The Pregnant Woman

Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc.

The Pregnant WomanThe Pregnant Woman

Chapter 29Chapter 29


Chapter 29: The Pregnant WomanChapter 29: The Pregnant Woman

Structure and FunctionStructure and Function

Pregnancy and the endocrine placentaPregnancy and the endocrine placenta First day of menses is day 1 of menstrual cycleFirst day of menses is day 1 of menstrual cycle

• For first 14 days of cycle, one or more follicles in ovary For first 14 days of cycle, one or more follicles in ovary develops and maturesdevelops and matures

• One follicle grows faster than others, and on day 14 of One follicle grows faster than others, and on day 14 of cycle this dominant follicle ruptures and ovulation occurs cycle this dominant follicle ruptures and ovulation occurs

• If ovum meets viable sperm, fertilization occurs If ovum meets viable sperm, fertilization occurs somewhere in oviduct (fallopian tube)somewhere in oviduct (fallopian tube)

• Remaining cells in follicle form corpus luteum, or “yellow Remaining cells in follicle form corpus luteum, or “yellow body,” which makes important hormonesbody,” which makes important hormones

Chief among these is progesterone, which prevents Chief among these is progesterone, which prevents sloughing of endometrial wall, ensuring a rich vascular sloughing of endometrial wall, ensuring a rich vascular network into which fertilized ovum will implantnetwork into which fertilized ovum will implant

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Structure and FunctionStructure and Function (cont.)(cont.)

Pregnancy and the endocrine placenta (cont.)Pregnancy and the endocrine placenta (cont.) Blastocyst, or fertilized ovum, continues to divide, Blastocyst, or fertilized ovum, continues to divide,

differentiate, and grow rapidlydifferentiate, and grow rapidly• Specialized cells in blastocyst produce human chorionic Specialized cells in blastocyst produce human chorionic

gonadotropin (hCG), which stimulates corpus luteum to gonadotropin (hCG), which stimulates corpus luteum to continue making progesteronecontinue making progesterone

• Between days 20 and 24, blastocyst implants into wall of Between days 20 and 24, blastocyst implants into wall of uterus, and may cause small amount of vaginal bleedinguterus, and may cause small amount of vaginal bleeding

• Specialized layer of cells around blastocyst becomes Specialized layer of cells around blastocyst becomes placentaplacenta

• Placenta starts to produce progesterone to support Placenta starts to produce progesterone to support pregnancy at 7 weeks and takes over this function pregnancy at 7 weeks and takes over this function completely from corpus luteum at about 10 weekscompletely from corpus luteum at about 10 weeks

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Pregnancy and the endocrine placenta (cont.)Pregnancy and the endocrine placenta (cont.) Placenta functions as an endocrine organ and Placenta functions as an endocrine organ and

produces several hormonesproduces several hormones• These hormones help growth and maintenance of fetus, These hormones help growth and maintenance of fetus,

and direct changes in woman’s body to prepare for birth and direct changes in woman’s body to prepare for birth and lactationand lactation

• The hCG stimulates rise in progesterone during The hCG stimulates rise in progesterone during pregnancypregnancy

• Progesterone maintains endometrium around fetus, Progesterone maintains endometrium around fetus, increases alveoli in breast, and keeps uterus in a increases alveoli in breast, and keeps uterus in a quiescent statequiescent state

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Pregnancy and the endocrine placenta (cont.)Pregnancy and the endocrine placenta (cont.) Estrogen stimulates duct formation in breastEstrogen stimulates duct formation in breast

• Also increases weight of uterus and increases certain Also increases weight of uterus and increases certain receptors in uterus that are important at birthreceptors in uterus that are important at birth

• Average length of pregnancy is 280 days from first day of Average length of pregnancy is 280 days from first day of last menstrual period (LMP), which is equal to:last menstrual period (LMP), which is equal to:

• 40 weeks40 weeks

• 10 lunar months10 lunar months

• 9 calendar months 9 calendar months Note that this includes 2 weeks when follicle was maturing Note that this includes 2 weeks when follicle was maturing

but before conception actually occurredbut before conception actually occurred

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Pregnancy and the endocrine placenta (cont.)Pregnancy and the endocrine placenta (cont.) Pregnancy is divided into three trimestersPregnancy is divided into three trimesters

• First trimester is the first 12 weeks First trimester is the first 12 weeks

• Second trimester is from 13 to 27 weeks Second trimester is from 13 to 27 weeks

• Third trimester is from 28 weeks to deliveryThird trimester is from 28 weeks to delivery

Woman pregnant for first time called primigravidaWoman pregnant for first time called primigravida• After she delivers, she is called a primiparaAfter she delivers, she is called a primipara

• Multigravida: pregnant woman who has previously Multigravida: pregnant woman who has previously carried a fetus to the point of viabilitycarried a fetus to the point of viability

• Any pregnant woman might be called a gravidaAny pregnant woman might be called a gravida

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Pregnancy and the endocrine placenta (cont.)Pregnancy and the endocrine placenta (cont.) Commonly used terminology is Commonly used terminology is

• G, gravidaG, gravida

• P, paraP, para

• T, termT, term

• PT, preterm deliveriesPT, preterm deliveries

• A, abortion—including missed, therapeutic, or voluntary A, abortion—including missed, therapeutic, or voluntary

• L, living childrenL, living children

It may be written as It may be written as • G5 T3 PT0 A2 L3G5 T3 PT0 A2 L3

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Changes during normal pregnancyChanges during normal pregnancy• Pregnancy is diagnosed by three types of signs and Pregnancy is diagnosed by three types of signs and

symptomssymptoms

• Presumptive signs are those woman experiences, such Presumptive signs are those woman experiences, such as amenorrhea, breast tenderness, nausea, fatigue, and as amenorrhea, breast tenderness, nausea, fatigue, and increased urinary frequencyincreased urinary frequency

• Probable signs are those detected by examiner, such as Probable signs are those detected by examiner, such as an enlarged uterusan enlarged uterus

• Positive signs of pregnancy are those that are direct Positive signs of pregnancy are those that are direct evidence of fetus, such as auscultation of fetal heart evidence of fetus, such as auscultation of fetal heart tones (FHTs) or positive cardiac activity on ultrasound tones (FHTs) or positive cardiac activity on ultrasound (US)(US)

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Changes during normal pregnancy: first Changes during normal pregnancy: first trimestertrimester Conception occurs on approximately 14th day of Conception occurs on approximately 14th day of

menstrual cyclemenstrual cycle• Blastocyst, which is the developing fertilized ovum, Blastocyst, which is the developing fertilized ovum,

implants in uterus 6 to 10 days after conception, implants in uterus 6 to 10 days after conception, sometimes accompanied by small amount of painless sometimes accompanied by small amount of painless bleedingbleeding

• Serum hCG becomes positive after implantation when it Serum hCG becomes positive after implantation when it is first detectable in maternal serum at approximately 8 is first detectable in maternal serum at approximately 8 to 11 days after conceptionto 11 days after conception

• Following menstrual period is missedFollowing menstrual period is missed

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Changes during normal pregnancy: first Changes during normal pregnancy: first trimester (cont.)trimester (cont.) At time of missed menses, hCG can be detected At time of missed menses, hCG can be detected

in urinein urine• Breast tingling and tenderness begin as rising estrogen Breast tingling and tenderness begin as rising estrogen

levels promote mammary growth and development of levels promote mammary growth and development of ductal system; progesterone stimulates alveolar system ductal system; progesterone stimulates alveolar system as well as the mammary growthas well as the mammary growth

• Chorionic somatomammotropin (also called human Chorionic somatomammotropin (also called human placental lactogen or hPL), which is also produced by placental lactogen or hPL), which is also produced by placenta, stimulates breast growth and exerts lactogenic placenta, stimulates breast growth and exerts lactogenic propertiesproperties

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Changes during normal pregnancy: first Changes during normal pregnancy: first trimester (cont.)trimester (cont.) More than half of all pregnant women have More than half of all pregnant women have

nausea and vomitingnausea and vomiting• Cause is unclear but may involve hormonal changes of Cause is unclear but may involve hormonal changes of

pregnancy, low blood sugar, gastric overloading, slowed pregnancy, low blood sugar, gastric overloading, slowed peristalsis, an enlarging uterus, and emotional factorsperistalsis, an enlarging uterus, and emotional factors

• Fatigue is common and may be related to initial fall in Fatigue is common and may be related to initial fall in metabolic rate that occurs in early pregnancymetabolic rate that occurs in early pregnancy

• Estrogen, and possibly progesterone, cause hypertrophy Estrogen, and possibly progesterone, cause hypertrophy of uterine muscle cells and uterine blood vessels, and of uterine muscle cells and uterine blood vessels, and lymphatics enlargelymphatics enlarge

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Changes during normal pregnancy: first Changes during normal pregnancy: first trimester (cont.)trimester (cont.) Uterus becomes globular in shape, softens, and Uterus becomes globular in shape, softens, and

flexes easily over cervix (Hegar’s sign)flexes easily over cervix (Hegar’s sign)• This causes compression of bladder, which results in This causes compression of bladder, which results in

urinary frequencyurinary frequency

• Increased vascularity, congestion, and edema cause Increased vascularity, congestion, and edema cause cervix to soften (Goodell’s sign) and become bluish cervix to soften (Goodell’s sign) and become bluish purple (Chadwick’s sign)purple (Chadwick’s sign)

• Early first-trimester blood pressures (BPs) reflect Early first-trimester blood pressures (BPs) reflect prepregnancy valuesprepregnancy values

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Changes during normal pregnancy: first Changes during normal pregnancy: first trimester (cont.)trimester (cont.) In 7th gestational weekIn 7th gestational week

• BP begins to drop until midpregnancy as a result of BP begins to drop until midpregnancy as a result of falling peripheral vascular resistancefalling peripheral vascular resistance

• Systemic vascular resistance decreases from Systemic vascular resistance decreases from vasodilatory effect of progesterone and prostaglandinsvasodilatory effect of progesterone and prostaglandins

• At end of 9 weeks, embryonic period ends and fetal At end of 9 weeks, embryonic period ends and fetal period begins, at which time major structures are presentperiod begins, at which time major structures are present

• FHTs can be heard by Doppler US between 9 and 12 FHTs can be heard by Doppler US between 9 and 12 weeksweeks

• Uterus may be palpated at about 12 weeksUterus may be palpated at about 12 weeks

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Height of Fundus at Weeks of Height of Fundus at Weeks of GestationGestation

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Changes during normal pregnancy: second Changes during normal pregnancy: second trimestertrimester By weeks 12 to 16By weeks 12 to 16

• Nausea, vomiting, fatigue, and urinary frequency of first Nausea, vomiting, fatigue, and urinary frequency of first trimester improvetrimester improve

