Chapter 9: Nursing Care of the Growing Fetus

Feeling a fetus move is often the trigger that makes STAGES OF FETAL DEVELOPMENT Normally, an ejaculation of semen averages 2.5 ml of fluid
having a baby “real” for many women. The more women know In just 38 weeks, a fertilized egg (ovum) containing 50 to 200 million spermatozoa per milliliter, or an average of
about fetal development before and after this event, the easier it is matures from a single cell to a fully developed fetus 400 million sperm per ejaculation.
for them to begin to think of the pregnancy not as something ready to be born. Fetal growth and development can
interesting happening to them, but as an act producing a separate be divided into three time periods:
life. • Pre-embryonic (first 2 weeks, beginning with At the time of ovulation, there is a reduction in the
fertilization) viscosity (thickness) of the woman’s cervical mucus, which makes
• Embryonic (weeks 3 through 8) it easy for spermatozoa to penetrate it. Sperm transport is so
Throughout history, different societies have held a variety of • Fetal (from week 8 through birth) efficient close to ovulation that spermatozoa deposited in the
beliefs and superstitions about the way the fetus (i.e., the infant vagina generally reach the cervix within 90 seconds and the outer
during intrauterine life) originates and grows. end of a fallopian tube within 5 minutes after deposition. The
In 1758, Kaspar Wolff proposed that both parents mechanism whereby spermatozoa are drawn toward an ovum is
contribute equally to the structure of the baby. The work of Fertilization: The Beginning of Pregnancy
probably a species-specific reaction. Hyaluronidase (a proteolytic
modern research and photographers who have been able to Fertilization (also referred to as
enzyme) is released by the spermatozoa and dissolves the layer of
capture the process of fertilization and fetal development by conception and impregnation) is the union of an
cells (corona cells) protecting the ovum. Only one spermatozoon is
ultrasound and high-tech photography, there is now a clear ovum and a spermatozoon. This usually occurs in
able to penetrate the cell membrane of the ovum. Once it
picture of what a fetus looks like which allows both families and the outer third of a fallopian tube, termed the
penetrates the cell, the cell membrane changes composition to
health care providers to view the fetus as a patient separate from ampullar portion. Only one of a woman’s ova
become impervious to other spermatozoa. An exception to this is
the mother. reaches maturity each month. Once the mature
the formation of gestational trophoblastic disease in which
ovum is released (ovulation), fertilization must
multiple sperm enter an ovum; this leads to abnormal zygote
occur fairly quickly because an ovum is capable of
formation.
fertilization for only about 24 hours (48 hours at
Nursing Process Overview the most). After that time, it atrophies and
To Help Ensure Fetal Health: becomes nonfunctional. Because the functional life Immediately after penetration of the ovum, the
A. Assessment of a spermatozoon is also about 48 hours, possibly chromosomal material of the ovum and spermatozoon fuse to
Assessing fetal growth throughout as long as 72 hours (the total critical time span) form a zygote. Each carried 23 chromosomes (22 autosomes and 1
pregnancy, by such means as measuring fundal during which sexual relations must occur for sex chromosome), the fertilized ovum has 46 chromosomes. If an X-
height and fetal heart rate, is important because fertilization to be successful is about 72 hours (48 carrying spermatozoon entered the ovum, the resulting child will
these signs of fetal development provide hours before ovulation plus 24 hours afterward). have two X chromosomes and will be female (XX). If a Y-carrying
guidelines for determining the well-being of a
spermatozoon fertilized the ovum, the resulting child will have an X
fetus.
and a Y chromosome and will be male (XY).
B. Nursing Diagnosis
As the ovum is extruded from the graafian follicle of Fertilization is never a certain occurrence because it
Nursing diagnoses related to growth and
an ovary with ovulation, it is surrounded by a ring of depends on at least three separate factors:
development of the fetus focus on the mother and
mucopolysaccharide fluid (the zona pellucida) and a • Equal maturation of both sperm and ovum
family as well as the fetus.
circle of cells (the corona radiata). The ovum and • Ability of the sperm to reach the ovum
C. Outcome Identification and Planning
these surrounding cells increase the bulk of the • Ability of the sperm to penetrate the zona pellucida and cell
Be certain plans for care include ways to
ovum and serve as protective buffers against injury membrane and achieve fertilization
educate potential parents about teratogens (i.e.,
any substance harmful to a fetus) that have the are propelled into a nearby fallopian tube by
potential to interfere with fetal health. currents initiated by the fimbriae (fine, hairlike Terms Used to Describe Fetal Growth
D. Implementation structures that line the openings of the tubes. A Name Time Period
Most expectant parents are interested in combination of peristaltic action of the tube (uterine Ovum From ovulation to fertilization.
learning about how mature their fetus is at various contractions) and movements of the tube, cilia help Zygote From fertilization to implantation.
points in pregnancy which helps them to propel the ovum along the length of the tube. Embryo From implantation to 5–8 weeks.
understand the importance of implementing Fetus From 5–8 weeks until term.
healthy behaviors. Conceptus Developing embryo and placental structures
E. Outcome Evaluation throughout pregnancy.
Focuses on determining whether a woman Age of viability The earliest age at which fetuses survive if they
are born is generally accepted as 24 weeks, or
at the point a fetus weighs more than 500–600
g.
 The middle layer (trophoblast), the
cytotrophoblast or Langhans’ layer, appears to have a
Implantation Implantation or contact between the growing second function to protect the growing embryo and fetus
Once fertilization is complete, a zygote migrates over structure and the uterine endometrium, occurs approximately 8 from certain infectious organisms such as the spirochete
the next 3 to 4 days toward the body of the uterus. During this to 10 days after fertilization. About 8 days after ovulation, the of syphilis early in pregnancy. Because this layer of cells
time, mitotic cell division, or cleavage, begins. The first cleavage blastocyst sheds the last residues of the corona and zona disappears between the 20th and 24th week of
occurs at about 24 hours; cleavage divisions continue to occur at a pellucida, brushes against the rich uterine endometrium (in the pregnancy, this is why syphilis is not considered to have a
rate of about one every 22 hours so by the time the zygote second [secretory] phase of the menstrual cycle), and settles high potential for fetal damage early in pregnancy, only
reaches the body of the uterus, it consists of 16 to 50 cells. Over down into its soft folds. Implantation usually occurs high in the after the point at which cytotrophoblast cells are no
the next 3 or 4 days, large cells tend to collect at the periphery of uterus, on the posterior surface. If the point of implantation is longer present.
the ball, leaving a fluid space surrounding an inner cell mass. At low in the uterus, the growing placenta may occlude the cervix The Placenta
this stage, the structure is termed a blastocyst. The cells in the and make birth of the child difficult (placenta previa), because The placenta (Latin for “pancake,” which is
outer ring are trophoblast cells. They are the part of the structure the placenta can block the birth canal. Almost immediately, the descriptive of its size and appearance at term) grows from
that will later form the placenta and membranes. The inner cell blastocyst burrows deeply into the endometrium and a few identifiable trophoblast cells at the beginning of
mass (embryoblast cells) is the portion of the structure that will establishes an effective communication network with the blood pregnancy to an organ 15 to 20 cm in diameter and 2 to 3
form the embryo. system of the endometrium. Once implanted, the zygote is cm in depth, covering about half the surface area of the
called an embryo. Implantation is an important step in internal uterus at term.
pregnancy, because as many as 50% of zygotes never achieve it.
In these instances, the pregnancy ends as early as 8 to 10 days
after conception, often before a woman is even aware she was Circulation
pregnant. Occasionally, a small amount of vaginal spotting As early as the 12th day of pregnancy,
appears on the day of implantation because capillaries are maternal blood begins to collect in the intervillous
ruptured by the implanting trophoblast cells. spaces of the uterine endometrium surrounding the
chorionic villi. By the third week, oxygen and other
nutrients such as glucose, amino acids, fatty acids,
EMBRYONIC AND FETAL STRUCTURES minerals, vitamins, and water osmose from the
The placenta and membranes, which will serve as maternal blood through the cell layers of the chorionic
the fetal lungs, kidneys, and digestive tract in utero as well as villi into the villi capillaries. From there, nutrients are
help provide protection for the fetus, begin growth in early transported to the developing embryo. Because almost
pregnancy in coordination with embryo growth. all drugs are able to cross into the fetal circulation, it is
The Decidua or Uterine important that a woman take no nonessential drugs
Lining After fertilization, the corpus luteum (including alcohol and nicotine) during pregnancy.
(responsible for the production of the hormone progesterone) Example: Alcohol can cause fetal alcohol spectrum
in the ovary continues to function under the influence of human disorder (unusual facial features, lowset ears, and
chorionic gonadotropin (hCG) secreted by the trophoblast cells. cognitive challenge). Fetal cells do cross into the
This hormone also causes the uterine endometrium to continue maternal bloodstream, as well as fetal enzymes such as
to grow in thickness and vascularity instead of sloughing off -fetoprotein (AFP) produced by the fetal liver (this
(usual in menstrual cycle). The endometrium is now typically allows testing of fetal cells for genetic analysis as well as
termed the decidua (the Latin word for “falling off”), because it the level of AFP in the maternal blood). As the number of
will be discarded after birth of the child. chorionic villi increases with pregnancy, the villi form an
Chorionic Villi increasingly complex communication network with the
As early as the 11th or 12th day after fertilization, maternal bloodstream. Intervillous spaces grow larger
miniature villi, resembling probing fingers and termed chorionic and larger, becoming separated by 30 or more
villi, reach out from the trophoblast cells into the uterine partitions or septa. These compartments (cotyledons)
endometrium to begin formation of the placenta. Chorionic villi are what make the maternal side of the placenta look
have a central core consisting of connective tissue and fetal rough and uneven. To provide enough blood for
capillaries surrounded by a double layer of cells, which produce exchange, the rate of uteroplacental blood flow in
various placental hormones, such as hCG, pregnancy increases from about 50 ml/min at 10 weeks
somatomammotropin (human placental lactogen [hPL]), to 500 to 600 ml/min at term. No additional maternal
estrogen, and progesterone. arteries appear after the first 3 months of pregnancy;
instead, to accommodate the increased blood flow, the
 The woman’s heart rate, total cardiac output, and blood volume all increase to supply blood
to the placenta. Braxton Hicks contractions, the barely noticeable uterine contractions present from Endocrine Function
about the 12th week of pregnancy on, aid in maintaining pressure in the intervillous spaces by closing Besides serving as the source of oxygen and nutrients for the fetus, the
off the uterine veins momentarily with each contraction. Uterine perfusion and placental circulation syncytial (outer) layer of the chorionic villi develops into a separate and important
are most efficient when the mother lies on her left side, as this position lifts the uterus away from the hormone-producing system.
inferior vena cava, preventing blood from becoming trapped in the woman’s lower extremities. If the Human Chorionic Gonadotropin
woman lies on her back and the weight of the uterus compresses on the vena cava, placental circulation The first placental hormone produced, hCG, can be found in maternal blood
can be so sharply reduced that supine hypotension (very low maternal blood pressure and poor uterine and urine as early as the first missed menstrual period (shortly after implantation has
circulation) can occur. At term, the placental circulatory network has grown so extensively that a occurred) through about the 100th day of pregnancy. Because this is the hormone
placenta weighs 400 to 600 g (1 lb), onesixth the weight of the newborn. If a placenta is smaller than analyzed by pregnancy tests, a false-negative result from a pregnancy test may be
this, it suggests circulation to the fetus may have been inadequate. A placenta bigger than this also may obtained before or after this period. The mother’s blood serum will be completely
indicate circulation to the fetus was threatened, because it suggests the placenta was forced to spread negative for hCG within 1 to 2 weeks after birth. Finding no serum hCG after birth can be
out in an unusual manner to maintain a sufficient blood supply. The fetus of a woman with diabetes used as proof that placental tissue is no longer present. hCG’s purpose is to act as a fail-
may also develop a larger than usual placenta from excess fluid collected between cells. safe measure to ensure the corpus luteum of the ovary continues to produce
progesterone and estrogen so the endometrium of the uterus is maintained. hCG also
may play a role in suppressing the maternal immunologic response so placental tissue is
not detected and rejected as a foreign substance. Because the structure of hCG is similar
to that of luteinizing hormone of the pituitary gland, if the fetus is male, it exerts an
effect on the fetal testes to begin testosterone production and maturation of the male
reproductive tract. At about the eighth week of pregnancy, the outer layer of cells of the
developing placenta begins to produce progesterone, making the corpus luteum, which
was producing progesterone, no longer necessary.
Progesterone
Estrogen is often referred to as the “hormone of women,” and progesterone
as the “hormone of mothers.” This is because, although estrogen influences a female
appearance, progesterone is necessary to maintain the endometrial lining of the uterus
during pregnancy. It is present in maternal serum as early as the fourth week of
pregnancy as a result of the continuation of the corpus luteum. After placental production
begins (at about the 12th week), the level of progesterone rises progressively during the
remainder of the pregnancy. This hormone also appears to reduce the contractility of the
uterus during pregnancy, thus preventing premature labor.
Estrogen
Estrogen (primarily estriol) is produced as a second product of the syncytial
cells of the placenta. Estrogen contributes to the woman’s mammary gland development
in preparation for lactation and stimulates uterine growth to accommodate the
developing fetus.
Human Placental Lactogen (Human Chorionic Somatomammotropin)
hPL is a hormone with both growth promoting and lactogenic (milk-producing)
properties. It is produced by the placenta beginning as early as the sixth week of
pregnancy, increasing to a peak level at term. It promotes mammary gland (breast)
growth in preparation for lactation in the mother. It also serves the important role of
regulating maternal glucose, protein, and fat levels so adequate amounts of these
nutrients are always available to the fetus.

