A thorough, general physical examination should be completed at the initial prenatal encounter. Pelvic examination is performed as part of this evaluation. he cervix is visualized employing a speculum lubricated with warm water or waterbased lubricant gel. Bluish-red passive hyperemia of the cervix is characteristic, but not of itself diagnostic, of pregnancy. Dilated, occluded cervical glands bulging beneath the ectocervical mucosa-nabothian cysts-may be prominent. he cervix is not normally dilated except at the external os. To identiy cytological abnormalities, a Pap test is performed according to current guidelines noted in Chapter 63 (p. 1193). Specimens for identiication of Chlamydia trachomatis and Neisseria gonorrhoeae are also obtained when indicated.
Bimanual examination is completed by palpation, with special attention given to the consistency, length, and dilatation of the cervix; to uterine and adnexal size; to the bony pelvic architecture; and to any vaginal or perineal anomalies. Later in pregnancy, fetal presentation often can also be determined. Lesions of the cevix, vagina, or vulva are further evaluated as needed by colposcopy, biopsy, culture, or dark-field examination. The perianal region is visualized, and digital rectal examination performed as required for complaints of rectal pain, bleeding, or mass.
Precise knowledge of gestational age is one of the most important aspects of prenatal care because several pregnancy complications may develop for which optimal treatment will depend on fetal age. As discussed earlier and in Chapter 7 (p. 124), irst-trimester sonographic assessment is best correlated with menstrual history. That said, gestational age can also be estimated with considerable precision by carefully performed clinical uterine size examination that is coupled with knowledge of the last menses. Uterine size similar to a small orange roughly correlates with a 6-week gestation; a large orange, with an 8-week pregnancy; and a grapefruit, with one at 12 weeks (Margulies, 2001).
Recommended routine tests at the first prenatal encounter are listed in Table 9-1. Initial blood tests include a complete blood count, a determination of blood type with h status, and an antibody screen. The Institute of Medicine recommends universal human immunodeiciency virus (HIV) testing, with patient notiication and right of refusal, as a routine part of prenatal care. The CDC (Branson, 2006) as well as the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists (20 16f, 2017) continue to support this practice. If a woman declines testing, this is recorded in the prenatal record. All pregnant women are also screened for hepatitis B virus infection, syphilis, and immunity to rubella at the initial visit. Based on their prospective investigation of 1000 women, Murray and coworkers (2002) concluded that in the absence of hypertension, routine urinalysis beyond the irst prenatal visit was not necessary. A urine culture is recommended by most because treating bacteruria signiicantly reduces the likelihood of developing symptomatic urinary tract infections in pregnancy (Chap. 53, p. 1026).
Chlamydia trachomatis is isolated from the cervix in 2 to 13 percent of pregnant women. he American Academy of Pediatrics and the American College of Obstetricians and Gynecologists (2017) recommend that all women be screened for chlamydia during the irst prenatal visit, with additional third-trimester testing for those at increased risk. Risk factors include unmarried status, recent change in sexual partner or multiple concurrent partners, age younger than 25 years, inner-city residence, history or presence of other sexually transmitted diseases, and little or no prenatal care. For those testing positive, treatment described in Chapter 65 (p. 1240) is followed by a second testing-a test of cure-3 to 4 weeks after treatment completion.