• 18 to 20 weeks woman recognizes fetal movement 18 to 20 weeks woman recognizes fetal movement (“quickening”) (“quickening”)

• As breast enlargement continues, the veins of breast As breast enlargement continues, the veins of breast enlarge and are more visible through skin of lightly enlarge and are more visible through skin of lightly pigmented womenpigmented women

• Colostrum, precursor of milk, may be expressed from Colostrum, precursor of milk, may be expressed from nipplesnipples

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Changes during normal pregnancy: second Changes during normal pregnancy: second trimester (cont.)trimester (cont.) ColostrumColostrum

• Yellow in color, contains more minerals and protein but Yellow in color, contains more minerals and protein but less sugar and fat than mature milkless sugar and fat than mature milk

• Also contains antibodies, which are protective for Also contains antibodies, which are protective for newborn during its first days of life until mature milk newborn during its first days of life until mature milk production beginsproduction begins

• Areola and nipples darken, it is thought, because Areola and nipples darken, it is thought, because estrogen and progesterone have a melanocyte-estrogen and progesterone have a melanocyte-stimulating effect, and melanocyte-stimulating hormone stimulating effect, and melanocyte-stimulating hormone levels escalate from second month of pregnancy until levels escalate from second month of pregnancy until deliverydelivery

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Changes during normal pregnancy: second Changes during normal pregnancy: second trimester (cont.)trimester (cont.) For same reason, midline of abdominal skin For same reason, midline of abdominal skin

becomes pigmented, called linea nigrabecomes pigmented, called linea nigra• You may note striae gravidarum (“stretch marks”) on You may note striae gravidarum (“stretch marks”) on

breast, abdomen, and areas of weight gainbreast, abdomen, and areas of weight gain

• Systolic BP may be 2 to 8 mm Hg lower and diastolic BP Systolic BP may be 2 to 8 mm Hg lower and diastolic BP 5 to 15 mm Hg lower than prepregnancy levels 5 to 15 mm Hg lower than prepregnancy levels

• Drop most pronounced at 20 weeks and may cause Drop most pronounced at 20 weeks and may cause symptoms of dizziness and faintness, particularly after symptoms of dizziness and faintness, particularly after rising quicklyrising quickly

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Changes during normal pregnancy: second Changes during normal pregnancy: second trimester (cont.)trimester (cont.)

• Stomach displacement from enlarging uterus and altered Stomach displacement from enlarging uterus and altered esophageal sphincter and gastric tone as a result of esophageal sphincter and gastric tone as a result of progesterone predispose woman to heartburnprogesterone predispose woman to heartburn

• Intestines are also displaced by growing uterus, and tone Intestines are also displaced by growing uterus, and tone and motility are decreased because of action of and motility are decreased because of action of progesterone, often causing constipationprogesterone, often causing constipation

• Gallbladder, possibly resulting from action of Gallbladder, possibly resulting from action of progesterone on its smooth muscle, empties sluggishly progesterone on its smooth muscle, empties sluggishly and may become distendedand may become distended

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• Stasis of bile, together with increased cholesterol Stasis of bile, together with increased cholesterol saturation of pregnancy, predisposes some women to saturation of pregnancy, predisposes some women to gallstone formationgallstone formation

• Progesterone and, to lesser degree, estrogen cause Progesterone and, to lesser degree, estrogen cause increased respiratory effort during pregnancy by increased respiratory effort during pregnancy by increasing tidal volumeincreasing tidal volume

• Hemoglobin, and therefore oxygen-carrying capacity, Hemoglobin, and therefore oxygen-carrying capacity, also increasesalso increases

• Increased tidal volume causes slight drop in partial Increased tidal volume causes slight drop in partial pressure of arterial carbon dioxide (PaCOpressure of arterial carbon dioxide (PaCO22), causing ), causing

woman to occasionally have dyspneawoman to occasionally have dyspnea

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• Cutaneous blood flow augmented during pregnancy Cutaneous blood flow augmented during pregnancy caused by decreased vascular resistance, presumably caused by decreased vascular resistance, presumably helping to dissipate heat generated by increased helping to dissipate heat generated by increased metabolismmetabolism

• Gums may hypertrophy and bleed easily; condition is Gums may hypertrophy and bleed easily; condition is called gingivitis or epulis of pregnancycalled gingivitis or epulis of pregnancy

• For same reason, nosebleeds may occur more frequentlyFor same reason, nosebleeds may occur more frequently

• Pregnant women with periodontal disease, a chronic local Pregnant women with periodontal disease, a chronic local oral infection, are at risk for preterm deliveryoral infection, are at risk for preterm delivery

• Untreated, this may lead to systemic infection that affects Untreated, this may lead to systemic infection that affects maternal levels of prostaglandin E2 (PGE-2)maternal levels of prostaglandin E2 (PGE-2)

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Changes during normal pregnancy: second Changes during normal pregnancy: second trimester (cont.)trimester (cont.) 17 to 19 weeks 17 to 19 weeks

• FHTs are audible by fetoscope, as opposed to Doppler FHTs are audible by fetoscope, as opposed to Doppler imagingimaging

• Fetal outline palpable through abdominal wall at Fetal outline palpable through abdominal wall at approximately 20 weeksapproximately 20 weeks

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Changes during normal pregnancy: third Changes during normal pregnancy: third trimestertrimester

• Blood volume, which increased rapidly during second Blood volume, which increased rapidly during second trimester, peaks in middle of third trimester at trimester, peaks in middle of third trimester at approximately 45% greater than prepregnancy level and approximately 45% greater than prepregnancy level and plateaus thereafterplateaus thereafter

• This volume is greater in multiple gestationsThis volume is greater in multiple gestations

• Erythrocyte mass increases by 20% to 30%, caused by Erythrocyte mass increases by 20% to 30%, caused by an increase in erythropoiesis, mediated by progesterone, an increase in erythropoiesis, mediated by progesterone, estrogen, and placental chorionic somatomammotropin estrogen, and placental chorionic somatomammotropin

• However, plasma volume increases slightly more, However, plasma volume increases slightly more, causing slight hemodilution and small drop in hematocritcausing slight hemodilution and small drop in hematocrit

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Changes during normal pregnancy: third Changes during normal pregnancy: third trimester (cont.)trimester (cont.)

• BP slowly rises again to approximately prepregnant levelBP slowly rises again to approximately prepregnant level

• Uterine enlargement causes diaphragm to rise and Uterine enlargement causes diaphragm to rise and shape of rib cage to widen at baseshape of rib cage to widen at base

• Decreased space for lung expansion may cause a sense Decreased space for lung expansion may cause a sense of shortness of breathof shortness of breath

• Rising diaphragm displaces heart up and to leftRising diaphragm displaces heart up and to left

• Cardiac output, stroke volume, and force of contraction Cardiac output, stroke volume, and force of contraction are increasedare increased

• Pulse rate rises 15 to 20 beats per minutePulse rate rises 15 to 20 beats per minute

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• Because of increase in blood volume, a functional Because of increase in blood volume, a functional systolic murmur, grade ii/iv or less, can be heard in more systolic murmur, grade ii/iv or less, can be heard in more than 95% of pregnant women (Creasy and Resnick, than 95% of pregnant women (Creasy and Resnick, 2004)2004)

• Edema of lower extremities may occur as result of Edema of lower extremities may occur as result of enlarging fetus impeding venous return, and from lower enlarging fetus impeding venous return, and from lower colloid osmotic pressure; worsens with dependency, colloid osmotic pressure; worsens with dependency, such as prolonged standingsuch as prolonged standing

• Varicosities, which have a familial tendency, may form or Varicosities, which have a familial tendency, may form or enlarge from progesterone-induced vascular relaxationenlarge from progesterone-induced vascular relaxation

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• Also causing varicosities is engorgement caused by Also causing varicosities is engorgement caused by weight of full uterus compressing inferior vena cava and weight of full uterus compressing inferior vena cava and vessels of pelvic area, resulting in venous congestion in vessels of pelvic area, resulting in venous congestion in legs, vulva, and rectumlegs, vulva, and rectum

• Hemorrhoids are varicosities of rectum that are Hemorrhoids are varicosities of rectum that are worsened by constipation, which occurs from relaxation worsened by constipation, which occurs from relaxation of large bowel by progesteroneof large bowel by progesterone

• Progressive lordosis, an inward curvature of lumbar Progressive lordosis, an inward curvature of lumbar spine, occurs to compensate for shifting center of spine, occurs to compensate for shifting center of balance caused by anteriorly enlarging uterus, balance caused by anteriorly enlarging uterus, predisposing woman to backachespredisposing woman to backaches

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• Slumping of shoulders and anterior flexion of neck from Slumping of shoulders and anterior flexion of neck from increasing weight of breasts may cause aching and increasing weight of breasts may cause aching and numbness of arms and hands as a result of compression numbness of arms and hands as a result of compression of median and ulnar nerves in arm, commonly referred to of median and ulnar nerves in arm, commonly referred to as carpal tunnel syndromeas carpal tunnel syndrome

• Approximately 2 weeks before going into labor, Approximately 2 weeks before going into labor, primigravida experiences engagement, also called primigravida experiences engagement, also called “lightening” or “dropping,” when fetal head moves down “lightening” or “dropping,” when fetal head moves down into pelvisinto pelvis

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• Symptoms include lower-appearing and smaller-Symptoms include lower-appearing and smaller-measuring fundus, urinary frequency, increased vaginal measuring fundus, urinary frequency, increased vaginal secretions from increased pelvic congestion, and secretions from increased pelvic congestion, and increased lung capacity increased lung capacity

• In multigravida, fetus may move down at any time in late In multigravida, fetus may move down at any time in late pregnancy or often not until laborpregnancy or often not until labor

• Cervix, in preparation for labor, begins to thin (efface) Cervix, in preparation for labor, begins to thin (efface) and open (dilate)and open (dilate)

• Thick mucous plug, formed in cervix as a mechanical Thick mucous plug, formed in cervix as a mechanical barrier during pregnancy, is expelled at variable times barrier during pregnancy, is expelled at variable times before or during laborbefore or during labor

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Changes during normal pregnancy: third Changes during normal pregnancy: third trimester (cont.)trimester (cont.) Between 37 and 42 weeksBetween 37 and 42 weeks

• Pregnancy is considered termPregnancy is considered term

• After 42 weeks, pregnancy is considered postdatedAfter 42 weeks, pregnancy is considered postdated

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Determining weeks of gestationDetermining weeks of gestation Expected date of delivery, or EDDExpected date of delivery, or EDD

• 280 days from first day of LMP, may be calculated by 280 days from first day of LMP, may be calculated by using Nägele’s ruleusing Nägele’s rule

• Determine first day of last normal menstrual period Determine first day of last normal menstrual period

• Using first day of LMP, add 7 days and subtract 3 Using first day of LMP, add 7 days and subtract 3 monthsmonths

• This is the EDD that can then be used with a pregnancy This is the EDD that can then be used with a pregnancy wheel, on which EDD arrow is set, and then present date wheel, on which EDD arrow is set, and then present date will be pointing to present week’s gestationwill be pointing to present week’s gestation

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Determining weeks of gestationDetermining weeks of gestation (cont.)(cont.) Expected date of delivery, or EDD (cont.)Expected date of delivery, or EDD (cont.)

