Maternal Adaptations to Pregnancy

• Houses the fetus (aka womb)

• Thickens at the beginning of pregnancy, and usually thins towards the end of 2nd trimester (around 20ish weeks)

• Has to contract (can be false (Braxton Hicks) or true (cervical dilation and effacement))

Uterus

It's normal for the mom to not feel any "kicks" or fluttering/movement at 14 weeks' gestation. True or false?

True

Why is it normal for mom to not feel any kicks or fluttering earlier than 20 weeks gestation?

The uterus thickens in the beginning of the pregnancy, but doesn't start thinning until about 20 weeks of pregnancy.

How can we measure fetal growth?

• From the symphysis pubis (SP) to the umbilicus (16wks)

• At 20 weeks: SP level to umbilicus

• At 36 weeks: SP to xiphoid process

• After 37 wks (full term), the baby drops and the measurement decreases → Lightning

(remember, wks = cm; if the numbers are off, something is wrong)

Baby drops into pelvis at 37 weeks

Lightning

What is the age of fetal viability?

20 weeks’ gestation

Which hormone must be present in adequate amounts to sustain pregnancy?

Progesterone (especially in early stages, 6-7weeks, because that's when the gestational sac forms; progesterone prevents uterine contractions during pregnancy and aids in lactation)

• without adequate amounts of progesterone, there would be no gestational sac → no baby (early spontaneous abortions)

What is the thick, yellowish fluid that is present in the beginning of lactation? It’s normal to see or not see it. Can happen any time during pregnancy, even after.

Colostrum

Cardiovascular changes in pregnancy

RBC's/blood volume increase. Physiologic Anemia in pregnancy results from the dilution of RBC's from a decrease in Hgb and Hct (hemodilution → natural response)

PT EDUCATION: increase iron supplements, prenatal vitamins, and an iron-rich diet!

Changes in CO in pregnancy

Assess CO to see how much blood flow is going from baby to mom (CO is going to INCREASE TREMENDOUSLY → best way to ensure comfort and prevent supine hypotensive syndrome = mom is to to lay left lateral (NEVER SUPINE)

Blood volume begins to increase at

6 weeks

Why does BP drop mid-pregnancy (2nd trimester)?

SVR drops due to vasodilation from progesterone and prostaglandins (blood volume increases, but BP does not).

Why should pregnant clients never lie supine

Because blood flow to the placenta decreases, resulting in fetal hypoxia. This can also lead to uterus putting pressure on superior vena cava causing hypotension in mom → Tell mom to turn on her side or place a pillow under her hip

Pregnancy is a hypercoagulable state =

• Caused by increase blood volume.

• Risk for DVTs

• Intervention → SCD’s, Ted Hose, compression stockings

Respiratory system changes during pregnancy

During the last/third trimester the uterus pushes the diaphragm upward. To compensate, the ribs flare, the substernal angle widens, and the circumference of the chest increases → dyspnea, SOB

GI changes during pregnancy

• Increased (or decreased) appetite

• Increased salivation (esp Nigerian patients)

• Ptyalism: excessive salivation & epulis: gum hypertrophy

• Less esophagus tone → GERD (LES loses its tone due to progesterone)

• Constipation + bloating (decreased motility from an increase in progesterone & increased water absorption); sometimes diarrhea but more constipation

• Uterus presses on liver and gallbladder (patient can develop gallstones since gallbladder becomes hypotonic and bile becomes thicker)

  • Liver total protein and serum albumin decreases due to hemodilution

Moms are at an increased risk of bladder and kidney infections because of the __________ on the ureters

Heavy pressure (think about a baby standing on the bladder)

What are the two biggest skin changes during pregnancy? (HINT: hyperpigmentation)

• Melasma/chloasma & linea negra

• Melasma: "raccoon eyes" - dark pigmentation around the eyes/freckles

• Linea negra: dark line along the abdomen from the symphysis pubis to the umbilicus

• honorable mention: striae gravidarum (stretch marks)

What are some common musculoskeletal changes during pregnancy?

• Fetal demands for calcium increase (especially in the third trimester)

• Back pain due to uterine expansion

• Lordosis: increased swayback ; waddle-like gait

The separation of muscles in the middle of the abdominal wall, influenced by the hormone relaxin (common in multips and patients who've undergone C-sections) → Kegel exercises and flex abd wall all the time throughout pregnancy to strengthen the pelvic floor and abd

Diastis recti

A patient has missed her period by 2 weeks and is now experiencing, nausea, vomiting, fatigue, and breast and skin changes. what type of pregnancy confirmation do these signs indicate?

Presumptive

A few weeks go by and the patient now notices an enlarged abdomen, ballottement, Braxton Hick's contractions, and a softening of her cervix. which type of pregnancy sign do these clues allude to?

