Chapter 26: Pregnant Woman

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Welcome back to the Deep Dive.

Today we are tackling a big one.

We're not just reviewing a textbook chapter.

We are walking into what feels like a physiological mind field.

It really is.

We are breaking down chapter 26 of Bates' Guide to Physical Examination, focused entirely on the pregnant woman.

And calling it a mind field isn't hyperbole at all.

I mean, for a student or even for a clinician who doesn't do this every day, this is the one exam where all the normal rules of medicine seem to just invert.

Yeah, they get turned completely upside down.

And you're suddenly assessing two patients at once, the mother and the fetus.

Exactly.

And the stakes are just, you know, incredibly high.

So our mission today is to move past the simple checklist.

Anyone can memorize, check blood pressure or measure the belly.

We want to get into the why.

We want to understand the physics of why the blood pressure changes,

chemistry, the hormones.

Exactly.

We want to give you, the listener, the why so that the how becomes second nature, not just rote memorization.

Right.

And we're going to follow the chapter.

We'll cover the anatomy, the physiology,

the tricky math of dating a pregnancy, which always trips people up.

And then the physical exam, including the Leopold maneuvers, which I think everyone struggles with at first.

Yeah.

And then finally, the health promotion and counseling piece.

OK, so let's start with the big picture.

If you take nothing else away from this entire deep dive, what is the one core concept from this chapter?

The core concept is that pregnancy is, for all intents and purposes, a nine month physiological stress test.

That's the frame you have to put around it.

A stress test.

I like that.

The body increases its metabolism by 20 percent.

It dilutes its own blood.

It grows an entirely new organ, the placenta that weighs a kilogram.

I mean, if a non -pregnant person walked into the ER with the lab values of a third trimester pregnant woman, we would probably admit them to the ICU.

Right.

You'd be thinking sepsis or some kind of shock state.

Exactly.

Yeah.

In pregnancy, it's normal.

So your job as a clinician is to spot the exact moment when that normal chaos, as I call it, tips over into actual pathology.

That is a perfect setup.

So OK, let's unpack the engine that's driving all this chaos.

Section one in Bates,

anatomy and physiology.

And that engine is all hormonal.

It all starts with the hormones.

And Bates lists a metabolic surge right out of the gate, a 15 to 20 percent increase in basal metabolic rate, which is huge.

Just think about that.

By the third trimester, you're looking at an extra 475 calories a day.

The body is burning just to exist.

Wow.

That is a massive energy tax on the system.

And the architects of this whole new system, this whole new tax, are the hormones.

So we should probably start with estrogen.

OK, estrogen.

I think most students think of it as just, you know, the female hormone.

But here it's acting like a growth factor on steroids.

It absolutely is.

It's the builder.

It's the foreman on site.

It causes the uterus to grow, the breast to prepare for lactation.

But here's an insight that often gets missed.

Something Bates points out.

Estrogen changes the size of the pituitary gland.

Wait, wait, the brain anatomy actually changes.

Yes.

The pituitary enlarges by 135 percent.

It's just pumping out prolactin in preparation.

But, you know, I want to play devil's advocate on estrogen for a second.

We call it a builder, which is true.

But in a clinical setting, I think of it as a clotter.

Great.

The hypercoagulable state.

That's a huge red flag.

It's the biggest one.

Estrogen drives up fibrinogen and a bunch of other clotting factors.

Bates notes the risk of thromboembolism, you know, blood clots, is four to five times higher in pregnancy.

Which, when you think about it, makes evolutionary sense, right?

The body is preparing for birth.

You don't want to hemorrhage and bleed out.

Correct.

It's a survival mechanism that's baked into our biology.

It's to guard against postpartum hemorrhage.

But in modern medicine, with our longer lifespans and different risks, it means that if a pregnant woman comes into the clinic with a swollen leg or sudden shortness of breath,

you have to assume it's a clot until you prove it's not.

The index of suspicion has to be way, way higher.

Through the roof.

Okay.

So estrogen is the builder and the clotter.

What about its partner, progesterone?

If estrogen is the builder, progesterone is the relaxer.

Its levels just skyrocket.

