Physiological Changes - Regional Perinatal System

7/8/2015
REVIEW
Physiological Changes of
Pregnancy & Labor
Instructor: Luann Beacom, FNP, MPH, MSN
Outline: Susan A. Merica-Jones MSN, CNM
Objective 1
Pregnancy Changes
Reproductive
Gastrointestinal
Respiratory
Renal
Hematologic
Musculoskeletal
Cardiovascular
Integumentary
Metabolic changes
Endocrine
2
Objective 2
Common Discomforts:
Pregnancy
Nausea / vomiting
Round ligament
Joint pain
Shortness of
breath
Urinary frequency
Pruritis
Back pain
Heart burn
Edema
Headache
Leukorrhea
…others…
3
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Objective 3
Differential Assessments
Of normal discomforts of pregnancy
Review & discuss differences in class
4
Objective 4
Labor Changes
Blood pressure
Renal functioning
Metabolism
Gastrointestinal
functioning
Temperature
Blood count
Respiration
5
Objective 1
6
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Reproductive System
Uterus
Vagina
size & shape
position
discharge
sensitivity
dextra-rotary
Breasts
contractility
Braxton-Hick’s
blood flow
20 fold
development
colostrum
Pelvic floor
cervix
Shape & friability
hypertrophy &
hyperplasia
7
Cervical Changes
Nullipara
Multipara
8
Cervical Changes
Mucous Plug
Non-pregnant
Pregnant
9
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Cervical Changes
Initial 6 Weeks
Presumptive sign
Chadwick’s sign
Bluish /
purplish
discoloration
Vulva, vaginal
mucosa &
cervix
Probable signs
Goodell’s
Softening of
cervix
nose >>>>
lips
Hegar’s
Softening of
lower uterus
10
Pelvic Floor Changes
Non-pregnant
Term Pregnancy
Note: bladder & urethral elongation
11
General Body Systems
Cardiovascular
Hematological *
Respiratory
Metabolic *
Renal
Gastrointestinal
Musculoskeletal
Integumentary
Neurological
Endocrine
12
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Cardiovascular System
Heart
Size
Position
Heart sounds
Circulation
Blood volume
by 40 – 50%
physiological anemia
split S1 & S2
Cardiac output
Stroke volume
Heart rate (pulse)
BP changes
26 to 29 weeks
lowest
13
Changes
in
heart, lung, diaphragm
location
during pregnancy
14
Cardiovascular &
Hematological Changes
Heart rate
10-15 bpm
Volume
40-50%
Output
30-50%
BP
2nd:
RBC mass
By 17%
WBC
2nd & 3rd
Clotting factors
Hgb & Hct
especially 2nd
physiological anemia
15
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Respiratory System
Anatomical changes
Diameter, circumference & costal vertebral
angle all increase
Diaphragm displacement
thoracic replaces abdominal breathing
Upper respiratory changes
vascularity increases
Pulmonary function
See next slide
16
Pulmonary Function Changes
Respiratory rate
Unchanged or
slightly
Total lung capacity
Unchanged or
slightly
Oxygen
consumption
15-20%
Tidal volume
30-40%
Inspiratory capacity
Increased
Expiratory capacity
Decreased
Vital capacity
unchanged
17
Pulmonary Function Changes
18
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Basal Metabolism Changes
Increases
15-20%
At onset of pregnancy
Resolves 5-6 days postpartum
Effects
Heat intolerance
Perspiration
Increase in sleep
Metabolic acid-base changes
19
Acid-Base Balance Changes
Progesterone
Respiratory
alkalosis
pCO2 falls
HCO3 falls
pH increases (alkaline)
compensated by
Facilitates transport
Mild Metabolic
CO2 from baby
O2 from mother
acidosis
To baby
10th week:
air hunger
20
Oxygen Dissociation Curve
Bohr Effect
moves in favor of the baby
21
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Renal System
Anatomic changes
Lead to…
Kidney
renal pelvis dilates
Ureters
dilate (see next slide)
elongate
compression
Urinary frequency
Urinary tract
infection
susceptibility
Bladder
< tone…capacity
22
Ureteral Dilation
36 weeks
1 week PP
23
Renal Function
Electrolyte / pH balance
maintained
Extracellular fluid volume
regulated
Waste products
excreted
Essential nutrients
conserved
24
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Renal Changes
Glomerular filtration
rate
30-50%
Renal plasma flow
30%
Urinary glucose
BUN
Creatinine
Uric acid
20%
25
Renal Metabolic Changes
Selective tubular
reabsorption
Na+ & H20
Selective tubular
excretion
Glucose
H20 (1st ^)
Protein
Water soluble vits
Increased blood
volume
Increase thirst
1st ^
Physiological
Glycosuria
Edema
Proteinuria
26
Gastrointestinal System
Mouth
gums
Ptyalism
Stomach/intestine
Herniation
HCl
Motility
Rectum
Hemorrhoids
water resorption
Liver/gallbladder
gallstones (cholelithiasis)
cholestasis of pregnancy
Appendix
Location
McBurney’s point
moves up & back to R
27
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Position of Appendix
= McBurney’s point (note how it moves up)
