(19) Pregnant Woman

Question 1

Pregnancy Hormonal Changes:

Estrogen

Answer 1

• promotes endometrial growth that supports the early embryo
• stimulates marked enlargement of the pituitary gland (by up to 135%) and increased prolactin output from its anterior lobe, which readies breast tissue for lactation
• contributes to the hypercoagulable
  state that puts pregnant women at four to five times higher risk for thromboembolic events, primarily in the venous system

Question 2

Pregnancy Hormonal Changes:

Progesterone

Answer 2

• levels increase throughout pregnancy, leading to increased tidal
  volume and alveolar minute ventilation, though respiratory rate remains constant; respiratory alkalosis and subjective shortness of breath result from these changes
• Lower esophageal sphincter tone resulting from rising levels
  of estradiol and progesterone contributes to gastroesophageal reflux
• relaxes tone in the ureters and bladder, causing hydronephrosis (in
  the right ureter more than the left) and an increased risk of bacteriuria

Question 3

Pregnancy Hormonal Changes:

HCG

Answer 3

• has five variant subtypes
• Two are produced by the placenta and support progesterone synthesis in the corpus luteum, stabilizing the endometrium and effectively preventing loss of the early embryo to menstruation
• Serum and urine pregnancy assays test primarily for the two pregnancy-related HCG variants; three isoforms are produced by different cancers and the pituitary gland

Question 4

Pregnancy Hormonal Changes:

Placental Growth Hormone

Answer 4

• influences fetal growth and the development of preeclampsia
• implicated in insulin resistance after midpregnancy and in gestational diabetes, which carries a lifetime risk of progressing to type 2 diabetes of up to 60%

Question 5

Pregnancy Hormonal Changes:

Thyroid function

Answer 5

• changes include an increase in thyroid-binding globulin due
  to rising levels of estrogen and stimulation of thyroid-stimulating hormone (TSH) receptors by HCG
• results in a slight increase, usually in the normal range, in serum concentrations of free T3 and T4, while serum TSH concentrations appropriately decrease
• This transient apparent “hyperthyroidism” should be considered physiologic.

Question 6

Pregnancy Hormonal Changes:

relaxin

Answer 6

secreted by the corpus luteum and placenta and is involved in the
remodeling of reproductive tract connective tissue to facilitate delivery, increased
renal hemodynamics, and increased serum osmolality. Despite its
name, relaxin does not affect peripheral joint laxity during pregnancy. Weight
gain, especially around the gravid uterus, and shifts in the center of gravity
contribute to lumbar lordosis and other musculoskeletal strain.

Question 7

Pregnancy Hormonal Changes:

Erythropoietin

Answer 7

increases during pregnancy, which raises erythrocyte mass.
Plasma volume increases to a greater extent, causing relative hemodilution
and physiologic anemia, which can protect against blood loss during birth.
Cardiac output increases but systemic vascular resistance decreases, resulting
in a net fall in blood pressure, especially during the second trimester and
returning to normal by the third trimester.

Question 8

Pregnancy Hormonal Changes:

Basal Metabolic Rate

Answer 8

increases 15% to 20% during pregnancy, increasing daily
energy demands by an estimated 85, 285, and 475 kcal/d in the first, second,
and third trimesters, respectively.

Question 9

Pregnancy Anatomic Changes:

Breasts

Answer 9

breasts become moderately enlarged due to hormonal
stimulation that causes increased vascularity and glandular hyperplasia. By the
third month of gestation, the breasts become more nodular. The nipples become
larger and more erectile, with darker areolae and more pronounced Montgomery
glands. The venous pattern over the breasts becomes visibly more prominent as
pregnancy progresses. In the second and third trimesters, some women secrete
colostrum, a thick, yellowish, nutrient-rich precursor to milk. Breast tenderness
may make them more sensitive during examination.

