The Nursing Process in Maternal-Neonatal Nursing

ASSESSMENT
During pregnancy, assess such maternal factors as:
• Patient’s age
• Past medical, pregnancy, and birth history
• Reaction to fetal movements
• Nutritional status
After birth, asses such neonatal factors as:
• APGAR score
• Gestational age
• Weight in relation to gestational age
• Vital signs
• Feeding patterns
• Muscle tone
• Condition of the fontanels
• Characteristics of the neonate’s cry

Assessment should always reflect a family-centered approach. Be sure to assess

family status, and note how it’s affected by the pregnancy and birth. Be aware of
how the family is coping with the new arrival and how parents, siblings, and other
family members are affected. Also, assess how the mother, father and siblings, and
other family members bond with the neonate.

DIAGNOSIS

In maternal-neonatal nursing you’ll develop nursing diagnosis for patient, family,

and neonate that are appropriate for the prenatal, intrapartum and postpartum
periods. The information gathered during your nursing assessment can be used to
help you formulate appropriate nursing diagnoses.
For example, a new mother might experience frustration because her neonate is
fussing and crying within the first hour after breast-feeding. Based on this
assessment data, the patient would be assigned a nursing diagnosis of Ineffective
breast-feeding.

Factors influencing family’s response to pregnancy:

1. Maternal age 5. Social and economic resources
2. Cultural beliefs 6. Age and health status of other
family members
3. Whether the pregnancy was planned 7. Mother’s medical and obstetrical
history
4. Family dynamics

PHYSIOLOGIC AND PSYCHOSOCIAL ADAPTATIONS TO PREGNANCY

SIGN WEEKS OTHER POSSIBLE CAUSES

FROM
IMPLANTAT
ION
PRESUMPTIVE
• Breast changes, • Hyperprolactenemia induced by
including feelings of 2 tranquilizers
tenderness, fullness, or • Infection
tingling and • Prolactin-secreting pituitary tumor
enlargement or • Pseudocyesis
darkening of areola • Premenstrual syndrome
• Feeling of nausea or 2
• Gastric disorders
vomiting upon arising
• Infections
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Janet Alexis A. De los Santos, RN, MAN
 • Psychological disorders such as
pseudocyesis and anorexia nervosa
2
• Amenorrhea • Anovulation
• Blocked endometrial cavity
• Endocrine changes
• Medications(phenothiazines)
3 • Metabolic changes

• Frequent urination • Emotional stress

• Pelvic tumor
• Renal disease
• UTI
12
• Anemia
• Fatigue • Chronic illness
12
• Ascites
• Uterine enlargement in • Obesity
which the uterus can be • Uterine or pelvic tumor
18
palpated over the
symphysis pubis • Excessive flatus
24 • Increased peristalsis
• Quickening
• Cardiopulmonary disorders
• Estrogen-progestin hormonal
• Linea Nigra
contraceptives
24 • Obesity
• Pelvic tumor

• Melasma • Cardiopulmonary disorders

24 • Estrogen-progestin hormonal
contraceptives
• Obesity
• Pelvic tumor
• Striae gravidarum
• Cardiopulmonary disorders
• Estrogen-progestin hormonal
contraceptives
• Obesity
• Pelvic tumor

PROBABLE

• Serum laboratory test 1 • Cross-reaction of leutinizing hormone

revealing presence of
hCG hormone
• Chadwick’s sign (bluish
discoloration of the
vagina)
• Goodell’s sign (cervix
softens)
6 • Hyperemia of cervix, vagina, and
vulva
6
• Estrogen-progestin hormonal
6 contraceptives

• Hegar’s (softening of • Excessively soft uterine walls

6
lower uterine segment)

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• Sonographic evidence of • None
gestational sac in which 16
characteristic ring is
evident
• Ascites
• Ballottement (fetus can • Uterine tumor or polyps
be felt to rise against
abdominal wall when
lower uterine segment is 20
tapped on during
bimanual examination)
20
• Hematoma
• Uterine tumor
• Braxton Hicks
contractions (periodic • Subserous uterine myoma
uterine tightening)

• Palpation of fetal outline

through abdomen
POSITIVE

• Sonographic evidence of 8 None

fetal outline
• Fetal heart audible by 10-12 None
Doppler ultrasound
• Palpation of fetal 20 None
movement through
abdomen

