Anatomy and Physiology

Saturday, 24 July 2021 2:49 pm

Physiologic Hormonal Changes

• alter many of the body systems
• result in visible changes in anatomy
• estrogen
○ promotes endometrial growth
○ stimulate marked enlargement of the pituitary gland (up to 135%)
○ increases prolactin output
 readies breast tissue for lactation
○ contributes to the hypercoagulable state
 pregnant women have 4-5 times higher risk for thromboembolic events, primarily in the venous system
○ increases thyroid-binding globulin
• progesterone
○ increases tidal volume and alveolar minute ventilation
 though respiratory rate remains constant
 can result to respiratory alkalosis and shortness of breath
○ increased progesterone and estradiol can result to lower esophageal sphincter tone
 contributes to gastroesophageal reflux
○ relaxes tone in the ureters and bladder
 can cause hydronephrosis (right ureter more than the left)
□ more on right because of dextrorotation of the uterus
 increased risk of bacteriuria
• human chorionic gonadotropin
○ has five variant subtypes
 two are produced by the placenta and support progesterone synthesis in the corpus luteum, stabilizing the endometrium and
preventing loss of the early embryo to menstruation
□ serum and urine pregnancy assays test primarily for the two pregnancy-related HCG variants
 three isoforms are produced by different cancers and the pituitary gland
○ stimulates TSH receptors
• placental growth hormone
○ influences fetal growth and the development of preeclampsia
○ implicated in insulin resistance after midpregnancy and in gestational diabetes
 carries a lifetime risk of progressing to type 2 diabetes of up to 60%
• physiologic hyperthyroidism
○ results from increase thyroid-binding globulin due to rising levels of estrogen and stimulation of thyroid-stimulating hormone (TSH)
receptors by HCG
 this results in a slight increase in serum concentrations of free T3 and T4, while serum TSH concentrations appropriately decrease
• relaxin
○ secreted by the corpus luteum and placenta
○ involved in the remodeling of reproductive tract connective tissue
 facilitate delivery
 increased renal hemodynamics
 increased serum osmolality
○ despite its name, it does not affect peripheral joint laxity during pregnancy
• weight gain and shifts in the center of gravity
○ contribute to lumbar lordosis and other musculoskeletal strain
• erythropoietin
○ raises erythrocyte mass
• plasma volume increases to a greater extent
○ causes relative hemodilution and physiologic anemia
 can protect against blood loss during birth
• cardiac output increases but systemic vascular resistance decreases
○ resulting in a net fall in blood pressure
 especially during the second trimester
 returns to normal by the third trimester
• basic metabolic rate increases up to 15-20%
○ increases daily energy demands
 85 kcal/d in the 1st trimester
 285 kcal/d in the 2nd trimester
 475 kcal/d in the 3rd trimester

Anatomic Changes
• changes in the breasts, abdomen, and urogenital tract are the most visible signs of pregnancy
• breasts

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• breasts
○ become moderately enlarged
 due to hormonal stimulation that causes increased vascularity and glandular hyperplasia
○ become more nodular in the 3rd month of gestation
○ nipples
 larger
 more erectile
 darker areolae
 more pronounced Montgomery glands
○ venous pattern becomes visibly more prominent as pregnancy progresses
○ in 2nd & 3rd trimester, some women secrete colostrum
 colostrum is a thick, yellowish, nutrient-rich precursor to milk
○ breast tenderness may make pregnant women more sensitive during examination
• uterus
○ contributors of the growth of uterus
 muscle cell hypertrophy
 increases in fibrous and elastic tissue
 development of blood vessels and lymphatics

○ increases in weight
 from 70 g at conception to 1100 g at delivery, when it accommodates 5-20 L of fluid
○ first trimester:
 confined to the pelvis
 shaped like an inverted pear
○ 12-14 weeks:
 beyond the pelvic rim
 globular shape
 externally palpable
○ beginning in 2nd trimester
 enlarging fetus pushes the uterus into an anteverted position
□ encroaches into the space usually occupied by the bladder
 triggers frequent voiding
□ intestines are displaced laterally and superiorly
○ stretches its own supporting ligaments
 causes “round ligament pain” in the lower quadrants
○ slightly dextrorotates to accommodate the rectosigmoid structures on the left side of the pelvis
 leads to greater discomfort on the right side as well as increased right-sided hydronephrosis
• vagina
○ Chadwick's sign
 bluish color due to increased vascularity throughout the pelvis
○ vaginal walls
 deeply rugated
□ causes
 thicker mucosa
 loosening of the connective tissue
 hypertrophy of smooth muscle cells
○ vaginal secretions
 may become thick, white, and more profuse, known as leukorrhea of pregnancy
○ increased glycogen stores in the vaginal epithelium
 proliferates Lactobacillus acidophilus
□ lowers vaginal pH
 protects against some vaginal infections
 may contribute to higher rates of vaginal candidiasis
• cervix

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• cervix
○ softens and turns bluish or cyanotic in color 1 month after conception
 causes
□ increased vascularity
□ edema
□ glandular hyperplasia
○ Hegar's sign
 palpable softening of the cervical isthmus

○ cervical remodeling involves rearrangement of the cervical connective tissue

 decreases collagen concentration
 facilitates dilatation during delivery
○ mucus plug
 fill the cervical canal soon after conception
 protects the uterine environment from outside pathogens
 expelled as bloody show at delivery
• adnexae
○ corpus luteum
 ovarian follicle that has discharged its ovum
 may be prominent enough to be felt on the affected ovary as a small nodule in early pregnancy
□ disappears by midpregnancy
• external abdominal wall
○ the skin stretches to accommodate the fetus
 may result to:
□ striae gravidarum
 purplish
 "stretch marks"
□ linea nigra
 brownish black pigmented vertical stripe along the midline skin

○ abdominal wall tension increases with advancing pregnancy

 may result to diastasis recti
□ caused by separation of rectus abdominis muscles
□ if it is severe, especially in multiparous women:
 only a layer of skin, fascia, and peritoneum may cover the anterior uterine wall
◊ fetal parts may be palpable through this muscular gap

