Examination of the obstetric patient

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.

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

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

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

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

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

Weight Dubious value - poor predictive value Average weight gain for pregnancy 11-15 kg 1 kg/month before 20 weeks, 1.5 kg/month after Low weight gain ?IUGR Excess weight gain ?Preeclampsia, fetal macrosomia

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

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

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

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

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

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

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

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

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

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

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

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

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

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