Obstetric Abdominal Examination – OSCE Guide

geekymedics.com/obstetric-abdominal-examination/

October 8,
2010

Obstetric abdominal examination (examination of the pregnant abdomen) frequently

appears in OSCEs. You’ll be expected to pick up the relevant clinical signs using your
examination skills. This obstetric abdominal examination OSCE guide provides a clear
step-by-step approach to examining the pregnant abdomen.

Check out the obstetric abdominal examination OSCE mark scheme here.

Introduction
Wash your hands

Introduce yourself

Confirm the patient’s details (name and date of birth)

Ask if the patient currently has any pain

Explanation

Describe the examination

“Today I need to examine your tummy as part of the assessment of your pregnancy. This will
involve me looking and feeling the tummy, in addition to performing some measurements.
Although it may be a little uncomfortable, it shouldn’t be painful. If at any point you’d like me
to stop then please just let me know.”

Gain consent
“Are you happy for me to carry out the examination?”

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“If you’d like to first empty your bladder before the examination then now would be the best
time to do it.”

General inspection

Carry out a general inspection of the patient:

Do they appear comfortable at rest?
Note any evidence of jaundice or gross oedema

Hands

Radial pulse:
Assess pulse rate and rhythm
Women typically have a higher baseline heart rate during pregnancy (80-90 beats
per minute)

Capillary refill time:

Less than 2 seconds is normal
A prolonged capillary refill time may suggest hypovolaemia (e.g. antepartum
haemorrhage)

Peripheral oedema:
It is normal for women to have a degree of peripheral oedema during pregnancy
(particularly in the later stages)
However, oedema can also be a sign of pre-eclampsia and therefore this diagnosis
needs to be excluded.
If pre-eclampsia is suspected, you should check the patient’s blood pressure and
perform urinalysis (looking for proteinuria)

Face

Inspect the patient’s face, looking for relevant clinical signs:

Jaundice – associated with obstetric cholestasis
Melasma (benign dark and irregular hyperpigmented macules) – a non-pathological
sign associated with pregnancy
Oedema – associated with pre-eclampsia
Conjunctival pallor – associated with anaemia

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General inspection

Assess the pulse rate

Check capillary refill time

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 Inspect the hands

Inspect the face

Inspect the abdomen

Position the patient

The recommended positioning during pregnancy varies, depending

on the patient’s current gestation:
Early pregnancy – position the patient supine on the couch, with the head end of
the bed elevated to 15-30 degrees
Late pregnancy – position the patient in the left lateral position to avoid inferior
vena cava compression

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Closely inspect the abdomen

Expose the abdomen appropriately, from the xiphisternum to the pubic

symphysis and inspect for relevant clinical signs:
Note the shape of the abdomen (this may give an indication of the fetal lie)
Look for fetal movements (from 24 weeks gestation onwards)
Note any surgical scars (e.g. previous caesarean section)

Inspect for cutaneous signs of pregnancy:

Linea nigra
Striae gravidarum
Striae albicans

Inspect the abdomen

Inspect the abdomen

Palpation

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Ask about abdominal tenderness before palpating the abdomen and continue to
monitor the patient’s face for signs of discomfort throughout the examination.

Palpate the 9 regions of the abdomen

Perform light palpation in each of the 9 regions of the abdomen
Note any tenderness, guarding, rebound or masses (other than the gravid uterus
itself)

Palpate the uterus

Identify the borders of the uterus, feeling for its upper and lateral edges

The fundus is found at different places during pregnancy, depending on

the current gestation:
12 weeks gestation – pubic symphysis
20 weeks gestation – umbilicus
36 weeks gestation – the xiphoid process of the sternum

Palpate the upper border of the uterus

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 Uterine location at various stages of pregnancy

Determine fetal lie

1. Place your hands either side of the patient’s uterus (ensuring you are facing the
patient)

2. Apply gentle pressure to each side of the uterus

3. One side of the uterus should feel full in nature (due to the presence of the fetal
back)

4. On the other side of the uterus, you may be able to feel the fetus’s limbs

Types of fetal lie:

