Examinations & Procedures - Part 2

OBSTETRICS EXAMINATION

Guide to antenatal assessment

You must know a detailed guide on how to perform an antenatal examination as a doctor. Here are the steps you can follow:

1. Introduction and obtaining consent: Start by introducing yourself to the patient and explaining the purpose of the examination. Obtain informed consent from the patient to perform the examination.

2. General assessment: Begin with a general assessment of the patient, including their overall appearance, vital signs, and any signs of distress.

3. Abdominal examination: Proceed with an abdominal examination to assess the size, position, and presentation of the fetus. Start by inspecting the abdomen for any abnormalities or deformities, such as asymmetry, scars, or distension. Then, palpate the abdomen to determine the fundal height, position of the fetus, and any tenderness or pain.

4. Fetal heart rate monitoring: Use a fetal heart rate monitor to assess the fetal heart rate and rhythm. This can be done using a handheld doppler or a cardiotocography (CTG) machine.

5. Pelvic examination: Perform a pelvic examination to assess the cervix and vaginal walls for any abnormalities or signs of infection. Use a speculum to visualize the cervix and take a swab for culture if necessary.

6. Urine and blood tests: Collect a urine sample for routine analysis and test for glucose and protein levels. Take a blood sample to test for blood type, Rh factor, and other indicators such as hemoglobin levels, infectious diseases, and other relevant markers.

7. Discussion and counseling: Discuss the results of the examination with the patient and provide any necessary counseling or advice on diet, exercise, and other lifestyle factors that can affect the pregnancy. Provide the patient with any necessary prescriptions or referrals to specialists as needed.

Overall, an antenatal examination is an essential part of prenatal care, and performing a thorough and comprehensive examination can help ensure the health and well-being of both the mother and the developing fetus.

Four grips palpated in antenatal assessment and what is their importance

In antenatal assessment, there are four main grips that are used during abdominal examination. These grips are important for assessing the size, position, and presentation of the fetus, as well as detecting any abnormalities or complications that may arise during pregnancy. Here are the four grips:

1. Fundal grip: This grip is used to determine the height of the uterus and the position of the fetus. To perform this grip, place both hands on the upper abdomen with the fingers pointing towards the head. Press down gently and palpate for the top of the uterus (fundus). This grip is important for estimating the gestational age of the fetus and detecting any growth abnormalities.

2. Umbilical grip: This grip is used to determine the location of the fetus and the position of the umbilical cord. To perform this grip, place one hand on either side of the abdomen, just above the umbilicus. Press down gently and palpate for the fetal back on one side and the umbilical cord on the other. This grip is important for detecting any abnormalities such as cord prolapse or nuchal cord (cord wrapped around the fetal neck).

3. Pelvic grip: This grip is used to determine the fetal presentation and position in the pelvis. To perform this grip, place both hands on either side of the lower abdomen, just above the pubic bone. Press down gently and palpate for the fetal head or buttocks. This grip is important for detecting any malpresentation such as breech or transverse lie.

4. Flank grip: This grip is used to determine the fetal lie and the position of the back and limbs. To perform this grip, place both hands on either side of the abdomen, just above the flanks. Press down gently and palpate for the fetal spine and limbs. This grip is important for detecting any abnormalities such as limb deformities or spinal defects.

Overall, the four grips used in antenatal assessment are important for assessing the size, position, and presentation of the fetus, as well as detecting any complications or abnormalities that may arise during pregnancy.

Examination findings in breech presentation

Breech presentation is a condition in which the fetus is positioned in the uterus with its buttocks or feet downward, instead of the head. This can cause complications during delivery, and therefore, it is important to identify breech presentation during antenatal examinations. Here are some examination findings in breech presentation:

1. Fundal height: The fundal height may be higher than expected for the gestational age, or the uterus may have a bulging shape at the top due to the position of the buttocks.

2. Leopold's maneuvers: During abdominal palpation, the fetus may be felt as a hard, round mass in the upper abdomen, which is the buttocks. This is in contrast to a cephalic presentation, where the fetal head is felt in the lower abdomen.

3. Fetal heart rate: The fetal heart rate may be heard higher in the abdomen than expected, due to the position of the fetal buttocks.

4. Pelvic examination: During a vaginal examination, the presenting part of the fetus may be felt to be the buttocks or feet, rather than the head. The cervix may also be less effaced and dilated compared to a cephalic presentation.

5. Ultrasound: An ultrasound can confirm the presence of a breech presentation and provide more detailed information about the position of the fetus, including its attitude and degree of flexion.

