Suzanne al-amro

Maternity course
KHMC
 1.presumitive: nausea, vomit, fatigue, breast
change, amenorrhea.
 2. probable: hegar sign, ballottement,

pregnancy test.
 3.positive:FHS, fetal movement, visualization

of fetus.
 Signs of pregnancy
Positive Probable Presumptive
Fetal heart Goodell’s Amenorrhea
sounds, Hegar’s Nausea &
Outline & Chadwick's sign, vomiting
move on ballottement Urinary
ultrasound braxton hicks frequency
contractions Quickening
+preg test Uterine
enlargement
Pigmentation
changes
 Goodell sign : softening of the cervical tip
hypertrophy, hyperplasia, increase in
vascularity,edematous.
 Chadwick sign: violet –bluish color of
vaginal mucosa (increase vascularity)
 Leukorrhea: white (epithelial cell) or slightly
gray mucoid discharge with faint musty odor
occur in response to estrogen and
progesterone.
 Operculum: mucus fills the endocervical
canal act as barrier against bacterial
invasion during pregnancy like plug.
 During pregnancy the PH is more acidic (3.5
-6) because increase production of lactic
acid caused by lactobacillus acido philus
that work on glycogen in ephiythelium,and
from increase of estrogen.
 Many physiological changes occur during
pregnancy such as minor symptoms or
discomforts. These discomforts do not need
for medical management but need
observation and education.
 Two major sources of physiological changes
during pregnancy are changes in the
endocrine system and physical changes in the
body
 The high level of the hormones during
pregnancy affects all the body systems.
 Hormones essential in pregnancy:
 Estrogen: produced by ovaries and placenta.
 Responsible for: enlargement of uterus,
breast, genitals, promotes fat deposit
changes, stimulates melanocyte-stimulating
hormone in hyper pigmentation of skin.
Promotes vascular changes and
developments of striae gravidarum.
 Produced by corpus luteum, and ovary and
later by the placenta.
 Maintains edometrium for implantation.
 Inhibits uterine contractions, prevent
abortion.
 Promotes development of secretory ducts of
breasts for lactation.
 Stimulate sodium secretion reduces smooth
muscle tone ( causing constipation,
heartburn)
 Secreted by the thyroid gland.
 Increases basal metabolic rate 23% during

pregnancy.
 Produced in early pregnancy by trophoblastic
tissue.
 Stimulates progesterone and estrogen

production by corpus luteum to maintain

pregnancy until placenta take over.
 Used In pregnancy test to determine

pregnancy state.
 Produced by placenta.
 Affects glucose and protein metabolism.
 has a diabetogenic effect allows increased

glucose to stimulate pancreas and insulin

level.
 Produced by anterior pituitary gland.
 Causes pigmentation of the skin to darken.
 Chloasma, linea nigra, darken of nipples and

areolae.
 Produced by corpus luteum and placenta.
 Causing connective tissue of symphsis pubis

to be more movable and cervix to soften.

 Inhibits uterine activity.
 Prepares breast for lactation.
 Produced by posterior pituitary gland.
 Stimulate uterine contractions.
 During pregnancy is inhibited by

progesterone.
 After birth helps uterine contracted.
 Stimulates milk ejection reflex during

breastfeeding.
 Before pregnancy: small, semi solid, pear shape, wt
about 60g.
 At the end of pregnancy: thin walled, ease to
palpate the fetal parts, contains fetus, placenta,
amniotic fluids) weight about 1000g due to
hyperplasia and hypertrophy.
 The circulatory requirements of the uterus increase
as it enlarges and the fetus and placenta develop.
 The growth and position of the uterus provides
information about fetal growth and EDD.
 12 weeks can be felt above symphysis pubis.
 Braxton Hicks contractions: irregular, painless
contractions, help move the blood through
the placenta to the fetus.
 Become shorter and softer during
pregnancy.
 During labor effacement (thinning cervix),
and dilatation the opining of the internal os
to permit the fetus to pass from the uterus
at birth.
 The softening of the cervix is due to:
hormonal, increase secretion from the
cervical glands ( operculum) act as barrier
to prevents organisms from entering the
uterus.
 During pregnancy follicles in the ovaries
cease to develop to maturity.
 Ovulation dose not occur.
 Corpus luteum persists and produce estrogen

and progesterone until the placenta develop.

