PSYCHOLOGICAL AND PHYSIOLOGIC

CHANGES OF PREGNANCY
(part 3)
 THE NORMAL ANTEPARTAL PERIOD

ANTEPARTAL PERIOD
The period of pregnancy or the period before labor is the
antepartal period, also called prenatal period. The
woman in this period is called the gravida.

LENGTH OF PREGNANCY
• Days - 267 to 280 
• Calendar months – 9
• Weeks – 40
• Trimesters – 3
• Lunar months – 10
• It is best to express gestational age or length of
pregnancy in weeks. At expected of confinement
(EDC), the fetus is 40 weeks old.
 TRIMESTERS OF PREGNANCY

• FIRST TRIMESTER: period of rapid

organogenesis; teratogens like alcohol,
drugs, virus, and radiation are highly
damaging.

• SECOND TRIMESTER: most comfortable for

the mother; with continued growth of the
fetus.

• THIRD TRIMESTER: with rapid deposition of

fats, iron and calcium; the period of most
rapid fetal growth.
Common Psychosocial Changes That Occur
With Pregnancy
Emotional Responses to Pregnancy
1. Grief
2. Narcissism
3. Introversion VS Extroversion
4. Body Image and Boundary
5. Stress
6. Couvade syndrome
7. Emotional lability
8. Changes in sexual desire
9. Changes in the expectant family
 PHYSIOLOGIC ADAPTATIONS IN PREGNANCY

REPRODUCTIVE SYSTEM CHANGES

Uterus
• Uterine size is increased due to hypertrophy of existing muscles and
connective tissues (No formation of new muscle fibers in pregnancy).

• Weight increases from 60 g (non-pregnant) to 1000 g (fullterm).

• Length increases from 7.5 cm to 32 cm; width from 4 cm to 24 cm and

depth from 2.5 cm to 22 cm.

• Uterine shape changes from globular to OVAL.

• New fibroelastic changes are formed; this makes up stronger uterine

walls.
Fundic height changes
• 12th week: level of symphysis pubis
• 13th week: rising from pelvic cavity; may be palpable just
above the symphysis pubis
• 14th week: an abdominal content
• 20th to 22nd week: at umbilical level
• 36th week: at xiphoid process level

Fundus height at various weeks

of pregnancy
Increased vascularity to the pelvic region
(estrogen effect) results:

• Hegar’s sign: softening of lowering uterine

segment the isthmus → easy compressibility of
the uterus
• Goodell’s sign: softening of the cervix
– Consistency of the tip of the nose; non-pregnant cervix
– Consistency of ear lobe: pregnant cervix (Goodell’s sign)
– Consistency of whipped butter: cervix ripe for labor
• Chadwick’s sign: bluish or purplish discoloration
of the vaginal mucosa and cervix
Examining for Hegar’s sign. If the sign is
present, the wall of the uterus is softer than
usual.
• Braxton-Hick’s Contractions: intermittent
irregular, painless, abdominal and false
labor contractions felt as abdominal muscle
tightening by about 4 months; more
pronounced at 8 months.

• Ballottement: rebounding of fetal head

against examining fingers by 4 to 5 months

•  Secondary amenorrhea: due to the

persistence of the corpus luteum
Cervix
• Shorter, thicker, more elastic
• With edema and hyperplasia of mucus
lining, there is increased mucus
production which makes up the
protective mucus plug (week 7),
operculum,. As it seals the cervix, it also
prevents bacterial contamination of the
uterine cavity
• Increased vascularity causes cervix to be
soft: Goodell’s sign
Vagina
• Hypertrophy and hyperplasia → thickened vaginal mucosa
• Leukorrhea: whitish, mucoid, non-foul, non-pruritic vaginal
secretions increases as estrogen level increases; provides
increased vaginal acidity, an added protection from bacterial
invasion
• Increased vascularity results to bluish discoloration:
Chadwick’s sign
Perineum
• Hypertrophy, edema and relaxation; there is an
increase in size
• Increased vascularization; changes into deeper
color

