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Lecture 5

Psychological and Physiological �Changes of Pregnancy

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Objectives

On completion of this part, the student will be able to:

Describe terminology used in discussing pregnancy.
Identify signs and symptoms of pregnancy.
Discuss the factors that can have an influence on pregnancy.
Describe the physiological changes during pregnancy.
Describe the psychological changes during pregnancy.
Explain reasons of different psychological and physiological changes of pregnancy.

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Purpose of the physiologic changes

To allow a woman to be able to provide oxygen and nutrients for her growing fetus, and extra nutrients for her own increased metabolism during the pregnancy.

2. To prepare the woman’s body for labor and birth and for lactation once the baby is born.

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Causes of Psychological Changes

Response to the physiologic alterations.

Increased responsibility.

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Psychosocial Changes With Pregnancy

Woman and husband both spend time recovering from shock of learning they are pregnant and concentrate on what it feels like to be pregnant. A common reaction is ambivalence, or feeling both pleased and not pleased about the pregnancy.

First Trimester

Accepting the pregnancy

Woman and husband move through emotions such as narcissism and introversion as they concentrate on what it will feel like to be a parent. Role-playing and increased dreaming are common.

Second Trimester

Accepting the baby

Woman and husband grow impatient with pregnancy as they ready themselves for birth.

Third Trimester Preparing for the baby and end of pregnancy

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Emotional Responses to Pregnancy

Ambivalence: refers to the interwoven feelings of wanting and not wanting that can exist at high levels.

Grief: must incorporate her new role as a mother into her other roles as a daughter, wife, or friend.

Narcissism: self-centeredness (dress, meals, her body, activity level, driving, herself).

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Emotional Responses to Pregnancy

Introversion Versus Extroversion: introversion, or turning inward to concentrate on oneself and one's body. Extroversion is the reaction in an entirely opposite fashion and become more extroverted.

Body Image and Boundary: Body image and body boundary (a zone of separation you perceive between yourself and objects or other people), see herself becoming “bigger”

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Emotional Responses to Pregnancy

Stress: because of pregnancy is a major role change, which lead to a decrease in the responsibilities that a pregnant woman takes on.

Couvade Syndrome: Many men experience physical symptoms such as nausea, vomiting, and backache, perceive himself as growing larger, changing boundaries. These symptoms apparently result from stress, anxiety, and empathy for the pregnant woman.

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Emotional Responses to Pregnancy

Emotional Lability: Mood changes, and mood swings because of increase in estrogen and progesterone.

Changes in Sexual Desire: a loss of desire due to the estrogen increase.

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The Diagnosis of Pregnancy

Presumptive Signs of Pregnancy
Probable Signs of Pregnancy
Positive Signs of Pregnancy

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Presumptive Signs of Pregnancy

They are least indicative of pregnancy, they could easily indicate other conditions.

They are largely subjective in that they are experienced by the woman but cannot be documented by an examiner.

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Presumptive finding

Weeks since implantation

Breast changes: tenderness, fulness, tingling, enlargment and darkening of areola

2

Nausea vomiting

2

Amenorrhea: absence of menstruation

2

Frequent urination

3

Fatigue

12

Uterine enlargement: uterus can be palpated above the symphysis pubis

12

Quickening

18

Linea nigra

24

Melasma

24

Striae gravidarum

24

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Presumptive findings �

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Probable Signs of Pregnancy

They can be documented by the examiner.

They are more reliable than the presumptive signs, they still are not positive or true diagnostic findings.

