5.Special Population- Pregnant Women.pptx

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1. Prepared by: Dr. Maryjo Valerie C. Salazar Special Population Pregnant Women Department of Physical Diagnosis Dr . Lecturer

2. OUTLINE ANATOMY/ PHYSIOLOGY REVIEW HEALTH HISTORY HEALTH PROMOTION AND COUNSELLING 01 02 03 TECHNIQUES OF EXAMINATION RECORDING FINDINGS 04 05

3. ANATOMY / PHYSIOLOGY REVIEW 01

4. ANATOMIC CHANGES BREAST UTERUS VAGINA CERVIX ADNEXAE EXTERNAL ABDOMEN 01 Moderately Enlarged d/t hormonal stimulation that causes increased vascularity and glandular hyperplasia 3rd Month of Gestation Breasts are more nodular Nipples become larger and more erectile Darker Areolae More pronounced Montgomery glands

5. ANATOMIC CHANGES BREAST UTERUS VAGINA CERVIX ADNEXAE EXTERNAL ABDOMEN 01 V enous pattern over the breasts visibly more prominent as pregnancy progresses 2nd - 3rd trimesters S ome women secrete colostrum thick, yellowish, nutrient-rich precursor to milk Breast tenderness

6. ANATOMIC CHANGES BREAST UTERUS VAGINA CERVIX ADNEXAE EXTERNAL ABDOMEN 01 The ff c ontributes to growth of the uteru: Muscle cell hypertrophy ↑ in fibrous and elastic tissue development of blood vessels and lymphatics ↑ in weight From ∼70 g (conception) to almost 1,100 g (delivery) accommodates from 5 to 20 L of fluid

7. ANATOMIC CHANGES BREAST UTERUS VAGINA CERVIX ADNEXAE EXTERNAL ABDOMEN 01 Growth patterns of the uterine fundus by weeks of pregnancy

8. ANATOMIC CHANGES BREAST UTERUS VAGINA CERVIX ADNEXAE EXTERNAL ABDOMEN 01 1st trimester confined to the pelvis inverted pear shaped may retain its prior position: anteverted (forward-leaning) retroverted (backward-leaning) retroflexed (backward-bent)

9. ANATOMIC CHANGES BREAST UTERUS VAGINA CERVIX ADNEXAE EXTERNAL ABDOMEN 01 12 to 14 weeks Externally palpable Expands into a globular shape beyond the pelvic brim

10. ANATOMIC CHANGES BREAST UTERUS VAGINA CERVIX ADNEXAE EXTERNAL ABDOMEN 01 1st Trimester

11. ANATOMIC CHANGES BREAST UTERUS VAGINA CERVIX ADNEXAE EXTERNAL ABDOMEN 01 Beginning in the 2nd trimester A nteverted position d /t enlarging fetus that pushes the uterus encroaches into the space occupied by the bladder triggering frequent voiding Intestines displaced laterally and superiorly

12. ANATOMIC CHANGES BREAST UTERUS VAGINA CERVIX ADNEXAE EXTERNAL ABDOMEN 01 Beginning in the 2nd trimester Uterus stretches its own supporting ligaments “round ligament pain” Slight dextrorotation accommodate the rectosigmoid structures on the left side of the pelvis leads greater discomfort on the right side increased right-sided hydronephrosis

13. ANATOMIC CHANGES BREAST UTERUS VAGINA CERVIX ADNEXAE EXTERNAL ABDOMEN 01 2nd Trimester

14. ANATOMIC CHANGES BREAST UTERUS VAGINA CERVIX ADNEXAE EXTERNAL ABDOMEN 01 3r d Trimester

15. ANATOMIC CHANGES BREAST UTERUS VAGINA CERVIX ADNEXAE EXTERNAL ABDOMEN 01 Chadwick sign Increased vascularity throughout the pelvis gives the vagina a bluish color V aginal walls appear deeply rugated due to: Thicker mucosa Loosening of connective tissue Hypertrophy of smooth muscle cells

16. ANATOMIC CHANGES BREAST UTERUS VAGINA CERVIX ADNEXAE EXTERNAL ABDOMEN 01 Leukorrhea of pregnancy Normal vaginal secretions may become thick, white, and more profuse Increased glycogen stores in the vaginal epithelium proliferation of Lactobacillus acidophilus ↓ vaginal pH protects against some vaginal infections contribute to higher rates of vaginal candidiasis

17. ANATOMIC CHANGES BREAST UTERUS VAGINA CERVIX ADNEXAE EXTERNAL ABDOMEN 01 ∼1 month after conception Cervix softens Bluish or cyanotic in color increased vascularity edema, glandular hyperplasia throughout the cervix

18. ANATOMIC CHANGES BREAST UTERUS VAGINA CERVIX ADNEXAE EXTERNAL ABDOMEN 01 Hegar sign palpable softening of the cervical isthmus rearrangement of the cervical connective tissue ↓ collagen concentration facilitates dilatation during delivery

