1

1. FETAL CIRCULATION
 As early as the third week of intrauterine
life, fetal blood begins to exchange nutrients
with the maternal circulation across the chorionic
villi.
 Fetal circulation differs from extrauterine
circulation because the fetus derives oxygen and
excretes carbon dioxide not from gas exchange in
the lung but from gas exchange in the placenta.
 Three shunts also are present during fetal life:
1. Ductus venosus—connects the umbilical
vein to then inferior vena cava
2. Ductus arteriosus—connects the main pulmonary artery to the aorta
3. Foramen ovale—anatomic opening between the right and left atrium

OXYGENATED blood → UMBILICAL VEIN

↓
DUCTUS VENOSUS → directs oxygenated blood to the fetal liver
↓
Fetal Inferior vena cava
↓
Oxygenated blood directed to right side of the heart via Right atrium
↓
Then shunted to the left atrium via the FORAMEN OVALE
↓
From the left atrium, blood flows to the left ventricle
↓
AORTA and out to the body parts
↓
Small amount of blood returns to the heart via the vena cava
↓
Right atrium
↓
Tricuspid valve → Right ventricle → Pulmonary artery and lungs to service the lung tissue)
↓
Blood is shunted away from the lungs →DUCTUS ARTERIOSUS
↓
Directly into the descending aorta
↓
DEOXYGENATED blood → to the descending aorta
↓
Through the umbilical arteries
↓
Back through umbilical cord to the Placental villi (and the cycle repeats)

NOTE:
 Oxygen and carbon dioxide exchange occurs in the placenta not in the lungs
 Blood enters the fetal lungs not for
exchange but to supply the lung cells
with oxygen
 There are specialized structures
present in the fetus that shunt blood
flow to supply the most important
organs: the brain, liver, heart and
kidneys
 blood oxygen saturation level of the
fetus is about 80% of a newborn’s
saturation level
2

Figure 6.1. Fetal Circulation

2. FETAL HEMOGLOBIN
 Has a different composition (two alpha and two gamma chains, compared with two alpha and
two beta chains of adult hemoglobin).
 It is also more concentrated and has greater oxygen affinity.
 A newborn’s hemoglobin level is about 17.1 g/100 mL, compared with an adult normal level of
11 g/100 mL.
3. RESPIRATORY SYSTEM
3rd week…
 The respiratory and digestive tracts exist as a single tube.
4 week…
th

 Septum begins to divide the esophagus from the trachea. At the same time, lung buds appear
on the trachea
7th week …
 The diaphragm does not completely divide the thoracic cavity from the abdomen. This causes
lung buds to extend down into the abdomen, re-entering the chest only as the chest’s
longitudinal dimension increases and the diaphragm becomes complete.
12th week…
 Spontaneous respiratory practice movements begin and continue throughout pregnancy.
24 and 28th week…
th

 Alveoli and capillaries begin to form, both capillary and alveoli development must be complete
before gas exchange can occur in the fetal lung.
 Specific lung fluid with a low surface tension and low viscosity forms in alveoli to aid in
expansion of the alveoli at birth; it is rapidly absorbed after birth
 Surfactant, a phospholipid substance, is formed and excreted by the alveolar cells. This
decreases alveolar surface tension on expiration, preventing alveolar collapse and improving
the infant’s ability to maintain respirations in the outside environment at birth.
 2 COMPONENTS:
a. Sphingomyelin (S) – early in the formation of surfactant, this is the chief component.
b. Lecithin (L) – at about 35 weeks surge in the production and becomes the chief
component.
 As a fetus practices breathing movements, surfactant mixes with amniotic fluid. Analysis of the
L/S ratio regarding whether lecithin or sphingomyelin is the dominant component by
amniocentesis technique is a primary test of fetal maturity.
 Respiratory distress syndrome, a severe breathing disorder, can develop if there is a lack of
surfactant or it has not changed to its mature form at birth.
4. NERVOUS SYSTEM
3rd and 4th week…
 Begins to develop extremely early in pregnancy, possibly before the woman even realizes she is
pregnant.
 Neural plate (a thickened portion of the ectoderm) is apparent, the top portion differentiates
into the neural tube, which will form the central nervous system (brain and spinal cord), and
the neural crest, which will develop into the peripheral nervous system.
 All parts of the brain (cerebrum, cerebellum, pons, and medulla oblongata) form in utero,
although none are completely mature at birth. Growth proceeds rapidly during the first year
and continues at high levels until 5 or 6 years of age.
3

 The eye and inner ear develop as projections of the original neural tube.
8 week…
th

 Brain waves can be detected on an electroencephalogram (EEG).

24 week…
th

 The ear is capable of responding to sound; the eyes exhibit a pupillary reaction, indicating that
sight is present.
5. ENDOCRINE SYSTEM
 The fetal adrenal glands supply a precursor necessary for estrogen synthesis by the placenta.
 The fetal pancreas produces insulin needed by the fetus (insulin is one of the few substances
that does not cross the placenta from the mother to the fetus).
 The thyroid and parathyroid glands play vital roles in fetal metabolic function and calcium
balance.
6. DIGESTIVE SYSTEM
 Separates from the respiratory tract at about the fourth week of intrauterine life and, after
that, begins to grow extremely rapidly. Initially solid, the tract canalizes (hollows out) to
become patent. Later, the endothelial cells of the gastrointestinal tract proliferate extensively,
occluding the lumen once more, and the tract must canalize again.
 The proliferation of cells shed in the second recanalization forms the basis for meconium.
 Meconium, a collection of cellular wastes, bile, fats, mucoproteins, mucopolysaccharides, and
portions of the vernix caseosa, the lubricating substance that forms on the fetal skin,
accumulates in the intestines as early as the 16th week.
7. MUSCULOSKELATAL SYSTEM
 During the first 2 weeks of fetal life, cartilage prototypes provide position and support.
Ossification of this cartilage into bone begins at about the 12th week. Ossification continues all
through fetal life and actually until adulthood.

8. REPRODUCTIVE SYSTEM
 A child’s sex is determined at the moment of conception by a spermatozoon carrying an X or a
Y chromosome and can be ascertained as early as 8 weeks by chromosomal analysis.
 About the sixth week of life, the gonads (ovaries or testes) form. If testes form, testosterone is
secreted, apparently influencing the sexually neutral genital duct to form other male organs
 In the absence of testosterone secretion, female organs will form (maturation of the müllerian,
or paramesonephric, duct).
 The testes first form in the abdominal cavity and do not descend into the scrotal sac until the
34th to 38th week.
9. URINARY SYSTEM
 Although rudimentary kidneys are present as early as the end of the fourth week of
intrauterine life, the presence of kidneys does not appear to be essential for life before birth
because the placenta clears the fetus of waste products.
 Urine is formed by the 12th week and is excreted into the amniotic fluid by the 16th week of
gestation.
10. INTEGUMENTARY SYSTEM
 Skin of a fetus appears thin and almost translucent until subcutaneous fat begins to be
deposited at about 36 weeks.
 Skin is covered by soft downy hairs (lanugo) that serve as insulation to preserve warmth in
utero and a cream cheese–like substance, vernix caseosa, which is important for lubrication
and for keeping the skin from macerating in utero.
11. IMMUNE SYSTEM
 Immunoglobulin G (IgG) maternal antibodies cross the placenta into the fetus as early as the
20th week and certainly by the 24th week of intrauterine life to give a fetus temporary passive
immunity against diseases for which the mother has antibodies.
 Infants born before antibody transfer has taken place have no natural immunity and need
more than the usual protection against infectious disease in the newborn period.
 The level of these acquired passive IgG immunoglobulins peaks at birth and then decreases
over the next 8 months as the infant builds up his or her own stores of IgG, as well as IgA and
IgM.
The passive immunity received by the newborn has already declined substantially by about 2 months,
immunization is typically started at this time.
4