Question 10

Pregnancy Anatomic Changes:

uterus

Answer 10

Muscle cell hypertrophy, increases in fibrous and elastic tissue, and
development of blood vessels and lymphatics all contribute to growth of the uterus.
The uterus increases in weight from ∼70 g at conception to almost 1,100 g at
delivery, when it accommodates from 5 to 20 L of fluid.1 In the first trimester, the
uterus is confined to the pelvis and shaped like an inverted pear; it may retain its
prior anteverted (forward-leaning), retroverted (backward-leaning), or retroflexed
(backward-bent) position. By 12 to 14 weeks, the gravid uterus becomes externally
palpable as it expands into a globular shape beyond the pelvic brim.
Beginning in the second trimester, the enlarging fetus pushes the uterus into an
anteverted position that encroaches into the space usually occupied by the bladder,
triggering frequent voiding. The intestines are displaced laterally and superiorly.
The uterus stretches its own supporting ligaments, causing “round ligament
pain” in the lower quadrants. Often, slight dextrorotation to accommodate the
rectosigmoid structures on the left side of the pelvis leads to greater discomfort
on the right side as well as increased right-sided hydronephrosis.1 Growth patterns
of the gravid uterus are shown in Figure 19-4. Sagittal depictions of the
gravid abdomen during each trimester appear in Figures 19-5 to 19-7.

Question 11

Pregnancy Anatomic Changes:

Vagina

Answer 11

Increased vascularity throughout the pelvis gives the vagina a bluish
color, known as Chadwick sign. The vaginal walls appear deeply rugated due to
thicker mucosa, loosening of connective tissue, and hypertrophy of smooth
muscle cells. Normal vaginal secretions may become thick, white, and more
profuse, known as leukorrhea of pregnancy. Increased glycogen stores in the
vaginal epithelium give rise to a proliferation of Lactobacillus acidophilus, which
lowers the vaginal pH. This acidification protects against some vaginal infections,
but at the same time, increased glycogen may contribute to higher rates of vaginal
candidiasis.

Question 12

Pregnancy Anatomic Changes:

Cervix

Answer 12

At ∼1 month after conception,
the cervix softens and also turns bluish or
cyanotic in color, reflecting the increased
vascularity, edema, and glandular hyperplasia
throughout the cervix.1 Hegar sign is the
palpable softening of the cervical isthmus,
the portion of the uterus that narrows into
the cervix, illustrated in Figure 19-8. This
cervical remodeling involves rearrangement
of the cervical connective tissue that decreases
collagen concentration and facilitates dilatation
during delivery. Copious cervical secretions
fill the cervical canal soon after
conception with a tenacious mucus plug that
protects the uterine environment from
outside pathogens and is expelled as bloody
show at delivery.

Question 13

Pregnancy Anatomic Changes:

Adnexae

Answer 13

Early in pregnancy, the corpus luteum, which is the ovarian follicle
that has discharged its ovum, may be prominent enough to be felt on the affected
ovary as a small nodule; this disappears by
midpregnancy.

Question 14

Pregnancy Anatomic Changes:

External Abdomen

Answer 14

As the skin
over the abdomen stretches to ac commodate
the fetus, purplish striae gravidarum
or “stretch marks” and a linea nigra, a
brownish black pigmented vertical stripe
along the midline skin, may appear
(Fig. 19-9). As tension on the abdominal
wall increases with advancing pregnancy,
the rectus abdominis muscles may separate
at the midline, called diastasis recti. If
diastasis is severe, especially in multiparous
women, only a layer of skin, fascia, and
peritoneum may cover the anterior uterine
wall, and fetal parts may be palpable
through this muscular gap.

Question 15

Common Concerns in Pregnancy:

Amenorrhea

Answer 15

all trimesters

High levels of estrogen, progesterone, and HCG build up the endometrium and prevent
menses, causing missed periods which are often the first noticeable sign of
pregnancy

Question 16

Common Concerns in Pregnancy:

Heartburn

Answer 16

all trimesters

Progesterone relaxes the lower esophageal sphincter, allowing gastric contents to
reflux into the esophagus. The gravid uterus also exerts physical pressure against
the stomach, contributing to reflux symptoms

Question 17

Common Concerns in Pregnancy:

Urinary Frequency

Answer 17

all trimesters

Increases in blood volume and filtration rate through the kidneys result in increased
urine production, while pressure from the gravid uterus reduces potential space for
the bladder. Dysuria or suprapubic pain should be investigated for urinary tract
infection

Question 18

Common Concerns in Pregnancy:

Vaginal discharge

Answer 18

all trimesters

Asymptomatic milky white discharge, leukorrhea, results from increased secretions
from vaginal and cervical epithelium due to vasocongestion and hormonal changes.
Any foul-smelling or pruritic discharge should be investigated.

