Clinical Methods in Obstetrics & Gynecology Manju Puri
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1OBSTETRICS2
  • ○ Approach to a Pregnant Woman Attending Antenatal Clinic
  • ○ Approach to a Pregnant Woman Presenting with Bleeding Per Vaginam
  • ○ Approach to a Pregnant Woman Presenting with Abdominal Pain
  • ○ Approach to a Pregnant Woman Presenting with Discharge Per Vaginam
  • ○ Approach to a Pregnant Woman Presenting with Vomiting
  • ○ Approach to a Pregnant Woman Presenting with Diarrhea
  • ○ Approach to a Pregnant Woman Presenting with Fever
  • ○ Approach to a Pregnant Woman Presenting with Headache
  • ○ Approach to a Pregnant or Puerperal Woman Presenting with Convulsions
  • ○ Approach to a Pregnant Woman Presenting with Heart Disease
  • ○ Approach to a Pregnant Women Presenting with Pruritus
  • ○ Approach to a Pregnant Woman Presenting with Breathlessness
  • ○ Approach to a Pregnant Woman Presenting with Pallor
  • ○ Approach to a Pregnant Woman Presenting with Jaundice
  • ○ Approach to a Pregnant Woman Presenting with Swelling Feet
  • ○ Approach to a Pregnant Woman Presenting with Hypertension
  • ○ Approach to a Pregnant Woman with Fundal Height Not Corresponding to Period of Gestation
  • ○ Approach to a Pregnant Woman ‘Not Sure of Dates’
  • ○ Approach to a Pregnant Woman Presenting with Bad Obstetric History
  • ○ Approach to a Pregnant Woman with a Congenitally Malformed Fetus
  • ○ Approach to a Primigravida with Free Head at Term
  • ○ Approach to a Pregnant Woman with Trauma
  • ○ Approach to a Pregnant Woman Brought in an Unconscious State
  • ○ Approach to a Pregnant Woman with Previous Cesarean Section
  • ○ Approach to a Postnatal Woman
  • ○ Approach to a Woman with Specific Problems in Puerperium
  • ○ Approach to a Woman Presenting with Lower Abdominal Pain in Puerperium
  • ○ Approach to a Woman Presenting with Urinary Complaints in Puerperium
  • ○ Approach to a Woman Presenting with Postpartum Bowel Complaints
  • ○ Approach to a Woman with Abnormal Behavior in Puerperium

Approach to a Pregnant Woman Attending Antenatal ClinicCHAPTER 1

Richa Aggarwal*,
Pooja Dwivedi
 
INTRODUCTION
The objective of antenatal care (ANC) is to ensure a normal pregnancy culminating in the delivery of a healthy baby from a healthy mother. Every pregnant woman should make a minimum of four visits for antenatal checkup.1 The first visit should take place as soon as she misses her periods, preferably not later than the second missed period. However, even if a woman presents late in pregnancy she should be registered and given care according to the gestational age. The second visit should be scheduled between the 4th and 6th month or 26 weeks, third in the 8th month or 32 weeks and fourth in the 9th month or 36 weeks of pregnancy.1 Early registration is required to help the woman recall the date of her last menstrual period (LMP) and calculate expected date of delivery (EDOD), help the woman to undergo an early safe abortion if she is not keen to continue with pregnancy, assess the status of health of mother, record baseline blood pressure (BP)and weight, screen for any complications and provide appropriate management. It helps in building rapport with the pregnant woman and start folic acid supplementation during the first trimester.
 
AIMS OF ANTENATAL CARE
The aims of antenatal care are as described in Box 1.1.
 
VARIOUS TERMS USED INOBSTETRIC PRACTICE
Various terms used while recording obstetric history are given in (Box 1.2).
 
HISTORY TAKING
The aim of history taking is to elicit an accurate account of the symptoms that represent the clinical problem and to set it against the background of the patient's life. The doctor must put the woman at ease and encourage her to talk freely. During the first visit, a detailed history is taken to diagnose pregnancy, to identify any complications in previous pregnancies that may affect the outcome of present pregnancy and to identify any medical or obstetric condition that may affect the present pregnancy. For the purpose of record keeping and reference for the subsequent visits, an antenatal card should be filled up for every registered pregnant woman and she should be asked to carry it with her for all successive visits. Following details should be asked and recorded in the antenatal card.
 
Vital Statistics
 
Name and Address
Name and address is asked to become familiar with the pregnant woman and establish a rapport with her. It also helps to understand how far she stays from the medical facility. This also enables us to trace or contact her in future, if required.
 
Age
Women below 16 years of age or above 35 years are at a higher risk of pregnancy-related complications.
 
Occupation
Knowing occupation helps in interpreting symptoms due to fatigue or occupation hazards and gives a reasonable and realistic antenatal advice to the woman.
 
Period of Gestation
The duration of pregnancy is to be expressed in terms of completed weeks. For calculating the weeks of gestation, counting is started from the first day of last menstrual period. It is important to ensure that the last period was normal as some women have implantation bleeding every month in first trimester, which is usually scanty and the women may consider it as her last menstrual period. If the woman does not remember the exact date of LMP, she can be encouraged to remember some major event or festival around which she had her LMP. If she has undergone any test for confirmation of pregnancy, such as urine pregnancy test or ultrasonography (USG) look at the date, when it was done and what was the calculated period of gestation at that time. This will assist in dating her pregnancy. If she is around 4–5 months pregnant, she is asked for the date of quickening that is feeling the fetal movements for the first time and calculates EDOD. In a primigravida EDOD can be calculated by adding 18 weeks to the date of quickening and 20 weeks in case of multigravida. The EDOD is calculated using 5Naegele's formula in woman with regular 28–30 days menstrual cycles before conception. The formula is EDOD = LMP + 9 months + 7 days.
 
