Obstetric Examination

OBSTETRIC EXAMINATION, in the strict sense of the word, encompasses all methods of external and internal examination used at the present time during pregnancy, labor, and in the postpartum period. External obstetric examination is divided into: 1) inspection, 2) palpation, 3) auscultation, and 4) measurement. Obstetric inspection consists of examining the face, mammary glands, abdomen, and the entire body in general, which is especially necessary in cases of spinal deformity, suspected pelvic contraction, and the presence of a limp. In the first case, inspection of the spine determines the degree and nature of changes in it—most often this will be a curvature to one side or the other—kyphosis, lordosis, scoliosis; the influence of these curvatures on the position, dimensions, and shape of the pelvis is also determined. When pelvic contraction is suspected, inspection of the lower extremities and palpation of the bones determine the presence of traces of rickets in the skeleton. Inspection of the lumbar region is also of essential importance, as the so-called rhombus of Michaelis (see Table I, Fig. 1*) is located there; changes in its shape and size provide specific indications of the presence and nature of changes in the pelvis. Inspection of this rhombus is usually performed during pelvimetry, i.e., in the woman's recumbent position, but in the standing position, such an inspection provides much more accurate data. Inspection of the face itself often allows for a diagnosis of pregnancy to be made; very often in the first weeks of it, characteristic pigmentation appears on the face, the so-called “pregnancy spots” (chloasma gravidarum). If this pigmentation is accompanied by the puffiness of the face characteristic of pregnancy, then a diagnosis of pregnancy is highly probable. At the same time, facial mimicry is strongly disturbed—it acquires a somewhat indifferent, mask-like expression (“mask of pregnancy”). Inspection of the mammary glands reveals pigmentation of the nipples, areolae, and also hypertrophy of the Montgomery glands; the inspection is supplemented by palpation of the glands themselves and the expression of colostrum from them, which, on the one hand, indicates the presence of pregnancy, and on the other, makes it possible to judge the functional suitability of the mammary glands. Inspection of the abdomen of a pregnant woman and a woman in labor, first of all, allows a conclusion to be drawn about the properties of the abdominal wall; at the end of pregnancy, the shape of the abdomen allows one to judge the lie of the fetus. The presence on the skin of the abdomen (in its lower half) of fresh “scars of pregnancy,” colored in a bluish-purple hue, almost always speaks in favor of pregnancy, since with abdominal tumors, even large ones, such characteristic scars are usually absent. Palpation of the abdomen must always be systematic and complete. First of all, it must provide the boundaries of the pregnant uterus; here, the peculiar consistency of the uterus and sometimes the contractions of its walls are of the greatest importance. Both signs are very characteristic and are usually not observed with abdominal tumors. The reverse cannot be said, as sometimes a pregnant uterus has a firm consistency and firmly retains it. It happens that both pregnancy and a tumor are present simultaneously. Palpation of the uterus gives an idea of its size, which, together with the height of its fundus, allows the duration of pregnancy to be determined. Until the 3rd month of pregnancy, the uterus is entirely contained within the cavity of the lesser pelvis, and only in the 3rd month does its fundus begin to be palpable above the pubic bone (do not confuse with a full bladder!); in the 4th month, the uterus is already easily palpable in the lower part of the abdomen, and its fundus by the end of this month rises to the middle of the distance between the pubic bone and the navel; sometimes by the end of the 5th month and always in the 6th, the fundus of the uterus reaches the level of the navel; in the 7th month, the uterus rises above this level and in the 8th reaches the middle of the distance between the navel and the xiphoid process; by the end of the 9th month, the fundus of the uterus rises to the xiphoid process itself, and then begins to descend again, and by the end of the 10th, it occupies the same position as in the 8th, i.e., its fundus stands at the middle of the distance between the navel and the xiphoid process. In such a case, it is required to clarify which month of pregnancy it is—the 8th or the 10th. Here, by means of palpation, one is guided by the size of the fetus and the engagement of the presenting part into the pelvic inlet. If the presenting part has definitely, even if only slightly, engaged into the pelvic inlet, then this speaks in favor of the pregnancy being in the 10th month. In cephalic presentation, ballottement of the head almost always speaks for the 8th month of pregnancy, since in the 10th, even a well-movable head almost never ballottes. The size of the uterus may be larger than expected: in multiple pregnancy, polyhydramnios, a large