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Chapter 4
Physiologic and Psychological Changes During Pregnancy
Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 1
Determining Pregnancy and Physiological Changes
Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 2
Objectives
Define key terms listed. Calculate the expected date of delivery and
duration of pregnancy. Relate the differences among probable,
presumptive, and positive signs of pregnancy.
Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 3
Objectives (cont.)
Outline the physiologic changes in pregnancy.
Explain how pregnancy affects blood volume and blood plasma.
Describe aortocaval compression or supine hypotension during pregnancy.
Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 4
Profile of Previous Obstetric History
Mnemonic commonly used for recording Systematic, quick way to indicate the number
of pregnancies as well as outcomes. GTPALM
G: gravida T: term pregnancies P: premature births A: abortions L: live births M: multiple gestations and births
Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 5
Profile of Previous Obstetric History (cont.)
G: gravida Any pregnancy, regardless of duration, including
the present one P: para
number of births after 20 weeks gestation
e.g.: woman pregnant for first time would be:
P0, G1
Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 6
Determining Date of Birth
EDD: estimated date of delivery Nägele’s rule:
Identify first day of last normal menstrual period (LNMP)
Count backward 3 months Add 7 days
Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 7
Duration of Pregnancy
Calculated in 28-day month calendar, called lunar months
10 lunar months in a full-term pregnancy 40 weeks 280 days on average
Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 8
Trimester
Pregnancy broken out into 3-month segments called trimesters First trimester: first 14 weeks Second trimester: 15 to 28 weeks Third trimester: 29 weeks to delivery
Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 9
Pregnancy Terms
Terminates before fetus reaches 20 weeks gestation: abortion (lay term is miscarriage)
Terminates after 20th week but before full term is reached: preterm (premature) birth
Terminates 2 weeks after EDD, or 42 weeks: postterm birth
Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 10
Signs of Pregnancy
Presumptive signs Suggest pregnancy
Probable signs Likely pregnant
Positive signs Definite evidence of pregnancy
Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 11
Three Signs that Define Pregnancy
Hearing fetal heart sounds Audible by doppler 10-12 weeks
Palpation of active fetal movements Visualization of a developing fetus via
ultrasound Gestational sac can be viewed as early as 10 days
after implantation
Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 12
Pregnancy Tests
Presence of the hormone human chorionic gonadotropin (hCG) Produced by the chorionic villi of the placenta Can be found in woman’s urine as early as 1 week
postconception PROBABLE indicator of pregnancy
Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 13
Physiologic Changesin Body Systems
Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 14
Major Sources of Change
Hormonal (endocrine system) Mechanical pressure (physical changes
within the body)
Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 15
Changes in the Endocrine System
Dramatic hormonal increase affects all body systems
Essential to maintain pregnancy Initially produced by corpus luteum Later by placenta
A temporary endocrine organ Role is to produce high levels of estrogen and
progesterone
Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 16
Human Placental Lactogen (hPL)
Increases maternal insulin resistance during pregnancy
Provides fetus with glucose needed for growth
Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 17
Changes in the Reproductive System
Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 18
Uterus
Enlarges during pregnancy Increase in size of preexisting muscle cells
(hypertrophy) Formation of new cells (hyperplasia)
Circulatory requirements increase as it enlarges
Growth stimulated by hormones Pressure of growing fetus against uterine wall
Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 19
Cervix
Becomes shorter and softer during pregnancy Prepares for
Thinning (effacement) Enlargement (dilation)
Softening caused by Hormones leading to increased blood supply Increase in cervical gland secretions
• Mucous plug formation provides barrier to prevent organisms from entering uterus.
Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 20
Ovaries
Follicles cease to develop to maturity Ovulation does not occur
Corpus luteum produces estrogen and progesterone for first 7 to 10 weeks until placenta can take over Also produces hormone relaxin
• Thought to help relax symphysis pubis and pelvic joint, and softens cervix
Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 21
Vagina
Wall thickens, becomes more pliable, and expandable
Rugae (folds) more prominent Discharge increases, leads to increased
glycogen, which increases risk of vaginal infection Increased risk for infection and Candida albicans pH decreases (becomes more acidic), preventing
growth of harmful microbes
Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 22
Breasts
Hormones prepare breasts for lactation Rapidly enlarge during first 8 weeks of
gestation Vascular engorgement
Beginning in 9th week Ductal growth stimulated by estrogen Alveolar hypertrophy stimulated by progesterone
Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 23
Breast Changes Size increases
Become fuller, more sensitive, and tender Pigmentation of areola and nipple darkens Montgomery’s glands more prominent
Lubricate and protect nipples Striae may occur Colostrum excretion as early as 10th week
Thin, yellowish fluid excreted until 3rd post partum day
Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 24
Initiation of Lactation
Profound drop in estrogen and progesterone After delivery of placenta
Increase in prolactin Responsible for milk production
Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 25
Changes in the Cardiovascular System
Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 26
Cardiovascular
Deliver oxygen and nutrients Blood must be at pressures sufficient to meet
placental circulation 10% of maternal output channeled to uterine blood
flow in third trimester Greatest increase occurs during labor and
delivery More vulnerable to thrombus formation
Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 27
Changes in Respiratory System
Thoracic circumference increases Hormonal influence
Lung capacity remains the same Inspiration increases
Allows greater intake of oxygen Expiration increases
Allows greater removal of carbon dioxide Breathing changes from abdominal to
thoracic Oxygen consumption increased by 15-40%
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Dyspnea
Respiratory system has increased sensitivity due to progesterone
Pressure of uterus on diaphragm Normally does not interfere with activities of
daily living
Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 30
Epistaxis
Nosebleeds and nasal stuffiness common Likely from increased vascularity related to
estrogen Voice may become deeper
Vocal cords increase in size, likely due to progesterone
Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 31
Changes in the GI System Gum hypertrophy Saliva production increased (ptyalism) Nausea and/or vomiting, especially in first
trimester Constipation
Due to increase in progesterone and relaxin Pyrosis (heartburn)
Relaxation of cardiac sphincter from progesterone Carbohydrate metabolism altered
Increased insulin resistance can cause gestational DM
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Compression of Abdominal Contents
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Audience Response System Question 1
The two major sources of the physiological changes during pregnancy are the physical changes (enlargement of uterus) and the:A. Respiratory system
B. Musculoskeletal system
C. Gastrointestinal system
D. Endocrine system
Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 34
Physiological, Psychological and Developmental Changes in
Pregnancy
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Objectives
Explain why frequency of urination occurs early and late in pregnancy.
Recognize the changes in skin pigmentation during pregnancy.
Discuss the influence of pregnancy on the skeletal system.
Differentiate the risk categories assigned to drugs as they relate to use during pregnancy.
Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 36
Objectives (cont.)
Summarize the psychological changes that occur during pregnancy.
Describe the developmental tasks of pregnancy.
Discuss the impact on and special needs of pregnancy for the adolescent, single parent, and extended family.
Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 37
Changes in the Renal System
Early and late pregnancy increase in bladder pressure
Ureters dilate from smooth muscle relaxation Increased risk of pyelonephritis if woman has
asymptomatic bacteriuria
Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 38
Fluid and Electrolyte Balance
Increased glomerular filtration rate Increased sodium filtration (up to 50%) Tubular reabsorption (up to 99% reabsorption
of sodium) Increases risk of sodium retention Blood more alkaline
Enhanced by hyperventilation during labor Does not interfere with pregnancy
Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 39
Changes in the Integumentaryand Skeletal Systems
Relaxin and placental progesterone Relaxation and softening of pelvic joints
Widening of symphysis pubis “waddling gate”
Facilitates delivery of fetus Center of gravity shifts forward as uterus
enlarges Progressive lordosis
May experience difficulty with balance
Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 40
Changes in the Skeletal System
Uterus stretches round ligaments Woman may develop diastasis recti
abdominis Separation of rectum abdominis muscles
Increased risk of carpal tunnel syndrome Due to weight gain and edema
Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 42
Changes in the Integumentary System
Chloasma (“mask of pregnancy”)
Linea nigra (dark line on abdomen)
Striae gravidarum (stretch marks)
Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 43
Effect of Pregnancy and Lactation on Medication Ingestion Subtherapeutic levels may occur due to
increased Plasma volume Cardiac output Glomerular filtration
Decreased gastric emptying Changes absorption and can delay onset of action
Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 44
Effect of Pregnancyon Medication Ingestion
Parenteral medications may absorb more rapidly due to Increased blood flow Faster onset of action
Increased levels of estrogen and progesterone may alter hepatic function Results in increased drug accumulation
Some drugs can cross placenta
Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 45
Effect of Lactation and Medications
Some drugs pass into breast milk If lactating, mother must take medication
immediately after infant breastfeeds
Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 46
FDA Pregnancy Risk Categories
Category A: no demonstrated risk to fetus in any trimester
Category B: no adverse effects in animals, no human studies available
Category C: only prescribed after risk to fetus is considered
Category D: definite fetal risks Category X: absolute fetal anomalies
Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 47
Psychological ChangesDuring Pregnancy
Body image changes Emotional security Cultural expectations Support from partner Whether pregnancy is unexpected Financial situations
Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 48
Psychological ChangesDuring Pregnancy (cont.)
Major factors that influence the psychological impact of pregnancy A woman’s level of maturity Readiness for childbearing
Hormones contribute to mood swings
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Body Image
Considered from four aspects Appearance
• May be difficult and occurs quickly
Function• Difficult if associated with loss of control (urinary
incontinence)
Sensation• More sensitive to touch due to increased vasocongestion
Mobility
Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 50
Developmental Tasks Relate to sequence of trimesters; more
apparent in some than others Pregnancy validation
Focus is nurturing and protecting fetus May question identity as woman and mother
Fetal embodiment Incorporates fetus into body image; deals with
repressed thought and matures Fetal distinction (when quickening occurs)
Sees fetus as individual Role transition
Makes concrete plans for baby 52
Pregnant Women May Experience
Emotional lability Heightened sensitivity Increased need for affection Greater irritability Fear Anxiety
Needs to receive rather than give emotional support
Provide guidance and support
Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 53
Impact on the Father
Announcement Pregnancy confirmed
Adjustment Faces reality of pregnancy, asks questions
Focus May begin to feel like a parent
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Impact on the Adolescent
May be fraught with conflict Dealing with being a teenager and becoming a
parent Anxiety from having to tell parents May have financial problems, shame, guilt,
relationship problems with father of baby, feelings of low self-esteem
Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 55
Impact on the Adolescent (cont.)
Assess Developmental and educational level Support system Age
The younger the adolescent, the more difficulty one may see in considering the needs of others
Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 56
Impact on the Older Couple
If the woman is 35 years or older, she is considered to be an “elderly primip.”
Factors contributing to delayed pregnancy Effective birth control alternatives Increasing career options High cost of living Development of fertilization techniques to enable
pregnancy later in life
Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 57
Impact on the Older Couple (cont.)
Because of age, may encounter special problems during the labor and delivery process
Usually adjust to pregnancy because of factors such as Often well-educated Have achieved life experiences, goals Ready for a lifestyle change
Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 58
Impact on the Single Mother
May have emotional needs May have difficulty completing tasks of
pregnancy May see pregnancy as financial burden, or
may have planned for the event Social acceptance not as difficult
Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 59
Impact on the Single Father
May take active interest in and financial responsibility for child
May want to participate in plans for the child Participation may not be accepted by the
mother
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Impact on the Grandparents
May eagerly anticipate the baby’s arrival or feel they are not ready for their new role
Level of involvement in baby’s life may be an issue, based on Distance Relationship between parents and grandparents Role expectations Different beliefs regarding child-rearing
Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 61
Audience Response System Question 2
Name at least two signs that:
A.May suggest pregnancy (presumptive)
B.Strongly indicate pregnancy (probable)
C.Confirm pregnancy (positive)
Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 62