Sequential Stages of Fetal Growth

The following discussion of fetal developmental milestones is based on gestational weeks, because it is
helpful when talking to expectant parents to be able to correlate fetal development with the way they
measure pregnancy—from the first day of the last menstrual period.

Table 4. ✽ Milestones of Fetal Growth and Development

 Length: 0.75–1 cm
 Weight: 400 mg
 The spinal cord is formed and fused at the midpoint.
 Lateral wings that will form the body are folded forward
to fuse at the midline.
End of 4th
 The head is large in proportion and represents about
Gestational Week
one-third of the entire structure.
 The rudimentary heart appears as a prominent bulge on
the anterior surface.
 Arms and legs are budlike structures.
 Rudimentary eyes, ears, and nose are discernible.
 Length: 2.5 cm (1 in)
 Weight: 20 g
 Organogenesis is complete.
 The heart, with a septum and valves, beats rhythmically.
 Facial features are definitely discernible.
End of 8th  Arms and legs have developed.
Gestational Week  External genitalia are forming, but sex is not yet
distinguishable by simple observation.
 The abdomen bulges forward because the fetal
intestine is growing so rapidly.
 An ultrasound shows a gestational sac, which is
diagnostic of pregnancy
 Length: 7–8 cm
 Weight: 45 g
 Nail beds are forming on fingers and toes.
 Spontaneous movements are possible, although they
are usually too faint to be felt by the mother.
End of 12th
 Some reflexes, such as the Babinski reflex, are present.
Gestational Week
 Bone ossification centers begin to form.
(First Trimester)
 Tooth buds are present.
 Sex is distinguishable by outward appearance.
 Urine secretion begins but may not yet be evident in
amniotic fluid.
 The heartbeat is audible through Doppler technology
 Length: 10–17 cm
 Weight: 55–120 g
 Fetal heart sounds are audible by an ordinary
stethoscope.
End of 16th  Lanugo is well formed.
Gestational Week  Liver and pancreas are functioning.
 Fetus actively swallows amniotic fluid, demonstrating an
intact but uncoordinated swallowing reflex; urine is
present in amniotic fluid.
 Sex can be determined by ultrasound.
End of 20th  Length: 25 cm
Gestational Week  Weight: 223 g
 Spontaneous fetal movements can be sensed by the
mother.
 Antibody production is possible.
 Hair forms on the head, including eyebrows.
5

 Meconium is present in the upper intestine.

 Brown fat, a special fat that aids in temperature
regulation, begins to form behind the kidneys, sternum,
and posterior neck.
 Vernix caseosa begins to form and cover the skin.
 Passive antibody transfer from mother to fetus begins.
 Definite sleeping and activity patterns are
distinguishable as the fetus develops biorhythms that
will guide sleep/wake patterns throughout life.
 Length: 28–36 cm
 Weight: 550 g
 Meconium is present as far as the rectum.
 Active production of lung surfactant begins.
 Eyebrows and eyelashes become well defined.
 Eyelids, previously fused since the 12th week, now
End of 24th
open, pupils react to light.
Gestational Week
 When fetuses reach 24 weeks, or 500-600g, they have
(Second Trimester
achieved a practical low-end age of viability (earliest age
at which fetuses could survive if born at that time), if
they are cared for after birth in a modern intensive care
nursery.
 Hearing can be demonstrated by response to sudden
sound
 Length: 35–38 cm
 Weight: 1200 g
 Lung alveoli are almost mature, surfactant can be
demonstrated in amniotic fluid.
End of 28th  Testes begin to descend into the scrotal sac from the
Gestational Week lower abdominal cavity.
 The blood vessels of the retina are formed but thin and
extremely susceptible to damage from high oxygen
concentrations (an important consideration when caring
for preterm infants who need oxygen)
 Length: 38–43 cm
 Weight: 1600 g
 Subcutaneous fat begins to be deposited (the former
stringy, “little old man” appearance is lost).
 Fetus responds by movement to sounds outside the
End of 32nd
mother’s body.
Gestational Week
 Active Moro reflex is present.
 Iron stores, which provide iron for the time during
which the neonate will ingest only breast milk after
birth, are beginning to be built.
 Fingernails reach the end of fingertips
 Length: 42–48 cm
 Weight: 1800–2700 g (5–6 lb)
 Body stores of glycogen, iron, carbohydrate, and
calcium are deposited.
End of 36th  Additional amounts of subcutaneous fat are deposited.
Gestational Week  Sole of the foot has only one or two crisscross creases,
compared with a full crisscross pattern evident at term.
 Amount of lanugo begins to diminish.
 Most fetuses turn into a vertex (head down)
presentation during this month.
6

 Length: 48–52 cm (crown to rump, 35–37 cm)

 Weight: 3000 g (7–7.5 lb)
 Fetus kicks actively, sometimes hard enough to cause
the mother considerable discomfort.
 Fetal hemoglobin begins its conversion to adult
hemoglobin. The conversion is so rapid that, at birth,
End of 40th about 20% of hemoglobin will be adult in character.
Gestational Week  Vernix caseosa starts to decrease after the infant
(Third Trimester) approaches 37 weeks gestation and maybe more
apparent in the creases than the covering of the body as
the infant approaches 40 weeks or more gestational
age.
 Fingernails extend over the fingertips.
 Creases on the soles of the feet cover at least two thirds
of the surface.

Figure 7

Determination of Estimated Birth Date

It is impossible to predict the day an infant will be born with a high degree of accuracy. Traditionally, this
date was referred to as the estimated date of confinement (EDC). Because women are no longer “confined”
after childbirth, the abbreviation EDB (estimated date of birth) or EDD (estimated date of delivery) is more
commonly used today.

If fertilization occurred early in a menstrual cycle, the pregnancy will probably end “early”; if ovulation
and fertilization occurred later in the cycle, the pregnancy will end “late.” Because of these normal variations,
a pregnancy ending 2 weeks before or 2 weeks after the calculated EDB is considered well within the normal
limit.

Nagele’s rule is the standard method used to predict the length of a pregnancy.

*Nagele’s Rule: minus 3, plus seven, plus one*

Table 5. ✽ NAEGELE’S RULE

To calculate the date of birth by this rule, count backward 3 calendar months
from the first day of a woman’s last menstrual period and add 7 days.

