Adaptations to Pregnancy

Question 1

Pregnancy challenges each body system to adapt to the increasing demands of the reproductive system & the growing fetus

Question 2

Changes in the Reproductive System

Vagina & vulva

Cervix

Uterus (5000mL capacity at birth)

Ovaries

Breasts

Question 3

Ovaries secrete ___ from corpus luteum in first 6-7 weeks; prevents spontaneous abortion

Breasts become highly vascular; areola become larger

___ (stretch marks)

Answer 3

progesterone

Striae gravidarum

Question 4

By late pregnancy, blood flow 1200mL/min to uterus & placenta

Uterus grows through hyperplasia & hypertrophy

___ (top of uterus) helps to measure pregnancy

> Highest level that this reaches is the xiphoid process

Irregular uterine contractions in 1st & 2nd trimester

___ contractions ARE NOT labor contractions

Answer 4

Fundus

Braxton Hicks

Question 5

Increase in vascularity to vaginal walls, leading to a bluish color

Increase in glycogen production leads to an increase in vaginal discharge

> Creates a favorable environment for yeast infections

Estrogen causes ___ (congestion w/blood) of cervix

Answer 5

hyperemia

Question 6

___ sign - a softening of the cervix that can be felt

___ sign - a bluish-purple color of the cervix, labia, & vagina

Answer 6

Goodell’s

Chadwick’s

Question 7

Respiratory Changes

Oxygen consumption increases by 20%

Hyperventilation - normal range for pregnant adult: __-__

(normal __-__)

___ PCO₂

Respiratory Alkalosis

Movement of the diaphragm due to enlarging uterus

Answer 7

16-24

16-20

Lower

Question 8

Cardiovascular Changes

Heart

Blood Volume

Blood Pressure

Blood Flow

Blood Components

Answer 8

Heart

• Slight increase in size
• Can be displaced in position
• PMI site
• Systolic murmurs common due to inc in blood volume

Question 9

Blood Volume

• Increases in plasma, WBC’s, RBC’s, platelets
• Plasma increases 1200-1600 mL to transport O₂ & nutrients
• Creates a reserve for blood loss that occurs during delivery
• RBC’s inc 20-30% above pre-pregnancy levels
• pseudoanemia; iron supplementation in 2nd trimester

> constipation & nausea

Answer 9

Blood Pressure

• Minimal changes d/t easier flow throughout body

> Positioning can impact BP

• supine hypotension syndrome; DO NOT lay flat

Question 10

Blood Flow

• Flow to the uterus, placenta, & fetus
• Inc flow to kidneys to remove waste products from mother & fetus
• Inc flow to growing breasts
• Stasis can cause venous distension, leading to varicose veins & inc clot risk

Answer 10

Blood Components

• Iron for erythrocyte production

> Supplements increase it by 30%

• WBC’s inc by up to 15,000; inc in labor, delivery, & postpartum
• Platelet’s & coag factors change slightly to protect from hemorrhage (inc risk of DVT or PE)

Question 11

Gastrointestinal Changes

• Mouth - gingivitis, bleeding gums as sign of pregnancy & anemia
• Esophagus - pyrosis (heartburn)
• Stomach - slower motility –> constipation
• Small and Large intestine

Answer 11

• Liver & Gallbladder

> prolonged emptying; gallstone formation; retainment of bile salts

> itchy in hands & feet

> may have to undergo GB surgery

> alterations in LFT’s d/t displacement

Question 12

Genitourinary Changes

Bladder

Ureters

Kidneys

• Frequent urination; nocturia
• Stress & urge incontinence (encourage Kegel exercises)
• Bladder moves forward & upward; inc risk of infection & trauma during childbirth

Answer 12

• Ureters compressed d/t shrinkage of abdominal cavity; stasis can occur
• Inc risk of UTI or kidney stone development
• Renal blood flow inc 50-80% during pregnancy
• Tubules can’t reabsorb all components going through so you see glucose, amino acids, electrolytes & water-soluble vitamins in urine in larger amts
• Glucosuria common in pregnancy

Question 13

Musculoskeletal Changes

Pelvic instability - allows for fetus to descend into pelvic cavity

___ - curvature of lower back

___ - abdominal muscles end up slightly or severely separating

Answer 13

Lordosis

Diastasis Recti

Question 14

Skin Changes

Circulation increases

Acne development - sweat & sebaceous gland accelerated activity

Hyperpigmentation

Striae gravidarum - fade but don’t disappear

Hair growth

> postpartum hair loss can occur > pregnancy

Question 15

Hyperpigmentation

• Elevated estrogen, progesterone, & melanocyte-stimulating hormone leading to hyperpigmentation; begins as early as 8th week

___ - the “mask” of pregnancy; brownish patches on cheeks, nose

___ - a dark line over longitudinal line of abdomen

Answer 15

melasma

linea nigra

Question 16

Endocrine Changes

• Pituitary gland
• Thyroid gland
• Pancreas
• Placental hormones
• Metabolism

Question 17

?