Placental Proteins
In addition to hormones, the placenta also produces a number of plasma
proteins. The function of these has not been well documented, but they may contribute
to decreasing the immunologic impact of the growing placenta and help prevent
hypertension of pregnancy.
 ORIGIN AND DEVELOPMENT OF ORGAN SYSTEMS
The Amniotic Membranes Another function is that it aids in muscular Stem Cells
The chorionic villi on the medial surface of development, as amniotic fluid allows the fetus freedom During the first 4 days of life, zygote cells are termed totipotent
the trophoblast (those that are not involved in to move. Finally, it protects the umbilical cord from stem cells, or cells so undifferentiated they have the potential to
implantation because they do not touch the pressure, thus protecting the fetal oxygen supply. Even if grow into any cell in the human body. In another 4 days, as the
endometrium) gradually thin until they become the the amniotic membranes rupture before birth and the bulk structure implants and becomes an embryo, cells begin to show
chorionic membrane, the outermost fetal membrane. of amniotic fluid is lost, some will always surround the differentiation, or lose their ability to become any body cell.
The amniotic membrane or amnion, forms beneath the fetus in utero because new fluid is constantly being Instead, they are slated to become specific body cells, such as
chorion. Beginning early in pregnancy, these formed. Amniotic fluid is slightly alkaline, with a pH of nerve, brain, or skin cells and are termed pluripotent stem cells.
membranes become so adherent they seem as one at about 7.2. Checking the pH of the fluid at the time In yet another few days, the cells grow so specific they are
term. They have no nerve supply, so when they membranes rupture and amniotic fluid is released helps to termed multipotent, or are so specific they cannot be deterred
spontaneously rupture at term or are artificially differentiate amniotic fluid from urine, because urine is from growing into a particular body organ such as spleen or liver
ruptured, neither mother nor child experiences any or brain.
acidic.
Zygote Growth
pain. In contrast to the chorionic membrane, the The Umbilical Cord
As soon as conception has taken place, development
second membrane (the amniotic membrane) not only The umbilical cord is formed from the fetal proceeds in a cephalocaudal (head-to-tail) direction; that is,
offers support to amniotic fluid but also actually membranes (amnion and chorion) and provides a head development occurs first and is followed by development
produces the fluid. In addition, it produces a circulatory pathway that connects the embryo to the of the middle, and finally, the lower body parts.
phospholipid that initiates the formation of chorionic villi of the placenta. Its function is to transport Primary Germ Layers
prostaglandins, which may be the trigger that initiates oxygen and nutrients to the fetus from the placenta and As a fetus grows, body organ systems develop from
labor. to return waste products from the fetus to the placenta. It specific tissue layers called germ layers. At the time of
is about 53 cm (21 in.) in length at term and about 2 cm implantation, the blastocyst already has differentiated to a point
The Amniotic Fluid (0.75 in.) thick. The bulk of the cord is a gelatinous at which three separate layers of these cells are present: the
Amniotic fluid never becomes stagnant mucopolysaccharide called Wharton jelly, which gives the ectoderm, the endoderm, and the mesoderm. Each of these
because it is constantly being newly formed and cord body and prevents pressure on the vein and arteries germ layers develops into specific body systems. Knowing which
absorbed by direct contact with the fetal surface of the that pass through it. An umbilical cord contains only one structures arise from each germ layer is helpful to know because
placenta. The major method of absorption, however, coexisting congenital disorders found in newborns usually arise
vein (carrying blood from the placental villi to the fetus)
from the same germ layer. For example, a fistula between the
happens within the fetus. Because the fetus continually but two arteries (carrying blood from the fetus back to
trachea and the esophagus (both of which arise from the
swallows the fluid, it is absorbed from the fetal the placental villi). The rate of blood flow through an endoderm layer) is a common birth anomaly. In contrast, it is
intestine into the fetal bloodstream. From there, it umbilical cord is rapid (350 ml/min at term). The adequacy rare to see a newborn with a malformation of the heart (which
goes to the umbilical arteries and to the placenta and is of blood flow (blood velocity) through the cord, as well as arises from the mesoderm) and also a malformation of the lower
exchanged across the placenta to the mother’s both systolic and diastolic cord pressure , can be urinary tract (which arises from the endoderm). One reason
bloodstream. At term, the amount of amniotic fluid has determined by ultrasound examination. Counting the rubella infection is so serious in pregnancy is because this virus
grown so much it ranges from 800 to 1,200 ml. If for number of coils in the cord may be used as a prediction of is capable of infecting all three germ layers so can cause
any reason the fetus is unable to swallow (esophageal healthy fetal growth, as hypocoiling is associated with congenital anomalies in a myriad of body systems. All organ
atresia or anencephaly are the two most common maternal hypertension and hypercoiling is associated with systems are complete, at least in a rudimentary form, at 8 weeks
reasons), excessive amniotic fluid or hydramnios (more respiratory distress in the newborn. Because the rate of gestation (the end of the embryonic period). During this early
than 2,000 ml in total, or pockets of fluid larger than 8 blood flow through the cord is so rapid, it is unlikely a time of organogenesis (organ formation), the growing structure
cm on ultrasound) will result. Hydramnios may also cord will twist or knot enough to interfere with the fetal is most vulnerable to invasion by eratogens (any factor that
occur in women with diabetes, because hyperglycemia affects the fertilized ovum, embryo, or fetus).
oxygen supply. In about 20% of all births, a loose loop of
Cardiovascular System
causes excessive fluid shifts into the amniotic space. cord is found around the fetal neck (nuchal cord) at birth.
The cardiovascular system is one of the first systems
Early in fetal life, as soon as the fetal kidneys become If this loop of cord is removed before the newborn’s to become functional in intrauterine life. Simple blood cells
active, fetal urine adds to the quantity of the amniotic shoulders are born (not usually hard to do) so there is no joined to the walls of the yolk sac progress to become a network
fluid. A disturbance of kidney function, therefore, may traction on it, the oxygen supply to the fetus remains of blood vessels and a single heart tube, which forms as early as
cause oligohydramnios, or a reduction in the amount unimpaired. The walls of the umbilical cord arteries are the 16th day of life and beats as early as the 24th day. The
of amniotic fluid (less than 300 ml in total, or no pocket lined with smooth muscle. When these muscles contract septum that divides the heart into chambers develops during the
on ultrasound larger than 1 cm). The most important after birth, the cord arteries and vein are compressed to 6th or 7th week; heart valves develop in the 7th week. The
purpose of amniotic fluid is to shield the fetus against prevent hemorrhage of the newborn through the cord. heartbeat may be heard with a Doppler instrument as early as
pressure or a blow to the mother’s abdomen. Because Because the umbilical cord contains no nerve supply, it can the 10th to 12th week of pregnancy. An electrocardiogram
liquid changes temperature more slowly than air, it also be clamped and cut at birth without discomfort to either (ECG) may be recorded on a fetus as early as the 11th week,
protects the fetus from changes in temperature. the child or mother. although the accuracy of such ECGs is in doubt until about the
20th week of pregnancy, when conduction is more regulated
 The heart rate of a fetus is affected by oxygen level, Respiratory System
activity, and circulating blood volume, just as in adulthood. After the At the third week of intrauterine life, the respiratory Nervous System
28th week of pregnancy, when the sympathetic nervous system has and digestive tracts exist as a single tube. Like all body tubes, Like the circulatory system, the nervous
matured, the heart rate stabilizes or begins to show a consistent initially this forms as a solid structure, which then canalizes system begins to develop extremely early in
beat of 110 to 160 beats/min. (i.e., hollows out). By the end of the fourth week, a septum pregnancy. • A neural plate (a thickened portion of
begins to divide the esophagus from the trachea. At the same the ectoderm) is apparent by the third week of
time, lung buds appear on the trachea. Until the seventh week gestation. The top portion differentiates into the
Origin of Body Tissue of life, the diaphragm does not completely divide the thoracic neural tube, which will form the central nervous
Germ Layer Body Portions Formed cavity from the abdomen. This causes lung buds to extend system (brain and spinal cord), and the neural
Ectoderm Central nervous system (brain & spinal cord) down into the abdomen, re-entering the chest only as the crest, which will develop into the peripheral
Peripheral nervous system chest’s longitudinal dimension increases and the diaphragm nervous system. • All parts of the brain (cerebrum,
Skin, hair, nails, and tooth enamel becomes complete (at the end of the seventh week). If the cerebellum, pons, and medulla oblongata) form in
Sense organs diaphragm fails to close completely, the stomach, spleen, liver, utero, although none are completely mature at
Mucous membranes of the anus, mouth, and nose or intestines may be pulled up into the thoracic cavity. This birth. Brain growth continues at high levels until 5
Mammary glands causes the child to be born with intestine present in the chest or 6 years of age. • Brain waves can be detected on
Mesoderm Supporting structures of the body (connective tissue, (i.e., diaphragmatic hernia), compromising the lungs and an electroencephalogram (EEG) by the eighth
bones, cartilage, muscle, ligaments, and tendons) perhaps displacing the heart. week. • The eye and inner ear develop as
Upper portion of the urinarysystem(kidneys& ureters) Other important respiratory developmental milestones projections of the original neural tube. • By 24
Reproductive system include: weeks, the ear is capable of responding to sound
Heart, lymph, and circulatory systems and blood cells • Spontaneous respiratory practice movements begin as early and the eyes exhibit a pupillary reaction, indicating
Endoderm Lining of pericardial, pleura, and peritoneal cavities as 3 months gestation and continue throughout pregnancy. sight is present. The neurologic system seems
Lining of the gastrointestinal tract, respiratory tract, • Specific lung fluid with a low surface tension and low particularly prone to insult during the early weeks
tonsils, parathyroid, thyroid, and thymus glands viscosity forms in alveoli to aid in expansion of the alveoli at of the embryonic period and can result in neural
Lower urinary system (bladder and urethra) birth; it is rapidly absorbed shortly after birth. tube disorders, such as a meningocele (i.e.,
• Surfactant, a phospholipid substance, is formed and excreted herniation of the meninges), especially if there is
by the alveolar cells of the lungs beginning at about the 24th lack of folic acid (which is contained in green leafy
week of pregnancy. This decreases alveolar surface tension on vegetables and pregnancy vitamins). All during
Fetal Circulation expiration, preventing alveolar collapse and improving the pregnancy and at birth, the system is vulnerable to
Fetal circulation differs from extrauterine circulation infant’s ability to maintain respirations in the outside damage if anoxia should occur.
because the fetus derives oxygen and excretes carbon dioxide not environment at birth. Endocrine System
from gas exchange in the lungs but from exchange in the Surfactant has two components: lecithin (L) and sphingomyelin The function of endocrine organs begins
placenta. (S). Early in the formation of surfactant, sphingomyelin is the along with neurosystem development.
Fetal Hemoglobin chief component. At about 35 weeks, there is a surge in the • The fetal pancreas produces insulin needed by
Fetal hemoglobin differs from adult hemoglobin in production of lecithin, which then becomes the chief the fetus (insulin is one of the few substances that
several ways. It has a different composition (two alpha and two component by a ratio of 2:1. As a fetus practices breathing does not cross the placenta from the mother to the
gamma chains, compared with two alpha and two beta chains movements, surfactant mixes with amniotic fluid. Using an fetus).
of adult hemoglobin). It is also more concentrated and has amniocentesis technique, an analysis of the lecithin/ • The thyroid and parathyroid glands play vital
greater oxygen affinity, two features that increase its efficiency. sphingomyelin (L/S) ratio in surfactant (whether lecithin or roles in fetal metabolic function and calcium
Because hemoglobin is more concentrated, a newborn’s sphingomyelin is the dominant component) is a primary test of balance.
hemoglobin level is about 17.1 g/100 ml, compared with a normal fetal maturity. Respiratory distress syndrome, a severe • The fetal adrenal glands supply a precursor
adult level of 11 g/100 ml; a newborn’s hematocrit is about 53%, breathing disorder, can develop if there is a lack of surfactant necessary for estrogen synthesis by the placenta.
compared with a normal adult level of 45%. The change from or it has not changed to its mature form at birth (see Chapter Digestive System
fetal to adult hemoglobin levels begins before birth (gamma cells 26). Any interference with the blood supply to the fetus, such The digestive tract separates from the
are exchanged for beta cells) but the process is still not complete as occurs with placental insuffi ciency or maternal respiratory tract at about the fourth week of
at birth. Major blood dyscrasias, such as sickle cell anemia, tend hypertension, appears to raise steroid levels in the fetus and intrauterine life and, after that, begins to grow
to be defects of the beta hemoglobin chain, which is why clinical enhance surfactant development. Synthetically increasing extremely rapidly. Initially solid, the tract canalizes
symptoms of these disorders do not become apparent until the steroid levels in the fetus (e.g., the administration of (hollows out) to become patent. Later in the
bulk of fetal hemoglobin has matured to adult hemoglobin, at betamethasone to the mother late in pregnancy) can also pregnancy, the endothelial cells of the
about 6 months of age. hurry alveolar maturation and surfactant production without gastrointestinal tract proliferate extensively,
interfering with permanent lung function prior to a preterm occluding the lumen once more, and the tract must
must canalize again. Atresia (blockage) or stenosis (narrowing) of the Musculoskeletal System Urinary System
track are common fetal anomalies and develop if either the fi rst or During the fi rst 2 weeks of fetal life, Although rudimentary kidneys are present as early as
second canalization does not occur (Lin, Munsie, HerdtLosavio, et al., cartilage prototypes provide position and support the end of the fourth week of intrauterine life, the presence of
2012). The proliferation of cells shed in the second recanalization to the fetus. Ossifi cation of this cartilage into kidneys does not appear to be essential for life before birth
forms the basis for meconium (see below). Because of this rapid bone begins at about the 12th week, continues all because the placenta clears the fetus of waste products. Urine,
intestinal growth, by the sixth week of intrauterine life, the intestine through fetal life and into adulthood. Carpals, however, is formed by the 12th week and is excreted into the
becomes too large to be contained by the abdomen. A portion of the tarsals, and sternal bones generally do not ossify amniotic fl uid by the 16th week of gestation. At term, fetal urine is
intestine, therefore, is pushed into the base of the umbilical cord, until birth is imminent. A fetus can be seen to being excreted at a rate of up to 500 ml/day. An amount of
where it remains until about the 10th week of intrauterine life or move on ultrasonography as early as the 11th amniotic fl uid less than usual (oligohydramnios) suggests fetal
until the abdominal cavity has grown large enough to accommodate week, although the mother usually does not feel kidneys are not secreting adequate urine and that there is a kidney,
the bulky intestines. As intestine returns to the abdominal cavity at this movement (quickening ) until almost 20 ureter, or bladder disorder (Kumar, 2012). The complex structure
this point, it must rotate 180 degrees. Failure to do so can result in weeks of gestation. of the kidneys gradually develops during intrauterine life and
inadequate mesentery attachments, possibly leading to volvulus of Reproductive System continues to mature for months afterward. The loop of Henle, for
the intestine in the newborn. If any intestine remains outside the A child’s sex is determined at the example, is not fully differentiated until the child is born.