For example, if the last menstrual period began May 15, you would count back 3
months (April 15, March 15, and February 15) and add 7 days, to arrive at a date of
birth of February 22.

EXAMPLE --- Determine the EDC:

CALCULATE Maria’s LMP:
July (7) 14, 2019

Solution:
LMP: July (7) 14, 2019
- 3 +7 +1
____________
Answer: April 21, 2020
ASSESSMENT OF FETAL GROWTH AND DEVELOPMENT
7

Fetal growth and development can be compromised if a fetus has a metabolic or chromosomal disorder that
interferes with normal growth, if the supporting structures such as the placenta or cord do not form normally,
or if environmental influences such as cigarette smoking (the nicotine in cigarettes causes fetal growth
restriction) or alcohol consumption (alcohol causes severe cognitive challenge) interfere with fetal growth.
Much information regarding whether a fetus is growing and is healthy can be gathered through a variety of
assessment techniques.

Table 6. ✽ OTHER RULES Estimating Fetal Growth

McDonald’s  Fundal height is measured by tape measure from the
Rule notch of the symphysis pubis to the fundus (in
centimeters).
 Result is equals to age in weeks
*Note Discrepancy
 If height is greater than standard, it may suggest
multiple pregnancy, miscalculated due date, big
infant, hydramnios, H. Mole, etc.
 If height is less than standard, it may suggest that
fetus fails to thrive, pregnancy is miscalculated, or
there is an anomaly.

Haase’s Rule  Determines length in centimeters

 First half – square the number of the month
i.e. first month:
1X1 = 1cm
 Second half – multiply the month by 5
i.e. 6th month:
6X5 = 30cm

Bartholomew  Estimates AOG by the relative position of the uterus

’s Rule in the abdominal cavity
 after 2nd lunar month = fundus is palpable slightly
above the symphysis pubis
 on the 5th lunar month = fundus is at the level of
umbilicus
 on the 9th lunar month = fundus is slightly below the
xyphoid process
 on the 10th lunar month = fundus is at the level of the
8th lunar month due to: LIGHTENING

Assessing Fetal Well-being

1. Fetal Movement
 that can be felt by the mother (quickening) occurs at approximately 18 to 20 weeks of
pregnancy and peaks in intensity at 28 to 38 weeks.
 A healthy fetus moves at least 10 times a day. In contrast, a fetus not receiving enough
nutrients because of placental insufficiency has greatly decreased movements.
 Ask the woman to lie in a left recumbent position after a meal and record how many fetal
movements she feels over the next hour (the Sandovsky method). In this position, a fetus
normally moves a minimum of twice every 10 minutes or an average of 10–12 times an hour.
2. Fetal Heart Rate
 120 to 160 beats per minute throughout pregnancy. Fetal heart sounds can be heard and
counted as early as the 10th to 11th week of pregnancy by the use of an ultrasonic Doppler
technique.
a. Rhythm Strip Test - assessment of the fetal heart rate for whether a good baseline rate
and a degree of variability are present
b. Non-Stress Test - measures the response of the fetal heart rate to fetal movement. A
nonstress test usually is done for 10 to 20 minutes.
c. Contraction Stress Testing - the fetal heart rate is analyzed in conjunction with contractions.

TABLE 7. ✽ Comparison of Nonstress and Contraction Tests

8

Assessment Nonstress Contraction

What is measured Response of fetal heart Response of fetal heart rate in
rate in relation to fetal relation to uterine contractions
movements produced by nipple stimulation
Normal findings Two or more No late decelerations with
accelerations of fetal contractions
heart rate of 15
beats/min lasting 15 sec
or longer following fetal
movements in a 20-min
period
Safety Woman should not lie In addition to preventing supine
considerations supine to prevent supine hypotension syndrome, observe
hypotension syndrome woman for 30 min afterward to
see that contractions are quiet
and preterm labor does not
begin

3. Ultrasonography
 Which measures the response of sound waves against solid objects, is a much-used tool in
modern obstetrics.
 It can be used to:
 Diagnose pregnancy as early as 6 weeks’ gestation
 Confirm the presence, size, and location of the placenta and amniotic fluid
 Establish that a fetus is growing and has no gross anomalies, such as hydrocephalus,
anencephaly, or spinal cord, heart, kidney, and bladder defects
 Establish sex if a penis is revealed
 Establish the presentation and position of the fetus
 Predict maturity by measurement of the biparietal diameter of the head
 Discover complications of pregnancy, such as the presence of an intrauterine device,
hydramnios or oligohydramnios, ectopic pregnancy, missed miscarriage, etc.
4. Maternal Serum Alpha-Fetoprotein
 AFP is a substance produced by the fetal liver that is present in both amniotic fluid and
maternal serum
 Level is abnormally high if the fetus has an open spinal or abdominal wall defect, because the
open defect allows more AFP to enter the mother’s circulation.
 level is low if the fetus has a chromosomal defect such as Down syndrome
 Levels begin to rise at 11 weeks’ gestation and then steadily increase until term.
5. Amniocentesis
 The aspiration of amniotic fluid from the pregnant uterus for examination.
 Typically scheduled between the 14th and 16th weeks of pregnancy to allow for a generous
amount of amniotic fluid to be present. The technique can be used again near term to test for
fetal maturity.
 A needle is inserted until it reaches the amniotic cavity and a pool of amniotic fluid, carefully
avoiding the fetus and placenta. About 15 mL of amniotic fluid is withdrawn.
a. Bilirubin Determination. The presence of bilirubin may be analyzed if a blood
incompatibility is suspected.
b. Color. Normal amniotic fluid is the color of water; late in pregnancy, it may have a
slightly yellow tinge. A strong yellow color suggests a blood incompatibility (the yellow
results from the presence of bilirubin released with the hemolysis of red blood cells). A
green color suggests meconium staining, a phenomenon associated with fetal distress.
c. Lecithin/Sphingomyelin Ratio - are the protein components of the lung enzyme
surfactant that the alveoli begin to form at the 22nd to 24th weeks of pregnancy. An L/S
ratio of 2:1 is traditionally accepted as lung maturity.
9

Figure 8. Amniocentesis. A pocket of amniotic fluid is located by

ultrasound. A small amount of fluid is removed by needle
aspiration

PSYCHOLOGICAL CHANGES IN PREGNANCY

1. Social Influences
 How well a pregnant woman and her partner feel during pregnancy and childbirth is related to
their cultural background, their personal experiences, and the experiences of friends and
relatives, as well as that taught by childbirth educators, and the current public philosophy of
childbirth.

2. Cultural Influences
 A woman’s cultural background may strongly influence how active a role she wants to take in
her pregnancy, because certain beliefs and taboos may place restrictions on her behavior and
activities.
 At prenatal visits if there is anything they believe should or should not be done to make the
pregnancy successful and keep the baby healthy
3. Family Influences
 The family in which a woman was raised can be influential to her beliefs about pregnancy
because it is part of her cultural environment.
4. Individual Influences
 Ability to cope with or adapt to stress plays a major role in how she will resolve conflict and
adapt to the new life contingencies that are coming. This ability to adapt—to being a mother
without needing mothering, to loving a child as well as a husband, to becoming a mother of
each new child—depends on her basic temperament.

