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Physiologic and Psychologic Changes During
Pregnancy:
1. Presumptive Signs- those that are least indicative of pregnancy,taken as single entities, they could easily
indicate other conditions
- largely subjective
a. Breast changes
b. Nausea and vomitingc. Amenorrhea
d. Frequent urination
e. Fatigue
f. Uterine enlargementg. Quickening
h. Linea nigra
i. Melasma
j. Striae gravidarum
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MELASMA
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Sstri
STRIAE GRAVIDARUM
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2. Probable Signs-
a. Serum laboratory test
hCG- a hormone created by the chorionic villi inthe placenta.
*Reaches a measurable level (50mIU/ml) 7-
9 days after conception
*Peaks at about 100mIU/ml but by the 60th
-80thday after this it declines again and is
no longer detectable in the serum.
b. Chadwicks Sign- color change of the vagina from pink
to violetc. Goodellssign- softening of the cervix
d. Hegarssign- softening of the lower uterine segment
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CHADWICK S SIGN WITH LEUKORRHEA
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e. Sonographic evidence of gestational sac
f. Ballotement- when lower uterine segment istapped on a bimanual
examination, the fetus can be
felt to rise against theabdominal wall.
g. Braxton Hicks contractions- periodic
uterine tighteningh. Fetal outline felt by the examiner
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3. Positive Signs
a. Sonographic evidence of the fetal outline
b. Fetal heart audible
* 18-20 weeks of pregnancy audible by anordinary stethoscope 120-160 bpm
c. Fetal movement felt by the examiner- 20th-24th
weeks AOG
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PsychologicaL Changes During Pregnancy
1. Social Influences
2. Cultural Influences
3. Family Influences
4. Individual Influences
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The Psychological Tasks of Pregnancy:
First Trimester: Accepting the pregnancy- spends time
recovering from shock of learning they are
pregnant and concentrate on what it feels like
to be pregnant.
Second Trimester: Accepting the baby- moves through
emotions such as narcissism and introversion as they
concentrate on what will happen and what it feels
like to be pregnant.
Third Trimester: Preparing for parenthood
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EMOTIONAL RESPONSES TO PREGNANCY:
1. Ambivalence- interwoven feelings of wanting and not wanting
2. Grief
3. Narcissism-reaction to self-intrusion; self centeredness
4. Introversion vs. Extroversion
5. Body Image and Boundary
Body Image- the way your body appears to yourself
Body Boundary- a zone of separation you perceive between yourself
and objects or other people
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6. Stress
7. Couvade syndrome- men experiencing physicalsymptoms such as nausea,
vomiting etc. to some degree or
even more intensely than their
partners do.
8. Emotional lability
9. Changes in sexual desire
10. Changes in the expectant family
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PHYSIOLOGIC CHANGES OF PREGNANCY
A. Reproductive System
A1. Uterine Changes- increase in length, depth, widthweight, wall thickness and
volume
12thweek- uterus is firm and sphenoid under the
abdominal wall just above the
symphysis pubis
20th
-22nd
week- fundus is at the level of the umbilicus
36thweek- fundus is at the level of the xiphoid process
38th-40thweek- lowers
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*Increase of blood flow to the uterus- pre-pregnancy- 15-20
ml/min by the end of pregnancy- 500-750 ml/min 75 % of
which is going to the placenta
*Uterus is more anteflexed, larger, softer to touch than usual
*6th week of pregnancy- lower uterine segment just above thecervix becomes soft (HegarsSign)
* 12thweek of pregnancy- Braxton Hicks contractions begin
*16
th
-20
th
week of pregnancy- Ballottment may be noted*20th-24thweek- fetal outline may be palpated
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A2. Amenorrhea- due to suppression to FSH
Other possible reasons: uterine infection,
climate change, worry, chronic illness such assevere anemia or stress
A3. Cervical Changes- becomes vascular and edematous
- becomes soft in consistency (GoodellsSign) due to the high estrogen level
Operculum- mucus plug which acts to seal out bacteria during
pregnancy and to help prevent infection in the
fetus and membranes.