And its number one job is to relax smooth muscle, specifically to keep the uterus from contracting and, well, expelling the fetus too early.

It maintains the pregnancy.

But the body can't just aim that effect at the uterus, can it?

It's not a sniper rifle.

Exactly.

It's a systemic shotgun.

It relaxes all smooth muscle everywhere.

So it relaxes the smooth muscle in the walls of the blood vessels.

And that's what causes blood pressure to drop.

It relaxes the lower esophageal sphincter.

And hello, heartburn.

Exactly.

Gastroesophageal reflux.

It relaxes the smooth muscle of the colon.

Hello, constipation.

Yes.

So many of the common complaints of pregnancy trace right back to this one hormone.

And what about the lungs?

How does it affect breathing?

This is a really key physiological nuance.

And it's a bit of a paradox.

Progesterone actually stimulates the respiratory drive in the brainstem.

It also relaxes the airways to increase what we call tidal volume.

So she's actually breathing deeper, taking in more air with each breath.

She is.

Her body is moving more air, getting more oxygen.

But, and here's the paradox, she often feels shorter breath.

So it's a subjective feeling, even though her oxygenation is objectively better than normal.

Yes.

The subjective sensation of dyspnea is extremely common.

And it's important to know that so you don't immediately jump to thinking it's a pulmonary embolism, though you always keep that in the back of your mind.

And we have to talk about the kidneys and the ureters.

This is a classic board exam question.

Ah, the progesterone effect on the urinary tract.

It's the same principle.

The smooth muscle in the ureters, those little tubes from the kidneys to the bladder, they relax.

So they get floppy?

They dilate, yeah.

And they stop squeezing urine down as effectively.

That peristalsis slows down.

So you get urinary stasis.

The urine just sits there longer.

And static fluid anywhere in the body is a breeding ground for bacteria?

Precisely.

That is why asymptomatic bacteria, that's bacteria in the urine without any symptoms of a UTI,

is something we screen for and treat aggressively in pregnancy.

Why so aggressively?

Because if you don't treat it, that relaxed dilated plumbing provides a super highway for the infection to travel straight up to the kidneys.

You get pylonephritis, which can be a very serious condition in pregnancy, potentially leading to preterm labor.

So progesterone relaxes the tubes and things get stuck or go the wrong way.

Okay, now let's talk about a tricky one.

The thyroid.

Bates mentions something that sounds like a total medical trap.

Transient apparent hyperthyroidism.

This is one of my favorite bits of physiology.

It's so elegant.

So early in pregnancy, you have this hormone called HCG human chorionic gonadotropin.

That's the pregnancy test hormone, right?

The one the placenta makes.

That's the one.

But here's the thing.

Molecularly, HCG looks a lot like TSH thyroid stimulating hormone.

They're structurally very similar.

They're like cousins.

Okay.

So when HCG levels spike in the first trimester, it's so abundant that it accidentally binds to and stimulates the TSH receptors on the thyroid gland.

Hey, it's crosstalk.

The wires get crossed.

It's a perfect case of mistaken identity.

The thyroid gland thinks it's being bombarded with TSH, so it thinks it's being told to work harder.

So it starts pumping out more thyroid hormone, T3 and T4.

Right.

T3 and T4 go up.

And because of the body's negative feedback loop, when T3 and T4 are high, the pituitary shuts down its own TSH production.

So if I were a student and I just looked at the lab report, I'd see high T3, T4, and a low suppressed TSH.

That is the textbook definition of hyperthyroidism, like Graves' disease.

On paper, yes.

It looks identical.

But the patient is clinically fine.

She's a euthyroid.

She doesn't have bulging eyes or a racing heart.

This is transient, apparent hyperthyroidism.

The absolute worst thing you could do is start this woman on an antithyroid drug like methamazole.

Because it's not a real disease.

It'll resolve on its own as the HCG levels fall after the first trimester.

100%.

It's a classic example of why you have to treat the patient, not the number on the lab report.

That is a crucial, crucial insight.

Okay, let's touch on one more hormone.

Relaxin.

I feel like this is the one everyone blames for oh,

my knee's hurt.

That must be the relaxin.

And Bates specifically calls that out as a myth.

It does.

I missed that.

Yes.

