Physiologic and Psychologic Changes During

Pregnancy:
1. Presumptive Signs- those that are least indicative of pregnancy,
taken as single entities, they could easily
indicate other conditions
- largely subjective
a. Breast changes
b. Nausea and vomiting
c. Amenorrhea
d. Frequent urination
e. Fatigue
f. Uterine enlargement
g. Quickening
h. Linea nigra
i. Melasma
j. Striae gravidarum

MELASMA

Sstri

STRIAE GRAVIDARUM

2. Probable Signsa. Serum laboratory test

hCG- a hormone created by the chorionic villi in
the placenta.
*Reaches a measurable level (50mIU/ml) 79 days after conception
*Peaks at about 100mIU/ml but by the 60th80th day after this it declines again and is
no longer detectable in the serum.
b. Chadwicks Sign- color change of the vagina from pink
to violet
c. Goodells sign- softening of the cervix
d. Hegars sign- softening of the lower uterine segment

CHADWICK S SIGN WITH LEUKORRHEA

e. Sonographic evidence of gestational sac

f. Ballotement- when lower uterine segment is
tapped on a bimanual
examination, the fetus can be
felt to rise against the
abdominal wall.
g. Braxton Hicks contractions- periodic
uterine tightening
h. Fetal outline felt by the examiner

3. Positive Signs
a. Sonographic evidence of the fetal outline
b. Fetal heart audible
* 18-20 weeks of pregnancy audible by an
ordinary stethoscope 120-160 bpm
c. Fetal movement felt by the examiner- 20th-24th
weeks AOG

PsychologicaL Changes During Pregnancy

1. Social Influences

2. Cultural Influences
3. Family Influences
4. Individual Influences

The Psychological Tasks of Pregnancy:

First Trimester: Accepting the pregnancy- spends time
recovering from shock of learning they are
pregnant and concentrate on what it feels like
to be pregnant.
Second Trimester: Accepting the baby- moves through
emotions such as narcissism and introversion as they
concentrate on what will happen and what it feels
like to be pregnant.
Third Trimester: Preparing for parenthood

EMOTIONAL RESPONSES TO PREGNANCY:

1. Ambivalence- interwoven feelings of wanting and not wanting
2. Grief
3. Narcissism-reaction to self-intrusion; self centeredness
4. Introversion vs. Extroversion
5. Body Image and Boundary
Body Image- the way your body appears to yourself
Body Boundary- a zone of separation you perceive between yourself
and objects or other people

6. Stress

7. Couvade syndrome- men experiencing physical

symptoms such as nausea,
vomiting etc. to some degree or
even more intensely than their
partners do.
8. Emotional lability
9. Changes in sexual desire

10. Changes in the expectant family

PHYSIOLOGIC CHANGES OF PREGNANCY

A. Reproductive System
A1. Uterine Changes- increase in length, depth, width
weight, wall thickness and
volume
12th week- uterus is firm and sphenoid under the
abdominal wall just above the
symphysis pubis
20th-22nd week- fundus is at the level of the umbilicus
36th week- fundus is at the level of the xiphoid process
38th-40th week- lowers

*Increase of blood flow to the uterus- pre-pregnancy- 15-20

ml/min by the end of pregnancy- 500-750 ml/min 75 % of
which is going to the placenta
*Uterus is more anteflexed, larger, softer to touch than usual
*6th week of pregnancy- lower uterine segment just above the
cervix becomes soft (Hegars Sign)
* 12th week of pregnancy- Braxton Hicks contractions begin
*16th-20th week of pregnancy- Ballottment may be noted
*20th-24th week- fetal outline may be palpated

A2. Amenorrhea- due to suppression to FSH

Other possible reasons: uterine infection,
climate change, worry, chronic illness such as
severe anemia or stress

A3. Cervical Changes- becomes vascular and edematous

- becomes soft in consistency (Goodells
Sign) due to the high estrogen level
Operculum- mucus plug which acts to seal out bacteria during
pregnancy and to help prevent infection in the
fetus and membranes.

