TUMAOB, LEALYN A.
GROUP H
Ideally, women who are planning to become
pregnant should see a physician before
conception; then they can learn about
pregnancy risks and ways to reduce risks. As
part of preconception care, primary care
clinicians should advise all women of
reproductive age to take a vitamin that contains
folic acid 400 to 800 mcg (0.4 to 0. 8 mg) once a
day. Folate reduces risk of neural tube defects.
If women have had a fetus or infant with a
neural tube defect, the recommended daily
dose is 4000 mcg (4 mg). Taking folate before
and after conception may also reduce the risk of
other birth defects (1).
Once pregnant, women require routine prenatal
care to help safeguard their health and the
health of the fetus. Also, evaluation is often
required for symptoms and signs of illness.
Common symptoms that are often pregnancy-
related include
 Vaginal bleeding
 Pelvic pain
 Vomiting
 Lower-extremity edema
Prenatal visits may be scheduled more
frequently if risk of a poor pregnancy outcome
is high or less frequently if risk is very low.
Prenatal care includes
 Screening for disorders
 Taking measures to reduce fetal and
maternal risks
 Counseling
History
During the initial visit, clinicians should obtain a
full medical history, including
 Previous and current disorders
 Drug use (therapeutic, social, and illicit)
 Risk factors for complications of
pregnancy (see table Pregnancy Risk
Assessment)
 Obstetric history, with the outcome of
all previous pregnancies, including
maternal and fetal complications (eg,
gestational diabetes, preeclampsia,
congenital malformations, stillbirth)
Family history should include all chronic
disorders in family members to identify possible
hereditary disorders (genetic evaluation).
During subsequent visits, queries focus on
interim developments, particularly vaginal
bleeding or fluid discharge, headache, changes
in vision, edema of face or fingers, and changes
in frequency or intensity of fetal movement.
Gravidity and parity
Gravidity is the number of confirmed
pregnancies; a pregnant woman is a gravida.
Parity is the number of deliveries after 20
weeks. Multifetal pregnancy is counted as one
in terms of gravidity and parity. Abortus is the
number of pregnancy losses (abortions) before
20 weeks regardless of cause (eg, spontaneous,
therapeutic, or elective abortion; ectopic
pregnancy). Sum of parity and abortus equals
gravidity.
Parity is often recorded as 4 numbers:
 Number of term deliveries (after 37
weeks)
 Number of premature deliveries (> 20
and < 37 weeks)
 Number of abortions
 Number of living children
Thus, a woman who is pregnant and has had
one term delivery, one set of twins born at 32
weeks, and 2 abortions is gravida 5, para 1-1-2-
3.
Physical Examination
A full general examination, including blood
pressure (BP), height, and weight, is done first.
Body mass index (BMI) should be calculated and
recorded. BP and weight should be measured at
each prenatal visit.
In the initial obstetric examination, speculum
and bimanual pelvic examination is done for the
following reasons:
 To check for lesions or discharge
 To note the color and consistency of the
cervix
 To obtain cervical samples for testing
Also, fetal heart rate and, in patients presenting
later in pregnancy, lie of the fetus are assessed.
Pelvic capacity can be estimated clinically by
evaluating various measurements with the
middle finger during bimanual examination. If
the distance from the underside of the pubic
symphysis to the sacral promontory is > 11.5
cm, the pelvic inlet is almost certainly adequate.
Normally, distance between the ischial spines
is ≥ 9 cm, length of the sacrospinous ligaments
is 4 to ≥ 5 cm, and the subpubic arch is ≥ 90°.
During subsequent visits, BP and weight
assessment is important. Obstetric examination
focuses on uterine size, fundal height (in cm
above the symphysis pubis), fetal heart rate and
activity, and maternal diet, weight gain, and
overall well-being. Speculum and bimanual
examination is usually not needed unless
vaginal discharge or bleeding, leakage of fluid,
or pain is present
Testing
Laboratory testing
Prenatal evaluation involves urine tests and
blood tests. Initial laboratory evaluation is
thorough; some components are repeated
during follow-up visits.
In some pregnant women, blood tests to screen
for thyroid disorders (measurement of thyroid-
stimulating hormone [TSH]) are done. These
women may include those who
 Have symptoms
 Come from an area where moderate to
severe iodine insufficiency occurs
 Have a family or personal history of
thyroid disorders
 Have type 1 diabetes
 Have a history of infertility, preterm
delivery, or miscarriage
 Have had head or neck radiation
therapy
 Are morbidly obese (BMI > 40 kg/m2)
 Are > 30 years
Treatment
Diet and supplements
To provide nutrition for the fetus, most women
require about 250 kcal extra daily; most calories
should come from protein. If maternal weight
gain is excessive (> 1.4 kg/month during the
early months) or inadequate (< 0.9 kg/month),
diet must be modified further. Weight-loss
dieting during pregnancy is not recommended,
even for morbidly obese women.
Most pregnant women need a daily oral iron
supplement of ferrous sulfate 300 mg or ferrous
gluconate 450 mg, which may be better
tolerated. Woman with anemia should take the
supplements twice a day.
