quality, eating habits, nutritional risk factors, medical conditions, and access to adequate food before pregnancy when possible.

• Timing:

  • The first trimester is critical for embryonic organ development, while accelerated fetal growth during the second and especially third trimesters increases nutrient needs.

• Why requirements rise:

  • Pregnancy supports development of the uterus, placenta, fetus, breasts, and amniotic fluid; maternal blood volume increases approximately 40%–50%, and metabolic rate increases approximately 20%.

• Nursing role:

  • Individualize nutrition counseling, support realistic healthy choices, monitor weight patterns, identify barriers, and refer to a registered dietitian when needed.

Recommended Pregnancy Weight Gain by Prepregnancy BMI

• BMI calculation:

  • Body mass index equals prepregnancy weight in kilograms divided by height in meters squared:

    • BMI = weight (kg) ÷ height (m)²

• Underweight:

  • BMI below 18.5: Recommended total pregnancy gain: 28–40 lb.

• Normal weight:

  • BMI 18.5–24.9: Recommended total pregnancy gain: 25–35 lb.

• Overweight:

  • BMI 25–29.9: Recommended total pregnancy gain: 15–25 lb.

• Obesity:

  • BMI 30 or greater: Recommended total pregnancy gain: 11–20 lb.

• First trimester:

  • For a singleton pregnancy in a person with normal prepregnancy weight, expected total first-trimester gain is approximately 2–4 lb.

• Second and third trimesters:

  • Underweight and normal-weight patients generally gain approximately 1 lb/week; overweight patients approximately 0.6 lb/week; patients with obesity approximately 0.5 lb/week.

• Monitoring:

  • Establish an individualized weight-gain goal at the first prenatal visit and monitor progress at each subsequent visit.

• Inadequate gain:

  • Increases risk of fetal growth restriction, small-for-gestational-age infants, low birth weight, and preterm birth.

• Excessive or sudden gain:

  • Can contribute to adverse maternal-fetal outcomes; rapid gain exceeding approximately 6.6 lb in a month, especially after 20 weeks, can indicate fluid accumulation associated with preeclampsia.

• Avoid restrictive dieting:

  • Even patients who are overweight or obese require sufficient nutrition and weight gain for the fetus, placenta, maternal tissues, and amniotic fluid; energy restriction can limit essential nutrients.

Energy and Macronutrient Needs During Pregnancy - Calories by trimester

• First trimester:

  • Calorie needs are generally the same as before pregnancy.

• Second trimester:

  • Approximately 340 additional kcal/day above nonpregnant energy needs.

• Third trimester:

  • Approximately 452 additional kcal/day above nonpregnant energy needs.

• Individual variation:

  • Patients who are highly active, underweight, carrying more than one fetus, or gaining inadequately may require additional individualized intake.

• Practical teaching:

  • Pregnancy requires nutrient-dense food choices rather than unrestricted eating or intentional weight loss.

Energy and Macronutrient Needs During Pregnancy - Protein, carbohydrates, fat, and fiber

• Protein:

  • Baseline nonpregnant requirement is approximately 46 g/day; during the second and third trimesters, the chapter recommends approximately 25 g/day more.

• Protein functions:

  • Supports fetal growth; enlargement of the uterus, placenta, and breasts; expansion of maternal blood volume and plasma proteins; and formation of amniotic fluid.

• Carbohydrates:

  • Primary energy source; pregnancy requirement increases to approximately 175 g/day. Emphasize fruits, vegetables, and whole grains instead of highly processed foods.

• Fat:

  • The chapter recommends approximately 20%–35% of daily calories from fat and avoiding trans fats.

• DHA:

  • Supports fetal brain and eye development; the chapter notes many providers recommend approximately 300 mg/day and describes low-mercury seafood as a dietary source.

• Fiber:

  • Pregnancy target is approximately 28 g/day

  • practical range of 25–35 g/day to help prevent or relieve constipation.

• High-protein supplements:

  • Not recommended because of potential harmful fetal effects; aim to meet needs through an appropriately balanced diet.

Preconception and Pregnancy Folate Requirements

• Folate versus folic acid:

  • Folate is naturally present in foods; folic acid is the form used in supplements and fortified foods.

• Why it matters:

  • Folate supports maternal red-blood-cell formation and rapid fetal/placental cell growth and reduces the risk of neural tube defects such as spina bifida and anencephaly.

• Critical timing:

  • The neural tube begins closing within the first month of gestation, often before pregnancy is recognized, so adequate intake must begin before conception.

