Port said University

Faculty of Medicine
Department of Obs & Gyne

PHYSIOLOGIC CHANGES IN PREGNANCY

TERMINOLOGY
Labor and delivery

Dr: Ibrahim Arafa 2023-2024

skin
Striae gravidarum—“Stretch marks” that develop in genetically predisposed
women on the abdomen and buttocks.
Spider angiomata and palmer erythema—From increased skin vascularity.
Chadwick sign—Bluish or purplish discoloration of the vagina and cervix as a
result of increased vascularity.
Linea nigra—Increased pigmentation of the lower abdominal midline from
the pubis to the umbilicus.
Chloasma—Blotchy pigmentation of the nose and face.
Cardiovascular
Arterial blood pressure—Systolic and diastolic values both decline early in
the first trimester, reaching a nadir by 24–28 weeks, then they gradually rise
toward term but never return quite to prepregnancy baseline. Diastolic falls
more than systolic, as much as 15 mm Hg. Arterial blood pressure is never
normally elevated in pregnancy.
Plasma volume—Plasma volume increases up to 50% with a significant
increase by the first trimester. Maximum increase is by 30 weeks. This
increase is even greater with multiple fetuses.
Hematologic
Red blood cells (RBC)—RBC mass increases by 30% in pregnancy; thus,
oxygen-carrying capacity increases. However, because plasma volume
increases by 50%, the calculated hemoglobin and hematocrit values decrease
by 15%. The nadir of the hemoglobin value is at 28–30 weeks’ gestation. This
is a physiologic dilutional effect, not a manifestation of anemia.
White blood cells (WBC)—WBC count increases progressively during
pregnancy with a mean value of up to 16,000/mm in the third trimester
White blood cells (WBC)—WBC count increases progressively during
pregnancy with a mean value of up to 16,000/mm
Platelet count—Platelet count normal reference range is unchanged in
pregnancy.
Coagulation factors—Factors V, VII, VIII, IX, XII, and von Willebrand Factor
increase progressively in pregnancy, leading to a hypercoagulable state.
Gastrointestinal
Stomach—Gastric motility decreases and emptying time increases from the
progesterone effect on smooth muscle.
Large bowel—Colonic motility decreases and transit time increases from the
progesterone effect on smooth muscle. This predisposes to increased colonic
fluid absorption resulting in constipation.

