Physical examination in obstetric

Physical Examination Tools

Physical examination tools include:
• Examination room
• Weighing scale
• Height measurement facility
• Sphygmomanometer
• Stethoscope
• Thermometer
• Speculum
• Sterile gloves
• Swabs and disinfectants
• Foetoscope

Systemic Approach in Examination of a Pregnant Woman

General Examination
•  Height, weight, pallor, jaundice, cyanosis, state of the tongue, angular stomatitis, finger
status (clubbing, koilonichia), physical deformities, enlarged lymph nodes, skin condition, oedema, neck swellings, blood pressure, pulse rate and temperature
Cardiovascular System
•    Pulse, blood pressure, look for engorged neck veins, precordial examination (inspection, palpation, and auscultation)

Respiratory system
•    Respiratory rate, position of the trachea, percussion, auscultation
•   Breasts should be examined separately- nipple (retraction and discharge)

Abdominal examination
•    Inspection
o Configuration of the abdomen, movement of the abdomen with respiration, surgical scars
• palpation

    Fundal height, fundal palpation (which foetal parts occupies the fundus), lie,
presenting and level of the presenting part, foetal heart beats, then assess other
internal organs (liver, spleen, kidneys).
Note: In normal pregnancy the fundus is just palpable above the symphysis pubis at 12 weeks, between symphysis pubis and umbilicus is 16 weeks, at the umbilicus is 22 weeks, between the umbilicus and xiphoid process is 28 weeks and at the xiphoid is 36 weeks.

Vaginal Examination
• Only recommended for specific conditions
•    If necessary perform sterile speculum examination
Document of Obstetric Examination Findings
•    Remember to document the findings systematically after examination:
o Have a plain paper and pen
o Write down the findings obtained from the general, systemic and vaginal examination
o Write the comments for specific conditions
o Document for any action taken
Controlling haemorrhage

Stopping convulsions
     Inserting the NGT (Nasal Gastric Tube)
     Inserting Intra Venous Fluid
     Interpretation of Findings, Diagnosis and Differentials
   • Interpret the examination findings in order to establish the most likely diagnosis and differentials:
o Use the list of findings to grade the severity
o Correlate all the findings to have the comprehensive outcome which will lead to diagnosis
o Make sure the findings will direct you to the relevant differential diagnosis and

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In details
General Examination
The assessment should begin with a general examination.
• The general examination should include the woman’s height and weight.
o From these, the body mass index (BMI) can be calculated as follows:
BMI = Weight = kg
(Height)2m2
The metric BMI formula accepts weight measurements in kg, and height
measurements in either cm or meters
o Some antenatal and perinatal complications are associated with a BMI <20 or >25.
•    The thyroid gland and breasts should be examined at a booking visit and auscultation of the heart sounds and lungs is essential.
•    More detailed examinations are indicated when a sign is detected (e.g. multinodular of the goitre, bruit over the mass, ophthalmic signs, tremors) or in specific situations
o For example, examination of the eyes with an ophthalmoscope to look for retinopathy in a diabetic or hypertensive woman.
•     The measurement of maternal blood pressure is of great importance in pregnancy.
o It is not appropriate to measure this in the supine position as pressure from a gravid uterus on the inferior vena cava impedes venous return resulting in a falsely low blood pressure. This is often referred to as the supine hypotension syndrome.
o The correct position is ‘semi recumbent’ – a 45° tilt. When auscultating the brachial artery in measuring the diastolic blood pressure, the value at which the sounds disappear is currently accepted as it gives the closest reading to the direct arterial
blood pressure measurement.
o An appropriate size cuff should be utilised with a larger cuff for those with a larger upper arm circumference – the smaller cuff in these women would give a falsely high reading.

Performing Abdominal Examination
•    The fundamental steps in abdominal examination, namely inspection, palpation and auscultation apply to the pregnant woman and occasionally the art of percussion to elicit fluid thrill when polyhydramnios is suspected.
•     The specific manoeuvres and techniques vary in an obstetric examination.
•      The clinician may be guided by the preceding history and general examination to conduct this more specific part of the physical examination.
•      For instance, a history of abdominal pain should prompt a careful palpation for uterine contractions (suggestive of labour) or localised tenderness (associated with red degeneration of a fibroid, accident of an adnexal mass, dehiscence of a previous scar or rarely placental abruption)

Abdominal Inspection
•    Note the distension of the abdomen that may indirectly indicate the shape and size of the uterus. Any asymmetry of the abdomen and foetal movements should be recorded.
•     It is important to note any surgical scars, particularly a low transverse incision that may be obscured by pubic hair and a laparoscopic scar within the umbilicus. The scars observed should be correlated to previous surgical and gynaecological history.
•     Coetaneous signs of pregnancy such as linea nigra (dark pigmented line stretching from just below the xiphi sternum through the umbilicus to the supra-pubic area) or striae gravidarum (recent striae are purplish in colour) are often present though they are of no clinical significance.
•    Old striae (striae albicans) are silvery-white and are evidence of previous parity.
•     The umbilicus may be flat with the surface or everted due to increased intra-abdominal pressure.
•      Superficial veins may be seen denoting alternate paths of venous drainage due to pressure on the inferior vena cava by the gravid uterus.

