The

Pregnant
Woman

Airiee Arranguez-Tello, MD
 Conversation with my 4 year old
daughter.

AYA: mama.. can I have a baby brother?

ME : uhm(groping for appropriate words..)
okayI will buy in SM tomorrow(stating
in a matter-of -factly tone)
AYA: (with a confused expression on her face)
BUT MAMA! YOU DONT BUY BABIES!!!!
Uh-oh.
A.
B.
C
POINTS OF DISCUSSION
I. Anatomic and Physiologic Changes

II. Health History

III. Health Promotion

IV. Physical Examination

Pregnancy Changes

Physiologic

Anatomic
Physiologic Hormonal Changes
Hormones
1. Estrogen
2. Progesterone
3. Human Chorionic Gonadotropin
4. Human Placental Lactogen
5. Thyroid Hormones
6. Relaxin
7. Eryhtropoietin
Estrogen
1. Promotes endometrial growth that
supports early embryo

2. Stimulate prolactin output in the Ant

Pituitary gl. Which readies breast tissue
for lactation
EStrogen

3. Contributes to the hypercoagulable state

of pregnancy; high risk for
thromboembolic
events
Progesterone

1. tidal volume and alveolar minute

ventilation, though respiratory rate
remains constant; respiratory alkalosis
and subjective shortness of breath
result from these changes
Progesterone

esophageal sphincter tone results from

rising levels of estradiol and
progesterone, contributing to
gastroesophageal reflux.
Progesterone

relaxes tone in the ureters and bladder,

causing hydronephrosis and increased
risk for bacteriuria
HCG
Produced by the placenta
Supports progesterone synthesis in the
corpus luteum preventing the early
embryo from being lost to menstruation.
Serum and urine pregnancy assays test
for this hormone, which is only present
at clinically significant levels during
pregnancy and selected pathologic
states (such as gestational trophoblastic
disease)
Human Placental Lactogen
implicatedin the insulin resistance and
hyperglycemia associated with
gestational diabetes (GDM).

Half
of all women who have GDM will
develop Type 2 diabetes in their lifetime
Thyroid Hormone

Thyroid hormone (T3 and free T4) and

thyroid stimulating hormone (TSH)
levels fluctuate, usually within the normal
range, due to HCGs stimulation
of the TSH receptor.
Relaxin
Is secreted by the corpus luteum and
placenta, promoting ligamentous laxity
in the sacroiliac joints and pubic
symphysis in preparation for passage of
the baby
Weight gain, especially around the
gravid uterus, contributes to lumbar
lordosis and other musculoskeletal
strain.
Erythropoietin
increases during pregnancy, which raises
erythrocyte mass.
Plasma volume also increases to a greater
extent, causing relative hemodilution
and physiologic anemia, which can
protect against blood loss during birth.
Cardiac output increases but systemic
vascular resistance decreases, resulting in
a net fall in BP especially in the 2 nd TM
Anatomic Changes
Mostvisible in the breasts, urogenital tract,
and abdomen

BUAVCE Breasts
- Uterus
- Adnexae
- Vagina
- Cervix
- External Abdomen
Breasts
enlargemoderately due to hormonal
stimulation causing increased
vascularity and glandular hyperplasia.

Bythe third gestational month, breasts

become more nodular. The nipples
become larger and more erectile, with
darker areolae and more pronounced
Montgomery glands.
Breasts
The venous pattern over the breasts
visibly increases as pregnancy progresses.

In
the second and third trimesters, some
women secrete colostrum, a thick,
yellowish, nutrient-rich precursor to milk

Breast
tenderness sensitive to
examination
Uterus

Muscle cell hypertrophy, increases in

fibrous and elastic tissue, and
development of blood vessels and
lymphatics all contribute to the growth
of
the uterus.
Uterus
1st trimester
-the uterus is confined to the pelvis
-shaped like an inverted pear
-it may retain its prior anteverted
(forward-leaning), retroverted
(backward-leaningretain its prior
anteverted (forward- leaning),
retroverted (backward-leaning),
or retroflexed (backward-bent) position.
Uterus

12 to 14 weeks
- the gravid uterus becomes externally
palpable as it expands into a
globular shape beyond the pelvic
brim
Uterus
2nd trimester

uterus
assumes an anteverted position that
encroaches on the space usually occupied by the
bladder, triggering frequent voiding.