19. ANATOMIC CHANGES BREAST UTERUS VAGINA CERVIX ADNEXAE EXTERNAL ABDOMEN 01 Soon after conception Copious cervical secretions fill the cervical canal T enacious mucus plug protects the uterine environment from outside pathogens expelled as bloody show at delivery

20. ANATOMIC CHANGES BREAST UTERUS VAGINA CERVIX ADNEXAE EXTERNAL ABDOMEN 01 Early in pregnancy Corpus luteum ovarian follicle that has discharged its ovum may be prominent enough to be felt on the affected ovary as a small nodule Disappears by midpregnancy

21. ANATOMIC CHANGES BREAST UTERUS VAGINA CERVIX ADNEXAE EXTERNAL ABDOMEN 01 Skin over the abdomen stretches to accommodate the fetus purplish striae gravidarum “stretch marks” linea nigra brownish black pigmented vertical stripe along the midline skin

22. ANATOMIC CHANGES BREAST UTERUS VAGINA CERVIX ADNEXAE EXTERNAL ABDOMEN 01 Diastasis Recti R ectus abdominis muscles separate at the midline due to ↑ abdominal wall tension (advancing pregnancy) If severe, only a layer of skin, fascia, and peritoneum may cover the anterior uterine wall fetal parts may be palpable through this muscular gap

23. PHYSIOLOGIC HORMONAL CHANGES Estrogen Progesterone HCG PGH Thyroid Function Relaxin Erythropoietin BMR 01 Promotes endometrial growth supports early embryo Stimulates marked enlargement of the pituitary gland ↑ prolactin output from the anterior lobe readies breast tissue for lactation Contributes to the hypercoagulable state 4-5x higher risk for thromboembolic events

24. PHYSIOLOGIC HORMONAL CHANGES Estrogen Progesterone HCG PGH Thyroid Function Relaxin Erythropoietin BMR 01 Levels increase throughout pregnancy ↑ tidal volume and alveolar minute ventilation RR remains constant Causing respiratory alkalosis and subjective SOB Lower esophageal sphincter tone d/t rising levels of estradiol and progesterone contributes to GERD Relaxes tone in the ureters and bladder hydronephrosis right ureter > left ureter ↑ risk of bacteriuria

25. PHYSIOLOGIC HORMONAL CHANGES Estrogen Progesterone HCG PGH Thyroid Function Relaxin Erythropoietin BMR 01 Human chorionic gonadotropin (HCG) 5 variant subtypes 2 are produced by the placenta and support progesterone synthesis in the corpus luteum stabilizing the endometrium effectively preventing loss of the early embryo to menstruation Serum and urine pregnancy assays test primarily for the two pregnancy-related HCG variants

26. PHYSIOLOGIC HORMONAL CHANGES Estrogen Progesterone HCG PGH Thyroid Function Relaxin Erythropoietin BMR 01 Placental Growth Hormone Influences fetal growth and the development of preeclampsia PGH and other hormones implicated in insulin resistance after mid-pregnancy and in gestational diabetes lifetime risk (60%) of progressing to type 2 diabetes

27. PHYSIOLOGIC HORMONAL CHANGES Estrogen Progesterone HCG PGH Thyroid Function Relaxin Erythropoietin BMR 01 Thyroid Function Changes ↑ in thyroid-binding globulin d/t rising levels of estrogen and stimulation of TSH receptors by HCG results in slight ↑ serum concentrations of free T3 and T4 ( usually in the normal range) ↓ serum TSH concentrations Transient apparent “hyperthyroidism” = physiologic

28. PHYSIOLOGIC HORMONAL CHANGES Estrogen Progesterone HCG PGH Thyroid Function Relaxin Erythropoietin BMR 01 Secreted by corpus luteum and placenta Involved in the remodeling of reproductive tract connective tissue to : facilitate delivery increased renal hemodynamics increased serum osmolality Does not affect peripheral joint laxity during pregnancy ( despite its name) Weight gain and shifts in the center of gravity contribute to: lumbar lordosis other musculoskeletal strain

29. PHYSIOLOGIC HORMONAL CHANGES Estrogen Progesterone HCG PGH Thyroid Function Relaxin Erythropoietin BMR 01 ↑ during pregnancy raises erythrocyte mass Plasma volume increases to a greater extent causing: relative hemodilution physiologic anemia can protect against blood loss during birth. N et fall in blood pressure (returning to normal by the 3rd trimester) Cardiac output increases systemic vascular resistance decreases

30. PHYSIOLOGIC HORMONAL CHANGES Estrogen Progesterone HCG PGH Thyroid Function Relaxin Erythropoietin BMR 01 Basal Metabolic Rate ↑ 15% to 20% during pregnancy ↑ daily energy demands by an estimated: First Trimester Second Trimester Third Trimester 85 kcal/d 285 kcal/d 475 kcal/d

