This document discusses the physiological changes that occur during pregnancy to promote maternal health and support fetal development. It covers changes in various body systems including the reproductive, cardiovascular, respiratory, renal, gastrointestinal, endocrine, integumentary, and musculoskeletal systems. Key changes include increased blood volume and cardiac output, skin pigmentation, weight gain, and adaptations in organs and tissues to accommodate the growing fetus. The document provides information on signs and symptoms of pregnancy and details nutritional needs that increase to support the demands of pregnancy.

1. THE PHYSIOLOGICAL CHANGES OF
PREGNANCY: PROMOTING MATERNAL HEALTH
Aries Glenn B. Galao, RN
Jurmaida H. Pagayao, RN
Marnelle Joy S. Pulmano, RN

4. Presumptive Signs and Symptoms
• Abrupt cessation of menses - more than 10 days
• Breast changes
• Skin pigmentation changes:
– Chloasma/melasma gravidarum
– Linea nigra
– Abdominal striae
• Nausea and vomiting (morning sickness)
• Frequency of urination
• Fatigue

6. Probable Signs and Symptoms
• Objective findings detected by 12 to 16 weeks of gestation
• Enlargement of abdomen
• Hegar's sign
• Chadwick's sign
• Goodell's sign
• Braxton Hicks contractions
• Ballottement
• Leukorrhea
• Quickening
• Positive hCG - test for pregnancy

7. Positive Signs and Symptoms
• Fetal heart tones (FHTs)
- usually heard between 16th and 20th week of gestation
with a fetoscope or the 10th and 12th week of gestation
with a Doppler stethoscope
• Fetal movements felt by the examiner (after about 20
weeks gestation)
• Outlining of the fetal body through the maternal abdomen
in the second half of pregnancy
• Sonographic evidence (after 4 weeks gestation) using
vaginal ultrasound. Fetal cardiac motion can be detected by
6 weeks gestation

10. MATERNAL
PHYSIOLOGY
DURING PREGNANCY

11. Duration of Pregnancy
• Averages 280 days/40 weeks (10 lunar months; 9 calendar
months) from the 1st day of LMP
• Divided into 3 trimesters of slightly more than 13 weeks or
3 calendar months each
• EDC is calculated by Nägele's rule
+7 days, -3 months to LMP
• McDonald's rule: after 24 weeks' gestation, the fundal
height measurement will correspond to the week of
gestation plus 2-4 weeks

12. CHANGES IN THE
REPRODUCTIVE TRACT

14. Uterus
• Enlargement, stretching and marked hypertrophy of
existing muscle cells 2° to increased estrogen and
progesterone levels
• Increase in fibrous tissue and elastic tissue; increase in size
and number of blood vessels and lymphatics
• Enlargement and thickening of the uterine wall are most
marked in the fundus
• By the end of 12 weeks, the uterus can be palpated
suprapubically
• The uterus rotates somewhat to the right because of the
rectosigmoid colon on the left side of the pelvis

15. • 20 weeks: fundus has reached the level of the umbilicus
• 36 weeks: fundus has reached the xiphoid process
• End of 5th month, the myometrium hypertrophy ends and
the walls of uterus become thinner, allowing palpation of
the fetus
• During the last 3 weeks, the uterus descends slightly
because of fetal descent into the pelvis
• Changes in contractility occur - from the first trimester,
Braxton Hicks contractions; in latter weeks of pregnancy,
contractions become stronger and more regular
• Progressive increase in uteroplacental blood flow during
pregnancy

16. Cervix
• Pronounced softening and cyanosis - due to increased
vascularity, edema, hypertrophy, and hyperplasia of the
cervical glands
• Operculum - prevents bacteria and other substances from
entering and ascending into the uterus
• Erosions of cervix, common during pregnancy, represent an
extension of proliferating endocervical glands and columnar
endocervical epithelium
• Evidence of Chadwick's sign due to the increased
vascularity and hyperemia caused by increased estrogen
levels

18. Ovaries
• Ovulation ceases during pregnancy; maturation of new
follicles is suspended
• One corpus luteum functions during early pregnancy (first
10 to 12 weeks), producing progesterone and small levels
of estrogen and relaxin
• After 8 weeks gestation, the corpus luteum remains the
source for the hormone relaxin