Gravidity and Parity
Primigravida and grand multigravida (those who have had four or more previous pregnancies) are at a higher risk of pregnancy-related complications.
‘Gravida’ and ‘para’ refer to pregnancies and not to babies. A woman, who delivers twins in first pregnancy is still a gravida one and para one. Obstetric history is usually summarized as gravida, para, abortion, and live issues (GPAL). Some clinicians summarize past obstetric history by two digits, first one relates to viable births and second one relates to abortions connected with a plus sign affixing the letter ‘P’, e.g. P2 + 1 denotes that the woman has had two viable births and one abortion. In some centers it is expressed by four digits, e.g. PA + B + C + D, where A denotes number of term (37–42 week) pregnancies, B refers to the number of preterm (28 to < 37 week) pregnancies, C refers to the number of abortions (< 28 week) and D refers to the number of living children, e.g. P2 + 3 + 1 + 4 that refers to 2 term pregnancies, 3 preterm pregnancies, 1 abortion and 4 living children.
 
Complaints
Any complaint such as abdominal pain, bleeding or leaking per vaginam should be noted with its mode of onset, duration, progress, severity, associations and treatment received. If there is no specific complaint, enquire about bladder and bowel habits, sleep and appetite.
 
History of Present Pregnancy
The important symptoms that must be asked in each of the three trimesters are as follows.
 
First Trimester
It is important to find out whether pregnancy is planned or not? Whether it is spontaneous or after ovulation induction? Whether it was confirmed with urine pregnancy test or USG, if yes when? The reports should be reviewed to check for the correctness of dating of pregnancy. Any exposure to irradiation should be noted. History of any bleeding per vaginam, excessive nausea or vomiting, or fever with or without rash is important. Any history of drug intake including folic acid intake should be elicited.
 
Second Trimester
History of quickening, tetanus toxoid (TT) immunization, iron and calcium supplements, antenatal checkup and USG should be elicited.
 
Third Trimester
Symptoms suggestive of preeclampsia; headache, epigastric pain, blurring of vision, rapid gain of weight, swelling feet and anemia; easy fatigability, breathlessness, palpitations, generalized swelling, passage of worms in stools should be asked for. Any symptoms suggestive of urinary tract infection; burning micturition, abdominal pain, increased frequency of micturition and any history of watery or foul-smelling discharge per vaginam, or any bleeding per vaginam is asked for. It is also important to find out if the woman is perceiving fetal movements.
 
Menstrual History
Age of menarche, duration and amount of blood flow, length and cyclical pattern of the menstrual cycles should be recorded. The date of the LMP must be noted and EDOD should be calculated accordingly using the Naegele's formula. In case the menstrual cycles are irregular EDOD has to be corrected with the help of first trimester USG.6
 
Obstetric History
Obstetric history is relevant in multigravidae. It starts with enquiring how long the woman has been married and cohabiting followed by the details of her previous pregnancies including the antenatal, intranatal, postnatal periods and the outcome of each pregnancy. Woman is asked about any complications in the previous pregnancy such as abortion, preterm birth, stillbirth, neonatal death, hypertensive disorder of pregnancy, convulsions, malpresentation, antepartum or postpartum hemorrhage, prolonged labor obstructed labor, instrumental delivery, cesarean section, anti-D administration in case of Rh-negative woman, as they may recur during the present pregnancy. The previous obstetric events are recorded chronologically as per the format given in Table 1.1. Details of the baby such as sex, birth weight, Apgar score, duration of breastfeeding, immunization status, milestones and present condition of the child must be recorded.
 
Clinical Significance of Takinga Detailed Obstetric History
Table 1.1   Format for recording obstetric history (e.g. a multigravida with obstetric formula G4 P2 L2 A1)
Date and year
Pregnancy events
Labor events
Puerperium
Family planning
Outcome of the baby
Antenatal period
Intranatal period/abortion events
Postnatal/Postabortal period
Contraception
Sex, birth weight, Apgar score, duration of breastfeeding, immunization status, present condition
June 2006
Spontaneous abortion, 2 month gestation, confirmed by urine pregnancy test
Check curettage done at private nursing home
Uneventful
None
December 2007
Regular antenatal checkup, uneventful antenatal period
Uneventful
Spontaneous term
Normal vaginal delivery with episiotomy at private hospital
Uneventful
Barrier contraceptive condoms
2.6 kg, girl, cried at birth, breastfed till 1 year, immunized, attained normal milestones, alive and healthy
March 2010
Regular antenatal checkup, had preterm premature rupture of membranes (PPROM) at 32 week
Spontaneous preterm vaginal delivery at 33 week at private hospital
Uneventful
None
1.2 kg, boy, cried after resuscitation, kept in nursery for 5 day, breastfed for 15 month, immunized, attained normal milestones, alive and healthy7
History of prolonged labor, obstructed labor, difficult or instrumental vaginal delivery, birth of an asphyxiated baby, neonatal convulsions or birth of a baby with cerebral palsy points toward likely presence of cephalopelvic disproportion, contracted pelvis or other causes of mechanical dystocia in that pregnancy. History of previous cesarean delivery for a recurrent indication would require repeat cesarean section. An abnormal presentation like breech or transverse lie in previous pregnancy may be due to contracted pelvis or uterine anomaly. History of repeated midtrimester abortions or premature births may be due to incompetent cervical os. History of previous child being born with congenital abnormalities requires further investigations in current pregnancy, because of the possibility of recurrence. An unimmunized Rh-negative woman, who gives birth to a Rh-positive baby is likely to have her baby affected in next pregnancy and requires further investigations and intervention. History of previous stillbirth or big baby or hydramnios may suggest maternal diabetes.
 