abdomen in the base of the cord, a congenital anomaly, termed moment of conception by a spermatozoon Glomerular fi ltration and concentration of urine in the newborn
omphalocele , will be present at birth. A similar defect, carrying an X or a Y chromosome and can be are still not effi cient, because the ability to concentrate urine is
gastroschisis , occurs when the original midline fusion that occurred ascertained as early as 8 weeks by chromosomal still not mature at birth. Early in the embryonic stage of urinary
at the early cell stage is incomplete. Meconium , a collection of analysis or analysis of fetal cells in the mother’s system development, the bladder extends as high as the umbilical
cellular wastes, bile, fats, mucoproteins, mucopolysaccharides, and bloodstream. At about the sixth week after region and there is an open lumen between the urinary bladder
portions of the vernix caseosa (i.e., the lubricating substance that implantation, the gonads (i.e., ovaries or testes) and the umbilicus. If this fails to close, (termed a patent urachus),
forms on the fetal skin), accumulates in the intestines as early as the form. If testes form, testosterone is secreted, this is revealed at birth by the persistent drainage of a clear, acid–
16th week. Meconium is sticky in consistency and appears black or apparently infl uencing the sexually neutral genital pH fl uid (urine) from the umbilicus
dark green (obtaining its color from bile pigment). An important duct to form other male organs (i.e., maturity of Integumentary System
neonatal nursing responsibility is recording that a newborn has the wolffi an, or mesonephric, duct). In the The skin of a fetus appears thin and almost translucent
passed meconium as this rules out a stricture (noncanalization) of absence of testosterone secretion, female organs until subcutaneous fat begins to be deposited underneath it at
the anus. The gastrointestinal tract is sterile before birth. Because will form (i.e., maturation of the müllerian, or about 36 weeks. Skin is covered by soft downy hairs (lanugo) that
vitamin K, necessary for blood clotting, is synthesized by the action paramesonephric, duct). This is an important serve as insulation to preserve warmth in utero, as well as a cream
of bacteria in the intestines, vitamin K levels are almost nonexistent phenomenon, because if a woman should cheese–like substance, vernix caseosa, which is important for
in a fetus and are still low in a newborn (vitamin K is routinely unintentionally take an androgen or an androgen- lubrication and for keeping the skin from macerating in utero. Both
administered intramuscularly at birth). Sucking and swallowing refl like substance during this stage of pregnancy, a lanugo and vernix are still present at birth.
exes are not mature until the fetus is at about 32 weeks gestation, or child who is chromosomally female could appear Immune System
weighs 1,500 g. The ability of the gastrointestinal tract to secrete more male than female at birth. If defi cient Immunoglobulin (Ig) G maternal antibodies cross the
enzymes essential for carbohydrate and protein digestion is mature testosterone is secreted by the testes, both the placenta into the fetus as early as the 20th week and certainly by
at 36 weeks. However, amylase, an enzyme found in saliva and müllerian (female) duct and the wolffi an (male) the 24th week of intrauterine life to give a fetus temporary passive
necessary for digestion of complex starches, does not mature until 3 duct could develop (i.e., pseudohermaphroditism, immunity against diseases for which the mother has antibodies.
months after birth. Many newborns have also not yet developed or intersex). The testes fi rst form in the These often include poliomyelitis, rubella (German measles),
lipase, an enzyme needed for fat digestion (a reason breast milk is abdominal cavity and do not descend into the rubeola (regular measles), diphtheria, tetanus, infectious parotitis
the best food for newborns because its digestion does not depend scrotal sac until the 34th to 38th week of (mumps), hepatitis B, and pertussis (whooping cough). Infants born
on these enzymes). The liver is active throughout intrauterine life, intrauterine life. Because of this, many male before this antibody transfer has taken place have no natural
functioning as a fi lter between the incoming blood and the fetal preterm infants are born with undescended immunity and so need more than the usual protection against
circulation and as a deposit site for fetal stores such as iron and testes. These boys need a followup to be certain infectious disease in the newborn period. A fetus only becomes
glycogen. Unfortunately, during intrauterine life, the fetal liver is their testes do descend when they reach what capable of active antibody production late in pregnancy. Generally,
unable to prevent recreational drugs or alcohol ingested by the would have been the 34th to 38th week of it is not necessary for a fetus to produce antibodies because they
mother from entering the fetal circulation and possibly causing birth gestational age, because testicular descent does need to be manufactured only to counteract an invading antigen,
anomalies (Singer, Moore, Fulton, et al., 2012). Newborns need not always occur as readily in extrauterine life as it and antigens rarely invade the intrauterine space. Because IgA and
careful assessment at birth for hypoglycemia (low blood sugar) and would have in utero. Testes that do not descend IgM antibodies (the types which develop to actively counteract
hyperbilirubinemia (excessive breakdown products from destroyed (cryptorchidism) require surgery as they are infection) cannot cross the placenta, their presence in a newborn is
red blood cells), two serious problems that can occur in the fi rst 24 associated with poor sperm production and proof that the fetus has been exposed to an infection.
hours after birth because, although active, liver function is still possibly testicular cancer later in life.
 End of 28th Gestational Week
Milestones of Fetal Growth and Development
End of 12th Gestational Week (First Trimester) • The length of the fetus is 35 to 38 cm; weight is 1,200 g.
When fetal milestones occur can be confusing because • The length of the fetus is 7-8 cm; weight is about 45 g. • Lung alveoli are almost mature; surfactant can be
the life of the fetus is typically measured from the time of • Nail beds are forming on fingers and toes. demonstrated in amniotic fluid.
ovulation or fertilization (ovulation age), but the length of a • Spontaneous movements are possible, although they
• Testes begin to descend into the scrotal sac from the lower
pregnancy is more commonly measured from the fi rst day of the are usually too faint to be felt by the mother.
abdominal cavity.
last menstrual period (gestational age). Because ovulation and • Some refl exes, such as the Babinski reflex, are
present. • Bone ossification centers begin to form. • The blood vessels of the retina are formed but thin and
fertilization take place about 2 weeks after the last menstrual
• Tooth buds are present. extremely susceptible to damage from high oxygen
period, the ovulation age of the fetus is always 2 weeks less than
• Sex is distinguishable on outward appearance. concentrations (an important consideration when caring for
the length of the pregnancy or the gestational age. Both ovulation
• Urine secretion begins but may not yet be evident in preterm infants who need oxygen).
and gestational age are typically reported in lunar months (4-week
amniotic fluid. End of 32nd Gestational Week
periods) or in trimesters (3-month periods) rather than in weeks.
• The heartbeat is audible through Doppler technology. • The length of the fetus is 38 to 43 cm; weight is 1,600 g.
In lunar months, a total pregnancy is 10 months (40 weeks, or 280
End of 16th Gestational Week • Subcutaneous fat begins to be deposited (the former stringy,
days) long; a fetus grows in utero for 9.5 lunar months or three full
• The length of the fetus is 10 to 17 cm; weight is 55 to “little old man” appearance is lost).
trimesters (38 weeks, or 266 days). The following discussion of
120 g. • Fetus responds by movement to sounds outside the mother’s
fetal developmental milestones is based on gestational weeks, • Fetal heart sounds are audible by an ordinary body.
because it is helpful when talking to expectant parents to stethoscope. • An active Moro reflex is present.
correlate fetal development with the way they measure • Lanugo is well formed.
• Iron stores, which provide iron for the time during which the
pregnancy—from the fi rst day of the last menstrual period. Figure • Both the liver and pancreas are functioning.
neonate will ingest only breast milk after birth, are beginning
9.6 illustrates the comparative size and appearance of human • The fetus actively swallows amniotic fluid,
demonstrating an intact but uncoordinated swallowing to be built.
embryos and fetuses at different stages of development.
refl ex; urine is present in amniotic fluid. • Fingernails reach the end of fingertips.
• Sex can be determined by ultrasonography. End of 36th Gestational Week
End of 20th Gestational Week • The length of the fetus is 42 to 48 cm; weight is 1,800 to
• The length of the fetus is 25 cm; weight is 223 g. 2,700 g (5 to 6 lb).
• Spontaneous fetal movements can be sensed by the • Body stores of glycogen, iron, carbohydrate, and calcium are
mother. deposited.
End of Fourth Gestational Week • Antibody production is possible. • Additional amounts of subcutaneous fat are deposited.
• The length of the embryo is about 0.75 cm; weight is about 400 • Hair, including eyebrows, forms on the head; vernix • Sole of the foot has only one or two crisscross creases,
mg. caseosa begins to cover the skin. compared with a full crisscross pattern evident at term.
• The spinal cord is formed and fused at the midpoint. • Meconium is present in the upper intestine. • Amount of lanugo begins to diminish.
• The head is large in proportion and represents about one third • Brown fat, a special fat that aides in temperature
• Most babies turn into a vertex (head down) presentation
of the entire structure. regulation, begins to form behind the kidneys, sternum,
during this month.
• The rudimentary heart appears as a prominent bulge on the and posterior neck.
• Passive antibody transfer from mother to fetus End of 40th Gestational Week (Third Trimester)
anterior surface. • The length of the fetus is 48 to 52 cm (crown to rump, 35 to
begins. •Definite sleeping and activity patterns are
• Arms and legs are bud-like structures; rudimentary eyes, ears, 37 cm); weight is 3,000 g (7 to 7.5 lb).
distinguishable as the fetus develops biorhythms that
and nose are discernible. • Fetus kicks actively, sometimes hard enough to cause the
will guide sleep/wake patterns throughout life.
End of Eighth Gestational Week mother considerable discomfort.
End of 24th Gestational Week (Second Trimester)
• The length of the fetus is about 2.5 cm (1 in.); weight is about 20 • The length of the fetus is 28 to 36 cm; weight is 550 g. • Fetal hemoglobin begins its conversion to adult hemoglobin.
g. • Organogenesis is complete. • Meconium is present as far as the rectum. • Vernix caseosa is fully formed.
• The heart, with a septum and valves, beats rhythmically. • Active production of lung surfactant begins. • Fingernails extend over the fingertips.
• Facial features are defi nitely discernible; arms and legs have • Eyelids, previously fused since the 12th week, now • Creases on the soles of the feet cover at least two thirds of
developed. open; pupils react to light. the surface.
• External genitalia are forming, but sex is not yet distinguishable • Hearing can be demonstrated by response to sudden In primiparas (i.e., women having their first baby),
by simple observation. • The abdomen bulges forward because sound.
the fetus often sinks into the birth canal during the last 2
the fetal intestine is growing so rapidly. • When fetuses reach 24 weeks, or 500–600 g, they
weeks of pregnancy, giving the mother a feeling the load she is
• A sonogram shows a gestational sac, which is diagnostic of have achieved a practical low-end age of viability if they
are cared for after birth in a modern intensive care carrying is less. This event, termed lightening, is a fetal
pregnancy. announcement the third trimester of pregnancy has ended and
nursery.
birth is at hand.
Determination of Estimated Birth Date CHAPTER 9: Nursing Care of the Growing Fetus
It is impossible to predict with a high degree of 1. How much longer will you refer the baby inside the mother’s
accuracy the exact day an infant will be born because fewer than womb as an embryo?
5% of pregnancies end exactly 280 days from the last menstrual D. A future baby is an embryo during the period between
period; fewer than half end within 1 week of the 280th day. implantation and 5 to 8 weeks. After that, a baby is termed a
Traditionally, this date was referred to as the estimated date of fetus.
confinement (EDC). Because women are no longer confined” after 2. What assessment of the umbilical cord at birth would be
childbirth, the acronym EDB (estimated date of birth) is more most important to help detect congenital heart defects?
commonly used today. If fertilization occurred early in a menstrual B. A normal umbilical cord has one vein and two arteries.
cycle, the pregnancy will probably end “early”; if ovulation and Other patterns are associated with cardiac or chromosomal
fertilization occurred later than the midpoint of the cycle, the disorders.
pregnancy will end “late.” Because of these normal variations, a 3. What is surfactant?
pregnancy ending 2 weeks before or 2 weeks after the calculated A. Surfactant, produced by the lining of the alveoli, keep lung
EDB is considered well within the normal limit (38 to 42 weeks). alveoli from collapsing on expiration, aiding alveoli expansion
Gestational age wheels and birth date calculators, which can be at birth.
used to predict a birth date are available, but calculation by 4 What would make you most worried that your patient might
Naegele’s rule is the standard method used to predict the length have difficulty quitting smoking during her pregnancy?
of a pregnancy. A. The study reveals that low socioeconomic status and
Naegele’s Rule depression contribute to smoking. Stating that she has a
To calculate the date of birth by this rule, count backward constant shortage of money is suggestive of low
3 calendar months from the first day of a woman’s last menstrual socioeconomic status.
period and add 7 days. For example, if the last menstrual period 5. What instruction would you give to your patient who will
began May 15, you would count back 3 months (April 15, March 15, have an ultrasound before her examination?
