PHYSIOLOGIC CHANGES OF PREGNANCY before term (the 38th week) for a primigravida, a woman

Physiologic changes that occur with pregnancy are both in her first pregnancy, the fetal head settles into the pelvis
local (uterine, ovarian, and vaginal changes) and systemic to prepare for birth, and the uterus returns to the height it
(respiratory, cardiovascular, urinary, and skin changes). was at 36 weeks. This event is termed lightening, because
● Women may have read about the expected psychological a woman’s breathing is so much easier it seems to lighten a
and physiologic changes of pregnancy, but once these woman’s load. When lightening will occur is not predictable
changes are actually being experienced, they may find in a multipara (a woman who has had one or more
them more intense than anticipated. children). In these women, it may not occur until labor
begins.
Physiologic changes that occur during pregnancy can be Changes in fundal height during pregnancy are shown in
categorized as local (confined to the reproductive organs) or Figure 10.2. Uterine height is measured from the top of the
systemic (affecting the entire body). Both symptoms (subjective symphysis pubis to over the top of the uterine fundus
findings) and signs (objective findings) of the physiologic (Neilson, 2009). Because a uterine tumor could mimic this
changes of pregnancy are used to diagnose and mark steady growth, uterine growth is only a presumptive sign of
the progress of pregnancy. Table 10.3 summarizes the pregnancy.
physiologic changes that occur in body organs or systems The exact shape of the expanding uterus is influenced by
during a typical 40-week pregnancy. the position of the fetus inside. The fundus of the uterus
Reproductive System Changes
Reproductive tract changes are those involving the uterus,
ovaries, vagina, and breasts.
Uterine Changes
The most obvious alteration in a woman’s body during
pregnancy
is the increase in the size of the uterus to accommodate
the growing fetus. Over the 10 lunar months of pregnancy,
the uterus increases in length, depth, width, weight, wall
thickness, and volume.
• Length increases from approximately 6.5 to 32 cm.
• Depth increases from 2.5 to 22 cm.
• Width expands from 4 to 24 cm.
• Weight increases from 50 to 1000 g.
• Early in pregnancy, the uterine wall thickens from about
1 cm to about 2 cm; toward the end of pregnancy, the
wall thins to become supple and only about 0.5 cm thick.
• The volume of the uterus increases from about 2 mL to
more than 1000 mL. The uterus can hold a 7-lb (3175-g)
fetus plus 1000 mL of amniotic fluid for a total of about
4000 g at term.
This great uterine growth is due partly to formation of a
few new muscle fibers in the uterine myometrium but principally
to the stretching of existing muscle fibers: by the end
of pregnancy, muscle fibers in the uterus have become two to
seven times longer than they were before pregnancy. The
uterus is able to withstand this stretching of its muscle fibers
because of the formation of extra fibroelastic tissue between
fibers, which binds them closely together. Because uterine
fibers simply stretch during pregnancy and are not newly
built, the uterus is able to return to its prepregnant state at
the end of the pregnancy with little difficulty and almost no
destruction of tissue (Kahn & Koos, 2007).
A woman becomes aware of her growing uterus early in
pregnancy; by the end of the 12th week, the uterus is large
enough to be palpated as a firm globe under the abdominal
wall, just above the symphysis pubis. An important factor
to assess regarding uterine growth is its constant, steady,
predictable increase in size. By the 20th or 22nd week of
pregnancy, for example, it should reach the level of the
umbilicus. By the 36th week, it should touch the xiphoid
process and can make breathing difficult. About 2 weeks
 (Rojas, Wood, & Blakemore, 2007).

usually remains in the midline during pregnancy, although it

may be pushed slightly to the right side because of the larger
bulk of the sigmoid colon on the left. As the uterus increases
in size, it pushes the intestines to the sides of the abdomen, During the 16th to 20th week of pregnancy, when the
elevates the diaphragm and liver, compresses the stomach, fetus is still small in relation to the amount of amniotic fluid
and puts pressure on the bladder. present, ballottement (from the French word balloter, meaning
“to toss about”) may be demonstrated. On bimanual
Uterine blood flow increases during pregnancy as the placenta examination, if the lower uterine segment is tapped sharply
grows and requires more and more blood for perfusion. by the lower hand, the fetus can be felt to bounce or rise in
Doppler ultrasonography has shown that, before pregnancy, the amniotic fluid up against the top examining hand.
uterine blood flow is 15 to 20 mL/min. By the end of pregnancy, Although this phenomenon is interesting, it also may be simulated
it expands to as much as 500 to 750 mL/min, with by a uterine tumor, and therefore it is no more than a
75% of that volume going to the placenta. Measuring that probable sign of pregnancy. Between the 20th and 24th week
placenta blood volume and velocity is increasing this way is of pregnancy, the uterine wall has become thinned to such a
one of the most important gauges of fetal health (Gonzalez et degree that a fetal outline within the uterus may be palpated
al., 2007). by a skilled examiner. Because a tumor with calcium deposits
Toward the end of pregnancy, one-sixth of a woman’s could simulate a fetal outline, palpation of a uterine mass,
blood supply is circulating through the uterus at any given like other uterine assessments, does not constitute a sure
time; therefore, uterine bleeding in pregnancy is always confirmation
potentially serious because it could result in a major blood of pregnancy.
loss. Uterine contractions begin early in pregnancy, at least
A bimanual examination (one finger of an examiner is by the 12th week, and are present throughout the rest of
placed in the vagina, the other hand on the abdomen) can pregnancy, becoming stronger and harder as the pregnancy
demonstrate that, with pregnancy, the uterus feels more advances. They may be felt by a woman as waves of hardness
anteflexed, larger, and softer to the touch than usual. At or tightening across her abdomen. An examining hand
about the sixth week of pregnancy (at the time of the second may be able to feel a contraction as well, and an electronic
missed menstrual period), the lower uterine segment just monitor will be able to measure the frequency and length of
above the cervix becomes so soft that when it is compressed such contractions. These “practice” contractions, termed
between examining fingers on bimanual examination, the Braxton Hicks contractions, serve as warm-up exercises
wall cannot be felt or feels as thin as tissue paper. This extreme for labor and also increase placental perfusion. They may
softening of the lower uterine segment is known as become so strong and noticeable in the last month of pregnancy
Hegar’s sign (Fig. 10.4). It is a probable sign of pregnancy that they are mistaken for labor contractions (false
labor). They can be differentiated from true labor contractions
on internal examination because they do not cause
cervical dilation (Bernstein & Weinstein, 2007). Although
these contractions are always present with pregnancy, they
also could accompany any growing uterine mass; so, like
ballottement, they are no more than a probable sign of addition to a cream cheese–like discharge. A nonpregnant
pregnancy. woman needs medication for such an infection to relieve discomfort.