Past Medical History
Ask for any history of systemic illness such as hypertension, diabetes mellitus, jaundice, tuberculosis, asthma, heart disease, renal disease, seizures and blood transfusion. One can ask the woman if she has had any prolonged illness, treatment or hospitalization in past. Pre-existing medical disorders can worsen during pregnancy or influence the obstetric outcome necessitating a joint management by a physician and obstetrician. It is important to find out if the woman has any history of drug allergy or if she is on any drug that might harm the fetus.
 
Past Surgical History
Past history of surgery on bowel or appendix may cause intra-abdominal adhesions. Previous surgeries such as classical cesa­rean, metroplasty and myomectomy can cause adhesions. If the uterine cavity is opened during myomectomy or she has had a classical cesarean section there is an increase in the risk for uterine rupture in subsequent pregnancy or labor and is an indication for elective cesarean delivery. The surgical notes of the previous surgery should be reviewed.
 
Family History
Family history of hypertension or diabetes is important as it increases the risk of these during pregnancy. Any history of hereditary diseases such as thalassemia or whether any family member has received repeated blood transfusions should be elicited. Family history of multiple pregnancy or congenitally malformed child is important as it increases the chances of same in the pregnant woman.
 
Personal History
Contraceptive practice prior to pregnancy must be enquired as use of oral pills may delay ovulation and the period of gestation and EDOD may be wrongly estimated by Naegele's rule. Ask for history of tobacco chewing, smoking or alcohol consumption as they harm the fetus and have been shown to cause intrauterine growth restriction (IUGR).
 
Socioeconomic History
Ask the woman about her education, occupation, husband's occupation, per capita income and assess her socioeconomic status as prematurity, low birth weight and anemia have been related to low-socioeconomic status and gestational diabetes mellitus and obesity with high-socioeconomic status.
 
Dietary History
A simple evaluation of diet is valuable in all patients especially in women with anemia, diabetes mellitus, IUGR and those who are malnourished. Daily total caloric and protein intake can be estimated by 24 hours recall method. It is important to corroborate the dietary history with the nutritional status8of the woman. The dietary history and the nutritional status of the woman should corroborate well. In a woman, who is well nourished, if the diet is significantly deficient in calories and proteins, the dietary history is likely to be inaccurate and needs to be elicited again.
 
CLINICAL EXAMINATION
A good physical examination requires a cooperative patient, a quiet, warm and well-lit room. Daylight is better than artificial light, which may mask changes in skin color. The woman should be reassured and be relaxed. The examination must be carried out as gently as possible. The woman is not exposed more than necessary.
 
General Physical Examination
The examination process is started the moment woman enters the room by observ­ing her appearance, gait, demeanor and responsiveness. A note is made of the following points.
 
Built
Whether she is obese, overweight or thin built.
 
Nutrition
Whether her nutrition is good, average or poor. We look for any evidence of nutritional deficiency like cheilosis, glossitis, etc.
 
Height
Short stature with height of less than 145 cm or 4’10” in India is likely to be associated with a small pelvis.2
 
Weight
The weight must be measured at each visit on the same weighing machine. The baseline weight would be the weight taken during the first visit in first trimester and body mass index (BMI) can be calculated with this weight if prepregnant weight is not known. BMI calculated later in pregnancy with the woman's weight at that time is not correct as the weight of the fetus and uterine contents add on to the maternal weight. Average weight gain during pregnancy is around 9–11 kg. After the first trimester, weight gain is around 2 kg every month or 0.5 kg per week. Rapid weight gain of more than 3 kg per month arouses the suspicion of preeclampsia or multiple pregnancies. A low-weight gain is suggestive of IUGR.
 
Pallor
Look at the color of the lower palpebral conjunctiva (Figs 1.1A and B), tongue (Figs 1.2A and B), lips, oral mucosa, nails and palmar creases (Figs 1.3A and B) for the color and presence of pallor, which is indicative of anemia.
 
Jaundice
Look for any yellowness of the bulbar conjunctiva, undersurface of the tongue, hard palate and skin.
 
Oral Cavity
Examine the tongue, teeth, gums and tonsils. Presence of glossitis and stomatitis suggests malnutrition. Patients with poor oral hygiene, gingivitis or dental caries should be referred to a dentist to minimize the risk of autoinfection.
9
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Figures 1.1A and B: Inspection of conjunctiva for anemia. A. Normal conjunctival color; B. Women with conjunctival pallor.
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Figures 1.2A and B: Inspection of tongue for anemia. A. Tongue with normal color; B. Pale tongue.
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Figures 1.3A and B: Examination of nails for anemia. A. Pale nails; B. Normal nails.
 
Hair
Look at the hair texture; poor texture and brittle hair may be due to malnutrition.
 