• common concerns during pregnancy

○ amenorrhea (missed periods)
 often the first noticeable sign of pregnancy
 due to high estrogen, progesterone and HCG

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  due to high estrogen, progesterone and HCG
□ prevents menses
 all trimester
○ heartburn
 causes
□ progesterone
 relaxes the lower esophageal sphincter
◊ allows gastric contents to reflux into the esophagus
□ gravid uterus
 exerts physical pressure against the stomach
◊ contributes to reflux symptoms
 all trimester
○ urinary frequency
 causes
□ increased blood volume and filtration rate
 result to increased urine production
□ gravid uterus
 exerts pressure that reduces potential space for the bladder
 all trimester
 dysuria or suprapubic pain should be investigated for urinary tract infection
○ vaginal discharge
 leukorrhea
□ asymptomatic milky white discharge
□ results from increased secretions from vaginal and cervical epithelium
 due to vasocongestion and hormonal changes
□ any foul-smelling or pruritic discharge should be investigated
 all trimester
○ constipation
 results from slowed gastrointestinal transit due to:
□ hormonal changes
□ dehydration from nausea and vomiting
□ supplemental iron in prenatal vitamins
 all trimester
○ hemorrhoids
 caused by
□ constipation
□ decreased venous return from increasing pressure in the pelvis
□ compression by fetal parts
□ changes in activity level during pregnancy
 all trimester
○ backache
 due to
□ hormonally induced relaxation of the pelvic ligaments
□ lordosis
 required to balance the gravid uterus
□ breast enlargement
 may contribute to upper backaches
 all trimester
○ nausea and/or vomiting
 poorly understood but appears to reflect:
□ hormonal changes
□ slowed gastrointestinal peristalsis
□ alterations in smell and taste
□ sociocultural factors
 hyperemesis gravidarum
□ vomiting with weight loss of >5% of prepregnancy weight
 1st trimester
○ breast tenderness/tingling
 due to pregnancy hormones stimulating growth of breast tissue, causing:
□ swelling and possible aching
□ tenderness
□ tingling
 increased blood flow
□ can make delicate veins more visible beneath the skin
 1st trimester
○ fatigue
 related to:
□ rapid change in energy requirements
□ sedative effects of progesterone
□ changes in body mechanics

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 □ changes in body mechanics
 due to the gravid uterus
□ sleep disturbance
 1st or 3rd trimester
□ many women report increased energy and well-being during the second trimester
○ lower abdominal pain
 2nd trimester
□ rapid growth
 causes tension and stretching of the round ligaments that support the uterus
◊ results to sharp or cramping pain with movement or position change
○ abdominal striae
 striae gravidarum
□ "stretch marks"
□ thin, usually pink bands
□ may persist or fade over time after delivery
 causes:
□ stretching of the skin
□ tearing of the collagen in the dermis
 2nd or 3rd trimester
○ contractions
 Braxton Hicks contractions
□ irregular and unpredictable uterine contractions
 rarely associated with labor
 painful or regular contractions should be evaluated for onset of labor
 3rd trimester
○ loss of mucus plug
 common during labor
 may occur prior to the onset of contractions
 unlikely to trigger the onset of labor when there are:
□ no regular contractions
□ no bleeding
□ no loss of fluid
 3rd trimester
○ lower extremity edema
 causes:
□ decreased venous return
□ obstruction of lymphatic flow
□ reduced plasma colloid oncotic pressure
 sudden severe edema and hypertension may signal preeclampsia

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The Health History
Saturday, 24 July 2021 2:51 pm

Overview
• common concerns
○ initial prenatal history
 confirmation of pregnancy
 symptoms of pregnancy
 concerns and attitude of pregnancy
 current health and past clinical history
 past obstetric history
 risk factors for maternal and fetal health
 family history of patient and father of the newborn
 plans for breastfeeding
 plans for postpartum contraception
○ determining gestational age and expected date of delivery
• prenatal care
○ optimizing health and minimizing risk for the mother and fetus
○ initial prenatal visit
 goals:
□ define the health status of the mother and fetus
□ confirm the pregnancy
□ estimate gestational age
□ develop a plan for continuing care
□ counsel the mother about her expectations and concerns
 best timed early in pregnancy, but may occur at later in gestation
○ subsequent visits
 assess any interim changes in the health status of the mother and fetus
 review specific physical examination findings related to the pregnancy
 provide counseling and timely preventive screenings

Initial Prenatal History

• tailor your history to where it falls during the mother’s gestational cycle
• confirmation of pregnancy
○ ask about:
 urine pregnancy test and when
 LMP
 ultrasound
○ explain that serum pregnancy tests are rarely required to confirm pregnancy
• symptoms of pregnancy
○ ask about
 amenorrhea
 breast tenderness
 nausea
 vomiting
 fatigue
 urinary frequency
 heartburn
 vaginal discharge
 constipation
 backache
 lower abdominal pain
• concerns and attitudes toward pregnancy
○ ask about
 how the patient feels:
□ excited? concerned? scared?
□ planned?
 if it is planned or not
□ if not, does she plan to complete the pregnancy to term, terminate, or consider adoption

