y4d nutrition and diet in pregnancy and postpartum
- 1. Maternal And Child Health Care Section 1 Nutrition And Diet
- 2. What is Balance nutrition ? Lifestyle • Sedentary work -1700 kcal • Moderate work - 2100 kcal • Heavy Work – 2700 kcal Additional calories Requirement in pregnancy • Average -350 kcal /day • T1 -85 kcal • T2 -280 kcal • T3 -470 kcal
- 4. Pre-pregnancy vs post- pregnancy Requirements in pregnancy • Folate rich foods –Green leafy Vegetables , supplements • Iron • Calcium • Vit D • Protein Requirements in post pregnancy • Omega 3 fatty acid – Fish ,eggs • Choline –meat ,fish ,eggs • Iron – supplements ,leafy vegetables , beans • Calcium • Protein
- 5. Importance Of Balanced Nutrition Pre conception care influences; • Reduction in maternal & child mortality • Helps prevent; – Unintended pregnancies – Complications in pregnancy & delivery – Stillbirths – Preterm birth – Low birth weight – Birth defects – Neonatal infections – Underweight & stunting – Vertical transmission of HIV/STIs • Lower risk of; some forms of childhood cancers, type 2 diabetes & cardiovascular disease later in life Pre conception care for nutritional conditions focus on; • Screening for anaemia & diabetes • Supplementing iron & folic acid • Information, education & counselling • Monitoring nutritional status • Supplementing energy & nutrient dense food • Management of diabetes & hypertension • Promoting exercise • Iodization of salt
- 6. Counseling Pre-Pregnancy, Pregnancy & Lactation Pre Conception Pregnancy Breastfeeding ANC attendance and HIV Attendance of antenatal care eight times during pregnancy √ Knowing HIV status, attending all the clinic appointments, & taking medicines as advised √ √ √ Dietary intake Healthy eating & physical activity to stay healthy, attain or maintain a healthy weight and/or prevent excessive weight gain √ √ √ Increase daily energy & protein intake to increase BMI and/or reduce the risk of LBW infants in undernourished populations √ √ √ Diverse diet, including locally available & affordable nutritious foods & fortified foods (iodized salt, fortified vegetable oil & fortified cereals) √ √ √ Avoid drinking tea or coffee with meals and limit the amount of coffee during pregnancy √ √ √ Adequate rest and reducing heavy workloads √ √ Dietary supplementation Continued & consistent use of IFA including how to take supplements & manage side effects √ √ √ Continued & consistent use of balanced energy-protein supplements in undernourished populations √ √ √ Breastfeeding Breastfeeding (initiation immediately after delivery, providing colostrum, not giving prelacteal feeds, exclusive breastfeeding, continued breastfeeding, managing breastfeeding problems) √ √ Family Planning Knowledge on Lactation Amenorrhoea Method (LAM) and child spacing √ √ Hygiene Hand washing at critical times & food hygiene practices through safe handling, preparation & storage √ √ √
- 7. Recommended maternal Preconception care: maximizing the gains for maternal & child health • Preconception care package includes; information, education & counselling on nutrition, promotion of exercise, IFA supplementation, & energy- & nutrient- dense food supplementation Recommendations on postnatal care • All women should be counselled on nutrition as part of postnatal care IFA supplementation should be provided for at least three months postpartum
- 8. Recommendations for a positive pregnancy Counsel on healthy eating & keeping physically active to stay healthy & prevent excessive weight gain A healthy diet during pregnancy; adequate energy, protein, vitamins & minerals, through consumption of a variety of locally available nutritious foods Counselling should be women-centred & delivered in a non-judgmental manner In undernourished populations, nutrition education on increasing daily energy & protein intake to reduce the risk of LBW