February15) and add 7 days, to arrive at the predicted date of birth as C. A full bladder improves the accuracy of the scan. There is
no pain involved.
ASSESSMENT OF FETAL GROWTH AND DEVELOPMENT
Tests for fetal growth and development are
commonly done for a variety of reasons, including to:
• Predict the outcome of the pregnancy
• Manage the remaining weeks of the pregnancy
• Plan for possible complications at birth
• Plan for problems that may occur in the newborn infant
• Decide whether to continue the pregnancy
• Find conditions that may affect future pregnancies
Both fetal growth and development can be compromised if a
fetus has a metabolic or chromosomal disorder that interferes
with normal growth, if the supporting structures such as the
placenta or cord do not form normally, or if environmental infl
uences such as the nicotine in cigarettes causes fetal growth
restriction (including testes growth in a male fetus). Nursing
responsibilities for these assessment procedures include
verifying that a signed consent form has been obtained as
needed (which is necessary if the procedure poses any risk to the
mother or fetus that would not otherwise be present), being
certain the woman and her support person are aware of what
the procedure will entail and any potential risks, preparing the
woman physically and psychologically, providing support during
the procedure, assessing both fetal and maternal responses
during and after the procedure, providing any necessary follow-
up care, and managing equipment and specimens.
 Chapter 10 216 Nursing Care Related to Psychological and Physiologic Changes of Pregnancy

Family Influences Partner’s Adaptation

PSYCHOLOGICAL CHANGES OF PREGNANCY
The family in which a woman was raised The more emotionally attached a partner is to a
Pregnancy is such a huge change in a woman’s life, it brings about
can be infl uential to her beliefs about pregnancy pregnant woman, the closer the partner’s attachment is
more psychological changes than any other life event besides puberty. How a
because it is part of her cultural environment. If she apt to be to the child. Whether partners are able to form a
woman adjusts to a pregnancy depends a great deal on psychological aspects,
and her siblings were loved and their births were close relationship with each other, as well as accept a
such as the environment in which she was raised, the messages about
seen as a pleasant outcome of their family, she is pregnancy and a coming child depends on the same factors
pregnancy her family communicated to her as a child, the society and culture in
more likely to have a positive attitude toward that affect the pregnant woman’s decision making: cultural
which she lives as an adult, and whether the pregnancy has come at a good
learning she is pregnant than if she and her siblings background, past experience, and relationships with family
time in her life. For many women, a prenatal visit is the first time they have
were blamed for the breakup of a marriage or a members. Although partners may be inarticulate about
seen a health care provider since childhood. Guidance given during this time
relationship, for example. A woman who views such emotional factors, they may be able to convey such
can be instrumental in not only guiding a woman safely through a pregnancy
mothering as a positive activity is more likely to be feelings by a touch or a caress, which is one reason a
but also connecting her back with ongoing health care.
pleased when she becomes pregnant than one who partner’s presence is always desirable at a prenatal visit
Social Influences
does not value mothering. and certainly in a birthing room.
From the first part of the 20th century until about the 1960s, there
was such heavy emphasis on medical management for women during Individual Differences
pregnancy that it conveyed the idea that pregnancy was a 9-month-long illness. A woman’s ability to cope with or adapt
The pregnant woman went alone to a physician’s office for care; at the time of to stress plays a major role in how she can resolve
THE PSYCHOLOGICAL TASKS OF PREGNANCY
birth, she was separated from her family, hospitalized in seclusion from any conflict she feels at becoming a mother. This
During the 9 months of pregnancy, a woman
visitors, and even from the new baby for 1 week afterward so the newborn ability to adapt (e.g., to being a mother without
and her partner run a gamut of emotions, ranging from
could be fed by nurses. Today, pregnancy is viewed as a healthy span of time needing mothering, to loving a child as well as a
surprise at finding out about the pregnancy (or wishing
best shared with a supportive partner and/or family. Women bring their partner, to becoming a mother for each new child)
she were not), to pleasure and acceptance as they begin
families for prenatal care visits as well as to watch the birth. Women choose depends, in part, on her basic temperament, on
to identify with the coming child at the middle of
what level of pain management they want to use for labor and birth; they whether she adapts to new situations quickly or
pregnancy, to worry for themselves and the child, to
expect to breastfeed their newborn. How well a pregnant woman and her slowly, on whether she faces them with intensity or
acute impatience near the end of pregnancy. Once the
partner feel during pregnancy and are prepared to meet the challenges this maintains a low-key approach, and on whether she
child is born, a woman and her partner may feel
new responsibility brings is related to their cultural background, their personal has had experience coping with change and stress.
surprised again that the pregnancy is over and they really
beliefs, the experiences reported by friends and relatives, as well as by the The extent to which a woman feels secure in her
do have a child. From a physiologic standpoint, it is
current plethora of information available on the Internet. Nurses play an relationship with the people around her, especially
fortunate that a pregnancy is 9 months long, because this
important role in teaching women about their health care options as well as the father of her child or her chief support person,
gives the fetus time to mature and be prepared for life
continuing to work with other health care providers to “demedicalize” or is usually also important to her acceptance of a
outside the protective uterine environment. From a
humanize childbirth pregnancy. Anxiety as to whether her partner may
psychological standpoint, the 9-month period is also
Cultural Influences soon disappear, leaving her alone to raise a child,
fortunate, because it gives a family time to prepare
A woman’s cultural background may strongly infl uence how active may make her reexamine whether her pregnancy is
emotionally as well. These psychological changes are
a role she wants to take in her pregnancy, because certain beliefs and taboos a wise life step. Yet another influence on how
frequently termed “guaranteeing safe passage” for the
can place restrictions on her behavior and activities (Krans & Chang, 2011). To women perceive pregnancy as a positive or negative
fetus. Although the average woman is happy to be
learn about the beliefs of a particular woman and her partner, ask at prenatal experience is past experiences. A woman who
pregnant, don’t underestimate the effect the emotional
visits if there is anything the couple believes should or should not be done to thinks of brides as young but mothers as old may
and physical upheavals brought about by the hormonal
make the pregnancy successful and keep the fetus healthy. Supporting these believe pregnancy will rob her of her youth. If she’s
changes of pregnancy can cause. These can be so
beliefs shows respect for the individuality of a woman and her knowledge of concerned about her appearance, she may worry
tremendous that they can influence whether a pregnancy
good health (Box 10.2). Before evidence-based practice was available to pregnancy will permanently stretch her abdomen
scientifi cally support why pregnancy brought about changes in a woman’s and breasts. She may also worry pregnancy will rob
Common Psychological Changes That Occur With Pregnancy
body, different societies devised differing explanations about why changes her financially and ruin her chances of job
Psychological ----------------Change Description
occurred. These myths became so well engrained in cultures that some persist promotion (referred to as a “mommy track”). These
First trimester task: Accepting the pregnancy
to the present. For example, a belief that lifting your arms over your head are real feelings and must be taken seriously when
The woman and her partner both spend time
during pregnancy will cause the cord to twist or that watching a lunar eclipse assessing or counseling pregnant women. Women
recovering from the surprise of learning they are pregnant
will cause a birth deformity are still believed by some women (Lauderdale, who do not have a supportive partner may look to
and concentrate on what it feels like to be pregnant. A
2011). Find a compromise that will assure a woman that these are not really health care providers during pregnancy to fi ll the
common reaction is ambivalence, or feeling both pleased and
harmful to a fetus, but that still respects these beliefs. role of an attentive listener.
not pleased about the pregnancy.
Second trimester task: Accepting the fetus
The woman and her partner move through emotions The Partner
In the past, partners were The Woman
such as narcissism and introversion as they concentrate on what it
forgotten persons in the childbearing During the second trimester, the psychological task of a woman is to
will feel like to be a parent. Role-playing and increased dreaming
process. Unwed fathers were dismissed as accept she is having a baby, a step up from accepting the pregnancy. This change
are common.
not interested in either the pregnancy or usually happens at quickening , or the fi rst moment a woman feels fetal
Third trimester task: Preparing for the baby and end of
the woman’s health. A female partner was movement. Until a woman experiences for herself this proof of the child’s
pregnancy
completely ignored. In actuality, all existence and although she ate to meet nutritional needs and took special vitamins
The woman and her partner prepare clothing and
partners are important and should be to help the fetus grow, it seemed more like just another part of her body. With
sleeping arrangements for the baby, but also grow impatient as
encouraged to play a continuing quickening, the fetus becomes a separate identity. She then may imagine herself as
they ready themselves for birth.
emotional and supportive role in a a mother, teaching her child the alphabet or how to ride a bicycle. This anticipatory
First Trimester: Accepting the Pregnancy role-playing is an important activity for midpregnancy as it leads her to a greater
pregnancy. Accepting the pregnancy for a
The Woman The task of women during the first concept of her condition and helps her realize she is more than just pregnant—
partner means not only accepting the
trimester of pregnancy is to accept the reality of the pregnancy; there is a separate human being inside her. Women often use the term “it” to refer
certainty of the pregnancy and the reality
later will come the task of accepting the baby. Most cultures to their fetus before quickening but begin to use he or she afterward. Some
of the child to come but also accepting the
structure celebrations around important life events such as women continue to use it, however, so doing so is not a sign of poor attachment
woman in her changed state. Like women,
coming of age, marriages, birthdays, and deaths, all of which but an individual preference as some women believe referring to the child as “she”
partners may also experience a feeling of
have rituals to help individuals face and accept the coming or “he” will bring bad luck or disappointment if the sonogram report was wrong.
ambivalence. A partner may feel proud
change in their lives. A diagnosis of pregnancy is a similar rite of Most women can pinpoint a moment during each pregnancy when they knew defi
and happy at the beginning of pregnancy,
passage, but an unusual one among passages because the nitely they wanted their child. The fi rmer this attachment, the less postpartum
for example. Soon, however, it’s easy to
suspicion of pregnancy is made initially not on something depression they are apt to experience (Goecke, Voigt, Faschingbauer, et al., 2012).
begin to feel both overwhelmed with
happening but the absence of something: a missed menstrual For a woman who carefully planned the pregnancy, this moment of awareness may
what the loss of a salary will mean to the
flow. With the availability and common use of reproductive occur as soon as she recovers from the surprise of learning she has actually
family if the woman has to quit work, and
planning measures today, it would seem few pregnancies would conceived. For others, it may come when she announces the news to her parents
a feeling close to jealousy of the growing
any longer be a surprise. In reality, as many as 49% of and hears them express their excitement or when she sees a look of pride on her
baby who, although not yet physically
pregnancies are still unintended, unwanted, or mistimed. partner’s face. For example, shopping for baby clothes for the fi rst time, setting up
apparent, seems to be taking up a great
Because no woman can be absolutely confident in advance that the crib, or seeing a blurry outline on a sonogram screen may suddenly make the
deal of the woman’s time and thought.
she will be able to conceive until it happens, even planned coming baby seem real and desired (Fig. 10.1). Accepting the baby as a welcome
Remember, once partners feel an
pregnancies are a surprise to some extent because a woman addition to the family might not come, however, until labor has begun or a woman
attachment to a coming child, they can
can be amazed it either happened so quickly or took so long. fi rst hears her baby’s cry or feeds her newborn. If a woman has a complication of
then feel as deep a sense of loss as the
refers to the interwoven feelings of wanting and not wanting, pregnancy, it could take several weeks after the baby is born for her to accept that
woman if the pregnancy should end
feelings which can be confusing to an ordinarily organized the birth was real and to come to terms with motherhood. A good way to measure
before term or the baby is born with a
woman. Fortunately, most women who were not happy about the level of a woman’s acceptance of her coming baby is to measure how well she
unique concern. In addition, they may not
being pregnant at the beginning are able to change their follows prenatal instructions. Until a woman views the growing life inside her as
have anyone to turn to for support
attitude toward their pregnancy by the time they feel the child something desired, it may be diffi cult for her to substitute a high-protein food for
because no one recognizes how involved
move inside them. Some health care plans provide for a routine her favorite high-calorie coffee drink, for instance. After all, until her abdomen
they were in the pregnancy. To help both
sonogram at about this time in pregnancy to date the begins to enlarge, watching herself gain weight may be the most certain proof she
male and female partners resolve these
pregnancy and to assess for growth anomalies. This can be a has that she is pregnant.
feelings, be certain to make partners feel
major step in promoting acceptance, because women can see a
welcome at prenatal visits or during fetal
beating heart or a fetal outline or can learn the sex of their
testing, provide an outlet for them to
fetus. Although most women self-diagnose their pregnancy by
discuss concerns, and offer parenting
using a urine pregnancy test strip, hearing their pregnancy
information as necessary.
officially diagnosed at a first prenatal visit is another step
toward accepting a pregnancy. Because this happens, woman
often comment after such a visit they feel “more pregnant” or it
makes a first visit more than an ordinary one. Early diagnosis is
important because the earlier a woman realizes she is pregnant Second Trimester: Accepting the Baby
or comes for a fi rst prenatal visit, the sooner she can begin to As soon as fetal movements can
safeguard fetal health by measures such as discontinuing all be felt, psychological responses of both
drugs not specifi - cally prescribed or approved by her primary partners usually begin to change.
health care provider.
