ASSESSMENT & MANAGEMENT OF PREGNANCY

1. ASSESSMENT & MANAGEMENT OF
PREGNANCY
MRS ELIZEBETH RANI. V,
READER, VHS - MACCON

2. NORMAL PREGNANCY
• Normal pregnancy begins when a sperm fertilizes an egg.
• The normal duration of pregnancy is about 9 months.
• During this period, the body of women provides protection &
nourishment for the development of the fetus.
• Pregnancy end at delivery, when a baby is born.

3. • Pregnancy is a state of dynamic, physiologic adaptations to meet the
demands of a developing fetus, child birth & lactation.
• Some changes occurring during this period seem exiting to the mother,
others can create discomforts.
• The female body adapts to these changes normally.
• Normal duration of pregnancy = 40 weeks ( calculation from the first day
of last menstrual period).
• For a term pregnancy, there is requirement of at least 37 weeks.
There are 3 trimester of equal length.
• 1st trimester - conception to 12 weeks.
• 2nd trimester – 13 to 28 weeks.
• 3rd trimester – 29 to 40 weeks.

4. Physiological Changes
of Pregnancy
Physiological Changes of Pregnancy

6. • During the course of pregnancy, many physiological & anatomical
alterations occur in many organ systems.
• Early changes are due to metabolic demands brought on by the fetus ,
placenta, uterus & due to the increasing levels of pregnancy hormones,
such as , progesterone & estrogen.
• Later changes are anatomical in nature & are caused by mechanical
pressure from the expanding uterus.

7. CHANGES OF THE REPRODUCTIVE
SYSTEM

8. A. UTERUS
• (1) Changes in the uterus are phenomenal. By the time the pregnancy
has reached term, the uterus will have increased five times its normal
size:
(a) In length from 7.5 to 30 cm.
(b) In depth from 2.5 to 20 cm.
(c) In width from 5 to 23 cm.
(d) In weight from 60 to 1000 grams.
(e) In thickness of the walls from 1 to 0.5 cm.
• (2) The capacity of the uterus must expand to normally accommodate
a seven-pound fetus and the placenta, the umbilical cord, 500 ml to
1000 ml of amniotic fluid, and the fetal membranes.

9. SHAPES
WEEKS SIZE POSITION
12 weeks grape fruit above the symphysis pubis
16th week globular shape Conceptus has grown
24th week spherical shape Palpated at the level of
umbilicus
30th week cabbage above the internal os of the
cervix
38th week Dropped appearance at the level of the xiphi
sternum

10. Changes in the isthmus
• The isthmus forms the lower uterine segment after 12 weeks
of pregnancy
• It dilates the last trimester
• Measures 7.5 – 10 cm in length.

11. B. CERVIX
• The cervix undergoes a marked softening which is referred to as the Goodell's
sign."
• Cervix becomes vascular, oedematus & soft.
• The length becomes double & volume increases.
• A mucus plug, which is known as "operculum" is formed in the cervical canal. This
is the result of enlarged and active mucus glands of the cervix. It serves to seal the
uterus and to protect the fetus and fetal membranes from infections .

12. C. VAGINA
• Increased circulation to the vagina early in pregnancy changes the
color from normal light pink to a purple blue which is known as the
“Chadwick's sign”.
• It becomes vascular & feels soft .
• Vaginal secretions are acidic.

13. D. OVARIES
• The follicle-stimulating hormone (FSH) ceases its activity due to the
increased levels of estrogen and progesterone secreted by the ovaries
and corpus luteum. The FSH prevents ovulation and menstruation.
• The corpus luteum enlarges during early pregnancy and may even
form a cyst on the ovary.
• The corpus luteum produces progesterone to help maintain the
lining of the endometrium in early pregnancy.
• It functions until about the 10th to 12th week of pregnancy when the
placenta is capable of producing adequate amounts of progesterone and
estrogen. It slowly decreases in size and function after the 10th to 12th
week.

14. CHANGES OF THE CARDIOVASCULAR SYSTEM
• Heart slightly shift in position
• Enlarging Uterus → diaphrym→ displace up ward → shift of apex beat
Cardiac capacity increase by 70-80ml.
• a. Blood Volume.
• (1) Blood volume increases gradually by 30 to 50 percent (1500 ml to 3
units). This results in decrease concentration of red blood cells and
hemoglobin. This explains why the need for iron is so important during
pregnancy.
• (2) By the time pregnancy reaches term, the body has usually compensated
for the decrease resulting in an essentially normal blood count.
• (3) Blood count is interpreted as anemia by the physician if the
hemoglobin falls below 10.5 grams per 100 ml and the hematocrit
drops below 30 percent.