Question 19

Common Concerns in Pregnancy:

Constipation

Answer 19

all trimesters

Constipation results from slowed gastrointestinal transit due to hormonal changes,
dehydration from nausea and vomiting, and the supplemental iron in prenatal
vitamins

Question 20

Common Concerns in Pregnancy:

Hemorrhoids

Answer 20

all trimesters

Hemorrhoids may be caused by constipation, decreased venous return from increasing
pressure in the pelvis, compression by fetal parts, and changes in activity level
during pregnancy.

Question 21

Common Concerns in Pregnancy:

Backache

Answer 21

all trimesters

Hormonally induced relaxation of the pelvic ligaments contributes to musculoskeletal

aches. Lordosis required to balance the gravid uterus contributes to lower back
strain. Breast enlargement may contribute to upper backaches.

Question 22

Common Concerns in Pregnancy:

N/V

Answer 22

1st trimester

This is poorly understood but appears to reflect hormonal changes, slowed gastrointestinal
peristalsis, alterations in smell and taste, and sociocultural factors. Hyperemesis
gravidarum is vomiting with weight loss of >5% of prepregnancy weight.

Question 23

Common Concerns in Pregnancy:

Breast tenderness/tingling

Answer 23

1st trimester

Pregnancy hormones stimulate the growth of breast tissue, which causes swelling and
possible aching, tenderness, and tingling. Increased blood flow can make delicate
veins more visible beneath the skin.

Question 24

Common Concerns in Pregnancy:

fatigue

Answer 24

1st/3rd trimester

Fatigue is related to the rapid change in energy requirements, sedative effects of progesterone,
changes in body mechanics due to the gravid uterus, and sleep disturbance.
Many women report increased energy and well-being during the second
trimester

Question 25

Common Concerns in Pregnancy:

lower abdominal pain

Answer 25

2nd trimester

Rapid growth in the second trimester causes tension and stretching of the round ligaments
that support the uterus, causing sharp or cramping pain with movement or
position change.

Question 26

Common Concerns in Pregnancy:

abdominal striae

Answer 26

2nd or 3rd trimester

Stretching of the skin and tearing of the collagen in the dermis contribute to thin,
usually pink, bands, or striae gravidarum (stretch marks). These may persist or fade
over time after delivery

Question 27

Common Concerns in Pregnancy:

Contractions

Answer 27

3rd trimester

Irregular and unpredictable uterine contractions (Braxton Hicks contractions) are rarely
associated with labor. Contractions that become regular or painful should be evaluated
for onset of labor.

Question 28

Common Concerns in Pregnancy:

Loss of mucus plug

Answer 28

3rd trimester

Passage of the mucus plug is common during labor but may occur prior to the onset of
contractions. As long as there are no regular contractions, bleeding, or loss of fluid,
loss of the mucus plug is unlikely to trigger the onset of labor.

Question 29

Common Concerns in Pregnancy:

Edema

Answer 29

3rd trimester

Decreased venous return, obstruction of lymphatic flow, and reduced plasma colloid
oncotic pressure commonly cause lower extremity edema. However, sudden severe
edema and hypertension may signal preeclampsia.

Question 30

Pregnancy:

Common Concerns

Answer 30

● Initial prenatal history
● Confirmation of pregnancy
● Symptoms of pregnancy
● Concerns and attitudes toward the pregnancy
● Current health 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

Question 31

Prenatal care focuses on ?

Answer 31

optimizing health and minimizing risk for mother and fetus

Question 32

The girls of the initial prenatal visit are:

Answer 32

• define health status of mother and fetus
• confirm pregnancy
• estimate gestational age
• develop plan for continuing care
• counsel mother about expectations and concerns

Question 33

Gestational Age

Answer 33

To establish gestational age, count the number of weeks and
days from the first day of the LMP. Counting this menstrual age from the
LMP, although biologically distinct from date of conception, is the 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),
a conception age which is 2 weeks less than the menstrual age can be
used to calculate menstrual age (i.e., a corrected or adjusted LMP dating) to
establish dating.

