Postpartum Counseling

(Updated July 2013)

Diet, Nutrition, and Exercise

The Dietary Guidelines published by the US Department of Agriculture and endorsed by the American Dietetic Association form the basis for nutrition counseling for postpartum women.¹ Counseling can be tailored to the individual woman based on risk factors for poor nutrition such as extremes of maternal age, restrictive dietary practices (e.g., vegan), excessive weight gain during pregnancy, deviations from ideal body weight, multiple gestation, history of eating disorders, and a close interconceptional period. An additional 500 Kcal/day is recommended for women who breastfeed (e.g., 2,300–2,500 Kcal/day versus 1,800–2,000 for a moderately active non-pregnant, non-lactating women).¹ Even higher intake may be recommended for lactating women who are underweight, women who exercise vigorously, or women who are breastfeeding more than one infant.²

Many women consume less than the recommended amounts of calcium, magnesium, zinc, vitamin B6, and folate.² New mothers are likely to have stopped taking a prenatal vitamin. If a nutritional deficit is suspected, reinstitution of prenatal nutritional supplementation may be appropriate. Prenatal supplements generally do not include a significant amount of calcium; in addition, during lactation, 250–350 mg of calcium is transferred daily from the mother to the neonate through breast milk.³ Patients should be apprised of the need for additional supplementation to meet the requirement for this key mineral.

Calcium. The recommended daily allowance of calcium for lactating women ages 19 to 50, as for pregnant and non-pregnant women, is 1,000 mg/day.¹ Adolescents may require 1,300 mg/day.¹ Some postpartum women restrict caloric intake for weight loss, and there is some evidence that diet-induced weight loss results in generalized bone loss in all women.⁴ Calcium has many functions in the body— aiding in muscle relaxation, blood coagulation, transmission of nerve impulses, and enzyme reactions, as well as promoting tooth and bone health and preventing osteoporosis. The postpartum period is a time when women tend to be receptive to health counseling, and this provides an excellent opportunity to promote lifelong habits to ensure adequate calcium intake.

Numerous studies reveal transient bone loss during lactation, which is rapidly regained after weaning.³ The rate and extent of recovery are influenced by the duration of lactation and postpartum amenorrhea and differ by skeletal site. However, studies have not revealed that pregnancy and lactation are associated with an increased risk of osteoporotic fracture.³

There is controversial and conflicting evidence that, in comparison with a low-calcium diet, a high-calcium diet may increase weight loss slightly.^5-7 This statement may be an incentive for some women to boost their calcium intake.

Most women do not obtain enough calcium from dietary sources and will benefit from calcium supplementation. Calcium carbonate (found in Calcium Soft Chews, Caltrate^®, Os-Cal^®, Tums^®, Viactiv^®, and other supplements) is readily absorbed by most people and is the least costly form of calcium supplement.^8,9 Calcium citrate products (such as Citracal^®) may also be recommended but may be more expensive and require patients to take more tablets to achieve the optimal dosage. To improve absorption, calcium supplements can be divided into two or three doses and taken with meals. Vitamin D facilitates absorption of calcium, so whenever possible, recommend a calcium supplement that contains 400 to 800 IU of this vitamin.

Iron. Dietary requirements for iron return to pre-pregnancy levels in the postpartum period—15mg/day.¹⁰ Postpartum iron supplementation may be indicated when blood loss is higher than usual during vaginal delivery or the interval between pregnancies is less than two years. In the presence of a low hemoglobin or hematocrit, and if other causes of anemia such as thalassemia are ruled out, oral supplementation of 60 to 120 mg of iron can be recommended. Many fortified cereals provide 100 percent (18 mg) of a woman’s daily requirement for iron. Oysters, beef liver, and lean beef are excellent sources of iron. Other good, non-meat food sources include tofu and, to a lesser extent, potatoes with skin, watermelon, figs, spinach, chard, and dried fruits such as apricots, raisins, and prunes. Foods that inhibit iron absorption, such as whole-grain cereals, unleavened whole-grain breads, legumes, tea, and coffee, should be consumed separately from iron-fortified foods and iron supplements.¹⁰

