Physical Examination of Antenatal Mother

Subject: Midwifery I (Theory)

Overview

An prenatal examination is a checkup performed before conception in order to thoroughly analyze the expectant mother. The supervision should be on-going and consistent. As soon as a pregnancy is confirmed, prenatal visits should begin. The goal of an antenatal examination is to determine the woman's socioeconomic status, level of education, and screening for "high risk" cases. It also aims to identify any deviation from normal conditions that could result in maternal morbidity or mortality, such as obstructed labor and APH, and to identify and treat any illnesses that the woman may have, such as TB or anemia, by taking a medical history. Lab tests, systemic examination, and observation should all be part of the general evaluation.Health state, gait, dietary status (good, average, poor), body type (obesity, average, thin), personal hygiene, and walking capacity. Follow the correct physical examination techniques while examining the mother from head to toe. During the physical examination, a nurse must concentrate on the abdominal examination. Women should get prenatal abdominal exams starting at 12 weeks until the baby is delivered. Every time a patient returns, they should have the examination. Inspection, palpation, measurement of fundal height, and palpation are the steps in an abdominal examination. An auscultation is performed to evaluate a fetus's heartbeat. It provides accurate information on fetal life inside the uterus. The physical checkup includes a vaginal examination as well. It is generally known that a meticulous vaginal examination performed in an aseptic environment is safe.

General examination

The general examination should include observation, systemic examination, and laboratory tests.

  • Inspection
    • Health state, gait, dietary status (good, average, poor), body type (obesity, average, thin), personal hygiene, and walking capacity.
  • Weight
    • Every time you visit after that, you should weigh yourself and note it in kilograms or pounds. During pregnancy, the average patient will gain 8 to 12 kg. Low-weight pregnant women typically gain less weight throughout pregnancy. Low birth weight newborns, IUGR, preterm labor, and poor perianal outcomes are frequently linked to inadequate weight gain.
    • Fluid retention may be the cause of excessive weight gain.
  • Height
    • The height in centimeters. A tiny pelvis is frequently linked to short stature. Women who are under 4.8" or 150 cm in height are more likely to experience mechanical dystocia issues and atypical presentation.
  • Vital sign
    • Take your temperature, blood pressure, pulse, and breathing, note any irregularities, and then contact a senior or doctor right away.
  • Head
    • Colour, texture, cleanliness of head and hair, check for extra growth or tumor.
  • Eye
    • Examine the conjunctiva, tongue, and nails for pallor, which is a sign of anemia, and check the eyelids, sclera, and cornea for any infections.
  • Oral cavity
    • Check the tonsils, tongue, teeth, and gums. A patient should be referred for dental care if they have poor oral hygiene, gingivitis, or dental cavities. Both glossitis and angular stomatitis symptoms could be present.
  • Neck
    • Check for any abnormalities in the lymph nodes, thyroid, or neck veins. In 50% of pregnancies, the thyroid gland slightly enlarges physiologically.
  • Respiratory system
    • Check for breathing, chest size and shape, any nodes or tumors, and chest muscle movement during breathing. Check the chest wall for resonance sounds and listen for breathing sounds by auscultating.
  • Cardiovascular system
    • Look for any anomalies in the heart's sound and note any cases of cardiac disease.
  • Abdomen
    • Early in pregnancy, the abdomen is palpated for any abnormalities and enlarged liver, spleen, or kidney. However, the abdomen is palpated for a gravid uterus in later stages of pregnancy.
  • Breast
    • Early in pregnancy, the abdomen is palpated for any anomalies and enlarged liver, spleen, or kidney. However, the abdomen is palpated for a gravid uterus in later stages of pregnancy.
  • Edema of legs
    • In the bottom third of the leg, above the medial malleolus, look for pitting edema. Edema might have a physiological and postural cause or it can be a symptom of a medical condition such pre-eclampsia, anemia, or cardiac illness.
  • Varicosities
    • Take note of the location and existence of varicose veins. This problem tends to get worse during pregnancy.

Abdominal examination

Women should have a prenatal abdominal exam starting at 12 weeks until the baby is delivered. Every time a patient returns, they should have the examination.

After 28 weeks of pregnancy, a comprehensive abdominal exam can reasonably diagnose the location, appearance, posture, and attitude of the fetus.

Objectives

  • To look out for pregnancy symptoms.
  • To measure fetal size and development.
  • To determine the fetal art's location, lie, presentation, position, presenting part, etc.
  • Height of the fundus to determine gestational period.