The Partner Additional Preparation Work to Complete in
Role-Playing and Fantasizing
As a woman begins to actively prepare for the coming Pregnancy
Another step in preparing for parenthood is role-playing, or
baby, a partner increasingly may feel as if he or she is left standing In addition to the three main tasks of
fantasizing about what it will be like to be a parent. Just as a child learns
in the wings, waiting to be asked to take part in the event. To pregnancy, more subtle emotions also surface
what to do by following a mother as she sets a table or balances her
compensate for this feeling, a partner may become overly or need to be worked through.
checkbook, a pregnant woman may begin to spend time with other
absorbed in work, striving to produce something concrete on the Reworking Developmental Tasks
pregnant women or mothers of young children to learn how to be a
job as if to show the woman is not the only one capable of creating An important task to complete
mother. As a part of this role-playing process, women’s dreams tend to
something. This preoccupation with work may limit the amount of during pregnancy is working through previous
focus on the pregnancy and concerns about keeping herself and her
time a partner spends with family or is available for prenatal visits, life experiences or Erikson’s developmental
coming child safe. If the only role models an adolescent has are other
just when the pregnant woman most needs emotional support. tasks of autonomy, industry, and identity Needs
girls her age, who typically are not interested in a commitment to
Some men may have diffi culty enjoying the pregnancy because and wishes that have been repressed for years
mothering, or if her role model is her own mother, who has shown poor
they have been misinformed about sexuality, pregnancy, and may surface to be studied and reworked, often
coping in the face of poverty, too many children, or an ineffectual
women’s health. A man might believe, for example, that to an extreme extent along these lines. Fear of
husband, a worry is the young girl will assume the same role. Try to
breastfeeding will make his wife’s breasts no longer attractive or being separated from family or fear of dying are
locate good role models (e.g., in classes for mothers, at the health care
that after birth, sexual relations will no longer be enjoyable. Such a common preschool fears that can be revived
agency, or in a social agency) for adolescents so they can find a good
man needs education to correct misinformation. Read the during pregnancy. A clue that might signal a
maternal role to copy and integrate into their own behavior. A woman’s
pamphlets supplied by your prenatal health care setting and ask: woman’s distress over this could be, “Am I ever
partner also has the same role-playing to do during pregnancy, to
Do they contain mainly information about childbirth and pregnancy going to make it through this?” Such an
imagine himself or herself as the parent of a boy or a girl. A partner
from a woman’s perspective? Would they be relevant to a expression might mean simply she is tired of
who is becoming a parent for the first time may have to change a view
her backache, but it also might be a plea for
of being a carefree individual to being a significant member of a family
reassurance she will survive this event in her
unit. If the partner already is a parent from a former relationship, he or
Third Trimester: Preparing for Parenthood life. Part of gaining a sense of identity is
she has to cast aside the parent-of-one identity to accept a parent-of-
During the third trimester, couples usually begin “nestbuilding” establishing a working relationship with
two image, and so forth. Other support persons who will have an active
activities, such as planning the infant’s sleeping arrangements, parents, which may still be an awkward one
role in raising the child, such as grandparents, close friends, or an ex-
choosing a name for the infant, and “ensuring safe passage” by since adolescence. For the first time in her life,
spouse, also have to work out their roles with regard to the pregnancy
learning about birth. These preparations are evidence the couple is a woman during pregnancy can begin to
and impending parenthood. This may be particularly difficult, because
completing the third trimester task of pregnancy or preparing for empathize with the way her mother used to
the roles for these support persons may not be clearly defined, and no
parenthood. Couples at this point are usually interested in worry because she’s already begun to worry
role model may be apparent.
attending prenatal classes and/or classes on preparing for about her child when she feels no movement
childbirth. It’s helpful to ask a couple what specifically they are for a few hours. This can make her own mother
doing to get ready for birth to see if they are interested in taking become more important to her and a new,
such a class and to document how well prepared they will be for more equal relationship may develop.
the baby’s arrival. Attending a childbirth education class or one on Teenagers who are pregnant need to resolve
preparing for parenthood can not only help a couple accept the the double conflict of still establishing a sense
fact they are about to become parents but also expose them to of identity (teenagers are still children
Emotional Responses That Can Cause Concern in Pregnancy
other parents as role models who can provide practical developmentally) at the same time they are
Because of all the tasks that need to be worked through
information about pregnancy and child care. Although pregnancy is planning to be a mother. Unless these feelings
during a pregnancy, emotional responses can vary greatly, but common
a happy time for most women, certain external life contingencies are examined and resolved, teenagers can have
reactions include grief, narcissism, introversion or extroversion, body
such as an unwanted pregnancy, financial difficulties, lack of a difficult time thinking about enjoying their
image and boundary concerns, couvade syndrome, stress, mood swings,
emotional support, or high levels of stress can slow the pregnancy or becoming a mother. A partner
and changes in sexual desire. These are all normal, so it is helpful to
psychological work of pregnancy or attachment to the child. During needs to do the same reworking of old values
caution a pregnant woman and her partner that these common changes
prenatal visits, ask such questions as, “Is pregnancy what you and forgotten developmental tasks. A man has
may occur so they’re not alarmed if they appear. Otherwise, a partner
thought it would be?” or “Has anything changed in your home life to rethink his relationship with his father, for
can misinterpret the woman’s mood swings, decreased sexual interest,
since you last came to clinic?” to reveal if any situation that could example, to understand better what kind of
introversion, or narcissism not as changes from pregnancy, but as a loss
potentially interfere with bonding has occurred. It is unrealistic to father he will be. Some men may have had
of interest in their relationship.
believe any one health care professional has all the solutions to the emotionally distant fathers and wish to be more
problems couples reveal when asked these questions. An emotionally available to their own children.
interprofessional approach (referral to a nutritionist, a primary Support from health care providers and
health care provider, or social services) is often necessary to help exposure to caring role models can be
solve some of these multifaceted problems. instrumental in helping a man achieve this goal.
 Introversion Versus Extroversion
Grief Introversion, or turning inward to concentrate on Depression
The thought that grief can be associated with such a oneself and one’s body, is a common fi nding during Depression—a feeling of sadness marked by loss
positive process as having a child seems at first incongruent. But pregnancy. Some women, however, react in an entirely of interest in usual things, feelings of guilt or low self-worth,
before a woman can take on a mothering role, she has to give up opposite fashion and become more extroverted. They are disturbed sleep, low energy, and poor concentration—is a
or alter her present role as she will never be the woman she has more active, appear healthier than ever before, and are more common finding in young adults. Depression causes as many
been in exactly the same way again. She will never be able to be outgoing. This tends to occur in women who are fi nding as 14% to 15% of women to enter pregnancy feeling
as irresponsible and carefree again, or perhaps sleep soundly for unexpected fulfi llment in pregnancy, perhaps who had depressed; others grow depressed during pregnancy,
the next few years. All of this takes mental preparation, which seriously doubted they would be lucky enough or fertile especially if they lack a meaningful support person.
may manifest as a form of grief, as she incorporates her new enough to conceive. Such a woman regards her expanding Screening for women who have a history of depression is
role as a mother into her other roles as daughter, wife, business abdomen as proof she is equal to her sisters. Although these important at a preconception visit as common drugs
professional, or friend. Partners must also incorporate a new changes may make a woman become more varied in her prescribed for depression can be teratogenic to a fetus as
role as a parent into their other roles in life. interests during pregnancy, she may be puzzling to those well as cause hypertension in the woman. It is also
Narcissism around her who liked her for her quiet and self-contained important to investigate if the woman has a meaningful
Self-centeredness (narcissism) may be an early manner. support person or the stress and anxiety that can come with
reaction to pregnancy. A woman who previously perhaps was Body Image and Boundary pregnancy can increase depression substantially and lead to
barely conscious of her body, who dressed in the morning with Body image (i.e., the way your body appears to postpartum depression (see Chapter 25). A woman with few
little thought about what to wear, suddenly begins to yourself) and body boundary (i.e., a zone of separation you support people around her almost automatically has more
concentrate on these aspects of her life. She dresses so her perceive between yourself and objects or other people) both difficulty adjusting to and accepting a pregnancy and a new
pregnancy will or will not show. She makes a ceremony out of change during pregnancy as a woman begins to envision child than women with more support. A woman who begins
fixing her meals. She may lose interest in her job or community herself as a mother or becoming “bigger” in many different a pregnancy with a strong support person and then loses
events because the work seems alien to the more important ways. Changes in concept of body boundaries are so startling that person through trauma, illness, separation, or divorce
event taking place inside her. Narcissism may also be revealed that a pregnant woman may walk far away from an object such needs special attention with regard to loneliness and
by changes in activity. A woman may stop playing tennis, for as a table to avoid bumping against it. At the same time, she depression. Evaluate her carefully as to how she is managing
example, even though her primary health care provider has may perceive herself as needing body boundaries as if her and give her extra support as needed because her feeling of
assured her it will do no harm in moderation. She may criticize body were delicate and easily harmed. loss is likely to be extremely acute. Knowing she has
her husband’s driving, although it never bothered her before. Stress supportive health care providers she can call on when
She does these things to unconsciously protect her body and her Because pregnancy brings with it such a major role needed is the one thing that may make her pregnancy
baby. Men may demonstrate the same behavior by reducing change, it can cause extreme stress in a woman who was not acceptable.
risky activities, such as mountain biking, trying to ensure they planning to be pregnant or if she fi nds her lifestyle changing Couvade Syndrome
will be present to raise their child. This need of a woman to dramatically after she becomes pregnant. Stress in pregnancy, Many partners experience physical symptoms such as
protect her body has implications for nursing care. It means a like stress at any time, can make it diffi cult for a woman to nausea, vomiting, and backache to the same degree or even
woman may regard unnecessary nudity as a threat to her body make decisions, be as aware of her surroundings as usual, or more intensely than their partners during a pregnancy; some
(e.g., be sure to drape properly for pelvic and abdominal maintain time management with her usual degree of skill. This begin to gain weight along with their partner. As a woman’s
examinations). She may resent casual remarks such as, “Oh my, may cause people who were dependent on her before abdomen begins to grow, partners may perceive themselves
you’ve gained weight” (i.e., a threat to her appearance) or, “You pregnancy to feel neglected, because now that she is pregnant, as growing larger too, as if they were the ones who were
don’t like milk?” (i.e., a threat to her judgment). There is a she seems to have strength only for herself. If a woman was in experiencing changing boundaries the same as the pregnant
tendency to organize health instructions during pregnancy a violent relationship before the pregnancy, the increased woman. These symptoms apparently result from stress,
around the baby: “Be sure to keep this appointment. You want stress of pregnancy is apt to cause even more violence. Asking anxiety, and empathy for the pregnant woman. The
to have a healthy baby.” “You really ought to eat more protein whether intimate partner violence has ever occurred in the phenomenon is common enough that it has been given a
for the baby’s sake.” This approach may be particularly past to help predict if it could occur during pregnancy is an name: couvade syndrome (from the French word “to
inappropriate early in pregnancy, before the fetus stirs and important part of prenatal interviewing. To help families keep hatch”). The more a partner is involved in or attuned to the
before a woman is convinced not only that she is pregnant but their perspective for the full length of a pregnancy, remind changes of the pregnancy, the more symptoms a partner
also that there is a baby inside her. At early stages, a woman them that any decrease in the ability to function that happens may experience. For the most part, these are healthy
may be much more interested in doing things for herself to a pregnant woman is a reaction to the stress of pregnancy. A happenings. A close marital relationship, which this reflects,
because it is her body, her tiredness, and her well-being that will woman may need to remind an employer that any lack of can increase the strength of the partner–infant attachment.
be directly affected (e.g., “Eat protein because it keeps your decision-making ability is no different than in people who are Such symptoms are only worrisome and require
fingernails from breaking.” or “Protein will give you longterm feeling stress because of marital discord or a loved one’s psychological attention if they become so extreme that they
energy.”). illness. Pregnancy may actually be less stressful and less of a create intolerable emotional stress.
concern than those situations because of its predictable 9-
Emotional Lability THE CONFIRMATION OF PREGNANCY Laboratory Tests
Mood changes occur frequently in a pregnant A medical diagnosis of pregnancy The commonly used laboratory tests for pregnancy are based on the use of a
woman, partly as a symptom of narcissism (i.e., her serves to date when the birth will occur and also venipuncture or a urine specimen to detect the presence of human chorionic
feelings are easily hurt by remarks that would have been helps predict the existence of a high-risk status. gonadotropin (hCG), a hormone created by the chorionic villi of the placenta, in
laughed off before) and partly because of hormonal Most women who come to a health care facility the urine or blood serum of the pregnant woman. Because these tests are only
changes, particularly the sustained increase in estrogen for a diagnosis of pregnancy have already accurate 95% to 98% of the time, positive results from these tests are considered
and progesterone. Mood swings may be so common that guessed they are pregnant based on a multitude probable rather than positive signs. In the nonpregnant woman, no units of hCG
they can make a woman’s reaction to her family and to of subjective symptoms as well as having will be detectable because there are no trophoblast cells producing hCG. In the
health care routines unpredictable. She may cry over her completed a home pregnancy test, so a health pregnant woman, trace amounts of hCG appear in her serum as early as 24 to 48
children’s bad table manners at one meal, for example, care visit is more a confirmation of pregnancy hours after implantation and reach a measurable level (about 50 milli-
and fi nd the situation amusing or even charming at the than a diagnosis. If a pregnancy was planned, this International Unit/ml 7 to 9 days after conception. Levels peak at about 100 milli-
next. Caution families that such mood swings occur official confirmation of pregnancy produces a International Unit/ ml between the 60th and 80th day of gestation. After that
beginning with early pregnancy so they can accept them as feeling of intense fulfillment and achievement. If point, the concentration of hCG declines again so, at term, it is again barely
part of a normal pregnancy. the pregnancy was not planned (remember detectable in serum or urine.
