OBSTETRICS | PHYSICAL EXAMINATION

Dr. Frances Janine Vera Cruz | April 12, 2021

Overview: I. ABDOMINAL EXAM

I. Abdominal Exam Remember to gather all your equipment first before
A. Inspection you start the examination.
i. Pruritic Urticarial Papules & And you have to have a side table to the bed so it
Plaques of Pregnancy (PUPPP) is easier for you to reach it or have an assistant to
ii. Fundic Height hand it over to you.
B. Palpation Always remember to use drapes even when lying
i. Leopold’s Maneuver in supine position. Ask the patient to remove her
ii. Uterine contractions underwear before the exam to avoid interruption
C. Auscultation when going to lithotomy position, that’s why you
i. Fetal Heart Tones (FHT) need drapes.
II. Pelvic Examination
A. Internal Examination
A. INSPECTION OF THE ABDOMEN
III. Samplex
When you inspect the abdomen of a pregnant
patient, if she’s still on the 1 st trimester, the
PHYSICAL EXAMINATION abdomen is flat, but if she’s on the 2 nd or 3rd
• GENERAL SURVEY trimester, the abdomen is globular in shape. So
• VITAL SIGNS mostly, if you report it, globularly enlarged.
• HEENT/NECK Then take note of the surface, if the surface is
• CHEST/LUNGS/HEART smooth or if the abdomen has striae.
• ABDOMEN Take note of:
• PELVIC EXAMINATION • Striae gravidarum (stretch marks)
• EXTREMITIES • Linea Nigra not necessarily to put this but just
check it.
PREGNANT PATIENT • Previous abdominal scars not only for
This is the continuation of the history taking caesarean scars but the presence of
• Explain the procedures to be done. You previous CS scars is important. Remember,
have to tell her you need to change position Doc Tet got mad at the new nurse for not
because she’s currently sitting down while checking it.
you are doing history taking. Then next • Rashes
position would be the supine position then
when doing the pelvic exam, the position
would be lithotomy position. So, there’s a lot
of position and it is uncomfortable for the
patient because she has huge belly. Also,
when doing the physical exam, you have to
have someone (nurse/ nursing aide) to help
the patient reposition.
• Have the patient empty her bladder
because it can derange measurements like
fundic height and to avoid getting up while
doing the physical examination
• Lie the patient supine while examining the
abdomen then convert to the lithotomy
position for the pelvic and internal
examination.

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 Sometimes, other people don’t notice the
previous CS scar because it is Pfannenstiel
incision/ bikini cut

PRURITIC URTICARIAL PAPULES & PLAQUES OF

PREGNANCY (PUPPP)
• Usually occurs later on the pregnancy. JOHNSON’S FORMULA
• Said to have been caused by the stretching • We use the fundic height to measure the
of the abdomen. estimated the fetal weight.
• One of the most common causes of • Before we do this, know first if the head is
dermatologic problem of pregnancy. engaged or unengaged.
They actually start on the abdomen then to the • Above the ischial spines (n=12)
extremities. They disappear after pregnancy. • Below the ischial spines (n=11)
• Ischial spines is station zero (0)
REPORTING:
ABDOMEN: Globularly enlarged, smooth, previous (Fundic ht. in cm – n) x 155 = EFW in grams
midline incisional scar. EFW- estimated fetal weight

FUNDIC HEIGHT / FUNDAL HEIGHT UTERINE SIZE

FH= 30, station +2 (30cm -11) x 155= 2945g
• Between 20 and 34weeks gestation, height
in cm correlates closely w/ gestational age
FH=27, station -3 (27cm-12) x 155= 2325g
in weeks. We still follow the LMP for
gestational age and we use the fundic
REPORTING:
height for estimated fetal weight. We have
Abdomen is globularly enlarged, smooth, with
to empty the bladder because it is just
previous abdominal scar.
below the uterus so if the bladder is full, the
Fundic height (FH) - 31cm
uterus rises and it adds to the fundic height,
Estimated fetal weight- 3,100g
making the fundic height unreliable.
• This is use to monitor fetal growth and
amniotic fluid volume. B. PALPATION
• It is measured along the abdominal wall LEOPOLD’S MANEUVER
from the top of the symphysis pubis to the • To determine the presenting part, fetal lie
top of the fundus. Using one hand, place the and fetal attitude.
zero (0) of the tape measure on top of the • Done in between contractions. We don’t do
symphysis pubis, then using the other hand, this during uterine contractions because the
pull the tape measure towards the fundus. abdomen is slightly hard during that time so
(The tape measure is between your fingers. you can’t feel the fetal part you are trying to
Doc Tet will send a video on how to measure examine.
fundic height)

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 • Presenting Part
➢ Vertex - head /cephalic
➢ Breech-buttocks

