Table of Contents
- Wash hands
- Introduce self
- Ask Patient’s name, DOB and what they like to be called
- Explain examination and obtain consent
- Position patient lying at 15˚ and expose their abdomen
- Reassure throughout (e.g. congratulate patient, ask how it’s going so far, and if they have thought of a name)
- General: well/unwell, comfortable, breathlessness, pallor
- Pulse rate
- Head and neck: chloasma/jaundiced sclera (obstetric cholestasis), conjunctival pallor (anaemia), nasal congestion, facial oedema
- Legs and feet: swelling, oedema and varicose veins
- Fetal movements
- Scars: especially previous lower segment transverse/longitudinal scars (C-section) or laparoscopic scars (may indicate ectopic)
- Skin changes
- 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.
- 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 below for normal fundal height.
- Bigger than expected = macrosomia, polyhydramnios, multiple pregnancy, wrong dates, fibroids
- Smaller than expected = intrauterine growth restriction, oligohydramnios, small baby
- 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 and engagement
- 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
- 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’ gestation from 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?