NURS N231F Specialty Nursing (General Health Care) 2024-2025 Lecture 2.2 Physiology & Psychosocial Adaptations During Pregnancy PDF

NURS N231F Specialty Nursing (General Health Care) 2024-2025 Lecture 2.2 Physiologic & Psychosocial Adaptation during Pregnancy Ms. Margaret Wong E-mail: [email protected] Tel: 3970 8747...

NURS N231F Specialty Nursing (General Health Care) 2024-2025 Lecture 2.2 Physiologic & Psychosocial Adaptation during Pregnancy Ms. Margaret Wong E-mail: [email protected] Tel: 3970 8747 1 Learning Outcomes 2  Learning Outcomes On completion, students will be able to: ✓ Describe the maternal physiological, emotional and psychological changes during pregnancy ✓ Describe the pregnancy induced discomforts and nursing management 3  Physiological & Psychological Changes during Pregnancy 4  Physiologic Adaption to Pregnancy Pregnancy exerts profound physiological changes on a mother’s body almost in every organ and system Changes are necessary (Aims) To support and nourish the fetus To prepare the woman for childbirth To prepare the woman for lactation The physiological changes mainly due to Hormonal influence (estrogen and progesterone ) Growth of fetus Mother’s physiologic adaptation to pregnancy 5  Reproductive system A. Uterus Protect and support fetus, placenta, and amniotic fluid size, 20 times as compare with the non-pregnant size.  weight (60g → 1100g)  capacity (10ml → 5000ml)  Blood supply Shape: Pear → Ovoid Position: Ascent into abdomen after 1st trimester Thickness of uterine wall: 8mm → 25mm at 12 weeks → 10mm at term (Source: https://useruploads.socratic.org/qLRoG2dWQOSyDba4zxf0_pregnancyorgansjpg.jpg) 6  Reproductive system A. Uterus Change in uterine size: Traditional method of assessing gestational age Progressive↑ in the height of fundus Different gestations to abdominal landmarks throughout pregnancy ▪ By the end of the 12th week, uterus rise into abdominal cavity→ palpated just above the symphysis pubis ▪ At around 20th week, fundal height rise to the level of umbilicus ▪ At around 36th week, uterus rise to the xiphoid process ▪ After 37 weeks, fundal height drops → fetus (Source: https://www.stepwards.com/?page_id=10721; begins to descend and engage in the pelvis https://www.grepmed.com/images/4172/approximation-obstetrics-diagnosis-fundal- height) (Lightening) 7  Reproductive system A. Uterus Isthmus of uterus forms the lower uterine segment (~1/3 uterine body), from ~ 26 weeks till 32 weeks Braxton Hicks contractions starts ~20th weeks → promote blood circulation to placenta (Source: https://geekymedics.com/anatomy-of-the-uterus/) (Source: https://slideplayer.com/slide/3503452/) 8  Reproductive system B. Cervix  vascularity (Chadwick’s sign) Softening (Goodell’s sign) Start to ripe about 4 weeks before birth Mucus plug in cervical canal protect the fetus and the membranes from bacteria → ascend through the vagina Shed with a little blood when cervix begins to dilate - “show” (Source: https://lh3.googleusercontent.com/proxy/8f624rnBmbBckPhd4Gl_tLMVHfca8Lgxiea0XJT1wor-f4zSdKVHFuKsOTLEZY_uHe5- hW509zeOMaXE5FR9u6sShX66b_B5km7_; https://www.mamanatural.com/wp-content/uploads/Photo-of-a-mucus-plug-does-labor-start- 9 When-You-Lose-it.jpg)  Reproductive system C. Vagina  vascularity because of estrogen influences  vaginal secretions More acidic increase amount of thick and whitish vaginal discharge  risk of vulvovaginal candidiasis (VVC) due to increase oestrogen level Itching, irritating and erythema Candida albicans is the most common species. 