All women should be given oral prenatal
vitamins that contain folate 400 mcg (0.4 mg),
taken once a day; folate reduces risk of neural
tube defects. For women who have had a fetus
or infant with a neural tube defect, the
recommended daily dose is 4000 mcg (4 mg).
Physical activity
Pregnant women can continue to do moderate
physical activities and exercise but should take
care not to injure the abdomen.
Sexual intercourse can be continued throughout
pregnancy unless vaginal bleeding, pain,
leakage of amniotic fluid, or uterine
contractions occur.
Immunizations
Vaccines for measles, mumps, rubella, and
varicella should not be used during pregnancy.
The hepatitis B vaccine can be safely used if
indicated, and the influenza vaccine is strongly
recommended for women who are pregnant or
postpartum during influenza season. Booster
immunization for diphtheria, tetanus, and
pertussis (Tdap) between 27 and 36 weeks
gestation or postpartum is recommended, even
if women have been fully vaccinated.
Modifiable risk factors
Pregnant women should not use alcohol and
tobacco and should avoid exposure to
secondhand smoke. They should also avoid the
following:
 Exposure to chemicals or paint fumes
 Direct handling of cat litter (due to risk
of toxoplasmosis)
 Prolonged temperature elevation (eg, in
a hot tub or sauna)
 Exposure to people with active viral
infections (eg, rubella, parvovirus
infection [fifth disease], varicella)
Women with substance abuse problems should
be monitored by a specialist in high-risk
pregnancy. Screening for domestic
violenceand depression should be done.
Drugs and vitamins that are not medically
indicated should be discouraged.
 Obstetric Examination
Introduction
 Introduce yourself to the patient
 Wash your hands
 Explain to the patient what the
examination involves and why it is
necessary
 Obtain verbal consent
Preparation
 Measure the patient’s height and
weight
 Patient should have an empty bladder
 Expose the abdomen from the
xiphisternum to the pubic symphysis
 Cover above and below where
appropriate
 Ask the patient to lie in the supine
position with the head of the bed raised
to 15 degrees
 Prepare your equipment: measuring
tape, pinnard stethoscope or doppler
transducer, ultrasound gel
General Inspection
 General wellbeing – at ease or
distressed by physical pain.
 Hands – palpate the radial pulse.
 Head and neck – melasma, conjunctival
pallor, jaundice, oedema.
 Legs and feet – calf swelling, oedema
and varicose veins.
Abdominal Inspection
In the obstetric examination, inspect the
abdomen for:
 Distension compatible with pregnancy
 Fetal movement (>24 weeks)
 Surgical scars – previous Caesarean
section, laproscopic port scars
 Skin changes indicative of pregnancy –
linea nigra (dark vertical line from
umbilicus to the pubis), striae
gravidarum (‘stretch marks’), striae
albicans (old, silvery-white striae)
Palpation
Ask the patient to comment on any tenderness
and observe her facial and verbal responses
throughout. Note any guarding.
Fundal Height
 Use the medial edge of the left hand to
press down at the xiphisternum,
working downwards to locate the
fundus.
 Measure from here to the pubic
symphysis in both cm and inches. Turn
the measuring tape so that the numbers
face the abdomen (to avoid bias in your
measurements).
 Uterus should be palpable after 12
weeks, near the umbilicus at 20 weeks
and near the xiphisternum at 36 weeks
(these measurements are often slightly
different if the woman is tall or short).
 The distance should be similar to
gestational age in weeks (+/- 2 cm).
Lie
 Facing the patient’s head, place hands
on either side of the top of the uterus
and gently apply pressure
 Move the hands and palpate down the
abdomen
 One side will feel fuller and firmer – this
is the back. Fetal limbs may be palpable
on the opposing side
Presentation
 Palpate the lower uterus (below the
umbilicus) to find the presenting part.
 Firm and round signifies cephalic, soft
and/or non-round suggests breech. If
breech presentation is suspected, the
fetal head can be often be palpated in
the upper uterus.
 Ballot head by pushing it gently from
one side to the other.
Liquor Volume
 Palpate and ballot fluid to approximate
volume to determine if there is
oligohydraminos/polyhydramnios
 When assessing the lie, only feeling
fetal parts on deep palpation suggests
large amounts of fluid
Engagement
 Fetal engagement refers to whether the
presenting part has entered the bony
pelvis
 Note how much of the head is palpable
– if the entire head is palpable, the
fetus is unengaged.
 Engagement is measured in 1/5s
Fetal Auscultation
 Locate the back of the fetus to listen for
the fetal heart, aim to put your
instrument between the fetal scapulae
to aim toward the heart.
 o Hand-held Doppler machine
>16 weeks (trying before this
gestation often leads to anxiety
if the heart cannot be
auscultated).
o Pinard stethoscope over the
anterior shoulder >28 weeks
 Feel the mother’s pulse at the same
time
 Measure fetal HR for one minute
o Should be 110-160bpm (>24
weeks)
Completing the Examination
 Palpate the ankles for oedema and test
for hyperreflexia (pre-eclampsia)
 Thank the patient and allow them to
dress in private
 Wash your hands
 Summarise findings
 Perform:
o Blood pressure
o Urine dipstick