examination of the obstetric patient
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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. - PowerPoint PPT PresentationTRANSCRIPT
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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.
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First visit General examination Gynaecological examination
Subsequent visits Late pregnancy Labour
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Often first medical contact in a healthy woman
Opportunity for general health screening Specific aims for pregnancy
Establish baselines Detect abnormalities Determine gestation
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Teeth Neck
Thyroid often palpable Cardiovascular
Murmurs common BP technique
Chest Breasts Abdomen
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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
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Examination limited to pregnancy unless specific problems
Weight Blood pressure Abdominal examination Urine
Protein, glucose
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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
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Correct technique vital Woman seated Correct cuff size Upper arm level with heart Systolic = Korotkow phase I Diastolic = Korotkow phase V
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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
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General contour ‘C’ (flexed) versus ‘S’ (extended)
?Heart-shaped uterus Bicornuate
Scaphoid abdomen Posterior position
Fetal movements Linea nigra, striae gravidarum
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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
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1. Fundal2. Lateral3. Pawlik4. Deep pelvic
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Place both hands on sides of fundus Usually feel breech If head in fundus = breech presentation
Harder, more definite, ballotable
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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
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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
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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
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Using Pinard stethoscope or Doppler Antenatally of little clinical value, but
reassuring to mother Important in labour
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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
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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
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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
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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