Maternal Nursing NCM 205 Lecture Notes Week 5 PDF

MATERNAL NURSING NCM 205 – Maternal And Child Health Nursing Ms. Ederlyn Maura Monzon-Delamide RN MAN Week 5 Changes during Pregnancy 1. Amenorrhea of more than 10 days 2. Morning sickness (nausea and vomiting) 3. Easy fatigability 4. Urinary frequency 5. PRESUMPTIVE Striae gravidarum...

MATERNAL NURSING NCM 205 – Maternal And Child Health Nursing Ms. Ederlyn Maura Monzon-Delamide RN MAN Week 5 Changes during Pregnancy 1. Amenorrhea of more than 10 days 2. Morning sickness (nausea and vomiting) 3. Easy fatigability 4. Urinary frequency 5. PRESUMPTIVE Striae gravidarum 6. SIGNS (Subjective Chloasma, melasma or “mask of pregnancy” 7. Signs) Linea nigra 8. Quickening – first fetal movement 4th month in Multis – 16 weeks 5th month in Primis – 20 weeks 9. Leukorrhea  SKIN Pink or reddish abdominal streaks (striae gravidarum) which is caused by stretching of the skin Chloasma or “mask or pregnancy” – increased pigmentation can occur on the face as blotchy brown areas on the forehead and cheeks Linea nigra – on the abdomen as a dark line from the symphysis pubis Minute vascular spiders may occur The umbilicus is pushed downward, and by about the seventh month its depression disappears and becomes a darkened area on the abdominal wall Sweat and sebaceous glands are more active. CHLOASMA LINEA NIGRA STRIAE GRAVIDARUM SPIDER VEINS 1. CHADWICK’S SIGN – purplish discoloration of the vagina due to high vascularity in the area. 2. GOODEL’S SIGN – softening of the cervix 3. 4. PROBABLE HEGAR’S SIGN – softening of the lower uterine segment BALLOTEMENT – bouncing of the baby when tapped by an examining finger 5. 6. SIGNS BRAXTON HICK’S – painless uterine contraction (+) POSITIVE pregnancy test 7. 8. (Objective Fetal outline palpated by the examiner Sonographic evidence of gestational sac Signs) GOODEL’S SIGN & HEGAR’S SIGN 1. PRESENCE OF FETAL HEART TONE POSITIVE SIGNS 2. FETAL OUTLINE BY X-RAY/ ULTRASOUND OF PREGNANCY 3. FETAL MOVEMENT FELT BY EXAMINER  Maternal Adaptations In Pregnancy A. ANATOMICAL UTERUS Changes in size, structure, and position to become a thin-walled, muscular abdominal organ capable of containing the fetus, placenta, and amniotic fluid In the early months of pregnancy, growth is partly due to formation of new muscle fibers and enlargement of preexisting muscle fibers After the first trimester, the increase in size is partly mechanical due to the pressure of the developing fetus The full-term pregnant uterus and its contents weigh about 12 lbs.  Location of the Fundus:  12 weeks  at the level of the symphysis pubis  16 weeks halfway between symphysis pubis and umbilicus  20weeks  at the level of the umbilicus  24 weeks  two fingers above umbilicus  32 weeks  midway between umbilicus and xiphoid process  36 weeks  at the level of xiphoid process  40 weeks  two fingers below umbilicus, drops at 34 weeks level because of lightening Contractility: Being muscular, the uterus is a highly contractile organ. Beginning on the first trimester, the uterus undergoes irregular contractions. Late in pregnancy, these contractions, known as Braxton-Hicks, become more intense and frequent causing some discomfort on the pregnant woman. It is the cause of false labor.  CERVIX undergoes increased blood supply, edema, and hyperplasia of the cervical glands contributing to: Softening (Goodell’s sign) about 6 wks Increased friability (bleeds easily after Pap smear and intercourse) Distention of cervical mucosa glands with mucus, creating a tenacious “mucous plug” that seals the endocervical canal and inhibiting the ascent of bacteria and other substances into the uterus 3. Vagina and External genital organs  enlarge, soften, thicken, and develop blue-violet hue as a result of increased vasculature  Vaginal secretions become alkaline, causing an increased risk of vaginitis  Connective tissue loosens in preparation for labor and delivery  A blue-violet color (Chadwick’s sign) about 6-8 wks.  