Abdominal examination - General examination of the ante-natal patients

Abdominal examination

Aims: To observe signs of pregnancy, to assess fetal sign andgrowth, To assess fetal health, to detect any deviation from normal, to diagnose the location of fetal parts.

Preparation:

1.           Ensure that patient empties her bladder

2.           Let the patient lie in the supine position on the couch, with one pillow under her head. Her arms should be by her sides to prevent traction of abdominal muscles.

3.           Draw the screen in order to ensure privacy.

4.           Talk to the patient nicely to aid relaxation.

5.           The examiner’s arms and hands should be relaxed.

Three ways of obtaining information required are: - Inspection, palpation, Auscultation

Inspection: note the size and shape of the abdomen

a. Size: Should correspond with the supposed period of gestation.

If much larger or smaller:-

·              Review the date of the last normal menses

·              Note the size of the patient. If dates are correct but uterus is large, possibilities are: multiple pregnancy, polyhydramnios, a large fetus, a fetus plus uterine fibroid.

b. Shape: Should be longitudinally ovoid. This is clear in mostprimigravidae.

Round: is due to multiparity, transverse lie, obesity,polyhydramnios.

In addition to the above, note on inspection: Pigmentation, scars, striae gravidarum, The quality of the muscles of abdomen and the contour.

c. Fetal Movement: This is evidence that the fetus is alive. It alsoaids in the diagnosis of position as the back will be on the opposite side where movement is seen.

d. Contour of the abdomen: (a) Normal is dome –shape (b)Pendulous abdomen is common with multigravid woman. (c) when lightening has taken place the uterus sag forward and uterus is more prominent e.g. when standing. (d) Depression at the umbilical level suggest occipito posterior (e) skin-scar, stiae gravidarum, Linea Nigera are observed.

Palpation;

Aim

·              To observe signs of pregnancy. To determine fundal height Size and growth of the fetus. This should correspond with the period of gestation.

·              To ascertain fetal parts of the fetus is in different parts of the uterus, also the lie and attitude of the fetus.

·              Relationship of presenting part to the pelvis: how to palpate the uterus. Detect any deviation from normal.

The hands should be clean and warm, cold hands do not have necessary acute sense of touch and tend to induce contraction of the abdominal muscles. Arms and hands should be relaxed and the pads NOT THE TIPS of the fingers are used with delicate precision moving smoothly over the abdomen without lifting them. Erratic and sudden pressure and rough manipulation are irritating and can cause contractions making detection of fetal parts impossible.

Abdominal palpation is done by the following maneuvers: (though not by mean the order)

·              Estimation of fundal height

·              Fundal palpation – To determine the part of the fet us in the fundus.

·              Lateral palpation

·              Pelvic palpation (lower pole palpation)

Fundal height:

Method: The ulnar border of the left hand is placed at theupper border of the fundus in order to locate the highest point of the fundus. As many fingers of the left, hand as can be accommodated are laid flat between the upper border of the fundus and the xiphisternum. The distance between fundus and xiphisternum is estimated in fingers breadth. At 36 weeks gestation no fingers can be inserted.

Using MC Donald’s technique – A measuring tape tha t has centimeter is used. After locating the fundal height, the zero end of the tape is paced on the symphysis pubic and stretched to the height of fundus. The measurement on the tape is recorded as the fundal height. It is more accurate between 20-31 weeks gestation.

Fundal palpation: This manoeuvre will help to determinewhether the presentation is cephalic or breech and the lie longitudinal or transverse. In 95% of cases the breech will be in the fundus and this denotes a cephalic presentation. When the head is in the fundus, the presentation is breech. While facing the woman’s head “walk” up both hands, one o n either side of the uterus and lay them flat on the fundus of the uterus to feel what is lying there.

Lateral Palpation: This maneuver is useful to locate thefetal back as an aid to diagnosis of position.

Method: while still facing the patient’s head or feet, thehands are placed on both sides of the uterus at about umbilical level. Pressure is applied with the palms of alternate hands to differentiate the degree of resistance between the two sides of the uterus. One hand is used to steady the uterus and press the fetus over towards the examining hand which determines the presence of the broad resistant back or the small parts that slip under the examining fingers.

By using a rotary movement of the fingers:

·              The back may be mapped out as a continuous smooth resistant mass from the breech down to the neck.

·              The limbs are noted as small irregularities which are often felt to move.

Pelvic palpation: This is the most important maneuver inabdominal palpation because of its value in the diagnosis of presentation of the fetus, engagement of its fetal head and disproportion between head and pelvis. It should not cause discomfort to the women.

Method: The midwife stands on the patient’s right with herthighs against the couch, her body, turned at the waist, facing towards the women’s feet. Using both hands, the midwife finds out what is in the lower pole of the uterus as follows:

The sides of the uterus, just below the umbilical level are grasped snugly between the palms of the hands, the fingers held close together, pointing downwards and inwards. What ever is in the lower pole can then be held between both hands. In most cases it is the head that is in the lower pole and is recongised as follows:

·              It is smooth, round and hard.

·              It is ballotable (if not engaged).

·              It is separated from the trunk by a groove (the neck)

Occasionally it is the breech; which is

·              Less hard

·              More irregular

·              The lower limbs are nearer to it.

Pawlik’s grip

This method of palpating the lower pole of the uterus is most effective when the head is not engaged.

Method: The midwife, standing on the patient’s right, faces thewoman’s head and using the right hand, grasps the lower pole of

the uterus with the thumb on the woman’s right side and the fingers on the left side of the uterus. Fingers and thumb must be sufficiently far apart to accommodate the fetal head.

Engagement of the head

Definition

Engagement means when the widest diameter of the presenting part has passed through the pelvic brim. In some women engagement does not take place before term. In some African women it occurs during the first stage of labour.

Recognition of engagement

·              The head or breech is not mobile

·              Less of the head will be felt per abdomen

Auscultation

The fetal heart sounds are like the ticking of a watch under a pillow. The rate may be double that of the mother’s heart beast observed at the wrist. About 140 beat per minute.

Procedure

Place Pinard’s stethoscope over the back of the fetus and support with the pinna of the ear while the right hand feels maternal pulse at her wrist.

NOTE: All information obtained must be considered in making diagnosis. If any information does not correspond, repeat and think again.