Amenorrhea A pregnant woman needs medication not only to
Amenorrhea (absence of menstruation) occurs with pregnancy relieve discomfort but also to prevent transmission of the infection
because of the suppression of follicle-stimulating hormone to the newborn as it passes through the birth canal at
(FSH) by rising estrogen levels. In a healthy woman term. Candidal infection in the newborn is termed thrush or
who has menstruated previously, the absence of menstruation oral monilia. Therapy for this infection is discussed in
strongly suggests that impregnation has occurred. Chapter 43.
Amenorrhea, however, also heralds the onset of menopause Ovarian Changes
or could result from delayed menstruation because of unrelated Ovulation stops with pregnancy because of the active feedback
reasons, such as uterine infection, worry (perhaps over mechanism of estrogen and progesterone produced by
becoming pregnant), a chronic illness such as severe anemia, the corpus luteum early in pregnancy and by the placenta
or stress. It occurs in athletes who train strenuously, especially later in pregnancy. This feedback causes the pituitary gland
in long-distance runners whose percentage of body fat to halt production of FSH and luteinizing hormone (LH).
drops below a critical point. Amenorrhea is, therefore, only a Without stimulation from FSH and LH, ovulation does not
presumptive sign of pregnancy. occur.
Cervical Changes The corpus luteum that was created after the ovulation
In response to the increased level of circulating estrogen from that led to the pregnancy continues to increase in size on the
the placenta during pregnancy, the cervix of the uterus becomes surface of the ovary until about the 16th week of pregnancy,
more vascular and edematous. Increased fluid between by which time the placenta takes over as the chief provider of
cells causes it to soften in consistency, and increased vascularity progesterone and estrogen. The corpus luteum, no longer essential
causes it to darken from a pale pink to a violet hue. The for the continuation of the pregnancy, regresses in size
glands of the endocervix undergo both hypertrophy and and appears white and fibrous on the surface of the ovary (a
hyperplasia as they increase in number and distend with corpus albicans).
mucus. A tenacious coating of mucus fills the cervical canal.
This mucous plug, called the operculum, acts to seal out Changes in the Breasts
bacteria during pregnancy and therefore helps prevent infection Subtle changes in the breasts may be one of the first physiologic
in the fetus and membranes. changes of pregnancy a woman notices (at about
Softening of the cervix in pregnancy (Goodell’s sign) is 6 weeks) (Fig. 10.5). She may experience a feeling of fullness,
marked. The consistency of a nonpregnant cervix may be tingling, or tenderness in her breasts because of the increased
compared with that of the nose, whereas the consistency of a stimulation of breast tissue by the high estrogen level in her
pregnant cervix more closely resembles that of an earlobe. body. As the pregnancy progresses, breast size increases because
This softening is so marked it is rated as a probable diagnostic of hyperplasia of the mammary alveoli and fat deposits.
sign of pregnancy. Just before labor, the cervix becomes so The areola of the nipple darkens, and its diameter increases
soft that it takes on the consistency of butter or is said to be from about 3.5 cm (1.5 in) to 5 or 7.5 cm (2 or 3 in). There
“ripe” for birth (Kahn & Koos, 2007). is additional darkening of the skin surrounding the areola in
Vaginal Changes some women, forming a secondary areola. As vascularity of
Under the influence of estrogen, the vaginal epithelium and the breasts increases, blue veins may become prominent over
underlying tissue become hypertrophic and enriched with the surface of the breasts. The sebaceous glands of the areola
glycogen; structures loosen from their connective tissue (Montgomery’s tubercles) enlarge and become protuberant.
attachments in preparation for great distention at birth. The secretions from these glands are what keeps the nipple
This increase in the activity of the epithelial cells results in a supple and helps to prevent nipples from cracking and drying
white vaginal discharge throughout pregnancy (a presumptive during lactation.
sign). Early in pregnancy, the breasts begin readying themselves
An increase in the vascularity of the vagina, beginning for the secretion of milk. By the 16th week, colostrum, the
early in pregnancy, parallels the vascular changes in the thin, watery, high-protein fluid that is the precursor of breast
uterus. The resulting increase in circulation changes the color milk, can be expelled from the nipples. Talking to women
of the vaginal walls from the normal light pink to a deep during pregnancy about breast changes and breastfeeding for
violet (Chadwick’s sign), a probable sign of pregnancy. their infant’s health can be the trigger that alerts them to the
Vaginal secretions during pregnancy fall from a pH of importance of breastfeeding (Mattar et al., 2007).
greater than 7 (an alkaline pH) to 4 or 5 (an acid pH). This Systemic Changes
occurs because of the action of Lactobacillus acidophilus, bacteria Although the physiologic changes first noticed by a woman
that grow freely in the increased glycogen environment are apt to be those of the reproductive system and breasts,
and by so doing increase the lactic acid content of secretions. changes are occuring in almost all body systems.