Neck
Neck veins, thyroid gland and lymph nodes are looked for any abnormality. Examine the neck veins of the patient in good light. The woman is reclined at an angle of about 45° with neck supported, so as to relax the neck muscles, especially the sternocleidomastoids. The vertical distance from the angle of Louis (sternal angle) to the imaginary line drawn from the upper end of jugular venous column gives jugular venous pressure (JVP), which is measured in centimeters. When JVP is raised 3 cm above the sternal angle or internal jugular vein is engorged above the level of clavicle it is abnormal and suggestive of congestive heart failure (CHF), pericardial effusion, constrictive pericarditis or any mediastinal mass.
Significant thyroid enlargement is usually evident on inspection. Thyroid gland always moves on swallowing. Normal thyroid gland may be palpable in thin patients. Palpation of the thyroid gland is best carried out from behind the patient with the fingers encircling the neck; the landmarks for palpation are the laryngeal cartilage, just below which are the cricoid cartilage and the isthmus of thyroid. If palpable, note whether the enlargement is diffuse and smooth or nodular.
10
 
Lymph Nodes
Examine for occipital, submandibular, cervical, supraclavicular, axillary, epitrochlear, inguinal, femoral and popliteal groups of lymph nodes. If palpable, note the number, location, size, consistency, mobility, confluence, warmth, tenderness and whether discrete or matted.
 
Pedal Edema
Patient is examined for pitting edema over the medial malleolus and anterior surface of lower one third of tibia that is shin. The area is pressed with thumb at least for 5 seconds to note whether the edema is pitting or not (Fig. 1.4). Edema in pregnancy
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Figure 1.4: Examination of pedal edema in pregnant woman
can be physiological or pathological. Physiological edema is due to the pressure of the gravid uterus on the common iliac vessels and pathological as a manifestation of disorders such as preeclampsia, anemia, hypoproteinemia, cardiac disease or renal disease.
 
Varicosities
Note the presence of varicose veins and their distribution. Pregnancy tends to worsen them.
 
Temperature
The thermometer must be accurate and kept in position for a full minute. The temperature is usually taken in the mouth or in the axilla. The temperature of the mouth and rectum is generally at least half a degree higher than that of the axilla or groin.
 
Pulse
The presence or absence of the main peripheral arterial pulses should be noted. These include radial, brachial, carotid, femoral, popliteal, posterior tibial and dorsalis pedis. The volume of each pulse is compared with that of the other side. The arterial pulses are detected by gently compressing the vessel against some firm underlying structure, usually bone. The radial pulse is felt with the tips of the fingers by compressing the radial artery against the head of the radius with patients’ forearm slightly pronated and wrist slightly flexed (Fig. 1.5). Note the rate, rhythm, character and volume of the pulse and also for presence or absence of any radiofemoral delay.
 
Blood Pressure
The BP is measured at every visit. The BP should be measured with the patient sitting or lying laterally at ease with the manometer placed at the same level as the cuff on the patient's arm and the observer's eye (Fig. 1.6).11All clothing should be removed from the arm. The cuff should be applied to the upper arm with the lower border of the cuff more than 2.5 cm from the cubital fossa. The cuff should be of appropriate size that is 12.5–13 cm in width and 35 cm in length for an average adult. The first appearance of repetitive sounds or Korotkoff first sound is taken as the systolic pressure. Disappearance of sounds that is Korotkoff fifth rather than muffling of sounds or Korotkoff fourth sound are taken for measurement of diastolic pressure during pregnancy.
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Figure 1.5: Recording pulse rate
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Figure 1.6: Blood pressure measurement
 
Breast Examination
Examination of the breasts is essential not only to note the changes of pregnancy but also to detect any abnormality, which can be timely corrected for successful breastfeeding. With the patient reclining, arms to the sides, inspect the shape and symmetry of breasts and nipples. Look for any reddening, ulceration or dimpling of the skin, retraction or cracking of the nipples, any discharge. Palpate each breast with the flat part of the fingers of both hands for any lump and if found, determine its situation, size, surface, edge, consistency and mobility in relation to deep and superficial structures.
 
Respiratory System
Note the respiratory rate and inspect the exposed chest for its shape, symmetry and movements. Palpate the chest for any swelling, tenderness, position of trachea and cardiac impulse. Percuss the chest and note its resonance to detect any area of dullness. Auscultate the chest for the intensity or loudness and quality of breath sounds, that is vesicular or bronchial, and presence of any adventitious sounds such as pleural rub, rhonchi or crepitations. In a normal woman, bilateral vesicular breathing with no added sounds is heard all over the chest.
 
Cardiovascular System
Inspect the chest for any bulge, pulsations, dilated veins and cardiac impulse. Locate the apex beat with the patient sitting or lying straight. Assess whether it is visible or not (look on both sides), its site whether shifted up, down, outwards, inwards or on right side, and character whether normal, feeble, tapping, heaving and hyperkinetic. Apex beat is shifted to fourth intercostal space 2.5 cm outside the midclavicular line in pregnancy. Palpate for any thrill and note its site and timing.12Thrill is associated with a murmur of grade IV or higher. Functional murmurs are never associated with a thrill. Auscultate the mitral, tricuspid, aortic and pulmonary areas, and look for intensity of heart sounds, splitting whether fixed or variable, third and fourth heart sounds, opening snap and additional sounds like ejection systolic clicks, and murmurs. If murmur is present, evaluate its site of maximum intensity, grade, timing, character, quality and radiation.
 
Abdominal Examination
Before inspecting the abdomen, make sure that the light is good, the room comfortably warm and there is adequate exposure. The patient should pass urine and comfortably lie in the supine position with the thighs slightly flexed and abducted, so as to relax the abdominal muscles. The examiner stands on the right side of the patient. Ask about any tender areas before palpating the abdomen, so that palpation can be started from the non-tender areas. Comfort and gentleness can be enhanced by using the flat of the hand as well as the examining fingers.
 
Inspection
Note the uterine ovoid whether longitudinal, transverse or oblique; contour of the uterus whether the fundus is convex or flattened or notched; shape of the uterus whether spherical or cylindrical; any undue enlargement of the uterus; any dilated veins, striae gravidarum, linea nigra or scar marks of previous cesarean or laparotomy; any evidence of ringworm or scabies infection and any visible fetal movements or peristalsis.
 
