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

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 abdomen
A. When should you examine the It is helpful to look at the shape and contour of
abdomen of a woman 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 51
Figure 3A-1: Vertex, face and brow presentations
D. Height of the fundus whether a vaginal delivery is possible. With
breech presentation, there is an increased risk
It is important to ask yourself whether the
of cord prolapse or a placenta praevia.
height of the fundus is in keeping with the
woman’s dates and the findings at previous
antenatal attendances. G. Cephalic presentation of the fetus
If the presentation is cephalic, it is sometimes
E. Size of the fetus possible when palpating the abdomen to
determine the presenting part of the fetal
It is important, on palpation, to assess the size
head (vertex, face or brow). Figure 3A-1
of the fetus. This is best done by feeling the
indicates some features that can assist you in
size of the fetal head. Is the size of the fetus in
determining the presentation.
keeping with the woman’s dates and the size
of the uterus? A fetus which feels smaller than
expected is likely to be associated with: H. Descent and engagement of the head
1. Incorrect dates. This assessment is an essential part of every
2. Intra-uterine growth restriction. examination of a woman in labour. The
3. Multiple pregnancy. descent and engagement of the head is an
important part of assessing the progress of
labour and must be assessed before each
F. Lie and presentation of the fetus
vaginal examination.
It is important to know whether the lie is
The amount of descent and engagement of
longitudinal (cephalic or breech presentation),
the head is assessed by feeling how many
oblique, or transverse. The normal lie is
fifths of the head are palpable above the brim
longitudinal. 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 the
multiple pregnancy or a placenta praevia. whole head is above the brim of the pelvis.
2. 4/5 of the head palpable means that a small
It is also important to know the presentation
part of the head is below the brim of the
of the fetus. The normal presentation is
pelvis and can be lifted out of the pelvis
cephalic (fetal head presentation). If a breech
with the deep pelvic grip.
presentation is present, it must be decided

3. 52 INTRAPAR TUM CARE
Figure 3A-2: An accurate method of determining the amount of head palpable above the brim of the pelvis
3. 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. SK ILLS WORKSHOP : EXAMINATION OF THE ABDOMEN IN LABOUR 53
Figure 3A-3: Method of grading the duration of uterine contractions for recording on the partogram
When there is both hardness and tenderness of K. Grading the duration of contractions
the uterus, without period of relaxation during
1. Contractions lasting less than 20 seconds
which the uterus is not tender, the commonest
(‘weak contractions’).
causes are:
2. Contractions lasting 20–40 seconds
1. 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 problem
if the uterus is harder than normal and there is
also tenderness without periods of relaxation. L. Grading the frequency
Hardness or tenderness of the uterus must duration of contractions
be recorded on the partogram and the most The frequency of contractions is assessed by
experienced person called to assess the woman. counting the number of contractions that
occur in a period of 10 minutes
ASSESSING
CONTRACTIONS ASSESSING THE
FETAL HEART RATE
J. Contractions
Contractions can be felt by placing a hand M. Fetal heart rate pattern
on the abdomen and feeling when the uterus The fetal heart must be detected and the fetal
becomes hard, and when it relaxes. It is, heart rate pattern assessed and recorded every
therefore, possible to assess the length of time the abdomen is examined in labour.
the contractions by taking the time at the
beginning and end of the contraction. The
strength of each contraction is assessed by
measuring the duration of the contraction.