Obstetric Topic 44. Obstetrical examinations

I. General Obstetrical Examination

Purpose

• Assess maternal health, gestational age, fetal growth, lie, presentation, position, engagement and fetal well-being.
• Routine checks: BP, pulse, weight, edema, urine protein/glucose, fundal height and fetal heart activity.
• Use targeted speculum/vaginal examination, US, Doppler or CTG when symptoms or risk factors are present.

II. Leopold Maneuvers

General

• Abdominal palpation, most useful in late pregnancy.
• Purpose: determine fetal lie, presentation, position and engagement.

1st Maneuver: Fundal Grip

• Palms on uterine fundus/upper abdomen → identify fetal part in the upper pole.
• Hard, round, ballotable part = fetal head.
• Soft, broad, irregular part = breech.

2nd Maneuver: Umbilical / Lateral Grip

• Palms on both sides of maternal abdomen; apply gentle deep pressure.
• Smooth, firm, resistant surface = fetal back.
• Irregular, mobile structures = fetal extremities.
• Determines fetal position and best site for fetal heart auscultation.

3rd Maneuver: Pawlik's Grip / 1st Pelvic Grip

• Grab lower maternal abdomen just above the symphysis pubis.
• Differentiates vertex/head vs breech presenting part.
• Mobile presenting part → not engaged.
• Fixed presenting part → engaged or partly engaged.

4th Maneuver: 2nd Pelvic Grip

• Examiner faces maternal feet; palms/fingertips on both sides of lower abdomen toward pelvic inlet.
• Identifies fetal part in the lower uterine pole and assesses descent/flexion.

III. Fetal Heart Assessment

• Listen where fetal back is closest to the maternal abdominal wall.
• Cephalic presentation: best heard below the umbilicus; breech: above the umbilicus.
• Normal fetal heart rate: 110-160 BPM.
• CTG: records fetal heart rate + uterine contractions; details are in O39-O40.

IV. Vaginal Examination

Indications

• Labor assessment: cervical dilation, effacement, station, presentation, position and membrane status.
• Complaints: bleeding, pain, rupture of membranes, discharge, suspected infection or threatened preterm labor.
• Avoid digital exam in placenta previa suspicion; minimize exams in PPROM → speculum + US when appropriate.

Findings During Labor

• Cervical dilation: 0-10 cm; effacement = shortening/thinning of cervix.
• Presentation: vertex/cephalic, breech, shoulder/transverse lie, face/brow.
• Position in vertex presentation: fetal occiput relation to maternal pelvis, e.g. LOA, ROA, OP.
• Station: descent of presenting part relative to ischial spines.
• 0 station = at ischial spines.
• Negative station = above spines; positive station = below spines.
• Also assess membranes, caput/molding, pelvic adequacy and cord prolapse if membranes ruptured.

V. Other Examinations

• Ultrasound: gestational age, viability, fetal number/growth/anatomy, presentation, placenta and AFI/SDP.
• Doppler: uteroplacental/fetoplacental blood flow and fetal oxygenation risk; useful in FGR and fetal anemia assessment.
• CTG: fetal heart rate pattern and uterine contractions.