Ppt19

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Chapter 19
The Pregnant Woman

Anatomy and Physiology
• Hormonal changes
– Lead to extensive anatomical and physiologic changes in every
major body system
– Increases in levels of estradiol, progesterone, and the pregnancy
hormones (especially HCG) drive many of the pregnancy-related
endocrine and metabolic changes
• Cardiovascular changes
– Erythrocyte mass and plasma volume increase
– Cardiac output increases
– Systemic vascular resistance and pressure fall
• Musculoskeletal changes
– Ensue from weight gain and the hormone relaxin
– Lumbar lordosis
– Ligamentous laxity in the SI joints and pubic symphysis

Anatomy and Physiology (cont.)
• Breast changes
– Enlarge moderately
o Hormone stimulation
o Increased vascularity
o Hyperplasia of glandular tissue
– Become more nodular by 3rd month of pregnancy
– From mid-to-late pregnancy
o Colostrum may be expressed
o Areolae darken
o Montgomery’s glands are more pronounced
o Venous pattern increasingly visible

Anatomy and Physiology (cont.)
• Pelvic changes
– Uterus
o Most easily palpable beyond 12 to 14 weeks when it straightens
(from early anteverted position) and rises up out of the pelvis
o As uterus enlarges, it rotates to the right to accommodate the
rectosigmoid structures on the left side of the pelvis
– Vagina
o Walls appear thicker and deeply rugated
o Vaginal secretions are thick, white, and more profuse
– Cervix
o Chadwick’s sign
o Mucous plug
– Ovaries
o Changes generally not noticeable on physical examination

Prenatal Care Visits
• Initial visit concerns
– Confirm the pregnancy with lab tests (urine or
blood)
– Assess the health status of the mother
– Counsel mother to ensure a healthy pregnancy
• Subsequent visits
– Assess health status of the mother
– Assess fetus
– Educate to ensure a healthy pregnancy

History Taking in the Pregnant Woman
• Ask about symptoms of pregnancy
– Absence of menses; breast tenderness
– Nausea and vomiting; fatigue
– Increased frequency of urination
• Assess maternal concerns and attitudes about pregnancy
– How does she feel about the pregnancy?
– Was it planned?
– Is it desired?
– Does she plan to continue to term?
• Assess the current state of health
– Review nutrition and exercise
– Obtain smoking, alcohol, and drug history
– Obtain occupational history, looking for workplace hazards
– Assess woman’s social support and finances

History Taking in the Pregnant Woman
(cont.)
• Assess past obstetrical history
– Take histories of past pregnancies including
prenatal and labor problems
– Review birth weights of prior pregnancies
– Review any miscarriages or fetal demises
• Assess past medical history
– Review for any systemic diseases that would affect
pregnancy (e.g., hypertension, diabetes)
• Assess family history of congenital diseases
– Investigate for diseases such as sickle cell or cystic
fibrosis

Establishing the EDD
(Expected Date of Delivery)
• Naegele’s rule: take the first date of the LMP (last menstrual
period), add one week, subtract three months and add one
year
• Example: LMP 5/19/08 - add one week for a date of
5/26/08; subtract three months for a date of 2/26/08; add
one year gives for an EDD of 2/26/09
• The EDD can be verified in several ways:
– Doptone (positive at 10 to 12 weeks)
– Fetoscope (heard at 18 weeks)
– Fetal movement (quickening) 18 to 24 weeks
– Ultrasound

Question
A pregnant patient reports the first day of her LMP
(last menstrual period) was 7/11/08. Based on this
information, determine her EDD using Naegele’s
rule.
• Which of the following is the correct EDD?
a. 5/11/09
b. 4/18/09
c. 4/11/09
d. Information given is not sufficient to
determine EDD

Answer
b. 4/18/09
• Naegele’s rule: take the first date of the LMP, add
one week, subtract three months, and add one
year
• LMP 7/11/08: add one week for a date of
7/18/08; subtract three months for a date of
4/18/08; and add one year for the EDD of
4/18/09.

Examination of the Pregnant Woman
• General inspection
– Overall health status, emotional state, nutritional status
• Vital signs
– Baseline blood pressure is very important in
establishing
if a patient becomes hypertensive during pregnancy
o Chronic hypertension: blood pressure is elevated
>140/>90 before 20 weeks’ gestation
o Gestational hypertension: blood pressure becomes
elevated >140/>90 after 20 weeks’ gestation
o Preeclampsia: elevated blood pressure >140/>90
after 20 weeks’ gestation with protein in the urine

(cont.)
• Weight and BMI (body mass index) are very
important for educating the patient on proper weight
gain and nutrition
Low BMI (>19.8) 28- to 40-lb. gain recommended
Normal BMI (19.9-26) 25- to 35-lb. gain recommended
High BMI (26.1-29) 15- to 25-lb. gain recommended
Obese BMI (>29) <15-lb. gain recommended

(cont.)
• Head: look for mask of pregnancy (chloasma) and edema
• Hair: often dry and thinning
• Eyes: examine conjunctiva; pallor often means anemia
• Nose: edema causing congestion is normal
• Mouth: examine gums and teeth; periodontal disease is
common in pregnancy
• Thorax and lungs: patients complain of shortness of breath
• Heart: listen for venous hums which are common in pregnancy
• Breasts: look for symmetry and color; veins are often
prominent

