Obstetrics Examination

We will start by explaining several important terms used

in obstetrics community.

• Expected Date of Delivery (E.D.D): It is calculated

by adding 9 months and 7 days from the first day of
the patient’s last period, assuming she has a regular
28-day cycle. Doctors sometimes use wheel
gestation calculator to avoid unneeded errors.
Sometimes the case is not usual, in longer
Extra Note on E.D.D: Bleeding
cycles, ovulation and the first day of from implantation of the fertilized
menstruation is always 14 days; so for a 35- ovum can mimic a period, but is
day cycle, the expected date of delivery is 7 usually lighter and shorter, and the
days later than the date calculated for a 28-day expected date of delivery will be 4
cycle. weeks earlier than anticipated. If
the period occurred on stopping
• Gestational Age: Gestational age refers to the the oral contraceptive pill,
duration of pregnancy from the last menstrual ovulation may be delayed and the
period, expressed in weeks plus days: for expected date of delivery will be 1-
example, 7(+6) weeks. 2 weeks after the calculated.

Extra Note: • Age of viability: It is the age of pregnancy in

The World Health Organisation weeks that if the baby was delivered it will
(WHO) recommends that a survive. It is variable depending on the
fetus should be considered Neonatal I.C.U facilities. In our area, it is
viable after 22 weeks or if it
weighs more than 500g. between 24-28 weeks.

• Normal Vaginal Delivery (NVD): There is a criteria that should be

met so we can call a delivery a NVD, these points are:
§ Singleton pregnancy.
§ Reached GA of 37-41 weeks.
§ Labour should be spontaneous.
§ Non-instrumental delivery.
§ Live birth with no neonatal complications.
§ No post-partum complications.
• Live Birth: A live birth refers to a baby that shows signs of life after
delivery, irrespective of the length of gestation.

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 • Miscarriage: The expulsion of the fetus before it reaches viability
may be spontaneous or induced (termination of pregnancy).
• Stillbirth: a baby delivered after 24 weeks that does not breathe or
show any other sign of life.
• Neonatal Death: A baby who dies before 28 completed days of life is
deemed to be a neonatal death.
• Maternal Mortality: a woman who dies while pregnant, or within 42
days of delivery, miscarriage or termination, is classed as a maternal
mortality.
• Gravidity: is the total number of times that a woman has been
pregnant.
• Parity: is defined as the number of times that she has given birth to a
fetus with a gestational age of 24 weeks or more, regardless of
whether the child was born alive or was stillborn.

For example, a woman who is described as "gravida 2, para 2" (sometimes abbreviated to
G2 P2) has had two pregnancies and two deliveries after 24 weeks, and a woman who is
described as "gravida 2, para 0 " (G2 P0) has had two pregnancies, neither of which
survived to a gestational age of 24 weeks. If they are both currently pregnant again, these
women would have the obstetric resumé of G3 P2 and G3 P0 respectively. Sometimes a
suffix is added to indicate the number of miscarriages or terminations a woman has had.
So if the second woman had had two miscarriages, it could be annotated G3 P0+2.

• Puerperium: The puerperium is the time from the end of the third
stage of labour until involution of the uterus is complete:
approximately 6 weeks.
• Attitude: The fetal attitude describes the relationship of the fetus'
body parts to one another. The normal fetal attitude is commonly
referred to as the fetal position. The head is tucked down to the chest,
with arms and legs drawn in towards the center of the chest.
Abnormal fetal attitudes may include a head that is extended back or
other body parts extended or positioned behind the back. Abnormal
fetal attitudes can increase the diameter of the presenting part as it
passes through the pelvis, increasing the difficulty of birth.

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 • Lie of the fetus: The lie is the relationship of the long axis of the
fetus to the long axis of the uterus. It is normally longitudinal but may
be oblique or transverse.
• Presentation of the fetus: describes the
leading part of the fetus in the lower pole of
the uterus. Normally this is cephalic (95%),
with the head presenting. There are different
types of cephalic presentation, which
depend on the fetal attitude, which may be
vertex or face presentation. It may be breach
(4%), or shoulder (<1%), or compound
(<1%) when the head and a limb are
presenting.

External cephalic version, or version, is a procedure used to turn a fetus from a breech
position or side-lying (transverse) position into a head-down (vertex) position before
labor begins. When successful, version makes it possible for you to try a vaginal birth.
Version is done most often before labor begins, generally around 36 to 37 weeks because
if done earlier, it may revert. The success rate for this maneuver is up to 76%. But the
chance to do the version can be lost if labor speeds up or the amniotic sac ruptures.

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• Station (Descent): This is the relationship between the presenting part of
the baby and the mother’s ischial spines. Normally the ischial spines are
the narrowest part of the pelvis. They are a natural measuring point for
the delivery progress.
If the presenting part lies above
the ischial spines, the station is
reported as a negative number
from -1 to -5 (each number is a
centimeter). If the presenting
part lies below the ischial
spines, the station is reported as
a positive number from +1 to
+5. The baby is said to be
"fixed" when it is three-fifths
palpable and "engaged" when
two/one-fifths palpable, it is "fully engaged" in the pelvis when it is even
with the ischial spines at 0 station.

