Physiologic and Psychological Changes During Pregnancy
Braxton Hicks contractions (p. 49)
chloasma (klō-ĂZ-mă, p. 54)
colostrum (kŏ-LŎS-trŭm, p. 50)
diastasis recti abdominis (dī-ĂS-tă-sĭs RĔK-tīăb-DŎM-ĭnĭs, p. 53)
effacement (ĕFĀS-mĕnt, p. 49)
lightening (p. 49)
lordosis (lŏr-DŌ-sĭs, p. 53)
Nägele’s rule (nah’gĕ-le p. 44)
orthostatic hypotension (ŏr-thō-STĂT-ĭc hī-pō-TĔN-shŭn, p. 51)
striae gravidarum (STRĪ-ā grăv-ĭDĂrŭm, p. 54)
supine hypotensive syndrome (SOO-pīn hī-pō-TĔN-sĭv, p. 51)
trimesters (trī-MĔS-tĕrz, p. 44)
The nurse and other caregivers need to understand the physiologic and psychological changes that occur during pregnancy to promote health and prevent complications. Also, the nurse should know appropriate nursing and medical interventions for the uneventful (normal) pregnancy. Because culture often determines health beliefs, values, and family expectations, the assessment of cultural beliefs is important to include in patient care. With this knowledge, the nurse can develop adequate nursing care plans that include nursing diagnoses, nursing interventions related to body changes, and appropriate outcomes. Patient self-care should be a part of the care plan.
Profile of Previous Obstetric History
GTPALM is a mnemonic (an aid to memory) that is commonly used for recording, with the use of shorthand symbols, a woman’s pregnancy history (Box 4-1). It provides a systematic, quick way to indicate the number of pregnancies the woman has had, as well as the outcomes. The letters indicate the following:G, gravida; T, term pregnancies; P, preterm births; A, abortions; L, number of living children; and M, multiple gestations and births. For example, a pregnant woman who has four living children, all single births, and who has had no preterm births and no abortions would be a gravida 5-4-0-0-4-0.
Some institutions use only two letters, P and G, to indicate para and gravida. A woman pregnant for the first time would be P0, G1.
Determining Date of Birth
After the diagnosis of pregnancy, the woman’s question usually is, “When is the baby due?” In the past, the term estimated date of confinement (EDC) was used to describe the time of birth as a period of confinement. Currently, the term estimated date of delivery (EDD) is considered the more accurate term. Some texts, however, also use the term estimated date of birth (EDB). Therefore, EDC, EDD, and EDB are interchangeable terms that refer to the expected time of labor and birth. This text uses EDD.
Nägele’s rule is a method for obtaining an EDD (Box 4-2). To calculate the EDD, identify the first day of the last normal menstrual period (LNMP), count backward 3 months, and then add 7 days. An example is as follows:
The average duration of pregnancy is approximately 280 days. This period is calculated in 28-day months, called lunar months. There are 10 lunar months (40 weeks, 280 days) in a full-term pregnancy, which is approximately the same as 9 calendar months. For convenience, the 9 months of pregnancy are divided into three trimesters, each generally representing a 3-month period. Although most women refer to their pregnancy in terms of months, the medical community refers to pregnancy in terms of weeks. The first trimester is considered the first 14 weeks, the second trimester is 15 to 28 weeks, and the third trimester is 29 weeks to delivery (Gabbe, Niebyl, & Simpson, 2007).
Not all pregnancies continue to term (40 weeks). A pregnancy that terminates before the fetus reaches 20 weeks’ gestation is called an abortion (laypersons use the term miscarriage). A pregnancy that terminates after the age of 20 weeks but before full-term is called a preterm (premature) birth. A pregnancy that terminates 2 weeks after the EDD, or 42 weeks’ gestation, is called a postterm birth.