Intestines are displaced laterally and superiorly.

Theuterus stretches its own supporting ligaments,

causing round ligament pain in the lower quadrants.
Often, slight dextrorotation to accommodate the
rectosigmoid structures on the left side of the pelvis
leads to greater discomfort on the right side.
Uterus
Growth patterns of the gravid uterus are
shown
36w
32w
28w
24w
20 w

16w

12-14w
Vagina
Chadwicks sign bluish color in vagina
due to increased vascularity throughout
the pelvis during pregnancy

Vaginalwallsappear deeply rugated due

to thicker mucosa, loosening of
connective tissue,and hypertrophy of
smooth muscle cells.
Vagina
vaginal secretions may become thick, white,
and more profuse.
Increased glycogen stores in the

vaginal epithelium give rise to a

proliferation of Lactobacillus acidophilus,
which lowers the pH in the vagina. This
acidification protects against some
vaginal infections, but at the same
time increased glycogen may
contribute to higher rates of
Candidiasis
Cervix

Chadwicks sign is also apparent as

cyanosis of the cervix.
Cervix
Hegars sign - the
palpable softening
of the cervical
isthmus, the
portion of the
uterus that
narrows into the
cervix
Cervix
The cervical canal fills with a
tenacious mucous plug that protects
the uterine environment from outside
pathogens
Adnexae
Earlyin pregnancy the corpus luteum,
the ovarian follicle that has discharged
its ovum, may be prominent enough to
be felt on the affected ovary as a small
nodule; this disappears by
midpregnancy.
External Abdomen
striae gravidarum (stretch marks)
External Abdomen

Lineanigra, a brownish black pigmented

vertical stripe along the midline skin,
may develop
External Abdomen
Diastasis
Recti separation of the rectus
abdominis muscles at the midline as the
abdominal wall increases with
advancing
pregnancy
Common Concerns (read pg
896)

1. Missed period
2. Heartburn
3. Urinary frequency
4. Vaginal discharge
5. Constipation
Common Concerns

1. Backache
2. N/V
3. Breast tenderness/tingling
4. Fatigue
5. Lower abdominal pain
6. Abdominal striae
7. contractions
Common Concerns
Loss of mucus plug

edema
THE HEALTH HISTORY
Prenatal care:

optimize health and minimize risk for the

mother and fetus.
Prenatal Care
Initialvisit
- done early in pregnancy
- goals:
1. to confirm the pregnancy
2. to assess the health of the mother and
risks of complications
3. counsel the mother about
expectations for the pregnancy
Prenatal Care
Subsequent visits
- review specific exam findings in the
mother and fetus
- employ timely preventive
screenings
- assess any interim changes to health
status
Prenatal History
Should be done early in pregnancy but
may not happen until later stages of
gestation

tailor your history to the timing of this

visit within the gestational cycle.
Prenatal History
What to ask?
1. Ask about confirmation of pregnancy:
-confirmatory urine pregnancy test?
when?
- When was her last menstrual period
(LMP)?
- ultrasound done to establish dates?
Prenatal History
2 . Ask about symptoms of pregnancy:
- missed periods, breast tenderness,
nausea or vomiting, fatigue, or
urinary frequency?
 Prenatal History
3. Ask about concerns and attitudes toward the pregnancy:
- feelings about the pregnancy? Is she excited,
concerned, or scared?
- Was the pregnancy planned and desired? If not desired,
does she plan to keep the pregnancy to term, terminate,
or consider adoption?
- Is a partner, father of the baby, or other family support
network involved?

open-ended fashion, without conveying judgment;

