The document outlines the diagnosis and signs of a normal pregnancy, including possible presumptive signs like breast tenderness and morning sickness, probable signs like a positive pregnancy test and uterine growth, and positive signs like visualization of the fetus on ultrasound or feeling fetal movement. It also discusses taking an obstetric history, including calculating gestational age and expected due date based on the last normal menstrual period, as well as conducting a physical examination of a pregnant woman.

1. NORMAL PREGNANCY
5/24/2023 1

2. Objective
At the end of this lesson students will be able to:
•Define normal pregnancy
•Diagnose pregnancy
•Identify the physiological, anatomical and
biochemical changes during pregnancy
•Describe the minor disorders of pregnancy and their
managements
5/24/2023 2

3. Cont’d
•Pregnancy; is the course that the embryo and the fetus
grow in the maternal body
•Is the period from conception to delivery of the fetus
5/24/2023 3

4. Diagnosis of pregnancy
Pregnancy is mainly diagnosed on the symptoms
reported by the woman and signs elicited by a health
care provider.
Signs and symptoms of pregnancy
These signs and symptoms are divided in to three
classifications; presumptive, probable, and positive.
5/24/2023 4

5. Possible (presumptive) signs
Breast swelling and tenderness
 Amenorrhea
Morning sickness
Increased frequency of urination/micturation
 Quickening-the first fetal movement felt by the mother.
Constipation and weight gain
Increased skin pigmentation and striae
5/24/2023 5

6. Probable signs
Uterine enlargement
Positive pregnancy test
Uterine growth
Braxton Hicks contractions- intermittent uterine
contraction during Px.
5/24/2023 6

7. Positive signs
Visualization of fetus by
•Ultrasound 6 weeks of gestation
•X-ray after 12 weeks of gestation
Fetal heart sounds by
•Ultrasound (at 5th week)
•Fetal stethoscope or fetoscope (20th to 24th weeks
of gestation)
Fetal movements by
•Palpation
•Visible
5/24/2023 7

8. History Taking and physical
examination in Obstetrics and
Gynecology
5/24/2023 8

9. Terminologies
Menarche: age at which menses began
LNMP (last normal menstrual period): first day of last
normal menstrual period
Dysmenorrhea: cramping with period
Climacteric: time of transition when ovarian function
begins to wane
5/24/2023 9

10. Terminologies…cont’d
Postmenopausal bleeding: bleeding 6 months after
cessation of menses
Gravidity: number pregnancy
Parity: outcomes of each pregnancy
Gravida: a woman who is or has been pregnant
Primigravida: a woman who is in or who
experienced her first pregnancy
5/24/2023 10

11. Terminologies…cont’d
Multigravida: a woman who has been pregnant more
than once
Nulligravida: a woman who has never been and is not
now pregnant
Primipara: a woman who has delivered one pregnancy
(regardless of the number of fetuses) that progressed
beyond the gestational age of abortion (that reached the
age of viability, ≥ 28 weeks)
5/24/2023 11

12. Terminologies…cont’d
Multipara: a woman who has delivered two or
more pregnancies that reached the age of viability
Nullipara: a woman who has never had a pregnancy
progressed beyond the gestational age of abortion
Parturient: a woman currently in labour
Puerpera: a woman who jus gave birth
5/24/2023 12

13. A. History
Assessing px to determine risk, as well as careful monitoring
of pregnancies with a recognized risk, begins early in the
gestation.
Early and frequent prenatal care allows the care provider to
screen pregnant women and identify pregnancies at risk and
act accordingly.
5/24/2023 13

14. History
Detailed information concerning past obstetrical
history is crucial because many prior pregnancy
complications tend to recur in subsequent
pregnancies.
5/24/2023 14

15. Obstetric History
1. Identification-
Name
Age <18yrs and > 35 yrs. – high risk groups
Marital status- unmarried & unsupported – high risk
groups
Address
Religion
Occupation
Date of admission,
Ward, bed number
5/24/2023 15

16. Obstetric History…cont’d
2. Chief Complaint - Patient may have come for
routine ANC follow-up or
May have a specific complaint e.g. nausea and
vomiting, vaginal bleeding, pushing down pain etc.
5/24/2023 16

