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Obstetrics Examination - Coggle Diagram
Obstetrics Examination
Equipement
Pinard stethoscope
Measuring tape
Brief Obs Hx
Parity
Previous delivery hx
Current gestation
Singletone or multiple pregnancy
Fetal movements present
Contractions / pain
Vaginal loss
Current issues / symptoms
Prep
Review Vital on IMEWS chart
WIPER
Ask woman if she would like to empty bladder
Inspection
Distension
Size
Shape
Round ovoid
Movements
Visible from 24 weeks
May start to feel during 2nd trimester from 13w
Ideally 10 in 12 hours
Longer to feel in anterior placenta
Scars
C section
Laparoscopy
Laparotomy
Linea nigra
Dark pigmentation line running vetically down the middle of the abdomen - normal finding in pregnancy
Striae gravidarum
Reddish or purple lesions that develop due to overstretching of abdominal skin as gravid uterus exapnds
Striae albicans
Mature stretch marks
Measuring the Symphysis Fundal Height (SFH)
Distance in centimetres between fundus of the uterus and the pubic symphysis bone
Use
Monitor size and growth of baby
Further investigation
if SFH does not correlate with gestational age / expected growth
Measuring
Ulnar border of left hand begin palpating the abdomen just inferior to xiphisternum
Locate the fundus of the uterus
12+0 : Pubic symphysis
20+0 Umbilicus
36+0 under xiphisternum
Locate upper border of symphysis pubis
Measure distance between fundus and pubic symphysis in cm
Distance should correlate with gestational age in wks +/- 2cm
Best practice: Place measuring tape facing down on abdomen- tear tap and turn over
Incorrect Measuring
Measuring Large
Wrong date
Macrosomia
Polyhydramnios - more water
Multiple pregnancy
Fibroids
Measuring Small
Wrong dates
Small baby
Intra uterine growth restriction (IUGR)
Oligohydramnios
Spontaneous rupture of membranes
Preterm rupture of membranes
Action
Review hx and dates
Re check measurement
Obs review
Bedside scan
Refer for departmental scan
Measuring large - Refer for OGTT
The fetal Lie
Relationship between the long axis of the baby in relation to the long axis of the mother
Types
Longitudinal - most common
Fetla spine parallel with mothers spine
Head and buttocks of baby - fetal poles - are palpable at each end of the uterus
Most babies turn to longitudinal lie by 37 weeks
Most common
Transverse
Baby lying directly across uterus
From 37 weeks gestation - unstable
Most unstable babies will turn to longitudinal lie at 40w
Oblique
Diagonal in uterus
Head and buttocks palpable in iliac fossa
Unstable from 37 weeks
Lateral Palpation
Place hands either dise of uterus while facing woman
Stabilize the uterus with one hand and gently palpate along the other side, repeat manoeuvre for opposite side of uterus
One side may feel full - back
Other side feel limbs
Leopolds Palpation manouvres
Presention / Presenting Part
Part of the fetus that leads the way through the birth canal
Usually head (cephalic) but can be buttocks (Breech)
Transverse or oblique lie has no presenting part - pelvis is empty
Assessment
Stand facing body away from woma's face, ensure to look for signs of discomfort
Place hands together above pelvic brim
Apply firm pressure angled medially to feel for presenting part
Firm / round - cephalic presentation
Broader softer - breech presentation
Palpate fetal pole at fundus to confirm findings
Engagement
Location of presenting part in realtion to the pelvic brim
Occurs when widest diameter of fetal head passes through pelvic brim
Pawlicks Grip maneouvre
C/I Placental praevia
Assessent
Face woman place thumb + index finger above pelvic brim
Press firmly inwards and downwards
Fetal head deivided into fifths when assessing engagement
Presenting part considered engaged when 2/5 or less are palpable abdominally
May be uncomfortable
May not engage before labour
May not engage due to cephalo-pelvic disproportion - fetal head may be deflexed, size of the fetal head or size / shape of the pelvis
