KENYA METHODIST UNIVERSITY

SCHOOL OF HEALTH SCIENCES

DEPARTMENT OF NURSING

COURSE TITLE REPRODUCTIVE HEALTH I

PRESENTED TO E. KIRINYA.

PRESENTED BY MTANGO UPENDO HAWA

REG NO BSN-1-0183-1/2009

DATE DUE 11/10/2010

Physiological changes that occur in pregnancy.

Weight increase

These metabolical changes, accompanied by fetal growth, result in an increase in weight of

around 25% of non-pregnant state i.e. approximately 12.5 kg on average.

There is marked variation in normal women but the main increase occurs in the second half of
pregnancy which is usually about 0.5kg per week.

Towards term the rate of gain actually diminishes and weight can fall after 40 weeks gestation.

The increase is caused by

• Growth of the conceptus/fetus.

• Enlargement of maternal organs

• Maternal storage of fat and protein and increase in maternal blood volume and interstitial
fluid.

The table below further explains weight gain.

Location Weight allocated

Protein storage and Fat storage in the 4-4.5 kg

subcutaneous tissues.
Breasts 1-1.5 kg
Uterus 0.5-1kg
Fetus and placenta 5kg
Water and electrolytes 1-1.5kg

The increased metabolic rate is primarily due to the fetus and leads to an increase in maternal
oxygen consumption of about 20% mainly due to endocrine factors.

The anterior pituitary gland secretes more thyroid stimulating hormone (TSH), the thyroid gland
hypertrophies and is palpably enlarged in approximately 70% of pregnant women.
A summary of endocrine changes in maternal and placental hormones in pregnancy and
their supposed effects.

Progesterone Produced by the corpus luteum in the first few weeks of pregnancy. Later on the
placenta produces it. Levels rise steadily in pregnancy with a fall towards term.

There is an output maximum of at least 250 mg per day.

This results in possible actions such as

Reduced

• Smooth muscle tone i.e. stomach motility diminishes and could induce anemia.

• Colonic activity, delayed emptying and increased water reabsorption which could result
in

• constipation.

• Uterine tone with dimished uterine activity and reduced bladder and ureteric tone hence
causing

• stasis of urine.

• Vascular tone with decreased diastolic pre s sure resulting in venous dilatation.

Increased

• Temperature.

• Fat storage.

• Induces

• Over breathing i.e. because alveolar and arterial carbon dioxide tension reduced.

• Development of breasts.

Estrogens

Produced from ovary in early pregnancy but later oestrone and oestradiol are produced by
placenta and are increased about a hundredfold.
Oestriol is a product of the interaction of the placenta and the fetal adrenals and is increased a
thousand fold.

The output of oestrogens reaches a maximum of at least 30-40 mg per day. Oestriol forms 85%
of the total. Levels increase up to term.

Estrogens possible actions

They induce growth of uterus and control its function.

Responsible with progesterone for development of the breasts.

Alters the chemical constitution of connective tissue, making it more pliable thus stretching of
cervix is possible, the joint capsules relax and pelvic joints become mobile.

It causes water retention.

It may reduce sodium excretion.

Cortisol

The maternal adrenals are the sole source in early pregnancy but later considerable quantities
are produced by the placenta i.e. 25 mg per day. Much of this is protein bound and hence may
not be generally active.

Possible actions of Cortisol

• Increases blood sugar.

• Modifies antibody activity.

Aldosterone

Almost certainly wholly derived from the maternal adrenals. The amounts produced during the
pregnancy are much increased. It promotes the retention of sodium and water.

Renin

Plasma rennin activity is 5-10 times the non-pregnant state. Also, angiotensinogen levels are
increased but with a reduced sensitivity to hypertensive effects of angiotensin.

Human chorionic gonadotrophin (HCG) is produced by the trophoblast and peak levels are
reached before 16 weeks of gestation. From 18 weeks onwards, levels remain relatively constant.
It functions in early maintenance of corpus luteum and has a thyrotrophic action and also
initiates testosterone secretion from the Leydig cells.

Human placental lactogen (HPL)

Levels of HPL/chorionic somatomammotrophin) rise steadily with the growth of the placenta
throughout pregnancy. It is lactogenic and antagonistic to insulin.