10  Reproductive system D. Ovaries Ovulation ceases during pregnancy due to increase level of estrogen & progesterone Secretes estrogen and progesterone from the corpus luteum for the first 6-8weeks until placenta is developed 11  Breasts Breasts changes are prepared for lactation ↑in weight by ~ 500-800g → tenderness is common Growth of glandular tissue and ducts Pigmentation in nipple and areola Nipples increase erect to prepare for lactation. Double blood flow to breast and dilated veins visible under skin 12  Breasts Montgomery’s tubercles become prominent In 3rd trimester : creamy, yellowish breast fluid (colostrum) provide nourishment for breastfeeding newborn in the first few days Colostrum (Source: https://tap-assets-prod.dexecure.net/wp-content/uploads/sites/12/2018/12/montgomerys-glands.jpg; https://cdn.shopify.com/s/files/1/0010/5683/3654/articles/Untitled_design_-_2019-11- 07T201612.780.png?v=1573119235) 13  Cardiovascular system Associated with profound but reversible changes in maternal cardiovascular system and haemodynamics. Significance of the changes: Meet the increased demand for maternal organs during pregnancy Compensate the blood loss during childbirth Provide the needs and support for fetal growth and development 14  Cardiovascular system Cardiac function ↑cardiac output by 20% at 8 weeks of gestation and continues to rise until 32 weeks, by 50% above the baseline. ↑ stroke volume by 30% in late pregnancy ↑maternal heart rate by 15-20 beats per minute. 15  Cardiovascular system Blood pressure Slight  in first 2 trimesters → gradually  to pre-pregnant levels at term Due to peripheral vasodilation caused by progesterone How much does it drop? ↓5-10 mmHg (Source: https://www.researchgate.net/figure/Pattern-of-change-in-blood-pressure-with-advancing-pregnancy_fig1_251124459) 16  Cardiovascular system Haemodynamics ***Physiologic anaemia At 32th weeks,  plasma volume by 40-50% but the red blood cell volume by 20-30% → haemodilution →  haemoglobin and haematocrit → anaemia Mild ↑white blood cell (Neutrophils) Slightly ↓ in platelet count, ↑ in fibrin, plasma fibrinogen and other clotting factors concentration. 17  Cardiovascular system Supine hypotension syndrome Lies supine, weight of uterus may partially occlude the aorta and inferior vena cava → can reduce the blood flow up to 80%. Compression of aorta →  uteroplacental blood flow→ fetal compromise Compression of inferior vena cava →  venous return to the heart → Hypotension, dizziness, light-headedness, nausea, agitation ** Key messages : from 20 weeks of pregnancy, women should sleep on their side (left lateral) to alleviate the compression (Source: https://www.lagreefitness.com/images/new/science8-img3.jpg) 18  Upper airway Generalized vasodilation and increase in mucosal edema due to progesterone → nasal congestion and epistaxis are common Oxygen consumption Lung volume ↑20-30% due to oxygen requirements of Enlargement of uterus elevates the the developing fetus, placenta and diaphragm ~ 4cm by 3rd trimester→↓in maternal organ functional residual capacity Pregnant women are more prone to hypoxia, hyperventilation and dyspnea than non- pregnant women 19  Respiratory system Compensation mechanism Muscles and cartilage in thoracic region relax, the subcostal angle ↑ from 68 to 103 in late pregnancy and chest circumference ↑5-7cm → chest broadens→ maintain constant lung capacity Relaxation of bronchial and tracheal smooth muscles ↓ airway resistance→ improve efficiency of breathing (Source: https://doctorlib.info/gynecology/williams-obstetrics/williams-obstetrics.files/image058.jpg) 20  Respiratory system ↑respiratory rate by 1-2 breaths  in tidal volume by 30-40% by deeper breathing →compensate the decrease in functional residual capacity ↑ in PaO2 to facilitate the transfer of oxygen from mother to fetus and ↓PaCo2 to facilitate the transfers of carbon dioxide from fetus to mother (Source: https://www.e-safe- anaesthesia.org/sessions/08_01/gif/ana_4a_001_physiological_changes_during_pregnancy_07_t1.gif) 21  Gastrointestinal system Mouth Gums swollen due to the effect of estrogen →  risk of gingivitis and bleeding gums  salivary gland activity and saliva production. Altered sense of taste Oesophagus Progesterone relax cardiac sphincter → reflux of gastric content → heartburn cardiac sphincter 22 (Source: https://i1.wp.com/eoeguru.com/wp-content/uploads/2018/06/GERD.jpg?fit=660%2C330)  Gastrointestinal system Stomach Progesterone causes  gastric acid production, relax smooth muscle in stomach,  tone and motility →  emptying time of stomach contents → delay food digestion and  reflux and vomiting ( gastric aspiration ) Intestine (Source: https://i1.wp.com/eoeguru.com/wp-content/uploads/2018/06/GERD.jpg?fit=660%2C330) Progesterone