Psychological and Physiologic

Changes in Pregnancy
Pregnancy brings both psychological and
physical changes to the woman and her
partner.
Physiologic changes occur gradually but
eventually affect all organ systems of a
woman’s body.
Psychological changes occur in response to
physiologic alterations.
Pregnancy represents wellness not illness.
Diagnosis of Pregnancy
Marks a major milestone.
Presumptive Signs of Pregnancy:
• least indicative of pregnancy, could indicate
other conditions
• subjective-experienced by the woman
– breast changes, nausea, vomiting,
amenorrhea, frequent urination, fatigue,
uterine enlargement, quickening, linea
nigra, melasma, stria gravidarum.
Probable Signs of Pregnancy
Signs that can be documented by the examiner
Serum laboratory tests:
• hCG in urine or blood serum of the women.
• accurate 95% to 98 % of the time.
• home pregnancy tests are 97% accurate.
• women taking psychotropic drugs may have
a false positive result on pregnancy test.
• discontinue oral contraceptives 5 days
before the test.
• Chadwick’s sign
• Goodell’s sign
• Hegar’s sign
• Sonographic evidence of gestational sac
• Ballottement
• Braxton Hicks sign
• Fetal outline felt by examiner
 Positive Signs of Pregnancy
• Sonographic evidence of fetal outline
– week 6-8
• Fetal heart audible
– week 18-20
• Fetal movement felt by examiner
– week 20-24
Psychological Changes of Pregnancy
Psychological Changes of Pregnancy:
The woman’s attitude toward the pregnancy depends
on the environment in which she is raised.
Social influences
• Pregnancy is not an illness, now the family is
included.
• Use of birthing centers has increased.
• Demedicalize childbirth.
Cultural influences
• How active a role she wants to take.
• Certain beliefs and taboos may place restrictions
on her behaviors and activities.
Psychological Changes of Pregnancy
Family influences
• Viewed in a positive or negative light.
• Stories about pain and endless suffering in
labor.
• People love as they have been loved.
Individual influences
• Ability to cope with or adapt to stress.
• Secure in her relationship.
• Pregnancy takes away her freedom.
Psychological Tasks of Pregnancy

1st Trimester:
Accepting the Pregnancy
• 50% of all pregnancies are unintended,
unwanted or mistimed. Surprise!
• Women sometimes experience
disappointment, anxiety or ambivalence.
• Partner may go through some changes also.
• Partner should give emotional support.
• May feel proud, happy, jealous or loss.
Psychological Tasks of Pregnancy
2nd Trimester
Accepting the Baby:
• Second turning point is often quickening.
• Proof of the child’s existence.
• Anticipatory role playing.
• May accept at conception, at birth or later.
• How well she follows prenatal instructions.
• Partner may feel left out, he may increase
his work, he has misinformation.
• Educate both partners.
Psychological Tasks of Pregnancy