• Before pregnancy:

  • All adolescents and women capable of becoming pregnant should take 400 mcg (0.4 mg) folic acid daily and consume dietary folate sources.

• During pregnancy:

  • Recommended folate intake increases to 600 mcg (0.6 mg) daily.

• Previous neural tube defect:

  • A patient with a prior pregnancy affected by a neural tube defect is advised to take 4 mg folic acid daily starting at least 1 month before conception and continuing through the first trimester.

• Key teaching:

  • Taking folic acid only after pregnancy is recognized may miss part of the period when neural tube closure occurs.

Good Dietary Sources of Folate

• Fortified foods:

  • Fortified ready-to-eat breakfast cereals, enriched grain products, breads, pasta, and rice.

• Legumes:

  • Black beans, kidney beans, pinto beans, navy beans, chickpeas, black-eyed peas, and lentils.

• Vegetables:

  • Cooked spinach, asparagus, broccoli, collard greens, mustard greens, and other dark-green leafy vegetables.

• Fruit:

  • Oranges/orange juice, avocado, and papaya.

• Other sources:

  • Wheat germ, eggs, and liver are identified in the chapter.

• Practical principle:

  • Include folate-containing foods regularly while also following the recommended folic-acid supplementation plan.

Good Dietary Sources of Protein

• Animal-based sources:

  • Lean meat, poultry, fish, eggs, milk, yogurt, and cheese.

• Plant-based sources: Dried beans, peas, lentils, peanuts/peanut butter, nuts, seeds, whole grains, and soy products.

• Practical daily pattern:

  • The chapter describes approximately three dairy servings plus two servings totaling approximately 5–6 oz of meat, poultry, or fish as supplying most recommended protein; adolescents are advised to have four dairy servings.

• Food-guide equivalents:

  • One ounce of meat, poultry, or fish; one egg; ¼ cup cooked dried beans; 1 tablespoon peanut butter; or ½ ounce nuts/seeds each represents approximately one protein-food ounce equivalent.

• Vegetarian intake:

  • A variety of grains, legumes, nuts, and seeds can supply essential amino acids when the overall diet is well planned.

    
    

• Nausea-friendly choices:

  • Some patients tolerate small high-protein meals or snacks; yogurt and nuts are chapter-supported examples of protein-containing foods.

• Food safety:

  • Select lower-mercury fish; the chapter advises avoiding shark, swordfish, king mackerel, and tilefish, and limiting albacore/white tuna to 6 oz/week.

Calcium Requirements and Food Sources

• Function:

  • Supports fetal bone and tooth formation while maintaining maternal bone and tooth mineralization.

• Patients younger than 19:

  • Recommended calcium intake is 1,300 mg/day.

• Patients ages 19–50:

  • Recommended calcium intake is 1,000 mg/day.

• Pregnancy distinction:

  • Calcium recommendations do not increase above the usual age-specific nonpregnant requirements, although adequate intake remains essential.

• Dairy sources:

  • Milk, yogurt, and cheese are especially rich sources.

• Nondairy sources:

  • Calcium-fortified orange juice or other beverages; calcium-set tofu; sardines or canned salmon eaten with bones; collard greens, kale, turnip greens, and baked beans.

• Lactose intolerance:

  • Yogurt, cheese, acidophilus milk, buttermilk, lactase-treated milk, or lactase supplements may improve tolerance; assess other calcium sources when milk is avoided.

• Supplements:

  • A calcium supplement may be appropriate when dietary intake remains inadequate and is recommended by the health care provider.

• Safety:

  • The chapter cautions that bone-meal calcium products may contain lead; discuss safe calcium supplements with the health care provider.

Iron Requirements, Dietary Sources, and Supplement Teaching

• Function:

  • Iron supports expansion of the maternal red-blood-cell mass and transfer/storage of iron for the developing fetus.

• Pregnancy requirement: chapter discrepancy:

  • The narrative identifies 27 mg/day, while Table 9.1 lists 30 mg/day. Both figures appear in the supplied chapter; follow the prescribed prenatal supplement plan and the course’s preferred reference.

• Animal sources:

  • Meat, liver, and other heme-iron-containing animal foods.

• Plant and fortified sources:

  • Whole-grain or enriched breads and cereals, dark-green leafy vegetables, legumes, and dried fruits.

• Improve absorption:

  • Take iron with vitamin-C-containing foods such as citrus fruit, tomatoes, melons, or strawberries; meat-derived heme iron also improves absorption.