PHYSIOLOGIC CHANGES
I. REPRODUCTIVE SYSTEM
• Hegar’s sign
• Goodel’s sign
• Enlargement of the external reproductive structures due to increased
vascularity and fat deposits
• Varices
• Ovaries : When fertilization occurs, ovarian follicles cease to mature and
ovulation
stops. The chorionic villi, which develop from the fertilized ovum, begin
to produce hCG to maintain the ovarian corpus luteum. The corpus
luteum produces estrogen and progesterone until the placenta
assumes production of these hormones. The corpus luteum, which is
no longer needed, then involutes (becomes smaller due to reduction in
cell size).
• Uterus : In a nonpregnant woman, the uterus is smaller than the size of
a fist, measuring approximately 7.5cmx5cmx2.5cm. It can weigh60-70 g in
a nulliparous patient. In a non-pregnant state, a woman’s uterus can hold
up to 10mL of fluid. Its walls are composed of several overlapping layers of
muscle fibers that adapt to the developing fetus and help in expulsion of
the fetus and placenta during labor and birth.
First trimester : the pear shaped uterus lengthens and
enlarges in e=response to elevated levels of estrogen and
progesterone. This hormonal stimulation primarily increases in
cell number (hyperplasia) also occurs. These changes increase
the amount of fibrous and elastic tissue to more than 20 times
that of the nonpregnant uterus. Uterine walls become stronger
and more elastic.

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Janet Alexis A. De los Santos, RN, MAN
 : during the first few weeks of pregnancy, the
uterine walls remain thick and the fundus rests low in the
abdomen. The uterus can’t be palpated through the abdominal
wall. After 12 weeks of pregnancy, however, the uterus typically
reaches the level of the symphysis pubis and may be palpated
through the abdominal wall.
Second trimester: the corpus and fundus become globe-
shaped. As pregnancy progresses, the uterine walls thin as the
muscle stretch and rises out of the pelvis, shifts to the right and
rests against the anterior abdominal wall. At 20 weeks gestation,
the uterus is palpable just below the umbilicus and reaches the
umbilicus and reaches the umbilicus at 22 weeks gestation. As
uterine muscles stretch, Braxton Hick’s contractions may occur,
helping to move the blood more quickly through the intervillous
spaces of the placenta.
Third trimester : the fundus reaches nearly to the xiphoid
process. Between week 38 and 40, the fetus begins to descend
into the pelvis (lightening), which causes fundal height to
gradually drop. The uterus remains oval in shape. Its muscular
walls becomes progressively thinner as it enlarges, finally
reaching a muscle wall thickness of 5mm or less. At term (40
weeks), the uterus typically weighs approximately 1,100g
(2lbs), holds 5 to 10 L of fluid, and has stratched to
approximately 28cmx24cmx21cm.

