Abdominal Palpation in Pregnancy

Image by Øyvind Holmstad (Own work) [CC BY-SA 4.0 (http://creativecommons.org/licenses/by-sa/4.0)], via Wikimedia Commons

Abdominal Palpation in Pregnancy

Abdominal examination in pregnancy comprises of four steps such as

• Inspection
• Palpation 
• Percussion
• Auscultation

Preparation of the patient

• Ask the mother to empty the bladder
• Check height, weight and blood pressure of the mother
• Position the patient in supine position at an angle of 30 degree
• Provide privacy
• Expose the abdomen from below chest to symphysis pubis and keep a drape sheet to cover the abdomen when you are not examining her
• Stand on the right side of the mother and warm up your hands

Inspection

Remember 'SSSFU' during inspection of the abdomen which means size, scars, skin changes, fetal movements and umbilicus.

Size and shape of the uterus should be appropriate to the gestational age and symmetrical. It might be in round or ovoid in shape.

Transverse scars, laparoscopic or laparotomy scars indicates previous surgeries including LSCS.

Skin changes includes striae gravidarum, striae albicantes and linea nigra.  Striae gravidarum is caused by hormonal changes and appears early in prenancy.  Striae albicantes are stretch marks from previous pregnancies. Linea nigra is a dark coloured straight line from below chest to symphysis pubis.

Fetal movements are visible from 24 weeks which indicates viability.

Umbilicus  may become flattened.

Palpation

Before proceeding into palpation, measure abdominal girth in inches or centimeters by keeping a inch tape around the abdomen. Then, palpate the fundus by ulnar border of the left hand and measure the gestational weeks using fingerbreadth method. Up to umbilicus, it is to be considered as 24 weeks. Keep four fingers of right palm above the umbilicus and measure it by considering one finger width is one week.

To measure the fundal height, keep the inch tape from symphysis pubis to fundus. The fundal height in centimeters is equal to gestation weeks with a difference up to +/-3 cm.

1. Fundal grip- Palpate the superior border of the fundus by using palms of two hands determine the pole of the fetus.
2. Lateral grip- Palpate the lateral sides of the abdomen to determine the spine and limbs of the fetus. If the fetus lies at a right angle to the axis of the uterus, it is in a transverse lie. If the head and buttocks are palpable on lateral sides, it indicates the fetus is in a oblique lie.
3. Pelvic grip-Turns into foot end of the patient and move both of your hands from lateral sides to pubis. If the hands are converged, it indicates head is not engaged. If the hands are not converged, it indicates engaged head.
4. Pawlick grip-  Grasp the lower portion of the abdomen using the fingers and thumb of the right hand to feel the ballotment of the head, which indicates the floating head and the progress of the labour.

Percussion

This technique can be used in mothers with polyhydramnios.

Auscultation

Fetal Heart Sounds (FHS) can be heard by fetoscope/ stethescope/ hand held doppler monitor. The fetal heart rate is normally between 110 and 160 b.p.m.

Sahli's Acid Hematin Method

Sahli's Acid Hematin Method

Principle- The hydrochloric acid in the acid hematin solution converts the hemoglobin into acid hematin and the value is determined by matching with the color comparator

Article needed are:

• Pipette, marked at the 20 mm level
• Stirring rod
• Color comparator
• 0.1N Hydrochloric Acid Solution- Add 1 ml of concentrated HCL to 99 ml of distilled water
• Graduated tube with scale on two sides, percentage scale reads from 0 to 170 and gram scale reads from 0 to 24.
• Distilled water

Procedure

1. Pour 5 drops of 0.1N HCL solution in graduated tube.
2. Wear gloves and aspirate the blood from the finger tip with pipette up to 20 mm mark .
3. Pour blood into graduated tube and note the time.
4. Shake the tube well and add distilled water drop by drop until the color of the solution matches the color comparator. Stir it well using stirring rod.
5. After five minutes, read the result from the scale by noting the lower edge of the meniscus.
6. Finding are reported in gm per 100 ml of whole blood

Normal Values

Male- 14-16 gm/ 100 ml of whole blood

Female- 12-14 gm/100 ml of whole blood

Maternal Near Miss(MNO)

Maternal Near Miss/ Obstetric Near Miss

A ' near miss' is an unplanned event that didnot result in injury or damage, but had the potential. This is a fortunate break in the events prevented an injury or death. This term actually represents safety.