 During pregnancy proliferation of the cells
and hyperemia of the vaginal connective
tissue, which allows to become more
elastic, thickens.
 The vaginal discharges increases

( leucorrhea), bring greater amount of

glycogen, this increase the risk for infection
such as Candida albicans.
 Also the vaginal PH decreases  prevent

growth of microorganisms.
 All changes due to increased hormonal
activity.
 The breasts rapidly enlarges in the first 8

weeks, mostly from vascular engorgement.

 estrogen ductal growth.
 progesterone  alveolar hyper trophy.
 Size increases, breasts become full, sensitive,
and tender.
 Increase in pigmentation.
 Montgomery's glands become more

prominent and lubricate.

 Striae may occur.
 Colostrums a thin yellowish fluid excreted at

12-16 wks until 3-5 days after delivery.

 Progesterone and relaxin causes relaxing
and softening of the pelvic joints and
widening of the symphysis pubis.
 The widening facilitates passage of the

fetus through the pelvis in preparation for

vaginal delivery.
 As the uterus enlarges, the woman's center

of gravity shifts forward. Woman develop

progressive lordosis ( low back pain,
imbalance)
 Abdominal muscles are stretched during
pregnancy, the rectus abdominis muscle to
separate, causing condition called diastasis
recti abdominis.
 Increase weight and edema can produce
compression of the medial nerve ( carpal
tunnel syndrome. S&S includes: pain,
numbness, weakness and decrease in motor
function.
 Weight: increased during pregnancy about12
kg.
 Expected increase;
 2 kg in the 1st 20 weeks.
 0.5 kg until term.
3.4 Kg Baby
1 Kg Uterus
,6 Kg Placenta
1.5 Kg Blood volume increase in mother
,6 Kg Amniotic fluid
1 kg ECF

,5 Kg Breast tissue increase

3.5 Kg Increased fat stores in mother
12.5 Kg Total Average
 In early and late pregnancy increase
frequency duo to increase bladder
compression.
 Urine stasis increase the risk for infection
 Thoracic circumference increased during
pregnancy , because of the relaxation of the
ligaments ( progesterone) and the flaring of
the lower ribs.
 Elevation of the diaphragm 4 cm in late
pregnancy but the lung capacity remains
the same.
 Increase respiratory rate, more deep, more
frequent to increase O2 intake.
 Breathing changes from abdominal to
thoracic as pregnancy progresses.
 Dyspnea: is a common complaint due to
pressure on the diaphragm and due to
increase sensitivity of the respiratory
caused by increased progesterone level.
 Epistaxis: Nasal bleeds and congestion

occurs increased vascularity from estrogen.

 Change of the voice more deep due to

increase the size of the vocal cord caused

by increased progesterone.
 Gum hypertrophy may occur .
 Estrogen affect on the gum and makes them
spongy and easy to bleed, dental problem,
increased salivation( ptyalism) change in
sense of taste.
 Increased in appetite and thirst to facilitate
fetal growth.
 Nausea and vomiting occur early due to
increased estrogen and HCG.
 Progesterone relaxes smooth muscle this
has major effect on the gut.
 Gastric emptying and peristalsis are slowed
to increase absorption of nutrients.
 Heart burn due to relaxation of the cardiac

sphincter.
 Constipation due to decrease bowel

movement.
 Metabolic changes:
 CHO metabolism alters allowing maternal

tissue to be more resistant to insulin and

allowing the fetus to have a source of high
energy in the form of glycogen.
 Fat metabolism alter to facilitates growth of

the fetus and provides maternal stores for

lactation.
 Skin undergoes hyper pigmentation.
 Chlosma, linea nigra, striae gravidarum.
 Nipples, areolae, vulva, and perineum al
darken.
 Increased blood supply sweating and
feeling of hotness in pregnancy due to the
effect of the progesterone vasodilatation
and increase temp 0.5C.
 Increase hair growth.
 Blood vessels have increased permeability
causing palmer erythema, and formation of
spider nevi.
 Changes in the CVS are essential to deliver
O2 and nutrients to the growing fetus and
the enlarging uterus.
 Laying on her back decrease cardiac output

due to compression on the inferior vena

cava (supine hypotension syndrome).
 Heart is displaced by elevation of

diaphragm.
 Cardiac output is double, and there is a

30%-50% increase in blood volume.

