Maternity - Pregnancy, part 4: Maternal Teaching: Nutrition/Weight Gain, Warning Signs, Unpleasant Side Effects
by Meris Shuwarger BSN, RN, CEN, TCRN August 30, 2021 Updated: June 16, 2022 11 min read
In this article, we cover maternal teaching on nutrition, weight gain, calorie intake, what to avoid, warning signs, and unpleasant side effects. These are the topics that nurses need to be able to teach pregnant patients about.
During pregnancy, certain macronutrients and vitamins are required to sustain the health of the patient and their baby. This includes folic acid, protein, iron, calcium, vitamin D, and fluids.
Pregnant patients should increase folic acid to 600 mcg per day. Folic acid prevents neural tube defects. Read more on folic acid.
Protein promotes tissue growth and helps build muscle (e.g., the tissue and muscles of the baby!). Pregnant patients should increase their protein intake to 60 g per day.
However, patients who have phenylketonuria (PKU) need to follow a strict low-phenylalanine (low-protein) diet and have phenylalanine levels monitored through pregnancy.
Pregnant patients should increase their iron intake to 27 mg per day. Iron helps with production of red blood cells to supply oxygen to the fetus. Patients can take an iron supplement (ferrous sulfate) with vitamin C to increase absorption.
Calcium helps formation of fetal bones and teeth; pregnant patients should increase intake of calcium to 1,000 mg per day.
Vitamin D promotes the absorption of calcium. Patients who are pregnant should increase their vitamin D intake to 600 IU per day.
Patients should get 2 - 3 L of water per day.
Underweight patients should aim to gain between 28 - 40 pounds. For patients of average weight, 25 - 35 pounds, and for overweight patients, 15 - 25 pounds.
Weight gain is more rapid in the beginning of the pregnancy. In the first trimester, patients should gain 2.2 - 4.4 pounds a week. In the second and third trimesters, patients should gain approximately 1 pound a week.
During the first trimester, pregnant patients should not increase calorie intake. During the second trimester, patients should increase calorie intake by around 340 per day. During the third trimester, patients should increase calorie intake by 450 per day. After delivery when the patient is breastfeeding, they should have a calorie intake that is increased by approximately 450 - 500 per day. These amounts are not cumulative, and the increase is calculated over the patient's baseline caloric intake. For example, if a patient normally consumes 2000 calories a day, according to these guidelines they would consume:
- Pre-pregnancy, the example patient consumes 2000 calories a day.
- First trimester: 2000 calories.
- Second trimester: 2340 calories.
- Third trimester: 2450 calories.
- Breastfeeding: 2450-2500 calories.
What to avoid during pregnancy
During pregnancy, patients should avoid taking medications and supplements unless their provider is aware and confirms the drugs to be safe during pregnancy. Check out our Pharmacology Flashcards for black box warnings on drugs during pregnancy.
Pregnant patients should limit caffeine intake to under 200mg per day. Patients should also avoid fish high in mercury, e.g., albacore tuna—limit to less than 6 ounces a week.
As you probably already know, patients who are pregnant should avoid alcohol, drugs, and smoking. Pregnant patients should also avoid hot tubs/saunas as they can be too hot.
Warning signs during pregnancy
There are some warning signs to watch out for during pregnancy. Patients who experience any of these should contact their provider right away:
- Diarrhea, fever, chills
- Severe abdominal cramping/pain
- Severe vomiting
- Vaginal bleeding
- Decreased fetal activity
Unpleasant side effects of pregnancy
Pregnant patients should be given teaching on the potentially unpleasant side effects they may encounter during pregnancy. Not all patients experience these, but it is good for patients to be aware that they may happen. These include congestion, constipation, epistaxis, fatigue, gingivitis, heartburn, hemorrhoids, nausea/vomiting, urinary frequency, varicose veins, and more.
Read on to find out more about these side effects and what can be done to mitigate them.
Patients may become congested during pregnancy. If so, they can try a normal saline spray. Certain antihistamines are appropriate for pregnancy, e.g., Zyrtec.
Patients might become constipated during pregnancy. To help combat this, they can increase their fluid and fiber intake.
Epistaxis is a fancy word for a nosebleed, and pregnant patients may get them. To help with this, they can use a humidifier if that's an option available to them.
Patients who are pregnant may become fatigued—creating a person can be exhausting! Patients should take frequent rest periods or naps to help combat fatigue.
Pregnant patients may get gingivitis (gum disease). To help combat this, patients should practice good dental hygiene, brush with a soft toothbrush, and floss daily.
