General overview: This review of the normal physiological and psychosocial changes occurring during each trimester of pregnancy provides essential components of the database for accurate nursing judgments and anticipatory guidance during the prenatal period. Complications of pregnancy are correlated with the trimester of common occurrence; relationships with other NCLEX^® categories of human function are described.

1. GENERAL ASPECTS OF NURSING CARE
1. Assessment—based on nursing knowledge of the following:
1. Biophysical and psychosocial aspects of conception and gestation.
2. Parameters of normal pregnancy.
3. Risk factors, signs, symptoms, and implications of deviations from normal patterns of maternal and fetal health.
2. Analysis/nursing diagnosis:
1. Knowledge deficit related to normal pregnancy-related alterations (physiological and emotional alterations per trimester).
2. Pain related to normal physiological alterations in pregnancy.
3. Altered elimination related to normal physiological changes during pregnancy (polyuria, constipation).
4. Altered nutrition related to increased metabolic needs due to pregnancy.
5. Impaired adjustment related to altered self-image; anticipated role change; resurgence of old, unresolved conflicts.
3. Nursing care plan/implementation:
1. Goal: emotional support.
1. Encourage verbalization of feelings, fears, concerns.
2. Validate normalcy of behavioral response to pregnancy.
2. Goal: anticipatory guidance.
1. Facilitate achievement of developmental tasks.
2. Strengthen coping techniques for pregnancy, labor, birth. Suggest appropriate resources (preparation for childbirth classes).
3. Goal: health teaching. Describe, explain, discuss:
1. Normal physiological alterations during pregnancy.
2. Common discomforts of pregnancy, management.
4. Evaluation/outcome criteria:
1. Woman takes an active, informed part in her pregnancy-related care.
2. Woman copes effectively with common alterations associated with pregnancy (physiological, psychological, role change).
3. Woman successfully carries an uneventful pregnancy to term.
2. BIOLOGICAL FOUNDATIONS OF PREGNANCY
1. Conception
1. Egg—life span, approximately 24 hours after ovulation.
2. Sperm—life span, approximately 72 hours after ejaculation into female reproductive tract.
3. Conception (fertilization)—usually occurs 12 to 24 hours after ovulation, within fallopian tube.
4. Implantation (nidation)—usually occurs within 7 to 9 days of conception, or about day 21 to 23 of a 28-day menstrual cycle.
5. Ovum—period of conception until primary villi have appeared; usually about 12 to 14 days.
6. Embryo—period from end of ovum stage until measurement reaches approximately 3 cm; 54 to 56 days.
7. Fetus—period from end of embryo stage until birth.
• First Trimester
• Susceptible to teratogens
• Heart functions at 3–4 wk
• Eye formation at 4–5 wk
• Arm and leg buds at 4–5 wk
• Recognizable face at 8 wk
• Brain: rapid growth
• External genitalia at 8 wk
• Placenta formed at 12 wk
• Bone ossification at 12 wk
• Second Trimester
• Less danger from teratogens after 12 wk
• Facial features formed at 16 wk
• Fetal heartbeat heard by 18–20 wk; with a fetoscope/Doppler at 10–12 wk
• Quickening at 18–20 wk
• Length: 10 inches, weight: 8–10 oz
• Vernix: present
• Third Trimester
• Iron stored
  Surfactant production begins in increasing amounts
• Size: 15 inches, 2–3 lb
• Calcium stored at 28–32 wk
• Reflexes present at 28–32 wk
• Subcutaneous fat deposits at 36 wk
• Lanugo shedding at 38–40 wk
• Average size: 18–22 inches, 7.5–8.5 lb at 38–40 wk
2. Anatomical and physiological modifications
1. Bases of functional alterations
1. Hormonal—Table 4-4. Hormones of Pregnancy discusses the effects of estrogen and progesterone during pregnancy. Nursing implications provide the knowledge base for the following:
1. Anticipatory guidance regarding normal maternal adaptations.
2. Early identification of deviations from normal patterns.
2. Mechanical—enlarging uterus→ displacement and pressure; increased weight of uterus and breasts → changes in posture and pressure.
