OBSTETRIC ABDOMINAL EXAMINATION

OBSTETRIC ABDOMINAL EXAMINATION – OSCE GUIDE Posted by Dr Lewis Potter Obstetric abdominal examination 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 Check out the obstetric abdominal examination OSCE mark scheme here Introduction Wash hands Introduce yourself Confirm patient details – name/DOB Ask if the patient currently has any pain Explain the examination (as shown below) Explanation Describe the examination “Today I need to examine your tummy [bụng] as part of the assessment of your pregnancy [thai kỳ] 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.” Gain consent “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 it” General inspection [nhìn] Overall appearance – discomfort / body habitus [thể trạng] / jaundice [vàng da] Hands Pulse rate [mạch] Capillary refill time – < seconds is normal Peripheral oedema [phù ngoại biên] – may be normal, but pre-eclampsia [tiền sản giật] should be considered Face Conjunctival pallor [nhợt nhạt kết mạc] – anaemia [thiếu máu] Jaundice – e.g obstetric cholestasis [ứ mật thai kì] Melasma [nám da] – benign [lành tính] dark and irregular hyperpigmented [tăng sắc tố] macules – associated with pregnancy Oedema [phù] – consider pre-eclampsia • Inspect the abdomen Close inspection Position the patient: • • Supine [nằm ngửa] (this usually involves having the patient lay on the couch, with the top end of the couch elevated by 15-30 degrees) Left lateral position [nằm nghiêng bên trái] (in late pregnancy) to avoid inferior vena cava [tĩnh mạch chủ dưới] compression Expose the abdomen – xiphisternum [mũi ức] to the pubic symphysis [khớp mu (vệ)] Inspect the abdomen Observe the shape of the abdomen as this may give an indication of the fetal lie Fetal movements [sự chuyển động thai] – observe for evidence of fetal movements (24 weeks onwards) Surgical scars [sẹo mổ] – e.g previous caesarean section [mổ lấy thai] Cutaneous signs of pregnancy: • Linea nigra [đường đen bụng] • Striae gravidarum [vết rạn da đỏ] • Striae albicans [vết rạn da trắng] Palpation [sờ] Ask about abdominal tenderness [đau bụng] before palpating the abdomen and continue to monitor the patient’s face for signs of discomfort throughout the examination Lightly palpate the regions of the abdomen surrounding the uterus [tử cung]: • Note any tenderness [đau (triệu chứng thực thể), guarding [đề kháng thành bụng] or rebound [phản ứng dội] Lightly palpate the uterus: • Identify the borders of the uterus, feeling for its upper and lateral edges The fundus [đáy tử cung] is found at different places during pregnancy: • • • 12 weeks gestation – pubic symphysis 20 weeks – umbilicus [rốn] 36 weeks – xiphoid process [mỏm mũi kiếm (mỏm ức] of the sternum [xương ức] • Uterine location at various stages of pregnancy Determine fetal lie Place your hands either side of the mother’s uterus (facing the mother) Apply gentle pressure to the sides of the uterus One side should feel full in nature (this is likely the fetal back) On the opposite side, you may be able to feel the fetal limbs Types of fetal lie Longitudinal [dọc] – head/buttocks palpable at each end of the uterus Oblique [nghiêng] – head/buttocks palpable in the iliac fossae [hố chậu] Transverse [ngang] – the fetus is lying directly across the uterus • Place hands either side of the uterus • Longitudinal lie • Oblique and Transverse lie Presentation [ngôi thai] Ensure you are facing the mother to observe for signs of discomfort Warn the mother this may feel a little uncomfortable Place your hands either side of the lower pole of the uterus (just above pubic symphysis) Apply firm pressure angled medially, feeling for the presenting part: • • A hard round presenting part is suggestive of a cephalic presentation [ngôi đầu] (head first) A broader, softer, less defined presenting part is suggestive of a breech presentation [ngôi mông] • Cephalic presentation • Breech presentation Measure symphyseal-fundal height [bề cao tử cung] Measure the distance between the fundus [đáy tử cung] and pubic symphysis [khớp vệ] This is only accurate after 20 weeks gestation Begin palpation just inferior to the xiphisternum Palpate using the ulnar border [bờ trụ] of the left hand Locate the fundus of the uterus (firm feeling edge at the upper border of the bump) Now locate the upper border of the pubic symphysis Measure the distance between the two in centimetres using a tape measure [thước dây] 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 • Palpate upper border of uterus • Palpate upper border of pubic symphysis • Measure the distance between the two Assessment of engagement [độ lọt] In late pregnancy, the level of engagement should be assessed Engagement refers more than 50% of the presenting part (usually the head) having descended into the pelvis The level of engagement varies and for this purpose, the fetal head is divided into fifths: • • If you are able to feel the entire head in the abdomen, it is five fifths [5/5] palpable (not engaged - chưa lọt) If you are not able to feel the head at all abdominally, it is zero fifths [0/5] palpable (fully engaged - lọt hồn tồn) • Assess fetal engagement To complete the examination… Re-cover the patient – allow the patient time to redress in privacy Thank patient Wash 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 – Pinard stethoscope [ống nghe tim thai] or Doppler ultrasound [siêu âm Doppler] Blood pressure [huyết áp] measurement Urinalysis [tổng phân tích nước tiểu] Weight and height measurement Speculum examination [khám mỏ vịt] REVIEWED BY Mr Isaac Magani Consultant Obstetrician ILLUSTRATED BY Aisha Ali Medical student and illustrator ...Ask if the patient currently has any pain Explain the examination (as shown below) Explanation Describe the examination “Today I need to examine your tummy [bụng] as part of the... me know.” Gain consent “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 it” General inspection... Palpation [sờ] Ask about abdominal tenderness [đau bụng] before palpating the abdomen and continue to monitor the patient’s face for signs of discomfort throughout the examination Lightly palpate