This changing acid content helps to make the vagina resistant Integumentary System
to bacterial invasion for the length of the pregnancy. This As the uterus increases in size, the abdominal wall must stretch
change in pH also, unfortunately, favors the growth of to accommodate it. This stretching (plus possibly increased
Candida albicans, a species of yeast-like fungi. A candidal adrenal cortex activity) can cause rupture and atrophy of small
infection is manifested by an itching, burning sensation in segments of the connective layer of the skin. This leads to pink
or reddish streaks (striae gravidarum) appearing on the sides
of the abdominal wall and sometimes on the thighs (Fig. 10.6). women, it may appear as if it has turned inside out, protruding
During the weeks after birth, striae gravidarum lighten to a silvery- as a round bump at the center of the abdominal wall.
white color (striae albicantes or atrophicae), and, although Extra pigmentation generally appears on the abdominal
permanent, they become barely noticeable. wall. A narrow, brown line (linea nigra) may form, running
Occasionally, the abdominal wall has difficulty stretching from the umbilicus to the symphysis pubis and separating the
enough to accommodate the growing fetus, causing the rectus abdomen into right and left hemispheres (see Fig. 10.6).
muscles to actually separate, a condition known as diastasis. Darkened areas may appear on the face as well, particularly
on the cheeks and across the nose. This is known as melasma
(chloasma), or the “mask of pregnancy.” These increases in
pigmentation are caused by melanocyte-stimulating hormone,
which is secreted by the pituitary. With the decrease
in the level of the hormone after pregnancy, these areas
lighten and again disappear.
Vascular spiders or telangiectases (small, fiery-red branching
spots) are sometimes seen on the skin of pregnant women,
particularly on the thighs. These probably result from the
increased level of estrogen in the body. They may fade but not
completely disappear after pregnancy. The activity of sweat
glands increases throughout the body during pregnancy.
Women notice this as an increase in perspiration. Palmar erythema
(redness and itching) may occur on the hands from the
increased estrogen level. Fewer hairs on the head enter a resting
phase because of overall increased metabolism, so scalp
hair growth is increased.
Respiratory System
A local change that often occurs in the respiratory system is
marked congestion, or “stuffiness,” of the nasopharynx, a response
to increased estrogen levels. Women may worry that
this stuffiness indicates an allergy or a cold. Not realizing
that it is happening because they are pregnant, some women
take over-the-counter cold medications or antihistamines in
an effort to relieve the congestion. Some continue to take
the medication after pregnancy is confirmed, not mentioning
they are taking this medication to health care providers
because they think the stuffiness is a separate problem and
not related to the pregnancy. Ask all women at prenatal visits
if they are taking any kind of medicine or if they have noticed
nasal stuffiness to detect this possibility.
As the uterus enlarges during pregnancy, a great deal of
pressure is put on the diaphragm and, ultimately, on the
lungs. This can displace the diaphragm by as much as 4 cm
upward. This crowding of the chest cavity causes an acute
sensation of shortness of breath late in pregnancy, until lightening
relieves the pressure.
Even with all this crowding, a woman’s vital capacity (the
maximum volume exhaled after a maximum inspiration) does
not decrease during pregnancy because, although the lungs
are crowded in the vertical dimension, they can still expand
horizontally. Residual volume (the amount of air remaining
in the lungs after expiration) is decreased up to 20% by the
pressure of the diaphragm. Tidal volume (the volume of air
inspired) is increased up to 40% as a woman draws in extra
volume to increase the effectiveness of air exchange. Total
oxygen consumption increases by as much as 20%.
If this happens, it will appear after pregnancy as a bluish The increased level of progesterone during pregnancy appears
groove at the site of separation. to set a new level in the hypothalamus for acceptable
The umbilicus is stretched by pregnancy to such an extent blood carbon dioxide levels (PCO2), because, during pregnancy,
that by the 28th week, its depression becomes obliterated and a woman’s body tends to maintain a PCO2 at closer to
smooth because it has been pushed so far outward. In most 32 mm Hg than the normal 40 mm Hg. This low PCO2 level
causes a favorable CO2 gradient at the placenta (the fetal think they need medication. Explaining the reason for these
CO2 level is higher than that in the mother, allowing CO2 to changes allows a woman to accept them without worrying.
cross readily from the fetus to the mother). Cardiovascular System
To keep the mother’s pH level from becoming acid because Changes in the circulatory system are extremely significant to
of the load of CO2 being shifted to her by the fetus, increased the health of the fetus, because they are necessary for adequate
ventilation (mild hyperventilation) to blow off excess CO2 placental and fetal circulation. Table 10.5 summarizes
begins early in pregnancy. At full term, a woman’s total ventilation these changes.
capacity may have risen by as much as 40%. This Blood Volume. To provide for an adequate exchange of
increased ventilation may become so extreme that a woman nutrients in the placenta and to provide adequate blood to
develops a respiratory alkalosis or exhales more than the usual compensate for blood loss at birth, the total circulatory blood
CO2. To compensate, kidneys excrete plasma bicarbonate in volume of a woman’s body increases by at least 30% (and
urine. This results in increased urination or polyuria, an early possibly as much as 50%) during pregnancy. Blood loss at a
sign of pregnancy. With greater urine output, both additional normal vaginal birth is about 300 to 400 mL; blood loss from
sodium and additional water are lost. a cesarean birth can be as high as 800 to 1000 mL. The increase
The slight increase in pH in serum because of the changed in blood volume occurs gradually, beginning at the
expiratory effort is advantageous because it slightly increases end of the first trimester. It peaks at about the 28th to the
the binding capacity of maternal hemoglobin and thereby 32nd week and then continues at this high level throughout
raises the oxygen content of maternal blood (PO2), from a the third trimester. Because the plasma volume increases
normal level of about 92 mm Hg to about 106 mm Hg early faster than red blood cell production, the concentration of
in pregnancy. This is advantageous to fetal growth because it hemoglobin and erythrocytes may decline, giving a woman a
allows good placental exchange. pseudoanemia early in pregnancy. A woman’s body compensates
The cumulative effect of these respiratory changes is often for this change by producing more red blood cells,
experienced by a woman as chronic shortness of breath. creating near- normal levels of red blood cells again by the
Although her breathing rate is more rapid than usual (18–20 second trimester.
breaths per minute), this is normal for pregnancy. Iron, Folic Acid, and Vitamin Needs. Almost all women
The total respiratory changes and the compensating mechanisms need some iron supplementation during pregnancy because
that occur in the respiratory system can be described as of a variety of factors. The fetus requires a total of about
350 to 400 mg of iron to grow. The increases in the
a chronic respiratory alkalosis fully compensated by a chronic mother’s circulatory red blood cell mass require an additional
metabolic acidosis. Changes in respiratory function during 400 mg of iron. This is a total increased need of
pregnancy are summarized in Table 10.4. about 800 mg. Because the average woman’s store of iron is
less than this amount (about 500 mg), and because iron
absorption may be impaired during pregnancy as a result of
decreased gastric acidity (iron is absorbed best from an acid
medium), additional iron is often prescribed during pregnancy
to prevent a true anemia.
