obstetrical condition

1. Assessment & Management
of Pregnancy (Antenatal)
CHAPTER III

2. NORMAL PREGNANCY
• Normal pregnancy begins when a sperm fertilizes an
egg. The normal duration of pregnancy is about 09
months. During this period, the body of woman
provides protection & nourishment for the
development of fetus. Pregnancy ends at delivery,
when a baby is born.
• Pregnancy is the state of dynamic, physiologic
adaptations to meet the demands of a developing
fetus, childbirth & *lacation. Some changes occurring
during this period seem exciting and pleasant to the
mother, others can create discomforts. The female
body adopts to this changes normally.

3. • Normal duration of pregnancy = 40 Weeks(
Calculates from last day of menstrual period)
• For a term pregnancy, there is requirement of at
least 37 weeks.
 These are 3 trimesters of equal length
I. 1st trimester – conception to 12 weeks
II. 2nd trimester – 12 to 28 weeks.
III. 3rd trimester – 28 to 40 weeks.
Normal Pregnancy

4. • There are certain physiological changes occuring in
the every system of the body. These changes are
natural and normal. Certain maternal activities can
harm the fetus during this period, Such as
 Smoking
 Taking alcohol
 Using illegal drugs
• During the course of pregnancy many physiological &
anatomical alterations occur in many organ system.
Early changes are due to metabolic demands brought
on by the fetus, placenta & uterus due to increasing
levels of pregnancy hormones, such as progesterone &
Oestrogen. Later changes are anatomical in nature are
caused by mechanical pressure from the expanding
uterus.
Normal Pregnancy

5. A. Uterus
• The part of the body which undergoes the most
significant changes and is affected first during the
pregnancy, is the uterus. (It increases to 20 times its
original weight (from 50 to 1000 grams)
• The capacity of the uterus must expand to normally,
accommodate a fetus & a placenta, the umbilical cord,
500ml to 1000ml of amniotic fluid & the fetal
membranes. The volume of uterine cavity increases
to around 5 litres.
• The amount of its muscle, blood vessels, and nerves
increases. By the time of pregnancy has reached
term, the uterus will have increased 5 times to its
normal size.
Reproductive system

6. • Its shape changes from elongated to oval by the 2nd month, to
round by midgestation, then back through oval to elongated at
term.
• During the 4th month the uterus grows into the abdomen,
causing the abdominal wall to expand to accommodate it. Length
increase from 7.5 cm to 35 cm, breadth 22.5 cm and thickness 20
cm.
• Growth that occurs too fast or too slow could be an indication
of problems. The connective and elastic tissues stretch and
straighten, creating thinned areas called striae ( Stretch marks).
• While the red of the striae may fade, silver remnants usually
remain after delivery. It also becomes more contractile with
irregular, painless Braxton hicks contractions beginnings in the
1st trimester.
• When the uterus increases in size, it rotates on its long axis,
usually to the right. This happens because the recto sigmoid
occupies the left posterior quadrant of the pelvis. As a result the
cervix shifts to left side 9 Levorotation).
Reproductive system

7. 1.Changes occurring in uterus during pregnancy
Weight increases
from 50 gm to
1000 gms (20
times)
Volume increases
to around 5 litres
Shape
• Elongated to oval
• Round
• Oval to elongated
( by term)
Muscular layer of
uterus
Length, breath &
thickness
Outer
longitudinal
layer
Middle
muscular
Inner
circular
Length
increases
from 7.5 cm
to 35 cm
Breadth
increases
from 5 cm to
22.5 cm
Thickness
increases
from 2.5cm
to 20cm

8. • The muscle fibres undergo hyperplasia &
hypertrophy. There is stretching of muscle fibers .
• There are 3 layers of uterine muscles, namely
outer longitudinal layer, middle vascular layer &
inner circular layer.
• The middle layer is the longest layer arranged in
criss cross pattern. The muscle fibres give the
figure of 8 form. It is called as a living ligature, as
when contract they occlude the blood vessels
running through fibres.
2.Changes in muscles of uterus

9. • The Isthmus forms the lower uterine segment
after 12 weeks of pregnancy. It dilates the last
trimester & measure 7.5cm- 10 cm in length.
3.Changes in Isthmus
4.Changes in Cervix
• The cervix undergoes a marked softening which is
referred to as the goodell’s sign’’. During pregnancy
cervix becomes vascular, oedematous and soft. The
length becomes double & volume increases.
• These are enlarged & active muscus glands of the
cervix, which help in forming a muscle plug during the
pregnancy.
• It protects the uterus, fetus and fetal membranes from
infection.