Preparation of patient for examination

  • Asking the patient to empty their bladder.
  • Maintain the woman in a dorsal or supine position with slightly contracted thighs.
  • Remove all clothing and reveal the abdomen completely.
  • The examiner ought to be positioned to the right of the patient.
  • Washing, drying, and warming your hand with rubbing.

Steps of abdominal examination

  • Inspection
    • Observe the abdomen for:
      • Determine whether the uterus is longitudinal, transverse, or oblique .
      • The shape of the uterus might be spherical, cylindrical, anteriorly flattened, or pendulous.
      • The uterus seems excessively tiny or swollen.
      • Any surgical incision scars from earlier procedures.
      • Skin alterations include a glossy, stretched-out appearance, signs of scabies, eczema, or pronounced veins.
      • Abdominal blood vessels.
  • Palpation
    • Measurement of fundal height:
      • The height of the uterus' fundus, expressed in centimeters, is determined by centralizing the symphysis pubis and measuring from there to the topmost margin's midpoint.
      • Investigation should be conducted if the fundal height does not match the anticipated amenorrhea period.
  • Fundal grip
    • This is performed late in pregnancy to differentiate the fetal parts.
    • Steps:
      • Examiner looking at woman's head.
      • Put your hand on the sides of the fundus while using your fingers' tips together.
      • By moving the fetal parts from side to side and feeling their surface, consistency, and ease with which it can be estimated that a fetal part is occupying the fundus of the gravid uterus, you can curve around the top border of a uterus and palpate them up to the fundus.
      • Fetal breech is the most frequent part of the fetus to occupy the fundus. It is softer, more uneven, and has limited mobility; it is less clearly defined than the cephalic pole. It is unable to move without the fetal back.
      • A movable mass that is smooth, firm, and spherical and suggests a head.
      • In transverse lie, neither of the fetal poles palpated in the fundal areas.
  • Lateral or umbilical grip
    • It determines the position e.g. where the fetal back is.
    • Steps:
      • Face the patient's direction.
      • To determine the right and left sides of the uterus, position the hands flat on each side of the umbilicus and palpate each side sequentially.
      • To determine the fetal back, support the uterus with your palm on one side, palpate the opposite side, and repeat on the right and left sides.
      • The smooth, curved, and unyielding feel alludes to the back.
      • There are little knob-like irregular sections on the limb side, which is generally empty.
  •  Pelvic grip
    • It determines what the presenting feature is in the uterus' lower pole.
    • Steps
      • Facing the woman's feet, turn your head.
      • Knee should be relaxed and slightly bent.
      • Just above the symphysis pubis, place the tips of the four fingers of each hand on either side of the patient's abdomen.
      • To palpate, ask a lady to exhale deeply while you place your finger slowly and deeply around the presenting part.
  •  Pawlik's grip
    • Steps:
      • Face the patient's direction.
      • Keeping the ulnar border of the palm on the upper border of the symphysis pubis, the right hand's outstretched thumbs and four fingers are placed on the lower pole of the uterus.
      • The presenting component is clearly grabbed when the finger and thumb are approximated, and if it is not engaged, its mobility from side to side is examined. The most prevalent fetal part to occupy the lower segment, the fetal head, can be felt as a hard, spherical, globular, ballotable part.
      • There is no Pawlik grip in a transverse lay.
  • Auscultation
    • An auscultation is performed to evaluate a fetus's heartbeat. It provides accurate information on fetal life inside the uterus.
    • The tone, rate, and rhythm of the fetal heart can be auscultated to determine the health of the fetus. The position of maximal intensity might help dispel any uncertainty regarding the fetus's presentation.
    • In breech and vertex presentations, the fetal heart sound can be heard most clearly through the back (left scapular region). The FHS are audible through the fetal chest during face presentation, though. Generally speaking, the FHS's maximal intent is below the umbilicus in cephalic presentation and around the umbilicus in breech presentation.

Vaginal examination

It is well known that a delicate, thorough vaginal examination carried out in an aseptic environment is safe, instructive, and doesn't hurt the patient. It offers a chance to evaluate the pelvis and infer the fetal pelvic connection. Additionally, it offers the following details:

  • General assessment of pelvis
  • Feto-pelvic relationship
  • Bishop score: to assess inducibility of the cervix for labor
  • Sign of onset of labor
  • Perineal floor: evaluate whether the perineum is soft, stretchable and elastic or hard and rigid.

