Maternal Care addresses all the common and important problems that occur during pregnancy, labour, delivery and the puerperium. It covers: the antenatal and postnatal care of healthy women with normal pregnancies, monitoring and managing the progress of labour, specific medical problems during pregnancy, labour and the puerperium, family planning, regionalised perinatal care

1. 8A
Skills workshop:
Examination of
the abdomen
in labour
B. What should be assessed on
Objectives examination of the abdomen of
a patient 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 fetal heart rate pattern.
• Grade the uterine contractions. 7. The descent and engagement of the head.
8. The presence or absence of hardness and
tenderness of the uterus.
9. The contractions.
ABDOMINAL PALPATION
C. Shape of the abdomen
A. When should you examine the It is helpful to look at the shape and contour of
abdomen of a patient who is in labour? the abdomen.
The abdominal examination forms an 1. The shape of the uterus will be oval with a
important 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 with
done: a multiple pregnancy or polyhydramnios.
1. On admission. 3. A ‘flattened’ lower abdomen suggests
2. 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. SK ILLS WORKSHOP : EXAMINATION OF THE ABDOMEN IN LABOUR 167
Figure 8A-1: Vertex, face and brow presentations
D. Height of the fundus It is also important to know the presentation
of the fetus. If a breech presentation is present,
It is important to ask yourself whether the
it must be decided whether a vaginal delivery
height of the fundus is in keeping with the
is possible. With breech presentation, there is
patient’s dates and the findings at previous
an increased risk of cord prolapse or a placenta
antenatal attendances.
praevia.
E. Size of the fetus
G. Cephalic presentation of the fetus
It is important on palpation to assess the size
If the presentation is cephalic, it is sometimes
of the fetus. This is best done by feeling the
possible when palpating the abdomen to
size of the fetal head. Is the size of the fetus in
determine the presenting part of the fetal
keeping with the patient’s dates and the size
head (vertex, face or brow). Figure 8A-1
of the uterus? A fetus which feels smaller than
indicates some features that can assist you in
expected is likely to be associated with:
determining the presentation.
1. Incorrect dates.
2. Intra-uterine growth restriction. H. Descent and engagement of the head
3. Multiple pregnancy.
This assessment is an essential part of every
examination of a patient in labour. The
F. Lie and presentation of the fetus
descent and engagement of the head is an
The lie and presentation of the fetus is decided important part of assessing the progress of
on abdominal palpation by using the four labour and must be assessed before each
steps described for antenatal care. vaginal examination.
It is important to know whether the The amount of descent and engagement of
lie is longitudinal (cephalic or breech the head is assessed by feeling how many
presentation), oblique, or transverse. With fifths of the head are palpable above the brim
an abnormal lie, there is an increased risk of of the pelvis:
umbilical cord prolapse. An abnormal lie may
1. 5/5 of the head palpable means that the
suggest that there is a multiple pregnancy or a
whole head is above the inlet of the pelvis.
placenta praevia.
2. 4/5 of the head palpable means that a small
part of the head is below the brim of the

3. 168 MATERNAL CARE
Figure 8A-2: An accurate method of determining the amount of head palpable above the brim of the pelvis
pelvis and can be lifted out of the pelvis possibility of disproportion at the pelvic inlet
with a deep pelvic grip. can be ruled out.
3. 3/5 of the head palpable means that the
head cannot be lifted out of the pelvis. On
doing a deep pelvic grip, your fingers will
Descent and engagement of the head are assessed
move outwards from the neck of the fetus, on abdominal and not on vaginal examination.
then inwards before reaching the pelvic
brim. I. Hardness and tenderness of the uterus
4. 2/5 of the head palpable means that most
A uterus may be regarded as abnormally hard:
of the head is below the pelvic brim, and
on doing a deep pelvic grip, your fingers 1. When it is difficult to palpate fetal parts.
only splay outwards from the fetal neck to 2. When the uterus feels harder than usual.
the pelvic brim.
This may occur:
5. 1/5 of the head palpable means that only
the tip of the fetal head can be felt above 1. In some primigravidas.
the pelvic brim. 2. During a contraction.
3. When there has been an abruptio placentae.
It is very important to be able to distinguish
4. When the uterus has ruptured.
between 3/5 and 2/5 head palpable above the
5. When there is polyhydramnios.
pelvic brim. If only 2/5 of the head is palpable,
then engagement has taken place and the When there is both hardness and tenderness of
the uterus, without period of relaxation during

4. SK ILLS WORKSHOP : EXAMINATION OF THE ABDOMEN IN LABOUR 169
Figure 8A-3: Method of grading the duration of uterine contractions for recording on the partogram
which the uterus is not tender, the commonest K. Grading the duration of contractions
causes are:
1. Contractions lasting less than 20 seconds
1. An abruptio placentae. (‘weak contractions’).
2. A ruptured uterus. 2. Contractions lasting 20–40 seconds
(‘moderate contractions’)
Therefore, there is likely to be a serious
3. Contractions lasting more than 40 seconds
problem if the uterus is harder than normal
(‘strong contractions’).
and there is also tenderness without periods
of relaxation. Hardness or tenderness of the
uterus must be recorded on the partogram and L. Grading the frequency and
reported immediately to the responsible doctor. duration of contractions
The frequency of contractions is assessed by
counting the number of contractions that
ASSESSING occur in a period of ten minutes
CONTRACTIONS
ASSESSING THE
J. Contractions FETAL HEART RATE
Contractions can be felt by placing a hand
on the abdomen and feeling when the uterus
becomes hard, and when it relaxes. It is M. Fetal heart rate pattern
therefore possible to assess the length of a
contraction by taking the time at the beginning The fetal heart rate must be detected and the fetal
and end of the contraction. The strength of heart rate pattern assessed and recorded every
contractions is assessed by measuring their time the abdomen is examined in labour.
duration, and also the frequency with which
they occur in a period of ten minutes.