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  • Ask the woman to completely empty her bladder immediately before proceeding with the abdominal examination. This is important as even a half full bladder might result in an increase in the fundal weight
  • Ask the woman to lie on her back with the upper part of her body supported by cushions. Never make a pregnant woman lie flat on her back as the heavy uterus may compress the main blood vessels returning to the heart and cause fainting (supine hypotension). Ask her to partially flex her hips and knees
  • Stand on the right side of the woman to examine her in a systematic manner
  • The attention of the woman may be diverted by conversation
  • Your hand must be warm and should be placed on the abdomen till the uterus is relaxed before the palpation is actually begun. Poking the abdomen with the fingertips should be avoided at all costs
  • To measure the fundal height, place the ulnar (medial/inner) border of the hand on the woman’s abdomen, parallel to the symphysis pubis. Start from the xiphisternum (the lower end of the sternum/breastbone), and gradually proceed downwards towards the symphysis pubis, lifting you hand between each step down, till your finally feel a bulge/resistance, which is the uterine fundus
  • Mark the level of the fundus. Using a measuring tape (a tailor’s tape measure which is made of non-stretchable material), measure the distance (in cm) from the upper border of the symphysis pubis to the top of the fundus. After 24 weeks of gestation, the fundal weight (in cm) corresponds to the gestational age in weeks (within 1-2 cm deviation). Remember, at the time of measuring the fundal height in cm, the legs of the woman should be kept straight and not flexed
  • The supine position in late pregnancy and labor has also been shown to be associated with higher fundal height readings; therefore, this can give to false readings and an inaccurate estimate of the gestational age. It is therefore, recommended that the woman lies down in a half-lying position when measuring the fundal height
  • When the same operator is measuring the fundal height at each visit, this technique has been shown to have good predictive values, especially for identifying major intrauterine growth retardation (IUGR) and multiple pregnancies
  • The normal fundal height is different at different weeks of pregnancy. To estimate the gestational age through the fundal height, the abdomen is divided into parts by imaginary lines. The most important one is the one passing through the umbilicus. Then divide the lower abdomen (below the umbilicus) into 3 parts with 2 equidistant lines between the symphysis pubis and the umbilicus. Similarly, divide the upper abdomen into three parts, again with two imaginary equidistant lines, between the umbilicus and the xiphisternum
  • Look where the fundal height is and judge as given below:

At 12th week: just palpable above the symphysis pubis

At 16th week: lower one-third of the distance between the symphysis pubis and umbilicus

At 20th week: two-thirds of the distance between the symphysis pubis and umbilicus

At 24th week: at the level of the umbilicus

At 28th week: lower one-third of the distance between the umbilicus and xiphisternum

How to Determine Fetal Lie and Presentation

  • At 32nd week: two-thirds of the distance between the umbilicus and xiphisternum
  • At 36th week: at the week of the xiphisternum
  • At 40th week: sinks back to the level of the 32nd week, but the flanks are full, unlike that in the 32nd week

The pelvic grips (four in number) are performed to determine the lie and the presenting part of the fetus

  • Fundal palpation/fundal grip

This palpation helps determine the lie and presentation of the fetus

Palpate the uterine fundus gently by laying both hands on the sides of the fundus in an attempt to determine which pole of the fetus (the breech or the head) is occupying the uterine fundus. The head feels like a hard globular mass which is ballotable (moves between the fingertips of the two hands), whereas the breech is of a softer consistency and has an indefinite outline

In the case of a transverse lie, the fundal grip will be empty

  • Lateral palpation/lateral grip

This palpation is used to locate the fetal back to determine the fetal lie

Place the hands on either side of the uterus at the level of the umbilicus and apply gentle pressure. The back of the fetus is felt like a continuous hard, flat surface on one side of the midline and the limbs are felt as irregular small knobs on the other side

In the case of a transverse lie, the back is felt transversely, i.e. stretching across both sides of the midline

  • First pelvic grip/superficial pelvic grip

The third maneuver must be performed gently, or it will cause pain to the woman. Spread you right hand widely over the symphysis pubis, with the ulnar border of the hand touching the symphysis pubis. Try to approximate the finger and thumb, putting gentle but deep pressure over the lower part of the uterus. The presenting part can be felt between the fingers and the thumb. Determine whether it is the head or the breech (in the case of a longitudinal lie)

The mobility of the presenting part can also be determined by gripping the presenting part and trying to move it. If it cannot be moved, it indicates that the presenting part is “engaged”. The fetal head is said to be engaged if the widest diameter of the fetal head has passed through the brim of the pelvis, or only two finger-breadths are felt above the pelvic brim

In the case of a transverse lie, the third grip will be empty

  • Second pelvic grip/deep pelvic grip

To perform this grip, you must face the foot end of the mother. Keep both the palms of your hands on the sides of the uterus, with the fingers held close together, pointing downward and inward, and palpate to recognize the presenting part

If the presenting part is the head (felt like a firm, round mass, which is ballotable, unless engaged), this maneuver, in experienced hands, will also be able to tell us about its flexion

If the woman cannot relax her muscles, tell her to flex her legs slightly and to breathe deeply. Palpate in between the deep breaths

  • How to auscultate for fetal heart sounds (FHS):

Use a fetoscope or the bell of the stethoscope for this. Remember, the FHS is best heard on the side where the spine/back of the fetus is. For a normal vertex presentation, the FHS is best heard midway between the line joining the umbilicus and the anterior superior iliac spine, on the side where the back is

In a breech presentation, the fetal heart is usually heard above the umbilicus

Count the FHR rate for one full minute

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