Obstetric Examination

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Clinical Skills Resource Centre, University of Liverpool, UK

Prior to examination
Need a warm and private environment. Check patients ID, consider the need for a Chaperone Wash your hands (preferably ensuring they are warm) Introduce yourself and say what status you hold Explain why you need to palpate the patients abdomen Gain verbal consent Ensure the patient has emptied her bladder to avoid discomfort Position patient appropriately supine - head and top of shoulders only supported by pillow - hands by side. (Be aware of supine hypotensive syndrome!)
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Back to Basics ..

Inspect
Inspect the abdomen (shape, size, scars, linea nigra, striae, movements, colour,)

Palpate Abdomen for - growth (gestational age estimated by fundal height measurement) , movements, Fetal parts, No. of fetus, lie, position, presentation and engagement.

Auscultate
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Abdomen for Fetal Heat Rate. Use fetal stethoscope - pinnard or sonicaid.

Clinical Skills Resource Centre, University of Liverpool, UK

Palpation
Maintain your patients dignity at all times Expose only as much of your patient as is required Ensure that your patient is positioned appropriately and that you have warm hands. Palpate the abdomen using even movements of the flat of the palmar surface of closed fingers. (Aim to maintain hand to skin contact as much as possible rather than taking hands on and off the surface of the abdomen) Do not prod the abdomen or use jerky movements as these are likely to irritate the uterus and stimulate a contraction.
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Use even movements of the flat of the palmar surface of closed fingers. Aim to maintain hand to skin contact as much as possible Do not prod the abdomen or use jerky movements as these are likely to irritate the uterus and stimulate a contraction.

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Jewellery should be removed

Clinical Skills Resource Centre, University of Liverpool, UK

Points to record
Inspection The Fundal Height The Lie The Presentation The Position Engagement Fetal Heart Rate

This might help you to remember - I F Li P P E R

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Accurate palpation requires practice and experience. Uncertain or abnormal findings on palpation may need to be investigated /confirmed other means, e.g.. Ultrasound scan.

Clinical Skills Resource Centre, University of Liverpool, UK

The fundal height

The woman lies supine Palpate for the fundus first. The fundus is not usually palpated abdominally before 12 weeks gestation. Apply gentle pressure with the flat palmar surface of your hand moving downwards from the xiphisternum to palpate the top of the fundus. The fundal height can be measured in CMS from 24 weeks gestation. Place the zero end of the tape measure at the fundus. Stretch the tape measure over the abdomen face down so the measurements can not be seen - this avoids observer bias - to the superior border of the symphisis. ( This may be done with zero at the symphis ie the other way round but the measurement should be the same) Look on the reverse of the tape, and document the measurement in centimetres.
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Measurement of fundal height

Palapate the shape of the uterus to clearly identify the fundus. Zero of the tape measure is held at the fundus Gently stretch the tape measure over the abdomen to the superior border of the symphisis

Disposable tape measure placed face down

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Symphysis-fundal height chart

Fundal height (+2 SD) chart
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35

30

25

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15 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Weeks gestation

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The obtained measurement is then charted The height measured is plotted against number of weeks gestation worked out from LMP The chart shows the mean height against gestation The outer lines represent 1 standard deviation Clinical Skills Resource Centre, and below 9 above University of Liverpool, UK
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Fundal height in cm s

The lie
Longitudinal

Transverse Oblique

The lie of the fetus refers to its long axis in relation to the long axis of the mother (i.e. spine) Only LONGITUDINAL lie is normal (This usually
enables the presenting part to enter the pelvis)

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Clinical Skills Resource Centre, University of Liverpool, UK

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Palpation- identifying the LIE

The palpation continues down the body of the uterus The smooth back of the fetus is palpated and identified (the lie) The irregular surface created by the limbs, hands and feet is identified
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The presentation
The presentation is the part of the foetus in the lower pole of the uterus

Cephalic
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Breech

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Palpation- identifying the PRESENTATION

