1. Chapter 4 Physiologic and Psychological Changes During Pregnancy
Review the chapter objectives.
Review the terminology used to describe the pregnant woman.
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2. Determining Pregnancy and Physiological Changes
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3. Objectives Define key terms listed.
Calculate the expected date of delivery and duration of pregnancy.
Relate the differences among probable, presumptive, and positive signs of pregnancy.
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4. Objectives (cont.) Outline the physiologic changes in pregnancy.
Explain how pregnancy affects blood volume and blood plasma.
Describe aortocaval compression or supine hypotension during pregnancy.
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5. Profile of Previous Obstetric History
GTPALM
G: gravida
T: term pregnancies
P: premature births
A: abortions
L: live births
M: multiple gestations and births
Refer to Box 4-1 (p. 44).
Pregnant woman has four living children, all single births, no preterm births, no abortions. How would this be documented? Answer:
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6. Determine Kitty’s TPALM status
Your patient, Kitty, is a 42 yr. old who is pregnant for the 5th time currently at 32 wks. gestation. Her past obstetrical history includes a 15 yr. old daughter who was born prematurely at 36 weeks and a 4 yr. old who was a full term delivery. She also had 2 spontaneous miscarriages. How would her obstetrical history be recorded via the TPALM system?

7. Kitty’s TPALM status G5 P2 11220
*TPALM method counts # of babies instead of # of pregnancies.

8. Determining Date of Birth
EDD: estimated date of delivery
Nägele’s rule:
Identify first day of last normal menstrual period (LNMP)
Count backward 3 months
Add 7 days
See Box 4-2 (p. 44).
Review the various terms that can be applied to this (e.g., EDB, EDD).
Demonstrate examples of EDD where the baby would be born during current year, and demonstrate one where the baby will be born in the next year.
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9. Gestation Wheel

10. Nagele’s Rule….what is Kitty’s EDD/EDC?
Your patient, Kitty, is 42 years old. Using Nagele’s rule, calculate Kitty’s EDD (EDC). Her LMP is: September 4, 2010.
See Box 4-2, page 48, for an example.
The date of delivery will be determined by Nagel’s Rule. This is calculated by subtracting 3 months and adding 7 days to the last normal menstrual period.

11. Nagele’s Rule: Kitty’s EDD/EDC is…..
Using Nagele’s rule, Kitty’s EDD (EDC) based on her LMP of September 4, 2010 is:
June 11, 2011
See Box 4-2, page 48, for an example.
The date of delivery will be determined by Nagel’s Rule. This is calculated by subtracting 3 months and adding 7 days to the last normal menstrual period.

12. Duration of Pregnancy
Calculated in 28-day month calendar, called lunar months
10 lunar months in a full-term pregnancy
40 weeks
280 days on average
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13. Trimester Pregnancy broken out into 3-month segments called trimesters
First trimester: first 14 weeks
Second trimester: 15 to 28 weeks
Third trimester: 29 weeks to delivery
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14. Pregnancy Terms
Terminates before fetus reaches 20 weeks gestation: abortion (lay term is miscarriage)
Terminates after 20th week but before full term is reached: preterm (premature) birth
Terminates 2 weeks after EDD, or 42 weeks: postterm birth
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15. Signs of Pregnancy Presumptive signs Probable signs Positive signs
Suggest pregnancy
Probable signs
Likely pregnant
Positive signs
Definite evidence of pregnancy
Review Table 4-1 (p. 45).
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16. Signs of Pregnancy 3 P’s: Presumptive
Amenorrhea
Nausea
Breast tenderness
Deepening pigmentation
Urinary frequency
Quickening
Presumptive signs of pregnancy are those which are frequently associated with pregnancy, but they could be attributed to many other phenomena as well.
Probable signs are associated with pregnancy and can be evidenced by an examiner. Probable signs, like presumptive signs, can be associated with other situations.
Positive signs can only be associated with the presence of pregnancy.

17. Signs of Pregnancy 3 P’s: Probable
Goodell’s sign
Chadwick’s sign
Hegar’s sign
McDonald’s sign
Abdominal enlargement
Braxton Hicks contractions
Ballottement
Striae
Positive pregnancy test
Presumptive signs of pregnancy are those which are frequently associated with pregnancy, but they could be attributed to many other phenomena as well.
Probable signs are associated with pregnancy and can be evidenced by an examiner. Probable signs, like presumptive signs, can be associated with other situations.
Positive signs can only be associated with the presence of pregnancy.

