Obstetric abdominal examination (examination of the pregnant abdomen) frequently appears in OSCEs. You’ll be expected to pick up the relevant clinical signs using your examination skills. This obstetric abdominal examination OSCE guide provides a clear step-by-step approach to examining the pregnant abdomen.
Wash your hands
Confirm the patient’s details (name and date of birth)
Ask if the patient currently has any pain
Describe the examination
“Today I need to examine your tummy as part of the assessment of your pregnancy. This will involve me looking and feeling the tummy, in addition to performing some measurements. Although it may be a little uncomfortable, it shouldn’t be painful. If at any point you’d like me to stop then please just let me know.”
“Are you happy for me to carry out the examination?”
“If you’d like to first empty your bladder before the examination then now would be the best time to do it.”
Carry out a general inspection of the patient:
- Do they appear comfortable at rest?
- Note any evidence of jaundice or gross oedema
- Assess pulse rate and rhythm
- Women typically have a higher baseline heart rate during pregnancy (80-90 beats per minute)
Capillary refill time:
- Less than 2 seconds is normal
- A prolonged capillary refill time may suggest hypovolaemia (e.g. antepartum haemorrhage)
- It is normal for women to have a degree of peripheral oedema during pregnancy (particularly in the later stages)
- However, oedema can also be a sign of pre-eclampsia and therefore this diagnosis needs to be excluded.
- If pre-eclampsia is suspected, you should check the patient’s blood pressure and perform urinalysis (looking for proteinuria)
Inspect the patient’s face, looking for relevant clinical signs:
- Jaundice – associated with obstetric cholestasis
- Melasma (benign dark and irregular hyperpigmented macules) – a non-pathological sign associated with pregnancy
- Oedema – associated with pre-eclampsia
- Conjunctival pallor – associated with anaemia
Inspect the abdomen
Position the patient
The recommended positioning during pregnancy varies, depending on the patient’s current gestation:
- Early pregnancy – position the patient supine on the couch, with the head end of the bed elevated to 15-30 degrees
- Late pregnancy – position the patient in the left lateral position to avoid inferior vena cava compression
Closely inspect the abdomen
Expose the abdomen appropriately, from the xiphisternum to the pubic symphysis and inspect for relevant clinical signs:
- Note the shape of the abdomen (this may give an indication of the fetal lie)
- Look for fetal movements (from 24 weeks gestation onwards)
- Note any surgical scars (e.g. previous caesarean section)
- Inspect for cutaneous signs of pregnancy:
- Linea nigra
- Striae gravidarum
- Striae albicans
Ask about abdominal tenderness before palpating the abdomen and continue to monitor the patient’s face for signs of discomfort throughout the examination.
Palpate the 9 regions of the abdomen
- Perform light palpation in each of the 9 regions of the abdomen
- Note any tenderness, guarding, rebound or masses (other than the gravid uterus itself)
Palpate the uterus
- Identify the borders of the uterus, feeling for its upper and lateral edges
The fundus is found at different places during pregnancy, depending on the current gestation:
- 12 weeks gestation – pubic symphysis
- 20 weeks gestation – umbilicus
- 36 weeks gestation – the xiphoid process of the sternum
Determine fetal lie
1. Place your hands either side of the patient’s uterus (ensuring you are facing the patient)
2. Apply gentle pressure to each side of the uterus
3. One side of the uterus should feel full in nature (due to the presence of the fetal back)
4. On the other side of the uterus, you may be able to feel the fetus’s limbs
Types of fetal lie:
- Longitudinal – head/buttocks palpable at each end of the uterus
- Oblique – head/buttocks palpable in one of the iliac fossae
- Transverse – the fetus is lying directly across the uterus
1. Ensure you are facing the patient to observe for signs of discomfort
2. Warn the patient this may feel a little uncomfortable
3. Place your hands either side of the lower pole of the uterus (just above pubic symphysis)
4. Apply firm pressure angled medially, feeling for the presenting part:
- A hard round presenting part is suggestive of a cephalic presentation
- A broader, softer, less defined presenting part is suggestive of a breech presentation
Assessment of engagement
In late pregnancy, the level of fetal engagement should be assessed.
Engagement refers more than 50% of the presenting part (usually the head) having descended into the pelvis.
The fetal head is divided into fifths when assessing engagement:
- If you are able to feel the entire head in the abdomen, it is five fifths palpable (not engaged)
- If you are not able to feel the head at all abdominally, it is zero fifths palpable (fully engaged)
Measure symphyseal-fundal height
Symphyseal-fundal height is the distance between the fundus and the upper border of the pubic symphysis. After 20 weeks gestation, the symphyseal-fundal height should correlate with the gestational age of the fetus in weeks (+/- 2cm).
1. Begin palpation just inferior to the xiphisternum
2. Palpate using the ulnar border of the left hand
3. Locate the fundus of the uterus (a firm feeling edge at the upper border of the bump)
4. Now locate the upper border of the pubic symphysis
5. Measure the distance between the two in centimetres using a tape measure
6. This distance should correlate with the gestational age in weeks (+/- 2cm)
To avoid bias, it’s best to place the tape measure facing down, only turning to view the numbers once in position.
Using a Pinard stethoscope
You may be asked to identify the fetal heartbeat using a Pinard stethoscope (or a Doppler ultrasound probe). As a result, it is important to have a basic understanding of how to locate and identify the fetal heartbeat.
1. Based on your assessment of the fetus’s position, you should place the Pinard stethoscope aiming between the fetal shoulders on the fetal back.
2. Palpate the patient’s radial pulse (maternal pulse).
3. Place your ear to the Pinard and take your hand away (so the Pinard is held against the abdomen using your ear only):
- You should be applying gentle pressure, to ensure a good seal between your ear and the Pinard, as well as between the Pinard and the abdomen.
- Pressing too hard will be uncomfortable for the patient and pressing too softly will make it difficult to hear anything at all.
4. Listen for the fetal heartbeat:
- If the maternal pulse coincides with the pulse you can hear, you are most likely listening to the flow through the uterine vessels, rather than the fetal heartbeat.
To complete the examination…
Re-cover the patient and allow time for them to get dressed in private
Thank the patient
Wash your hands
Summarise your findings:
“I examined Mrs Smith, a 28-year-old female who is currently at 36 weeks gestation. On examination, she was comfortable at rest. Symphyseal-fundal height was 36cm, which is in keeping with her current gestation. The fetus was positioned in a longitudinal lie with a cephalic presentation. The fetal head was three fifths palpable.”
Suggest further assessments and investigations
- Assessment of the fetal heartbeat using a Pinard stethoscope or Doppler ultrasound
- Blood pressure measurement
- Weight and height measurement
- Speculum examination
Mr Isaac Magani
Medical Student and Illustrator