Either a hemoglobin concentration of less than 11 g/100
mL or a hematocrit value below 33% in the first or third
trimester of pregnancy or a hemoglobin concentration of
less than 10.5 g/dL (hematocrit _32%) in the second
trimester is considered true anemia, for which iron therapy
above normal supplementation is advocated (Arnett &
Greenspoon, 2007). Caution women that, like all drugs, a
prescribed dose of iron is good for them. Taking excess iron
pills over this prescribed amount can cause stomach irritation
and possibly iron accumulation in body cells (Pena-
Rosas & Viteri, 2009). (See Chapter 20 for additional information
on anemia in pregnancy.) The need for folic acid
increases even more during pregnancy. If the intake of folic
Temperature acid is not great enough, megalohemoglobinemia (large,
Early in pregnancy, body temperature increases slightly because nonfunctioning red blood cells) will result. Inadequate folic
of the secretion of progesterone from the corpus luteum acid levels have also been linked to an increased risk for
(the temperature, which increased at ovulation, remains elevated). neural tube disorders in fetuses (Lumley et al., 2009).
As the placenta takes over the function of the corpus
luteum at about 16 weeks, the temperature usually decreases
to normal.
Some women may mistakenly assume that this slight rise
in temperature (99.6° F orally), associated with pregnancyrelated
nasal congestion, is a sure sign of a cold, and may
 pressure of the expanding uterus on veins and arteries. This
resistance to blood flow in the venous system can lead to
edema and varicosities of the vulva, rectum, and legs.
Supine Hypotension Syndrome. When a pregnant woman
lies supine, the weight of the growing uterus presses the vena
cava against the vertebrae, obstructing blood flow from the
lower extremities. This causes a decrease in blood return to
the heart and, consequently, decreased cardiac output and
hypotension
(Fig. 10.8). A woman experiences this hypotension
as lightheadedness, faintness, and palpitations (Bernstein &
Weinstein, 2007).The condition is potentially dangerous because
Encourage women to eat foods that are high in folic acid it can cause fetal hypoxia.
(e.g., spinach, asparagus, legumes) both during the prepregnancy Supine hypotension syndrome can easily be corrected by
period and during pregnancy. Prenatal vitamins that having a woman turn onto her side (preferably the left side), so
contain folic acid are routinely prescribed. Unexpectantly, that blood flow through the vena cava increases again. To
an association between multivitamin supplementation during lessen the possibility of occurrence of this phenomenon,
pregnancy and reduced cancers in children, such as neuroblastoma, women develop an increase in collateral blood circulation during
leukemia, and brain tumors, can be documented pregnancy. Teach women always to rest on the left side
(Goh et al., 2007). rather than the back, because even with additional collateral
Heart. To handle the increase in blood volume in the circulatory circulation, a supine position tends to lead to hypotension.
system, a woman’s cardiac output increases significantly, Blood Constitution. The level of circulating fibrinogen, a
by 25% to 50%; the heart rate increases by 10 beats constituent of the blood that is necessary for clotting, increases
per minute. Like the circulating volume increase, the bulk of as much as 50% during pregnancy, probably because
the cardiac work increase occurs during the second trimester, of the increased level of estrogen. Other clotting factors,
with a small increase in the third trimester. An average such as factors VII, VIII, IX, and X, and the platelet count
woman is unaware of the significant circulatory system also increase. These increases are a safeguard against major
changes that are occurring inside her to supply adequate bleeding should the placenta be dislodged and the uterine
blood to the placenta. However, this rise in circulating load arteries or veins be opened. Total white blood cell count
has implications for a woman with cardiac disease. Although rises slightly, both as a protective mechanism and as a reflection
an average woman’s heart is able to adjust to these changes of a woman’s increased total blood volume (up to
readily, a woman whose heart has difficulty handling her normal about 20,000 cells/mm3). The total protein level of blood
circulating load can be overwhelmed by the requirements decreases, perhaps indicating the amount of protein being
placed on it when she is pregnant. used by the fetus. Because the circulating system has a lower
Because the diaphragm is pushed upward by the growing total protein load and hypervolemia, fluid readily leaves the
uterus late in pregnancy, the heart is shifted to a more transverse blood for institial tissue vessels to equalize osmotic and hydrostatic
position in the chest cavity, a position that may make it pressure. This causes the common ankle and foot
appear enlarged on x-ray examination. Some women have edema of pregnancy (not to be confused with nondependent
audible functional (innocent) heart murmurs during pregnancy, or generalized edema, which is a symptom of pregnancyinduced
probably because of the altered heart position. hypertension).
Palpitations of the heart are not uncommon during pregnancy, Blood lipids increase by one third, and the cholesterol
particularly on quick motion. You can caution serum level increases by 90% to 100%. These increases provide
women not to feel frightened if palpitations do occur. a ready supply of available energy for the fetus.
Palpitations in the early months of pregnancy are probably Gastrointestinal System
caused by sympathetic nervous system stimulation; in later At least 50% of women experience some nausea and vomiting
months, they may result from increased thoracic pressure early in pregnancy. This is one of the first sensations a woman
caused by the pressure of the uterus against the diaphragm. may experience with pregnancy (sometimes it is noticed even
Blood Pressure. Despite the hypervolemia of pregnancy, the before the first missed menstrual period). It is most apparent
blood pressure does not normally rise because the increased early in the morning, on rising, or if a woman becomes fa-
heart action takes care of the greater amount of circulating
blood. Average blood pressures for adult women are shown
in Appendix G.
