PHYSIOLOGIC CHANGES

Reproductive organs – High levels of estrogen and progesterone stimulate phenomenal growth
in the first trimester.

Breasts
o darkening and increase in size of areola,
o enlargement of Montgomery tubercles (sebaceous glands of areola),
o May see an intertwining network of bluish veins beneath the surface of the skin
o Possible secretion of colostrum by 16 wks
o Breast fullness, heightened sensitivity, tingling and heaviness occur primarily in early
weeks due to increases in estrogen and progesterone. Second trimester - growth of
mammary tissue for progressive breast enlargement (Ratio of Glandular tissue to adipose
tissue is 2:1 in pregnancy as compared to 1:1 in a non-pregnant woman)

Uterus
o uterus – early uterine enlargement
o Size increases 20 times non –pregnant size
o Softening of lower uterine segment growth (Hegars sign)
o Becomes globular in shape
o ↑ vascularity of uterus → ↑ size– due to hypertrophy and hyperplasia of muscle cells
(combination of longitudinal and circular musculature to increase strength and elasticity)
o Uterine Blood flow holds 1/6th of maternal blood volume in uterine vascular system

Cervix
o ↑ vascularity → softening (Goodell’s sign)
o Slight hypertrophy and hyperplasia (increase in the number of cells)
o Deep bluish colour (Chadwick’s sign).
o Becomes shorter, thicker, more elastic, thickening of mucosa

Vagina
o hyperemia → deepened color
o thickening of mucosa
o Leukorrhea – secondary to estrogen imbalance, ↑ mucus, “show”
o Ph is more acidic – vulnerable to infections
o Development of operculum – mucus plug

Cardiovascular system
o blood - blood volume ↑ by 40 - 45%. (1000 mls of Plasma and approx. 450 mls of
RBC’s)
o Cardiac output increase by 30 - 50 % (increase in venous return)
o Heart rate increases by 10 -15 beats per minute (b/c of increased Blood volume and CO)
o Iron needs- blood volume ↑ RBC production → ↑ demand on Fe stores → Fe
deficiency anemia
 o BP should remain relatively stable. Decreases slightly during trimester 2 (5-10 mm Hg
for both systolic and diastolic) and returns to prepregnancy levels by trimester 3
o Effects of uterine size → supine hypotension, varicosities, edema
o Hypercoagulability  protective function to decrease the chance of bleeding

Respiratory system
o Physical changes include a broadening of the chest circumference by approx. 7.5 cm and
widening of costal angle to increase and lower rib cage to flare out (allows for larger
tidal volume)
o Diaphragm shifts upwards by about 4 cm above its usual position
o Breathing becomes more diaphragmatic than abdominal
o Increased sensitivity to C02 (lower threshold) -dyspnea common
o Increased vascularity of respiratory tract (estrogen influence) – capillaries become
engorged and edema develops – sinus stuffiness, nosebleeds, change in woman’s tone
and quality of voice.

Basal Metabolic Rate

o BMR increases during pregnancy and returns to pre- pregnant state 5-6 days after
childbirth
o Reflects increased oxygen demands of utero-feto-placental unit and greater oxygen
consumption because of maternal cardiac work
o Heat is produced with increased BMR – peripheral vasodilation (↑sweating)
o

Integumentary system - primarily caused by estrogen changes

Estrogen induced vascular and pigment changes:
o Darkened areolas, nipples, umbilicus, perineum, and axilla areas
o linea nigra – dark pigmented line extends from umbilicus to pubic area. Some woman
may also get a line of hair growth with or without a change in pigmentation
o striae gravidarum – stretch marks (reduced connective tissue strength)
o chloasma – Mask of pregnancy
o Palmar erythema – red, pink diffuse blotches over palmar surfaces
o Gum Hypertrophy (sensitivity and bleeding may occur)
o Epulis
o Increased nail growth and softening, thinning of nail
o Increased hair growth
o Overall skin may clear and look radiant “pregnancy glow”
o May experience itching
Musculoskeletal system

o Hormone related changes - Relaxin induces the softening and stretching of ligaments and
enables the artilcautions between the joints to widen and become more movable. e.g.
sacroiliac joint and symphysis pubis
o Abdominal wall also begins to lose tone, stretch and separate (Diastasis recti)
o Posture changes → increasing curvature of back to compensate for protruding abdomen.
Centre of gravity shifts forward.
o Physical posture changes plus increased mobility of joints and articulations may result in
back pain, instability, waddling, sway back.