It is important to note that not all breech presentations require intervention, and the appropriate management will depend on the individual case and the stage of pregnancy. In some cases, a vaginal delivery may be possible with close monitoring, while in other cases, a cesarean delivery may be recommended to reduce the risk of complications.

How to confirm fetal lie on antenatal examination

Determining the fetal lie is an important part of antenatal examination as it helps in assessing the position of the fetus in the uterus. The fetal lie refers to the relationship between the long axis of the fetus and the long axis of the mother. There are three possible fetal lies: longitudinal (head down or breech), transverse, and oblique. Here are the steps to confirm a fetal lie during antenatal examination:

1. Position the patient: Ask the patient to lie down on her back with her knees bent and her abdomen exposed. The bladder should be empty for better visualization and palpation.

2. Locate the fetal back: Place both hands on either side of the abdomen, just above the flanks. Press down gently and palpate for the fetal spine. The fetal back feels firm and smooth, while the limbs and head feel softer and more irregular.

3. Determine the presenting part: Once the fetal back is located, determine which part of the fetus is closest to the pelvic inlet. This is the presenting part and can be felt as a hard, round mass in the lower abdomen.

4. Identify the fetal lie: Once the presenting part is identified, determine the relationship between the presenting part and the maternal long axis. If the presenting part is head down, the fetal lie is longitudinal. If the presenting part is perpendicular to the maternal long axis, the fetal lie is transverse. If the presenting part is at an angle to the maternal long axis, the fetal lie is oblique.

5. Confirm with ultrasound: If there is any uncertainty about the fetal lie or position, an ultrasound can be used to confirm the findings.

Confirming the fetal lie is important for assessing the position of the fetus and planning for delivery. If the fetal lie is longitudinal, the fetus is in a good position for a vaginal delivery, while a transverse or oblique lie may require a cesarean delivery to reduce the risk of complications.

Management of breech presentation

Breech presentation is a condition in which the fetus is positioned in the uterus with its buttocks or feet downward, instead of the head. The management of breech presentation depends on several factors, including the gestational age, the size of the fetus, the position of the fetus, and the maternal and fetal conditions. Here are some management options for breech presentation:

1. Vaginal delivery: In some cases, a vaginal delivery of a breech presentation may be attempted. This approach is generally reserved for cases of a term, singleton pregnancy with a frank or complete breech presentation and an estimated fetal weight of less than 4 kg. However, it requires close monitoring and a skilled obstetrician. The decision to attempt a vaginal delivery should be made on a case-by-case basis, taking into account the potential risks and benefits.

2. External cephalic version (ECV): This is a procedure in which the obstetrician manually manipulates the fetus to turn it into a head-down position. This procedure is typically performed after 37 weeks of gestation in multigravida and after 36 weeks of gestation in primigravida, and the success rate varies depending on several factors, including the position of the fetus, the amount of amniotic fluid, and the experience of the obstetrician.

3. Cesarean delivery: This is the most common approach for delivering a breech presentation. A cesarean delivery is recommended for most cases of a preterm or footling breech presentation, a transverse lie, an estimated fetal weight of more than 4 kg, or other complicating factors such as a previous cesarean delivery, placenta previa, or fetal distress.

4. Expectant management: In some cases, a wait-and-see approach may be taken, especially if the pregnancy is preterm or the fetus is small. In these cases, the obstetrician may monitor the fetal position and condition closely and wait for labor to begin spontaneously. However, this approach carries a risk of complications, including umbilical cord prolapse, and should be used with caution.

The management of breech presentation requires careful consideration of the individual case and the potential risks and benefits of each approach. The decision on the appropriate management should be made by an experienced obstetrician after a thorough evaluation of the patient and the fetus.

Success rate of ECV

The success rate of external cephalic version (ECV) varies depending on several factors, including the position of the fetus, the amount of amniotic fluid, the gestational age, and the experience of the obstetrician performing the procedure. However, studies have shown that the overall success rate of ECV is approximately 50-60%.

Factors that increase the likelihood of a successful ECV include a frank or complete breech presentation, an anterior placenta, a normal amount of amniotic fluid, a relaxed uterus, and an experienced obstetrician. Factors that decrease the success rate include a footling breech presentation, a posterior placenta, oligohydramnios (low amniotic fluid), a contracted uterus, and a large fetus.

It is important to note that ECV is not without risks, including fetal distress, placental abruption, and preterm labor. Therefore, ECV should only be performed in a hospital or a facility equipped to deal with potential complications, and only by an experienced obstetrician who has undergone appropriate training. The decision to perform an ECV should be made on a case-by-case basis, taking into account the individual patient and fetal factors.