NCM 107 – Care of the Mother, Child and Adolescent

S.Y. 2023-2024 | 1st Semester | Mid Term

Module 5: Pregnancy – Maternal Changes
Description
This module explores the physiological and psychological changes that occur during pregnancy
and their effects on the woman and fetus. From the time just before conception, and then for the
following 280 days, the woman’s body undergoes many alterations that prepare her to nurture a new
life. The physical, psychological and emotional changes that accompany pregnancy are all focused on the
growth, development of the fetus. The major responsibility for nurses caring for pregnant women is not
only to help the mother adapt to these changes but also to help the family maintain feeling of wellness
throughout the pregnancy.

Learning Outcomes
LO1 Integrate concepts of common psychological and physiologic changes that occur with pregnancy
and formulation and application of appropriate nursing care to the mother during childbearing years.
LO3 Assess a mother and her support team for psychological adjustment to the physiologic changes
that occur with pregnancy.
LO4 Formulate nursing diagnosis/es related to adjustment necessary because of psychological and
physiologic changes in pregnancy.
LO5 Implement safe and quality nursing interventions related to the expected changes of pregnancy.
LO6 Provide individual/group health education activities related to the expected changes of
pregnancy.
LO7 Evaluate with the mother outcomes for the achievement and effectiveness of the goals to be
certain expected outcomes have been achieved.

Module Outline

I. Physiological maternal changes

II. Psychological maternal changes
III. Maternal risk factors

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 IV. Nursing Diagnoses: Psychological and Physiologic Changes of Pregnancy
V. Outcome Identification and Planning
VI. Evaluating nursing care

Module
Gestation
A. Time from fertilization of the ovum until the date of delivery.
B. About 280 days or 40 weeks or 10 lunar months (4 weeks/month) or 9 calendar months.
C. It is divided into 3 trimesters: 1-3 months (first trimester); 4-6 months (second trimester); 7-9
months (third trimester).
D. Nagel’s rule for estimating the date of delivery, also known as date of birth
- Subtract 3 months and add 7 days to the first day of the last menstrual period; then add 1
year (if LMP falls on the months of April to December)
- Example: (April 20, 2019) 4 20 2019
- 3 months + 7 days + 1 year
1 27 2020
- Add 9 months and 7 days to the first day of the last menstrual period (if LMP falls on the
months of January to March)
- Example: (February 14, 2019) 2 14 2019
+ 9 months + 7 days
11 21 2019
OB Score (Gravidity and Parity)
A. Gravida refers to a pregnant woman
- Gravidity refers to number of pregnancies.
- A nulligravida is a woman who has never been pregnant.
- A primigravida is a woman who is pregnant for the first time.
- A multigravida is a woman in at least her second pregnancy.
B. Parity is the number of births carried past 20 weeks of gestation, whether or not the fetus was
born alive.
- A Nullipara is a woman who has not had a birth at more than 20 weeks of gestation.
- A primipara is woman who has had 1 birth that occurred after 20th weeks of gestation

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 - A multipara is a woman who has had 2 or more pregnancies to the stage of fetal viability
C. Pregnancy outcomes can be described with the acronym GTPAL
- G is gravidity, the number of pregnancies regardless of outcome, including the present
one
- T is term births, the number born at term (longer than 37 weeks of gestation)
- P is preterm births, the number of infants born before term (before 37 weeks of
gestation)
- A is abortions or miscarriages, the number of abortions or miscarriages.
- L is the number of current living children. This number can be greater than the G if
multiples were delivered or less than G is a loss occurred
- Multiples count as 1 for gravidity and 1 for term, preterm or abortion but are recorded
as the actual number for living.
Example: A woman who is pregnant and has two children at would be gravida 3, para
2002 (GTPAL = 3 pregnancies, 2 term, 0 preterm, 0 abortion, 2 living children.

