1. Clinical skills 2012NRMSM,UKZNCompiled by: Dr RM Abraham

2. INTRODUCTION ABDOMINALEXAMINATION INPREGNANCY STAGES OF LABOUR MECHANISM OFLABOUR AND THEPARTOGRAM 3. Always explain to the patient the need and thenature of the proposed examination. Obtain a verbal consent once she has been toldwhat the examination would entail. The examiner (male or female) should beaccompanied by another female(chaperone). Examination performed in a private side-room,respecting patients privacy at all times. Patient should be covered at all times and relevantparts of her anatomy only exposed. Make sure the room is well lit and comfortablywarm. 4. Ensurethe patient has emptied her bladderbefore examining her abdomen. Patient should lie in the supine position with apillow under the head and arms by her side. She is slightly rolled to the left side to preventcompression of the inferior vena cava by theenlarged uterus (inferior venacaval syndromeor supine hypotensive syndrome). Ask for any tender area before palpating theabdomen. 5. Inspection Palpation Auscultation 6. - Describe the abdominaldistension (pyriform).- Previousoperative(Caesarean)scars- Striae gravidarum or stretchmarks- Linea nigra- a dark verticalline appearing on theabdomen from the pubis toabove the umbilicus duringpregnancy due to increasemelanocyte-stimulatinghormone made by theplacenta.- Visible foetal movements. 7. Fundalheight (Symphysis-fundal height) Foetal poles Foetal lie Presentation- cephalic(head),breech,etc Attitude Level of engagement of presenting part State of uterine wall/ myometrium Liquor volume Estimate foetal weight Foetal movements 8. 1) Symphysis-fundal height(Size and gestational age of the uterus):More objective, distance from thesymphysis pubis to the uterinefundus (top of the uterus)- size of theuterus directly related to the size ofthe fetus.Technique:-Palpate down from xiphi-sternum todetermine the highest part of theuterus(fundus),may not always be inthe midline.-Mark this point with a pen after obtainingher permission.-A tape measure turned upside-down(blinded to avoid bias) is thenplaced from the mid-point on theuppermost border of the symphysispubis over the curve of the uterus tothe marked highest point of theuterus.-The tape is then turned and actualmeasurement in cm isrecorded, preferably in graphic form. 9. Recording of the symphysis- fundalheight (SFH) on antenatal growthchart:-The first SFH plotted against a particulargestational age(if this is known), on thehorizontal axis of the graph.-If menstrual dates uncertain and no earlyultrasound scan available, the first SFHplotted against its own particularmeasurement on the verticalaxis, placed on the 50th percentile line.-The estimated gestational age read offthe horizontal axis.-All subsequent SFH measurements thenplotted at the correct time intervalsfrom the first measurement.-SFH should increase by about 1cm perwk from 20 to 34 weeks with normalgrowth. 10. 2) Palpation of the contents of the uterus:Palpated using four Leopolds manoeuvres The fundal grip(foetalpoles):-Both hands placed over thefundus and the contents ofthe fundus determined.-A hard smooth, round poleindicates a fetal head.-A softer triangular polecontinuous with the fetalbody is the fetalbuttocks(breech). 11. The lateral grip(Fetal lie):-Move both hands in a downward directionfrom the fundus along the sides of theuterus to determine the "lie" of thefoetus.-"Lie" is the relationship btw thelongitudinal axis of the foetus and thelongitudinal axis of the mother.-The "lie" is usually longitudinal, hencebaby is lying length-wise in the samedirection as mothers longitudinal axis.-Other "lies" are transverse lie (fetus liesacross the long. axis of mother) andoblique lie (foetus lies at an obliqueangle to the mothers long. axis).-Can also determine which side the foetalback is situated by feeling the firmregular surface of the foetal back onone side and the irregular, lumpysurface as the foetal limbs on the otherside. 12. Pawliks grip (Presentingpart):-The thumb and middle fingers ofthe right hand are placed wideapart over the suprapubic areato determine the presentingpart.-Presenting part of fetus is thelowest most part of the fetus atthe inlet of the pelvis(the lowerfetal pole as opposed to thefetal pole in the fundus).-Cephalic or breech presentationdistinguished from each otheras indicated in the previousslide. 