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 □ if not, does she plan to complete the pregnancy to term, terminate, or consider adoption
 if a partner or other family support network is involved
○ support the patient’s choices when unexpected admissions arise, such as a pregnancy resulting from a
coerced sexual act, or the wish to end the pregnancy
• current health and past clinical history
○ pay particular attention to conditions that affect pregnancy such as:
 abdominal surgeries
 hypertension
 diabetes
 cardiac disorders including childhood surgery for congenital heart disease
 asthma
 hypercoagulability states
□ from lupus anticoagulant or anticardiolipin antibodies
 mental health disorders such as postpartum depression
 human immunodeficiency virus (HIV)
 sexually transmitted infections (STIs)
 abnormal Pap smears
 exposure to diethylstilbestrol (DES) in utero
• past obstetric history
○ ask about
 number of prior pregnancies
□ number of term deliveries
□ number of preterm deliveries
□ number of spontaneous pregnancies
□ number of terminated pregnancies
 complications during pregnancy
□ diabetes
□ hypertension
□ preeclampsia
□ intrauterine growth restriction
□ preterm labor
 complications during labor and delivery
□ large babies (fetal macrosomia)
□ fetal distress
□ emergency interventions
 deliveries
□ vaginal delivery
□ assisted delivery
 vacuum
 forceps
□ cesarean section
• risk factors for maternal and fetal health
○ ask about
 vices
□ tobacco
□ alcohol
□ illicit drugs
 medications
 over-the-counter-drugs
 herbal preparations
 toxic exposures
□ work
□ home
□ other settings
 nutrition
□ adequate?
 risk from obesity
 social support network?
□ adequate?
 source of income
□ adequate?
 unusual sources of stress

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  unusual sources of stress
□ home
□ work
 history of physical abuse
 history of domestic violence
• family history
○ ask about
 family history of the partner
 ethnic backgrounds of the patient and partner
 genetic diseases
□ sickle cell anemia
□ cystic fibrosis
□ muscular dystrophy
□ others
 if there are babies with congenital problems in the family
• plans for breastfeeding
○ breastfeeding
 protects the baby against a variety of infectious and noninfectious conditions
 exerts a protective effect on the mother against breast cancer and other conditions
○ education during pregnancy and clinician encouragement increase the subsequent rate and duration of
maternal breastfeeding
• plans for postpartum contraception
○ initiate this discussion early
 postpartum conception reduces the risk of unintended pregnancy and shortened interpregnancy
intervals
 the latter two are linked to increases in adverse pregnancy outcomes

Determining Gestational Age and the Expected Date of Delivery

• accurate dating
○ best done early
○ contributes to appropriate management of the pregnancy
○ establishes the timeframe for
 reassuring the patient about normal progress
 establishing paternity
 timing screening tests
 tracking fetal growth
 triaging preterm and postdated labor
• gestational age
○ count the number of weeks and days from the first day of the LMP
 counting this menstrual age from the LMP, although biologically distinct from date of
conception, is the standard
means of calculating fetal age, yielding an average pregnancy length of 40 weeks
○ if the actual date of conception is known (as with in vitro fertilization), a conception age which is 2
weeks less than the menstrual age can be used to calculate menstrual age (i.e., a corrected or adjusted
LMP dating) to establish dating
○ example:
 LMP is 06 02 2021 and today is 07 26 2021
 gestational age
□ 30 (number of days of June) - 2 (LMP) = 28
□ 28 + 26 (remaining days) = 54
 note that the number of days in different months may not be the same
□ 54 ÷ 7 (number of days in a week) = 7 remainder 5
□ thus gestational age is 7 weeks and 5 days
• expected date of delivery
○ abbreviated as EDD
○ 40 weeks from the first date of the LMP
○ can be estimated using Naegele's rule
 take the LMP
 subtract 3 months
 add 7 days
 add 1 year
○ example:
 LMP is 06 02 2021

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  LMP is 06 02 2021
 so,
06 02 2021
-3 +7 +1
03 09 2022
 thus the EDD is March 09, 2022
○ commonly used tools to calculate EDD
 pregnancy wheels
 online calculator
□ may be more reliable
□ should be checked for accuracy before routine use
• limitations on pregnancy dating
○ patient recall of the LMP is highly variable
 even when this date is accurate, the LMP can be affected by the following that result in atypical
cycle lengths:
□ hormonal contraceptives
□ menstrual irregularities
□ variations in ovulation
○ LMP dating should be checked against physical examination markers such as fundal height
 any wide discrepancies should be clarified by ultrasound evaluation
○ dating by ultrasound
 widespread, regardless of the certainty of the LMP
 not currently endorsed by national guidelines

Concluding the Initial Visit

• reaffirm your commitment to the woman’s health and her concerns during pregnancy
• review your findings
• discuss any tests or screenings that are needed
• ask if she has further questions
• reinforce the need for regular prenatal care
• review the timing of future visits
• record your findings in the prenatal record

Subsequent Prenatal Visits

• optimal number of prenatal appointments has not been well established
• obstetric visits traditionally follow a set schedule
○ monthly until 28 gestational weeks (7th month)
○ biweekly until 36 weeks (9th month)
○ weekly until delivery
• update and document the history at every visit, especially:
○ fetal movement felt by the patient
○ contractions
○ leakage of fluid
○ vaginal bleeding
• physical examination findings at every visit should include
○ vital signs
 especially blood pressure and weight
○ fundal height
○ verification of fetal heart rate (FHR)
○ determination of fetal position and activity
○ testing of urine for infection and protein

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Health Promotion and Counseling
Saturday, 24 July 2021 2:52 pm

Overview
• important topics for health promotion and counseling
○ nutrition
○ weight gain
○ immunizations
○ exercise
○ substance abuse
○ intimate partner violence
○ prenatal laboratory screening

Nutrition
• evaluate the nutritional status during the 1st prenatal visit
• diet history
○ typical meal
○ how often does she eat?
○ with nausea that limits her eating?
○ with history of conditions that affect food intake?
 diabetes
 eating disorders
 past bariatric surgery
• review BMI and laboratory findings
○ BMI reflects the gravid uterus later in pregnancy
○ hematocrit
 screen for anemia
 may reflect
□ nutritional deficiency
□ underlying clinical issues
□ expected hemodilution later in pregnancy
• recommend a prenatal vitamin
○ daily supplements
 folic acid (400 μg)
 vitamin D (600 IU)
 iron (27 mg)
 calcium (>1000 mg)
 iodine (150 to 290 μg)
□ including breastfeeding women
○ patients should be advised that excess amounts of fat-soluble vitamins (A, D, E,
and K) can cause toxicity
• pregnant women are especially vulnerable to listeriosis
○ to prevent it, caution the patient about foods to avoid as encouraged by ACOG:
 unpasteurized milk
 foods made with unpasteurized milk
 raw and undercooked seafood, eggs, and meat
 refrigerated paté
 meat spreads
 smoked salmon
 hot dogs
 luncheon meats
 cold cuts unless served steaming hot
• fish and shellfish
○ omega-3 fatty acids and dehydroepiandrostenedione (DHEA) may enhance fetal brain development
○ ACOG recommends:
 two servings a week of selected fish and shellfish
○ intake should include 8 to 12 ounces a week of fish lower in mercury such as:
 salmon
 shrimp