THE PSYCHOLOGICAL TASKS OF PREGNANCY

During the 9 months of pregnancy, a woman and her partner run a gamut of emotions ranging from
the surprise at finding out the woman is pregnant (or wishing she were not), the pleasure and acceptance of
the fact as they begin to identify with the coming child, the worry for themselves and the child, as well as the
acute impatience near the end of pregnancy

TABLE 8 ✽ Common Psychosocial Changes That Occur with

Pregnancy
Psychosocial Description
Change
10

 Woman and partner both spend time recovering

from shock of learning they are pregnant and
concentrate on what it feels like to be pregnant.
First Trimester: A common reaction is ambivalence, or feeling
Accepting the both pleased and not pleased about the
Pregnancy pregnancy.
 M - ood swings
 A - mbivalence
 D - enial
 Woman and partner move through emotions
such as narcissism and introversion as they
concentrate on what it will feel like to be a
Second Trimester: parent. Roleplaying and increased dreaming are
Accepting the Baby common
 F-antasy
 A-bsorption (self-absorption)
 D-aydream
 Woman and partner prepare clothing and
sleeping arrangements for the baby but also
Third Trimester: grow impatient with pregnancy as they ready
Preparing for themselves for birth.
Parenthood  F-ear
 A-pprehension
 N-esting behavior

EMOTIONAL RESPONSES THAT CAN CAUSE CONCERN IN PREGNANCY

1. Grief
 The thought that grief could be associated with such a positive process as having a child seems
at first incongruent. But before a woman can take on a mothering role, she has to give up or
alter her present roles.
 She will never be as irresponsible and carefree as she is now again. She will not even
sleep soundly for the next 18 years.
2. Narcissism
 Self-centeredness (narcissism) is generally an early reaction to pregnancy. A woman who
previously was barely conscious of her body, who dressed in the morning with little thought
about what to wear, who was unconcerned about her posture or her weight, suddenly begins
to concentrate on these aspects of her life.
 Narcissism may be manifested by a change in activity
3. Introversion Versus Extroversion
 Introversion, or turning inward to concentrate on oneself and one’s body, is a common finding
during pregnancy. Some women, however, react in an entirely opposite fashion and become
more extroverted.
4. Body Image and Boundary
 Body image (the way your body appears to yourself) and body boundary (a zone of separation
you perceive between yourself and objects or other people) change during pregnancy as a
woman begins to envision herself as a mother. Changes in concept of body boundaries leads to
a firmer distinction between objects, yet at the same time her body boundary is perceived as
extremely vulnerable, as if her body were delicate and easily harmed.

5. Stress
 Because pregnancy brings with it such a major role change, it can cause extreme stress in a
woman. This stress of pregnancy, like any stress, can make it difficult for a woman to make
decisions, be as aware of her surroundings as usual, or maintain time management with her
usual degree of skill
6. Couvade Syndrome
 Many men experience physical symptoms such as nausea, vomiting, and backache to the same
degree or even more intensely than their partners during a pregnancy. These symptoms
apparently result from stress, anxiety, and empathy for the pregnant woman. The more the
11

partner is involved in or attuned to the changes of the pregnancy, the more symptoms a
woman’s partner may experience.
7. Emotional Lability
 Mood changes occur frequently in a pregnant woman, partly as a manifestation of narcissism
(her feelings are easily hurt by remarks that would have been laughed off before) and partly
because of hormonal changes, particularly the sustained increase in estrogen and
progesterone. Mood swings may be so common that they make a woman’s reaction to her
family and to health care routines unpredictable. What she finds acceptable one week she may
find intolerable the next.
8. Changes in Sexual Desire
 Women who formerly were worried about becoming pregnant may truly enjoy sexual relations
for the first-time during pregnancy. Others might feel a loss of desire because of their estrogen
increase, or they might unconsciously view sexual relations as a threat to the fetus they must
protect. Some may worry that having sexual relations could bring on early labor.
 During the first trimester, most women report a decrease in libido because of the nausea,
fatigue, and breast tenderness that accompany early pregnancy. During the second trimester,
as blood flow to the pelvic area increases to supply the placenta, libido, and sexual enjoyment
rise markedly. During the third trimester, sexual desire may remain high, or it may decrease
because of difficulty finding a comfortable position and increasing abdominal size.

9. Changes in the Expectant Family

 Most parents are aware that their older children need preparation when a new baby is on the
way; however, knowing that preparation is needed and being prepared to do this are two
different things.
 Both preschool and school-age children may need to be reassured periodically during
pregnancy that a new baby will be an addition to the family and will not replace them in their
parents’ affection.

PHYSIOLOGIC CHANGES OF PREGNANCY

A. Reproductive System Changes
Reproductive tract changes are those involving the uterus, ovaries, vagina, and breasts.

1. Uterine Changes
 Most obvious alteration in a woman’s body during pregnancy is the increase in the size of the
uterus to accommodate the growing fetus. Over the 10 lunar months of pregnancy, the uterus
increases in length, depth, width, weight, wall thickness, and volume.
a. Length increases from approximately 6.5 to 32 cm.
b. Depth increases from 2.5 to 22 cm.
c. Width expands from 4 to 24 cm.
d. Weight increases from 50 to 1000 g.
e. Early in pregnancy, the uterine wall thickens from about 1 cm to about 2 cm; toward the
end of pregnancy, the wall thins to become supple and only about 0.5 cm thick.
f. The volume of the uterus increases from about 2 mL to more than 1000 mL. The uterus can
hold a 7-lb (3175-g) fetus plus 1000 mL of amniotic fluid for a total of about 4000 g at term

12 th
week…
The uterus is large enough to be palpated as a firm
globe under the abdominal wall, just above the
symphysis pubis.

20 th
or 22nd week…
It should reach the level of the umbilicus.

36 th
week…
It should touch the xiphoid process and can make
breathing difficult.
12

FIGURE 8. Fundus height at various weeks of pregnancy

38th week…
For a primigravida, a woman in her first pregnancy, the fetal head settles into the pelvis to prepare for birth,
and the uterus returns to the height it was at 36 weeks. This is termed lightening, because a woman’s
breathing is so much easier it seems to lighten a woman’s load.