• Reduce absorption interference:

  • Avoid taking iron at the same time as bran, tea, coffee, milk, egg yolk, spinach, or Swiss chard.

• Administration:

  • Iron is best absorbed on an empty stomach between meals; taking it at bedtime may help when abdominal discomfort occurs.

• Expected effects:

  • Stools may become black or dark green; constipation is common and may improve with adequate fiber and fluids.

• Missed dose and safety:

  • Take a missed dose according to the chapter’s timing instructions without doubling doses; store iron in a childproof container away from children.

• Nausea considerations:

  • Supplements may be difficult to tolerate during the first trimester; timing changes should be discussed with the health care provider.

Additional Vitamins, Fluids, and Balanced Food Choices

• Vitamin B6:

  • Pregnancy requirement is approximately 1.9 mg/day; vitamin B6 supports nutrient metabolism and may be prescribed in larger therapeutic doses for pregnancy-related nausea.

• Vitamin B12:

  • Pregnancy requirement is approximately 2.6 mcg/day; supports red-blood-cell formation and neurologic function. Sources include milk, eggs, meat, and fortified soy milk.

• Vitamin C:

  • Supports tissue formation and enhances iron absorption; sources include citrus fruit, strawberries, melons, broccoli, tomatoes, and peppers.

• Vitamin D:

  • Supports calcium and phosphorus absorption and fetal skeletal mineralization; the chapter identifies fortified milk/cereal and fish such as salmon or tuna.

• Fluids:

  • Aim for approximately 8–12 cups of fluid daily; foods contribute additional water for approximately 3 L total intake daily.

• Why hydration matters:

  • Supports blood volume, nutrient exchange, amniotic fluid, temperature regulation, and regular bowel function; dehydration may increase cramping, contractions, and preterm labor risk.

• General food pattern:

  • Emphasize whole grains, varied vegetables, fruits, low-fat dairy or appropriate alternatives, lean proteins/legumes, and healthier oils.

• Sodium:

  • Routine sodium restriction is not recommended in uncomplicated pregnancy; restriction may be appropriate only when a medical condition specifically warrants it.

• Foodborne illness prevention:

  • Avoid unpasteurized milk and soft cheeses made from unpasteurized milk; reheat hot dogs or deli/luncheon meats until steaming hot.

Caffeine During Pregnancy

• Recommended limit:

  • Keep total caffeine intake below 200 mg/day according to the chapter.

• Approximate comparison:

  • The chapter estimates approximately 100 mg caffeine in one cup of coffee, although intake must include all dietary sources.

• Other sources:

  • Tea, some soft drinks, chocolate, and energy drinks also contain caffeine.

• Evidence limitation:

  • The chapter describes mixed research and notes uncertainty about whether any level is completely risk-free; its practical recommendation remains less than 200 mg/day.

• Teaching:

  • Ask about coffee, tea, soda, chocolate, and energy drinks together rather than assessing coffee intake alone.

Pica and Pregnancy-Related Food Cravings

• Definition:

  • Pica is the consumption of nonfood substances or excessive quantities of low-nutrient substances during pregnancy.

• Examples:

  • Clay, soil, laundry starch, cornstarch, ice or freezer frost, baking powder, raw rice, and flour.

• Why it matters:

  • Pica can displace nutritious foods, interfere with mineral absorption, and expose the patient or fetus to heavy metals or other toxins.

• Iron-deficiency association:

  • Pica is strongly associated with iron deficiency during pregnancy, although the chapter states the exact cause of the association is unclear.

• Screening:

  • Ask about pica at the first prenatal visit, during each trimester, and whenever anemia is present.

• Communication:

  • Use sensitive, nonjudgmental questions about cravings, what substances are eaten, how much is consumed, and how often.

• Management:

  • Assess dietary adequacy and possible iron deficiency, identify dangerous exposures, discuss safer alternatives, and encourage regular meals and nutritious snacks.

• Distinguishing ordinary cravings:

  • eating reasonable amounts of normal foods is usually not harmful, but cravings become concerning when they create nutritional imbalance or involve nonfood substances.

Nutrition Considerations in Adolescent Pregnancy

• Why adolescents are at risk:

  • Many adolescents consume less than the recommended amounts of important nutrients, especially calcium and iron.

• Maternal-fetal competition:

  • a growing adolescent and the fetus may compete for nutrients, contributing to adverse pregnancy outcomes.

