11/13/24, 7\:07 PM Guide | Obstetric abdominal exam

Obstetric abdominal exam

Table of contents
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Gather equipment

Gather relevant equipment including\:
Measuring tape
Pinard stethoscope

Introduction

Wash your hands and don PPE if appropriate.
Introduce yourself to the patient including your name and role.
Con
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p a r t o f t h e a s s e s s m e n t o f y o u r p r e g n a n c y . T h i s w i l l i n v o l v e m e l o o k i n g a n d f e e l i n g t h e t u m m y , i n a d d i t i o n t o p e r f o r m i n g s o m e
m e a s u r e m e n t s . A l t h o u g h i t m a y b e a l i t t l e u n c o m f o r t a b l e , i t s h o u l d n' t b e p a i n f u l . I f a t a n y p o i n t y o u' d l i k e m e t o s t o p t h e n
p l e a s e j u s t l e t m e k n o w .
"
O
Gain consent to proceed with the examination\:
e x a m i n a t i o n ?"
" D o y o u u n d e r s t a n d e v e r y t h i n g I' v e s a i d ? A r e y o u h a p p y f o r m e t o c a r r y o u t t h e
Position the patient on the clinical examination couch with the head of the bed at a 30-45° angle for the initial assessment.
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Adequately expose the patient's abdomen for the examination from the pubic symphysis to the xiphisternum (o
to allow exposure only when required).
Provide the patient with the opportunity to pass urine before the examination.
Ask the patient if they have any pain before proceeding with the clinical examination.

General inspection

Clinical signs

Inspect the patient from the end of the bed whilst at rest, looking for clinical signs suggestive of underlying pathology\:
Pain\: if the patient appears uncomfortable, ask where the pain is and whether they are still happy for you to examine them.
Obvious scars\: may provide clues regarding previous abdominal surgery (e.g. caesarean section).
Pallor\: a pale colour of the skin that can suggest underlying anaemia. It should be noted that healthy individuals may have a
pale complexion that mimics pallor.
Jaundice\: a yellowish or greenish pigmentation of the skin and whites of the eyes due to high bilirubin levels (e.g. obstetric
cholestasis).
Oedema\: a small amount of oedema is normal in the later stages of pregnancy however if there is widespread oedema
a

Objects and equipment

Look for objects or equipment on or around the patient that may provide useful insights into their medical history and current
clinical status\:
Mobility aids\: items such as wheelchairs and walking aids give an indication of the patient's current mobility status.
Vital signs\: charts on which vital signs are recorded will give an indication of the patient's current clinical status and how their
physiological parameters have changed over time (e.g. blood pressure).
Fluid balance\:
patient appears
Prescriptions\: prescribing charts or personal prescriptions can provide useful information about the patient's recent
medications.
General inspection
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Obstetric cholestasis
Obstetric cholestasis is a multifactorial condition that is characterised by abnormal liver function tests, jaundice and
intense pruritis (typically a
and is associated with an increased risk of intrauterine death and premature delivery.

Hands

The hands can provide lots of clinically relevant information and therefore a focused, structured assessment is essential.
Inspect the hands for relevant clinical signs\:
Colour\: pale hands suggest poor peripheral perfusion (e.g. hypovolaemic shock, aortocaval compression) and cyanosis may
suggest underlying hypoxaemia.
Peripheral oedema\: may be a normal
is suspected, you should check the patient's blood pressure and perform urinalysis (looking for proteinuria).
Palmar erythema\: a redness involving the heel of the palm that is a normal

Temperature

Place the dorsal aspect of your hand onto the patient's to assess temperature\:
In healthy individuals, the hands should be symmetrically warm, suggesting adequate perfusion.
Cool hands may suggest poor peripheral perfusion (e.g. hypovolaemic shock, aortocaval compression).

Capillary re

Measuring capillary re
Apply
In healthy individuals, the initial pallor of the area you compressed should return to its normal colour in less than two
seconds.
A CRT that is greater than two seconds suggests poor peripheral perfusion (e.g. antepartum haemorrhage, aortocaval
compression) and the need to assess central capillary re

Radial pulse

Palpate the patient's radial pulse, located at the radial side of the wrist, with the tips of your index and middle
longitudinally over the course of the artery.
Once you have located the radial pulse, assess the rate and rhythm.
Heart rate
Assessing heart rate\:
You can calculate the heart rate in a number of ways, including measuring for 60 seconds, measuring for 30 seconds
and multiplying by 2 or measuring for 15 seconds and multiplying by 4.
For irregular rhythms, you should measure the pulse for a full 60 seconds to improve accuracy.
Women typically have a higher baseline heart rate during pregnancy (80-90 beats per minute).
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Assess the pulse rate

Face

Inspect the patient's face for relevant clinical signs\:
Jaundice\: most evident in the superior portion of the sclera (ask the patient to look downwards as you lift their upper eyelid).
In the context of an obstetric abdominal examination, it is most likely secondary to obstetric cholestasis.
Melasma\: benign dark and irregular hyperpigmented macules which are normal in pregnancy.
Oedema\: may be a normal
Conjunctival pallor\: ask the patient to gently pull down their lower eyelid to allow you to inspect the conjunctiva for pallor.
Conjunctival pallor is associated with anaemia.
Inspect the face
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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).

