Normal Changes In pregnancy

a. Physiologic Changes of Pregnancy

a.1.Local–confined to the reproductive organs
1. uterine changes
Over the 10 lunar months of pregnancy, the uterus increase in
length, depth, width, weight, wall thickness and volume
Length grows from approximately 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 1000g
> The uterine wall thickens from about 1 cm to above 2 cm; by
the end of pregnancy, the wall thins so it is supple and only about
0.5 cm thick
> The volume of the uterus increases from about 2ml to more
than 1000 ml (the uterus can hold a 7lb (3,175g)fetus plus 1000
ml of amniotic fluid for a total of about 4000g)
*This great uterine growth is due partly to formation of a few
new muscles fibers in the uterine myometrium, but
principally to the stretching of existing muscle fibers (by the
end of pregnancy, muscle fibers in the uterus are two to seven
times longer than they were pregestationaly)
Because uterine fibers only stretch during pregnancy and are
not newly built, the uterus is able to return to its prepregnant
state at the end of the pregnancy with little difficulty and almost
no destruction of tissue
Uterine height is measured from the top of the symphysis pubis
over the top of the fundus.
The exact shape of the expanding uterus is influenced by the
position of the fetus inside
The fundus of the uterus usually remains in the midline during pregnancy,
although it may be pushed slightly to the right side because of the larger
bulk of the sigmoid colon on the left.
As the uterus increases in size, it pushes the intestines to the sides of the
abdomen, elevates the diaphragm and liver, compresses the stomach, and
puts pressure on the bladder
CHANGES:
a. Hegar’s Sign-softening of the isthmus of the uterus, the area between
the cervix and the body of the uterus which occur at 6 to 8 weeks of
pregnancy
Review: Division of the uterus:
a.Fundus -Upper portion
b.The body –central portion
c.Isthmus -narrow lower portion
> This area may become so soft so that on
bimanual examination, the anterior fornix fingers
meet each other.
>Ballotement-came from the
frenchword “balloter” meaning,
“to toss about”
> a sharp upward pushing against the
uterine wall with a finger inserted
into the vagina for diagnosing pregnancy
by feeling the return impact of the
displaced fetus also
> Considered as probable sign of pregnancy because the
movement of the fetus can be simulated by a uterine tumor
b. Braxton Hicks contractions-serve as warm up exercises for
labor and increase placental perfusion
May become so strong and noticeable in the last month of
pregnancy that they are mistaken for labor contractions (false
labor)
Can be differentiated from true labor contractions on internal
examination because they do not cause cervical dilatation
Considered also as a probable sign of pregnancy
c.Amenorrhea
Absence of menstruation
Occurs with pregnancy because of the suppression of FSH
In a healthy woman who has menstruated previously, the absence of
menstruation strongly suggests that impregnation has occurs
Can be considered as presumptive signs of pregnancy due to following
reasons:
•Menopause
•Delayed menstruation
•Uterine infection
•Climate change
•Worry
•Chronic illness such as severe anemia or stress
•Occurs in athletes who train strenuously
2. Cervical changes
In response to the increased level of circulating estrogen from the
placenta during pregnancy, the cervix of the uterus becomes more
vascular and edematous
Increased fluid between cells causes the cervix to soften in
consistency and increased vascularity causes it to darken
from a pale pink to a violet hue.
•Goodell’s Sign –softening of the cervix
The consistency of a nonpregnant cervix may be compared with
that of the nose, whereas the consistency of pregnant cervix
resembles that of an earlobe
Just before the onset of labor, the cervix becomes so soft that it
takes on the consistency of butter and is said to be “ripe” for birth
> Considered as a probable sign of pregnancy
3. Vaginal Changes
> Under the influence of estrogen, the vaginal epithelium and
underlying tissue become hypertrophic and enriched with
glycogen
• Chadwick’s sign–changes in vaginal color from the normal
light pink color to a deep violet
Growth of Candida Albicans-a species of yeast-like fungi
 Vaginal secretions during pregnancy fall from a pH of over 7
(an alkaline pH) to 4 or 5 (an acidic pH).
This is due to the action of Lactobacillus acidophilus, bacteria
that grow freely in the
increased glycogen environment and by so doing increase the
lactic acid content of secretions
Signs & Symptoms:
• itching, burning sensation in addition to a cream-cheeses like
discharge
A nonpregnant woman needs medication for such an infection
to relieve discomfort
A pregnant woman needs medication not only to relieve
discomfort but also to prevent transmission of the infection to
the infant as it passes through the birth canal at term
• Candidal infection in the newborn is termed thrush or oral monilla
• Symptoms of oral thrush can include:
> one or more white spots or patches in
and around the baby’s mouth and tongue.
Nursing Management:
1.Maintain or increase cleanliness by taking daily shower baths using
cool water
2.Douching is contraindicated in pregnancy because in some women the
placenta is not well implanted
> The pH of the vagina changes from normally acidic because of the
presence of the Doderlin bacilli to alkaline because of increased
estrogen that favors the growth of trichomonas protozoa of flagellate-the
condition is called Trichomonas vaginalis or trichomoniatis
Signs and Symptoms
frothy, greenish, irritatingly itchy and foul smelling discharges
Vulvar edema and hyperemia secondary to irritation from
discharges
Treatment:
> Flagyl for 10 days or vaginal suppositories
of Trichomonicidal compounds
> Acidic vaginal douche (1 tbsp. White
• vinegar in 1 quart of water or 15 ml white
• vinegar to 1000 ml of water to counteract
• alkaline= preferred environment of the protozoa
Treat male partner also with flagyl
Avoid intercourse to prevent re-infection