Palpation
Palpate for the presence of any uterine contractions, uterine tone, any tenderness and fetal movements.
 
Fundal Height
Uterus remains a pelvic organ until 12th week of gestation and hence is usually not palpable in the first trimester. The ulnar border of the left hand is placed on the uppermost level of the fundus and an approximate duration of pregnancy is ascertained in terms of weeks of gestation (Fig. 1.7). In later half of pregnancy the uterus is centralized if it is deviated on one side for assessing the fundal height. The assessment of fundal height is as given in Table 1.2.
Table 1.2   Estimation of fundal height in weeks
Weeks
Features
12 week
Uterus is just palpable
16 week
Fundus is equidistant from the symphysis pubis and the umbilicus
24 week
Uterus reaches just above the level of umbilicus
30 week
Uterus is equidistant from the xiphisternum and umbilicus
36 week
Uterus reaches up to the level of xiphisternum
40 week
Height is equivalent to 32–34 week, but flanks are full
Alternatively, symphysis-fundal height (SFH) can be measured with a tape more accurately. The upper border of the fundus is located by the ulnar border of the left hand and is marked after correcting the dextrorotation of the uterus. The distance between the upper border of the symphysis
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Fig. 1.7: Assessment of fundal height
13pubis up to the marked point is measured by a tape in centimeters (Figs 1.8A and B). After 24 weeks, SFH measured in centimeters corresponds to the number of weeks till 36 weeks, in a singleton pregnancy with longitudinal lie in a non-obese woman and with empty bladder. A variation of ± 2 cm is accepted as normal. Variation, beyond the normal range needs further evaluation.
The causes of fundal height being more than or less than the period of gestation are listed in Table 1.3.
 
Abdominal Girth
Abdominal girth is measured in inches by a tape at the level of the umbilicus (Fig. 1.9). Abdominal girth in inches corresponds to the period of gestation after 28 weeks and increases at the rate of 1 inch per week. At 40 weeks, the abdominal girth is 40” or 100 cm. It is better to record uterine girth in inches and height in cm. Abdominal girth is more than the period of gestation in women with wrong dates, central obesity, transverse lie, multiple pregnancy and hydramnios.
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Figures 1.8A and B: Measurement of symphysis-fundal height. A. Marking the fundal height; B. Measurement of distance in centimeters between the fundus and the pubic symphysis.
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Figure 1.9: Measuring abdominal girth
Table 1.3   Causes of fundal height not corresponding to the period of gestation
Fundal height more than the period of gestation
Fundal height less than the period of gestation
Wrong date of LMP*
Wrong date of LMP
Full bladder
Missed abortion
Hydatidiform mole
IUGR
Multiple pregnancy
Intrauterine death
Polyhydramnios
Oligohydramnios
Pregnancy with pelvic mass
Transverse lie
Concealed accidental hemorrhage
Big baby
*LMP, last menstrual period; IUGR, intrauterine growth restriction.
 
Obstetric Grips
Palpation must be conducted with utmost gentleness as clumsy and purposeless palpation is not only uninformative, but may stimulate uterine contractions with resultant difficulty in getting satisfactory information. Palpation should be temporarily14suspended in the presence of Braxton Hicks contraction or uterine contraction in a laboring woman and resumed after the contraction passes off. Abdominal examination is done using four maneuvers described by Leopold in 1894.3 It may be difficult to perform and interpret the maneuvers in the presence of obesity, hydramnios and anterior placenta. The first three maneuvers are done with the examiner facing the woman's face whereas the fourth maneuver is performed with the examiner facing the woman's feet.
 
