Psychological and Physiological Changes of Pregnancy

 Pregnancy brings both psychological and physical changes to the woman

and her partner.

 Physiologic changes occur gradually but eventually affect all organ

systems of a woman’s body.

 Psychological changes occur in response to physiologic alterations.

 Pregnancy represents wellness not illness.

Changes in Pregnancy

 The nurse will help the family maintain a state of wellness throughout the

pregnancy and into early parenthood.

 Nursing Process:

 Assessment begins before pregnancy

 Plan-women are often surprised to see the changes occurring in herself

 Implementation-women need help in voicing their concerns about the

physiologic changes of pregnancy.

 Evaluation

 Evaluation-determined if the woman has really “heard” your teaching.

Diagnosis of Pregnancy
 Marks a major milestone.

 Presumptive Signs of Pregnancy:

 least indicative of pregnancy, could indicate other conditions

 subjective-experienced by the woman

 breast changes, nausea, vomiting, amenorrhea, frequent urination,

fatigue, uterine enlargement, quickening, linea nigra, melasma, stria gravidarum.

Probable Signs of Pregnancy

 Signs that can be documented by the examiner

 Serum laboratory tests:

 hCG in urine or blood serum of the women.

 accurate 95% to 98 % of the time.

 home pregnancy tests are 97% accurate.

 women taking psychotropic drugs may have a false positive result on

pregnancy test.

 discontinue oral contraceptives 5 days before the test.

 Chadwick’s sign

 Goodell’s sign

 Hegar’s sign

 Sonographic evidence of gestational sac

 Ballottement
 Braxton Hicks sign

 Fetal outline felt by examiner

 Sonographic evidence of fetal outline

 week 6-8

 Fetal heart audible

 week 18-20

 Fetal movement felt by examiner

 week 20-24

 Psychological Changes of Pregnancy:

 The woman’s attitude toward the pregnancy depends on the environment

in which she is raised.

Psychological Changes of Pregnancy

 Social influences

 Pregnancy is not an illness, now the family is included.

 Use of birthing centers has increased.

 Demedicalize childbirth.

 Cultural influences

 How active a role she wants to take.

 Certain beliefs and taboos may place restrictions on her behaviors and

activities.

 Family influences
 Viewed in a positive or negative light.

 Stories about pain and endless suffering in labor.

 People love as they have been loved.

 Individual influences

 Ability to cope with or adapt to stress.

 Secure in her relationship.

 Pregnancy takes away her freedom.

Psychological Tasks of Pregnancy

 1st Trimester:

 Accepting the Pregnancy

 50% of all pregnancies are unintended, unwanted or mistimed. Surprise!

 Women sometimes experience disappointment, anxiety or ambivalence.

 Partner may go through some changes also.

 Partner should give emotional support.

 May feel proud, happy, jealous or loss.

 2nd Trimester

 Accepting the Baby:

 Second turning point is often quickening.

 Proof of the child’s existence.

 Anticipatory role playing.

 May accept at conception, at birth or later.

 How well she follows prenatal instructions.

 Partner may feel left out, he may increase his work, he has

misinformation.

 Educate both partners.

 3rd Trimester:

 Preparing for Parenthood

 “nest building”

 attending prenatal classes or parenting classes.

 Reworking Developmental Tasks

 working through previous life experiences.

 woman’s relationship with her parents, particularly her mother.

 fear of dying.

 Needs confidence in health care providers.

 Men may need to reconcile feelings toward fathers and learn a new

pattern of behavior.

 Role-playing and Fantasizing:

 Second step in preparing of parenthood.

 Spend time with other mothers to learn how to be a mother. Needs good

role models.
 Father may need to change his carefree individual to a member of a

family unit.

 Nurturing roles.

Emotional Responses to Pregnancy

 Ambivalence

 Grief

 Narcissism

 Introversion versus Extroversion

 Body Image and Boundary

 Stress

 Couvade Syndrome

 Emotional Lability

 Changes in Sexual Desire

 Changes in the Expectant Family

 Local changes - confined to the reproductive organs.

 Systemic changes - affecting the entire body.

 Both subjective (symptoms) and objective (signs) findings are used to

diagnose and mark the progress of the pregnancy.

 Reproductive System Changes: (table 9.3)

 Uterine changes:

 Increase in size, length, depth, width, weight, wall thickness and volume.
 Length-from 6.5 to 32 cm.

 Depth-increases from 2.5 to 22 cm.

 Width-expands from 4 to 24 cm.

 Weight-increases from 50 to 1,000 g.

 Uterine wall thickens from 1 cm to 2 cm by the end of pregnancy, the wall

thins so it is supple and 0.5 cm thick.

 Volume of uterus increases from 2 mL to 1,000 mL. It can hold a 7 lb.

fetus plus 1,000 mL of amniotic fluid. Total 4,000 g.

