ABDOMINAL EXAMINATION
Examination of the pregnant women to determine the foetal growth in relation to gestational age, position of the foetus in uterus and its relationship to maternal pelvis.
PURPOSES:
To determine whether the height of the fundus is normal in relation to the period of gestation
To observe the lie, presentation and position of the foetus and the relation of the fetal head to the pelvic brim.
To measure the abdominal girth and fundal height
To determine the abdominal muscle tone
To determine whether the foetal heart rate and foetal movements are normal.
To detect any risk factors
PREPARATION:
The abdominal examination is carried out during antenatal visit before examination
Consent for examination is taken
The patient is asked to evacuate the bladder
History should be taken
Provide privacy and comfortable position
Hand hygiene before and after patient contact
Lie on dorsal position with thighs flexed exposing abdomen
If women in third trimester observe closely for supine hypotension syndrome.
GENERAL ASSESMENT
Temperature
Pulse
Respiration
BP
Weight
Height
METHODS:
Inspection
Palpation
Auscultation
I. INSPECTION:
Inspect the abdomen
Shape, size , scars , linea nigra, striae , movements ,colour
II. PALPATION:
Maintain the patients dignity at all times
Expose only as much of patient as is required
Ensure the patient is positioned appropriately and with warm hands
Palpate the abdomen using even movements of the flat of the palmar surface of closed fingers.
Do not prod the abdomen or use jerky movements as these are likely to irritate the uterus and stimulate a contraction
PNEMONICS – FLIPPER
The Fundal height
The Lie
The Presentation
The Position
Engagement
Fetal Heart rate
THE FUNDAL HEIGHT
Measurement of Fundal height using Measuring Tape
Measure the fundal height in weeks by using the measuring tape at the upper border of symphysis pubis and straight up to the fundal margin
Place zero line of the tape measure on the superior border of the symphysis pubis.
Stretch the tape across the contour of the abdomen to the top of the fundus along the midline
Record the measurement
Measurement of Fundal Height using Palm
12 weeks
16 weeks
20 weeks
24 weeks
28-30 weeks
32 weeks
36 weeks
40 weeks
Level of symphysis pubis
Half way between symphysis pubis and umbilicus
2 fingers below the umbilicus
Level of umbilicus
3 fingers above the level of umbilicus
Half way between umbilicus and xiphoid process
Level of xiphoid process
2 fingers below the xiphoid process, when lightening occurs
PALPATION – IDENTIFYING the LIE
Palpation continues down the body of the uterus
The smooth back of the foetus is palpated and identified(the lie)
The irregular surface created by the limbs, hands and feet is identified
PALPATION – IDENTIFYING the PRESENTATION
The uterus is palpated between the palms of the two hands
The foetal part in the upper pole – in case of breech
And lower pole of the uterus are identified
POSITION
The position of the foetus described by the relationship of the presenting part to the maternal pelvis
The denominator for the presenting part
For the cephalic presentation = occiput and
For the Breech presentation = Sacrum
FOETAL POLE, LIE, PRESENTING PART, ENGAGEMENT and ATTITUDE of FOETAL HEAD are assessed by LEOPOLD’S MANOUVRE.
LEOPOLD’S MANOUEVRE: done by FOUR obstetric grips
Fundal grip – to assess the foetal pole
Lateral grip
to assess the foetal lie
Pawlik’s grip – to assess the presenting part
Deep pelvic grip – to assess the engagement and attitude of foetal head.
FUNDAL GRIP
The first maneuver involves palpating the fundus to determine which part of the foetus occupies the fundus.
Maneuver:
Bygrasping the fundus of the uterus bythe palms of the 2 hands with your fingers quite close
A hard, smooth, round pole indicates a foetal head
Broad ,soft and irregular mass suggestive of Breech
In transverse lie no parts are palpated
LATERAL GRIP:(UMBILICAL GRIP)
The second maneuver involves palpating the either side of the abdomen to determine on which side of the foetal back lies.
The palpation is done facing the patient’s face.
The hands are to be placed flat on either side of the umbilicus to palpate one after the other, the side and front of the uterus to find out the position of the back,limbs and the anterior shoulder.
The back is suggested by smooth curved and resistant feel.
The limb side is comparatively empty and there is small knob-like irregular parts.
After identification of the back it is essential to note its lie as longitudinal lie, transverse lie, and oblique lie.
PAWLIK GRIP: (PRESENTING PART)
The examination is done facing downward the patient’s face.
The overstretched thumb and four finger of the right hand are placed over the lower pole of the uterus keeping the ulnar border of the palm on the upper border of the symphysis pubis.
Presenting part of foetus is the lowest most part of the foetus at the inlet of the pelvis
Thumb is parallel to the right inguinal ligament and the other four fingers is parallel to the left inguinal ligament.
Cephalic or breech presentation
PELVIC GRIP: (FOURTH MANEUVER)
The examination is done facing toward the patient’s feet
Fourfingersofboththehandsareplacedoneithersideoftheuterusbelowumbilical line.
Pelvic grip involves palpating for the brow and the occiput of the foetus determine the foetal position when the foetus in a vertex position.
FOETAL LIE: longitudinal axis of the uterus to the longitudinal axis of the foetus (longitudinal, transverse, oblique)
PRESENTATION: The part of the foetus that overlays the pelvic brim (eg:vertex, breech, shoulder)
ENGAGEMENT: occurred when the widest part of the presenting part has passed successfully through the pelvic inlet.
DESCENT OF THE FOETAL HEAD:
Assessed abdominally
Using the rule of fifth to assess the engagement
Asses how much of the head is still felt per abdomen
When only 2/5 or less of the foetal head palpated above the level of symphysis pubis, this implies the head is engaged
III. AUSCULTATION:
Auscultation is to be done for distinct foetal heart sounds (FHS)
FSH is heard where the concave portion of the back is in contact with the uterine wall
Hear the FHS and count the heart beat per minute.
The normal foetal heart rate is 120-160 per minute.
The foetal heart rate should be auscultated using a fetal stethoscope known either as
Pinnard ( a wood metal or plastic device)
Or a sonic aid (an electronic device)
The chosen device is placed over the baby’s back
Location of the foetal heart may help to confirm the findings on palpation.
RECORDING THE FINDINGS:
1. Report – observation / inspection
2. Fundal height
3. The lie
4. The presentation
5. The position
6. Engagement
7. Foetal heart rate
Documentation the findings on palpation, foetal activity and the FHR in the woman’s medical records.