FUNDAL HEIGHT THROUGHOUT PREGNANCY

• Endomerial Development
During the menstrual cycle, progesterone stimulates increased
thickening and vascularity of the endometrium, preparing the uterine
lining for implantation and nourishment of a fertilized ovum. After
implantation, menstruation stops. The endometrium then becomes the
decidua which is divided into three layers:
1. Decidua capsularis – covers the blastocyst (fertilized ovum)
2. Decidua basalis- lies directly under the blastocysts and forms
part of the placenta
3. Decidua vera- lines the rest of the uterus.
• Vascular growth
By the end of pregnancy, an average of 500ml of blood may flow
through the maternal side of the placenta each minute. Maternal arterial
pressure, uterine contractions, and maternal position may affect uterine
blood flow throughout pregnancy.
• Cervical changes
The cervix consists of connective tissue, elastic fibers and
endocervical folds. This connection allows it to stretch during childbirth.
During pregnancy, the cervix softens. It also takes on bluish color during
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 the second month due to increases vasculature. It becomes edematous
and may bleed easily on examination or sexual activity.
During pregnancy, hormonal stimulation causes the glandular
cervical tissue to increase in cell number and become hyperactive,
secreting thick, tenacious mucus. This mucus thickens into a mucoid
weblike structure, eventually forming a mucus plug that blocks the
cervical canal. This creates a protective barrier against bacteria and other
substances attempting to enter the uterus.
• Vagina
During pregnancy, estrogen stimulates vascularity, tissue
growth, and hypertrophy in the vaginal epithelial tissue. White thick,
odorless and acidic vaginal secretions increases. The acidity of these
secretions helps to prevent bacterial infections but unfortunately, also
fosters yeast infections, a common occurrence during pregnancy.
Other vaginal changes include:
a. Development of bluish discoloration
b. Hypertrophy of the smooth muscle and relaxation of
connective tissues, which allow the vagina to stretch
during childbirth
c. Lengthening of the vaginal vault
d. Possible heightened sexual sensitivity.
• Breast
In addition to the presumptive sign that occur in the breasts
during pregnancy (such as tenderness, tingling, darkening of the
areola, and appearance of Montgomery’s tubercles), the nipples
enlarge, become erectile, and darken in color. The areole widen from a
diameter of less than 3cm to 5 or 6 cm in the primigravid patient.
Rarely, patches of brownish discoloration appear on the skin
adjacent to the areola. This patches, known as secondary areola, may
indicate pregnancy if the patient has never breast-fed an infant.
As blood vessels enlarge, veins beneath the skin of the breast
become more visible and may appear as intertwining patterns over the
anterior chest wall.
Increasing hormones cause the secretion of colostrum (a
yellowish viscous fluid) from the nipples. High protein, antibodies, and
minerals- but low in fat and sugar relative to mature human milk-
colostrum may be secreted as early as 16th week of pregnancy, but it’s
most common during the last trimester. It continues until 2-4 days
after delivery and is followed by mature milk production.

II. ENDOCRINE CHANGES

• Placenta
: a large endocrine organ that produces a large amounts of
estrogen, progesterone,
hCG, human placental lactogen (hPL), relaxin, and prostaglandin.
: the estrogen produced by the placenta causes breast and uterine
enlargement as well
as palmar erythema.
: progesterone helps maintain the endometrium by inhibiting uterine
contractility. It
also prepares the breast for lactation by stimulating breast tissue
development.
: relaxin is secreted primarily by the corpus luteum. It helps inhibit
uterine activity. It also helps to soften the cervix, which allows for
dilation at delivery, and softens the collagen in body joints, which
allows for laxness in the lower spine and helps enlarge birth canal.
: secreted by the trophoblast cells of the placenta in early pregnancy,
hCG stimulates progesterone and estrogen synthesis until the placenta
assumes this role.
: Human chorionic somatomammotropin (hPL) is a hormone
produced by the palcenta that promotes breakdown of fat providing
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Janet Alexis A. De los Santos, RN, MAN
 patient an alternate source of energy so that glucose is available for
fetal growth. Along with estrogen, progesterone, and cortisol, hPL
inhibits the action of insulin needed throughout pregnancy.
• Prostaglandin
: found in high concentration in the female reproductive tract and
the decidua
during pregnancy. They affect smooth muscle contractility to
such an extent that
they may trigger labor at the pregnancy’s term.
• Pituitary Gland
: high estrogen and progesterone levels in the placenta stop the
pituitary gland from producing follicle stimulating hormone and
leutinizing hormone. Increased production of growth hormone and
melanocyte-stimulating hormone causes skin pigment changes.
: late in pregnancy, the posterior pituitary gland begins to produce
oxytocin, which stimulates uterine contractions during labor.
Prolactin production also starts late in pregnancy as the breast
prepare for lactation after birth.
• Thyroid Gland
:As early as the second month or pregnancy, the thyroid gland’s
production of thyroxine-binding protein increases, causing total
thyroxine (T4) levels to rise. Because the amount of unbound T4
doesn’t increase, these thyroid changes don’t cause hyperthyroidism;
however they increase BMR, cardiac output, pulse rate, vasodilation,
and heat tolerance. BMR increases by about 20% during the second
and third trimester as the growing fetus places additional demands for
energy on the woman’s system. By term, the woman’s BMR may
increase by 25%.
• Parathyroid Gland
: fetal demands for calcium and phosphorus increases causing the
increase release of these hormones by the parathyroid gland during
the third trimester, as much as twice the prepregnacny level.
• Adrenal Gland
A. Corticosteroid : some researchers believe that increases corticosteroid
levels suppress inflammatory reactions and help to reduce the
possibility of the woman’s body rejecting the foreign protein of
the fetus. Corticosteroids also help to regulate glucose
metabolism in the woman.
B. Aldosterone : increased aldosterone levels help to promote sodium
reabsorption and maintain the osmolarity of retained fluid. This
indirectly helps to safeguard the blood volume and provide
adequate perfusion pressure across the placenta.
• Pancreas
: although the pancreas itself doesn’t change during pregnancy,
maternal insulin, glucose and glucagon production do. In response to
the additional glucocorticoids produced by the adrenal glands, the
pancreas increases insulin production. Insulin is less effective than
normal because of the antagonistic effects ot estrogen, progesterone,
and hPL.

