Nutrition and Pregnancy If you are pregnant or breastfeeding, you should add: * four servings of vitamin B12-fortified foods; * 15 minutes of sunshine on your arms and face or 200 IU [international units] of vitamin D; * eight servings (12001500 mg) of calcium-rich foods; * iron-rich foods; * 1 tablespoon of ground flax seed or other N-3 fatty acid-rich food.

Vitamin B12: Vitamin B12 is important for the growth of nerve and blood cells. It is only found naturally in animal foods like meat, fish, and milk. Plant-based foods that are fortified with vitamin B12 Vitamin B12 is important for the growth of nerve and blood cells. It is only found naturally in animal foods like meat, fish, and milk. Plant-based foods that are fortified with vitamin B12 include soymilk, tofu, cereal, and nutritional yeast.

Vitamin D: Vitamin D is important for growth of the bones and the teeth. It is found in animal foods, but can also be absorbed through the skin from sunlight. Vitamin D-fortified foods include cow's milk, some soymilk, and some breakfast cereals. Vitamin D is important for growth of the bones and the teeth. It is found in animal foods, but can also be absorbed through the skin from sunlight. Vitamin D-fortified foods include cow's milk, some soymilk, and some breakfast cereals.

Calcium: Calcium is very important for bone growth and strength. Calcium is very important for bone growth and strength.

Calcium is found in milk products. Plant-based food sources include broccoli, collards, kale, sesame seeds, almonds, and soy products.

Iron: Iron is used in making blood. It is most commonly found in meat and eggs. Plant-based iron-rich foods include soy, bean, lentils, spinach, mola.s.ses, dried apricots, prunes, and raisins. To make the most of your iron, eat it with a high vitamin C food like oranges or strawberries. Iron is used in making blood. It is most commonly found in meat and eggs. Plant-based iron-rich foods include soy, bean, lentils, spinach, mola.s.ses, dried apricots, prunes, and raisins. To make the most of your iron, eat it with a high vitamin C food like oranges or strawberries.

Essential fatty acids: Essential fatty acids are important to the function of cells and the development of the brain. There are two types of fatty acids: N-3 and N-6. Vegetarian diets tend to have a lot of N-6 Essential fatty acids are important to the function of cells and the development of the brain. There are two types of fatty acids: N-3 and N-6. Vegetarian diets tend to have a lot of N-6 fatty acids but be low in N-3. Sources of N-3 fatty acids include eggs, flaxseed, and canola and soybean oils.

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Pregnancy and Birth Sourcebook, Third Edition Section 21.3 Anemia and Pregnancy "Anemia and Pregnancy," 2003 University of Pittsburgh Medical Center (www.upmc.com). Reprinted with permission. The text that follows this doc.u.ment under the heading "Health Reference Series Medical Advisor's Notes and Updates" was provided to Omnigraphics, Inc. by David A. Cooke, MD, FACP, March 31, 2009. Dr. Cooke is not affiliated with the University of Pittsburgh Medical Center. Medical Advisor's Notes and Updates" was provided to Omnigraphics, Inc. by David A. Cooke, MD, FACP, March 31, 2009. Dr. Cooke is not affiliated with the University of Pittsburgh Medical Center.

What is anemia?

Anemia means you have low iron in your blood or "low blood."1 Iron helps your red blood cells carry oxygen to all parts of your body.

What are the symptoms of anemia?

Anemia can make you feel very tired and have no energy. You may feel light-headed or dizzy and may "black out."

How does anemia affect my baby?

Your baby depends on you for oxygen. If you have severe anemia, your baby may not get enough oxygen to grow well. The baby may be small at birth. Anemia may increase the chance that you will give birth early. If you have anemia and bleed heavily after the birth, you may need a blood transfusion.

What treatment is available?

To treat anemia, you need to replace the iron in your body. It is important that you and your doctor work together to treat anemia.

Here are some tips for treating anemia: * Take vitamins and iron pills every day as your doctor tells you to.

* Do not take iron pills with milk. The calcium in the milk does not let the iron work well in your body.