I. Physiological maternal changes and discomforts

A. Cardiovascular
• Pulse rate may increase about 10 to 15 beats per minute to supply the demand of the
growing fetus while blood pressure slightly decreases in the second trimester, then increases
during third trimester.
• Supine hypotensive syndrome during second and third trimester. The supine position places
the woman at risk for supine hypotension, which occurs as a result or pressure of the uterus
on the inferior vena cava.
Intervention:
1. Sitting with feet elevated.
2. Avoid supine position, assume side lying position.
3. Risk for falls; teach to change positions slowly.
• Circulating blood volume increases by 40-50%, plasma increases together with other blood
components: white blood cells, red blood cells, fibrinogen, clotting factors.

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 • Physiologic Anemia occurs as the plasma increase exceeds the increase in production of red
blood cells (known as hemodilution) in the third trimester but not above the pre pregnancy
level.
Interventions:
1. Eat rich foods such as meat, liver, green leafy vegetables
2. Iron requirements are increased to 30 mg / day
3. Drink iron supplements with orange juice for absorption
• Heart size increases, and the heart is elevated slightly upward and to the left because of
displacement of diaphragm as the uterus enlarges.

B. Respiratory system
• Because the mother is not only supplying oxygen to her body but also the fetus, respiratory rate
slightly increases, and oxygen consumption is elevated by approximately 15% to 20%.
Hyperventilation is also present caused by need to blow off increased carbon dioxide
transferred from fetus.
• Shortness of breath may be experienced during second and third trimesters. Results from the
pressure on the diaphragm of the enlarged uterus
Interventions:
1. Taking frequent rest periods
2. Sitting and sleeping with head elevated with pillows or on the side
3. Avoiding overexertion
• Nasal stuffiness occurs in the first through third trimesters; results from the increased estrogen,
which causes edema of the nasal tissues and dryness.
Interventions:
1. Encouraging the use of a humidifier
2. Avoiding the use of nasal sprays or antihistamine unless prescribed

C. Gastrointestinal system
• Nausea and vomiting may occur as a result of the secretion of human chorionic gonadotropin; it
typically subsides by third month.

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 Interventions:
1. Eat dry crackers before arising.
2. Avoid brushing teeth immediately after arising.
3. Eating small, frequent meals, low-fat meals during the day.
4. Drinking liquids between meals rather than at meals
5. Avoiding fried and spicy foods
6. Asking primary health care provider about acupressure and use of herbal medications
7. Taking antiemetic as prescribed
• Poor appetite may occur because of decreased gastric motility and alterations in taste and
smell. Pica may be also present. Some mothers have cravings to nonfood substances, such as
dirt, clay, starch, and freezer frost. The cause is unknown; cultural values, such as beliefs
regarding the effect of a material on the mother or fetus, may make pica a common practice.
Iron deficiency anemia may occur as a result of pica.
• Heartburn occurs in the second and third trimesters. Results from increased gastrointestinal
motility, esophageal reflux, and displacement of the stomach by enlarging uterus.
Interventions:
1. Eating small, frequent meals
2. Sitting upright for 30 minutes after a meal
3. Drinking milk between meals
4. Avoiding fatty and spicy foods
5. Performing tailor-sitting exercises
6. Antacid as prescribed
• Constipation occurs during second and third trimesters. Resulting from an increase in
progesterone production, decreased intestinal motility, displacement of the intestines, pressure
of the uterus, and taking iron supplements
Interventions:
1. Drinking no less than 200mL per day
2. Eating high-fiber foods such as whole grains, fruits, and vegetables
3. Exercising regularly, such as a daily 20-minute walk
4. Stool softeners and laxative as ordered
• Hemorrhoids usually occur in the second and third trimesters. Results from increased venous

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 pressure and constipation.
Interventions:
1. Soaking in a warm sitz bath
2. Sitting on a soft pillow
3. Eating high fiber foods and drinking sufficient fluids to avoid constipation
4. Exercise such as walking
5. Applying ointments, suppositories or compresses as prescribed
• Gum tissue may become swollen and easily bleed because of increasing levels of estrogen.
Intervention: Use soft bristles when brushing the teeth and maintain oral hygiene.
• Ptyalism (excessive secretion of the saliva) may occur because of increasing levels of estrogen
Intervention: Use sugarless candy

D. Renal system
• Frequency of urination usually occurs in the first and third trimesters. This is caused by pressure
of the uterus on the bladder
Interventions:
1. Drinking no less than 2,000 mL of fluid during the day
2. Limiting fluid intake in the evening
3. Voiding at regular intervals
4. Sleeping side lying at night
5. Wearing perineal pads, if necessary
6. Performing Kegel exercise
• Decreased bladder tone may occur and is caused by an increase in progesterone and estrogen
levels; bladder capacity increases in response to increasing levels of progesterone.
• Renal threshold for glucose may be reduced.