Question 34

Expected Date of Delivery (EDD)

Answer 34

The EDD is 40 weeks from the first date of the LMP.

Using the Naegele rule, the EDD can be estimated by taking:
LMP + 7 days - 3 months + 1 year

Question 35

Tools for Pregnancy Calculations

Answer 35

Pregnancy wheels and online calculators are commonly
used to calculate the EDD. However, pregnancy wheels vary widely in quality
and accuracy, and are often produced as commercial marketing tools. Online
calculators may be more reliable, but should be checked for accuracy before
routine use.
● Limitations on

Question 36

Limitations on Pregnancy Dating

Answer 36

Patient recall of the LMP is highly variable.
Even when this date is accurate, the LMP can be affected by hormonal contraceptives,
menstrual irregularities, or variations in ovulation that result in
atypical cycle lengths. LMP dating should be checked against physical examination
markers such as fundal height, and any wide discrepancies should be
clarified by ultrasound evaluation. In clinical practice, dating by ultrasound is
widespread, regardless of the certainty of the LMP, even though this approach
is not currently endorsed by national guidelines.

Question 37

Typical OB visit schedule

Answer 37

• monthly until 28 weeks
• biweekly until 36 weeks
• weekly until delivery

Question 38

Physical exam findings at every prenatal visit:

Answer 38

The physical examination findings at every visit
should include vital signs (especially blood pressure and weight), fundal
height, verification of fetal heart rate (FHR), and determination of fetal position
and activity, as described in Techniques of Examination to follow. At each visit,
the urine should be tested for infection and protein.

Question 39

Subjective findings at every prenatal visit:

Answer 39

Update and document the history at
every visit, especially fetal movement felt by the patient, contractions, leakage
of fluid, and vaginal bleeding

Question 40

Pregnancy health promotion topics

Answer 40

Nutrition
● Weight gain
● Immunizations
● Exercise
● Substance abuse
● Intimate partner violence
● Prenatal laboratory screening

Question 41

Prenatal vitamin recommendations

Answer 41

Daily prenatal supplements should include
400 μg of folic acid, 600 International Units of vitamin D, 27 mg of
iron, and at least 1,000 mg of calcium.14 If not present in the prenatal vitamins,
recommend 150 to 290 μg of daily iodine in pregnant and breastfeeding
women as iodine deficiency is widespread.15 Patients should be
advised that excess amounts of fat-soluble vitamins like vitamins A, D, E,
and K can cause toxicity.

Question 42

Hematocrit in pregnancy

Answer 42

The hematocrit is a screen for anemia, which may
reflect nutritional deficiency, underlying clinical issues, or the expected
hemodilution later in pregnancy.

Question 43

Pregnancy: foods to avoid

Answer 43

Caution the patient about foods to avoid. Pregnant women are especially vulnerable
to listeriosis. To help prevent listeriosis, the American College of Obstetricians
and Gynecologists (ACOG)14 encourages pregnant patients to avoid:
■ Unpasteurized milk and foods made with unpasteurized milk
■ Raw and undercooked seafood, eggs, and meat
■ Refrigerated paté, meat spreads, and smoked salmon
■ Hot dogs, luncheon meats, and cold cuts unless served steaming hot
■ Regarding fish and shellfish, some nutrients like omega-3 fatty acids and dehydroepiandrostenedione
(DHEA) may enhance fetal brain development.
For pregnant and breastfeeding women, ACOG recommends two servings a
week of selected fish and shellfish. Intake should include 8 to 12 ounces a
week of fish lower in mercury such as salmon, shrimp, pollock, tuna (light
canned), tilapia, catfish, and cod. White tuna consumption should be
limited to 6 ounces a week. Pregnant women should avoid fish higher in
mercury like tilefish, shark, swordfish, and king mackerel.