III. RESPIRATORY SYSTEM

A. Anatomical changes
a. The diaphragm rises by approximately 4cm during pregnancy, which
prevents the lungs from
expanding as much as they normally do. The diaphragm compensates by
increasing its
respiratory excursion ability.
b. The antero-posterior and transverse diameters of the ribcage increase by
approximately 2cm

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 and the circumference increase by 5-7 cm. This expansion is possible
because of the
increases progesterone relaxing the ligaments that join the ribcage. As
uterus enlarges,
thoracic breathing replaces abdominal breathing.
c. Increased estrogen production leads to increased vascularization of the
upper respiratory tract.
As a result the patient may develop: respiratory congestion, voice changes,
epistaxis as
capillaries becomes engorged in the nose, pharynx, larynx, trachea,
bronchi, and vocal cords.
It may also cause swelling of Eustachian tubes to swell, leading to such
problems as impaired
hearing, earaches, and sense of fullness in the ears.

B. Physiological changes
a. Respiratory rate typically remains unaffected in early pregnancy. By third
trimester however,
increases progesterone may increase the rate by approximately two
breaths per minute.
b. Tidal volume (amt. of air inhaled and exhaled) rises throughout pregnancy
as a result of
increased progesterone and increases diaphragmatic excursion. In fact a
pregnant patient
breathes 30%-40% more air during pregnancy.
c. Minute volume (amt of air expired per minute) increases by approx. 50% by
term.
d. An elevated diaphragm decreases functional residual capacity (volume of air
remaining in the
lungs after exhalation), which contributes to hyperventilation. Maternal
hyperventilation is
considered a protective measure that prevents the fetus from being
exposed to excessive
levels of carbon dioxide.
e. Vital capacity (the largest volume of air that can be expelled voluntarily after
maximum
inspiration) slightly increase during pregnancy.
f. During third month of pregnancy, increased progesterone sensitizes
respiratory receptors and
increases ventilation, leading to a drop in carbon dioxide levels. This
increases pH, which might cause mild respiratory alkalosis; however the
decreased level of bicarbonate present in a pregnant woman partially or
completely compensates for this tendency.

IV. CARDIOVASCULAR SYSTEM

A. Anatomical changes
: The heart slightly enlarges probably because of increased blood volume
and cardiac output. As pregnancy advances, the uterus moves up and presses
the diaphragm displacing the heart upward and rotating it on its long axis.

B. Auscultatory changes
: Changes in blood volume, cardiac output, and the size and position of the
heart alter heart sounds during pregnancy. During pregnancy, S1 tends to
exhibit a pronounced splitting, and each component tends to be louder. An
occasional S3 sound may occur after 20 weeks gestation. Many pregnant
patients exhibit a systolic ejection murmur over the pulmonic area.
: Cardiac rhythm disturbances, such as sinus arrhythmia, premature atrial
contractions, and premature ventricular systole, may occur.

