NURSING CARE RELATED

TO PSYCHOLOGICAL AND
PHYSIOLOGICAL
CHANGES OF PREGNANCY

GLORIA P. DE LEON,
RN,RM, MAN, Ed.D.
KEY TERMS
1. BALLOTMENT-
2. BRAXTON HICKS CONTRACTIONS-
3. CHADWICK’S SIGNS
4. COUVADE SYNDROME-
5. DIASTASIS
6. GOODELL’S SIGN
7. HEGAR SIGN
8. LIGHTENING
9. LINEA NIGRA
10. MELASMA

11. MONTGOMERY’S TUBERCLE

12. MULTIPARA

13. OPERCULUM

14. PRIMIGRAVIDA
15. QUICKENING

16. STRIAE GRAVIDARUM

OBJECTIVES
1. Describe common physiological and physiological
changes that occur with pregnancy and the
relationship of the changes to pregnancy diagnosis
2. Identify 2020 National Health Goals related to
preconception counseling and prenatal care that
nurses can help the nation achieve.
3. Assess a woman and her support team for
psychological adjustment to the physiologic
changes that occur with pregnancy.
4. Formulate nursing diagnosis related to adjustments
necessary because of psychological and
physiologic changes of pregnancy.
5. Identify expected outcomes in relation to a family’s
psychological and physical adaptation to
pregnancy to help them manage seamless
transitions across differing health care settings .
6. Using the nursing process, plan nursing care that
includes the six competencies QSEN,PCC,
teamwork , collaboration, evidence based practice,
Quality Improvement, safety and informatics
7. Implement nursing care, such as health teaching
related to the expected changes of pregnancy.
8. Evaluate outcomes for achievement and
effectiveness of goals to be certain expected
outcomes have been achieved.
9. Integrate knowledge of psychological and
physiologic changes of pregnancy with the interplay
of nursing process, the six competencies of QSEN and
family Nursing to promote quality maternal and child
health nursing care.
Nursing Care Planning Based on 2020 National Health
Goals
A number of a 2020 National Health Goals speak to
the care necessary because of physiologic and
psychological changes of pregnancy.
 Increase abstinence from alcohol, cigarettes, and
elicit drugs among pregnant women from baseline
of 89.45 % and 94.9% to target levels of 98.4%,
98.6% and 100 %.
 Reduce maternal deaths from a baseline of
12.7/100,00 live births to a target 11.4/100,000.
 Increase the proportion of pregnant women who
receive early and adequate prenatal care for a
baseline of 70.5% to a target level of 77.6% (US
Department of Health and Human Services,2010.
 Nurses can help the nation achieve these objectives
by being certain women receive counseling in
nutrition, safer sex practices, and low uses of alcohol
and tobacco before pregnancy so they can enter
intended pregnancies in the best health possible.
FOR HEALTHY ADAPTATION TO PREGNANCY
ASSESSMENT
 It begins before the pregnancy with preconception counseling
 Evaluate a woman’s overall health status, nutritional
intake(sufficient intake of folic acid and protein
 Lifestyle(drinking , smoking, and recreational drug habits

NURSING PROCESS OVERVIEW

 Identify any potential problems (ectopic pregnancy because of
tubal scarring
 Identify a woman’s understanding and expectations of
conception, pregnancy and parenthood.
NURSING DIAGNOSIS
1. Altered breathing patterns related to respiratory
system changes of pregnancy.
2. Disturbed body image related to weight gain from
pregnancy
3. Deficient knowledge related to normal changes of
pregnancy.
4. imbalance nutrition, less than body requirements,
related to early morning nausea.
5. Powerlessness related to unintended pregnancy.
6. Possible impaired health and prenatal care
behaviors associated with cultural beliefs.
OUTCOME IDENTIFICATION AND PLANNING
-Planning nursing care in connection with the
physiologic and psychological changes of pregnancy
should involve a plan to reviews the common
concerns women have about being pregnant before
changes occur, so there are no surprise.
 IMPLEMENTATION
1. They participate in sports or other activities that
conform to that self-image.
2. Help women at prenatal visits to voice their
concerns about the changes happening to them so
any worry brought on by these changes doe not
lead to stressful 9 months for them or prevent solid
bonding with their baby.
OUTCOME EVALUATION
1. Patients states she is able to continue her usual
lifestyle throughout pregnancy.
2. Family members describe ways they have adjusted
their lifestyles to accommodate the mother’s fatigue.
3. Couple states they appreciate the physiologic changes
of pregnancy and even though they are causing
discomfort, they know these are healthy changes .
 The various changes that a woman undergoes
during pregnancy entirely sweep the entirety of the
human body.