Ovaries
• Ovum production ceases
• Corpus luteum persists and takes over
hormonal production task in early pregnancy
• Placenta: major endocrine organ in pregnancy
Breasts
• Increased size and firmness
• There is tingling sensation in the nipples in 4 weeks and
there is also breast tenderness
• Enlargement of areola, alveoli duct and alveoli system
• Darkening of areola and skin around it
• Enlargement and prominence of superficial veins
• Enlargement of Montgomery’s glands
• Colostrum (4 to 5 months): thin, watery, light yellow,
high protein secretion
Comparison of breasts from nonpregnant and pregnant
women.
INTEGUMENTARY SYSTEM CHANGES:
present in the second trimester onwards

• Chloasma: dark patches on the cheeks, nose and neck; ‘mask’ of

pregnancy due to increased melanocyte-stimulating hormones of
pregnancy

• Linea Nigra: dark line from symphysis pubis upward to xyphoid process
due to increased estrogen
• Striae Gravidarum: stretch marks; silvery streaks on the
abdomen, upper thighs and lower breast due to adrenal
hypertrophy

• Palmar Erythema (reddened palms) and vascular spider

nevi (facial) from increased vascularity due to elevated
estrogen
• Diaphoresis: due to increased activity of the sweat and
sebaceous glands from pregnancy’s increased metabolic
rate
• Diastasis:the abdominal wall has difficulty stretching
enough to accommodate the growing fetus, causing the
rectus muscles to actually separate
Skin changes in pregnancy: striae gravidarum
and linea nigra
RESPIRATORY SYSTEM CHANGES

Nose: increased vascularity (estrogen effect) →

common epistaxis, nasal stuffiness, hoarseness,
Eustachean tube blockage causing temporary
deafness or difficulty in hearing.

Respiratory Rate:
• Not much change; rate increase can be constant at
6/min. and deeper
• Maximum increase under normal conditions:
24/min. at rest
• Lung volume changes due to mechanical,
hormonal, or biochemical influences
Diaphragm rises by as much as 1 inch at 36 to 38 weeks resulting in
dyspnea which is relieved by lightening.
 
Lungs
• Slight increase in vital capacity
• Increase in oxygen consumption by 15% at 6 to 40 weeks
• Tendency to hyperventilate due to 1) mother’s need to blow off
carbon dioxide transferred to her from fetus; and 2) direct effect
of progesterone on respiratory center
Signs of Hyperventilate
• Dizziness/light headedness
• Pallor
• Tingling sensation of fingertips/lips
Management: encourage the woman to breathe into a paper bag or
her cupped hands to prevent complication respiratory alkalosis.
In normal pregnancy, lung volume changes and progesterone
cause a state of compensated respiratory alkalosis.
CIRCULATORY SYSTEM

Cardiac rate increases by10 to15 bpm/min. in the

second to third trimesters.
 
Palpitation in early and late pregnancy due to:
• Sympathetic nervous system disturbances (early)
• Increased intraabdominal pressure (late)

Transient murmurs and slight cardiomegaly; systolic

murmurs due to increased viscosity of the blood and
upward displacement of the heart
Blood pressure changes:
• Remains constant, but may drop slightly in the second
trimester..

• Supine position → inferior vena caval compression →

decreased venous return → decreased cardiac output →
hypotension. Prevention and management: left lateral
recumbent (LLR)

Circulating volume increase from the end of the first

trimester (30%) up to the period just before labor (50%).
Physiologic Anemia of pregnancy results from the
disproportionate increase between the circulating blood
volume and the red blood cells.
Supine hypotension can occur if a pregnant woman lies on her back. (A)
The weight of the uterus compresses the vena cava, trapping blood in
the lower extremities. (B) If a woman turns on her side, pressure is
lifted off of the vena cava.
Cardiac output increases by 20 to 30% in
the first and second trimesters to meet
increased tissue demands.

Vascularity increases (estrogen effect):

• Dilation of pelvic veins or/resulting in
deep pelvic veins varicosities
• Leg varicosities
Fibrinogen level increases by 50% due to
progesterone effect (Normal fibrinogen, non-
pregnant state: 200-400 mg.dL):
• Increased tendency to clotting → high risk for
thrombophlebitis
• Positive Homan’s sign is a danger sign of deep vein
thrombosis (DVT).
• Non-pathologic increased in sedimentation rate (Normal
value, non-pregnant state: 20-30 mm/hr.).