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  shrimp
 pollock
 tuna (light canned)
□ white tuna consumption should be limited to 6 ounces a week
 tilapia
 catfish
 cod
○ pregnant women should avoid fish higher in mercury like:
 tilefish
 shark
 swordfish
 king mackerel
• make a nutritional plan
○ review goals for weight gain that are tailored to the patient’s BMI
 weight gain recommendations are incorporated into the Pregnancy Weight Gain Calculator and
Super Tracker at the user-friendly ChooseMyPlate.gov website
(http://www.choosemyplate.gov/pregnancy-weight-gain-calculator)
□ this calculator displays the daily recommended intake of each of the five food groups for
each trimester
 calculations of these amounts are based on:
◊ woman’s height
◊ prepregnancy weight
◊ due date
◊ levels of weekly exercise
○ small frequent meals may help with mild nausea
○ in complex cases such as gestational diabetes or eating disorders
 consider a team-based approach involving dieticians or behavioral health specialists

Weight Gain
• weight gain should be closely monitored during pregnancy
○ poor birth outcomes are associated with both excess and inadequate weight gain
• women with a normal BMI should gain 25 to 35 pounds during pregnancy

• weigh the patient at each visit and plot the results on a graph

Immunizations
• Tdap
○ persistent increase in pertussis infection in the United States
○ administered during each pregnancy
ideally at 27 to 36 weeks of gestation

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 ○ ideally at 27 to 36 weeks of gestation
○ regardless of the prior immunization history
○ caretakers in direct contact with the infant should also receive Tdap
• influenza
○ indicated in any trimester during the influenza season
• safe vaccines during pregnancy
○ pneumococcal
○ meningococcal
○ hepatitis B
• vaccines that can be given if indicated:
○ Hepatitis A and B
○ meningococcal polysaccharide and conjugate
○ pneumococcal polysaccharide
• unsafe vaccines during pregnancy
○ measles/mumps/rubella
 all women should have rubella titers drawn during pregnancy and be immunized after birth if
found to be nonimmune
○ polio
○ varicella
• anti-D immunoglobulin
○ check Rh(D) and antibody typing at:
 first prenatal visit
 28 weeks
 delivery
○ should be given to all Rh-negative women at 28 weeks’ gestation and again within 3 days of delivery

Exercise
• has a number of psychological benefits
• reduces risk of:
○ excessive gestational weight gain
○ gestational diabetes
○ preeclampsia
○ preterm birth
○ varicose veins
○ deep vein thrombosis (DVT)
• may reduce the length of labor
• may reduce complications during delivery
• excess activity is associated with low birth weight
• ACOG recommends that pregnant women should engage in ≥30 minutes of moderate exercise on most days
of the week unless there are contraindications
• pregnant women should be cautious
○ they must consider programs developed specifically for them
• water-based exercises can temporarily help alleviate musculoskeletal aches
○ immersion in hot water should be avoided
• after the first trimester, women should avoid exercise in the supine position which:
○ compresses the inferior vena cava
○ can cause dizziness and decreased placental blood flow
• because the center of gravity shifts in the third trimester, advise against exercises that cause loss of balance
• contact sports or activities that risk abdominal trauma are contraindicated throughout pregnancy
• pregnant women should avoid
○ overheating
○ dehydration
○ any exertion that causes notable fatigue or discomfort

Substance Use
• abstinence from substances of abuse is a top priority goal during pregnancy
• providing universal screening
○ can uncover subtle issues
○ help you address these topics in a neutral and constructive manner
• incarceration, confrontation, and criminalization of substance abuse have all been shown to worsen outcomes
of pregnancy for women and their children

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 of pregnancy for women and their children
• tobacco
○ implicated in:
 13% to 19% of all low–birth weight babies
 twofold risk of:
□ placenta previa
□ placental abruption
□ preterm labor
 increased risk of:
□ spontaneous abortion
□ fetal death
□ fetal digit anomalies
○ cessation is the goal
○ any decrease in use is favorable
• alcohol
○ fetal alcohol syndrome
 neurodevelopmental sequela of alcohol exposure during fetal development
 leading cause of preventable mental retardation in the United States
○ no safe dose of alcohol has been established
○ ACOG strongly recommends that women abstain throughout pregnancy
○ to promote abstinence, make use of:
 ACOG and CDC resources
 professional counseling
 inpatient treatment
 Alcoholics Anonymous
• illicit drugs
○ have significant detrimental effects on fetal development
○ pregnant women with addiction should be:
 referred for treatment immediately
 screened for HIV and hepatitis C infection
• abuse of prescription drugs
○ Ask about the unusual use of commonly abused drugs:
 narcotics
 stimulants
 benzodiazepines
 others
• herbal and unregulated supplements
○ review and discuss any intake of supplements and consider pregnancy toxicology
○ herbal supplements during pregnancy
 have been poorly studied
 can harm the developing fetus
○ unregulated supplements or vitamins
 may contain lead and other toxins

Intimate Partner Violence

• pregnancy is a time of increased risk from intimate partner violence
• pre-existing patterns of abuse may intensify from verbal to physical abuse or from mild to severe physical
abuse
has been associated with
○ delayed prenatal care
○ low infant birth weight
○ murder of the mother and fetus.
• ACOG recommends universal screening of all women for domestic violence without regard to socioeconomic
status
○ at the first prenatal visit
○ at least once each trimester

