1. Physical Assessment the Pregnant Woman
Happy Barnes, CNM
ATM Conference
May 2006

2. Review of Systems – 1st Trimester
Nausea
Vomiting
Headaches
Dizziness
Cramping
Urinary frequency
Pain with urination
Changes in discharge (amount, color, odor)
Pruritis
Bleeding

3. Review of System – 2nd Trimester
Gums bleeding
Nose bleeding
Constipation
Fetal movement
Cramping
Bleeding
Dysuria
Abnormal discharge
pruritis

4. Review of Systems – 3rd Trimester
Indigestion
Swelling
Leg cramps
Fetal movement
Difficulty sleeping
Contractions
Bleeding
Calf pain
Headaches
Epigastric pain
Visual changes

5. History - Menstrual Menarche Interval Length
Recent birth control or lactation
LMP
Sure of date?
Normal in length & flow
Other helpful tidbits
Date of conception
ER sonogram

6. Obstetric History
Dates of all pregnancies (include previous miscarriage or termination) GA
Gender, weight
Length of labor
Coping techniques
Route of delivery
Special events AP, IP, PP, Neo

7. Gynecologic History Last Pap Abnormal pap
Gyn surgery or problems (e.g. infertility)
Family planning methods
Sexually transmitted infections

8. Medical/Surgical History
Serious illnesses
Hospitalizations
Surgery
Drug allergies or unusual reactions
Meds since LMP

9. Family History Maternal Maternal or Paternal Diabetes CAD
Pre-eclampsia
Preterm delivery
Cancers (breast, ovarian, colon)
Depression, bipolarity
Twins
Anesthesia reactions
Maternal or Paternal
Birth defects
Mental retardation
Bleeding disorders
Chromosomal abnormalities (e.g. Dpwn Syndrome)

10. Vital Signs
Temperature
Blood pressure
Respirations
Radial pulse

11. Additional Measurements
Height
Weight
BMI
Wt in lbs X 730 / Ht in inches²
Wt in Kgs / Ht meters²

12. The hands and nails Clubbing – caused by chronic hypoxia Severe asthma
Severe anemia, e.g. sickle cell disease
COPD
Cardiac conditions
Disappearance of “diamond” seen when nails opposed

13. Beau’s lines Lines coincide with periods of acute illness or stress
Caused by disruption of nail plate growth

14. Koilonychia
Spoon-shaped nails
Chronic iron deficiency anemia

15. Cyanosis of nail beds

16. Simian crease
Certain syndromes (Down, FAS, Turner, Klinefelter, trisomy 13)
In 3% of normal population

17. HEENT – Lymph Nodes Occipital Posterior cervical Supraclavicular
Anterior cervical
Parotid
Submandibular
Submental

18. Lymph Nodes Anterior cervical chain
Located along the sternocleidomastoid muscle

19. Check Jaw for Dysfunctional TMJ

20. Pregnancy and the mouth
Hypertrophy of the gums
Increased vascularity
Changes in salivary composition
Increased plaque deposition
Exposure to stomach acids (1st trimester)
Loosening of teeth (3rd trimester)

21. The mouth Angular cheilitis B vitamin deficiency Fungal infections
Over-biting

22. The mouth
Actinic cheiliosis
Sun exposure
Precancerous (SC)

23. “Gingivitis of pregnancy”

24. The mouth Mild aphthous ulcer (AKA canker sore) Viral, bacterial
Stress
Underlying immune disease if frequent

25. Oral candidiasis (thrush)

26. The tongue
The normal tongue

27. The tongue Geographic tongue “designs” shift May resolve spontaneously
Often asymptomatic

28. The tongue
Black hairy tongue
ideopathic
candidiasis
antibiotics

29. The tongue
Blacker and hairier tongue

30. Ankyloglossia (tongue tie)
Heart-shaped
Tongue doesn’t extend over lower gum ridge
Clicking noise while nursing

31. Severe tongue tie

32. Throat Deviated uvula Can be a normal finding
In conjunction with other symptoms, indicates a central nervous system lesion.

33. Enlarged Tonsils

34. Chronic tonsilitis Large tonsils Chronic inflammation Crypts
Tonsilar “stones”

35. Superficial Nasal Sinuses

36. Eyes
Pupillary light reflexes

37. Swinging Light Test

38. Chalazion (plugged sebaceous gland)

39. Conjutivitis – bacterial (strep)

40. Conjuctivitis - allergic

41. Conjunctivitis - viral

42. Conjunctivitis - gonococcal

43. The eyes - pterygium

44. The eyes - icterus

45. The thyroid Some amount of thyromegaly is normal in pregnancy
Important to explore history
Important to explore other signs & symptoms

46. Signs & symptoms Hypothyroid Hyperthyroid Cold intolerance Slow pulse
Thin, dry hair & dry, puffy skin
Fatigue
Thick tongue
Delayed relaxation of Achilles reflex
Hyperthyroid
Heat intolerance
Rapid pulse
Flushed, sweating
Anxious
Fine tremors
Exaggerated reflexes