- 9. Recommended weight gain in pregnancy Recommended monthly weight Adapted from Institute of Medicine (US), 1991 Total recommended weight gain Trimester Weight gain per month 1st trimester 0.5 kgs per month 2nd trimester 1 – 1.5 kgs per month 3rd trimester 2 kgs per month Nutritional status Pre pregnancy BMI Recommended weight gain Underweight < 18.5 kg/m2 12.5–18 kg Normal weight 18.5–24.9 kg/m2 11.5–16 kg Overweight 25–29.9 kg/m2 7–11.5 kg Obese > 30 kg/m2 5–9 kg
- 10. Screening of Pregnant and lactating Women Admission criteria for pregnant & lactating women MUAC used to: • To identify underweight • Identify Pregnant & lactating women at greater risk • Systematically screen for acute malnutrition Low MUAC in pregnant women associated with intrauterine growth restriction, LBW, neonatal morbidity Admission criteria Under nutrition status PLW with MUAC ≥ 18 - ≤ 21cm Moderate Acute Malnutrition PLW discharged from stabilization centers with MUAC ≥ 18 - ≤ 21cm PLW less than 18cm MUAC Severe Acute Malnutrition (OTP/SC management)
- 11. Iron and Folic Acid supplementation Supplementation of pregnant women with Iron & Folic Acid (IFA) • Part of ante-natal care • Treatment of severe anaemia • Women with anaemia, treated with daily iron (120 mg of elemental iron) & folic acid (400 g or 0.4 mg) supplementation μ Daily IFA supplementation in pregnant women Supplement Composition Iron: 30-60mg of elemental iron Folic Acid: 400 µg (0.4mg) Target Group All pregnant adolescents & women Frequency One supplement Daily Duration Throughout pregnancy, starting as early as possible
- 12. Deworming and malaria control in pregnancy Deworming Administration • To control intestinal parasites • Provided to pregnant women • Provided after first trimester of pregnancy • Use single-dose albendazole (400 mg) or mebendazole (500 mg)
- 13. Section 2 Identifying Nutritional Deficiencies 1) Anemia In Pregnancy 2) Neural Tube Defects In Pregnancy And folate Deficiency 3)Iodine Deficiency And Growth Restriction 4) Protein And Vit D deficiency - Osteoporosis in later life
- 14. ANAEMIA IN PREGNANCY • Commonest medical disorder. • High incidence in underdeveloped countries • Increased Maternal morbidity & mortality • Increased perinatal mortality
- 15. ANAEMIA IN PREGNANCY Definition: By WHO Hb. < 11 gm /dl (or haematocrit <32%). Mild anaemia -------- 9 -10.9 gm /dl Moderate anaemia--- 7-8.9 gm /dl Sever anaemia-------- < 7gm /dl Very sever anaemia-- < 4gm/dl
- 16. Common Anaemias in pregnancy Common types: • Nutritional deficiency anaemias - Iron deficiency - Folate deficiency - Vit. B12 deficiency • Haemoglobinopathies: - Thallassemias - SCD Rare types: - Aplastic - Autoimmune hemolytic - Leukemia - Hodgkin’s disease - Paroxysmal nocturnal haemoglobinurea
- 17. IRON DEFICIENCY ANAEMIA • Iron required for fetus and placenta ------- 500mg. • Iron required for red cell increment ------- 500mg • Post partum loss --------- 180mg. • Lactation for 6 months - 180mg. • Total requirement -------1360mg • 350mg subtracted (saved as a result of amennorrhoea) • So actual extra demand ----------------------1000mg • Full iron stores --------------------------------1000mg
- 18. ETIOLOGY OF IRON DEFICIENCY ANAEMIA Depleted iron stores – dietary lack, chronic renal failure, worm infestation, chronic menorrhagia Chronic infections: ( like malaria) Repeated pregnancies : - with interval < 1 year - blood loss at time of delivery - multiple pregnancy. CLINICAL FEATURES Symptoms usually in severe anaemia - Fatigue - Giddiness
- 19. EFFECTS OF ANAEMA IN PREGNANCY • . Mother : • High output Cardiac failure (more likely if precelampsia present. inadequate tissue oxygenation increase requirments for excessive blood flow ) • PPH • Predisposes to infection • Risk of thrombo-embolism • Delayed general physical recovery esp after c. section • Fetus: . IUGR . Preterm birth . LBW . Depleted Fe store . Delayed Cognitive function.
