Maternal Nutrition

Unit-I
Shabnam
Faculty of Nursing Sciences KMU
 Nutrition during pregnancy
• Maternal diet and nutritional status have a direct impact on the
course of pregnancy and its outcome.

• Malnutrition that occurs in the early months of pregnancy

affects development and the capacity of the embryo to survive
whilst poor nutrition in the latter part of pregnancy affects fetal
growth.
1- Altered Metabolism:
• Increase the basal metabolic rate: by the fourth month of
gestation and rises to 15 - 20% above normal by term.

• Altered the metabolism of nutrients: fat becomes the major

source of maternal fuel, making glucose available for the fetus.
 Pregnancy physiology that
alters nutritional needs
2- Gastrointestinal Changes:
• Slow gastrointestinal motility: an advantage of slowed motility
is that nutrient absorption increases.
• Nausea and vomiting are common in the first trimester and
may be related to hypoglycemia, decreased gastric motility,
relaxation of the cardiac sphincter, or anxiety.
• Increases in appetite and thirst are also common.
• Heartburn and constipation: due to slow motility or
enlarging uterus..
 Pregnancy physiology that
alters nutritional needs
3- Blood Volume Changes:
• Increase total body water throughout pregnancy.
• Hemodilution or a physiologic anemia of pregnancy: due
to the increase in blood volume.
• Minor edema: may be considered normal if it is not
accompanied by hypertension and proteinuria.
4- Ideal Weight Gain:
• The average weight gain is about 25 to 30 lb (11.5 kg to
14.0 kg).
• Weight gain during pregnancy consists of the weight of
the fetus and associated fetal tissues (e.g. placenta),
plus the weight increases in maternal tissue.
 Pregnancy physiology that
alters nutritional needs

4- Ideal Weight Gain:

• Recommendations for weight gain are
divided into three categories based on the
woman’s pre-pregnancy weight. The
weight category is determined using body
mass index (BMI).
• The range for women carrying twins is 35
lb to 45 lb (16 - 20 kg).
 Distribution of weight gain in pregnancy
Body Part Weight (kg)

Full term baby 3.42

Placenta 0.62 Fetal

Amniotic and body fluids 0.80 Tissue

Uterus 0.89

Breasts 0.40

Blood volume 1.78 Maternal

Interstitial body fluids 1.20 Tissue

Maternal storage fat 0.66 – 3.18

Total 10.71 – 12.5

 Recommended total weight gain ranges for pregnant
women*
Pre-pregnancy Recommended Total Gain
Weight-for-Height
Category (lb) (kg)

Low (BMI < 19.8) 28 - 40 12.5 - 18.0

Normal (BMI 19.8 - 26.0) 25 - 35 11.5 - 16.0

High (BMI >26 - 29) 15 - 25 7.0 - 11.5

Obese (BMI > 29)  15 7

 Nutrient requirements during pregnancy
• Actual requirements during pregnancy are influenced by
previous nutritional status and health history, including:
chronic illnesses, multiple pregnancies and closely spaced
pregnancies.
• The requirement for one nutrient may be altered by the intake
of another. E.g., women who do not meet their calorie
requirements need higher amounts of protein.
• Nutrient needs are not constant throughout the course of
pregnancy - nutrient needs change little during the first
trimester and are at their highest during the last trimester.

• The Food Guide Pyramid can be used to teach women how

to make food choices that will provide the balanced intake
they need.
 Calories
• The increased need for calories is 300 extra calories per
day, which is @ 15% of a woman’s normal calorie
requirement.
• The increased need for calories does not occur until the
beginning of the second trimester.
Calorie needs increase because of:
• The increase in basal metabolic rate.
• Weight gain increases the amount of calories burned during
activity.
• Uses additional calories to store energy in preparation for
lactation after delivery.
 Energy Requirement During
Pregnancy
• Additional energy is required during
pregnancy.
• Additional 300 Kcal is required
Group Energy Requirement (Kcal)

Sedentary 1875 + 300 = 2175

worker
Moderate 2225 + 300 = 2525
worker
Heavy worker 2925 + 300 = 3225
 Protein

The RDA for protein increases by 10 g for

pregnant women ages 25 and older.

