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When you have completed this skills chapter you should be able to:
The abdominal examination forms an important part of every complete physical examination in labour. The examination is done:
It is helpful to look at the shape and contour of the abdomen.
It is important to ask yourself whether the height of the fundus is in keeping with the woman’s dates and the findings at previous antenatal attendances.
It is important, on palpation, to assess the size of the fetus. This is best done by feeling the size of the fetal head. Is the size of the fetus in keeping with the woman’s dates and the size of the uterus? A fetus which feels smaller than expected is likely to be associated with:
It is important to know whether the lie is longitudinal (cephalic or breech presentation), oblique, or transverse. The normal lie is longitudinal. With an abnormal lie, there is an increased risk of umbilical cord prolapse. An abnormal lie may suggest that there is a multiple pregnancy or a placenta praevia.
It is also important to know the presentation of the fetus. The normal presentation is cephalic (fetal head presentation). If a breech presentation is present, it must be decided whether a vaginal delivery is possible. With breech presentation, there is an increased risk of cord prolapse or a placenta praevia.
If the presentation is cephalic, it is sometimes possible when palpating the abdomen to determine the presenting part of the fetal head (vertex, face or brow). Figure 3A-1 indicates some features that can assist you in determining the presentation.
Figure 3A-1: Vertex, face and brow presentations
This assessment is an essential part of every examination of a woman in labour. The descent and engagement of the head is an important part of assessing the progress of labour and must be assessed before each vaginal examination.
The amount of descent and engagement of the head is assessed by feeling how many fifths of the head are palpable above the brim of the pelvis:
It is very important to be able to distinguish between 3/5 and 2/5 head palpable above the pelvic brim. If only 2/5 of the head is palpable, then engagement has taken place and the possibility of disproportion at the pelvic inlet can be ruled out. The head is still unengaged if 3/5 head is palpable above the pelvic brim.
Descent and engagement of the head are assessed on abdominal and not on vaginal examination.
Figure 3A-2: An accurate method of determining the amount of head palpable above the brim of the pelvis
A uterus may be regarded as abnormally hard:
This may occur:
When there is both hardness and tenderness of the uterus, without period of relaxation during which the uterus is not tender, the commonest causes are:
Therefore, there is likely to be a serious problem if the uterus is harder than normal and there is also tenderness without periods of relaxation. Hardness or tenderness of the uterus must be recorded on the partogram and the most experienced person called to assess the woman.
Contractions can be felt by placing a hand on the abdomen and feeling when the uterus becomes hard, and when it relaxes. It is, therefore, possible to assess the length of the contractions by taking the time at the beginning and end of the contraction. The strength of each contraction is assessed by measuring the duration of the contraction.
Figure 3A-3: Method of grading the duration of uterine contractions for recording on the partogram
The frequency of contractions is assessed by counting the number of contractions that occur in a period of 10 minutes
The fetal heart must be detected and the fetal heart rate pattern assessed and recorded every time the abdomen is examined in labour.