10. • Increases circulation to the vagina early in
pregnancy changes the color from normal light
pink to a purple blue whish is known as
``Chadwick’s sign’’.
• It becomes vascular and feels soft.
• Vaginal secretion are acidic.
5.vagina

11. • There is hypertrophy of fallopian tubes and they
become vascular. The corpus luteum progesterone
to help maintain the lining of the endometrium in
early pregnancy.
• The corpus luteum enlarges early pregnancy. It
function until about the 10th & 12th week of
pregnancy when the placenta is capable of
producing adequate amounts of progesterone and
estrogens.
• It slowly decreases in size & function after 10th &
12th week.
• The FSH prevents ovulation and menstruation.
6.Ovaries & Fallopian tubes

12. Ovaries & Fallopian tubes
Weight gain upto 20 weeks Form 20 weeks till full term Total increase
2.0Kg 0.5 Kg/Week 12 kg
• Weight gain during pregnancy:
• A pregnant woman gains around 12 kg of weight.
a) Reproductive weight gain:
 Weight of Fetus – 3.3 kg
 Weight of uterus – 0.9 kg
 Weight of Placenta – 0.6 kg
 Weight of Liquor – 0.8 kg
 Weight of Breast- 0.4 Kg

13. b. Net maternal weight gain:
 Increase in blood volume – 1.3 kg
 Increase in extracellular fluid – 1.2 Kg
 Accumulation of fat & protein – 3.5 Kg
I. The Weight distributed as:
 First 20 weeks = 2.0 kg
 After 20 weeks, per week increase = 0.5 Kg 1st
trimester – 1kg
 Total increase in weight = 12.0 Kg
Ovaries & Fallopian tubes

14. • Breast become more vascular & total weight is
around 0.4 kg. At 16th week there is a pale yellow
coloured secretion from the breast, called as
colostrum.
• There is pigmentation of areola with development
of sebaceous glands called as Montogomer’s
tubercles.
• During 2nd trimester, secondry areola appears
around primary areola.
• Nursing Implication: Inform the pregnant patient
to wear a good, supporting bra.
7.Breasts

15. • Position and size of heart
• With the enlargement of the uterus, the
diaphragm becomes elevated; the heart is
displayed upward and somewhat to the left with
rotation on its long axis, so that the apex beat is
moved laterally.
• The size of the heart appears to increase by about
12 %.
• Cardiac capacity increases by 70 – 80ml; this may
by due to increased volume or hypertrophy of
cardiac muscle
• It can lead to changes in ECG appearance.
A.CARDIOVASCULAR SYSTEM

16. • cardiac output increases approximately 30% to
40% during pregnancy reaching its maximum at
around 30 week’s gestation and continuing at 15%
above level until term.
• There is an increase in cardiac output due to
increased heart and increased stroke volume.
Cardiac Output

17. • Systemic blood declines slightly during pregnancy.
There is little change in systolic blood pressure,
but diastolic pressure is reduced from about 12-26
weeks.
• The obstruction posed by the uterus on the
inferior vena cava & the pressure of fetal
presenting part of the common illiac vein can
result in decreased blood return to the heart.
• This decrease cardiac output, leads to a fall in
blood pressure and causes edema in the lower
extremities.
Blood Pressure

18. • It increases progressively from 6-8 weeks
gestation & reaches a maximum at approximately
32-34 weeks with little change thereafter.
• The magnitude of the increases varies according
to the size of the woman, the number of
pregnancies she has had the number of infants she
has delivered, & whether there is 1 or multiple
fetuses.
• The increase in needed for extra blood flow to
uterus , extra metabolic needs of fetus and
increased perfusion of others organs, especially
kidneys.
Blood Volume

19. • Extra volume also compensate for maternal
blood loss in delivery.
• The increase in plasma volume ( 40%¬
50%) is relatively greater than that of red
cell mass (20%- 30%) resulting in
hermodilution & decreases in haemoglobin
concentration.
• Intake of supplemental iron & folic acid is
necessary to restore haemoglobin levels to
normal (12g/dl).