Fluid intake. Adequate fluid intake is an important element of good nutrition. Women, especially those who are lactating, should be encouraged to drink enough to satisfy thirst and prevent constipation.¹¹ However, controlled studies provide no evidence that increased fluid intake will result in weight loss, improved lactation, or diuresis.¹²

Weight loss. Returning to their pre-pregnancy weight is a common interest among postpartum women. Many women feel societal pressure—enforced by images of postpartum celebrities who appear to return to their former figures effortlessly—to lose weight and get back into shape quickly after giving birth. With a healthy diet and exercise, much of the weight that women gain during pregnancy will be shed naturally during the first year postpartum. The goal should be gradual weight loss. For all but those women with high or very high pre-pregnancy weights, the recommended weight loss after the first month postpartum is a maximum of 4.5 lbs/month.¹³

Caloric intake should not fall below 1,800 Kcal/day, and this figure may need to be revised upward on the basis of such considerations as breastfeeding, nutritional status, and level of activity.^1,4 Inadequate caloric intake may increase postpartum fatigue and have a negative impact on mood, especially if the mother is breastfeeding. Postpregnancy dieting may be accompanied by a significant decrease in bone mineral density.³

Weight loss should not be promoted as a benefit of breastfeeding, because some studies suggest that lactation may actually impede weight loss.¹⁴ Often, instructing lactating women to focus on nutritional foods and exercise, and to eat to satisfy their hunger, will result in the desired slow pattern of weight loss. Women who are overweight or obese before, during, or after pregnancy should be counseled and, if appropriate, referred to weight-loss programs led by specialists. Recent research suggests that excess weight gain that persists after pregnancy is an indicator of obesity in midlife.¹⁵

Alcohol and caffeine. Occasional consumption of small amounts of alcohol and moderate ingestion of caffeine-containing products are not contraindicated during breastfeeding, according to guidelines of the Institute of Medicine (IOM).¹⁶ The American Academy of Pediatrics (AAP), while noting that excessive maternal consumption of caffeine may adversely affect the infant who is breastfeeding, also considers moderate consumption of caffeine (e.g., a morning cup of coffee) to be acceptable during breastfeeding.¹⁷ AAP advises women who choose to drink alcohol to do so after nursing, rather than before. Women also can be advised to delay breastfeeding until alcohol is cleared from their milk—e.g., to express milk and store it before they drink alcohol. Some experts note that although an occasional alcoholic drink causes no problem, alcohol can interfere with the letdown reflex and reduce milk production by 23 percent for a few hours after consumption.¹⁸

Women should be cautioned that consuming large amounts of alcohol may interfere with their ability to breastfeed effectively and may adversely affect their infant in other ways (e.g., impaired motor development, altered sleep patterns, decreased milk intake).¹⁹ Alcohol consumption may also impair a mother’s ability to nurture and care for her infant.

Fish consumption. The health benefits of fish and seafood have been well documented and widely promoted in recent years. Fish is low in saturated fat and is a healthy alternative to red meat. It provides the body with essential vitamins and minerals, including iron; zinc (from shellfish); vitamins A, B, and D; and, of course, protein. Omega-3 fatty acids found in fish are also beneficial, particularly for cardiovascular health.

At the same time, women of reproductive age are particularly vulnerable to the industrial pollutants—mercury and polychlorinated biphenyls (PCBs)—that accumulate in fish flesh. Multiple studies have documented prenatal exposure to mercury and its effects on fetal development, and breastfeeding mothers are advised to minimize fish consumption because mercury passes through breast milk.^20-23 Early life exposure to PCBs can cause harmful neurological effects, leading to learning deficits, poor memory, and behavioral problems. PCBs are highly toxic, and infants may be particularly vulnerable to the adverse effects of these chemicals.²⁴ Women of child-bearing age can minimize their blood mercury levels by eating fish with care, but PCBs accumulate over time, and lifelong vigilance is required to minimize maternal body burden of these chemicals.