Normally enlarges

Important in fetal brain development

Have level checked during appointments

Answer 17

Thyroid gland

Question 18

?

Expected 25-35 lb weight gain

Body water inc 6.5-8.5L (stay hydrated) = edema

Answer 18

Metabolism

Question 19

Pancreas

Fluctuations in ___ production & alterations in maternal blood glucose

Answer 19

insulin

Question 20

Pituitary gland

___ secretion happens; prepares breast to produce milk

Estrogen & progesterone levels are high

After birth > breast milk production

___ stimulates uterine contractions; milk ejection reflex

Answer 20

Prolactin

Oxytocin

Question 21

Placental Hormones

• Cause maternal resistance to insulin; inadequate insulin production = maternal DM

___ starts developing at moment of conception & stimulates corpus luteum to make progesterone until placenta develops & takes over; also creates positive test result

Answer 21

hCG

Question 22

?

Is a relaxant for smooth muscles; prevents spontaneous abortion; prevents tissue rejection of fetus

Answer 22

Progesterone

Question 23

?

Stimulates uterine growth; develops ductal system in breast for breastfeeding; hyperemia; gum bleeding

Answer 23

Estrogen

Question 24

?

Increases glucose availability for fetus

Answer 24

Human chorionic sommatomammotropin (HCS)

Question 25

? Inhibits uterine activity; helps soften cervix; lengthens pubic ligaments

Answer 25

Relaxin

Question 26

So now that we know all the changes that occur in pregnancy, it should be easy to tell if I am pregnant...right?

Answer 26

_Presumptive_ Signs of Pregnancy - Amenorrhea - Nausea & vomiting - Fatigue - Urinary frequency - Breast & skin changes - Vaginal & cervical color changes - Fetal movement (as perceived by the mother)

Question 27

_Probable_ Signs of Pregnancy - Abdominal enlargement - Cervical softening - ___ sign - Uterine consistency - ___ sign - Braxton-Hicks contractions - Palpation of fetal outline \_\_\_ (a soft, blowing sound that can be auscultated over the top of the uterus) - Positive pregnancy test (could be from hematuria, proteinuria; certain diseases or rx's)

Answer 27

Goodell's Hegar's uterine souffle

Question 28

**_Positive_** Indicators of Pregnancy \* Auscultation of fetal heart sounds \> handheld doppler @ 9 weeks \> US @ 8 weeks \* Fetal movements felt by the examiner \* Visualization of the fetus \> By US as early as 3 weeks gestation on transvaginal US

Answer 28

Now that we know she is pregnant, let's look at how we can best care for her

Question 29

Preconception/Interconception Care Because the first weeks of pregnancy are such a sensitive period of fetal development, preconception or interconception is recommended for all women of childbearing age

Answer 29

Look for comorbidities; e.g. DM, HTN Use of alcohol, tobacco, illicit drugs Partner violence? Taking harmful drugs? Are overweight or obese? Look at vaccination history

Question 30

? Take 400-800 micrograms of ___ 1 month \< conception; consider family history of neural tube defects (would increase dosage to \_\_\_)

Answer 30

folate 4 mg

Question 31

Obtaining an Obstetric History: GPTPAL Obstetric history is reported through the acronym GPTPAL G = ? P = ? T = ? P = ? A = ? L = ?

Answer 31

Gravidity Parity Term Preterm Abortions Living Children

Question 32

? number of pregnancies, regardless of duration

Answer 32

Gravidity

Question 33

? number of pregnancies that ended at 20 weeks or greater \> a miscarriage @ 16 weeks gestation WOULD NOT count

Answer 33

Parity

Question 34

? deliveries between 38 and 42 weeks

Answer 34

Term

Question 35

? deliveries between 20 and 38 weeks

Answer 35

Preterm

Question 36

? spontaneous or therapeutic

Answer 36

Abortions

Question 37

? number of children currently living

Answer 37

Living Children

Question 38

? is a miscarriage "therapeutic" is choosing to end the pregnancy; more common of what we think

Answer 38

spontaneous abortion

Question 39

Put It Into Practice Alia gave birth to a daughter 5 years ago at 41 weeks gestation. She then had a miscarriage one year later at 9 weeks gestation. Two years ago, she birthed her son at 36 weeks gestation. She thinks she may be pregnant again after having a positive home pregnancy test, with her last menstrual period being 11/27. What is Alia's GPTPAL?

Answer 39

G = 4 P = 2 T = 1 P = 1 A = 1 L = 2

Question 40

Calculating Estimated Date of Delivery Estimated Date of Delivery (EDD) is commonly done based on the first day of the last normal menstrual period (LNMP) **Nagele's Rule** Subtract 3 months from the first day of the LNMP Add 7 days Correct for the year, if needed

Answer 40

\* Rule only works if it's a 28-day cycle

Question 41

Put It Into Practice Alia gave birth to a daughter 5 years ago at 41 weeks gestation. She then had a miscarriage one year later at 9 weeks gestation. Two years ago, she birthed her son at 36 weeks gestation. She thinks she may be pregnant again after having a positive home pregnancy test, with her last menstrual period being 11/27/21. According to Nagele's rule, what is Alia's EDD?