The uterus is gently palpated between the palms of two hands The fetal part in the upper pole (in this case the breech) and the lower pole of the uterus are identified Characteristically the breech is softer than the head, there is no angle formed by the neck and the surface continues smoothly with the back.
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Cephalic Presentation
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Clinical Skills Resource Centre, University of Liverpool, UK

Position
The position of the foetus is described by the relationship of the presenting part to the maternal pelvis
The denominator for the presenting part for a Cephalic presentation = occiput

and for a Breech presentation = sacrum

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Position
LOL The description for a cephalic presentation with the occiput lying directly lateral to the left would be LEFT OCCIPITO-LATERAL
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The Position
Imagine the mother is lying supine and you are looking through her pelvis facing her feet
Mothers LEFT
Direct anterior

Symphysis pubis
Left anterior Right anterior Right lateral Right posterior

= Position of Fetal Occiput (or presenting part)

Left lateral Left posterior

Direct posterior

Mothers Spine
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PRESENTING and RECORDING Your findings (1)

What did you find ? - You need to report your findings clearly and systematically whether it be a verbal report or documented in the patients notes. If you are unsure or were not able to determine a particular aspect SAY SO . (for example - Presentation - ?presenting part . Position Not determined DO not be tempted to Make it UP!)
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PRESENTING and RECORDING Your findings (2)

1. REPORT - observation / inspection 2. Fundal height in CMS = 3.The Lie is .. 4.The Presentation is 5.The Position is 6. Engagement ? 7. Fetal Heart (FH) is 8. Other ???
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Cephalic presentation
Cephalic presentation is the presentation of the fetal head.This is the normal and most common presentation.The position is described by the direction in which the occiput faces the mothers pelvis.

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Clinical Skills Resource Centre, University of Liverpool, UK

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Mums Right Placenta

Direct occipitoanterior (DOA)

Occiput directly faces the front. Fetal spine is in alignment with mothers spine.

occiput
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Left occipitoLateral (LOL)

Placenta Mums Left

Think Where do you think Fetal limbs would be palpated?

Where do you think you would listen for the Fetal Heart?
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occiput

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Clinical Skills Resource Centre, University of Liverpool, UK

Right occipitoanterior (ROA)

Mums Right Placenta

Occiput faces mothers right. Widest part of fetal skull is well into the brim of the pelvisHead is engaged.
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occiput

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Left occipitoAnterior (LOA)

Mums Right

Fetal spine is in the same plane as the mothers spine,

occiput

This is a longitudinal lie

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Clinical Skills Resource Centre, University of Liverpool, UK

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Right occipitolateral (ROL)

Mums Left

The Occiput points to the mothers Right. The fetal spine is in alignment with the mothers spine. Think. Where do you think Fetal Limbs may be palpated? Do you think the head would be engaged?

occiput OCCIPUT

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Clinical Skills Resource Centre, University of Liverpool, UK

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Mums Right Placenta

Direct occipitoposterior (DOP)

Fetal spine is in alignment with the mothers spine. Think.. Where do you think Fetal parts could be palpated? Where might be a good place to listen for the Fetal Heart? Would you be able to palpate the back of the Fetus?

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Clinical Skills Resource Centre, University of Liverpool, UK

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Mums Right

Left occipitoposterior (LOP)

Occiput here is slightly to the Mothers left It is nearly a Direct Occipito posteriorIt may be difficult to palpate the fetal back
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Mums Right

occiput occiput
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Clinical Skills Resource Centre, University of Liverpool, UK

Mums Right

Right occipitoposterior(ROP)
Placenta

Mums Right

Fetal spine is in alignment with mothers spine. Think .. Would you palpate the Fetal back? Where would you listen for the Fetal Heart?
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occiput occiput
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Breech presentation
The position is described by the direction in which the sacrum faces the mothers pelvis. In a breech presentation legs may be flexed or extended. Breech is not a normal presentation and reasons why the breech is presenting should be considered.
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Mums Right

Direct sacro-anterior (DSA)

The sacrum is referred to when the presenting part is a BREECH
Think What is the LIE ? Do you think the Breech is engaged?