Patients who are pregnant may get heartburn after eating. To help reduce this, patients can eat small and frequent meals, avoid laying down after meals, and avoid spicy or greasy foods which may exacerbate it.
Patients who are pregnant may get hemorrhoids, which are swollen veins on the anus or rectum. They can be painful and cause bleeding during bowel movements. Patients can take a warm sitz bath (which is sitting in shallow warm water in the tub), and use witch hazel pads as an antiseptic. Patients should avoid straining during bowel movements.
Patients may experience morning sickness, which is nausea and vomiting, that—surprise!—doesn't always happen in the morning. Patients can try eating some crackers to help settle the stomach before getting out of bed, eat small/frequent meals, and bland foods which may be easier to keep down.
Patients who are pregnant have extra pressure on their bladder and so may need to urinate frequently. These patients should pee often, and practice kegel exercise to help decrease stress incontinence.
Pregnant patients may get varicose veins, which are enlarged and twisted veins that become swollen. To help prevent varicose veins, patients can elevate legs, wear compression socks/stockings, walk often, and avoid prolonged standing.
Other unpleasant side effects of pregnancy
Other unpleasant side effects of pregnancy may include backaches because of new weight distribution, breast tenderness, cramps, and edema (swelling).
Hi, I'm Meris, and in this video, I'm going to be talking to you about different education we need to provide to a pregnant patient during their pregnancy. Things such as nutritional guidance, weight gain, warning signs of complications, and other things along those lines. So if you're ready, I would invite you to go ahead and follow along using our Maternity Flashcards. If you don't have a set for yourself yet, these are available on our website leveluprn.com.
All right. Let's get started. So first up, we're going to be talking about nutritional guidance for pregnant patients. And if you look here on the card, you can see that there is a lot of bold red text because there's a lot of really important stuff that you need to teach your patients about. The three big things that I think of when I think of nutritional teaching for a pregnant patient is going to be folic acid, iron, and protein. These are really important for pregnancy for a bunch of different reasons. But those are the ones that we provide really specific and direct teaching to our patients. So on here, you'll see that we have under folic acid, that a pregnant patient needs to increase their intake of folic acid to 600 micrograms per day. This is so incredibly important because it helps to prevent neural tube defects. So remember that when that embryo is forming, it forms around a tube, the neural tube. And if the patient doesn't have enough folic acid, there can be a defect in this tube which can lead to birth defects and even death in some cases. So very important teaching. Now, protein, why does protein matter? Well, remember that protein is the building blocks of life. So literally when we are building new life, we need to have more protein. So here we have 60 grams per day. That's going to be an important number to know as well. And then iron. Remember that during pregnancy, a patient's blood volume increases significantly and we need to have enough iron in the body to make enough hemoglobin to transport the oxygen in this larger volume of blood. So on here, we have that iron should be increased to 27 milligrams per day. And you'll see that a lot of your patients will actually start taking an iron supplement. The best teaching for anybody taking an iron supplement is to take it with vitamin C, such as orange juice or eating citrus fruit or even just taking vitamin C supplements to increase the absorption of that iron. So very important stuff here. Now, we also do have here that a patient who has Phenylketonuria, PKU, this patient needs to follow a strict low protein diet because of the presence of something called phenylalanine. So that is the one time that we would not encourage our patient to follow a high protein diet.
Moving on to maternal teaching for weight gain and calorie intake, you'll see here that we have a lot of bold red tags. And I'm saying this frequently, but it's because there's some really important stuff in these cards. This in particular, a lot of maternity is, what are you going to teach your patients? So there's a lot of really important stuff to know. So you'll see on here that we have weight gain guidance based on BMI. Now, this is pre-pregnancy BMI. And of course, BMI is not always the best indicator of health status. So in the real world, this may be different based on a specific patient's experience or context for their care. But in general, an underweight patient needs to gain 28 to 40 pounds. A patient with average weight should gain 25 to 35 pounds. And remember, average means that that's what most people are. So that's the number that I would be focusing on the most, because most of your patients will be of average weight. And then for a patient with an overweight BMI, they should gain between 15 to 25 pounds in pregnancy.
You'll also see on here that we have the weight gain broken down by trimester. So in the first trimester, only 2.2 to 4.4 pounds should be gained in total in that entire first trimester. That's going to be one to two kilograms. When we get into the second and third trimesters, however, then we expect our patients to be gaining about one pound per week. So very important to know that we have very little weight gain in that first trimester and then one pound a week thereafter. You'll see here too, that calorie intake that is recommended based on trimester. I'll let you go through that on your own, but just know that it does vary and the caloric needs will vary throughout pregnancy and breastfeeding.