Be prepared to counsel patients when challenging answers arise
Prenatal History
4. Ask about current health and past medical history:
- acute or chronic medical concerns, past or
present?
- Pay particular attention to issues that affect
pregnancy:
abdominal surgeries,
hypertension
diabetes
cardiac conditions including any that were
surgically corrected in childhood, asthma,
hypercoagulability states involving lupus or
anticardiolipin antibodies
mental health disorders including postpartum depression
HIV, sexually transmitted infections (STIs),
abnormal Pap smears
and exposure to diethylstilbestrol (DES) in utero
Prenatal History
5. Ask about the patients past obstetric history:
- obstetric score: G#P(TPAL)
- pregnancy complications: DM. HPN .
preeclampsia, IUGR, or preterm labor?
- labor and delivery complications
such as large babies (fetal macrosomia),
fetal distress, or emergency
interventions?
- mode of deliveries? NSVD, assisted delivery
vacuum or forceps), or cesarean section?
 Prenatal History
6. Ask about the patients risk factors for maternal and fetal
health:

-use tobacco, alcohol, or illicit drugs?

-any medications, over the counter drugs, or herbal
preparations?
-any toxic exposures at work, home, or otherwise?
-nutritional intake adequate, or is she at risk from problems
stemming from obesity?
-adequate social support network and income source? Are
there unusual sources of stress at home or work? Is
there
any history of physical abuse or domestic violence?
Prenatal History
7. Ask about family history:
- genetically transmitted diseases: sickle cell
anemia, cystic fibrosis, or muscular
dystrophy?
- Have babies in the family had any
congenital problems?

8. Ask about plans for breast-feeding:

- offers protection to the baby against a
variety of infectious and noninfectious
conditions
Determining Gestational Age and
Expected Date of Delivery
Accurate dating is best done early
Contributes to appropriate management

of the pregnancy
Dating establishes the timeframe for

reassuring the patient about normal progress,

establishing paternity, timing screening tests,

tracking fetal growth, and effectively triaging

preterm and postdates labor.
Determining Gestational Age and
Expected Date of Delivery
Computation for Gestational age
- count the number of weeks and
days from the first day of the LMP
-average pregnancy length of 40
weeks
- example: LMP 4/4/16
AOG as of today 40
weeks
Determining Gestational Age and
Expected Date of Delivery
Computation for EDD
- 40 weeks from the first date of the LMP.
- Naegeles rule: the EDD can
be estimated by
-3 + 7 + (1) taking the LMP,
adding 7
days, subtracting 3
months, and adding 1
year.
Determining Gestational Age and
Expected Date of Delivery
Tools for calculations
Pregnancy wheels and online
calculators: expedite; varied accuracy
Determining Gestational Age and
Expected Date of Delivery
Limitations on pregnancy dating
- Patients recall of the LMP is highly variable
- LMP can be biased by hormonal contraceptives
or menstrual irregularities such as lengthy
cycles.
- LMP dating should be checked against physical
exam markers such as fundal height, and any
wide discrepancies should be clarified by
ultrasound evaluation
Concluding the Initial Visit
Once your examination is complete and your
patient has dressed, reaffirm your commitment to
her health and her concerns during pregnancy.

Review your findings and ask if she has any further

questions. If further pregnancy confirmation,
dating, or screening tests are required, discuss the
next steps.

Reinforce the importance of regular prenatal

care and review the sequence of future visits.

Record your findings in the prenatal record

Subsequent Prenatal Visits
schedule: monthly until 30 gestational weeks
biweekly until 36 weeks
then weekly until delivery

Update and document the history at every visit, especially

fetal movement felt by the patient, contractions, leakage of
fluids, and vaginal
bleeding

physical examination findings at every visit: include vital

signs (especially BP and wt)
fundal height
fetal heart rate (FHR)
determination of fetal position and activity,
Health Promotion and
Counseling
Nutrition

Evaluate nutritional status during the first prenatal visit

Take a diet history

- What does the patient typically eat for each
meal?
- How often does she eat?
- Is she experiencing severe nausea that prevents
adequate intake? Does she have any prior
issues that affect her diet such as diabetes,
eating disorders, or history of bariatric surgery?
Health Promotion and
Counseling
Nutrition

Review examination and laboratory findings.

