Position the pregnant woman in a semi-sitting position with her knees flexed (see p. 417).
Inspect any scars or striae, the shape and contour of the abdomen, and the fundal height. Purplish striae and linea nigra are normal in pregnancy. The shape and contour may indicate pregnancy size (see figures on p. 410).
Scars may confirm the type of prior surgery, especially cesarean section.
Palpate the abdomen for:
■ Organs or masses. The mass of pregnancy is expected.
■ Fetal movements. These can usually be felt by the examiner after 24 weeks (and by the mother at 18-20 weeks).
If movements cannot be felt after 24 weeks, consider error in calculating gestation, fetal death or morbidity, or false pregnancy.
■ Uterine contractility. The uterus contracts irregularly after 12 weeks and often in response to palpation during the third trimester. The abdomen then feels tense or firm to the examiner, and it is difficult to feel fetal parts. If the hand is left resting on the fundal portion of the uterus, the fingers will sense the relaxation of the uterine muscle.
Prior to 37 weeks, regular uterine contractions with or without pain or bleeding are abnormal, suggesting preterm labor.
Measure the fundal height with a tape measure if the woman is more than 20 weeks' pregnant. Holding the tape as illustrated and following the midline of the abdomen, measure from the top of the symphysis pubis to the top of the uterine fundus. After 20 weeks, measurement in centimeters should roughly equal the weeks of gestation. For estimating fetal height between 12 and 20 weeks, see p. 410.
Auscultate the fetal heart, noting its rate (FHR), location, and rhythm. Use either:
If fundal height is more than 2 cm higher than expected, consider multiple gestation, a big baby, extra amniotic fluid, or uterine myomata. If it is lower than expected by more than 2 cm, consider missed abortion, transverse lie, growth retardation, or false pregnancy.
■ A doptone, with which the FHR is audible after 12 weeks, or
■ A fetoscope, with which it is audible after 18 weeks.
Lack of an audible fetal heart may indicate pregnancy of fewer weeks than expected, fetal demise, or false pregnancy.
The rate is usually in the 160s during early pregnancy, and then slows to the 120s to 140s near term. After 32 to 34 weeks, the FHR should increase with fetal movement.
An FHR that drops noticeably near term with fetal movement could indicate poor placental circulation.
The location of the audible FHR is in the midline of the lower abdomen from 12 to 18 weeks of gestation. After 28 weeks, the fetal heart is heard best over the fetal back or chest. The location of the FHR then depends on how the fetus is positioned. Palpating the fetal head and back helps you identify where to listen. (See Modified Leopold's Maneuvers, pp. 424-426.) If the fetus is head down with the back on the woman's left side, the FHR is heard best in the lower left quadrant. If the fetal head is under the xiphoid process (breechpresentation) with the back on the right, the FHR is heard in the upper right quadrant.
After 24 weeks, auscultation of more than one FHR with varying rates in different locations suggests more than one fetus.
Rhythm becomes important in the third trimester. Expect a variance of 10 to 15 beats per minute (BPM) over 1 to 2 minutes.
M Genitalia. Anus; and Rectum_
Inspect the external genitalia, noting the hair distribution, the color, and any scars. Parous relaxation of the introitus and noticeable enlargement of the labia and clitoris are normal. Scars from an episiotomy, a perineal incision to facilitate delivery of an infant, or from perineal lacerations may be present in multiparous women.
Inspect the anus for hemorrhoids. If these are present, note their size and location.
Palpate Bartholin's and Skene's glands. No discharge or tenderness should be present.
Speculum Examination. Inspect the cervix for color, shape, and healed lacerations. A parous cervix may look irregular because of lacerations (see p. 403).
Take Pap smears and, if indicated, other vaginal or cervical specimens. The cervix may bleed more easily when touched due to the vasocongestion of pregnancy.
Inspect the vaginal walls for color, discharge, rugae, and relaxation. A bluish or violet color, deep rugae, and an increased milky white discharge, leukor-rhea, are normal.
Bimanual Examination. Insert two lubricated fingers into the introi-tus, palmar side down, with slight pressure downward on the perineum. Slide the fingers into the posterior vaginal vault. Maintaining downward pressure, gently turn the fingers palmar side up. Avoid the sensitive urethral structures at all times. With the relaxation of pregnancy, the bimanual examination is usually easier to accomplish. Tissues are soft and the vaginal walls usually close in on the examining fingers, giving the sensation of being immersed in a bowl of oatmeal. It may be difficult to distinguish the cervix at first because of its softer texture.
Place your finger gently in the os, then sweep it around the surface of the cervix. A nulliparous cervix should be closed, while a multiparous cervix may admit a fingertip through the external os. The internal os—the narrow passage between the endocervical canal and the uterine cavity—should be
Lack of beat-to-beat variability late in pregnancy suggests fetal compromise.
Some women have labial varicosities that become tortuous and painful.
Varicosities often engorge later in pregnancy. They may be painful and bleed.
May be pronounced due to the muscle relaxation of pregnancy
A pink cervix suggests a nonpreg-nant state.
Vaginal infections are more common during pregnancy, and specimens may be needed for diagnosis.
A pink vagina suggests a nonpregnant state. Vaginal irritation and itching with discharge suggest infection.
closed in both situations. The surface of a normal multiparous cervix may feel irregular due to the healed lacerations from a previous birth.
Estimate the length of the cervix by palpating the lateral surface of the cervix from the cervical tip to the lateral fornix. Prior to 34 to 36 weeks, the cervix should retain its normal length of about 1.5 to 2 cm.
A shortened effaced cervix prior to 32 weeks may indicate preterm labor.
Palpate the uterus for size, shape, consistency, and position. These depend on the weeks of gestation. Early softening of the isthmus, Hegar's sign, is characteristic of pregnancy. The uterus is shaped like an inverted pear until 8 weeks, with slight enlargement in the fundal portion. The uterus becomes globular by 10 to 12 weeks. Anteflexion or retroflexion is lost by 12 weeks, with the fundal portion measuring about 8 cm in diameter.
With your internal fingers placed at either side of the cervix, palmar surfaces upward, gently lift the uterus toward the abdominal hand. Capture the fundal portion of the uterus between your two hands and gently estimate uterine size.
Palpate the left and right adnexa. The corpus luteum may feel like a small nodule on the affected ovary during the first few weeks after conception. Late in pregnancy, adnexal masses may be difficult to feel.
Palpate for pelvic muscle strength as you withdraw your examining fingers.
A rectovaginal examination may be done if you need to confirm uterine size or the integrity of the rectovaginal septum. A pregnancy of less than 10 weeks in a retroverted and retroflexed uterus lies totally in the posterior pelvis. Its size can be confirmed only by this examination.
An irregularly shaped uterus suggests uterine myomata or a bicornuate uterus, which has two distinct uterine cavities separated by a septum.
Early in pregnancy, it is important to rule out a tubal (ectopic) pregnancy. See Table 11-7 Adnexal Masses, p. 408.
General inspection may be done with the woman seated or lying on her left side.
Inspect the hands and legs for edema. Palpate for pretibial, ankle, and pedal edema. Edema is rated on a 0 to 4+ scale. Physiologic edema is more common in advanced pregnancy, during hot weather, and in women who stand a lot.
Obtain knee and ankle reflexes.
Varicose veins may begin or worsen during pregnancy.
Pathologic edema associated with PIH is often 3+ or more pretibially; it also affects the hands and face.
After 24 weeks, reflexes greater than 2+ may indicate PIH.
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