1. Examination of the obstetric patient

2. Introduction
Physical examination in pregnancy is directed at confirming normality of progress of pregnancy, reassuring the pregnant woman, detecting deviations from normality and detecting possible underlying disease. The vast majority of pregnant women are healthy and have no abnormalities detected during pregnancy.

3. Specific timing First visit Subsequent visits Late pregnancy Labour
General examination
Gynaecological examination
Subsequent visits
Late pregnancy
Labour

4. First visit Often first medical contact in a healthy woman
Opportunity for general health screening
Specific aims for pregnancy
Establish baselines
Detect abnormalities
Determine gestation

5. General examination Teeth Neck Cardiovascular Chest Breasts Abdomen
Thyroid often palpable
Cardiovascular
Murmurs common
BP technique
Chest
Breasts
Abdomen

6. Gynaecological examination
May not be necessary?
Inspection (speculum)
Vulva, vagina, cervix
Cervical cytology, microbiology
Bimanual examination
Uterus
Size, consistency, shape, position
Cervix
Fornices
Pelvic muscles
Bony pelvis
Diagonal conjugate, sacral curve, ischial spines, subpubic angle

7. Subsequent visits
Examination limited to pregnancy unless specific problems
Weight
Blood pressure
Abdominal examination
Urine
Protein, glucose

8. Weight Dubious value - poor predictive value
Average weight gain for pregnancy kg
1 kg/month before 20 weeks, 1.5 kg/month after
Low weight gain
?IUGR
Excess weight gain
?Preeclampsia, fetal macrosomia

9. Blood pressure Correct technique vital Woman seated Correct cuff size
Upper arm level with heart
Systolic = Korotkow phase I
Diastolic = Korotkow phase V

10. Abdominal examination
Main purpose to detect abnormalities in uterine size
Excessive - multiple pregnancy, polyhydramnios, macrosomia, fibroids, wrong dates
Inadequate - IUGR, wrong dates
Also detect lie, presentation and station in late pregnancy

11. Inspection General contour ?Heart-shaped uterus Scaphoid abdomen
‘C’ (flexed) versus ‘S’ (extended)
?Heart-shaped uterus
Bicornuate
Scaphoid abdomen
Posterior position
Fetal movements
Linea nigra, striae gravidarum

12. Palpation Fundal height
Symphisis pubis = 12 weeks
Umbilicus = 20 weeks
Xiphisternum = 40 weeks (lightening)
Alternatively and better - measure symphyseal-fundal height (SFH) in cm
SFH ~ weeks’ gestation ± 2
More objective, less interobserver variation
Mother supine, legs straight, bladder empty

13. 4 Methods of Palpation
1. Fundal 2. Lateral 3. Pawlik 4. Deep pelvic

14. 1. Fundal Place both hands on sides of fundus Usually feel breech
If head in fundus = breech presentation
Harder, more definite, ballotable

15. 2. Lateral Used to ascertain position of fetal back
If limbs felt on both sides of mother’s abdomen, posterior position more likely
Anterior shoulder important landmark
In transverse lie fetal poles in each flank

16. 3. Pawlik Determine lie, flexion, station and position
Fingers of right hand spread, palpate in suprapubic skin fold
Station usually described in “fifths” of head above pelvic brim - 1/5 = 1 finger = 2 cm
‘Fixed’  ‘Engaged’
Engagement = only sinciput palpable above brim
Combined fundal-Pawlik palpation

17. 4. Deep Pelvic Used when head has entered pelvis
Late pregnancy and labour
Examiner faces woman’s feet, uses both hands in iliac fossae
Determines station, position and lie

18. Auscultation Using Pinard stethoscope or Doppler
Antenatally of little clinical value, but reassuring to mother
Important in labour

19. Urinalysis Protein Glucose Screening for preeclampsia
‘trace’ or ‘+’ usually not significant
Other causes
UTI, chronic renal disease, alkaline urine (pH > 8)
Glucose
Screening for gestational diabetes
30% of women have glycosuria, usually renal
Only 40% of women with GDM have glycosuria

20. Examination during labour
Extension of pregnancy, with addition of vaginal examination
Regular assessment of pulse rate (maternal and fetal), blood pressure, temperature and contractions
Regular abdominal and vaginal examination to monitor progress of labour

21. Vaginal examination during labour
Usually performed on admission then every 4 hours
Also prior to epidural analgesia, or if signs of ‘fetal distress’ or need for urgent delivery
Necessary to perform amniotomy or apply fetal electrode
Increases risk of infection

22. Technique of vaginal examination
Mother supine, hips flexed and abducted, knees flexed
Aseptic technique as much as possible
Determine:
Cervix
Dilatation, effacement, position, consistency
Membranes
Intact/ ruptured
Liquor
Presenting part
Nature, station, position, caput, moulding