Auscultation of Fetal Heart Rate (FHR)
Normal rate 110-160
Equipment
Pinard stethoscope
Hand held doppler
CTG machine
Pinard Stethascope
Use
Allows intermittent assessment of FHR during antenatal visits and labour
Procedure
Listen for 60s due to decelerations and accelerations in foetal HR
Place over the anterior shoulder of the foetus
Palpate the maternal radial pulse to ensure they are differenct
If abnormal - Carry out CTG
Hang Held Doppler
Use
Audible simulation of the FHR
Procedure
Place over anterior shoulder of the baby
Ausculate for 60 sec
CArry out CTG if deviations are heard
Cardiotocography (CTG)
USe
Monitor and record fetal hearbeat
continuously
and uterine contractions during pregnancy and labour
Monitor fetal wellbeing and identify babies at risk of hypoxia
Monitors
Contractions
Baseline FHR
Variability
Acceleration and decelerations of the FHR
Procedure
Place uterine activity transducer at fundus of the uterus
Place heart rate transducer over anterior shoulder of baby
Mother given button to record fetal movements
20min at least - often for duration of labour
Abdomen Palpation for Multiple Pregnancy
Same Technique and approach
Women usually attend designated mutiple pregnancy clinic for antenatal care
Inspection
Size emay be larger for period of gestation
Measuring FSH
Will measure larger than dates
Palpation
2 fetal backs palpated
At least 3 fetal poles should be palpated
Auscultation
USe CTG machine with 2 abdominal transducers
Difference of 5bpm between babies heartbeats should be recorded
Unstable Lie
A fetus that continues to change positino and does not remain in a fix longitudinal lie at term (>37 weeks
) - transverse or oblique
No cephalic presetation - reduced possibility of a normal vaginal birth
Management
US to confirm findings
Advise admission to hospital
Mother should alert staff of any signs of labour / rupture of membranes
Discuss mode of delivery, LSCS if baby remains unstable
Causes
Polyhydramnios
High parity
Placenta praevia
Fibroids
Fetal abnormality
Multiple pregnancy
Risks
Cord prolapse if membranes rupture
Uterine rupture - esp if uterine scar
Considerations
Does the liquor volume feel normal
Has woman any pain at a previus LSCS scar site?
Is woman having contractions?
If so, how often and ow long to they last
If indicated perform Vaginal Exam (VE) to assess labour
Any bleeding, leakage or discharge?
If indicated -
sterile
speculum exam to assess for rupture of membranes or possible cause of bleeding
Abdomen soft and non-tender?
If not consider sigs of abruption or infection such as chorioamnionitis
HTN / Pre-eclampsia?
May be additional abnormal findings on exam
Correlate with vital signs on IMEWS
Full clinical exam if indicated
Irish Maternity Early Warning Score (IMEWS)
And Observations
Scoring system for detection of life-threatening illness in pregnancy and postnatal period up to 6 weeks
Indications
Full set of vitals
RR
Temperature
Maternal HR
BP
Neurological response
Pain score
ISBAR
Validated tool to im prove communication between healthcare professionals, better pt safety and reduced adverse events
Recording Observations
Antenatal Visits
BP
Urine
Antenatal Inpatient
IMEWS once per day
4 hourly observation for women w HTN / at risk of infection
During Labour
Observations hourly and documented on the
partogram
Complicated pregnancy / labour - observations monitored more closely
Previous LSCS have BP monitored every 30 min and maternal HR every 15 min
Increased BP / Pre-eclampsia hav HR and BP monitored every 30 min
Postnatal
IMEWS routinely once per day
4 hourly observations for women who:
HTN / PET
Risk of infection
Post-surgery
Post partum haemorrhage
Triggering IMEWS
Perform full set of observations as recommended
Inform obs team
Completing the Exam
Cover up woman
Esure dignity is maintained
Explain findings
Answer any questions
Document findinds
Make relevant referrals
Thank woman and wish her well