31. PHYSIOLOGIC HORMONAL CHANGES 01

32. PHYSIOLOGIC HORMONAL CHANGES 01

33. HEALTH HISTORY 02

34. COMMON CONCERNS 02 Initial prenatal history Confirmation of pregnancy Symptoms of pregnancy Concerns and attitudes toward the pregnancy Current and past clinical history Past Obstetric history Risk factors for maternal and fetal health Family history of patient and father of the newborn Plans for breastfeeding Plans for postpartum contraception Determining gestational age and expected date of delivery

35. INITIAL PRENATAL HISTORY 02 Goals of the initial prenatal visit To define the health status of the mother and fetus Confirm the pregnancy and estimate gestational age Develop a plan for continuing care Counsel the mother about her expectations and concerns

36. INITIAL PRENATAL HISTORY 02 CONFIRMATION OF PREGNANCY SYMPTOMS OF PREGNANCY Has the patient had a confirmatory urine pregnancy test, and when? When was her last menstrual period (LMP)? Has she had an ultrasound to establish dates? Explain that serum pregnancy tests are rarely re quired to confirm pregnancy. Has the patient had missed periods, breast tenderness, nausea or vomiting, fatigue, or urinary frequency?

37. INITIAL PRENATAL HISTORY 02 CONCERNS & ATTITUDES TOWARD THE PREGNANCY Ask how the patient feels about the pregnancy. U se open-ended questions Be flexible and nonjudgmental Respect diverse family structures extended family support single motherhood pregnancy conceived by sperm donation with or without a partner of either gender. Support the patient’s choices when unexpected admissions arise, such as: pregnancy resulting from a coerced sexual act, or the wish to end the pregnancy.

38. INITIAL PRENATAL HISTORY 02 CURRENT PAST CLINICAL HISTORY Explore any past or present clinical conditions Pay particular attention to conditions that affect pregnancy

39. INITIAL PRENATAL HISTORY 02 PAST OBSTETRIC HISTORY How many prior pregnancies has the patient had? How many were term deliveries, preterm deliveries, spontaneous and terminated pregnancies, and how many were live births? Were there any complications from diabetes, hypertension, preeclampsia, intrauterine growth restriction, or preterm labor? Were there any complications during labor and delivery such as large babies (fetal macrosomia), fetal distress, or emergency interventions? Were deliveries by vaginal delivery, assisted delivery (vacuum or forceps), or cesarean section?

40. INITIAL PRENATAL HISTORY 02 RISK FACTORS FOR MATERNAL AND FETAL HEALTH Does she use tobacco, alcohol, or illicit drugs? What about medications, over-the-counter drugs, or herbal preparations? Does she have any toxic exposures at work, at home, or in other settings? Is her nutritional intake adequate, or is she at risk from obesity? Does she have an adequate social support network and source of income? Are there unusual sources of stress at home or work? Is there any history of physical abuse or domestic violence?

41. INITIAL PRENATAL HISTORY 02 FAMILY HISTORY OF PATIENT AND FATHER OF THE NEWBORN Ask about the genetic and family history of the patient and her partner and/or father. What are the ethnic backgrounds of the patient and father? Is there any family history of genetic diseases such as sickle cell anemia, cystic fibrosis, or muscular dystrophy, among others? Have babies in the family had any congenital problems?

42. INITIAL PRENATAL HISTORY 02 PLANS FOR BREASTFEEDING Protects the baby against a variety of infectious and noninfectious conditions Protective effect on the mother against breast cancer and other conditions. Education during pregnancy and clinician encouragement increase the subsequent rate and duration of maternal breastfeeding.

43. INITIAL PRENATAL HISTORY 02 PLANS FOR POSTPARTUM CONTRACEPTION Initiate this discussion early Reduces risk of: unintended pregnancy shortened interpregnancy intervals Plans for contraception will depend on: patient’s preferences clinical history decision about breastfeeding

44. DETERMINING GESTATIONAL AGE AND THE EDD 02 Gestational Age Count the number of weeks and days from the first day of the LMP standard means of calculating fetal age yielding an average pregnancy length of 40 weeks. If the actual date of conception is known (as with in vitro fertilization) conception age which is 2 weeks less than the menstrual age can be used to calculate menstrual age Expected date of delivery (EDD) 40 weeks from the first date of the LMP. Naegele rule EDD can be estimated by taking the LMP, adding 7 days subtracting 3 months adding 1 year. Tools for calculations Pregnancy wheels and online calculators are commonly used to calculate the EDD. Limitations on pregnancy dating Patient recall of the LMP is highly variable. Even when this date is accurate, the LMP can be affected by: hormonal contraceptives, menstrual irregularities, variations in ovulation that result in atypical cycle lengths. LMP dating should be checked against physical examination markers such as: fundal height any wide discrepancies should be clarified by ultrasound evaluation