• Edema of lower extremities is common

in the last 6 weeks of pregnancy because of the
pressure on the pelvic girdle.
Hematologic Changes
• Red Blood Cells: increased by 30% but usually drops

• Hemoglobin: 12 to 15 g/dL (average: 13 to 14 g/dL)

• Hematocrit: 37% to 42%

• Hgb and Het may drop by 10% in the second and third
trimesters → pseudoanemia/physiologic anemia

• WBC: 5,500 to 11,500/mm3 (in labor) → 25,000/mm3 (in

post-partum). Leucocytosis is pregnancy is not usually a
sign of infection.
GASTROINTESTINAL SYSTEM CHANGES
Mouth: increased estrogen level
• Increased acidity of saliva
• Ptyalism: increase saliva in women with nausea; appears 2 to 3 weeks
and disappears after delivery (Gabbe et al., 2002)
• Increased vascularity → soft and swollen gums/gingivitis → difficulty in
chewing and gum bleeding. Prevention of gum bleeding: dental
hygiene
• NO tooth loss in pregnancy.
• May have benign mouth tumors due to vascular proliferation secondary
to hormonal changes; may not resolve after delivery.
Stomach
• Displaced backwad: appendix palpated as high as right flank;
bowel sounds may not be auscultated in 4 abdominal
quadrants.
• Displaced upward and compressed resulting in difficult
digestion.
• Cardiac sphincter relaxed → esophageal reflux → heartburn or
pyrosis, a common discomfort felt as burning sensation behind
the sternum.
• Motility and slow digestion (progesterone effect)
• Emptying time delayed
• Decreased free hydrochloric acid plus decreased motility and
digestion contribute to morning sickness and
heartburn/pyrosis.
GI Tract Relaxation (progesterone effect) →
discomforts:
• Morning sickness (nausea and vomiting)
• Flatulence
• Constipation and hemorrhoids

Gall Bladder
• Progesterone relaxes gall bladder wall → poor tone
→ delayed emptying time → cholesterol in the bile
likely to crystalize → tendency to gallstones
formation.
 
Liver: displaced by uterus; blood flow to it not
markedly changed; expected liver laboratory
findings mimic liver disease (Gabbe at al., 1996):
URINARY SYSTEM CHANGES
• Renal Plasma Volume: increased by 25% to 50% in the first and
second trimesters; normal by the end of third trimester

• Globular filtration rate (GPR): increased by 50% in the second

and third trimesters → increased urinary output with
decreased specific gravity

• Increased renal tubular reabsorption rate

• Increased renal urea and creatinine clearance

• Frequency of Voiding: increased in the first and third

trimesters because of uterine pressure on the bladder; usually
not in the second trimester when the uterus has risen into the
abdominal cavity.
Bladder Capacity: 1,500 mL in the second trimester

Glycosuria: the presence of glucose in the urine due to

lowered renal threshold for glucose

Relaxed Smooth Muscles of Bladder, Ureters (persists up to 4

to 6 weeks after delivery) results to:
• Dilation of ureters (May also result from uterine pressure.)
• Decreased bladder tone
• Increased potential for stasis and urinary infection (UTI)

Renal function is compromised in both sitting and standing

positions due to the effects of vena caval syndrome. The
best position that enhances renal perfusion is the lateral
(LLR) or the left side-lying position.
MUSCULO-SKELETAL SYSTEM CHANGES
Increased estrogen, progesterone and relaxin; relaxed ligaments and joints
• Softening and relaxation of symphysis pubis and sacroiliac joints increased
the birth canal
• Pelvic looseness results in duck-waddle/waddling gait
• Difficulty maintaining balance predisposes to slips and falls

The number one reason why tub bathing in pregnancy is not encouraged is the
change in the musculo-skeletal system that results in poor balance
predisposing to slips and other injuries.
 
Stress on ligaments and muscles of the mid- and lower spine results in
backache.
 
Lordosis from shift in the center of gravity during pregnancy results in
backache and fatigue.