19. Vagina and Outlet
• Increased vascularity, hyperemia, and softening of
connective tissue in skin and muscles of the perineum and
vulva
• Vaginal walls prepare for labor: mucosa increases in
thickness, connective tissue loosens, and small-muscle cells
hypertrophy
• Vaginal secretions: thick, white, and acidic; pH=3.5 to 6
because of increased production of lactic acid from
glycogen in the vaginal epithelium by Lactobacillus
acidophilus; prevention of infections
• Hypertrophy of the structures, along with fat deposits,
causes the labia majora to close and cover the vaginal
introitus (vaginal opening)

20. Changes in the Abdominal Wall
• Striae gravidarum (stretch marks) - reddish, slightly
depressed streaks in the skin of abdomen, breast, and
thighs (become glistening silvery lines after pregnancy)
• Linea nigra - line of dark pigment extending from the
umbilicus down the midline to the symphysis. Commonly
during the first pregnancy, the linea nigra occurs at the
height of the uterus. During subsequent pregnancies, the
entire line may be present early in gestation.
• Diastasis recti may occur as muscles (rectus) separate. If
severe, a part of the anterior uterine wall may be covered
by only a layer of skin, fascia, and peritoneum.

21. Breast Changes
• Tenderness and tingling occur in early weeks of pregnancy
• Increase in size by 2nd month - hypertrophy of mammary
alveoli. Veins more prominent, and striae may develop
• Nipples become larger, more deeply pigmented, and more
erectile early in pregnancy
• Colostrum may be expressed by 2nd trimester
• Areolae become broader and more deeply pigmented.
• Scattered through the areola are glands of Montgomery,
which are hypertrophic sebaceous glands.

23. METABOLIC
CHANGES

24. Weight gain average
• 25 to 35 lb (11.5
to 16 kg)

25. Water metabolism
• Retains 6-8 L of extra water during the pregnancy
• Approximately 4-6 L of fluid cross into the extracellular
spaces (hypervolemia)
• Normal accumulation of fluid in their legs and ankles at the
end of the day - 3rd trimester (physiologic edema)
• Sodium retention is usually directly proportional to the
amount of water accumulated during the pregnancy
• Additional sodium is required during pregnancy to meet the
need for increased intravascular and extracellular fluid
volumes and to maintain a normal isotonic state

26. Protein Metabolism
• The fetus, uterus, and maternal blood are rich in protein
• At term, fetus and placenta contain 500 g of protein or
approximately half of the total protein increase of
pregnancy
• Approximately 500 g more of protein is added to the
uterus, breasts, and maternal blood in the form of
hemoglobin and plasma proteins

28. Carbohydrate Metabolism
• Early in pregnancy, the effects of estrogen and
progesterone can induce a state of hyperinsulinemia. As
pregnancy advances, there is increased tissue resistance
coupled with increased hyperinsulinemia
• Approximately 2% to 3% of all women will develop
gestational DM during pregnancy
• Pregnant women with preexisting DM may experience a
worsening of the disease attributed to hormonal changes
• “sparing” of glucose used by maternal tissues and shunting
of glucose to the placenta for use by the fetus
• HPL, estrogen, progesterone, and cortisol oppose the action
of insulin during pregnancy and promote maternal lipolysis

30. Fat Metabolism
• Lipid metabolism during pregnancy causes an accumulation
of fat stores, mostly cholesterol, phospholipids, and
triglycerides
• Fat storage occurs before the 30th week of gestation
• After 30 weeks' gestation, there is no further fat storage,
only fat mobilization that correlates with the increased
utilization of glucose and amino acids by the fetus.
• The ratio of low-density proteins to high-density proteins is
increased during pregnancy

32. NUTRIENT REQUIREMENTS

33. Caloric Requirements
• An additional 300 kcal/dL are required during the 2nd and
3rd trimester
• Caloric expenditure varies throughout pregnancy. There is a
slight increase in early pregnancy and a sharp increase near
the end of the 1st trimester, continuing throughout
pregnancy.
Protein Requirements
• An additional requirement of 10 g of protein per day is
recommended over the nonpregnant intake.

34. Carbohydrate and Fat Requirements
• Carbohydrates should supply 55% to 60% of calories in the
diet and should be in the form of complex carbohydrates,
such as whole-grain cereal products, starchy vegetables,
and legumes
• Fat intake should not exceed 30% of the diet. Saturated
fats should not exceed 10% of the total calories.
Iron Requirements
• Iron requirements are increased to 20 to 40 mg daily
• Supplemental iron is valuable and necessary during
pregnancy and postpartum
• During the last half of pregnancy, iron is transferred to the
fetus and stored in the fetal liver. This store lasts 3 to 6
months.

