Unit X

Prenatal Care
Pelvic Examination
Pelvic examination is a procedure in which a skilled health care provider examines the
vaginal area as well as the surrounding area of pelvis. It gives information for verifying the
pregnancy, determining the length of the pregnancy, and identifying pelvic features and any
anomalies that could lead to pregnancy complications as well as look for external genital
regions. Simultaneously, specimens are gathered to screen for any abnormalities that could
impair the pregnancy's progress or outcome.
The pelvic exam is usually performed during the 1 st or third trimester of pregnancy. It is not
routine part of basic care to the pregnant women. It may be performed in some uncommon
instances such as when a women is experiencing particular difficulties. It should be
undertaken under aseptic condition and should be performed by skilled professionals only
when indicated.

Components of Pelvic examination

 Pelvic exam involves mainly two components;

1. Manual: The manual evaluation involves checking of the vulva or the external genitalia,
and the internal evaluation of the vaginal walls.

2. Visual (Speculum examination): the visual examination involves scrutinizing of all the
pelvic organs with the help of a device known as the speculum.

Indications for pelvic examination

 First Trimester: A pelvic exam during early pregnancy is conducted in order to see if
the cervix has been appropriately covered up by the mucus plug.

 Third Trimester: A pelvic exam during the third trimester of pregnancy is a standard
prenatal screening. The pelvic exam is performed to determine the effacement and
dilatation of the cervix in order to determine the remaining time for delivery.

 Complications: In case you are going through complications such as spotting, you
are prone to preterm labour, a noticeable growth in the pelvic area is observed or are
suffering from any vaginal infection; a pelvic exam could be conducted during any time of
your pregnancy.
 Contraindications for Pelvic Examination
1. Antepartum haemorrhage.
2. Preterm and prelabour rupture of the membranes without contractions (except with a sterile
speculum to confirm or exclude rupture of the membranes).

Procedure of Pelvic Examination

1) The bladder must be empty.
2) The procedure must be carefully explained to the patient.
3) The patient is put in the dorsal or lithotomy position:
a) The dorsal position is more comfortable and less embarrassing than the lithotomy
position and does not require any equipment. This is the position most often used.
b) The lithotomy position provides better access to the genital tract than the dorsal position.
Lithotomy poles and stirrups are required.
4) Examination of vulva:
The vulva must be carefully inspected for any abnormalities, such as scars, warts,
varicosities, congenital abnormalities, ulcers or discharge.

5) Speculum Examination:
a. A speculum examination is always performed at the first antenatal visit. At subsequent
antenatal visits this examination is only done when indicated, e.g. to investigate a vaginal
discharge or in the case of preterm or prelabour rupture of the membranes.
b. The Cusco or bivalve speculum is the one most commonly used.

6) Performing a bimanual examination:

a. Gloved the hand and lubricate the fingers and gently inserted into the vagina.
b. If a vaginal septum or stenosis is present, the patient should be referred to a doctor to
decide whether delivery will be interfered with or not.
c. The cervix is palpated and the following are noted:
 Whether the surface is smooth.
 Any dilatation.
 The length of the cervix in cm, i.e. whether the cervix is effaced or not.
 The surface should be smooth and regular.
 The consistency, which will become softer during pregnancy.
d. Special care must be taken, when performing a bimanual examination late in pregnancy
and in the presence of a high presenting part, not to damage a low-lying placenta. If the
latter is suspected, a finger must not be inserted into the cervical canal. Instead, the
presenting part is gently palpated through all the fornices. If any bogginess is noted
between the fingers of the examining hand and the presenting part, the examination must
be immediately abandoned and the patient must be referred urgently for ultrasonography.
e. Where possible the presenting part is identified.
f. A most important part of the bimanual examination is the determination of the gestational
age, by estimating the size of the uterus and comparing it with the period of amenorrhea.
This is only really accurate in the first trimester. Thereafter, the fundal height and the size
of the fetus must be determined by abdominal examination.
g. The uterine wall is palpated for any irregularity, suggesting the presence of a congenital
abnormality (e.g. bicornuate uterus) or fibroids.
h. Lastly, the fornices are palpated to exclude any masses, the commonest of which is an
ovarian cyst or tumor.