• Lie (the relationship of the long axis of the

fetus to the long axis of the mother)
➢ Longitudinal Transverse
➢ Oblique

• Attitude of the fetal head if it is the

presenting part
➢ Flexed
➢ Extended
3. LM3-PAWLIK'S GRIP
For the first 3 of the Leopold’s maneuver, we will be
• You’ll be using your dominant hand. With
facing the head of the mother and the last
your right hand (if you are right handed) or
Leopold’s maneuver. LM 4, we will be facing the
v v, using the thumb and third finger, gently
feet of the mother.
grasp the presenting part over the symphysis
pubis.
1. LM1-FUNDAL GRIP
• Determines the fetal presentation. You can
• Uterine fundus is palpated using both of your
also do the ballottement ensuring the head
hands to determine which fetal part
is not yet engaged.
occupying the fundus.
• The head will feel firm. If not engaged, will
• The head feels round, firm, and freely
be movable from side to side and easily
movable and is detectable by ballottement
displaced upward. If the buttocks are
(bouncing off of the head because of the
presenting, they will feel softer. If the
amniotic fluid). The buttocks (breech) felt as
presenting part is not engaged, the fourth
a large nodular mass, it feels softer and less
step is used because if it is engaged, the
mobile and regular.
head is not movable, you can’t do the LM4.

2. LM2- UMBILICAL GRIP

• Palpate the paraumbilical areas or the sides
of the uterus. With the palmar surface of 4. LM4 – PELVIC GRIP
your hand, locate the back of the fetus by • Turn and face the woman's feet and use two
applying gentle but deep pressure because hands to outline the fetal head. If the head
there’s more fatty tissues on the side so you is presenting and is deep into the pelvis, only
can’t feel the part immediately a small portion may be felt. Palpation of the
• The back feels hard, resistant and convex, cephalic prominence (the part of the fetus
whereas the fetal small parts will feel more that prevents the descent of the examiners
nodular and irregular. hand) on the same side as the small parts
• This is important for you to easily find the fetal suggest that the head is flexed and the
heart tones. We usually get the fetal heart vertex presenting. This is the optimal position.
tones to the back area near the head. Palpation of the cephalic prominence on

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 the same side as the back suggests that the REPORTING:
presenting part is extended. Moderate to strong uterine contractions, lasting for
30 seconds, occurring every 5 minutes.

C. AUSCULTATION
FETAL HEART TONES (FHT)
• Easier to find once you've performed the
Leopold's Maneuver
• Heard most at the fetal back
• 110-160 beats per minute.
• Use the bell of the stethoscope. You can
also use doppler. The patient must hear the
fetal heart tones. After you count the FHT
using the stethoscope, use doppler so the
patient can hear the FHT. Write down
REPORTING: everything you’ll be doing, including all the
LM1-breech vital signs.
LM2-fetal back on the right, small parts on the left • Other instruments used:
LM3-cephalic (not engaged) ➢ Cardiotopogram (CTG machine,
LM4-flexed electronic fetal monitor (EFM))
➢ Ultrasound – can see and hear the
UTERINE CONTRACTIONS FHT, this is better
➢ Stemoscope, new instrument where
• Can be assessed with abdominal palpation, you can monitor the FHT using your
but more accuracy is obtained thru the use phone
of electronic monitoring equipment.
REPORTING:
• Place the fingertips (fingertips will FHT – 140 beats per minute (Left lower quadrant)
measure/feel) on the abdomen so that you remember to put where you got the FHT
are able to detect contraction and
relaxation of the uterus, and keep them
there throughout the entire contraction, II. PELVIC EXAMINATION
including the period of relaxation. Labor PREPARATION
watch • Explain in general term what you are going
to do because this is the most sensitive part
• The strength of the contraction is classified of the physical examination since you will be
as follows: touching the patient, for boys you have to
➢ Mild: slightly tense fundus that is easy have someone else there while examining
to indent with the fingertips. Lips the patient to avoid harassment issues
➢ Moderate: firm fundus that is difficult
• Maintain eye contact with the patient
to indent with the fingertips. Tip of the
• Assure the patient that you will explain to her
nose
➢ Strong: rigid or hard, boardlike fundus what you are going to do as the
or one that does not indent with examination proceeds. Be gentle as
fingertips. Forehead possible and tell her to let you know if she
feels any discomfort.
• The frequency of contraction is measured • Make sure room temperature is comfortable
from the beginning of one contraction to • Ensure privacy that’s why you have to drape
the beginning of the next. The frequency of the patient
contractions is assessed for regularity (at • Gather all your equipments
regular intervals, such as every 5 minutes or
at irregular or sporadic intervals). The EQUIPMENTS
importance of this is to know whether the • Light source/ Lamp
patient is in true labor or not. • Drapes

