References:
- Dr. RPS Maternal and Newborn Care: A Comprehensive Guide and Source Book for Teaching and Learning, 2nd Edition, ISBN 978-971-98-2265-3, by Rosalinda Parado Salustiano (Ch. 5, pp. 105–116)
Nutrition
Always start with the dietary history when giving nutritional instructions to the mother. A Nutritional Profile should contain: pre-pregnant and current nutritional status, dietary habits (food type, quality, schedule, amount, culture), and the mother’s knowledge of nutritional needs.
Pica
Pica is a craving for the consumption of items not culturally defined as food. It is a common psychobehavioral disorder manifested during pregnancy, and can displace nutritious foods, interfere with nutrient absorption, and cause anemia.
- Common cravings include coffee grounds, clay, dirt, chalk, baby powder*, ice, charcoal, ash, eggshells, feces, hair, string, cloth, paint chips, laundry starch, paper, pet food, pebbles, and soap. (Geddes, 2023).
- Treatment is often not necessary; the disorder tends to resolve by itself. In cases of lingering pica, coping mechanisms or behavioral therapy sessions might be recommended.
Poor nutritional status may manifest with anemia, dull hair, dry/scaly skin, pale/dull mucus membranes/conjunctiva, and being under- or overweight. Particularly, the following the factors require special attention:
- Primigravidity
- Low pre-pregnant weight (<90 lbs.)
- Obesity
- Low socioeconomic status/economic deprivation
- Pre-pregnant debilitating conditions
- Vegetarianism, lacking essential protein and minerals and may need B12 supplementation.
- Successive short-interval pregnancies
- Education: nutritional teaching focusing on affordable but nutritious foods.
Calories
- Non-pregnant: 1,800 to 2,200 Kcal/day.
- Pregnant: +300 Kcal/day; 2,100 to 2,500 Kcal/day
- Avoid empty (non-nutritious) calories, such as calories gained from soft-drinks.
Essential Nutrients
- Protein: +30 g/day; 74 to 76 g/day. Milk, meat, fish, poultry, eggs.
- Carbohydrates: sufficient intake for energy needs (see calories), while avoiding empty calories.
- Fiber: fruits, vegetables; prevents constipation.
- Fats: energy-dense foods for absorption of fat-soluble vitamins (ADEK). Avoid too much fat to prevent vomiting and heartburn.
Minerals and Vitamins
- Iron: most important mineral; supplemented. It aids in the required increase in maternal RBC (~30%) and fetal liver storage in the third trimester (8th month). Supplementation begins in the fourth month of pregnancy and continues to delivery. Iron supplementation is continued for 3 months after delivery.
- 18 mg/day (non-pregnant), and 30 to 60 mg/day (pregnant). Liver, read meats, green leafy vegetables, egg yolk, cereals, dried fruits, and nuts. If the pregnant client is anemia, a dosage of up to 120 mg/day may be suggested.
- Best absorbed in an acidic medium; take between meals and with Vitamin C-rich juice.
- Can contribute to constipation; adequate increase of fibers, fluid, and activity is also recommended.
- Darkened stool is normal.
- Calcium: needed for maternal calcium and phosphorus metabolism and fetal bone and skeletal growth (particularly in the 7th month).
- 1,200 mg/day, equivalent to 1 quart of milk a day (four glasses). Milk, milk products, and broccoli.
- Vitamin D improves calcium absorption and can be given in amounts of 600 IU/day.
- Sodium: the most abundant cation in extracellular fluid. It effectively dictates fluid retention. Most foods contain sodium, and is not restricted unless seriously indicated. It is required for fetal tissue growth and development.
- Folic Acid/Folate/Vitamin B9: important for blood product production, metabolic demands in pregnancy, proper development of the fetus. Deficiency can result in fetal anomalies, neural defects, brain and spinal cord abnormalities, and bleeding complications. Supplementation is ideally began even before the pregnancy, and is best observed during the first 28 days of gestation.
- Neural Tube Defects (NTDs) are birth defects of the brain, spine or spinal cord that happen in fetuses within the first month of pregnancy, often even before awareness of the pregnancy. The two most common forms of NTDs are spina bifida and anencephaly.
- 400–800 mcg/day (+100% requirement to prevent fetal malformations and neural tube defects). Liver, dark green leafy vegetables, avocados, papayas, and beans.
- More: legumes, asparagus, eggs, leafy greens, beets, citrus fruits, Brussels sprouts, broccoli, nuts and seeds, beef liver, wheat germ, papaya, bananas, avocado, and fortified grains. Fruits, green and leafy vegetables, nuts, and seeds, and fortified foods.
