Normal pregnancy notes

INTRODUCTION TO NORMAL
PREGNANCY
BY SHUKRI ELMI MOHAMED LECTURER KMTC GARISSA
CAMPUS

INTRODUCTION TO COMMON TERMS
GP/TPAL Gravida, para/term, preterm, abortions, living Examples:
Mary Jo is G2 P1/T2 P0 A0 L2; second pregnancy, one delivery/two
infants at term (twins), both living.
Susan is G4 P2/T1 P1 A1 L2; fourth pregnancy, two deliveries/one
term infant, one preterm infant, one abortion, two living children.
 Gravida Pregnancy, regardless of duration, includes present
pregnancy
Para Delivery (birth) after 20 weeks’ gestation, whether infant born
alive or dead or number of infants born

Preterm Delivery after 20 weeks’ gestation but before 38
weeks (full term)
Term A pregnancy between 38 and 42 weeks’ gestation
Nulligravida Never been pregnant
Primigravida Pregnant for first time
Multigravida Pregnant two or more times
Nullipara Never having delivered an infant after 20 weeks’
gestation

Primipara Has delivered once after 20 weeks’ gestation
Multipara Has delivered twice or more after 20 weeks’
gestation
Postterm Delivery after 42 weeks’ gestation

Naegele’s Rule
Naegele’s Rule
Naegele’s rule is the most common method of calculating the
EDB. The rule is:
Take the date of the first day of the last menstrual period, subtract
3 months, and add 7 days.
For instance, if the LMP was June 28, the calculation would be as
follows:
Month Day 6 ( June) 28 –3 months +7 days 3 (March) 35
Because there are 31 days in March, the EDB moves forward to
April 4.

Gestation Calculator A gestation calculator, in the shape of
either a chart or a wheel, allows a quick EDB calculation. The
wheel generally provides other information also, such as fetal
weight and body length for each week
Fundal Height Fundal height generally indicates gestational
age through the second trimester

MATERNAL PHYSIOLOGICAL CHANGES OF PREGNANCY
Many physiological changes take place when a woman is pregnant. Every
system of the mother’s body undergoes some change during pregnancy.
Reproductive System
The most obvious physiological changes occur in the reproductive system.
UterusThe most dramatic change occurs in the size of the uterus. Before
pregnancy, it is a small, pear-shaped, thick-walled, muscular organ
weighing 60 g (2 oz).
At the end of pregnancy, it is a large, thin-walled organ weighing 1,000 g (2
lb). Its capacity has increased from 10 mL to 5 L.
The uterus enlarges mainly by hypertrophy of the muscle cells stimulated
by estrogen and the growing fetus.

Irregular uterine contractions occur throughout pregnancy.
About 16 weeks or later, the mother may become aware of
these
Braxton-Hicks contractions. These generally painless
contractions assist in uterine and placental circulation. Pain is
an individual perceptual experience.
A softening of the uterine isthmus about the sixth week of
pregnancy, noted during a pelvic exam, is called Hegar’s
sign.

Cervix
The cervix increases in cell number by the influence of estrogen.
It secretes a thick, sticky mucus that forms a plug in the cervix.
 This plug prevents microorganisms from entering through the
vagina. During labor, as the cervix dilates, this mucus plug is
expelled.
Goodell’s sign (softening of the cervix) and Chadwick’s sign (a
purplish-blue color of the cervix and vagina caused by the
increased vascularity) are both noted at about 8 weeks.

Ovaries
Follicles do not mature and ovulation does not occur during
pregnancy. The corpus luteum produces progesterone and estrogen for
about 12 weeks, at which time the placenta takes over the production.
Vagina
Estrogen causes a loosening of connective tissue and an increase in
vaginal secretions. The acidic secretions prevent bacterial infections.
The increased level of glycogen in cells may enhance growth of
organisms such as Trichomonas vaginalis or Candida albicans.

Breasts
In addition to breast enlargement from hormonal influence,
the nipples become more erect, the areolas darken, and
Montgomery’s tubercles enlarge.
Colostrum, an antibody-rich yellow fluid, is secreted by the
breasts during the last trimester and first 2–3 days after birth,
and gradually changes to milk a few days after delivery.

