Emotional Aspects of Pregnancy Nutritional Needs in Pregnancy Educational Needs in Pregnancy

1. Emotional Aspects of PregnancyNutritional Needs in PregnancyEducational Needs in Pregnancy Ambivalence Couvade Calories Folic Acid Lamaze

2. Psychological Responses • Ambivalence • Acceptance • Introversion • Mood swings • Changes in body image

3. Reva Rubin’s Maternal Tasks • Safe passage • Seeking acceptance • Binding in to the child • Giving of oneself

4. Expectant Father • First trimester- confused, baby seems “unreal” • Second trimester- Proud,acceptance and attachment, financial concerns • Third trimester- anticipating the birth, some fears about labor process, baby’s health • Couvade- unintentional development of physical sx: nausea, aches and pains, etc

5. Fathering steps • Accepting the pregnancy • Identifying with father role • Reordering personal relationships • Establishing relationship with fetus 

6. Extended Family Preparation • Siblings • Preparation: • Inclusion: • Grandparents • Preparation: • Inclusion

7. Nursing Care in Pregnancy What happens throughout the pregnancy

8. Initial Prenatal Visit • Generally recommended after 2nd missed period • Begin with thorough history • Chronic illnesses • Social history • Psychological needs • Determine Estimated Due Date (EDD) or Estimated Date of Confinement (EDC) • Present pregnancy~ LMP, presumptive signs, GTPAL

9. Complete physical examination • Assess pelvis for diagonal conjugate, and adequacy of pelvis for vaginal delivery of average-sized baby • Draw all prenatal labs • Begin all the prenatal education: books, videos, etc.

10. Nagele’s Rule for EDC • Begin with LMP • Subtract 3 months • Add 7 days

11. EDC EDC EDC LMP 1-05-13 LMP 3-25-13 LMP 10-10-13 Let’s try it!!!

12. GTPAL vs Gravida - Para • Gravida= # of pregnancies • Term deliveries= > 37 weeks-42 weeks • Preterm deliveries= < 37 weeks(also Pt) • Abortions= < 20 weeks • Living children • Gravida/Para = Pregnancy/Delivery

13. Gravida and Para vs GTPAL • Gravida= any pregnancy regardless of duration • Para= Birth after 20 weeks’ gestation, regardless of whether the infant is born alive or dead • “When using the detailed system, GTPAL, GRAVIDA keeps the same meaning, but the meaning of PARA changes because the detailed system counts each infant born rather than the number of pregnancies carried to viability” (Davidson et al, p.318, 2012).

14. Lab Tests • UA and culture • Blood: CBC, Type/Rh • VDRL/RPR/Serology • Toxoplasmosis • Rubella • Hepatitis B • HIV • Antibody Screening

15. 10-12 wks: Chorionic Villi Sampling • 14-16 wks: Amniocentesis • 15-20 wks: MSAFP (see Fetal Assessment Wksht) • 24-28 wks: Blood sugar 3 hr GTT • 36 wks + : Beta strep vaginal cultureWebsite for Group B Beta Strep~ CDC pamphlet • Hgb & Hct repeated prn throughout pg. • Urine:  glucose and protein at every prenatal visit. Should be 1st morning specimen collected and refrigerated, but can also be fresh sample upon arrival at office.

16. Other diagnostic testing... • Pap test (hold her over until postpartum) • Ultrasound for dates/anomalies

17. rest and sleep exercise employment recreation travel use ofdrugs &alcohol immunizations skin and breast care clothing Dental health nutrition Educational Needs~begins at 1st prenatal visit but continues throughout pregnancy

18. Website on prenatal exercises Refer to pp. 364-366 for suggested exercises Be open to discussion during prenatal visits re: sexual activity.See Teaching Plan p. 367-368. Changes in desire r/t nausea, fatigue in 1st trimester,  desire in 2nd trimester,  desire in 3rd trimester r/t backache, size of baby Suggest alternative methods to express intimacy Stress importance of open communication between partners Prenatal Exercises & Sexual Activity during Pregnancy

19. WARNING SIGNS~assessed at each prenatal visit • vaginal bleeding • edema of face and in fingers • severe continuous headache • dim or blurred vision/spots/flashes • abdominal pain/persistant vomiting • fever and chills • gush of fluid from vagina • dysuria, backache, flank pain

20. Subsequent prenatal visits • Generally recommend monthly visits for low-risk mothers through 32 weeks gestation • Assess weight, BP, urine, sx of complications, FHR, McDonald’s Rule • 32-36 weeks~ bi-monthly • 36 weeks-delivery~ weekly

21. Maternal and Fetal Nutrition

22. Why Pregnancy= more need for nutrients? • Uterine-placental-fetal unit • Maternal blood volume  • Mammary changes • RDA = 300 kcal more / day than prepregnant dietary needs • Look at Teaching plan on p.399 Davidson et al

23. Choose My Plate http://www.choosemyplate.gov

24. Weight Gain over entire pregnancy • Underweight - 28 – 40 lbs. • Normal weight - 25 – 35 lbs. • Overweight - 15 – 25 lbs. • Obese - 15 lbs. • Adolescents - high end of range • Short women – low end of range • Twins - ~44 lbs. Has best outcome

