A consulta pré-natal envolve a escuta ativa da gestante, avaliação das queixas trazidas e orientações específicas. O exame físico faz parte de todas as consultas pré-natais e compreende a avaliação do ganho de peso da gestante e dos sinais vitais, especialmente da pressão arterial. Ela deve ser aferida em todas as consultas, e se nível igual ou maior que 140×90 mmHg, deve ser investigada. Quando a pressão arterial apresenta-se normal até a 20ª semana e passa a se elevar a partir desse momento, existe possibilidade de pré-eclâmpsia. Quando ocorre antes dessa idade gestacional, considera-se como hipertensão na gestação.
O exame físico obstétrico propriamente dito se inicia com a mensuração da altura uterina. É uma medida com fita métrica do fundo uterino até a sínfise púbica. Quando a altura uterina é maior que o esperado para a idade gestacional, deve-se suspeitar de gestação múltipla, polidrâmnio, macrossomia fetal, doença trofoblástica gestacional ou alterações uterinas estruturais, como miomatose. Nós cenários de útero menor que o esperado para a idade gestacional, deve-se pensar em restrição de crescimento intrauterino, oligodrâmnio ou malformações.
O próximo tempo do exame físico é a realização das manobras de Leopold. A primeira delas é espalmar as mãos no fundo uterino para determinar a parte fetal que ocupa essa topografia. A segunda consiste em deslizar as mãos espalmadas nas laterais do útero com o objetivo de determinar para qual lado está o dorso fetal. Portanto, a segunda manobra determina a posição do feto. A terceira manobra é a realização de um pinçamento com os dedos do polo fetal que se apresenta no estreito superior da pelve materna. Ela tem por objetivo determinar a mobilidade do polo fetal. A quarta manobra consiste em voltar-se de costas para a paciente e espalmar as mãos na escava pélvica para determinar o grau de penetração do polo fetal.
Seguindo a sequência do exame físico, após as manobras de Leopold, deve-se auscultar os batimentos cardíacos fetais. A situação de normalidade ocorre quando eles estão entre 110 e 160 batimentos por minuto. A ausência de batimentos, assim como a identificação de valores anormais, indica a realização de ultrassonografia obstétrica.
O exame ginecológico e o toque vaginal são procedimentos que podem ser prescindidos na ausência de queixas como corrimento, sangramento ou perdas líquidas. Nos demais cenários, o exame pélvico poderá ser indicado. Todos os passos do exame físico obstétrico devem ser registrados na caderneta pré-natal da gestante.
REFERÊNCIA
BRASIL. Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Atenção ao pré-natal de baixo risco. 1. ed. rev. Brasília: Editora do Ministério da Saúde, 2013.
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