Leopold's Maneuvers
Leopold's first maneuver or fundal grip
The whole of the fundal area is palpated using both hands laid flat on it to identify the fetal pole occupying the uterine fundus, broad, soft and irregular mass suggestive of breech or hard, globular and ballotable mass suggestive of head (Fig. 1.10). In transverse lie, none of the fetal poles is palpable in fundal area.
Leopold's second maneuver or lateral grip
The hands are placed flat on either side of the umbilicus to palpate the sides and front of the uterus to locate the position of fetal back and limbs (Fig. 1.11). The back is suggested by smooth, curved and resistant feel whereas the limbs feel small, knobby and irregular. By noting whether the back is directed anteriorly, transversely or posteriorly, the orientation and position of the fetus can be made out. To palpate one side, a hand on the other side stabilizes the uterus to facilitate palpation.
Leopold’ third maneuver or superficial pelvic grip or Pawlik's grip
The overstretched thumb and four fingers of the right hand are placed over the lower pole of the uterus keeping the ulnar border of the palm on the upper border of the symphysis pubis (Fig. 1.12). When the fingers and the thumb are approximated, the presenting part is grasped distinctly and side-to-side mobility of the presenting part can be tested. If the presenting part is not engaged, a mobile mass (usually head) will be felt. In transverse lie, this grip is empty. However, findings from this maneuver are simply indicative of the lower fetal pole presenting in the pelvis; the details are defined by the fourth maneuver.
Leopold's fourth maneuveror deep pelvic grip
With the examiner facing the feet of the patient four fingers of both hands are placed on either side of the midline in the lower pole of the uterus and parallel to the inguinal ligament. The fingers are pressed downwards and backwards in a manner of approximation of finger tips to palpate the part occupying the lower pole of the uterus (Fig. 1.13).
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Figure 1.10: Leopold's first maneuver
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Figure 1.11: Leopold's second maneuver
15
The presenting part, attitude and engagement in case of cephalic presentation can be commented on fourth maneuver. In vertex presentation, the cephalic prominence on the side of the back is the occiput and that on the side of limbs is the sinciput. The attitude of the head is inferred by noting the relative position of the sinciput and occiput. In well-flexed head, the sincipital pole is placed at a higher level, but in deflexed head, both the poles are at a same level. The engagement is ascertained noting the presence or absence of the sincipital and occipital prominences or whether there is convergence or divergence of the fingertips during palpation. Divergence of the fingers indicates engaged head and convergence of the fingers indicates an unengaged head. This pelvic grip gives maximum information.
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Figure 1.12: Leopold's third maneuver
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Figure 1.13: Leopold's fourth maneuver
The amount of liquor is assessed by palpating in between the limbs. The fetal weight can be estimated either by clinical experience or by using Johnson's formula in cephalic presentation. Johnson's formula is estimated fetal weight in gram = symphysis-fundal height in centimeters − 12 (if head is not engaged) or 11 (if head is engaged) × 155. Abdomen is then palpated gently to rule out any organomegaly. This is possible only in first half of pregnancy, when the uterus is small. Abdominal assessment of descent of the fetal head is done using ‘fifths’ or Crichton's.4 It is especially useful while monitoring labor to assess progressive descent of head. Progress of labor is assessed by descent of head, rotation of the anterior shoulder toward midline and change in position of the fetal heart sound (FHS) downwards and medially. Crichton used ‘fifth’ formula by estimating the number of ‘fifths’ of the head palpable above the pelvic brim.4 The amount of head felt suprapubically in finger breadths is assessed by placing the radial margin of the index finger above the symphysis pubis successively until the groove of the neck is reached. When one fifth above, only the sinciput can be felt abdominally and when no fifth is felt, it represents a head entirely in the pelvis with no poles felt abdominally (Figs 1.14A and B).
 
Auscultation
Auscultation of distinct FHS helps in not only diagnosing a live baby but also indicates the presentation of the fetus and descent of presenting part (Fig. 1.15). The fetal heart sounds can be heard after 24 weeks and are best audible through the back in vertex and breech presentation and through the fetal chest in face presentation. The maximum intensity of FHS is below the umbilicus in cephalic presentation and around the umbilicus in breech.
16
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Figures 1.14A and B: Assessment of descent of fetal head
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Figure 1.15: Auscultation of fetal heart sounds
In different positions of the vertex, the location of the FHS depends on the position of the back and the degree of the descent of the head. In the occipitoanterior position, the FHS is located in the middle of the spinoumbilical line of the same side. In occipitolateral position, it is heard more laterally and in occipitoposterior position, it is heard toward the mother's flank on the same side. The rate and rhythm of the FHS is noted. The normal fetal heart rate range between 110 and 160 beats per minute.
 
Vaginal Examination
 
First Trimester
Vaginal examination is performed under all asepsis before 12 weeks to confirm the diagnosis of pregnancy; corroborate the size of uterus with the period of amenorrhea and rule out any adnexal pathology like ectopic pregnancy or ovarian cysts. It is avoided in cases of recurrent abortions, bleeding in current pregnancy or when the patient is unwilling. These days ultrasound examina­­tion has replaced routine internal examination as it is more informative in confirming the pregnancy, its viability and gestational age. However, one vaginal examination including per speculum examination and Pap smear is a good practice in women, who have not been examined anytime in the past.
Steps of vaginal examination: As the examination proceeds it is important to explain every step to the patient. The patient is asked to empty her bladder prior to examination and lie in dorsal position with legs flexed at hips and knees, and buttocks at the edge of the table. Before conducting the examination, the hands should be washed with soap and sterile gloves are worn.
Inspection
Look for any redness, swelling or ulceration of the vulva, perineum or anus. Separate the labia using left thumb and index finger, and note the character of vaginal discharge, if any. Presence of cystocele, rectocele or uterine prolapse is noted.
Speculum examination
The speculum should be warmed to body temperature and lubricated with a water-based jelly. Vulva is cleaned with Savlon swabs, cleaning it from above downwards17and discarding the swab. Cervix and vagina are examined with the help of good light source. Bluish discoloration of vagina and cervix is seen due to increased vascularity in pregnancy. Cervical smear for exfoliative cytology is collected and a vaginal swab for culture sensitivity and a wet smear is prepared in the presence of abnormal discharge.
Bimanual examination
The examining fingers are lubricated with a water-based jelly and labia are gently parted with the index finger and thumb of the left hand, while index and middle fingers of right hand are introduced deep into the vagina. The left hand is now placed suprapubically, this provides gentle pressure to bring the pelvic viscera toward the vaginal fingers and serves to assess the size, mobility and regularity of abdominopelvic masses in a bimanual manner. Gentle and systematic examination is done to feel the cervix for its direction, consistency and any growth; uterus for its size, shape, position, consistency and regularity; adnexae for any enlargement, mass or tenderness. In pregnancy, the vaginal walls become soft and increased pulsations are felt through the lateral fornices. The pregnant cervix feels as soft as lips of the mouth compared to the feel of the tip of the nose in a non-pregnant uterus. The pregnant uterus also feels soft and enlarged depending on the period of amenorrhea. The size of a pregnant uterus corresponds to the size of a cricket ball at 8 weeks gestation and fetal head size at 12 weeks gestation.
 
