Physiological and psychological changes during pregnanc

1. Chapter 4
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2. Determining Pregnancy and
Physiological Changes
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3. 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
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4. 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
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5. 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
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6. 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
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7. 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
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8. 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
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9. Signs of Pregnancy
 Presumptive signs
 Suggest pregnancy
 Probable signs
 Likely pregnant
 Positive signs
 Definite evidence of pregnancy
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10. 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
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11. 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
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12. Physiologic Changes
in Body Systems
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13. Major Sources of Change
 Hormonal (endocrine system)
 Mechanical pressure (physical changes within
the body)
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14. 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
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15. Human Placental Lactogen (hPL)
 Increases maternal insulin resistance during
pregnancy
 Provides fetus with glucose needed for
growth
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16. Changes in the
Reproductive System
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17. 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
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18. 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.
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19. 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
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20. 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
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21. 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
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22. 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
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23. Initiation of Lactation
 Profound drop in estrogen and progesterone
 After delivery of placenta
 Increase in prolactin
 Responsible for milk production
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24. Changes in the
Cardiovascular System
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25. 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
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26. Supine Hypotensive Syndrome
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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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28. Dyspnea
 Respiratory system has increased sensitivity
due to progesterone
 Pressure of uterus on diaphragm
 Normally does not interfere with activities of
daily living
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29. 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
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30. 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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31. Compression of Abdominal
Contents
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32. 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
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33. 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
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34. Changes in the Integumentary
and 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
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35. Lordosis
 Lordosis
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36. 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
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37. Changes in the Integumentary
System
 Chloasma (“mask of
pregnancy”)
 Linea nigra (dark
line on abdomen)
 Striae gravidarum
(stretch marks)
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38. 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
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39. Effect of Pregnancy
on 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
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40. Effect of Lactation and
Medications
 Some drugs pass into breast milk
 If lactating, mother must take medication
immediately after infant breastfeeds
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41. Psychological Changes
During Pregnancy
 Body image changes
 Emotional security
 Cultural expectations
 Support from partner
 Whether pregnancy is unexpected
 Financial situations
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42. Psychological Changes
During 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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43. 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
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44. Responses to Pregnancy
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45. 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 45

46. 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
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