Physical Examination


Physical Examination

The physical examination is performed for all women during the pre-conceptional visit or the first pregnancy visit. The elements of the physical examination include: general appearance and nutrition; blood pressure, pulse, height to weight profile, present weight; head and neck, heart and lungs, breasts, abdomen, pelvic area tenderness, extremities and back, neuromuscular; and pelvic evaluation - speculum and bimanual examination, clinic pelvimetry.

At each follow-up visit, the patient should be given an opportunity to ask questions about her pregnancy or comment on changes that she has noted. The physical exam should include general appearance, nutrition, blood pressure, weight (including pattern of weight gain), uterine size, heart rate of mother and fetus, and cervical check after 40 weeks. The cervical check should include dilatation effacement, fetal presentation, and station. The findings of this exam should be carefully documented and should be assessed during each visit. The patient should be asked about fetal movement at each visit. Urine should be checked to detect protein and glucose. Any change in the pregnancy risk assessment should be recorded after each evaluation and an appropriate management plan outlined. Continual risk assessment should be a standard part of the ante-partum care.

At 24 to 28 weeks gestation an interval history since the last visit should be obtained and should include questions on the general state of health, nutrition, fetal movement and unusual symptoms such as frequent contractions or vaginal bleeding. Continuing assessment is indicated of psycho-social risks, maternal stress or anxiety, and habits to determine significant changes and the need for support or other interventions. The physical examination should include weight as a measure of health for the woman and fetus; blood pressure as a continuing screen for hypertension; and auscultation of fetal heart rate, assessment of fetal activity, and fundal height for growth pattern.

A repeat hematocrit or hemoglobin is indicated during the second and third trimester to help monitor nutritional status and identify anemia. Since the one-hour glucose screen for diabetes is recommended for all women near 26 weeks, both laboratory tests can be done at this time. For Rh-negative women, a repeat Rh titer should be done at this visit and, if unsensitized, RhoGAM should be given. This is the beginning of the third trimester and is 10 weeks after the previous risk assessment. At this time, diagnoses of problems such as toxemia, growth retardation, or abnormal fetal presentation may first be made. The timing also reflects the optimal screening time for pregnancy-induced diabetes and anemia.

At 32 weeks gestation take a pregnancy history since the last visit, maternal general well-being, nutrition, and signs and symptoms of complications (e.g. , bleeding, contractions, or pregnancy-induced hypertension). Psycho-social assessment should include changes in home environment, new environment risks or stresses, adaptation to the pregnancy, and planning for the post-delivery environment. The partial physical examination should include maternal weight; blood pressure as a screen for pregnancy-induced hypertension; and auscultation of fetal heart rate, assessment of fetal activity, and fundal heights for growth pattern. These interim assessments should be a part of every subsequent prenatal visit until labor. Urinalysis for protein is not suggested unless signs or symptoms of possible toxemia are present.

At 36 weeks gestation, the history and physical examination are the same as that set forth for the 32 weeks visit, with increasing emphasis on fetal lie, position, and presentation and on maternal blood pressure. No pelvic examination is indicated except in women at high risk for sexually transmitted disease or if risk of premature labor is suspected. A culture for gonorrhea should be obtained from the former.

At 38 weeks gestation, the interval history should focus on signs and symptoms of labor, fetal activity, and symptoms of pregnancy-induced hypertension. The partial physical examination should include weight, blood pressure, fetal heart rate, fundal height, fetal size estimate, descent, presentation and position.

At 40 weeks gestation, the history and physical are the same as those done during the visit in week 38, with emphasis on screening for pregnancy-induced hypertension and fetal condition, size, descent, and position.

The nulliparous woman is at increased risk for pregnancy-induced hypertension and therefore needs to be followed more closely at the end of pregnancy. Weekly visits are appropriate dependent on clinical status.