Cardiovascular System
Blood flow increases to the uterus and kidneys, where the
workload is increased.
The pulse increases by 10 to 15 beats/ minute by the end of
pregnancy. Cardiac output increases 30% to 50% early in
pregnancy.
Blood pressure decreases, is lowest during the second trimester,
and increases gradually to near the prepregnant level during the
third trimester.
This occurs because of the progesterone’s relaxing effect on the
smooth muscles.

• Stasis of blood in the lower extremities, caused by the enlarged uterus
interfering with return blood flow, may lead to dependent edema and
varicose veins of the legs, vulva, or rectum.
• Supine hypotensive syndrome, also known as vena caval syndrome,
occurs when the mother lies supine.
• The enlarged, heavy uterus presses on the inferior vena cava, causing a
reduced blood flow back to the right atrium The mother experiences
dizziness, clammy-pale skin, nausea, and a lowering of her blood
pressure.
• This decreases placental perfusion, which can affect fetal reserve. The
situation is relieved when the mother lies on her side.

Maternal blood volume increases 30% to 50%, reaching its peak at
about 30 weeks. There is some increase in red blood cells, but most of
the increase is plasma. This hemodilution is manifested by a lower
hematocrit (34% to 40%) and is termed physiologic anemia of
pregnancy.
The white blood cell count begins to increase by about 8 weeks and
may reach 18,000/mm3 by the time of delivery. Platelets, fibrin,
fibrinogen, and coagulation factors VII, IX, and X increase. This
increase with possible venous stasis in late pregnancy increases the
risk of venous thrombosis.

Respiratory System
Progesterone decreases airway resistance, allowing an
increase in oxygen consumption. The depth of respirations
increases, causing a mild respiratory alkalosis, which is
compensated by increased renal secretion of bicarbonate
(Littleton & Engebretson, 2002).
The enlarging uterus presses upward on the diaphragm. The
rib cage flares and the chest circumference expands to keep
the intrathoracic volume the same as when not pregnant.
Estrogen causes edema and vascular congestion of the nasal
mucosa.

Gastrointestinal System
Nausea and/or vomiting, known as “morning sickness,” are
common in early pregnancy but usually disappear by 12
weeks.
The smooth muscle relaxation effect of progesterone results
in delayed gastric emptying and decreased peristalsis. The
enlarging uterus displaces the stomach and intestines.
All of these changes contribute to constipation. Relaxation of
the cardiac sphincter allows reflux of acidic gastric contents
into the esophagus, giving the mother heartburn.

Integumentary System
Several skin pigment changes generally occur during pregnancy. The nipples,
areola, vulva, and perineal area darken.
Linea nigra is a pigmented line on the abdomen from umbilicus to
symphysis pubis.
Chloasma, also called “mask of pregnancy,” is a darkening of the skin of
the forehead and around the eyes. It is generally more pronounced in dark-
haired women.
Striae gravidarum, or “stretch marks,” are reddish streaks frequently
found on the abdomen, thighs, buttocks, and breasts. They are the result of
separation of the underlying connective tissue of the skin
 As the skin stretches, the client may experience itching.

Endocrine System
The anterior pituitary hormone prolactin is responsible for initial milk
production. The posterior pituitary hormone oxytocin causes uterine
contractions and the ejection of milk from the breasts (let-down reflex)
after delivery.
The placental hormones, especially hPL, are insulin antagonists, so a
greater insulin production is required. This puts an increased stress on
the islets of Langerhans in the pancreas to put out more insulin.
A woman with a marginally functioning pancreas may show signs of
gestational diabetes in the latter half of pregnancy.

A slight increase in the size of the thyroid often occurs, as
well as an increase in its capacity to bind thyroxine.
 Maternal thyroxine is important for fetal neural development
throughout pregnancy, especially during the first trimester.
This results in a higher level of serum protein-bound iodine
(PBI).

Metabolism
Metabolism
The metabolic rate of the mother increases during pregnancy
as the demands of the growing fetus increase. The mother
must meet her own and the fetus’s nutritional needs.

SIGNS OF PREGNANCY
The many physiological changes that a woman
experiences during pregnancy are categorized as
presumptive, probable, or positive signs of
pregnancy.

