Antenatal Check Up: Abdominal Examination

1. SBA - Presentation 2 (d) Antenatal Check Up: Abdominal Examination Maternal Health Division Ministry of Health & Family Welfare Government of India

2. Abdominal Examination What is the importance of abdominal examination? • Monitor progress of pregnancy and fetal growth • Check for fetal lie and presentation • Auscultate fetal heart sounds Antenatal Check Up: Abdominal Examination

3. Abdominal Examination What does it include? • Measurement of fundal height • Assessment of fetal lie and presentation • Assessment of fetal movement • Auscultation of fetal heart sounds • Inspection for scars • Other relevant abdominal findings Antenatal Check Up: Abdominal Examination

4. Preparation for abdominal examination • Ensure privacy • Examination room should be well lit and airy • Woman is asked to empty her bladder • Explain the women about the procedure/process • To make her comfortable, keep talking to her • She lies supine with legs partially flexed • Stand on her right side • Palpate the uterus with warm hands Antenatal Check Up: Abdominal Examination

5. Significance of fundal height Indicates • Duration of pregnancy • Fetal growth • Any abnormality in the pregnancy Antenatal Check Up: Abdominal Examination

6. Assessment of fundal height • Keep the ulnar border of curved left hand on woman’s abdomen parallel to symphysis pubis • Start from xiphisternum and gradually proceed towards symphysis pubis lifting the hand between each step till a bulge / resistance of uterine fundus is felt • Mark the level of fundus Antenatal Check Up: Abdominal Examination

7. How will you estimate gestational age from fundal height? Measurement of fundal height • Divide the abdomen by an imaginary lines passing through umbilicus • Divide the lower abdomen in 3 parts with 2 equidistant lines between the pubic symphysis and the umbilicus • Divide the upper abdomen into 3 parts again with 2 imaginary equidistant lines between the umbilicus and xiphisternum 36 wk Xiphisternum 40 wk 32 wk 28 wk 24 wk Umbilicus 20 wk 16 wk Pubic symphysis (Uterus becomes an abdominal organ after 12 weeks) Antenatal Check Up: Abdominal Examination

8. Measuring Fundal Height • Measure the distance from the upper border of symphysis pubis along the uterine curvature to the top of the fundus with a tape. • Gestational age in weeks corresponds to the fundal height in cms from 24 weeks to 30 weeks • Refer to MO (with referral slip) if Disparity between the fundal height and gestational age is > 3 cm or No increase in fundal height on subsequent visit Antenatal Check Up: Abdominal Examination

9. What are the reasons of fundal height more than the period of gestation? • Wrong date of LMP • Full bladder • Multiple pregnancy • Large baby • Polyhydramnios • Hydrocephalous • Hydatidiform mole Antenatal Check Up: Abdominal Examination

10. What are the reasons of fundal height less than the period of gestation? • Wrong date of LMP • Intra-uterine growth restriction (IUGR) • Missed abortion • Intrauterine death ( IUD) • Transverse lie Antenatal Check Up: Abdominal Examination

11. Fetal lie and presentation • Examine after 32 wks pregnancy (after this period the lie usually remains the same till delivery) • Palpate for fetal lie and presentation • Normal lie is longitudinal with cephalic presentation • Abnormal lie and presentation should be referred to FRU with referral slip Antenatal Check Up: Abdominal Examination

12. Abdominal palpation: Four grips • Fundal grip • Lateral grip • Superficial pelvic grip • Deep pelvic grip Antenatal Check Up: Abdominal Examination

13. Fundal Palpation / Fundal Grip Helps to determine lie and presentation of fetus Antenatal Check Up: Abdominal Examination

14. Lateral Palpation / Lateral Grip Helps to locate fetal back Antenatal Check Up: Abdominal Examination

15. First Pelvic Grip / Superficial Pelvic Grip • Helps to determine whether head or breech is presenting at pelvic brim • Whether the presenting part is engaged / fixed / free Antenatal Check Up: Abdominal Examination

16. Second Pelvic Grip / Deep Pelvic Grip Helps to know the degree of flexion of head Antenatal Check Up: Abdominal Examination

17. Foetal movements • Fetal movement are reliable sign of foetal well - being • These are felt around 18-22 wks of pregnancy (felt earlier in multigravida than primigravida) • Normally 10-12 foetal movements should be felt by the pregnant woman in a day • Decreased foetal movements may be an indication of foetal distress • Pattern of foetal movement may change prior to labour due to reduced space • If Foetal Movements are absent or not felt, consult ANM or doctor Antenatal Check Up: Abdominal Examination

18. Fetal heart sound (FHS) and rate (FHR) • FHS is heard per abdomen by stethoscope / fetoscope after 24 weeks of pregnancy • Normal FHR is 120 – 160 beats per min • FHR < 120 beats per min or > 160 beats per min : Indicates fetal distress and calls for referral • Confirm that you are listening to the FHS and not maternal pulse Antenatal Check Up: Abdominal Examination

19. Auscultation of FHS • Use a fetoscope or stethoscope • Best heard on the side of the back of the fetus • In vertex presentation FHS is best heard midway between the line joining the umbilicus and the anterior superior iliac spine on the side of the back • In breech presentation FHS is heard above the umbilicus • Count the FHS for one full minute (FHR) Antenatal Check Up: Abdominal Examination

20. Suspicion of multiple pregnancy on abdominal examination • An unexpectedly large uterus for the estimated gestational age • Multiple fetal parts felt on abdominal palpation • FHS is heard at more than one place Refer the woman to FRU with referral slip and arrange for institutional delivery Antenatal Check Up: Abdominal Examination

21. To summarize Abdominal examination is done for : • Fundal height • Fetal lie and presentation • Fetal movement • Fetal heart sounds • Any other abdominal finding Antenatal Check Up: Abdominal Examination

22. Thank you Antenatal Check Up: Abdominal Examination