.
 Almost every aspect is altered, hormones get
together to create a whole new modifications in the
mind, the body, and the emotions.
 Psychological aspects would also be given a new
perspective as it also alters together with the rest of
the woman’s body.
How a Woman Responds to Pregnancy

 Mood swings, grief, changes in sexual desires, and

stress are only some of the psychological changes
that a pregnant woman experiences.
 The couple might misinterpret these changes, so
health education must be integrated in the care of
the pregnant woman.
Grief
 Grief may arise from the realization that one’s roles
would be changed permanently.

 A pregnant woman would be weaned off her role as

a dependent daughter, or as a happy-go-lucky girl,
or a friend who is always available.
.
 Even the partner would have to leave the roles or
the life he has been accustomed to as a man
without a child to support.
Mood Swings

 Also known as emotional liability, this psychological

reaction can be caused by two factors:
* hormonal changes or narcissism.
.
 The comments that she had brushed off in her non-
pregnant state can now touch a nerve or hurt her.
 Crying is a common
manifestation of mood swings,
during and even
after the pregnancy
Changes in Sexual Desire

 Women who are on the first trimester of pregnancy

experience a decrease
in libido mainly
because of breast
tenderness, nausea,
and fatigue.
 On the Second trimester, sexual libido may rise
because of
increased blood flow of the
pelvic area that
supplies the placenta.
 The Third trimester might bring
an increase or decrease
in sexual libido due
to an increase in
the abdominal size
or difficulty in finding
a comfortable position.
 Estrogen increase may also affect sexual libido as
it may bring a loss of desire.

 The couple must be informed that these changes

are normal to avoid misunderstanding the woman’s
attitude.
Stress
 Pregnancy is a major change in roles that could
cause stress.
 The stress that a pregnant
woman feels might
affect her ability
to decide.
 The discomforts that she may feel could also add up
to the stress she is experiencing.

 Assess whether the woman is in an abusive

relationship as it may contribute further to the
stress.
Introversion/Extroversion

 Introversion refers to someone who focuses entirely

on her own body and a common manifestation
during pregnancy.
 Some pregnant women also manifest extroversion,
or acting more active, healthier and more outgoing
than before their pregnancy.
 Extroversion commonly happens to women who had
a hard time conceiving and finally hit jackpot.
Social Changes
 In the past, a pregnant woman is isolated from her
family starting from visiting for prenatal
consultation until the day of birth.
 She is isolated from her
family and the
baby a week after birth.
 Today, having a support system for pregnant
women is highly encouraged, like bringing along
someone to accompany her during prenatal visits
and allowing the husband to be with the wife during
birth if he chooses to.
 Opinions on teenage pregnancy, late pregnancies,
and having the same sex parents are now widely
accepted compared to being taboos in the past.
Cultural Changes
 A pregnant woman’s culture and beliefs may also
greatly affect the course of her pregnancy.
 Assess if the woman and her partner have particular
beliefs that might affect the way the take care of
the pregnancy so you can integrate them in your
plan of care.
 Despite the modern ages, there are still groups who
firmly believe in their culture’s explanations about
birth complications and the health care providers
must respect this.
 Myths that surround the pregnancy should always
be respected, but the couple should be educated
properly regarding what could be dangerous for the
fetus’ health.
 Family Changes
 The environment where the woman grew influences
the way she would perceive her pregnancy.
 Family culture and beliefs also affect a woman’s
perception of pregnancy.
 If she is loved as a child, she would have an easy
time accepting her pregnancy compared to women
who were neglected by her family during childhood.
 A woman who has been told of disturbing stories
about giving birth and pregnancy would view her
own in a negative light, while those who grew with
beautiful birth stories would more likely be excited
for their pregnancy.
 A positive attitude would only result from a positive
outcome and influence from the woman’s own
family.
Individual Changes
 Becoming a new mother is never an easy transition.
The woman must first be able to cope with stress
effectively, as this is a major concern during
pregnancy.
 She needs to have the ability to adapt effectively to
any situation, especially if the pregnancy is her first
because there might be a lot of new situations that
would arise.
 Her ability to cope with a major change and manage
her temper would be put to a test during
motherhood.
 The woman’s relationship with her partner also
affects her ability to accept her pregnancy easily.
 If she feels secure with her relationship with the
father of her child,
 She would have an easier time accepting her
pregnancy as opposed to an unstable relationship
where she feels insecure and may doubt the
decision of keeping the pregnancy.
 A woman who feels that the pregnancy may rob her
of her looks, her freedom, a promotion, or her youth
would need to have a strong support system so she
could express her feelings and unburden her chest.
 The father’s acceptance of the pregnancy also
influences the woman’s ability to accept the
marriage.
 Utmost support from her husband would be very
meaningful for the woman especially during birth.
 Both the woman and her husband walk through a
tangle of emotions during pregnancy.
 Accepting that a new life would be born out of your
blood is not as easy as others may think.
 There are several stages that both should undergo,
the psychological way.