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Nutrition and Pregnancy * Take your iron pill with juices that have vitamin C in them.

Some examples are orange juice and tomato juice. This helps the iron get into your blood better.

* Do not take antacids like Tums or Maalox at the same time you take iron pills. These can affect how your body uses the iron pills.

* Iron pills can cause problems having a bowel movement. Eat more foods with fiber, like fruits, vegetables, and cereals.

* Drink 6 to 8 gla.s.ses of water or juice daily.

* Your bowel movements may turn dark black. This is normal.

* Eating foods that are high in iron is very important. Foods that help increase your iron level are: * red meats, like beef and pork; * liver; * black mola.s.ses; * peanut b.u.t.ter; * nuts, like almonds and cashews; * beans; * dried fruits, like prunes, apricots, figs, raisins, peaches, and dates; * egg yolks; * sweet potatoes; * dark green or yellow vegetables, like collard greens, kale, spinach, turnips, and mustard greens; * raisin bran cereal and wheat germ.

Eating right and taking iron and vitamins will help keep you and your baby healthy.

Health Reference Series Medical Advisor's Notes and Updates Most cases of anemia in pregnancy are due to iron deficiency, and the advice in this article is directed toward this. However, not all anemia is due to iron deficiency. A variety of other conditions including kidney disease, bone marrow disease, drug 189 Pregnancy and Birth Sourcebook, Third Edition effects, and other vitamin deficiencies can also cause anemia.

Check with your doctor that your anemia is due to iron deficiency, because treatment might be quite different with other conditions.

Section 21.4 What You Need to Know about Mercury in Fish and Sh.e.l.lfish Excerpted from "What You Need to Know about Mercury in Fish and Sh.e.l.lfish," by the Environmental Protection Agency (EPA, www.epa.gov), August 14, 2008.

Fish and sh.e.l.lfish are an important part of a healthy diet. Fish and sh.e.l.lfish contain high-quality protein and other essential nutrients, are low in saturated fat, and contain omega-3 fatty acids. A well-balanced diet that includes a variety of fish and sh.e.l.lfish can contribute to heart health and children's proper growth and development. So, women and young children in particular should include fish or sh.e.l.lfish in their diets due to the many nutritional benefits.

However, nearly all fish and sh.e.l.lfish contain traces of mercury.

For most people, the risk from mercury by eating fish and sh.e.l.lfish is not a health concern. Yet, some fish and sh.e.l.lfish contain higher levels of mercury that may harm an unborn baby or young child's developing nervous system. The risks from mercury in fish and sh.e.l.lfish depend on the amount of fish and sh.e.l.lfish eaten and the levels of mercury in the fish and sh.e.l.lfish. Therefore, the Food and Drug Administration (FDA) and the Environmental Protection Agency (EPA) are advising women who may become pregnant, pregnant women, nursing mothers, and young children to avoid some types of fish and eat fish and sh.e.l.lfish that are lower in mercury.

By following these three recommendations for selecting and eating fish or sh.e.l.lfish, women and young children will receive the benefits of eating fish and sh.e.l.lfish and be confident that they have reduced their exposure to the harmful effects of mercury.

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Nutrition and Pregnancy Do not eat shark, swordfish, king mackerel, or tilefish because they contain high levels of mercury.

Eat up to 12 ounces (2 average meals) a week of a variety of fish and sh.e.l.lfish that are lower in mercury. Five of the most commonly eaten fish that are low in mercury are shrimp, canned light tuna, salmon, pollack, and catfish. Another commonly eaten fish, albacore ("white") tuna has more mercury than canned light tuna. So, when choosing your two meals of fish and sh.e.l.lfish, you may eat up to 6 ounces (one average meal) of albacore tuna per week.

Check local advisories about the safety of fish caught by family and friends in your local lakes, rivers, and coastal areas. If no advice is available, eat up to 6 ounces (one average meal) per week of fish you catch from local waters, but don't consume any other fish during that week.

Follow these same recommendations when feeding fish and sh.e.l.lfish to your young child, but serve smaller portions.