Measure the height and weight, then calculate the

body weight, then calculate the body mass index (BMI);
note that later in pregnancy,
BMI is biased by the gravid uterus

Hematocrit is used to screen for anemia, which may

reflect nutritional deficiency, underlying medical
issues, or a normal state relative to pregnancy
Health Promotion and
Counseling
Nutrition

Recommend a multivitamin. Prenatal

vitamins should include 0.4 to 0.8 mg of
folic acid, 30 mg of iron, and a variety of
other routine vitamins.
Health Promotion and
Counseling
Nutrition

Caution the patient about foods to avoid

- unpasteurized dairy products, soft cheeses,

raw eggs, and delicatessen meats due to
the risk of Listeria, Salmonella, and
Toxoplasmosis

- Large amounts of vitamin A, can become

toxic.
Health Promotion and
Counseling
Nutrition

- Ingestion of large sea-going fish including shark,

swordfish, mackerel, and tuna, should be minimized
due to their concentration of mercury and possible
effects on the neurologic development in the fetus;

**this recommendation is controversial because some

nutrients from seafoods also contribute to healthy
development of the fetal brain
Health Promotion and
Counseling
Nutrition

Make a nutritional plan; In general, the pregnant

woman will need to increase her oral intake by
only 300 calories per day

Review weight and exercise tailored to her BMI

GDM and Eating Disorder: team based approach

involving dietitians or behavioral health specialists
Health Promotion and
Counseling
Weight Gain
Recommendations for Total and Rate of Weight Gain Durin
Pregnancy, by Pregnancy BMI, 2009

Pregnancy BMI BMI (wt in Total wt gain (lbs) Rate of wt gain

lbs/(Ht in 2TM and 3rdTM
inches x ht (lbs/week)
in inches) x
703
underweight <18.5 28-40 1
Normal wieght 18.5-24.9 25-35 1
Overweight 25-29.9 15-25 0.6
Obese >/=30 11-20 0.5
 Health Promotion and
Counseling
Exercise

-30 mins of moderate exercise or more: most days of the week unless there are
contraindications

-should be cautious and consider programs developed specifically for pregnant women

-Water-based exercises can temporarily help alleviate musculoskeletal aches, but

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, resulting in dizziness and decreased placental blood
flow

-Third trimester, advise against exercises that may cause loss of balance.

-All trimesters : no contact sports or activities that risk abdominal trauma

-avoid overheating, dehydration, and any exertion that causes notable fatigue or discomfort
Health Promotion and
Counseling
Substance Abuse
-open-ended non-judgmental approach
- Absitnence

1. Tobacco - low-birth-weight babies,

placental abruption and
preterm labor
- Cessation is the goal, but any
decrease in usage is favorable
Health Promotion and
Counseling
Substance abuse

2. Alcohol

- Fetal alcohol syndrome: the neurodevelopmental sequela of

alcohol exposure during fetal
development, is the leading cause of
preventable mental retardation in the
United States
- Abstinence

- Support for abstinence may come from counseling, inpatient

treatment, Alcoholics Anonymous, or a variety of other
programs.
Health Promotion and
Counseling
Substance Abuse

3. Illicit drugs
- have a variety of effects on fetal development
- if issues of addiction arise, women should be
referred for treatment immediately.
- Women using illicit drugs are often at risk for
infectious diseases such as HIV and hepatitis C,
and should be counseled and screened
accordingly.
Health Promotion and
Counseling
Substance Abuse

4. Abuse of prescription drugs

- Ask about unusual use of narcotics,

stimulants, benzodiazipines
 Health Promotion and
Counseling
Domestic Violence

- direct, non judgemental approach

- Since youve been pregnant, have you been hit, slapped, or otherwise hurt by anyone?

- Nonverbal clues include frequent last-minute changes to appointments, unusual behavior

during visits, partners who refuse to leave the patient alone, and bruises or other injuries

- Admission of abuse may arise only after severalvisits because of fear about safety and reprisal.

- When abuse becomes apparent, ask the patient how you can best help her.

- Respect the limits she places on sharing information, and presume that she knows best how
to handle her own situation (with the caveat that, if minor children are involved, you may be
forced to report certain behaviors to authorities
Health Promotion and
Counseling
Prenatal Laboratory Screenings

-initial standard screening panel :

blood type and Rh antibody screen, complete blood count
rubella titer, syphilis test, hepatitis B surface antigen, HIV test, STI
screen for gonorrhea and chlamydia, and urinalysis with culture.