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Probable signs

Weeks since implantation

Serum laboratory tests (hCG)

1

Chadwick’s sign: color change of vagina from pink to violet

6

Goodell’s sign: Softening of the cervix

6

Hegar’s sign: softening of the lower uterine segment

6

Sonographic evidence of gestational sac

6

Ballottement: when lower uterine segment is tapped on a bimanual examination, the fetus can be felt to rise against abdominal wall

16

Braxton Hicks contractions: periodic uterine contractions

20

Fetal outline felt by examiner: through abdomen

20

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Probable Signs �of Pregnancy

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hCG

24-48 hrs after implantation: traces amount of hCG
7-9 days after conception: 50 mIU/ml
Peak 60-80 days of gestation: 100mIU/ml
At term: barley detectable

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Positive findings

Weeks since implantation

Sonographic evidence of fetal outline

8

Fetal heart audible

10-12

Fetal movement felt by examiner

20

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Demonstration of a Fetal Heart Separate from the Mother's

Echocardiography can demonstrate a heartbeat as early as 5 weeks.
Ultrasound can visualize the fetal heart as early as the 6th to 7th week of pregnancy.
Doppler technique can detect fetal heart sounds as early as the 10th to 12th week of gestation.
Ordinary stethoscope at about 18 to 20 weeks of pregnancy.
Heard best over the area of the fetus's back.
Usually ranges between 120 and 160 beats per minute.

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Fetal Movements Felt by the Examiner: may be felt by the 20th to 24th week of pregnancy.
Visualization of Fetus by Ultrasound:
gestational sac as early as the 4th to 6th week of pregnancy.
By the 8th week, a fetal outline can be seen so clearly within the sac that the crown-to-rump length can be measured to establish the gestational age of the pregnancy.
Fetal heart movement may be demonstrated as early as the 6th week with transvaginal sonography and the 7th week with transabdominal sonography

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Physiologic Changes

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Physiologic Changes: Reproductive changes�

Uterine changes
Amenorrhea
Cervical changes
Vaginal changes
Ovarian changes
Breast changes

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Uterine Changes

Increase in the size of the uterus (at term the uterus length 32 cm , depth 22 cm , width 24 cm , weight 1,000 g , wall thickness wall thins to become 0.5 cm, and volume more than 1,000 mL), why?
12th week of pregnancy the uterus above the symphysis pubis.
Uterine height is measured from the top of the symphysis pubis over the top of the uterine fundus.

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Physiologic Changes: fundal hight

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Cont. Uterine Changes

False signs because of:
tumor with calcium deposits could simulate a fetal outline
uterine tumor could mimic growth and ballottement
contractions could accompany any growing uterine mass

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Crowding of abdominal contents late in �pregnancy

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Amenorrhea

Absence of menstruation
In pregnancy: why is it absent during pregnancy?
Without pregnancy: Amenorrhea could result in the onset of menopause or could result from delayed menstruation due to unrelated reasons, as uterine infection, worry, a chronic illness as severe anemia, or stress. It occurs in athletes who train strenuously, especially in long-distance runners whose percentage of body fat drops below a critical point.

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Cervical Changes

The cervix of the uterus becomes more vascular and edematous because of estrogen.
It soften in consistency (Goodell's sign).
It darken from a pale pink to a violet hue.
The glands hypertrophy and hyperplasia.
Mucous plug, called the operculum.

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Vaginal Changes

Under the influence of estrogen:

Tissue become hypertrophic and enriched with glycogen.
The structures loosen from their connective tissue attachments.
A white vaginal discharge throughout pregnancy.
Chadwick's sign: color deep violet.
pH 4 or 5 (an acid pH): make the vagina resistant to bacterial invasion and unfortunately favors the growth of Candida albicans.

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Ovarian Changes

Ovulation stops with pregnancy.

The corpus luteum: increase in size until about the 16th week then regresses, why?

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Changes in the Breasts

As a result of estrogen and progesterone:

Fullness, tingling, or tenderness in the breasts.
Size increases because of hyperplasia
Areola of the nipple darkens, and its diameter increases to 5 or 7.5 cm.
Secondary areola.
Veins may become prominent.
Montgomery's tubercles enlarge.
By the 16th week, colostrum, the thin, watery, high-protein fluid.