35. CHANGES IN THE
CARDIOVASCULAR
SYSTEM

37. Heart
• Diaphragm is progressively elevated during pregnancy;
heart is displaced to the left and upward, with the apex
moved laterally
• Heart sounds - exaggerated splitting of the first heart
sound; a loud, easily heard third sound
• Heart murmurs - systolic murmurs are common and usually
disappear after delivery

38. Blood Volume Changes
• Cardiac volume increases by 40% to 50% (1,450 to 1,750
mL) by 32 weeks' gestation
• Cardiac output increases by 30% to 50% above normal
within the first 13 weeks of pregnancy and reaches a
volume of 6 to 7 L/minute by term
• Femoral venous pressure increases
• Increased cutaneous blood flow dissipates excess heat
• Physiologic anemia of pregnancy or physiologic dilutional
anemia

39. • Supine hypotensive syndrome

40. Blood Pressure Changes
• During the first half of pregnancy, there is a slight (5 to 10
mm Hg) decrease in systolic and diastolic BP
• By the third trimester, the BP gradually returns to
prepregnancy levels
• Maternal position influences blood pressure: the highest
reading is obtained in the sitting position, the lowest
reading is obtained in the left lateral position, and an
intermediate reading is obtained in the supine position
• Maternal blood pressure will also rise with uterine
contractions and returns to the baseline level after the
uterine contraction is over

42. Hematologic Changes
• Total volume of circulating RBCs increases 18% to 30%;
hemoglobin concentration at term averages 12 to 16 g/dL;
hematocrit concentration at term averages 37% to 47%.
• WBC count in the 3rd trimester is 5 to 12,000/ml
• Pregnancy is a hypercoagulable state due to the increased
levels of a number of essential coagulation factors.
• Average platelet count is 140,000 to 400,000/mm3, which
increases the risk to the pregnant woman for venous
thrombosis.

43. CHANGES IN THE
RESPIRATORY TRACT

44. • Diaphragm is elevated during pregnancy
• Thoracic cage expands its anteroposterior diameter causing
flaring of the ribs
• Breathing is more diaphragmatic than costal
• Hyperventilation occurs - increase in respiratory rate, tidal
volume increases 30% to 40%, and minute ventilation
increases 40%
• Increased total volume lowers blood partial pressure of
carbon dioxide (Pco2), causing mild respiratory alkalosis
that is compensated for by lowering of the bicarbonate
concentration

46. • Increased respiratory rate and reduced Pco2 are probably
induced by progesterone and estrogen
• Oxygen consumption increases 15% to 20% and as much
as 300% in labor
• This increase leads to increased maternal alveolar and
arterial oxygen partial pressure levels.
• Approximately 60% to 70% of pregnant women experience
shortness of breath; unknown cause
• Nasal stuffiness and epistaxis secondary to vascular
congestion caused from the increased estrogen levels

48. CHANGES IN
RENAL
SYSTEM

49. • Ureters become dilated and elongated during
pregnancy because of mechanical pressure
• When the uterus rises out of the
uterine cavity, it rests on the
ureters, compressing them at the
pelvic brim
• Glomerular filtration rate (GFR)
increases 50% by the 2nd trimester,
and the increase persists almost to
term
• Glucosuria may be evident because
of the increase in glomerular
filtration without an increase in
tubular resorptive capacity for
filtered glucose

50. • Excreted protein may be increased due to the increased
GFR, but is not considered abnormal until the level exceeds
250 mg/dL
• Toward the end of pregnancy, pressure of the presenting
part impedes drainage of blood and lymph from the bladder
base, typically leaving the area edematous, easily
traumatized, and more susceptible to infection.

52. CHANGES IN
GI TRACT

53. • Gums may become hyperemic and softened and may bleed
easily
• A localized vascular swelling of the gums may appear
(epulis of pregnancy)
• Stomach and intestines are displaced upward and laterally
by the enlarging uterus. Heartburn (pyrosis) is common.
• Decreased motility, mechanical obstruction by the fetus,
and decreased water absorption from the colon leads to
constipation
• Hemorrhoids are common because of elevated pressure in
veins below the level of the large uterus and constipation

54. • Distention and hypotonia of the gallbladder are common,
which can cause stasis of bile
• Decrease in emptying time and thickening of bile, resulting
in hypercholesterolemia and gallstone formation
• Prothrombin time may show a slight increase or be
unchanged
• Peptic ulcer formation or exacerbation is uncommon during
pregnancy due to decreased hydrochloric acid (caused by
increased estrogen levels
• The appendix is pushed superiorly

