SCHOOL OF NURSING SCIENCE AND RESEARCH

SHARDA UNIVERSITY

LESSON PLAN
ON
PHYSIOLOGICAL CHANGES DURING PREGNANCY

SUBJECT: OBSTETRIC AND GYNECOLOGICAL NURSING

SUBMITTED TO SUMBITTED BY
Ms. Komal Sharma Ms. Bhawna joshi
Lecturer, nursing M.sc Nursing Ist year
Obstetrical and Gynecologial Nursing Deppt. SNSR
SNSR
 TITLE PAGE

NAME OF THE STUDENT TEACHER : BHAWNA JOSHI

NAME OF THE SUPERVISOR : MS. KOMAL SHARMA .
NAME OF THE SUBJECT : OBG
NAME OF THE TOPIC : PHYSIOLOGICAL CHANGES DURING PREGNANCY
DATE : 1/12/2019
TIME :
DURATION : 45 MINUTES
CLASS : BSC NURSING 3RD YEAR
AV AIDS : BLACK BOARD,PPT, HAND OUT, FLASH CARD, CHARTS
METHOD OF TEACHING : LECTURE,DISCUSSION.
 OBJECTIVES

General objectives: By the end of the class students will be able to understand the Physiological changes during pregnancy.
Specific objective: By the end of the class students will be able
 To Introduce the Physiological changes during pregnancy
 To Define the Physiological changes during pregnancy
 To explain the physiological changes In reproductive system
 To discuss the breast changes
 To explain the Respiratory changes during pregnancy
 To describe the Cardiovascular changes during pregnancy
 To discuss the Hematological changes during pregnancy
 To explain the renal changes during pregnancy
 To elaborate the neurological changes during pregnancy
 To explain the Gastrointestinal changes during pregnancy
 To describe the Hepatic changes during pregnancy
 To explain the Endocrine changes during pregnancy
 To discuss the Changes in the Dermatological System
TIM SPECIFI CONTENT TEACHING LEARNING TEACHING A.V.AI EVALVATI
E C ACTIVITY METHOD DS ON
OBJECT
IVE

2min introduce Introduction

To the
Maternal physiological Lecture cum White
topic
changes in pregnancy are the discussion board
normal adaptations that a
woman undergoes during
pregnancy in order to nurture
and accommodate the
developing fetus. These
changes resolve after
pregnancy with minimal
residual effects.Many of these
physiological changes appear
to be adaptive in order to meet
the increased metabolic
demand of the fetus and useful
to the mother in tolerating the
stresses of pregnancy, labor,
and delivery.

2min Definition What is the

To define Student teacher will define the
Lecture cum Ppt Physiologic
the  Physiological changes occur in pregnancy to Physiological changes during
discussion al changes
Physiologi nurture the developing foetus and prepare the pregnancy
during
cal mother for labour and delivery. pregnancy ?
changes
 during
pregnancy

To explain
Changes in reproductive system Lecture cum What are
the
discussion the
5min physiologi VULVA Student teacher will To explain Ppt
physiologic
cal  Vulva becomes edematous and more vascular the physiological changes In
al changes
changes Superficial varicosities may appear especially reproductive system
in
in multiparae.
In reproductiv
 Labia minora are pigmented and
reproducti hypertrophied. e system
ve system
VAGINA
 Vaginal walls become hypertrophied,
edematous and more vascular.
 Increased blood supply of the venous plexus
surrounding the walls gives the bluish
coloration of the mucosa (Jacquemier’s sign)
 The length of the anterior vaginal wall is
increased.

Secretion:
 The secretion becomes copious, thin and curdy
white due to marked exfoliated cells and
bacteria. The pH becomes acidic (3.5–6) due to
more conversion of glycogen into lactic acid
by the Lactobacillus acidophilus consequent on
high estrogen level.
 The acidic pH prevents multiplication of
pathogenic organisms.
 BODY OF THE UTERUS:
Enlargement: Changes in the muscles

Hypertrophy and hyperplasia: These occur

under the influence of the hormones—estrogen
and progesterone

Stretching: The muscle fibers further elongate

beyond 20 weeks due to distension by the
growing fetus. The wall becomes thinner and,
at term, measures about 1.5 cm or less. The
uterus feels soft and elastic in contrast to firm
feel of the nongravid uterus.
Weight:
The increase in weight is due to the increased
growth of the uterine muscles, connective
tissues and vascular channels. Shape
Nonpregnant pyriform shape is maintained in
early months. It becomes globular at 12 weeks.
As the uterus enlarges, the shape once more
becomes pyriform or ovoid by 28 weeks and
changes to spherical beyond 36th week.