Question 44

Weight Gain by BMI

underweight <18.5
normal 18.5-24.9
overweight 25-29.9
obese >30

Answer 44

underweight 28-40 (1/wk)

normal 25-35 (1/wk)

overweight 15-25 (0.6/wk)

obese 11-20 (0.5/wk)

Question 45

Pregnancy: immunizations

Answer 45

Tdap 27-36 weeks (& all caretakers)

inactivated flu - any week

Safe:

• pneumococcal
• meningococcal
• hep b
• hep a

Not safe:

• MMR
• polio
• varicella

Question 46

Pregnancy: Rh

Answer 46

chest at first visit, 28 weeks, delivery

• give anti-D immunoglobulin to Rh- at 28 weeks and 3 days of delivery

Question 47

Pregnancy: exercise

Answer 47

> 30 minutes moderate most days

• avoid supine position after 1st trimester
• avoid contact sports
• avoid overheating/dehydration

Question 48

Pregnancy: tobacco

Answer 48

Tobacco use is implicated in 13% to 19% of all low–birth weight babies and many other poor pregnancy outcomes, including a twofold risk of placenta previa, placental abruption, and preterm labor
- Risk of spontaneous abortion, fetal death, and fetal digit anomalies is also increased.
Cessation is the goal, but any decrease in use is favorable

Question 49

Pregnancy: alcohol

Answer 49

Fetal alcohol syndrome, the neurodevelopmental sequela of alcohol
exposure during fetal development, is the leading cause of preventable
mental retardation in the United States. No safe dose of alcohol has been
established. ACOG strongly recommends that women abstain throughout
pregnancy.31 To promote abstinence, make use of the numerous ACOG and
CDC resources, professional counseling, inpatient treatment, and Alcoholics
Anonymous

Question 50

Pregnancy: Intimate partner Violence

Answer 50

Pregnancy is a time of increased risk from
intimate partner violence. Pre-existing patterns of abuse may intensify from
verbal to physical abuse or from mild to severe physical abuse. Up to one in five
women experiences some form of abuse during pregnancy, which has been
associated with delayed prenatal care, low infant birth weight, or even murder
of the mother and fetus.32
ACOG recommends universal screening of all women for domestic violence
without regard to socioeconomic status, including pregnant women at the first
prenatal visit and at least once each trimester

Question 51

ACOG Screening Approach for Intimate Partner Violence

Answer 51

Initial Statement: “Because violence is so common in many women’s lives and
because there is help available for women being abused, I now ask every patient
about domestic violence.”
Screening Questions:
1. “Within the past year—or since you have been pregnant—have you been hit,
slapped, kicked, or otherwise physically hurt by someone?”
2. “Are you in a relationship with a person who threatens or physically hurts you?”
3. “Has anyone forced you to have sexual activities that made you feel uncomfortable?”

Question 52

Prenatal Lab Screenings

Answer 52

The standard prenatal screening
panel includes blood type and Rh, antibody screen, complete blood count—
especially hematocrit and platelet count, rubella titer, syphilis test, hepatitis B
surface antigen, HIV test, STI screen for gonorrhea and chlamydia, and urinalysis
with culture. Scheduled screenings include an oral glucose tolerance test for
gestational diabetes around 24 to 28 weeks and a rectovaginal swab for group B
streptococcus between 35 and 37 weeks.
Because obesity is associated with insulin resistance, the obese pregnant patient
is at increased risk of both gestational diabetes and type 2 diabetes mellitus. Both
ACOG and the American Diabetes Association recommend testing for glucose
tolerance in the first trimester for obese pregnant patients.33
If indicated, pursue additional tests related to the mother’s risk factors, such as
screening for aneuploidy, Tay–Sachs disease, or other genetic diseases, and
amniocentesis.

Question 53

Supine hypotensive syndrome (pregnancy)

Answer 53

Compression interferes with venous
return from the lower extremities and
pelvic vessels, causing the patient to
feel dizzy and faint

Question 54

type of cervical sampling device for pregnancy

Answer 54

broom is preferred b/c brush may cause bleeding

Question 55

Pregnancy: weight loss >5%

Answer 55

Weight loss due to nausea and vomiting
that exceeds 5% of prepregnancy weight
is considered excessive, representing
hyperemesis gravidarum, and can lead to
adverse pregnancy outcomes

Question 56

Gestational Hypertension

Answer 56

Gestational hypertension is systolic blood
pressure (SBP) >140 mm Hg or diastolic
blood pressure (DBP) >90 mm Hg first
documented after 20 weeks, without
proteinuria or preeclampsia, that
resolves by 12 weeks postpartum.