56. CHANGES IN THE
ENDOCRINE
SYSTEM

57. • APG enlarges slightly; PPG remains unchanged
• Thyroid is moderately enlarged because of hyperplasia of
glandular tissue and increased vascularity
– BMR increases progressively during normal pregnancy
(25%) because of metabolic activity of fetus
– Level of protein-bound iodine and thyroxine rises sharply
and is maintained until after delivery because of
increased estrogen and hCG
• Parathyroid gland size and concentration of parathyroid
hormone increase and peak between 15 and 35 weeks

59. • Adrenal secretions considerably increased - amounts of
aldosterone increase as early as the 15th week
• Pancreas
– Estrogen, progesterone, cortisol, and hPL decrease the
maternal utilization of glucose
– Cortisol also increases maternal insulin production
– Insulinase, an enzyme produced by the placenta,
deactivates maternal insulin
– These changes result in an increased need for insulin,
and the islets of Langerhans increase their production of
insulin

60. CHANGES IN
INTEGUMENTARY
SYSTEM

61. • Pigment changes because of MSH; elevated from the 2nd
month of pregnancy until term
• Striae gravidarum - slightly depressed streaks in the skin of
the abdomen, breasts and thighs
• Linea nigra - brownish-black line of pigment in the midline
of the abdominal skin
• Chloasma/melasma or “mask of pregnancy” - brownish
patches of pigment on the face
• Angiomas (vascular spider nevis), minute red elevations on
the skin of the face, neck, upper chest, legs, and arms
• Reddening of the palms (palmar erythema)
• Increased warmth to the skin and increased nail growth

63. CHANGES IN THE
MUSCULOSKELETAL
SYSTEM

64. • Relaxin - increases mobility of sacroiliac, sacrococcygeal,
and pelvic joints
• The center of gravity shifts secondary to increased weight
gain, fluid retention, lordosis, and mobile ligaments. This
contribute to alteration of maternal posture and back pain
• Late in pregnancy, aching, numbness, and weakness in the
upper extremities may occur because of lordosis and
paresthesia, which ultimately produces traction on the ulnar
and median nerves
• Separation of the rectus muscles due to pressure of the
growing uterus creates a diastasis recti

66. CHANGES IN THE
NEUROLOGIC
SYSTEM

67. • Mild frontal headaches are common in the 1st and 2nd
trimester; related to tension or hormonal changes
• Dizziness is common and is related to vasomotor instability,
postural hypotension, or hypoglycemia following long
periods of standing or sitting
• Tingling sensations in the hands are common and are due
to excessive hyperventilation, which decreases maternal
Pco2 levels
• Severe headaches that occur after 20 weeks' gestation and
are accompanied by visual changes, elevated blood
pressure, proteinuria, and facial edema should be evaluated
immediately.

68. CHANGES IN HORMONAL
RESPONSES

69. Steroid Hormones
• Estrogen:
– secreted by the ovaries in early pregnancy, but by 7
weeks' gestation over half of the estrogen is secreted by
the placenta
– ensure uterine growth and development, maintenance of
uterine elasticity and contractility, maintenance of breast
growth and its ductal structures, and enlargement of the
external genitalia
• Progesterone:
– initially secreted by corpus luteum; later by placenta
– suppresses the maternal immunologic response to the
fetus and rejection of the trophoblasts
– helps to maintain the endometrium, inhibits uterine
contractility, helps in the development of breast lobules
for lactation, stimulates the maternal respiratory center,
and relaxes smooth muscle

70. Placental Protein Hormones
• hCG:
– Secreted by the syncytiotrophoblasts; stimulates the
production by the corpus luteum of progesterone and
estrogen
– 2x as high in multiple gestation than in single pregnancy
– hlevels peak around 10 weeks' gestation (50,000 to
100,000 mIU/mL) then decrease to 10,000 to 20,000
mIU/mL by 20 weeks' gestation
• hPL:
– human chorionic somatomammotropin
– Produced by the syncytiotrophoblasts of the placenta
– increases the amount of free fatty acids available to the
fetus and decreases the maternal metabolism of glucose
allowing for protein synthesis. This allows the fetus to
have the needed nutrients when the woman has not or
is not eating