E. Endocrine system
• Placenta as temporary endocrine gland secreting hormones to maintain pregnancy (hCG, hPL,
Estrogen, Progesterone). The basal metabolic rate increases and metabolic function increases
making the mother experience more fatigue during the first and third trimesters. Fatigue can

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 also be due to hormonal changes.
Interventions:
1. Arranging frequent rest periods
2. Using correct posture and body mechanics
3. Obtaining regular exercise
4. Performing muscle relaxation and strengthening exercises for the legs and hip joints
5. Avoiding eating and drinking foods containing stimulants
• The anterior lobe of the pituitary gland enlarges and produces serum prolactin needed for the
lactation process while the posterior lobe of the pituitary gland produces oxytocin, which
stimulates uterine contractions. The thyroid and the parathyroid enlarges slightly and activity
increases. Aldosterone increases as a result water retention increases, which can contribute to
weight gain.

F. Reproductive system
1. Uterus
o Uterus enlarges, increasing in mass approximately 60 to 1000 g as a result of hyperplasia
(influence of estrogen) and hypertrophy. The woman experiences irregular contraction typically
occurring at the beginning at 16weeks of gestation known as Braxton Hick’s contraction. Upon
examination, the examiner may feel a softening of the lower uterine segment at about sixth
week of pregnancy called Hegar’s sign.
o If the lower uterine segment is tapped sharply during a pelvic exam, the fetus can be felt to
bounce or rise in the amniotic fluid up against hand placed on the abdomen. This is called
Ballottement which present during 16th to 20th week of pregnancy.
o Uterine soufflé is a rushing or blowing sound of maternal blood flowing through uterine arteries,
similar to the maternal pulse rate. Sometime heard when listening to the fetal heart rate.
o Funic soufflé is caused is caused by fetal blood flowing through the umbilical cord.
2. Cervix
o The cervix softens at around sixth week known as Goodell sign. It can have increased friability,
resulting in slight bleeding after examination or coitus. It changes in color and consistency,
glands in cervical mucosa increase producing a mucus plug to prevent ascent of organisms in the
uterus known as Operculum.

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 3. Ovaries
The corpus luteum continue its function because of human chorionic gonadotropic hormone as
a result ovaries secrete progesterone for the first 6 to 7 weeks of pregnancy. While
progesterone and estrogen are elevated, maturation of follicle is blocked and ovum production
ceases.
4. Vagina
Vaginal secretions increase making pH more acidic. This is important to prevent opportunistic
infection to thrive, however the higher glycogen level promotes Candida albicans (yeast)
infection. Due to increase vaginal secretions, mothers complain of white discharge known as
Leukorrhea.
Interventions
1. Using proper cleansing and hygiene technique
2. Wearing cotton underwear
3. Consulting the doctor if infection is suspected
5. Breasts
High levels of estrogen and progesterone prepare breasts for lactation as a result, mothers
complain of breast fullness, tingling sensation, darkened areolae and nipples. The
Montgomery’s tubercle found around the areola secrete substance to lubricate nipples.
Interventions
1. Wearing supportive bra
2. Avoiding the use of soap on the nipples and areolar area to prevent drying of skin.

