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Course: Maternity Nursing

Topic: Maternal Physical Examination

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Module Goals

The learner will be able to:

Discuss the purpose of the maternal physical examination.
Identify the components of the maternal physical examination.
Discuss the nurse's role in performing a comprehensive physical examination.

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Purpose of Maternal Physical Examination

To assess health status of the mother and fetus
To determine the gestational age of the infant
To identify warning signs or potential problems
To corroborate the maternal health history
To establish a trusting relationship with the nurse and health care provider

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Components of Physical Examination

General examination

Height, weight, blood pressure,pulse rate, respiratory rate, temperature
General appearance

Systems examination

Thyroid gland
Breasts
lymph nodes in the neck, axillae (armpits) and inguinal areas.
Respiratory system
Cardiovascular system
Both external and internal genitalia
Abdomen

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General Examination

Height: Measure height without wearing shoes
Weight:Weigh with light clothing

weighing scale should be checked for accuracy and calibration

Blood pressure (BP): Measure BP after woman rests for 5 minutes.
Pulse rate: Measure pulse rate for one minute.
Respiratory Rate: assess respiratory rate for one full minute
Temperature: Oral or temporal temperature
General appearance and comportment

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General Examination

General appearance:

How does the patient look and sound?
Check for signs of anaemia: Pale conjunctiva, fingernails and gums
Oedema, jaundice and enlarged lymph nodes should be specifically looked for

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System Examination: Thyroid Gland

Inspect the thyroid

Visibly enlarged- possibly abnormal,
Slightly diffusely enlarged on palpation- normal in pregnancy
Obviously enlarged gland, a single palpable nodule, or a nodular goitre in abnormal

Abnormal finding should be further investigated by the health practitioner.

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System Examination: Breasts

Breasts should be examined with patient both sitting and lying on her back, with hands above her head.
Look for:

Obvious gross abnormalities
Distortion of the breasts or nipples
Nipples-their position and shape, discharge, inversion
Areola- any eczema of the areola

Palpate for lumps, using the flat hand rather than fingers.
A breast lump or blood stained discharge from the nipple must be further investigated.

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System Examination: Lymph Nodes

System Examination: Respiratory System

Palpate neck for enlarged lymph nodes

Note enlargement of thyroid gland

Palpate axilla and inguinal areas.
Note: Patients with AIDS usually have enlarged lymph nodes in all these areas.

Observe for signs of difficulty in breathing (dyspnea)
Listen to lung sounds

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System Examination: Cardiovascular System

Measure blood pressure

Accurate initial assessment is essential for future comparisons

Measure Pulse rate.

A rapid heart rate may be an indication of anxiety or illness

Check for oedema around ankles, feet, hands, face

(facial oedema may indicate a condition called pre eclampsia)

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Case study:

A 16 week pregnant woman came in for her first antenatal check up. After establishing the positive test results for pregnancy, the nurse took a health history and vital signs. The nurse then discussed nutritional needs during pregnancy and management of nausea. The nurse advised the woman to return at 20 weeks of gestation for second antenatal visit.

What nursing actions demonstrated the nurse’s role for assessment and education?

What additional nursing actions are required regarding the physical assessment?

Explain the rationale for conducting a complete physical assessment.

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What did the nurse do right?

Established the positive test results for pregnancy
Took a complete health history
Measureed blood pressure
Counseled about the nutrition and management of nausea
Give a date for the second antenatal visit

What else should the nurse have done regarding physical assessment?

The nurse should have conducted a physical assessment of the following:

Height and Weight
General appearance
Systems examination
Thyroid Gland
Breasts
lymph nodes in the neck, axillae (armpits), and inguinal areas.
Respiratory System
Cardiovascular system
Abdomen
Both external and internal genitalia

Why should the nurse conduct a complete physical assessment?

A complete physical assessment gives a general idea about the health status of the mother and fetus. It helps the nurse rule out/identify warning signs that could pose risks to the health of the mother and the fetus.