Changes in Sexual Desire almost half of pregnancies are unintended), it Home Pregnancy Tests
Most women report their sexual desire can result in an equally extreme crisis state. From A number of brands for pregnancy testing are available over the counter, take only
changes, at least to some degree, during pregnancy. the day a pregnancy is officially confirmed, most 2 to 3 minutes to complete, and have a high degree of accuracy (97% to 99%) if
Women who formerly were worried about becoming women try to eat a more nutritious diet, give up the instructions are followed exactly because they can detect as little as 35 milli-
pregnant might truly enjoy sexual relations for the first cigarette smoking and alcohol ingestion, and stop International Unit/ml of hCG. For the test, a woman dips a reagent strip into her
time during pregnancy. Others might feel a loss of desire taking nonessential medications. Because a stream of urine. A color change or the appearance of two bars on the strip
because of their increase in estrogen, or they might woman may not take these measures before denotes pregnancy. Tips to give the woman for successful testing include: • Check
unconsciously view sexual relations as a threat to the fetus confirmation of her pregnancy, this makes early the expiration date on the package to be certain the kit has not expired; an
they must protect. Some may worry coitus could bring on confirmation of pregnancy important. If a woman outdated kit can give false-positive results. • Read the instruction pamphlet
early labor. During the first trimester, most women report does not wish to continue the pregnancy, early provided with the test, noting especially the time period you should wait before
a decrease in libido because of the nausea, fatigue, and confirmation is also imperative; therapeutic reading the result, and follow this instruction carefully.
breast tenderness that accompany early pregnancy. During termination of pregnancy always should be • A concentrated urine sample such as a first urine in the morning tests best. Don’t
the second trimester, as blood flow to the pelvic area carried out at the earliest stage possible for the drink a large quantity of water beforehand because this can dilute a urine sample.
increases to supply the placenta, libido and sexual safest outcome Before there were sonograms • Read the test results at the exact time the instructions dictate. Reading the strip
enjoyment can rise markedly. During the third trimester, and maternal serum pregnancy tests, pregnancy after the designated time can cause inaccurate results (e.g., denoting that you are
sexual desire may remain high, or it may decrease because was diagnosed on symptoms reported by the pregnant when you are not).
of difficulty finding a comfortable position and increasing woman and the signs elicited by a health care • Some prescription medicines cause false-positive results. Contact your health
abdominal size. When a couple knows early in pregnancy provider. These signs and symptoms, still care provider if you get an unexpected positive result and ask if any medication
such changes may occur, it’s easier for them to interpret important today, are traditionally divided into you are taking could cause that result.
these in the correct light or as a normal change, not as loss three classifications: presumptive (subjective • Early prenatal care is the best safeguard to ensure a successful pregnancy. If
of interest in a sexual partner or as a diminishment of the symptoms); probable (objective signs); and your test result is positive, your next step should be to make a health care
strength of the total relationship. positive (documented signs) appointment as early as possible to begin care.
Changes in the Expectant Family Most manufacturers suggest a woman wait until at least the day of the
Most parents are aware that their older Presumptive (Subjective) Symptoms missed menstrual period to test. If a woman thinks she is pregnant but gets a
children need preparation when a new baby is on the way; Presumptive symptoms are those negative result, she could repeat the test 1 week later if she still has not had a
however, knowing preparation is needed and being which, when taken as single entities, could easily menstrual fl ow. If symptoms of pregnancy persist after two tests, she needs to
prepared to explain where babies come from are two indicate other conditions. These findings, see her health care provider as she might have a condition such as an ovarian cyst
different things. For this reason, many couples appreciate discussed in connection with the body system in causing the amenorrhea; she would need appropriate diagnosis and therapy for
suggestions from health care providers as to how this task which they occur, are experienced by the woman this. A worry about the common use of home test kits is that because women do
can be accomplished. Both preschool and school-age but cannot be documented by an examiner. not have to come to a health care setting for confirmation of pregnancy, they may
children may need to be assured periodically during Probable Signs not seek prenatal care until something seems to be going wrong with their
pregnancy a new baby will be an addition to the family and In contrast to presumptive symptoms, pregnancy or until they feel they need to arrange added health care provider
will not replace them or change their parents’ affection for probable signs of pregnancy are objective and so coverage for the birth. After a positive pregnancy test, the first step should
them. Preparing a child for the birth of a sibling is can be verified by an examiner. Although they are therefore be to arrange for prenatal care.
discussed in Chapters 14 and 31 with other growth and more reliable than presumptive symptoms, they
development concerns. still do not positively diagnosis a pregnancy.
Positive Signs of Pregnancy
There are only three documented or positive signs of PHYSIOLOGIC CHANGES OF PREGNANCY This settling of the fetus into the midpelvis is termed
pregnancy: Physiologic changes that occur during pregnancy lightening , because a woman’s breathing is so much easier that she
1. Demonstration of a fetal heart separate from the are the basis for the signs and symptoms used to confirm a feels as if her load is lightened. The point at which lightening will occur
mother’s pregnancy. They can be categorized as local (i.e., confined to is not predictable in a multipara (a woman who has had one or more
2. Fetal movements felt by an examiner the reproductive organs) or systemic (i.e., affecting the entire children). In such women, it may not occur until labor begins. Uterine
body). For easy reference, height is measured from the top of the symphysis pubis to over the top
Reproductive System Changes of the uterine fundus. Although growth of a uterus implies a pregnancy
Demonstration of a Fetal Heart Separate From the Reproductive tract changes are those involving the is causing the increase in size, because a uterine tumor could also
Mother’s uterus, ovaries, vagina, and breasts. cause uterine growth, uterine growth is only a presumptive symptom
Although a fetal heart beat cannot be heard Uterine Changes of pregnancy. The exact shape of the expanding uterus can be
through an ordinary stethoscope until 18 to 20 weeks The most obvious alteration in a woman’s body influenced by the position of the fetus. As the uterus grows larger, it
of pregnancy, an echocardiography can demonstrate a during pregnancy is the increase in size of the uterus to pushes the intestines to the sides of the abdomen, elevates the
heartbeat as early as 5 weeks. An ultrasound can reveal accommodate the growing fetus. Over the 10 lunar months of diaphragm and liver, compresses the stomach, and puts pressure on
a beating fetal heart as early as the sixth to seventh pregnancy, the uterus increases in length, depth, width, the bladder. It usually remains in the midline during pregnancy,
week of pregnancy. Doppler instrumentation that weight, wall thickness, and volume. although it may be pushed slightly to the right side because of the
converts ultrasonic frequencies to audible frequencies • Length grows from approximately 6.5 cm to 32 cm. larger bulk of the sigmoid colon on the left. A woman may worry there
is able to detect fetal heart sounds as early as the 10th • Depth increases from 2.5 cm to 22 cm. will not be enough room inside her abdomen for this much increase in
to 12th week of gestation. The fetal heart rate ranges • Width expands from 4 cm to 24 cm. size. You can assure her the abdominal contents will readily shift to
between 110 and 160 beats/ min. Sounds are more • Weight increases from 50 g to 1,000 g. accommodate uterine enlargement (Fig. 10.3). Uterine blood flow
difficult to hear if a woman’s abdomen has a great deal • Early in pregnancy, the uterine wall thickens from about 1 increases during pregnancy as the placenta requires more and more
of subcutaneous fat or if there is a larger than normal cm to about 2 cm; toward the end of pregnancy, the wall blood for perfusion. Doppler ultrasonography has shown that, before
amount of amniotic fluid present (hydramnios). They thins to become supple and only about 0.5-cm thick. pregnancy, uterine blood flow is 15 to 20 ml/min. By the end of
are heard best when the position of the fetus is • The volume of the uterus increases from about 2 ml to more pregnancy, it expands to as much as 500 to 750 ml/min, with 75% of
determined by palpation and the stethoscope is placed than 1,000 ml. This makes it possible for a uterus to hold a 7- that volume going to the placenta. Measuring an increase in placenta
over the area of the fetal back. lb (3,175-g) fetus plus 1,000 ml of amniotic fluid for a total of blood volume and velocity is an important gauge of fetal health.
Fetal Movements Felt by an Examiner about 4,000 g. Circulation to the uterus increases so much that, toward the
Fetal movements may be felt by a woman as This great uterine growth is due partly to end of pregnancy, one sixth of a woman’s blood supply is circulating
early as 16 to 20 weeks of pregnancy. An objective formation of a few new muscle fibers in the uterine through the uterus at any given time; this means uterine bleeding in
examiner can discern fetal movements at about the myometrium but principally to the stretching of existing pregnancy has to always be regarded as serious because it could result
20th to 24th week of pregnancy unless the woman is muscle fibers (by the end of pregnancy, muscle fibers in the in sudden and major blood loss. Caution women to contact their health
extremely obese. This outside evaluation is considered uterus, because of fibroblastic tissue that forms between care provider if any vaginal bleeding occurs during pregnancy. A
the more reliable assessment because a woman could them, are two to seven times longer than they were before bimanual examination (one finger of an examiner is placed in the
mistake the movement of gas through her intestines pregnancy). Because uterine fibers simply stretch during vagina, the other hand on the abdomen) can demonstrate, during a
for fetal movement. pregnancy and are not newly built, the uterus is able to return pregnancy, that the uterus feels more anteflexed, larger, and softer to
Visualization of the Fetus by Ultrasound to its prepregnant state at the end of the pregnancy with little the touch than usual. At about the sixth week of pregnancy (at the time
Ultrasound is the most common method for diff culty and almost no destruction of tissue. By the end of of the second missed menstrual flow), the lower uterine segment just
confi rmation of pregnancy today. If a woman is the 12th week of pregnancy, the uterus is large enough that it above the cervix becomes so soft when it is compressed between
pregnant, a characteristic ring, indicating the can be palpated as a firm globe under the abdominal wall, just examining fingers on bimanual examination that the wall feels as thin
gestational sac, will be revealed on an oscilloscope above the symphysis pubis. An important factor to assess as tissue paper. This extreme softening of the lower uterine segment is
screen as early as the fourth to sixth week of regarding uterine growth at health care visits is its constant, known as Hegar’s sign. During the 16th to 20th week of pregnancy,
pregnancy. This method also gives information about steady, and predictable increase in size. when the fetus is still small in relation to the amount of amniotic fluid
the site of implantation and whether a multiple • By the 20th or 22nd week of pregnancy, it typically reaches present, if the lower uterine segment is tapped sharply during a pelvic
pregnancy exists. By the eighth week, a fetal outline the level of the umbilicus. exam, the fetus can be felt to bounce or rise in the amniotic fluid up
can be seen so clearly that the crown-to-rump length • By the 36th week, it usually touches the xiphoid process and against a hand placed on the abdomen. This phenomenon, termed
can be measured to establish the gestational age of the can make breathing difficult. ballottement (from the French word ballotter , meaning “to quake”),
pregnancy. Seeing the fetal outline on a sonogram is • About 2 weeks before term (the 38th week) for a may, however, also be simulated by a loosely attached uterine tumor
also clear proof for a couple that they are pregnant if primigravida, a woman in her first pregnancy, the fetal head and, therefore, is no more than a probable sign of pregnancy.
they had any doubt up to that point. settles into the pelvis and the uterus returns to the height it
was at 36 weeks.
Between the 20th and 24th week of pregnancy, the uterine wall Vaginal Changes
Changes in the Breasts
becomes thinned to such a degree a fetal outline within the uterus Under the influence of
Subtle changes in the breasts may be one of the first physiologic changes of
may be palpated by a skilled examiner. Because a tumor with estrogen, the vaginal epithelium and
pregnancy a woman notices (at about 6 weeks). Typical changes are a feeling of
calcium deposits could simulate a fetal outline, palpation of what underlying tissues increase in size as they
fullness, tingling, or tenderness that occurs because of the increased stimulation
seems to be a fetus, like other uterine assessments, does not become enriched with glycogen. Muscle
of breast tissue by the high estrogen level in her body. As the pregnancy
constitute a sure confirmation of pregnancy. Uterine contractions fibers loosen from their connective tissue
progresses, breast size increases because of growth in the mammary alveoli and
begin early in pregnancy, at least by the 12th week, and are base in preparation for great distention at
in fat deposits. The areola of the nipple darkens, and its diameter increases from
present throughout the rest of pregnancy, becoming stronger and birth. This increase in the activity of the
about 3.5 cm (1.5 in.) to 5 cm or 7.5 cm (2 or 3 in.). There is additional darkening
harder as the pregnancy advances. A woman experiences them as epithelial cells results in a slight white
of the skin surrounding the areola in some women, forming a secondary areola.
waves of hardness or tightening across her abdomen. If a hand is vaginal discharge throughout pregnancy
Early in pregnancy, the breasts begin readying themselves for the secretion of
placed on her abdomen, an examiner may be able to feel these (but this is only a presumptive symptom
milk. By the 16th week, colostrum—the thin, watery, high-protein fluid that is
contractions as well; an electronic monitor can easily measure both as vaginal infections also produce
the precursor of breast milk—can be expelled from the nipples. As vascularity of
the frequency and length of such contractions. These “practice” discharges). An increase in the vascularity
the breasts increases, blue veins may become prominent over the surface of the
contractions, termed Braxton Hicks contractions, serve as warm-up of the vagina parallels the vascular
breasts. The sebaceous glands of the areola (Montgomery’s tubercles) , which
exercises for labor and also play a role in ensuring the placenta changes in the uterus. The resulting
keep the nipple supple and help to prevent nipples from cracking and drying
receives adequate blood. They may become so strong in the last increase in circulation changes the color
during lactation, enlarge and become protuberant. Talking to women during
month of pregnancy that a woman mistakes them for labor of the vaginal walls from their normal light
pregnancy about breast changes and how these changes are devised to aid
contractions (i.e., false labor). One way they can be differentiated pink to a deep violet (Chadwick’s sign).
breastfeeding can be the trigger that alerts women to the importance of
from true contractions is that true contractions cause cervical Vaginal secretions before pregnancy have
breastfeeding for their baby.
dilation, and Braxton Hicks contractions do not. Although these a pH value greater than 7 (an alkaline pH).