A4. Vaginal Changes

Estrogen- causes the vaginal epithelium and underlying
tissue becomes hypertrophic and enriched
with glycogen.
*Changes in color from pink to dark violet (Chadwicks
Sign)
*pH of vaginal secretions decreases from 7 to 4-5 due to
the action of Lactobacillus acidophilus and Doderlein
bacillus
A5. Ovarian Changes

B. Breast Changes
*Estrogen- causes a feeling of fullness, tingling sensation and
tenderness
* Hyperplasia of the mammary alveoli
* Areola darkens and its diameter increases from about 3.5 cm
to 5 or 7.5 cm (1.5-2-3 inches)
*There is formation of secondary areola, increase in vascularity,
blue veins become prominent over the surface of the breast,
sebaceous glands of the areola (Montgomery tubercles)
enlarge.
*16th week of pregnancy- colostrums is expelled from the
nipples in a form of thin watery fluid which is high in protein
and considered to be a precursor of breast milk

SYSTEMIC CHANGES
A. Integumentary System
A1. Striae gravidarum- pink or reddish streaks appearing on the sides of the
abdominal wall and sometimes on the thighs.
A2. Diastasis- separation of rectus muscle, bluish grooveat the site of the
separation

*At the 28th week AOG the depression of the umbilicus becomes
obliterated and smooth.
A3. Linea nigra- dark line running from the umbilicus to the symphysis pubis
A4. Melasma/ chloasma or the mask of pregnancy
A5. Vascular spiders- small, fiery-red branching spots commonly found on
the thighs.
A6. Increased perspiration
A7. Palmar erythema- due to increased estrogen level in the body

PALMAR ERYTHEMA

B. Respiratory system
* NO change in vital capacity
* Tidal volume is increased by 30-40 %
*Respiratory rate is increased by 1-2 cpm/minute (1820cpm/min)
* Residual volume- decreased by 20 %
* Plasma PCO2- decreased by 27-32 mHg
* PlasmaO2- increased to 104-108 mmHg
* Blood pH- increased to 7.40-7.45
*Respiratory minute volume- increased by 40%
* Expiratory reserve- decreased by 20%
*Increased ventilation

D. Cardiovascular System
D1. Blood volume increases by at least 30% and
possibly as much as 50%
Normal blood loss for NSVD- 300-400 ml
Normal blood loss for CS- 800-1000 ml
* The increase in blood volume peaks at the 28th-32nd
week
D2. Iron needs- 800 mg during pregnancy
True anemia- either a hemoglobin concentration of
less than 11.5 g/100 ml or a Hct of less than 30 %

D3. Folic acid- helps in preventing neural tube defects

D4. Heart- increase in cardiac output by 25-50%

HR increases by 10 bpm
*Innocent heart murmurs may be heard r/t altered heart
position and decreased blood viscosity.
* Palpitations are also common due to the stimulation of
SNS
D5. Regional blood flow- impaired to the lower extremities
D6. BP- does not normally rise
D7. Supine hypotension syndrome- light headedness,
faintness and palpitations
Interventions: lie on the left side and rise from bed slowly

D8. Blood Constitution

*Increase in circulating fibrinogen (as much as
50 %) due to increased level of estrogen
*Increase in clotting factors VII, VIII, IX, and X
and platelet count
*Increase in WBC
* Decrease in total protein which may be a
cause of ankle edema
*Increase in body lipid by 1/3 and cholesterol
by 90-100%

E. Gastrointestinal system
*Slow intestinal peristalsis and emptying of the
stomach
*heartburn, constipation andf flatulence is common
*Nausea and vomiting is common due to increase l
level of hCG and progesterone or as a
systemic reaction to the increased level of estrogen
and decreased level of glucose.
*Subclinical jaundice may be experienced
*Hypertrophy of the gumlines and possible bleeding
of the gingival tissue
*Decreased pH in the mouth

F. Urinary System
*Glomerular filtration rate- increased by 50 %
* Renal plasma flow- increased by 25-80 %
* BUN- decreased by 25%
* Plasma creatinine level- decreased by 25%
* Renal threshold for sugar- decreased to allow
spillage
* Bladder capacity- increased by 1000 ml
* Diameter of ureters- increased by 25%
* Frequency of urination- increased in the 1st
trimester and the last two weeks of
pregnancy to 10-12 times/day

