MODULE 4 Psychological and Physiologic Changes of Pregnancy

Module 4:
Psychological and
Physiologic Changes
of Pregnancy
PAIDA P. ABDULMALIK, RN, MAN
OBJECTIVES:
Describe common Define different

psychological and terms related to the
physiologic changes psychological and
that occur with physiologic changes
pregnancy. of pregnancy.
Common Terms
Braxton hicks Chadwick’s Couvade

Ballottement Diastasis
contractions sign syndrome
Goodell’s sign Hegar’s sign Lightening Linea nigra Melasma
Montgomery’s
Multipara Operculum Polyuria Primigravida
tubercles
Striae
Quickening
gravidarum
Psychological Changes of
Pregnancy
Common Psychological Changes That Occur With
Pregnancy
Psychological Description
Change
First trimester Couple spend time recovering from the
discovery of pregnancy and concentrates
task: Accepting the concentrate on what it
Pregnancy feels like to be pregnant. common
reaction is ambivalence.
Second trimester Couple move through emotions such as
narcissism and introversion. Role-
task: Accepting the fetus playing and increased dreaming are
common.
Third trimester Couple prepare clothing and sleeping

arrangements for the baby but also
task: Preparing for the grow impatient as they ready
baby and end of themselves for birth.
pregnancy
Checkpoint Question 1
Lauren wasn’t totally happy about learning that she was pregnant.
What psychological task is important for the woman to complete
during the first trimester of her pregnancy?
a. Accepting morning sickness nausea

b. Accepting the fact that she is pregnant
c. Appreciating the responsibility of having a baby
d. Choosing a name for her baby
First Trimester: Accepting
The Pregnancy
• a missed menstrual flow.
 Because of this suspicion of pregnancy is
made.
• women often experience feelings less than pleasure

and closer to anxiety or a feeling of ambivalence.
• self-diagnose their pregnancy by using a urine
pregnancy test strip
• first prenatal visit is another step toward
accepting a pregnancy.
Second Trimester:
Accepting The Baby
• Quickening
 first moment a woman feels fetal movement
 With quickening, the fetus becomes a
separate identity
• Women often use the term “it” to refer to their fetus
before quickening but begin to use he or she
afterward.
• A good way to measure the level of a woman’s
acceptance of her coming baby is to measure
how well she follows prenatal instructions
Third Trimester: Preparing
For Parenthood
• classes on preparing for childbirth
 couples usually begin “nest-building”
activities, such as planning the infant’s
sleeping arrangements, choosing a name for
the infant, and “ensuring safe passage” by
learning about birth
• Couples at this point are usually interested

in attending prenatal classes and/or
Emotional Responses That Can
Cause Concern In Pregnancy
Introversion Body Image

Grief Narcissism or and Boundary
Extroversion Concerns
Couvade Changes in
Stress Mood Swings
Syndrome Sexual Desire
Grief
• Before a woman can take on a
mothering role, she has to give up
or alter her present role as she will
never be the woman she has been
in exactly the same way again.
• She will never be able to be as
irresponsible and carefree again, or
perhaps sleep soundly for the next
few years
Narcissism
• Excessive interest in or admiration of
oneself and one's physical appearance.
• She dresses so her pregnancy will or will