REFERENCE

Memorize. 12.2. 2012. http://memorize.com/antenatal-examination/drlmorice

PatientInfo. 01 December 2015. http://patient.info/doctor/antenatal-examinations

Scribd. https://www.scribd.com/doc/43985359/Antenatal-Assessment

Sweet, B.r., 1989, maye’s midwifery, A textbook for midwives; 11th edition, Bailliere Tindall, London, Philadelphia

Tuitui R. 2002, A textbook of Midwifery A (Antenatal), 3rd edition, Vidyarthi Pustak Bhandari (Publisher and Distributor), Bhotahity, Kathmandu

 
Things to remember
  • Antenatal examination is the examination done during antenatal period to have detail assessment of women.
  • The supervision should be regular and periodic in nature.Antenatal visit should be start as soon as after pregnancy has been confirmed .
  • The purpose of antenatal examination are to identify the social, economic and education status of the woman ,to screen the "high risk" cases,to detect the complications of pregnancy at an early stage like hypertension , anemia, and take appropriate action,to detect any deviation from normal condition which may lead to maternal morbidity or mortality like obstructed labour and APH and to  detect and treat illness which the women may have e.g. TB, anemia by history taking and lavatory investigation.
  • The general examination should include observation, systemic examination and laboratory tests.State of health , gait, nutritional status : good/average/poor, build obese/average/thin , personal hygiene , ability to walk. Examine the mother head to toe and follow the proper techinique of physical examination.
  • A nurse must focuse on abdominal examintaion during the physical examination.Prenatal abdominal examination should be performed on women from 12 weeks till delivery of the baby.
  • The examination should be done on each subsequent visit.Steps of abdominal examination includes Inspection,Palpation,Measurement of fundal height and Palpation.
  • Auscultation is done to assess the heartbeat of a fetus. It is a reliable indicator of the fetal life inside the uterus.
  • Vaginal examination is also done during the physical examination.
  • It has been well established that a gentle , careful vaginal examination undertaken under aseptic condition is safe, informative and doesn’t cause discomfort to the patient.
Questions and Answers

Physical examination

  • General examination
    • Lab tests, systemic examination, and observation should all be part of the general evaluation.
  • Inspection
    • Inspection of physical condition, gait, dietary state (good, average, poor), body type (obesity, average, thin), personal hygiene, and walking capacity.
  • Weight
    • Weigh in kilograms or pounds and record it for each subsequent appointment. During pregnancy, the average patient will gain 8 to 12 kg. Low-weight pregnant women typically gain less weight throughout pregnancy. Poor perianal outcomes, low birth weight kids, IUGR, premature delivery, and inadequate weight gain are frequently linked.
    • Fluid retention may be the cause of excessive weight gain.
  • Height
    • Record the height in centimeters. A tiny pelvis is frequently linked to short stature. Women who are under 4.8" or 150 cm in height are more likely to experience mechanical dystocia issues and atypical presentation.
  • Vital sign
    • Take your temperature, blood pressure, pulse, and breathing, note any irregularities, and then contact a senior or doctor right away.
  • Head
    • Check for additional growth or tumors and observe the color, texture, and cleanliness of the head and hair.
  • Eye
    • Examine the conjunctiva, tongue, and nails for pallor, which is a sign of anemia, and check the eyelids, sclera, and cornea for any infections.
  • Oral cavity
    • Check your tonsils, teeth, gums, and tongue. A patient should be referred for dental care if they have poor oral hygiene, gingivitis, or dental cavities. Both glossitis and angular stomatitis may be present.
  • Neck
    • Check for any abnormalities in the lymph nodes, thyroid, or neck veins. In 50% of pregnancies, the thyroid gland slightly enlarges physiologically.
  • Respiratory system
    • Examine your breathing, the size and form of your chest, and any nodes or tumors that may be present. Check the chest wall for resonance sounds and listen for breathing sounds by auscultating.
  • Cardiovascular system
    • Look for any anomalies in the heart's sound and note any cases of cardiac illness.
  • Abdomen
    • Early in pregnancy, the abdomen is palpated for any anomalies and enlarged liver, spleen, or kidney. However, the abdomen is palpated for a gravid uterus in later pregnancy.
  • Breast
    • Keep an eye out for skin changes during pregnancy, and carefully palpate your breasts to check for any tumors or nodes, colostrum secretion, or striae.
  • Edema of legs
    • In the bottom third of the leg, above the medial malleolus, look for pitting edema. Edema might have a physiological and postural cause or it can be a symptom of a medical condition such pre-eclampsia, anemia, or cardiac illness.
  • Varicosities
    • Take note of the location and existence of varicose veins. This problem tends to get worse during pregnancy.