• Number of weeks of gestation also can be estimated by Number of weeks of gestation also can be estimated by Physical examination (bimanual and pelvic exam)Physical examination (bimanual and pelvic exam) Measurement of maternal serum hCGMeasurement of maternal serum hCG UltrasoundUltrasound Signs such as first perceived fetal movementSigns such as first perceived fetal movement

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Weight gain in pregnancyWeight gain in pregnancy Amount of weight gained by term Amount of weight gained by term

• Represents a baby, amniotic fluid, placenta, increased Represents a baby, amniotic fluid, placenta, increased uterine size, increased blood volume, increased uterine size, increased blood volume, increased extravascular fluid, maternal fat stores, and increased extravascular fluid, maternal fat stores, and increased breast sizebreast size

• Weight gain during pregnancy reflects both mother and Weight gain during pregnancy reflects both mother and fetus and is approximately 62% water gain, 30% fat gain, fetus and is approximately 62% water gain, 30% fat gain, and 8% proteinand 8% protein

• Approximately 25% of the total gain is attributed to the Approximately 25% of the total gain is attributed to the fetus, 11% to placenta and amniotic fluid, and remainder fetus, 11% to placenta and amniotic fluid, and remainder to motherto mother

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Weight gain in pregnancy (cont.)Weight gain in pregnancy (cont.) The American College of Obstetricians and The American College of Obstetricians and

Gynecologists recommends following weight gain Gynecologists recommends following weight gain during pregnancyduring pregnancy• 28 to 40 lb for underweight women28 to 40 lb for underweight women

• 25 to 35 lb for normal-weight women25 to 35 lb for normal-weight women

• 15 to 25 lb for overweight women15 to 25 lb for overweight women

• 35 to 45 lb for twin gestation35 to 45 lb for twin gestation

A healthy outcome may be expected within a great A healthy outcome may be expected within a great range of weight gainrange of weight gain

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Structure and FunctionStructure and FunctionDevelopmental CompetenceDevelopmental Competence

Each year in U.S., almost one million teenage Each year in U.S., almost one million teenage women become pregnantwomen become pregnant 78% are unplanned78% are unplanned

• Many pose serious medical risks for both mother and Many pose serious medical risks for both mother and fetus, such as toxemia, anemia, prematurity, low birth fetus, such as toxemia, anemia, prematurity, low birth weight infants, prolonged labor, and postpartum weight infants, prolonged labor, and postpartum complicationscomplications

• Some teen pregnancies are planned and due in part to Some teen pregnancies are planned and due in part to maladaptive attempts to solve social issues within home maladaptive attempts to solve social issues within home environment or manipulation of a boyfriend with promise environment or manipulation of a boyfriend with promise of a prolonged relationshipof a prolonged relationship

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(cont.)(cont.) Each year in the U.S., almost one million Each year in the U.S., almost one million

teenage women become pregnant (cont.)teenage women become pregnant (cont.)• Either attempt can bring bitterness from family and Either attempt can bring bitterness from family and

friends leading to cycle of poor reproductive and social friends leading to cycle of poor reproductive and social choiceschoices

• It is important for those teens wishing to continue a It is important for those teens wishing to continue a pregnancy to seek early prenatal care because they are pregnancy to seek early prenatal care because they are at risk for maternal/fetal morbidity and mortalityat risk for maternal/fetal morbidity and mortality

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(cont.)(cont.) Other risks for pregnant adolescents are Other risks for pregnant adolescents are

largely psychosociallargely psychosocial• This young woman is at risk for downward cycle of This young woman is at risk for downward cycle of

poverty beginning with an incomplete education, failure poverty beginning with an incomplete education, failure to limit family size, and continuing with failure to establish to limit family size, and continuing with failure to establish a vocation and become independenta vocation and become independent

• She may be unprepared emotionally to be a motherShe may be unprepared emotionally to be a mother

• Her social situation may be stressfulHer social situation may be stressful

• She may not have the support of her family, her partner, She may not have the support of her family, her partner, or his familyor his family

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(cont.)(cont.) Other risks for pregnant adolescent are Other risks for pregnant adolescent are

largely psychosocial (cont.)largely psychosocial (cont.)• Medical risks for pregnant adolescent are generally Medical risks for pregnant adolescent are generally

related to poverty, inadequate nutrition, substance related to poverty, inadequate nutrition, substance abuse, and sometimes sexually transmitted infections abuse, and sometimes sexually transmitted infections (STIs), poor health before pregnancy, and emotional and (STIs), poor health before pregnancy, and emotional and physical abuse from her partnerphysical abuse from her partner

• Adolescents, for social reasons, seek health care later Adolescents, for social reasons, seek health care later when early prenatal care provides optimal managementwhen early prenatal care provides optimal management

• In developing countries, maternal mortality for pregnant In developing countries, maternal mortality for pregnant teenagers is major concern because of hypertension, teenagers is major concern because of hypertension, embolism, ectopic pregnancy, and complications from embolism, ectopic pregnancy, and complications from pregnancy termination where abortion is illegalpregnancy termination where abortion is illegal

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(cont.)(cont.) Fertility Fertility

Declines with advancing maternal ageDeclines with advancing maternal age Due in part to a decrease in number and health of Due in part to a decrease in number and health of

eggs to be ovulated, a decrease in ovulation, eggs to be ovulated, a decrease in ovulation, endometriosis, and early onset of menopause endometriosis, and early onset of menopause • According to the American Society for Reproductive According to the American Society for Reproductive

Medicine there is an unrealistic expectation that medical Medicine there is an unrealistic expectation that medical science can undo effects of aging when women delay science can undo effects of aging when women delay childbearing; therefore, more women of advanced childbearing; therefore, more women of advanced maternal age are choosing to use donor eggs from maternal age are choosing to use donor eggs from younger womenyounger women

• The age of egg is important factor, not age of uterusThe age of egg is important factor, not age of uterus

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(cont.)(cont.) As we come to end of baby boomers’ fertility, As we come to end of baby boomers’ fertility,

many women of advanced maternal age (40s and many women of advanced maternal age (40s and 50s) are choosing to become pregnant with 50s) are choosing to become pregnant with assisted fertilityassisted fertility

With this comes concern not only for physical and With this comes concern not only for physical and emotional well-being of mother, but of psycho-emotional well-being of mother, but of psycho-logical challenges that child growing up with logical challenges that child growing up with parents of advanced age will faceparents of advanced age will face

Women age 35 and older experience an increased Women age 35 and older experience an increased risk of intrauterine fetal death, pregnancy induced risk of intrauterine fetal death, pregnancy induced hypertension, gestational diabetes, and delivery by hypertension, gestational diabetes, and delivery by cesareancesarean

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(cont.)(cont.) Risk of Down syndrome increases with maternal Risk of Down syndrome increases with maternal

age age • 1 in 1,250 at age 251 in 1,250 at age 25

• 1 in 1,000 at age 301 in 1,000 at age 30

• 1 in 400 at age 351 in 400 at age 35

• 1 in 100 at age 401 in 100 at age 40

• 1 in 30 at age 451 in 30 at age 45

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(cont.)(cont.) Women age 35 years or older or who have a Women age 35 years or older or who have a

history of a genetic abnormality are offered genetic history of a genetic abnormality are offered genetic counseling, and the options of both prenatal counseling, and the options of both prenatal diagnostic screening testsdiagnostic screening tests

Two prenatal diagnostic options are: Two prenatal diagnostic options are: • Chorionic villi sampling (CVS) performed between Chorionic villi sampling (CVS) performed between

gestational weeks 11 and 13 in which small sample of gestational weeks 11 and 13 in which small sample of chorionic villi is removed to analyze genetic makeupchorionic villi is removed to analyze genetic makeup

• Amniocentesis, which is performed between gestational Amniocentesis, which is performed between gestational weeks 15 and 20 in which a small amount of amniotic weeks 15 and 20 in which a small amount of amniotic fluid is removed to analyze genetic makeupfluid is removed to analyze genetic makeup

• Both associated with small risk of complications and Both associated with small risk of complications and miscarriagemiscarriage

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(cont.)(cont.) Prenatal screening involves a fetal anatomy Prenatal screening involves a fetal anatomy

ultrasound (US) scan and serum screeningultrasound (US) scan and serum screening There are two US scans used in genetic screening There are two US scans used in genetic screening

• Nuchal translucency (NT) done between gestational weeks 11 Nuchal translucency (NT) done between gestational weeks 11 and 14, which measures a collection of fluid at nape of fetal and 14, which measures a collection of fluid at nape of fetal neckneck

• Detailed anatomy scan done between gestational weeks 18 Detailed anatomy scan done between gestational weeks 18 and 20and 20

• Some facilities continue to use Integrated Prenatal Risk Profile Some facilities continue to use Integrated Prenatal Risk Profile (IPRP), which uses a first trimester US between 10 and 12 (IPRP), which uses a first trimester US between 10 and 12 weeks to measure NT and maternal serum analysis and a weeks to measure NT and maternal serum analysis and a second maternal serum blood draw in the second trimester; second maternal serum blood draw in the second trimester; results are only received after second maternal blood drawresults are only received after second maternal blood draw

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(cont.)(cont.) There are two US scans used in genetic screening There are two US scans used in genetic screening

(cont.) (cont.) • Because integrated screen requires a waiting period, the Because integrated screen requires a waiting period, the

sequential screen was developedsequential screen was developed Similar to IPRP, except that those whose risk for Down Similar to IPRP, except that those whose risk for Down

syndrome is increased after first blood draw are given an syndrome is increased after first blood draw are given an earlier option for prenatal diagnostic testingearlier option for prenatal diagnostic testing

• Women of advanced maternal age (over 35 years old) Women of advanced maternal age (over 35 years old) experience increased risk of prenatal and neonatal experience increased risk of prenatal and neonatal deaths, pregnancy-induced hypertension, preterm deaths, pregnancy-induced hypertension, preterm delivery, small for gestational age (SGA), and large for delivery, small for gestational age (SGA), and large for gestational age (LGA) neonates, gestational diabetes, gestational age (LGA) neonates, gestational diabetes, severe preeclampsia, anal sphincter tears, and cesarean severe preeclampsia, anal sphincter tears, and cesarean deliveriesdeliveries

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Structure and FunctionStructure and FunctionCultural CompetenceCultural Competence

Over 30 million women worldwide have undergone Over 30 million women worldwide have undergone female genital cutting, or female circumcisionfemale genital cutting, or female circumcision

Due to large racial demographic in U.S., more with Due to large racial demographic in U.S., more with this condition are seen in current clinical settingthis condition are seen in current clinical setting

These women are at an increased risk of perineal These women are at an increased risk of perineal tears, wound infections, separation of tears, wound infections, separation of episiotomies, postpartum hemorrhage and sepsisepisiotomies, postpartum hemorrhage and sepsis

Every minute, another woman dies in pregnancy Every minute, another woman dies in pregnancy or childbirth leaving children without a mother and or childbirth leaving children without a mother and families shattered struggling to care for those left families shattered struggling to care for those left behindbehind

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Structure and FunctionStructure and FunctionCultural CompetenceCultural Competence (cont.)(cont.)