71. Other Hormones
• Prostaglandins:
– Affect smooth muscle contractility and some potent
vasodilators
– Essential for the cardiovascular adaptation to pregnancy,
cervical ripening, and initiation of labor.
• Relaxin:
– Secreted by the corpus luteum, decidua and placenta
– Inhibits uterine activity, decreases the strength of
uterine contractions, softens the cervix, and remodels
collagen
• Prolactin:
– Released from the APG
– Responsible for sustaining milk protein, casein, fatty
acids, lactose, and the volume of milk secretion during
lactation

72. PRENATAL ASSESSMENT

73. HEALTH HISTORY

74. Age
• Adolescents (younger than age 19) have an increased
incidence of anemia, gestational hypertension, preterm
labor (PTL), small-for-gestational-age (SGA) infants,
intrauterine-growth-restricted infants, cephalopelvic
disproportion, dystocia
• Women of advanced maternal age (over age 35) have an
increased incidence of hypertension, pregnancies
complicated by diabetes, multiple gestation, and infants
with genetic abnormalities
Family History
• Includes maternal and paternal history
• Congenital disorders, hereditary diseases, multiple
pregnancies, diabetes, heart disease, hypertension, mental
retardation, renal disease, use of diethylstilbestrol

75. Woman's Medical History
• Childhood diseases (rubella, measles, chickenpox)
• Major illnesses, surgery (reproductive tract, spinal surgery or
appendectomy), blood transfusions
• Chronic medical conditions (epilepsy, diabetes mellitus)
• Drug, food, and environmental sensitivities
• UTI, heart disease, HTN, endocrine disorders, anemia
• Menstrual history (menarche, length, amount, regularity,
dysmenorrhea, menstrual cycle, bleeding between periods
• Gynecologic history (STD, contraceptive use, sexual hx)
• Use of medications (prescription and OTC), recreational drugs,
alcohol, nicotine, tobacco, caffeine
• History of TB, hepatitis, group B beta-hemolytic streptococcus, HIV

76. Woman's Nutritional History
• Adherence to special dietary practices (religious, social or
cultural preferences)
• Eating disorders (obesity, bulimia, anorexia nervosa).
Woman's Past Obstetric History
• Problems of infertility, date of previous pregnancies, and
deliveries - dates; infant weights; length of labors; types of
deliveries; multiple births; abortions; and maternal, fetal,
and neonatal complications.
• Woman's perception of past pregnancy, labor, and delivery
for herself and effect on her family.

77. Woman's Present Obstetric History
• Gravida, Para / GTPALM, LMP, EDC
• Signs and symptoms of pregnancy; Expectations for her
present pregnancy, labor, and delivery
• Rest and sleep patterns
• Activity and employment
• Sexual activity
• Diet history
• Psychosocial status

78. PHYSICAL
ASSESSMENT

80. General Examination
• Empty her bladder before the examination to enhance her
comfort and to facilitate palpation of uterus and pelvic
organs
• Evaluation of the wt and BP
• Examination of the eyes, ears, and nose
• Examination of the mouth, teeth, throat, and thyroid
• Inspection of breasts and nipples
• Auscultation of the heart
• Auscultation and percussion of the lungs.

82. Abdominal Examination
• Examination for scars or striations, diastasis (separation of
the rectus muscle), or umbilical hernia
• Palpation of the abdomen for height of the fundus (palpable
after 13 weeks of pregnancy)
• Palpation of the abdomen for fetal outline and position
(Leopold's maneuvers) - third trimester
• Check of FHT; audible with a Doppler after 10 to 12 weeks
and at 18 to 20 weeks with a fetoscope
• Record fetal position, presentation, and FHTs

83. Leopold’s Maneuvers

84. Pelvic Examination
• lithotomy position
• Inspection of external genitalia
• Vaginal examination
• Examination of the cervix for position, size, mobility, and
consistency
• Identification of the ovaries (size, shape, and position)
• Rectovaginal exploration to identify hemorrhoids, fissures,
herniation, or masses
• Evaluation of pelvic inlet, midpelvis, pelvic outlet

85. Vaginal Speculum Examination

86. Vaginal Examination

87. Subsequent Prenatal Assessments
• Uterine growth and estimated fetal growth.
– Fundus at symphysis pubis indicates 12 weeks
– Fundus at umbilicus indicates 20 weeks
– Fundal height corresponds with gestational age between
22 and 34 weeks.
– Fundus at lower border of rib cage indicates 36 weeks
– Uterus becomes globular, and drop indicates 40 weeks
• A greater fundal height suggests:
– Multiple pregnancy.
– Miscalculated due date.
– Polyhydramnios (excessive amniotic fluid).
– Hydatidiform mole (degeneration of villi into grapelike
clusters; fetus does not usually develop).
– Uterine fibroids