Relaxin

Is a hormone produced by the corpus luteum. It can be detected throughout pregnancy but
highest levels are in the first trimester. It’s used in cervical ripening.

Pituitary hormones

Maternal FSH and LH levels are suppressed during pregnancy but prolactin levels rise
throughout. Lactation occurs until delivery when high prolactin levels persist in association with
falling oestrogen levels.

Carbohydrate Metabolism

In non-pregnant state ingested glucose is dealt with in 4 ways i.e.

Under influence of insulin it may be deposited in the liver as glycogen while some escapes into
general circulation and a proportion of this is metabolized directly by tissues, the rest is stored as
muscle glycogen again with aid of insulin.

A marked alteration in carbohydrate metabolism occurs in pregnancy i.e.

A demand on the part of the fetus for an easily convertible source of energy. At the same time,
there is a need to store energy for future demands i.e. lactation and the steadily increasing growth
of the pregnancy and also to provide a more steady source of energy in the form of a high energy
fuel.

Thus the maternal body achieves by storage of fat.

The major component of the diet is carbohydrate based and this requires to be redirected to
satisfy these requirements.

The first noticeable change occurs in the blood sugar and this can be demonstrated by giving a
glucose load as in an oral glucose test. Thus after a meal, blood sugar remains high, facilitating
placental transfer.

Pregnancy is said to be diabetogenic and is associated with reduced tissue sensitivity to insulin.
sensitivity to actions of insulin could be reduced in tissues by up to 80%. This effect is in part
due to an increase in specific antagonists to insulin, with the most important of these being
Human placental lactogen (HPL).

With the increased steroid levels produced by the placenta less glycogen is deposited in the liver
and muscles. Higher circulating levels of blood sugar mean that more glucose is available to the
fetus.

The effect of fasting is pronounced in pregnancy and even an overnight fast of 12 hours will
result in hypoglycaemia and increased production of beta hydroxybutyric acid and acetoacetic
acid, the ketone bodies.

Glucose levels are lower in the fetus and transport across the placenta is by a carrier mediated
mechanism which gives a greater rate of transfer than simple diffusion.

High glucose levels in renal circulation together with an increased glomerular filtration rate give
rise to glycosuria which is seen in pregnancy.

The following chart explains carbohydrate metabolism

Increased intake of carbohydrate Blood glucose to tissue for oxidation.

Depot fat.

Insulin Less glycogen in liver. Insulin

Insulin antagonists

Human placental lactogen

Placental corticoids

Placenta Less muscle glycogen

(Provides energy, fat and glycogen to fetus)

Slight spill of sugar in urine

Protein Metabolism

There is a positive nitrogen balance with an average of a 20% increase in dietary protein intake.

On average about 500 g of protein is retained by the end of pregnancy.

Both chorionic gonadotrophin and the placental lactogen tend to reduce the deamination process
and as a result, blood and urine are reduced.

The diagram below summarizes protein metabolism

Increased appetite= increased intake

Dimished motility= improved absorption in the GIT Amino acids In liver Plasma proteins

Blood amino acids

Deamination N2 storage Fetal growth

Urea Inhibitory substances

Kidneys (Chorionic gonadotrophin

(Human placental lactogen)

Fat Metabolism

Fat is a major form of stored energy during pregnancy and by 30 week about 4 kg are stored
mainly in the form of depot fat in the abdominal wall, back and thighs. A modest amount is
stored in the breast.

Increased food intake

GIT Fat, Blood stream Depot fat.

Glucose Insulin Liver glycogen

Placental antagonists to insulin

Three points may be made in relation to fat metabolism

The total metabolism and demand for energy are increased in pregnancy.

Glycogen stores are diminished and therefore energy obtained directly from carbohydrate will be
reduced.

Although blood fat is greatly increased only a moderate amount is laid down in fat stores.

Respiratory changes

Physical changes in the respiratory system begin early in pregnancy and are responsible for
improvement in gaseous exchange. The respiratory rate is unchanged and the elevation of the
diaphragm decreases the volume of the lungs at rest, but the tidal volume is increased by up to
40% leading to an increase in minute ventilation from 7.25-10.5 litres.