 10% of the maternal CO is channeled to
uterine flow in the 3rd trimester.
 Blood clotting factors increases.
 Plasma and RBCs volumes increases.
 Pulse rate and stroke volume increase.
 Blood pressure dose not increase.
 Pregnancy is a profound event in the life of woman
and her family need to redefining their roles. The
emotional and physical adjustments of pregnancy
lead to increase level of anxiety and stress.
 Some factors that contributes to either positive or
negative psychological response during pregnancy:
 Body image.
 Emotional security.
 Cultural expectation.
 Support system.
 Increased level of hormone contributes to mood
swings.
 Body image:
 Appearance: feeling ugly, fat, happy.
 Function: negative response when the
pregnant feels losing control urinary
incontinence need explanation.
 Sensation: may become more acute, may be
more sensitive to touch, change in sexuality
and libido.
 Mobility: when the woman feels restricted in
her usual routine physical activity.
 In the first trimester:
 Nausea with or without vomiting :
 Influencing factors :
 Increased in hormone level (progesterone &

relaxin hormone  decreased gastric motility

, fatigue , emotional factor (usually disappear
between 12-16 wks) if persist lead to
hyperemesis gravidarum.
 Avoid an empty stomach, eat salty biscuits or
toast ½ to 1 hrs before rising in the morning
 Small frequent meals
 Drink fluids between meals
 Increased vit B6
 Avoid greasy , spicy, and gas forming foods
 Causes :  pressure in the urinary bladder
 Care : void when urge is felt , increase

fluids , decrease fluids in late evening & limit

caffeine intake.
 Causes: increase the vascular supply And
hypertrophy of breast tissues
 Tingling , fullness & tenderness.
 Care : wear a supportive bra & avoid soap

the nipples (to prevent cracking).

 Leukorrhea
 Causes :increased production of mucus from
endocervical glands, and increase blood supply to
the pelvis (white discharge)
 Care :
 Daily bathing
 Wear cotton clothes
 Avoid tight clothes
 Keep the perineal area clean
 Avoid doucing & tempons
 Inform the doctor if there is any changes
 Care :
 Sitting position for 30 min after eating , avoid over
eating
 Avoid gas-forming and greasy food
 Use low sodium liquid antiacid
 Avoid NaHCO3.
 One large study involving 607 pregnant women
reported an increased frequency of heartburn with
gestation, with 39% of women reporting heartburn
in the second trimester, and 72% in third trimester.
(The National Collaborating Centre Women’s and children Health
2003)
use of antacids :An RCTof antacid treatment
compared with placebo found that 80% of
women reported relief of heartburn pain
within one hour compared with 13% from the
placebo group.
 Causes :
 Increased levels of hormones
 Increased water absorption  hard stool
 Pressure of enlarging uterus
 Diet , decrease exercise , decrease fluids & iron supplement
 Care : increase fluids but not including carbonate or caffeine
 it has a diuretic effect , fibre diet & exercise , daily habits ,
decrease cheese intake.
 Don’t take mineral oil or enemas.
 No evidence was found for the effectiveness or safety of
osmotic laxatives (e.g. lactulose) or softeners for use in
pregnancy.
(The National Collaborating Centre Women’s and children Health 2003)
 Causes: relaxation of calf muscle
 Wight that compression on the leg
 Hormones effect
 Care : avoid standing or sitting for long time &
constrictive clothing
 Walk frequently
 Rest with legs elevated
 Wear sport stocking (avoid tight knee highs &
exercise).
 Avoid bearing down during bowel movement.
 Relieve haemorrhoid swelling with worm sitz bath
& analgesic ointment
 Causes : relaxation of the muscle
 Compression from gravida
 Care : sleep with several pillows under head ,

