MATERNAL ADAPTATION TO PREGNANCY

Nursing Process OverviewFor Healthy Adaptation to Pregnancy

AssessmentIdeally, begins before the pregnancy. During a

preconception assessment Evaluate

Woman's health status Nutritional intake Lifestyle Identify any potential problems Identify the woman's understanding and

expectations of conception, pregnancy, and parenthood.

Establish a trusting relationship Assess the woman's health and nutritional status, as

well as the well-being of the fetus, throughout pregnancy.

Document the woman's physiologic adaptations and the family's psychological adaptations to pregnancy

Physical findings are gained through the health history, physical assessment, and laboratory tests.

Assessment in psychological areas interviewing

should include societal, cultural, family, and personal influences on the client's adaptation to pregnancy.

Nursing DiagnosisExamples of nursing diagnoses

Anxiety related to unexpected pregnancy Altered breathing pattern related to respiratory

system changes of pregnancy Disturbed body image related to weight gain with

pregnancy Deficient knowledge related to normal changes of

pregnancy Imbalanced nutrition, less than body requirements,

related to morning sickness

Outcome Identification and PlanningPlan to review concerns of the woman as well

as a plan to ask about the individual responses she is experiencing.

ImplementationHelp women at prenatal visits to voice their

concerns about either physiologic or psychological changes of pregnancy,

May need suggestions on exercise and nutrition to prepare for pregnancy and to follow during pregnancy.

Nursing interventions can be instrumental in not only guiding a woman safely through a pregnancy but also connecting her back with ongoing health care.

Outcome EvaluationClient states she is able to continue her usual

lifestyle throughout pregnancy.Family members describe ways they have

adjusted their lifestyles to accommodate the mother's fatigue.

Couple states they accept the physiologic changes of pregnancy as normal.

Psychological Changes of Pregnancy Woman's attitude toward a pregnancy

depends a great deal on psychological aspectsthe environment the messages about pregnancy her family

communicated to her as a childthe society and culture in which she lives as an

adultwhether the pregnancy has come at a good

time in her life.

Social Influencescultural backgroundtheir personal experiencesthe experiences of friends and relativescurrent public philosophy of childbirth. People's opinions about adolescent

pregnancies, “late in life” pregnancies, or lesbian pregnancies have changed markedly.

Cultural Influencesmay strongly influence how active a role she wants

to take in her pregnancycertain beliefs and taboos may place restrictions on

her behavior and activities To learn about the beliefs of a particular woman and

her partner, ask at prenatal visits if there is anything they believe should or should not be done to make the pregnancy successful and keep the baby healthy.

Supporting these beliefs shows respect for the individuality of the woman and her knowledge of good health

Family InfluencesLoving family: more likely to have a

positive attitude toward her pregnancy “People love as they have been loved” Woman who views mothering as a

positive activity is more likely to be pleased when she becomes pregnant than one who devalues mothering

Individual InfluencesWoman's ability to cope with or adapt to stress Security in her relationship with the people

around her, especially the father of her child, is usually also important to her acceptance of a pregnancy.

A woman who thinks of brides as young but mothers as old may believe pregnancy will rob her of her youth.

The Psychological Tasks of Pregnancy First Trimester: Accepting the Pregnancy

Accept the reality of the pregnancy. A diagnosis of pregnancy is a similar rite of

passage. In reality, as many as 50% of pregnancies are

still unintended, unwanted, or mistimed Often women immediately experience

something less than pleasure and closer to disappointment or anxiety at the news that they are pregnant.

The PartnerPartner may go through some of the same

psychological changes.Accepting the woman in her changed state. A partner should try to give the woman emotional

support while she is learning to accept the reality of pregnancy

Often partners are proud and happy about the pregnancy, facilitating acceptance of it.

An unwed father may have a great deal of difficulty accepting a pregnancy unless he is actively involved in prenatal care.

Second Trimester: Accepting the BabyThe WomanAccept that she is having a baby, a separate

step from accepting the pregnancy. Second turning point in pregnancy :

quickening, or the first moment a woman feels fetal movement.

She begins to imagine herself as a motherRealize that not only is she pregnant but also

there is a child inside her.

Second Trimester: Accepting the BabyThe Partner

Feeling of being left outSome men may have difficulty enjoying the

pregnancy if they have been misinformed about sexuality, pregnancy, and women's health.

Many men comment that the information they receive about childbirth and pregnancy is too concerned with their partner or the child and not enough with how they feel to be relevant to them.

Third Trimester: Preparing for Parenthood“nest-building” activities”It is helpful for couples to attend

childbirth education classes or classes on preparing for parenthood.