 Uterine height is measured from the top of the symphysis pubis to over the top of the uterine
fundus
 Uterine blood flow increases as the placenta grows and requires more and more blood for
perfusion. Before pregnancy, uterine blood flow is 15 to 20 mL/min. By the end of pregnancy, it
expands to as much as 500 to 750 mL/min, with 75% volume going to the placenta.
 Hegar’s sign during 6 to 8 weeks of gestation, this softening and compressibility of the lower
uterine segment results in exaggerated uterine anteflexion during the early months of
pregnancy, which adds to urinary frequency.
 16th to 20th week, when the fetus is still small in relation to the amount of amniotic fluid
present, ballottement (from the French word balloter, meaning “to toss about”) may be
demonstrated.
 Braxton-Hicks contractions intermittent, painless, and physiological uterine contractions, begin
in the second trimester, some women do not feel them until the third trimester. These
contractions are irregular with no particular pattern. As the uterus enlarges, they are more
noticeable.
2. Amenorrhea
 Absence of menstruation occurs with pregnancy because of the suppression of follicle-
stimulating hormone (FSH) by rising estrogen levels.
3. Cervical
 Increased level of estrogen, the cervix of the uterus becomes more vascular and edematous.
Increased fluid between cells causes it to soften in consistency, and increased vascularity
causes it to darken from a pale pink to a violet hue.
 Hypertrophy of cervical glands leads to formation of mucus plug, (operculum) acts to seal out
bacteria during pregnancy and therefore helps prevent infection in the fetus and membranes.
 Goodell’s sign: Softening of the cervix

4. Vagina
 Increased estrogen, the vaginal epithelium and underlying tissue become hypertrophic and
enriched with glycogen; structures loosen from their connective tissue attachments in
preparation for great distention at birth.
 An increase of vaginal discharge (leukorrhea), which is in response to the estrogen-induced
hypertrophy of the vaginal glands
 Chadwick’s sign: Bluish coloration of cervix, vaginal mucosa, and vulva due to increase
vascularity.
 Acid pH of vagina fall from a pH of greater than 7 (an alkaline pH) to 4 or 5 (an acid pH).
 Acid environment inhibits growth of bacteria.
 Acid environment allows growth of Candida albicans, leading to increased risk of candidiasis
(yeast infection).
5. Ovary
 The corpus luteum, is maintained during the first couple months of pregnancy by high levels of
human chorionic gonadatropin (hCG).
 The corpus luteum, produces progesterone in order to maintain the thick lining of the uterus to
allow for implantation and establishment of the pregnancy.
 Corpus Luteum degenerates when placenta begins producing progesterone.
6. Breast
 Increase of estrogen and progesterone levels: Initially produced by the corpus luteum and
then by the placenta
 Tenderness, feeling of fullness, and tingling sensation
13

 Increase in weight of breast by 400 grams

 Enlargement of breasts, nipples, areola, and Montgomery follicles (small glands on the areola
around the nipple)
 Striae: Due to stretching of skin to accommodate enlarging breast tissue
 Prominent veins due to a twofold increase in blood flow
 Increase of prolactin: Produced by the anterior pituitary
 Increased growth of mammary glands
 Increase in lactiferous ducts and alveolar system
 Production of colostrum, a yellow secretion rich in antibodies, begins to be produced as early
as 16 weeks

Figure 9. Comparison of breasts from

nonpregnant and pregnant women
14
TABLE 9 ✽ DISCOMFORTS OF PREGNANCY
PHYSICAL CHANGES AND
COMMON DISCOMFORTS
BREAST
 Tenderness, enlargement,
upper back pain
(throughout pregnancy;
tenderness mostly in the
first trimester)
 Leaking of colostrum from
nipples (starting second
trimester onward)
UTERUS
 Braxton-Hicks contractions
(midpregnancy onward)
CERVIX / VAGINA
 Increased secretions
Yeast infections (throughout
pregnancy)
 Dyspareunia (throughout
pregnancy)
NURSING ACTIONS / EDUCATION
♥ Encourage the woman to wear a well-
fitting, supportive bra.
♥ Instruct woman in correct use of good
body mechanics
♥ Reassure the woman of the normalcy.
♥ Recommend soft cotton breast pads if
leaking is troublesome.
♥ Reassure the woman that occasional
contractions are normal.
♥ Instruct the woman to call her
provider if contractions become
regular and persist before 37 weeks.
♥ Ensure adequate fluid intake.
♥ Recommend a maternity girdle for
uterus support.
♥ Encourage daily bathing.
♥ Recommend cotton underwear.
♥ Recommend wearing panty liner,
changing pad frequently.
♥ Instruct the woman to avoid douching
or using feminine hygiene sprays.
♥ Inform provider if discharge changes
in color, or accompanied by foul odor
or pruritus
♥ Reassure the woman/couple of
normalcy of response, provide
information.
♥ Suggest alternative positions for
sexual intercourse and alternative
sexual activity to sexual intercourse.
15

B. Cardiovascular System
Changes in the circulatory system are extremely significant to the health of the fetus, because they are
necessary for adequate placental and fetal circulation.

1. Blood Volume, Blood Constitution

 Cardiac output (CO) increases 30%–50% and reaches a peak at 25–30 weeks.
 The heart rate increases 15–20 beats per minute (bpm).
 Stroke volume increases by 25%–30%.
 Basal metabolic rate (BMR) increases 10%–20% by the third trimester.
 The white blood cell (WBC) count increases, with values up to 16,000 mm3 in the absence of
infection.
 The increase is hormonally induced and similar to elevations seen in physiological stress.
 Plasma volume increases 40%–50% during pregnancy until reaching a peak about 32–34 weeks
and remaining there until term.
 In response to increased oxygen requirements of pregnancy, the red blood cell (RBC) count
increases 30% and RBC volume increases up to 33% with iron supplementation (up to 18%
without supplementation).
 The increase in plasma volume is relatively larger than the increase in RBCs. This
hemodilution is evidenced by decreased hemoglobin and hematocrit values and is known
as physiological anemia of pregnancy, or pseudo anemia of pregnancy.
 Cardiac work is eased as the decrease in blood viscosity facilitates placental perfusion.
 Blood volume increases by 1,500 mL or by 40%–45% to support uteroplacental demands and
maintenance of pregnancy. This is referred to as hypervolemia of pregnancy.
 The heart enlarges slightly as a result of hypervolemia and increased cardiac output.
 The heart shifts upward and laterally as the growing uterus displaces the diaphragm
 Hypercoagulation occurs during pregnancy to decrease the risk of postpartum hemorrhage.
These changes place the woman at increased risk for thrombosis and coagulopathies.
 Plasma fibrin increase of 40%
 Fibrinogen increase of 50%
 Coagulation inhibiting factors decrease

Figure 10. The Blood Components

2. Blood Pressure
 Blood pressure decreases in the first trimester due to a decrease in peripheral vascular
resistance. The blood pressure returns to normal by term.
 Systolic heart murmur or a third heart sound (gallop) may be heard by mid-pregnancy.
3. Iron, Folic Acid, and Vitamin Needs
 Iron-deficiency anemia is defined as hemoglobin less than 11.0 g/dL and hematocrit less than
33%.
 Maternal iron stores are insufficient to meet the demands for iron in fetal development.
16

 Folic acid increases even more during pregnancy, inadequate folic acid levels have also been
linked to an increased risk for neural tube disorders in fetuses
Management: encourage to eat green leafy vegetables such as (spinach, asparagus,
malungay).
4. Supine Hypotension Syndrome
 Supine hypotension can occur when the woman is in the supine position as the enlarging
uterus can compress the inferior vena cava (Figure 9)

Figure 9. (A) The weight of the uterus compresses the vena cava, trapping blood in the lower extremities. (B) If a
woman turns on her left side, pressure is lifted off of the vena cava

5. Peripheral Blood Flow

 Peripheral dilation is increased.
 Varicosities may develop in the legs or vulva as a result of increased venous pressure below
the level of the uterus.
 Dependent edema in the lower extremities is caused by increased venous pressure from the
enlarging uterus.