Physical changes which take place to improve gaseous interchange

There are changes due to increased need for oxygen intake and carbon dioxide discharge.

Increased oxygen consumption of 20-30% during pregnancy is needed for cardiac work, renal
performance, respiratory performance, and breast, uterine and placental demands.

Progesterone lowers the carbon dioxide threshold in the respiratory centre which increases
sensitivity to carbon dioxide. The hormone decreases pulmonary resistance creating an
environment for increased alveolar function i.e. movement of the diaphragm is increased with a
change in the inspiratory level of diaphragm.

There is flaring of ribs thus a change in the expiratory level of the diaphragm, however, the dead
space is unaltered. There is a 30-40% increase in tidal volume, with lungs having a greater
capacity to exchange gases.

Fetal plasma carbon dioxide tension exceeds that of maternal plasma and hence passes easily into
maternal blood. Despite this, due to the pulmonary hyperventilation, the concentration of carbon
dioxide in maternal plasma is reduced by around 8 % as compared with the non-pregnant woman
i.e. in order to accommodate for carbon dioxide transfer to the fetus, the pregnant woman has a
state of compensated respiratory alkalosis with a lowered carbon dioxide pressure.

Maternal partial pressure of oxygen increases to 100-108mmHg during pregnancy allowing for
maternal red cells to give oxygen to fetus.

Diagram to illustrate respiratory changes

Increased inspiration Increased expiration

Increased oxygen intake Carbon dioxide output in expired air increased

High arterial oxygen Low maternal blood carbon dioxide

(Placenta)

Improved supply to fetus Easy transfer of carbon dioxide from fetal to maternal blood

Hyperemia

Nasopharngeal congestion occurs as more blood enters the respiratory system. Secretions
increase and at times discomfort results due to edema in the upper airway. Chronic nasal
stuffiness can result with woman having a hoarse voice i.e. changes in pitch .

Cardiovascular Physiology
Cardiac output increases dramatically in pregnancy. The average increase is from 4.5-6.0
l/minute . The greatest increase is seen within the first trimester although further rises lead to a
peak at around twenty-four weeks. This increase results from an increase in both heart rate and
stroke volume.

According to Basavanthappa pg 209, Blood volume expansion occurs to provide circulation to

all developing organs and body parts. Inorder to accommodate expansion, hormone progesterone
causes relaxation of smooth vascular tissue i.e. intravascular space expanded thus enhancing
greater blood volume to allow for the increased needs of the pregnant mother and fetus.

Plasma increases with about 300-450 ml composed of red blood cells resulting in decrease in
heamatocrit i.e. haemodilution of pregnancy. Heamatocrit decreases from ratio of 37-45%
falling.

Heamoglobin levels drop slightly due to demand for extra iron.

In pregnancy there is an increase in platelets, fibrin, fibrinogen and coagulation factors

prominently those of 7,8,9 and 10.

These changes are needed to protect the mother from bleeding at delivery while the
hypercoagulability makes her more susceptible to thrombus development during pregnancy and
the puerperium, the post birth period.

White blood cell count rise during the second month to about 1000 mm3 by late pregnancy and
at labour reaches 18,000 or more.

There is an increase in granulocytes especially Neutrophils i.e. Polymorphonuclear cells (PMN).

This occurs in response to inflammation , pain, anxiety, stress and labour and delivery in order to
protect one against invading organisms.

Cardiac output increases by 30-50% early in pregnancy. Heart rate increases from 70 beat/minute
in non-pregnant state to 78 beats/minute at twenty weeks gestation with a peak of around 85
beats/minute in late pregnancy.

Blood pressure in the first 24 weeks decreases 5-10 mmHg systolic and 10-15 mmHg for
diastolic resulting in widening of the pulse pressure. These occur due to

Relaxation of vascular smooth muscle layer.

Formation of new peripheral vascular beds in the breasts, uterus, and placenta. With the onset of
labour, the BP stabilize to non-pregnant levels.