not show
• She may criticize her partner’s driving,

although it never bothered her before.
• She does these things to unconsciously

protect her body and her baby.
Introversion Versus Extroversion
• Pregnant women can either be
an introvert or extrovert.
• Introversion, or turning inward
to concentrate on oneself and
one’s body.
• Extroversion- more active,
appear healthier than ever
before, and are more outgoing.
Body Image and Boundary
• Both change during pregnancy as a woman
begins to envision herself as a mother or
becoming “bigger” in many different ways.
• Body image (i.E., The way your body
appears to yourself) .
• Body boundary (i.E., A zone of
separation you perceive between
yourself and objects or other people).
 Ex. Woman may walk far away from
an object such as a table to avoid
bumping against it.
Stress
• Can happen in in a woman who was not
planning to be pregnant or if she finds her
lifestyle changing dramatically after she
becomes pregnant.
• 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.
• Remind the family that any decrease in the
ability to function that happens to a pregnant
woman is a reaction to the stress of pregnancy.
Depression
• Depression—a feeling of sadness marked by
loss of interest in usual things, feelings of guilt
or low self-worth, disturbed sleep, low energy,
and poor concentration—is a common finding
in late adolescents
• It is important to screen for women who have a
history of depression during preconception visit
because common drugs prescribed for
depression can be teratogenic to a fetus as well
as cause hypertension in the woman .
• investigate if the woman has a meaningful
support person
Lauren Maxwell is aware she’s been
showing some narcissism since becoming
pregnant. How would the nurse describe
this phenomenon to an unlicensed care
provider?
a. She feels pulled in multiple directions.
b. She feels a need to sleep more than usual.
c. Her thoughts tend to be mainly about herself.
d. She often feels emotionally “numb.”
Couvade Syndrome
• is a term used to describe sympathetic
pregnancy in men;
• the word couvade comes from the Breton
word couver, which means to brood, hatch, or
incubate.
• 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 a partner is involved in or attuned
to the changes of the pregnancy, the more
symptoms a partner may experience
Emotional
Lability
• Mood changes occur frequently in a
pregnant woman, partly as a
symptom of narcissism and partly
because of hormonal changes.
• She may cry over her children’s
bad table manners at one meal, for
example, and find the situation
amusing or even charming at the
next.
• Caution families that such mood
swings occur beginning with early
pregnancy so they can accept them
as part of a normal pregnancy.
Nursing Care Planning Based on Family Teaching
Q. Lauren Maxwell tells you she has noticed extreme mood
swings since she’s been pregnant. She asks you how she can
reduce them.
A. Everyone is different, but good measures to try include:
• Avoid fatigue
• Reduce your level of stress by setting priorities.
• Don’t let little problems grow into big ones; attack them when
they first occur.
• Try to view situations from other people’s perspective.
• Let others know you’re aware you’re having trouble with
emotions since you became pregnant
Changes In Sexual Desire
• Women who formerly were worried about

becoming pregnant might truly enjoy sexual
relations for the first time during pregnancy.\
• Others might feel a loss of desire because of
their increase in estrogen, or they might
unconsciously view sexual relations as a threat
to the fetus they must protect.
• Some may worry coitus could bring on early
labor.
• During the first trimester: there is decrease in
libido.
• 2nd trimester: libido and sexual enjoyment can
rise markedly.
• 3rd trimester: sexual desire may remain high, or
it may decrease.
3 Classifications Of Signs And Symptoms Of
Pregnancy
Presumptive (Subjective
Symptoms)
Probable (Objective
Signs),
Positive (Documented
Signs)
Presumptive, Probable, and Positive
Indications of Pregnancy
Time From Presumptive Probable Positive Description
Implantation Finding Finding Finding
(Weeks)
1 Maternal A venipuncture of blood
serum test serum reveals the
presence of human
chorionic
gonadotropin
hormone
2 Breast Feelings of tenderness,
changes fullness, tingling;
Feelings enlargement and
darkening of areola
(Weeks)
2 Nausea, Nausea or vomiting on
vomiting arising or when
fatigued
2 Amenorrhea Absence of
menstruation
3 Frequent Sense of having to void

urination more often than usual
(Weeks)
6 Chadwick’s sign Color change of the
vagina from pink to
violet
6 Goodell’s sign Softening of the cervix
6 Hegar’s sign Softening of the lower

uterine segment
6 Sonographic Characteristic ring is

evidence of evident
gestational
sac
(Weeks)
8 Sonographic Fetal outline can be seen
evidence of and measured by
fetal outline sonogram
10-12 Fetal heart Doppler ultrasound

audible reveals heartbeat
12 Fatigue General feeling of

tiredness
12 Uterine Uterus can be palpated

enlargement over symphysis pubis
Time From Presumpt Probable Positive Description
Implantation ive Finding Finding
(Weeks) Finding
16 Ballottement When lower uterine segment is

tapped on a bimanual
examination, the fetus can be
felt to rise against the abdominal
wall
18 Quickening Fetal movement felt by woman

(Weeks)
20 Fetal movement Fetal movement can be

felt by examiner palpated through
abdomen
20 Braxton Hicks Periodic uterine

contractions tightening occurs
20 Fetal outline Fetal outline can be

felt by Examiner palpated through
abdomen
(Weeks)
24 Linea nigra Line of dark pigment

forms on the abdomen
24 Melasma Dark pigment forms on

face
24 Striae Stretch marks form on

gravidarum abdomen
Presumptive Symptoms Of
Pregnancy
• Subjective Symptoms
• are those that are least indicative of
pregnancy; taken as single entities,
they could easily indicate other
conditions (Rojas, Wood, &
Blakemore, 2007).
• are experienced by the woman but
cannot be documented by an
examiner
Probable Signs of
Pregnancy
• are objective and so can be verified