20. • Size of the heart – Increases about 12 %
• Cardiac capacity – Increases 70-80ml
• Cardiac output – Increases by 30% - 40% till 30 weeks
after that continue to increase 15% till term.
• White blood cells – Increases & reach upto level of 10.0-15.
x 10^9/1
• Clotting time – Coagulation time from 12 minute, it comes
to 8 minute
• Blood pressure
o Systolic – slight change or same
o Diastolic – reduced 5-10mm of Hg at about 12 – 36 weeks
& by 36 weeks comes to pre pregnancy level.
Main cardiovascular changes during pregnancy

21. • As mentioned above, red cells mass is increased 20%-30%
Leukocyte counts are variable during gestation, but usually
remain within the upper limits of normal.
• Marked elevations however develop during & after
parturition.
• Fibrinogen as well as total body and plasma levels of
factors VIII, X and XII increases markedly.
• The number of platelets also rises. Thus pregnancy is a
relatively hypercoagulable state, but during pregnancy
neither clotting or bleeding times are abnormal.
• With the increase in red blood cells, the need for iron for
the production of haemoglobin increases, If supplements
iron is not added to the diet, Iron deficiency anemia will
result
Blood Constituents

22. • Due to the hormonal effect, a pregnant woman
breathes slightly faster & more deeply to exhale
more carbon di oxide & keep the carbon dioxide
level low. She may breathe deeper & faster also
because the enlarging uterus limits the expansion
of the lungs. The circumference of the woman
chest enlarges slightly.
• Changes in the rib cage- is displaced upward. This
displacement is due to elevation of diaphragm,
because of enlarged uterus. The anteroposterior &
transverse diameters increase, lower ribs flare out
and the shape of chest changes.
B.RESPIRATORY TRACT

23. • almost every pregnant woman becomes
somewhat more out of breath when she exerts
herself especially toward end of pregnancy.
• Because of blood volume expansion, there is
hyperaemia & expansion of upper respiratory
mucosa. As a result, the nose occasionally feels
stuffy and this can cause slightly change in the
tone & quality of woman’s voice.
• The woman may suffer from chronic cold
during pregnancy.
• Tidal volume increases to 700.

24. C.URINARY SYSTEM
• The kidneys also work harder throughout
pregnancy .
• They filter the increasing volume of blood
throughout pregnancy.
• During pregnancy, each kidney increases in
length by 1-1.5cm.
• The urters are dilated above the brim of the
bony pelvis.
• The ureters elongate, widen, and become more
curved, which result in increase in urinary
stasis.

25. • It may lead to infection.
• Right uteres dilates more, may be due to the
dextorotation.
• Bladder vascularity increases muscle tone
decreases & mucosa becomes oedematous.
• Pressure from the uterus leads to increase
in urinary frequency.
• There can be ‘’Stress incontinence also in
the later pregnancy’’.

26. • The glomerular filtaration rate (GFR)
increases during pregnancy by about 50%
• The renal plasma flow rate increases by as
much as 25-50%.
• though GFR increased dramatically during
pregnancy, the volume of urine passed each
day is not that much increased.
• Increase in GFR with impairment of tubular
reabsorbtion capacity for filtered glucose
may lead to glycosuria during pregnancy.
• It can be cause of urinary tract infections.

27. • Protein and amino acids are not properly re
absorbed , so they are found in much greater
amount in urine of pregnant women.
• Activity of the kidneys normally decreases
when a person stands and increases when a
person lies down.
• During pregnancy, this activity increases, which
is a reason, why a pregnant woman needs to
urinate frequently while trying to sleep .
• Later in pregnancy , lying particularly on the
left side increases kidney activity more than
lying on the back.

28. Nursing implication:
Pregnant woman should be advised to lie on
the left side as it relieves the pressure that the
enlarged uterus puts on the main vein that
carries blood from the legs.
As a result, blood flow improves and kidney
activity increases.
The uterus presses on the bladder, reducing in
size so that it fills with urine more quickly than
usual.
This pressure also makes a pregnant woman
need to urinate more often and more urgently.

29. D.GASTRO INTESTINAL SYSTEM
Oral cavity – during pregnancy, more
saliva is produced and the saliva is more
acidic, which promotes tooth decay.
The gums are more sensitive and may
swell and bleed easily.
There can be a change in sense of taste .
There is association of pica, in which
there is craving for bizzarre substances,
like chalk pieces, wall plaster, mud etc.

30.  Stomach and oesophagus- there is presence of
morning sickness, characterized by vomiting and
a poor appetite
 One of the pregnancy hormones causes the
muscles of the digestive tract to relax, therefore;
they pass the food more slowly the intestines.
 In addition, the uterus can press on the colon,
inhibiting passage of feces.
 The muscles at the junction of the esophagus
and the stomach relax, and the uterus presses on
the stomach from below, causing the stomach
contents to flow back into the esophagus.
 Gastric reflux is more prevalent in later
pregnancy owing to elevation of the stomach by
the enlarged uterus. It can result in heartburn.

