Obstetric Examination Techniques

10/26/2011 © Clinical Skills Resource Centre,
University of Liverpool, UK
1
Obstetric Examination

2
Prior to examination
• Need a warm and private environment.
• Check patients ID, consider the need for a Chaperone
• Wash your hands (preferably ensuring they are warm)
• Introduce yourself and say what status you hold
• Explain why you need to palpate the patient’s abdomen
• Gain verbal consent
• Ensure the patient has emptied her bladder to avoid
discomfort
• Position patient appropriately – supine - head and top of
shoulders only supported by pillow - hands by side. (Be
aware of supine hypotensive syndrome!)

3
Back to Basics …..
Inspect –
Inspect the abdomen (shape, size, scars, linea nigra, striae,
movements, colour,)
Palpate -
 Abdomen for - growth (gestational age estimated by fundal height
measurement) , movements, Fetal parts, No. of fetus, lie, position,
presentation and engagement.
Auscultate–
Abdomen for Fetal Heat Rate. Use fetal stethoscope - pinnard or sonicaid.

4
Palpation
• Maintain your patient’s dignity at all times
• Expose only as much of your patient as is required
• Ensure that your patient is positioned appropriately and
that you have warm hands.
• Palpate the abdomen using even movements of the flat
of the palmar surface of closed fingers. (Aim to maintain
hand to skin contact as much as possible rather than
taking hands on and off the surface of the abdomen)
• Do not prod the abdomen or use jerky movements as
these are likely to irritate the uterus and stimulate a
contraction.

5
•Use even movements of the flat of the palmar surface of
closed fingers.
•Aim to maintain hand to skin contact as much as possible
•Do not prod the abdomen or use jerky movements as these
are likely to irritate the uterus and stimulate a contraction.
Jewellery should be removed

6
Points to record
• Inspection
• The Fundal Height
• The Lie
• The Presentation
• The Position
• Engagement
• Fetal Heart Rate
• This might help you to
remember - I F Li P P E R
• Accurate palpation
requires practice and
experience.
• Uncertain or abnormal
findings on palpation
may need to be
investigated /confirmed
other means, e.g..
Ultrasound scan.

7
The fundal height
• The woman lies supine
• Palpate for the fundus first. The fundus is not usually
palpated abdominally before 12 weeks gestation.
• Apply gentle pressure with the flat palmar surface of
your hand moving downwards from the xiphisternum -
to palpate the top of the fundus. The fundal height can
be measured in CMS from 24 weeks gestation.
• Place the zero end of the tape measure at the fundus.
• Stretch the tape measure over the abdomen face down
so the measurements can not be seen - this avoids
observer bias - to the superior border of the symphisis.
( This may be done with zero at the symphis ie the other
way round but the measurement should be the same)
• Look on the reverse of the tape, and document the
measurement in centimetres.

8
Measurement of fundal height
Palapate the
shape of the
uterus to
clearly
identify the
fundus.
Zero of the
tape
measure is
held at the
fundus
Gently
stretch the
tape measure
over the
abdomen to
the superior
border of the
symphisis
Disposable tape measure placed face down

9
Symphysis-fundal height chart
Fundal height (+2 SD) chart
15
20
25
30
35
40
19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40
Weeks gestation
Fundalheightincms
• The obtained
measurement is then
charted
• The height measured is
plotted against number of
weeks gestation worked
out from LMP
• The chart shows the
mean height against
gestation
• The outer lines represent
1 standard deviation
above and below

10
The lie
• The lie of the fetus
refers to its long axis
in relation to the long
axis of the mother
(i.e. spine)
• Only LONGITUDINAL
lie is normal (This ‘usually’
enables the presenting part to
enter the pelvis)
Longitudinal
Transverse
Oblique

11
Palpation- identifying the LIE
• The palpation
continues down the
body of the uterus
• The smooth back of
the fetus is palpated
and identified (the lie)
• The irregular surface
created by the limbs,
hands and feet is
identified

12
The presentation
• The presentation is the part of the foetus
in the lower pole of the uterus
Cephalic Breech

13
Cephalic Presentation
Palpation- identifying the
PRESENTATION
• The uterus is gently palpated
between the palms of two
hands
• The fetal part in the upper pole
(in this case the breech) and
the lower pole of the uterus are
identified
• Characteristically the breech is
softer than the head, there is
no angle formed by the neck
and the surface continues
smoothly with the back.