By identifying warning signs, nurse can plan and implement antenatal care that would prevent or manage the risks to the mother and fetus.

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System Examination: External and Internal Genitalia

Examine external and internal genitalia for signs of sexually transmitted diseases (STDs)

Single or multiple ulcers
Purulent discharge
Enlarged inguinal lymph nodes

Examine cervix:

Wart like growth or an ulcer may be indication of advanced stages of carcinoma
Normal looking cervix does not exclude possibility of early carcinoma

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System Examination: Abdomen

General appearance of the abdomen
Palpation of the abdomen
Examination of the uterus and surrounding organs
Assessment of uterine irritability (contractions)
Assessment of amount of amniotic fluid quantity
Examination of the fetus (Depending on gestational age: Leopold maneuver, Ultrasound)
Listening to the fetal heart
Assessment of fetal movements

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Abdomen Examination

General appearance

Obesity
Note presence and reason for any scars
Apparent size and shape of the uterus
Any additional abnormalities

Palpation of the abdomen

Palpate liver, spleen, and kidneys
Any abdominal mass should be noted
Refer presence of an enlarged organ or mass to the healthcare provider

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Abdomen Examination: Uterus

Palpation of the uterus:

Check whether uterus is located midline in the abdomen.

Sometimes it may be rotated either to the right or to the left

Palpate the wall of the uterus for irregularities. Irregular uterine wall suggests either:

the presence of myomas (fibroids), usually enlarge during pregnancy and may become painful
a congenital abnormality such as a bicornuate uterus

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Abdomen Examination: Uterus

Bimanual exam:

Can be done before 12 weeks (3 months) of pregnancy
Feel the uterus using two hands 2 hands and check for:

Shape and size of the uterus
Size of the ovaries
Infections or growths
To determine gestational age

(The nurse’s role concerning performance of a bimanual exam varies with country regulations)

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Bimanual exam is performed by a skilled practitioner and according to national regulations. and professional guidelines.
According to Hesperian Health Guides ‘A Book for Midwives’:

Steps for a bimanual exam:

1. Wash hands and wear very clean or sterile gloves.

2. Have the woman lie on her back with a pillow under her head.

3. Explain the bimanual exam procedure to the woman

4. Remind her to relax during the exam and stop the exam if she has pain

5. When she is ready, put lubricating jelly-like K-Y jelly (do not use oil or petroleum jelly) on the first 2 fingers of your hand that you will be

inserting inside the vagina.

6. Gently open the lips of her genitals with lubricated fingers, ask the woman to take a deep breath to help her relax, then with the palm

facing up gently put the fingers al the way into the woman’s vagina

7. Feel the cervix which should be firm, round, and smooth.

· If you cannot feel the cervix ask the woman to cough or push down as if she were passing stool until the cervix touches your fingers.

· Laying woman more flat can help as well

8. Check for pain in the cervix:

· Putting a finger on each side of the cervix, move it side to side.

· the woman might feel strange but should not hurt.

· if it hurts then she might have an infection in her uterus or tubal pregnancy.

· Soft and easy to move cervix may mean a woman is pregnant.

9. Put your other freehand on the woman’s abdomen, below her navel and above the hair around her genitals.

10. Feel the uterus by lifting the cervix and uterus with two fingers while pressing down on the woman’s lower belly with your outside hand.

· Try feeling the uterus between two fingers and your hand.

· You will know you are pressing on the uterus when you feel the cervix move.

11. Feel the size and shape of the uterus

· Usually feels firm, smooth, smaller than a lemon (about 6 cm to 10 cm). ( The uterus grows larger during pregnancy.)

· Feel for lumps or growths on the uterus. Some growths are called fibroids which though not dangerous may cause pain, heavy monthly bleeding, or bleeding between monthly bleedings. Other growths may indicate cancer of the uterus.

