Patient and Family

Education in Pregnancy
Marzena Slater, MD
PGY-3
Objectives
To discuss the following in the context of
patient education:
Guidelines for Exercise in Pregnancy
Nutrition and Dietary changes in Pregnancy
Discomforts and Physical Changes Commonly
Found in Pregnancy & Treatments available for
each.
A Reminder: Levels Of Evidence
Level A: Good scientific evidence suggests that the benefits of the clinical service
substantially outweighs the potential risks. --consistent, good-quality patient-oriented
evidence (i.e RCT)

Level B: At least fair scientific evidence suggests that the benefits of the clinical
service outweighs the potential risks. --inconsistent or limited-quality patient-oriented
evidence (i.e meta analysis)

Level C: At least fair scientific evidence suggests that there are benefits provided by
the clinical service, but the balance between benefits and risks are too close for
making general recommendations. --consensus, disease-oriented evidence (i.e usual
practice, opinion, or case series)

Level D: At least fair scientific evidence suggests that the risks of the clinical service
outweighs potential benefits. Clinicians should not routinely offer the service to
asymptomatic patients.

Level I: Scientific evidence is lacking, of poor quality, or conflicting, such that the risk
versus benefit balance cannot be assessed. Clinicians should help patients
understand the uncertainty surrounding the clinical service.

Exercise in Pregnancy
Physical activity is essential to the health
of women in their childbearing years.
Pregnancy is a normal condition for
women, and exercise can be part of a
normal pregnancy.
The research studies dealing with exercise
in pregnancy have shown no harmful
effects to the mother and fetus.
Exercise in Pregnancy
For most pregnant women,
exercise is not only safe but also beneficial
to the health of the mother and the infant.
Pregnant women who exercise have:
reduced weight gain
more rapid weight loss after pregnancy
improved mood and sleep patterns
Some studies have also shown faster labors
and less need for induction with pitocin.

Exercise in Pregnancy
Precautions that patients should take to ensure that their exercise program
does not lead to pregnancy complications:

An exercise routine prior to the pregnancy should be able to be maintained to some extent
throughout pregnancy.

If patients are just starting an exercise program, they should start very slowly and be careful
not to over exert themselves.

Regular activity (ex. 3 times/week) is preferable to intermittent activity

Special care should be taken to:
drink plenty of fluids
wear comfortable clothing/shoes
not to exercise in hot environments to prevent overheating & dehydration.

Weight training exercises should emphasize improving tone, especially in the upper body
and abdominal area. Heavy lifting or lifting weight above the head and using weights that
strain the lower back should be avoided.

Pregnancy requires an additional 300 kcal/day, make sure your patients are getting adequate
nutrition
Exercises Not
Recommended
Any type of exercise that has risks of fall/injury
to the abdomen should be avoided.
These include contact sports. (Level C evidence)

Sports considered unsafe in pregnancy include:
Horseback riding
Skiing/snowboarding
Water Skiing
Scuba diving (Level C)
Kick boxing
Soccer/basketball/baseball or any other contact sports where patient could collide with
another player
Cycling- other than a stationary bike

During the second and third trimester patients should avoid exercises that involve
laying flat on the back, since this decreases blood flow to the uterus and baby.

In general counsel patients to stop exercising if they are fatigued and to not exercise
to exhaustion. They should be able to talk while exercising.
When to avoid exercise during
pregnancy
High blood pressure/Pre-eclampsia
Placenta Previa/Vaginal Bleeding
Preterm labor or history of preterm labor
Intrauterine Growth Restriction (IUGR)
Twin pregnancy
Heart Disease
Other conditions
Uncontrolled kidney disease
Anemia
Uncontrolled diabetes
Thyroid disease
Extreme obesity.
The Exercise Prescription
Sedentary women
Mode Walking, stair climbing, biking, swimming, aerobic dance
Intensity 65-75% max heart rate; perceived exertion= moderate hard
Duration 30 min
Frequency 3 times/week
Recreational athletes/regular Fitness Exercises
Mode Same as above plus running/jogging, dance, tennis
Intensity 65-85% max heart rate; perceived exertion= moderate to hard
Duration 30-60 min
Frequency 3-5 times/week
Elite Athletes
Mode Same as above plus some competitive activities- depends on pregnancy trimester
Intensity 75-85% max heart rate; perceived exertion= hard
Duration 60-90 min
Frequency 4-6 times/week
Nutrition and Dietary Changes in
Pregnancy