4. Ovarian changes
Ovulation stops with pregnancy because of the active
feedback mechanism of estrogen-progesterone produced by
the corpus luteum early in pregnancy and the placenta later in
pregnancy
This feedback causes the pituitary gland to halt production of
FSH and luteinizing hormone
Without stimulation from these, ovulation will not occur.
5. Changes in the breasts
Changes in the breasts that occur as a result of the effect of estrogen-
progesterone production
Feeling of fullness, tingling or tenderness in breasts because of the
increased stimulation of breast tissue by the high estrogen level in the
body
Breast size increases because of hyperplasia of the mammary alveoli
and fat deposits
The areola of the nipple darkens in color, and its diameter increases
from about 3.5 to 5 or 7.5 cm (1.5 in to 2 -3 in)
There is additional darkening of the skin surrounding the areola in
some women, forming a secondary areola
As vascularity of the breasts increases, blue veins may become
prominent over the surface of the breasts
> During pregnancy, the Montgomery glands,
which are located in the areola, tend to
become raised and more noticeable.
> These small lumps are sometimes
described as looking like goosebumps.
>This change in structure is completely normal and not a cause for
concern.
> Early in pregnancy, the breasts begin readying themselves for
the secretion of milk
> By the 16thweek, colostrum, the thin, watery, high protein fluid
that is the precursor of breast milk, can be expelled from the nipple
a.2. Systemic Changes –affecting the entire body
1. Integumentary System
As the uterus increases in size, the abdominal wall must stretch to
accommodate it.
This stretching can cause rupture and atrophy of small segments
of the connective layer of the skin
Changes:
1.Striae Gravidarum
Appearing on the sides of the abdominal walls and sometimes on
the thighs
In the weeks after birth, striae gravidarum lighten to a silvery white
color (striae albicantes or atrophicae), permanent become barely
noticeable
>Striae gravidarum known also as
stretch marks of pregnancy

> In the weeks after birth,

striae gravidarum lighten to a silvery white color
(striae albicantes or atrophicae)
> permanent become barely noticeable
2. Diastasis recti means the belly sticks out
because the space between the left and right
belly muscles has widened.
It might be called as “pooch”
It's very common among pregnant women.