7) Explanation to Patient
Do not forget to explain to the patient, after the examination is completed, what you have
found. It is especially important to tell her how far pregnant she is, if that can be determined,
and to reassure her, if everything appears to be normal.

Risk of Pelvic Examination

The following risks may be involved in a pelvic exam;

 Infections may spread due to a pelvic exam. This is due to bacteria that may be
present in the vagina being pushed up the cervix.

 Severe damage could also occur, i.e. the cervix may get stimulated which, in turn,
could lead to labour. And, in case your baby is not yet developed to come out, the
probability of a preterm baby would increase.

 The pelvic exam could also lead to a condition known as PROM, i.e. premature
rupture of membrane.
 The result of a pelvic exam indicates the time when a woman would go into the
labour. And, in case that time doesn’t match in reality, a woman may get anxious. This, in
turn, can lead to her requesting for labour induction.
 Assessment of Fetal Well Being
Nowadays, the intrauterine fetus is regarded as the second patient, while the expectant mother
is regarded as the first. The fetus is at a higher risk of illness and mortality during pregnancy
than the mother. As a skilled midwife, we must examine the fetus prior to delivery and take
necessary measures based on the condition.
Approximately 3% of live born infants have a major congenital anomaly. Genetic factors are
usually responsible. About 50% of 1st trimester spontaneous abortions and about 5% of still
birth infants have chromosomal abnormalities.

Known Risk Factors for Developing Fetal Compromise

 Primigravida above the age of 30 years.
 Pregnancy above 35 years. There is an increased risk of Down's syndrome.
 Pregnancy associated with medical complications. E.g. epilepsy, HTN, renal disease,
cardiac disease, diabetes, syphilis & AIDS etc.
 Clinical evidence of polyhydraminous or Oligohydraminous, placental insufficiency.
 Previous history of still birth or neonatal death.
 History of recurrent abortion or preterm labour.
 Rh- isoimmunization.
 Previous baby with structural / congenital defect. E.g. Spinal bifida, cleft palate,
anencephaly etc.
 Previous child with chromosomal abnormalities. E.g. autosomal trisomy.
 Maternal illness during 1st trimester of pregnancy.
 Methods of Fetal Assessment

Maternal serum alpha fetoprotein

(MSAFP)

Triple Test

Biochemical Amniocentesis

Chorionic Villi
Sampling
Early Pregnancy

Cordocentesis

Biophysical USG imaging

 Late Pregnancy

Clinical Biochemical Biophysical

Maternal wt. gain Urinary or plasma Fetal Movement Count

Oestriol

Fundal Height Plasma Human Placental Cardiotocography

lactogen
Blood Pressure Non- stress Test
Amniocentesis
Oedema Doppler
Ultrasonography
Amniotic Fluid
distribution

Fetal Position/
Presentation

Girth of Abdomen
Ultrasound (USG) Imaging
An ultrasound is a type of imaging exam that uses sound waves to see how a fetus develops
inside the womb and also it is performed to examine the female pelvic organs during
pregnancy.
The individual conducting the test applies a transparent water-based gel to the woman's
abdomen and pelvic area before moving a hand-held probe over it. The gel aids in the
transmission of sound waves by the probe. The ultrasound equipment creates an image by
bouncing these waves off the body components, including the developing fetus. In the same
situation, a pregnancy ultrasound can be performed by inserting the probe into the vaginal
canal.

Preparation before Ultrasonography

In the early stages of pregnancy, this scan is frequently performed in the outpatient
department of a hospital. It is possible that women will be needed to have a full bladder. So,
you need to drink fluids (3 to 4 glasses of water) around an hour before the scan. A full
bladder helps to elevate the big bowel out of the pelvis, allowing the womb to be seen more
clearly, as well as move the uterus higher up in the women's belly, allowing the unborn baby
to be seen more clearly.