by an examiner.
• Common labs test include urinalysis
or Serum laboratory Tests of blood
serum reveal the tests
Laboratory Tests
• trace amounts of HCG appear in her serum as early as 24 to 48 hours after

implantation and reach a measurable level (about 50 milli-International Unit/ml
7 to 9 days after conception.
• Levels peak at about 100 milli-International Unit/ml between the 60th and 80th
day of gestation.
• Home Pregnancy Tests
 take only 2 to 3 minutes to complete, and have a high degree of accuracy (97% to
99%) if the instructions are followed exactly because they can detect as little as 35
milli- International Unit/ml of HCG.
 a woman dips a reagent strip into her stream of urine. A color change or the
appearance of two bars on the strip denotes pregnancy
Laboratory Tests
Tips to give the woman for successful testing include:
 Check the expiration date on the package.
 Read the instruction pamphlet provided with the test
 A concentrated urine sample such as a first urine in the morning

tests best
 Read the test results at the exact time the instructions dictate
 Some prescription medicines, like methadone or chlordiazepoxide, may

cause false-positive results
 Early prenatal care is the best safeguard to ensure a successful pregnancy

Laboratory Tests
• Conditions/ situations that may cause false positive result:
• taking psychotropic drugs (e.g., antianxiety agents)
• taking oral contraceptives (for such a test to be accurate, oral
contraceptives should have been discontinued 5 days before the test).
• Women who have proteinuria, are postmenopausal, or have
hyperthyroid disease also may show false-positive results.
POSITIVE SIGNS OF PREGNANCY
• 1. Demonstration Of A Fetal Heart Separate From The

Mother’s
• 2. Fetal Movements Felt By An Examiner
• 3. Visualization Of The Fetus By Ultrasound
Demonstration of a Fetal Heart Separate From
the Mother’s
• Fetal heart rate ranges between 120 and 160 beats/min.
• Sounds are more difficult to hear if a woman’s abdomen has a
great deal of subcutaneous fat or if there is a larger-than-
normal amount of amniotic fluid present (polyhydramnios).
• FHT can be heard through:
 Stethoscope - until 18 to 20 weeks of pregnancy.
 Echocardiography - as early as 5 weeks
 Ultrasound - as early as the 6TH to 7TH week of pregnancy.
 Doppler instrumentation - as early as the 10th to 12th week
of gestation.
Fetal Movements Felt by an Examiner
• An objective examiner can discern fetal movements at

about the 20th to 24th week of pregnancy unless the
woman is extremely obese.
Visualization of the Fetus by Ultrasound
• Ultrasound is the most common method for confirmation of

pregnancy today
• 4th to 6th week - a characteristic ring, indicating the gestational sac,
will be revealed on an oscilloscope.
• 8th week- a fetal outline can be seen so clearly that the crown-to-
rump length can be measured to establish the gestational age of the
pregnancy.
• Lauren Maxwell did a urine pregnancy test but was surprised to
learn a positive result is not a sure sign of pregnancy. As the nurse is
recording her result in the electronic health record, she asks what a
positive sign would be. The nurse should cite what finding?
• a. She has noticed consistent abdominal and uterine growth.
• b. She can feel her fetus move more than once per hour.
• c. A serum tests reveals HCG.
• d. A fetal heartbeat can be seen during an ultrasound exam.
PHYSIOLOGIC
CHANGES OF
PREGNANCY
Physiologic Changes of Pregnancy
• Basis for the signs and symptoms used to confirm a
pregnancy.
• Can be categorized as local (i.E., Confined to the
reproductive organs) or systemic (i.E., Affecting the
entire body).
Timetable For Physiologic Changes Of Pregnancy
Location of First Trimester Second Third Trimester

Change Trimester
Cardiovascular Blood volume Blood pressure Blood pressure
increasing slightly decreased returns to
prepregnancy
Pseudoanemia may levels
occur
Clotting factors
increasing
Ovarian Corpus luteum active Corpus luteum
fading
Location of First Trimester Second Trimester Third Trimester

Change
Uterine Steady increased Placenta producing Steady increased

growth estrogen and growth
progesterone, steady
increased growth
Cervix Softening begins Softening increases “Ripe”

Location of First Second Trimester Third

Change Trimester Trimester
Vaginal White Increasing in

discharge amount
present
Musculoskeletal Progressive Possible back or

cartilage Softening pelvic girdle
pain
Lordosis increasing
Location of First Trimester Second Third