3rd Trimester:
Preparing for Parenthood
• “nest building”
• attending prenatal classes or parenting
classes.
Reworking Developmental Tasks
• working through previous life experiences.
• woman’s relationship with her parents,
particularly her mother.
• fear of dying.
• Needs confidence in health care providers.
• Men may need to reconcile feelings toward
fathers and learn a new pattern of behavior.
Psychological Tasks of Pregnancy
.
Role-playing and Fantasizing:
• Second step in preparing of parenthood.
• Spend time with other mothers to learn how
to be a mother. Needs good role models.
• Father may need to change his carefree
individual to a member of a family unit.
• Nurturing roles.
Emotional Responses to Pregnancy
• Ambivalence
• Grief
• Narcissism
• Introversion versus Extroversion
• Body Image and Boundary
• Stress
• Couvade Syndrome
• Emotional Lability
• Changes in Sexual Desire
• Changes in the Expectant Family
Physiologic Changes of Pregnancy
Local changes - confined to the reproductive
organs.
Systemic changes - affecting the entire body.
Both subjective (symptoms) and objective
(signs) findings are used to diagnose and
mark the progress of the pregnancy.
Physiologic Changes of Pregnancy
Reproductive System Changes:
Uterine changes:
• Increase in size, length, depth, width, weight,
wall thickness and volume.
Length-from 6.5 to 32 cm.
Depth-increases from 2.5 to 22 cm.
Width-expands from 4 to 24 cm.
Weight-increases from 50 to 1,000 g.
Uterine wall thickens from 1 cm to 2 cm by the
end of pregnancy, the wall thins so it is supple and
0.5 cm thick.
Volume of uterus increases from 2 mL to 1,000
mL. It can hold a 7 lb. fetus plus 1,000 mL of
amniotic fluid. Total 4,000 g.
Physiologic Changes of Pregnancy
Uterine growth is due to formation of a few
new muscle fibers and stretching of existing
muscle fibers (2 to 7 times longer).
Week 12 the fetus is palpated just above the
symphysis pubis.
Week 20 or 22 the fetus is at the umbilicus.
Week 36 should touch the xiphoid process
which causes some SOB.
 Terms
Primigravida - woman in her 1st pregnancy.
Multipara - a woman who has had 1 or more
children.
Physiologic Changes of Pregnancy
Lightening - 2 weeks before term (week 38)
the fetal head settles into the pelvis to
prepare for birth and the uterus returns to
the height it was at on the 36 week.
• This permits better lung expansion and
easier breathing.
• This is predictable in 1st birth but not
others.
• Uterine growth is a presumptive sign of
pregnancy.
Physiologic Changes of Pregnancy
As the uterus increases in size it:
• pushes the intestines to the side
• elevates the diaphragm and liver
• puts pressure on the bladder
Uterine blood flow increases:
• before pregnancy - 15 to 20 mL/ min.
• by the end of pregnancy - 500 to 750
mL/min. with 75% going to the placenta.
• Uterine bleeding can be a major blood loss.
• Uterus is anteflexed, larger and softer.
Physiologic Changes of Pregnancy
Hegar’s sign - extreme softening of the lower
uterine segment. The wall can not be felt or
it feels as thin as tissue paper with bimanual
exam.
Ballottement - on bimanual exam, tapping of
lower segment the fetus is felt to bounced or
rise in the amniotic fluid up against the to
top examining hand (week 16 to 20).
Braxton Hicks contractions - practice
contractions. Week 12 until term. Waves of
hardness or tightening across the abdomen.
Physiologic Changes of Pregnancy
• They serve as warm-up exercise and
increase placental perfusion.
• False labor, the do not cause cervical
dilation.
Amenorrhea - absence of menstruation due
to suppression of FSH.
• Presumptive sign.
Cervical changes:
• Cervix more vascular and edematous.
• Increased fluid between the cells causes
Physiologic Changes of Pregnancy
the cervix to soften and increased
vascularity causes it to darken from pale
pink to a violet hue.
• A tenacious coating of mucus fills the
cervical canal.
• Operculum - mucous plug - seals out
bacteria during pregnancy.
• Goodell’s sign - softening of the cervix.
– Nonpregnant cervix is like the nose.
– Pregnant is like earlobe.
Physiologic Changes of Pregnancy
• Just before labor the cervix becomes soft
like butter and is “ripe” for birth.
Vaginal changes:
• vaginal epithelium become hypertrophic
and enriched with glycogen which results in
white vaginal discharge throughout
pregnancy.
• Chadwick’s sign - vaginal walls are deep
violet color due to increased circulation.
• pH 4 to 5 (from pH over 7) favors growth of
Candida albicans (yeast like fungi).
Physiologic Changes of Pregnancy

• due to Lactobacillus acidophilus a bacteria

that grows freely in glycogen environment,
so this increases the lactic acid content.
Ovarian changes:
• ovulation stops.
• Corpus luteum increases in size until week
16 and then the placenta has taken over as
provider of progesterone and estrogen.
Physiologic Changes of Pregnancy
Changes in the breasts:
• result of estrogen and progesterone
production. (1st change)
• feeling of fullness, tingling or tenderness.
• Size increases due to hyperplasia of
mammary alveoli and fat deposits.
• aerola darkens and diameter increases to 3.5
cm to 5 or 7.5 cm (1 1/2 to 3 inches)
• blue veins become prominent.
• Montgomery’s tubercles-sebaceous glands
Physiologic Changes of Pregnancy
of the areola enlarge and become protuberant.
• secretions keep the nipple supple and help
prevent cracking and drying during lactation
• week 16 colostrum-a thin, watery, high
protein fluid can be expelled from the breast
Systemic Changes:
Integumentary System
• Abdominal wall must stretch
• Striae gravidarum - pink or reddish
streaks on sides of abdomen and thighs.
Systemic Changes
• Caused by rupture and atrophy of the
connective layer of the skin.
• After birth this lightens to silvery-white
color. (permanent)
• Diastasis-rectus muscles separate, will
appear after pregnancy as a bluish groove.
• Umbilicus stretches until it is smooth.
• Extra pigmentation on abdominal wall.
• Linea nigra - brown line from umbilicus to
symphysis pubis.
Systemic Changes
• Melasma - darkened areas on face due to
melanocyte-stimulating hormone secreted
by the pituitary.
• Vascular spiders - small fiery-red branching
spots on thighs, increases estrogen.
• Palmar erythema - redness and itching.
• Increased sweat gland activity.
• Scalp hair growth increases.
Systemic Changes
Respiratory System
• SOB
• Chronic respiratory alkalosis compensated
by chronic metabolic acidosis.
• Diaphragm is displaced by 4 cm upward.
• Vital capacity does not decrease.
• Total O2 consumption is increased by 20%.
• Mild hyperventilation.
• Polyuria - increased urination due to
plasma bicarbonate excreted by the kidneys.
Systemic Changes
• respirations > 20/min.
• congestion of nasopharynx - increased
estrogen levels
Temperature:
• increased for 16 weeks due to secretion of
progesterone from the corpus luteum,
returns to normal once the placenta takes
over.
Systemic Changes
Cardiovascular System:
Changes are extreme and significant to the
health of the fetus.
Blood volume
• increases by 30 to 50 %
• blood loss at birth-300 to 400 mL
• cesarean birth-800 to 1,000 mL
• increase blood volume peaks at week 28 to
32
Systemic Changes
• Pseudoanemia - concentration of
hemoglobin and erythrocytes decline.
Iron needs
• fetus requires 350 to 400 mg to grow.
• Mother has an increase in RBC needing an
additional 400 mg of iron.
• Prenatal vitamins and foods supply needs.
Heart
• cardiac output increases by 25 to 50 %
• heart rate increases by 10 beats/ min.
• heart is shifted more transverse
Systemic Changes
• Innocent heart murmurs due to positioning.
• Palpitations SNS
Regional blood flow:
• 3rd trimester blood flow to lower
extremities is impaired due to pressure on
veins and arteries.
• leads to edema and varicoaities.
Blood pressure:
• does not normally rise
• may decrease in 2nd trimester
Systemic Changes
Supine hypotension syndrome:
• when woman lies supine the weight of the
uterus presses on the vena cava obstructing
blood return to the heart.
• risk fetal hypoxia
• lightheadedness, faintness and palpitations.
• rest on left side.
Blood constitution:
• level of circ. fibrinogen increases 50%.
• Factors VII, VIII, IX, X and platelets
increase.
Systemic Changes
• Blood lipids increase by 1/3
• cholesterol level increase 90 to 100 %
Gastrointestinal system
Uterus displaces the stomach and intestines
toward the back and sides of the abdomen.
• Pressure slows peristalsis and the emptying
time of the stomach.
• Leads to heartburn, constipation and
flatulence.
• Nausea and vomiting in early morning
when hCG and progesterone begin to rise.
Systemic Changes