Method
1) Abdominal Ultrasound: This method is usually used for scans after 12 to 14 weeks of
pregnancy.
2) Transvaginal Ultrasound: It's a sort of ultrasound that looks at the inside of the pelvis. It
examines a woman's reproductive organs, such as the uterus, ovaries, cervix, and vagina. The
term "transvaginal" refers to a procedure that takes place through the vaginal canal. The
healthcare provider will insert a transducer into the vaginal canal.
This method is used only if the scan is being done in the 1 st 12 to 14 weeks of pregnancy. At
this stage, the fetus is very small and vaginal scans gives a better view compared to an
abdominal scan.
What to look through USG??

 In 1st Trimester (16- 18 weeks) to obtain the information about;

- Number, size and location of gestational sac.
- Presence or absence of fetal cardiac and body movements.
- Presence or absence of uterine abnormality.
- Pregnancy dating

 In 2nd and 3rd Trimester to obtain the information about;

- Fetal viability
- Number, position, gestational age, growth pattern and abnormality.
- Amniotic fluid volume.
 - Placental location and maturity.
- Uterine fibroid and other abnormalities.
- IUGR with abdominal circumference, head circumference and amniotic fluid volume.

Doppler Ultrasound (Doppler Flow Studies or Doppler Velicometry)

It is a non- invasive method for studying intrauterine environment specifically the utero
placental blood flow in the umbilical arteries. Doppler ultrasound monitors flow in blood
vessels and can be used to check placental function. A specialized ultrasound machine is used
to measure the flow of blood through fetal vessels. The ultrasound transducer is placed on the
women's abdomen and blood flow can be assessed in the umbilicus vessels, fetal brain, and
fetal heart. If test shows that the blood flow via fetal vessels is less than normal, the fetus may
not be receiving enough oxygen and nutrients from the placenta.

Procedure
 Position the patient in supine.
 A pulsed Doppler device will be positioned over the fetus.
 The direction of blood flow within the umbilical arteries is calculated using the difference
between the systolic and diastolic flow.

Interpretation
 Elevation of the systolic/ diastolic ratio above 3.0 are considered abnormal.
 Elevation of the (S/D) ratio are seen in hypertensive disorders of pregnancy, fetal growth
retardation and other causes of utero placental insufficiency.
 Normal umbilical venous flow in monophonic.

Care Needed for Pregnant Women

One of the most important aspects of preconception and prenatal treatment is women's
education and care. When used broadly, the phrase prenatal education refers to information
sharing between childbearing women and their parents or caregivers, with the goal of
assisting women in making informed choices and decisions regarding their pregnancy,
childbirth, and early postnatal period.
Need for care:
1) Nutrition/ Diet
2) Antenatal Hygiene
- Rest and Sleep
- Exercise
- Travel
- Smoking
 - Alcohol
- Personal hygiene
- Sexual relation & safer sex
3) Immunization
4) Birth preparedness
5) Family planning
6) Early exclusive breast feeding
7) HIV counselling & testing
8) Routine Antenatal Care
9) Malaria prophylaxis in endemic
10) Deworming
11) Teratogens
12) Behavior change communication (BCC)

References;
Subedi,D.,& Gautam, S. (Jan, 2016). Midwifery Nursing Part- I. In Antenatal Examination and Care
(3rd edition ed., pp. 219- 222, 239- 242, 259 - 276). Medhabi Publication, Jamal, Kantipath,
Kathmandu.
Tuitui, R. (2018). Manual of Midwifery - I (Antepartum Care and Gynecological Nursing). In
Antenatal Examination (pp. 243- 246, 250, 253- 270). Vidyarthi Pustak Bhandar, Bhotahiti,
Kathmandu.

https://parenting.firstcry.com/articles/pelvic-exam-during-pregnancy-procedure-and-risks-
associated/
https://bettercare.co.za/learn/maternal-care/text/01c.html