Probable

which is a positive confirmation of pregnancy? (SATA)

A) auscultation of fetal heart sounds

B) ballottement

C) fetal movement detected by an examiner

D) Goodell's sign

E) positive pregnancy test

AC

Why is elevated hCG a probable sign of pregnancy?

• Prevents involution of corpus luteum to maintain production of estrogen and progesterone until placenta is formed

• Indicates presence of a placenta

• But can also be a sign of cancer

CBBG (Probable signs of pregnancy)

C – Chadwick sign

B – Blood/urine test

B – Braxton hicks/ballottement (physically detect fluid)

G – Goodells sign

FH-FM-U (positive signs of pregnancy)

Detected by trained examiner at clinic/hospital:

FH – Fetal Heart tone

FM – Fetal movements

U – Ultrasound

NV-FAUB (presumptive signs of pregnancy)

NV – Nausea/vomiting

F – Fatigue

A – Amenorrhea

U – Urinary frequency

B – Breast changes

What’s the purpose of Braxton hicks?

Practice contractions

If SP to umbilicus measurement is off, that may mean

Abnormality; baby may be too small or too big, or examiner error

Changes to vagina during pregnancy

• Increased vascularity (spotting, bleeding with pregnancy = normal)

• The vaginal mucosa thickens

• Vaginal rugae becomes prominence

• Increase in lactic acid

Changes in ovaries during pregnancy

• Progesterone must be present in adequate amounts at early stages (if mom has recurrent miscarriages → progesterone supplements)

• Corpus luteum of the ovaries secretes progesterone

• Ovulation ceases during pregnancy

Decrease in progesterone at 6-7 week =

Early miscarriage, gestational sack does not form

When does placenta take over producing progesterone for mom and fetus?

After 10 weeks

Changes in breasts during pregnancy

• Estrogen stimulates growth of mammary ductal tissue

• Progesterone promotes the growth of the lobes, lobules, and alveoli

• Changes in color and contour of nipple/areola (check mom on very first exam; do thorough breast exam on first visit)

• Colostrum is secreted (thick, yellow fluid; absence or presence is fine)

What is often diagnosed in a prenatal visit?

Breast/cervical cancer; this is because very first OB visit we do extensive breast exam (e.g. assessing breast for changes in pigmentation). Look for abnormal moles, modules, etc.

When can colostrum (yellowy discharge during pregnancy) appear?

Anytime during pregnancy

How does the heart change during pregnancy?

Muscles of the heart (myocardium) enlarge 10% to 15% during the first trimester

Heart sounds during pregnancy?

• Splitting of the first heart sound

• Systolic murmur

Patient teaching for iron-deficiency

• Need iron to prevent physiologic anemia and restore oxygen perfusion/Hgb

• Eat multivitamins and iron-rich diet

• Warn about constipation

Acceleration of 15-20 beats at 32 weeks in fetus =

Normal; left-lateral position = best position for promoting CO

It is normal for mother’s BP to go up during pregnancy (e.g. 2nd trimester)?

Abnormal; can be sign of preeclampsia

How does plasma volume change during pregnancy

Increases from 6-8 weeks until 32 weeks of gestation

How does blood flow change during pregnancy?

• Altered to include uteroplacental unit

• Renal plasma flow increases

• Skin requires increased circulation

• Blood flow to the breasts increases

• Expanding uterus partially obstructs blood return from veins in legs (r/o DVT)

Changes in blood components during pregnancy

• Increased iron absorption

• Increased clotting factors (DVT, obesity increases r/o DVT)

Changes in respiratory system

• O2 consumption due to progesterone and estrogen (deeper breaths) → hyperventilation and respiratory alkalosis

Physical effects of enlarging uterus

• Lifts diaphragm and relaxes ligaments around ribs due to relaxin → increased r/o respiratory disorder

• Relaxin in hips → increased r/o falls

• Abd wall → diastasis recti (common in multips or previous C-sections) → makes patient look pregnant all the time

Bladder compression in pregnancy by enlarged uterus causes →

• Urinary frequency & urgency → Kegel exercises, drink water

• Nocturia

• Frequency alone = normal

• Frequency + burning or dysuria = abnormal; UTI

Why do women not want to drink water?

Pregnancy induces frequent urination due to uterus pressing on bladder and increased renal blood flow/GFR (30-50% increased frequency); they don’t want to drink water and go to the bathroom all the time (even though fluid intake is not the cause.

Why is there increased r/o kidney/bladder infections due to uterine compression of the bladder?