Isthmus
 During the first trimester isthmus
hypertrophies and elongates to about 3 times
its original length Becomes softer
Cervix
 Hypertrophy and hyperplasia of the elastic and
connective tissues
 Vascularity is increased
 Softening of the cervix (Goodell’s sign)
 Squamous cells also become hyperactive
 Mucosal changes simulate basal cell
hyperplasia or cervical intraepithelial neoplasia
(CIN)
 Secretion is copious and tenacious –
physiological leucorrhoea of pregnancy
 Becomes bulky

Fallopian Tube
 Total length is increased
 Tube becomes congested
 Muscles undergo hypertrophy

Ovary
 Growth and function of the corpus luteum
 reaches its maximum at 8th week
 Hormones-oestrogen and progesterone
secreted by the corpus luteum maintain the
environment for the growing ovum
 Control the formation and maintenance of
decidua of pregnancy
 Inhibit ripening of the follicles

To discuss BREAST CHANGES

the breast  Increased size of the breasts
 Marked hypertrophy and proliferation of the Student teacher will discuss Lecture cum What are
changes
ducts (oestrogen and progesterone) the breast changes discussion the breast
1min Ppt
 Vascularity is increased changes
 The nipples become larger, erectile and deeply during
pigmented pregnancy?
 To explain Respiratory changes
the
Respirator  Respiratory changes are of great significance
to the anesthetists and reports in literatures
4min y changes Student teacher will explain Lecture cum What are
during suggest failure to intubate the trachea is 7-10
the Respiratory changes during discussion the
pregnancy times more common in term pregnancy Ppt
pregnancy respiratory
compared to nonpregnant.
changes
 There is a significant increase in oxygen during
demand during normal pregnancy due to 15% pregnancy?
increase in MR and 20-50% increase in oxygen
consumption.
 There is a 40–50% increase in MV mostly due
to an increase TV, rather than in the respiratory
rate.
 This maternal hyperventilation causes increase
arterial PO2 and decrease arterial PCO2 (to 28-
32mmHg), with a compensatory fall in serum
HCO 3 to 18–22 mmol/l.
 A mild fully compensated respiratory alkalosis
is therefore normal in pregnancy (arterial pH
7.44).
 Decrease FRC (20%) in late pregnancy due to
diaphragmatic elevation (Diaphragmatic
excursion and VC left unaffected)
 FRC is the “air tank” during apnea.
 Decrease IRV early in pregnancy due to
increase TV but increase IRV in late
 pregnancy.
 The combination of decreased FRC and
increased oxygen consumption promotes rapid
oxygen desaturation during periods of apnea
 Subjective feeling of breathlessness without
hypoxia usually at rest or during talking and
paradoxically improves during mild activity.
 The available evidence suggests a monitored,
stepwise increase in physical activity will
decrease adverse pregnancy outcomes.
To What are
describe the
4min Cardiovascular changes
the
Cardiovasc
Cardiovas  Increase COP by 40-50 % above second Student teacher will describe Lecture cum
ular
cular trimester the Cardiovascular changes discussion
Ppt changes
changes during pregnancy
 Increase SV due to increase blood volume during
during
secondary to changes in the RAAS promoting pregnancy?
pregnancy
sodium absorption and water retention.

 Increase in circulating estrogen and

progesterone results in vasodilation and
decrease PVR and increase HR by 15-25%
 Left ventricular hypertrophy and dilation is the
cause of these changes. But contractility
remains unchanged.
 Blood pressure decreases in the first and
 second trimesters but increases to normal (non-
pregnant) levels in the third trimester.
 With the upward displacement of the
diaphragm, the apex will moved left and
anterior. (results in ECG findings of left axis
deviation, ST-segment depression, inversion or
flattening of T-wave in lead III)
 Increase loudness of both S1 & S2.
 >95% develop systolic murmur which
disappears after delivery.
 20% have a transient diastolic murmur.
 10% develop continues murmur due to
increase mammary blood flow.
 All murmurs are not “flow murmurs”! But
most are innocent
 Relative tachycardia, collapsing pulse
 Aortocaval compression during supine position
by the gravid uterus causes decreased systemic
blood pressure resulting in supine hypotension
syndrome (characterized by diaphoresis,
nausea vomiting and change in mentation )

