Obstetric Abdominal Palpation

Obstetric Abdominal Palpation Indication Every lady in the birthing suite Not the same for every lady Athletic ladies -> thigh muscles Ladies with large BMIs -> hard to feel Challenging for both of the above In a first time mum -> high and round Multiple times more -> uterus on the wider side General Inspection of the abdomen Features of distress Pain Obvious scars E.g. from previous C section Pallor Jaundice Oedema Skin changes Is the degree of distension compatible with pregnancy? Linea nigra Striae gravidarum Striae albicans Palpation Palpate the uterus Location depends on gestational age 12 weeks -> pubic symphysis 20 weeks -> umbilicus 36 weeks -> xiphoid of the sternum After 36 weeks -> may decrease as the fetal head engages Fundal height Edge of the left hand From below the xiphisternum downward until feeling the fundus of the uterus (curved top) Measure with a non-elastic tap Place the zero at the fundus Run it along the midline to the top of the pubic symphysis Measure in cm -> compare with gestational age After 20 weeks gestation -> correlates with GA in weeks -> +/- 2cm A variation of +/- 2 is normal If the variation is more than 3m -> U/S Refer when: Fundal height more 3 or more cm below expected Serial measurements show static or slow growth Height plots are below 10 th percentile on the growth chart Fetal lie Relationship between the long axis of the foetus and the long axis of the mother Assess the gravid uterus to determine this. Place hands on both sides of the mother’s uterus while facing her just above the pubic symphysis Palpate the sides of the uterus (lateral grip) Once side should feel full Due to the presence of the fetal back In the other side should feel the limbs of the foetus Types of lies: Fundal grip – helps with presentation assessment Palpate the fundus The head feels round, firm and mobile Cephalic presentation -> normal Breech feels softer and irregular and the fetal legs at the bottom Abnormal Pelvic grip Palpate just above the pubic symphysis Helps confirm if the head or breech in the pelvis Pawlik’s Grip Use the fingers above the pubic bone to assess engagement of the presenting part Type Description Most common Longitudinal Fetal is parallel to the maternal spine Fetal spine is perpendicular to the maternal spine Transverse May indicate placenta previa, uterine anomalies or multiparity. Least common Oblique Fetal spine is angled between the above two Fetal engagement Positive prognostic sign for vaginal delivery Esp if head is occipto-anterior When more than 50% of the presenting part (most commonly the head) has descended into the pelvis Widest diameter of the presenting part passes through the pelvic brin Enters maternal pelvic brin and pelvis No longer floating -> locked in -> ready for descent If can feel entire head in abdomen -> five fifths palpable -> not engaged If cannot feel head at all in the abdomen -> zero fifths palpable -> fully engaged. When it happens Primigravida -> 36 weeks -> usually before labour Multipara -> may happen during labour Lack of engagement Cephalopelvic disproportion Malpresentation Placenta previa Polyhydramnios or high parity Symphyseal-fundal height Distance between fundus and upper border of pubic symphysis Technique: Abdominal palpation inferior to the xiphisternum using the ulnar boarder of the left hand Locate fundus Locate pubic Fetal Heartbeat Use pinard stethoscope or doppler U/S Based on assessment of position -> place between fetal shoulders on fetal back Place ear on pinard and take hand away Hold using ear only Apply gentle pressure -> neither too hard nor too soft Listen for heartbeat If the pulse heard correlates with maternal pulse -> most likely listening through the uterine vessels not the fetal heartbeat. If have to guess -> 5 cm from the pubics smphsis Start to feel fundus at 20 weeks -> start examine at 24 weeks Heart beat felt at 26 weeks Paper tabes because we can dispose them after We do not want to use it the same one on multiple women If have to go to theatres -> remove piercing that is on the umbilicus -> put a flexi rod Stretch marks are familial but hereditary Can be all over the body Half way though pregnancy cannot see below belly She may not notice she has stretch marks Freckls in pregnancy If get burnt in sun -> do not go away Use sunscreen and stay away from sun -> frekles go away after Cholestasis Very dangerous in pregnancy Itchy hands and itchy feet and red rash on tummy Test for cholestasis Measuring tape Fold the 0.5cm Do it blind Most babies are in a longtuidnal line Only in travserse for a short period as they are doing the rotation It wabbles -> not engaged If does not wabble -> negaged First time mum -> engage in 36 weeks Not first mums -> do not engages until labour Examinations in labour ar done 4 hours Types of cephalic Vertex Most commo Brow Does not feet through a pelvis Sinciput Mentum Flexes all the way The only type of breech that does not deliver vaginally is incomplete breech Because for the rest the width is same as the head so can come out Need to take maternal pulse at the same time Need to confirm the difference between them Must be two disnict rates For baby 1 minute For mum does not have to be one minue If the baby kicks we want to hear an increase in beats In anateanal period there should be no decerelation in beat In labour there are lots of reasons as to why there may be deacceleration Oedema of the feet is common in pregnancy No new tattoos or peiecing in pregnancy because we do not want to expose the baby to infectious diseases