fetus, and in the first months of pregnancy—in hydatidiform mole. The fundus of the uterus may stand higher than the expected level, in addition to the cases listed, also with a contracted pelvis, especially in the second half and at the end of pregnancy. If the size of the uterus is smaller than expected and its fundus stands lower than it should be according to the duration of pregnancy, then one must think about the retention of a dead ovum, and in a later stage of pregnancy—about the death of the fetus or its poor development. In the second half of pregnancy, palpation of the uterus allows one to determine the lie of the fetus, its position, and the presenting part (see Table II, Fig. 5). The lie of the fetus is determined as longitudinal if one can clearly palpate the large parts of the fetus above the pelvic inlet and in the fundus of the uterus. The position of the fetus is determined by palpating the lateral sides of the uterus (see Table II, Fig. 6), whereby on one side a uniform density is felt, and on the other, the “fiddling” of the fetal limbs is felt, and its “small parts” are palpated. The sensation of uniform density is given by the back of the fetus, and by it, the position is determined (back on the left—first position, back on the right—second position). The presenting part is palpated either with one hand, while trying to grasp it between the first and all other fingers, or it is grasped with both hands, placing them on the lateral sides (see Table II, Fig. 7). The sensation of a spherical, dense, almost hard, large part speaks in favor of the head presenting. Conversely, the presenting pelvic end does not give such a definite sensation, and in such cases, a large part is palpated in the fundus of the uterus. In multiple pregnancy, it is sometimes possible to clearly palpate three large parts. During labor, when the uterus is already in a contracted state, the parts of the fetus are palpated with difficulty, and the presenting part may, in addition, have already descended into the lesser pelvis and be poorly palpable above the pubic bone. Palpation of the uterus during labor gives a clear idea of the character and strength of uterine contractions and, in general, of labor activity. In addition, by palpating the uterus during labor, one can follow the change in its shape, which to a certain extent allows one to judge the period of labor. Thus, in the first stage of labor, the fundus of the uterus during a contraction lowers somewhat and simultaneously rises anteriorly, clearly approaching the abdominal wall; conversely, in the second stage of labor, it rises upward during a contraction, approaching the xiphoid process. If at the beginning of labor it is possible to clearly palpate the presenting part, then subsequently, by means of repeated palpation, one can follow its gradual descent into the pelvic cavity and in this way draw a conclusion about the course of labor. In practical terms, it is precisely the sensation of this gradual entry of the presenting part into the inlet and further into the pelvic cavity that is especially important. Such entry at the end of pregnancy (in primigravidae) and at the beginning of labor (in multigravidae) always indicates that there is correspondence between the presenting part and the capacity of the lesser pelvis, and this allows a favorable prognosis to be made regarding the further course and termination of labor. Conversely, if during palpation of the uterus during labor the presenting part is palpated above the pelvic inlet either entirely or for the most part and does not descend into the inlet (“does not engage”) during the further course of labor, then one can almost always draw one of the following three conclusions: 1) either there is a contracted pelvis with a fetus of normal size, 2) or a large fetus with a normal pelvis, 3) or, finally, a normal fetus with a normal pelvis has an incorrect presentation (in cephalic presentations, this will be one of the extension presentations—parietal, frontal, or face). Palpation of the uterus in the third stage of labor gives an idea of its course. Until the placenta is expelled from the uterus, it retains a spherical shape, and its fundus stands at the level of the navel; after the detached placenta is expelled from the uterus into the upper part of the vagina, the body of the uterus takes on a shape flattened from front to back, and at the same time, its fundus rises about two fingers above the navel. In addition, palpation of the abdomen immediately above the pubic bone makes it possible to feel the appearance and presence of a soft tumor here, which turns out to be nothing other than the placenta that has descended here. Thus, by means of palpation of the uterus, we can draw a very important conclusion about whether the placenta has been expelled from the uterine cavity. Palpation of the uterus in the postpartum period allows one to follow the course of postpartum involution. Immediately after labor, the fundus of the uterus stands at the level of the navel; subsequently, with the gradual decrease of the uterus, its fundus begins to lower by approximately two cm (one finger) per day.