Protein needs increase to support :

• Fetal growth and development.
• The formation of the placenta and amniotic
fluid.
• The growth of maternal tissues and the
expanded blood volume.
 Protein

Women who fail to consume adequate

protein may be at increased risk for:
• Development of toxemia.
• Anemia.
• Poor uterine muscle tone.
• Abortion.
• Decreased resistance to infection.
• Shorter, lighter infants with low Apgar
scores.
 Folic acid
• The Institute of Medicine in U.S.A. recommends that synthetic
folic acid intake increase to 600 g daily once pregnancy is
confirmed.
Importance of folic acid for pregnancy:
• Women who consume adequate amounts of folic acid before
conception and throughout the first month of pregnancy
reduce their risk of having a baby with a neural tube defect
(e.g., spina bifida, anencephaly).
Importance of folic acid for pregnancy:
• Women who consume adequate amounts of folic acid before
conception and throughout the first month of pregnancy
reduce their risk of having a baby with a neural tube defect
(e.g., spina bifida, anencephaly).
 Folic acid
Folic acid sources:
• Natural form of folic acid (folate): orange
juice, other citrus fruits and juices, green
leafy vegetables, dried peas and beans,
broccoli, and whole-grain products.

• Synthetic folic acid is found in

multivitamins, fortified breakfast cereals
and enriched grain products.
 Other B vitamins

• The increased requirement for vitamin B6

is proportional to the increase in protein
because it is involved in protein
metabolism.

• Because vitamin B12 is necessary for the

metabolism of folate, a slight increase in
intake is recommended.
 Calcium

• The AI for calcium for pregnant women 19

years of age and older is 1000 mg.

• The reason why the AI is not higher for

pregnant women compared with non
pregnant women is that calcium
absorption more than doubles early in
pregnancy.
 Iron

• A daily supplement of 30 mg of ferrous

iron is recommended for all women during
the second and third trimesters.

• It is preferably taken between meals or at

bedtime on an empty stomach to
maximize absorption.
 Iron

Importance for iron during pregnancy:

• To support the increase in maternal blood
volume.
• To provide iron for fetal liver storage,
which will sustain the infant for the first 4 -
6 months of life.
 The advices should be given to a pregnant women
concerning her nutrition
1- Eat in moderation.
2- Aim for balance.
3- Eat three meals daily plus two or three snacks.
4- Drink adequate fluids.
5- Do not restrict salt intake.
6- Moderate Caffeine consumption does
not pose a problem.
7- If you use artificial sweeteners, do so
judiciously.
8- Be aware of food borne risks during pregnancy.
 Daily food guide for pregnancy and breastfeeding
Pregnancy
Food Group Adult Woman Adolescent Breastfeeding
Woman
Milk, Yogurt, 3 - 4 servings 4 - 5 serving 4 - 5 servings
Cheese
Meat and Meat 5 - 6 oz 6 - 7 oz 6 - 7 oz
substitutes
Fruits 2 - 4 servings 2 - 4 servings 2 - 4 servings
Vitamin C-rich 1 - 2 servings 1 - 2 servings 2 servings
Vegetables 3 - 5 servings 3 - 5 servings 3 - 5 servings
Vitamin A-rich 1 serving 1 serving 1 serving
Breads, Cereals, 6 -11 servings 6 - 11 servings 6 - 11 servings
Rice, Pasta
Fats, Oils, To meet caloric To meet caloric To meet caloric
Sweets needs needs needs
 Indications for supplements
use during pregnancy
• Drug abusers.
• Those carrying twins.
• Women who are unlikely to consume an
adequate diet despite nutritional advice or
nutrition counseling.
 Weight Gain During Pregnancy

• It is natural and necessary to gain weight

during pregnancy as uterus, placenta, breast,
blood volume, body fluids and fat increases.
• Average weight gain is 25—35 lbs
• Teen pregnant gains more weight than a
mature woman.
 Recommended Weight Gain
S.No BMI Weight (kg) BMI Value Weight Gain (kg) Weight Gain (lbs)
Height (m2)

1 Underweight BMI < 18.5 12.7-18 28-40

2 Normal Weight BMI 19-24.9 11.3-15.8 25-35

3 Overweight BMI 25-29.9 6.8-11.3 15-25

4 Obese BMI > 30.0 5-9 11-20

 Conti…
The IOM guidelines for pregnancy weight gain
when a woman is having twins are as follows:

S.No BMI Weight (kg) Weight Gain (kg) Weight Gain (lbs)
Height (m2)
1 Underweight 22.6 kg to 28.1 kg 50 to 62 lbs

