Approach to Patients in Labor

EXAMINATION OF A PREGNANT
PATIENT
by NMD COMCHECS Clerk #20 COMCHECS Preceptor
Victoria Eliza B. Inguillo Ruby E. Robiso, MD, FPOGS

Date: April 23, 2024

 OBJECTIVES
1. To identify the different procedures done in examining a
pregnant patient in labor;
2. To discuss the step-by-step process of each procedure;
3. To execute the said procedures correctly; and
3. To discuss the examination findings of a patient in labor.
 OUTLINE
1. Patient Preparation
2. Abdominal Exam
3. Fundic Height Measurement
4. Leopold’s Maneuver
5. Fetal Heart Tone Determination
6. Vaginal Exam
7. Clinical Pelvimetry
8. Patient Aftercare
 1. PATIENT PREPARATION

ü Greet patient and introduce yourself

ü Inform patient of the procedure to be performed
ü Secure consent
ü Let the patient empty her bladder
ü Offer a chaperone
ü Let the patient lie comfortably in supine position
ü Drape the patient and bare her abdomen
 2. ABDOMINAL EXAM

ü Palpate the abdomen

ü Determine if there is presence of fetal movement,
mass and uterine contractions
ü If with uterine contractions, describe according to
intensity, interval and duration
 3. FUNDIC HEIGHT MEASUREMENT
ü Place the tip of the tape measure over
the anterior border of the symphysis
pubis up to the level of the top of the
fundus.
ü Record fundic height in centimeters.
ü Correlate the fundic height with the age
of gestation
ü Give the estimated fetal weight using
Johnson’s Formula
 JOHNSON’S FORMULA
ü The fundic height is correlated to the AOG and the fetal weight
ü To get the fetal weight, Johnson’s formula is used
EFW(g)=155(FH–n)

N = 12, if vertex is above the ischial spine (unengaged)

N = 11, if vertex is at the level of or below the ischial spine (engaged)

Example:
FH = 39 cm; unengaged
EFW = 155 (39-12)
= 155 (27) = 4,185 g
 4. LEOPOLD’S MANEUVER
First Maneuver: Fundal Grip
ü Face the mother’s head
ü Place both hands on the fundal area so
that the fingers almost touch each other.
Note:
Breech gives the sensation of a large, nodular
mass while the fetal head feels hard & round
and is more mobile and ballotable
 4. LEOPOLD’S MANEUVER (CONT.)
Second Maneuver: Lateral Grip
ü Place palms on either side of the maternal
abdomen.
ü Exert gentle but deep pressure to feel the entire
fetus.
ü Assess on which side is the fetal back or spine and
which side has the small parts or extremities.

Note:
On one side, a hard resistant structure is felt (Fetal
Back)
On the other side, numerous, small, irregular, mobile
parts are felt (Fetal Extremities)
 4. LEOPOLD’S MANEUVER (CONT.)
Third Maneuver: Pawlik’s Grip
ü Grasp the lower portion of the maternal abdomen just
above the symphysis pubis with the thumb and
fingers of one hand
ü Hold presenting part between index finger and thumb
ü Assess for cephalic versus breech presentation
ü Move the fetal presenting part gently back and forth
in your hand
Note:
If the presenting part is not engaged, a movable mass will
be felt, usually the head.
If the presenting part is engaged, the mass is no longer
movable, and the lower pole is in the pelvis.
 4. LEOPOLD’S MANEUVER (CONT.)
Fourth Maneuver: Pelvic Grip
ü Face the mother’s feet.
ü Place hands on either side of the lower abdomen with
finger pads at the lower uterine pole and thumbs
directed toward the umbilicus.
ü Palpate fetal head pressing downward towards the
pubic symphysis.
Note:
The fetal head is flexed if the cephalic prominence
corresponds to the side of the fetal small parts.
The fetal head is extended if the cephalic prominence is on
the same side with the fetal back.
 5. FETAL HEART TONE DETERMINATION

ü Locate the fetal heart tone based on the Leopold’s

maneuver
ü Place the stethoscope over where the fetal back is
located and count one full minute
Note:
Normal fetal heart tones usually ranges from 110-160
bpm and is heard as a double sound resembling the tick
of a watch under a pillow.
 6. VAGINAL EXAM
ü Inform patient that you will now proceed with vaginal exam
ü Secure consent
ü Place the patient in a lithotomy position
ü Drape the patient and expose the perineum
ü Wear gloves
ü Separate the labia using two fingers of one hand
ü The first and second fingers of the other hand are carefully inserted
into the introitus and carried up to the cervix to determine the
following: Cervical dilatation, Cervical effacement, Cervical
consistency, Presenting part, Station, Position, and BOW
 6. VAGINAL EXAM (CONT.)
ü Two fingers are directed in the posterior aspect of the vagina
and swept forward over the fetal head toward the maternal
symphysis.
ü The positions of the two fontanels are ascertained.
ü The fetal position in vertex presentation is determined
 7. CLINICAL PELVIMETRY
ü Pelvic Inlet Measurement: the sacral promontory should not be
reached at 11.5 cm.
ü Midpelvis Measurement: palpate for the ischial spines, should be
widely spread (>10cm), sidewalls should be parallel and determine
the concavity of the sacrum, must be curved.
ü Pelvic Outlet Measurement: assess the mobility of the coccyx,
subpubic arch should be wide, and estimate by placing a closed fist
against the perineum between the ischial tuberosities. The diameter
must be more than 8 cm.
 8. PATIENT AFTERCARE
ü Assist the patient from dorsal lithotomy to sitting
position
ü Explain findings and answer patient’s questions
ü Thank the patient