The obstetrical examination is a thorough and systemic abdominal examination to assess the health of the mother and the foetus during pregnancy. It is performed beyond 28 weeks of pregnancy to diagnose the lie, presentation, position, and attitude of the foetus.
Preliminaries
- Introduce yourself to the patient.
- Take informed consent.
- Explain the entire procedure to the patient.
- Ask the patient to evacuate the bladder.
- Ask the patient to lie in a dorsal position with thighs slightly flexed.
- Keep the abdomen fully exposed.
- Wash your hands and stand by the side of the patient.
Inspection
Inspect the abdomen for the following-
- Uterine ovoid (longitudinal, transverse or oblique).
- Uterine enlargement is consistent with the pregnancy.
- Any undue enlargement of the uterus.
- The skin condition of the abdomen for the presence of linea nigra, striae gravidarum, and striae albicans.
- Any incisional scar marks on the abdomen.
- The contour of the uterus.
- Fetal movements.
Palpation
During palpation, the height of the uterus is ascertained by placing the ulnar border of the left hand on the upper border of the fundus of the uterus. Symphysis fundal height (distance between the upper border of the fundus and symphysis pubis) can also be measured by using a tape in cm.
There are conditions where the height of the uterus may not correspond with the period of gestational age. There are conditions where the height of the uterus is more than the period of gestational age are-
- Polyhydramnios
- Twins
- Ovarian tumors or fibroid
- Big baby
- Mistaken date of the last menstrual period
The conditions where the height of the uterus is less than the period of gestation age are –
- Oligohydramnios
- Intrauterine growth retardation
- Intrauterine fetal death
- Mistaken date of the last menstrual period
Obstetric grips
There are four obstetric grips to perform the abdominal examination.
Fundal grip
- Fundal grip, also known as the first maneuver of Leopold.
- The palpation is done facing the patient’s face.
- Examiner palpates the fundal area by placing both hands on the side of the fundus and finding out the presence of a breech or the head lying in the fundus.
- Presence of soft, irregular mass suggestive of buttocks; hard and globular mass suggestive of the head, but if it is a transverse lie, neither of the fetal poles are palpated in the fundal area.
Lateral grip or Umbilical grip
- Lateral grip, also known as the second maneuver of Leopold.
- It is also done by facing the patient’s face to locate the foetal back in order to determine the position.
- The hands are placed on either side of the uterus at the level of the umbilicus and palpated. Smooth curved, and resistant feel suggestive of the back, and the limb side is empty, and small regular parts can be felt.
- During palpation, it is very essential to note the position of the back, whether placed anteriorly or towards the flank, or placed transversely.
First pelvic grip
- This grip is also known as Leopold fourth maneuver.
- It is performed by facing the patient’s feet to ascertain the presenting part.
- Four fingers of both hands are placed on either side of the lower pole of the uterus and pressed downwards and backwards to palpate the part occupying the lower pole of the uterus.
Second pelvic grip (Pawlik’s grip)
- The second pelvic grip is also known as the third maneuver of Leopold.
- It is done by facing the patient’s face.
- Examiner grasps the lower pole of the uterus between fingers and thumb, which should be spread wide enough apart to accommodate the fetal head.
- This grip is performed to check whether the head is engaged or not.
- Pawlik’s grip is empty in a transverse lie.
Auscultation
- Listening to the fetal heart sounds (F.H.S) is an important part of the abdominal examination and helps in the diagnosis of a live baby.
- Pinard’s fetal stethoscope or Doppler ultrasound can be used to hear the fetal heart sounds.
- Fetal heart sounds are best audible through the back of the fetus, and the examiner should take the women’s pulse at the same time as listening to the fetal heart to distinguish between the two.
- F.H.S should be 110-160 beats/min.
Findings
The findings from the abdominal palpation should be considered as a part of the holistic picture of pregnant women.
Lie
- The lie of the foetus is the relationship of the long axis of the foetus to the long axis of the uterus.
- In the majority of cases, the lie is longitudinal, and it is evident from the longitudinal uterine ovoid on inspection, the fundal, and first pelvic grips.
Attitude
- Attitude is the relationship of the fetal head and limbs to its trunk, and the attitude should be of flexion.
- It is evident from the first pelvic grip; in the well flexed head, the sincipital pole is placed at a higher level, but in a deflexed state, both the poles remain at the same level.
Presentation
- Presentation refers to the part of the foetus that lies in the lower pole of the uterus.
- Presentations can be a vertex, breech, shoulder, face, or brow and can be evident by the first pelvic grip.
Position
- The position is the relationship between the denominator of the presentation and eight points on the pelvic brim.
- Anterior positions are more favorable than posterior positions, and these positions can be diagnosed by inspection and lateral grip.
Engagement
- Engagement is said to have occurred when the presenting part of the foetus has passed through the brim of the pelvis.
- It can be diagnosed by a second pelvic grip. When the head is palpable or ballotable, it is not engaged and if the head is not palpable, it is said to be engaged.
Completion of examination
- Thank the patient for cooperation during an examination.
- Wash your hands.
- Summarize and document the findings
- If any deviation is found from the normal findings, report it to the obstetrician.
Conclusion
In the above post, we discussed the obstetrical examination, its preliminaries, obstetric grips, findings, and activities after completion of the examination.
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