ISTHMUS During pregnancy, the isthmus softens and elongates up to 25 mm. It will later form the lower uterine segment, together with the cervix Hegar’s sign  softening of the lower uterine segment begins as early as 5 weeks gestation OVARIES No Graafian follicles develop, and no ovulation occurs during pregnancy Corpus luteum of pregnancy  the corpus luteum is the chief source of hormone progesterone during the first 12 weeks of gestation. The corpus luteum also produces estrogen, relaxin, inhibin and sometimes oxytocin  BREASTS enlarge early in pregnancy, causing progressive feelings of heaviness, fullness, and tenderness; the nipple and areola become larger, darker in color; blood vessels enlarge and become prominent beneath the skin  Body mass  changes with weight gain; total desirable weight gain in pregnancy (for average woman) is about 23-28 lbs. (11-13 kg); 3-4 lbs. (1.36-1.81 kg) during the first trimester, followed by an average of slightly less than one pound per week for the rest of the pregnancy 1st trimester: 3-4 lbs. 2nd trimester: 12-14 lbs. 3rd trimester: 8-12 lbs. SYSTEMIC CHANGES  CIRCULATORY/ CARDIOVASCULAR Beginning the end of the first trimester, there is a gradual increase of about 30%-50% in total cardiac volume. This causes a drop in HgB & HcT values since the increase is only in plasma “PHYSIOLOGIC ANEMIA OF PREGNANCY” Management: Iron supplement 1. Easy fatigability and shortness of breath due to increased workload of the heart Mx: Rest 2. Slight hypertrophy of the heart causing it to be displaced to the left. 3. Systolic murmurs due to lowered blood viscosity CONSEQUENCES 4. Nosebleeds may occur dueOFto marked congestion of the nasopharynx. INCREASED 5. Palpitations due to increased pressure on the diaphragm CARDIAC 6. Edema VOLUME of the lower extremities occurs due to poor circulation resulting from pressure of the gravid uterus on the blood vessels Mx: Raise legs above hip level. Avoid prolonged standing and sitting NOTE: Edema of the leg is not a sign of toxemia ** Varicosities could occur due to pressure of the gravid uterus on the blood vessels of the legs. Mx: 1. Do not cross legs when sitting. 2. Wear support hose to promote venous flow thus preventing stasis in the lower extremities. 3. Apply distal bandage – start at the distal end towards the trunk to avoid congestion & impaired circulation in the distal part. 4. Avoid use of knee-high socks.  Varicosities of the vulva and rectum Mx: 1. Side lying position with hips elevated on pillows 2. Modified knee chest position. ** There is increased circulating FIBRINOGEN (clotting factor) that is why pregnant women are normally safeguarded against undue bleeding. However, this also predisposes them to clot formation (THROMBI)  Implication: pregnant women should not be massaged since blood clots can be released & cause thromboembolism. BP decreases slightly in the 2nd trimester due to lowered peripheral resistance to circulation but arises in the 3rd trimester. During delivery, the allowable blood loss is 250-450 ml (maximum 500 ml) for a single fetus, 1000 ml for vaginal delivery of twins or cesarian section.  During delivery, the IMPLICATION: Pregnant allowable blood loss is 250- women should not be 450 ml (maximum 500 ml) massaged since blood clots for a single fetus, 1000 ml can be released & cause for vaginal delivery of twins thromboembolism. or cesarian section.  ** SUPINE HYPOTENSION SYNDROME or VENA CAVA SYNDROME – the weight of the Mx: Left side lying or left lateral so gravid uterus presses on the vena as not to compress the vena cava. cava obstructing blood flow the No supine position after 20 weeks woman experiences AOG. lightheadedness, faintness and heart palpitations.  RESPIRATORY SYSTEM: The enlarged uterus causes the diaphragm to be displaced upward, putting pressure on the lungs and causing shortness of breath Slight dyspnea may occur until lightening caused by increased O2 consumption and production of CO2.  GASTROINTESTINAL SYSTEM Morning sickness Mx: Eat dry crackers 30 minutes before arising in the morning. Avoid spicy, fatty foods HYPEREMESIS GRAVIDARUM – excessive nausea and vomiting which persists beyond 3 months that could result to dehydration, starvation, malnutrition and fluid and electrolytes imbalance. Mx: D10NSS 3000 ml in 24 hours is the priority of treatment. Rest Anti-emetics (ex: Plasil)  GASTROINTESTINAL SYSTEM CONSTIPATION – due to displacement of the stomach & intestines; due to increased progesterone during pregnancy Mx: increased fluid intake Hi fiber diet Establish regular elimination pattern exercise mineral oil should not be used because it interferes with absorption of fat-soluble vitamins (ADEK)  GASTROINTESTINAL SYSTEM HEARTBURN – reflux of stomach content into the esophagus due to the increased progesterone which decreases gastric motility Mx: pats of butter before meals Avoid fried, fatty foods Bend at the knees no at the waist Take antacids ex. Milk of magnesia but never sodium NHCO3 (Alka Seltzer or Baking Soda) because it promotes fluid retention.  