ANKLE EDEMA

G. Skeletal System
* Ca and Ph needs are increased
* There is softening of pelvic ligaments and joints which
causes the waddling gait
H. Endocrine System
*Placenta- produces hCG, estrogen, progesterone, hPL,
relaxin and prostaglandins
Estrogen- causes breast changes and palmar erythema
Progesterone- maintains endometrium inhibiting uterine
contractions;aids in the preparation of the
breasts for lactation.
Relaxin- secreted primarily by the corpus luteum
- inhibits uterine contractions; softens the cervix
and the collagen in joints

hCG- secreted by the trophoblast in the placenta

stimulates estrogen and progesterone synthesis until the
placenta can take its role.
hPL- also known as human chorionic somatomammotropin hormone
- serves as the antagonist to insulin, freeing fatty acids for
energy
Prostaglandin- affects smooth muscle contractility to such an
extent they may be the trigger that initiates labor at
term

*Pituitary gland- halted FSH and LH release because of increased

levels of estrogen and progesterone
- late in pregnancy it produces oxytocin
- produces prolactin which prepares the breasts for
lactation

*Thyroid and parathyroid glands- glands enlarges and

BMR increases by 20%
*Protein based-iodine, butanol-extractable iodine,
and thyroxine are all elevated as well.

* Adrenal glands- increased function due to increased

level of corticosteroid and
aldosterone.
- aids in suppressing inflammatory
reaction , helps in regulating the
glucose metabolism in the woman
Increase in aldosterone aids in promoting sodium
reabsorption

*Pancreas- increased production of insulin in response

to increased amount of glucocorticoid
produced by the adrenal glands. However
insulin are less effective during pregnancy
because of the increase level of estrogen,
progesterone, and hPL which are
antagonists to insulin.
*FBS- 80-85 mg/100ml
I. Immune System- decreased functioning and
decreased level of IgG

ASSESSING FETAL AND MATERNAL HEALTH

1.Para- The number of pregnancies that reached viability (24

wks, reached 400 g), regardless of whether the
infants were born alive or not
2.Gravida- a woman who is or has been pregnant
3.Primigravida- a woman who is pregnant for the first time
4.Primipara- a woman who has given birth to one child past
age of viability
5.Multigravida- a woman who has been pregnant
previously
6. Multipara- a woman who has carried two or more
pregnancies to viability
7. Nulligravida- a woman who has never been and is not
currently pregnant

Estimating Pelvic Sizepelvic pelvimetry and fetal

sonography
*Estimation should be done at least by the 24th week of
pregnancy because by this time there is danger that the fetal
head will reach a size that will interfere with safe passage
and birth if pelvic measurements are small
TYPES OF PELVES:
1. Android
2. Anthropoid
3. Gynecoid
4. Platypelloid

2. True conjugate or conjugate vera- measurement

between the anterior surface of the
sacral prominence and of the posterior
surface of the inferior margin
of the symphysis pubis.
- cannot be measured directly,
subtract the usual depth of the
symphysis pubis (assumed to be 1.22 cm) from the diagonal
conjugate measurement.
-actual diameter of the pelvic inlet
(10.5-11 cm)

Common Measurements:
1. Diagonal conjugate- distance between the anterior
surface of the sacral
prominence and the anterior
surface of the inferior margin of
symphysis pubis
-considered to be the most useful
measurement for the estimation
of pelvic size.
-suggests the anteroposterior
diameter of the pelvic inlet
* Measured while the client is in a lithotomy position
>12.5 cm- adequate for childbirth (average fetal head
is 9 cm)

3. Ischial tuberosity diameter- distance

between the ischial tuberosity or the
transverse diameter of the outlet. Made
at the medial or lowermost aspect of the
ischial tubersities at the level of the anus
(11 cm)

LEOPOLDS MANEUVER

LEOPOLDS MANEUVER

DISSCOMFORTS DURING THE FIRST TRIMESTER

1. Breast Tenderness
2. Palmar Erythema
3. Constipation

4. Nausea Vomitting and Pyrosis

5. Fatigue
6. Muscle cramps- due to decreased Calcium and increased Phosphorus
7. Hypotension
8. Varicosities- Let client rest in Sims position or with legs raised for 15-20
min 2x a day

9. Hemorrhoids- modified Sims position or knee chest position

for 10-15 min.
-apply Witch hazel or cold compress to relieve
pain
10. Heart palpitations
11. Frequency of urination- reduce caffeine intake and practice
Kegels exercise

12. Abdominal discomfort

13. Leukorrhea- a whitish vaginal discharge or increased vaginal
secretions brought about by increased
estrogen level and blood supply to the vaginal
epithelium and cervix.