C. Hemodynamic changes
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Janet Alexis A. De los Santos, RN, MAN
 1. Heart rate and Cardiac output
: during second trimester, HR gradually increases. It may reach
10-15bpm above the patient’s prepregnancy rate. By the third
trimester, HR may increase 15-20bpm above prepregnant rate.
: Patient may feel palpitations occasionally throughout
pregnancy.
: Increased tissue demands for oxygen and increased stroke
volume raise
cardiac output by up to 50% by the 32nd week of pregnancy. The
increase is highest
when the patient is lying on her side and lowest when she’s lying on
her back. The side
lying position reduces pressure on the great vessels, which increases
venous return to
the heart. Cardiac output peaks during labor, when tissues demand are
greatest.
2. Venous and arterial blood pressure
: When the patient lies on her back, femoral venous pressure
increases
threefolds from early pregnancy to term, This occurs because the
uterus exerts pressure
on the inferior vena cava and pelvic veins, slowing venous return from
the legs and feet.
The patient may feel light-headed if she rises abruptly after lying on
her back. Edema in
the legs and varicosities in the legs, rectum, and vulva may occur.
: Early in pregnancy, increases progesterone levels relax smooth
muscles and dilate arterioles, resulting in vasodilation. Despite the
hypervolemia that occurs during pregnancy, the woman’s blood
pressure doesn’t normally rise because the increased action of the
heart enables the body to handle the increased amount of circulating
blood.
: in most women, blood pressure actually decrease slightly
during the second trimester because of the lowered peripheral
resistance to circulation that occurs as the placenta rapidly expands.
: systolic and diastolic pressures may decrease by 5 to 10
mmHg. The pregnant patient’s blood pressure is at its lowest during
the second half of the second trimester. By term, arterial blood
pressure approaches prepregnancy levels.
3. Circulation and Coagulation
: venous return decrease slightly during the eith month of
pregnancy, and at term, increases to normal levels. Blood is able to
clot more easily during pregnancy and postpartum period because of
increases levels of clotting factors VII, IX, and X.
4. Blood Volume
: Total intravascular volume increases beginning between 10-12
weeks gestation and peaks with approximately a 40% increase
between weeks 32 and 34. This increase can total 5,250mL in a
pregnant patient compared with 4000 ml in a non pregnant patient.
Volume decreases slightly in the 40th week and returns to normal
several weeks after delivery.
: Increase blood volume , which consists of two thirds plasma
and one third RBC, performs several functions. For example:
1. It supplies the hypertrophied vascular system of the
enlarging uterus
2. It provided nutrition for fetal and maternal tissues
3. It serves as a reserve for blood loss during childbirth and
puerperium
As the plasma volume first increases, the concentration of Hgb and
erythrocytes may decline, giving the woman pseudoanemia. The woman’s

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 body compensates for this change by producing more RBCs. The body can
create nearly normal levels of RBCs by the second trimester.

D. Hematologic changes
Pregnancy affects iron demands and absorption as well as RBC, WBC,
and fibrinogen levels. In addition the bone marrow becomes more active
during pregnancy, producing upto a 30% excess of RBCs.
The developing fetus require approximately 350-400mg of iron per
day for healthy growth, but also the mother’s iron requirement increases by
400mg per day. This iron increase is necessary to promote RBC production
and accommodate the increased blood volume that occurs during pregnancy.
The total daily iron requirements of a woman and her fetus amount to
roughly 800mg. Because the average woman’s store of iron is only about
500mg, a pregnant woman should take iron supplements.
Absorption of iron may be hindered during pregnancy as a result of
decreased gastric acidity. In addition, increases plasma volume (from 2,600
ml in a nonpregnant woman to 3,600 ml in a pregnant woman) is
disproportionately greater than the increase in RBCs, which lowers the
patient’s hematocrit (the percentage of RBCs in the whole blood) and
causes anemia. A hematocrit below 35% and hemoglobin level below
11.5g/dl indicate pregnancy-related anemia.
WBC count rises from 7,000 ml before pregnancy to 20,500ml during
pregnancy. The count may increase to 25,000 ml more during labor,
childbirth and the early postpartum period.
Fibrinogen (a protein in blood plasma) is converted to fibrin by
thrombin and is known as coagulation factor I. In a nonpregnant patient,
levels average 250 mg/dl. In a pregnant patient, levels average 450mg/dl,
increasing as much as 50% by term.