88. Height of Fundus

89. • A lesser fundal height suggests:
– Intrauterine fetal growth restriction.
– Error in estimating gestation.
– Fetal or amniotic fluid abnormalities.
– Intrauterine fetal death.
– SGA
• FHTs - palpate abdomen for fetal position.
– Normal - 110 to 160 beats per minute (bpm)
• Weight - major increase in weight occurs during second half
of pregnancy; usually between 0.5 lb (0.2 kg)/week and 1
lb (0.5 kg)/week
• BP- should remain near woman's prepregnant baseline
• Complete blood count at 28 and 32 weeks' gestation; VDRL
- rechecked at 36 to 40 weeks' gestation.

90. • Antibody serology screen if Rh negative at 36 weeks
• Culture smears for gonorrhea, chlamydia, group B beta-
hemolytic streptococcus, and herpes; usually at 36 and 40
weeks
• Urinalysis - for protein, glucose, blood, and nitrates
• AFP - done at 15 to 20 weeks
• Diabetic screening - done as indicated at 24 to 28 weeks
• Administer RhoGAM as indicated at 28 weeks
• Edema - check the lower legs, face, and hands
• Evaluate discomforts of pregnancy, eating and sleeping
patterns, general adjustment and coping with the
pregnancy

92. HEALTH EDUCATION AND
INTERVENTION

93. NURSING DIAGNOSES

94. • Acute Pain (backache, leg cramps, breast tenderness)
related to physiologic changes of pregnancy
• Imbalanced Nutrition: Less Than Body Requirements
related to morning sickness and heartburn and lack of
knowledge of requirements in pregnancy
• Impaired Urinary Elimination (frequency) related to
increased pressure from the uterus
• Constipation related to physiologic changes of
pregnancy and pressure from the uterus

95. • Impaired Tissue Integrity related to pressure from the
uterus and increased blood volume
• Anxiety or Fear related to the birth process and infant care
• Ineffective Role Performance related to the demands of
pregnancy
• Activity Intolerance related to physiologic changes of
pregnancy and enlarging uterus

96. PATIENT EDUCATION
GUIDELINES

98. Prenatal Care
• Prenatal care appointments:
– Weeks 1-28: Every month
– Weeks 28-36: Every 2 weeks
– Weeks 36-delivery: Every week
• Expect the discomforts of pregnancy:
– Back pain, leg cramps, breast tenderness
– Morning sickness, heartburn
– Frequent urination
– Constipation
– Swelling of legs, varicose veins
– Fatigue
• Follow a healthy, balanced diet with 3 meals per day, and
take prenatal vitamin as directed by health care provider

99. • Get regular exercise, and use proper body mechanics to
avoid injury.
• Be aware of danger symptoms of pregnancy; report to your
health care provider promptly:
– Vision disturbances - blurring, spots, or double vision
– Vaginal bleeding, new or old blood
– Edema of the face, fingers, and sacrum
– Headaches - frequent, severe, or continuous
– Fluid discharge from vagina; unusual or severe
abdominal pain
– Chills, fever, or burning on urination
– Epigastric pain (severe stomachache)
– Muscular irritability or convulsions
– Inability to tolerate food or liquids, leading to severe
nausea and hyperemesis

100. NURSING INTERVENTIONS

101. Minimizing Pain
• Use good body mechanics - wear comfortable, low-heeled
shoes with good arch support
• Pelvic rocking exercises
• Take rest periods with legs elevated
• Adequate calcium intake may decrease leg cramps
• Dorsiflex the foot while applying pressure to the knee to
straighten the leg for immediate relief of leg cramps
• Wear a fitted, supportive brassiere
• Wash breasts and nipples with water only
• Apply vitamin E or lanolin cream to the breast and nipple
area

103. Minimizing Morning Sickness and
Heartburn and Maintaining
Adequate Nutrition
• Eat low-fat protein foods and dry carbohydrates (toast,
crackers); Eat small, frequent meals, Eat slowly
• Avoid brushing teeth soon after eating
• Get out of bed slowly
• Drink soups and liquids between meals to avoid stomach
distention and dehydration
• Caution against the use of sodium bicarbonate because it
results in the absorption of excess Na and fluid retention
• Avoid offensive foods or cooking odors that may trigger
nausea