Pulmonary
Tidal volume (Vt)—Vt is volume of air that moves in and out of the lungs at
rest. Vt increases with pregnancy to 40%. It is the only lung volume that does
not decrease with pregnancy.
Residual volume (RV)—RV is the volume of air trapped in the lungs after
deepest expiration. RV decreases up to 20% by the third trimester. To a great
extent this is because of the upward displacement of intraabdominal
contents against the diaphragm by the gravid uterus.
Renal
Kidneys—The kidneys increase in size because of the increase in renal blood
flow. This hypertrophy doesn’t reverse until 3 months postpartum.
Ureters—Ureteral diameter increases owing to the progesterone effect on
smooth muscle. The right side dilates more than the left in 90% of patients.
Glomerular filtration rate (GFR)—GFR, renal plasma flow, and creatinine
clearance all increase by 50% as early as the end of the first trimester. This
results in a 25% decrease in serum blood urea nitrogen (BUN), creatinine,
and uric acid.
Glucosuria—Urine glucose normally increases. Glucose is freely filtered and
actively reabsorbed. However, the tubal reabsorption threshold falls from
195 to 155 mg/dL.
Proteinuria—Urine protein remains unchanged.
Endocrine Pituitary—Pituitary size increases by 100% by term from
increasing vascularity. This makes it susceptible to ischemic injury (Sheehan
syndrome) from postpartum hypotension.
Adrenals Adrenal gland size is unchanged, but production of cortisol
increases two- to threefold.
Thyroid Thyroid size increases 15% from increased vascularity. increased
total T3 and T4 but free T3 and T4 remain unchanged.
PERINATAL STATISTICS AND TERMINOLOGY
Terminology Definition
Gravidity Total number of pregnancies irrespective of the
pregnancy duration
Nulligravida Woman who is not currently pregnant and has
never been pregnant
Primigravida Woman who is pregnant currently for the first time
Multigravida Woman who is pregnant currently for more than the first time
Parity Total number of pregnancies achieving ≥20 weeks’ gestation
Nullipara Woman who has never carried a pregnancy achieving
≥20 weeks’ gestation
Primipara Woman who has carried one pregnancy achieving ≥20
weeks’ gestation
Multipara Woman who has carried more than one pregnancy to
≥20 weeks’ gestation
Parturient Woman who is in labor
Puerpera Woman who has just given birth
Terminology for Perinatal Losses
Terminology Definition
Abortion Pregnancy loss prior to 20 menstrual weeks
Antepartum death Fetal death between 20 menstrual
weeks and onset of labor
Intrapartum death Fetal death from onset of labor to birth
Fetal death Fetal death between 20 menstrual weeks and birth
Perinatal death Fetal/neonatal death from 20 menstrual
weeks to 28 days after birth
Neonatal death Newborn death between birth and
the first 28 days of life
Infant death Infant death between birth and first year of life
Maternal death A woman who died during pregnancy
or within 90 days of birth
Labor and delivery
Definition: Labor is regular, painful contractions that result in progressive
cervical dilation and effacement.
Stages of labor
1 . First stage (cervical stage).
The first stage of labor entails cervical change. It begins when uterine
contractions become sufficiently strong or adequate to initiate effacement
and dilation of the cervix.
a-. Effacement of the cervix is the shortening of the cervical canal into a
paper-thin orifice.
Effacement occurs as the muscle fibers near the internal os are pulled
upward into the lower uterine segment.
b-dilation of the cervix involves the gradual widening of the cervical os.
For the head of the average fetus at term to be able to pass through the
cervix, the cervix must dilate to a diameter of approximately 10 cm. When
the fetal head is able to descend past the remaining cervix, the cervix is no
longer palpable and is said to be completely or fully dilated.
 2. Second stage (pelvic stage).
The second stage of labor involves the passage of the fetus through the
maternal pelvis and expulsion of the fetus. It begins with the complete
dilation of the cervix and ends when the infant is delivered.
According to the Friedman curve:
a . In a nulliparous patient, the second stage of labor should last less
than 2 hours without regional anesthesia, and less than 3 hours if a woman
has regional anesthesia.
b-In a multiparous patient, the second stage of labor should last less
than 1 hour without regional anesthesia, and less than 2 hours if a woman
has regional anesthesia.
3. Third stage (placental stage).
The third stage of labor involves the separation and expulsion of the
placenta. It begins with the delivery of the infant and ends with the delivery
of the placenta.
4-Fourth stage of labor:
Not actually included in stages of labor but for observation two hours
postpartum to guard against postpartum hemorrhage.
Components of labor (the three P’s)
1 . Powers ( Contractions )
As uterine contractions involve increasing numbers of myometrial fibers, the
intensity and duration of the contractions increase.
In early labor, the contractions occur every 5 to 10 minutes, last for 30 to 45
seconds, and are 20 to 30 mm Hg in intensity.
As labor progresses, the contractions occur every 2 to 3 minutes, last for 50
to 70 seconds with 40 to 60 mm Hg in pressure/intensity.
2. Passenger (The fetus )
a .Presentation —indicates that portion of the fetus that overlies the
pelvic inlet, and can be determined by inspection and palpation of the
maternal abdomen (Leopold’s maneuvers).
(1) Cephalic—occurs in approximately 95% of at or near-term labors. The
type of cephalic presentation depends on the degree of flexion or extension
of the fetal head.
(2) Breech—occurs in approximately 3.5% of at or near-term labors.
(3) Shoulder—0.4% of at or near-term labors
3. Passage (The pelvis )
Mechanism of labor and delivery
mechanism of labor and delivery involve seven cardinal movements. A
process of positional adaptation of the fetal head to the various segments of
the pelvis is required to complete childbirth.
These positional changes occur sequentially in the following order:
engagement, descent, flexion, internal rotation, extension, external rotation,
and expulsion ,
1 .Engagement.The biparietal diameter of the fetal head, the greatest
transverse diameter of the head in occiput presentations, passes through the
pelvic inlet
2.Descent.The first requirement for the birth of an infant is descent.
3. Flexion.When the descending head meets resistance from either soft or
bony tissue in the pelvis, flexion of the fetal head normally occurs.
4.Internal rotation. It occurs at the level of the ischial spines (0 station).
5.Extension of the fetal head.This extension is essential during the birth
process
6.External rotation.After delivery of the head, restitution occurs
7. Expulsion