47. Palpation of the thyroid
Best palpated with examiner behind
Have patient swallow
Palpate both lobes

48. Normal position of the thyroid

50. The thyriod Massive goiter
Seen in areas with iodine deficient soil (at the base of rocky mountain ranges)
This woman is from the mountains of Viet Nam

51. The Neck - Acanthosis nigrans
Appears slowly without symptoms
Dark, velvety skin with markings and creases
Neck, armpits, and groin
Associated with obesity, Type II DM, PCOS, some cancers
Can be normal, isolated finding

52. The Back Scoliosis Rib prominence Curving spine Uneven waist
Lumbar prominence

53. Scoliosis

54. The Back – Costovertebral angle
Use your fist to strike the angle made by the ribs and the spine
Do this gently, as there is extreme tenderness with pyelonephritis

55. Auscultation of the lungs
Warm your stethoscope.
Use the diaphragm.
Move from one point to the same point on the other side, to compare sounds
There are 3 lobes on the right & 2 on the left
Always assess the posterior back
If there are concerns, check the anterior fields, also

56. Lung fields

57. Auscultation points

58. Lungs sounds (the Cliff Notes)
Normal breath sounds
Crackles
Rhonchi
Wheezes

59. Normal breath sounds Normal vesicular breath sounds.
Heard over most of the peripheral lung fields.
Soft, low pitched, and with a gentle rustling quality.
In this sample you can also hear the heart beat in the background

60. Crackles (rales) Scattered wet crackles. Also known as coarse rales
Usually caused by excessive fluid in the airways.
Crackles are typically inspiratory.
Dry crackles sound more like rubbing hair together next to your ear or like the sound of opening Velcro.

61. Wheezes Wheezes are ususally expiratory
Caused by air forced through collapsed airways with residual trapping of air.
Commonly associated with asthma
May also be caused by airway swelling, tumor, or obstructing foreign bodies.

62. Deep tendon reflexes Most commonly assessed: 0: absent reflex
Patellar
Achilles
0: absent reflex
1+: trace, or seen only with reinforcement
2+: normal
3+: brisk
4+: nonsustained clonus (i.e., repetitive vibratory movements)
5+: sustained clonus

63. Reinforcement
When unable to obtain a patellar reflex, have the patient hook together their flexed fingers and pull apart.

64. Patellar reflex Leg should dangle freely
Support the thigh above the knee
Tap sharply on the space just beneath the knee cap

65. Achilles reflex Loosely support the ball of the foot.
Sharply tap the Achilles tendon
Note whether plantar flexion and dorsiflexion are equal
Delayed dorsiflexion is a possible sign of hypothyroidism

66. Clonus Hold the relaxed lower leg in your hand
Sharply dorsiflex the foot and hold it dorsiflexed.
Feel for oscillations between flexion and extension of the foot.

67. Babinski reflex
The great toe flexes toward the top of the foot and the other toes fan out after the sole of the foot has been firmly stroked.
Abnormal after the age of 2.
Indicates damage to the nerve paths connecting the spinal cord and the brain
May be seen for a short time after a seizure.
Also seen in ALS, tumors, head injury, meningitis, MS, stroke, some forms of polio, spinal cord injury.

68. Visual Inspection Retractions Increased vascularity Skin changes
Dimpling
Marked differences in configuration
Spontaneous discharge
As she moves, note any differences in mobility or visible masses

69. Positions for visual inspection

70. Lateral and medial patterns

71. Method of palpation

72. Levels of palpation

73. Additional aspects of exam
Evaluate the supraclavicular notches
Evaluate the tail of Spence and axilla
Check for nipple discharge

74. The cardiac cycle
S1 and S2 (Lub-Dub) are the most obvious normal sounds
This is a normal sinus rhythm, with a sharp S1 and S2
S1 marks the beginning of systole, and is created when the heart muscle’s contraction causes closing of the tricuspid and mitral (or AV) valves.
At the end of systole, the ventricles begin to relax, and the pressures within the heart become less than that in the aorta and pulmonary artery
A brief back flow of blood causes the semilunar valves to snap shut, producing S2.

75. Flow murmur You are listening to an innocent flow murmur.
Caused by abnormally high flow through normal valves.
These are very common in pregnancy.
The murmur is in early systole, has a definite start and end point, is crescendo-decrescendo in shape, and could be described as “twangy”.

76. Mitral valve prolapse This is a murmur of mitral valve prolapse.
The papillary muscles fail to firmly hold the mitral valve during late systole, and the valve bulges into the left atrium.
This is common in young adult women.
It can present as attacks of palpitations, anxiety, or light-headedness.
Although rarely serious, patients with mitral valve prolapse with regurgitation by echo are given antibiotic prophylaxis during invasive procedures to prevent bacterial endocarditis.