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 • watch for nonverbal clues of abuse such as:
○ frequent last-minute appointment changes
○ unusual behavior during visits
○ partners who refuse to leave the patient alone during the visit
○ bruises
○ other injuries
• it may take several visits for the patient to admit to abuse due to fear about safety and reprisal
• once the patient acknowledges abuse, ask about the best way for you to help her.
○ she may set limits on sharing information
○ accept her decisions about how to handle her situation safely, with the caveat that if children are
involved, you may be required to report harmful behaviors to the authorities
○ maintain an updated list of:
 shelters
 counseling centers
 hotline numbers
 other trusted local referrals
○ plan future appointments at more frequent intervals
○ complete as thorough a physical examination as the patient permits
 document all injuries on a body diagram

Prenatal Laboratory Screenings

• standard prenatal screening panel includes
○ blood type
○ Rh antibody
○ CBC
 especially:
□ hematocrit
□ platelet count
○ rubella titer
○ syphilis test
○ hepatitis B surface antigen
○ HIV test
○ STI
 gonorrhea c
 chlamydia
○ urinalysis with culture
• scheduled screenings include
○ oral glucose tolerance test
 for gestational diabetes
 24 to 28 weeks
 ACOG and the American Diabetes Association recommend testing for glucose tolerance in the
first trimester for obese pregnant patients

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 first trimester for obese pregnant patients
○ rectovaginal swab
 for group B streptococcus
 between 35 and 37 weeks
• if indicated, pursue additional tests related to the mother’s risk factors, such as screening for:
○ aneuploidy,
○ Tay–Sachs disease
○ genetic diseases
○ amniocentesis.

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Techniques of Examination
Saturday, 24 July 2021 2:52 pm

Overview
• be responsive to the patient’s comfort, and individual and cultural sensitivities
• if partners or children are present, ask if she wants them to stay during the physical examination
• if she has never had a pelvic examination, take the time to explain what is involved and seek her cooperation with each step
○ patients who have experienced sexual assault may resist the pelvic examination
 this reluctance should be explored and understood
• to ease examination of the breasts and abdomen, ask the patient to gown with the opening in front
• make sure that the equipment and examining tables accommodate obese patients
• make your touch and hand motions comforting as you examine the pregnant woman
• warm your hands
• use firm yet gentle palpation rather than abrupt pressure or kneading
• when possible, keep your fingers flattened together in smooth continuous contact with the skin on the abdominal surface
• the palmar surfaces of your fingertips are the most sensitive

Positioning
• in early pregnancy, the patient can be examined in the supine position
○ in later trimesters, the patient should adopt the semisitting position with the knees bent

 this position is more comfortable and reduces the weight of the gravid uterus on the descending aorta and inferior vena
cava
□ compression interferes with venous return from the lower extremities and pelvic vessels, causing the patient to feel
dizzy and faint, the supine hypotensive syndrome
• the pregnant woman should avoid lying supine for long periods
• most portions of the examination (except the pelvic examination) should be done in the sitting or left-side lying position
• during the examination:
○ encourage the patient to sit upright if she feels lightheaded
○ make sure she takes her time if she needs to stand up
• she may need to empty her bladder, especially before the pelvic examination
• complete your examination relatively quickly

Examining Equipment
• before beginning the examination, gather the equipment listed:
○ gynecologic speculum and lubrication
 a larger-than-usual speculum may be needed in multiparous patients
□ due to vaginal wall relaxation during pregnancy
○ sampling materials
 “broom” sampling device is preferred during pregnancy
□ because of the increased vascularity of vaginal and cervical structure, cervical brush may cause bleeding that
interferes with Pap smear samples
 use additional swabs as needed for
□ STIs screening
□ group B strep screening
□ wet mount preparations
○ tape measure
 plastic or paper tape measure is used to assess the size of the uterus after 20 gestational weeks
○ Doppler FHR monitor and gel
 “Doppler” or “Doptone”
□ a handheld device used to assess FHR after 10 weeks of gestation when applied externally to the gravid belly

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 □ a handheld device used to assess FHR after 10 weeks of gestation when applied externally to the gravid belly

General Inspection
• as she walks into the room and moves onto the examining table assess:
○ general health
○ emotional state
○ nutritional status
○ neuromuscular coordination

Height, Weight, and Vital Signs

• measure the height and weight
○ calculate the BMI with standard tables, using 19 to 25 as normal for the prepregnant state
○ hyperemesis gravidarum
 nausea and vomiting with weight loss that exceeds 5% of prepregnancy weight
 can lead to adverse pregnancy outcomes
• measure the blood pressure at every visit
○ blood pressure parameters in pregnancy follow the recommendations of the Eighth Joint National Committee (JNC8)
○ in the second trimester, blood pressure normally drops below the nonpregnant state
○ hypertensive disorders affect 5% to 10% of all pregnancies
○ all elevations in blood pressure must be closely monitored
○ hypertension can be both an independent diagnosis and a marker of preeclampsia syndrome
○ gestational hypertension
 systolic blood pressure (SBP) >140 mm Hg or diastolic blood pressure (DBP) >90 mm Hg
 first documented after 20 weeks
 without proteinuria or preeclampsia
 resolves by 12 weeks postpartum
○ chronic hypertension
 SBP >140 or DBP >90 that predates pregnancy
 affects almost 2% of U.S. births
○ preeclampsia syndrome
 a pregnancy-specific syndrome that can affect virtually every organ system
 lethal for the mother and fetus
 doubles the risk of later-life cardiovascular disease
 increases cardiovascular disease risk eight to ninefold in women with preeclampsia giving birth before 34 weeks’
gestation
 definition (either of the following)
□ SBP ≥140 or DBP ≥90 after 20 weeks on two occasions at least 4 hours apart in a woman with previously normal
BP or BP ≥160/110 confirmed within minutes and any of the following:
 proteinuria ≥300 mg/24 hours
 protein:creatinine ≥0.3
 dipstick 1+
□ new onset hypertension without proteinuria and any of the following:
 thrombocytopenia (platelets <100,000/μL)
 impaired liver function
◊ liver transaminase levels more than twice normal
 new renal insufficiency
◊ creatinine >1.1 mg/dL or doubles in the absence of renal disease
 pulmonary edema
 new onset cerebral or visual symptoms