14
Position
• The position of the foetus is described by
the relationship of the presenting part to
the maternal pelvis
• The denominator for the presenting part
for a Cephalic presentation = occiput
and for a Breech presentation =
sacrum

15
Position
• The description for a
cephalic presentation
with the occiput lying
directly lateral to the
left would be – LEFT
OCCIPITO-LATERAL
LOL

16
=
Position of
Fetal Occiput (or
presenting part)
The Position
Imagine the mother is lying supine and you are looking through
her pelvis facing her feet
Direct
posterior
Direct
anterior
Left
lateral
Right
lateral
Right
anterior
Left
anterior
Right
posterior
Left
posterior
Mothers Spine
Symphysis
pubis
Mother’s LEFT

17
Cephalic presentation
Cephalic presentation is the presentation
of the fetal head.This is the normal and
most common presentation.The position
is described by the direction in which the
occiput faces the mother’s pelvis.

18
Direct occipito-
anterior (DOA)
Mum’s Right
Placenta
occiput
Occiput
directly faces
the front.
Fetal spine is
in alignment
with mothers
spine.

19
Left occipito-
Lateral (LOL)
occiput
Placenta Mum’s Left
Think…
Where do you think
Fetal limbs would be
palpated?
Where do you think
you would
listen for the Fetal
Heart?

20
Right occipito-
anterior (ROA)
Mum’s Right Placenta
occiput
Occiput faces
mother’s right.
Widest part of
fetal skull is well
into the brim of
the pelvis-
Head is engaged.

21
Left occipito-
Anterior (LOA)
Mum’s Right
occiput
Fetal spine is in
the same plane
as the mother’s
spine,
This is a
longitudinal lie

22
Right occipito-
lateral (ROL)
occiput
The Occiput points to the
mother’s
Right.
The fetal spine is in alignment
with the mother’s spine.
Think….
Where do you think
Fetal Limbs may be palpated?
Do you think the head would
be engaged?
Mum’s Left
OCCIPUT

23
Direct occipito-
posterior (DOP)
Mum’s Right
Placenta
Fetal spine is in alignment
with the mother’s spine.
Think…..
Where do you think
Fetal parts could be
palpated?
Where might be a good place
to listen for the Fetal Heart?
Would you be able to palpate
the back
of the Fetus?

24
Left occipito-
posterior (LOP)
Mum’s Right
occiput
Mum’s Right
occiput
Occiput here is
slightly to the
Mother’s left -
It is nearly a
Direct Occipito
posterior-
It may be difficult
to
palpate the fetal
back

25
Mum’s Right
Placenta
occiput
Right occipito-
posterior(ROP)
Mum’s Right
occiput
Fetal spine is in
alignment
with mother’s
spine.
Think …..
Would you palpate
the Fetal back?
Where would you
listen for
the Fetal Heart?

26
Breech presentation
The position is described by the direction
in which the sacrum faces the mother’s
pelvis. In a breech presentation legs may
be flexed or extended. Breech is not a
normal presentation and reasons why the
breech is presenting should be
considered.

27
Direct sacro-anterior
(DSA)
Mum’s Right
Sacrum
Placenta The sacrum is
referred
to when the
presenting part
is a BREECH –
Think…
What is the LIE ?
Do you think the
Breech is engaged?

28
Left sacro-
anterior (LSA)
Sacrum
Mum’s Right
Placenta

29
Right sacro-
anterior (RSA)Mum’s Right
Placenta
Think….
Where do you think
you would listen for
the Fetal Heart?

30
Left sacro-lateral
(LSL)
mum's Right
Placenta
Mum’s Right
Placenta
Sacrum
Fetal spine is in the
same
plane as the mothers
spine.
The sacrum faces
the mothers left.