DISCOMFORTS DURING MIDDLE AND LATE

PREGNANCY
1. Backache- Pelvic rocking and tilting exercise

2. Headache
3. Dyspnea
4. Ankle edema

5. Braxton Hicks Contractions

Danger Signs of Pregnancy:

1. Vaginal bleeding
2. Persistent vomiting
3. Chills and fever

4. Sudden escape of clear fluid from the

vagina
5. Abdominal or chest pain

6. PIH
6a. rapid wt. gain (over 2 lbs/week in the 2nd
trimester and 1lb/week in the 3rd
trimester)
6b. Swelling of the face and the fingers
6c. Flashes of light or dots before the eyes
6d. Dimness or blurring of vision
6e. Severe continuous headache
6f. decreased urine output

7. Increased or decreased fetal movement

VARICOSITIES

HEMORRHOIDS

ELASTIC STOCKINGS

LEFT SIDE LYING POSITION

SQUATTING

TAILOR SITTING

BACKACHE

PELVIC ROCKING

KNEE-CHEST POSITION

PREVENTION OF EXPOSURE TO
TERATOGENS
Teratogen- any factor, chemical
and physical that
adversely affects the
fertilized ovum,
embryo or fetus.

Maternal Infection
TO- TOxoplasmosis
* a protozoan infection spread through uncooked
meat, and through handling cat stool in soil or cat
litter.
* Effect to fetus: CNS damage, hydrocephalus,
microcephaly, intracerebral
Calcification and retinal deformities.
*Dx: Serum analysis
*Tx: sulfonamides- but this can lead to increased
bilirubin in the newborn
Pyrimethamine- antiprotozoal drug but an
antifolic acid drug at the
same time

R- Rubella
*otherwise known as German measles
*Effect to fetus: deafness, mental or motor
challenges, cataract, cardiac
defects (PDA or pulmonary
stenosis), retarded
intrauterine growth,
thrombocytopenic purpura,
dental and facial clefts.
*Dx. Rubella titer- > 1:8 suggests immunity
< 1:8 susceptible to viral
invasion
Greatly increased- suggests recent infection

RUBELLA

C- Cytomegalovirus (CMV)
* a member of the herpes virus family
*MOT: Droplet
* Effect to the fetus: neurologically
challenged (hydrocephalus, microcephaly
spasticity with eye damage [optic atrophy
and chorioretinitis]) deafness, chronic liver
disease, skin covered with large petechiae
(blueberry muffin lesions)
*Dx. Isolation of CMV antibodies in the
serum
* No treatment

CHILD AFFECTED WITH CMV

H- Herpes simplex
*1st trimester- congenital anomalies or
spontaneous miscarriage
*2nd or 3rd trimester- premature birth, intrauterine
growth retardation and
continuing infection
Other viral infection
Rubeola
Coxsackievirus
Mumps
Varicella (chickenpox)
Poliomyelitis
Influenza
Viral hepatitis

Parvovirus B19- causative agent of Erythema infectiosum (5th

dise. ) attacks the RBC
-associated with fetal death in early pregnancy
and anemia and congenital heart defect in late pregnancy
Syphylis- caused by Trepenoma pallidum
*causes damage to the fetus after the 16th-18th week of
intrauterine life when the cytotrophoblastic layer of the
placental villi has atrophied
* causes deafness, cognitive challenge, osteochondritis and
death
*Dx. VDRL and rapid plasma regain- remains high for more than
2oo days
*infants born of a mother with syphilis- remains to be (+) up to
3 mos. even if the dse has
already been treated.
*Tx. Benzathine penicillin

SYPHILIS

Lyme disease- Borrelia burdorferi

*Tx. Tetracycline or doxycyclinenot safe for pregnant women
Penicillin- drug of choice

TRICHOMONIASIS & VAGINITIS

FETAL ALCOHOL SYNDROME

AMELIA

PHOCOMELIA