Physical examination in pregnancy is directed at confirming normality of progress of pregnancy, reassuring the pregnant woman, detecting deviations from normality and detecting possible underlying disease.The vast majority of pregnant women are healthy and have no abnormalities detected during pregnancy.

First visit General examination Gynaecological examination

Subsequent visits Late pregnancy Labour

Often first medical contact in a healthy woman

Opportunity for general health screening Specific aims for pregnancy

Establish baselines Detect abnormalities Determine gestation

Teeth Neck

Thyroid often palpable Cardiovascular

Murmurs common BP technique

Chest Breasts Abdomen

May not be necessary?

Inspection (speculum) Vulva, vagina,

cervix Cervical cytology,

microbiology

Bimanual examination Uterus

Size, consistency, shape, position

Cervix Fornices Pelvic muscles Bony pelvis

Diagonal conjugate, sacral curve, ischial spines, subpubic angle

Examination limited to pregnancy unless specific problems

Weight Blood pressure Abdominal examination Urine

Protein, glucose

Dubious value - poor predictive value Average weight gain for pregnancy 11-

15 kg 1 kg/month before 20 weeks, 1.5 kg/month

after Low weight gain

?IUGR Excess weight gain

?Preeclampsia, fetal macrosomia

Correct technique vital Woman seated Correct cuff size Upper arm level with heart Systolic = Korotkow phase I Diastolic = Korotkow phase V

Main purpose to detect abnormalities in uterine size Excessive - multiple pregnancy,

polyhydramnios, macrosomia, fibroids, wrong dates

Inadequate - IUGR, wrong dates Also detect lie, presentation and station

in late pregnancy

General contour ‘C’ (flexed) versus ‘S’ (extended)

?Heart-shaped uterus Bicornuate

Scaphoid abdomen Posterior position

Fetal movements Linea nigra, striae gravidarum

Fundal height Symphisis pubis = 12 weeks Umbilicus = 20 weeks Xiphisternum = 40 weeks (lightening)

Alternatively and better - measure symphyseal-fundal height (SFH) in cm SFH ~ weeks’ gestation ± 2 More objective, less interobserver variation Mother supine, legs straight, bladder empty

1. Fundal2. Lateral3. Pawlik4. Deep pelvic

Place both hands on sides of fundus Usually feel breech If head in fundus = breech presentation

Harder, more definite, ballotable

Used to ascertain position of fetal back If limbs felt on both sides of mother’s

abdomen, posterior position more likely Anterior shoulder important landmark In transverse lie fetal poles in each flank

Determine lie, flexion, station and position Fingers of right hand spread, palpate in

suprapubic skin fold Station usually described in “fifths” of head

above pelvic brim - 1/5 = 1 finger = 2 cm ‘Fixed’ ‘Engaged’

Engagement = only sinciput palpable above brim

Combined fundal-Pawlik palpation

Used when head has entered pelvis Late pregnancy and labour

Examiner faces woman’s feet, uses both hands in iliac fossae

Determines station, position and lie

Using Pinard stethoscope or Doppler Antenatally of little clinical value, but

reassuring to mother Important in labour

Protein Screening for

preeclampsia ‘trace’ or ‘+’

usually not significant

Other causes UTI, chronic renal

disease, alkaline urine (pH > 8)

Glucose Screening for

gestational diabetes

30% of women have glycosuria, usually renal

Only 40% of women with GDM have glycosuria

Extension of pregnancy, with addition of vaginal examination

Regular assessment of pulse rate (maternal and fetal), blood pressure, temperature and contractions

Regular abdominal and vaginal examination to monitor progress of labour

Usually performed on admission then every 4 hours

Also prior to epidural analgesia, or if signs of ‘fetal distress’ or need for urgent delivery

Necessary to perform amniotomy or apply fetal electrode

Increases risk of infection

Mother supine, hips flexed and abducted, knees flexed

Aseptic technique as much as possible Determine:

Cervix Dilatation, effacement, position, consistency

Membranes Intact/ ruptured Liquor

Presenting part Nature, station, position, caput, moulding