- 20. INVESTIGATIONS • Hb • Haematocrit • RBC Indices: - Low MCV - Low MCH - Low MCHC - Low PCV • Peripheral blood picture : Microcytic Hypochromic anaemia .
- 21. MANAGEMENT • Objectives: 1- To achieve a normal Hb by end of pregnancy 2- To replenish iron stores • Two ways to correct anaemia: I- Iron supplementation . Oral Fe . Parenteral Fe II- Blood transfurion • Choice of method: It depends on three main factors: • Severity of the anaemia • Gestational Age.
- 22. MANAGEMENT Side effect of Fe Oral therapy: . G. I upset. . Constipation. . Diarrhoea. Parentral: - skin discolouration - local abscess - allergic reaction - Fe over load.
- 23. MANAGEMENT • Severe anaemia: (Hb < 8gm/dl)- preferably parenteral theraphy in the form of I/M or I/V iron - I/M : ( Iron sorbitol) with “Z” technique - I/V : (iron sucrose) • Iron neede = (Normal Hb – Pt. Hb)* Wt in Kg*2.21+1000)
- 24. FOLATE DEFICIENCY ANAEMIA Folic acid deficiency more likely if . Woman taking anticonvulsants. . Multiple pregnancy. . Hemolytic anemia; thalasemia H.spherocytosis Maternal risk: Megaloblastic anemia Fetal risk: Pre-conception deficiency cause neural tube defect and cleft palate etc.
- 27. SICKLE CELL SYNDROME. • Autosomally inherited . • Structural abnormality. • HbS - susceptible to hypoxia, when oxygen supply is reduced. • Hb precipitates & makes the RBCs rigid & sickle shaped. • Heterozygous----HbAS. • Homozygous-----HbSS. • Compound heterozygous---HbSC etc.
- 28. Manifestation of Sickle cell Anemia
- 30. Peripheral smear : Sickle cells and target cells; Features of splenic atrophy (Howell- Jolly Bodies) Sickling Test : Mixing of blood sample with oxygen consuming reagent (Sodium metabisulfite) induces sickling of red cells if HbS is present Reticulocytosis & Hyperbilirubinema Hb Electrophoresis : Predominance of HbS & 2-20 % HbF Sickle cell Anemia - Morphology
- 31. SCD • Diagnosis: - Hb. Electrophoresis - Sickledext test is screening test • Management: - No curative Tx. - only symptomatic - Well hydration, effective analgesia, prophylactic antibiotics, O2 inhalation, folic acid, oral iron supplement (I/V iron is C/I), blood transfusion
- 32. Iodine
- 33. What is iodine? • Essential mineral needed in very small trace amounts • Helps with thyroid function and prevents goiter • Helps prevent birth defects like cretinism, a condition characterized by severely stunted physical and mental growth
- 34. Where is iodine found? • Varying amounts in the soil • Table salt – iodized since the 1920’s • Seafood and seaweed • Small amounts found in: • Grains • Dairy • Meat
- 35. Why add iodine to salt? • Iodine was one of the first food fortifications designed to prevent a common health issue (goiter). Later discovered to prevent certain birth defects (cretinism). • Salt was chosen for iodine supplementation because everyone routinely uses salt and fortification is easy and inexpensive.