45. DETERMINING GESTATIONAL AGE AND THE EDD 02 Expected date of delivery (EDD) 40 weeks from the first date of the LMP. Naegele rule EDD can be estimated by taking the LMP

46. DETERMINING GESTATIONAL AGE AND THE EDD 02 Limitations on pregnancy dating Patient recall of the LMP is highly variable. LMP dating should be checked against physical examination markers such as: Fundal height Wide discrepancies should be clarified by ultrasound evaluation

47. CONCLUDING THE INITIAL VISIT 02 Reaffirm your commitment to the woman’s health and her concerns during pregnancy. Review your findings, discuss any tests or screenings that are needed, and ask if she has further questions. Reinforce the need for regular prenatal care and review the timing of future visits. Record your findings in the prenatal record.

48. SUBSEQUENT PRENATAL VISITS 02 Obstetric visits traditionally follow a set schedule: M onthly until 28 gestational weeks Biweekly until 36 weeks Weekly until delivery Update and document the history at every visit, especially fetal movement felt by the patient, contractions, leakage of fluid, and vaginal bleeding.

49. SUBSEQUENT PRENATAL VISITS 02 PE findings at every visit should include: Vital signs (BP , wt) fundal height verification of fetal heart rate (FHR) determination of fetal position and activity At each visit, the urine should be tested for infection and protein.

50. HEALTH PROMOTION AND COUNSELING 03

51. HEALTH PROMOTION AND COUNSELING Nutrition Weight gain Immunization Exercise Substance Abuse Intimate Partner Violence Prenatal Lab screening 03 Take a Diet history Recommend a prenatal multivitamin Daily prenatal supplements should include: 400 μg of folic acid 600 IU of vitamin D 27 mg of iron at least 1,000 mg of calcium Caution the patient about foods to avoid Vulnerable to listeriosis

52. HEALTH PROMOTION AND COUNSELING Nutrition Weight gain Immunization Exercise Substance Abuse Intimate Partner Violence Prenatal Lab screening 03 For pregnant and breastfeeding women, ACOG recommends 2 servings a week of selected fish and shellfish Intake should include: F ish lower in mercury 8 to 12 ounces a week White tuna consumption limited to 6 ounces a week Avoid fish higher in mercury tilefish, shark, swordfish, and king mackerel

53. HEALTH PROMOTION AND COUNSELING Nutrition Weight gain Immunization Exercise Substance Abuse Intimate Partner Violence Prenatal Lab screening 03 Make a nutritional plan Small frequent meals may help with mild nausea

54. HEALTH PROMOTION AND COUNSELING Nutrition Weight gain Immunization Exercise Substance Abuse Intimate Partner Violence Prenatal Lab screening 03 Ideally, patients should begin pregnancy with a BMI close to the normal range as possible Women with a normal BMI should gain 25 to 35 pounds during pregnancy

55. HEALTH PROMOTION AND COUNSELING Nutrition Weight gain Immunization Exercise Substance Abuse Intimate Partner Violence Prenatal Lab screening 03 CDC Advisory Committee on Immunization Practices and ACOG recommend Tdap administered during each pregnancy ideally at 27 to 36 weeks of gestation regardless of the prior immunization history Caretakers in direct contact with the infant should also receive Tdap Inactivated influenza vaccination indicated in any trimester during the influenza season

56. HEALTH PROMOTION AND COUNSELING Nutrition Weight gain Immunization Exercise Substance Abuse Intimate Partner Violence Prenatal Lab screening 03 SAFE DURING PREGNANCY NOT SAFE DURING PREGNANCY P neumococcal Meningococcal Hepatitis B Can be given if indicated: Hepatitis A and B Meningococcal polysaccharide and conjugate, Pneumococcal polysaccharide vaccines M easles/mumps/rubella Polio Varicella

57. HEALTH PROMOTION AND COUNSELING Nutrition Weight gain Immunization Exercise Substance Abuse Intimate Partner Violence Prenatal Lab screening 03 All women should have rubella titers drawn during pregnancy immunized after birth if found to be nonimmune Check Rh(D) and antibody typing first prenatal visit 28 weeks delivery Anti-D immunoglobulin should be given to all Rh-negative women 28 weeks’ gestation again within 3 days of delivery to prevent sensitization if the infant is Rh-D positive

58. HEALTH PROMOTION AND COUNSELING Nutrition Weight gain Immunization Exercise Substance Abuse Intimate Partner Violence Prenatal Lab screening 03 ≥30 minutes of moderate exercise on most days of the week Physical activity during pregnancy has a number of psychological benefits and reduces risk of: Excessive gestational weight gain Gestational diabetes Preeclampsia Preterm birth Varicose veins Deep vein thrombosis (DVT) Avoid Immersion in hot water Avoid Exercise in supine position (after 1st trimester) Avoid Contact sports

