Obstetrics and Gynecology - A.M. Gromova 2000

Diagnosis of pregnancy. Monitoring its course
Methods of examining a pregnant woman
Objective examination

A mandatory stage in the Objective Examination of a woman during Pregnancy, labor, and the postnatal period is the Assessment of the condition of her main Organs and systems, which provides a comprehensive Overview of her general somatic health.

The physical examination of a pregnant woman is carried out according to a specific protocol.

1. Correspondence of the pregnant woman's general appearance to her age (infantile features in an adult woman indicate infantilism).

2. Height. If a woman's height is short (less than 145 cm), she may have a narrow pelvis; if tall (180 cm or more), a wide pelvis or a male-type pelvis.

3. Body build. An irregular body build, spinal and tibial curvatures, thickening of the costal cartilages, a square HEAD, unequal length of the lower extremities, joint ankylosis, and other skeletal changes indicate Rickets or Osteoarticular Tuberculosis suffered in childhood. In such cases, pelvic deformations and narrowing are possible, which leads to complications during labor.

4. Nutritional status. Obesity or emaciation indicates Metabolic Disorders.

5. Skin. Pigmentation of the facial skin, linea alba, skin around the nipples, and the presence of fresh striae gravidarum on the abdomen and thighs are doubtful Signs of Pregnancy. Edema of the lower extremities, face, and other body parts indicates toxicosis of pregnancy, heart disease, or Kidney disease. Paleness of the skin and mucous membranes, cyanosis of the Lips, and yellowish discoloration of the skin and sclera are signs of severe conditions (Hemorrhage, Liver or heart disease, etc.).

6. Abdomen. The shape of the pregnant abdomen is of great diagnostic significance. A sharply enlarged, spherical abdomen occurs with polyhydramnios; a pendulous or anteriorly pointed abdomen is characteristic of a narrow pelvis. An everted umbilicus is observed in early pregnancy, a smoothed umbilicus when pregnancy reaches 8 months, and a protruding umbilicus at 9 months of gestation.

7. Condition of the Mammary Glands. Development of the mammary glands, shape of the nipples (protruding, flat, inverted), striae gravidarum, nipple discharge (a doubtful sign of pregnancy), and the presence of scars following mastitis.

An important issue determining the course and outcome of labor is the assessment of the shape and dimensions of the true pelvis, which is one of the Components of the birth process. As is known, the dimensions of the true pelvis are not directly measurable; therefore, its shape and size are inferred indirectly from the dimensions of the false pelvis.

In the standing position, attention should be paid to the CHARACTERISTICS OF THE lumbosacral rhombus (Michaelis rhombus). The Structure of the rhombus reflects the Anatomical Features of the woman's true pelvis. The upper apex of the rhombus corresponds to the suprasacral fossa—a depression below the spinous process of the fifth lumbar vertebra; the lower apex corresponds to the apex of the sacrum (the point of Water/144.html">Origin of the gluteal Muscles). Laterally, the rhombus is bounded by points corresponding to the posterior superior iliac spines. The length of the rhombus (vertical dimension) averages 11 cm, and the transverse diameter is 10 cm. The more well-formed the pelvis, the closer the shape of the rhombus is to a square. Changes in the shape and dimensions of the pelvis alter the shape and size of the lumbosacral (Michaelis) rhombus, serving as one of the diagnostic criteria for assessing the birth canal.

An obstetric pelvimeter is used to measure the dimensions of the false pelvis (Chapter 10).

The measurement of the pelvic outlet has certain clinical significance and is performed with the woman in the supine position and her legs pressed against her abdomen.

The direct (anteroposterior) dimension of the outlet is measured with a standard pelvimeter — the tips of the pelvimeter are placed externally on the lower edge of the symphysis pubis and the tip of the coccyx. To determine the true outlet dimension, 2 cm must be subtracted from the measured value (to account for soft tissue thickness). The transverse diameter of the outlet (the distance between the inner surfaces of the ischial

tuberosities) is measured with a special pelvimeter or a tape measure, and 2 cm is added to the obtained value to account for soft tissue thickness. Of utmost importance in pelvic measurements is the evaluation of the conjugate vera (true conjugate), the most critical dimension of the true pelvis. It is precisely at the level of the direct dimension of the pelvic inlet that the fetal head encounters the greatest resistance while passing through the birth canal. The indirect Determination of the conjugate vera is carried out based on the external conjugate, by measuring the diagonal conjugate (which is determined during a vaginal examination), and by measuring the vertical dimension of Michaelis rhombus.

The most accurate dimensions of the true pelvis, and first and foremost the value of the conjugate vera, can be determined using radiography and ultrasound Diagnostics.

To determine the gestational age and fetal size, a tape measure is used to measure the abdominal circumference at the umbilical level and the height of the uterine fundus above the upper margin of the symphysis pubis along the midline.

The primary method of external obstetric examination is abdominal Palpation, which allows for the assessment of the condition of the anterior abdominal wall, the size, shape, and tone of the Uterus, the position and presentation of the fetus, and The amount of Amniotic Fluid.

When palpating the fetus within the uterus, four Methods of external obstetric examination (Leopold's maneuvers) are used (Fig. 9).

The first maneuver makes it possible to estimate the size of the uterus, the height of its fundus, and the fetal part located in the fundus — the palms of both hands are placed on the uterus, embracing its fundus with the fingers pointing toward each other.