The text is very clear.

It says, I'm paraphrasing,

despite its name, relaxin does not affect peripheral joint laxity.

Its primary job is in the reproductive tract, remodeling the connective tissue, softening the cervix, loosening the pelvic ligaments to prepare for delivery.

So if your knee's hurt during pregnancy?

It's probably because you're carrying 30 extra pounds of weight, not because of relaxin.

Myth officially busted.

Okay, let's move from the invisible hormones to the visible anatomy.

The patient is in front of you.

What are you seeing?

Well, the skin is telling a story right away.

You have the striae gravidarm stretch marks.

You'll likely see the linea nigra, that dark brownish line running from the umbilicus down to the pubic bone.

And the one that sounds really dramatic, the diastasis recti.

This one can be really shocking to patients and students if they haven't seen it before.

The tension on the abdominal wall from the growing uterus is so great that the rectus abdominis muscles, the six -pack muscles, literally split apart down the midline.

They separate.

They just unzip.

In some severe cases, there's basically no muscle covering the uterus in the midline.

It's just skin, fascia, and peritoneum.

You can lay your hand there and feel the fetus right through that thin tissue.

It's wild.

That sounds incredibly vulnerable.

Does it cause problems?

It can contribute to back pain, but it's usually benign and often improves after delivery, though not always completely.

Let's talk about the star of the show, the uterus itself.

The dimensions here are just staggering.

They really are.

It goes from a small 70 -gram organ, about the size of an inverted pair, to an 1100 -gram organ.

It increases its capacity by 500 to a thousand times.

A thousand times.

It ends up holding five liters of fluid and fetus on average, but Bates notes it can go up to 20 liters in cases of multiples or excess amniotic fluid.

And it doesn't just grow straight up, does it?

It twists.

It does.

It undergoes what we call dextral rotation.

It rotates to the right.

Why to the right, specifically?

Because the sigmoid colon is on the left.

The colon takes up space in the left side of the pelvis, so the uterus, as it grows, takes the path of least resistance and just sort of leans over to the right.

And that anatomical fact explains a very specific, very common pain pattern.

Right -sided round ligament pain.

100%.

The uterus leaning right puts a constant stretch on that right round ligament.

It also means it's more likely to compress the right ureter than the left, so right -sided hydronephrosis, or swelling of the kidney, is more common than on the left.

So clinical reasoning check.

If a pregnant patient comes in with right flank pain, it might just be her anatomy.

But if she has left flank pain, you might need to look a little closer for things like kidney stones or infection, because the normal anatomy doesn't explain that as well.

That's an excellent rule of thumb to keep in mind.

Before we leave anatomy, we have to cover the color and feel of the cervix and vagina.

There are these three eponymous signs that are total exam fodder.

Ah, yes.

Chadwick, Hagar, and Weaver.

Well, the mucus plug isn't named after anyone, but it's just as important.

Let's start with Chadwick's cell.

Easy one.

Blue.

The cervix and vagina turn a distinct blue -ic purple color because of the massive increase in blood flow and vascular congestion.

Okay, Hagar sign.

This one's about feel.

It's softening.

Specifically, the isthmus of the uterus, that little narrow part where the uterus joins the cervix, gets so soft and compressible that on a bimanual exam, you can almost feel your fingers touch through it.

And the mucus plug.

It's often called the bloody show, which sounds like a title for a horror movie, but it's actually a really good sign.

It's a thick plug of mucus that seals the cervix shut.

When it gets expelled, it means the cervix is starting to dilate and labor is likely imminent.

All right.

So we've built the hormonal engine and mapped the changing anatomy.

Now let's actually drive the car.

Section two in Bates.

The health history.

You're in the room with the patient.

First thing you do before you ask a single question,

shut the door.

And if there's a partner or family member in there, you have to find a way to get them out for at least part of the visit.

Why is that privacy so heavily emphasized here?

More so than in other visits.

Two big reasons.

First,

pregnancy is a high risk time for the escalation of domestic violence.

Second, a woman might not want her partner to know about her previous abortions, her history of STIs, her current substance use, or even her uncertainty about the pregnancy.

And if you ask those critical questions with the partner sitting right there holding her hand.