Over 500,000 women die in childbirth each yearOver 500,000 women die in childbirth each year According to United Nations Populations Fund, According to United Nations Populations Fund,

this number remains globally high in an age where this number remains globally high in an age where these deaths are preventablethese deaths are preventable

90% of these maternal deaths occur in Africa and 90% of these maternal deaths occur in Africa and Asia, and they occur from severe bleeding, sepsis, Asia, and they occur from severe bleeding, sepsis, eclampsia, obstructed labor, and unsafe abortionseclampsia, obstructed labor, and unsafe abortions

Many women who survive pregnancy and Many women who survive pregnancy and childbirth may suffer lifetime of physical and childbirth may suffer lifetime of physical and emotional complications such as vaginal or rectal emotional complications such as vaginal or rectal fistulafistula

Slide 29-44




Hispanic population within U.S. between 1990 and Hispanic population within U.S. between 1990 and 2000 grew by more than 40%2000 grew by more than 40%

It is projected that between 2000 and 2010 that It is projected that between 2000 and 2010 that will increase by another 34%will increase by another 34%

Hispanics had highest birth rate in 2003 with 82.2 Hispanics had highest birth rate in 2003 with 82.2 births per 1,000 teen females aged 15 to 19births per 1,000 teen females aged 15 to 19

Still there are disparities in adequate access to Still there are disparities in adequate access to preventative, prenatal, and dental care with these preventative, prenatal, and dental care with these cultural groups along with Asian/Pacific islander, cultural groups along with Asian/Pacific islander, American Indian, and Alaskan Native populationsAmerican Indian, and Alaskan Native populations

Slide 29-45




Pregnancy is not only a medical event, but also one Pregnancy is not only a medical event, but also one with profound psychological and social meaning for with profound psychological and social meaning for woman and for her family and communitywoman and for her family and community

All cultures recognize pregnancy as a unique period in All cultures recognize pregnancy as a unique period in a woman’s life that surrounds special customs and a woman’s life that surrounds special customs and beliefs that have been developed throughout the agesbeliefs that have been developed throughout the ages

Spiritual practices and beliefs either provide her with or Spiritual practices and beliefs either provide her with or without supportwithout support

Understanding what role these beliefs and practices Understanding what role these beliefs and practices play in woman’s pregnancy helps health care provider play in woman’s pregnancy helps health care provider to acknowledge cultural differencesto acknowledge cultural differences

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• Pregnancy is intensely personal and involves such Pregnancy is intensely personal and involves such charged issues as sexuality, relationships, contraception, charged issues as sexuality, relationships, contraception, nutritional practices, maternal weight gain, and abortion nutritional practices, maternal weight gain, and abortion

• You must be sensitive to these issuesYou must be sensitive to these issues

• You may begin by inquiring whether woman or her You may begin by inquiring whether woman or her significant others have any special requestssignificant others have any special requests

• This communicates your intention to respect cultural This communicates your intention to respect cultural differences and preferencesdifferences and preferences

• Continuing rapport will help enable woman to bring up Continuing rapport will help enable woman to bring up issues as they developissues as they develop

• A woman’s resistance to an action or a suggestion by A woman’s resistance to an action or a suggestion by clinician may represent a cultural issueclinician may represent a cultural issue

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• Such issues may also be held differently by woman and Such issues may also be held differently by woman and one or more of her significant others, and such situations one or more of her significant others, and such situations must be handled with caremust be handled with care

• Examples of culturally-charged issues are: Examples of culturally-charged issues are: Dietary practicesDietary practices Sexuality during and after pregnancySexuality during and after pregnancy Preference for gender of care providerPreference for gender of care provider Preference for gender of infantPreference for gender of infant Contraceptive usageContraceptive usage

• Use your skill to understand such preferences within a Use your skill to understand such preferences within a cultural context and accept rather than judge the person cultural context and accept rather than judge the person

• Whenever safe and possible, respect such wishes; this Whenever safe and possible, respect such wishes; this enhances success of birth in psychosocial dimensionsenhances success of birth in psychosocial dimensions

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Subjective DataSubjective Data

Menstrual historyMenstrual history Gynecologic historyGynecologic history Obstetric historyObstetric history Current pregnancyCurrent pregnancy Medical historyMedical history Family historyFamily history Review of systemsReview of systems Nutritional historyNutritional history Environment/hazardEnvironment/hazard

Slide 29-49



Subjective DataSubjective Data (cont.)(cont.) Menstrual historyMenstrual history

When was the first day of your last menstrual When was the first day of your last menstrual period that was normal in timing? Describe period that was normal in timing? Describe premenstrual symptoms, length, amount of flow, premenstrual symptoms, length, amount of flow, cramping.cramping.

Number of days in cycle?Number of days in cycle? Age at menarche?Age at menarche?

Gynecologic historyGynecologic history Have you ever had surgery of the cervix or uterus?Have you ever had surgery of the cervix or uterus? Do you have any known history of or exposure to Do you have any known history of or exposure to

genital herpes?genital herpes?

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Subjective DataSubjective Data (cont.)(cont.)

Gynecologic history (cont.)Gynecologic history (cont.) When your mother was pregnant with you, did she When your mother was pregnant with you, did she

ever take a drug called diethylstilbestrol (DES)? ever take a drug called diethylstilbestrol (DES)? • DES was a synthetic nonsteroidal estrogen given to DES was a synthetic nonsteroidal estrogen given to

pregnant women between 1948 and 1971 in an attempt pregnant women between 1948 and 1971 in an attempt to prevent various pregnancy-related complications to prevent various pregnancy-related complications

Pap smears: When was your last one? Any history Pap smears: When was your last one? Any history of abnormal results? If so, when? Have you ever of abnormal results? If so, when? Have you ever had a colposcopy? had a colposcopy?

Do you have any history of infertility, fibroids, or Do you have any history of infertility, fibroids, or uterine abnormalities?uterine abnormalities?

Slide 29-51




Gynecologic history (cont.)Gynecologic history (cont.) Any history of gonorrhea, chlamydia, syphilis, Any history of gonorrhea, chlamydia, syphilis,

trichomoniasis, or pelvic inflammatory disease trichomoniasis, or pelvic inflammatory disease (PID)?(PID)?

Do you or your partner have more than one sexual Do you or your partner have more than one sexual partner? partner?

Were you a preterm infant?Were you a preterm infant? Have you had a mammogram, breast biopsy, Have you had a mammogram, breast biopsy,

breast implants, lumpectomy, or mastectomy?breast implants, lumpectomy, or mastectomy?

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Obstetric historyObstetric history In earlier pregnancies, did you have any history of In earlier pregnancies, did you have any history of

hypertension, preeclampsia, eclampsia, HELLP hypertension, preeclampsia, eclampsia, HELLP (hemolysis, elevated liver enzymes, low platelets) (hemolysis, elevated liver enzymes, low platelets) syndrome, diabetes, hemolytic Streptococcus syndrome, diabetes, hemolytic Streptococcus infection, intrauterine growth restriction, congenital infection, intrauterine growth restriction, congenital anomalies, premature labor, postpartum anomalies, premature labor, postpartum hemorrhage, or postpartum depression?hemorrhage, or postpartum depression?

How did you experience previous pregnancies and How did you experience previous pregnancies and deliveries?deliveries?

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Subjective DataSubjective Data (cont.)(cont.) Obstetric history (cont.)Obstetric history (cont.)

Have you ever had a cesarean section? If so, what Have you ever had a cesarean section? If so, what was the indication? At how many centimeters of was the indication? At how many centimeters of dilation, if any, was the surgery performed? What dilation, if any, was the surgery performed? What type of uterine incision was made? (Confirming type of uterine incision was made? (Confirming records of this surgery must be obtained.) Have records of this surgery must be obtained.) Have you ever had a vaginal birth after a cesarean you ever had a vaginal birth after a cesarean section (VBAC)?section (VBAC)?

How many times have you been pregnant? How many times have you been pregnant? Number of term or preterm deliveries? Number of Number of term or preterm deliveries? Number of spontaneous miscarriages, elective abortions, or spontaneous miscarriages, elective abortions, or ectopic pregnancies? Any fetal or neonatal deaths?ectopic pregnancies? Any fetal or neonatal deaths?

Slide 29-54




Obstetric history (cont.)Obstetric history (cont.) Any history of infertility? Have you used assisted Any history of infertility? Have you used assisted

reproductive technology?reproductive technology? Any history of preterm labor or preterm rupture of Any history of preterm labor or preterm rupture of

membranes?membranes? Have you been told you have cervical insufficiency Have you been told you have cervical insufficiency

or incompetency? Have you had a cervical or incompetency? Have you had a cervical cerclage placed in previous pregnancies? cerclage placed in previous pregnancies?

What were the gestational ages and weights of What were the gestational ages and weights of your infants at birth?your infants at birth?

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Obstetric history (cont.)Obstetric history (cont.) Did you breastfeed the previously born infants? Did you breastfeed the previously born infants?

How was that experience for you? How was that experience for you? Any history of mastitis?Any history of mastitis?

Present pregnancyPresent pregnancy Having calculated current number of weeks of Having calculated current number of weeks of

gestation, you can reassess probable accuracy of gestation, you can reassess probable accuracy of that date when eliciting the following historythat date when eliciting the following history

What method of contraceptive did you use most What method of contraceptive did you use most recently, and when did you discontinue it?recently, and when did you discontinue it?

Slide 29-56




Present pregnancyPresent pregnancy Was the pregnancy planned? How do you feel Was the pregnancy planned? How do you feel

about it?about it? How does the baby’s father feel about the How does the baby’s father feel about the

pregnancy? How do other family members feel?pregnancy? How do other family members feel? Have you experienced any vaginal bleeding? Have you experienced any vaginal bleeding?

When? How much? What color was it? Was it When? How much? What color was it? Was it accompanied by any pain?accompanied by any pain?

Are you experiencing any nausea or vomiting?Are you experiencing any nausea or vomiting?