To discuss
the
Hematological changes What are
Hematolo
the
5min gical  Increase BV by increase progestrone  Hematologi
changes increase RAAS (promotes sodium absorption cal changes
Student teacher will discuss Lecture cum
during and water retention). during
the Hematological changes discussion
pregnancy Ppt pregnancy ?
 Plasma protein concentrations accordingly during pregnancy
decrease
== with a 25% decrease in albumin and
== 10% decrease in total protein at term
compared with nonpregnant levels.
 TBW will increase due to sodium retention.
 Does increase of these volumes can result in
circulatory over load?
 Renal erythropoietin increases red cell mass by
20- 30% which is a smaller rise than the
plasma volume in hemodilution and a
decrease in hemoglobin concentration from 15
g/dl to 12 g/dl. (physiological anemia of
pregnancy)
 Supplemental intake of iron and folic acid help
to restore hemoglobin levels.
 The blood volume returns to normal 10-14
days post partum.
Increase in blood volume will help
==== To compensate blood loss during delivery
==== Facilitate maternal and fetal exchanges of
respiratory gases, nutrients and metabolites.
  Increase WBC count (leucocytosis) without
infection may be normal which will be normal
4-5 days after delivery.
 Platelet count may decrease to 10% (100-
150*103 /mm3 )
 Pregnancy is associated with a
hypercoagulable state that may be beneficial in
limiting blood loss at delivery.
 Fibrinogen and concentrations of factors VII,
VIII, IX, X, and XII increase
 Factor XI levels may decrease
 Anti coagulants antithrombin III and
fibrinolysis will decrease and it may result in
risk of DVT.

Renal Changes
To explain What are
the renal  The increased blood volume and COP cause the renal
renal vasodilatation  the RBF and GFR to Student teacher will explain
changes changes
increase progressively during pregnancy to 50- the renal changes during
3min during during
60% higher at term. pregnancy
pregnancy pregnancy ?
Lecture cum
 The increased clearance of urea, creatinine, discussion
and excretion of bicarbonate results in lower Ppt
plasma levels than in the non-pregnant
population.
  Mild glycosuria and/or proteinuria can occur in
normal pregnancy due to increase GFR
overwhelm the renal tubules ability to reabsorb
glucose and protein.
 Plasma osmolality falls because of water
retention secondary to increased the activity of
progesterone RAAS pathways.
 The volume of distribution and excretion of
certain drugs may be increased and therefore
dose adjustments required.
 Pregnant women are more prone to urinary
tract infections because of progesterone-
mediated ureteric smooth muscle relaxation.
 After the 12th week of gestation, the enlarging
uterus can compress the ureters as they cross
the pelvic brim and cause further dilatation by
obstructing flow.

Neurologic Changes
To  Pregnant patients are considered more What are
elaborate sensitive to both inhaled and local anesthetics. the
the neurologica
 MAC decrease by 40% at term
5min neurologic Student teacher will elaborate l changes
al changes  Pregnant women are more sensitive to local the neurological changes during
during Lecture cum pregnancy ?
anesthetics. during pregnancy
pregnancy discussion
Ppt
 At term the epidural veins are engorged, which
 decreases the size of the epidural space and
volume of cerebrospinal fluid (CSF) in the
subarachnoid space.
 Oxytocin neurons are inhibited from releasing
the stored oxytocin prematurely through
several hormonal mechanisms involving
progesterone, oestrogen and opioid peptides.
 At term, progesterone secretion falls and the
inhibitory mechanism modified to allow
gradual release of oxytocin in labour followed
by a surge at the time of birth.
 Sleep disturbances are a common complaint of
pregnancy.
 Pregnant women's sleep patterns are affected
by both mechanical and hormonal influences.
 These include nocturia, dyspnoea, nasal
congestion, stress and anxiety as well as
muscular aches and pains, leg cramps and fetal
activity.

