Initial Comprehensive Evaluation

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There are three main goals to the initial evaluation:

1. Determine the health of the mother and fetus.

2. Determine the gestational age of the fetus.

3. Initiate a plan for continuing care.

The physical examination must include the following:

Determination of height and weight Assessment of blood pressure Inspection of the teeth and gums Palpation of the thyroid gland Auscultation of the heart and lungs

• Examination of the breasts and nipples

# Examination of the abdomen

Examination of the legs for varicosities and edema Inspection of the vulva, vagina, and cervix

# Cytologic study (Pap smear)

• Swab for Chlamydia organisms and gonorrhea

Palpation of the cervix, uterus, and adnexa, including physical assessment of uterine size in terms of gestational age

Whenever possible, ultrasonography should be performed at the first prenatal visit in order to verify the presence of an intrauterine pregnancy with a fetal heartbeat, to confirm or adjust the gestational age, and to check for multiple fetuses. Another sonographic examination is usually performed at about 16 to 20 weeks to confirm that the pregnancy is progressing normally and to recognize any major abnormality.

Figure 23-11 Technique for measuring fundal height.

Head, Eyes, Ears, Nose, Throat, and Neck

Inspect the face. Is chloasma present? What is the texture of the hair and skin? Inspect the mouth. What is the condition of the teeth and gums? Palpate the thyroid. Is it enlarged symmetrically?

Chest

Inspect, palpate, and auscultate the chest. Is there any evidence of labored breathing? Heart

Palpate for the point of maximum impulse. Is it displaced laterally? During the later stages of pregnancy, the gravid uterus pushes up on the diaphragm, and the point of maximum impulse is displaced laterally. Auscultate the heart. Systolic ejection murmurs are common during pregnancy as a result of the hyperdynamic state. Diastolic murmurs are always pathologic.

Breasts

Inspect the breasts. Are they symmetric? Notice the presence of vascular engorgement and pigmentary changes. Are the nipples everted? An inverted nipple may interfere with a woman's plans to breast-feed. Palpate the breasts. The normal nodularity of breast tissue is accentuated during pregnancy, but any discrete mass should be considered pathologic until proved otherwise.

Abdomen

Inspect for the linea nigra and striae gravidarum. Notice the contour of the abdomen. Palpate the abdomen. Fetal movement may be felt by the examiner after 24 weeks. Are there uterine contractions? Hold your hand on the abdomen as the uterus relaxes.

Use a tape measure to assess the fundal height. The measurement should be taken from the top of the symphysis pubis in a straight line to the top of the fundus, with the bladder empty. The technique is demonstrated in Figure 23-11. Between 20 and 32 weeks, the superior-inferior measurement in centimeters should equal the number of weeks of gestation. The uterus rises up and enters the abdomen at 12 weeks. It reaches the umbilicus at about 20 weeks and is just under the costal margin by 36 weeks. The reduction in fundal height that usually occurs between the 38th and 40th weeks is called lightening and results from the descent of the fetus into the pelvis, or ''dropping.'' Figure 23-12 illustrates the approximate size of the uterus by weeks.

Auscultate the fetal heart and determine the fetal heart rate (FHR), and note its location. Throughout pregnancy, the FHR is approximately 120 to 160 beats per minute. From weeks 12 to 18, the FHR is usually detected in the midline of the mother's lower abdomen. After 30 weeks, the FHR is best heard over the fetal chest or back. Knowing the location of the fetal back is helpful in determining where to listen for the FHR.

Genitalia

Inspect the mother's external genitalia. Are any lesions present? Inspect the anus. Are varicos-ities present?

With gloves on, perform a speculum examination as described in Chapter 19, Female Genitalia. Inspect the cervix. A dusky blue color is characteristic of pregnancy and occurs by weeks 6 to 8. Is the cervix dilated? If so, fetal membranes may be seen within. Note the character of the vaginal secretions. Obtain cytologic studies for a Pap test and a swab for Chlamydia organisms and gonorrhea. As the speculum is removed, inspect the vaginal walls. The vaginal walls are commonly violaceous in pregnancy. Withdraw the speculum carefully.

Perform a digital bimanual examination, paying special attention to the consistency, length, and dilation of the cervix; the fetal presenting part (in advanced pregnancy); the structure of the pelvis; and any abnormalities of the vagina and perineum. Is the cervix closed? A nulliparous cervix should be closed, whereas a multiparous cervix may allow the tip of a finger through the external os. Estimate the length of the cervix by palpating the lateral side of the cervix from the cervical tip to the lateral fornix. Only at term should the cervix shorten, or efface. The normal length of the palpable (vaginal) portion of the cervix is 1.5 to 2 cm.

Palpate the uterus for size, consistency, and position. An early sign of pregnancy, at about 6 to 12 weeks, is the softening of the entire isthmus of the cervix; this is known as Hegar's sign. During the bimanual examination of the uterus, the examiner will notice an extreme softening of the lower uterine segment. This produces a sensation of the close proximity of the fingers of the hand in the vagina (internal) and that in the abdomen (external). The technique for evaluating the presence of Hegar's sign is illustrated in Figure 23-13. Bimanual palpation of the uterus is useful up to about 12 to 14 weeks' pregnancy. After that, the uterus can be palpated abdominally. Fetal parts are usually palpated from about 26 to 28 weeks' gestation by abdominal examination (described later).

Palpate the adnexa. Early in pregnancy, the corpus luteum may be palpable as a cystic mass on one ovary. As you withdraw your hand from the vagina, evaluate the pelvic muscles.

A rectovaginal examination is not indicated unless the woman has a retroverted, retroflexed uterus and needed information cannot be obtained by other means.

Extremities

Inspect for varicosities. Is edema present?

This completes the routine initial examination.

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