Section 21.5 Caffeine Use during Pregnancy From "Caffeine," by the Center for the Evaluation of Risks to Human Reproduction (CERHR, cerhr.niehs.nih.gov), part of the National Inst.i.tute of Environmental Health Sciences (NIEHS), April 23, 2008.

Numerous studies have examined the effects of caffeine intake on fertility and pregnancy. Most studies found that moderate caffeine intake does not affect fertility or increase the chance of having a miscarriage or a baby with birth defects; some studies did find a relationship between caffeine intake and fertility or miscarriages.

However, most of those studies were judged to be inadequate because they did not consider other lifestyle factors that could contribute to infertility or miscarriages. The Organization of Teratology Information Services (OTIS) stated that there is no evidence that caffeine 191 Pregnancy and Birth Sourcebook, Third Edition causes birth defects in humans. Groups such as OTIS and Motherisk agree that low caffeine intake (<150 mg/day="" or="" 1="" 1/2="" cups="" of="" coffee)="" will="" not="" likely="" increase="" a="" woman's="" chance="" of="" having="" a="" miscarriage="" or="" a="" low="" birth="" weight="" baby.="" motherisk="" recommends="" that="" caffeine="" intake="" by="" pregnant="" women="" not="" exceed="" 150="" mg/day="" whereas="" otis="" stated="" that="" moderate="" caffeine="" intake="" of="" 300="" mg/day="" (equivalent="" to="" about="" 3="" cups="" of="" coffee)="" does="" not="" seem="" to="" reduce="" fertility="" in="" women="" or="" increase="" the="" chances="" of="" having="" a="" child="" with="" birth="" defects="" or="" other="" problems.="" caffeine="" can="" enter="" breast="" milk,="" and="" high="" amounts="" can="" cause="" the="" baby="" to="" become="" wakeful="" and="" agitated.="" the="" american="" academy="" of="" pediatrics="" recommends="" that="" nursing="" women="" limit="" caffeine="" intake,="" but="" states="" that="" no="" harm="" is="" likely="" to="" occur="" in="" a="" nursing="" child="" whose="" mother="" drinks="" one="" cup="" of="" coffee="" a="" day.="" otis="" recommends="" that="" pregnant="" and="" nursing="" women="" drink="" plenty="" of="" water,="" milk,="" and="" juice="" and="" not="" subst.i.tute="" those="" fluids="" with="" caffeinated="">

Caffeine and Fertility Numerous studies have been conducted to determine the effects of caffeine intake on fertility in women. The International Food Information Council (IFIC) has described and made conclusions about the following studies.

One small study in 1988 suggested that caffeine, equivalent to the amount consumed in 1 to 2 cups of coffee daily, might decrease female fertility. However, the researchers acknowledged that delayed conception could be due to other factors they did not consider, such as exercise, stress, or other dietary habits. Since then, larger, well-designed studies have failed to support the 1988 findings.

In 1990, researchers at the Centers for Disease Control and Prevention and Harvard University examined the a.s.sociation between the length of time to conceive and consumption of caffeinated beverages. The study involved more than 2,800 women who had recently given birth and 1,800 women with the medical diagnosis of primary infertility. Each group was interviewed concerning caffeine consumption, medical history, and lifestyle habits. The researchers found that caffeine consumption had little or no effect on the reported time to conceive in those women who had given birth. Caffeine consumption also was not a risk factor for infertility.

Supporting those findings, a 1991 study of 11,000 Danish women examined the relationship among number of months to conceive, cigarette smoking, and coffee and tea consumption. Although smokers who consumed eight or more cups of coffee per day experienced 192 Nutrition and Pregnancy delayed conception, nonsmokers did not, regardless of caffeine consumption.

