Abdominal Examination

Question 1

Aims of abdominal examination

Answer 1

Observe signs of pregnancy
Assess fetal growth, size (SGA or LGA) + wellbeing
Locate fetal parts, position and presentation
Detect deviations from the norm

Question 2

Why have antenatal care?

Answer 2

Fetal growth restriction is associated with stillbirth, neonatal death, and perinatal morbidity

Enquiries have found stillbirths are avoidable and due to suboptimal care

This can be reduced via early antenatal detection

Question 3

Indications for abdominal examination

Answer 3

Antenatal clinic
Antenatal ward admission
Prior to amniocentesis or other invasive screening test
Prior to auscultation of FH and use of CTG equipment
Prior to vaginal examination
Labour

Question 4

Points to consider prior to examination

Answer 4

Infection control - wash hands before and after
Knowledge of medical/obstetric history
Explanations/informed consent
Dignity/privacy - abdomen only exposed to an extent needed
Semi-recumbent - not too long
Bladder should be empty
Arms by side - as relaxed as possible
Warm hands - uterus can be stimulated
Assessment by same person can reduce errors (NICE)

Question 5

What are the three stages?

Answer 5

1. Inspection - look
2. Palpating - leopald’s manoeuvres
   A) fundal
   B) lateral
   C) pelvic
3. Auscultation - listen

Question 6

1) Inspection - what are we looking for?

Answer 6

Skin - lines nigra, stretch marks, surgery, skin irritation, bruising

Size - obesity, lax abdominal muscles, multiple pregnancy, polyhydramnious, oligohydramnious, ?fetal size, fibroids, gestation period

Fetal movements - visible, have an awareness of maternal concerns

Shape - may indicate position/presentation e.g. dip for occipital posterior position

Question 7

2) Palpation, what do we identify?

Answer 7

Fundal height 
Lie 
Presentation
Position - fetal back to determine position
Engagement 
Attitude

Question 8

What are the three stages of palpation?

Answer 8

Fundal
Lateral
Pelvic

Question 9

What can fundal palpation tell us?

Answer 9

Height - estimated growth in relation to gestational age
Indication of lie and presentation - according to presence of fetal pole
Influenced by parity, size, full bladder, transverse lie, and multiples

Question 10

Fundal palpation - procedure to find fetal pole

Answer 10

Place hands on abdomen, below xiphisternum and move gently down until firmness of fundus felt

Use palmar surface both hands to palpate and identify pole (usually head/buttocks)

Question 11

Difference between head and buttocks?

Answer 11

Head - firm, rounded and ballotable

Buttocks - less firm, larger mass and less ballotable, less clearly defined

Question 12

Fundal palpation - measurement procedure

Answer 12

Identify fundus via palpation 
Use tape measure cm side down 
Measure from top of fundus to symphysis pubis 
Only measure once 
Two - three week intervals 
Refer if concerned

Question 13

What can it indicate if fundal height is inconsistent with gestation?

Answer 13

Unreliable landmarks i.e. long abdomen 
Foetus larger or smaller than expected 
Amniotic fluid is < or > than expected 
Multiple pregnancy
Abnormal lie 
Uterine mass
Poor technique 
Intrauterine death 
Inaccurate dates

Question 14

What does lateral palpation tell us?

Answer 14

Assesses main body of the uterus, identifies lie and position

Gives info re: size/tone/fluid volume and fetal movements

Question 15

Lateral palpation technique

Answer 15

One hand to support uterus at level of umbilicus while other palpated and progresses down the length of uterus on the opposite side

Spine feels smoother and firmer
Limbs less well defines, uterus softer on side where limbs are lying
Fingertips can be walked along uterus

Question 16

Terminology - Lie

Answer 16

Determined by relationship of long axis of fetal spine to long axis of maternal uterus

Question 17

Three types of lie

Answer 17

Longitudinal
Transverse
Oblique

Question 18

Terminology - attitude

Answer 18

Relationship of fetal head and limbs to its body

Question 19

Three types of attitude

Answer 19

Fully flexed

Deflexed

Extended

Question 20

Position of baby when fully flexed

Answer 20

Head and spine flexed, arms cross over ches and legs and things flexed - compact ovoid - fitting uterus comfortably but can move freely

Question 21

What is the optimal fetal skull diameter?

Answer 21

Suboccipitobregmatic as skull bones can overlap (back of head)

Question 22

Terminology - denominator

Answer 22

Fixed position on the presenting part used to indicate the position

Cephalic presentation = occiput
Breech = sacrum
Face = mental

Question 23

Position

Answer 23

Relationship of the denominator to six areas on the mothers pelvis

Also defined according to whether it is on the maternal left or right

Question 24

What is the ideal position?

Answer 24

Left occipito anterior LOA

Question 25

Types of positions

Answer 25

Right left Occipito Posterior transverse/lateral anterior

Question 26

Pelvic palpation - what does it tell us?

Answer 26

Assesses the presentation of the features lying in the lower segment or at the pelvic brim Tells us whether fetus is flexed and if presenting part engaged

Question 27

Pelvic palpation - procedure

Answer 27

Using both hands / fingers facing feet / press in gently - helpful for women to take a deep breath and hold - pawliks manoeuvre

Question 28

Terminology - presentation

Answer 28

Anatomical part of fetus that is leading, directly over cervix Part of baby that will deliver first e.g. cephalic/vertex/brow/face/breech/shoulder

Question 29

What is the Pawlik’s manoeuvre and why should we be cautious?

Answer 29

Pelvic palpation using one hand, fingers facing mothers head, presenting part held between fingers and thumb Can be painful for woman

Question 30

Terminology - engagement

Answer 30

Relationship between the presenting part and the brim of the maternal pelvis Measured in fifths, felt above the symphysis pubis, if head is ballotable on palpation it is 5/5ths palpable When 3/5 passes through brain and can only palpate 2/5 then presenting part is said to be engaged Document whether palpable or engaged

Question 31

Where would you find fetal heart sounds?

Answer 31

Clearest sounds heard through scapula (fetal shoulder blade) can also be heard through chest wall depending on position Locating position and presentation indicates where equipment should be placed

Question 32

Auscultation - what do we assess fetal heart for?

Answer 32

Presence Rate 110-160bpm Regularity Variability

Question 33

Pinard procedure

Answer 33

Undertake abdominal examination Place pinard over area expect heart sounds to be Remove hand so ear pinard and abdomen are in indirect contact Listen and count for one minute Simultaneously assess mothers radial pulse Discuss findings Document and act accordingly

Question 34

Sonicaid - procedure

Answer 34

``` Undertake abdominal palpation Listen to FH with pinard stethoscope Lubricate probe with a suitable conductive gel Place sonicaid over area expect to hear Count for one minute Reassure woman that other sounds may be heard such as uterine blood flow, fetal movements or cord pulsation Wipe of gel Discuss findings Document and act accordingly ```

Question 35

Auscultation - Nice guidance...

Answer 35

Auscultation of FH may confirm fetus alive but unlikely to have any predictive value and routine listening is not therefore recommended However, when requested by mother, may provide reassurance

Question 36

Presentation - NICE guidance...

Answer 36

Fetal presentation should be assessed by abdominal palpation at 36 weeks or later, when it is likely to influence the plans for the birth Routine assessment of presentation by abdominal presentation should not be offered before 36 weeks as not always accurate and may not be comfortable Suspected malpresentation should be confirmed by ultrasound

Question 37

NMC Code

Answer 37

Informed consent Undertake competent examination in which all info is obtained Recognise deviations from the norm and instigate referral Education, explanation and support women Accurate and contemporaneous record keeping