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Physiologic Changes: Systematic Changes

Integumentary system

Striae gravidarum; rupture and atrophy of small segments of the connective layer of the skin.
Diastasis: rectus muscles separate.
linea nigra.
Melasma (chloasma) or the “mask of pregnancy: caused by melanocyte-stimulating hormone.
Vascular spiders over the thighs.
Increase in perspiration: result from sweat gland activity increase.
Scalp hair growth is increased

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Respiratory System

Congestion of the nasopharynx.
Chronic shortness of breath.
Breathing rate is more rapid than normal (increased 1-2/min).
Diaphragm may be displaced by as much as 4 cm upward.
Vital capacity (the maximum volume exhaled after a maximum inspiration) : no change.

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Cont. Respiratory System

Residual volume: decreased up to 20%.
Tidal volume is increased up to 40%.
Total oxygen consumption increases by as much as 20%.
P CO2 at closer to 32 mm Hg than the normal 40 mm Hg.
Raises the oxygen content (P O2), from 92 mm Hg to about 106 mm Hg.

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Temperature

Early in pregnancy, body temperature increases slightly.

At about 16 weeks, the temperature usually decreases to normal.

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Physiologic Changes: Systematic Changes

Cardiovascular system

Blood volume
Iron needs
Heart
Blood pressure
Peripheral blood flow
Supine hypotension syndrome
Blood constitution

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Blood Volume

Gradually increases by at least 30%.

Blood loss at a normal vaginal birth is about 300 to 400 mL; blood loss from a cesarean birth can be as high as 800 to 1,000 mL.

Pseudoanemia: what and why?

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Iron Needs

Almost all women need some iron supplementation as a result of:

fetus requires a total of about 350 to 400 mg of iron.
increases in the mother's circulatory red blood cell (need 400mg).

Either a hemoglobin concentration of less than 11.5 g/100 mL or a hematocrit value below 30% is considered true anemia.
Need for folic acid increases to prevent?

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Heart

Cardiac output increases significantly, by 25% to 50%.
Heart rate increases by 10 beats per minute (heart work increase occurs during the second trimester).
The heart is shifted to a more transverse position.
Audible functional (innocent) heart murmurs.
Palpitations are common

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Blood Pressure

Blood pressure actually decreases slightly during the second trimester.
During the third trimester, the blood pressure rises again.

Peripheral Blood Flow

In the third trimester: edema and varicosities of the vulva, rectum, and legs due to pressure of the expanding uterus on veins and arteries.

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Supine Hypotension Syndrome

When a pregnant woman lies supine, the weight of the growing uterus presses the vena cava against the vertebrae, obstructing blood flow from the lower extremities. So?
Can cause fetal hypoxia.
A woman experiences this hypotension as light-headedness, faintness, and palpitations.
Solution: the woman turn onto her side

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Supine hypotension can occur if a pregnant woman lies on her back

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Blood Constitution

Fibrinogen, a constituent of the blood that is necessary for clotting, increases as much as 50%.
Clotting factors, such as factors VII, VIII, IX, and X, and the platelet count also increase.
Total white blood cell count rises slightly.
The total protein level of blood decreases lead to fluid readily leaves the blood vessels which in turn cause ankle and foot edema.
Blood lipids increase by one third.
Cholesterol serum level increases by 90% to 100%.

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Physiologic Changes: Systematic Changes

Gastrointestinal System

Slow intestinal peristalsis which cause constipation and flatulence.
Slow the emptying time of the stomach leading to Heartburn, as a result of

pushing the stomach and intestines toward the back and sides of the abdomen
Progesterone, Relaxin (hormone from ovary)

Hemorrhoids; caused by pressure on veins returning from the lower extremities.
Morning sickness (nausea and vomiting) caused by increased estrogen levels or decreased glucose levels; nausea usually subsides after the first 3 months.

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cont. Gastrointestinal System

Hypertrophy at gumlines and bleeding of gingival tissue.
Increased saliva formation (hyperptyalism).
A lower than normal pH of saliva may lead to increased tooth decay.
Acidity of stomach secretions decreases
Decreased emptying of bile from the gallbladder may result. This can lead to reabsorption of bilirubin into the maternal bloodstream, giving rise to a symptom of generalized itching (subclinical jaundice).