TABLE 10 ✽ DISCOMFORTS OF PREGNANCY

PHYSICAL CHANGES AND
COMMON DISCOMFORTS
CARDIOVASCULAR
 Supine hypotension
(mid-pregnancy onward)
NURSING ACTIONS / EDUCATION
♥ Instruct the woman to avoid supine position from
midpregnancy onward.
♥ Advise her to lie on her LEFT side and rise slowly
to decrease the risk of a hypotensive event.

 Orthostatic hypotension ♥ Advise woman to keep feet moving when standing

and avoid standing for prolonged periods.
♥ Instruct to rise slowly from a lying position to
sitting or standing to decrease the risk of a
hypotensive event.

 Anemia (throughout ♥ Encourage the woman to include iron-rich foods in

pregnancy; more daily dietary intake and take iron
common in late second supplementation.
trimester)

 Dependent edema lower Instruct the woman to:

extremities and/or vulva
(late pregnancy)
♥ Wear loose clothing
♥ Use a maternity girdle (abdominal support), which
may help reduce venous pressure in pelvis/lower
extremities and enhance circulation
♥ Avoid prolonged standing or sitting
♥ Dorsiflex feet periodically when standing or sitting
♥ Elevate legs when sitting
 F – lat shoes
17

 A - nti embolic stockings

 M – assage is discouraged
 E – levate legs

 Varicosities (later ♥ Instruct woman in all measures for dependent

Pregnancy) edema.
♥ Suggest the woman wear support hose (put on
before rising in the morning, before legs have
been in dependent position).
♥ Instruct the woman to lie on her back with legs
propped against a wall in an approximately 45-
degree angle to spine periodically throughout the
day.
♥ Instruct the woman to avoid crossing legs when
sitting.

C. Respiratory System
Adapts in response to physiological and anatomical demands related to fetal growth and development
as well as maternal metabolic needs. Pulmonary function is not compromised in a normal pregnancy.

Physiological changes include:

 Tidal volume increases 35%–50%
 Slight respiratory alkalosis
 Decrease in PCO2 leads to an increase in pH (more alkaline) and decrease in
bicarbonate.
 This change promotes transport of carbon dioxide away from the fetus.
 Increases in estrogen, progesterone, and prostaglandins cause vascular engorgement and
smooth muscle relaxation resulting in edema and tissue congestion, which can lead to:
 Dyspnea
 Nasal and sinus congestion
 Epistaxis (nosebleeds)

Anatomical changes include:

 Diaphragm is displaced upward approximately 4 cm.
 Increase in chest circumference of 6 cm with an increase in the costal angle of greater than 90
degrees
 There is a shift from abdominal to thoracic breathing as the pregnancy progresses (see Figure
10)
 These anatomical changes may contribute to the physiological dyspnea that is common during
pregnancy.

Figure 10. Dotted lines indicate displacement of heart and lungs

as pregnancy progresses and uterus enlarges.
18

TABLE 11 ✽ DISCOMFORTS OF PREGNANCY

PHYSICAL CHANGES AND
NURSING ACTIONS / EDUCATION
COMMON DISCOMFORTS
D. Renal
RESPIRATORY SYSTEM ♥ Reassure the woman of the normalcy of her
 Hyperventilatio response and provide information.
n and dyspnea ♥ Instruct the woman to slow down respiration rate
(throughout and depth when hyperventilating.
pregnancy; may ♥ Encourage good posture.
worsen in later ♥ Instruct the woman to stand and stretch, taking a
pregnancy) deep breath, periodically throughout the day;
stretch and take a deep breath periodically
throughout the night.
♥ Suggest sleeping semi-sitting with additional
pillows for support.

 Nasal and sinus ♥ Suggest the woman try a cool-air humidifier.

congestion/ ♥ Instruct the woman to avoid use of decongestants
Epistaxis and nasal sprays and instead to use normal saline
(throughout drops.
pregnancy)
System
The kidneys undergo change during pregnancy as they adapt to perform their basic functions of regulating fluid
and electrolyte balance, eliminating metabolic waste products, and helping to regulate blood pressure.

Physiological changes include:

 Renal plasma flow increases.

 Glomerular filtration rate (GFR) increases.
 Renal tubular reabsorption increases.
 Proteinuria and glucosuria can normally occur in small amounts related to tubal reabsorption
threshold of protein and glucose being exceeded due to increased volume.
 Even though a small amount of proteinuria and glucosuria can be normal, it is
important to assess and monitor for pathology.
 Shift in fluid and electrolyte balance
 The need for increased fluid and electrolytes results in alteration of regulating
mechanisms including the renin–angiotensin–aldosterone system and antidiuretic
hormone.
 Positional variation in renal function
 In the supine and upright maternal position, blood pools in the lower body, causing a
decrease in cardiac output, GFR, and urine output; also causing excess sodium and fluid
retention.
 A left lateral recumbent maternal position can:
♥ Maximize cardiac output, renal plasma volume, and urine output
♥ Stabilize fluid and electrolyte balance
♥ Minimize dependent edema
♥ Maintain optimal blood pressure

These changes support the increased circulatory and metabolic demands of the pregnancy because the renal
system secretes both maternal and fetal waste products.

Anatomical changes include:

 Renal pelvis dilation with increased renal plasma flow

 Ureter alterations
 Become elongated, tortuous, and dilated
 Bladder alterations
 Bladder capacity increases and bladder tone decreases related to progesterone effect
on smooth muscle of the bladder causing relaxation and stretching.
 Urinary stasis
 Progesterone reduces the tone of renal structures, allowing for pooling of urine.
 Stasis promotes bacterial growth and increases the woman’s risk for urinary tract
infections and pyelonephritis.
19

 Hyperemia of bladder and urethra related to increased vascularity that results in pelvic
congestion; edematous mucosa is easily traumatized.
 Urinary symptoms of frequency, urgency, and nocturia primarily a result of the systemic
hormonal changes and also anatomical changes in the renal system.
 Urinary Tract Infection UTI) most common bacterial infection during pregnancy.
Physiological changes that occur in the renal system during pregnancy predispose
pregnant women to urinary tract infections.
 Treatment includes anti-infective medication for a 7- to 10-day period. If untreated, the
infection can lead to pyelonephritis or premature labor.

TABLE 12 ✽ DISCOMFORTS OF PREGNANCY

PHYSICAL CHANGES AND
NURSING ACTIONS / EDUCATION
COMMON DISCOMFORTS
RENAL SYSTEM
 Frequency and ♥ Reassure the woman of normalcy of response.
urgency/nocturia ♥ Encourage the woman to empty her bladder
(may be frequently, always wiping front to back.
throughout ♥ Stress the importance of maintaining adequate
pregnancy; most hydration, reducing fluid intake only near
common in first bedtime. Instruct her to urinate after
and third intercourse.
trimesters) ♥ Teach the woman to notify her provider if there
is pain or blood with urination.
♥ Encourage Kegel exercises; wear perineal pad if
needed.

