Pregnant Abdomen

Link: https://www.youtube.com/watch?v=-pkkgBX7OFQ https://www.youtube.com/watch?v=QKLsmNUoRNk

Wash your hands

Introduce yourself

Confirm the patient’s details (name and date of birth)

Ask if the patient currently has any pain

Always have a chaperone present

Ensure privacy

Exposure from just below the breasts to symphysis fundus

[examination should be focused based on clinical context and history]

Explanation

Describe the examination

“Today I need to examine your tummy as part of the assessment of your pregnancy. This will involve me looking and feeling the tummy, in addition to performing some measurements. Although it may be a little uncomfortable, it shouldn’t be painful. If at any point you’d like me to stop then please just let me know.”

Gain consent

“Are you happy for me to carry out the examination?”

“If you’d like to first empty your bladder before the examination then now would be the best time to do it.”

Weight and height measuring important in first clinical exam

BP measurement [over 140/90 in two separate occasions over 4 hours apart] – deflate slowly to measure BP to nearest 2 mmHg

Urinary examination – urinalysis [asymptomatic bacteriuria and proteins]

General inspection

Carry out a general inspection of the patient:

Do they appear comfortable at rest?

Note any evidence of jaundice or gross oedema

Hands

Radial pulse:

Assess pulse rate and rhythm

Women typically have a higher baseline heart rate during pregnancy (80-90 beats per minute)

Capillary refill time:

Less than 2 seconds is normal

A prolonged capillary refill time may suggest hypovolaemia (e.g. antepartum haemorrhage)

Peripheral oedema:

It is normal for women to have a degree of peripheral oedema during pregnancy (particularly in the later stages)

However, oedema can also be a sign of pre-eclampsia and therefore this diagnosis needs to be excluded.

If pre-eclampsia is suspected, you should check the patient’s blood pressure and perform urinalysis (looking for proteinuria) AND REFLEXES???

Face

Inspect the patient’s face, looking for relevant clinical signs:

Jaundice – associated with obstetric cholestasis

Melasma (benign dark and irregular hyperpigmented macules) – a non-pathological sign associated with pregnancy

Oedema – associated with pre-eclampsia

Conjunctival pallor – associated with anaemia

General inspection

Assess the pulse rate

Check capillary refill time

Inspect the hands

Inspect the face

General medical examination for at risk woman: CVS – Auscultation for heart sounds unnecessary but if in area with rheumatic heart disease or known history of heart disease or murmur then need to do CVS exam.

Breast exam – no need. Encourage self examination.

Inspect the abdomen

Position the patient

The recommended positioning during pregnancy varies, depending on the patient’s current gestation:

Early pregnancy – position the patient supine on the couch, with the head end of the bed elevated to 15-30 degrees

Late pregnancy – position the patient in the left lateral position to avoid inferior vena cava compression

Closely inspect the abdomen

Expose the abdomen appropriately, from the xiphisternum to the pubic symphysis and inspect for relevant clinical signs:

Note the shape of the abdomen (this may give an indication of the fetal lie and asymmetry. A saucer shape indentation = OP position)

Look for fetal movements (from 24 weeks gestation onwards. Ask about baby’s movemets)

Note any surgical scars and rashes

Suprapubic (CS, laparotomy for ectopic pregnancy or ovarian masses)
Right iliac fossa (appendictectomy)
Right upper quadrant (cholecystectomy)
Sub-umbilical (laparoscopy)

Inspect for cutaneous signs of pregnancy:

Linea nigra (faint brown line running from umbilicus to symphysis pubis)
Striae gravidarum (stretch marks)
Striae albicans

Inspect the abdomen

Palpation

[for number of babies, size of the baby, lie of the baby, presentation of the baby, whether the baby is engaged] [SFH, number of fetal poles, fetal lie, presentation in that order] [lie and presentation only in late pregnancy] Ask about abdominal tenderness before palpating the abdomen and continue to monitor the patient’s face for signs of discomfort throughout the examination.

Palpate the 9 regions of the abdomen

Perform light palpation in each of the 9 regions of the abdomen

Note any tenderness, guarding, rebound or masses (other than the gravid uterus itself)

Palpate the uterus

Identify the borders of the uterus, feeling for its upper and lateral edges

The fundus is found at different places during pregnancy, depending on the current gestation:

12 weeks gestation – pubic symphysis

20 weeks gestation – umbilicus

36 weeks gestation – the xiphoid process of the sternum

Palpate the upper border of the uterus

Uterine location n at various stages of pregnancy

Count number of poles = a head or bottom , if more than two then twin pregnancy but can be mimicked by large fibroids

Determine fetal lie (ask where do you normally feel kicks)

1. Place your hands either side of the patient’s uterus (ensuring you are facing the patient)

2. Apply gentle pressure to each side of the uterus

3. One side of the uterus should feel full in nature (due to the presence of the fetal back)

4. On the other side of the uterus, you may be able to feel the fetus’s limbs

Types of fetal lie:

Longitudinal – head/buttocks palpable at each end of the uterus

Oblique – head/buttocks palpable in one of the iliac fossae

Transverse – the fetus is lying directly across the uterus

Palpate the abdomen to determine fetal lie

Longitudinal lie

Oblique and Transverse lie

If pole over the pelvis then longitudinal, regardless whether the other pole is lying more to the left or right. Oblique is when not lying over pelvis but just to one side, Transverse is directly across the abdomen. Presentation (important at 24 weeks’gestation unless P/C = threatened preterm labour. The part of the foetus occupying the lower pole of the uterus)

1. Ensure you are facing the patient to observe for signs of discomfort

2. Warn the patient this may feel a little uncomfortable and watch the patients face and use two hands

3. Place your hands either side of the lower pole of the uterus (just above pubic symphysis)

4. Apply firm pressure angled medially, feeling for the presenting part:

A hard round presenting part is suggestive of a cephalic presentation

A broader, softer, less defined presenting part is suggestive of a breech presentation

Assess the presenting part of the fetus

Cephalic presentation

Breech presentation

Assessment of engagement

In late pregnancy, the level of fetal engagement should be assessed. At the same time as feeling for the presenting part assess whether it is engaged or not.