• May be a systemic reaction to increases

estrogen or decreased glucose levels.
• Subsides after 3 months
• Generalized itching due to reabsorption of
bilirubin into the mother’s blood stream due
to decreased emptying of bile from the GB.
• Hypertrophy of the gumlines and bleeding.
• Peptic ulcers improve.
Systemic Changes
Urinary System
• Effects of estrogen and progesterone
activity.
• Compression of the bladder and ureters.
• Increased blood volume
• Postural influences
Fluid retention:
• total body water increases to 7.5 L
• increase sodium reabsorption
Systemic Changes
• Increased aldosterone production.
• Potassium remains adequate.
• Water retension increases blood volume to
serve as a source of nutrients to the fetus.
Renal Function:
• Kidneys change size.
• Urinary output increases by 60 to 80 %.
• GFR and renal plasma flow increase.
• Creatinine clearance tests for renal function.
Systemic Changes
Ureter and Bladder Function
• ureters increase in diameter due to increased
progesterone.
• bladder capacity increases to 1,500 mL
• pressure on the urethra may lead to poor
bladder emptying and infections.
• May lead to kidney infection.
Systemic Changes
Skeletal System
• Calcium and phosphorus increase for fetal
skeleton.
• Softening of pelvic ligaments and joints.
• Relaxin (ovarian hormone) and placental
progesterone.
• Separation of symphysis pubis-3 to 4 mm.
• Stand straighter and taller - lordosis
• Center of gravity is changed.
Systemic Changes
Endocrine System
Almost all aspects of the endocrine system
increase.
• Placenta is an endocrine organ
• Produces estrogen, progesterone, hCG,
human placental lactogen,relaxin,
prostaglandins.
Pituitary Gland
• there is a halt to FSH and LH due to high
estrogen and progesterone levels.
Systemic Changes
• Increase in production of growth hormone
and melanocyte-stimulating hormone.
• Late in pregnancy it produces oxytocin and
prolactin.
Thyroid and Parathyroid Glands
• thyroid enlarges and BBM (metabolism)
increases by 20%
• iodine and thyroxine are elevated.
• Parathyroid enlarges due to increased
calcium requirements.
Systemic Changes

Adrenal Gland
• Elevated levels of corticosteroids and
aldosterone are produced.
• Aids in suppressing an inflammatory
reaction or helps to reduce the possibility of
rejection of the fetus.
• Regulates glucose metabolism.
• Promotes sodium reabsorption and
maintaining osmolarity in fluid retained.
• Safeguards blood volume and perfusion
Systemic Changes
Pancreas
• Increases insulin production in response to
high glucocorticoid production.insulin is
less effective then normal because estrogen,
progesterone and hPL are antagonists to
insulin.
• Diabetic needs more insulin.
• Maternal glucose levels are usually higher.
• Fat stores and available glucose are utilized.
Systemic Changes
Immune System
• Competency decreases (IgG) to not reject
the fetus.
• Increase in WBC to counteract the decrease.