Mean Arterial Pressure(MAP)

In the 2nd trimester (MAP) of greater than 100mmHg after 20 weeks is interpreted as
hypertension. Stroke volume increases from 64-70ml in mid pregnancy. Stroke volume actually
reduces towards term and the increase in cardiac output is maintained by the increase in heart
rate.

Increased gaseous interchange Increased metabolism = increased heat

production peripheral vasodilatation to get
rid of excess heat.

DEMAND FOR Increased BLOOD supply

Increased metabolism = increased excretion of waste products Growth of conceptus and uterus

Reduced pulmonary vascular resistance results in a 40% increase in pulmonary blood flow.Renal
blood flow increases by 35% and uterine blood flow by around 250%. Blood volume and organ
perfusion increase.

Peripheral vascular dilatation Uterine vascular dilatation Fetus in utero

Low pressure circulation in

placenta= reduction valve effect

Reduced peripheral resistance Placental steroid

Lower diastolic pressure Reduced excretion of water salts

Stimulation of adrenal cortex Secretion of aldosterone Kidney (reduced excretion of water)

Fluid retention

Blood volume Changes

In non-pregnant state, 70% of body weight is water. Of this, 5% is intravascular. Intracellular

fluid makes up about 70% and the remainder is interstitial fluid.

In pregnancy intracellular water is unchanged but both blood and interstitial fluid are increased.
Plasma volume increases at a greater rate than red cell mass and protein levels, resulting in a
reduction in blood viscosity.

Local Vascular Changes

Local changes are most apparent in the lower limbs and are due to pressure exerted by the
enlarging uterus on the pelvic veins. Since one third of the total circulating blood is distributed to
the lower limbs the increased venous pressure may produce varicosities and oedema of the vulva
and legs. These changes are most marked during the daytime due to the upright /supine posture.

Varicose veins may appear early in the 2nd trimester and worsen with pregnancy progression.

Varicosities of the saphenous system, vulva and rectum are predominantly affected by rising
venous pressure in the lower extremities. They are more common and pronounced in the
multigravida but may occur for the first time in a young primigravida with a family history of
varicose veins. In additional to being unsightly, these enlarged superficial veins may be painful
and throbbing, especially those in the vulva and rectal/anal area.

The resultant hypotension in 10% of pregnant women results in dizziness, light-headedness,

nausea, pallor, clamminess of skin and even syncope.

They tend to be reversed at night when the pregnant woman retires to bed, oedema fluid is
reabsorbed, venous return increased and renal output rises, resulting in nocturnal frequency. If
the patient adopts the supine position, however, the uterine pressure on the veins increases and
this could lead to reduced venous return to the heart. This in turn leads to a reduction in cardiac
output. An extreme example of this occurs when the uterus compresses the vena cava and
reduces cardiac output to the point where the mother feels faint and may become unconscious. A
sensation of nausea also occurs and vomiting may result. This condition is called Supine
Hypotension Syndrome and it occurs in late pregnancy i.e.

Pressure of uterus on pelvic veins Reduced venous return to heart Reduced cardiac output

Orthostatic Hypotension

Due to a decrease in carbon monoxide caused by an interference of venous return can result
from effects of orthostatic hypotension i.e. occurs when a pregnant woman moves from a
recumbent position to a standing position.

Normal, uncomplicated pregnancies usually can withstand this with little/no stress to fetus and
mother.
Hematological Changes

The change in blood values i.e. haemoglobin content is the result of demand s of the growing
pregnancy modified by the increase in plasma volume. This represents an increase in red cell
mass of 18%. The plasma volume increases by 40-45%. Thus there is a reduction in the red cell
count per milliliter from 4.5 to 3.8 million.

Towards term as the placenta volume diminishes the red cell count rises slightly. Similarly the
haemotocrit falls during pregnancy with a slight rise at term i.e.

Increase in total metabolism

Increase in total oxygen consumption

Demand for increase in total oxygen carrying capacity of blood

Increase in total red cell volume

Packed cell Volume ( percent)

Non-pregnant 40-42
20 weeks pregnant 39
30 weeks pregnant 38
40 weeks pregnant 40

Changes in haemoglobin run parallel with those in red cells. The mean cell haemoglobin
concentration in the non-pregnant is 34%, i.e. each 100ml of red cells contain 34g of
haemoglobin. This does not alter in pregnancy, therefore, as with total red cell volume, the total
haemoglobin rises throughout pregnancy.