17. Obstetric History…cont’d
3. History of present pregnancy
 Gravidity – all previous pregnancies – term live births,
stillbirths, abortions, ectopic pregnancy or hydatidiform mole.
 Party – Pregnancies that have extended beyond fetal viability
whether the fetus is delivered alive or dead
• Twin/triplet/quadriplet etc delivery is considered as one
parity
• 28 weeks- UK and Ethiopia
• 20 weeks-WHO
 Abortions
 LNMP
5/24/2023 17

18. Obstetric History…cont’d
Calculate the EDD
• To calculate Expected Date of Deliveery (EDD) –
If we are using European calendar-
Negele’s rule – LNMP – 3 months +7 days
- LNMP + 9 months + 7 days
Ethiopian calendar
LNMP +9 months + 10 days or + (5 if
pagume is 5 or 4 days if pagume is 6) if
Pagume is passed.
5/24/2023 18

19. Obstetric History…cont’d
Calculate gestational age in completed weeks and days.
 Is calculated as, GA= Date of visit - LNMP
Quickening - 1st time the mother felt fetal movement
Used to date the pregnancy if LNMP is unknown.
• Primigravida – 18 – 20 weeks.
• Multigravida – 16 – 18 weeks.
ANC status should be documented and if not followed the
reason should be sought.
Is the current pregnancy planned, wanted and supported
5/24/2023 19

20. Case study
W/o Abebech, a 20 years old primigravida mother
come to your clinic for ANC on 13/07/2009 E.c.
Her LNMP was on 04/05/2009 E.c Based on the
given information when will be her expected date of
confinement and gestational age?
5/24/2023 20

21. Early measurements that correlate well with
gestational age
Measurement Corresponding GA
Date of quickening Primigravida – 18-20 weeks;
Multigravida- 16-18 weeks
Uterine size measurement before 16 weeks during
pelvic exam
Correlates well with the
gestational age
Fundal height felt at umbilicus 20 weeks
First time fetal heart auscultated with fetal
stethoscope
20 weeks
First time fetal heart auscultated with a doppler
device
10 weeks
First day urinary pregnancy test was positive 6 weeks
The above early milestones if present can be used either to confirm the accuracy of
gestational age calculated from LNMP or can be used to estimate gestational age in
mothers with unknown LNMP.
5/24/2023 21

22. Elaborate the chief complaint
Any complaints during the present pregnancy – eventful
or uneventful ask for danger signs.
Vaginal bleeding
Leakage of liquor
Abdominal pain etc.
Fetal movements decreased or increased? Useful to
assess fetal well-being.
Other negative and positive statement according to the
patients complaints
5/24/2023 22

23. 4. Past Obstetric History
If there were previous deliveries, ask for
Year, GA, Place, Route, Outcome, Wt, Ante/post
partum Complications
E.g. 2005, Term, WGH, SVD, L/B 3.2kg PPH
5/24/2023 23

24. A 24 years old pregnant women come to your hospital for a
complaint of sever vomiting and nausea. Her past obstetric
history included the following information. One baby was
stillborn at 19 weeks. One pregnancy resulted in twins born
at 35 weeks ,and both survived. One was born alive at 38
weeks . Depending on the above information elaborate her
past obstetrics history using the five digit system.
5/24/2023 24

25. Past Obstetric History…cont’d
Also includes:
Recurrent abortion
Previous stillbirth or neonatal death
Previous preterm delivery
Previous preeclampsia–eclampsia
Previous infant with genetic disorder or congenital
anomaly
5/24/2023 25

26. 5. Gynecologic History
Contraception - use or need for any form of contraception
type and duration
Sexual history – including history of STD, Assess risk of
HIV/AIDS
History of gynecologic operations including history of
circumcision (FGM)– History of previous gynecologic
surgery – e.g. prior emergency Laparotomy,.
5/24/2023 26

27. Gynecologic History…cont’d
Menstrual history
• Age at menarche
•Interval between periods
•Duration of flow
•Amount and character of flow
•Degree of discomfort.
5/24/2023 27