Emotional Responses to PregnancyAmbivalence

may want to be pregnant, and yet she may not be enjoying it. This leads to some degree of ambivalence.

refers to the interwoven feelings of wanting and not wanting that can exist at high levels.

It is important to emphasize that this ambivalence is normal.

Partners also experience ambivalence, sometimes more so than pregnant women.

To help partners resolve some ambivalence, provide an outlet for them to discuss concerns, and offer parenting information at prenatal visits.

GriefBefore a woman can take on a mothering

role, she has to give up or alter her present roles.

She must incorporate her new role as a mother into her other roles as a daughter, wife, or friend.

Her partner must incorporate a new role as a father into his other roles of son, husband, or friend.

NarcissismSelf-centeredness (narcissism) is generally an

early reaction to pregnancy. Dressing becomes a time-consuming, mirror-

studying procedure. She makes a ceremony out of fixing her meals. May lose interest in her job or community events Men may demonstrate the same behavior by

reducing risky activities Need to protect her body has implications for

nursing care.

Introversion Versus ExtroversionIntroversion, or turning inward to

concentrate on oneself and one's body, is a common finding during pregnancy.

They become more active, appear healthier than ever before, and are more outgoing.

StressTime of extreme stress for a womaMay cause people who were dependent on the

woman before pregnancy to feel neglectedTo help families keep their perspective, remind

them that a decrease in the responsibilities that a pregnant woman takes on is a reaction to the stress of pregnancy, not the pregnancy itself.

A woman with few support people around her almost automatically has more difficulty adjusting to and accepting a pregnancy

Couvade SyndromeMen experience physical symptoms such as nausea,

vomiting, and backache to the same degree or even more intensely than their partners do during a pregnancy.

These symptoms apparently result from stress, anxiety, and empathy for the pregnant woman.

The more the partner is involved in or attuned to the changes of the pregnancy, the more symptoms he may experience.

For the most part, these are healthy happenings and require psychological attention only if the man becomes emotionally stressed or delusional

Changes in Sexual Desire1st Trimester: decrease in libido

nausea, fatigue, and breast tenderness that accompany early pregnancy.

2nd trimester: libido and sexual enjoyment rise markedly. blood flow to the pelvic area increases to

supply the placenta 3rd trimester: sexual desire may remain high,

or it may decrease because of difficulty finding a comfortable

position and increasing abdominal size.

Reproductive System

Uterus (UterineMeasurements)

UterineWt.ThicknessLengthDepthWidthCapacity

Pregnancy50 gm.2 cm6.5 cm2.5 cm4 cm10 ml

Term Pregnancy1100 gm.0.5 cm32 cm20 cm24 cm5000 ml

Blood Flow : Uterine blood flow increases from 20 ml before pregnancy to 700 to 900 ml at the end of pregnancy. ¾ of the blood supply goes to the placenta.

Shape : From pear shape before pregnancy to spherical and later on to ovoid shape in the last months of pregnancy

Position : After 12 weeks gestation, the uterus loses its anteflexed position.

Reproductive System

Location of the Fundus :

12 weeks - at the level of the symphisis16 weeks – halfway between symphisis and

umbilicus20 weeks – level of the umbilicus24 weeks – 2 fingers above the umbilicus30 weeks – midway between umbilicus and

xiphoid process36 weeks – level of the xiphoid process40 weeks – 2 fingers below the umbilicus, drops

at 34 weeks level because of lightening

Reproductive System

Contractility : uterus is a highly contractile organ. Beginning on the first trimester, the uterus undergoes irregular contractions.

Late in pregnancy, these contractions, known as Braxton-Hicks, becomes more intense and frequent causing some discomfort on the pregnant woman. It is the cause of false labor.

Reproductive System

CervixColor : Change from pink to purplish due to

increase blood supplyLeukorrhea : Estrogen stimulation results in

increase mucus production that leads to the formation of operculum, the mucus plug of the cervix that protects against bacteria and infection.

Consistency: Softening of the cervix, known as Goodel’s sign, is observable by 6 to 8 weeks gestation.

Reproductive System

IsthmusDuring pregnancy, the isthmus softens and elongates up to 25 mm. It will later form the lower uterine segment, together with the cervix.

Hegar’s sign – softening of the lower uterine segment begins as early as 5 week gestation

Reproductive System

VaginaIncrease blood supply results in:

Chadwick sign – change color from pinkish to purplish or dark-blue

Increase sensitivity and heightened sexual responsiveness

Vaginal ph 3.5 to 6, acidic

Reproductive System

Ovaries

No Graafian follicle develop and no ovulation occurs during pregnancy

Corpus luteum is the chief source of hormone progesterone during the first 12 weeks gestation, it also produces estrogen, relaxin, inhibins and sometimes oxytocin.