THE PSYCHOLOGICAL TASKS OF

PREGNANCY
First Trimester: Accepting the Pregnancy
 The shock of learning about a new pregnancy is
sometimes too heavy for a couple, so it is just
proper for the both of them to spend some time
recovering from this major
life-altering situation
and avoid overwhelming
themselves at first.
 One of the most common reactions of a couple who
would be having a baby for the first time is
ambivalence, or feeling both pleased and unhappy
about the pregnancy.
Second Trimester: Accepting the Baby
 The woman and her partner will start to merge into
the role of novice parents as second trimester
closes in.
 Emotions such as narcissism and introversion are
commonly present at this stage.
 Role playing and increased dreaming are activities
that help the couple embrace their roles as parents.
 At this stage, the woman and her partner must start
to concentrate on what it will feel like to be parents
Third Trimester: Preparing for the Baby
 The couple starts to grow impatient as birth nears.
 Preparations for the baby, both small and big, takes
place during this stage.

 The baby’s clothing and sleeping arrangements are

set and the couple is excited for his arrival.
 The transition of a woman from the start until the
end of the pregnancy is a big turning point for her
and the people who surround her.
 Every single one of them must be prepared
physically, mentally and emotionally because
pregnancy is also considered a crisis in life;
something that could turn your world upside down.
 Pregnancy is confirmed with a pregnancy test.
 A pregnancy test can be done on either urine or
blood.
 Pregnancy tests find the presence of human
chorionic gonadotropin hormone (hCG).

 This is a hormone made by

the placenta about
10 days after fertilization
 Levels of the hCG hormone approximately double
every two days during the first 60 days of
pregnancy.
 Pregnancy tests that use the woman's blood are
done by a healthcare provider usually to get a very
early diagnosis of pregnancy or to confirm an at-
home pregnancy test.

 Blood tests are very accurate and can find

pregnancy by the second week after conception.
 Women can conduct an at-home pregnancy test by
testing a sample of urine about two weeks after
conception, or about the time a period is due.

.
 Home pregnancy tests have become more accurate
in the last decade.

 If the test is used correctly, most home pregnancy

tests are 97% to 99% accurate.
 Always talk with your healthcare provider to confirm
a positive at-home pregnancy test with a more
reliable pregnancy test and physical exam.

 If your at-home pregnancy test results are

negative, and you think you are pregnant, you
should also talk with your healthcare provider.
 DEFINITION OF PREGNANCY It is the state of
carrying a developing embryo or fetus within the
female body from conception to birth.