On average pregnant women should be eating 300 calories more per day
than usual.
Weight Gain (lbs)
Maternal classification Total (lbs) Rate (lbs/4wk)*
Pre-pregnant BMI
Underweight (<19.8) 28-40 5.0
Normal Weight (19.8-28) 25-35 4.0
Overweight (28.1-29.0) 15-25 2.6
Obese (>29.0) 15 2.0
Twin Gestation 35-45 6.0
Calcium
1200 mg of calcium is required-- an
additional 400 mg over non-pregnant
amount.
Three to four milk servings per day are
sufficient to achieve this additional need.
Sources of calcium other than milk include
yogurt, cheese, ice cream, broccoli,
spinach.
Iron
Iron is needed in larger doses, especially in the later stages of
pregnancy. In healthy, well nourished women, routine iron
supplementation is not necessary.

Select iron supplementation may be necessary depending on
patients blood counts (Hb < 10.5 g/dL) . Some iron rich foods
include iron fortified cereals, certain beans, red meats, spinach &
eggs.

Educate patients that if they are started on an iron supplementation
to not take it with milk, antacids, or anything containing calcium
(including prenatal vitamins) since calcium blocks absorption of iron.

Warn patients about constipation associated with iron use.
Folic Acid
Women of reproductive age should take a
multivitamin with 0.4 mg to 0.8 mg of folic acid
before trying to conceive. This vitamin can be
found in many food sources:
Dark, leafy green vegetables (spinach, collard, turnip
green, romaine lettuce, broccoli, asparagus)
Whole grain breads & cereals
Citrus fruits & juices (strawberries, oranges)
Dried peas & beans (pinto, black, navy & lima beans)
Foods To Avoid In Pregnancy
Raw meat
Uncooked seafood, beef or poultry should be avoided, because
it may be contaminated with salmonella, E. coli and
toxoplasmosis.
Listeriosis
Bacteria that can occur in un-pasteurized milk and soft cheese
and prepared and uncooked meats, poultry, and shellfish. It can
cause miscarriage. May be found in:
Deli Meat- Counsel patients that if they choose to eat deli meat, to
buy it from a reputable source and eat within 48 hours of purchase.
They may also consider heating it up in the microwave until it is
steaming.
Soft Cheeses- brie, feta, gorgonzola, Mexican style cheeses such
as queso blancho and queso fresco. Soft non-imported cheeses
made with pasteurized milk are safe to eat.
Unpasteurized Milk
Pate
Foods To Avoid In Pregnancy
Fish
Fish containing mercury-
shark, swordfish, king mackerel, fresh tuna, sea bass, and tilefish.
(Level B evidence)
Canned tuna is safe, but patients should not eat more than 12 oz. in
a week. Mercury consumed during pregnancy has been linked to
developmental delays
Fish exposed to Industrial Pollutants-
Fish from contaminated lakes & rivers that may be exposed to high
levels of polychlorinated biphenyls.
These fish include: blue fish, striped bass, salmon, pike, trout &
walleye.
This is regarding fish caught in local waters and not fish from local
grocery store.
Raw Shellfish- The majority of seafood related illnesses are
caused by undercooked shellfish, which include oysters, clams &
mussels. They should be avoided in pregnancy.

Foods To Avoid In Pregnancy
Caffeine
There has been some controversy in linking maternal
caffeine use and pregnancy complications, with some
studies suggesting excess intake increasing the risk
for miscarriage, low birth weight.
General rules of thumb:
Counsel to avoid caffeine during the first trimester to reduce
the likelihood of miscarriage.
In later stages of pregnancy, caffeine should be limited to
less than 300 mg/day (which is about 2 beverages/day).
Caffeine is a diuretic. Make sure your patients are drinking
plenty of fluids.
Foods To Avoid
In Pregnancy
Alcohol
Safe levels of alcohol in pregnancy have not been
established.
Counsel your patients to AVOID alcohol during
pregnancy.
Alcohol depletes the body of zinc and magnesium,
which are necessary for fetal development.
Alcohol consumption during pregnancy can lead to
Fetal Alcohol Syndrome or other developmental
disorders.
Alcohol should continue to be avoided during
breastfeeding.
Common Discomforts Of
Pregnancy & Treatments

A Word on Medications in Pregnancy
Counsel patients that risks and benefits of any drug therapy taken during pregnancy
should be discussed with physician.

The effect a medication has on the fetus depends on the medicine itself and the
trimester of pregnancy it is taken in:

First trimester- the period of greatest risk for the fetus. Up till 12 weeks is the period of
organogenesis

Second trimester- in general is the safest period to take medications. However, medications
may still affect the fetal nervous system or the growth of the fetus, resulting in low birth
weight.