G. Integumentary system
• The following changes occur because the levels of melanocyte stimulating hormone increase as
a result of an increase in estrogen and progesterone levels:
- Increased pigmentation
- Linea nigra - a dark streak down the midline of the abdomen.
- Chloasma (mask of pregnancy) - a blotchy brownish hyperpigmentation over the forehead,
cheeks, and nose
- Striae gravidarum - a reddish-purple stretch marks on the abdomen, breasts, thighs, and

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 upper arms.
• Vascular spider nevi may occur on the neck, chest, face, arms, and legs.
• Rate of hair growth increases

H. Musculoskeletal system
• Back ache, usually occurs in the second and third trimesters, caused by an exaggerated
lumbosacral curve resulting from an enlarge uterus.
Interventions:
1. Using correct posture and body mechanics
2. Wearing low-heeled, comfortable, and supportive shoes
3. Performing pelvic tilt (rock) exercises
4. Sleeping on a firm mattress
• Leg cramps, usually occur in the second and third trimesters, results from an altered calcium-
phosphorus balance and pressure of the uterus and nerves or from fatigue.
Interventions:
1. Getting regular exercise
2. Dorsiflexing the foot of the affected leg
3. Increasing calcium intake
• Relaxation and increased mobility of pelvic joints occur, which permit enlargement of pelvic
dimensions.
• Abdominal wall stretches with loss of tone throughout pregnancy, regained postpartum. The
umbilicus flattens or protrudes.

Pregnancy Signs
All the physiologic changes that happened to a pregnant woman can be categorized according to:
Presumptive; Probable; Positive signs.
A. Presumptive signs– subjective cues, reported by the mother (may be indicative of other
conditions)
1. Amenorrhea
2. Nausea and vomiting

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 3. Breast tenderness
4. Urinary frequency
5. Quickening
6. Fatigue
B. Probable signs – objective cues but not definite confirmation
1. Uterine enlargement
2. Hegar’s sign
3. Goodell’s sign
4. Chadwick’s sign
5. Ballottement
6. Braxton hicks’ contraction
7. Positive pregnancy test
C. Positive signs – absolute signs; confirmation
1. Fetal heartbeat; heard with stethoscope or Doppler
2. Fetal outline and movement felt by examiner
3. Ultrasonography: visualization of fetus and movement of fetal heart

II. Psychological Changes

A. Ambivalence
• Ambivalence may occur early in pregnancy, even when pregnancy is planned.
• The mother may experience a dependence-independence conflict and ambivalence related to
role changes.
• The partner may experience ambivalence related to the new role being assumed, increased
financial responsibilities, and sharing the mother’s attention with a child.
B. Acceptance
• Factors that may be related to acceptance of the pregnancy are the woman’s readiness for the
experience and her identification with the motherhood role. Specific developmental tasks must
be accomplished successfully for positive maternal role adaptation. These tasks include
accepting the pregnancy, identifying with the mothering role, solidifying her relationship with
her partner, establishing a relationship with her unborn infant and preparing for her birth

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 experience.
• Couvade syndrome refers to the partner who is experiencing physical symptoms along with
the pregnant woman.
C. Emotional liability
• Emotional liability may be manifested by frequent changes of emotional states or extremes in
emotional states.
• These emotional changes are common, but mother may think these changes are abnormal.
D. Body image changes
• The changes in a woman’s perception of her image during pregnancy occur gradually and may
be positive or negative.
• The physical changes and signs and symptoms that the woman experiences during pregnancy
contribute to her image.
E. Relationship to the Fetus
• The woman may daydream to prepare for motherhood and thick about the maternal qualities
that she would like to possess.
• The woman first accepts the biological fact that she is pregnant
• The woman next accepts the growing fetus as distinct from herself and a person to nurture.
• Finally, the woman prepares realistically for the birth and parenting of the child.
These common psychological changes that occur in pregnancy can be summarized as:
Trimester Task Psychological Change
First (1-3 months) Accepting Ambivalence
the pregnancy
Second (4-6 months) Accepting the fetus Narcissism
Introversion
Third (7-9 months) Preparing for the baby and Preparation for parenthood;
end of pregnancy Grows impatient as the couple
ready themselves for birth.
F. Maternal Role Attainment Theory
The Maternal Role Attainment Theory was developed to serve as a framework for nurses to
provide appropriate health care interventions for nontraditional mothers for them to develop a strong