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Head and Neck
• face the seated patient and inspect the head and neck
○ face
 chloasma
□ also known as melasma
□ known as the "mask of pregnancy"
□ irregular brownish patches around the forehead, cheeks, nose, and jaw
□ normal skin finding during pregnancy
 facial edema after 20 gestational weeks is suspicious for preeclampsia and should be investigated
○ hair
 may become dry, oily, or sparse during pregnancy
 mild hirsutism on the face, abdomen, and extremities is also common
 localized patches of hair loss should not be attributed to pregnancy
□ postpartum hair loss is common
○ eyes
 assess the conjunctivae and sclera for signs of pallor and jaundice
□ anemia may cause conjunctival pallor
○ nose
 inspect the mucus membranes and septum
□ nasal congestion and nose bleeds are more common during pregnancy
□ erosions and perforations of the nasal septum may represent use of intranasal cocaine
○ mouth
 examine the teeth and gums
□ gingival enlargement with bleeding is common during pregnancy
□ dental problems are associated with poor pregnancy outcomes
 initiate prompt dental referrals for tooth and gum pain or infections
○ thyroid gland
 modest symmetric enlargement is normal on inspection and palpation
□ caused by glandular hyperplasia and increased vascularity
 thyroid enlargement, goiters, and nodules are abnormal
□ require investigation

Thorax and Lungs

• count the respiratory rate
○ should remain normal throughout pregnancy
○ dyspnea accompanied by increased respiratory rate, cough, rales, or respiratory distress point to possible:
 infection
 asthma
 pulmonary embolus
 peripartum cardiomyopathy
• inspect the thorax
○ for contours and breathing patterns
• percuss
○ to observe diaphragmatic elevation that may be seen as early as the first trimester
• auscultate
○ for clear breath sounds without wheezes, rales, or rhonchi

Heart
• palpate
○ apical impulse
 may be rotated upward and to the left toward the fourth intercostal space by the enlarging uterus
• auscultate
○ venous hum or a continuous mammary souffle
 often found during pregnancy due to increased blood flow through normal vessels
○ mammary souffle
 commonly heard during late pregnancy or lactation
 strongest in the second or third intercostal space at the sternal border
 typically both systolic and diastolic
□ only the systolic component may be audible
○ assess dyspnea and signs of heart failure for possible peripartum cardiomyopathy, particularly in the late stages of pregnancy
○ murmurs
 may signal anemia
 investigate any diastolic murmur

Breasts

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Breasts
• breast examination is similar to that of a nonpregnant woman but with some notable differences
• inspect
○ symmetry and color
○ normal changes
 marked venous pattern
 darkened nipples and areolae
 prominent Montgomery's glands
○ inverted nipples need attention at the time of birth if breastfeeding is planned
• palpate
○ masses
 pathologic masses
□ may be difficult to isolate
□ warrant immediate attention
○ axillary lymph nodes
○ normal breasts may be tender and nodular during pregnancy
 severe focal tenderness with erythema in mastitis requires immediate treatment
• compress each nipple between your thumb and index finger
○ colostrum may express from the nipples during later trimesters
 reassure the patient that this is normal and that she may also experience “let down”
□ a "let down" is a spontaneous mild leakage often accompanied by a cramping sensation in the breast during a hot
shower or orgasm in the third trimester
○ bloody or purulent discharge should not be attributed to pregnancy

Abdomen
• help the patient move into a semisitting position
• inspect
○ striae
 normal in pregnancy:
□ purplish striae
□ linea nigra
○ scars
 cesarean scars on the abdomen may not match the orientation of the scar on the uterus
□ important when evaluating whether vaginal delivery is appropriate after cesarean section
○ size
○ shape
○ contour
• palpate
○ organs
○ masses
 mass of the gravid uterus is expected
○ fetal movements
 the examiner can usually feel these externally after 24 gestational weeks
 the mother can usually feel these by 18 to 24 weeks
□ quickening
 maternal sensation of fetal movement
 if fetal movement is not felt after 24 weeks:
□ consider:
 miscalculation of gestational age
 fetal death
 severe morbidity
 false pregnancy
□ confirm fetal health and gestational age with an ultrasound
○ uterine contractility
 irregular contractions
□ occur as early as 12 weeks
□ may be triggered by external palpation during the third trimester
 during contractions:
□ the abdomen feels tense or firm to the examiner, obscuring the palpation of fetal parts
 after the contraction:
□ the palpating fingers sense the relaxation of the uterine muscle
 regular uterine contractions before 37 weeks
□ abnormal regardless of pain and bleeding
□ suggests preterm labor
• fundal height

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• fundal height
○ measure the fundal height if gestational age is >20 weeks, when the fundus should reach the umbilicus
 with a plastic or paper tape measure, locate the pubic symphysis and place the “zero” end of the tape measure where you
can firmly feel that bone
 extend the tape measure to the very top of uterine fundus and note the number of centimeters measured