31
Right sacro-lateral
(RSL)
Mum’s Right
Placenta
Sacrum
Think…
What is the LIE?
What is the
presenting part?

32
Direct sacro-
posterior (DSP)
Mum’s Right
Placenta

33
Left sacro-posterior (LSP)
Mum’s Right
Mum’s Right
View from below
Placenta
Sacrum

34
Right sacro-posterior (RSP)
Placenta
Sacrum
View from below
Mum’s Right
Sacrum

35
Engagement
• Refers to the descent of widest
transverse diameter of the
presenting part (breech or
cephalic) through the true pelvic
brim. (The widest transverse
diameter of the fetal skull is the
bi-parietal).
• The amount of presenting part
palpable is used to describe
descent into the pelvis
• When 2/5ths or less of the
presenting part is palpable
abdominally it is engaged

36
Engagement
• Engagement occurs around 36 weeks in a
primigravida (first pregnancy) with a
cephalic presentation.
• In a multigravida (a patient who has had
more than 1 pregnancy) engagement may
occur after the onset of labour.

37
Engagement ….
It is common in later
pregnancy to refer to-
Mobile – the presenting part is
free above the brim
Fixed – the presenting part is
entering the pelvis
If the presenting part does not
engage when anticipated -
‘causes of non engagement’
should be investigated
Think -
What could be a cause of non
–engagement?
Pelvic BRIM
Pelvic BRIM

38
Assessing engagement
• The examiner usually stands on the
mothers right side and faces the
mothers feet.
• The presenting part is identified
(cephalic presentation feels hard,
rounded with a dip at the neck,
breech may feel softer and
continuous with spine)
• The presenting part is palpated
using both hands
• An assessment is made of how
much of the presenting part can be
palpated and whether the head is
engaged, fixed or mobile

39
Assessing the fetal heart rate 1
• The Fetal Heart (FH) should
be auscultated using a fetal
stethoscope known either
as
– Pinnard ( a wood metal
or plastic device)
– or a sonicaid (an
electronic device)
• The chosen device is
placed over the baby’s
back (the nearer the
shoulder the clearer the FH
can be heard)
• Location of the fetal heart
may help to confirm your
findings on palpation

40
Assessing the fetal heart rate 2
• The fetal heart rate should be counted
for a full minute while also palpating
the mother’s pulse (allows the
examiner to differentiate between
maternal and fetal heart rate)
• A normal fetal heart rate is between 110
– 160 beats per minute (mother’s pulse
should be counted separately).

41
PRESENTING and RECORDING
Your findings (1)
• What did you find ? - You need to report
your findings clearly and systematically
whether it be a verbal report or
documented in the patient’s notes.
• If you are unsure or were not able to
determine a particular aspect SAY SO ….
(for example - Presentation - ?presenting
part . Position – Not determined – DO not
be tempted to Make it UP!)

42
PRESENTING and RECORDING
Your findings (2)
• 1. REPORT - observation / inspection
• 2. Fundal height in CMS = ……
• 3.The Lie is …..
• 4.The Presentation is ……
• 5.The Position is ……
• 6. Engagement ?
• 7. Fetal Heart (FH) is ……
• 8. Other ???

43
PRESENTING and RECORDING Your findings (3) …
• 1. REPORT - Anything significant on observation
unusual colouration rashes / size
• 2. Fundal height in CMS = ……
• Height in CMS above 24 weeks = to gestational age
and should be consistent with dates agreed +/- 2
weeks . (Agreed dates are by scan or LMP)
• 3.The Lie is ….. (Longitudinal / Transverse/
Oblique)
• 4.The Presentation is ….( Cephalic / Breech –
other presentations difficult to determine on
abdominal palpation)

44
PRESENTING and RECORDING Your findings (3) cont…
• 5.The Position is … (eg LOL / ROA / DOP etc)
• 6.Engagement - Is the presenting part engaged ?
(YES if less than 2/5ths palpable abdominally. If you
can feel around the presenting part and it is mobile it
is NOT engaged. IF the presenting part is not mobile
and you can feel most of it - it is NOT engaged)
• 7. Fetal Heart (FH) – Did you hear it ? With what ?
Was it definitely the FH and NOT maternal pulse.
For eg you might say - Fetal Heart Heard regularly
144bpm with Pinnards. Maternal Pulse taken 82bpm
• 8. Other relevant findings for example Fetal
Movements Felt or Observed / Fetal Parts Palpated

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