A maternal near miss case is defined as 'women who nearly die but survived from complications that occurred during pregnancy, child birth or with in 42 days of termination of pregnancy. In practical terms, those who survived from life threatening situations during those minutes.

The concept has been coined by WHO, to focus on the health system failures in relation to obstetric care.

The CBH criteria( Cairns Base Hospital, Far North Queensland) for potential cases of ONM are

• any admission to ICU
• APH/PPH requiring operative interventions
• severe pre-eclampsia
• pulmonary embolism
• ruptured ectopic pregnancy
• shock

The proposed WHO Near Miss Criteria

Near Miss Criteria(WHO)

The near miss audits in hospitals based on WHO criteria, will help to analyse the ill women, identify the deficiencies in the care and able to do comparisons between or within the countries. This will, ultimately, help to reduce the maternal morbidity and mortality worldwide.

Rokitansky syndrome

I am very glad to say that a woman's dream come true. In October 2014, it was reported that a 36 years old Swedish woman, who was diagnosed with Rokitansky Syndrome and was undergone womb transplant, gave birth to a healthy baby.

Mayer-Rokitansky-Küster-Hauser Syndrome

Mayer-Rokitansky-Küster-Hauser Syndrome is a disorder that affects female reproductive system. It is a congenital malformation, characterized by a failure of development of mullerian duct, resulting in underdevelopment of uterus and vaginal hypoplasia.

It may be associated with other malformations such as renal agenesis, ectopia of kidneys and cardiac anomalies.

Signs and Symptoms

• Primary Amenorrhea

• Infertility

• Difficulty with sexual intercourse

• History of recurrent urinary tract infection

Management

Goal: To provide the patient with an unscarred vagina

• Perineal dilation

• Vaginal reconstruction by Mclndoe technique with skin graft

• William's vaginoplasty with vulval flap

• Intestinal neovagina uses an isolated segment of bowel

• Uterus transplantation

In conclusion, the risk for transmission of the disease can not be predicted, as the genetics of the MRKH Syndrome is very little known currently.

The Medical Termination of pregnancy - India

Unsafe abortions are taking a huge toll on lives of women, as these victims opt for backroom procedures. Here, I am posting about MTP Act in India to inculcate awareness among the public about "how can abortion legally be done?".

It extends to all states in India except Jammu and Kashmir. It lays down,

• The conditions under which a pregnancy can be terminated.
• The persons who can perform such terminations.
• The place where such termination can be performed.

·       The conditions under which a pregnancy can be terminated:

There are five conditions that have been identified in the Act, where the pregnancy might endanger mother’s life or cause injury to mother’s physical or mental health, where there is a risk of child being born with serious handicaps, where the pregnancy is the result of rape, where actual or reasonably foreseeable environments could lead to risk of injury to the health of the mother and an unwanted pregnancy resulting from a failure of any contraceptive devices.

·       The persons who can perform abortion:

If the length of pregnancy doesn't exceed 12 weeks, a Registered Medical Practitioner having experience in gynecology and obstetrics can perform abortion but, if pregnancy exceeds 12 weeks and is not more than 20 weeks, the opinion of two Registered Medical Practitioners is necessary to terminate the pregnancy.

·       Where abortion can be done:

Termination of pregnancy can be made at a hospital maintained by government or a place approved for the purpose of this Act by government. It should be done in hospitals in strict confidence. 

The written consent of the guardian is necessary before performing abortion in women under 18 years of age, and in case of lunatics even if there are older than 18 years.