Third Trimester
Per vaginal examination is indicated at term for assessment of the adequacy of pelvis. It is best done near the EDOD or at the onset of labor or before induction of labor. During labor, a digital vaginal examination is done to determine consistency and position of cervix, its effacement and dilation, the station and position of presenting part, presence or absence of amniotic membranes, degree of molding of the head, presence of caput succedaneum and shape, size and adequacy of pelvis. Any history of vaginal bleeding contraindicates vaginal examination. In a woman, who has to undergo induction of labor, the cervix is assessed for its favorability for induction of labor. The various cervical and pelvic parameters are described collectively as Bishop's score (Table 1.4). The decision regarding method of induction is decided depending upon the Bishop's score.
Table 1.4   Modified Bishop's score
Score
0
1
2
3
Cervical position
Posterior
Central
Anterior
Cervical consistency
Firm
Medium
Soft
Cervical length (cm)
> 4
3–4
1–2
< 1
Cervical dilation (cm)
0
1–2
3–4
> 4
Station in relation to spine (cm)
3
2
1 to 0
Below spines
The total score is 13, a score between 6 and 13 is favorable and any score of < 6 is unfavorable.
Assessment of pelvis: Clinical pelvimetry is usually performed at term in primigravida and in labor in multiparas. Delaying the assessment is useful due to progressive softening of the tissues. The patient is asked to empty her bladder and lie in dorsal position with legs flexed at knees and hips, and buttocks at the edge of the table. The pelvic examination is done taking all aseptic precautions. The internal examination should be gentle, methodical and purposeful. The sterilized gloved fingers once taken out should not be reinserted.
The features to be noted during examination are as listed in Table 1.5.
Table 1.5   Features to be noted in pelvic assessment
Inlet
Cavity
Outlet
Sacral promontory
Sacral curve
Subpubic angle
Diagonal conjugate
Side walls
Subpubic arch
Posterior surface of symphysis pubis
Ischial spines
Transverse diameter of outlet (TDO)
Sacrosciatic notch
Sacrococcygeal joint
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Sacrum: Using two fingers of right hand the length, breadth and curvature of sacrum from above down and side to side is noted. Normally, it is smooth, well curved and usually inaccessible beyond lower three pieces. Any forward prominence of the sacrum is noted.
Sacrococcygeal joint: Its mobility and any forward projection of coccyx are noted.
Sacrosciatic notch: It is sufficiently wide to accommodate two fingers placed over the sacrospinous ligament covering the notch. Its configuration denotes the capacity of the posterior segment of the pelvis and the side walls of the lower pelvis.
Ischial spines: They are usually smooth, everted and difficult to palpate simultaneously with maximally stretched index and middle fingers of pronated right hand. They may be prominent and encroach on to the cavity, thereby reducing the available space in the midpelvis (Fig. 1.16).
Iliopectineal lines: To note any beaking suggestive of narrow fore pelvis (android pelvis).
Side walls: Normally they are not easily palpable unless convergent.
Posterior surface of the symphysis pubis: It forms a smooth rounded curve normally and any angulation or beaking suggests abnormality.
Subpubic arch: It is rounded and accommodates the palmar aspect of two fingers in a normal pelvis (Fig. 1.17).
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Figure 1.16: Assessment of interischial diameter
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Figure 1.17: Assessment of subpubic arch
Diagonal conjugate: The fingers are to follow the anterior sacral curvature. In normal pelvis, it is difficult to feel the sacral promontory or at best can be felt with difficulty. In order to reach the promontory, the elbow and the wrist are to be depressed sufficiently while the fingers are mobilized upwards. The point at which the bone recedes from the fingers is the sacral promontory. The fingers are then mobilized toward the symphysis pubis and a marking is placed over the gloved index finger. The distance between the marking and the tip of the middle finger gives the measurement of diagonal conjugate (Fig. 1.18). If the middle finger fails to reach the promontory or touches it with difficulty, it is likely that the conjugate is adequate for passage of an average size fetal head. Every obstetrician should know the distance between his/her tip of middle finger to the base of thumb and widely separated index and middle fingers of pronated dominant hand usually right.
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Transverse diameter of the outlet: It is measured by placing the knuckles of first interphalangeal joints or knuckles of the clinched fist between the ischial tuberosities. Normally, four knuckles can be easily placed in a normal pelvis (Fig. 1.19).
Pubic angle: The inferior pubic rami are defined on both sides and the angle roughly corresponds to the fully abducted thumb and index fingers. The angle is narrow in contracted pelvis.
 
INVESTIGATIONS
Most of the investigations are carried out in a pregnant woman during her first antenatal visit however there are others, which are gestation dependent.
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Figure 1.18: Measuring diagonal conjugate
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Figure 1.19: Assessment of transverse diameter of outlet
At the first visit, investigations to be ordered are hemoglobin (Hb), ABO and Rh typing, Venereal Disease Research Laboratory (VDRL) test, human immunodeficiency virus (HIV) testing, hepatitis B surface antigen (HBsAg) and urine routine and microscopic examination. Hemoglobin level of more than 11 g/dL in first and third trimesters and more than 10.5 g/dL during the second trimester is considered normal in pregnancy.5 Pregnant women with hemoglobin levels below this are diagnosed as anemia.
Given the increasing incidence of diabetes mellitus globally and pregnancy being a diabetogenic state, International Association of Diabetes in Pregnancy Study Group has proposed first trimester screening of pregnant women by offering hemoglobin (HbA1c) levels or a fasting or random blood sugar levels. In women presenting late, a 75 g oral glucose tolerance test (OGTT) may be carried out.
At subsequent visits hemoglobin estimation at 28 and 36 weeks, urine for albumin and sugar at each visit, screening for gestational diabetes by glucose challenge test (GCT) or 75 g OGTT at 24–28 weeks and an ultrasound examination to rule out congenital anomalies between 18 and 20 weeks is indicated.
 