Moving on, we're going to be talking about things to avoid in pregnancy and warning signs of complications. This is so important in that first trimester visit to make sure that your patients understand what's normal and what is something that could be concerning where they need to follow up with their provider. So this is a hugely important card to review. Things to avoid during pregnancy, it's more than we could ever possibly fit on a flash card, right? There's so much to avoid in pregnancy. Alcohol is going to be the big one, along with smoking. If your patient is able or interested or willing to talk about smoking cessation, that's going to be huge for the pregnancy. Caffeine should be limited. The intake of certain fish should be limited as well. And the hot tubs and saunas as well. So there's way more than that. Those are just some of the highlights. But specific drugs should be avoided. And in general, when I worked in outpatient OBGYN land, we said that you shouldn't take any medication during pregnancy without speaking to your OBGYN, because there's just very few that are considered across the board to be okay. So every medication should be reviewed and approved by your provider.
Now warning signs of possible complications to notify your doctor of. So, so, so important to know these: diarrhea, fever, and chills. Anything like that, we don't like it. We want to know about it. Severe abdominal cramping. It is normal and expected to have some cramping in pregnancy. The uterus is growing and changing and pulling on ligaments and all of these different things. It's going to be a little uncomfortable. But if your patient is having severe pain or cramping, that is something that they need to call the doctor about. Severe vomiting, which we will talk about in another video. But severe vomiting can be a really big warning sign that your patient is experiencing something called hyperemesis gravidarum. They are very much at risk for dehydration and electrolyte imbalances. And then decreased fetal activity. This, of course, only applies once the patient is able to feel the fetal activity in the first place, which is usually going to be somewhere between 17 and 24 weeks, depending on the patient and the location of their placenta. But once they feel fetal activity, it's going to become more and more consistent and kind of fall into a pattern. If your patient recognizes decreased movement, that is always a time to call the doctor.
Okay, moving on, let's talk about unpleasant side effects. These are pretty common. You may be familiar with a bunch of them already, but these are things to just tell your patients, "Hey, this might happen to you. It's okay. It's expected. It's a side effect of pregnancy, but we just want you to be aware of it." So congestion, again, remember, we have that increased blood flow. So we're going to end up with nasal congestion. They can use a normal saline spray. But again, we're avoiding any kind of medication unless we talk to the doctor. Constipation. That uterus is putting tons of pressure on the bowels and it's going to make it really hard for things to move through there unobstructed. That's normal. Increase your fluid and fiber, right? Very important. Epistaxis, meaning nose bleed. Again, very, very common because of that increased blood flow. So here we would tell our patients to use a humidifier if possible.
And then things like fatigue and heartburn are expected as well. Gingivitis, again, remember, we have this blood flow situation, so we're going to end up with gingivitis. We also have a decreased immune response because we're trying to suppress the immune response to protect the baby. So we can end up with gingivitis, dental caries. This is why you need to educate your patients to continue good oral hygiene, but also to continue to see the dentist during pregnancy. On this last card that we're covering, some more really fun, unpleasant side effects, hemorrhoids. Okay. Hemorrhoids are prolapsed vessels in or around the rectum. Again, we have increased blood flow and constipation. Your patient is probably straining with bowel movements. So, again, fiber and fluid. And then if they actually have hemorrhoids, they can use witch hazel to try and soothe that or warm sits baths where they actually sit in warm water to help relieve some of that pain. Nausea and vomiting. I don't think I know a single person who made it through pregnancy without at least a little nausea and vomiting. So things that we can tell our patients to do would be to eat crackers or a carbohydrate heavy snack before getting out of bed. My doctor told me, literally, she said, "Before you even sit up in bed, I want you to take a handful of Teddy Grahams or Saltines or something like that and eat them." And that really did help me with some of my nausea, because it helped to settle my stomach before I got the day started. They can also eat frequent meals which are smaller. So rather than three large meals, five or six small ones and bland foods. It's also going to be up to patient preference. Whatever helps your nausea is what we want you to eat, right? For me, it was milkshakes. All I could stomach was a chocolate milkshake. And my doctor said, "That's fine. Just drink it. We want you to get some calories."
Urinary frequency. More blood volume means more blood that gets filtered and turned into urine, right? Plus a large, heavy uterus pushing on that bladder. You're going to be using the bathroom more frequently. Varicose veins also are something that you may experience in pregnancy, so wear compression garments and things of that nature.
All right. I hope that review was helpful for you. If it was, please, like this video so that I know. If you think of something I left out or a really great way to remember it, I would love to hear it in the comments below, and be sure to subscribe so that you're the first to know when the next video in this series comes out. Thanks so much for joining me and happy studying.
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