OSCE AN examination Flashcards
how would you welcome Marsha to her appointment? 6
Hi Marsha, welcome to your antenatal examination. My name is Ayesha, and I am the student midwife. I will be looking after you today. First, to confirm we have the right person in the right place at the right time I will ask Marsha to tell me her name and DOB and compare this with her case notes.
It’s nice to meet you today and with your informed consent I will be undertaking a full antenatal examination.
I’m also going to make sure that there are no contraindications such as vaginal bleeding or if you have abdominal pain. If that was the case, we would make a referral and we wouldn’t do the examination today.
I am going to take a holistic approach to Marsha’s examination which means I will take an overall view of how she looks and her behaviours, looking for if she looks pale, stressed, or tired. If so, I will follow this up by asking appropriate open-ended questions and ensure that her non-verbal cues match with what she is orally verbalising.
what is the purpose of AN care? 3
The purpose of doing antenatal care is to ensure maternal and fetal health and wellbeing as well as assessing fetal growth, position and lie. We are looking for deviations from the normal and where we find them, we escalate this to the appropriate person.
how would you prepare the room for the AN examination? 2
To prepare for this examination, I would make sure we had a space that could maintain Marsha’s dignity and privacy. I’d want to be able to close the door and close any curtains. I would make sure that the room was warm and comfortable and that any equipment in the room such as the bed was clean. If possible, I would put a do not disturb sign on the door so that we wouldn’t be interrupted. I would also make sure I have the right equipment that I will need for the examination in the room.
How would you prepare yourself and what equipment would you require? 4
I would make sure that I followed the WHO five stages of hand hygiene and the seven stages of hand washing. I would also make sure to have my PPE and ensure that my equipment is clean.
I would require a blood pressure machine, a urinalysis stick, a Daptone, Daptone gel, a pinnard and a single use measuring tape for infection control purposes. I would also need Marsha’s case notes and would make sure I had read over them prior to the appointment .
Describe the component parts of an AN examination. 5
Describe the component parts of an antenatal examination
The component parts of an antenatal examination would be an overall view of Marsha’s wellbeing, which we have done upon her arrival by asking open ended questions and observing her verbal and non-verbal cues.
I would then move on to do Marsha’s blood pressure and would gain her consent before doing so. I would make sure Marsha is sitting and calm and not speaking so that this doesn’t have an impact on the readings. Once I have her blood pressure, I will compare this with her initial booking blood pressure as we are looking for signs of hypertension or pre-eclampsia. I would also ask Marsha for a urine specimen which was provided within the last hour and we test for traces of protein which could be an indication of a UTI or sugar which could be a sign of gestational diabetes. We would also look for signs of oedema and ask Marsha if she feels her symptoms are worsening. These would be deviations from the normal and these would be escalated to the appropriate person.
Next, I would move on to the abdominal examination, which includes inspection, palpation, measurement and auscultation.
Explain your reasons for performing an abdominal examination at this stage of Marsha’s pregnancy? 4
The reason for performing an abdominal examination is to assess the fetal size and growth in comparison to previous appointments. We also want to assess fetal health as well as position and lie of the fetus.
Where there are any deviations from the normal, we will escalate this to the appropriate person.
Preparation and positioning of Marsha is important, explain how you would prepare Marsha and what position, which she should adopt and give your reasons? 5
To prepare Marsha for her antenatal examination, I would ask her to go to the toilet. The reason for this is if she had a full bladder, this would impact on the measurement of her abdomen, and it could also make the palpation uncomfortable for Marsha.
I will lower the bed down for Marsha to be able to get onto the bed comfortably and assist her to do so safely if needed.
Once Marsha was on the bed, I would ask her to lie in a semi recumbent position and place a pillow or a wedge underneath her left side to ensure she is in a left lateral tilt. I will explain to Marsha that this tries to keep the weight of Marsha’s uterus off her large vessels as to avoid vena-caval occlusion.
What will be the effect of inferior vena-caval occlusion? 3.5
This is when the uterus compresses the vena cava and stops the venous return. If this happened, Marsha would suffer from a condition called supine hypotension which might make her feel lightheaded, dizzy, nauseous and she may even vomit or lose consciousness.