Abdominal Palpation
•    Uterine size: The uterine size is objectively measured and expressed as fundo-symphyseal height.
•    First the highest point of the fundus of the uterus should be palpated.
•    One should bear in mind that the uterus may be displaced to the left or right of the midline.
•     Use the ulnar border of the left hand and move it downwards from below the xiphi sternum and from below each subcostal margin until the fundus is located.
•      Once the highest point of the uterine fundus is identified the fundo-symphysial height (SFH) can be measured with a tape measure.
•      The upper margin of the bony pubic symphysis is located by palpating downwards in the midline starting from few centimetres above the pubic hair margin.
•       The SFH in centimetres ± 2 cm should approximate the gestation of the pregnancy in weeks from 20 until 36 weeks gestation.
•       From 36 to 40 weeks this could be ± 3 cm and at 40 weeks it is ± 4 cm.
•      The decrease in height is due to reduction in the amniotic fluid volume and descent of the foetal head.
•       On the contrary, the increase in size may be due to further growth of the foetus, increase of amniotic fluid and non descent of the foetal head.
•       It is important at this stage that the number of foetuses is determined.
•      Palpation of a larger uterus than that expected for that gestation, two heads, three poles, multiple foetal parts, excessive amniotic fluid, and auscultation of two foetal heart rates with a difference of greater than 10 beats per minute suggests the presence of multiple pregnancies.

Checking for Foetal Presentation
•     Presentation is the part of the foetus that overlies the pelvic brim and is of importance especially after 37 weeks gestation when the majority of women go into labour.
•     This is determined by placing both hands on either side of the lower pole of the uterus while facing the woman’s feet.
•     Approximate the hands firmly but gently towards the midline to ascertain the presenting part.

A hard rounded presenting part suggests a cephalic presentation while a broader, soft object suggests breech presentation.
•     In cephalic presentation, it is usual to report the number of fifths of the head palpable.
o This is a rough approximation of how many finger breadths are necessary to cover the head above the pelvic brim.
•      When touching the abdomen look at the woman’s face, as palpation of the foetal head may be tender. The clinician should detect any signs of discomfort from her facial expression and be gentle with the palpation.
o Paulik’s grip is a one-handed technique to feel for the presenting part.
o The cupped right hand is used to grasp the lower pole of the uterus and it is possible to feel the hard rounded foetal head in nearly 95% of pregnancies at term.
o It can cause discomfort and is not a necessary part of the examination if the head can
be palpated with ease by the two hands.
•       If the hands on the sides of the head converge above the pelvic brim then the head is not engaged as more of the head is above whilst if the hands diverge then it is suggestive of engagement i.e. more than half the head has descended below the pelvic brim.

Checking for Lie of the Foetus and Location of the Foetal Back
•    Lie of the foetus describes the relationship of the longitudinal axis of the foetus to the longitudinal axis of the uterus.
•      This is best done by facing the woman and placing one hand on each side of the uterus and applying gentle pressure when one should be able to perceive the resistance of the firm foetal back and on the opposite side it may be possible to feel the foetal limbs.
•       This can be confirmed by alternately palpating with one hand while using the opposite hand to steady the foetus.
•       If the presentation is cephalic or breech (the buttocks of the foetus) it has to be a longitudinal lie as the lower pole of the longitudinal lie of the uterus is occupied by one pole of the longitudinal axis of the foetus.
•      If no presenting part was palpable in the lower pole and if the head or a breech was in one of the iliac fossa then it is an oblique lie and if the longitudinal axis of the foetus straddles right across the horizontal axis of the uterus then it is a transverse lie.
•       Once the foetal lie is determined the anterior shoulder should be palpated as the foetal heart sounds are best heard over this area.
•      A shallow groove palpable between the presenting part and the rest of the foetus helps to identify the prominent anterior shoulder in most cases.
Estimation of Foetal Weight and Quantity of Amniotic Fluid
•     Assessing foetal weight can be difficult but it is important to determine whether the foetus is small, average or big.
•   It is usually assessed by placing one hand over each pole of the foetus and by guessing the approximate weight.
•   With experience and by checking the guessed weight to the actual weight after delivery the clinician is able to improve his/her performance although many a times the error would exceed more than 10% especially with the very small and the very large fetuses.
•     The ease with which the foetal parts are palpable, ballotment of the fetal parts and the ‘cystic’ feeling for the fluid in the uterus should give some idea of the amniotic fluid.