 After the egg is fertilized by sperm and then

implanted in the lining of the uterus, it develops into
placenta and embryo or fetus.
DURATION OF PREGNANCY
1. Usually 40 weeks or
2. 280 days or 10 lunar months or
3. 9 months and 7 days,
calculated from the first
day of last menstrual period.
 Beginning from the first day of last menstrual period
, It is divided into three trimesters, each lasting
three months.
 First trimester ( First 12 weeks)
 Second trimester ( 13-28 weeks)
 Third trimester ( 29-40 weeks)
FIRST TRIMESTER PRESUMPTIVE SIGNS OR SUBJECTIVE
SYMPTOMS
 AMENORRHOEA
 MORNING SICKNESS
 FREQUENCY OF MICTURITION
 BREAST DISCOMFORT
 FATIGUE
 FAINTING
 AMENORRHOEA
• Absence of menstruation in woman of reproductive
age.
• Since nine months
during pregnancy
periods are not occurred .
 •If any type of bleeding is occurred during 9 months
should not be confused with the commonly met
pathological bleeding
. E.g. – Threatened abortion.
 MORNING SICKNESS
• It is present in about 50% cases, mostly during first
pregnancy.
 • Nausea and vomiting begins about 6 weeks after
the last menstrual period and usually disappears by
about 14 weeks.
 • It is due to the high level of pregnancy hormones
 Increased human chorionic gonadotrophin (hCG)
levels — a hormone the body begins to produce
after conception.
 FREQUENCY OF MICTURITION
• Resting of bulky uterus on the fundus of the bladder
because of anteverted position of uterus.
• It is present during 8-12 week of pregnancy and
subside after 12 weeks
 BREAST DISCOMFORT
• It is present during 6th week in the form of feeling of :
* Tenderness.
* Tingling.
* Fullness.
* Increase in size.
* Pigmentation of areola.
* Pricking sensation.
 FATIGUE
• It is frequent in early pregnancy
and subside around
12-14 weeks of pregnancy
with bringing renew energy
 Hormonal changes most likely contribute to exhaustion,
but other common pregnancy discomforts also play a
role.
For example, it's hard to get a good night's sleep if your
back aches or if you have to get up to use the bathroom
frequently.

Nausea and vomiting can certainly cost you energy as

well
 FIRST TRIMESTER PROBABLE SIGNS OR OBJECTIVE
SIGNS
• Breast changes
• Cardio-vascular changes
• Respiratory changes
• Integumentary changes
• Musculo-skeletal changes
• Abdomen and uterine changes
• Pelvic changes
 BREAST CHANGES
 • These are valuable only in primipara, compared to
multipara.
Breast changes are
evident between 6-8 weeks.
 There is enlargement with vascular engorgement
with delicate veins visible under the skin due to
increased blood supply, making the veins more
noticeable.
 .Nipples and areola (primary) become more
pigmented or darker.
 Montgomery’s tubercles are prominent.
 The thick yellowish secretion (colostrum) can be
expressed as early as 12th week
 PELVIC CHANGES
 Jacquemier’s or Chadwick’s sign:
It is dusky hue of vestibule and anterior vaginal wall
visible at about 8th week of pregnancy.
The discoloration is
due to local vascular
congestion.
Vaginal sign :
 Apart from bluish discoloration of the anterior
vaginal wall, walls become softened, copious
amount of non-irritating mucoid discharge appears
at 6th week.
 There is increased pulsation felt through the lateral
fornices at 8th week called Osiander’s Sign.
 Cervical signs :
Cervix becomes soft as early as 6th week ( Goodell’s
sign), the pregnant cervix feels like lip of mouth, while
in non-pregnant state like tip of nose.
UTERINE CHANGES
A) Size, shape and consistency :
Uterus enlarged to:
• size of hen’s egg at 6th week.
•Size of cricket ball at 8th week.
•Size of fetal head at 12th week
 Pyriform shape of nonpregnant uterus becomes
globular by 12th week.
There may be asymmetrical
enlargement of uterus
if there is lateral implantation.
 ( One half is more firm than other half.
 As pregnancy advances, symmetry is restored,
uterus feels soft and elastic)
Hegar’s sign:
• It is present in two third of cases.
• It can be demonstrated
between 6-10 weeks.
 • It is softening and compressibility of the lower
segment of the uterus felt on bimanual examination
( Two fingers in anterior fornix and abdominal fingers
behind uterus).
 C) Palmer’s sign:
Regular rhythmic uterine
contraction on bimanual
examination at 4-8 weeks .
POSITIVE SIGNS COMMON TO ALL TRIMESTER
 IMMUNOLOGICAL TEST
 ULTRASONOGRAPHY
IMMUNOLOGICAL TEST
• Agglutination test
• Dip stick test
• Enzyme linked monoclonal
antibody tests.
URINE PREGNANCY TESTS:
• Fluoro-immunoassay (FIA)
• Radioimmunoassay (RIA)
• Immuno-radiometric assay (IRMA)
• ELISA SERUM PREGNANCY TESTS
SECOND TRIMESTER SUBJECTIVE SYMPTOMS
AMENORRHOEA