Pigmentation Progressively
increasing
Kidney Maternal glomerular
filtration rate increasing
Glycosuria begins and

increases
Aldosterone increased, aiding

retention of sodium and fluid
Location of First Second Third Trimester

Gastrointestinal Slowed peristalsis
Thyroid Increased
metabolic
rate
Local Physiologic
Changes of
Pregnancy
REPRODUCTIVE SYSTEM CHANGES
• are those changes involving the uterus, ovaries, vagina,
and breasts.
• Uterine Changes
 Length: 6.5 cm to 32 cm.
 Depth : 2.5 cm to 22 cm.
 Width : 4 cm to 24 cm.
 Weight : 50 g to 1,000 g.
 Uterine wall: thickens from 1cm to about 2 cm ( early
pregnancy); wall thins to become supple and only about 0.5- cm
thick (toward the end of pregnancy)
 Volume: increases from about 2 ml to more than 1,000 ml.
Uterine Changes
• 12th week - just above the symphysis
pubis
• 20th or 22nd week- level of the
umbilicus.
• 36th week- xiphoid process
• 38th week- lightening in primigravida
occurs.
• Lightening- fetal head settles into the
pelvis and the uterus returns to the
height it was at 36.
Uterine Changes
• Uterine height is
measured from the top of
the symphysis pubis to
over the top of the
uterine fundus.
• exact shape of the
expanding uterus can be
influenced by the
position of the fetus
Uterine Changes
• Hegar’s sign - extreme
softening of the lower uterine
segment.
• How to assess?
 Perform A bimanual
examination (two fingers of an
examiner are placed in the
vagina, the other hand on the
abdomen).
 It can demonstrate, during a
pregnancy, that the uterus
feels more anteflexed, larger,
and softer to the touch than
usual
Uterine Changes
• Ballottement
 from the French word ballotter, meaning “to quake”)
 Occurs during 16th to 20th week of pregnancy
 On bimanual examination, if the lower uterine segment
is tapped sharply by the lower hand, the fetus can be
felt to bounce or rise in the amniotic fluid up against the
top examining hand.
 Although this phenomenon is interesting, it also may be
simulated by a uterine tumor, and therefore it is no
more than a probable sign of pregnancy.
Uterine Changes
• Braxton Hicks contractions
 Uterine contractions begin early in pregnancy, at least by the
12th week, and are present throughout the rest of pregnancy,
becoming stronger and harder as the pregnancy advances.
 They may be felt by a woman as waves of hardness or
tightening across her abdomen.
 “practice” contractions, serve as warm-up exercises for labor
and also increase placental perfusion but cannot cause
cervical dilation
 Still a probable sign since they also could accompany any
growing uterine mass
Uterine Changes
• Amenorrhea
 an absence of a menstrual flow) occurs with
pregnancy because of the suppression of follicle-
stimulating hormone (FSH) by rising estrogen levels.
 also heralds the onset of menopause or could result
from delayed menstruation because of unrelated
reasons, such as uterine infection, a chronic illness
such as severe anemia, or stress. It occurs in athletes
who train strenuously, therefore, only a presumptive
symptom of pregnancy
Uterine Changes
• Cervical Changes
 Becomes more vascular and edematous because of estrogen .
 Cervix darken from a pale pink to a violet hue.
 A mucus plug, called the operculum, forms to seal out bacteria
and help prevent infection in the fetus and membranes.
 Softening of the cervix in pregnancy (Goodell’s sign) is marked.
 Nonpregnant cervix can be compared with that of the nose.
 Pregnant cervix more closely resembles an earlobe
• Vaginal Changes
 Vaginal epithelium and underlying tissues increase in size as they
become enriched with glycogen due to estrogen.
 Slight white vaginal discharge
 Chadwick’s sign- color of vaginal walls turns from their normal light
pink to a deep violet.
 From alkaline area to acidic area (7-4 or 5) because eof lactobacillus
acidophilus
 Lactobacillus acidophilus- a bacteria that grows freely in the increased
glycogen environment; helps in making the vaginal area acidic.
• Ovarian Changes
 Ovulation stops with pregnancy.
• Lauren Maxwell’s doctor told her she had a positive

Chadwick’s sign. When she asks the nurse what this means,
the best answer would be which of the following?
a. “Your abdomen feels soft and tender, a normal finding.”