15. b. Cardiac Output.
• Cardiac output increases about 30 percent during the first and
second trimester to accommodate for hypervolemia.
• Change in output is reflected in the heart rate. It usually increases
by 10 beats per minute.
c. Blood Pressure.
• Normally, the patient's blood pressure will not rise.
d. Venous Return.
• The lower extremities are often hampered in the last months of
pregnancy due to the expanding uterus restricting physical movement
and interfering with the return of blood flow. This results in swelling
of the feet and legs.

16. Vena cava syndrome
• Remind the patient not to lie in a supine position since this inhibits
return blood flood flow as the heavy uterus presses on the vessels.
This leads to the vena cava syndrome or supine hypotension. The
mother may complain of feeling dizzy, nauseated, or weak.

17. • Increase in blood volume – most striking change
• The change occurs until term and the average increase in volume is 45-50%
• The mechanism for increase the volume of blood is not well understood (aldosterone related
factor during pregnancy may contribute to this effect) increase water and salt retention.
• RBC increased by 33%
• Iron need increases because of increase in red blood cell mass. This is why Iron supplementation
is necessary during pregnancy.
• WBC total count usually increase
• Platelets increase in production
• Clotting factors - Several factors increase- F- I, F-VIII mainly
• To lessees extent, F-VII, IX, X and XII
• Decrease- F- XI, F-XIII
HEMATOLOGICAL SYSTEM

18. CHANGES OF THE RESPIRATORY SYSTEM
• a. The respiratory rate rises to 18 to 20 to compensate for increased
maternal oxygen consumption, which is needed for demands of the
uterus, the placenta, and the fetus.
• b. Women may feel out of breath and may need to sit a moment to
catch their breath.
Pulmonary system
• Capillary dilatation occurs in the respiratory route
(Nasopharynx, larynx, trachea, bronchi) → make
breathing difficult through nose, enlarged Uterus pushes the
diaphragm and the lungs as well.

19. CHANGES OF THE GASTROINTESTINAL
SYSTEM
• Estrogen exerts its hygroscopic effect on the gums, which makes
them spongy & leads to bleeding during pregnancy.
• Dental problems occur because of gingivitis rather than from dental
carries.
• Oral cavity feels increased salivation, ptyalism.
• Changes in their sense of taste, leading to dietary changes & food
cravings.
• Craving for unnatural substances such as coal is termed pica.
• pregnancy progresses, the uterus enlarges. It rises up and out of the
pelvic cavity. This action displaces the stomach, intestines, and other
adjacent organs.
• Nutritional requirements including for vitamin and minerals are
increased so usually mother’s appetite increase.

20. • Gastrointestinal mobility May be reduced due to increased progesterone (w/c
decreased the hormone motile stimulate smooth muscles in Gut) hence gastric
emptying is slowed and similarly in other part of GIT constipation (due to increased
water absorption).
• Constipation is a result of sluggish gut motility. It can exacerbate hemorrhoids.
• Gastric emptying & peristalsis are slowed in order to maximize the absorption of
nutrients.
• Enlarging uterus slower emptying time, increase intra gastric Pressure increase
acidity and increased gastric reflex.
• Heart burn is associated with gastric reflex due to the relaxation cardiac sphincter.
• Nausea & vomiting occur mainly during early pregnancy possibly due to raised
oestrogen or HCG levels.
• The anatomical position of small and large intestine as well as appendix will shift
because of the enlarging uterus.

21. CHANGES OF THE SKIN DURING
PREGNANCY
• CHOLASMA Mask of Pregnancy:
• This is the brownish hyper
pigmentation of the skin over the
face and forehead.
• It gives a bronze look, especially
in dark-complexioned women.
• It begins about the 16th week of
pregnancy and gradually
increases, then it usually fades
after delivery.

22. STRIAE GRAVIDARUM (STRETCH MARKS)
AND THE MIDLINE LINEA NIGRA
• Striae Gravidarum (Stretch
Marks):
• This may be due to the
action of the
adrenocorticosteroids.
• It reflects a separation within
underlying connective tissue
of the skin.
• This occurs over areas of
maximal stretch--the
abdomen, thighs, and
breasts.
• It will usually fade after
delivery although they never
completely disappear.
• Linea Nigra: This is a dark line that runs
from the umbilicus to the symphysis pubis
and may extend as high as the sternum.
• It is a hormone- induced pigmentation. After
delivery, the line begins to fade, though it
may not ever completely disappear.

23. CHANGES OF THE SKELETAL SYSTEM
Postural changes during pregnancy

24. CHANGES OF THE SKELETAL SYSTEM
• There is a realignment of the spinal curvatures during pregnancy
to maintain balance . It is due to the increase in size of the uterus and
pressure on the abdominal wall. The patient walks with head and
shoulders thrust backward and chest protruding outward to
compensate. This gives the patient a "waddling" gait.
• Lordosis shifts the woman’s centre of gravity back over her legs.
• There is a slight relaxation and increased mobility of the pelvic joints,
which allows stretching at the time of delivery of the infant.