 

Abdominal examination

Women should get prenatal abdominal exams starting at 12 weeks until the baby is delivered. Every time a patient returns, they should have the examination.

After 28 weeks of pregnancy, a comprehensive abdominal exam can reasonably diagnose the location, appearance, posture, and attitude of the fetus.

Objectives

  • To look out for pregnancy symptoms.
  • To measure fetal size and development.
  • To determine the location, lay, presentation, position, presenting component, etc. of fetal art.
  • Height of the fundus to determine gestational period.

Preparation of patient for examination

  • Asking the patient to empty their bladder
  • Maintain the woman in a dorsal or supine position with slightly contracted thighs.
  • Remove all clothing and reveal the abdomen completely.
  • The examiner ought to be positioned to the right of the patient.
  • Hands should be washed, dried, and warmed by massage.

Steps of abdominal examination

  • Inspection
  • Measurement of fundal height
  • Palpation
    • Obstetric grip
      • Fundal grip
      • Lateral or umbilical grip
    • Pelvic grip
      • Pawlik's grip
      • Auscultation

Inspection

Observe the abdomen for:

  • Whether the uterus is transverse, oblique, or longitudinal.
  • The uterine outlines can be cylindrical, pendulous, spherical, or anteriorly flattened.
  • The uterus appears to be excessively big or tiny.
  • The existence of any surgical incision scars.
  • Skin alterations stretchy, glossy skin with signs of eczema, scabies, or visible veins.
  • Abdominal blood vessels.

Measurement of fundal height

The height of the uterus' fundus, expressed in centimeters, is determined by centralizing the symphysis pubis and measuring from there to the uppermost margin's midpoint.

Investigation should be conducted if the fundal height does not match the anticipated amenorrhea period.

Palpation- Obstetric grip

  • Fundal grip:
    • To distinguish the fetal parts, this procedure is carried out late in pregnancy.
    • Steps:
      • Examiner looking at woman's head.
      • Put your palm on the sides of the fundus and squeeze the tips of your fingers together.
      • By rocking the fetal parts from side to side and palpating their surface, consistency, and ease with which it can be balloted an estimate of fetal part occupying the fundus of the gravid uterus, curve around the upper border of the uterus and palpate them up to the fundus.
      • Fetal breech is the most frequent part of the fetus to occupy the fundus. It is softer, more uneven, and has limited mobility; it is less clearly defined than the cephalic pole.
      • Smooth, spherical, and mobile mass that resembles a head
      • Neither of the fetal poles could be felt in the fundal regions while in transverse lie.
  • Lateral or umbilical grip:
    • It establishes the position, such as where the fetal back is.
    • Steps:
      • Face the patient's face.
      • To determine the right and left sides of the uterus, position the hands flat on each side of the umbilicus and palpate each side sequentially.
      • To determine the fetal back, support the uterus with your palm on one side, palpate the opposite side, and repeat on the right and left sides.
      • The smooth, curved, and unyielding feel alludes to the back.
      • There are little knob-like irregular sections on the limb side, which is generally empty.
  • Pelvic grip:
    • It finds out what is the presenting part in the lower pole of the uterus
    • Steps:
      • Facing the woman's feet, turn your head.
      • Knee should be relaxed and slightly bent.
      • Just above the symphysis pubis, place the tips of the four fingers of each hand on either side of the patient's abdomen.
      • To palpate, ask a lady to exhale deeply while you place your finger slowly and deeply around the presenting part.
  • Pawlik's grip:
    • Steps:
    • Face the patient's direction.
    • Right hands are used, with the ulnar border of the palm resting on the upper border of the symphysis pubis, and the thumbs and four overextended fingers resting on the lower pole of the uterus.
    • The presenting component is clearly grabbed when the finger and thumb are approximated, and if it is not engaged, its mobility from side to side is examined. The most frequent fetal portion to occupy the lower segment, the fetal head, can be felt as a hard, spherical, globular, ballotable part:
    • A pawlik grip is vacant in transverse lie.

Auscultation

An auscultation is performed to evaluate a fetus's heartbeat. It provides accurate information on fetal life inside the uterus.

The tone, rate, and rhythm of the fetal heart can be auscultated to determine the health of the fetus. The position of maximal intensity might help dispel any uncertainty regarding the fetus's presentation.

In breech and vertex presentations, the fetal heart sound can be heard most clearly through the back (left scapular area). The FHS, however, are audible through the fetal chest during face presentation. The FHS is often most intened below the umbilicus in cephalic presentation and around the umbilicus in breech presentation.

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