○ though subject to error between 16 and 36 weeks, measurement in centimeters should roughly equal the number of weeks of
gestation
 this low-technology, widely used technique may underdetect newborns who are small for gestational age
○ if fundal height is 4 cm greater than expected, consider:
 multiple gestation
 large fetus
 extra amniotic fluid
 uterine leiomyoma
○ if fundal height is 4 cm smaller than expected, consider:
 low-level amniotic fluid
 missed abortion
 intrauterine growth retardation
 fetal anomaly
○ the latter considerations should be investigated by ultrasound
• auscultate the fetal heart tones
○ Doppler fetal rate monitor (“Doppler” or “Doptone”)
 standard instrument for measuring FHR
□ FHR
 normally audible as early as 10 to 12 weeks’ gestation
 detection of the FHR may be slightly delayed in obese patients
 inability to locate the FHR should always be investigated with formal ultrasound
○ inaudible fetal heart tones may indicate:
 fewer weeks of gestation than expected
 fetal demise
 false pregnancy
 observer error
○ location
 FHR is located along the midline of the lower abdomen from 10 to 18 weeks’ gestation
□ after that time, the FHR is best heard over the back or chest and depends on fetal position
 Leopold's maneuvers can help identify the position
 after 24 weeks, auscultation of more than one FHR in different locations with varying rates suggests multiple gestation
○ rate
 110 to 160 beats per minute (BPM)
 60 to 90 BPM is usually maternal
 sustained dips in FHR, or “decelerations”
□ have a wide differential diagnosis
□ always warrant investigation, at least by formal FHR monitoring
○ rhythm
 FHR should vary 10 to 15 BPM from second to second
□ especially later in the pregnancy
 after 32 to 34 weeks, the FHR should become more variable and increased with fetal activity
 the subtlety can be difficult to assess with a Doppler but can be tracked with an FHR monitor if any questions arise
 lack of beat-to-beat variability is difficult to discern with a handheld Doppler, so this finding warrants formal FHR
monitoring

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Genitalia
• the patient will need to be supine with her feet placed in stirrups
○ assemble the needed equipment in advance
○ minimize the time she spends in this position to avert dizziness and hypotension from uterine compression of the major
abdominal vessels
• external genitalia
○ inspect
 normal changes of pregnancy:
□ relaxation of the vaginal introitus
□ enlargement of the labia and clitoris
 scars
□ in multiparous women, scars from perineal lacerations or episiotomy incisions may be present
 labial varicosities
□ labial varicosities that arise during pregnancy can become tortuous and painful
 cystoceles
 rectoceles
□ cystoceles and rectoceles may be pronounced due to the muscle relaxation of pregnancy
 lesions
 sores
□ lesions and sores occur with herpes simplex infection
○ palpate
 Bartholin's glands
□ tenderness
□ cysts
 Skene's Glands
□ tenderness
□ cysts
• internal genitalia
○ prepare for both a speculum and bimanual examination
○ speculum examination
 relaxation of the perineal and vulvar structures during pregnancy may minimize discomfort from the speculum
examination
 insert and open the speculum gently to prevent tissue trauma and bleeding
□ increased vascularity of vaginal and cervical structures promotes friability
 during the third trimester, perform this examination only when necessary
□ descent of the fetal parts into the pelvis can make the examination very uncomfortable
 inspect the cervix
□ color
 pink cervix suggests a nonpregnant state
□ shape (external os)
 circular dot in nulliparous cervix
 arc or "smile: in parous cervix
◊ parous cervix may also look irregular due to healed lacerations from prior deliveries
□ closure
□ ectropion
 inner portion of the cervix everts slightly during pregnancy
 appears as a glandular friable darker pink or red area inside the os
 cervical erosion, erythema, discharge, or irritation suggests cervicitis, and warrants investigation for STIs
 perform a Pap smear if indicated
 collect other vaginal specimens such as
□ STI cultures
□ wet mount samples
□ or group B strep swabs as appropriate
 inspect the vaginal walls as you withdraw the speculum and check for
□ color
 bluish in normal
□ relaxation
□ rugae
 deep in normal
□ discharge
 leukorrhea in normal
 investigate abnormal vaginal discharges for possible candida or bacterial vaginosis, which can affect
pregnancy outcome
○ bimanual examination
 often easier during pregnancy due to pelvic floor relaxation

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  often easier during pregnancy due to pelvic floor relaxation
 avoiding sensitive urethral structures, insert two lubricated fingers into the introitus, palmar side down, with slight
pressure downward on the perineum
 maintaining downward pressure on the perineum, gently turn the fingers palmar side up
 cervix
□ may be difficult to identify
 because of softening during pregnancy
◊ also known as the Hegar's sign
□ may feel irregular if there are nabothian cysts or healed lacerations from prior deliveries
□ cervical length
 to estimate, palpate the lateral surface of the cervical tip to the lateral fornix
 prior to 34 to 36 weeks’ gestation, the cervix should retain its initial length of 3 cm or greater
□ palpate the cervical os
 may be easier if
◊ the patient moves her heels as close to her buttocks as possible
 shortens the vagina
◊ and places her closed fists under her buttocks to tip the pelvis upward
 makes posterior cervices easier to palpate
 external os
◊ may be open to admit a fingertip in multiparous women
 internal os
◊ narrow passage between the endocervical canal and the uterine cavity
◊ should be closed until late pregnancy, regardless of parity
◊ may only be palpable by reaching behind or past the fetal parts
□ cervical opening or shortening (effacement) prior to 37 weeks may indicate preterm labor
□ as with speculum examination in late pregnancy, examine the cervix only when necessary because palpation is very
uncomfortable
 warn patients that it may cause cramping and pressure
 uterus
□ with your internal fingers placed at either side of the cervix and the external hand on the patient’s abdomen, use the
internal fingers to gently lift the uterus upward toward the abdominal hand
□ capture the fundal portion of the uterus between your two hands and assess the uterine size, keeping in mind the
contours of the gravid uterus at various gestational intervals
□ palpate
 shape
◊ an irregularly shaped uterus suggests
 uterine leiomyomata
 fibroids
 bicornuate uterus
– with two distinct cavities separated by a septum
 consistency
 position
 adnexa
□ palpate the right and left adnexa
 corpus luteum may be palpable as a small nodule on the affected ovary during the first weeks after
conception
□ after the first trimester, adnexal masses become difficult to feel
□ adnexal tenderness or masses early in gestation require ultrasound evaluation to rule out ectopic pregnancy
 pelvic floor
□ evaluate pelvic floor strength as you withdraw your examining fingers
□ acute pelvic inflammatory disease
 rare in pregnancy, especially after the first trimester
◊ because the adnexae are sealed by the gravid uterus and mucus plug

