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Maternity and Pediatric Nursing


Chapter 11
Maternal Adaptation During Pregnancy

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Objectives:
Upon completion of the chapter the learner will be able to:
1.

Define the key terms used in this chapter.

2.
Differentiate between subjective (presumptive), objective (probable),
and diagnostic (positive) signs of pregnancy.
3.

Explain maternal physiologic changes that occur during pregnancy.

4.

Summarize the nutritional needs of the pregnant woman and her fetus.

5.
Identify the emotional and psychological changes that occur during
pregnancy

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Key Terms
Ballottement
Braxton Hicks Contractions
Chadwicks Sign
Goodells Sign
Hegars Sign
Linea nigra
Physiologic anemia of Pregnancy
Pica
Quickening
Trimester

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Assessment of Pregnancy

Internal ballottement (18 weeks).


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Hegar's sign.
Bimanual
examination for
assessing
compressibility
and softening of
isthmus (lower
uterine segment)
while the cervix is
still firm

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Signs and Symptoms of Pregnancy


Presumptive Signs (subjective)
Fatigue (12 weeks)
Breast tenderness (3-4 weeks)
Nausea and vomiting (4-14 weeks)
Amenorrhea (4 weeks)
Urinary frequency (6-12 weeks)

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Signs and Symptoms of Pregnancy


(contd)
Presumptive signs (contd)
Hyperpigmentation of skin (16 weeks)
Fetal movements (quickening) (16-20 weeks)
Uterine enlargement (7-12 weeks)
Breast enlargement (6 weeks)

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Signs and Symptoms of Pregnancy


(contd)
Probable (objective) signs
Braxton Hicks contractions (16-28 weeks)
Positive pregnancy test (4-12 weeks)
Abdominal enlargement (14 weeks)
Ballottement (16-28 weeks)
Goodells sign (5 weeks)
Chadwicks sign (6-8 weeks)
Hegars sign (6-12 weeks)
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Signs and Symptoms of Pregnancy


(contd)
Positive signs
Ultrasound verification of embryo or fetus (4-6
weeks)
Fetal movement felt by experienced clinician (20
weeks)
Auscultation of fetal heart tones via Doppler (1012 weeks)

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Question

Is the following statement True or False?


A positive pregnancy test is a positive sign of pregnancy.

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Answer
False.
A positive pregnancy test is considered a probable sign of
pregnancy because conditions other than pregnancy can
also elevate hCG levels.

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Pregnancy Adaptations

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Reproductive System Adaptations


Uterus
Increase in size, weight, length, width, depth,
volume, and overall capacity
Pear shape to ovoid shape; positive Hegars sign
Enhanced uterine contractility; Braxton Hicks
contractions
Ascent into abdomen after 1st 3 months
Fundal height by 20 weeks gestation at level of
umbilicus; 20 cm; reliable determination of
gestational age until 36 weeks gestation
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Height of fundus
by weeks of
normal gestation
with a single
fetus. Dashed
line, height after
lightening

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17

Reproductive System Adaptations (contd)


Cervix
Softening (Goodells sign)
Mucous plug formation
Increased vascularization (Chadwicks sign)
Ripening about 4 weeks before birth
Vagina
Increased vascularity with thickening
Lengthening of vaginal vault
Secretions more acidic, white, and thick;
leukorrhea
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Reproductive System Adaptations


Ovaries
Enlargement until 12th to 14th week of gestation
Cessation of ovulation
Breasts
Increase in size and nodularity to prepare for
lactation; increase in nipple size, becoming more
erect and pigmented
Production of colostrum: antibody-rich, yellow
fluid that can be expressed after the 12th week;
conversion to mature milk after delivery
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Vena Cava Compression

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GI System Adaptations
Gums: hyperemic, swollen, and friable
Ptyalism
Dental problems; gingivitis
Decreased peristalsis and smooth muscle relaxation;
constipation
Constipation + increased venous pressure + pressure
from uterus = hemorrhoids
Slowed gastric emptying; heartburn
Prolonged gallbladder emptying
Nausea and vomiting
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Cardiovascular System Adaptations