2 Normal weight 16.7 to 24.5 kg 37 to 54 lbs

3 Overweight 14 to 22.6 kg 31 to 50 lbs

4 Obese 11.3 to 19 kg 25 to 42 lbs

 Indications for supplements
use during pregnancy

• Women who do not receive adequate

exposure to sunlight.
• Women who do not consume adequate
calcium.
 Nutritional intervention for
problems during pregnancy
1- Nausea and Vomiting
Women should be advised to:
• Eating small, frequent meals every 2 to 3
hours.
• Eat carbohydrate foods such as: dry
cereal, or hard candy before getting out of
bed in the morning.
 Nutritional intervention for
problems during pregnancy
1- Nausea and Vomiting

Women should be advised to:

• Avoid drinking liquids with meals.
• Avoid coffee, tea and spicy foods.
• Limit high-fat foods, because they delay
gastric emptying time.
• Eliminate individual intolerances.
 Nutritional intervention for
problems during pregnancy
2.Constipation, may be caused by:
• Relaxation of gastrointestinal muscle tone
and motility
• Pressure of the fetus on the intestines.
• Decrease in physical activity
• Inadequate intake of fluid and fiber.
• Side effect of the consumption of iron
supplements.
 Nutritional intervention for
problems during pregnancy
2. Constipation
Encourage the client to:
• Increase fiber intake.
• Drink at least eight 8-ounce glasses of
liquid daily.
• Try hot water with lemon or prune juice
upon waking to help stimulate peristalsis
• Participate in regular exercise.
 Nutritional intervention for
problems during pregnancy
3- Heartburn:
Encourage client to:
• Eat small, frequent meals and eliminate
liquids immediately before and after meals to
avoid gastric distention.
• Avoid coffee, high-fat foods and spices.
• Eliminate individual intolerances.
• Avoid lying down or bending over after
eating.
 Nutritional intervention for
problems during pregnancy

4- Inadequate Weight Gain:

• Inadequate weight gain during pregnancy
increases the risk of giving birth to a low-
birth-weight (LBW) infant (i.e., a baby
weighing less than 2500 g).
 Nutritional intervention for
problems during pregnancy

4- Inadequate Weight Gain:

• The recommended weight gain for normal
weight women is @ 0.44 kg/week,
• Underweight women more than 0.44
kg/week whilst overweight women about
0.29 kg/week and women pregnant with
twins at least 0.44 kg/week.
 Nutritional intervention for
problems during pregnancy

4- Inadequate Weight Gain, may occur

secondary to:
• Poor appetite related to nausea, vomiting,
heartburn or smoking.
• From an inadequate intake related to lack
of knowledge or fear of gaining weight.
 Nutritional intervention for
problems during pregnancy

4- Inadequate Weight Gain

• Encourage the client to ask questions and
verbalize feelings.

• Advise the client that extra weight gained

during pregnancy is quickly lost during
lactation or through dieting after pregnancy.
 Nutritional intervention for
problems during pregnancy
4- Inadequate Weight Gain
• Advise the client that if her diet is inadequate
in calories, it probably inadequate in other
nutrients.
• Advise the client that although the fetus can
use maternal nutrient stores if the mother’s
diet is inadequate.
 Nutritional intervention for
problems during pregnancy

4- Inadequate Weight Gain

• Advise the client that an inadequate intake
can adversely affect maternal health (e.g.,
poor iron intake leading to anemia) and infant
health (e.g., lbw, anemia, other postnatal
complications).
 Nutritional intervention for
problems during pregnancy

5- Excessive Weight Gain, may be related

to:
• Overeating.
• Stress.
• Decrease in physical activity.
 Nutritional intervention for
problems during pregnancy

5- Excessive Weight Gain:

• Counsel the client on the recommended rate
and quantity of weight gain associated with
optimal maternal and infant health and
successful breast-feeding.

• Explain that the weight gain is distributed

among the fetus, placenta and maternal
tissues.
 Nutritional intervention for
problems during pregnancy

5- Excessive Weight Gain:

• Set mutually agreeable weight gain goals.

• Substitute skim or low-fat milk for whole milk.

• Bake, broil or steam foods instead of frying.

 Nutritional intervention for
problems during pregnancy

5- Excessive Weight Gain:

• Eliminate empty calories: carbonated
beverages, candy, rich desserts and
traditional snack foods.

• Use fats and oils sparingly.