Placenta

Sacrum
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Mums Right

Left sacroanterior (LSA)

Placenta

Sacrum
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Mums Right

Right sacroanterior (RSA)

Placenta

Think. Where do you think you would listen for the Fetal Heart?

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Clinical Skills Resource Centre, University of Liverpool, UK

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Mums Right mum's Right

Left sacro-lateral (LSL)

Fetal spine is in the same plane as the mothers spine.

Placenta Placenta

The sacrum faces the mothers left.

Sacrum

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Clinical Skills Resource Centre, University of Liverpool, UK

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Mums Right

Right sacro-lateral (RSL)

Placenta

Think What is the LIE? What is the presenting part?

Sacrum
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Mums Right

Direct sacroposterior (DSP)

Placenta

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Clinical Skills Resource Centre, University of Liverpool, UK

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Left sacro-posterior (LSP)

Mums Right

View from below

Mums Right Placenta

Sacrum

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Clinical Skills Resource Centre, University of Liverpool, UK

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Right sacro-posterior (RSP)

Mums Right

View from below

Placenta

Sacrum Sacrum

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Clinical Skills Resource Centre, University of Liverpool, UK

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Engagement
Refers to the descent of widest transverse diameter of the presenting part (breech or cephalic) through the true pelvic brim. (The widest transverse diameter of the fetal skull is the bi-parietal). The amount of presenting part palpable is used to describe descent into the pelvis When 2/5ths or less of the presenting part is palpable abdominally it is engaged
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Engagement
Engagement occurs around 36 weeks in a primigravida (first pregnancy) with a cephalic presentation. In a multigravida (a patient who has had more than 1 pregnancy) engagement may occur after the onset of labour.
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Engagement .
Pelvic BRIM

Pelvic BRIM

It is common in later pregnancy to refer toMobile the presenting part is free above the brim Fixed the presenting part is entering the pelvis If the presenting part does not engage when anticipated causes of non engagement should be investigated Think What could be a cause of non engagement?
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Clinical Skills Resource Centre, University of Liverpool, UK

Assessing engagement
The examiner usually stands on the mothers right side and faces the mothers feet. The presenting part is identified (cephalic presentation feels hard, rounded with a dip at the neck, breech may feel softer and continuous with spine) The presenting part is palpated using both hands An assessment is made of how much of the presenting part can be palpated and whether the head is engaged, fixed or mobile
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Assessing the fetal heart rate 1

The Fetal Heart (FH) should be auscultated using a fetal stethoscope known either as Pinnard ( a wood metal or plastic device) or a sonicaid (an electronic device) The chosen device is placed over the babys back (the nearer the shoulder the clearer the FH can be heard) Location of the fetal heart may help to confirm your findings on palpation
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Assessing the fetal heart rate 2

The fetal heart rate should be counted for a full minute while also palpating the mothers pulse (allows the examiner to differentiate between maternal and fetal heart rate) A normal fetal heart rate is between 110 160 beats per minute (mothers pulse should be counted separately).
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PRESENTING and RECORDING Your findings (3)

1. REPORT - Anything significant on observation unusual colouration rashes / size

2. Fundal height in CMS = Height in CMS above 24 weeks = to gestational age and should be consistent with dates agreed +/- 2 weeks . (Agreed dates are by scan or LMP)
3.The Lie is .. (Longitudinal / Transverse/ Oblique)

4.The Presentation is .( Cephalic / Breech other presentations difficult to determine on abdominal palpation)
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PRESENTING and RECORDING Your findings (3) cont

5.The Position is (eg LOL / ROA / DOP etc) 6.Engagement - Is the presenting part engaged ? (YES if less than 2/5ths palpable abdominally. If you can feel around the presenting part and it is mobile it is NOT engaged. IF the presenting part is not mobile and you can feel most of it - it is NOT engaged) 7. Fetal Heart (FH) Did you hear it ? With what ? Was it definitely the FH and NOT maternal pulse. For eg you might say - Fetal Heart Heard regularly 144bpm with Pinnards. Maternal Pulse taken 82bpm 8. Other relevant findings for example Fetal Movements Felt or Observed / Fetal Parts Palpated
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