FIGURE 11 Bladder changes during pregnancy. (A) Early pregnancy: the uterus presses against the bladder, causing
frequent urination. (B) Middle pregnancy: urinary frequency is relieved. (C) Late pregnancy: the uterus is again pressing
on the bladder, leading to the recurrence of urinary frequency.

E. Gastrointestinal System
Adapts in its anatomy and physiology during pregnancy in support of maternal and fetal nutritional
requirements. The adaptations are related to hormonal influences as well as the impact of the
enlarging uterus on the GI system as pregnancy progresses.
 (90%) experience some degree of nausea and vomiting in pregnancy. As the pregnancy
progresses, NVP symptoms usually diminish; 60% of cases resolve by 12 weeks’ gestation
and 90% have symptom improvement by 16 weeks’ gestation.
 Increase in appetite and intake
 Cravings for specific foods
 Pica is a craving for and consumption of nonfood substances such as starch and clay. It can
result in toxicity due to ingested substances or malnutrition from replacing nutritious foods
with nonfood substances.
 Avoidance of specific foods

Anatomical and physiological changes include:

 Uterine enlargement displaces the stomach, liver, and intestines as the pregnancy
progresses.
 By the end of pregnancy, the appendix is situated high and to the right along the costal
margin.
20

 GI tract experiences a general relaxation and slowing of its digestive processes, contributing
to common discomforts such as heartburn, abdominal bloating, and constipation.
 Hemorrhoids (varicosities in the anal canal) are common due to increased venous pressure
and are exacerbated by constipation. 30%–40% of pregnant women experience
hemorrhoidal discomfort, pruritis, and/or bleeding.
 Gallstones: Progesterone-induced relaxation of smooth muscle results in distention of
gallbladder and slows emptying of bile; bile stasis and elevated levels of cholesterol
contribute to formation of gallstones.
 Pruritus: Abdominal pruritus may be an early sign of cholestasis.
 Ptyalism: Increase in saliva
 Bleeding gums and periodontal disease.
 Increased vascularity of the gums can result in gingivitis
 TABLE 13 ✽ DISCOMFORTS OF PREGNANCY
PHYSICAL CHANGES AND
21 NURSING ACTIONS / EDUCATION
COMMON DISCOMFORTS
GASTROINTESTINAL
 Nausea and/or ♥ Reassure the woman of normalcy and self-limiting nature
vomiting in pregnancy of response.
(NVP) (first trimester ♥ Avoid strong odors and causative factors (e.g., spicy foods,
and sometimes into greasy foods, large meals, stuffy rooms, hot places or loud
the second trimester) noises).
♥ Encourage women to experiment with alleviating factors:
 Eating small, frequent meals as soon as, or before,
feeling hungry
 Eat a slow pace
 Eat crackers or dry toast before rising or whenever
nauseous
 Drink cold, clear carbonated beverages such as ginger
ale, or sour beverages such as lemonade
 Avoid fluid intake with meals
 Eat ginger-flavored lollipops or peppermint candies
 Brush teeth after eating
 Take vitamins at bedtime with a snack (not in the
morning)
 Suggest vitamin B6, 25 mg by mouth three times daily
or ginger, 250 mg by mouth four times daily
♥ Oral or rectal medications may be prescribed for
management of troublesome symptoms.
♥ Identify, acknowledge, and support women with
significant NVP to offer additional treatment options.

 Increase or sense of ♥ Suggest use of gum or hard candy or use astringent

increase in salivation mouthwash.
(mostly first trimester
if associated with
nausea)

 Bleeding gums ♥ Encourage the woman to maintain good oral hygiene

(throughout (brush gently with soft toothbrush, daily flossing).
pregnancy) ♥ Maintain optimal nutrition.

 Flatulence Encourage the woman to:

(throughout ♥ Maintain regular bowel habits
pregnancy) ♥ Engage in regular exercise
♥ Avoid gas-producing foods
♥ Chew food slowly and thoroughly
♥ Use the knee-chest position during periods of discomfort.

 Heartburn (later Suggest:

pregnancy) ♥ Small, frequent meals
♥ Maintain good posture
♥ Maintain adequate fluid intake, but avoid fluid intake with
meals
♥ Avoid fatty or fried foods
♥ Remain upright for 30–45 minutes after eating
♥ Refrain from eating at least 3 hours prior to bedtime

 Constipation Encourage the woman to:

(throughout ♥ Maintain adequate fluid intake
pregnancy) ♥ Engage in regular exercise such as walking
♥ Increase fiber in diet
♥ Maintain regular bowel habits
♥ Maintain good posture and body mechanics

 Hemorrhoids (later  Avoid constipation

pregnancy) ♥ Instruct the woman to avoid bearing down with bowel
movements.
♥ Instruct the woman in comfort measures (e.g., ice packs,
warm baths or sitz baths, witch hazel compresses).
♥ Elevate the hips and lower extremities during rest periods
throughout the day.
♥ Gently reinsert into the rectum while doing Kegel
exercises
22

F. Musculoskeletal System
Hormonal shifts are responsible for many of these changes. Mechanical factors attributable to the
growing uterus also contribute to musculoskeletal adaptation.
Anatomical and physiological changes include:
 Altered posture and center of gravity related to distention of the abdomen by the expanding
uterus and reduced abdominal tone that shifts the center of gravity forward.
 A shift in the center of gravity places the woman at higher risk for falls.
 Altered gait (“pregnant waddle”): Hormonal influences of progesterone and relaxin soften
joints and increase joint mobility.
 Lordosis: Abnormal anterior curvature of the lumbar spine. The body compensates for the shift
in center of gravity by developing an increased curvature of the spine.
 Joint discomfort: Hormonal influences of progesterone and relaxin soften cartilage and
connective tissue, leading to joint instability.
 Round ligament spasm: Estrogen and relaxin increase elasticity and relaxation of ligaments,
and abdominal distention stretches round ligaments causing spasm and pain.
 Diastasis recti: separation of the rectus abdominis muscle in the midline caused by the
abdominal distention. A benign condition that occur in the third trimester.

TABLE 14 ✽ DISCOMFORTS OF PREGNANCY

G. PHYSICAL CHANGES AND
NURSING ACTIONS / EDUCATION
COMMON DISCOMFORTS
MUSCULOSKELATAL Instruct the woman to:
 Low back pain/joint ♥ Utilize proper body mechanics (e.g., stoop using knees
discomfort/ difficulty vs. bend for lifting)
walking (later ♥ Maintain good posture
pregnancy) ♥ Do pelvic rock/pelvic tilt exercises
♥ Wear supportive shoes with low heels
♥ Apply warmth or ice to painful area
♥ Use of maternity girdle
♥ Use massage
♥ Use relaxation techniques
♥ Sleep on a firm mattress with pillows for additional
support of extremities, abdomen, and back

 Diastasis recti (later ♥ Instruct the woman to do gentle abdominal strengthening

pregnancy) exercises (e.g., tiny abdominal crunches, may cross arms
over abdomen to opposite sides for splinting, no sit-ups).
♥ Teach proper technique for sitting up from lying down
(i.e., roll to side, lift torso up using arms until in sitting
position).

