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Chapter 4 Physiologic and Psychological Changes During Pregnancy Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 1.

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Presentation on theme: "Chapter 4 Physiologic and Psychological Changes During Pregnancy Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 1."— Presentation transcript:

1 Chapter 4 Physiologic and Psychological Changes During Pregnancy Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 1

2 Determining Pregnancy and Physiological Changes Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 2

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. Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 3

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. Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 4

5 Profile of Previous Obstetric History  Mnemonic commonly used for recording  Systematic, quick way to indicate the number of pregnancies as well as outcomes.  GTPALM  G: gravida  T: term pregnancies  P: premature births  A: abortions  L: live births  M: multiple gestations and births Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 5

6 Profile of Previous Obstetric History (cont.)  G: gravida  Any pregnancy, regardless of duration, including the present one  P: para  number of births after 20 weeks gestation e.g.: woman pregnant for first time would be: P0, G1 Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 6

7 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 Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 7

8 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 Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 8

9 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 Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 9

10 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 Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 10

11 Signs of Pregnancy  Presumptive signs  Suggest pregnancy  Probable signs  Likely pregnant  Positive signs  Definite evidence of pregnancy Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 11

12 Three Signs that Define Pregnancy  Hearing fetal heart sounds  Audible by doppler weeks  Palpation of active fetal movements  Visualization of a developing fetus via ultrasound  Gestational sac can be viewed as early as 10 days after implantation Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 12

13 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 Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 13

14 Physiologic Changes in Body Systems Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 14

15 Major Sources of Change  Hormonal (endocrine system)  Mechanical pressure (physical changes within the body) Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 15

16 Changes in the Endocrine System  Dramatic hormonal increase affects all body systems  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 Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 16

17 Human Placental Lactogen (hPL)  Increases maternal insulin resistance during pregnancy  Provides fetus with glucose needed for growth Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 17

18 Changes in the Reproductive System Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 18

19 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 Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 19

20 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 Mucous plug formation provides barrier to prevent organisms from entering uterus. Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 20

21 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 hormone relaxin Thought to help relax symphysis pubis and pelvic joint, and softens cervix Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 21

22 Vagina  Wall thickens, becomes more pliable, and expandable  Rugae (folds) more prominent  Discharge increases, leads to increased glycogen, which increases risk of vaginal infection  Increased risk for infection and Candida albicans  pH decreases (becomes more acidic), preventing growth of harmful microbes Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 22

23 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 Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 23

24 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  Thin, yellowish fluid excreted until 3 rd post partum day Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 24

25 Initiation of Lactation  Profound drop in estrogen and progesterone  After delivery of placenta  Increase in prolactin  Responsible for milk production Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 25

26 Changes in the Cardiovascular System Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 26

27 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 Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 27

28 Supine Hypotensive Syndrome Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 28

29 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% Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 29

30 Dyspnea  Respiratory system has increased sensitivity due to progesterone  Pressure of uterus on diaphragm  Normally does not interfere with activities of daily living Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 30

31 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 Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 31

32 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)  Relaxation of cardiac sphincter from progesterone  Carbohydrate metabolism altered  Increased insulin resistance can cause gestational DM Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 32

33 Compression of Abdominal Contents Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 33

34 Audience Response System Question 1 The two major sources of the physiological changes during pregnancy are the physical changes (enlargement of uterus) and the: A.Respiratory system B.Musculoskeletal system C.Gastrointestinal system D.Endocrine system Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 34

35 Physiological, Psychological and Developmental Changes in Pregnancy Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 35

36 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. Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 36

37 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. Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 37

38 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 Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 38

39 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 during labor  Does not interfere with pregnancy Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 39

40 Changes in the Integumentary and Skeletal Systems  Relaxin and placental progesterone  Relaxation and softening of pelvic joints  Widening of symphysis pubis  “waddling gate”  Facilitates delivery of fetus  Center of gravity shifts forward as uterus enlarges  Progressive lordosis  May experience difficulty with balance Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 40

41 Lordosis  Lordosis Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 41

42 Changes in the Skeletal System  Uterus stretches round ligaments  Woman may develop diastasis recti abdominis  Separation of rectum abdominis muscles  Increased risk of carpal tunnel syndrome  Due to weight gain and edema Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 42

43 Changes in the Integumentary System  Chloasma (“mask of pregnancy”)  Linea nigra (dark line on abdomen)  Striae gravidarum (stretch marks) Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 43

44 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 Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 44

45 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 Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 45

46 Effect of Lactation and Medications  Some drugs pass into breast milk  If lactating, mother must take medication immediately after infant breastfeeds Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 46

47 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 Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 47

48 Psychological Changes During Pregnancy  Body image changes  Emotional security  Cultural expectations  Support from partner  Whether pregnancy is unexpected  Financial situations Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 48

49 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 Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 49

50 Body Image  Considered from four aspects  Appearance May be difficult and occurs quickly  Function Difficult if associated with loss of control (urinary incontinence)  Sensation More sensitive to touch due to increased vasocongestion  Mobility Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 50

51 Responses to Pregnancy Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 51

52 Developmental Tasks  Relate to sequence of trimesters; more apparent in some than others  Pregnancy validation  Focus is nurturing and protecting fetus  May question identity as woman and mother  Fetal embodiment  Incorporates fetus into body image; deals with repressed thought and matures  Fetal distinction (when quickening occurs)  Sees fetus as individual  Role transition  Makes concrete plans for baby 52

53 Pregnant Women May Experience  Emotional lability  Heightened sensitivity  Increased need for affection  Greater irritability  Fear  Anxiety  Needs to receive rather than give emotional support  Provide guidance and support Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 53

54 Impact on the Father  Announcement  Pregnancy confirmed  Adjustment  Faces reality of pregnancy, asks questions  Focus  May begin to feel like a parent Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 54

55 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 Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 55

56 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 Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 56

57 Impact on the Older Couple  If the woman is 35 years or older, she is considered to be an “elderly primip.”  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 Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 57

58 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 Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 58

59 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 Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 59

60 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 Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 60

61 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 Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 61

62 Audience Response System Question 2 Name at least two signs that: A.May suggest pregnancy (presumptive) B.Strongly indicate pregnancy (probable) C.Confirm pregnancy (positive) Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 62

63 Review Key Points Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 63


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