18. Signs of Pregnancy 3 P’s: Positive
Positive- can only be associated with presence of pregnancy
Audible fetal heartbeat
Fetal movement felt by examiner
Ultrasound visualization of fetus
Presumptive signs of pregnancy are those which are frequently associated with pregnancy, but they could be attributed to many other phenomena as well.
Probable signs are associated with pregnancy and can be evidenced by an examiner. Probable signs, like presumptive signs, can be associated with other situations.
Positive signs can only be associated with the presence of pregnancy.

19. Pregnancy Tests
Presence of the hormone human chorionic gonadotropin (hCG)
Produced by the chorionic villi of the placenta
Can be found in woman’s urine as early as 1 week postconception
PROBABLE indicator of pregnancy
Ask the class: What else can cause hCG to be present or produced? Answer: from the ingestion of antianxiety medications or anticonvulsants, blood in the urine, malignant tumors, and menopause.
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20. Physiologic Changes in Body Systems
Refer to Table 4-2 (pp ) regarding the physiologic and psychological changes in pregnancy.
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21. Major Sources of Change
Hormonal (endocrine system)
Mechanical pressure (physical changes within the body)
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22. Changes in the Endocrine System
Essential to maintain pregnancy
Initially produced by corpus luteum
Later by placenta
A temporary endocrine organ
Role is to produce high levels of estrogen and progesterone
Refer to Table 4-3 (p. 49) regarding hormones essential in pregnancy.
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23. Human Placental Lactogen (hPL)
Increases maternal insulin resistance during pregnancy
Provides fetus with glucose needed for growth
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24. Normal Physiological Changes in Pregnancy
These changes can be attributed to three factors. Two of them are hormones….can you identify them?
These changes can be attributed to three factors. Can you identify them? The presence of estrogen, progesterone, and growth of the fetus

25. Changes in the Reproductive System
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26. Uterus Enlarges during pregnancy
Increase in size of preexisting muscle cells (hypertrophy)
Formation of new cells (hyperplasia)
Circulatory requirements increase as it enlarges
Growth stimulated by hormones
Pressure of growing fetus against uterine wall
If uterus can be felt above the symphysis pubis, about how many weeks gestation is it? Answer: 12
If uterine fundus can be felt near the umbilicus, about how many weeks gestation is it? Answer: 20
If uterine fundus is at its highest and at the xiphoid process of the rib cage, how many weeks gestation is it? Answer: 36
By 40 weeks when the fetus descends, what happens? What is this called? Answers: fetal head descends into pelvis and is called lightening.
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27. Height of Fundus During Gestation
The height of the fundus will normally follow the milestones presented in the figures.
What factors might be associated with a fundal height that does not match the gestational age? These factors would include: intrauterine growth restriction (IUGR), SGA, LGA, multiple gestation, and molar pregnancies.