- Vitamins: water-soluble vitamins C and B and fat-soluble vitamins A, D, E, and K.
| Vitamin | Source |
|---|---|
| C | Citrus fruits and vegetables e.g. broccoli, bell peppers, and tomatoes |
| B Group | Legumes, beans, nutes, whole grain, oatmeal, pork, beef, fish, liver, organ meats, eggs, and green leafy vegetables |
| A | Milk and dairy products, dark green and dark yellow fruits and vegetables, eggs, and liver |
| D | Milk and foods fortified with vitamin D, egg yolk, fish |
| E | Nuts, seeds, wheat germ, whole grain products, green leafy vegetables, vegetable oils |
| K | Meats, liver, cheese, tomatoes, peaks, egg yolk |
| Food | Number of Servings |
|---|---|
| Milk and milk products | 1 quart (4 glasses) a day |
| Meat and meat products | 3 to 4 servings |
| Cereals/grain products | 4 to 5 servings |
| Fruit/fruit juices | 3 to 4 servings with at least one serving of vitamin C-rich fruit/juice |
| Vegetables/vegetable juices | 3 to 4 servings with at least one serving of dark green or yellow vegetable |
| Fluids | 4 to 6 glasses of water plus other fluids to equal 8 to 10 cups/day |
The WHO also suggests two priority antenatal nutrition recommendations: Multiple Micronutrient Supplements (MMS, often contains 30 mg; 60 mg if anemia is a severe public health problem) and Vitamin D supplements during pregnancy.
Bath and Clothing
A daily bath can be taken if desired, but soap should not be used for cleaning the nipples; they produce a drying effect. The nipples should be dried with a towel to increase their toughness/integrity.
- Tub baths should only be done with care and anti-slip precautions (nonskid rubber mat). The risk of falls is great with the loss of balance in pregnancy.
- Douching, especially for leukorrhea associated with elevated estrogen levels, is not necessary. A daily bath should suffice.
Clothing should be comfortable and loose; not constricting especially around the breasts, abdomen, or legs. Round garters should not be used.
- Flat-heeled shoes help maintain balance and comfort.
- Supportive hip-high panty hose is used to manage varicosities.
- Supportive, cotton-lined brassieres may be used.
- Maternity girdle can be used as necessary.
Sleep and Rest
- Assess activities to identify the need for rest and sleep.
- The average number of hours of sleep is 8. 1 to 2 hours of afternoon nap may be required. In the second half of pregnancy onwards, sleeping supine should be advised against.
- Plan rest times during the day.
- At work, get to stand and walk for a few minutes at least once every 2 hours (if the task requires prolonged sitting, there should be time to walk about and sit in intervals)
Traveling
- Long distance travelling should provide stopovers so pregnant women can get out of the car and walk. Seatbelts are needed.
- Air travel before the 36th week of pregnancy is considered safe, but with prior checking with the health care provider. Some flights require a medical certificate indicating fitness to travel by air.
- The best time for travel is the second trimester, when the woman feels most comfortable, with the least risk for abortion and premature labor.
- Aisle seating in various forms of transportation is ideal.
- Journeys when close to term is discouraged.
Exercises
- Generally, low-impact and moderate intensity exercises are done. These commonly include walking progressing to jogging, stationary cycling, routine swimming, and yoga.
- Cleansing breathing: deep, relaxed breathing (i.e., a sigh). Can be practiced in pregnancy and used in labor to signal the beginning of uterine contractions.
- Pelvic Rock: highly important for comfort, this exercise increases the flexibility of the lower back, strengthens the abdominal muscles, shifts the center of gravity back to the uterine spine, and relieves backache and improves posture and appearance in late pregnancy.
- Squatting or Tailor-sitting: strengthens the perineal muscles, making pelvic joints more pliable.
- Abdominal Breathing: primarily utilizing the diaphragm to breath rather than the chest muscles, helpful during the first half of labor. With total relaxation, it can carry women through most of the first stage.
- Kegel: improves the tone of pubococcygeal, perineal, vaginal, and pelvic flor muscles needed for pregnancy, labor, and delivery, in uterine prolapse, cystocele, and rectocele; this can be done hourly.
- Panting: best for the crowning period, leaving the work to be accomplished by the uterus. Only by panting can the mother avoid pushing in the transition phase of labor; pushing should be in the second stage of labor except during crowning.
Remember to avoid dehydration, fatigue, contact sports and , high-impact and high-intensity or excessive/strenuous exercises. Maternal exercises do not need to be limited as long as usual and customary and does not cause fatigue. Exercises reduce the rates of emergent cesarean section rate and length of hospitalization. Exercises should be stopped if danger signs are present: dizziness, headache, overheating, fast and unsteady heart rate, difficulty breathing, and nausea; seek emergency management if vaginal bleeding, uterine contractions, abdominal or pelvic pain, or chest pain occurs.