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 maternal identity. This mid-range theory can be used throughout pregnancy and postnatal care, but is
also beneficial for adoptive or foster mothers, or others who find themselves in the maternal role
unexpectedly. The process used in this nursing model helps the mother develop an attachment to the
infant, which in turn helps the infant form a bond with the mother. This helps develop the mother-child
relationship as the infant grows.
The primary concept of this theory is the developmental and interactional process, which occurs
over a period of time. In the process, the mother bonds with the infant, acquires competence in general
caretaking tasks, and then comes to express joy and pleasure in her role as a mother.
MERCER’S MATERNAL ROLE ATTTAINMENT STAGES

1. Anticipatory Stage – during pregnancy

✓ Commitment and preparation
✓ Seeks information.
✓ Visualizes herself as a mother.
2. Formal stage – first 2 weeks after delivery
✓ Acquaintance, practice, and physical restoration
✓ Role-taking stage
✓ Learns from others and replicate their behavior.
✓ Mother gains competence through practice
3. Informal stage – 2 weeks to 4 months
✓ Learns infant cues and develops her unique style in mothering.
✓ Settling in
✓ Becoming a new family
4. Personal stage – 4 months and beyond
✓ Integrates mothering into her system.
✓ Internalizes the role and views self as a competent mother.

III. Nursing Diagnoses: Psychological and Physiologic Changes of Pregnancy

Examples of nursing diagnoses involving the changes that occur with pregnancy include:
• Altered breathing patterns related to respiratory system changes of pregnancy
• Disturbed body image related to weight gain from pregnancy.
• Deficient knowledge related to normal changes of pregnancy.
• Imbalanced nutrition, less than body requirements, related to early morning nausea.
• Powerlessness related to unintended pregnancy.
• Possible impaired health and prenatal care behaviors associated with cultural beliefs.

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IV. Outcome Identification and Planning
Planning nursing care in connection with the physiologic and psychological changes of pregnancy should
include the review the common concerns of women about being pregnant before changes occur, so
they will not be surprised. Examples of outcome identification and planning include:
• Patient states that she is able to continue her usual lifestyle throughout the pregnancy.
• Family members describe ways they have adjusted their lifestyles to accommodate the mother’s
fatigue.
• Couple states they understand the physiologic changes of pregnancy.

V. Evaluating nursing care

Evaluation should determine whether a woman has really understood the nurse’s teaching. Remember
that people under stress do not always comprehend well. Examples of outcome criteria:
• Patient states she is able to continue her usual lifestyle throughout pregnancy.
• Family members describe ways they have adjusted their lifestyles to accommodate the mother’s
fatigue
• Couple states they appreciate the physiologic changes of pregnancy and even though they are
causing discomfort, they know these are healthy changes

Module Subsection 1
Watch the following videos:
1. Physiologic changes of pregnancy https://www.youtube.com/watch?v=8RGRnCQNZWc
2. First trimester changes https://www.youtube.com/watch?v=cfn04QUO4B8
3. Second trimester changes https://www.youtube.com/watch?v=IPj4dJnP85o&t=188s
4. Third trimester changeshttps://www.youtube.com/watch?v=lpDW00nQhUo

References
Flagg, J. (2018). Maternal and child health nursing: Care of the childbearing and
childbearing family (8thed.). Philadelphia, PA: WoltersKluwer.

Green, C.J. (2016). Maternal newborn nursing care plans (3rded.). Burlington, MA: Jones
& Bartlett Learning.

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Tharpe, N.L. (2017). Clinical practice guidelines for midwifery and women’s health
(5thed.). Burlington, MA: Jones and Bartlett Publishers.

Credits and Quality Assurance

Prepared: Recommending Approval:

MELANIE C. TAPNIO, MAN, RN, LPT DENMARK D. GABRIEL, MSN, RN, LPT
Assistant Professor Assistant Professor & Chairperson, Nursing Program

Reviewed by:
Approved by:
JENNY ROSE LEYNES-IGNACIO, EdD, MAN, RN
Assistant Professor & OBE Facilitator PRECIOUS JEAN M. MARQUEZ, PhD, MSN, RN
OIC Dean
School of Nursing and Allied Medical Sciences

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