Physical Assessment the Pregnant Woman

Happy Barnes, CNM ATM Conference May 2006

Review of Systems ± 1st Trimester 

Nausea Vomiting Headaches Dizziness Cramping Urinary frequency 


Pain with urination Changes in discharge (amount, color, odor) Pruritis Bleeding

Review of System ± 2nd Trimester 

Gums bleeding Nose bleeding Constipation Fetal movement 


Cramping Bleeding Dysuria Abnormal discharge pruritis

Review of Systems ± 3rd Trimester      Indigestion Swelling Leg cramps Fetal movement Difficulty sleeping       Contractions Bleeding Calf pain Headaches Epigastric pain Visual changes .

History .Menstrual     Menarche Interval Length Recent birth control or lactation  LMP ± ± Sure of date? Normal in length & flow Date of conception ER sonogram  Other helpful tidbits ± ± .

PP.Obstetric History        Dates of all pregnancies (include previous miscarriage or termination) GA Gender. weight Length of labor Coping techniques Route of delivery Special events AP. IP. Neo .

g.Gynecologic History      Last Pap Abnormal pap Gyn surgery or problems (e. infertility) Family planning methods Sexually transmitted infections .

Medical/Surgical History      Serious illnesses Hospitalizations Surgery Drug allergies or unusual reactions Meds since LMP .

g.Family History  Maternal ± ± ± ± ±  Maternal or Paternal ± ± ± ± ± ± ± Diabetes CAD Pre-eclampsia Preterm delivery Cancers (breast. ovarian. Dpwn Syndrome) . colon) Depression. bipolarity Twins Anesthesia reactions Birth defects Mental retardation Bleeding disorders Chromosomal abnormalities (e.

Vital Signs     Temperature Blood pressure Respirations Radial pulse .

Additional Measurements    Height Weight BMI ± ± ± Wt in lbs X 730 / Ht in inches² Wt in Kgs / Ht meters² .whathealth.

g. sickle cell disease COPD Cardiac conditions Disappearance of ³diamond´ seen when nails opposed . e.The hands and nails  Clubbing ± caused by chronic hypoxia ± ± ± ± ± Severe asthma Severe anemia.

Beau¶s lines   Lines coincide with periods of acute illness or stress Caused by disruption of nail plate growth .

Koilonychia  Spoon-shaped nails ± Chronic iron deficiency anemia .

Cyanosis of nail beds .

trisomy 13)  In 3% of normal population . Klinefelter. FAS. Turner.Simian crease  Certain syndromes (Down.

HEENT ± Lymph Nodes        Occipital Posterior cervical Supraclavicular Anterior cervical Parotid Submandibular Submental .

Lymph Nodes  Anterior cervical chain ± Located along the sternocleidomastoid muscle .

Check Jaw for Dysfunctional TMJ .

Pregnancy and the mouth       Hypertrophy of the gums Increased vascularity Changes in salivary composition Increased plaque deposition Exposure to stomach acids (1st trimester) Loosening of teeth (3rd trimester) .

The mouth  Angular cheilitis ± B vitamin deficiency ± Fungal infections ± Over-biting .

The mouth  Actinic cheiliosis ± ± Sun exposure Precancerous (SC) .

³Gingivitis of pregnancy´ .

The mouth  Mild aphthous ulcer (AKA canker sore) ± ± ± Viral. bacterial Stress Underlying immune disease if frequent .

Oral candidiasis (thrush) .

The tongue

The normal tongue

The tongue 

Geographic tongue
± ±


³designs´ shift May resolve spontaneously Often asymptomatic

The tongue 

Black hairy tongue
± ± ±

ideopathic candidiasis antibiotics

The tongue Blacker and hairier tongue .

Ankyloglossia (tongue tie)    Heart-shaped Tongue doesn¶t extend over lower gum ridge Clicking noise while nursing .

Severe tongue tie .

.Throat  Deviated uvula ± ± Can be a normal finding In conjunction with other symptoms. indicates a central nervous system lesion.

Enlarged Tonsils .

Chronic tonsilitis     Large tonsils Chronic inflammation Crypts Tonsilar ³stones´ .

Superficial Nasal Sinuses .

Eyes  Pupillary light reflexes .

Swinging Light Test .

Chalazion (plugged sebaceous gland) .

Conjutivitis ± bacterial (strep) .

Conjuctivitis .allergic .

Conjunctivitis .viral .

Conjunctivitis .gonococcal .

The eyes .pterygium .

icterus .The eyes .

The thyroid    Some amount of thyromegaly is normal in pregnancy Important to explore history Important to explore other signs & symptoms .

sweating Anxious Fine tremors Exaggerated reflexes . dry hair & dry. puffy skin Fatigue Thick tongue Delayed relaxation of Achilles reflex Heat intolerance Rapid pulse Flushed.Signs & symptoms  Hypothyroid ± ± ± ± ± ±  Hyperthyroid ± ± ± ± ± ± Cold intolerance Slow pulse Thin.