Third trimester- Medications taken during this time can stick around in the fetal bloodstream
after birth, causing problems such as breathing difficulties.

Clinical trials/actual studies on the safety of medications are rarely or never done on
pregnant women, for obvious reasons Most medications are level C evidence
Nausea & Vomiting
Up to 70 % of pregnancies. Usually begins
early 6-8 weeks and continues up to 13-16 weeks.
Caused by hormonal changes (higher level
of circulating Estrogen) that decrease the motility
of the intestines.
Behavioral Rx:
Eating small, frequent meals, avoiding spicy and fried foods.
A protein snack before bedtime and keeping dry crackers at the bedside to eat
before rising in the morning.
Medical Rx:
Vitamin B6 (100 mg twice a day)
Doxylamine (Unisom), tab at bedtime (Antihistamine) or Benadryl
Emetrol liquid as directed
Ginger (250mg cap po qid)
If patient is unable to tolerate prenatal vitamin in the morning, they may try
taking it in the evening or taking 2 chewable Flinstone vitamins daily
Things we can perscribe:
Category B: Meclizine, Reglan, Zofran
Category C: Phenergan, Compazine
Heartburn
Delayed emptying from the stomach due to hormonal
changes and pressure from an enlarging uterus
commonly cause reflux in pregnancy.
Behavioral Rx:
Eating smaller, more frequent meals and taking antacids.
Avoiding spicy, fatty and gas producing foods, such as
cabbage.
Avoiding eating close to bedtime.
Medical Rx:
Antacids are generally safe
Gaviscon is safe to take as directed
Tums, Maalox, Mylanta, Rolaids, Milk of Magnesia as directed
for minor discomfort.
Pepcid AC or over the counter Zantac are safe.
Mylicon (simethicone) as directed for gas


Constipation
Due to slowed motility of the
gastrointestinal tract and growing size of
the uterus.
Behavioral Rx:
Increasing fluid intake (2 quarts/day), fiber intake.
Regular exercise.
Medical Rx:
1
st
line:
Bulking agents- Fibercon, Benefiber, or Metamucil.
Stool softeners - Colace as directed.
2
nd
line: (Have patients consult you 1
st
)
Stimulant laxatives - Senekot
If no relief after the above measures, patients may try a glycerin suppository as
directed
If no relief after above, patients may use as Ducolax suppository as directed
If no relief after above, patients may use Fleet enema as directed


Hemorrhoids/Varicose Veins
Occur due to the pressure of the growing uterus as
well as inactivity, prolonged standing and constipation.
Behavioral Rx:
Avoid constipation with stool softeners and with increased fluid
and fiber intake.
Sitz baths- warm water for 20 minutes, 3-4 times per day
Prevention of varicose veins from occurring by resting the feet
up, wearing support hose and proper shoes.
Increasing water and decreasing salt intake.
Kegel exercises
Medical Rx:
Anusol cream or Preparation H as directed
Tucks pads as directed



Urinary frequency/
incontinence
Due to the growing uterus
pushing down on the bladder.
Incontinence is usually of the
stress type- i.e. occurring with
coughing, sneezing or laughing
increases pressure on the bladder.
Behavioral Rx:
Educate patients to continue to drink plenty of fluids during
the day, less so at night.
Educate patients regarding sxs of urinary tract infection.
Symptoms of urinary incontinence can be improved by
regular Kegel exercises
Round Ligament Pain
Pain on the sides of the
abdomen that can extend into the groin.

Caused by stretching of the ligaments that
support the uterus as the uterus grows.

Behavioral Rx:
Applying heat, Tylenol and lying with a pillow between
the knees at night.

Backache
As the uterus enlarges during pregnancy, the
center of gravity will be shifted, putting more
strain on the lower back.

It may be prevented by avoiding excessive
weight gain, improving posture, proper bending
with a straight back and wearing flat shoes.

Behavioral Rx:
Tylenol as needed
Heating pads
At night sleeping with a pillow between the legs to improve
hip/knee alignment.

Headaches
Are common during pregnancy.

May be related to tension, increased sinus congestion
head colds/allergies, increased blood flow and nasal
edema or high blood pressure.

Women who suffer from headaches or migraines prior
to pregnancy, will often find their headaches become
more frequent & severe while pregnant.