Anus
• inspect for external hemorrhoids
○ hemorrhoids
 often become engorged late in pregnancy
 may be painful, bleed, or thrombose
○ if present, note:
 size
 location
 any evidence of thrombosis

Rectum and Rectovaginal Septum

• rectal examination

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 • rectal examination
○ not standard in prenatal care unless there are concerning symptoms like
 rectal bleeding
 rectal masses
 conditions that compromise the rectovaginal septum
○ may help you assess the size of a retroverted or retroflexed uterus
 transvaginal ultrasound provides superior information

Extremities
• ask the patient to resume sitting or to lie on her left side
• inspect the legs for varicose veins
○ varicose veins may begin or worsen during pregnancy
• edema
○ rated on a 0 to 4+ scale
○ palpate the extremities for edema in:
 pretibial
 ankle
 pedal distributions
○ physiologic edema is common in the following due to decreased venous return from the lower extremities:
 advanced pregnancy
 hot weather
 women who stand for long periods of time
○ unilateral severe edema with calf tenderness warrants prompt evaluation for DVT
○ hand or facial edema after 20 gestational weeks
 nonspecific for eclampsia
 should be investigated
• elicit the knee and ankle deep tendon reflexes
○ hyperreflexia may signal cortical irritability from eclampsia, but clinical accuracy is variable

Special Techniques
• Leopold's maneuver
○ used to determine the fetal position in the maternal abdomen beginning in the second trimester
○ accuracy is greatest after 36 weeks’ gestation
○ less accurate for assessing fetal growth
○ findings help determine readiness for vaginal delivery by assessing:
 fetal pole
□ upper
 proximal fetal part
□ lower
 distal fetal part
 maternal side
□ where the fetal back is located
 descent of the presenting part into the maternal pelvis
 extent of flexion of the fetal head
 estimated size and weight of the fetus
□ an advanced skill that will not be addressed further here
○ common deviations include:
 breech presentation
□ when parts other than the head, such as buttocks or foot, present at the maternal pelvis
□ if discovered prior to term, breech presentations may sometimes be corrected by rotational maneuvers
 lack of engagement of the presenting part in the maternal pelvis at term
○ 1st maneuver
 upper fetal pole

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  stand at the woman’s side, facing her head
 palpate the uppermost part of gravid uterus gently, with the fingertips together, to determine what fetal part is located at
the fundus, which is the “upper fetal pole”
□ fetal buttocks
 usually at the upper fetal pole
 feels firm
 irregular
 less globular than the head
□ fetal head
 feels firm
 smooth
 round
□ occasionally, neither part is easily palpated at the fundus, as when the fetus is in a transverse lie
○ 2nd maneuver
 sides of the maternal abdomen

 place one hand on each side of the woman’s abdomen, capturing the fetal body between them
 steady the uterus with one hand and palpate the fetus with the other
□ look for the back on one side and extremities on the other
 fetal back
◊ by 32 weeks, has a smooth, firm surface as long or longer than the examiner’s hand
 fetal arms and legs
◊ feel like irregular bumps
 the fetus may kick if awake and active
○ 3rd maneuver
 lower fetal pole and descent into pelvis

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  face the woman’s feet
 place the flat palmar surfaces of the fingertips on the fetal pole just above the pubic symphysis
 palpate the presenting fetal part for texture and firmness to distinguish the head from the buttock
□ fetal head
 feels very firm
 smooth
 globular
□ fetal buttocks
 feels firm
 irregular
 less globular than the head
□ if the most distal part of the lower fetal pole cannot be palpated, it is usually engaged in the pelvis
 if you can depress the tissues over the maternal bladder without touching the fetus, the presenting part is
proximal to your fingers

 judge the descent, or engagement, of the presenting part into the maternal pelvis
 alternatively, use the Pawlik's grip by grasping the lower fetal pole with the thumb and fingers of one hand to assess the
presenting part and descent into pelvis
□ tends to be uncomfortable to the gravid patient
 vertex or cephalic presentation
□ the fetal head is the presenting part
○ 4th maneuver
 flexion of the fetal head

 this maneuver assesses the flexion or extension of the fetal head, presuming that the fetal head is the presenting part in the
pelvis
 still facing the woman’s feet, with your hands positioned on either side of the gravid uterus:
□ identify the fetal front and back sides
 using one hand at a time, slide your fingers down each side of the fetal body until you reach the “cephalic prominence,”

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 using one hand at a time, slide your fingers down each side of the fetal body until you reach the “cephalic prominence,”
that is, where the fetal brow or occiput juts out
□ head is extended if
 cephalic prominence juts out along the line of the fetal back
□ head is flexed if
 cephalic prominence juts out along the line of the fetal anterior side

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Recording Your Findings
Saturday, 24 July 2021 2:52 pm

• pregnant women are described in terms of number of pregnancies (gravida) and labors (para)
○ parity
 further broken down into
□ term deliveries
□ preterm deliveries
□ abortions
 spontaneous abortions
 terminated pregnancies
□ living children
 TPAL
○ examples
 a woman who has had two prior children and is pregnant with her third pregnancy
□ G3P2
 a woman with two spontaneous losses prior to 20 weeks’ gestation, three living children who were delivered at term, and
a current pregnancy
□ G6P3023
 first pregnancy with twins delivered at term
□ G1P1002
 each pregnancy receives only one count in any of the categories regardless of the number of fetuses, except
for living children, when all are counted
• typically, the presentation of a pregnant patient follows a standard order:
○ age
○ Gs and Ps
○ weeks of gestation
○ means of determining gestational age
 ultrasound
 LMP
○ chief complaint
○ chief pregnancy complications
○ important history and examination findings

○ examples:

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