OBSTETRICAL EXAMINATION

Definition
Examination of a pregnant women to determine the normalcy of fetal growth in relation to the gestational
age , position of fetus in uterus and its relationship to maternal pelvis
PURPOSES
A thorough and systemic abdominal examination beyond 28 weeks of pregnancy can reasonably
diagnose
 The lie, presentation, position and the attitude of the fetus. (It is not unlikely that the lie and
presentation of the fetus might change, especially in association with excess liquor amnii and
hence periodic check up is essential.)
 To observe signs of pregnancy
 To measure the abdominal girth and fundal height.
 To determine abdominal muscle tone
 To determine the engagement
 To determine the abdominal muscle tone
 To detect any deviation from normal
 To determine the possible location of the fatal heart tone.
ARTICLES
 Weight and height measurement tools
 BP apparatus
 Stethoscope/ Doppler/ fetoscope
 Measuring tape
 Kidney tray
 A bowel with cotton/gauze
 Thermometer
 Towels
Preliminaries:
(a) Verbal consent from the patient should be taken,
(b) presence of a female attendant,
(c) prior bladder evacuation,
(d) proper exposure of abdomen,
(e) woman in dorsal posture with thighs and knees slightly flexed
  candidate is to stand on the right side of the patient
General Physical Examination
Build: Obese/average/thin.
Nutrition: Good/average/poor
Height: Short stature is likely to be associated with a small pelvis. Thus, in primigravidae, the height is to
be measured to screen out the short stature. While an arbitrary
measurement of 5 feet. is considered as short stature in western countries, it is 4' 7" in India considering
the low average height.
Weight: Weight should be taken in all cases in an accurate weighing machine. Repeated weight
checking in subsequent visit should preferably be done in the same weighing machine.
Pallor: The sites to be noted are lower palpebral conjunctiva, dorsum of the tongue and nail beds.
Jaundice: The sites to be noted are bulbar conjunctiva, under surface of the tongue, hard palate and skin.
Tongue, teeth, gums and tonsils: Evidences of malnutrition are evident from glossitis and stomatitis.
Evidence of any source of infection in the mouth is to be eradicated least there be a chance of autogenous
infection in puerperium.
Neck: Neck veins, thyroid gland or lymph glands are looked for any abnormality. Slight physiological
enlargement of the thyroid gland occurs during pregnancy in 50% of cases.
edema of legs: Both the legs are to be examined. The sites for evidence of edema are over the medial
malleolus and anterior surface of the lower one-third of the tibia. The area is to be pressed with the thumb
for at least 5 seconds. Varicosity in the legs, if any, is to be noted.
Causes of edema in pregnancy: (1) Physiological (2) Preeclampsia (3) Anemia and hypoproteinemia
(4) Cardiac failure (5) Nephrotic syndrome. Dependent edema is physiological in pregnancy but
generalized edema (anasarca) or facial edemacan be a first sign of disease.
Physiological edema: The cause of physiological edema is due to increased venous pressure of
the inferior extremities by the gravid uterus pressing on the common iliac veins.
The features of the physiological edema are: (1) slight degree (ankle edema), usually confined to one
leg, more on the right,(2) unassociated with any other features of preeclampsia or proteinuria, (3)
disappears on rest alone,(4) other pathologies of cardiac, renal and hematological are absent.