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Present pregnancy (cont.)Present pregnancy (cont.) Have you experienced abdominal pain? When? Have you experienced abdominal pain? When?

Where in your abdomen? Was it accompanied by Where in your abdomen? Was it accompanied by vaginal bleeding?vaginal bleeding?

Have you experienced any illnesses since Have you experienced any illnesses since becoming pregnant? Have you had any recent becoming pregnant? Have you had any recent fevers, unexplained rashes, or infections?fevers, unexplained rashes, or infections?

Have you had any x-rays? Have you had any x-rays? Have you taken any medications? Have you used Have you taken any medications? Have you used

any recreational drugs or alcohol? Do you smoke any recreational drugs or alcohol? Do you smoke cigarettes?cigarettes?

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Subjective DataSubjective Data (cont.)(cont.) Present pregnancy (cont.)Present pregnancy (cont.)

Are you experiencing any visual changes, such as Are you experiencing any visual changes, such as the new onset of blurred vision or spots before your the new onset of blurred vision or spots before your eyes?eyes?

Are you experiencing any edema? Where and under Are you experiencing any edema? Where and under what circumstances does it occur?what circumstances does it occur?

Do you have any frequency or burning with urination? Do you have any frequency or burning with urination? Is there any blood in your urine? Do you void in small Is there any blood in your urine? Do you void in small amounts? Do you have a history of urinary tract amounts? Do you have a history of urinary tract infections, pyelonephritis, or kidney stones? infections, pyelonephritis, or kidney stones?

Do you have any vaginal burning or itching? Do you Do you have any vaginal burning or itching? Do you have any foul-smelling or colored discharge? have any foul-smelling or colored discharge?

Slide 29-59




Present pregnancy (cont.)Present pregnancy (cont.) What date did you first feel the fetus move?What date did you first feel the fetus move? How does the fetus move on a daily basis?How does the fetus move on a daily basis? Do you have cats in the home?Do you have cats in the home? Do you plan to breastfeed this infant?Do you plan to breastfeed this infant?

Slide 29-60




Medical historyMedical history Do you have allergies to medications or foods? If Do you have allergies to medications or foods? If

so, what type of reaction? so, what type of reaction? Any personal or family history of cancer? Any personal or family history of cancer? Do you have a history of asthma? If yes, have you Do you have a history of asthma? If yes, have you

ever been intubated? ever been intubated? Have you ever had German measles (rubella)?Have you ever had German measles (rubella)? Have you ever had chickenpox?Have you ever had chickenpox? Have you had an injury to your back or another Have you had an injury to your back or another

weight-bearing part?weight-bearing part?

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Subjective DataSubjective Data (cont.)(cont.) Medical history (cont.)Medical history (cont.)

Have you been tested for HIV? When? What was the Have you been tested for HIV? When? What was the result? Have you ever had a blood transfusion? Have result? Have you ever had a blood transfusion? Have you used intravenous drugs? Have you had a sexual you used intravenous drugs? Have you had a sexual partner who had any HIV risk factors? partner who had any HIV risk factors?

Do you smoke cigarettes? How many? For how many Do you smoke cigarettes? How many? For how many years? Have you ever tried to quit? Do you drink any years? Have you ever tried to quit? Do you drink any alcohol? How many times per week? Do you use any alcohol? How many times per week? Do you use any street drugs?street drugs?

Do you take any prescribed, over-the-counter, or Do you take any prescribed, over-the-counter, or herbal medications?herbal medications?

Do you have regular exercise program? What type?Do you have regular exercise program? What type?

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Subjective DataSubjective Data (cont.)(cont.) Family historyFamily history

Does anyone in your family have hypertension?Does anyone in your family have hypertension? Does anyone in your family have diabetes? If so, is it of Does anyone in your family have diabetes? If so, is it of

juvenile or adult onset? Is he or she insulin dependent?juvenile or adult onset? Is he or she insulin dependent? Do you have a family history of mental illness?Do you have a family history of mental illness? Do you have a family history of kidney disease?Do you have a family history of kidney disease? Do you have a family history of fraternal twins? Do you have a family history of fraternal twins? Has anyone in your family, or in the family of the Has anyone in your family, or in the family of the

baby’s father, had congenital anomalies?baby’s father, had congenital anomalies? Is your racial descent Mediterranean? Black? Is your racial descent Mediterranean? Black?

Ashkenazi Jewish? Irish?Ashkenazi Jewish? Irish?

Slide 29-63




Review of systemsReview of systems What was your weight before pregnancy?What was your weight before pregnancy? Do you wear glasses?Do you wear glasses? When did you last see the dentist? Did you need When did you last see the dentist? Did you need

any dental work?any dental work? Have you been exposed to tuberculosis (TB) or Have you been exposed to tuberculosis (TB) or

had a positive PPD or chest x-ray?had a positive PPD or chest x-ray? Any cardiovascular disease, such as vascular Any cardiovascular disease, such as vascular

disease, or disease of a heart valve?disease, or disease of a heart valve? Any anemia? What kind? When? Was it treated? Any anemia? What kind? When? Was it treated?

How? Did it improve?How? Did it improve?

Slide 29-64




Review of systems (cont.)Review of systems (cont.) Have you had thrombophlebitis, pulmonary Have you had thrombophlebitis, pulmonary

embolus (PE), or deep venous thrombosis (DVT)? embolus (PE), or deep venous thrombosis (DVT)? Have you had hypertension or kidney disease?Have you had hypertension or kidney disease? Have you any history of hepatitis B or C?Have you any history of hepatitis B or C? Have you any history of thyroid disease? Have you any history of thyroid disease? Have you any history of seizures? Have you any history of seizures? Have you had any urinary tract infections?Have you had any urinary tract infections? Have you had depression or any other mental Have you had depression or any other mental

illness?illness?

Slide 29-65




Review of systems (cont.)Review of systems (cont.) Do you feel safe in your relationship or home Do you feel safe in your relationship or home

environment? environment? Are you in a relationship with someone who Are you in a relationship with someone who

physically or emotionally abuses or threatens you? physically or emotionally abuses or threatens you? Has anyone forced you to do sexual activities Has anyone forced you to do sexual activities

against your will? against your will? Do you have diabetes? Did you have diabetes Do you have diabetes? Did you have diabetes

during a previous pregnancy?during a previous pregnancy?

Slide 29-66




Nutritional historyNutritional history Do you follow a special diet?Do you follow a special diet? Do you have any food intolerance?Do you have any food intolerance? Do you crave nonfoods such as ice, paint chips, Do you crave nonfoods such as ice, paint chips,

dirt, or clay?dirt, or clay? Environment/hazardsEnvironment/hazards

What is your occupation? What are the physical What is your occupation? What are the physical demands of the work? Are you exposed to any demands of the work? Are you exposed to any strong odors, chemicals, radiation, or other strong odors, chemicals, radiation, or other harmful substances?harmful substances?

Slide 29-67




Environment/hazards (cont.)Environment/hazards (cont.) Do you consider your food and housing adequate?Do you consider your food and housing adequate? How do you wear your seat belt when driving?How do you wear your seat belt when driving? Do you have any other questions or concerns?Do you have any other questions or concerns?

Slide 29-68



Objective DataObjective Data

PreparationPreparation Initial examination for pregnancy is often first Initial examination for pregnancy is often first

pelvic examination, and many women extremely pelvic examination, and many women extremely anxiousanxious• Alternatively, woman may not know for certain whether Alternatively, woman may not know for certain whether

she is pregnant, and may be anxious about findingsshe is pregnant, and may be anxious about findings

• Verbally prepare woman for what will happen during Verbally prepare woman for what will happen during examination before touching herexamination before touching her

• Save pelvic examination for last, as woman will be more Save pelvic examination for last, as woman will be more comfortable with your gentle, informing mannercomfortable with your gentle, informing manner

Slide 29-69



Objective DataObjective Data (cont.)(cont.)

Preparation (cont.)Preparation (cont.) Communicate all findings as you go along to Communicate all findings as you go along to

demonstrate respect for her control and demonstrate respect for her control and responsibility in her own health and her childresponsibility in her own health and her child• Ask the woman to empty her bladder before Ask the woman to empty her bladder before

examination, reserving specimenexamination, reserving specimen

• Before examination, ask her to weigh herself on office Before examination, ask her to weigh herself on office scalescale

• Provide woman with a chaperone, if desiredProvide woman with a chaperone, if desired

• Some clinics require an escort or chaperone during Some clinics require an escort or chaperone during examinationsexaminations

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Preparation (cont.)Preparation (cont.) Give woman a gown and drapeGive woman a gown and drape

• Begin examination with woman sitting on examination Begin examination with woman sitting on examination table, wearing gown, her lap covered by drapetable, wearing gown, her lap covered by drape

• During breast examination, help her to lie downDuring breast examination, help her to lie down

• She remains recumbent for abdominal and extremity She remains recumbent for abdominal and extremity examinationexamination

• Use lithotomy position for pelvic examinationUse lithotomy position for pelvic examination

• Help her to a seated position to check her BPHelp her to a seated position to check her BP

• Recheck after examination if BP is elevatedRecheck after examination if BP is elevated

Slide 29-71




Equipment neededEquipment needed StethoscopeStethoscope BP cuffBP cuff Centimeter measuring tapeCentimeter measuring tape Fetoscope and Doppler sonometerFetoscope and Doppler sonometer Reflex hammerReflex hammer Urine collection containersUrine collection containers Chemostix for checking urine for glucose and Chemostix for checking urine for glucose and

proteinprotein

Slide 29-72




General surveyGeneral survey Observe woman’s state of nourishment, and her Observe woman’s state of nourishment, and her

grooming, posture, mood, and affect, which reflect grooming, posture, mood, and affect, which reflect her mental stateher mental state

Throughout examination, observe her maturity and Throughout examination, observe her maturity and ability to attend and learn to plan your teaching of ability to attend and learn to plan your teaching of information needed to successfully complete information needed to successfully complete healthy pregnancyhealthy pregnancy

Slide 29-73




SkinSkin Note any scars, particularly those of previous Note any scars, particularly those of previous

cesarean deliverycesarean delivery• Many women have skin changes during pregnancy that Many women have skin changes during pregnancy that

may spontaneously resolve after pregnancy, such as may spontaneously resolve after pregnancy, such as acne or skin tagsacne or skin tags

• Vascular spiders may be present on upper bodyVascular spiders may be present on upper body

• Some women have chloasma, known as “mask of Some women have chloasma, known as “mask of pregnancy,” which is a butterfly-shaped pigmentation of pregnancy,” which is a butterfly-shaped pigmentation of face face

• Note presence of linea nigra, a hyperpigmented line that Note presence of linea nigra, a hyperpigmented line that begins at sternal notch and extends down abdomen begins at sternal notch and extends down abdomen through umbilicus to pubisthrough umbilicus to pubis