The increasing plasma volume, however produces an apparent reduction in haemoglobin. The
haemoglobin concentration falls throughout pregnancy until the last four weeks when there
might be a slight rise. The fall is apparent by the 12th week of pregnancy and the minimum value
is reached at 32 weeks.

No single value can be taken as normal throughout pregnancy and this is crucial in diagnosing
anemia. At 30 weeks a haemoglobin reading of 105g/l is normal but the same value at 20 weeks
indicates anaemia.

Leukocytes
There is a marked increase in white cells during pregnancy from 7*10 /litre in the non-pregnant
to 10.5* 10/litre in late pregnancy. The increase is almost entirely due to an increase in
neutrophil polymorphonuclear cells. The white cell count may rise markedly in labour.

Platelets

Platelets decline progressively through pregnancy. The mean value in early pregnancy is
275000/mmm3 to 260 000/mmm3 beyond 35 weeks.

Mean platelet size increases slightly and the lifespan of platelets is shortened.

Coagulation system

Pregnancy is said to be a hypercoagulable state. Fibrinogen and Factors VII to X rise

progressively. Factors II, V and XI to XIII are unaltered or slightly lower. It thus seems likely
that the increased risk of thrombo-embolism associated with pregnancy results more from

venous stasis and vessel wall injury than changes in the coagulation factors themselves.

Gastro-Intestinal Tract

Progesterone causes the GI system to relax, and the growing fetus causes crowding of the
surrounding organs.

In the mouth, gums become more vascular and hence more likely to bleed when the woman
brushes her teeth or eats crunchy foods. Some women experience ptyalism i.e. increased
secretion of saliva and results in nausea and discomfort due to frequent wiping of mouth,
enlarged reddened tongue.

Changes in the gastro-intestinal tract are chiefly the result of relaxation of smooth muscle. This
effect is induced by the high progesterone levels of pregnancy.

Relaxation of sphincter muscles in stomach results in regurgitation and hence heartburn causing
burping and an acidic taste in the mouth.

Slight reduction in gastric secretion and diminished gastric motility results in slow emptying and
hence more efficient pulping of food, however this could cause nausea.

Reduced motility in small intestines enhances/ increases time for absorption e.g. of iron.

Reduced motility of large intestine increases time for water reabsorption but also tends to induce
constipation.

Growth of conceptus and uterus increases appetite and thirst. In late pregnancy, pressure of the
uterus reduces capacity for large meals hence the need for small frequent snacks. Serum levels
change as follows
 • Serum albumin levels fall gradually.

• Increase in levels of alkaline phosphatase, protein and cholesterol by the end of the
pregnancy.

Nausea and Vomiting occurs in about 50% of pregnancies due to rise in human chorionic
gonadotrophin (hCG) and steroidal hormones. This occurs in the first trimester, around 4-6
weeks, and persists until the early part of the second trimester, and subsidies in 100 days. Studies
on ultrasonography determined that corpus luteum was located on the right ovary in most
women.

Diarrhoea can occur in pregnancy due to food source/related viral infection. Can also occur as
labour begins and the uterine activity increases i.e. uterine contractions stimulate bowel activity
causing frequent bowel movements.

Renal System

Hemodynamic changes include

increase in glomerular filtration rate, renal plasma flow, excretion of amino acids and elimination
of water-soluble vitamins.

In early pregnancy, creatinine excretion levels increase with increased reabsorption of sodium
chloride and water.

Positional changes affect kidney function i.e. in supine position the uterus presses on renal veins
and arteries thus reducing effective flow of urine.

Frequency of micturition is a common symptom of early pregnancy and again at term. This is
due to changes in pelvic anatomy which is a feature of normal pregnancy.

Early pregnancy, the uterus is enlarging but it is within the pelvis compressing the bladder
resulting in increased frequency of micturition.

Mid-pregnancy, the uterus is lifted out of the pelvis hence micturition is normal.