You will get false data.

You'll get the answer she thinks is safe to give.

You need five minutes alone with her.

It is absolutely non -negotiable for a complete and honest history.

That's a huge clinical pearl.

Okay.

So you have your private space.

The first big question everyone wants to know.

When is the baby due?

You need to do the math.

The nagel rule.

This is the old school industry standard for dating a pregnancy without an ultrasound.

Walk us through it.

And let's be really specific, because I feel like I always mess up the months when I try to do it in my head.

We all do.

The formula is the first day of her last menstrual period or LMP, you take that date, you add seven days, you subtract three months, and then you add one year.

Okay.

Let's try an example that's a little harder than the one in the book.

Let's say the LMP was February 20th.

Okay.

February 20th.

Step one,

add seven days.

February 22nd.

Subtract three months.

So February minus one month is January, minus two is December, minus three is November.

So November 27th.

And step three, add a year.

So her due date is November 27th of the next year.

Exactly.

The add one year part is what adjusts for crossing over the new year.

It sounds kind of confusing when you say it out loud, but if you just write it down and do the days first, then the month, it works.

It works.

But this rule has a massive fatal flaw.

Which is?

It assumes every woman has a perfect robotic 28 day cycle and that she ovulates exactly on day 14.

Which, let's be honest, is incredibly rare.

Almost unheard of.

If she has 35 day cycles or irregular periods, or she just came off birth control pills,

the naggle rule is basically garbage.

It'll give you the wrong date.

And why does a wrong due date matter so much?

It's just an estimate, right?

It matters for interventions.

If you think she's 41 weeks along based on a faulty Nigel date, and you decide to induce labor, but she's actually only 37 weeks along based on her true ovulation, you've just turned a term baby into a late preterm baby because of bad math.

And that can have real consequences.

Absolutely.

That's why a first trimester ultrasound is now the gold standard for dating a pregnancy.

It's far more accurate.

Let's talk about the alphabet soup of obstetric history.

The G's and P.

Gravidity and parity.

Gravidity seems simple enough.

It's the total number of times she has ever been pregnant, right?

Yes.

That includes the current pregnancy.

It also includes any miscarriages or abortions.

It's just a raw count of pregnancies.

Parity is where it gets more complicated.

Parity is the outcome of those pregnancies.

Specifically, it's the number of births that occurred after 20 or 24 weeks gestation, depending on the definition you're using.

And to make this more granular, we use the T -P -A -L system.

T -P -A -L.

Right.

Term births, preterm births, abortions, which includes spontaneous and induced and living children.

This is where we run into the twin strap.

This is where students always lose points on exams.

The classic twin strap.

Okay.

Let's run the scenario.

A woman is pregnant for the very first time.

She delivers healthy twins at 38 weeks.

What is her GMP?

Okay.

Well, she was pregnant one time, so that's G1.

Great.

She had one delivery event, so P1.

Correct again.

P1.

But she has two babies.

Right.

So the L for living in the T -P -A -L system is two.

Her full designation would be G1 P1002.

One term delivery, zero preterm, zero abortions, two living children.

So the key is that twins do not count as P2.

No.

Parity counts the number of pregnancy events that go past 20 weeks, not the number of fetuses.

It's a super counterintuitive point, but it is vital to get right for documentation.

That's a great clarification.

Okay.

Moving into section three, the physical exam.

We're starting with vitals and the general survey.

But before we even touch the patient, we have to talk about how she's sitting on the exam table.

Supine hypotension.

This is not a suggestion.

It's a rule of physics.

Break down the mechanism for us.

Why does this happen?

After about 20 weeks gestation, the uterus is big and heavy.

If a woman lies flat on her back, supine, that heavy uterus flops straight backward and it lands directly on top of the abdomen.

The inferior vena cava and the descending aorta.

It's like stepping on a garden hose.

That is the perfect analogy.

It completely compresses the IVC, which cuts off venous return from the lower half of the body.

Less blood gets back to the heart.

So the heart has less blood to pump out.

And cardiac output plummets.

It crashes.

Yeah.

And blood pressure crashes with it.

And how does the patient feel when this happens?

Dizzy, lightheaded, nauseous, clammy.

