Psychological and Physiologic Changes in Pregnancy

Pregnancy brings both psychological and physical changes to the woman and her partner. Physiologic changes occur gradually but eventually affect all organ systems of a womans body. Psychological changes occur in response to physiologic alterations. Pregnancy represents wellness not illness.

Diagnosis of Pregnancy
Marks a major milestone.

Presumptive Signs of Pregnancy:

least indicative of pregnancy, could indicate other conditions subjective-experienced by the woman breast changes, nausea, vomiting, amenorrhea, frequent urination, fatigue, uterine enlargement, quickening, linea nigra, melasma, stria gravidarum.

Probable Signs of Pregnancy

Signs that can be documented by the examiner Serum laboratory tests: hCG in urine or blood serum of the women. accurate 95% to 98 % of the time. home pregnancy tests are 97% accurate. women taking psychotropic drugs may have a false positive result on pregnancy test. discontinue oral contraceptives 5 days before the test.

Chadwicks sign Goodells sign Hegars sign Sonographic evidence of gestational sac Ballottement Braxton Hicks sign Fetal outline felt by examiner

Positive Signs of Pregnancy

Sonographic evidence of fetal outline week 6-8 Fetal heart audible week 18-20 Fetal movement felt by examiner week 20-24

Psychological Changes of Pregnancy

Psychological Changes of Pregnancy: The womans attitude toward the pregnancy depends on the environment in which she is raised. Social influences Pregnancy is not an illness, now the family is included. Use of birthing centers has increased. Demedicalize childbirth. Cultural influences How active a role she wants to take. Certain beliefs and taboos may place restrictions on her behaviors and activities.

Psychological Changes of Pregnancy

Family influences Viewed in a positive or negative light. Stories about pain and endless suffering in labor. People love as they have been loved. Individual influences Ability to cope with or adapt to stress. Secure in her relationship. Pregnancy takes away her freedom.

Psychological Tasks of Pregnancy 1st Trimester:

Accepting the Pregnancy 50% of all pregnancies are unintended, unwanted or mistimed. Surprise! Women sometimes experience disappointment, anxiety or ambivalence. Partner may go through some changes also. Partner should give emotional support. May feel proud, happy, jealous or loss.

Psychological Tasks of Pregnancy

2nd Trimester Accepting the Baby: Second turning point is often quickening. Proof of the childs existence. Anticipatory role playing. May accept at conception, at birth or later. How well she follows prenatal instructions. Partner may feel left out, he may increase his work, he has misinformation. Educate both partners.

Psychological Tasks of Pregnancy

3rd Trimester: Preparing for Parenthood nest building attending prenatal classes or parenting classes.

Reworking Developmental Tasks working through previous life experiences. womans relationship with her parents, particularly her mother. fear of dying. Needs confidence in health care providers. Men may need to reconcile feelings toward fathers and learn a new pattern of behavior.

Psychological Tasks of Pregnancy

. Role-playing and Fantasizing: Second step in preparing of parenthood. Spend time with other mothers to learn how to be a mother. Needs good role models. Father may need to change his carefree individual to a member of a family unit. Nurturing roles.

Emotional Responses to Pregnancy

Ambivalence Grief Narcissism Introversion versus Extroversion Body Image and Boundary Stress Couvade Syndrome Emotional Lability Changes in Sexual Desire Changes in the Expectant Family

Physiologic Changes of Pregnancy

Local changes - confined to the reproductive organs. Systemic changes - affecting the entire body. Both subjective (symptoms) and objective (signs) findings are used to diagnose and mark the progress of the pregnancy.

Physiologic Changes of Pregnancy

Reproductive System Changes: Uterine changes: Increase in size, length, depth, width, weight,

wall thickness and volume.

Length-from 6.5 to 32 cm. Depth-increases from 2.5 to 22 cm. Width-expands from 4 to 24 cm. Weight-increases from 50 to 1,000 g. Uterine wall thickens from 1 cm to 2 cm by the end of pregnancy, the wall thins so it is supple and 0.5 cm thick. Volume of uterus increases from 2 mL to 1,000 mL. It can hold a 7 lb. fetus plus 1,000 mL of amniotic fluid. Total 4,000 g.

Physiologic Changes of Pregnancy

Uterine growth is due to formation of a few new muscle fibers and stretching of existing muscle fibers (2 to 7 times longer). Week 12 the fetus is palpated just above the symphysis pubis. Week 20 or 22 the fetus is at the umbilicus. Week 36 should touch the xiphoid process which causes some SOB.