31. Gastro intestinal motility- due to
increased level of progestrone , gastro
intestinal motility may be reduced
during pregnancy .
Transit time of food throughout the
gastrointestinal tract may be so much
slower that more water than normal is
reabsorbed, leading to constipation.

32. E.METABOLIC CHANGES
 Metabolically speaking , pregnant woman live in
a state of ‘’accelerated starvation’’.
 All metabolic function are increased during
pregnancy to provide for the demands of fetus,
placenta and uterus as well as for the gravida’s
increased basal metabolic rate and oxygen
consumption.
 Protein metabolism is enhanced to supply
substrate for maternal and fetal growth.
 Protein storage occurs and conversion of amino
acid to urea is suppresed , so the blood urea
level falls.
 Fat metabolism increases as evidenced by
elevation in all lipid fractions in the blood.

33. Cholestrol rises and there is increased
absorption of fat in later months.’
carbohydrates metabolism , however,
demonstrates the most dramatic changes.
Normal prgnancy shows Fasting
hypoglycemia and hyperinsulinaemia, as
the nutritional demands of the growing
fetus are met by the intake of glucose and,
second , secretion of insulin in response to
glucose is augmented.
Iron demand is increased in pregnancy and
almost doubles.

34. F.SKELETAL CHANGES
 As the gravid uterus has to be compensated ,
there is alteration in the posture of the female.
 Lordosis shifts the womans centre of gravity
back over her legs.
 Later in pregnancy , it can lead to numbness,
aching and weakness in the arms, with anterior
flexion of neck and slumping of the shoulder
girdle.
 The hormones in pregnancy such as oestrogen,
progestrone and relaxin help in the relaxation of
pelvic joints.
 There is relaxation of symbysis pubis , which
may lead to pelvic pain.

35. The increased mobility of sacroiliac and
sacrococcygeal joints, lead to alteration
in posture and low back pain in later
pregnancy .

36. G.SKIN CHANGES
The following changes occur during
pregnancy:
Linea nigra: a hormonal induced
pigmentation is a dark line that runs from
the umblicus to the symbysis pubis and may
extend as high as the sternum.
After delivery, the lines begins to fade,
though it may not ever completely
disappear.
Mask of pregnancy (cholasma): affects half
of all pregnant woman. This is the brownish
hyper pigmentation of the skin over the face
and fore head.

37. Striae gravidarum(stretch marks);
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 change to white silvery lines few
months after delivery.

38. H..ENDOCRINE SYSTEM
Pregnancy affects almost all hormones in the
body , mostly because of the effects of
hormones produced by the placenta.
1.Placental hormones –
human chorionic gonadotrophin (HCG) is
secreted by syncytotrophoplast.
It can be detected in maternal urine after 8-
9 days of fertilization and thus forms the
basis of pregnancy tests.
It helps in maintaining the secretion of
progestrone by the corpus luteum.

39. Human placental lactogen (HPL)
Acts like a growth hormone.
It plays role in some important
metabolic processes such as increasing
maternal blood free fatty acids, glucose
and insulin concentration, and
increasing lipolysis and insulin
resistance.
It shifts glucose towards utilization by
the growing fetus.

40. 2.Maternal endocrine glands:
Pituitary gland and this enlargement can
compress optic chiasma, leading to
headache.
 secretion of FSH and LH is inhibited
during pregnancy.
TSH and ACTH are secreted by anterior
lobe.
The posterior lobe secretes oxytocin,
whose secretion increases in second
stage of labour.

41. 3. Steroid hormone
 Main steroidal hormones are progestrone and oestrogen
(oestrone , oestriol, oestradiol)
 Among the three oestrogens , oestrone is the most
important.
 Levels of oestrogen and progestrone increases early during
pregnancy because human chorionic gonadotropin, the
main hormone the placenta produces, stimulates the
ovaries to continuously produce them.
 Oestriol seems to increase the placental blood flow.
 Progestrone maintains the pregnacy.
 Corpus leutium secretes progestrone up to 10weeks and
later on , placenta takes over this function.
 Steroidal hormone stimulates growth of the uterus.
 They help in starting of the normal labour
 They also help in the developement of breasts during the
pregnancy.