They feel awful.

And more importantly, the blood flow to the placenta and the baby drops precipitously.

So the number one rule of the exam in the second half of pregnancy is never flat on the back.

Never.

She needs to be in a semi -sitting position.

Or you can prop a small pillow or a wedge under her right hip to tilt her whole uterus over to the left, off the vessels.

Let's talk blood pressure.

This is arguably the most important single vital sign you'll take in pregnancy.

It absolutely is.

And context is everything.

Remember our discussion about progesterone?

The relaxer.

It relaxes and dilates blood vessels.

So what should happen to blood pressure normally in the second trimester?

It should drop.

It should drop.

It reaches its lowest point, its nadir, around 24 to 26 weeks.

So if you see a blood pressure that looks normal, say 120 over 80, in a woman whose baseline is usually 90 over 60, that relative rise is actually a warning sign.

You have to compare it to her baseline.

Always.

But we also have very strict objective definitions for hypertensive disorders of pregnancy, like preeclampsia.

Okay, let's define it.

Because I feel like people throw that word around pretty loosely sometimes.

The strict definition is new onset of blood pressure greater than 140 systolic, or greater than 90 diastolic, documented on at least two occasions, four hours apart after 20 weeks of gestation.

After 20 weeks.

Yes.

And classically, this was paired with proteinuria protein in the urine.

But wait, I thought the guidelines changed.

I thought you could have preeclampsia without protein in the urine now.

You can.

That's a critical update.

If she has the high blood pressure, no proteinuria, but she has any what we call severe features.

It is still diagnosed as preeclampsia with severe features.

And what are those severe features?

What should we be looking for?

Think of them as signs of end organ damage.

So a low platelet count.

Elevated liver enzymes or severe persistent right upper quadrant pain that suggests the liver is swelling.

A rising creatinine, which points to kidney injury.

Pulmonary edema, which is fluid in the lungs.

And brain symptoms, right?

Yes.

And this is a big one.

New onset, persistent blinding headaches that don't respond to Tylenol or visual changes like seeing spots or flashing lights.

So if a patient at 30 wince calls and says she has a blood pressure of 150 over 100

and a headache that won't go away.

That is a medical emergency.

She needs to be evaluated immediately.

That is a seizure and stroke risk.

How's that different from chronic hypertension?

It's all about the timeline.

If she had high blood pressure before she ever got pregnant or if it's diagnosed before the 20 week mark, that's chronic hypertension.

Preeclampsia is a disease of the placenta.

So it can't happen until the placenta is well established, which is why we use that 20 week line in the sand.

That 20 week mark is just critical for everything, it seems.

Memorize it.

It separates the differential diagnoses for so many things in pregnancy.

Okay.

Let's move up the body to the head, neck and heart.

On the face, you might see cloasma, the mask of pregnancy.

These are branish hyperpigmented patches on the cheeks and forehead.

It's cosmetic, but patients are often concerned about it.

And the nose.

The nose is often congested.

Again, estrogen driven vascular engorgement.

Nose bleeds are super common.

And the gums, don't forget to look in the mouth.

Gum hypertrophy and bleeding are very common.

And the text makes a point to mention that gum health, periodontal health, is actually linked to pregnancy outcomes.

It is.

There's a known association between poor periodontal health and an increased risk for preterm birth.

So it's not just a comfort issue, it's a risk factor.

Don't skip looking in the mouth.

Now, the heart.

Listening to a pregnant heart can be a noisy affair.

Very noisy.

Remember, you have 40 to 50 % more blood volume circulating around.

The heart is working harder, pumping faster.

So all that extra volume creates turbulence.

And turbulence creates murmurs.

A soft systolic ejection murmur is present in over 90 % of pregnant women by the end of pregnancy.

It's benign, it's physiologic.

But a diastolic murmur.

A diastolic murmur is never normal, ever.

If you hear a murmur during the relaxation phase of the heartbeat, diastole, that is a red flag and needs a cardiology referral.

And then there's a mammary souffle.

I just love saying that, souffle.

It's French for a puff or a breath.

And it's this continuous soft blowing sound that you can sometimes hear over the upper chest, usually in the second or third intercostal space.