-Timed screenings include:

24 weeks: an oral glucose tolerance test for gestational diabetes and a

35-37 weeks: vaginal swab for group B streptococcus

-Additional tests related to the mothers risk factors

Health Promotion and
Counseling
Immunizations

- up to date on tetanus vaccination.

- Influenza vaccination is indicated if the patient is in
the second or third trimester during the influenza
season
- The following vaccines are safe during pregnancy:
pneumococcal, meningococcal, and hepatitis B
- The following vaccines are NOT safe during
pregnancy:
measles/mumps/rubella, polio, varicella
Techniques of Examination

Positioning

Examination Technique

Equipment
Techniques of Examination
Comfort
Privacy
Individual sensitivities
Cultural sensitivities
Respect
Techniques of examination
1stvisit: hx clothed patient
Significant others: stay or leave?
pelvic examination: explain process, seek
cooperation
Personal/Cultural constraints : modesty vs
complete examination
Patients gown: open front
Positioning
Early pregnancy: no special concerns

Later trimesters:
* semisitting position, knees bent
: affords greater comfort by
reducing the weight of the gravid
uterus on the abdominal vessels
Positioning

*Supine position : causes the uterus to

overlie the vertebral column and
compress the descending aorta
and inferior vena cava
Positioning

* Compression interferes with venous

return from the lower extremities
and pelvic vessels, causing the
patient to feel dizzy and faint, the
supine hypotensive syndrome.
Positioning
Most portions of the exam (except pelvic
exam) should be done in the sitting or left
side-lying position

Between portions of the examination, allow

the patient to sit upright again,taking care
that she feels acclimated before she stands.

Offer
her time to empty her bladder,
especially prior to the pelvic examination,
which you should complete relatively quickly
Examination Technique
Hands: warm; palmar surface

Applygentle palpation with smooth

continuous contact with the skin rather
than abrupt pressure or kneading

Fingers
held together and flat against the
abdominal or pelvic surface to minimize discomfort

Gather all equipment prior to examination

Equipment
A larger than usual speculum may be needed.

Ayre wooden spatula or broom sampling device:

Pap smear; the cervical brush may cause
bleeding that interferes with Pap smear samples

Swabs: may be needed to screen for sexually

transmitted infections, group B strep, and
wet mount preparations.

Tape measure: A plastic or paper tape measure is

used to assess the size of the uterus after
20 gestational weeks.
Equipment
Doppler FHR monitor and gel:
A Doppler or Doptone is a handheld
device used to assess FHR after 10
weeks
of gestation when applied externally to
the gravid belly.

fetoscope (an elongated bell stethoscopelike

device) was used historically,
but is no longer in common practice
General Inspection

general health
emotional state
nutritional status
Neuromuscular coordination
Vital signs, Height, Weight
Measure the height and weight.

Calculate the BMI with standard tables, using 19 to

25 as normal for the prepregnant state
*1st-trimester weight loss due to nausea and
vomiting depends on prepregnancy BMI,
* losses in excess of 5% of prepregnancy
weight are considered excessive,
representing hyperemesis gravidarum, and
may lead to adverse pregnancy outcomes
Blood Pressure
Measure at every visit

A baseline prepregnancy reading helps

determine a patients usual range
*2nd trimester : BP below nonpregnant state

All elevations in blood pressure must be

characterized and closely monitored,
as hypertension can be both an independent
diagnosis and a marker of preeclampsia
Elevated BP
Conditions:
1. Chronic Hypertension
- SBP > 140 or DBP >90 before
pregnancy, 20 weeks and after 12
weeks postpartum

2. Gestational Hypertension
-SBP >140 or DBP>90 first documented
after 20 weeks w/o proteinuria
Elevated BP

3. Preeclampsia
- SBP >140 or DBP >90 after 20 weeks
with proteinuria
Head and Neck
Face the seated patient and observe the head and neck,
paying particular attention to the following features:

Face:
- Chloasma or melasma: Irregular brownish patches
around the forehead, cheeks,
nose, and jaw
: the mask of pregnancy,
: a normal skin finding
during pregnancy.