13. Deep pelvic grip:Determines two points about the fetus1)The attitude of the fetal head:-The examiner turns around to face patients feet.-Each hand placed on either side of the fetal trunk lower down.-The hands moved downwards towards the fetal head.-Note made as to which hand first touches the fetal head (This point called cephalic prominence).-Cephalic prominence helps determine the attitude (i.e. flexion, deflexed or extended) of fetal head.-If cephalic prominence is on the opposite side of fetal back, fetal head is well flexed (normal position).-If cephalic prominence on the same side as fetal back, fetal head is extended (abnormal position).-If examiners hands reach the fetal head equally on both sides, fetal head is deflexed (Military position, indicating mal-position) 14. 2)Engagement of the fetal head:- If you divide the fetal head into- Continue moving both hands downfive-fifths, you estimate how many around the fetal head, determinefifths of the fetal head can be felt. how far around the head you can - If 5,4 or 3 fifths can still be get.palpated, most of the head is still- Engagement of the fetal head up, hence the widest part of the defined as having occurred once head has not engaged into the the widest transverse diameter of pelvis. the fetal head (bi-parietal diameter) - If only 2,1 or 0 fifths of fetal head has passed through the pelvic inlet felt, the widest part of the head has into the true pelvis. engaged into the pelvis.- Examiner should be able to palpate part of fetal head still in the lower abdomen (also called the false pelvis but cannot palpate the part of fetal head in the true pelvis. 15. TheLeopoldsManouevre. 16. Additional uterine assessment:1) The myometrium (uterine wall):-Comment on whether the myometrium is soft (normal antenatal state)or contracting (normal state when in labour is 30-60 sec period ofbeing firm to hard followed by 2-5 min interval of being soft).-It may also be hard in abruptio placentae or irritable wheneverpalpation of uterus attempted as in intrauterine growth impairmentof the foetus).2) The liquor volume:-Assessment made of the volume of amniotic fluid surrounding thefoetus.-Reduced volume called Oligohydranios and foetal parts are easily felt.-Increased volume called polyhydramnios and there is difficulty infeeling the foetal parts. 17. 3) Estimate foetal weight:-Difficult and requires practice.- Foetus of 28wks gestation and SFH of 28cm is approx 1.1kg- A 34wk foetus with SFH of 34cm is approx 2.2kg- A term foetus (40wks) with variable SFH btw 36 and 40cm isapprox 3.3kg.- Each week btw these parameters accounts for about 200g.4) Foetal movements:-During the examination note any foetal movements (kicks androlling motions).-Healthy foetuses move, sick or sleepy foetuses dont move. 18. Auscultation of thefoetal heart:- Auscultated with a foetalstethoscope( Pinardsfoetal stethoscope) or witha doptone machine.- Best place to listen is overthe foetal back, closer tothe cephalic pole.- The normal foetal heartrate is btw 110 to 160beats per minute. 19. Part 2 20. Introduction Learning objectives The Partogram Stages of labour Mechanism of a normal delivery 21. Labour divided into 3 stages: The first stage of labour: from onset of labour to full cervical dilatation.This has 2 phases-a) Latent phase: from onset of labour to 3cm cervical dilatation with full effacement. This phase of variable duration- on average last 8 hrs.b) Active phase: From 3cm dilatation to full cervical dilatation. Duration more predictable.Primigravidas (first pregnancy)- dilate at rate of 1cm/hr. Takes a max. of 7hrs.Multigravidas (given birth at least once)- dilate at a rate of 1.5cm/hr. Takes a max. of 4 to 5 hrs. 22. The second stage of labour: from full cervical dilatation to the delivery of the fetus.This has 2 phases:a) First phase of second stage: from full cervical dilatation to until the woman feels the urge to bear down.Primigravidas- lasts from a few mins up to 1hrMultigravidas- lasts from a few mins up to 30 minsb) Second phase of second stage: From the woman feeling the urge to bear down to the delivery of the fetus. This is the phase when the woman pushes and expels the fetus.In uncomplicated delivery, takes 5 to 10 mins. The third stage of labour: from delivery of the fetus to completion of delivery of the placenta and membranes.This stage usually