Cramps from calcium and phosphorous imbalance, and pressure of the gravid
uterus on nerves supplying the lower extremities
ENDOCRINE SYSTEM CHANGES
Placenta
1. Chorion of placenta secretes HCG which functions to:
a. Maintain the corpus luteum (most important function)
b. Aid in diagnosing pregnancy by its detection in maternal serum and
urine
– Serium/blood: as early as 8 to 10 days or at the time of implantation
– Urine: as early as 10 to 14 days after the missed menstruation
c. Found elevated in excessive vomiting

2. Mature placenta at 10 to 12 weeks; increased placental hormones

estrogen, progesterone, HCG and HPL/HCS (human placental
lactogen/human chorionic somatomammotropin).

• HPL is the major diabetogenic hormones or insulin antagonist in

pregnancy → gestational DM or difficulty to control pre-existing DM.
Anterior Pituitary Gland (APG)
• No ovulation from increased follicle stimulating
hormone
• Breast is prepared for lactation with increased
prolactin
 
Posterior Pituitary Gland (PPG)
• Oxytocin is produced by hypothalamus, stored and
secreted by the PPG.
• Fetal head pressure on the cervix stimulates PPG to
secrete oxytocin → stimulates uterine myometrium
→ uterine contractions → labor onset (aided by the
drop in progesterone in late pregnancy).
Thyroid Gland
• Changes in thyroid activity resulting to elevated
BMR are due to (Cunningham et al., 2001):
• Increased thyroid activity → increased BMR; any
extraordinary growth must be assessed (Littleton
& Engebretson, 2006)
• The 25% increased in metabolic rate activity by
25% returns to normal levels at 6th week
postpartum.

Parathyroid Gland
• Enhanced calcium and phosphorus metabolism to
meet fetal needs for increased calcium
• The leading cause of cramps in pregnancy is
calcium-phosphorus imbalance.
Pancreas
• Increased insulin secretion in response to increase metabolism in
pregnancy.
• Insulin secreted by pancreas is rendered ineffective by insulin
antagonists of pregnancy most importantly human placental
lactogen or human chorionic somatomammotropin (HCS).

Adrenal Cortex
• Increased cortisol works at multiple sites promoting metabolism
of macronutrients carbohydrates, protein, and fat. When the
gravida needs more energy, cortisol activates gluconeogenesis,
converting stored protein to glucose.
• Increased aldosterone promotes sodium retention, and thereby
water reabsorption; enhances the water-retaining effect of
progesterone resulting in the cushingoid feature in pregnancy.
SIGNS OF PREGNANCY

A. PRESUMPTIVE SIGNS: subjective; may be noticed by the woman but are

not conclusive proof of pregnancy

• Amenorrhea: first sign at 2 weeks from fertilization because of persistence

of corpus luteum
• Nausea and vomiting: are the most common forms of discomfort
• Urinary frequency: is the most disturbing sign especially in the third
trimester
• Fatigue: estrogen-induced in early pregnancy
• Breast changes: tingling of nipples (4 weeks), darkening and enlargement
of areola, enlargement of breasts, increased number of milk-secreting
cells
• Skin changes: chloasma, linea nigra, striae gravidarum, diaphoresis
• Quickening: usually felt stronger at 20 weeks
• Leukorrhea: whitish, mucoid vaginal discharge due to estrogen
• Weight increase
B. PROBABLE SIGNS: objective; as notice or observed by healthcare
provider but still not conclusive for pregnancy

• Uterine enlargement causing abdominal enlargement

• Goodell’s sign: softening of the cervix
• Hegar’s sign: softening of lower uterus (isthmus) →
compressibility of the uterus
• Chadwick’s sign: bluish discoloration of cervix, vagina and
perineum
• Braxton-Hick’s contractions: painless, abdominal contractions;
relived by walking
• Ballottement: rebound of fetus against examining fingers
• Positive pregnancy test: due to presence and rising HCG in
maternal blood and urine
• Radioimmunoassay (RIA): test for the beta subunit of HCG →
accurate as to be diagnostic of pregnancy (Kain & Hall, 2000)
C. POSITIVE SIGNS: objective, emanate
from the fetus; conclusive for pregnancy

• FHT, Demonstration of a fetal heart

separate from the mother’s
• Fetal movements felt by an examiner
• Visualization of the fetus by ultrasound
Assessing the Client for Presumptive Signs of Pregnancy
Assessing the Client for Probable Signs of Pregnancy