In most women, blood pressure actually decreases slightly
during the second trimester because the peripheral resistance
to circulation is lowered as the placenta expands rapidly.
During the third trimester, the blood pressure rises again to
first-trimester levels (Fig. 10.7).
Peripheral Blood Flow. During the third trimester of pregnancy,
blood flow to the lower extremities is impaired by the
 and bleeding of gingival tissue when they brush their
teeth. There may be increased saliva formation (hyperptyalism),
probably as a local response to increased levels of estrogen.
This is an annoying but not serious problem. A lower
than normal pH of saliva may lead to increased tooth decay
if tooth brushing is not done conscientiously. This can be a
problem for homeless women or any other women who do
not have frequent access to a place to brush their teeth
(Agueda et al., 2008).

Urinary System
Like other systems, the urinary system undergoes many physiologic
changes during pregnancy. These include alterations
in fluid retention and renal, ureter, and bladder function.
tigued during the day. It is more frequent in women who Changes in the urinary system are summarized in Table 10.6.
smoke cigarettes. Known as morning sickness, nausea and These changes result from:
vomiting begin to be noticed at the same time levels of hCG • Effects of high estrogen and progesterone levels
and progesterone begin to rise so these may contribute to its • Compression of the bladder and ureters by the growing
cause. It may occur as a systemic reaction to increased estrogen uterus
levels or decreased glucose levels, because glucose is being used • Increased blood volume
in such great quantities by the growing fetus (see Focus on • Postural influences
Nursing Care Planning Box 10.8). Many alternative or complementary Fluid Retention. To provide sufficient fluid volume for effective
methods to help reduce nausea with pregnancy are placental exchange, total body water increases to 7.5 L;
available such as acupuncture or wrist bands, or drinking ginger this requires the body to increase its sodium reabsorption in
or peppermint tea. These are discussed in Chapter 13.
This common feeling of nausea usually subsides after the
first 3 months, after which time a woman may have a voracious
appetite. Although the acidity of stomach secretions
decreases during pregnancy, heartburn may result from reflux
of stomach contents into the esophagus, caused by upward
displacement of the stomach by the uterus, and a relaxed
cardioesophageal
sphincter, caused by the action of relaxin, an
enzyme produced by the ovary. Interventions for heartburn
are also discussed in Chapter 13.
As the uterus increases in size, it pushes the stomach and
intestines toward the back and sides of the abdomen. At about
the midpoint of pregnancy, this pressure may be sufficient to
slow intestinal peristalsis and the emptying time of the stomach,
leading to increased heartburn, constipation, and flatulence.
Relaxin may contribute to decreased gastric motility;
this natural slowing can be helpful, because the blood supply
may be reduced to the gastrointestinal tract (i.e., blood is
drawn to the uterus). Progesterone also has an effect on
smooth muscle, such as that in the intestine, making the
gastrointestinal the tubules to maintain osmolarity. Under the influence of
tract less active. progesterone, there is an increased response of the angiotensinrenin
Women with chronic gastric reflux usually find their system in the kidney, which leads to an increase in
condition improved during pregnancy because the acidity of aldosterone production. Aldosterone aids sodium reabsorption.
the stomach is decreased. Because of the gradual slowing of Progesterone appears to be potassium-sparing, so that
the gastrointestinal tract, decreased emptying of bile from the even with an increased urine output, potassium levels remain
gallbladder may result. This can lead to reabsorption of adequate.
bilirubin into the maternal bloodstream, giving rise to a Water is retained during pregnancy to aid the increase in
symptom of generalized itching (subclinical jaundice). A blood volume and to serve as a ready source of fluid for the
woman who has had gallstones may have an increased tendency fetus. Because nutrients can pass to the fetus only when dissolved
to stone formation during pregnancy as a result of the in or carried by fluid, this ready fluid supply is a fetal
increased plasma cholesterol level and additional cholesterol safeguard.
incorporated in bile. Pressure from the uterus on veins returning At one time, pregnant women were administered diuretics
from the lower extremities can lead to hemorrhoids. to help clear this excess fluid from their system. A sodiumrestricted
Some pregnant women notice hypertrophy at their gumlines diet was also recommended. Today, it is recognized
that these practices are actually harmful, because the increased (Cootauco & Althaus, 2007).
fluid volume provides physiologic benefits for the Skeletal System
fetus. In addition, the excess fluid can serve to replenish the Calcium and phosphorus needs are increased during pregnancy,
mother’s own blood volume, should hemorrhage occur. because the fetal skeleton must be built. As pregnancy
Renal Function. During pregnancy, a woman’s kidneys advances, there is a gradual softening of a woman’s pelvic ligaments
must excrete not only the waste products from her body but and joints to create pliability and to facilitate passage
also those of the growing fetus. Also, her kidneys must be of the baby through the pelvis at birth. This softening is
able to excrete additional fluid and manage the demands of probably caused by the influence of both the ovarian hormone
increased renal blood flow. The kidneys may increase in relaxin and placental progesterone. Excessive mobility
size, changing their structure and ultimately affecting their of the joints can cause discomfort. A wide separation of the
function. symphysis pubis, as much as 3 to 4 mm by 32 weeks of pregnancy,
During pregnancy, urinary output gradually increases (by may occur. This makes women walk with difficulty
about 60% to 80%). The specific gravity of urine decreases. because of pain.
The glomerular filtration rate (GFR) and renal plasma flow To change her center of gravity and make ambulation
begin to increase in early pregnancy to meet the increased easier, a pregnant woman tends to stand straighter and taller
needs of the circulatory system. By the second trimester, both than usual. This stance is sometimes referred to as the “pride
the GFR and the renal plasma flow have increased by 30% to of pregnancy.” Standing this way, with the shoulders back
50%, and they remain at these levels for the duration of the and the abdomen forward, creates a lordosis (forward curve of
pregnancy. This rise is consistent with that of the circulatory the lumbar spine), which may lead to backache (Box 10.9).
system increase, peaking at about 24 weeks. This efficient Endocrine System
GFR level leads to a lowered blood urea nitrogen (BUN) Almost all aspects of the endocrine system increase during
and low creatinine levels in maternal plasma. A BUN of pregnancy (Table 10.7).