HEARTBURN – reflux of stomach content into the esophagus due to the increased progesterone which decreases gastric motility Mx:  pats of butter before meals Avoid fried, fatty foods Bend at the knees no at the waist Take antacids ex. Milk of magnesia but never sodium NHCO3 (Alka Seltzer or Baking Soda) because it promotes fluid retention. PICA – abnormal craving for non-nutritious substances. The most common is craving for ice cubes, there could be also craving for paper etc. ** often accompanies iron deficiency anemia ** encouraged to take iron supplements  MUSCULOSKELETAL SYSTEM Gradual softening of pelvic ligaments ad joints to facilitate passage of the baby. LORDOSIS – forward curvature of the lumbar spine. “THE PRIDE OF PREGNANCY” LEG CRAMPS – also know as “CHARLEY HORSE”, may occur from an imbalance of calcium phosphorus ratio in the body and from pressure of the uterus on lower extremities; fatigue; chills  MUSCULOSKELETAL SYSTEM BACK PAINS – relieved by wearing low heeled shoes Mx: frequent rest periods with feet elevated wear warm comfortable clothing increase calcium intake Do not massage – blood clots can cause embolism Most effective relief: press knee of the affected leg and dorsiflex the foot.  URINARY SYSTEM Urinary output is increased and has a low specific gravity; possible tendency to excrete glucose; reabsorption of sodium and decreased water output (latter half of pregnancy) is a compensatory mechanism to maintain increased blood volume Ureters become dilated (especially the right ureter) due to the pressure of the enlarged uterus; the dilated ureters are unable to propel urine as efficiently, resulting in stasis of urine and possible urinary tract infection Bladder – urinary frequency may occur early in pregnancy and later again when “lightening” occurs as a result of increased pressure on the bladder from the enlarged uterus  Pregnancy Activity EMPLOYMENT – if the job does not entail handling toxic substances or lifting heavy objects or excessive emotional strain, there is no contraindication to working. Advise pregnant women to walk about every few hours of her workday during long periods of standing or sitting to promote circulation thereby minimizing varicose veins. TRAVELLING – no travel restrictions but postpone a trip during the last trimester. On long rides, 15-20 minutes rest periods every 2-3 hours to walk about or empty the bladder is advisable. EXERCISE – should be done in moderation; should be individualized according to age, physical condition, customary amount of exercise (swimming or tennis) not contraindicated unless done for the first time & stage of pregnancy  Recommended Exercises - Strengthen muscles used in labor and delivery Pelvic Rocking Relieve low backache, strengthens the muscles of the lower back Squatting / Tailor sitting Stretches the perineal muscles, improves circulation in the perineum Pelvic floor contractions / Kegels Strengthens perineal muscles Abdominal muscle contractions Helps strengthen abdominal muscles  BATHING Due to increase perspiration, the pregnant woman is encouraged to have a daily bath to keep her fresh and clean Tub bath is discouraged because alteration in the woman’s balance makes getting in & out of the bathtub is difficult, she might slip & fall & hurt herself Swimming is ok but not diving Douching is contraindicated during pregnancy – can introduce infection **DRINKING – in moderation is not contraindicated but when excessive, can cause transient respiratory depression in the newborn and fetal withdrawal syndrome: besides, alcohol supplies only empty calories **DRUGS – dangerous to fetus especially during the first trimester when the placental barrier is still incomplete and the different body organs are developing. Teratogenic can cause congenital defects and therefore contraindicated unless prescribed by the doctor.  SMOKING causes vasoconstriction leading to decreased blood flow to the placenta which in turn diminishes O2 supply to the fetus. Fetal hypoxia leads to low-birth-weight babies and therefore is contraindicated during pregnancy.  