lasts 5 mins. 23. After this skills training session you will haveachieved the following: Know what a partogram is and how it is used as atool to assess the following:I.Progress of labour in the first stage of labourII. Maternal well-beingIII. Foetal well-being Learnt the mechanism of normal vaginal deliveryin the second stage of labour of a foetus with acephalic presentation in a left occipito-anteriorposition(LOA). The management of the third stage of labourshould be witnessed in the labour ward. 24. The following information recorded on the partogram at theextreme left hand side, irrespective of the phase of labour. This recorded information represents initial findings onadmission of the patient to the labour ward. Thereafter, if the pregnant labouring woman is in the latentphase of the first stage of labour, repeat observationsdocumented at correct time interval along the x-axis fromprevious findings. Once the woman is assessed as progressing into active phaseof labour, the observations are shifted from the left hand sideof the partogram to the middle of the partogram onto the firstof two diagonal lines drawn across the cervical graphic part ofthe partogram. 25. Firststage of labour Second stage of labourI. The maternal well-beingII.The progress of labourIII. The fetal well-beingThird stage of labour 26. I. The maternal well-being:-Established from the history and physical examination.-Patients antenatal card is also reviewed.-Certain features are documented on the partogram:i. Age, gravidity and parity: documented on the top of the partogram, together with pts name, hospital number and the date.ii. Risk factors: identified from history, antenatal card or fromphysical examination also documented on the top of thepartogram.iii. Blood pressure and pulse rate: recorded on the lower part ofthe partogram under maternal condition. The BP and Pulse isrepeated every 2hrs in the latent phase of labour and hrlyin the active phase. 27. iv. Temperature: documented every 4hrs through out labour. Recorded beneath section for BP and pulse.v. Urine output: Volume of urine documented and recorded beneath BP and pulse. Urine also tested for protein, glucose and ketones every 4hrs in the latent phase of labour and 2hrly in the active phase.vi. Treatment: Any treatment given recorded at the time given beneath the section on contractions. Examples include analgesia (pethidine for pain relief), intravenous fluids, and oxytocin (given to improve contractions). 28. II. The progress of labour: 5)Attitude-well flexed head.-This is repeated 4hrly in theA-The intrapartum abdominallatent phase and 2hrly in examination:the active phase of labour.-conducted as explained earlier 6)Engagement/decent of the and document findings as: presenting part-(fifths of the fetal head palpable1)SFH-38cm.abdominally above the pelvic2)Upper Pole-Breech in the inlet). fundus.-Documented on the partogram3)Lie- Longitudinal with fetal backby drawing a circle O-size on the patients left side. of a R1 coin ( to represent4)Presentation-Cephalic. cephalic presentation) on the cervical graph against the measurements on the y-axis representing 0,1,2,3,4, or 5 fifths above the pelvic inlet. 29. B-Contractions:-Assessing the state of the myometrium.-In labour uterus is contracting and feels hard during the contractions.-Place your hand on the abdomen for 10 mins and record contractions.-Done 4hrly in the latent phase and 2hrly in the active phase of labour.-Assess the following:1)The frequency of contractions:-the number of contractions felt in 10mins.-recorded on the partogram by shading in the number of blocks below the cervical graph corresponding to the number of contractions palpated in 10mins.-Normally there should be 3 contractions per 10mins in the active phase of labour. 30. 2)The intensity and duration of each contraction:-Time the strength of each contraction.-A weak contraction lasting less than 20secsrecorded on the partogram by a light stippling ofthe blocks to be shaded for the frequency ofcontractions.-Moderate contractions lasting 20 to 40secs areshaded in the relevant blocks with diagonal lines.-Strong contractions lasting more than 40secs areshaded in the relevant blocks solidly or darkly. 31. C-The intrapartum vaginal examination:-Bearing in mind privacy, respect and a female chaperone.-Patient informed that an internal examination to be performed.