Abdominal Auscultation
•     The foetal stethoscope or any other device can be placed over the anterior shoulder and the foetal heart can be heard. The rate can be determined by auscultation over one minute.

Abdominal Percussion
•      Percussion is generally not used in an obstetric examination.
•      If the quantity of amniotic fluid is felt to be excessive (shining, stretched abdomen with
       difficulty in feeling foetal parts) then the sign of ballottement is useful to identify the head.
•      Fluid thrill may be elicited by tapping in the midpoint of the uterus on one side and trying to feel it with the hand placed on the opposite side at the same level.
•       The passage of surface vibrations should be damped by an assistant or patient keeping the ulnar border of the hand firmly in the midline on the abdominal wall.

After Taking the History
•      Inform the woman of identified problems or high risk factors
•       Educate the client as necessary addressing harmful beliefs and misconceptions
•       Give explanations in clear language avoiding jargon
•       Allow client to ask questions and check for understanding
•       Record all the findings in the antenatal card
•        The examination should add to information gathered during history taking in order to assist in making clinical judgements for further investigations if needed, and to help further management.

Performing a Vaginal Examination
Introduction
•     Vaginal speculum and digital examinations are not a routine part of the obstetric physical
examination but are performed when indicated
o For example, a speculum examination to confirm leaking amniotic fluid in cases of pre-labour rupture of membranes, or to carry out inspection and take swabs in cases with abnormal vaginal discharge.

The Procedure
•      Introduce yourself and explain the procedure to the client
•     Establish names/relationship of family
•     Start with an open-ended question
• Use appropriate eye contact, body language
•     Use facilitative listening skills
•     Demonstrate empathy
•     Describe each step of exam to patient prior to performing it
•     Maintain patient privacy
• Attend to patient’s comfort throughout the procedure
•     Perform exam in a gentle and professional manner

Preparation
•     Prepare all the needed equipment and supplies
•      Prepare the examination table and the light prior to gloving
•      Wash hands in running water with soap

General Techniques/Exam Skills
•      Demonstrate concern for the patient’s comfort and maintain client’s privacy
•       Explain to patient/client about the procedure
•       Ask for the patient’s/client’s cooperation during the exam
•       Follow a logical sequence of exam from one region to another
•       Emphasize areas of importance as suggested by interview
•       Modify the examination to adapt to patient limitations (imposed by illness, age or temperament of patient)
•       Position patient on the examination couch, making sure that you maintain privacy, hips to end of table and heels on foot rests or stirrups
•       Wash hands and wear gloves throughout the examination

External Examination of the genitalia

Examine the external genitalia:
o Inspect mons pubis
o Inspect labia majora
o Inspect labia minora
o Inspect clitoris
o Inspect urethal meatus
o Inspect introitu

o Inspect Bartholin’s gland
o Inspect perineum
o Inspect anus
Speculum Examination
• Hold speculum at 45-degree angle
• Insert speculum properly
• Rotate speculum at full insertion
Angle at full insertion: 45 degree angle
Source: APGO, 2008.
• Open speculum slowly
Source: APGO, 2008.
• Identify cervix
• Secure speculum in open position
• Inspect cervix
• Inspect vaginal walls while removing speculum
• Handle speculum appropriately
• Remove speculum appropriately

Bimanual Pelvic Examination
• Change gloves and inform the woman that you are going to insert fingers to inspect the
inside of the vagina
• Introduce fingers into vagina
Source: APGO, 2008.
• Palpate cervix and cervical os
• Palpate uterine body, apex of fundus
• Note uterine size
• Describe position of uterus
• Palpate right adnexa/ovary
• Palpate left adnexa/ovary
Bimanual Rectovaginal (RV) Examination
• Change gloves for rectal examination
• Explain the procedure to the client saying that you are going to insert a finger in the anus, being sensitive to culture
• Ask patient to bear down as finger is inserted
• Insert middle finger into rectum
• Palpate uterus
• Palpate right adnexa/ovary
• Palpate left adnexa/ovary
• Remove finger smoothly
After the Examination
• Assist the woman to a sitting position
• Inform the woman the identified problems or risks
• Educate the client as necessary addressing harmful beliefs and misconceptions
• Give explanations in clear language avoiding jargon
• Allow client to ask questions and check for understanding

By: Welfare Jambo

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