Increase in blood volume (50% above prepregnant
levels)
Increase in cardiac output; increased venous return;
increased heart rate
Slight decline in blood pressure until midpregnancy,
then returning to prepregnancy levels
Increase in number of RBCs; plasma volume > RBC
leading to hemodilution (physiologic anemia)
Increase in iron demands, fibrin & plasma fibrinogen
levels, and some clotting factors, leading to
hypercoagulable state
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Question

When assessing a pregnant woman, which of the following


would the nurse expect to find?
A. Increase in blood pressure
B. Complaints of nausea
C. Dry mouth
D. Diarrhea

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Answer
B.
A woman would most likely complain of nausea due to
high levels of hCG and circulating estrogens,
reduced stomach acidity, and lowered tone and
motility of the digestive tract. Blood pressure usually
declines and then returns to prepregnant levels after
midpregnancy. Constipation, not diarrhea, and
excess salivation, not dry mouth, might also be
found.

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Respiratory System Adaptations


Breathing more diaphragmatic than abdominal due
to increase in diaphragmatic excursion, chest
circumference, and tidal volume
Increase in oxygen consumption
Congestion secondary to increased vascularity

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Renal/Urinary System Adaptations


Dilation of renal pelvis; elongation, widening, and
increase in curve of ureters
Increase in length and weight of kidneys
Increase in GFR; increased urine flow and volume
Increase in kidney activity with woman lying down;
greater increase in later pregnancy with woman
lying on side

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Musculoskeletal System Adaptations


Softening and stretching of ligaments holding
sacroiliac joints and pubis symphysis
Postural changes: increased swayback and upper
spine extension
Forward shifting of center of gravity
Increase in lumbosacral curve (lordosis);
compensatory curve in cervicosdorsal area
Waddle gait
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Integumentary System Adaptations


Hyperpigmentation; mask of pregnancy (facial
melasma)
Linea nigra
Striae gravidarum
Varicosities
Vascular spiders
Palmar erythema
Decline in hair growth; increase in nail growth
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Palmer Erythema

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29

Facial Melasma

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30

Linea nigra
Striae
gravidarum

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31

Endocrine System Adaptations


Thyroid gland: slight enlargement; increased activity;
increase in BMR
Pituitary gland: enlargement; decrease in TSH, GH;
inhibition of FSH & LH; increase in prolactin, MSH;
gradual increase in oxytocin with fetal maturation
Pancreas; insulin resistance due to hPL and other
hormones in 2nd half of pregnancy (see Box 11-2)
Adrenal glands: increase in cortisol and aldosterone
secretion
Prostaglandin secretion
Placental secretion: hCG, hPL, relaxin, progesterone,
estrogen (see Table 11-3)
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Question
Is the following statement True or False?
Oxytocin is a hormone secreted by the anterior pituitary
gland.

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Answer
False.
Oxytocin is a hormone secreted by the posterior pituitary
gland.

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Nutritional Needs
Direct effect of nutritional intake on fetal well-being and
birth outcome
Need for vitamin and mineral supplement daily
Dietary recommendations
Increase in protein, iron, folate, and calories (see
Table 11-5)
Use of USDAs Food Guide Pyramid (see Figure 115)
Avoidance of some fish due to mercury content

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Maternal Weight Gain


Healthy weight BMI: 25 to 35 lb
1st trimester: 3.5-5 lb
2nd & 3rd trimesters: 1 lb/week
BMI < 19.8: 28 to 40 lb
1st trimester: 5 lb
2nd & 3rd trimesters: 1+ lb/week
BMI > 25: 15 to 25 lb
1st trimester: 2 lb
2nd & 3rd trimesters: 2/3 lb/week
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Nutrition Promotion
Food Guide Pyramid
Client education (see Teaching Guidelines 11-1)
Special considerations
Cultural variations
Lactose intolerance
Vegetarianism
Pica

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Maternal Emotional Responses


Ambivalence
Introversion
Acceptance
Mood swings
Changes in body image

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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 (see Box 11-4)

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Question
Is the following statement True or False?
Ambivalence is a normal response during the first
trimester of pregnancy.

