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 woman’s 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.

Chadwick’s sign

Goodell’s sign

Hegar’s sign

Sonographic evidence of gestational sac

Ballottement

Braxton Hicks sign

Fetal outline felt by examiner

Sonographic evidence of fetal outline


Fetal heart audible


week 6-8
week 18-20
Fetal movement felt by examiner

week 20-24

Psychological Changes of Pregnancy:

The woman’s 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 child’s existence.

Anticipatory role playing.

May accept at conception, at birth or later.
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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.

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.

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
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Body Image and Boundary
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Stress

Couvade Syndrome
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Emotional Lability
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Changes in Sexual Desire
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Changes in the Expectant Family
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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.

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.

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.

Goodell’s 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.

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).

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.

Montgomery’s 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 mother’s 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.