The Pregnant Woman

Joyce E. (Beebe) Thompson

This chapter focuses on the evaluation of the healthy adult woman who is pregnant. The techniques of history-taking and examination for pregnant and nonpregnant women are similar. However, it is important to recognize the changes in anatomy and physiology that are related to pregnancy rather than an abnormality. This chapter emphasizes the common changes in anatomy and physiology that evolve throughout pregnancy, special concerns for the health history, and recommendations for nutrition and exercise. There is also information on screening pregnant women for domestic violence. Next are the techniques of examination for initial and follow-up care. Ideally, the pregnant woman begins her prenatal visits 6 to 8 weeks after conception. For those women seeking initial care in the second or third trimesters, the modified Leopold's maneuvers are reviewed to help you assess the woman presenting late in pregnancy.

As you begin thinking about the pregnant woman, you may wish to review the sections on anatomy and physiology in Chapter 8, The Breasts and Axillae, and in Chapter 11, Female Genitalia. During pregnancy, there are changes in the thyroid gland, breasts, abdomen, and pelvis. You may also detect minor skin changes such as the mask of pregnancy and abdominal striae.

During pregnancy, the thyroid gland and the breasts undergo moderate enlargement due to hormonal stimulation and increased vascularity and hyperplasia of glandular tissue. There may be tenderness and tingling in the breasts that makes them more sensitive during examination. By the third month of gestation, the breasts become more nodular, requiring careful palpation to avoid discomfort as you examine for any breast masses. The nipples become larger and more erectile. From mid to late pregnancy, colostrum, a thick, yellowish secretion rich in nutrients, may be expressed from the nipples. The areolae darken, and Montgomery's glands are more prominent. The venous pattern over the breasts becomes increasingly visible as pregnancy progresses.

The abdomen's most notable change is distention, primarily from the increasing size of the growing uterus and fetus. Early distention from fluid retention and relaxation of abdominal muscles may be noted before the uterus becomes an abdominal organ (12-14 weeks of gestation). The expected growth patterns of the normal uterus and fetus are illustrated on the right, and the standing contours of the primigravid abdomen in each trimester of pregnancy are illustrated below.

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