(cont.)
• Abdominal exam
– Inspect for scars (from earlier C-sections), striae,
and the linea nigra
– Palpate the abdominal organs for masses
– Palpate the uterus
o Fetal movement felt by examiner at 24 weeks
o Contractions can also be palpated by examiner

(cont.)
• Fundal height
– Measure the fundal height from the superior portion of
the pubis symphysis to the top of the fundus
– From 20 weeks to 32 weeks, the fundal height in
centimeters should approximate the number of weeks
of gestation
• Auscultation
– Auscultate the fetal heart rate with the Doptone (from
10 weeks) or the fetoscope (from 18 weeks)
– The fetal heart rate will be in the 150s to 160s during
the first weeks of pregnancy and in the 120s to 140s
by term

Question
A pregnant patient at 8 weeks’ gestation presents to clinic
for her routine prenatal check. She is excited and wants to
hear the fetus’ heart beat. Using the Doptone to listen
midline just below the umbilicus, a student shadowing you
finds a heart rate of 88 bpm. You suspect this is a maternal
heart rate. Which of the following facts leads you to this
conclusion?
a. Normal fetal heart rate at this gestation is 150-160 bpm
b. The pregnancy is too early to auscultate a fetal heart
beat
c. The student is listening too high on the abdomen for
this early gestation
d. All of the above

Answer
d. All of the above
• Normal fetal heart rate at this gestation is 150-
160 bpm
• The pregnancy is too early to auscultate a fetal
heart beat (10 weeks is generally the earliest)
• The student is listening too high on the
abdomen for this early gestation (the uterus is
in the pelvis until 12 to 14 weeks; therefore the
fetal heart beat would not be located just below
the umbilicus in the 1st trimester)

(cont.)
Expected Height of the Uterine Fundus by Month of Pregnancy

Examination of the Pregnant Woman:
Leopold’s Maneuver
• First maneuver
• Stand at the patient’s side
facing her head. Keep the
fingers of the hands together
and gently palpate with the
fingertips the upper pole of
the uterine fundus to
determine what part of the
fetus is there (e.g., buttocks
in a vertex position or head
in a breach position)

(cont.)
• Second maneuver
• Place one hand on each side of
the woman’s abdomen,
capturing the fetus between
the hands. Use one hand to
steady the fetus while the
other feels for parts (back,
elbows, knees, arms, legs,
hands, feet). Once the back is
determined, the Doptone
should be placed there to
assess heart sounds.

(cont.)
• Third maneuver
• Now facing the patient’s feet,
use the flat surface of the
fingers of both hands to palpate
the area just above the pubic
symphysis. Note whether the
hands diverge with downward
pressure or stay together. If the
hands diverge, the presenting
part has descended into the
pelvis. If the hands stay
together, the presenting part is
above the pelvis.

(cont.)
• Fourth maneuver
• With your dominant hand,
grasp the part of the fetus in
the lower pole and, with your
non-dominant hand, grasp the
part of the fetus in the upper
pole. With this maneuver,
you are often able to
distinguish between a breech
and vertex presentation.

(cont.)
• Genitalia: look for episiotomy scars or perineal
lacerations from prior deliveries
• Anus: note any hemorrhoids, fissures, or warts present
• Have patient bear down to look for rectoceles or
cystoceles
• Speculum exam
– Note the cervix color (the gravid cervix appears
bluish in color), consistency (softness of cervix
during pregnancy is called Chadwick’s sign), and
shape
– Obtain PAP smear and STD cultures

(cont.)
• Bimanual exam
• Place two fingers inside the vagina, palpating the cervix.
Place the other hand on the lower abdomen. In between
the hands, the uterus and adnexal areas can be palpated.
• Assess how long the cervix is so that during labor the
thinning of the cervix can be estimated
• Assess if the external and internal os are open or closed
• In the term patient, assess the station of the presenting
part (how inferior the presenting part is compared to the
ischial spines)

(cont.)
• Extremities: examine the extremities for varicose veins
and edema; check reflexes
• Lab work
• Initial lab work: complete blood count (CBC), blood
typing, hepatitis panel, HIV testing, syphilis testing, urine
analysis and culture, PAP smear, chlamydia and
gonorrhea cultures
• Every consequent visit tests urine for glucose (looking for
gestational diabetes), protein (looking for preeclampsia),
and white blood cells (looking for infection)

Frequency of Prenatal Visits
• Generally, one visit is needed during the first trimester
for a full history and physical with the lab work
• During the second trimester and in the third trimester until 32
weeks’ gestation, the patient is seen monthly. From 32 weeks
until 36 weeks, the patient is seen every two weeks. From 36
weeks until delivery the patient is seen weekly.
• During these visits, extra tests such as genetic screening (at
15 to 18 weeks), ultrasounds (20 weeks), diabetes screening
(at 24 to 28 weeks), and group B strep screening (number
one cause of neonatal meningitis) should be performed
• Also problems such as Rh negative status, anemia, and
urinary tract infections can be treated

Health Promotion and Counseling
• Every exam during the prenatal time is an excellent
opportunity to emphasize healthy habits. Areas to
stress include:
– Nutrition
– Weight gain
– Exercise
– Smoking cessation, alcohol, and illicit drugs
– Screening for domestic violence
– Immunizations

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