b. “Your uterus has tipped forward, a potential complication.”
c. “Your cervical mucus feels sticky, just as it should feel.”
d. “Your vagina looks dark in color, a typical pregnancy sign.”
CHANGES IN THE BREASTS • Typical changes are a feeling of
fullness, tingling, or tenderness.
• Breast size increases because of
hyperplasia of the mammary alveoli
and fat deposits.
• Areola of the nipple darkens, and its
diameter increases from about 3.5 cm
(1.5 in.) To 5 cm or 7.5 cm (2 or 3 in.).
• Formation of secondary areola in
some women.
• By the 16th week, colostrum can be
expelled from the nipples.
• Blue veins may become prominent
over the surface of the breasts
• Montgomery’s tubercles- becomes
enlarge and protuberant
Comparison of nonpregnant and pregnant breasts
SYSTEMIC
CHANGES
Integumentary System  Striae gravidarum formation
 Pink or reddish streaks
appearing on the sides of the
abdominal wall and sometimes
on the thighs
 after birth, striae gravidarum
lighten to a silvery color (striae
albicantes or atrophicae)
 Diastasis
 occurs when the rectus abdominis
muscles (six-pack ab muscles)
separate during pregnancy from
being stretched.
 If this happens, it will appear after
pregnancy as a bluish groove at
the site of separation.
Integumentary System • Umbilicus
 is stretched to such an extent
that by the 28th week, its
depression becomes obliterated
and smooth because it has been
pushed so far outward
• Linea Nigra
 narrow, brown line may form,
running from the umbilicus to
the symphysis pubis and
separating the abdomen into
right and left hemispheres.
• Melasma (Chloasma)
 Darkened areas may appear on
the face as well, particularly on
the cheeks and across the nose.
 “mask of pregnancy.”
Integumentary System • Telangiectasias or Vascular
Spiders
 Are small, fiery-red branching spots
seen on the skin, particularly on
the thighs.
• Increase in perspiration
• Palmar erythema
 may occur on the hands.
• Scalp hair growth is increased
Respiratory System
• Marked congestion, or “stuffiness,” of the

nasopharynx
 a normal response to increased estrogen levels.
 Ask all women at prenatal visits if they are
taking any kind of medicine or if they have
noticed nasal stuffiness to detect this
possibility.
• Acute sensation of shortness of breath (late
in pregnancy)
 Due to great deal of pressure is put on the
diaphragm and, ultimately, on the lungs by the
uterus.
• Breathing rate is more rapid than usual (18–

20 breaths per minute)
Respiratory System
• Vital capacity (the maximum volume

exhaled after a maximum inspiration) does
not decrease
• Residual volume (the amount of air
remaining in the lungs after expiration) is
decreased up to 20% by the pressure of the
diaphragm.
• Tidal volume (the volume of air inspired) is
increased up to 40% as a woman draws in
extra volume to increase the effectiveness of
air exchange.
• Total oxygen consumption increases by as
much as 20%.
Respiratory System
• Decreased level of Partial carbon

dioxide(PCO2) from 40 mmHg to 32mmHg
 This causes a favorable CO2 gradient at the
placenta (the fetal CO2 level is higher than that
in the mother, allowing CO2 to cross readily
from the fetus to the mother).
• Mild Hyperventilation
 Occurs in order to blow off excess CO2 during
early in pregnancy
• Respiratory alkalosis or exhales more than
the usual CO2.
 Occurs because the total ventilation capacity
may have risen by as much as 40%.
• Temperature
 Slightly Increased during Early in pregnancy
because of progesterone.
 At 16 weeks, it usually decreases to normal.
• Gastrointestinal System
 nausea and vomiting (morning sickness,)
early on in pregnancy (It is more frequent in
women who smoke cigarettes.).
 To lessen N&V: acupuncture or wrist bands,
or drinking ginger or peppermint tea may
provide relief.
 acidity of stomach secretions decreases.
 Heartburn due to upward displacement of the
stomach by the uterus, and a relaxed
cardioesophageal sphincter, caused by the
action of relaxin, an enzyme produced by the
ovary
• Gastrointestinal System.
 Constipation, and flatulence
 Decreased emptying of bile from the
gallbladder therefore generalized itching
 Hemorrhoids due to pressure from the uterus
on veins returning from the lower
extremities.
 Hypertrophy at gum lines and bleeding of
gingival tissue.
 Hyperptyalism (increased saliva formation)
 Increased tooth decay due to lower than
normal ph of saliva
Cardiovascular System
• Blood Volume
 total circulatory blood volume increases by at least 30% (and possibly
as much as 50%) during pregnancy.
 Blood loss at a normal vaginal birth is about 300 to 400 mL; blood loss
from a cesarean birth can be as high as 800 to 1000 mL.
 pseudoanemia early in pregnancy
• Heart
 woman’s cardiac output increases significantly, by 25% to 50%; the heart
rate increases by 10 beats per minute.
 appear enlarged on x-ray examination.
 Some women have audible functional (innocent) heart murmurs
during pregnancy, probably because of the altered heart position.
 Palpitation is not uncommon
 Blood Pressure
 Decreases in 2nd trimester,
 3rd tri- rises again to 1st trimester levels
 Peripheral Blood Flow