Engagement refers more than 50% of the presenting part (usually the head) having descended into the pelvis.

The fetal head is divided into fifths when assessing engagement:

If you are able to feel the entire head in the abdomen (easily moveable aka free), it is five fifths palpable (not engaged)

If you are not able to feel the head at all abdominally, it is zero fifths palpable (fully engaged). 1/5 , 2/5th also engaged.

Assess fetal engagement

Measure symphyseal-fundal height (from 24 weeks’onwards)

Symphyseal-fundal height is the distance between the fundus and the upper border of the pubic symphysis. After 20 weeks gestation, the symphyseal-fundal height should correlate with the gestational age of the fetus in weeks (+/- 2cm). [but can have customized SFH chart with serial measurements which are more sensitive and specific to detect growth trends]

1. Begin palpation just inferior to the xiphisternum

2. Palpate using the ulnar border of the left hand

3. Locate the fundus of the uterus (a firm feeling edge at the upper border of the bump)

4. Now locate the upper border of the pubic symphysis

5. Measure the distance between the two in centimetres using a tape measure

6. This distance should correlate with the gestational age in weeks (+/- 2cm)

To avoid bias, it’s best to place the tape measure facing down, only turning to view the numbers once in position. POORNI's METHOD OF FINDING THE FUNDUS

Palpate the upper border of the pubic symphysis

*TV :

Measure from the pubic symphysis to the upper border of the uterus

Record the SFH

Palpate the upper border of the uterus

Palpate the upper border of the pubic symphysis

Measure the distance between the two

Large SFH = multiple pregnancy, macrosomia, polyhydramnios

Small SFH = FGR, Oligohydramnios

Using a Pinard stethoscope (110-160 bpm measure for at least one minute, regularity?) whiole one minute because of variations!!

You may be asked to identify the fetal heartbeat using a Pinard stethoscope (or a Doppler ultrasound probe). As a result, it is important to have a basic understanding of how to locate and identify the fetal heartbeat. [if fetus is active and can feel kicks then no need]

1. Based on your assessment of the fetus’s position, you should place the Pinard stethoscope aiming between the fetal shoulders on the fetal back. [during palpation helpful to determine whether the fetal head is occipito-posterior, lateral or anterior]

2. Palpate the patient’s radial pulse (maternal pulse).

3. Place your ear to the Pinard and take your hand away (so the Pinard is held against the abdomen using your ear only):

You should be applying gentle pressure, to ensure a good seal between your ear and the Pinard, as well as between the Pinard and the abdomen.

Pressing too hard will be uncomfortable for the patient and pressing too softly will make it difficult to hear anything at all.

4. Listen for the fetal heartbeat:

If the maternal pulse coincides with the pulse you can hear, you are most likely listening to the flow through the uterine vessels, rather than the fetal heartbeat.

Listen to the fetal heartbeat using a Pinard stethoscope (or a doppler ultrasound) If cannot hear fetal heart sounds then don’t say cannot detect..instead say another method is required like a doppler US. (CTG?)

To complete the examination…

Re-cover the patient and allow time for them to get dressed in private

Thank the patient

Wash your hands

Summarise your findings:

“I examined Mrs Smith, a 28-year-old female who is currently at 36 weeks gestation. On examination, she was comfortable at rest. Symphyseal-fundal height was 36cm, which is in keeping with her current gestation. The fetus was positioned in a longitudinal lie with a cephalic presentation. The fetal head was three fifths palpable.”

Suggest further assessments and investigations and referrals

Assessment of

Blood pressure measurement the fetal heartbeat using a Pinard stethoscope or Doppler ultrasound (if pre-eclampsia cleck ankle clonus / reflexes. More than three beats of clonus is pathological)

Urinalysis

Proteinuria? Pre-eclampsia?
Asymptomatic bacteriuria => acute pyelonephritis => pregnancy complications

Weight and height measurement [important in first exam]

When BMI < 20, risk of foetal growth restriction and in creightonased perinatal mortality rate
When BMI > 30, risks of gestational diabetes, hypertensions. Fetal assessment is more difficult. Increased birthweight,higher perinatal mortality rate

Speculum examination

Vaginal discharge (in the absence of placental praevia)
Excessive or offensive discharge
To do a pap smear
To confirm potential rupture of membranes
To confirm and assess the extent of FGM in women who have been subjected to it how to do in obs setting? (check textbook)

Digital examination For a sthsessment of the cervix => Information about consistency and effacement. C/I in PROM (increased risk of ascending infection) and known placenta praevia or vaginal bleeding when placental site is unknown and presenting part unengaged.

How to do in obs setting (check textbook)

For suspected pre-eclampsia, reflexes should be assessed. Check ankle reflex and clonus. (if more than three beats of clonus then pathological). Non-dependant oedema should also be noted. Dependant oedema (extremities) not significant as common.

INTERPRETATION OF PHYSICAL SIGNS IN OBS ABDOMINAL EXAM