Reproductive System

BreastIncrease breast size due to alveolar tissue

growth, fat deposition and increase vascularity.associated with pregnancy includes

feeling of fullness and tingling sensationdarkening of the skin around the areola.Montgomery’s gland becomes prominent and

nipples stand out. A clear fluid called colustrum, can be

expressed from it as early as the 4th month.

Reproductive System

Cardiovascular SystemBlood Volume

Total volume increases by 45 to 50% for which 75% is plasma and 25% is RBC.

Increase volume leads to increase in cardiac output by 25 to 50%

Increase in blood volume reaches its peak at about 24 weeks, cardiac workload also reaches its peak during the 2nd trimester.

Blood ConstituentsIncrease production of RBC by the bone marrowHemodilution occurs causing pseudoanemiaIncrease protein requirement of the fetus and

hemodilution contribute to the reduction of maternal plasma protein level. Reduction of protein level lowers osmotic pressure within intravascular spaces which causes fluid shift from intravascular to interstitial space. This contributes to the normal ankle and foot edema of pregnancy.

Blood lipid and cholosterol level increases to provide an available supply of energy for the fetus

Increase level of clotting factor making woman prone to thrombus formation. Instruct to avoid massage

Cardiovascular System

Heart

The heart is displaced to the left and upward of the diaphragm

Slight cardiac enlargementPalpitation during pregnancy.

In the 1st trimester is due to parasympathetic stimulation

In the latter part of pregnancy, it is due to enlarged uterus.

Cardiovascular System

Blood PressureBlood pressure remains the same as

pre-pregnancy level. It may drop slightly on the 2nd trimester but returns to normal levels on the 3rd trimester.

Arterial blood pressure is highest in sitting position, intermediate in supine and lowest in left lateral position.

Supine Hypotensive Syndrome.

Cardiovascular System

Respiratory systemIncrease oxygen requirementEffects of estrogen and progesteroneMechanical effect of the enlarge uterusHyperventilation – in an effort to blow off the extra

CO2 from the fetus.Displacement of the diaphragm – because of the

enlarged uterus Chest crowding – compensate by expanding the

lung horizontally Decrease residual volume – less air is left in the

lung after expiration Shortness of breath

Total body comsumption of O2 increase by 15 – 20%

Nasal congestion occurs due to estrogen stimulation.

Respiratory system

Urinary SystemUrinary frequency during pregnancy is due to:

1st trimester – uterus exerts pressure on the bladder as it rises out of the pelvic cavity

2nd trimester – pressure of the presenting part on the bladder after lightening

Increase blood flow to the kidney which increases glomerular filtration rate and consequently, urinary output.

Lactosuriapresence of lactose in the urine is considered

normal.Lactose is secreted by the mammary glands but

since it is not yet used during pregnancy, it normally spills in the urine.

Nocturia – increase urination at night

Gastrointestinal System

Nausea and vomiting on the 1st trimester is attributed to:increase HCG levelIncrease estrogen level decrease maternal glucose level is being

utilized for fetal brain development

Effects of ProgesteroneDecrease GIT motility – constipationPyrosis / Heartburn – relaxation of

cardiac sphincterSlowed bile movement from gall bladder

result in reabsorption of bilirubin in the maternal blood stream – pruritus

Gastrointestinal System

Effects of Estrogen Ptyalism – increase salivation Epulis – hypertrphy or swelling of the

gums.

Gastrointestinal System

Intergumentary SystemMelasma – facial discolorationLinea Negra – dark line from the umbilicus

to the symphisisDarker areola

Increase melanin productionStriae gravidarumPalmar erythemaVascular Spider neviActivation of sweat and oil glands

Endocrine System

Thyroid glands – slightly enlarge due to increase metabolic rate

Pancreas – elevated glucocorticoid level increase insulin production

Parathyroid gland – increase needs for calcium

Adrenal gland – increased corticosteroid production and aldosterone promote sodium reabsorption and water retention.Posterior pituitary secretes increase amount of oxytocin and prolactin as pregnancy nears.

Skeletal System

Softening of joints and ligaments, especially symphisis and sacroiliac joint is caused by relaxin and estrogen

Leg cramps is caused by pressure of gravid uterus on nerves and imbalance of calcium in the body.

SIGNS AND SYMPTOMS OF PREGNANCYPressumptiveAmenorrheaBreast changeUrinary frequencyQuickeningEasy fatigabilityLeukorrheaNausea and vomitingChadwick signStriaeLinea negraMelasma

ProbableHegar’s sign Uterine growthBallotementUterine ShuffleGoodel’s signBraxton-Hicks ContractionFetal outlinePositive Pregnancy test

PositivePositive FHTFunic ShuffleFetal movementX-ray visualizationPositive Ultrasound