 During 3rd trimester- blood flow to the lower extremities is impaired by the
pressure of the expanding uterus on veins and arteries which can lead to
edema and varicosities of the vulva, rectum, and legs.
 Supine Hypotension Syndrome
 Occurs when a pregnant woman lies
supine, & the weight of the growing uterus
presses the vena cava against the
vertebrae, obstructing blood flow from the
lower extremities. This causes a decrease
in blood return to the heart and,
consequently, decreased cardiac output and
hypotension.
 s/sx: lightheadedness, faintness, and
palpitations (Bernstein & Weinstein,
2007).
 is potentially dangerous because it can
cause fetal hypoxia.
 can easily be corrected by having a woman
turn onto her side (preferably the left side)
• Blood Constitution
 Fibrinogen increases as much as 50% probably together with other clotting
factors, such as factors VII, VIII, IX, and X, and the platelet count.
 Total WBC rises slightly
 Total protein level of blood decreases- This causes the common ankle and foot
edema of pregnancy (not to be confused with nondependent or generalized edema,
which is a symptom of pregnancy induced hypertension).
• Blood lipids increase by one third, and the cholesterol serum level increases
by 90% to 100%.
Iron, Folic Acid, and Vitamin
Needs
 fetus requires a total of about 350 to 400 mg of iron to grow.
 The increases in the mother’s circulatory red blood cell mass require an
additional 400 mg of iron. This is a total increased need of about 800 mg.
 500 mg- stored iron by an average woman
 true anemia
 hemoglobin concentration of less than 11 g/100 mL or a hematocrit
value below 33% in the first or third trimester of pregnancy or a
hemoglobin concentration of less than 10.5 g/dL (hematocrit 32%) in the
second trimester is considered
 Taking excess iron pills over this prescribed amount can cause stomach
irritation and possibly iron accumulation in body cells (Pena- Rosas &
Viteri, 2009)
Iron, Folic Acid, and Vitamin
Needs
 folic acid intake is very important in pregnancy.
 Low folic acid may cause megalohemoglobinemia (large,
nonfunctioning red blood cells) and have been linked to
an increased risk for neural tube disorders in fetuses
 Encourage women to eat foods that are high in folic acid
(e.g., spinach, asparagus, legumes) both during the
prepregnancy period and during pregnancy
Assessment Prepregnancy Pregnancy Reason
Factor
Cardiac output 25%–50% Increased blood volume

increase
Heart rate 70–80 80–90 Increased blood volume

(beats/min)
Blood volume 4,000 5250 Compensate for blood loss at birth,

(ml) ensure transport of nutrients to
fetus
Red blood cell 4.2 million 4.65 million Increased blood volume requires
mass (mm3) increased RBCs
SYSTEMIC CHANGES: Cardiovascular System
Assessment Prepregnancy Pregnancy Reason
Factor
Leukocytes 7,000 25,000– To accommodate increased blood

(mm3) 30,0000 volume
Fibrinogen 300 450 To accommodate increased blood

(mg/dl) volume
Blood Decreases in Increased heart rate and cardiac

pressure Second output
(BP) trimester, usually cause no change in BP
rises to
prepregnancy
level in third
trimester
Assessment Prepre Pregnancy Reason
Factor gnancy
Iron Need 800 μg Fetal growth, increase in
more daily maternal red blood cells
Folic acid Need 400 μg Low folic acid leads to large

daily nonfunctioning red blood
cells and increase risk for
fetal neural tube
and abdominal wall defects
Peripheral Impaired blood Leads to edema and
blood flow return from lower varicosities in
extremities through vulva, rectum, and legs
the pelvis (due to
weight of the baby)
Assessment Prepreg Pregnancy Reason
Factor nancy
Supine Lying supine Decreased cardiac output and
hypotension compresses the vena hypotension leading to faintness
syndrome cava, blood return to the and palpitations and possibly fetal
Heart decreases hypoxia
Blood Increased clotting Increased clotting factors and

constitution factors, platelets, white platelets help with bleeding
blood cells, lipids. during delivery
Decreased protein level WBC increase to protect against

infection and as a result of blood
volume increases, blood lipids
increase to provide energy to the
fetus.
Protein decreases as a result of

the proteins being used by the
fetus and can lead to edema.
Urinary System
 Changes in the Urinary System result from:

 Effects of high estrogen and progesterone levels
 Compression of the bladder and ureters by the growing
uterus
 Increased blood volume that increases kidney production of
more urine
 Postural influences
Urinary System
• Fluid Retention.
 to aid the increase in blood volume and to serve as a ready source of fluid
for the fetus (FOR NUTRITION) .
• Renal Function.
 The kidneys may increase in size, changing their structure and
ultimately affecting their function.
 urinary output gradually increases (by about 60% to 80%).
 specific gravity of urine decreases.
 glomerular filtration rate (GFR) and renal plasma flow begin to
increase in early pregnancy to meet the increased needs of the
circulatory system.
 By the 2ND trimester, both the GFR and the renal plasma flow have
increased by 30% to 50%, and they remain at these levels for the
duration of the pregnancy.
Urinary System
• Ureter and Bladder Function.
 A pregnant woman may notice an increase in urinary
frequency during the first 3 months of pregnancy, until the
uterus rises out of the pelvis and relieves pressure on the
bladder.
 Frequency of urination may return at the end of pregnancy, as
lightening occurs and the fetal head exerts renewed pressure
on the bladder.
 ureters increase in diameter and the bladder capacity
increases to about 1500 mL.
Urinary System
• Ureter and Bladder Function.
 pressure on the right ureter may lead to urinary stasis and
pyelonephritis if not relieved.
 Pressure on the urethra may lead to poor bladder emptying and
bladder infection.
 Such infections are potentially dangerous to the pregnant woman,
because they can ascend to become kidney infections.
 urinary tract infections are associated with preterm labor (Cootauco
& Althaus, 2007).
Urinary Tract Changes During Pregnancy
Variable Change
Renal function Changes to excrete waste from maternal and fetal blood
supplies
Glomerular filtration rate Increased by 50%
Blood urea nitrogen Decreased by 25%, BUN of 15 mg/100 ml or higher is abnormal
Creatinine Decreased in pregnancy, creatinine clearance should be 90–180

ml/min in 24-hour urine sample, serum creatinine greater than
1 mg/100 ml is abnormal
Renal threshold for sugar Decreased to allow slight spillage
Urinary Tract Changes During Pregnancy
Variable Change
Ureter and bladder Increase in urinary output but also physiologic increase in
function urinary stasis (bladder infections and pyelonephritis are more
likely)
Bladder capacity Increased by 1,000 ml
Diameter of ureters Increased by 25%
Frequency of urination Increased slightly in first trimester, last 2 weeks of pregnancy

increases to 10–12 times per day
Fluid retention Increased aldosterone production causes increased sodium

reabsorption and fluid retention
Musculoskeletal System
 gradual softening of a woman’s pelvic

ligaments and joints occurs
 A wide separation of the symphysis pubis, as
much as 3 to 4 mm by 32 weeks of pregnancy,
may occur. This makes women walk with
difficulty because of pain.
 pregnant woman tends to stand straighter
and taller than usual (“pride of pregnancy.”)
 lordosis (forward curve of the lumbar spine)
is notable.
Endocrine System
• Lauren Maxwell overheard her doctor say insulin is not as

effective during pregnancy as usual. How would the nurse
explain how decreased insulin effectiveness safeguards the
health of her fetus?
a. Decreased effectiveness of insulin prevents the fetus from

having low blood sugar.
b. Because insulin is ineffective, it cannot cross the placenta
and harm the fetus.
c. The lessened action of insulin prevents the fetus from
gaining too much weight.
d. It is the mother, not the fetus, who is guarded by this
decreased insulin action
Immune System
 Immunologic competency during pregnancy decreases.

 Immunoglobulin G (IgG) production is particularly decreased.
 A simultaneous increase in the white blood cell count may
help to counteract this decrease in the IgG response.
Q. You notice Lauren Maxwell rubbing her back at a
prenatal visit. She asks how she can keep her
backache from becoming worse.
• A. Backache is a common symptom of pregnancy because of the strain

the extra uterine weight puts on lower vertebrae.
• Common measures to relieve backache in pregnancy include:
 Limit the use of high heels because they add to the natural lordosis of
pregnancy.
 Try to rest daily with feet elevated.
 Walk with head high and pelvis straight.
 Pelvic rocking at the end of the day may relieve pain for the night.
Backache should be reported if:
➢ It is experienced as waves of pain (i.e., could be preterm labor).