3. Melasma
> Darkened area on the face,
cheeks and across the nose
>Also known as
“mask of pregnancy”
Due to melanocytes stimulating hormone secreted by the pituitary
With the decrease in the level of the hormone after pregnancy,
these areas lighten and again disappear
2. Respiratory System
1.Shortness of breath
> Some women notice this as pregnancy progresses
> As the uterus enlarges during pregnancy, a great deal of pressure
is put on the diaphragm and on the lungs
This crowding of the chest cavity causes an acute sensation of
shortness of breath late in pregnancy until lightening relieves the
pressure
Lightening-settling of the fetal part into the pelvic inlet
Lightening

3. Temperature
> Body temperature increases slightly because of the secretion
of progesterone from the corpus luteum (the temperature, which
elevated at ovulation, remains elevated)
4. Cardiovascular System
Changes in the circulatory system are extremely significant to
the health of the fetus because they are important for adequate
placental and fetal circulation.
The circulatory blood volume of a woman increases at least 30%
-50% during pregnancy
As the plasma volume increases, the concentration of
hemoglobin and erythrocytes may decline, giving the woman a
condition known as “pseudoanemia”
4.1.IRON needs-almost all women need some iron
supplementation during pregnancy. They have low iron stores
because of their monthly menstrual loss
> The fetus requires about 350-400mg of iron to grow
4.2. EDEMA-of the lower extremities, NOT a sign of toxemia
Nursing Management:
1.Raise legs above hip level
2.Use/wear supportive hose or elastic
stockings to promote venous flow,
thus preventing stasis in lower extremities
• Note: support hose should be worn early in the morning upon
waking up; otherwise advise patient to lie down first for 20
minutes to even up flow in the lower extremities
3. Apply elastic bandage
Start at the distal end of the extremity and work toward the
trunk to avoid congestion and impaired circulation in the distal
part,
Do not wrap toes to determine adequacy of circulation
(principle of Bandaging): blood flow through tissues is
decreased by applying excessive pressure on blood vessels
5.Gastrointestinal System
1. Heartburn
> Especially during the last trimester is due to
increased progesterone which decrease gastric
motility and thereby causing reverse peristaltic
waves which leads to regurgitation of acidic
stomach content through the cardiac sphincter
into the esophagus causing irritation
Nursing Management:
1.Pats of butter before meals
2.Avoid fried, fatty food
3. Sips of milk at frequent intervals
4. small, frequent meals taken slowly
5. Bend at the knees, not at the waist

6. Take antacids as prescribed by the doctor

2 Constipation and Flatulence
Causes:
1. Are due to the displacement of the stomach and intestines
thus,slowing peristalsis and gastric emptying progesterone which
inhibits gastric motility
2.Relaxin-a hormone produced by the ovary may contribute to
decreased gastric motility
3. Progesterone has also an effect on smooth muscle making
the intestine less active
Nursing Management:
1.Increase fluids and roughage in diet
2.Establish regular elimination time

3.Increase exercise
4.Avoid enemas
5.Avoid harsh laxatives
3. Morning Sickness
Nausea and vomiting begin to be noticed at the time the
human chorionic gonadotropin (HCG) begin to rise.
It may also occur as a systemic reaction to increased estrogen
levels or decreased glucose levels, because glucose is being
utilized in great quantities by the growing fetus
Nursing Management
1.Advice pregnant client to eat dry crackers 30 minutes before
arising in the morning or eat dry, high carbohydrates, low fat and
low spices in the diet
2.Offer ice chips-to paralyze the taste buds
4. Hemorrhoids
> Are due to pressure of the enlarged uterus on the intestines
Nursing Management:
> Cold compress with witch hazel and Epsom salts
6. Urinary System
Causes:
1.effects of estrogen and progesterone
2.Compression of the bladder by the growing fetus
3.Increased blood volume
4.Postural influences
Nursing management
> Advise client to maintain proper hygiene and visit physician if
infection is present
7. Skeletal System
Calcium and phosphorous needs are increased during pregnancy
because the fetal skeleton must be built
To change her center of gravity and make ambulation easier, the
pregnant woman tends to stand straighter and taller than usual
This stance is sometimes referred to as the 1.“pride of pregnancy”

Pride of pregnancy
> Standing this way,
with the shoulders,
back and the abdomen
forward, creates a
Lordosis (forward curve of the lumbar spine) which may cause :
2.backache
Nursing Management:
> Advise the pregnant woman to use low heeled shoes and not
to use bath tubs unless accompanied or to use non –skid
materials on the bottom of the tub and floor
3. Leg cramps
> Are caused by increased pressure of gravid uterus on lower extremities,
fatigue and muscle tenseness, chills, low calcium, high phosphorous serum
level

