Describing a Pregnant Female on Physical Examination
When documenting a pregnant female on physical examination, focus on gestational age, fetal presentation, and maternal physiological adaptations to pregnancy while ensuring appropriate positioning to avoid supine hypotension syndrome.
Key Elements to Include in Documentation
Gestational Age and Dating
- Document gestational age in weeks and days (e.g., "32 weeks and 4 days")
- Note method of dating (last menstrual period, early ultrasound)
- Include estimated due date
Maternal Vital Signs
- Blood pressure (compare to pre-pregnancy baseline if available)
- Heart rate (typically increased by 10-20 beats/minute during pregnancy)
- Respiratory rate
- Temperature
- Oxygen saturation (should be maintained >95% for adequate fetal oxygenation) 1
Maternal Position During Examination
- Document patient position (left lateral tilt recommended after mid-pregnancy)
- Avoid prolonged supine positioning after 20 weeks to prevent inferior vena cava compression 2
- If examination requires supine position, use left lateral tilt or manual uterine displacement 1
Abdominal Examination
- Fundal height measurement in centimeters (should approximate gestational age in weeks from 20-36 weeks)
- Fetal lie (longitudinal, transverse, or oblique)
- Fetal presentation (cephalic, breech, or shoulder) 3
- Fetal position (first, second, etc.)
- Fetal heart rate (normal range 110-160 bpm)
- Presence/absence of contractions
Pelvic Examination (if indicated)
- Cervical assessment (if indicated): dilation, effacement, consistency, position
- Important safety note: Avoid digital or speculum examination if vaginal bleeding is present until placenta previa is ruled out by ultrasound 1
Special Considerations
Imaging Documentation
- If ultrasound was performed, document:
Pregnancy-Related Physical Changes
- Breast changes: enlargement, tenderness, darkening of areola
- Skin changes: linea nigra, striae gravidarum, melasma
- Extremity examination: presence/absence of edema
- Reflexes (hyperreflexia may indicate preeclampsia)
Pregnancy Confirmation (Early Pregnancy)
- For early pregnancy, document signs that help confirm pregnancy:
- Amenorrhea duration
- Breast tenderness
- Morning sickness if present
- Uterine enlargement and cervical softening (after 8 weeks) 4
- Results of pregnancy testing if performed
Documentation Example
"32-year-old G2P1 at 28 weeks 3 days gestation (dated by 8-week ultrasound, EDD 10/15/2024) presenting for routine prenatal visit. Vital signs with BP 118/72, HR 82, RR 16, T 98.6°F, SpO2 99% on room air. Patient examined in left lateral tilt position. Fundal height measures 28 cm. Fetus in longitudinal lie, cephalic presentation, first position. FHR 140 bpm by Doppler. No contractions palpated. Extremities with trace bilateral ankle edema. No calf tenderness or swelling."
Common Pitfalls to Avoid
Positioning errors: Failing to document or use left lateral tilt after mid-pregnancy, which can lead to supine hypotension syndrome 2
Incomplete documentation: Omitting key elements such as gestational age, fetal presentation, or maternal adaptations to pregnancy
Vaginal examination with bleeding: Performing digital or speculum examination when vaginal bleeding is present before ruling out placenta previa 1
Inaccurate terminology: Using imprecise terms to describe fetal position or presentation
Radiation exposure concerns: Delaying necessary radiographic studies due to unfounded concerns about fetal radiation exposure when clinically indicated 1
By following these guidelines, clinicians can ensure comprehensive and accurate documentation of pregnant patients during physical examination, which is essential for optimal maternal and fetal outcomes.