L1 Normal Pregnancy and Family adjustment

How does the size and position of uterus change during pregnancy ?

• Increase the size to 1100-1200 gm (38-42 weeks)

• Uterus gradually grow on the bladder, press on the bowel, gut and diaphragm

Describe the pattern of uterine growth (gestation)

• 12 weeks palpable

• 16 weeks fundus reaches midway between the symphysis pubis & umbilicus

• 20 weeks below umbilicus

• 36 weeks xiphoid process

• 40 weeks slightly descended (~1-2 fingers below xiphoid process)

What is Braxton Hicks contractions ? (+ when, why ?)

• False labour pains, mild and irregular contractions of the uterus

• Starts around 6 weeks of gestation but usually not felt until the 2nd, 3rd trimester

• Purpose: to promote blood flow to the placenta

suggest 2 changes related to presence of fetus in the reproductive system.

1. Ballottement (move like a ball)

2. quickening (move hands, legs)

The change of blood flow in reproductive system during pregnancy.

Uteroplacental blood flow increase in size and number of blood vessels

Describe / list the change of cervix during pregnancy. (4) + which hormones affect it ?

• Affected by estrogen

  1. Change to bluish purple colour

  2. Soft in consistency

  3. Formation of operculum (cervical mucus plug)

  4. Friable (鬆軟)

What is chadwick’s sign ?

Cervix change to bluish purple colour

What is Goodell sign ?

Soft in consistency in cervix

Describe / list the change of ovaries during pregnancy. (2)

• Ovulation stopped

• Secretion of progesterone is replaced by the placenta after 6-7 weeks of pregnancy

Describe / list the change of vagina & vulva during pregnancy. (5)

• Bluish purple colour due to increased vascularity of vagina

• Leukorrhea 白帶

• Lower pH in vagina

• Vaginal mucosa thicken and rugae become prominent

• Loosen of the abundant connective tissue to allow vagina distend during childbirth

Describe / list the change in size and appearance of breast during pregnancy. (5) + a function for lactation (1)

• Enlarge around 6-8 weeks

• Nipples increase in size and become darker, more erect

• Areola become larger and more pigmented

• Veins along the breast become darken due to increased vascularity

• Striae developed

• Tubercles of montgomery 乳暈上的粒粒 become more prominent

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Lactogenesis occurs at 12-16 weeks, colostrum 初乳 is secreted & can be expressed manually

Explain the change of blood & plasma volume during pregnancy.

Total blood volume increase (reach avg. of at least 30%)

• it is a protective mechanism to provide fluid reserve to compensate for blood loss during birth and postpartum.

Plasma volume (concentration) increase

Describe the change of cardic output, HR, BP during pregnancy.

• CO increase from week 5, peaks at 30-34 weeks

• HR progressively increase throughout the pregnancy

• BP remains the same or slightly

Why pregnant women easily have supine hypotensive syndrome ?

Because the infant at the uterus press on the inferior vena cava, venous return reduce.

Turn the body to lateral side / sit up can relieve the condition.

Why pregnant women may experience anaemia (e.g. Hb = 11.6) ?

Since a relative decline in maternal haemoglobin and haematocrit

Why hypercoagulable state in pregnant women ?

= Increased tendency for blood to clot, it is designed to prevent excessive bleeding at childbirth and miscarriage.

Describe / list the changes of cardiovascular structural adaptions during pregnancy. (2)

• Heart size increase & change in position

• Heart sound may be altered (splitting of the 1st heart sound and a systolic murmur)

Describe / list the changes of cardiovascular system in each trimester of pregnancy.

