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Comprehensive Study Notes: Maternal Adaptation During Pregnancy (NUR 4636)

Chadwick Sign

  • Chadwick sign: bluish-purple coloration of the vaginal mucosa and cervix
  • Associated observation: commonly noted in multiparous women with leukorrhea
  • Indicator: an early sign of pregnancy, supporting diagnosis but not definitive on its own

Goodell Sign

  • Goodell sign: softening of the cervix
  • Clinical indication: early pregnancy sign
  • Relationship to Chadwick sign: may accompany Chadwick sign; part of early cervical changes

Hegar Sign

  • Hegar sign: softening of the lower uterine segment (isthmus)
  • Significance: reflects softening of the uterus where the body meets the cervix

Background: Early Pregnancy Signs

  • Early pregnancy signs include Goodell sign and Chadwick sign (blue/purple cervix)
  • HeGAR sign, Chadwick sign, and Goodell sign are commonly cited together as early indicators of pregnancy
  • Note: All are not definitive alone; require correlation with other findings (e.g., hCG, ultrasound)

Signs & Symptoms of Pregnancy (Presumptive)

  • Fatigue – around 12 weeks
  • Breast tenderness – 3 to 4 weeks
  • Nausea and vomiting – 4 to 14 weeks
  • Amenorrhea – around 4 weeks
  • Urinary frequency – 6 to 12 weeks
  • Hyperpigmentation of skin – around 16 weeks
  • Fetal movements (quickening) – 16 to 20 weeks
  • Uterine enlargement – 7 to 12 weeks
  • Breast enlargement – around 6 weeks

Signs & Symptoms of Pregnancy (Probable)

  • Braxton Hicks contractions – 16 to 28 weeks
  • Positive pregnancy test – 4 to 12 weeks (hCG detection)
  • Abdominal enlargement – 14 weeks
  • Ballottement – 16 to 28 weeks
  • Goodell sign – 5 weeks
  • Chadwick sign – 6 to 8 weeks
  • Hegar sign – 6 to 12 weeks
  • These signs are more reliable than presumptive signs but still not definitive without fetal visualization or biomarker confirmation

Table 11.1: Select Pregnancy Tests (Overview)

  • Types of tests and specimens:
    • Agglutination inhibition tests (qualitative): Urine
    • Examples: Pregnosticon, Gravindex
    • Immunoradiometric assay: Blood serum
    • Examples: Neocept, Pregnosis
    • Enzyme-linked immunosorbent assay (ELISA): Blood serum or urine
    • Used in over-the-counter home/office pregnancy tests
  • Remarks:
    • If hCG is present in urine, agglutination does not occur → positive for pregnancy; reliable 14–21 days after conception; ~95% accurate
    • Immunoradiometric assay measures the ability of a blood sample to inhibit binding of radiolabeled hCG to receptors; reliable 6–8 days after conception; ~99% accurate
    • ELISA uses an enzyme to bond with hCG in the urine if present; reliable 4 days after implantation; ~99% accurate if hCG-specific
  • References: Office on Women’s Health (2019); Luppa & Junker (2018); Edmonds et al. (2019)

Positive Signs of Pregnancy (Objective indicators)

  • Ultrasound verification of embryo or fetus (4–6 weeks)
  • Fetal movement felt by an experienced clinician (20 weeks)
  • Auscultation of fetal heart tones via Doppler (10–12 weeks)

Reproductive System Adaptations During Pregnancy

Uterus

  • Increase in size, weight, length, width, depth, volume, and overall capacity
  • Shape: pear to ovoid
  • Positive Hegar sign observed
  • Enhanced uterine contractility; Braxton Hicks contractions
  • Ascent into abdomen after first 3 months
  • Fundal height by 20 weeks gestation at level of umbilicus; ~20 cm; reliable for estimating gestational age until 36 weeks

Cervix

  • Softening (Goodell sign)
  • Mucus plug formation
  • Increased vascularization (Chadwick sign)
  • Ripening about 4 weeks before birth

Vagina

  • Increased vascularity with thickening
  • Lengthening of vaginal vault
  • Secretions more acidic, white, and thick; leukorrhea

Ovaries

  • Enlargement until 12th to 14th week of gestation
  • Cessation of ovulation

Breasts

  • Increase in size and nodularity to prepare for lactation
  • Tenderness; increase in nipple size; becoming more erect and pigmented (estrogen and progesterone)
  • Production of colostrum (antibody-rich, yellow fluid) that can be expressed after the 12th week
  • Conversion to mature milk after delivery

Other Organ Changes (General Adaptations)

