Introduce yourself, confirm the patient's name, date of birth, and gestational age. Ask the patient if the pregnancy is single or multiple.
Ask if they have had a pregnant abdominal examination before and whether they understand what it involves. Explain the purpose of today’s examination and obtain consent. Inform them that the examination may be slightly uncomfortable. Always call for a female chaperone. Ask the patient if they would like to empty their bladder before beginning.
Knowing what to say in a pregnant abdominal examination is important. Here are a few recommended phrases:
“I have been asked to perform an examination of your tummy (can also say ‘baby bump’) today. Have you had one before? Do you understand what it involves?”
“In this examination, I will be taking a few measurements of your tummy and feeling to see which way the baby is facing. The examination should not be painful but it may feel slightly uncomfortable. I will use a special stethoscope to listen to the baby’s heart.”
Positioning and exposure
Ask the patient to lie supine on the bed set at 15o; this is to reduce the risk of aortocaval compression. Next, ask them to uncover their abdomen. They will need to be completely exposed from the xiphisternum to the pubic symphysis. You may the curtains to give the patient privacy as they get ready.
When a pregnant woman, especially those >20 weeks gestation, lies on her back, there is a risk of the pregnant uterus compressing the abdominal aorta and inferior vena cava. This reduces maternal cardiac output, hence decreasing blood flow to both the foetus and vital maternal organs.
Whilst the patient is preparing, wash your hands, grab a measuring tape and a Pinard stethoscope.
Begin the examination by looking at the overall appearance of the patient. Ask if they are in any pain and are comfortable. Signs such as jaundice and oedema may be clearly visible from the end of the bed.
Assess distal perfusion by recording the capillary refill time. Apply pressure to the distal phalanx of the patient's index finger for five seconds. The finger should turn pale but revert back to its normal colour within less than two seconds. Poor perfusion can be caused by many pathologies including dehydration, aortocaval compression and septic shock.
Look in the eyes for conjunctival pallor (anaemia) and jaundice (intrahepatic cholestasis of pregnancy or hepatitis). Check for oedema of the face (a sign of pre-eclampsia).
Also known as obstetric cholestasis, it is the most common liver disease of pregnancy. The aetiology is thought to be multifactorial due to the cholestatic effect of oestrogen. Obstetric cholestasis is characterised by pruritis (severe itching of the skin) in the absence of a rash. This commonly affects the palm and soles. You may see excoriations which are a result of the excessive scratching. The pruritis is due to increased bile salts in the maternal circulation. Liver function tests will be noticeably abnormal.
It is important to inspect the abdomen for pregnant signs such as:
Linea nigra: A dark vertical line running along the midline of the abdomen)
Striae gravidarum: Stretch marks on the abdomen due to the sudden weight gain of pregnancy
Striae albicans: Silvery-white stretch marks indicative of a previous pregnancy, where old stretch marks have since changed colour.
Observe for any scarring, which may be from previous abdominal surgery or a previous Caesarean section. The most common Caesarean section scar is the Pfannenstiel scar.
If the woman is greater than 24 weeks gestation, foetal movements may be visible.
A Caesarean section scar can either be longitudinal or transverse. A longitudinal scar is due to a classical caesarean section, a procedure which is now only very rarely performed. A transverse scar is due to lower uterine caesarean section. There are many types of transverse incisions which the surgeons can choose to use, of which the most common is the Pfannenstiel incision. Also known as the “bikini line scar,” a Pfannenstiel scar is a curved, transverse scar present just 2-3cm above the pubic symphysis.
Ask again if the patient has any pain around their abdomen. Softly palpate the 9 quadrants (see the abdominal examination page) of the pregnant abdomen, feeling for the borders of the uterus. Whilst palpating, look at the patient's face for any signs of discomfort and note down any tenderness or guarding.
The symphysis-fundal height is the length measured between the fundus (the top of the uterus) and the pubic symphysis. This is important as it helps determine if the pregnancy is too large or small for the gestational age.
To measure the symphysis-fundal height, use the ulnar aspect of your left hand, palpate close to the xiphisternum and slowly move inferiorly to locate the fundus. The fundus will feel firm at the uppermost part of the pregnant abdomen. Place one end of the measuring tape face down at this location, and then, palpate for the pubic symphysis and place the other end of the tape there. Measure this distance and repeat two more times.
We measure using the tape measure face down in order to avoid any bias. This distance should correlate with the gestational age +/- 2cm.
There are a few key points to know about the fundus that will help you predict the gestational age of the foetus. At 12 weeks gestation, the fundus is normally at the level of the pubic symphysis. At 20 weeks, it is found at the umbilicus. At 36 weeks, it is found at the xiphoid process of the sternum.
Large for gestational age is present when the fundal height lies above the 90th percentile for that gestational age. There are a number of causes including a familial cause, obesity and most importantly gestational diabetes.