2. Breasts—enlarged darkened areolae; secrete colostrum.
3. Reproductive organs
1. Uterus
1. Amenorrhea. Occasional spotting common, especially at time of first missed menstrual period.
2. Increased vascularity adds to increase in size and softening of the lower uterine segment (Hegar's sign).
3. Growth is due to hypertrophy and hyperplasia of existing muscle cells and connective tissue.
4. Fundal height measurement landmarks:

   Uterus	Nonpregnant	Pregnant (at Term)
   Length	6.5 cm	32 cm
   Width	4 cm	24 cm
   Depth	2.5 cm	22 cm
   Weight	50 gm	1000 gm

2. Cervix
1. Increased vascularity → softening (Goodell's sign) and deepened blue-purple coloration (Chadwick's sign).
2. Edema, hyperplasia, thickening of mucous lining, and increased mucus production; formation of mucous plug by end of second month.
3. Becomes shorter, thicker, and more elastic.
3. Vagina
1. Hyperemia deepens color (Chadwick's sign).
2. Hypertrophy and hyperplasia thicken vaginal mucosa.
3. Relaxation of connective tissue.
4. pH acidic (4.0–6.0).
5. Leukorrhea—nonirritating.
4. Perineum
1. Increases in size—hypertrophy of muscle cells, edema, and relaxation of elastic tissue.
2. Deepened color—increased vascularization/hyperemia.
5. Ovaries
1. Ovum production ceases.
2. Corpus luteum persists; produces hormones to weeks 10 to 12 until placenta "takes over."
3. Alterations affecting fluid-gas transport
1. Cardiovascular system(Table 4-5. Blood Values )
1. Physiological changes
1. Heart displaced upward and to the left.
2. Circulation:
1. Cardiac volume increases by 20% to 30%.
2. Labor—cardiac output increases by 20% to 30%.
3. Hemoglobin and hematocrit values remain between 10 and 14 gm and 35% and 42%; normal drop is 10% during second trimester.
4. Hypercoagulability—increased levels of blood factors VII, VIII, IX, and X.
5. Nonpathological increased sedimentation rate—due to 50% increase in fibrinogen level.
6. Blood pressure should remain stable with drop in second trimester.
7. Heart rate often increases 10 to 15 beats/min at term.
8. Compression of pelvic veins → stasis of blood in lower extremities.
9. Compression of inferior vena cava when supine → bradycardia→ reduced cardiac output, faintness, sweating, nausea (supine hypotension). Fetal response: marked bradycardia due to hypoxia secondary to decreased placental perfusion
2. Assessment:
1. Apical systolic murmur.
2. Exaggerated splitting of first heart sound.
3. Physiological anemia.
4. Dependent edema in third trimester (Table 4-6. Common Discomforts During Pregnancy ).
5. Vena cava syndrome (supine hypotension)—drop in systolic blood pressure may occur due to compression of descending aorta and inferior vena cava when supine.
6. Varicosities (vulvar, anal, leg).
3. Nursing care plan/implementation: Goal: health teaching.
1. Elevate lower extremities frequently.
2. Apply support hose.
3. Avoid excess intake of sodium.
4. Assume side-lying position at rest.
5. Learn signs and symptoms of pregnancy-induced hypertension.
2. Respiratory system
1. Physiological changes:
1. Increased: tidal volume, vital capacity, respiratory reserve, oxygen consumption, production of CO₂.
2. Diaphragm elevated, increased substernal angle → flaring of rib cage.
3. Uterine enlargement prevents maximum lung expansion in third trimester.
2. Assessment:
1. Shortness of breath or dyspnea on exertion and when lying flat in third trimester.
2. Nasal stuffiness due to estrogen-induced edema (see Table 4-6. Common Discomforts During Pregnancy ).
3. Deeper respiratory excursion.
3. Nursing care plan/implementation: Goal: health teaching.
1. Sit and stand with good posture.
2. When resting, assume semi-Fowler's position.
3. Avoid overdistention of stomach.
4. Alterations affecting elimination
1. Urinary system
1. Physiological changes:
1. Relaxation of smooth muscle results in conditions that can persist 4 to 6 weeks after birth:
1. Dilatation of ureters.
2. Decreased bladder tone.
3. Increased potential for urinary stasis and urinary tract infection (UTI).
2. Increased glomerular filtration rate (50%) during last two trimesters.
3. Increased renal plasma flow (25%–50%) during first two trimesters; returns to near-normal levels by end of last trimester.
4. Increased renal-tubular reabsorption rate—compensates for increased glomerular activity.
5. Glycosuria—reflects kidney's inability to reabsorb all glucose filtered by glomeruli (may be normal or may indicate gestational diabetes; glycosuria always warrants further testing).