104. • Basic food groups with appropriate daily servings.
– 7 servings of protein-rich foods, including one serving of
a vegetable protein
– 3 servings of dairy products or other calcium-rich foods
– 7 servings of grain products
– 2 or more servings of vitamin C-rich vegetable or fruit
– 3 servings of other fruits and vegetables
– 3 servings of unsaturated fats
– 2 or more servings of other fruits and vegetables
• If the woman is a vegetarian, inform her of appropriate
intake. Assess type of vegetarian and food intake
– Recommend iron and folic acid supplements

105. • Average weight gain: 25-35 lb (11-16 kg).
– 2-5 lb (0.9-2.3 kg) gained in the 1st trimester;
– 1 lb (0.5 kg)/wk for the remainder of the gestation
• Average weight gain
– Obese: 15 lb (6.8 kg)
– Adolescent: 5 lb more than for adult women if within 2
years of starting menses
– Multiple pregnancy: 35-45 lb (15.9-20.5 kg)
– Underweight: 28-40 lb (12.7-18.1 kg)
• Limit the use of caffeine; Eliminate alcohol and smoking
– Risk of spontaneous abortion, fetal death, low birth
weight, and neonatal death
• Ingesting any drug during pregnancy may affect fetal
growth; discuss with health care provider

106. Minimizing Urinary Frequency and
Promoting Elimination
• Limit fluid intake in the evening
• Void before going to bed
• Void after meals
• Void when feeling the urge and after sexual intercourse
• Wear loose-fitting cotton underwear
• Cranberry or blueberry juice to help prevent UTIs
• Avoid caffeine

107. Avoiding Constipation
• Increase fluid intake to at least 8 glasses of water/day; 1-2
quarts of fluid per day
• Eat foods high in fiber daily
• Establish regular patterns of elimination
• Daily exercise (walking)
• Avoid OTC laxatives; bulk-forming agents may be
prescribed if indicated

108. Maintaining Tissue Integrity
• Take frequent rest periods with legs elevated
• Wear support stockings and loose-fitting clothing for leg
varicosities
• Rest periodically with a small pillow under the buttocks to
elevate the pelvis for vulvar varicosities
• Avoid constipation, apply cold compresses, take sitz baths,
and use topical anesthetics, such as Tucks, for the relief of
anal varicosities (hemorrhoids)
• Varicosities will totally or greatly resolve after delivery

109. Reducing Anxiety and Fear and
Promoting Preparation for Labor,
Delivery, and Parenthood
• Discuss knowledge, perceptions, cultural values, and
expectations of the labor and delivery process
• Provide information on childbirth education classes and
sibling and grandparent preparation
•
• Tour of the birth facility
• Coping and pain control techniques for labor and birth
• Common procedures during labor and birth

111. • Guidelines for coming to the birth facility
• Discuss perceptions and expectations of parenthood and
their “idealized child”
• Discuss the infant's sleeping, eating, activity, and response
patterns for the first month of life
• Physical preparations for the infant, such as a sleeping
space, clothing, feeding, changing, and bathing equipment
• Plans for returning to work and childcare arrangements
• Planning time for themselves and each other apart from the
newborn
• Attend baby care, breast-feeding, and parenting classes
• Answer any questions the woman/couple may have

112. Enhancing Role Changes
• Discussion of feelings and concerns regarding the new role
of mother and father
• Emotional support to the woman/couple regarding the
altered family role
• Physiologic causes for changes in sexual relationships
(fatigue, loss of interest, discomfort from advancing
pregnancy); Some women experience heightened sexual
activity during the 2nd trimester
• There are no contraindications to intercourse or
masturbation to orgasm provided the woman's membranes
are intact, there is no vaginal bleeding, and she has no
current problems or history of premature labor
• Female superior or side-lying positions are usually more
comfortable in the latter half of pregnancy

114. Minimizing Fatigue
• Teach the reasons for fatigue, and plan a schedule for
adequate rest
– Fatigue in the 1st trimester is due to increased
progesterone and its effects on the sleep center.
– Fatigue in the 3rd trimester is due mainly to carrying
increased weight of the pregnancy
– About 8 hours of rest are needed at night
– Inability to sleep may be due to excessive fatigue during
the day
– In the latter months of pregnancy, sleep on the side with
a small pillow under the abdomen
– Frequent 15-30 minute rest periods during the day
– Work while sitting with legs elevated
– Avoid standing for prolonged periods, especially during
the 3rd trimester.