  • Liver pushed up; stomach compressed; bladder compressed

Gastrointestinal (GI) System Adaptations

  • Gums: hyperemic, swollen, friable due to estrogen and vascular proliferation
  • Ptyalism; dental problems; gingivitis
  • Decreased peristalsis and smooth muscle relaxation; constipation due to increased venous pressure and uterine pressure
  • Hemorrhoids due to increased venous pressure
  • Slowed gastric emptying; heartburn; management: decrease caffeine, chew slowly, remain upright after eating
  • Prolonged gallbladder emptying
  • Nausea and vomiting (NPO if needed)

Cardiovascular System Adaptations

  • Blood volume increases by ~50% above prepregnancy levels
  • Cardiac output increases; venous return increases; heart rate increases
  • Slight decline in blood pressure until mid-pregnancy, then returns to prepregnancy levels
  • Increase in red blood cells; plasma volume > red blood cells → physiologic anemia of pregnancy
  • Iron requirements rise; fibrin and plasma fibrinogen increase; some clotting factors rise → hypercoagulable state

Respiratory System Adaptations

  • Breathing becomes more diaphragmatic than abdominal due to increased diaphragmatic excursion, chest circumference, and tidal volume (approximately 40% increase)
  • Increased oxygen consumption
  • Congestion due to increased vascularity

Renal/Urinary System Adaptations

  • Dilation of renal pelvis; elongation, widening, and increased curvature of ureters
  • Increase in length and weight of kidneys
  • Increase in glomerular filtration rate (GFR); increased urine flow and volume
  • Kidney activity increased with the woman lying down; greater increase in later pregnancy with side-lying position

Musculoskeletal System Adaptations

  • Softening and stretching of ligaments holding sacroiliac joints and pubic symphysis
  • Postural changes: increased swayback and upper spine extension
  • Forward shifting of center of gravity
  • Increase in the lumbosacral curve (lordosis); compensatory curve in cervicodorsal area
  • Waddle gait

Integumentary System Adaptations

  • Hyperpigmentation; mask of pregnancy (facial melasma)
  • Linea nigra
  • Striae gravidarum
  • Varicosities; vascular spiders
  • Palmar erythema
  • Hair growth declines while nail growth increases

Endocrine System Adaptations

  • Thyroid gland: slight enlargement; increased activity; rise in basal metabolic rate
  • Pituitary gland: enlargement; decrease in TSH and GH; inhibition of FSH and LH; increase in prolactin and MSH; gradual increase in oxytocin with fetal maturation
  • Pancreas: insulin resistance due to human placental lactogen (hPL) and other hormones in second half of pregnancy
  • Adrenal glands: increased cortisol and aldosterone secretion
  • Prostaglandin secretion
  • Placental secretions: hCG, hPL, relaxin, progesterone, estrogen

Nutritional Needs During Pregnancy

  • Direct effect of nutritional intake on fetal well-being and birth outcomes
  • Daily vitamin and mineral supplementation recommended
  • Folic acid: increased intake to prevent neural tube defects; alpha-fetoprotein (AFP) monitoring mentioned
  • Example foods: citrus fruits
  • Dietary recommendations: increase protein, iron, folate, and overall calories
  • Use USDA MyPlate guidance; encourage more fruits, vegetables, and whole grains; limit saturated fats, trans fats, and cholesterol
  • Mercury considerations: avoid certain fish; avoid smoking and alcohol

Practical Nutrition Promotion and Counseling

  • Follow USDA MyPlate; select varied foods from each group
  • Aim for gradual and steady weight gain; weight gain targets depend on prepregnancy weight
  • Prenatal vitamin/mineral supplementation daily
  • Do not pursue weight-reduction diets during pregnancy
  • Eat three meals daily with one or two snacks
  • Limit sodas and caffeine-containing drinks
  • Avoid diuretics unless advised by healthcare provider
  • Do not unnecessarily restrict salt without clinician instruction
  • Encourage reasonable daily physical activity

Weight Gain Guidelines (Summary from provided notes)

  • First trimester general gain: approximately 3.5 ext{-}5 ext{ lb}; second and third trimesters: about 1 ext{ lb/week}
  • Healthy weight BMI: 25 to 35 lb total gain
    • First trimester: about 5 ext{ lb}
    • Second/third trimesters: +1 ext{ lb per week}
  • BMI < 19.8: 28 to 40 lb total
    • First trimester: about 2 ext{ lb}
    • Second/third trimesters: +2/3 ext{ lb per week}
  • BMI > 25: 15 to 25 lb total

Nutritional Education and Special Considerations

  • MyPlate guidance for diverse needs
  • Cultural variations in diet
  • Special diets and restrictions: gluten-free, lactose intolerance, vegetarianism
  • Counseling on pica and other concerns as part of nutrition education