➢ There are accompanying urinary symptoms, such as frequency and
pain on urination (i.e., could be a urinary tract infection).
➢ The back is tender at the point of backache (i.e., could be
pyelonephritis or a kidney infection or a ruptured vertebrae).
➢ Rest doesn’t relieve it (i.e., could be a muscle strain).
KEY POINTS FOR REVIEW
• The ability of a woman to accept and enjoy a pregnancy

depends on social, cultural, family, and individual influences.
• The psychological tasks of pregnancy are centered on ensuring
safe passage for the fetus. They consist of, in the first
trimester, accepting the pregnancy; in the second trimester,
accepting the baby; and in the third trimester, preparing for
parenthood.
• Common emotional responses that occur with pregnancy can
include grief, narcissism, introversion or extroversion, stress,
couvade syndrome, body image and boundary confusion,
emotional lability, and changes in sexual desire.
• Physiologic changes that occur with pregnancy are both local,

such as uterine, ovarian, and vaginal changes as well as
systemic changes such as those that occur in the endocrine,
respiratory, cardiovascular, urinary, and immune systems.
• Women may have read about the expected psychological and
physiologic changes of pregnancy but once they are
experiencing them may find them more intense than
anticipated.
• The confirmation of pregnancy may be assisted by three levels
of findings: presumptive (subjective), probable (objective), and
positive (documented).
• The positive signs of pregnancy are demonstration of a

fetal heartbeat separate from the mother’s, feta movement
felt by an examiner, and visualization of a fetus by
ultrasound.

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MODULE 4 Psychological and Physiologic Changes of Pregnancy

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Module 4:

Describe common Define different

Braxton hicks Chadwick’s Couvade

Goodell’s sign Hegar’s sign Lightening Linea nigra Melasma

Third trimester Couple prepare clothing and sleeping

a. Accepting morning sickness nausea

• women often experience feelings less than pleasure

• Couples at this point are usually interested

Introversion Body Image

• She dresses so her pregnancy will or will

• She may criticize her partner’s driving,

• She does these things to unconsciously

• Women who formerly were worried about

3 Frequent Sense of having to void

6 Goodell’s sign Softening of the cervix

6 Hegar’s sign Softening of the lower

6 Sonographic Characteristic ring is

10-12 Fetal heart Doppler ultrasound

12 Fatigue General feeling of

12 Uterine Uterus can be palpated

16 Ballottement When lower uterine segment is

18 Quickening Fetal movement felt by woman

20 Fetal movement Fetal movement can be

20 Braxton Hicks Periodic uterine

20 Fetal outline Fetal outline can be

24 Linea nigra Line of dark pigment

24 Melasma Dark pigment forms on

24 Striae Stretch marks form on

• are objective and so can be verified

• trace amounts of HCG appear in her serum as early as 24 to 48 hours after

 Check the expiration date on the package.

 Read the instruction pamphlet provided with the test

 A concentrated urine sample such as a first urine in the morning

 Some prescription medicines, like methadone or chlordiazepoxide, may

 Early prenatal care is the best safeguard to ensure a successful pregnancy

• 1. Demonstration Of A Fetal Heart Separate From The

• An objective examiner can discern fetal movements at

• Ultrasound is the most common method for confirmation of

Location of First Trimester Second Third Trimester

Location of First Trimester Second Trimester Third Trimester

Uterine Steady increased Placenta producing Steady increased

Cervix Softening begins Softening increases “Ripe”

Location of First Second Trimester Third

Vaginal White Increasing in

Musculoskeletal Progressive Possible back or

Location of First Trimester Second Third

Glycosuria begins and

Aldosterone increased, aiding

Location of First Second Third Trimester

Gastrointestinal Slowed peristalsis

• Lauren Maxwell’s doctor told her she had a positive

a. “Your abdomen feels soft and tender, a normal finding.”

• Marked congestion, or “stuffiness,” of the

• Breathing rate is more rapid than usual (18–

• Vital capacity (the maximum volume

• Decreased level of Partial carbon

 Peripheral Blood Flow

Cardiac output 25%–50% Increased blood volume

Heart rate 70–80 80–90 Increased blood volume

Blood volume 4,000 5250 Compensate for blood loss at birth,

Leukocytes 7,000 25,000– To accommodate increased blood

Fibrinogen 300 450 To accommodate increased blood

Blood Decreases in Increased heart rate and cardiac

Folic acid Need 400 μg Low folic acid leads to large