59. HEALTH PROMOTION AND COUNSELING Nutrition Weight gain Immunization Exercise Substance Abuse Intimate Partner Violence Prenatal Lab screening 03 Abstinence is a top priority goal during pregnancy Tobacco Twofold risk of: placenta previa placental abruption, preterm labor Increased risk of: spontaneous abortion, fetal death, fetal digit anomalies

60. HEALTH PROMOTION AND COUNSELING Nutrition Weight gain Immunization Exercise Substance Abuse Intimate Partner Violence Prenatal Lab screening 03 Alcohol (Fetal alcohol syndrome) neurodevelopmental sequela of alcohol exposure during fetal development leading cause of preventable mental retardation Illicit drugs significant detrimental effects on fetal development Abuse of prescription drugs Herbal and Unregulated supplements poorly studied and can harm the developing fetus

61. HEALTH PROMOTION AND COUNSELING Nutrition Weight gain Immunization Exercise Substance Abuse Intimate Partner Violence Prenatal Lab screening 03 Pregnancy is a time of increased risk from intimate partner violence

62. HEALTH PROMOTION AND COUNSELING Nutrition Weight gain Immunization Exercise Substance Abuse Intimate Partner Violence Prenatal Lab screening 03 The standard prenatal screening panel includes: Blood type and Rh Antibody screen CBC Rubella titer Syphilis test Hepatitis B surface antigen HIV test STI screen for gonorrhea and chlamydia Urinalysis with culture

63. HEALTH PROMOTION AND COUNSELING Nutrition Weight gain Immunization Exercise Substance Abuse Intimate Partner Violence Prenatal Lab screening 03 Scheduled screenings include: Oral glucose tolerance test (OGTT) for gestational diabetes 24 to 28 weeks Rectovaginal swab for group B streptococcus 35 to 37 weeks

64. TECHNIQUES OF EXAMINATION 04

65. TECHNIQUES OF EXAMINATION Positioning Examining Equipment General Inspection Ht, Wt, VS Head & Neck Thorax & Lungs Heart 04 Early pregnancy examined in the supine position Later trimesters Semi sitting position with the knees bent more comfortable reduces the weight of the gravid uterus on the descending aorta and inferior vena cava Avoid lying supine for long periods Supine hypotensive syndrome Compression interferes with venous return from the lower extremities and pelvic vessels, causing the patient to feel dizzy and faint

66. TECHNIQUES OF EXAMINATION Examining Equipment General Inspection Ht, Wt, VS Head & Neck Thorax & Lungs Heart Breast 04 Warm your hands and use firm yet gentle palpation Palmar surfaces of your fingertips are the most sensitive Before beginning the examination, gather the equipment listed: Gynecologic speculum and lubrication Sampling materials Tape measure Doppler FHR monitor and gel

67. TECHNIQUES OF EXAMINATION General Inspection Ht, Wt, VS Head & Neck Thorax & Lungs Heart Breast Abdomen 04 Assess the general health, emotional state, nutritional status, and neuromuscular coordination of the patient as she walks into the room and moves onto the examining table.

68. TECHNIQUES OF EXAMINATION Ht, Wt, VS Head & Neck Thorax & Lungs Heart Breast Abdomen Genitalia Anus 04 Measure the height and weight Calculate the BMI with standard tables 19 to 25 (normal for the prepregnant state) Measure the blood pressure at every visit. Baseline pre-pregnancy readings important for determining the patient’s usual range. 2nd trimester BP normally drops below the nonpregnant state.

69. TECHNIQUES OF EXAMINATION Ht, Wt, VS Head & Neck Thorax & Lungs Heart Breast Abdomen Genitalia Anus 04 Measure the blood pressure at every visit. Hypertensive disorders A ffect 5% to 10% of all pregnancies Hypertension can be both: independent diagnosis marker of preeclampsia syndrome

70. TECHNIQUES OF EXAMINATION Ht, Wt, VS Head & Neck Thorax & Lungs Heart Breast Abdomen Genitalia Anus 04 PREECLAMPSIA SBP ≥140 or DBP ≥90 after 20 weeks on two occasions at least 4 hours apart in a woman with previously normal BP BP ≥160/110 confirmed within minutes proteinuria ≥300 mg/24 hours, protein:creatinine ≥0.3 dipstick 1+ OR new onset hypertension without proteinuria and any of the following: thrombocytopenia (plt <100,000/μL) impaired liver function (liver transaminase levels > 2x normal) new renal insufficiency (creatinine >1.1 mg/dL or doubles in the absence of renal disease), pulmonary edema new onset cerebral or visual symptoms