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Answer
True.
Ambivalence is a universal feeling and is considered
normal when preparing for a lifestyle change and
new role. Pregnant women commonly experience
ambivalence during the first trimester.

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Pregnancy and Sexuality


Numerous changes, possibly stressing sexual
relationship
Changes in sexual desire with each trimester
Sexual health and link to self-image

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Pregnancy and Partner


Family-centered emphasis
Partners reaction to pregnancy and changes
Couvade syndrome, ambivalence
Acceptance of roles (2nd trimester)
Preparation for reality of new role (3rd trimester)

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Pregnancy and Siblings


Age-dependent reaction
Sibling rivalry with introduction of new infant into family
Sibling preparation imperative

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Review
1.

What factors would change in a pregnancy if the hormone progesterone


were reduced or withdrawn?
A. The womans gums would become red
and swollen and would bleed easily.
B. The uterus would contract more and peristalsis
would increase.
C. Morning sickness would increase and would be
prolonged.
D. It would inhibit the secretion of prolactin by the
pituitary gland.

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Review
The correct response is B.
Progesterone is an essential hormone to maintain the
pregnancy and prevent early labor. Progesterone
decreases systemic vascular resistance early in
pregnancy, leading to a decline in blood pressure. It
causes relaxation of the uterus and gastrointestinal
smooth muscle, resulting in delayed gastric emptying and
calming of the uterus. This relaxation mechanism is vital
to reduce uterine contractions.

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Review
2. Which sign is a presumptive sign of pregnancy?
A. Restlessness
B. Elevated Mood
C. Urinary Frequency
D. Low Backache

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Review
The correct response is C.
Urinary frequency occurs during early pregnancy
secondary to pressure on the bladder by the expanding
uterus. This is one of the presumptive signs of
pregnancy. Restlessness or elevated mood is not a sign of
pregnancy. As hormones increase during pregnancy, the
mood might change, but it is not indicative of pregnancy.
Low backache is frequently experienced by many women
during the third trimester of pregnancy secondary to the
change in their center of gravity, but it is not a
presumptive sign of pregnancy.
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Review
3. During pregnancy, which of the following should the
expectant mother reduce or avoid?
A. Raw meat or uncooked shellfish
B. Fresh washed fruits and vegetables
C. Whole grains
D. Protein and iron from meat sources

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Review
. The correct response is A.
Consuming raw meat can increase the pregnant womans risk
of picking up toxoplasmosis, a parasitic infection that can be
passed on to her fetus. Although toxoplasmosis may go
unnoticed in the pregnant woman, it may cause abortion or
result in the birth of an infant with the disease. Uncooked
shellfish may contain high levels of mercury, which can damage
the fetal central nervous system. Some raw or undercooked
can also be contaminated with Listeria, which may result in
abortion, stillbirth, or severe illness of the newborn. Raw or
undercooked food items should be avoided during pregnancy .

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Review
4. The feeling expressed by most women upon learning the
they are pregnant?
A. Acceptance
B. Depression
C. Jealousy
D. Ambivalence

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Review
5. The correct response is D.
The feeling of ambivalence is experienced by most women when
they question their ability to become a mother. Feelings fluctuate
between happiness about the pregnancy and anxiety and fear
about the prospect of new responsibilities and a new family
member. Acceptance usually develops during the second trimester
after fetal movement is felt by the mother and the infant becomes
real to her. Depression is not a universal feeling experienced by
most women unless there is a past history of underlying depression
experienced by the woman. Jealousy is not a universal feeling of
pregnant women. It can occur in partners, because attention is
being diverted from them to the pregnancy and the newborn.

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Questions?

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