keep breathing , use proper posture while

sitting or standing
 Avoid exertion
 Causes : postural hypotension
 Standing for long period with venous stasis
 Care :
 Avoid sudden changes in position, prolong

standing
 Warm crowded area
 Avoid hypoglycaemia & lie on Lt side
 Causes : circulatory congestion if persist 
indicate PIH
 Care :
 Elevate legs when sitting
 Increase rest period
 Avoid constriction clothing & standing or

sitting for long time

 Causes : pressure of uterus on blood vessels ,
decrease blood supply to legs  muscle
strain & fatigue , imbalance in Ca & ph ratio
 Care :dorsiflex foot , straight leg with down

word pressure on knee on stand with the feet

flat on floor
 Causes : abdominal ligament are stretched by
enlarging uterus  pain in lower abdomen
after sudden movements.
 Care :
 Avoid sudden movement
 Use pillow support for abdomen
 Use body mechanism
 Causes : increased circulatory blood volume
and heart rate  causes dilatation &
distension of cerebral vessels
 Fatigue & tension causes.
 Care :
 Emotional support , relaxation , exercises ,

eat regular diet (if continue report to the care

giver)
 Causes :
 Hormonal changes , periodic hypoglycemia 

more prominent in early pregnancy

 Care :
 Sleep from 8-10 hrs & take naps during the

day , relaxation techniques , medication .

 Causes : pelvic congestion & increase
vascularity, constipation , descent of fetal
head in to the pelvis
 Disappear after birth
 Care :
 Use anaesthetic ointment
 Cool witch-hazel pads or rectal suppositories
 Sitz bath , increase fiber diet , daily habits
 Causes : spins adaptation to posture change as the uterus
enlarge
 Alters centre of gravity  strain
 Care :
 Correct posture shoulders back & head up & use body
mechanism
 Do exercise , localized heat
 Squat rather than bending over picking up objects
 Wear comfortable shoes.
 prevalence of backache during pregnancy ranges between
35% and 61%. Among these women, 47–60% reported
backache first developing during the 5th to 7th months of
pregnancy. It was also reported that the symptoms of
backache were worse in the evenings. (Young & Jewell.2003)
 Teaching the women how to carry out self
care & report any changes
 So we must provide information to the

women & her family about changes that

occurs during pregnamcy, labour , birth &
after delivery & reviews positive health
practices .
 Excessive sweating due to hormonal effect
 Excessive vaginal discharge (leukorrhea)
 Teaching :
 Frequent baths or showers , tub bath may
become in late pregnancy not suitable
 She Should consider safety measures rubber
mats and hand rails
 Avoid bathing in hot tubs
 Tub bath is contraindicated when ruptured
membranes or mucus plug is expelled
 Encourage to continue some kind of physical
activity to improve her physical and psychological
status
 Strength her muscles without the risk of joint &
muscle injuries
 Mild to moderate & regular exercise as walking
swimming , cycling.
 Benefits from exercises during the pregnancy.
 RCT done in 2007 by cooker and his colleagues in
second trimester .
 Aerobic physical activity in pregnancy may be an
important determinant of birth weight within the
normal range, especially in taller mothers .
(Kramer et al 2004)
 If high temp result in decreased fetal
circulation & cardiac function
 Maternal body temp should not exceed 38 ,

avoid hot tub sauna

 Teach to monitor the baby temp and any

changes
 Flat position
 Increasing uterine wt & size
 Orthostatic hypotension can occur 
decrease flow of the blood to the fetus
 Cardiac out put :
 During increased workload
 If hard exercise increased cardiac work load
because the blood diverted from the uterus
causing fetal hypoxia.
 during exercise increased catecholamine
levels cross the placenta  fetal
bradycardia , hypoxia
 If decreased in uterine blood flow exceeds
50% adverse effects to the fetus  because
increase uterine O2 up take
 Exercises cause changes in O2 consumption &
others hormone such as cortisol , prolactin &
epinephrine
 Early in pregnancy the changes in the hormone
level can effect implantation & vascularity.
 In late pregnancy the increase in catecholamine
during exercise can stimulate the labour.
 Joint instability due to hormonal changes can
lead to injuries if engages in or demonstrate
deep flexion or extension of the joint.