- 36. How much iodine is needed each day? • Infants under 12 months of age: 110 to 130 mcg • Children over age 1 year: 90 mcg • Adults and adolescents: 150 mcg • Pregnant: 220 to 250 mcg • Breastfeeding Women: 290 mcg
- 37. Why add iodine to supplements? • Women of childbearing age are at higher risk of low iodine levels. • There is an increased need during pregnancy and breastfeeding because mothers are the sole source of iodine for their babies. • There is decreased use of iodized salt in U.S as people use more non-iodized salts (i.e. sea salt, kosher salt, flavored salts, rock salt, pickling salt)
- 38. When are iodine supplements needed? • Taking prenatal vitamins with iodine before and during pregnancy can help prevent Iodine Deficiency Disorders (IDDs). • Taking vitamins with iodine while breastfeeding helps to maintain adequate iodine levels for mom and baby.
- 39. Vitamin D And Calcium • Vitamin D 10 micrograms/day non pregnant adult RDA = 5 micrograms Calcium – 1200 -1500 mg/day non pregnant adult RDA = 1000 mg/day
- 45. Care after delivery: Postpartum Care 45 Postpartum visits by ANM/ASHA * There should be three additional visits in case of babies with low birth weight, on days 14, 21 and 28 as per Integrated Management of Neonatal and Childhood Illness (IMNCI) guidelines. 6 weeks after delivery 6 weeks after delivery Fourth visit 7th day after delivery 7th day after delivery Third visit * 3rd day after delivery 3rd day after delivery Second visit Not applicable 1st day(within 24 hrs) First visit After delivery at PHC/FRU (woman discharged after 48 hrs) After delivery at home / sub centre Visits
- 46. Care after delivery: Postpartum Care 46 Management / Counseling contd.. 2. Nutritional Advice • To increase intake of fluid and food especially iron and protein rich foods like green leafy vegetables, jaggery, lentils, eggs and meat • Increase intake of milk and milk products like curd, cheese etc 3. Advise adequate rest First postpartum visit: Mother
- 47. Care after delivery: Postpartum Care 47 First postpartum visit: Mother History • Place of delivery • Initiation of breast feeding • Any complaints : Excessive bleeding Abdominal pain Convulsions Loss of consciousness Pain in legs , fever Urinary retention Difficulty in breathing Foul smelling lochia Examination • Pulse, BP, RR. Temp • Pallor • Abdomen : tender uterus, refer to FRU • Vulva and perineum: tear, swelling or pus, refer to FRU after initial management • Excessive bleeding P/V refer to FRU after initial management • Breast : lump, tender refer to FRU
- 48. Care after delivery: Postpartum Care 48 Management / Counseling contd.. 4. IFA Supplementation • Women with normal Hb are advised to take 1 IFA tablet daily for 3 months • If Hb below 11 gm%, advise her to take 2 IFA tabs daily and repeat Hb after 1 month 5. Contraception • Counsel couple regarding contraception First postpartum visit: Mother
- 49. Care after delivery: Postpartum Care 49 Management / Counseling contd.. 6. Breastfeeding Advise the mother- • For exclusive breast feeding on demand, at least 6 to 8 times during day & 2-3 times during night AVOID PRE- LACTEAL FEEDS First postpartum visit: Mother
- 50. Care after delivery: Postpartum Care 50 Breast feeding problems: Cracked /sore nipples Advise the mother: • to apply hind milk for soothing effect • ensure correct positioning and attachment of baby Engorged breasts Advise the mother: • to continue breast feeding • to put warm compresses First postpartum visit: Mother
- 51. Care after delivery: Postpartum Care 51 Postpartum period: danger signs Woman should be counseled to report to FRU if she has • Fever • Convulsions • Excessive bleeding • Severe abdominal pain • Difficulty in breathing • Foul smelling lochia
- 52. Care after delivery: Postpartum Care 52 First postpartum visit for baby History taking: • Ask if breast feeding has been initiated • Inquire whether the baby has passed urine and meconium • Elicit h/o any problems in newborn Refer to FRU if • Not feeding well • Cold to touch or fever • Baby is lethargic or has had convulsions • Difficulty in breathing
- 53. Care after delivery: Postpartum Care 53 First postpartum visit for baby Examination of newborn Refer to FRU Cry and activity Poor cry Lethargic / unconscious Chest in drawing Severe chest in drawing is a sign of pneumonia Respiration If <30 or 60 breaths /min ≥ Central Cyanosis Bluish discoloration of tongue and lips Body temperature If temperature is <35.5o C or > 37.4o C
- 54. Care after delivery: Postpartum Care 54 First postpartum visit for baby Breast Feeding : Signs of good attachment • Chin touching breast • Mouth wide open • Lower lip turned outward • More areola visible above than below the mouth A baby poorly attached to the breast A baby well attached to the breast
- 55. Care after delivery: Postpartum Care 55 First postpartum visit for baby Breast Feeding: Effects of poor attachment • Pain and damage to nipples, leading to sore nipples • Breast is not emptied completely, resulting in breast engorgement • Poor milk supply: baby not satisfied • Poor weight gain of baby.
