Head and neck: chloasma/jaundiced sclera (obstetric cholestasis), conjunctival pallor(anaemia), nasal congestion, facial oedema
Legs and feet: swelling, oedema and varicose veins
Scars: especially previous lower segment transverse/longitudinal scars (C-section) or laparoscopic scars (may indicateectopic)
Linea nigra: dark line from umbilicus or xiphisternum to suprapubic region
Striae gravidarum: purplish striae of no clinical significance
Striae albicans: old silvery-white striae(parity)
Excoriations (obstetric cholestasis)
Distended superficial veins (increased inferior vena cava pressure due to gravid uterus)
Umbilicus eversion (occurs due to increased abdominal pressure)
Cough for hernias
Warm hands first, ask about pain, and always watch mother’s face while examining.
Fundal height: use the ulnar edge of your left hand to press down in a stepwise fashion from xiphisternum downwards to find the fundus (first bit of resistance); then measure from there to the pubic symphysis with measuring tape. To eliminate bias, measure with the inches side upwards, then turn over for centimetres reading. See box for normal fundal height.
Smaller than expected = intrauterine growth restriction, oligohydramnios, small baby
Lie: face the mother’s head and place your hands each side of the top pole of the uterus, applying gentle pressure. Walk hands down the sides of the abdomen using your palms and all four fingers (one side feels firm and is the back; on the other side you may be able to feel limbs). You can support each side in turn and push the fetus up against it with the other hand. You can also palpate around and on top for parts (the head should be ballotable).
Longitudinal = baby vertical
Oblique = baby diagonal
Transverse = baby horizontal
Presentation (important over 37 weeks):
Feel for a presenting part by pressing on either side of the lower pole of the uterus simultaneously (one hand on each side), while facing mother’s feet. If you are unable to feel a presenting part, press progressively more medially until you are able to
Cephalic = round presenting part, i.e. head
Breech = broader soft presenting part, e.g. bottom
Ballot head by pushing it gently from one side to the other. Be as gentle as possible and watch mother’s face for pain throughout.
Engagement: note how many fifths of the head are palpable. See if your hands can come together below the head (unengaged), or if hands remain separate (engaged). Some people do a finger pinch of the head from below but it is not recommended because it is painful.
‘Engaged’ = >50% of the presenting part is inside pelvis
Liquor volume: palpate around and ballot fluid to assess the approximate quantity (oligohydramnios, polyhydramnios)
Normal fundal height
Fundal height in centimetres should approximate the number of weeks’ gestationfrom 20 weeks onwards (± 2cm until 36cm, and ±3cm from 36cm as may engage after)
At 12 weeks: uterus should be palpable
At 20-22 weeks: fundus should be near umbilicus
At 36 weeks: fundus should be near xiphisternum
Fetal heart auscultation
Find the back of the fetus and place the Pinard Horn or Doppler fetal monitor (Sonicaid) just behind the anterior shoulder, i.e. halfway between mother’s umbilicus and ASIS on the side of the fetus’ back (try both sides if unsure)
Feel the mother’s pulse at the same time
Calculate the fetal heart rate (should be 120-160 bpm). Listen for 1 minute.
Thank patient and restore clothing
‘To complete my examination, I would measure blood pressure and dipstick the urine.’
Summarise and suggest further investigations you would consider after a full history
Try some questions
What may cause the fundal height to be smaller than expected?
What symptoms and signs may suggest obstetric cholestasis?
Please list some causes of polyhydramnios
What are the three different types of breech presentation?