Marital Relations and Coitus
The gravid woman loses interest in sexual intercourse during the first trimester due to fatigue, nausea, or adaptation to pregnancy; and the third trimester due to discomforts of pregnancy. The second trimester may feature regained interest in sex as it is the most comfortable period of pregnancy.
Generally, no restricts are placed except in the presence of premature rupture of membranes (PROM), premature labor, history of abortion and bleeding, deep engagement of the head in late pregnancy, and an incompetent cervix. In healthy pregnant women, sexual intercourse does not usually cause harm. Avoid fatigue, exercise moderation. It is suggested to take on side-lying and woman-on-top positions.
Employment
Work may continue, provided it does not pose hazards to the health of the mother and fetus. Safety and rest are the two most important considerations in deciding whether or not the pregnant woman should stop working.
- The mother should be able to walk every few hours to improve blood circulation, regardless of sitting or standing during work.
- Adequate rest periods should be provided.
- Previous conditions, which are likely to be repetitive (e.g., SGA, premature labor, abortions) should minimize physical work.
- Maternity leave: R.A. 7322 amended by R.A. 11210, the Expanded Maternity Leave Act.
| Republic Act 7322 | Republic Act 11210 |
|---|---|
| 60 days of maternal leave for NSD and 78 days for CS 15 days of paternity leave | 105 days paid leave between prenatal and postnatal leave, at least 60 days of which should be for the postnatal period. + 15 days for parents qualifying as a solo parent under R.A. 8972 + Optional additional 30 days of unpaid leave. |
| For the first four pregnancies only | No limit on applicable pregnancies regardless of mode of delivery |
| In case of an emergency termination or miscarriage, 60 days of unpaid leave is provided. |
Oral Hygiene
The teeth and gums should be regularly examined as part of the prenatal general physical examination. Dental caries require prompt management in pregnancy, but major dental surgeries should be postponed for the postpartal period.
- Due to estrogen’s effect on vascularity, the gums of pregnant women are painful and swollen. Instruct them on the use of a soft-bristled toothbrush and gentle brushing.
- The concept that dental caries are aggravated by pregnancy is not supported by literature; there is no tooth loss secondary to pregnancy.
SAD Habits
- Smoking: should absolutely avoided, whether cigarettes or electronic cigarettes. This also applies to secondhand smoke.
- Smoking is a risk factor for SGA, prematurity, infant mortality, spontaneous abortion, placenta previa, abruption placenta, and premature rupture of membranes. It also causes learning and attention problems in children.
- This is caused by the vasodilator effect of nicotine on the body, reducing placental perfusion. Carbon monoxide binds to hemoglobin, inactivating maternal and fetal hemoglobin. Smokers also have decreased plasma volume and reduced appetite.
Caffeine
Caffeine also produces vasoconstriction, and is worse when combined with alcohol. The WHO recommends a caffeine limitation of 300 mg per day, nor more than 2 to 3 servings.
- Alcohol: alcohol ingestion is likely to cause fetal abnormalities. It is the leading known teratogen in the west. There is no safe amount of alcohol in pregnancy.
- Alcohol also produces pronounced learning and attention problems, more consistently than smoking does.
- Fetal alcohol syndrome (FAS) occurs at a rate of 10% of births with heavy use of alcohol (2 or more drinks per day). FAS is characterized by: retardation (cognitive, motor, attention, learning), microcephaly, seizure disorders, craniofacial defects (“FAS facies”; flat midface, wide nasal bridge, thin upper lip), cardiovascular defects, limb defects, and impaired fine and gross motor function.
- Drugs should only be taken if prescribed by their physician. Risks should never outweigh the benefits of taking drugs. Illicit drugs can result in the most adverse fetal malformations in the first trimester, as (1) the placental barrier is not yet fully developed until the 10th to 12th week of gestation, and (2) rapid organogenesis occurs within the first two months of pregnancy.
- “Hard drugs” may cause growth retardation and drug withdrawal, which are associated with increased neonatal mortality. The most common harmful effect of heroin on neonates is withdrawal or neonatal abstinence syndrome, giving rise to a group of signs that include sneezing, irritability, vomiting and diarrhea, and seizures.
- The use of illegal drugs also come with the risk of acquiring HIV and other STDs because women may trade sex for drugs, or provide sexual favors for the money to acquire drugs.
- Herbal drugs are not always safe. As a general rule, they must be approved and supervised by the health care provider.