Presumptive Signs
Presumptive Signs
Changes that the woman experiences and reports are termed
presumptive or subjective signs. They may be caused by other
conditions, so are not diagnostic of pregnancy.
Presumptive signs include:
 Amenorrhea (absence of menses), usually the first sign that a
woman notices causing her to think she is pregnant.
Nausea and vomiting, often referred to as “morning sickness,” but
can occur any time of the day. This sign usually disappears by 12
weeks of pregnancy.

Breast changes, tenderness, or tingling.
 Urinary frequency, as the growing uterus presses against the
bladder, giving the woman the sensation of needing to
urinate.
Excessive fatigue, often noted after the first missed
menstrual period. It may last for several months. Abdominal
enlargement usually noticed by the woman, generally after 12
weeks.

Quickening, perception of fetal movement by the mother,
usually between 16 and 20 weeks.
It begins as a fluttering sensation and gradually gets stronger
and more frequent.
A positive diagnosis of pregnancy is usually made before
these last two signs are noted by the woman; however, there
is a condition called pseudocyesis or false pregnancy, in
which the woman believes so strongly that she is pregnant
that she appears to have all the early presumptive signs of
pregnancy.

Probable Signs
The examiner can identify these objective changes, but since they can be
caused by conditions other than pregnancy, they are not diagnostic of
pregnancy.
Pelvic SignsGoodell’s sign (softening of the cervix), Hegar’s sign
(softening of the uterine isthmus), and Chadwick’s sign (purplish
discoloration of the vagina, cervix, and vulva) can be identified by the
examiner during the first 12 weeks of pregnancy.
Uterine enlargement is identified after the eighth week of pregnancy.
The fundus is palpable just above the symphysis at 12 weeks and at the
umbilicus at 20 weeks . If these uterine enlargement milestones are reached
earlier, multiple pregnancy, or polyhydramnios, excessive amniotic fluid,
is suspected.

Braxton-Hicks Contractions
After the 28th week, these contractions can be felt by the
examiner and also by the client.
Increased Pigmentation
The nipples and areola darken. Linea nigra may appear on
the abdomen, chloasma may mark the face, and striae
gravidarum may be noticed on the breasts and abdomen.

Ballottement
• During the fourth or fifth month, if the fetus is pushed upward through
the vagina or abdomen, the floating fetus rebounds against the
examiner’s fingers; this is known as ballottement
Pregnancy Test
• The basis for a pregnancy test is the presence of hCG in either the
urine or blood of the woman. A test of the blood is positive 8 days
after conception, and a test of the urine is positive 10 to 14 days after
conception.

Positive Signs
Positive Signs
A positive sign of pregnancy proves conclusively that the
woman is pregnant. No other condition can cause these signs
to appear. There are only three positive signs of pregnancy:
hearing the fetal heartbeat, visualization of the fetus, and the
examiner feeling fetal movement.
Hearing the Fetal Heartbeat
The fetal heartbeat can be detected at 10 to 12 weeks using
the Doppler ultrasound method

When auscultating the abdomen over the uterus, a soft,
blowing sound may be heard.
The sound occurring at the same rate as the mother’s pulse is
called the uterine souffle, caused by the blood pulsating
through the uterus and placenta.
The sound occurring at the same rate as the fetal heart rate is
called the funic souffle, caused by blood pulsating through
the umbilical cord.

Visualization of the Fetus
An abdominal ultrasound examination can detect a
pregnancy by the sixth week after the last menstrual period
(LMP). An endovaginal ultrasound examination, using a
vaginal probe, can detect a gestational sac 10 days after
implantation.
Examiner Feeling Fetal Movement
Fetal movement felt by the examiner, not the mother, is a
positive sign of pregnancy.

PSYCHOLOGICALADAPTATION TO PREGNANCY
Pregnancy is often viewed as a developmental stage having its own
developmental tasks. Both the expectant mother and father deal with
significant changes and major psychosocial adjustment.
Developmental Tasks
Four major developmental tasks are identified for pregnancy. They are
pregnancy validation, fetal embodiment, fetal distinction, and role
transition. These developmental tasks are met in this order. The rate at
which they are met varies. According to Malnory (1996), completion
of the developmental tasks is critical to positive parenting.