Slide 29-74




Skin (cont.)Skin (cont.) Note striae, or stretch marks, in areas of weight Note striae, or stretch marks, in areas of weight

gain, particularly on abdomen and breasts of gain, particularly on abdomen and breasts of multiparous womenmultiparous women• These marks are bright red when they first form, but will These marks are bright red when they first form, but will

shrink and lighten to silvery color after pregnancy in shrink and lighten to silvery color after pregnancy in lightly pigmented womanlightly pigmented woman

Slide 29-75




MouthMouth Mucous membranes should be red and moistMucous membranes should be red and moist

• Gum hypertrophy, surface looks smooth and stippling Gum hypertrophy, surface looks smooth and stippling disappears, may occur normally during pregnancy disappears, may occur normally during pregnancy (pregnancy gingivitis)(pregnancy gingivitis)

• Bleeding gums may be from estrogen stimulation, which Bleeding gums may be from estrogen stimulation, which causes increased vascularity and fragilitycauses increased vascularity and fragility

NeckNeck Thyroid may be palpable and may feel full but Thyroid may be palpable and may feel full but

smooth during normal pregnancy of euthyroid smooth during normal pregnancy of euthyroid womanwoman

Slide 29-76




BreastsBreasts Breasts are enlarged, perhaps with striae, and are Breasts are enlarged, perhaps with striae, and are

very tendervery tender• Areolae and nipples enlarge and darken in pigmentation, Areolae and nipples enlarge and darken in pigmentation,

nipples become more erect, and “secondary areolae,” nipples become more erect, and “secondary areolae,” mottling around areolae, may developmottling around areolae, may develop

• Blood vessels of breast enlarge and may shine blue Blood vessels of breast enlarge and may shine blue through more translucent chest wallthrough more translucent chest wall

• When auscultating, flow through these blood vessels can When auscultating, flow through these blood vessels can be heard and may be mistaken for a cardiac murmurbe heard and may be mistaken for a cardiac murmur

• Sound is called mammary souffleSound is called mammary souffle

Slide 29-77




Breasts (cont.)Breasts (cont.) Montgomery’s tubercles, located around areola Montgomery’s tubercles, located around areola

and responsible for skin integrity of areola, enlargeand responsible for skin integrity of areola, enlarge• Colostrum, a thick yellow fluid, may be expressed from Colostrum, a thick yellow fluid, may be expressed from

nipplesnipples

• Breast tissue feels nodular as mammary alveoli Breast tissue feels nodular as mammary alveoli hypertrophyhypertrophy

• Take this opportunity to teach or reinforce breast self-Take this opportunity to teach or reinforce breast self-examination (BSE)examination (BSE)

• Woman should expect changes in breast tissue during Woman should expect changes in breast tissue during pregnancypregnancy

Slide 29-78




Breasts (cont.)Breasts (cont.) Because of lack of menses, instruct woman to Because of lack of menses, instruct woman to

perform BSE according to calendar on a monthly perform BSE according to calendar on a monthly basisbasis• Recall that some women have an embryologic remnant Recall that some women have an embryologic remnant

called a supernumerary nipple, which may or may not called a supernumerary nipple, which may or may not have breast tissue beneath ithave breast tissue beneath it

• Possibly mistaken previously for a mole, these occur Possibly mistaken previously for a mole, these occur under arm or in line directly underneath each nipple on under arm or in line directly underneath each nipple on abdominal wall abdominal wall

• This nipple and breast tissue may show same changes This nipple and breast tissue may show same changes during pregnancyduring pregnancy

• Instruct woman to check these areas as well during BSEInstruct woman to check these areas as well during BSE

Slide 29-79




HeartHeart Pregnant woman often has functional, soft, Pregnant woman often has functional, soft,

blowing, systolic murmur as result of increased blowing, systolic murmur as result of increased volumevolume• Murmur requires no treatment and will resolve after Murmur requires no treatment and will resolve after

pregnancypregnancy

LungsLungs Lungs are clear bilaterally to auscultation with no Lungs are clear bilaterally to auscultation with no

crackles or wheezingcrackles or wheezing• Shortness of breath common in third trimester from Shortness of breath common in third trimester from

pressure on diaphragm from enlarged uteruspressure on diaphragm from enlarged uterus

Slide 29-80




Peripheral vasculaturePeripheral vasculature Legs may show diffuse, bilateral pitting edema, Legs may show diffuse, bilateral pitting edema,

particularly if examination occurs later in day when particularly if examination occurs later in day when woman has been on her feet and in third trimesterwoman has been on her feet and in third trimester• Varicose veins in the legs are common in third trimesterVaricose veins in the legs are common in third trimester

• Homans’ sign is negativeHomans’ sign is negative

NeurologicNeurologic Using the reflex hammer, check biceps, patellar, Using the reflex hammer, check biceps, patellar,

and ankle deep tendon reflexesand ankle deep tendon reflexes Normally these are 1+ to 2+ and are equal Normally these are 1+ to 2+ and are equal

bilaterallybilaterally

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Objective DataObjective Data

Inspect and palpate the abdomenInspect and palpate the abdomen Observe shape and contours of abdomen to Observe shape and contours of abdomen to

discern signs of fetal position discern signs of fetal position • As the woman lifts her head, you may see diastasis recti, As the woman lifts her head, you may see diastasis recti,

separation of abdominal muscles, which occurs during separation of abdominal muscles, which occurs during pregnancy, with muscles returning together after pregnancy, with muscles returning together after pregnancy with abdominal exercisepregnancy with abdominal exercise

• When palpating, note abdominal muscle tone, which When palpating, note abdominal muscle tone, which grows more relaxed with each subsequent pregnancygrows more relaxed with each subsequent pregnancy

• Note any tenderness; uterus is normally nontenderNote any tenderness; uterus is normally nontender

• Fundus should be palpable abdominally from 12 weeks Fundus should be palpable abdominally from 12 weeks of gestation onof gestation on

Slide 29-82




Inspect and palpate the abdomen (cont.)Inspect and palpate the abdomen (cont.) Use side of hand and begin palpating centrally on Use side of hand and begin palpating centrally on

abdomen higher than you expect uterus to beabdomen higher than you expect uterus to be• Palpate down until you feel fundus (top of uterus)Palpate down until you feel fundus (top of uterus)

• Alternatively, stand at woman’s right side facing her head Alternatively, stand at woman’s right side facing her head

• Place palm of your right hand on curve of uterus in left Place palm of your right hand on curve of uterus in left lower quadrant and your left palm on curve of uterus in lower quadrant and your left palm on curve of uterus in right lower quadrantright lower quadrant

• Moving from hand to hand, allowing curve of uterus to Moving from hand to hand, allowing curve of uterus to guide you, “walk” your hands to where they meet guide you, “walk” your hands to where they meet centrally at funduscentrally at fundus

Slide 29-83




Inspect and palpate the abdomen (cont.)Inspect and palpate the abdomen (cont.) Note fundal location by landmarksNote fundal location by landmarks

• More accurate to use centimeter measuring tape and More accurate to use centimeter measuring tape and measure height of fundus in centimeters from superior measure height of fundus in centimeters from superior border of symphysis to fundusborder of symphysis to fundus

• After 20 weeks, number of centimeters should After 20 weeks, number of centimeters should approximate number of weeks of gestationapproximate number of weeks of gestation

• Beginning at 20 weeks, you may feel fetal movement, Beginning at 20 weeks, you may feel fetal movement, and fetus’s head can be ballottedand fetus’s head can be ballotted

• Gentle, quick palpation with fingertips can locate head Gentle, quick palpation with fingertips can locate head that is not only hard when you push it away, but hard as that is not only hard when you push it away, but hard as it bobs or bounces back against your fingersit bobs or bounces back against your fingers

Slide 29-84




Inspect and palpate the abdomen (cont.)Inspect and palpate the abdomen (cont.) If you suspect woman to be in labor, palpate for If you suspect woman to be in labor, palpate for

uterine contractionsuterine contractions• Palpate uterus over its entire surface to familiarize Palpate uterus over its entire surface to familiarize

yourself with its “indentability” yourself with its “indentability”

• Then rest your hand lightly on uterus with fingers openedThen rest your hand lightly on uterus with fingers opened

• When uterus contracts, it rises and pulls together, When uterus contracts, it rises and pulls together, drawing your fingers closer togetherdrawing your fingers closer together

• During contraction, notice that uterus is less “indentable” During contraction, notice that uterus is less “indentable”

• When uterus relaxes, your fingers relax open againWhen uterus relaxes, your fingers relax open again

Slide 29-85




Inspect and palpate the abdomen (cont.)Inspect and palpate the abdomen (cont.) In this way, contractions can be monitored for In this way, contractions can be monitored for

frequency, length, and qualityfrequency, length, and quality• Mild contraction feels like firmness of tip of your nose Mild contraction feels like firmness of tip of your nose

• Moderate contraction feels like your chinModerate contraction feels like your chin

• Hard contraction feels like a foreheadHard contraction feels like a forehead Make allowance for the amount of soft tissue between your Make allowance for the amount of soft tissue between your

fingers and the uterusfingers and the uterus

Slide 29-86




Leopold’s maneuversLeopold’s maneuvers In third trimester, perform Leopold’s maneuvers to In third trimester, perform Leopold’s maneuvers to

determine fetal:determine fetal:• LieLie

• Presentation Presentation

• AttitudeAttitude

• Position Position

• VarietyVariety

• EngagementEngagement

Slide 29-87




Leopold’s maneuversLeopold’s maneuvers (cont.)(cont.)• Fetal lie: orientation of fetal spine to maternal spine;Fetal lie: orientation of fetal spine to maternal spine;

may be longitudinal, transverse, or obliquemay be longitudinal, transverse, or oblique

• Presentation: describes part of fetus entering pelvis firstPresentation: describes part of fetus entering pelvis first

• Attitude: position of fetal parts in relation to each other, Attitude: position of fetal parts in relation to each other, and may be flexed, military (straight), or extended and may be flexed, military (straight), or extended

• Position: designates location of fetal part to right or left of Position: designates location of fetal part to right or left of maternal pelvismaternal pelvis

• Variety: location of fetal back to anterior, lateral, or Variety: location of fetal back to anterior, lateral, or posterior part of the maternal pelvisposterior part of the maternal pelvis

• Engagement: when widest diameter of presenting part Engagement: when widest diameter of presenting part has descended into pelvic inlet; specifically, to imagined has descended into pelvic inlet; specifically, to imagined plane at level of ischial spinesplane at level of ischial spines

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Leopold’s maneuvers: first maneuverLeopold’s maneuvers: first maneuver Performed by facing gravida’s head and placing Performed by facing gravida’s head and placing

your fingertips around top of fundusyour fingertips around top of fundus• Note its size, consistency, and shapeNote its size, consistency, and shape