Gestational diabetes is diabetes which develops after the 20th week of pregnancy. It is likely to develop in patients with multiple risk factors for it. The foetus tends to be large for gestational age as a result of foetal pancreatic islet cell hyperplasia, leading to foetal hyperinsulinaemia and fat deposition. Mothers with risk factors for the disease must have a glucose tolerance test for diagnosis. They may then be required to start on metformin or insulin therapy
Small for gestational age is present when the fundal height lies below the 10th centile for that gestational age. This may be because the foetus is constitutionally small or has intrauterine growth restriction. Note that it is very important to distinguish between a foetus which is constitutionally small due to familial reasons but is healthy, and one that has intrauterine growth restriction. Constitutionally small foetuses grow consistently without any compromise. In contrast foetuses that are growth restricted have failed to reach their ‘growth potential.’ There are numerous causes of intrauterine growth restriction including underlying maternal illness, multiple pregnancy (one foetus is commonly compromised), chromosomal abnormalities and maternal smoking.
Palpation of the foetus
The foetal lie governs the direction the foetus is facing. Start on the right-hand side of the bed, face the patient and place your hands on either side of the pregnant abdomen. Gently palpate each side. One should be firmer than the other; this will be the foetal back. On the opposite side, you may be able to feel the foetal limbs.
The foetus may lie in one of three ways:
1. Longitudinal: The spine of the foetus is parallel to the mother’s.
2. Transverse: The spine of the foetus is perpendicular to the mother’s.
3. Oblique: The foetal lie is in a direction such that the head or bottom is palpable in one of the iliac fossae.
The presentation refers to the anatomical part of the foetus that is closest to the pelvic inlet.
Facing the mother, place your hands on either side of the lower abdomen just above the pubic symphysis. Apply pressure firmly towards the midline to feel the presenting part. If this feels hard, round, and mobile, then it is likely the foetal head. If it feels softer and less well defined, then this is suggestive of another anatomical part such as the bottom.
The presentation can be described in many ways. Three important ones are:
1. Cephalic presentation: he presenting part is the foetal head. This is normal.
2. Breech presentation: the presenting part is either the bottom or feet. This is abnormal.
3. Shoulder presentation: the presenting part is the shoulder. This is abnormal.
Foetal engagement refers to when the presenting part of the foetus descends into the pelvis. This can be measured as “fifths palpable”. Assuming a cephalic presentation, if the foetal head is not engaged, you will be able to feel the whole foetal head on the abdomen using your hand (five fifths palpable). If you cannot feel the foetal head, then it may have descended into the pelvis (zero fifths palpable). If you can feel the foetal head with only three fingers, it is three fifths palpable. This means that the foetal head is two fifths engaged.
Auscultation of the foetal heart is performed using the Pinard stethoscope, or otherwise a Doppler foetal heart rate monitor. Awareness of the foetal lie and presentation makes it much easier to place the stethoscope. It best to try to place it over the anterior shoulder of the foetus. This is typically found around two inches laterally from the midpoint between the umbilicus and pubic symphysis. Place the wide end of the stethoscope on the patients abdomen and your ear on the flat end. Next, press your ear firmly down and let go of the stethoscope with your hands; it should be balanced between your ear and the patient’s abdomen. Palpate the maternal pulse at the same time to distinguish between the maternal and foetal heart beat.
Completing the examination
Thank the patient allow them to re-dress behind the curtains and wash your hands. Complete your examination by offering to measure blood pressure, perform urinalysis, measure weight and height, and accurately assess foetal heart rate using a Doppler ultrasound.
When assessing each other, click on each list item as you go along. Doing so will turn the list item green. Make careful note of any steps missed at the end.
We recommend completing any examination or procedure in under 10 minutes, but you can adjust the timer to suit your needs.
Introduction: “Hello, I’m SimpleOSCE and I am a medical student. I have been asked to perform an examination of your tummy today to check for any abnormalities, would that be okay? Can I confirm your name and DOB? Thank you.”
"For the purpose of this examination the examiner will act as a chaperone." Ideally a female chaperone should be asked for.
Gathers the appropriate equipment (measuring tape, Pinard stethoscope).
Position the bed raised at 15 degrees and ensure adequate exposure.
Ask about pain and discomfort.
Inspect the patient and their surroundings.
Examine the hands for capillary refill, pulse, and warmth.
Examine the face, looking specifically at the eyes for conjunctival pallor and jaundice.
Inspect the abdomen for scars, striae, and foetal movements.
Gently palpate the 9 quadrants.
Correctly identify the pubic symphysis and xiphisternum.
Measures the symphysio-fundal height and repeats twice.
Assess foetal lie.
Assess foetal presentation.
Measure the foetal engagement.
Use the Pinard stethoscope to listen for foetal heartbeat.
Thank and cover up the patient.
"To conclude, I would like to take a full history, perform a blood pressure measurement, urinalysis, plot patients weight and height, and conduct Doppler ultrasound scan of foetal arteries.”