25. Recommended Weight Gain Throughout Pregnancy~ know this! • 1st Trimester~ 3.5-5 lbs (1.6-2.3kg) • 2nd & 3rd trimesters~1 lb/week (0.5 kg/wk)

26. PROTEIN~60g/day • Fetal growth • Placental growth • Amniotic fluid production • Uterine muscle growth • Blood production

27. IRON (27 mg/day) • Facilitates blood cell production • If mom is anemic, there is  risk of lethargy in mom, preterm births, intolerance to blood loss at delivery • Guidelines for taking Iron (e.g.. Ferrous Sulfate FeSO4 , FerroSequels, Ferrous Fumarate)-- Take on an empty stomach with OJ-- Do NOT take with milk, coffee, tea-- Keep away from CHILDREN--  risk of toxic ingestion-- Instruct mom on possible stool changes: black and tarry,  risk of constipation

28. WATER • Necessary for expansion of blood volume& to  risk of constipation • Need to drink 6 – 8 glasses/day • Limit caffeine intake • Avoid artificial sweeteners in beverages

29. SODIUM • Needed due to expanding circulating fluid volume • Need to balance ECF concentration due to  GFR • Don’t restrict because Sodium is essential to fluid & electrolyte balance • Don’t overdue as it may lead to excessive fluid retention (edema of face & hands)

30. CALCIUM(1000mg) • Fosters fetal calcification of bones • If intake not adequate, demineralization of maternal bones occurs • 4 cups of milk or its equivalent • Assess cultural diet as some cultures do not advocate milk & dairy products • Review alternative resources ofCalcium as green leafy vegetables, and Ca+++ fortified foods

31. FAT-SOLUBLE VITAMINS • A D E K • In excess amounts, they are toxic • Necessary for tooth budding and bone growth • Excellent source of Vitamin D:fortified milk& sunlight which produces D on our skin • May be taken in water-miscible form if not able to metabolize properly

32. ZINC • Contained in enzymes of metabolic pathways • Best resources~ meats, shellfish, poultry, OR whole grains and legumes • Iron and folic acid inhibit absorption

33. LACTATION • RDA: 500 kcal more than non-pregnant woman • Minimum of 1800 kcal/day •  Calcium and Iron intake • Smoking: impairs milk production • Alcohol in excess impairs milk ejection reflex • Caffeine: accumulated in infant through breastmilk will be manifested as a wakeful and active baby!

34. FOLIC ACID • Low levels correlate with neural tube defects. • Critical to begin increasing Folic Acid intake at least 3 months before conception! • Supplemental Folic Acid only begun in 1992, Now a big March of Dimes initiative • Acceptable Folic Acid levels are most critical in the 1st 6 wks of pregnancy and should be continued throughout pregnancy.

35. Factors affecting nutrition • Eating disorders • Lactase deficiency (lactose intolerance) • Pica~Pica is the practice of eating non-edible substances(clay, dirt, laundry starch, etc.). • It is especially important for the nurse to assess the pregnant patient who has lower hemoglobin levels as she may be replacing low-nutrient products for nutritious foods.

36. Cultural Spiritual influences • MANY cultures have “hot/cold” theories on nutrition and pregnancy is often viewed as a “hot” time that requires foods that fall under the “cold” categories. These foods generally include dairy foods. Be sure to assess carefully. • Vegetarians still need adequate proteins and need to be taught of good resources.

37. Vegetarians~ website Types • Lacto-ovovegetarians~mild, dairy products, & eggs • Lactovegetarians~ include dairy, but no eggs • Vegans~strict vegetarians who eat no food from any animal sources. These persons need to plan how to get adequate complete proteins and sufficient calories. • Examples of complete proteins: beans & rice, or peanut butter on whole grain bread, whole grain cereal with soy milk.

38. Psychosocial factors~role of food and serving food as a maternal role • Socioeconomic factors (see slide on WIC) • Education~ it is essential for nurses to integrate teaching on healthy eating in pregnancy from the first prenatal visit. • Psychological Factors~ food may be used as a substitute for emotions OR may be avoided if patient is depressed.

39. Common Discomforts of Pregnancy • Refer to pp.349-359 in Davidson et al for discussion of many general discomforts of pregnancy and how to alleviate them. • The following discussion focuses on those related to nutrition in pregnancy and discomforts associated with it.

40. eat dry foods(CHO’s) small amts frequently don’t get hungry! fresh air helps limit fried/fatty foods eat cold foods foods with little or no smell don’t brush teeth right after eating Feeling GREEN(nauseated)?

41. FeelingSTUCK(constipated)?!? • eat high fiber • increase fluids •  exercise to increase bowel motility • Avoid laxatives

42. PLOP PLOP FIZZ FIZZ(heartburn) • small frequent meals • avoid spicy foods • no tight clothes across tummy • don’t lie down after meals • may need to sleep in recliner in last weeks

43. WIC • Women Infants & Children(federally funded program provided by Health Dept.) • Supplemental nutrition program for moms & babies • Income eligible • Food coupons for pregnant & lactating women • Formula available for bottlefed babies • Must go to nutrition class taught by dietician • Children have regular developmental assessments by nurses

44. There you have it!!