What would the midwife do if Marsha becomes dizzy and why? 2
If Marsha was feeling dizzy the midwife would assist her to roll onto her left lateral. This will take off the uterus weight from the vena cava and allow venous return and Marsha will quickly begin to feel better. The midwife will stay in the room with Marsha and will also call for help.
Explain how you would perform an abdominal examination, explaining in detail what you would do and why. 9.5
To carry out the abdominal examination I will need to see Marsha’s abdomen so I will ask her to lower the covers to a place where she is comfortable with, with her informed consent. I will inform Marsha that she can withdraw her consent at any time.
Firstly, I will inspect the shape of Marsha’s uterus. If this was her first baby, we would expect her uterus to look more ovoid and if second baby it would look rounder. This is due to the tone in uterine muscles. The lie of the fetus will also affect the shape of her uterus. I will also look for any fetal movements that are visible to the eye, and look for a dip in Marsha’s umbilicus which could be an indication that the fetus in an occipital posterior position. I will also look for any signs of rashes or itching and if this was the case I would provide Marsha with self-care advice. I will also look for any scars such as a previous c/s and I also might notice striae gravidarum which are stretch marks as the growing uterus is stretching the skin. I’m also going to look for a linea nigra which is a line of pigmentation from the umbilicus down to the pubis symphysis. Whilst making these observations, i will be mindful that this may look different on different ethnicities and skin tones. I will also look for any bruising or signs of domestic abuse and if this is the case, I will speak to Marsha about this in a confidential and sensitive manner.
Fundal height measurement 10
The next thing I will do is the fundal height measurement, which is taken in order to estimate the gestation of the fetus. This should measure approximately the same in cm as Marsha’s gestational age. We measure from the fundal region of the uterus down to the symphysis pubis and we do this because the fundus moves as pregnancy progresses however the pubis symphysis is in a static position. I will make sure that the tape is blind side down as to avoid bias.
Before beginning to palpate, I will make sure my hands are warm. With Marsha’s consent, I am going to gently palpate from the zippy sternum with the side of my hand and work my way down until I feel the curved area of the upper border of Marsha’s uterus. I will place the measuring tape from the fundus down the centre of Marsha’s abdomen to her symphysis pubis and reveal the measurement. Marsha is measuring at 36cm which is appropriate for her gestation. I will document this in Marsha’s growth chart.
fundal palpation 5
Next, I will move on to the fundal palpation. This will help us to determine what part of the fetus is in which pole of the uterus. Using both my hands I will start at the side of Marsha’s uterus, and keeping my fingertips close together I will work my way around until I can feel something in the upper pole. I can feel something here; I am trying to detect if this is soft and broad and whether I can move it. This feels like buttocks; if it was a head, it would be round and hard and ballotable so it would move easily.
lateral palpation 5
Following on from this I will do the lateral palpation. I will anchor Marsha’s uterus with one hand, just at the level of the umbilicus. With my other hand I am going to work my way all the way down the side of the uterus and trying to look for anything that is firm, solid and resistant against my fingers. I will do this again on the other side by switching hands. Here I can feel softness and irregularity. I think the fetal spine is towards the maternal left and the fetal limbs are towards the maternal right.
pelvic palpation 7
Next I’m going to do the pelvic palpation and this is looking for presentation and engagement. in order to do this, I am going to have to turn away from Marsha so I will ask her to indicate if this is uncomfortable for her at any stage and I will stop. NICE suggests we don’t do routine pelvic palpation until 36 weeks’ gestation because that’s when it’s important that we know what the presentation is. I’m going to use my two hands and place them above the symphysis pubis and ask Marsha to bend her knees slightly as to make this more comfortable for her. I will ask her to take a deep breath in and as she does, I’m going to push inwards and downwards and see how much of the fetal head I can feel. It is round and firm and not ballotable; I feel this is a cephalic presentation and 3/5ths palpable.
When would you expect the head to become engaged? 2
Engagement would be expected at 36 weeks if Marsha is a primigravida