Nursing Management:
1.Frequent rest periods with feet elevated
2.Comfortable warm clothing
3.Increase calcium intake
4.Do not massage-
• blood clots may be dislodged
and cause embolism
5. Most effective treatment-
• press knee of the affected leg and dorsiflex
b.Psychological Changes During Pregnancy
1.FIRST TRIMESTER OF PREGNANCY
➢The task of women during the
first trimester of pregnancy is to accept the reality of the
pregnancy
> Women often experience feelings less than pleasure and
closer to anxiety of a feeling ambivalence
> The woman is feeling nothing or inter woven feelings of
wanting and not wanting
➢The partner may also experience a feeling ambivalence
➢All partners are important and should be encouraged to play a
continuing emotional and supportive role in a pregnancy
b. SECOND TRIMESTER OF PREGNANCY
➢The woman is accepting she is having the baby
➢This change usually happens at quickening or the first moment
a woman feels fetal movement
➢Women often use the term “it” to refer to their fetus before
quickening but begin to use “he” or “she” afterward
➢Following prenatal instructions can be a gauged of measuring
the woman’s level of acceptance of pregnancy
c.THIRD TRIMESTER OF PREGNANCY
➢Couples begin “nest-building” activities
➢Choosing the infant’s name, sleeping arrangement and
ensuring safe passage by learning about birth
➢Attending pre natal classes
➢Unwanted pregnancy, financial difficulties, lack of emotional
support or high levels of stress can slow the process of
acceptance.
COMMON PHYSIOLOGIC DISCOMFORTS DURING
PREGNANCY
1.THE FIRST TRIMESTER
1. Breast tenderness – breasts may feel sore or tender to touch,
or feel heavier or fuller during pregnancy due to increased
progesterone level
Nursing Management
1. Encourage the woman to wear bra with a wide shoulder strap
for support and to dress warmly
2. Palmar Erythema
➢Caused by increased estrogen level
Nursing management:
➢Advise the woman to avoid using different detergent bar or
soaps
➢Calamine lotion can be used to help reduce itchiness
3. Constipation
Causes:
➢The weight of the growing uterus presses against the bowel
and slows peristalsis.
➢Production of relaxin by the ovary
Nursing management:
➢Advise the woman not to use “home” remedies to prevent
constipation especially mineral oil
➢Avoid gas forming food such as cabbage, or beans
4. Muscle cramps
➢Decreased serum calcium and increased serum phosphorous
interfere with circulation cause muscle cramps
Nursing Management:
➢Advise woman to press knee of the affected leg and dorsiflex
the foot
➢Lie on her back momentarily and extending the involved leg
while keeping her knee straight and dorsiflexing the foot
5. Hypotension
When the woman lies on her back and the uterus presses on the
inferior vena cava, this impair the blood returning to the heart
Nursing Management:
➢Turn the woman on her left side to removed pressure from the
vena cava
6. Varicosities
> The weight of the distended uterus puts pressure on the veins
returning blood from the lower extremities, this cause a pooling of
blood in the vessels
➢The veins become engorged, inflamed and painful
Nursing Management:
➢Advise the woman to rest in a Sim’s position or on the back with the
legs raised against the walls or elevated on a footstool for 15 to 20
minutes twice a day
7. Hemorrhoids
➢Due to bulk and pressure of the growing fetus
Nursing Management:
➢Advise the woman to practice daily bowel elimination
➢Rest in Sim’s position
➢Assuming a knee-chest position at the end of the day, reduce
the pressure on the rectus
8. Heart Palpitations
> Due to the circulatory adjustments necessary to accommodate
her increased blood supply during pregnancy
Nursing Management:
➢Advise the woman to slow down movements
9. Frequency of Urination
10.Leukorrhea
➢Is a whitish vaginal discharge or an increase in the amount or
normal vaginal secretions.
Nursing Management
> Daily bath or shower and personal hygiene
2. THE MIDDLE AND LATE PREGNANCY
1. Backache – wear low heeled shoes
2. Dyspnea
3. Ankle Edema