12. Feel the ovaries

· Put both your inside fingers on one side of the cervix and lift the ovary while sliding your outside fingers down the same side of the woman’s abdomen.

· When you push down deep you can feel the ovary slip between your fingers. Ask the woman to take a deep breath and let it go before you palpate her ovary.

· Stop pushing if she has pain.

· Ovaries are usually 3 cm long and 2 cm wide. If ovaries are bigger than this and/or this exam is painful, she might have a growth on the ovary or tubal pregnancy.

13. Taking out your fingers from the vagina, hold the lips of her genitals open and ask her to cough or push down as if she were passing stool.

· Watch her vagina to see if anything protrudes. If it does, she could have a fallen uterus or bladder, or part of her bowel could be bulging into the vagina.

14. Feeling the uterus and ovaries take a lot of practice. It is especially difficult to feel a woman’s uterus and ovaries with strong abdominal muscles or with a lot of abdominal fat.

Refer to the health care provider if the exam is painful, the woman during the examination of cervix or uterus or ovaries, palpation of any growths or lumps, and/or anything bulges out of her vagina.

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Abdomen Examination: Uterus

Determining size of uterus before 18 weeks gestation

Anatomical landmarks: the symphysis pubis and the umbilicus
Gently palpate fundus in the abdomen:

Palpable just above symphysis pubis, gestational age probably 12 weeks
Palpable halfway between symphysis pubis and umbilicus, gestational age is probably 16 weeks
Palpable at the same height as the umbilicus, gestational age is probably 22 weeks

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Abdomen Examination: Uterus

Determining size of uterus from 18 weeks gestation:

Feel for the fundus of the uterus, and mark at the highest point of the fundus
Measure the symphysis-fundus (SF) height by measuring distance from the top of the symphysis pubis to the top of the uterus marked
Assess whether determined SF height corresponds to the patients date and size of fetus

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According to Bettercare/Primary Maternal care/1b.Skills: Examination of the abdomen in pregnancy:

Steps for palpation of the abdomen:

· Feel for the fundus of the uterus

o start to gently palpate from the lower end of the sternum

o continue palpating down the abdomen until the fundus is reached

o mark the skin at the point of the highest part of the fundus

o Find and mark the highest point of the fundus to the right or left, of the abdomen, if not in the midline

· Measure the symphysis-fundus (SF) height

o hold the end of the tape measure at the top of the symphysis pubis

o Lay the tape measure over the curve of the uterus to the point marking the top of the uterus.

o the tape measure must not be stretched while measuring.

o measure distance from the top of the symphysis pubis to the point marking the top of the fundus.

if the uterus lies away from the midline, to the right or left, then the distance of the highest point of the uterus must still be measured without moving the uterus into the midline.

According to the Hesperian Health Guides - a Book for Midwives:

Warning signs

· The size of the uterus does not match the due date

· the uterus grows more or less than 2 finger-widths every month

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Case study:

Two pregnant women of 8 weeks gestation and 24 weeks gestation respectively, came to the antenatal clinic.

What differences in the physical assessment of the uterus would nurse expect between the two clients?

How would the nurse identify gestational age of these women?

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What differences in the physical assessment of the uterus would the nurse expect between the two clients?

Uterus fundus height would be at the umbilicus level in 22 weeks pregnant woman whereas fundus height would be below symphysis pubis in the 8 weeks pregnant woman.

How would the nurse identify the gestational age of these women through physical assessment?

To identify 8 weeks pregnant woman through physical assessment, the nurse would use bimanual examination to feel the shape and size of the uterus, and then identify the gestational age. Also, simply palpating on outside of the lower abdomen, she would find the uterus below the level of the symphysis pubis.

To identify 24 weeks of gestation in the pregnant woman through physical assessment:

1. The nurse would palpate on the outside of the woman’s abdomen, find the fundal height of the uterus and mark it exactly where she finds it (regardless of where the uterus is in the abdomen). Then the nurse would tape measure, without stretching, from the symphysis pubis to the marked fundal height and then identify the gestational age.