Terms
Primigravida - woman in her 1st pregnancy. Multipara - a woman who has had 1 or more children.

Physiologic Changes of Pregnancy

Lightening - 2 weeks before term (week 38) the fetal head settles into the pelvis to prepare for birth and the uterus returns to the height it was at on the 36 week. This permits better lung expansion and easier breathing. This is predictable in 1st birth but not others. Uterine growth is a presumptive sign of pregnancy.

Physiologic Changes of Pregnancy

As the uterus increases in size it: pushes the intestines to the side elevates the diaphragm and liver puts pressure on the bladder Uterine blood flow increases: before pregnancy - 15 to 20 mL/ min. by the end of pregnancy - 500 to 750 mL/min. with 75% going to the placenta. Uterine bleeding can be a major blood loss. Uterus is anteflexed, larger and softer.

Physiologic Changes of Pregnancy

Hegars sign - extreme softening of the lower uterine segment. The wall can not be felt or it feels as thin as tissue paper with bimanual exam. Ballottement - on bimanual exam, tapping of lower segment the fetus is felt to bounced or rise in the amniotic fluid up against the to top examining hand (week 16 to 20). Braxton Hicks contractions - practice contractions. Week 12 until term. Waves of hardness or tightening across the abdomen.

Physiologic Changes of Pregnancy

They serve as warm-up exercise and increase placental perfusion. False labor, the do not cause cervical dilation. Amenorrhea - absence of menstruation due to suppression of FSH. Presumptive sign. Cervical changes: Cervix more vascular and edematous. Increased fluid between the cells causes

Physiologic Changes of Pregnancy

the cervix to soften and increased vascularity causes it to darken from pale pink to a violet hue. A tenacious coating of mucus fills the cervical canal. Operculum - mucous plug - seals out bacteria during pregnancy. Goodells sign - softening of the cervix. Nonpregnant cervix is like the nose. Pregnant is like earlobe.

Physiologic Changes of Pregnancy

Just before labor the cervix becomes soft like butter and is ripe for birth. Vaginal changes: vaginal epithelium become hypertrophic and enriched with glycogen which results in white vaginal discharge throughout pregnancy. Chadwicks sign - vaginal walls are deep violet color due to increased circulation. pH 4 to 5 (from pH over 7) favors growth of Candida albicans (yeast like fungi).

Physiologic Changes of Pregnancy

due to Lactobacillus acidophilus a bacteria that grows freely in glycogen environment, so this increases the lactic acid content. Ovarian changes: ovulation stops. Corpus luteum increases in size until week 16 and then the placenta has taken over as provider of progesterone and estrogen.

Physiologic Changes of Pregnancy

Changes in the breasts: result of estrogen and progesterone production. (1st change) feeling of fullness, tingling or tenderness. Size increases due to hyperplasia of mammary alveoli and fat deposits. aerola darkens and diameter increases to 3.5 cm to 5 or 7.5 cm (1 1/2 to 3 inches) blue veins become prominent. Montgomerys tubercles-sebaceous glands

Physiologic Changes of Pregnancy

of the areola enlarge and become protuberant. secretions keep the nipple supple and help prevent cracking and drying during lactation week 16 colostrum-a thin, watery, high protein fluid can be expelled from the breast Systemic Changes: Integumentary System Abdominal wall must stretch Striae gravidarum - pink or reddish streaks on sides of abdomen and thighs.

Systemic Changes
Caused by rupture and atrophy of the connective layer of the skin. After birth this lightens to silvery-white color. (permanent) Diastasis-rectus muscles separate, will appear after pregnancy as a bluish groove. Umbilicus stretches until it is smooth. Extra pigmentation on abdominal wall. Linea nigra - brown line from umbilicus to symphysis pubis.

Systemic Changes
Melasma - darkened areas on face due to melanocyte-stimulating hormone secreted by the pituitary. Vascular spiders - small fiery-red branching spots on thighs, increases estrogen. Palmar erythema - redness and itching. Increased sweat gland activity. Scalp hair growth increases.

Systemic Changes
Respiratory System SOB Chronic respiratory alkalosis compensated by chronic metabolic acidosis. Diaphragm is displaced by 4 cm upward. Vital capacity does not decrease. Total O2 consumption is increased by 20%. Mild hyperventilation. Polyuria - increased urination due to plasma bicarbonate excreted by the kidneys.

