Inspection

During inspection of the abdomen make note of scars from previous surgery (especially laparoscopic and suprapubically), striae gravidarum and linea nigra. In later pregnancy one may note fetal movements.

Palpation

The uterus can be felt abdominally after about 12 weeks’ gestation; by 20 weeks’ gestation it is generally at the level of the umbilicus and by term it is at the xyphisternum. During palpation the questions that need to be answered are:

To measure the symphyseal–fundal height, feel for the fundus of the uterus with the tips of the fingers or ulnar surface of the hand and measure the distance to the symphysis pubis with a tape measure, turning it over so that the centimetre markings cannot be seen, to avoid bias (Fig. 4.1). The manoeuvres for palpation of the uterus include: lateral uterine grip with the hands, assessing the lie of the fetus by palpating the sides of the uterus (Fig. 4.2); fundal grip with the hands, assessing the fetus at the uterine fundus; the deep pelvic grip with both hands pointed towards the pelvis to assess for presentation and engagement, ensuring that one is not causing discomfort by observing the mother’s face during palpation. An alternative to the latter is Pawlik’s grip, which is the grasping of the presenting fetal part between the index finger and thumb, taking care to avoid patient discomfort. Engagement of the fetal head is said to occur when the largest diameter has passed into the pelvis. For a subjective description of this, the fetal head is divided into fifths palpable abdominally. The head is engaged if less than two-fifths of it can be palpated abdominally (Fig. 4.3).

Figure 4.1 Measuring the height of the fundus.

(Redrawn with permission from Hanretty K P 2003 Obstetrics Illustrated, 6th edn. Edinburgh: Churchill Livingstone, p. 76.)

Figure 4.2 Abdominal palpation.

(Redrawn with permission from Hanretty K P 2003 Obstetrics Illustrated, 6th edn. Edinburgh: Churchill Livingstone, p. 75.)

Figure 4.3 Palpation for engagement of fetal head with corresponding station of head on vaginal examination.

(Reproduced with permission from Rymer J, Davis G, Rodin A et al. 2003 Preparation and Revision for the DRCOG, 3rd edn. Edinburgh: Churchill Livingstone, p. 210.)

Auscultation

The final part of the abdominal examination is auscultation of the fetal heart. To locate the best position to auscultate, palpate for the fetal shoulder and place the Pinard stethoscope or Sonicaid just behind this.

Just like in the obstetric history, a short summary of the clinical examination should be prepared, mentioning relevant negative findings also if necessary, e.g. in a case of pre-eclampsia it is important to mention the absence of hyperreflexia or clonus if these are not present.