Psychological and Physiological Changes of Pregnancy

Pregnancy brings both psychological and physical changes to the

woman and her partner.

Physiologic changes occur gradually but eventually affect all

organ systems of a womans body.

Psychological changes occur in response to physiologic

alterations.

Pregnancy represents wellness not illness.

Changes in Pregnancy

The nurse will help the family maintain a state of wellness

throughout the pregnancy and into early parenthood.

Nursing Process:

Assessment begins before pregnancy

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

herself

Implementation-women need help in voicing their concerns

about the physiologic changes of pregnancy.

Evaluation

Evaluation-determined if the woman has really heard your

teaching.

Diagnosis of Pregnancy

Marks a major milestone.

Presumptive Signs of Pregnancy:

least indicative of pregnancy, could indicate other conditions

subjective-experienced by the woman

breast changes, nausea, vomiting, amenorrhea, frequent

urination, fatigue, uterine enlargement, quickening, linea nigra,

melasma, stria gravidarum.

Probable Signs of Pregnancy

Signs that can be documented by the examiner

Serum laboratory tests:

hCG in urine or blood serum of the women.

accurate 95% to 98 % of the time.

home pregnancy tests are 97% accurate.

women taking psychotropic drugs may have a false positive

result on pregnancy test.

discontinue oral contraceptives 5 days before the test.

Chadwicks sign

Goodells sign

Hegars sign

Sonographic evidence of gestational sac

Ballottement

Braxton Hicks sign

Fetal outline felt by examiner

Sonographic evidence of fetal outline

week 6-8

Fetal heart audible

week 18-20

Fetal movement felt by examiner

week 20-24

Psychological Changes of Pregnancy:

The womans attitude toward the pregnancy depends on the

environment in which she is raised.

Psychological Changes of Pregnancy

Social influences

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

Use of birthing centers has increased.

Demedicalize childbirth.

Cultural influences

How active a role she wants to take.

Certain beliefs and taboos may place restrictions on her

behaviors and activities.

Family influences

Viewed in a positive or negative light.

Stories about pain and endless suffering in labor.

People love as they have been loved.

Individual influences

Ability to cope with or adapt to stress.

Secure in her relationship.

Pregnancy takes away her freedom.

Psychological Tasks of Pregnancy

1st Trimester:

Accepting the Pregnancy

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

Surprise!

Women sometimes experience disappointment, anxiety or

ambivalence.

Partner may go through some changes also.

Partner should give emotional support.

May feel proud, happy, jealous or loss.

2nd Trimester

Accepting the Baby:

Second turning point is often quickening.

Proof of the childs existence.

Anticipatory role playing.

May accept at conception, at birth or later.

How well she follows prenatal instructions.

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

misinformation.

Educate both partners.

3rd Trimester:

Preparing for Parenthood

nest building

attending prenatal classes or parenting classes.

Reworking Developmental Tasks

working through previous life experiences.

womans relationship with her parents, particularly her mother.

fear of dying.

Needs confidence in health care providers.

Men may need to reconcile feelings toward fathers and learn a

new pattern of behavior.

Role-playing and Fantasizing:

Second step in preparing of parenthood.

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

Needs good role models.

Father may need to change his carefree individual to a member

of a family unit.

Nurturing roles.

Emotional Responses to Pregnancy

Ambivalence

Grief

Narcissism

Introversion versus Extroversion

Body Image and Boundary

Stress

Couvade Syndrome

Emotional Lability

Changes in Sexual Desire

Changes in the Expectant Family

Local changes - confined to the reproductive organs.

Systemic changes - affecting the entire body.

Both subjective (symptoms) and objective (signs) findings are

used to diagnose and mark the progress of the pregnancy.

Reproductive System Changes: (table 9.3)

Uterine changes:

Increase in size, length, depth, width, weight, wall thickness and

volume.

Length-from 6.5 to 32 cm.

Depth-increases from 2.5 to 22 cm.

Width-expands from 4 to 24 cm.

Weight-increases from 50 to 1,000 g.

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

the wall thins so it is supple and 0.5 cm thick.