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.
Fetal movements\: these are typically visible from 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
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.
Inspect the abdomen
Aortocaval compression syndrome
Aortocaval compression syndrome occurs due to compression of the abdominal aorta and inferior vena cava by
the gravid uterus when a pregnant woman is supine. Aortocaval compression can result in maternal hypotension, loss of
consciousness and in rare cases fetal demise. Women in late pregnancy are positioned in the left lateral position when
supine to reduce pressure on the aorta and inferior vena cava.
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Abdominal palpation

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 abdomen

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relate to the pregnancy (e.g. appendicitis). See the abdominal examination guide for more details.

Palpate the uterus

Palpate the uterus to identify its borders, including the upper and lateral edges.
The uterine fundus can be found at di
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

Fetal lie

Fetal lie refers to the relationship between the long axis of the fetus with respect to the long axis of the mother.
Assess the gravid uterus to determine the fetal lie\:
1. Place your hands on either side of the patient's uterus (ensuring you are facing the patient).
2. Gently palpate each side of the uterus\:
One side of the uterus should feel full in nature (due to the presence of the fetal back).
On the other side of the uterus, you may be able to feel the fetus's limbs.
Types of fetal lie
There are three main types of fetal lie which include\:
Longitudinal lie\: the head and buttocks are palpable at each end of the uterus.
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Oblique lie\: the head and buttocks are palpable in one of the iliac fossae.
Transverse lie\: the fetus is lying directly across the uterus.
Palpate the abdomen to determine fetal lie

Fetal presentation

Fetal presentation refers to which anatomical part of the fetus is closest to the pelvic inlet.
Assess the gravid uterus to determine fetal presentation\:
1. Ensure you are facing the patient to observe for signs of discomfort and warn the patient this may feel a little uncomfortable.
2. Place your hands either side of the lower pole of the uterus, just above the pubic symphysis.
3. Apply
A hard round presenting part is suggestive of a cephalic presentation (normal).
A broader, softer, less de
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Assess the presenting part of the fetus

Fetal engagement

In late pregnancy, the level of fetal engagement should be assessed. A fetus is considered 'engaged' when more than 50% of
the presenting part (usually the head) has descended into the pelvis.
The fetal head is divided into
If you are able to feel the entire head in the abdomen, it is
If you are not able to feel the head at all abdominally, it is zero
Assess fetal engagement

Symphyseal-fundal height

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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).
To measure the symphyseal-fundal height\:
1. Begin palpation of the abdomen just inferior to the xiphisternum using the ulnar border of your left hand.
2. Locate the fundus of the uterus (a
3. Once the fundus has been identi
4. 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).
To avoid bias, it's best to place the tape measure facing down and only turn to view the numbers once in position.
Palpate the upper border of the pubic symphysis

Fetal heartbeat

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 (i.e. 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 di
4. Listen for the fetal heartbeat\:
If the maternal pulse coincides with the pulse you can hear, you are most likely listening to the
vessels, rather than the fetal heartbeat.
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Assess the fetal heartbeat using a Pinard stethoscope (or a Doppler ultrasound)

To complete the examination...

Explain to the patient that the examination is now
Thank the patient for their time.
Dispose of PPE appropriately and wash your hands.
Summarise your
Example summary
" T o d a y I e x a m i n e d M r s S m i t h , a 2 8 - y e a r-o l d f e m a l e w h o i s c u r r e n t l y a t 3 6 w e e k s g e s t a t i o n. O n g e n e r a l i n s p e c t i o n , t h e
p a t i e n t a p p e a r e d c o m f o r t a b l e a t r e s t . T h e r e w e r e n o o b j e c t s o r m e d i c a l e q u i p m e n t a r o u n d t h e b e d o f r e l e v a n c e . T h e r e
w a s n o e v i d e n c e o f o e d e m a o f t h e f a c e o r p e r i p h e r i e s o n a s s e s s m e n t .
"
" S y m p h y s e a l -f u n d a l h e i g h t w a s 3 6 c m , w h i c h i s i n k e e p i n g w i t h t h e p a t i e n t' s c u r r e n t ge s t a t i o n . T h e f e t u s w a s p o s i t i o n e d i n
a l o n g i t u d i n a l l i e w i t h a c e p h a l i c p r e s e n t a t i o n . T h e f e t a l h e a d w a s t h r e e
"
" I n s u m m a r y, t h e s e
"
" F o r c o m p l e t e n e s s , I w o u l d l i k e t o p e r f o r m t h e f o l l o w i n g f u r t h e r a s s e s s m e n t s a n d i n v e s t i g a t i o n s.
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