- 56. Care after delivery: Postpartum Care 56 First postpartum visit for baby Immunization of Newborn Counsel mother on where and when to take baby for immunization
- 57. Care after delivery: Postpartum Care 57 2nd and 3rd visit for mother On 3rd and 7th day following delivery History taking: As on first visit In addition ask for history of • Continued bleeding P/V, foul discharge P/V • Swelling or tenderness of breast. • Feeling unhappy or crying easily Examination: Same as on 1st visit Management and Counseling: Same as on 1st visit
- 58. Care after delivery: Postpartum Care 58 History taking and Examination: Same as in first visit Management and Counseling: In addition to counseling in first visit, advise the mother : To exclusively breast feed for six months. To wean at six months. 2nd and 3rd visit for baby
- 59. Care after delivery: Postpartum Care 59 Fourth visit for mother At 6 weeks following delivery History taking: Ask the mother for following: • Has vaginal bleeding stopped? • Has menstrual cycle returned? • Is there any foul smelling vaginal discharge? • Any problems regarding breast feeding? • Any other complaints? • Give relevant advice & refer to M.O. if needed
- 60. Care after delivery: Postpartum Care 60 Fourth visit for mother Examination: Similar to examination during previous visit Management and Counseling: Diet and Rest: Emphasize importance of nutrition as in second and third visit. Contraception: Emphasize importance of using contraceptive methods for spacing and limiting family size
- 61. Care after delivery: Postpartum Care 61 Fourth visit for baby History taking: Ask the mother about • Vaccines received by baby so far • Is baby taking breast feed well? • Weight gain of baby • Any other problem Examination: • Check weight of baby. • General examination of baby
- 62. Care after delivery: Postpartum Care 62 Key messages Post partum care: Mother • Make at least 4 postpartum visits for timely recognition of complications like PPH, puerperal sepsis • Advise mother on nutrition • Advise mother on rest, hygiene, breast feeding and contraception
- 63. Care after delivery: Postpartum Care 63 Fourth visit for baby Management and Counseling: Emphasize on exclusive breast feeding Refer baby to F.R.U. if • Not sucking well at breast • Is lethargic / unconscious • Has fever or is cold to touch • Cord - swollen or discharge present • Diarrhea, blood in stool • Convulsions • Difficulty in breathing
- 64. Care after delivery: Postpartum Care 64 Steps for transfer of baby Care during transfer: • Keep baby in skin to skin contact with mother, if not possible keep baby dressed and covered • Ensure that baby receives feeds • If baby gasping or respiratory rate <30 breaths /minute, resuscitate baby using bag and mask
- 65. Infant Nutrition • Breastfeeding, (preferred and recommended), or formula supply nutrients for the infant. • Start to introduce solid foods at about 6 mths. • Energy needs start at about 1000 cal/day at age one and increase gradually (100 calories per year) to about 2000 cal at age 10.