Answer 41

Answer: September 3, 2022

Question 42

Other Historical OB Information to Obtain - Past pregnancies & deliveries - Length of gestations - h/o preterm births - Weight of infants - Labor experience & type of delivery - Anesthesia history

Answer 42

- Prenatal, intrapartum, & postpartum complications - Neonatal complications - Methods of newborn feeding used (e.g. breastfeed, bottle-feed) - Any special concerns

Question 43

More Patient History to Review - Gynecologic & contraceptive history \> STI's present? infertility issues? IUD used? oral contraceptives taken? - Medical-surgical history - Family health history (patterns of congenital/genetic abnormalities) - Partner's health history (assess Rh type) - Psychosocial history

Question 44

Schedule of Antepartum Visits Conception to 28 Weeks: every 4 weeks 29 through 36 Weeks: every 2 weeks 37 Weeks until Birth: Weekly

Answer 44

Monitor mom & baby & ensure proper growth is occurring Provide frequent touchpoints for pregnancy, L&D, & postpartum education Centering pregnancy concept - schedule for meetings that meets at 12 weeks & into postpartum period

Question 45

? Could experience preterm labor w/a viable baby @ this period

Answer 45

29 through 36 Weeks: Every 2 Weeks

Question 46

? Check fetal HR Measure fundal height Take mother's BP

Answer 46

Conception to 28 Weeks: Every 4 Weeks

Question 47

? Ensure that no fetal complications occur Make sure no maternal complications develop

Answer 47

37 Weeks until Birth: Weekly

Question 48

Ongoing Antepartum Assessments and Teaching - Vital signs (BP) - Weight - Urinalysis (look for protein, glucose, ketones, UTI) - Fundal height (centimeters correlates to week's gestation; e.g. 20 weeks gestation = 20 cm) - Leopold's maneuver's - Fetal heart rate (what is the normal range ?)

Answer 48

110-160 bpm

Question 49

Ongoing Antepartum Assessments and Teaching cont'd - Fetal activity - Signs of labor - Ultrasound screening - Glucose screening (24-48 weeks gestation) - Isoimmunization (Rh factor) - Pelvic examinations

Question 50

Common Discomforts of Pregnancy - Nausea & vomiting / heartburn - Backache / round ligament pain - Urinary frequency / varicosities - Constipation - Hemorrhoids / leg cramps

Answer 50

Safety Alert! Signs of Possible Complications During Pregnancy \* Vaginal bleeding / visual disturbances / painful urination \* Fluid leaking from vagina / persistent or severe epigastric pain \* Persistent vomiting / swelling of the fingers or face \* Convulsions / decrease in frequency or strength of fetal movements \* Continuous, pounding headache \* Chills or fever / sxs of preterm labor

Question 51

Remember, we need a holistic approach...we have covered the needs of the changing pregnant body, what about the psychological responses to pregnancy?

Answer 51

Maternal Psychological Responses \* First Trimester \* Second Trimester \* Third Trimester

Question 52

? \* Vulnerability \* Increasing dependance \* Preparation for birth ("nesting")

Answer 52

Third (Trimester)

Question 53

? \* Uncertainty \* Ambivalence \* Focus on Self

Answer 53

First (Trimester)

Question 54

? \* Physical evidence of pregnancy \* Focus on fetus \* Narcissism & introversion \* Body image \* Changes in sexuality

Answer 54

Second (Trimester)

Question 55

Factors that Influence Psychological Adaptations - Age (e.g. geriatric 35+) - Multiparity - Social support - Absence of partner - Socioeconomic status - Abnormal situations (e.g. partner violence, substance abuse)

Answer 55

Familial Adaptations - Paternal adaptations - Adaptation of grandparents - Adaptation of siblings (based on age; e.g. toddlers don't understand situation)

Question 56

Cultural Influences on Childbearing - Health beliefs - Communication techniques - Time orientation

Question 57

Health Beliefs \* Healthcare maintenance practices (pregnancy thought of as an illness in the US) \* Belief in fate \* Practices for preventing illness \* Ways to restore health \* Modesty (preference for female caregivers; lack of male nurses in L&D) \* Female genital cutting (happens in childhood; pelvic exams uncomfortable & difficulty during delivery)

Answer 57

Communication Techniques \* Language \* Communication style \* Decision making \* Eye contact (can be offensive in some cultures) \* Touch (e.g. welcomed in Hispanic cultures)

Question 58

? (is) Providing information while acknowledging that the client or family members may hold different views Allow the family to express their beliefs, and then provide rationales for why the recommendations are made. Together, compromise to an outcome that is satisfactory for all.

Answer 58

Cultural Negotiation

Question 59

Perinatal Education - Preconception classes - Early pregnancy classes - Exercise classes - Childbirth preparation classes - Cesarean birth preparation classes

Answer 59

- Breastfeeding classes - Parenting classes - Classes for partners - Classes for siblings - Postpartum classes