71. TECHNIQUES OF EXAMINATION Head & Neck Thorax & Lungs Heart Breast Abdomen Genitalia Anus Rectum and Rectovaginal Septum 04 Face chloasma or melasma Irregular brownish patches around the forehead, cheeks, nose, and jaw “mask of pregnancy,” normal skin finding during pregnancy. Hair may become dry, oily, or sparse mild hirsutism on the face, abdomen, and extremities is common Eyes Assess for signs of pallor and jaundice

72. TECHNIQUES OF EXAMINATION Head & Neck Thorax & Lungs Heart Breast Abdomen Genitalia Anus Rectum and Rectovaginal Septum 04 Nose Inspect the mucus membranes and septum Nasal congestion and nose bleeds more common during pregnancy. Mouth Examine the teeth and gums Gingival enlargement with bleeding is common Thyroid gland Modest symmetric enlargement caused by glandular hyperplasia and increased vascularity normal on inspection and palpation

73. TECHNIQUES OF EXAMINATION Thorax & Lungs Heart Breast Abdomen Genitalia Anus Rectum and Rectovaginal Septum 04 Count the respiratory rate remain normal throughout pregnancy Inspect thorax for contours and breathing patterns Percuss observe diaphragmatic elevation may be seen as early as the first trimester. Auscultate clear breath sounds without wheezes, rales, or rhonchi.

74. TECHNIQUES OF EXAMINATION Heart Breast Abdomen Genitalia Anus Rectum and Rectovaginal Septum Extremities 04 Palpate the apical impulse may be rotated upward and to the left toward the fourth intercostal space by the enlarging uterus. Auscultate the heart Listen for a venous hum or a continuous mammary souffle often found during pregnancy due to increased blood flow through normal vessels

75. TECHNIQUES OF EXAMINATION Heart Breast Abdomen Genitalia Anus Rectum and Rectovaginal Septum Extremities 04 Mammary souffle commonly heard during late pregnancy or lactation strongest in the second or third intercostal space at the sternal border, typically both systolic and diastolic Auscultate for murmurs

76. TECHNIQUES OF EXAMINATION Breast Abdomen Genitalia Anus Rectum and Rectovaginal Septum Extremities Special Techniques 04 similar to that of a nonpregnant woman Inspect the breasts and nipples for symmetry and color Normal changes include: marked venous pattern darkened nipples and areolae prominent Montgomery glands Palpate for masses and axillary lymph nodes Normal breasts may be tender and nodular during pregnancy.

77. TECHNIQUES OF EXAMINATION Breast Abdomen Genitalia Anus Rectum and Rectovaginal Septum Extremities Special Techniques 04 Compress each nipple between your thumb and index finger Colostrum may express from the nipples Reassure the patient that this is normal and that she may also experience “let down, ” spontaneous mild leakage often accompanied by a cramping sensation in the breast

78. TECHNIQUES OF EXAMINATION Abdomen Genitalia Anus Rectum and Rectovaginal Septum Extremities Special Techniques 04 Position: semi sitting with knees flexed Inspect the abdomen for striae, scars, size, shape, and contour. Purplish striae and a linea nigra are normal in pregnancy. Palpate the abdomen for: Organs and masses Fetal movement Uterine contractility Measure Fundal Height Auscultate FHT Location Rate Rhythm

79. TECHNIQUES OF EXAMINATION Abdomen Genitalia Anus Rectum and Rectovaginal Septum Extremities Special Techniques 04 Organs and masses mass of the gravid uterus is expected Fetal movement A fter 24 gestational weeks Movements felt externally 18 to 24 weeks The Mother feels the fetal movement Quickening Maternal sensation of fetal movement

80. TECHNIQUES OF EXAMINATION Abdomen Genitalia Anus Rectum and Rectovaginal Septum Extremities Special Techniques 04 Uterine contractility Irregular uterine contractions occur as early as 12 weeks may be triggered by external palpation during the third trimester. During contractions abdomen feels tense or firm to the examiner obscuring the palpation of fetal parts After the contraction palpating fingers sense the relaxation of the uterine muscle

81. TECHNIQUES OF EXAMINATION Abdomen Genitalia Anus Rectum and Rectovaginal Septum Extremities Special Techniques 04 Measure the fundal height >20 weeks fundus should reach the umbilicus. Procedure: With a tape measure, locate the pubic symphysis and place the “zero” end of the tape measure where you can firmly feel that bone. extend the tape measure to the very top of uterine fundus and note the number of centimeters measured.