2. Nurse would find fundal height to be one finger width above the umbilicus.

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Abdomen Examination: Fetus

Lie and presenting part of the fetus is important to assess after 34 weeks gestation
Determine Lie of the fetus

relationship of the long axis of the fetus to that of the mother
may be longitudinal, transverse, or oblique

Determine the presentation of the fetus:

breech presentation, cephalic presentation, or no presenting part felt (transverse or oblique lie).

Determine the location of the back of the fetus and whether the back of the fetus is on mother’s right or left side

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Four Steps of Palpating Fetus

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Leopold Maneuver
According to Bettercare/Primary Maternal care/1b.Skills: Examination of the abdomen in pregnancy:

Methods of palpation:

Four specific steps of palpating the fetus are performed systematically with the mother lying comfortably on her back with the examiner facing the patient for the first three steps, and facing her feet for the fourth.

First step:

· Establish the height of the fundus.

· The fundus is gently palpated to discover which pole of the fetus (breech or head) is present.

· The Head feels hard and round, easily movable, and ballotable.

· The breech feels soft, triangular, and continuous with the body.

Second step:

· Pllace hands on the sides of the abdomen.

· On one side there is the smooth, firm curve of the back of the fetus, on the other side, a rather knobbly feel of the fetal limbs.

Third step:

· Grasp the lower portion of the abdomen, just above the symphysis pubis, between the thumb and fingers of one hand.

· The objective is to feel for the presenting part of the fetus and to decide whether the presenting part is loose above the pelvis or fixed in the pelvis.

· If the head is loose above the pelvis, it can be easily moved and balloted.

· The head and breech are differentiated in the same way as described in the first step.

Fourth step:

· The objective of this is to determine the amount of head palpable above the pelvis brim in the fifths if there is a cephalic presentation.

· Face the patient’s feet, and with the tips of the middle 3 fingers palpate deeply in the pelvic inlet. This way head can usually be readily palpated unless it is already deeply in the pelvis.

· The amount of the head palpable above the pelvic brim can also be determined.

It is often difficult to feel the fetus well when the patient is obese, when there is a lot of liquor/amniotic fluid, or when the uterus is tight, as in some primigravidas.

Warning signs:

· Size of fetal head smaller relative to the size of the uterus- multiple pregnancies

· Relatively small fetus with hard head to the gestational weeks- intrauterine growth restriction

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Abdomen Examination: Uterine Irritability

Abdomen Examination: Amount of Liquor/Amniotic fluid Present

Uterus feels tight, or has a contraction on palpation
Normally only occurs after 36 weeks of gestation, near term
Irritable uterus before 36 weeks gestation may indicate:

intrauterine growth restriction
patient may be in, or is likely to go into preterm labor

Not always easy to feel (accurate only by ultrasound)
Amount of fluid decreases as the pregnancy nears term
Assessed clinically by feeling the way that the fetus can be moved (balloted) while being palpated

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Abdomen Examination: Fetal Heart

Begin listening to fetal heart at 5 months gestation
Method:

Most easily heard by listening over the back of the fetus; First, determine fetal lie and position by palpation
Place fetoscope or stethoscope near the spot where you think the fetal heart should be heard (Infant’s back)
Listen in many places until you hear the heartbeat most loudly and clearly
Count the fetal heart rate for a minute

Head down

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Abdomen Examination: Fetal Heart

When to listen?