Obstetrics Examination:
Examining a pregnant lady differs from examining other patients because
two individuals are assessed simultaneously. Just like any other medical
examination, introduce yourself in full and ask for permission to start
examination, explain to her what you are going to do.
• Start your examination at the moment you meet the lady, gain an
impression of how she looks, does she appear exhausted or anxious?
• Offer her a chance to empty her bladder before you examine her, and
ask her to collect a specimen of urine for dip-stick testing.
• Measure her height and weight. Work out her BMI (Body Mass
Index), women with BMI<20 or BMI>35 are at higher risk in
pregnancy. As shorter women are more likely to have obstructed
labour and small babies, and 100kg or more women are prone to
develop gestational diabetes and have large (macrosomic) babies.
• Ask her to lie down, with her back resting at a 30˚ angle.
• Take her vital signs beginning with her blood pressure, and the rest
(Temperature, pulse rate, respiratory rate).
• Ask the lady to expose her abdomen from the lower chest to the
symphysis pubis (ideally to her knee caps).

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Inspection:
Start inspection from the foot of the bed, check for two things:
1- Note the shape of the abdominal distention caused by the gravid
uterus rising from the pelvis.
2- Her abdominal movement with respiration if it moves
symmetrically and/or her breathing is labored.
Then move to her right side, and inspect for:
1- Increased pigmentation, caused by increased melanocyte
activity related to sex hormone activity, commonly
produces a dark line extending from the pubic symphysis
upwards in the midline “Linea nigra”, nipple
pigmentation, over the nasal bridge,
and under the eyes (Chloasma).
2- Surgical scars, most importantly
Caesarean section scars, which are of
two types, “classical C-section”
(midline longitudinal incision) or
“lower uterine segment section”
(transverse cut just above the edge of
the bladder).
3- Abdominal striae; newly formed striae are red and called “Striae
gravidarum”, and striae from previous pregnancies are white and
called “Striae albicantes”.
4- Umbilicus, which is flat in most pregnancies, sometimes bulging
out (everted) in cases of polyhydramnios or multiple pregnancy.
5- Visible veins, as pregnancy pressures veins and might dilate some
superficial veins.
6- Increased hair growth, which is attributed to the amplified
production of various hormones in your body.
7- Fetal movements; sometimes are visible after 24 weeks of
gestation, which shows fetal viability.

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Palpation:
Next, start palpation step, make sure your hands are clean and warmed, show
the pregnant lady that you washed and warmed your hands as this will help
you gain her confidence.
1- Now start superficial palpation, ask for any tender areas before
touching the patient, and start from the right iliac fossa and in anti-
clockwise fashion round the abdomen with constant eye contact. It
is really not of great importance, but you can do it to feel for:
i. Tenderness
ii. Fetal movement
iii. Uterine contractions
iv. To gain your pregnant lady’s
confidence.

2- Use your left hand to feel the uterus

abdominally and get a quick estimate of the
height of the uterus (check figure).

3- After 20 weeks measure the fundal height

in centimeters. With a tape measure, fix the
end at the highest point on the fundus and measure to the
symphysis pubis. The highest point is not always in the midline.
To avoid bias, do this with the blank side of the tape facing you, so
that you only see the measurement on lifting the tape. The
measurement equals the weeks of the gestational age ±3 cm and is
an indicator of growth problems in the fetus. In a tall or thin
patient, the fundal height may be
less than expected; in an obese
patient, it may be greater.

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Fundal height: Fundal height:
Measuring large for GA: Measuring small for GA:
1- Wrong date (corrected by US) 1- Wrong date (corrected by US)
2- Loose abdominal muscles, as in 2- Intra-Uterine Growth
multiparous women Restriction
3- Having uterine fibroids 3- Oligohydramnios
4- Multiple pregnancy 4- Short stature of mother
5- Polyhydramnios 5- Well conditioned abdominal
6- Tall stature of mother muscles
7- Baby position is high above the 6- Small but healthy baby
pelvis, this occurs in case of (constitutional)
breech presentation and in 7- Transverse lie
placenta previa 8- Head already engaged
8- Macrosomia of diabetic mother. 9- Missed or incomplete abortion
9- Simply carrying a big healthy
baby (Constitutional)

4- Start abdominal palpation using Leopold’s maneuvers, as the aim

is to identify the position, lie, and presentation of the fetus inside
the uterus.

a. First maneuver - fundal palpation (or fundal grip). Palpate

the fundal area gently to identify which pole of the fetus
(breech or head) is occupying the fundus.
b. Second maneuver - lateral palpation (or lateral grips). Slip
your hands gently down the sides of the uterus, one hand
pushes in and the other palpates and again using opposite
hands, to try to identify on which side the firm back and
knobbly limbs of the fetus are positioned.

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 c. Pelvic maneuver. Turn to face the patient's feet and slide
your hands gently on the lower part of the uterus, pressing
down on each side to determine the presenting part. If it is
the fetal head, it feels hard and may be balloted between
your fingers.
d. Sometimes if the head was not palpable well
enough in step (C), you can try Pawlick’s
maneuver (or grip). While facing the lady’s
face, grasp the lower portion of the abdomen
just above the symphysis pubis with
the thumb and fingers of the right hand. This
maneuver is not recommended, as it causes
more discomfort to the pregnant lady, and
using the two hand technique is advised.

Auscultation:
After palpating the gravid uterus, you should have an idea of the baby’s
position and lie, locate the baby’s back, and monitor the baby’s heart rate.
This procedure is done either by:
a. Using an electronic hand-held Doppler fetal
heart rate monitor, or called Sonicaid. It is
useful as early as 14 weeks of gestational age.
b. Or a Pinard stethoscope, but it is not useful
until after 28 weeks of gestational age. Place
the widest part over the anterior shoulder of the
fetus and listen with your left ear facing the
lady's feet.

Tareq Fawzi Al-

Al-Hammouri
Special thanks to Maen K Abu Hoseh and Mojahed Kurdeyeh ☺

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