Prof. Dr. Yasamin Hamza Sharif
Medical College
• The obstetric examination is a type of abdominal examination
performed in pregnancy. It is unique in the fact that the
clinician is simultaneously trying to assess the health of two
individuals – the mother and the fetus.
•
• Briefly explain what the examination will involve
using patient-friendly language
• Gain consent to proceed with the examination:
• Position the patient on the clinical examination couch with
the head of the bed at a 30-45° angle for the initial
assessment.
• Adequately expose the patient’s abdomen for the
examination from the pubic symphysis to the xiphisternum
(offer a blanket to allow exposure only when required).
• 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.
• General inspection
• Clinical signs
• Inspect the patient from the end of the bed whilst at rest, looking for
clinical signs suggestive of underlying pathology:
• Inspect the patient’s face for relevant clinical signs:
• Pain: if the patient appears uncomfortable
• Melasma: benign dark and irregular hyperpigmented macules which are
normal in pregnancy.
• Pallor: a pale colour of the skin that can suggest underlying anaemia. It
should be noted that healthy individuals may have a pale complexion that
mimics pallor.
• Jaundice: a yellowish or greenish pigmentation of the skin and whites of
the eyes due to high bilirubin levels (e.g. obstetric cholestasis).
• Oedema: a small amount of oedema is normal in the later stages of
pregnancy however if there is widespread oedema affecting the arms, legs
and face consider the possibility of pre-eclampsia.
• Hands
• The hands can provide lots of clinically relevant information and therefore a focused,
structured assessment is essential.
• Inspect the hands for relevant clinical signs:
• Colour: pale hands suggest poor peripheral perfusion (e.g. hypovolaemic shock,
aortocaval compression) and cyanosis may suggest underlying hypoxaemia.
• Peripheral oedema: may be a normal finding in late pregnancy, but if widespread
consider pre-eclampsia. If pre-eclampsia is suspected, you should check the
patient’s blood pressure and perform urinalysis (looking for proteinuria).
• Palmar erythema: a redness involving the heel of the palm that is a normal finding in
pregnancy.
• Temperature
• Place the dorsal aspect of your hand onto the patient’s to assess temperature:
• In healthy individuals, the hands should be symmetrically warm, suggesting adequate
perfusion.
• Cool hands may suggest poor peripheral perfusion (e.g. hypovolaemic shock,
aortocaval compression).
• Radial pulse
• Palpate the patient’s radial pulse, located at the radial side of the
wrist, with the tips of your index and middle fingers aligned
longitudinally over the course of the artery.
• Once you have located the radial pulse, assess the rate and rhythm.
• Heart rate
• Assessing heart rate:
• 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.
• For irregular rhythms, you should measure the pulse for a full 60
seconds to improve accuracy.
• Women typically have a higher baseline heart rate during pregnancy
(80-90 beats per minute).
•
Blood pressure :
• The aspect of BP measurement during pregnancy has
received the most attention as to whether diastolic pressure
should be registered by the 4th or 5th phase Korotkoff sound.
Pregnancy is the only situation where phase 4 ever had much
support as the best measure of diastolic pressure because it
was stated that in many pregnant women, Korotkoff sounds
might be audible even when there was no pressure in the cuff
which would, of course, give a 5th‐phase diastolic reading of
zero.
• So , The diastolic blood pressure in pregnancy is denoted by
the disappearance of the sound K5 , but should the sound not
disappeared , the pressure at muffling of the sound K4 denotes the
diastolic blood pressure.
• Blood pressure should be taken on both arms at the first antenatal
visit. It is recommended that the patient be seated, with feet
supported, for 2–3 minutes before blood pressure is measured.
Blood pressure should be taken on both arms at the first antenatal
visit. The right arm should be used thereafter if there is no
significant difference between the arms. When measuring blood
pressure, SBP should be palpated at the brachial artery before
inflating the cuff to 20 mmHg above the recorded level.
• The American College of Obstetricians and Gynecologists( ACOG)
advises that optimal measurement of blood pressure is performed
with the patient comfortably seated , legs uncrossed, and her back
and arm supported. The middle of the blood pressure cuff on the
upper arm should be level with the heart . She should be relaxed
and not talking.
• measurement on the left arm in the left lateral recumbent position
is a reasonable alternative to the seated position during labor .
• Measurement on the RT arm while the patient in LT recumbent
position may give false hypotension reading.
• Blood pressure was measured with the woman comfortably
seated, on the right arm, or semirecumbent (45 degree)
posture , with the lower end of the cuff 2.5 cm above the
antecubital fossa. The SBP was initially determined by
palpation and then by auscultation using
sphygmomanometer. The Korotkoff sounds were auscultated
with the cuff deflated by approximately 2 mmHg per second.
SBP was recorded as K1. The DBP was recorded as the
disappearance K5 sound or K4( muffling sound) if no
disappearance.
• There are a number of different techniques for blood pressure
assessment, including the auscultatory method, automated
oscillometric devices, aneroid devices( using no liquid specifically
operating by the effect of outside air pressure on a diaphragm
forming one wall of an evacuated container) .
• The auscultatory method with a mercury sphygmomanometer and
the use of Korotkoff sounds was previously recommended as the
gold standard technique. Mercury sphygmomanometers have been
withdrawn owing to safety concerns (mercury toxicity)and replaced
with aneroid devices, but these are particularly prone to calibration
errors due to (mechanical trauma)and regular calibration is
imperative to ensure accuracy .
• Automated oscillometric devices are straightforward to use, but the
physiological changes in healthy pregnancy and pathologic changes
in preeclampsia may affect the accuracy of a device and monitors
must be validated.
• 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 couch, 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).
• Closely inspect the abdomen
• Expose the abdomen appropriately, from the xiphisternum to the pubic symphysis and
inspect for relevant clinical signs:
• Abdominal shape: 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).
• 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.
• 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.
• Palpate the abdomen
• 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
(e.g. appendicitis).
• Palpate the uterus
• Palpate the uterus to identify its borders, including the upper and lateral
edges.
• 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
• 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.
• 2. Locate the fundus of the uterus (a firm feeling edge at the upper
border of the protrusion ).
• 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 centimetres using a tape measure. The distance
measured should correlate with the gestational age in weeks (+/- 2cm).
• To avoid bias, it’s best to place the tape measure facing down and only
turn to view the numbers once in position.
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