6. Increased renal clearance of urea and creatinine (creatinine clearance used as test of renal function during pregnancy).
7. Hormone-induced turgescence of bladder and pressure on bladder from gravid uterus (see Table 4-5. Blood Values ).
2. Assessment:
1. Urinary frequency, first and third trimesters (see Table 4-6. Common Discomforts During Pregnancy ).
2. Nocturia.
3. Stress incontinence in third trimester.
3. Nursing care plan/implementation: Goal: health teaching.
1. Void with urge, to prevent bladder distention.
2. Learn signs and symptoms of UTI.
3. Decrease fluid intake in late evening.
4. Perform Kegel exercises to reduce incontinence.
2. Gastrointestinal system(see Table 4-6. Common Discomforts During Pregnancy )
1. Physiological changes:
1. General decrease in smooth-muscle tone and motility due to actions of progesterone.
2. Intestines: slowed peristalsis, increased water reabsorption in bowel.
3. Stomach
1. Gastric emptying time is delayed (e.g., 3 hours vs. 1½ hours).
2. Gastric secretion of HCl and pepsin decreases.
3. Decreased motility delays emptying; increased acidity.
4. Cardiac sphincter relaxes.
5. Increasing size of uterus and displacement of intra-abdominal organs.
6. Gallbladder: decreased emptying.
2. Assessment:
1. Nausea and vomiting in first trimester.
2. Constipation and flatulence.
3. Hemorrhoids.
4. Heartburn, reflux esophagitis, indigestion.
5. Hiatal hernia.
6. Epulis—edema and bleeding of gums.
7. Ptyalism—excessive salivation.
8. Jaundice.
9. Gallstones.
10. Pruritus due to increased retention of bile salts.
3. Nursing care plan/implementation: Goal: health teaching: dietary.
1. Nausea and vomiting
1. Avoid fatty food; increase carbohydrates.
2. Eat small, frequent meals.
3. Eat dry crackers in morning.
4. Decrease liquids with meals.
5. Avoid odors that predispose to nausea.
6. Avoid acidic foods (e.g., citrus, tomatoes).
2. Constipation and flatulence
1. Increase fluids (6–8 glasses/day).
2. Maintain exercise regimen.
3. Add fiber to diet.
4. Avoid mineral oil laxatives.
5. Avoid gas-producing foods (e.g., beans, cabbage).
3. Heartburn and indigestion
1. Eliminate fatty, spicy, or acidic foods.
2. Eat small, frequent meals (6/day).
3. Eat slowly.
4. Avoid gastric irritants (e.g., alcohol, coffee).
5. Avoid lying flat.
6. Take antacids without sodium or phosphorus.
7. Try chewing gum to increase the secretion of alkaline saliva.
8. Wait 2 to 3 hours after meals before lying down.
9. Wear loose-fitting clothes.
4. Hemorrhoids
1.  Increase fluid and fiber intake.
2. Maintain exercise regimen.
3. Avoid constipation and straining to defecate.
4. Take warm sitz baths.
5.  Apply witch hazel pads.
6. Elevate hips and legs frequently.
7. Use hemorrhoidal ointments only with advice of health-care provider.
5. Alterations affecting nutrition
1. Physiological changes:
1. Gastrointestinal system
1. Gingivae soften and enlarge due to increased vascularity.
2. Increased saliva production.
2. Endocrine system
1. Increased size and activity of pituitary, parathyroids, adrenals.
2. Increased vascularity and hyperplasia of thyroid.
3. Pancreas—increased insulin production during second half of pregnancy, needed to meet rising maternal needs; human placental lactogen (HPL) and insulinase deactivate maternal insulin; may precipitate gestational diabetes in women who are susceptible.
3. Metabolism
1. Basal metabolic rate (BMR)—increases 25% as pregnancy progresses, due to increasing oxygen consumption; proteinbound iodine (PBI) increases to 7 to 10 mcg/dL; metabolism returns to normal by sixth postpartum week.
2. Protein—need increased for fetal and uterine growth, maternal blood formation.
3. Water retention—increased.
4. Carbohydrates—need increases to spare protein stores.
1. First half of pregnancy—glucose rapidly and continuously siphoned across placenta to meet fetal growth needs; may lead to hypoglycemia and faintness.
2. Second half of pregnancy—placental production of anti-insulin hormones; normal maternal hyperglycemia; affects coexisting diabetes.