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A4. Vaginal Changes
Estrogen- causes the vaginal epithelium and underlyingtissue becomes hypertrophic and enriched
with glycogen.
*Changes in color from pink to dark violet (Chadwicks
Sign)
*pH of vaginal secretions decreases from 7 to 4-5 due to
the action of Lactobacillus acidophilus and Doderlein
bacillus
A5. Ovarian Changes
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B. Breast Changes
*Estrogen- causes a feeling of fullness, tingling sensation and
tenderness* Hyperplasia of the mammary alveoli
* Areola darkens and its diameter increases from about 3.5 cm
to 5 or 7.5 cm (1.5-2-3 inches)
*There is formation of secondary areola, increase in vascularity,
blue veins become prominent over the surface of the breast,
sebaceous glands of the areola (Montgomery tubercles)
enlarge.
*16th week of pregnancy- colostrums is expelled from thenipples in a form of thin watery fluid which is high in protein
and considered to be a precursor of breast milk
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SYSTEMIC CHANGES
A. Integumentary System
A1. Striae gravidarum- pink or reddish streaks appearing on the sides of the
abdominal wall and sometimes on the thighs.
A2. Diastasis- separation of rectus muscle, bluish grooveat the site of the
separation
*At the 28thweek AOG the depression of the umbilicus becomes
obliterated and smooth.A3. Linea nigra- dark line running from the umbilicus to the symphysis pubis
A4. Melasma/ chloasma or the mask of pregnancy
A5. Vascular spiders- small, fiery-red branching spots commonly found on
the thighs.
A6. Increased perspiration
A7. Palmar erythema- due to increased estrogen level in the body
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B. Respiratory system
* NO change in vital capacity
* Tidal volume is increased by 30-40 %*Respiratory rate is increased by 1-2 cpm/minute (18-
20cpm/min)
* Residual volume- decreased by 20 %
* Plasma PCO2- decreased by 27-32 mHg
* PlasmaO2- increased to 104-108 mmHg
* Blood pH- increased to 7.40-7.45
*Respiratory minute volume- increased by 40%* Expiratory reserve- decreased by 20%
*Increased ventilation
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D. Cardiovascular System
D1. Blood volume increases by at least 30% and
possibly as much as 50%
Normal blood loss for NSVD- 300-400 ml
Normal blood loss for CS- 800-1000 ml
* The increase in blood volume peaks at the 28th-32nd
week
D2. Iron needs- 800 mg during pregnancy
True anemia- either a hemoglobin concentration of
less than 11.5 g/100 ml or a Hct of less than 30 %
D3. Folic acid- helps in preventing neural tube defects
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D4. Heart- increase in cardiac output by 25-50%
HR increases by 10 bpm
*Innocent heart murmurs may be heard r/t altered heart
position and decreased blood viscosity.* Palpitations are also common due to the stimulation of
SNS
D5. Regional blood flow- impaired to the lower extremities
D6. BP- does not normally rise
D7. Supine hypotension syndrome- light headedness,faintness and palpitations
Interventions: lie on the left side and rise from bed slowly
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D8. Blood Constitution
*Increase in circulating fibrinogen (as much as
50 %) due to increased level of estrogen
*Increase in clotting factors VII, VIII, IX, and X
and platelet count
*Increase in WBC* Decrease in total protein which may be a
cause of ankle edema
*Increase in body lipid by 1/3 and cholesterolby 90-100%
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E. Gastrointestinal system
*Slow intestinal peristalsis and emptying of the
stomach
*heartburn, constipation andf flatulence is common
*Nausea and vomiting is common due to increase l
level of hCG and progesterone or as a
systemic reaction to the increased level of estrogenand decreased level of glucose.