causes  mobility of large intestine→ constipation Constipation + pressure of uterus→ Haemorrhoids 23 (Source: https://colorectalsurgeonssydney.com.au/sites/default/files/inline-images/haemorrhoids_e.jpg)  Integumentary system Hyperpigmentation Due to increase in Melanocyte-stimulating hormone (MSH) Linea nigra: dark pigmented line from symphysis pubis to umbilicus in midline Chloasma: pigmentation covering forehead, nose and cheeks Pigmentation of areola, vulva and recent scar (Source: https://en.wikipedia.org/wiki/Linea_nigra) (Source: http://siasah.com.my/pregnant-skin-what-is-chloasma/) 24  Integumentary system Striae gravidarum Bluish pink lines in abdomen, breasts, thighs and buttocks Caused by stretching and small tears of collagen layer of skin (most prominent by 6-7 months) Become silvery white after delivery ↑ activity of sebaceous and sweat glands Post delivery During pregnancy (Source: https://o.quizlet.com/nsRpkDOH9cbtKqgN-GeybA.jpg) 25 (Source: https://cdn2.momjunction.com/wp-content/uploads/2014/04/How-To-Remove-Stretch-Marks- After-Pregnancy-16-Home-Remedies-Medical-Treatments-3-624x702.jpg)  Musculoskeletal system Soften and stretching of pelvic ligaments Hormonal effect of progesterone and relaxin https://lovelace.com/news/blog/practic →ligaments become stretchy and the e-correct-body-mechanics-and-posture- during-your-pregnancy (walking) spinal, pelvic & pubic joints become loosen →resulting in “ waddle gait” & pelvic discomfort →in late pregnancy, pelvic ligaments & joints are further relaxed in symphysis pubis & sacroiliac joint to prepare for labour → pelvic girdle and pubic pain  Musculoskeletal system Postural change Enlarged uterus tilts the pelvis forward →shifting center of gravity →compensated by an increased curvature (lordosis) of spine→ backache (Source: https://lupinepublishers.com/gynecology-women-health-journal/images/lupinepublishers-openaccess-journal- gynaecology-women-health-care.ID.000127.G001.png) 27  Renal system/Urinary system  Blood flow to kidneys~50-80%  Glomerular filtration rate (GFR)~50% →  urine flow and volume  frequency of micturition Due to compression on urinary bladder Early pregnancy : due to enlarging uterus in pelvis End of pregnancy : due to engagement of fetal head 28  Endocrine system Placenta Human chorionic gonadotrophin (hCG) ▪ Prevent involution of corpus luteum and cause spontaneous abortion ▪ Corpus luteum synthesis progesterone during the early stage of pregnancy ▪ Can be detected in maternal serum as early as day 8 after conception and reach its maximum level at week 8 of gestation ▪ By week 13, the hCG level drops dramatically as the placenta itself produces enough progesterone to support pregnancy 29  Endocrine system Placenta Progesterone ▪ Prevent the uterus from contracting → prevent spontaneous abortion/ preterm birth ▪ Immunosuppressive functions which protect the conceptus from immunological rejection by the mother ▪ Post fertilization to week 12: produced by corpus luteum ▪ After week 12 : produced by placenta Estrogen ▪ Promote proliferation of uterine lining and enlargement of the uterus and breasts → support pregnancy ▪ Secreted by the corpus luteum; adrenal cortex and the placenta. 30  Endocrine system Placenta Human placental lactogen (hPL) ▪ Also called human chorionic somatomammotropin (hCS) ▪ Support fetal nutrition by increasing the supply of glucose to the fetus → decreasing maternal glucose utilization → mobilizing maternal stores of fatty acids →decease maternal insulin sensitivity, leading to an increase in maternal blood glucose levels. Relaxin ▪ Relax the muscles, ligaments and joints during pregnancy →Uterus: prevent contraction, relax ligaments for uterine expansion →Pelvis: relax the ligaments and joints for delivery →Abdomen: make the abdominal muscles more flexible. 