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 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).

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.

12. 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.

13.  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

15. 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.

16. 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.

18. 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.

19. 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).

21. 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).

22. 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.

23. 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).

24. 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.

25. 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.

27. 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.

28. 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.