Nutritional interventions for medical
complications during pregnancy
Diabetes mellitus
• It characterized by abnormal glucose
tolerance, requires dietary management
regardless of whether it was present
before conception (established diabetes)
or developed during gestation (gestational
diabetes) as a result of the metabolic
changes of pregnancy.
Nutritional interventions for medical
complications during pregnancy
Diabetes increases the risk of:
• Infection, especially urinary tract infection
• Preeclampsia & Eclampsia
• Spontaneous abortion
• Extrauterine conception
• Neonatal death
• Congenital abnormalities
Nutritional interventions for medical
complications during pregnancy
Diabetes
• Gestational diabetes does not usually
produce maternal complications or birth
defects, but it can make delivery difficult,
because babies born to gestational
diabetics are usually large, which may
increase the risk of postpartum
hemorrhage.
Nutritional interventions for medical
complications during pregnancy

Diabetes Management:
• Monitor the progress and course of
pregnancy of established diabetics.
• Screen all women for gestational diabetes
between 24 - 28 weeks of pregnancy.
• Check for ketonuria regularly.
• Diabetic management during pregnancy
includes nutrition therapy and, possible,
multiple daily doses of insulin.
Nutritional interventions for medical
complications during pregnancy
Diabetes
Advise the client that:
• Pregnant diabetics require the same
nutrients and weight gain as non diabetic
pregnant women.
• She is not on a “diet” weight loss and
fasting should never be undertaken during
pregnancy.
• Calorie requirements are based on pre-
pregnancy weight.
Nutritional interventions for medical
complications during pregnancy
Diabetes
Suggested guidelines are as follows:
• 30 cal/kg for women of normal weight
before conception.
• 24 cal/kg for women weighing more than
120% of desirable weight before
conception
• 36-40 cal/kg for women weighing less than
90% of desirable weight before
conception.
Nutritional interventions for medical
complications during pregnancy
2- Anemia
• Non pregnant women (non smokers) who
have a hemoglobin below 12 g/dL are
considered anemic.
• Pregnant women (non smoker) with a
hemoglobin below 11 g/dL in the first and
third trimesters or below 10.5 g/dL in the
second trimester are considered anemic.
Nutritional interventions for medical
complications during pregnancy
2- Anemia Management:
• A therapeutic dose of 60 mg to 120
mg/day of elemental iron is prescribed.
• In addition, a low-dose vitamin/mineral
supplement is prescribed to ensure
adequate amounts of copper and zinc.
Nutritional interventions for medical
complications during pregnancy
2- ANEMIA
• The RDA of 400 mcg of folate during
pregnancy can be met by a well-chosen
diet. Supplements of folate are
recommended for pregnant women who
are not meeting this level of intake.
Nutritional interventions for medical
complications during pregnancy
Pregnancy-induced hypertension:
• Pregnancy–induced hypertension (PIH or
toxemia) is a hypertensive syndrome that
occurs in approximately 6 - 7% of all
pregnancies. Severe cases are
associated with increased risks of
maternal, fetal and neonatal death.

• Although the exact cause is unknown.

Nutritional interventions for medical
complications during pregnancy
Risk factors for pregnancy-induced
hypertension:
• Poorly nourished.
• Primigravida.
• Economically deprived.
• Very young or very old.
• Obese.
• Underweight.
 Nutritional interventions for
medical complications during
pregnancy
Pregnancy-induced hypertension:
• Advise clients at risk for pre- eclampsia to
consume a liberal intake of calories, protein
and calcium and to salt their food to taste.
 Risk factors for poor nutritional status
during pregnancy
 Prepartum weight < 85% or > 120% of ideal weight
 Use of a therapeutic diet for a chronic disease
 Use of alcohol, tobacco, or drugs
 Food faddism, unbalanced diet, pica
 Teens and women older than 40 years of age
 Poor obstetric history (LBW, stillbirth, abortion, fetal
anomalies), high parity, multipara
 Repetitive pregnancies at short intervals
 Low socioeconomic status
 Chronic preexisting medical problems, such as hypertension,
diabetes, heart disease, pulmonary disease, renal disease
 Untimely prenatal care
 Lactation

• Because of the unquestionable benefits to

both mother and infant, exclusive breast-
feeding for the first 4 - 6 months of age is
recommended for most full-term infants.