- Facial edema: >20wks may reflect preeclampsia

: should be investigated
Head and Neck
Hair

-Hair may become dry, oily, or sparse

during pregnancy
- mild hirsutism on the face, abdomen,
and extremities is also common.

Eyes

- Assess the conjunctivae and sclera

for signs of pallor and jaundice.
- pale conjunctivae: Anemia
Head and NEck
Nose
- Inspect the mucous membranes and septum
- perforation/erosion nasal septum: intranasal
cocoaine
- Nasal congestion and nose bleeds are common

Mouth
- Examine the teeth and gums
- Gingival enlargement with bleeding: common
- dental infections: poor pregnancy outcomes

Thyroid gland
- Modest symmetric enlargement is normal on
inspection and palpation
Thorax and Lungs
RR - normal
Inspect : 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.

*Dyspnea accompanied by increased RR, cough, rales, or

respiratory distress raises concerns of possible infection, asthma,
pulmonary embolus, or peripartum cardiomyopathy
Heart
Palpate the apical impulse, which may be rotated upward
and leftward toward the fourth intercostal space by the
enlarging uterus.

Auscultate the heart.

- Listen for a venous hum or continuous
mammary souffle often found during pregnancy
due to increased blood flow through normal vessels
- The mammary souffle is commonly heard during late
pregnancy or lactation, is strongest in the second or
third intercostalspace at the sternal border, and is
typically both systolic and diastolic, though only the
systolic component may be audible.
- Listen for murmurs.
Breasts
examination is similar to nonpregnant woman

Inspect: breasts and nipples - symmetry,color

Normal changes: marked venous pattern,
: darkened nipples and areolae,
: prominent Montgomerys glands.

Palpate : masses, axillary lymph nodes

Normal breasts: tender and nodular during
pregnancy.

Compress each nipple between your thumb and index finger:

expression of colostrum in late trimester
Abdomen
Semisitting position with knees flexed,

Inspect: striae, scars, size, shape, and contour

Palpate:

1. organs, masses
2. fetal movements - examiner: >24wks
- patient: 18-24 wks ---
Quickening
3. uterine contractions
Abdomen
4. Fundal height
- >20wks
- tape measure
- If fundal height is 4 cm larger than expected, consider
multiple gestation, a large fetus, extra amniotic fluid, or
uterine leiomyoma.
- If fundal height is 4 cm smaller than expected, consider
low level of amniotic fluid, missed abortion, intrauterine
growth retardation, or fetal anomaly

** Both of these conditions should be investigated by

ultrasound
Abdomen
Auscultate

-FHR: Doppler 10 wks AOG

- absent FHR: very early pregnancy,
fetal demise, false pregnancy or
observer error
- ultrasound recommended if no FHR
FHR
Location

10-18wks: midline of the lower abdomen

>18wks: back or chest depends on fetal
position; identified through
Leopolds Manuever

Rate: 120-160 bpm

Rhythm: variability: 10-15 bpm

Genitalia
Supine with feet placed in stirrups

External Genitalia
* Inspect
1. relaxation of the vaginal introitus : Normal
2. enlargement of the labia and clitoris: normal
3. multiparous women: scars from perineal
lacerations or episiotomy
incisions
4. labial varicosities, cystoceles, and rectoceles.

* Palpate
1. Bartholins and Skenes glands for tenderness
and cysts.
Genitalia
Internal Genitalia
*speculum and bimanual examination

Speculum Examination
-due to increased vascularity of vaginal and
cervical structures promotes friability, insert
and open the speculum gently to prevent
tissue trauma and bleeding.