28. 6. Past medical and surgical history
Past medical and surgical history
• Medical disorders may affect the outcome of pregnancy and
the physiological changes of pregnancy may aggravate the
medical disorder.
E.g. diabetes mellitus, Hypertension, Thyrotoxicosis or
Hyperthyroidism.
• Previous blood transfusions
• Hypersensitivity to drugs.
5/24/2023 28

29. 7. Personal, family and social history
Early childhood history, number of sibling, whether parents
and siblings are alive or not.
Education
Habits- smoking, alcohol and drug use Occupation and
family income.
Socio economic status
Family history – Diabetes mellitus, Hypertension,
Tuberculosis, Hereditary disease and chromosomal
anomalies and pregnancy-induced hypertension, allergics,
mental disorders- runs in families.
8. Systemic Review: the same as non-pregnant
5/24/2023 29

30. B. Physical Examination
5/24/2023 30

31. Physical Examination
Examination must be done in a private room
Proper explanation must be offered for the client before,
during and after the examination
Bladder should be emptied and the patient properly
positioned on the couch
Adequate light, appropriate gloves and swabs should be
used
5/24/2023 31

32. Physical Examination…cont’d
General appearance: e.g. Well looking, acutely
sick looking, on labour pain
Vital signs and anthropometric measurements
Blood pressure,
Pulse rate and respiratory rate
Temperature
Height and weight
5/24/2023 32

33. Physical Examination…cont’d
HEENT: emphasis on
Conjunctiva for pallor
Sclera for jaundice
Buccal mucus membrane and teeth for mucosal
congestion and dental carries
5/24/2023 33

34. Physical Examination…cont’d
Lympho-glandular system
Thyroid gland for signs of hyper or hypothyroidism
Breast for nipple retraction, pigmentation, lumps,
discharge, colour change
 Respiratory and cardiovascular system
The same as in non pregnant state
5/24/2023 34

35. Physical Examination…cont’d
 Abdomen
Inspection
Inspect the abdomen for 5 s:
Size: Should correspond with the supposed period of
gestation.
Shape: usually ovoid in the primigravida, with
longitudinal lie. In multigravida round and broad in
transverse lie.
Skin: Linea nigra
Striae Gravidram
Scar: Any operation scar (c/s)
5/24/2023 35

36. Physical Examination…cont’d
Palpation
Superficial palpation: for rigidity tenderness,
superficial mass
Deep palpation: for mass, organomegally and
characterize the mass
Obstetric palpation or Leopold’s maneuver
5/24/2023 36

37. Physical Examination…cont’d
Obstetric palpation or Leopold’s maneuver
 It is preferably performed after 24 weeks gestation
when fetal outline can be already palpated.
Preparation:
 Instruct woman to empty her bladder first.
 Place woman in dorsal recumbent position (supine
with knees flexed) to relax abdominal muscles; with
her arms down.
 Place a small pillow under the head for comfort.
5/24/2023 37

38. Physical Examination…cont’d
Drape properly to maintain privacy.
Explain procedure to the patient.
Warms hands by rubbing together. (Cold hands can
stimulate uterine contractions).
Use the palm with the fingers held together for
palpation.
5/24/2023 38

39. 1. Fundal height & Fundal palpation
(1st Leopold Maneuver)
Purpose: determination of Fundal height and what occupies the
fundus.
I. Fundal height measurement
Method: Measure the fundal height in finger breadth or by
centimetre.
Two methods:
a. Finger method:
• Below the umbilicus 1 finger indicates 1 week.
• Above the umbilicus 1 finger indicates 2 weeks.
b. Tape measurement: fundal height measurement in cm from
symphysis pubis to the top of uterine fundus; 1cm = 1wk.
5/24/2023 39

40. Cont’d…
5/24/2023 40

41. Physical Examination…cont’d
Palpation
Generally fundal height reaches:
12 weeks- fundus slightly above symphysis pubis.
16 weeks- fundus half way between symphysis
pubis and umbilicus.
20 weeks- fundus at umbilicus
36 weeks- fundus at xiphisternum.
5/24/2023 41