At term, the head of the fetus descends into the pelvis hence increased frequency of micturition
once again. Striking anatomical changes occur in the kidneys and ureters. A degree of
hydronephrosis and hydro-ureter exist. These result from loss of smooth muscle tone due to
progesterone, aggravated by mechanical pressure from the uterus at the pelvic brim. Vesico-
ureteric reflux is also increased. These changes predispose to urinary tract infection. The
appearances improve in the latter part of pregnancy as the uterus grows above the pelvic brim
and rising oestrogen levels cause hypertrophy of the ureteric muscle.

Nocturia The horizontal sleeping position promotes renal flow thus acts to reduce lower
extremity oedema how ever results in interruption of sleep several times during the night.

Urinary output on a normal fluid intake tends to be slightly dimished. This seems paradoxically
in view of the increased renal blood flow. However there is an increase in tubular reabsorption of
water and electrolytes.

Glycosuria occurs commonly because the increased glomerular filtration rate presents the tubules
with a sugar load which cannot be completely reabsorbed. Protenuria can also result.

As a result the amount of fluid filtered off the plasma through the renal glomeruli is similarly
increased and 100 extra litres of fluid pass into the renal tubules each day. Despite this,the
urinary output is diminished, with an increased tubular reabsorption.

There is an approximate increase of 6-7 litres of extracellular water in pregnancy. Along with
this water, sodium and other electrolytes are reabsorbed by the tubules to maintain body
osmolarity.

Under test the pregnant woman excretes only 80% of the total found in the urine of non-pregnant
woman.

The mechanism whereby this is achieved is not yet known but it is thought to be due to increased
amounts of aldosterone, progesterone and oestrogen are responsible.

Glycosuria of mild degree occurs in 35-50% of all pregnant women. Increased glomerular
filtration leads to more sugar reaching the tubules that can be reabsorbed. Glycosuria occurs
therefore with lower blood sugar levels than in a non-pregnant woman hence called lowered
renal threshold.

Urinary Tract Infections some experience asymptomatic bacteriuria due to

Obstruction of free flow of urine by pressure exerted of the uterus on ureters.

The relaxing effect of progesterone on smooth muscle. The bladder could contain residual urine
and the ureters loop and dilate. The stasis of urine provides medium for bacterial growth.

Integumentary system

Vascular changes occur i.e. due to high oestrogen levels, superficial vascular changes related to
increased blood flow include

• Spider angioma seen in light-skinned women seen as tiny vessel network on face, chest
and arms.
 • Erythema/redness of palms and soles of the feet.

• Nose bleeds, nasal congestion and increased bleeding of the gums.

Many women are comfortable during pregnancy due to increased peripheral circulation.

Striae Gravidarum known as stretch marks appear as dark lines on the breasts, lower abdomen or
thighs.

Glandular changes i.e. sweating and excretion of sebum increase during pregnancy necessitating
more frequent baths.

Oily skin and acne can recur in women with a history of acne. In contrast, other women
experience pruritus due to dry skin.

Other women experience pruritic urticarial papules and plaques i.e. eruptions in stretch marks
and spreads to buttocks, arms and legs.

Hormonal changes result in spur increased pigmentation i.e. nipples and areolae.

The linea nigra forms as a line between the symphysis and the umbilicus. Mask of pregnancy
occurs as a melasma blotchy irregular hyperpigmentation of the forehead, cheeks, nose and
upper lip.

Pigmented nevi are stimulated and become larger and darker i.e. new moles can appear but
usually regress after labour.

Growth of hair and nails is accelerated in pregnancy with quickened hair growth and follicles
become more active. After labour, there is a decreased rate with follicles ceasing activity and
increased hair loss.

Musculoskeletal system

With pregnancy progression, there is progressive lordosis of the spine in order to keep the centre
of gravity over the woman’s legs resulting in backache and a characteristic carriage and GAIT.

Calcium Metabolism Increased action of maternal parathyroid hormones (PTH) acts on the
intestines to increase absorption of calcium and in the kidneys to decrease filtration thus more
calcium is recovered from diet of woman. This aids in providing adequate supply of maternal
and fetal needs and prevents loss of bone density from pregnancy.