-In the supine position, hips and knees flexed and hips slightly abducted with feet together.-Examiner on the right side of patient.-Initially the gloved index finger of the right hand inserted through the introitus into the vaginal canal. If patient comfortable with this, the middle finger of the same hand also inserted. If painful then a limited bimanual examination with one finger can be performed.-This is repeated 4hrly in the latent phase and 2hrly in the active phase of labour.-Assess the features of the Cervix and the fetal head. 32. 1) The cervix:b. The cervical effacement:a. The cervical dilatation: - The external length of the-The cervical os dilatation is cervix is assessed by placing estimated in centimeters, bythe index and middle fingers placing the index and middlelateral to the cervix in the right fingers at 3 and 9 oclock on lateral fornix. the edge of the cervical os. - Estimate the length of the-It may be closed i.e. 0cm cervix in centimeters.-It may be 1,2,3.....9 or 10 cm - It may be 3,2,1cm long (fully dilated.effaced).-Record this measurement on - Record this on the partogram the partogram by means of a by means of a bar column large X at the correspondingequivalent to the length of the dilatation on the cervicalcervix on the x-axis of the graph.cervical graph.- A fully effaced cervix indicated as a flat line on the x-axis. 33. 2) The foetal head:Foetal head is felt and the following assessed:a. Foetal head position:-A well-flexed fetal head defines the position of the head asfoetal Occiputrelative to the maternal pelvis.-Palpating the suture lines on the foetal skull helps assess wherethe fetal occiputis.-In the LOA position, the foetal occiput is on the left hand side of the maternal pelvis and is more displaced towards the anterior part of her pelvis.-The position of the foetal head is documented on the partogramby drawing the palpated suture lines within the large O thatdocumented the degree of engagement of the foetal head. 34. b. Moulding:-These same suture lines are then assessed for moulding (degree ofoverlap between the fetal bones during passage through the birthcanal).-Normally the skull bones are slightly apart and a gap or groove ispalpable btw the bones (0+ moulding).-As labour progresses, this gap may disappear as the bone edges arepushed together (1+ moulding).-If there is a tight fit btw the fetal head and the birth canal, the skullbones overlap slightly, but this can be reduced with gentle digitalpressure (2+ moulding).-In case where the fetal head is too big for the birth canal, the skullbones clearly overlap and cannot be reduced (3+ moulding)-The degree of moulding is recorded on the partogram as 0,1+,2+,3+for both sagittal and lamboid suture lines just above the cervicalgraph. 35. c. Caput:- During labour fetal is pushed against the steadilydilating cervix and a degree of swelling on the fetalscalp does occur called cervical caput (1+ caput) andconsidered normal.- If fetal head too big for the birth canal ,it is compressedagainst the pelvic bones and extensive caput formsbeyond the confines of the cervical os, termedextensive caput (caput2+) and indicates a problemwith labour.- -The degree of caput is recorded on the partogram as0,1+,or 2+ in the area just above the cervical graph. 36. III. Fetal well-being:The following features of fetal well-being assessed during labour:a) The liquor fluid/amniotic fluid:-Assessment made whether the fetal membranes(amnion andchorion) are still intact(I) or ruptured, eitherspontaneously(SROM) or artificially(AROM) anddocumented in the section just above the cervical graph.-If no membranes are felt, note made of the colour of liquor fluiddraining at the time of examination. Documented as C forclear liquor or M as meconium stained liquor.-Meconium stained means that the liquor is green in colourindicating the foetus has passed meconium (foetal gastro-intestinal content) indicating possible foetal distress orcompromise 37. b) Fetal heart rate monitoring:-- Monitored using the foetal stethoscope(Pinards), adoptone, or a cardiotocograph.- Foetal heart rate auscultated just before, duringand directly after a contraction to assess the effectof contraction on the foetal heart rate.