• Other clinical concerns:

  • Adolescents and their infants face increased pregnancy, labor, and birth complications; incomplete pelvic growth may contribute to mechanical labor difficulties.

• Weight-gain goals:

  • Use the same adult prepregnancy BMI categories and weight-gain ranges; encourage a goal toward the upper end of the appropriate BMI range.

• Avoid calorie restriction:

  • Provide enough energy and nutrients for both adolescent growth and fetal development; restrictive dieting can reduce essential nutrient intake.

• Calcium:

  • Patients younger than 19 require approximately 1,300 mg/day; the chapter suggests four servings of milk, yogurt, or cheese for adolescents.

• Iron and folate:

  • Assess intake carefully because low iron intake is common and folic acid is essential before conception and early in pregnancy.

• Protein:

  • Assess for inadequate intake and teach practical food choices including dairy, eggs, lean meats, legumes, peanut butter, and nuts.

• Nursing education:

  • Build nutrition knowledge, practical meal planning, food selection, and food preparation skills; promote prenatal care access and identify barriers to meaningful change.

• Individualized approach:

  • Respect the adolescent’s circumstances, resources, preferences, and concerns while reinforcing achievable, nutrient-dense choices.

• Postpartum considerations:

  • Provide guidance on healthy nutrition and physical activity for appropriate postpartum weight management.

Nutrition Teaching for Nausea and Vomiting

• Typical timing:

  • Nausea and vomiting are most common during the first trimester and are usually mild to moderate, although symptoms can interfere with adequate intake.

• Dry starchy foods:

  • Eat dry toast, melba toast, or crackers upon awakening and at other times when nausea occurs.

• Small, frequent meals:

  • Eat small portions every 2–3 hours; avoid large meals and do not skip meals or become excessively hungry.

• Bedtime snack:

  • Try cereal with milk, a small sandwich, or yogurt before bedtime.

• Other tolerated carbohydrates:

  • Toast, rice, and potatoes may be easier to tolerate than fried or fatty foods.

• Protein:

  • Some patients find small high-protein meals or snacks helpful; yogurt and nuts are chapter-supported protein foods.

• Fluids:

  • Avoid excessive fluid intake early in the day or during active nausea, but compensate by drinking enough fluids at other times.

• Reduce triggers:

  • Limit fried/fatty foods, spicy foods, strong cooking odors, and sudden movements; choose cool foods with little aroma and get out of bed slowly.

• Ginger:

  • The chapter suggests ginger ale, candied ginger, fresh ginger in tea, or ginger boiled in water.

• Herbal teas: Raspberry-leaf or peppermint tea may reduce nausea according to the chapter.

• Vitamin B6:

  • Vitamin B6 alone or a prescribed combination of vitamin B6 and doxylamine may be recommended by the health care provider.

• Other measures:

  • Fresh air, a well-ventilated environment, avoiding tooth brushing immediately after meals, and motion-sickness wristbands may help.

• When symptoms are concerning:

  • Severe persistent vomiting with weight loss, dehydration, or electrolyte abnormalities suggests hyperemesis gravidarum and requires further evaluation.

Nutrition Teaching for Constipation

• Why fiber helps:

  • Dietary fiber creates bulkier stool, stimulating intestinal peristalsis and supporting more regular bowel movements.

• Daily fiber goal:

  • 28 g/day during pregnancy.

• Food sources:

  • Bran

  • whole-wheat products

  • whole grains

  • popcorn

  • raw or lightly steamed vegetables

  • fruits

  • nuts

  • seeds

• Increase fluids:

  • Adequate water and other appropriate fluids hydrate the fiber and increase stool bulk

  • 8–12 cups of fluids daily

• Physical activity:

  • Walking, swimming, and water aerobics can stimulate bowel motility when appropriate for the patient.

• Iron-related constipation:

  • Iron supplements commonly worsen constipation

  • reinforce fiber and fluid intake while following the prescribed iron regimen.

Nutrition Teaching for Heartburn

• Meal size:

  • Choose small, frequent meals rather than two or three large meals that distend the stomach.

• Separate food and fluids:

  • Avoid consuming large amounts of fluid with meals; drink adequate fluids between meals instead.

• Food triggers:

  • Avoid spicy foods when they worsen symptoms.

• Positioning:

  • Do not lie down immediately after eating because this can worsen reflux.

• Clothing:

  • Avoid garments that fit tightly across the abdomen.

• Teaching principle:

  • Maintain adequate nutrition and hydration while modifying meal size, food triggers, fluid timing, and positioning.