8A                                               Skills workshop:                                               Examinatio...
SK ILLS WORKSHOP : EXAMINATION OF THE ABDOMEN IN LABOUR       167Figure 8A-1: Vertex, face and brow presentationsD. Height...
168   MATERNAL CAREFigure 8A-2: An accurate method of determining the amount of head palpable above the brim of the pelvis...
SK ILLS WORKSHOP : EXAMINATION OF THE ABDOMEN IN LABOUR           169Figure 8A-3: Method of grading the duration of uterin...
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Maternal Care: Skills workshop Examination of the abdomen in labour

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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

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Maternal Care: Skills workshop Examination of the abdomen in labour

  1. 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 abdomenA. When should you examine the It is helpful to look at the shape and contour ofabdomen of a patient 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 167Figure 8A-1: Vertex, face and brow presentationsD. 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 deliveryheight of the fundus is in keeping with the is possible. With breech presentation, there ispatient’s dates and the findings at previous an increased risk of cord prolapse or a placentaantenatal attendances. praevia.E. Size of the fetus G. Cephalic presentation of the fetusIt is important on palpation to assess the size If the presentation is cephalic, it is sometimesof the fetus. This is best done by feeling the possible when palpating the abdomen tosize of the fetal head. Is the size of the fetus in determine the presenting part of the fetalkeeping with the patient’s dates and the size head (vertex, face or brow). Figure 8A-1of the uterus? A fetus which feels smaller than indicates some features that can assist you inexpected is likely to be associated with: determining the presentation.1. Incorrect dates.2. Intra-uterine growth restriction. H. Descent and engagement of the head3. Multiple pregnancy. This assessment is an essential part of every examination of a patient in labour. TheF. Lie and presentation of the fetus descent and engagement of the head is anThe lie and presentation of the fetus is decided important part of assessing the progress ofon abdominal palpation by using the four labour and must be assessed before eachsteps described for antenatal care. vaginal examination.It is important to know whether the The amount of descent and engagement oflie is longitudinal (cephalic or breech the head is assessed by feeling how manypresentation), oblique, or transverse. With fifths of the head are palpable above the briman 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 thesuggest 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. 3. 168 MATERNAL CAREFigure 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 uterus4. 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. 4. SK ILLS WORKSHOP : EXAMINATION OF THE ABDOMEN IN LABOUR 169Figure 8A-3: Method of grading the duration of uterine contractions for recording on the partogramwhich the uterus is not tender, the commonest K. Grading the duration of contractionscauses are: 1. Contractions lasting less than 20 seconds1. 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 secondsproblem if the uterus is harder than normal (‘strong contractions’).and there is also tenderness without periodsof relaxation. Hardness or tenderness of theuterus must be recorded on the partogram and L. Grading the frequency andreported immediately to the responsible doctor. duration of contractions The frequency of contractions is assessed by counting the number of contractions thatASSESSING occur in a period of ten minutesCONTRACTIONS ASSESSING THEJ. Contractions FETAL HEART RATEContractions can be felt by placing a handon the abdomen and feeling when the uterusbecomes hard, and when it relaxes. It is M. Fetal heart rate patterntherefore possible to assess the length of acontraction by taking the time at the beginning The fetal heart rate must be detected and the fetaland end of the contraction. The strength of heart rate pattern assessed and recorded everycontractions is assessed by measuring their time the abdomen is examined in labour.duration, and also the frequency with whichthey occur in a period of ten minutes.

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