Chapter 19 The Pregnant Woman

1. Chapter 19 The Pregnant Woman

2. 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

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

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

5. 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

6. 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

7. 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

8. 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

9. 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? • 5/11/09 • 4/18/09 • 4/11/09 • Information given is not sufficient to determine EDD

10. Answer • 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.

11. 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 • Chronic hypertension: blood pressure is elevated >140/>90 before 20 weeks’ gestation • Gestational hypertension: blood pressure becomes elevated >140/>90 after 20 weeks’ gestation • Preeclampsia: elevated blood pressure >140/>90 after 20 weeks’ gestation with protein in the urine

12. Examination of the Pregnant Woman (cont.) • Weight and BMI (body mass index) are very important for educating the patient on proper weight gain and nutrition

13. Examination of the Pregnant Woman (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

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

15. Examination of the Pregnant Woman (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

16. 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? • Normal fetal heart rate at this gestation is 150-160 bpm • The pregnancy is too early to auscultate a fetal heart beat • The student is listening too high on the abdomen for this early gestation • All of the above

17. Answer • 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)

18. Examination of the Pregnant Woman (cont.) Expected Height of the Uterine Fundus by Month of Pregnancy

19. 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)

20. Examination of the Pregnant Woman: Leopold’s Maneuver(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.

21. Examination of the Pregnant Woman: Leopold’s Maneuver(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.

22. Examination of the Pregnant Woman: Leopold’s Maneuver(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.

23. Examination of the Pregnant Woman (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

24. Examination of the Pregnant Woman (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)

25. Examination of the Pregnant Woman (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)

26. 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

27. 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