BREAST CARE Well fitting and larger sized brassier (wide straps and deep cups to prevent loss of breast tone.) Wash breast with water only. NO SOAPS OR ALCOHOL should be used as these causes drying & cracking. Dry nipples thoroughly.  WEIGHT During the first trimester, weight gain of 1.5 – 3 lbs. On the 2nd and 3rd trimesters, weight gain of 10-11 pounds per trimester is recommended Total allowable weight gain during the entire period of pregnancy is 20-25 lbs. (10-12 kgs) More than 30 lbs. of weight gain is a danger sign – possible preeclampsia  DISTRIBUTION OF WEIGHT GAIN DURING PREGNANCY: FETUS 7 LBS PLACENTA 1 LB AMNIOTIC FLUID 11/2 LBS INCREASED WT. OF UTERUS 2 LBS INCREASED BLOOD VOLUME 1 LB INCREASED WT. OF THE BREASTS 11/2-3 LBS WT. OF ADDITIONAL FLUID 2 LBS FAT & FLUID ACCUMULATION 4-6 LBS.  FIRST TRIMESTER – sexual desire is decreased as caused by nausea, fatigue & sleepiness. CHANGES SECOND TRIMESTER – sexual desire is increased due to pelvic IN SEXUAL congestion and sense of well being. DESIRE: THIRD TRIMESTER – sexual desire is decreased due to fatigue and physical bulkiness  SEXUAL INTERCOURSE Is allowed until the last weeks of pregnancy (because it ha been found out that there is increased incidence of postpartum infection in women who engage in sex during the last 6 weeks) as there are no contraindications like the following: Bleeding Incompetent cervical os Deeply engaged presenting part Ruptured bow  SEXUAL INTERCOURSE Sexual Intercourse should be done with the woman in a compatible position: 1. Side lying 2. WOMAN SUPERIOR – woman on top  PSYCHOLOGICAL TASKS OF PREGNANCY First Trimester – ACCEPTING THE PREGNANCY “I am pregnant.” Maternal ambivalence, even in planned pregnancy, is usual; there may be some anticipation and concern related to fears and fantasies about pregnancy. The fetus is an unidentified concept with great future implications but without tangible evidence of reality. Implication: when giving health teachings, be sure to emphasize the bodily changes in pregnancy.  PSYCHOLOGICAL TASKS OF PREGNANCY Second Trimester ACCEPTING THE BABY as a separate individual “I am going to have a baby.” Quickening by 20 weeks can help a a woman realize that the fetus inside her womb is a real & separate individual to care for. She begins to fantasize about the child’s sex and appearance.  PSYCHOLOGICAL TASKS OF PREGNANCY Third Trimester PREPARING FOR DELIVERY AND PARENTHOOD “I am going to be a mother” Possible new fears related to labor and delivery and fantasies about the appearance of the baby. Woman begins to plan about the birth of baby. She selects a baby layette, choose names for her new baby, makes plans on how the baby will be fed, where the baby will sleep at home etc.  PATERNAL REACTIONS TO PREGNANCY A. FIRST TRIMESTER – Ambivalence & anxiety about role change; concern for identification with mother’s discomfort (Couvade syndrome) B. SECOND TRIMESTER – increased confidence & interest in mother’s care; difficulty relating to fetus; “JEALOUSY” Assessment of Fetal Growth  ASSESSMENT OF FETAL GROWTH Assessing Fetal Well-being  Fetal movement  Maternal serum alpha-  Fetal heart rate fetoprotein  Triple screening (AFP, estriol and  Ultrasound HCG)  Nonstress Test  Chorionic villi sampling  Electrocardiography  Amniocentesis  MRI  Percutaneous umbilical blood  Amnioscopy sampling  Fetoscopy  Biophysical profile  Fetal Movement Fetal movement that can be felt by the mother: QUICKENING begins at approximately 18-20 weeks of pregnancy; peaks at 28-38 weeks Primigravida – quickening 20 weeks (5 months) Multigravida – 16 weeks (4 months) Ask the mother to observe fetal movement A healthy fetus moves at least 10x a day  Fetal Movement Sandovsky Method Mother is in a left lateral recumbent position; fetus normally moves a minimum of twice every 10 minutes or an average of 10-12x an hour Cardiff Method – Count to ten - records the time it takes for her to feel 10 fetal movements; usually within 60 minutes  Fetal Heart Rate FHR should be 120-160 beats per minute Can be heard with a Doppler : 10th- 12th week of pregnancy (3months) Fetoscope: 18th-20th weeks (4 months) Stethoscope: 20 weeks (5 months  Ultrasound Respond of sound waves against objects Allows visualization of the uterine content Transabdominal UTZ full bladder client lies on her back  Ultrasound