Longitudinal – head/buttocks palpable at each end of the uterus
Oblique – head/buttocks palpable in one of the iliac fossae
Transverse – the fetus is lying directly across the uterus

Palpate the abdomen to determine fetal lie

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Palpate the abdomen to determine fetal lie

Palpate the abdomen to determine fetal lie

Palpate the abdomen to determine fetal lie

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 Longitudinal lie

Oblique and Transverse lie

Presentation
1. Ensure you are facing the patient to observe for signs of discomfort

2. Warn the patient this may feel a little uncomfortable

3. Place your hands either side of the lower pole of the uterus (just above
pubic symphysis)

4. Apply firm pressure angled medially, feeling for the presenting part:

A hard round presenting part is suggestive of a cephalic presentation

A broader, softer, less defined presenting part is suggestive of a breech
presentation

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 Assess the presenting part of the fetus

Cephalic presentation

Breech presentation

Assessment of engagement
In late pregnancy, the level of fetal engagement should be assessed.
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Engagement refers more than 50% of the presenting part (usually the head) having
descended into the pelvis.

The fetal head is divided into fifths when assessing engagement:

If you are able to feel the entire head in the abdomen, it is five fifths palpable
(not engaged)
If you are not able to feel the head at all abdominally, it is zero fifths palpable
(fully engaged)

Assess fetal engagement

Assess fetal engagement

Measure symphyseal-fundal height

Symphyseal-fundal height is the distance between the fundus and the upper border of
the pubic symphysis. After 20 weeks gestation, the symphyseal-fundal height should
correlate with the gestational age of the fetus in weeks (+/- 2cm).

1. Begin palpation just inferior to the xiphisternum

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2. Palpate using the ulnar border of the left hand

3. Locate the fundus of the uterus (a firm feeling edge at the upper border of the
bump)

4. Now locate the upper border of the pubic symphysis

5. Measure the distance between the two in centimetres using a tape measure

6. This distance should correlate with the gestational age in weeks (+/- 2cm)

To avoid bias, it’s best to place the tape measure facing down, only turning to view the
numbers once in position.

Palpate the upper border of the pubic symphysis

Measure from the pubic symphysis to the upper border of the uterus

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Measure from the pubic symphysis to the upper border of the uterus

Measure from the pubic symphysis to the upper border of the uterus

Record the SFH

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 Palpate the upper border of the uterus

Palpate the upper border of the pubic symphysis

Measure the distance between the two

Using a Pinard stethoscope

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You may be asked to identify the fetal heartbeat using a Pinard stethoscope (or a
Doppler ultrasound probe). As a result, it is important to have a basic understanding of
how to locate and identify the fetal heartbeat.

1. Based on your assessment of the fetus’s position, you should place the Pinard
stethoscope aiming between the fetal shoulders on the fetal back.

2. Palpate the patient’s radial pulse (maternal pulse).

3. Place your ear to the Pinard and take your hand away (so the Pinard is held
against the abdomen using your ear only):

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.
Pressing too hard will be uncomfortable for the patient and pressing too softly will
make it difficult to hear anything at all.

4. Listen for the fetal heartbeat:

If the maternal pulse coincides with the pulse you can hear, you are most likely
listening to the flow through the uterine vessels, rather than the fetal heartbeat.

Listen to the fetal heartbeat using a Pinard stethoscope (or a doppler ultrasound)

To complete the examination…

Re-cover the patient and allow time for them to get dressed in private

Thank the patient

Wash your hands

Summarise your findings:

“I examined Mrs Smith, a 28-year-old female who is currently at 36 weeks gestation. On

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examination, she was comfortable at rest. Symphyseal-fundal height was 36cm, which is in
keeping with her current gestation. The fetus was positioned in a longitudinal lie with a
cephalic presentation. The fetal head was three fifths palpable.”

Suggest further assessments and investigations

Assessment of the fetal heartbeat using a Pinard stethoscope or Doppler
ultrasound
Blood pressure measurement
Urinalysis
Weight and height measurement
Speculum examination

REVIEWED BY

Mr Isaac Magani
Consultant Obstetrician

Mr Gareth Waring
Senior Obstetric Registrar

ILLUSTRATED BY

Aisha Ali
Medical Student and Illustrator

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