ENLARGEMENT OF LOWER ABDOMEN

DECREASE MORNING SICKNESS
DECREASE URINARY SYMPTOMS
QUICKENING
VAGINAL CHANGES Second trimester
Objective symptoms
ABDOMINAL SIGNS SKIN CHANGES
Cholasma
 ABDOMINAL SIGNS SKIN
• LINEA NIGRA
• CHOLASMA GRAVIDARUM
• STRIAE GRAVIDARUM PALPATION
 • FUNDAL HEIGHT
 • SHAPE & CONSISITENCY OF UTERUS
 • BRAXTON- HICKS CONTRACTION
 • PALPATION OF FETAL PARTS
 • ACTIVE FETAL MOVEMENTS AUSCULTATION
 • FETAL HEART SOUND:
 • - UTERINE SOUFFLE
 • -FETAL SOUFFLE
FETAL HEART SOUND FETAL HEART SOUND :
FHS is the most conclusive clinical sign of pregnancy.
It can be detected between 18-20 weeks by
stethoscope.
 The fetal heart rate varies from 120-160 beats/ min.
 Two other sounds are confused with FHS.
 Those are:
 UTERINE SOUFFLE: It is soft blowing and systolic
murmur heard low down at the side of uterus, best
on left side.
 This sound is synchronized with maternal pulse and
is due to increase in blood flow through dilated
uterine vessels.
 . FETAL SOUFFLE or FUNIC
 : It is due to rush of blood through umbilical
arteries. It is soft, blowing murmur , synchronized
with FHS.
 THIRD TRIMESTER SUBJECTIVE SYMPTOMS OBJECTIVE SIGNS
SUBJECTIVE SYMPTOMS
  Amenorrhea.
  Progressive enlargement of abdomen.
 Palpitation and dyspnea following
exertion due to enlarge abdomen
  Palpitation and dyspnea following exertion due to
enlarge abdomen.
  Lightening: At about 38 week, sense of relief of
pressure symptoms obtained due to engagement of
presenting part.
 Frequency of micturition reappears.
 Fetal movements are more pronounced
OBJECTIVE SYMPTOMS
• Palpation of fetal parts.
• Palpation of fetal movements.
• Auscultation of fetal heart sound.
• Occasional auscultation of funic soufflé.
 Cutaneous changes are more prominent with
increase pigmentation and striae.
 • Uterine shape is changed from cylindrical to
spherical by 36th week.
 • Fundal height: The distance between umbilicus
and inseform cartilage is divided into three equal
parts
 FUNDAL HEIGHT Pregnancy in weeks
 Fundal height At 32th week
 Junction of upper and middle third of ensiform
cartilage At 36th week Up to the level of ensiform
cartilage.
 At 40th week Down to the 32th week due to
engagement of presenting part
Physiological Changes of Pregnancy

* There are physiological biochemical and

anatomical changes that occur during pregnancy.
 These changes occur during pregnancy to maintain
a
healthy environment for the fetus with out
compromising the mother’s health.
 And prepare for the process of delivery and care of
the newborn.

 Understanding of the normal changes helps to

understand coincidental disease processes.
 Gastro Intestinal Tract (GIT)
 Nutritional requirements including for vitamin and
minerals are increased so usually mother's appetite
increase.
 Pregnant women tend to rest more often conserving
energy and there by enhancing fetal nutrition
 Oral cavity feels salivation
 Gums- hypertrophic and hyperemic easily bleed (20
to increased systemic estrogen)
 Gastrointestinal mobility May be reduced due to increased
progesterone (w/c decreased the hormone motile stimulate.
 smooth muscles in GIT) hence gastric emptying is
slowed and similarly in other part of GIT
constipation (due to increased water absorption)
 Stomach Production of gastrin increase increased
gastric volume and decreases PH, mucous
production increased PUD usually improve or
disappear because of these changes during
pregnancy.
 However during the pregnancy because of the
enlarging uterus heart burn is common due to
gastric reflux
 Enlarging uterus slower emptying time, increase
intragstric pressure increase acidity and increased
gastric reflux.