If the patient has not felt fetal movement during the day
To rule out intrauterine death

Fetal heart rate :

Should be between 120 and 160 beats per minute
Rate < 120 or >160 beat/min may indicate fetal problems and further assessment
fetal heart rate < 100 or >180 beat/min requires immediate referral for assessment

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Abdomen Examination: Fetal Movements

Assess both:

Kicking movements are caused by movement of limbs
Rolling movement are caused by fetus changing position

Patient should count fetal movements:

Best to do it same time everyday
Do it for 1 hour per day or until there are 10 movements
Position of the patient: may sit or lie down (side way)
Fetal movement must be recorded

Date	Time		Total
3 July	8–9	✓✓✓✓✓✓	6
4 July	11–12	✓✓✓✓✓✓✓✓✓	9
5 July	8–9	✓✓✓	3

Recording of the Fetal Movement

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Nurses Role in Comprehensive Physical Examination

Ensure clients comfort and privacy
Ensure client understands the importance of the physical examination and how it is done
Obtain clients’ consent before conducting physical examination
Inform client about the findings of the physical examination
Encourage client to voice her concerns
Document the important findings

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Nurses Role in Comprehensive Physical Examination

Assure clients comfort and privacy by:

Explaining the purpose of the physical examination with rationale
Obtaining client’s consent
Closing the door and/or pulling curtains for privacy
Exposing only the parts that needs to be examined and only during examination
Informing the clients of the findings
Communicate in a gentle calm voice using layman terms

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Case study:

A woman comes to the clinic at 22 weeks gestation for her first antenatal visit. For physical assessment the nurse closed the door and directed the woman to lie down on the bed/stretcher. The nurse then instructed the woman to lift her dress up to her chest and lower her pants to just below her navel. The woman hesitantly adjusted her clothing. After assessing her abdomen, the nurse instructed the woman to come for the next antenatal visit. The woman stated to a friend that she was not sure if she wanted to come for the next antenatal visit.

Why do you think the woman felt unsure that she wanted to come for next antenatal visit?

What should the nurse have done while conducting physical examination?

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Red Flags

The woman looks or sounds unhealthy or unhappy
Pallor- Shortness of Breath
Vaginal bleeding
Swelling of ankle and legs
Fever
Breast lump or a blood discharge from nipple
Enlarged lymph nodes in neck, above clavicles, behind ears, axillae and inguinal area

Wart like growth or ulcer in genital area
Pain during bimanual exam (if performed)
Size of the uterus inconsistent with due date
The uterus measures more or less than 2 finger widths each month
Fresh unexplained wounds, or wounds at different levels of healing (May indicate intimate partner violence)

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Cultural Considerations

A Muslim female will likely not want to be examined by a male due to religious beliefs and modesty

Some women prefer to have a family member or friend present during an exam. Be sure to check on this prior to the exam

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Reference:

Bettercare (n.d.). Primary Maternal Care/ Antenatal Care/ 1a. Skills: General examination of first antenatal visit. Retrieved from: https://bettercare.co.za/learn/primary-maternal-care/text/01a.html#objectives

Bettercare (n.d.). Primary Maternal Care/ Antenatal Care/ 1b. Skills: Examination of the abdomen in pregnancy. Retrieved from: https://bettercare.co.za/learn/primary-maternal-care/text/01b.html#1b-skills-examination-of-the-abdomen-in-pregnancy

Biggers, A. (2017). What is a bicornuate uterus and how does it affect fertility?. Healthline. Accessed from: https://www.healthline.com/health/womens-health/bicornuate-uterus#causes

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Reference:

Klein, S. Miller, S., & Thomson, F. (2020). Check the mother’s body. A Book for Midwives; Care for pregnancy, birth, and women’s health. Berkeley, California: Hesperian Health Guides.

https://en.hesperian.org/hhg/A_Book_for_Midwives:Check_the_mother%E2%80%99s_body

Manchester University (n.d.). Glossary of Obstetric Terminology. Accessed from: https://mft.nhs.uk/saint-marys/services/maternity-services-obstetrics/glossary-of-obstetric-terminology/

Mayo Clinic. (n.d.). Uterine fibroids. Accessed from: https://www.mayoclinic.org/diseases-conditions/uterine-fibroids/symptoms-causes/syc-20354288

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