And it's not coming from the heart.

No,

it's the sound of increased blood flow rushing through the internal mammary arteries to supply the rapidly growing breasts.

So how do you tell it apart from a true cardiac murmur?

There's a great clinical trick.

You can actually obliterate the sound by pressing firmly on that spot with your finger or the edge of your stethoscope.

You're compressing the artery.

You can't press away a heart murmur.

That is a fantastic clinical pearl.

Okay, section four, the abdominal exam.

This is the centerpiece of the whole visit.

It really is.

We're inspecting, we're palpating, we're measuring, and we're listening.

When you're palpating, one of the key things you're doing is measuring fundal height.

Why do we do this?

What's the point?

It's a simple, low -tech, but surprisingly effective screening tool for fetal growth.

You take a tape measure and you measure from the top of the pubic bone, the symphysis pubis, to the very top of the uterus, which is called the fundus.

And there's a magic rule of thumb here, isn't there?

There is.

Between about 16 and 36 weeks, the number of centimeters should be roughly equal to the number of weeks of gestation.

So a woman who is 24 weeks pregnant should measure about 24 centimeters, plus or minus a little bit.

Exactly.

Plus or minus two centimeters is generally considered normal.

So what does it mean if it's way off?

Say she's 30 weeks, but only measuring 24 centimeters.

If the measurement is off by more than, say, four centimeters,

that's a red flag.

If she's measuring too small, you worry about things like fetal growth restriction or not enough amniotic fluid, what we call oligohydromios.

And if she's measuring too big?

Too big could mean she's having twins or she has too much fluid, polyhydromios, or the baby is just very large for its gestational age, which is called macrosomia.

Could even be an error in her dates.

So either way, the tape measure doesn't give you the diagnosis.

No.

It just tells you that you need to order an ultrasound to figure out what's really going on.

It's a triage tool.

Okay.

Now for the part that I think is the hardest to learn from a book,

the Leopold maneuvers.

These are four specific hand movements to figure out how the baby is lying in there.

Can we try to sort of simulate it verbally?

Let's try.

So everyone listening, just close your eyes for a second.

Imagine the woman is lying on the table, tilted slightly to her left.

You are standing at her side, facing her head.

Okay.

Maneuver number one,

the upper pole.

You place both of your hands gently but firmly at the very top of the belly, at the fundus, and you're asking one question.

What part of the baby is up here?

And what are the options?

What could be up there?

Usually it's the buttocks.

A butt feels soft, broad, and irregular.

It doesn't move independently.

But if you feel something that is hard, round, and you can sort of ballot it or move it back and forth, that's a head.

And if the head is at the top of the uterus, that means the baby is breech.

Exactly.

And that's information we need to have.

So we've established we hope there's a butt at the top.

Now, maneuver number two,

the sides.

You move your hands from the top down to the sides of the uterus.

You keep one hand steady on one side to brace the uterus, and you palpate with the other.

You're looking for the back.

What does a fetal back feel like?

It feels like a long, smooth, continuous, resistant surface.

On the other side, you'll feel lots of little bumps and nodules.

The hands and feet?

The knees, feet, and elbows.

We call them the small parts.

Now you know.

But is up, and the back is on her left side, for example.

OK, so that's lying position.

Now, maneuver number three,

the lower pole.

For this one, you use just one hand.

You gently grasp the part of the fetus that's just above the pubic bone.

You form a C shape with your thumb and fingers.

You're feeling the presenting part.

Which we hope is the head.

We hope it's the head.

It should feel hard and round.

And you're also checking to see if it's mobile.

Can you wiggle it?

If you can easily wiggle it side to side, we say it's floating.

If it feels stuck and you can't move it, it's engaged down on the pelvis.

And finally, maneuver four.

This is the only one where you change your own position.

Right.

We turn around, and you now face the woman's feet.

You place your hands on both sides of the lower abdomen, and you try to slide your fingers down into the pelvis, alongside the presenting part.

You're checking for something called cephalic prominence.

What does that mean?

What are you feeling for?

You're trying to figure out if the baby's head is nicely tucked, with the chin to the chest, what we call flexed, or if it's looking up, extended.