A study of 210 women, published in the American Journal of Public Health American Journal of Public Health in 1998, examined the differences in fertility a.s.sociated with consumption of different caffeinated beverages. This study, prompted by an inconsistency in previously reported findings, did not find a significant a.s.sociation between total caffeine consumption and reduced fertility. In fact, the researchers found that women who drank more than one-half cup of tea per day had a significant increase in fertility. This was particularly true with caffeine consumption in the early stages of a woman's attempt at conception. The caffeinated tea and fertility correlation was supported by a 1994 study; however, those women had significantly higher consumption levels. OTIS reviewed the studies examining caffeine effects on fertility and concluded that, in 1998, examined the differences in fertility a.s.sociated with consumption of different caffeinated beverages. This study, prompted by an inconsistency in previously reported findings, did not find a significant a.s.sociation between total caffeine consumption and reduced fertility. In fact, the researchers found that women who drank more than one-half cup of tea per day had a significant increase in fertility. This was particularly true with caffeine consumption in the early stages of a woman's attempt at conception. The caffeinated tea and fertility correlation was supported by a 1994 study; however, those women had significantly higher consumption levels. OTIS reviewed the studies examining caffeine effects on fertility and concluded that, "Low to moderate caffeine consumption (<300 mg/day)="" does="" not="" seem="" to="" reduce="" a="" woman's="" chance="" of="" becoming="">

Caffeine and Pregnancy The March of Dimes notes that during pregnancy, caffeine easily pa.s.ses from the mother to her unborn child through the placenta.

Because the systems for breaking down and eliminating chemicals are not fully developed in the unborn child, blood levels of caffeine may remain elevated for longer periods in the unborn child compared to the mother. OTIS notes that, "higher amounts of caffeine could affect babies in the same way as it does adults. Some reports have stated that children born to mothers who consumed >500 mg/day were more likely to have faster heart rates, tremors, increased breathing rate, and spend more time awake in the days following birth." The effects of caffeine intake on miscarriages, birth defects, and low birth weight have been studied, and different results were obtained in the various studies. The International Food Information Council (IFIC) has described and made conclusions about the following studies.

Recently, researchers from McGill University in Montreal published a study showing a relationship between caffeine intake and miscarriage. While caffeine intake before and during pregnancy appeared to be a.s.sociated with increased fetal loss, the authors failed to account for a number of factors that could result in a false a.s.sociation, including effects of morning sickness or nausea, the number of cigarettes smoked, and amount of alcohol consumed.

Just prior to the McGill study, a research team from the U.S. National Inst.i.tute of Child Health and Human Development conducted 193 Pregnancy and Birth Sourcebook, Third Edition a study of 431 women. The researchers monitored the women and the amount of caffeine they consumed from conception to birth. After accounting for nausea, smoking, alcohol use, and maternal age, the researchers found no relationship between caffeine consumption of up to 300 mg per day and adverse pregnancy outcomes, including miscarriage.

Earlier, in 1992, researchers a.n.a.lyzed the effects of cigarettes, alcohol, and coffee consumption on pregnancy outcome in more than 40,000 Canadian women. Although alcohol consumption and smoking tended to have adverse effects on pregnancy outcome, moderate caffeine consumption was not a.s.sociated with low birth weight or miscarriages.

Further, the relationship of caffeine consumption to spontaneous abortion was investigated in a study of 5,342 pregnant women in 1997 in which researchers concluded that there was no increased risk for spontaneous abortion a.s.sociated with moderate caffeine consumption. Another very comprehensive study, done in Uppsala, Sweden, and reported in December 2000, concluded reducing caffeine intake during early pregnancy may be prudent.

Studies published during the 1980s also support the conclusion that moderate caffeine consumption during pregnancy does not cause early birth or low birth-weight babies. A review of more than 20 studies conducted since 1980 found no evidence that caffeine consumption at moderate levels has any discernible adverse effect on pregnancy outcome.

A seven-year study of 1,500 women examined caffeine use during pregnancy and subsequent child development. Caffeine consumption, equivalent to about 1 1/22 cups of coffee per day had no effect on birth weight, birth length, or head circ.u.mference. Follow-up examinations at ages 8 months, 4 years, and 7 years also revealed no effects of caffeine consumption on a child's motor development or intelligence.