Constipation. Constipation is common during pregnancy and the postpartum period. Contributing factors include relaxed muscle tone following delivery, inadequate fluid intake, a diet low in fiber, iron or calcium supplementation, painful hemorrhoids, or fear of damaging perineal repair during a bowel movement. Suggestions for preventing constipation include eating foods high in fiber, drinking eight to 10 large glasses of liquid daily (water, juice—including prune juice—or milk), and getting regular exercise. The use of ice packs or sitz baths can be encouraged to alleviate persistent hemorrhoidal or perineal pain that interferes with bowel movements.

Exercise. Published studies confirm the importance of regular exercise in the postpartum period, as in other times of life, although its effect on weight loss may not be significant without specific calorie restriction.²⁵ Women can be reassured that exercise will promote healing, support emotional well-being, and not adversely affect their ability to breastfeed successfully. Even strenuous exercise minimally increases lactic acid levels in breast milk and has no effect on an infant’s acceptance of breast milk one hour after exercise.^26,27 One study found that women who consume adequate amounts of long-chain polyunsaturated fatty acids (LC-PUFA), which are essential for infants’ growth and development, can exercise moderately without decreasing the LC-PUFA in their breast milk.²⁷ Breastfeeding before exercise may reduce the discomfort of engorged breasts.

Evaluating the integrity and function of the pelvic floor and assessing the diastasis recti are integral components of the postpartum visit. Kegel exercises have been shown to be effective in reducing the incidence of stress incontinence.²⁸ Proper technique is important. Patients should be instructed to contract the pelvic muscles for 10 seconds and then relax them for 10 seconds for 15 minutes four times per day. Women may need help from a qualified provider in locating the right muscles antepartum.

Providers can offer information on postpartum exercise programs available at the YMCA, fitness centers, or hospitals in the community to all new mothers in the birth center, hospital, or at the four- to six-week visit. Postpartum exercise programs are good resources that offer opportunities for physical activity, mutual support, short-term daycare, and a way to meet other women with infants. New mothers also may find it convenient to use postpartum DVDs or videos to supplement their exercise regimen. Fast walking with a baby jogger-type stroller, either outdoors or in a local indoor mall, also can be recommended. Many pregnancy magazines are an excellent resource for women of all fitness levels, both during pregnancy and postpartum. They offer step-by-step exercise programs, which are particularly useful for women who were not very physically fit before they became pregnant.

The appropriate exercise level will depend on each woman’s medical history, obstetrical course, level of fitness, and postpartum recovery. Some women may be able to engage in an exercise routine within days of delivery; others may need to wait four to six weeks.²⁹ Gradual resumption of exercise is recommended to gauge effect and identify appropriate level of intensity.

As with vaginal birth, recommendations for exercise after cesarean birth depend upon obstetric and medical history and rate of physical recovery. In most cases, exercises to restore abdominal muscle tone in the cesarean mother can begin as soon as abdominal soreness diminishes.³⁰ According to some experts, women can safely start doing straight and diagonal curl-ups within the first few days after a cesarean birth. These exercises can help in bringing the rectus muscles back together.³¹