 Uterine growth is due to formation of a few new muscle fibers and

stretching of existing muscle fibers (2 to 7 times longer).

 Week 12 the fetus is palpated just above the symphysis pubis.

 Week 20 or 22 the fetus is at the umbilicus.

 Week 36 should touch the xiphoid process which causes some SOB.

 Primigravida - woman in her 1st pregnancy.

 Multipara - a woman who has had 1 or more children.

 Lightening - 2 weeks before term (week 38) the fetal head settles into the

pelvis to prepare for birth and the uterus returns to the height it was at on the

36 week.

 This permits better lung expansion and easier breathing.

 This is predictable in 1st birth but not others.

 Uterine growth is a presumptive sign of pregnancy.

 As the uterus increases in size it:

 pushes the intestines to the side

 elevates the diaphragm and liver

 puts pressure on the bladder

 Uterine blood flow increases:

 before pregnancy - 15 to 20 mL/ min.

 by the end of pregnancy - 500 to 750 mL/min. with 75% going to the

placenta.

 Uterine bleeding can be a major blood loss.

 Uterus is anteflexed, larger and softer.

 Hegar’s sign - extreme softening of the lower uterine segment. The wall

can not be felt or it feels as thin as tissue paper with bimanual exam.

 Ballottement - on bimanual exam, tapping of lower segment the fetus is

felt to bounced or rise in the amniotic fluid up against the to top examining hand

(week 16 to 20).

 Braxton Hicks contractions - practice contractions. Week 12 until term.

Waves of hardness or tightening across the abdomen.

 They serve as warm-up exercise and increase placental perfusion.

 False labor, the do not cause cervical dilation.

 Amenorrhea - absence of menstruation due to suppression of FSH.

 Presumptive sign.
 Cervical changes:

 Cervix more vascular and edematous.

 Increased fluid between the cells causes the cervix to soften and

increased vascularity causes it to darken from pale pink to a violet hue.

 A tenacious coating of mucus fills the cervical canal.

 Operculum - mucous plug - seals out bacteria during pregnancy.

 Goodell’s sign - softening of the cervix.

 Nonpregnant cervix is like the nose.

 Pregnant is like earlobe.

 Just before labor the cervix becomes soft like butter and is “ripe” for birth.

 Vaginal changes:

 vaginal epithelium become hypertrophic and enriched with glycogen which

results in white vaginal discharge throughout pregnancy.

 Chadwick’s sign - vaginal walls are deep violet color due to increased

circulation.

 pH 4 to 5 (from pH over 7) favors growth of Candida albicans (yeast like

fungi).

 due to Lactobacillus acidophilus a bacteria that grows freely in glycogen

environment, so this increases the lactic acid content.

 Ovarian changes:

 ovulation stops.
 Corpus luteum increases in size until week 16 and then the placenta has

taken over as provider of progesterone and estrogen.

 Changes in the breasts:

 result of estrogen and progesterone production. (1st change)

 feeling of fullness, tingling or tenderness.

 Size increases due to hyperplasia of mammary alveoli and fat deposits.

 aerola darkens and diameter increases to 3.5 cm to 5 or 7.5 cm (1 1/2 to

3 inches)

 blue veins become prominent.

 Montgomery’s tubercles-sebaceous glands of the areola enlarge and

become protuberant.

 secretions keep the nipple supple and help prevent cracking and drying

during lactation

 week 16 colostrum-a thin, watery, high protein fluid can be expelled from

the breast

 Systemic Changes:

 Integumentary System

 Abdominal wall must stretch

 Striae gravidarum - pink or reddish streaks on sides of abdomen and

thighs.

Systemic Changes

 Caused by rupture and atrophy of the connective layer of the skin.

 After birth this lightens to silvery-white color. (permanent)

 Diastasis-rectus muscles separate, will appear after pregnancy as a bluish

groove.

 Umbilicus stretches until it is smooth.

 Extra pigmentation on abdominal wall.

 Linea nigra - brown line from umbilicus to symphysis pubis.

 Melasma - darkened areas on face due to melanocyte-stimulating

hormone secreted by the pituitary.

 Vascular spiders - small fiery-red branching spots on thighs, increases

estrogen.

 Palmar erythema - redness and itching.

 Increased sweat gland activity.

 Scalp hair growth increases.

 Respiratory System

 SOB

 Chronic respiratory alkalosis compensated by chronic metabolic acidosis.

 Diaphragm is displaced by 4 cm upward.

 Vital capacity does not decrease.

 Residual volume is decreased by 20%.

 Tidal volume is increased up to 40%

 Total O2 consumption is increased by 20%.

 Pco2 is 32 mm Hg
 Mild hyperventilation.