42. Cont’d…
II. Fundal palpation
Purpose: to know what occupies the fundus.
Method: - using two hands, palpate on either side of the
fundus and feel for the fetal part lying in the fundus.
If it is head: firm, hard, and round, that moves
independently of the body (ballottable mass).
If it is breech: soft, irregular, bulky mass
5/24/2023 42

43. 5/24/2023 43

44. Fundal palpation
5/24/2023 44

45. 2. Latéral Palpation: (2nd Léopold Maneuver)
•Purpose: to know lie and side of the back
Lie: (the long axis of the fetus in relation to that
of mother) it may be longitudinal, transverse,
and oblique lie.
Back of the fetus: to auscultate FHB, b/s FHB
at 20 weeks well heard on the back.
5/24/2023 45

46. Cont’d…
Method: One hand is used to steady the uterus on
one side of the abdomen while the other hand
moves slightly on a circular motion from top to the
lower segment of the uterus to feel for the fetal
back and small fetal parts.
Use gentle but deep pressure. Note the regularity;
the regular side is the back.
5/24/2023 46

47. 5/24/2023 47

48. Lateral palpation
5/24/2023 48

49. 3. Deep pelvic Palpation: (3rd Leopold’s
Maneuver)
Purpose:
 To know presentation, decent, and attitude.
 To determine the degree of flexion of fetal head.
 Method: Facing foot part of the woman, palpate
fetal head pressing downward about 2 inches
above the inguinal ligament.
5/24/2023 49

50. Cont’d…
Use both hands.
 Feel presenting part, is it hard or soft while
palpating for the presenting part feel for
eminences on back side.
 Presentation: part of the fetus on the lower
uterine pole it may be cephalic, breech, or
shoulder Presentation.
5/24/2023 50

51. 5/24/2023 51

52. 4. Paw lick’s Grip: (4th Leopold’s Maneuver)
Purpose:
To determine engagement of presenting part.
To know presentation & descent of fetal head.
• Engagement: when the biparietal diameter of the fetal head
passes through the pelvic brim.
• Method: Using thumb and finger, grasp the lower portion of the
abdomen above symphysis pubis, press in slightly and make gentle
movements from side to side and feel the occiput and sinciput, note
which is lower.
5/24/2023 52

53. Cont’d…
• The presenting part is engaged if it is not movable.
• It is not yet engaged if it is still movable.
• The head is engaged when the largest the transverse
diameter (bi-parietal diameter) has passed the pelvic brim.
• It can be diagnosed on palpation, when two fifth of the head
or less is felt above the brim.
• The head should be engaged in a primigravida after 36
weeks.
5/24/2023 53

54. 5/24/2023 54

55. Cont’d…
For laboring mother additional Palpation includes:
Counting uterine contraction every 30 minute for:
Frequency/10min
Intensity or strength (mild, moderate, severe),
Duration in seconds.
5/24/2023 55

56. Cont’d…
Auscultation
 Fetal heart beat is first heard on the back side at 16-18
weeks in multipara and 18-20 weeks in primigravida
 In complete breech presentation: it is heard above the
umbilicus
 In cephalic presentation: it is heard below the umbilicus
 In occipito-posterior position it is heard in the flanks
5/24/2023 56

57. GUS- Urinary & Genital
Costo vertebral angle and Suprapubic tenderness
Pelvic Examination
Cervix by speculum
Perianal region should be visualized and digital rectal
examination performed.
Digital pelvic examination by palpation
Assess cervical dilation, an effacement, status of
membrane and liquor fluid, presenting part, position,
moulding, caput (for laboring mother)
5/24/2023 57

58. Cont’d…
 Integumentary system
 Hyperpigmentation the breast, lower and mid
abdomen and genitalia are normally seen in
pregnancy
 Vascular changes-spider angiomata and palmar
erythema
5/24/2023 58

59. Cont’d…
 Extremities
Check for edema
Dependent edema (ankle and pedal edema), seen in
80% of pregnancies
 Central nervous system
 As in general physical examination
5/24/2023 59

60. Laboratory Tests
PIHTC
Blood group and Rh factor
Hematocrit (or hemoglobin)
Urinalysis
HBSAg
Syphilis serology
5/24/2023 60

61. THANKS
5/24/2023 61