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Intrapartum Care: Skills workshop Examination in labour


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Intrapartum Care was developed for doctors and advanced midwives who care for women who deliver in district hospitals. It contains theory chapters and skills workshops adapted from the labour chapters of Maternal Care. monitoring the mother, fetus, and progress of labour, the second and third stages of labour, managing pain, the puerperium and family planning

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Intrapartum Care: Skills workshop Examination in labour

  1. 1. 3A Skills workshop: Examination of the abdomen in labour B. What should be assessed on Objectives examination of the abdomen of a woman who is in labour? When you have completed this skills 1. The shape of the abdomen. 2. The height of the fundus. workshop you should be able to: 3. The size of the fetus. • Assess the size of the fetus. 4. The lie of the fetus. • Determine the fetal lie and presentation. 5. The presentation of the fetus • Determine the descent of the head. 6. The descent and engagement of the head. • Grade the uterine contractions. 7. The presence or absence of hardness and tenderness of the uterus. 8. The contractions. 9. Fetal heart rate pattern.ABDOMINAL PALPITATION C. Shape of the abdomenA. When should you examine the It is helpful to look at the shape and contour ofabdomen of a woman who is in labour? the abdomen.The abdominal examination forms an 1. The shape of the uterus will be oval with aimportant part of every complete physical singleton pregnancy and a longitudinal lie.examination in labour. The examination is 2. The shape of the uterus will be round withdone: a multiple pregnancy or polyhydramnios.1. On admission. 3. A ‘flattened’ lower abdomen suggests2. Before every vaginal examination. a vertex presentation with an occipito-3. At any other time when it is considered posterior position (ROP or LOP). necessary. 4. A suprapubic bulge suggests a full bladder.
  2. 2. SK ILLS WORKSHOP : EXAMINATION OF THE ABDOMEN IN LABOUR 51Figure 3A-1: Vertex, face and brow presentationsD. Height of the fundus whether a vaginal delivery is possible. With breech presentation, there is an increased riskIt is important to ask yourself whether the of cord prolapse or a placenta praevia.height of the fundus is in keeping with thewoman’s dates and the findings at previousantenatal attendances. G. Cephalic presentation of the fetus If the presentation is cephalic, it is sometimesE. Size of the fetus possible when palpating the abdomen to determine the presenting part of the fetalIt is important, on palpation, to assess the size head (vertex, face or brow). Figure 3A-1of the fetus. This is best done by feeling the indicates some features that can assist you insize of the fetal head. Is the size of the fetus in determining the presentation.keeping with the woman’s dates and the sizeof the uterus? A fetus which feels smaller thanexpected is likely to be associated with: H. Descent and engagement of the head1. Incorrect dates. This assessment is an essential part of every2. Intra-uterine growth restriction. examination of a woman in labour. The3. Multiple pregnancy. descent and engagement of the head is an important part of assessing the progress of labour and must be assessed before eachF. Lie and presentation of the fetus vaginal examination.It is important to know whether the lie is The amount of descent and engagement oflongitudinal (cephalic or breech presentation), the head is assessed by feeling how manyoblique, or transverse. The normal lie is fifths of the head are palpable above the brimlongitudinal. With an abnormal lie, there is of the pelvis:an increased risk of umbilical cord prolapse.An abnormal lie may suggest that there is a 1. 5/5 of the head palpable mean that themultiple pregnancy or a placenta praevia. whole head is above the brim of the pelvis. 2. 4/5 of the head palpable means that a smallIt is also important to know the presentation part of the head is below the brim of theof the fetus. The normal presentation is pelvis and can be lifted out of the pelviscephalic (fetal head presentation). If a breech with the deep pelvic grip.presentation is present, it must be decided
  3. 3. 52 INTRAPAR TUM CAREFigure 3A-2: An accurate method of determining the amount of head palpable above the brim of the pelvis3. 3/5 of the head palpable means that the NOTE Another method that could be used to head cannot be lifted out of the pelvis. On determine the amount of fetal head above the doing the deep pelvic grip, your fingers pelvis is to assess the number of fingers that will move outwards from the neck of the could be placed on the remaining fetal head above the pelvic brim, i.e. three fingers indicate fetus, then inwards before reaching the that the fetal head is 3/5 above pelvic brim. pelvic brim.4. 2/5 of the head palpable means that most of the head is below the pelvic brim, and Descent and engagement of the head are assessed on doing the deep pelvic grip, your fingers on abdominal and not on vaginal examination. only splay outwards from the fetal neck to the pelvic brim.5. 1/5 of the head palpable means that only I. Hardness and tenderness of the uterus the tip of the fetal head can be felt above A uterus may be regarded as abnormally hard: the pelvic brim. 1. When it is difficult to palpate fetal parts.It is very important to be able to distinguish 2. When the uterus feels harder than usual.between 3/5 and 2/5 head palpable above the This may occur:pelvic brim. If only 2/5 of the head is palpable,then engagement has taken place and the 1. In some primigravidas.possibility of disproportion at the pelvic inlet 2. During a contraction.can be ruled out. The head is still unengaged if 3. When there has been an abruptio placentae.3/5 head is palpable above the pelvic brim. 4. When the uterus has ruptured.
  4. 4. SK ILLS WORKSHOP : EXAMINATION OF THE ABDOMEN IN LABOUR 53Figure 3A-3: Method of grading the duration of uterine contractions for recording on the partogramWhen there is both hardness and tenderness of K. Grading the duration of contractionsthe uterus, without period of relaxation during 1. Contractions lasting less than 20 secondswhich the uterus is not tender, the commonest (‘weak contractions’).causes are: 2. Contractions lasting 20–40 seconds1. An abruptio placentae. (‘moderate contractions’)2. A ruptured uterus. 3. Contractions lasting more than 40 seconds (‘strong contractions’).Therefore, there is likely to be a serious problemif the uterus is harder than normal and there isalso tenderness without periods of relaxation. L. Grading the frequencyHardness or tenderness of the uterus must duration of contractionsbe recorded on the partogram and the most The frequency of contractions is assessed byexperienced person called to assess the woman. counting the number of contractions that occur in a period of 10 minutesASSESSINGCONTRACTIONS ASSESSING THE FETAL HEART RATEJ. ContractionsContractions can be felt by placing a hand M. Fetal heart rate patternon the abdomen and feeling when the uterus The fetal heart must be detected and the fetalbecomes hard, and when it relaxes. It is, heart rate pattern assessed and recorded everytherefore, possible to assess the length of time the abdomen is examined in labour.the contractions by taking the time at thebeginning and end of the contraction. Thestrength of each contraction is assessed bymeasuring the duration of the contraction.