• Imagine what fetal part is in fundusImagine what fetal part is in fundus

• Breech feels large and firm because it is attached to Breech feels large and firm because it is attached to fetus at waistfetus at waist

• In contrast, fetal head feels large, round, and hardIn contrast, fetal head feels large, round, and hard When ballotted, it feels hard as you push it away and hard When ballotted, it feels hard as you push it away and hard

again as it bobs back against your fingersagain as it bobs back against your fingers

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Leopold’s maneuvers: first maneuver (cont.)Leopold’s maneuvers: first maneuver (cont.) Note that “bobbing” or “ballotting” sensation of Note that “bobbing” or “ballotting” sensation of

movement occurs because head attached at neck movement occurs because head attached at neck and moves easilyand moves easily• If there is no part in fundus, fetus is in the transverse lieIf there is no part in fundus, fetus is in the transverse lie

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Leopold’s maneuvers: second maneuverLeopold’s maneuvers: second maneuver Move your hands to sides of uterusMove your hands to sides of uterus

• Note whether small parts or a long, firm surface palpable Note whether small parts or a long, firm surface palpable on woman’s left or right sideon woman’s left or right side

• Long, firm surface is the backLong, firm surface is the back

• Note whether back is anterior, lateral, or out of reach Note whether back is anterior, lateral, or out of reach (posterior)(posterior)

• Small parts, or limbs, indicate a posterior position when Small parts, or limbs, indicate a posterior position when they are palpable all over abdomenthey are palpable all over abdomen

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Leopold’s maneuvers: third maneuverLeopold’s maneuvers: third maneuver Also called Pawlik’s maneuver, requires woman to Also called Pawlik’s maneuver, requires woman to

bend her knees up slightlybend her knees up slightly• Grasp lower abdomen just above symphysis pubis Grasp lower abdomen just above symphysis pubis

between thumb and fingers of one hand and, as you did between thumb and fingers of one hand and, as you did at fundus during first maneuver, to determine what part at fundus during first maneuver, to determine what part of fetus is thereof fetus is there

• If presenting part is beginning to engage, it will feel If presenting part is beginning to engage, it will feel “fixed” “fixed”

• With this maneuver alone, it may be difficult to With this maneuver alone, it may be difficult to differentiate shoulder from vertexdifferentiate shoulder from vertex

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Leopold’s maneuvers: fourth maneuverLeopold’s maneuvers: fourth maneuver Assists in determining engagement and, in vertex Assists in determining engagement and, in vertex

presentation, to differentiate shoulder from vertexpresentation, to differentiate shoulder from vertex• Woman’s knees are still bentWoman’s knees are still bent

• Facing her feet, place your palms, with fingers pointing Facing her feet, place your palms, with fingers pointing toward feet, on either side of lower abdomentoward feet, on either side of lower abdomen

• Pressing your fingers firmly, move slowly down toward Pressing your fingers firmly, move slowly down toward pelvic inletpelvic inlet

• If your fingers meet, presenting part is not engagedIf your fingers meet, presenting part is not engaged

• If your fingers diverge at pelvic rim meeting a hard If your fingers diverge at pelvic rim meeting a hard prominence on one side, this prominence is the occiputprominence on one side, this prominence is the occiput

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Leopold’s maneuvers: fourth maneuver Leopold’s maneuvers: fourth maneuver (cont.)(cont.) This indicates vertex is presenting with a deflexed This indicates vertex is presenting with a deflexed

head, the face presentinghead, the face presenting• If your fingers meet hard prominences on both sides, If your fingers meet hard prominences on both sides,

vertex is engaged in either a military or a flexed positionvertex is engaged in either a military or a flexed position

• If your fingers come to pelvic brim diverged but with no If your fingers come to pelvic brim diverged but with no prominences palpable, vertex is “dipping” into pelvis, or prominences palpable, vertex is “dipping” into pelvis, or is engagedis engaged

• In this case, firm object felt above symphysis pubis in the In this case, firm object felt above symphysis pubis in the third maneuver is shoulderthird maneuver is shoulder

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Auscultate the fetal heart tonesAuscultate the fetal heart tones FHTs are positive sign of pregnancyFHTs are positive sign of pregnancy

• They can be heard by Doppler US at 8 to 10 weeks’ They can be heard by Doppler US at 8 to 10 weeks’ gestation and with a fetoscope at 20 weeks’ gestationgestation and with a fetoscope at 20 weeks’ gestation

• This use of fetoscope assists in dating pregnancyThis use of fetoscope assists in dating pregnancy

• FHTs are auscultated best over shoulder of fetusFHTs are auscultated best over shoulder of fetus

• After identifying position of fetus, use heart tones to After identifying position of fetus, use heart tones to confirm your findingsconfirm your findings

• Count FHTs for 15 seconds and multiply by four to obtain Count FHTs for 15 seconds and multiply by four to obtain the ratethe rate

• Normal rate is between 120 and 160 beats per minuteNormal rate is between 120 and 160 beats per minute

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Auscultate the fetal heart tones (cont.)Auscultate the fetal heart tones (cont.) Spontaneous accelerations of FHTs indicate fetal Spontaneous accelerations of FHTs indicate fetal

well-beingwell-being• Differentiate FHTs from slower rate of maternal pulse Differentiate FHTs from slower rate of maternal pulse

and uterine souffle (the soft, swishing sound of the and uterine souffle (the soft, swishing sound of the placenta receiving the pulse of maternal arterial blood) placenta receiving the pulse of maternal arterial blood) by palpating the mother’s pulse while you listenby palpating the mother’s pulse while you listen

• Also, distinguish FHTs from funic souffle (blood rushing Also, distinguish FHTs from funic souffle (blood rushing through umbilical arteries at same rate as FHTs)through umbilical arteries at same rate as FHTs)

• FHTs are a double sound, like tick-tock of a clock under FHTs are a double sound, like tick-tock of a clock under a pillow, whereas funic souffle is sharp, whistling sound a pillow, whereas funic souffle is sharp, whistling sound heard only 15% of timeheard only 15% of time

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Pelvic examinationPelvic examination GenitaliaGenitalia

• Use procedure for pelvic examination described in Use procedure for pelvic examination described in Chapter 26Chapter 26

• Note following characteristicsNote following characteristics

• Enlargement of labia minora common in multiparous Enlargement of labia minora common in multiparous womenwomen

• Labial varicosities may be presentLabial varicosities may be present

• Perineum may be scarred from a previous episiotomy or Perineum may be scarred from a previous episiotomy or from lacerationsfrom lacerations

• Note presence of any hemorrhoids of rectumNote presence of any hemorrhoids of rectum

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Pelvic examination (cont.)Pelvic examination (cont.) Speculum examinationSpeculum examination

• When examining vagina, you may see Chadwick’s sign, When examining vagina, you may see Chadwick’s sign, the bluish-purplish discoloration and congested look of the bluish-purplish discoloration and congested look of vaginal wall and cervix from increased vascularity and vaginal wall and cervix from increased vascularity and engorgementengorgement

• Note vaginal discharge; discharge in pregnancy may be Note vaginal discharge; discharge in pregnancy may be heavier in amount but should be similar in description to heavier in amount but should be similar in description to woman’s nonpregnant discharge and should not be woman’s nonpregnant discharge and should not be associated with itching, burning, or an unusual odor associated with itching, burning, or an unusual odor (except that, occasionally, chapping of vaginal area may (except that, occasionally, chapping of vaginal area may be seen due to excessive moisture)be seen due to excessive moisture)

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Pelvic examinationPelvic examination (cont.)(cont.) Speculum examination (cont.)Speculum examination (cont.)

• Perform a wet mount or culture of discharge when you Perform a wet mount or culture of discharge when you are uncertain of its normalcyare uncertain of its normalcy

• Note whether cervix appears openNote whether cervix appears open

• Note whether it is smooth, round cervix with a dotlike Note whether it is smooth, round cervix with a dotlike external os of nulliparous woman or irregular multiparous external os of nulliparous woman or irregular multiparous cervix with an external os that appears more like a cervix with an external os that appears more like a crooked line, result of cervical dilation and possibly crooked line, result of cervical dilation and possibly lacerations in a previous pregnancylacerations in a previous pregnancy

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Pelvic examination (cont.)Pelvic examination (cont.) Bimanual examinationBimanual examination

• Palpate the uterus between your internal and external Palpate the uterus between your internal and external hands; note its positionhands; note its position

• Pregnant uterus may be rotated toward right side as it Pregnant uterus may be rotated toward right side as it rises out of pelvis because of presence of descending rises out of pelvis because of presence of descending colon on leftcolon on left

• This is called dextrorotation; irregular enlargement of This is called dextrorotation; irregular enlargement of uterus may be noted at 8 to 10 weeks of gestation and uterus may be noted at 8 to 10 weeks of gestation and occurs when implantation occurs close to a cornual area occurs when implantation occurs close to a cornual area of uterusof uterus

• This is called Piskacek signThis is called Piskacek sign

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Pelvic examinationPelvic examination (cont.)(cont.) Bimanual examination (cont.)Bimanual examination (cont.)

• May also note Hegar’s sign, when enlarged uterus bends May also note Hegar’s sign, when enlarged uterus bends forward on its softened isthmus between 4th and 6th forward on its softened isthmus between 4th and 6th weeks of pregnancyweeks of pregnancy

• Note size and consistency of uterusNote size and consistency of uterus

• 6-week gestation uterus may seem only slightly enlarged 6-week gestation uterus may seem only slightly enlarged and softenedand softened

• 8-week gestation uterus is approximately size of an 8-week gestation uterus is approximately size of an avocado, approximately 7 to 8 cm across fundusavocado, approximately 7 to 8 cm across fundus

• 10-week gestation uterus about size of grapefruit and 10-week gestation uterus about size of grapefruit and may reach to pelvic brim, but is narrow and does not fill may reach to pelvic brim, but is narrow and does not fill pelvis from side to sidepelvis from side to side

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• 12-week gestation uterus will fill pelvis12-week gestation uterus will fill pelvis

• After 12 weeks, uterus is sized from abdomenAfter 12 weeks, uterus is sized from abdomen

• Softening of cervix is called Goodell’s signSoftening of cervix is called Goodell’s sign

• When examining cervix, note its position (anterior, When examining cervix, note its position (anterior, midposition, or posterior), degree of effacement (or midposition, or posterior), degree of effacement (or thinning, expressed in percentages assuming a 2-cm thinning, expressed in percentages assuming a 2-cm long cervix initially), dilation (opening, expressed in long cervix initially), dilation (opening, expressed in centimeters), consistency (soft or firm), and station of centimeters), consistency (soft or firm), and station of presenting part (centimeters above or below ischial presenting part (centimeters above or below ischial plane)plane)