Maternal Emotional Responses

  • Ambivalence: conflicting feelings
  • Introversion: focusing on self
  • Acceptance: positive feelings
  • Mood swings: emotional lability
  • Changes in body image: feelings range from beautiful to uncomfortable

Maternal Role Tasks

  • Ensuring safe passage throughout pregnancy and birth
  • Seeking acceptance of infant by others
  • Seeking acceptance of self in maternal role to infant ("binding in")
  • Learning to give of oneself

Considerations During Pregnancy

  • Adolescents: self-identity development; 3rd trimester questioning whether they will be a good mother

Pregnancy and Sexuality

  • Numerous changes can stress sexual relationship
  • Changes in sexual desire across trimesters
  • Sexual health and self-image play a role in sexual behavior during pregnancy

Pregnancy and Partner

  • Family-centered emphasis; partner’s reaction and changes
  • Couvade syndrome; ambivalence (sympathetic response)
  • Acceptance of roles (second trimester)
  • Preparation for reality of new role (third trimester)

Pregnancy and Siblings

  • Age-dependent reactions
  • Sibling rivalry with introduction of a new infant
  • Sibling preparation is imperative

Nutritional Knowledge Check: Lactose Intolerance and Calcium

  • Question: A lactose-intolerant client needs calcium-rich foods. Which foods could be suggested? (Select all that apply.)
    • Almonds
    • Molasses
    • Carrots
    • Peanuts
    • Broccoli
  • Correct responses: almonds, molasses, peanuts, broccoli
  • Rationale: While dairy is the best source of calcium, lactose-intolerant individuals may need alternatives such as nuts, seeds, greens, and fortified products. Lactose-free dairy or calcium-enriched beverages can help supplement calcium intake.

Question: Hormones and Labor

  • Question: Which hormone stimulates uterine contractions during labor and birth?
    • Options: progesterone, prolactin, estrogen, oxytocin
  • Correct answer: oxytocin
  • Rationale: Oxytocin stimulates uterine contractions required for delivery; progesterone and estrogen help maintain pregnancy; prolactin stimulates milk production after delivery

Question: Vegan Diet and Pregnancy Nutrition

  • Scenario: Vegan pregnant patient; which nutrients require special attention? (Select all that apply.)
    • Folate
    • Protein
    • Calcium
    • Vitamin B12
    • Iron
  • Correct answers: protein, calcium, vitamin B12, iron
  • Rationale: Vegan diets exclude animal products; pregnant vegetarians/vegans must ensure adequate intake of protein, iron, calcium, and B12 to support both mother and fetus. Folate is important but not listed as a required avoidance; it should be continued as part of prenatal nutrition, but the selected correct set emphasizes non-animal-derived nutrients important in pregnancy

Question: Expected Heart Rate Change in Pregnancy

  • Question: A woman with a prepregnancy heart rate of 72 bpm at 15 weeks gestation would be expected to have a heart rate of approximately:
    • 90, 95, 100, or 85 bpm
  • Correct answer: 85 bpm
  • Rationale: Heart rate increases by about 10–15 bpm between 14 and 20 weeks and remains elevated toward term. 72 + 10 to 15 = 82–87 bpm; closest option is 85 bpm

Quick Reference: Key Numerical Facts (Selected)

  • Normal to early signs: notable early signs include Chadwick sign (blue-purple cervix), Goodell sign (cervical softening), and Hegar sign (softening of the lower uterine segment)
  • Positive signs of pregnancy: ultrasound verification (4–6 weeks), fetal movement by clinician (20 weeks), fetal heart tones with Doppler (10–12 weeks)
  • Uterine fundal height: at 20 weeks, about at the level of the umbilicus (~20 cm)
  • Blood volume increase: ~50% above prepregnancy levels
  • CO and HR: increased cardiac output and heart rate; BP tends to decline slightly in mid-pregnancy then returns toward baseline
  • Hematology: plasma volume increases more than RBC mass → physiologic anemia; iron needs rise; hypercoagulable state
  • GI: pregnancy hormones increase vascularity; gums and dental health affected; constipation and hemorrhoids common; nausea/vomiting common especially early; heartburn common due to slowed gastric emptying
  • Respiratory: more diaphragmatic breathing; increased oxygen consumption; nasal congestion due to vascular changes
  • Renal: dilation of urinary tract; increased GFR; increased urine flow
  • Skin and hair: hyperpigmentation, linea nigra, striae, vascular changes, palmar erythema
  • Endocrine: multiple hormonal shifts including hCG, hPL, relaxin, progesterone, estrogen; thyroid and pituitary changes; insulin resistance in later pregnancy
  • Nutrition: emphasis on MyPlate, folic acid, avoidance of mercury-containing fish, no smoking or alcohol; balanced protein, iron, folate intake; maintain adequate calories and hydration