28. Cervix Becomes shorter and softer during pregnancy Prepares for
Thinning (effacement)
Enlargement (dilation)
Softening caused by
Hormones leading to increased blood supply
Increase in cervical gland secretions
Discuss the mucous plug’s function.
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29. Ovaries Follicles cease to develop to maturity
Ovulation does not occur
Corpus luteum produces estrogen and progesterone for first 7 to 10 weeks until placenta can take over
Also produces relaxin
Thought to help relax symphysis pubis and pelvic joint, and softens cervix
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30. Vagina Wall thickens, becomes more pliable, and expandable
Rugae (folds) more prominent
Discharge increases, leads to increased glycogen, which increases risk of vaginal infection
pH decreases (becomes more acidic), preventing growth of harmful microbes
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31. Breasts Hormones prepare breasts for lactation
Rapidly enlarge during first 8 weeks of gestation
Vascular engorgement
Beginning in 9th week
Ductal growth stimulated by estrogen
Alveolar hypertrophy stimulated by progesterone
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32. Breast Changes Size increases
Become fuller, more sensitive, and tender
Pigmentation of areola and nipple darkens
Montgomery’s glands more prominent
Lubricate and protect nipples
Striae may occur
Colostrum excretion as early as 10th week
See Figure 4-2 (p. 50) regarding striae and pigmentation changes of the breasts during pregnancy.
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33. Initiation of Lactation
Profound drop in estrogen and progesterone
After delivery of placenta
Increase in prolactin
Responsible for milk production
Review Figure 4-2 (p. 50).
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34. Changes in the Cardiovascular System
Review Table 4-4 (p. 51) regarding changes in the cardiovascular system during pregnancy; discuss the physiologic changes and the clinical significance. How will these changes affect the nursing care that may be provided?
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35. Cardiovascular Deliver oxygen and nutrients
Blood must be at pressures sufficient to meet placental circulation
10% of maternal output channeled to uterine blood flow in third trimester
Greatest increase occurs during labor and delivery
More vulnerable to thrombus formation
Discuss with the class how blood values change during pregnancy. Refer to Table 4-5 (p. 52).
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36. Supine Hypotensive Syndrome
Also known as aortocaval compression
How can supine hypotensive syndrome be prevented? Answer: by having the woman lie on her side.
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37. Changes in Respiratory System
Thoracic circumference increases
Hormonal influence
Lung capacity remains the same
Inspiration increases
Allows greater intake of oxygen
Expiration increases
Allows greater removal of carbon dioxide
Breathing changes from abdominal to thoracic
Oxygen consumption increased by 15-40%
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38. Dyspnea
Respiratory system has increased sensitivity due to progesterone
Pressure of uterus on diaphragm
Normally does not interfere with activities of daily living
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39. Epistaxis Nosebleeds and nasal stuffiness common
Likely from increased vascularity related to estrogen
Voice may become deeper
Vocal cords increase in size, likely due to progesterone
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40. Changes in the GI System
Gum hypertrophy
Saliva production increased (ptyalism)
Nausea and/or vomiting, especially in first trimester
Constipation
Due to increase in progesterone and relaxin
Pyrosis (heartburn)
Carbohydrate metabolism altered
What patient teaching should be provided to the pregnant woman to decrease some of these symptoms? Answer: stay upright for at least 30 minutes after eating.
Review common interventions to decrease nausea and vomiting found in Chapter 5.
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41. Compression of Abdominal Contents
Discuss how abdominal contents change as pregnancy progresses.
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42. Audience Response System Question 1
The two major sources of the physiological changes during pregnancy are the physical changes (enlargement of uterus) and the:
Respiratory system
Musculoskeletal system
Gastrointestinal system
Endocrine system
Answer: D. The dramatic increase in hormones that occurs during pregnancy affects all body systems and these hormones are necessary to sustain the pregnancy.
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43. Physiological, Psychological and Developmental Changes in Pregnancy
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44. Objectives
Explain why frequency of urination occurs early and late in pregnancy.
Recognize the changes in skin pigmentation during pregnancy.
Discuss the influence of pregnancy on the skeletal system.
Differentiate the risk categories assigned to drugs as they relate to use during pregnancy.
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45. Objectives (cont.)
Summarize the psychological changes that occur during pregnancy.
Describe the developmental tasks of pregnancy.
Discuss the impact on and special needs of pregnancy for the adolescent, single parent, and extended family.
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46. Changes in the Renal System
Early and late pregnancy increase in bladder pressure
Ureters dilate from smooth muscle relaxation
Increased risk of pyelonephritis if woman has asymptomatic bacteriuria
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47. Fluid and Electrolyte Balance
Increased glomerular filtration rate
Increased sodium filtration (up to 50%)
Tubular reabsorption (up to 99% reabsorption of sodium)
Increases risk of sodium retention
Blood more alkaline
Enhanced by hyperventilation
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48. Changes in the Integumentary and Skeletal Systems
Relaxin and placental progesterone
Relaxation and softening of pelvic joints
