Examination of the Pregnant Abdomen

NB The examination of the pregnant abdomen is not technically an intimate exam, and thus does not require a chaperone.  However, it is often suitable to ask if the patient has a partner/friend/family member with them whom they would like to be with them for the examination.

Intro

• Wash hands, introduce self, check patient name and DOB/CHI, explain procedure and gain consent

Before you start/General Examination:

• Does the patient look well?  Is she happy with the pregnancy?  Or is she tired/exhausted/in pain/pale etc?
  • Signs of anaemia may be seen
• Offer the patient the opportunity to empty her bladder prior to examining her.
  • You may use this sample for urinalysis.  This is important as part of the antenatal check-up routine.
• Also, you would want to check her height/weight and BP
• Have the patient lie/sit on a bed at around a 30° angle, so that she is comfortable.  Expose her abdomen and use a sheet to cover up any exposed underwear (for the comfort of the patient).

Inspection

• Look at the pregnant abdomen,
  • linea nigra (the dark line from the pubis symphysis caused by increased melanocyte activity),
  • any striae (pink- striae gravidarum; white- striae albicantes (old pregnancy)),
  • any scars (previous caesarean) or excoriations (obstetric cholestasis)
  • any distended veins (IVC compression)
  • umbilical eversion
• Ask the patient to cough to look for any hernias

Palpation

• With your left hand (if examining from the right), feel for the top of the uterus and estimate the height of the fundus from the symphysis pubis.
  • Now is a good time to measure the height with a tape measure
    • If beyond 20 weeks gestation: 1cm=1 week gestation (roughly)
• Palpate down the sides of the abdomen (you may wish to change your position as you do this i.e. start by facing the patient to feel the superior abdomen and turn to face the end of the bed to feel the inferior abdomen).  Note any tenderness, rigidity, guarding etc.
  • Feel for the landmarks of the foetal lie (head, shoulders, back) and describe the foetal lie, presenting part and orientation.
    • Lie can be longitudinal, transverse or oblique.
    • Presentation can be head first (cephalic), feet first (breech) or another part (e.g. shoulder)
    • Orientation/position refers to the direction the foetus is facing e.g. left occiput anterior (LOA) position is when the occiput faces anteriorly and to the left.
    • Also feel around the head (if presenting part) to estimate degree of engagement
      • You do this by loosely determining how many fifths of the foetal head can be palpated through the abdomen
        • 5/5 – the head is ‘floating’
        • 3/5 means the head is fixed
        • 2/5 the head is usually engaged
        • 0/5 the head is at the ischial spines
    • Also feel for the anterior shoulder (for auscultation later, but also to estimate position)
      • A shallow groove between the presenting part (head) and rest of foetus
      • usually in the right or left lower quadrants
• NB Percussion is only useful if you suspect polyhydramnios, where fluid thrill would be illicited but no shifting dullness

Auscultation

• Using a Pinard stethoscope held over the foetus’ shoulders, using your head/ear to stabilise it on the mother’s abdomen (i.e. not holding it), listen for a faint ticking sound of the foetal heart
  • normally 100-120bpm and may be slightly erratic
  • NB this is only really effective after 28 weeks gestation, before which time an US doppler scan is used

Other investigations

• It is a good idea to measure BP and take a urine sample if this has not been done already

After you have finished

Make sure you let the patient dress herself comfortably, record all findings, thank the patient and end the consultation.  Wash hands.