Pressure of baby on ureters dilate them, making it easier for bacteria to infiltrate

Changes in skin

• Hyperpigmentation

  • Darkening of skin

  • Melasma/Chloasma

  • Linea Negra

• CT

  • Striae gravidarum → stretch marks → vitamin E, coco butter (not really effective

• Hair and nails → rapid growth

Patient teaching for diastasis recti

Encourage patients to hold stomach muscles tight and hold it in as if wearing blue jeans

Changes in pituitary gland during pregnancy

• Prolactin (milk production; antagonizes insulin)

• Oxytocin (stimulates uterine contractions, milk ejection reflex after birth, inhibited during pregnancy)

• FSH (initiates maturation of ovum, suppressed during pregnancy

• Luteinizing hormone → stimulates ovulation of mature ovum in nonpreg state, suppressed in preg

Changes in thyroid gland during pregnancy

Rise in total T4 and thyroxine-binding globulin → often patients need to be put on thyroid meds to antagonize thyroid

Changes in adrenal gland during pregnancy

• Enlarges slightly during pregnancy

• Cortisol → increased during pregnancy; insulin antagonist, active in metabolism of glucose, protein, and fats

• Aldosterone → increased during pregnancy to conserve sodium and maintain fluid balance

• Aldosterone counteracts progesterone salt-wasting; helps kidneys adjust to pregnancy

Suppresses FSH and LH; stimulates development of uterus and breasts; causes vascular changes in skin, uterus, respiratory tract, and bladder; causes hyperpigmentation; insulin antagonist; increases fat stores and cortisol + aldosterone

Estrogen

• Maintains uterine lining for implantation

• Relaxes smooth muscles

• Decreases uterine contractions

• Develops breasts for lactation

• Increases carbon dioxide sensitivity

• Increases resistance to insulin

• Inhibits FSH and LH, prevents fetal tissue rejection, retains sodium

Progesterone

Changes in parathyroid gland during pregnancy

• Controls calcium

• Decreased by 10-30% in first trimester

• Increased by term, but remains in normal range throughout most of pregnancy

Placenta produces what hormones?

• hCG (probable sign)

• Estrogen

• Progesterone

• hCS

• Relaxin

Changes in metabolism during pregnancy

• Weight gain

• Water metabolism

• Edema

• Carbohydrate metabolism

Changes in sensory organs during pregnancy

• Eye → vision issues (but most doctors won’t change prescription)

• Ear → hearing issues due to changes in mucus membranes in ear tubes

Changes immune system during pregnancy

• Autoimmune (arthritis/MS)

• Infection resistance (more immunosuppressed)

• NV

• Fatigue

• Amenorrhea

• Urinary frequency

• Breast/skin changes

• Quickening

• Chadwick (color change)

Presumptive signs

• Abd enlargement

• Goodells sign (soft)

• Hegars sign (extremely soft)

• Ballottement (fluid under abd)

• Braxton Hicks contractions

• Palpation of fetal outline

• Uterine souffle (murmur auscultated over the uterus)

• Positive pregnancy test (testing for hCG)

Probable signs of pregnancy

• Auscultation of fetal heart sounds

• Detection of fetal movements by examiner

• Visualization of embryo or fetus (e.g. ultrasound)

Positive signs of pregnancy

Couvade syndrome

Male pregnancy

Second trimester psychosocial

• Physical evidence of pregnancy

• Fetus as the primary focus

• Narcissism and introversion

• Body image

• Changes in sexuality

First trimester psychosocial

• Uncertainty

• Ambivalence

• The self as primary focus

Third trimester

• Vulnerability

• Increasing dependence on partner

• Preparation

  • Fears

  • Nesting behavior (preparing for the baby, buying supplies for the baby, etc.)

Seeking safe passage involves

• Seeking care of HCP

• Following the advice of the HCP

• Adhering to culture practices

Four maternal tasks of pregnancy

• Seeking safe passage

• Gaining acceptance

• Learning to give of self

• Developing attachment and interconnection

Committing self to the unknown child

• Attachment

  • Development of strong of affectional ties begins in early pregnancy

Learning to give of self

• Giving space and nurturing

• Providing food, care, and acts of thoughtfulness

Toddlers psychosocial support

• Unaware that a new brother is sister is going to be born

• Cannot leave newborn infant with a toddler → the newborn will get killed

Older children psychosocial support

• Children from 3-12 years may realize a baby is to be born

• Reassure the children about their continued importance

• Dedicated support person if events become overwhelming

The basic structures of all organ systems are established during the first

8 weeks of pregnancy. During this period, teratogens may cause major structural and functional damage to the developing organs.

Function of amniotic fluid

Fetal membranes contain the amniotic fluid, which cushions the fetus, allows normal prenatal development, and maintains a stable temperature.

Function of umbilical cord

Lifeline between the fetus and the placenta. Two umbilical arteries carry deoxygenated blood and waste products to the placenta for transfer to the mother’s blood. One umbilical vein carries oxygenated and nutrient-rich blood to the fetus. Coiling of the vessels and enclosure in Wharton’s jelly reduce the risk for obstruction of the umbilical vessels.