Special Investigations
Special investigations are indicated in woman, who are at a high risk of certain disorders such as toxoplasmosis, other infection, rubella, cytomegalovirus, herpes simplex virus (TORCH) infections, thyroid disorders, thalassemia, Down syndrome, etc.
 
Screening for Thyroid Disorders
Considering the high incidence of maternal and perinatal morbidity, impaired neurological development of the offspring in pregnant woman with thyroid disorders, selective screening by offering serum thyroid-stimulating hormone (TSH) is recommended in high-risk group (Box 1.3).
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Screening for Thalassemia
The importance of recognizing thalassemia lies in the fact that the prenatal diagnosis and timely intervention can prevent birth of babies with thalassemia major and save the families of mental, emotional and financial distress. Screening may be offered to those at higher risk due to their ethnic origin such as Sindhi and Punjabi populations or those with a family history of thalassemia or repeated blood transfusions. Red blood cell (RBC) indices mean corpuscular volume (MCV) < 75 femtoliters and mean corpuscular hemoglobin (MCH) < 27 picograms and naked eye single tube red cell osmotic fragility test (NESTROFT) are simple screening tests. Further confirmation can be done by HbA2 estimation by high-performance liquid chromatography (HPLC) or Hb electrophoresis. If the mother is carrying thalassemia trait, husband should be screened and if the husband tests positive for the thalassemia trait, prenatal diagnosis is offered to the couple.
 
Screening for TORCH Infections
Routine screening for TORCH infections is not recommended. The indications of maternal TORCH screen during pregnancy are as listed in (Box 1.4).
*TORCH, ‘toxoplasmosis, other infection, rubella, cytomegalovirus, herpes simplex virus 2’
 
Screening for Down Syndrome
Down syndrome is the most common chromosomal abnormality. Every woman is at risk for having an affected baby. In general population the risk of giving birth to an affected baby is 1:800. The risk of having an affected baby increases with the maternal age from 1 in 1,500 at age of 25 years, 1 in 1,000 at age 30, 1 in 417 at 33 years, 1 in 250 at 35 years, 1 in 69 at 40 years and 1 in 19 at 45 years of age.6 As majority of pregnancies occur in women less than 35 years of age almost two thirds of Down syndrome babies are born to mothers less than 35 years of age. The background risk of a woman of carrying a fetus with Down syndrome depends upon her age and any history of chromosomal defects. Although universal screening for Down syndrome is not a part of routine antenatal care, but it should be offered to all pregnant women after pretest counseling. Various methods of screening for Down syndrome are:
• Ultrasound for nuchal translucency (NT) at 10–14 weeks
• Fetal NT and first trimester maternal serum screening [pregnancy-associated plasma protein-A (PAPP-A) and beta-human chorionic gonodotropin (b-HCG)] at 10–14 weeks
  • Second trimester maternal serum biochemical screening:
    • Triple test [b-HCG, maternal serum alpha-fetoprotein (MSAFP) and unconjugated estriol]
    • Quadruple test (triple test plus inhibin A).
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Nuchal translucency is the measurement of the subcutaneous collection of fluid at the back of the fetal neck and is increased in Down syndrome. PAPP-A, MSAFP and unconjugated estriol levels are reduced in Down syndrome, whereas b-HCG and inhibin A levels are raised in Down syndrome. Women are counseled regarding the interpretation of the test and need of further confirmation by diagnostic invasive tests.
 
CONCLUSION
At first visit a detailed history is taken followed by general physical and systemic examination. Vaginal examination may be done if required. Investigations such as Hb, ABO and Rh grouping, VDRL, HIV, HBsAg testing, urine routine analysis and culture are ordered and woman is started on folic acid supplementation.
At subsequent visits any history of any new complaints and perception of fetal movements is elicited. General physical examination including weight, BP, pallor and pedal edema is carried out at each visit. The fundal height and abdominal girth (after 28 week) is measured at each visit. In late pregnancy, besides fundal height the woman is examined for the fetal lie, presentation, amount of liquor and FHS. Pelvic assessment is either carried out after 37 completed weeks in primigravida or at the time of labor.
As regards investigations, Hb estimation at first visit and then at 28 and 36 weeks, urine for glucose and albumin at each visit, GCT or 75 g OGTT at 24–28 weeks, USG to rule out congenital anomalies at 18–20 weeks, screening for Down syndrome at 11–14 weeks is advised.
The woman is prescribed iron and calcium supplements, and prescribed two doses of TT at 4–6 weeks interval.
REFERENCES
  1. Guidelines for pregnancy care and management of common obstetric complications by medical officers. Maternal Health Division, Department of Family Welfare, Ministry of Health and Family Welfare, Government of India; 2005.
  1. WHO. Risk approach for MCH care. WHO offset publication. No. 39.
  1. Leopold J. Conduct of normal births through external examination alone. Arch Gynaecol. 1894;45:337.
  1. Crichton D. A reliable method of establishing the level of fetal head in obstetrics. S Afr Med J. 1974;48:784–7.
  1. Centers for Disease Control (CDC). CDC criteria for anaemia in children and childbearing-aged women. MMWR. 1989;38:400–4.
  1. Cunningham GF, Bloom, Leveno KJ, et al. Prenatal diagnosis and fetal therapy. In: Cunningham GF, Lenevo Gant FN (Eds). Williams Obstetrics, 23rd edition. Mcgraw-Hill  ; 2010. pp. 287-333.