In the early 1980s, the U.S. Food and Drug Administration (FDA) conducted a study where rats were force-fed very high doses of caffeine through a stomach tube. While the results prompted an advisory to pregnant women to avoid caffeine, the study was criticized as not being representative of the way humans consume caffeine.

In 1986, FDA researchers carried out another study, in which rats consumed high doses of caffeine in their drinking water. At the conclusion of the second study, the FDA found no adverse effects in the offspring, contradicting the agency's earlier findings.

A recent study published in 2001 examined the effect of maternal caffeine consumption throughout pregnancy on fetal growth and found evidence that caffeine consumption during pregnancy has no adverse 194 Nutrition and Pregnancy effect on fetal growth. Additionally, a 2002 study ent.i.tled "Effect of caffeine exposure during pregnancy on birthweight and gestational age," in the American Journal of Epidemiology American Journal of Epidemiology found no a.s.sociation between moderate caffeine consumption and reduced birthweight, gestational age, or fetal growth. found no a.s.sociation between moderate caffeine consumption and reduced birthweight, gestational age, or fetal growth.

Major studies over the last decade have shown no a.s.sociation between birth defects and caffeine consumption. FDA has evaluated this scientific evidence and concluded that caffeine does not adversely affect reproduction in humans. However, as with other dietary habits, the agency continues to advise pregnant women to consume caffeine in moderation.

Groups such as OTIS, March of Dimes, and Motherisk reviewed studies examining caffeine intake during pregnancy and are in agreement that high caffeine intake (>300 mg/day, equivalent to more than 3 cups of coffee/day) should be avoided during pregnancy. There is also general agreement that low caffeine intake (<150 mg/day,="" about="" 1="" cups="" of="" coffee)="" during="" pregnancy="" is="" not="" likely="" to="" harm="" the="" unborn="">

However, there is some disagreement regarding moderate caffeine intake.

Following a statistical a.n.a.lysis of studies examining caffeine intake in pregnant woman, Motherisk stated, "Our results suggest a small but statistically significant increase in risk of spontaneous abortion and low birth weight babies in pregnant women consuming more than 150 mg of caffeine per day. Pregnant women should be encouraged to be aware of dietary caffeine intake and to consume less than 150 mg of caffeine a day from all sources throughout pregnancy."

Subsequent to their review of caffeine studies, OTIS stated that "Recent reports suggest that low to moderate consumption of caffeine does not increase the risk for miscarriage. A few studies have shown that there may be an increased risk for miscarriage with high caffeine consumption (>300 mg/day), particularly in combination with smoking or alcohol, or with very high levels of caffeine consumption (>800 mg/day)." OTIS goes on to say that, "In humans, even large amounts of caffeine have not been shown to cause an increased chance for birth defects." OTIS concluded that, "Most experts agree that moderation and common sense are the keys for consuming caffeinated items during pregnancy." Moderate caffeine consumption is approximately 300 mg/day, which is similar to 3 cups of coffee. It is also important for pregnant women to drink sufficient quant.i.ties of water, milk, and juice. These fluids should not be replaced with caffeinated beverages."

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Chapter 22.

Exercise during Pregnancy Fitness goes hand in hand with eating right to maintain your physical health and well-being during pregnancy. Pregnant or not, physical fitness helps keep the heart, bones, and mind healthy. Healthy pregnant women should get at least 2 hours and 30 minutes of moderate-intensity aerobic activity a week. It's best to spread your workouts throughout the week. If you regularly engage in vigorous-intensity aerobic activity or high amounts of activity, you can keep up your activity level as long as your health doesn't change and you talk to your doctor about your activity level throughout your pregnancy.

Special benefits of physical activity during pregnancy: * Exercise can ease and prevent aches and pains of pregnancy including constipation, varicose veins, backaches, and exhaustion.

* Active women seem to be better prepared for labor and delivery and recover more quickly.

* Exercise may lower the risk of preeclampsia and gestational diabetes during pregnancy.

* Fit women have an easier time getting back to a healthy weight after delivery.