31  Endocrine system Thyroid gland Enlarge & becomes more active during pregnancy Basal metabolic rate (BMR) ~ 25% along with heart rate & cardiac output Pituitary gland Enlarged and  production of prolactin; Melanocyte-stimulating hormone (MSH); oxytocin ↑Prolactin for breast development & stimulate lactation process ↑MSH to work with estrogen for skin pigmentation in pregnancy ↑Oxytocin for uterine contractions that bring about delivery 32  Psychological changes Influenced by hormonal change 1st trimester Emotional lability (rapid, often exaggerated changes in mood, uncontrollable laughing or crying, or heightened irritability or temper) Feel uncertain towards pregnancy Daydreams of possible miscarriage Anxious about labor Renew her personal identity Worry about own ability and responsibility of childcare Uncomfortable due to early symptoms Concern about change of body image Happy, anxiety, physiological changes 33  Psychological changes 2nd trimester Emotional stability Physically feels better Become more excited about the pregnancy and increase confidence. Fetal movement and aware of closeness to fetus. Expect the partner will be caring and affection 3rd trimester Increase anxiety and concerns Feel pride about the pregnancy. Eager the pregnancy to end due to increase physical discomfort. Concern the health and safe of unborn baby. Anxiety about labor pain and birth. A surge of energy when prepare the home for the baby. 34  Common pregnancy induced discomforts and nursing management 35 Common discomfort and related care during pregnancy The discomforts are due to rapid increase of hormone including estrogen, progesterone, relaxin and prolactin. Most of these changes are normal and will spontaneously subside after delivery. Management goal: improve symptoms while minimize the risk to mother & fetus Nursing management: Reassurance Assessment Advices 36  Minor discomfort related to Gastrointestinal system i) Nausea and Vomiting (Morning sickness) Affects about 70-80% pregnant women The severity and duration is various from individuals. Symptoms usually subside by the end of first trimester Persists throughout the day in majority of affected mothers https://health.clevelandclinic.org/morning-sickness-at-night/ Causes: Exact cause is unknown possibly due to  hCG & estrogen Nausea is always triggered by hypoglycemia and tiredness 37 Minor discomfort related to Gastrointestinal system Management: Reassurance: explain the probable causes Assessment: ▪ onset, frequency of symptoms, eating habit, physical assessment on body ? What are the assessment weight, skin turgor and hydration ▪ If vomiting becomes severe→ may lose weight significantly and become ? Why we need assessment dehydrate and ketotic→ Hyperemesis gravidarum 38 Minor discomfort related to Gastrointestinal system Management: Advice: ▪ Don’t stop eating→ may cause hypoglycemia → worsen the sickness ▪ Eat dry food like cracker/ toast and rather than to absorb the gastric juice. ▪ Have small and frequent meal rather than large meals ▪ Avoid greasy or highly seasoned food. Try protein and carbohydrate-rich food for nutritional and energy supply. ▪ Try some sour drink, e.g., lemonade, plum juice ▪ Avoid brushing teeth immediately following eating ▪ Get plenty of rest and sleep as tiredness → worsen the sickness 39 Minor discomfort related to Gastrointestinal system ii) Heartburn Affects about 70% pregnant women The regurgitation of acidic gastric contents into the oesophagus Causing a burning sensation in epigastric and sternal regions Causes: progesterone → relaxation of cardiac sphincter of the oesophagus and  in gastric motility (Source: https://i1.wp.com/eoeguru.com/wp- content/uploads/2018/06/GERD.jpg?fit=660%2C330) Tends to worsen as pregnancy advances→ displacement of stomach by the enlarging uterus Improper diet and nervous tension may be precipitating factors 40 Minor discomfort related to Gastrointestinal system Management: Reassurance Assessment: review the dietary intake and stress which may trigger the symptom; time of discomfort (usually 30-45 minutes after eating) to exclude other gastric problem, past health history and medication. Advice: ▪ Have small & frequent meals ▪ Eat slowly and chewing the foods thoroughly ▪ Avoid late-night/ large meals ▪ Avoid fatty and spicy food & caffeinated drinks ▪ Avoid lying down and suggest walking / sitting for 1-2 hours after meal. ▪ Wear loose-fitting