obstetric examination

10/26/2011 © Clinical Skills Resource Centre,

University of Liverpool, UK

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Obstetric Examination



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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 patient’s 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 –

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



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Palpation• Maintain your patient’s 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.

Jewellery should be removed



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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

• Accurate palpation

requires practice and

experience.

• Uncertain or abnormal

findings on palpation

may need to be

investigated /confirmed

other means, e.g..

Ultrasound scan.



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The fundal height

• The woman lies supine

• Palpate for the fundus first. The fundus is not usuallypalpated abdominally before 12 weeks gestation.

• Apply gentle pressure with the flat palmar surface ofyour hand moving downwards from the xiphisternum -to palpate the top of the fundus. The fundal height canbe 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 downso the measurements can not be seen - this avoidsobserver bias - to the superior border of the symphisis.( This may be done with zero at the symphis ie the otherway round but the measurement should be the same)

• Look on the reverse of the tape, and document themeasurement in centimetres.



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Measurement of fundal heightPalapate 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

15

20

25

30

35

40

19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40

Weeks gestation

Fu

nd

al h

eig

ht

in c

ms

• 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

above and below



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The lie

• 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)

Longitudinal

Transverse

Oblique



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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 Breech



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Cephalic Presentation

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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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

• The description for a

cephalic presentation

with the occiput lying

directly lateral to the

left would be – LEFT

OCCIPITO-LATERAL

LOL



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=

Position of

Fetal Occiput (or

presenting part)

The PositionImagine the mother is lying supine and you are looking through

her pelvis facing her feet

Direct

posterior

Direct

anterior

Left

lateral

Right

lateral

Right

anterior

Left

anterior

Right

posteriorLeft

posterior

Mothers Spine

Symphysis

pubisMother’s LEFT



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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 mother’s pelvis.



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Direct occipito-

anterior (DOA)Mum’s Right

Placenta

occiput

Occiput

directly faces

the front.

Fetal spine is

in alignment

with mothers

spine.



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Left occipito-

Lateral (LOL)

occiput

Placenta Mum’s LeftThink…

Where do you think

Fetal limbs would be

palpated?

Where do you think

you would

listen for the Fetal

Heart?



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Right occipito-

anterior (ROA)

Mum’s Right Placenta

occiput

Occiput faces

mother’s right.

Widest part of

fetal skull is well

into the brim of

the pelvis-

Head is engaged.



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Left occipito-

Anterior (LOA)

Mum’s Right

occiput

Fetal spine is in

the same plane

as the mother’s

spine,

This is a

longitudinal lie



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Right occipito-

lateral (ROL)

occiput

The Occiput points to the

mother’s

Right.

The fetal spine is in alignment

with the mother’s spine.

Think….

Where do you think

Fetal Limbs may be palpated?

Do you think the head would

be engaged?

Mum’s Left

OCCIPUT



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Direct occipito-

posterior (DOP)Mum’s Right

Placenta

Fetal spine is in alignment

with the mother’s 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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Left occipito-

posterior (LOP)

Mum’s Right

occiput

Mum’s Right

occiput

Occiput here is

slightly to the

Mother’s left -

It is nearly a

Direct Occipito

posterior-

It may be difficult

to

palpate the fetal

back



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Mum’s Right

Placenta

occiput

Right occipito-

posterior(ROP)Mum’s Right

occiput

Fetal spine is in

alignment

with mother’s

spine.

Think …..

Would you palpate

the Fetal back?

Where would you

listen for

the Fetal Heart?



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Breech presentation

The position is described by the direction

in which the sacrum faces the mother’s

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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Direct sacro-anterior

(DSA)Mum’s Right

Sacrum

Placenta The sacrum is

referred

to when the

presenting part

is a BREECH –

Think…

What is the LIE ?

Do you think the

Breech is engaged?



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Left sacro-

anterior (LSA)

Sacrum

Mum’s Right

Placenta



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Right sacro-

anterior (RSA)Mum’s Right

Placenta

Think….

Where do you think

you would listen for

the Fetal Heart?



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Left sacro-lateral

(LSL)mum's Right

Placenta

Mum’s Right

Placenta

Sacrum

Fetal spine is in the

same

plane as the mothers

spine.

The sacrum faces

the mothers left.



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Right sacro-lateral

(RSL)Mum’s Right

Placenta

Sacrum

Think…

What is the LIE?

What is the

presenting part?



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Direct sacro-

posterior (DSP)

Mum’s Right

Placenta



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Left sacro-posterior (LSP)Mum’s Right

Mum’s Right

View from below

Placenta

Sacrum



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Right sacro-posterior (RSP)

Placenta

Sacrum

View from below

Mum’s Right

Sacrum



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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 ….It is common in later

pregnancy to refer to-

Mobile – 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?

Pelvic BRIM

Pelvic BRIM



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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 baby’s 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 mother’s pulse (allows the

examiner to differentiate between

maternal and fetal heart rate)

• A normal fetal heart rate is between 110

– 160 beats per minute (mother’s pulse

should be counted separately).



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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 patient’s 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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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

obstetric examination

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