Systemic Changes
respirations > 20/min. congestion of nasopharynx - increased estrogen levels Temperature: increased for 16 weeks due to secretion of progesterone from the corpus luteum, returns to normal once the placenta takes over.

Systemic Changes
Cardiovascular System: Changes are extreme and significant to the health of the fetus. Blood volume increases by 30 to 50 % blood loss at birth-300 to 400 mL cesarean birth-800 to 1,000 mL increase blood volume peaks at week 28 to 32

Systemic Changes
Pseudoanemia - concentration of hemoglobin and erythrocytes decline. Iron needs fetus requires 350 to 400 mg to grow. Mother has an increase in RBC needing an additional 400 mg of iron. Prenatal vitamins and foods supply needs. Heart cardiac output increases by 25 to 50 % heart rate increases by 10 beats/ min. heart is shifted more transverse

Systemic Changes
Innocent heart murmurs due to positioning. Palpitations SNS Regional blood flow: 3rd trimester blood flow to lower extremities is impaired due to pressure on veins and arteries. leads to edema and varicoaities. Blood pressure: does not normally rise may decrease in 2nd trimester

Systemic Changes
Supine hypotension syndrome: when woman lies supine the weight of the uterus presses on the vena cava obstructing blood return to the heart. risk fetal hypoxia lightheadedness, faintness and palpitations. rest on left side. Blood constitution: level of circ. fibrinogen increases 50%. Factors VII, VIII, IX, X and platelets increase.

Systemic Changes
Blood lipids increase by 1/3 cholesterol level increase 90 to 100 % Gastrointestinal system Uterus displaces the stomach and intestines toward the back and sides of the abdomen. Pressure slows peristalsis and the emptying time of the stomach. Leads to heartburn, constipation and flatulence. Nausea and vomiting in early morning when hCG and progesterone begin to rise.

Systemic Changes
May be a systemic reaction to increases estrogen or decreased glucose levels. Subsides after 3 months Generalized itching due to reabsorption of bilirubin into the mothers blood stream due to decreased emptying of bile from the GB. Hypertrophy of the gumlines and bleeding. Peptic ulcers improve.

Systemic Changes
Urinary System Effects of estrogen and progesterone activity. Compression of the bladder and ureters. Increased blood volume Postural influences Fluid retention: total body water increases to 7.5 L increase sodium reabsorption

Systemic Changes
Increased aldosterone production. Potassium remains adequate. Water retension increases blood volume to serve as a source of nutrients to the fetus. Renal Function: Kidneys change size. Urinary output increases by 60 to 80 %. GFR and renal plasma flow increase. Creatinine clearance tests for renal function.

Systemic Changes
Ureter and Bladder Function ureters increase in diameter due to increased progesterone. bladder capacity increases to 1,500 mL pressure on the urethra may lead to poor bladder emptying and infections. May lead to kidney infection.

Systemic Changes
Skeletal System Calcium and phosphorus increase for fetal skeleton. Softening of pelvic ligaments and joints. Relaxin (ovarian hormone) and placental progesterone. Separation of symphysis pubis-3 to 4 mm. Stand straighter and taller - lordosis Center of gravity is changed.

Systemic Changes
Endocrine System Almost all aspects of the endocrine system increase. Placenta is an endocrine organ Produces estrogen, progesterone, hCG, human placental lactogen,relaxin, prostaglandins. Pituitary Gland there is a halt to FSH and LH due to high estrogen and progesterone levels.

Systemic Changes
Increase in production of growth hormone and melanocyte-stimulating hormone. Late in pregnancy it produces oxytocin and prolactin. Thyroid and Parathyroid Glands thyroid enlarges and BBM (metabolism) increases by 20% iodine and thyroxine are elevated. Parathyroid enlarges due to increased calcium requirements.

Systemic Changes
Adrenal Gland Elevated levels of corticosteroids and aldosterone are produced. Aids in suppressing an inflammatory reaction or helps to reduce the possibility of rejection of the fetus. Regulates glucose metabolism. Promotes sodium reabsorption and maintaining osmolarity in fluid retained. Safeguards blood volume and perfusion

Systemic Changes
Pancreas Increases insulin production in response to high glucocorticoid production.insulin is less effective then normal because estrogen, progesterone and hPL are antagonists to insulin. Diabetic needs more insulin. Maternal glucose levels are usually higher. Fat stores and available glucose are utilized.

Systemic Changes
Immune System Competency decreases (IgG) to not reject the fetus. Increase in WBC to counteract the decrease.