• Breast-feeding with weaning to foods is

recommended for at least the first 12
months of age.
 Benefits of breast feeding

For the mother:

• Promotes optimal maternal-infant bonding.
• Can mobilize fat stores to help women lose
weight.
• Early breast-feeding stimulates uterine
contractions to help control blood loss and
regain pre pregnant size.
• Breast milk is readily available and requires
no mixing or dilution.
 Benefits of breast feeding

For the mother:

• Is less expensive than purchasing bottles,
nipples, sterilizing equipment and formula.
• May decrease the risk of thromboembolism,
especially after operative deliveries.
• Childbirth and breast-feeding may be
protective against breast cancer.
 Benefits of breast feeding
For the infant:
• Breast milk is unique in its types and
concentrations of macronutrients,
micronutrients, enzymes, hormones,
growth factors, inducers/modulators of the
immune system and anti-inflammatory
agents.
 Benefits of breast feeding

For the infant:

• The infant can easily tolerate and digest
and it changes to match the needs of a
growing infant.
• Is a “natural” food.
• Sterile, is at the proper temperature and is
readily available.
 Benefits of breast feeding

For the infant:

• Breast-feeding promotes better tooth and
jaw development than bottle-feeding
because the infant has to suck harder.
• Breast-feeding avoids nursing-bottle caries.
• Breast-feeding is protective against food
allergies.
 Benefits of breast feeding

For the infant:

• Overfeeding is not likely with breast-
feeding.
• Breast-feeding is associated with
decreased frequency of certain chronic
diseases later in life, such as non-insulin-
dependent diabetes mellitus & lymphoma.
 Variables affecting breast milk
composition

• Stage of lactation.
• The mother’s diet.
• The duration of the feeding.
 Variables affecting breast milk
composition
Stage of lactation:
• Colostrum, which is secreted during the first
few post-partum days, is a thick, yellowish
fluid that is higher in protein, minerals and
sodium than mature milk, but lower in sugar,
fat and calories.

• Colostrum is rich in antibodies and anti-

infective factors.
 Variables affecting breast milk
composition
Stage of lactation:
• Colostrum begins to change to transitional
milk about 3 to 6 days after delivery as the
protein content decreases and the
carbohydrate and fat contents increase.

• Major changes in the milk take place by the

tenth day and mature milk is stable by the
end of the first month.
 Variables affecting breast milk
composition

The mother’s diet:

• The vitamin content of breast milk declines
as a result of inadequate maternal intake,
especially B6, B12, A and D.
 Variables affecting breast milk
composition

The duration of the feeding:

• The milk secreted as each feeding begins
is significantly lower in fat than the milk
secreted at the end of each feeding.
Nutritional needs for lactation

Calories:
• The average woman uses approximately
640 cal/day for the first 6 months and 510
cal/day during the second 6 months to
produce a normal amount of milk.
Nutritional needs for lactation

Protein
• Women need an additional 20 g of
protein while breast-feeding. Extra 2 cups
of milk provide 16 g of protein.
Nutritional needs for lactation

Fluid
• It is suggested that nursing mothers drink
2 to 3 liters of fluid daily, preferably in
the form of water, milk and fruit juices.
Nutritional needs for lactation

Vitamins and minerals:

• Foods, rather than supplements, are the
preferred source of these nutrients,
• women are encouraged to choose a varied
diet that includes enriched and fortified
grains and cereals, fresh fruits and
vegetables and lean meats and dairy
products.
Nutritional needs for lactation

Vitamins and minerals:

• Multivitamin and mineral supplements are not
recommended for routine use. However,
specific supplements may be indicated when
maternal intake is inadequate.
Nutritional needs for lactation

Foods to avoid:
• Caffeine: consumption of one to two cups of
coffee daily does not pose any problems.
Intakes higher than this may cause the infant
to become irritable and restless.
• It usually is not necessary to eliminate any
other foods while breast-feeding unless the
infant shows intolerance.
 Factors that impair lactation
Impaired letdown, related to
 Embarrassment or stress
 Fatigue
 Negative attitude, lack of desire, lack of family support
 Excessive intake of caffeine or alcohol
 Drugs
Failure to establish lactation, related to
 Delayed or infrequent feedings
 Weak infant sucking because of anesthesia during labor and delivery
 Nipple discomfort or engorgement
 Lack of support, especially from baby’s father
Decreased demand, related to
 Supplemental bottles of formula or water
 Introduction of solid food
 The infant’s lack of interest
 Lactation in the diabetic mother
• Breast-feeding complicates blood glucose
control in women with type 1 diabetes by
inducing hypoglycemia and lowering insulin
requirements.

• 35 cal/kg is usually recommended to

achieve optimal glucose and lipid levels
and promote moderate weight loss (4.5
pounds/month).
 Lactation in the diabetic mother

Other points to consider include:

• Careful and frequent monitoring of blood
glucose level is essential.
• Frequent snacks are recommended.
• Unless breast-feeding occurs within 1 to 2
hours after eating, women should eat a
light snack before or during breast-feeding.
 Lactation in the diabetic mother

Other points to consider include:

• Support groups may be especially helpful.
• Encourage participation in appropriate
programs that provide support and education.