Ten days after childbirth, the fundus of the uterus descends to the level of the upper edge of the pubic symphysis; further, the entire body of the uterus moves into the cavity of the lesser pelvis. When palpating the uterus, one must always take into account whether the bladder and rectum are distended, as in this case the uterus, even if well contracted, stands significantly higher than it should. Auscultation of the abdomen of pregnant women is one of the most important methods of obstetric examination, as it allows for the listening of the fetal heartbeat, thereby establishing one of the reliable signs of pregnancy. The fetal heartbeat can be heard no earlier than the 5th-6th month. The inability to hear the heartbeat does not yet indicate the absence of pregnancy, since sometimes even at the end of it, it is not possible to hear the heartbeat, even with a known living fetus. Auscultation of the heartbeat also has great significance for determining the presentation and position of the fetus. Thus, in cephalic presentations, the heartbeat, as a rule, is best heard below the navel; in breech presentations, above the navel. Since the heartbeat is heard better from the side of the fetal back, the position of the fetus is also determined by auscultation, namely: if the heartbeat is heard to the left of the midline, then the back of the fetus is turned to the left (first position); in the second position, it is the opposite. An exception is represented by extension presentations of the fetal head. Here, the chest of the fetus lies closer to the abdominal wall, and therefore the clarity of the heartbeat will be better precisely from the side of the chest, and not from the side of the back. Multiple pregnancy is also recognized by auscultation. In this case, it is possible to hear the fetal heartbeat, differing in frequency, in two places distant from each other; for greater certainty, it is better if the auscultation and counting of heartbeats in both places are performed simultaneously by two examiners. During labor, auscultation of the heartbeat acquires even greater significance, as it indicates the condition of the fetus. Immediately after a contraction, the fetal heartbeat noticeably quickens; however, this acceleration quickly levels off and returns to normal (120-140 beats per minute). If, on the contrary, the heartbeat persistently remains at a high frequency, this always indicates that the fetus is at risk of asphyxia. If the heartbeat becomes slower than one hundred beats per minute, this indicates an extremely dangerous condition for the fetus, and therefore, if possible, one must proceed to delivery. When conducting labor without internal examination, auscultation must have particularly important significance, as in this way one can judge the progress of labor. (The zone of clearest heartbeat gradually lowers during the progressive movement of the fetus, approaching the pelvic inlet.) In addition to the fetal heartbeat, the uterine souffle, synchronous with the mother's heartbeat, and the umbilical cord souffle, in the form of a light blowing sound synchronous with the fetal heartbeat, are also heard. Pelvic measurement is performed using a pelvimeter. Usually, only 4 external dimensions of the pelvis are measured, which allows one to partially judge its internal dimensions (see Table I, Figs. 2 and 3). The following are measured: 1) the distance between the anterior superior iliac spines (distantia spinarum); for this, the tips of the pelvimeter are placed on the outer edges of the spines; this dimension is normally 25-26 cm; 2) the distance between the iliac crests (distantia cristarum): the tips of the pelvimeter are placed on the most distant points of the crests; this dimension is normally 28-29 cm; 3) the distance between the greater trochanters of both femurs (distantia intertrochanterica): the tips of the pelvimeter are placed on the outer protrusions of the trochanters; normally 31-32 cm; and 4) the most important dimension—the external conjugate (conjugata externa; see Table I, Fig. 3); this distance is measured between the upper edge of the pubic symphysis and the point lying immediately below the spinous process of the fifth lumbar vertebra. This point is easily found—almost in the middle of the Michaelis rhomboid—somewhat above the line connecting the lateral angles of the rhomboid, which correspond to the posterior superior iliac spines. The external conjugate is normally 20 cm. Thus, the approximate indicator of a normal female pelvis will be 26, 29, 32, 20. External measurement of the pelvis is a most necessary method of obstetric examination, completely unavoidable in practical work. It makes it possible to determine both the norm and significant deviations from it, i.e., various forms of pathological pelvis. Internal obstetric examination in the first half of pregnancy is performed exactly the same way as a gynecological one; for convenience, it should be performed on a gynecological chair. The examination itself must be preceded by a careful inspection of the external genitalia and the vaginal entrance, where the bluish discoloration of the mucous membrane characteristic of pregnancy has a definite diagnostic significance; it is one of the signs of pregnancy. Passing a finger along the vagina, attention is paid to its walls, which during pregnancy acquire a special softness and velvety texture. By palpating the vaginal portion of the uterus with a finger, one judges its shape, direction, and simultaneously examines the vaginal fornices. A fairly frequent phenomenon during pregnancy is the pulsation of the uterine arteries in both the lateral and anterior fornices. After such an examination with one finger, one proceeds to a bimanual examination. For its success, it is necessary that the examinee makes her abdomen as "soft" as possible, i.e., does not tense the muscles of the abdominal wall at all. This is achieved by the appropriate position of her body and by distracting her attention from the examination itself. It is very important that the bladder and rectum are free of contents. With the external hand, one grasps the uterus and palpates it between the external hand and the fingers inserted