Question 57

Pregnancy: Chronic HTN

Answer 57

Chronic hypertension is SBP >140 or
DBP >90 that predates pregnancy.
Chronic hypertension affects almost
2% of U.S. births

Question 58

Preeclampsia

Answer 58

Preeclampsia is SBP ≥140 or DBP ≥90 after 20 weeks on two occasions at least
4 hours apart in a woman with previously normal BP or BP ≥160/110 confirmed
within minutes and proteinuria ≥300 mg/24 hours, protein:creatinine ≥0.3, or
dipstick 1+;
OR
new onset hypertension without proteinuria and any of the following: thrombocytopenia
(platelets <100,000/μL), impaired liver function (liver transaminase
levels more than twice normal), new renal insufficiency (creatinine >1.1 mg/dL or
doubles in the absence of renal disease), pulmonary edema, or new onset cerebral
or visual symptoms.

Question 59

Pregnancy: chloasma or melasma

Answer 59

“mask of pregnancy”

- normal skin finding during pregnancy

Question 60

Facial edema after 20 weeks gestation is suspicious for ?

Answer 60

preeclampsia

Question 61

Pregnancy: hair

Answer 61

Hair may become dry, oily, or sparse during pregnancy; mild hirsutism
on the face, abdomen, and extremities is also common

Localized patches of hair loss should
not be attributed to pregnancy (though
postpartum hair loss is common

Question 62

Pregnancy: heart

Answer 62

Palpate the apical impulse, which 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
(pronounced soo-fl) often found during pregnancy due to increased blood flow
through normal vessels. The mammary souffle is commonly heard during late
pregnancy or lactation, is strongest in the second or third intercostal space at the
sternal border, and is typically both systolic and diastolic, though only the systolic
component may be audible.

Assess dyspnea and signs of heart failure
for possible peripartum cardiomyopathy,
particularly in the late stages
of pregnancy.

Murmurs may signal anemia. Investigate
any diastolic murmur.

Question 63

Pregnancy: bloody or purulent nipple discharge

Answer 63

should not be attributed to pregnancy

Question 64

Fetal movement

Answer 64

The examiner can usually feel movements externally after
24 gestational weeks; the mother can usually feel these by 18 to 24 weeks.
The maternal sensation of fetal movement is traditionally known as
“quickening.”

If fetal movement is not felt after
24 weeks, consider a miscalculation
of gestational age, fetal death or
severe morbidity, or false pregnancy.
Confirm fetal health and gestational
age with an ultrasound.

Question 65

Uterine Contractility

Answer 65

Irregular uterine contractions occur as early as 12 weeks
and may be triggered by external palpation during the third trimester. During
contractions, the abdomen feels tense or firm to the examiner, obscuring the
palpation of fetal parts; after the contraction, the palpating fingers sense the
relaxation of the uterine muscle

Before 37 weeks, regular uterine contractions
with or without pain and
bleeding are abnormal, suggesting
preterm labor.

Question 66

Fundal Height

Answer 66

if gestational age is >20 weeks, when the fundus
should reach the umbilicus. With a plastic or paper tape measure, locate the
pubic symphysis and place the “zero” end of the tape measure where you can
firmly feel that bone (Fig. 19-12). Then extend the tape measure to the very
top of uterine fundus and note the number of centimeters measured. Though
subject to error between 16 and 36 weeks, measurement in centimetersshould roughly equal the number of weeks of gestation. This low-technology,
widely used technique may underdetect newborns who are small for gestational
age.

If fundal height is 4 cm greater than
expected, consider multiple gestation,
a large fetus, extra amniotic
fluid, or uterine leiomyoma. If fundal
height is 4 cm smaller than expected,
consider low-level amniotic fluid,
missed abortion, intrauterine growth
retardation, or fetal anomaly. These
conditions should be investigated by
ultrasound

Question 67

Fetal Heart Tones: location

Answer 67

If fundal height is 4 cm greater than
expected, consider multiple gestation,
a large fetus, extra amniotic
fluid, or uterine leiomyoma. If fundal
height is 4 cm smaller than expected,
consider low-level amniotic fluid,
missed abortion, intrauterine growth
retardation, or fetal anomaly. These
conditions should be investigated by
ultrasound

After 24 weeks, auscultation of more
than one FHR in different locations
with varying rates suggests multiple
gestation

Question 68

Fetal heart Tones: rate

Answer 68

110-160

Question 69

Fetal Heart Tones: rhythm

Answer 69

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.

