clinical obstetrical examination

Obstetric Abdominal Examination
Instructions - “
Perform an obstetric abdominal examination on this patient
”


Washes hands
Introduces themselves & confirms patient details
Explains examination & gains consent
Requests a chaperone
Positions & exposes patient appropriately
Inspects the abdomen
Performs light palpation of the abdomen
(all 9 regions)
Palpates the uterus
Determines fetal lie
Assesses presentation of the fetus
Measures symphyseal-fundal height
Assesses level of fetal engagement
Observes patient’s face throughout examination and ensures patient is comfortable
Thanks patient
Washes hands
Summarises salient findings
Suggests further assessments & investigations.
Cardiovascular Evaluation During Pregnancy
The patient s history is an essential part of the initial risk assessment and should include information on the baseline functional status and previous cardiac events because these are strong predictors of peripartum cardiac events. The strongest predictors include the following:
• Any prior cardiac event
• Cyanosis or poor functional class
• Left-sided heart obstruction
• Ventricular dysfunction
Left-sided heart obstruction includes;

valve disease or hypertrophic cardiomyopathy(aortic valve area < 1.5 cm2, mitral valve area < 2 cm2, or left ventricular outflow tract peak gradient >30 mm Hg). Impaired ventricular function is significant when the ejection fraction is below 40%. [Prior events of interest also include treatment for heart failure, TIA or stroke, or arrhythmia.
The 2011 update to the American Heart Association guideline for the prevention of cardiovascular disease (CVD) in women recommends that risk assessment at any stage of life include a detailed history of pregnancy complications. Gestational diabetes, preeclampsia, preterm birth, and birth of an infant small for gestational age are ranked as major risk factors for CVD. []
Many of the normal symptoms of pregnancy, such as dyspnea on exertion, orthopnea, ankle edema, and palpitations, are also symptoms of cardiac decompensation. However, angina, resting dyspnea, paroxysmal nocturnal dyspnea, or a sustained arrhythmia are not expected with pregnancy and warrant a further diagnostic workup.
] Almost all pregnant women develop physiologic murmurs, which are usually soft, midsystolic murmurs heard along the left sternal border usually caused by functional pulmonary stenosis due to increased transvalvular flow.

Physical signs
; commonly seen with pregnancy are jugular venous distension, an apical S3, basal crackles, prominent left and right ventricular apical impulses, exaggerated heart sounds, and peripheral edema. Diastolic murmurs are rare with pregnancy despite the increased blood flow through the atrioventricular valves; []their presence should prompt further diagnostic evaluation. [] Systolic murmurs more than 2/6 in intensity, continuous murmurs, and murmurs that are associated with symptoms or electrocardiographic changes should also prompt further investigation such as echocardiography. [
Electrocardiography offers low-cost screening that may identify the need for further study if findings otherwise appear benign. In pregnancy, the axis can shift right or left but usually stays in the normal range
. [] During normal pregnancy, multiple changes can be seen such as
- increased R wave amplitude in leads V1 and V2,
-T wave inversion in lead V2
- a small Q wave
-inverted P wave in lead III.
[]Pregnancy is associated with a higher rate of maternal arrhythmias, [] ranging from 73-93% in some studies. [
If impaired functional status is a concern or the patient s history is unreliable, baseline oxygen saturation and low-level exercise testing (targeted to 70% of age-predicted maximum heart rate; 70% of 220 – age) with oxygen monitoring and oxygen consumption may be helpful. Cardiac catheterization should be avoided in pregnancy and should be reserved only for situations in which therapeutic intervention is being considered. [] Findings such as ventricular hypertrophy, evidence of a prior myocardial infarction or ischemia, atrial enlargements, conduction abnormalities, or arrhythmias should prompt a more extensive workup.[