 Polyuria - increased urination due to plasma bicarbonate excreted by the

kidneys.

 respirations > 20/min.

 congestion of nasopharynx - increased estrogen levels.

 Temperature:

 increased for 16 weeks due to secretion of progesterone from the corpus

luteum, returns to normal once the placenta takes over.

 Cardiovascular System:

 Changes are extreme and significant to the health of the fetus.

 Blood volume

 increases by 30 to 50 %

 blood loss at birth-300 to 400 mL

 cesarean birth-800 to 1,000 mL

 increase blood volume peaks at week 28 to 32

 Pseudoanemia - concentration of hemoglobin and erythrocytes decline.

 Iron needs

 fetus requires 350 to 400 mg to grow.

 Mother has an increase in RBC needing an additional 400 mg of iron.

 Prenatal vitamins and foods supply needs.

 Heart

 cardiac output increases by 25 to 50 %

 heart rate increases by 10 beats/ min.

 heart is shifted more transverse

 Innocent heart murmurs due to positioning.

 Palpitations SNS

 Regional blood flow:

 3rd trimester blood flow to lower extremities is impaired due to pressure

on veins and arteries.

 leads to edema and varicoaities.

 Blood pressure:

 does not normally rise

 may decrease in 2nd trimester

 Supine hypotension syndrome:

 when woman lies supine the weight of the uterus presses on the vena

cava obstructing blood return to the heart.

 risk fetal hypoxia

 lightheadedness, faintness and palpitations.

 rest on left side.

 Blood constitution:

 level of circ. fibrinogen increases 50%.

 Factors VII, VIII, IX, X and platelets increase.

 Blood lipids increase by 1/3

 cholesterol level increase 90 to 100 %

 Gastrointestinal system

 Uterus displaces the stomach and intestines toward the back and sides of

the abdomen.

 Pressure slows peristalsis and the emptying time of the stomach.

 Leads to heartburn, constipation and flatulence.

 Nausea and vomiting in early morning.

 When hCG and progesterone begin to rise.

 May be a systemic reaction to increases estrogen or decreased glucose

levels.

 Subsides after 3 months

 Generalized itching due to reabsorption of bilirubin into the mother’s blood

stream due to decreased emptying of bile from the GB.

 Hypertrophy of the gumlines and bleeding.

 Peptic ulcers improve.

 Urinary System

 Effects of estrogen and progesterone activity.

 Compression of the bladder and ureters.

 Increased blood volume

 Postural influences

 Fluid retention:

 total body water increases to 7.5 L

 increase sodium reabsorption

 Increased aldosterone production.

 Potassium remains adequate.

 Water retension increases blood volume to serve as a source of nutrients

to the fetus.

 Renal Function:

 Kidneys change size.

 Urinary output increases by 60 to 80 %.

 GFR and renal plasma flow increase.

 Creatinine clearance tests for renal function.

 Ureter and Bladder Function

 ureters increase in diameter due to increased progesterone.

 bladder capacity increases to 1,500 mL

 pressure on the urethra may lead to poor bladder emptying and

infections.

 May lead to kidney infection.

 Skeletal System

 Calcium and phosphorus increase for fetal skeleton.

 Softening of pelvic ligaments and joints.

 Relaxin (ovarian hormone) and placental progesterone.

 Separation of symphysis pubis-3 to 4 mm.

 Stand straighter and taller - lordosis

 Center of gravity is changed.

 Endocrine System

 Almost all aspects of the endocrine system increase.

 Placenta is an endocrine organ

 Produces estrogen, progesterone, hCG, human placental lactogen,relaxin,

prostaglandins.

 Pituitary Gland

 there is a halt to FSH and LH due to high estrogen and progesterone

levels.

 Increase in production of growth hormone and melanocyte-stimulating

hormone.

 Late in pregnancy it produces oxytocin and prolactin.

 Thyroid and Parathyroid Glands

 thyroid enlarges and BBM (metabolism) increases by 20%

 iodine and thyroxine are elevated.

 Parathyroid enlarges due to increased calcium requirements.

 Adrenal Gland

 Elevated levels of corticosteroids and aldosterone are produced.

 Aids in suppressing an inflammatory reaction or helps to reduce the

possibility of rejection of the fetus.

 Regulates glucose metabolism.

 Promotes sodium reabsorption and maintaining osmolarity in fluid

retained.

 Safeguards blood volume and perfusion

 Pancreas

 Increases insulin production in response to high glucocorticoid

production.insulin is less effective then normal because estrogen, progesterone

and hPL are antagonists to insulin.

 Diabetic needs more insulin.

 Maternal glucose levels are usually higher.

 Fat stores and available glucose are utilized.

 Immune System

 Competency decreases (IgG) to not reject the fetus.

 Increase in WBC to counteract the decrease.