1st: Vasodilation and heart enlarged

2nd: Due to decrease in arterial pressure, there is an increased incidence of supine hypotension

3rd: arterial pressure goes back to preconception, heart sound may be shifted upward & laterally

Describe / list the changes of respiratory system in pregnancy. (6)

• Maternal O2 consumption increase

• Chest breathing replaces abdominal breathing

• Pregnancy-related dyspnea (due to) congestion within the tissue of the respiratory tract

• Increase AP & transverse diameter at 3rd trimester

• Tidal volume increase by 40%

• Chronic mild hyperventilation-normal state —> lead to mild respiratory alkalosis, this facilitate the transport of CO2 from fetus to mother and O2 release from mother to fetus

Describe / list the changes of GI system in the 1st trimester of pregnancy. (4)

• Nausea & Vomiting (peak at 9 week, usually subsides by the end of 1st trimester)

• Peculiarity of taste and smell, change in appetities

• Increase chance of gingivitis 牙龈炎 & gum bleeding (epulis)

• Increase secretion of saliva (ptyalism)

Describe / list the changes of GI system in the 2nd trimester of pregnancy. (1) + explain

Pyrosis (Heartburn)

• Due to increase level of hormone progesterone, it relax the smooth muscle of the oesophageal sphincter.

Describe / list the changes of GI system in the 3rd trimester of pregnancy. (4)

• Serum alkaline phosphatase level rise 2-4 times than non-pregnant women

• Serum albumin and total protein decrease

• Gallbladder emptying time is prolonged

• Constipation, bloating, abdominal discomfort

Explain why pregnancy may easily experienced constipation/

• Smooth muscle relaxation and reduced peristalsis caused by increased progesterone

• Maternal gut microbiome changes

• Iron is absorbed more readily

Describe / list + explain the changes of urination in pregnancy. (3)

• Urine output increase due to increased blood volume

• Frequency and urgency of urination, nocturia due to pressure from an enlarging uterus

• Stress and urge incontinence

Describe / list the changes of renal function in pregnancy. (3)

• GFR increase by 50%

• Mild proteinuria (normal)

• Tubular reabsorption of glucose is impaired, causing glucosuria to occur at varying times and to varying degrees

Describe / list + explain the changes of hyperpigmentation in pregnancy. (7)

Due to the increase of melanotropin

• Melasma 黄褐斑

• Linea nigra

• Striae gravidarum 妊娠纹

• Angiomas

• Palmar erythema

• Pruritus gravidarum 妊娠瘙痒症

• Nipples, areola, moles become darker

Describe the hair amount change during pregnancy

Less hair loss during pregnancy, more obvious hair loss 2-4 months after childbirth

Describe / list + explain the changes of musculoskeletal system in pregnancy. (5)

• Center of gravity shifts forward

• Posture changes

• Tendency of decalcification of bones, joints subluxation 輕微移位

• Pelvic joints relaxes & create pelvic instability

• Separation of rectus abdominis muscles (Six pack)

What are the posture changes durng pregnancy?

• Forward head, rounded shoulders

• ↑ lumbar lordosis 腰椎前凸

• Hyper extended knees and pronated feet

• Some balance disturbance → Leans backward posture to maintain balance

• Wide stance and the waddling gait

Describe / list the changes of neurologic system in pregnancy. (3)

• Headaches

• Alterations in sleep

• Carpal tunnel syndrome in some women

Describe / list the changes of endocrine system in pregnancy. (3)

• Thyroid gland enlarges

• Pituitary gland enlarges

• Pancreas: insulin needs increase

List the source of stress affecting paternal role transition

• Financial issue

• Unexpected events during pregnancy

• Concern about the health of the baby and wife

• Concern about the change relationship with his wife

List the struggling for recognition as a parent of 3 different trimester.

• 1st trimester: feels left out of the pregnancy; confused by his wife’s mood change

• 2nd trimester: increase involvement by feeling fetal movement and hearing the fetal heartbeat

• 3rd trimester: growing relationship with wife, involved in preparing for childbirth

What means by Couvade ?

describes a situation in which expectant father experiences pregnancy- related symptoms

Describe the change of psychologic response from 1st to 3rd trimester.

1st:

• Uncertainty

• Ambivalence 矛盾心理

• Primary focus on self

2nd:

• Primary focus on fetus

• Narcissism & introversion 自恋与内向

• Change in sexuality

3rd:

• Vulnerability

• Increase dependence

• Preparation for birth

Nursing implications for take caring pregnant women & family. (3)

• Learn to view the mother, the father, and the infant as one patient and not focus exclusively on the mother or the fetus (Family-centred care)

• Encourage the father to ask questions about his partner’s pregnancy

• Provide information e.g. the process of pregnancy, what would happen at laboring and how the father can help, etc.