 Round ligament spasm Instruct the woman to:

& pain (late second ♥ Lie on side and flex knees up to abdomen
and third trimester) ♥ Bend toward pain • Do pelvic tilt/pelvic rock exercises
♥ Use warm baths or compresses
♥ Use side-lying in exaggerated Sim’s position with pillows
for additional support of abdomen and in between legs
♥ Use maternity belt

 Leg cramps Instruct the woman to:

(throughout ♥ Dorsiflex foot to stretch calf muscle
pregnancy) ♥ Warm baths or compresses to the affected area
♥ Change position slowly
♥ Regular exercise and muscle conditioning
Integumentary System
Hormonal influences are primary factors in integumentary system adaptations during
pregnancy, with mechanical factors associated with the enlarging uterus playing a lesser role in
changes associated with this body system.
Anatomical and physiological changes include:
 Hyperpigmentation: Estrogen and progesterone stimulate increased melanin deposition of
light brown to dark brown pigmentation.
 Linea nigra: Darkened line in midline of abdomen
23

 Melasma (chloasma), also referred to as mask of pregnancy, is a brownish pigmentation

of the skin over the cheeks, nose, and forehead. This occurs in 50%–70% of pregnant
women and is more common in darker skinned. Usually occurs after the 16th week of
pregnancy and is exacerbated by sun exposure.
 Striae (stretch marks): Stretching of skin due to growth of breast, hips, abdomen, and
buttocks plus the effects of estrogen, relaxin, and adrenocorticoids may result in tearing of
subcutaneous connective tissue/collagen.

Figure 12. Skin changes in pregnancy:

striae gravidarum and linea nigra.

 Varicosities, spider nevi, and palmer erythema: Vascular changes related to hormonally
induced increased elasticity of vessels and increased venous pressure from enlarged uterus.
 Hot flashes and facial flushing: Caused by increased blood supply to skin, increase in basal
metabolic rate, progesterone-induced increased body temperature, and vasomotor instability.
 Oily skin and acne: Effects of increase in androgens.
 Sweating: Thermoregulation process at the level of skin increased in response to increases in
thyroid activity, basal metabolic rate (BMR), metabolic activity of fetus, and increased
maternal body weight

TABLE 15 ✽ DISCOMFORTS OF PREGNANCY

PHYSICAL CHANGES
AND COMMON NURSING ACTIONS / EDUCATION
DISCOMFORTS
INTEGUMENTARY ♥ Reassure the woman that there is no method to prevent them.
 Striae (stretch marks)♥ Suggest maintaining skin comfort (e.g., lotions, oatmeal baths,
(later pregnancy) non-binding clothing).
♥ Encourage good weight control.

 Dry skin or pruritus ♥ Suggestions for maintaining skin comfort use tepid water for
H.
(itching) (later baths and showers and rinse with cooler water.
Endocrine
pregnancy) ♥ Avoid hot water (drying effect and may increase itching). Use
System
moisturizing soaps or body wash.
♥ Avoid exfoliating scrubs or deodorant soaps (has drying effect
and may increase itching). Use of lotions, oatmeal baths, non-
binding clothing may lessen itching.

 Skin ♥ Limit sun exposure.

hyperpigmentation ♥ Wear sunscreen regularly.

 Acne ♥ Use products developed for the face only (e.g., cleansers,
sunscreen), avoid body soaps and facial scrubs (both have
drying effects), body lotions/creams (clog pores); use tepid
water when washing face and always follow with cold rinse to
close pores before applying moisturizers (if needed) or
sunscreen.
24

Almost all aspects of the endocrine system increase during pregnancy

Physiologic changes include:

 Significant alterations in pituitary, adrenal, thyroid, parathyroid, and pancreatic functioning

occur in pregnancy. For example, the hormonal production activity and size of the thyroid
gland increase during pregnancy in support of maternal and fetal physiological needs, and
there is an increase in pancreatic activity during pregnancy to meet both maternal and fetal
needs related to carbohydrate metabolism.

Pregnancy-specific hormones

 The hormones of pregnancy are responsible for most of the physiological adaptations and
physical changes seen throughout the entire pregnancy. The placental hormones are initially
produced by the corpus luteum of pregnancy. Once implantation occurs, the fertilized ovum
and chorionic villi produce hCG.
 The function of the high hCG level in early pregnancy is to maintain the corpus luteum and its
production of progesterone and, to a lesser extent, estrogen until the placenta develops and
takes over this function.
 After the development of a functioning placenta, the placenta produces most of the
hormones of pregnancy, including estrogen, progesterone, human placental lactogen (hPL),
and relaxin.
 Each of these hormones plays a role in the physiology of pregnancy, resulting in specific
alterations in nearly all body systems, as described in this chapter, to support maternal
physiological needs, maintenance and progression of the pregnancy, and fetal growth and
development

I. IMMUNE SYSTEM
Immunologic competency during pregnancy apparently decreases, probably to prevent a
woman’s body from rejecting the fetus as if it were a transplanted organ. Immunoglobulin G (IgG)
production is particularly decreased, which can make a woman more prone to infection during
pregnancy. A simultaneous increase in the white blood cell count may help to counteract the
decrease in IgG response.

TABLE 16 ✽ DISCOMFORTS OF PREGNANCY

PHYSICAL CHANGES AND
COMMON NURSING ACTIONS / EDUCATION
DISCOMFORTS
GENERALIZED OR ♥ Reassure the woman of the normalcy of her response.
MULTISYSTEM ♥ Encourage the woman to plan for extra rest during the
day and at night; focus on “work” of growing a healthy
 Fatigue (first and baby.
third trimesters) ♥ Enlist support and assistance from friends and family.
♥ Encourage the woman to eat an optimal diet with
adequate caloric intake and iron-rich foods and iron
supplementation if anemic.

 Insomnia ♥ Instruct the woman to implement sleep hygiene measures

(throughout (regular bedtime, relaxing or low-key activities pre-
pregnancy) bedtime).
♥ Encourage the woman to create a comfortable sleep
environment (body pillow, additional pillows).
♥ Teach breathing exercises and relaxation
techniques/measures [progressive relaxation, effleurage
(a massage technique using a very light touch of the
fingers in two repetitive circular patterns over the gravid
abdomen), warm bath or warm beverage pre-bedtime.
♥ Evaluate caffeine use.

 Emotional lability ♥ Reassure the woman of the normalcy of response.

(throughout ♥ Encourage adequate rest and optimal nutrition.
pregnancy) ♥ Encourage communication with partner/significant
support people.
♥ Refer to pregnancy support group.
25

End of Prelim period