* Regular exercise may improve sleep during pregnancy.

Excerpted from "Staying Healthy and Safe," by the Office of Women's Health (www.womenshealth.gov), March 2009.

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Pregnancy and Birth Sourcebook, Third Edition * Staying active can protect your emotional health. Pregnant women who exercise seem to have better self-esteem and a lower risk of depression and anxiety.

* Results from a recent, large study suggest that women who are physically active during pregnancy may lower their chances of preterm delivery.

Getting Started For most healthy moms-to-be who do not have any pregnancy- related problems, exercise is a safe and valuable habit. Even so, talk to your doctor or midwife before exercising during pregnancy. She or he will be able to suggest a fitness plan that is safe for you. Getting a doctor's advice before starting a fitness routine is important for both inactive women and women who exercised before pregnancy.

If you have one of these conditions, your doctor will advise you not to exercise: * Risk factors for preterm labor * v.a.g.i.n.al bleeding * Premature rupture of membranes (when your water breaks early, before labor) Best Activities for Moms-to-Be Low-impact activities at a moderate level of effort are comfortable and enjoyable for many pregnant women. Walking, swimming, dancing, cycling, and low-impact aerobics are some examples. These sports also are easy to take up, even if you are new to physical fitness.

Some higher intensity sports are safe for some pregnant women who were already doing them before becoming pregnant. If you jog, play racquet sports, or lift weights, you may continue with your doctor's okay.

Keep these points in mind when choosing a fitness plan: * Avoid activities in which you can get hit in the abdomen like kickboxing, soccer, basketball, or ice hockey.

* Steer clear of activities in which you can fall like horseback riding, downhill skiing, and gymnastics.

* Do not scuba dive during pregnancy. Scuba diving can create gas bubbles in your baby's blood that can cause many health problems.

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Exercise during Pregnancy Tips for Safe and Healthy Physical Activity Follow these tips for safe and healthy fitness: * When you exercise, start slowly, progress gradually, and cool down slowly.

* You should be able to talk while exercising. If not, you may be overdoing it. Take frequent breaks.

* Don't exercise on your back after the first trimester. This can put too much pressure on an important vein and limit blood flow to the baby.

* Avoid jerky, bouncing, and high-impact movements. Connective tissues stretch much more easily during pregnancy. So these types of movements put you at risk of joint injury.

* Be careful not to lose your balance. As your baby grows, your center of gravity shifts making you more p.r.o.ne to falls. For this reason, activities like jogging, using a bicycle, or playing racquet sports might be riskier as you near the third trimester.

* Don't exercise at high alt.i.tudes (more than 6,000 feet). It can prevent your baby from getting enough oxygen.

* Make sure you drink lots of fluids before, during, and after exercising.

* Do not workout in extreme heat or humidity.

* If you feel uncomfortable, short of breath, or tired, take a break and take it easier when you exercise again.

Stop exercising and call your doctor as soon as possible if you have any of the following: * Dizziness * Headache * Chest pain * Calf pain or swelling * Abdominal pain * Blurred vision * Fluid leaking from the v.a.g.i.n.a * v.a.g.i.n.al bleeding 199.

Pregnancy and Birth Sourcebook, Third Edition * Less fetal movement * Contractions Work out Your Pelvic Floor (Kegel Exercises) Your pelvic floor muscles support the r.e.c.t.u.m, v.a.g.i.n.a, and urethra in the pelvis. Toning these muscles with Kegel exercises will help you push during delivery and recover from birth. It also will help control bladder leakage and lower your chance of getting hemorrhoids.

* Pelvic muscles are the same ones used to stop the flow of urine.

Still, it can be hard to find the right muscles to squeeze. You can be sure you are exercising the right muscles if when you squeeze them you stop urinating. Or you can put a finger into the v.a.g.i.n.a and squeeze. If you feel pressure around the finger, you've found the pelvic floor muscles. Try not to tighten your stomach, legs, or other muscles.

* Tighten the pelvic floor muscles for a count of three, then relax for a count of three.