Leg cramping Muscle cramps occur due to change in electrolyte, calcium and phosphorus
levels.

Backache and Neuralgia occurs due to strain on weak abdominal muscle and lower back muscles
and increased weight of the uterus.
Others include

• Serious problems with backaches or with pain radiating along the nerve to the leg,

• Sacroiliac joint strain is common with tenderness over the posterior aspect of the joint
which occurs due to relaxin effects.

Reproductive System

Breasts

Each breast is made up of 15-20 glandular lobules separated by fat. The glands lead into tubules
and then into ducts which open onto the nipple. The breasts increase in size in pregnancy due to
proliferation of the glands and ducts under the influence of oestrogen and progesterone. The
secretion of colostrums may begin in the first trimester and continues to term.

Body of uterus

Under the influence of oestrogen the uterus grows by hyperplasia and hypertrophy of its muscle
fibers. Its weight increases from the non-pregnant level of 50g up to 1000g. The lower uterine
segment is formed from the isthmus i.e. area between the uterine cavity and the endocervical
epithelium.

Cervix

The cervix softens due to increased vascularity, and changes in its connective tissue, due mainly
to oestrogen. There is increased secretion from its glands and the mucus becomes thickened thus
forming a protective plug called operculum in the cervical os.

Vagina and Pelvic Floor

The changes of increased vascularity, muscular hypertrophy and softening of connective tissues
are seen, allowing distention of the vagina at birth.

Pelvic Ligaments

There is softening of the ligaments of the pelvic joints, presumably due to oestrogen. The effect
is to make the pelvis more mobile and increase its capacity.
ROLE OF THE Nurse

Adequate assessment of the problems that the pregnant woman comes with at the antenatal clinic
(ANC). This involves comprehensive physical examination and history taking in order to detect
abnormalities in pregnancy and provide necessary treatment.

Provide quality, affordable health services to the pregnant woman and community in order to
safe guard her life and that of the future generation e.g. immunization of tetanus toxoid.

Evaluate services provided to mother and community by using evidence based methods in
service provision.

Participate in research by reviewing and reporting any abnormal changes noted in her
community and desire to investigate more on the same.

Advocate for pregnant women exposed to cultures that have negative impacts on labour e.g.
female genital mutilation, violence in the home.

Provide reassurance to the mother about skin, hair and other bodily changes that result with
pregnancy hence relieve unnecessary anxiety of pregnancy.

Provide adequate knowledge to the pregnant woman and community on questions which arise
during prenatal visits on what is deemed normal and abnormal changes in pregnancy i.e. through
use of printed material, discussions with pregnant women etc.

Encourage women to be active participants in their pregnancy i.e. by inquiring on presence of an

individual birth plan.

Encourage care-giver support to pregnant woman i.e. teach on measures to reduce workload and
further strain which could result in miscarriages.

Observe for indications that the woman isn’t coping well with pregnancy’s impact on her body
e.g. wearing tight clothes and arrange for counseling for women with inappropriate self-care and
psychologic stresses.
Determine impact on sexuality of pregnancy on woman and her partner i.e. need of couple to
share concerns, and nurse to suggest alternative sexual activities and positions.

Provide health education to pregnant woman on the management of minor complications of

pregnancy i.e.

on nausea and vomiting, encourage small frequent snacks.

Teach proper hygiene to pregnant mother.

Teach on importance of balanced diet for adequate nutrition and also to avoid constipation and
complications due to nutritional deficiencies.

Teach on good posture while sitting, standing up and lying down to avoid backache and further
strain onto the back.

Teach on importance of pregnant woman to wear low healed shoes to avoid further back strain.

Importance of prevention and detection of diseases with detrimental effects to mother and fetus
e.g. HIV/AIDs and other sexually transmitted diseases.

Teach on importance of avoiding use of alcohol, smoking, drug abuse even for non-prescribed
(OTC) over the counter medications.

Reference

Basavanthappa..(2006) Textbook of Midwifery and Reproductive Health Nursing. New Delhi.

JayPee.

Hanretty.K. (2010). Obstetrics Illustrated. Churchill Livingstone. Elsevier Ltd.