Behavioral Rx:
Tylenol & rest may help.
Pain (Ligament pain, Backaches,
Headaches)
Medical Rx:
Tylenol is safe in all three trimesters. Educate patients not
exceed recommended doses.
Aspirin is not acceptable.
Advil, Motrin or Ibuprofen should be avoided, particularly in the
third trimester.
Codeine and hydrocodone:
Found in most narcotics
Can affect the babys breathing if taken in the last trimester or
during labor in large amounts.
Chronic use may cause withdrawal symptoms in the newborn.
In general try to avoid prescribing these medications if
possible
They may be taken for short periods of time to treat specific
pain conditions in the second and third trimester.
Shortness of Breath


Due to hormonal changes and upward pressure of the
growing uterus.

Behavioral Rx:
Sleeping with head elevated on pillows.
Pacing self when it comes to daily activities.
Nasal Congestion
Due to increased blood volume & hormonal changes of
pregnancy.

Pre-existing allergies may make it worst.

Behavioral Rx:
Using of a room humidifier.
Saline nose drops

Medical Rx:
Tylenol cold & sinus, Sudafed (caution if high blood pressure) -
may be taken in limited quantities for short amounts of time.
Afrin and other nasal decongestants, such as phenylephrine
are NOT acceptable & should be avoided.


Colds, Cough & Allergies- RX
Behavioral Rx:
Educate patients to stay well hydrated, eat plenty of protein, and get extra rest
Steam inhalation/humidifiers also help
Have patients call you if Temp>100.5

Medical Rx:
Allergies:
Claritin or benadryl are safe.
Nasal steroid sprays such as Flonase, with long term use can be absorbed in
sufficient amounts to impair the growth of the fetus. They may be used short term
Coughs:
Cough medicines often contain several ingredients- educate patients to check the
safety of each one before use.
Cough expectorants, such as guaifenesin, are safe to use.
Educate patients to AVOID cough medicines containing iodine
Cough suppressants, such as codeine or dextromethorphan, can be used in the
second and third trimester for short periods of time. Educate patients to avoid them
in the first trimester.
Lozenges are the safest option.



Edema
Swelling of the ankles and feet commonly
occur during pregnancy due to decreased
circulation and pressure from enlarging uterus.
Behavioral RX:
Avoidance of sitting and standing for long periods of
time
Sleeping on side & elevating the legs
Increasing fluid intake, decreasing salt intake and
wearing support stockings.

Skin changes
Chloasma- Mask of pregnancy. Increased pigmentation over
the face/neck. Hormonal- patients may try to avoid direct sun
exposure/wear sun screen. Will fade after delivery.
Areola- area around nipple becomes darker
Linea Nigra- dark line between the belly button and pubic
region. Normal in pregnancy. Will eventually fade after
delivery.
Stretch Marks- Develop over the abdomen, hips, and breasts
in over 50% of pregnant women. They will fade in color after
delivery.
Behavioral Rx: There are no proven methods for preventing stretch
marks- likely genetically determined. Cocoa butter and vitamin E
creams may help with the itching that often accompanies striae
formation
Skin conditions (Eczema, dermatitis &
skin allergies)
Medical Rx:
Moisturizers and soothing products are completely
safe and should be the first line rx.
Steroid creams can be used in pregnancy, but should
be avoided on large areas of skin, for long periods of
time or under dressings since they can be absorbed
into the bloodstream.

Recommended Vaccinations
Flu vaccine.
Tetanus vaccine if patient hasnt had one in > 10
years (Td not Tdap)
NO LIVE VACCINES are allowed during and up to
3 months before pregnancy.
REFERENCES
1. Ratcliffe, S.D. et al; Family Practice Obstetrics, 2nd ed..
Philadelphia:Hanley & Belfus Inc. 2001
2. Kirkham, C., Harris, S. & Grzybowski, S.; Evidence Based
Prenatal Care: Part 1. General Prenatal Care and counseling
issues. American Family Physician, April 1, 2005.
3. Kirkham, C., Harris, S. & Grzybowski, S.; Evidence Based
Prenatal Care: Part 2. Third Trimester Care and prevention of
infectious diseases. American Family Physician, April 15, 2005.
4. Choby; Pregnancy Care: FP essentials 292. AAFP home study.
September 2003.
5. Lu, M.C. Recommendations for preconception care. American
Family Physician, August 1, 2007
6. Cunningham, G. et al; Williams Obstetrics. McGraw-Hill
Companies, March 2005.
7. http://www.acog.org/publications/patient_education
8. http://www.perinatology.com/Reference/RDApregnancy.htm