If the head is well flexed, the back of the head is lower than the forehead, and you'll feel that prominence on the opposite side from the back.

It's a subtle finding.

So all together, these four maneuvers tell you the fetus's orientation, lie, and attitude, all without an x -ray or an ultrasound.

It's an art form.

It really is.

And it takes a lot of practice to get good at it.

After you figure out where the back is, that's the best place to listen for the heart, right?

Fetal heart tones.

Yes.

You put the Doppler right over the fetal back.

The normal range you're listening for is between 110 and 160 beats per minute.

What if you're listening and you hear a sound that's kind of swooshing, and it's beating at, say, 80 beats per minute, the same rate as the mom's pulse?

That's the uterine souffle?

Right.

That's the sound of blood rushing through the mother's uterine arteries.

You're not hearing the baby.

So how do you avoid that mistake?

You must always, always, always palpate the mother's radial pulse on her wrist while you are listening to the belly.

If the two rates match, you need to move the Doppler and find the baby.

Another critical check.

OK, section five, the pelvic exam.

Right.

We check the external genitalia first.

Look for things like labial varicosities.

You can get varicose veins on the vulva.

Oh, yes.

And they can be incredibly painful and swollen for the patient.

You also look for signs of pelvic organ prolapse, like a cystosil or rectosil.

Then the speculum exam.

We already mentioned the bluish color, the Chadwick sign.

But let's talk about ectropion.

Ectropion really freaks students out the first time they see it.

The cervix looks angry.

The glandular tissue from inside the cervical canal, the columnar epithelium, averts or rolls outward onto the face of the cervix.

It looks bright red, velvety and like raw meat.

Is it dangerous?

Is it a sign of cancer or something?

No, not at all.

It's a normal physiologic change driven by estrogen.

But that tissue is very friable.

It bleeds very easily when you touch it.

So if a pregnant woman reports some light spotting after intercourse or after an exam,

this is very often the cause.

So it's important to recognize it as normal to avoid an unnecessary workup.

Exactly.

Then the bimanual exam.

What are you feeling for there?

One of the most important things you're assessing is the cervix itself.

Specifically, its length and consistency.

Think of the cervix as the gatekeeper, the bottleneck.

It needs to stay long, firm and closed until the very end of the pregnancy.

What's considered a normal length?

It should be more than three centimeters long.

If you feel it's starting to shorten or a face before 34 to 36 weeks, that is a major red flag for preterm labor.

Okay, let's move on to section six.

Documentation.

Writing the note.

The structure of the note really matters for clear communication.

You always start with an opening sentence that's like an executive summary.

Give me an example.

32 -year -old G3P1011 at 34 weeks gestation by confirmed first trimester ultrasound here for routine follow -up.

That one sentence tells the next person reading the chart almost everything they need to know at a glance.

And Bates makes a point to emphasize recording how you got the due date.

Why is that so important?

Because it tells the reader how much confidence to have in that date.

At 34 weeks by an eight -week ultrasound tells me that date is rock solid.

We can rely on it for decision making.

Versus at 34 weeks by an unsure LMP, that tells me we might be off by a week or two.

And that distinction could change how you manage a complication down the line.

Completely.

Is the difference between intervening at 37 weeks versus what might actually be 35 weeks?

Finally, we get to section seven.

Health promotion and counseling.

This is often the part of the visit the patient cares about the most.

It is.

The first question patients almost always ask is what can I eat and what can I eat?

Let's talk about the big one.

Listeria.

Listeria monocytogenes.

It's a particularly nasty bacteria because it can cross the placenta and cause miscarriage, stillbirth, or severe infection in the newborn.

And where does it hide?

What are the high -risk foods?

The classic ones are unpasteurized soft cheeses like brie or queso fresco,

refrigerated pates or meat spreads.

And the one that's hardest for many people, deli meats.

Cold cuts.

So no turkey sandwiches for nine months.

Not unless you take the meat home and heat it in a microwave or on a skillet until it is steaming hot.

You have to kill the bacteria thermally.

And what about fish?

There's all this confusion about mercury.

Right.

Mercury is a neurotoxin that can damage the developing fetal brain.

So the rule is to avoid the big predatory long -living fish.

