Chapter 1

Examination of the obstetric patient

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P HUGHES

Examination of the obstetric patient

Taking a history of the obstetric patient will vary whether it is a booking visit or presentation with a clinical problem or presentation in labour. For most women their pregnancy, labour, and delivery are normal physiological events and they will not present with serious complaints or complications. Each woman must be treated as an individual and the purpose of any consultation must be outlined to her, beginning with an appropriate introduction. In every case an account of the pregnancy to date and any background risk need to be acquired logically to allow an appropriate focused clinical examination to follow. The following template is suggested below. Drug history and allergies Current medication should be noted and thought given to whether it is licensed in pregnancy and breast feeding and may even need to be changed due to potential teratogenesis. Specic drug allergies must be clearly marked on the notes Social history Whether the woman works, has support (emotional and nancial) and living conditions now and for the rest of the pregnancy are important factors to ascertain. Where suitable, support agencies can be offered. Appropriate sensitive questioning of certain women about female genital mutilation (FGM) is advised to identify these women early. Smoking, past or current recreational drug use and alcohol consumption are important for documentation and provide an opportunity for advice and offer of help if abuse is suspected. When unaccompanied by partner, family or friends, enquiry about domestic violence, both physical and verbal, may be appropriate to give the woman the opportunity to disclose any issues. Family history Family history should include history of multiple pregnancies, diabetes, hypertension, pre-eclampsia in a rst-degree female relative, and congenital disorders. In certain ethnic minorities it may be appropriate to ask about consanguineous marriage.

Obstetric history
History of present pregnancy Once basic biographical details (name, age, current gestation, gravidity, and parity) have been obtained enquiry will follow more in-depth questioning about the current pregnancy: last menstrual period (LMP) and expected date of delivery (EDD) ultrasound scan results (e.g. rst trimester scan agreed with LMP date, nuchal translucency screening test, anomaly scan and site of placenta, any subsequent scans) screening and laboratory tests and results if known any problems or concerns during the pregnancy to date. A detailed history of the presenting complaint should be taken. Past obstetric history Details of all previous pregnancies in chronological order and their outcomes (gestation, mode of delivery, birthweight, and condition of the baby). If there have been any abnormal pregnancy outcomes, e.g. second trimester miscarriages, premature deliveries or still births, then enquiry of any subsequent investigations should be sought in a compassionate manner. If the patient reports a previous termination of pregnancy then it can be prudent to ensure that she is happy for this to be documented in her handheld maternity notes. Past gynaecological history Previous gynaecological conditions and operations may be relevant to the current pregnancy, in particular previous myomectomy or laparotomy, for severe endometriosis with bowel involvement might inuence surgical expertise available at the time of a possible Caesarean section. Previous or current sexually transmitted infections may be relevant as this could inuence the fetus or neonate if left untreated, e.g. syphyllis and chlamydia respectively. Details that should also be noted are a cervical smear and contraceptive history as these are important factors that can be addressed in the postnatal period. Past medical and surgical history A detailed history of any current medical condition is important and enquiry about the condition within a previous pregnancy may be useful for management or surveillance of the current pregnancy. All previous surgery should be noted, but in particular abdominal procedures should be thoroughly detailed. For example, entry into the abdomen might be affected at the time of Caesarean section by the location of a pelvic kidney in a renal transplant patient.

Clinical examination
Explanation about the purpose of the examination must be given and it is essential that the woman be put at ease and every effort taken to ensure that the woman remains as comfortable as possible throughout the examination. Do not allow a woman in late pregnancy to lie on her back for a prolonged period of time as the reduced venous return to the heart by pressure from the gravid uterus can make her feel faint. At the booking visit, general examination of the patient includes height and weight to calculate body mass index. Auscultation of the chest (heart sounds and lungs) is essential at the booking visit to rule out previously undetected or asymptomatic conditions. Examination of the breasts is not recommended as identication of at or inverted nipples antenatally does not affect breast feeding rates postnatally (NICE clinical guideline 62). Subsequent visits, unless otherwise indicated will have a more specically directed examination of the patient. Measurement of blood pressure in all women is vital and should ideally be taken manually with a sphygnometer using Korotkoff V (value at which the sounds disappear) as the recorded diastolic blood pressure value. The correct size cuff must be used for the size of the arm. Those women with an arm circumference larger than 35 cm should have a large cuff applied to ensure that a correct reading is obtained, as a smaller cuff can result in a falsely high blood pressure. Abdominal examination This should follow the routine examination of any system: inspection, palpation, and auscultation. Percussion is rarely used but can illicit a uid thrill in a case of polyhydramnios. The history and general examination will direct the specic part of the clinical examination. Where appropriate, the examination may take place concurrently with resuscitation, e.g. massive antepartum haemorrhage or eclampsia.