References

1. US Department of Agriculture Dietary Guidelines. Available from: http://www.health.gov/DietaryGuidelines/ [Accessed July 14, 2006].
2. Institute of Medicine. Nutrition Services in Perinatal Care. 2nd ed. Washington, DC. 1992
3. Oliveri B, Parisi MS, Zeni S, Mautalen C. Mineral and bone mass changes during pregnancy and lactation. Nutrition 2004;20(2):235-40.
4. Jensen LB, Kollerup G, Quaade F, Sorensen OH. Bone mineral changes in obese women during a moderate weight loss with and without calcium supplementation. J Bone Miner Res 2001;16(1):141-7.
5. Heaney RP, Davies KM, Barger-Lux MJ. Calcium and weight: clinical studies. J Am Coll Nutr 2002;21(2):152S-5S.
6. Zemel MB. The role of dairy foods in weight management. J Am Coll Nutr 2005;24(6 Suppl):537S-46S.
7. Teegarden D. The influence of dairy product consumption on body composition. J Nutr 2005;135(12):2749-52.
8. Heaney RP, Recker RR, Weaver CM. Absorbability of calcium sources: the limited role of solubility. Calcif Tissue Int 1990;46(5):300-4.
9. Heaney RP, Dowell MS, Bierman J, Hale CA, Bendich A. Absorbability and cost effectiveness in calcium supplementation. J Am Coll Nutr 2001;20(3):239-46.
10. American Dietetic Association. Medical Nutrition Therapy. Chicago, Illinois. 2006.
11. American Academy of Pediatrics and the American College of Obstetricians and Gynecologists. Guidelines for Perinatal Care. 5th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2002.
12. Keirse MJ, Enkin M, Crowther C, Nelison J, Hodnett E, Hofmeyr J, Duley L. A Guide to Effective Care in Pregnancy and Childbirth. London: Oxford University Press; 2000.
13. Institute of Medicine. Nutrition During Pregnancy and Lactation. Washington, DC. 1992.
14. Reece EA, Hobbins JC. Medicine of the Fetus and Mother. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 1999.
15. Rooney BL, Schauberger CW, Mathiason MA. Impact of perinatal weight change on long-term obesity and obesity-related illnesses. Obstet Gynecol 2005;106(6):1349-56.
16. Institute of Medicine. Nutrition During Lactation. Washington, DC 1991.
17. [homepage on the Internet]. Elk Grove Village, IL: American Academy of Pediatrics. [Accessed May 11, 2006.]
18. Lawrence RA, Lawrence RM. Breastfeeding: A Guide for the Medical Profession. St. Louis: C.V. Mosby; 2000.
19. American Academy of Pediatrics. Pediatrics. Elk Grove Village, IL: 2001.
20. Grandjean P, Weihe P, White RF, Debes F. Araki S. Murata K, Sørensen N. Dahl D, Yokoyama K, Jorgensen PJ. Cognitive deficits in 7-year-old children with prenatal exposure to methylmercury. Neurotoxicol Teratol. 1997;19(6):417–28.
21. National Academy of Sciences, National Research Council. Toxicological Effects of Methylmercury 2000. Available at: http://books.nap.edu/catalog/9899.html. [Accessed May 26, 2004.]
22. Steuerwald U, Weihe P, Jorgensen PJ, Bjerve K, Brock J, Heinzow B, Budtz- Jorgensen E, Grandjean P. Maternal seafood diet, methylmercury exposure, and neonatal neurologic function. J Pediatr 2000:136(5);599–605.
23. Murata K, Weihe P, Budtz-Jorgensen E, Jorgensen PJ, Grandjean P. Delayed brainstem auditory evoked potential latencies in 14-year-old children exposed to methylmercury. J Pediatr 2004:144;177-83.
24. Environmental Protection Agency, Office of Research and Development. Draft Dioxin Reassessment 2001.
25. Larson-Meyer DE. Effect of postpartum exercise on mothers and their offspring: a review of the literature. Obes Res 2002;10(8):841-53.
26. Wright KS, et al. Quinn TJ, Carey GB. Infant acceptance of breast milk after maternal exercise. Pediatrics 2002;109(4):585-9.
27. Bopp M, Lovelady C, Hunter C, Kinsella T. Maternal diet and exercise: effects on long-chain polyunsaturated fatty acid concentrations in breast milk. J Am Diet Assoc 2005;105(7):1098-103.
28. Elia G, Bergman A. Pelvic muscle exercises: when do they work? Obstet Gynecol 1993;81(2):283-6.
29. ACOG Committee on Obstetric Practice. ACOG Committee opinion. Washington, DC: American College of Obstetricians and Gynecologists; 2002.
30. Cunningham FG, Leveno KJ, Bloom SL, Hauth JC, Gilstrap LC, Wenstrom KD. Williams Obstetrics. 22nd ed. Dallas, TX: McGraw-Hill; 2004.
31. Noble E. Essential Exercises for the Childbearing Year. Waltham, MA: New Life Images; 2003.