Systemic Changes
contractions are always present with pregnancy, they also could During pregnancy, the pH level falls to 4 or
Although the physiologic changes first noticed by a woman are apt to be those of
accompany any growing uterine mass; so, like ballottement, they 5 (an acid pH), which helps make the
the reproductive system, changes also occur in almost all body systems.
are no more than a probable sign of pregnancy. vagina resistant to bacterial invasion for
Endocrine System
Amenorrhea the length of the pregnancy. This occurs
Almost all aspects of the endocrine system increase during pregnancy in order to
Amenorrhea (i.e., an absence of a menstrual fl ow) because of the action of Lactobacillus
support fetal growth. Important among these is the presence of a new endocrine
occurs with pregnancy because of the suppression of follicle- acidophilus, a bacteria that grows freely in
organ, or the placenta.
stimulating hormone (FSH) by rising estrogen levels. In a healthy the increased glycogen environment,
Placenta.
woman who has menstruated previously, the absence of a which increases the lactic acid content of
The placenta is responsible for the production of large amounts of
menstrual fl ow strongly suggests impregnation has occurred. secretions.
estrogen, progesterone, hCG, human placental lactogen (hPL), relaxin, and
Amenorrhea, however, also heralds the onset of menopause or Ovarian Changes
prostaglandins during pregnancy.
could result from unrelated reasons such as uterine infection, Ovulation stops with pregnancy because
• The effect of estrogen is to cause breast and uterine enlargement. Palmar
anxiety (perhaps over becoming pregnant), a chronic illness such as of the active feedback mechanism of
erythema (i.e., redness and itching of the palms) may occur early in pregnancy as
severe anemia, or undue stress. It also is seen in athletes who train estrogen and progesterone produced
a response to this high circulating estrogen level.
strenuously, especially in long-distance runners and ballet dancers early in pregnancy by the corpus luteum
• Progesterone has a major role in maintaining the endometrium, inhibiting
if their body fat percentage drops below a critical point. and late in pregnancy by the placenta.
uterine contractility, and aiding in the development of the breasts for lactation.
Amenorrhea is, therefore, only a presumptive symptom of This feedback causes the pituitary gland to
• hCG is secreted by the trophoblast cells beginning early in pregnancy. It
pregnancy. halt production of FSH and luteinizing
stimulates progesterone and estrogen synthesis in the ovaries until the placenta
Cervical Changes hormone (LH); without stimulation from
can assume this role.
In response to the increased level of circulating FSH and LH, ovulation does not occur. The
• hPL, also known as human chorionic somatomammotropin, serves as an
estrogen produced by the placenta during pregnancy, the cervix of corpus luteum that was created after
antagonist to insulin, making insulin less effective, and so allows more glucose to
the uterus becomes more vascular and edematous than usual. A ovulation continues to increase in size on
become available for fetal growth.
mucous plug, called the operculum , forms to seal out bacteria and the surface of the ovary until about the
• Relaxin, secreted by the corpus luteum of the ovary as well as the placenta, is
help prevent infection in the fetus and membranes. Increased fl uid 16th week of pregnancy, by which time
responsible for helping to inhibit uterine activity and to soften the cervix and the
between cells causes it to soften in consistency, and increased the placenta takes over as the chief
collagen in joints. Softening of the cervix allows for dilatation at birth; softening
vascularity causes it to darken from a pale pink to a violet hue provider of progesterone and estrogen.
of collagen allows for laxness in the lower spine, which helps enlarge the birth
( Goodell’s sign ). The consistency of a nonpregnant cervix can be The corpus luteum, no longer essential for
canal.
compared with that of the nose; the consistency of a pregnant the continuation of the pregnancy,
• Prostaglandins affect smooth muscle contractility to such an extent they may
cervix more closely resembles an earlobe. Just before labor, the regresses in size and appears white and fi
be the trigger that initiates labor at term.
cervix becomes so soft it takes on the consistency of butter or is brous on the surface of the ovary (a
said to be “ripe” for birth corpus albicans).
Pituitary Gland Immune System
Respiratory System
A major change in the pituitary gland is the halt in production of FSH Immunologic competency during pregnancy
A local change that often occurs in the respiratory
and LH because of the high estrogen and progesterone levels produced by the decreases, probably to prevent a woman’s body from
system is marked congestion, or “stuffi ness,” of the
placenta. rejecting the fetus as if it were a transplanted organ.
nasopharynx, a response, again, to increased estrogen levels.
• At the same time, there is increased production of other pituitary hormones Immunoglobulin G (IgG) production is particularly
Women may worry this stuffi ness indicates an allergy or a
such as growth hormone and melanocytestimulating hormone, which causes skin decreased, which can make a woman more prone to
cold. Not realizing it is a symptom of pregnancy, some women
pigment changes. infection during pregnancy. A simultaneous increase in the
take overthe-counter cold medications or antihistamines in an
• Prolactin production begins late in pregnancy and helps breasts prepare for white blood cell count may help to counteract this
effort to relieve the congestion. Ask women at prenatal visits if
lactation. decrease in the IgG response.
they are taking any kind of medicine for this to detect this
• Late in pregnancy, the posterior pituitary also begins to produce oxytocin, which Integumentary System
possibility and to be certain the medication they are taking is
is needed to aid labor. As the uterus increases in size, the abdominal
safe during pregnancy. Because the uterus enlarges so much
Thyroid and Parathyroid Glands wall must stretch to accommodate it. This stretching (plus
during pregnancy, the diaphragm, and ultimately, the lungs,
The thyroid gland enlarges to produce increased levels of protein-bound iodine, possibly increased adrenal cortex activity) can cause
receive an increasing amount of pressure. Toward the end of
butanolextractable iodine, and thyroxine to such an extent a woman’s basal body rupture and atrophy of small segments of the connective
pregnancy, this can actually displace the diaphragm by as
metabolic rate increases by about 20%. These thyroid changes along with layer of the skin, leading to pink or reddish streaks ( striae
much as 4 cm upward. Even with all this crowding, however, a
emotional lability, tachycardia, palpitations, and increased perspiration may lead gravidarum ) on the sides of the abdominal wall and
woman’s vital capacity (the maximum volume exhaled after a
to a mistaken diagnosis of hyperthyroidism if pregnancy has not yet been sometimes on the thighs. During the weeks after birth,
maximum inspiration) does not decrease during pregnancy
diagnosed. The parathyroid glands, which are necessary for the metabolism of striae gravidarum lighten to a silvery color (striae albicantes
because, although the lungs are crowded in the vertical
calcium, also increase in size during pregnancy. Because calcium is important for or atrophicae), and, although permanent, they become
dimension, they can still expand horizontally. Two major
fetal growth, the hypertrophy and increased action is probably necessary to barely noticeable. Occasionally, the abdominal wall has
changes do occur with pregnancy: a more rapid than usual
satisfy this increased requirement. Adrenal Glands. Adrenal gland activity difficulty stretching enough to accommodate the growing
breathing rate (18 to 20 breaths/min) and a chronic feeling of
increases in pregnancy so additional levels of corticosteroids and aldosterone can fetus, causing the rectus muscles underneath the skin to
shortness of breath.
be produced. These increased levels probably aid in suppressing an inflammatory actually separate, a condition known as diastasis. If this
The physiologic reasons for those changes include:
reaction or help reduce the possibility of a woman’s body rejecting the foreign happens, it will appear after pregnancy as a bluish groove
• Residual volume (the amount of air remaining in the lungs
protein of the fetus, the same as it would reject a foreign-tissue transplant. They at the site of separation. The umbilicus is stretched by
after expiration) is decreased up to 20% because of the
also help to regulate the woman’s glucose metabolism. The increased level of pregnancy to such an extent that by the 28th week, its
pressure of the diaphragm.
aldosterone plays a major role in promoting sodium reabsorption and maintaining depression becomes obliterated and it is pushed so far
• Tidal volume (the volume of air inspired) is increased up to
osmolarity in the amount of fluid retained, which indirectly helps to safeguard the outward in most women, it appears as if it has turned
40% as a woman draws in deeper breaths trying to increase
blood volume and provide adequate perfusion pressure across the placenta. inside out, protruding as a round bump at the center of the
the effectiveness of her air exchange.
Pancreas abdominal wall. Extra pigmentation generally appears on
• Total oxygen consumption increases by as much as 20%. •
The pancreas increases the production of insulin in response to the higher levels the abdominal wall, because of melanocyte-stimulating
The increased level of progesterone appears to set a new level
of glucocorticoid produced by the adrenal glands. Insulin is less effective than hormone from the pituitary. A narrow, brown line (linea
in the hypothalamus for acceptable serum carbon dioxide
usual, however, because estrogen, progesterone, and hPL are all antagonists of nigra) may form, running from the umbilicus to the
levels (P co2 ) because, during pregnancy, a woman’s body
insulin. Overall, this diminished action of insulin is benefi cial because it ensures a symphysis pubis and separating the abdomen into right and
tends to maintain a P co2 at closer to 32 mmHg than the usual
ready supply of glucose for fetal growth. As a rule, to maintain a high insulin level left halves. Darkened or reddened areas may appear on the
40 mmHg. This low P co2 level is helpful as it causes a
during pregnancy, a woman who is diabetic and self-injects insulin may need to face as well, particularly on the cheeks and across the nose.
favorable CO 2 gradient at the placenta (i.e., because the fetal
increase the amount of insulin she takes while she is pregnant. A woman who is This is known as melasma (chloasma) or the “mask of
CO 2 level is higher than that in the mother, CO 2 crosses
prediabetic may develop overt diabetes for the fi rst time and may need insulin pregnancy.” With the decrease in the level of melanocyte-
readily from the fetus to the mother).
administration during pregnancy. The glucose level of a fetus averages about 30 stimulating hormone after pregnancy, these areas lighten
• To keep the mother’s pH level from becoming acidic because
mg/100 ml, lower than the maternal serum glucose level. Because the rapidly and disappear. Vascular spiders or telangiectasias (small, fi
of the load of CO 2 being shifted to her from the fetus,
developing fetus uses so much glucose in early pregnancy, a woman’s fasting ery-red branching spots) sometimes develop on the skin,
increased expiration (mild hyperventilation) to blow off excess
blood glucose level early in pregnancy may be unusually low (80 to 85 mg/100 particularly on the thighs. Palmar erythema, as mentioned
CO 2 begins early in pregnancy.
ml). To prevent fetal hypoglycemia with resultant cell destruction or lack of fetal earlier, may occur on the hands. Both of these symptoms
• At full term, a woman’s total ventilation capacity may have
growth, maternal serum glucose usually rises to a higher than normal level as result from the increased level of estrogen in the body;
risen by as much as 40%. This increased ventilation may
pregnancy progresses. This allows a woman to maintain a fairly steady level of telangiectasias may fade but not completely disappear
become so extreme toward the end of pregnancy that a
serum glucose despite long intervals between meals or days of increased activity. after pregnancy. The activity of sweat glands increases
woman develops a respiratory alkalosis or exhales more than
To help ensure against hypoglycemia, a pregnant woman should keep her diet throughout the body beginning early in pregnancy, leading
the usual amount of CO2 . To compensate, kidneys excrete
adequate in calories and should try to not go longer than 12 hours between to increased perspiration. Fewer hairs on the head enter a
plasma bicarbonate in urine to lower this pH. This results in
meals. resting phase because of overall increased metabolism, so
increased urination or polyuria , a sign of pregnancy.
scalp hair growth is increased.