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Physiologic Changes: Systematic Changes

Urinary System

Changes result from

Effects of high estrogen and progesterone levels
Compression of the bladder and ureters by the growing uterus
Increased blood volume
Postural influences

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Fluid Retention

Total body water increases to 7.5 L (for effective placental exchange).
This requires the body to increase its sodium re-absorption (by Aldosterone aid) in the tubules to maintain osmolarity.
Water is retained during pregnancy to:

aid the increase in blood volume
serve as a ready source of nutrients to the fetus

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Renal Function

Kidneys may increase in size.
Urinary output gradually increases (by about 60% to 80%).
The glomerular filtration rate (GFR) and renal plasma flow begin to increase (increased by 30% to 50%).
Lowered blood urea nitrogen (BUN) and low creatinine levels in maternal plasma.
Increased filtration of glucose as a result of increased GFR (sugar traces is normal in urine).
Pressure on the right ureter may lead to urinary stasis and pyelonephritis.

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Urinary Tract Changes During Pregnancy

Change

Variable

Increased by 50%

Glomerular filtration rate

Increased by 25%–80%

Renal plasma flow

Decreased by 25%

Blood urea nitrogen

Decreased by 25%

Plasma creatinine level

Decreased to allow slight spillage

Renal threshold for sugar

Increased by 1,000 mL

Bladder capacity

Increased by 25%

Diameter of ureters

Increased 1st trimester, last 2 weeks of pregnancy to 10–12 times/day

Frequency of urination

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Physiologic Changes: Systematic Changes

Skeletal System

Calcium and phosphorus needs are increased.
Gradual softening of the woman's pelvic ligaments and joints caused by the influence relaxin and progesterone.
Wide separation of the symphysis pubis, as much as 3 to 4 mm by 32 weeks of pregnancy (cause pain).
Pride of pregnancy: a pregnant woman tends to stand straighter and taller than usual to change her center of gravity and make ambulation easier which creates a lordosis (forward curve of the lumbar spine), which may lead to backache.

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Physiologic Changes: Systematic Changes

Endocrine System

Placenta
Pituitary Gland
Thyroid and Parathyroid Glands
Adrenal Glands
Pancreas

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�Placenta�

Estrogen: causes breast and uterine enlargement, Palmar erythema.
Progesterone: maintaining the endometrium, inhibiting uterine contractility, and aiding in the development of the breasts for lactation.
hCG: It stimulates progesterone and estrogen synthesis.
human Placental Lactogen (hPL): an antagonist to insulin, making insulin less effective.
Relaxin: helping to inhibit uterine activity and to soften the cervix and the collagen in joints.
Prostaglandins: affect smooth muscle contractility.

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Pituitary Gland

Halt in the production of FSH and LH brought on by the high estrogen and progesterone levels.
Increased production of growth hormone and melanocyte-stimulating hormone.
Late in pregnancy, the posterior pituitary begins to produce oxytocin.
Prolactin production is also begun late in pregnancy.

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Thyroid and Parathyroid Glands

The thyroid gland enlarges.
Basal body metabolic rate increases by about 20%.
The parathyroid glands increase in size during pregnancy to satisfy the increased requirement of calcium.

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Adrenal Glands

Adrenal gland activity increases in pregnancy as increased levels of corticosteroids and aldosterone are produced, in order to:
Suppressing an inflammatory reaction.
2. Regulate glucose metabolism.

3. Aldosterone: help in sodium reabsorption and maintaining osmolarity.

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Pancreas

Increases production of insulin.

Insulin is less effective than normal (because estrogen, progesterone, and hPL).

Level is usually at a higher than normal level.

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Physiologic Changes: Systematic Changes

Immune system

Competency decreases
IgG is decreased
Increase in WBC

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Nursing Process: Healthy Adaptation to Pregnancy

Assessment
Nursing diagnosis
Outcome identification, planning
Implementation
Outcome evaluation