Gastrointestinal changes
What are
 Aspiration of gastric contents is an important the
To explain
cause of maternal morbidity and mortality in Gastrointest
the
3min association with general anaesthesia. Student teacher will explain inal
Gastrointe
the Gastrointestinal changes changes
stinal  Heartburn can affect up to 80% of woman at during
during pregnancy
changes term and the supine position may exacerbate
 during the reflux. Lecture cum pregnancy ?
pregnancy discussion
 Parturients should be considered to have a "full Ppt
stomach" with increased risk of aspiration
during most of gestation.
 Decrease Gastric motility
 upward and anterior displacement of the
stomach by the uterus promotes incompetence
of the gastroesophageal sphincter.
 high risk for regurgitation and pulmonary
aspiration
 gastric acidity and gastric volume no changes
significantly during pregnancy.
 Opioids and anticholinergics reduce lower
esophageal sphincter pressure, may facilitate
gastroesophageal reflux, and delay gastric
emptying.

Hepatic changes
 Hepatic blood flow is unaffected What are
To the Hepatic
 Liver enzymes AST,ALT and Bilirubin Student teacher will describe
describe changes
increased to upper limit the Hepatic changes during
2min the during
pregnancy
Hepatic  Plasma concentrations of ALP are increased up pregnancy ?
changes to 3 times normal, as a result of placental
during Lecture cum
production. discussion
pregnancy
  Plasma cholinesterase levels fall by 25% at Ppt
term and a further 8% three days postpartum
prolonging effect of sux.
 Plasma protein concentrations are reduced
during pregnancy, and the decreased serum
albumin levels can result in elevated free blood
levels of highly protein-bound drugs.
 The risk for gallbladder disease is increased
during pregnancy with incomplete gallbladder
emptying and changes in bile composition.

Endocrine Changes
 Complex metabolic and hormonal changes
To explain
occur during pregnancy.
the
Student teacher will explain What are
Endocrine  Altered metabolism of carbohydrate, fat and the Endocrine changes during the
changes protein  fetal growth and development. pregnancy Endocrine
during
3min pregnancy  Starvation resembling changes : (Decrease changes
blood glucose and Amino acid where as  Free during
Lecture cum pregnancy ?
fatty acids, ketones and Triglycerides) discussion
 Decrease in insulin production, but pregnancy
is associated with insulin resistance caused Ppt
predominantly by human placental lactogen.
 This facilitates placental glucose transfer and
any carbohydrate load will cause a greater than
normal increase in plasma glucose.
  The fetus relies on its own production of
insulin, as maternal insulin does not cross the
placenta.
 Maternal hyperglycaemia can result in fetal
hyperglycaemia with secondary fetal
hyperinsulinism and neonatal hypoglycaemia
 Insulin is the main 'growth hormone' of the
fetus and therefore infants of diabetic mothers
are often macrosomic (> 4,000 g), resulting in
an increase in assisted deliveries and caesarean
sections.
 Secretion of HCG and elevated levels of
estrogens promote hypertrophy of the thyroid
gland and increase thyroid- binding globulin.
 Increase T 4 and T 3 levels
 free T 4 , free T 3 , and TSH remain normal.
 Serum calcium levels decrease, but ionized
calcium concentration remains normal.
To discuss
the
What are
Changes Changes in the Dermatological System the
in the
 Hyperpigmentation of certain parts of the Changes in
Dermatolo
2min gical body such as the face, neck, and midline of Lecture cum the
the abdomen is not uncommon during discussion Dermatolog
System Student teacher will discuss ppt
pregnancy. Melanocyte-stimulating hormone ical System
the Changes in the
is responsible for this change. Dermatological System during during
 pregnancy pregnancy ?

Conclusion
 This system plays an important role in growth
and development of the foetus in pregnancy. It
2min
is important for the midwives trained staff to
know the changes during pregnancy and to
deliver good care and reduces complication.

summary

1min  Physiologic changes during pregnancy can

alter a woman’s response to trauma and create
or exacerbate medical conditions.
.Physiological changes of pregnancy affect
various body organs and system.

Recaptualization

 What is the Physiological changes during

pregnancy ?
 What are the physiological changes in
reproductive system ?
REFERENCES

1. Dutta D.C., Textbook of Gynaecology, 6th Edition, India: published by new central book agency; 2004.

2. Dr Dawn C. S.. Textbook of Gynaecology, contraceptives & reproductive & demography .16th edition. Kolkata: Smt. Arati
Dawn, Debabrata Dawn publishers;2004.

3. Dass Anusuya. Textbook of obstetrics. 1st Edition. New Delhi: Jaypee Publishers(P)Ltd; 2007.

4. PV. Textbook of midwives. 9th Edition. New Delhi: Jaypee Brothers Publishers (P)Ltd.
5. WWW.google .com