15 mg/100 mL or higher or a serum creatinine concentration Placenta. The most striking change in the endocrine system
greater than 1 mg/100 mL is considered abnormal and reflects during pregnancy is the addition of the placenta as an endocrine
the kidneys’ difficulty in handling the increased blood organ that produces large amounts of estrogen, progesterone,
load. The higher GFR leads to increased filtration of glucose hCG, human placental lactogen (hPL), relaxin, and
into the renal tubules. Because reabsorption of glucose by the prostaglandins. Estrogen causes breast and uterine enlargement.
tubule cells occurs at a fixed rate, there may be some accidental Palmar erythema during early pregnancy may also be a
spilling of glucose into the urine during pregnancy. response to the high circulating estrogen levels. Progesterone
Lactose, which is being produced by the mammary glands has a major role in maintaining the endometrium, inhibiting
but is not used during pregnancy, will also be spilled into the uterine contractility, and aiding in the development of the
urine. Although minimal spilling of glucose into the urine breasts for lactation. Relaxin, secreted primarily by the corpus
may occur this way, the finding of more than a trace of glucose luteum, is responsible for helping to inhibit uterine activity
in a routine sample of urine from a pregnant woman is and to soften the cervix and the collagen in joints. Softening
considered abnormal until proved otherwise, because this can of the cervix allows for dilatation at birth; softening of collagen
be a sign of gestational diabetes (see Chapter 20). allows for laxness in the lower spine and helps enlarge the
Creatinine clearance has become the standard test for birth canal. hCG is secreted by the trophoblast cells of the placenta
renal function during pregnancy, because creatinine is in early pregnancy. It stimulates progesterone and estrogen
cleared from the body at a steady rate in relation to GFR. A synthesis in the ovaries until the placenta can assume
normal pregnancy value is 90 to 180 mL/min. This is analyzed this role. hPL, also known as human chorionic somatomammotropin,
from a 24-hour urine sample. is also produced by the placenta. It serves as an antagonist
Ureter and Bladder Function. A pregnant woman may to insulin, making insulin less effective, which allows
notice an increase in urinary frequency during the first more glucose to become available for fetal growth.
3 months of pregnancy, until the uterus rises out of the pelvis
and relieves pressure on the bladder. Frequency of urination In addition to these changes, prostaglandins are found in
may return at the end of pregnancy, as lightening occurs and high concentrations in the female reproductive tract and the
the fetal head exerts renewed pressure on the bladder. decidua during pregnancy. Prostaglandins affect smooth
Because of the increased level of progesterone during muscle contractility to such an extent they may be the trigger
pregnancy, the ureters increase in diameter and the bladder that initiates labor at term.
capacity increases to about 1500 mL. The uterus tends to rise Pituitary Gland. The pituitary gland is affected by pregnancy,
on the right side of the abdomen because it is pushed slightly because there is a halt in the production of FSH and
in that direction by the greater bulk of the sigmoid colon. As LH brought on by the high estrogen and progesterone levels
a result, pressure on the right ureter may lead to urinary stasis of the placenta. There is increased production of growth hormone
and pyelonephritis if not relieved. Pressure on the urethra and melanocyte-stimulating hormone (which causes
may lead to poor bladder emptying and bladder infection. skin pigment changes). Late in pregnancy, the posterior
Such infections are potentially dangerous to the pregnant pituitary begins to produce oxytocin, which will be needed to
woman, because they can ascend to become kidney infections. aid labor. Prolactin production is also begun late in pregnancy,
They are potentially dangerous to the fetus, because as the breasts prepare for lactation.
urinary tract infections are associated with preterm labor Thyroid and Parathyroid Glands. The thyroid gland enlarges
in early pregnancy to such an extent that the basal body metabolic
rate increases by about 20%. Levels of protein-bound and taking insulin before pregnancy will need more insulin
iodine, butanol-extractable iodine, and thyroxine are all elevated during pregnancy. A woman who is prediabetic may develop
in blood serum. If a sufficient supply of iodine is not overt diabetes for the first time during pregnancy.
present during pregnancy, goiter (thyroid hypertrophy) can Overall, the effect of diminishing the action of insulin is
occur as the gland intensifies its productive effort. beneficial because it ensures a ready supply of glucose for
These thyroid changes, along with emotional lability, fetal growth.
tachycardia, palpitations, and increased perspiration, may The glucose level of a fetus is about 30 mg/100 mL lower
lead to a mistaken diagnosis of hyperthyroidism if pregnancy than the maternal glucose level. To prevent fetal hypoglycemia,
has not been determined. with resultant cell destruction or lack of fetal
The parathyroid glands, which are necessary for the metabolism growth, the maternal glucose level is usually at a higher than
of calcium, also increase in size during pregnancy. normal level during pregnancy. Several fail-safe physiologic
Because calcium is important for fetal growth, the hypertrophy measures are initiated to achieve this.
is probably necessary to satisfy the increased requirement As mentioned, although the pancreas secretes an increased

level of insulin throughout pregnancy, it appears to of this.

Adrenal Glands. Adrenal gland activity increases in pregnancy be not as effective. With insulin that is less effective, fat
as increased levels of corticosteroids and aldosterone stores of a woman are utilized, as well as available glucose.
are produced. It is assumed that these increased levels aid in This maintains maternal glucose levels at a fairly steady
suppressing an inflammatory reaction or help reduce the level despite long intervals between meals or days of increased
possibility of a woman’s body rejecting the foreign protein activity. To ensure against hypoglycemia, a pregnant
of the fetus, the same as it would a foreign-tissue transplant. woman should keep her diet high in calories and
They also help to regulate glucose metabolism in a woman. should never go longer than 12 hours between meals.