Widening of symphysis pubis
Facilitates delivery of fetus
Center of gravity shifts forward as uterus enlarges
May experience difficulty with balance
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49. Lordosis
Lordosis
Discuss how the changes in spinal curvature can affect the balance of the pregnant woman and nursing interventions that may be required.
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50. Changes in the Skeletal System
Uterus stretches round ligaments
Woman may develop diastasis recti abdominis
Increased risk of carpal tunnel syndrome
See Figure 4-6 (p. 54).
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51. Changes in the Integumentary System
Chloasma (“mask of pregnancy”)
Linea nigra (dark line on abdomen)
Striae gravidarum (stretch marks)
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52. Effect of Pregnancy and Lactation on Medication Ingestion
Subtherapeutic levels may occur due to increased
Plasma volume
Cardiac output
Glomerular filtration
Decreased gastric emptying
Changes absorption and can delay onset of action
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53. Effect of Pregnancy on Medication Ingestion
Parenteral medications may absorb more rapidly due to
Increased blood flow
Faster onset of action
Increased levels of estrogen and progesterone may alter hepatic function
Results in increased drug accumulation
Some drugs can cross placenta
What OTC drug, if taken in the third trimester, can cause early closure of the ductus arteriosus in the fetus? Answer: ibuprofen
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54. Effect of Lactation and Medications
Some drugs pass into breast milk
If lactating, mother must take medication immediately after infant breastfeeds
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55. FDA Pregnancy Risk Categories
Category A: no demonstrated risk to fetus in any trimester
Category B: no adverse effects in animals, no human studies available
Category C: only prescribed after risk to fetus is considered
Category D: definite fetal risks
Category X: absolute fetal anomalies
Review Box 4-3 (p. 55). Refer students to any nursing drug book, PDR, or websites for more detailed information related to this topic.
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56. Psychological Changes During Pregnancy
Body image changes
Emotional security
Cultural expectations
Support from partner
Whether pregnancy is unexpected
Financial situations
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57. Psychological Changes During Pregnancy (cont.)
Major factors that influence the psychological impact of pregnancy
A woman’s level of maturity
Readiness for childbearing
Hormones contribute to mood swings
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58. Body Image Considered from four aspects Appearance Function Sensation
Mobility
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59. Responses to Pregnancy
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60. Developmental Tasks Pregnancy validation Fetal embodiment
Fetal distinction
Role transition
Refer to Table 4-6 (p. 57). Present case scenarios and ask the class to discuss what nursing interventions may be required at the various stages of development.
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61. Pregnant Women May Experience
Emotional lability
Heightened sensitivity
Increased need for affection
Greater irritability
Fear
Anxiety
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62. Impact on the Father Announcement Pregnancy confirmed Adjustment
Faces reality of pregnancy, asks questions
Focus
May begin to feel like a parent
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63. Impact on the Adolescent
May be fraught with conflict
Dealing with being a teenager and becoming a parent
Anxiety from having to tell parents
May have financial problems, shame, guilt, relationship problems with father of baby, feelings of low self-esteem
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64. Impact on the Adolescent (cont.)
Assess
Developmental and educational level
Support system
Age
The younger the adolescent, the more difficulty one may see in considering the needs of others
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65. Impact on the Older Couple
Factors contributing to delayed pregnancy
Effective birth control alternatives
Increasing career options
High cost of living
Development of fertilization techniques to enable pregnancy later in life
If the woman is 35 years or older, she is considered to be an “elderly primip.”
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66. Impact on the Older Couple (cont.)
Because of age, may encounter special problems during the labor and delivery process
Usually adjust to pregnancy because of factors such as
Often well-educated
Have achieved life experiences, goals
Ready for a lifestyle change
For example, women over 35 may have a decreased ability to adjust uterine blood flow to meet the needs of the fetus.
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67. Impact on the Single Mother
May have emotional needs
May have difficulty completing tasks of pregnancy
May see pregnancy as financial burden, or may have planned for the event
Social acceptance not as difficult
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68. Impact on the Single Father
May take active interest in and financial responsibility for child
May want to participate in plans for the child
Participation may not be accepted by the mother
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69. Impact on the Grandparents
May eagerly anticipate the baby’s arrival or feel they are not ready for their new role
Level of involvement in baby’s life may be an issue, based on
Distance
Relationship between parents and grandparents
Role expectations
Different beliefs regarding child-rearing
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70. Audience Response System Question 2
Name at least two signs that:
May suggest pregnancy (presumptive)
Strongly indicate pregnancy (probable)
Confirm pregnancy (positive)
See Table 4-1 (p. 45) for answers.
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71. Review Key Points
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72. Questions?
No notes