82. TECHNIQUES OF EXAMINATION Abdomen Genitalia Anus Rectum and Rectovaginal Septum Extremities Special Techniques 04

83. TECHNIQUES OF EXAMINATION Abdomen Genitalia Anus Rectum and Rectovaginal Septum Extremities Special Techniques 04 Auscultate the fetal heart tones Doppler fetal rate monitor standard instrument for measuring FHR, Audible as early as 10 to 12 weeks’ gestation. Detection of the FHR may be slightly delayed in obese patients. ■ Location. From 10 to 18 weeks’ gestation, the FHR is located along the midline of the lower abdomen. After that time, the FHR is best heard over the back or chest and depends on fetal position; the Leopold maneuvers can help identify the position. ■ Rate. 110 and 160 beats per minute (BPM). ■ Rhythm. FHR should vary 10 to 15 BPM from second to second, especially later in the pregnancy. After 32 to 34 weeks, the FHR should become more variable and increased with fetal activity. This subtlety can be difficult to assess with a Doppler but can be tracked with an FHR monitor if any questions arise.

84. TECHNIQUES OF EXAMINATION Abdomen Genitalia Anus Rectum and Rectovaginal Septum Extremities Special Techniques 04 Auscultate the fetal heart tones Doppler fetal rate monitor standard instrument for measuring FHR Audible as early as 10 to 12 weeks’ gestation may be slightly delayed in obese patients Location of FHR 10 - 18 weeks’ gestation along the midline of the lower abdomen After that time best heard over the back or chest depends on fetal position Leopold maneuvers can help identify the position

85. TECHNIQUES OF EXAMINATION Abdomen Genitalia Anus Rectum and Rectovaginal Septum Extremities Special Techniques 04 Rate 110 - 160 beats per minute (BPM) Rhythm vary 10-15 BPM from second to second After 32-34 weeks FHR become more variable and increased with fetal activity

86. TECHNIQUES OF EXAMINATION Genitalia Anus Rectum and Rectovaginal Septum Extremities Special Techniques 04 Position: supine with her feet placed in stirrups External Genitalia Inspect the external genitalia. Normal changes of pregnancy: Relaxation of the vaginal introitus Enlargement of the labia and clitoris Multiparous women scars may be present from perineal lacerations or episiotomy incisions Palpate the Bartholin and Skene glands for tenderness and cysts Internal Genitalia Prepare for both a speculum and bimanual examination.

87. TECHNIQUES OF EXAMINATION Genitalia Anus Rectum and Rectovaginal Septum Extremities Special Techniques 04 Speculum Examination The increased vascularity of vaginal and cervical structures promotes friability insert and open the speculum gently to prevent tissue trauma and bleeding. During the third trimester perform this examination only when necessary as descent of the fetal parts into the pelvis can make the examination very uncomfortable.

88. TECHNIQUES OF EXAMINATION Genitalia Anus Rectum and Rectovaginal Septum Extremities Special Techniques 04 Inspect the cervix Inspect for for color, shape, and closure Typically, the external os: nulliparous cervix appears as a circular dot parous cervix an arc or “smile.” may also look irregular due to healed lacerations from prior deliveries

89. TECHNIQUES OF EXAMINATION Genitalia Anus Rectum and Rectovaginal Septum Extremities Special Techniques 04 Inspect the cervix Ectropion I nner portion of the cervix everts slightly during pregnancy appears as a glandular friable darker pink or red area inside the os. Perform a Pap smear if indicated collect other vaginal specimens such as STI cultures, wet mount samples, or group B strep swabs as appropriate.

90. TECHNIQUES OF EXAMINATION Genitalia Anus Rectum and Rectovaginal Septum Extremities Special Techniques 04 Inspect the vaginal walls Check for color, relaxation, rugae, and discharge. Normal findings include: bluish color, deep rugae, and increased milky white discharge, or leukorrhea.

91. TECHNIQUES OF EXAMINATION Genitalia Anus Rectum and Rectovaginal Septum Extremities Special Techniques 04 Bimanual Examination - Cervix Because of softening during pregnancy ( Hegar sign ) cervix may be difficult to identify. (+) nabothian cysts or healed lacerations from prior deliveries cervix may feel irregular. Estimate the cervical length palpate the lateral surface of the cervical tip to the lateral fornix. Prior to 34 to 36 weeks’ gestation cervix should retain its initial length of 3 cm or greater.

92. TECHNIQUES OF EXAMINATION Genitalia Anus Rectum and Rectovaginal Septum Extremities Special Techniques 04 Bimanual Examination - Palpate the cervical os External os may be open to admit a fingertip in multiparous women. Internal os narrow passage between the endocervical canal and the uterine cavity closed until late pregnancy

93. TECHNIQUES OF EXAMINATION Genitalia Anus Rectum and Rectovaginal Septum Extremities Special Techniques 04 Bimanual Examination - Uterus Procedure: internal fingers placed at either side of the cervix external hand on the patient’s abdomen use the internal fingers to gently lift the uterus upward toward the abdominal hand. Capture the fundal portion of the uterus between your two hands Palpate for shape, consistency, and position.