That's shark, swordfish, king mackerel, and tilefish.

But you don't want women to stop eating all fish.

Absolutely not.

The omega -3 fatty acids like DHA in fatty fish are crucial for the baby's brain development.

So we encourage them to eat 8 to 12 ounces a week of low mercury fish.

Things like salmon, shrimp, pollock, and catfish are great choices.

Let's talk about weight gain.

The old saying was, you're eating for two.

Which is completely false.

It's more like you're eating for one in a tenth.

The recommendations are now tailored to the woman's pre -pregnancy BMI.

Break that down.

If a woman starts at a normal BMI,

she should aim to gain about 25 to 35 pounds.

If she starts in the overweight category, the target is lower, 15 to 25 pounds.

And if she starts with obesity, a BMI over 30, she should only gain about 11 to 20 pounds.

So we really have to tailor that advice to the starting point.

It's not one size fits all.

Not at all.

Okay, let's talk about vaccines.

This is another area with a lot of misinformation.

The two big ones to get are the Tdap and the flu shot.

Tdap is crucial.

We recommend it during every single pregnancy, usually between 27 and 36 weeks.

Why every pregnancy?

If she got it two years ago with her last baby, does she need it again?

Yes.

Because the goal isn't just to protect the mother.

The goal is to have her create a huge surge of antibodies to protest this whooping cough and pass those antibodies through the placenta to the baby.

Ah, so it's to protect the newborn.

Exactly.

Whooping cough can be deadly to a newborn, and they can't get their own first vaccine until they're two months old.

So we vaccinate the mom to give the baby a shield of passive immunity for those first two vulnerable months.

That's a brilliant public health strategy.

It really is.

And the flu shot is totally safe and strongly recommended.

But the key is no live virus vaccines.

So no MMR, no varicella.

One last topic, and it's a heavy one,

safety,

abuse screening.

We touched on this earlier, but it deserves to be re -emphasized.

Pregnancy can be a major trigger for the onset or escalation of IPV intimate partner violence.

The stress, the financial pressure, the changes in the relationship, the volatile time.

And the statistic you mentioned is just chilling.

It is.

Homicide is the leading cause of death among pregnant women in the United States.

That's just awful.

That's why we say universal screening.

We ask every single patient every time in private.

We aren't just checking a box on a form.

We are potentially offering a lifeline to someone in a dangerous situation.

We have covered a massive amount of ground today.

I mean, from the invisible hormonal architects to the physics of blood pressure to the very tactile art of the Leopold maneuvers.

It's an incredibly dense chapter.

But if you step back and look at it, the narrative, the story it's telling is actually very clear.

So what is your final takeaway for the listener who's trying to put all these pieces together?

My final takeaway is about what I call clinical vigilance.

In pregnancy, the body is practically shouting with new signs and symptoms.

There's swelling, there are heart murmurs, there's shortness of breath, fatigue.

In any other patient, these are clear signs of disease.

Right.

You'd think heart failure or kidney disease.

Exactly.

In pregnancy, most of the time, they're normal physiologic changes.

But, and this is the big but, they're also the exact same signs of life -threatening complications like preeclampsia, cardiomyopathy, and pulmonary embolism.

You have to be the detective who can discern the noise of normal pregnancy from the signal of true pathology.

That is the art of obstetric medicine.

And I'll leave you with this thought to mull over.

We often treat pregnancy as this temporary condition, you know, a nine -month event, and then it's over and things go back to normal.

But the data is showing us more and more that pregnancy acts like a crystal ball.

How so?

If a woman develops preeclampsia or gestational diabetes, her body has essentially failed that nine -month stress test we talked about at the beginning.

It has revealed an underlying predisposition.

We now know that these women are at a much, much higher risk for heart attacks, hypertension, and strokes 20 or 30 years later.

Wow.

So the prenatal exam isn't just about ensuring the health of the baby in a safe delivery.

It's the first real look we get at a woman's long -term cardiovascular destiny.

That changes the whole perspective on the importance of what you're doing in that room.

It's preventive medicine, not just for the next generation, but for the mother's entire future health.

Fascinating stuff.

Thanks for diving deep with the Last Minute Lecture team.

My pleasure.

See you next time.