clothing ▪ Avoid stress and practice relaxation exercises ▪ Do not take any antacids without consulting a doctor 41 Minor discomfort related to Gastrointestinal system iii) Constipation This affects 10-40% of pregnant women. Causes: Progesterone lowers intestinal muscle tone and movement of colon. Estrogen increases the reabsorption of water from bowel mucosa. Management: Reassurance Assessment: review the bowel habit, nature of the stools, dietary intake, physical activities, medication or supplement Minor discomfort related to Gastrointestinal system Management: Advice: ▪ Drink at least 8-12 cups of fluid everyday in the form of water, milk, juice or soup. ▪ Warm or hot fluid is particularly helpful. ▪ Increase fiber intake such as whole grain breads and cereals, vegetables and fruits. ▪ Maintain an active lifestyle with regular exercise as tolerated ▪ Develop a toileting routine or bowel training to facilitate regular defecation ▪ Avoid using any laxatives except those prescribed by doctors ▪ In case of severe constipation, consult doctor for further investigations and pharmacologic measures  Minor discomfort related to urinary system i) Urinary frequency & Urinary incontinence Causes:  blood flow to kidneys by 50% during pregnancy and the relaxation effect of progesterone on smooth muscle of the urinary tract Occurs in which trimester? Common in 1st & 3rd trimester, and improve in 2nd trimester 1st trimester: growing uterus compresses the bladder during 1st trimester 2nd trimester: uterus is lifted out of the pelvis → symptoms improve 3rd trimester: fetus head descends into the pelvis → compress the bladder 44  Minor discomfort related to urinary system Management: Reassurance: explain the symptoms may improve in the 2nd trimester but reoccur again in the 3rd trimester Assessment : ▪ rules out urinary tract infection & gestational diabetes ▪ How ? Advice: ▪  fluid intake 2-3 hours before bedtime ▪ Limit the intake of caffeinated beverages ▪ Perform Kegel exercise (Pelvic floor exercise) to ✓ Strengthen perineal muscle tone https://www.fhs.gov.hk/english/mulit_med/000097.html ✓ Enhancing urinary control &  chance of incontinence 45  Minor discomfort related to Circulatory system i) Edema About 80% of the pregnant women have ankle swelling May also have hand or facial swelling Causes: The rapidly rising estrogen level during pregnancy causes water retention As a result of gravity and growing uterus, most of the water accumulates in the ankle and feet Management: Reassurance: symptoms are due to hormonal effect Assessment: ▪ watch for any generalized oedema, ▪ rules out the possibility of pre-eclampsia, gestational hypertension and cardiac problem. 46  Minor discomfort related to Circulatory system Management: Advice: ▪ Wear comfortable shoes of a slightly bigger size than that before pregnancy ▪ Elevate the legs comfortably on a footstool or pillows while resting. ▪ Avoid taking diuretics because these medications will lower blood pressure. The placental blood flow will be decreased and the oxygen and nutrient supply to the fetus will be impaired 47  Minor discomfort related to Circulatory system ii). Dizziness Feel light-headed, weak, unsteady or as if you might faint Causes: progesterone → dilates blood vessels → blood tends to pool in the legs → blood flow to maternal brain & maternal BP blood flow to the developing fetus → blood flow to maternal brain & maternal BP Supine hypotension syndrome Orthostatic hypotension (postural hypotension) due to pooling of blood in the veins 48  Minor discomfort related to Circulatory system Management: Reassurance Assessment: onset time, frequency, living habits and sleeping position Advice: ▪ Avoid prolonged standing ▪ Move slowly when rising from resting position ▪ Avoid supine position and recommend to lie left laterally 49  Minor discomfort related to Circulatory system iii) Varicose veins/ Varicosities Affects about 70% pregnant women Dilation of the veins, which may become engorged, inflamed, and painful Causes: progesterone → weakening of walls of veins blood volume to pelvic region during pregnancy & poor circulation of lower