Urinary system
Anatomic changes:
o Dilatation of ureters and renal pelves by 10th week,
o Progesterone causes smooth muscle walls of ureters to relax and elongate - decreased
bladder tone,
o Increased potential for urinary stasis and urinary tract infection

Functional changes:
A pregnant womans kidneys must meet the increased metabolic demands of maternal body as
well as excretion of fetal wastes
o GFR ↑ and renal plasma flow increase early in pregnancy (caused by pregnancy
hormones, ↑ BV, maternal position – sidelying most effective)
o renal threshold for glucose ↓. Glucose may spill out into urine making it more alkaline
and again increasing susceptibility to infection
o ↑ renal clearance of urea and creatinine
o ↑ urinary output and bladder irritability - Frequency in early and late pregnancy (different
reasons). May improve after lightening occurs.
o Pelvic congestion can at times lead to mild trauma of sensitive bladder mucosa

Fluid and electrolyte balance:

o Increase plasma and blood volume = increased fluids (additional sodium is needed to
expand fluid volume to maintain an isotonic state)
o Increased Selective renal tubular resorption maintains sodium and H20 balance
o To meet fetal needs, extra sodium is normally retained in pregnancy
o Body cannot be overstressed by excessive dietary intake of sodium. Body can
compensate naturally if taken in moderation

Gastrointestinal system
o bleeding gums - soften and ↑ vascularity
o decreased gastric motility → prolonged gastric emptying time ↑ transit time
o ↓gastric secretion of HCl and pepsin,
o displacement of intra abdominal organs by increasing uterine size,
o ↓ emptying of gallbladder.
o Progesterone → relaxation of smooth muscle → constipation, heartburn
 o pancreas - ↑ insulin production in second half of pregnancy (needed to meet rising
maternal needs; placental HPL and insulinase deactivate maternal insulin)
o BMR ↑ approx 25%
o Increased need for protein, CHO increased. Water retention ↑;
o plasma lipid levels ↑

PSYCHOSOCIAL ASPECTS

Attitudes to pregnancy - influenced by society and culture.

Pregnancy as a life event - transition

In 1967 Rubin introduced the concept of the attainment of the maternal role and went on to
identify maternal tasks in pregnancy, maternal identity and maternal experience (1975, 1984).
She is recognized as a major theorist in the area of maternity nursing and stimulated the work of
another major theorist, Ramona Mercer.

Maternal Role Tasks

Rubin’s 4 major tasks that the expectant mother needs to accomplish during pregnancy, as she
becomes a mother:
1. Ensuring safe passage through pregnancy, labour and birth.
 First trimester- focuses on herself, not the baby
 Second trimester- develops attachment to the baby
 Third trimester- has concern for herself and baby as a unit
 Participates in positive self care activities
2. Seeking acceptance of baby by others
 First trimester- acceptance of pregnancy by self and others
 Second trimester-family needing to relate to baby as member of family
 Third trimester- unconditional acceptance
3. Seeking commitment and acceptance of herself as mother to the infant (binding in)
 First trimester- mother accepting idea of pregnancy, but not of infant
 Second trimester- quickening leads to acknowledgement of baby as a separate
entity within her
 Third trimester- mother longing to hold infant, becoming tired of being pregnant
4. Learning to give of herself on behalf of her child
 First trimester-identification of what must be given up to assume new role
 Second trimester- identification with baby, learning how to delay own desires
 Third trimester- questioning ability to become a good mother