94. TECHNIQUES OF EXAMINATION Genitalia Anus Rectum and Rectovaginal Septum Extremities Special Techniques 04 Bimanual Examination - Adnexa Palpate the right and left adnexa Corpus luteum may be palpable as a small nodule on the affected ovary during the first weeks after conception Pelvic floor Evaluate pelvic floor strength as you withdraw your examining fingers

95. TECHNIQUES OF EXAMINATION Anus Rectum and Rectovaginal Septum Extremities Special Techniques 04 Inspect for external hemorrhoids If present, note their: size, location, and any evidence of thrombosis.

96. TECHNIQUES OF EXAMINATION Rectum and Rectovaginal Septum Extremities Special Techniques 04 Rectal examination Not standard in prenatal care unless there are concerning symptoms like: rectal bleeding masses conditions that compromise the rectovaginal septum

97. TECHNIQUES OF EXAMINATION Extremities Special Techniques 04 Resume sitting or to lie on her left side Inspect the legs for varicose veins . Palpate extremities for edema in the pretibial, ankle, and pedal distributions Physiologic edema common in advanced pregnancy during hot weather women who stand for long periods of time due to decreased venous return from the lower extremities.

98. TECHNIQUES OF EXAMINATION Special Techniques (Leopold Maneuvers) 04 Determine the fetal position in the maternal abdomen beginning in the second trimester Accuracy greatest after 36 weeks’ gestation . Examination findings help determine readiness for vaginal delivery by assessing: upper and lower fetal pole , namely, the proximal and distal fetal parts maternal side where the fetal back is located descent of the presenting part into the maternal pelvis extent of flexion of the fetal head estimated size and weight of the fetus

99. TECHNIQUES OF EXAMINATION Special Techniques (Leopold Maneuvers) 04 1st maneuver (Upper Fetal Pole) Position: Stand at the woman’s side facing her head. Palpate the uppermost part of gravid uterus gently fingertips together to determine what fetal part is located at the fundus “upper fetal pole”

100. TECHNIQUES OF EXAMINATION Special Techniques (Leopold Maneuvers) 04 2nd maneuver (sides of the maternal abdomen) Position: Place one hand on each side of the woman’s abdomen , capturing the fetal body between them. Steady the uterus with one hand and palpate the fetus with the other, Looking for the back on one side and extremities on the other

101. TECHNIQUES OF EXAMINATION Special Techniques (Leopold Maneuvers) 04 3rd maneuver (lower fetal pole and descent into pelvis) Face the woman’s feet Place the flat palmar surfaces of the fingertips on the fetal pole just above the pubic symphysis Palpate the presenting fetal part for texture and firmness to distinguish the head from the buttock.

102. TECHNIQUES OF EXAMINATION Special Techniques (Leopold Maneuvers) 04 3rd maneuver (lower fetal pole and descent into pelvis) Judge the descent, engagement, of the presenting part into the maternal pelvis. Alternatively, use the Pawlik grip grasping the lower fetal pole with the thumb and fingers of one hand to assess the presenting part and descent into pelvis

103. TECHNIQUES OF EXAMINATION Special Techniques (Leopold Maneuvers) 04 4th maneuver (Flexion of the fetal head) Still facing the woman’s feet Assesses the flexion or extension of the fetal head hands positioned on either side of the gravid uterus, identify the fetal front and back sides

104. TECHNIQUES OF EXAMINATION Special Techniques (Leopold Maneuvers) 04 4th maneuver (Flexion of the fetal head) Still facing the woman’s feet Using one hand at a time, slide your fingers down each side of the fetal body until you reach the “cephalic prominence,” where the fetal brow or occiput juts out

105. RECORDING FINDINGS 05

106. Recording Findings 05 Pregnant women are described in terms of: number of pregnancies (gravida) labors (para) Parity is further broken down into TPAL: Term deliveries Preterm deliveries Abortions (spontaneous abortions and terminated pregnancies) Living children, This is expressed in “Gs and Ps”

107. Recording Findings 05 For example A woman who has had two prior children and is pregnant with her third pregnancy

108. Recording Findings 05 For example A woman who has had two prior children and is pregnant with her third pregnancy G3P2

109. Recording Findings 05 For example A woman who has had two prior children and is pregnant with her third pregnancy A woman with two spontaneous losses prior to 20 weeks’ gestation, three living children who were delivered at term, and a current pregnancy G3P2

110. Recording Findings 05 For example A woman who has had two prior children and is pregnant with her third pregnancy A woman with two spontaneous losses prior to 20 weeks’ gestation, three living children who were delivered at term, and a current pregnancy G3P2 G6P3023

111. Recording Findings 05

112. Recording Findings 05

113. Thank You! Reference: Bickley, L. S., & Szilagyi, P. G. (2017). Bates’ Guide to Physical Examination and History Taking. LWW.