- The following are recorded at the top of thepartogram with dots or crosses corresponding tothe foetal heart rate grading:- Baseline foetal heart rate (normal btw 110 and 160beats per minute) and presence or absence ofdecelerations (a decrease below the baselinefoetal heart rate, normally not present). 38. Fetal heart rate grading:Grade 1- Normal heart rate and pattern 110-160.Grade 2- rate > 160 or 100-110 with no decelerationsGrade 3- fetal heart rate pattern shows decelerations during contractiononly (Early deceleration).3a with normal hear rate and 3b with abnormal heart rateGrade 4- decelerations during contraction that only recover slowly,about 30 secs after contraction has ended (Late deceleration)4a with normal heart rate and 4b with an abnormal rateGrade 5- persistent fetal bradycardia below 100 beats per minute.-Fetal heart rate should be assessed and recorded everyhour during the latent phase, every half hourly duringthe active phase and every 15mins in the second stageof labour. 39. I. Maternal condition:III. Fetal condition:-As documented during the first stageof labour.-Fetal heart rate monitoring is done-During this expulsive phase, when as described earlier.pushing, the woman needs-Performed more frequently (every 15support and encouragement. minutes).II. Progress of labour:-Vaginal examination performed more frequently, every 30 to 60 mins to assess signs mentioned above as well as the decent of the presenting part.-Decent- movement of presenting part down the birth canal towards the introitus. 40. Anormal vaginal delivery of a foetus with acephalic presentation in a left occipito-anterior position(LOA) will be described. Note: the maternal bony pelvis made up ofthree parts, the pelvic inlet, the mid-pelvisand the pelvic outlet. The foetus will need to negotiate theseparts of the pelvis during the birth process. 41. Descent:-The fetal head descends through the pelvic inlet to the mid-pelvis inthe LOA position. Flexion:-During this process the fetal head becomes more and more flexed. Internal rotation:-The foetus rotates 45 degrees internally, from LOA position, to directoccipito-anterior position (OA) due to the shape of the pelvic floormuscles( levator ani muscles). Birth by extension:-The foetal head passes through the pelvic outlet in the direct OAposition and is born through the introitus by now extending the head. 42. Restitution:-The foetal had undergone 45 degreesinternal rotation relative to the maternalpelvis and also relative to the rest of thefoetal body.-Now that it is free of the maternal introitus,the babys head will revert back to itsoriginal position relative to its body, i.e.back to an LOA position by turning back 45degrees. 43. External rotation:-At the same time as internal rotation and the birth of thehead, the foetal shoulders have descended in an obliquediameter through the pelvic inlet to the mid-pelvis.-As restitution of babys head takes place, the fetalshoulders now undergo internal rotation from theiroblique diameter into a direct anterior-posterior positionin order to negotiate the pelvic outlet, just as the headdid.-The babys free head rotates further from LOA position toa direct left occipito-transverse position(LOT).-Both restitution and external rotation take place as onemovement. 44. Birth of the shoulders:-The shoulders are now born. The anteriorshoulder is born under the pubicsymphysis and pivots there while theposterior shoulder is born over theperineum by lateral flexion. Birth of the trunk and extremities:-Once the shoulders are born, the rest of thebaby is born with relative ease. 45. You must observe this stage on your visit to the labour ward. Oxytocin (medication that contracts the uterus) should havebeen given at some stage between delivery of the anteriorshoulder of the baby and complete expulsion of the baby. The umbilical cord is clamped and cut and the baby is driedand wrapped up. Gentle traction applied to the umbilical cord while awaitingplacental separation. The placenta has separated from the uterine wall once youobserve a gush of blood and gradual lengthening of theumbilical cord. The placenta is then removed by gentle traction, ensuring allfetal membranes are also removed, often by repeatedlyrotating the placenta. The placenta is inspected for completeness. 46. Skillstraining protocol from department ofObstetrics and Gynaecology. South African Family Practice Manual byBob Mash. Hutchinsons clinical methods by MichealSwash. Pictures from Google images.