Pregnant abdomen examination
Introduction
- Wash hands
- Introduce self
- Ask Patientโs name, DOB and what they like to be called
- Explain examination and obtain consent
- Position patient lying at 15ห and expose their abdomen
- Reassure throughout (e.g. congratulate patient, ask how itโs going so far, and if they have thought of a name)
General inspection
- 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
Abdominal inspection
- Distension
- 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
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Abdominal palpation
Warm hands first, ask about pain, and always watch motherโs 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,ย thenย turn over for centimetres reading. See box below for normal fundal height.
- Abnormalities
- Bigger than expected = macrosomia, polyhydramnios, multiple pregnancy, wrong dates, fibroids
- Smaller than expected = intrauterine growth restriction, oligohydramnios, small baby
Lie
- Face the motherโs 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 feelsย firmย and is the back; on the other side youย mayย 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)
- Lies
- Longitudinal = baby vertical
- Oblique = baby diagonal
- Transverse = baby horizontal
Presentation and engagementย
- Presentationย (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 motherโs 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. bottomย
- Ballot head by pushing it gently from one side to the other. Be as gentle as possible and watch motherโs face for pain throughout.
- Engagement:ย 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.
- โEngagedโ = >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 weeksโ gestation from 20 weeks onwards (ยฑ 2cm until 36cm, and ยฑ3cm 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 motherโs umbilicus and ASIS on the side of the fetusโ back (try both sides if unsure)
- Feel the motherโs pulse at the same time
- Calculate the fetal heart rate (should be 120-160 bpm). Listen for 1 minute.
To complete
- Thank patient and restore clothing
- โTo complete my examination, I would measure blood pressure and dipstick the urine.โ
- Summarise and suggest further investigations you would consider after a full history
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Try some questions
What may cause the fundal height to be smaller than expected?
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What symptoms and signs may suggest obstetric cholestasis?
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Please list some causes of polyhydramnios
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What are the three different types of breech presentation?
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- Pregnant abdomen examination
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