115. • To promote placental perfusion, the woman should lie on
left lateral position; either side is acceptable
• Plan for adequate exercise
– Keep with the prepregnancy pattern and type of exercise
– Avoid activities or sports that have a risk of bodily harm
(skiing, snowmobiling, ice skating, inline skating,
horseback riding)
– Endurance during exercise may be decreased
– Exercise classes for pregnant women that concentrate
on toning and stretching have resulted in enhanced
physical condition, increased self-esteem, and greater
social support as a result of being in the exercise group.

116. COMMUNITY AND HOME
CARE INSTRUCTIONS

117. • Prevention-oriented care
• Case management coordinates health care management
collaboratively
• Register for prepared childbirth classes; Preferable to those
associated with the family's intended delivery hospital
• Prenatal education on nutrition, sexuality, stress reduction,
lifestyle behaviors, and hazards at home or work
• Cultural practices have important implications for the
provision of nursing care

118. EVALUATION: EXPECTED
OUTCOMES

119. • Verbalizes understanding of proper body mechanics and
wears low-heeled shoes
• Identifies the basic food groups and describes meals to
include needed servings for pregnancy
• Reports limited fluid intake in the evening
• Describes foods high in fiber
• Wears support stockings and loose-fitting clothing
• Discusses expectations for labor, delivery, and parenthood
and attends educational classes
• Verbalizes an understanding of the physiologic causes that
may change the sexual relationship
• Reports engaging in regular exercise

120. UPDATES

121. Oxytocin as a High-Alert Medication:
Implications for Perinatal Patient Safety
Kathleen Rice Simpson PhD, RNC, FAAN and G. Eric Knox, MD
MCN, The American Journal of Maternal/Child Nursing, January/February 2009, Volume
34, Number 1, Pages 8 - 15
• In 2007, the Institute for Safe Medication Practices added
intravenous (IV) oxytocin to their list of high-alert
medications.
• Errors that involve IV oxytocin administration for labor
induction or augmentation are most commonly dose related
and often involve lack of timely recognition and appropriate
treatment of excessive uterine activity (tachysystole).

122. • Other types of oxytocin errors involve mistaken
administration of IV fluids with oxytocin for IV fluid
resuscitation during nonreassuring (abnormal or
indeterminate) fetal heart rate patterns and/or maternal
hypotension and inappropriate elective administration of
oxytocin to women who are less than 39 completed weeks'
gestation.
• Oxytocin medication errors and subsequent patient harm
are generally preventable.
• The perinatal team can develop strategies to minimize risk
of maternal-fetal injuries related to oxytocin administration
consistent with safe care practices used with other high-
alert medications.

123. Oral Intake During Labor: A Review of the
Evidence
Nancy C. Sharts-Hopko PhD, RN, FAAN
MCN, The American Journal of Maternal/Child Nursing, July/August 2010, Volume
35, Number 4, Pages 197 - 203
• Fasting in labor became standard policy in the United
States after findings of a 1946 study suggested that
pulmonary aspiration during general anesthesia was an
avoidable risk.
• Today general anesthesia is rarely used in childbirth and its
associated maternal mortality usually results from difficulty
in intubation.
•

124. • Research from the United States, Australia, and Europe
suggests that oral intake may be beneficial, and adverse
events associated with oral intake such as vomiting and
prolongation of labor do not seem to be associated with
alterations in maternal or infant outcomes.
• The World Health Organization recommends that healthcare
providers should not interfere in women's eating and
drinking during labor when no risk factors are evident.
• Nurses in intrapartum settings are encouraged to work in
multidisciplinary teams to revise policies that are
unnecessarily restrictive regarding oral intake during labor
among low-risk women.

125. Overcoming the Challenges: Maternal
Movement and Positioning to Facilitate
Labor Progress
Elaine Zwelling PHD, RN, LCCE, FACCE
MCN, The American Journal of Maternal/Child Nursing, March/April 2010, Volume
35, Number 2, Pages 72 - 78
• The benefits of maternal movement and position changes
to facilitate labor progress have been discussed in the
literature for decades.
• Recent routine interventions such as amniotomy, induction,
fetal monitoring, and epidural anesthesia, as well as an
increase in maternal obesity, have made position changes
during labor challenging.

126. • The lack of maternal changes in position throughout labor
can contribute to dystocia and increase the risk of cesarean
births for failure to progress or descend.
• This article provides a historical review of the research
findings related to the effects of maternal positioning on the
labor process and uses six physiological principles as a
framework to offer suggestions for maternal positioning
both before and after epidural anesthesia.

127. A baby is something
You carry inside you for nine months,
In your arms for three years,
And in your heart till the day you die.
-Anonymous (A Mother)

128. Thank You!
Have a nice day.