Palpation of the thyroid    Best palpated with examiner behind Have patient swallow Palpate both lobes .

Normal position of the thyroid .


The thyriod  Massive goiter ± ± Seen in areas with iodine deficient soil (at the base of rocky mountain ranges) This woman is from the mountains of Viet Nam .

isolated finding . and groin Associated with obesity. armpits.Acanthosis nigrans      Appears slowly without symptoms Dark. velvety skin with markings and creases Neck.The Neck . Type II DM. some cancers Can be normal. PCOS.

The Back  Scoliosis ± ± ± ± Rib prominence Curving spine Uneven waist Lumbar prominence .

Scoliosis .

as there is extreme tenderness with pyelonephritis .The Back ± Costovertebral angle   Use your fist to strike the angle made by the ribs and the spine Do this gently.

to compare sounds There are 3 lobes on the right & 2 on the left Always assess the posterior back If there are concerns. check the anterior fields. Move from one point to the same point on the other side.Auscultation of the lungs       Warm your stethoscope. Use the diaphragm. also .

Lung fields .

Auscultation points .

Lungs sounds (the Cliff Notes)     Normal breath sounds Crackles Rhonchi Wheezes .

and with a gentle rustling quality.Normal breath sounds     Normal vesicular breath sounds. Soft. low pitched. Heard over most of the peripheral lung fields. In this sample you can also hear the heart beat in the background .

.Crackles (rales)     Scattered wet crackles. Dry crackles sound more like rubbing hair together next to your ear or like the sound of opening Velcro. Crackles are typically inspiratory. Also known as coarse rales Usually caused by excessive fluid in the airways.

. tumor.Wheezes     Wheezes are ususally expiratory Caused by air forced through collapsed airways with residual trapping of air. Commonly associated with asthma May also be caused by airway swelling. or obstructing foreign bodies.

.Deep tendon reflexes  Most commonly assessed: ± ±      Patellar Achilles  : absent reflex 1+: trace. repetitive vibratory movements) 5+: sustained clonus .e. or seen only with reinforcement 2+: normal 3+: brisk 4+: nonsustained clonus (i.

Reinforcement  When unable to obtain a patellar reflex. . have the patient hook together their flexed fingers and pull apart.

Patellar reflex    Leg should dangle freely Support the thigh above the knee Tap sharply on the space just beneath the knee cap .

Achilles reflex     Loosely support the ball of the foot. Sharply tap the Achilles tendon Note whether plantar flexion and dorsiflexion are equal Delayed dorsiflexion is a possible sign of hypothyroidism .

. Feel for oscillations between flexion and extension of the foot.Clonus    Hold the relaxed lower leg in your hand Sharply dorsiflex the foot and hold it dorsiflexed.

. spinal cord injury. Also seen in ALS. head injury. some forms of polio. Abnormal after the age of 2. tumors. meningitis. MS. Indicates damage to the nerve paths connecting the spinal cord and the brain May be seen for a short time after a seizure. stroke.Babinski reflex      The great toe flexes toward the top of the foot and the other toes fan out after the sole of the foot has been firmly stroked.

Visual Inspection 

Retractions Increased vascularity Skin changes Dimpling Marked differences in configuration Spontaneous discharge As she moves, note any differences in mobility or visible masses

Positions for visual inspection

Lateral and medial patterns

Method of palpation .

Levels of palpation .

Additional aspects of exam    Evaluate the supraclavicular notches Evaluate the tail of Spence and axilla Check for nipple discharge .

producing S2.The cardiac cycle      S1 and S2 (Lub-Dub) are the most obvious normal sounds This is a normal sinus rhythm. with a sharp S1 and S2 S1 marks the beginning of systole. the ventricles begin to relax. At the end of systole. . and the pressures within the heart become less than that in the aorta and pulmonary artery A brief back flow of blood causes the semilunar valves to snap shut. and is created when the heart muscle¶s contraction causes closing of the tricuspid and mitral (or AV) valves.

Flow murmur     You are listening to an innocent flow murmur. These are very common in pregnancy. . The murmur is in early systole. Caused by abnormally high flow through normal valves. and could be described as ³twangy´. is crescendodecrescendo in shape. has a definite start and end point.

The papillary muscles fail to firmly hold the mitral valve during late systole. or light-headedness. It can present as attacks of palpitations.Mitral valve prolapse      This is a murmur of mitral valve prolapse. . and the valve bulges into the left atrium. This is common in young adult women. Although rarely serious. patients with mitral valve prolapse with regurgitation by echo are given antibiotic prophylaxis during invasive procedures to prevent bacterial endocarditis. anxiety.