28
Musculoskeletal System
Center of gravity
Joints
Estrogen & Relaxin
hypermobility
lordosis
Ligaments (see slide)
Round
Uterosacral
backache
moves forward
Abdominal wall
Diastasis (see slide)
Assess post-partum
Exercises
chin lifts, single
leg lifts,
abdominal
tightenings
29
Uterine Ligaments
30
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Diastasis Recti Abdominis
Non-pregnant
Pregnant / PP
31
Integumentary System
Striae
50-90%
Collagen: genetic
Pigmentation
Linea nigra
Chloasma
Oil & sweat
Vascular changes
Angiomas
Estrogen
Racially related
Palmar erythema
Edema
Allergic reactions
enhanced
32
Neurological System
Sensory changes
Legs
Acrodysthesia
Hands
etiology: stooped
shoulders
Carpal tunnel
Back pain
traction
compression
Tension headache
estrogen
P/S
Lightheadedness
vasomotor instability
postural hypotension
hypoglycemia
Muscle cramps
hypo-calcemia
33
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Endocrine System
Pituitary & placenta
20% painless
spotting 1st ^
Thyroid
T3 increases 1st ^
TSH same
Parathyroids
Hyperparathyroidism
15 – 35 weeks
Adrenals
Reabsorption
excess Na+
water balance
Pancreas
baby depletes
maternal amino acids
mother decreases
own response to her
own insulin
> insulin
production
34
Objectives 2 & 3
35
Discomforts of Pregnancy
are related to
Physiological Changes
36
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…but…
be aware of
differential assessments
which may be
abnormal
37
First Trimester
Breast changes
Prenatal mastitis
Urgency/frequency
UTI
Nausea/vomiting
Appendicitis
Hyperemesis
Ptyalism
Gingivitis/epulis
Abscess
Nasal
stuffiness/nose
bleeds
URI
Leukorrhea
Infection
38
Second Trimester
Pigmentation
Palpitations
Angiomas
Faintness/syncope
Palmar erythema
Food cravings
Pruritis
Heartburn
Cholestasis
Epigastric pain
39
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Second Trimester
Constipation
Headaches
Flatulence
Carpal tunnel /
Acrodysthesia
Varicosities
Deep vein
thrombosis
Leukorrhea
Pre-eclampsia
Round ligament pain
Kidney stones
Abruption
Appendicitis
Pre-term labor
Joint pain
40
Uterine Ligaments
41
Ureteral Pain Locations
(Kidney Stones)
36 weeks
1 week PP
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Position of Appendix
= McBurney’s point (note how it moves up)
43
Third Trimester
Dyspnea/SOB
Insomnia
Mental illness
Back pain
Normal
Preterm labor
Kidney stones
Gingivitis/epulis
Frequency/urgency
UTI
Perineal discomfort
Vulvar varicosities
Braxton Hicks
Normal
Preterm labor
Leg cramps
Edema
Heartburn / nausea
Gallstones (cholelithiasis)
Cholestasis of pregnancy
44
Objective 4
45
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REVIEW
Normal
Physiological
Changes
during labor
46
Normal Physiologic Changes
(7 Areas of Assessment)
Blood Pressure
increases
Temperature
increases
Cardiac
Renal
increases
Gastrointestinal
decreases
Hematological
changes
Respiratory
increases
increases
Documentation
ALWAYS
47
Overview
Hemodynamic Changes Peripartum
Intrapartum
Pain
 HR + BP
Contractions
 preload 300-500cc
Pushing
 card output 50%
Valsalva
& preload /
cardiac ouput (CO)
Postpartum
 CO 30%
500cc uterine venous
Autodiuresis
24-48 hrs PP
Return to prepregnancy
physiology
6-8 weeks
48
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Blood Pressure
Rises with uterine contractions
Systolic
10 – 20 mm Hg
Diastolic
5 – 10 mm Hg
Rises with fear, tension, pain
49
Temperature
Elevated
Not greater than
1 – 2 degrees F
0.5 – 1 degrees C
Variables
Dehydration
Versus chorio-amnionitis
50
Cardiac Output
Elevated slightly
assess maternal pulse
Decreases during uterine contraction
acme
not true if mother in lateral position
51
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Respirations
Elevated
Especially if pain & fear present
Avoid hyperventilation
Respiratory alkalosis
52
Renal
Polyuria
Ensure q 2 hour voiding
Proteinuria
Trace to +1 normal in ½ to 1/3 of women
Membrane status
Ketones
Never normal
53
Gastrointestinal Changes
Motility and absorption
Decreased
Secretion of gastric juices
Decreased
Absorption of liquid NOT affected
England & Wales experience
54
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Hematological Changes
Hgb decreases by 1.2 gm / 100 ml
Coagulation time decreases
Plasma fibrinogen increases
WBCs increase to 15,000 by birth
Glucose levels decrease
55
Vital Sign Documentation
Site Dependent
Hospital
Generally q 30 - 60 min
Labor dependent
Variables
Pitocin augmentation
Regional anesthesia
Birth Centers (NACC)
Generally q 4 – 8 hours
56
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