The increased level of aldosterone aids in promoting sodium Because the rapidly developing fetus uses so much glucose
reabsorption and maintaining osmolarity in the amount of in early pregnancy, a fasting blood glucose level at this time
fluid retained. This indirectly helps to safeguard the blood is usually low (80–85 mg/100 mL).
volume and to provide adequate perfusion pressure across Immune System
the placenta. Immunologic competency during pregnancy apparently decreases,
Pancreas. The pancreas increases production of insulin in probably to prevent a woman’s body from rejecting
response to the higher levels of glucocorticoid produced by the fetus as if it were a transplanted organ.
the adrenal glands. Insulin is less effective than normal, Immunoglobulin(ANTIBODIES)
however, because estrogen, progesterone, and hPL are all G (IgG) production is particularly decreased, which can
antagonists to insulin. Therefore, a woman who is diabetic make a woman more prone to infection during pregnancy. A
simultaneous increase in the white blood cell count may help The same contraction process reduces the bulk of the
to counteract the decrease in IgG response. uterus. Devoid of the placenta and the membranes, the walls
of the uterus thicken and contract, gradually reducing the
PHYSIOLOGIC CHANGES OF THE uterus from a container large enough to hold a full-term fetus
POSTPARTAL PERIOD to one the size of a grapefruit. A few cells of the uterine wall
Retrogressive physiologic changes that occur during the are broken down into their protein components by an autolytic
postpartal process. These components are then absorbed by the
period include those related specifically to the reproductive bloodstream and excreted by the body in urine. The main
system as well as other systemic changes (Box 17.3). mechanism that reduces the bulk of the uterus, however, is
Reproductive System Changes contraction, a phenomenon that can be compared with a rubber
Involution is the process whereby the reproductive organs band which has been stretched for many months and now
return to their nonpregnant state. A woman is in danger of is regaining its normal contour. None of the rubber band is
hemorrhage from the denuded surface of the uterus until destroyed; the shape is simply altered. For this reason, the
involution postpartal period, like pregnancy, is not a period of illness, of
is complete (Poggi, 2007). necrosing cells being evacuated, but primarily a period of
The Uterus healthy change (Pavone, Purinton, & Petersen, 2007).
Involution of the uterus involves two main processes. First, Although the uterus will never completely return to its
the area where the placenta was implanted is sealed off to prepregnancy state, its reduction in size is dramatic.
prevent Immediately after birth, the uterus weighs about 1000 g. At
bleeding. Second, the organ is reduced to its approximate the end of the first week, it weighs 500 g. By the time
pregestational size. involution
The sealing of the placenta site is accomplished by rapid is complete (6 weeks), it weighs approximately 50 g,
contraction of the uterus immediately after delivery of the similar to its prepregnancy weight.
placenta. This contraction pinches the blood vessels entering Because uterine contraction begins immediately after placental
the 7-cm-wide area left denuded by the placenta and stops delivery, the fundus of the uterus may be palpated
bleeding. With time, thrombi form within the uterine sinuses through the abdominal wall, halfway between the umbilicus
and permanently seal the area. Eventually, endometrial and the symphysis pubis, within a few minutes after birth.
tissue undermines the site and obliterates the organized One hour later, it will have risen to the level of the umbilicus,
thrombi, covering and healing the area so completely that the where it remains for approximately the next 24 hours.
process leaves no scar tissue within the uterus and does not From then on, it decreases one fingerbreadth per day—on
compromise future implantation sites. the first postpartal day, it will be palpable one fingerbreadth
below the umbilicus; on the second day, two fingerbreadths
below the umbilicus; and so on. Because a fingerbreadth is
about 1 cm, this can be recorded as 1 cm below the umbilicus,
2 cm below it, and so forth. In the average woman, by
the ninth or tenth day, the uterus will have contracted so
much that it is withdrawn into the pelvis and can no longer
be detected by abdominal palpation (Fig. 17.4). The uterus
of a breastfeeding mother may contract even more quickly,
because oxytocin, which is released with breastfeeding,
stimulates
uterine contractions. However, breastfeeding alone is
not sufficient to protect against postpartum hemorrhage.
The fundus is normally in the midline of the abdomen.
Occasionally, it is found slightly to the right, because the
bulk of the sigmoid colon forces it to that side during
pregnancy
and it tends to remain in that position. Assess fundal
height shortly after a woman has emptied her bladder for
most accurate results, because a full bladder can keep the
uterus from contracting, pushing it upward and possibly
deviating
it from the midline, because of the laxness of the uterine
ligaments.
Uterine involution may be delayed by a condition such as
the birth of multiple fetuses, hydramnios, exhaustion from
 remaining under the placental site (an area 7 cm
wide) and throughout the uterus differentiates into two
distinct layers. The inner layer attached to the muscular
wall of the uterus remains, serving as the foundation from
which a new layer of endometrium will be formed. The
layer adjacent to the uterine cavity becomes necrotic and is
cast off as a uterine discharge similar to a menstrual flow.
This uterine flow, consisting of blood, fragments of decidua,
white blood cells, mucus, and some bacteria, is
known as lochia.
The portion of the uterus where the placenta was not attached
is so fully cleansed by this sloughing process that it
will be in a reproductive state in about 3 weeks’ time. It takes
approximately 6 weeks (the entire postpartal period) for the
placental implantation site to be healed.
For the first 3 days after birth, a lochia discharge consists
almost entirely of blood, with only small particles of decidua
and mucus. Because of its mainly red color, it is termed
lochia rubra. As the amount of blood involved in the cast-off
tissue decreases (about the fourth day) and leukocytes begin
to invade the area, as they do with any healing surface, the
flow becomes pink or brownish (lochia serosa). On about the
10th day, the amount of the flow decreases and becomes
colorless
or white (lochia alba). Lochia alba is present in most
women until the third week after birth, although it is not
prolonged labor or a difficult birth, grand multiparity, or unusual
physiologic effects of excessive analgesia. Contraction may be for a lochia flow to last the entire 6 weeks of the puerperium.
difficult if there is retained placenta or membranes. Characteristics of lochia are summarized in Table
Involution will occur most dependably in a woman who is 17.1. Several rules for judging whether lochia flow is normal
well nourished and who ambulates early after birth (gravity are summarized in Box 17.4.
may play a role).