Transvaginal UTZ probe is inserted into the vagina lithotomy position empty bladder Ultrasound is best performed between 8-18 weeks  Ultrasound Diagnose pregnancy as early as 6 weeks Confirm the presence, size and location of the placenta and amniotic fluid Establish that the fetus is growing and has no gross defects (e.g., hydrocephalus, anencephaly, spinal cord, heart, kidney and bladder defects) Establish the presentation and position of the fetus Predict maturity by measurement of the biparietal diameter (BPD) Discover complications of pregnancy / fetal anomalies  Nonstress Test (NST) Measures the response of fetal heart rate to fetal movement Determines fetal well-being Performed to assess placental function and oxygenation  Nonstress Test (NST) An external ultrasound transducer and the tocodynamometer are applied to the mother and a tracing of at least 20 minutes duration is obtained so that the FHR and the uterine activity can be observed. Obtain baseline blood pressure and monitor blood pressure frequently. Position mother in semi-Fowler’s or side lying position to avoid vena cava compression. The mother may be asked to press a button every time she feels fetal movement; the monitor records a mark at each point of fetal movement, which is used as a reference point to assess FHR response  Results of NST: REACTIVE NONSTRESS TEST : Normal/Negative Indicates a healthy fetus Requires 2 or more FHR accelerations of at least 15 beats per minute, lasting at least 15 seconds from the beginning of the acceleration to the end, in association with fetal movement, during a 20-minute period. NONREACTIVE NONSTRESS TEST: Abnormal No accelerations or accelerations of than 15 bpm or lasting than 15 seconds in duration occur in a 40-minute observation. UNSATISFACTORY – The result cannot be interpreted because of the poor quality of FHR traing.  Contraction Stress Test (CST) or Oxytocin Challenge Test Assesses placental oxygenation and function Determines fetal ability to tolerate labor and determines fetal well- being Fetus is exposed to the stressor of contractions to assess the adequacy of placental perfusion under simulated labor conditions.  Contraction Stress Test (CST) or Oxytocin Challenge Test (OCT External fetal monitor is applied to the mother and a 20-to-30-minute baseline strip is recorded The uterus is stimulated to contract by the administration of a dilute dose of oxytocin of by having the mother use nipple stimulation until 3 palpable contractions with a duration of 40 seconds or more in 10-minute period have been achieved. Frequent maternal BP readings are done, and the mother is monitored closely while increasing doses of oxytocin are given.  Results of CST: NEGATIVE CST /NORMAL - no late or variable deceleration of FHR POSITIVE CST / ABNORMAL - late variable deceleration of FHR with 50% or more of the contractions in the absence of hyperstimulation of the uterus. EQUIVOCAL – with deceleration but with less than 50% of the contractions, or the uterine activity shows a hyper stimulated uterus. UNSATISFACTORY – adequate uterine contractions cannot be achieved, or the FHR tracing is no of sufficient quality for adequate interpretation.  Amniocentesis Amniotic fluid is aspirated by a needle inserted through the abdominal and uterine walls; indicated early in pregnancy (14-17 weeks) to detect inborn errors of metabolism, chromosomal abnormalities, open NTD (neural tube defect); sex-linked disorders after 28 weeks; determine lung maturity Indicated for pregnant women 35 years and older; couples who already have had a child with genetic disorder; one or both parents affected with a genetic disorder; mothers who are carriers for X-linked disorders An ultrasound is performed to determine a safe site for the needle to enter. Watch out for cramping, leakage of fluid, minor irritation around entry site & slight risk for miscarriage  Amniocentesis Prior to the procedure, the patient’s bladder should be emptied if AOG is more than 20 weeks. Post procedure, monitor for sign and symptoms of hemorrhage, labor,premature separation of placenta, fetal distress, amniotic fluid embolism, infection, inadvertent injury to maternal intestines/bladder or fetus; RhoGam is indicated for Rh (-) mothers.  