2/3 are secondary to rheumatic heart disease Other causes are congenital. 3:1 ratio male:female. syphilis infection.Aortic regurgitation      This murmur is caused by aortic valve regurgitation. The most notable aspect of the murmur is the diastolic sound characterized as a blowing decrescendo. . Marfan syndrome. or valvular damage due to infective endocarditis.

It is caused by blood flowing through a hole in the wall between the right and left ventricles. . There is usually no diastolic component to the murmur. It is a holosystolic because the pressure difference between the ventricles is generated almost instantly at the onset of systole. radiating to the right lower sternal border. with a left to right shunt continuing throughout ventricular contraction.VSD (ventricular septal defect)     This murmur is heard best over the lower left sternal border.

S4 or gallop     A fourth heart sound. If the ventricle is stiff and non-compliant. the atrial contraction produces an S4. as in ventricular hypertrophy due to long-standing hypertension. A good mnemonic to remember the cadence and pathology of an S4 is: ³a-STIFF-wall a-STIFF-wall´ . The late stage of diastole is marked by atrial contraction. or kick. where the final 20% of the atrial output is delivered to the ventricles. or S4. is due to a stiff ventricle.

loud +/.very faint.thrills 5/6 . +/.may be heard with stethoscope completely off chest.thrills . may be heard with stethoscope partly off chest 6/6 . not always heard in all positions 2/6 .thrills.Grading murmurs       1/6 .very loud +/.moderately loud 4/6 .quiet but not difficult to hear 3/6 .

Positions of cardiac auscultation .

Abdominal assessment  Inspect abdomen ± ± ± contour asymmetry scars.  Deep palpation for masses . rashes. increased. decreased. high-pitched  Light palpation for tenderness ± ± most sensitive indicator is facial expression voluntary or involuntary guarding may also be present.  Listen for bowel sounds ± present. or other lesions. absent.

Rebound tenderness  This is a test for peritoneal irritation. the patient has rebound tenderness. If it hurts more when you release. . Palpate deeply and then quickly release pressure.

. which covers the front surface of the abdomen Diastasis recti is a common and normal condition in newborns. It is also common in women postpartum A diastasis recti appears as a ridge running down the midline of the abdomen from the bottom of the breastbone to the navel. It is seen most frequently in premature and African-American infants.Diastasis recti     A separation between the left and right side of the rectus abdominis muscle.

. It is recorded as fingerbreadths: relaxed/contracted. then again as she lifts her head.Measurement of the diastasis   It is measured with the woman supine and relaxed.

The lower extremities     Edema Signs of deep vein thrombosis Homan¶s sign Abnormalities of toe nails .

Edema     1+ slight pitting. disappears in 10-15 secs. The extremity looks fuller & swollen (6 mm) 4+ the pit is very deep. lasts 2-5 mins. and the extremity is grossly distorted (8 mm) . disappears rapidly (2 mm) 2+ deeper pit.(4 mm) 3+ pit is noticeably deep and may last more than a minute.

Pedal edema .

Edema .

i. discolored. warm to the touch Pain with stretching of the overlying muscle (+ Homan¶s sign). May have systemic symptoms.Deep vein thrombosis      Swelling of the affected extremity. shortness of breath. fever. .e.. Area over vein may be red. Area may be tender. chills. flu-like symptoms.

.DVT left saphenous vein.

forcibly dorsiflex the ankle.Homan¶s sign Elicitation: With the knee in the flexed position. Response: Pain in the calf with this maneuver is consistent with deep venous thrombosis.   .

Dermatophyte infection of toe nails .

The skin  Our largest and heaviest organ .

Linea negra .

Melasma .

red and pink. brown. black. usually some over 8mm Color: Multiple shades of tan. often variegated .Atypical moles     Number of moles: Often over 50 Uniformity: Neighboring moles differ from each other Size: Many over 5mm.

no tenderness. no burning. often with a pink base Surface: Often mammillated with tiny outward domelike dimples Symptoms: No pain. usually no symptoms .Atypical moles. no itching. cont. usually fuzzy. edges blend imperceptibly with surrounding skin "Shoulder": Outer periphery is usually flat and tan.      Elevation: Center is only slightly raised in comparison with the relatively large diameter Perimeter (edge): Often irregular.

Note an appearance close to a "fried egg.Malignant melanoma    Atypical mole of the trunk. The center is elevated and the size of a pencil eraser." .

The ABCDs of abnormal moles A. Border of the mole is jagged or irregular C. Diameter is greater than 5 mm (the size of a pencil eraser) . Asymmetry: One-half of the mole does not match the other half B. Color ± more than one is present D.

Asymmetry .

Border .

Color .

Diameter .

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