V. URINARY SYSTEM
A. Anatomical changes
• Significant dilation of the renal pelves, calyces, and ureters begin as
early as 10weeks gestation probably due to increases estrogen and
progesterone.
• As the uterus goes dextroverted, the uterus and renal pelves becomes
more dilated above the pelvic brim, particularly on the right side.
• The smooth muscle of the uterus undergoes hypertrophy and
hyperplasia and muscle tone decreases, primarily because of the
muscle-relaxing effect of progesterone. These changes slows the flow
of urine through the ureters and result in hydronephrosis and
hydroureter (distension of the renal pelves and ureter with urine),
predisposing the pregnant to UTI.
• Hormonal changes causes the bladder to relax during pregnancy,
permitting it to distend to hold approximately 1,500ml of urine.
B. Functional changes
1. Fluid retention
• Water is retained during pregnancy to help handle the increase in
blood volume and to serve as a ready source of nutrients for the
fetus. This excess fluid also replenishes the mother’s blood volume
in case of hemorrhage.
• To provide sufficient fluid volume for effective placental exchange, a
pregnant woman’s total body water increases about 7.5L from pre
pregnancy levels of 30-40L.
• To maintain osmolarity, the body has to increase sodium
reabsorption in the tubules. To accomplish this, the body’s increased
progesterone levels stimulate the angiotensin-renin system in the
kidneys to increase aldosterone production. Aldosterone helps with
sodium reabsorption. Potassium levels however, remain adequate
despite the increased urine output during pregnancy, because

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 progesterone is potassium-sparing and doesn’t allow excess
potassium to be excreted in the urine.
2. Renal Function
• Urine gradually increase to 60% to 80% more than prepregnancy
output (1,500mL/day)
• Urine specific gravity decreases
• The GFR and Renal Plasma Flow (RPF) begin to increase in early
pregnancy to meet the increased needs of the circulatory system.
• By the second trimester, the GFR and RPF have increased by 30% to
50% and remain at this level for the duration of the pregnancy.
• The rise is consistent with that of the circulatory system increase,
peaking at about 24 weeks gestation. This efficient GFR level leads
to lowered BUN and lowered creatinine levels in maternal plasma.
• An increase GFR leads to increased filtration of glucose into the
renal tubules. Because reabsorption of glucose by the tubule cells
occurs at a fixed rate, glucose sometimes is excreted, or spills into
urine during pregnancy.
• Lactose that is produced by the mammary glands during pregnancy
but is not being used also spills into the urine.
3. Ureter and bladder function
• The uterus is pushed slightly toward the right side of the abdomen
by the increased bulk of the sigmoid colon. The pressure on the right
ureter caused by this movement may lead to urinary stasis and
pyelonephritis (inflammation of the kidney cased by bacterial
infection).
4. Renal Tubular Resorption
• To maintain sodium and fluid balance, renal tubular resorption
increases by as much as 50% during pregnancy. She may
accumulate 6.2 to 8.5L of water to meet the mother’s needs and
that of the fetus.
• Up to 75% of maternal weight gain is due to increased body water in
the extracellular space.
• Amniotic fluid and the placenta account for about one-half of this
amount; increased maternal blood volume and enlargement of the
breasts and uterus account for the rest.
5. Nutrient and Glucose excretion
• Proteinuria can occur during pregnancy because the filtered load of
amino acids may exceed the tubular reabsorptive capacity. When
the renal tubules can’t reabsorb the amino acids, protein may be
excreted in small amounts in the patient’s urine. Values of +1
protein on a urine dipstick aren’t considered abnormal until the
levels exceed 300mg/24hours.
• Glycosuria may also occur as GFR increases without a corresponding
increase in tubular resorptive capacity.

VI. GASTROINTESTINAL SYSTEM

A. Mouth
• Salivary glands become more active especially in the latter half of
pregnancy. The gums become edematous and bleed easily because
of increased vascularity.
• Epulides, also known as gingival granuloma gravidarum, are raised,
red, fleshy areas that appear on the gums as a result of increased
estrogen. They may enlarge, cause severe pain, and bleed
profusely. An epulis that grows rapidly may require excision.
B. Stomach and Intestines
• Decreased gastric tone and motility thus slowing the stomach’s
emptying time and possibly causing regurgitation and reflux of
stomach contents.