Chorionic Villus Sampling (CVS) Transcervical aspiration of chorionic villi that allows for first trimester (8-12 wk) diagnosing of genetic disorders comparable to amniocentesis (except for NTD because no amniotic fluid is retrieved during the procedure) Pre-procedure: there should be full bladder; ultrasound is used as in amniocentesis. Post-procedure: same as for amniocentesis  Estriol Levels Serial 24-H maternal urine samples or serum specimens to determine fetoplacental status; falling levels usually indicate deterioration  Percutaneous Umbilical Blood Sampling (PUBS) Second and third trimester method to aspirate cord blood (location identified by ultrasound) to test for genetic conditions, chromosomal abnormalities, fetal infections, hemolytic or hematological disorders.  Lecithin / Sphingomyelin Ratio (2:1) Important components of surfactant, a phosphoprotein that lowers surface tension of the lungs that facilitates extrauterine expiration. Prevents lung collapse  Biophysical Profile (BPS) Assesses 4 to 6 parameters (fetal breathing movement, fetal movement, fetal tone, amniotic fluid volume, placental grading, and fetal heart reactivity / reactive NST) Each item has a potential for scoring a 2; 12 highest possible score BPS 8 – 10: fetus is doing well BPS 6: fetus is in jeopardy; worrisome BPS 4 or less is ominous. The doctor may decide to deliver the baby of the score is 6 or below.  Maternal Serum Alphaprotein Involves drawing a small amount of BLOOD from the mother to check the level of alpha protein. AFP is produced by the liver and is excreted thru placenta into the mother’s blood (usually tested at 15 & 17 weeks) High amount: Neural tube defect (NTD) such as spina bifida (open spine) or anencephaly (absence of brain) Low amount: Indicative of Trisomy 21 Best results are obtaine if taken between 16-18 wks.  Maternal Serum Alpha protein TESTS DONE Between 16-18 weeks - Maternal serum Alphaprotein Between 26-28 weeks - Diabetic screening for all pregnant women - Repeat Hgb and Hct _Repeat Antibody for unsensitized Rh negative women Between 32-36 weeks - Ultrasound - Testing for STD 3. Post Consultation Phase (Health Teachings) Schedule of clinic visits Exercises Dental hygiene Clothing Traveling Bathing Employment Sexual relation Immunization  Nutrition Nutrition = most important aspect Food sources: Protein rich foods = meat, fish, eggs, milk, poultry, cheese, beans, mongo Vitamin A = eggs, carrots, squash, cheese, beans, vegetables Vitamin D = fish. Liver, eggs, milk (excess vit. D during pregnancy can lead to fetal cardiac problems) Vitamin E = green leafy vegetables, fish  Nutrition Vitamin C = tomatoes, guava, papaya Vitamin B = protein rich foods Calcium / phosphorous = milk, cheese Iron = especially important during the last trimester when the pregnant woman is going to transfer her iron stored from herself to her fetus so that the baby has enough iron stored during the 1st 3 months of life when all he takes is mik (which is deficient in iron). Iron has a very low absorption rate: only 10% of the iron intake can be absorbed by the body. Thus, for optimum absorption, vive vitamin C.  Nutrition Iron should be given after meals because it is irritating to the gastric mucosa Sources: liver and other internal organs, camote tops, kangkong, egg yolk, ampalaya, amlunggay, saluyot. Malnutrition during pregnancy can result in prematurity, preeclampsia, abortion, low birth weight babies, congenital defects or even stillbirth  Nutrition Folic acid – to prevent neural tube defects (spina bifida, meningocoele) Sources: Green leafy vegetables Fruits (oranges) Liver, legumes, nuts RDA FOR SALT IN A PREGNANT WOMAN IS 3g/DAY BECAUSE OF INCREASE IN BLOOD VOLUME TO MAINTAIN F & E BALANCE.  NUTRITIONAL REQUIREMENTS CALORIES – 300 kcal/d; may need adjustment for prepregnant under/overweight There should be no attempt at weight reduction during pregnancy. CARBOHYDRATES – needed to prevent unsuitable use of fats/proteins for added energy needs; important to “empty” calorie sources  NUTRITIONAL REQUIREMENTS Iron – a total of 30 mg/d of elemental iron; usually requires supplement Calcium – 1,200 mg; best obtained from dairy products; if milk is disliked or poorly tolerated, calcium supplement may be necessary. Sodium – should not e restricted without serious indication; excess should be discouraged Phosphorus – for the development of fetal bones and teeth. 1200mg 24-H recall/diet diaries may be used to evaluate high-risk woman