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1 EXAMINATION OF THE OBSTETRIC PATIENT

Inspection Distension of the abdomen may indicate the size of the uterus and visible fetal movements can be documented. Surgical scars must be noted. Special attention must be given to identifying a low transverse Pfannestiel incision and laparoscopic scar within the umbilicus both of which are often obscured. Cutaneous signs of pregnancy (linea nigra and striae gravidarum and albicans) can be seen but are of no clinical signicance. The umbilicus can change from being inverted to at or everted as the pregnancy advances. Supercal veins can become evident as the pressure on the vena cava by the increasingly gravid uterus causes alternative paths of venous drainage to become more prominent.

described as engaged if the widest diameter has passed beyond the pelvic brim, i.e. only two-fths felt abdominally. Assessment of liquor volume Estimating liquor volume on palpation can be difcult. If there is difculty palpating fetal parts and particularly if the abdomen feels large, tense, and looks shiny then the suspicion of polyhydramnios should be raised. Although not a denitive indicator of polyhydramnios, a uid thrill may be elicited in such cases. A detailed ultrasound to exclude any obvious anomaly can be undertaken and blood glucose levels checked to rule out a pathological cause. In contrast, a pregnancy with oligohydramnios may reveal fetal parts very easily without the feeling of adequate liquor and a small for dates SFH. Again referral for detailed ultrasound is appropriate as a further investigation. Auscultation The fetal stethoscope, Pinard, or electronic device using Doppler ultrasound can be used to hear the fetal heart by placing the device over the anterior shoulder in the third trimester. Prior to this the Doppler device can usually elicit a fetal heart rate placed anteriorly on the lower abdominal wall over the uterus from 1214 weeks onwards. Routine auscultation for the fetal heart is not recommended at antenatal visits (NICE clinical guideline 62) although women and their partners often expect it.

Palpation
Uterine size Using the ulnar border of the left hand and starting at xiphisternum, move it downwards until the fundus is identied. When the highest part of the symphyseal fundal height (SFH) is located, a tape measure (ideally paper for single use) is used to measure to the upper border of the symphysis pubis in the midline. Care should be made when palpating for this bony prominence as it is often tender in advanced pregnancy and in women with symphysis pubis dysfunction. The SFH in centimetres should equate to the gestation in weeks: 2036 weeks 2 cm and from 36 weeks 3 cm. If the patient has not presented for antenatal scans then it should be remembered that palpation may diagnose a multiple pregnancy. Lie and presentation Lie describes the longitudinal axis of the fetus(es) in relation to that of the uterus, and presentation describes the fetal part that overlies the pelvic brim. Prior to 28 weeks lie and presentation are not important (and often difcult to determine on palpation) unless the woman is in premature labour. After this, gestation it is of more clinical relevance and longitudinal lie with a cephalic presentation are most important from 36 weeks. Palpation of lie is done by placing the hands over the anterolateral sides of the abdomen and moving towards the midline and feeling at the pelvic inlet for the presence or absence of a fetal pole. A fetal back will demonstrate a rm resistance and fetal limbs an irregular or less solid feel. To determine presentation and engagement, towards term, palpate with two hands in the lower pole of the uterus. This can be uncomfortable for the woman and should be done cautiously. The head will feel round and hard. It can be balloted between the examining hands prior to engagement whereas the buttocks are softer and more diffuse and the breech is not ballotable. Beware of the deeply engaged head as this may in fact be a breech presentation. Reassessment of the upper pole of the fetus is advised and an ultrasound performed (or vaginal examination if appropriate) to conrm the presentation. Powliks grip (examining the lower pole between the thumb and index nger of the right hand) can also be used for assessment of engagement of the fetal head. Engagement This describes the passage of the largest diameter of the presentation past the pelvic inlet and is referred to in fifths palpable abdominally. The level of the head is

Vaginal examination
A vaginal examination is performed in the obstetric patient only when indicated. Antenatally This is not a routine examination during the antenatal period. In the rst and second trimesters a woman presenting with bleeding pain (e.g. miscarriage) should be fully assessed including a speculum examination to visualize the cervix, assess the quantity of bleeding and determine digitally whether the cervical os is open or closed. In the third trimester the possibility of placenta praevia should be excluded rst by ultrasound examination. Speculum examinations can be done to investigate vaginal discharge, to take swabs as appropriate, and to conrm or dispute the leakage of amniotic uid. Cervical smears can be taken during pregnancy but unless overt malignancy is suspected then this can usually be postponed until the postpartum period. Prior to induction A digital examination of the cervix can be offered to a woman as part of a membrane sweep at a 41-week antenatal visit (NICE clinical guideline 62) and is undertaken prior to induction of labour to determine its Bishop Score, a subjective assessment of favourability of the cervix In labour At term a digital vaginal examination is done in labour to assess the dilatation of the cervix and hence progress in labour. A nal summary must present a logical synopsis of the patients current pregnancy, relevant background or risk factors followed by the salient ndings of the clinical examination. This will then lead on to appropriate investigations and a plan of management.

Further reading
www.nice.org.uk NICE Reference: NICE Guidance 62. Antenatal care: Routine care for the healthy pregnant women.

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