extremities especially after prolonged standing or sitting Enlarging uterus → partially block the veins in lower limbs and rectum Other risk factors: excessive weight gain, heredity, large fetus and maternal age, constipation and previous history 50  Minor discomfort related to Circulatory system Management: For varicose veins/ varicosities in legs or vulva Reassurance Assessment: severity, pain and bleeding Advice: ▪ Elevate both legs above the level of heart for 5-10 minutes at least twice a day ▪ Regular exercise ▪ Wear low heeled shoes ▪ Wear support hose or elastic stockings ▪ Avoid crossing legs or wear pantyhose with constricting bands ▪ Avoid prolonged standing or sitting 51  Minor discomfort related to Circulatory system Management: For varicose veins/ varicosities in rectum or anus (Haemorrhoid) Advice: ▪ Avoid constipation ( fiber intake & drinking fluid ≥ 2L / day) ▪ Minimize the risk of straining while defecating ▪ Avoid prolonged sitting/standing ▪ Educate the use of topical medication to smooth the pain, itching & swelling as prescribed ▪ Consult doctor if there is large amount of bleeding while opening the bowel. ▪ The haemorrhoid may subside spontaneously a few months after delivery 52 Minor discomfort related to musculoskeletal system i) Backache Very common during pregnancy. Backache may start from 1st trimester, aggravate in 2nd and 3rd trimester. Causes: Shifting of center of gravity by enlarging uterus joint laxity due to progesterone and relaxin Poor posture History of back pain Management: Reassurance Assessment: onset time, severity, posture, working and living condition to 53 identify any risk factors  Minor discomfort related to musculoskeletal system Management: Advice: ▪ Maintain correct posture when standing and walking ▪ Avoid prolonged standing or sitting ▪ Use pillow to support lower back when sitting and lying sideways ▪ Practice lower back stretching and pelvic tilt exercises to relieve pain and strengthen the back ▪ Wear low-heeled shoes with good arch support ▪ Practice proper body mechanics when lifting objects ▪ Use warm compress for pain relief ▪ Use of supportive abdominal girdle may be helpful ▪ Avoid self administrative of analgesic ▪ Consult professional for pain relief measures if necessary 54  Minor discomfort related to musculoskeletal system Abdominal girdle https://www.ebay.com/itm/Maternity-Belt-Waist-Abdomen-Support-Pregnant-Belly-Band-Back-Brace-Girdle-IK45-/131914292614 https://www.youtube.com/watch?v=C9AO7yXs8V4 End at 01:33 https://www.amazon.com/Maternity-Adjustable-Pregnancy-Abdominal-Strengthen/dp/B071F17PTQ 55 Minor discomfort related to musculoskeletal system https://www.youtube.com/watch?v=moa4h-rjuNE Pelvic tilt exercise https://r.search.yahoo.com/_ylt=AwrwS2AN6Ghh3FsAJ_6.ygt.;_ylu=c2VjA2ZwLWF0dHJpYgRzbGsDcnVybA-- /RV=2/RE=1634293901/RO=11/RU=https%3a%2f%2fcommunity.babycenter.com%2fpost%2fa57800485%2fpelvic_rock_exercise/RK=2/RS=zNqIKfMG_dlxtVZudAbcd5h5QSc- 56 Minor discomfort related to musculoskeletal system ii) Pelvic Girdle Pain The pain is common in later stage of pregnancy and may present after delivery Causes: The hormonal effect of relaxin cause the ligaments becoming stretchy and loosen the sacroiliac and pubic joint Source: https://www.thrivephysioplus.com.au/get-relief-from-pelvic-girdle-and-lower-back-pain-today/ 57 Minor discomfort related to musculoskeletal system Management: Reassurance: improve after birth Assessment: gait, severity and predisposing factors Advice: ▪ Keep good postures and pay attention to the movements that will increase pelvic and pubic joint pain. Avoid position that separating legs too far, such as squatting or sitting on a low stool Avoid standing on one leg or going up/downstairs Avoid lifting heavy objects if you have pelvic pain ▪ Practice pelvic floor muscles exercise and deep abdominal muscles exercises regularly to stabilize the pelvic joint and reduce pelvic and pubic bone pain ▪ Consult professionals for pain relief measures, e.g. analgesic, physiotherapy and pelvic grindle 58  Minor discomfort related to musculoskeletal system iii) Leg Cramping Usually occurs at rest