*Subclinical jaundice may be experienced
*Hypertrophy of the gumlines and possible bleeding
of the gingival tissue*Decreased pH in the mouth
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F. Urinary System
*Glomerular filtration rate- increased by 50 %* Renal plasma flow- increased by 25-80 %
* BUN- decreased by 25%
* Plasma creatinine level- decreased by 25%
* Renal threshold for sugar- decreased to allowspillage
* Bladder capacity- increased by 1000 ml
* Diameter of ureters- increased by 25%
* Frequency of urination- increased in the 1sttrimester and the last two weeks of
pregnancy to 10-12 times/day
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ANKLE EDEMA
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G. Skeletal System
* Ca and Ph needs are increased
* There is softening of pelvic ligaments and joints which
causes the waddling gait
H. Endocrine System
*Placenta- produces hCG, estrogen, progesterone, hPL,
relaxin and prostaglandinsEstrogen- causes breast changes and palmar erythema
Progesterone- maintains endometrium inhibiting uterine
contractions;aids in the preparation of the
breasts for lactation.Relaxin- secreted primarily by the corpus luteum
- inhibits uterine contractions; softens the cervix
and the collagen in joints
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hCG- secreted by the trophoblast in the placenta
stimulates estrogen and progesterone synthesis until the
placenta can take its role.hPL- also known as human chorionic somatomammotropin hormone
- serves as the antagonist to insulin, freeing fatty acids for
energy
Prostaglandin- affects smooth muscle contractility to such an
extent they may be the trigger that initiates labor at
term
*Pituitary gland- halted FSH and LH release because of increased
levels of estrogen and progesterone
- late in pregnancy it produces oxytocin
- produces prolactin which prepares the breasts for
lactation
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*Thyroid and parathyroid glands- glands enlarges and
BMR increases by 20%
*Protein based-iodine, butanol-extractable iodine,and thyroxine are all elevated as well.
* Adrenal glands- increased function due to increased
level of corticosteroid and
aldosterone.
- aids in suppressing inflammatory
reaction , helps in regulating theglucose metabolism in the woman
Increase in aldosterone aids in promoting sodium
reabsorption
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Estimating Pelvic Sizepelvic pelvimetry and fetal
sonography
*Estimation should be done at least by the 24thweek ofpregnancy because by this time there is danger that the fetal
head will reach a size that will interfere with safe passage
and birth if pelvic measurements are small
TYPES OF PELVES:
1. Android
2. Anthropoid
3. Gynecoid
4. Platypelloid
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Common Measurements:
1. Diagonal conjugate- distance between the anterior
surface of the sacralprominence and the anterior
surface of the inferior margin of
symphysis pubis
-considered to be the most usefulmeasurement for the estimation
of pelvic size.
-suggests the anteroposterior
diameter of the pelvic inlet* Measured while the client is in a lithotomy position
>12.5 cm- adequate for childbirth (average fetal head
is 9 cm)
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3. Ischial tuberosity diameter- distance
between the ischial tuberosity or thetransverse diameter of the outlet. Made
at the medial or lowermost aspect of the
ischial tubersities at the level of the anus(11 cm)
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LEOPOLDS MANEUVER
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LEOPOLDS MANEUVER
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DISSCOMFORTS DURING THE FIRST TRIMESTER
1. Breast Tenderness
2. Palmar Erythema
3. Constipation
4. Nausea Vomitting and Pyrosis
5. Fatigue
6. Muscle cramps- due to decreased Calcium and increased Phosphorus
7. Hypotension
8. Varicosities- Let client rest in Simsposition or with legs raised for 15-20
min 2x a day
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9. Hemorrhoids- modified Simsposition or knee chest position
for 10-15 min.
-apply Witch hazel or cold compress to relieve
pain
10. Heart palpitations
11. Frequency of urination- reduce caffeine intake and practiceKegelsexercise
12. Abdominal discomfort
13. Leukorrhea- a whitish vaginal discharge or increased vaginal
secretions brought about by increased
estrogen level and blood supply to the vaginal
epithelium and cervix.
