Pregnant abdomen examination.pptx

Pregnant Abdominal Examination

1. Pregnant abdomen examination Dr Suleman Abdirahman

2. Gather equipment Gather relevant equipment including: Measuring tape Pinard stethoscope Vital sign Equipment’s Gloves

3. Introduction Wash hands Introduce self Ask Patient’s name, DOB and what they like to be called Explain examination and obtain consent Position patient lying at 15˚ and expose their abdomen for the examination from the pubic symphysis to the xiphisternum. Gain consent to proceed with the examination.

4. Provide the patient with the opportunity to pass urine before the examination. Ask the patient if they have any pain before proceeding with the clinical examination. “Today I need to examine your tummy as part of the assessment of your pregnancy. This will involve me looking and feeling the tummy, in addition to performing some measurements. Although it may be a little uncomfortable, it shouldn’t be painful.”

5. General inspection General: well/unwell, comfortable, breathlessness, pallor Hands: Color: pale hands suggest poor peripheral perfusion cyanosis may suggest underlying hypoxemia. Peripheral oedema Palmar erythema

6. Temperature Capillary refill time (CRT) Radial pulse: assess the rate and rhythm, For irregular rhythms, you should measure the pulse for a full 60 seconds to improve accuracy. You can calculate the heart rate in a number of ways, including measuring for 60 seconds, measuring for 30 seconds and multiplying by 2 or measuring for 15 seconds and multiplying by 4.

7. Face

8. Abdominal inspection Position the patient The recommended positioning for a patient during pregnancy varies, depending on the current gestation: Early pregnancy : position the patient supine on the bed, with the head end of the bed elevated to 15-30°. Late pregnancy : position the patient in the left lateral position (tilted 15° to the horizontal level) to avoid compression of the abdominal aorta and inferior vena cava by the gravid uterus (known as aortocaval compression).

9. Closely inspect the abdomen Abdominal sha pe: this may give an initial indication of the fetal lie. Fetal movements : these are typically visible from 24 weeks gestation. Surgical scars : may provide clues regarding previous abdominal surgery (e.g. caesarian section). Linea nigra : a dark line running vertically down the middle of the abdomen (a normal finding in pregnancy).

10. Striae gravidarum : reddish or purple lesions that develop due to overstretching of the abdominal skin as the gravid uterus expands (commonly referred to as stretch marks). Striae albicans : mature stretch marks which appear silver-like in colour and are less pronounced.

11. Abdominal palpation Ask about abdominal tenderness before palpating the abdomen and continue to monitor the patient’s face for signs of discomfort throughout the examination. Briefly perform light palpation over each of the nine regions of the abdomen to identify any tenderness or masses that may not relate to the pregnancy. Palpate the uterus to identify its borders, including the upper and lateral edges.

12. The uterine fundus can be found at different locations during pregnancy, depending on the patient’s current gestation: 12 weeks gestation: pubic symphysis 20 weeks gestation: umbilicus 36 weeks gestation: the xiphoid process of the sternum

13. Fetal lie Fetal lie refers to the relationship between the long axis of the fetus with respect to the long axis of the mother. Assess the gravid uterus to determine the fetal lie: 1. Place your hands on either side of the patient’s uterus (ensuring you are facing the patient). 2. Gently palpate each side of the uterus: One side of the uterus should feel full in nature (due to the presence of the fetal back). On the other side of the uterus, you may be able to feel the fetus’s limbs.

14. Types of fetal lie There are three main types of fetal lie which include: Longitudinal lie : the head and buttocks are palpable at each end of the uterus. Oblique lie : the head and buttocks are palpable in one of the iliac fossae. Transverse lie : the fetus is lying directly across the uterus.

15. Fetal presentation Fetal presentation refers to which anatomical part of the fetus is closest to the pelvic inlet. Assess the gravid uterus to determine fetal presentation: 1. Ensure you are facing the patient to observe for signs of discomfort and warn the patient this may feel a little uncomfortable. 2. Place your hands either side of the lower pole of the uterus, just above the pubic symphysis.

16. 3. Apply firm pressure to the uterus angled medially, palpating for the presenting part: A hard round presenting part is suggestive of a cephalic presentation (normal). A broader, softer, less defined presenting part (i.e. the fetal bottom or legs) is suggestive of a breech presentation (abnormal).

17. Fetal engagement In late pregnancy, the level of fetal engagement should be assessed. A fetus is considered ‘engaged’ when more than 50% of the presenting part (usually the head) has descended into the pelvis. The fetal head is divided into fifths when assessing engagement: If you are able to feel the entire head in the abdomen, it is five fifths palpable (i.e. not engaged). If you are not able to feel the head at all abdominally, it is zero fifths palpable (i.e. fully engaged).

18. Symphyseal-fundal height Symphyseal-fundal height is the distance between the fundus and the upper border of the pubic symphysis. After 20 weeks gestation, the symphyseal-fundal height should correlate with the gestational age of the fetus in weeks (+/- 2cm). To measure the symphyseal-fundal height: 1. Begin palpation of the abdomen just inferior to the xiphisternum using the ulnar border of your left hand.

19. 2. Locate the fundus of the uterus (a firm feeling edge at the upper border of the bump). 3. Once the fundus has been identified, locate the upper border of the pubic symphysis. 4. Measure the distance between the upper uterine border and the pubic symphysis in centimeters using a tape measure. The distance measured should correlate with the gestational age in weeks (+/- 2cm).

20. Fetal heartbeat You may be asked to identify the fetal heartbeat using a Pinard stethoscope (or a Doppler ultrasound probe). halfway between mother’s umbilicus and ASIS on the side of the fetus’ back (try both sides if unsure) 1. Based on your assessment of the fetus’s position, you should place the Pinard stethoscope aiming between the fetal shoulders on the fetal back. 2. Feel the mother’s pulse at the same time.

21. 3. Place your ear to the Pinard and take your hand away (so the Pinard is held against the abdomen using your ear only): You should be applying gentle pressure, to ensure a good seal between your ear and the Pinard, as well as between the Pinard and the abdomen. Pressing too hard will be uncomfortable for the patient and pressing too softly will make it difficult to hear anything at all. 4. Listen for the fetal heartbeat: If the maternal pulse coincides with the pulse you can hear, you are most likely listening to the flow through the uterine vessels, rather than the fetal heartbeat.

22. To complete the examination… Explain to the patient that the examination is now finished. Thank the patient for their time and restore clothing. Dispose of PPE appropriately and wash your hands. Summarise your findings.

23. Further assessments and investigations Blood pressure measurement: to assess for evidence of hypertension (e.g. pre-eclampsia). Urinalysis: to assess for evidence of proteinuria (pre-eclampsia) and urinary tract infection. Speculum examination: if there are concerns about vaginal bleeding or premature rupture of membranes. Weight and height measurement Ultrasound scan: to assess the position and wellbeing of the fetus.