- 1. Inspect the cervix for color, shape, and

closure; parous cervix look irregular
because of healed lacerations from prior
births.
Internal Genitalia: Speculum Exam

- 2. Perform a Pap smear if indicated, and

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; Check for color, relaxation,
rugae, and discharge.
Normal findings include bluish color,
deep rugae, and increased milky white
discharge, or leukorrhea (Candidiasis)
Genitalia

Bimanual examination.
- The bimanual examination is 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.
Genitalia
Bimanual examination:

1. Cervix - difficult to distinguish at first

- cervical length: estimate by palpating 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
- cervical os: external os , open: in multiparous
women.
: internal os, closed: closed until
late in pregnancy
Genitalia
Bimanual Examination

2. Uterus : With your internal fingers placed at either

side of the cervix and the external hand
on the patients 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, shape, consistency, and position.

****irregular shape: leiomyoma, bicornuate uterus

Genitalia
Bimanual examination

3. Adnexae- palpate right and left

*tenderness/masses in early gestation
may be an ectopic pregnancy
---UTZ

4. Pelvic Floor evaluate floor strength as

you withdraw the examining fingers
Anus and Rectum
Anus inspect for external hemorrhoids; note size, location
and thrombosis

Rectum and Rectovaginal Septum

- Rectal examination is not standard in PNC unless
(+) rectal bleeding/ masses.
- Rectovaginal examination is limited to conditions
compromising the integrity of the rectovaginal
septum
- This examination may assist in determining the size of
a retroverted or retroflexed uterus, but transvaginal
ultrasound provides superior information, if available.
Extremities
Sitting or left side lying
Inspection: varicosities
Palpation: edema(pretibial, ankle and
pedal)
Elicit knee and ankle DTR

hyperreflexia: preeclampsia
Special Techniques: Leopolds
Manuevers
determine the fetal position within the maternal abdomen
beginning in the second trimester

accuracy is greatest after 36 weeks gestation

findings can help ascertain the adequacy of fetal growth

and the readiness for vaginal birth by assessing:
1. the upper and lower fetal pole
2. the maternal side where the fetal back is located
3. the descent of the presenting part into the maternal
pelvis
4. the extent of flexion of the fetal head
Leopolds Manuevers
First Manuever(Upper LM 1
Fetal Pole)
Stand at the womans
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
Leopolds Manuevers
Second Manuever ( Sides of
the Maternal Abdomen) LM2
Place one hand on
each side of the womans
abdomen, capturing the
fetal body between them.
Steady the uterus with one

hand and palpate the fetus

with the other, looking for
the back on one side and
extremities on the other.
Leopolds Manuevers
Third Maneuver (Lower Fetal P LM3
ole and Descent into Pelvis).

Face the womans 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 distinguishhead from buttock

Judge the descent (or engagement) of the presenting

part into the maternal pelvis.

Pawliks grip may be employed by

using the thumb and fingers of one hand
to grasp the lower fetal pole and assess
the presenting part and descent into pelvis;
.
Leopolds MAnuevers
Fourth Manuever:
Flexion of the Fetal Head LM4
assesses the flexion or extension of the fetal
head, presuming that the
fetal head is the presenting
part in the pelvis.

Still facing the womans 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, that is,

where the fetal brow or occiput juts out.
Recording your Findings
32-year-old G3,P1102 at 18 weeks gestation as
determined by LMP presents to establish prenatal care.
Patient endorses fetal movement; denies
contractions,vaginal bleeding, and leakage of fluids. On
external exam, low transverse cesarean scar is evident;
fundus is palpable just below umbilicus. On internal exam,
cervix is open to fingertip at the external os but closed at
the internal os; cervix is 3 cm long; uterus enlarged to size
consistent with 18-week gestation. Speculum exam shows
leucorrhea with positive Chadwicks sign. FHT by Doppler
are between 140 and 145 bpm .
Recording your findings
21-year-old G1,P1000 at 33 weeks gestation as determined
by 19-week ultrasound presents with chief complaint of
decreased fetal movement. Patientendorses minimal fetal
movement over the last 24 hours; denies
contractions,vaginal bleeding, and leakage of fluids. On
external exam, nontender gravid abdomen with no scars is
noted; fundus is measured at 32 cm; fetus is vertex but not
engaged in pelvis by Leopold maneuvers. On internal exam,
cervix is
closed, thick, and high; speculum exam shows thin grey
discharge with clue cells on wet mount. FHT by Doppler are
between 155 and 160 bpm .
ENDTHANK YOU!