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• Ovaries rise with growing uterus; always examine Ovaries rise with growing uterus; always examine adnexae to rule out presence of a mass, such as an adnexae to rule out presence of a mass, such as an ectopic pregnancyectopic pregnancy

• To determine tone, ask woman to squeeze your fingers To determine tone, ask woman to squeeze your fingers as they rest in vaginaas they rest in vagina

• Take this opportunity to teach Kegel exercise, squeezing Take this opportunity to teach Kegel exercise, squeezing of vagina, which woman can do to prepare for and to of vagina, which woman can do to prepare for and to recover from birth recover from birth

Woman can also identify exercise of these muscles by Woman can also identify exercise of these muscles by stopping flow of urine midstream, although she should only stopping flow of urine midstream, although she should only do this once, and should usually let urine flow freelydo this once, and should usually let urine flow freely

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Direct woman to squeeze slowly to a peak at count of eight Direct woman to squeeze slowly to a peak at count of eight and then release slowly to count of eightand then release slowly to count of eight

You can prescribe this exercise to be performed 50 to 100 You can prescribe this exercise to be performed 50 to 100 times a daytimes a day

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PelvimetryPelvimetry Assess bones of the pelvis for shape and sizeAssess bones of the pelvis for shape and size

• Dimensions may indicate favorableness of bony Dimensions may indicate favorableness of bony structure for vaginal deliverystructure for vaginal delivery

• However, relaxation of pelvic joints, widening of pelvis in However, relaxation of pelvic joints, widening of pelvis in squatting position, and capacity of fetal head to mold to squatting position, and capacity of fetal head to mold to shape of pelvis may enable a vaginal birth despite shape of pelvis may enable a vaginal birth despite seemingly unfavorable measurementsseemingly unfavorable measurements

• To aid in visualizing pelvis, imagine three planes: To aid in visualizing pelvis, imagine three planes: Pelvic inlet, from sacral promontory to upper edge of pubisPelvic inlet, from sacral promontory to upper edge of pubis Midpelvis, and pelvic outlet, from coccyx to lower edge of Midpelvis, and pelvic outlet, from coccyx to lower edge of

pubispubis

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Pelvimetry (cont.)Pelvimetry (cont.) Assessment of each of these pelvic planes allows Assessment of each of these pelvic planes allows

you to estimate adequacy of pelvis for vaginal you to estimate adequacy of pelvis for vaginal deliverydelivery• There are four general types of pelves: gynecoid, There are four general types of pelves: gynecoid,

anthropoid, android, and platypelloidanthropoid, android, and platypelloid You may postpone examination of bony pelvis until third You may postpone examination of bony pelvis until third

trimester when vagina is more distensibletrimester when vagina is more distensible

• With your two fingers still in the vagina, note shape and With your two fingers still in the vagina, note shape and width of pubic arch (a 90-degree arch, or 2 width of pubic arch (a 90-degree arch, or 2 fingerbreadths, is desirable)fingerbreadths, is desirable)

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Pelvimetry (cont.)Pelvimetry (cont.)• If you are right-handed, move your hand to right side of If you are right-handed, move your hand to right side of

woman’s pelviswoman’s pelvis

• If you are left-handed, move it to left side of woman’s If you are left-handed, move it to left side of woman’s pelvispelvis

• Assess the inclination and curve of side walls and Assess the inclination and curve of side walls and prominence of ischial spineprominence of ischial spine

• Move your fingers back and forth between spines to get Move your fingers back and forth between spines to get an impression of transverse diameter; 10 cm is desirablean impression of transverse diameter; 10 cm is desirable

• Sweep your fingers down sacrum, noting its shape and Sweep your fingers down sacrum, noting its shape and inclination (hollow, J-shaped, or straight)inclination (hollow, J-shaped, or straight)

• Assess coccyx for prominence and mobilityAssess coccyx for prominence and mobility

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Pelvimetry (cont.)Pelvimetry (cont.)• From sacrum, locate sacrospinous ligamentFrom sacrum, locate sacrospinous ligament

• Assess length of the ligament; 2½ to 3 fingerbreadths is Assess length of the ligament; 2½ to 3 fingerbreadths is adequateadequate

• Assess shape and width of sacrospinous notchAssess shape and width of sacrospinous notch

• Shift to other side of pelvis and assess it for similarity to Shift to other side of pelvis and assess it for similarity to the firstthe first

• The pelvic inlet cannot be reached by clinical examination, The pelvic inlet cannot be reached by clinical examination, but you can estimate it by measure of diagonal conjugate, but you can estimate it by measure of diagonal conjugate, which indicates anteroposterior diameter of pelvic inletwhich indicates anteroposterior diameter of pelvic inlet

• Having measured length of second and third fingers of Having measured length of second and third fingers of your examining hand, with your fingers still in vagina, point your examining hand, with your fingers still in vagina, point these fingers toward sacral promontorythese fingers toward sacral promontory

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Pelvimetry (cont.)Pelvimetry (cont.)• If you cannot reach promontory, note measurement as If you cannot reach promontory, note measurement as

being greater than centimeters of length of your being greater than centimeters of length of your examining fingers; measurement of 11.5 to 12.0 cm is examining fingers; measurement of 11.5 to 12.0 cm is desirabledesirable

• Remove your fingers from vaginaRemove your fingers from vagina

• Having previously measured width of your own hand Having previously measured width of your own hand across knuckles, form your hand into a closed fist and across knuckles, form your hand into a closed fist and place it across perineum between ischial tuberosities. place it across perineum between ischial tuberosities.

• Estimate this diameter, which is bi-ischial diameter (also Estimate this diameter, which is bi-ischial diameter (also known as the intertubous diameter and transverse known as the intertubous diameter and transverse diameter of pelvic outlet)diameter of pelvic outlet)

• Measurement greater than 8 cm is generally adequateMeasurement greater than 8 cm is generally adequate

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Pelvimetry (cont.)Pelvimetry (cont.) When describing pelvimetry, note all above When describing pelvimetry, note all above

measurements and state pelvic typemeasurements and state pelvic type• Pelvis may be described as being “proven” to number of Pelvis may be described as being “proven” to number of

pounds of largest vaginally-born infantpounds of largest vaginally-born infant

• Alternatively, to describe a small pelvis, you may make Alternatively, to describe a small pelvis, you may make assessment, for example, “adequate for a 7-lb infant”assessment, for example, “adequate for a 7-lb infant”

Blood pressureBlood pressure After examination, take blood pressure when After examination, take blood pressure when

woman is most relaxed, in semi-Fowler’s or upright woman is most relaxed, in semi-Fowler’s or upright positionposition• Recheck an elevated pressureRecheck an elevated pressure

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Routine laboratory and radiologic imaging Routine laboratory and radiologic imaging studiesstudies At onset of pregnancy, order routine prenatal At onset of pregnancy, order routine prenatal

panelpanel• Usually includes complete blood cell count, serology, Usually includes complete blood cell count, serology,

rubella antibodies, hepatitis B screening, blood type and rubella antibodies, hepatitis B screening, blood type and Rhesus factor, and an antibody screeningRhesus factor, and an antibody screening

• Some providers screen for herpes simplex virus I and IISome providers screen for herpes simplex virus I and II

• Sickle cell screening may be indicatedSickle cell screening may be indicated

• For some populations, a PPD/TINE test may be For some populations, a PPD/TINE test may be indicated to rule out active or exposure to tuberculosisindicated to rule out active or exposure to tuberculosis

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Routine laboratory and radiologic imaging Routine laboratory and radiologic imaging studies (cont.)studies (cont.) Offer woman HIV screening and cystic fibrosis Offer woman HIV screening and cystic fibrosis

screeningscreening• Obtain Papanicolaou smear at initial visit along with Obtain Papanicolaou smear at initial visit along with

cervical culturescervical cultures

• Collect a clean-catch urinalysis at initial prenatal visit to Collect a clean-catch urinalysis at initial prenatal visit to rule out cystitisrule out cystitis

• At each prenatal visit, check urine for protein and glucoseAt each prenatal visit, check urine for protein and glucose Clean-catch specimen ideal for this dip because a random Clean-catch specimen ideal for this dip because a random

specimen may include vaginal secretions, which contain specimen may include vaginal secretions, which contain protein, skewing resultsprotein, skewing results

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Routine laboratory and radiologic imaging Routine laboratory and radiologic imaging studies (cont.)studies (cont.)

• Each agency has policy regarding frequency of US examEach agency has policy regarding frequency of US exam

• Some providers prefer to do US for dating at time of Some providers prefer to do US for dating at time of maternal serum alpha-fetoprotein or “quad” screening is maternal serum alpha-fetoprotein or “quad” screening is drawn because accurate dating is essentialdrawn because accurate dating is essential

• Others will do it later (11 to 14 weeks of gestation), when Others will do it later (11 to 14 weeks of gestation), when measuring for fetal nuchal translucency (another fetal measuring for fetal nuchal translucency (another fetal risk screening tool), which is best done at this gestationrisk screening tool), which is best done at this gestation

• Some providers use US only with a medical indicationSome providers use US only with a medical indication

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Routine laboratory and radiologic imaging Routine laboratory and radiologic imaging studies (cont.)studies (cont.)

• Others routinely order US to confirm dates and fetal Others routinely order US to confirm dates and fetal normalcy (insofar as US is able to determine normalcy) normalcy (insofar as US is able to determine normalcy) and for any specific medical indication, such as fundus and for any specific medical indication, such as fundus measuring small or large for datesmeasuring small or large for dates

• US shows placental and fetal location and fetal genderUS shows placental and fetal location and fetal gender

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Sample chartingSample charting

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Sample chartingSample charting (cont.)(cont.)

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Abnormal Findings:Abnormal Findings:Fetal Size Inconsistent with DatesFetal Size Inconsistent with Dates

Size small for datesSize small for dates Inaccuracy of datesInaccuracy of dates Premature laborPremature labor Intrauterine growth restriction (IUGR) or fetal Intrauterine growth restriction (IUGR) or fetal

growth restrictiongrowth restriction Fetal positionFetal position

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Abnormal Findings:Abnormal Findings:Fetal Size Inconsistent with DatesFetal Size Inconsistent with Dates

(cont.)(cont.) Size large for datesSize large for dates

Inaccuracy of datesInaccuracy of dates Multiple fetusesMultiple fetuses PolyhydramniosPolyhydramnios Fetal macrosomiaFetal macrosomia Leiomyoma (myoma or “fibroids”)Leiomyoma (myoma or “fibroids”)

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Abnormal Findings:Abnormal Findings:Disorders of PregnancyDisorders of Pregnancy

PreeclampsiaPreeclampsia Vaginal bleedingVaginal bleeding Incompetent cervixIncompetent cervix HyperemesisHyperemesis Preterm laborPreterm labor Decreased fetal movementDecreased fetal movement

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The Pregnant Woman