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 • Slowed intestinal peristalsis and emptying time of the stomach
leading to heartburn, constipation, and flatulence. Relaxin may
contribute to decreased gastric motility, which may cause a
decreased gastric motility, which may cause a decrease in blood
supply to the GI tract as blood is drawn to the uterus.
• the enlarged uterus puts pressure on the veins below the uterus and
may predispose the patient to hemorrhoids.
C. Galbladder and liver
• Gallbladder empties sluggishly which can lead to reabsorption of
bilirubin into the maternal bloodstream, causing generalized itching
(subclinical jaundice).
• Increased plasma cholesterol level and additional cholesterol
incorporated in bile.
• Hepatic blood flow may increase slightly, causing the livers workload
to increase as BMR increases. Factors within the liver as well as
increased estrogen and progesterone decrease blood flow.
• Some normal changes may include:
o Doubled alkaline phosphatase levels, caused in part by
increased alkaline phosphatase isoenzymes from the placenta
o Decreased serum albumin
o Increased plasma globulin levels, causing decrease in albumin
globulin ratios
o Decreased plasma cholinesterase levels.

Functional changes:
a. Nausea and vomiting (morning sickness) : may be caused by hCG
and/or fatigue
:may also be caused by lack of glucose levels in the blood
or increased estrogen
b. Carbohydrate, lipid and protein metaboliosm
: Plasma lipid levels increasew starting in the first trimester,
rising at term to 40% to 50% above prepregnancy levels.
: Cholesterol, triglyceride, and lipoprotein levels increase as well.

the total concentration of serum proteins decreases, especially

serum albumina sn perhaps, gamma globulin.

VII. Musculoskeletal system

A. Skeleton
• Enlarging uterus tilts the pelvis forward, shifting the patient’s center
of gravity. The lumbosacral curve increases, accompanied by a
compensatory curvature in the cervicodorsal region.
• Increasing sex hormones (and possibly by the hormone relaxin)
relaxes the sacroiliac, sacrococcygeal and pelvic joints.
B. Muscles
• The prominent rectus abdominis muscles 9rectus muscle of the
abdomen) separate, allowing the abdominal contents to protrude at
the midline.
• Occassionally, the abdominal wall may not be able to stretch enough
and the rectus muscles may actually separate. A condition known as
diastasis. If this happens, a bluish groove appears at the site of
separation after pregnancy.
• The umbilicus is stretched by pregnancy to such extent that by the
28th week, its depression becomes obliterated and smooth because
it has been pushed so far outward.
C. Nerves
• In the third trimester, Carpal Tunnel Syndrome may occur when the
median nerve of the carpal tunnel of the wrist is compressed by
edematous surrounding tissue.

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Janet Alexis A. De los Santos, RN, MAN
 • Numbness or tingling in the hands also may result from pregnancy-
related postural changes such as slumped shoulders that pull on the
brachial plexus.

VIII. INTEGUMENTARY SYSTEM

A. Striae gravidarum
• The patient’s weight gain and enlarging uterus, combined with the
action of adenocorticosteroids, lead to stretching of the underlying
connective tissue of the skin, creating striae gravidarum.
• They develop most commonly on the skin covering the breasts,
abdomen, buttocks, and thighs.
• After labor, they typically grow lighter until they appear silvery white
in light-skinned patients and light brown on dark-skinned patients.
B. Pigment changes
• Begins at approximately 8th week of pregnancy, partly because of
melanocyte-stimulating and adrenocorticotropic hormones and partly
because of estrogen and progesterone.
• Melasma and linea nigra
C. Vascular markings
• Tiny bright-red angiomas (vascular spiders) may appear on the
cheeks, neck, arms, face, and legs during pregnancy as a result of
estrogen release, which increases subcutaneous blood flow.

IX. IMMUNE SYSTEM

• Immunologic competency naturally decreases during pregnancy,
most likely to prevent the woman’s body from rejecting the fetus.
• In particular, IgG production is decreased, which increases the risk of
infection during pregnancy. A simultaneous increase in WBC count
may help to counteract the decrease in IgG response.

X. NEUROLOGIC SYSTEM
• Functional disturbances called entrapment neuropathies occur in the
peripheral nervous system as a result of mechanical pressure. Nerves
become trapped and pinched by the enlarging uterus and enlarged
edematous vessel, making them less functional.
• More common in late pregnancy.