25. CHANGES IN BODY WEIGHT DURING
PREGNANCY
• Normal weight gain is about 12 Kg during pregnancy.
• EXPECTED INCREASE :
• 2 kg in first 20 weeks
• 0.5Kg per week until term
• 12 Kg approximate total.
• REPRODUCTIVE WEIGHT GAIN :
• FETUS – 3.3 KG
• Uterus –0.9 kg
• Placenta – 0.6 kg
• Liquor -- 0.8 kg
• Breast – 0.4 kg
NET MATERNAL WEIGHT GAIN :
• Blood volume – 1.3 kg
• Extracellular – 1.2 kg
• Acumulation of fat & proteins – 3.5 kg

26. CHANGES OF THE URINARY SYSTEM
• The kidneys must work extra hard excreting the mother's own waste products
plus those of the fetus. There is an increase in urinary output and a
decrease in the specific gravity.
• The patient may develop urine stasis and pyelonephritis in the right kidney.
This is due to pressure on the right ureter resulting from displacement of the
uterus slightly to the right by the sigmoid colon.
• Frequent urination is a complaint during the first through third trimester. As
the uterus rises out of the pelvic cavity in early pregnancy, pressure on the
bladder decreases and frequency diminishes. When lightening occurs during
the final weeks of pregnancy, pressure on the bladder returns to cause
frequency.

27. Bladder
• Is displaced upward and anteriorly by enlarged uterus as a result it increases pressure
leading to and urinary urgency and frequency.
Galbladder
• Progesterone decreased motility → decreased empty time of Bile →stasis →stone
formation and infection.
Liver
• No morphological changes but functional changes
• Decreased plasma protein (albumen) an globline (synthesized By liver) increases serum
alkaline phosphatese activity.

28. CHANGES OF BODY TEMPERATURE
• A slight increase in body temperature in early pregnancy is
noted. The temperature returns to normal at about the 16th
week of gestation.
• The patient may feel warmer or experience "hot flashes" caused
by increased hormonal level and basal metabolic rate.

29. CHANGES OF THE BREASTS
• In early pregnancy, the breast may feel full or tingle, and increase in
size as pregnancy progresses.
• The areola of the nipples darken and the diameter increases.
• The Montgomery's glands (the sebaceous glands of the areola)
enlarge and tend to protrude.
• The surface vessels of the breast may become visible due to
increased circulation and turns to a bluish tint to the breasts.
• By the 16th week (2nd trimester) the breasts begin to produce
colostrum. This is the precursor of breast milk. It is a thin, watery,
yellowish secretion that thickens as pregnancy progresses. It is
extremely high in protein.

31. CHANGES IN THE ENDOCRINE SYSTEM
• a. Parathyroid Gland. This gland increases in size slightly. It meets
the increased requirements for calcium needed for fetal growth.
• b. Posterior Pituitary. Near the end of term, the posterior pituitary will
begin to secrete oxytocin that was produced in the hypothalamus and
stored there. It will serve to initiate labor.
• c. Anterior Pituitary. At birth, the anterior pituitary will begin to
secrete prolactin. This stimulates the production of breast milk.
• d. Placenta. The placenta acts as a temporary endocrine gland during
pregnancy. It produces large amounts of estrogen and
progesterone by 10 to 12 weeks of pregnancy. It serves to maintain
the growth of the uterus, helps to control uterine activity, and is
responsible for many of the maternal changes in the body.

32. CONCLUSION
• The physiologic changes that occur during pregnancy are
the result of hormonal and metabolic adaptations that are
necessary to support the developing fetus. They also produce a
variety of cutaneous findings, which are easily apparent to both
patient and Midwife.

33. REFERENCE
• Bobak, I.M., & Leonard, D. (1995). Text Book Of Maternity & Gynecologic Care :The Nurse & The
Family (4th ed.). Mosby Publication.
• Diane., Fraser., & Margret. (2003). Text Book for Midwives (14th ed.). Elsevier Publishers.
• Dutta, D.c., & Hiralal Konar. (2013). Text Book of Obstetrics (7th ed.). Jaypee Brothers Medical
Publishers.
• Elizabeth, M (2014). Midwifery for Nurses (2nd ed.). Sathish Kumar Jain Publishers.
• Jacob, A. (2008). A Comprehensive textbook of Midwifery & Gynecological Nursing (4th ed.).
Newyork: Jaypee Brothers Medical Publishers.
• Kumari Neelam., Sharma Shivani., & Gupta Preethi. (2010). A Text Book of Midwifery and
Gynecological Nursing.
• Ladewig, L. Maternal & Newborn Nursing (3rd ed.). Cumming Publication.
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• Richa S. Snapshort In Obstetrical & Gynaecology. Jaypee Brother’s Medical Publisher.