into the vagina. To recognize pregnancy, one must pay attention to the size, shape, and consistency of the uterus. If the enlargement of the uterus corresponds to the anamnestic data (in the sense of the time of the last menses, the beginning of fetal movement), then there is great reason for diagnosing pregnancy. The shape of the uterus during pregnancy changes from flattened to spherical, and in the first 2-3 months, the uterus may not be entirely symmetrical: this depends on the fact that one half of it, specifically the one where the egg is located, may be noticeably larger than the other (Piskacek's sign). By the 3rd-4th month, as the egg grows and fills the entire cavity of the uterus, the asymmetry is smoothed out. A particularly important sign of pregnancy is the peculiar consistency of the uterus (softening), caused by serous infiltration of its walls. This softening is especially pronounced in the area bordering between the body and the cervix of the uterus. Therefore, if the external hand is moved along the posterior surface of the uterus toward the internal fingers inserted into the anterior fornix, they can be brought together as if closely between the body of the uterus and the cervix. This is the so-called first Hegar's sign (see Table I, Fig. 4). The second Hegar's sign—the external hand is moved toward the internal fingers along the anterior surface of the uterus, and one tries to pinch the uterus between the external hand and the internal fingers. During pregnancy, this is often successful due to the same softening of the uterine wall. The most reliable sign of pregnancy will be the corresponding enlargement of the uterus upon repeated examination 10-15 days after the first. At the end of pregnancy, internal examination can be used to determine the presenting part if the external one does not provide a completely clear picture. Internal examination is also used to measure the diagonal conjugate, i.e., the distance from the sacral promontory to the lower edge of the pubic symphysis (see Table III, Fig. 11). To measure it, the 2nd and 3rd fingers of the right hand are inserted into the vagina, and one tries to reach the sacral promontory with the 3rd finger. Normally, the diagonal conjugate is 13 cm, and the promontory is reached with great difficulty. Therefore, if the promontory cannot be reached during internal examination, we are dealing with a normal pelvis. If the promontory is reached, the radial edge of the palm is pressed against the lower edge of the pubic symphysis, and a mark is made on the palm with the fingernail of one of the fingers of the left hand at the very edge of the pubic symphysis. Then the fingers are removed from the vagina and the distance from the mark to the end of the third finger is measured. The resulting size will correspond to the magnitude of the diagonal conjugate in the given pelvis. To find the magnitude of the true conjugate, i.e., the distance from the promontory to the upper edge of the pubic symphysis, or the straight dimension of the pelvic inlet, one must subtract 1.5-2 cm from the obtained magnitude of the diagonal conjugate. The entire significance of internal obstetric examination comes to the fore especially when examining women in labor. Where external examination gives an unclear picture and where there is doubt about the correctness of the course of labor, it is often impossible to do without an internal one. It is also impossible to do without it when the obstetrician arrives at the woman in labor already in the midst of labor and is required to provide an immediate conclusion about the state of labor. One also has to resort to internal examination in all those cases where there are indications for surgical intervention and when it is necessary to accurately clarify whether all the necessary conditions for performing one operation or another are present.

In cases where a cesarean section is anticipated, an internal examination is contraindicated (to avoid the possible introduction of infection). An internal examination during labor must, of course, be performed with strict adherence to all requirements of surgical asepsis. If it is performed at the beginning of labor, it is used to determine the degree of cervical dilation, the properties of its edges, the integrity and character of the amniotic sac, the presenting part, the height of its station, the nature of its engagement, etc. During an internal examination, one must obtain not only a planar impression but must form a completely clear idea of the spatial relationships (such an ability is conditioned by a peculiar "stereognostic" sense of touch, which is by no means possessed by everyone). If labor has progressed and it is necessary to precisely determine the nature of the presentation, the ability of the head to undergo configuration, and the degree of this configuration by means of an internal examination, then sutures and fontanelles must be used as landmarks. Here, an internal examination with two fingers does not always provide entirely clear data; to clarify them, it is useful to perform an additional examination with the half-hand, i.e., with four fingers, or even the full hand. An internal examination is always greatly hindered by the presence of a caput succedaneum; here, even an experienced obstetrician is often left at a loss. It is impossible to abandon internal examination entirely. Recently, it has been proposed to replace it with an examination via the rectum (using a rubber glove). Such a substitution is not always possible, however, because the data obtained from an examination via the rectum are always significantly inferior in reliability to those obtained from an examination via the vagina. Modern obstetrics sometimes uses X-rays for the diagnosis of pregnancy (especially multiple pregnancy), for determining the position and presentation of the fetus, for precise measurement of the pelvis, and for clarifying the age of the fetus and its diseases. Undoubtedly, in the near future, X-rays will occupy a prominent place in obstetric examination, but for now, this method of examination still has insignificant application. Regarding biological reactions of pregnancy, see Abderhalden reaction.