and may affect sleep. Causes Due to tightness of leg muscles. Severe vomiting →low level of calcium and potassium in blood Dehydration Stress Management: Reassurance Assessment: onset, frequency, morning sickness, activity and exercise Minor discomfort related to musculoskeletal system Management: Advice Stretching the calf muscles regularly or before going to bed helps to reduce leg cramps. Regular exercise to strengthen the leg muscles Use pillow to rest and evaluate the legs. Gentle leg massage or apply a hot pad to the calf if leg cramp persists Avoid foot bath with hot water Drink adequate fluid to avoid dehydration Wear comfortable shoes and use supportive foot wares Check the serum calcium and potassium level in case of severe vomiting  Minor discomfort related to genital system i) Leucorrhoea ↑ vaginal discharge which is clear or white, not foul-smelling Begins during 1st trimester & continues throughout pregnancy Causes: oestrogen→ hyperplasia of vaginal mucosa and ↑mucus production  acidity of secretions predisposes woman to vaginal candidiasis (Yeast infection) 61  Minor discomfort related to genital system Management: Reassurance: due to hormonal influence Assessment: Exclude the possibility of infection (high vaginal swab x culture) Advice: ▪ Keep the perineal clean and dry (Wash with mild soap & water during daily bath) ▪ Avoid douching & tampon use https://images.medindia.net/amp-images/patientinfo/vaginal- ▪ Wear cotton underwear douching.jpg ▪ Avoid wearing tight pantyhose ▪ Change pad frequently if used ▪ Wear a nightgown rather than pajamas (allow for air flow) ▪ Consult a doctor if the discharge is smelly or with blood or feel itchy or sore over the vulva https://static.onecms.io/wp- 62 content/uploads/sites/14/2020/07/31/073120-tampon-lead- 2000.jpg  Summary Physical changes in pregnancy: distinctive and important changes Uterus- increase in size with abdominal landmarks Cervix- mucus pug Vagina- increase secretion and acidity Ovary- stop ovulation Breast- growth in ducts and glandular tissue, colostrum Cardiovascular- increase cardiac output & HR, haemodilution, slightly decrease BP, supine hypotension syndrome Respiratory- change of lung volume, increase in tidal volume, PaO2 increased and PaCO2 decreased Musculoskeletal- postural change, backache, pelvic girdle and pubic pain Integumentary- increase pigmentation, linea nigra, striae gravidarum, chloasma 63  Summary GI- relax smooth muscles, heartburn Renal- increase GFR and urine volume Endocrine- placental hormone, thyroid & pituitary Psychological changes: 1st trimester- emotional lability 2ndtrimester- more stable 3rd trimester- increase anxiety and concerns Discomforts: causes and nursing management Morning sickness, heartburn, frequency of micturition, constipation, oedema, varicose vein, hemorrhoids, dizziness, back pain, pelvic girdle pain, leg cramps & leucorrhoea 64  References Department of Health. (2020). Your pregnancy guide. https://www.fhs.gov.hk/english/health_info/woman/30005.pdf Dutta, D. C. (2015). DC Dutta’s Textbook of Obstetrics: Including Perinatology and Contraception (8th ed.). The Health Sciences Publisher. London, M. L. (2017). Maternal & child nursing care (5th ed.). Pearson. McKinney, E. S. (2018). Maternal-child nursing (5th ed.). Elsevier. Rocci, S., Kyle, T., & Carmen, S. (2021). Maternity and Pediatric Nursing (4th ed.). Wolters Kluwer. Weiland Ladewig, P.A., London, M.L., & Davidson, M.R. (2017). Contemporary Maternal-Newborn Nursing Care 9e. Pearson. 65  References Department of Health. (2020). Your pregnancy guide. https://www.fhs.gov.hk/english/health_info/woman/30005.pdf Dutta, D. C. (2015). DC Dutta’s Textbook of Obstetrics: Including Perinatology and Contraception (8th ed.). The Health Sciences Publisher. London, M. L. (2017). Maternal & child nursing care (5th ed.). Pearson. McKinney, E. S. (2018). Maternal-child nursing (5th ed.). Elsevier. Rocci, S., Kyle, T., & Carmen, S. (2021). Maternity and Pediatric Nursing (4th ed.). Wolters Kluwer. Weiland Ladewig, P.A., London, M.L., & Davidson, M.R. (2017). Contemporary Maternal-Newborn Nursing Care 9e. Pearson. 65