PSYCHOSOCIAL CHANGES

Stages of Acceptance
I. Full Embodiment : a woman may become dependent on her
partner or significant
others and may be introspective and calm.
Feelings of ambivalence are common.
II. Fetal Distinction : woman starts to view her fetus as a separate
individual. She begins to accept her new body
image and may even characterize it as being ‘full of
life’. She may become more dependent and closer
on her mother at this stage.
III. Role Transition : the woman prepares to separate from and give up
her attachment to the fetus. She may become more
anxious about labor and delivery. Discomfort and
frustration over the awkwardness of her body may
lead the mother to become impatient about the
impending delivery. During this stage the mother
begins to get ready for the baby and o mentally
prepare for her role as mother.
Factors affecting Acceptance
1. Culture
2. Family
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Janet Alexis A. De los Santos, RN, MAN
 3. Individual
4. The child’s father

Promoting Acceptance of Pregnancy

1. Promote each family member’s self-esteem
2. Elicit questions and concerns from the family and listen to them attentively
3. Discuss the roles and tasks for each family member, affirm their efforts and
inquire about and show concern for each family member’s health care needs.
Make referrals as needed.
4. Involve all family members in prenatal visits, as appropriate.
5. Facilitate communication among family members and offer anticipatory
guidelines about family changes during pregnancy and the postpartum
period.
6. Help to mobilize the family’s resources
7. Offer sexual counseling to the patient and her partner
8. Help the patient maximize her family’s positive contributions and minimize
negative ones.
9. Praise the family’s effort
10.Offer books and other materials that address all family members
11.Promote the family’s prenatal bonding (attachment) with the fetus by sharing
information about fetal development and helping family identify fetal heart
tones, position and movements. Reinforce bonding behaviors, such as patting
the abdomen or talking to the fetus, by asking the patient or her partner to
note and report fetal movements.

FIRST TRIMESTER

• The family’s psychosocial task is to resolve ambivalence

• The first trimester is known as the trimester of ambivalence because parents
experience mixed feelings. Many women have unrealistic ideas about
maternal instincts, expecting to feel only loving , happy thoughts about the
fetus and motherhood. Encourage partners to discuss these feelings to each
other to resolve their grief and fears and enjoy the gratifications of expecting
a child.
• Body image may be a factor depending on a woman’s acceptance of
pregnancy
• Sexual relationship may vary. Some woman are too uncomfortable to enjoy
sexual activity while others may feel sexually stimulated by the freedom from
conception, the joy of conception and the lack of pressure to avoid
pregnancy.
Acceptance of and preparation for fatherhood
The father typically find pregnancy unreal and intangible. The idea of the
fetus may be abstract to him because he can’t observe physical changes in
his partner. Accepting the reality of pregnancy is the father’s main
psychosocial task in the first trimester.

3 types of fathering styles:

1. The Observer style describes a father who’s happy about the
pregnancy and provides much support to his wife. However, due to
personal shyness or cultural values, he doesn’t participate in such
activities.
2. The Expressive style describes a man who shows a strong
emotional response to the pregnancy and wishes to be fully
involved in it. He may experience common pregnancy symptoms
such as nausea, vomiting and fatigue
3. The instrumental style describes a man who takes on the role of
“manager” of the pregnancy. He asks questions and takes pictures
throughout the pregnancy, carefully plans for the birthing event,
prepares to serve as labor coach etc.

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Janet Alexis A. De los Santos, RN, MAN
 Couvades’ Syndrome - describes physical symptom such as backache,
nausea and vomiting experienced by the man that mimic the symptoms
experienced by the pregnant woman.

SECOND TRIMESTER
Psychosocial tasks include:
a. mother-image development
b. father-image development
c. coping with body image and sexuality changes
d. development of prenatal attachment.

THIRD TRIMESTER
During this trimester the woman and her partner must:
a. adapt to activity changes
b. prepare for parenting
c. provide partner support
d. accept body image and sexuality changes
e. develop birth plans
f. prepare for labor.

At this time, the woman needs to overcome any fears she may have
about the unknown, labor pain, loss of self-esteem, loss of control
and death. The technique of dream and fear examination may help
the couple accomplish these tasks

Page 14 Maternal and Child Health Nursing (Introduction)

Janet Alexis A. De los Santos, RN, MAN