Physical examination in obstetrics Flashcards
General, systemic and routine examinations
Mom
- Height, weight and BMI
- Blood pressure
- Heart and lungs
- Head and neck
- Breasts
- Abdomen
- Limbs and skeletal
- Pelvis
Fetal assessment
- Features
- Lie
- Presentation
- Position
- Station
- Engagement
- Synclitism
- Height, weight and BMI
a. BMI = weight (kg) / height.2 (m)
b. Weight increase 0.5kg per week from week 18.
i. Normal weight gain associated with fluid retention
ii. Excessive weight gain associated with edema
Blood pressure
a. Taken at every visit
b. Recorded in the same position for all visits.
i. If supine position then performed on the left-lateral position to avoid IVC
compression (supine hypotensive syndrome associated with syncope and
nausea)
c. Diastolic measurement of the 5
th Korotkoff sound
i. 4 th Korotkoff sound is from the beginning of fading of sound
ii. 5th Korotkoff sound is when the sound disappears completely
Heart and lungs
a. Cardiac murmurs
b. Rate of respiration and use of accessory muscles (if any)
Head and neck
a. Chloasma – brownish pigmentation on forehead and cheeks which disappears at
puerperium period (the 6 weeks period after birth).
b. Color of mucosal surfaces (conjunctiva and others)
c. Dental hygiene
d. Thyroid enlargement
Breasts
a. Inverted nipples
b. Cysts or solid nodules
c. Hyperpigmentation - normal
Abdomen
a. Striae gravidarum (stretch marks) – due to rapid expansion of the uterus and
weight gain.
b. Linea nigra – hyperpigmentation of linea alba (line running vertically) along
the midline of the abdomen from the pubis to the umbilicus, but can also
run from the pubis to the top of the abdomen. It is due to placental
increased secretion of MSH. Disappears few months following delivery.
c. Uterus
i. Palpable after week 12
ii. Reaches level of umbilicus by week 24
iii. Palpable at the xiphoid at week 36 and remain at this level
d. Symphysial-fundal height
i. Assessing fetal growth and gestational age
ii. Technique – left hand is placed on the uterine fundus. Distance between that
and the top margin of the pubic symphysis is measured in centimeters.
iii. Short measure (might suggest) - oligohydramnios, small fetus, IUGR
iv. Long measure (might suggest) - twins, gestational diabetes, polyhydramnios
Symphysial-fundal height
i. Assessing fetal growth and gestational age
ii. Technique – left hand is placed on the uterine fundus. Distance between that
and the top margin of the pubic symphysis is measured in centimeters.
iii. Short measure (might suggest) - oligohydramnios, small fetus, IUGR
iv. Long measure (might suggest) - twins, gestational diabetes, polyhydramnios
e. Hepatosplenomegaly
Limbs and skeletal
a. Edema and varicose
b. Posture – kyphosis and lumbar lordosis due to compensation of weight of developing
fetus
Pelvis
a. Vulvar lesions
b. Speculum examination – used during gynecological examination (for complaints about
bleedings, abnormal vaginal discharge, Pap test, during labor in cases of bleeding or
cervical assessment.
c. Digital vaginal examination – contraindicated in later pregnancy due to the risk of
introducing infection, artificial rupture of membranes. However, used during labor for
evaluation of cervical effacement and assessment of fetal presentation.
d. Pelvimetry – not a routine anymore but used in cases of
i. Delayed labor progression
ii. Previous fractures
iii. Abnormal development of bony pelvis
iv. Includes the following measurements:
- Transverse diameter – line between widest iliopectineal points
- True conjugate – line between the sacral promontory and superior
pubic symphysis - Obstetric conjugate – line between the sacral promontory and midline
pubic symphysis - Diagonal conjugate diameter – line between inferior margin of the pubic
symphysis to sacral promontory (most clinically important)
Mid-cavity – line between ischial spines
Anteroposterior diameter (least pelvic diameter) - sacrococcygeal joint
and the inferior margin of pubic symphysis
* Intertuberous diameter – line between ischial tuberosities
Palpation of fetal parts
1. Features
Features:
* Head is firm
* Buttocks are soft
* Breech is not ballotable
* Normal fetal altitude is flexion
Lie
a. Definition: relationship of long axis of fetus to the long axis of uterus
b. Types:
i. Transverse - poles of fetus palpable in the lumber regions
ii. Oblique - presenting part is palpable in iliac fossa
iii. Longitudinal - presenting part (head or breech) palpable over pelvic inlet
Presentation
a. Definition: the leading body part of the fetus through the birth canal (dilated cervix and
vagina)
b. Types:
i. Cephalic presentation (head) – longitudinal lie
* Vertex (occipito-) – hyperflexed (most common)
* Brow (eyebrows) – partially extended
* Forehead – partially flexed
* Face (mento-) – hyperextended
ii. Breech
* Buttocks (sacro-)
* Feet (podalic-)
iii. Shoulder - transverse or oblique lie
iv. Compound presentation – more than >1 presenting part (e.g. cephalic and an
extremity)
c. Diagnosis – vaginal examination in established labor
Position
a. Definition: relationship of the denominator (the prominent part of the presenting part)
to the maternal pelvis (direction the fetus is facing in relation to the mother’s spine.
b. Examples:
i. Vertex presentation – occiput is the denominator and occipito- is the prefix
ii. Face presentation – chin is leading part and mento- is the prefix
c. Diagnosis – vaginal examination in established labor (dilated cervix and palpable
fontanelles)