Pregnancy Validation
During the first trimester, the pregnant woman’s task is to
validate and accept the pregnancy.
Until the woman meets this task, she cannot meet the rest of
the developmental tasks.
 Even when pregnancy is planned, there are normal feelings
of ambivalence and disbelief about the pregnancy.
Many women become introspective or have mood swings
caused by hormone fluctuations.

Fetal Embodiment
Fetal embodiment occurs as the mother incorporates the
growing fetus into her body image.
The physical changes she is experiencing, especially the
growing uterus, help her meet this task.
She feels that the fetus is a part of her.
Self-involvement, depression, or regressive behavior are
signs of difficulty in meeting this task.

Fetal Distinction
When fetal movement is felt, it becomes easier for the
mother to think of the fetus as a separate being. She may
daydream about what the baby will be like and think about
the kind of mother she wants to be.

Role Transition
• The last trimester is a time of preparation. Many expectant parents
attend childbirth classes to learn about and prepare for labor, delivery,
infant care, and self-care.
• Preparing a nursery, buying baby clothes, and selecting a day care are
all ways of preparing for the infant’s arrival.
• Role transition also includes parents exploring together the meaning of
fathering and mothering, learning parenting skills, the amazing skills
of a newborn for interactions, and the physical maturing and
behavioral changes of the first 12 months of life. Another aspect is
learning to enjoy watching the other parent interact with the newborn.

At the end of pregnancy, many mothers experience a surge of
energy and see to it that the entire household is organized for
the coming of the infant.
This is called nesting. All of these preparations assist the
pregnant woman in the transition to her new role of mother.

Partners’ Tasks
Fathers and other partners must meet the same developmental tasks as
the expectant mother but in a more abstract way.
Accepting the fact that they (as a couple) are pregnant and announcing
it to family and friends meets the first task. The partner may also have
ambivalent feelings about the pregnancy.
By accepting the changes in the pregnant partner, both physical and
psychological, the task of fetal embodiment is met. Fetal distinction is
generally met when the partner hears the fetal

Factors Affecting Psychological Response
Factors that contribute to a woman’s psychological response to her
pregnancy include body image, financial situation, cultural expectations,
emotional security, and support from significant others.
Body Image
The mother’s body image, or perception of her own body, may change
in several areas. The noticeable changes in body shape and the speed
with which those changes occur may be very threatening to some
women. Some women feel “fat” and “ugly” when they are pregnant,
and others feel “so good” and “beautiful” when they are pregnant.

The physical discomforts of pregnancy may cause the mother
to feel a lack of control over her own body.
For example, urinary frequency or urinary incontinence may
increase negative feelings about the pregnancy.
 Pregnant women often feel restricted in their physical
activities.
As long as there is no problem with the pregnancy,
encourage the mother to continue regular activities, keeping
in mind that moderation is the key.

• Financial Situation
• A poor financial situation may cause anxiety about paying bills,
buying needed items for infant care, or having enough and proper
foods for good nutrition. Financial consideration may also be a
significant concern for the expectant mother’s partner.
• Cultural Expectations
• Cultural expectations of the family may cause conflicts for the
pregnant woman and her partner if their ideas are different from their
families’ expectations. Conflicts occur if the cultural expectations of
the mother are different from the cultural expectations of the father or
partner.

Emotional Security
A pregnant woman’s satisfaction with herself and her life
situation has an impact on how she responds to being pregnant.
If the woman is secure in her feelings about herself and her
perceived abilities as a mother, the pregnancy is more likely to be
enjoyable.
A pregnancy that was planned or long anticipated will likely be
received with joy and excitement, whereas an unexpected or
unwanted pregnancy may be met with fear, dread, or uncertainty.

Support from Significant Others
It is important for the nurse and the expectant mother to take
into consideration the psychological responses of significant
others, namely, the father/partner, siblings, and grandparents.
Father/Partner The expectant father or partner must shift
thinking from being a person without children to a person
with a child. He may feel left out, neglected, or resent the
attention focused on the expectant mother.

Normal pregnancy notes

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Normal pregnancy notes