Examination of the obstetric patient

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 • 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 • 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 11-15 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 • ‘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 • 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