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 • Speculum
INTERNAL EXAMINATION
• Gloves (clean and sterile)
• Water soluble lubricant PREPARATION
• Pap smear collection equipment • Lubricate the gloved fingers with water or
➢ Spatula, cervical brush, glass slides, water-soluble lubricant
cytologic fixative or fluid collection
media PREGNANT
• Other specimen collection equipment 1. Consistency (soft), non-pregnant (firm)
➢ Cotton swab, culture plates/ media, 2. Closed, open (in cm), 10 cm is fully dilated
DNA probe kits 3. Effacement (thinning of the cervix)
4. Bag of water (intact, ruptured)
POSITIONING 5. Presenting part (cephalic)
• Assist the patient into the lithotomy position 6. Station of the head (relation of the
on the examining table presenting part to that of the ischial spines)
• Help the woman stabilize her feet in the
stirrups and slide her buttocks down to the CERVIAL DILATATION AND LENGTH
edge of the examining table. If the patient is • Dilatation - involves opening of the cervical
not positioned correctly, you will have canal to allow for the passage of the fetus,
difficulty with the speculum exam. this process is measured in centimeters and
progress from a closed os to 10 cm, which is
full or complete dilatation

DRAPING/ GLOVING
• Patient can be draped in such a way that • Effacement – the thinning of the cervix that
allows minimal exposure (make sure results when a myometrial activity pulls the
equipment is nearby and in easy reach) cervix upward, allowing the cervix to
• Wash your hands and put gloves on both become part of the isthmus.
hands
• Ask her to separate or drops open her knees
(never try to spread her legs forcibly or even
gently). Ask the patient first if it is already ok
for her to start the exam. You can also tap
the side of her thighs first before going to the
vaginal area. Pelvic exam is an intrusive
procedure and you may need to wait until
the women is ready
• Tell her that you are going to begin, then
start with a neutral touch on her lower thigh,
moving your examining hand along the
thigh without breaking contact, to the
external genitalia
• Even if asked earlier during your history
taking, ask AGAIN for LATEX allergy. Very
important

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BAG OF WATER STATION
• Intact – you can feel a bulging balloon filled • Is the relationship of the presenting part to
with water. the ischial spine of the mother’s pelvis.
• Ruptured - you can feel the hair strands of Vaginal exam and palpation are performed
the fetus. Asses for the amniotic fluid. during labor to estimate the descent of the
➢ Clear (clear to whitish in color) presenting part. We only do this for patients
➢ Thinly stained (light yellow or green) who are in labor.
➢ Thickly stained (looks like poop) • The measurement is determined by
➢ Bloody centimeters above and below the ischial
spines and is recorded by plus and minus
PRESENTING PART signs
1. Cephalic (most common) • For example, the station at 1 cm below the
2. Breech (buttocks) spines is recorded as +1, at the spines as 0,
3. Footling breech (1 feet outside, if complete and at 1 cm above the spines as -1.
2 feet outside)
4. Transverse (the presenting is either the
shoulder, back or fetal small parts)
5. Brow/ Face (the fetal attitude is extende, we
usually do CS here)
6. Compound- usually for preterm, the hands
are the presenting part

EXAMPLE OF PELVIC EXAM

• Cervix soft, 3 cm dilated, 50% effaced,
intact bag of water, cephalic stations -2
• For ruptured BOW; Cervix soft, 8 cm dilated,
70 % effaced, (-) bag of water – thinly
stained, cephalic, st -3

III. SAMPLEX
MCQ
1. Which of the following is not included in the
abdominal examination
A. Inspection
B. Palpation
C. Percussion
D. Auscultation
2. It is said to have been caused by the stretching
of the abdomen. One of the most common causes
of dermatologic problem of pregnancy.
A. PUPPP
B. Striae gravidarum
C. Linea nigra
Patient shown here is G2P1, footling breech. We did
D. Rashes
CS here.
3. This is used to monitor fetal growth and amniotic
fluid volume.
A. Leopold’s maneuver

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 B. Fundic height
C. Ballottement
D. Uterine contractions
4. Normal range for FHT
A. 110-160 beats per minute
B. 120-150 beats per minute
C. 100-150 beats per minute
D. 100-160 beats per minute
5. The relationship of the presenting part to the
ischial spine of the mother’s pelvis.
A. Fetal lie
B. Effacement
C. Fetal attitude
D. Station
T/F
1. For the first 3 of the Leopold’s maneuver, we will
be facing the head of the mother.
2. Leopold’s maneuver is used to determine the
presenting part, fetal lie and fetal attitude.
3. The buttocks in fundal grip, felt as a large
nodular mass, it feels softer and less mobile and
regular.
4. FHT is heard most at the fetal back.
5. The frequency of contraction is measured from
the beginning of one contraction to the
beginning of the next.
6. Lubricate the gloved fingers with water or
water-soluble lubricant.
7. 4 cm is full or complete dilatation.
8. Patient can be draped in such a way that
allows minimal exposure.
9. The measurement for fetal station is
determined by centimeters above and
below the ischial spines and is recorded by
plus and minus signs.
10. Supine position is used during pelvic
examination.
F 10.
T 9.
T 8.
T 7.
T 6.
T 5.
T 4.
T 3.
T 2.
T 1.
T/F

5. D.
4. A.
3. B.
2. A.
1. C.
MCQ
Answers:

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