Lack of beat-to-beat variability is
difficult to discern with a handheld
Doppler, so this finding warrants
formal FHR monitoring

Question 70

Pregnancy: Acute PID

Answer 70

Acute pelvic inflammatory disease is
rare in pregnancy, especially after the
first trimester, because the adnexae
are sealed by the gravid uterus and
mucus plug.

Question 71

Pregnancy: Hyperreflexia

Answer 71

Hyperreflexia may signal cortical
irritability from eclampsia, but
clinical accuracy is variable.

Question 72

Leopold Maneuvers

Answer 72

Leopold maneuvers are used to determine the fetal
position in the maternal abdomen beginning in the second trimester; accuracy
is greatest after 36 weeks’ gestation.41 Although less accurate for assessing fetal
growth,42 these examination findings help determine readiness for vaginal
delivery by assessing:
■ The upper and lower fetal pole, namely, the proximal and distal fetal parts
■ The maternal side where the fetal back is located
■ The descent of the presenting part into the maternal pelvis
■ The extent of flexion of the fetal head
■ The estimated size and weight of the fetus (an advanced skill that will not be
addressed further here)

Question 73

Leopold Maneuver: 1st, Upper Fetal Pole

Answer 73

Stand at the woman’s
side, facing her head. Palpate
the uppermost part of
gravid uterus gently, with the
fingertips together, to determine
what fetal part is located at the
fundus, which is the “upper fetal
pole”

The fetal buttocks are usually at the
upper fetal pole; they feel firm but
irregular, and less globular than the
head. The fetal head feels firm, round,
and smooth. Occasionally, neither
part is easily palpated at the fundus,
as when the fetus is in a transverse lie

Question 74

Leopold Maneuver: 2nd, Sides of Maternal Abdomen

Answer 74

Place one hand on each side of
the woman’s abdomen, capturing
the fetal body between them
(Fig. 19-14). 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

By 32 weeks’ gestation, the fetal back
has a smooth, firm surface as long or
longer than the examiner’s hand. The
fetal arms and legs feel like irregular
bumps. The fetus may kick if awake
and active.

Question 75

Leopold Maneuver: 3rd, Lower Fetal Pole and Descent into Pelvis

Answer 75

Face the woman’s feet.
Place the flat palmar surfaces of
the fingertips on the fetal pole
just above the pubic symphysis
(Fig. 19-15). Palpate the presenting
fetal part for texture and
firmness to distinguish the head
from the buttock. Judge the
descent, or engagement, of the
presenting part into the maternal
pelvis. Alternatively, use the
Pawlik grip by grasping the
lower fetal pole with the thumb
and fingers of one hand to assess
the presenting part and descent
into pelvis; however, this technique
tends to be uncomfortable
to the gravid patient.

Again, the fetal head feels very firm
and globular; the buttocks feel firm
but irregular, and less globular than
the head. In a vertex or cephalic presentation,
the fetal head is the presenting
part. If the most distal part of
the lower fetal pole cannot be palpated,
it is usually engaged in the pelvis.
If you can depress the tissues over
the maternal bladder without touching
the fetus, the presenting part is
proximal to your fingers

Question 76

Leopold Maneuver: 4th, Flexion of the Fetal Head

Answer 76

This maneuver
assesses the flexion or
extension of the fetal head, presuming
that the fetal head is the
presenting part in the pelvis. Still
facing the woman’s feet, with
your hands positioned on either
side of the gravid uterus, identify
the fetal front and back sides
(Fig. 19-16). Using one hand at
a time, slide your fingers down
each side of the fetal body until
you reach the “cephalic prominence,”
that is, where the fetal
brow or occiput juts out.

If the cephalic prominence juts out
along the line of the fetal back, the
head is extended. If the cephalic
prominence juts out along the line
of the fetal anterior side, the head is
flexed.