Signs of Pregnancy
It is important to establish the diagnosis of pregnancy or to confirm that the woman is pregnant. Many signs of pregnancy assist in the confirmation. These signs are divided into the following three categories: (1) presumptive signs, which suggest pregnancy; (2) probable signs, which indicate that the woman is probably pregnant; and (3) positive signs, which give definite evidence that the woman is pregnant (Table 4-1). The three positive signs are the only signs that clearly establish a diagnosis of pregnancy. They are hearing fetal heart sounds (Figure 4-1), which are audible by a Doppler device by 10 to 12 weeks’ gestation; palpating active fetal movements; and visualizing the fetus via ultrasound. The gestational sac can be detected as early as 10 days after implantation. Many of the signs and symptoms that are present in pregnancy also may be present in other conditions.
|Signs||Description||Possible Alternative Causes|
|Presumptive (May Suggest Pregnancy)|
|Amenorrhea||Cessation of menses; often the first sign of pregnancy||Emotional stress, chronic disease, or metabolic factors such as menopause|
|Nausea and vomiting||Occurs during first trimester in 50% of pregnancies; called “morning sickness” because it is usually present in morning||Gastrointestinal disorders or acute infections|
|Urinary frequency||Related to pressure on bladder||Urinary tract infection|
|Fatigue||Noticed during early pregnancy by many women||Response to increased hormones or depression|
|Quickening||Feeling of slight, fluttery movements of fetus at about 18-20 weeks of pregnancy||Gas movements within bowel or increased peristalsis|
|Breast tenderness||Tenderness and tingling caused by hormonal changes||Premenstrual status or oral contraceptives|
|Probable (Strongly Indicate Pregnancy)|
|Uterine enlargement||Enlarged abdomen occurring as a result of growth of uterus from fetal growth||Obesity or pelvic tumors|
|Pigmentation changes||Darkening of skin such as linea nigra on abdomen and of nipples and areolae because of hormonal increase||Hormone stimulation related to a medical condition|
|Goodell’s sign||Softening of cervix||Estrogen related to oral contraceptives|
|Hegar’s sign||Softening of lower portion of uterus||Abnormal hormonal activity|
|Chadwick’s sign||Bluish purple discoloration of vaginal mucous membrane caused by increased vascularity or pelvic congestion||Pelvic congestion due to inflammation|
|Ballottement||Rebounding of fetus in amniotic fluid felt by examiner during pelvic examination||Uterine polyps or ascites|
|Braxton Hicks contractions||Painless, irregular uterine contractions; may be felt by the woman as a tightening across the abdomen||Medical condition such as fibroids|
|Positive pregnancy tests||Presence of human chorionic gonadotropin indicative of pregnancy||False results because of timing or technique or use of recreational drugs|
|Positive (Confirm Pregnancy)|
|Ultrasound visualization||One of three signs that clearly establish a pregnancy: fetal heart sounds heard, fetal movements palpated by the examiner, and fetal outline visualized by ultrasound||Ultrasound visualization of fetus is a positive sign of pregnancy|
In recent years, the accuracy of pregnancy tests has improved. These tests are based on the presence of the hormone human chorionic gonadotropin (hCG), which is produced by the chorionic villi of the placenta. It is present in a pregnant woman’s urine or blood as early as 1 week after conception. Home pregnancy test kits are uncomplicated and convenient and are capable of greater than 97% accuracy; however, the instructions must be followed precisely to obtain this accuracy. Pregnancy test kits are probable indicators because several factors may interfere with their accuracy, including medications such as antianxiety drugs or anticonvulsant drugs, blood in the urine, malignant tumors, and menopause.
Physiologic Changes in Body Systems
Many physiologic changes occur during pregnancy. Because of these changes, a number of minor symptoms or discomforts result. Most of these discomforts do not require medical treatment. However, they do require evaluation, explanation, and reassurance to allay fears and anxieties. Many discomforts during pregnancy can be alleviated by relatively simple nursing care, including patient self-care instruction.
The two major sources of the physiologic changes during pregnancy are changes in the endocrine system and the physical changes in the body. The hormonal changes and mechanical pressures that occur from an enlarging uterus account for many of the physiologic changes and psychological adaptations that occur during pregnancy (Table 4-2).