 The anatomical position of small and large intestine

as well as appendix will shift because of the
enlarging uterus
 Gallbladder

 Progesterone decreased motility → decreased

emptiy time of bile →stasis →stone formation and
infection.
Liver
 No morphological changes but functional changes
 Decreased plasma protein (albumen) an globline
(synthesized by liver) increases serum alkaline
phosphatase activity.
Urinary Systems

 - Each kidney increase in length and weight

 The renal pelvis and ureter dilate and lengthen
 Thus there is an increase urinary stasis increase risk
of infection and stone formation .
Renal Function
 ƒ Change occur due to increased maternal and
placental hormonesƒ (ACTH, ADH, cortisole, etc.)
and increase in plasma volume
 ƒGlomerular Filtration Rate increase by 50% (begins
early and last up to term)
 Renal blood flow rate increase by 20-25% (early to
 Mid trimester) after the end of 2nd trimester remain
 constant.

 ƒ Urine volume dose not increase although

glomerular
 filtration rate increase because of reabsorption.
 Creatinine and BUN decrease because of increased
Clearance ƒ rate

 ƒ Glycosuria is not necessarily as normal

 ƒ Protein urea changes little during pregnancy

 Bladder

 Is displaced upward and anteriorly by enlarged

uterus as a result it increases pressure leading to
and urinary urgency and frequency
Hematological System:
- Increase in blood volume – most striking change
- The change occurs until term and the average
increase in volume is 45-50%
 - The mechanism for increase the volume of blood is
not well understood (aldosterone related factor
during pregnancy may contribute to this effect)
increase water and salt retention.
 RBC increased by 33%
 - Iron need increases because of increase in red
blood cell mass.
 This is why Iron supplementation is necessary
during pregnancy.
 - WBC total count usually increase
 - Platelets increase in production
 Clotting factors
 - Several factors increase- F- I, F-VIII mainly
 - To lessees extent, F-VII, IX, X and XII
 - Decrease- F- XI, F-XIII
Cardiovascular System
 Heart slightly shift in position
 Enlarging Uterus → diaphragm→ displace up ward →
shift of apex beat Cardiac capacity increase by 70-
80m
 Cardiac out put
 - increase a 49% during pregnancy reach may at 20-
24weeks of gestation the constant until term
Blood Pressure
Systemic blood pressure declines slightly during
pregnancy
 There is little change in SBP but DBP decrease by 5-
10
mmHg from 12-26 weeks, then increase to non
pregnant level by term.
Venous Pressure
- No change in the upper body
- Increase in the lower extremities enlarged
- Decrease venous return to the heart increases
pressure
and results in edema.
Pulmonary System
 - Capillary dilatation occurs in the respiratory route
(Naso-pharynx, larynx, trachea, bronchi) → make
breathing difficult through nose,
enlarged Uterus pushes
the diaphragm
and the lungs as well.
Summary of Pulmonary changes

Changes to volume
 Tidal volume increase by 35-50%
 Residual volume decreased by 20%
 Expiratory reserve volume decrease by 20%
 So increase Tidal volume and decrease
 Residual volume → increased alveolar ventilation by
65%
 Functional respiratory changes include

 A slight increase in respiratory rate 50% increase in

minute ventilation 40% increase in minute tidal
volume.

 Progressive increase in oxygen consumption (15-

20% above non pregnant level by term)
 Changes in the Breast

 Breast increases in size with enlargement of the

nipple and increased vascularity and pigmentation
of areola
Change in Skin
 Hyperpigmentaion over some part of the body
 Face (forehead, cheek) - cholasma
 Abdomen –sub-umbilical midline dark purplish
pigmentation of
 linea alba- linea nigra Streach mainly
 - Striea gravidarum
 Enlarging abdomen → stretch on collagen fibbers of
the skin and effect of ACTH
Change in Vagina and Uterus
 Vagina – increase in capacity and length secondary
to the hypertrophy of the lining epithelium and
muscle layer.
 Increased glycogen content in the wall secondary to
the effect of estrogen Increases vascularity and
change the color to purple
 Fold increases by term
 Uterus – Upper part fundus and body change in to
upper uterine segment
 - Lower part cervix and isthmus change in to lower
uterine segment
 - Weight increases from 60gm to l kg at term,
volume 10ml to 5 liters.