Oxford Handbook of Midwifery by Janet Medforth, Sue Battersby, Maggie Evans, Beverley Marsh, Angela Walker Page B

and provide iron supplementation if necessary.
At 36–37 weeks’ gestation, confirm the lie and presentation of the fetus, and offer external cephalic version for women whose babies are in the breech position.
If an earlier report showed the placenta extending over the internal cervical os, a further scan should be arranged and reviewed at 36 weeks.
A further appointment should be arranged for women who have not given birth by 41 weeks, to offer a membrane sweep and induction of labour if this is unsuccessful.
1 National Institute for Health and Clinical Excellence (2008). Antenatal care: Routine care for the healthy pregnant woman. Clinical guideline 62. London: NICE. Available at: M www.nice.org.uk/cg62.
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CHAPTER 4 Antenatal care
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Abdominal examination
An abdominal examination can be carried out at any stage of pregnancy and is used to determine the progress of pregnancy or labour and fetal well-being.
The examination is in three parts: inspection, palpation, and auscultation.
Ask for the woman’s consent before the examination. Make her comfortable on the examination couch, lying supine with her head supported by one pillow. Her arms should be relaxed by her sides. Expose her abdomen but use a sheet or towel to cover her pelvic area and legs, preserving her privacy and dignity.
Inspection
Inspect the abdomen for size and shape. In the primigravida the shape is oval, due to abdominal muscle tone. In the parous client, the shape may be more rounded.
There may be a saucer-shaped depression below the umbilicus if the fetus is presenting in an occipito-posterior position.
A heart-shaped uterus may indicate a transverse lie.
The umbilicus may protrude and the linea nigra, which is the pigmented midline of the rectus sheath, may be apparent.
Other abdominal scars may be apparent, as will striae gravidarum or stretch marks, which are pink at first turning to a silvery white as they age.
Size should indicate the stage of pregnancy, which will be confirmed by measuring the symphysis–fundal height.
Observe for fetal movements—this confirms a live fetus.
Palpation
Locate the fundus and measure and plot its height above the symphysis pubis (in centimetres).
The measurement in centimetres should approximately correspond to the number of weeks’ gestation after 20 weeks. However, there is a
wide variation of normal, due to maternal height, weight, and the length of the maternal abdomen. This does not have a proven predictive value in detecting small for gestational age fetuses. 1
The lie of the fetus is normally longitudinal, with the long axis of the fetus lying along the long axis of the mother.
The presenting part is normally the fetal head. Breech presentation occurs in approximately 3% of pregnancies at term.
Determine the position of the fetus:
The position of the occiput can be found by locating the fetal back, which feels smooth and firm and will lie anteriorly in the left or right side of the uterus if the occiput is anterior.
In posterior positions, the back may be felt in the left or right flank, or it may not be palpable. If fetal limbs are felt on both sides of
the midline it is likely that the fetus is lying in an occipito-posterior position.
Establish the relationship of the presenting part to the pelvic brim. The fetal head is engaged in the pelvis when the widest diameter of the fetal head has entered the pelvic brim.
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Auscultation
Hearing the fetal heart will confirm that the fetus is alive, but it does not have any proven predictive value. Routine listening is not
recommended but, if the mother requests it, auscultation may provide reassurance. 1
Explain the findings of the examination to the mother and record them in her notes.
1 National Institute for Health and Clinical Excellence (2008). Antenatal care: Routine care for the healthy pregnant mother. Clinical guideline 62. London: NICE. Available at: M www.nice.org. uk/cg62.
CHAPTER 4