5. Fat—increased plasma lipid levels.
6. Iron—supplements recommended to meet increased need for red blood cells (RBCs) by maternal/placental/fetal unit.
2. Assessment:
1. Weight gain: 20 to 35 lb (11.5–16 kg); depends on body mass index (BMI) and prepregnant nutritional status.
2. Normal pattern: first trimester, 2 to 5 lb (1–2.3 kg); remainder of gestation, approximately 1 lb/wk (0.4–0.5 kg/wk).
3. Nursing care plan/implementation: Goal: health teaching.
1. Evaluate diet for adequacy of nutrient and caloric intake.
2. Evaluate cultural, religious, and economic influences on diet.
3. Review dietary recommendation for pregnancy with woman.
4. Avoid dieting in pregnancy (even if obese).
5. Supplement diet with vitamins, iron, or folic acid on advice of health provider.
6. Ptyalism:
1. Suck hard candies.
2. Perform frequent oral hygiene.
3. Maintain adequate oral intake (6–8 glasses/day).
4. Use lip balm to prevent chapping.
7. Epulis:
1. Frequent oral hygiene.
2. Use soft toothbrush.
3. Floss gently.
4. See dentist regularly.
6. Alterations affecting protective functions—integumentary system
1. Physiological changes—estrogen-induced vascular and pigment changes.
2. Assessment:
1. Increased pigmentation (chloasma and linea nigra).
2. Striae gravidarum (stretch marks).
3. Increased sebaceous and sweat gland activity.
4. Palmar erythema.
5. Angiomas—vascular "spiders."
3. Nursing care plan/implementation: Goal: health teaching.
1. Bathe or shower daily.
2. Reassure woman that skin changes decrease after pregnancy.
7. Alterations affecting comfort, rest, mobility—musculoskeletal system
1. Physiological changes
1. Progesterone, estrogen, and relaxin-induced relaxation of joints, cartilage, and ligaments.
2. Function in childbearing—increases anteroposterior diameter of rib cage and enlarges birth canal.
2. Assessment:
1. Complaint of pelvic "looseness."
2. Duck-waddle walk.
3. Tenderness of symphysis pubis.
4. Lordosis (exaggerated lumbar curve)—increased weight of pelvis tilts pelvis forward; to compensate, woman throws head and shoulders backward; complaint of leg and back strain and fatigue (see Table 4-6. Common Discomforts During Pregnancy ).
5. Feet often increase by half a shoe size or more.
3. Nursing care plan/implementation: Goal: health teaching.
1. Good body alignment—tuck pelvis under; tighten abdominal muscles.
2. Pelvic-rock exercises.
3. Squat; bend at knees, not at waist.
4. Wear low-heeled, sturdy shoes.
5. Avoid tight-fitting clothing that interferes with circulatory return in legs.
3. PSYCHOSOCIAL-CULTURAL ALTERATIONS
1. Emotional changes—affected by: age, maturity, support system, amount of current stresses, coping abilities, physical and mental health status. Developmental tasks of pregnancy:
1. Accept the pregnancy as real: "I am pregnant"; progress from symbiotic relationship with the fetus to perceiving the child as an individual.
2. Seek and ensure acceptance of child by others.
3. Seek protection for self and fetus through pregnancy and labor ("safe passage").
4. Prepare realistically for the coming child and for necessary role change: "I am going to be a parent."
2. Physical bases of changes
1. Increased metabolic demands may result in anemia and fatigue.
2. Increased hormone levels (steroids, estrogen, progesterone)—affect mood as well as physiology.
3. Characteristic behaviors—Table 4-7. Behavioral Changes in Pregnancy describes behaviors commonly exhibited in each trimester.
4. Sexuality and sexual expression—feelings and expressions of sexuality may vary during pregnancy due to maternal adaptations and physiological changes.
5. Intrafamily relationships
1. Pregnancy is a maturational crisis for the family.            
2. Requires changes in lifestyle and interactions:
1. Increased financial demands.
2. Changing family and social relationships.
3. Adapting communication patterns.
4. Adapting sexual patterns.
5. Anticipating new responsibilities and needs.
6. Responding to reactions of others.

• Prenatal Management
• Antepartum
• Lifestyle Choices and Influences that Impact Health in Pregnancy, Intrapartum, Postpartum, and Newborn
• Common Complications of Pregnancy