Obstetrics topic

1. Abdominal inspection
Position the patient:The recommended positioning for a
patient during pregnancy varies, depending on the current
gestation:
❖ Early pregnancy: position the patient supine on the couch,
with the head end of the bed elevated to 15-30°.
❖ Late pregnancy: position the patient in the left lateral
position (tilted 15° to the horizontal level) to avoid
compression of the abdominal aorta and inferior vena cava
by the gravid uterus (known as aortocaval compression).

2. Closely inspect the abdomen
Expose the abdomen appropriately, from the xiphisternum to the pubic symphysis and inspect for
relevant clinical signs:
❖ Abdominal shape: this may give an initial indication of the fetal lie. Length should be larger than
broad. This indicates longitudinal lie. But if the uterus is low and broad indicates transverse fetus
lie.
❖ Fetal movements: these are typically visible from 22-24 weeks gestation.
❖ Surgical scars: may provide clues regarding previous abdominal surgery (e.g. caesarian section).
❖ Linea nigra: a dark line running vertically down the middle of the abdomen (a normal
fi
nding in
pregnancy).
❖ Striae gravidarum: reddish or purple lesions that develop due to overstretching of the
abdominal skin as the gravid uterus expands (commonly referred to as stretch marks).
❖ Striae albicans: mature stretch marks which appear silver-like in colour and are less pronounced.

4. Abdominal palpation
Palpate the uterus
Palpate the uterus to identify its borders, including the upper
and lateral edges.
The uterine fundus can be found at different locations during
pregnancy, depending on the patient’s current gestation:
❖ 12 weeks gestation: pubic symphysis
❖ 20 weeks gestation: umbilicus
❖ 36 weeks gestation: the xiphoid process of the sternum

6. Obstetric Abdominal
Examination

7. Fundal height
❖ Between 20 and 34 weeks, the height of the uterine fundus measured
in centimeters correlates closely with gestational age in weeks .
❖ This measurement is used to monitor fetal growth and amnionic
fl
uid volume. It is measured as the distance along the abdominal
wall from the top of the symphysis pubis to the top of the fundus.
Importantly, the bladder must be emptied before fundal
measurement.
❖ Obesity or the presence of uterine masses such as leiomyoma may
also limit fundal height accuracy. In such cases, sonography may be
necessary for assessment.
❖

8. To measure the symphyseal-fundal height:
❖ Begin palpation of the abdomen just inferior to the xiphisternum using
the ulnar border of your left hand.
❖ Locate the fundus of the uterus (a
fi
rm feeling edge at the upper
border of the bump).
❖ Once the fundus has been identi
fi
ed, locate the upper border of the
pubic symphysis.
❖ Measure the distance between the upper uterine border and the pubic
symphysis in centimetres using a tape measure. The distance
measured should correlate with the gestational age in weeks (+/- 2cm).

12. Palpation by Leopold maneuver
❖ Palpate the fundus - to determine if it contains head or breech. The breech gives the sensation of a
large, nodular mass, soft whereas the head feels hard and round and is more mobile and
ballottable.
❖ Performed after determination of fetal lie, the second maneuver is accomplished as the palms
are placed on either side of the maternal abdomen, and gentle but deep pressure is exerted.
On one side, a hard, resistant structure is felt—the back. On the other, numerous small,
irregular, mobile parts are felt—the fetal extremities. By noting whether the back is directed
anteriorly, transversely, or posteriorly, fetal orientation can be determined.
❖ The third maneuver is performed by grasping with the thumb and
fi
ngers of one hand the
lower portion of the maternal abdomen just above the symphysis pubis. If the presenting
part is not engaged, a movable mass, usually the head, will be felt. The differentiation
between head and breech is made as in the
fi
rst maneuver. A fetus is considered ‘engaged’
when more than 50% of the presenting part (usually the head) has descended into the pelvis.
❖ To perform the fourth maneuver, the examiner faces the mother’s feet. Used to determine the
degree of descent. When the head has descended, can the feet anterior shoulder or the space
created by the neck from the head

13. Fetal heartbeat-the fetal heart rate ranges from 110 to 160 beats per minute and is
typically heard as a double sound.
Identify the fetal heartbeat using a Pinard stethoscope (or a Doppler ultrasound probe.
❖ Based on your assessment of the fetus’s position, you should place the Pinard
stethoscope aiming between the fetal shoulders on the fetal back.
❖ Palpate the patient’s radial pulse (i.e. maternal pulse).
❖ Place your ear to the Pinard and take your hand away (so the Pinard is held against
the abdomen using your ear only).
A. You should be applying gentle pressure, to ensure a good seal between your ear and
the Pinard, as well as between the Pinard and the abdomen.
B. Pressing too hard will be uncomfortable for the patient and pressing too softly will
make it dif
fi
cult to hear anything at all.
❖ Listen for the fetal heartbeat: If the maternal pulse coincides with the pulse you can
hear, you are most likely listening to the
fl
ow through the uterine vessels, rather than
the fetal heartbeat.

15. To complete the examination…
❖ Explain to the patient that the examination is
now
fi
nished.
❖ Thank the patient for their time.
❖ Dispose of PPE appropriately and wash your hands.
❖ Summarise your
fi
ndings.