→ Pulse
→ Blood pressure
→ Temperature
→ Respiratory rate
Mental status
To assess whether the individual is alert, conscious and co-operative.
􀂠Systemic examination
. Examination of cardiovascular and respiratory system
• Heart
• Lungs
™. Musculoskeletal system
™. Examination of abdomen
• Inspection
• Palpation
Any tenderness, liver, spleen (any organomegaly)
SPECIFIC OBSTETRIC EXAMINATION:
→ Breasts
Inspection
 Primary and secondary areola:
 Montgomery’s tubercle :
 Any other :
Palpation :
 Enlargement of lymph nodules :
 Engorgement of breast :
 Presence of colostrums/ nil :
 Any other
Examination of abdomen
1. Inspection:
To note (1) whether the uterine ovoid is longitudinal or transverse or oblique (2) contour
of the uterus—fundal notching, convex or flattened anterior wall, cylindrical or spherical shape (3)
undueenlargement of the uterus (4) skin condition of abdomen for evidence of ringworm or scabies and
(5)any incisional scar mark on the abdomen.
2. Palpation:
Height of the uterus: The uterus is to be centralized, if it is deviated. The ulnar border of
the left hand is placed on the upper most level of the fundus and an approximate duration of pregnancy
is ascertained in terms of weeks of gestation . Alternatively, the SFH can be measured with a tape.
Obstetric grips (Leopold’s maneuvers):
i. First Leopold (fundal grip) :The palpation is done facing the patient’s face. The whole of the fundal
area is palpated using both hands laid flat on it to find out which pole of the fetus is lying in the fundus
(a) broad, soft and irregular mass suggestive of breech, or (b) smooth, hard and globular mass suggestive
of head. Intransverse lie, neither of the fetal poles are palpated in the fundal area.
ii. Second Leopold (lateral or umbilical grip)
The palpation is done facing the patient’s face. The hands are to be placed flat on either side of the
umbilicus to palpate one after the other, the sides and front of the uterusto find out the position of the
back, limbs and the anterior shoulder.
The back is suggested by smooth curved and resistant feel. The ‘limb side’ is comparatively empty and
there are small knob like irregular parts. After the identification of the back, it is essential to note its
position whether placed anteriorly or towards the flank or placed transversely. Similarly, the disposition
of the small parts, whether placed to one side or placed anteriorly occupying both the sides, is to be
noted.
The position of the anterior shoulder is to be sought for. It forms a well-marked prominence in the
lower part of the uterus above the head. It may be placed near the midline or well away from the midline
iii. Third Leopold (Pawlik’s grip)
The examination is done facing toward the patient’s face. The overstretched thumb and four fingers of
the right hand are placed over the lower pole of the uterus keeping the ulnar border of the palm on the
upper border of the symphysis pubis. When the fingers and the thumb are approximated, the presenting
part is grasped distinctly (if not engaged) and also the mobility from side to side is tested. In transverse
lie, Pawlik’s grip is empty.
iv. Fourth Leopold (pelvic grip): The examination is done facing toward the patient’s face. The
overstretched thumb and four fingers of the right hand are placed over the lower pole of the uterus
keeping the ulnar border of the palm on the upper border of the symphysis pubis. When the fingers
and the thumb are approximated, the presenting part is grasped distinctly (if not engaged) a To ascertain
the presenting part, the greater mass of the head (cephalic prominence) is carefully
palpated and its relation to the limbs and back is noted. The attitude of the head is inferred by noting the
relative position of the sincipital and occipital poles . The engagement is ascertained noting the
presence or absence of the sincipital and occipital poles or whether there is convergence or divergence
of the finger tips during palpation . This pelvic grip using both the hands is favored as it is most
comfortable for the woman and gives most information. nd also the mobility from side to side is tested.
In transverse lie, Pawlik’s grip is empty.
 3. Percussion (not done)
4. Auscultation
Auscultation for fetal heart sound The fetal heart sounds are best audible through the back (left scapular
region) in vertex and breech presentation. As a rule, the maximum intensity of the FHS is below the
umbilicus in cephalic presentation and around the umbilicus in breech
REFERENCE

1. Fraser DM, Cooper MA. Myles Textbook for Midwives. 15th edition. Philadelphia: Churchill
livingstone elsevier; 2009
2. Dutta DC. Textbook of obstetrics. 6th edition. Calcutta: New central book agency;2004
3. Annamma Jacob.Clinical Nursing Procedures: The Art of Nursing Practice. 3rd edition. New Delhi
Jaypee Brothers Medical Publishers; 2015