77. Aortic regurgitation
This murmur is caused by aortic valve regurgitation.
3:1 ratio male:female.
2/3 are secondary to rheumatic heart disease
Other causes are congenital, syphilis infection, Marfan syndrome, or valvular damage due to infective endocarditis.
The most notable aspect of the murmur is the diastolic sound characterized as a blowing decrescendo.

78. VSD (ventricular septal defect)
This murmur is heard best over the lower left sternal border, radiating to the right lower sternal border.
It is caused by blood flowing through a hole in the wall between the right and left ventricles.
It is a holosystolic because the pressure difference between the ventricles is generated almost instantly at the onset of systole, with a left to right shunt continuing throughout ventricular contraction.
There is usually no diastolic component to the murmur.

79. S4 or gallop A fourth heart sound, or S4, is due to a stiff ventricle.
The late stage of diastole is marked by atrial contraction, or kick, where the final 20% of the atrial output is delivered to the ventricles.
If the ventricle is stiff and non-compliant, as in ventricular hypertrophy due to long-standing hypertension, the atrial contraction produces an S4.     
A good mnemonic to remember the cadence and pathology of an S4 is: “a-STIFF-wall    a-STIFF-wall”

80. Grading murmurs 1/6 - very faint; not always heard in all positions
2/6 - quiet but not difficult to hear
3/6 - moderately loud
4/6 - loud +/- thrills
5/6 - very loud +/- thrills; may be heard with stethoscope partly off chest
6/6 - may be heard with stethoscope completely off chest; +/- thrills

81. Positions of cardiac auscultation

82. Abdominal assessment Inspect abdomen Listen for bowel sounds
contour
asymmetry
scars, rashes, or other lesions.
Listen for bowel sounds
present, increased, decreased, absent, high-pitched
Light palpation for tenderness
most sensitive indicator is facial expression
voluntary or involuntary guarding may also be present.
Deep palpation for masses

83. Rebound tenderness
This is a test for peritoneal irritation. Palpate deeply and then quickly release pressure. If it hurts more when you release, the patient has rebound tenderness.

84. Diastasis recti
A separation between the left and right side of the rectus abdominis muscle, which covers the front surface of the abdomen
Diastasis recti is a common and normal condition in newborns. It is seen most frequently in premature and African-American infants.
It is also common in women postpartum
A diastasis recti appears as a ridge running down the midline of the abdomen from the bottom of the breastbone to the navel.

85. Measurement of the diastasis
It is measured with the woman supine and relaxed, then again as she lifts her head.
It is recorded as fingerbreadths: relaxed/contracted.

86. The lower extremities Edema Signs of deep vein thrombosis Homan’s sign
Abnormalities of toe nails

87. Edema 1+ slight pitting, disappears rapidly (2 mm)
2+ deeper pit, disappears in secs.(4 mm)
3+ pit is noticeably deep and may last more than a minute. The extremity looks fuller & swollen (6 mm)
4+ the pit is very deep, lasts 2-5 mins, and the extremity is grossly distorted (8 mm)

88. Pedal edema

89. Edema

90. Deep vein thrombosis Swelling of the affected extremity.
Area over vein may be red, discolored.
Area may be tender, warm to the touch
Pain with stretching of the overlying muscle (+ Homan’s sign).
May have systemic symptoms, i.e., fever, chills, flu-like symptoms, shortness of breath.

91. DVT left saphenous vein.

92. Homan’s sign
Elicitation: With the knee in the flexed position, forcibly
dorsiflex the ankle.
Response: Pain in the calf with this maneuver is consistent with deep venous thrombosis.

93. Dermatophyte infection of toe nails

94. The skin
Our largest and heaviest organ

95. Linea negra

96. Melasma

97. Atypical moles Number of moles: Often over 50
Uniformity: Neighboring moles differ from each other
Size: Many over 5mm, usually some over 8mm
Color: Multiple shades of tan, brown, black, red and pink, often variegated

98. Atypical moles, cont.
Elevation: Center is only slightly raised in comparison with the relatively large diameter
Perimeter (edge): Often irregular, usually fuzzy, edges blend imperceptibly with surrounding skin
"Shoulder": Outer periphery is usually flat and tan, often with a pink base
Surface: Often mammillated with tiny outward dome-like dimples
Symptoms: No pain, no itching, no tenderness, no burning, usually no symptoms

99. Malignant melanoma Atypical mole of the trunk.
The center is elevated and the size of a pencil eraser.
Note an appearance close to a "fried egg."

100. The ABCDs of abnormal moles
A. Asymmetry: One-half of the mole does not match the other half B. Border of the mole is jagged or irregular C. Color – more than one is present D. Diameter is greater than 5 mm (the size of a pencil eraser)

101. Asymmetry

102. Border

103. Color

104. Diameter

105. Thanks!!!!!!