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DISCOMFORTS DURING MIDDLE AND LATE
PREGNANCY
1. Backache- Pelvic rocking and tilting exercise
2. Headache
3. Dyspnea
4. Ankle edema
5. Braxton Hicks Contractions
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Danger Signs of Pregnancy:
1. Vaginal bleeding
2. Persistent vomiting
3. Chills and fever
4. Sudden escape of clear fluid from the
vagina
5. Abdominal or chest pain
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6. PIH
6a. rapid wt. gain (over 2 lbs/week in the 2nd
trimester and 1lb/week in the 3rdtrimester)
6b. Swelling of the face and the fingers
6c. Flashes of light or dots before the eyes6d. Dimness or blurring of vision
6e. Severe continuous headache
6f. decreased urine output
7. Increased or decreased fetal movement
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VARICOSITIES
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HEMORRHOIDS
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ELASTIC STOCKINGS
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LEFT SIDE LYING POSITION
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SQUATTING
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TAILOR SITTING
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PREVENTION OF EXPOSURE TO
TERATOGENSTeratogen- any factor, chemical
and physical thatadversely affects the
fertilized ovum,
embryo or fetus.
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Maternal Infection
TO- TOxoplasmosis
* a protozoan infection spread through uncooked
meat, and through handling cat stool in soil or cat
litter.
* Effect to fetus: CNS damage, hydrocephalus,
microcephaly, intracerebralCalcification and retinal deformities.
*Dx: Serum analysis
*Tx: sulfonamides- but this can lead to increased
bilirubin in the newbornPyrimethamine- antiprotozoal drug but an
antifolic acid drug at the
same time
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R Rubella
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R- Rubella
*otherwise known as German measles
*Effect to fetus: deafness, mental or motor
challenges, cataract, cardiac
defects (PDA or pulmonary
stenosis), retarded
intrauterine growth,thrombocytopenic purpura,
dental and facial clefts.
*Dx. Rubella titer- > 1:8 suggests immunity< 1:8 susceptible to viral
invasion
Greatly increased- suggests recent infection
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RUBELLA
C- Cytomegalovirus (CMV)
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C- Cytomegalovirus (CMV)
* a member of the herpes virus family
*MOT: Droplet
* Effect to the fetus: neurologically
challenged (hydrocephalus, microcephaly
spasticity with eye damage [optic atrophy
and chorioretinitis]) deafness, chronic liverdisease, skin covered with large petechiae
(blueberry muffin lesions)
*Dx. Isolation of CMV antibodies in theserum
* No treatment
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CHILD AFFECTED WITH CMV
H- Herpes simplex
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H Herpes simplex
*1sttrimester- congenital anomalies or
spontaneous miscarriage
*2nd or 3rd trimester- premature birth, intrauterinegrowth retardation and
continuing infection
Other viral infection
RubeolaCoxsackievirus
Mumps
Varicella (chickenpox)
Poliomyelitis
Influenza
Viral hepatitis
Parvovirus B19- causative agent of Erythema infectiosum (5th
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Parvovirus B19 causative agent of Erythema infectiosum (5
dise. ) attacks the RBC
-associated with fetal death in early pregnancy
and anemia and congenital heart defect in late pregnancy
Syphylis- caused by Trepenoma pallidum
*causes damage to the fetus after the 16th-18thweek of
intrauterine life when the cytotrophoblastic layerof the
placental villi has atrophied* causes deafness, cognitive challenge, osteochondritis and
death
*Dx. VDRL and rapid plasma regain- remains high for more than
2oo days*infants born of a mother with syphilis- remains to be (+) up to
3 mos. even if the dse has
already been treated.
*Tx. Benzathine penicillin
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SYPHILIS
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Lyme disease- Borrelia burdorferi
*Tx. Tetracycline or doxycycline-
not safe for pregnant womenPenicillin- drug of choice
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TRICHOMONIASIS & VAGINITIS
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AMELIA
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PHOCOMELIA