"Abdomen: Low transverse surgical scar. Active bowel sounds. Soft, nontender; no palpable hepatosplenomegaly or masses. Fundus: barely palpable above symphysis pubis. Fetal heart rate not heard. No inguinal adenopathy. Bimanual examination: cervix midline, soft, internal os closed. No pain on movement of cervix. Right ovary palpable, left nonpalpable; no other adnexal masses. Fundus anteverted, enlarged to 14-16 weeks' size; moderate vaginal tone."

Describes examination of healthy pregnant woman at 20 weeks' gestation, third pregnancy

Describes examination of healthy pregnant woman reporting dates of 20-week gestation but with examination consistent with 16-week gestation

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As with all patients, as you begin your examination of the pregnant woman show consideration for her comfort and sense of privacy, as well as for her individual needs and sensitivities. Have the needed equipment readily at hand. If you have not met the woman before, taking the history before asking her to gown shows respect for her right to be treated with dignity. Ask the woman to put on the gown with the opening in front to ease the examination of both the breasts and the pregnant abdomen. Draping for the abdominal and pelvic examinations is similar to that discussed in earlier chapters.

Positioning. Positioning is important when examining the abdomen of a pregnant woman given the added time and attention needed to palpate the uterus and listen to the fetal heart. The semi-sitting position with the knees bent, as shown below, affords the greatest comfort, as well as protection from the negative effects of the weight of the gravid uterus on abdominal organs and vessels.

This position is especially important when examining a woman with an advanced pregnancy. Prolonged periods of lying on the back should be avoided because the uterus then lies directly on the woman's vertebral column and may compress the descending aorta and inferior vena cava, interfering with return of venous blood from the lower extremities and the pelvic vessels. Therefore, abdominal palpation should be efficient in time and results.

Supine hypotension is a severe form of this diminished circulation and may lead the woman to feel dizzy and faint, especially when lying down.

Encourage the woman to sit again briefly before proceeding to the pelvic evaluation. This pause also provides time for the woman to empty her bladder again. Make sure, however, that she is acclimated to sitting before allowing her to stand up. The pelvic examination should likewise be relatively quick. All other examination procedures should be done in the sitting or left-side-lying position.

Equipment. The examiner's hands are the primary "equipment" for examination of the pregnant woman; they should be warm and firm yet gentle in palpation. Whenever possible the fingers should be together and flat against the abdominal or pelvic tissue to minimize discomfort. Likewise, all touching and palpation should be done with smooth continuous contact against the skin rather than kneading or abrupt motion. The more sensitive palmar surfaces of the ends of the fingers yield the greatest amount of information. Avoid tender areas on the woman's body until the end of the examination.

The gynecologic speculum is used for inspecting the cervix and the vagina and for taking specimens for cytologic or bacteriologic study. Because the vaginal walls are relaxed during pregnancy and may fall medially, obscuring your view, a speculum of larger than expected size may be needed. The relaxation of perineal and vulvar structures allows you to use it with minimal discomfort for the woman. Because of the increased vascularity of the vaginal and cervical structures, insert and open the speculum gently. You will thus avoid tissue trauma and bleeding, which interfere with the interpretation of Pap smears.

The cervical brush is not recommended for Pap smears in pregnant women because it often causes bleeding. The Ayre wooden spatula and/or cotton-tipped applicator is appropriate.

Review Chapter 11 for instruments and techniques used to take cervical smears.

■ General Inspection_

Inspect the overall health, nutritional status, neuromuscular coordination, and emotional state as the woman walks into the exam room and climbs on the examination table. Discussion of the woman's priorities for the examination, her responses to pregnancy, and her general health provide useful information and help to put the woman at ease.

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Your heart pumps blood throughout your body using a network of tubing called arteries and capillaries which return the blood back to your heart via your veins. Blood pressure is the force of the blood pushing against the walls of your arteries as your heart beats.Learn more...

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