• The slight increase in pH in serum because of the changed A hemoglobin concentration of less than 11 g/100 ml, a
expiratory effort is advantageous because it slightly increases hematocrit value below 33% in the fi rst or third trimester of
the binding capacity of maternal hemoglobin and thereby pregnancy, or a hemoglobin concentration of less than 10.5 g/dl
raises the oxygen content of maternal blood (Po2), from a (hematocrit 32%) in the second trimester is considered true Blood Pressure
usual level of about 92 mmHg to about 106 mmHg. This can be anemia. Daily supplementation of iron for values above this Despite the hypervolemia of pregnancy, blood pressure
advantageous to fetal growth because it helps ensure good level (over and above as a component of prenatal vitamins) is in women normally does not rise because the increased heart action
oxygenation of the fetus. generally recommended as needed (Reveiz, Gyte, Cuervo, et al., takes care of the greater amount of circulating blood. In some
• The total respiratory changes and the compensating 2011). If iron is prescribed, caution women that, although the women, blood pressure actually decreases slightly during the second
mechanisms that occur in the respiratory system can be prescribed dose is good for them, excess iron can lead to trimester because the expanding placenta causes peripheral
described as a chronic respiratory alkalosis fully compensated stomach irritation and possibly iron accumulation in body cells. resistance to circulation to lower. During the third trimester, the
by a chronic metabolic acidosis The demand for folic acid increases beginning early on in blood pressure rises again to first trimester levels. A steadily
Temperature pregnancy. If the intake of this is not great enough, increasing blood pressure is a danger sign that gestational
Early in pregnancy, body temperature increases slightly megalohemoglobinemia (i.e., large, nonfunctioning red blood hypertension may be developing. Peripheral Blood Flow. During the
because of the secretion of progesterone from the corpus cells) can result. Inadequate folic acid levels are also linked to an third trimester of pregnancy, blood flow to the lower extremities is
luteum (the temperature, which increased at ovulation, increased risk of neural tube or abdominal wall disorders in impaired by the pressure of the expanding uterus on veins and
remains elevated). As the placenta takes over the function of fetuses (Lumley, Watson, Watson, et al., 2011). For this reason, arteries. This resistance to blood flow in the venous system can lead
the corpus luteum at about 16 weeks, the temperature usually prenatal vitamins that contain folic acid are routinely to edema and varicosities of the vulva, rectum, and legs.
decreases to normal. prescribed. Encourage women to eat foods that are high in folic Supine Hypotension Syndrome
Cardiovascular System acid such as spinach, asparagus, and legumes both during their When a pregnant woman lies supine, the weight of the
Changes in the circulatory system are extremely significant to prepregnancy period and during pregnancy so that the prenatal growing uterus presses the vena cava against the vertebrae,
the health of a fetus, because they determine whether there vitamin is truly a supplement. You may need to remind women obstructing blood flow from the lower extremities. This causes a
will be adequate placental and fetal circulation for oxygenation to be conscientious about not just buying but taking a decrease in blood return to the heart and, consequently, decreased
and nutrition. Table 10.5 summarizes these changes. prescribed prenatal vitamin to be certain their intake of cardiac output and hypotension. A woman experiences this
Blood Volume common vitamins is adequate. Surprisingly, although other hypotension as light-headedness, faintness, and palpitations. The
To provide for an adequate exchange of nutrients across the factors also come into play, an association between condition is potentially dangerous because it can cause fetal
placenta and for adequate blood to compensate for maternal multivitamin supplementation during pregnancy and reduced hypoxia. To lessen the possibility that the syndrome will happen,
blood loss at birth, the total circulatory blood volume of a cancers in children such as neuroblastoma, leukemia, and brain women develop an increase in collateral blood circulation during
woman’s body increases by at least 30% (and possibly as much tumors can be documented. pregnancy. The symptoms can be alleviated by having a woman turn
as 50%) during pregnancy. This is important protection because Heart onto her side (preferably the left side), so blood flow through the
blood loss at a normal vaginal birth is 300 to 400 ml; blood loss To handle the increase in blood volume in the vena cava increases again. Teach women to always rest on the left
from a cesarean birth can be as high as 800 to 1,000 ml. The circulatory system, a woman’s heart rate increases by at least side rather than their back, because even with additional collateral
increase in blood volume occurs gradually, beginning at the 10 beats/min, causing her cardiac output to increase as much as circulation, a supine position can lead to hypotension.
end of the fi rst trimester. It peaks at about the 28th to the 25% to 50%. Some women develop audible functional Blood Constitution
32nd week and then continues at this high level throughout the (innocent) heart murmurs during pregnancy, probably because A variety of changes occur in the constitution of blood.
third trimester. Because the plasma volume increases faster of the increased blood volume and pressure from the • The level of circulating fi brinogen, a constituent of the blood
than red blood cell production, the concentration of diaphragm shifts heart position. The bulk of these cardiac necessary for clotting, increases by as much as 50%, probably
hemoglobin and erythrocytes usually declines early in changes occur during the second trimester, with a small stimulated by the increased level of estrogen.
pregnancy, giving the woman pseudoanemia. Her body increase in the third trimester. Although the average woman • Other clotting factors, such as factors VII, VIII, IX, and X, and the
compensates for this change by producing more red blood barely notices these circulatory system changes, the increased platelet count also increase as safeguards against major bleeding
cells, bringing the hemoglobin level back to near normal by the heart rate along with the rise in circulating blood volume can should the placenta be dislodged and the uterine arteries or veins
second trimester. have serious implications for a woman with cardiac disease open.
Iron, Folic Acid, and Vitamin Needs. because her heart can be overwhelmed by these new • The total white blood cell count rises signifi cantly, both as a
Almost all women need some iron supplementation during requirements placed on it. Sudden palpitations of the heart are protective mechanism against infection and as a refl ection of a
pregnancy by prenatal vitamins because of a number of not uncommon during pregnancy, particularly on quick motion. woman’s increased total blood volume (to about 20,000 cells/mm 3
factors: You can caution women not to feel frightened if these do occur. • The total protein level of blood decreases, perhaps indicating the
• The fetus requires a total of about 350 to 400 mg of iron per In the early months of pregnancy, they are probably caused by amount of protein being used by the fetus.
day to grow. sympathetic nervous system stimulation; in later months, a
• The increases in the mother’s circulatory red blood cell mass cause could be increased thoracic pressure from the upward
require an additional 400 mg of iron per day, which creates a pressure of the diaphragm. Either way, unless the woman has a
total needed increase of about 800 mg. previous heart condition or if they are caused by supine
• Iron absorption may be impaired during pregnancy as a result hypotension syndrome (see the following), they are innocent
• Blood lipids increase by one third, and the cholesterol serum level increases by 90% to 100% Urinary System
to provide a ready supply of available energy for the fetus. Like other systems, the urinary system undergoes specific physiologic changes during
`Because the circulating system has a lower total protein load, in combination with pregnancy, including alterations in fl uid retention and renal, ureter, and bladder function. These
hypervolemia, fl uid readily leaves the blood vessels for interstitial tissue to equalize osmotic changes, summarized in Table 10.6, result from:
and hydrostatic pressure. This leads to the common ankle and foot edema of pregnancy (not • Effects of high estrogen and progesterone levels
to be confused with nondependent or generalized edema, which is a symptom of • Compression of the bladder and ureters by the growing uterus • Increased blood volume that
hypertension of pregnancy. increases kidney production of more urine
Gastrointestinal System • Postural influences
At least 50% of women experience some nausea and vomiting early on in Fluid Retention
pregnancy. For many women, this is the fi rst sensation a woman experiences with pregnancy To provide sufficient fluid volume for effective placental exchange, a woman’s total
(it can be noticed even before the fi rst missed menstrual period). It is most apparent early in body water almost doubles. Because nutrients can pass to the fetus only when dissolved in or
the morning, on rising, or if a woman becomes fatigued during the day. Known as morning carried by fl uid, this ready fluid supply is a safeguard to ensure the fetus can be supplied with
sickness, nausea and vomiting begins to be noticed at the same time levels of hCG and adequate nutrients. It also can provide excess fluid to replenish the mother’s blood volume,
progesterone begin to rise so these may contribute to its cause. Another reason may be a should hemorrhage occur. Under the influence of progesterone, an increased response of the
systemic reaction to increased estrogen levels or decreased glucose levels, because glucose is angiotensin–renin system in the kidney occurs leading to an increase in aldosterone production
being used in such great quantities by the growing fetus. Nausea usually subsides after the and increased sodium reabsorption and regulation of serum osmolarity. Progesterone appears to
first 3 months, after which time a woman may have a voracious appetite. Many alternate or be potassium sparing, so even with an increased urine output, potassium levels remain adequate.
complementary methods to help reduce nausea are available, such as acupuncture or wrist Renal Function
bands. Box 10.8 is an interprofessional care map illustrating both nursing and team planning During pregnancy, a woman’s kidneys must excrete not only the waste products from
for a woman with nausea of pregnancy. In addition to nausea, other gastrointestinal tract her body but also those of the fetus. Also, her kidneys must be able to excrete additional fluid and
changes occur: manage the demands of an increased renal blood flow. The glomerular filtration rate (GFR) and
• Although the acidity of stomach secretions decreases during pregnancy, heartburn can renal plasma flow both increase in pregnancy by 30% to 50% in order to meet the increased
readily result from refl ux of stomach contents into the esophagus, caused by both the demands of the circulatory system volume. The elevation of the GFR leads to increased filtration
upward displacement of the stomach by the uterus, and a relaxed cardioesophageal sphincter, of glucose into the renal tubules. Because reabsorption of glucose by the tubule cells occurs at a
caused by the action of relaxin produced by the ovary fixed rate, this causes some accidental spilling of glucose into the urine during pregnancy. Lactose,
• As the uterus increases in size, it pushes the stomach and intestines toward the back and which is being produced by the mammary glands but which is not used during pregnancy, will also
sides of the abdomen. At about the midpoint of pregnancy, this pressure may be sufficient to be spilled into the urine. Although minimal spilling of glucose into the urine normally occurs, the
slow intestinal peristalsis and the emptying time of the stomach, leading to renewed finding of more than a trace of glucose in a routine sample of urine from a pregnant woman is
heartburn, constipation, and flatulence. considered abnormal until proven otherwise, because this can be a sign of gestational diabetes.
• Pressure from the uterus on veins returning from the lower extremities can lead to Another tract change is that urinary output gradually increases by about 60% to 80%. In contrast,
hemorrhoids. the specific gravity of urine, the blood urea nitrogen (BUN) and creatinine levels all lower. A BUN
• The entire gastrointestinal tract may become less active from the combined actions of of 15 mg/100 ml or higher, or a serum creatinine concentration greater than 1 mg/100 ml are
relaxin and progesterone. This natural slowing of the stomach and intestine can be helpful considered abnormal values and reflect the kidneys’ difficulty in handling the increased blood
because the blood supply is reduced in the gastrointestinal tract as more blood is drawn to load. Creatinine clearance has become the standard test for renal function during pregnancy
the uterus. because creatinine is cleared from the body at a steady rate in relation to GFR. A normal
• Women with chronic gastric refl ux usually fi nd their condition either improved because the pregnancy value is 90 to 180 ml/min analyzed from a 24-hour urine sample.
acidity of the stomach is decreased or worsened because of upward uterine pressure. Ureter and Bladder Function
• Because of the gradual slowing of the gastrointestinal tract, decreased emptying of bile from A pregnant woman may notice an increase in urinary frequency during the first 3
the gallbladder may result. This can lead to reabsorption of bilirubin into the maternal months of pregnancy, until the uterus rises out of the pelvis and relieves pressure on the bladder.
bloodstream, giving rise to a symptom of generalized itching (subclinical jaundice). A woman Frequency of urination may return at the end of pregnancy, as lightening occurs and the fetal
who has had gallstones may have an increased tendency for stone formation during head exerts renewed pressure on the bladder. Because of the increased level of progesterone
pregnancy as a result of the increased plasma cholesterol level and additional cholesterol during pregnancy, the ureters increase in diameter and the bladder capacity increases to about
incorporated in bile. 1,500 ml. The uterus tends to rise on the right side of the abdomen because it is pushed slightly in
• Some pregnant women notice hypertrophy at their gum lines and bleeding of gingival tissue that direction by the greater bulk of the sigmoid colon. As a result, pressure on the right ureter
when they brush their teeth. There also may be increased saliva formation (hyperptyalism), may lead to urinary stasis. Pressure on the urethra may lead to poor bladder emptying resulting in
probably as a local response to increased levels of estrogen. This is an annoying, but not a bladder infection. Such infections are potentially dangerous to the pregnant woman, because they
serious problem. can ascend to become kidney infections. They are potentially dangerous to the fetus because
• A lower than normal pH of saliva may lead to increased tooth decay if tooth brushing is not urinary tract infections are strongly associated with preterm labor
Musculoskeletal System
Calcium and phosphorus needs are increased
during pregnancy because an entire fetal skeleton must be
built. As pregnancy advances, a gradual softening of a
woman’s pelvic ligaments and joints occurs to create
pliability and to facilitate passage of the baby through the
pelvis at birth. This softening is probably caused by the infl
ence of both the ovarian hormone relaxin and placental
progesterone. This excessive mobility of joints can cause
discomfort late in pregnancy, especially if there is a
separation of the symphysis pubis. Separation this way
causes acute pain and makes walking difficult and painful.
To change her center of gravity and make ambulation
easier, a pregnant woman tends to stand straighter and
taller than usual. This stance is sometimes referred to as
the “pride of pregnancy.” Standing this way, with the
shoulders back and the abdomen forward, however,
creates a lordosis (forward curve of the lumbar spine),
which may lead to chronic backache, particularly in older
women.

WOMEN WITH UNIQUE CONCERNS IN PREGNANCY

Women with disabilities may have specific
concerns about how to care for themselves during pregnancy
and for their child when he or she is born, and so need a
careful assessment as to their feelings about having a baby
along with an assessment of special adjustments they may
need to make during pregnancy. Assess if they are concerned
their child may be born with their disability. Research or ask a
knowledgeable team member to be certain your advice will
be accurate before assuring women this is not apt to happen.
Two other concerns that arise more frequently in pregnant
women than others are restless leg syndrome and carpal
tunnel syndrome.
Carpal tunnel syndrome is named for the Greek word karpos
meaning “wrist” and the narrow space where the median
nerve passes between the bones of the wrist. Repetitive
movements, such as typing or swinging a tennis racket, can
irritate the nerve resulting in sensations of pain, tingling, and
numbness. Probably because of the effect of the hormone
relaxin secreted by the placenta, pregnant women seem to
be more susceptible to this condition than others.
Restless leg syndrome is the uncontrollable urge to move the
legs, often accompanied by itching, tingling, or aching to such
an extent a person has difficulty falling or staying asleep. It
tends to occur more often in pregnant women and people
with iron deficiency than others.
CHAPTER 10: Nursing Care Related to Psychological and Physiologic Changes of Pregnancy
10.1 A. Women in the study reacted both positively and negatively at the thought of a second
pregnancy. Lauren’s paradoxical response represents this.
10.2 B. Ensuring safe passage for the fetus consists of accepting the pregnancy (first trimester),
accepting the coming baby (second trimester), and preparing for parenthood (third trimester).
10.3 C. Narcissism refers to interest in oneself in contrast to interest in others.
10.4 D. The three positive signs of pregnancy are fetal heartbeat heard by examiner or fetal
outline or heartbeat seen on sonogram and fetal movement felt by examiner.
10.5 D. Chadwick’s sign is a color change in the vagina from pink to purple because of increased
formation of blood vessels and blood flow.
10.6 A. With insulin becoming ineffective, glucose levels rise, serving to safeguard the fetus from
hypoglycemia. Maternal insulin does not cross the placenta.