An estimation of the consistency of the postpartal uterus
is as important as measurement of its height. A well-contracted
fundus feels firm. It can be compared with a grapefruit
in both size and tenseness. Whenever the fundus feels
boggy (soft or flabby), it is not as contracted as it should be,
despite its position in the abdomen.
The first hour after birth is potentially the most dangerous
time for a woman. If her uterus should become relaxed
during this time (uterine atony), she will lose blood very
rapidly, because no permanent thrombi have yet formed at
the placental site.
In some women, contraction of the uterus after birth
causes intermittent cramping termed afterpains, similar to
that accompanying a menstrual period. Afterpains tend to be
noticed most by multiparas rather than primiparas and by
women who have given birth to large babies or multiple The Cervix
births. In these situations, the uterus must contract more Immediately after birth, a uterine cervix is soft and malleable.
forcefully to regain its prepregnancy size and has difficulty Both the internal and external os are open. Like contraction
maintaining a steady contracted state. These sensations are of the uterus, contraction of the cervix toward its prepregnant
noticed most intensely with breastfeeding, when the infant’s state begins at once. By the end of 7 days, the external
sucking causes a release of oxytocin from the posterior os has narrowed to the size of a pencil opening; the cervix
pituitary, feels firm and nongravid again.
increasing the strength of the contractions. In contrast to the process of uterine involution, in which
Lochia the changes consist primarily of old cells being returned to
The separation of the placenta and membranes occurs in their former position by contraction, the process in the cervix
the spongy layer or outer portion of the decidua basalis involves the formation of new muscle cells. Like the fundus,
of the uterus. By the second day after birth, the layer of decidua the cervix does not return exactly to its prepregnancy state.
The internal os closes as before, but after a vaginal birth the milk production). When breast milk first begins to form, the
external os usually remains slightly open and appears slitlike milk ducts become distended. The nipple secretion changes
or stellate (star shaped), whereas previously it was round. from the clear colostrum to bluish white, the typical color of
Finding this pattern on pelvic examination suggests that breast milk. A woman’s breasts become fuller, larger, and
childbearing has taken place. firmer. In many women, breast distention becomes marked,
The Vagina and this often is accompanied by a feeling of heat or throbbing
After a vaginal birth, the vagina is soft, with few rugae, and pain. Breast tissue may appear reddened, simulating an
its diameter is considerably greater than normal. The hymen acute inflammatory or infectious process. The distention is
is permanently torn and heals with small, separate tags of not limited to the milk ducts but occurs in the surrounding
tissue. tissue as well, because blood and lymph enter the area to
It takes the entire postpartal period for the vagina to involute contribute fluid to the formation of milk. This feeling of
(by contraction, as with the uterus) until it gradually tension in the breasts on the third or fourth day after birth
returns to its approximate prepregnancy state. Thickening of is termed primary engorgement. It fades as the infant begins
the walls also appears to depend on renewed estrogen effective sucking and empties the breasts of milk.
stimulation Whether milk production continues depends on the sucking
from the ovaries. Because a woman who is breastfeeding of the infant at the breasts as this releases oxytocin and
may have delayed ovulation, she may continue to have causes new milk to form. Whether women continue to
thin-walled or fragile vaginal cells that cause slight vaginal breastfeed after hospital discharge is influenced by such factors
bleeding during sexual intercourse until about 6 weeks’ time. as employment, personal habits, and how important
Like the cervix, the vaginal outlet remains slightly more they view breastfeeding to be (Abdulwadud & Snow, 2009).
distended They must be certain to drink adequate fluid daily, eat a
than before. If a woman practices Kegel exercises, the nutritious
strength and tone of the vagina will increase more rapidly diet, and check with their health care provider before
(see Chapter 12). This may be important for the sexual ingesting alternative therapies such as herbs as most of
enjoyment these can be found in breast milk and could be toxic to a
of both a woman and her partner. newborn (Seely et al., 2008). Techniques of breastfeeding
The Perineum are discussed in Chapter 19.
Because of the great amount of pressure experienced during Return of Menstrual Flow
birth, the perineum feels edematous and tender immediately With the delivery of the placenta, the production of placental
after birth. Ecchymosis from ruptured capillaries may show estrogen and progesterone ends. The resulting decrease in
on the surface. The labia majora and labia minora typically hormone concentrations causes a rise in production of FSH
remain atrophic and softened after birth, never returning to by the pituitary, which leads, with only a slight delay, to the
their prepregnancy state. return of ovulation. This initiates the return of normal
menstrual
Progressive Changes cycles.
Two physiologic changes that occur during the puerperium A woman who is not breastfeeding can expect her menstrual
involve progressive changes, or the building of new tissue. flow to return in 6 to 10 weeks after birth. If she is
Because building new tissue requires good nutrition, caution breastfeeding, a menstrual flow may not return for 3 or 4
women against strict dieting that would limit cell-building months (lactational amenorrhea) or, in some women, for
ability during the first 6 weeks after childbirth (Rolfes, Pinna, the entire lactation period. However, the absence of a menstrual
& Whitney, 2009). flow does not guarantee that a woman will not conceive
Lactation during this time, because she may ovulate well before
The formation of breast milk (lactation) begins in a postpartal menstruation returns (Van der Wijden, Kleijnen, & Van
woman whether or not she plans to breastfeed (Pavone, den Berk, 2009).
Purinton, & Petersen, 2007). Early in pregnancy, the increased
estrogen level produced by the placenta stimulates
the growth of milk glands; breasts increase in size because of
the larger glands, accumulated fluid, and some extra adipose
tissue. For the first 2 days after birth, an average woman
notices
little change in her breasts from the way they were
during pregnancy. Since midway through pregnancy, she has
been secreting colostrum, a thin, watery, prelactation secretion.
She continues to excrete this fluid the first 2 postpartum
days. On the third day, her breasts become full and feel tense
or tender as milk forms within breast ducts.
Breast milk forms in response to the decrease in estrogen
and progesterone levels that follows delivery of the placenta
(which stimulates prolactin production and, consequently,