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

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

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

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

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

Week 20 or 22 the fetus is at the umbilicus.

Week 36 should touch the xiphoid process which causes some

SOB.

Primigravida - woman in her 1st pregnancy.

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

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

into the pelvis to prepare for birth and the uterus returns to the height
it was at on the 36 week.

This permits better lung expansion and easier breathing.

This is predictable in 1st birth but not others.

Uterine growth is a presumptive sign of pregnancy.

As the uterus increases in size it:

pushes the intestines to the side

elevates the diaphragm and liver

puts pressure on the bladder

Uterine blood flow increases:

before pregnancy - 15 to 20 mL/ min.

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

the placenta.

Uterine bleeding can be a major blood loss.

Uterus is anteflexed, larger and softer.

Hegars sign - extreme softening of the lower uterine segment.

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

Ballottement - on bimanual exam, tapping of lower segment the

fetus is felt to bounced or rise in the amniotic fluid up against the to

top examining hand (week 16 to 20).

Braxton Hicks contractions - practice contractions. Week 12 until

term. Waves of hardness or tightening across the abdomen.

They serve as warm-up exercise and increase placental

perfusion.

False labor, the do not cause cervical dilation.

Amenorrhea - absence of menstruation due to suppression of

FSH.

Presumptive sign.

Cervical changes:

Cervix more vascular and edematous.

Increased fluid between the cells causes the cervix to soften and

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

A tenacious coating of mucus fills the cervical canal.

Operculum - mucous plug - seals out bacteria during pregnancy.

Goodells sign - softening of the cervix.

Nonpregnant cervix is like the nose.

Pregnant is like earlobe.

Just before labor the cervix becomes soft like butter and is ripe

for birth.

Vaginal changes:

vaginal epithelium become hypertrophic and enriched with

glycogen which results in white vaginal discharge throughout

pregnancy.

Chadwicks sign - vaginal walls are deep violet color due to

increased circulation.

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

(yeast like fungi).

due to Lactobacillus acidophilus a bacteria that grows freely in

glycogen environment, so this increases the lactic acid content.

Ovarian changes:

ovulation stops.

Corpus luteum increases in size until week 16 and then the

placenta has taken over as provider of progesterone and estrogen.

Changes in the breasts:

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

feeling of fullness, tingling or tenderness.

Size increases due to hyperplasia of mammary alveoli and fat

deposits.

aerola darkens and diameter increases to 3.5 cm to 5 or 7.5 cm

(1 1/2 to 3 inches)

blue veins become prominent.

Montgomerys tubercles-sebaceous glands of the areola enlarge

and become protuberant.

secretions keep the nipple supple and help prevent cracking and

drying during lactation

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

expelled from the breast

Systemic Changes:

Integumentary System

Abdominal wall must stretch

Striae gravidarum - pink or reddish streaks on sides of abdomen

and thighs.
Systemic Changes

Caused by rupture and atrophy of the connective layer of the

skin.

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

Diastasis-rectus muscles separate, will appear after pregnancy as

a bluish groove.

Umbilicus stretches until it is smooth.

Extra pigmentation on abdominal wall.

Linea nigra - brown line from umbilicus to symphysis pubis.

Melasma - darkened areas on face due to melanocyte-stimulating

hormone secreted by the pituitary.

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

increases estrogen.

Palmar erythema - redness and itching.

Increased sweat gland activity.

Scalp hair growth increases.

Respiratory System

SOB

Chronic respiratory alkalosis compensated by chronic metabolic

acidosis.

Diaphragm is displaced by 4 cm upward.

Vital capacity does not decrease.

Residual volume is decreased by 20%.

Tidal volume is increased up to 40%

Total O2 consumption is increased by 20%.

Pco2 is 32 mm Hg

Mild hyperventilation.

Polyuria - increased urination due to plasma bicarbonate

excreted by the kidneys.

respirations > 20/min.

congestion of nasopharynx - increased estrogen levels.

Temperature:

increased for 16 weeks due to secretion of progesterone from the

corpus luteum, returns to normal once the placenta takes over.