The second maneuver determines which side the fetal back and small parts are facing (i.e., the fetal lie and position) — the hands are placed on the sides of the uterus, gently palpating the fetus at the umbilical level.

The third maneuver aims to determine The Nature of the presenting part and its relation to the pelvic inlet — the right hand embraces the presenting part above the Pubic Symphysis so that the thumb is on one side and the other four fingers are on the opposite side. In cephalic presentation, the head is palpated as a large, dense, rounded part.

The fourth maneuver allows not only to clarify the Nature of the presenting part but also to determine the level of its station relative to the inlet and the planes of the true pelvis. The physician stands facing the pregnant woman's feet, places their hands on the lateral surfaces of the uterus slightly above the symphysis, and gently slides them deep down between the head and the lateral sections of the pelvic inlet.

Auscultation is used to assess the condition of the fetus. Auscultation is performed using an obstetric stethoscope with a wide bell. Fetal heart tones are clear and rhythmic, with a normal frequency of 120-140 bpm. The point of optimal auscultation depends on the fetal position, variety, and presentation (Fig. 10). In cephalic presentation, heart tones are heard below the umbilicus to the right or left depending on the position; in breech presentation, they are heard above the umbilicus. When assessing fetal Cardiac Activity, not only the frequency but also the loudness and rhythm of the tones are taken into account. Modern ultrasound diagnostic equipment allows for amplified sound reproduction of fetal heart tones. For this purpose, the domestic device "Malyuk" can be used. During auscultation, one can frequently hear the murmur of the umbilical cord and placental vessels, the rhythm of which is synchronous with the pregnant woman's pulse.

The most important diagnostic method for examining a pregnant woman is the internal obstetric examination.

Vaginal examination in the first trimester is one of the primary methods of pregnancy Diagnosis. The Procedure begins with an inspection of the external genitalia, Perineum, and perianal region, noting the height of the perineum (normally 4-5 cm), the degree of closure of the urogenital cleft, and the presence of any pathological changes (such as varicose Veins, pustules, or scars). Next, using the fingers of the left hand, the Labia minora are separated to examine the vaginal introitus, paying attention to the color of the mucosa (hyperemia, cyanosis), the condition of the Urethra, the excretory ducts of the greater vestibular glands, and the remnants of the hymen. A mandatory component of the vaginal examination is a speculum examination of the Vagina and cervix, which evaluates the condition of the vaginal and cervical mucosa, as well as the nature of the cervical discharge and vaginal contents. The fingers of the right hand, inserted into the vagina, are used to determine its length and width, the condition of its walls (edema, rugosity, elasticity), followed by an assessment of the cervix—its length, consistency, position, and the state of the external os—as well as the vaginal fornices, noting their depth and any tenderness. After this, the bimanual examination is performed. Using the fingers of both the internal and external hands, the position, size, shape, consistency, mobility, and tenderness of the uterus are evaluated, revealing A number of characteristics typical of pregnancy. Subsequently, the state of the uterine appendages, pelvic cellular tissue, and uterine ligaments is assessed. The vaginal examination also includes the palpation of all accessible internal surfaces of the lesser pelvis (the inner surface of the pubic arch, the sacral hollow, the ischial spines, and the Sacrococcygeal joint). An internal pelvic examination can reveal pathological bone formations (exostoses) or alterations in sacral shape, providing an overall assessment of pelvic capacity. The examination concludes with the measurement of the diagonal conjugate—the distance from the most prominent point of the sacral promontory to the inferior margin of the symphysis pubis. To do this, the tip of the middle finger of the right hand, placed in the vagina, is pressed against the promontory, and the point on the index finger corresponding to the inferior margin of the symphysis pubis is marked by the external hand. The fingers are then withdrawn from the vagina, and a pelvimeter is used to measure the distance between the marked point and the tip of the middle finger. Normally, the diagonal conjugate measures 12.5-13 cm. Subtracting 1.5-2 cm from this measurement yields the true conjugate.

Vaginal examination In the second and third trimesters of pregnancy is performed exclusively in a hospital Setting, strictly adhering to asepsis and antisepsis protocols.

When performing a vaginal examination in late pregnancy, In addition to the assessments mentioned above, it is essential to determine the degree of readiness of the birth canal for labor and to evaluate the fetal presenting part. The preparedness of the birth canal is gauged by the 'maturity' of the cervix, the criteria for which include its length, consistency, position within the pelvic cavity, and the state of the external os and cervical canal. The term 'immature cervix' refers to a state where signs of labor readiness are minimal or absent. In this case, the cervical length is 4 cm or more, its consistency is firm, the external os is closed, and the cervix is deflected posteriorly. A 'mature cervix' is shortened to 1-2 cm, has a soft consistency, and its external os easily admits one finger in primiparas, while in multiparas the cervical canal is passable along its entire length to the examining finger, with the axis of the cervix aligned with the leading axis of the pelvis. Palpation through the vaginal fornices allows identification of the presenting part, the consistency of which helps determine the type of presentation. By gently attempting to push the fetal head away with the examining finger, its station can be clarified—whether it is engaged at the pelvic inlet or mobile above the pelvic inlet.

In cases of obstetric pathology such as Placenta Previa, an internal examination may reveal a characteristic doughy consistency in the vaginal fornix along with enhanced vascular pulsation.