Cardiovascular System:

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

Blood volume

increases by 30 to 50 %

blood loss at birth-300 to 400 mL

cesarean birth-800 to 1,000 mL

increase blood volume peaks at week 28 to 32

Pseudoanemia - concentration of hemoglobin and erythrocytes

decline.

Iron needs

fetus requires 350 to 400 mg to grow.

Mother has an increase in RBC needing an additional 400 mg of

iron.

Prenatal vitamins and foods supply needs.

Heart

cardiac output increases by 25 to 50 %

heart rate increases by 10 beats/ min.

heart is shifted more transverse

Innocent heart murmurs due to positioning.

Palpitations SNS

Regional blood flow:

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

pressure on veins and arteries.

leads to edema and varicoaities.

Blood pressure:

does not normally rise

may decrease in 2nd trimester

Supine hypotension syndrome:

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

vena cava obstructing blood return to the heart.

risk fetal hypoxia

lightheadedness, faintness and palpitations.

rest on left side.

Blood constitution:

level of circ. fibrinogen increases 50%.

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

Blood lipids increase by 1/3

cholesterol level increase 90 to 100 %

Gastrointestinal system

Uterus displaces the stomach and intestines toward the back and

sides of the abdomen.

Pressure slows peristalsis and the emptying time of the stomach.

Leads to heartburn, constipation and flatulence.

Nausea and vomiting in early morning.

When hCG and progesterone begin to rise.

May be a systemic reaction to increases estrogen or decreased

glucose levels.

Subsides after 3 months

Generalized itching due to reabsorption of bilirubin into the

mothers blood stream due to decreased emptying of bile from the GB.

Hypertrophy of the gumlines and bleeding.

Peptic ulcers improve.

Urinary System

Effects of estrogen and progesterone activity.

Compression of the bladder and ureters.

Increased blood volume

Postural influences

Fluid retention:

total body water increases to 7.5 L

increase sodium reabsorption

Increased aldosterone production.

Potassium remains adequate.

Water retension increases blood volume to serve as a source of

nutrients to the fetus.

Renal Function:

Kidneys change size.

Urinary output increases by 60 to 80 %.

GFR and renal plasma flow increase.

Creatinine clearance tests for renal function.

Ureter and Bladder Function

ureters increase in diameter due to increased progesterone.

bladder capacity increases to 1,500 mL

pressure on the urethra may lead to poor bladder emptying and

infections.

May lead to kidney infection.

Skeletal System

Calcium and phosphorus increase for fetal skeleton.

Softening of pelvic ligaments and joints.

Relaxin (ovarian hormone) and placental progesterone.

Separation of symphysis pubis-3 to 4 mm.

Stand straighter and taller - lordosis

Center of gravity is changed.

Endocrine System

Almost all aspects of the endocrine system increase.

Placenta is an endocrine organ

Produces estrogen, progesterone, hCG, human placental

lactogen,relaxin, prostaglandins.

Pituitary Gland

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

progesterone levels.

Increase in production of growth hormone and melanocyte-

stimulating hormone.

Late in pregnancy it produces oxytocin and prolactin.

Thyroid and Parathyroid Glands

thyroid enlarges and BBM (metabolism) increases by 20%

iodine and thyroxine are elevated.

Parathyroid enlarges due to increased calcium requirements.

Adrenal Gland

Elevated levels of corticosteroids and aldosterone are produced.

Aids in suppressing an inflammatory reaction or helps to reduce

the possibility of rejection of the fetus.

Regulates glucose metabolism.

Promotes sodium reabsorption and maintaining osmolarity in

fluid retained.

Safeguards blood volume and perfusion

Pancreas

Increases insulin production in response to high glucocorticoid

production.insulin is less effective then normal because estrogen,

progesterone and hPL are antagonists to insulin.

Diabetic needs more insulin.

Maternal glucose levels are usually higher.

Fat stores and available glucose are utilized.

Immune System

Competency decreases (IgG) to not reject the fetus.

Increase in WBC to counteract the decrease.